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Evaluation of left atrial volume and function by real time three-dimensional echocardiography in anemic patients without overt heart disease before and after anemia correction

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Seçkin Dereli at Ordu Üniversitesi
Seçkin Dereli
Adil Bayramoğlu
Adil Bayramoğlu
Adil Bayramoğlu
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Nurtaç Özer at Baskent Üniversitesi Konya Hastanesi
Nurtaç Özer
  • Baskent Üniversitesi Konya Hastanesi
Sinan Cerşit
Sinan Cerşit
Sinan Cerşit
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Abstract and Figures

There are few data on the effects of low hemoglobine levels on the left atrium (LA) in anemic patients. Our aim was to evaluate left atrial (LA) volume and functions in anemic patients using real time three-dimensional echocardiography (RT3DE) and also to investigate changes in variables of LA after the correction of anemia. In total, 55 iron-deficiency anemia patients without traditional cardiovascular (CV) risk factors and 30 age- and gender-matched controls were studied. Assessments included history, physical examination and echocardiography. Of the 55 patients with anemia enrolled, 50 (39 females and 11 males 40.3 years) were followed and underwent echocardiography after correction of the anemia. LA maximum volume (LAVmax), LA minimal volume (LAVmin), LAVmax index (LAVI), before atrial contraction volume (LAVpreA), LA total emptying fraction, LA active emptying volume were higher in anemic patients. LA passive emptying fraction was significantly lower in anemic patients. Following correction of anemia, LA volume and function parameters were observed to be significantly reduced. Moreover, significant increase was noted in LA passive emptying fraction. Correlation analysis was performed and a significant negative correlation was noted between the percentage change in hemoglobin level and percentage change in LAVI (r = − 0.382, p = 0.003). It was shown that volume and functions of LA are impaired in anemic patients. However impaired parameters were improved after correction of anemia. It may be thought that RT3DE LA parameters can be used as an important preclinical marker of disease pathogenesis before developing heart failure or atrial arrhythmia.
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Vol.:(0123456789)
1 3
The International Journal of Cardiovascular Imaging (2019) 35:1619–1626
https://doi.org/10.1007/s10554-019-01609-6
ORIGINAL PAPER
Evaluation ofleft atrial volume andfunction byreal time
three‑dimensional echocardiography inanemic patients withoutovert
heart disease beforeandafteranemia correction
SeçkinDereli1 · AdilBayramoğlu2· NurtaçÖzer1· SinanCerşit3· AhmetKaya2· MuhammetÖzbilen4
Received: 26 February 2019 / Accepted: 22 April 2019 / Published online: 30 April 2019
© Springer Nature B.V. 2019
Abstract
There are few data on the effects of low hemoglobine levels on the left atrium (LA) in anemic patients. Our aim was to evalu-
ate left atrial (LA) volume and functions in anemic patients using real time three-dimensional echocardiography (RT3DE)
and also to investigate changes in variables of LA after the correction of anemia. In total, 55 iron-deficiency anemia patients
without traditional cardiovascular (CV) risk factors and 30 age- and gender-matched controls were studied. Assessments
included history, physical examination and echocardiography. Of the 55 patients with anemia enrolled, 50 (39 females and
11 males 40.3years) were followed and underwent echocardiography after correction of the anemia. LA maximum volume
(LAVmax), LA minimal volume (LAVmin), LAVmax index (LAVI), before atrial contraction volume (LAVpreA), LA total
emptying fraction, LA active emptying volume were higher in anemic patients. LA passive emptying fraction was signifi-
cantly lower in anemic patients. Following correction of anemia, LA volume and function parameters were observed to be
significantly reduced. Moreover, significant increase was noted in LA passive emptying fraction. Correlation analysis was
performed and a significant negative correlation was noted between the percentage change in hemoglobin level and percent-
age change in LAVI (r = − 0.382, p = 0.003). It was shown that volume and functions of LA are impaired in anemic patients.
However impaired parameters were improved after correction of anemia. It may be thought that RT3DE LA parameters
can be used as an important preclinical marker of disease pathogenesis before developing heart failure or atrial arrhythmia.
Keywords Left atrium· Left atrial volume and function· Three dimensional transthoracic echocardiography· Diastolic
dysfunction
Introduction
Iron deficiency anemia is one of the most common global
health problems frequently observed in daily clinical practice
[1]. Anemia is a common co-morbid condition in patients
with heart failure, and multiple observational studies showed
an independent association between low hemoglobin and
adverse cardiovascular (CV) outcomes [2, 3]. Reduction in
oxygen carrying capacity of blood caused by iron deficiency
leads to tissue hypoxia, and consequently structural and
hemodynamic changes are observed in the heart [4]. Func-
tional disorders develop primarily in response to decreased
hemoglobin [5]. Long-term haemodynamic changes in
chronic anemia increase the workload and volume burden
of the heart, cause remodeling of myocytes and vessels and
hypertrophy is observed on the left ventricle (LV) [6, 7].
Several published studies support the relationship between
anemia and LV diastolic dysfunction in patients with car-
diovascular disease, but the results are in conflict and the
relationship between anemia and diastolic dysfunction is still
unclear [8-10].
Previous studies showed several minor cardiovascular
changes from hyperdynamic circulation to subclinical car-
diac structural changes in anemic patients without overt
* Seçkin Dereli
drseckindereli@gmail.com
1 Department ofCardiology, Ordu State Hospital, Ordu,
Turkey
2 Faculty ofMedicine, Department ofCardiology, Ordu
University, Ordu, Turkey
3 Department ofCardiology, Koşuyolu Kartal Heart Training
andResearch Hospital, İstanbul, Turkey
4 Faculty ofMedicine, Department ofInternal Medicine, Ordu
University, Ordu, Turkey
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Haemoglobin variations have previously been reported as associated with left atrial volume variations [52,53]. In contrast, the association of blood calcium levels with left atrial remodelling is a novel finding and raises the hypothesis of a possible association between severe hyperparathyroidism and cardiac remodelling. ...
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Background Chronic kidney disease leads to cardiac remodelling of multifactorial origin known as “uraemic cardiomyopathy”, the reversibility of which after kidney transplantation (KT) remains controversial. Our objectives were to assess, in the modern era, changes in echocardiographic parameters following KT and identify predictive clinical and biological factors associated with echocardiographic changes. Methods One hundred six patients (mean age 48 ± 16, 73% male) who underwent KT at the University Hospital of Nancy between 2007 and 2018 were retrospectively investigated. Pre- and post-KT echocardiography findings (8.6 months before and 22 months after KT on average, respectively) were centralised, blind-reviewed and compared. Results A majority of patients (60%) had either a left ventricular (LV) ejection fraction < 50%, at least moderately abnormal LV mass index or left atrial (LA) dilatation at pretransplanted echocardiography. After KT, LV remodelling and diastolic doppler indices did not significantly change whereas LA volume index (LAVI) increased (35.9 mL/m² post-KT vs. 30.9 mL/m² pre-KT, p = 0.006). Advancing age, cardiac valvular disease, delayed graft function, lower post-KT haemoglobin, and more severe post-KT hypertension were associated with higher LAVI after KT. Higher post-KT serum creatinine, more severe post-KT hypertension and lower pre-KT blood calcium levels were associated with a deterioration in LAVI after KT. Discussion/Conclusion Adverse remodelling of the left atrial volume occurred after KT, predominantly in patients with lower pre-KT blood calcium, poorer graft function and post-KT hypertension. These results suggest that a better management of modifiable factors such as pre-KT hyperparathyroidism or post-KT hypertension could limit post-KT cardiac remodelling. Graphical Abstract
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... However, anemia in T2DM patients is likely to be unrecognized and lead to inadequate treatment [14,29]. If anemia could be reversed in a timely manner in patients without overt heart disease, LV hypertrophy might be corrected [30,31]. However, when anemia is severe or accompanied by other heart diseases, irreversible impairment would be left and the prognosis might be worse [32].Thus, once a diagnosis of T2DM is made, clinicians and patients should pay attention to detecting, preventing and managing anemia. ...
The worsening effect of anemia on left ventricular function and global strain in type 2 diabetes mellitus patients: a 3.0 T CMR feature tracking study
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Objective To explore the additive effects of anemia on left ventricular (LV) global strains in patients with type 2 diabetes mellitus (T2DM) with or without anemia via cardiac magnetic resonance (CMR) feature tracking technology. Materials and methods 236 T2DM patients with or without anemia and 67 controls who underwent CMR examination were retrospectively enrolled. LV function parameters, LV global radial peak strain (GRPS), longitudinal peak strain (GLPS), and circumferential peak strain (GCPS) were used to analyze the function and global strain of the heart. One-way analysis of variance and the chi-square test were used for intergroup analysis. Multivariable linear regression analysis was performed for the two T2DM groups to explore factors associated with LV global strains. Results The T2DM group with anemia was oldest and had a lowest hemoglobin (Hb) concentration, lowest estimated glomerular filtration rate, highest LV end-systolic volume index, highest end-diastolic volume index and highest LV mass index than the control group and T2DM without anemia group (all P ≤ 0.001). Besides, The LV global peak strains in all three directions worsened successively from the control group to the T2DM without anemia group to the T2DM with anemia group (all p < 0.001). Among all clinical indices, the decrease in Hb was independently associated with the worsening in GRPS (β = 0.237, p = 0.001), GCPS (β = 0.326, p < 0.001), and GLPS (β = 0.265, p < 0.001). Conclusion Anemia has additive deleterious effects on LV function and LV global strains in patients with T2DM. Regular detection and early intervention of anemia might be beneficial for T2DM patients.
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... These values are well within the usual range reported in the literature. 10,28,29 Postprocessing of the atrial geometry and the integration of the cannulas were performed using 3-matic (Materialise NV, Leuven, Belgium). The geometry of the multistage cannula was derived from patent US20110160517A1 and designed in Ansys DesignModeler (Ansys Inc, Canonsburg, Pennsylvania, USA). ...
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... Some studies have shown that patients with hypertension have increased LA volumes and impaired diastolic functions by using RT-3DE [11,12]. At present, RT-3DE is also used in healthy Children, anemic patients and subclinical hypothyroidism [13][14][15]. RT-3DE can provide dynamic volume measurement data, which can more accurately assess the volume of the left atrium than traditional methods, as well as provide mechanical parameters. Compared with 2D ultrasound, RT-3DE does not rely on the geometric shape of each section of the left atrium to obtain its overall shape. ...
Assessment of real-time three-dimensional echocardiography as a tool for evaluating left atrial volume and function in patients with type 2 diabetes mellitus
Article
Full-text available
  • Dec 2020
Objective: To assess the value of real-time three-dimensional echocardiography (RT-3DE) in evaluating changes in left atrial volume and function in type 2 diabetes mellitus (DM) and type 2 diabetic nephropathy (DN) patients. Method: 104 control subjects, 109 DN patients, and 111 DM patients were recruited and underwent RT-3DE. Data pertaining to the left atrium were analyzed using the 3DQA software in order to determine left atrial maximum volume index (LAVImax), left atrial pre-systolic volume index (LAVIp), left atrial minimum volume index (LAVImin), total left atrial ejection fraction (LAEFt), passive left atrial ejection fraction (LAEFp), and active left atrial ejection fraction (LAEFa). Differences between these three groups and correlations between individual index values and E/e' ratios were additionally assessed. Result: LAVImax, LAVIp, and LAVImin were higher in the DN and DM groups relative to controls, whereas LAEFt and LAEFp were higher in controls relative to DM and DN patients (P < 0.05). LAVImax, LAVIp, and LAVImin in the DN group were significantly higher than those in the DM group, while LAEFt, LAEFp were higher in DM patients relative to DN patients (P < 0.05). The E/e' ratio was also found to be significantly correlated with LAVImax, LAVIp, and LAVImin. Conclusion: Our results indicate that RT-3DE can be used to assess changes in left atrial volume and function in patients with diabetes and can be used to monitor disease progression-related damage to such left atrial functionality.
View
Evaluation of left atrial function in patients with iron-deficiency anemia by two-dimensional speckle tracking echocardiography
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Background: Iron-deficiency anemia (IDA) is a global health problem and a common medical condition that can be seen in everyday clinical practice. And two-dimensional speckle tracking echocardiography (2D-STE) has been reported very useful in evaluating left atrial (LA) function, as well as left ventricular (LV) function. The aim of our study is to evaluate the LA function in patients with IDA by 2D-STE. Methods: 65 patients with IDA were selected. This group of patients was then divided into two groups according to the degree of hemoglobin: group B (Hb > 90 g/L) and group C (Hb60 ~ 90 g/L). Another 30 healthy people were also selected as control group A. Conventional echocardiography parameters, such as left atrial diameter (LAD), peak E and A of mitralis (E, A), E/A, end-diastolic thickness of ventricular septum (IVST d), end-diastolic thickness of LV posterior wall (PWTd) and left ventricular end-diastolic dimension (LVDd) were obtained from these three groups. Left atrial minimum volume (LAVmin), left atrial pre-atrial contraction volume (LAVp) and left atrial maximum volume (LAVmax) were measured by Simpson's rule, whereas left atrial active ejection fraction (LAAEF) and left atrial passive ejection fraction (LAPEF) were obtained from calculation. Two-dimensional images were acquired from apical four-chamber view and two-chamber view to store images for offline analysis. The global peak atrial longitudinal strain and strain rate of systolic LV (GLSs, GLSRs) as well as early and late diastolic LV strain rate (GLSRe, GLSRa) curves of LA were acquired in each LA segment from basal segment to top segment of LA by 2D-STE. Results: Compared with group A, there were no differences between group B and group A (all P > 0.05). The LAAEF and GLSRa were significantly higher in group C compared with those of group A and group B (all P < 0.01). The LAPEF, GLSs, GLSRs and GLSRe were significantly lower in group C compared with those of group A and group B (all P < 0.01). Conclusions: 2D-STE could evaluate the LA function in patients with IDA.
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Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
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Full-text available
  • Jul 2016
Echocardiographic assessment of left ventricular (LV) diastolic function is an integral part of the routine evaluation of patients presenting with symptoms of dyspnea or heart failure. The 2009 American Society of Echocardiography (ASE) and European Association of Echocardiography (now European Association of Cardiovascular Imaging [EACVI]) guidelines for diastolic function assessment were comprehensive, including several two-dimensional (2D) and Doppler parameters to grade diastolic dysfunction and to estimate LV filling pressures.1 Notwithstanding, the inclusion of many parameters in the guidelines was perceived to render diastolic function assessment too complex, because several readers have interpreted the guidelines as mandating all the listed parameters in the document to fall within specified values before assigning a specific grade. The primary goal of this update is to simplify the approach and thus increase the utility of the guidelines in daily clinical practice. LV diastolic dysfunction is usually the result of impaired LV relaxation with or without …
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Effect of anemia correction on left ventricular structure and filling pressure in anemic patients without overt heart disease
Article
Full-text available
  • Jul 2014
  • Kor J Intern Med
Background/Aims There are few data on the effects of low hemoglobin levels on the left ventricle (LV) in patients without heart disease. The objective of this study was to document changes in the echocardiographic variables of LV structure and function after the correction of anemia without significant cardiovascular disease. Methods In total, 34 iron-deficiency anemia patients (35 ± 11 years old, 32 females) without traditional cardiovascular risk factors or cardiovascular disease and 34 age- and gender-matched controls were studied. Assessments included history, physical examination, and echocardiography. Of the 34 patients with anemia enrolled, 20 were followed and underwent echocardiography after correction of the anemia. Results There were significant differences between the anemia and control groups in LV diameter, left ventricular mass index (LVMI), left atrial volume index (LAVI), peak mitral early diastolic (E) velocity, peak mitral late diastolic (A) velocity, E/A ratio, the ratio of mitral to mitral annular early diastolic velocity (E/E'), stroke volume, and cardiac index. Twenty patients underwent follow-up echocardiography after treatment of anemia. The follow-up results showed significant decreases in the LV end-diastolic and end-systolic diameters and LVMI, compared with baseline levels. LAVI, E velocity, and E/E' also decreased, suggesting a decrease in LV filling pressure. Conclusions Low hemoglobin level was associated with larger cardiac chambers, increased LV, mass and higher LV filling pressure even in the subjects without cardiovascular risk factors or overt cardiovascular disease. Appropriate correction of anemia decreased LV mass, LA volume, and E/E'.
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Left atrium function assessment by echocardiography-physiological and clinical implications
Article
Full-text available
  • Jun 2014
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Left atrium enlargement is a pathophysiological response to volume and pressure overload associated with a wide range of cardiovascular disorders leading to left ventricle systolic and diastolic dysfunction. Physiological factors contribute to significant differences in left atrium size in normal individuals. Moreover, left atrium enlargement was shown to have a significant prognostic value for cardiovascular events such as heart failure, atrial fibrillation or stroke, and increased cardiovascular and all-cause mortality rates. Current imaging techniques such as two- and three dimensional echocardiography, cardiac magnetic resonance imaging and multi-detector computed tomography allow a detailed assessment of the left atrium. The current paper aims to offer an overview of two-dimensional echocardiography parameters which provide data concerning left atrium dimensions and phasic functions and may lead to a better understanding of left atrium physiology and pathology.
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Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD) and is frequently overlooked as a complication. Patients with IBD are commonly found to have iron deficiency anemia (IDA) secondary to chronic blood loss, and impaired iron absorption due to tissue inflammation. Patients with iron deficiency may not always manifest with signs and symptoms; so, hemoglobin levels in patients with IBD must be regularly monitored for earlier detection of anemia. IDA in IBD is associated with poor quality of life, necessitating prompt diagnosis and appropriate treatment. IDA is often associated with inflammation in patients with IBD. Thus, commonly used laboratory parameters are inadequate to diagnose IDA, and newer iron indices, such as reticulocyte hemoglobin content or percentage of hypochromic red cells or zinc protoporphyrin, are required to differentiate IDA from anemia of chronic disease. Oral iron preparations are available and are used in patients with mild disease activity. These preparations are inexpensive and convenient, but can produce gastrointestinal side effects, such as abdominal pain and diarrhea, that limit their use and patient compliance. These preparations are partly absorbed due to inflammation. Non-absorbed iron can be toxic and worsen IBD disease activity. Although cost-effective intravenous iron formulations are widely available and have improved safety profiles, physicians are reluctant to use them. We present a review of the pathophysiologic mechanisms of IDA in IBD, improved diagnostic and therapeutic strategies, efficacy, and safety of iron replacement in IBD.
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Iron-Deficiency Anemia
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Left atrial minimum volume by real-time three-dimensional echocardiography as an indicator of diastolic dysfunction
Article
  • Nov 2013
Left atrial (LA) maximum volume is becoming a prognostic biomarker for left ventricular (LV) diastolic dysfunction. However, we assessed LV diastolic function by measuring LA phasic volumes using real-time threedimensional echocardiography (RT3DE) in patients with stable coronary artery disease (CAD). Sixty-five stable CAD patients with normal LV ejection fraction (LVEF) were divided into three groups according to degree of coronary stenosis: control (n = 15) with <50% stenosis as control group, mildS (n = 25) with mild stenosis (50%-70%) and severeS (n = 25) with >70% stenosis. LA phasic volumes and function were evaluated and compared using RT3DE and two dimensional echocardiography (2DE). N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were examined. The correlations of RT3DE-derived parameters with other conventional indices were analyzed. Significant correlations between RT3DE and 2DE for LA volume measurements were: control, r = 0.93; mildS, r = 0.94; severeS, r = 0.90 (all P < 0.05). Patients with severe coronary stenosis presented higher NT-proBNP level, indices of LA minimum volume and volume before atrial contraction, but lower LA total emptying fraction (LAEF) and LAEFpassive. Significant correlations of RT3DE derived LA volume indices with E/E' (r = 0.695) and NF-proBNP (r = 0.630) level were found. RT3DE derived, LA indices correlate well with NT-proBNP level and may be superior to 2DE measurements for the evaluation of LV diastolic dysfunction. Enlargement of LA minimum volume in stable CAD patients without systolic dysfunction appears earlier and may be better correlated with LV diastolic function than that of LA maximum volume.
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