Atrial Failure: What Do We Know About It?

Sidhi Laksono Purwowiyoto, Budhi Setianto, Steven Philip Surya


Heart failure is the end of all pathological conditions in the heart. Most accepted paradigms in heart failure are always preceded by left ventricle disfunction. Currently, there are several clinical studies that show that heart failure may occur without prior left ventricular dysfunction. Left atrial dysfunction may play a more important role in heart failure than previously expected. Failure of the left atrium can exist independently of left ventricle dysfunction and mitral valve abnormalities. Atrial failure, just like left ventricular failure, can lead to global heart failure. Etiology, pathomechanism and clinical symptoms of atrial failure are complex and not well understood. This review will explain atrial failure.


atrial dysfunction; failure; etiology; pathomechanism; clinical symptoms


Kirali K, Ozer T, Ozgur MM. Pathophysiology in heart failure. In: Kirali K, editor. Cardiomyopaties: type and treatment. Crotia: InTech; 2017. p. 17-38.

Hasenfuss G, Mann DL. Pathophysiology of heart failure. In: Mann DL, Zipes DP, Libby P, Bonow RO, editor. Braunwald’s heart disease: a textbook of cardiovascular medicine. 10th ed. Philadelphia: Elsevier, Inc.; 2015. p. 454-72.

Bisbal F, Baranchuk A, Braunwald E, de Luna AB, Bayes-Genis A. Atrial failure as a clinical entity: jacc review topic of the week. J Am Coll Cardiol. 2020;75:222-32.

Rossi A, GheorghiadeM, Triposkiadis F, Solomon SD, Pieske B, Buttler J. Left atrium in heart failure with preserved ejection fraction: structure, function, and significance. Circ Heart Fail. 2014;7(6):1042-9.

Triposkiadis F, Pieske B, Butler J, et al. Global left atrial failure in heart failure. Eur J Heart Fail. 2016;18:1307-20.

Ho SY, Cabrera JA, Sanchez-Quintana D. Left atrial anatomy revisited. Circ Arrhytm Electrophysiol. 2012;5:220-8.

Sanchez-Quintana D, Cabrera JA, Climent V, Farre J, Mendonca MC, Ho SY. Anatomic relations between the esophagus and left atrium and relevance for ablation of atrial fibrillation. Circulation. 2005;112(10):1400-5.

Whiteman S, Saker E, Courant V, et al. An anatomical review of the left atrium. Transl Res Anat. 2019;17:100052.

Ho S, Cabrera J, Tran V, Farre J, Anderson R, Sanchez-Quintana D. Architecture of the pulmonary veins: relevance to radiofrequency ablation. Heart. 2001:86(3):265-70.

Kilner PJ, Yang GZ, Wilkes AJ, Mohiaddin RH, Firmin DN, Yacoub MH. Asymmetric redirection of flow through the heart. Nature. 2000;13;404(6779):759-61.

Syed FF, Noheria A, DeSimone CV, Asirvatham SJ. Left atrial appendafe ligation and exclusion technology in the incubator. J Atr Fibrillation. 2015;8(2):1160.

Yamamoto M, Seo Y, Kawamtsu N, et al. Complex left atrial appendage morphology and left atrial appendage thrombus formation in patients with atrial fibrillation. Circ Cardiovasc Imaging. 2014;7(2):337-43.

Karayannis G, Kitsios G, Kotidis H, Triposkiadis F. Left atrial remodeling contributes to the progression of asymptomatic left ventricular systolic dysfunction to chronic symptomatic heart failure. Heart Fail Rev. 2008;13(1):91-8.

Seward JB, Hebl VB. Left atrial anatomy and physiology: echo/doppler assessment. Curr Opin Cardiol. 2014;29(5): 403-7.

Mateescu AD, Calin A, Beladan CC, et al. Left atrial dysfunction as an independent correlate of heart failure symptoms in patients with severe aortic stenosis and preserved left ventricular ejection fraction. J Am Soc Echocardiogr. 2019;32(2):257-66.

Wang YC, Lin JL, Hwang JJ, et al. Left atrial dysfunction in patient with atrial fibrillation after successful rhythm control for >3 months. Chest. 2005; 128(4):2551-6.

Wang D, Xu JZ, Chen X, et al. Left atrial myocardial dysfunction in patients with primary aldosteronism as assessed by speckle-tracking echocardiography. J Hypertens. 2019;37(10):2032-40.

Wozakowska-Kaplon B, Opolski G. Concomitant recovery of atrial mechanical and endocrine function after cardioversion in patient with persistent atrial fibrillation. J Am Coll Cardiol. 2003;41(10):1716-20.

Siontis KC, Geske JB, Gersh BJ. Atrial fibrillation pathophysiology and prognosis: insight from cardiovascular imaging. Circ Cardiovasc Imaging. 2015;8(6):e003020.

Goette A, Kalman JM, Aguinaga L, et al. EHRA/HRS/APHRS/SOLAECE expert consensus on trial cardiomyopathies: definition, characterization, and clinical implication. Heart Rhythym. 2017;14(1):e3-e40.

Agarwal R. Atrial cardiomyopathy: a new and novel concept. J Pract Cardiovasc Sci. 2019;5:64-5.

Fatkin D, Nikolova-Krstevski VN. Atrial cardiomyopathy an orphan disease or common disorder? Circ Cardiovasc Genet. 2013;6:6-5.

Dan GA. Rhythm control in AF: have we reached the last frontier? European Cardiology Review. 2019;14(2):77-81.

Miller JD, Aronis KN, Chrispin J, et al. Obesity, exercise, obstructive sleep apnea, and modifiable atherosclerotic cardiovascular disease risk factors in atrial fibrillation. J Am Coll Cardiol. 2015;66(25):2899-906.

Selvetella G, Hirsch E, Notte A, Tarone G, Lembo G. Adaptive and maladaptive hypertrophic pathway: points of convergence and divergence. Cardiovasc Res. 2004;63(3):373-80.

Jalife J, Kaur K. Atrial remodeling fibrosis, and atrial fibrillation. Trends Cardiovasc Med. 2014;25(6):475-84.

Pinho-Gomes AC, Reilly S, Brandes RP, Casadei B. Targeting inflammation and oxidative stress in atrial fibrillation: role of 3-hydroxyl-3methylglutaryl-coenzyme a reductase inhibition with statins. Antioxid Redox Signal. 2014;20(8):1268-85.

Hou Y, Scherlag BJ, Lin J, et al. Ganglionated plexi modulate extrinsic cardiac autonomic nerve input: effects on sinus rate, atrioventricular conduction, refractoriness, and inducibility of atrial fibrillation. J Am Coll Cardiol. 2007;50(1):61-8.

Arrigo M, Huber LC. Eponyms in cardiopulmonary reflexes. Am J Cardiol. 2013;112(3):449-53.

Bichet DG. Central vasopressin: dendritic and axonal secretion and renal actions. Clin Kidney J. 2014;7(3): 242-7.

Zhang DY, Anderson AS. The sympathetic nervous system and heart failure. Cardiol Clin. 2014;32(1):33-vii.

Januzzi JL. Natriuretic peptide as biomarkers in heart failure. J investing Med. 2013;61(6)950-5.

Mair J, Lindahl B, Giannitsis E, et al. Will sacubitril-valsartan diminish the clinical utility of b-type natriuretic peptide testing in acute cardiac care? Eur Heart J Acute Cardiovasc Care. 2017;6(4):321-8.

Nishikimi T, Kuwahara K, Nakao K. Current biochemistry, molecular biology, and clinical relevance of natriuretic peptides. J Cardiol. 2011;57(2):131-40.

Brutsaert DL. Cardiac endothelial-myocardial signaling: its role in cardiac growth, contractile performance, and rhythmicity. Physiol Rev. 2003;83(1):59-115.

Calenda BW, Fuster V, Halperin JL, Granger CB. Stroke risk assessment in atrial fibrillation: risk factor and markers of atrial myopathy. Nat Rev Cardiol. 13(9):549-59.

Habibi M, Zareian M, Ambale Venkatesh B, et al. Left atrial mechanical function and incident ischemic cerebrovascular event independent of AF: insight from the MESA study. JACC Cardiovasc Imaging. 2019;12(12):2417-27.

Kuppahally SS, Akoum N, Burgon NS, et al. Left atrial strain and strain rate in patient with paroxysmal and persistent atrial fibrillation: relationship to left atrial structural remodeling detected by delayed-enhancement MRI. Circ Cardiovasc Imaging. 2010;3(3):231-9.

Fonseca AC, Alves P, Inacio N, et al. Patients with undetermined stroke have increased atrial fibrosis: a cardiac magnetic resonance imaging study. Stroke. 2018;49(3):734-7.

Balint B, Jaremek V, Thorburn V, Whitehead SN, Sposato LA. Left atrial microvascular endothelial dysfunction, myocardial inflammation and fibrosis after selective insular cortex ischemic stroke. Int J Cardiol. 2019;292:148-55.

Psaty BM, Manolio TA, Kuller LH, et al. Incidence of and risk factors for atrial fibrillation in older adults. Circulation. 1997;96(7):2455–61.

Abhayaratna WP, Fatema K, Barnes ME, et al. Left atrial reservoir function as a potent marker for first atrial fibrillation or flutter in persons ≥ 65 years of age. Am J Cardiol. 2008;101(11):1626–9.

King JB, Azadani PN, Suksaranjit P, et al. Left atrial fibrosis and risk of cerebrovascular and cardiovascular events in patients with atrial fibrillation. J Am Coll Cardiol. 2017;70:1311–21.

Barnes ME, Miyasaka Y, Seward JB, et al. Left atrial volume in the prediction of first ischemic stroke in an elderly cohort without atrial fibrillation. Mayo Clin Proc. 2004;79(8):1008–14.

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(1):71-79.e1.

Santos AB, Roca GQ, Claggett B, et al. The prognostic relevance of left atrial dysfunction in heart failure with preserved ejection fraction. Circ Heart Fail. 2016;9(4):e002763.

Khan MS, Memon MM, Murad MH, et al. Left atrial function in heart failure with preserved ejection fraction: a systematic review and meta-analysis. Eur J Heart Fail. 2020;22(3):472-85.

Full Text: PDF


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.