Left atrial function analysis in patients with functional mitral regurgitation associated with dilated cardiomyopathy / Análise da função atrial esquerda em pacientes com insuficiência mitral funcional associada à miocardiopatia dilatada

BACKGROUND: Functional mitral regurgitation (FMR) is associated with dilated cardiomyopathy (DC), heart failure (HF), and worsening left atrial function (LAF). Patients with DC and FMR may present left atrial dysfunction resulting from both ventricular dysfunction and valve disease, but it is unknown whether the presence of valve disease will lead to greater LAF impairment. OBJECTIVE: This study aimed to evaluate the relationship between LAF parameters and FMR degree in patients with DC. METHODS: This cross-sectional observational study included 214 patients with DC, 46 without FMR (control group) and 168 with mild, moderate or severe FMR. An LAF analysis was performed by speckle tracking echocardiography (STE) and atrial volumetric variation. RESULTS: LAF analyzed by STE by means of reservoir strain, conduit strain and active contraction strain was reduced in the sample, with values of 14.3%, 8.49% and 5.92%, respectively. FMR degree was significantly associated with reservoir strain (0.27 ± 0.16 versus 0.15 ± 0.09; p < 0.001) and contraction strain (19.2 ± 7.3 versus 11.2 ± 2.7; p < 0.001). FMR was also associated with a reduced LAF assessed by volumetric analysis: total atrial emptying fraction of 0.51 ± 0.13 versus 0.34 ± 0.11 and active atrial emptying fraction of 0 .27 ± 0.16 versus 0.15 ± 0.09 (p < 0.001). CONCLUSION: In a population with DC, FMR was associated with reduced LAF assessed by STE and atrial volume variation.

FUNDAMENTO: A insuficiência mitral funcional (IMF) está associada à miocardiopatia dilatada (MD), à insuficiência cardíaca (IC) e à piora da função atrial esquerda (FAE). A FAE pode decair tanto pela disfunção ventricular quanto pela valvopatia, mas não se sabe se esta leva a um prejuízo maior da FAE. OBJETIVO: Avaliar a relação entre a piora de parâmetros de FAE com o grau de IMF, em pacientes com MD. MÉTODOS: Trata-se de estudo observacional transversal, que incluiu 214 pacientes com MD, sendo 46 sem IMF (controle) e 168 com IMF discreta, moderada ou grave. A análise da FAE foi realizada por ecocardiografia por speckle tracking (STE) e por variação volumétrica atrial. RESULTADOS: A FAE, analisada por STE­ por meio do strain de reservatório, conduto e contração ativa ­ encontrou-se reduzida na amostra, com valores respectivos de 14,3%, 8,49% e 5,92%. O grau de IMF associou-se significativamente com os valores do strain de reservatório (0,27±0,16 versus 0,15±0,09; p <0,001. CONCLUSÃO: Em uma população com MD, a presença de IMF associa-se à redução da FAE de reservatório e de contração, avaliada por STE e pela variação volumétrica atrial.

Incremental value of left atrial strain to predict atrial fibrillation recurrence after cryoballoon ablation.

OBJECTIVE: Atrial fibrillation (AF) recurrence occurs in approximately 25% of the patients undergoing cryoballoon ablation (CBA), leading to repeated ablations and complications. Left atrial (LA) dilation has been proposed as a predictor of AF recurrence. However, LA strain is a surrogate marker of LA mechanical dysfunction, which might appear before the enlargement of the LA. The purpose of this study was to evaluate the additional predictive value of LA function assessed using strain echocardiography for AF recurrence after CBA. METHODS: 172 consecutive patients (62.2 ± 12.2 years, 61% male) were prospectively analyzed. Echocardiography was performed before CBA. Blanking period was defined as the first three months post-ablation. The primary endpoint was AF recurrence after the blanking period. RESULTS: 50 (29%) patients had AF recurrence. In the overall study population, peak atrial longitudinal strain (PALS) ≤ 17% had the highest incremental predictive value for AF recurrence (HR = 9.45, 95%CI: 3.17-28.13, p < 0.001). In patients with non-dilated LA, PALS≤17% remained an independent predictor of AF recurrence (HR = 5.39, 95%CI: 1.66-17.52, p = 0.005). CONCLUSIONS: This study showed that LA function assessed by PALS provided an additional predictive value for AF recurrence after CBA, over LA enlargement. In patients with non-dilated LA, PALS also predicted AF recurrence. These findings emphasize the added value of LA strain, suggesting that it should be implemented in the systematic evaluation of AF patients before CBA.

Elevated Left and Right Atrial Pressures Long-Term After Atrial Septal Defect Correction: An Invasive Exercise Hemodynamic Study.

Background Despite correction of the atrial septal defect (ASD), patients experience atrial fibrillation frequently and have increased morbidity and mortality. We examined physical capacity, cardiac performance, and invasive hemodynamics in patients with corrected ASD. Methods and Results Thirty-eight corrected patients with isolated secundum ASD and 19 age-matched healthy controls underwent right heart catheterization at rest and during exercise with simultaneous expired gas assessment and echocardiography. Maximum oxygen uptake was comparable between groups (ASD 32.7±7.7 mL O2/kg per minute, controls 35.2±7.5 mL O2/kg per minute, P=0.3), as was cardiac index at both rest and peak exercise. In contrast, pulmonary artery wedge v wave pressures were increased at rest and peak exercise (rest: ASD 14±4 mm Hg, controls 10±5 mm Hg, P=0.01; peak: ASD 25±9 mm Hg, controls 14±9 mm Hg, P=0.0001). The right atrial v wave pressures were increased at rest but not at peak exercise. The transmural filling pressure gradient (TMFP) was higher at peak exercise among patients with ASD (10±6 mm Hg, controls 7±3 mm Hg, P=0.03). One third of patients with ASD demonstrated an abnormal hemodynamic exercise response defined as mean pulmonary artery wedge pressure ≥25 mm Hg and/or mean pulmonary artery pressure ≥35 mm Hg at peak exercise. These patients had significantly elevated peak right and left atrial a wave pressures, right atrial v wave pressures, pulmonary artery wedge v wave pressures, and transmural filling pressure compared with both controls and patients with ASD with a normal exercise response. Conclusions Patients with corrected ASD present with elevated right and in particular left atrial pressures at rest and during exercise despite preserved peak exercise capacity. Abnormal atrial compliance and systolic atrial function could predispose to the increased long-term risk of atrial fibrillation. Registration Information clinicaltrials.gov. Identifier: NCT03565471.

Left atrial compression by a large hiatal hernia: A rare cause of cardiac dysfunction.

Symptomatic hiatal hernia (HH) is most often revealed by gastroesophageal reflux disease, but there are atypical presentations some of which are life-threatening. We report the case of a 57-year-old woman brought to the emergency department with isolated shortness of breath for 24 h. Initial explorations revealed unexplained hyperlactatemia (6.4 mmol/L) without clinical or biological evidence of hypovolemia, distributive, obstructive or cardiogenic shock. Two hours after admission, we observed a decreased of blood pressure and an increase of lactate level to 7.9 mmol/L. A bedside echocardiography revealed an extra-cardiac left atrial compression and thoracoabdominal computed tomography showed a large sliding HH compressing the left atrium. After an upper gastrointestinal endoscopy permitting the aspiration of gastric contents, a repair surgery was performed without complications and patient was discharge three days later. Emergency physicians should be aware that HH can be a rare cause of cardiac symptoms by heart compression and certainly use echocardiography for unexplained hemodynamic failure.

Characteristics of left atrial remodeling in patients with atrial fibrillation and hypertrophic cardiomyopathy in comparison to patients without hypertrophy.

Atrial fibrillation (AF) leads to remodeling characterized by changes in both size and shape of the left atrium (LA). Here we aimed to study the effect of hypertrophic cardiomyopathy (HCM) on the pattern of LA remodeling in AF-patients. HCM-patients (n = 23) undergoing AF ablation (2009-2012) were matched and compared with 125 Non-HCM patients from our prospective registry. Pre-procedural CT data were analyzed (EnSite Verismo, SJM, MN) to determine the maximal sagittal (anterior-posterior, AP), coronal (superior-inferior, SI and transversal, TV) dimensions and the sphericity index (LAS). Volume (LAV) was rendered after appendage (LAA) and pulmonary vein (PV) exclusion. A cutting plane, between PV ostia/LAA and parallel to the posterior wall, divided LAV into anterior- (LA-A) and posterior-LA (LA-P) parts. The ratio LA-A/LAV was defined as asymmetry index (ASI). HCM patients had a wider inter-ventricular septum and a smaller LV than Non-HCM patients. LA volume (LAV 166 ± 72 vs. 130 ± 36 ml, p = 0.03) and LA diameters were significantly larger in HCM patients. Anterior volume (LA-A: 112 ± 48 vs. 83 ± 26 ml, p < 0.001) differed significantly between groups, whereas the posterior volume LA-P (55 ± 28 vs. 47 ± 13 ml, p = 0.23) and LAS (75% vs. 78%, p = 0.089) was similar in both groups. As a result, ASI was significantly higher (67 ± 6 vs. 63 ± 6%, p = 0.01) in HCM than in Non-HCM patients. In conclusion, LA remodeling in patients with AF and HCM is characterized by asymmetric dilatation, driven by an anterior rather than a posterior dilatation. This can be characterized by three-dimensional imaging and could be used as surrogate of advanced atrial remodeling.

Discrepancy between CARTO and Rhythmia maps for defining the left atrial low-voltage areas in atrial fibrillation ablation.

Reported mapping procedures of left atrial (LA) low-voltage areas (LVAs) vary widely. This study aimed to compare the PentaRay®/CARTO®3 (PentaRay map) and Orion™/Rhythmia™ (Orion map) systems for LA voltage mapping. This study included 15 patients who underwent successful pulmonary vein isolation (PVI) for atrial fibrillation. After PVI, PentaRay and Orion maps created for all patients were compared. LVAs were defined as sites with ≥ 3 adjacent low-voltage points < 0.5 mV. LVAs were indicated in 8 (53%) among 15 patients, and the average values of the measured LVAs was comparable between the systems (PentaRay map = 5.4 ± 8.7 cm2; Orion map = 4.3 ± 6.4 cm2, p = 0.69). However, in 2 of 8 patients with LVAs, the Orion map indicated LVAs at the septum and posterolateral sites of the LA, respectively, whereas the PentaRay map indicated no LVAs. In those patients, sharp electrograms of > 0.5 mV were properly recorded at the septum and posterolateral sites during appropriate beats in the PentaRay map. The PentaRay map had a shorter procedure time than the Orion map (12 ± 3 min vs. 23 ± 8 min, respectively; p < 0.01). Our study results showed a discrepancy in the LVA evaluation between the PentaRay and Orion maps. In 2 of 15 patients, the Orion map indicated LVAs at the sites where > 0.5-mV electrograms were properly recorded in the PentaRay map.

The effect of left atrial remodeling after cryoballoon ablation and radiofrequency ablation for paroxysmal atrial fibrillation.

BACKGROUND: Cryoballoon ablation (CBA) and radiofrequency ablation (RFA) are the most common procedures used to treat refractory atrial fibrillation (AF) and are performed through pulmonary vein isolation (PVI). Studies have shown that CBA can approximately match the therapeutic effects of RFA against AF. However, few studies have investigated the difference between CBA and RFA of the effects on left atrial remodeling for paroxysmal AF. OBJECTIVE: Atrial remodeling is considered pivotal to the occurrence and development of AF, therefore we sought to assess the influence of atrial remodeling in patients with paroxysmal AF after CBA and RFA in this study. METHODS: In this nonrandomized retrospective observational study, we enrolled 328 consecutive patients who underwent CBA or RFA for refractory paroxysmal AF in May 2014 to May 2017 in our hospital. After propensity score matching, 96 patients were included in the CBA group, and 96 were included in the RFA group. Patients were asked to undergo a 12-lead electrocardiogram, a 24-h Holter monitor, and an echocardiogram and to provide their clinical history and symptoms at 6 months and 1, 2, and 3 years postprocedurally. Electrical remodeling of the left atrium was assessed by P wave dispersion (Pdis); structural remodeling was assessed by the left atrium diameter (LAD) and left atrial volume index (LAVI) during scheduled visits. RESULTS: As of January 2020, compared with baseline, at 1 year, 2 years, and 3 years after ablation, the average changes in Pdis (∆Pdis), LAD (∆LAD), and LAVI (∆LAVI) were significant in both the CBA and RFA groups. Six months after ablation, ∆Pdis, ∆LAD, and ∆LAVI were greater in the CBA group than in the RFA group. There was no significant difference between the two groups in AF/flutter recurrence, but the AF/flutter-free survival time of CBA group may be longer than RFA group after 2 years after ablation. A higher ∆Pdis, ∆LAD, or ∆LAVI at 1 year after ablation may increase AF/flutter-free survival. CONCLUSIONS: Although CBA and RFA are both effective in left atrial electrical and structural reverse-remodeling in paroxysmal AF, CBA may outperform RFA for both purposes 6 months after ablation. However, during long-term follow-up, there was no significant intergroup difference.

Variation of Left Atrial Function in Different Stages of Mitral Regurgitation and Its Association With Guidelines-Based Surgical Indication.

PURPOSE: The current guidelines associate indications for surgery in mitral regurgitation (MR) with left ventricle size and function. However, there is not enough emphasis in current guidelines on left atrial function, which is thought to be an important factor predicting adverse outcomes in MR. The aim of this study was to investigate the left atrial function at different stages of mitral regurgitation and its value in predicting the indications of mitral valve surgery. METHODS: This was a retrospective study with 163 consecutive chronic primary MR patients who underwent color doppler echocardiography at the Guangxi Zhuang Autonomous Region Second People's Hospital between January 2016 and June 2018. All patients were in sinus rhythm, classified into three groups, according the degree of mitral regurgitation. Comparison was made with 30 control patients. Using Simpson's methods, we recorded maximal left atrial volume, left atrial volume before active contraction and minimal left atrial volume, from which left atrial expansion index, left atrial passive emptying fraction, left atrial active emptying fraction, and the total left atrial emptying fraction were derived. RESULTS: Left atrial volume was expanded and left atrial emptying fraction was reduced in the mitral regurgitation group. By multivariate analysis, left atrial passive emptying fraction and left atrial active emptying fraction were independent predictors of mitral regurgitation requiring surgery. Using receiver-operating characteristic analysis, left atrial passive emptying fraction <97.4% demonstrated 98% sensitivity and 67% specificity for predicting the presence of surgical indication (area under the curve: 0.91; P < .001). CONCLUSION: During mitral regurgitation, left atrial volume increases and functions decrease. The left atrial passive emptying fraction can be used as an additional tool to predict the indications of mitral valve surgery.

Volumétrico ecocardiográfico de cuatro dimensiones y Evaluación Funcional de la Aurícula Izquierda en Sujetos masculinos sanos en relación con la edad / Four-Dimensional Echocardiographic Volumetric and Functional Assessment of the Left Atrium in Healthy Male Subjects in Relation to Age

Background: Four-dimensional echocardiography technique results in marked improvements in terms of quality and accuracy in assessing the size and function of heart chambers, especially the left atrium as its geometric variation has a notable impact on the results when using traditional echocardiographic techniques alone. Thus, this study aimed at investigating the probability of significant functional and morphological changes in the left atrium with advancing age using Four-dimension echocardiography. Method: Four-dimensional technique derived left atrial phasic volumes and functions were assessed in (30) healthy subjects with mean age of 73.6 (±3.6) years and (30) young subjects with mean age of 23.17 (±3.5) years. Results: Old age group showed a significant increase in maximum left atrial volume index, minimum left atrial volume index and pre-atrial contraction left atrial volume index compared to young age group (31.52±1.09 vs. 26.44±1.03, P < 0.001), (17.93±0.43 vs. 15.89±0.44, P < 0.00) and (25.73±1.003 vs. 22.34±0.77, P < 0.01), respectively. In the old age group, the passive left atrial emptying function (LAEF) significantly decreased (20.43±0.25% vs. 24.96±0.93%, p<0.00), while the active LAEF significantly increased (37.36±1.33% vs. 32.65±1.13%, P< 0.009) in comparison to the values of the young subjects. Conclusions: These results suggest that left atrial structural as well as functional changes occur with advancing age in absence of evident pathological causes and 4-dimentional echocardiography can be used to evaluate these changes

Left Atrial Mechanical Function Predicts Postoperative AF in Patients with Rheumatic Mitral Valve Disease Who Underwent Mitral Valve Surgery.

OBJECTIVE: Postoperative atrial fibrillation (PoAF) is a common complication after surgical mitral valve replacement. Late PoAF is independently associated with long-term mortality. This study aimed to test the utility of preoperative left atrial mechanical function as a predictor of early and late PoAF in clinical practice. METHODS: Patients (N = 150) with a rheumatic mitral valve who underwent mitral valve replacement with or without tricuspid valvuloplasty and who were in stable sinus rhythm were included. Baseline characteristics and transthoracic echocardiographic assessment information on the day before surgery were collected. Em, Em´, and Ei´ indicate early diastolic peak velocity of the mitral valve, early diastolic velocity at the lateral wall of the mitral annulus, and early diastolic velocity at the interventricular septal annulus, respectively. RESULTS: Early PoAF was present in 59 of 150 patients (39.3%), and 32 of 150 patients (21.3%) developed late PoAF within 1 year after surgery. Among all of the variables examined, age, diabetes, early mitral filling velocity (Mitral E), left atrial mechanical function (Mitral A), Em/Em´, Em/Ei´, and mitral transvalvular gradient showed a significant correlation with PoAF. Only age, Mitral A, and mitral transvalvular gradient showed strong, significant correlations with the occurrence of late PoAF. In a multivariate analysis, predictors of late PoAF recurrence included early PoAF and Mitral A. CONCLUSION: Routine evaluation of Mitral A is feasible and useful to predict early and late PoAF in patients with a rheumatic mitral valve undergoing surgical mitral valve replacement.

Left atrial structure and function predictors of recurrent fibrillation after catheter ablation: a systematic review and meta-analysis.

BACKGROUND: Catheter ablation (CA) has become a conventional treatment for atrial fibrillation (AF), but remains with high recurrence rate. The aim of this meta-analysis was to determine left atrial (LA) structure and function indices that predict recurrence of AF. METHODS: We systematically searched PubMed-Medline, EMBASE, Scopus, Google Scholar and the Cochrane Central Registry, up to September 2017 in order to select clinical trials and observational studies which reported echocardiographic predictors of AF recurrence after CA. Eighty-five articles with a total of 16 126 patients were finally included. RESULTS: The pooled analysis showed that after a follow-up period of 21 ± 12 months, patients with AF recurrence had larger LA diameter with weighted mean difference (WMD: 2·99 ([95% CI 2·50-3·47], P<0·001), larger LA volume index (LAVI) maximal and LAVI minimal (P<0·0001 for both), larger LA area (P<0·0001), lower LA strain (P<0·0001) and lower LA total emptying fraction (LA EF) (P<0·0001) compared with those without AF recurrence. The most powerful LA predictors (in accuracy order) of AF recurrence were as follows: LA strain <19% (OR: 3·1[95% CI, -1.3-10·4], P<0·0001), followed by LA diameter ≥50 mm (OR: 2·75, [95% CI 1·66-4·56,] P<0·0001), and LAVmax >150 ml (OR: 2·25, [95% CI, 1.1-5·6], P = 0·0002). CONCLUSIONS: Based on this meta-analysis results, a dilated left atrium with diameter more than 50 mm and volume above 150 ml or myocardial strain below 19% reflect an unstable LA that is unlikely to hold sinus rhythm after catheter ablation for atrial fibrillation.

Relationship between Cardiac Remodeling and Exercise Capacity in Elite Athletes: Incremental Value of Left Atrial Morphology and Function Assessed by Three-Dimensional Echocardiography.

BACKGROUND: Data are scarce regarding left atrial (LA) adaptation to regular physical exercise. The aim of this study was to examine left ventricular (LV) and also LA morphologic and functional remodeling in elite athletes using three-dimensional (3D) echocardiography. METHODS: In this retrospective analysis, the study group consisted of 138 elite athletes (mean age, 20 ± 4 years; 62% men) and 50 sedentary control subjects. Electrocardiographically gated full-volume 3D data sets were obtained for offline analysis using dedicated software for 3D LA and LV measurements. Body surface area-indexed LA maximal volume (LAVmax) and LV end-diastolic volume were determined. LA total emptying fraction, LA passive and LA active emptying fraction, and LV global longitudinal strain were also calculated. Athletes also underwent cardiopulmonary exercise testing to determine peak oxygen uptake. RESULTS: Athletes demonstrated higher 3D LAVmax (32 ± 6 vs 26 ± 8 mL/m2) and indexed LV end-diastolic volume (85 ± 12 vs 62 ± 10 mL/m2) compared with control subjects (P < .001 for both). Functional measures of the left ventricle and left atrium, such as the absolute value of 3D LV global longitudinal strain (19 ± 2% vs 22 ± 2%), LA total emptying fraction (58 ± 6% vs 64 ± 6%), and active emptying fraction (24 ± 10% vs 32 ± 10%) were lower in athletes (P < .001 for all). Male athletes had higher indexed LV end-diastolic volume compared with female athletes (89 ± 13 vs 80 ± 8 mL/m2, P < .001), but LAVmax did not differ between genders (32 ± 6 vs 33 ± 5 mL/m2, P = .18). Besides heart rate, gender, and body surface area, 3D LAVmax, LV global longitudinal strain, and LA passive emptying fraction were independent predictors of peak oxygen uptake. CONCLUSIONS: Regular physical exercise results in marked LA and LV remodeling with considerable gender differences as explored by 3D echocardiography. In contrast with various cardiovascular diseases, more pronounced LA dilation and lower resting functional measures are associated with better exercise performance.

Preoperative left atrial volume index is associated with postoperative outcomes in mitral valve repair for chronic mitral regurgitation.

OBJECTIVE: To assess determinants of left atrial reverse remodeling after mitral valve repair and to evaluate the impact of preoperative left atrial volume on postoperative outcomes. METHODS: We reviewed the records of 720 patients who underwent mitral valve repair from September 2008 to July 2015 and had preoperative measurement of left atrial volume index. We analyzed the association of preoperative left atrial volume index on early and late outcomes, and determined which baseline characteristics are associated with left atrial reverse remodeling, as measured by changes in left atrial volume index in 512 patients who had at least 1 postoperative measurement. RESULTS: The median (interquartile range) preoperative left atrial volume index was 54.0 (44.0-66.0) mL/m2. Preoperative left atrial volume index, age, body mass index, and atrial fibrillation were independently associated with the degree of left atrial reverse remodeling over the follow-up period. Reverse remodeling was greatest in patients with higher baseline left atrial volume index (P < .001), but less reverse remodeling was observed in patients with advanced age (P < .001), preoperative atrial fibrillation (P < .001), and extreme values of body mass index (P = .004), although these effects were moderately attenuated when limiting the analysis to 6-month follow-up. Secondary analysis demonstrated marginally significant effects of preoperative left atrial volume index on risks of early postoperative atrial fibrillation (P = .030) and late mortality (P = .077) after adjusting for age and sex. CONCLUSIONS: In patients with degenerative mitral valve regurgitation who had mitral valve repair, preoperative left atrial volume index was associated with extent of left atrial reverse remodeling, risk of early postoperative atrial fibrillation, and late mortality. The majority of reverse remodeling occurs within the first month after operation and is greatest in younger patients.

LEFT ATRIAL FUNCTION AND VOLUME BY MAGNETIC RESONANCE IN PATIENTS WITH HEREDITARY AMYLOIDOSIS.

BACKGROUND: Left atrial (LA) enlargement is a reliable predictor of adverse cardiovascular events, and reduced atrial function is an independent risk factor for mortality in patients with amyloidosis. The objective of this study was to characterize the LA function in Mexican patients with a confirmed diagnosis of hereditary transthyretin amyloidosis (amyloid transthyretin [ATTR]). METHODS: All consecutive patients with diagnosis of hereditary ATTR who underwent a cardiac magnetic resonance study in the period from March 2016 to June 2017 were included in the study; the volumes and function of the left atrium were evaluated. RESULTS: Patients were divided into two groups, one with and one without cardiac amyloidosis. Statistically significant differences were observed between both groups in terms of indexed maximal LA volume, 26 mL versus 35.9mL, p = 0.03; indexed minimal LA volume, 10.7 mL versus 13.6mL, p = 0.03; and indexed LA pre-contraction volume, 17 mL versus 22.4mL, p = 0.03. No statistically significant differences were observed between both groups when comparing neither different ejection volumes nor the different ejection fractions. CONCLUSIONS: Patients with hereditary ATTR with cardiac involvement have remodeling of the left atrium, with increased atrial volumes, without diminishing its function.

Left atrial function and volume by magnetic resonance in patients with hereditary amyloidosis

ABSTRACT Background Left atrial (LA) enlargement is a reliable predictor of adverse cardiovascular events, and reduced atrial function is an independent risk factor for mortality in patients with amyloidosis. The objective of this study was to characterize the LA function in Mexican patients with a confirmed diagnosis of hereditary transthyretin amyloidosis (amyloid transthyretin [ATTR]) Methods All consecutive patients with diagnosis of hereditary ATTR who underwent a cardiac magnetic resonance study in the period from March 2016 to June 2017 were included in the study; the volumes and function of the left atrium were evaluated Results Patients were divided into two groups, one with and one without cardiac amyloidosis. Statistically significant differences were observed between both groups in terms of indexed maximal LA volume, 26 mL versus 35.9mL, p = 0.03; indexed minimal LA volume, 10.7 mL versus 13.6mL, p = 0.03; and indexed LA pre-contraction volume, 17 mL versus 22.4mL, p = 0.03. No statistically significant differences were observed between both groups when comparing neither different ejection volumes nor the different ejection fractions Conclusions Patients with hereditary ATTR with cardiac involvement have remodeling of the left atrium, with increased atrial volumes, without diminishing its function.

The role of the left atrial function in the surgical management of aortic and mitral valve disease.

The right management of both mitral and aortic disease can be challenging, especially in asymptomatic patients. The current guidelines recommend valve repair or replacement when symptoms arise or when there is an evident left ventricular dysfunction. However, deciding the optimal surgical timing can be very difficult, since the line between the absence of symptoms and being minimally symptomatic, especially in the elderly, is blurred. Another relevant issue regards the second surgical criterion: operating on a patient with a reduced left ventricular ejection fraction or with a dilated left ventricle might jeopardize the possibility of a fully reverse remodeling of the heart after surgery. In this scenario, the left atrium might play an important role. In particular, left atrial deformation might be a very useful tool to detect early ultrastructural alterations, and help or support guiding a patient-tailored treatment at an early stage, optimizing the outcome in the long term.

Left Atrial Stiffness: A Predictor of Atrial Fibrillation Recurrence after Radiofrequency Catheter Ablation - A Systematic Review and Meta-Analysis / Rigidez do Átrio Esquerdo: Preditor de Recorrência de Fibrilação Atrial após Ablação por Cateter de Radiofrequência - Revisão Sistemática e Metanálise

Abstract Background: Radiofrequency 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. Objective: To 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. Methods: The 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. Results: All 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). Conclusion: A 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.

Resumo Fundamento: A ablação por cateter de radiofrequência (ACRF) é um procedimento padrão para pacientes com fibrilação atrial (FA) não responsivos a tratamentos prévios, que tem sido cada vez mais considerada como terapia de primeira linha. Nesse contexto, o screening para fatores de risco perioperatório tornou-se importante. Um estudo prévio mostrou que uma pressão do átrio esquerdo (AE) elevada está associada a recorrência de FA após a ablação, podendo ser secundária a um AE rígido. Objetivo: Investigar, por meio de revisão sistemática e metanálise, se a rigidez do AE é um preditor de recorrência de FA após ACRF, e discutir seu uso na prática clínica. Métodos: A metanálise foi realizada seguindo-se as recomendações do MOOSE. A busca foi realizada nas bases de dados MEDLINE e Cochrane Central Register of Controlled Trials, até março de 2018. Dois autores realizaram triagem, extração de dados e avaliação da qualidade dos estudos. Resultados: Todos os estudos obtiveram boa qualidade. Um gráfico de funil foi construído, não identificando viés de publicação. Quatro estudos prospectivos observacionais foram incluídos na revisão sistemática e 3 deles na metanálise. Foi adotado o nível de significância estatística de p < 0,05. Rigidez do AE foi um forte preditor independente da recorrência de FA após ACRF (HR = 3,55, IC 95% 1,75-4,73, p = 0,0002). Conclusão: A avaliação não invasiva da rigidez do AE antes da ablação pode ser utilizada como um potencial fator de rastreamento para a seleção ou acompanhamento de pacientes com maiores riscos de recorrência de FA e desenvolvimento da síndrome do AE rígido.