Larger Left Atrial Volume Research Articles

Discordance between left atrial volume and scar burden in patients with atrial fibrillation and its impact on atrial fibrillation recurrence after catheter ablation

Abstract Background Large left atrial (LA) volume and a high burden of LA low voltage zone (LVZ) are associated with atrial fibrillation (AF) recurrence after AF catheter ablation. There is a scarcity of information on the association between LA volume and LVZ and its impact on the risk of AF recurrence. Purpose To investigate the relationship between the LA volume and LVZ, as well as how these factors contribute to the recurrence of atrial fibrillation (AF). Methods From Nov 2021 to Oct 2023, drug-refractory AF patients who underwent AF catheter ablation were included. LA volume was assessed using the LA volume index (LAVI) using echocardiography. The LVZ was evaluated by conducting high-density electroanatomical mapping using a multipolar catheter. The cut-off value associated with AF recurrence was 48ml/m2 in LAVI and 4.5% in scar burden. Patients were categorised into four groups according to the LAVI and scar burden: Group 1 (Low LVZ and small LA), group 2 (Low LVZ and large LA), group 3 (High LVZ and small LA), and group 4 (High LVZ and large LA). Results A total of 170 patients were included (mean age 62± 9 years, 82% of men, 68.2% of non-paroxysmal AF and 81 [48%] in group 1; 32 [19%] in group 2, 27 [16%] in group 3, 30 [17%] in group 4, respectively). Among total, mean follow-up duration was 266.5 ± 174.4 days, and 8.8% of patients received additional LA ablation beyond pulmonary vein isolation. Among the four groups, group 2 and 4 were significantly associated with higher risks of AF recurrence compared to group 1 (HR 2.36 [1.04-5.34], p=0.039; 3.56 [1.59-7.95], p=0.002, respectively). The risk of AF recurrence was highest in group 4, followed by group 2 (log-rank P=0.002). Comparing group 2 and 3, AF recurrence occurred predominantly within 6-month after catheter ablation in group 2, while after 1-year in group 3 (log-rank P=0.83). Conclusion About one-third of patients showed discordance between the LAVI and LVZ, which are both independent predictors for AF recurrence. A substantial LA volume seems to contribute to early AF recurrence, whereas a high scar burden appears to affect late AF recurrence.

Tricuspid regurgitation in the context of severe concomitant left-sided valvular heart disease: patients characteristics and long-term clinical and interventional outcomes

Abstract Background The clinical features, therapeutical management and outcome of patients with significant tricuspid regurgitation (TR) in the context of multiple valvular disease (VD) are poorly defined. Purpose To assess the characteristics, management and long-term prognosis of a large cohort of patients with multiple VD, focusing on the context of significant TR and concomitant severe mitral or aortic disease. Methods Clinical and echocardiographic data were collected in 1183 patients with ≥moderate TR diagnosed at our centers from January 2012 to June 2020: after propensity score matching for age to create matched cohort with < 10% of absolute difference, 975 patients were included in this study and divided in 4 groups as shown in Figure 1. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization+any valvular intervention. Results Patients with isolated TR (356, 37%) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). TR+ severe MR patients (466, 48%) showed higher rates of concomitant coronary artery disease, NYHA class III/IV symptoms and larger left atrial volumes. The group of TR+ severe AS (131 patients, 13%) was characterized by older age, more comorbidities and lower LVEF. Patients with TR and severe AR (22, 2%) were younger, with larger LV dimensions and higher pulmonary pressures. Overall, in 37(4%) patients tricuspid intervention was performed: no differences were found between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment (p=0.444 and p= 0.624, respectively), while left-valve only surgical treatment was more common among patients with TR and severe MR and left-valve transcatheter treatment among patients with TR and severe AS (both p<0.001). After a median follow-up of 2.8 years, the primary endpoint occured in 374 (38%) of patients, and was significantly more frequent in the group of patients with TR and severe AS (p<0.001, Figure 2). In this group, after multivariate analysis, indexed stroke volume remained independenty associated with ACD (OR 0.96, CI 0.93-0.98, p =0.040). Eventually, the secondary endpoint too was more common in patients with TR and severe AS (p<0.001, Figure 2). Conclusions In the context of significant TR, concomitant severe left-sided VD is common, and each subtype presents with different clinical features and echocardiographic phenotypes; in this scenario, TR was profoundly underteated. Long-term, patients with significant TR+ severe AS have considerable worse prognosis.Figure 1Figure 2

Impact of Premature Ventricular Complex Burden on Ischemic Stroke in Patients with Non-Valvular Atrial Fibrillation.

Background/Objectives: Limited data are available regarding the prognostic impact of premature ventricular complex (PVC) burden in patients with atrial fibrillation (AF). We sought to compare clinical outcomes in patients with AF according to PVC burden via 24 h Holter monitoring. Methods: From January 2010 to December 2020, 4834 oral anticoagulant (OAC)-naïve non-valvular AF (NVAF) patients who underwent 24 h Holter monitoring were included for analysis. Results: Among the 4834 OAC-naïve NVAF patients, 2835 patients (58.6%) exhibited at least one PVC within a 24 h monitoring period, and 120 patients (2.5%) displayed a daily PVC burden exceeding 10%. In the follow-up echocardiography, patients with a daily PVC burden of ≥10% exhibited lower left ventricular ejection fraction, larger left atrial volume, and higher right ventricular systolic pressure and E/e' than those with a daily PVC burden of <10%. The risk of ischemic stroke (adjusted HR 2.332, p = 0.015) and heart failure admission (adjusted HR 2.147, p = 0.010) were significantly higher in the patients with a daily PVC burden of ≥10% than in those with a daily PVC burden of <10%. However, the incidence of cardiac death was not significantly different between the two groups. A daily PVC burden of ≥10% was independently associated with the risk of ischemic stroke in the OAC-naïve NVAF patients, irrespective of the CHA2DS2-VASc score, AF type, and left atrial size. Conclusions: The current results suggest that evaluating and monitoring the burden of PVCs in patients with NVAF is an important aspect of predicting stroke and heart failure admission.

Determinants of invasive left atrial pressure in patients with atrial fibrillation.

Estimation of left ventricular (LV) filling pressures in patients with atrial fibrillation (AF) is challenging due to lack of reliable parameters. This study investigates the association between cardiac structure and function and invasive mean left atrial pressure (LAP). This is a multi-center prospective study enrolling patients undergoing transcatheter ablation for AF. The invasive measurement of LAP was performed at the time of the procedure while the echocardiography within the previous 24 hours. A mean LAP ≥ 15 mmHg was considered as increased. Overall, 101 patients were included (mean age 65.8 ± 8.5 years, 68% male, mean LV ejection fraction 56.6 ± 8.0%). No significant differences regarding clinical characteristics were detected between the group of patients with normal (n=47) or increased LAP (n=54). The latter showed lower values of LV global longitudinal strain, larger left atrial volumes (LAV) and worse right ventricular (RV) function. After multivariable adjustment, higher E/e' ratio (p=0.041) and minimal LAV index (LAVI min) (p=0.031), lower peak atrial longitudinal strain (PALS) (p=0.030) and RV free wall strain (p=0.037), but not maximal LAV index (LAVI max) (p=0.137), were significantly associated with mean LAP. The associations were not modified by cardiac rhythm. Overall, LAVI min showed the best diagnostic accuracy to predict elevated LAP (AUC 0.703). LA structure and function assessment well correlates with mean LAP in patients with AF. These measures may be used in the assessment of filling pressure in these patients.

Tricuspid regurgitation in the context of severe left-sided valvular disease: Patients characteristics and outcome

BackgroundWe aimed to assess the characteristics, management and long-term prognosis of a cohort of patients with multiple valvular disease, focusing on the context of severe mitral or aortic disease with concomitant significant tricuspid regurgitation (TR). MethodsAfter using a propensity score matching for age, 975 patients with ≥ moderate TR, diagnosed at our centers from 2012 to 2020, were included and divided in four groups, including isolated TR patients as reference group. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization + any valvular intervention. ResultsPatients with isolated TR (356, 37 %) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). Patients with severe mitral regurgitation (MR) + TR (466, 48 %) showed higher rates of concomitant coronary artery disease, advanced functional class symptoms and larger left atrial volumes. Severe aortic stenosis (AS) patients (131, 13 %) were older, with more comorbidities and lower LVEF. Patients with severe aortic regurgitation and TR (22, 2 %) were younger, with larger LV dimensions and higher pulmonary arterial pressures.After a median follow-up of 2.8 years, both endpoints were univariably more frequent in patients with severe AS + TR (all p < 0.001), but after comprehensive adjustment difference in the primary endpoint became insignificant, underscoring the serious outcomes of all significant TR groups significantly. Overall, in 44 (5 %) patients tricuspid intervention was performed, with no differences between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment. ConclusionsIn the context of severe left-sided VD, concomitant significant TR is common, and each subtype presents with different clinical and echocardiographic features: patients with severe AS and TR have considerable worse prognosis, although comprehensive adjustment reflected the poor outcomes affecting all types of patients with significant TR. In this scenario, TR was profoundly undertreated.

A Long Atrial Electromechanical Interval is Associated with Arrhythmic Recurrence after Catheter Ablation: How to Find What Has Been Lost.

Atrial fibrillation (AF) results in electrical and structural remodeling of the atria, which extent is known to be associated with a higher AF recurrence rate after catheter ablation (CA). Recently, a novel echocardiographic parameter derived from tissue Doppler imaging (TDI) [PA-TDI] has been introduced to assess the total atrial activation time, as a noninvasive surrogate of fibrosis and remodeling. The aim of the study is to investigate the role of PA-TDI interval as a predictor of AF ablation efficacy. We retrospectively included patients with paroxysmal symptomatic drug-refractory AF referred to our institution for CA procedure, who presented sinus rhythm at admission. A complete transthoracic echocardiogram was performed before the ablation procedure, including the assessment of PA-TDI interval. From January 2015 to April 2018, 128 patients (mean age: 61.86 ± 9.08 years, 68% male, body surface area: 1.97 ± 0.21 mq, body mass index: 26.98 ± 3.86 kg/mq, and ejection fraction: 59% ±6.06%) with symptomatic drug-refractory AF who received radiofrequency CA were enrolled. During the follow-up of 15.80 ± 6.7 months, 30 patients (23%) developed AF recurrence out of the blanking period. Compared with those without recurrence (group 1), patients with recurrence (group 2) had a larger left atrium (LA) size (Group 1 vs. Group 2: mean LA area: 22.2 ± 4.6 cmq vs. 25 ± 6.6 cmq, P = 0.015; mean indexed LA volume: 35 ± 10 mL/mq vs. 40 ± 12 mL/mq, P = 0.04) and longer PA-TDI interval (Group 1 vs. Group 2: 162 ± 33 ms vs. 133 ± 26 ms, P < 0.0001). A cutoff of PA-TDI > 150 ms identified patients with recurrence after ablation with a sensibility of 82% and specificity of 83% (area under the curve 0.879). The total activation time assessed by PA-TDI is an independent predictor of AF recurrence and can be used to predict the efficacy of transcatheter ablation.

Distinct leaflet-annular remodeling pattern in severe atrial functional mitral regurgitation: a three-dimensional echocardiography study

BackgroundAtrial functional mitral regurgitation (AFMR) is best described with normal left ventricular size and function, structurally normal mitral leaflets and dilated left atrium. Unlike the ventricular functional phenotype, changes in the annular geometry more than the tethering forces are the main culprit for mitral regurgitation. The aim of this study is to illuminate the leaflet-annular remodeling in patients with mitral regurgitation and atrial fibrillation (AF) using three-dimensional transesophageal echocardiography (3D TOE).ResultsConsecutive fifty patients with AFMR underwent transthoracic echocardiography and 3D TOE: 25 patients with AF and non-mild MR and 25 patients with AF and mild MR were studied. A special mitral valve analysis software was used to accurately assess the three unique pillars for MR: annular size, leaflets’ geometry and tenting parameters.Compared to the mild MR group, non-mild MR group had long-standing AF of more than 1 year and larger left atrial volumes (51.83 ± 12.07 ml/m2 vs 33.68 ± 10.97 ml/m2, p < 0.001). No significant differences were noted in respect of tenting height, area and volume (13.06 ± 2.57 mm vs 11.43 ± 2.89 mm, p = 0.064, 3.58 ± 1.26 cm2 vs 2.80 ± 0.95 cm2, 0.081 and 6.70 ± 2.96 cm3 vs 5.04 ± 2.32 cm3, p = 0.081). Conversely, the non-mild MR group had larger annular area and perimeter (16.20 ± 3.90 cm2 vs 13.51 ± 3.85 cm2, p = 0.023 and 14.73 ± 1.72 cm vs 13.46 ± 1.79 cm, p = 0.033). Similarly, the non-mild MR group had larger anterior and posterior leaflets’ areas (10.18 ± 4.02 cm2 vs 8.71 ± 3.08 cm2, p = 0.04 and 8.96 ± 2.60 cm2 vs 7.30 ± 2.17 cm2, p = 0.029). Correspondingly, more disproportionate leaflet-annular remodeling, as assessed by the ratio of total leaflets’ area to the annular area, was noted in the non-mild MR as opposed to the mild MR group (1.22 ± 0.04 vs 1.26 ± 0.04, p = 0.008).ConclusionsRecently, AFMR has been recognized as a remarkable entity of secondary MR with unique mechanisms. Annular dilatation with disproportionate leaflet remodeling can validate the central regurgitation. However, the call for more parameters is being emphasized to characterize the suitable candidates for percutaneous interventions.Graphical abstract

X-ray endovascular surgery for in-hospital acute ischemic stroke

The OBJECTIVE was to determine the efficacy of endovascular surgery for in-hospital acute ischemic stroke (AIS) and to identify predictors of unfavorable AIS outcome.METHODS AND MATERIALS. We performed 42 endovascular thrombectomies for in-hospital AIS in patients treated in the hospital for another pathology. Neurological defiCIT was determined by NIHSS scale, thrombectomy efficacy was evaluated by the degree of cerebral revascularization by mTICI scale, functional outcome was determined by Rankin scale (mRS). Multivariate analysis with evaluation of clinical and laboratory, neuroimaging data, and analysis of surgical technique was performed to identify factors contributing to adverse stroke outcome.RESULTS. The mean age of patients was 73.8±11.8 years old. Neurological defiCIT before surgery was 12.8±6.7 points by to NIHSS. Thrombolytic therapy was used in one third of cases, thrombectomy in 92.9 %, and carotid artery stent ing in 2 cases. Successful revascularization (mTICI2b-3) was achieved in 83.3 % of cases. The significant reduction in neurological defiCIT after surgery was achieved to NIHSS 6.0±5.9 points, mRS 2.7±2.1. The mortality rate amounted to 16.7 % of cases. Poor functional outcome (mRS3-5) was significantly associated with: female gender, older age, presence of cardiovascular pathology, recurrent stroke, postoperative tachycardia, low renal tubular filtration rate, hypocoagulation, low cardiac ejection fraction, low aortic valve opening amplitude, high pulmonary hypertension, large left atrial volume, initial severe neurological defiCIT, poor collaterals in the area of cerebral ischemia, proximal internal carotid artery occlusion, hemorrhagic saturation, increased operation time, low degree of revascularization (mTICI0-2a).CONCLUSION. Endovascular surgery has demonstrated its safety and high efficacy in the treatment of in-hospital AIS in surgical hospitalized patients. Endovascular thrombectomies allow to significantly reduce neurological defiCIT and decrease mortality in the severe category of patients with cardioembolic AIS. clinical, laboratory, hemodynamic and neuroimaging factors influencing on poor functional outcome of in-hospital AIS have been determined.

Catheter ablation for persistent atrial fibrillation: patterns of recurrence and impact on quality of life and health care utilization.

Patterns of atrial fibrillation (AF) recurrence post-catheter ablation for persistent AF (PsAF) are not well described. This study aimed to describe the pattern of AF recurrence seen following catheter ablation for PsAF and the implications for healthcare utilization and quality of life (QoL). This was a post-hoc analysis of the CAPLA study, an international, multicentre study that randomized patients with symptomatic PsAF to pulmonary vein isolation plus posterior wall isolation or pulmonary vein isolation alone. Patients underwent twice daily single lead ECG, implantable device monitoring or three monthly Holter monitoring. 154 of 333 (46.2%) patients (median age 67.3 years, 28% female) experienced AF recurrence at 12-month follow-up. Recurrence was paroxysmal in 97 (63%) patients and persistent in 57 (37%). Recurrence type did not differ between randomization groups (P = .508). Median AF burden was 27.4% in PsAF recurrence and .9% in paroxysmal AF (PAF) recurrence (P < .001). Patients with PsAF recurrence had lower baseline left ventricular ejection fraction (PsAF 50% vs. PAF 60%, P < .001) and larger left atrial volume (PsAF 54.2 ± 19.3 mL/m² vs. PAF 44.8 ± 11.6 mL/m², P = .008). Healthcare utilization was significantly higher in PsAF (45 patients [78.9%]) vs. PAF recurrence (45 patients [46.4%], P < .001) and lowest in those without recurrence (17 patients [9.5%], P < .001). Patients without AF recurrence had greater improvements in QoL as assessed by the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire (Δ33.3 ± 25.2 points) compared to those with PAF (Δ24.0 ± 25.0 points, P = .012) or PsAF (Δ13.4 ± 22.9 points, P < .001) recurrence. AF recurrence is more often paroxysmal after catheter ablation for PsAF irrespective of ablation strategy. Recurrent PsAF was associated with higher AF burden, increased healthcare utilization and antiarrhythmic drug use. The type of AF recurrence and AF burden may be considered important endpoints in clinical trials investigating ablation of PsAF.

Structural and functional abnormalities of left-sided cardiac chambers in Barlow's disease without significant mitral regurgitation.

This study aims to explore the presence of left ventricular (LV) and left atrial (LA) morphological and functional abnormalities in patients with Barlow's disease (BD) without significant mitral regurgitation (MR) and to investigate whether these abnormalities may predict MR progression. Consecutive patients with BD were retrospectively identified from two tertiary centres; those with MR graded from trivial to mild-to-moderate were selected and matched with healthy controls in a 1:1 ratio. Conventional and speckle-tracking echocardiographic data were collected. The development of moderate-to-severe or greater MR was evaluated on follow-up echocardiograms. Patients with BD (n = 231) showed increased LV dimensions and indexed LV mass (LVMi) in comparison with controls (P < 0.001); LV remodelling worsened with higher MR severity and was accompanied by an increased prevalence of eccentric LV hypertrophy (eLVH). Moreover, BD patients had larger LA volumes and more impaired LA reservoir strain vs. controls (P < 0.001), while LV strain was similar between the two groups. Multivariable linear regression analyses in the overall population identified BD and MR grade as independent predictors of remodelling markers (LV dimensions, LVMi, and LA volume) and BD as independent correlate of LA strain. MR progression was observed in 51 BD subjects (out of 170 patients with available follow-up). On Cox regression analysis, age, eLVH, mild-to-moderate MR, and mitral annular disjunction (MAD) emerged as independent predictors of MR progression. BD patients without significant MR show early LV and LA remodelling, together with reduced LA strain. MR progression was associated with eccentric LV remodelling, MAD, and MR severity.

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

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

Association between left atrial volume index and infarct volume in patients with ischemic stroke.

Left atrial volume index (LAVI) is one marker of atrial myopathy, which is increasingly being recognized as a cause of cardioembolic stroke even in the absence of atrial fibrillation. Cardiac embolism is associated with larger strokes than other stroke mechanisms. The purpose of this study was to examine the association between LAVI and total brain infarct volume in patients with ischemic stroke. This was a retrospective study of 545 patients prospectively enrolled in the Cornell ActuE Stroke Academic Registry (CAESAR), which includes all acute ischemic stroke patients admitted to our hospital since 2011. LAVI measurements were obtained from our echocardiography image store system (Xclera, Philips Healthcare). Brain infarcts on diffusion-weighted images (DWI) were manually segmented and infarct volume was obtained on 3D Slicer. We used multiple linear regression models adjusted for age, sex, race, and vascular comorbidities including atrial fibrillation. Among 2,945 CAESAR patients, 545 patients had both total infarct volume and LAVI measured. We found an association between LAVI and log-transformed total brain infarct volume in both unadjusted (β = 0.018; p = 0.002) and adjusted (β = 0.024; p = 0.001) models. We found that larger left atrial volume was associated with larger brain infarcts. This association was independent of known cardioembolic risk factors such as atrial fibrillation and heart failure. These findings support the concept that atrial myopathy may be a source of cardiac embolism even in the absence of traditionally recognized mechanisms such as atrial fibrillation.

Impaired retinal micro-vascular function in patients with atrial fibrillation

BackgroundCardiovascular (CV) risk factors and CV diseases, in particular heart failure, are strongly associated with impaired microvascular retinal endothelial function. Whether atrial fibrillation (AF) contributes to vascular dysfunction is not clear. Therefore, the aim of this study was to investigate the impact of AF on retinal microvascular function. MethodsIn this study, vascular function was measured non-invasively with flicker-light induced vasodilatation of retinal arterioles (FIDart%). Patients with a history of AF and risk factors for heart failure (HF) or heart failure (n = 69; age 67.9 ± 9.2 years, 71% male, 35% HFrEF, 56% paroxysmal, 25% persistent, 19% permanent AF), as well as age, sex and ejection fraction matched patients with absent history of AF (n = 66; age 63.4 ± 10.6 years, 67% male, 47% HFrEF) were included. Patients with AF were further divided into those with paroxysmal AF (in sinus rhythm – AFSR: n = 38, age 71.4 ± 9.2, 73% male), and those with AF at the time of the study visit. ResultsRetinal microvascular function was impaired in patients with AF compared to patients without AF (FIDart% 1.1% [0.3–2.8] vs. 2.7% [1.3–5.1], p < 0.001). Patients currently in AF have poorer retinal microvascular function (FIDart% 0.8% [0.1–1.9) compared to patients with a history of AF but currently in SR at the time of retinal function measurement (1.5% [0.6–4.9] p = 0.017). In patients with AF, impaired retinal vascular function was independently associated with larger left atrial volume (mean 49.8 ± 18.4), even after correction for confounding factors in different models (SCR = -0. 251 to −0.256, p = 0.035–0.01). ConclusionsAF in patients with heart failure is associated with impaired vascular function, even if currently in sinus rhythm. The association of retinal microvascular dysfunction with left atrial volume, a surrogate for elevated cardiac filling pressures, may further highlight the important interplay between the vasculature and elevated filling pressures in the development of AF.

3D atrial stiffness in chronic mitral regurgitation: impact of sex, regurgitation mechanism and valve geometry - the 3D-PRIME study

Abstract Background Chronic mitral regurgitation (MR) is both a cause and a consequence of progressive left atrial (LA) remodeling. The degree of LA stiffness in relation to clinical risk factors as well as atrio-valvular remodeling has not been reported in patients with MR. Aims To assess the severity and determinants of 3D LA stiffness in chronic MR. Methods In the prospective 3D-PRIME (3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation) study, 100 patients with chronic MR (70±13years, 38% women, 55% with a history of atrial fibrillation (AF), 42% with severe MR) recruited at one heart valve center were investigated with 2D and 3D transthoracic and transesophageal echocardiography. MR severity was quantified by the regurgitant fraction and MR classified as primary (54%), atrial functional (26%) or ventricular functional (20%). 3D LA volume (LAV) was measured at end-diastole (min LAV) and end-systole (max LAV), and 3D LA function assessed in by the emptying fraction (EF) and the peak strain in the reservoir phase (LASr). LA stiffness was estimated from the ratio: mitral peak E-wave velocity divided by the mitral annular e’ velocity (E/e´) / LASr and classified as high for age if ≥ 0.55. Results High LA stiffness for age was present in 58% of patients and more often in those with a history of AF (73% vs. 45%) and in severe vs moderate MR (70% vs. 42%) (both p &amp;lt;0.01). Patients with high LA stiffness had larger LAVs with lower LA EF, lower right ventricular ejection fraction, increased mitral annulus area, and larger mitral valve leaflets (all p&amp;lt;0.05). Men had considerably larger LAVs in all MR subgroups, and highly stiff LAs in atrial functional MR compared to women (p &amp;lt;0.05, Figure) despite similar MR severity (regurgitation fraction 50% vs 52%, respectively). In multiple regression analysis, after stepwise removal of the following factors: MR severity, mitral leaflet to ring area ratio, and right ventricular ejection fraction, increased LA stiffness was independently associated with male sex, history of AF, lower LA EF and lower mitral intertrigonal diameter (R2 0.40, p &amp;lt;0.001, Table). Conclusion LA is stiff for age in over half of patients with chronic MR, excessively stiff in men with atrial functional MR, and associated with specific changes in mitral valve geometry and LA function. This gives mechanistic insights into the complex atrio-valvular interplay in chronic MR.Figure.Table.

Left atrial strain and long-term risk of atrial fibrillation in hypertrophic cardiomyopathy

Abstract Background The prevalence of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients is higher than in the general population, and it is associated with an increased risk of adverse outcomes, such as stroke, heart failure, and mortality. The left atrium (LA) plays an important role in maintaining normal cardiac function, and alterations in its structure and function can contribute to the development of AF. LA strain, a surrogate of LA remodeling, has been suggested a predictor of future AF. Purpose The aim of this study was to explore risk factors of new onset AF highlighting LA strain in patients with HCM. Methods Among a prospective cohort of 865 HCM patients collected at two large tertiary centers, 696 with adequate echocardiographic images to measure LA strain without a history of AF were included in the analysis. LA strain was measured on apical four-chamber view at initial evaluation using vendor-independent speckle-tracking software. The primary endpoint was new onset AF during 10 years after initial evaluation. Results The median age was 55.0 years and 74.3% were male. A median value of LA reservoir strain (LARS) was 26.2 % [interquartile range 20.4, 33.3]. Among the 696 patients, 66 had new onset AF 10 years, with a 10-year incidence of 15.8%. The unadjusted risk factors for new onset AF were previous stroke, non-apical HCM, family history of HCM, non-sustained ventricular tachycardia, obstructive HCM, extensive late gadolinium enhancement, larger LA diameter, larger LA volume, and lower LARS. LARS remained an independent predictor of new onset AF in multivariable analysis. The best cut-off value of LARS was 17.9% (hazard ratio 4.00, 95% confidence interval 2.44–6.55, p&amp;lt;0.001). Compared with LARS ≥17.9%, LARS &amp;lt;17.9% was significantly associated with a higher incidence of new onset AF, irrespective of presence of clinical risk factors (Figure 1) and LA enlargement (Figure 2). Conclusions In patients with HCM, low LA strain is an independent predictor of new onset AF.

Structural and functional abnormalities of cardiac chambers in Barlow disease without significant mitral regurgitation

Abstract Background Limited and conflicting data have been reported on the existence of an early chamber remodelling in patients with Barlow disease (BD) without significant mitral regurgitation (MR). Purpose To explore the presence of left ventricular (LV) and left atrial (LA) morphological and functional abnormalities, evaluated by conventional and speckle-tracking echocardiography, in patients with BD and without significant MR; in addition, potential determinants of MR progression in these patients have been investigated. Methods We retrospectively identified consecutive patients with BD evaluated in two tertiary centers between 2010 and 2021. Only patients with MR graded from trivial to mild-to-moderate, as defined by an integrated multiparametric echocardiographic assessment, were selected. BD patients were matched with healthy controls with similar demographic characteristics and prevalence of cardiovascular risk factors, in a 1:1 ratio. A comprehensive echocardiographic evaluation, including LV and LA strain assessment by speckle-tracking analysis, was performed in all patients. Follow-up echocardiograms, when available, were reviewed in BD patients to evaluate the MR progression. Results A total of 231 patients with BD were included, of which 109 (56%) had trivial or mild MR and the remaining 122 (44%) had mild-to-moderate MR. As showed in Figure 1, patients with BD showed increased LV dimensions and indexed LV mass (LVMi), as compared with controls (all p&amp;lt;0.001); LV remodelling worsened with higher degree of MR (trivial-mild vs mild-to-moderate) and was accompanied by an increased prevalence of eccentric LV hypertrophy (eLVH). Conversely, parameters of LV systolic performance, including LV strain, were similar to controls and between the two groups. In addition, BD patients had larger LA volumes and more impaired LA reservoir strain than controls (p&amp;lt;0.001), without differences in the latter according to MR severity. Multivariable linear regression analyses in the overall population identified BD and MR grade as independent predictors of remodelling markers (LV dimensions, LVMi and LA volumes), and BD as independent correlate of LA reservoir strain. Progression to moderate-to-severe or greater MR was observed in 51 subjects (on 172 with available follow-up) after a median time of 38 (range: 24-68) months. On multivariable Cox regression analysis, LVMi (or alternatively eLVH), together with age, MR grade and the presence of mitral annular disjunction emerged as independent predictors of MR progression (Figure 2). Conclusions Patients with BD and no significant MR show an early LV and LA remodeling, together with a mild impairment of LA reservoir strain, but not of LV function. LV remodelling, and the presence of eLVH in particular, portends a higher risk of MR progression.Comparative echocardiographic analysisMultivariable Cox regression analyses

Cardiac magnetic resonance correlates of staging algorithm in patients with asymptomatic severe aortic stenosis

Abstract Background The staging algorithm recently proposed to risk stratify patients with severe aortic stenosis (AS) has not been largely applied to patients who are asymptomatic. While the presence of severe tricuspid regurgitation, pulmonary hypertension and right ventricular dysfunction (stages 3-4) is expected to be low, the prevalence of left ventricular damage (LV), mitral regurgitation, left atrial (LA) dilation and atrial fibrillation (stages 1-2) can be higher in patients with asymptomatic severe AS. The cardiac magnetic resonance (CMR) correlates of the staging algorithm have not been described. Purpose To investigate the distribution of patients with asymptomatic severe AS in the staging algorithm and its differences with CMR findings. In addition, differences in CMR data between patients presenting with AS-related adverse events at 1-year follow-up and patients free of events were compared. Methods Patients with asymptomatic severe AS (aortic valve area, AVA&amp;lt;1.0 cm2) and preserved LV ejection fraction (EF) (&amp;gt;50%) that were referred to CMR were included. Biomarkers, echocardiographic and CMR data were assessed retrospectively. CMR-derived parameters included LV and right ventricular (RV) volumes and systolic function, LA volumes and tissue characterization were reported at baseline and compared with AS-related events (a composite of all-cause mortality, symptoms onset, or need for aortic valve replacement) during 1-year follow-up. Results Of 97 patients included (73±9 years old; 36% males), 3 (%) patients were classified in Stage 0, 34 (35%) in Stage 1, 59 (61%) in Stage 2, and 1 (1%) in Stage 3 or 4. Compared to stage 1, patients in stage 2 were older (P=0.006) and had a higher prevalence of overweight (P=0.037), hypertension (P=0.018), NT-proBNP (P=0.030) and hsTnT (p=0.011) levels. On CMR, they showed higher LV volumes and mass index, larger LA volumes and reduced LA ejection fraction, but no differences on myocardial tissue characteristics (Table 1). Regarding prognosis, 45 (46.5%) patients presented AS-related events at 1-year follow-up. Those with events were mainly in stage 2 (36%) and presented higher NT-proBNP levels despite showing no differences in AVA. On CMR, those with events had lower LVEF, greater LV to RV end-diastolic volume ratio, greater left atrio-ventricular coupling index, reduced LA function and a higher extension of late gadolinium enhancement (Table 2). Conclusions In our cohort, most patients with severe asymptomatic AS were in stage 2. Stage 2 patients presented a higher degree of left-chambers remodelling on CMR compared to patients in stage 1. Patients in stage 2 or with lower LVEF, LV remodelling or reduced LAEF on CMR were those with an increased risk for events at follow-up.

The classification shifting and outcomes of DELIVER-type patients with acute heart failure and preserved ejection fraction

Abstract Background The DELIVER trial enrolled subjects with acute heart failure (AHF) and preserved ejection fraction (HFpEF) who had elevated biomarkers and cardiac structural abnormalities. Given the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in AHF, it is important to understand the differences between DELIVER-type and non-DELIVER-type patients and how their classification may shift over time. Method This study enrolled patients hospitalized for AHF with LVEF ≥ 50%. Patients with elevated N-terminal pro B-type natriuretic peptide (NT-proBNP ≥ 300 or 600 pg/mL, depending on cardiac rhythm) and cardiac structural abnormalities (enlarged left atrial volume or index, or left ventricular hypertrophy) were classified as DELIVER-type. Patients who did not meet these criteria were classified as non-DELIVER-type. Patients with estimated glomerular filtration rate ≤ 25 mL/min/1.73m2 and those receiving SGLT2i treatment were excluded. Echocardiographic variables were obtained pre-discharge and one year after the index day. All-cause mortality and heart failure hospitalization up to one year were determined by web-based electronic record. Result The study included 385 subjects with an average age of 83.7 ± 13.9 years, of whom 53.2% were men. The DELIVER-type group had a higher proportion of atrial fibrillation, larger left atrial volume, thicker left ventricular wall, higher levels of the ratio of early diastolic mitral inflow velocity to early diastolic medial mitral annulus velocity (medial mitral E/e'), and higher pulmonary artery systolic pressure (PASP), as well as more evident haemoconcentration and body weight reduction during hospitalization. Kaplan-Meier curve analysis revealed higher rates of all-cause mortality and hospitalization for heart failure at one year in patients with DELIVER-type (Figure 1). In Cox regression analysis, the DELIVER-type subjects had comparable clinical outcomes after accounting for factors such as age, gender, atrial fibrillation, haemoglobin levels, and estimated glomerular filtration rate, compared to non-DELIVER subjects (hazard ratio and 95% confidence interval of mortality [1.62 (0.81-3.25)]). In one-year follow-up, 41.7% of patients shifted from non-DELIVER type to DELIVER-type, but only 14.6% of DELIVER-type subjects had classification shifting. Conclusion Non-DELIVER-type subjects had modestly lower event rates compared to those with DELIVER-type. The high proportion of classification shifting from non-DELIVER-type to DELIVER-type suggested that eligibility could vary during follow-up and that these patients could benefit from SGLT2i therapy.Baseline characteristicsClass shifting in DELIVER type

Abstract 14461: Impact of Intermittent vs Persistent Left Ventricle Outflow Tract Obstruction on Left Atrial Strain and Diastolic Function in a Young Hypertrophic Cardiomyopathy Cohort

Background: Adolescents and young adults with hypertrophic cardiomyopathy (HCM) and persistent left ventricular outflow tract obstruction (LVOTO) have larger left atrial volume (LAV) and abnormal diastolic function and left atrial (LA) strain compared to those without resting LVOTO. It is unknown whether intermittent LVOTO with exercise results in smaller LAV and improved diastolic function and LA strain indices compared to persistent LVOTO. Methods: All HCM patients with echo and exercise stress echocardiography (ESE) from 2014-2022 at a single center were enrolled. The cohort was divided into 3 ESE hemodynamics groups: 1) No LVOTO (all gradients &lt; 30 mmHg, n=48); 2) Intermittent LVOTO (no rest gradient, exercise ≥30 mmHg, n=41); 3) Persistent LVOTO (rest/exercise ≥30mm Hg, n=29). LAV (biplane method), LAV Z scores, LV lateral e’, lateral e’ Z scores, LA reservoir (LASr), conduit (LAScd), and contractile (LASct) strain (TOMTEC Arena AutoSTRAIN) were analyzed. For each parameter, mean values were compared across groups using one-way analysis of variance. The Bonferroni method was used to compare Group 2 to 1 and 3. Results: 118 patients (31% F, median age 17 yrs, range 7-39) formed the cohort. Mean LAV was 64.9, 65.1, and 79.5 ml in Groups 1, 2, and 3 respectively. Differences in group means were found for LAV Z score, lateral e’, lateral e’ Z score, LASr, and LAScd (all p≤0.01). In Group 2 vs 3, LAV Z score was significantly lower (0.46 v 1.89) and LV lateral e’, lateral e’ Z score, and LAScd were significantly higher (lateral e’: 13.1 v 9.0 cm/s; lateral e’ Z score: -2.0 v -3.4; LAScd: 26.0 v 21.1%) (Fig 1). LASr did not differ significantly in Group 2 vs 3. No significant differences were found in Group 2 vs 1. Conclusion: In one of the largest young HCM cohorts, intermittent obstruction was associated with smaller LAV, better diastolic indices, and higher LA conduit strain versus persistent obstruction. Longer follow-up is needed to assess change as those with intermittent LVOTO age.

Abstract 12359: Does E/e’ Independently Predict Atrial Fibrillation Recurrence Post Catheter Ablation?

Introduction: Left atrial size has been traditionally used as a surrogate of atrial fibrillation (AF) chronicity and prognosticator for success post catheter ablation (CA). The importance of other echocardiographic parameters in predicting maintenance of sinus rhythm post CA has not been well studied. Research Question: Which echocardiographic parameter best predicts 1 year AF-free survival post CA? Goal: Elucidate which parameter best independently predicts AF recurrence and identify which patients may benefit from earlier intervention. Methods: We conducted a retrospective cohort study of patients with symptomatic AF. We included patients who were undergoing first-time ablation and had follow-up visits for at least 24 months post CA. Baseline echocardiographic and laboratory data were extracted from common electronic medical records across a large healthcare system. Clinical outcomes were determined after manual review of each 6, 12, and 24-month visit. Echocardiographic measures were used in a stepwise estimation logistic regression model using STATA /IC 16.1. Results: Out of a cohort of 1,435 patients (age 67.1 ± 10.4 years, 565 female) who received CA for AF between 2014 and 2022, 402 had AF recurrence at their 12-month follow-up visit (28%). Larger left atrial volumes (p = 0.01), higher mitral valve E/e’ ratios (p = 0.008), and higher degree of aortic regurgitation (p = 0.02) were univariately associated with AF recurrence in 1 year. Stepwise estimation regression model showed that after adjusting for age, sex, BMI, mitral valve E/e’, and left atrial volume, the only independently associated predictor was mitral valve E/e’. The R 2 of our model was 0.31 and its predictive accuracy for recurrence was 85%. Conclusion: Among all echocardiographic measures, the diastolic dysfunction parameter of E/e’ was the only independent predictor of 1-year AF recurrence.