Left atrial appendage strain rate is associated with documented thromboembolism in nonvalvular atrial fibrillation
The left atrial appendage (LAA) strain and strain rate have not yet been studied in the prediction of cardiac thromboembolism. Therefore, this study aimed to evaluate the significance of LAA strain and strain rate as assessed by speckle-tracking imaging in relation to documented thromboembolic events.
A group of 80 patients with a mean age of 65 years who were referred for electrical cardioversion of nonvalvular atrial fibrillation was retrospectively analyzed. Each patient underwent 2D transesophageal echocardiography (TEE). Velocity vector imaging (VVI)-derived LAA strain and strain rate in parallel with other conventional TEE predictors were analyzed in terms of their association with previous embolic stroke and peripheral embolization.
By comparing the two groups of patients with (22/80) and without embolic events (58/80), patients with embolic events were older, had higher CHA2DS2-VASc scores, higher incidence of coronary artery disease and LAA thrombi, and worse LAA strain and strain rate. Moreover, patients without embolization more often used anticoagulants than patients with embolic events. After adjusting for the abovementioned embolic risk factors, only the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [double weight], diabetes mellitus, stroke [double weight], vascular disease, age from 65 to 74 years, sex category) score and the LAA strain rate remained as significant predictors of embolic events.
The results of the study show that the VVI-derived LAA strain rate is a significant predictor of documented ischemic stroke and systemic thromboembolism in patients with nonvalvular atrial fibrillation. Its predictive power is similar to the predictive power of the CHA2DS2-VASc score.
KeywordsVelocity vector imaging Echocardiography Predictor Dysrhythmia Cardioversion
Compliance with ethical guidelines
Conflict of interest
M. Jankajova, L. Kubikova, G. Valocik, P. Candik, P. Mitro, M. Kurecko, F. Sabol, A. Kolesar, M. Kubikova, M. Vachalcova and M. Dvoroznakova declare that they have no competing interests.
The trial protocol involving a retrospective analysis was approved by the Ethics Committee of the Hospital and the trial was conducted in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For images or other information within the manuscript which identifies patients, consent was obtained from them and/or their legal guardians.
- 1.Zabalgoitia M, Halperin JL, Pearce LA, Blackshear JL, Asinger RW, Hart RG, Stroke Prevention in Atrial Fibrillation III Investigators. Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. J Am Coll Cardiol. 1998;31(7):1622–6. https://doi.org/10.1016/S0735-1097(98)00146-6.CrossRefPubMedGoogle Scholar
- 4.Buss SJ, Emami M, Mereles D, Korosoglou G, Kristen AV, Voss A, et al. Longitudinal left ventricular function for prediction of survival in systemic light-chain amyloidosis: incremental value compared with clinical and biochemical markers. J Am Coll Cardiol. 2012;60(12):1067–76. https://doi.org/10.1016/j.jacc.2012.04.043.CrossRefPubMedGoogle Scholar
- 5.Kearney LG, Lu K, Ord M, Patel SK, Profitis K, Matalanis G, et al. Global longitudinal strain is a strong independent predictor of all-cause mortality in patients with aortic stenosis. Eur Heart J Cardiovasc Imaging. 2012;13(10):827–33. https://doi.org/10.1093/ehjci/jes115.CrossRefPubMedGoogle Scholar
- 6.Takahashi N, Nakamura Y, Komatsu S, Kusano KF, Ohe T. The feasibility of tissue Doppler acceleration as a new predictor of thrombogenesis in the left atrial appendage associated with nonvalvular atrial fibrillation. Echocardiography. 2008;25(1):64–71. https://doi.org/10.1111/j.1540-8175.2007.00565.x.CrossRefPubMedGoogle Scholar
- 8.Sevimli S, Gundogdu F, Arslan S, Aksakal E, Gurlertop HY, Islamoglu Y, Tas H, Acikel M, Erol MK, Senocak H, Karakelleoglu S, Atesal S, Alp N. Strain and strain rate imaging in evaluating left atrial appendage function by transesophageal echocardiography. Echocardiography. 2007;24(8):823–9. https://doi.org/10.1111/j.1540-8175.2007.00469.x.CrossRefPubMedGoogle Scholar
- 10.Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16(3):233–70. https://doi.org/10.1016/j.echo.2014.10.003.CrossRefPubMedGoogle Scholar
- 11.Flachskampf FA, Wouters PF, Edvardsen T, Evangelista A, Habib G, Hoffman P, Hoffmann R, Lancellotti P, Pepi M, European Association of Cardiovascular Imaging Document reviewers: E Donal and F Rigo. Recommendations for transoesophageal echocardiography: EACVI update 2014. Eur Heart J Cardiovasc Imaging. 2014;15(4):353–65. https://doi.org/10.1093/ehjci/jeu015.CrossRefPubMedGoogle Scholar
- 13.Welch W. A system of medicine. 2nd ed. London: MacMillan and Co, Ltd; 1909.Google Scholar
- 19.Di Minno MN, Ambrosino P, Dello Russo A, Casella M, Tremoli E, Tondo C. Prevalence of left atrial thrombus in patients with non-valvular atrial fibrillation. A systematic review and meta-analysis of the literature. Thromb Haemost. 2016;115(3):663–77. https://doi.org/10.1160/TH15-07-0532.CrossRefPubMedGoogle Scholar
- 21.Shirani J, Alaeddini J. Structural remodeling of the left atrial appendage in patients with chronic non-valvular atrial fibrillation: implications for thrombus formation, systemic embolism, and assessment by transesophageal echocardiography. Cardiovasc Pathol. 2000;9(2):95–101. https://doi.org/10.1016/S1054-8807(00)00030-2.CrossRefPubMedGoogle Scholar