Atrial cardiopathy in young adults with embolic stroke of undetermined source: a myocardial deformation imaging analysis

Abstract

Background Atrial cardiopathy (AC) has emerged as a potential pathological thrombogenic atrial substract of embolic stroke of undetermined source (ESUS), even in the absence of atrial fibrillation. Left atrium (LA) myocardial deformation analysis may be of value as a subclinical marker of AC and a predictor of ESUS. Aims To compare LA mechanical function between ESUS cases and age and sex-matched controls. Methods A single-center analytical study with case-control design was performed. Case group was composed by young patients admitted in the Neurology department from January 2017 to June 2021. Control group was composed by age and sex matched controls recruited from the community. All participants performed echocardiogram and a smaller sample underwent cardiac magnetic resonance. Results We recruited 31 ESUS patients aged between 18 and 65 years and 31 age and sex matched controls. ESUS patients had a significantly higher prevalence of cardiovascular risk factors and patent foramen ovale (PFO). The prevalence of AC was not different between groups. Echocardiogram parameters, including strain analysis, were similar between groups, except for LA appendage (LAA) ostium variation which was significantly lower in ESUS patients (absolute: 6.5vs8.7mm, p<0.001; relative: 44.5%vs53.4%, p=0.002). After exclusion of patients with PFO, all the results were statistically similar. Regarding cardiac magnetic resonance analysis, there were no statistically significant differences between groups. Conclusion This study shows that in our population atria cardiopathy and atrial function was not associated with ESUS.LAA structural and functional abnormalities may play a major role. The role of LAA in ESUS warrants further studies.

Altered left atrial metrics in patients with cryptogenic stroke: A systematic review and meta‐analysis

“…We initially identified 6897 articles, with 4292 excluded as duplicates and 2402 excluded as nonrelevant based on title and abstract screening. Full text was examined in 200 articles, with 29 fulfilling inclusion criteria for data analysis 6,7,14–40 …”

“…We therefore examined meta‐regression bubble plots and performed an exclusion analysis to identify outlier studies for sources of influence. A number of studies were identified over all meta‐analysis studies, with resolution of heterogeneity observed following their exclusion 6,16,21–23,26,28,30,32,34,35,37,39 . Notably, the majority of outlier studies were observed in studies comparing CS‐ESUS to HC, indicating probable unidentified clinical covariates in patients compared with healthy participants.…”

“…visible outlier studies, and also performed a rigorous exclusion protocol by sequentially leaving out one or more studies from each analysis, in order to identify influential studies for potential sources of variation (Table 4). 6,16,[21][22][23]26,28,30,32,34,35,37,39 Following outlier omission, variability was significantly reduced for all LA metrics, after controlling for age (I 2 < 40% for all variables). Due to the number of outlier studies, potential for pooled effect bias/distortion, reduction in generalizability following exclusion and lack of single obvious cause of outlier status, 13 we maintained these studies within the analysis and performed a thorough exploration for sources of discrepancy.…”

“…A number of studies were identified over all meta-analysis studies, with resolution of heterogeneity observed following their exclusion. 6,16,[21][22][23]26,28,30,32,34,35,37,39 Notably, the majority of outlier studies were observed in studies comparing CS-ESUS to HC, indicating probable unidentified clinical covariates in patients compared with healthy participants. In addition, meta-analysis examining the advanced measurement of LASr had a number of outlier studies which may indicate technical limitations.…”

“…42 Some variation in study design was observed as two studies demonstrated lower risk-of-bias score, 23,35 and five studies began patient enrolment in 2010 or earlier, 6,21,28,30,35 which we conject may have played a role in image acquisition and analysis due to earlier ultrasound systems and older TTE guidelines. Importantly, five outlier studies enrolled ≤31 participants in comparator groups 16,30,32,35,39 while only 10 studies were considered large scale (>100 participants), thereby reducing the power, precision and generalizability of results. While initial heterogeneity was high, after controlling for age and excluding outlier studies, residual heterogeneity of <40% for all metrics indicates our overall findings of differences between CS-ESUS patients and comparator subgroups are robust; however, we do advise caution at this stage in regard to clinical application of measurements.…”