Atrial Failure as a Clinical Entity (published JACC January 2020)
(i) Definition of Atrial Failure
“Any atrial dysfunction (anatomical, mechanical, electrical, and/or rheological, including blood homeostasis) causing impaired heart performance and symptoms, and worsening quality of life or life expectancy, in the absence of significant valvular or ventricular abnormalities.”
(ii) Causes
- Atrial rhythm disorders
- Atrial Cardiomyopathy
- Atrial remodelling
| A. Electrical Dyssynchrony • AV dyssynchrony Left bundle branch block First-degree AV block Suboptimal pacemaker programming • Atrial dyssynchrony Advanced interatrial block Slow intra-atrial conduction velocities |
| B. Booster-Pump and Reservoir Dysfunction • Fast/disorganized atrial activation Atrial fibrillation Focal/reentrant atrial tachycardia • Extensive atrial fibrosis Advanced atrial remodeling Extensive post-ablation scarring Atrial infarction Atrial cardiomyopathy |
| C. Impaired Conduit Function • Severe atrial dilation • Spherical atrial deformation • Altered transmitral pressure gradient |
(iii) Mechanisms and Manifestations of Atrial Failure
- Atrial failure and risk of thromboembolic events
2. Atrial and ventricular interaction in HF
Worsening of heat failure symptoms
Stroke
Pulmonary artery hypertension
3. Extra-Atrial Consequences of Atrial Failure
Tachycardia-induced cardiomyopathy
Increased risk of HF and sudden cardiac death
Ventricular ischemia and type 2 myocardial infarction
Atrial functional mitral and tricuspid regurgitation
(iv) Potential Intervention
| Areas of Impact | Potential Future Interventions |
| Risk of stroke | OAC might be indicated in individuals without AF or discouraged in patients with AF Upstream therapy to reduce fibrosis/thrombotic milieu |
| Heart failure | Tailored HF treatment Upstream therapy to reduce fibrosis Interventions to reduce MR Left atrial pacing |
| AF management | Tailored ablation approach (substrate-based vs. pulmonary vein isolation) Selection of candidates for rhythm or rate control |
| Dyssynchrony | Left atrial or bi-atrial pacing |
| Extra-atrial involvement | Sudden death risk stratification OAC indicated in advanced atrial failure to prevent embolic myocardial infarction AF suppression by ablation to improve MR/TR Interventions to reduce MR/TR (MitraClip, annuloplasty) |
