Quantitative tissue-tracking cardiac magnetic resonance (CMR) of left atrial deformation and the risk of stroke in patients with atrial fibrillation

Yuko Y Inoue, Abdullah Alissa, Irfan M Khurram, Kotaro Fukumoto, Mohammadali Habibi, Bharath A Venkatesh, Stefan L Zimmerman, Saman Nazarian, Ronald D Berger, Hugh Calkins, Joao A Lima, Hiroshi Ashikaga, Yuko Y Inoue, Abdullah Alissa, Irfan M Khurram, Kotaro Fukumoto, Mohammadali Habibi, Bharath A Venkatesh, Stefan L Zimmerman, Saman Nazarian, Ronald D Berger, Hugh Calkins, Joao A Lima, Hiroshi Ashikaga

Abstract

Background: Recent evidence suggests that left atrial (LA) dysfunction may be mechanistically contributing to cerebrovascular events in patients with atrial fibrillation (AF). We investigated the association between regional LA function and a prior history of stroke during sinus rhythm in patients referred for catheter ablation of AF.

Methods and results: A total of 169 patients (59 ± 10 years, 74% male, 29% persistent AF) with a history of AF in sinus rhythm at the time of pre-ablation cardiac magnetic resonance (CMR) were analyzed. The LA volume, emptying fraction, strain (S), and strain rate (SR) were assessed by tissue-tracking cardiac magnetic resonance. The patients with a history of stroke or transient ischemic attack (n=18) had greater LA volumes (Vmax and Vmin; P=0.02 and P<0.001, respectively), lower LA total emptying fraction (P<0.001), lower LA maximum and pre-atrial contraction strains (Smax and SpreA; P<0.001 and P=0.01, respectively), and lower absolute values of LA SR during left ventricular (LV) systole and early diastole (SRs and SRe; P=0.005 and 0.03, respectively) than those without stroke/transient ischemic attack (n=151). Multivariable analysis demonstrated that the LA reservoir function, including total emptying fraction, Smax, and SRs, was associated with stroke/transient ischemic attack (odds ratio 0.94, 0.91, and 0.17; P=0.03, 0.02, and 0.04, respectively) after adjusting for the CHA2DS2-VASc score and LA Vmin.

Conclusions: Depressed LA reservoir function assessed by tissue-tracking cardiac magnetic resonance is significantly associated with a prior history of stroke/transient ischemic attack in patients with AF. Our findings suggest that assessment of LA reservoir function can improve the risk stratification of cerebrovascular events in AF patients.

Keywords: atrial fibrillation; atrial strain; magnetic resonance imaging; stroke; tracking.

© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1.
Figure 1.
Patient enrollment. AF indicates atrial fibrillation; CMR, cardiac magnetic resonance.
Figure 2.
Figure 2.
LA measurements by tissue‐tracking CMR in a patient without stroke. A and B, Left atrium (LA) longitudinal strain in the 2‐ and 4‐chamber views at the end of left ventricular (LV) systole. C, LA volume curve. The pink dotted line is the average of the values of volume in the 2‐ and 4‐chamber views. The LA maximum volume (Vmax), the pre‐atrial contraction volume (VpreA), and the minimum volume (Vmin) were identified. The LA emptying fractions (EFs) were calculated using Vmax, VpreA, and Vmin. D and E, The LA strain and strain rate curve. The LA maximum strain (Smax) and pre‐atrial contraction strain (SpreA) were identified from the strain curve. The strain rates during LV systole (SRs), LV early diastole (SRe), and atrial contraction (SRa) were also analyzed from the strain rate curve. CMR indicates cardiac magnetic resonance.
Figure 3.
Figure 3.
LA measurements by tissue‐tracking CMR in patients with and without stroke. A, The LA volume, (B) LA global longitudinal strain, and (C) LA strain rate in a patient with stroke (red line) and without stroke (blue line). The patient with stroke has a larger LA volume and smaller strain and strain rate. The LA serves as a reservoir during LV systole, as a conduit during LV early diastole, and as an active pump during late diastole. CMR indicates cardiac magnetic resonance; LA, left atrial; LV, left ventricular; Smax, maximum strain; SpreA, pre‐atrial contraction strain; SRa, strain rate at atrial contraction; SRe, strain rate at LV early diastole; SRs, maximum strain rate; Vmax, maximum indexed volume; Vmin, minimum indexed volume; VpreA, pre‐atrial contraction indexed volume.
Figure 4.
Figure 4.
Incremental value of left atrial (LA) strain for diagnosis of stroke. The addition of the LA minimum volume (Vmin) to the model on the basis of the CHA2DS2‐VASc score resulted in significant improvement in the diagnostic value for stroke. The value was further increased by adding the LA global longitudinal maximum strain (Smax).

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