[A rare cause of right heart insufficiency: idiopathic dilatation of the right atrium (a case report)].
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Adolescent↗
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Wavelength and atrial vulnerability: an endocavitary approach in humans.
If atrial vulnerability parameters are well defined, wavelength (WL) measurement (conduction velocity x refractory period), has never been assessed through an endocavitary electrophysiological exam. We investigated 30 patients (14 female, mean age 63.4 +/- 13 y.o.), 10 with paroxysmal atrial fibrillation (PAF group), 10 with ischemic cerebral injury (ICI group) by comparison with 10 controls (C group). The upper to lower right atrium conduction time and velocity were measured in the right atrium with a decapolar electrode catheter applied along the free wall. Others parameters correlated to atrial excitability were also taken into account: effective (ERP) and functional refractory periods (FRP); spontaneous or paced atrial electrogram (A1) or extrastimulated atrial electrogram (A2) widths, ERP/A2 ratio, provocative atrial testing. Measurements were taken in sinus rhythm and in 600-460 ms paced cycle lengths. If ERP, FRP, A1 widths are the same in the 3 groups, PAF and ICI groups have a significant increased conduction time and lower conduction velocity, leading to a shorter A1 WL during 600 and 460 ms paced rhythms (p < 0.05) and A2 WL during 460 ms paced rhythm. The provocative testing was positive in 60% of PAF and ICI groups, and there is a significant correlation between arrhythmia induction and 600 ms A1 WL or 460 ms A2 WL. This electrophysiological study suggests the possibility of an approach in humans of wavelength concept and proves the presence of correlation between a short wavelength and atrial spontaneous or induced arrhythmias. A no-arrhythmia band (A1 WL > 17 cm during 600 ms paced rhythm, A1 WL > 16 cm or A2 WL > 12 cm during 460 ms paced rhythm) and a fibrillation-band (A1 WL < 12 cm during 600 and 460 ms pacing, A2 WL < 7 cm during 460 ms pacing) can be defined. Therefore, the ICI group has the same atrial pattern as the AF group.
Atrial Fibrillation↗
[Hemodynamics mechanisms of changes in the right atrial pressure following intravenous injection of the depressor drugs].
Changes of the right atrial pressure, superior and inferior vena cava flows, right ventricular myocardial contractility (first derivate of right ventricular pressure, dP/dt max) following i.v. injection of acetylcholine, histamine and isoproterenol, were studied in acute experiments on anaesthetized mongrel cats with artificial lung ventilation and opened chest. The right atrial pressure in those cases could be increased (I group of animals) or decreased (II group). In maximal shifts of right atrial pressure following acetylcholine injection, the superior vena cava flow increased but the inferior vena cava flow decreased in equal proportion. When the right ventricular myocardial contractility decreased more than the right atrial pressure was augmented, and when the cardiac negative inotropic effect was weak, the right atrial pressure was reduced. After histamine injection in both groups of animals, right ventricular myocardial contractility was increased on the same level, and changes of the inferior vena cava flow were insignificant. The right atrial pressure was elevated following greater increase of superior vena cava flow. Isoproterenol caused the positive cardiac inotropic effect and augmenting of the superior vena cava flow in both groups of animals. The right atrial pressure was elevated if the inferior vena cava flow increased and, on the other hand, when the inferior vena cava flow decreased the right atrial pressure was reduced. Thus different maximal changes of the right atrial pressure following i.v. injection of acetylcholine, histamine and isoproterenol could be explained by different hemodynamic mechanisms of the interaction between superior and inferior vena cava flow shifts and changes of the right ventricular myocardial contractility.
Acetylcholine↗
Expression of angiotensin II receptors in human left and right atrial tissue in atrial fibrillation with and without underlying mitral valve disease.
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Angiotensin II↗
High incidence of focal atrial fibrillation (AF) from the right atrium (RA).
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Atrial Fibrillation↗
Atrial function during cardiac arrest caused by ventricular fibrillation.
OBJECTIVES: To report observations on preserved regular atrial electrical and mechanical systole during ventricular fibrillation (VF) and to quantitate blood flow generated by atrial contractions in this setting. METHODS: In 10 rats, right atrial pressure pulses were continuously recorded before and for an interval of 8 min after inducing VF. In 3 isolated, perfused rat hearts, epicardial right atrial electrograms were recorded after inducing VF. In 15 pigs, transesophageal echo-Doppler measurements were obtained with pulsed and color-Doppler visualization of flow across the mitral valve after onset of VF. RESULTS: In each rat, regular right atrial pressure pulses were documented during VF. These persisted over an average interval of 7.5 min. In isolated, perfused hearts, right atrial contractions were accompanied by regular atrial depolarizations. In pigs, regular atrial contractions generated atrial stroke volumes of approximately 12 mL, or 25% of prearrest values during the first minute after onset of VF, but those declined to approximately 6 mL after 10 min of untreated cardiac arrest. Blood flow from the left atrium into the left ventricle failed to advance significantly into the systemic circuit. During atrial diastole, we observed reversal of flow into the left atrium. CONCLUSIONS: Atrial contractions are preserved during the initial 8 min or more after cardiac arrest due to VF. Substantial forward flow into the left ventricle failed to advance through the outflow tract but regurgitated into the atrium during atrial diastole.
Animals↗
Influence of negative intrathoracic pressure on right atrial and systemic venous dynamics.
To investigate the effect of a sustained fall in intrathoracic pressure (Mueller manoeuvre) on blood flow through the right heart and on systemic venous dynamics, 16 patients were studied using thermodilution, cinevenograms and simultaneous pressure recordings with two micromanometric transducers. The reductions in airway pressure (median [range]) during two graded Mueller manoeuvres were 25 (20-30) and 42 (22-52) mmHg. Right atrial mean pressure decreased by 17 (2-25) mmHg during the former and 38 (0-49) mmHg during the latter, and simultaneously, pressure gradients of 23 (1-32) and 45 (1-82) mmHg developed between the inferior vena cava and right atrium (P < 0.003 for all). Internal jugular venous pressure decreased by 16 (4-25) and 24 (4-43) mmHg (P < 0.03 for both), respectively, and no pressure gradient developed between internal jugular and superior caval veins. The minimum diameter of the proximal inferior vena cava decreased by 69 (-49-84)% (P = 0.002) during the greater manoeuvre. Cardiac index tended to increase by 26 (-17-40)% (P < 0.066) during the lesser manoeuvre but did not change statistically significantly during the greater. In conclusion, during negative intrathoracic pressure caused acutely by the Mueller manoeuvre, right atrial pressure decreases and the inferior vena cava collapses partially at or below the diaphragm. Despite a significant venous obstruction between the lower body and right atrium, blood flow through the right heart increases or remains constant.
Adult↗
Hemodynamic changes associated with thermodilution cardiac output determination in canine acute blood loss or endotoxemia.
Since the technique of thermodilution (TD) cardiac output measurement, per se, causes hemodynamic alterations, the author examined whether the alterations elicited by iced injectate are augmented in the presence of acute blood loss or endotoxemia, compromised conditions frequently associated with critically ill patients. Acute blood loss (N = 8) and endotoxemia (N = 8) were induced by withdrawing arterial blood approximately 20-30 ml.kg-1 over 30 min and by a slow intravenous infusion of E. coli endotoxin 2.5-3.0 mg.kg-1 over 10 min, respectively, in anesthetized dogs. The magnitudes of decreases in mean arterial and pulmonary artery pressures during slowing of heart rate (HR) following injection of iced injectate 3 ml were slightly less in acute blood loss than in normovolemia, whereas in endotoxemia the degree of mean arterial pressure decrease during slowing of HR following iced injectate 3 ml was slightly less as compared with that before endotoxemia. However, the alterations in other hemodynamic variables following injection of iced injectate 3 ml were similar between dogs with and without acute blood loss or endotoxemia. No profound hemodynamic changes were observed during any TD cardiac output measurements under both conditions. Cardiac output estimated by TD correlated closely with pulmonary blood flow measured by electromagnetic flowmeter in endotoxemia (r > 0.9) but not during acute blood loss. These results indicate that TD cardiac output determination does not cause serious hemodynamic alterations in endotoxemia or acute blood loss, and can estimate right ventricular output accurately in endotoxemia but not in acute blood loss.
Acidosis↗
[Does Doppler analysis of hepatic venous flow predict increased right atrial pressure and right ventricular dysfunction?].
The aim of this study was to test the hypothesis that Doppler study of hepatic venous flow, reflecting right atrial pressures and right ventricular dysfunction, allows prediction of increased right atrial pressure and right ventricular dysfunction in patients with right ventricular infarction. The authors studied 30 patients (27 men, mean age 54 +/- 12 years) in sinus rhythm with acute inferior myocardial infarction who underwent right heart catheterisation and Doppler echocardiography including recording of regurgitant and hepatic vein flow within 48 hours of hospital admission. Hepatic venous flow was used to measure peak velocity and velocity time integrals (VTI) of the systolic (S), diastolic (D) and atrial (a) contraction waves. The fraction of systolic filling was calculated: VTI S/VTI S + VTI D. The pressure half-time of pulmonary regurgitant flow (PHT IP) was also measured. Using haemodynamic criteria (non-compliant right atrial pressure wave form or right ventricular end diastolic pressure/pulmonary capillary pressure > or = 0.8), patients were divided into two groups: Group 1: right ventricular infarction (VD+, N = 22). Group 2: no right ventricular infarction (VD-, N = 8). No correlation was observed between Doppler parameters of hepatic venous flow and haemodynamic data, in particular right atrial pressure and pressure wave form. Moreover, no statistically significant difference was observed between the two groups with respect to the Doppler parameters derived from hepatic venous flow. On the other hand, the results confirmed good diagnostic performance of Doppler analysis of pulmonary regurgitant flow: sensitivity 80%, specificity 83%, positive predictive value 94%, negative predictive value 55%. The authors conclude that, in patients with acute inferior wall infarction, Doppler analysis of hepatic venous flow does not allow assessment of right atrial pressure or of ischaemic right ventricular dysfunction.
Adult↗
Portal vein pulsatility index is a more important indicator than congestion index in the clinical evaluation of right heart function.
AIM: To study the changes of portal blood flow in congestive heart failure. METHODS: We studied the congestion index (CI) and portal vein pulsatility index (PI) in patients with varied degrees of congestive heart failure using ultrasonic Doppler. Ten patients with (mean) right atrial pressure (RA) < 10 mmHg were classified as group 1 and the remaining 10 patients with RA > or = 10 mmHg as group 2. RESULTS: There were no difference on cardiac index (HI, P=0.28), aortic pressure (AO, P=0.78), left ventricular end-diastolic pressure (LVED, P=0.06), (max)imum portal blood velocity (Vmax, P=0.17), (mean) portal blood velocity (Vmean, P=0.15) and portal blood flow volume (PBF, P=0.95) between the two groups. Group 2 patients had higher pulmonary wedge pressure (PW, 29.9+/-9.3 mmHg vs 14.6+/-7.3 mmHg, P=0.002), pulmonary arterial pressure (PA, 46.3+/-13.2 mmHg vs 25.0+/-8.2 mmHg, P=0.004), RA (17.5+/-5.7 mmHg vs 4.7+/-2.4 mmHg, P<0.001), right ventricular end-diastolic pressure (RVED, 18.3+/-5.6 mmHg vs 6.4+/-2.7 mmHg, P<0.001), CI (8.7+/-2.4 vs 5.8+/-1.2, P=0.03), and PI (87.8+/-32.3% vs 27.0+/-7.4%, P<0.001) than Group 1. CI was correlated with PI (P<0.001), PW (P<0.001), PA (P<0.001), RA (P=0.043), RVED (P=0.005), HI (P<0.001), AO (P<0.001), CO (P<0.001), LVED (P<0.001), Vmax (P<0.001), Vmean (P<0.001), cross-sectional area of the main portal vein (P<0.001) and PBF (P<0.001). CI could be as high as 8.3 in patients with RA < 10 mmHg and as low as 5.9 in those with RA > or = 10 mmHg. CONCLUSION: Our data show that RI is a more significant indicator than CI in the clinical evaluation of high RA > or = 10 mmHg, whereas CI is better than PI in the assessment of left heart function.
Adult↗
[The "flickering" phenomenon in the right atrium].
To specify characteristics and reasons of flickering in the right auricle (FRA) detected at two-dimensional ECG, 278 patients with innocent cardiac murmur (ICM) and 93 patients with congenital heart disease (CHD) underwent clinical and ECG examinations. FRA was found in 34.5% of ICM and 57.0% of CHD patients. Topographic-anatomical, ECG, intraoperative comparative investigations suggested that FRA may result from the eustachian valve movements and fenestration-filament structure of the endocardium at the opening of the inferior vena cava, interatrial septum, coronary sinus valve, base of the atrioventricular cusps. The movement of the eustachian valve was followed through the cardiac cycle. It is thought advisable that FRA characteristics should be taken into consideration for valid understanding of right atrial circulation in normal and CHD conditions.
Adult↗
Noninvasive assessment of right heart function by 81mKr equilibrium radionuclide ventriculography in chronic pulmonary diseases.
Noninvasive multigated equilibrium radionuclide ventriculography with krypton-81m (81mKr) was used to assess right heart relaxation in patients with chronic pulmonary diseases (CPD). The subjects consisted of 30 patients with CPD and 8 patients free of cardiopulmonary diseases admitted to our department. A region of interest (ROI) was selected on both the right atrium (RA) and right ventricle (RV). A time activity curve was obtained for each ROI. As a diastolic index of the right heart performance, the right atrial early emptying rate (RAER) was obtained from the right atrial time activity curve, while the right ventricular rapid filling rate (RVRFR) was obtained from the right ventricular time activity curve. The mean RAER was significantly lower in CPD patients compared with the control (CPD, 9.5 +/- 4.5; control, 16 +/- 3.4%/100 ms). Similarly, the mean RVRFR was significantly lower in CPD patients compared with the control (CPD, 27.3 +/- 9.9; control, 34 +/- 8.5%/100 ms). A strong negative correlation was noted between the mean pulmonary arterial pressure (mPAP) and RAER (r = -0.77; p < 0.001) and between the mPAP and the RVRFR (r = -0.63; p < 0.001). Our results suggest that RAER and RVRFR measured by 81mKr are clinically useful in the noninvasive assessment of right heart relaxation in patients with CPD.
Adult↗
Demonstration of an area of slow conduction in human atrial flutter.
Ten patients with chronic atrial flutter were studied prospectively using electrophysiologic mapping and pacing techniques to assess the mechanism of atrial flutter and the presence of an area of slow conduction in the atria. Electrograms recorded from greater than or equal to 30 right atrial sites for each patient during atrial flutter demonstrated that right atrial free wall activation was craniocaudal and that the interatrial septum activation was caudocranial, consistent with a reentrant circuit involving the right atrium. In six patients, slow conduction occurred during atrial flutter in the inferior right atrium and was spatially associated with fractionated electrographic recordings. In the other four patients, a "missing" interval of electrical activity occurred in the inferior right atrium for an average of 40% of the atrial flutter cycle. Transient entrainment criteria were demonstrated in each patient during rapid high right atrial pacing. The mean activation time from the high right atrial pacing site to the coronary sinus (inferior left atrial) recording site was long (228 ms) and consistent with activation through an area of slow conduction. During rapid pacing of atrial flutter from the coronary sinus site, no transient entrainment criteria could be demonstrated. The mean activation time from the coronary sinus pacing site to the high right atrial recording site was relatively short (134 ms) and consistent with orthodromic activation of the high right atrium not through an area of slow conduction. High right atrial pacing during sinus rhythm at rates similar to atrial flutter demonstrated a short activation time to the coronary sinus and low right atrial sites (mean 169 and 88 ms, respectively), indicating activation that did not traverse an area of slow conduction. Coronary sinus pacing during sinus rhythm demonstrated the same phenomena. Low right atrial electrograms recorded during sinus rhythm and during rapid pacing of sinus rhythm were not fractionated, although they were during atrial flutter. Thus, atrial mapping and pacing data were complementary, indicating that human atrial flutter in the patients studied was generated by a reentrant circuit in the right atrium, with an area of slow conduction in the low right atrium present only during atrial flutter.
Atrial Flutter↗
Long-term outcome for right heart function after biventricular repair of pulmonary atresia and intact ventricular septum.
OBJECTIVES: The right heart function of the patients with pulmonary atresia and intact ventricular septum was assessed periodically during the process of staged biventricular repair, and the implications for its long-term outcome were analyzed. SUBJECTS AND METHODS: During the period from 1971 to 1990, 21 neonates or infants with pulmonary atresia and intact ventricular septum had undergone initial palliative surgery. There were seven early postoperative deaths and one late death. Of the 13 survivors, 10 patients underwent subsequent biventricular repair and form the basis of this study. Their clinical records of roentgenography, electrocardiography, and catheterization studies at each staged period were reviewed retrospectively. RESULTS: Arrhythmia occurred late in 2 patients, one of whom died by arrhythmia at 11 years after definitive surgical repair. Therefore the actuarial survival rate was 85.7% at 14 years. The catheterization study after the definitive biventricular repair revealed a significant fall in the right heart pressure (p = 0.0005) and significant improvement in the right ventricular ejection fraction (p = 0.0004). In angiocardiography, dilatation of the right atrium was noted in all patients and was more marked in those who developed arrhythmia in conjunction with rapid growth of the right ventricle. Moreover, the serial repeated electrocardiography disclosed progressive and significant prolongation of both PQ interval (p = 0.003) and QRS duration (p = 0.021). CONCLUSIONS: Although biventricular repair for pulmonary atresia and intact ventricular septum proved to attain a satisfactory long-term result, it failed to resolve right heart dysfunction. Postoperative arrhythmia was prone to precipitate progressive dilatation of the right atrium.
Atrial Function, Right↗
Effect of acute haemodilution on right atrial type-A receptor activity and right atrial pressure in anaesthetized cats.
To determine the effects of acute haemodilution on right atrial pressure and right atrial type-A receptor activity, experiments were conducted in nine anaesthetized cats. Haemodilution was induced by replacement of blood by same volume of dextran (molecular weight-150000). Arterial blood pressure, right atrial pressure and right atrial type-A receptor activity were recorded. Hematocrit, arterial blood pO2, pCO2, and pH were measured. Mean arterial blood pressure, pO2, pCO2, and pH were not altered by haemodilution which extended to a hematocrit level of about 13%. Mean right atrial pressure, 'a' wave pressure showed significant changes after 2nd and 3rd exchange. Heart rate and 'a' wave amplitude changed significantly (P < 0.05) after 3rd exchange. The amplitude of the 'a' wave was increased from 3.57 +/- 0.93 to 5.79 +/- 1.46 cm H2O, heart rate was increased from 163.89 +/- 5.36 to 169.22 +/- 4.84 beats/min, mean right atrial pressure was increased from 2.85 +/- 0.31 to 4.61 +/- 0.27 cm H2O, initial 'a' wave pressure was increased from 1.78 +/- 0.09 to 5.06 +/- 0.44 cm H2O. The data indicate that under present experimental conditions, the activity of the type-A receptor did not show any significant change (P > 0.05) on acute haemodilution. Significant increase (P < 0.05) in the amplitude of 'a' wave, mean right atrial pressure and initial 'a' wave pressure could be attributed to increased myocardial contractility.
Animals↗
[Thrombosis of the right auricle in pulmonary embolism: value of echocardiography and indications for thrombolysis].
The presence of a right atrial thrombus is a recognized predictive factor of high mortality in patients with pulmonary embolism. In this report we describe two cases in which a free-floating thrombus in the right atrium was demonstrated by echocardiography; it resolved rapidly in both cases after thrombolytic therapy which resulted in a rapid clinical improvement and favorable outcome. During the acute phase of pulmonary embolism, a dilated right ventricle, a dilated pulmonary artery, a left ventricle of small size and paradoxical motion of the interventricular septum can be detected by echocardiography. In cases of massive pulmonary embolism or when there is doubt regarding the diagnosis, this noninvasive method serves to guide diagnostic and therapeutic decisions. In the special case where a right atrial thrombus is detected by echocardiography, thrombolytic therapy seems warranted.
Aged↗
Atrial function after surgical and percutaneous closure of atrial septal defect: a strain rate imaging study.
The effect of operation and the effect of the imposition of an occluding device on atrial function for patients with an atrial septal defect (ASD) has never been studied. Thus, the aim of this study was to evaluate for the first time both left atrial (LA) and right atrial (RA) function of children after transcatheter ASD closure with that of sex- and age-matched patients with surgically treated ASD, and sex- and age-matched control subjects using strain (epsilon) and epsilon rate imaging (SR). In all, 45 participants formed our studied sample: 15 patients after successful ASD device closure (ASD-D [atrial septal defect device closure] group, mean age: 9 +/- 3 years) and 15 age- and sex-matched patients after successful ASD surgical closure (ASD-S [atrial septal defect surgical closure] group, mean age: 9 +/- 3 years). All patients underwent ASD correction at least 6 months before the study. As a control group we selected 15 age- and sex-matched control subjects. In the ASD-S group the peak systolic epsilon and SR values were significantly reduced in both RA and LA when compared with control and ASD-D groups (P < .01). In the ASD-D group there was no significant difference in both LA and RA deformation properties when compared with control subjects. SR imaging indexes could provide new, noninvasive, clinically relevant insight on regional changes in atrial function for patients with ASD. ASD percutaneous closure is useful not only because it is less expensive and invasive than open-heart operation but also for its conservation of both LA and RA regional myocardial properties.
Atrial Function↗
Sarcoplasmic reticulum Ca2+ regulatory protein gene expression in human right atrium under hemodynamic overload.
Sarcoplasmic reticulum (SR) Ca2+-adenosine triphosphatase (ATPase) mRNA expression is reduced in the failing human myocardium. However, it is not known whether SR Ca2+-regulatory protein gene expression is altered in human myocardial tissue subjected to pressure overload or volume overload. We sought to determine whether SR Ca2+-regulatory protein gene expression is altered in human atrial tissue subjected to mechanical overload. We obtained right atrial myocardial tissue (about 250mg) at open-heart surgery from three groups of patients: no hemodynamic overload to the right atrium (control group; 12 patients), atrial septal defect (ASD group; 8 patients), and tricuspid regurgitation (TR group; 7 patients). We measured the myocyte size, the area of interstitial fibrosis, SR Ca2+,-ATPase, and ryanodine receptor mRNA abundance. The isolated cardiocyte area and the percent area of interstitial fibrosis were in the order TR > ASD > control (P < 0.05). The SR Ca2+-ATPase mRNA level in TR was significantly decreased (P = 0.004) compared with the control, whereas in the ASD group it did not differ significantly from control. There were no significant differences in ryanodine receptor mRNA levels among the three groups. SR Ca2+-ATPase gene expression was downregulated in human atrial tissue with TR but not in ASD, which might have resulted from the differences in the degree and/or the type of hemodynamic overload to the myocardium.
Adolescent↗