Journal Reading

Atai Watanabe,1 MD, Shinya Suzuki,2 MD, Hiroto Kano,2 MD, Syunsuke Matsuno,2 MD, Hideaki Takai,3
MD, Yuko Kato,2 MD,
Takayuki Otsuka,2 MD, Tokuhisa Uejima,2 MD, Yuji Oikawa,2 MD, Kazuyuki Nagashima,2 MD, Hajime
Kirigaya,2 MD, Takashi Kunihara,3 MD, Koichi Sagara,2 MD, Naohide Yamashita,1 MD, Hitoshi Sawada,2
MD, Tadanori Aizawa,2 MD, Junji Yajima,2 MD, and Takeshi Yamashita,2 MD

Annis Rakhmawati
Pembimbing:
dr. Lucia Krisdinarti, SpPD, SpJP (K)
dr. Hasanah Mumpuni, SpPD, SpJP (K)

 Title:

Left Atrial Remodeling Assessed by

Transthoracic Echocardiography Predicts
Left Atrial Appendage Flow Velocity in
Patients With Paroxysmal Atrial
Fibrillation

Authors:

Watanabe, A., et.al.

Publication:

182

Int Heart J 2016; 57: 177-

 Atrial

fibrillation (AF) the most

common cardiac arrhythmia risk
of stroke and thromboembolic events.
1 in 5 strokes is caused by AF, and
stroke risk is 4- to 5-fold greater in
patients with AF

 Doppler

TEE measurement of blood flow

velocity in the LAA & the presence of
LASEC to assess the severity of blood
stasis risk factor for thrombus
formation & stroke.
Previous reports dense of LASEC,
LAA flow velocity (LAA-FV), and complex
aortic plaques on TEE independent
risk factors for thromboembolic events.

 TTE

is less invasive than TEE for

assessment of LAA-FV in patients
with AF.

 Several

parameters measured using

TTE have been proposed as markers of
advanced atrial remodeling.
The velocity of a represent LA pump
function
a velocity advanced LA
remodeling in patients with PAF

 Another

study LA pump function was

inversely correlated with LA volume in
patients with PAF.
Furthermore, the delay of interatrial
conduction time using tissue Doppler
imaging marker of electrical and
structural remodeling of the atrial

 Allessie,

et al proposed 3 positive
feedback-loops of atrial remodeling
on AF electrical, contractile, and
structural remodeling.
However, it is still not clear which
parameter is the best for the
estimation of LAA-FV.

combination of TTE parameters

sufficiently estimates LAAFV
measured using TEE, a
representative marker of LA blood
stasis in patients with PAF.

 190

patients nonvalvular paroxysmal

AF (NVAF)
The Cardiovascular Institute Hospital
in Tokyo
November 2009 - March 2014
Patients with MS, mechanical heart
valves, HR > 90 bpm excluded.

 TTE

using a 3-MHz phased-array

transducer
TEE using a 5-MHz multiplane
transducer (SSD-6500 and ProSound
10, Hitachi Aloka Medical, Ltd. Tokyo).
TTE parameters TTE B-mode images,
pulsed Doppler recording, and tissue
Doppler imaging (TDI).
Doppler spectral velocities for TTE and
TEE were recorded at sweep speeds of
100 mm/s and 66.7 mm/s, respectively.

 Right

ventricular systolic pressure

(RVSP) estimated from peak
tricuspid regurgitation jet velocities,
adding right atrial pressure.
The time interval from the initiation
of the P-wave in lead II of the
echocardiogram (ECG) to the
initiation of the A-wave of transmitral
flow was assessed using TTE

 AF

was diagnosed by 12 leads ECG &

24-hours Holter recordings within 3
months after the initial visit, and by
the medical history of AF from the
referring physicians.
All clinical and echocardiographic
data were obtained within 3 months
following the first visit

 The

indication for TEE evaluation

of potential thromboembolic risk or
identification of stroke secondary to
confirmed cardiogenic embolism.

LASEC was diagnosed by the presence of

characteristic swirling, smoke-like echoes within
LA or LAA distinct from the white-noise artifact.
LAA-FV by pulse-wave Doppler TTE at the
orifice of the appendage, and the peak outflow
velocity was measured.
The severity of atherosclerosis of the
descending aorta was defined as follows:
0 = none
1+ = calcification and plaque thickness less than

grade 2+
2+ = complex aortic plaques with any combination
of mobile, pedunculated, and ulcerated, or plaque
thickness 4 mm.

 Data

are presented as the mean

SD.
Each parameter that may determine
LAA-FV was analyzed using t-test or
simple regression analysis.
Multiple regression analysis to
determine echocardiographic factors
relevant to estimating LAA-FV.
SPSS version 22.0 software

Electrical, contractile, and structural remodeling

occurs during AF interstitial fibrosis may
explain interatrial conduction disturbances.
Mizuno, et al interatrial conduction time
determined using TTE and ECG was delayed in
patients with progressive systemic sclerosis. The
time interval between initiation of the P-wave and
onset and the peak of the A-wave was prolonged
in the transmitral flow in these patients.
This study duration of PA-TMF was inversely
correlated with LAA-FV suggesting that PA-TMF
reflects LA electrical and structural remodeling,
resulting in prolonged inter-atrial conduction time
enabling the estimation of LAA-FV in patients
with PAF.

 The

geometrical distance between

the two atrial may also be an
important determining factor for
interatrial conduction time.
Our study demonstrated that LAD
was positively correlated with PATMF
duration suggests that LAD also
contributes to the estimation of LAAFV.

 Masuda,

et al a velocity observed by
TDI useful parameter for estimating LA
blood stasis in patients with PAF the
impairment of LA contractile function during
AF and atrial stunning would be more severe
in patient with advanced atrial remodeling
as a possible explanation for the relationship
between decreased a velocity and LA blood
stasis.
Our study demonstrated that the velocity of
a was also an independent predictor of LAAFV.

 This

study suggested that LAA-FV

was estimated by the following
equation:

LAA-FV (cm/s) = 79.79 + 2.73

septal a velocity 0.64 LAD
0.19 PA-TMF (ms).

 Tamura,

et al LAA wall velocity

measured using TTE was associated
with risk of cerebrovascular events.
The advantage of our study is that a
velocity, LAD, and PA-TMF more
easily measured than LAA wall
velocity in most cases.

 Many

reports found a strong

relationship between LAA-FV and LA
thrombus formation
LAA-FV < 20 cm/s risk of thrombus
formation in LA.

 Combination

of a velocity, LAD, and

PA-TMF could be used as a substitute
for LAA-FV.
However, whether there is any
association between these TTE
parameters and clinical thromboembolic
events remains uncertain because no
patient in the present study had LA
thrombus or embolic events.

Small study population (190

subjects)
2. Retrospective data of TTE and TEE
3. No data on the temporal stability of
PA-TMF.
4. Lacks data on the TDI of the lateral
wall.
1.

a velocity, LAD and PA-TMF

during sinus rhythm may be useful
parameters for the prediction of LA
blood stasis in patients with
nonvalvular PAF.