Elevated Left Atrial Pressure Research Articles

Left ventricular diastolic dysfunction worsens prognosis in patients with heart failure due to dilated cardiomyopathy.

The prognostic significance of left ventricular (LV) diastolic dysfunction (LVDD) severity in patients with dilated cardiomyopathy (DCM) remains uncertain. This study aimed to evaluate the association of LVDD severity and elevated left atrial pressure (eLAP) with patient outcomes in stable, non-acutely decompensated patients with DCM. This single-centre, retrospective, observational study involved 740 DCM patients (either inpatients or outpatients) managed at our tertiary cardiac centre between 2010 and 2021. Due to incomplete data, 96 patients were excluded. LVDD and eLAP were assessed using echocardiography according to the 2016 guidelines of the European Association of Cardiovascular Imaging (EACVI). The primary outcomes were all-cause mortality and heart failure (HF)-related mortality. The final cohort comprised of 644 DCM patients [mean age: 52±12years, LV ejection fraction (LVEF): 26±10%]. Over a median follow-up period of 41 (18.5-66.7) months, 105 (16.3%) patients died: 8 (5.3%) patients in the normal left atrial pressure (nLAP) group and 97 (19.6%) patients in the eLAP group. eLAP was identified as an independent prognostic factor for both all-cause mortality [hazard ratio (HR) 2.0; 95% confidence interval (CI) 1.1-3.7; P=0.01] and HF-related mortality (HR 2.5; 95% CI 1.01-6.5; P=0.04), even after adjusting for LVEF and atrial fibrillation (AF) presence. Additionally, HF-related mortality rates were significantly higher in patients with moderate to severe LVDD compared with those with mild LVDD [5 (3.3%) vs. 67 (13.6%), P<0.05]. This study's findings highlight the importance of assessing the severity of LVDD in patients with DCM, which provides incremental prognostic information over LVEF.

LA reservoir strain predicts elevated left atrial pressure in patients with Veno-Arterial (VA) extracorporeal membrane oxygenator (ECMO) support for cardiogenic shock

Abstract Background Veno-arterial (VA) extracorporeal membrane oxygenator (ECMO) is not a left ventricular (LV) support system as it increases aortic pressure and LV afterload due to retrograde blood flow in the aorta. This can lead to complications such as increased LV volume (LV distention), increased LV and left atrial (LA) pressures, and pulmonary edema. We sought to investigate the correlation between LA strain and invasive LA pressure (LAP) in patients with ECMO support for cardiogenic shock undergoing atrial septostomy with stenting. Methods and Results A total of 24 consecutive patients (52±20 years; 83% were male) undergoing atrial septostomy with stenting while being on ECMO support for cardiogenic shock for left heart decompression were analyzed. LAP was measured immediately after transeptal puncture and before deployment of interatrial septal stent. A comprehensive echocardiogram was performed in all patients prior to atrial septostomy. Median time difference between echocardiogram and LAP measurement was 3.5 (0.5-20) hours. LA strain analysis was performed using the TomTec Arena 2D-cardiac performance analysis (CPA) software. LA reservoir strain was measured at peak systole during the reservoir phase in a single apical 4-chamber view. Intraclass correlation coefficients between 2 different investigators were excellent (All&amp;gt; 0.95). Median LA reservoir strain and LAP were 3.2 (0.5-1) % and 23 (8-53) mmHg, respectively. LA reservoir strain significantly correlated with LAP (r=0.53, p=0.034). LA reservoir strain of &amp;lt; 1.5% can effectively predict markedly elevated LAP (LA&amp;gt; 30 mmHg) (OR =9.9, p =0.0016). Conclusions LA reservoir strain significantly correlated with invasive LAP. With the advent of strain imaging software, LA reservoir strain is a feasible, reproducible, noninvasive, and straightforward method to predict the need for left heart decompression and/or to guide optimal afterload management in patients with VA-ECMO for cardiogenic shock. Further a prospective simultaneous echocardiographic and invasive LAP study is needed.

Time Interval Between Right Ventricular Early Diastolic Velocity by Tissue and Pulse Wave Doppler: An Index of Right Atrial Pressure in Pulmonary Hypertension Patients.

Background: A reversal of time difference between the onset of early diastolic velocity (e') during tissue Doppler imaging and the onset of mitral inflow (E) has been observed in cases of elevated left atrial pressure. Whether this interval (Te'-E) may be useful to assess right atrial pressure has never been investigated, neither in healthy subjects nor in pulmonary hypertension patients. Methods: Right ventricular Te'-E was assessed in patients with pre-capillary pulmonary hypertension and compared with healthy volunteers who underwent comprehensive echocardiography examination. Te'-E is the difference between the interval from R wave at the superimposed electrocardiogram to the e' wave during right ventricular tissue Doppler imaging and the interval from the R wave to transtricuspid E wave during pulsed wave Doppler imaging. Right atrial pressure was invasively measured in pulmonary hypertension patients. Results: Fifty-six patients were enrolled. Te'-E was prolonged in pulmonary hypertension subjects compared with healthy subjects (p < 0.001). Amongst the pulmonary hypertension patients, strong correlations were found between Te'-E and right atrial pressure (r = -0.885, p < 0.001), systolic pulmonary pressure (r = -0.85, p < 0.001) and the duration of tricuspid regurgitation (r = 0.72, p < 0.001). The area under the receiver operating characteristic curve of Te'-E in identifying right atrial pressure higher than 15 mm of mercury was 0.992 (sensitivity 100%, specificity 83%). Conclusions: In contrast to the left ventricle, there is a delay in the proto-diastolic filling in pulmonary hypertension patients, which correlates with the increase in systolic pulmonary arterial pressure, right atrial pressure, tricuspid regurgitation duration and restrictive diastolic pattern.

TCT-535 Watchman Left Atrial Appendage Occlusion Peri-Device Leaks With Elevated Mean Left Atrial Pressure Associated With Clinical Outcomes (WATCH-OUT) Study

TCT-535 Watchman Left Atrial Appendage Occlusion Peri-Device Leaks With Elevated Mean Left Atrial Pressure Associated With Clinical Outcomes (WATCH-OUT) Study

Determinants of invasive left atrial pressure in patients with atrial fibrillation.

Estimation of left ventricular (LV) filling pressures in patients with a history of atrial fibrillation (AF) is challenging due to lack of reliable parameters. This study investigates the association between cardiac structure and function and invasive mean left atrial pressure (LAP). This is a multi-centre prospective study enrolling patients undergoing transcatheter ablation for AF. The invasive measurement of LAP was performed at the time of the procedure while the echocardiography within the previous 24 h. A mean LAP ≥ 15 mmHg was considered as increased. Overall, 101 patients were included (mean age 65.8 ± 8.5 years, 68% male, mean LV ejection fraction 56.6 ± 8.0%). No significant differences regarding clinical characteristics were detected between the group of patients with normal (n = 47) or increased LAP (n = 54). The latter showed lower values of LV global longitudinal strain, larger left atrial volumes (LAVs) and worse right ventricular (RV) function. After multivariable adjustment, higher E/e' ratio (P = 0.041) and minimal LAV index (LAVI min) (P = 0.031), lower peak atrial longitudinal strain (P = 0.030), and RV free wall longitudinal strain (P = 0.037), but not maximal LAV index (LAVI max) (P = 0.137), were significantly associated with mean LAP. The associations were not modified by cardiac rhythm. Overall, LAVI min showed the best diagnostic accuracy to predict elevated LAP (area under the curve 0.703). LA structure and function assessment well correlates with mean LAP in patients with a history of AF. These measures may be used in the assessment of filling pressure in these patients.

HeartMate 3 for Heart Failure with Preserved Ejection Fraction: In Vitro Hemodynamic Evaluation and Anatomical Fitting.

Heart failure with preserved ejection fraction (HFpEF) constitutes approximately 50% of heart failure (HF) cases, and encompasses different phenotypes. Among these, most patients with HFpEF exhibit structural heart changes, often with smaller left ventricular cavities, which pose challenges for utilizing ventricular assist devices (VADs). A left atrial to aortic (LA-Ao) VAD configuration could address these challenges, potentially enhancing patient quality of life by lowering elevated mean left atrial pressure (MLAP). This study assessed the anatomical compatibility and left atrial unloading capacity using a simulated VAD-supported HFpEF patient. A HeartMate3-supported HFpEF patient in an LA-Ao configuration was simulated using a cardiovascular simulator. Hemodynamic parameters were recorded during rest and exercise at seven pump flow rates. Computed tomography scans of 14 HFpEF (NYHA II-III) and six heart failure with reduced ejection fraction patients were analysed for anatomical comparisons. HFpEF models were independently assessed for virtual anatomical fit with the HM3 in the LA-Ao configuration. Baseline MLAP was reduced from 15 to 11mmHg with the addition of 1L/min HM3 support in the rest condition. In an exercise simulation, 6L/min of HM3 support was required to reduce the MLAP from 29 to 16mmHg. The HM3 successfully accommodated six HFpEF patients without causing interference with other cardiac structures, whereas it caused impingement ranging from 4 to 14mm in the remaining patients. This study demonstrated that the HM3 in an LA-Ao configuration may be suitable for unloading the left atrium and relieving pulmonary congestion in some HFpEF patients where size-related limitations can be addressed through pre-surgical anatomical fit analysis.

Remote dielectric sensing predicts elevated left atrial pressure in patients with atrial fibrillation

BackgroundThere are currently no established non-invasive indices of echocardiography for elevated left atrial pressure (LAP) especially in patients with atrial fibrillation (AF). Remote dielectric sensing (ReDS) is a novel non-invasive electromagnetic energy-based technology that quantifies total lung fluid, enabling the monitoring of volume status in patients with heart failure. The utility of ReDS for estimating LAP in patients with AF remains unknown. MethodsWe prospectively investigated patients with AF in whom LAP was directly measured during catheter ablation for AF, and ReDS measurements were conducted the day before ablation. Elevated LAP was defined as LAP ≥ 15 mmHg. ResultsA total of 61 patients were included (median age 66 years, 38 % female). Among them, 26 patients had elevated LAP. There was a positive correlation between ReDS and LAP (r = 0.363, P = 0.004). Receiver operating characteristic curve analysis for the prediction of elevated LAP demonstrated that the best cut-off value of ReDS was 30 %, with a sensitivity of 65 %, specificity of 69 %, and an area under the curve of 0.703 (95 % confidence interval 0.568–0.837). Multivariate logistic regression analysis revealed that ReDS was an independent predictor of elevated LAP, among covariates including left ventricular ejection fraction, the ratio of early transmitral flow velocity to septal mitral annular early diastolic velocity, and left atrial volume index. ConclusionsOur results suggest ReDS could be a valuable marker of elevated LAP even in patients with AF. Further studies are needed to elucidate the effectiveness of a ReDS-guided decongestive strategy in patients with heart failure.

Left atrial strain parameters to predicting elevated left atrial pressure in patients with atrial fibrillation.

To assess the ability of left atrial (LA) strain parameters to discriminate patients with elevated left atrial pressure (LAP) from patients with atrial fibrillation (AF). A total of 142 patients with non-valvular AF who underwent first catheter ablation (CA) between November 2022 and November 2023 were enrolled in the study. Conventional and speckle-tracking echocardiography (STE) were performed in all patients within 24h before CA, and LAP was invasively measured during the ablation procedure. According to mean LAP, the study population was classified into two groups of normal LAP (LAP<15mmHg, n=101) and elevated LAP (LAP≥15mmHg, n=41). Compared with the normal LAP group, elevated LAP group showed significantly reduced LA reservoir strain (LASr) [9.14 (7.97-11.80) vs. 20 (13.59-26.96), p<.001], and increased LA filling index [9.60 (7.15-12.20) vs. 3.72 (2.17-5.82), p<.001], LA stiffness index [1.13 (.82-1.46) vs..47 (.30-.70), p<.001]. LASr, LA filling index and LA stiffness index were independent predictors of elevated LAP after adjusted by the type of AF, EDT, E/e', mitral E, and peak acceleration rate of mitral E velocity. The receiver-operating characteristic curve (ROC) analysis showed LA strain parameters (area under curve [AUC].794-.819) could provide similar or greater diagnostic accuracy for elevated LAP, as compared to conventional echocardiographic parameters. Furthermore, the novel algorithms built by LASr, LA stiffness index, LA filling index, and left atrial emptying fraction (LAEF), was used to discriminate elevated LAP in AF with good accuracy (AUC.880, accuracy of 81.69%, sensitivity of 80.49%, and specificity of 82.18%), and much better than 2016 ASE/EACVI algorithms in AF. In patients with AF, LA strain parameters could be useful to predict elevated LAP and non-inferior to conventional echocardiographic parameters. Besides, the novel algorithm built by LA strain parameters combined with conventional parameters would improve the diagnostic efficiency.

Design and Rationale of the V-Wave Shunt MitraClip Study

Heart failure (HF) and moderate-to-severe mitral regurgitation (MR) with residual elevations in left atrial pressure (LAP) after MitraClip may remain symptomatic and experience subsequent HF readmissions. The V-Wave interatrial shunt system is a permanent interatrial septal implant that shunts blood from the left-to-right atrium and serves to continuously unload the left atrium. Although the V-Wave shunt has previously been studied in patients with HF, the safety and feasibility of its deployment at the time of the MitraClip procedure is unknown. The V-Wave Shunt MitraClip Study (NCT04729933) is an early feasibility study that aims to demonstrate the safety and efficacy of implantation of the V-Wave shunt device at the time of MitraClip procedure. Patients with moderate-to-severe secondary MR with left ventricular ejection fraction 20% to 50% and New York Heart Association functional class III/IV symptoms despite optimal medical therapy, residual mean LAP ≥20 mm Hg after MitraClip, and mean LAP-right atrial pressure difference ≥5 mm Hg are included. The primary safety end point is a composite outcome of all-cause death, stroke, myocardial infarction device embolization, cardiac tamponade, or device-related re-intervention or surgery at 30 days. Patients will be followed up to 5 years. Enrollment is ongoing, with 30-day results expected by the end of 2024. The V-Wave Shunt Mitraclip Study aims to demonstrate the safety and efficacy of the implantation of the V-Wave interatrial shunt device at the time of index MitraClip placement which may serve as an adjunctive method by which continuous left atrial unloading may be achieved.

2-Year Outcomes of an Atrial Shunt Device in HFpEF/HFmrEF: Results From REDUCE LAP-HF II

BackgroundThe REDUCE LAP-HF II (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure II) trial found that, compared with a sham procedure, the Corvia Atrial Shunt did not improve outcomes in heart failure with preserved or mildly reduced ejection fraction. However, after 12-month follow-up, “responders” (peak-exercise pulmonary vascular resistance <1.74 WU and absence of a cardiac rhythm management device) were identified. ObjectivesThis study sought to determine: 1) the overall efficacy and safety of the atrial shunt vs sham control after 2 years of follow-up; and 2) whether the benefits of atrial shunting are sustained in responders during longer-term follow-up or are offset by adverse effects of the shunt. MethodsThe study analyzed 2-year outcomes in the overall REDUCE LAP-HF II trial, as well as in responder and nonresponder subgroups. The primary endpoint was a hierarchical composite of cardiovascular death or nonfatal ischemic/embolic stroke, total heart failure events, and change in health status. ResultsIn 621 randomized patients, there was no difference between the shunt (n = 309) and sham (n = 312) groups in the primary endpoint (win ratio: 1.01 [95% CI: 0.82-1.24]) or its individual components at 2 years. Shunt patency at 24 months was 98% in shunt-treated patients. Cardiovascular mortality and nonfatal ischemic stroke were not different between the groups; however, major adverse cardiac events were more common in those patients assigned to the shunt compared with sham (6.9% vs 2.7%; P = 0.018). More patients randomized to the shunt had an increase in right ventricular volume of ≥30% compared with the sham control (39% vs 28%, respectively; P < 0.001), but right ventricular dysfunction was uncommon and not different between the treatment groups. In responders (n = 313), the shunt was superior to sham (win ratio: 1.36 [95% CI: 1.02-1.83]; P = 0.037, with 51% fewer HF events [incidence rate ratio: 0.49 [95% CI: 0.25-0.95]; P = 0.034]). In nonresponders (n = 265), atrial shunting was inferior to sham (win ratio: 0.73 [95% CI: 0.54-0.98]). ConclusionsAt 2 years of follow-up in REDUCE LAP-HF II, there was no difference in efficacy between the atrial shunt and sham groups in the overall trial group. The potential clinical benefit identified in the responder group after 1 and 2 years of follow-up is currently being evaluated in the RESPONDER-HF (Re-Evaluation of the Corvia Atrial Shunt Device in a Precision Medicine Trial to Determine Efficacy in Mildly Reduced or Preserved Ejection Fraction Heart Failure) trial. (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure II [REDUCE LAP-HF II]; NCT03088033)

Impact of Left Atrial Pressure on Outcomes After Mitral Transcatheter Edge-to-Edge Repair.

Increased left atrial pressure (LAP) has been associated with adverse outcomes after mitral transcatheter edge-to-edge repair (M-TEER). We sought to evaluate outcomes based on differences in postprocedural LAP measured after the final clip deployment. We included consecutive patients who underwent M-TEER at our institution between 2014 and 2022 with LAP monitoring. Patients were stratified into 3 groups according to tertiles of post-TEER mean LAP. Outcomes were assessed using Kaplan-Meier analysis and Cox proportional hazards models. We included 273 patients (mean age, 76.8±10.8 years; 42.5% women; 78.4% White). The mean post-TEER LAP was 8.7±1.7 mm Hg in tertile 1 (n=85), 14.4±1.6 mm Hg in tertile 2 (n=95), and 21.9±3.8 mm Hg in tertile 3 (n=93). In comparison with tertile 1, both tertiles 2 and 3 were associated with increased risk of all-cause mortality or heart failure hospitalization at 2 years (adjusted hazard ratio [adjHR], 2.27 [95% CI, 1.25-4.12] and adjHR, 3.00 [95% CI, 1.59-5.64], respectively). Among patients with primary mitral regurgitation, higher LAP was associated with increased risk of 2-year all-cause mortality or heart failure hospitalization (tertile 2 versus 1: adjHR, 3.00 [95% CI, 1.37-6.56]; tertile 3 versus 1: adjHR, 5.52 [95% CI, 2.04-14.95]). However, in patients with secondary mitral regurgitation, neither being in tertile 2 (adjHR, 1.53 [95% CI, 0.55-4.24]) nor tertile 3 (adjHR, 2.18 [95% CI, 0.82-5.77]) were associated with the composite outcome compared with tertile 1. Any degree of LAP reduction following M-TEER was associated with lower mortality or heart failure hospitalization compared with no LAP reduction (adjHR, 0.59 [95% CI, 0.39-0.88]). Elevated LAP after M-TEER was associated with increased 2-year risk of mortality or heart failure hospitalization. Exploration of reasons for elevated LAP after M-TEER and ways to lower it warrant further investigation.

An association between Dasatinib, elevated left atrial pressure and pleural effusion

BackgroundTyrosine kinase inhibitors (TKI), such as Dasatinib, are effective in the treatment of chronic myeloid leukemia (CML) but associated with development of pleural effusions (PE). The relationship between haemodynamic parameters identified on transthoracic echocardiogram (TTE) such as elevated estimated left atrial pressure (LAP), and PE development is unknown. This study aims to describe associations between Dasatinib, elevated LAP and PE. MethodsThis was a retrospective study of 71 CML patients who underwent TTE during treatment with various TKIs. Descriptive analysis was performed to identify associations between TKI use, PE and elevated LAP on TTE. Multivariate logistic regression was performed to identify predictors of elevated LAP. ResultsThere were 36 patients treated with Dasatinib, 15 Nilotinib, and 20 Imatinib. Those treated with Dasatinib had higher rates of elevated LAP (44% vs 7% Nilotinib vs 10% Imatinib, p < 0.01) and PE (39% vs 7% vs 0%, p < 0.01). In the 15 patients who developed PE, 14 (93%) patients were treated with Dasatinib. Patients with PE had higher rates of elevated LAP (67% vs 16%, p < 0.01). Nineteen (26.8%) patients in the entire cohort had elevated LAP. After multivariate adjustment, Dasatinib (OR 33.50, 95% CI = 4.99–224.73, p < 0.01) and age (OR 1.12, 95% CI = 1.04–1.20, p < 0.01) were associated with elevated LAP. ConclusionsAmong patients with CML, there was an association between Dasatinib use, PE and elevated LAP on TTE. These findings are hypothesis generating and further studies are required to evaluate the utility of elevated LAP on TTE as a novel marker for prediction and surveillance of PE.

Agreement of left atrial pressure with clinical risk scores and echocardiographic features in patients with atrial fibrillation referred for catheter ablation

Abstract Background Heart failure with preserved ejection fraction (HFpEF) frequently coexists with atrial fibrillation (AF). The diagnosis of HFpEF in AF is difficult because some diagnostic criteria for HFpEF may be associated with AF instead of HFpEF per se. Left atrial pressure (LAP) ≥15 mmHg has been used to confirm the diagnosis of HFpEF. Purpose We aimed to 1) determine LAP measurements in patients with AF undergoing catheter ablation; 2) assess the agreement between LAP measurement HFpEF risk scores and 3) determine the association between LAP measurement and clinical and echocardiographic features. Methods Consecutive patients with paroxysmal or persistent AF scheduled for catheter ablation were included. Participants were considered to have HFpEF if the mean LAP was ≥15 mm Hg. The LAP was measured only in sedated patients with spontaneous breathing. Participants had high probability of HFpEF if scored &amp;gt;5points in H2FPEF and/or ≥5 points in HFA-PEFF score. Results Of 107 participants, 29 (27%) had HFpEF according to mean LAP and 32 (30%) had high probability of HFpEF according to HFpEF scores. The highest agreement of HFpEF risk scores relative to elevated LAP was observed for H2FPEF score; among patients with mean LAP ≥15 mm Hg, 38% [n=11/29] of them had also high risk of HFpEF based on H2FPEF score, whereas only 10% [n=3/29] had high risk of HFpEF based on HFA-PEFF score. In multivariable analysis, the independent predictors of HFpEF were left ventricular ejection fraction (LVEF; OR 0.77, 95%CI 0,.64-0.91), intraventricular septum diameter (IVSd; OR 1.75, 95%CI 1.11-2.74), global longitudinal strain (GLS; OR 1.24, 9%CI 1.05-1.48). Conclusions More than one-fourth of patients scheduled for catheter ablation had HFpEF according to elevated LAP. The highest agreement to elevated LAP was observed for the H2FPEF score. Predictors of HFpEF diagnosis were lower LVEF, higher IVSd and GLS.

Increased left atrial pressure distorts pulmonary arterial impedance estimates in the low-range of frequency in rats

BACKGROUD: Post-capillary pulmonary hypertension (PH), characterized as increased downstream pressure such as left atrial pressure (LAP), is the most prevalent type of PH and a significant contributor to right heart failure. Accurate estimation of pulmonary arterial characteristics, serving as right ventricular afterload, is crucial for management of PH. These characteristics can be captured comprehensively through pulmonary arterial impedance (PAZ), which elucidates pulmonary arterial pressure-flow relationship within the frequency domain. Although LAP waveforms are potential to affect the contours of pulmonary arterial pressure (PAP) and flow (PAF) waveforms, it remains unknown whether increased LAP affects the accuracy of PAZ measurement. This study aimed to investigate the impact of LAP on the accuracy of PAZ using an acute rodent model. METHODS: We measured pulmonary arterial blood flow (PAF), PAP, and LAP simultaneously in eight male Sprague-Dawley rats. PAZ was calculated as a reciprocal of admittance. Admittance was calculated in the following two ways: 1) one-input (PAP) and one-output (PAF) analysis (I1O1 analysis): the ratio of PAP(f) to PAF(f) at each frequency, where PAP(f) and PAF(f) are frequency spectra of PAP and PAF, respectively, and 2) two-input (PAP and LAP) and one-output (PAF) analysis (I2O1 analysis): excluding the potential effect of LAP from PAP and PAF. We measured PAZ under both normal physiological condition and post-capillary PH condition. To induce acute post-capillary PH by raising LAP &gt;15 mmHg, we ligated aortic arch at the site between brachiocephalic artery and left common carotid artery and performed blood transfusion from a donor rat (TAL/BT). The accuracy of PAZ was examined as the coherence function representing the linearity between the input and output signals. Results: TAL/BT significantly increased LAP from 3 ± 1mmHg to 21 ± 4 mmHg and PAP from 17 ± 3 mmHg to 34 ± 3 mmHg (p&lt;0.01 for both). The I2O1 analysis provided a consistently accurate estimation of PAZ under both normal and elevated LAP conditions with high coherence function (&gt;0.9) in the wide range of frequency between 0.12 and 10.7 Hz. The I1O1 analysis also estimated the PAZ accurately in normal condition with high coherence function (&gt;0.9) in the wide range of frequency, however, the I1O1 analysis overestimated PAZ in the low-range frequency between 0.12 and 1.0 Hz compared with the I2O1 analysis (I1O1: 0.32±0.10 vs. I2O1 0.23±0.06 mmHg/ml/min, p&lt;0.01), with significantly lower coherence function (I1O1: 0.77±0.05 vs. I2O1: 0.96±0.01, p&lt;0.01). CONCLUSION: Increased LAP may have the impact on the accuracy of PAZ estimation in the low-range frequency. The I2O1 analysis can lead to more accurate assessment of right ventricular afterload in post-capillary PH, compared with the I1O1 analysis. Grant-in-Aid for Young Scientists of the Japanese Society of Cardiovascular Anesthesiologists Project Number 2271000048. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Atrial Shunt Device Effects on Cardiac Structure and Function in Heart Failure With Preserved Ejection Fraction

Although the results of A Study to Evaluate the Corvia Medical Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure (REDUCE LAP-HF II) trial were neutral overall, atrial shunt therapy demonstrated potential efficacy in responders (no latent pulmonary vascular disease and no cardiac rhythm management device). Post hoc analyses were conducted to evaluate the effect of shunt vs sham stratified by responder status. To evaluate the effect of atrial shunt vs sham control on cardiac structure/function in the overall study and stratified by responder status. This was a sham-controlled randomized clinical trial of an atrial shunt device in heart failure with preserved ejection fraction (HFpEF)/HF with mildly reduced EF (HFmrEF). Trial participants with evaluable echocardiography scans were recruited from 89 international medical centers. Data were analyzed from April 2023 to January 2024. Atrial shunt device or sham control. Changes in echocardiographic measures from baseline to 1, 6, 12, and 24 months after index procedure. The modified intention-to-treat analysis of the REDUCE LAP-HF II trial included 621 randomized patients (median [IQR] age, 72.0 [66.0-77.0] years; 382 female [61.5%]; shunt arm, 309 [49.8%]; sham control arm, 312 [50.2%]). Through 24 months, 212 of 217 patients (98%) in the shunt arm with evaluable echocardiograms had patent shunts. In the overall trial population, the shunt reduced left ventricular (LV) end-diastolic volume (mean difference, -5.65 mL; P <.001), left atrial (LA) minimal volume (mean difference, -2.8 mL; P =.01), and improved LV systolic tissue Doppler velocity (mean difference, 0.69 cm/s; P <.001) and LA emptying fraction (mean difference, 1.88 percentage units; P =.02) compared with sham. Shunt treatment also increased right ventricular (RV; mean difference, 9.58 mL; P <.001) and right atrial (RA; mean difference, 9.71 mL; P <.001) volumes but had no effect on RV systolic function, pulmonary artery pressure, or RA pressure compared with sham. In the shunt arm, responders had smaller increases in RV end-diastolic volume (mean difference, 5.71 mL vs 15.18 mL; interaction P =.01), RV end-systolic volume (mean difference, 1.58 mL vs 7.89 mL; interaction P =.002), and RV/LV ratio (mean difference, 0.07 vs 0.20; interaction P <.001) and larger increases in transmitral A wave velocity (mean difference, 5.08 cm/s vs -1.97 cm/s; interaction P =.02) compared with nonresponders randomized to the shunt, suggesting greater ability to accommodate shunted blood through the pulmonary circulation enabling LA unloading. In this post hoc analysis of the REDUCE LAP-HF II trial, over 2 years of follow-up, atrial shunting led to reverse remodeling of left-sided chambers and increases in volume of right-sided chambers consistent with the shunt flow but no change in RV systolic function compared with sham. Changes in cardiac structure/function were more favorable in responders compared with nonresponders treated with the shunt, supporting the previously identified responder group hypothesis and mechanism, although further evaluation with longer follow-up is needed. ClinicalTrials.gov Identifier: NCT03088033.

The plasma proteome is linked with left ventricular and left atrial function parameters in patients with chronic heart failure.

Examining the systemic biological processes in the heterogeneous syndrome of heart failure with reduced ejection fraction (HFrEF), as reflected by circulating proteins, in relation to echocardiographic characteristics, may provide insights into HF pathophysiology. We investigated the link of 4210 repeatedly measured circulating proteins with repeatedly measured echocardiographic parameters, as well as with elevated left atrial pressure (LAP), in HFrEF patients, to provide insights into underlying mechanisms. In 173 HFrEF patients, we performed six-monthly echocardiography and trimonthly blood sampling during a median follow-up of 2.7(IQR:2.5-2.8) years. We investigated circulating proteins in relation to echocardiographic parameters of left ventricular (left ventricular ejection fraction[LVEF], global longitudinal strain[GLS]), and left atrial function (left atrial reservoir strain[LASr]) and elevated LAP(E/e' ratio >15), and used gene enrichment analyses to identify underlying pathophysiological processes. We found 723, 249, 792 and 427 repeatedly measured proteins, with significant associations with LVEF, GLS, LASr and E/e' ratio, respectively. Proteins associated with LASr reflected pathophysiological mechanisms mostly related to the extracellular matrix (ECM). Proteins associated with GLS reflected cardiovascular biological processes and diseases, whereas those associated with LVEF reflected processes involved in the sympathetic nervous system. Moreover, 49 proteins were associated with elevated LAP; after correction for LVEF, three proteins remained: Cystatin-D, Fibulin-5 and HSP40. Circulating proteins show varying associations with different echocardiographic parameters in HFrEF patients. These findings suggest that pathways involved in atrial and ventricular dysfunction, as reflected by the plasma proteome, are distinct.

Pulmonary hypertension is an adverse risk factor for patients admitted with atrial fibrillation

Abstract Background Atrial Fibrillation (AF) poses a significant burden on the resources of the American Healthcare system. Heart failure and AF commonly coexist in patients. Elevated left ventricular and atrial pressures result in progressive left atrial dilation and remodeling which in turn predisposes to the generation of AF. Many of these patients develop pulmonary hypertension (PHT) due to the remodeling and elevated left-sided pressures. Since many who have AF could have PHT, we aimed to assess outcomes in this population. Methods We utilized the National Inpatient Sample from 2016-2019 to identify roughly 16,500,000 hospitalized adults who had AF. These hospitalizations were further stratified based on the presence of PHT. A multivariate regression model was used to adjust for confounders and analyze the variables. Results Of those with AF, 1,855,020 (11.2%) had PHT. In-hospital mortality was higher in those with PHT (5.6% vs 4.9%; p&amp;lt;0.001). Figure 1 shows the Forrest plot for multivariate analysis of in-hospital outcomes when adjusted for patient demographics, comorbidities, and hospital characteristics. When adjusted similarly, patients with AF and PHT had longer length of stay (LOS) by 0.92 days (p&amp;lt;0.001) and had additional hospital costs (HC) of $9,463 (p&amp;lt;0.001). Conclusion In this study, patients admitted with AF with co-existing PHT had significantly worse outcomes in terms of in-hospital mortality, LOS, HC, cardiac arrest, pulmonary embolism, atrial flutter, AKI, blood transfusions, pneumonia, and endotracheal intubation. One major limitation of our study is the lack of outpatient follow up. Given that overall outcomes are worse in the setting of PHT, potential strategies for early rhythm control for AF should be pursued to avoid negative cardiac remodeling that would predispose to the development of PHT. AF patients with co-existing PHT should be aggressively monitored during hospitalizations as they have the potential to have worse outcomes.

Pulmonary hypertension is an adverse risk factor for peri-procedural complications in patients undergoing cardioversion for atrial fibrillation

Abstract Background Atrial Fibrillation (AF) poses a significant burden on the American Healthcare system. Heart failure and AF commonly coexist in patients. Elevated left ventricular and atrial pressures result in progressive left atrial dilation and remodeling which in turn predisposes to the generation of AF. Many of these patients develop pulmonary hypertension (PHT) due to the remodeling and elevated left-sided pressures. Cardioversion (CV) for non-valvular atrial fibrillation (AF) is commonplace for patients during their initial presentation. Since many who undergo CV for AF could have PHT, we aimed to assess the periprocedural outcomes in this population. Methods We utilized the National Inpatient Sample from 2016-2019 to identify roughly 330,820 hospitalized adults who had CV for AF. These hospitalizations were further stratified based on the presence of PHT. A multivariate regression model was used to adjust for confounders and analyze the variables. Results Of those who underwent CV for AF, 45,345 (13.7%) had PHT. In-hospital mortality was interestingly lower in those with PHT (9.6% vs 10.37%; p&amp;lt;0.001). Figure 1 shows the Forrest plot for multivariate analysis of in-hospital outcomes when adjusted for patient demographics, comorbidities, and hospital characteristics. When adjusted similarly, patients who underwent CV for AF and PHT had longer length of stay (LOS) by 2.11 days (p&amp;lt;0.001) and had additional hospital costs (HC) of $29,470 (p&amp;lt;0.001). Conclusion In this study, patients who underwent CV for AF with co-existing PHT had significantly worse outcomes in terms of LOS, HC, pulmonary embolism, atrial flutter, VT, SVT, AKI, and intubation. Of note, they interestingly had better outcomes in terms of in-hospital mortality, respiratory failure, and strokes. Returning the patient to sinus rhythm likely improved the left heart hemodynamics reducing post capillary pulmonary hypertension explaining the reduced mortality rate in this population. One major limitation of our study is the lack of outpatient follow up and the inability to differentiate between the different groups of PHT. Since several outcomes are worse in the setting of PHT, potential strategies for aggressive rate and volume control for those in AF should be pursued to avoid negative cardiac remodeling that would predispose to the development of PHT. AF patients with co-existing PHT should be aggressively monitored during hospitalizations as they have the potential to have worse outcomes.

Correlation between energy loss index and B-type natriuretic peptide: a vector flow mapping study.

Vector Flow Mapping (VFM) and Energy Loss (EL) evaluation are emerging echocardiographic techniques that offer detailed insights into cardiac function. This study aimed to explore the relationship between EL parameters and B-type natriuretic peptide (BNP) levels, a well-established marker of heart failure severity. Our study prospectively enrolled 62 patients experiencing shortness of breath and suspected heart failure, who underwent echocardiography and had BNP levels measured between January 2018 and August 2020. Patients were stratified based on BNP levels, and their clinical and echocardiographic characteristics were evaluated. Univariate and multivariate regression analyses were performed to assess the correlation between BNP levels and various echocardiographic variables, including VFM parameters. Patients were stratified into two groups based on their BNP levels: BNP < 200pg/ml (n = 53) and BNP ≥ 200pg/ml (n = 9). Patients with BNP ≥ 200pg/ml presented significantly different clinical and echocardiographic characteristics, such as older age, larger left ventricular mass and volume indices, higher pulmonary artery systolic pressure, higher E/e' ratio, and larger EL parameters. Multivariate regression analysis demonstrated the E/e' ratio and ELA (EL during Atrial contraction phase/A wave ratio as significant determinants of logBNP. Receiver operating characteristic curve analysis showed ELA/A > 36.0J/m2 as a significant predictor of high BNP with 89% sensitivity and 85% specificity. ELA/A demonstrated an incremental diagnostic value over elevated left atrial pressure for predicting high BNP (C statistic = 0.98 vs 0.74, P = 0.006). This study provides novel insights into the potential utility of EL parameters as auxiliary indicators of cardiac load, thereby enhancing our understanding of heart failure.

Prevalence, Associated Factors, and Echocardiographic Estimation of Left Atrial Hypertension in Patients With Atrial Fibrillation.

Background Elevated left atrial (LA) pressure predisposes individuals to the initiation and persistence of atrial fibrillation (AF), and LA hypertension is associated with AF recurrence after catheter ablation (CA). However, the exact frequency and factors associated with LA hypertension are unknown, and its noninvasive estimation is challenging. This study aimed to investigate the prevalence and determinants of LA hypertension in patients with AF who underwent first CA. Methods and Results We examined 183 patients with AF who underwent conventional and speckle-tracking echocardiography before CA to assess LA size, reservoir strain, and stiffness. Direct LA pressure was measured at the time of CA, and LA hypertension was defined as mean LA pressure >15 mm Hg. Thirty-three (18.0%) patients exhibited LA hypertension. Patients with LA hypertension had a significantly larger LA volume index (40.2 [28.4-52.1] versus 34.1 [26.9-42.4] mL/m2, P=0.025), reduced LA reservoir strain (15.1 [10.4-21.7] versus 22.7 [14.4-32.3] %, P=0.002) and increased LA stiffness (0.69 [0.34-0.99] versus 0.36 [0.24-0.54], P<0.001). Multivariable analyses showed that waist circumference, C-reactive protein level, LA reservoir strain, and LA stiffness were independently associated with LA hypertension (all P<0.05), while LA volume and E/e' ratio were not. Among echocardiographic parameters, receiver operating characteristic curve analysis identified LA stiffness as the best predictor of LA hypertension. Conclusions Approximately 20% of patients with AF who underwent CA had LA hypertension. Central obesity and inflammation might be involved in the pathophysiological mechanisms of LA hypertension, and echocardiography-derived LA stiffness may have clinical utility for the detection of LA hypertension before CA.