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\begin{document}

\title{Is Brain Natriuretic Peptide specific for the left atrial appendage?}



\author[1]{Erdi Babayiğit}%
\author[2]{Andaç Karadeniz}%
\author[1]{Bulent Gorenek}%
\affil[1]{1Eskişehir Osmangazi University}%
\affil[2]{Erzurum Bolge Egitim ve Arastirma Hastanesi}%


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  \date{May 22, 2024}


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\begin{abstract}
Dear Editor, We read with great interest the article recently published
in Journal of Cardiovascular Electrophysiology, ``Left atrial appendage
dimension predicts elevated brain natriuretic peptide in nonvalvular
atrial fibrillation'' by Cook JA. et al. \textsuperscript{1} The authors
have studied the relation between Brain natriuretic peptide (BNP)
elevations and left atrial appendage measurements in patients who
referred for left atrial appendage (LAA) occlusion in patients with
nonvalvular atrial fibrillation (AF). BNP release is largely from the
ventricles and it is also dynamically dependent on myocardial stretch
and fluid volume status. However, it seems difficult to prove that BNP
levels are directly related to the LAA measurements. Correlating BNP
elevation only with left atrial or LAA measurements means ignoring left
ventricular strain. Considering that these patients were referred for
LAA occlusion and had a high CHA \textsubscript{2}DS
\textsubscript{2-}VASc score, and not taking heart failure with
preserved ejection fraction into account may lead to errors in
interpreting the results. Moreover, it should be evaluated that the left
atrial appendage may undergo remodeling or enlargement as a result of
the left ventricular end-diastolic pressure increase. In this case,
although the study is valuable, remains a cross-sectional study and a
snapshot of the correlation of BNP and LAA. Second, it should be
disclosed whether patients have paroxysmal or chronic AF and how long
the patient has had AF. A relationship was established between LAA
dimensions and BNP in the study, it is essential that the duration of AF
should be considered and subgroup analyses should be evaluated if
possible, since AF has a significant effect on BNP release. We
appreciate this study and believe that a more detailed evaluation
including left ventricular evaluation and prospectively monitored LAA
and BNP would yield more realistic results. In addition, we think that
it would be useful to evaluate midregional pro-A-type natriuretic
(MR-proANP) in LAA studies, which is specific to the left atrial
enlargement and similar physiology to BNP. \textsuperscript{2}%
\end{abstract}%



\sloppy


\textbf{Is Brain Natriuretic Peptide specific for the left atrial
appendage?}

Erdi Babayi\selectlanguage{polish}ğ\selectlanguage{english}it, MD\textsuperscript{1}, Anda\selectlanguage{ngerman}ç Karadeniz,
MD\textsuperscript{2}, Prof. Bülent Görenek, MD, FACC,
FESC\textsuperscript{1}

1.Eski\selectlanguage{polish}ş\selectlanguage{english}ehir Osmangazi University, School of Medicine, Department of
Cardiology, Eski\selectlanguage{polish}ş\selectlanguage{english}ehir, Turkey

2. Erzurum State Hospital, Department of Internal Medicine, Erzurum,
Turkey

Corresponding Author:

Erdi Babayi\selectlanguage{polish}ğ\selectlanguage{english}it, MD

Department of Cardiology,

Eskisehir Osmangazi University School of Medicine,

Eskisehir, Turkey

Tel: +90 535 740 9486

e-mail: erdibabayigit@gmail.com

Dear Editor,

We read with great interest the article recently published in Journal of
Cardiovascular Electrophysiology, ``Left atrial appendage dimension
predicts elevated brain natriuretic peptide in nonvalvular atrial
fibrillation'' by Cook JA. et al.\textsuperscript{1} The authors have
studied the relation between Brain natriuretic peptide (BNP) elevations
and left atrial appendage measurements in patients who referred for left
atrial appendage (LAA) occlusion in patients with nonvalvular atrial
fibrillation (AF).

BNP release is largely from the ventricles and it is also dynamically
dependent on myocardial stretch and fluid volume status. However, it
seems difficult to prove that BNP levels are directly related to the LAA
measurements. Correlating BNP elevation only with left atrial or LAA
measurements means ignoring left ventricular strain. Considering that
these patients were referred for LAA occlusion and had a high
CHA\textsubscript{2}DS\textsubscript{2-}VASc score, and not taking heart
failure with preserved ejection fraction into account may lead to errors
in interpreting the results. Moreover, it should be evaluated that the
left atrial appendage may undergo remodeling or enlargement as a result
of the left ventricular end-diastolic pressure increase. In this case,
although the study is valuable, remains a cross-sectional study and a
snapshot of the correlation of BNP and LAA.

Second, it should be disclosed whether patients have paroxysmal or
chronic AF and how long the patient has had AF. A relationship was
established between LAA dimensions and BNP in the study, it is essential
that the duration of AF should be considered and subgroup analyses
should be evaluated if possible, since AF has a significant effect on
BNP release.

We appreciate this study and believe that a more detailed evaluation
including left ventricular evaluation and prospectively monitored LAA
and BNP would yield more realistic results. In addition, we think that
it would be useful to evaluate midregional pro-A-type natriuretic
(MR-proANP) in LAA studies, which is specific to the left atrial
enlargement and similar physiology to BNP.\textsuperscript{2}

Cook JA, Lancaster MC, Kanagasundram AN, et al. Left atrial appendage
dimension predicts elevated brain natriuretic peptide in nonvalvular
atrial fibrillation.~\emph{J Cardiovasc Electrophysiol} .
2023;34(1):135-141. doi:10.1111/jce.15719

Behnes M, Sartorius B, Wenke A, et al. Percutaneous Closure of Left
Atrial Appendage affects Mid-Term Release of MR-proANP.~\emph{Sci Rep} .
2017;7(1):9028. Published 2017 Aug 22. doi:10.1038/s41598-017-08999-4

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