Evaluation of Inter-atrial Septal Defect Diameter and Left Ventricular Systolic Function in Children with Ostium Secundum Atrial Septal Defect in Enugu, Nigeria.

BACKGROUND: Children with ostium secundum atrial septal defect (OS ASD) usually present with varying degrees of ventricular dysfunction. OBJECTIVES: This study aimed to evaluate the left ventricular systolic function of children with OS ASD compared with control. METHODS: This was a cross-sectional study involving 113 children with OS ASD and 113 age- and sex- matched controls. Their age ranged from 1 month to 16 years. There were 49 males and 64 females in each group. Left ventricular systolic function of children with isolated OS ASD were compared with that of controls using echocardiography. Subjects and controls who fulfilled the inclusion criteria were consecutively recruited in the study. The data elicited from the study were analyzed with the IBM SPSS version 20 (IBM Corp, Chicago). RESULTS: The mean left ventricular mass (LV mass) of the control, 93.9±113.6 gm was significantly higher than that of subjects with OS ASD, 39.4±74.3 gm, (Mann Whitney U= 4.266, p< 0.001). Similarly, the mean left ventricular internal diameter in diastole (LVIDd) of the control,25.8±11.7 mm was significantly higher than that of participants with OS ASD, 19.9±7.1 mm (Mann Whitney U=4.522, p<0.001). The mean interventricular septal diameter in systole (IVSs) of the control, 7.2±3.5 mm was higher than that of participants with OS ASD, 5.0±1.9 mm and the mean difference was found to be statistically significant, (Student t=5.738, p<0.001). The mean left ventricular internal diameter in systole (LVIDs) of the control, 16.2±7.6 mm was significantly higher than that of participants with OS ASD, 12.9±5.8 mm, (Student t= 3.660, p< 0.001). There was no significant correlation between the size of interatrial septal defect of children with OS ASD and left ventricular systolic function and age :(Corr. Coef. 0.065, p= 0.492) ; EF( Corr. Coef. 0.121,p=0.202), FS (Corr. Coef. 0.139, p=0.143). CONCLUSION: Children with OS ASD had lower left ventricular mass compared with those with control. Females seem to have higher function than males.

CONTEXTE: Les enfants atteints de communication interauriculaire type ostium secundum (CIASOS) présentent généralement des degrés variables de dysfonction ventriculaire. OBJECTIFS: Cette étude visait à évaluer la fonction systolique ventriculaire gauche des enfants atteints de CIASOS par rapport à des témoins. MÉTHODES: Il s'agissait d'une étude transversale portant sur 113 enfants atteints de CIASOS et 113 témoins appariés selon l'âge et le sexe. Leur âge variait de 1 mois à 16 ans. Il y avait 49 garçons et 64 filles dans chaque groupe. La fonction systolique ventriculaire gauche des enfants présentant un CIASOS isolé a été comparée à celle des témoins à l'aide de l'échocardiographie. Les sujets et les témoins qui remplissaient les critères d'inclusion ont été recrutés consécutivement dans l'étude. Les données recueillies ont été analysées avec la version 20 d'IBM SPSS (IBM Corp, Chicago). RÉSULTATS: La masse moyenne du ventricule gauche (VG) du groupe témoin, 93,9±113,6 g, était significativement plus élevée que celle des sujets atteints d'OS ASD, 39,4±74,3 g (Mann-Whitney U = 4,266, p < 0,001). De même, le diamètre interne moyen du ventricule gauche en diastole (LVIDd) du groupe témoin, 25,8±11,7 mm, était significativement plus élevé que celui des participants atteints d'OS ASD, 19,9±7,1 mm (Mann-Whitney U = 4,522, p < 0,001). Le diamètre moyen du septum interventriculaire en systole (IVSs) du groupe témoin, 7,2±3,5 mm, était plus élevé que celui des participants atteints d'OS ASD, 5,0±1,9 mm, et la différence moyenne était statistiquement significative (Student t = 5,738, p < 0,001). Le diamètre interne moyen du ventricule gauche en systole (LVIDs) du groupe témoin, 16,2±7,6 mm, était significativement plus élevé que celui des participants atteints d'OS ASD, 12,9±5,8 mm (Student t = 3,660, p < 0,001). Il n'y avait pas de corrélation significative entre la taille du défaut septal interauriculaire chez les enfants atteints d'OS ASD et la fonction systolique du ventricule gauche et l'âge : (Coef. Corr. 0,065, p = 0,492) ; FE (Coef. Corr. 0,121, p = 0,202), FS (Coef. Corr. 0,139, p = 0,143). CONCLUSION: Les enfants atteints de CIASOS avaient une masse ventriculaire gauche plus faible que ceux du groupe témoin. Les filles semblent avoir une fonction plus élevée que les garçons. MOTS-CLÉS: Fonction ventriculaire gauche; Communication interauriculaire type ostium secundum (CIASOS); Malformation septale interauriculaire; Enfants; Échocardiographie.

Efficacy of a mitral regurgitation severity index to predict long-term outcome in dogs with myxomatous mitral valve disease.

BACKGROUND: Predicting progression of myxomatous mitral valve disease (MMVD) in dogs can be challenging. HYPOTHESIS/OBJECTIVES: The mitral regurgitation severity index (MRSI) will predict time to congestive heart failure (CHF) and all-cause death in dogs with MMVD. ANIMALS: Eight hundred sixty-nine client-owned dogs. METHODS: Retrospective study pooling data from 4 previous samples including dogs with MMVD stage B2 or C. MRSI was calculated as: (heart rate [HR]/120) × left atrium-to-aorta ratio (LA:Ao) × (age in years/10) × 100. Alternative MRSI formulas substituting radiographic measures of left atrial size were also calculated. Cox proportional hazard modeling and time-dependent receiver-operator characteristic curves quantified prognostic performance. RESULTS: For Stage B2 pooled samples, MRSI > 156 was predictive of time to CHF (median 407 vs 1404 days; area under the curve [AUC] 0.68; hazard ratio 3.02 [95% CI 1.9-4.9]; P < .001). MRSI > 173 was predictive of all-cause death (median survival 868 vs 1843 days; AUC 0.64; hazard ratio 4.26 [95% CI 2.4-7.5]; P < .001). MRSI showed superior predictive value compared to the individual variables of HR, LA:Ao, and age. Variations of the MRSI equation substituting radiographic vertebral left atrial size for LA:Ao were also significantly predictive of outcome in stage B2. MRSI was not consistently predictive of outcome in Stage C. CONCLUSIONS AND CLINICAL IMPORTANCE: MRSI was predictive of outcome (onset of CHF and all-cause death) in MMVD Stage B2, demonstrating utility as a useful prognostic tool. Echocardiographic LA:Ao can be effectively replaced by radiographically determined LA size in the MRSI formula.

Predictors of New Onset Atrial Fibrillation Burden in the Critically Ill.

INTRODUCTION: Atrial fibrillation (AF) is common in the intensive care unit (ICU) setting and has been associated with adverse outcomes. In this context, there is increasing research interest in AF burden as a predictor of subsequent adverse events. However, the pathophysiology and drivers of AF burden in the ICU are poorly understood. This study sought to evaluate the predictors of AF burden in critical illness-associated new-onset AF (CI-NOAF). METHODS: Out of 7,030 admissions in a tertiary general ICU between December 2015 and September 2018, 309 patients developed CI-NOAF. AF burden was defined as the percentage of monitored time in AF, as extracted from hourly interpretations of continuous ECG monitoring. Low and high AF burden groups were defined relative to the median AF burden. Clinical, laboratory, and echocardiographic parameters were extracted, and multivariable modelling with binary logistic regression was performed to evaluate for independent associations with AF burden. RESULTS: The median AF burden was 7.0%. Factors associated with increased AF burden were age, dyslipidaemia, chronic kidney disease, increased creatinine, CHA2DS2-VASc score, ICU admission diagnosis category, amiodarone administration, and left atrial area (LAA). Factors associated with lower AF burden were previous alcohol excess, burden of ventilation, the use of inotropes/vasopressors, and beta blockers. On multivariate analysis, increased LAA, chronic kidney disease, and amiodarone use were independently associated with increased AF burden, whereas beta blocker use was associated with lower AF burden. CONCLUSION: Left atrial size and chronic cardiovascular comorbidities appear to be the primary drivers of CI-NOAF burden, whereas factors related to acute illness and critical care intervention paradoxically did not appear to be a substantial driver of arrhythmia burden. Further research is needed regarding drivers of AF and the efficacy of rhythm control intervention in this unique setting.

Predictive value of a comprehensive atrial assessment with cardiac magnetic resonance in non-ischemic cardiomyopathy: keep it simple.

Cardiac magnetic resonance (CMR) can provide a multi-parametric evaluation of left atrial (LA) size and function. A complete CMR-based LA assessment might improve the risk stratification of patients with non-ischemic dilated cardiomyopathy (DCM). We performed a comprehensive CMR-based evaluation of LA size and function, in order to assess the prognostic impact of specific LA parameters in DCM. Secondary analysis of a prospective registry (UHSM-CMR study, NCT02326324) including 648 consecutive patients with DCM and CMR evaluation of LA area and LA length. Of these, 456 had complete LA assessment covering reservoir, conduit and booster pump function and including LA reservoir strain evaluated with feature tracking. The heart failure (HF) endpoint included HF hospitalizations, HF death and heart transplant. The arrhythmic endpoint included ventricular arrhythmias (VA) (sustained or treated by implantable defibrillator) and sudden death (SD). At median follow-up of 23 months, 34 patients reached the HF endpoint; in a multivariable model including NYHA class and LVEF, LA length had incremental predictive value. LA length ≥ 69 mm was the best cut-off to predict HF events (adjusted HR 2.3, p = 0.03). Among the 456 patients with comprehensive LA assessment, only LA length was independently associated with the HF endpoint after adjusting for LVEF and NYHA class. By contrast, no LA parameter independently predicted the arrhythmic risk. In DCM patients, LA length is an independent predictor of HF events, showing stronger association than other more complex parameters of LA function. No atrial parameter predicts the risk of VA and SD.

Radiographic Left Atrial Size Measurement of Dogs in Different Mitral Valve Disease Stages with Four Different Methods.

The left atrial size increases (LAS) in patients with mitral valve disease (MVD) as the disease progresses. The vertebral left atrial size (VLAS), the modified-vertebral left atrial size (M-VLAS), and the radiographic left atrial dimension (RLAD) are methods reported to assess LAS on dogs' radiographs. All these methods transform the LAS into vertebral units. The thoracic inlet (TI) has been used as a reliable reference point to measure the cardiac silhouette of dogs with MVD in different stages. The objective of this study was to assess the clinical utility of measuring a dog LAS on right thoracic X-rays using the TI as a reference and determine whether it could differentiate dogs in different MVD stages. LAS was divided by the TI to obtain the thoracic inlet left atrial score (TILAS). This was a retrospective observational study including 135 apparently healthy dogs performed to assess their LAS with four different methods: VLAS, M-VLAS, RLAD, and TILAS. Thirty-six dogs from the general population were selected and compared to 100 dogs in different MVD stages. The TILAS was significantly different between the control dogs and MVD dogs, increasing with the disease stage: control dogs 0.51 ± 0.08, B1 0.57 ± 0.14, B2 0.75 ± 0.13, and C 0.84 ± 0.18. VLAS, M-VLAS, and RLAD also increased as the disease progressed, as shown in previous studies. The TILAS accuracy to distinguish MVD dogs with cardiac enlargement was comparable to VLAS, M-VLAS, and RLAD (AUC 0.91 vs. 0.93, 0.90, and 0.94 respectively). A TILAS > 0.8 can identify dogs with cardiac enlargement secondary to MVD.

Echocardiographic Phenotypes of Subclinical Organ Damage: Clinical and Prognostic Value in the General Population. Findings from the Pamela Study.

Subclinical alterations in cardiac structure and function include a variety of abnormal phenotypes of established adverse prognostic significance such as left ventricular hypertrophy (LVH), alterations of LV geometry, left atrial (LA) enlargement, and aortic root (AR) dilatation. The excess cardiovascular (CV) risk associated with these phenotypes has been consistently demonstrated in different clinical settings such in patients with systemic hypertension, coronary heart disease, diabetes mellitus, chronic kidney disease, heart failure and in geneal population samples. The Pressioni Monitorate e Loro Associazioni (PAMELA), a longitudinal population-based study originally designed to assess the normality values, prognostic significance of office, home and 24-hour blood pressure, including among the many clinical and laboratory variables the collection of echocardiographic data, allowed to gather important information on the clinical prognostic significance of subclinical cardiac damage during a long follow-up period. This article summarizes the original findings provided by the PAMELA study on the clinical correlates and prognostic significance of echocardiographic markers of subclinical organa damage namely LVH, left atrial enlargement (LA) and AR dilatation at the community level.

Left atrial area index provides the best prediction of atrial fibrillation in ischemic stroke patients: results from the LAETITIA observational study.

Background and aims: Left atrial (LA) enlargement has been repeatedly shown to be associated with the diagnosis of atrial fibrillation (AF). In clinical practice, several parameters are available to determine LA enlargement: LA diameter index (LADI), LA area index (LAAI), or LA volume index (LAVI). We investigated the predictive power of these individual LA parameters for AF in patients with acute ischemic stroke or transient ischemic attack (TIA). Methods: LAETITIA is a retrospective observational study that reflects the clinical reality of acute stroke care in Germany. Consecutive patient cases with acute ischemic cerebrovascular event (CVE) in 2019 and 2020 were identified from the Mannheim stroke database. Predictive power of each LA parameter was determined by the area under the curve (AUC) of receiver operating characteristic curves. A cutoff value was determined. A multiple logistic regression analysis was performed to confirm the strongest LA parameter as an independent predictor of AF in patients with acute ischemic CVE. Results: A total of 1,910 patient cases were included. In all, 82.0% of patients had suffered a stroke and 18.0% had a TIA. Patients presented with a distinct cardiovascular risk profile (reflected by a CHA2DS2-VASc score ≥2 prior to hospital admission in 85.3% of patients) and were moderately affected on admission [median NIHSS score 3 (1; 8)]. In total, 19.5% of patients had pre-existing AF, and 8.0% were newly diagnosed with AF. LAAI had the greatest AUC of 0.748, LADI of 0.706, and LAVI of 0.719 (each p < 0.001 vs. diagonal line; AUC-LAAI vs. AUC-LADI p = 0.030, AUC-LAAI vs. AUC-LAVI p = 0.004). LAAI, increasing NIHSS score on admission, and systolic heart failure were identified as independent predictors of AF in patients with acute ischemic CVE. To achieve a clinically relevant specificity of 70%, a cutoff value of ≥10.3 cm2/m2 was determined for LAAI (sensitivity of 69.8%). Conclusion: LAAI revealed the best prediction of AF in patients with acute ischemic CVE and was confirmed as an independent risk factor. An LAAI cutoff value of 10.3 cm2/m2 could serve as an inclusion criterion for intensified AF screening in patients with embolic stroke of undetermined source in subsequent studies.

The contribution of competing mechanisms in stroke despite anticoagulation in patients with atrial fibrillation.

BACKGROUND: For reasons poorly understood, strokes frequently occur in patients with atrial fibrillation (AF) despite oral anticoagulation. Better data are needed to inform randomised trials (RCTs) of new strategies to prevent recurrence in these patients. We investigate the relative contribution of competing stroke mechanisms in patients with AF who have stroke despite anticoagulation (OAC+) compared with those who are anticoagulant naïve (OAC-) at the time of their event. PATIENTS AND METHODS: We performed a cross-sectional study leveraging data from a prospective stroke registry (2015-2022). Eligible patients had ischemic stroke and AF. Stroke classification was performed by a single stroke-specialist blinded to OAC status using TOAST criteria. The presence of atherosclerotic plaque was determined using duplex ultrasonography, computerised tomography (CT) or magnetic resonance (MR) angiography. Imaging was reviewed by a single reader. Logistic regression was used to identify independent predictors of stroke despite anticoagulation. RESULTS: Of 596 patients included, 198 (33.2%) were in the OAC+ group. A competing cause for stroke was more frequent in patients with OAC+ versus OAC- (69/198 (34.8%)) versus 77/398 (19.3%), p < 0.001). After adjustment, both small vessel occlusion (odds ratio (OR): 2.46, 95% CI: 1.20-5.06) and arterial atheroma (⩾50% stenosis) (OR: 1.78, 95% CI: 1.07-2.94) were independently associated with stroke despite anticoagulation. DISCUSSION AND CONCLUSION: Patients with AF-associated stroke despite OAC are much more likely than patients who are OAC-naïve to have competing stroke mechanisms. Rigorous investigation for alternative stroke causes in stroke despite OAC has a high diagnostic yield. These data should be used to guide patient selection for future RCTs in this population.

The Use of Automated Atrial CMR Measures and a Novel Atrioventricular Coupling Index for Predicting Risk in Repaired Tetralogy of Fallot.

Atrial size and function have been recognized as markers of diastolic function, and diastolic dysfunction has been identified as a predictor of adverse outcomes in repaired tetralogy of Fallot (rTOF). This was a retrospective single-center study with the objective of investigating the use of atrial measurements obtained via CMR for predicting outcomes in rTOF patients. Automated contours of the left and right atria (LA and RA) were performed. A novel parameter, termed the Right Atrioventricular Coupling Index (RACI), was defined as the ratio of RA end-diastolic volume to right ventricle (RV) end-diastolic volume. Patients were risk-stratified using a previously validated Importance Factor Score for the prediction of life-threatening arrhythmias in rTOF. Patients with a high-risk Importance Factor Score (>2) had a significantly larger minimum RA volume (p = 0.04) and RACI (p = 0.03) compared to those with scores ≤2. ROC analysis demonstrated RACI to be the best overall predictor of a high-risk Importance Factor Score (AUC 0.73, p = 0.03). Older age at the time of repair and a diagnosis of pulmonary atresia were associated with a larger RACI. Automated atrial CMR measurements are easily obtained from standard CMRs and have the potential to serve as noninvasive predictors of adverse outcomes in rTOF.

Left atrial size predicts long-term outcome after balloon mitral valvuloplasty.

BACKGROUND: The treatment of choice for severe rheumatic mitral stenosis is balloon mitral valvuloplasty (BMV). Numerous predictors of immediate and long-term procedural success have been described. The aims of this study were to describe our experience with BMV over the last decade and to evaluate predictors of long-term event-free survival. METHODS: Medical records were retrospectively analyzed of patients who underwent BMV between 2009 and 2021. The primary outcome was a composite endpoint of all-cause mortality, mitral valve replacement (MVR), and repeat BMV. Long-term event-free survival was estimated using Kaplan-Meier curves. Logistic regression was used to create a multivariate model to assess pre-procedural predictors of the primary outcome. RESULTS: A total of 96 patients underwent BMV during the study period. The primary outcome occurred in 36 patients during 12-year follow-up: one (1%) patient underwent re-BMV, 28 (29%) underwent MVR, and eight (8%) died. Overall, event-free survival was 62% at 12 years. On multivariate analysis, pre-procedural left atrial volume index (LAVI) > 80 mL/m2 had a significant independent influence on event-free survival, as did previous mitral valve procedure and systolic pulmonary arterial pressure above 50 mmHg. CONCLUSIONS: Despite being a relatively low-volume center, excellent short and long-term results were demonstrated, with event-free survival rates consistent with previous studies from high-volume centers. LAVI independently predicted long-term event-free survival.

Biatrial Volumetric Assessment by Non-ECG-Gated CT Pulmonary Angiography Correlated with Transthoracic Echocardiography in Patients with Normal Diastology.

Atrial size is a predictor of cardiovascular mortality. Non-ECG-gated computed tomography pulmonary angiography (CTPA) is a common test for cardiopulmonary evaluation but normative values for biatrial volumes are lacking. We derived normal CT biatrial volumes using manual and semiautomated segmentation with contemporaneous transthoracic echocardiography (TTE) to confirm normal diastology. Thirty-five consecutive cases in sinus rhythm with no history of cardio-vascular, renal, or pulmonary disease and normal diastolic function were selected. Planimetric CTPA measurements were compared to TTE volumes measured using area length method. TTE and CTPA derived normal LAVi and RAVi were 27 + 5 and 20 + 6 mL/m2, and 30 + 8 and 29 + 9 mL/m2, respectively. Bland-Altman analysis revealed an underestimation of biatrial volumes by TTE. TTE-CT mean biases for LAV and RAV were -5.7 + 12.0 mL and -16.2 + 14.8 mL, respectively. The CT intraclass correlation coefficients (ICC 95% CI) for LA and RA volumes were 0.99 (0.96-1.00) and 0.96 (0.76-0.99), respectively. There was excellent correlation (p < 0.001) between the semiautomated and manual measurements for LA (r 0.99, 95% CI 0.98-0.99) and RA (r 0.99, 95% CI 0.99-1.00). Atrial volumetric assessment on CTPA is easy and reproducible and can provide additional metric in cardiopulmonary assessment.

Methods of Radiographic Measurements of Heart and Left Atrial Size in Dogs with and without Myxomatous Mitral Valve Disease: Intra- and Interobserver Agreement and Practicability of Different Methods.

Dogs suffering from Myxomatous Mitral Valve Disease (MMVD) show a potential heart enlargement, especially in the left atrium, detectable by radiography. Due to digital radiography, different radiographic measurements estimate cardiac size quite uncomplicatedly. The Vertebral Heart Size (VHS), Radiographic Left Atrial Dimension (RLAD), Left Atrial Width (LAWidth), and the Vertebral Left Atrial Size (VLAS) used anatomical landmarks for measuring cardiac size in relation to the vertebral column. This study aimed to compare VHS, RLAD, LAWidth, and VLAS measured in conventional and inverted radiographs by veterinarians with different levels of experience in healthy dogs and dogs with MMVD. The reliability and user-friendliness of these measurements were evaluated, and the staging was compared to the echocardiography staging. A total of 50 unaffected dogs and 150 dogs with MMVD in stages B1, B2, and C were assessed. Three veterinarians with different levels of experience examined 200 conventional radiographs and their corresponding inverted radiographs blinded to the echocardiographic and clinical examination results. Analyses were performed to compare the measurements' grading and determine anatomical landmarks with measurement difficulties. Additionally, inter- and intraobserver agreement was assessed using intraclass correlation coefficient, and the agreement between radiographic and echocardiographic staging was compared using the kappa coefficient. The VHS, LAWidth, and VLAS were easier to define than the RLAD. The interobserver agreement was almost perfect for VHS (0.962) and good for the other radiographic measurements (RLAD: 0.778, LAWidth: 0.772, VLAS: 0.858). The VHS assigned the most dogs to the correct stage. However, VHS, RLAD, LAWidth, and VLAS presented an almost perfect intraobserver agreement. The dorsal left atrial margin of the RLAD was the most difficult measurement point to identify. The VHS is the most reproducible radiographic method for measuring the canine heart size and shows the highest agreement with echocardiography. An observer-related influence could be detected for RLAD, LAWidth, and VLAS.

Enlargement of the Left Atrium Strongly Predicts Postoperative Mortality Following Heart Valve Surgery.

Background: Enlargement of the left atrium has been thoroughly studied in many clinical situations, especially its association with mortality and morbidity. Patients and Methods: The study cohort included patients with rheumatic valve pathology such as stenosis and regurgitation. All patients underwent valvular surgical procedures including mitral valve replacement (MVR), aortic valve replacement (AVR), AVR with coronary artery bypass grafting (CABG), MVR with CABG, or AVR and MVR with or without CABG. This study included patients who underwent surgery between 2002 and 2017. Results: Three hundred and forty-six patients were included in this study. The mean patient age was 51.6±16.1 years; 37% of the patients underwent AVR, 28% underwent MVR, and 13% underwent a combination of MVR with AVR, AVR with CABG in 6%, and MVR with CABG in 10%. The operative mortality rate was 5.8% (n=20). Univariate analysis revealed that the predictors of mortality included age (P < 0.001), body mass index (BMI) (P = 0.003), type of surgery performed (P = 0.007), hypertension (P = 0.005), emergent surgeries (P = 0.018), left atrial diameter (P = 0.003), cross-clamp time greater than 90 minutes (P = 0.007), postoperative acute kidney injury (AKI) (P = 0.044), postoperative stroke (P = 0.049), and surgical site infection (P = 0.047). Multivariate analysis revealed that predictors of mortality included age (P = 0.028, AOR=10.6), BMI (P = 0.003, AOR=3.12), re-exploration (P = 0.006, AOR=8.38), length of intensive care unit stay (P ≤ 0.002, AOR=4.55), and left atrial diameter (P = 0.003, AOR=10.64). Conclusion: Enlargement of the left atrium has been studied extensively as a predictor of mortality and morbidity in different clinical situations, to the extent that some authors suggest adding it to risk stratification models. In this study, left atrial size >4 cm was found to strongly predict mortality after rheumatic heart valve surgery.

Validation of a focused echocardiographic training program in first opinion practice.

BACKGROUND: The EPIC study defines criteria, including echocardiographic assessments of left atrial to aortic ratio (LA: Ao) and left ventricular internal diameter in diastole normalized for body weight (LVIDdN), for dogs with preclinical myxomatous mitral valve disease (MMVD) likely to benefit from pimobendan therapy. Access to echocardiography by a cardiologist is not universally available. HYPOTHESIS/OBJECTIVES: Completion of a focused echocardiographic training program would result in accurate identification of dogs fulfilling the EPIC criteria by primary care veterinarians (PC). PARTICIPANTS: Six PCs with no previous echocardiographic experience. METHODS: Prospective diagnostic test accuracy study. After training, each PC evaluated ≤10 dogs that they believed to have preclinical MMVD. The evaluation was repeated by 1 of 3 cardiology diplomates, blinded to the PC's findings. Agreement between clinical assessments and echocardiographic measurements was assessed. RESULTS: Fifty-seven dogs were evaluated by PCs; 1 dog was withdrawn because of congestive heart failure. The median time between PC and cardiologist evaluation was 0 days (range, 0-8). One incorrect diagnosis of MMVD was made by a PC (this dog had dilated cardiomyopathy [DCM]); preclinical MMVD was confirmed by the cardiologist in 55 dogs. No difference in LA: Ao (P = .96; CV = 6.9%) was detected between PCs and cardiologists. LVIDdN (1.69 cm/kg0.294 (1.26-2.21) vs 1.73 cm/kg0.294 (1.32-2.73); P = .001; CV = 6.5%), was significantly lower when measured by PCs vs cardiologists. PCs and cardiologists agreed regarding assessment of EPIC criteria in 49/56 dogs (Alpha = .761, 95% confidence interval 0.697-0.922). CONCLUSIONS AND CLINICAL IMPORTANCE: The program effectively trained PCs to accurately assess EPIC criteria in dogs with preclinical MMVD.

Comparison of different radiographic scores with associated echocardiographic measurements and prediction of heart enlargement in dogs with and without myxomatous mitral valve disease.

INTRODUCTION: Staging of myxomatous mitral valve disease (MMVD) requires an echocardiographic examination along with thoracic radiographs. The aims of this study were to calculate mean values for radiographic scores vertebral heart size (VHS), left atrial width (LAWidth), radiographic left atrial dimension (RLAD), and vertebral left atrial size (VLAS) in conventional and grayscale inverted images in healthy dogs and dogs with different stages of MMVD, and to find cutoff values for a stage assignment. ANIMALS: One hundred fifty dogs in different stages of MMVD and 50 unaffected dogs were evaluated. METHODS: Radiographic scores, echocardiographic left atrium-to-aorta ratio and normalized left ventricular internal dimension at end-diastole, and results of a clinical examination were obtained. Analyses were performed to evaluate the correlation between radiographic scores and echocardiographic values, to determine cutoff values for a radiographic stage assignment, and to compare measurements in conventional and inverted radiographs. RESULTS: After excluding breed-specific higher VHS, the means of VHS, LAWidth, RLAD, and VLAS were similar in the control group and stage B1. All radiographic scores increased in stages B2 and C. The cutoff values identifying heart enlargement, and therefore differentiating stages B1 and B2, were 11.0 for VHS, 1.8 for LAWidth, 2.0 for RLAD, and 2.3 for VLAS. Besides RLAD, scores were similar in conventional and inverted radiographs. CONCLUSION: Cutoff values for the different radiographic scores for stage assignment were calculated. Radiographic cardiac scores using either conventional or inverted grayscale could be a tool to differentiate between different stages of MMVD when echocardiography is unavailable.

The Role of the Left Atrium: From Multimodality Imaging to Clinical Practice: A Review.

In recent years, new interest is growing in the left atrium (LA). LA functional analysis and measurement have an essential role in cardiac function evaluation. Left atrial size and function are key elements during the noninvasive analysis of diastolic function in several heart diseases. The LA represents a "neuroendocrine organ" with high sensitivity to the nervous, endocrine, and immune systems. New insights highlight the importance of left atrial structural, contractile, and/or electrophysiological changes, introducing the concept of "atrial cardiomyopathy", which is closely linked to underlying heart disease, arrhythmias, and conditions such as aging. The diagnostic algorithm for atrial cardiomyopathy should follow a stepwise approach, combining risk factors, clinical characteristics, and imaging. Constant advances in imaging techniques offer superb opportunities for a comprehensive evaluation of LA function, underlying specific mechanisms, and patterns of progression. In this literature review, we aim to suggest a practical, stepwise algorithm with integrative multimodality imaging and a clinical approach for LA geometry and functional analysis. This integrates diastolic flow analysis with LA remodelling by the application of traditional and new diagnostic imaging techniques in several clinical settings such as heart failure (HF), atrial fibrillation (AF), coronary artery disease (CAD), and mitral regurgitation (MR).

Left Atrial Diameter in the Prediction of Thromboembolic Event and Death in Atrial Fibrillation.

Background: This study aimed to determine the predictive value of left atrial diameter (LAD), and the incremental prognostic value of LAD in combination with CHA2DS2-VASc score for predicting thromboembolic event and all-cause death in patients with non-valvular atrial fibrillation (AF). Methods: This is a prospective study from 27 hospitals during 2014−2017. LADi is LAD data indexed by body surface area, and LADi in the 4th quartile (LADi Q4) was considered high. Results: A total of 2251 patients (mean age 67.4 years, 58.6% male) were enrolled. Mean follow-up duration was 32.3 months. Rates of thromboembolic events and all-cause death were significantly higher in LADi Q4 patients than in LADi Q1−3 patients (2.89 vs. 1.11 per 100 person-years, p < 0.001, and 7.52 vs. 3.13 per 100 person-years, p < 0.001, respectively). LADi Q4 is an independent predictor of thromboembolic events and all-cause death with an adjusted hazard ratio and 95% confidence interval of 1.94 (1.24−3.05) and 1.81 (1.38−2.37), respectively. LADi has incremental prognostic value on top of the CHA2DS2-VASc score with the increase in global chi-square for thromboembolism (p = 0.005) and all-cause death (p < 0.001). Conclusions: LADi is an independent predictor of thromboembolic event and has incremental prognostic value in combination with CHA2DS2-VASc score in AF patients.

Association of Left Atrial Size Measured by Non-Contrast Computed Tomography with Cardiovascular Risk Factors-The Danish Cardiovascular Screening Trial (DANCAVAS).

Left atrium (LA) size is associated with adverse cardiovascular events. The purpose of this study was to investigate the association of LA enlargement measured by non-contrast CT (NCCT) with traditional cardiovascular risk factors. Individuals aged 60-75 years from the population-based multicentre Danish Cardiovascular Screening (DANCAVAS) trial were included in this cross-sectional study. The LA was manually traced on the NCCT scans, and the largest cross-section area was indexed to body surface area. All traditional risk factors were recorded, and a subgroup received an echocardiographic examination. We enrolled 14,987 individuals. Participants with known cardiovascular disease or lacking measurements of LA size or body surface area were excluded, resulting in 10,902 men for the main analysis and 616 women for a sensitivity analysis. Adjusted multivariable analysis showed a significantly increased indexed LA size by increasing age and pulse pressure, while smoking, HbA1c, and total cholesterol were associated with decreased indexed LA size. The findings were confirmed in a supplementary analysis including left ventricle ejection fraction and mass. In this population-based cohort of elderly men, an association was found between age and pulse pressure and increasing LA size. Surprisingly, smoking, HbA1c, and total cholesterol were associated with a decrease in LA size. This indicates that the pathophysiology behind atrial cardiomyopathy is not only reflected by enlargement, but also shrinking.