Mechanical dyssynchrony of the left atrium during sinus rhythm is associated with history of stroke in patients with atrial fibrillation

Ciuffo, Luisa; Inoue, Yuko; Tao, Susumu; İpek, Esra Gücük; Balouch, Muhammad; Lima, João A.C.; Nazarian, Saman; Spragg, David D.; Marine, Joseph E.; Berger, Ronald D.; Calkins, Hugh; Ashikaga, Hiroshi

doi:10.1093/ehjci/jex156

Cited by 26 publications

(27 citation statements)

References 27 publications

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“…Other studies also subsequently demonstrated that increased LA size as characterised by LA volume, even in patients with no prior AF, was predictive of first ischaemic stroke, incremental to other established stroke risk factors 6 21. Evidence from population-based studies indicates that LA enlargement is associated with ischaemic stroke independently of diagnosed AF 22–24. The novelty of our study shows that geometric shape of the LA is more reflective of the blood flow profile within the LA, which mechanistically explains the increased risk of stroke.…”

Section: Discussionsupporting

confidence: 65%

Left atrial cross-sectional area is a novel measure of atrial shape associated with cardioembolic strokes

Tan

Nunes²,

Handschumacher

et al. 2020

Heart

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ObjectiveCardioembolic (CE) stroke carries significant morbidity and mortality. Left atrial (LA) size has been associated with CE risk. We hypothesised that differential LA remodelling impacts on pathophysiological mechanism of major CE strokes.MethodsA cohort of consecutive patients hospitalised with ischaemic stroke, classified into CE versus non-CE strokes using the Causative Classification System for Ischaemic Stroke were enrolled. LA shape and remodelling was characterised by assessing differences in maximal LA cross-sectional area (LA-CSA) in a cohort of 40 prospectively recruited patients with ischaemic stroke using three-dimensional (3D) echocardiography. Flow velocity profiles were measured in spherical versus ellipsoidal in vitro models to determine if LA shape influences flow dynamics. Two-dimensional (2D) LA-CSA was subsequently derived from standard echocardiographic views and compared with 3D LA-CSA.ResultsA total of 1023 patients with ischaemic stroke were included, 230 (22.5%) of them were classified as major CE. The mean age was 68±16 years, and 464 (45%) were women. The 2D calculated LA-CSA correlated strongly with the LA-CSA measured by 3D in both end-systole and end-diastole. In vitro flow models showed shape-related differences in mid-level flow velocity profiles. Increased LA-CSA was associated with major CE stroke (adjusted relative risk 1.10, 95% CI 1.04 to 1.16; p<0.001), independent of age, gender, atrial fibrillation, left ventricular ejection fraction and CHA2DS2-VASc score. Specifically, the inclusion of LA-CSA in a model with traditional risk factors for CE stroke resulted in signiﬁcant improvement in model performance with the net reclassification improvement of 0.346 (95% CI 0.189 to 0.501; p=0.00001) and the integrated discrimination improvement of 0.013 (95% CI 0.003 to 0.024; p=0.0119).ConclusionsLA-CSA is a marker of adverse LA shape associated with CE stroke, reflecting importance of differential LA remodelling, not simply LA size, in the mechanism of CE risk.

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Section: Discussionsupporting

confidence: 65%

Left atrial cross-sectional area is a novel measure of atrial shape associated with cardioembolic strokes

Tan

Nunes²,

Handschumacher

et al. 2020

Heart

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“…Moreover, in individuals with A‐IAB, low LA strain rate during atrial contraction (Sra) by speckle‐tracking echocardiography predicts incident AF and ischemic stroke 8 . LA volumes, strain, dyssynchrony, and fibrosis are also predictors of stroke, 9,10 incident AF, 11 and AF recurrence after catheter ablation 12‐14 . Understanding which features of LA structural remodeling are associated with A‐IAB would improve the diagnostic and prognostic value of 12‐lead ECG.…”

Section: Introductionmentioning

confidence: 99%

Association between interatrial block, left atrial fibrosis, and mechanical dyssynchrony: Electrocardiography‐magnetic resonance imaging correlation

Ciuffo

Bruña

Martínez‐Sellés

et al. 2020

Cardiovasc electrophysiol

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Introduction Advanced interatrial block (IAB) on a 12‐lead electrocardiogram (ECG) is a predictor of stroke, incident atrial fibrillation (AF), and AF recurrence after catheter ablation. The objective of this study was to determine which features of IAB structural remodeling is associated with left atrium (LA) magnetic resonance imaging structure and function. Methods/Results We included 152 consecutive patients (23% nonparoxysmal AF) who underwent preprocedural ECG and cardiac magnetic resonance (CMR) in sinus rhythm before catheter ablation of AF. IAB was defined as P‐wave duration ≥120 ms, and was considered partial if P‐wave was positive and advanced if P‐wave had a biphasic morphology in inferior leads. From cine CMR and late gadolinium enhancement, we derived LA maximum and minimum volume indices, strain, LA fibrosis, and LA dyssynchrony. A total of 77 patients (50.7% paroxysmal) had normal P‐wave, 52 (34.2%) partial IAB, and 23 (15.1%) advanced IAB. Patients with advanced IAB had significantly higher LA minimum volume index (25.7 vs 19.9 mL/m2, P = .010), more LA fibrosis (21.9% vs 13.1%, P = .020), and lower LA maximum strain rate (0.99 vs 1.18, P = .007) than those without. Advanced IAB was independently associated with LA (minimum [P = .032] and fibrosis [P = .009]). P‐wave duration was also independently associated with LA fibrosis (β = .33; P = .049) and LA mechanical dyssynchrony (β = 2.01; P = .007). Conclusion Advanced IAB is associated with larger LA volumes, lower emptying fraction, and more fibrosis. Longer P‐wave duration is also associated with more LA fibrosis and higher LA mechanical dyssynchrony.

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“…The clinical significance of inter‐atrial dyssynchrony has been recently highlighted. It was found to be a putative mechanism for cardioembolic stroke in the absence of atrial fibrillation . In this way, inter‐atrial dyssynchrony can be viewed as a feature of atrial cardiopathy, a syndrome linking LA dysfunction in the absence of atrial fibrillation to increased risk of thromboembolism …”

Section: Discussionmentioning

confidence: 99%

Tissue Doppler‐derived atrial dyssynchrony predicts new‐onset atrial fibrillation during hospitalization for ST‐elevation myocardial infarction

2019

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Background Atrial dyssynchrony, but not atrial enlargement/dysfunction, reflects acute atrial histopathological changes. It has been shown to be associated with new‐onset atrial fibrillation (NOAF) in various clinical conditions but was not studied in the acute phase of ST‐elevation myocardial infarction (STEMI) which is the aim of the current study. Methods A total of 440 STEMI patients underwent primary percutaneous coronary intervention (PCI) and were monitored for NOAF during hospitalization. Immediately after primary PCI, P‐wave dispersion was calculated and conventional/tissue Doppler echocardiography was done. Results During a median hospitalization period of 3 days, 80 (18.2%) patients developed NOAF. The group with NOAF showed significantly higher prevalence of hypertension (P = .049), higher P‐wave dispersion (P = .018), higher post–PCI‐corrected TIMI frame count (P < .001), and lower incidence of post‐PCI myocardial blush grade 2–3 (P = .031). Indexed left atrial maximum volume (LAVImax), left atrial dyssynchrony, and inter‐atrial dyssynchrony were significantly higher in NOAF group (P < .001, each). Using ROC curve analysis, inter‐atrial dyssynchrony showed the highest diagnostic performance (AUC 85%, 95% CI: 0.77–0.94, P < .001). A cutoff value at 23.8 ms showed a good validity for predicting NOAF with a sensitivity of 93.8% and a specificity of 68.1%. Using binary logistic regression analysis, history of hypertension (OR = 10.72, P = .03), LAVImax (OR = 7.47, P = .04), and inter‐atrial dyssynchrony (OR = 45.58, P = .001) were independent determinants of NOAF. Conclusions In the acute phase after STEMI, history of hypertension, LAVImax, and inter‐atrial dyssynchrony were independent determinants of inhospital NOAF, with the latter being the strongest.

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Mechanical dyssynchrony of the left atrium during sinus rhythm is associated with history of stroke in patients with atrial fibrillation

Abstract: Higher mechanical dyssynchrony of the LA during sinus rhythm is associated with a history of stroke/TIA in patients with AF.

Cited by 26 publications

References 27 publications

Left atrial cross-sectional area is a novel measure of atrial shape associated with cardioembolic strokes

Left atrial cross-sectional area is a novel measure of atrial shape associated with cardioembolic strokes

Association between interatrial block, left atrial fibrosis, and mechanical dyssynchrony: Electrocardiography‐magnetic resonance imaging correlation

Tissue Doppler‐derived atrial dyssynchrony predicts new‐onset atrial fibrillation during hospitalization for ST‐elevation myocardial infarction

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