© 2015, Wiley Periodicals, Inc. DOI: 10.1111/echo.12908
Echocardiography
Atrial Septal Aneurysms and Supraventricular Arrhythmias: The Role of Atrial Electromechanical Delay Vincenzo Russo, M.D., Ph.D., M.M.Sc.,* Anna Rago, M.D.,* Federica Di Meo, M.D.,* , M.D., Andrea Antonio Papa, M.D.,* Carmine Ciardiello, Ph.D.,† Anna Cristiano, M.D.,* Raffaele Calabro Ph.D.,* Maria Giovanna Russo, M.D.,* and Gerardo Nigro, M.D., Ph.D.* *Chair of Cardiology, Second University of Naples, Naples, Italy; and †H.T. MED Pozzuoli (NA), Naples, Italy
Background: Paroxysmal supraventricular arrhythmias (SVAs) frequently occur in patients with atrial septal aneurysm (ASA). The aim of the current study was to evaluate the electrocardiographic (P-wave duration and dispersion) and echocardiographic (atrial electromechanical delay, AEMD) noninvasive indicators of atrial conduction heterogeneity in healthy ASA subjects without interatrial shunt and to assess the AEMD role in predicting the SVAs onset in this population. Materials and Methods: One hundered ASA patients (41 males, mean age of 32.5 8 years) and 100 healthy subjects used as controls, matched for age and gender, were studied for the occurrence of SVAs during a 4-year follow-up, through 30-day external loop recorder (ELR) monitoring performed every 3 months. ASAs were diagnosed by transthoracic echocardiography based on the criteria of a minimal aneurismal base of ≥15 mm and an excursion of ≥10 mm. Intra-AEMD and inter-AEMD of both atria were measured through tissue Doppler echocardiography. P-wave dispersion (PD) was carefully measured using 12-lead electrocardiogram (ECG). Results: Compared to the healthy control group, the ASA group showed a statistically significant increase in inter-AEMD, intra-left AEMD, maximum P-wave duration, and PD. Dividing the ASA group into 2 subgroups (patients with or without SVAs), the inter-AEMD, intra-left AEMD, P max, and PD were significantly higher in the subgroup with SVAs compared to the subgroup without SVAs. There were significant good correlations of intra-left AEMD and inter-AEMD with PD. A cutoff value of 40.1 msec for intra-left AEMD had a sensitivity of 82% and a specificity of 83% in identifying ASA patients at risk for SVA. Conclusion: Our results showed that the echocardiographic AEMD indices (intra-left and inter-AEMD) and the PD were significantly increased in healthy ASA subjects without interatrial shunt. PD and AEMD represent noninvasive, inexpensive, useful, and simple parameters to assess the SVAs’ risk in ASA patients. (Echocardiography 2015;32:1504–1514) Key words: supraventricular arrhythmias, atrial septal aneurysm, atrial electromechanical delay, P-wave dispersion
Atrial septal aneurysm (ASA) is a well-recognized cardiac anomaly consisted in a saccular deformity located in the atrial septum,1 but little is still known about its clinical significance. ASA has been reported to be associated with congenital heart diseases,2 systemic and pulmonary hypertension,3 thrombus formation, and thromboembolic stroke.4,5 Previous studies demonstrated an association between ASA and supraventricular arrhythmias (SVAs)6–12 and between ASA and atrial conduction disturbances.13,14 Little is still known about the association between ASA without interatrial shunt and SVAs.15 The aim of this study was to evaluate the Address for correspondence and reprint requests: Anna Rago, M.D., Corso Garibaldi, 168, 80055 Portici (Naples) Italy. Fax: 08231971858; E-mail:[email protected]
1504
electrocardiographic (P-wave duration and dispersion) and echocardiographic (atrial electromechanical delay [AEMD]) noninvasive indicators of atrial conduction heterogeneity in healthy ASA subjects without interatrial shunt and to assess the AEMD role in predicting the paroxysmal SVAs onset in this population. Methods: Study Population: The study involved 100 patients (41 males, mean age of 32.5 8 years) with diagnosis of ASA on transthoracic echocardiography, recruited among 2500 patients referred to Arrhythmology Unit of Second University of Naples for various clinical reasons (palpitations, fainting) from January 2010 to December 2013. We enrolled in our
Atrial Septal Aneurysm and Atrial Electromechanical Delay
study only subjects with diagnosis of ASA without interatrial shunt and normal cardiac function, who referred to our Arrhythmology Unit for palpitations, but did not present sustained arrhythmias prior to inclusion in the study; some of them presented sporadic isolated supraventricular extrasystoles (SVEs). Subjects with a history of hypertension (systolic and diastolic blood pressure > 140/90 mmHg; 1173 patients), diabetes mellitus or impaired glucose tolerance (IGT) (577 patients), obesity (39 patients), electrolyte imbalance (18 patients), valvular heart disease (18 patients), heart failure (22 patients), coronary artery disease (161 patients), systolic and diastolic dysfunction (41 patients), left and right atrial enlargement (108 patients), connective tissue disorders (9 patients), left bundle branch block or atrioventricular conduction abnormalities on electrocardiogram (ECG) (48 patients), hepatic (60 patients), renal (40 patients), thyroid diseases (7 patients), syncope (22 patients), stroke (4 patients), sleep disorders (6 patients), patent foramen ovale (28 patients), atrial septal defect (8 patients), or having a permanent pacemaker (18 patients) were excluded from the study. One hundred sex- and agematched healthy subjects, recruited from medical volunteers, were served as the control group. Study Protocol: Medical history, physical examination, anthropometric evaluation, 12-lead surface ECG (MAC 2000 Resting ECG System, General Electric Company, Fairfield, Ct, USA), high-capacity memory ELR, 2D color Doppler transthoracic echocardiogram with tissue Doppler evaluation, and transesophageal (TEE) echocardiogram (Vivid 9, General Electric Company) were performed in the study population. All subjects gave their written informed consent. Electrocardiographic Measurements: All subjects underwent a routine standard 12-lead body surface ECG recorded at a paper speed of 50 mm/sec and gain of 10 mm/mV in the supine position and were breathing freely but not allowed to speak during the ECG recording. To avoid diurnal variations, we generally evaluated the ECG recordings at the same time (9:00– 10:00 A.M.). The analysis was performed by one investigator only without knowledge of subject’s clinic status. ECGs were transferred to a personal computer by an optical scanner and then magnified to 400% by Adobe Photoshop software (Adobe Systems Inc., San Jose, CA, USA). P-wave duration measurement was manually performed with the use of computer software (ImageJ, NIH, Bethesda, MD, USA) from all 12 ECG leads. Intraobserver coefficients of variation for P-wave vari-
ables were found to be
Echocardiography
Atrial Septal Aneurysms and Supraventricular Arrhythmias: The Role of Atrial Electromechanical Delay Vincenzo Russo, M.D., Ph.D., M.M.Sc.,* Anna Rago, M.D.,* Federica Di Meo, M.D.,* , M.D., Andrea Antonio Papa, M.D.,* Carmine Ciardiello, Ph.D.,† Anna Cristiano, M.D.,* Raffaele Calabro Ph.D.,* Maria Giovanna Russo, M.D.,* and Gerardo Nigro, M.D., Ph.D.* *Chair of Cardiology, Second University of Naples, Naples, Italy; and †H.T. MED Pozzuoli (NA), Naples, Italy
Background: Paroxysmal supraventricular arrhythmias (SVAs) frequently occur in patients with atrial septal aneurysm (ASA). The aim of the current study was to evaluate the electrocardiographic (P-wave duration and dispersion) and echocardiographic (atrial electromechanical delay, AEMD) noninvasive indicators of atrial conduction heterogeneity in healthy ASA subjects without interatrial shunt and to assess the AEMD role in predicting the SVAs onset in this population. Materials and Methods: One hundered ASA patients (41 males, mean age of 32.5 8 years) and 100 healthy subjects used as controls, matched for age and gender, were studied for the occurrence of SVAs during a 4-year follow-up, through 30-day external loop recorder (ELR) monitoring performed every 3 months. ASAs were diagnosed by transthoracic echocardiography based on the criteria of a minimal aneurismal base of ≥15 mm and an excursion of ≥10 mm. Intra-AEMD and inter-AEMD of both atria were measured through tissue Doppler echocardiography. P-wave dispersion (PD) was carefully measured using 12-lead electrocardiogram (ECG). Results: Compared to the healthy control group, the ASA group showed a statistically significant increase in inter-AEMD, intra-left AEMD, maximum P-wave duration, and PD. Dividing the ASA group into 2 subgroups (patients with or without SVAs), the inter-AEMD, intra-left AEMD, P max, and PD were significantly higher in the subgroup with SVAs compared to the subgroup without SVAs. There were significant good correlations of intra-left AEMD and inter-AEMD with PD. A cutoff value of 40.1 msec for intra-left AEMD had a sensitivity of 82% and a specificity of 83% in identifying ASA patients at risk for SVA. Conclusion: Our results showed that the echocardiographic AEMD indices (intra-left and inter-AEMD) and the PD were significantly increased in healthy ASA subjects without interatrial shunt. PD and AEMD represent noninvasive, inexpensive, useful, and simple parameters to assess the SVAs’ risk in ASA patients. (Echocardiography 2015;32:1504–1514) Key words: supraventricular arrhythmias, atrial septal aneurysm, atrial electromechanical delay, P-wave dispersion
Atrial septal aneurysm (ASA) is a well-recognized cardiac anomaly consisted in a saccular deformity located in the atrial septum,1 but little is still known about its clinical significance. ASA has been reported to be associated with congenital heart diseases,2 systemic and pulmonary hypertension,3 thrombus formation, and thromboembolic stroke.4,5 Previous studies demonstrated an association between ASA and supraventricular arrhythmias (SVAs)6–12 and between ASA and atrial conduction disturbances.13,14 Little is still known about the association between ASA without interatrial shunt and SVAs.15 The aim of this study was to evaluate the Address for correspondence and reprint requests: Anna Rago, M.D., Corso Garibaldi, 168, 80055 Portici (Naples) Italy. Fax: 08231971858; E-mail:[email protected]
1504
electrocardiographic (P-wave duration and dispersion) and echocardiographic (atrial electromechanical delay [AEMD]) noninvasive indicators of atrial conduction heterogeneity in healthy ASA subjects without interatrial shunt and to assess the AEMD role in predicting the paroxysmal SVAs onset in this population. Methods: Study Population: The study involved 100 patients (41 males, mean age of 32.5 8 years) with diagnosis of ASA on transthoracic echocardiography, recruited among 2500 patients referred to Arrhythmology Unit of Second University of Naples for various clinical reasons (palpitations, fainting) from January 2010 to December 2013. We enrolled in our
Atrial Septal Aneurysm and Atrial Electromechanical Delay
study only subjects with diagnosis of ASA without interatrial shunt and normal cardiac function, who referred to our Arrhythmology Unit for palpitations, but did not present sustained arrhythmias prior to inclusion in the study; some of them presented sporadic isolated supraventricular extrasystoles (SVEs). Subjects with a history of hypertension (systolic and diastolic blood pressure > 140/90 mmHg; 1173 patients), diabetes mellitus or impaired glucose tolerance (IGT) (577 patients), obesity (39 patients), electrolyte imbalance (18 patients), valvular heart disease (18 patients), heart failure (22 patients), coronary artery disease (161 patients), systolic and diastolic dysfunction (41 patients), left and right atrial enlargement (108 patients), connective tissue disorders (9 patients), left bundle branch block or atrioventricular conduction abnormalities on electrocardiogram (ECG) (48 patients), hepatic (60 patients), renal (40 patients), thyroid diseases (7 patients), syncope (22 patients), stroke (4 patients), sleep disorders (6 patients), patent foramen ovale (28 patients), atrial septal defect (8 patients), or having a permanent pacemaker (18 patients) were excluded from the study. One hundred sex- and agematched healthy subjects, recruited from medical volunteers, were served as the control group. Study Protocol: Medical history, physical examination, anthropometric evaluation, 12-lead surface ECG (MAC 2000 Resting ECG System, General Electric Company, Fairfield, Ct, USA), high-capacity memory ELR, 2D color Doppler transthoracic echocardiogram with tissue Doppler evaluation, and transesophageal (TEE) echocardiogram (Vivid 9, General Electric Company) were performed in the study population. All subjects gave their written informed consent. Electrocardiographic Measurements: All subjects underwent a routine standard 12-lead body surface ECG recorded at a paper speed of 50 mm/sec and gain of 10 mm/mV in the supine position and were breathing freely but not allowed to speak during the ECG recording. To avoid diurnal variations, we generally evaluated the ECG recordings at the same time (9:00– 10:00 A.M.). The analysis was performed by one investigator only without knowledge of subject’s clinic status. ECGs were transferred to a personal computer by an optical scanner and then magnified to 400% by Adobe Photoshop software (Adobe Systems Inc., San Jose, CA, USA). P-wave duration measurement was manually performed with the use of computer software (ImageJ, NIH, Bethesda, MD, USA) from all 12 ECG leads. Intraobserver coefficients of variation for P-wave vari-
ables were found to be
