Atrial Ejection Fraction Research Articles

CHA2DS2VASC score for predicting atrial fibrillation in patients with cryptogenic stroke

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Society of Cardiology Introduction CHA2DS2-VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). However the role of CHA2DS2-VASC score for predicting AF in patients with cryptogenic stroke (CS) remains unknown. Methods Sixty-three consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale≥4 of unknown etiology, were prospectively recruited. They were classified according to CHA2DS2-VASc Score: group 1 (score ≤ 5), and group 2 (score >5). The primary outcome measure was the occurrence of AF during clinical follow-up. Results Twenty-six (41%) patients had a CHA2DS2VASC score > 5 (group 2). Patients in this group were older (81 ± 5.5 vs 75 ± 8 years; p < 0.001) and more frequently female (73% vs 43% p = 0.019). Patients in group 2 present more often hypertension (84% vs 43% p = 0.001), diabetes (38% vs 11%, p = 0.009) , dyslipidemia 77% vs 49%, p = 0.024), and a prior history of coronary artery disease (27% vs 5%, p = 0.026). Notably, patients with higher CHA2DS2VASC showed worse left atrial ejection fraction (41.7 ± 13.1 vs 52.2 ± 15%, p = 0.009) and worse left atrial strain reservoir (21.5 ± 7.1 vs 33.8 ± 11%, p < 0.001), conduct (9.5 ± 4.8 vs 16.6 ± 8.4%;p < 0.001) and contraction (12 ± 4.6 vs 17.2 ± 7.3, p = 0.002). During follow-up AF was detected more often in group 2 (42% vs 11% p = 0.006). In multivariate analysis CHA2SD2VAS > 5 was an independent predictor of AF in patients with CS (HR 7.3 [95% CI 1.2-45.6] p = 0.032) Conclusion A CHA2DS2VASC score >5 is an independent predictor of AF in patients with CS. This score provides a new clinical tool to inform clinicians with regards to the optimal treatment of these challenging patients

Left atrial functional reverse remodeling assessed by speckle tracking echocardiography in a real-life population of patients with chronic heart failure after therapy with sacubitril/valsartan

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial (LA) enlargement has been demonstrated to be a predictor of adverse cardiovascular outcomes, such as atrial fibrillation (AF), heart failure (HF), and cardiovascular death (1). Previous studies showed left atrial structural reverse remodeling (LARR), defined as >15% reduction in LA end-systolic volume index (LAESVi) (2), can be achieved after therapy with Sacubitril/Valsartan (S/V) in real-world settings. On the other hand, LA functional reverse remodeling is not well defined. Purpose We sought to investigate the association between left atrial (LA) structural and functional remodelling in patients with chronic heart failure after therapy with S/V. Methods Patients with chronic HF, LV dysfunction (EF < 35%), NYHA class II-III were followed up between September 2019 and March 2020. All patients underwent clinical and echocardiography follow up at baseline and after 6 months of therapy with S/V. Measures of LA structure [LA end-systolic volume index (LAESVi)] and function [left atrial ejection fraction (LAEF), peak atrial longitudinal strain (PALS), LA conduit strain, and peak atrial contraction strain (PACS)] were calculated. We divided our population into two subgroups based on whether reverse remodeling was achieved (LARR+) or not (LARR-). Results Forty-seven consecutive outpatients (mean age 66 ± 8 years; 85% males) were enrolled in the study. At follow-up visit, a positive LARR was found in nearly half of patients treated with S/V, resulting in line with previous studies (3). Furthermore, global PALS was significantly improved in both groups compared to baseline (15 ± 7 vs 19 ± 8 %, p < 0.001), but the LARR+ group showed an improvement that was twice higher (55 ± 66 vs 25 ± 26, p = 0.039), supporting the potential role of PALS as marker of functional LARR. Conclusions Treatment with S/V in patients with systolic dysfunction is associated with an improvement in LA structural and functional remodelling in a real-world scenario. Therefore, PALS could be the benchmark for the assessment of left atrial functional reverse remodeling.

Reproducibility of 4D cardiac computed tomography feature tracking myocardial strain and comparison against speckle-tracking echocardiography in patients with severe aortic stenosis

BackgroundMyocardial strain is an established parameter for the assessment of cardiac function and routinely derived from speckle tracking echocardiography (STE). Novel post-processing tools allow deformation imaging also by 4D cardiac computed tomography angiography (CCT). This retrospective study aims to analyze the reproducibility of CCT strain and compare it to that of STE. MethodsLeft (LV) and right ventricular (RV), and left atrial (LA) ejection fraction (EF), dimensions, global longitudinal (GLS), circumferential (GCS) and radial strain (GRS) were determined by STE and CCT feature tracking in consecutive patients with severe aortic stenosis evaluated for transcatheter aortic valve implantation. Results106 patients (mean age 79.9 ​± ​7.8, 44.3% females) underwent CCT at a median of 3 days (IQR 0–28 days) after STE. In CCT, strain measures showed good to excellent reproducibility (intra- and inter-reader intraclass correlation coefficient ≥0.75) consistently in the LV, RV and LA. In STE, only LV GLS and LA GLS yielded good reproducibility, whereas LV GCS and LV GRS showed moderate, and RV GLS and free wall longitudinal strain (FWLS) poor reproducibility. Agreement between CCT and STE was strong for LV GLS only, while other strain features displayed moderate (LV GCS, LA GLS) or weak (LV GRS, RV GLS and FWLS) inter-modality correlation. ConclusionLV, RV and LA CCT strain assessments were highly reproducible. While a strong agreement to STE was found for LV GLS, inter-modality correlation was moderate or weak for LV GCS, LV GRS, and RV and LA longitudinal strain, possibly related to poor reproducibility of STE measurements.

Plasma levels of miRNA-1-3p are associated with subclinical atrial fibrillation in patients with cryptogenic stroke

Introduction and objectivesIdentifying biomarkers of subclinical atrial fibrillation (AF) is of most interest in patients with cryptogenic stroke (CrS). We sought to evaluate the circulating microRNA (miRNA) profile of patients with CrS and AF compared with those in persistent sinus rhythm. MethodsAmong 64 consecutive patients with CrS under continuous monitoring by a predischarge insertable monitor, 18 patients (9 with AF and 9 in persistent sinus rhythm) were selected for high-throughput determination of 754 miRNAs. Nine patients with concomitant stroke and AF were also screened to improve the yield of miRNA selection. Differentially expressed miRNAs were replicated in an independent cohort (n=46). Biological markers were stratified by the median and included in logistic regression analyses to evaluate their association with AF at 6 and 12 months. ResultsEight miRNAs were differentially expressed between patients with and without AF. In the replication cohort, miR-1-3p, a gene regulator involved in cardiac arrhythmogenesis, was the only miRNA to remain significantly higher in patients with CrS and AF vs those in sinus rhythm and showed a modest association with AF burden. High (= above the median) miR-1-3p plasma values, together with a low left atrial ejection fraction, were independently associated with the presence of AF at 6 and 12 months. ConclusionsIn this cohort, plasma levels of miR-1-3p were elevated in CrS patients with subsequent AF. Our results preliminarily suggest that miR-1-3p could be a novel biomarker that, together with clinical parameters, could help identify patients with CrS and a high risk of occult AF.

Normal ranges of left atrial volumes and ejection fraction by 3D echocardiography in adults: a systematic review and meta-analysis.

Increased sizes and dysfunction of the left atrium have been related to adverse outcomes. 3D-echocardiography is more accurate than 2D-echocardiography in estimating LA volumes and ejection fraction. However, the use of 3DE for LA analysis is limited by the absence of established reference values. We performed a systematic review and meta-analysis to provide reference ranges of LA maximum and minimum volumes indexed for body surface area (LAVi max and LAVi min, respectively), and LA-EF assessed by 3DE in healthy adults. Data search was conducted from inception through September 15, 2021, using the following Medical Subject Heading terms: left atrial/atrium, three-dimensional/3D echocardiography. The study protocol was registered in the PROSPERO database (CRD42021252428). 15 studies including 4,226 healthy adults (51% males) and reporting 3DE values of LAVi max, LAVi min and LA-EF were selected. LAVi max, LAVi min and LA-EF mean and reference values were equal to 25.18ml/m2 (95% CI 23.10, 27.26), 11.10ml/m2 (10.01, 12.18) and 55.94% (51.92, 59.96), respectively. No influential studies were identified. Pooled estimates per age group- and sex were also estimated. By meta-regression analyses, we identified variability in LA volumes and LA-EF depending on participants' age, ethnicity and number of heart cycles at 3D multi-beat acquisition. At individual patient data analysis conducted on 374 subjects, a software effect on LA-EF was shown. This systematic review and meta-analysis provides reference values of LAVi max, LAVi min and LA-EF assessed by 3DE in healthy adults, encouraging 3DE evaluation of the LA evaluation in daily practice.

Evaluation of left atrial remodeling using cardiovascular magnetic resonance imaging in breast cancer patients treated with adjuvant trastuzumab.

We evaluated left atrial (LA) remodeling using cardiac MRI (CMR) in patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer during and after trastuzumab therapy. In this prospective 2-center longitudinal study, 41 women with HER2-positive breast cancer received adjuvant trastuzumab for 12months, in addition to standard chemotherapy. Serial CMRs were performed at baseline, 6, 12, and 18months after initiation of trastuzumab. LA volumes were measured by a blinded reader. Linear mixed model was used to evaluate longitudinal changes. Of 41 women (mean age 52 ± 11 [SD] years; 56% received anthracycline), one patient experienced trastuzumab-induced cardiotoxicity (TIC) for which trastuzumab was interrupted for one cycle. Mean baseline left ventricular ejection fraction (LVEF) was 68.0 ± 5.9% and LA ejection fraction (LAEF) was 66.0 ± 6.6%. Compared to baseline, LAEF decreased significantly at 6months (62.7 ± 5.7%, p = 0.027) and 12months (62.2 ± 6.1%, p = 0.003), while indexed LA minimum volume (LAmin) significantly increased at 12months (11.6 ± 4.9ml/m2 vs 13.8 ± 4.5ml/m2, p = 0.002). At 18months, all changes from baseline were no longer significant. From baseline to 6months, change in LAEF correlated with change in LVEF (Spearman's r = 0.41, p = 0.014). No significant interactions (all p > 0.10) were detected between time and anthracycline use for LA parameters. Among trastuzumab-treated patients with low incidence of TIC, we observed a small but significant decline in LAEF and increase in LAmin that persisted for the duration of therapy and recovered 6months after therapy cessation. These findings suggest that trastuzumab has concurrent detrimental effects on atrial and ventricular remodeling. • In trastuzumab-treated breast cancer patients evaluated by cardiac MRI, left atrial ejection fraction declined and minimum volume increased during treatment and recovered to baseline after trastuzumab cessation. • Changes in left atrial ejection fraction correlated with changes in left ventricular ejection fraction in the first 6months of trastuzumab treatment. • Trastuzumab therapy is associated with concurrent detrimental effects on left atrial and ventricular remodeling.

MIP-1α Level and Its Correlation with the Risk of Left Atrial Remodeling in Patients with Atrial Fibrillation.

The aim of this study is to investigate the expression level of macrophage inflammatory protein-1α (MIP-1α) in atrial fibrillation patients and its correlation with the risk of left atrial remodeling. A total of 64 atrial fibrillation patients admitted to our hospital from April 2020 to December 2021 were prospectively selected as the case group and 61 healthy subjects who received physical examination during the same period were selected as the control group. Serum MIP-1α level was determined by a double-antibody sandwich enzyme-linked immunosorbent assay. Serum MIP-1α expression levels were compared between the case and the control groups. The case group was divided into high-level and low-level groups according to the serum MIP-1α median. Simultaneously, the sociodemographic data, clinical data, and left atrial remodeling indexes of the patients were collected in the case group. The Pearson correlation analysis was applied to analyze the correlation between the serum MIP-1α level and the risk of left atrial remodeling in patients with atrial fibrillation. The serum MIP-1α level was significantly higher in the case group than that in the control group (P < 0.05), high-level group (≥2.14 pg/mL, 32 cases), and low-level group (<2.14 pg/mL, 32 cases). There were significant differences in the anteroposterior diameter, upper and lower diameter, left and right diameter of the left atrium, left atrial volume, volume index, left atrial global ejection fraction, and sphericity between the low-level and high-level groups (P < 0.05). The Pearson correlation analysis showed that serum MIP-1α level was positively correlated with the left atrial anteroposterior diameter (r = 0.745), left atrial left and right diameter (r = 0.759), left atrial upper and lower diameter (r = 0.810), left atrial volume (r = 0.837), left atrial volume index (r = 0.813), and left atrial sphericity (r = 0.785) but negatively correlated with the left atrial global ejection fraction (r = -0.731) (P < 0.05). The expression level of serum MIP-1α is high in atrial fibrillation patients and is associated with the risk of left atrial remodeling.

Correlation between Left Atrial Thrombosis and Neutrophil-to-Lymphocyte Ratio upon Non-Valvular Atrial Fibrillation.

To explore the correlation between left atrial thrombosis and peripheral blood neutrophil-to-lymphocyte ratio (NLR) in patients with non-valvular atrial fibrillation (NVAF). A total of 207 NVAF patients treated from March 2016 to August 2020 were divided into low and high NLR groups. Their clinical data were compared, and the correlations of NLR with clinical indicators and left atrial thrombosis were analyzed. The influencing factors for left atrial thrombosis and their predictive values were investigated. CHADS2 score, CHA2DS2-VASc score, NLR, D-dimer (D-D), serum uric acid (SUA), brain natriuretic peptide (BNP), C-reactive protein (CRP), left atrial dimension (LAD) and ratio of early mitral diastolic flow peak value to early diastolic mitral annular velocity (E/Em) increased, while left atrial ejection fraction (LAEF) decreased in high NLR group compared with those in low NLR group (p < 0.05). NLR was significantly positively correlated with the CHADS2 score, CHA2DS2-VASc score, D-D, SUA, BNP, CRP, LAD and E/Em, and significantly negatively correlated with LAEF (p < 0.0001). Left atrial thrombosis had positive correlations with CHADS2 score, CHA2DS2-VASc score, NLR, D-D, SUA, BNP, CRP, LAD and E/Em, and negative correlation with LAEF (p = 0.000). CHA2DS2-VASc score, NLR, D-D and LAD were risk factors for left atrial thrombosis (p < 0.05). The optimal cut-off value was 1.85 when the area under the curve of NLR for predicting left atrial thrombosis in the case of NVAF was 0.806 [95% confidence interval (CI): 0.746 - 0.865], the sensitivity was 74.82% (95% CI: 0.668 -0.818) and the specificity was 67.65% (95% CI: 0.552 - 0.785). The increase of NLR prominently elevates the risk of left atrial thrombosis in NVAF patients, and NLR was an independent risk factor, with certain predictive value.

Predictors of Procedural Success and Durable Outcomes in Percutaneous Mitral Balloon Valvuloplasty: Not Just the Wilkins Score

Global migration means rheumatic heart disease (RHD) and mitral stenosis (MS) remain important issues in Western health systems. Percutaneous mitral balloon valvuloplasty (PMBV) is a durable treatment strategy relying on suitable leaflet characteristics adjudged by a Wilkins score. Commissural calcification alone has been thought as reliable as Wilkins score. Timing PMBV is also important. Falling left atrial ejection fraction (LAEF) has been theorised to predict future MS intervention. This study compared Wilkins score and commissural calcification as predictors of procedural success and durability; and, observed if LAEF improved post-valvuloplasty.

Abstract 13557: Impact of Cardiac Resynchronization Therapy on Clinical Outcomes in Transthyretin Amyloid Cardiomyopathy

Introduction: Due to conduction disease and dyssynchrony in transthyretin amyloid cardiomyopathy (ATTR-CM), cardiac resynchronization therapy (CRT) may be beneficial. We aimed to determine the impact of CRT on clinical outcomes in ATTR-CM. Methods: We studied 116 consecutive ATTR-CM patients, 23 of whom underwent CRT (70% CRT + defibrillator, median 10 months (IQR 4-20) from ATTR-CM diagnosis). Outcome was a composite of 1 st cardiovascular hospitalization or all-cause mortality. CRT was treated as a time dependent co-variate and entered into multivariate Cox proportional hazards model. Results: Both groups were similar at diagnosis except for a higher proportion with atrial fibrillation (AF) and lower ejection fraction among those who underwent CRT ( Table 1) . CRT indication in 80% was progressive LV dysfunction with wide QRS [mean 152 ± 36 msec] and the remaining at time of AV node ablation for AF. Half of CRT group were ≥ NYHA class III at device implantation. Older age, higher National Amyloidosis Cohort (NAC) ATTR stage, and not taking tafamidis were significantly associated with the outcome. On multivariate analysis, CRT was associated with a HR of 0.6 (95% CI: 0.32 - 1.16) for all-cause mortality or cardiovascular hospitalization after adjusting for age at diagnosis, NAC ATTR stage, and tafamidis use ( Figure 1). Conclusion: CRT implantation maybe associated with improved outcomes in ATTR-CM. Larger prospective randomized, sham-controlled trials are warranted to confirm these findings.

Abstract 12337: Gender Specific Phenomapping and Outcomes in Ischemic Cardiomyopathy

Background: There is limited data on gender specific remodeling and its associated risk in patients with ischemic cardiomyopathy (ICM). We conducted gender based phenomapping analysis using Cardiac MRI (CMR) variables to identify novel sex-specific phenotypes in patients with ICM. We then assessed if these phenotypes were predictive of overall survival. Methods: Patients with ICM who underwent CMR between January 2002 and January 2017, were retrospectively evaluated . Cluster analysis was performed using nearest centroid sorting with nine variables: left ventricular end systolic volume index (LVESVi), mitral regurgitation severity on CMR (MR) , left atrial volume index (LAVi), right ventricular ejection fraction (RVEF), RV end diastolic volume index (RVEDVi) , LVEF, LV mass index (LVmassi), left atrial ejection fraction (LAEF), and myocardial scar burden (Scar). For each cluster size a Cox proportional hazards model was used to test if the phenotypes were predictive of survival. Results: Data was analyzed from 407 males and 119 females. The optimal number of clusters was four, based on the ability of the phenotypes to predict overall survival. Phenotype was a statistically significant predictor of overall survival in men (p=0.002) and women (p=0.016) after adjusting for age, body mass index, renal function, hypertension, diabetes, revascularization and mitral valve intervention. (Figure 1a) These distinct phenotypes predicted survival differently in men compared to women. Of interest, there were significant differences in the contribution of each CMR variable to predict the phenotype based on sex. (Figure 1b) In females, CMR MR and RVEF were stronger contributors to the phenotype. Conclusion: Significant differences in phenotypic signatures based on gender are present in patients with ICM. These distinct phenotypes predicted survival differently in men compared to women and emphasizes the importance of sex specific risk stratification in the ICM cohort.

Abstract 14081: Predictors of Left Atrial Ejection Fraction in Patients With Nonischemic Cardiomyopathy

Background: The impact of cardiomyopathy on left atrial function is currently unclear. The aim of this study was to assess the predictors of left atrial function in patients with non-ischemic dilated cardiomyopathy (NICM) utilizing cardiovascular magnetic resonance (CMR) assessment. Methods: We evaluated 251 NICM patients who underwent CMR in our study, between 12/2008 - 1/2014. LA volumes were measured by the modified biplane method from 2- and 4-chamber long axis views at end-systole and end-diastole. Left atrial ejection fraction (LAEF) was calculated. Multivariable linear regression was performed to determine significant covariate associations with LA EF. Results: We studied 251consecutive patients (61 % male), mean age of 52.5 ± 15.5 years . The results of the multivariable linear regression are provided in Figure 1. Younger age, female sex, and less myocardial fibrosis were significantly associated with higher LAEF (p=0.008, p= 0.004, and p= 0.031, respectively). Additionally, increasing left ventricular end diastolic volume index (LVEDVi) and left ventricular ejection fraction (LVEF) was significantly associated with increasing LAEF (both with a significance of p&lt;0.0001). Increased LA volume index (LAVi) was significantly associated with decreased LAEF (p&lt;0.0001). Of note, there was a trend towards less mitral regurgitation fraction being significantly associated with higher LA EF, but did not demonstrate a significant effect on the LAEF (p=0.083). Similarly, right ventricular size and function were not significantly associated with LA EF. Conclusions: In patients with NICM, age, sex, LVEDVi, LVEF, myocardial fibrosis, and LAVi were independently associated with LAEF. Keywords: Nonischemic cardiomyopathy, left atrial ejection fraction, left atrial function, cardiovascular magnetic resonance

Anatomical variants of the cavotricuspid isthmus in patients undergoing catheter ablation for atrial flutter and/or atrial fibrillation

Abstract Background We evaluated the differences in the anatomy of the cavotricuspid isthmus (CTI) by assessing image loops provided by intracardiac echocardiography (ICE) in patients who underwent ablation for atrial flutter and/or atrial fibrillation. Purpose CTI is an essential component of the reentrant circle in isthmus–dependent atrial flutter (CTI-AFL) and a target for catheter ablation. In some patients, CTI anatomy may be responsible for a difficult procedure. The aim of this study is to describe in details the anatomical variants of this structure. Methods We included a group of 138 patients, who underwent cardiac ablation for atrial flutter and/or atrial fibrillation between August 2020 and January 2021. Intracardiac echocardiography was employed during the intervention to evaluate the morphology of CTI. Analysis was focused on size, shape, presence of sub-eustachian pouch (excavation more than 5 mm) or presence of prominent Eustachian ridge (ER, embryologic remnant of the valve of the IVC) and mobility of the structure. Results The length of CTI measured during ventricular systole averaged at 38,4mm (min 22,5mm, max 60mm). The most frequent pattern was a flat CTI without sub-eustachian excavation or with excavation less than 5mm (71 patients; 51.4%). A pouch (excavation more than 5mm) was observed in 41 pts (29.7%), where the deepest pouch reached 10,5mm. Prominent ER was present in 58 pts (42%). The remaining 26 of CTIs (18.8%) were classified in the “unclassifiable” category with deviations from common anatomic variants - substantial convexity, pronounced trabeculation of isthmus or double pouch. We observed 14 CTIs (10.1%), where the structure was partially or in full extent detached from the diaphragm, sliding during cardiac contractions. In addition to the described morphology, Chiari's network was observed in 18 pts (13%). In reference to mobility, 53 pts (38.4%) presented with hypermobile CTI with a difference in size of more than 1/3 between the diastole and systole. Moreover, we looked into differences of CTI related to BMI, left atrial volume index (LAVi) and ejection fraction of the left ventricle. A positive correlation was found between LVEF and mobility of CTI. Hypermobile CTI was present in 42.2% of pts with normal LVEF compared to only 18.9% of pts with reduced EF (EF less than 50%). Similar results were observed in pts with non-dilated LA, where hypermobile CTI was present in 51.9% of pts compared to only 35.1% of pts with dilated LA with LAVi &amp;gt;28 ml/m2 (see table below). Conclusions We observed a substantial differences in the anatomy of the CTI, which could play an important role in catheter ablation of this structure. Besides the prominent ER, significant sub-eustachian pouch and hypermobility appear to be variants predisposing to difficult ablation. Funding Acknowledgement Type of funding sources: None. CTI variants related to EFLV, BMI, LAViCTI detached from the diaphragm

A novel cardiovascular magnetic resonance risk score for predicting mortality following surgical aortic valve replacement

The increasing prevalence of patients with aortic stenosis worldwide highlights a clinical need for improved and accurate prediction of clinical outcomes following surgery. We investigated patient demographic and cardiovascular magnetic resonance (CMR) characteristics to formulate a dedicated risk score estimating long-term survival following surgery. We recruited consecutive patients undergoing CMR with gadolinium administration prior to surgical aortic valve replacement from 2003 to 2016 in two UK centres. The outcome was overall mortality. A total of 250 patients were included (68 ± 12 years, male 185 (60%), with pre-operative mean aortic valve area 0.93 ± 0.32cm2, LVEF 62 ± 17%) and followed for 6.0 ± 3.3 years. Sixty-one deaths occurred, with 10-year mortality of 23.6%. Multivariable analysis showed that increasing age (HR 1.04, P = 0.005), use of antiplatelet therapy (HR 0.54, P = 0.027), presence of infarction or midwall late gadolinium enhancement (HR 1.52 and HR 2.14 respectively, combined P = 0.12), higher indexed left ventricular stroke volume (HR 0.98, P = 0.043) and higher left atrial ejection fraction (HR 0.98, P = 0.083) associated with mortality and developed a risk score with good discrimination. This is the first dedicated risk prediction score for patients with aortic stenosis undergoing surgical aortic valve replacement providing an individualised estimate for overall mortality. This model can help clinicians individualising medical and surgical care.Trial Registration ClinicalTrials.gov Identifier: NCT00930735 and ClinicalTrials.gov Identifier: NCT01755936.

Relation of left atrial function with exercise capacity and muscle endurance in patients with heart failure

Abstract Aims Left atrial strain (LAS) and skeletal muscle endurance demonstrate a linear relationship to peak VO2. Less is known about the relationship between central (cardiac) and peripheral (muscle endurance) limitations of exercise capacity in patients with heart failure (HF). We investigated this relationship using novel cardiac markers such as LAS and left atrial ejection fraction (LAEF). Methods We analysed echocardiographic measurements, cardiopulmonary exercise testing, and isokinetic muscle function in 55 subjects with HF and controls (17 heart failure with preserved ejection fraction -HFpEF, 18 heart failure with reduced ejection fraction-HFrEF and 20 healthy controls). Results Patients with reduced LAEF showed reduced peak VO2: 14.3±3.5 vs. 18.5±3.5 ml/min/kg, p=0.003 and reduced muscle endurance (RME): 64.3±23.9 vs. 88.5±32.3 Nm/kg, p=0.028. Patients with reduced LAS showed similar results. Neither left ventricular global longitudinal strain (LVGLS) nor left atrial volume index (LAVI) were associated with RME. The area under the curve of LAS and LAEF in patients with HF in association with RME were (0.76 vs. 0.80) with 95% confidence interval (CI) (0.59–0.96, p=0.012 vs. 0.63–0.98, p=0.006, respectively). Peak torque of the left leg was associated with E/LAS (E: early diastolic) in patients with HFpEF (r=−0.6, p=0.020). Endurance of the left leg was associated with LAEF (r=0.79, p=0.001) in patients with HFrEF. Conclusion LAS/LAEF are potential cardiac markers in demonstrating the link between cardiac and peripheral limitations of exercise capacity. Thus, integrating LAS/LAEF in the evaluation of exercise intolerance in patients with HF could be useful. Funding Acknowledgement Type of funding sources: None.

Trans-esophageal Echocardiographic Assessment of Left Atrial and Left Atrial Appendage Function in Atrial Fibrillation and Rheumatic Heart Disease.

Introduction: Rheumatic heart disease (RHD) is one of the most typical causes of atrial fibrillation in developing countries like India. The left atrial and left atrial appendage structure and function are deranged in atrial fibrillation and are a major source of thromboembolism. The goal of this study was to assess the left atrial and left atrial appendage function by transesophageal echocardiography in patients with atrial fibrillation and their comparison in patients with or without RHD.Methods: A total of 172 consecutive patients with atrial fibrillation with or without RHD were subjected to trans-esophageal echocardiography to assess and compare left atrial (LA) and left atrial appendage (LAA) function.Results: Out of 172 patients with atrial fibrillation, 100 were female (58.1%) and 72 were male (48.9%). The mean age was 54.11±12.3 years, and rheumatic heart disease (RHD) was the commonest cause of atrial fibrillation found in 121 (70.3%) patients. The mean left atrium diameter was significantly higher in RHD patients than in Non-RHD patients (52.08±10.13 vs. 46.67±6.78 mm, p=0.001). Mean left atrial ejection fraction was significantly lower in RHD patients as compared to Non-RHD patients (33.53±5.06 vs. 35.49±5.40%, p=0.024). The mean LAA orifice area of RHD patients was significantly higher than the Non-RHD patients (7.52±1.22 vs 6.94±1.17 mm2, p=0.005). Mean LAA emptying velocity was significantly lower in RHD patients than Non-RHD (20.49±3.95 vs. 22.8±5.96 ml/s, p=0.002).Conclusion: Rheumatic heart disease is still a common cause of atrial fibrillation in developing countries. LA and LAA function is impaired in atrial fibrillation, more in patients with rheumatic heart disease.

Impact of left atrial geometric remodeling on late atrial fibrillation recurrence after catheter ablation.

To quantitatively investigate the impact of left atrial geometric remodeling on atrial fibrillation recurrence after catheter ablation. A retrospective analysis of 105 patients with atrial fibrillation who underwent coronary computed tomographic angiography before catheter ablation. Risk factors for atrial fibrillation recurrence were identified by multivariable logistic regression analysis and used to create a nomogram. After at least 12 months of follow-up, 30 patients (29%) developed recurrent atrial fibrillation. Patients with recurrence had higher left atrial volume, left atrial sphericity, and lower left atrial ejection fraction (LAEF) (P < 0.05). There was no significant difference in asymmetry index between the two groups (P = 0.121). Multivariable regression analysis showed that left atrial minimal volume index (LAVImin) [odds ratio (OR): 1.026, 95% confidence interval (CI): 1.002-1.050, P = 0.034], left atrial sphericity (OR: 1.222, 95% CI: 1.040-1.435, P = 0.015) and CHADS2 score (OR: 1.511, 95% CI: 1.024-2.229, P = 0.038) were independent predictors of atrial fibrillation recurrence. The combined model of the left atrial sphericity to the LAVImin substantially increased the predictive power for atrial fibrillation recurrence [area under the curve (AUC) = 0.736, 95% CI: 0.627-0.844, P < 0.001], with a sensitivity of 80% and a specificity of 61%. A nomogram was generated based on the contribution weights of the risk factors; the AUC was 0.772 (95% CI: 0.670-0.875) and had good internal validity. The CHADS2 score, left atrial sphericity, and LAVImin were significant and independent predictors of atrial fibrillation recurrence after catheter ablation. Furthermore, the nomogram had a better predictive capacity for atrial fibrillation recurrence.

Abstract P458: Myosin Light Chain Dephosphorylation By Ppp1r12c Promotes Atrial Hypocontractility In Atrial Fibrillation

Introduction: Atrial fibrillation (AF), is the most common sustained arrhythmia, with an estimated prevalence in the U.S. of 2.7 million to 6.1 million and is predictive to increase to 12.1 million in 2030. AF increases the chances of a thromboembolic stroke in five-fold. Although atrial hypocontractility contributes to stroke risk in AF, the molecular mechanisms reducing myofilament contractile function in AF remains unknown. Objective: The overexpression of PPP1R12C, causes hypophosphorylation of atrial myosin light chain 2 (MLC2a), decreasing atrial contractility. Methods and Results: Left and right atrial appendage tissues were isolated from AF patients versus sinus rhythm (SR). To evaluated the role of PP1c-PPP1R12C interaction in MLC2a de-phosphorylation we used Western blots, coimmunoprecipitation, and phosphorylation assays. In patients with AF, PPP1R12C expression was increased 3.5-fold versus SR controls with an 88% reduction in MLC2a phosphorylation. PPP1R12C-PP1c binding and PPP1R12C-MLC2a binding were significantly increased in AF. In vitro studies of either pharmacologic (BDP5290) or genetic (T560A) PPP1R12C activation demonstrated increased PPP1R12C binding with both PP1c and MLC2a, and dephosphorylation of MLC2a. Additionally, to evaluate the role of PPP1R12C expression in cardiac function, mice with lentiviral cardiac-specific overexpression of PPP1R12C (Lenti-12C) were evaluated for atrial contractility using echocardiography, versus wild-type and Lenti-controls. Lenti-12C mice demonstrated a 150% increase in left atrium size versus controls, with reduced atrial strain and atrial ejection fraction. Also, programmed electrical stimulation was performed to evaluate AF inducibility in vivo. Pacing-induced AF in Lenti-12C mice was significantly higher than controls. Conclusion: The Overexpression of PPP1R12C increases PP1c targeting to MLC2a and provokes dephosphorylation, that cause a reduction in atrial contractility and increases AF inducibility. All these discoveries advocate that PP1 regulation of sarcomere function at MLC2a is a main regulator of atrial contractility in AF.

Left Atrial Dimension to Left Ventricle Ejection Fraction Ratio Can Predict Long-Term Major Adverse Events In Patients With Acute Coronary Syndrome

Background: It is critical to specify the high-risk group in acute coronary syndrome following percutaneous coronary intervention. Left atrial diameter and Left ventricle ejection fraction are functional echocardiographic parameters for risk classification thanks to easy obtainable, cheap, and non-invasive nature. However, major adverse cardiovascular events may be predicted less than actual where ejection fraction or left atrial diameter are in the normal range. We aimed to assess the left atrial diameter to ejection fraction ratio for major adverse cardiovascular events prediction in acute coronary syndrome.Materials and Methods: Individuals with acute coronary syndrome were included in the study. Atrial diameter and ejection fraction parameters were obtained at admission. The left atrial diameter to left ventricular ejection fraction ratio was calculated through atrial diameter dividing by ejection fraction, and the relationship between new-onset heart failure and all-cause mortality with this ratio was investigated for two years period.Results: The mean age of total 262 patients were 62.1±11.5 years. Thirty-nine (18.9 %) of patients were female and major adverse cardiovascular events occurred in 73 (28%) of the patients. In the backward multivariable Cox regression analysis, age [Hazard ratio (HR)=1.039, 95%CI:1.017-1.060, p&amp;lt;0.001], Killip class [HR=2.099, 95%CI:1.011-4.365, p=0.045], serum creatinine level [HR=2.202, 95%CI:1.247-3.811, p=0.003], and left atrial diameter to left ventricular ejection fraction ratio [HR=1.029, 95%CI:1.019-1.038, p&amp;lt;0.001] were revealed to be independent predictors of major adverse events.Conclusion: Left atrial diameter to left ventricular ejection fraction ratio were predictors of two years new-onset heart failure and mortality in acute coronary syndrome. This novel practical index may provide better prediction for adverse events in all patient groups.Key Words: Acute coronary syndrome (ACS), Left atrial diameter (LAd), Left ventricle ejection fraction (LVEF), Left atrial diameter (LAd) to Left ventricle ejection fraction (LVEF) ratio (LAd/LVEF)

Rationale and design of the rigorous atrial analysis in advanced interatrial block (ARABIA) prospective study

BackgroundAdvanced interatrial block (IAB) is present in 10% of subjects ≥75 years and is associated with the risk of clinical events. Methods and resultsProspective multicenter study that will include subjects ≥75 years without exclusion criteria (indication for anticoagulation, cardiac devices, severe valve disease, systolic dysfunction, moderate or severe cognitive impairment, poor echocardiographic window, non-sinus rhythm or partial IAB, stroke, and life expectancy <2 years). A total of 356 subjects, 178 patients with advanced IAB (exposed) and 178 matched individuals with normal P-wave (non-exposed) will be included. Electrocardiogram and advanced transthoracic echocardiography will be performed. Two substudies will include magnetic resonance imaging: cardiac (86 subjects, 43 exposed, and 43 non-exposed) and brain (86 subjects, 43 exposed, and 43 non-exposed). The follow-up will be 2 years. Our main objective is to determine the association of advanced IAB, P-wave duration, and atrial imaging parameters (I] atrial global longitudinal strain, II] maximal left atrial volume index, III] left atrial ejection fraction, IV] left atrial fibrosis - % total left atrial area V] inter- and intra-atrial asynchrony/dyssynchrony) with clinical events (atrial fibrillation, stroke, cognitive impairment, and mortality). The secondary objective is to assess the association of the P-wave duration with atrial imaging parameters and of both with cerebral microemboli in magnetic resonance imaging. ConclusionOur study will provide data regarding the association of advanced IAB, P-wave duration, and atrial imaging parameters with clinical events. We will also assess the association P-wave duration-atrial imaging parameters-cerebral microemboli.