Böbrek nakli adaylarında transtorasik ekokardiyografi ile sol atriyal apendiks fonksiyonlarının değerlendirilmesi ve sol atriyal strain değerleri ile karşılaştırılması

Abstract

Amaç: Kronik böbrek hastalığı (KBH) olan hastalarda inme insidansı, atriyal aritmilerden bağımsız olarak yüüksektir. Bu çalışmanın amacı, sinüs ritmindeki son dönem böbrek hastalığı (SDBY) olan böbrek nakli adaylarında transtorasik ekokardiyografi (TTE) ile sol atriyal apendiks (SAA) fonksiyonlarını değerlendirmek ve sol atriyal (SA) gerilme değerleri ile karşılaştırmaktır. . Gereç ve Yöntemler: Çalışmaya 52 böbrek nakli adayı hasta ve yaş ve cinsiyet uyumlu, KBH olmayan 60 katılımcı dahil edildi. Parasternal kısa eksenden pulse wave Doppler ile SAA boşalma hızı (BH), doku Doppler görüntüleme kullanılarak erken diyastolik (SAA Em), kasılma (SAA Am) ve sistolik (SAA Sm) hızları ölçüldü. Atriyal pik longitudinal strain (PLS), pik kontraksiyon strain (PKS) ve konduit strain (KdS), iki boyutlu benek takibi ekokardiyografi kullanılarak hesaplandı. Bulgular: SAA BH, Am ve Sm ve SA PLS, PKS, KdS ölçümleri hasta grubunda kontrollere göre anlamlı olarak daha düşük bulundu. SAA BH ölçümleri, sol atriyal volüm indeksi (SAVİ), SA PLS ve SA PKS değerleri ile güçlü bir pozitif korelasyon ve sol ventrikül (SV) çapları ve E/e' değeri ile de anlamlı negatif korelasyon gösterdi. Çok değişkenli regresyon analizinde SA PLS ve SAVİ’nin SAA BH için bağımsız faktörler olduğu bulundu. Sonuçlar: Bulgularımız, TTE ile SAA fonksiyonlarının değerlendirilmesinin böbrek nakil adaylarında artmış atriyal aritmiler ve iskemik inme gelişme riskinin belirlenmesine yardımcı olabileceğini düşündürmektedir. Mevcut bulguların daha büyük çalışmalarla desteklenmesi bu hastalarda takip ve tedavi yaklaşımlarını değiştirebilir.

Keywords

• Sol atriyal strain
• sol atriyal apendiks fonksiyonu
• son dönem böbrek yetersizliği
• böbrek nakli.

Evaluation of left atrial appendage functions by transthoracic echocardiography and comparison with left atrial strain values in renal transplant candidates

Abstract

Aim: The incidence of stroke in patients with chronic kidney disease (CKD) is increased independent of atrial arrhythmias. The goal of this study is to evaluate, left atrial appendage (LAA) functions by transthoracic echocardiography (TTE) and comparison with left atrial (LA) strain values in patients with in renal transplant candidates with end stage renal disease (ESRD) with sinus rhythm. Material and Methods: Fifty two renal transplant candidates and 60 age- and sex-matched healthy participants were included in the study. LAA emptying velocity (EV) was measured with pulse wave Doppler, early diastolic (LAA Em), contraction (LAA Am) and systolic (LAA Sm) velocities were measured using tissue Doppler imaging from parasternal short axis view. Atrial peak longitudinal strain (PLS), peak contraction strain (PCS) and conduit strain (CdS) were calculated using two dimensional speckle tracking echocardiography. Results: LAA EV, Am and Sm and LA PLS, PCS, CdS measurements were found to be significantly lower in the patient group compared to controls. LAA EV measurements showed a strong positive correlation with left atrial volume index (LAVI), LA PLS and LA PCS values, and a negative correlation with left ventricular (LV) diameters, and E/e' value. In the multivariate regression analysis LA PLS and LAVI were found to be independent factors for LAA EV. Conclusion: Our findings suggest that the evaluation of LAA functions with TTE may help determine the increased risk of developing atrial arrhythmias and ischemic stroke in renal transplant candidates. Supporting the current findings with larger studies may change the follow-up and treatment approaches in these patients.

Keywords

• Left atrial strain
• left atrial appendage functions
• end stage renal disease
• kidney transplantation.

References

1. Stevens PE, O’Donoghue DJ, de Lusignan S, et al. Chronic kidney disease management in the United Kingdom: NEOERICA project results.Kidney Int. 2007; 72:92–99. doi: 10.1038/sj.ki.5002273.
2. Thompson S, James M, Wiebe N, et al. Alberta Kidney Disease Network. Cause of death in patients with reduced kidney function. J Am Soc Nephrol. 2015; 26:2504–2511. doi: 10.1681/ASN.2014070714.
3. Major RW, Cheng MRI, Grant RA, et al. Cardiovascular disease risk factors in chronic kidney disease: a systematic review and meta-analysis. PLoS One. 2018;13:e0192895. doi: 10.1371/journal.pone.0192895.
4. Buglioni A, Burnett JC Jr. Pathophysiology and the cardiorenal connection in heart failure. Circulating hormones: biomarkers or mediators. Clin Chim Acta. 2015;443:3–8. doi: 10.1016/j.cca.2014.10.027.
5. Nasrallah R, Hassouneh R, Hébert RL. PGE2, Kidney Disease, and Cardiovascular Risk: Beyond Hypertension and Diabetes. J Am Soc Nephrol. 2016;27:666–676. doi: 10.1681/ASN.2015050528.
6. Alhaj E, Alhaj N, Rahman I, Niazi TO, Berkowitz R, Klapholz M. Uremic cardiomyopathy: an underdiagnosed disease. Congest Heart Fail. 2013;19:E40–E45. doi: 10.1111/chf.12030.
7. Di Lullo L, Gorini A, Russo D, Santoboni A, Ronco C. Left ventricular hypertrophy in chronic kidney disease patients: from pathophysiology to treatment. Cardiorenal Med. 2015;5:254–266. doi: 10.1159/000435838.
8. Little WC. Heart failure with a normal left ventricular ejection fraction: diastolic heart failure. Trans Am Clin Climatol Assoc. 2008;119:93–99.

9. Dad T, Weiner DE. Stroke and chronic kidney disease: epidemiology, pathogenesis, and management across kidney disease stages. Semin Nephrol. 2015 Jul;35(4):311–22. doi: 10.1016/j.semnephrol.2015.06.003.
10. Savelieva I, Bajpai A, Camm AJ. Stroke in atrial fibrillation: update on pathophysiology, new antithrombotic therapies, and evolution of procedures and devices. Ann Med 2007;39:371e391. doi: 10.1080/07853890701320662.
11. Wong JM, Welles CC, Azarbal F, Whooley MA, Schiller NB, Turakhia MP. Relation of left atrial dysfunction to ischemic stroke in patients with coronary heart disease (from the heart and soul study). Am J Cardiol. 2014 May 15;113(10):1679-84. doi: 10.1016/j.amjcard.2014.02.021.
12. Stoddard MF, Dawkins PR, Prince CR, Ammash NM. Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: A transesophageal echocardiographic study. J Am Coll Cardiol. 1995; 25:452–459. doi: 10.1016/0735-1097(94)00396-8.
13. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996; 61:755–759. doi: 10.1016/0003-4975(95)00887-X.
14. Nakanishi K, Jin Z, Russo C, et al. Association of chronic kidney disease with impaired left atrial reservoir function: A community-based cohort study Eur J Prev Cardiol. 2017 Mar;24(4):392-398. doi: 10.1177/2047487316679903.
15. Sun Y, Ramires FJ, Weber KT. Fibrosis of atria and great vessels in response to angiotensin II or aldosterone infusion. Cardiovas Res 1997; 35: 138–147. doi: 10.1016/s0008-6363(97)00097-7.
16. Ghoshal S, Freedman BI. Mechanisms of Stroke in Patients with Chronic Kidney Disease. Am J Nephrol. 2019;50(4):229-239. doi: 10.1159/000502446.
17. Lee RJ, Bartzokis T, Yeoh TK, et al. Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography. Stroke 1991; 22:734–9.doi: 10.1161/01.str.22.6.734.
18. Omran H, Jung W, Rabahieh R, et al. Imaging of thrombi and assessment of left atrial appendage function: a prospective study comparing transthoracic and transoesophageal echocardiography. Heart. 1999 Feb;81(2):192-8. doi: 10.1136/hrt.81.2.192.
19. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16:233-271. doi: 10.1093/ehjci/jev014.
20. Morris DA, Takeuchi M, Krisper M, et al. Normal values and clinical relevance of left atrial myocardial function analysed by speckle-tracking echocardiography: multicentre study. Eur Heart J Cardiovasc Imaging. 2015 Apr;16(4):364-72. doi: 10.1093/ehjci/jeu219. Epub 2014 Nov 3. Nielsen AB, Skaarup KG, Hauser R, et al. Normal values and reference ranges for left atrial strain by speckle-tracking echocardiography: the Copenhagen City Heart Study. Eur Heart J Cardiovasc Imaging. 2021 Dec 18; 23(1):42-51. doi: 10.1093/ehjci/jeab201.
21. Gan GCH, Kadappu KK, Bhat A, et al. Left Atrial Strain Is the Best Predictor of Adverse Cardiovascular Outcomes in Patients with Chronic Kidney Disease. J Am Soc Echocardiogr. 2021 Feb; 34(2):166-175. doi: 10.1016/j.echo.2020.09.015.
22. Ayer A, Banerjee U, Mills C, et al. Left atrial strain is associated with adverse cardiovascular events in patients with end-stage renal disease: Findings from the Cardiac, Endothelial Function and Arterial Stiffness in ESRD (CERES) study. Hemodial Int. 2022 Jul;26(3):323-334. doi: 10.1111/hdi.13008.
23. Rao AK, Djamali A, Korcarz CE, Aeschlimann SE, Wolff MR, Stein JH. Left atrial volume is associated with inflammation and atherosclerosis in patients with kidney disease. Echocardiography. 2008;25:264–269. doi: 10.1111/j.1540-8175.2007.00589.x.
24. Ravarotto V, Bertoldi G, Innico G, Gobbi L, Calò LA. The Pivotal Role of Oxidative Stress in the Pathophysiology of Cardiovascular-Renal Remodeling in Kidney Disease Antioxidants (Basel). 2021 Jun 29; 10(7):1041. doi: 10.3390/antiox10071041.
25. Yuda, S. Current clinical applications of speckle tracking echocardiography for assessment of left atrial function. J. Echocardiogr. 2021, 19, 129–140. doi: 10.1007/s12574-021-00519-8.
26. Ohara Y, Yoshimura Y, Fukuoka Y, et al. Early detection of left atrial strain abnormalities by speckle-tracking in patients with chronic kidney disease and normal left atrial size. J Am Soc Echocardiogr. 2011;24: 898–908. doi: 10.1016/j.echo.2011.04.014.
27. Kadappu KK, Abhayaratna K, Boyd A, et al Independent echocardiographic markers of cardiovascular involvement in chronic kidney disease: the value of left atrial function and volume. J Am Soc Echocardiogr. 2016;29:359–367. doi: 10.1016/j.echo.2015.11.019.
28. Kadappu KK, Kuncoro AS, Hee L, et al. Chronic kidney disease is independently associated with alterations in left atrial function. Echocardiography. 2014;31:956–964. doi: 10.1111/echo.12503.
29. Habibi M, Zareian M, Ambale Venkatesh B, et al. Left Atrial Mechanical Function and Incident Ischemic Cerebrovascular Events Independent of AF: Insights From the MESA Study JACC Cardiovasc Imaging. 2019 Dec;12(12):2417-2427. doi: 10.1016/j.jcmg.2019.02.021.
30. Leong DP, Joyce E, Debonnaire P, et al. Left atrial dysfunction in the pathogenesis of cryptogenic stroke: novel insights from speckle-tracking echocardiography. J Am Soc Echocardiogr 2017;30:71–9. doi: 10.1016/j.echo.2016.09.013.
31. Sanchis L, Montserrat S, Obach V, et al. Left atrial function is impaired in some patients with stroke of undetermined etiology: potential implications for evaluation and therapy. Rev Esp Cardiol (Engl Ed) 2016;69:650–6. doi: 10.1016/j.rec.2015.11.033.
32. Ferro JM. Cardioembolic stroke: an update. Lancet Neurol. 2003;2:177–88. doi: 10.1016/s1474-4422(03)00324-7.
33. Di Tullio MR, Homma S. Mechanisms of cardioembolic stroke. Curr Cardiol Rep. 2002;4:141–8. doi: 10.1007/s11886-002-0027-3.
34. Yaghi S, Song C, Gray WA, Furie KL, Elkind MS, Kamel H. Left atrial appendage function and stroke risk. Stroke 46, 3554–3559. doi: 10.1161/STROKEAHA.115.011273.
35. Handke M, Harloff A, Hetzel A, Olschewski M, Bode C, Geibel A. Left atrial appendage flow velocity as a quantitative surrogate parameter for thromboembolic risk: determinants and relationship to spontaneous echocontrast and thrombus formation--a transesophageal echocardiographic study in 500 patients with cerebral ischemia. J Am Soc Echocardiogr. 2005 Dec;18 (12):1366–72. doi: 10.1016/j.echo.2005.05.006.
36. Karabay CY, Zehir R, Güler A, et al. Left atrial deformation parameters predict left atrial appendage function and thrombus in patients in sinus rhythm with suspected cardioembolic stroke: a speckle tracking and transesophageal echocardiography study. Echocardiography. 2013 May;30(5):572-81. doi: 10.1111/echo.12089. Epub 2013 Jan 11.
37. Bo S, Gambino R, Durazzo M, et al. Associations between serum uric acid and adipokines,markers of inflammation, and endothelial dysfunction. J Endocrinol Invest 2008; 31: 499–504. doi: 10.1007/BF03346397.
38. Power A, Chan K, Singh SK, Taube D, Duncan N. Appraising stroke risk in maintenance hemodialysis patients: A large single‑center cohort study. Am J Kidney Dis 2012;59:249‑57. doi: 10.1053/j.ajkd.2011.07.016.
39. Korantzopoulos, P.G., Goudevenos, J.A. Atrial fibrillation in end-stage renal disease: An emerging problem. Kidney Int. 2009 Aug;76(3):247-9.doi: 10.1038/ki.2009.144.
40. Yildirim U, Akcay M, Coksevim M, Turkmen E, Gulel O. Comparison of left atrial deformation parameters between renal transplant and hemodialysis patients. Cardiovasc Ultrasound. 2022 Feb 25;20(1):5. doi: 10.1186/s12947-022-00275-4.
41. Vianna-Pinton R, Moreno CA, Baxter CM, Lee KS, Tsang TS, Appleton CP. Two-dimensional speckle-tracking echocardiography of the left atrium: feasibility and regional contraction and relaxation differences in normal subjects. J Am Soc Echocardiog. 2009 Mar; 22(3):299-305. doi: 10.1016/j.echo.2008.12.017.
42. Cameli M, Caputo M, Mondillo S, et al. Feasibility and reference values of left atrial longitudinal strain imaging by two dimensional speckle tracking. Cardiovasc Ultrasoun. 2009 Feb 8; 7:6. doi: 10.1136/hrt.81.2.192.