Left atrial cross-sectional area is a novel measure of atrial shape associated with cardioembolic strokes.

OBJECTIVE: Cardioembolic (CE) stroke carries significant morbidity and mortality. Left atrial (LA) size has been associated with CE risk. We hypothesised that differential LA remodelling impacts on pathophysiological mechanism of major CE strokes. METHODS: A cohort of consecutive patients hospitalised with ischaemic stroke, classified into CE versus non-CE strokes using the Causative Classification System for Ischaemic Stroke were enrolled. LA shape and remodelling was characterised by assessing differences in maximal LA cross-sectional area (LA-CSA) in a cohort of 40 prospectively recruited patients with ischaemic stroke using three-dimensional (3D) echocardiography. Flow velocity profiles were measured in spherical versus ellipsoidal in vitro models to determine if LA shape influences flow dynamics. Two-dimensional (2D) LA-CSA was subsequently derived from standard echocardiographic views and compared with 3D LA-CSA. RESULTS: A total of 1023 patients with ischaemic stroke were included, 230 (22.5%) of them were classified as major CE. The mean age was 68±16 years, and 464 (45%) were women. The 2D calculated LA-CSA correlated strongly with the LA-CSA measured by 3D in both end-systole and end-diastole. In vitro flow models showed shape-related differences in mid-level flow velocity profiles. Increased LA-CSA was associated with major CE stroke (adjusted relative risk 1.10, 95% CI 1.04 to 1.16; p<0.001), independent of age, gender, atrial fibrillation, left ventricular ejection fraction and CHA2DS2-VASc score. Specifically, the inclusion of LA-CSA in a model with traditional risk factors for CE stroke resulted in significant improvement in model performance with the net reclassification improvement of 0.346 (95% CI 0.189 to 0.501; p=0.00001) and the integrated discrimination improvement of 0.013 (95% CI 0.003 to 0.024; p=0.0119). CONCLUSIONS: LA-CSA is a marker of adverse LA shape associated with CE stroke, reflecting importance of differential LA remodelling, not simply LA size, in the mechanism of CE risk.

Adverse impact of diabetes mellitus on left ventricular remodelling in patients with chronic primary mitral regurgitation.

BACKGROUND: Diabetes mellitus (DM) has an impact on left ventricular (LV) geometry and function, and is associated with worsening of pressure-overload LV remodelling; however, its impact on volume-overload LV remodelling is unknown. AIM: The objective of the study was to examine the association between DM and LV remodelling in patients with chronic mitral regurgitation (MR) caused by mitral valve prolapse. METHODS: During a median follow-up of 3.26 [interquartile range 1.59-6.06] years, we evaluated the evolution of echocardiographic variables in 375 consecutive patients, including 61 (16%) patients with DM. The main endpoint was LV remodelling evaluated by LV end-diastolic diameter (LVEDD) and LV mass index increase. LV end-systolic diameter (LVESD) and ejection fraction (LVEF) were also evaluated. RESULTS: Patients with DM increased their LVEDD more than patients without DM (1.98±4.1 vs 0.15±4.54mm/year of follow-up; P=0.002). LVEF remained stable in the two groups. After adjustment for potential confounders, including age, sex, hypertension, body mass index, MR severity, medications and follow-up duration, DM remained independently associated with LVEDD increase (ß=2.30; P<0.001). When comparing patients with DM with patients without DM matched for age, sex and LVEDD at baseline, DM was independently associated with increased LVEDD (ß=2.14; P=0.002), LV mass index (ß=10.7; P=0.004) and LVESD (ß=2.07; P=0.01). CONCLUSION: DM is associated with worsening of LV remodelling in patients with moderate or severe chronic MR caused by mitral valve prolapse.

Echocardiographic assessment of mitral regurgitation: general considerations.

Echocardiography is undoubtedly one of the main tools used in assessment of mitral regurgitation (MR) because it allows characterization of valvular morphology, assessment of the severity of the regurgitation, and its secondary effects. In this article we present an overview of the echocardiographic assessment of MR.

How to grade mitral regurgitation: an integrative approach.

Evaluation of mitral regurgitation (MR) severity remains complex and challenging. An integrative approach to grading MR is recommended. The use of multiple Doppler methods should be used to help discriminate between grades of severity. Importantly, MR severity should always be considered in the context of clinical data. The emerging inclusion of 3-dimensional echocardiography may provide complementary data for MR quantification and better anatomic and pathophysiological detail of the mitral valve. This article summarizes recommendations for MR assessment and highlights the importance of an integrated approach, using anatomic information as well as qualitative and quantitative Doppler measures.