In the derivation cohort, candidate differentiators predictive at univariate analysis with p b 0.05 were entered into a binary logistic regression to detect PAWP N 15 mm Hg using forward selection. Receiver operating characteristic (ROC) analysis was performed to determine diagnostic accuracy of candidate CT metrics with area under the ROC curve (AUC) results presented. Chi-square and Fishers exact test were used to calculate sensitiv- ity, speciﬁcity, positive and negative predictive values. Predictive thresholds for univariate CT metrics with high speciﬁcity were chosen for identiﬁcation of elevated PAWP (both PAWPN 15 and PAWP N 18) in the derivation cohort and were tested in the validation co- hort. MRI derived leftatrial volume was correlated with CT metrics and discriminatory ability of CT and MRI at ROC analysis compared. For these same variables, ROC analysis was undertaken in the whole cohort to predict how well these MRI-derived variables dis- criminated increased PAWP N 15 mm Hg andN18 mm Hg. 15 patients were analysed sep- arately by two observers to determine interobserver variability and one of the observers repeated analysis on 15 patients to assess for intraobserver variability.
alterations in the conduction of electrical stimulation, which would facilitate the initiation and maintenance of this arrhythmia. For this reason it is very useful to analyze the alterations in the function of the left atrium that can potentially help us in the study of this rhythm disorder. In patients with chronic AF often dysfunction and dilatation of the left atrium are present. Through the analysis of strain of the LA, it appears that the peak strain of atrial contraction is absent (Figure 6); recent evidences have demonstrated that lower PALS correlated with cerebral stroke events [42,43]; PALS is reduced after electrical cardioversion or ablation of the sinus node, while it increases gradually in subsequent months (Figure 7). Several studies have shown that the strain rate curve of the left atrium is impaired in patients with AF. The peak systolic strain rate is reduced in patients with paroxysms of AF and chronic AF in particular, goes gradually to normalization after cardioversion , and is inversely related to age, LA volume [45,46], and the presence of LA wall fibrosis . Even the peak of atrial contraction is reduced , and this value is inversely correlated with pul- monary pressures. In patients with various degrees of mitral regurgitation it has been demonstrated, in addi- tion to a progressively reduced atrial strain (Figure 8) , that subjects with the same severity of valvular disease, atrial strain was significantly lower in patients who reported a history of episodes of paroxysmal atrial fibrillation (Figure 9) .
Many studies have compared LA volume by 3DE with 2DE,  CT [13, 14] or MRI [11, 12, 17, 23]. These pub- lished results show that 3DE yields reduced variability and higher or similar accuracy to that of 2DE, mainly because 3DE addresses some of the limitations of 2DE, such as geometric assumption [22, 24–27]. Moreover, 3DE mea- surements of LA volumes have clinical value for assessing response to therapy and for predicting clinical events in patients with severe left ventricular dysfunction [24, 28, 29]. However, consistent underestimation was shown in most studies, because of ambiguous endocardial borders Table 2 Maximal leftatrial volume (mL) using different modalities
Image analysis was undertaken on a GE Advantage Workstation 4.4 and GE Advantage Workstation ReportCard. The MR observer was blinded to the patient clinical information and cardiac catheter parameters. Scans were deﬁned as non-diagnostic when image quality signiﬁcantly affected cardiac measurements or, volumetric analysis could not be accurately performed. LA volume was estimated using the well-established bi-plane area-length method [19,20]. LV long axis (two chamber view) and four chamber views were analysed. MRI LA measurements were taken at end-ventricular systole, equating to maximal atrial size.LA volume was calculated from the relation: (0.85 × LA area two chamber view × LA area four chamber view) / ((LA length two chamber + LA length four chamber) / 2). The CMR parameters were corrected where appropriate for body surface area (BSA), as previ- ously reported in the literature [21,22].
Echocardiographic examinations were performed on all participants by two expert cardiologists using a VingMED CFM 750 (VingMED Sound A/S, Horten, Norway) with a combined 3.25 MHz mechanical and 2.5 MHz Doppler probe. The examinations were per- formed using the standard apical and parasternal long- axis and short-axis views. Standard two-dimensional guided M-mode registrations of anteroposterior LA size, internal dimensions of the left ventricle and wall thick- ness of the septum and posterior wall were made from leading edge to leading edge convention. 16 In this study, LA size was indexed by BSA. Heart failure was de ﬁ ned as left ventricular ejection fraction <0.5.
In 1995, Buchanan and Bücheler introduced the verte- bral heart size (VHS), a standardised method of cardiac size evaluation using the thoracic vertebrae as a meas- urement unit . This method is based on the good cor- relation existing between cardiac size and thoracic vertebral body’s length. To include the leftatrial body, a slight variation was subsequently introduced, consisting in measuring the short axis from the dorsal edge of the caudal vena cava (CVC) . The overall size of the heart is then normalized to body size by expressing it as units of vertebral length. This method provided an objective numerical measurement for evaluation of general heart size.
with high velocity flows on one end of the spectrum (velocities similar to or even exceeding, those observed in sinus rhythm,) and minimal to absent flow on the other end. This represents the wide continuum of LAA contractile contraction to complete paralysis of the appendage. Of mitral and Aortic valve disorders, rheumatic mitral stenosis is most commonly associated with thromboembolism, irrespective of co- existence of MR. AF increase the risk thromboembolism upto 18 times, thrombi associated with MS can be found on either the atrial wall or in its appendage. The Risk of thromboembolism in rheumatic valve stenosis is related to age and low cardiac output, yet it does not correlate well with leftatrialsize, mitral calcification or severity of mitral stenosis. The Association of MR with thromboembolism correlates with the co- existence of MS.
Hypertension was the most common etiology found in males of elderly age group. The presenting complaints of these patients were dyspnea followed by pedal edema. These patients were associated with increased leftatrialsize and the most common complications present in this study were congestive cardiac failure followed by stroke. This study has provided many insights on potential risk factors for the occurrence of atrial fibrillation and its various presentations. This would help in early diagnosis and prompt treatment of patients with AF which remains a challenging problem in hours of emergency.
mitral stenosis and normal sinus rhythm. In their study, no meaningful relation was found between leftatrialsize and the presence of a clot in the left atrium, or between age and clot formation. On the other hand, despite the fact that the mean mitral valve score in the MS group in NSR with a clot was higher than the group without a clot, the difference was not significant. Another result of this study was the comparison of clot frequency in patients in NSR with those in AF rhythm. Clotting was more common in the AF group, with the difference being significant, as could be expected. Age of the patients in AF rhythm in that study was significantly higher than the group in NSR.
The most frequent benign tumor of the heart is myxomas and accounting in approximately 30% of all primary cardiac tumors . 75% are located in the left atrium . Myxoma is a benign polypoid neoplasm, usually ori- ginates from endocardial cells in the region of fossa ovalis and is attached to the interatrial septum. Myxomas are pedunculated, friable and appear as a soft, gelatinous, mucoid, usually gray-white mass often with areas of haemorrhage or thrombi. They are slowly growing and usually do not produce symptoms or signs until they en- large. Their size, shape and texture can be quite varied. Myxomas may be smooth surfaced but are more often irregularly shaped or have the appearance of a “cluster of grapes”. They are typically nonhomogeneous in tex- ture with lucent centers or areas of calcification. Myxomas can be quite large, occupying most of the left atrium and resulting obstruction to left ventricular filling. The diagnosis can be established by the demonstration of a characteristic echo producing mass in the left atrium by two-dimensional (2D) echocardiography  . Al- though asymptomatic patients with myxomas have been reported, most present with one or more effects of a triad of constitutional, embolic and obstructive manifestations . Typically, these large pedunculated tumors advance through and obstruct the atrioventricular valves during diastole and are expelled retrogradely into the atrium during systole. The most common clinical presentation mimics that of mitral valve disease —either stenosis due to tumor prolapse into mitral orifice or regurgitation due to tumor induced valve trauma.
The current study has limitations. The analyses are cross-sectional and hence we are unable to determine causality. The sample size is relatively small and participa- tion is voluntary, introducing possible biases in participant selection and inclusion of participants who were generally more interested in their health status (i.e, healthier). Even so, the true relationship between suPAR and myocardial function may only be underestimated, and not overesti- mated. uPAR has three domains D1, D2 and D3. Soluble forms are composed of D1-D2-D3 and D2-D3 which arise from cleavage of GPI-anchor. Further cleavage of the linker region gives rise to D1 domain . The assay used in our analysis could not differentiate between the forms of suPAR. Hence, we are unable to examine associations of different subtypes of suPAR to myocardial function.
Systemic hypertension leads to the development and progression of LVH . The presence of LVH confers an increased risk for subsequent major cerebrovascular event, this evidence suggests that major cerebrovascular injury can be preceded by asymptomatic cerebrovascular damage, which parallels the onset of cardiac hypertrophy . Systemic hypertension accelerates atherosclerosis in large arteries and causes hypertrophy and thickening of the media of the intracerebral vessels leading to hypoperfusion and ischemic rarefaction of white matter . The reduction in cerebral blood flow can produce any degree of brain injury, from asymptomatic (silent) cerebral infarction to reversible or persistent loss of function such as TIA and stroke . The stroke patients in our study had a significantly thicker IVSd compared to the controls (p=0.036) while the LVPWd is not significantly different from that of the controls (p=0.213). Abnormalities in the cardiac structure of stroke patients included a significant increase in LVMI and RWT compared to normal controls. The LVMI was increased in sixty (60%) of the patients compared to six (7.5%) controls (p<0.001). This is comparable to findings by other workers [22,25]. Left ventricular hypertrophy is mediated by mechanical stress of pressure overload and various neurohormonal substances that independently exert trophic effects on myocytes and non myocytes in the heart. Trophic factors such as angiotensin II, aldosterone, norepinephrine and insulin directly promote myocyte hypertrophy and stimulate production of cytokines and growth factors including transforming growth factor beta, fibroblast growth factor, and insulin growth factor that directly stimulate cardiac protein synthesis and hypertrophy .
The leftatrial appendage senior design team aims to assist in closing off the leftatrial appendage that is susceptible to coagulation due to non-valvular atrial fibrillation. Coagulation in the leftatrial appendage (LAA) can be life threatening as it can lead to a stroke. Dr. Chris Porterfield performs a procedure that uses the Boston Scientific Watchman to close the appendage. He finds that sizing the Watchman properly is difficult with limited visuals from live CT scans. He proposed converting the CT scans into a 3D printed model of the leftatrial appendage and left atrium so he can visually measure the opening and predict the trajectory angle of the Watchman device into the leftatrial appendage. He currently has a base algorithm and procedure to convert and modify the CT scan into a .stl file, which can then be printed with standard PLA material using a 3D printer on Cal Poly’s campus. The project is limited to the printers and their material capabilities on Cal Poly’s campus. There are currently many programs that convert CT scans to printable files and this project aims to evaluate each to conclude which produces the most accurate 3D model. The procedure to create the model must also be quick to perform, repeatable and reproducible as well as easy to follow.
Left ventricular noncompaction (LVNC) is a rare disease caused by intrauterine failure of the myocardium to compact. The major clinical manifestations of LVNC include heart failure, ventricular tachyarrhythmia, thromboembolic event, and sudden deaths. Atrial arrhythmia usually seen is atrial fibrillation. We report a rare case of focal leftatrial tachycardia in an 18-year-old patient who presented for evaluation of persistent tachycardia. Transthoracic echocardiogram showed severe systolic dysfunction and evidence of noncompaction of the left ventricle. A detailed review of ECG revealed the possibility of ectopic atrial tachycardia, most likely originating from the left side. Electrophysiology study showed sustained atrial tachycardia originating on the ridge anterior to the left sided pulmonary veins. A successful radiofrequency catheter ablation was performed at this site without any complications.
identification of the arrhythmogenic substrate and critical isthmus of a presumed macro-reentrant circuit with only brief episodes of induced tachycardia. First, a registered three-dimensional (3D) shell of the cardiac anatomy was created on an electroanatomical mapping system (Cartosound, Biosense Webster, Diamond Bar, California, USA) using intracardiac echocardiography (ICE). By positioning the ICE catheter inside the systemic venous atrium, the entire cardiac anatomy could be visualized including structures that form a potential area of conduction block such as the caval veins, the tricuspid valve annulus and surgical suture lines (e.g. atrial baffle suture line)(Figure 1). Second, bipolar voltage mapping of the systemic venous atrium was performed during sinus rhythm to further evaluate the arrhythmogenic substrate and to confirm areas of conduction block caused by surgical incisions (Figure 2). An area of low voltages (>0.5 mV) and persistent double potentials was found near the inter-atrial septum, confirming the location of the atrial baffle suture line. Based on these findings and the current literature on tachycardia ablation in Senning patients, 1 a selection of potential
We did not notice any difference in rhythm disturbances in our two group of patients the other is of the AV block. But as explained by the McGrath 10, by keeping the incision inferiorly within the fossa ovalis and extended it to the head side of the patient parallel to the right atrial wall is a safe approach. The cephalad extension should be aiming between SVC and pulmonary vein but short of it to avoid damage to the LA roof. This also has not been noted in our series; delayed rhythm disturbances as noted by Arsiwala 11 , have also not been seen in a group of patients.
Unruptured congenital sinus of valsalva aneurysm are usually silent lesions, their diagnosis depends on echo cardiograms or aortograms usually obtained to demonstrate associated symptomatic lesion such as VSD or AR. Diagnosis can be made incidentally during coronary angiography. Rarely unruptured aneurysm produce tricuspid dysfunction or RVOT obstruction bringing the patient to medical care. These aneurysm also produce severe ischemia by compressing the right or left main coronary artery. Embolism from unruptured sinus of valsalva aneurysm has also been reported.
Objectives: This study used cardiac CT to identify and name the different shapes of individual leftatrial appendage (LAA) lobes and identified correlations between the size and shape of the LAA ostium and the volume of the LAA in a population of normal individuals. Background: The anato- my of the LAA appendage has become the subject of current research, because appendage occlu- sion devices have emerged for patients with atrial fibrillation. The development of cardiac com- puted tomography (CT) allows researchers to identify and observe cardiac anatomy, including various shapes of the LAA lobes. Methods: This study was a retrospective review of 102 consecu- tive patients from March 2009 to November 2010 who underwent cardiac CT using the GE 64-slice Light Speed VCT CT scanner. For each patient, the LAA ostium was measured, and the shape of the ostium was observed and described. After the LAAs were reconstructed 3-dimensionally, each LAA was categorized by its shape and number of lobes. Results: No significant difference was observed between the average LAA volume between males and females. LAA appendages with circular os- tium (n = 61) were observed to have a larger mean volume than those with elliptical ostium (n = 39). Predictors of LAA volume were identified. The most common number of lobes was 2 (n = 61), followed by 1 (n = 27), 3 (n = 10), and 4 (n = 2). Eight unique LAA morphologies were identified and a name was assigned to each morphology. Based on the shape and number of lobes observed, the most common LAA lobe shape was hook (n = 55), followed by wing, arrowhead, flame, double wing, finger, sea horse, double hook, knob, spiral, and double knob. Conclusion: This study used