LAV Max Research Articles

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

Estimation of left ventricular (LV) filling pressures in patients with a history of 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-centre 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 h. 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 (LAVs) 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 (P = 0.030), and RV free wall longitudinal 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 (area under the curve 0.703). LA structure and function assessment well correlates with mean LAP in patients with a history of AF. These measures may be used in the assessment of filling pressure in these patients.

“Interstitial fibrosis is associated with left atrial remodeling and adverse clinical outcomes in selected low-risk patients with hypertrophic cardiomyopathy”

BackgroundCardiovascular magnetic resonance (CMR) extracellular volume (ECV) allows non-invasive detection of myocardial interstitial fibrosis, which may be related to diastolic dysfunction and left atrial (LA) remodeling in hypertrophic cardiomyopathy (HCM). While the prognostic role of LGE is well-established, interstitial fibrosis and LA dysfunction are emerging novel markers in HCM. This study aimed to explore the interaction between interstitial fibrosis by ECV, LA morpho-functional parameters and adverse clinical outcomes in selected low-risk patients with HCM. Methods115 HCM patients and 61 matched controls underwent CMR to identify: i) interstitial fibrosis by ECV in hypertrophied left ventricular LGE-negative remote myocardium (r-ECV); ii) LA indexed maximum (LAVi max) and minimum (LAVi min) volumes, ejection fraction (LA-EF) and strain (reservoir εs, conduit εe and booster εa), by CMR feature-tracking. 2D-echocardiographic assessment of diastolic function was also performed within 6 months from CMR. A composite endpoint including worsening NYHA class, heart failure hospitalization, atrial fibrillation and all-cause death was evaluated at 2.3 years follow-up. HCM patients were divided into two groups, according to r-ECV values of controls. ResultsPatients with r-ECV ≥29% (n = 45) showed larger LA volumes (LAVimax 63 vs. 54 ml/m2, p < 0.001; LAVimin 43 vs. 28 ml/m2, p 〈0001), worse LA function (εs 16 vs. 28%, εe 8 vs. 15%, εa 8 vs. 14%, LA-EF 33 vs. 49%, all p < 0.001) and elevated Nt-proBNP (1115 vs. 382 pg/ml, p = 0.002). LA functional parameters inversely correlated with r-ECV (εs r = −0.54; LA-EF r = −0.46; all p < 0.001) and E/e' (εs r = −0.52, LA-EF r = −0.46; all p < 0.006). r-ECV ≥29% and LAVi min >30 ml/m2 have been identified as possible independent factors associated with the endpoint. ConclusionsIn HCM diffuse interstitial fibrosis detected by increased r-ECV is associated with LA remodeling and emerged as a potential independent predictor of adverse clinical outcomes, on top of the well-known prognostic impact of LGE.

Left atrial remodeling in hypertrophic cardiomyopathy and Fabry disease: A CMR-based head-to-head comparison and outcome analysis

BackgroundHypertrophic cardiomyopathy (HCM) and Fabry disease cardiomyopathy (FD) are phenocopies, as they show left ventricular hypertrophy (LVH). The left atrium (LA) is emerging as a potential marker of disease severity in both cardiomyopathies. The present study compares HCM and FD cardiomyopathy with similar degree of LVH, exploring LA morpho-functional parameters and the correlates of clinical outcome. MethodsWe performed a comprehensive CMR-based comparison between 30 HCM and 30 FD patients matched on age, sex, BSA, LV mass and major cardiovascular risk factors affecting LA remodeling (arterial hypertension and diabetes). 30 healthy controls were also included. CMR feature tracking (CMR-FT) analysis, T1 mapping and conventional parameters were evaluated. Patients also underwent transthoracic echocardiography for LV diastolic function assessment. Clinical events at follow-up were collected (atrial and ventricular events, bradyarrhythmia, heart failure (HF) hospitalization and death). ResultsHCM patients showed greater LA remodeling compared to FD patients, namely higher LA end-systolic volume index (LAVi max), lower LA-ejection fraction (LA-EF) and worse reservoir (εs) and booster function (εa) (all p < 0.05). Accordingly, these parameters have demonstrated good potential for distinguishing between FD and HCM (AUC 0.68–0.73, all p < 0.05), with LAVi max being an independent predictor for HCM diagnosis (OR 1.07, 95%CI 1.011–1.132, p 0.02). Moreover, in HCM patients a significant association between εs and HF occurrence was observed at 2-year follow-up (OR 0.85, 95%CI 0.72–0.99, p 0.04). ConclusionsIn HCM, LA remodeling is greater than in FD cardiomyopathy with similar LVH, and reservoir strain is associated with HF at follow-up.

Left atrial remodeling and right ventricular-pulmonary arterial coupling after MitraClip implantation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter edge-to-edge mitral valve repair (TEER) with the MitraClip system has emerged as a therapeutic alternative to surgical solutions in high risk patients with severe mitral regurgitation (MR). MR is characterized by left ventricular volume overload, which leads to left ventricular dilatation. Furthermore, MR is a common cause of pulmonary hypertension. Right ventricular (RV) intrinsic contractility and its response to afterload is referred to as RV-pulmonary arterial (PA) coupling. Effect of TEER in patients with MR on left atrial (LA) function and RV-PA coupling is less investigated. Purpose The aim of our study was to assess clinical characteristics of patients undergoing MitraClip implantation including LA function and RV-PA coupling. Methods Eighty-eight consecutive patients with chronic severe MR were enrolled in the single-center observational study (mean age 71.5±7.9 years, male 54.5%, ischemic cardiomyopathy 54.5%). Primary MR (PMR) was present in 22.7%, secondary MR (SMR) in 73.9 % and mixed (MxMR) etiology in 3.4%. Conventional and advanced echocardiography examination was performed using speckle tracking echocardiography before TEER and at 6 month post-TEER follow-up. Left atrial maximal (LAV max) and minimal (LAV min) volumes were measured indexed for body surface area. Furthermore, we analysed left atrial functional parameters, such as reservoir strain, conduit strain and contraction strain. Results The technical success of MitraClip implantation was 95,5%. Mortality rate at 6 month follow-up time was 10.8% (1/88 PMR, 7/88 SMR, 1/88 MxMR). Severe residual MR developed during follow-up in 4.2% and New York Heart Association class III-IV functional status was concluded in 6.8% at 6 month post-TEER. Significant decrease in left ventricular end-diastolic median diameter (mm) was observed at follow-up compared to pre-TEER: 57.5 (IQR: 51.25 – 63.75) vs 60.5 (IQR: 52.5 – 66.75), respectively, p = 0.01. Similarly, the median value of pulmonary artery systolic pressure (PASP) substantially decreased (mmHg) after TEER: 42 (IQR: 32 – 52) vs 49.5 (IQR: 41 – 57), respectively, p = 0.003. Tricuspid annulus systolic excursion/PASP median value, representing RV-PA coupling, improved remarkably: 0.45 (IQR: 0.31 – 0.69) vs 0.38 (IQR: 0.29 – 0.52), respectively, p = 0.02. Compared to pre-TEER, median LA volumes and strain parameters did not change significantly at 6 month post-TEER: reservoir strain (%) 12.88 (IQR: 8.18–18.78) vs 11.74 (IQR: 7.48–20.36), p = 0.41; LAV max (ml) 48.70 (IQR: 39.81–62.29) vs 48.17 (IQR: 42.08–58.7), p = 0.31; LAV min (ml) 34.33 (IQR: 24.5–46.32) vs 33.89 (IQR: 26.02–44.53), p = 0.69. Conclusions The function of the enlarged LA was severely reduced, which did not change after MitraClip implantation in our population. However, positive left ventricular remodeling and improvement in RV-PA coupling was observed 6 month after MitraClip procedure.

Three-Dimensional Automated, Machine-Learning-Based Left Heart Chamber Metrics: Associations with Prevalent Vascular Risk Factors and Cardiovascular Diseases.

Three-dimensional transthoracic echocardiography (3DE) powered by artificial intelligence provides accurate left chamber quantification in good accordance with cardiac magnetic resonance and has the potential to revolutionize our clinical practice. To evaluate the association and the independent value of dynamic heart model (DHM)-derived left atrial (LA) and left ventricular (LV) metrics with prevalent vascular risk factors (VRFs) and cardiovascular diseases (CVDs) in a large, unselected population. We estimated the association of DHM metrics with VRFs (hypertension, diabetes) and CVDs (atrial fibrillation, stroke, ischemic heart disease, cardiomyopathies, &gt;moderate valvular heart disease/prosthesis), stratified by prevalent disease status: participants without VRFs or CVDs (healthy), with at least one VRFs but without CVDs, and with at least one CVDs. We retrospectively included 1069 subjects (median age 62 [IQR 49-74]; 50.6% women). When comparing VRFs with the healthy, significant difference in maximum and minimum indexed atrial volume (LAVi max and LAVi min), left atrial ejection fraction (LAEF), left ventricular mass/left ventricular end-diastolic volume ratio, and left ventricular global function index (LVGFI) were recorded (p &lt; 0.05). In the adjusted logistic regression, LAVi min, LAEF, LV ejection fraction, and LVGFI showed the most robust association (OR 3.03 [95% CI 2.48-3.70], 0.45 [95% CI 0.39-0.51], 0.28 [95% CI 0.22-0.35], and 0.22 [95% CI 0.16-0.28], respectively, with CVDs. The present data suggested that novel 3DE left heart chamber metrics by DHM such as LAEF, LAVi min, and LVGFI can refine our echocardiographic disease discrimination capacity.

Cardiac magnetic resonance feature-tracking analysis of left atrial volumes and function in standard vs left-atrial focused images

Abstract Background Left atrial (LA) volume and function have shown prognostic value in several cardiac conditions. Routine cardiac magnetic resonance (CMR) evaluation of the LA is obtained from standard 2- and 4-chamber long-axis cine images focused on the left ventricle. Previous echocardiographic data showed that LA-focused apical views provide a more accurate estimation of LA maximum volume, as compared to standard apical images. CMR LA-focused imaging could improve the accuracy of LA morpho-functional analysis. CMR feature-tracking (CMR-FT) analysis is emerging as a feasible semi-automatic tool for the evaluation of LA volumes and function. Purpose To investigate the potential of LA-focused CMR cine images using LA CMR-FT analysis. Methods 100 consecutive patients clinically referred to CMR were included in this prospective, observational, multicenter study. LA volumes (LAVmax, LAVmin), emptying fraction (EF), atrial strain reservoir (ɛs), conduit (ɛe), booster (ɛa) and strain rate reservoir (SRɛs) were calculated by CMR-FT analysis on both standard and LA-focused 2- and 4-chamber long-axis cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method (RefMeth) for LA volumes and EF. Results In comparison to the RefMeth, the standard acquisitions underestimated LA volumes (LAVmax: bias = −8ml, LOA = +20, −35ml; LAVmin: bias = −6 ml, LOA = +15, −27ml) and slightly overestimated EF (bias = +3%, LOA = +17, −11%). Conversely, LA-focused images provided a more accurate estimation (LAV max bias = −1ml, LOA = +11, −9ml; LAV min bias = −2ml, LOA = +12, −7ml) and EF (bias = −2%, LOA = +9, −12%). All three LA strain (εs: bias 7%, LOA = 25, −11%; εe: bias 4%, LOA = 15, −8%; εa: bias 3%, LOA = 14, −8%) and SRεs (bias 0.2 s–1, LOA = 1.13, −0.7 s–1) were significantly higher in standard vs LA-focused images (all p&amp;lt;0.001). Conclusions Assessment of LA volumes using CMR-FT applied to dedicated LA-focused long-axis cine images is more accurate than the use of standard acquisitions. LA strain and SRɛs obtained from LA-focused images are significantly lower than those obtained from standard LA acquisitions, possibly due to the inclusion in LA-focused images of LA posterior wall, where pulmonary veins convey and atrial deformation is blunted. Funding Acknowledgement Type of funding sources: None.

In patients with paroxysmal atrial fibrillation left atrial strain paramethers, left atrial function index and poor glycaemic control can be predictors of arrhythmia recurrence

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left atrial (LA) systolic dysfunction is present in early stages of atrial fibrillation (AFib) prior to left anatomical changes and is influenced by left ventricular systolic function. We evaluate weather left atrial function index (LAFI), left atrial strain parameters (LASP) and glycemic control can be a predictor of AFib recurrence after medical or electrical conversion patients with paroxysmal AFib. Material and method We evaluate 150 patients who underwent medical or electrical conversion for paroxysmal AFIb, for a period of 2 years. LA systolic function was appreciated with the echocardiography determined LA emptying volume = Maximum LA volume (LAV max)-minimum LA volume (LAV min), LA emptying fraction= {[LAV max-LAV min]/LAV max]x100}, and LAFI = LA emptying fraction x LVOT-VTILA max index. Left atrial strain (LAS) was assessed as reservoir strain[normal value(NV) 39%], conduit strain(NV 23%) and contractile strain(NV 17%). Flow mediated vasodilation was recorded at the level of brachial artery. Recurrent AFib was recorded in 75 patients (50%), time11,5 ± 10 month. Results Univariate analysis revealed as markers for arrhythmia recurrence low LAFI, reduced LA ejection force, altered LASP, high BMI, poor glycemic control (cut-off value for hemoglobin HbA1C 7%), high BMI, decreased index of flow mediated vasodilatation (FMD). On multivariate analysis poor glycemic control, reduced LAFI, altered LASP and larger LA diameter had a higher risk of AFib than patients with higher LAFI and good glycemic control (p &amp;lt; 0,004). Conclusion In patients with paroxysmal atrial fibrillation, reduced left atrial function index, altered left atrial strain parameters, larger left atrium, altered endothelial dysfunction appreciated by flow mediated vasodilatation, and poor glycemic control can be predictors of arial fibrillation recurrence.

Role of 3D echocardiography-determined atrial volumes in predicting elevated left ventricular filling pressure

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hungarian Government Research Fund, Szív- és érkutatási kiválóságközpont (IRONHEART) Aims Atrial sizes are considered markers of ventricular filling pressures. The studies focused on left atrial (LA) maximum volume (LAV max), however during diastole the left ventricular (LV) diastolic pressure affects the LA minimum volume (LAV min) instead. Therefore, we aimed to test the clinical applicability of atrial volumes measured by transthoracic three-dimensional echocardiography (3DE) in predicting elevated LV filling pressure. Methods Eighty-eight consecutive patients with and without left-sided heart disease were prospectively examined with transthoracic 3DE who underwent right heart catheterization because of clinical indication. Elevated LV filling pressure was determined as the pulmonary artery wedge pressure was higher than 15 mm Hg. The atrial volumes were measured offline with dedicated commercial software. Results Thirty-eight patients (24 males, age 62 ± 8 y) had left-sided heart disease (group A) and 50 (20 males, age 62 ± 15 y) had pulmonary hypertension because of lung disease (Group B). The left atrial indexed maximum (LAVi max) and minimum (LAVi min) volumes were significantly larger in group A than in group B (LAVi max: 64 ± 31 ml/m² vs. 40 ± 22 ml/m², p = 0.001; LAVi min: 51 ± 22 ml/m² vs. 25 ± 21 ml/m², p &amp;lt; 0.0001). The LA minimum volume correlated with the pulmonary artery wedge pressure [r = 0.6 (p &amp;lt; 0.0001) for LAV min vs. r = 0.47 (p &amp;lt; 0.0001) for LAV max]. In the receiver operating characteristic (ROC) curves of parameters predicting the elevated LV filling pressure, the areas under the curve (AUC) for LAVi min and LAVi max were 0.86 (95% CI, 0.79-0.94), 0.79 (95% CI, 0.70-0.89), respectively. The ROC analysis indicated a possible cutoff value of 28 ml/m² for LAVi min to elevated LV filling pressure (AUC = 0.86; sensitivity = 87%, specificity = 74%). Conclusion The left atrial minimum volume measured by transthoracic 3DE is a useful parameter for predicting elevated left ventricular filling pressure.

Left atrial function assessed by 3-dimensional echocardiography is an independent predictor for mortality in heart failure with reduced ejection fraction

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant TE 137/2020 Background. Patients with heart failure and reduced ejection fraction (HFrEF) are at high risk for death. So far, left ventricular ejection fraction (LVEF) measured by 2-dimensional echocardiography (2DE) has been considered the main predictor of mortality in HFrEF. However, there are new echo parameters reflecting cardiac remodeling, assessed by 3-dimensional echocardiography (3DE), that might improve risk stratification in HFrEF. Aim. To assess comparative prognostic value of left heart function and remodeling parameters, measured by 2DE versus 3DE, in patients with HFrEF. Methods. 142 consecutive patients (60 ± 17 years, 91 males), diagnosed with HFrEF, in sinus rhythm, were assessed by 2DE, using dedicated views for the LV and left atrium (LA), and by 3DE, with full-volume multi-beat acquisitions of the LV and LA. Left ventricular volumes (LVVs) were measured from 2DE views, using the modified Simpson biplane method, and from 3DE using dedicated software. Maximal and minimal indexed LAVs were measured from 2DE, using the biplane area-length formula (2D_LAVmax and 2D_LAVmin); and from 3DE, using dedicated software package (3D_LAVmax and 3D_LAVmin). Patients were followed for 5 years (57 ± 11 months) after the index event. Primary outcome was mortality. Secondary outcomes were a composite endpoint (CE) of death and hospitalization for heart failure (HHF); HHF; and a composite cardiac events end-point (MACE) of death, HHF, myocardial infarction, coronary revascularization, arrhythmias, or cardiac resynchronization therapy. Results. At 5 years we recorded 52 deaths, 70 CE, 36 HHF, and 73 MACE. At baseline, mean 2DE and 3DE LVEFs were 32 ± 10% and 32 ± 9%, respectively. There was no significant difference between the LVVs or LVEF by 2DE or 3DE between survivors and non-survivors. However, there was a significant difference for total and indexed 2D_LAVmax, 3D_LAVmax, and 3D_LAVmin (Table 1) between survivors and non-survivors. Similarly, there was no significant correlations with endpoints for the 2DE or 3DE LVVs. However, total and indexed 2D_LAVmax correlated with death, CE, HFH, and MACE, all with P &amp;lt; 0.03. Furthermore, total and indexed 3D_LAVmax, and 3D_LAVmin correlated with death, CE, HFH, and MACE, all with P &amp;lt; 0.05. In a linear multivariate regression model, that included 2DE and 3DE LVEF, indexed 2D and 3D LAV max and min, only indexed 3D_LAVmin was an independent predictor for death (p &amp;lt; 0.001), CE (p = 0.005), HFH (p = 0.009) and MACE (p = 0.006). Furthermore, by ROC analysis, an indexed LAV of 30 ml/m2 by 3DE was able to predict death ( Sb 94%, Sp 80%, AUC 0.70), CE (Sb 98%, Sp 80%, AUC 0.67), HFH (Sb 96%, Sp 80%, 0.67), and MACE (Sb 93%, Sp 76%, AUC 0.66). Conclusion. LVEF by 2DE and 3DE, while smaller in non-survivors, was unable to predict death in a small cohort of patients with HFrEF. However, LAVs, particularly by 3DE, were able to predict cardiac events, suggesting the potential key value of evolving cardiac substrate. Abstract Table 1

Left appendage morphology as risk factors for cardio-embolism in patients with stroke of undetermined source

Abstract Background Left atrium (LA) volume and function and certain left atrial appendage (LAA) morphologies are known to be strongly associated with the risk of thrombus formation and thromboembolism in patients with atrial fibrillation (AF). Little is known about the role of LA parameters and LAA morphology in patients with Embolic Stroke of Undetermined Source (ESUS). Purpose To assess LA volume and function and LAA morphologies in ESUS patients and the potential association with cardioembolic risk. Methods Twenty consecutive patients with ESUS who underwent contrast enhanced electrocardiogram-gated computed tomography (CT) as part of stroke etiology evaluation were matched by age and gender to patients with and without history of AF (twenty in each group) who had CT as part of standard evaluation before transcatheter aortic valve implantation. LA maximum (LAVmax) and minimum (LAVmin) volumes and function, measured as total emptying volume (LAEV) and total emptying fraction (LAEF) were assessed, and three- dimensional structures of the LA and LAA were constructed using the volume-rendered post-processing technique. Results The mean age of patients was 75.9±8.61, 76.1±8.52, 77.8±7.72) in the ESUS, AF and non-AF groups, respectively, with 11 (55%) females in each group. Compared to patients with ESUS, patients with AF showed significantly greater LAVmax (100.59±31.59 ml vs.155.78±63.15 ml, respectively, p=0.001) and LAVmin (71.38±30.69 ml vs. 140.73±64.60 ml; respectively, p&amp;lt;0.001), while LAV max and LAVmin were similar, in patients with ESUS and non-AF. The distribution of LAA morphologies significantly differed between patients with ESUS and patients with AF and non-AF: 1 (5%) vs. 9 (45%) chicken-wing; 14 (70%) vs. 8 (40%) cauliflower; and 5 (25%) vs. 3 (15%) Cactus; respectively. Conclusion LA appendage morphology, but not LA volume, seems to be associated with ESUS. LAA morphologies with multiple lobes, cauliflower and cactus, seems to be associated with ESUS. Larger studies are needed to confirm these associations. Funding Acknowledgement Type of funding sources: None.

Role of 3D echocardiography-determined atrial volumes in distinguishing between pre-capillary and post-capillary pulmonary hypertension.

AimsThe current guidelines on pulmonary hypertension (PH) recommend the use of invasive examination for differentiating between left‐sided heart disease‐related (post‐capillary) and pre‐capillary PH. However, atrial sizes are considered markers of ventricular filling pressures. Therefore, we aimed to test the clinical applicability of atrial volumes measured by transthoracic three‐dimensional echocardiography (3DE) in differentiating between pre‐capillary and post‐capillary PH.Methods and resultsSeventy‐five consecutive patients with PH were prospectively examined with transthoracic 3DE. After less than 24 h, the patients underwent right heart catheterization and 3DE and were classified as pre‐capillary or post‐capillary PH according to the recommendations of the ESC guidelines. The atrial volumes were measured offline with dedicated commercial software. Thirty‐eight patients (13 men, age 65 ± 18 year) had pre‐capillary PH, and 37 (23 men, age 62 ± year) had post‐capillary PH. The mean pulmonary artery pressures were similar in patients with pre‐capillary and post‐capillary PH (38 [IQR 26, 54] mmHg vs. 41 [IQR 33, 48] mmHg, respectively, P = 0.49). The left atrial indexed maximum (LAVi max) and minimum (LAVi min) volumes were significantly larger in the post‐capillary PH patient group than in the pre‐capillary PH patient group (LAVi max: 64 ± 32 mL/m2 vs. 41 ± 25 mL/m2, P = 0.001; LAVi min: 50 ± 22 mL/m2 vs. 26 ± 24 mL/m2, P < 0.0001). The indexed right atrial minimum volume (RAVi min) was also higher in patients with post‐capillary PH (51 ± 27 mL/m2 vs. 38 ± 26 mL/m2; P = 0.02). Both the left atrial (LA) and right atrial (RA) volumes, especially the LA minimum volume, correlated with the pulmonary artery wedge pressure (PAWP) (r = 0.62 (P < 0.0001) for LAV min vs. r = 0.49 (P < 0.0001) for LAV max; r = 0.32 (P = 0.005) for RAV min vs. r = 0.24 (P = 0.04) for RAV max). Multivariate logistic regression analysis showed that LAVi min was an independent predictor of post‐capillary PH. In the receiver operating characteristic (ROC) curves of parameters predicting the post‐capillary PH, the areas under the curve (AUC) for LAVi min, LAVi max, and RAVi min were 0.86 (95% CI, 0.76–0.95), 0.78 (95% CI, 0.67–0.89), and 0.66 (0.53–0.78), respectively. Concerning the performance of the atrial volume ratio for differentiating post‐capillary PH, the AUC of the atrial volume ratio was significantly lower [AUC: 0.66 (95% CI, 0.53–0.78)]. The ROC analysis indicated a possible cutoff value of 27.7 mL/m2 for LAVi min to predict post‐capillary PH (AUC = 0.86; sensitivity = 86%, specificity = 76%).ConclusionsThe BSA‐indexed left atrial minimum volume measured by transthoracic 3DE is a useful parameter for differentiating pre‐capillary from post‐capillary pulmonary hypertension.

The interplay of systemic atrial and ventricular function in patients with transposition of the great arteries after arterial switch operation

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction: The role of systemic atrial (LA) function and its interplay with the systemic ventricle (LV) in patients with transposition of the great arteries (TGA) after arterial switch operation (ASO) is currently not well defined. Purpose Investigate the role of LA function and its interplay with the LV. Methods Between 2007 and 2018 patients with TGA corrected by ASO and control patients of comparable age, sex, height but without known cardiovascular disease were included in this prospective single centre analysis of 3 Tesla cardiac magnetic resonance cine imaging studies of atrial and ventricular function. Additionally, in TGA patients extracellular volume fraction (ECV) was assessed by T1 mapping and global longitudinal strain (GLS) by feature tracking. Results Overall, 81 TGA (16.3 [IQR 10.5-21.2] years, 32% female) and 30 control patients (11.9 [IQR 8.7-22.5] years, 63% female) were included in the current analysis. TGA patients had smaller LA maximum volume index, and reduced total atrial and conduit volume emptying. This resulted in a reduced LA reservoir and conduit function compared to controls. In TGA, a higher LA active/conduit and active/total ratio indicated impaired passive filling of the LV. (Table 1) The median ECV was 28.3% (IQR 25.8-33.9) and the median GLS -24.2% (IQR -28.6- -20.4) in TGA patients. LA reservoir (Fig. 1A), conduit and contractile function showed a negative correlation with GLS (r=-0.470, p &amp;lt; 0.001, r=-0.270, p = 0.022 and r=-0.257, p = 0.030, respectively). Interestingly, the LA active/conduit ratio (Fig. 1B) and the active/total ratio showed a positive correlation with ECV (r = 0.418, p = 0.002 and r = 0.339, p = 0.013, respectively). Conclusion Impaired LA function is frequent among patients with TGA following ASO. The impairment of LA function is linked to both LV dysfunction and fibrosis. Table 1 Variable TGA (n = 81) Control (n = 30) p-value LAVI max.[ml/m&amp;sup2;] 37.8 (29.9-42.9) 42.02 (38.3-51.6) 0.002 LAVI total emptying [ml/m&amp;sup2;] 16.8 (13.7-20.8) 24.3 (20.6-29.4) &amp;lt;0.001 LAVI conduit emptying [ml/m&amp;sup2;] 10.3 (8.1-13.9) 17.5 (15.2-20.8) &amp;lt;0.001 LAVI active [ml/m&amp;sup2;] 6.7 (4.1-8.6) 6.4 (5.0-7.9) 0.984 LA-EF-reservoir [%] 46.6 (42.0-50.5) 57.2 (51.2-60.1) &amp;lt;0.001 LA-EF-conduit [%] 28.1 (23.4-34.3) 42.5 (35.4-45.8) &amp;lt;0.001 LA-EF-active [%] 24.11 (17.9-29.1) 25.7 (21.5-29.7) 0.339 LA active/conduit ratio 0.60 (0.41-0.90) 0.37 (0.28-0.44) &amp;lt;0.001 LA active/total ratio 0.38 (0.29-0.47) 0.27 (0.22-0.30) &amp;lt;0.001 Differences in left atrial function between TGA and control patients Abstract Figure. Fig. 1A and B

Prognostic marker for incident atrial fibrillation from the Multi-Ethnic Study of Atherosclerosis (MESA)

Atrial fibrillation (AF) is the most common sustained arrhythmia. LA and LV parameters have both a prognostic value to predict AF occurrence when taken separately. Based on the close physiological interaction between LA and LV, the simultaneous assessment of the left atrioventricular coupling could be even more accurate to predict AF. However, no data has been described on the existence of such an atrioventricular index. This study aimed to investigate the prognostic value of a novel left atrioventricular coupling index (LACI) that integrates LA and LV parameters and to assess its predictive value for AF occurrence throughout adult life in a large population without a history of CV diseases. A total of 4124 participants in the multi-ethnic study of atherosclerosis (MESA) underwent a cardiac MRI study. The LACI by cardiac MRI was defined by the ratio of the indexed LA end-diastolic volume divided by the indexed LV end-diastolic volume. Cox proportional hazard models were constructed to predict the occurrence of AF. In univariable and multivariable Cox analysis, the association between LACI or all other LA and LV variables and time-to-event was analysed, adjusting for traditional AF factors. A total of 237 (5.7%) patients experienced AF during a median (IQR) follow-up period of 10.8 (7.8–11.4) years. In univariate analysis, LACI was associated with incident AF (HR: 2.13, 95% CI [1.97–2.31] P < 0.0001). In Cox multivariable analysis, LACI had a significant independent predictive value for AF (adjusted HR: 1.91, 95% CI [1.73–2.08] P < 0.0001). Regarding the inter-models comparison to predict the occurrence of AF, C-statistic for LACI (0.76) was greater than LAVI min (0.74), LA strain (0.71), LAVI max (0.70) or LVEF (0.53). LACI showed better predictive performance than the multivariate model, including traditional AF risk factors (C-statistic: 0.85 versus 0.80) ( Fig. 1 ). The LACI was an independent predictor of incident AF.

P669 Functional remodeling of the left atrium after first acute ST-elevation myocardial infarction: a 3D echocardiography study

Abstract Background Left atrium (LA) is a dynamic structure which is functionally coupled with the left ventricle and modulates its function in many cardiac conditions. The geometric and functional remodeling of the LA occurring early after myocardial infarction are poorly understood. Purpose We sought to evaluate the early changes in LA geometry and function occurring in survivors of a first acute ST-elevation myocardial infarction (STEMI), using three-dimensional echocardiography (3DE). Methods LA phasic volumes and strain (both longitudinal and circumferential) were measured using a dedicated automated software package in 54 patients at pre-discharge after STEMI, and in 54 age- and sex-matched healthy volunteers (controls), (figure 1). Results In STEMI patients, both maximal (LAV max) and minimal (LAV min) LA volumes were significantly larger than in controls 63 ± 15 vs. 53 ±11 ml; p = 0,002 and 38 ± 15 ml vs. 25 ± 6; p &amp;lt;0.0001 (respectively). Moreover, when compared to controls (Table 1). Both longitudinal (LASr) and circumferential strain reservoirs showed a significant negative correlation with peak cardiac troponin I values (r=-0.344; p = 0.007 and r=-0.357; p = 0.005, respectively) as an estimate of the extent of myocardial damage. Conclusion STEMI was associated to significant geometrical and functional remodeling of the LA which was correlated with the extent of myocardial damage. Table 1 Controls STEMI patients P-value Longitudinal% LASr 21.8 ± 8.4 13.72 ± 8.27 &amp;lt;0.0001 LAScd -12.8 ± 8.48 -6.43 ± 4.74 &amp;lt;0.0001 LASct -9.73 ± 6.04 -7.26 ± 5.87 0.05 Circumferential % LASr-c 27.31 ± 8.07 18.92 ± 9.16 &amp;lt;0.0001 LAScd-c -11.2 ± 5.93 -6.46 ± 5.68 0.0002 LASct-c -16.22 ± 6.33 -12.41 ± 5.94 0.004 LASr longitudinal strain reservoir, LAScd: longitudinal strain conduit, LAScd: longitudinal strain contraction, LASr-c: circumferential strain reservoir, LAScd-c: circumferential strain conduit , LASct-c:circumferential strain contraction Abstract P669 Figure 1

P1797 Left atrial mechanics in patients with stoke: Implications for emprical anticoagulation

Abstract Purpose Detection of atrial fibrillation (AF) after stroke impacts patient management. However, detection of AF is difficult due to its paroxsysmal nature. We sought to test the hypothesis that echocardiographic quantification left atrial (LA) mechanics in patients with stoke can be an imaging biomarker to predict AF. Methods We enrolled prospectively and consecutively 131 patients in normal sinus rhythm with a new diagnosis of ischemic stroke. All patients underwent 48-hour Holter monitorization, transthoracic echocardiography with saline injection in addition to routine work-up of stroke evaluation. Two-dimensional and Doppler studies, together with most up-to-date LA quantification tools were performed including 3-dimensional LA phasic volumes (maxiumum and minimum LA Volume index - LAVImax, LAVImin) and LA strain quantification (average strain from apical 4- and 2-chamber during reservoir (Ss) and contraction (Sa) phases). Patients were followed-up and underwent second 48-hour Holter monitorization 6-12 months later if no etiologic cause was found. Any AF episode lasting &amp;gt;30 seconds was considered significant parosysmal AF. Results In 49 patients, causes other than AF were identified (Noncryptogenic). In 43 patients no discernable cause was found (NoAF Cryptogenic). Paroxysmal AF episodes lasting longer than 30 sec were documented in 27 patients at first 48-hour Holter and in 12 patients during follow-up (9.2 ± 3.1 months) either by second 48-hour Holter monitorization or clinically (AF cryptogenic). LAVImax and LAVImin were significantly increased, Ss and Sa were significantly reduced in patients with AF as compared to No AF and Noncryptogenic groups (Table). LA volumes and strain measures predicted AF development independently of CHA2DS2-VASc score. Better discrimination between No AF and AF groups was obtained after second Holter monitorization that enabled detection of more cases with paroxysmal AF (Figure). Conclusions Our findings underscore the value of echocardiographic assessment of LA function as a marker of AF development and for selection of patients who could benefit from empiric anticoagulation. Noncryptogenic AF cryptogenic No AF cryptogenic 3D LAVI max (ml/m&amp;sup2;) 30.1 ± 9,4 38.1 ± 12.7 28.9 ± 9.2 3D LAVI min (ml/m&amp;sup2;) 13.9 ± 7.5 20.7 ± 10.7 13.4 ± 5.3 3D LA EF (%) 55.5 ± 9.4 50.0 ± 10.5 53.8 ± 10.0 Ss (%) 17.4 ± 8.5 12.7 ± 5.3 17.5 ± 8.5 Sa (%) 12.7 ± 6.3 9.0 ± 5.0 12.8 ± 6.3 CHA2DS2-VASc 4.0 ± 1.6 5.0 ± 1.6 3.9 ± 1.5 Abstract P1797 Figure.

Compromised left atrial function and increased size predict raised cavity pressure: a systematic review and meta-analysis.

This meta-analysis assesses left atrial (LA) cavity and myocardial function measurements that predict pulmonary capillary wedge pressure (PCWP). PubMed-MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Central Registry were searched up to December 2018 for studies on the relationship of LA diameter, LA indexed volume (LAVI max, LAVI min), peak atrial longitudinal (PALS), peak atrial contraction (PACS) strain and total emptying fraction (LAEF) with PCWP. Eighteen studies with 1343 patients were included. Summary sensitivity and specificity (with 95% CI) for evaluation of diagnostic accuracy and the best cut-off values for different LA indices in predicting raised PCWP were estimated using summary receiver operating characteristic analysis. The pooled analysis showed association between PCWP and LA diameter: Cohen's d=0·87, LAVI max: d=0·92 and LAVI min: d=1·0 (P<0·001 for all). A stronger correlation was found between PCWP and PALS: d=1·26, and PACS: d=1·62, total EF d=1·22 (P<0·0001 for all). PALS ≤19% had a summary sensitivity of 80% (65-90) and summary specificity of 77% (52-92), positive likelihood ratio (LR+) 3·74, negative likelihood ratio (LR-) <0·25 and DOR>15·1 whereas LAVI ≥34mlm-2 had summary sensitivity of 75% (55-89) and summary specificity 77% (57-90), with LR+ >3, LR- 0·32 and DOR >10·1. Compromised LA myocardial function and increased size predict raised cavity pressure. These results should assist in optimum follow-up of patients with fluctuating LA pressure.

Left atrial compliance index predicts exercise capacity in patients with heart failure and preserved ejection fraction irrespective of right ventricular dysfunction.

Predictors of exercise capacity in heart failure (HF) with preserved ejection fraction (HFpEF) remain of difficult determination. The aim of this study was to identify predictors of exercise capacity in a group of patients with HFpEF and right ventricle (RV) dysfunction METHODS: In 143 consecutive patients with HFpEF (age 62±9years, LV EF ≥45) and 41 controls, a complete echocardiographic study was performed. In addition to conventional measurements, LA compliance was calculated using the formula: [LAV max-LAV min/LAV min×100]. Exercise capacity was assessed using the six-minute walking test (6-MWT). Tricuspid annular plane systolic excursion (TAPSE)<1.7cm was utilized to categorize patients with RV dysfunction (n=40) from those with maintained RV function (n=103). Patients with RV dysfunction were older (P=0.002), had higher NYHA class (P=0.001), higher LV mass index (P=0.01), reduced septal and lateral MAPSE (all P<0.001), enlarged LA (P=0.001) impaired LA compliance index (P<0.001) and exhibited a more compromised 6-MWT (P=0.001). LA compliance index correlated more closely with 6-MWT (r=0.51, P<0.001) compared with the other LA indices (AP diameter, transverse diameter and volume indexed; r=-0.30, r=-0.35 and r=-0.38, respectively). In multivariate analysis, LA compliance index <60% was 88% sensitive and 61% specific (AUC 0.80, CI=0.67-0.92 P=0.001) in predicting exercise capacity. An impairment in LA compliance was profound in patients with HFpEF and RV dysfunction and seems to be most powerful independent predictor of limited exercise capacity.

Left atrial stiffness is superior to volume and strain parameters in predicting elevated NT-proBNP levels in systemic sclerosis patients

Heart failure with preserved ejection fraction (HFpEF) is common in systemic sclerosis (SSc) and implies a worse prognosis therefore non-invasive assessment of left ventricular (LV) filling pressure is pivotal. Besides E/eʹ the use of maximal left atrial volume (LA Vmax index) is recommended. LA reservoir strain was also reported to be useful. The utility of LA stiffness, however, was never investigated in SSc. Thus we aimed to compare the diagnostic power of LA Vmax index, reservoir strain and stiffness in predicting elevated LV filling pressure in SSc patients. 72 SSc patients (age: 57 ± 11 years) were investigated. LA stiffness was calculated as ratio of E/eʹ to LA reservoir strain. Elevated LV filling pressure was defined as NT-proBNP > 220 pg/ml. Receiver-operating characteristic (ROC) curves were used to estimate the diagnostic performance of the investigated parameters. Average NT-proBNP level was 181 ± 154 pg/ml. NT-proBNP > 220 pg/ml was found in 21 SSc patients. LA stiffness showed the highest diagnostic performance in predicting NT-pro-BNP > 220 pg/ml, with a cut off value of 0.314 (Area under the curve: 0.719, specificity: 89.4%, sensitivity: 42.1%). AUC values for LA reservoir strain and Vmax index were 0.595 and 0.521, respectively. LA stiffness was superior to Vmax index and reservoir strain in predicting elevated NT-proBNP levels in SSc patients. Although invasive validation studies on larger samples are required, our data suggest, that the use of LA stiffness may significantly contribute to diagnostic precision in populations with a high suspicion of HFpEF.

Effect of transcatheter aortic valve replacement on left atrial function.

To investigate the effect of transcatheter aortic valve replacement on left atrial volumetric function and left atrial volume for the prediction of adverse outcomes. This is a retrospective analysis of 121 patients in sinus rhythm who underwent TAVR for severe AS. Maximum LA volume index (LAVI max), minimum LA volume index (LAVI min), and "pre-A" volume index (LAVIpre-A, the volume before atrial contraction) were measured by biplane Simpson's method at baseline, 1month, and 1year. The reservoir function, conduit function, booster pump function were calculated. All patients were followed for new-onset of atrial fibrillation, hospitalization and all-cause mortality. The reservoir function, conduit function and booster function before TAVR were 46%, 21%, 32%, respectively. LA volumetric function assessment demonstrated that reservoir function, conduit function increased over the time (all P<0.01). There was no difference in booster function after TAVR (P=0.18). Baseline markedly enlarged LA was significantly increased for AF (HR: 4.72; 95% CI, 1.11-20.13, P=0.04). In addition, There was a progressive decrease in LAVI max (P=0.02) and RVSP (P=0.03) over the time in non-AF group but not in AF group (P=0.62 and P=0.65, respectively). Although, the proportion of high left ventricular filling pressure decreased in both groups but a marked decrease was noted in non AF group in compared with AF group. Reservoir function, conduit function increased over time. Lack of negative LA remodeling post TAVR was associated with higher incidence of AF.

Prediction of postoperative atrial fibrillation with left atrial mechanical functions and NT‐pro ANP levels after coronary artery bypass surgery: A three‐dimensional echocardiography study

Postoperative AF (POAF) is the most common cause of morbidity after coronary artery bypass surgery. In this study, we aimed to show the relationship between POAF and N-terminal pro-atrial natriuretic peptide (NT-pro ANP) levels and the relationship between mechanical functions and left atrial volume measured using preoperative three-dimensional echocardiography (3D ECHO) among patients that will undergo isolated coronary artery bypass grafting (CABG) in elective conditions. Sixty-six consecutive patients (51 male, 15 female) who were decided to undergo CABG and had normal sinus rhythm were involved in the study. Patients were followed by continuous electrocardiography monitoring and daily electrocardiogram. LA volume and mechanical functions were calculated with 3D ECHO. In addition, for the analysis of plasma levels of NT-pro ANP, blood samples were collected before the surgery. During follow-up after the operation, 15 patients (22.7%) had postoperative atrial fibrillation. LA Vmax, Vmin, VpreA values were higher (P<.001, P=.004, P<.001 respectively) Also in POAF-developed group and SR group, LAVI values were 27.56±4.2 and 20.7±4.64mL/m2 , respectively (P<.001). In POAF-developing group, NT-pro ANP levels were significantly higher (P<.001). In multiple logistic regression analysis, age (β=0.355, P=.007) and LAVI (β=0.668, P=.012) are independent predictors of POAF. It was found that 3D echocardiography can be used as a helping noninvasive method to show subclinical atrial volume and mechanical dysfunction in patients undergoing CABG. Also, blood levels of NT-pro ANP in POAF group were increased.