Left Atrial Function In Patients Research Articles

Improved identification of left atrial enlargement in patients with obesity.

Accurate standardization of left atrium volume (LAV) in patients with obesity is challenging. The aim of this study was to investigate and to examine the relation between LAV indexed to height2 and left atrial function in patients with moderate to severe obesity. Echocardiograms of patients with moderate to severe obesity (body mass index (BMI) ≥ 35 kg/m2) without known cardiac disease were analyzed. LAV was indexed to body surface area (BSA) and height2, and patients were divided into those with or without left atrial enlargement (LAE) based on normalization using either BSA (LAEbsa) or height2 (LAEh2). Using speckle tracking echocardiography, LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were assessed as a measure of LA function. LA dysfunction was defined as LASct < 14%. A total of 142 patients were included in the analysis of whom 54.2% had LAEh2 and 18.3% LAEBSA. The LAEh2 group had significantly lower LASct (12.2% ± 3.2% vs. 13.6% ± 4.5%, p = 0.019) as compared to the patients without LAEh2. Significantly more patients with LA dysfunction would be correctly identified by LAEh2 than by LAEBSA (41.5% vs. 15.0%, p < 0.001). In patients with moderate to severe obesity, the use of LAEh2 identified significantly more patients with decreased LA function. LAVh2 should be preferred over LAVBSA in patients with moderate to severe obesity.

Study on Left Atrial Function in Patients with Early Left Ventricular Remodeling in Essential Hypertension Based on Two-Dimensional Speckle Tracking Technology

Objective: To use two-dimensional speckle tracking imaging (2D-STI) to analyze the functional changes of the left atrium before hypertrophic changes in the left ventricular configuration in the early stage of hypertension and to explore the clinical value of this technology in evaluating the changes of left atrial characteristics in patients with hypertension. Methods: 70 cases of patients with essential hypertension who met the requirements of this study after clinical diagnosis and routine ultrasound examination were recruited and divided into two groups according to the Ganan method: 38 cases in the left ventricular standard remodeling group, 32 cases in the left ventricular concentric remodeling group, and 40 healthy people with matched age and sex were randomly selected as the control group. The mean peak strains and strain rates of the left atrial systole, early diastole, and late diastole of each group were obtained using 2D-STI. The above parameters and indicators were used for comparative analysis. Results: Compared with the healthy control group, the values of peak strains and strain rates during early diastole were statistically different in both remodeling groups; compared with the standard remodeling group, the values of peak strains and strain rates in all periods were significantly different in the concentric remodeling group (P &lt; 0.05). Conclusion: 2D-STI can be more sensitive and convenient to reflect the characteristic changes of left atrial myocardium in patients with early essential hypertension.

Three-dimensional Echocardiography for the Early Detection of Cardiac Dysfunction in Patients with Rheumatoid Arthritis

Abstract Background Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease. Left atrial (LA) dysfunction is strongly linked to cardiovascular diseases, and the early detection of LA function in patients with RA is vital. Real-time three-dimensional echocardiography (RT-3DE) offers a noninvasive method to assess the structure and function of the LA. Aim of the study To assess LA volumes and phasic function in patients with RA using 3D transthoracic echocardiography. Materials and Methods This prospective case-control study included 162 subjects classified into two groups: Group 1 included 82 patients with RA, subdivided into an active RA group (n = 40) and an inactive RA group (n = 42), and Group 2 included 80 healthy matched controls. All study participants were examined using 2D and 3D transthoracic echo-cardiography. Results Diastolic dysfunction was significantly greater in patients with moderate and severe disease activity than in patients with mild disease activity. RT-3DE analysis of RA groups showed significantly higher maximum, minimum, and pre-atrial LA volumes compared to controls (p &lt;0.01), and these volumes were significantly higher in the active RA group than in the inactive RA group (p &lt;0.01). We also found significantly lower LA passive ejection fraction (EF) and active EF in both RA groups than the control group (p &lt;0.01), and significantly lower total EF in the active RA group than the inactive RA group (p &lt;0.01). Conclusion Patients with RA had increased 3D LA volumes and impaired mechanical function, especially in active RA. RT-3DE provides an accurate measurement of LA volumes and function, being a feasible and reproducible method in clinical applications.

The Improvement of Left Atrial Function after Twelve Weeks of Supervised Concurrent Training in Patients with Heart Failure with Mid-Range Ejection Fraction: A Pilot Study.

Left atrial dysfunction is associated with exercise intolerance and poor prognosis in heart failure (HF). The effects of exercise training on atrial function in patients with HF with mid-range ejection fraction (HFmrEF) are unknown. The purpose of the present study was to assess the effects of a supervised concurrent training (SCT) program, lasting 12 weeks, on left atrial function of patients with HFmrEF. The study included 70 stable patients, who were randomly assigned into two groups: SCT with (three sessions/week) or a control (CON) group directed to follow contemporary exercise preventive guidelines at home. Before starting the training program and at 12 weeks, all patients performed an ergometric test, a 6 min walk test, and echocardiography. Between-group comparisons were made by analysis of variance (ANOVA). At 12 weeks, the duration of the ergometric test and distance walked at 6 min walk test presented a significant greater increase in SCT compared to the control (between-group p 0.0001 and p 0.004 respectively). Peak atrial longitudinal strain and conduit strain presented an increase of 29% and 34%, respectively, in the SCT, and were unchanged in CON (between-group p 0.008 and p 0.001, respectively). Peak atrial contraction strain increased by 21% in SCT, with no changes in CON (between-group p 0.002). Left ventricular global longitudinal strain increased significantly in SCT compared to control (between-groups p 0.03). In conclusions, SCT improved left atrial and left ventricular function in HFmrEF. Further studies are needed in order to verify whether these favourable effects of SCT on LA function are sustained and whether they will translate into clinical benefits for patients with HFmrEF.

Correlation between left atrial strain and left ventricular diastolic function in hypertensive patients.

Early detection of asymptomatic diastolic dysfunction is essential to prevent the development of heart failure in hypertensive patients. Current studies suggest that left atrial strain contributes to the evaluation of left ventricular diastolic function, but there are fewer studies on the correlation between left atrial strain and diastolic function in hypertensive patients. In this study, we applied a two-dimensional speckle tracking technique to evaluate the changes in left atrial strain in hypertensive patients, and to investigate the relationship between left atrial strain and left ventricular diastolic function. A total of 82 hypertensive patients who were visited the Department of Cardiology at the Third Xiangya Hospital of Central South University from July 2021 to January 2022, were enrolled for this study, and 59 healthy subjects served as a control group. According to the number of left ventricular diastolic function indexes recommended by the 2016 American Society of Echocardiography Diastolic Function Guidelines (mitral annular e´ velocity: Septal e´<7 cm/s, lateral e´<10 cm/s, E/e´ ratio>14, left atrial volume index>34 mL/m2, peak tricuspid regurgitation velocity>2.8 m/s), the hypertensive patients were divided into 3 groups: Group Ⅰ (0 index, n=36 ), Group Ⅱ (1 index, n=39), and Group Ⅲ (2 indexes, n=7). Two-dimensional speckle tracking technique was used to measure left atrial reservoir strain (LASr), conduit strain, and contraction strain, and to analyze the correlation between left atrial strain and left ventricular diastolic function in hypertensive patients. The LASr, left atrial conduit strain (LAScd), and LASr/(E/septal e´) of the hypertension group were lower than those of the control group, and E/LASr was higher than that of the control group. There was no significant difference in left atrium volume index between the 2 groups (P>0.05). Compared with Group Ⅰ, LASr, LAScd, and LASr/(E/septal e´) were decreased in Group Ⅱ and Group Ⅲ, LASr/(E/septal e´) was also decreased in Group Ⅲ compared with Group Ⅱ (all P<0.05). Compared with Group Ⅰ, E/LASr was increased in Group Ⅲ. LASr was positively correlated with septal e´, lateral e´, E, and E/A, and negatively correlated with E/septal e´. The changes of left atrial function in patients with early hypertension are earlier than those of left atrial structure. Left atrial strain and its combination with conventional ultrasonographic indices [LASr/(E/septal e´)] of diastolic function are potentially useful in assessing left ventricular diastolic function in hypertensive patients.

Effect of glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors and their combination on left atrial strain and arterial function

Abstract Funding Acknowledgements Type of funding sources: None. Background We investigated the effects of insulin, glucagon-like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on left atrial function of patients with type 2 diabetes mellitus and we searched for a relation with arterial function. Patients and methods A total of 201 patients (59,5±9,1 year old, 161 male) with type 2 diabetes mellitus treated with metformin were randomized to insulin (n= 50 served as controls), liraglutide (n=51), empagliflozin (n=50) or their combination (GLP-1RA+SGLT- 2i) (n= 50) as add-on. We measured at baseline and 6 months posttreatment: (a) perfused boundary region of the sublingual arterial microvessels (marker of endothelial glycocalyx thickness), (b) pulse wave velocity (PWV) and central systolic blood pressure, (c) global left ventricular Longitudinal strain, (d) left atrial strain. Results Six months after intervention, all patients improved left atrial reservoir strain (GLP1RA 30,7±9,3 vs 33,9±9,7%, p = 0,011/SGLT2i 30±8,3 vs 32,3±7,3%, p = 0,04/ GLP1&amp;SGLT2i 29,1±8,7 vs 31,3±8,2, p = 0,007) in comparison with controls (33±8,3% vs 32,8±7,4, p = 0,829). Also, patients treated with GLP1RA and their combination improved left atrial conduction strain (p&amp;lt;0.05). GLP-1RA or GLP-1RA+SGLT-2i provided a greater improvement in GLS compared with insulin or SGLT-2i (controls –18,5±3,9% vs − 19,1±3%, p = 0,202/GLP1RA –18,2±4,1% vs –19,1±3,5%, p = 0,03/SGLT2i –19±4,1% vs − 19,1±3,8%, p = 0,764/GLP1&amp;SGLT2i –16,7±3,9% vs –17,5±4,3%, p = 0,026). SGLT-2i or GLP-1RA and SGLT-2i showed a greater decrease of PWV (Controls 12,06±3,02 vs 11,62±2,79 m/sec, p = 0,142/ GLP1 11,54±2,91 vs 11,45±2,52 m/sec, p = 0,822/ SGLT2 11,86±2,51 vs 11,33±2,28 m/sec, p = 0,047/ GLP1&amp;SGLT2 12,01±2,46 vs 10,85±1,79 m/sec, p = 0,021) and central and brachial systolic blood pressure than insulin or GLP-1RA. At baseline, there was a correlation of LA reservoir strain with PWV (r =−0,209, p = 0,008), central SBP (r =−0,151, p = 0,030), EF (r=0,214, p = 0,004), GLS (r =−0,279, p = 0,009). At 6 months follow up, there was a correlation of LA reservoir strain with PWV (r=0,217, p = 0,003), central SBP (r =0,214, p = 0,004), EF (r=–0,221, p = 0,049), GLS (r =0,275, p = 0,014). Conclusions Treatment with GLP-1RA, SGLT-2i, and their combination for 6 months showed a greater improvement of left atrial function compared to insulin treatment in parallel with improvement arterial and myocardial function.

Obesity, epicardial adipose tissue and left atrial cardiomyopathy in patients with heart failure with preserved ejection fraction: a cardiac MRI based study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): unrestricted grant from Abbott-Netherlands to the University Medical Center Groningen Introduction Atrial fibrillation (AF) and heart failure (HF) with preserved ejection fraction (HFpEF) commonly co-exist and both conditions are typically characterized by impaired left atrial (LA) function. While obesity is an important contributor to both AF and HFpEF, it has been suggested that specifically epicardial adipose tissue (EAT) may be involved in the pathophysiology of these diseases. However, data on the relation between EAT and atrial function using cardiac magnetic resonance imaging (MRI) is scarce. In this study we aimed to investigate the association of body mass index (BMI) and EAT with LA function in patients with HFpEF. Methods Patients with symptomatic HF and left ventricular ejection fraction &amp;gt;40% were enrolled. All patients underwent cardiac MRI. LA function was assessed using the cine long-axis 4-chamber and 2-chamber acquisitions. EAT volume was quantified on the short-axis cine-stacks and indexed for BSA. Patients were divided according to the presence of obesity (BMI &amp;gt;30 kg/m2) and by low and high EAT (i.e. &amp;gt;100 ml/m2). Results In total, 125 patients were included. Mean age was 71±10 years, 62 (50%) were women and mean BMI was 30±6 kg/m2. In total, 56 (45%) patients were obese, 56 (48%) had high EAT, 68 (54%) had a diagnosis of AF, 98 (78%) had hypertension, 48 (38%) had diabetes mellitus and 44 (35%) had coronary artery disease. There was no difference in LA end-systolic volume (63 vs. 59 ml/m2, p=0.6), LA emptying fraction (31 vs. 30%, p=0.9) and LA reservoir strain (15 vs. 14%, p=0.4) between obese and non-obese patients. However, when patients were divided according to EAT volume, patients with high EAT had higher LA end-systolic volume (67 vs. 56 ml/m2, p=0.01) and lower LA reservoir strain (12 vs 17%, p=0.03), as compared to patients with low EAT. LA emptying fraction was not significantly different between high and low EAT (38 vs. 33%, p=0.1). There was no significant correlation between BMI and LA end-systolic volume, LA emptying fraction and LA reservoir strain (data not shown). On the contrary, there was a significant correlation between EAT and LA end-systolic volume (r=0.3, p=0.002), LA emptying fraction (r= -0.2, p=0.01) and LA reservoir strain (r= -0.2, p=0.006). There were no differences in the presence of AF between obese and non-obese patients (57 vs 52%, p=0.6) and between high and low EAT (59 vs. 54%, p=0.6). Conclusion In patients with HFpEF, increased EAT but not obesity was associated with LA dysfunction. The cause effect relation between epicardial adipose tissue, atrial cardiomyopathy and the development of AF in patients with HFpEF need further investigation.

Left atrial Strain as a predictor of atrial fibrillation recurrence after catheter ablation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation (AF) is one of the most common cardiac arrhythmias. In arrhythmology, catheter ablation methods are successfully used in the treatment of AF. Objective To assess the significance of left atrial (LA) longitudinal deformity in predicting AF recurrence after catheter ablation. Research material and methods: The study was carried out on the basis of NJSC "National Scientific Cardiac Surgery Center" in the Department of Interventional Arrhythmology. The study included 150 patients, whose average age was 62.4 ± 7.47 years. All patients underwent catheter ablation of the pulmonary veins. Patients were divided into 2 groups depending on the effectiveness of ablation: with recurrent AF (47) and patients who maintained sinus rhythm for 12 months (103). Heart parameters were assessed in two-dimensional (2D) conventional and speckle-tracking echocardiography of the left atrium (LA). Results According to the results of Speckle-tracking echocardiography, the peak values of longitudinal and contractile LA deformity were significantly lower in the group where AF relapsed soon and amounted to -17.4319±0.52 and -22.9194±1.13, respectively (p&amp;lt;0, 0001). According to the results of an echocardiographic study, the LA volume was 100.10±28.5 ml in the first group and 74.85±14.44 ml in the 2nd group (p&amp;lt;0.01), which exceeds normal values. Statistical difference revealed (p&amp;lt;0.01), such indicators as the indexed volume of the LA and its area, which amounted to 47.27±9.21 ml/m²; 38.13±6.85 ml/m²; and 26.61±3.37 cm²; 22.72±3.12 cm², respectively. LVML in group 1 was 225.3±44.1, in group 2 160.29±40.61 (p&amp;lt;0.01), LVMI was 112±19.25 and 83.30±20.17 (p&amp;lt;0.01). Correlation analysis revealed a positive relationship between AF recurrence and LA area (r=0.599; p&amp;lt;0.01), longitudinal LA deformity (r=-0.804), RA area (r=0.479; p&amp;lt;0.01), LVMI (r=0.557; p&amp;lt;0.01), LVMI (r=0.367; p&amp;lt;0.01), LV EDR (r=0.381; p&amp;lt;0.01), LV ESR (r=0.375; p&amp;lt;0 .01). Analysis of the ROC curve of the relationship between relapse and LA volume showed that the area under the ROC curve was 0.786 ± 0.045 with 95% CI: 0.679-0.858. Assessing the relationship between AF recurrence and LA area, the area under the ROC curve was 0.783 ± 0.043 with 95% CI: 0.699-0.867. The threshold value of the volume and area of the LA at the cut-off point is 81.5 (sensitivity and specificity were 70.2% and 66%%) and 24.5 (sensitivity and specificity were 68.1% and 68.9%) ( p&amp;lt;0.001). Conclusion Speckle tracking echocardiography is a valuable tool for evaluating left atrial function in patients with AF and may be of diagnostic value for the prognostic detection of AF recurrence in patients after catheter ablation. Evaluation of echocardiographic parameters in patients with AF revealed that an increase in such parameters as the volume and area of the left and right atrium, LVMI, MMLV, LV EDD, LV ESD has a moderate positive correlation with recurrent AF.

Left atrial function after thoracoscopic left atrial appendage exclusion as standalone and as combined with epicardial atrial fibrillation ablation: echocardiographic findings at one- year follow up

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left atrial appendage (LAA) is the most common source of thrombi in patients with atrial fibrillation (AF). The Totally Thoracoscopic (TT)-LAA exclusion with epicardial clip is an effective procedure, however the effects on left atrial (LA) function remain unknown. Purpose The aim of this study was to assess the impact of TT-LAA exclusion on the LA function in patients undergoing to standalone TT-LAA exclusion and patients received combined procedure, namely: TT-LAA exclusion and Thoracoscopic Epicardial Ablation (TEA). Methods 39 AF Patients underwent to TT-LAA exclusion with the clip. Indication to standalone TT-LAA exclusion was: high risk for ischemic stroke or contraindication to long-term anticoagulant therapy. All patients were screened preoperatively with 3D CT scan, transthoracic and trans-esophageal echocardiography. Intraoperative clip positioning and LAA exclusion were guided by trans-esophageal echo. To evaluate LA function, standard transthoracic echocardiography and 2D strain of LA were performed before surgery, at discharge (3-4 days after the procedure), at 3-month and at 1 year. Routine blood tests and BNP levels were also measured. Results The study enrolled 39 consecutive patients, 25 underwent to standalone TT-LAA exclusion (mean age 78.6 ± 5.7 years, 79% males), and 14 LAA exclusion during TEA (mean age 64.5 ± 8.2 years, 82% males). The mean CHA2DS2-VASc and HASBLED scores were 3.5 and 2.1 respectively. Baseline characteristics are summarized in Figure 1. There were no major complications during the procedure. At median follow-up of 13 months, 1 non cardiovascular death, 1 ischemic stroke and 4 cardiovascular hospitalizations occurred. At 2D strain of LA, the reservoir function decreased significantly after clip implantation and recovered at 3-months follow-up; at 1 year it remained stable. Furthermore, NT-proBNP increased significantly after LAA exclusion with a return to baseline after 3 months. Changes in E/A occurred at predischarge and did not persist at follow up. Echocardiographic findings are summarized in Figure 2. Patients with indication to TEA and LAA exclusion presented a lower LA volume and a lower strain value. Conclusion The main findings of this study can be summarized as follows: 1) The amputation of LAA is a safe procedure at long term follow up. 2) LAA amputation with the clip is associated with acute elevation of BNP levels the days after the procedure with return to baseline at 3 months and one year. 3) LAA amputation impairs the LA reservoir function after the procedure, with recovery after 3 months and remains preserved at one-year. This occurs either when LA strain is measured in sinus rhythm or in AF. 4) LAA exclusion results in a change in E/A that does not persist at three months follow-up and at 1 year. 5) Patients with indication to epicardial AF ablation and LAA exclusion present a lower LA volume with a lower strain value than patients undergoing standalone TT-LAA exclusion.

Left Atrial Function in Patients with Titin Cardiomyopathy

BackgroundTruncating variants in titin (TTNtv) are the most prevalent genetic etiology of dilated cardiomyopathy (DCM). Although TTNtv has been associated with atrial fibrillation, it remains unknown whether and how left atrial (LA) function differs between patients with DCM with and without TTNtv. We aimed to determine and compare LA function in patients with DCM with and without TTNtv and to evaluate whether and how left ventricular (LV) function affects the LA using computational modeling. Methods and ResultsPatients with DCM from the Maastricht DCM registry that underwent genetic testing and cardiovascular magnetic resonance (CMR) were included in the current study. Subsequent computational modeling (CircAdapt model) was performed to identify potential LV and LA myocardial hemodynamic substrates. In total, 377 patients with DCM (n = 42 with TTNtv, n = 335 without a genetic variant) were included (median age 55 years, interquartile range [IQR] 46–62 years, 62% men). Patients with TTNtv had a larger LA volume and decreased LA strain compared with patients without a genetic variant (LA volume index 60 mLm−2 [IQR 49–83] vs 51 mLm−2 [IQR 42–64]; LA reservoir strain 24% [IQR 10–29] vs 28% [IQR 20–34]; LA booster strain 9% [IQR 4–14] vs 14% [IQR 10–17], respectively; all P < .01). Computational modeling suggests that while the observed LV dysfunction partially explains the observed LA dysfunction in the patients with TTNtv, both intrinsic LV and LA dysfunction are present in patients with and without a TTNtv. ConclusionsPatients with DCM with TTNtv have more severe LA dysfunction compared with patients without a genetic variant. Insights from computational modeling suggest that both intrinsic LV and LA dysfunction are present in patients with DCM with and without TTNtv.

Left atrial function evaluation by 2D speckle-tracking echocardiography in patients with vasovagal syncope.

Evidence indicates left atrial (LA) involvement in vasovagal syncope (VVS). The LA regulates left ventricular filling during the cardiac cycle. We aimed to assess LA function in patients with VVS by 2D speckle-tracking echocardiography. Sixty-nine consecutive patients with VVS were recruited. Based on the head-up tilt test (HUTT) results, the study population was divided into two groups: HUTT+ (n = 45) and HUTT- (n = 24). Fifty-one consecutive subjects were enrolled as the control group. LA myocardial deformation parameters were measured by 2D speckle-tracking echocardiography to evaluate LA function. Maximal, minimal, and pre-P LA volumes were lower in patients with VVS. Strain and strain rate during reservoir, conduit, and contraction phases in VVS patients with HUTT+ or HUTT- were not statistically significantly different from those in the control group. Additionally, the volumetric parameters of LA function showed no difference in statistical significance between the three study groups. While LA phasic function was not different between the two groups of VVS patients with HUTT+ or HUTT- and the control group, LA size during the three LA phases was smaller in patients with VVS.

Left atrial strain assessment using cardiac computed tomography in patients with hypertrophic cardiomyopathy

PurposeTo evaluate left atrial (LA) function in patients with hypertrophic cardiomyopathy (HCM) by LA strain assessment using cardiac computed tomography (CT-derived LA strain).Materials and methodsThis was a retrospective study of 34 patients with HCM and 31 non-HCM patients who underwent cardiac computed tomography (CT) using retrospective electrocardiogram-gated mode. CT images were reconstructed every 5% (0–95%) of the RR intervals. CT-derived LA strain (reservoir [LASr], conduit [LASc], and booster pump strain [LASp]) were semi-automatically analyzed using a dedicated workstation. We also measured the left atrial volume index (LAVI) and left ventricular longitudinal strain (LVLS) for the left atrial and ventricular functional parameters to assess the relationship with CT-derived LA strain.ResultsCT-derived LA strain significantly correlated with LAVI: r = − 0.69, p < 0.001 for LASr; r = − 0.70, p < 0.001 for LASp; and r = − 0.35, p = 0.004 for LASc. CT-derived LA strain also significantly correlated with LVLS: r = − 0.62, p < 0.001 for LASr; r = − 0.67, p < 0.001 for LASc; and r = − 0.42, p = 0.013 for LASp. CT-derived LA strain in patients with HCM was significantly lower than that in non-HCM patients: LASr (20.8 ± 7.6 vs. 31.7 ± 6.1%, p < 0.001); LASc (7.9 ± 3.4 vs. 14.2 ± 5.3%, p < 0.001); and LASp (12.8 ± 5.7 vs. 17.6 ± 4.3%, p < 0.001). Additionally, CT-derived LA strain showed high reproducibility; inter-observer correlation coefficients were 0.94, 0.90, and 0.89 for LASr, LASc, and LASp, respectively.ConclusionCT-derived LA strain is feasible for quantitative assessment of left atrial function in patients with HCM.

Gender-related differences in left atrial strain mechanics and exercise capacity in hypertrophic cardiomyopathy: a propensity-score matched study from the Cleveland Clinic.

Male and female patients with hypertrophic cardiomyopathy (HCM) differ in physiologic characteristics and hemodynamics. Little is known about gender-related differences in left atrial (LA) strain and exercise capacity. The aim of this study was to assess the gender-related differences in the relationship between exercise capacity and cardiac function including LA function in patients with HCM. Five hundred and thirty-two patients with HCM undergoing exercise stress echocardiography and cardiopulmonary exercise testing (CPET) were prospectively recruited between October 2015 and April 2019 as part of a cohort study in a quaternary referral center. To reduce potential confounding factors, propensity score (PS) matching was performed in 420 patients. LA strain mechanics were evaluated using speckle-tracking echocardiography. The majority of patients were male, comprising 58% of the total. Female HCM patients were older (54±14 vs. 50±15 years, P=0.002). After PS matching, percent-predicted peak VO2 was similar between the genders (67.5%±20.7% vs. 65.8%±21.8%, P=0.41), even though female HCM patients had lower peak VO2 (17.7±5.9 vs. 24.1±8.3 mL/kg/min, P<0.001). Left ventricular (LV) diastolic function was worse for female HCM patients. This is shown by worse E/e' ratio (15.0±5.9 vs. 12.9±6.4, P<0.001) and larger LA volume in respect to LV (0.88±0.35 vs. 0.74±0.31, P<0.001), compared with male HCM patients. The gender-related differences in LA reservoir strain were more evident for patients aged 60 years and older (27.5%±8.8% vs. 30.9%±9.1%, P=0.03). LA reservoir strain was found to have a significant association with exercise capacity in both male and female HCM patients (for females, β=0.27, P=0.001; for males, β=0.27, P<0.001), independent of LV diastolic dysfunction and stroke volume. Gender-related differences in LA reservoir strain were increasingly evident for older HCM patients aged 60 years and older. LA reservoir strain was an independent determinant of percent-predicted peak VO2 in male and female patients, underpinning the importance of LA function in determining exercise capacity in HCM.

Response to 'Is the left atrium the key in the amyloid imaging lock?'

We thank Dr Bart for her commentary on our paper.1 The echocardiogram is the first-line imaging technique in patients with suspected cardiac amyloidosis (CA).2 Speckle-tracking analysis of the left ventricle should be systematically performed, as the apical sparing pattern is strongly suggestive of CA, particularly in individuals with unexplained hypertrophy.2 In patients in sinus rhythm, the left atrial (LA) function may be studies by calculating the peak LA longitudinal strain (PALS), which reflects the reservoir function, and peak LA contraction strain (PACS), which explores the contractile function of the LA. In our study, we reported that both PALS and PACS are severely depressed in patients with amyloid transthyretin (ATTR) CA.3 The mechanisms are (i) a progressive dilation and remodelling of the LA, due to diastolic dysfunction and leading to a depressed LA contractility, and (ii) amyloid deposition in the atrial walls, with an expansion of extracellular spaces and cardiomyocyte dysfunction. Structural and functional remodelling of the LA is more prominent in ATTR-CA, which is a slowly progressive disease, than in amyloid light-chain (AL)-CA, which has a more rapid progression.3 We agree with Dr Bart that this difference between ATTR- and AL-CA may be useful for the purposes of differential diagnosis. The exact role of cardiovascular magnetic resonance (CMR) in the diagnostic workup of CA has not been standardized yet, but CMR may implement baseline examination in patients with suspected CA. Several techniques (feature tracking, tagging, and tissue-phase contrast) allow to track the motion of LA throughout the cardiac cycle and represent the CMR equivalents of speckle-tracking imaging. The study cited by Dr Bart investigated the value of CMR-based LA strain in 54 patients with CA (30 AL and 24 ATTR), reporting a lower LA function in patients with ATTR vs. AL despite no significant differences in LA geometry.4 These findings are in agreement with our study.1 Echo- or CMR-based LA strain might then help differentiate AL- from ATTR-CA among patients starting the diagnostic workup for suspected CA. On the other hand, further investigations (cardiac scintigraphy with bone tracers, search for a monoclonal protein, and often histological analyses) are still needed to confirm the diagnosis of CA and its subtype, in agreement with the current algorithm.1 Beyond its possible diagnostic value, we think that LA strain might prove helpful for risk stratification and to track disease evolution. A more depressed LA strain is reasonably associated with more blood stasis and a greater risk of atrial thrombosis, and could then suggest the potential need for an anticoagulant therapy even when there is no history of atrial fibrillation.1,2 As for the second point, LA strain has a close association with disease severity and is highly reproducible, meaning that a deterioration of LA strain over time reflects disease progression, while unchanged or improved values over times may mirror the stabilizing or positive effects of disease-modifying therapies.5 In summary, LA strain could really become a ‘key in the amyloid imaging lock’.

Abstract 12090: Catheter Ablation Impairs Left Atrial Function in Patients With Atrial Fibrillation: A Magnetic Resonance Imaging Study

Introduction: Atrial fibrillation (AF) is associated with left atrial (LA) fibrosis and morphological remodeling. Catheter ablation (CA) is a well-established method of treatment for AF which results in additional LA scarring. Cardiac magnetic resonance (CMR) imaging is the gold standard for evaluating LA volumes and function, and feature tracking in CMR has been increasingly confirmed as a feasible and reproducible technique for assessing LA function through strain. We used CMR to assess baseline fibrosis, ablation-induced scarring and the impact of CA on LA volume, shape and function in patients with AF undergoing their first catheter ablation. Methods: AF patients underwent late gadolinium enhancement CMR prior to, then at least 3 months after CA for quantification of LA volumes, fibrosis and ablation-induced scarring, respectively (Panel A). Global longitudinal reservoir strain (GLRS) was assessed by feature tracking (Panel B). Cine-images were used to assess sphericity and emptying fraction. All CMR images were obtained in sinus rhythm. Wilcoxon signed rank analysis was used to assess the effect of CA on LA volume and sphericity index, emptying fraction and GLRS. Results: 40 patients (57% male, average age 61.9 years, 72.5% paroxysmal AF) were included. Pre-ablation LA fibrosis was 16.6% [9.1, 20.7] whereas ablation-induced LA scar was 8.0% [6.5, 12.1]. GLRS and LA emptying fraction decreased after CA (17.8 [15.3, 20.5] vs 16.0 [13.5, 19.0] p=0.006, and 60.2% [51.3, 66.4] vs 51.6% [46.3, 61.1], p&lt;0.001, respectively). However, LA volume index and sphericity index were unchanged after CA in our study cohort (48.0 mL/m 2 [37.1, 61.1] vs 47.0 mL/m 2 [36.2, 52.7] p=0.91 and 54.6% [47.2, 65.4] vs 53.2% [46.5, 64.5] p=0.8, respectively) (Panel C). Conclusion: LA function is negatively impacted by catheter ablation for AF. The competing impact of ablation on rhythm control and atrial function with respect to stroke and heart failure need to be further evaluated.

Impaired Left Atrial Function in Patients with Atrial Septal Defect and History of Atrial Fibrillation.

In patients with atrial septal defect (ASD), atrial left-to-right shunting causes left atrial (LA) remodeling and dysfunction, leading to atrial fibrillation (AF). In adults with ASD and concomitant AF, LA function should be evaluated after ASD closure plus AF radiofrequency catheter ablation (RFCA).This multicenter retrospective cohort study included patients who underwent transcatheter ASD closure at one of the four leading hospitals. Patients with a history of AF also underwent preceding RFCA. The association between AF history and LA ejection fraction (EF) (indicating LA global function) at 6-12 months following ASD closure was evaluated. To account for differences in baseline characteristics between patients with and without a history of AF, we conducted the following statistical methods: (1) multivariate regression analysis in the prepropensity score (PS)-matched cohort and (2) univariate comparisons in the PS-matched cohort.Overall, this study included 231 patients (30 with AF history, 201 without). Multiple regression analysis showed that AF history was independently associated with impaired LAEF (β = -10.425, P < 0.001, model created prior to propensity matching). A one-to-one PS matching (25 pairs) showed that the LAEF at 6-12 months following ASD closure was significantly impaired in patients with ASD and AF history compared to that in patients without history of AF (median LAEF, 37.5% (interquartile range [IQR] 29.4%-48.5%) versus 52.3 [IQR 50.0%-56.6%]; P < 0.001).LA function was impaired in patients with ASD and a history of AF at 6-12 months after successful transcatheter ASD closure and on maintenance of sinus rhythm by RFCA.

The effect of different preoperative left atrial appendage emptying speeds on left atrial function in patients with persistent atrial fibrillation after left atrial appendage closure combined with catheter ablation

ObjectiveThe present study aimed to investigate whether different preoperative left atrial appendage emptying speeds (LAAEVs) have an effect on left atrial function in patients with sinus arrhythmia after left atrial appendage closure (LAAC) combined with catheter ablation (CA).MethodsA total of 163 patients with persistent non-valvular atrial fibrillation who received combined LAAC+CA surgery were included in the present study. Regular follow-up was conducted for 12 months, and patients with complete data and successful sinus rhythm recovery were selected as the study subjects (n = 82). The patients were divided into two groups: the LAAEV < 25 cm/s group and the LAAEV ≥ 25 cm/s group (n = 41 each). The propensity score was used for matching according to gender, age, CHA2DS2-VASc score, and HAS-BLED score. The changes in the two groups in LA structure, storage function, conduit function, and pump function were compared.ResultsBefore surgery, the maximum LA volume (LAVmax) and minimum LA volume (LAVmin) were greater in the LAAEV < 25 cm/s group than in the LAAEV ≥ 25 cm/s group. The LA storage function (eg. Ƹ and SRs), conduit function (eg. SRe), and pump function (eg. SRa) were all worse in the LAAEV < 25 cm/s group than in the LAAEV ≥ 25 cm/s group. After the combined LAAC+CA surgery, the LA storage, conduit, and pump functions improved in both groups. At 12 months after surgery, there were no statistically significant differences between the two groups.ConclusionBefore combined LAAC+CA surgery, the LA structure and function of the LAAEV < 25 cm/s group were worse than those of the LAAEV ≥ 25 cm/s group. However, after LAAC+CA surgery, the LA structure and function of the patients were improved, and there were no significant differences between the two groups. Inferred improvement in LA structure and function in the LAAEV < 25 cm/s group was superior to that in the LAAEV ≥ 25 cm/s group.

Cardiorespiratory fitness, obesity and left atrial function in patients with atrial fibrillation

BackgroundLow cardiorespiratory fitness (CRF) and obesity are related to the development and maintenance of atrial fibrillation (AF). The aim of this study was to determine the association between CRF, obesity and left atrial (LA) mechanical parameters in patients with AF.MethodsA cohort of 154 consecutive paroxysmal and persistent AF patients (Age: 62 ± 10, 26% female) referred for exercise stress testing and transthoracic echocardiography were included. We included patients in sinus rhythm with preserved left ventricular ejection fraction who were able to complete a maximal exercise test. Left atrial strain in the reservoir (LASr), booster (LASb) and conduit (LASc) phases were assessed using dedicated software. LA stiffness, emptying fraction (LAEF) and LA to LV ratio were calculated using previously described formulas.ResultsCRF was positively associated with LAEF (β = 1.3, 95% CI 0.1–2.3, p = 0.02), reservoir (β = 1.5, 95% CI 0.9–2.1, p < 0.001), booster (β = 0.8, 95% CI 0.4–1.2, p < 0.001) and conduit strain (β = 0.7, 95% CI 0.3–1.1, p = 0.001). We observed an inverse association between CRF and both LA stiffness index (β = −0.02, 95% CI (−0.03)–(−0.01), p < 0.001) and LA to LV ratio (β = −0.03, 95% CI (−0.04)–(−0.01), p < 0.001). Obese patients had significantly higher indexed LA volumes compared to overweight and normal BMI patients. The association between obesity and measures of LA function and stiffness did not reach statistical significance.ConclusionAmong AF patients, higher CRF was independently associated with greater LA function and compliance. Obesity was associated with higher LA volumes yet preserved mechanical function.

Left atrial reservoir and pump function after catheter ablation with persistent atrial fibrillation: a two-dimensional speckle tracking imaging study

Objective By using ultrasound strain rate (SR) imaging to evaluate the left atrial (LA) reservoir and pump function after catheter ablation (CA) with persistent atrial fibrillation (PAF). Methods A total of 45 patients with PAF underwent echocardiography examination before and after ablation as well as during 6 months of follow-up. Peak SR was measured at each LA segment (septal, lateral, anterior, inferior and posterior) during systole (LAs) and late diastole (LAa). Results During 6 months after CA, 30 patients were free of atrial fibrillation recurrence (AFR). left atrial area index (LAAI), left atrial maximum volume index (LAVImax), and E/Ea were obviously higher in patients with before CA, left atrial ejection fraction (LAEF), SR-LAs were lower than in normal cases, the SR-LAa was disappeared. Shortly after ablation, SR-LAa was recovered, and SR-LAs was reduced compared to those at baseline. At midterm follow-up, LAEF and SR-LAs were still lower than the control group, and LAAI and LAVImax were higher. SR-LAa was recovered slowly over time, but still lower. Conclusion LA reservoir function was seriously damaged and LA pump function disappeared in patients with PAF. LA reservoir function impairment appeared shortly after ablation, it showed improvement at midterm follow-up, but some degree of damage to the LA reservoir and pump function was still present. Speckle tracking imaging is a feasible technique for the assessment of LA function in patients with PAF, which is a potentially valuable clinical tool to assist in the early detection of atrial remodelling and reverse remodelling.

Left atrial function in patients with heart failure

Improvement of the treatment and diagnosis of hypertension and heart failure (HF) contributes to an increase in life expectancy of the population and, accordingly, its aging. The problem of diagnosing and predicting HF with preserved ejection fraction (HFpEF) is currently one of the urgent problems. The role of left atrial function in the development and course prediction of HF are the subject of scientific study. This review provides an analysis of recent studies on left atrial function in HF patients.