Atrial DCM : A brand new entity within the making

Atrial DCM : A brand new entity within the making

November 4, 2023 by dr s venkatesan

A short studying session with cardiology fellow a few potential new idea in Left coronary heart failure.

What’s the commmest trigger for acute pulmonary edema?

“Left sided coronary heart failure”

“Are you able to be extra particular , Left sided means ?

“I meant LV failure , usually DCM of any trigger or Extreme un-controlled HT”

“Okay .good. Does Left Coronary heart failure embody mitral valve dysfunction additionally ?

“Sure sir, very a lot. Classical mitral stenosis and Remoted MR may cause pulmonary edema. Actually, acute AR Iis additionally a part of left coronary heart illness”

To this point, so good, now coming to the advanced a part of left coronary heart

Can LA fail in isolation unbiased of LV , ie I imply with regular Left ventricle ?

I’m not certain. Can we name new onset atrial fibrillation as a major atrial failure that can lead to pulmonary edema?

Wonderful. You might be completely proper. However I’m speaking about mechanical atrial failure, not electrical. Are you conscious that more often than not AF is a effectively tolerated arrhythmia , it may even be silent in lots of circumstances. It is because the pumping perform of the atria contributes solely 20-25% to LV filling. This will simply be compensated by augmented LV suction power , supplied the baseline LV perform is regular.

Have you ever heard about ACM. Atial cardiomyopathy?

“No sir”,

“You’ll hear extra about it quickly” (Ref 1) Scientists, particularly Echo guys are closing in on this idea. We all know, the atria has three purposeful parts, specifically conduit, reservoir, and pumping. Curiously, we’ve got realized that the pumping perform of LA is probably not that crucial from oblique observations from some land mark research . (Charge management vs rhythm management research in AF are a robust proof on the atrial pumping perform .(AFFIRM/RACE and so forth ) I don’t know, whether or not I’m proper in saying the above assertion.

It’s tempting to conclude , provided that all of the three purposeful parts of atria will get affected , then solely major atrial dysfunction might be recognized. The idea is extra advanced than we realise. In diastole , pulmonary vein, LA , LV all work as single purposeful unit. Solely in systole, we see them as various things.

Atrial DCM

Like LV systolic perform, which is coupled with RV in parallel , LA perform is carefully knitted to LV in sequence throughout diastole. The important thing to suspect or diagnose this entity is to display dissociation of LVEDP with LA imply strain & PCWP. This isn’t a simple job in bedside. Remoted Improve in LA quantity with none motive , is one clue. LA ejection fraction is feasible marker. (Kanagala P, . Int J Cardiovasc Imaging. 2020)

Remaining message

We’re within the early days of understanding major atrial mechanical failure, Atrial cardiomyopathy (ACM) or atrial DCM is being proposed as separate entity. It is vitally doubtless, some subsets of HFpEF would possibly develop into major atrial illness, relying on the extent of investigation we do.

Reference

1.Li M, Ning Y, Tse G, Saguner AM, Wei M, Day JD, Luo G, Li G. Atrial cardiomyopathy: from cell to bedside. ESC Coronary heart Fail. 2022 Dec;9(6):3768-3784. doi: 10.1002/ehf2.14089.

2.Patel, R.B., Lam, C.S.P., Svedlund, S. et al. Disproportionate left atrial myopathy in coronary heart failure with preserved ejection fraction amongst individuals of the PROMIS-HFpEF research. Sci Rep 11, 4885 (2021). https://doi.org/10.1038/s41598-021-84133-9