Assessment Of Left Atrial Function Research Articles

Left atrial function assessment to refine indications to mitral valve surgery.

Left atrial function assessment to refine indications to mitral valve surgery.

Atrial Dysfunction in Significant Atrial Functional Mitral Regurgitation: Phenotypes and Prognostic Implications.

Atrial functional mitral regurgitation (AFMR) is associated with increased morbidity and mortality. Left atrial (LA) size and function in AFMR are poorly characterized. We aimed to assess LA function by reservoir strain (LASr) and estimated reservoir work (LAWr) and their impact on outcome in AFMR. Consecutive patients at our institution between 2001 and 2019 and with significant (moderate or greater) AFMR were examined. LAWr was estimated as LASr×LA reservoir volume, and patients were grouped by median LASr and LAWr. Outcomes were all-cause death or heart failure hospitalizations. Five hundred fifteen AFMR patients were followed up for 5 (1-17) years. Patients had previously documented atrial fibrillation (AF; 37%), heart failure with preserved ejection fraction (HFpEF) without AF (24%), or both (HFpEF+AF, 39%). LA volume was largest in AF, while LA function parameters were most impaired in the combined HFpEF+AF group. During follow-up, patients with low LASr or LAWr had higher risk of death (P<0.001) and heart failure hospitalization (P<0.05). In Cox regression analyses, low LASr and LAWr, but not LA volume or left ventricular function, were associated with a higher risk of death (LASr: hazard ratio, 2.3 [95% CI, 1.6-3.5]; LAWr: hazard ratio, 3.4 [95% CI, 2.4-4.9]; both P<0.001) after adjustment for clinical and echocardiographic confounders. Low LASr and LAWr were strongest associated with death in HFpEF and HFpEF+AF. LA reservoir function but not LA size is a robust predictor of outcome in significant AFMR. This provides mechanistic insights into the interplay of functional versus geometric LA changes in AFMR.

Left atrial function evaluation by 2D speckle-tracking echocardiography in patients with vasovagal syncope.

Evidence indicates left atrial (LA) involvement in vasovagal syncope (VVS). The LA regulates left ventricular filling during the cardiac cycle. We aimed to assess LA function in patients with VVS by 2D speckle-tracking echocardiography. Sixty-nine consecutive patients with VVS were recruited. Based on the head-up tilt test (HUTT) results, the study population was divided into two groups: HUTT+ (n = 45) and HUTT- (n = 24). Fifty-one consecutive subjects were enrolled as the control group. LA myocardial deformation parameters were measured by 2D speckle-tracking echocardiography to evaluate LA function. Maximal, minimal, and pre-P LA volumes were lower in patients with VVS. Strain and strain rate during reservoir, conduit, and contraction phases in VVS patients with HUTT+ or HUTT- were not statistically significantly different from those in the control group. Additionally, the volumetric parameters of LA function showed no difference in statistical significance between the three study groups. While LA phasic function was not different between the two groups of VVS patients with HUTT+ or HUTT- and the control group, LA size during the three LA phases was smaller in patients with VVS.

Left atrial reservoir strain measurements derived from intracardiac echocardiography in patients with atrial fibrillation: comparison with transthoracic echocardiography

BackgroundIntracardiac echocardiography (ICE) provides accurate left atrial (LA) anatomical information in the procedure of atrial fibrillation (AF) ablation but lacks LA functional assessment. LA reservoir strain (LASr) is an excellent marker of LA reservoir function. This study aimed to assess the agreement between LASr derived from ICE and transthoracic echocardiography (TTE) in AF patients and analyze the reproducibility of LASr assessed by ICE combined with speckle tracking imaging.MethodsThis study prospectively enrolled 110 patients with a clinical diagnosis of AF who were ready for AF ablation, including 71 patients with paroxysmal AF and 39 with persistent AF. TTE and ICE examinations were performed on each individual before AF ablation. LASr measurements derived from ICE and TTE images were using dedicated LA-tracking software. Pearson correlation coefficients (r) and Bland–Altman plots were used to evaluate the agreement of LASr between the two modalities. Intraclass correlation coefficients (ICCs) were used to assess intra- and inter-observer reproducibility.ResultsThe agreement between LASr obtained from ICE and TTE, especially between LASrLPV (LASr derived from LA left pulmonary vein view of ICE) and LASrTTE (LASr derived from TTE) were good in both paroxysmal and persistent AF patients [r = 0.890 (P < 0.001) for overall population; r = 0.815 (P < 0.001) and Bias ± LOA: -0.3 ± 9.9% for paroxysmal AF; r = 0.775 (P < 0.001) and Bias ± LOA: -2.6 ± 3.9% for persistent AF, respectively]. But the values of LASr derived from ICE were slightly lower than those of TTE, especially in patients with persistent AF. The ICCs for LASr derived from ICE were excellent (all ICCs > 0.90).ConclusionsIn patients with AF, LASr derived from ICE demonstrated excellent reproducibility and showed good agreement with LASr obtained from TTE. Obtaining LASr from ICE images may be a supplementary method to evaluate LA reservoir function in AF patients and expands the potential of ICE in the field of cardiac function assessment.Graphical

Left atrial strain assessment using cardiac computed tomography in patients with hypertrophic cardiomyopathy

PurposeTo evaluate left atrial (LA) function in patients with hypertrophic cardiomyopathy (HCM) by LA strain assessment using cardiac computed tomography (CT-derived LA strain).Materials and methodsThis was a retrospective study of 34 patients with HCM and 31 non-HCM patients who underwent cardiac computed tomography (CT) using retrospective electrocardiogram-gated mode. CT images were reconstructed every 5% (0–95%) of the RR intervals. CT-derived LA strain (reservoir [LASr], conduit [LASc], and booster pump strain [LASp]) were semi-automatically analyzed using a dedicated workstation. We also measured the left atrial volume index (LAVI) and left ventricular longitudinal strain (LVLS) for the left atrial and ventricular functional parameters to assess the relationship with CT-derived LA strain.ResultsCT-derived LA strain significantly correlated with LAVI: r = − 0.69, p < 0.001 for LASr; r = − 0.70, p < 0.001 for LASp; and r = − 0.35, p = 0.004 for LASc. CT-derived LA strain also significantly correlated with LVLS: r = − 0.62, p < 0.001 for LASr; r = − 0.67, p < 0.001 for LASc; and r = − 0.42, p = 0.013 for LASp. CT-derived LA strain in patients with HCM was significantly lower than that in non-HCM patients: LASr (20.8 ± 7.6 vs. 31.7 ± 6.1%, p < 0.001); LASc (7.9 ± 3.4 vs. 14.2 ± 5.3%, p < 0.001); and LASp (12.8 ± 5.7 vs. 17.6 ± 4.3%, p < 0.001). Additionally, CT-derived LA strain showed high reproducibility; inter-observer correlation coefficients were 0.94, 0.90, and 0.89 for LASr, LASc, and LASp, respectively.ConclusionCT-derived LA strain is feasible for quantitative assessment of left atrial function in patients with HCM.

Association of left atrial size and function by cardiac magnetic resonance imaging with long term outcomes in patients with hypertrophic cardiomyopathy.

Left atrial (LA) function and strain are being investigated as markers of disease progression in hypertrophic cardiomyopathy (HCM). To assess LA function and strain by cardiac magnetic resonance imaging (MRI) in patients with HCM and evaluate the association of these parameters with long-term clinical outcomes. We retrospectively evaluated 50 HCM patients and 50 patients with no significant cardiovascular disease (control) who underwent clinically indicated cardiac MRI. We calculated LA volumes using the Simpson area-length method to derive LA ejection fraction and expansion index. MRI-derived left atrial reservoir (ƐR), conduit (ƐCD), and contractile strain (ƐCT) were measured using dedicated software. A multivariate regression analysis with endpoints of ventricular tachyarrhythmias (VTA) and heart failure hospitalization (HFH) was performed. HCM patients had significantly higher LV mass, higher LA volumes and lower LA strain compared to controls. During the median follow up of 15.6months (interquartile range 8.4-35.4months), 11 patients (22%) experienced a HFH, while 10 patients (20%) had VTA. Multivariate analysis demonstrated that ƐCT (odds ratio (OR) 0.96, confidence interval (CI) 0.83-1.00) and LA ejection fraction (OR 0.89, CI 0.79-1.00) were significantly associated with VTA and HFH respectively.

Left atrial strain is associated with arrhythmia recurrence after atrial fibrillation ablation: Cardiac magnetic resonance rapid strain vs. feature tracking strain

PurposeThe present study assesses different left atrial (LA) strain approaches in relation to atrial fibrillation (AF) recurrence after ablation and compares LA feature tracking (FT) strain to novel rapid LA strain approaches in AF patients. MethodsThis retrospective single-center study comprised of 110 prospectively recruited AF patients who underwent cardiac magnetic resonance (CMR) imaging in sinus rhythm prior to their first pulmonary vein isolation ablation. LA rapid strain (long axis strain and atrioventricular (AV)-junction strain), LA FT strain, and LA volumes were derived from 2-chamber and 4-chamber cine images. AF recurrence was followed up for 12 months using either 12‑lead ECGs or rhythm Holter monitoring. ResultsArrhythmia recurrence was observed in 39 patients (36%) after the 90-day blanking period, occurring at a median of 181 (122–286) days. LA long axis strain, AV-junction strain, and FT strain were all more impaired in patients with AF recurrence compared to patients without AF recurrence (long axis strain: P < 0.01; AV-junction strain: P < 0.001; FT strain: P < 0.01, respectively). Area under the curve (AUC) values for LA remodeling parameters in association with AF recurrence were 0.68 for long axis strain, 0.68 for AV-junction strain, 0.66 for FT strain, 0.66 for LA volume index. Phasic FT LA strain demonstrated that contractile strain had the highest AUC (0.70). ConclusionBoth LA rapid strain and LA FT strain are associated with arrhythmia recurrence after ablation in AF patients. LA rapid strain can be a convenient and reproducible alternative for LA FT strain to assess LA function in clinical practice.

The involvement of left atrial dysfunction in the occurrence of cardiovascular events in heart failure with preserved ejection fraction

The left atrium is an essential compartment for left ventricular diastolic function. The volume of the left atrium and its size are incriminated in the occurrence of cardiovascular events in heart failure with impaired or preserved ejection fraction. However, few studies have evaluated its function in the occurrence of cardiovascular events. Evaluation of left atrial function in the occurrence of cardiovascular events in heart failure with preserved ejection fraction. This is a prospective study, carried out over 10 months, including 115 patients in sinus rhythm at the time of echocardiography, for whom an assessment of left atrial function was performed, excluding all patients with left and right ventricular systolic dysfunction. The three functions of the left atrium were assessed, namely, reservoir function, driving function and pump function. The cardiovascular events studied were mainly: diastolic dysfunction, rhythm disorders especially atrial fibrillation, stroke and death. Left atrial dysfunction was associated with older age, higher prevalence of atrial fibrillation and deterioration of left ventricular diastolic function and stroke. Diastolic dysfunction was the most frequent event encountered with recurrence in 62 patients (53.9%), followed by supraventricular rhythm disorder in 39% (45 patients). Atrial fibrillation was present in 73% of cases followed by variable conduction atrial flutter in 17% and atrial tachycardia in 10%. Stroke was found in 7 patients (6%) and death of unknown cause in one of our patients (0.8%). Left atrial dysfunction is associated with a high risk of cardiovascular events. It is necessary to assess the function of the left atrium once the diameter and volume of the left atrium is dilated.

Conventional and two-dimensional strain echocardiography in predicting postoperative atrial fibrillation after coronary artery bypass grafting surgery.

Atrial fibrillation (AF) is a common complication after heart surgeries. Advances in imaging technologies and an understanding of the pathophysiology of preoperative left atrial (LA) dysfunction can lead to more definitive potential therapeutic approaches. This study aimed to determine the role of conventional echocardiography and LA two-dimensional (2D) strain echocardiography in assessing LA function and predicting POAF after CABG surgery. All patients with sinus rhythm who underwent CABG surgery were enrolled. All the patients had undergone conventional echocardiography and LA 2D-strain echocardiography 24 hours before surgery. In addition to demographic, clinical, and perioperative features, electrocardiogram (ECG) and Holter monitoring were recorded. Of the 105 patients included, 85 patients (81%) were men with a mean age of 60.26±10.61 years. POAF was seen in 22.9% of patients during hospitalization, and AF duration was 10 hours (median; IQR: 2.0-19.5). AF patients had a higher LA volume index (LAVI) than patients with sinus rhythm (p=0.018). Patients with sinus rhythm had higher rates of LA reservoir (26.97±6.87 VS. 20.46±4.27, p<0.001), LA contractile (14.98±3.68 VS. 12.76±3.72, p =0.012) and LA global strain (24.28±6.57 VS. 17.71±4.11, p<0.001) than AF patients. The results of the multivariate logistic regression showed that LAVI (p=0.014) and LA global strain (p=0.027) were independent predictors of AF detection. Compared to conventional echocardiography, 2D-strain echocardiography is a more effective diagnostic method to predict the possibility of post-CABG AF.

Conventional and Two-dimensional Strain Echocardiography in Predicting Postoperative Atrial Fibrillation after Coronary Artery Bypass Grafting Surgery in Shahid Madani Hospital of Tabriz, Iran

Objectives: Atrial fibrillation (AF) is a common complication of heart surgery with favorable short- and long-term outcomes. Preoperative left atrial (LA) dysfunction may be a significant component in identifying patients at risk for postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG (surgery. Advances in imaging technologies and an understanding of AF pathophysiology can lead to more definitive potential therapeutic approaches. The paper has the aim to present the role of conventional echocardiography and LA two-dimensional (2D) strain. 2D Strain echocardio graphies in assessing LA function in predict POAF after CABG surgery.&#x0D; Materials and Methods: In this study, all patients with sinus rhythm who underwent CABG surgery were selected. All the patients had undergone conventional echocardiography and LA 2D-strain echocardiography 24 hours before surgery. In addition to demographic, clinical, and intraoperative features, other assessments, including electrocardiogram (ECG) and Holter monitoring, were recorded. The obtained information was recorded, and the study results were reported using descriptive statistics (mean, standard deviation, and percentage frequency). A Chi-square test was used to evaluate the qualitative variables, and a t-test was used to compare the quantitative variables. Given the multi-factorial nature of AF, univariate and multivariate methods were used to analyze the data and the effect of STRAIN. In this study, P &lt; 0.05 was considered significant.&#x0D; Results: According to the findings, 85 patients (81%) were male with a mean age of 60.26 ± 10.61 years. 50% of the patients underwent off-pump CABG surgery, and 50% underwent on-pump surgery with a mean time of 98.52 ± 22.44 minutes. POAF was seen in 22.9% of patients during hospitalization, and AF's duration was 13.85 ± 14.41 hours. AF patients had higher LA volume index (LAVI) than non-AF patients (p = 0.018). There was no significant difference between the two groups in terms of left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), E/e, E/A,and deceleration time(DT) . Non-AF patients had higher rates of LA reservoir (26.97 ± 6.87 VS. 20.46 ± 4.27, p &lt;0.001), LA contractile (14.98 ± 3.68 VS. 12.76 ± 3.72, p =0.012) and LA global (24.28 ± 6.57 VS. 17.71 ± 4.11, p &lt;0.001) than AF patients. The results of the multivariate logistic regression showed that LAVI (p= 0.014) and LA global (p = 0.027) were significant predictors of AF detection. Thus with increasing LAVI, the probability of developing AF increases, and with decreasing LA global, this probability decreases.&#x0D; Conclusions: Compared to conventional echocardiography, 2D-strain echocardiography is a more effective diagnostic tool in predicting the possibility of post-CABG AF.

Abstract 12090: Catheter Ablation Impairs Left Atrial Function in Patients With Atrial Fibrillation: A Magnetic Resonance Imaging Study

Introduction: Atrial fibrillation (AF) is associated with left atrial (LA) fibrosis and morphological remodeling. Catheter ablation (CA) is a well-established method of treatment for AF which results in additional LA scarring. Cardiac magnetic resonance (CMR) imaging is the gold standard for evaluating LA volumes and function, and feature tracking in CMR has been increasingly confirmed as a feasible and reproducible technique for assessing LA function through strain. We used CMR to assess baseline fibrosis, ablation-induced scarring and the impact of CA on LA volume, shape and function in patients with AF undergoing their first catheter ablation. Methods: AF patients underwent late gadolinium enhancement CMR prior to, then at least 3 months after CA for quantification of LA volumes, fibrosis and ablation-induced scarring, respectively (Panel A). Global longitudinal reservoir strain (GLRS) was assessed by feature tracking (Panel B). Cine-images were used to assess sphericity and emptying fraction. All CMR images were obtained in sinus rhythm. Wilcoxon signed rank analysis was used to assess the effect of CA on LA volume and sphericity index, emptying fraction and GLRS. Results: 40 patients (57% male, average age 61.9 years, 72.5% paroxysmal AF) were included. Pre-ablation LA fibrosis was 16.6% [9.1, 20.7] whereas ablation-induced LA scar was 8.0% [6.5, 12.1]. GLRS and LA emptying fraction decreased after CA (17.8 [15.3, 20.5] vs 16.0 [13.5, 19.0] p=0.006, and 60.2% [51.3, 66.4] vs 51.6% [46.3, 61.1], p&lt;0.001, respectively). However, LA volume index and sphericity index were unchanged after CA in our study cohort (48.0 mL/m 2 [37.1, 61.1] vs 47.0 mL/m 2 [36.2, 52.7] p=0.91 and 54.6% [47.2, 65.4] vs 53.2% [46.5, 64.5] p=0.8, respectively) (Panel C). Conclusion: LA function is negatively impacted by catheter ablation for AF. The competing impact of ablation on rhythm control and atrial function with respect to stroke and heart failure need to be further evaluated.

Assessment of left atrial function and diastolic dysfunction in patients with Becker muscular dystrophy

Abstract Background Becker muscular dystrophy (BMD) is frequently characterized by myocardial involvement1 but little is known about the prevalence of left ventricular (LV) diastolic dysfunction (DD) in these patients, particularly when using more recently proposed measure of left atrial (LA) function. Purpose Purpose of our study was to assess LVDD in patients with BMD using the currently recommended echocardiographic multiparametric approach and adding LA reservoir strain as advanced measure of LVDD. Methods A total of 33 BMD patients (38±13 years) were analyzed including standard and advanced echocardiography at the time of their first visit and at 24 months follow-up. A control group consisted of 20 age- and gender-matched healthy subjects. Results 18% of BMD patients showed an e'lateral &amp;lt;10, 0% an E/e' &amp;gt;14, 22% a LAVI &amp;gt;34ml/m2 and 11% a tricuspid velocity &amp;gt;2.8m/s. When applying the currently recommended multiparametric approach, 83% of BMD patients showed normal DD and 17% showed indeterminate LV diastolic dysfunction (50% positive parameters); no BMD patient had &amp;gt;50% positive DD parameters for confirmed DD. LA reservoir strain was significantly lower in BMD patients as compared to controls (28±10% vs. 42±11%; p&amp;lt;0.001) (Figure), while LA indexed volume (LAVI) was not (26±19 ml/m2 vs. 21±6 ml/m2; p=0.142). When using the reported median value of LA reservoir strain (47%) for normal subjects with comparable age2, 31 (94%) BMD patients had impaired LA strain, but when using the cut-off value of &amp;lt;19% for increased LV filling pressure, 6 (18%) patients showed affected LA reservoir strain. Patients with more impaired six minute walk test (6MWT), defined as in the 1st tertile (1st tertile 0–309m; 2nd tertile 310–523m; 3rd tertile &amp;gt;523m) had significantly lower LA reservoir strain (1st tertile, 22±6% vs. 2nd tertile, 29±14% vs. 3rd tertile, 33±5%; p=0.022). LA reservoir strain tended to deteriorate at 1 year follow-up but not significantly (from 29±10% to 26±12%; p=0.200). Conclusions LVDD is not highly prevalent in BMD patients but LA dysfunction as assessed by LA reservoir strain is reduced and may improve detection of myocardial involvement in these patients, also over time. Funding Acknowledgement Type of funding sources: None.

Left atrial reservoir and pump function after catheter ablation with persistent atrial fibrillation: a two-dimensional speckle tracking imaging study

Objective By using ultrasound strain rate (SR) imaging to evaluate the left atrial (LA) reservoir and pump function after catheter ablation (CA) with persistent atrial fibrillation (PAF). Methods A total of 45 patients with PAF underwent echocardiography examination before and after ablation as well as during 6 months of follow-up. Peak SR was measured at each LA segment (septal, lateral, anterior, inferior and posterior) during systole (LAs) and late diastole (LAa). Results During 6 months after CA, 30 patients were free of atrial fibrillation recurrence (AFR). left atrial area index (LAAI), left atrial maximum volume index (LAVImax), and E/Ea were obviously higher in patients with before CA, left atrial ejection fraction (LAEF), SR-LAs were lower than in normal cases, the SR-LAa was disappeared. Shortly after ablation, SR-LAa was recovered, and SR-LAs was reduced compared to those at baseline. At midterm follow-up, LAEF and SR-LAs were still lower than the control group, and LAAI and LAVImax were higher. SR-LAa was recovered slowly over time, but still lower. Conclusion LA reservoir function was seriously damaged and LA pump function disappeared in patients with PAF. LA reservoir function impairment appeared shortly after ablation, it showed improvement at midterm follow-up, but some degree of damage to the LA reservoir and pump function was still present. Speckle tracking imaging is a feasible technique for the assessment of LA function in patients with PAF, which is a potentially valuable clinical tool to assist in the early detection of atrial remodelling and reverse remodelling.

Quantitative assessment of left atrial functions by speckle tracking echocardiography in hypertensive patients with and without retinopathy.

The association between hypertensive retinopathy and left atrial (LA) impairment is unknown. Accordingly, it was aimed to investigate the possible relationship between hypertensive retinopathy and LA phasic functions by means of two-dimensional speckle-tracking echocardiography (2D-STE). A total of 124 hypertensive patients and 27 control subjects were included in the study. LA reservoir strain (LAS-S ), LA conduit strain (LAS-E ), and LA booster strain (LAS-A ) parameters were used to evaluate LA myocardial functions. Hypertensive patients (with and without retinopathy) displayed an obvious reduction in the LA reservoir strain (LAS-S ), and LA conduit strain (LAS-E ). Moreover, further impairment in LA reservoir and conduit strain was found in patients with hypertensive retinopathy than in the isolated hypertensive patients. There were no significant differences in LA booster strain (LAS-A ) among the three groups. Impaired LAS-S (OR: 0.764, CI: 0.657-0.888, and p< 0.001), LAS-E (OR: 0.754, CI: 0.634-0.897, and p= 0.001), and hypertension (HT) duration (OR: 2.345, CI: 1.568-3.507, and p< 0.001) were shown to be independent predictors of hypertensive retinopathy. Impaired LA reservoir and conduit strain may be used to predict hypertensive patients at higher risk of developing hypertensive retinopathy, and to determine which patients should be followed more closely for hypertensive retinopathy.

Incremental Prognosis by Left Atrial Functional Assessment: The Left Atrial Coupling Index in Patients With Floppy Mitral Valves

BackgroundEmerging data suggest important prognostic value to left atrial (LA) characteristics, but the independent impact of LA function on outcome remains unsubstantiated. Thus, we aimed to define the incremental prognostic value of LA coupling index (LACI), coupling volumetric and mechanical LA characteristics and calculated as the ratio of left atrial volume index to tissue Doppler imaging a′, in a large cohort of patients with isolated floppy mitral valve.Methods and ResultsAll consecutive 4792 patients (61±16 years, 48% women) with isolated floppy mitral valve in sinus rhythm diagnosed at Mayo Clinic from 2003 to 2011, comprehensively characterized and with prospectively measured left atrial volume index and tissue Doppler imaging a′ in routine practice, were enrolled, and their long‐term survival analyzed. Overall, LACI was 5.8±3.7 and was <5 in 2422 versus ≥5 in 2370 patients. LACI was independently higher with older age, more mitral regurgitation (no 3.8±2.3, mild 5.1±3.0, moderate 6.5±3.8, and severe 7.8±4.3), and with diastolic (higher E/e′) and systolic (higher end‐systolic dimension) left ventricular dysfunction (all P≤0.0001). At diagnosis, higher LACI was associated with more severe presentation (more dyspnea, more severe functional tricuspid regurgitation, and elevated pulmonary artery pressure, all P≤0.0001) independently of age, sex, comorbidity index, ventricular function, and mitral regurgitation severity. During 7.0±3.0 years follow‐up, 1146 patients underwent mitral valve surgery (94% repair, 6% replacement), and 880 died, 780 under medical management. In spline curve analysis, LACI ≥5 was identified as the threshold for excess mortality, with much reduced 10‐year survival under medical management (60±2% versus 85±1% for LACI <5, P<0.0001), even after comprehensive adjustment (adjusted hazard ratio, 1.30 [95% CI, 1.10–1.53] for LACI ≥5; P=0.002). Association of LACI ≥5 with higher mortality persisted, stratifying by mitral regurgitation severity of LA enlargement grade (all P<0.001) and after propensity‐score matching (P=0.02). Multiple statistical methods confirmed the significant incremental predictive power of LACI over left atrial volume index (all P<0.0001).ConclusionsLA functional assessment by LACI in routine practice is achievable in a large number of patients with floppy mitral valve using conventional Doppler echocardiographic measurements. Higher LACI is associated with worse clinical presentation, but irrespective of baseline characteristics, LACI is strongly, independently, and incrementally determinant of outcome, demonstrating the crucial importance of LA functional response to mitral valve disease.

The Added Value of Atrial Strain Assessment in Clinical Practice.

Speckle tracking echocardiography has emerged as a sensitive tool to analyze myocardial function with improved diagnostic accuracy and prognostic value. Left atrial strain assessment has become a novel imaging method in cardiology with superior prognostic value compared to conventional left atrial volume indices. Left atrial function is divided into three phases, reservoir function being the most important. This review summarizes the added value of speckle tracking echocardiography derived left atrial strain assessment in clinical practice. Recently published data suggest the prognostic value of left atrial reservoir function in heart failure, atrial fibrillation, stroke and valvular heart disease. Furthermore, left atrial reservoir strain proved to be a predictor of cardiovascular morbidity and mortality in the general population. Thus, routine assessment of left atrial function can be an optimal strategy to improve cardiovascular risk prediction and supplement the current risk prediction models.

Echocardiographic Assessment of Atrial Function: From Basic Mechanics to Specific Cardiac Diseases.

The left and right atria serve as buffer chambers to control the flow of venous blood for ventricular filling. If an atrium is absent, blood does not flow effectively into the ventricle, leading to venous blood retention and low cardiac output. The importance of atrial function has become increasingly recognized, because left atrial (LA) function contributes to cardiac performance, and loss of LA function is associated with heart failure. LA volume change has been used for LA function assessment in experimental and clinical studies. In conjunction with LA pressure, the LA pressure–volume relationship provides a better understanding of LA mechanics. LA strain measurement by speckle tracking echocardiography was introduced to evaluate three components of LA function as a (booster) pump, reservoir and conduit. Furthermore, increasing evidence supports the theory that LA reservoir strain has prognostic utility in various cardiac diseases. In this review, we summarize LA contribution to maintain cardiac performance by evaluating LA function with echocardiography according to our experiences and previous reports. Furthermore, we discuss LA dysfunction in challenging cardiac diseases of cardiac amyloidosis and adult congenital heart disease.

Myocardial work and left atrial function, by speckle tracking echocardiography, are the only independent predictors of mid-term mortality in HFpEF

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by 2 National grants of Romanian Ministry of Research and Innovation - UEFISCDI (PN-III-P1-1-TE-2016-0669, acronym Heart-Preserved and PN-III-P1-1.2-PCCDI2017-0527, acronym BIOVEA). OnBehalf HEART-PRESERVED Background. Heart failure with preserved ejection fraction (HFpEF), defined by the 2021 ESC guidelines and the new universal definition, is one of the most challenging diagnosis in cardiology. Parameters for predicting mortality in HFpEF are still debatable. Left atrial (LA) function and myocardial work (MW) by speckle-tracking echocardiography (STE) might be promising tools for predicting mortality in HFpEF. Methods. We assessed 88 patients (67 ± 9 years, 33 men) with HFpEF (mean NTproBNP of 357 ± 350 pg/ml) by 2D echo, STE, and CMR. By echo we measured LV ejection fraction (LVEF), E/E’, sPAP, left atrial volume indexed (LAVi), and global longitudinal strain (GLS). We assessed LA function by 2DSTE: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), and LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct) (Figure 1); and MW by 2DSTE: global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), as GCW/(GCW + GWW) in %. By CMR we evaluated LVEFcmr, LV mass, T1 mapping with mean extracellular volume (ECVm), and pre-gadolinium times quantification (preGDT1m) as markers of myocardial fibrosis. A follow-up visit for cardiovascular mortality was performed by phone at 18 months from the baseline visit. Results. 12 patients died during follow-up (14%). Comparing non-survivors vs. survivors (see tables from Figure 2), NTproBNP level and LV mass were significantly higher in non-survivors (P &amp;lt; 0.001); meanwhile, GWE was lower, whereas GWW was higher in non-survivors vs. survivors. Moreover, LASRct was lower in non-survivors vs. survivors. All the other echo or CMR parameters, including markers of myocardial fibrosis were not different between non-survivors and survivors (Figure 2). By multiple regression analysis, GWE &amp;lt; 92% (AUC = 0.72, p = 0.018) and LASRct &amp;lt;-1 (AUC = 0.70, p = 0.014) were the only independent predictors of mortality, from all conventional echo, STE, and CMR parameters. Conclusions LV assessment by myocardial work and LA assessment by STE are the only independent predictors of mid-term mortality in HFpEF. Abstract Figure. LA deformation analysis Abstract Figure. Survivors vs non-survivors

Incremental prognosis by left atrial functional assessment: The left atrial coupling index in patients with floppy mitral valves

To define the incremental prognostic value of the left atrial coupling-index (LACI), calculated as ratio of left atrial volume-index (LAVI) to Tissue-Doppler-Imaging a’ (TDI-a’), in a large cohort of patients with isolated floppy mitral valve (FMV). All consecutive 4792 patients (61 ± 16 years, 48% women) with isolated FMV in sinus rhythm diagnosed at Mayo Clinic 2003-2011, comprehensively characterized and with prospectively measured LAVI and TDI-a’ in routine practice, were enrolled and their long-term survival analyzed. Overall LACI was 5.8 ± 3.7 and was < 5 in 2422 vs. ≥ 5 in 2370. LACI was independently higher with older age, more mitral regurgitation and with diastolic and systolic left-ventricular (LV) dysfunction (all P ≤ 0.0001). At diagnosis higher LACI was associated with more severe presentation ( P ≤ 0.0001) independently of age, sex, comorbidity-index, ventricular function and MR-severity. During 7.0 ± 3.0 years follow-up, 1146 underwent mitral-valve surgery (94% repair-6% replacement) and 880 died, 780 under medical management. In spline-curve analysis LACI ≥ 5 was identified as threshold for excess-mortality, with much reduced 10-year survival under medical management (60 ± 2% vs. 85 ± 1% for LACI < 5, P < 0.0001), even after comprehensive adjustment (adjusted-hazard-ratio 1.30[1.10–1.53] for LAC I≥ 5, P = 0.002). Association of LACI ≥ 5 with higher mortality persisted, stratifying by mitral-regurgitation severity of LA enlargement grade (all P < 0.001). Nested-models confirmed LACI incremental prognosis ( P < 0.0001) with net-reclassification-improvement vs. LAVI 0.21 ± 0.02, P < 0.0001 ( Fig. 1 ). LA functional assessment by LACI is strongly, independently and incrementally determinant of outcome, demonstrating the crucial importance of LA functional response to the mitral valve disease, achievable using conventional Doppler-echocardiographic measurements

Comment on "Assessment of left atrial function by strain in patients with acute ischemic stroke left atrial function and acute stroke".

Comment on "Assessment of left atrial function by strain in patients with acute ischemic stroke left atrial function and acute stroke".