Amiodarone is associated with adverse outcomes in patients with sustained ventricular arrhythmias upgraded to cardiac resynchronization therapy-defibrillators.

INTRODUCTION: Amiodarone reduces recurrent ventricular tachyarrhythmias (VTA) but may worsen cardiovascular outcomes in heart failure (HF) patients. Cardiac resynchronization therapy (CRT) may also be antiarrhythmic. When patients with prior sustained VTA are upgraded to CRT defibrillators (CRT-D) from conventional implantable cardioverter-defibrillators (ICDs), should concomitant amiodarone be continued or is CRT's antiarrhythmic potential sufficient? METHODS AND RESULTS: We identified 67 patients from a prospective CRT registry with spontaneous sustained VTA, New York Heart Association (NYHA) II-IV HF, and left bundle-branch block (LBBB) who were upgraded to CRT defibrillators from conventional ICDs. We compared changes in QRS duration and left ventricular ejection fraction (LVEF) pre- and post-CRT, time to death, transplant or ventricular assist device (VAD), and time to recurrent VTA therapies between 37 patients continuing amiodarone therapy and 30 amiodarone-naïve patients. Amiodarone-treated patients had worse renal function and a higher prevalence of prior VTA storm compared with amiodarone-naïve patients. After CRT, amiodarone-treated patients demonstrated less QRS narrowing (8 vs 20 ms; P = 0.021) and less LVEF improvement (-2.7 vs +5.2%; P = 0.006). Over 29 months, 31 (47%) patients died and 13 (20%) received transplant or VAD. Risk of death, transplant, or VAD was greater in amiodarone-treated than -naïve patients (corrected hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.12-4.11; P = 0.022). Appropriate CRT-D therapies occurred in 37 (55%) patients; amiodarone use was not associated time to first therapy (HR, 1.13; 95% CI, 0.59-2.16; P = 0.72). CONCLUSION: In patients with sustained VTA and LBBB upgraded from conventional ICDs to CRT defibrillators, concomitant amiodarone use is associated with less QRS narrowing, less LVEF improvement, greater risk of death, transplant, or VAD, and similar risk of recurrent VTA.

Left ventricular dimensions predict risk of appropriate shocks but not mortality in cardiac resynchronization therapy-defibrillator recipients with left bundle-branch block and non-ischemic cardiomyopathy.

AIMS: Patients with non-ischaemic cardiomyopathy (NICM) and left bundle-branch block (LBBB) often benefit markedly from cardiac resynchronization therapy (CRT). Cardiac resynchronization therapy responders have a lower risk of appropriate device shocks from CRT-defibrillators (CRT-D) than do non-responders. Larger baseline left ventricular (LV) dimensions may be associated with less CRT response and thus greater risk of appropriate shocks. METHODS AND RESULTS: We analysed all (n = 249; 55% female) primary prevention CRT-D recipients at our institution with LBBB, NICM, and measured LV dimensions prior to device implant for the outcomes of (i) appropriate shocks, (ii) any appropriate tachyarrhythmia therapies, and (iii) risk of death, transplant, or left ventricular assist device (LVAD). During 59 months (interquartile range 21.5-91.5) follow-up, 19 (8%) patients received ≥1 appropriate shock, and 67 (27%) patients died, received a transplant, or required LVAD. Receiver-operating characteristic analysis of LV end-diastolic diameter (LVEDD) per meter height vs. appropriate shock(s) revealed an area under the curve of 0.75 (95% CI 0.65-0.85; P < 0.001). No patient with indexed LVEDD <3.36 cm/m (n = 76) received a shock. There was no statistically significant difference in risk of death, transplant, or LVAD (corrected HR 1.67, 95% CI 0.90-3.03; P = 0.103) in patients with indexed LVEDD above this cut-off compared to those with smaller dimension. Among 102 patients with paired quantitative echocardiograms, there was no difference in LVEF change between patients with indexed LVEDD <3.36 cm/m (n = 27; median 11%) and larger (n = 75; median 14%). CONCLUSION: Patients with LVEDD <3.36 cm/m height prior to CRT-D implant in the setting of NICM and LBBB have minimal risk of appropriate shocks but similar risk of death, transplant- and LVAD and similar extent of LV functional improvement as patients with larger LVEDD. CRT-pacemakers may be appropriate in such patients.

A pilot study to assess benefit of atrial rhythm control after cardiac resynchronization therapy and atrioventricular node ablation.

BACKGROUND: Atrial fibrillation (AF) is frequently comorbid in patients receiving cardiac resynchronization therapy (CRT), and suppression is typically difficult. Herein, we sought to understand the benefit of atrial rhythm control in the setting of ventricular rate and regularity control induced by atrioventricular node (AVN) ablation. METHODS: Fifty-two patients with heart failure, persistent AF, left ventricular (LV) ejection fraction <35%, and left bundle branch block underwent cardiac resynchronization therapy (CRT) + AVN ablation, and were randomized to one of the following groups: (1) Atrial Rhythm Control (ARC); (2) AF. Patients were subsequently followed for up to 1 year. RESULTS: Similar numbers of patients in each group were lost to follow-up or have withdrawn (ARC two; AF three). Rhythm control in four patients in the ARC group was inadequate. Among the remaining patients, the incidence of death (ARC=1, AF=2) or left ventricular assist device +/- transplantation (ARC=2, AF=1) were similar. Among the remaining patients (ARC 16, AF 19), at 1 year, there were no significant differences in CRT response rate, Minnesota Living with Heart Failure survey score, 6-minute hall walk distance, ventricular tachyarrhythmia occurrence, or LV dimensions. A significantly higher hospital encounter rate among ARC patients was attributable to efforts to maintain uniform atrial rhythm. CONCLUSIONS: In this pilot study, no incremental benefit for ARC was apparent. A larger study will be necessary to adequately examine these issues.

Failure-free survival of the Durata defibrillator lead.

AIMS: Given design similarities and a common manufacturer, there have been suspicions regarding the Durata™ defibrillator (ICD) lead, in the aftermath of the Riata™ class I recall. We therefore examined the failure-free survival rates of the Durata™ compared with the Riata™ and Sprint Quattro™ ICD leads. METHODS AND RESULTS: All patients (n = 2475) implanted with a Durata (n = 828), Riata [n = 627; 8 Fr. (n = 472) and 7 Fr. (n = 155)], or Sprint Quattro (n = 1020) leads at our institution were included and Kaplan-Meier failure-free survival curves were constructed for all leads. Lead failure was defined as electrical malfunction resulting in lead replacement, excluding dislodgements or perforations. Annual electrical failure rates were 0.3%, 1.7, and 0.3% for the Durata, Riata, and Sprint Quattro leads, respectively (P < 0.0001 for the comparison of Durata to Riata and P = 0.1.0 for the comparison of Durata to Sprint Quattro). The failure-free survival of the Durata lead was significantly better than that of the Riata lead (P < 0.0001) and similar to that of the Sprint Quattro (P = 0.94). The 7 Fr. Riata ST lead had better survival compared with the 8 Fr. Riata lead (P = 0.050) and comparable survival with the Durata lead (P = 0.12). CONCLUSION: The Durata lead failure-free survival is significantly better than the 8 Fr. Riata, albeit at a shorter follow-up time. Riata and comparable with that of the 7 Fr. Riata ST and the Sprint Quattro ICD leads. These data provide an insight into the mechanism of electrical failure of Riata leads and have implications for patient management.

Impact of a dedicated center for atrial fibrillation on resource utilization and costs.

BACKGROUND: Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays. HYPOTHESIS: We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care. METHODS: The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics. RESULTS: We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AF between October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days. CONCLUSION: Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital.

Association of pre-left ventricular assist device defibrillator shocks for ventricular arrhythmia with clinical outcomes after left ventricular assist device implantation.

Background: Implantable cardioverter-defibrillation (ICD) shocks after left ventricular assist device therapy (LVAD) are associated with adverse clinical outcomes. Little is known about the association of pre-LVAD ICD shocks on post-LVAD clinical outcomes and whether LVAD therapy affects the prevalence of ICD shocks. Objectives: The purpose of this study was to determine whether pre-LVAD ICD shocks are associated with adverse clinical outcomes post-LVAD and to compare the prevalence of ICD shocks before and after LVAD therapy. Methods: Patients 18 years or older with continuous-flow LVADs and ICDs were retrospectively identified within the University of Pittsburgh Medical Center system from 2006-2020. We analyzed the association between appropriate ICD shocks within 1 year pre-LVAD with a primary composite outcome of death, stroke, and pump thrombosis and secondary outcomes of post-LVAD ICD shocks and ICD shock hospitalizations. Results: Among 309 individuals, average age was 57 ± 12 years, 87% were male, 80% had ischemic cardiomyopathy, and 42% were bridge to transplantation. Seventy-one patients (23%) experienced pre-LVAD shocks, and 69 (22%) experienced post-LVAD shocks. The overall prevalence of shocks pre-LVAD and post-LVAD were not different. Pre-LVAD ICD shocks were not associated with the composite outcome. Pre-LVAD ICD shocks were found to predict post-LVAD shocks (hazard ratio [HR] 5.7; 95% confidence interval [CI] 3.42-9.48; P <.0001) and hospitalizations related to ICD shocks from ventricular arrhythmia (HR 10.34; 95% CI 4.1-25.7; P <.0001). Conclusion: Pre-LVAD ICD shocks predicted post-LVAD ICD shocks and hospitalizations but were not associated with the composite outcome of death, pump thrombosis, or stroke at 1 year. The prevalence of appropriate ICD shocks was similar before and after LVAD implantation in the entire cohort.

Persistent and Recurrent Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes.

BACKGROUND: Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC). OBJECTIVES: This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients. METHODS: Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT. RESULTS: DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02). CONCLUSIONS: About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.

Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion.

BACKGROUND: Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited. OBJECTIVES: This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT. METHODS: Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT. RESULTS: A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors. CONCLUSIONS: DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.

TUNEL assay for identifying ablated myocardium.

The terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) assay identifies apoptosis and is used in transplant pathology to detect cardiac allograft rejection. We illustrate the use of TUNEL in identifying segments of ablated ventricular myocardium, and discuss its advantages over conventional histopathological stains. The TUNEL assay can be useful to investigators of catheter ablation therapy.

Apical systolic eccentricity index: a better marker of right ventricular compromise in pulmonary hypertension.

BACKGROUND: Systolic eccentricity index (sEI) has been traditionally measured at the papillary muscle (PM) level. However, this measurement does not take into account the remodeling that occurs in the right ventricle (RV) during chronic pulmonary hypertension (cPH). METHODS: Standard echocardiographic data were collected on 50 patients (age 58 + or - 14 years) with known cPH (74 + or - 22 mmHg; range 45-120 mmHg) who had adequate short-axis views at the mitral valve (MV), PM, and apical (AP) levels to measure sEI. All had a normal left ventricular ejection fraction (72 + or - 10%). RESULTS: In a multivariate analysis, the traditional PM level sEI correlated the best with cPH when pulmonary artery systolic pressures (PASP) ranged between 45 and 60 mmHg (r =-0.569, P < 0.001) while AP level sEI was better when all patients were included in the analysis (r =-0.843, P < 0.0001). Not only was AP level sEI the only echo variable helpful in identifying a dilated end diastolic RV area (r =-0.730, P < 0.0001) but also patients with worse RV systolic performance (r = 0.686, P < 0.0001). MV level sEI was not better than PM level sEI. CONCLUSIONS: AP level sEI appears to be superior to traditional PM level sEI measurement as it correlates better with worsening PH severity, RV cavity dilation and RV systolic dysfunction. Further studies are now required to prospectively study how these septal abnormalities in cPH may affect RV as well as LV systolic and diastolic function. (Echocardiography 2010;27:534-538).

The anatomic substrate of mitral annular contraction.

BACKGROUND: Despite the absence of contractile elements, the mitral annulus undergoes sphincter-like "contraction" resulting in an area reduction of approximately 25%. Its anatomic basis has not, however, been delineated. Since annular contraction helps draw the mitral leaflets into apposition, an appreciation of its anatomic basis could enhance our understanding of the pathogenesis of mitral regurgitation. METHODS: Gross dissection of >100 bovine, ovine and human hearts as well as histologic examination of 5 ovine hearts was performed to ascertain the origins, course and insertion points of the atrial and ventricular muscle bundles related to the annulus. RESULTS: Significant circumferentially-oriented left atrial fibers derived from Bachman's bundle flank the annulus internally. These fibers encircle the base of the atrium and insert into the right fibrous trigone. Externally, the annulus is anatomically related to the superficial obliquely-oriented fibers of the left ventricular inlet which course from the subepicardium to the subendocardium. CONCLUSIONS: Intercalation of the annulus between the musculature of the left atrium and left ventricle subjects it to extrinsic contractile forces resulting in sphincter-like narrowing. The circumferential fibers of the left atrial base are favorably positioned such that their contraction imparts a centripetal force onto the inner aspect of the adjacent fibrous annulus which causes it to translate inward in late diastole. During systole, the superficial oblique fibers of the left ventricular inlet, impose a torsional force onto the outer aspect of the annulus causing it to translate inwards. These observations may have mechanistic implications in mitral regurgitation.

Contemporary insights into the functional anatomy of the mitral valve.

The mitral valve is a highly complex structure the normal functioning of which requires the coordinated interaction of the leaflets, annulus, chordae tendineae, and papillary muscles. Perturbations of any of these components can interfere with normal valve function. The integrity of the mitral valve is also essential to maintaining normal left ventricular geometry and function through closely coupled ventricular-valvular interactions. This review summarizes recent developments in our understanding of the anatomy and physiology of the mitral valve.

Time shift of marker legend in stored intracardiac events in three patients with the vitality 2 EL DR (model T167) and Prizm 2DR (model 1861) dual-chamber defibrillators.

With the increase in complexity of implantable cardioverter defibrillators (ICD), the reliability of these devices has been put in question in recent years. We report on 3 patients implanted with the Boston Scientific Vitality 2 EL DR (n = 2) and the Prizm 2 DR (n = 1) ICD who exhibited a malfunction in the stored cardiac electrograms from arrhythmic events, manifesting as a time shift in stored markers compared to the stored electrograms.

Pulmonary hypertension affects left ventricular basal twist: a novel use for speckle-tracking imaging.

BACKGROUND: Chronic pulmonary hypertension (PH) results in right ventricular (RV) mechanical dyssynchrony. However, its effects on left ventricular (LV) mechanics have not been examined. OBJECTIVE: Since speckle-tracking echocardiography (STE) is a novel approach to quantify LV dyssynchrony; we decided to use STE to assess the effect of PH on LV mechanics. METHODS: Our echocardiography database was queried for patients with PH who had undergone STE analysis and compared to similarly collected data from a group of healthy volunteers. RESULTS: Group I (15 patients, age of 53 +/- 17 years, pulmonary artery pressure of 62 +/- 20 mmHg, eccentricity index of 0.78 +/- 0.06, and LV ejection fraction of 64 +/- 11%) and Group II (8 healthy volunteers, age 41 +/- 9 years, pulmonary artery pressure 14.6 +/- 4.2 mmHg, eccentricity index of 1.02 +/- 0.05, and LV ejection fraction of 66 +/- 6 mmHg). There was no difference in QRS duration between the two groups. Although PH significantly altered basal LV twist (Group I: M =-5.76 degrees versus Group II: M =-1.82 degrees , P < 0.05), it had no effect on LV apical twist (5.29 degrees versus 4.50 degrees ; P = NS, respectively). More notably, significant LV radial basal LV dyssynchrony, measured as the time to peak LV basal twist, was seen as a result of PH. CONCLUSIONS: STE identifies the presence of LV dyssynchrony in PH despite normal LV ejection fraction and no difference in QRS duration. Additional studies are now required to further characterize these results and determine their prognostic significance.

Altered early left ventricular diastolic wall velocities in pulmonary hypertension: a tissue Doppler study.

BACKGROUND: Left ventricular diastolic dysfunction (LVDD) is known to occur in severe chronic pulmonary hypertension (PH); however, the mechanism(s) remains unclear. METHODS: Tissue Doppler imaging (TDI) was used to track early (E) diastolic signals of basal and mid portions of the interventricular septum (IS) and LV free wall (LVFw) in 20 patients (60 +/- 8 years) with documented LVDD without PH and in 30 patients (60 +/- 11 years) with known chronic PH. All subjects were in normal sinus rhythm and had normal LV ejection fraction. RESULTS: PH patients had lower early (E) wave velocities in basal IS (-4.2 +/- 1.9 vs. -5.9 +/- 1.2 cm/sec; P < 0.001), distal IS (-2.6 +/- 2.6 vs. -4.2 +/- 1.1 cm/sec; P < 0.01), and basal LVFw (-5.2 +/- 1.7 vs. -6.5 +/- 1.2 cm/sec; P < 0.01) than patients with LVDD and no PH. Finally, worsening PH distorts the entire IS diastolic tracing resulting in asynchronous diastolic signals. CONCLUSIONS: The presence of PH not only decreases IS early (E) wave diastolic velocity generation but also distorts the entire pattern of IS diastolic relaxation when compared to patients with typical LVDD and no PH. Further studies are now needed to assess the full effect of PH on LV diastole and how this influences clinical outcomes.

B-Cell lymphoproliferative disorder of an ICD pocket: a diagnostic puzzle in an immunosuppressed patient.

We present a case of a patient with lymphoma in an ICD pocket in the setting of posttransplant immune suppression. Infection of the ICD system was suspected and the correct diagnosis was established by biopsy.

A delayed time of the peak tricuspid regurgitation signal: marker of right ventricular dysfunction.

BACKGROUND: Worsening degrees of tricuspid regurgitation (TR) have been associated with worse outcomes. We investigated the time it takes for the TR jet to attain its maximum peak (tmpTR) with measures of right ventricular (RV) function. METHODS: Several echocardiographic variables of RV size and function and tmpTR corrected for heart rate were collected from 140 patients (mean age 57 +/- 20 years). RESULTS: Mean RV end systolic (15 +/- 9 cm) and end diastolic (25 +/- 9 cm) areas, RV fractional area change (44 +/- 19%), maximal tricuspid annular motion (1.98 +/- 0.71 cm), pulmonary artery systolic pressure (57 +/- 33 mm Hg) and tmpTR (248 +/- 75 ms). A negative correlation was seen between tmpTR and RV fractional area change (r = -0.74; P < 0.0001) and between tmpTR and maximal tricuspid annular excursion (r = -0.69; P < 0.0001). On a multiple stepwise linear regression analysis tmpTR was better than pulmonary artery systolic pressure in predicting RV dysfunction (P < 0.001). Receiver operating characteristic curve analysis demonstrated that a tmpTR value >240 ms identified RV systolic dysfunction (sensitivity 79% and specificity 94%, areas under the curves 0.923, P = 0.0001). The longest tmpTR values were seen in patients with both RV systolic dysfunction and pulmonary hypertension (310 +/- 30 ms, P < 0.0001). CONCLUSION: A delayed time to peak of the maximum TR jet correlates with RV dysfunction. Patients with normal RV function and no pulmonary hypertension had abnormal tmpTR values (243 +/- 57 ms) implying an underlying RV mechanical abnormality that requires further investigation.

Evidence of robust coupling of atrioventricular mechanical function of the right side of the heart: insights from M-mode analysis of annular motion.

BACKGROUND: Extensive data exist regarding annular descent and ventricular function. We have already demonstrated significant differences in amplitude and timing of events between maximal mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursion as well as described quantitative temporal differences in annular ascent (AA) between the right and left sides of the heart. However, whether any relationship exists between annular ascent and descent components remains uninvestigated. METHODS: Left ventricular ejection fraction (LVEF), right ventricular fractional area change (RVFAC), MAPSE, TAPSE, MV, and TV AA as well as pulsed tissue Doppler of the lateral MV and TV annuli were recorded from 53 patients. RESULTS: In this population (age 55 +/- 17 years) mean LVEF was 55 +/- 19%, mean RVFAC was 47 +/- 20%, mean MAPSE was 2.11 +/- 0.72 cm, mean TAPSE was 1.48 +/- 0.44 cm, mean MV AA was 0.52 +/- 0.17 cm, TV AA was 0.96 +/- 0.47, MV A-wave 0.10 +/- 0.04 cm/s, and TV A-wave was 0.13 +/- 0.05 cm/s. A more robust correlation was seen between TV AA and RVFAC than between MV AA and LVEF and also between TV AA and pulsed TDI TV A-wave velocity than between MV AA and pulsed TDI MV A-wave. CONCLUSION: Our data reveal that mechanical systolic functions of the atria and the ventricles are more closely coupled on the right than on the left side of the heart. Whether this is a result of anatomic linking or chamber geometry will require further study.