LA Dimension Research Articles

Morphology and location of thrombus and sludge in patients with non-valvular atrial fibrillation

BackgroundStroke and thromboembolism in nonvalvular atrial fibrillation (NVAF) primarily arise from thrombi or sludge in the left atrial appendage (LAA). Comprehensive insight into the characteristics of these formations is essential for effective risk assessment and management.MethodsWe conducted a single-center retrospective observational of 176 consecutive NVAF patients with confirmed atrial/appendage thrombus or sludge determined by a pre-ablation transesophageal echocardiogram (TEE) from December 2017 to April 2019. We obtained clinical and echocardiographic characteristics, including left atrial appendage emptying velocity (LAAeV) and filling velocity (LAAfV). Data analysis focused on identifying the morphology and location of thrombus or sludge. Patients were divided into the solid thrombus and sludge groups, and the correlation between clinical and echocardiographic variables and thrombotic status was analyzed.ResultsMorphological classification: In total, thrombi were identified in 78 patients, including 71 (40.3%) mass and 7 (4.0%) lamellar, while sludge was noted in 98 (55.7%). Location classification: 92.3% (72/78) of patients had thrombus confined to the LAA; 3.8% (3/78) had both LA and LAA involvement; 2.7% (2/78) had LA, LAA and RAA extended into the RA, the remained 1.2%(1/78) was isolated to RAA. 98.0% (96/98) of patients had sludge confined to the LAA; the remaining 2.0% (2/98) were present in the atrial septal aneurysm, which protrusion of interatrial septum into the RA. The thrombus and sludge groups showed low LAAeV (19.43 ± 9.59 cm/s) or LAAfV (17.40 ± 10.09 cm/s). Only LA dimension ≥ 40 mm was independently associated with the thrombus state in the multivariable model.ConclusionThis cohort study identified rare thrombus morphology and systematically summarized the classification of thrombus morphology. The distribution of thrombus and sludge outside limited to LAA was updated, including bilateral atrial and appendage involvement and rare atrial septal aneurysm sludge. LAAeV and LAAfV were of limited value in distinguishing solid thrombus from sludge.Clinical Trial NumberChiCTR-OCH-13,003,729.

Effect of Sacubitril / Valsartan Combination on Abnormal ECG Findings in Patients with Heart Failure with Reduced Ejection Fraction

Abstract Background The mortality rate of patients suffering from choronic heart failure is still high despite advantages in diagnosis and treatment. A new therapeutic class of agents acting on the renin angiotensin aldosterone system (RAAS) and neutral endopeptidase system has been developed, known as angiotensin receptor neprilysin inhibitors (ARNI). Recently, promising data from its administration have demonstrated a decrease in the mortality rate as compared to angiotensin receptor blocker alone. Aim of the Work The aim of this study is to asses effect of Sacubitril/Valsartan combination on abnormal ECG and ECHO parameters in patients with heart failure with reduced ejection fraction as a marker of reverse cardiac remodeling. Patients and Methods Our study was conducted at Ain Shams university hospitals and our target population was heart failure patients with reduced ejection fraction planned to initiate Sacubitril \ Valsartan combination therapy. 100 patients were collected from February 2022 to August 2022. It was an interventional study to follow up the effects of the drug on ECG parameters besides ECHO parameters 6 months after drug initiation. Results We found that in Sacubitril/Valsartan combination therapy there was significant decrease in HR, QRS width and QTc values which reflects the role of this combination to reduce ventricular arrhythmias and preventing SCD. There was significant increase in the EF which was correlated to the significant decrease in QRS width. There was significant improvement in diastolic dysfunction. There was significant decrease in the LA and LV dimensions giving an explanation of the role of the drug in reverse cardiac remodeling. There was significant improvement in NYHA class reflecting the role of the drug in improving quality of life. Conclusion HR, QRS width and QTc were significantly decreased with Sacubitril/Valsartan combination therapy through the follow up period reflecting the effect of the drug on ECG. EF, LA dimension and LVID were improving with Sacubitril/Valsartan combination therapy through the follow up period which give an explanation of the combination therapy for its role in reverse cardiac remodeling. NYHA class of our patients was improving through follow up period which means this drug improves quality of life and reduces hospitalization.

Atrial anatomical variations on computed tomography angiography associated with atrial fibrillation and those predicting recurrence following pulmonary vein isolation

Abstract Background We aim to investigate the atrial anatomical variations in patients with and without atrial fibrillation (AF) using cardiac-computed tomography angiography (CCTA) and identify features associated with AF recurrence following pulmonary vein isolation. Materials and Methods We retrospectively reviewed 502 CCTAs of patients with AF performed prior to a pulmonary vein isolation procedure with 1058 CCTAs of patients without AF performed to rule out coronary artery disease between 2014 and 2017. Anatomical variations of both atria including left atrial diverticula (LAD), right atrial diverticula (RAD), Bachmann bundle shunt (BBS), and pulmonary vein anatomy were assessed. Results We found that patients with AF were older (67 ± 14 vs 63 ± 13 years, P = .039), had a higher prevalence of diabetes (24.4%) versus (14.7%), P = .006, and cerebrovascular accidents (3.8%) versus (0.9%), P = .044 when compared with patients without AF. Furthermore, on CCTAs patients with AF demonstrated a significantly higher prevalence of BBS (11% vs 4.1%, P < .001), LAD (19% vs 7.7%, P < .001), and RAD (9.8% vs 2.1%, P < .001) when compared to patients without AF. Logistic multivariable regression analyses of CCTA findings demonstrated increased odd ratios (OR) in those with AF of BBS (OR = 3.51, 95% CI, 2.32-5.35, P < .001), LAD (OR = 2.94, 95% CI, 2.12-4.07, P < .001), RAD (OR = 1.54, 95% CI, 1.19-2.11, P = .03), LA diameter (OR = 2.42, 95% CI, 1.65-3.39, P < .001). Importantly, multivariate Cox regression showed that the LA dimension is a predictor of AF recurrence (HR = 1.019, 95% CI, 1.001-1.051, P = .02). Conclusion AF patients have a higher prevalence of BBS, LAD, and RAD in comparison to patients without AF. Mean LA diameter predicts AF recurrence after the pulmonary vein isolation procedure.

Abstract 17855: Improvement of Mitral Valve Regurgitation Severity Following Catheter Ablation for Atrial Fibrillation

Background: The presence of concomitant mitral valve regurgitation (MR) in patients with atrial fibrillation (AF) is well known, yet the degree of MR improvement after catheter ablation is not well studied. We investigated the effect of catheter ablation on the degree of MR in patients with baseline ≥moderate MR and AF. Methods: We retrospectively reviewed charts of AF catheter ablation patients at Montefiore Medical Center (2018-2019). Patients with prior or subsequent mitral valve surgeries were excluded. Degree of MR, assessed through echocardiograms, was compared at baseline and follow-up. Early follow-up was defined as 6 months post-ablation. Patients were stratified by left atrial size and left ventricular ejection fraction (LVEF) to assess the influence of these parameters on MR severity after ablation. Results: A total of 202 patients were included in our analysis with an average age of 64 years. At baseline there were 149 patients (74%) with <moderate MR and 44 patients with ≥moderate MR (22%). There was a statistically significant reduction in the number of patients with ≥moderate MR following ablation both at early and late follow-up (p<0.0001, Figure 1). Our results remained statistically significant after stratification by LVEF (<40% vs ≥ 40%) and LA dimension (<4.5cm vs ≥ 4.5cm) (p<0.001, Figure 2). Conclusions: Catheter ablation of AF improved the degree of MR severity in patients with baseline ≥moderate MR and AF. Our findings were preserved across stratification by left atrial size and LVEF subgroups. Further investigation is necessary to validate our findings.

Effect of Telehealth Services on Mitral and Tricuspid Regurgitation Progression: Retrospective Study.

Mitral regurgitation (MR) and tricuspid regurgitation (TR) are common cardiac conditions with high mortality risks, which can be improved through early intervention. Telehealth services, which allow for remote monitoring of patient conditions, have been proven to improve the health management of chronic diseases, but the effects on MR and TR progression are unknown. This study aimed to explore whether patients receiving telehealth services have less MR and TR progression compared with a control group. We also aimed to identify the determinants of MR and TR progression. This single-center retrospective study conducted at the National Taiwan University Hospital compared MR and TR progression (defined as either progression to moderate or greater MR and TR or MR and TR progression by ≥2 grades during the study period) between the telehealth and control groups. Patients had a minimum of 2 transthoracic echocardiograms at least 6 months apart; baseline mild-moderate MR and TR or lower; and no prior surgeries on the mitral or tricuspid valve. Telehealth patients were defined as those who received telehealth services for at least 28 days within 3 months of baseline. Basic demographics, baseline blood pressure measurements, prescribed medication, and Charlson Comorbidity Index components were obtained for all patients. A total of 1081 patients (n=226 in the telehealth group and n=855 in the control group) were included in the study analyses. The telehealth group showed significantly lower baseline systolic blood pressure (P<.001), higher Charlson Comorbidity Index (P=.02), higher prevalence of prior myocardial infarction (P=.01) and heart failure (P<.001), higher beta-blocker (P=.03) and diuretic (P=.04) use, and lower nitrate use (P=.04). Both groups showed similar cardiac remodeling conditions at baseline. Telehealth was found to be neutral for both MR (hazard ratio 1.10, 95% CI 0.80-1.52; P=.52) and TR (hazard ratio 1.27, 95% CI 0.92-1.74; P=.14) progression. Determinants for moderate or greater MR progression included older age, female sex, diuretic use, larger left atrial dimension, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction. Determinants of moderate or greater TR progression included older age, female sex, diuretic use, presence of atrial fibrillation, LA dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction; statin use was found to be protective. This is the first study to assess the association between telehealth services and the progression of MR and TR. Telehealth patients, who had more comorbidities, displayed similar MR and TR progression versus control patients, indicating that telehealth may slow MR and TR progression. Determinants of MR and TR progression included easy-to-measure traditional echo parameters of cardiac function, older age, female sex, and atrial fibrillation, which can be incorporated into a telehealth platform and advanced alert system, improving patient outcomes through personalized care.

Impact of pre-ablation left appendage flow velocities on long term recurrence of catheter ablation for paroxysmal atrial fibrillation.

Despite undergoing a single ablation, many patients with paroxysmal atrial fibrillation (PAF) experience a gradually increasing recurrence rate. This study aims to examine the relationship between left atrial appendage emptying velocity (LAAeV) and filling velocity (LAAfV) profiles and 3-year recurrence of AF after ablation. We conducted a prospective study of 658 consecutive PAF patients who underwent their first ablation between January 2018 and December 2019. We collected the clinical and echocardiographic characteristics of the patients. LAAeV and LAAfV were obtained from a transesophageal echocardiogram (TEE) before catheter ablation. Patients were followed at regular intervals to monitor for the primary outcome of AF recurrence. After a median follow-up period of 35.3 months (range, 10.7-36.3), 288 patients (43.8%) experienced AF recurrence after catheter ablation. Patients who experienced AF recurrence had decreased LAAeV and LAAfV (LAAeV: 56.5±21.2vs. 59.6±20.7cm/s, p=.052; LAAfV: 47.5±17.9vs. 51.7±18.2, p=.003). Kaplan-Meier analysis showed that patients in the low LAAeV(<55cm/s) group had a poorer event-free survival rate than those in the high LAAeV (≥55cm/s) group (log-rank p=.012). Patients with LAAfV<48cm/s had a significantly higher risk of AF recurrence than those with LAAfV ≥48cm/s (log-rank p=.003). In the multivariable model, low LAAfV pre-ablation in TEE-guided was significantly independently associated with 3-year recurrence after single radiofrequency ablation in patients with PAF, along with LA dimension and duration of AF. This study found an independent association between low LAAfV pre-ablation in TEE-guided and 3-year recurrence after single radiofrequency ablation in patients with PAF.

Incidence and Risk Factors for Long-Term Persistence of Diastolic Dysfunction after Aortic Valve Replacement for Aortic Stenosis Compared with Aortic Regurgitation

(1) Background: Severe left ventricular (LV) diastolic dysfunction with a restrictive diastolic pattern (LVDFP) is generally associated with a worse prognosis. Its evolution and reversibility in the short- and medium-term after aortic valve replacement (AVR) has been little-studied. We aimed to evaluate the evolution of LV remodeling and LV systolic and diastolic function after AVR in aortic stenosis (AS) patients compared to aortic regurgitation (AR). Moreover, we tried to identify the main predictive parameters for postoperative evolution (cardiovascular hospitalization or death and quality of life) and the independent predictors for the persistence of restrictive LVDFP after AVR. (2) Methods: A five-year prospective study on 397 patients undergoing AVR for AS (226 pts) or AR (171 pts), evaluated clinically and by echocardiography preoperatively and until 5 years postoperatively. (3) Results: 1. In patients with AS, early post AVR, LV dimensions decreased and diastolic filling and LV ejection fraction (LVEF) improved more rapidly compared to patients with AR. At 1 year postoperatively, persistent restrictive LVDFP was found especially in the AR group compared to the AS group (36.84% vs. 14.16%). 2. Cardiovascular event-free survival at the 5-year follow-up was lower in the AR group (64.91% vs. 87.17% in the AS group). The main independent predictors of short- and medium-term prognosis after AVR were: restrictive LVDFP, severe LV systolic dysfunction, severe pulmonary hypertension (PHT), advanced age, severe AR, and comorbidities. 3. The persistence of restrictive LVDFP after AVR was independently predicted by: preoperative AR, the E/Ea ratio > 12, the LA dimension index > 30 mm/m2, an LV endsystolic diameter (LVESD) > 55 mm, severe PHT, and associated second-degree MR (p < 0.05). (4) Conclusions: AS patients had an immediate postoperative evolution in terms of LV remodeling, and LV systolic and diastolic function were more favorable compared to those with AR. The restrictive LVDFP was reversible, especially after the AVR for AS. The main prognostic predictors were the presence of restrictive LVDFP, advanced age, preoperative AR, severe LV systolic dysfunction, and severe PHT.

Abstract 11182: The Morphological Feature of Left Atrial Appendage With Thrombus in Patients With Atrial Fibrillation

Background: In atrial fibrillation (AF) patients, non-chicken wing type left atrial appendage (LAA) morphology is involved in thromboembolic events, and windsock and cauliflower LAA morphologies have been reported to be related to silent cerebral ischemia (CI). However, the morphology of the LAA in patients with left atrial appendage thrombus (LAAT) that is the main pathogenesis of cardiogenic CI due to AF remains unclear. Methods: We retrospectively studied the LAA morphology in 43 patients with LAAT detected by transesophageal echocardiography (TEE) prior to cardioversion or catheter ablation for AF and the LAA morphology of 144 patients without LAAT who undertook TEE on the same day, out of 1864 examined patients. Patients with significant valvular disease and cardiac surgery were excluded. LAA morphology constructed by computed tomography has been classified into 4 types: chicken wing, cauliflower, windsock, and cactus. We evaluated clinical data, blood samples, and transthoracic echocardiography at the time of TEE. Results: Non-paroxysmal AF (37% vs. 0%, P&lt;0.0001), higher history of heart failure (40% vs. 15%, P=0.0004), elevated BNP level (454±436 vs. 119±133 pg/mL, &lt;0.0001), reduced left ventricular ejection fraction (LVEF, 52.3±16.8% vs. 65.2±10.2%, P &lt;0.0001), larger LA dimension (LAD, 48.6±6.0 vs. 41.9±6.1 mL/m 2 , P&lt;0.0001), higher E/e` ratio (13.4±7.0 vs. 10.7±3.8, p=0.0017), and LAA morphology were associated with LAAT (Figure). On multivariate analysis, non-paroxysmal AF (P=0.0002), BNP level (P=0.0033), LVEF (P=0.0015), and LAA morphology (especially, cactus type LAA, P=0.0027) were significantly correlated to LAAT. Conclusion: The LAA morphology relates to the LAAT in AF patients. The characteristics of the LAA morphology in LAAT patients may be different from those in silent CI patients.

Left Atrial Thrombus and Dense Spontaneous Contrast in Direct Oral Anticoagulant Therapy of Atrial Fibrillation: Insights from a Reference Center.

ResumoFundamentoNo tratamento da fibrilação atrial (FA), a arritmia sustentada mais frequente, com ablação por cateter (ABL) ou cardioversão elétrica (CVE), o período periprocedimento é uma das fases mais críticas. Atualmente, o uso de novos anticoagulantes orais de ação direta (DOAC) é cada vez mais frequente, no entanto, no mundo real, ainda existem poucos dados de estudos sobre a incidência de trombo no átrio esquerdo (TrAE) ou contraste espontâneo denso (CE) no ecocardiograma transesofágico (ETE).ObjetivoAnalisar a prevalência de TrAE, por ETE, em pacientes em uso de DOAC submetidos à CVE/ABL. Secundariamente: avaliar a associação de comorbidades com a presença de trombos e CE.MétodosEstudo de coorte retrospectivo, unicêntrico, com pacientes do Ambulatório de Arritmia (InCor-HCFMUSP). Foram selecionados e analisados dados clínicos e ecocardiográficos no prontuário da instituição de pacientes com indicação de procedimentos e em uso de DOACs. Considerado um nível de significância de 5%.ResultadosForam incluídos 354 pacientes, no total de 400 procedimentos, de março de 2012-março de 2018. TrAE foi encontrado em 11 pacientes (2,8%), associado com idade avançada (p=0,007) e CHA2DS2-VASc maior (p<0,001). Foi encontrado CE no AE no procedimento antes da ETE em 29 pacientes (7,3%), com menor FEVE (p <0,038) e maior dimensão do AE (p <0,0001).ConclusãoA incidência de TrAE e CE em pacientes em uso de DOAC no contexto de CVE/ABL de FA, embora pequena, não é desprezível. Pacientes com escore CHA2DS2-VASc maior, principalmente mais idosos e com diâmetro do AE maior, são mais propensos a esses achados ecocardiográficos.

Difference in cardiac remodeling between female athletes and pregnant women: a case control study

ObjectivesThe aim of this study was to detect possible differences in reversible cardiac remodeling occurring in sport training and twin pregnancy. Background: cardiac remodeling occurs in athletes and pregnant women due to training and fetal requirements, respectively. These changes could be apparently similar.Methods21 female elite athletes (23.2 ± 5.3 years), 25 women with twin pregnancies (35.4 ± 5.7 years) and 25 healthy competitive female athletes (controls), age-matched with pregnant women (34.9 ± 7.9 years), were enrolled. This latter group was included to minimize the effect of age on cardiac remodeling. All women evaluated through anamnestic collection, physical examination, 12 leads ECG, standard echocardiogram and strain analysis. Sphericity (SI) and apical conicity (ACI) indexes were also calculated.ResultsPregnant women showed higher LA dimension (p < 0.001) compared to both groups of athletes. LV e RV GLS were significantly different in pregnant women compared to female athletes (p = 0.02 and 0.03, respectively). RV GLS was also different between pregnant women and controls (p = 0.02). Pregnant women showed significantly higher S′ wave compared to female athletes (p = 0.02) but not controls. Parameters of diastolic function were significantly higher in athletes (p = 0.08 for IVRT and p < 0.001 for E/A,). SI was lower in athletes in both diastole (p = 0.01) and systole (p < 0.001), while ACIs was lower in pregnant women (p = 0.04).ConclusionsCardiac remodeling of athletes and pregnant women could be similar at first sight but different in LV shape and in GLS, highlighting a profound difference in longitudinal deformation between athletes and pregnant women. This difference seems not to be related with age. These findings suggest that an initial maternal cardiovascular maladaptation could occur in the third trimester of twin pregnancies.

Left atrial volume index in diabetic hypertensive patients with acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial (LA) dimension is a marker of LV filling pressure, reflecting the severity and chronicity of diastolic dysfunction. LA is a stable parameter that combines chronic cardiovascular conditions effects and acute increase in filling pressure in acute myocardial infarction. Patients with acute coronary syndrome and increased left atrial volume index (LAVI) have a worse long-term prognosis. In patients with hypertension and diabetes, an increase in the LA dimension predicts cardiovascular events. There are limiting data about the impact of LAVI on the outcome in diabetic hypertensive patients with ST-elevation myocardial infarction (STEMI). Purpose: of the study was to compare LAVI in diabetic and nondiabetic hypertensive patients admitted with STEMI. Methods: ninety-eight hypertensive patients admitted with STEMI were enrolled, sixty-seven with diabetes mellitus and thirty-one without diabetes. The patients with atrial fibrillation and significant valvular disease were not included in the study. The evaluation consisted in clinical examination, echocardiographic measurements, laboratory tests, and 12 leads electrocardiography. 2D Echocardiography area-length technique was used for LA volume measurement. The LA endocardial borders were traced in both the apical four- and two-chamber views, and the results were body surface area indexed. The cut of value was 34ml/m2. The Devereaux formula determined left ventricle mass index (LVMI), and the ranges were: 125 kg/m2 for males and 95 mg/m2 for females. Left ventricle ejection fraction (LVEF) was &amp;lt; 50% in all cases. Measurements were obtained in the first week after STEMI. The patients were divided into two groups: the first was between 40 and 60 years and the second was above 60 years. According to the age group, mean values (MV) and standard deviation (SD) were calculated, obtaining a comparison between diabetic and nondiabetic patients. Results: LAVI had higher values in diabetic patients: MV: 37.37 (SD: 3.39, CV: 9.07%) compare with nondiabetic patients: MV: 31.07 (SD: 2.67, CV 8.59%), p &amp;lt; 0.0001. Between 40-60 years LAVI MV were 36.43 +/- 3.21 in diabetic patients vs. 29.62+/-1.89 in nondiabetic patients (p = 0.0001); above 60 years of age LAVI MV were: 38.99 +/- 3.04 in diabetic patients and 31.14 +/- 2.8 in nondiabetics patients (p &amp;lt; 0.0001). In both group of age LAVI also correlated with body mass index, LVMI, LV volumes, LV diastolic dysfunction, LVEF, dyslipidemia and smoking. Conclusions: 1. In hypertensive patients admitted with STEMI, diabetes mellitus was an additional factor contributing to increased left atrium dimensions. 2. This study showed a correlation between LAVI and other factors involved in increasing LV filling pressure in hypertensive diabetic patients admitted with STEMI, underlying the importance of LA enlargement evaluation. Further studies with a larger number of patients are need to confirm these results.

Pathophysiological, haemodynamic and prognostic implications of left atrial dysfunction in cardiac amyloidosis and other cardiomyopathies with hypertrophic phenotype

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND &amp; PURPOSE. Left atrial function (LAF) is a determinant of clinical status and outcome in many cardiac disorders, including cardiac amyloidosis (CA). Aim of this study is to explores the LAF in CA and other cardiomyopathies with hypertrophic phenotype, and its consequences on cardiovascular haemodynamics, right ventricular function and survival. METHODS. We enrolled 50 patients with CA (26 AL and 24 wtATTR) and 75 with hypertrophic phenotype (LVH group) [25 hypertrophic cardiomyopathy (HCM) pts, 25 hypertensive pts (HypCM), and 25 pts with aortic stenosis (AS)]. LAF was analysed using the phasic method [LAEI as reservoir, LAPEF as conduit, LAAEF as active pump and TLAEF as total emptying function; see figure 1] by LA volumes determination. RESULTS. ATTR patients showed higher LA dimensions and impaired reservoir and total LA emptying function (TLAEF) compared to AL without differences LAF. Compared to the LVH group, CA patients showed higher LA dimension with impaired LAF in all phasic parameters, higher LV filling pressures and reduced biventricular function. We further divided CA and LVH patients into four subgroups based on the presence or absence of LA dysfunction (LADys+ for TLAEF values below the median: &amp;lt;50.2%; range 9.3-70.9%]. Among the groups, patients with CA/LADys+ showed worst clinical status, higher pulmonary pressures (sPAP) and lower TAPSE and TAPSE/sPAP ratio values. After a median follow-up of 24 months, 19 patients died from cardiovascular (CV) causes (15 in CA/LADys+ group and 4 in LVH/LADys+). The overall survival free of CV death was 64% in CA/LADys+ and 85% in LVH/LADys+ (4/26) group [log-rank χ2 29.6; p &amp;lt; 0.0001]. A sequential multivariate model was employed to assess whether LAF could predict CV deaths: TLAEF was entered together with established clinical and echocardiographic parameters (NYHA functional class, LAVI, E/Em, sPAP, TAPSE and TAPSE/sPAP ratio). At the final backward analysis, LAVI, TAPSE/sPAP and TLAEF were independent prognosticators of CV death. CONCLUSIONS. LAF is significantly more impaired in CA than LVH group and is associated with worst clinical status, RV dysfunction and higher LV filling and pulmonary pressure. Moreover, LADys is a frequent feature of CA and significantly associated with higher CV mortality. We suggests that LADys in LVH group could results from chronic pressure overload due to LA"s exposure to high LV diastolic pressure (impaired LV compliance). In CA, LADys could also be determined by direct LA infiltration. The pathophysiological result is a progressive LA remodelling with increased LA pressure, consequent backward transmission to the pulmonary venous system and, ultimately, RV dysfunction. TLAEF is parameter of LAF that correlates with increased pulmonary vascular resistance (measured elsewhere with cardiac catheterisation) and RV dysfunction. In CA, it seems promising as marker of the haemodynamic consequences of LADys and CV mortality. Abstract Figure 1 Abstract Figure 2

Clinical impact of left atrial enlargement in Korean patients with atrial fibrillation

We sought to evaluate the clinical implication of LAE based on left atrial anterior–posterior (LA AP) dimension or LA volume index (LAVI) in Korean patients with atrial fibrillation (AF). We enrolled 8159 AF patients from the CODE-AF registry. The primary outcome was rate of stroke or systemic embolism (SSE). The prevalence of mild, moderate, and severe LAE by LA AP dimension was 30.6%, 18.5%, and 21.4%, and by LAVI (available in 5808 patients) was 15.7%, 12.5% and 37.8%, respectively. Compared with no or mild LAE, patients with significant LAE (moderate to severe LAE, n = 3258, 39.9%) were associated with a higher rate of SSE (2.5% vs. 1.4%, P = 0.001). Multivariable analysis suggested presence of significant LAE by LA AP dimension was associated with a higher risk of SSE in the overall population (HR 1.57, 95% CI: 1.14–2.17, P = 0.005) and in patients using anticoagulants (n = 5836, HR 1.79, 95% CI: 1.23–2.63, P = 0.002). Patients with significant LAE by LAVI were also at higher risk of SSE (HR 1.58, 95% CI: 1.09–2.29, P = 0.017). In conclusion, significant LAE by LA dimension or LAVI was present in 39.9% and 50.2% of AF patients, respectively, and was associated with a higher rate of SSE.

Abstract 9755: Impact of Outflow Obstruction and Septal Myectomy on Long Term Risk of New Onset Atrial Fibrillation in Hypertrophic Cardiomyopathy

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM), with patients having a 4 to 6 fold greater likelihood of developing AF as compared to the general population, and is an important cause of morbidity, impaired quality of life and embolic stroke in HCM. The impact of outflow obstruction and the influence of surgical septal myectomy on the development of new-onset AF has not been well described. Aim: To characterize the risk of new-onset AF in nonobstructive and obstructive HCM and compare to AF risk in patients after myectomy. Methods: 1767 consecutive HCM patients without prior AF history, seen at the Tufts HCM Institute between 2004 and 2019, including 712 with obstruction (outflow gradients ≥ 30mmHg at rest or following provocation) who did not undergo invasive septal reduction therapy (SRT), 552 with nonobstructive HCM (outflow gradients &lt; 30mmHg), and 503 who underwent surgical myectomy were followed for an average of 4.3 ±4.2 years for new-onset symptomatic AF. Isolated post-operative episodes of AF, i.e., occurring within the first 3 months after myectomy, were excluded from analysis. Results: Patients with obstructive HCM who did not undergo SRT had a 1.5-fold increased risk for new-onset AF as compared to nonobstructive HCM (rate onset of 2.8%/year vs.1.7%/year, p=0.04), with freedom from AF at 10-years of 72% in obstructive patients. Patients undergoing myectomy were older (52 ± 15 vs. 50 ± 15 years; p&lt;0.01), had larger LA dimension (42 ± 7 vs 40 ± 6mm; p&lt;0.01), and higher HCM-AF risk scores (22 ± 3.5 vs. 19 ± 3.8; p&lt;0.01) as compared to nonobstructive HCM. However, despite a higher predicted risk for new-onset AF at time of myectomy (2.7%/year vs. 1.5%/year), after myectomy the risk of new onset AF was no different from patients with nonobstructive HCM (hazard ratio 0.9; rate of onset of 1.8%/year vs. 1.7%/year; p=.73), with freedom from AF at 10-years of 83% post-myectomy. Conclusions: Patients with obstructive HCM have a higher risk of AF as compared to nonobstructive HCM. After myectomy risk of new-onset AF is substantially reduced, such that risk is no different from patients with nonobstructive HCM. These data demonstrate efficacy of myectomy in decreasing long term risk of AF in obstructive HCM.

Left atrial dynamics and congestion status analysis in acute decompensated heart failure based on LVEF categorization

Abstract Background Left atrial (LA) dynamics play a key role in the hemodynamics assessment of heart failure (HF). LA strain analysis by speckle tracking echocardiography (STE) has recently been introduced in clinical practice. In acute decompensated heart failure (ADHF), LA functional deterioration leads to worsening of pulmonary capillary hypertension and congestion, ultimately impacting prognosis. However, how LA size and function behaves in ADHF according to the different HF phenotypes has never been studied. Purpose To evaluate the diverse morphology and dynamics of the LA, along with a thorough congestion analysis, in ADHF patients with HFpEF, HFmrEF and HFrEF. Methods Eighty-five ADHF patients (mean age 75.6±10.4 years, 59% males) were prospectively enrolled within 24–48 hours from admission to the emergency department. In the acute phase all patients underwent a complete transthoracic echocardiography (TTE) and lung ultrasonography (LUS) associated with blood sample and a thorough clinical examination. LA mechanics was assessed with STE, through the evaluation of global peak atrial longitudinal strain (GPALS). Results Out of 85 patients, 51% were classified as HFrEF, 20% as HFmrEF and 29% as HFpEF. At admission, all patients exhibited a comparable degree of congestion, as testified by increased IVC max. diameter (HFpEF 19±7 mm vs HFrEF 20±6.3 mm vs HFmrEF 17±5.3 mm, p=0.167), incremented PASP (HFpEF 39.2±13.5 mmHg vs HFrEF 42±12 mmHg vs HFmrEF 35.3±10.1 mmHg, p=0.15) and a rising number of B-lines on LUS (HFpEF 20±12.8 vs HFrEF 24±17 vs HFmrEF 21±19, p=0.62). Increased NT-proBNP values in the cohort were also noted, with HFrEF exhibiting the highest levels (HFrEF 11747±1069 ng/l vs HFmrEF 6905±811 ng/l vs HFpEF 3918±374 ng/l; p&amp;lt;0.001). When evaluating LA size and dynamics in the different HF phenotypes (HFrEF, HFmrEF and HFpEF respectively) a significant difference among the three subgroups was noted with HFrEF patients exhibiting a greater LA dilation and a higher impairment in terms of LA reservoir function (lowest GPALS/LAVi ratio) compared to HFpEF patients, who showed relatively less enlarged LA chambers and more preserved dynamics. Interestingly, HFmrEF patients expressed the best coupling between LA function and dimension, with significantly reduced LA dimensions and a more preserved LA function compared to HFrEF and HFpEF (LAVi: HFpEF 50.7±16 ml/m2 vs HFrEF 53.9±15 ml/m2 vs HFmrEF 42.8±10.8 ml/m2, p=0.05*; GPALS HFpEF 17±9.1% vs HFrEF 10±4.85% vs HFmrEF 18.3±6.2%, p&amp;lt;0.001*) (Figure 1 and 2). Conclusions ADHF patients exhibit an heterogeneous response in terms of LA size and function according to LVEF categorization. The definition of subjects expressing the worst coupling between LA size and function appears of relevance in order to facilitate risk stratification and identify patients at higher risk of early re-hospitalization. Funding Acknowledgement Type of funding sources: None.

B-PO04-110 IMPACT OF A DEDICATED ATRIAL FIBRILLATION CLINIC ON DIAGNOSIS-TO-ABLATION TIME

Outcomes following catheter ablation for atrial fibrillation (AF) improve as the diagnosis-to-ablation time (DAT) shortens. Use of a protocol based integrated care model through a dedicated Atrial Fibrillation Clinic (AFC) may serve to standardize treatment pathways and decrease DAT. Systematic risk-factor-modification (RFM) when built into these pathways can further improve the long-term success of catheter ablation. To evaluate the DAT for patients with AF referred from an AFC versus a conventional Electrophysiology Clinic (EC). Retrospective analysis was completed in consecutive patients undergoing index AF ablation from January 2019 to December 2019 at Riverside Methodist Hospital with minimum one year follow-up. Patients were categorized based off their referral source (AFC vs EC) and where the initial visit following index diagnosis occurred (AFC vs EC). A total of 182 patients (mean age 65±11 years, 116 [64%] male) were reviewed. The mean ejection fraction was 57±10% and 133 patients (73.1%) had paroxysmal AF. Patients referred from the AFC (21%) had a median DAT of 342 days (IQR, 125-855) compared to patients referred from EC (79%) with a median DAT of 813 days (IQR, 241-1444; P = 0.01). Patients with the index visit following AF diagnosis occurring in the AFC (9%) had significantly shorter median DAT when compared to EC (91%) (127 days [IQR, 95-188] compared to 789 days [IQR, 253-1503]; P = 0.002). Significantly higher number of patients underwent RFM counseling in the AFC (95% vs 40%; P < 0.00001), and referred for sleep apnea screening as clinically indicated (50% vs 20%; P = 0.003). There were no significant differences between the AFC and the EC patients with respect to antiarrhythmic drug use, type of AF (paroxysmal and persistent), BMI, LA dimension, and AF recurrence or time to recurrence after ablation. Patients referred from a dedicated AFC have shorter DAT than patients referred from a standard EC. Diagnosis to ablation time is further decreased if an index visit following diagnosis occurs in an AFC. Patients in an AFC are more likely to be referred for sleep apnea evaluation and receive documented RFM counseling. Longer term follow-up is recommended to assess the durable benefit of these interventions.

Artificial intelligence-predicted poor responders to catheter ablation for atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Although atrial fibrillation (AF) catheter ablation is effective for rhythm control, in some patients it is hard to maintain sinus rhythm in spite of repeated AF catheter ablation (AFCA) procedures and anti-arrhythmic drugs (AADs). We explored the pre-procedural predictors for poor responders to AFCA and tested whether artificial intelligence (AI) assists the prediction of poor responders in the independent cohort by determining the invasive parameters. Methods Among 1,214 patients who underwent AFCA and regular rhythm follow-up for 56.2 ± 33.8 months (59 ± 11 years, 73.5% male, 68.6% paroxysmal AF), we differentiated 92 poor responders defined as those with sustained AF despite repeat AFCAs, AADs, or electrical cardioversion. Using the Youden index, we identified advanced LA remodeling with lower LA voltage under 1.109mV. AI model, which was derived from development cohort using medical record, was applied to predict LA voltage &amp;lt;1.109mV in the independent cohort (n = 634, poor responders = 24) using a grad-cam score. Results The patients with lower LA voltage under 1.109mV showed significantly poorer rhythm outcomes (Log-rank p &amp;lt; 0.001). We determined invasive parameter LA voltage by using the multiple variables (age, female sex, AF type, CHA2DS2VASc score, LA dimension, E/em, hemoglobin, PR interval) and achieved relatively good prediction power of AI for LA voltage &amp;lt;1.109mV (AUC = 0.734, sensitivity 0.729, specificity 0.643) in the test cohort. In the independent cohort, the AI model showed good discrimination power for poor responders (AUC 0.751, p &amp;lt; 0.001) by estimating LA voltage, which is an invasive variable. The patients with predicted lower LA voltage (grad-cam score &amp;lt;0) showed poorer rhythm outcome after active rhythm control (Log-rank p &amp;lt; 0.001) Conclusions The patients with advanced atrial remodeling with low LA voltage, which can be predicted by an AI, showed significantly higher recurrence of AF after AFCA with AADs or cardioversion. AI may assist to select these poor responder patients before the AFCA procedure. Abstract Figure.

Comparison of six risk scores for the prediction of atrial fibrillation recurrence after cryoballoon-based ablation and development of a simplified method, the 0-1-2 PL score.

IntroductionThere are several prognostic scores for the assessment of risk of atrial fibrillation (AF) recurrence post ablation procedure. However, the use of these complex scores is difficult and the validation on different populations brought divergent results. Our goal was to compare the performance of these risk scores as the basis for the development of a new, simplified score based only on few universally predictive variables.MethodsAll cryoballoon‐based AF ablations performed in a single‐center over a 10‐year period were prospectively analyzed with regard to AF recurrence. This served to analyze the performance of APPLE, CAAP‐AF, SCALE‐CryoAF, MB‐LATER, CHADS2, and CHA2DS2‐VASc risk scores.ResultsA total of 597 patients, mostly (78.1%) with paroxysmal AF were studied. Analyzed risk scores performed poorer than in the original publications because some risk factors were not predictive of AF recurrence. A simplified score named 0‐1‐2 PL, composed of just two universally predictive variables, AF type (1 point for P ersistent AF) and LA dimension (1 point for L A size >45 mm) was developed. The 0‐1‐2 PL score stratified patients into low risk (0 points), intermediate risk (1 point), and high risk categories (2 points) which were related to a 2‐year risk of AF recurrence of 21%, 37%, and 55%, respectively. This score had C‐statistics (0.620) higher/comparable to other investigated much more complex scores.ConclusionThe assessment of risk of AF recurrence at the pre‐ablation stage can be simplified without compromising accuracy. This could help to popularize risk assessment and standardization of AF management.

Cardiac remodeling in adults following percutaneous PDA closure: A meta-analysis

While percutaneous closure is preferred in adults with a patent ductus arteriosus (PDA), the extent of cardiac remodeling following percutaneous PDA closure in adults is not well understood. We performed a meta-analysis to characterize cardiac remodeling following percutaneous PDA closure in adults. MEDLINE and EMBASE were systematically searched for original studies that reported echocardiographic variables at baseline, immediately post-procedure (24 h), and at follow-up (>1 month) in adults undergoing percutaneous PDA closure. Additionally, we included data from patients >18 years of age that underwent percutaneous PDA closure between January 2015–December 2019 at our centre. Weighted averages were calculated for parameters with sufficient data. Pooled differences were presented as weighted mean differences (WMD). After screening 278 abstracts, 5 studies were identified. When combined with our cohort, our meta-analysis encompassed 244 patients. Immediately post-procedure, LVEF was the only parameter to change significantly (64 vs 52%, WMD -8.64 95%, CI -14.04 to −3.25). All parameters significantly decreased from baseline to follow-up: LVEF: 64 vs 60% (WMD -3.95, CI -5.80 to −2.09), LVEDD: 62 vs 53 mm (WMD -8.79, CI -12.78 to −4.81) LVEDVI 172 vs 123 mL/m 2 (WMD -26.60, CI -45.4 to −7.85), LVESD 42 vs 36 mm (WMD -4.64, CI -9.10 to −0.17) and LA dimension: 42 vs 37 mm (WMD -5.87, CI -9.85 to −1.90). As compared to the baseline values, left ventricular and left atrial sizes decreased. The LVEF decreased immediately following PDA closure and, while it recovers, it remained lower on follow-up testing. Abbreviations: CI: Confidence interval; LA: left atrium, LVEDD: left ventricular end-diastolic dimension, LVEDVI: left ventricular end-diastolic index, LVEF: left ventricular ejection fraction. LVESD: left ventricular end-systolic dimension, LVESVI: left ventricular end-systolic index, WMD: weighted mean difference. • Left atrial and left ventricular sizes decrease after percutaneous PDA closure. • LVEF decreases acutely after percutaneous PDA closure. • LVEF improves however remains lower on follow-up testing than the baseline LVEF.

Interobserver variability of radiographic methods for the evaluation of left atrial size in dogs.

The objectives of this retrospective, observer agreement study were to (a) test variability of radiographic left atrial dimension (RLAD) and vertebral left atrial size (VLAS) measurements among observers with different levels of expertise in thoracic radiology and cardiology, (b) assess whether one method is better than the other in detecting left atrial enlargement (LAE), and (c) assess the agreement among RLAD, VLAS, and American College of Veterinary Internal Medicine (ACVIM) classes. Seventy-four dogs (eight healthy and 66 with mitral valve disease) with thoracic radiographs and echocardiography performed on the same day were reviewed. Thirty showed echocardiographic LAE. Left atrial dimension was quantified using RLAD and VLAS by six different operators with three levels of clinical experience in veterinary cardiology/radiology. Vertebral heart score and fourth thoracic vertebra (T4) were also measured. Differences in T4, vertebral heart score (VHS), RLAD, and VLAS measurements were found among six operators and among the three levels of clinical expertise as well as between veterinary cardiology readers and veterinary radiology readers (P<.05). The area under the receiver operating characteristic (AUC) curve for VHS showed good performances for all observers and level and type of expertise; the AUC for RLAD and VLAS was suboptimal only for the radiology student. Our RLAD and VLAS cutoffs (1.9 and 2.43 v, respectively) were better related to qualitative radiographic than quantitative echocardiographic LAE evaluation. Radiographic LA dimension and VLAS showed an increase proportional to the worsening of the ACVIM class. In conclusion, these results allow us to affirm that RLAD and VLAS are reproducible measurements for detecting LAE. Better performances are associated with clinical expertise and background.