The prognostic value of P-wave dispersion and left atrial functions assessed with three-dimensional echocardiography in patients with cirrhosis.

BACKGROUND: Cirrhotic cardiomyopathy (CCM) is a well-known entity. The aim of this study was to compare left atrial three-dimensional (3D) volume and P-wave dispersion (PWd) in patients with cirrhosis and a healthy population. The secondary purpose was to assess the left phasic volumes and reservoir functions with 3D echocardiography for the prediction of an increased risk of poor outcomes in patients with cirrhosis. METHODS: The study included 50 patients with cirrhosis and 43 healthy control subjects without atrial fibrillation. All patients were assessed with two-dimensional (2D), 3D, and tissue Doppler transthoracic echocardiography. The PWd was calculated using a 12-lead surface electrocardiogram (ECG). Cirrhotic patients were followed up for 2.5 years for the evaluation of poor outcomes and the development of atrial fibrillation. RESULTS: Patients with cirrhosis were observed to have significantly higher left atrial phasic volumes such as minimal left atrial volume (3D-LAVmin, P = 0.004) and indexed LAVmin (3D-LAVImin, P = 0.0001), and significantly decreased left atrial reservoir functions such as left atrial emptying volume (3D-LAEV, P = 0,001), left atrial ejection fraction (3D-LAEF, P = 0,001) on 3D echocardiography. PWd was determined to be significantly longer in the cirrhotic group compared with the control group (P = 0.003). In the 2.5-year follow-up period, poor outcomes occurred in 34 patients (22 patients died, six patients had liver transplantation, six patients developed atrial fibrillation/AHRE episodes). In Cox regression analysis, the MELD score (HR, 1.16 (1.06-1.26), P = 0.001) and 3D-LAVImin (HR, 0.95 (0.86-1.00), P = 0.040) were significantly associated with all-cause mortality. Cirrhotic patients with LAVImin of >15 ml/m2 were seen to have poor survival (long rank P = 0.033). CONCLUSION: The results of this study showed that patients with cirrhosis had higher left atrial volume, longer PWd and worse diastolic functions compared with the control group. Higher disease severity scores were associated with left atrial function and volume. In addition, left atrial volume measured with 3DE was a strong predictor of future adverse events, and minimal left atrial volumes had a higher prognostic value than any other left atrial function indices.

Assessment of Contributors of Aortopathy and Subclinical Left Ventricular Dysfunction in Normally Functioning Bicuspid Aortic Valves.

BACKGROUND: Left ventricular (LV) function and the dimensions of aortic valves from normally functioning bicuspid aortic valve (BAV) patients were compared with those of healthy control patients. A comparison between patients with antero-posterior BAV (BAV-AP) or right-left BAV (BAV-RL) was also performed, and the determinants of aortopathy and LV function were investigated. METHODS: Sixty-eight patients with aortic velocities <2 m/s and trivial or mild aortic regurgitation were included in the study. All patients underwent transesophageal echocardiography to diagnose BAV and identify associated phenotypes. Twodimensional (2D), Doppler echocardiographic evaluation, and strain imaging were also performed, and the results compared with those obtained from 55 age- and gender-matched healthy controls. RESULTS: The LV ejection fractions were similar between BAV patients and healthy controls, while LV global longitudinal strain (LVGLS) (p = 0.03) and LV global circumferential strain (LVGCS) (p = 0.02) were significantly lower among BAV patients. Aortic velocities and aortic dimensions at theannulus, sinus of Valsalva and sinotubular junction were significantly greater in BAV patients (all p <0.001). The diameter of the tubular ascending aorta (AA) was correlated with age (r = 0.55, p <0.001), septal E/e' (r = 0.4, p = 0.003), and LV mass index (r = 0.29, p = 0.024). Multivariate analyses revealed that the primary determinant of the AA diameter in BAV patients was age (ß = 0.38, p = 0.04), and enlargement of the AA was independent of the diastolic properties of the left ventricle and LVGLS. No significant differences were observed among the 2D or Doppler echocardiography parameters, nor among strain measurements, between BAV-AP (n = 47) and BAV-RL (n = 21) phenotypes. CONCLUSIONS: Subclinical myocardial dysfunction was observed in BAV patients with normal aortic valve function. LV dysfunction was independent of age, aortic velocity and AA diameter, which suggested the presence of intrinsic myocardial disease. Aging contributes to aortic dilatation in normally functioning BAV.