Atrial Conduction Delay Predicts Atrial Fibrillation in Paroxysmal Supraventricular Tachycardia Patients after Radiofrequency Catheter Ablation

This study aimed to assess whether intra- and inter-atrial conduction delay could predict atrial fibrillation (AF) for paroxysmal supraventricular tachycardia (PSVT) patients after successful treatment by radiofrequency catheter ablation (RFCA). Echocardiography examination was performed on 524 consecutive PSVT patients (15 patients were excluded). Left atrial dimension, right atrial diameter and intra- and inter-atrial conduction delay were measured before ablation. Patients were divided into group A (n = 32): occurrence of AF after the ablation and group B (n = 477): remained in sinus rhythm during follow-up. Receiver operating characteristic (ROC) curve analysis was performed to estimate the predictive value of intra- and inter-atrial conduction delay. Both intra- and inter-atrial conduction delay were higher in group A than in group B (4.79 ± 0.30 msec vs. 4.56 ± 0.32 msec; 21.98 ± 1.32 msec vs. 20.01 ± 1.33; p < 0.05). Binary logistic regression analysis showed that intra- and inter-atrial conduction were significant influential factors for the occurrence of AF (odds ratio [OR] = 13.577, 95% confidence interval [CI], 3.469–48.914; OR = 2.569, 95% CI, 1.909−3.459, p < 0.05). The ROC cure analysis revealed that intra-atrial conduction delay ≥ 4.45 msec and inter-atrial conduction delay ≥ 20.65 were the most optimal cut-off value for predicting AF in PSVT patients after RFCA. In conclusion, this is the first study to show that the intra- and inter-atrial conduction delay could effectively predict AF in post-ablation PSVT patients.     

Patent foramen ovale in patients with tension headache: is it as common as in migraineurs? An age- and sex-matched comparative study

The association of patent foramen ovale (PFO) and atrial septal aneurysm (ASA) with migraine headache attack (MHA) has been clearly shown. The same findings have been recently demonstrated also in cluster headache. Although tension-type headaches (TTH) are the most common kind of headache, their association with these atrial septal abnormalities has never been studied before. The study was conducted to clarify whether there was a significant association between the presence of such atrial septal abnormalities and tension headache, when compared with migraineurs. One hundred consecutive patients with migraine and 100 age- and sex-matched subjects with TTH and 50 healthy volunteers with no headache were enrolled in the study and underwent a complete transesophageal echocardiographic study with contrast injections at rest and with the Valsalva maneuver. There was no significant difference between the age and the sex of the participants of the three groups. The overall prevalence of PFO was 23% in patients with TTH and that of large PFOs was only 11%. The 23% prevalence of PFO in patients with TTH was not statistically different from 16% found in our normal control group. Furthermore, we found a significantly higher prevalence of PFO in migraineurs (50%) when compared with patients with tension headache (p < 0.001). This was also true for the collective presence of large PFOs and ASAs (35%) (p < 0.001). Although atrial septal anomalies have an association with MHA, they do not have a significant association with TTH.     

Determinants of plasma NT-pro-BNP levels in patients with atrial fibrillation and preserved left ventricular ejection fraction

Objectives  The present study aimed to investigate the clinical and echocardiographic determinants of plasma NT-pro-BNP levels in patients with atrial fibrillation (AF) and preserved left ventricular ejection fraction (LVEF). Methods  NT-pro-BNP levels were measured in 45 patients with paroxysmal AF, 41 patients with permanent AF and 48 controls. Results  NT-pro-BNP levels were found significantly elevated in patients with paroxysmal (215 ± 815 pg/ml) and permanent AF (1,086 ± 835 pg/ml) in relation to control population (86.3 ± 77.9 pg/ml) (P < 0.001). According to the univariate linear regression analysis, age, hypertension, β-blocker use, left atrial diameter (LAD), LVEF and AF status (paroxysmal or permanent or both) were significantly associated with NT-pro-BNP levels (P < 0.05). In multiple linear regression analysis, LVEF (B coefficient: −53.030; CI: −95.738 to −10.322; P: 0.015) and LAD (B coefficient: 285.858; CI: 23.731–547.986; P: 0.033) were significant and independent determinants of NT-pro-BNP levels. Conclusions  Plasma NT-pro-BNP levels were significantly higher in patients with paroxysmal and permanent AF compared to those with sinus rhythm in the setting of preserved left ventricular systolic function. LVEF and LAD were independent predictors of NT-pro-BNP levels.     

Mitral annular velocity by Doppler tissue imaging for the evaluation of atrial stunning after cardioversion of atrial fibrillation

Objective Atrial and/or appendage stunning (AS) usually occur after successful cardioversion of atrial fibrillation (AF). Several parameters except mitral annular velocity were previously evaluated to determine AS. We investigated whether mitral annular velocity was useful for determining of AS. Methods This study consisted of 52 consecutive patients with AF <3 months who converted to the sinus rhythm. Mitral inflow and annular velocities were measured before and after cardioversion. Left atrial appendage (LAA) size and flow were assessed. The average velocity of septal and lateral segments of mitral annulus was considered as the final annular velocity. Thrombus and/or spontaneous echo contrast (SEC) were also investigated. Results Of 52 patients, 29 (56%) had AS but 23 did not. There was no significant difference in age, gender, and cardioversion type between two groups. Hypertension was more prevalent in patients without AS compared to those with AS (P = 0.02). Mitral annular systolic and E-wave velocities were comparable in both groups (P > 0.05). Mitral annular A-wave velocity (3.1 ± 2.9 vs. 7.1 ± 2.2 cm/s, P < 0.001), and its velocity-time integral (0.27 ± 0.22 vs. 0.74 ± 0.19 cm, P < 0.001) were significantly lower in patients with AS compared with those without AS. The annular A-wave velocity ≤3.3 cm/s predicted AS with a sensitivity of 59% and specificity of 76%. It was correlated with mitral inflow A velocity (r = 0.85, P < 0.001), LAA emptying velocity (r = 0.41, P = 0.003) and presence of SEC (r = −0.52, P < 0.001). Conclusion After cardioversion of AF, mitral annular A-wave velocity may be a new marker to determine AS.     

Characterization of the Left Atrial Vortex Flow by Two-Dimensional Transesophageal Contrast Echocardiography Using Particle Image Velocimetry

This article is the first clinical investigation of the quantitative left atrial (LA) vortex flow by two-dimensional (2-D) transesophageal contrast echocardiography (2-D-TECE) using vector particle image velocimetry (PIV). The aims of this study were to assess the feasibility of LA vortex flow analysis and to characterize and quantify the LA vortex flow in controls and in patients with atrial fibrillation (AF). Thirty-five controls and 30 patients with AF underwent transesophageal contrast echocardiography. The velocity vector was estimated by particle image velocimetry. The morphology and pulsatility of the LA vortex flow were compared between the control and AF groups. In all patients, quantitative LA vortex flow analysis was feasible. In the control group, multiple, pulsatile, compact and elliptical-shaped vortices were seen in the periphery of the LA. These vortices were persistently maintained and vectors were directed toward the atrioventricular inflow. In the AF group, a large, merged, lower pulsatile and round-shaped vortex was observed in the center of the LA. In comparisons of vortex parameters, the relative strength was significantly lower in the AF group (1.624 ± 0.501 vs. 2.105 ± 0.226, p < 0.001). It is feasible to characterize and quantify the LA vortex flow by transesophageal contrast echocardiography in patients with AF, which offers a new method to obtain additional information on LA hemodynamics. The approach has the potential for early detection of the LA dysfunction and in decisions regarding treatment strategy and guiding anticoagulation treatment in patients with AF.     

Factors associated with the development of atrial fibrillation in patients with rheumatic mitral stenosis

The aim of this study was to evaluate the factors associated with the development of atrial fibrillation (AF) in patients with rheumatic mitral stenosis (MS). A total of 146 consecutive patients with rheumatic MS were screened. They were accepted to be in AF group and sinus rhythm group according to their rhythm in the baseline ECG. After screening, 38 patients were excluded due to hyperthyroidism (n = 13), chronic obstructive pulmary disease (n = 22), malignancy (n = 2) and romatoid arthritis (n = 1). Therefore, remaining 108 patients, 74 of whom in sinus rhythm (MS-SR) and 34 of whom in AF (MS-AF) constituted study population. Fourty age- and gender-matched patients constituted control group. Factors associated with development of AF in multivariable analysis included High sensitivity C reactive protein (P = 0.005; odds ratio, 3.44; 95% confidence interval, 1.44–8.22), N-terminal of brain natriuretic peptide precursor (P < 0.0001; odds ratio, 1.03; 95% confidence interval, 1.02–1.06) and left atrial diameter (P < 0.0001; odds ratio, 1.68; 95% confidence interval, 1.32–2.14). Present study suggests that High sensitivity C reactive protein, N-terminal of brain natriuretic peptide precursor and left atrial diameter are associated with development AF in patients with MS.     

Impact of Atrial Fibrillation Termination on Clinical Outcome after Ablation in Relation to the Duration of Persistent Atrial Fibrillation

Background: Whether procedural termination of persistent atrial fibrillation (AF) is necessary for optimal clinical efficacy still remains controversial. We sought to characterize the patients with persistent AF in whom procedural AF termination impacted an improved clinical outcome after ablation. Methods: We retrospectively assessed 132 patients (61.0 ± 9.3 years, 114 males) undergoing catheter ablation of persistent AF (duration 3 years, median). A stepwise ablation approach including pulmonary vein isolation and atrial substrate ablation targeting complex fractionated and high‐frequency electrograms was performed with desired endpoint of AF termination. Results: Overall, 90 patients (68%) were free from recurrent arrhythmias at 20 ± 11 months of follow‐up after one or two procedures. The left atrial diameter and continuous AF duration according to medical history were associated with the outcome (P = 0.002 and P< 0.001, respectively). In multivariate Cox regression analysis, the continuous AF duration was the only independent predictor of recurrent arrhythmias (hazard ratio 1.17, 95% confidence interval 1.10–1.23, P < 0.001). In patients with AF duration of ≥3 years, the clinical success was comparable regardless of whether AF termination was achieved or not (log‐rank, P = 0.27). In the remaining patients with AF duration of <3 years, procedural AF termination was associated with a higher arrhythmia‐free rate than when AF was sustained after ablation (log‐rank, P = 0.023). Conclusion: Extensive ablation to terminate AF might not be warranted in patients with a longer AF duration. On the contrary, procedural AF termination could be associated with maintenance of sinus rhythm in patients with a shorter AF duration with a less proarrhythmic substrate. (PACE 2012;35:1436–1443)     

Distinct impacts of heart rate and right atrial‐pacing on left atrial mechanical activation and optimal AV delay in CRT

1 Background

Controversy exists regarding how atrial activation mode and heart rate affect optimal atrioventricular (AV) delay in cardiac resynchronization therapy. We studied these questions using high‐reproducibility hemodynamic and echocardiographic measurements.

2 Methods

Twenty patients were hemodynamically optimized using noninvasive beat‐to‐beat blood pressure at rest (62 ± 11 beats/min), during exercise (80 ± 6 beats/min), and at three atrially paced rates: 5, 25, and 45 beats/min above rest, denoted as A_paced,r+5, A_paced,r+25, and A_paced,r+45, respectively. Left atrial myocardial motion and transmitral flow were timed echocardiographically.

3 Results

During atrial sensing, raising heart rate shortened optimal AV delay by 25 ± 6 ms (P < 0.001). During atrial pacing, raising heart rate from A_paced,r+5 to A_paced,r+25 shortened it by 16 ± 6 ms; A_paced,r+45 shortened it 17 ± 6 ms further (P < 0.001). In comparison to atrial‐sensed activation, atrial pacing lengthened optimal AV delay by 76 ± 6 ms (P < 0.0001) at rest, and at ～20 beats/min faster, by 85 ± 7 ms (P < 0.0001), 9 ± 4 ms more (P  =  0.017). Mechanically, atrial pacing delayed left atrial contraction by 63 ± 5 ms at rest and by 73 ± 5 ms (i.e., by 10 ± 5 ms more, P < 0.05) at ～20 beats/min faster. Raising atrial rate by exercise advanced left atrial contraction by 7 ± 2 ms (P  =  0.001). Raising it by atrial pacing did not (P  =  0.2).

4 Conclusions

Hemodynamic optimal AV delay shortens with elevation of heart rate. It lengthens on switching from atrial‐sensed to atrial‐paced at the same rate, and echocardiography shows this sensed‐paced difference in optima results from a sensed‐paced difference in atrial electromechanical delay. The reason for the widening of the sensed‐paced difference in AV optimum may be physiological stimuli (e.g., adrenergic drive) advancing left atrial contraction during exercise but not with fast atrial pacing.     

Evaluation of right ventricular and right atrial size in children with atrial septal defect using two-dimensional apex echocardiography

The ability of two-dimensional apex echocardiography to evaluate right ventricular and right atrial size was evaluated in 43 normal children and compared with 20 patients with a secundum atrial septal defect. From the apical four chamber view, the long axis length and short axis diameter of the right ventricle and right atrium were measured. The end-diastolic area of the right ventricle and end-systolic area of the right atrium were determined by planimetry. These data were indexed for body surface area. When compared with normal subjects, the area index of the right atrium and right ventricle were enlarged significantly in patients with a secundum atrial septal defect (p < 0.001 and p < 0.001, respectively). Mean values for the short axis dimension of the right ventricle and for the short axis and long axis diameter of the right atrium were greater in atrial septal defect patients than in normal subjects (p < 0.001 for all). However, when both groups were compared, considerable overlap existed between the dimension measurements. Right ventricular long axis length failed to separate the two groups. Thus, two-dimensional apex echocardiography provides a noninvasive means of assessing right ventricular and right atrial size in children with an atrial septal defect.     

Left ventricular long-axis function in treated haemochromatosis

We recently demonstrated reduced exercise capacity in treated genetic haemochromatosis, in spite of normal radial left ventricular (LV) systolic function assessed by 2-dimensional echocardiography at rest. It remains unknown if haemochromatosis-related impairment of LV long-axis function can be demonstrated also at rest. LV long-axis function was assessed by echocardiography including spectral tissue Doppler of systolic (S′) and early (E′) diastolic velocities in 105 treated haemochromatosis patients and 50 controls. Patients had higher body mass index, systolic atrioventricular excursion, and smaller LV end-systolic diameter (all P < 0.05). Other conventional echocardiographic variables did not differ. S′ was normal in both groups, though significantly higher among the patients (11.1 vs. 9.9 cm/s, P < 0.001). In multiple regression analysis, higher S′ was associated with having haemochromatosis, independently of significant contributions from higher atrioventricular excursion and LV length, and lower body mass index and E/E′-ratio (multiple R ² = 0.44, P < 0.001). E′ did not differ between patients and controls. However, in multivariate analysis lower E′ was associated with having haemochromatosis independently of significant contributions from higher age and diastolic blood pressure, and lower transmitral E and end-diastolic LV length (multiple R ² = 0.57, P < 0.001). The long-axis function in the haemochromatosis group was normal. Still haemochromatosis, even in this group of patients treated with regular phlebotomy, influenced both systolic and early diastolic long-axis function, and was associated with higher atrioventricular excursion and S′, and with lower E′.     

Outcome in patients with left common pulmonary vein after cryoablation with second‐generation cryoballoon

1 Background

Pulmonary vein isolation (PVI) has become a widely accepted therapy in patients suffering from symptomatic atrial fibrillation (AF).

2 Hypothesis

AF‐free survival differs in patients with left common pulmonary vein (LCPV) after PVI with second‐generation cryoballoon.

3 Methods

We included patients scheduled for first PVI for paroxysmal or persistent AF. Symptomatic and/or documented arrhythmia episodes (>30 seconds) were defined as AF recurrence, excluding a 3‐month blanking period.

4 Results

We observed a LCPV in 37 of 270 consecutive patients (13.7%). Analyses were performed in a 1:1 propensity score matched cohort of 68 patients. During a median follow‐up of 77.0 weeks, 37 patients (54.4%) had recurrent AF. The prevalence of LCPV was numerically higher in patients with AF recurrence (62.2% vs 35.5%, P  =  0.051) and Kaplan‐Meier analysis showed lower AF‐free survival in patients with existence of a LCPV (P  =  0.028). At 1‐year follow‐up, 70.6% of patients without versus 55.1% of patients with LCPV were free of AF. Multivariate Cox regression analysis revealed presence of a LCPV (hazard ratio [HR]: 2.996), chronic heart failure (HR: 3.423), and mitral regurgitation > I° (HR: 2.571) as predictors of AF recurrence.

5 Conclusion

Patients with LCPV had significantly reduced AF‐free survival after ablation with the second‐generation cryoballoon, despite similar acutely successful PVIs.     

Migraineurs with patent foramen ovale have larger right-to-left shunt despite similar atrial septal characteristics

The objective of the study was to assess differences in proportion of large right-to-left shunt (RLS) and atrial septal characteristics between migraineurs and non-migraineurs referred for transcatheter closure of patent foramen ovale (PF0). This retrospective study took place in a large metropolitan medical centre. The patients were migraineurs with aura (n=52), migraineurs without aura (n=19) and non-migraineurs (n=149). RLS was evaluated before closure using bilateral power m-mode transcranial Doppler at rest and after calibrated, sustained Valsalva manoeuvre, and graded with a validated 0–5 scale. Intracardiac echocardiography was used to assess atrial septal characteristics. Migraineurs had a higher proportion of large RLS (Grade IV or V) than nonmigraineurs at rest and after calibrated Valsalva (rest, p=0.04; Valsalva, p=0.01). Atrial septal characteristics were similar between groups. Migraine is associated with larger RLS at rest and strain; however migraine status does not predict PFO characteristics.     

PAR1 contribution in acute electrophysiological properties of oral anticoagulants in rabbit pulmonary vein sleeve preparations

Whether oral anticoagulants, vitamin K antagonists (VKAs), and nonvitamin K oral anticoagulant (NOACs) frequently prescribed to atrial fibrillation (AF) patients, do themselves have a pro‐ or anti‐arrhythmic effect have never been addressed. Transmembrane action potentials were recorded in an acute rabbit model of superfused pulmonary veins (PVs) sleeves preparations using standard microelectrode technique. Fluindione 10 μm (n = 6) increased the AP (action potential) duration (APD), induced a significantly V_max depression (from 95 ± 14 to 53 ± 5 V/s, P < 0.05), and 2 : 1 blocks during rapid atrial pacing thus evoking class I anti‐arrhythmic properties, and prevented spontaneous trigger APs. Apixaban 10 μm (n = 6) increased the APD, significantly prolonged the effective refractory period (from 56.3 ± 4.2 to 72.0 ± 8.6 ms, P < 0.05), and prevented triggered APs occurrence. Fluindione and apixaban effects were suppressed with the addition of the protease‐activated receptors 1 (PAR 1) agonist SFLLR‐NH₂. Warfarin 10 μm (n = 6) significantly abbreviated the early refractory period (from 56.3 ± 4.2 to 45.0 ± 2.2 ms, P < 0.05) and increased triggered APs occurrence that were successfully prevented by nifedipine but not by the addition of the protease‐activated receptors 1 agonist SFLLR‐NH₂. In this acute rabbit PVs model, VKAs and NOACs, at physiological concentrations, exhibited very different pharmacological properties that influence PVs electrophysiology, implying PAR1, with fluindione and apixaban which exhibited more anti‐arrhythmic properties, whereas warfarin exhibited more pro‐arrhythmic properties.     

Risk Factors of Adverse Presentation as the First Arrhythmia in Wolff‐Parkinson‐White Syndrome

Background: The aim of the study was the evaluation of the predictors of adverse presentation as first arrhythmia in Wolff‐Parkinson‐White syndrome; they usually affect young patients with septal or multiple accessory pathways (AP). Methods: Our population comprised 645 patients with a preexcitation syndrome. Among them, adverse presentation (sudden death, hemodynamically not tolerated atrial fibrillation [AF]) occurred in 60 (9%) (group I). Their clinical and electrophysiological features were compared to group II patients, which consisted of 75 patients with syncope (IIa), 287 with reentrant tachycardia (RT) (IIb), 211 asymptomatic patients (IIc), and 12 with well‐tolerated AF. Results: Sixteen group I patients had triggering factors. Group I patients were older (40 ± 18.5) than group II (34 ± 16) (P = 0.02). Male gender was as frequent in both groups (63%, 59%). Free wall left AP was more frequent in group I (65%) than in group II (37%) (P < 0.001), septal AP less frequent (27% vs 47%) (P = 0.004), multiple APs exceptional. RT was more frequent in group I (57%) than in group IIc (12%) (P < 0.001), less frequent than in group IIb (90.5%) (P < 0.001). AF was more frequent in group I (85%) than in group IIc (22%), or IIb (19%) (P < 0.001). Maximal rate through AP was higher in group I than in group II (P < 0.001). Conclusions: Adverse presentation in WPW may affect patients older than 35 years of both sexes, with a single free wall lateral AP. All could have been identified by an electrophysiological study. (PACE 2010; 33:1074–1081)     

Correlation of right ventricular ejection fraction and tricuspid annular plane systolic excursion in tetralogy of Fallot by magnetic resonance imaging

The correlation between right ventricular ejection fraction (RVEF) and tricuspid annular plane systolic excursion (TAPSE) by two-dimensional (2-D) echo has been repeatedly validated, but not by magnetic resonance imaging (MRI) nor in patients with congenital heart disease. We tested whether TAPSE measurements by MRI correlate with RVEF in surgically repaired tetralogy of Fallot (TOF) patients. TAPSE was measured from systolic displacement of the RV-freewall/tricuspid annular plane junction in the apical 4-chamber view in 7 normal subjects and 14 TOF patients. The RV was reconstructed in 3-D from manually traced borders on MR images to compute true EF. Because we previously observed discrepancy between TAPSE and RVEF in the presence of regional dysfunction, we also analyzed RV wall motion in terms of regional stroke volume at 20 short axis slices from apex to tricuspid annulus. RVEF was 52 ± 3% in normal subjects and 41 ± 9% in TOF (P < 0.01). TAPSE correlated weakly (r = 0.50, P < 0.05) with RVEF. TOF patients exhibited increased regional stroke volume from apical portions of the RV and decreased regional stroke volume at the base compared to normal (P < 0.05 at 15 of 20 slices). Regional stroke volume in apical slices correlated inversely with RVEF such that patients with higher apical stroke volume had lower RVEF (P < 0.05). TAPSE is not a reliable measure of RVEF in TOF by MRI. TAPSE may be of limited use in conditions that exhibit abnormal regional contraction.     

Atrial fibrillation—

Summary Objective Patients with atrial fibrillation (AF) have a risk of cerebral embolism. Echocardiographic parameters elevate this risk significantly. However, there is little knowledge about the long–term fate and the rate of clinically silent cerebral embolism under continued oral anticoagulation. The aims of our study were to assess prognosis of patients with AF and determine a high risk group with an increased risk of cerebral embolism under oral anticoagulation. Methods Consecutive patients with persistent or permanent AF and left atrial (LA) thrombi, dense spontaneous echo contrast (SEC) and/or reduced LA appendage peak emptying velocities (LAAv) were included in the study (N = 128). Patients with AF and without echocardiographic risk factors (N = 114) served as controls. All patients were examined with transesophageal echocardiography, cranial magnetic resonance imaging and clinically during a period of three years. Results During the three–year follow–up period 6 (5%) of the high risk patients had cerebral embolism with neurological deficits. 4 (3%) patients died due to embolic events and 17 (13%) patients had silent embolism as documented on MRI. In the control group 8 (7%) patients had embolic events (n = 1 clinically apparent and n = 7 silent embolism) documented on MRI, one was clinically apparent. Study patients with an event had more commonly previous thromboembolism (p < 0.0001). Conclusions Patients with peristent or permanent AF and LA thrombi, dense SEC or reduced LAAv have an explicitly increased risk of cerebral embolism (21%) despite oral anticoagulation. Previous thromboembolic event is another important predictor for an event.     

Left atrial electromechanical conduction time predicts atrial fibrillation in patients with mitral stenosis: a 5-year follow-up speckle-tracking echocardiography study

Prolonged left atrial electromechanical conduction time is related with atrial electrical remodeling, and is predictive of the development of atrial fibrillation. The aim of our study was to examine whether left atrial electromechanical conduction time (EMT) and left atrial strain as measured by speckle tracking echocardiography (STE) are predictors for the development of atrial fibrillation (AF) in patients with mitral stenosis (MS) at 5-year follow-up. A total of 81 patients (61% females; mean age 38.1?±?12.1 years) with mild or moderate MS of rheumatic origin according to ACC/AHA guidelines who were in sinus rhythm, and were asymptomatic or have NYHA class 1 symptom were included in the study. AF was searched by 12-lead electrocardiograms or 24-h Holter recordings during follow-up period. Atrial electromechanical conduction time (EMT), peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) were measured by STE. EMTs was defined as the interval between the onset of P-wave to the peak late diastolic longitudinal strain in the basal lateral and septal wall. During the follow-up period of 5 years (mean follow-up duration, 48.2?±?13.3 months), 30 patients (37%) developed AF on standard 12-lead ECG or at their 24-h Holter recording. At follow-up, patients who developed AF were older than patients without AF (42.4?±?11.3 vs. 35.6?±?11.9, p?=?0.014). Mitral valve area (MVA) (1.39?±?0.14 vs. 1.48?±?0.18, p?=?0.03), PALS (13.4?±?4.6 vs. 19?±?5.2, p?<?0.001) and PACS (6?±?2.7 vs. 8.4?±?3.8, p?=?0.004), were lower in patients who developed AF than in patients who did not develop. However, EMTs-Septal (208.2?±?28.4 vs. 180.2?±?38, p?=?0.001), and EMTs-Lateral (247.1?±?27.6 vs. 213.3?±?43.5, p?<?0.001) were longer in patients with AF than in patients without. In multivariate Cox regression analysis, PALS and left atrial EMTs-Lateral were independent predictors for development of AF at follow-up. In patients with mitral stenosis, left atrial strain and electromechanical conduction time in the lateral wall during the long term follow-up period are predictive for the development of atrial fibrillation. Speckle tracking echocardiography is a basic and easily-implemented method based on left atrial parameters which may be helpful for early detection of atrial fibrillation in patients with mitral stenosis.     

Incremental predictive value of pre-procedural N-terminal pro-B-type natriuretic peptide for short-term recurrence in atrial fibrillation ablation

The objective of this work was to assess the predictive value of pre-procedural N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients undergoing atrial fibrillation (AF) ablation. Seventy-three consecutive patients with AF (paroxysmal n = 49, persistent n = 24) and preserved left ventricular (LV) systolic function (LV ejection fraction > 45%) were prospectively enrolled in this study. All of the enrolled patients underwent catheter ablation after a measurement of their plasma NT-proBNP levels, and an echocardiographic examination with assessment of their LV diastolic function and left atrial(LA) volume. Patients with AF recurrence at 3 months had more persistent AF (P = 0.001), a higher LA volume index (P = 0.002), lesser decelerating times (DT) of mitral inflow (P = 0.014), and higher NT-proBNP levels (P < 0.001), when compared with patients with sinus rhythm restoration. The baseline log NT-proBNP correlated significantly with age (r = 0.26, P = 0.025), LA volume index (r = 0.41, P = 0.001), E/E’ (r = 0.34, P = 0.007), DT (r = −0.34, P = 0.007), and E (r = 0.25, P = 0.04). The log NT-proBNP (HR 7.76, 95% CI 2.95–20.39, P < 0.001) was an independent predictor of AF recurrence. The measurement of NT-proBNP added incremental predictive value to standard indexes of LA size or diastolic function, including LA volume index and DT (P = 0.02). This study suggests the clinical utility of the level of NT-proBNP as an integrating marker of various risk factors, and as an incremental predictive marker for AF catheter ablation. Dr. Hwang and Dr. Son contributed equally to this work.     

Impact of atrial fibrillation on NT-proBNP levels in a 75-year-old population

Objective: The objective of this study was to investigate the impact of atrial fibrillation (AF) on serum levels of N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) in a 75-year-old population. Methods: All 75-year-old citizens in Asker and Baerum counties in Norway were invited to participate in a prevalence study of AF. Blood samples for measurement of NT-proBNP were collected at rest from 61 subjects with AF and a gender-matched control group of 126 subjects in sinus rhythm. NT-proBNP was measured in serum using the Elecsys proBNP sandwich immunoassay (Roche Diagnostics, Basel, Switzerland). Results: Subjects with permanent AF had higher levels of NT-proBNP (median 1119pg/mL (interquartile range 701, 1643)) than subjects with paroxysmal AF (257pg/mL (169, 382)) and controls (95pg/mL (60, 171)), p<0.001 for both. The presence of AF was still significantly associated with higher log NT-proBNP (B=0.61, p<0.001) after adjusting for the presence of heart failure, coronary heart disease and hypertension. Conclusion: In this stable, out-of-hospital population of 75-year-old subjects, AF was independently associated with increased levels of NT-proBNP. Permanent AF was associated with higher NT-proBNP levels than paroxysmal AF.     

The efficacy of tissue Doppler imaging in predicting myocardial iron load in patients with beta-thalassemia major: correlation with T2* cardiovascular magnetic resonance

Tissue Doppler imaging (TDI) can detect myocardial dysfunction related to iron load in patients with beta-thalassemia major (TM). We aimed to assess the efficacy of pulsed-wave TDI (PW-TDI) in predicting myocardial iron load in patients with TM using T2* magnetic resonance (MR) as the gold-standard non-invasive diagnostic test. 33 asymptomatic TM patients, mean aged 18 ± 6 years (6–31) with normal left ventricular (LV) global systolic function were evaluated by conventional echocardiography and PW-TDI. Results were compared with 20 age and sex-matched controls. TDI measures included myocardial systolic (Sm), early (Em) and late (Am) diastolic velocities at basal and middle segments of septal and lateral LV wall. Myocardial iron deposition were measured in 29/33 patients by T2* MR. TM patients were also subgrouped according to those with iron load (T2* ≤ 20 ms) and those without (T2* > 20 ms). Mean T2* was 12.3 ± 7.8 ms (4–31.3). Abnormal myocardial iron load (T2* < 20 ms) was found in 25/29 (86%) patients. The following TDI measures were lower in patients than in controls: basal septal Em (P < 0.001) and Am (P < 0.05), mid-septal Am (P < 0.05), mid-lateral LV wall Sm (P < 0.05) and Am (P < 0.05). Regional myocardial dysfunction were more prominent in patients with T2* ≤ 20 ms. Mid-septal Sm and Em significantly correlated with mid-septal T2*(r = 0.44, P = 0.023 and r = 0.54, P = 0.004, respectively). The PW-TDI parameters and the cut-off values for predicting presence of myocardial iron load were determined. PW-TDI technique was found both sensitive and specific in predicting presence of myocardial iron load in TM patients with normal LV global systolic function. Therefore, it can be used for screening of TM patients.