Left atrial strain: A memory of the severity of atrial myocardial stress in atrial fibrillation.

BACKGROUND: Left atrial (LA) strain is a simple marker of LA function. The aim of the study was to evaluate the determinants of atrial cardiomyopathy in AF. METHODS: In this pilot study, we prospectively evaluated clinical, biological, metabolomic and echocardiographic parameters for 85 consecutive patients hospitalized for atrial fibrillation (AF) with restoration of sinus rhythm at 6 months. Eighty-one patients with an analysable LA strain at 6 months were divided into groups according to median reservoir strain:<23.3% (n=40) versus≥23.3% (n=41). RESULTS: Compared to patients with the highest LA strain, patients with lowest LA strain had multiple differences at admission: clinical (older age; more frequent history of AF; more patterns of persistent AF); biological (higher fasting blood glucose levels, glycated haemoglobin, high-sensitivity C-reactive protein, and urea; lower glomerular filtration rate); metabolomic (higher levels of kynurenine, kynurenine/tryptophan, and urea/creatinine; lower levels of arginine and methionine/methionine sulfoxide); and echocardiographic (higher two-dimensional end-systolic LA volume [LAV] indexes; higher three-dimensional end-systolic and end-diastolic LAV and right atrial volume indexes; lower LA and right atrial emptying fractions and three-dimensional right ventricular ejection fraction) (all P<0.05). Area under the receiver operating characteristic curve to predict LA strain alteration at 6 months was highest for a combined score including clinical, biological, metabolomic and echocardiographic variables at admission (area under the receiver operating characteristic curve 0.871; P<0.0001). CONCLUSIONS: LA reservoir strain could be a memory of initial atrial myocardial stress in AF. It can be predicted using a combination of clinical, biological, metabolomic and echocardiographic admission variables.

Restoring Sinus Rhythm Reverses Cardiac Remodeling and Reduces Valvular Regurgitation in Patients With Atrial Fibrillation.

BACKGROUND: Cardiac chamber remodeling in atrial fibrillation (AF) reflects the progression of cardiac rhythm and may affect functional regurgitation. OBJECTIVES: The purpose of this study was to explore the 3-dimensional echocardiographic variables of cardiac cavity remodeling and the impact on functional regurgitation in patients with AF with/without sinus rhythm restoration at 12 months. METHODS: A total of 117 consecutive patients hospitalized for AF were examined using serial 3-dimensional transthoracic echocardiography at admission, at 6 months, and at 12 months (337 examinations). RESULTS: During follow-up, 47 patients with active restoration of sinus rhythm (SR) (through cardioversion and/or ablation) had a decrease in all atrial indexed volumes (Vi), end-systolic (ES) right ventricular (RV) Vi, an increase in end-diastolic (ED) left ventricular Vi, and an improvement in 4-chambers function (P < 0.05). Patients with absence/failure of restoration of SR (n = 39) had an increase in ED left atrial Vi and ED/ES RV Vi without modification of 4-chambers function, except for a decrease in left atrial emptying fraction (P < 0.05). Patients with spontaneous restoration of SR (n = 31) had no changes in Vi or function. The authors found an improvement vs baseline in severity of functional regurgitation in patients with active restoration of SR (tricuspid and mitral regurgitation) and in spontaneous restoration of SR (tricuspid regurgitation) (P < 0.05). In multivariable analysis, right atrial and/or left atrial reverse remodeling exclusively correlated with intervention (cardioversion and/or ablation) during 12-month follow-up. CONCLUSIONS: Management of AF should focus on restoration of SR to induce anatomical (all atrial Vi, ES RV Vi) and/or functional (4 chambers) cardiac cavity reverse remodeling and reduce severity of functional regurgitation. (Thromboembolic and Bleeding Risk Stratification in Patients With Non-valvular Atrial Fibrillation [FASTRHAC]; NCT02741349).

Does layer-specific strain using speckle tracking echocardiography improve the assessment of left ventricular myocardial deformation? A review.

An increasing number of studies of left ventricular myocardial deformation have been published. Layer-specific strain using speckle tracking echocardiography to evaluate left ventricular function is not recommended in clinical practice. However, evaluation of myocardial mechanics using longitudinal and circumferential layer-specific strain enables the detection of subclinical impairment of myocardial deformation in various diseases. Unfortunately, normal values for longitudinal and circumferential strain have not been clearly defined. In normal subjects, layer-specific strain decreases from the endocardial to the epicardial layer, and from the apex to the base of the left ventricle. Although various studies have tried to define normal values for each layer in healthy subjects, studies with more subjects are needed. This tool has good reproducibility in terms of intraobserver and interobserver variability, but, as with monolayer strain, it has poor intervendor variability. Efforts that aim for standardization between vendors will be required before widespread use of this technique can be advocated.

[Cardiovascular imaging in heart failure]. / L'imagerie cardiovasculaire dans l'insuffisance cardiaque.

Transthoracic echocardiography remains the first-line cardiac imaging for diagnosis, management and screening of heart failure, whatever its phenotype (heart failure with reduced, mid-range and preserved ejection fraction). It allows anatomic characterization, systolic and diastolic functions of left and right ventricles assessment, intracardiac hemodynamic evaluation and for the assessment of valve disease. Myocardial deformation imaging (strain) is indicated in patients with heart failure for the assessment of systolic ventricles function and the diagnosis of specific heart diseases. Strain is indicated for the screening of preclinical myocardial dysfunction in patients at risk or exposed to cardiotoxic treatment. Altered global longitudinal strain is associated with a poor prognosis in heart failure. Cardiac magnetic resonance is recommended for the assessment of myocardial structure and function in subjects with poor acoustic window and patients with complex congenital heart diseases, in order to distinguish between ischemic and non-ischemic myocardial damage in patients with dilated cardiopathy and to characterize myocardial tissue in case of suspected specific heart disease.

Biatrial remodelling in atrial fibrillation: A three-dimensional and strain echocardiography insight.

BACKGROUND: Atrial remodelling has been poorly investigated in atrial fibrillation (AF), and few studies have focused on biatrial remodelling. AIM: To evaluate right atrial (RA) and left atrial (LA) remodelling in AF using global atrial reservoir strain and three-dimensional (3D) atrial volumes, according to rhythm outcome at mid-term follow-up. METHODS: Two-dimensional and 3D transthoracic echocardiography (TTE) were performed within 24hours after admission (M0) and at 6-month follow-up (M6) in patients admitted for AF. RA and LA variables were assessed: body surface area-indexed maximum 3D volume (Max 3D RA Voli, Max 3D LA Voli) and minimum 3D volume (Min 3D RA Voli, Min 3D LA Voli); atrial emptying fraction (3D RAEF, 3D LAEF); atrial expansion index (3D RAEI, 3D LAEI); and global RA and LA reservoir strain. RESULTS: Forty-eight consecutive patients were included prospectively. Three groups were identified depending on rhythm at M0 and M6: AF at M0 and sinus rhythm (SR) at M6 (AF-SR) in 25 (52.1%) patients; AF at M0 and AF at M6 (AF-AF) in 13 (27.1%) patients; and SR at M0 (spontaneous cardioversion before first TTE) and SR at M6 (SR-SR) in 10 (20.8%) patients. Between M0 and M6 in the AF-SR group, we found: significant decreases in Max 3D RA Voli (P=0.020), Min 3D RA Voli (P=0.0008), Max 3D LA Voli (P=0.001) and Min 3D LA Voli (P=0.0021); significant increases in 3D RAEF (P=0.037) and 3D RAEI (P=0.034); no significant differences in 3D LAEF and 3D LAEI; and significant increases in global RA and LA reservoir strain (both P<0.0001). There was no significant difference with regard to these variables in the AF-AF and SR-SR groups. CONCLUSION: 3D volume and strain analyses were useful in the evaluation of RA and LA reverse remodelling in successfully cardioverted patients with AF.

Is von Willebrand factor associated with stroke and death at mid-term in patients with non-valvular atrial fibrillation?

BACKGROUND: Heart failure and atrial fibrillation share common mechanisms that may contribute to hypercoagulability and thrombotic risk. Elevated von Willebrand factor (vWF) concentration has been associated with increased risk of thromboembolism and cardiovascular events. AIM: To investigate whether increased vWF plasma concentration predicts occurrence of a composite endpoint (all-cause death and stroke) in patients with non-valvular atrial fibrillation (NVAF). METHODS: We prospectively studied 122 patients (mean age 70±14years; 46% men) hospitalized with NVAF, and followed over a median (interquartile range) of 5.4 (2.3-9.0)years. Cox proportional models were used to estimate the association of vWF concentration with time to stroke and death. RESULTS: Forty-three patients (35%) had at least a stroke or died during the 5-year follow-up. Kaplan-Meier curves using vWF plasma concentration tertiles (≤191IU/dL;>191 to≤295IU/dL;>295IU/dL) showed that vWF plasma concentrations discriminated groups of patients with higher cardiovascular event rates (log-rank P=0.01). In the multivariable analysis, higher vWF concentrations (middle tertile hazard ratio [HR] 4.59, 95% confidence interval [CI] 1.55-13.50 [P=0.006]; upper tertile HR 4.10, 95% CI 1.43-11.75 [P=0.009]), age≥75years (HR 5.02, 95% CI 1.53-16.49; P=0.008), heart failure (HR 2.05, 1.01-4.19; P=0.048), C-reactive protein, log2 per unit increase (HR 1.29, 95% CI 1.04-1.61; P=0.021), no warfarin at discharge (HR 4.96, 95% CI 2.02-12.20; P<0.0001) and no aspirin at discharge (HR 4.41, 95% CI 1.71-11.97; P=0.002) were independently associated with an increased risk of stroke and all-cause death, whereas female sex was a protective factor (HR 0.35, 0.16-0.78; P=0.01). CONCLUSIONS: High vWF plasma concentrations may discriminate patients with NVAF at greater risk of stroke or all-cause death.

Multilayer global longitudinal strain in patients with cancer: A comparison of two vendors.

BACKGROUND: Global longitudinal strain (GLS) has several sources of variation. Strain multilayer tracking is a new tool that has not yet been validated in clinical practice. AIM: The purpose of this study was to investigate intervendor variability when measuring multilayer strain in patients receiving chemotherapy for cancer. METHODS: Patients receiving chemotherapy for cancer, who were referred for echocardiography, were included prospectively. First, the same operator performed two-dimensional echocardiography on each patient using the Vivid E9™ (General Electric, Fairfield, CT, USA) and the ACUSON SC2000™ (Siemens, Munich, Germany) ultrasound systems. Second, we assessed myocardial deformation by using their respective speckle-tracking software. Third, we compared absolute values of GLS for the two vendors in each apical view (four-, three- and two-chamber) and for each layer (endocardial, mid-myocardial and epicardial). RESULTS: Eighty patients with cancer were included prospectively between February and June 2015. For a given vendor, GLS values decreased from the endocardial layer to the epicardial layer. For a given view, GLS values obtained with the ACUSON SC2000 platform were systematically lower than those obtained with the Vivid E9 platform (P<0.0001). We observed a significant difference between the two platforms, irrespective of the layer, interlayer gradient or chamber view considered (P<0.0001). CONCLUSIONS: There was poor agreement for layer-specific strain evaluation between the Vivid E9 and ACUSON SC2000 platforms, using their dedicated software for strain multilayer assessment. These results suggest that, in clinical practice, the same system and software from the same vendor should be used for longitudinal follow-up.

[Early detection of cancer therapeutics-related cardiac dysfunction]. / Stratégie de dépistage précoce de la toxicité cardiaque secondaire aux anthracyclines et thérapies moléculaires ciblées.

Anthracyclines and molecular targeted agents have improved prognosis of patients undergoing chemotherapeutics for malignancy. However, the use of these therapies is limited because of risk of cardiac toxicity. The severity of the cardiomyopathy can range from an asymptomatic left ventricular (LV) dysfunction to a severe congestive heart failure. Cardiomyopathy can be reversible or irreversible according to the type of chemotherapy, modality of administration and patient's characteristics. Several studies aimed to early detection and the evaluation of tools to characterize patients at risk to develop cardiac side effects in order to prevent severe LV dysfunction. According to this literature, it is recommended that initial assessment and follow-up of patients undergoing these chemotherapies be performed using troponin dosage, assessment of left ventricle ejection fraction and evaluation of LV myocardial deformation assessing LV global longitudinal strain.