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Canadian Journal of Cardiology

Sleep Apnea and Left Atrial Phasic Function in Heart Failure With Reduced Ejection Fraction

  • Nobuhiko Haruki
    Affiliations
    University Health Network and Mount Sinai Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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  • Wendy Tsang
    Affiliations
    University Health Network and Mount Sinai Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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  • Paaladinesh Thavendiranathan
    Affiliations
    University Health Network and Mount Sinai Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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  • Anna Woo
    Affiliations
    University Health Network and Mount Sinai Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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  • George Tomlinson
    Affiliations
    University Health Network and Mount Sinai Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Alexander G. Logan
    Affiliations
    University Health Network and Mount Sinai Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • T. Douglas Bradley
    Affiliations
    University Health Network and Mount Sinai Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute and Toronto General Hospital, Toronto, Ontario, Canada
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  • John S. Floras
    Correspondence
    Corresponding author: Dr John S. Floras, Suite 1614, Mount Sinai Hospital, 600 University Ave, Toronto, Ontario M5G 1X5, Canada. Tel.: +1-416-586-8704; fax: +1-416-586-8702.
    Affiliations
    University Health Network and Mount Sinai Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
    Search for articles by this author
  • for theADVENT-HF Investigators
    Author Footnotes
    ∗ For a complete list of ADVENT-HF Committees and Principal Investigators, see Supplemental Appendix S1.
  • Author Footnotes
    ∗ For a complete list of ADVENT-HF Committees and Principal Investigators, see Supplemental Appendix S1.
Published:February 12, 2016DOI:https://doi.org/10.1016/j.cjca.2016.02.047

      Abstract

      Background

      The study aim was to determine whether phasic left atrial (LA) function of patients with heart failure with reduced ejection fraction differs between those with obstructive sleep apnea (OSA) and central sleep apnea (CSA).

      Methods

      Participation in the Adaptive Servo Ventilation for Therapy of Sleep Apnea in Heart Failure (ADVENT-HF) trial requires 2-dimensional echocardiographic documentation of left ventricular ejection fraction ≤ 45% and a polysomnographic apnea hypopnea index (AHI) ≥ 15 events per hour. Of initial enrollees, we identified 132 patients in sinus rhythm (82 with predominantly OSA and 50 with CSA). To determine LA reservoir (expansion index; EI), conduit (passive emptying index; PEI), and booster function (active emptying index), we blindly quantified maximum and minimum LA volume and LA volume before atrial contraction.

      Results

      Each of EI (P = 0.004), PEI (P < 0.001), and active emptying index (P = 0.045) was less in participants with CSA compared with those with OSA, whereas average left ventricular ejection fraction and LA and left ventricular volumes were similar. Multivariable analysis identified an independent relationship between central AHI and LA EI (P = 0.040) and PEI (P = 0.005). In contrast, the obstructive AHI was unrelated to any LA phasic index, and slopes relating central AHI to EI and PEI differed significantly from corresponding relationships with obstructive AHI (P = 0.018; P = 0.006).

      Conclusions

      In these ADVENT-HF patients with heart failure with reduced ejection fraction, all 3 components of LA phasic function (reservoir, conduit, and contractile) were significantly reduced in those with CSA compared with participants with OSA. The severity of CSA, but not OSA associated inversely and independently with LA reservoir and conduit function. Impaired LA phasic function might be consequent to or could exacerbate CSA.

      Résumé

      Introduction

      L’étude avait pour objectif de déterminer si, chez les patients atteints d’insuffisance cardiaque avec réduction de la fraction d’éjection, la fonction auriculaire gauche phasique différait entre les patients souffrant d’apnée du sommeil obstructive (ASO) et ceux souffrant d’apnée centrale du sommeil (ACS).

      Méthodes

      Pour participer à l’étude « Adaptive Servo Ventilation for Therapy of Sleep Apnea in Heart Failure » (ADVENT-HF), les patients devaient avoir une fraction d’éjection ventriculaire gauche ≤ 45 % documentée par échocardiographie bidimensionnelle et un indice d’apnée et d’hypopnée (IAH) ≥ 15 événements par heure selon les résultats polysomnographiques. Parmi l’ensemble des patients initialement inscrits à l’étude, nous avons recensé 132 cas de rythme sinusal (82 patients chez qui l’ASO prédominait et 50 chez qui l’ACS prédominait). Pour déterminer les indices des fonctions de réservoir (indice d’expansion), de conduite (indice de vidange passive) et de contraction (indice de vidange active), nous avons calculé à l’insu les volumes maximum et minimum de l’oreillette gauche, ainsi que le volume avant la contraction auriculaire.

      Résultats

      Les indices d’expansion (p = 0,004), de vidange passive (p < 0,001) et de vidange active (p = 0,045) étaient moindres chez les patients atteints d’ACS par rapport à ceux atteints d’ASO, tandis que la fraction d’éjection ventriculaire gauche moyenne et les volumes de l’oreillette et du ventricule gauches étaient semblables. L’analyse multivariée a permis d’établir une relation indépendante entre l’IAH centrale et les indices d’expansion (p = 0,040) et de vidange passive (p = 0,005) de l’oreillette gauche. En revanche, l’IAH obstructive ne présentait aucune relation avec les indices phasiques de l’oreillette gauche, et les courbes établissant le lien entre l’IAH centrale et les indices d’expansion et de vidange passive différaient de façon significative de celles observées pour l’IAH obstructive (p = 0,018; p = 0,006).

      Conclusions

      Dans le cadre de l’étude ADVENT-HF menée auprès de patients atteints d’insuffisance cardiaque avec réduction de la fraction d’éjection ventriculaire gauche, les valeurs observées pour les trois composantes de la fonction phasique auriculaire gauche (fonctions de réservoir, de conduite et de contraction) étaient significativement inférieures chez les patients atteints d’ACS par rapport à ceux atteints d’ASO. Contrairement à l’ASO, la gravité de l’ACS était inversement associée, de manière indépendante, à une baisse des indices d’expansion et de vidange passive (fonctions de réservoir et de conduite). Ce dysfonctionnement phasique pourrait être une conséquence de l’ACS, ou encore constituer un facteur d’exacerbation de cette dernière.
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      References

        • Kasai T.
        • Floras J.S.
        • Bradley T.D.
        Sleep apnea and cardiovascular disease: a bidirectional relationship.
        Circulation. 2012; 126: 1495-1510
        • Lyons O.D.
        • Bradley T.D.
        Heart failure and sleep apnea.
        Can J Cardiol. 2015; 31: 898-908
        • Bradley T.D.
        • Floras J.S.
        Sleep apnea and heart failure: part II: central sleep apnea.
        Circulation. 2003; 107: 1822-1826
        • Bradley T.D.
        • Floras J.S.
        Sleep apnea and heart failure: part I: obstructive sleep apnea.
        Circulation. 2003; 107: 1671-1678
        • Melenovsky V.
        • Hwang S.J.
        • Redfield M.M.
        • et al.
        Left atrial remodeling and function in advanced heart failure with preserved or reduced ejection fraction.
        Circ Heart Fail. 2015; 8: 295-303
        • Fang F.
        • Lee A.P.
        • Yu C.M.
        Left atrial function in heart failure with impaired and preserved ejection fraction.
        Curr Opin Cardiol. 2014; 29: 430-436
        • Hsiao S.H.
        • Chiou K.R.
        Left atrial expansion index predicts all-cause mortality and heart failure admissions in dyspnoea.
        Eur J Heart Fail. 2013; 15: 1245-1252
        • Rossi A.
        • Temporelli P.L.
        • Quintana M.
        • et al.
        Independent relationship of left atrial size and mortality in patients with heart failure: an individual patient meta-analysis of longitudinal data (MeRGE Heart Failure).
        Eur J Heart Fail. 2009; 11: 929-936
        • Pellicori P.
        • Zhang J.
        • Lukaschuk E.
        • et al.
        Left atrial function measured by cardiac magnetic resonance imaging in patients with heart failure: clinical associations and prognostic value.
        Eur Heart J. 2015; 36: 733-742
        • Mauser W.
        • Sandrock S.
        • Demming T.
        • Kotzott L.
        • Bonnemeier H.
        Sleep disordered breathing is an independent risk factor for left atrial enlargement in patients with congestive heart failure.
        Int J Cardiol. 2013; 167: 2323-2324
        • Solin P.
        • Bergin P.
        • Richardson M.
        • et al.
        Influence of pulmonary capillary wedge pressure on central apnea in heart failure.
        Circulation. 1999; 99: 1574-1579
        • Lorenzi-Filho G.
        • Azevedo E.R.
        • Parker J.D.
        • Bradley T.D.
        Relationship of carbon dioxide tension in arterial blood to pulmonary wedge pressure in heart failure.
        Eur Respir J. 2002; 19: 37-40
        • Kasai T.
        • Motwani S.S.
        • Yumino D.
        • et al.
        Contrasting effects of lower body positive pressure on upper airways resistance and partial pressure of carbon dioxide in men with heart failure and obstructive or central sleep apnea.
        J Am Coll Cardiol. 2013; 61: 1157-1166
        • Lang R.M.
        • Bierig M.
        • Devereux R.B.
        • et al.
        Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology.
        J Am Soc Echocardiogr. 2005; 18: 1440-1463
        • Devereux R.B.
        Detection of left ventricular hypertrophy by M-mode echocardiography. Anatomic validation, standardization, and comparison to other methods.
        Hypertension. 1987; 9: II19-II26
        • Zoghbi W.A.
        • Enriquez-Sarano M.
        • Foster E.
        • et al.
        Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.
        J Am Soc Echocardiogr. 2003; 16: 777-802
        • Haruki N.
        • Takeuchi M.
        • Kaku K.
        • et al.
        Comparison of acute and chronic impact of adaptive servo-ventilation on left chamber geometry and function in patients with chronic heart failure.
        Eur J Heart Fail. 2011; 13: 1140-1146
        • Iwataki M.
        • Takeuchi M.
        • Otani K.
        • et al.
        Measurement of left atrial volume from transthoracic three-dimensional echocardiographic datasets using the biplane Simpson’s technique.
        J Am Soc Echocardiogr. 2012; 25: 1319-1326
        • Okamatsu K.
        • Takeuchi M.
        • Nakai H.
        • et al.
        Effects of aging on left atrial function assessed by two-dimensional speckle tracking echocardiography.
        J Am Soc Echocardiogr. 2009; 22: 70-75
        • Wu V.C.
        • Takeuchi M.
        • Kuwaki H.
        • et al.
        Prognostic value of LA volumes assessed by transthoracic 3D echocardiography: comparison with 2D echocardiography.
        JACC Cardiovasc Imaging. 2013; 6: 1025-1035
        • Chadha T.S.
        • Watson H.
        • Birch S.
        • et al.
        Validation of respiratory inductive plethysmography using different calibration procedures.
        Am Rev Respir Dis. 1982; 125: 644-649
      1. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force.
        Sleep. 1999; 22: 667-689
        • Rechtschaffen A.
        • Kales A.
        A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects.
        (NIH Publication No 204) US National Institute of Neurological Diseases and Blindness, Neurological Information Network, Bethesda, MD1968
        • Bradley T.D.
        • Logan A.G.
        • Kimoff R.J.
        • et al.
        Continuous positive airway pressure for central sleep apnea and heart failure.
        N Engl J Med. 2005; 353: 2025-2033
        • Oliveira W.
        • Campos O.
        • Bezerra Lira-Filho E.
        • et al.
        Left atrial volume and function in patients with obstructive sleep apnea assessed by real-time three-dimensional echocardiography.
        J Am Soc Echocardiogr. 2008; 21: 1355-1361
        • Kasai T.
        • Yumino D.
        • Redolfi S.
        • et al.
        Overnight effects of obstructive sleep apnea and its treatment on stroke volume in patients with heart failure.
        Can J Cardiol. 2015; 31: 832-838
        • Calvin A.D.
        • Somers V.K.
        • Johnson B.D.
        • Scott C.G.
        • Olson L.J.
        Left atrial size, chemosensitivity, and central sleep apnea in heart failure.
        Chest. 2014; 146: 96-103
        • Lanfranchi P.A.
        • Braghiroli A.
        • Bosimini E.
        • et al.
        Prognostic value of nocturnal Cheyne-Stokes respiration in chronic heart failure.
        Circulation. 1999; 99: 1435-1440
        • Vazir A.
        • Hastings P.C.
        • Dayer M.
        • et al.
        A high prevalence of sleep disordered breathing in men with mild symptomatic chronic heart failure due to left ventricular systolic dysfunction.
        Eur J Heart Fail. 2007; 9: 243-250
        • Oldenburg O.
        • Lamp B.
        • Faber L.
        • et al.
        Sleep-disordered breathing in patients with symptomatic heart failure: a contemporary study of prevalence in and characteristics of 700 patients.
        Eur J Heart Fail. 2007; 9: 251-257
        • Tsang T.S.
        • Abhayaratna W.P.
        • Barnes M.E.
        • et al.
        Prediction of cardiovascular outcomes with left atrial size: is volume superior to area or diameter?.
        J Am Coll Cardiol. 2006; 47: 1018-1023
        • Hoit B.D.
        Left atrial size and function: role in prognosis.
        J Am Coll Cardiol. 2014; 63: 493-505
        • Lancellotti P.
        • Henri C.
        The left atrium: an old ‘barometer’ which can reveal great secrets.
        Eur J Heart Fail. 2014; 16: 1047-1048
        • Wakami K.
        • Ohte N.
        • Asada K.
        • et al.
        Correlation between left ventricular end-diastolic pressure and peak left atrial wall strain during left ventricular systole.
        J Am Soc Echocardiogr. 2009; 22: 847-851
        • Tkacova R.
        • Wang H.
        • Bradley T.D.
        Night-to-night alterations in sleep apnea type in patients with heart failure.
        J Sleep Res. 2006; 15: 321-328
        • Tamura A.
        • Kawano Y.
        • Kadota J.
        Carvedilol reduces the severity of central sleep apnea in chronic heart failure.
        Circ J. 2009; 73: 295-298
        • Triposkiadis F.
        • Moyssakis I.
        • Hadjinikolaou L.
        • et al.
        Left atrial systolic function is depressed in idiopathic and preserved in ischemic dilated cardiomyopathy.
        Eur J Clin Invest. 1999; 29: 905-912
        • Sin D.D.
        • Fitzgerald F.
        • Parker J.D.
        • et al.
        Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure.
        Am J Respir Crit Care Med. 1999; 160: 1101-1106
        • Toh N.
        • Kanzaki H.
        • Nakatani S.
        • et al.
        Left atrial volume combined with atrial pump function identifies hypertensive patients with a history of paroxysmal atrial fibrillation.
        Hypertension. 2010; 55: 1150-1156
        • Mullens W.
        • Borowski A.G.
        • Curtin R.J.
        • Thomas J.D.
        • Tang W.H.
        Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure.
        Circulation. 2009; 119: 62-70
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • et al.
        2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.
        Circulation. 2013; 128: e240-e327
        • Cowie M.R.
        • Woehrle H.
        • Wegscheider K.
        • et al.
        Adaptive servo-ventilation for central sleep apnea in systolic heart failure.
        N Engl J Med. 2015; 373: 1095-1105
        • Magalang U.J.
        • Pack A.I.
        Heart failure and sleep-disordered breathing–the plot thickens.
        N Engl J Med. 2015; 373: 1166-1167
        • Hsiao S.H.
        • Chiou K.R.
        Left atrial expansion index predicts atrial fibrillation in dyspnea.
        Circ J. 2013; 77: 2712-2721