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PubMed2003

Atrial compartment operation for atrial fibrillation: to isolate the left atrium or not?

BACKGROUND: The atrial compartment operation was designed to convert atrial fibrillation (AF) to sinus rhythm with intentional preservation of the electrical connection between adjacent atrial compartments. However, incidental left atrial isolation was observed in some patients. This study compared the long-term clinical outcomes of left atrial isolation for AF with those with right and left atrial connection. METHODS: Twenty patients with mitral valve disease and chronic AF who underwent atrial compartment operation with successful sinus conversion were studied. Left atrial isolation was documented by local electrogram recording. When there were no signs of electrical connection between the left atrium and the rest of the heart, either during sinus rhythm or during stimulation from various atrial compartments, left atrial isolation was confirmed. All patients were followed by electrocardiogram and echocardiogram serial recordings. Clinical signs and symptoms of cardiac performance and thromboembolism were also examined. RESULTS: Seven patients showed an isolated left atrium and 13 patients had electrical connection between the right and left atria. The age, gender, AF duration, and underlying disease were not different between the two groups of patients. During a mean follow-up period of 66 +/- 15 months, none of the patients with left atrial isolation showed recurrence of AF, although one experienced paroxysmal atrial flutter. However, 8 of the 13 patients with right and left atrial connection experienced recurrent atrial flutter/fibrillation (6 atrial flutter and 5 AF) (p = 0.058). The propensity for recurrent atrial flutter/fibrillation in these patients may be related to the conduction delay between the two atrial compartments, measured at 142 +/- 48 ms. At the end of the follow-up period, all patients with left atrial isolation remained in normal sinus rhythm without antiarrhythmic drugs. Of the patients who had right and left atrial connection, 2 developed sustained AF and 1 developed atrial flutter. Patients with left atrial isolation showed a decreased transmitral "A" flow compared with those with right and left atrial connection. Postoperative left atrial diameter and clinical functional class did not differ between patients with and without left atrial isolation. The incidence of embolization observed in both treatment groups did not differ significantly: 14% (1/7) in patients with left atrial isolation and 8% (1/13) in patients with right and left atrial connection (p > 0.05 between the groups). CONCLUSIONS: Left atrial isolation confers a better arrhythmia outcome but at the expense of poorer mechanical performance as compared with preserved electrical connection between the two atria. Nonetheless, all patients remain at risk for systemic embolization. Therefore, modifications of current surgical incisions for AF are needed.

Adult↗

PubMed2005

Usefulness of left atrial emptying fraction to predict exercise capacity in patients with normal systolic left ventricular function and without myocardial ischemia.

The association of left atrial volume at rest and the left atrial emptying fraction with exercise capacity during stress echocardiography was examined in patients with normal left ventricular function and without ischemia. The left atrial emptying fraction, along with body mass index, was found to be an independent predictor of poor exercise capacity (<5 METs).

Adult↗

PubMed2001

The relation between transmitral early filling wave deceleration time and the recovery of atrial contractility after electrical cardioversion of atrial fibrillation.

BACKGROUND: Electrical cardioversion of atrial fibrillation (AF) to sinus rhythm is associated with transient left atrial dysfunction and this phenomenon may lead to thrombus formation and embolic stroke. Delay of atrial mechanical function recovery may be related to ventricular diastolic function. OBJECTIVE: This study examined the effects of left ventricular diastolic function as well as the multiple clinical factors on the recovery of atrial systolic function after cardioversion for atrial fibrillation. METHODS: A total of 44 patients (28 male, 16 female, 61+/-18 years) with chronic AF (> or =1 month) underwent electrical cardioversion. Deceleration time of early filling wave (pre-CV EDT) on transmitral inflow obtained by using Doppler echocardiography before cardioversion and serial transmitral inflow Doppler variables were recorded through a 1 week study period in all patients. Various clinical (age, gender, the duration of AF) and echocardiographic variables (pre-CV EDT, left atrial dimension, left ventricular ejection fraction) were tested for an association with peak atrial filling wave velocity (VA) on day 1, 3 and 7 after cardioversion. RESULTS: EDT measured before cardioversion had a strong linear correlation with peak VA on every echocardiographic evaluation after cardioversion (Regression coefficient (R)=0.69, P<0.001; R=0.78, P<0.001 and R=0.83, P<0.001, on day 1, day 3 and day 7, respectively). The effect of left ventricular ejection fraction on peak VA was weaker than those of EDT. The duration of AF showed an inverse association with the recovery of atrial function, but this lost on multivariate analysis. None of the other parameters significantly correlated with peak VA after cardioversion. CONCLUSION: The recovery of atrial mechanical function after cardioversion, as assessed by peak VA on transthoracic Doppler echocardiography is mainly associated with the left ventricular diastolic function as measured by EDT, whereas the left ventricular systolic function relatively a small effect on this outcome. The duration of AF does not have any association with peak VA, possibly if it is chronic.

Analysis of Variance↗

PubMed1993

Assessment of preload reserve in myocardial ischemia--the relation between preload reserve and ischemic size differs between anterior descending and circumflex coronary artery occlusions in a canine model.

The role of changes in preload in maintaining stable hemodynamics during coronary obstruction was assessed in the presence of myocardial ischemia due to occlusions of the left anterior descending (LAD) and left circumflex (LCX) coronary arteries. Changes in preload (mean left atrial pressure) to maintain a constant stroke volume after coronary occlusion were examined in 18 anesthetized dogs (LAD occlusion in 9 dogs, LCX occlusion in 9 dogs). The level of ischemia was assessed sonomicrometrically. Ventricular function curves relating left atrial pressure to stroke volume were assessed during a control state and after 1 min of coronary occlusion. The extent of preload reserve after coronary occlusion was examined on the ventricular function curves and was defined as the change in mean left atrial pressure required to maintain stroke volume at the level of the control state under conditions of regional ischemia. Ischemic size was determined by a stereo-angiogram after the animals were sacrificed. The extent of preload reserve (X) was linearly related to the ischemic size (Y) in both LAD (Y = 0.90 + 0.16X, r = 0.76, p < 0.001) and LCX (Y = -1.79 + 0.19X, r = 0.79, p < 0.001) occlusions. The slopes of the regression lines in LAD and LCX occlusions were the same. The X intercepts of these lines were -5.6% and 9.4% of the left ventricular weight in LAD and LCX ischemia (p < 0.001), respectively. Thus, the presence of systolic wall motion abnormalities due to coronary occlusion can be compensated for hemodynamically by changes in the preload reserve.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1993

Assessment of left ventricular diastolic function and potential by quantitative analysis of left ventricular filling curves in patients with atrial fibrillation. A new algorithm for Doppler echocardiographic study.

To evaluate left ventricular (LV) diastolic function and potential, LV filling curves for 18 patients with atrial fibrillation (Af) were constructed and their positions and appearance were evaluated quantitatively by analysis of 95% maximal filling volume points and maximal curvature alteration points. The LV filling curves of group A (Af only) lay left superiorly, while those of group B (impaired LV diastolic function) were situated right inferiorly, all bending steeply. The LV filling curves of group C (mitral stenosis) bent slightly. The lowest normal filling volume points and compensation areas were calculated to evaluate LV diastolic function and were demonstrated to be very different in groups A and B. The lowest normal filling volume points of group C were similar to those of group A, but compensation areas were smaller, indicating a lower LV diastolic potential. It is concluded that the 95% maximal filling volume point, maximal curvature alteration point, lowest normal filling volume point and compensation area are effective indices for evaluating not only LV diastolic function but also the diastolic potential.

Algorithms↗

PubMedDate not supplied

Time interval determination from left atrial appendage ejection flow in patients with mitral stenosis.

The feasibility of determining the time interval from left atrial appendage (LAA) flow was examined using transesophageal Doppler echocardiography. Time intervals were compared between LAA flow and mitral flow patterns during late diastole in 8 patients with mitral stenosis and in 12 controls. The start of ejection flow from the LAA was later than the initiation of mitral flow, but the termination was same in both flows, indicating the contribution of LAA ejection to the latter half of the left atrial booster pump function. The pre-ejection time and the time interval from P-wave to end-ejection correlated significantly with left atrial dimensions (r = 0.55, and r = 0.70, respectively). The pre-ejection time, duration of the ejection flow from the LAA, and duration of mitral flow in the atrial contraction phase were significantly longer in patients with mitral stenosis (126 +/- 14 msec, 131 +/- 36 msec, and 167 +/- 28 msec, respectively) than in the controls (109 +/- 13 msec, 108 +/- 15 msec, and 141 +/- 17 msec, respectively). These results indicate that electrical conduction time from the right atrium to LAA can be estimated from the LAA ejection flow, and the time is related to the left atrial size. In patients with mitral stenosis, LAA contraction may contribute to left ventricular filling in the latter half of the atrial contraction phase.

Blood Flow Velocity↗

PubMed2003

Heart rate turbulence after atrial and ventricular premature beats: relation to left ventricular function and coupling intervals.

UNLABELLED: Heart rate turbulence (HRT) represents a biphasic chronotropic response of the sinus node to a single ventricular premature beat (VPB). OBJECTIVES: To determine whether HRT is present after an atrial premature beat (APB) and to investigate the effects of paced VPB and APB coupling intervals on HRT quantifiers in patients with and without left ventricular dysfunction. METHODS: A total of 37 subjects (54 +/- 16 years, 32 men) referred for electrophysiologic evaluation for ventricular tachycardia underwent a stimulation protocol consisting of 3 series of single atrial and ventricular extrastimuli with coupling intervals decremented from 750 to 400 ms at a 50 ms-step. Turbulence onset (TO) and turbulence slope (TS) after an APB and a VPB were calculated separately using a dedicated computer algorithm. RESULTS: After an APB, TS was significantly attenuated (3.95 +/- 0.99 vs 8.32 +/- 1.9 ms/RR, P < 0.008) and TO was positive (1.37 +/- 0.35% vs -2.03 +/- 0.42%, P < 0.001) compared with those after a VPB. There was a strong correlation between TS (r = 0.71, P = 0.0002) but not between TO (r = 0.07, P = 0.074) after an APB and a VPB. In subjects with normal ejection fraction, the prematurity of ventricular coupling intervals was strongly related to TO (r = 0.68) and TS (r = -0.61), P < 0.0001 for both. These effects were less pronounced in patients with left ventricular dysfunction (TO: r = 0.25, P < 0.01; TS: r = -0.07, P = ns). No correlation was found between the APB coupling interval and TS or TO in both groups. CONCLUSIONS: An APB induces HRT but the response is substantially attenuated and is not influenced by the APB coupling interval. In contrast to a VPB, TO is positive after an APB. Lack of correlation between HRT after a VPB and the VBP coupling interval indicates blunted baroreflex response in patients with left ventricular dysfunction.

Atrial Premature Complexes↗

PubMed2001

[Postinfarction remodeling of the left atrium and left ventricle: effects of long-term treatment with beta adrenergic blockers and angiotensin converting enzyme inhibitors].

AIM: To study changes in left atrial volume, geometry and function in myocardial infarction (MI) patients treated with beta-adrenoblocker and ACE inhibitor. MATERIAL AND METHODS: 65 patients with Q-wave myocardial infarction (MI) were followed up for 6 months. Regular check-ups included clinical examination, ECG, echo-CG, dopplercardiography. RESULTS: In MI patients left ventricular remodeling is associated with left atrial remodeling. The greatest inhibition of remodeling in patients with symptoms of cardiac failure was reached with captopril therapy. Atenolol in this respect is less effective. If cardiac failure in MI patients is absent, atenolol impact on the remodeling is stronger than that of captopril. CONCLUSION: In postmyocardial infarction patients remodeling occurs in both heart chambers. The presence of cardiac failure affects remodeling inhibition rate, especially under treatment with beta-adrenoblocker.

Adrenergic beta-Antagonists↗

PubMed1990

An evaluation of right and left ventricular function after anatomical correction and intra-atrial repair operations for complete transposition of the great arteries.

Anatomical correction of complete transposition of the great arteries has the potential advantage over intra-atrial repair in that the left ventricle becomes the systemic pump. To investigate the importance of this, we evaluated right and left ventricular function in 21 patients after anatomical correction and in 21 patients after Mustard or Senning operations. First-pass and equilibrium-gated radionuclide angiography were used to measure right and left ventricular ejection fractions between 17 and 78 (mean, 47) months after anatomical correction and between 3 and 187 (mean, 67) months after intra-atrial repair. The mean age of the patient groups at the time of study was 52 and 84 months, respectively. The right ventricular ejection fraction ranged from 35% to 78% (mean, 58%) in patients after anatomical correction and from 27% to 68% (mean, 51%) after intra-atrial repair (p = 0.066). The left ventricular ejection fraction ranged from 39% to 74% (mean, 58%) after anatomical correction and from 35% to 74% (mean, 58%) after intra-atrial repair (p = 0.86). The mean right and left ventricular ejection fractions of both groups were significantly lower than those of normal children. Individuals with systemic ventricular dysfunction were identified after both types of operations; however, symptomatic dysfunction occurred only after intra-atrial repair (p = 0.24).

Cardiac Surgical Procedures↗

PubMed1983