LA Deformation Research Articles

The Effect of Upright Posture on Left Atrial Strain in Competitive Athletes.

Left atrial strain (LAS) assessment by speckle tracking echocardiography (STE) has been shown to be a remarkable means of quantifying LA function as an early marker of LV pathology. As exercise testing is also performed on a treadmill, the aim of this study was to investigate the effect of upright posture on LAS in healthy athletes. Fifty male athletes (mean age 25.7 ± 7.3 years) underwent transthoracic echocardiography (TTE) in the upright and left lateral positions. In addition to the conventional echocardiographic parameters, in all athletes, LA conduction strain (LAScd), contraction strain (LASct), reservoir strain (LASr), and maximum LA volume (LAVmax) were assessed by STE in both positions. Comparing upright posture and the left lateral position, LAScd (-14.0 ± 5.9% vs. -27.4 ± 7.1%; p < 0.001), LASct (-4.6 ± 3.5% vs. -11.3 ± 4.1%; p < 0.001), LASr (18.7 ± 7.6% vs. 38.7 ± 8.0%; p < 0.001), and LAVmax (24.4 ± 8.8% vs. 50.0 ± 14.2%) differed significantly. Upright posture has a significant effect on LA deformation, with decreased LAScd, LASct, and LASr. The results of this study contribute to the understanding of athletes' hearts and must be considered when performing echocardiography in healthy athletes on a treadmill.

Sex-specific differences in bi-atrial strain in elite athletes: results from the ELITE cohort

Abstract Background Athletes frequently demonstrate increased atrial volumes as a result of physiological adaptation to sports. In the general population, atrial dilatation is associated with decreased atrial function, measured as atrial ejection fraction and strain. However, studies on bi-atrial function in athletes have been limited and have primarily focused on male endurance athletes. Purpose To determine sex-specific differences in left- and right atrial strain in elite athletes. Methods The study population consisted of elite athletes included in the ELITE-cohort older than 16 years of age and exercising ≥10 hours per week and competing at the highest national, international or Olympic level in the Netherlands. All included athletes underwent a standardised resting transthoracic echocardiogram. Left- and right atrial (LA/RA) reservoir-, conduit- and cntractile- strain were measured with grey-scale-based 2D Speckle tracking software in the four- and two-chamber views and bi-atrial volume and function parameters were collected. Results A total of 166 elite athletes were included (48.2% female, media age 25 years [22, 28]), with athletic disciplines road cycling 25.3%, hockey 16.9%, rowing 14.5%, soccer 12.7%, water polo 9.6%, sailing 6.0%, track cycling 3.6%, and other 11.6%. There were no sex differences in age and training hours (18 hours per week). Athletic disciplines were evenly distributed among female- and male athletes. Female athletes had a lower BSA than male athletes (1.8 cm2 [1.7, 1.9] vs 2.1 cm2 [1.9, 2.2], p &amp;lt;0.001). Female athletes had similar LAESVi (36.5 ml/cm2 [32.0, 42.0] vs 36.5 ml/cm2 [31.0, 47.8]) and LAESAi (11.2 cm2/m2 [9.5, 12.2] vs 10.6 cm2/m2 [9.0, 11.9]) compared with male athletes. Female athletes had a higher LAEF (63.2 ±6.2% vs 60.7 ±5.8%, p =0.007) and greater LA deformation than male elite athletes during the reservoir- (34.7 ±6.2% vs 31.4 ±4.9%, p &amp;lt;0.001) and conduit phase (-25.2 ±5.2% vs -22.6 ±3.7% p &amp;lt;0.001). LA deformation during the contractile phase (-9.0% [-12.0, -7.0] vs – 9.0% [-11,-7]) was similar (figure 1). Female athletes had a lower RAESVi (29.5 ml/m2 [25.2, 36.4] vs 35.3 ml/m2 [28.5, 41.9], p &amp;lt;0.01) but there were no differences in RAEF (42.6 ±10.3% vs 45.2 ±11.1%) and RAESAi (9.8cm2/m2 [8.8, 11.3] vs 10.1 cm2/m2 [8.8-11.3]). There were no differences in RA reservoir- (30.7 ±7.6% vs 29.4 ±8.0%), conduit (-21.4 ±6.6% vs -20 ±6.6%) and contractile strain (-9.0% [-11.0, -6.8] vs -9.0% [-11.8, -7.0]) (figure 2). Conclusion In both male and female elite athletes, the LA is of comparable area and volume. However, in female athletes LA deformation is greater during the reservoir and conduit phases, resulting in a greater LA ejection fraction in the presence of similar LA contractile deformation. Conversely, RA volumes were smaller in female athletes, but deformation was similar compared with male athletes. Our findings suggest the presence of sex-specific atrial exercised-induced adaptation.Figure 1.Figure 2.

Dynamics of left and right atrial strain after radiofrequency ablation in patients with paroxysmal and persistent atrial fibrillation

Aim. To assess the dynamics of left (LA) and right atrium (RA) strain after antral pulmonary vein isolation in patients with paroxysmal and persistent atrial fibrillation.Methods. The study included 57 subjects (31 men and 26 women) aged of 55.4±9.8 years. Patients were divided into 2 groups: group 1 with paroxysmal atrial fibrillation (n=40; 70%) and group 2 with persistent atrial fibrillation (n=17; 30%). All patients were treated (were undergone) with antral isolation of the pulmonary veins. Speckle-tracking echocardiography at sinus rhythm was performed before interventional treatment, after 3 days, 3 months and one year. The reservoir, conduit and contractile LA function and peak longitudinal RA strain were analyzed.Results. In both groups, reservoir (p&lt;0.001), conductive (p&lt;0.001) and contractile LA functions (p&lt;0.001 and p=0.001) decreased significantly in the early postoperative period. LA mechanics recovered after 3 months in all patients and were comparable to the level before and one year after radiofrequency ablation. RA strain was significantly increased in the early postoperative period. RA strain was significantly higher at one year follow-up period compared with baseline.Conclusion. Catheter ablation has a damaging effect on the LA - inhibition of reservoir, conductive and contractile functions in the early postoperative period, while the RA strain is intensified. LA strain is recovered in 3 months after radiofrequency ablation and remains comparable with the baseline level at one year follow-up. Reservoir and conduction function of LA and longitudinal deformation of RA are better in the patients with a stable sinus rhythm for a year after ablation compared with patiens who had a tachyarrhythmia recurrence.

Left atrial deformation discloses atrial amyloid infiltration among patients with increased myocardial thickness

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Swedish research council Swedish heart and lung foundation Background Transthyretin cardiac amyloidosis (ATTR-CA) is an infiltrative disease with thickening and stiffening of the heart walls as a result. Amyloid deposits are found not only in the ventricular walls, but in the atriums as well. Atrial function is known to play an integral part in the overall function of the heart. Purpose We aimed to evaluate left atrial deformation including left ventricular-atrial strain loop (LV-LA loop). The latter to test LA deformation and its dependence of LV deformation in ATTR CA and compare it to left ventricular hypertrophy (LVH). Methods Retrospective analysis was performed on available echocardiographic data, obtained between years 2004–2022. The study population was divided into three groups: healthy controls with no identified cardiac disease; ATTR-CA patients with verified ATTR-CA diagnosis and interventricular septal thickness end diastole (IVSd) of ≥14mm; LVH including IVSd ≥14mm and no CA diagnosis. Left heart strain measurements, including LV global longitudinal strain (LV GLS) and LA peak atrial longitudinal strain (LA PALS), were acquired from apical 4-chamber view during same single heart cycle. Strain coordinates throughout the heart cycle were plotted using MATHLAB, combining LV GLS and LA PALS to compute a strain-strain loop. A slope was determined using regression line to index relative function of the left ventricle to left atrium (GLS-PALS-slope). Results Data was gathered in total of 90 patients (67.8±1.2 years, 55,6% male) divided into three groups containing 30 patients each: ATTR-CA including 24 hereditary ATTR (including mutations; 19 Val30Met, one The60Ala, one Val122Ile, one Ala45Glys, one Ala97Ser and one His88Arg) and six wild type ATTR, LVH with increased myocardial thickness believed caused by aortic stenosis (n=13; one grade I, three grade II-III and eight grade III), essential hypertension (n=10) and hypertrophic cardiomyopathy (n=7, four of which had outflow obstruction). The lowest PALS and PALS-GLS slope was detected in ATTR-CA (p-value 0.005 respectively 0.003 between ATTR-CA compared to LVH). No significant statistical difference could be verified in GLS between ATTR-CA and LVH (p-value 0.114). A ROC curve of ATTR-CA demonstrated similar results between PALS and GLS-PALS slope (AUC 0.79 resp. 0.78) which was slightly higher than GLS (AUC 0.69). Slightly higher AUC was generated when slope was indexed with LAVI (AUC 0.80). Conclusions LA deformation demonstrates a strong ability to differentiate ATTR-CA from LV hypertrophy. Adding LV strain in relation to LA deformation showcases the mechanical dissociation of LA to LV in ATTR-CA, potentially unmasking atrial infiltration. Its use in prognostic evaluation needs further studies.

Ventricular-atrial coupling in subjects with normal, preserved, and reduced left ventricular ejection fraction: insights from cardiac magnetic resonance imaging.

To assess the correlation between LA and LV strain measurements in different clinical scenarios and evaluate to what extent LA deformation contributes to the prognosis of patients. A total of 297 consecutive participants including 75 healthy individuals, 75 hypertrophic cardiomyopathy (HCM) patients, 74 idiopathic dilated cardiomyopathy (DCM), and 73 chronic myocardial infarction (MI) patients were retrospectively enrolled in this study. The associations of LA-LV coupling with clinical status were statistically analyzed by correlation, multiple linear regression, and logistic regression. Survival estimates were calculated by receiver operating characteristic analyses and Cox regression analyses. Overall, moderate correlations were found between LA and LV strain in every phase of the cardiac cycle (r: -0.598 to -0.580, all p < 0.001). The slope of the regression line of the individual strain-strain curve had a significant difference among 4 groups (-1.4 ± 0.3 in controls, -1.1 ± 0.6 in HCM, -1.8 ± 0.8 in idiopathic DCM, -2.4 ± 1.1 in chronic MI, all p < 0.05). During a median follow-up of 4.7 years, the total LA emptying fraction was independently associated with primary (hazard ratio: 0.968, 95% CI: 0.951-0.985) and secondary endpoints (hazard ratio: 0.957, 95% CI: 0.930-0.985) with an area under the curve (AUC) of 0.720 respectively, 0.806, which was significantly higher than the AUC of LV parameters. The coupled correlations between the left atria and ventricle in every phase and the individual strain-strain curve vary with etiology. LA deformation in late diastole provides prior and incremental information on cardiac dysfunction based on LV metrics. The total LA emptying fraction was an independent indicator for clinical outcome superior to that of LV typical predictors. Left ventricular-atrial coupling is not only valuable for comprehending the pathophysiological mechanisms of cardiovascular diseases caused by different etiologies but also holds significant importance for the prevention of adverse cardiovascular events and targeted treatment. • In HCM patients with preserved LVEF, LA deformation is a sensitive indicator for cardiac dysfunction prior to LV parameters with a reduced LA/LV strain ratio. • In patients with reduced LVEF, LV deformation impairment is more consequential than that of the LA with an increased LA/LV strain ratio. Furthermore, impaired LA active strain indicates potential atrial myopathy. • Among LA and LV parameters, the total LA emptying fraction is the best predictor for guiding clinical management and follow-up in patients with different statuses of LVEF.

Percutaneous left atrial appendage occlusion: impact on left atrial deformation indices.

Percutaneous left atrial appendage occlusion (LAAO) is an accepted alternative to thromboprophylaxis in patients with atrial fibrillation (AF) who are: (i) intolerant to oral anticoagulation (OAC) (e.g. life-threatening haemorrhage), (ii) non-adherent to OAC, or (iii) at a high bleeding risk with OAC. Improvement in LA mechanics was shown post-LAAO in the LAFIT-LARIAT study, using the Lariat device. No significant change was seen in LA mechanics after LAAO with the Watchman device in the LAFIT-Watchman study. The impact of LAAO with the Amplatzer or Amulet device on LA deformation mechanics has not been investigated. To evaluate the impact of LAAO with the Amplatzer or Amulet device on echocardiographic LA deformation indices. All patients undergoing percutaneous LAAO from 2013 to 2021 at a single centre were included from an ongoing clinical registry. LA reservoir (εreservoir), conduit (εconduit) and contractile strain (εcontractile) and strain rate (SRreservoir, SRconduit, SRcontractile) were assessed with two-dimensional speckle tracking echocardiography from an apical four-chamber view. Conduit and contractile strain and strain rates were only recorded for patients without AF at the time of echocardiography. Changes in LA deformation indices over time were compared with a linear mixed model. 28 LAAO recipients (mean age 73 ± 12 years, 68% male) were analysed. 5 (18%) patients had AF pre- or post-procedure. After a mean follow-up of 1.6 ± 1.4 months, the mean LA εreservoir increased from 10.15 ± 6.44% to 10.18 ± 8.72% (p = 0.985), the mean LA εconduit increased from 5.12 ± 5.48% to 5.31 ± 6.11% (p = 0.891) and the mean LA εcontractile decreased from 5.14 ± 4.32% to 4.95 ± 5.30% (p = 0.898). During the same time interval, the mean LA SRreservoir decreased from + 0.54 ± 0.23.s- 1 to + 0.48 ± 0.43.s- 1 (p = 0.566), the mean LA SRconduit remained stable: -0.47 ± 0.41.s- 1 to -0.47 ± 0.32.s- 1 (p = 0.997) and the mean LA SRcontractile decreased from - 0.66 ± 0.50.s- 1 to -0.55 ± 0.46.s- 1 (p = 0.660). No significant improvement in LA mechanical function was seen after LAAO with the Amplatzer or Amulet device. Different LAAO devices therefore appear to have divergent effects on LA deformation, the clinical implications of which may warrant further study.

New insights into the potential utility of the left atrial function analysis in heart failure with preserved ejection fraction diagnosis.

AimsNone of the conventional echocardiographic parameters alone predict increased NTproBNP level and symptoms, making diagnosis of heart failure with preserved ejection fraction (HFpEF) very difficult in some cases, in resting condition. We evaluated LA functions by 2D speckle tracking echocardiography (STE) on top of conventional parameters in HFpEF and preHF patients with diastolic dysfunction (DD), in order to establish the added value of the LA deformation parameters in the diagnosis of HFpEF.MethodsWe prospectively enrolled 125 patients, 88 with HFpEF (68±9 yrs), and 37 asymptomatic with similar risk factors with DD (preHF) (61±8 yrs). We evaluated them by NTproBNP, conventional DD parameters, and STE. Global longitudinal strain (GS) was added. LA reservoir (R), conduit (C), and pump function (CT) were assessed both by volumetric and STE. 2 reservoir strain (S) derived indices were also measured, stiffness (SI) and distensibility index (DI).ResultsLA R and CT functions were significantly reduced in HFpEF compared to preHF group (all p<0.001), whereas conduit was similarly in both groups. SI was increased, whereas DI was reduced in HFpEF group (p<0.001). By adding LA strain analysis, from all echocardiographic parameters, SR_CT<-1.66/s and DI<0.57 (AUC = 0.76, p<0.001) demonstrated the highest accuracy to identify HFpEF diagnosis. However, by multivariate logistic regression, the model that best identifies HFpEF included only SR_CT, GS and sPAP (R2 = 0.506, p<0.001). Moreover, SR_CT, DI, and sPAP registered significant correlation with NTproBNP level.ConclusionsBy adding LA functional analysis, we might improve the HFpEF diagnosis accuracy, compared to present guidelines. LA pump function is the only one able to differentiates preHF from HFpEF patients at rest. A value of SR_CT < -1.66/s outperformed conventional parameters from the scoring system, reservoir strain, and LA overload indices in HFpEF diagnosis. We suggest that LA function by STE could be incorporated in the current protocol for HFpEF diagnosis at rest as a major functional criterion, in order to improve diagnostic algorithm, and also in the follow-up of patients with risk factors and DD, as a prognostic marker. Future studies are needed to validate our findings.

Clinical implications of left atrial reverse remodelling after cardiac resynchronization therapy.

AimsLeft atrial (LA) function is a marker of prognosis in patients with heart failure. The prognostic implications of an improvement in LA function in addition to an improvement in left ventricular (LV) function after cardiac resynchronization therapy (CRT) implantation are unknown. This study aimed to evaluate the prognostic value of a significant change in LA reservoir strain (RS) and/or LV global longitudinal strain (GLS) after initiation of CRT.Methods and resultsLARS and LVGLS were measured with speckle-tracking echocardiography. Significant improvement in LARS and LVGLS was defined as a percentage change of +5% and +20% at 6 months after CRT implantation, respectively. Patients were divided into three groups: no significant reverse remodelling (no improvement in LARS and LVGLS), incomplete reverse remodelling (improvement in LARS or LVGLS), and complete reverse remodelling (improvement in LARS and LVGLS). The primary endpoint was all-cause mortality. A total of 923 patients (mean age 65 ± 10 years, 77% male) were included, of which 221 (24%) had complete reverse remodelling, 414 (45%) incomplete reverse remodelling, and 288 (31%) no significant reverse remodelling. Five-years’ mortality was 24%, 29%, and 36% for patients with complete, incomplete, and no significant reverse remodelling, respectively (P < 0.001). On multivariable analysis, complete reverse remodelling (hazard ratio 0.477; 95% confidence interval: 0.362–0.628; P < 0.001) was associated with the lowest risk of mortality.ConclusionsPatients with complete reverse remodelling have a lower mortality risk than those showing incomplete or no significant reverse remodelling. The use of integrated LA and LV deformation imaging may improve risk-stratification of CRT recipients.

Changes in left atrial function in patients undergoing cardioversion for atrial fibrillation: relevance of left atrial strain in heart failure

BackgroundLeft atrial (LA) reservoir strain provides prognostic information in patients with and without heart failure (HF), but might be altered by atrial fibrillation (AF). The aim of the current study was to investigate changes of LA deformation in patients undergoing cardioversion (CV) for first-time diagnosis of AF.Methods and resultsWe performed 3D-echocardiography and strain analysis before CV (Baseline), after 25 ± 10 days (FU-1) and after 190 ± 20 days (FU-2). LA volumes, reservoir, conduit and active function were measured. In total, 51 patients were included of whom 35 were in SR at FU-1 (12 HF and preserved ejection fraction (HFpEF)), while 16 had ongoing recurrence of AF (9 HFpEF). LA maximum volume was unaffected by cardioversion (Baseline vs. FU-2: 41 ± 11 vs 40 ± 10 ml/m2; p = 0.85). Restored SR led to a significant increase in LA reservoir strain (Baseline vs FU-1: 12.9 ± 6.8 vs 24.6 ± 9.4, p < 0.0001), mediated by restored LA active strain (SR group Baseline vs. FU-1: 0 ± 0 vs. 12.3 ± 5.3%, p < 0.0001), while LA conduit strain remained unchanged (Baseline vs. FU-1: 12.9 ± 6.8 vs 13.1 ± 6.2, p = 0.78). Age-controlled LA active strain remained the only significant predictor of LA reservoir strain on multivariable analysis (β 1.2, CI 1.04–1.4, p < 0.0001). HFpEF patients exhibited a significant increase in LA active (8.2 ± 4.3 vs 12.2 ± 6.6%, p = 0.004) and reservoir strain (18.3 ± 5.7 vs. 22.8 ± 8.8, p = 0.04) between FU-1 and FU-2, associated with improved LV filling (r = 0.77, p = 0.005).ConclusionReestablished SR improves LA reservoir strain by restoring LA active strain. Despite prolonged atrial stunning following CV, preserved SR might be of hemodynamic and prognostic benefit in HFpEF.Graphical abstract

Percutaneous left atrial appendage occlusion: impact on left atrial deformation indices

Abstract Background Percutaneous left atrial appendage occlusion (LAAO) is an accepted alternative to thromboprophylaxis in atrial fibrillation (AF) patients who are: i) intolerant to oral anticoagulation (OAC) (e.g. life-threatening haemorrhage), ii) non-adherent to OAC, or iii) at a high bleeding risk with OAC. Improvement in LA mechanics was shown post-LAAO in the LAFIT-LARIAT study, using the Lariat device (SentreHEART, Redwood City, CA, USA). No significant change was seen in LA mechanics after LAAO with the Watchman device (Boston Scientific, St. Paul, MN, USA) in the LAFIT-Watchman study. The impact of LAAO with the Amplatz or Amulet device (Abbot Vascular, St. Paul, MN, USA) on LA deformation mechanics, has not been investigated. Purpose To evaluate the impact of LAAO with the Amplatz or Amulet device on echocardiographic LA deformation indices. Methods All patients undergoing percutaneous LAAO from 2013 to 2021 at a single centre were included from an ongoing clinical registry. LA reservoir, conduit and contractile strain and strain rate were assessed with two-dimensional speckle tracking echocardiography from an apical four-chamber view. Conduit and contractile strain and strain rates were only recorded for patients without AF at the time of echocardiography. Changes in LA deformation indices over time were compared with a linear mixed model. Results 32 LAAO recipients (mean age 72±12 years, 63% male) were analysed. 5 (16%) patients had AF pre- or post-procedure. After a mean follow-up of 17 months, the mean LA reservoir strain increased from 11.8±7.7% to 12.9±9.1% (P=0.49), the mean LA conduit strain increased from 6.8±6.0% to 8.0±7.4% (P=0.42) and the mean LA contractile strain decreased from 5.7±5.2% to 5.3±5.4% (P=0.77). During the same time interval, the mean LA reservoir strain rate decreased from 0.68±0.44/s to 0.64±0.47/s (P=0.70), the mean LA conduit strain rate increased from −0.52±0.43/s to −0.44±0.32/s (P=0.42) and the mean LA contractile strain rate decreased from −0.77±0.55/s to −0.83±0.53/s (P=0.66). Conclusions No statistically significant improvement in LA mechanical function was seen after LAAO with the Amplatz or Amulet device, although a trend towards improved strain was observed for reservoir and conduit strain, with a worsening in contractile strain. Different LAAO devices therefore appear to have divergent effects on LA deformation, the clinical implications of which require further study. Funding Acknowledgement Type of funding sources: None.

Differences in left atrial stain, endothelial glycocalyx and arterial elasticity between ESUS, lacunar and atherosclerotic type of stroke

Abstract Background and purpose Patients with stroke are at high risk to develop cardiovascular complications. We assessed endothelial glycocalyx, aortic elastic properties, left atrial and ventricular function in patients with lacunar, atherosclerotic and stroke of undetermined source (ESUS). Methods In 68 patients (age 56,1±10.9) with acute cerebral stroke (22 lacunar, 19 atherosclerotic and 27 ESUS) and 20 controls with similar risk factors, we measured: (1) perfused boundary region (PBR) of the sublingual arterial microvessels (range 5–25 μm), a marker inversely related with glycocalyx thickness, (2) pulse wave velocity (PWV), central systolic blood pressure (cSBP), and augmentation index (AIx), (3) LA volume and strain using speckle-tracking imaging, and (4) left ventricular global longitudinal strain. Results Compared with controls, patients with stroke had higher PWV (11,38±3,62 vs 9,51±1,57 m/sec, p=0,045), PBR (2,10±0,27 vs 1,94±,020, p=0,039) and central SBP (139,64±26,31 vs 116,36±37,23 mmHg, p=0,039), while ventricular (−17,902±3,77 vs −19,87±1,17%, p=0,025) and atrial deformation (24,8±9,99 vs 39,050±2,08%, p&amp;lt;0.001) were impaired in patients with stroke (p&amp;lt;0.05). LA reservoir strain was more reduced in ESUS patients compared to other 2 stroke types (ESUS 21,7±6,6%, Lacunar 25,6±13,2%, atherosclerotic 22,3±7,8%, P&amp;lt;0.05). Regarding endothelial glycocalyx, PBR5–9 (the smallest vessels with diameter 5–9 μm) was higher in patients with ESUS than in the other two types of stroke (ESUS 1,22±0,12 μm, LACUNAR 1,19±0,12 μm, ATHEROSCLEROTIC 1,15±0,09 μm, p&amp;lt;0.05), despite the fact that PBR5–25 was similar between all stroke types (ESUS 2,09±0.23 μm, LACUNAR 2,13±0,33 μm, ATHEROSCLEROTIC 2,09±0,24 μm, p=0.8). PWV was significantly higher in patients with atherosclerotic stroke (15,57±5,50 m/sec, p=0,007), while in patients with lacunar it was mildly elevated (10,53±3,22 m/sec) and in ESUS patients it was moderately increased (11,7±3 m/sec). Conclusion Patients with stroke have impaired atrial strain, endothelial glycocalyx and arterial elasticity, compared with controls. Arterial stiffness is more affected in atherosclerotic stroke, while LA deformation and glycocalyx of small size micro vessels are more affected in ESUS patients. Funding Acknowledgement Type of funding sources: None.

Atrial Strain by Feature-Tracking Cardiac Magnetic Resonance Imaging in Takotsubo Cardiomyopathy. Features, Feasibility, and Reproducibility.

The purpose of this study was to investigate whether there may be a bi-atrial dysfunction in Takotsubo syndrome (TS) during the transient course of the disease, using cardiac magnetic resonance imaging feature tracking (CMR-FT) in analyzing bi-atrial strain. Eighteen TS patients and 13 healthy controls were studied. Reservoir, conduit, and booster bi-atrial functions were analyzed by CMR-FT. The correlation between LA and RA strain parameters was assessed. Intra- and inter-observer reproducibility was evaluated for all strain and strain rate (SR) parameters using intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Atrial strain were feasible in all patients and controls. Takotsubo patients showed an impaired LA Reservoir strain (∊s), LA Reservoir strain rate (SRs), LA and RA Conduit strain(∊e), LA and RA conduit strain rate (SRe) in comparison with controls (P < 0.001 for all of them), while no differences were found as to LA and RA booster deformation parameters (∊a and SRa). Analysis of correlation showed that LA ∊s, SRs, ∊e, and SRe were positively correlated with corresponding RA strain measurements (P < 0.001, r = 0.61 and P = 0,03, r = 0,54, respectively). Reproducibility was good to excellent for all atrial strain and strain rate parameters (ICCs ranging from 0,50 to 0,96). Atrial strain analysis using CMR-FT may be a useful tool to reveal new pathophysiological insights in Takotsubo cardiomyopathy. Additional studies, with a larger number of patients, are needed to confirm the possible role of these advanced CMR tools in characterizing TS patients.

Left atrial regional strain assessed by novel dedicated three-dimensional speckle tracking echocardiography

BackgroundLeft atrial (LA) global strain has been studied as an early marker of LA dysfunction, followed by LA dilatation. Recently, a novel dedicated software for LA 3-dimensional speckle tracking echocardiography (LA-3DSTE) has allowed us to assess anatomy-based six-segmental LA deformation. This study aimed to assess the accuracy of LA-3DSTE software in measuring LA volume and to reveal the characteristics of regional LA reservoir strain. MethodsFifty patients with paroxysmal atrial fibrillation who underwent computed tomography (CT) and 3D-STE were enrolled. The LA volumes obtained by 3D-STE and CT were compared, and regional LA strain was analyzed. Six LA segments (anterior, septal, inferior, lateral, roof, and posterior) were determined on the basis of LA anatomy. ResultsIn 50 patients (mean age, 64 years; 62% male), the 3D-STE-derived LA volume index (LAVI) showed good correlation with the CT-derived index, (r = 0.78, p < 0.001) with an underestimate bias of 10.5 ± 11.0 ml/m2 (p < 0.001). The lateral LA strain was negatively correlated with LAVI and emptying fraction, while the anterior and septal strains were not. In the 1st quantile LA volume group, the segmental LA strain was heterogeneous, that is, the lateral and inferior strains were greater than the anterior strain. While in the 3rd quantile LA volume group, the lateral and inferior strains were decreased, and there was no regional difference. ConclusionLA volume obtained by 3D-STE and CT showed a good correlation. LA segmental analysis by 3D-STE enables early identification of how LA dysfunction affects lateral and inferior LA strains, consistent with anatomical features.

A Systematic Review on the Correlations between Left Atrial Strain and Cardiovascular Outcomes in Chronic Kidney Disease Patients.

Left atrial strain (LASr) represents a relatively new but promising technique for left atrial and left ventricle function evaluation. LASr was strongly linked to myocardial fibrosis and endocardial thickness, suggesting the utility of LASr in subclinical cardiac dysfunction detection. As CKD negatively impacts cardiovascular risk and mortality, underlying structural and functional abnormalities of cardiac remodeling are widely investigated. LASr could be used in LV diastolic dysfunction grading with an excellent discriminatory power. Our objectives were to assess the impact and existing correlations between LASr and cardiovascular outcomes, as reported in clinical trials, including patients with CKD. We searched PubMed, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials for full-text papers. As reported in clinical studies, LASr was associated with adverse cardiovascular outcomes, including cardiovascular death and major adverse cardiovascular events (HR 0.89, 95% CI, 0.84–0.93, p < 0.01), paroxysmal atrial fibrillation (OR 0.847, 95% CI, 0.760–0.944, p = 0.003), reduced exercise capacity (AUC 0.83, 95% CI, 0.78–0.88, p < 0.01), diastolic dysfunction (p < 0.05), and estimated pulmonary capillary wedge pressure (p < 0.001). Despite limitations attributed to LA deformation imaging (image quality, inter-observer variability, software necessity, learning curve), LASr constitutes a promising marker for cardiovascular events prediction and risk evaluation in patients with CKD.

Incremental value of left atrial booster and reservoir strain in predicting atrial fibrillation in patients with hypertrophic cardiomyopathy: a cardiovascular magnetic resonance study

BackgroundLeft atrial (LA) size and function are known predictors of new onset atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients. Components of LA deformation including reservoir, conduit, and booster function provide additional information on atrial mechanics. Whether or not LA deformation can augment our ability to predict the risk of new onset AF in HCM patients beyond standard measurements is unknown.MethodsWe assessed LA size, function, and deformation on cardiovascular magnetic resonance (CMR) in 238 genotyped HCM patients and compared this with twenty age, sex, blood pressure and body mass index matched control subjects. We further evaluated the determinants of new onset AF in HCM patients.ResultsCompared to control subjects, HCM patients had higher LA antero-posterior diameter, lower LA ejection fraction and lower LA reservoir (19.9 [17.1, 22.2], 21.6 [19.9, 22.9], P = 0.047) and conduit strain (10.6 ± 4.4, 13.7 ± 3.3, P = 0.002). LA booster strain did not differ between healthy controls and HCM patients, but HCM patients who developed new onset AF (n = 33) had lower booster strain (7.6 ± 3.3, 9.5 ± 3.0, P = 0.001) than those that did not (n = 205). In separate multivariate models, age, LA ejection fraction, and LA booster and reservoir strain were each independent determinants of AF. Age ≥ 55 years was the strongest determinant (HR 6.62, 95% CI 2.79–15.70), followed by LA booster strain ≤ 8% (HR 3.69, 95% CI 1.81–7.52) and LA reservoir strain ≤ 18% (HR 2.56, 95% CI 1.24–5.27). Conventional markers of HCM phenotypic severity, age and sudden death risk factors were associated with LA strain components.ConclusionsLA strain components are impaired in HCM and, together with age, independently predicted the risk of new onset AF. Increasing age and phenotypic severity were associated with LA strain abnormalities. Our findings suggest that the routine assessment of LA strain components and consideration of age could augment LA size in predicting risk of AF, and potentially guide prophylactic anticoagulation use in HCM.

Myocardial deformation imaging in early prediction of heart failure development after STEMI is better than conventional echocardiography: true or false?

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf PREDICT-VT Heart failure (HF) still develops in 4% up to 28% of STEMI pts treated by pPCI, with the highest incidence in the first year. Accurate and early identification of high-risk patients would allow targeted and personalized intensive treatment . Aim the current study is a sub-study of PREDICT-VT study (NCT03263949). Its aim is to define multi-parametric model for early HF prediction in STEMI patients treated by pPCI, based on clinical data, conventional echocardiographic data and data from myocardial deformation analysis obtained by early speckle tracking echocardiography. Methods in 307 consecutive pts enrolled in PREDICT-VT, early echocardiography (5 ± 2 days after pPCI) was done and included LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec). LV indices of post systolic shortening for longitudinal (PSS LS) and circumferential (PSS CS) strains were also calculated . Results From 242 patients who completed 1-year follow-up, 9 % develop HF NYHA class 3 or 4, 27 % NYHA class 2 and remaining 64% were in NYHA class I. Significant univariate NYHA predictors were: from clinical parameters - female gender (ß =0.156, p = 0.015; 95% CI -0.431 to – 0.047), older age (ß =0.130, p = 0.044; 95% CI 0.000 to 0.017), Killip class on admission (ß=0.131, p = 0.043; 95% CI 0.007 to 0.435) and previous atrial fibrillation (ß=0.181, p = 0.005; 95% CI 0.175 to 0.960); from conventional echo parameters- LVEF (ß=-0.302, p &amp;lt; 0.001; 95% CI -0.029 to -0.012), LAVI (ß=0.134, p = 0.046; 95%CI 0.000 to 0.030), degree of diastolic dysfunction (ß=0.297, p &amp;lt; 0.001; 95% CI 0.192 to 0.465) and TAPSE (ß=-4.255, p &amp;lt; 0.001); from parameters of longitudinal LV deformation – peak systolic epicardial LS (ß=0.293, p &amp;lt; 0.001; 95% CI 0.030 to 0.074), SRs (ß=0.274, p &amp;lt; 0.001; 95% CI 0.398 to 1.069) and epicardial PSS (ß=0.336, p &amp;lt; 0.001; 95%CI 0.925 to 2.019); from parameters of LV circumferential deformation – peak systolic endocardial CS (ß=0.254, p &amp;lt; 0.001; 95% CI 0.013 to 0.041), SR E (ß= -0.247, p &amp;lt; 0.001; 95%CI -0.556 to -0.173) and epicardial PSS CS (ß=0.206, p = 0.003; 95% CI 0.302 to 1.473); from left atrial mechanics - LA strain (ß=-0.231, p = 0.001; 95% CI -0.025 to -0.007). Predictive power of model based on clinical variables (Killip class on admission, female gender, and history of atrial fib) for HF development was significantly improved when conventional ehocardiographic variables were added (LVEF, TAPSE, degree of diastolic function) (R2 from 0.076 to 0.197, p &amp;lt; 0.001). However, addition of MDI parameters (longitudinal and cirumferential PSS on epicardial levels) increased it further (R2 from 0.200 to 0.229, p &amp;lt; 0.001). Conclusion above from clinical and conventional echocardiographic parameters, amount of left ventricular post-systolic deformation in longitudinal and circumferential directions, expressed as LV indexes of post-systolic shortening, significantly improved early prediction of HF after pPCI.

Left ventricular and left atrial deformation imaging early after pPCI: does diabetes mellitus make any difference?

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf PREDICT-VT More extensive coronary atherosclerosis in diabetes mellitu (DM) induces poorer clinical outcomes after STEMI, but there are data suggesting that impaired myocardial function in DM, even independently from epicardial coronary lesions severity, might have detrimental effect, predominately on heart failure development in DM. Aim the current study is a sub-study of PREDICT-VT study (NCT03263949), aimed to analyse LV and LA function using myocardial deformation imaging based on speckle tracking echocardiography after pPCI in STEMI patients with and without DM. Methods in 307 consecutive pts enrolled in PREDICT-VT study early echocardiography (5 ± 2 days after pPCI) was done including LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec), LV index of post systolic shortening for longitudinal (PSS LS) and circumferential (PSS CS) strains and analysis of LV rotation mechanic. Results from 242 patients who completed 1 year follow up, 48 (20%) had DM. Pts with DM were older (60 ± 1,01 vs 57 ± 10; p = 0.067) and had insignificantly higher SYNTAX score (18.5 ± 9.2 vs 15.8 ± 9.8, p = 0.118) . However, diabetics had more severely impaired EF (44.2 ± 8.6 vs 49.2 ± 9.8, p = 0.001), E/A ratio (0.78 ± 0.33 vs 0.90 ± 0.34; p = 0.036) and MAPSE (1.18 ± 0.32 vs 1.32 ± 0.33; p = 0.001). Global LV LS on all layers (endo: -13.6 ± 4.0 vs-16.2 ± 4.7; mid: -11.9 ± 3.5 vs -14.1 ± 4.1; epi: -10.4 ± 3.1 vs -12.3 ± 3.6; p &amp;lt; 0.005 for all) was impaired in DM patients, as well as longitudinal systolic SR (-0.71 ± 0.23 vs -0.84 ± 0.24; p = 0.001) and SR during early diastole (0.65 ± 0.26 vs 0.83 ± 0.33, p &amp;lt; 0.001). Patients with DM had more pronounced longitudinal posts-systolic shortening throughout LV wall (endo: 21.4 ± 16.1 vs 13.7 ± 13.3, p = 0.005; mid: 21.9 ± 16.1 vs 14.3 ± 13.1, p = 0.006; epi: 22.4 ± 16.5 vs 15.3 ± 13.7, p = 0.010) and higher LV mechanical dispersion (MDI: 71.3 ± 38.3 vs 59.0 ± 18.9, p = 0.037). LA strain was significantly impaired in DM patients (18.9 ± 7.7 vs 22.6 ± 10.0, p = 0.011) and even more profoundly LA strain rate during early diastole (-0.73 ± 0.48 vs -1.00 ±0.58, p = 0.002). Patients with DM also had more impaired LV global (15.7 ± 9.1 vs 19.8 ± 10.4, p = 0.013) radial strain, global LV circumferencial strain, especially at the mid-wall level (-13.9 ± 4.2 vs -16.0 ± 4.3, p = 0.005) and impaired circumferential SR E (1.25± 0.44 vs 1.49 ± 0.46, p = 0.003). End-systolic rotation of the LV apex was more impaired in DM (4.7 ± 5.1 vs 6.8 ± 5.5, p= 0.022). During 1 year follow-up heart failure and all-cause mortality tend to be higher among DM pts (46.7% vs 35.2%, p = 0.153). Conclusion STEMI patients with DM have more severely impaired LV systolic and diastolic function estimated both by traditional parameter and advanced echo techniques. These results might, at least partially, explain why outcomes after STEMI in DM might be poorer, even in the absence of more complex angiographic findings, pointing to the significance of impaired myocardial function DM itself.

Can analysis of myocardial mechanic help me to predict heart failure development in my STEMI patient whose EF is equal or above 50% after pPCI?

Abstract Funding Acknowledgements Type of funding sources: None. onbehalf PREDICT-VT In spite of contemporary STEMI management, heart failure (HF) develops in 4% up to 28% of pPCI-treated patients, with the highest incidence in the first year. Left ventricular ejection fraction (EF) is strong predictor predominately for HFrEF development, but risk stratification in case of preserved post pPCI EF (i.e. EF ≥ 50%) is still challenging. Aim the current study is a sub-study of PREDICT-VT study (NCT03263949). Its aim is to define clinical and "echocardiographic" profile of STEMI patient at risk to develop HF despite preserved post pPCI EF, including not only conventional echocardiographic data, but data from myocardial mechanic analysis obtained by early speckle tracking echocardiography. Methods in 307 consecutive pts enrolled in PREDICT-VT study early echocardiography (5 ± 2 days after pPCI) was done and included LA and multilayer LV deformation analysis with longitudinal (L), radial (R) and circumferential (C) strain (S; %) and strain rate (SR, 1/sec), calculation of LV index of post systolic shortening for longitudinal (PSS LS) and circumferential (PSS CS) strains and thorough analysis of LV rotation mechanic. Results From 242 patients who completed 1-year follow-up, 109 pts (45 %) had post pPCI EF ≥50%. Of those patients 34 (31%) became NYHA ≥ 2 or died during 1-year follow-up (MACE+ group). Patients with MACE were older (63 ± 8 vs 55 ± 10, p &amp;lt; 0.001), more frequently were female (47% vs 27%; p = 0.036) and more frequently had hypertension (40% vs 20%; p = 0.025). There were no significant differences in LV EF ( 56.5 ± 4.8% vs 56.3 ± 4.8 %; p = 0.849) and from conventional echo parameters only differences in E/A ratio (0.75 ± 0.24 vs 0.92 ± 0.32; p = 0.015) and MAPSE (1.54 ± 0.40 vs 1.36 ±0.27; p = 0.015) reached statistical significance. Surprisingly, there were no significant differences neither in LV longitudinal, nor circumferential deformations. However, LV radial deformation was significantly impaired in MACE+ pts both during systole (global radial strain: 16.4 ± 7.1 vs 21.1 ± 10.3; p = 0.008; end-systolic radial strain 13.1 ± 7.3 vs 18.1 ± 9.9; p = 0.005), early (radial SR E: -1.27 ± 0.66 vs 1.59 ± 0.79; p = 0.044) and late (radial SR A: -0.94 ± 0.41 vs -1.20 ± 0.59, p = 0.011) diastole. LV rotation was not significantly impaired, but slowed and delayed both during systole (time to peak systolic apical rotation (ms) 168 ± 86 vs 128 ± 70; p = 0.022) and diastole (rotation rate of LV base during early diastole (°/sec): 38.3 ± 27.4 vs 55.0 ± 31.5, p = 0.008; time to maximal LV untwisting rate (ms) 580 ± 210 vs 484 ± 154; p = 0.044), despite no differences in HR. Conclusion STEMI patients who will develop heart failure despite preserved post pPCI EF might have different clinical profile and different pattern of deviation in LV mechanic (predominately involving radial and rotational mechanic) and can be detected by contemporary echocardiographic techniques.

Left atrial strain rate during atrial contraction predicts raised pulmonary capillary wedge pressure: evidence for left atrio-ventricular interaction

This study aimed to assess the relationship between different LA strain components and PCWP as well as to the relationship with other established methods. We studied 144 symptomatic patients, age 63 ± 14 years, 54 males, using conventional transthoracic echocardiography protocols, including LA and LV myocardial deformation from speckle tracking technique investigations along with simultaneous right heart catheterization (RHC) using established techniques. From RHC, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) were measured and pulmonary vascular resistance (PVR) calculated. LA strain rate during atrial contraction (LASRa) was the strongest correlate with PCWP (r2 = − 0.40, p < 0.001), over and above both LASR during LV systole (LASRs) and LA longitudinal strain during ventricular systole (LASs) (r2 = 0.21 and 0.19, respectively, p < 0.001 for both). The correlation between LASRa and PCWP was stronger in patients with post-capillary PH compared to pre-capillary PH (r2 = 0.21 vs. r2 = 0.02, respectively). The strongest relationship between LASRa and PCWP was in patients with enlarged LA volume > 34 ml/m2 (r2 = 0.60, p < 0.001). In all patients LASRa < = 0.9 1/s was 88% accurate in predicting LA pressure > 15 mmHg which was superior to recently proposed uni- and multi-variable models. LASR during atrial contraction is the strongest predictor of PCWP, particularly in patients with post-capillary PH and with dilated LA cavity. Furthermore, it proved superior to recently proposed uni- and multi-variable based algorithms. Its close relationship with LV strain rate counterpart reflects important left heart chamber interaction in patients with raised LA pressure.

Atrial Myocardial Deformation Changes in Patients with Non-Valvular Atrial Fibrillation

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia. It increases cardiovascular morbidity, especially embolic stroke and mortality. Two-dimensional speckle tracking echocardiography (2D STE) is a useful method that has been used to detect changes in atrial myocardial deformation in AF patients. Objectives: To study atrial myocardial deformation changes in patient with non-valvular AF using 2D STE. Patients and Methods: This study included 25 patients with non-valvular AF and 25 normal healthy controls. 2D STE was used for assessment of strain and strain rate of septal and free walls of both right atrium (RA) and LA and left ventricle (LV). Results: Mean LA septal and lateral strain and strain rate were significantly reduced in the AF group compared to the control group (-7.2% ± 5.2% vs. -20.4% ± 3.9%, -8.7% ± 8.8% vs. -21.7% ± 3.4%) and (-0.9 ± 0.5 S-1 vs. -1.9 ± 0.4 S-1, –1.1 ± 0.6 S-1 vs. -2.04 ± 0.3 S-1) respectively. Mean RA septal and lateral strain and strain rate were significantly reduced in the AF group compared to the control group (-5.9% ± 6.1% vs. -23.4% ± 4.5%, -8.9% ± 9.3% vs. -21.7% ± 3.4%) and (-0.98 ± 0.6 S-1 vs. -1.9 ± 0.3 S-1, -1.3 ± 0.9 S-1 vs. -2.1 ± 0.5 S-1) respectively. Mean LV global longitudinal strain (GLS) and strain rate were significantly reduced in the AF group compared to the control group (-8.8% ± 4.6% vs -19.6% ± 2.4%) and (-0.8 ± 0.3 S-1 vs -1.5 ± 0.4 S-1) respectively (P 0.001 for all). Conclusion: AF is a bi-atrial disease, LA and RA myocardial deformation properties as well as LV GLS and strain rate measured by 2D STE were significantly impaired in AF patients compared to healthy controls.