LA Remodeling Research Articles

Left Atrial Remodeling and Recurrence of Congestive Heart Failure in Patients Initially Diagnosed with Heart Failure

Left atrial volumes (LAVs) have been suggested to represent long-term exposure to elevated pressures. This study examined the recurrence of heart failure (HF) based on LAV in patients initially diagnosed with congestive HF (CHF). This study comprised 77 patients (age, 75±8years) with well-documented, clinically defined HF, and complete two-dimensional echocardiographic examinations. The echocardiographic examinations were performed on admission and after medical treatment (90±43days after initial examination). Patients with atrial fibrillation, flail mitral valve, or mitral valve replacement were excluded from this study. The initial left ventricular ejection fraction (LVEF) was 44±17% and the indexed LAV (LAVI) was 61±22mL/m(2) . After medical treatment, a decreased LAVI was observed in 38 patients and an increased LAVI (LA remodeling) was observed in 39 patients. With median follow-up periods of 454days, compared to patients with decreased LAVI, patients with LA remodeling had a significantly higher incidence of CHF recurrence (P=0.008). Patients with LA remodeling had a CHF-free survival rate of 36±13% vs. 81±9% (those without LA remodeling). A multivariate analysis indicated that, follow-up LV end-systolic volume (P=0.04), LVEF (P=0.005) and LAVI (P=0.04) independently predicted CHF recurrence. Patients initially diagnosed with CHF follow divergent courses based on their LAV. LA remodeling after medical treatment can be useful for predicting CHF recurrence during follow-up.

Left atrial remodeling and recurrence of congestive heart failure

Background: It has been suggested that left atrial volumes (LAV) represent long-term exposure to elevated pressures. The objectives of this study were to determine the recurrence of heart failure based on LAV in patients originally diagnosed congestive heart failure (CHF). Methods and results: This study comprised 77 patients (75±8 years) with well-documented, clinically defined heart failure and complete two-dimensional echocardiographic examinations. The echocardiographic examinations were performed on admission and after medical treatment (60±43 days after initial study). Patients with atrial fibrillation, flail mitral valve or mitral valve replacement were excluded from this study. The initial left ventricular ejection fraction (LVEF) was 44±17% and indexed LAV was 61±22 ml/m2. A decrease in indexed LAV was observed in 38 patients and an increase in indexed LAV (LA remodeling) was observed in the remaining 39 patients after medical treatment. With mean follow-up periods of 424 days, patients with LA remodeling had a significantly higher incidence of recurrence of CHF compared to patients with decreased indexed LAV (p=0.008). Their event (recurrence of CHF)-free survival rate was 36±13% vs. 81±9%. In a multivariate analysis, follow-up LV end-systolic volume (p=0.04), LVEF (p=0.005) and indexed LAV (p=0.04) independently predicted recurrence of CHF, compared with clinical and other echocardiographic variables. Conclusion: Patients originally diagnosed with CHF follow divergent courses based on LAV. LA remodeling after medical treatment can be useful for predicting recurrence of CHF during follow-up.

Spironolacton reduces left ventricular diastolic stiffness, remodeling and improves functional status in hypertensive patients with preserved ejection fraction heart failure

Mineralocorticoid receptor antagonists have been shown to be beneficial in treatment and mortality reduction in heart failure with reduced ejection fraction in randomized trials. Data regarding their usefulness in HFPEF remains to be studied. We studied the effects of spironolacton (S) on diastolic stiffness and LV remodeling in diabetic pts with HFPEF. Methods: 137 pts 64±12 yrs (56% female) with HFPEF NYHA III with diabetes mellitus and without renal failure were randomized to two groups in order to receive S on top of their treatment (n=68) 25mg/day to further increase to 50mg/day after 8 weeks if no hyperkalemia (>5.5 mmol/l) has been developed or amilorid (A) 2.5 mg/day to increase to 5mg/day after 8 weeks in pts without hyperkalemia (n=69) for 6 months. Medications as ACEI/ARB, β-blockers, loop diuretics were evenly distributed in groups. NTproBNP levels, and diastolic wall stress (DWS) as (PWs - PWd) /PWs, LV mass index (LVMI), septal E/Em, LA volume index (LAVI) were measured by EchoCG by two independent observers unaware of the aim of the study in 1, 30, 90 and 180 days follow up. Results: In 30 days there were no significant changes in all parameters. In 90 day E/Em were significantly less in S compared with A (10.8±2.3 vs 12.1±3.1, p<0.05) without changes in other parameters. This difference remained unchanged throughout the study. In 180 days DWS, LVMI, LAVI and NTproBNP levels were significantly better in S group. (DWS: S 0.37±0.3 vs A 0.31±0.2, p<0.03; LWMI: male S 114±6 vs A 118±8, p<0.05; female S 96±5 vs A 110±3, p<0.05; LAVI: S 28±5 vs 32±7, p<0.03; NTproBNP S 938±69 vs A 1602±197 pg/ml p<0.02). Conclusion: In our study spironolacton reduces diastolic stiffness and alters LV and LA remodeling as well as NTproBNP levels in diabetic pts with HFPEF.

Comparative efficacy of resistance and aerobic training on functional status and cardiac parameters in hypertensive patients with diastolic heart failure with preserved ejection fraction

Exercise has been shown to be a beneficiary in pts with systolic heart failure. Yet little data regarding heart failure with preserved ejection fraction (HFPEF) are available. We compare the influence of two exercise modalities on cardiac parameters and functional status in pts with HFPEF. Methods: 139 pts with HFPEF NYHA IV, 65±12 years (43 female) were randomized to three groups in order to receive resistance (RT, n=47) or aerobic (AT, n=47) training for 4 weeks or passive group (PG, n=45). Medications (ACEI, β-blockers, Ca2+ channel lockers, diuretics) were evenly distributed in groups. The study started after one week pre-training adaptation. Aerobic training (AT) was performed on treadmill four times per week with 30 min duration (excluding 5 min warm up and cooling down) and 70% maximum oxygen uptake. Resistance training (RT) was implemented as a weight lifting of 10 predetermined exercises of the upper and the lower body (2 set of 10 repetitions) for the same duration and frequency with the intensity of 50% of the one repetition maximum. EchoCG parameters as EF, indexes of LV EDV, ESV, maximal LA volume (LAVI), E/Em septal, LV diastolic wall strain (DWS) as (PWs – PWd)/PWs, as well as NTproBNP levels were obtained at the onset and the end of the study. Baseline parameters were comparable between groups. Results: Both exercises interventions significantly improve E/Em and NTproBNP levels compare to baseline and PG end-study parameters which remained unchanged (E/Em: AT 13.9±2.2 vs 11.6±1.3, p<0.05; RT: 13.7±2.1 vs 9.4±1.2, p<0.03; NTproBNP: AT 1592±193 vs 923±62 pg/ml, p<0.05; RT 1587±191 vs 531±37 pg/ml, p<0.02) without changes in EF, EDVI and ESVI. The RT group reduced E/EM, NTproBNP in greater degree compared with AT group (E/Em 11.6±1.3 vs 9.4±1.2, p<0.05; NTproBNP 923±62 vs 531±37 pg/ml, p<0.05). Also in RT group LAVI reduced in a greater degree compare with AT (29±4 vs 34±6, p<0.05) whereas in PG remained unchanged. DWS significantly improved in both AT and RT to a greater degree in RT (0.37±0.3 vs 0.31±0.2, p<0.05) without changes in PG. 37 pts (78%) in RT and 38 pts (80%) in AT improved their functional status compare with baseline as assessed on 9 min self-powered treadmill test peak VO2 consumption (AT: 13.7±1.4 to 18.3±1.6 ml/kg/min, p<0.05; RT: 13.6±1.4 to 18.6±1.7 ml/kg/min, p<0.05). Conclusion: Both exercise modalities are beneficial in hypertensive pts with HFPEF. RT appears to be a better choice probably because of better improvement of LV diastolic function and alteration of LA remodeling.

Increased pericardial adipose tissue is correlated with atrial fibrillation and left atrial dilatation

Pericardial adipose tissue (PAT), a visceral fat depot surrounding the heart, serves as an endocrine active organ and is associated with inflammation. There is growing evidence that atrial fibrillation (AF) is linked with inflammation, which in turn can be a promoter of left atrial remodeling. The aim of this study was to evaluate a potential correlation of PAT to AF and left atrial structural remodeling represented by LA size. PAT was measured in 1,288 patients who underwent coronary artery calcium-scanning for coronary risk stratification. LA size was determined by two independent readers. Patients were subdivided into patients without AF, patients with paroxysmal and persistent AF. PAT was independently correlated with AF, persistent AF, and LA size (all p values <0.001). No association could be observed between paroxysmal AF and PAT. These associations persisted after multivariate adjustment for AF risk factors such as age, hypertension, valvular disease, heart failure, and body mass index (AF: OR 1.52, 95 % CI 1.15-2.00, p = 0.003; persistent AF: OR 2.58, 95 % CI 1.69-3.99, p = 0.001; LA size: regression coefficient 0.15 with 95 % CI 0.10-0.20, p < 0.001). PAT is associated with AF, in particular with persistent AF and LA size. These findings suggest that PAT could be an independent risk factor for the development of AF and for LA remodeling.

STRUCTURAL AND FUNCTIONAL DIFFERENCES IN PHYSIOLOGICAL VERSUS PATHOLOGICAL PATTERNS OF LEFT ATRIAL REMODELING: A SPECKLE TRACKING STRAIN ECHOCARDIOGRAPHY STUDY

methods: A total of 143 subjects were studied in two groups: 91 healthy volunteers included 77 athletes, and 52 patients with diastolic dysfunction including 27 patients with AF. LAVi was correlated with diastolic function and speckle tracking derived global LAƐ and LVƐ. results: For patients, LAƐ and LVƐ (Fig. A and B) independently predicted LAVi (R2=0.51, P=0.04 for both). In contrast, volunteers showed higher LAƐ (40±10 vs. 23±12%, P<0.01) despite similar LAVi (P=0.21). LAƐ in volunteers correlated with LV early (r=0.36; P<0.01), late diastolic (r=0.39; P<0.01) annular velocities and end-diastolic volume (r=0.27; P=0.02). LAƐ showed diagnostic value in differentiating pathologic and physiologic LA remodeling (Fig. C; AUC, 0.84, P< 0.01).

900 A Prospective Canadian Multi-Center Randomized Parallel Study on Spontaneous Atrioventricular Conduction Preservation

Limiting unnecessary ventricular pacing (VP) in patients (pts) who receive a dual-chamber (DDD) pacemaker (PM) appears desirable. Programming long AV delays have serious limitations in that respect: long PR intervals may be suboptimal to preserve AV synchrony, and often times % of VP >10% are observed despite all the efforts to minimize VP. On the other hand, despite the fact that AAI pacing has been superior to DDD with long AV delay, it is seldom used because of the fear of AV conduction problems. The SafeR™ mode by Sorin is one of the available algorithmS that aim to minimize unnecessary VP while decreasing the associated risk of AAI pacing. The CAN-SAVE R study is a Canadian multi-center randomized study that compares the efficacy the SafeR™ mode with DDD pacing with a long AV delay in a large population of pts not presenting with permanent high degree AV Block (AVB). Its objectives are three-fold: to compare the % of VP, atrial fibrillation (AF)(primary endpoint) and the impact on LV and LA remodeling at 3 years (by echo). 373 patients from10 centers in Canada were randomized by July 2nd 2009: 63% males, mean age= 71±10 years, LVEF= 50±5%, LAVol= 24±3mL. Pacing indications were Sinus Node dysfunction (SND) (47%), AV block (24%), SND + AV block (14%) and other (mainly syncope: 15%). By July 31st 2012, 330 patients are expected to have completed their 3-year follow-up (89%). This is more than the 270 pts needed to achieve the primary endpoint (at 0.8 power). The data should be available for analysis in early September 2012, in time for presentation at CCC in October. Tabled 1

The Impact of Isolated Diastolic Dysfunction on Atrial Fibrillation Recurrence After Catheter Ablation

Patients with normal ejection fraction but significant diastolic dysfunction (isolated DD) may tolerate atrial fibrillation (AF) poorly and be referred for radiofrequency catheter ablation (RFA) for symptomatic AF. Elevated left atrial pressure (LAP) due to isolated DD promotes LA remodeling which creates a substrate for AF, and may limit efficacy of RFA which primarily targets AF triggers.

Indexed Left Atrial Volume Is Superior to Left Atrial Diameter in Predicting Nonvalvular Atrial Fibrillation Recurrence after Successful Cardioversion: A Prospective Study

Although indexed left atrial volume (iLAV) is the most accurate measure of left atrial size, it has not been evaluated prospectively as predictor of recurrence of atrial fibrillation (AFib) after successful cardioversion (CV). We prospectively selected 76 patients (mean age 66.1 ± 13.6 years, 65.8% men) with AFib who underwent successful CV. Baseline clinical and echocardiographic characteristics were obtained before CV. LAV was measured using Simpson's method and indexed to body surface area. All patients were scheduled for follow-up visit at 1, 6, 12 months, and then annually. A 24-hour Holter ECG was performed within 6 months and each time the patients reported symptoms suggestive of arrhythmia. The 52 patients (68.4%) with AFib recurrence had larger iLAV (35.5 ± 8.9 mL/m(2) vs 27.0 ± 6.7 mL/m(2) , P < 0.001). Anteroposterior LA diameter was not associated with AFib relapse (OR 1.08, 95% CI: 0.96-1.21, P = 0.09). Each unit increase in iLAV was associated with a 1.15-fold increased risk of recurrence (OR 1.15, 95% CI: 1.06-1.25, P < 0.001). In a multivariable model, iLAV remained the only independent predictor of relapse (adjusted OR 1.14, 95% CI: 1.02-1.28, P = 0.02). The area under ROC curves, generated to compare LA diameter, and iLAV as predictors of AFib recurrence were 0.56 (SE 0.07) versus 0.78 (SE 0.05), respectively (P = 0.003). This is the first prospective study to show that larger iLAV, as a more accurate measure of LA remodeling than anteroposterior diameter, is strongly and independently associated with a higher risk of AFib recurrence after CV.

095 Resumption of sinus rhythm post-modified maze is associated with left atrial contraction and possible progressive left atrial reverse remodeling

We had previously demonstrated the safety and the efficacy of the modified MAZE procedure in restoring sinus rhythm in patients undergoing mitral valve and other cardiac surgeries. It remains unclear if sinus rhythm post-MAZE is associated with resumption of hemodynamically meaningful LA contraction and reverse LA remodeling. Modified MAZE procedure for chronic or persistent AF was performed with laser or radiofrequency source on 82 consecutive patients, mostly as part of mitral valve surgeries. 39 Patients were ablated in the left atrium only whereas the remaining 43 were ablated bi-atrially; left atrial appendectomy was performed in all patients. All received coumadin and were cardioverted in the perioperative period if found in AF. Most patients received antiarrhythmic therapy in the 3 months following their surgery; later it was discontinued whenever possible. Reports and images from post-operative echocardiograms up to 3 years were reviewed to obtain the cardiac rhythm during the studies and the presence of distinct A-waves on mitral inflow pulse wave doppler (MI-PWD). When available, mean LA size as measured on parasternal long axis (PSLX) were obtained from post-op echocardiograms at various points within the 3-year interval and were paired to their pre-op study for analysis. Of the 82 patients who underwent the modified-MAZE procedure (table1), 43 had documented sinus rhythm during their transthoracic echocardiogram and MI-PWD data was available in 39 for analysis. Mitral inflow A-waves were present in 100% of these patients. The overall mean LA size pre-op was 51+/−7mm vs 47+/−8mm at within 3 years post-operatively (n = 23, P = 0.06). There is trend towards progressive reduction in LA size at 1-week, 1-year and 2-year interval. (Fig1.)Tabled 1View Large Image Figure ViewerDownload Hi-res image Download (PPT) The recovery of sinus rhythm in patients undergoing modified MAZE-procedure plus LA appendectomy is always associated with resumption of hemodynamically meaningful atrial contraction. Furthermore, there is trend towards progressive LA reverse remodeling with the resumption of sinus rhythm.

Experience of Radiofrequency Catheter Ablation of Atrial Fibrillation in Patients with Structural Heart Disease: Comparable Clinical Outcome Despite Advanced Atrial Remodeling

Backgrounds: We hypothesized radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) in patients with structural heart disease (SHD) results in outcomes comparable to those with lone AF. Methods: We included 428 patients (age, 56.0±11.0 years; male, 77.3%; paroxysmal AF, 69.4%; persistent AF, 30.6%) who underwent RFCA of AF and compared imaging, hemodynamic, electrophysiologic parameters and clinical outcome between the patients with (n=77) and without (n=351) SHD. SHD included coronary artery disease (CAD, 57.1%), valvular heart disease (23.4%), cardiomyopathy (10.4%), heart failure (6.5%), and congenital heart disease (2.6%). Results: In patients with SHD, LA diameter (p<0.001), LA volume index (p<0.001), E/E′ (p<0.001), LA mean pressure (p=0.003), effective refractory period (ERP: p=0.027), and ANP (p=0.005) were significantly higher than those without SHD. In patients with CAD (n=44), there was no significant differences in terms of culprit vessels or number of coronary lesions. There were no significant differences of complications (2.6% vs. 3.7%) and recurrence rates after blanking period (21.1% [28.6% with anti-arrhythmic drug [AAD]] vs. 20.2% [25.9% with AAD]) during 12.7±5.9 months in SHD and no SHD groups, respectively (p=0.859). Conclusion: RFCA of AF in patients with selected SHD results in clinical outcome comparable to those with lone AF, in spite of advanced LA remodeling.

Long‐Term Mechanical Consequences of Permanent Right Ventricular Pacing: Effect of Pacing Site

Long-term right ventricular apical (RVA) pacing has been associated with adverse effects on left ventricular systolic function; however, the comparative effects of right ventricular outflow tract (RVOT) pacing are unknown. Our aim was therefore to examine the long-term effects of septal RVOT versus RVA pacing on left ventricular and atrial structure and function. Fifty-eight patients who were prospectively randomized to long-term pacing either from the right ventricular apex or RVOT septum were studied echocardiographically. Left ventricular (LV) and atrial (LA) volumes were measured. LV 2D strain and tissue velocity images were analyzed to measure 18-segment time-to-peak longitudinal systolic strain and 12-segment time-to-peak systolic tissue velocity. Intra-LV synchrony was assessed by their respective standard deviations. Interventricular mechanical delay was measured as the difference in time-to-onset of systolic flow in the RVOT and LV outflow tract. Septal A' was measured using tissue velocity images. Following 29 ± 10 months pacing, there was a significant difference in LV ejection fraction (P < 0.001), LV end-systolic volume (P = 0.007), and LA volume (P = 0.02) favoring the RVOT-paced group over the RVA-paced patients. RVA-pacing was associated with greater interventricular mechanical dyssynchrony and intra-LV dyssynchrony than RVOT-pacing. Septal A' was adversely affected by intra-LV dyssynchrony (P < 0.05). Long-term RVOT-pacing was associated with superior indices of LV structure and function compared with RVA-pacing, and was associated with less adverse LA remodeling. If pacing cannot be avoided, the RVOT septum may be the preferred site for right ventricular pacing.

Favourable effects of exercise-based Cardiac Rehabilitation after acute myocardial infarction on left atrial remodeling

Background Left atrial enlargement is an important predictor of cardiovascular outcomes in patients after acute myocardial infarction. While the favourable effect of exercise exercise-based Cardiac Rehabilitation (CR) on postinfarction LV remodeling has been well documented, those on LA remodeling have yet to be defined. This study investigated the effects of CR on LA remodeling in postinfarction patients with moderate left ventricular (LV) dysfunction. Methods Sixty postinfarction patients were randomised randomized into two groups, each composed of 30 patients: group T (LV ejection fraction (EF) 43.7 ± 4.2%, mean ± SD) entered a 6-month CR program, whereas group C (EF 44.7 ± 4.4%, P = ns) did not. Doppler echocardiography and cardiopulmonary exercise test were performed upon enrolment and at 6-month. Results At 6-month, trained patients showed a significant ( P < 0.001) improvement in peak oxygen consumption (ΔVO 2peak = + 5.2 ± 2.1 ml/kg/min) and a reduction in LA (ΔLA V MAX = − 1.9 ± 3.7 ml/m 2) and in LV volumes (ΔLVEDV = − 3.6 ± 4.4 ml/m 2). At 6-month, untrained patients showed LA V MAX (+ 3.6 ± 4.4 ml/m 2, P < 0.001) and LV dilation (+ 4.2 ± 5.1 ml/m 2, P < 0.001; group T vs. C, P < 0.001); whereas no significant changes in VO 2peak were observed. Multiple linear regression analysis showed that age ( β = 0.442, P < 0.001), inclusion in the training group ( β = − 0.599, P < 0.001), E/A ratio ( β = − 0.210, P = 0.038), LVEDV ( β = 0.376, P < 0.001), and LVEF ( β = − 0.279, P = 0.007) are significant predictors of LA remodeling. Conclusions Six-month exercise-based CR in postinfarction patients with mild to moderate LV dysfunction induced a favourable LA remodeling.

Abstract 3068: Intra-left Ventricular Contractile Dyssynchrony As An Independent Determinant Of Left Atrial Remodeling In Patients With Atrial Fibrillation Managed by Catheter-based Circumferential Pulmonary Venous Isolation

BACKGROUND. Enlarged left atrial volume (LAV), resulting from multifactorial pathogenesis, carries a poorer prognosis to patients with atrial fibrillation (AF) even under well rhythm control. We hypothesized that the preexistence of intra-left ventricular (LV) contractile dyssynchrony impaired diastolic filling, which contribute to atrial remodeling in AF patients. METHODS. We investigated 40 patients (34 men and 6 women, mean age 60 ± 10 years) with paroxysmal or persistent AF who were converted mainly by catheter ablation-based circumferential pulmonary venous isolation and then pharmacologically maintained in sinus rhythm. Exclusion criteria included significant (&gt;moderate) valvular heart disease, LV ejection fraction &lt;55 %, or ischemic heart disease confirmed by positive stress tests or coronary angiography. The LAV was measured by 2D echocardiography [π×D1×D2×D3/6 from parasternal long-axis view (D1) and apical four-chamber view (D2 &amp; D3)]. The peak myocardial systolic velocity (S M ) and the time to peak S M (T S ) of the 6-basal and 6-mid LV segments were measured by tissue Doppler imaging (TDI). RESULTS. With similar AF duration before conversion, patients with LAV &gt;40ml (n = 16) had similar baseline characteristics, cardiovascular medications, QRS width, and LV chamber sizes as those with LAV &lt;40ml (n = 24). However, TDI showed the mean S M was borderline lower (6.3 ± 1.2 vs. 7.1 ± 1.2 cm/s, p &lt; 0.05), and the maximal intersegmental difference in T S (77 ± 43 vs. 40 ± 22 ms, p &lt; 0.003) was greater in patients with larger LAV. The intersegmental difference in T S correlated positively with LAV (r = 0.41, p &lt; 0.009), and LV filling pressure estimated by early transmitral flow velocity/annular diastolic velocity was significantly higher (12.3 ± 7.8 vs. 8.7 ± 2.2, p &lt; 0.045) in patients with intersegmental difference in T S &gt;65 ms. After adjusting for age, gender, and the diastolic parameters, intersegmental difference in T S &gt;65ms emerged as an independent determinant of larger LAV in multivariate logistic analysis (OR=17; 95% CI=2–166, p &lt; 0.016). CONCLUSIONS. Intraventricular dyssynchrony, which accompanied with elevated LV filling pressure, contributed independently to LA remodeling in AF patients converted into sinus rhythm by catheter ablation.

Diastolic dysfunction and left atrial volume: A population-based study

We examined the association between diastolic function and left atrial volume indexed to body surface area (LAVi) in a population-based study. Atrial enlargement has been suggested as a marker of the severity and duration of diastolic dysfunction (DD). However, the association between DD and atrial enlargement and their individual prognostic implications in the population is poorly defined. A cross-sectional sample of Olmsted County, Minnesota, residents > or =45 years of age (n=2,042) underwent comprehensive Doppler echocardiography and medical record review. The LAVi increased with worsening DD: 23 +/- 6 ml/m2 (normal), 25 +/- 8 ml/m2 (grade I DD), 31 +/- 8 ml/m2 (grade II DD), 48 +/- 12 ml/m2 (grades III to IV DD). In bivariate analyses, age, left ventricular mass index, and DD grade were positively associated, whereas female gender and ejection fraction (EF) were inversely associated with LAVi (p <0.001 for all). When controlling for age, gender, cardiovascular (CV) disease, EF, and left ventricular mass, grade II DD was associated with a 24%, and grade III to IV DD was associated with a 62% larger LA volume (p <0.0001 for both). The area under the receiver-operator characteristic curve for LAVi to detect grade I, grade II, or grade III to IV DD was 0.57, 0.81, and 0.98, respectively. Both DD and LAVi were predictive of all-cause mortality, but when controlling for DD, LAVi was not an independent predictor of mortality. These data suggest that DD contributes to LA remodeling. Indeed, DD is a stronger predictor of mortality; presumably it better reflects the impact of CV disease within the general population.