Underestimation of left atrial volume by three-dimensional echocardiography validated by magnetic resonance imaging: a meta-analysis and investigation of the source of bias

Background: Left atrial volume (LAV) is a fundamental prognostic factor in a variety of cardiac diseases including atrial fibrillation, heart failure, and valvular diseases. Developing a repeatable, noninvasive, and accurate method of measuring LAV is crucial. Three‐dimensional echocardiography (3DE) has achieved better estimation of LAV than two‐dimensional echocardiography. However, underestimation of LAV by 3DE has often been reported and no previous study has synthesized these data. The present study aimed at revealing existence and extent of bias in LAV measurement by 3DE and investigating related factors affecting the bias. Methods: Studies comparing LAV between 3DE and magnetic resonance imaging published before August 15, 2011 were eligible. A meta‐analysis with random effects model was performed to evaluate the systematic bias. Factors affecting the bias were investigated by univariate followed by multivariate analysis. Results: A total of 14 studies including 395 subjects revealed underestimation of LAV by 3DE (?9.4 mL; 95% confidence interval, ?13.2 to ?5.6mL; P < 0.00001, Fig. 2 ). Existence of cardiac disease led to more underestimation, whereas increasing the number of plane included in the analysis counteracted the underestimation (P < 0.00001 for each comparison). Conclusions: Only by synthesizing a number of small studies as a meta‐analysis could we display underestimation of LAV by 3DE and factors influencing the systematic bias. These data provide a more detailed basis for analyzing and improving the accuracy of 3DE, an indispensable step toward further clinical application in LAV assessment. (Echocardiography 2012;29:385‐390)

Figure 2 Open in figure viewer PowerPoint Meta‐analysis of difference in left atrial volume between 3D‐echocardiography and magnetic resonance imaging. Note the significant underestimation of left atrial volume by 3D‐echocardiography. 3DE = three‐dimensional echocardiography; CI = confidence interval; Max = maximal volume; Min = minimal volume; MRI = magnetic resonance imaging; Nl = normal subjects; pl = planes; Pt = patients.     

Effects of Right Coronary Artery PTCA on Variables of P‐Wave Signal Averaged Electrocardiogram

Background: P‐wave signal averaged ECG has been used to detect atrial late potentials that were found in paroxysmal atrial fibrillation. Ischemia is supposed to trigger ventricular late potentials, which indicate an elevated risk for ventricular tachycardia. Preexistent ventricular late potentials measured by ventricular signal averaged ECG is supposed to be eliminated by successful PTCA. Methods: We examined the incidence of atrial late potentials in patients with a proximal stenosis of the right coronary artery and new onset of atrial fibrillation. Furthermore, we investigated the anti‐ischemic effect of a successful percutaneous transluminal coronary angioplasty.(PTCA) of the right coronary artery. P‐wave signal averaged ECG from 23 patients who had a PTCA of the right coronary artery (group A) were compared to age, sex, and disease‐matched control subjects (group B) one day before, one day after, and one month after PTCA. Results: A new appearance of paroxysmal atrial fibrillation was presented in eight patients before PTCA (group A1) of group A. Patients with a stenosis of the right coronary artery had a significantly higher incidence of supraventricular extrasystoles in a 24‐hour‐Holter ECG (131.1 ± 45.4 vs 17.1 ± 18.9, P < 0.0002 ). The duration of the filtered P wave was longer (124.8 ± 11.9 vs 118.5 ± 10.1 ms, P < 0.04 ) and the root mean square of the last 20 ms (RMS 20) was significantly lower in group A than in group B (2.87 ± 1.09 vs 3.97 ± 1.12 μV, P < 0.01 ). A successful PTCA caused an increase in RMS 20 (2.87 ± 1.11 vs 4.19 ± 1.19 μV, P < 0.02 ) and a decrease in filtered P‐wave duration (124.8 ± 11.9 vs 118.4 ± 10.4 ms, P < 0.04 ). Preexistent atrial late potentials were found among 15 patients before PTCA. After successful PTCA only 3 out of 15 patients were affected (P < 0.0004) after one day, as well as after one month. All patients with a history of atrial fibrillation did not suffer from an arrhythmic recurrence within the following six months after successful PTCA. Conclusion: A stenosis of the right coronary artery is associated with atrial late potentials. A successful PTCA of the right coronary artery eliminates preexistent atrial late potentials and may reduce the risk of atrial fibrillation.     

The impacts of transcatheter occlusion for congenital atrial septal defect on atrial volume, function, and synchronicity in children: a three-dimensional echocardiography study

Objective: To evaluate the impacts of transcatheter closure for atrial septal defect (ASD) on the atria. Methods: Thirty‐four patients with ASD undergoing transcatheter occlusion were recruited in the study, and 34 patients undergoing surgical operation and 34 healthy children were age‐matched as controls. A real time three‐dimensional (RT3DE) echocardiography was used to measure the volume, function, and synchronicity of the atria. Results: There was no difference in the atrial volume and function between the transcatheter occlusion group and healthy control group (P > 0.05). However, the parameters reflecting the atrial asynchrony were larger in the transcatheter occlusion group (P < 0.05). Compared to the surgical repair group, the transcatheter occlusion group had smaller maximum volume of the left atrium (21.0 ± 5.2 ml/m² vs 24.3 ± 5.8 ml/m², P = 0.01), smaller total emptying volume of the left atrium (12.7 ± 4.3 ml/m² vs 15.1 ± 3.8 ml/m², P = 0.014), smaller total emptying volume of the right atrium (13.5 ± 5.2 ml/m² vs 16.1 ± 4.7 ml/m², P = 0.029), and larger atrial systolic asynchrony indices. Conclusions: An atrial asynchrony is observed in patients with transcatheter closure of ASD, although little negative impacts on the atrial volume and function are demonstrated, which deserves more attention during follow‐up of this specific population.     

Assessment of Interventricular Dyssynchrony by Real Time Three‐Dimensional Echocardiography: An In Vitro Study in a Porcine Model

Background: Loss of synchronous contraction between or within the right and left ventricle (RV, LV) leads to adverse ventricular function. We used real time three‐dimensional echocardiography (RT3DE) for evaluation of severity of interventricular dyssynchrony and function in a porcine heart model. Methods: Six fresh in vitro porcine hearts were used to create a controlled model of LV and RV dyssynchrony using two sets of pulsatile pumps. Synchronized and dyssynchronized pump settings were used with two different dyssynchronized settings: LV filled first and RV filled first. Results: There was good correlation between actual measurement and RT3DE for interventricular time difference (r = 0.95, P < 0.0001) and stroke volume (SV) for LV and RV (0.89, 0.85; P < 0.0001, respectively). RT3DE data showed a small but significant underestimation for actual volume (P < 0.05). The intra‐ and interobserver variabilities are 2.9 ± 1.5% and 3.1 ± 5.4% for LV and RV SVs, and 1.7 ± 2.4% and 2.2 ± 3.2% for time differences by RT3DE. There was significant difference in RV SV between synchrony and dyssynchrony when the RV filled first (P < 0.05), but not in other groups. The same pattern was found in RT3DE derived SVs (synchrony versus dyssynchrony with RV filled first, P < 0.05). Conclusions: There is no compromise in LV SV during interventricular dyssynchrony; but RV SV was significantly diminished when the RV filled first. RT3DE is a feasible, robust and reproducible method to identify interventricular dyssynchrony and to evaluate ventricular SVs. (Echocardiography 2010;27:709‐715)     

采用实时三维超声和斑点追踪技术评价非酒精性脂肪性肝病肝硬化患者右心功能*

目的 探讨采用实时三维超声（RT-3DE）和二维斑点追踪技术（2D-STI）检测评价非酒精性脂肪性肝病肝硬化患者右心功能变化的价值。方法 2015年2月~2016年11月诊治的非酒精性脂肪性肝病肝硬化患者70例,其中代偿期肝硬化35例,失代偿期肝硬化患者35例,选择同期健康志愿者35例作为对照组。采用RT-3DE测量右心房容积指数（RAVI）,常规测量左心房前后径（LAD）、右心室舒张末内径（RVIDd）、右心室收缩末内径（RVIDs）、室间隔（IVS）和左心室后壁（LVPW）,计算右心室面积变化分数（RVFAC）。测量三尖瓣口前向血流舒张早期E峰（ETV）,运用脉冲多普勒超声成像测量三尖瓣环舒张早期峰值e' （e'TV）,计算ETV/e'TV比值。采用M型超声测量三尖瓣环收缩期位移（TAPSE）。采用2D-STI技术测量右左心室收缩期右心房心肌平均峰值应变（MSs）、左心室舒张早期右心房心肌平均峰值应变（MSe）、左心室舒张晚期右心房心肌平均峰值应变（MSa）,并获得左心室收缩期右心房心肌平均峰值应变率（MSRs）、左心室舒张早期右心房心肌平均峰值应变率（MSRe）和左心室舒张晚期右心房心肌平均峰值应变率（MSRa）。结果 与健康人比较,代偿期肝硬化患者LAD、LVPW、ETV/e'TV升高,TAPSE降低（P<0.05）;与失代偿期肝硬化患者比较,代偿期肝硬化患者RVIDs、IVS、LVPW、ETV/e'TV降低,TAPSE升高（P<0.05）;与健康人比,代偿期肝硬化和失代偿期肝硬化患者RAV max、RAV min、RAV pre、RAVIa和RAVIt显著增大,而RAVIp显著减小,差异具有统计学意义（P<0.05）;与失代偿期肝硬化患者比,代偿期肝硬化患者RAV max、RAV min、RAV pre、RAVIa和RAVIt显著减小,而RAVIp显著增大,差异具有统计学意义（P<0.05）;与健康人比,代偿期肝硬化患者MSe、MSRs和MSRa显著增大,而MSRe和MSa显著减小,差异具有统计学意义（P<0.05）;与失代偿期肝硬化患者比,代偿期肝硬化患者MSs、MSe、MSRs、MSRe和MSRa显著增大,而MSa显著减少,差异具有统计学意义（P<0.05）。结论 借助RT-3DE和2D-STI技术检测可以敏感地反映非酒精性脂肪性肝病肝硬化患者左心功能状况,对早期正确评估心脏功能有极大的帮助。     

Evaluation of right atrial size in patients with atrial arrhythmias: comparison of 2D versus real time 3D echocardiography

Aim: This study compares different parameters of right atrial size evaluated by two-dimensional (2D) echocardiography with right atrial volume measured using three-dimensional echocardiography (3DE). Methods and Results: One hundred sixty-three consecutive patients with a history of atrial arrhythmias were studied by standard two-dimensional and by real time 3DE. Of these 142 (87%) recordings were of sufficient quality for interpretation of the right atrium by both imaging techniques. The following parameters of right atrial size were measured: apical four-chamber short-axis diameter (4CH short axis), apical four-chamber long axis diameter (4CH long axis), and apical four-chamber planimetry area. The 2D-derived right atrial volume was calculated by using the single plane area-length method (4CH area-length). The 2D parameters were then correlated with right atrial volume measured by real time 3DE. Linear regression analysis showed moderate correlation for four-chamber planimetry area (r = 0.72, P < 0.001) and 2D-derived volume calculation (r of 4CH single plane area-length RA volume = 0.70, P < 0.001). Diameters correlated clearly less well with 3DE volume (r of 4CH short axis = 0.61, 4CH long axis = 0.59, P < 0.001 respectively). Conclusion: Real time 3DE is highly feasible for right atrial volume determination. The results demonstrate that measurements of dimensions using 2D echocardiography may not accurately assess right atrial size. If 3DE is not available, apical 4CH planimetry area is a simple alternative that may be used for evaluating right atrial size in clinical practice. The 2D-derived right atrial volume by single plane area-length method was not better correlated with 3DE volume than four-chamber planimetry area.     

A novel finding of the atrial substrate properties and long-term results of catheter ablation in chronic atrial fibrillation patients with left atrial spontaneous echo contrast

Atrial Substrate Properties in Chronic AF Patients with LASEC. Background: The atrial substrate in chronic atrial fibrillation (AF) patients with a left atrial spontaneous echo contrast (LASEC) has not been previously reported. The aim of this study was to investigate the atrial substrate properties and long‐term follow‐up results in the patients who received catheter ablation of chronic AF. Methods: Of 36 consecutive patients with chronic AF who received a stepwise ablation approach, 18 patients with an LASEC (group I) were compared with 18 age‐gender‐left atrial volume matched patients without an LASEC (group II). The atrial substrate properties including the weighted peak‐to‐peak voltage, total activation time during sinus rhythm (SR), dominant frequency (DF), and complex fractionated electrograms (CFEs) during AF in the bi‐atria were evaluated. Result: The left atrial weighted bipolar peak‐to‐peak voltage (1.0 ± 0.6 vs 1.6 ± 0.7 mV, P = 0.04), total activation time (119 ± 20 vs 103 ± 13 ms, P < 0.001) and DF (7.3 ± 1.3 vs 6.6 ± 0.7 Hz, P < 0.001) differed between group I and group II, respectively. Those parameters did not differ in the right atrium. The bi‐atrial CFEs (left atrium: 89 ± 24 vs 92 ± 25, P = 0.8; right atrium: 92 ± 25 vs 102 ± 3, P = 0.9) did not differ between group I and group II, respectively. After a mean follow‐up of 30 ± 13 month, there were significant differences in the antiarrhythmic drugs (1.1 ± 0.3 vs 0.7 ± 0.5, P = 0.02) needed after ablation, and recurrence as persistent AF (92% vs 50%, P = 0.03) between group I and group II, respectively. After multiple procedures, there were more group II patients that remained in SR, when compared with group I (78% vs 44%, P = 0.04). Conclusion: There was a poorer atrial substrate, lesser SR maintenance after catheter ablation and need for more antiarrhythmic drugs in the chronic AF patients with an LASEC when compared with those without an LASEC. (J Cardiovasc Electrophysiol, Vol. pp. 1‐8)     

Feasibility of three-dimensional transthoracic echocardiography to evaluate right ventricular volumes in children and comparison to left ventricular values

Background: Three‐dimensional echocardiography (3DE) allows accurate estimation of left ventricular (LV) volumes and function in children. Because of the peculiar morphology of the right ventricle (RV), RV volumes and function assessment remain challenging. 3D software adapted for RV morphology is a promising noninvasive method. Aims: The aims of this study were to evaluate the feasibility of 3D RV analysis in a normal pediatric population and to compare 3D RV to 3D LV measurements. Patients and methods: 3D transthoracic echocardiography was performed in 50 patients (mean age 9.5 years ± 5.1) with normal cardiac anatomy and function. Measurements were performed with the X3‐1 or the X7‐2 matrix probe (iE33, Philips Medical Systems, Andover, MA, USA). Ventricular volumes were analyzed with dedicated analysis software (TomTec Imaging Systems, Munich, Germany). Results: Measurements were possible in 100% of LVs and 94% of RVs. The stroke volumes of the two ventricles correlated well (r = 0.81 [95% CI, 0.68–0.89], P < 0.0001) with a mean difference of 3.6 mL (±9.2). Compared to the LV, the RV had higher mean end‐diastolic volume (53 mL [±29] versus 46 mL [±46], P = 0.020) and end‐systolic volume (29 mL [±17] versus 17 mL [±12], P < 0.0001) but lower mean ejection fraction (49%[±8] versus 67%[±10], P < 0.0001). Conclusion: 3DE using dedicated software is a feasible and reproducible method for RV volume quantification in children with normal hearts. Further studies are needed to validate the accuracy of the measurements. (Echocardiography 2012;29:492‐501)     

The Normal Sequence of Right and Left Atrial Contraction

Objective: To study the sequence of atrial activation and the interatrial electromechanical delay (IEmD) noninvasively in healthy subjects during sinus rhythm (SR). Methods and Results: In 66 SR healthy subjects P‐wave activation was analyzed by means of vectorcardiography. The timing of atrial contractions was measured as the intervals between the P‐wave and the A‐wave of the Doppler right and left ventricular inflows (P‐A_t and P‐A_m), and IEmD was calculated as the algebraic difference PA_m P‐A_t. In the horizontal plane the vectorcardiographic P‐loop was anteroposterior (“typical”, 41 subjects), anterior (18), or posterior (7). IEmD (mean ±; SE 17 ±; 8 ms) was directly related to R‐R and P‐R intervals. IEmD was significantly shorter in anterior and posterior P loops than in the typical (6.5 ±; 5.3 and 8.1 ±; 10.1, respectively, vs 24.2 ±; 3.1 ms). In the posterior P‐loop group, who exhibited longer P‐A_t, mitral E‐wave velocity and E/A ratio were reduced, and left atrial booster function was increased. Conclusion: IEmD was widely variable in SR, reflecting the origin site of sinus impulse, which independently influenced ventricular filling dynamics. A.N.E. 2001;6(3):222–228     

Atrial fibrosis quantified using late gadolinium enhancement MRI is associated with sinus node dysfunction requiring pacemaker implant

Atrial Fibrosis and Sinus Node Dysfunction . Introduction: Sinus node dysfunction (SND) commonly manifests with atrial arrhythmias alternating with sinus pauses and sinus bradycardia. The underlying process is thought to be because of atrial fibrosis. We assessed the value of atrial fibrosis, quantified using Late Gadolinium Enhanced‐MRI (LGE‐MRI), in predicting significant SND requiring pacemaker implant. Methods: Three hundred forty‐four patients with atrial fibrillation (AF) presenting for catheter ablation underwent LGE‐MRI. Left atrial (LA) fibrosis was quantified in all patients and right atrial (RA) fibrosis in 134 patients. All patients underwent catheter ablation with pulmonary vein isolation with posterior wall and septal debulking. Patients were followed prospectively for 329 ± 245 days. Ambulatory monitoring was instituted every 3 months. Symptomatic pauses and bradycardia were treated with pacemaker implantation per published guidelines. Results: The average patient age was 65 ± 12 years. The average wall fibrosis was 16.7 ± 11.1% in the LA, and 5.3 ± 6.4% in the RA. RA fibrosis was correlated with LA fibrosis (R²= 0.26; P < 0.01). Patients were divided into 4 stages of LA fibrosis (Utah I: <5%, Utah II: 5–20%, Utah III: 20–35%, Utah IV: >35%). Twenty‐two patients (mean atrial fibrosis, 23.9%) required pacemaker implantation during follow‐up. Univariate and multivariate analysis identified LA fibrosis stage (OR, 2.2) as a significant predictor for pacemaker implantation with an area under the curve of 0.704. Conclusions: In patients with AF presenting for catheter ablation, LGE‐MRI quantification of atrial fibrosis demonstrates preferential LA involvement. Significant atrial fibrosis is associated with clinically significant SND requiring pacemaker implantation. (J Cardiovasc Electrophysiol, Vol. 23, pp. 44‐50, January 2012)     

Left Atrial Function during Pregnancy: A Three‐Dimensional Echocardiographic Study

Background: Alteration of diastolic function is considered a sensitive means for detecting changes in the normal cardiac adaptation to pregnancy. Our aim was to evaluate volumetric and functional atrial parameters, using real time three‐dimensional echocardiography (RT3DE) in women in early and late third trimester of pregnancy. Methods: We studied pregnant women in early third trimester (III‐E = gestational age 26–33 weeks), in late third trimester (III‐L = gestational age 34–40 weeks), and control nonpregnant women (C). Two‐dimensional (2D‐Echo) and RT3DE were used to study 3D left atrial (LA) systolic and diastolic stroke volumes and index (LASVI, LAEDVI), emptying fraction, left ventricular and LA cavities. Results: Although the LA end systolic volume index increased significantly (from 19.42 ± 0.1 to 24.7 ± 3.5 mm², P < 0.01), the EF did not change significantly. This was mainly achieved by increasing atrial contraction (A‐wave), maintaining cardiac output by increasing heart rate. A decrease in diastolic E‐wave, increased atrial kick (A‐wave) with reduced E/A ratio, was noted as the pregnancy progressed. Pulmonary pressure increased from 16.9 ± 6.6 to 20.5 ± 2.9 mmHg (P < 0.01), Using 2D‐Echo revealed no change in LA diameter from control to III‐E and III‐L, respectively (from 17.1 ± 2.3 to 16.7 ± 2.6, 17.5 ± 2.2 mm) and area (from 11.7 ± 3.1 to 16.5 ± 2.3, 17.6 ± 1.6 cm²). However, using RT3DE, a significant increase in the LASVI, LAEDVI, and LA stroke volume index (from 12.02 ± 2.5 to 14.7 ± 3.2, and 15.1 ± 2.7 mL/m²) was detected. Conclusions: Enlargement of the LA volume with unchanged blood pressure values, as found using RT3DE, may be part of the adaptation to increased blood volume during pregnancy.     

Measurement of effective aortic valve area using three-dimensional echocardiography in children undergoing aortic balloon valvuloplasty for aortic stenosis

Aims: Pressure gradient is used for timing of balloon aortic valvuloplasty for aortic stenosis (AS) in children, but does not correlate well with outcome and is limited if ventricular function is poor. In adults, effective orifice area (EOA) is used to assess AS severity, but EOA by continuity equation or 2D echo is unreliable in children. Three‐dimensional echocardiography (3DE) may reliably assess EOA but has not been studied in children. We assessed measurement of aortic valve EOA by 3DE in children with AS before and after balloon aortic valvuloplasty and compared results with change in aortic valve gradient. Methods: 3DE was performed at time of catheterization before and after balloon aortic valvuloplasty. Using 3DE multiplanar review mode, valve annulus diameter, area, and EOA were measured and compared with change in aortic gradient and degree of aortic insufficiency. Results: Twenty‐four 3DE studies in 12 children (mean age 4.4 ± 5.0 years) were analyzed. EOA was measurable in all. Catheter peak gradient decreased from 45 ± 10 to 26 ± 17 mmHg (P = 0.0018). 3DE EOA increased after balloon aortic valvuloplasty (0.59 ± 0.52 cm² vs 0.80 ± 0.70 cm²; P = 0.03), without change in valve diameter. EOA change correlated with change in peak (r = 0.77; P = 0.005) and mean (r = 0.60; P = 0.03) aortic valve gradient post balloon aortic valvuloplasty. Conclusion: 3DE facilitates EOA measurement in pediatric AS and correlates with change in aortic valve gradient after balloon valvuloplasty. (Echocardiography 2012;29:484‐491)     

Evaluation of right ventricular function in early period following transcatheter closure of atrial septal defect

Aims: There is limited data on alterations in novel right ventricular (RV) function indices like tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (TASV) after transcatheter atrial septal defect (ASD) closure. We aimed to evaluate RV function by echocardiography (ECG) with these novel indices in early period in patients with secundum‐type ASD that was closed percutaneously. Methods: Patients were enrolled to study if they had secundum‐type ASD that was suitable for percutaneous closure. Patient population consisted of 4 men and 16 women. Echocardiography was performed before and 1 month after closure. Results: Mean age was 37 ± 16. Mean diameter of ASD and total atrial septum length measured by ECG were 19 ± 6 mm and 49 ± 7 mm, respectively. Mean diameter of defect in transesophageal echocardiography was 20 ± 6 mm. Stretched mean diameter in catheterization was 23 ± 6 mm. One month after closure, there were statistically significant decreases in RV end‐diastolic diameters (43.3 ± 10.7 mm vs. 34.9 ± 5.5 mm; P < 0.001), RV/left ventricular (LV) end‐diastolic diameter ratio (1.1 ± 0.3 vs. 0.87 ± 0.1; P < 0.001), TASV (16.9 ± 3.2 cm/sec vs. 14.3 ± 3.3 cm/sec; P < 0.05), early diastolic tricuspid annular velocity (15.3 ± 3.1 cm/sec vs. 13.4 ± 2.4 cm/sec P <0.05), late diastolic tricuspid annular velocity (16.2 ± 5.4 cm/sec vs. 14.3 ± 6.3 cm/sec; P < 0.05), and TAPSE (29.9 ± 6.2 mm vs. 22.4 ± 7.4 mm; P < 0.001). LV end‐diastolic diameter (38.0 ± 6.9 mm and 40.0 ± 4.5 P < 0.05) was increased, whereas there was no change in LV ejection fraction. Conclusion: Closure of ASD by using Amplatzer devices led to decrease in right heart chamber size, tissue Doppler–derived tricuspid annular velocities and TAPSE in early period. (Echocardiography 2012;29:358‐362)     

Factors Associated with the Development of Atrial Fibrillation in COPD Patients: The Role of P‐Wave Dispersion

Background: Supraventricular tachyarrhythmia is a common problem in chronic obstructive pulmonary disease (COPD) patients. The purpose of this study is to analyze the factors associated with paroxysmal atrial fibrillation (AF) in COPD patients. Methods: Forty COPD patients (38 male, 2 female, mean age 60 ± 9 years) and 33 healthy controls (29 male, 4 female, mean age: 58 ± 10 years) were included in this study. Echocardiography, 24‐hour ambulatory and 12‐lead ECG, pulmonary function tests, arterial blood gases, and serum electrolytes were measured. On ECG, maximum (P_max) and minimum (P_min) duration of P wave and its difference, P‐wave dispersion (PWd), were measured. Results: On echocardiography, diastolic dysfunction was found in 14 of the 40 (35%) COPD patients. Heart rate variability analysis revealed that COPD patients had decreased SDANN, SDNN, SDNNIDX in time‐domain, and decreased LF in frequency domain parameters. Fourteen of the 40 COPD patients (35%) had AF. Patients with AF were older (57 ± 10 vs 64 ± 5 years, P = 0.03) and had lower SDANN, SDNN, and LF/HF ratio as compared to patients without AF in univariate analysis. All P‐wave intervals (P_max P_min and PWd) were increased in COPD patients compared to controls. P‐wave dispersion was significantly increased in COPD patients with AF, as compared to patients without AF (57 ± 11 vs 44 ± 7 ms, P = 0.001). In logistic regression analysis PWd was found to be the only factor associated with the development of AF (P = 0.04). Conclusions: The presence of AF was significantly related to the prolongation of PWd, but not with pulmonary function, arterial blood gasses, and left and right atrial function. A.N.E. 2002;7(3):222–227     

Evaluation of the Relationship between Atrial Septal Aneurysm and Cardiac Arrhythmias via P‐Wave Dispersion and Signal‐Averaged P‐Wave Duration

Objective: The aim of the study was to investigate the relationship between atrial septal aneurysms (ASAs) and cardiac arrhythmias via signal‐averaged P‐wave duration (SAPWD) and P‐wave dispersion (Pd). Methods: Sixty‐six patients with ASA served as the study group (group 1; 28 men and 38 women; mean age, 34 ± 10 years) and 62 healthy volunteers served as the control group (group 2; 29 men and 33 women; mean age, 31 ± 8 years) in the current study. ASAs were diagnosed by transthoracic echocardiography based on the criteria of a minimal aneurysmal base of ≥15 mm; and an excursion of ≥10 mm. All subjects were evaluated by 24‐hour Holter monitoring, 12 lead body surface electrocardiogram for P‐wave analysis, and signal‐averaged electrocardiogram for P‐wave duration (PWD). Results: There was no significant difference between the study and control groups in terms of age, gender, left atrium diameter, and left ventricular ejection fraction. Supraventricular arrhythmias (SVAs) were detected in 29 patients with ASA (43.9%) and 5 controls (8.1%; P < 0.001). The mean Pd in patients with ASA was significantly longer compared to the control group (14.1 ± 8 ms vs 7.0 ± 2.9 ms; P < 0.001). Similarly, the mean SAPWD in group 1 was significantly longer compared to group 2 (127.4 ± 17.6 ms vs 99.8 ± 12.3 ms; P < 0.001). Conclusion: Prolonged SAPWD and Pd were determined to indicate electrical disturbances in the atrial myocardium, and predict the increase in the prevalence of SVA in patients with ASA. Ann Noninvasive Electrocardiol 2010;15(2):157–164     

Simplified Single Plane Echocardiography Is Comparable to Conventional Biplane Two‐Dimensional Echocardiography in the Evaluation of Left Atrial Volume: A Study Validated by Three‐Dimensional Echocardiography in 143 Individuals

The left atrial volume index (LAVI) is a biomarker of diastolic dysfunction and a predictor of cardiovascular events. Three‐dimensional echocardiography (3DE) is highly accurate for LAVI measurements but is not widely available. Furthermore, biplane two‐dimensional echocardiography (B2DE) may occasionally not be feasible due to a suboptimal two‐chamber apical view. Simplified single plane two‐dimensional echocardiography (S2DE) could overcome these limitations. We aimed to compare the reliability of S2DE with other validated echocardiographic methods in the measurement of the LAVI. We examined 143 individuals (54 ± 13 years old; 112 with heart disease and 31 healthy volunteers; all with sinus rhythm, with a wide range of LAVI). The results for all the individuals were compared with B2DE‐derived LAVIs and validated using 3DE. The LAVIs, as determined using S2DE (32.7 ± 13.1 mL/m²), B2DE (31.9 ± 12.7 mL/m²), and 3DE (33.1 ± 13.4 mL/m²), were not significantly different from each other (P = 0.85). The S2DE‐derived LAVIs correlated significantly with those obtained using both B2DE (r = 0.98; P < 0.001) and 3DE (r = 0.93; P < 0.001). The mean difference between the S2DE and B2DE measurements was <1.0 mL/m². Using the American Society of Echocardiography criteria for grading LAVI enlargement (normal, mild, moderate, severe), we observed an excellent agreement between the S2DE‐ and B2DE‐derived classifications (κ = 0.89; P < 0.001). S2DE is a simple, rapid, and reliable method for LAVI measurement that may expand the use of this important biomarker in routine echocardiographic practice.     

Functional Assessment of Donor and Recipient Left Atrium in Heart Transplant Patients Using Full‐Volume Three‐Dimensional Echocardiography

Background: Atrial function plays an important role in many cardiac conditions, how recipient and donor compartments of left atrium (LA) of transplanted hearts differentially contribute to overall LA function in transplanted hearts has not been described. We tested whether three‐dimensional transthoracic echocardiography (3DE) could be used to calculate these compartment‐specific atrial functions. Methods and Results: We analyzed 3DE images of 22 consecutive transplant patients who had diagnostic imaging quality (ages 59 ± 16 years) using TomTec Research Arena. The contour of the recipient and total LA were traced frame by frame, and the donor LA volume was calculated as the difference of the total LA volume minus the recipient LA volume. The LA ejection fractions of total LA, donor LA, and recipient LA were also calculated as (LA atrial end‐diastolic volume ? LA atrial end‐systolic volume)/LA atrial end‐diastolic volume of each compartment. Interobserver variability of LA volumes for the total, recipient, and donor compartments were 5.6 ± 2.4, 5.4 ± 2.0, and 9.3 ± 3.2 mL, respectively (n = 11). The donor LA ejection fraction was higher than that of recipient (41 ± 18% vs. 30 ± 14%, P = 0.013). When the patients were categorized as asymptomatic (New York Heart Association functional class [NYHA] functional class I) and symptomatic (NYHA functional class II–III), indexed donor LA atrial end‐diastolic volume was significantly lower in asymptomatic patients as compared with symptomatic patients. Conclusions: Compartment‐specific LA volumes can be calculated in orthotopic heart transplant patients using full‐volume 3DE. Our findings may suggest that unique contribution of each LA compartment of transplanted hearts toward the symptoms of these patients.     

The Effect of Exercise to P Wave Dispersion and Its Evaluation as a Predictor of Atrial Fibrillation

Aim: Prolongation of P wave time and increase of its dispersion as an independent predictor of atrial fibrillation. In patients with paroxysmal atrial fibrillation (PAF) as in healthy people, exercise augments sympathetic activity and therefore can cause the development of atrial fibrillation. The aim of this study is to evaluate the effect of exercise on P wave dispersion and to predict the development of atrial fibrillation. Methods: One hundred and ninety‐eight patients (93 women, 105 men, mean age: 59.05 ± 11.01 years ) having the diagnosis of PAF were included in the study. The left atrial diameter of all these patients was more than 4.0 cm. One hundred and fifty‐five patients (72 females, 83 males, mean age: 58.41 ± 10.79 years ), with left atrial diameter more than 4.0 cm and without PAF were taken as control group. Symptom limited exercise test with modified Bruce protocol was performed on all patients. Rest, maximum exercise and recovery, and first, third, and fifth‐minute 12‐derivation ECG was taken in all patients. The velocity of ECG was adjusted to 50 mm/s; shortest and largest P wave durations were measured and P wave dispersion was calculated. Results: The mean left atrial diameter was 4.41 ± 0.58 cm in PAF patients and 4.38 ± 0.48 cm in control group. No differences were found between PAF patients with the controls in exercise time (10.38 ± 2.93 vs 10.81 ± 2.75 minutes ); METs (6.98 ± 1.72 vs 7.28 ± 1.75 minutes ); resting heart rate (79.13 ± 14.86 vs 79.69 ± 10.43 bpm ); peak heart rate (146.83 ± 23.21 vs 146.94 ± 16.13 bpm ). Maximum exercise P wave duration and P wave dispersion were greater than the rest measurements in PAF group (respectively P < 0.0001 and P = 0.0004 ). Conclusion: In PAF patients, P wave dispersion is significantly longer at rest, maximum exercise and recovery time than in a control group without PAF.     

The Impacts of Transcatheter Occlusion for Congenital Atrial Septal Defect on Left Ventricular Systolic Synchronicity: A Three‐Dimensional Echocardiography Study

Objectives: To investigate the impacts of transcatheter occlusion for congenital atrial septal defect (ASD) on left ventricular (LV) systolic synchronicity using a real time three‐dimensional echocardiography (RT3DE). Methods: Thirty patients with ASD closure were recruited for the study. Realtime three‐dimensional echocardiographic data sets were acquired for the measurement of LV volumes LV ejection fractions and LV three‐dimensional systolic synchronicity before and at 6 months after transcatheter occlusion for ASD. M‐mode echocardiography and RT3DE were performed to characterize interventricular septal (IVS) motion. Results: There were no differences in LV systolic synchronicity between before and after transcatheter closure of ASD (Tmsv‐16SD%: 5.6%± 1.4% vs 5.8%± 1.8%, P > 0.05; Tmsv—12SD%: 5.2 ± 1.1% vs 5.4 ± 1.2%, P > 0.05). But the abnormal IVS motion was found before device closure and normalized after transcatheter occlusion for ASD using M‐mode echocardiography and the excursion‐time figure (bull's‐eye derived from RT3DE); At the same time, LV ejection fraction (59.8 ± 2.6 vs 66.7 ± 5.9, P < 0.05) stroke volume (49 ± 14 vs 63 ± 11, P < 0.05) was improved significantly as well as normalization of IVS motion after transcatheter occlusion for ASD. The correlation between ASD diameter and change of LVEF is significant (r = 0.85, P < 0.001). Conclusion: Although transcatheter occlusion did not significantly impact on intrinsic LV systolic synchronicity in patients with ASD, LV systolic function can be improved through normalization of IVS abnormal motion after transcatheter ASD occlusion. (Echocardiography 2010;27:324‐328)     

Signal‐Averaged P Wave Duration and the Dimensions of the Atria

Background: Delay of atrial electrical conduction measured as prolonged signal‐averaged P wave duration (SAPWD) could be due to atrial enlargement. Here, we aimed to compare different atrial size parameters obtained from echocardiography with the SAPWD measured with a signal‐averaged electrocardiogram (SAECG). Methods: In 74 patients scheduled for elective echocardiography, an SAECG was recorded directly after the echocardiogram. We measured the SAPWD and registered clinical characteristics. The correlation between the SAPWD and the left atrial diameter (LAD), left atrial volume (LAV), right atrial volume (RAV), and total atrial volume (TAV) was analyzed by linear regression analyses. The effect of concomitant risk factors on TAV and the SAPWD was examined. Results: Linear regression analysis showed that the correlation between the SAPWD and the LAD was significant (R²= 0.11, P = 0.03). However, LAV (R²= 0.15, P = 0.009), RAV (R²= 0.27, P = 0.0003), and TAV (R²= 0.37, P < 0.0001) were more strongly correlated to the SAPWD. The TAV and the SAPWD were not significantly associated with coexisting risk factors. Conclusions: The SAPWD is significantly correlated to the atrial size; most strongly to the TAV. The size of the right atrium, with the sinus node area, appears to affect the SAPWD.