L’atrio sinistro conferme e novità A. Sulla e R. Lumare Unità Operativa di Cardiologia – UTIC P.O. San Giovanni di Dio Crotone “Incontri Pitagorici di Cardiologia 2010” 1 - 2 Ottobre 2010 - Crotone

Come deve essere studiato l’atrio sinistro ?

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 Roberto M. Lang, MD, Michelle Bierig, MPH, RDCS, Richard B. Devereux, MD, Frank A. Flachskampf, MD, Elyse Foster, MD, Patricia A. Pellikka, MD, Michael H. Picard, MD, Mary J. Roman, MD, James Seward, MD, Jack S. Shanewise, MD, Scott D. Solomon, MD, Kirk T. Spencer, MD, Martin St John Sutton, MD, William J. Stewart, MD and Members of the Chamber Quantification Writing Group Journal of the American Society of Echocardiography Volume 18, Issue 12, Pages 1440-1463 (December 2005)

Dimensione lineare Measurement of left atrial diameter (LAD) from M-mode, guided by parasternal short-axis image (upper right) at level of aortic valve. Linear method is not recommended. Journal of the American Society of Echocardiography 2005; 18:1440-1463

Raccomandazioni ASE-EAE ……..AP linear dimensions of the LA as the sole measure of LA size may be misleading and should be accompanied by LA volume determination in both clinical practice and research. …… when LA size is measured in clinical practice, volume determinations are preferred over linear dimensions because they allow accurate assessment of the asymmetric remodeling of the LA chamber. Journal of the American Society of Echocardiography Volume 18, Issue 12, Pages 1440-1463 (December 2005)

Area e volume bidimensionale Measurement of left atrial (LA) volume from biplane method of disks (modified Simpson’s rule) using apical 4-chamber (A4C) and apical 2-chamber (A2C) views at ventricular end systole (maximum LA size). Journal of the American Society of Echocardiography 2005; 18:1440-1463

Lester Am J Cardiol 1999; 84:829

Perché è importante la determinazione delle dimensioni?

Left Atrium Size and the Risk of Cardiovascular Death in Middle-aged Men

Razionale della valutazione dell’atrio sin. Abhayaratna W.P. JACC 2006:47-12

Prediction of Cardiovascular Outcomes With Left Atrial Size Is Volume Superior to Area or Diameter? Left atrial volume is a more robust marker of cardiovascular events than LA area or diameter in subjects with sinus rhythm. The overall performance for the indipendent prediction of cardiovascular events was greatest for LA volume (area under the receiver operator characteristic curve: indexed LA volume 0.71; LA area 0.64; LA diameter 0.59). A graded association between the degree of LA enlargement and risk of cardiovascular events was only evident for indexed LA volume. Tsang S.M., J Am Coll Cardiol 2006; 47:1018 –23

Left Atrial Size by Planimetry is Superior to M-mode Diameter: Biochemical Calibration by Atrial and Brain Natriuretic Peptide The current population-based echocardiographic study allows new insight into the value of different measures of LA size. The closer association between natriuretic peptide concentrations and parameters derived from planimetry and volumetry suggests a superiority of these parameters LA diameter. LA volumetry should be included in routine echocardiography for optimized assessment of LA size. 2C area and 2C volume were also independent predictors of BNP and additionally displaced EF and LVMI (Table 3). The tightness of correlation between the measures of LA size and the natriuretic peptides is qualitatively depicted in Table 4. Buchner, JASE 2008; 21-4,380

Quale è la spiegazione ?

Left Atrial Volume as a Morphophysiologic Expression of Left Ventricular Diastolic Dysfunction Tsang S.M., AmJ Cardiol 2002; 90

Relation to diastolic disfunction Receiver-operator curves for the detection of diastolic dysfunction (area under curves 0.95 for indexed LA volume, 0.82 for M-mode LA dimension, p 0.006; 0.83 for E/E, p 0.002)

Pritchett, A. M. et al. J Am Coll Cardiol 2005;45:87-92 Kaplan-Meier survival curves demonstrating the relationships between severity of diastolic dysfunction (DD) (left) and left atrial (LA) volume index and survival In this updated analysis, both DD grade and LAVi were predictive of all-cause mortality in the population (Fig. 2). Pritchett, A. M. et al. J Am Coll Cardiol 2005;45:87-92

Il volume atriale sinistro meglio riflette, rispetto ad altri indici, la severità della disfunzione diastolica e la prolungata esposizione della camera atriale ad un alterata funzione diastolica ed elevate pressioni di riempimento e come la disfunzione diastolica ha un forte legame con la prognosi.

L’informazione prognostica è aggiuntiva ed indipendente ?

Left Atrial Volume Is a Predictor of Atrial Fibrillation Recurrence After Catheter Ablation Indexing left atrial volume, calculated by the biplane area-length method, may be an important factor for the prediction of AF recurrence at 6 months after catheter ablation. Left atrial volume of more than 34 mL/m2 showed a sensitivity of 70% and a specificity of 91% for the prediction of AF recurrence. Therefore, indexing left atrial volume might be useful for identifying patients with a high likelihood of AF recurrence after ablation. Sung-Hee Shin, JASE 2008

Determinants and Prognostic Value of Left Atrial Volume in Patients With Dilated Cardiomyopathy On bivariate Cox analysis, LAmax predicted the prognosis independently of each determinant. Patients with a larger LA volume (LAmax/m2 68.5 ml/m2) had a risk ratio of 3.8 compared with those with a smaller LA volume. Rossi et al., JACC Vol. 40, No. 8, 2002

Left Atrial Volume A Powerful Predictor of Survival After Acute Myocardial Infarction LA volume index was a powerful predictor of mortality and remained an independent predictor (hazard ratio 1.05 per 1-mL/m2 change, 95% CI 1.03 to 1.06, P0.001) after adjustment for clinical factors, LV systolic function, and Doppler-derived parameters of diastolic function. Increased LA volume index is a powerful predictor of mortality after AMI and provides prognostic information incremental to clinical data and conventional measures of LV systolic and diastolic function Moller, Circulation 2003;107

Long-term prognostic significance of left atrial volume in acute myocardial infarction In patients with acute MI, increased LA volume is an independent predictor of five-year mortality with incremental prognostic information to clinical and echocardiographic data Beinart, JACC 2004;44

Independent relationship of left atrial size and mortality in patients with heart failure: an individual patient meta-analysis of longitudinal data (MeRGE Heart Failure) In multivariate analysis (Cox proportion hazard model), LA area was associated with prognosis (HR 1.03 per cm2, 95% CI 1.02, 1.05; P , 0.0001) independently of age, NYHA class, LV ejection fraction, and restrictive filling pattern (RFP). When LA area was used as a categorical variable, the HR associated with larger LA area (above median) was 1.4 (95% CI 1.13, 1.74) and when LA area index was used, the HR was 2.36 (95% CI 1.80, 3.08). When the patients with and without RFP were divided on the basis of either LA area or LA area index, significantly higher event rates were observed in those with larger LA area. Left atrial area is a powerful predictor of outcome among HF patients with predominantly impaired systolic function, and is independent of, and provides additional prognostic information beyond LV systolic and diastolic function Rossi, Eur J of Heart Failure ; 2009-11

Impact of Left Atrial Volume on Clinical Outcome in Organic Mitral Regurgitation In organic MR, LA index at diagnosis predicts long-term outcome, incrementally to known predictors of outcome. This marker of risk is particularly important because mitral surgery in these patients markedly improves outcome and restores life expectancy Le Tourneau, JACC 2010;56

Prognostic Significance of Left Atrial Volume Dilatation in Patients with Hypertrophic Cardiomyopathy Patients with normal LA volume at baseline in whom volume increased more than 3 mL per year (fast dilating LA volume) had a worse prognosis than patients with normal and stable volume (P .001) and similar to patients with dilated LA volume at baseline (P not significant). LA volume dilated at baseline, fast dilating LA volume, and New York Heart Association functional class were independent predictors of unfavorable outcome development (odds ratio: 11.453; P .021, P 2.019, P .020, respectively). The assessment of LA volume at baseline and during follow-up adds information regarding prognosis in patients with HCM. Losi MA, J Am Soc Echocardiogr 2009;22:76-81.)

Conclusioni La dilatazione dell’atrio sin. comporta importanti implicazioni cliniche e prognostiche. La determinazione del volume è superiore al diametro AP come misura delle dimensioni atriali. Le attuali lineeguida sconsigliano la determinazione con misura lineare. La determinazione del volume aggiunge informazioni che hanno importante valore prognostico aggiuntivo ed indipendente da altri fattori. La valutazione del volume dovrebbe essere quindi inserita nella valutazione ecocardiografica di routine.