Left Atrial Global Longitudinal Strain Research Articles

Association of atrial mechanical dispersion with atrial fibrillation recurrence following catheter ablation: results of the ASTRA-AF pilot study.

For patients with symptomatic drug-refractory atrial fibrillation (AF), catheter ablation to achieve rhythm control is an important therapeutic option. The atrial mechanical dispersion measured as standard deviation of the time to peak strain (SD-TPS) is associated with the risk of AF recurrence following catheter ablation. The study cohort prospectively enrolled n = 132 consecutive patients with paroxysmal (n = 88) or persistent AF (n = 44) presenting for de novo pulmonary vein isolation (PVI) and followed for 1year. We related left atrial (LA) volume, LA ejection fraction, SD-TPS, and global longitudinal strain of the left ventricle and clinical variables (sex, age, and type of AF) to AF recurrence. Kaplan-Meier curves showed higher AF recurrence rate with an increase of SD-TPS with the calculated cut-off of 38.6ms. Uni- and multivariable Cox regression analysis could show that SD-TPS had the highest relevance regarding AF recurrence with a HR of 1.05 (95% CI, 1.01; 1.09, p = 0.01) and HR of 1.05 (95% CI, 1.01; 1.09, p = 0.02) per 10ms increase. In the additional analyses for the model including the clinical variables age, sex, and type of AF with paroxysmal or persisting AF, SD-TPS did only show a trend and after adjusting for covariates, SD-TPS showed a HR of 1.04 (95% CI, 0.99; 1.09, p = 0.09) per 10ms increase. Atrial mechanical dispersion was associated with recurrent AF.

Characteristics and prognostic value of cardiac magnetic resonance strain analysis in patients with different phenotypes of heart failure

BackgroundStrain analysis of cardiac magnetic resonance imaging (CMR) is important for the prognosis of heart failure (HF). Herein, we aimed to identify the characteristics and prognostic value of strain analysis revealed by CMR in different HF phenotypes.MethodsParticipants with HF, including HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction, and controls were enrolled. The baseline information and clinical parameters of participants were collected, and echocardiography and CMR examination were performed. Three-dimensional strain analysis was performed in the left ventricle, right ventricle, left atrium, and right atrium using CMR. A multifactor Cox risk proportional model was established to assess the influencing factors of cardiovascular adverse events in patients with HF.ResultsDuring a median follow-up of 999 days (range: 616–1334), 20.6% of participants (73/354) experienced adverse events (HF readmission and/or cardiovascular death). Univariable Cox regression revealed that a 1% increase in left atrial global longitudinal strain (LAGLS) was associated with a hazard ratio (HR) of 1.21 [95% confidence interval (CI):1.15–1.28; P < 0.001]. Left ventricular global circumferential strain (LVGCS) (HR, 1.18; 95% CI: 1.12–1.24; P < 0.001), and left ventricular global longitudinal strain (LVGLS) (HR, 1.27; 95% CI: 1.20–1.36; P < 0.001) were also associated with HF hospitalizations and cardiovascular deaths. Among clinical variables, hypertension (HR, 2.11; 95% CI: 1.33–13.36; P = 0.002), cardiomyopathy (HR, 2.26; 95% CI: 1.42–3.60; P < 0.001) were associated with outcomes in univariable analysis. Multivariable analyses revealed that LAGLS (95% CI: 1.08–1.29; P < 0.001), LVGLS (95% CI:1.08–1.29; P < 0.001) and LVGCS (95% CI: 1.19–1.51; P < 0.001) were significantly associated with outcomes. Among clinical variables, hypertension (95% CI: 1.09–3.73; P < 0.025) remained a risk factor.ConclusionCMR plays an obvious role in phenotyping HF. Strain analysis, particularly left atrial and left ventricular strain analysis (LAGLS, LVGLS, and LVGCS) has good value in predicting adverse outcome events.

Serum Biomarkers and Their Association with Myocardial Function and Exercise Capacity in Cardiac Transthyretin Amyloidosis.

Transthyretin cardiac amyloidosis (ATTR amyloidosis) is a frequent etiology of heart failure. Inflammation and mineral metabolism are associated with myocardial dysfunction and clinical performance. Cardiac global longitudinal strain (GLS) allows function assessment and is associated with prognosis. Our aim was to describe possible correlations between GLS, biomarker levels and clinical performance in ATTR amyloidosis. Thirteen patients with ATTR amyloidosis were included. Clinical characteristics; echocardiographic features, including strain assessment and 6 min walk test (6MWT); and baseline inflammatory, mineral metabolism and cardiovascular biomarker levels were assessed. Of the 13 patients, 46.2% were women, and the mean age was 79 years. TAPSE correlated with NT-ProBNP (r -0.65, p < 0.05) and galectin-3 (r 0.76, p < 0.05); E/E' ratio correlated with hsCRP (r 0.58, p < 0.05). Left ventricular GLS was associated with NT-ProBNP (r 0.61, p < 0.05) (patients have a better prognosis if the strain value is more negative) and left atrial GLS with NT-ProBNP (r -0.73, p < 0.05) and MCP1 (r 0.55, p < 0.05). Right ventricular GLS was correlated with hsTnI (r 0.62, p < 0.05) and IL6 (r 0.881, p < 0.05). Klotho levels were correlated with 6MWT (r 0.57, p < 0.05). While inflammatory biomarkers were correlated with cardiac function, klotho levels were associated with clinical performance in the population with TTR-CA.

An Increase in the Left Atrium Volume During Exercise is Associated With a Positive Result of a Diastolic Stress Test in Patients With Arterial Hypertension.

To study the relationship between changes in left atrial volume (LAV) during exercise and the result of a diastolic stress test (DST) in patients with arterial hypertension (AH). The study included 219 patients with AH without ischemic heart disease and atrial fibrillation. During the DST performed before and after exercise, the ratio of transmitral flow velocity to mitral annular velocity (E/e'), the left atrial global longitudinal strain in the reservoir phase (reservoir strain), and LAV were determined. The criterion for a positive DST was an increase in E/e' ≥15. A positive result of DST was observed in 90 (41.1%) patients. Patients with positive DST were older (65.0 and 59.0 years); among them, there were fewer men (24.4 and 41.1%), but more patients with obesity (66.7 and 40.3%) and diabetes mellitus (36.7 and 8.5%). At rest, patients with positive DST had higher E/e' ratio (11.5 and 8.8), pulmonary artery systolic pressure (29.0 and 27.0 mm Hg), and LAV (60.0 and 52.0 ml), but a lower left atrial reservoir strain (20.0 and 24.0%). During exercise in patients with positive and negative DST, E/e' increased by 5.46 and 0.47 units, respectively. Changes in the LAV and reservoir strain during exercise in these groups were directed differently. In patients with positive DST, the left atrial reservoir strain decreased by 1.0 percentage points (pp) whereas in patients with negative DST, it increased by 8.0 pp. During exercise, the LAV increased by 10.0 ml in patients with a positive DST, whereas in the alternative group, the LAV decreased by 8.5 ml. The AUC for changes in LAV as an indicator of a positive DST was 0.987 while the AUC for the resting left atrial reservoir strain was 0.938. An increase in LAV &gt;1 ml, as an indicator of a positive DST has a sensitivity of 96.9% and a specificity of 95.1%. In AH patients, changes in left ventricular filling pressure are associated with a unidirectional change in LAV. An increase in LAV during exercise by more than 1 ml can serve as a criterion for a positive DST result. This assessment was consistent with the assessment of the DST result by the E/e' criterion &gt;15 in 94.5% of cases.

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.

Left atrial strain in adults after the arterial switch operation for transposition of the great arteries.

No study has focused on left atrial (LA) function assessed by echocardiography in adult patients with simple D-TGA after arterial switch operation (ASO). We aimed to describe LA strain parameters in these patients. A prospective cohort study including 42 adult patients with simple D-TGA after ASO and 33 aged-matched controls. Phasic LA and LV global longitudinal strain (GLS) were obtained by transthoracic 2D-speckle tracking echocardiography (STE). Volumetric and functional analysis of LA and LV were also evaluated by 2D and 3D analysis. A multivariable model was performed to investigate the variables that best differentiate patients with D-TGA from healthy controls. LA strain parameters in D-TGA patients were within the normal range described for healthy subjects. However, the three LA strain parameters (Reservoir, Conduit, and Contraction) were lower in patients (LASr: 31.13±7.67vs. 49.71±8.38; LAS cd: -22.91±5.69vs. -34.55±6.54; LASct: -8.14±4.93vs. -15.15±6.07, p<.001 for all three comparisons). LA volumes were similar between patients and controls. LV-GLS remained significantly lower in the D-TGA group than in controls (-17.29±2.68vs. -21.98±1.84, p<.001). D-TGA patients had evidence of worse LV ejection fraction measured by the Teichholz method (63.38±8.23vs. 69.28±5.92, p=.001) and 3D analysis (57.97%±4.16vs. 60.67±3.39, p=.011) and diastolic dysfunction as compared to healthy controls. LV-GLS and conduit LAS were the variables best differentiating patients with D-TGA from healthy controls. LA strain is impaired in young adults with simple D-TGA late after the ASO, probably in agreement with some degree of LV dysfunction previously described.

Spironolactone improves left atrial function and atrioventricular coupling in patients with resistant hypertension.

To determine the blood pressure independent effects of spironolactone on left atrial (LA) size and function in patients with resistant hypertension (RHTN). Patients with RHTN (n = 36, mean age 55 ± 7) were prospectively recruited. Spironolactone was initiated at 25mg/day and increased to 50mg/day after 4 weeks. Other antihypertensives were withdrawn to maintain constant blood pressure. Cardiac magnetic resonance imaging was performed at baseline and after 6 months of spironolactone treatment and changes in LA functional metrics were assessed. LA size and function parameters were improved (p < 0.05) from baseline to month-6: LA volumes indexed to body surface area (LAVI) were reduced (LAVImaximum 41.4±12 vs. 33.2±9.7 mL/m2; LAVIpre-A 32.6±9.8 vs. 25.6±8.1 mL/m2; median LAVIminimum 18.5 [13.9-24.8] vs. 14.1 [10.9-19.2] mL/m2); left atrioventricular coupling index was reduced (28.2±11.5 vs. 22.7±9.2%); LA emptying fractions (LAEF) were increased (median total LAEF 52.4 [48.7-60.3] vs. 55.9 [50.3-61.1] %; active LAEF 40.2±8.6 vs. 43.1±7.8%). LA global longitudinal strain in the active phase was increased (16.3±4.1 vs. 17.8±4.2%). The effect of spironolactone was similar in patients with high (N = 18) and normal (N = 18) aldosterone status (defined by plasma renin activity and 24-h urine aldosterone). Treatment of RHTN with spironolactone is associated with improvements in LA size and function, and atrioventricular coupling, regardless of whether aldosterone levels were normal or high at baseline. This study suggests the need for larger prospective studies examining effects of mineralocorticoid receptor antagonists on atrial function and atrioventricular coupling.

The value of TDI combined with myocardial strain parameters in quantitative evaluation of left heart function in parturient with pregnancy-induced hypertension

This study aimed to investigate the value of tissue doppler imaging (TDI) and 4D myocardial strain parameters in evaluating left heart function of pregnant women with hypertension and the association between these parameters and relevant factors. Forty-five pregnant women with hypertensive disorder, including 20 with hypertension, 15 with mild preeclampsia, and 10 with severe preeclampsia, were recruited, and their cardiac functions were compared with those of 30 healthy pregnant women as controls. High Left ventricular end-systolic volume (LVESV), Left atrial volume index (LAVI), E/e were observed in hypertensive disorder, while Mitral peak diastolic velocity(E), Early diastolic peak velocity(e), E/A, Left ventricularglobal longitudinal strain (LVGLS), Left ventricularglobal area strain (LVGAS), and Left atrialglobal longitudinal strain (LAGLS) were decreased; for pre-eclampsia, Left ventricular end-systolic diameter (LVESD), Left atrial anteroposterior diameter (LAD-ap), LVESV, LAVI were significantly increased, LVGLS, LAGLS were significantly decreased, Left ventricular end-diastolic diameter (LVEDD), Left ventricular end-diastolic volume (LVEDV), A peak, E/e were increased, while E peak, E/A, e, Left ventricle global radial strain (LVGRS), Left ventricle global circumferential strain (LVGCS), LVGAS were decreased but not significantly; for severe preeclampsia, Left ventricular end diastolic diameter (LVEDD), LVESD, LAD-ap, Left ventricular end-diastolic volume (LVEDV), LVESV, LAVI, A, and E/e were significantly increased, while LVGLS, LVGRS, LVGCS, LVGAS, LAGLS, E peak, E/A, and e were significantly reduced. TDI combined with 4D myocardial strain parameters can detect early changes in cardiac function of hypertensive disorders in pregnancy, with LVGLS, LVGAS, and LAGLS being the most sensitive indicators for early changes. Such findings provide a basis for effective clinical treatment of these symptoms.

Immediate, short-term, and long-term effects of balloon mitral valvuloplasty on the left atrial global longitudinal strain and its correlation to the outcomes in patients with severe rheumatic mitral stenosis

BackgroundLeft atrial global longitudinal strain (LA GLS) has been used as a new assessment tool for left atrial function. This article aims to investigate the effect of balloon mitral valvuloplasty (BMV) in patients with severe rheumatic mitral stenosis on LA GLS and its relation to the mitral valve area achieved after the procedure. The study included 95 patients with severe mitral stenosis who fulfilled the criteria for BMV (case group) and 80 normal healthy subjects (control group). All included participants underwent complete echocardiographic examinations. For the case group, LA GLS was assessed by 2D speckle-tracking Echocardiography before valvuloplasty, immediately after, within 24 h, at 6 months, and at 12 months, and the results were compared.ResultsThe impaired left-atrium strain in patients with severe mitral stenosis was improved immediately after BMV, and the improvement continued at 6 and 12 months post-BMV (23.1% ± 4.2 vs. 36.0% ± 4.9, 36.2% ± 4.5, and 40.1% ± 9.5, respectively p < 0.01). After BMV, there was a significant decrease in left atrial volume (76.3 ± 12.4 ml/m2 vs. 68.6 ± 10.4 ml/m2, p < 0.01) and a significant increase in the area occupied by the mitral valve (1.02 ± 0.18 cm2 vs. 1.60 ± 0.31 cm, p < 0.01). The immediate LA GLS and the mitral valve area were positively correlated (r = 0.64, p < 0.01). Furthermore, the immediate LA GLS was associated with significantly improved function class (p < 0.01).ConclusionsLA GLS can indicate left atrial (mainly reservoir) function. The improvement observed in patients after BMV may indicate that LA GLS can be used to evaluate the progress after BMV.Trial registration: The study was approved by the local ethics committee of the Faculty of Medicine in Minia University (Registration No. MUFMIRB 324-4-2022). Institutional Review Board, Faculty of Medicine, Minia University, Egypt. 324-4-2022, 24 18 April, 2022.

A comprehensive CMR analysis improves risk stratification in left ventricular noncompaction

Abstract Background Left ventricular noncompaction (LVNC) is a heterogeneous and controversial entity. Risk assessment by cardiovascular magnetic resonance (CMR) remains poorly defined. Purpose To develop a CMR prediction model of major adverse cardiovascular events (MACE) in LVNC. Methods We conducted a retrospective longitudinal multicentre cohort study of LVNC patients with core-lab CMR analysis. The endpoint was a composite of MACE: heart failure, ventricular arrhythmias, systemic embolisms and all-cause death. The effect of variables on the endpoint was analysed by Cox regression and variables were dichotomized according to their association with the outcome. Three sequential prediction models were developed: a "traditional model" based on LV ejection fraction (LVEF); a "clinical model" based on daily-practice CMR variables (e.g.: LVEF, right ventricular (RV) EF, and late gadolinium enhancement (LGE)); and a "research model" including advanced parameters (e.g.: global longitudinal strain (GLS) and hemodynamic forces (HDF)). The best prediction models were chosen based on C-statistic and Akaike information criterion (AIC). A risk score was developed based on the third model, and according to proportional hazard ratios. Results A total of 348 patients were included, age was 46 (19) years and 150 (43%) were female. LVEF was 48 (14) % and 32 (10%) had LGE. During a median follow-up of 3.9 (1.8-6.1) years, 54 (16%) patients developed MACE: 27 (8%) heart failure, 32 (9%) ventricular arrhythmias, 2 (1%) systemic embolisms and 6 (2%) deaths. Figure 1 shows the association of the main CMR variables with the endpoint. The "traditional model" (dichotomic LVEF with cut-off point at 40%) had an AUC of 0.71 (95% CI: 0.64-0.78). The best "clinical model" was a combination of LVEF, RVEF (cut-off point 35%), left atrium (LA) volume index (cut-off point 53 mL/m2) and percentage of LGE mass (LGE%, cut-off point 5%), with an AUC of 0.77 (95% CI: 0.70-0.85; p=0.006 compared to the first model). The best "research model" included LVEF, RVEF, LGE%, LA GLS (two cut-off points 17% and 28%), and lateral-septal HDF (cut-off point 3%), with an AUC of 0.85 (95% CI: 0.80-0.90; p=0.007 compared to the second model) (Figure 2a). Subsequently, a risk score was developed: 1 point was assigned to LVEF&amp;lt;40%, RVEF&amp;lt;35%, LGE% &amp;gt;5% and LA-GLS &amp;lt;28%, 2 points to LA-GLS &amp;lt;17% and 4 points to HDF&amp;lt;3%. The score was accurate at identifying both low- (0-4 points), intermediate- (5-7 points) and high-risk (8-9 points) patients (Figure 2b). Conclusions A comprehensive CMR evaluation in LVNC allows for precise risk stratification. Our proposed prediction model could be used to individualise patients’ management, which might improve long-term outcomes.CMR characteristics according to MACEPrediction models of MACE and risk score

Canagliflozin improves hemodynamic parameters by impedance cardiography and left ventricular diastolic function in patients with type 2 diabetes mellitus

Abstract Background Sodium-glucose cotransporter type 2 (SGLT2) inhibitors have been shown to reduce cardiovascular risk in patients with type 2 diabetes mellitus (T2DM) in large trials, independent of glycemic control. The mechanisms behind this cardioprotective effect remain uncertain, although evidence suggests that positive hemodynamic changes and favorable cardiac remodeling may contribute to the clinical outcomes. However, results have been conflicting. The aim of this study was to investigate the potential impact of canagliflozin on hemodynamic parameters, cardiac structure, and function. Methods This prospective observational study included T2DM patients receiving canagliflozin 100mg per day in addition to their antidiabetic treatment. We analyzed hemodynamic parameters assessed by impedance cardiography (ICG) and echocardiographic measurements to evaluate systolic and diastolic functions from baseline to 24 weeks after treatment. Results A total of 47 patients (25 males and 22 females) with an average age of 64.4±10.8 years experienced a significant reduction in HbA1c, hematocrit, body weight, and systolic blood pressure. NT-proBNP levels remained the same. ICG suggested significant improvement in hemodynamic parameters, with increased stroke volume index and cardiac output index and decreased systemic vascular resistance index at 12 and 24 weeks. E/e’, left atrial (LA) volume, and LA stiffness were reduced, while left ventricular (LV) global longitudinal strain (GLS) and LA strain rates increased at 24 weeks, as measured by conventional and speckle tracking echocardiography. LV mass and ejection fraction showed no differences. Conclusions Canagliflozin improved hemodynamic parameters and had a favorable impact on LA and LV reverse remodeling. These changes may explain the beneficial effect on cardiovascular outcomes seen in large clinical trials.

Advanced echocardiographic assessment in wild-type and hereditary transthyretin cardiac amyloidosis: the role of myocardial work and left atrial strain

Abstract Introduction Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive infiltrative cardiomyopathy caused by extracellular deposition of insoluble transthyretin (TTR) amyloid fibrils in the myocardium. ATTR-CA can be classified as wild type ATTR-CA (ATTRwt-CA), caused by age-related misfolding of TTR, and hereditary ATTR-CA (ATTRv-CA), an autosomal dominant disease in which gene mutations lead to changes in TTR protein. Speckle tracking echocardiography and myocardial work (MW) analysis can better characterize left ventricular and left atrial (LA) function in ATTRwt-CA and in ATTRv-CA. Aims to investigate differences in myocardial work and left atrial strain parameters between patients affected by ATTRwt-CA and patients affected by ATTRv-CA. Material and methods 40 male patients affected by ATTR-CA were prospectively enrolled, distinguishing between 20 patients with ATTRwt-CA (76 ± 7 yrs) and 20 patients with ATTRv-CA (74 ± 6 yrs) (1 pts with Val30Met mutation, 6 pts with Val122Ile mutation; 8 pts with Glu89Gln mutation; 5 pts with Phe64Leu mutation). All underwent a transthoracic echcoardiogram to calculate global longitudinal strain (GLS), MW parameters and LA strain. Results No difference was found between the two groups (ATTRwt-CA vs ATTRv-CA) for what regards age (76 ± 7 vs 74 ± 6 yrs, p = 0,06), BMI (27,2 ± 2,2 vs 26,6 kg/mq; p = 0,3), BSA (1,8 ± 0,2 vs 1,7 ± 0,1 mq; p = 0,1) and left ventricle mass index (LVMi) (183,41 ± 45,2 vs 148,5 ± 47,3 g/mq; p = 0,07). In ATTRwt-CA patients, ejection fraction (EF) is lower, but without any statistical significance (50 ± 6,9 vs 54 ± 6,4 %, p = 0,06). On the other hand, in ATTRwt-CA patients GLS is significantly higher than in ATTRv-CA patients (-9,8 ± 3,2 vs -15,0 ± 2,5 %; p &amp;lt; 0,0001). Global work index (GWI) (853,6 ± 367,6 vs 1431,6 ± 318,3 mmHg%; p &amp;lt; 0,0001), global constructive work (GCW) (1169 ± 303 vs 1726,5 ± 310,3 mmHg %; p &amp;lt; 0,0001) and global work efficiency (GWE) (83,2 ± 9,4 vs 89 ± 5,3 %; p = 0,04) are significantly reduced in ATTRwt-CA in comparison with ATTRv-CA. For what regards atrial function, in ATTwt-CA patients LA reservoir (9,7 ± 3,7 vs 17,6 ± 7,5 %; p = 0,004) and LA ejection fraction (LAFE) (28,9 ± 13,6 vs 46,2 ± 8,9; p = 0,02) are reduced, while LA booster is higher (-2,5 ± 3,1 vs -10 ± 4,7 %; p &amp;lt; 0, 0001). Conclusion In patients with ATTR-CA advanced echocardiographic assessment can better differentiate left atrial and left ventricular involvement in ATTRwt-CA versus ATTRv-CA.TablesGraphs

The assessment of left atrial and left atrial appendage mechanics in patients with different stages of atrial fibrillation

Abstract Background Atrial fibrillation (AF) is associated with left atrial (LA) mechanical dysfunction, which predisposes to stasis of blood within the LA and thus increases the risk of stroke. However, limited is known about the mechanical functional alterations of left atrial appendage (LAA) in relation to stages of AF. Here, we sought to analyse LA and LAA mechanics during different stages of AF in detail. Methods A total of 92 patients with AF referring for radiofrequency ablation were consecutively enrolled. Patients were categorized according to rhythm and stages of AF:sustained AF(SAF) (n=31), paroxysmal AF with sinus rhythm(PAF-SR)(n=30) andAF rhythm(PAF-AF)(n=31)at the time of echocardiography. Twenty-seven patients without a history of AF were included as controls. Using speckle-tracking echocardiography, LA and LAA global peak positive longitudinal strain (GLS) and mechanical dispersion (MD) were measured in all patients. Mechanical dispersion was defined as the standard deviation of the time to peak of the regional strain corrected by R-R interval. Results Patients with PAF-AF and SAF displayed prominently impaired LA and LAA mechanics(all P &amp;lt; 0.01 vs. PAF-SR and no AF). In the presence of SR, only LAA mechanical function were lower in PAF patients than patients without AF(LAA GLS 20.5±5.7%(no AF) vs 15.9±5.4%(PAF-SR); LAA MD 6.9±3.8%(no AF) vs 9.4±3.9(PAF-SR),both P&amp;lt;0.01). AF stages were independent determinants of LA and LAA mechanics after adjusting for age and comobidities. Conclusions AF affected mechanical function of LA and LAA on their own, and more so if stage of AF has advanced to more persistent forms. In addition, LAA mechanical dysfunction occurred earlier than that of LA.fig 1fig 2

Abstract 16239: Left Atrial Function by Speckle-Tracking Echocardiography in Mitral Valve Prolapse: Evidence of a Primary Atriopathy and Clinical Implications

Background: Prior studies support the prognostic role of left atrial (LA) volume in predicting overall mortality in mitral valve prolapse (MVP). However, the prognostic impact of LA function on cardiac outcome as quantified by speckle tracking echocardiography (STE) is unknown. Moreover, whether the mitral leaflet “atrialization” observed in bileaflet MVP with mitral annular disjunction (MAD) affects LA function irrespective of mitral regurgitation (MR) severity remains unclear. We sought to investigate the prognostic role of LA global longitudinal strain (LAGLS) and MVP subtype in a large registry of MVP patients with various degrees of MR. Methods: We identified 411 consecutive patients (59±17 years, 52% women) with MVP and clinical, echocardiographic and outcome data. LAGLS was measured offline using STE. Survival analysis was performed to assess the composite risk of cardiac death, heart failure hospitalization, or new onset of atrial fibrillation. Results: Compared to other MVP subtypes, bileaftlet MVP had lower LAGLS regardless of MR severity ( Fig 1A&amp;1B ). Of note, in the subgroup with no or mild MR, LAGLS was significantly lower in bileaflet compared to posterior MVP (p=0.003). There was a trend toward lower LAGLS according to MVP with vs without MAD (p=0.08) ( Fig 1C ). In multivariable linear regression adjusted for several risk factors, including MR grade, bileaflet MVP remained significantly associated with lower LAGLS (p=0.003). A total of 79 cardiovascular events occurred during a mean follow-up of 4.6±2.9 years. There was a significant increase in the risk of events as LAGLS decreased (log-rank: p&lt;0.001) ( Fig 1D ). Conclusion: Bileaflet MVP is associated with lower LAGLS regardless of MR severity, suggesting a primary atriopathy in this MVP subtype. Abnormal LAGLS is linked to higher risk of cardiovascular events. Hence, assessment of LA function using STE may help improve risk stratification in MVP and could represent a useful tool in clinical practice.

Immediate, short-term, and long-term effects of balloon mitral valvuloplasty on the left atrial global longitudinal strain and its correlation to the outcomes in patients with severe rheumatic mitral stenosis

Abstract Background Global longitudinal left atrial strain (GLS) has been used as a new assessment tool for left atrial function. Aim To investigate the effect of balloon mitral valvuloplasty (BMV) in patients with severe rheumatic mitral stenosis on GLS and its relation to the mitral valve area achieved after the procedure. Methods The study included 95 patients with severe mitral stenosis who fulfilled the criteria for BMV (case group) and 80 normal healthy subjects (control group). All included participants underwent complete echocardiographic examinations. For the case group, GLS was assessed by 2D speckle-tracking Echocardiography before valvuloplasty, immediately after, within 24 h, at 6 months, and at 12 months, and the results were compared. Results The impaired left-atrium strain in patients with severe mitral stenosis was improved immediately after BMV, and the improvement continued at 6 and 12 months post-BMV (23.1% ± 4.2 vs. 36.0 % ± 4.9, 36.2% ± 4.5, and 40.1% ± 9.5, respectively P &amp;lt; 0.01). After BMV, there was a significant decrease in left atrial volume (76.3 ± 12.4 mL/m2 vs. 68.6 ± 10.4 mL/m2, P &amp;lt; 0.01) and a significant increase in the area occupied by the mitral valve (1.02 ± 0.18 cm2 vs. 1.60 ± 0.31 cm, P &amp;lt; 0.01).The immediate GLS and the mitral valve area were positively correlated (r = 0.64, P &amp;lt; 0.01). Furthermore, the immediate GLS was associated with significantly improved function class (P &amp;lt; 0.01). Conclusion GLS can indicate left atrial function (mainly reservoir function). The improvement observed in patients after BMV may indicate that GLS can be used to evaluate the progress after BMV. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Comparison of left atrial and left atrial appendage mechanics in the recurrence of atrial fibrillation after radiofrequency catheter ablation.

Although radiofrequency catheter ablation (RFCA) has become an important treatment strategy for paroxysmal or persistent atrial fibrillation (AF), AF recurrence after RFCA remains an important issue that plagues clinicians and patients. This study aimed to investigate the association of left atrial (LA) and left atrial appendage (LAA) mechanics with AF recurrence after RFCA and to compare their prognostic values in patients with AF undergoing RFCA. A total of 160 patients with non-valvular AF who underwent RFCA for the first time were included in this study. All patients underwent transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) before the procedure. All patients were followed up for one year after RFCA, and AF recurrence was recorded. Speckle-tracking echocardiography was used to measure LA and LAA global longitudinal strain (GLS). LA and LAA mechanical dispersion (MD) were defined as the standard deviation of time to peak strain at each segment standardized by the R-R interval. Logistic regression analysis was used to analyze independent contributors for AF recurrence after RFCA. The prediction efficiency of factors associated with the presence of AF recurrence was evaluated by the receiver operating characteristic (ROC) curve with area under curve (AUC). During 1-year follow-up, 45 (28%) patients had recurrence, and 115 (72%) patients had no recurrence. The age, CHA2 DS2 -VASc score, NT-proBNP, LA volume index (LAVI), LA MD, and LAA MD of patients in recurrence group were significantly higher than those in no recurrent group (p<.05). The LAA emptying fraction (LAAEF), LA GLS, and LAA GLS in recurrence group were significantly lower than those in no recurrent group (p<.05). Logistic regression analysis showed that LA and LAA GLS were independent contributors for AF recurrence (p<.05), providing incremental values. The AUCs of LA and LAA GLS in predicting AF recurrence were higher than that of other factors, and the LA GLS+LAA GLS joint model had higher prediction efficiency. This study demonstrated the LA and LAA GLS were independent contributors for AF recurrence after RFCA and provided incremental values. LA and LAA GLS can be used as the predictor of AF recurrence after RFCA, and they may be beneficial for the risk stratification of AF recurrence.

Characterization of biatrial sports adaption in a large, highly trained athletes cohort using feature tracking cardiac magnetic resonance

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Project no. TKP2021-NKTA-46 has been implemented with the support provided by the Ministry of Innovation and Technology of Hungary from the National Research, Development and Innovation Fund, financed under the TKP2021-NKTA funding scheme. This project was also supported by a grant from the National Research, Development, and Innovation Office (NKFIH) of Hungary (K135076 to BM). Introduction Feature tracking strain analysis using cardiac magnetic resonance (CMR) imaging enables the appreciation of complex mechanics of the athlete’s heart without adding extra sequences and increasing image acquisition time. Purpose We evaluated the associations of the left (LA) and right atrial (RA) functional and strain parameters with sports activity and demographic characteristics in a large cohort of competitive athletes. We compared the athlete’s biatrial remodelling with healthy, sex-matched control subjects. Methods We performed a retrospective analysis on native CMR cine images acquired between 2009 and 2021. Standard two-chamber and four-chamber long-axis cine movies were analyzed using Medis Suite software. We excluded images with foreshortening or apparent planning flaw. Subjects were categorized into four groups based on their weekly training loads (&amp;lt;6 hours, 6-10 hours, 11-20 hours and 21&amp;lt; hours). Results We performed CMR on 510 subjects, of which 375 were highly trained athletes (median age 20 ys, IQR 16-25; 244 male). A group of 135 healthy volunteers [median (mdn) age 25 ys, IQR 23-28, 64 male] served as controls. Left atrial global longitudinal strain (GLS) was lower (p=.002) in athletes (mdn 41%) than in controls (mdn 43%), whereas RA GLS showed a more pronounced decrease (mdn 32% vs 43%, p&amp;lt;.0001). Between male athletes and controls, LA global circumferential strain [(GCS), mdn 40% vs 47%, p=.0001], LA conduit (mdn 26% vs 28%, p=.025), RA GLS (mdn 31% vs 38%, p&amp;lt;.0001), RA GCS (mdn 17% vs 20%, p=.024), RA booster (mdn 10% vs 9%, p&amp;lt;.001) and RA conduit (mdn 21% vs 24%, p=.001) strain values showed a difference. Between female athletes and controls, RA GLS (mdn 34% vs 44%, p&amp;lt;.0001), RA GCS (mdn 19% vs 29%, p&amp;lt;.001), RA booster (mdn 9% vs 13%, p=.006), and RA conduit (mdn 25% vs 32%, p&amp;lt;.001) were significantly different, while LA strain values were comparable. We found a significant difference between male and female athletes in terms of LA GLS (mdn 39%, vs 43%, p=.0001), LA GCS (mdn 40% vs 42%, p=.01) and LA conduit strain (mdn 26% vs 29%, p&amp;lt;.001). Regarding the right atrium, GLS (mdn 31% vs 34%, p=.047) and conduit strain (mdn 21% vs 25%, p=.004) were significantly lower in male athletes. LA GLS only differed between the lowest and highest training volumes (p=0.048). LA GCS was higher in the least trained group (p&amp;lt;.001) than in the other three categories. Interestingly, the LA end-diastolic volume index was less (r=0.13, p=0.008) correlated to weekly training volume than the left ventricular end-diastolic volume index (r=0.51, p&amp;lt;.0001). Conclusion The atrial adaptation of the athlete’s heart shows distinct mechanic properties, which are further stratified with exercise level and sex. The RA seems to be more prone to increasing exercise load than the LA. Sophisticated atrial function characterization by strain analysis might provide novel insight into healthy sports adaptation.

Impact of vein of Marshall ethanol infusion on left atrial function: an MRI study

Abstract Funding Acknowledgements Type of funding sources: None. Background Previous data suggested that left atrial (LA) function may be impaired by extensive atrial fibrillation (AF) ablation. Ethanol infusion of Vein of Marshall (EI-VOM) as an adjunctive therapy to pulmonary vein isolation is an emerging therapeutic strategy that has shown to improve efficacy in persistent AF ablation procedures and mitral isthmus line. The impact of EI-VOM scar formation on LA function has not been addressed. Purpose To analyse the effect of EI-VOM on LA function, evaluated by magnetic resonance imaging (MRI) strain parameters. Methods Twelve patients referred for de novo persistent AF or any repeat procedure were included. MRI was performed previous (baseline) and 3-month after AF ablation. MRI images were analyzed off-line with specialized post-processing software. LA volumes, LA strain parameters, including LA global longitudinal strain (GLS), LA reservoir (LASr), conduit (LAScd) and contractile (LASct) strain; LA ejection fraction (LAEF), LA passive emptying function (LAPEF) and LA active emptying function (LAAEF) were measured from SSFPs two-chamber cine sequences. Results Two patients were excluded due to absence of VOM and failed ethanolization. Ten patients (83%) underwent both MRI studies (64 [55-71]years; 80% men; de novo ablation of persistent AF (50%)). Six patients received additional mitral isthmus line and three posterior wall isolation. Mean baseline indexed LA volume was 62.7ml/m2 [47-73]. Baseline LA strain and EF parameters were: LA GLS 17.16±15.3, LASr 17.80±14.9%, LAScd -5.96±3.7%, LASct -10.35±9.5%; LAPEF 5.89±9.8, LAAEF 23.87±17.0 and LAEF 27.6±18.3%. At 3-months follow-up, no AF recurrences were detected. No differences were found regarding LA volume (57.6ml/m2 [42-64], p=0.671), strain parameters (LA GLS Δ0.62, p=0.903; LASr Δ0.02, p=0.991; LAScd Δ-0.84, p=0.563; LASct Δ0.54, p= 0.874) and LAEF parameters (LAPEF Δ4.82, p=0.592; LAAEF Δ3.03, p=0.903; and LAEF Δ7.0, p=0.213). Conclusions EI-VOM appears as a safe adjunctive strategy in AF ablation in terms of LA function. The present study did not show impairment in the main MRI strain parameters.

Right ventricle to pulmonary artery coupling after transcatheter aortic valve implantation-Determinant factors and prognostic impact.

Right ventricular (RV) dysfunction and pulmonary hypertension (PH) have been previously associated with unfavorable outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI), but little is known about the effect of right ventricle (RV) to pulmonary artery (PA) coupling. Our study aimed to evaluate the determinant factors and the prognostic value of RV-PA coupling in patients undergoing TAVI. One hundred sixty consecutive patients with severe AS were prospectively enrolled, between September 2018 and May 2020. They underwent a comprehensive echocardiogram before and 30 days after TAVI, including speckle tracking echocardiography (STE) for myocardial deformation analysis of the left ventricle (LV), left atrium (LA), and RV function. Complete data on myocardial deformation was available in 132 patients (76.6 ± 7.5 years, 52.5% men) who formed the final study population. The ratio of RV free wall longitudinal strain (RV-FWLS) to PA systolic pressure (PASP) was used as an estimate of RV-PA coupling. Patients were analyzed according to baseline RV-FWLS/PASP cut-off point, determined through time-dependent ROC curve analysis, as follows: normal RV-PA coupling group (RV-FWLS/PASP ≥0.63, n = 65) and impaired RV-PA coupling group (RV-FWLS/PASP < 0.63, n = 67). A significant improvement of RV-PA coupling was observed early after TAVI (0.75 ± 0.3 vs. 0.64 ± 0.3 before TAVI, p < 0.001), mainly due to PASP decrease (p < 0.001). LA global longitudinal strain (LA-GLS) is an independent predictor of RV-PA coupling impairment before and after TAVI (OR = 0.837, p < 0.001, OR = 0.848, p < 0.001, respectively), while RV diameter is an independent predictor of persistent RV-PA coupling impairment after TAVI (OR = 1.174, p = 0.002). Impaired RV-PA coupling was associated with a worse survival rate (66.3% vs. 94.9%, p-value < 0.001) and emerged as an independent predictor of mortality (HR = 5.97, CI = 1.44-24.8, p = 0.014) and of the composite endpoint of death and rehospitalization (HR = 4.14, CI = 1.37-12.5, p = 0.012). Our results confirm that relief of aortic valve obstruction has beneficial effects on the baseline RV-PA coupling, and they occur early after TAVI. Despite significant improvement in LV, LA, and RV function after TAVI, RV-PA coupling remains impaired in some patients, it is mainly related to persistent pulmonary hypertension and is associated with adverse outcomes.

Prognostic Role of Right Ventricular-Pulmonary Artery Coupling Assessed by TAPSE/PASP Ratio in Patients With Acute Heart Failure.

Right ventricular (RV) dysfunction is a significant risk of major adverse cardiac events in patients with acute heart failure (AHF). In this study, we evaluated RV-pulmonary artery (PA) coupling, assessed by tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) and assessed its prognostic significance, in AHF patients. We measured the TAPSE/PASP ratio and analyzed its correlations with other echocardiographic parameters. Additionally, we assessed its prognostic role in AHF patients. A total of 1147 patients were included in the analysis (575 men, aged 70.81 ± 13.56 years). TAPSE/PASP ratio exhibited significant correlations with left ventricular (LV) ejection fraction(r = 0.243, p < 0.001), left atrial (LA) diameter(r = -0.320, p < 0.001), left atrial global longitudinal strain (LAGLS, r = 0.496, p < 0.001), mitral E/E' ratio(r = -0.337, p < 0.001), and right ventricular fractional area change (RVFAC, r = 0.496, p < 0.001). During the median follow-up duration of 29.0 months, a total of 387 patients (33.7%) died. In the univariate analysis, PASP, TAPSE, and TAPSE/PASP ratio were significant predictors of mortality. After the multivariate analysis, TAPSE/PASP ratio remained a statistically significant parameter for all-cause mortality (hazard ratio [HR], 0.453; p = 0.037) after adjusting for other parameters. In the receiver operating curve analysis, the optimal cut-off level of TAPSE/PASP ratio for predicting mortality was 0.33 (area under the curve = 0.576, p < 0.001), with a sensitivity of 65% and a specificity of 47%. TAPSE/PASP ratio < 0.33 was associated with an increased risk of mortality after adjusting for other variables (HR, 1.306; p = 0.025). In AHF patients, TAPSE/PASP ratio demonstrated significant associations with RVFAC, LA diameter and LAGLS. Moreover, a decreased TAPSE/PASP ratio < 0.33 was identified as a poor prognostic factor for mortality.