E Evaluation of Left Atrial Functions in Patients with Dilated Cardiomyopathy Using Conventional echocardiography and Strain Imaging
DOI:
https://doi.org/10.28922/qmj.v18i2.813Keywords:
Dilated cardiomyopathy; Left Atrial Functions; NYHA class; Speckle-tracking echocardiography.Abstract
background
Dilated cardiomyopathy (DCM) is characterized by a dilated left ventricle with systolic dysfunction that is not caused by ischemic or valvular heart disease.
Left atrial (LA) size is a predictor of adverse cardiovascular outcome both in the general population and in selected clinical conditions. The left atrium modulates left ventricular filling through three components: a reservoir phase during systole, a conduit phase during diastole and an active contractile component during late diastole. During diastole the LA is directly exposed to the left ventricular (LV) cavity pressure. With progressive impairment of LV diastolic function, and the consequent increase in LV end-diastolic pressure, the LA increases in size with a reduction of both the LA passive emptying and conduit functions, with a compensatory increase of the active LA emptying, at least in the first stages of LV diastolic dysfunction.
Methods
The study included 50 patients with the diagnosis of DCM (NYHA class I to IV and normal sinus rhythm) and 10 healthy control subjects. Two-dimensional (2D) conventional echocardiography was performed to assess LV dimensions, volumes, ejection fraction (EF), fractional shortening (FS), wall thickness, LA diameter, LA area, Mitral annular plane systolic excursion (MAPSE). Mitral E-wave (E) and A-wave (A) velocities, as well as their ratio (E/A), E’ wave and E/E’ ratio were measured. LA volumes including maximum (at the end of systole), minimum (at the end of diastole) and pre A LA volumes (before atrial contraction) were measured using the modified Simpson method. LA emptying volume (LAEV) and emptying fraction (LAEF), passive emptying volume (LAPEV) and passive emptying fraction (LAPEF) and active emptying volume (LAAEV) and active emptying fraction (LAAEF) were calculated in apical four-chamber view. We measured the peak LA strain, and strain rate during systole and late diastole using speckle tracking echocardiography in both apical four-chamber and apical two-chamber views.
Results
Patients with DCM showed a significant increase in LA volumes (Maximum, Minimum and Pre-A volumes) compared with the control group. LAEV and LAEF (reservoir function), LAPEV and LAPEF (conduit function) were significantly lower in patients with DCM compared to normal subjects. No significant difference was observed in LAAEV and LAAEF (pump function) between patients and controls. LA strain and LA strain rate and late diastolic strain rate values were decreased in patients with DCM. A negative correlation between LA strain measured in septal, lateral, anterior, and inferior walls and NYH class was observed. Only LAEV and LAEF (reservoir function) was correlated with NYHA class.
Conclusion
In patients with DCM, LA volumes, LA reservoir, Conduit, and pump functions were significantly reduced. Atrial myocardial deformation properties, assessed by strain and strain rate imaging, are abnormal in patients with DCM. The severity of
HF symptoms correlated positively with the LA reservoir function and negatively with the LA strain parameters. These findings suggest that LA systolic and diastolic dysfunction assessed either by conventional echocardiography or speckle tracking imaging could be related to reduced functional capacity in patients with DCM.
References
2. Appleton CP, Galloway JM, Gonzales MS, Gaballa M, Basnight MA. Estimation of left ventricular filling pressure using two-dimensional and Doppler echocardiography in adult patients with cardiac disease: additional value of analyzing left atrial size, left atrial ejection fraction and the difference in duration of pulmonary venous and mitral flow velocity at atrial contraction. J Am Coll Cardiol 1993;22:1972–82.
3. Rossi A, Golia G, Gasparini G, Prioli MA, Anselmi M, Zardini P. Left atrial filling volume can be used to reliably estimate the regurgitant volume in mitral regurgitation. J Am Coll Cardiol 1999;33:212–7.
4. Moller JE, Hillis GS, Oh JK, Seward JB, Reeder GS, Wright RS, Park SW, Bailey KR, Pellikka PA. Left atrial volume: a powerful predictor of survival after acute myocardial infarction. Circulation. 2003;107:2207–2212.
5. Tsang TS, Abhayaratna WP, Barnes ME, et al. Prediction of cardiovascular outcomes with left atrial size: is volume superior to area or diameter? J Am Coll Cardiol 2006;47:1018–23.
6. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440–63.
7. Mor-Avi V, Yodwut C, Jenkins C, et al. Real-time 3D echocardiographic quantification of left atrial volume: multicenter study for validation with magnetic resonance imaging. J Am Coll Cardiol Img 2012;5:769–77.
8. Miyasaka Y, Tsujimoto S, Maeba H, et al. Left atrial volume by realtime three-dimensional echocardiography: validation by 64-slice multidetector computed tomography. J Am Soc Echocardiogr 2011; 24:680–6.
9. Artang R, Migrino RQ, Harmann L, Bowers M, Woods TD. Left atrial volume measurement with automated border detection by 3-dimensional echocardiography: comparison with magnetic resonance imaging. Cardiovasc Ultrasound 2009;7:16.
10. Barbier P, Solomon SB, Schiller NB, Glantz SA. Left atrial relaxation and left ventricular systolic function determine left atrial reservoir function. Circulation 1999;100:427–36.
11. Payne RM, Stone HL, Engelken EJ. Atrial function during volume loading. J Appl Physiol 1971;31:326.
12. Chinali M, de Simone G, Roman MJ, Bella JN, Liu JE, Lee ET, et al. Left atrial systolic force and cardiovascular outcome. The Strong Heart Study. Am J Hypertens. 2005;18(12 Pt 1):1570–6.
13. Appleton CP, Kovacs SJ. The role of left atrial function in diastolic heart failure. Circ Cardiovasc Imaging. 2009; 2(1):6–9.
14. Castello R, Pearson AC, Lenzen P, et al. Evaluation of pulmonary venous flow by transesophageal echocardiography in subjects with a normal heart: comparison with transthoracic echocardiography. J Am Coll Cardiol. 1991; 18:65–71. [PubMed: 2050943]
15. Matsuda Y, Toma Y, Ogawa H, Matsuzaki M, Katayama K, Fujii T. Importance of left atrial function in patients with myocardial infarction. Circulation 1983;67:565–71.
16. Toutouzas, K.; Trikas, A.; Pitsavos, C.; Barbetseas, J.; Androulakis, A.; Stefanadis, C.; Toutouzas, P. Echocardiographic features of left atrium in elite male athletes. Am. J. Cardiol. 1996, 78, 1314–1317.
17. Smiseth OA, Thompson CR, Lohavanichbutr K, et al. The pulmonary venous systolic flow pulse—its origin and relationship to left atrial pressure. J Am Coll Cardiol 1999;34:802–9.
18. Appleton CP. Hemodynamic determinants of Doppler pulmonary venous flow velocity components: new insights from studies in lightly sedated normal dogs. J Am Coll Cardiol 1997;30:1562–74.
19. Castello R, Pearson AC, Lenzen P, Labovitz AJ. Evaluation of pulmonary venous flow by transesophageal echocardiography in subjects with a normal heart: comparison with transthoracic echocardiography. J Am Coll Cardiol 1991;18:65–71.
20. Nakatani S, Garcia MJ, Firstenberg MS, et al. Noninvasive assessment of left atrial maximum dP/dt by a combination of transmitral and pulmonary venous flow. J Am Coll Cardiol 1999;34:795– 801.
21. De Piccoli B, Rigo F, Ragazzo M, Zuin G, Martino A, Raviele A. Transthoracic and transesophageal echocardiographic indices predictive of sinus rhythm maintenance after cardioversion of atrial fibrillation: an echocardiographic study during direct current shock. Echocardiography 2001;18:545–52.
22. Thomas L, Levett K, Boyd A, Leung DYC, Schiller NB, Ross DL. Changes in regional left atrial function with aging: evaluation by Doppler tissue imaging. Eur J Echocardiogr 2003;4:92–100.
23. Sutherland GR, Di Salvo G, Claus P, D’hooge J, Bijnens B. Strain and strain rate imaging: a new clinical approach to quantifying regional myo-cardial function. J Am Soc Echocardiogr 2004;17:788–802.
24. Kim DG, Lee KJ, Lee S, Jeong SY, Lee YS, Choi YJ, et al. Feasibility of two-dimensional global longitudinal strain and strain rate imaging for the assessment of left atrial function: a study in subjects with a low probability of cardiovascular disease and normal exercise capacity. Echocardiography 2009;26:1179–87.
25. Brian D. Hoit. Left Atrial Size and Function. J Am Coll Cardiol 2014;63:493–505.
26. Quinones MA, Otto CM, Stoddard M, Waggoner A, ZoghbiWA. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. Jam Soc Echocardiogr 2002;15:167-84.
27. Alam M, Hoglund C, Thorstrand C, Philip A. Atrioventricular plane displacement in severe congestive heart failure following dilated cardiomyopathy or myocardial infarction. J Intern Med 1990;228:569–75.
28. Toma Y, Matsuda Y, Moritani K, Ogawa H, Matsuzaki M, Kusukawa R. Left atrial filling in normal human subjects: relation between left atrial contraction and left atrial early filling. Cardiovasc Res 1987;21:255-9.
29. Mustafa Kurt; Jianwen Wang;Guillermo Torre-Amione; Sherif F. Nagueh, Left Atrial Function in Diastolic Heart Failure. Circ Cardiovasc Imaging. 2009;2:10-15.
30. D’Andrea A, Caso P, Romano S, Scarafile R, Riegler L, Salerno G, Limongelli G, Di Salvo G, Calabro` P, Del Viscovo L, Romano G, Maiello C, Santangelo L, Severino S, Cuomo S, Cotrufo M, Calabro` R. Different effects of cardiac resynchronization therapy on left atrial function in patients with either idiopathic or ischaemic dilated cardiomyopathy: a two-dimensional speckle strain study. Eur Heart J. 2007;28:2738 –2748.
31. Prioli A, Marino P, Lanzoni L, Zardini P. Increasing degrees of left ventricular filling impairment modulate left atrial function in humans. Am J Cardiol. 1998;82:756 –761.
32. Matsuda Y, Toma Y, Ogawa H, Matsuzaki M, Katayama K, Fujii T, et al. Importance of left atrial function in patients with myocardial infarction. Circulation 1983;67:565-71.
33. LeungDY, Boyd A, NgAA, Chi C, Thomas L. Echocardiographic evaluation of left atrial size and function: current understanding, pathophysiologic correlates, and prognostic implications. Am Heart J 2008;156:1056-64.
34. Maryam Esmaeilzadeh; Farveh Vakilian; Majid Maleki; Ahmed Amin; Sepideh Taghavi; Hooman Bakhshandeh. Evaluation of Left Atrial Two-Dimensional Strain in Patients with Systolic Heart Failure using Velocity Vector Imaging. Arch Cardiovasc Image. 2013 November; 1(2): 51-7
35. Russo C, Jin Z, Homma S, Rundek T, Elkind MS, Sacco RL, Di Tullio MR. Left atrial minimum volume and reservoir function as correlates of left ventricular diastolic function: impact of left ventricular systolic function. Heart 2012; 98: 813-820
36. Ohno M, Cheng CP, Little WC. Mechanism of altered patterns of left ventricular filling during the development of congestive heart failure. Circulation 1994; 89: 2241-50.
37. Bilen Emine, Kurt Mustafa, Halil Tanboga, Ibrahim, Kocak Umran, Ayhan Huseyin, Durmaz, Tahir, et al. Assessment of left atrial phasic functions in heart failure patients with preserved or low ejection fractions. Cardiology 2012; 40: 122-8.
38. Mahmoud K. Ahmed, Mahmoud A. Soliman, Ahmed A. Reda, Rania S. abd El-Ghani. Assessment of left atrial deformation properties by speckle tracking in patients with systolic heart failure. The Egyptian Heart Journal (2015) 67, 199-208.
39. Daniel A. Morris, Mudather Gailani, Amalia Vaz P_erez, Florian Blaschke, Rainer Dietz, Wilhelm Haverkamp, and Cemil Ozcelik. Left Atrial Systolic and Diastolic Dysfunction in Heart Failure with Normal Left Ventricular Ejection Fraction. (J Am Soc Echocardiogr 2011;24:651-62.)
