Prognostic Value of Left Atrial Size and Function James D. Thomas, M.D., F.A.C.C. Cardiovascular Imaging Center Department of Cardiology Cleveland Clinic Foundation Cleveland, Ohio, USA Conflicts: None LAfxn:1
Now, that s a BIG Atrium! Almost a liter! LAfxn:2
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Assessment of LA Size Recommendations from ASE Guidelines M-mode Area-length Simpson s rule Lang et al. JASE 2005; 18: 1440 LAfxn:4
Assessment of LA Size Recommendations from ASE Guidelines Normal: 22±6 ml/m 2 Lang et al. JASE 2005; 18: 1440 LAfxn:5
Dimension, Area, or Volume? Indexed LA Volume Appears Best 423 pts (317 in SR) followed 3.5 ± 2.3 years for 1 st AF, CHF, CVA/TIA, MI, revascularization, CV death All size parameters were significant predictors or events, but volume index was superior Tsang et al. JACC 2006; 47: 1018-23 LAfxn:6
LA Volume and Prognosis Independent prognostic index Heart failure (Rossi A et al J Am Coll Cardiol 2002;40:1425) MI (Beinart R et al J Am Coll Cardiol 2004;44:327) Mitral regurgitation (Messika-Zeitoun et al Eur Heart J 2007;28:1773) Beinart R et al J Am Coll Cardiol 2004;44:327 LAfxn:7
LA Volume Predicts Incidence of AF 1655 pts without AF followed 4.0 ± 2.8 years 189 (11.4%) developed AF LA size strongly associated with incidence of AF Cumulative risks of AF by quartiles of LA volume were 3%, 12%, 15%, and 26%, respectively Tsang et al. Mayo Proc 2001; 76: 467-75 LAfxn:8
LA Size Predicts AF Recurrence Results from AFFIRM 2474 pts in SR at risk for recurrent AF Overall 46% recurred at 1 year, 84% at 5 years Recurrence associated with LA diameter (1.21, 1.16, 1.32 for 4.1-4.5 cm, 4.6-5.5 cm and >5.5 cm) Olshansky et al. JACC 2005; 45: 2026-33 LAfxn:9
Indexed LA Volume More Predictive of AF Recurrence n = 411, at least 6 month f/u ROC curve area: LA diameter = 0.59 vs 0.84 for ilav, p<0.001 Marchese et al. EJE 2011; 12: 214-21 LAfxn:10
LA Size Predicts Outcome in MR LA size predicts post-operative survival and incidence of a fib Reed D et al Circulation 1991; 84:23; Kernis SJ Circulation 2004; 110:2320 LAfxn:11
LA Volume and MR LA volume predicts occurrence of a fib and combined end-point of death or surgery < Messika-Zeitoun et al Eur Heart J 2007;28:1773 LAfxn:12
LA Size and Function 3D Echo vs MRI Bauer F et al. J Am Soc Echocardiogr 2004;17:968 LAfxn:14
LA volume 2D vs. 3D Correlation between LA volume measured by these two-methods are modest (Muller H et al Echocardiography 2007; 24:960). 2D underestimates LA volume (Maddukuri PV et al J Am Soc Echocardiogr 2006;19:1026) LAfxn:16
Maximum LA volume by RT3DE Association with Diastolic Dysfunction Positive correlation with: LV mass, E velocity, E/A ratio, and E/E` ratio Negative correlation with: LV EF and A` velocity De Castro et al Am J Cardiol 2008;101:1347 LAfxn:17
Atrial Systolic Function Complicated by Having Two Outlets and No Isovolumic Period Mitral Valve A Pulmonary Vein AR LAfxn:18
Three Components of Atrial Function Pump Conduit E A Reservoir S D AR LAfxn:19
LA Pressure & Volume Reservoir, Conduit, and Pump LA Volume (ml) 105 90 75 60 45 30 15 0 R C 1 2 3 4 0 120 240 360 480 600 720 840 Time LA LA Pressure Pressure (mmhg) LAP P LAV Bauer et al. JASE 2005; 18: 795-801 14 12 10 8 6 4 2 0 17 15 A-Loop 13 11 9 7 5 V-Loop R P C 20 30 40 50 60 70 LA Volume 80 LAfxn:20
LA elastance & stiffness LA Pressure (mmhg) 23 B N 7 V A Bauer et al. JASE 2005; 18: 795-801 Maximal elastance 5 10 LA Volume (ml) Volume Baseline Nitroprusside Stiffness Angiotensin LAfxn:21
Left Atrial Elastance Active Component Much Smaller than LV 2.5 2.0 Elastance (mmhg/ml) 1.5 1.0 0.5 V-zero (ml) 12.0 6.0 0.0 0.0 100.0 200.0 300.0 400.0 Time (msecs) Alexander Circ Res. 61:209;1987 LAfxn:22
LA Pressure-Diameter in Acute Mitral Regurgitation 60 LA Pressure (mmhg) 40 20 0 C Mod Severe 15 24 33 LA Diameter (mm) Sasayama et al. Circ. 60:177;1979 LAfxn:23
Left atrial pressure (mm Hg) Left atrial pressure (mmhg) LA pressure-volume loops LAD occlusion LCx occlusion 8 before occlusion 30 before occlusion 6 after occlusion a 20 after occlusion a 4 2 a 10 a 0 0 10 20 30 40 Left atrial volume (ml) 0 0 25 50 75 100 Left atrial volume (ml) Bauer et al. JASE 2005; 18: 795-801 LAfxn:24
Left atrial pressure (mmhg) Left atrial pressure (mmhg) LA elastance & stiffness 30 25 20 15 10 5 0 LAD occlusion A y = 1.9x - 21 r = 0.98 0.025x y = 5.8e y = 1.8x - 19 0.021x y = 5.8e r = 0.96 0 20 40 60 Left atrial volume (ml) 25 20 15 10 5 0 LCx occlusion B y = 1.4x - 3 r = 0.89 y = 0.8x - 2 y = 4.2e 0.043x y = 4.2e 0.027x r = 0.98 0 10 20 30 40 Left atrial volume (ml) Bauer et al. JASE 2005; 18: 795-801 LAfxn:25
Atrial Function in AF Pump function Effectively zero, except for tiny fibrillatory waves Reservoir and conduit function These remain, but because of loss of pump function, mean LA pressure increases, moving passive LA loop upward and to the right and onto steeper PV curve Left atrial appendage function Marker for LA systolic potential LAfxn:26
Why Is This Important?? Sinus Rhythm Atrial Fibrillation ECG ECG LAAF LAAE LAAE LAA velocity is often lower post DCC than pre Thus, patients are at higher risk for LAA clot following DCC Even if cleared by TEE, patients need anticoagulation following DCC Grimm et al. JACC 1997; 29: 582-589 LAfxn:27
Left Atrial Appendage Stunning Resolves Within Two Weeks of Ablation n = 16 A flutter Day 1 SR Day 7 SR Day 14 SR Takami et al. JACC 2003; 41: 2207-11 LAfxn:28
Yamada et al. JASE 2004;17:813 LAfxn:29
Recovery of LA Pressure and Function After 3 Hours of Pacing-Induced AF Yamada et al. JASE 2004;17:813 LAfxn:30
Recovery of Transmitral Flow After 3 Hours of Pacing-Induced AF Yamada et al. JASE 2004;17:813 LAfxn:31
Recovery of LV Function After 3 Hours of Pacing-Induced AF Yamada et al. JASE 2004;17:813 LAfxn:32
LA Function and Prognosis Reduced total LA emptying fraction linked to increased risk for first episode of atrial fibrillation in the elderly population Abhayaratna WP et al. Am J Cardiol 2008;101:1626 LAfxn:33
LA Remodeling vs Recurrence Results from GISSI-AF 340 pts post DCC Overall 54% recurred at 1 year Analyzed for groups with no recurrence and tertiles of AF duration (1-6d, 7-58d, and 59+d) Pt with less AF had favorable remodeling No impact of valsartan treatment Staszewsky et al. Circ Img 2011; 4: 711-8 LAfxn:34
LA Strain and Strain Rate Application of Speckle Tracking Saraiva et al. JASE 2010; 23: 172-80 LAfxn:35
Positive strain Age-dependence of positive and negative strain Total strain Negative strain Saraiva et al. JASE 2010; 23: 172-80 LAfxn:36
Speckle Tracking for Left Atrial Strain 498 Patients with Negative Stress Echo 40 strain (%) Positive peak 20 0 0.3 0.6 0.9 Time (sec) Total -20 Negative peak 4 chamber view 2 chamber view ECG Kusunose, et al. Heart 2012; 98: 1311-17 LAfxn:37
Speckle Tracking for Left Atrial Strain Prediction of Functional Capacity METs Total LA Strain (%) Kusunose, et al. Heart 2012; 98: 1311-17 LAfxn:38
Left atrial function Exercise Performance (METs) 15 Male Prediction range of METs 12 Female 9 LA strain total 6 90th percentile 50th percentile 10th percentile 3 20 40 60 80 Age (years old) Kusunose, et al. Heart 2012;98: 1311-1317. Welles, et al. JACC 2012;59: 673-680. LAfxn:39
Cardiovascular Imaging LAfxn:40