ISSN: 1223-1533

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LEFT ATRIAL TISSUE DOPPLER LEFT ATRIAL ABNORMALITIES IN PATIENTS WITH PAROXYSMAL ATRIAL FIBRILLATION


Authors: T. Ciocarlie, V. Moga, Florina Parv, M. Balint, C. Tudoran, Rodica Avram



Received for publication: 15th of April, 2013
Revised: 15th of May, 2013



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SUMMARY: (Hide the summary)

The aim of this study is to analyze the electrocardiographic left atrial abnormalities (LAA) in relation with the Pulsed wave tissue Doppler imaging (PW-TDI) of the left atrium, as well the relation of LAA and PW-TDI to the CHA2DS2-VASc score and the role of these abnormalities in predicting the recurrence of the atrial fibrillation. I studied two groups of patients, 15 without LAA and 15 with LAA, using anamnesis, surface electrocardiogram, two-dimensional and pulsed wave tissue Doppler echocardiography. From the 15 p. without ECG LAA, 3 had abnormalities at PW-TDI and in 12 p. with ECG LAA were also recorded PW-TDI abnormalities (p=0.0028). In 12 p. were not recorded any ECG and PW-TDI abnormalities, and 12 had both ECG and PW-TDI abnormalities. Only 8 patients with ECG and PW-TDI abnormalities had a CHA2DS2-VASc score ³1 but only 1 patient without these abnormalities had a score greater than 0 (p=0.0094). At the reevaluation using anamnesis, surface ECG or Holter monitoring, only 1 patient without ECG and PW-TDI abnormalities had recurrent AF versus 7 from the group with both ECG and PW-TDI abnormalities. It seems that there is a statistical significantly difference between the patients with ECG LAA regarding the left atria wall abnormalities, suggesting a high predictive accuracy of these ECG criteria in assessing atrial muscle abnormalities. Also, LAA in ECG and PW-TDI abnormalities together seem to have o high predictive value regarding both the thromboembolic risk and the risk for the recurrence of atrial fibrillation.


Key Words:

atrial fibrillation, electrocardiogram, tissue Doppler.

 


 

INTRODUCTION

The thromboembolic risk in atrial fibrillation remains one of the greatest challenges for the cardiologist. We have a pretty clear picture of what patients are at risk for stroke, but we still don't know exactly why, because only atrial fibrillation is not enough for an increase stroke risk. There need to be other pathologies over atrial fibrillation, in order for the patients to have a high risk for an embolic event and for antithrombotic treatment. So we know what the risk factors for thromboembolic events are, but we don't know exactly how those risk factors contribute to an increase left atrial thrombotic state. Anatomic or functional abnormalities of the left atrium (LA) that alter the P waves in the clinical ECG include atrial dilation, atrial muscular hypertrophy, elevated intra-atrial pressures, and delayed conduction. Because these abnormalities commonly coexist and can produce the same electrocardiographic effects, the resulting electrocardiographic patterns may best be referred to as left atrial abnormality (LAA).

Based on two-dimensional echocardiographic standards, the classic P wave patterns of LAA have sensitivities of only 12% to 70% and specificities of over 90% for detecting enlarged left atria. In general, the low overall predictive accuracy of these criteria renders them of limited clinical value for assessing atrial size.

Pulsed wave tissue Doppler imaging (PW-TDI) is a relatively new echocardiography tool for analyzing high amplitude and low frequency Doppler signals from the cardiac muscle. An excellent signal-to-noise ratio and the possibility of analyzing the data quantitatively are some of the new and attractive advantages of PW-DTI. This technique has been used to evaluate velocities and time intervals of the contraction and relaxation of both ventricles in different clinical situations. However, there are very few studies that have provided quantitative data on atrial function using PWDTI.

 

Figure 1. Pulse wave tissue Doppler

 

MATERIAL AND METHOD

The aim of this study is to analyze the LAA in relation with the tissue Doppler echocardiography of the left atrium, as well the relation of LAA and PW-TDI to the CHA2DS2-VASc score and the role of these abnormalities in predicting the recurrence of the atrial fibrillation. We studied two groups of patients, 15 without LAA and 15 with LAA, using anamnesis, surface electrocardiogram, two-dimensional and pulsed wave tissue Doppler echocardiography. The LAA were: prolonged P wave duration > 120 msec in lead II, prominent notching of P wave, usually most obvious in lead II, with interval between notches of 0.40 msec (P mitrale), ratio between the duration of the P wave in lead II and duration of the PR segment > 1.6, increased duration and depth of terminal- negative portion of P wave in lead V1 (P terminal force) so that area subtended by it > 0.04 mm-sec and the leftward shift of mean P wave axis to between -30 and -45 degrees.

 

Figure 2. ECG and TD abnormalities

 

 

Figure 3. P. with or without both ECG and TD abnormalities.

 

Figure 4. CHA2DS2-VASc score in p. without or with both ECG and PW-TDI abnormalities.

 

Figure 5. Recurrence of AF.

 

The left atrial wall velocities were recorded using PW-TDI as a triphasic signal formed by a positive A1 wave, followed by two negative A2 and A3 waves. The A1 component of the atrial wall occurs during ventricular systole and corresponds to the atrial relaxation period.

This wave could be due to the movement of the mitral ring during ventricular systole towards the base of the left atrial wall. The A2 wave is produced during early diastolic filling (the passive phase of ventricular filling) and the A3 wave coincides with atrial contraction (late ventricular or active filling). (Figure 1) The CHA2DS2-VASc risk scores were recorded and the patients were reevaluated in an interval between 3 and 6 months.

 

 

RESULTS

From the 15 p. without ECG LAA, 3 had abnormalities at PW-TDI and in 12 p. with ECG LAA were also recorded PW-TDI abnormalities (p=0.0028). (Figure 2) In 12 p. were not recorded any ECG and PW-TDI abnormalities, and 12 had both ECG and PW-TDI abnormalities. (Figure 3)

Only 8 patients with ECG and PW-TDI abnormalities had a CHA2DS2-VASc score ³1 but only 1 patient without these abnormalities had a score greater than 0 (p=0.0094). (Figure 4)

At the reevaluation using anamnesis, surface ECG or Holter monitoring, only 1 patient without ECG and PW-TDI abnormalities had recurrent AF versus 7 from the group with both ECG and PW-TDI abnormalities. (Figure 5)

 

 

CONCLUSIONS AND DISCUSSIONS

It seems that there is a statistical significantly difference between the patients with ECG LAA regarding the left atria wall abnormalities, suggesting a high predictive accuracy of these ECG criteria in assessing atrial muscle abnormalities.

If regarding the assessing of atrial size, the ECG LAA have a low predictive accuracy, they seem to be more useful in detecting the atrial wall motion abnormalities.

Also, LAA in ECG and PW-TDI abnormalities together seem to have o high predictive value regarding both the thromboembolic risk and the risk for the recurrence of atrial fibrillation.

The study is a small one, but it shows the need for a larger one that could include a signal-averaged P wave analysis, the analysis of individual TD waves in relation with P wave and with the thromboembolic risk and even the p. with permanent atrial fibrillation, because only the third wave is not present in permanent atrial fibrillation p., the other 2 waves are present and can be quantified.

 

 

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Correspondence to:
Tudor Ciocārlie, tudorfox@yahoo.com