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Atrial fibrillation (AF) is a common disease that changes cardiac morphology, especially in the left atrium (LA). It is now known that certain categories of functional mitral regurgitation (MR) are associated with AF; however, the influence of AF on right cardiac morphology is not fully understood. Our aim in this study was to investigate the association between AF and right cardiac morphology. This was a retrospective cohort study of 86 patients with persistent AF without other cardiac disease who underwent catheter ablation (CA). Seventy-one patients had sustained sinus rhythm (SR) (SR Group) and 15 patients had sustained AF (AF Group) during the study period. We compared the changes in the right cardiac dimensions and tricuspid regurgitation (TR) between the groups 12 months after CA. Patients' baseline echocardiographic assessments revealed that the LA volume index was significantly smaller in the SR group than in the AF group (46.8 ± 11.9 ml/m 2 vs 59.3 ± 12.8 ml/m 2 , respectively; p < 0.01). Comparing baseline data with the 12-month follow-up data, in the SR group, right atrial area (RAA, cm 2 ), tricuspid annular diameter (mm), and tricuspid regurgitant jet area (cm 2 ) were significantly decreased compared with the AF group (19.5 ± 4.5-15.5 ± 3.6 vs 20.7 ± 3.6-19.7 ± 2.3; 30.5 ± 4.9-26.4 ± 3.9 vs 28.7 ± 4.0-28.8 ± 3.1; and 1.4 [interquartile range (IQR) 0.7-2.6]-0.6 [IQR 0.2-1.2] vs 1.2 [IQR 1.1-1.5]-0.9 [IQR 0.4-1.3], respectively). On multivariate analysis, change in RAA correlated with the reduction in tricuspid regurgitant jet area (R = 0.51, p < 0.001). In conclusion, successful CA for persistent AF led to right heart reverse remodeling, and our findings suggested that persistent AF was associated with RAA dilatation and TR.

Aims We sought to propose a novel risk stratification system for severe tricuspid regurgitation (TR) using 3D-anatomical regurgitant orifice area (3D-AROA) and the slope of tricuspid annular plane systolic excursion vs. systolic pulmonary artery pressure (TAPSE/SPAP) and to validate its prognostic significance. Methods and results Sixty-four patients with severe functional TR (52% torrential) underwent 3D echocardiography and exercise–stress echocardiography. As an estimate of regurgitation severity, 3D-AROA was measured with the customized software package. As an index of right ventricular (RV) contractile reserve, the TAPSE/SPAP slope was calculated by plotting the relationship between TAPSE and SPAP during exercise test. Haemodynamic parameters were obtained by right heart catheterization (RHC). Based on receiver operating characteristics curves, optimal cut-off values of 3D-AROA and TAPSE/SPAP slope to identify all-cause mortality were 161 mm2 and 0.046 mm/mmHg, respectively. During a median follow-up of 559 days, 20 patients (31%) died. After correcting for potential confounders, 3DAROA≥ 161 mm2 (HR 4.37; 95% CI 1.34–14.07; P = 0.015) and TAPSE/SPAP slope≤0.046 mm/mmHg (HR 4.76; 95% CI 1.46–15.53; P = 0.009) were echocardiographic parameters independently associated with all-cause mortality. The cumulative survival rate was lower in patients with 3D-AROA≥161 mm2 and TAPSE/SPAP slope≤0.046 mm/mmHg compared with their counterparts (both P <0.05). RHC confirmed higher right atrial pressure (P <0.001) and lower cardiac index (P = 0.004) in patients with both 3D-AROA≥161 mm2 and TAPSE/SPAP slope ≤0.046 mm/mmHg. Conclusion Large AROA and reduced RV contractile reserve during exercise are independently associated with poor prognosis. The new grading scheme of severe TR was validated by haemodynamics and may improve risk stratification. [ABSTRACT FROM AUTHOR]

Aims  We sought to investigate tricuspid valve (TV) geometry and right heart remodelling in atrial functional tricuspid regurgitation (AF-TR) as compared with ventricular functional TR with sinus rhythm (VF-TR). Methods and results  Transoesophageal 3D echocardiography datasets of the TV and right ventricle were acquired in 51 symptomatic patients with severe TR (AF-TR, n  = 23; VF-TR, n  = 28). Three-dimensional right ventricular (RV) endocardial surfaces were reconstructed throughout the cardiac cycle and then postprocessed using semiautomated integration and segmentation software to calculate position of papillary muscle (PM) tips. Compared with VF-TR, AF-TR had more dilated and posteriorly displaced annulus and less leaflet tethering angles with more prominent right atrium and smaller RV end-systolic volume. On the XY (annular) plane, the centre of annulus was getting closer towards the anterior and posterior PM tips and was going away from the medial PM tip caused by prominent annular dilatation in AF-TR. On the Z -axis, the position of each PM tip in AF-TR was not so much displaced apically as that in VF-TR. Multiple linear regression analyses revealed that right atrial volume and right atrial/RV end-systolic volume ratio were determinants of annular area and orientation in AF-TR, respectively (both P  <   0.001). Additionally, the posteromedial-directed component of posterior PM tip position and the apically directed component of the position of all three PM tips were independently associated with TV tethering angles of each leaflet in AF-TR (all P  <   0.02). Conclusion  Right heart remodelling and its association with 3D TV geometry differ entirely between AF-TR and VF-TR, which may offer distinctive therapeutic implication. [ABSTRACT FROM AUTHOR]

Background: Estimation of left ventricular filling pressure (LVFP) is the essential part of the echocardiographic workup for exercise intolerance. The ratio of the mitral early filling velocity to the left ventricular global longitudinal strain (E/LVGLS) has emerged as a novel index of LVFP. This study aimed to investigate the relationship between E/LVGLS and exercise capacity. Methods and results: We retrospectively reviewed 90 patients with exertional dyspnea who underwent echocardiography and cardiopulmonary exercise test. Patients were classified into three groups according to their percent‐predicted maximal oxygen consumption (ppVo2) (G ≧ 75, ppVo2 > 75%, n = 20; G 50‐75, ppVo2 75‐50%, n = 57; G < 50, ppVo2 < 50%, n = 13). Measurements were (a) the relationship between ppVo2 and E/LVGLS and (b) the efficiency of integrated diastolic assessment using E/LVGLS, left ventricular volume, mitral annular early diastolic velocity (E′), and tricuspid regurgitation to identify the patient with impaired exercise capacity. Univariate linear regression analysis demonstrated that E/LVGLS had significant correlation with ppVo2 (ρ = 0.52, P < 0.001). The area under the ROC of E/LVGLS for ppVo2 < 50% was 0.86 (95%CI 0.75‐0.97). The DeLong test showed that E/LVGLS was efficient to detect ppVo2 < 50% than E/E′ (P = 0.007). When used in the integrated assessment of LVFP as the alternative for E/E′, E/LVGLS improved risk classification for impaired exercise capacity. Conclusion: E/LVGLS may be a more efficient index than E/E′ to identify exercise impairment as a single index and as a part of the integrated diastolic assessment. [ABSTRACT FROM AUTHOR]

Background: Persistent AF makes left side heart expansion especially left atrium, but the effect on the right side heart is unknown. The influence to right cardiac morphology with recovering from persistent AF by catheter ablation is almost uncertain even though some guidelines suggest characterize the category of tricuspid regurgitation (TR) due to persistent AF. Objectives: The aim of this study is to seek whether the recover from persistent atrial fibrillation (AF) would provide the contraction in volume of right heart and TR. Methods and Results: A total of 101 patients (60.4 ± 9.3 years, 83 male) with persistent AF continued more than one year were performed first catheter ablation in our institution for 5 years. Of those, 71 patients kept sinus rhythm (SR) at 3 month and one year after ablation (SR Group), 15 patients had AF rhythm at both times of follow up (Recurrence Group). Before catheter procedure, only left atrial (LA) size (LA volume index; 46.8 ± 11.9 vs. 59.3 ± 12.8 ml/m2, p<0.01) had significant difference in echocardiac parameters between two groups. In follow up, right atrium (RA) area (19.5 ± 4.5 vs. 15.5 ± 3.5 cm2, p<0.01), tricuspid annular diameter (28.7 ± 4.0 vs. 27.2 ± 3.8 mm, p<0.01) and TR area [1.4 (IQR 0.7 - 2.6) vs. 0.6 (IQR 0.2 - 1.2) cm2, p<0.01] decreased three month after catheter ablation and these were maintained at one-year follow up in SR Group. No parameters changed in Recurrence Group. Conclusions: In patients with persistent AF, restoration to SR makes RA area and tricuspid annular diameter decrease. Persistent AF can be the reason of right side heart enlargement and it is reversible change. [ABSTRACT FROM AUTHOR]

Tricuspid valve (TV) remodeling occurs in patients with atrial fibrillation (AF); however, the affecting factor related to TV remodeling in AF remains to be elucidated. We sought to explore whether the AF persistence itself affects right heart remodeling. A total of 372 lone AF patients (234 paroxysmal AF [paroxAF] and 138 persistent AF [persAF]) who underwent 3-dimensional transesophageal echocardiography (3D-TEE) was retrospectively reviewed. The duration from first-detected episode of AF to the TEE exam date was defined as AF duration. PersAF patients had a larger TV area index (625.4 vs 719.0 mm2/m2; P < 0.001) and a higher right atrium area-to-right ventricle end-systolic area ratio (RA/RVESA ratio, 1.7 vs 1.9; P = 0.005) than paroxAF patients. The prevalence of AF-tricuspid regurgitation was higher in persAF than in paroxAF patients (1.3% vs 12.3%; P < 0.001). In persAF patients, AF duration was moderately correlated with TV diameter and 3D-TEE-derived TV annular area but not in paroxAF. On multivariable analysis, AF duration was independently associated with TV annular dilatation even after adjustment for RA/RVESA ratio and tricuspid regurgitation severity (β 0.37 [95% CI: 0.77–1.81]; P < 0.001). Additionally, AF duration with cutoff values of 20 months for predicting TV annular dilatation and 37 months for predicting RA/RVESA ratio > 2.1 had both high diagnostic accuracies among persAF patients (both P < 0.01). AF duration itself is independently associated with right heart remodeling in persAF but not in paroxAF, such as TV annular dilatation and predominant RA remodeling which may lead to subsequent TR progression and adverse outcomes. • Previous studies have suggested that increasing tricuspid regurgitation (TR) severity is associated with worse survival and atrial fibrillation (AF) persisting itself is associated with adverse cardiovascular outcomes; hence it is important to prevent tricuspid valve (TV) remodeling and progression of atrial functional TR (AF-TR) to improve prognosis. • In this study, AF duration itself is one of independent determinants of TV annular dilatation only in patients with persistent AF, not in paroxysmal AF. • Significant TV annular dilatation (TV annular area index ≥840 mm2/m2) and predominant right atrial remodeling (right atrium area-to-right ventricle end-systolic area ratio > 2.1) has already initiated at AF duration of 20 months and 37 months, respectively. • Based on the relationship between AF duration and right heart remodeling to progress along the time sequence in this study, early rhythm control may be important in the management of AF patients to prevent right heart structure remodeling leading to the incidence of AF-TR. [ABSTRACT FROM AUTHOR]

Background: Currently the surgical decision-making of tricuspid annuloplasty for tricuspid regurgitation (TR) depends on the measurements of tricuspid annular diameter (TAD) obtained in the apical 4-chamber view on 2-dimensional transthoracic echocardiography (2DTTE). However, whether shape and orientation of the dilated annulus would affect the accuracy of 2DTTE-TAD is unknown. Methods: A total of 185 patients with moderate to severe TR with various underlying causes and 22 controls underwent 2DTTE and 3DTEE assessment of the tricuspid valve (TV). The 3DTEE-TAD defined as the maximum diameter and tricuspid annular (TA) eccentricity index defined as the minimum diameter/maximum diameter ratio, were obtained on mid-diastole frame. As an index of TA orientation, the angle between the 3D TEE-TAD and the interatrial septum parallel to the vertical axis (α°) was measured (Figure 1). Results: Compared with normal TV, TR subgroups had a larger α° irrespective of its etiology (all P <0.05 after multiple comparison) with most frequency of patients with posteriorly orientated TA in atrial fibrillation-TR (normal control, 49±10°; primary TR, 81±36°; left-sided heart disease-TR, 66±28°; atrial fibrillation-TR, 103±35°; Figure 2). An excellent correlation was found between 3DTEE-TAD and 2DTTE-TAD (r=0.88, P <0.001); but 2DTTE-TAD was significantly smaller than 3DTEE-TAD (36.6±5.3 vs 40.6±5.6 mm; P <0.001; bias, 4.0±2.7 mm; limits of agreement, –1.3 to 9.3 mm). After multivariate adjustment, a larger 3DTEE-TAD (P <0.001) and larger absolute value of 90–α° (P <0.001) were independent determinants of the bias between 3DTEE-TAD and 2DTTE-TAD. Notably, a strong curved correlation between TA orientation and the bias was observed (r=0.57, P <0.001; Figure 2). Conclusion: This 3DTEE study demonstrates various TA orientation and its impact on the measurement of 2DTTE-TAD in patients with TR, highlighting the need for reappraising methodology for the measurement of TAD. [ABSTRACT FROM AUTHOR]