Incremental diagnostic role of left atrial strain analysis in thrombotic risk assessment of nonvalvular atrial fibrillation patients planned for electrical cardioversion

Sonaglioni, Andrea; Lombardo, Michele; Nicolosi, Gian Luigi; Rigamonti, Elisabetta; Anzà, Claudio

doi:10.1007/s10554-020-02127-6

Cited by 14 publications

(15 citation statements)

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“…On the other hand, a STE analysis focused only on LAA myocardial strain and SR parameters, even if validated in previous studies at the population level [ 17 – 19 ], appears to not improve the echocardiographic prediction of LA stasis in NVAF patients, mostly in the risk assessment for each individual patient. Furthermore, a STE analysis should be used for detecting a subclinical cardiac dysfunction [ 50 – 52 ] rather than confirming an overt cardiac dysfunction, such as a LAAT and/or dense SEC.…”

Section: Discussionmentioning

confidence: 91%

“…Moreover, other Authors employed a STE analysis focused only on LAA myocardial strain and SR parameters in NVAF patients [ 17 – 19 ]. These studies all revealed a severe impairment in LAA deformation indices in NVAF patients with LAAT in comparison to those without.…”

Section: Discussionmentioning

confidence: 99%

“…Differently from previous studies which separately analyzed LA and LAA strain parameters by TTE [ 9 – 16 ] and TEE [ 17 – 19 ] respectively, the present study performed a concomitant analysis of both LA and LAA myocardial deformation indices in the same NVAF patients.…”

Section: Discussionmentioning

confidence: 99%

“…These studies demonstrated that impaired LA deformation could effectively predict LAAT in NVAF patients. On the other hand, only a few studies have employed TEE with STE methodology for the assessment of LAA myocardial strain and strain rate (SR) parameters in NVAF patients [ 17 – 19 ]; however, those, as well as previous studies [ 9 – 16 ], did not concomitantly investigate both LA and LAA deformation indices in the same patients. Accordingly, the present research was designed to investigate whether a correlation exists between LA and LAA myocardial strain parameters measured by both TTE and TEE in the same patients, and whether this could possibly be exploited to predict presence of LAA thrombi in a population of NVAF patients undergoing ECV, without the need for TEE.…”

Section: Introductionmentioning

confidence: 99%

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Mechanical concordance between left atrium and left atrial appendage in nonvalvular atrial fibrillation: can it be exploited to avoid transesophageal echocardiography prior to electrical cardioversion during Covid-19 pandemic?

Sonaglioni

Lombardo

Nicolosi³

et al. 2021

Int J Cardiovasc Imaging

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Transesophageal echocardiography (TEE) is the gold standard for assessing left atrial appendage (LAA) mechanic and thrombosis (LAAT); however, TEE is a high-risk procedure for viral transmission during coronavirus disease 2019 (COVID-19) pandemic. We investigated whether deformation indices of left atrium (LA) at transthoracic echocardiography (TTE) correlate with those of LAA assessed by TEE in nonvalvular atrial fibrillation (NVAF) patients undergoing electrical cardioversion (ECV). Consecutive patients with NVAF of ≥ 48 h or unknown duration, who underwent TEE and TTE at our Institution before ECV were retrospectively investigated. Standard echo-Doppler and LA and LAA myocardial strain and strain rate parameters were analyzed. A total of 115 NVAF patients (71.3 ± 8.1 yr/o, 59.1% men) were included: LAAT was diagnosed in 25 (21.7%) patients. Compared to patients without LAAT, those with LAAT had significantly higher CHA 2 DS 2 -VASc Risk score (4.5 ± 1.4 vs. 3.5 ± 1.1, p < 0.001), and lower ejection fraction (46.0 ± 14.8 vs. 57.6 ± 8.6%, p < 0.001). In LAAT patients, global strain of LA (8.7 ± 2.6 vs. 16.3 ± 4.5%, p < 0.001) and LAA (7.0 ± 1.7 vs. 11.7 ± 2.0%, p < 0.001) was significantly reduced compared to non-LAAT patients. A close relationship between left atrial strain reservoir (LASr) and LAA-global strain was demonstrated (r = 0.81). By univariable analysis, CHA 2 DS 2 -VASc Risk Score (OR 2.01, 95%CI 1.34–3.00), NT-proBNP (OR 1.36, 95%CI 1.19–1.54), ejection fraction (OR 0.92, 95%CI 0.88–0.96), E/e’ ratio (OR 2.07, 95%CI 1.51–2.85), and LASr (OR 0.39, 95%CI 0.25–0.62) were strongly associated with LAAT presence at TEE. By multivariable analysis, only LASr (OR 0.40, 95%CI 0.24–0.70) retained statistical significance. ROC curve analysis revealed that an LASr cut-off value ≤ 9.3% had 98.9% sensibility and 100% specificity to identify LAAT by TEE (AUC = 0.98). In patients with NVAF of ≥ 48 h or unknown duration, scheduled to undergo ECV, LA deformation assessment by TTE might substitute invasive measurement of LAA function by TEE, simplifying diagnostic approach and possibly contributing to reduce COVID-19 infection diffusion. Supplementary Information The online version contains supplementary material available at 10.1007/s10554-021-02414-w.

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Mechanical concordance between left atrium and left atrial appendage in nonvalvular atrial fibrillation: can it be exploited to avoid transesophageal echocardiography prior to electrical cardioversion during Covid-19 pandemic?

Sonaglioni

Lombardo

Nicolosi³

et al. 2021

Int J Cardiovasc Imaging

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“…An increasing number of studies have demonstrated that the morphology of the LAA is closely associated with the risk of stroke, with more than 90% of thrombosis occurring in the LAA among patients with nonvalvular atrial fibrillation (NVAF). 1,2 Currently, left atrial appendage occlusion (LAAO) is considered an ideal alternative treatment for preventing embolic stroke in patients with NVAF. 3 Standard LAAO (SLAAO) typically involves the use of X-rays, general anesthesia, endotracheal intubation, mechanical ventilation and transesophageal echocardiographic (TEE) guidance, especially in those centers at the beginning of their experience.…”

Section: Introductionmentioning

confidence: 99%

A preliminary study of minimal left atrial appendage occlusion using Watchman under the guidance of fluoroscopy

Ruan,

Li,

Jin

et al. 2023

Cathet Cardio Intervent

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BackgroundLeft atrial appendage occlusion (LAAO) has been considered an alternative treatment to prevent embolic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, it carries a risk of general anesthesia or esophageal injury if guided by transesophageal echocardiography (TEE).AimsWe aimed to investigate the feasibility and safety of minimal LAAO (MLAAO) using Watchman under fluoroscopy guidance alone in patients with NVAF.MethodsA total of 249 consecutive patients with NVAF who underwent LAAO using the WATCHMAN device were divided into two groups: the Standard LAAO (SLAAO) group and the MLAAO group. Procedural characteristics and follow‐up results were compared between the two groups.ResultsThere was no statistically significant difference in the rate of successful device implantation (p > 0.05). Fluoroscopy time, radiation exposure dose, and contrast medium usage in the MLAAO group were higher than those in the SLAAO group (p < 0.001). The procedure time and hospitalization duration were significantly lower in the MLAAO group than those in the SLAAO group (p < 0.001). The occluder compression ratio, measured with fluoroscopy, was lower than that measured with TEE (17.63 ± 3.75% vs. 21.69 ± 4.26%, p < 0.001). Significant differences were observed between the SLAAO group and the MLAAO group (p < 0.05) in terms of oropharyngeal/esophageal injury, hypotension, and dysphagia. At 3 months after LAAO, the MLAAO group had a higher incidence of residual flow within 1−5 mm compared to the SLAAO group, although the difference was not statistically significant.ConclusionMLAAO guided by fluoroscopy, instead of TEE, without general anesthesia simplifies the operational process and may be considered safe, effective, and feasible, especially for individuals who are unable to tolerate or unwilling to undergo TEE or general anesthesia.

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A quantitative gain‐independent assessment of the left atrial appendage as a method of thromboembolic risk stratification

Slostad

Lee

Trybula

et al. 2021

J of Clinical Ultrasound

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Background: Visual assessment of the left atrial appendage (LAA) by echocardiography for the presence of thrombus is inherently qualitative. However, whether quantitative assessments can provide increased value over qualitative assessment has not been thoroughly examined.Methods: One hundred and thirty-eight patients (mean age 59 ± 13 years, 70% male) undergoing transesophageal echocardiography prior to pulmonary vein isolation or electrical cardioversion were retrospectively studied. LAA were examined by two expert readers and identified as thrombus, sludge, spontaneous echocardiograph contrast, or normal.LAA were then separately examined to calculate a gain-independent ratio between the average pixel density of the LAA cavity and that of the LAA wall (C/W ratio).Results: C/W ratio was significantly related with qualitative LAA analysis (p < 0.0001) and with thromboembolic events (OR 1.60, 95% CI 1.095-2.347, p = 0.02). The C/W ratio (AUC 0.73, 95% CI 0.60-0.86) was a reliable predictor for future thromboembolic events when compared to expert reader LAA assessment (Expert Reader 1 AUC = 0.72, 95% CI 0.53-0.90; Expert Reader 2 AUC = 0.69). Conclusions:The C/W ratio may be a complementary method to adjudicate thromboembolic risk in patients with AF that is readily quantifiable at time of TEE.

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Incremental diagnostic role of left atrial strain analysis in thrombotic risk assessment of nonvalvular atrial fibrillation patients planned for electrical cardioversion

Cited by 14 publications

References 50 publications

Mechanical concordance between left atrium and left atrial appendage in nonvalvular atrial fibrillation: can it be exploited to avoid transesophageal echocardiography prior to electrical cardioversion during Covid-19 pandemic?

Mechanical concordance between left atrium and left atrial appendage in nonvalvular atrial fibrillation: can it be exploited to avoid transesophageal echocardiography prior to electrical cardioversion during Covid-19 pandemic?

A preliminary study of minimal left atrial appendage occlusion using Watchman under the guidance of fluoroscopy

A quantitative gain‐independent assessment of the left atrial appendage as a method of thromboembolic risk stratification

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