Serial changes of L wave according to heart rates in a heart failure patient with persistent atrial fibrillation

Abstract

Mid-diastolic forward flow velocity of transmitral flow (L wave) is known as a marker of diastolic dysfunction and is occasionally observed in patients with fluid retention, low heart rate, and atrial fibrillation (AF). However, how hemodynamic condition affects L wave is still unknown. An 81-year-old woman who underwent implantation of a DDD pacemaker due to complete atrioventricular block 38 years previously suffered from congestive heart failure and was admitted to our hospital. At the time of admission, electrocardiogram showed new-onset AF resulting in mode switch to VVI, and echocardiography showed a giant L wave. At the mid-term of the treatment, AF was converted to sinus rhythm resulting in mode switch to DDD, and pacemaker check-up was performed at pre- and post-cardioversion. During the pacemaker check-ups, L wave was assessed in various pacing rates. As pacing rate was increased, L wave altered according to heart rates and disappeared at 85 bpm in VVI with AF, whereas at 75 bpm in DDD. Through the treatment, L wave got smaller as fluid retention was improved and finally disappeared at the time of discharge. This case suggests that L wave is highly variable and affected by fluid volume, heart rate, and heart rhythm.<Learning objective: Although L wave is known as a marker of diastolic dysfunction and occasionally observed in patients with high left ventricular filling pressure, low heart rate, and atrial fibrillation, how hemodynamics affects L wave is still unknown. In this case, it was observed that L wave is highly variable in the therapeutic process of heart failure and affected by fluid volume, heart rate, and heart rhythm. L wave potentially can be a useful indicator to evaluate treatment efficacy for heart failure.>

Prevalence and prognostic role of L wave and selected clinical and echocardiographic variables in dogs with atrial fibrillation

“…Blood flow during diastasis is intrinsically related to the transmitral pressure gradient and diastolic time. Accordingly, these 2 parameters can determine whether L waves are detectable or not 37,41 . In humans, L waves become evident in pathologic conditions characterized by decreased LV diastolic active relaxation, increased LV stiffness, increased filling pressures or some combination of these, such as LV hypertrophy, 38,43,44 severe mitral valve disease, 45 heart diseases characterized by severe LV systolic dysfunction, 22,43 and AF 20,36,45 .…”

“…Pulsed‐wave Doppler analysis of transmitral blood flow was obtained from the left apical 4‐chamber view by positioning the sample volume at the tip of the mitral leaflets, and the peak velocity of the early diastolic wave was measured. Moreover, particular attention was paid to identify L waves, defined as distinct positive mid‐diastolic flow velocities recorded after the E waves, leading to a biphasic pattern in dogs with AF (i.e., E wave followed by an L wave) 20,36‐38 . Although low velocity flow could be recorded during diastasis, an L wave was defined when forward mid‐diastolic flow after the E wave had a peak velocity >0.2 m/s (Figure 1).…”

“…20,[36][37][38] Although low velocity flow could be recorded during diastasis, an L wave was defined when forward mid-diastolic flow after the E wave had a peak velocity >0.2 m/s (Figure 1). 20,[36][37][38] All echocardiographic images for identification of L waves were obtained or reviewed or both by a board-certified veterinary cardiologist (G.R. ).…”

Mid-Diastolic Events (L Events): A Critical Review

“…Some interesting single experiences reported the transient appearance of the L wave in different pathologic conditions of volume overload, such as severe anemia, new-onset HF (with or without new-onset AF), acute VHD, or acute coronary syndrome (ACS) [40,41]. Morisawa et al described an interesting case of a pacemaker (PM)-dependent patient (pacing mode DDD) developing acute HF and new-onset AF [42]. In these circumstances, the device pacing mode automatically switched to VVI.…”

“…Morisawa et al described an interesting case of a pacemaker (PM)-dependent patient (pacing mode DDD) developing acute HF and new-onset AF [ 42 ]. In these circumstances, the device pacing mode automatically switched to VVI.…”