Impaired Left Atrial Function Research Articles

Atrial fibrillation substrate and impaired left atrial function: a cardiac MRI study

Abstract Aims Structural and fibrotic remodelling is a well-known contributor to the atrial fibrillation (AF) substrate. Epicardial adipose tissue (EAT) is increasingly recognized as a contributor through electrical remodelling in the atria. We aimed to assess the association of LA fibrosis and EAT with LA strain and function using cardiac magnetic resonance (CMR) imaging in patients with AF. Methods and results LA fibrosis was assessed using late gadolinium enhancement CMR, LA EAT was assessed using the fat-water separation Dixon sequence, and feature tracking was applied to assess global longitudinal strain in its three components [reservoir (GLRS), conduit (GLCdS), and contractile (GLCtS)]. LA emptying fraction and LA volume were measured using the cine sequences. All CMR images were acquired in sinus rhythm. One hundred one AF patients underwent pre-ablation CMR (39% female, average age 62 years). LA fibrosis was negatively associated with the three components of global longitudinal strain (GLRS: R = −0.35, P < 0.001; GLCdS: R = −0.24, P = 0.015; GLCtS: R = −0.2, P = 0.046). Out of the different sections of the LA, fibrosis in the posterior and lateral walls was most negatively correlated with GLRS (R = −0.32, P = 0.001, and R = −0.33, P = 0.001, respectively). LA EAT was negatively correlated with GLCdS (R = −0.453, P < 0.001). LA fibrosis was negatively correlated with LA emptying fraction but LA EAT was not (R = −0.27, P = 0.007, and R = −0.22, P = 0.1, respectively). LA EAT and fibrosis were both positively correlated with LA volume (R = 0.38, P = 0.003, and R = 0.24, P = 0.016, respectively). Conclusion LA fibrosis, a major component of the AF substrate, and EAT, an important contributor, are associated with a worsening LA function through strain analysis by CMR.

Heart Failure with Preserved Ejection Fraction Correlates with Fibrotic Atrial Myopathy in Patients Undergoing Atrial Fibrillation Ablation.

Background: The incidence of atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFpEF) is high. Impaired left atrial (LA) function is a major determinant in HFpEF. However, the extent of electrical LA tissue degeneration in HFpEF is unknown. Therefore, we sought to investigate the amount of arrhythmogenic and fibrotic LA tissue degeneration in HFpEF patients presenting for AF ablation. Methods: We prospectively screened consecutive patients presenting for first time AF ablation. The HFA-PEFF score was used to identify HFpEF patients. Bipolar high-density voltage mapping was created in sinus rhythm prior to ablation to evaluate the general LA bipolar voltage and quantify areas of low voltage. LVAs were defined as areas with bipolar voltage < 0.5 mV. Results: In total, 187 patients were prospectively enrolled (age 65 ± 11 years, 45% female, 46% persistent AF, 25% HFpEF) in this study. HFpEF patients were older and had a higher CHA2DS2-VASc score (70 ± 9 vs. 63 ± 11 years and 3.2 ± 1.5 vs. 2.3 ± 1.5, each p < 0.001, respectively). Overall, low-voltage areas (LVAs) were present in 97 patients (52%), whereas 76% of the HFpEF population had LVA, as compared to 44% of patients without HFpEF (p < 0.001). HFpEF was associated with generally decreased LA bipolar voltage (1.09 ± 0.64 vs. 1.83 ± 0.91 mV; p < 0.001) and predictive of the presence of low-voltage areas (76% vs. 44% p < 0.001). The HFA-PEFF score inversely correlated with LA bipolar voltage (=-0.454; p < 0.001). Conclusions: HFpEF closely relates to generally decreased LA bipolar voltage and to the existence of fibrotic and arrhythmogenic LA tissue degeneration.

Impaired Left Atrial Reserve Function in Heart Failure With Preserved Ejection Fraction.

Left atrial (LA) dysfunction is common in heart failure (HF) with preserved ejection fraction. However, data on the pathophysiologic impacts of impaired LA functional reserve remained limited. We sought to determine the association of abnormal LA dynamics during exercise with cardiovascular reserve, exercise capacity, and clinical outcomes. Patients with HF with preserved ejection fraction (n=231) and controls without HF (n=219) underwent exercise stress echocardiography with simultaneous expired gas analysis. LA function was assessed at rest and during exercise using speckle-tracking echocardiography. Patients with HF with preserved ejection fraction demonstrated less increase in LA reservoir and booster pump strain during exercise than those in controls. The degree of LA dilation was more closely related to exercise LA reservoir strain than to resting LA strain (Meng test, P=0.002). The presence of impaired LA reservoir strain during exercise was associated with poorer biventricular systolic reserve and cardiac output augmentation, more severe right ventricular-pulmonary artery uncoupling, and lower peak oxygen consumption. Patients with a lower exercise LA reservoir strain had a 2.7-fold increased risk of HF events (hazard ratio, 2.66 [95% CI, 1.32-5.38]; P=0.006). Among patients with follow-up echocardiography, initiation of guideline-directed medical therapy or atrial fibrillation ablation showed significant improvements in LA reservoir (P<0.001 and P=0.022) and booster pump strain (P=0.011 and 0.028) at rest and during exercise, respectively. Impaired LA reservoir function during exercise in HF with preserved ejection fraction is associated with biventricular reserve limitations, exercise intolerance, and increased risks of HF events.

Association of Left Atrial Function With Incident Chronic Kidney Disease in Older Adults

ObjectiveTo examine the association of left atrial (LA) function with incident chronic kidney disease (CKD) and assess the clinical utility of adding LA function to a CKD risk prediction equation. Patients and MethodsWe included 4002 Atherosclerosis Risk in Communities study participants without prevalent CKD (mean ± SD age, 75±5 years; 58% female, 18% Black). Left atrial function (reservoir, conduit, and contractile strain) was evaluated by 2D-echocardiograms on 2011 to 2013. Chronic kidney disease was defined as greater than 25% decline in estimated glomerular filtration rate of less than 60 mL/min/1.73 m2, end-stage kidney disease, or hospital records. Cox proportional hazards models were used. Risk prediction and decision curve analyses evaluated 5-year CKD risk by diabetes status. ResultsMedian follow-up was 7.2 years, and 598 participants developed incident CKD. Incidence rate for CKD was 2.29 per 100 person-years. After multivariable adjustments, the lowest quintile of LA reservoir, conduit, and contractile strain (vs highest quintile) had a higher risk of CKD (hazard ratios [95% CIs]: 1.94 [1.42-2.64], 1.62 [1.19-2.20], and 1.49 [1.12-1.99]). Adding LA reservoir strain to the CKD risk prediction equation variables increased the C-index by 0.026 (95% CI: 0.005-0.051) and 0.031 (95% CI: 0.006-0.058) in participants without and with diabetes, respectively. Decision curve analysis found the model with LA reservoir strain had a higher net benefit than the model with CKD risk prediction equation variables alone. ConclusionLower LA function is independently associated with incident CKD. Adding LA function to the CKD risk prediction enhances prediction and yields a higher clinical net benefit. These findings suggest that impaired LA function may be a novel risk factor for CKD.

Effect of Metabolic Syndrome on Left Atrial and Left Ventricular Deformation and Atrioventricular Interactions in Patients With Myocardial Infarction.

Metabolic syndrome (MetS) is associated with worse prognosis in patients with myocardial infarction (MI). However, it is unclear how MetS in MI patients is associated with left atrial (LA) and left ventricular (LV) deformation. To determine the effect of MetS on LA and LV deformation and atrioventricular interactions in MI patients. Retrospective. One hundred eighty-one MI patients (73 MetS+ and 108 MetS-), 107 age- and sex-matched controls (49 MetS+ and 58 MetS-). 3.0 T/balanced steady-state free precession (SSFP)/segmented phase-sensitive inversion recovery SSFP sequence. LA strain and strain rates (reservoir, conduit, and active), left atrioventricular coupling index (LACI), and LV geometry and radial, circumferential and longitudinal global peak strains (PS) were compared among groups. Two-way analysis of variance, Spearman and Pearson's correlation coefficients, and multivariable linear regression analysis. P value <0.05 indicated statistical significance. Compared with controls, the MI patients with or without MetS showed impaired LA function (reservoir, conduit, and active) and LV deformation (radial, circumferential, and longitudinal PS) and higher LACI. The MetS+ group had lower LA reservoir and conduit function and LV deformationthan MetS- group. The MetS-MI interaction was not statistically significant. Furthermore, multivariable linear regression showed that MetS was independently associated with LA and LV deformation (β = -0.181 to -0.209) in MI patients; LA function was independently associated with LV circumferential PS (β = 0.230 to 0.394) and longitudinal PS (β = 0.189 to 0.420), and LA passive strain and strain rate were negatively associated with LV mass (β = -0.178 and -0.298). MetS may be associated with the LA and LV dysfunction in MI patients. Impaired LV deformation and LV hypertrophy are independently associated with LA dysfunction in MI patients, and the MI patients have higher LACI than controls, suggesting atrioventricular interaction alterations. 4 TECHNICAL EFFICACY: 3.

Left atrial function in patients with rheumatic mitral stenosis: addressing prognostic insights beyond atrial fibrillation prediction.

Rheumatic mitral stenosis (MS) frequently leads to impaired left atrial (LA) function because of pressure overload, highlighting the underlying atrial pathology. Two-dimensional speckle tracking echocardiography (2D-STE) offers early detection of LA dysfunction, potentially improving risk assessment in patients with MS. This study aims to evaluate the predictive value of LA function assessed by 2D-STE for clinical outcomes in patients with MS. Between 2011 and 2021, patients with MS underwent LA function assessment using 2D-STE, with focus on the reservoir phase (LASr). Atrial fibrillation (AF) development constituted the primary outcome, with death or valve replacement as the secondary outcome. Conditional inference trees were employed for analysis, validated through sample splitting. The study included 493 patients with MS (mean valve area 1.1 ± 0.4 cm2, 84% female). At baseline, 166 patients (34%) had AF, with 62 patients (19%) developing AF during follow-up. LASr emerged as the primary predictor for new-onset AF, with a threshold of 17.9%. Over a mean 3.8-year follow-up, 125 patients (25%) underwent mitral valve replacement, and 32 patients (6.5%) died. A decision tree analysis identified key predictors such as age, LASr, severity of tricuspid regurgitation (TR), net atrioventricular compliance (C n), and early percutaneous mitral valvuloplasty, especially in patients aged ≤49 years, where LASr, with a threshold of 12.8%, significantly predicted adverse outcomes. LASr emerged as a significant predictor of cardiovascular events in this MS cohort, validated through a decision tree analysis. Patients were stratified into low- or high-risk categories for adverse outcomes, taking into account LASr, age, TR severity, and C n.

Associations of Alcohol Consumption With Left Atrial Morphology and Function in a Population at High Cardiovascular Risk.

Excessive alcohol consumption has been associated with increased risk of atrial fibrillation, although the underlying mechanisms remain unclear. An enlarged left atrium and impaired left atrial function may lead to atrial fibrillation. The association of alcohol consumption with structural and functional left atrial measures, however, has received limited attention. We studied 503 participants from the PREDIMED-Plus (Prevención con Dieta Mediterránea) trial, a randomized trial testing intensive weight loss intervention with an energy-reduced Mediterranean diet and physical activity promotion in preventing cardiovascular disease in adults with metabolic syndrome. Participants underwent transthoracic echocardiography at baseline, year 3, and year 5 of the study. Outcomes of interest included volume index and reservoir, conduit, and contractile strains of the left atrium. Alcohol consumption was calculated through food frequency questionnaires and presented as drinks consumed per day. Multiple linear regression and mixed models estimated the association of alcohol consumption with left atrial measurements at baseline and through follow-up. Cross-sectionally, higher alcohol consumption (per 1 drink/day increases) was associated with larger left atrial volume (0.65 mL/m2 [95% CI, 0.18-1.11]) and lower left atrial reservoir and contractile strain (-0.44% [95% CI, -0.87 to -0.01]; and -0.44% [95% CI, -0.75 to -0.14]). Baseline alcohol consumption was not associated with changes in left atrial measurements, but increases in alcohol consumption (per 1 drink/day increase) during follow-up were associated with left atrial enlargement (0.71 mL/m2 [95% CI, 0.17-1.26]). In a population at high cardiovascular risk, increased alcohol consumption was associated with left atrial enlargement and worsening atrial function. URL: http://www.controlled-trials.com; Unique identifier: ISRCTN89898870.

Real-time cardiovascular magnetic resonance imaging for non-invasive characterisation of heart failure with preserved ejection fraction: final outcomes of the HFpEF stress trial

BackgroundThe diagnosis of heart failure with preserved ejection fraction (HFpEF) remains challenging. Recently, the HFpEF Stress Trial demonstrated feasibility and accuracy of non-invasive cardiovascular magnetic resonance (CMR) real-time (RT) exercise-stress atrial function imaging for early identification of HFpEF. However, no outcome data have yet been presented.MethodsThe HFpEF Stress Trial (DZHK-17) prospectively recruited 75 patients with dyspnea on exertion and echocardiographic preserved EF and signs of diastolic dysfunction (E/eʹ > 8). 68 patients entered the final study cohort and were characterized as HFpEF (n = 34) or non-cardiac dyspnea (n = 34) according to pulmonary capillary wedge pressure (HFpEF: PCWP rest: ≥ 15 mmHg stress: ≥ 25 mmHg). These patients were contacted by telephone and hospital charts were reviewed. The clinical endpoint was cardiovascular events (CVE).ResultsFollow-up was performed after 48 months; 1 patient was lost to follow-up. HFpEF patients were more frequently compared to non-cardiac dyspnea (15 vs. 8, p = 0.059). Hospitalised patients during follow-up had higher H2FPEF scores (5 vs. 3, p < 0.001), and impaired left atrial (LA) function at rest (p ≤ 0.002) and stress (p ≤ 0.006). Impairment of CMR-derived atrial function parameters at rest and during exercise-stress (p ≤ 0.003) was associated with increased likelihood for CVE. CMR-Feature Tracking LA Es/Ee (p = 0.016/0.017) and RT-CMR derived LA long axis strain (p = 0.003) were predictors of CVE independent of the presence of atrial fibrillation.ConclusionsLeft atrial function emerged as the strongest predictor for 4-year outcome in the HFpEF Stress Trial. A combination of rest and exercise-stress LA function quantification allows accurate diagnostic and prognostic stratification in HFpEF.Clinicaltrials.gov: NCT03260621.Graphical abstract

The value of serial echocardiography in risk assessment of patients with paroxysmal atrial fibrillation.

Progression from paroxysmal to persistent atrial fibrillation (AF) is associated with increased morbidity and mortality. We examined the association of left atrial (LA) remodeling by serial echocardiography, and AF progression over an extended follow-up period. Two-hundred ninety patients (mean age 61 ± 11years, 73% male) who underwent transthoracic echocardiography performed at first presentation for non-valvular paroxysmal AF (PAF) and repeat echocardiogram 1-year later, were followed for progression to persistent AF. LA and left ventricular (LV) dimensions, volumes, LA reservoir, conduit and booster pump strains, LV global longitudinal systolic strain (GLS) assessedby 2D speckle tracking, and PA-TDI (time delay between electrical and mechanical LA activation- reflecting the extent of LA fibrosis) were compared on serial echocardiography. Sixty-nine (24%) patients developed persistent AF over a mean follow-up period of 6.3years. At baseline, patients with subsequent persistent AF had larger LA dimensions (46mm vs. 42mm, p < 0.001), indexed LA volumes (41ml/m2 vs. 34ml/m2, p < 0.001), lower LA reservoir and conduit strain (17.6% vs. 27.6%, p < 0.001; 10.5% vs. 16.3%, p < 0.001; respectively) and longer PA-TDI (155ms vs. 132ms, p < 0.001) compared to the PAF group. Patients with subsequent persistent AF showed over time significant enlargement in LA volumes (from 37.7ml/m2 to 42.4ml/m2, p < 0.001), lengthening of PA-TDI (from 142.2ms to 162.2ms, p = 0.002), and decline in LA reservoir function (from 21.9% to 18.1%, p = 0.024) after adjusting for age, gender, diabetes and LV GLS. There were no changes in LA diameter, LA conduit or booster pump function. Conversely, the PAF group showed no decline in LA function. Patients who developed persistent AF had larger LAsize and impaired LA function and atrial conduction times at baseline, compared to patients who remained PAF. Over the 1-year time course of serial echocardiographic evaluation, there was progression of LA remodeling in patients who subsequently developed persistent AF, but not in patients who remained inPAF.

Impaired left atrial reservoir function associated with large v wave in patients with transthyretin amyloid cardiomyopathy

Abstract Background Impaired atrial function, in addition to ventricular diastolic dysfunction, is one of the hallmarks of cardiac amyloidosis (ATTR-CM). Two-dimensional speckle tracking echocardiography is a useful technique for quantitative assessment of LA stiffness. A large v wave on pulmonary artery wedge (PAW) pressure waveform is the findings suggesting LA overload and impaired LA reservoir function. Although large v waves on PAW pressure waveforms are sometimes observed in ATTR-CM patients, their hemodynamic background and clinical significance have not been well described. Purpose To investigate the clinical importance of LA function obtained by echocardiography and PAW pressure waveform and the association of enhanced large PAW v wave to clinical outcomes in ATTR-CM patients. Methods We retrospectively analyzed central hemodynamics in 136 ATTR-CM patients without severe mitral regurgitation. Large v wave was defined 10 mmHg above mean PAW pressure. We divided 136 ATTR-CM into large v wave group (n = 27) and non-large v wave group (n = 109), and compared the differences in baseline parameters and echocardiographic parameters. Results Patients in the large v wave group showed higher mean PAW pressure (24mmHg vs. 14mmHg, p&amp;lt;0.0001). There were no significant differences in age, prevalence of atrial fibrillation, high-sensitivity cardiac troponin T levels (0.060 ng/ml vs. 0.044 ng/mL, p = 0.341), B-type natriuretic peptide levels (188.3 pg/ml vs. 178.7 pg/mL, p = 0.386). In addition, LV ejection fraction, LA diameter, E/e` and cardiac index showed no significant differences between the two groups. However, LA peak longitudinal strain (LS) and LS rate (LSR), evaluation of LA reservoir function, expressed significant depression in large v wave group (LS: 6.24 % vs 9.21 %, p&amp;lt;0.0001, LSR: 0.29 1/s vs 0.38 1/s, p = 0.005). Conclusions In ATTR-CM patients, the impaired LA reservoir function associated with extent of large v wave on PAW pressure. This result suggested that impaired LA function may be useful for assessing the progression of ATTR-CM and the deterioration of central hemodynamics.

Diastolic disfunction in systemic right ventricle: a cardiac magnetic resonance study on atrial function in congenital corrected transposition of great arteries patients

Abstract Background congenital corrected transposition of great arteries (ccTGA) leads to systemic position of the right ventricle (sRV). Patients with ccTGA are usually asymptomatic in the first decades of life but over time sRV will fail to support elevated systemic pressure, possibly leading to systolic heart failure (HF) in adulthood. Several factors have been associated with sRV failure and worse prognosis such as tricuspid valve dysfunction, conduction abnormalities, previous surgery due to associated lesions. However, little is known about diastolic function in sRV. We hypothesize that diastolic dysfunction characterizes sRV pathophysiology, therefore an accurate evaluation of diastolic function would allow a better assessment and risk stratification of patients. The present study aims to investigate the diastolic function in patients with ccTGA by assessing left atrial (LA) morpho-functional parameters. Methods we retrospectively examined Cardiac Magnetic Resonance (CMR) imaging of 33 ccTGA patients clinically referred to our Center between April 2014 and December 2022. ccTGA patients were matched based on sex and age with a healthy volunteer population (control group) and a group of patients with Hypertrophic Cardiomyopathy (HCM) diagnosed with HFpEF according to HF guidelines criteria. LA morpho-functional parameters were compared among the three groups: LA volumes (obtained by the length-area method), ejection fraction (EF) and, by means of feature tracking analysis, strain reservoir (εs), conduit (εe) and booster pump (εa). All patients were in sinus rhythm at the time of CMR. Results In comparison with the control group, ccTGA patients had a significant impairment in LA function (LA EF: 41,6 ± 15,1 vs 63,9 ± 7,8, p &amp;lt; 0,001, εs: 19,0 ± 8,3 vs 38,0 ± 10,3, p &amp;lt; 0,001, εe: 11,7 ± 5,9 vs 21,1 ± 8,3 p &amp;lt; 0,001, εa: 7,6 ± 4,1 vs 16,8 ± 6,1, p &amp;lt; 0,001). Conversely, no significant difference was found between ccTGA and HCM group regarding LA function (EF: 41,6 ± 15,1 vs 42,0 ± 10,1, εs: 19,0 ± 8,3 vs 22,6 ± 8,8, εe: 11,7 ± 5,9 vs 12,6 ± 7,0, εa: 7,6 ± 4,1 vs 10 ± 3,7). As for morphological parameters, ccTGA patients had an increase of LA volumes compared to both the control group and HCM patients. Conclusion ccTGA patients present an impaired LA function and a significative increase in LA volume consistent with the presence of diastolic disfunction. Further studies are needed to assess the clinical impact of morpho-functional LA impairment in ccTGA patients.

Left atrial strain measurement to predict new-onset atrial fibrillation in ST-elevation myocardial infarction patients

Abstract Background/Introduction ST-elevation myocardial infarction (STEMI) remains a healthcare burden not only through increased mortality risk, but also development of chronic cardiac pathologies like atrial fibrillation (AF). Left atrial (LA) reservoir strain is a known predictor of incident AF in the general population. Purpose Our aim was to explore the additional prognostic value of LA reservoir strain measured by transthoracic echocardiography (TTE) in STEMI patients for new-onset atrial fibrillation (NOAF). Methods Data were analyzed retrospectively from an ongoing STEMI registry. Patients with previous myocardial infarction, AF, known history of heart failure, severe valvular pathology, suboptimal image quality, AF during TTE or missing follow-up were excluded. TTE was performed within 48 hours of hospitalization. LA reservoir strain was measured in apical 4-chamber view. LA strain &amp;lt;23% was used as cut-off value for impaired LA function as previously established. The endpoint was NOAF. Follow-up was censored at last patient visit or at 5 years. Results In total 1238 patients (mean age 60±12 years; 930 (75%) men) were included. After median follow-up of 22 months (IQR 12; 60) 106 (8.6%) patients developed NOAF, most events (71 (67%)) taking place within the first year after STEMI. Mean LA reservoir strain was more impaired in patients who developed NOAF as compared to those who did not (19.3 ± 8.1% versus 24.3 ± 8.8% respectively (p&amp;lt;0.001). Clinical and echocardiographical characteristics are shown in the table. Cumulative event-free survival rates at 1, 3 and 5 years in patients with preserved versus decreased LA strain were 97%, 95% and 93% versus 91%, 89% and 83% respectively (Log-rank X2 = 21.1; p&amp;lt;0.001; Figure). Factors significant on univariable Cox regression analysis (age, presence of chronic obstructive pulmonary disease, troponin levels, left ventricular end-diastolic diameter, interventricular septum diameter, left ventricular global longitudinal strain, LA volume index, LA reservoir strain, E/E’ ratio and right ventricular fractional area change) were included in multivariable model, where LA reservoir strain remained significantly associated with NOAF (HR 0.96 (0.93 – 0.99); p=0.015). Addition of LA strain provided incremental prognostic value over baseline clinical risk factors, traditional TTE parameters and left ventricular global longitudinal strain (X2 84.5 vs 88.8; p=0.013). Conclusion LA reservoir strain was associated with new-onset atrial fibrillation in STEMI patients after adjusting for relevant clinical and echocardiographic risk factors.TableFigure

Left Atrial Mechanical Function And Stiffness In Patients With Premature Ventricular Contraction: A Speckle Tracking Study.

Ventricular extrasystole (PVC) is characterized by premature ventricular depolarization and is associated with increased risk of arrhythmias and structural heart disease. This study aimed to investigate the association between the PVC burden and left atrial (LA) function in individuals without known cardiac disease. A cross-sectional study was conducted on 102 patients with PVCs who were admitted to a cardiology clinic. Transthoracic echocardiography was used to assess left ventricle (LV) parameters, including LV mass, LV ejection fraction (LVEF), LV global longitudinal strain (LVGLS), and LA function was evaluated using strain imaging. The PVC burden was categorized into three groups: &lt;10 %, 10-20 %, and &gt;20 %. Changes in LV dimensions and LV mass index were associated with the groups with the PVC burden with 10-20 %, and &gt;20 %. but differences in LVEF and LVGSL were not significant. Mean E / e' increased as the PVC burden increased (p&lt;0.001). The mean global LA peak strain decreased as the PVC burden increased (p&lt;0.001), while other mean LA measurements increased as the PVC burden increased (p&lt;0.001) A higher PVC burden was associated with impaired LA function, as indicated by decreased global LA peak strain (PVC burden &lt;10 %=38.1±3.2 vs. PVC burden 10-20 %=32.4±3.2 vs. PVC burden &gt;20 %=27.7±2.6, in all groups p&lt;0.001) and with increased LA stiffness (PVC burden &lt;10 %=18.6±3.2 vs. PVC burden 10-20 %=27.5±5.5 vs. PVC burden &gt;20 %=39.0±7.9, in all groups p&lt;0.001). A strong negative correlation was found between global LA peak strain and LA stiffness (r=-0.779, p&lt;0.001). In individuals without known cardiac disease, a higher PVC burden was associated with impaired LA function, indicated by increased E / e', decreased LA strain, and increased LA stiffness. These findings suggest that PVC burden may contribute to LA dysfunction, potentially increasing the risk of cardiovascular events.

Evaluation of left atrial and ventricular remodeling in atrial fibrillation subtype by using speckle tracking echocardiography.

Atrial fibrillation (AF) is associated with cardiac structural and functional remodeling. We investigated the left atrial (LA) and left ventricular (LV) changes in AF subtypes by using two-dimensional echocardiography strain techniques. The study population consisted of 102 subjects with sinus rhythm (control group) and 463 patients with AF, among which 284 patients had paroxysmal AF (PAF) and 179 patients had persistent AF (PerAF). A speckle tracking automatic functional imaging software was used to perform the strain analysis. Patients with AF had dilated LA maximum and minimum volume, decreased LA reservoir strain, lower LV ejection fraction (LVEF), and impaired global longitudinal strain (GLS) compared to those of the sinus rhythm control group. In patients with PerAF, the LA maximum and minimum volumes were larger, and the LA reservoir strain [PAF vs. PerAF, 28% (21,33) vs. 19% (14, 28), P < 0.05], LVEF, and absolute GLS value (PAF vs. PerAF, -16.9 ± 3.3 vs. -14.1 ± 3.5%) were lower than those in patients with PAF. Patients with AF regardless of LA enlargement had decreased LA reservoir strain and lower LVEF and absolute GLS value than those in the sinus rhythm control group. Compared with those with normal sinus rhythm, patients with AF had dilated LA volume and impaired LA function, which were further worsened in patients with PerAF than those in patients with PAF. LA functional impairment occurred before LA enlargement. Left atrioventricular remodeling happened across different stages of AF development.

Cardiac Magnetic Resonance Imaging-Derived Left Atrial Characteristics in Relation to Atrial Fibrillation Detection in Patients With an Implantable Cardioverter-Defibrillator.

Background Among patients with an implantable cardioverter-defibrillator, a high prevalence of atrial fibrillation (AF) is present. Identification of AF predictors in this patient group is of clinical importance to initiate appropriate preventive therapeutic measures to reduce the risk of AF-related complications. This study assesses whether cardiac magnetic resonance imaging-derived atrial characteristics are associated with AF development in patients with a dual-chamber implantable cardioverter-defibrillator or cardiac resynchronization therapy defibrillator, as detected by the cardiac implantable electronic device. Methods and Results This single-center retrospective study included 233 patients without documented AF history at the moment of device implantation (dual-chamber implantable cardioverter-defibrillator [63.5%] or cardiac resynchronization therapy defibrillator [36.5%]). All patients underwent cardiac magnetic resonance imaging before device implantation. Cardiac magnetic resonance-derived features of left atrial (LA) remodeling were evaluated in all patients. Detection of AF episodes was based on cardiac implantable electronic device interrogation. During a median follow-up of 6.1 years, a newly diagnosed AF episode was detected in 88 of the 233 (37.8%) patients with an ICD. In these patients, increased LA volumes and impaired LA function (LA emptying fraction and LA strain) were found as compared with patients without AF during follow-up. However, a significant association was only found in patients with dilated cardiomyopathy and not in patients with ischemic cardiomyopathy. Conclusions LA remodeling characteristics were associated with development of AF in patients with dilated cardiomyopathy but not patients with ischemic cardiomyopathy, suggesting different mechanisms of AF development in ischemic cardiomyopathy and dilated cardiomyopathy. Assessment of LA remodeling before device implantation might identify high-risk patients for AF.

Myocardial deformation as a stratification tool in HCM

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Sudden cardiac death (SCD) is a major issue in hypertrophic cardiomyopathy (HCM) management, and its risk prediction stays challenging for clinicians. Ventricular arrythmias (VAs) have to be treated rapidly, indeed VAs lower prognosis in HCM patients. Current ESC guidelines for cardioverter-defibrillator implantation include left atrial (LA) whereas left ventricle (LV) ejection function (LVEF) is incorporated in AHA latest guidelines. We explore the potential role of LA and LV strain as more sensible parameters in HCM rhythmic prognostication. Purpose To assess LA and LV strain in risk stratification in HCM patients as accurate markers of SCD. Methods Patients with newly diagnosed HCM were enrolled in three French University Hospital (Marseille, Bordeaux and Rennes) between 2007 and 2018. At the inclusion we realized a comprehensive clinical exam, biological analysis, an echocardiography including LA strain in two and four apical-chambers, and a MRI. Composite primary endpoint (PE) analysis was occurrence of rhythmic related adverse cardiac events: ventricular tachycardia (VT), ICD therapy for ventricular arrhythmia, or all-cause death. Occurrence and dates of endpoints were retrieved by patient’s medical records and phone calls to all patients and family members. Results At a mean follow-up of 57 (34–82) months, patients with adverse cardiac events (n = 52) presented with more impaired LA and LV deformation function. After multivariate analysis, we found a significant association between impaired LA strain and our composite primary endpoint P 0,023 HR 0,95. LV strain revealed to be correlated with our PE P 0,012 HR 2,48. Conclusions Myocardial deformation appears to be a relevant marker which could be linked to sudden cardiac death in HCM. These parameters might be relevant in new risk calculators.

Left Atrial Strain Imaging by Speckle Tracking Echocardiography: The Supportive Diagnostic Value in Cardiac Amyloidosis and Hypertrophic Cardiomyopathy.

Background: Left atrial (LA) function is crucial for assessing left ventricular filling in various cardiovascular conditions. Cardiac Amyloidosis (CA) is characterized by atrial myopathy and LA function impairment, with diastolic dysfunction up to restrictive filling pattern, leading to progressive heart failure and arrhythmias. This study evaluates LA function and deformation using speckle tracking echocardiography (STE) in patients with CA compared to a cohort of patients with sarcomeric Hypertrophic Cardiomyopathy (HCM) and a control group. Methods: We conducted a retrospective, observational study (from January 2019 to December 2022) including a total of 100 patients: 33 with ATTR-CA, 34 with HCMs, and 33 controls. Clinical evaluation, electrocardiograms, and transthoracic echocardiography were performed. Echocardiogram images were analyzed in post-processing using EchoPac software for LA strain quantification, including LA-reservoir, LA-conduit, and LA-contraction strain. Results: The CA group exhibited significantly impaired LA function compared to HCMs and control groups, with LA-reservoir median values of -9%, LA-conduit -6.7%, and LA-contraction -3%; this impairment was consistent even in the CA subgroup with preserved ejection fraction. LA strain parameters correlated with LV mass index, LA volume index, E/e', and LV-global longitudinal strain and were found to be associated with atrial fibrillation and exertional dyspnea. Conclusions: LA function assessed by STE is significantly impaired in CA patients compared to HCMs patients and healthy controls. These findings highlight the potential supportive role of STE in the early detection and management of the disease.

Obesity, epicardial adipose tissue and left atrial cardiomyopathy in patients with heart failure with preserved ejection fraction: a cardiac MRI based study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): unrestricted grant from Abbott-Netherlands to the University Medical Center Groningen Introduction Atrial fibrillation (AF) and heart failure (HF) with preserved ejection fraction (HFpEF) commonly co-exist and both conditions are typically characterized by impaired left atrial (LA) function. While obesity is an important contributor to both AF and HFpEF, it has been suggested that specifically epicardial adipose tissue (EAT) may be involved in the pathophysiology of these diseases. However, data on the relation between EAT and atrial function using cardiac magnetic resonance imaging (MRI) is scarce. In this study we aimed to investigate the association of body mass index (BMI) and EAT with LA function in patients with HFpEF. Methods Patients with symptomatic HF and left ventricular ejection fraction &amp;gt;40% were enrolled. All patients underwent cardiac MRI. LA function was assessed using the cine long-axis 4-chamber and 2-chamber acquisitions. EAT volume was quantified on the short-axis cine-stacks and indexed for BSA. Patients were divided according to the presence of obesity (BMI &amp;gt;30 kg/m2) and by low and high EAT (i.e. &amp;gt;100 ml/m2). Results In total, 125 patients were included. Mean age was 71±10 years, 62 (50%) were women and mean BMI was 30±6 kg/m2. In total, 56 (45%) patients were obese, 56 (48%) had high EAT, 68 (54%) had a diagnosis of AF, 98 (78%) had hypertension, 48 (38%) had diabetes mellitus and 44 (35%) had coronary artery disease. There was no difference in LA end-systolic volume (63 vs. 59 ml/m2, p=0.6), LA emptying fraction (31 vs. 30%, p=0.9) and LA reservoir strain (15 vs. 14%, p=0.4) between obese and non-obese patients. However, when patients were divided according to EAT volume, patients with high EAT had higher LA end-systolic volume (67 vs. 56 ml/m2, p=0.01) and lower LA reservoir strain (12 vs 17%, p=0.03), as compared to patients with low EAT. LA emptying fraction was not significantly different between high and low EAT (38 vs. 33%, p=0.1). There was no significant correlation between BMI and LA end-systolic volume, LA emptying fraction and LA reservoir strain (data not shown). On the contrary, there was a significant correlation between EAT and LA end-systolic volume (r=0.3, p=0.002), LA emptying fraction (r= -0.2, p=0.01) and LA reservoir strain (r= -0.2, p=0.006). There were no differences in the presence of AF between obese and non-obese patients (57 vs 52%, p=0.6) and between high and low EAT (59 vs. 54%, p=0.6). Conclusion In patients with HFpEF, increased EAT but not obesity was associated with LA dysfunction. The cause effect relation between epicardial adipose tissue, atrial cardiomyopathy and the development of AF in patients with HFpEF need further investigation.

Electrophysiological findings in HFpEF patients presenting for AF ablation

Abstract Funding Acknowledgements Type of funding sources: None. Aims The prevalence of atrial fibrillation (AF) in heart failure with preserved ejection fraction (HFpEF) patients is high. Impaired left atrial (LA) function is a major determinant in HFpEF. The extent of arrhythmogenic left atrial tissue degeneration in HFpEF patients is unknown. Methods and results We prospectively enrolled consecutive patients presenting for first time AF ablation. Each patient underwent baseline laboratory and transthoracic echocardiography assessment. The HFA-PEFF score was utilized to identify HFpEF patients. Bipolar high density voltage mapping [1213 (825 to 1606) mapping points] was created in sinus rhythm prior to PVI to evaluate the general LA bipolar voltage and quantify areas of low voltage, a well known surrogate for fibrosis and arrhythmogenesis. 160 patients were enrolled (55 % male). 42 patients (26 %) suffered from HFpEF. Low voltage areas (LVAs) were present in 84 patients (53 %). HFpEF was associated with generally decreased LA bipolar voltage (0.95 ± 0.45 mV vs. 1.59 ± 0.91 mV respectively; p &amp;lt; 0.001) (Fig. 1) and predictive for the existence of low voltage areas (81 % vs. 45 % low voltage area positive, respectively; p = 0.006). The HFA-PEFF score inversely correlated with LA bipolar voltage (r = - 0.380; p &amp;lt; 0.001) (Fig. 1). Furthermore, the HFA-PEFF score closely correlated to the extent of LVAs (r = 0.275; p = 0.001) and to the low voltage amplitude of atrial myocardium excluding areas of low voltage (r = - 0.403; p &amp;lt; 0.001). Conclusion HFpEF is highly predictive for generally decreased LA bipolar voltage and for the existence of fibrotic and arrhythmogenic left atrial tissue degeneration.

Prevalence of glucose metabolism disorders and its association with left atrial remodelling before and after catheter ablation in patients with atrial fibrillation

To investigate the exact prevalence of glucose metabolism disorders, and their impact on left atrial (LA) remodelling and reversibility in patients with atrial fibrillation (AF). We examined 204 consecutive patients with AF who underwent their first catheter ablation (CA). Oral glucose tolerance test was used to evaluate glucose metabolism disorders in 157 patients without known diabetes mellitus (DM). Echocardiography was performed before and 6 months after CA. Oral glucose tolerance test identified abnormal glucose metabolism in 86 patients [11 with newly diagnosed DM, 74 with impaired glucose tolerance (IGT) and 1 with impaired fasting glucose (IFG)]. Ultimately, 65.2% of patients had abnormal glucose metabolism. Diabetes mellitus group had the worst LA reservoir strain and LA stiffness (both P < 0.05), while there was no significant difference in baseline LA parameters between normal glucose tolerance (NGT) group and IGT/IFG group. The prevalence of LA reverse remodelling (≥15% decrease in the LA volume index at 6 months after CA) was significantly higher in NGT group compared with IGT/IFG and DM group (64.1 vs. 38.6 vs. 41.5%, P = 0.006). Both DM and IFG/IGT carry a significant risk of lack of LA reverse remodelling independent of baseline LA size and AF recurrence. Approximately 65% of patients with AF who underwent their first CA had abnormal glucose metabolism. Patients with DM had significantly impaired LA function compared with non-DM patients. Impaired glucose tolerance/IFG as well as DM carries significant risk of unfavourable LA reverse remodelling. Our observations may provide valuable information regarding the mechanisms and therapeutic strategies of glucose metabolism-related AF.