Left atrium veno-arterial extra corporeal membrane oxygenation as temporary mechanical support for cardiogenic shock:A case report

BACKGROUND Veno-arterial extra corporeal membrane oxygenation(VA-ECMO)support is commonly complicated with left ventricle(LV)distension in patients with cardiogenic shock.We resolved this problem by transeptally converting VAECMO to left atrium veno-arterial(LAVA)-ECMO that functioned as a temporary paracorporeal left ventricular assist device to resolve LV distension.In our case LAVA-ECMO was also functioning as a bridge-to-transplant device,a technique that has been scarcely reported in the literature.CASE SUMMARY A 65 year-old man suffered from acute myocardial injury that required percutaneous stents.Less than two weeks later,noncompliance to antiplatelet therapy led to stent thrombosis,cardiogenic shock,and cardiac arrest.Femorofemoral VA-ECMO support was started,and the patient underwent a second coronary angiography with re-stenting and intra-aortic balloon pump placement.The VA-ECMO support was complicated by left ventricular distension which we resolved via LAVA-ECMO.Unfortunately,episodes of bleeding and sepsis complicated the clinical picture and the patient passed away 27 d after initiating VA-ECMO.CONCLUSION This clinical case demonstrates that LAVA-ECMO is a viable strategy to unload the LV without another invasive percutaneous or surgical procedure.We also demonstrate that LAVA-ECMO can also be weaned to a left ventricular assist device system.A benefit of this technique is that the procedure is potentially reversible,should the patient require VA-ECMO support again.A transeptal LV venting approach like LAVA-ECMO may be indicated over ImpellaTM in cases where less LV unloading is required and where a restrictive myocardium could cause LV suctioning.Left ventricular over-distention is a well-known complication of peripheral VA-ECMO in cardiogenic shock and LAVA ECMO through transeptal cannulation offers a novel and safe approach for treating LV overloading,without the need of an additional percutaneous access.

Calcific left atrium:A rare consequence of endocarditis

Usually, cardiac calcifications are observed in aortic and mitral valves, atrio-ventricular plane, mitral annulus, coronary arteries, pericaridium(usually causing constrictive pericarditis) and cardiac masses. Calcifications of atrial walls are unusual findings that can be identified only using imaging with high spatial resolution, such as cardiac magnetic resonance and computed tomography. We report a case of a 43-year-old patient with no history of heart disease that underwent cardiac evaluation for mild dyspnoea. The echocardiogram showed a calcific aortic valve and a hyper-echogenic lesion located in atrio-ventricular plane. The patient was submitted to cardiac magnetic resonance and to computed tomography imaging to better characterize the localization of mass. The clinical features and location of calcified lesion suggest an infective aetiology causing an endocarditis involving the aortic valve, atrioventricular plane and left atrium. Although we haven't data to support a definite and clear diagnosis, the clinical features and location of the calcified lesion suggest an infective aetiology causing an endocarditis involving the aortic valve, atrio-ventricular plane and left atrium. The patient was followed for 12 mo both clinically and by electrocardiogram and echocardiography without worsening of clinical, electrocardiographic and echocardiographic data. Cardiac magnetic resonance imaging and computed tomography are ideal methods for identifying and following over time patients with calcific degeneration in the heart.

Device closure of fistula from left lower pulmonary artery to left atrium using a vascular plug:A case report

BACKGROUND Pulmonary artery-to-left atrial fistula is a variant of pulmonary arteriovenous fistula and is a developmental anomaly.Delayed presentation,cyanosis and effort intolerance are some of the important features.The diagnosis is confirmed by computed tomography or pulmonary artery angiography.Catheter-based closure is preferred to surgery.CASE SUMMARY Left pulmonary artery-to-left atrial fistula is rare.A 40-year-old male presented with effort intolerance,central cyanosis,and recurrent seizures.He had a large and highly tortuous left pulmonary artery-to-left atrial fistula associated with a large aneurysmal sac in the course.Catheter-based closure was performed using a vascular plug.CONCLUSION Left pulmonary artery-to-left atrial fistula is relatively uncommon compared to right pulmonary artery-to-left atrial fistula.Percutaneous closure by either a transeptal technique or guide wire insertion into the pulmonary vein through the pulmonary artery is preferred.The need for an arteriovenous loop depends on the tortuosity of the course of the fistula and the size of the device to be implanted because a larger device needs a larger sheath,necessitating firm guide wire support to facilitate negotiation of the stiff combination of the delivery sheath and dilator.

Left Atrium Emboligenic Myxoma: Case Report and Review of the Literature

Introduction: Cardiac myxomas represent the most frequent forms of primary tumors of the heart. The most frequent location is the interatrial septum. We report the clinical case of a myxoma of the left atrium and discuss its epidemiological and therapeutic aspects through a review of the literature. Observation: This was a 41-year-old female patient who presented with sudden rotational dizziness associated with vomiting. MRI revealed multiple punctiform bilateral supra and subtentorial strokes of different ages, recent and semi-recent, suggesting an embologenic etiology. Transesophageal echocardiography found a large pedunculated, homogeneous, avascular tumor hanging from the interatrial septum. The patient is operated on urgently under cardiopulmonary bypass for resection of a large tumor located in the left atrium. The pathological examination concluded with the diagnosis of myxoma of the left atrium. The postoperative follow-up was straightforward and the patient was discharged from the hospital via home hospitalization. Conclusion: The diagnosis of cardiac myxomas is suspected in the presence of symptoms associated with echocardiographic images of intracardiac masses and confirmed by histological study. Embolic accidents are one of the formidable complications of myxomas. Surgical management is urgent, especially in the presence of predictive morphological features of embolism on echocardiography.

Double Compression of Left Atrium and Pulmonary Artery by a Huge Descending Aortic Aneurysm with Intramural Hematoma Mimicking Pulmonary Embolism: A Case Report

Hemodynamic instability secondary to left atrial (LA) compression by an aortic aneurysm is a rare entity. We report?the case of a 43-year old woman with no previous diagnosis of congestive heart failure who was admitted for an initial diagnosis of pulmonary embolism (PE) based on shortness of breath, hypotension and D-Dimers?elevation. The electrocardiogram and blood counts were within normal limits. The chest X-ray revealed widening of the mediastinum. Transthoracic echocardiography demonstrated LA compression by a large descending thoracic aortic aneurysm. Left and right ventricle systolic functions were preserved. Chest angiography showed LA and left pulmonary artery (LPA) compression by a descending aortic aneurysm and an intramural hematoma with no evidence of PE evidence. Emergency surgery could not be done because of her financial status. She was treated medically and was discharged 1?week later with significant improvement. However she remained hypotensive.

Resection of Lung Cancer with Left Atrium Extension via the Pulmonary Vein: Case Report

A 49-year-old man had an abnormal shadow on chest X-ray. Enhanced chest computed tomography (CT) revealed an 8-cm diameter right lung mass invading the right chest wall, with a tumor thrombus extending from the superior pulmonary vein into the left atrium. Transesophageal echocardiography confirmed that the tumor adjoined the side wall of the atrium. Endobronchial and CT-guided needle biopsy demonstrated a low-grade carcinoma or small cell carcinoma. Operative findings through left atriotomy under cardiopulmonary bypass showed no tumor invasion of the atrium wall, but protrusion through the pulmonary vein. Frozen sections revealed a non-small cell carcinoma. We performed right upper lobectomy with parietal pleura and mediastinal lymph node dissection after detachment of cardiopulmonary bypass. Pathological examination demonstrated a large-cell neuroendocrine carcinoma p-T4N0M0, stage IIIA. The patient recovered without postoperative complications and tolerated two cycles of adjuvant chemotherapy. He was doing well without symptoms of recurrence 42 months after surgery.

Rheumatic Giant Left Atrium—An Overview

Aim: To present the aneurysmal dilatation of left atrium due to rheumatic mitral valve disease and its clinical consequences such as arrhythmic, thromboembolic and compressive manifestations. Introduction: Extreme enlargement of left atrium, usually referred to as giant, gigantic or aneurysmal dilatation is an uncommon finding with a reported incidence of 0.3% in rheumatic heart disease. It is an important clinical risk identifier to predict the outcome of cardiovascular disease. Case reports: Aneurysmal left atrium correlating with the length of pure mitral regurgitation jet in a 18-year-old girl, posterior mitral leaflet prolapse with regurgitation jet swirling around the entire interatrial septum in a 37-year-old male, Giant left atrium in mixed mitral valve disease in a 37-year-old female and a thrombosed giant left atrium resembling as “coconut” in a 50-year-old female were reported. Conclusion: Giant left atrium may be misinterpreted as right-sided pleural effusion, pericardial effusion and mediastinal tumor on X-ray chest and so echocardiographic evaluation is mandatory to exclude the aneurysmal left atrium in such conditions.

Idiopathic pulmonary vein thrombosis extending to left atrium： a case report with a literature review

Pulmonary vein thrombosis is a rare disease and is usually represented as a complication of atrial fibrillation, pulmonary tumors, and Iobectomy. Although it is a potentially life threatening condition, the venous disease is easy to misdiagnose because of the non-specific symptoms, In this article, we present a 30-year-old patient who suffered from pulmonary vein thrombosis without any causes. He was diagnosed with other pulmonary disorders till the thrombus within the pulmonary vein extended into the left atrium. Left atrium mass resection and a left lower Iobectomy were undertaken with relative urgency. The postoperative course was uneventful. The patient received a long course of oral anticoagulant therapy.

NEGATIVE EFFECTS OF ETHANOL ON ISOLATED GUINEA PIG LEFT ATRIUM AND PAPILLARY MUSCLES

Objective To investigate the effects of ethanol on physiological characteristics of the isolated guinea pig left atrium and papillary muscles.Methods The effects of ethanol on contractility, post-rest potentiation and positive staircase phenomenon were observed in isolated left atrium and papillary muscles of guinea pig.Results Ethanol(50.0,100.0,200.0mmol·L -1)prominently inhibited the contraction of papillary muscles. Ethanol(12.5,25.0,50.0,100.0,200.0mmol·L -1) inhibited the contraction of left atrium, and markedly decreased the post-rest potentiation of myocardial contractility in left atrium. High concentration of ethanol(100,200mmol·L -1) depressed the positive staircase phenomenon of isolated guinea pig left atrium.Conclusion These results suggest that ethanol induces inhibitory effects of the contractility, post-rest potentiation, positive staircase phenomenon of left atrium. The mechanism by which ethanol induces the negative inotropic effects may be related to decrease the amount of calcium released from the intracellular stores.

CartoXP Guided Catheter Ablation for Paroxysmal Atrial Fibrillation Without Three-dimensional Modeling of Left Atrium and Pulmonary Veins

Objectives This study was to investigate the differences between modeling and non-modeling left atrium （LA） in CartoXP system guided catheter ablation for paroxysmal atrial fibrillation （PAF）. Methods From Jan to Dec in 2008 total 31 cases with PAF were enrolled. All were treated by the same electrophysiologist with CartoXP guidance. Catheter ablation was accomplished without left atrium and pulmonary veins modeling in 17 patients （non-modeling group） and with left atrium modeling in 14 patients （modeling group）. The detailed ablation method was based on circumferential pulmonary veins isolation （CPVI）. And linear ablation of tricuspid valvular isthmus was performed individually. The ablation endpoint was a complete isolation of pulmonary vein potential from left atrium and no further induced continuous fast atrial arrhythmia including atrial fibrillation （AF）, atrial flutter （AFL） and atrial tachycardia （AT）. Each step for the procedures and the follow-up outcomes were compared correspondingly. Results The total procedure time was 107.23 ± 28.92 min in modeling group vs 93.47 ±26.09 min in non-modeling group （ P 〉 0.05 ）. The X-ray exposure time was significantly longer in modeling group （21.09 ±6. 49 rain） than in non-modeling group （14. 16 ± 5.35 min）. The CPVI times of right pulmonary veins and left pulmonary veins were 28. 14 ± 9. 26 min was 27.29 ± 18.53 min in modeling group respectively, vs 18.00 ±4. 51 min and 23.94 ± 7. 10 min in non-modeling group respectively, （P 〈 0. 05 ）. There is no significant difference between modeling group （85.7%） and non-modeling group （82.4%） over follow-up period of 2 to 13 months. Confusions CartoXP system guided catheter ablation of PAF without modeling of left atrium and pulmonary veins took less time in X-ray exposure and ablation steps, comparing with left atrium modeling procedure.

Dyspnea in a 26-Year-Old Woman with Fatal Left Atrial Myxoma

Cardiac myxoma is one of the primary intracardiac tumours. We report the case of a left atrial myxoma in a 26-year-old female patient admitted for investigation of dyspnoea. Echocardiography led to the diagnosis of a giant hypermobile myxoma prolapsing into the left ventricle. The patient died before being evacuated for surgical treatment.

Atrium of stone:A case of confined left atrial calcification without hemodynamic compromise

Dystrophic cardiac calcification is often associated with conditions causing systemic inflammation and when present,is usually extensive,often encompassing multiple cardiac chambers and valves.We present an unusual case of dystrophic left atrial calcification in the setting of end stage renal disease on hemodialysis diagnosed by echocardiography and computed tomography.Significant calcium deposition is confined within the walls of the left atrium with no involvement of the mitral valve,and no hemodynamic effects.

心脏磁共振在左心房评估中的应用

作为左心室的延续,左心房与左心室相互影响,在整个心脏的功能中发挥重要作用。目前评估心房结构及功能的技术很多,但是由于左心房结构复杂且心肌较薄,给相关评估带来了一定挑战。本文从心肌应变、延迟强化方面介绍左心房评估的参数、评估过程中的注意事项及相关临床应用。

心尖肥厚型心肌病患者心房颤动的相关因素分析

目的:分析心尖肥厚型心肌病患者(apical hypertrophic cardiomyopathy,ApHCM)心房颤动的相关因素。方法:连续入组2011年4月至2019年4月在首都医科大学附属北京安贞医院入院治疗的心尖肥厚型心肌病患者125例,其中49例诊断为心房颤动(观察组),76例无心房颤动(对照组),心房颤动组平均年龄65.5岁,男性比例59.2%,非心房颤动组平均年龄59.5岁,男性比例84.2%。收集患者年龄、性别、合并疾病、治疗及超声心动图检查结果,采用单因素及多因素Logistic回归分析评估ApHCM患者心房颤动的相关因素。结果:与对照组相比,心房颤动组年龄更大、纽约心功能分级Ⅲ者更高、经皮冠状动脉介入治疗比例更低、射频消融术比例更高、住院时间更长(P<0.05)。两组心脏超声参数差异无统计学意义(P> 0.05)。多因素Logistic逐步回归分析表明女性(OR=3.170,95%CI:1.124~8.942,P=0.029)、LAD(OR=1.287,95%CI:1.149~1.440,P=0.000)是该人群发生心房颤动的危险因素,左心室后壁厚度与心房颤动发生呈负相关(OR=0.690,95%CI:0.484~0.984,P=0.041)。结论:心房颤动是影响ApHCM的关键因素之一,且发生率较高,而女性和LAD是心房颤动发生的危险因素,因此根据人群进行针对性、个体化的治疗尤为重要。

三维斑点追踪技术评估非瓣膜性心房颤动患者左房低电压区对左房结构及功能的影响

目的应用三维斑点追踪技术(3D-STI)评估非瓣膜性心房颤动(以下简称房颤)患者不同程度左房低电压区(LVA)对左房结构及功能的影响。方法选取我院拟行射频消融术的非瓣膜性房颤患者66例,术前均行经胸超声心动图检查获得左房收缩末期前后径、左右径、上下径和左室舒张末期内径、左室射血分数、二尖瓣口舒张早期峰值血流速度与二尖瓣环峰值运动速度比值(E/e’);3D-STI获得左房储器期应变(LASr)、管道期应变(LAScd)、泵功能期应变(LASct)及左房射血分数(LAEF)。进行射频消融术时应用三维电解剖标测技术获得LVA,根据LVA面积占左房总面积的百分比定义LVA程度,将患者分为无LVA患者组(Ⅰ组)29例、LVA程度<10%组(Ⅱ组)26例、LVA程度≥10%组(Ⅲ组)11例,比较各组临床资料和超声心动图参数的差异;分析左房应变参数与LVA的相关性。结果Ⅲ组陈旧性脑梗死或一过性脑缺血、持续性房颤占比及CHA_(2)DS_(2)-VASc评分均高于Ⅰ组、Ⅱ组,差异均有统计学意义(均P<0.05)。Ⅰ组与Ⅲ组、Ⅱ组与Ⅲ组E/e’>14者占比比较,差异均有统计学意义(均P<0.05);其余常规超声心动图参数比较,差异均无统计学意义。Ⅲ组LASr、LAScd、LASct、LAEF均低于Ⅰ组、Ⅱ组,差异均有统计学意义(均P<0.05)。相关性分析显示,LASr、LAScd、LASct均与LVA呈负相关(r=-0.538、-0.448、-0.501,均P<0.05)。结论当LVA达到10%时,房颤患者左房结构虽未发生改变,但其功能已经减低;应用3D-STI可以早期发现非瓣膜性房颤患者LVA程度对左房功能的影响。

经食道超声心动图对非瓣膜性心房颤动患者左心房血栓形成的评价结果及其影响因素分析

目的探讨经食道超声心动图对非瓣膜性房颤(NVAF)患者左心房血栓形成的评价结果,并分析血栓形成或自发性超声显影的影响因素。方法选取2019年1月至2022年1月于山东省聊城市第二人民医院进行经食道超声心动图检查的NVAF患者150例,根据是否发生左心房血栓形成或自发性超声显影,分为血栓组(32例)和无血栓组(118例)。收集两组患者的一般资料和心脏超声参数,经单因素及多因素Logistics回归分析NVAF患者发生左心房血栓形成的危险因素,绘制受试者工作特征曲线(ROC),分析其对NVAF患者左心房血栓形成的预测价值。结果与无血栓组比较,血栓组左心房前后径(LAAPD)水平较高,左心耳峰值血流排空速度(LAAV)、左心室射血分数(LVEF)和整体左心房长轴应变(GLALS)水平较低(P<0.05)。二元Logistics回归分析显示:LAAPD、LAAV、LVEF和GLALS是左心房血栓形成的影响因素(P<0.05)。绘制ROC曲线发现,LAAPD、LAAV、LVEF、GLALS以及联合预测左心房血栓形成的AUC依次为0.899、0.892、0.816、0.822和0.986,联合预测效能最高(P<0.05)。结论经食道超声心动图检测的LAAPD、LAAV、LVEF、GLALS是NVAF患者左心房血栓形成的影响因素,且对左心房血栓形成具有一定预测价值,尤其是联合预测效能最高。

Predictive value of serum uric acid on left atrial spontaneous echo contrast in non-valvular atrial fibrillation patients

Objectives To investigate the relationship between serum uric acid （SUA） and left atrial spontaneous echo contrast （LA-SEC） in non-valvular atrial fibrillation （AF） patients. Methods We retrospectively screened 1,476 consecutive hospitalized patients with AF who underwent transesophageal echocardiography prior to radiofrequency catheter ablation, left atrial appendage closure and electric cardiover- sion at Guangdong General Hospital. Data on the clinical baseline characteristics of all patients were collected from electronic medical re- cords and analyzed. Results After exclusion of patients with left atrial thrombus, 1,354 patients entered into present study and 57 were LA-SEC. The mean female SUA level （380.88 ± 94.35 μmol/L vs. 323.37 ± 72.19μmol/L, P 〈 0.001） and male SUA level （416.97 ± 98.87 μmol/L vs. 367.88 ＋ 68.50 μmol/L, P = 0.008） were both significantly higher in patients with LA-SEC than in the controls. The mean left atrial dimension （41.32 ± 5.12 mm vs. 36.12 ± 5.66 mm, P 〈 0.001） was markedly larger in patients with LA-SEC. In multivariate regression analysis, SUA level was an independent risk factor for LA-SEC （OR： 1.008, P 〈 0.001）. In receiver operating characteristic curve analysis, the corresponding area under the curve for SUA predicting LA-SEC in female and male were 0.670 and 0.657, respectively. SUA level is significantly higher in non-valvular AF patients with LA-SEC. Conclusion SUA level is an independent risk factor and has a moderate predictive value for LA-SEC among non-valvular AF patients in Southern China.

Shortness of breath in clinical practice: A case for left atrial function and exercise stress testing for a comprehensive diastolic heart failure workup

The symptom cluster of shortness of breath(SOB) contributes significantly to the outpatient workload of cardiology services. The workup of these patients includes blood chemistry and biomarkers, imaging and functional testing of the heart and lungs. A diagnosis of diastolic heart failure is inferred through the exclusion of systolic abnormalities, a normal pulmonary function test and normal hemoglobin, coupled with diastolic abnormalities on echocardiography. Differentiating confounders such as obesity or deconditioning in a patient with diastolic abnormalities is difficult. While the most recent guidelines provide more avenues for diagnosis, such as incorporating the left atrial size, little emphasis is given to understanding left atrial function, which contributes to at least 25% of diastolic left ventricular filling; additionally, exercise stress testing to elicit symptoms and test the dynamics of diastolic parameters, especially when access to the "gold standard" invasive tests is lacking, presents clinical translational gaps. It is thus important in diastolic heart failure work up to understand left atrial mechanics and the role of exercise testing to build a comprehensive argument for the diagnosis of diastolic heart failure in a patient presenting with SOB.

Left atrial physiology and pathophysiology:Role of deformation imaging

The left atrium(LA) acts as a modulator of left ventricular(LV) filling. Although there is considerable evidence to support the use of LA maximum and minimum volumes for disease prediction,theoretical considerations and a growing body of literature suggest to focus on the quantification of the three basic LA functions:(1) Reservoir function:collection of pulmonary venous return during LV systole;(2) Conduit function:passage of blood to the left ventricle during early LV diastole; and(3) Contractile booster pump function(augmentation of ventricular filling during late LV diastole. Tremendous advances in our ability to non-invasively characterize all three elements of atrial function include speckle tracking echocardiography(STE),and more recently cardiovascular magnetic resonance myocardial feature tracking(CMR-FT). Corresponding imaging biomarkers are increasingly recognized to have incremental roles in determining prognosis and risk stratification in cardiac dysfunction of different origins. The current editorial introduces the role of STE and CMR-FT for the functional assessment of LA deformation as determined by strain and strain rate imaging and provides an outlook of how this exciting field may develop in the future.

四维斑点追踪显像评价高血压对糖尿病患者左心房功能影响的研究

目的探讨四维斑点追踪显像(4D-STI)评价高血压对糖尿病患者左心房功能的影响。方法回顾性选择2021年1月至12月杭州市临平区第一人民医院收治入院的2型糖尿病患者95例,合并高血压(合并高血压组)57例,未合并高血压(未合并高血压组)38例,健康体检者65人为对照组。采用4D-STI比较各组心室舒张末期左心房容积(LAVd)、心室收缩末期左心房容积(LAVs)、左心房射血前期容积(LAVp)、左心房每搏排血容积(LAEV)、左心房被动排血容积(LAPV)、左心房主动排血容积(LAAV)、左心房射血分数(LAEF)、左心房被动排血分数(LAPEF)、左心房主动排血分数(LAAEF),左心房储备期纵向应变(LALSr)、左心房储备期圆周应变(LACSr)、左心房管道期纵向应变(LALScd)、左心房管道期圆周应变(LACScd)、左心房收缩期纵向应变(LALSct)、左心房收缩期圆周应变(LACSct)。结果合并高血压组、未合并高血压组的LAVd、LAVp、LAAV高于对照组,LAPV、LAEF、LAPEF小于对照组,差异均有统计学意义(均P<0.05)。合并高血压组的LAVs高于对照组、未合并高血压组,LAVd、LAVp、LAAV高于未合并高血压组,LAEF、LAPEF小于未合并高血压组,差异均有统计学意义(均P<0.05)。3组对象的LALSr、LACSr、LALScd、LACScd比较差异均有统计学意义(均P<0.05),合并高血压组、未合并高血压组上述指标均低于对照组,差异均有统计学意义(均P<0.05)。结论利用4D-STI能够评价高血压对糖尿病患者左心房功能的影响。