Left Atrial Abnormality Research Articles

P055 ELECTROCARDIOGRAPHIC ABNORMALITIES AND ASSOCIATED FACTORS IN NORMOTENSIVE TYPE II DIABETIC PATIENTS

Background/Objective: Type II diabetes mellitus (T2DM) is a coronary heart disease (CHD) equivalent in the presence of target organ damage or at least three cardiovascular disease (CVD) risk factors. Resting electrocardiography (ECG) is recommended in T2DM patients only in the presence of hypertension or on suspicion of CVD. ECG abnormalities occur early in T2DM, are associated with future cardiovascular events/mortality after adjustment for traditional CVD risk factors. Early screening and detection may improve long term survival in T2DM patients hence, aim of study- to assess the patterns and factors associated with ECG abnormalities in T2DM patients without co-existing hypertension. Methods: One hundred normotensive (BP<130/80mmHg, not on any antihypertensive agent) T2DM patients were recruited consecutively, from the Endocrinology and Diabetes clinics of the Medical Outpatient Clinic and Family Medicine department of the University of Nigeria Teaching Hospital. Consents were obtained, before interviewers, administered questionnaire to get the biodata, T2DM history, complications and treatment. Anthropometric and blood pressure readings were taken using standard methods. A 12-hour overnight fasting blood sample was taken for biochemical assessment of blood glucose, glycated haemoglobin, lipids, urea and creatinine. A 12 lead ECG was performed and interpreted by one cardiologist using the Minnesota ECG code criteria. Descriptive statistics was used for patterns of ECG abnormalities while association between categorical variables were cross tabulated and tested using chi square. Results: Participants were majorly females 68(68.0%), overweight/obese 52(52.0%) with a mean age of 55.56±9.89 years. Duration of T2DM illness post diagnosis was 6.57±6.26years. T2DM was poorly controlled in 92(92.0%) while 93(93.0%) had dyslipidaemia. ECG was abnormal in 56(56.0%) with multiple abnormality in 12(21.4)%. Left atrial abnormality was the commonest 14(25.0%) ECG abnormality. No factor was associated with ECG abnormality. Conclusions: ECG abnormalities are common in T2DM, occurring early in the absence of co-existing hypertension. ECG should be done at diagnosis of T2DM irrespective of CVD risk factors, with frequent monitoring than recommended by guidelines. Table. Pattern of electrocardiographic abnormalities in normotensive type II diabetic patients.

Impaired Left Atrial Reserve Function in Heart Failure With Preserved Ejection Fraction.

Left atrial (LA) dysfunction is common in heart failure (HF) with preserved ejection fraction. However, data on the pathophysiologic impacts of impaired LA functional reserve remained limited. We sought to determine the association of abnormal LA dynamics during exercise with cardiovascular reserve, exercise capacity, and clinical outcomes. Patients with HF with preserved ejection fraction (n=231) and controls without HF (n=219) underwent exercise stress echocardiography with simultaneous expired gas analysis. LA function was assessed at rest and during exercise using speckle-tracking echocardiography. Patients with HF with preserved ejection fraction demonstrated less increase in LA reservoir and booster pump strain during exercise than those in controls. The degree of LA dilation was more closely related to exercise LA reservoir strain than to resting LA strain (Meng test, P=0.002). The presence of impaired LA reservoir strain during exercise was associated with poorer biventricular systolic reserve and cardiac output augmentation, more severe right ventricular-pulmonary artery uncoupling, and lower peak oxygen consumption. Patients with a lower exercise LA reservoir strain had a 2.7-fold increased risk of HF events (hazard ratio, 2.66 [95% CI, 1.32-5.38]; P=0.006). Among patients with follow-up echocardiography, initiation of guideline-directed medical therapy or atrial fibrillation ablation showed significant improvements in LA reservoir (P<0.001 and P=0.022) and booster pump strain (P=0.011 and 0.028) at rest and during exercise, respectively. Impaired LA reservoir function during exercise in HF with preserved ejection fraction is associated with biventricular reserve limitations, exercise intolerance, and increased risks of HF events.

Echocardiographic Parameters of Left Atrial Structure and Function and Clinical Outcomes at 2 Years in Elderly Patients With Atrial Fibrillation - The ANAFIE Echocardiographic Substudy.

This prospective ANAFIE Registry substudy investigated the relationship between the echocardiographic parameters of left atrial (LA) structure and function and clinical outcomes at 2 years among atrial fibrillation (AF) patients aged ≥75 years. Outcomes of 1,474 elderly non-valvular AF (NVAF) patients who underwent transthoracic echocardiography at baseline were analyzed by categories of maximum LA volume index (max. LAVi) and LA emptying fraction (LAEF) total. Baseline mean±standard deviation LAEF total and max. LAVi were 28.2±14.9% and 54.2±25.9 mL/m2, respectively. Proportions of oral anticoagulant (OAC), direct OAC, and warfarin use were 92.7%, 68.7%, and 24.0%, respectively. Patients with LAEF total ≤45.0% (n=1,213) vs. >45.0% (n=224) were at higher risk of cardiovascular events (hazard ratio [HR]: 2.19, P=0.021) and heart failure (HF) hospitalization (HR: 2.25, P=0.045). Risk of all-cause death was higher with max. LAVi >48.0 mL/m2(n=656) vs. ≤48.0 mL/m2(n=621) (HR: 1.69, P=0.048). Subgroups with abnormal LA function and structure had increased incidence of cardiac/cardiovascular events and HF hospitalization. No significant interaction was observed between echocardiographic parameters and OAC type. Elderly Japanese patients with NVAF and LAEF total ≤45.0% were at higher risk of cardiovascular events and HF hospitalization, and those with max. LAVi >48.0 mL/m2were at higher risk of all-cause death.

Primary Atriopathy in Mitral Valve Prolapse: Echocardiographic Evidence and Clinical Implications.

Prominent multi-scallop systolic leaflet displacement toward the left atrium (atrialization) is typically observed in bileaflet mitral valve prolapse (MVP) with mitral annular disjunction. We hypothesized that mitral leaflet atrialization is associated with an underlying left atrial (LA) myopathy characterized by progressive structural and functional abnormalities, irrespective of mitral regurgitation (MR) severity. We identified 334 consecutive patients with MVP, no prior atrial fibrillation, and comprehensive clinical and echocardiographic data. LA function was assessed by LA reservoir strain, LA function index, and LA emptying fraction. We also classified the stage of LA remodeling based on LA enlargement and LA reservoir strain (stage 1: no remodeling; stage 2: mild remodeling; stage 3: moderate remodeling; and stage 4: severe remodeling). The primary end point was the composite risk of sudden arrhythmic death, heart failure hospitalization, or the new onset of atrial fibrillation. Bileaflet MVP with no or mild MR had a lower LA reservoir strain (P=0.04) and LA function index (P<0.001) compared with other MVP subtypes. In multivariable linear regression adjusted for cardiovascular risk factors and MR ≥moderate, bileaflet MVP remained significantly associated with lower LA function parameters (all P<0.05). There was a significant increase in the risk of events as the LA reservoir strain and LA remodeling stage increased (P<0.001). In multivariable analysis, stage 4 of LA remodeling remained significantly associated with a higher risk of events compared with stage 1 (hazard ratio, 6.09 [95% CI, 1.69-21.9]; P=0.006). In a large MVP registry, bileaflet involvement is associated with reduced LA function regardless of MR severity, suggesting a primary atriopathy in this MVP subtype. Abnormal LA function, particularly when assessed through a multiparametric approach, is linked to a higher risk of cardiovascular events and may improve risk stratification in MVP, even in those without significant MR.

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.

Impact of Type 2 Diabetes Mellitus on Left Atrioventricular Coupling and Left Atrial Deformation in Patients with Essential Hypertension: An MRI Feature Tracking Study.

Hypertension (HTN) and type 2 diabetes mellitus (T2DM) are both associated with left ventricular (LV) and left atrial (LA) structural and functional abnormalities; however, the relationship between the left atrium and ventricle in this population is unclear. To identify differences between hypertensive patients with and without T2DM as the basis for further investigation the atrioventricular coupling relationship. Cross-sectional, retrospective study. 89 hypertensive patients without T2DM [HTN (T2DM-)] (age: 58.4 +/- 11.9 years, 48 male), 62 hypertensive patients with T2DM [HTN (T2DM+)] (age: 58.5 +/- 9.1 years, 32 male) and 70 matched controls (age: 55.0 +/- 9.6 years, 37 male). 2D balanced steady-state free precession cine sequence at 3.0 T. LA reservoir, conduit, and booster strain (εs, εe, and εa) and strain rate (SRs, SRe, and SRa), LV radial, circumferential and longitudinal peak strain (PS) and peak systolic strain rate and peak diastolic strain rate (PSSR and PDSR) were derived from LA and LV cine images and compared between groups. Chi-square or Fisher's exact test, one-way analysis of variance, analysis of covariance, Pearson's correlation, multivariable linear regression analysis, and intraclass correlation coefficient. A P value <0.05 was considered significant. Compared with controls, εs, εe, SRe and PS-longitudinal, PDSR-radial, and PDSR-longitudinal were significantly lower in HTN (T2DM-) group, and they were even lower in HTN (T2DM+) group than in both controls and HTN (T2DM-) group. SRs, εa, SRa, as well as PS-radial, PS-circumferential, PSSR-radial, and PSSR-circumferential were significantly lower in HTN (T2DM+) compared with controls. Multivariable regression analyses demonstrated that: T2DM and PS-circumferential and PS-longitudinal (β = -4.026, -0.486, and -0.670, respectively) were significantly associated with εs; T2DM and PDSR-radial and PDSR-circumferential were significantly associated with εe (β = -3.406, -3.352, and -6.290, respectively); T2DM and PDSR-radial were significantly associated with SRe (β = 0.371 and 0.270, respectively); T2DM and PDSR-longitudinal were significantly associated with εa (β = -1.831 and 5.215, respectively); and PDSR-longitudinal was significantly associated with SRa (β = 1.07). In hypertensive patients, there was severer LA dysfunction in those with coexisting T2DM, which may be associated with more severe LV dysfunction and suggests adverse atrioventricular coupling. 3. Stage 3.

Assessing left atrial size and pump function in ischemic stroke patients: Is cardiac MRI superior to transthoracic echocardiography?

ObjectivesCurrent guidelines recommend transthoracic echocardiography (TTE) following an ischemic stroke as the primary technique to identify cardiac abnormalities associated with an increased risk of cerebral embolism. It is unclear whether cardiac magnetic resonance imaging (cMRI), a technique shown to provide increased imaging resolution, may also enhance the cardiac assessment of ischemic stroke patients. We compared cMRI with TTE in the evaluation of Left Atrial (LA) size and pump function in a cohort of 44 patients with ischemic stroke. Materials and methodsThe biplane method was utilized to acquire LA diameters as well as area measurements in both TTE and cMRI. We calculated LA volume (LAV), LAV index (LAVI), LA Global Longitudinal Strain (GLS) and LA pump function. Results were compared using paired two sample for means t-test. Lin's concordance correlation coefficient (CCC) and Bland-Altman methods quantified the agreement of measurements obtained by TTE and cMRI. ResultsLAVI measurements by cMRI were significantly larger (34.97 v. 28.81; p = 0.001) than by TTE. The concordance correlation demonstrated only a weak agreement between LA size measured by cMRI and TTE (ρc = 0.397; p= 0.001, 95% CI 0.16 - 0.59), and the Bland-Altman plot demonstrated that LAVI measured by cMRI averaged 6.3 ml/m2 larger magnitude than those obtained by TTE. ConclusionsUsing TTE alone leads to an underestimation of LA abnormalities important in the evaluation of ischemic stroke patients. Nearly one in every five ischemic stroke patients evaluated based on the current guidelines may have a missed potential source of cardiac embolism.

2024 Guidelines of the Taiwan Society of Cardiology for the Diagnosis and Treatment of Heart Failure with Preserved Ejection Fraction.

Heart failure with preserved ejection fraction (HFpEF) is a multi-organ systemic syndrome that involves cardiac and extra-cardiac pathophysiological abnormalities. Its growing prevalence causes a major public concern worldwide. HFpEF is usually associated with multiple comorbidities, and non-cardiovascular death is common in patients with HFpEF. In Asia, patients with HFpEF has a younger age, higher prevalence of diabetes and chronic kidney disease than Western countries. A 2-step diagnostic algorithm is recommended in this guideline. In the first step, the diagnosis of HFpEF can be made if patients have symptoms and/or signs of heart failure, left ventricular ejection fraction ≥ 50%, increased natriuretic peptide, and objective evidence of left atrial or left ventricular abnormalities or raised left ventricular filling pressure. If diagnosis is still uncertain, invasive or noninvasive stress test can be performed in the second step. Comorbidities need to be controlled in HFpEF. Weight reduction for obesity and supervised exercise training are recommended for HFpEF. For pharmacological therapy, diuretic is used to relieve congestion and sodium-glucose cotransporter 2 inhibitor, empagliflozin or dapagliflozin, is recommended to improve prognosis of HFpEF. The research on HFpEF is advancing at a rapid pace. It is expected that newer modalities for diagnosis and management of HFpEF could appear in the near future.

Myocardial Mechanics and Associated Valvular and Vascular Abnormalities in Left Ventricular Noncompaction Cardiomyopathy.

Left ventricular (LV) non-compaction (LVNC) is a rare genetic cardiomyopathy due to abnormal intra-uterine arrest of compaction of the myocardial fibers during endomyocardial embryogenesis. Due to the partial or complete absence of LV compaction, the structure of the LV wall shows characteristic abnormalities, including a thin compacted epicardium and a thick non-compacted endocardium with prominent trabeculations and deep intertrabecular recesses. LVNC is frequently associated with chronic heart failure, life-threatening ventricular arrhythmias, and systemic embolic events. According to recent findings, in the presence of LVNC, dysfunctional LV proved to be associated with left atrial volumetric and functional abnormalities and consequential dilated and functionally impaired mitral annulus, partly explaining the higher prevalence of regurgitation. Although the non-compaction process morphologically affects only the LV, signs of remodeling of the right heart were also detected. Moreover, dilation and stiffening of the aorta were present. The aim of the present detailed review was to summarize findings regarding changes in cardiac mechanics, valvular abnormalities, and vascular remodeling detected in patients with LVNC.

Interaction effect of type 2 diabetes mellitus and hypertension on left atrial function: a three-dimensional echocardiography study.

Type 2 diabetes mellitus (T2DM) and hypertension (HT) often coexist and contribute to left atrial (LA) functional abnormalities. The aim of the present study was to explore whether there is a potential interaction effect between T2DM and HT on LA function. A total of 135 patients (45 with T2DM only, 45 with HT only, and 45 with both T2DM and HT) were enrolled and compared to 45 age- and sex-matched controls. LA volume fraction, including LA ejection fraction (LAEF), LA expansion index (LAEI), LA passive emptying fraction (LAPEF), and LA active emptying fraction (LAAEF), and strain parameters, including LA reservoir longitudinal strain (LASr), LA conduit longitudinal strain (LAScd), and LA contraction longitudinal strain (LASct), were obtained using three-dimensional echocardiography (3DE). Patients with T2DM had significantly more impaired LA reservoir and conduit functions compared to those without T2DM (P<0.05), and patients with HT had a significantly more impaired LA reservoir function, conduit function, and booster pump function compared to those without HT (P<0.05). Two-way analysis of variance showed that there were significant additive interaction effects between T2DM and HT with respect to LASr (PT2DM + HT =0.002) and LAScd (PT2DM + HT =0.001). Generalized linear model demonstrated that T2DM + HT had a greater relative contribution than either T2DM or HT alone to the LA strain indexes, even after adjustment for other confounders (LASr, βT2DM + HT =-3.931, 95% CI: -6.237 to -1.624, P=0.001; LAScd, βT2DM + HT=-3.781, 95% CI: -5.653 to -1.908, P<0.001). Both T2DM and HT had an adverse effect on LA function. The coexistence of both conditions further impaired LA performance in an additive interaction fashion.

Electrocardiographic left atrial abnormality and risk of heart failure

IntroductionThe association and the racial differences of the electrocardiographic markers of left atrial abnormality (ECG-LAA) with heart failure (HF) are unclear. MethodsWe examined the cross-sectional association of ECG-LAA, defined as deep terminal negativity of P wave in V1 (DTNPV1) with HF in 8460 participants (51.5% women, 60.3 ± 13.5 age and 49.8% Whites) from the US Third National Health and Nutrition Examination Survey. We excluded participants without P-wave in their ECG or with ECG findings that interfere with measurements of P-wave. DTNPV1 was automatically measured from ECGs processed at a central lab. Values of DTNPV1 ≥ 100 μV were considered abnormal. Past medical history of HF was identified through health interviews. Multivariable logistic regression analysis was used to examine the associations of DTNPV1 with HF. ResultsAbnormal DTNPV1 was detected in 3.2% (n = 271) of the participants. HF was significantly more common in individuals with abnormal, compared to those with normal, DTNPV1 (14.7% vs. 4.8%, respectively; p-value <0.001). In a model adjusted for socio-demographics and cardiovascular risk factors, ECG-LAA was associated with 98% increased odds of HF (OR (95% CI): 1.98 (1.30–3.01), p < 0.001). This association was stronger in non-White (vs. White) participants (OR (95% CI): 3.14 (1.82–5.43) vs. 1.01 (0.51–1.97), respectively; interaction p-value =0.01), but consistent in subgroups stratified by age and sex. ConclusionsECG-LAA, defined as abnormal DTNPV1, is associated with an increased risk of HF, underscoring the role of atrial disease in developing HF. Racial differences in this association exist, possibly suggesting considering ECG-LAA in personalized assessments of HF risk.

P-wave indices and left atrial mechanics as predictors of atrial cardiopathy in embolic stroke of undetermined source

Recent research has shed light on the culpability of LA (left atrial) abnormality, in the form of atrial cardiopathy, as an independent risk factor for the development of atrial fibrillation, LA thrombus and subsequent stroke. The aim of this study was to measure LA electromechanical dissociation (EMD), LA volumes, P-wave dispersion (PWD) and P-wave terminal force in V1 (PTFV1) as markers of atrial cardiopathy in patients with ESUS (embolic stroke of undetermined source), to determine whether atrial cardiopathy is an integral part in the causal pathway of ESUS. 28 patients presenting with ischemic stroke and fulfilling the criteria for ESUS were enrolled into this cross-sectional, observational study along with a control group of 28 age- and gender-matched apparently healthy individuals. On ECG, PWD and PTFV1 were measured. On echocardiography, LA EMD and LA volumes were recorded. Increased PWD (34.14 ± 9.89 ms vs. 27.32 ± 8.95 ms; p = 0.01), atrial EMD (73.32 ± 16.31 ms vs. 63.63 ± 13.59 ms; p = 0.02) and LA volumes were observed in patients with ESUS as compared to controls. A significant correlation was also found between these parameters (p < 0.01). According to the results of our study, PWD, atrial EMD and LA volumes may be novel predictors for ESUS. Our results support the notion that atrial cardiopathy is a distinct mechanism of thrombosis in ESUS patients. Further research is required to clarify its function in the causation of stroke, ESUS in particular.

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

Electrocardiographic Pattern of Pregnant Women with Advanced Maternal Age

Background: Advanced maternal age (AMA) is becoming increasingly common and is associated with increased maternal and fetal morbidity and mortality. Around 22,2% of maternal deaths were found to be from cardiovascular disease, and women with higher cardiovascular mortality were likely older. Electrocardiography (ECG) is a simple tool for detecting cardiovascular problems. Though there are many studies of the ECG in normal pregnant women, there is still limited data on the ECG pattern in pregnant women with AMA.Objective: Describe the characteristics of the ECG pattern in woman with AMA.Methods: This study used data retrospectively from medical records of patient in Kariadi General Hospital Semarang from 1st to 30th October 2018. The inclusion criteria were advanced age ³ 35 years, in the last trimester. Demography, clinical, laboratory , and 12-lead ECG data were collected and reported.Results: Thirteen patients were obtained, with mean age of 38,3 years. Majority of patients had preeclampsia (61,5%) and superimposed preeclampsia (15,4%). Mean systolic blood pressure was 168 mmHg. All of the patients was sinus rhythm, with a mean heart rate 92,5 bpm. Mean QTc was 430,7ms, with 3 patients (23,1%) having borderline prolongation grade. Another abnormality was a left atrial abnormality in 3 patients (23,1%), poor R wave progression in 2 patients (15,4%), and a pathological Q wave in 1 patients (7,7%).Conclusion: ECG abnormalities are seen in 38,4% of pregnant women over 35 years old. The performance of an ECG in AMA may be a first step toward improved pregnancy outcomes since it is widely available and easily interpreted by general practitioners.

Stroke in mitral valve prolapse: risk factors and left atrial function in cryptogenic versus non-cryptogenic ischemic subtypes.

Mitral valve prolapse (MVP) has been associated with an increased risk of ischemic stroke. Older age, thicker mitral leaflets, and significant mitral regurgitation (MR) leading to atrial fibrillation have been traditionally considered risk factors for ischemic stroke in MVP. However, specific risk factors for MVP-stroke subtypes are not well defined. The aim of this study is to evaluate clinical and echocardiographic parameters, including left atrial (LA) function, in MVP with cryptogenic (C) vs. non-cryptogenic (NC) stroke. In this case-control matched study, MVPs were identified in consecutive echocardiograms obtained after a stroke from January 2013 to December2016 at the University of California, San Francisco. MVP was defined as leaflet displacement ≥2 mm in the parasternal long-axis view at end-systole. Age/gender matched MVPs without stroke and healthy controls without MVP were also identified. We analyzed LA end-systolic/diastolic volume index, emptying fraction (LAEF), function index (LAFI), and global longitudinal strain in all MVPs and controls. We also measured left ventricular (LV) volume indexes, mass index, ejection fraction (EF), degree of MR and leaflet thickness. We identified a total of 30 MVPs (age 70 ± 12, 50% females) with stroke (11 with C- and 19 with NC-stroke), 20 age/gender matched MVPs without a stroke and 16 controls. MVPs without stroke had lower BMI, less hypertension but more MR (≥moderate in 45% vs. 17%), more abnormal LA function (lower LAEF, LAFI) and larger LV volumes/mass (all p < 0.05) when compared to MVPs with stroke. Leaflet thickness was overall mild (<3 mm) and similar in the 2 groups. Within the MVP stroke group, NC-stroke had higher BMI, more hypertension and more atrial fibrillation compared to C-stroke. In the variables tested, patients with C-stroke did not differ from controls. MVP-related MR may be protective against stroke despite abnormal LA function. Risk of NC-stroke in MVP is related to common stroke risk factors rather than mitral valve leaflet thickness. The etiology of C-stroke in MVP warrants further studies.

Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function.

Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS. We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A' wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73. The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.

Left atrial hyper-strain in dyssynchronous hearts: potential driver for adverse left atrial remodelling

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Institute for Surgical Research, Oslo University Hospital. Introduction It was recently shown that left bundle branch block (LBBB) is associated with risk of developing atrial fibrillation. A potential mechanism is abnormal left atrial (LA) loading caused by LA dyssynchrony. Purpose To investigate if LBBB is associated with abnormal LA loading as reflected in non-uniform segmental strains. Methods In a prospective study of 143 heart failure patients with LBBB, myocardial strain was measured by speckle-tracking echocardiography prior to and after 7±2 months on cardiac resynchronization therapy (CRT). As indicated by brackets in the lower panels in the Figure, LA strain amplitudes were calculated as the difference between minimum and peak strain during the reservoir phase. Results In the Figure, the upper panel shows segmental and average LA strain traces in a representative LBBB patient. This patient illustrates marked spatial non-uniformity in strain amplitude between the interatrial septum and the LA lateral wall during the reservoir phase. For the entire study population, strain amplitudes were 19±9% (mean±SD) for the interatrial septum and 24±11% for the LA lateral wall (p&amp;lt;0.0001). In the quartile of patients with largest differences, strain amplitudes were 16±9 and 32±12%, respectively (p&amp;lt;0.0001). CRT abolished these differences (p = NS). Conclusions Patients with LBBB showed marked spatial non-uniformity of LA strains. Potentially, the excessive LA lateral wall strain amplitudes may stimulate atrial adverse remodelling. Future studies should investigate if abnormal LA strains may be a trigger mechanism for atrial fibrillation in patients with LBBB.

The association of P-terminal force value and increased risk for ischemic stroke among admitted patients in a tertiary hospital: a retrospective case-control study

Abstract Funding Acknowledgements Type of funding sources: None. Background Cerebrovascular disease is the second leading cause of mortality in the Philippines, with prevalence of 0.9 to 2.6%.³ However, recent researches show that left atrial abnormality, even without atrial fibrillation, increases risk for ischemic stroke. Purpose This study aims to determine the association of P-terminal force value in V1 (PTFV1) and ischemic stroke. Secondary objectives are to elucidate the relationships of PTFV1 and dilated left atrium (LA), and dilated LA and ischemic stroke. Methods This is a retrospective case-control study which included adult Asian patients managed as first-time ischemic stroke, with an age-, gender- and co-morbidity-matched control group. A total of 290 patients were evaluated. Binary logistic regression was used in the analysis of the primary outcome, while independent T-test and chi-square test were utilized for the secondary outcomes. Results PTFV1 and ischemic stroke had a statistically significant positive association. Every 1 unit change of PTFV1 confers 1.7% increased risk for ischemic stroke. Furthermore, a higher PTFV1 was significantly correlated with dilated LA. However, there was no significant association between dilated LA and ischemic stroke. Conclusion PTFV1 confers an easier way to diagnose patients with left atrial abnormality, and stratify those with increased risk for ischemic stroke.

The relationship of plasma catestatin concentrations with the extension of left atrial fibrosis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrosis is increasingly considered an important part of vulnerable substrates, with an essential function in the induction of left atrial (LA) conduction abnormalities underlying the transition from paroxysmal (PAF) to persistent atrial fibrillation (PeAF), contributing to disease continuation. A substantial number of studies suggest a correlation between atrial fibrosis and low voltage zones (LVZ) (1). Previous studies have shown that catestatin (CST) regulates cardiac remodeling. The CST inhibition of catecholamine inhibits the Ang II-induced cell proliferation, and the extracellular matrix (ECM) downregulation to protect the heart from fibrosis produces similar results inhibition of catecholamine and the regulation of the beta-adrenergic receptors (β-ARs) (2). From the results, it is clear that CST inhibits cardiac fibrosis by regulating nitric oxide (NO) and the reactive oxygen species (ROS) pathways via inhibiting catecholamine release and influencing the production of the downstream molecule (2). Purpose This study investigated the potential association of serum catestatin level and LA fibrosis in AF patients. Methods The current study enrolled 18 consecutive patients with PeAF who had undergone bipolar voltage mapping of the left atrium before catheter ablation. The proportion of the mapped LA surface exhibiting low voltage (&amp;lt;0.5mV) was expressed as a percentage of the overall mapped LA surface area. In all participants, fasting laboratory tests were drawn at admission. The primary outcome measure of the current study was the association of serum CST and low-voltage zones (%LVZ ≥ 10% as a reference for severe LVZ). Results The patient characteristics were summarized in Table 1. The LA was mildly dilated, and the median %LVZ was 4 (IQR 0.75-31.25). The lower degree of cardiac fibrosis (LVZ &amp;lt; 10%) is significantly associated with higher levels of catestatin compared to severe LVZ &amp;gt;10% (8.6 (interquartile range-IQR 4.6 – 25.0) vs. 21.9 (IQR 11.1-100.0), p= 0.040)(Figure 1). Conclusion The higher catestatin level was associated with the lower extension of atrial fibrosis (low LA voltage zones).

Clinical markers of atrial abnormality as predictors of cardioembolic events in patients with embolic stroke of undetermined source

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Unrestrictive grant for fellowship support - Abbot Medical Background Embolic stroke of undetermined source (ESUS) represents 17% of ischemic strokes. The lack of etiology leads to unsuitable treatment, higher stroke recurrence, and death. Several features presume atrial cardiomyopathy (ACM) as a potential etiology of embolism among ESUS population, but its causative role is not steadily grounded. Purpose To assess predictors, focusing on markers of ACM, of diagnosis of a cardioembolic source in ESUS patients during a long-term follow-up. Methods (Figure 1) - This study was an observational, retrospective, monocentric, cohort trial designed to assess predictors of cardioembolic events occurrence in an ESUS population along a 9-year follow-up. 128 ESUS patients who faced an ischemic stroke with a negative extensive etiological assessment from 2009 to 2012 were consecutively included. Upon ESUS diagnosis, clinical, echocardiographic (including transthoracic and transoesophageal echocardiogram), electrocardiographic (ECG), and Holter-ECG features were recorded. The occurrence of atrial fibrillation (AF) and the recurrence of ischemic stroke were registered during follow-up. Diagnosis of a cardioembolic source, a composite outcome, was defined as AF occurrence and/or recurrence of ischemic stroke, for which a cardioembolic cause was diagnosed secondary to the etiologic evaluation. Results (Figure 2) - AF and a cardioembolic source were diagnosed in 13 patients (10.2%) and 17 patients (13.3%) respectively, during the 9-year follow-up. Overall ischemic stroke recurrence was diagnosed in 13 patients (10.2%). Through univariate analyses, age higher than 65 (HR=4.9, p&amp;lt;0.01, 95%CI:1.5-16.1), abnormal P-wave axis (HR=4.3, p=0.01, 95%CI:1.4-13.2), increased PAC burden (HR=6.0, p&amp;lt;0.01, 95%CI:2.0-18.5), left atrial (LA) dilation (HR=6.1, p&amp;lt;0.01, 95%CI:2.0-18.7), and abnormal LA appendage outflow velocity (HR=8.6, p&amp;lt;0.01, 95%CI:1.8-41.7) were associated with AF occurrence. The AF occurrence was independently predicted by LA dilation (HR=6.69, 95%CI:1.17-37.47, p=0.02) and abnormal P-wave axis (HR=5.91, 95%CI:1.37-25.56,p=0.02). High blood pressure(HR=4.7, p=0.04, 95%CI:1.1-20.6), CHA2DS2-VASc score higher than 2 (HR=3.3, p=0.03, 95%CI:1.1-9.3), age higher than 65 (HR=3.5, p=0.02, 95%CI:1.5-16.1), increased of PAC burden (HR=6.2, p&amp;lt;0.01, 95%CI:2.2-17.1), and LA dilation (HR=4.2, p&amp;lt;0.01, 95%CI=1.6-10.9) were found as predictors of the diagnosis of a cardioembolic source during follow-up. The abnormal P-wave axis was an independent predictor of the diagnosis of a cardioembolic source (HR=3.82, 95%CI:1.03-14.09, p=0.04) in ESUS population. No risk marker assessed at baseline was associated to the recurrence of overall ischemic stroke recurrence. Conclusion LA dilation and abnormal P-wave axis are significant and independent predictors of the diagnosis of cardioembolic source and AF occurrence in ESUS population. ACM seems to be involved in the cardioembolic process in a significant portion of ESUS population.