Larger Left Atrial Diameter Research Articles

Systemic inflammation is associated with myocardial fibrosis in patients with obstructive hypertrophic cardiomyopathy.

Chronic low-grade inflammation, often observed in hypertrophic cardiomyopathy (HCM), promotes adverse ventricular remodelling. This study aimed to investigate the relationship between inflammatory markers and myocardial fibrosis (MF) in patients with HCM. This study included 102 patients with complete baseline data who underwent septal myectomy. Myocardial samples were stained with Masson's trichrome and analysed to determine myocardial collagen content and MF levels. Plasma levels of inflammatory markers were measured using standard laboratory procedures. Univariate and multivariate logistic regression analyses were performed to explore the relationship between the inflammatory markers and MF. Among the 102 participants included in the analysis, the mean age was 48.9years, with 69 [67.6%] being men. The overall MF ranged from 2.5% to 40.7% (mean=15.2±8.1%, median=13.0%, IQR=9.9%-18.4%). Participants were divided into two groups based on a median MF of 13%. The high MF group had a larger left atrial diameter and left ventricular ejection fraction. Levels of interleukin (IL)-2, tumour necrosis factor (TNF)-α and interferon (IFN)-α were significantly higher in patients with high MF compared to those with low MF (2.3 vs. 4.0pg/mL, 3.1 vs. 3.9pg/mL, 4.2 vs.4.7pg/mL, respectively; all P<0.05). In multivariate models adjusted for age, sex and other clinical features, IL-2, IL-5 and TNF-α, were correlated with increased interstitial MF [odds ratio (OR): 1.54, 95% confidence interval (CI): 1.10-2.14; OR: 1.42, 95% CI: 1.02-1.98; OR: 1.33, 95% CI: 1.04-1.70]. After additional adjustment for imaging indicators, IL-2 and TNF-α remained significant (OR: 1.49, 95% CI: 1.06-2.09, P=0.021; OR:1.35, 95% CI: 1.01-1.80, P=0.044). The correlation analysis between inflammation and replacement fibrosis assessed by CMR in 97 patients revealed that 72 (74.2%) showed late gadolinium enhancement (LGE). No significant correlation was found between inflammatory markers and the presence or extent of LGE. Higher levels of IL-2 and TNF-α were associated with increased histopathological interstitial MF in patients with HCM. Given the gradual progression of MF in HCM, initiating anti-inflammatory treatment in the early stages may delay its progression.

Myocardial Scarring and Sudden Cardiac Death in Young Patients With Hypertrophic Cardiomyopathy

The ability to predict sudden cardiac death (SCD) in children and adolescents with hypertrophic cardiomyopathy (HCM) is currently inadequate. Late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR) imaging is associated with SCD events in adults with HCM. To examine the prognostic significance of LGE in patients with HCM who are younger than 21 years. This multicenter, retrospective cohort study was conducted from April 8, 2015, to September 12, 2022, in patients with HCM who were younger than 21 years and had undergone CMR imaging across multiple sites in the US, Europe, and South America. Observers of CMR studies were masked toward outcomes and demographic characteristics. Natural history of HCM. The primary outcome was SCD and surrogate events, including resuscitated cardiac arrest and appropriate discharges from an implantable defibrillator. Continuous and categorical data are expressed as mean (SD), median (IQR), or number (percentage), respectively. Survivor curves comparing patients with and without LGE were constructed by the Kaplan-Meier method, and likelihood of subsequent clinical events was further evaluated using univariate and multivariable Cox proportional hazards models. Among 700 patients from 37 international centers, median (IQR) age was 14.8 (11.9-17.4) years, and 518 participants (74.0%) were male. During a median (IQR) [range] follow-up period of 1.9 (0.5-4.1) [0.1-14.8] years, 35 patients (5.0%) experienced SCD or equivalent events. LGE was present in 230 patients (32.9%), which constituted an mean (SD) burden of 5.9% (7.3%) of left ventricular myocardium. The LGE amount was higher in older patients and those with greater left ventricular mass and maximal wall thickness; patients with LGE had lower left ventricular ejection fractions and larger left atrial diameters. The presence and burden of LGE was associated with SCD, even after correcting for existing risk stratification tools. Patients with 10% or more LGE, relative to total myocardium, had a higher risk of SCD (unadjusted hazard ratio [HR], 2.19; 95% CI, 1.59-3.02; P < .001). Furthermore, the addition of LGE burden improved the performance of the HCM Risk-Kids score (before LGE addition: 0.66; 95% CI, 0.58-0.75; after LGE addition: 0.73; 95% CI, 0.66-0.81) and Precision Medicine in Cardiomyopathy score (before LGE addition: 0.68; 95% CI, 0.49-0.77; after LGE addition: 0.73; 95% CI, 0.64-0.82) SCD predictive models. In this retrospective cohort study, quantitative LGE was a risk factor for SCD in patients younger than 21 years with HCM and improved risk stratification.

Predictors for major adverse cardiovascular events among patients with acute coronary syndrome in Bosnia and Herzegovina

&amp;lt;p&amp;gt;&amp;lt;strong&amp;gt;Aim&amp;lt;/strong&amp;gt; Despite advancements in the diagnosis, treatment and monitoring of patients with acute coronary syndrome (ACS), morbidity and mortality following ACS remain high. The aim of this study was to actively seek possible predictors of adverse outcomes after ACS aiming to identify high-risk patients promptly.&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Methods&amp;lt;/strong&amp;gt; This retrospective cohort study investigated patients with ACS hospitalized at Clinical Centre of the University of Sarajevo from 2019 to 2021. Patients were followed up for a period of 12 months post-discharge to assess major cardiovascular events (MACE) and MACE associated independent predictors.&amp;amp;nbsp;&amp;lt;br /&amp;gt;&amp;lt;strong&amp;gt;Results&amp;lt;/strong&amp;gt;. The study included 121 patients, mostly male 102 (84.3%), with a mean age of 60.83&amp;amp;plusmn;12.61 years; prevalent risk factors were hypertension 94 (77.7%), dyslipidaemia 84 (69.4%), diabetes mellitus 91 (75.2%), active smoking 67 (55.4%) and positive family history of cardiovascular diseases 81 (66.9%). MACE occurred in 33 (27.3%) patients since the initial ACS, and those patients were older (p=0.012), had higher level of creatinine (p&amp;amp;lt;0.001), lower ejection fraction at discharge (p&amp;amp;lt;0.001) and larger left atrial diameter (p=0.032). Serum creatinine (OR=1.014, 95% CI 1,003-1,026, p=0.017) and ejection fraction (OR=0.924, 95% CI 0,869-0,984, p=0.013) were independent predictors associated with a 12-month follow up MACE following ACS.&amp;lt;br /&amp;gt;Conclusion A monitoring of serum creatinine level, left atrial diameter, and ejection fraction post-acute coronary syndrome as potential indicators of future MACE within a 12-month follow-up period is of great importance. These findings emphasize the need for tailored management strategies to mitigate risks in this patient population.&amp;lt;/p&amp;gt;

Changes of cardiac structure and function in pregnant women with different types of hypertensive disorders in pregnancy and their influencing factors

Objective: To analyze the changes in cardiac structure and function in women with different types of hypertensive disorders in pregnancy (HDP) and explore their influencing factors. Methods: A total of 1 967 pregnant women diagnosed with HDP who delivered at Peking University Third Hospital from January 1, 2014 to April 15, 2022 were included in the study. They were categorized into four groups based on specific HDP diagnoses: gestational hypertension (506 cases, 25.7%), pre-eclampsia (589 cases, 29.9%), pregnancy complicated with chronic hypertension (332 cases, 16.9%) and chronic hypertension with pre-eclampsia (540 cases, 27.5%). Differences in cardiac structure and function among four groups were retrospectively analyzed. Cardiac structure indicators included left atrial diameter (LAD), left atrial area (LAA), right atrial area (RAA), left ventricular end-diastolic diameter (LVEDD), interventricular septal thickness (IVST), left ventricular posterior wall thickness (LVPWT), systolic function indicators included left ventricular ejection fraction (LVEF), lateral systolic mitral annular velocity (Sm), diastolic function indicators included peak early diastolic mitral in flow velocity (E)/peak late diastolic mitral in flow velocity (A), and E/peak early diastolic myocardial velocity of the lateral mitral annulus early diastolic velocity (Em). Influencing factors on cardiac structure and function were analyzed using generalized linear regression. Influencing factors were assessed by generalized linear regression. Results: (1) General clinical data: the differences in age, gestational week at delivery, blood pressure, proportion of diabetes, and length of hospital stay were statistically significant among four different HDP types (all P<0.05). (2) Compared with pregnant women with pregnancy complicated with chronic hypertension, pre-eclampsia, and gestational hypertension, those with chronic hypertension with pre-eclampsia had larger LAD, LAA, RAA and LVEDD (all P<0.001), thicker IVST and LVPWT (all P<0.001), and reduced left ventricular diastolic function (E/A, lateral Em, E/Em) and systolic function (lateral Sm; all P<0.001). Pregnant women with gestational hypertension had the least changes in cardiac structure and function. Compared with pregnant women with pre-eclampsia, those with pregnancy complicated with chronic hypertension had smaller RAA (P<0.001) and lower E/A (P<0.001), with no significant difference in other indicators (all P>0.05). (3) Chronic hypertension with pre-eclampsia, pregnancy complicated with chronic hypertension, and pre-eclampsia were associated with larger LAD, LAA, and LVEDD, and lower lateral Em (all P<0.05). Conclusions: Different types of HDP are associated with distinct changes in cardiac structure and function. Chronic hypertension with pre-eclampsia demonstrates the most pronounced alterations, followed by pre-eclampsia and pregnancy complicated with chronic hypertension, and gestational hypertension showed the least changes.

Effects of antiarrhythmic drug responsiveness and diagnosis-to-ablation time on outcomes after catheter ablation for persistent atrial fibrillation.

The impact of delaying atrial fibrillation catheter ablation (AFCA) for antiarrhythmic drug (AAD) management on the disease course remains unclear. This study investigated AFCA rhythm outcomes based on the diagnosis-to-ablation time (DAT) and AAD responsiveness in participants with persistent AF (PeAF). We included data from 1038 AAD-resistant PeAF participants, all of whom had a clear time point for AF diagnosis, especially PeAF at diagnosis time, and had undergone an AFCA for the first time. Participants who experienced recurrences of paroxysmal type on AAD therapy were analyzed as a cohort of AAD-partial responders; those maintaining PeAF on AAD were AAD-non-responders. We determined the DAT cutoff for best discriminating long-term rhythm outcomes using a maximum log-likelihood estimation method based on the Cox proportional hazard regression model. Of the participants (79.8% male; median age 61), 806 (77.6%) were AAD-non-responders. AAD-non-responders had a higher body mass index and a larger left atrial diameter than AAD-partial-responders. They also had a higher incidence of AF recurrence after AFCA (adjusted hazard ratio 1.75, 95% confidence interval 1.33-2.30; log-rank p < .001) compared to AAD-partial-responders. The maximum log-likelihood estimation showed bimodal cutoffs at 22 and 40 months. The optimal DAT cutoff rhythm outcome was 22 months, which discriminated better in the AAD-partial-responders than in the AAD-non-responders. Both DAT and AAD responsiveness influenced AFCA rhythm outcomes. Delaying AFCA to a DAT of longer than 22 months was inadvisable, particularly in the participants in whom PeAF was changed to paroxysmal AF during AAD therapy.

Long-term impact of transcatheter closure interatrial shunts on disabling migraine

Backgrounds Effectiveness of patent foramen ovale (PFO) closure on relief of migraine, is still unclear. We sought to analyse the long-term (>10 years) effects of interatrial septal shunt repair on disabling migraine performing a retrospective non-randomised study. Methods Clinical records of patients with disabling, medication-refractory migraine and PFO or significant ASD referred to our centre for closure from 2006 to 2018, were analysed. Results Forty -six patients (38 female, mean age 40.0 ± 3.7 years) with PFO and 32 patients with significant ASD (28 female, mean age 38.0 ± 4.1 years) submitted to transcatheter closure had a pre-existing disabling migraine with mean Migraine Disability Assessment Score (MIDAS) of 35.8 ± 4.7. After a mean follow-up of 118.2 ± 19.1 months (range 96 to 144), 72 out of 78 patients were still followed-up: in all subjects, aura was abolished, and migraine improved also in patients without aura. The mean MIDAS significantly decreased from baseline value (p < 0.01). Complete migraine resolution was associated in PFO patients with a shorter history of migraine, a more severe thrombophilic profile, a more severe Right-to-Left Shunt (RLS) and larger left atrial diameter and volume, and in ASD patients with bidirectional shunt. Conclusions Device-based repair of PFO/ASD in patients with migraine was associated with abolition of aura and symptoms reduction in the long-term period.

Effects of diagnosis-to-ablation time and antiarrhythmic drug responsiveness on the rhythm outcomes of atrial fibrillation catheter ablation

Abstract Background Atrial fibrillation (AF) is a progressive disease. Additionally, delaying AF catheter ablation (AFCA) for a year, during antiarrhythmic drug (AAD) therapy does not reduce the efficacy of this ablation. This study explored AFCA rhythm outcomes based on the diagnosis-to-ablation time (DAT) and AAD responsiveness in participants with either paroxysmal AF (PAF) or persistent AF (PeAF). Methods We included the data of 1,038 participants with AAD-resistant PeAF, all of whom had a clear time point for the diagnosis of PeAF and had undergone an AFCA for the first time. Participants who experienced recurrences of the paroxysmal type, while on AAD therapy, were analyzed as a cohort of AAD-partial-responders; whereas those who consistently maintained a PeAF, while on AAD therapy were analyzed as a cohort of AAD-non-responders. We calculated the DAT cutoff to determine long-term rhythm outcomes, using a maximum log-likelihood approach, based on the Cox proportional hazards regression model. Results Of the participants, 79.8% were male, and the median age was 61 years. The cohort of AAD-non-responders had a higher body mass index and larger left atrial diameter than that of the cohort of AAD-partial-responders. Furthermore, the cohort of AAD-non-responders showed a significantly higher incidence of AF recurrence subsequent to AFCA (adjusted hazard ratio= 1.75, 95% confidence interval: 1.33–2.30; log-rank test: p&amp;lt; 0.001) than that of the cohort of AAD-partial-responders. The log-likelihood graphs of the Cox proportional hazards regression models showed bimodal morphology for the cutoff values of 22 and 40 months. The cutoff value of DAT that most optimally discriminated between rhythm outcomes was 22 months. Conclusions Thus, both the DAT and AAD responsiveness affected the rhythm outcomes of AFCA. Delaying AFCA to a DAT of longer than 22 months was inadvisable, particularly in the participants in whom PeAF progressed to PAF during AAD therapy.

Left atrial stiffness is in correlation with left atrial reservoir strain in pediatric patients with mitral regurgitation.

Left atrial stiffness index (LASI), defined as the ratio of early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') to peak atrial strain, reflects reduced left atrial (LA) compliance and represents an emerging marker that can be used for noninvasive measurement of fibrosis of LA in patients with mitral regurgitation (MR). To investigate the impact of chronic MR in children and adolescents on the remodeling and function of the LA, quantified through strain parameters and diastolic function. The study included fifty patients (n= 50) diagnosed with primary and secondary chronic MR lasting at least 5 years. The echocardiographic recordings were performed by a third party, two cardiologists actively engaged in echocardiography on a daily basis. Older participants had higher values of the LASI (r= 0.467, p= 0.001). Participants with higher LASI values had a smaller LA reservoir (r= 0.784, p= 0.0001) and smaller LA conduit values (r=-0.374, p= 0.00). Participants with higher LASI values had a larger LA diameter (r= 0.444, p-value= 0.001) and higher average E/e' ratio (r= 0.718, p= 0.0001). There was a significant difference (p= 0.04) in the LASI among participants based on the MR jet area (< 20.85 cm2/⩾ 20.85 cm2), LASI was higher in participants with an area greater than 20.85 cm2. Differences in other parameters such as LA reservoir, LA conduit, LA contractile were not statistically significant. Increased LA stiffness is associated with diminished atrial compliance and reservoir capacity, and LASI has a potential to as an early marker for assessing disease severity and progression in pediatric MR.

Surface electrocardiogram f wave analysis in patients with atrial fibrillation undergoing thoracoscopic epicardial ablation.

To investigate the predictive values of surface electrocardiogram-derived parameters in patients with atrial fibrillation who underwent thoracoscopic epicardial ablation. The present study included 102 patients with atrial fibrillation who underwent thoracoscopic epicardial ablation and whose baseline 12-lead electrocardiograms were available. Frequency domain analysis was performed to calculate the electrocardiogram-derived parameters. Cox proportional hazards regression was used to identify predictive risk factors for postoperative recurrence. At 36-month interval, the overall rate of freedom from atrial tachyarrhythmia without antiarrhythmic drugs was 58.5%. The results of the univariable and multivariable analyses showed that larger left atrial diameter (hazard ratio: 1.074, 95% confidence interval: 1.021-1.130, P = 0.006) was an independent risk factor for atrial fibrillation recurrence, while higher fibrillatory wave amplitude was a protective factor (hazard ratio: 0.292, 95% confidence interval: 0.157-0.542, P < 0.001). The associations were clarified by the restricted cubic splines. The dominant frequency and organization index were not identified as statistically significant parameters. The fibrillatory wave amplitude has the highest predictive value for atrial fibrillation recurrence in electrocardiogram-derived parameters. Together with left atrial diameter, it may help identify patients in whom thoracoscopic ablation is likely to be effective.

Cardio-Ankle Vascular Index as a Marker of Left Ventricular Hypertrophy in Treated Hypertensives: Findings From the Pamela Study.

Findings regarding the association between Cardio-Ankle Vascular Index (CAVI) and cardiac hypertension-mediated organ damage (HMOD), such as left ventricular hypertrophy (LVH) assessed by echocardiography, in elderly hypertensive patients are scanty. We sought to investigate this issue in the hypertensive fraction of the general population treated with anti-hypertensive drugs enrolled in the Pressioni Monitorate E Loro Associazioni (PAMELA) study. The study included 239 out of 562 participants who attended the second and third surveys of the PAMELA study performed after 10 and 25 years from the initial evaluation. Data collection included medical history, anthropometric parameters, office, home, ambulatory blood pressure (BP), blood examinations, echocardiography, and CAVI measurements. In the whole study sample (age 69 ± 9 years, 54% males), CAVI was positively correlated with age, office, home, ambulatory systolic BP, LV mass (LVM) index, and negatively associated with body mass index (BMI). In multivariate analysis, CAVI was associated with the LVM index (P < 0.05) independently of major confounders. The participants with LVH exhibited significantly higher CAVI (10.6 ± 2.8 vs. 9.2 ± 1.8 m/s P < 0.001), larger left atrial diameter, and lower LV ejection fraction values than their counterparts without it. The CAVI value of 9.4 m/s was the best cut-off for prediction of LVH in the whole sample. Our study provides new evidence of an independent association between CAVI and LVH in treated elderly hypertensive patients and suggests that the use of this metric of arterial stiffness could not only be used to evaluate vascular damage but also to stratify the risk of LVH.

Association of left atrial enlargement with heart failure events in non-valvular atrial fibrillation patients with preserved left ventricular ejection fraction.

Atrial fibrillation (AF) increases the risk of heart failure (HF); however, little is known regarding the risk stratification for incident HF in AF patients, especially with preserved left ventricular ejection fraction (LVEF). The Fushimi AF Registry is a community-based prospective survey of AF patients. From the registry, 3002 non-valvular AF patients with preserved LVEF and with the data of antero-posterior left atrial diameter (LAD) at enrolment were investigated. Patients were stratified by LAD (<40, 40-44, 45-49, and ≥50 mm) with backgrounds and HF hospitalization incidences compared between groups. Of 3002 patients [mean age, 73.5 ± 10.7 years; women, 1226 (41%); paroxysmal AF, 1579 (53%); and mean CHA2DS2-VASc score, 3.3 ± 1.7], the mean LAD was 43 ± 8 mm. Patients with larger LAD were older and less often paroxysmal AF, with a higher CHA2DS2-VASc score (all P < 0.001). Heart failure hospitalization occurred in 412 patients during the median follow-up period of 6.0 years. Larger LAD was independently associated with a higher HF hospitalization risk [LAD ≥ 50 mm: hazard ratio (HR), 2.36; 95% confidence interval (CI), 1.75-3.18; LAD 45-49 mm: HR, 1.84; 95% CI, 1.37-2.46; and LAD 40-44 mm: HR, 1.34; 95% CI, 1.01-1.78, compared with LAD < 40 mm) after adjustment by age, sex, AF type, and CHA2DS2-VASc score. These results were also consistent across major subgroups, showing no significant interaction. Left atrial diameter is significantly associated with the risk of incident HF in AF patients with preserved LVEF, suggesting the utility of LAD regarding HF risk stratification for these patients.

Abstract TP223: Predicting Atrial Fibrillation in Embolic Stroke of Unknown Source

Background: A considerable portion of patients with embolic stroke of unknown source(ESUS)are later found to have occult atrial fibrillation (AF). Studies have shown that prolonged outpatient cardiac monitoring increases the chances of AF detection and impacts choice of antithrombotic therapy. The Brown ESUS-AF Score, a prediction tool utilizing age and left atrial enlargement has previously shown promise in predicting AF in ESUS patients. In this study we aimed to externally validate the Brown ESUS-AF score and compare its performance against a random forest classifier. Methods: We included all patients with ESUS who underwent an inpatient stroke evaluation followed by outpatient cardiac monitoring between October 9,2015-March 31,2023. To validate the Brown ESUS-AF score, our cohort was divided between those who developed AF during follow-up versus those who did not. To develop the random forest classifier, we included demographics, medical comorbidities, lab records, echocardiographic and electrocardiographic findings. We did 80/20 train-test split to fine tune the model, and we identified features that had the greatest performance contribution. Results: Of 468 patients, 97(20.7%) patients had occult AF. AF patients were older(68.6±13.0 vs 60.1±15.6;p=0.0001), had a higher left atrial (LA) volume index(30.6±12.3 vs 26.2±10.0;p=0.0001) and larger LA diameter(3.8 ± 0.7 vs 3.5 ± 0.7;p=0.002) compared to those who did not develop AF. We found that a Brown ESUS-AF score of≥2 had lower sensitivity in our patient cohort than the original development cohort (42%vs63%). In comparing our random forest classifier to the Brown ESUS-AF score, our model had higher c-statistic (0.71vs0.64). The most important features we identified are age, LAVI, PR and QT Interval, triglyceride level and platelets. Conclusion: Our machine learning model incorporating 52 variables performed better than the Brown ESUS-AF score in predicting AF in our large and diverse ESUS cohort.

The Risk Factors of Mitral Regurgitation Deterioration After Secundum Atrial Septal Defect Closure.

Association between secundum Atrial Septal Defect (ASD) and mitral valve (MV) disease has been recognized for decades. Secundum ASD closure can reduce mitral regurgitation (MR) degree. However, in some patients, deterioration of MR after ASD closure has been observed. We aimed to identify the risk factors of MR deterioration after ASD closure. This was an observational retrospective cohort study. Data were collected from the registry and echocardiogram report. We evaluated all patients with ASD closure by surgery and transcatheterization without MR intervention from January 2012 until June 2021 at Dr. Sardjito General Hospital, Yogyakarta. We excluded patients with multiple ASD and ASD with severe MR requiring MV intervention. Risk factors for MR deterioration were evaluated using multivariate logistic regression. A total of 242 patients who underwent post-secundum ASD closure were included. In multivariate analysis, ASD closure by surgery, large left atrial (LA) diameter (>40 mm), low left ventricular ejection fraction (LVEF; <55%), and MV regurgitation degree were significant risk factors for MR worsening after ASD closure, with OR of 2.103 (95% CI 1.124-3.937); 2.871 (95% CI 1.032-7.985); 5.531 (95% CI 1.368-22.366); and 2.490 (95% CI 1.339-4.630) respectively. ASD closure by surgery, large LA diameter (>40 mm), low LVEF (<55%), and MV regurgitation degree are independent significant risk factors for MR deterioration in post-secundum ASD closure patients. In adult ASD patients with reduced LV function, it is recommended to perform balloon testing and consider fenestrated closure, as low LVEF <55% has the highest risk of causing new or deteriorating MR.

Long-term Outcome of Cryoballoon Ablation in Korean Patients With Atrial Fibrillation: Real-world Experience From the Cryo Global Registry.

Atrial fibrillation (AF), the most common atrial arrhythmia (AA), is an increasing healthcare burden in Korea. The objective of this sub-analysis of the Cryo Global Registry was to evaluate long-term efficacy, symptom burden, quality of life (QoL), and healthcare utilization outcomes and factors associated with AA recurrence in Korean patients treated with cryoballoon ablation (CBA). Patients were treated and followed up according to local standard-of-care in 3 Korean hospitals. Kaplan-Meier estimates were used in analyzing (1) efficacy defined as freedom from ≥30 second recurrence of AA at 24 months, (2) healthcare utilization, and (3) predictors of 24-month AA recurrence. Patient-reported QoL (using European Quality of Life-5 Dimensions-3 Levels) and predefined AF-related symptoms were assessed at baseline and 24-month follow-up. Efficacy was 71.9% in paroxysmal AF (PAF) and 49.3% in persistent AF (PsAF) patients (p<0.01). A larger left atrial diameter (LAD), an increased time from AF diagnosis to CBA, and PsAF were independent predictors of AA recurrence. The percentage of patients with no AF symptoms significantly increased from baseline (24.5%) to 24-month (89.5%) follow-up (p<0.01). Improvement in QoL from baseline to 24 months was not statistically different between AF cohorts. PAF patients experienced greater freedom from repeat ablations (93.9% vs. 81.4%) and cardiovascular hospitalizations (91.3% vs. 72.5%, p<0.001 for both). In alignment with global outcomes, CBA is an effective treatment for AF in the Korean population, with patients possessing a large LAD and not receiving ablation soon after diagnosis being the most at risk for AA recurrence. ClinicalTrials.gov Identifier: NCT02752737.

Identification of Clinical Drivers of Left Atrial Enlargement Through Genomics of Left Atrial Size.

Greater left atrial size is associated with a higher incidence of cardiovascular disease and mortality, but the full spectrum of diagnoses associated with left atrial enlargement in sex-stratified clinical populations is not well known. Our study sought to identify genetic risk mechanisms affecting left atrial diameter (LAD) in a clinical cohort. Using Vanderbilt deidentified electronic health record, we studied 6163 females and 5993 males of European ancestry who had at least 1 LAD measure and available genotyping. A sex-stratified polygenic score was constructed for LAD variation and tested for association against 1680 International Classification of Diseases code-based phenotypes. Two-sample univariable and multivariable Mendelian randomization approaches were used to assess etiologic relationships between candidate associations and LAD. A phenome-wide association study identified 25 International Classification of Diseases code-based diagnoses in females and 11 in males associated with a polygenic score of LAD (false discovery rate q<0.01), 5 of which were further evaluated by Mendelian randomization (waist circumference [WC], atrial fibrillation, heart failure, systolic blood pressure, and coronary artery disease). Sex-stratified differences in the genetic associations between risk factors and a polygenic score for LAD were observed (WC for females; heart failure, systolic blood pressure, atrial fibrillation, and WC for males). By multivariable Mendelian randomization, higher WC remained significantly associated with larger LAD in females, whereas coronary artery disease, WC, and atrial fibrillation remained significantly associated with larger LAD in males. In a clinical population, we identified, by genomic approaches, potential etiologic risk factors for larger LAD. Further studies are needed to confirm the extent to which these risk factors may be modified to prevent or reverse adverse left atrial remodeling and the extent to which sex modifies these risk factors.

Predictors of Higher Frequency of Atrial Fibrillation in Patients with Cardiac Resynchronization Therapy.

Background and Objectives: Cardiac resynchronization therapy (CRT) is one of the effective therapeutic options in the treatment of systolic heart failure (HF) with persistent symptoms. This prospective study was designed to determine whether CRT with biventricular pacing would reduce the risk of development of atrial fibrillation (AF) and to identify predictors for AF occurrence. Materials and Methods: The study population consisted of 126 patients, with a mean age of 63.8 ± 9.1 years, who were eligible for CRT with biventricular pacing. Inclusion criteria were left ventricular ejection fraction (LVEF) ≤ 35%, QRS duration ≥ 130 msec, and persistent HF symptoms of New York Heart Association (NYHA) II or III, despite optimal drug therapy. Patients were followed for a period of 24 months and were evaluated through clinical, electrocardiographic, and echocardiographic examination at baseline (prior to CRT implantation), as well as at 6 and 24 months post-implantation. At the end of follow-up, patients were divided into clinical responders and non-responders based on the following criteria: decrease in NYHA class ≥ I, increase in LVEF ≥ 10%, and reduction in QRS duration ≥ 20 msec. Results: At follow-up, CRT was associated with a significant increase in LVEF (20.6 ± 6.9% pre-implantation, 32.9 ± 9.3% 24 months after implantation; p < 0.001), reduction in left ventricular end-diastolic and end-systolic diameters, and decrease in QRS duration (167.6 ± 14.3 msec pre-implantation, 131.7 ± 11.7 msec 24 months after implantation; p < 0.001), while left atrial (LA) diameter was slightly increased (p = 0.070). The frequency of AF occurrence increased after two years of follow-up (52.4% to 56.9%, p < 0.001). Significant predictors of AF occurrence in our study population were response to CRT-AF more frequent in non-responders (B = 8.134; p < 0.001), LA diameter-AF more frequent with larger LA diameter (B = 0.813; p < 0.001), and coronary sinus (CS) lead position-AF more frequent with posterolateral in comparison with lateral CS lead position (B = 5.159; p = 0.005). Conclusions: The results of our study provide new data on AF predictors in patients with HF subjected to CRT. There remains a permanent need for new predictors, which might help in patient selection and improvement in response rate.

Differences in clinical characteristics and mortality of de novo acute heart failure and acutely decompensated chronic heart failure: A prospective cohort study

Background: Acute heart failure carries a high risk of mortality. Understanding the characteristics and outcomes of acute heart failure subgroups may have important implications for clinical risk stratification. Objective: We examined the clinical characteristics and rates of the 12-month all-cause mortality in a cohort of patients hospitalized with acute heart failure according to heart failure duration new-onset or de novo acute heart failure and acutely decompensated chronic heart failure (ADCHF). Methods and Materials: The cohort study, with a 12-month followup, was conducted at Nhan Dan Gia Dinh Hospital in Vietnam from February 2022 to October 2023. Results: Among 316 patients with acute heart failure, 159 patients (50%) were admitted presenting de novo AHF, while the remaining 157 patients (50%) exhibited ADCHF. Patients with ADCHF were characterized by a higher proportion of elders, comorbidities including chronic kidney disease and atrial fibrillation, and a larger left atrial diameter than those with de novo acute heart failure. The rates of mortality in patients with ADCHF were 1.69 times more than in patients with de novo acute heart failure (the hazard ratio (HR): 1.69 (The 95% confidence interval (CI 95%): 1.10 - 2.60, p = 0.016). However, patients with ADCHF had not an independent predictor of 12-month mortality after adjusting factors in multivariable Cox regression models, including age, chronic pulmonary disease, diabetes mellitus, coronary heart disease, atrial fibrillation, sodium, hemoglobin, N-terminal prohormone BNP (NT-proBNP). Conclusions: Among patients hospitalized with acute heart failure, acutely decompensated chronic heart failure was associated with poorer outcomes.

Prediction of incident atrial fibrillation in hypertrophic cardiomyopathy

Background and aimAtrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) with significant effects on outcome. We aim to compare the left atrial (LA) diameter measurement with HCM-AF Score in predicting atrial fibrillation (AF) development in HCM. MethodsFrom the regional cohort of the Campania Region, Italy, 519 HCM patients (38% women, age45 ± 17 years) without history of AF, were enrolled in the study. The primary clinical endpoint was the development of AF, defined as at least 1 episode documented by ECG. ResultsDuring the follow-up (mean 8 ± 6, IQ range 2.5–11.2 years), 99 patients (19%) developed AF. Patients who developed AF were more symptomatic, had higher prevalence of ICD implantation, had larger LA diameter, greater left ventricular (LV) maximal wall thickness and LV outflow tract obstruction (p < 0.01). Both LA diameter and HCM-AF score were higher in patients who developed AF versus those who did not (LA diameter 49 ± 7 versus 43 ± 6 mm; HCM-AF score 22 ± 4 versus 19 ± 4; p < 0.0001); however, ROC curve analysis demonstrated that LA diameter had a significant greater area under the curve than HCM-AF Score (p < 0.0001). At 5 years follow-up, a LA diameter > 46 mm, showed a similar accuracy in predicting AF development of HCM-AF score ≥ 22, which identifies patients at high risk to develop AF. ConclusionOur analysis shows that LA diameter, a worldwide and simple echocardiographic measure, is capable alone to predict AF development in HCM patients.

Thirty-year follow-up of patients submitted to percutaneous balloon mitral valvuloplasty for severe rheumatic mitral stenosis

Abstract Background Percutaneous balloon mitral valvuloplasty (PBMV) remains the mainstay of treatment for patients with severe rheumatic mitral stenosis (MS) and a favorable anatomy. Aim The present study aimed to assess very long-term outcomes after PBMV. Methods A retrospective analysis of PBMV performed at a single tertiary center between August 1991 and September 2022 was conducted. Successful PBMV was defined as a post-procedural functional mitral valve area (MVA) ≥1.5 cm2, mitral regurgitation less than moderate, and absence of in-hospital major cardiac or cerebrovascular events. The primary endpoint was composed of overall mortality and need for mitral reintervention (percutaneous and/or surgical). Results A total of 238 PBMV for severe rheumatic MS were conducted in our center during the specified timeframe (88.7% [n=211] female gender; mean age 48 ± 16 years; 48.6% [n=108] had atrial fibrillation [AFib]; 78.8% [n=149] had a Wilkins score ≤8). Acute success was achieved in 88% (n=198) procedures. Acute complications were present in 10.2% (n=23), mainly severe mitral regurgitation (n=10) and acute cerebrovascular events (n=5). During a mean follow-up of 15.3 ± 9.4 years, the incidence of the primary endpoint was 55% (n=131) (overall mortality 32.9% [n=77] and mitral valve reintervention 22.1% [n=54]). On bivariate analysis, higher age (p=0.042), presence of AFib (p=0.002), unsuccess of the procedure (p&amp;lt;0.001), acute complications (p=0.001) and larger left atrial (LA) diameter (p=0.05) were statistically significant for the occurrence of the primary endpoint. On multivariate analysis, larger LA diameter (hazard ratio [HR]: 1.03; 95% CI: 1.00-1.06; p=0.022), unsuccessful procedure (HR: 3.30; 95% CI: 1.56-7.01; p=0.002) and presence of complications (HR: 0.37; 95% CI: 0.17-0.84; p=0.017) were the only independent predictors of the primary endpoint. Conclusion In a large registry of patients submitted to PBMV for severe rheumatic MS, more than half met the primary endpoint for overall mortality or need for reintervention, up to 30 years after the procedure. This supports the dismal prognosis of this pathology. Prediction of late favorable results is multifactorial and appears to be determined by smaller LA diameter, absence of complications and acute success of the procedure.Event-free survival after PBMV

Association of left atrial strain with long-term cardiovascular mortality in hypertrophic cardiomyopathy

Abstract Background Hypertrophic cardiomyopathy (HCM) is a relatively common genetic cardiac disease affecting 1 in 200 people. Although sudden cardiac death (SCD) is considered the most devastating event in patients with HCM, cardiovascular death (CVD) is the leading cause of death in this population. Little is known about the predictors of cardiovascular mortality. Purpose The aim of this study was to investigate prognostic implication of left atrial (LA) strain on long-term cardiovascular mortality in patients with HCM. Methods Peak longitudinal LA strain was measured on echocardiography at initial evaluation using vendor-independent speckle-tracking software. Among a prospective cohort of 865 HCM patients collected at two large tertiary centers, 697 with adequate echocardiographic images to measure biplane LA strain were included in the analysis. The primary endpoint was CVD during 10 years after initial evaluation. Results The median age was 56.0 years and 74.6% were male. Among the 697 patients, 25 died due to cardiovascular cause for 10 years. Among clinical and echocardiographic variables, older age, female sex, previous myocardial infarction, previous stroke, higher SCD risk score by European Society of Cariology, presence of SCD risk factors by American College of Cardiology, obstructive HCM, larger LA diameter, and lower LA strain were associated with CVD. LA strain had the highest predictive power for CVD occurrence, with a c-statistic of 0.79 (Figure 1). In multivariable Cox analysis, LA strain remains an independent predictor of CVD (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82–0.94). Patients with LA strain &amp;lt;19.4% (the lowest quartile), compared with those with LAS ≥19.4%, had a significantly higher risk of CVD (19.5% vs. 2.1%, HR 7.31, 95% CI 3.15–16.95), as well as death by any cause, SCD, and a composite of CVD, heart failure admission, and stroke (Figure 2). Conclusions In patients with HCM, LA strain is an independent predictor of long-term CVD.