Left Atrial Enlargement Research Articles

Prevalence and Prognostic Value of Atrial Cardiopathy in Embolic Stroke of Undetermined Source

Introduction: We utilized data from the Third China National Stroke Registry to investigate the prevalence of atrial cardiopathy markers in patients with embolic stroke of undetermined source (ESUS) and to assess their association with death and stroke recurrence. Methods: In China, patients experiencing transient ischemic attack or ischemic stroke were recruited consecutively by the Third China National Stroke Registry. We compared atrial cardiopathy markers, such as left atrial (LA) enlargement, increased P-wave terminal force in lead V1 (PTFV1), premature atrial contractions, paroxysmal supraventricular tachycardia, advanced interatrial block, prolonged PR interval, prolonged P-wave dispersion, and prolonged P-wave duration between ESUS patients and those with small vessel disease and large artery atherosclerosis strokes. The association between these markers and the recurrence of stroke as well as mortality risk in ESUS patients was evaluated using Cox regression analysis. Results: Of 8,528 ischemic stroke patients who underwent a standard diagnostic workup, 2,415 were identified as having ESUS. Multivariable analysis revealed a significant association between elevated PTFV1 and an increased risk of stroke recurrence (HR: 2.50; 95% CI: 1.53–4.09; p < 0.01) as well as mortality (HR: 3.76; 95% CI: 1.58–8.91; p < 0.01) at 1 year in patients with ESUS. Furthermore, we observed that moderate-severe LA enlargement slightly increased the risk of stroke recurrence in patients with ESUS (HR: 1.95; 95% CI: 0.90–4.26; p = 0.09). Both LA diameter (HR: 1.03; 95% CI: 1.00–1.06; p = 0.03) and the top quartile of the LA diameter index (HR: 1.56; 95% CI: 1.03–2.40; p = 0.04) were associated with stroke recurrence in patients with ESUS. Conclusions: PTFV1 was independently associated with an elevated risk of stroke recurrence and mortality in ESUS patients. Additionally, a trend toward a correlation between LA enlargement and high stroke recurrence risk after ESUS was observed.

The Atrial Natriuretic Peptide-to-brain Natriuretic Peptide Ratio Predicts Left Atrial Reverse Remodeling after Rhythm Control Therapy in Patients with Persistent Atrial Fibrillation.

Objective The association between natriuretic peptide levels in atrial fibrillation (AF) patients with advanced left atrial (LA) remodeling and reverse remodeling after rhythm control therapy has not been clarified. The present study assessed the role of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) measurements to predict LA reverse remodeling after catheter ablation (CA) in persistent AF patients with LA enlargement. Methods This study included 88 persistent AF patients with LA enlargement (volume index >48 mL/m2) who underwent CA. Plasma ANP and BNP levels were analyzed before CA in all patients. The study population was divided into 2 groups according to the extent of decrease in the LA volume index (LAVI) at 6 months after CA: responders were those with a ≥15% reduction in the LAVI, and all others were non-responders. Results At follow-up, 58 patients (66%) were classified as responders. The preprocedural ANP level was significantly higher in the responders than in the non-responders (p=0.03). Furthermore, the ANP-to-BNP ratio (ANP/BNP) was significantly higher in the responders than in the non-responders (p<0.01). The ANP/BNP was correlated with the percentage decrease in the LAVI (r = 0.391, p<0.01). A multivariate linear regression analysis revealed that the ANP/BNP before CA was an independent predictor of LA reverse remodeling (p<0.01). Conclusions The preprocedural ANP/BNP was a robust predictor of reverse remodeling of the enlarged LA after sinus rhythm restoration by rhythm control therapy in persistent AF patients.

Optimal Screening for Predicting and Preventing the Risk of Heart Failure Among Adults With Diabetes Without Atherosclerotic Cardiovascular Disease: A Pooled Cohort Analysis.

The optimal approach to identify individuals with diabetes who are at a high risk for developing heart failure (HF) to inform implementation of preventive therapies is unknown, especially in those without atherosclerotic cardiovascular disease (ASCVD). Adults with diabetes and no HF at baseline from 7 community-based cohorts were included. Participants without ASCVD who were at high risk for developing HF were identified using 1-step screening strategies: risk score (WATCH-DM [Weight, Age, Hypertension, Creatinine, HDL-C, Diabetes Control, QRS Duration, MI, and CABG] ≥12), NT-proBNP (N-terminal pro-B-type natriuretic peptide ≥125 pg/mL), hs-cTn (high-sensitivity cardiac troponin T ≥14 ng/L; hs-cTnI ≥31 ng/L), and echocardiography-based diabetic cardiomyopathy (echo-DbCM; left atrial enlargement, left ventricular hypertrophy, or diastolic dysfunction). High-risk participants were also identified using 2-step screening strategies with a second test to identify residual risk among those deemed low risk by the first test: WATCH-DM/NT-proBNP, NT-proBNP/hs-cTn, NT-proBNP/echo-DbCM. Across screening strategies, the proportion of HF events identified, 5-year number needed to treat and number needed to screen to prevent 1 HF event with an SGLT2i (sodium-glucose cotransporter 2 inhibitor) among high-risk participants, and cost of screening were estimated. The initial study cohort included 6293 participants (48.2% women), of whom 77.7% without prevalent ASCVD were evaluated with different HF screening strategies. At 5-year follow-up, 6.2% of participants without ASCVD developed incident HF. The 5-year number needed to treat to prevent 1 HF event with an SGLT2i among participants without ASCVD was 43 (95% CI, 29-72). In the cohort without ASCVD, high-risk participants identified using 1-step screening strategies had a low 5-year number needed to treat (22 for NT-proBNP to 37 for echo-DbCM). However, a substantial proportion of HF events occurred among participants identified as low risk using 1-step screening approaches (29% for echo-DbCM to 47% for hs-cTn). Two-step screening strategies captured most HF events (75-89%) in the high-risk subgroup with a comparable 5-year number needed to treat as the 1-step screening approaches (30-32). The 5-year number needed to screen to prevent 1 HF event was similar across 2-step screening strategies (45-61). However, the number of tests and associated costs were lowest for WATCH-DM/NT-proBNP ($1061) compared with other 2-step screening strategies (NT-proBNP/hs-cTn: $2894; NT-proBNP/echo-DbCM: $16 358). Selective NT-proBNP testing based on the WATCH-DM score efficiently identified a high-risk primary prevention population with diabetes expected to derive marked absolute benefits from SGLT2i to prevent HF.

Morbidity and mortality of acute heart failure patients stratified by mitral regurgitation in the Arabian Gulf: Observations from the Gulf acute heart failure registry (Gulf CARE)

This study aimed to evaluate the clinical outcomes of patients with acute heart failure (AHF) stratified by mitral regurgitation (MR) in the Arabian Gulf. Patients from the Gulf CARE registry were identified from 47 hospitals in seven Arabian Gulf countries (Yemen, Oman, Kuwait, Qatar, Bahrain, the United Arab Emirates, and Saudi Arabia) from February to November 2012. The cohort was stratified into two groups based on the presence of MR. Univariable and multivariable statistical analyses were performed. The population cohort included 5005 consecutive patients presenting with AHF, of whom 1491 (29.8 %) had concomitant MR. The mean age of patients with AHF and concomitant MR was 59.2 ± 14.9 years, and 63.1 % (n = 2886) were male. A total of 58.6 % (n = 2683) had heart failure (HF) with reduced ejection fraction (EF) (HFrEF), 21.0 % (n = 961) had HF with mildly reduced EF (HFmrEF), and 20.4 % (n = 932) had HF with preserved EF (HFpEF). Patients with MR had a lower haemoglobin (Hb) level (12.4 vs. 12.7 g/dL; p < 0.001), and a higher prevalence of left atrial enlargement (80.2 % vs. 55.1 %; p < 0.001), cardiogenic shock (9.7 % vs. 7.3 %; p = 0.006) and atrial fibrillation (7.6 % vs. 5.6 %; p = 0.006), and HFrEF (71.0 % vs. 52.6 %; P < 0.001). Multivariable analysis demonstrated that MR was independently associated with increased all-cause mortality at 1-year and 3-month HF rehospitalization [1-year all-cause mortality, adjusted odds ratio (aOR), 1.40; 95 % confidence interval (Cl): 1.13–1.74; p = 0.002; 3-month HF rehospitalization, aOR, 1.26; 95 % Cl: 1.06–1.49; p = 0.009]. In an Arabian Gulf cohort with AHF, concomitant MR was associated with an increased risk of 1-year mortality and 3-months HF rehospitalization.

Prognostic significance and pathophysiological insights of functional phenotypes clustering

Abstract Background Functional capacity (FC) is a marker of cardiorespiratory fitness reflecting the integrity of cardiac, respiratory and peripheral metabolic systems. Cardiopulmonary exercise test (CPET) is the method of reference to quantify the functional capacity through a multiparametric approach. Functional phenotypes can be identified according with the patterns of CPET variables. We sought to explore the prognostic role of CPET-derived functional phenotypes, identified by an automatic clustering process, and to understand the underlying cardiac pathophysiology as assessed by exercise-echocardiography (Exe-Echo). Methodology 1379 unselected subjects who underwent to CPET combined with Exe-Echo were included in the study. Cluster analysis based on CPET variables (% of predicted peakVO2, anaerobic threshold, VE/VCO2, peak respiratory ratio, chronotropic index, O2 pulse, peak PetCO2, VO2/WR slope and heart rate recovery) identified 4 clusters (C1= 207, C2= 546, C3= 475, C4= 151 subjects), differing primarily for a progressive worsening of FC (% of PeakVO2: 87±18, 75±13, 60±14, 48±13%; VE/VCO2 25.3±2.7, 26.5±3.0, 30.8±4.3, 39.4±7.8; in C1, C2, C3, C4 respectively, all p&amp;lt;.001). Rest and exercise parameters of Exe-Echo were used to define cardiac characteristics and presented in a standardized radar clustering (fig 1). Patients were tracked for the combined end-point of death + heart failure hospitalization. Results C1 presented normal cardiac morphology and function with expected increase of stroke volume (SV) and cardiac output (CO) during exercise, without significant valvular disease; C2 and C3 showed a mild-to-medarately abnormal rest and exercise echo parameters, characterized by LV progressive dilatation, mild systolic dysfunction, mitral regurgitation (MR) and increased systolic pulmonary pressure (SPAP); C4 corresponded to severe cardiac remodelling with LV and left atrial enlargement, severe MR, rest pulmonary hypertension and severely impaired contractile reserve (reduced exercise SV and CO). The 4 clusters were strongly associated with prognosis, as shown by KM of survival free from combined event (p&amp;lt;.0001; fig 2). Conclusions automatic clustering of CPET parameters identified 4 clusters strongly associated with hard end-points (mortality and HF hospitalization). Exe-Echo provided cluster-related pathophysiological insights explaining the mechanisms responsible for prognosis decline. This combined CPET-ExeEcho approach may help in identifying high risk patients and in defining new therapeutic targets.Radar chart of echo variablesKM of combined end-point (death+HF)

Artificial intelligence-enabled electrocardiogram in the detection of patients at risk of atrial functional mitral regurgitation

Abstract Background Atrial functional mitral regurgitation (AFMR) is an increasingly recognized cause of functional MR thought to result from left atrial enlargement and myopathy in the setting of preserved left ventricular geometry and function. AFMR mostly occurs in patients with atrial fibrillation (AF) and/or heart failure with preserved ejection fraction. Purpose We investigated whether the use of an artificial intelligence-based electrocardiogram (AI-ECG) can identify patients with new-onset AF and sinus rhythm (SR) who are at highest risk of developing AFMR. Methods Adults with a new diagnosis of AF between 2010 and 2021 who had a transthoracic echocardiogram (TTE) within 1 month after AF diagnosis were identified. Similarly, adults in SR who never had AF diagnosis and had a TTE during the same period were identified. Exclusion criteria from both groups included &amp;gt;mild MR at baseline, primary mitral valve disease, cardiomyopathy, ≥moderate aortic valve disease, current or previous low ejection fraction, enlarged left ventricle, cardiac devices, previous cardiac surgeries, and the absence of follow-up TTE ≥6 months from baseline. Only patients who had ECG within 10 days of the TTE were included. When multiple ECGs were available, the closest was considered. A previously trained AI-ECG algorithm to detect the probability of AF was utilized. Incident AFMR was defined as &amp;gt;mild functional MR in the absence of &amp;gt;mild left ventricle enlargement or dysfunction. Diastolic dysfunction was defined according to ASE/EACVI guidelines. Results Overall, 1,570 patients with new-onset AF (median age 67 years; 34% females) and 16,802 patients in SR (median age 59 years; 46% females) were included. The median AI ECG probability for AF was 43% (IQR 26%-59%) in the new-onset AF group and 2% (0.5%-7%) in the SR group, Figure 1. Incident AFMR occurred in 152 patients in the AF group over median 3.06 (IQR 1.5-5.2) years of follow-up and in 482 patients in the SR group over median 3.0 (1.5-5.6) years of follow-up. The probability of silent AF by the AI-ECG was associated with incident AFMR in the new-onset AF group [hazard ratio 1.19 (95% CI 1.11-1.28) per 10%, p &amp;lt;.001] and the SR group [hazard ratio 1.19 (95% CI 1.12-1.25) per 10%, p &amp;lt;.001]. The AI ECG-derived AF probability remained as an independent risk factor for AFMR in multivariable analysis in both AF and SR, Table 1. Conclusion The AI ECG for AF might be able to reflect the degree of left atrial myopathy and thus the risk of incident AFMR in patients with AF and SR.Distribution of AI ECG probability of AFMultivariable risk factors for AFMR

The significance of excessive supraventricular ectopic activity immediately after catheter ablation in the risk stratification for late recurrence of atrial fibrillation

Abstract Background/Introduction Early recurrence of atrial fibrillation (AF) (&amp;lt;3 months) after ablation is associated with late recurrence (≥3 months). Even absent early AF recurrence, patients frequently experience postprocedural supraventricular ectopic complexes (SVEC). Excessive supraventricular ectopic activity (ESVEA) is a new surrogate marker for new-onset AF and poor stroke prognosis. However, the relationship between ESVEA and late recurrence of AF post-ablation is poorly understood. Purpose We hypothesized that postprocedural ESVEA would be associated with late recurrence of AF. We also investigated use of ESVEA compared to early recurrence of AF for stratifying patients’ risk of late recurrence of AF. Methods Participants were patients with AF who underwent initial radiofrequency catheter ablation and 24-Holter monitoring the day after the procedure between 2014 and 2020. SVEC was defined as supraventricular complexes occurring ≥30% earlier than expected compared with the previous RR interval. ESVEA was defined as at least 30 beats of SVEC per hour, or any episodes of SVEC runs ≥20 beats. Atrial tachyarrhythmia lasting for longer than the 30s was defined as AF recurrence. We analyzed the association between postprocedural Holter monitoring results and late recurrence of AF. Results We enrolled 469 patients with AF (average ± SD 63.6 ± 10.1 years; 32% female; 56% paroxysmal AF). We observed early recurrence of AF (n = 57; 12%) and ESVEA (n = 287; 61%) during postprocedural Holter monitoring in these patients; 125 patients (27%) had no signs of AF or ESVEA. During a median follow-up of 25 months, 152 patients (32%) experienced a late recurrence of AF. Patients who demonstrated early AF recurrence or ESVEA during Holter monitoring were significantly more likely to experience late recurrence of AF, even after adjusting for various clinical parameters and left atrial enlargement. Patients with early recurrence of AF had the worst outcomes, and AF-free survival was significantly worse in patients with ESVEA than patients without early recurrence of AF (Figure). Conclusions ESVEA on post-procedure day 1, even without AF, was associated with worse clinical outcomes following initial AF ablation. Postprocedural 24-Holter monitoring may reveal an increased risk of late recurrence of AF secondary to observation of recurrent AF or ESVEA.

Left atrial mechanical dysfunction and the risk for ischemic stroke in HCM patients without prior atrial fibrillation or stroke

Abstract Background Patients with hypertrophic cardiomyopathy (HCM) are at high risk of atrial fibrillation (AF) and ischemic stroke. Left atrial enlargement and dysfunction that characterize atrial myopathy may precede and promote AF and cardiac thromboembolism. In HCM patients without prior AF or stroke, whether left atrial mechanical dysfunction can improve ischemic stroke prediction is unknown. Method Patients with prior AF or stroke (n = 121) were excluded and 653 consecutive patients with HCM (mean age 47.3 ± 12.3 years, 71% male) who underwent cardiac magnetic resonance (CMR) at Fuwai Hospital between January 2012 and December 2013 were finally enrolled. LA ejection fraction, strain and strain rate indices on reservoir, conduit and booster-pump phases that represent LA mechanical function were analyzed. The primary endpoint was ischemic stroke. The secondary endpoint was new-onset AF. Result At 7.6 ± 2.4 years of follow-up, 24 (3.7%) had ischemic stroke and 73 (11.2%) had new-onset AF. Patients with stroke had an older age (p = 0.014), higher incidence of hypertension (p &amp;lt; 0.001), more LGE presence (p = 0.006) and LGE extent (p = 0.007). For LA size and function, patients with stroke showed significantly higher LA volume index and lower LA ejection fraction and LA strain (all p &amp;lt; 0.01). Age, hypertension, LGE presence, LGE extent and all LA mechanical indices were univariably associated with stroke. On multivariate model, LA reservoir strain was associated with stroke (Hazard Ratio = 0.91. 95%CI 0.85-0.97, p = 0.005) independent of Age (p = 0.292), hypertension (p = 0.002), LGE extent (p = 0.003) and LA volume (p = 0.737). In addition, LA reservoir strain was also associated with new-onset AF (Hazard Ratio = 0.93. 95%CI 0.89-0.96, p &amp;lt; 0.001) independent of Age (p &amp;lt; 0.001), hypertension (p = 0.607), LGE extent (p = 0.882) and LA volume (p = 0.002). Conclusion In HCM patients without prior AF or stroke, LA mechanical dysfunction was a strong predictor for stroke and new-onset AF independent of LA enlargement, age, hypertension and LGE extent.

Electrocardiogram evolution in Anderson-Fabry disease patients during follow-up

Abstract Background Anderson-Fabry disease (AFD) is a rare and progressive X-linked metabolic disorder caused by mutations in alfa galactosidase A gene, which leads to a pathologic, multiorgan, accumulation of ceramides with cytotoxic, proinflammatory and fibrotic effects. Cardiovascular involvement represents one of the main causes of death. Although ECG has proven to be useful for early AFD recognition, little evidence is available on the evolution of ECG alterations during follow-up. Purpose and Methods The aims of the study were to describe ECG changes during a long-term follow up, and to evaluate their association with the progression of cardiac involvement. The presence of interactions between ECG changes and specific AFD therapy (treatment status) were also evaluated. 219 AFD patients from a multicentre cohort underwent 12-lead ECG extensive analysis, transthoracic echocardiography, and complete clinical evaluation. Results After the exclusion of 3 patients with a permanent pacemaker, 5 with poor ECG quality, 2 with only one ECG, and 18 ≤18 years old, 181 AFD patients composed the final cohort (age 46 [IQR 35-58], 36% male, 67% classic phenotype). Treatment status (either enzyme replacement or chaperone molecules) was distributed as follows: chronic therapy for at least one year (24%), specific therapy started during the follow up (39%), no specific therapy (37%). During a median follow up of 62 months (IQR 33-83 months), several ECG parameters showed significant changes: atrial fibrillation detection (p&amp;lt;0.001), PQ interval (p=0.004), left atrial enlargement (p=0.001), a new right bundle branch block (RBBB, p&amp;lt;0.001), QRS interval (p&amp;lt;0.001) and QRS fragmentation (p=0.022), QTcB interval (p=0.001), and negative T waves development (p=0.001) mostly lateral and symmetric (p=0.016). Among these, PQ interval showed a significant interaction with treatment status being significantly altered only in patients in the chronic therapy and no specific therapy groups, being stable in patients who started the specific therapy during the follow up (p for interaction=0.048). In addition, PQ, QRS interval duration, a new RBBB, and a new pathologic QT interval were associated with the evolution of the echocardiographic maximal left ventricular (LV) wall thickness during the follow up on univariable analysis, with the QRS duration losing the statistical significance on multivariable analysis but still showing a trend (p=0.089) toward an association with an increased LV wall thickness. Conclusions In this multicentric cohort of AFD patients, different ECG parameters underwent significant changes during follow-up. Of these, PQ interval duration showed a significant interaction with the specific therapy status in that it did not increase in patients who started the therapy at the begin of the follow up. PQ interval, a new RBBB and pathologic QTc development were also significantly associated with the progression of LV hypertrophy on multivariable analysis.Table 1 and Table 2Figure 1

Hand-held echocardiography-based heart failure screening in hypertensive or diabetic patients in community: a pilot study

Abstract Background There is lack of solid data on screening methods for preclinical heart failure (HF) in primary care settings. Standard echocardiography is not regarded as a routine test due to high cost and need of operation by specialists. Hand-held echocardiography (HHE) has been used in various clinical settings with easier access and lower price but has never been integrated into HF screening programme. Purpose This study aimed to explore the feasibility and cost-effectiveness of hand HHE-based HF screening strategies in patients with risk factors in community. Methods The registered patients with hypertension or diabetes at two Chinese community health service centres (CHSCs) who had not been diagnosed previously as HF were recruited. Every patient received symptom assessment (dyspnea and/or lower limb edema), blood test for N-terminal-probrain natriuretic peptide (NT-proBNP ≥ 125 pg/ml regarded as positive), and HHE for any indexed abnormality in the dedicated protocol with focused and semiquantitative scanning [i.e. left ventricular (LV) dilation, left atrial (LA) dilation, interventricular septum (IVS) thickening, LV systolic dysfunction by calipers, as well as region wall motion abnormality, valvular stenosis, ≥moderate valvular regurgitation, significant pericardial effusion by eyeballing). By using the results of all the three modalities for screening compared to the concurrent guidelines, the patients were categorized into HF stages A, B, or C as the "gold standard". Three screening strategies were proposed (Figure 1), of which Strategy I was designed as a single test, Strategy II as a combined test, and Strategy III as a stratified stepwise test. Diagnostic accuracy and cost-effectiveness of each strategy was calculated in comparison with the "gold standard". Results A total of 423 patients (70 ± 9 years; 46.6% males) were enrolled. There were 166 (39.2%) symptomatic patients, while 106 (25.1%) patients had elevated NT-proBNP. HHE abnormalities were found in 286 (67.0%) patients, of which IVS thickening was the most common finding (47.0%), followed by LA enlargement (30.0%). LV systolic dysfunction was identified in 18 (4.3%) patients. 232 (54.8%) and 59 (13.9%) patients were reclassified as HF stage B and C, respectively. As shown in Figure 2, the stepwise Strategy III of using symptoms for the first stratification, followed by choosing HHE or NT-proBNP test led to a 100% accuracy and a 35.6% reduction in cost. Conclusions HHE-based focused screening detects HF earlier in high-risk populations. The screening strategy combined with symptoms, NT-proBNP, and HHE is feasible for identifying underdiagnosed HF stage B or C that may be considered in primary care.Scheme of HF stage screening strategiesHF Screening and cost-effectiveness

Atrial septal defect detected on transesophageal echocardiography prior to atrial fibrillation ablation: prevalence, clinical features, and outcome after ablation

Abstract Background The prevalence rate of atrial septal defect (ASD) in the general population is about 0.09%. Long-term volume overload due to a left-to-right shunt (LRS) caused by ASD commonly results in atrial fibrillation (AF). Moreover, left atrial (LA) enlargement could lead to an increase stretched type patent foramen ovale (PFO) and LRS. However, the prevalence, clinical features, and clinical impact of LRS in AF prior to ablation remain unknown. Methods A total of 2966 AF patients (63 ± 11 years, 782 women) who underwent initial AF ablation were retrospectively enrolled in this study. All patients underwent transesophageal echocardiography (TEE) prior to ablation. Then, they were divided into three groups: the ASD, PFO, and control groups. Large ASD was defined as a defect with a diameter of ≥ 5 mm. Clinical and echocardiographic features and 5-year AF-free survival rate after ablation were compared between each group. Results Based on TEE prior to AF ablation, 40 (1.3%) and 174 (5.9%) patients had ASD and PFO, respectively. Patients with PFO had a high prevalence of persistent AF (P &amp;lt; 0.001). The The LA volume was larger in the ASD and PFO groups than in the control group (P &amp;lt; 0.001). Kaplan–Meier analysis showed that the AF-free survival rate was similar between all ASD groups (49 ± 10%, P = 0.24). Further, the 5-year AF-free survival rate was significantly lower in the large ASD group than in the small (&amp;lt; 5 mm) ASD, PFO, and control groups (28% ± 14%, 61% ± 3%, 59% ± 5%, and 60% ± 1%, respectively; P = 0.021). Cox proportional hazards regression analysis showed that a large ASD was an independent predictor of AF recurrence (odds ratio: 2.58, 95% confidence interval: 1.17−4.85, P = 0.02). Conclusions Patients with AF prior to ablation had a higher prevalence of ASD than the general population. TEE could identify ASD undiagnosed on transthoracic echocardiography. In particular, a large ASD on TEE could be associated with poor outcome after AF ablation.

Abstract 13771: Left Atrial Size and Frailty Indexes Predict Poor Prognosis in Hospitalized Elderly Patients With Heart Failure

Background: Left ventricular ejection fraction (LVEF) is a cardiac index used to diagnose and determine heart failure (HF) treatment strategy. However, in elderly patients with HF, LVEF is not a good predictor of prognosis. We have previously found that patient outcomes are associated with left atrial (LA) size and noncardiac factors such as malnutrition, muscle weakness, and cognitive dysfunction. This study examined whether a combination of LA function and noncardiac indicators related to frailty can predict an accurate prognosis in hospitalized elderly patients. Methods: Hospitalized HF patients over 65 years of age from January 2019 to December 2022 were consequently enrolled in the Yamaguchi Prefectural Grand Medical (YPGM) Center. We divided three categories: sinus rhythm (SR) with normal LA, SR with LA enlargement (LAE), and persistent or chronic atrial fibrillation (AFib) with LAE. Cox proportional hazard analyses were employed to determine the prognosis factors, i.e., the primary outcome as all-cause death or HF readmission and the secondary outcome as major adverse cardiac and cerebrovascular events (MACCE). Results: Overall, 676 HF patients were admitted to YPGM Center. Of those, 462 (median age 84.0, 47% female) met the study criteria. During the follow-up of 204.0 days, 46 patients reached all-cause death (10%), 82 experienced HF readmission (18%), and 116 developed MACCE (25%). LA volume index (LAVI) (Hazard ratio [HR]: 1.012; 95% confidence interval [CI]: 1.003-1.022; p = 0.013) and handgrip strength (HR: 0.917; 95%CI: 0.868-0.970; p = 0.002) were associated with the primary outcome. Nutritional status assessed by geriatric nutritional risk index (GNRI) was associated with the primary and secondary outcome (HR: 0.956; 95%CI: 0.927-0.985; p = 0.003, and HR: 0.937; 95%CI: 0.909-0.966; p &lt; 0.001, respectively), but neither AFib nor LVEF. The adverse events were lower in SR with the normal LA group than in other groups. Furthermore, a multiple logistic regression model, including LAVI, AFib, GNRI, and handgrip strength, most accurately predicted the primary outcome than those with the AFib or LVEF. Conclusion: The value of benefits as a prognosis lies more in LAVI and frailty indexes than in the presence of AFib and LVEF in elderly HF patients.

Abstract 17085: An Unusual Case of Severe Hypertrophic Cardiomyopathy in a 23-Year-Old Systemic Lupus Erythematosus Patient on Hydroxychloroquine

A 23-year-old female with Systemic lupus erythematosus (SLE), lupus nephritis, antiphospholipid syndrome, venous thromboembolism, stroke, Libman-Sacks endocarditis, and hypertension presented with right upper and lower extremity weakness, right facial droop, and aphasia. Her home medications included hydroxychloroquine, mycophenolate, apixaban, and losartan. ECG showed normal sinus rhythm, left atrial enlargement, ST and T wave abnormalities in V5 and V6. Computed tomography angiography of the brain showed left middle cerebral artery occlusion. Transthoracic echocardiogram (TTE) showed left ventricular ejection fraction of 65%, severe left ventricular hypertrophy, moderate pericardial effusion, and moderately thickened mitral valve (MV) leaflets. Transesophageal echocardiogram showed large vegetations on atrial aspect of both MV leaflets concerning for Libman-Sacks endocarditis. We attempt to investigate the cause of this hypertrophic cardiomyopathy (HCM) in a young patient with SLE. Few reported cases of HCM in patients with SLE were medication induced. Tacrolimus has been observed to induced HCM in a Japanese patient with dermatomyositis. Hydroxychloroquine has been associated with myocardial thickening. Its use can lead to enlarged myocardiocytes with intracytoplasmic vacuoles consisting of concentric lamellar myelin figures in single membrane bound vesicles, curvilinear bodies, glycogen accumulation and fused mitochondria. Hydroxychloroquine use led to reversible inhibition of lysosomal enzyme activity. Cessation of medication use in both cases led to reduction in left ventricle thickness. These patients, like our own, has no family history of aortic valve stenosis, mitral valve prolapse, or HCM. However, this patient’s use of hydroxychloroquine to treat her SLE can be assumed to be a contributing factor to her HCM. This could suggest possible screening with ECG and TTE in patients taking hydroxychloroquine.

Abstract 13403: Age-Related Echocardiographic Characteristics in Patients With Heart Failure With Preserved Ejection Fraction in PARAGON-HF

Introduction: Heart failure with preserved ejection fraction (HFpEF) may have different characteristics by age groups. Aim Compare clinical and echocardiographic characteristics in patients with HFpEF enrolled in the PARAGON-HF echocardiography substudy by age groups. Methods: Echocardiography was performed in 1097 patients in PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction), where patients with left ventricular ejection fraction (LVEF) &gt;=45% were enrolled. Clinical and echocardiographic characteristics were compared in patients who were &lt;65, 65-74, and &gt;75 years of age. Results: Younger patients were more likely to be male, obese, have prior myocardial infarction (MI) and diabetes, but less likely to have atrial fibrillation (AF, Table 1). Older patients had smaller left ventricular (LV) dimension indices, more likely to have concentric hypertrophy or remodeling, higher LVEF and better global longitudinal strain, and more likely to have left atrial enlargement and echocardiographic evidence of higher LV filling pressure (Table 1). Echocardiographic measures of pulmonary pressure and right ventricular function were similar across age groups. After adjusting for sex, race, region, history of MI, diabetes, AF, and body mass index, every 10 years of increase in age was associated with 5.1 mL/m 2 decrease in LV end-diastolic volume index (95% confidence interval [CI] 3.9 - 6.5, p &lt; 0.001), 0.4% increase in absolute global longitudinal strain (95% CI 0.1% - 0.7%, p = 0.017), and 1.07 increase in E/e’ septal ratio (95% CI 0.42 - 1.73, p = 0.001). Conclusions: Compared with younger patients, older patients with HFpEF were more likely to be female with AF, have better systolic function and higher LV filling pressure. These findings demonstrated the heterogeneity in cardiac structure and function in HFpEF by age and may have implications for treatment and future clinical trial recruitment.

Abstract 13381: Syncope as a Presentation of Waldenstrom Macroglobulinemia

Syncope as defined by ACC/AHA is defined as a symptom that presents with an abrupt, transient, complete loss of consciousness, associated with inability to maintain postural tone with rapid and spontaneous recovery without clinical features of other non-syncope causes of loss of consciousness, such as seizure, antecedent head trauma, or apparent loss of consciousness. Syncope is a common complaint treated in the emergency department and a major reason for hospital admissions. A rare etiology to this common symptom is Waldenstrom macroglobulinemia. Case: A 49-year-old man presented to the emergency department, referred for hypercalcemia. On review of records, the patient was noticed to have been seen previously in emergency visits for two episodes of syncope and recurrent anemia. The laboratory studies at the time of admission were remarkable for hemoglobin of 7.3, WBC of8.32, hematocrit of 28.5, MCV 77.2, platelets of 124,000. Complete metabolic panel showed a total protein of 13.1, calcium of 11.2 with an albumin of 1.6 and corrected sodium of 117. EKG demonstrated a sinus rhythm with left atrial enlargement and nonspecific T wave abnormalities. Echocardiogram demonstrated a LVEF of 60-65% with normal LV wall motion, posterior wall thickness, and septal wall thickness with grade 1 diastolic dysfunction. CT of the head was unremarkable. Further work up for recurrent microcytic anemia. Bone marrow biopsy was obtained which demonstrated a Waldenstrom macroglobulinemia. Further follow up revealed that the patient has not had any other syncopal episodes since initiation of treatment. Conclusion: Although current literature suggests a broad differential diagnosis for the symptom of syncope, Waldenström macroglobulinemia remains a rare etiology of syncope with an estimated incidence of 1000 to 1500 cases diagnosed per year. Waldenstrom macroglobulinemia can cause hyperviscosity syndrome in about 30 percent of the population with Waldentroms, which when severe and coupled with anemia and plasma volume expansion has been reported as arare cause of syncope. Syncope evaluation should be detailed with history and physical examination and hyper-viscosity syndromes, a medical emergency, should be considered as differential diagnosis of syncope.

Abstract 11565: Clinical Implications of Left Atrial Size and Its Changes After Cardiac Resynchronization Therapy in Patients With Heart Failure

Background: Little evidence is available regarding the impact of left atrial (LA) diameter, especially its changes after cardiac resynchronization therapy (CRT), on the prognosis of patients with heart failure (HF). Objective: To investigate the association of LA diameter and its changes with all-cause mortality and HF hospitalization in HF patients with CRT. Methods: This cohort study retrospectively included 488 HF patients with CRT, who were assessed with echocardiography at baseline and 6 months after CRT. The multivariate Cox proportional hazards regression models were used to examine the specific association of LA diameter and its changes with all-cause mortality and HF hospitalization. Results: Non-linear associations were found for LA diameter with all-cause mortality ( P = 0.006 for nonlinearity) and HF hospitalization ( P = 0.02 for nonlinearity). The positive association of LA diameter with all-cause mortality (HR, 1.88; 95% CI, 1.42-2.49) and HF hospitalization (HR, 1.72; 95% CI, 1.32-2.22) only in the range of LA diameter &lt;45 mm. There was a positive association of LA diameter changes with all-cause mortality (HR, 1.29; 95% CI, 1.12-1.48) and HF hospitalization (HR, 1.28; 95% CI, 1.13-1.45). LA adverse remodeling (LAAR) was associated with an increased risk of all-cause mortality (HR, 2.35; 95% CI, 1.46-3.79) and HF hospitalization (HR, 2.18; 95% CI, 1.40-3.41). Conclusions: LA enlargement and LAAR were associated with an unfavorable outcome in HF patients with CRT. These findings suggest that monitoring LA diameter and its changes has potential clinical implications for HF treatment.

Abstract 12449: Association of Left Atrial Function With Mitral Regurgitation Progression: Atherosclerosis Risk in Communities Study

Background: Left atrial (LA) enlargement and atrial fibrillation (AF) are associated with functional mitral regurgitation (MR). It is unknown whether lower (worse) LA function is associated with MR progression, independent of LA size, in individuals without AF. Hypothesis: We hypothesized that lower LA function was associated with higher odds of MR progression. Aims: To evaluate the association of echocardiographic-based LA function with MR progression in the Atherosclerosis Risk in Communities (ARIC) Study, a community-based cohort. Methods: We included 2,444 ARIC participants (mean age, 73.8 ± 4.4 years, 42% male, 21% Black) who underwent 2D-echocardiogram at visits 5 (2011-2013) and 7 (2018-2019) and excluded those with AF, heart failure, and heart valve surgery at visit 5. Based on American College of Cardiology/American Heart Association guidelines, MR was graded as stages A-D. MR progression was defined as new onset of MR at visit 7, any increase in MR stage, or mitral valve surgery for MR between visit 5 and 7. LA function was measured using strain analysis and included reservoir, conduit, and contractile strain. Logistic regression models were used for the analysis. Results: After mean follow up of 6.5 ± 2.4 years, MR progression occurred in 504 (21%) participants. As shown in the table, lower reservoir strain was associated with higher odds of MR progression (OR [95% CI] per SD decrement, 1.16 [1.003, 1.34]) after adjusting for demographics, clinical risk factors, LA size and LV mass and function. LA conduit and contractile strain were not significantly associated with MR progression. Conclusion: Lower LA function is associated with higher odds of MR progression, independent of LA size, in individuals without AF. More research is needed to clarify the mechanism to identify novel prevention strategies for MR progression.

Abstract 16161: Effects of Year Long Aerobic Exercise on Left Atrial Size in Patients With Left Ventricular Hypertrophy

Introduction: Habitual aerobic exercise is associated with left atrial (LA) enlargement and risk of atrial fibrillation. This risk may be accentuated in patients with increased left ventricular (LV) stiffness due to high LA pressure during exercise. We tested the hypothesis that 1 year long endurance exercise would increase LA size to a greater extent in patients with left ventricular hypertrophy (LVH) at risk for heart failure with preserved ejection fraction (HFpEF) than previously published age appropriate controls. Methods: Middle-aged adults (age 45-64 yrs) with LVH (n=53) enriched for increased HFpEF risk (N-terminal pro-B-type natriuretic peptide &gt;40 pg/mL or high-sensitivity cardiac troponin T &gt;0.6 pg/mL) and healthy subjects (n=58) were randomized to one year of high intensity aerobic exercise or yoga control. LA and LV volumes were measured using 3D echo. Results: Of 111 participants, 83 had complete data available (LVH cohort: 18 exercisers, 10 yoga; healthy cohort: 29 exercisers, 26 yoga). Baseline LA size was larger in LVH vs healthy subjects (42 ± 12 vs 35 ± 9 mL; p=0.005). There was a nominal increase in LA size in LVH exercisers compared to LVH yoga (8 ± 9 vs 4 ± 7 mL; p=0.29) which was proportional to LV size (LA/LV ratio 0.05 ± 0.07 vs 0.06 ± 0.1; p=0.81). Healthy subject exercisers increased LA size compared to healthy yoga controls (4 ± 5 vs 0 ± 6 mL; p=0.02) with no increase in LA/LV ratio (-0.02 ± 0.08 vs -0.03 ± 0.08; p=0.62). Among exercising subjects only, increase in LA size was larger in LVH compared to healthy subjects after year long aerobic training (p=0.04) with greater increase LA/LV ratio (p&lt;0.001). Conclusions: One year of aerobic training resulted in higher LA size in patients with at-risk LVH compared to healthy subjects. The increase in LA size was greater than changes in LV size suggesting chronic aerobic training may preferentially affect LA remodeling.

A Comprehensive Echocardiographic Portrait of Adult Sickle Cell Disease Patients in the Modern Era

Background Cardiovascular complications, especially pulmonary hypertension, are a known cause of mortality in patients with sickle cell disease (SCD). With advances in medicine and the introduction of various disease-modifying medications, the incidence and prevalence of cardiovascular complications are poorly documented. Aim To determine rates of cardiovascular complications in patients with SCD in the modern era of disease-modifying medications in a single center. Method We performed a retrospective observational single-center study of patients with SCD: all genotyped and ≥16 years old who had a recent echocardiogram performed during the study period of 2019-2023. Demographics, echocardiogram results, and laboratory findings were collected and analyzed. Descriptive statistics are presented in percentages, medians, and interquartile ranges. An unpaired Student's t-test and Fisher's exact test were used to determine, where appropriate, the level of significant differences among continuous and categorical variables, respectively, with p value &amp;lt;0.05 considered statistically significant. Data was analyzed using GraphPad Prism version 9.0.2. Results As of June 2023, 80 patients (38 male and 42 female, median age 30 years) had undergone a routine transthoracic echocardiogram. Sixty-five patients had the HbSS genotype, 8 HbSC, and 7 HbSB null. Sixty-one patients had received at least one treatment, and 19 (24%) were on concurrent therapy. Hydroxyurea was the common SCD-modifying therapy that the patients received (51 patients), followed by L-glutamine and voxelotor (11 each) and crizanlizumab (9 patients). In total, 56 (70%) patients had at least one cardiac abnormality. The most common cardiac abnormality was left atrial dilatation (41%), followed by left ventricular hypertrophy (33%), right atrial dilation (24%), and left ventricular dilatation (23%). Pulmonary hypertension was present in 30 (38%) patients with tricuspid regurgitation velocity (TRV) ≥2.5 msec (Table 1). The cohort of patients with pulmonary hypertension tended to be older (median age 31 years, p=0.0357), have a higher creatinine level (median 0.8, p=0.0414), and have coexisting echocardiographic abnormalities such as left atrial dilatation (70% vs. 24%, p&amp;lt;0.0001) or right atrial dilatation (40% vs. 14%, p=0.0136) than SCD patients without pulmonary hypertension (Table 2). Conclusion We present a comprehensive echocardiographic assessment of patients with SCD. Despite advances in the treatment of SCD, there remains a high prevalence of cardiac involvement in SCD patients. We found out that 70% of the patients we reviewed had at least one cardiac abnormality on echocardiography. Left atrial dilatation and left ventricular hypertrophy were the most common cardiac abnormalities noted. Pulmonary hypertension was observed in 37.5% of patients with co-existing right and left atrial enlargement. Larger studies are needed to corroborate these findings.

Obesity-hyperlipidemia, Hypertension, and Left Atrial Enlargement During Stroke in Young Adults.

This study investigated the association between left atrial enlargement and stroke severity in young adults. We also studied the differences between the normal and left atrial enlargement groups in clinical data. A total of 135 young stroke patients admitted to the Department of Neurology of the Taizhou People's Hospital were recruited from January 2018 to December 2021. The patients were divided into normal and enlarged groups by left atrial size. The relationship between the left atrial diameter and the National Institutes of Health Stroke Scale score was analyzed apart from the differences in clinical variables. No relationship was observed between the left atrial diameter and the National Institutes of Health Stroke Scale score (r=-0.045 P=0.603). The univariate analysis of both groups revealed that hypertension (P=0.004), hyperlipidemia (P=0.001), body mass index (P=0.000), obesity (P=0.015), and not stroke etiologic subtypes were associated with left atrial enlargement. In binary logistic regression analysis models, hyperlipidemia 3.384 (95% CI, 1.536 to 7.452), hypertension 2.661 (95% CI, 1.066 to 6.639), and obesity 2.858 (95% CI, 1.158 to 7.052) were significantly associated with the young stroke of left atrial enlargement. In young adults, obesity-hyperlipidemia and hypertension were significantly associated with left atrial enlargement in stroke.