Recent-onset atrial fibrillation: a study exploring the elements of Virchow’s triad after cardioversion

Purpose Atrial fibrillation (AF) imposes an inherent risk for stroke and silent cerebral emboli, partly related to left atrial (LA) remodeling and activation of inflammatory and coagulation systems. The aim was to explore the effects of cardioversion (CV) and short-lasting AF on left atrial hemodynamics, inflammatory, coagulative and cardiac biomarkers, and the association between LA functional recovery and the presence of a prior history of AF. Methods Patients referred for CV within 48 h after AF onset were prospectively included. Echocardiography and blood sampling were performed immediately prior, 1–3 h after, and at 7–10 days after CV. The presence of chronic white matter hyperintensities (WMH) on magnetic resonance imaging was related to biomarker levels. Results Forty-three patients (84% males), aged 55±9.6 years, with median CHA2DS2-VASc score 1 (IQR 0–1) were included. The LA emptying fraction (LAEF), LA peak longitudinal strain during reservoir, conduit, and contractile phases improved significantly after CV. Only LAEF normalized within 10 days. Interleukin-6, high-sensitivity cardiac-troponin-T (hs-cTNT), N-terminal-pro-brain-natriuretic peptide, prothrombin-fragment 1+2 (PTf1+2), and fibrinogen decreased significantly after CV. There was a trend towards higher C-reactive protein, hs-cTNT, and PTf1+2 levels in patients with WMH (n=21) compared to those without (n=22). At 7–10 days, the LAEF was significantly lower in patients with a prior history of AF versus those without. Conclusion Although LA stunning resolved within 10 days, LAEF remained significantly lower in patients with a prior history of AF versus those without. Inflammatory and coagulative biomarkers were higher before CV, but subsided after 7–10 days, which altogether might suggest an enhanced thrombogenicity, even in these low-risk patients.

Assessment of Longitudinal Left Ventricular Function in Patients with Coronary Artery Ectasia by 2D Speckle Tracking Echocardiography

Background Coronary artery ectasia (CAE) is one of the uncommon cardiovascular disorders. CAE is one of the known risk factors for acute coronary syndrome, its incidence ranges from 1.5%-5% of patients undergoing coronary angiography, with predominance in males. Coronary artery ectasia (CAE) is defined as dilatation of an arterial segment to a diameter at least 1.5 times that of an adjacent normal artery and involves at least one third of the affected artery (1)(1). The exact pathogenesis of CAE is not well established; however, Coronary atherosclerosis is detected in more than 50% of the patients. Objective To evaluate global left ventricle longitudinal strain by 2D speckle tracking echocardiography in patients with coronary artery ectasia and without significant (>50%) coronary artery stenosis. Patients and Methods This study carried on sixty patients referred to cath lab of Ain Shams university hospital for elective coronary angiography during period between January 2018 and Augest 2019. The patients were divided in to two groups (Group A) included thirty patients with ectasia in one or more of the coronary arteries without any significant coronary artery stenosis and (Group B) included thirty patients with normal coronary angiographic findings serving as control group. Results The present study showed a statistically significant decrease in EF comparing CAE group to control group .As regards other echocardiography parameters, there was a highly significant difference of LVEDD, LVEDD index, LVESD,, LVESD index, LV mass, LV mass index, LA volume and LA volume index between the two groups. Global peak longitudinal strain showed highly significant difference between two groups as its mean value was significantly lower in the CAE group. Conclusion In our study, we have concluded that global peak longitudinal strain was significantly impaired in patients with coronary artery ectasia without significant coronary artery lesion denoting subclinical LV systolic dysfunction .LV diastolic dysfunction was more prevalent in coronary artery ectasia patients compared to control subjects.

Segmental Strain for Scar Detection in Acute Myocardial Infarcts and in Follow-up Exams using Non-Contrast CMR Cine Sequences

Background The purpose of the study was to investigate feasibility of infarct detection in segmental strain derived from non-contrast cardiac magnetic resonance (CMR) cine sequences in patients with acute myocardial infarction (AMI) and in follow-up (FU) exams.Methods57 patients with AMI (mean age 61 ± 12 years, CMR 2.8 ± 2 days after infarction) were retrospectively included, FU exams were available in 32 patients (35 ± 14 days after first CMR). 28 patients with normal CMR (47 ± 8 years) served as controls. Dedicated software (Segment CMR, Medviso) was used to calculate global and segmental strain derived from cine sequences. Cine short axis stacks and segmental circumferential strain calculations of every patient and control were presented to two blinded readers in random order, who were advised to identify potentially infarcted segments, blinded to LGE and clinical information. Results Impaired global strain was measured in AMI patients compared to controls (global peak circumferential strain [GPCS] p= 0.01; global peak longitudinal strain [GPLS] p= 0.04; global peak radial strain [GPRS] p= 0.01). In both imaging time points, mean segmental peak circumferential strain [SPCS] was impaired in infarcted tissue compared to remote segments (AMI: p=0.03, FU: p=0.02). SPCS values in infarcted segments were similar between AMI and FU (p=0.8), remote segments were marginally more impaired in AMI than in FU (p= 0.07). In SPCS calculations, 141 from 189 acutely infarcted segments were accurately detected (74.6%), visual evaluation of correlating cine images detected 44.4% infarcts. In FU, 81.5 % infarcted segments (93/114 segments) were detected in SPCS and 51.8% by visual evaluation of correlating short axis cine images (p=0.01).ConclusionSegmental circumferential strain derived from routinely acquired native cine sequences detects nearly 75 % of acute infarcts and about 80% of infarcts in subacute follow-up CMR, significantly more than visual evaluation of correlating cine images alone. Acute infarcts may display only subtle impairment of wall motion and no obvious wall thinning, thus SPCS calculation might be helpful for scar detection in patients with acute infarcts, when only cine images are available.

The Prognostic Value of Left Atrial Global Longitudinal Strain and Left Atrial Phasic Volumes in Patients Undergoing Transcatheter Valve Implantation for Severe Aortic Stenosis

Introduction: The changes and the prognostic implications of left atrial (LA) volumes (LAV), LA function, and vascular load in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) are less known. Methods: We enrolled 150 symptomatic patients (mean age 82 ± 8 years, 58% female, and pre-TAVI aortic valve area 0.40 ± 0.19 cm/m2) with severe AS who underwent 2D transthoracic echocardiography and 2D speckle tracking echocardiography at average 21 ± 35 days before and 171 ± 217 days after TAVI. The end point was a composite of new onset of atrial fibrillation, hospitalization for heart failure and all-cause death (major adverse cardiac events [MACE]). Results: After TAVI, indexed maximal LA volume and minimum volume of the LA decreased by 2.1 ± 10 mL/m2 and 1.6 ± 7 mL/m2 (p = 0.032 and p = 0.011, respectively), LA function index increased by 6.8 ± 11 units (p < 0.001), and LA stiffness decreased by 0.38 ± 2.0 (p = 0.05). No other changes in the LA phasic volumes, emptying fractions, and vascular load were noted. Post-TAVI, both left atrial and ventricular global peak longitudinal strain improved by about 6% (p = 0.01 and 0.02, respectively). MACE was reached by 37 (25%) patients after a median follow-up period of 172 days (interquartile range, 20–727). In multivariable models, MACE was associated with both pre- and post-TAVI LA global peak longitudinal strain (hazard ratio [HR] 0.75, CI 0.59–0.97; and HR 0.77, CI 0.60–1.00, per 5 percentage point units, respectively), pre-TAVI LV global endocardial longitudinal strain (HR 1.37, CI 1.02–1.83 per 5 percentage point units), and with most of the LA phasic volumes. Conclusion: Within 6 months after TAVI, there is reverse LA remodeling and an improvement in LA reservoir function. Pre- and post-TAVI indices of LA function and volume remain independently associated with MACE. Larger studies enrolling a greater diversity of patients may provide sufficient evidence for the utilization of these imaging biomarkers in clinical practice.

Association between myocardial mechanical dispersion and ventricular arrhythmogenicity in Chagas cardiomyopathy.

Endemic Chagas diseaseis a major health concernin LatinAmerica. Ventricular arrhythmias (VA) is a hallmark of Chagas cardiomyopathy (ChC) associated with worse prognosis. To verify if there is an association between myocardial mechanical dispersion and ventricular arrhythmogenicity in CCM. This is a cross-sectional study involving 77 patients with CCM. Global longitudinal strain (GLS) and MD were evaluated by echocardiogram, derived from the speckle tracking technique. Myocardial MD was measured from the onset of the Q / R wave on electrocardiogram to the peak longitudinal strain in 16 segments of the left ventricle. Frequency and complexity of ventricular extrasystoles (VES) were assessed by dynamic electrocardiography. The density and complexity of VES and the presence of non-sustained ventricular tachycardias (NSVTs) increase as MD increases. In logistic regression, MD was the only variable associated with the presence of VES in pairs and bigeminy. In the univariate analysis, both MD and GLS were associated with the presence of NSVT (both, p < 0.01), and MD was independently associated with NSVT (OR 1.04, 95% CI: 1.004–1.201, p = 0.031). In Chagas cardiomyopathy, MD is associated with a higher density and complexity of ventricular extrasystoles, including NSVT.

Abstract 12570: Association Between Left Atrial Global Peak Longitudinal Strain and Tgfβ1 in Cardiovascular Surgery Patients

Introduction: Atrial fibrosis plays an important role in atrial remodeling and the development of atrial fibrillation (AF). Transforming growth factor β1 (TGFβ1) is one of the major factors that accelerate atrial fibrosis. Left atrium global peak longitudinal strain (GPLS) measured by two-dimensional speckle tracking (2DS) method has been reported to be a useful method to predict the degree of atrial fibrosis. Hypothesis: To investigate the association between GPLS, Af and atrial fibrotic remodeling by analyzing fibrosis-relating gene expression including collagen type 1 (COL1A1), and TGFβ1 in cardiovascular surgery patients. Methods: Conventional echocardiography and 2DS method were performed in 117 patients (36 atrial fibrillation (Af) patients, 81 patients with sinus rhythm (SR), average age 69.7 years, 69 males) before cardiovascular surgery including cardiac valve replacement, and CABG. The fibrosis-relating gene expression such as collagen type 1 (COL1A1), COL4A1, TGFβ1, and connective tissue growth factor (CTGF) mRNA were analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) in 39 cases in which LA tissues were removed from the appendage during surgery. Results: GPLS was significantly negatively correlated with left atrial diameter (LAD), E/e‘, and left atrial volume index (LAVI). Expression of TGFβ1 in the atrium was positively correlated with expression level of Col1A1, Col4A1, and CTGF mRNA. GPLS was significantly negatively correlated with the expression of Col1A1 (r = -0.418, p = 0.015), TGFβ1 (r = -0.557, p = 0.000), and Col4A1 (r = -0.411, p = 0.013). However, no clear correlation was observed with LAD and LAVI. In multivariate analysis, unlike LAD and LAVI, GSLS was a clear predictor of Col1A1 expression, even when corrected with gender, age, brain natriuretic peptide (BNP), and type of heart rhythm (Af, sinus rhythm). On the other hand, TGFβ1 concentration in blood did not correlate with TGFβ1, Col1A1 and Col41A mRNA expression level in the atrium. Conclusions: Low LA GPLS exhibits increased atrial fibrosis reflected by collagen and TGFβ1 expression , irrespectively of heart rhythm (Af or sinus rhythm), and becomes an extremely useful marker for predicting LA fibrosis in cardiovascular surgery patients.

Left atrial function assessed by speckle tracking echocardiography in anthracycline-induced cardiotoxicity: a case report

Background The onset prevention and early diagnosis in cardiotoxicity due to cancer chemotherapy are important, and it is important to detect cardiac dysfunction at an early stage and start treatment to enhance the therapeutic effect. Case summary A 31-year-old female with breast cancer received chemotherapy with epirubicin (400 mg/m2) and cyclophosphamide followed by docetaxel. Two months after the initiation of her chemotherapy, the left ventricular (LV) ejection fraction (LVEF) determined by echocardiography fell to 41.2%, and she was diagnosed with cancer therapy-related cardiac dysfunction (CTRCD). Three months after the initiation of cancer treatment, the peak velocity of late diastolic transmitral Doppler flow (A wave) became undetectable. Peak longitudinal strain (LS) and peak LS rate, which reflect left atrium (LA) reservoir function, gradually declined like the LVEF and LV-global LS (GLS). Seven months after the initiation of cancer treatment, she was diagnosed with acute decompensated heart failure. The changes in peak LS and peak LS at the onset were greater than those in LVEF and LV-GLS. Discussion This is a case report suggesting that LA reservoir function might be a more sensitive indicator than LVEF or LV-GLS in detecting CTRCD and that LA booster function might be the earliest. Left atrium reservoir function might be a more sensitive than conventional LV pump function and optimal indicator in CTRCD.

2D Speckle Tracking echocardiography in the prognostication of left ventricle diastolic dysfunction

The aim of the study: to develop prediction comprehensive criteria for the diastolic dysfunction (DD) of the left ventricle (LV) according to 2D Speckle Tracking echocardiography (STE).Materials and methods. A clinical and instrumental study of 91 patients aged 64.0 was performed [58.0; 70.0] years in the Minsk Scientific and Practical Center of Surgery, Transplantology and Hematology in 2019. Criteria for inclusion: sinus rhythm, essential arterial hypertension, chronic coronary artery disease, previous left myocardial infarction, after which at least six months have passed to stabilize the LV structural and functional parameters, chronic heart failure, patient informed consent. Exclusion criteria: primary mitral regurgitation, mitral stenosis, mitral valve repair or prosthetics, congenital heart defects, acute and chronic diseases of the kidneys, lungs. Transthoracic echocardiography and STE was performed on ultrasound machine Vivid E9 (GE Healthcare, USA).Results. The leading functional anomalies, interconnected in the development of LV DD, are decline of the LV longitudinal diastolic, regional and global systolic strain, LV mechanical dispersion and dyssynergy. Correlations between LV DD type II and the mechanical dispersion index (r = 0.69, p < 0.001), delta of LV time to peak longitudinal deformation (r = 0.66, p < 0.001), LV global post-systolic index (r = 0.58, p < 0.001), GLSAVG (r = 0.63, p < 0.001) were established. LV DD is characterized by early diastolic longitudinal strain E of the LV basal lateral segment > −6.75%, LV basal septal segment > −5.22%, early and late diastolic longitudinal strain ratio E/A of the LV basal lateral segment ≤0.91, basal-septal segment ≤0.69. LV DD type I is characterized by an LV mechanical dispersion index >49.34 ms, LV delta time to peak longitudinal strain >157 ms. Prognostic values for LV DD type II are LV mechanical dispersion index >49.34 ms, delta time to peak longitudinal strain is >136 ms, global post-systolic index >6.24%, mechanical dyssynergy index >4.60%, global LV peak longitudinal displacement ≤9.88 mm, GLSAVG > −18.5% (sensitivity 88.2%, specificity 83.3%).Conclusions. The use of the developed STE prediction value in practical public health will increase the efficiency of diagnosis of LV DD.