Stiff Left Atrial Syndrome Research Articles

Atrial Balloon Septostomy for Stiff Left Atrial Syndrome Secondary to Catheter Ablation: A Case Series

Atrial Balloon Septostomy for Stiff Left Atrial Syndrome Secondary to Catheter Ablation: A Case Series

Risk of stiff left atrial syndrome following pulse-field-based ablation of atrial fibrillation in patients with pulmonary hypertension at baseline

Abstract Introduction Studies have reported development of stiff LA syndrome, defined as pulmonary hypertension (PH) secondary to reduced LA compliance, in some patients following AF ablation. Purpose We compared the risk of worsening of baseline PH in non-paroxysmal AF (persistent and long-standing persistent AF) patients undergoing repeat procedures, either pulse-field ablation (PFA) or standard radiofrequency ablation (RFA). Methods This multicenter study included 28 non-paroxysmal AF patients with PH, undergoing PFA-based ablation procedure after >1 failed radiofrequency ablations (RFA). A cohort of 28 AF patients with PH that were scheduled for repeat RF ablation were identified. Propensity scores were computed using multivariate logistic model. Twenty-eight patients from the RFA cohort were selected by 1:1 propensity score matching with the PFA group. Right heart catheterization was performed pre- and post-procedure to assess the Pulmonary artery pressure (PAP). PH was defined as resting mean PAP of ≥20 mmHg. The follow-up PAP and change from baseline were compared between PFA and RFA groups, after controlling for baseline PAP in an ANCOVA model. Results Baseline characteristics of PFA (age 62.21 ± 9.3 yrs, male 19 (67.9%), LAD 3.7 ± 0.66 cm) and propensity-matched RF groups (age 62.39 ± 9.3 yrs, male 18 (64.3%), LAD 3.7 ± 0.74 cm) were comparable. The mean pulmonary artery pressure (PAP) assessments at baseline, follow-up and change from baseline are presented in table below. The groups had comparable baseline PAP (p= 0.157). At follow-up, RF group reported 19.81 mm Hg increase in PAP (within-group p <0.001). In PFA group, follow-up PAP showed a decreasing trend (-1.67 mm Hg, within-group p= 0.114). Compared to PFA, the change was significantly higher in RFA (p <0.0001) after controlling for baseline PAP). Conclusion In this propensity-matched population, pulse-field ablation was demonstrated to be a safer option in terms of post-ablation worsening of PAP, compared to the RF ablation in AF patients with pulmonary hypertension at baseline.

Stiff left atrial syndrome with pulmonary veins occlusion after percutaneous radiofrequency ablation: a life-long complication that can lead to heart transplantation

BackgroundStiff left atrial syndrome (SLAS) and pulmonary vein (PV) occlusion are rare yet potentially major life-long complications after radiofrequency ablation for atrial fibrillation. While mostly controlled by medical management, SLAS can progress to refractory congestive heart failure. Treatment of PV stenosis and occlusion remains a challenging problem with ongoing risk for recurrence regardless of techniques employed. Herein we present the case of a now 51-year-old male with acquired PV occlusion and SLAS who, over the course of eleven years, despite multiple interventions, ultimately required heart transplantation.Case presentationAfter undergoing three radiofrequency catheter procedures for paroxysmal atrial fibrillation (AF), a hybrid ablation was planned due to reappearance of symptomatic AF. Preoperative echocardiography and chest computed tomography (CT) revealed an occlusion of both left PVs. Furthermore, left atrial dysfunction, high pulmonary artery and pulmonary wedge pressures were diagnosed as well as an important reduction of the left atrial volume. The diagnosis of stiff left atrial syndrome was made. Primary surgical repair of the left-sided PVs was performed using a pericardial patch as a tubular neo-vein, combined with cryoablation in the left and right atrium to treat the patient’s arrhythmia. Initial results were favorable, however, after two years the patient experienced progressive restenosis with hemoptysis. Therefore, stenting of the common left PV was performed. Over the years, progressive right heart failure with severe tricuspid regurgitation developed, despite maximal medical therapy, which led to the need for heart transplantation.ConclusionThe impact of PV occlusion and SLAS after percutaneous radiofrequency ablation can be lifelong and devastating for the clinical course of the patient. Since the presence of a small left atrium could be an important predictor for SLAS in case of redo ablation, preprocedural imaging should guide the operator to an algorithm of a decision-making containing lesion set, energy source, and safety of re-ablation.

Noninvasive Echocardiographic Surrogate In Stiff Left Atrial Syndrome

Noninvasive Echocardiographic Surrogate In Stiff Left Atrial Syndrome

Stiff left atrial syndrome? Don't overlook underlying disease.

Stiff left atrial syndrome? Don't overlook underlying disease.

Abstract 12982: Between a Rock and a Hard Place: Stiff Left Atrial Syndrome in a Patient With Hereditary Rickets

Introduction: Stiff left atrial syndrome (SLAS) is an uncommon cause of pulmonary hypertension (PH) that has been described as a complication of ablation for atrial fibrillation; here we describe a unique case of SLAS in the setting of extensive left atrial calcification from the treatment of hereditary hypophosphatemia (HH). Case Presentation: A 44-year-old woman with a history of HH presented for evaluation of progressive exertional dyspnea. Previous treatment with calcitriol and phosphate had been complicated by severe calcific mitral and aortic stenosis requiring aortic and mitral valve replacement eight years prior. She reported initial improvement in her symptoms after surgery, but more recently had noted worsening dyspnea and edema despite escalating her home diuretic dose. TTE was notable for moderately severe PH with no evidence of valvular or ventricular dysfunction. Chest CT showed extensive left atrial mural calcification (Figure A) with corresponding calcium visible in the wall of the left atrium on TTE (Figure B). The patient was admitted and underwent IV diuresis followed by RHC confirming mPAP of 41mmHg with a PCWP of 20mmHg and prominent V waves to 33mmHg (Figure C-D). PCWP was confirmed by wedge oxyhemoglobin saturation. Symptoms were improved but not resolved with additional diuresis. Discussion: In this patient with metastatic calcinosis related to the treatment of her HH, we believe her PH is most likely secondary to SLAS due to marked circumferential left atrial calcification. SLAS is characterized by decreased left atrial compliance, leading to large V waves in the absence of mitral regurgitation or an elevated LVEDP. Beyond diuresis, there are no proven treatments for PH due to SLAS.

Stiff “Left Atrial” syndrome post-mustard procedure

Objectives: We describe the clinical course and management of two patients with post-capillary pulmonary hypertension due to diffuse pulmonary venous baffle calcification decades post-Mustard procedure. Background: From the late 1950s to the early 1990s, the definitive surgical repair for children with D-transposition of the great vessels (D-TGA) was an atrial switch procedure (either Senning or Mustard operation) which utilizes atrial-level baffles to shunt pulmonary venous blood to the morphologic right (systemic) ventricle and caval blood to the morphologic left (sub-pulmonary) ventricle. From a hemodynamic standpoint, baffle leaks and stenoses as well as precapillary pulmonary hypertension have all been described as both early and late complications [1]. Recently, delayed post-capillary pulmonary hypertension (in the absence of discrete baffle obstruction) decades post-atrial switch has also been described [2]. The underlying pathophysiology for this postcapillary pulmonary hypertension is unclear but is theorized to involve impaired diastology referable to the pulmonary venous baffle. Methods/Results: Using hemodynamic and imaging data, we describe two patients with extensive pulmonary venous baffle calcification and resultant pulmonary hypertension from the so-called “stiff left atrial (LA) syndrome.” This problem can be difficult to treat medically and is not amenable to catheter-based interventions. We hypothesize that this is an underlying mechanism for pulmonary hypertension in at least some post-Mustard and Senning patients. Conclusion: We describe the treatments and clinical course for each of these patients, and in particular describe how the surgical revision of the pulmonary venous baffle in one case led to the complete resolution of symptoms.

Stiff left atrial syndrome after low-dose radiotherapy for right breast cancer: The need for invasive hemodynamics at exercise

Stiff left atrial syndrome after low-dose radiotherapy for right breast cancer: The need for invasive hemodynamics at exercise

STIFF LEFT ATRIAL SYNDROME: THE MYSTERY BEHIND A PRESUMPTIC DIAGNOSIS OF PULMONARY ARTERY HYPERTENSION

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Atrial Fibrillation (AF) is one of the most prevalent arrhythmia. Radio frequency catheter ablation (RFCA) is an effective treatment for AF and is superior to medical therapy. here we report a case of he stiff left atrium syndrome (SLAS) is a newly recognized post-procedure complication of RFCA due to left atrial (LA) scarring and fibrosis. CASE PRESENTATION: A 66 y/o female with a history of AF status post four RFCAs, suspected heart failure with preserved ejection fraction (HFpEF) with associated PH presented to the emergency room with shortness of breath. An echo cardiogram showed normal left ventricular (LV) systolic function and dilation of the Left atrium. Right heart catheterization (RHC) showed a pulmonary capillary wedge pressure (PCWP) of 32mmHg, a mean pulmonary artery pressure (PAP) of 62mmHg, and near normal peripheral vascular resistance indicating PVH. Due to refractory symptoms a follow up left and RHC showed similar MPAP and PCWP but left ventricular end diastolic pressure (LVEDP) was surprisingly normal at 12mmHg. A CT scan showed normal pulmonary veins without stenosis. Given the discrepancy of elevated LA pressure with a normal LVEDP, a diagnosis of SLAS was confirmed. Treatment with diuretics and control of risk factors were initiated. DISCUSSION: The differential diagnosis for a patient presenting with dyspnea and pulmonary hypertension with a history of prior RFCA includes HfpEF, pulmonary vein stenosis, valvular pathology, and SLAS, with HFpEF begin the most common . The estimated incidence of SLAS after RFCA is 1.4% - 8%. Key distinguishing features of SLAS include prominent V-waves on LA pressure tracings (via PCWP) disproportionate to the LVEDP. The diagnosis of SLAS is challenging and can be easily missed. For example, isolated post-capillary PH with a normal LV ejection fraction would suggest a diagnosis of HFpEF. However, a LHC in a patient with a stiff left atrium that demonstrated a significantly elevated LA V-wave and a surprisingly normal LVEDP would indicate no LVDD. Thus, in addition to imaging with echocardiography, invasive hemodynamic testing with simultaneous LHC to measure the LVEDP in addition to RHC for the PAP and PCWP is essential to make the difficult diagnosis of SLAS. Diuretics are currently considered mainstay treatment for SLAS. Recent studies have evaluated the novel use of an interatrial septal device to create an atrial septostomy which relieves LA pressure by creating a left-to-right shunt. In a trial for patients with HFpEF, an atrial septostomy led to a significant decrease in PCWP (28%), symptomatic improvement, a longer 6-minute walk distance, and better quality of life after 30 days. CONCLUSIONS: This case demonstrates the diagnostic challenge of SLAS and the importance of invasive hemodynamic testing with simultaneous RHC and LHC in addition to imaging to identify the true underlying cause of pulmonary hypertension. Reference #1: Gibson, D.N., et al., Stiff left atrial syndrome after catheter ablation for atrial fibrillation: clinical characterization, prevalence, and predictors. Heart Rhythm, 2011. 8(9): p. 1364-71. Reference #2: Maeder, M.T., et al., Pulmonary hypertension in stiff left atrial syndrome: pathogenesis and treatment in one. ESC heart failure, 2018. 5(1): p. 189-192. Reference #3: Chandrashekar, P., et al., Atrial Septostomy to Treat Stiff Left Atrium Syndrome. Circulation. Heart failure, 2017. 10(7): p. e004160. DISCLOSURES: No relevant relationships by Mark Cromer, source=Web Response No relevant relationships by Abhijit Raval, source=Web Response

DIAGNOSING STIFF LEFT ATRIAL SYNDROME IN THE SETTING OF MITRAL STENOSIS

Stiff left atrial (LA) syndrome and pulmonary vein stenosis (PVS) are potential complications of atrial fibrillation (AF) ablation. In patients with mitral stenosis (MS) and prior AF ablation, identifying the cause of dyspnea is vital for management. A 74-year-old male with AF ablation a decade

STIFF LEFT ATRIAL SYNDROME MASQUERADING AS MITRAL STENOSIS

Stiff Left Atrial Syndrome is a rare condition that presents similarly to congestive heart failure. It must be considered in a patient with past atrial fibrillation (Afib) radiofrequency ablations (RFA) or mitral valve (MV) surgery. Diagnosis often requires multimodality testing. A 79-year-old

Stiff Left Atrial Syndrome; Prospects and Possibilities. Retrospective Analysis and Review of the Literature.

Stiff left atrial syndrome is an intriguing clinical phenomena characterized by reduced left atrial compliance, pulmonary venous hypertension and exacerbations of volume overload. We conducted a retrospective review of patients diagnosed with stiff left atrial syndrome at our center. All patients admitted to our hospital with volume overload and pulmonary venous hypertension who were diagnosed with stiff left atrial syndrome based on evidence by echocardiogram and right heart catheterization between July 2011 and July 2013 were included in this retrospective review. Twentythree patients (mean age 73 ± 11 years, 39% male and 61% female) were diagnosed with stiff left atrial syndrome at our center. Thirty-five percent had persistent while 39% had permanent atrial fibrillation. Mean duration of atrial fibrillation was 7.6 ± 2.1 years. Forty-three percent of patients had long standing hypertension. There was no mitral regurgitation in 39% of patients while 48% had mild mitral regurgitation. On right heart catheterization, mean right atrial pressure was 12.6±4.8 mm of Hg, mean pulmonary arterial pressure was 33±7.2 mm of Hg, mean pulmonary capillary wedge pressure was 24.8± 4.2mm of Hg while peak V waves were seen at mean of 37.8± 5.3 mm of Hg. Mean left atrial volume index was 49.8±17.1 mL/m 2. After the initial diagnosis with a two year follow- up, there were no readmissions in 65% of patients who were on appropriate diuretic therapy and had regular clinical visits. Frequent readmissions were seen in 35% of patients inspite of appropriate diuretic therapy. All-cause mortality rate was 4.3% at two year follow up. In patients with stiff left atrial syndrome, the presence of left atrial dilation, long standing atrial fibrillation and hypertension are the key factors associated with pathogenesis and clinical course. Close follow up and monitoring of volume status is essential to prevent hospital readmissions and improve long term prognosis.

Left Atrial Stiffness: A Predictor of Atrial Fibrillation Recurrence after Radiofrequency Catheter Ablation - A Systematic Review and Meta-Analysis.

BackgroundRadiofrequency catheter ablation (RFCA) is a standard procedure for patients with atrial fibrillation (AF) not responsive to previous treatments, that has been increasingly considered as a first-line therapy. In this context, perioperative screening for risk factors has become important. A previous study showed that a high left atrial (LA) pressure is associated with AF recurrence after ablation, which may be secondary to a stiff left atrium.ObjectiveTo investigate, through a systematic review and meta-analysis, if LA stiffness could be a predictor of AF recurrence after RFCA, and to discuss its clinical use.MethodsThe meta-analysis followed the MOOSE recommendations. The search was performed in MEDLINE and Cochrane Central Register of Controlled Trials databases, until March 2018. Two authors performed screening, data extraction and quality assessment of the studies.ResultsAll studies were graded with good quality. A funnel plot was constructed, which did not show any publication bias. Four prospective observational studies were included in the systematic review and 3 of them in the meta-analysis. Statistical significance was defined at p value < 0.05. LA stiffness was a strong independent predictor of AF recurrence after RFCA (HR = 3.55, 95% CI 1.75-4.73, p = 0.0002).ConclusionA non-invasive assessment of LA stiffness prior to ablation can be used as a potential screening factor to select or to closely follow patients with higher risks of AF recurrence and development of the stiff LA syndrome.

STIFF LEFT ATRIAL SYNDROME: AN UNDER-RECOGNIZED HFPEF MASQUARADER

The stiff left atrial syndrome (SLAS), a possible complication of catheter ablations or MAZE procedures for atrial fibrillation, results in increased left atrial scar formation resulting in left atrial hypertension. The syndrome can easily present as heart failure with preserved ejection fraction (

Evaluation of shortness of breath after atrial fibrillation ablation—Is there a stiff left atrium?

Ablation has emerged as the most effective therapy for atrial fibrillation (AF), with the primary goal to improve symptoms. However, there is a subset of patients who develop limiting symptoms after successful ablation despite reestablishment of sinus rhythm. There is now recognition of “stiff left atrial (LA) syndrome” related to adverse consequences of ablation itself on LA hemodynamics, as described by Gibson and others. 1 Gibson D.N. Di Biase L. Mohanty P. et al. Stiff left atrial syndrome after catheter ablation for atrial fibrillation: clinical characterization, prevalence, and predictors. Heart Rhythm. 2011; 8: 1364-1371 Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar , 2 Welch T.D. Coylewright M. Powell B.D. Asirvatham S.J. Gersh B.J. Dearani J.A. Nishimura R.A. Symptomatic pulmonary hypertension with giant left atrial v waves after surgical maze procedures: evaluation by comprehensive hemodynamic catheterization. Heart Rhythm. 2013; 10: 1839-1842 Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Although relatively uncommon (1.4% incidence in the Gibson series), this syndrome is important to diagnose, as it can cause severe unexplained dyspnea. In this review, we will discuss the hemodynamics of ablation-related injury and provide a diagnostic approach to persistent dyspnea after ablation.

Left atrial compliance: an overlooked predictor of clinical outcome in patients with mitral stenosis or atrial fibrillation undergoing invasive management.

In the assessment of cardiovascular disease, the clinical significance of left atrial (LA) pressure-volume relations has largely been overlooked in contrast to left ventricular (LV) compliance. However, LA compliance has recently gained more attention. Net atrioventricular compliance (Cn), a joint measure of LA and LV compliance, can be calculated non-invasively by a previously validated method using parameters from standard echocardiography. Compliance measurement may be of relevance in selected clinical settings. First, subjects with low Cn are more likely to have their mitral valve area overestimated by the traditional mitral pressure half-time method. Consequently, low Cn in mitral stenosis, usually resulting from reduced LA compliance, can be mistaken for mild mitral stenosis. Second, low Cn independently predicted pulmonary hypertension and disease progression in medically treated mitral stenosis, and late cardiovascular complications after successful percutaneous mitral valvuloplasty. Decreased LA compliance also accounts for stiff LA syndrome, a rare complication of radiofrequency catheter ablation for atrial fibrillation, manifesting as otherwise unexplained heart failure with elevated LA pressure and pulmonary hypertension. Finally, depressed pre-ablation LA stiffness index, i.e. the ratio of the change in LA pressure to the corresponding change in LA volume during passive LA filling, was an independent predictor of arrhythmia recurrence. Thus, LA stiffening translates into adverse clinical outcomes in patients with mitral stenosis or atrial fibrillation undergoing interventional procedures. Whether reduced LA compliance after LA appendage occlusion can result in the LA stiff syndrome, has not been reported so far.

Stiff Left Atrial Syndrome: A Complication Undergoing Radiofrequency Catheter Ablation for Atrial Fibrillation

Radiofrequency catheter ablation for atrial fibrillation is an effective approach for treating atrial fibrillation. Its complications have attracted much attention, of which the stiff left atrial syndrome is a recently discovered complication that has not been completely understood. This study aims to investigate the concept, pathologic basis, clinical characteristics, predictors, and treatment protocols of the stiff left atrial syndrome after radiofrequency ablation for atrial fibrillation.

Low Left Atrial Compliance Contributes to the Clinical Recurrence of Atrial Fibrillation after Catheter Ablation in Patients with Structurally and Functionally Normal Heart.

Stiff left atrial (LA) syndrome was initially reported in post-cardiac surgery patients and known to be associated with low LA compliance. We investigated the physiological and clinical implications of LA compliance by estimating LA pulse pressure (LApp) among patients with atrial fibrillation (AF) and structurally and functionally normal heart. Among 1038 consecutive patients with LA pressure measurements before AF ablation, we included 334 patients with structurally and functionally normal heart (81.7% male, 54.1±10.6 years, 77.0% paroxysmal AF) after excluding those with hypertension, diabetes, and previous ablation or cardiac surgery. We measured LApp (peak-nadir LA pressure) at the beginning of the ablation procedure and compared the values with clinical parameters and the AF recurrence rate.AF patients with normal heart were younger and more frequently male and had paroxysmal AF, a lower body mass index, and a lower LApp compared to others (all p<0.05).Based on the median value, the low LA compliance group (LApp≥13mmHg) had a smaller LA volume index and lower LA voltage (all p<0.05) compared to the high LA compliance group. During a mean follow-up of 16.7±11.8 months, low LA compliance was independently associated with two fold-higher risk of clinical AF recurrence (HR:2.202; 95%CI:1.077–4.503; p = 0.031).Low LA compliance, as determined by an elevated LApp, was associated with a smaller LA volume index and lower LA voltage and independently associated with higher clinical recurrence after catheter ablation in AF patients with structurally and functionally normal heart.

Novel use of sildenafil in the management of pulmonary hypertension due to post-catheter ablation ‘stiff left atrial syndrome’

Novel use of sildenafil in the management of pulmonary hypertension due to post-catheter ablation ‘stiff left atrial syndrome’

Increase in pulmonary arterial pressure after atrial fibrillation ablation: incidence and associated findings

The stiff left atrial (LA) syndrome is defined as pulmonary hypertension (PH) secondary to reduced LA compliance and has recently been shown to be one cause of PH after atrial fibrillation (AF) ablation. We aimed to determine the incidence of an increase in pulmonary arterial (PA) pressure post-ablation and examine the clinical and echocardiographic associations. Patients who underwent AF ablation between 1999 and 2011 were included if they had both an echocardiogram pre-ablation and 3 months post-ablation. Patients were then separated into two groups with the increased PA pressure group defined as patients with >10 mmHg increase in right ventricular systolic pressure (RVSP) post-ablation and a post-ablation RVSP >35 mmHg. Of the 499 patients meeting the study criteria, 41 (8.2%) had an increase in RVSP >10 mmHg and RVSP >35 mmHg post-ablation. On echocardiogram, the two groups had similar E/A and E/e' ratios pre-ablation. However, post-ablation, the increased PA pressure group had higher E/A (2.12 vs. 1.49, p < 0.01) and E/e' (14.7 vs. 11.2, p < 0.01) ratios. LA expansion index values were lower in the increased PA pressure group pre-ablation (51 vs. 92%, p < 0.01), but not significantly different post-ablation (82 vs. 88%, p = 0.44). Around 8% of patients develop an increase in estimated PA pressure after AF ablation. Echocardiographic parameters suggest that patients who develop increased PA pressure are developing (or unmasking) left ventricular diastolic dysfunction.