Minimal Left Atrial Volume Research Articles

Abstract 17275: The SGLT2 Inhibitor Empagliflozin Ameliorates Left Atrial Dilatation in Non-Diabetic Patients With Heart Failure With Reduced Ejection Fraction: A Secondary Analysis of the EMPATROPISM Trial

Background: SGLT2 inhibitors (SGLT2i) improve prognosis in HFrEF patients. We recently demonstrated in a porcine model of non-diabetic HFrEF that empagliflozin (EMPA) ameliorates adverse cardiac remodeling and improves LV systolic function. However, the effect of EMPA on left atrial (LA) dilatation has not yet been studied Hypothesis:: Empagliflozin ameliorates left atrial dilatation in non-diabetic HFrEF patients Methods: The EMPATROPISM clinical trial investigated the efficacy and safety of EMPA in non-diabetic HFrEF patients. 84 patients were randomized to EMPA 10mg daily for 6 months or placebo on top of optimal medical treatment, and were evaluated with cardiac magnetic resonance (CMR). LA Volumes were quantified by CMR using the Simpson method (the number of slices in the usual short axis SSFP cine sequence was increased to cover both LV and the whole of LA. The primary endpoint was change in LVEDV. Prespecified secondary endpoints were changes in maximal and minimal LA volumes (ΔMax LA Vol and ΔMin LA Vol) at the end of 6 months between both arms Results: 80 patients completed the follow up period. There were no differences at baseline in LVEDV (220±75 vs 209±68mL for EMPA vs placebo, p=0.5) or LVEF (36±8 vs 37±8%, p=0.7). There were no differences at baseline in both groups in either maximal or minimal LA volume (Table). In the primary endpoint, EMPA-treated patients showed decrease in LVEDV and increase in LVEF (ΔLVEDV -25±25 vs -1±25mL, p<0.001; and ΔLVEF 6±4 vs 0±4%, p<0.001 for EMPA vs placebo). EMPA-treated patients exhibited a reduction of both maximal LA volume (ΔMax LA Vol -16.2±17.8 vs 11.4±25.9mL for EMPA vs placebo, p<0.001) and minimal LA volume (ΔMin LA Vol -11.3±13.3 vs 6.4±19.3mL for EMPA vs control, p<0.001) Conclusions: In HFrEF patients without diabetes, treatment with empagliflozin ameliorates left atrial dilatation. As LA volume is a surrogate for chronic filling pressures, this reduced LA volume suggest improved diastolic function with EMPA

Structural and functional atrial remodelling after transcatheter closure of patent foramen ovale

Abstract Introduction Patent foramen ovale (PFO) is a common abnormality affecting more than 20% of the adult population. For most people they are accidental findings; however, in some the PFO can open widely enabling paradoxical embolisation. Randomised controlled trials have demonstrated in patients with cryptogenic stroke that transcatheter closure of PFO with a septal occluder device is associated with reduced rates of recurrent stroke. However, the impact of atrial septal closure on left atrial (LA) and right atrial (RA) structural and functional remodelling is less known. Methods We prospectively enrolled 53 patients with cryptogenic ischemic stroke and PFO eligible for transcatheter PFO closure (mean age 46±11 years, 44% females). National Institute of Health Stroke Score (NIHSS), and the modified Rankin score (mRS) were calculated as markers of clinical severity of the index stroke. Presence of any shunt, atrial volumes and functional parameters were evaluated including LA reservoir, conduit and contraction function before PFO closure and 12 months after procedure. Beyond conventional transthoracic echocardiography (Philips Epiq CVx Ultrasound), two dimensional speckle tracking method was used to assess body surface area-indexed LA maximal volume (LAVmaxi), LA minimal volume (LAVmini), LA volume before left atrial contraction (LApreAi), LA ejection fraction (LAEF), LA reservoir strain (LASres), LA conduit strain (LAScond), LA contraction strain (LAScontr), LA peak systolic strain rates (LASRs), LA peak early diastolic strain rate (LASRe) and LA peak late diastolic strain rate (LASRa) using dedicated software on separate workstation (Cardiac Performance; TomTec Imaging, Unterschleissheim, Germany). Results The index stroke was modest and non-disabling, with an NIHSS 3.37±2.63 and mRS 1.67±1.06. Baseline LA, RA volumes and dimensions were in normal range (LAVi 25.5±9.6 ml/m2; LA length 37.6±6.2 mm; LA width 40.4±7.1 mm; RA length 36.6±6.7 mm; RA width 39.5±8.6 mm). Thirty-seven patient had 12 month clinical follow-up examinations revealing no significant differences (all p values >0.05) in atrial volumes, ejection fraction and strain parameters. LASRa was significantly lower after 12 month (p=0.03; baseline LASRa −1.7±0.7 s–1 vs follow-up LASRa −1.3±0.9 s–1) No new cerebral ischaemic events, aortic erosions, atrial fibrillation, significant residual shunts or device thrombosis and displacement were recorded during the follow-up. Conclusion PFO-associated strokes in young individuals are mainly non-disabling. Our study suggests that transcatheter interatrial closure is effective without promoting unfavourable atrial anatomical remodelling during short-term follow-up, however, it may affect active atrial contraction. Long-term follow-up examinations are needed to investigate the potential late impact of occluders on atrial anatomical, functional remodelling. Funding Acknowledgement Type of funding source: None

Genome-wide association study based on cardiac magnetic resonance imaging in 23,634 individuals identifies five new loci associated with left atrial enlargement

Abstract Left atrial enlargement is associated with mortality due to cardiovascular disease and all-cause mortality. The pathology behind and the association with cardiovascular outcomes are, however, poorly characterised. Compromised atrial function seems to predispose for stroke. We obtained data from the UK Biobank cardiovascular magnetic resonance (CMR) protocol containing CMR scans from ∼31,000 individuals at the time of study (Fig. 1a). Genome-wide association studies were carried out on state-of-the-art imaging variables exposed to machine learning algorithms to investigate the genetic basis of left atrial volume and function. Deep learning algorithms segmented the atria in the CMR scans (Fig. 1b). Left atrial (LA) volume curves could then be extracted and analysed (Fig. 1c). We tested 10.6 million variants for association with LA minimum/maximum volumes and LA emptying fraction (LAEF) in 23,624 European individuals without prevalent myocardial infarction or heart failure. We identified five genetic loci located in close proximity to the genes EIF2D, C9orf3, ANKRD1, FGFR2, and MYO18B. We observed a notable genetic correlation between both maximum and minimum LA volumes and stroke and cardioembolic stroke (Fig. 1d). Conclusions We report on five genetic loci and suggest several plausible candidate genes important for atrial structural pathology. Genetic correlation analyses indicate that the genetic determinants of LA volumes could be markers of stroke risk. These findings enhance our understanding of the importance of the LA and are potential novel therapeutic targets for cardiovascular disease, including stroke. Figure 1. LA imaging GWAS Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Novo Nordisk, Halles Moeller

Comparisons of Left Atrial Functional Parameters with Left Ventricular Diastolic Dysfunction in a Large Taiwanese Population with Normal Left Ventricular Ejection Fraction According to Age.

Recent studies have shown that left atrial (LA) volume is a sensitive morphophysiological indicator of the severity of LV dysfunction and may also be a useful index of cardiovascular risk. In this study, we performed comparisons among left atrial (LA) functional parameters for predicting age-related diastolic dysfunction. Echocardiography was performed in 2248 healthy participants with a low possibility of heart disease according to the decennium of age, and reference values were established. Progressive diastolic dysfunction paralleled increasing age and could be well identified by traditional and advanced echocardiographic parameters, including mitral inflow pattern, tissue Doppler parameters, and LA volume. Regarding LA functional parameters analyzed based on the decennium of age, left atrial ejection fraction (LAEF) and emptying fraction could not represent aging diastolic dysfunction well, but LA expansion index ((Volmax - Volmin) × 100% / Volmin) could. Volmax indicated maximal LA volume and Volmin indicated minimal LA volume. In assessments of diastolic dysfunction with receiver operating characteristic curve analysis, the best cut-off value of LA expansion index was < 100%, with an area under the curve (AUC) of 0.86, sensitivity of 80%, and specificity of 74%. LAEF < 30% (AUC 0.76, sensitivity 67%, specificity 70%) and LA emptying fraction < 50% (AUC 0.80, sensitivity 72%, specificity 71%) were also useful but performed less well. Compared with other LA functional parameters, LA expansion index can well represent age-related diastolic dysfunction.

Effect of beta-blocker-induced heart rate lowering on left atrial function in patients with hypertension and recurrent atrial fibrillation

Abstract Background The ESC/ESH Hypertension Guidelines identify high resting heart rate (HR) as a risk factor in patients with hypertension. However, it is not known, whether pharmacological reduction in HR is associated with improvement of prognosis in patients with preserved ejection fraction. In retrospective studies beta blockers (BBs) use was associated with impaired left atrial (LA) function in hypertension, but the prospective data, concerning this relationship is scarce. Purpose To assess the effects of HR reduction with BBs on LA function in hypertensive patients with recurrent (rare paroxysms) mild symptomatic atrial fibrillation. Methods Open prospective trial included 91 patients with hypertension, elevated heart rate (≥80 bpm) and recurrent atrial fibrillation (EHRA 2A or less) with rare paroxysms to receive BBs with a target HR (sinus rhythm) of less or greater than 70 bpm. All the patients underwent an echocardiogram at baseline and at the end of the study. Conventional echo measures and extended LA measures, including the minimal and maximal LA volumes (LAVmin and LAVmax) and LA emptying fraction (LAEF) were performed. Patients were followed for 4 months on the change and assessed for primary endpoint of median LAEF measurement at the end of the study. Results 47 patients were randomized to group with a target HR of ≤70 bpm and 44 patients to &amp;gt;70 bmp. Among them, 44 and 41 patients completed the study (2 had AF at the final visit; 4 were lost to follow-up). Baseline median HR was 77 (75; 80) bpm. After 4.4 months of treatment, median HR was 62 (60; 67) bmp in ≤70 group and 73 (72; 76) bpm in &amp;gt;70 group (p&amp;lt;0.001). There were no intergroup differences in antihypertensive therapy and systolic (129 vs 130 mmHg; p=0.32) and diastolic (78 vs 78 mmHg; p=0.53) blood pressure. At the end of the study patients in ≤70 group had significantly lower LAEF compared with &amp;gt;70 group (37 vs 42%; p=0.01); a median change was −6.5 (−9.75; −3.9)% and −0.27 (−1.78; 1.18)%, respectively [estimated between group difference −5.89%; 95% confidence interval (CI): −8.06 to −3.71%]. Despite similar indices of LAVmin (22 vs 19 ml/m2; p=0.66) and LAVmax (38 vs 37 ml/m2), comparison of changes showed significant differences: median change LAVmin: 1.3 ml/m2 in ≤70 vs 0.5 ml/m2 in &amp;gt;70 groups (estimated between group difference −1.29%; 95% CI: −2.07 to −0.5%) and ΔLAVmax: 1.8 ml/m2 in ≤70 vs 1 ml/m2 in &amp;gt;70 groups (estimated between group difference −1.51%; 95% CI: −2.73 to −0.28%). E/E' and left ventricle mass index did not differ between study groups at the end of the study, but E' was significantly lower in the ≤70 group (7 vs 8.3 cm/s; p=0.04). Conclusion BB-induced HR lowering with a target ≤70 bpm significantly reduced LA function as compared to lenient target HR (&amp;gt;70 bpm). Although elevated HR is associated with adverse outcomes in patients with hypertension, excess HR lowering with BBs might not be beneficial in this group. Funding Acknowledgement Type of funding source: None

Variation of Left Atrial Function in Different Stages of Mitral Regurgitation and Its Association With Guidelines-Based Surgical Indication.

The current guidelines associate indications for surgery in mitral regurgitation (MR) with left ventricle size and function. However, there is not enough emphasis in current guidelines on left atrial function, which is thought to be an important factor predicting adverse outcomes in MR. The aim of this study was to investigate the left atrial function at different stages of mitral regurgitation and its value in predicting the indications of mitral valve surgery. This was a retrospective study with 163 consecutive chronic primary MR patients who underwent color doppler echocardiography at the Guangxi Zhuang Autonomous Region Second People's Hospital between January 2016 and June 2018. All patients were in sinus rhythm, classified into three groups, according the degree of mitral regurgitation. Comparison was made with 30 control patients. Using Simpson's methods, we recorded maximal left atrial volume, left atrial volume before active contraction and minimal left atrial volume, from which left atrial expansion index, left atrial passive emptying fraction, left atrial active emptying fraction, and the total left atrial emptying fraction were derived. Left atrial volume was expanded and left atrial emptying fraction was reduced in the mitral regurgitation group. By multivariate analysis, left atrial passive emptying fraction and left atrial active emptying fraction were independent predictors of mitral regurgitation requiring surgery. Using receiver-operating characteristic analysis, left atrial passive emptying fraction <97.4% demonstrated 98% sensitivity and 67% specificity for predicting the presence of surgical indication (area under the curve: 0.91; P < .001). During mitral regurgitation, left atrial volume increases and functions decrease. The left atrial passive emptying fraction can be used as an additional tool to predict the indications of mitral valve surgery.

Electromechanical dissociation of left atrium in patients with Cardiac Amyloidosis by Magnetic Resonance: Prognostic and clinical correlates.

ObjectivesLeft atrial (LA) function is an important marker of hemodynamic status in cardiac amyloidosis (CA), and its characterization may provide relevant prognostic information. We sought to assess the prevalence and prognostic impact of LA dysfunction by cardiac magnetic resonance (CMR) in patients with CA.MethodsWe performed CMR in 80 consecutive patients with CA, including 38 with AL (47%) and 42 with ATTR (53%). LA function was assessed by acquiring short axis cine steady-state free precession (SSFP) covering the entire chamber. The atrial emptying fraction (AEF) was calculated as the ratio between the difference of LA maximal and minimal volume to LA maximal volume, expressed as percentage. Severe atrial dysfunction was defined as AEF ≤ 14%.ResultsMean AEF was 18% (13–35%). Overall, AEF ≤ 14% was present in 19 patients (24%), including 21% of those in sinus rhythm (SR) with no history of atrial fibrillation (AF). After a median of 3 years (IQR 2–4), 36 patients (44%) died of cardiac causes. Patients with AEF ≤ 14% showed increased cardiac mortality, with an independent OR of 4.2 (95 IC 2.1–8.2, P < 0.0001). Of note, AEF ≤ 14% was the stronger independent predictor of cardiac death. Patients in SR with AEF ≤ 14% had worse outcome than those with AF.ConclusionsSevere impairment of LA contractile function was present in three-quarters of patients with CA, and was prevalent irrespective of CA etiology, both in the presence and absence of AF. Severe LA dysfunction was associated with an independent 4-fold increase in risk for cardiac death at three years.

Differing mechanisms of atrial fibrillation in athletes and non-athletes: alterations in atrial structure and function.

Atrial fibrillation (AF) is more common in athletes and may be associated with adverse left atrial (LA) remodelling. We compared LA structure and function in athletes and non-athletes with and without AF. Individuals (144) were recruited from four groups (each n = 36): (i) endurance athletes with paroxysmal AF, (ii) endurance athletes without AF, (iii) non-athletes with paroxysmal AF, and (iv) non-athletic healthy controls. Detailed echocardiograms were performed. Athletes had 35% larger LA volumes and 51% larger left ventricular (LV) volumes vs. non-athletes. Non-athletes with AF had increased LA size compared with controls. LA/LV volume ratios were similar in both athlete groups and non-athlete controls, but LA volumes were differentially increased in non-athletes with AF. Diastolic function was impaired in non-athletes with AF vs. non-athletes without, while athletes with and without AF had normal diastolic function. Compared with non-AF athletes, athletes with AF had increased LA minimum volumes (22.6 ± 5.6 vs. 19.2 ± 6.7 mL/m2, P = 0.033), with reduced LA emptying fraction (0.49 ± 0.06 vs. 0.55 ± 0.12, P = 0.02), and LA expansion index (1.0 ± 0.3 vs. 1.2 ± 0.5, P = 0.03). LA reservoir and contractile strain were decreased in athletes and similar to non-athletes with AF. Functional associations differed between athletes and non-athletes with AF, suggesting different pathophysiological mechanisms. Diastolic dysfunction and reduced strain defined non-athletes with AF. Athletes had low atrial strain and those with AF had enlarged LA volumes and reduced atrial emptying, but preserved LV diastolic parameters. Thus, AF in athletes may be triggered by an atrial myopathy from exercise-induced haemodynamic stretch consequent to increased cardiac output.

Real time three-dimensional echocardiographic quantification of left atrial volume in orthotopic heart transplant recipients: Comparisons with cardiac magnetic resonance imaging.

The accuracy of real time three-dimensional echocardiography (RT-3DE) in evaluating left atrial volume (LAV) of heart transplant recipients against cardiac magnetic resonance (CMR) has not been reported. The aim of this study was to compare LAV with RT-3DE with respect to CMR in heart transplant recipients. Thirty-one heart transplant recipients who received echocardiogram and CMR examination on the same day were prospectively enrolled. The maximal LAV, minimal LAV by RT-3DE, and two-dimensional echocardiography (2DE) were compared with CMR measurements. Inter-technique comparisons included Pearson's correlation coefficient and Bland-Altman analysis. Reproducibility of 2DE and RT-3DE technique was assessed by intra-class correlation coefficient (ICC). RT-3DE-derived LAV values showed higher correlation with CMR than 2DE measurements in heart transplant recipients (r=.93 vs r=.76 for maximal LAV; r=.91 vs r=.81 for minimal LAV). Two-dimensional echocardiography underestimated maximal LAV by 10±31mL and minimal LAV by 26±26mL. Although RT-3DE underestimated minimal LAV 15±19mL, no significant difference between RT-3DE and CMR was observed in maximal LAV (RT-3DE: 86±22mL; CMR: 89±23mL, P=.079), with a negligible bias of 3mL. Inter-observer and intra-observer agreement were excellent for 2DE and RT-3DE parameters. Compared with CMR reference, RT-3DE-derived LAV measurements are more accurate than 2DE-based analysis in heart transplant recipients, especially with regard to the assessment of maximal LAV. RT-3DE may be a valid alternative to CMR for quantification LAV in heart transplant recipients.

Normal reference values of left atrial volumes and volume-based functional properties using three-dimensional speckle-tracking echocardiography in healthy adults (Insights from the MAGYAR-Healthy Study).

The present study was designed to define normal reference values of three-dimensional speckle-tracking echocardiography (3DSTE)-derived left atrial (LA) volumes, stroke volumes (SVs), and emptying fractions (EFs) with regard to the cardiac cycle. The present study involved 256 healthy adult subjects in sinus rhythm who underwent complete two-dimensional Doppler echocardiography and 3DSTE at the same time. However, due to inferior image quality, 87 subjects have been excluded. The remaining population sample comprised of 169 patients who gave informed consent to participate in the study. While systolic maximum LA volume and early diastolic preatrial contraction LA volume did not change over age decades, late-diastolic minimum LA volume decreased and was lowest in subjects aged 40 to 49 years then increased after 50 years. Total atrial EF increased over age decades with a reduction after 50 years. Passive atrial EF showed a significant continuous increase over age decades. Active atrial EF did not change in younger ages and was the highest between ages 40 and 49 years with a significant impairment after 50 years. This study shows the age- and gender-dependency of normal values of 3DSTE-derived LA volumes, stroke volumes, and emptying fractions with regard to the cardiac cycle in healthy adult subjects.

Left atrial volume changes assessed by real time 3-dimensional echocardiography in relation to liver function and prognosis in patients with cirrhosis.

Left atrial enlargement is a known marker of chronic diastolic dysfunction and was recently shown to be an independent predictor of mortality in cirrhosis. Real time 3-dimensional echocardiography (3DE) is an emerging modality that enables accurate measurements of the left atrial (LA) volume and function. Assessment of LA volumes with 3DE has never been applied in cases of cirrhosis. We therefore aimed to investigate LA volumes using the novel 3DE technique in relation to liver dysfunction and outcome in patients with cirrhosis. A prospective study of 47 cirrhotic patients without cardiovascular disease and ten healthy controls. The patients underwent clinical evaluation, blood sampling, liver vein catheterization, ECG and tissue Doppler echocardiography, including 3DE. Patients were followed up for a median of 25months with registration of death and liver transplantation (LT). 3DE-derived maximal left atrial volume index (LAVImax) and minimal left atrial volume index (LAVImin) were higher in patients with a Child Pugh score of 8 or higher than in patients with a score lower than 8 (30.0 vs. 22.3mL/m2, P=0.008 and 14.6 vs. 9.5mL/m2, P=0.04, respectively). LA volumes correlated with model for end-stage liver disease (MELD) score (r=0.40, P=0.005), hepatic venous pressure gradient (r=0.34, P=0.04), and biochemical markers of advanced liver disease. Twelve patients experienced the composite end-point of death or LT during follow-up and these patients had increased LA volumes with a higher LAVImax (34.3±14.8 vs. 25.9±7.3mL/m2, P=0.01) and a higher LAVImin (16.3±7.3 vs. 10.8±5.1mL/m2, P=0.007). Patients with advanced cirrhosis have increased minimal and maximal left atrial volumes, which correlate with the degree of the liver dysfunction and poor prognosis.

Real-time three-dimensional echocardiography predicts cardiotoxicity induced by postoperative chemotherapy in breast cancer patients.

BACKGROUNDThe anthracycline chemotherapeutic drugs are cardiotoxic. Studies have found some indicators related to cardiotoxicity. However, there is currently no accurate indicator that can predict cardiac toxicity early.AIMTo explore the diagnostic value of real-time three-dimensional echocardiography (RT3DE) in predicting cardiac toxicity in breast cancer patients undergoing chemotherapy.METHODSFemale breast cancer patients who underwent radical mastectomy and postoperative chemotherapy at the Affiliated Hanzhou First People’s Hospital, Zhejiang University School of Medicine were recruited. All patients were routinely administered with chemotherapy for four cycles (T1-T4) after surgery. Two-dimensional (2D) echocardiography, RT3DE, and serological examinations were performed after each cycle of chemotherapy. Patients were divided into a toxic group and a non-toxic group based on whether patients had Δ left ventricular ejection fraction > 10% after one year of chemotherapy. Repeated measurement analysis of variance was used to compare the changes in 2D echocardiographic indicators, serological indicators, and RT3DE indicators before and after chemotherapy. Multivariate logistic regression was used to identify independent predictive indicators for cardiac toxicity in postoperative chemotherapy patients. Receiver operating characteristics (ROC) curve analysis was performed to analyze the diagnostic value of potential indicators in the diagnosis of cardiotoxicity.RESULTSA total of 107 female breast cancer patients were included in the study. T4 maximum peak velocity in early diastole (E peak)/mitral annulus lateral tissue Doppler (e' peak) (E/e'), serological indicators [T4 cardiac troponin I (cTnI) and T4 pro-brain natriuretic peptide (Pro-BNP)], T3 minimum left atrial volume (LAV), T4 LAVmin, T3 LAV before the start of the P wave (LAVprep), and T4 LAVprep in the toxicity group were significantly higher than those in the non-toxic group. Multivariate logistic regression found that T4 cTnI, T4 Pro-BNP, T3 LAVmin, T4 LAVmin, T3 LAVprep, and T4 LAVprep had potential predictive value for cardiac toxicity (P < 0.05). ROC results showed that T4 LAVmin had the highest accuracy for diagnosing cardiac toxicity [area under the curve (AUC) = 0.947; sensitivity = 78.57%; specificity = 94.62%], followed by T4 LAVprep (AUC = 0.899; sensitivity = 100%; specificity = 66.67%). The accuracies of LAVprep and LAVprep in predicting cardiac toxicity were higher than those of T3 LAVmin and T3 LAVprep.CONCLUSIONRT3DE of left atrial volume can be used to predict the cardiotoxicity caused by chemotherapy, and it is expected to guide the clinical adjustment of dose and schedule in time.

Left Atrial Function Determined by Cardiac Computed Tomography Predicts Device-Detected Atrial High-Rate Episodes in Patients Treated With Cardiac Resynchronization Therapy.

The objective of this study was to examine whether left atrial (LA) volumes and function were associated with atrial high-rate episodes (AHREs) in patients with cardiac resynchronization therapy (CRT). Ninety-two consecutive patients without prior atrial fibrillation underwent clinical evaluation, echocardiograms, and cardiac computed tomography (CT) before CRT implantation and after 6 months. Left atrial volumes and LA emptying fraction (LAEF) were derived by CT images reconstructed at 5% phase increments of the cardiac cycle. Cox regression was used to assess associations between AHRE and LA anatomical and functional variables. Twenty-two patients (24%) developed AHRE during 1.9 years (SD, 1 year) At baseline, higher LAEF was associated with a lower risk of AHRE (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.91-0.98; P = 0.003), and large LA minimal (LAmin) volume was related to higher risk of AHRE (HR, 1.03; 95% CI, 1.00-1.06; P = 0.04). When combining LAEF and LAmin volume, only LAEF remained associated with occurrence of AHRE. Higher passive LAEF was associated with lower risk of AHRE (HR, 0.95; 95% CI, 0.91-0.98; P = 0.003). In patients with CRT, low preimplant LAEF measured by cardiac CT was independently associated with device-detected AHRE.

Impact of stand-alone minimally invasive radiofrequency ablation with left atrial appendectomy on left atrial function assessed by echocardiography.

Stand-alone minimally invasive radiofrequency (RF) ablation with left atrial (LA) appendectomy has been an effective surgical intervention for non-paroxysmal atrial fibrillation (AF) (NPAF) in patients with a medical history of thromboembolism for secondary stroke prevention. This study sought to assess the impact of this surgery on LA function. A total of 37 NPAF patients with a medical history of stroke or thromboembolism were enrolled in this prospective observational study, all of whom underwent stand-alone minimally RF ablation with LA appendectomy. Echocardiography was used to evaluate LA function preoperatively and 1 week and 3 months postoperatively. All patients were divided into two groups (Group AF and Group SR) according to whether sinus rhythm (SR) was restored after the surgery. The surgery had no impact on LA function in Group AF. Once NPAF patients were restored to SR, LA minimal volume (LAVmin) decreased immediately compared with pre-operation (22.98±13.76 vs. 17.68±9.52 mL; P<0.05) and consequently LA reservoir function increased, including LAEF (37.69%±12.53% vs. 46.71%±8.53%, P<0.05) and LAEI (66.54%±34.39% vs. 92.15%±31.37%, P<0.05). PA-TDI of Group SR, indicating LA electromechanical coupling, were improved at three months of follow-up because of atrial stunning after the surgery (160.55±26.19 vs. 143.82±20.923 ms, P<0.05). LA contractile function was also improved at three months of follow-up (A-TVI: 2.95±1.16 vs. 5.10±1.85 cm, P<0.05). Stand-alone minimal invasive RF ablation with LA appendectomy had no impact on LA function in AF patients who could not be restored to SR. However, once AF patients were restored to SR after the surgery, LA function could recover better. Meanwhile, thromboembolic events could also be reduced after the surgery.

Assessment of left atrial volume and function in patients with Sjögren's syndrome using three-dimensional echocardiography.

We used real time, three-dimensional transthoracic echocardiography (3DTTE) to evaluate left atrial (LA) volume and mechanical function in patients with primary Sjögren's syndrome (SS). We prospectively included 42 consecutive patients with primary SS and 42 controls who were similar in terms of basal characteristics. 3DTTE was used to assess LA function. Maximum LA volume, minimum LA volume, pre-atrial contraction LA volume, LA Active Stroke Volume (ASV), LA Total Stroke Volume (TSV), maximal left atrial volume index (LAVImax), Left atrial pre-contraction volume index, and Left atrial minimum volume index, ASV index, and TSV index were significantly higher in the SS group, and the LA Total Emptying Fraction, LA Expansion Index, and LA Passive Emptying Fraction were significantly lower. Although the active emptying fraction was higher in the SS group, the difference was not statistically significant. LAVImax was positive correlated with disease duration (r=.753). Left atrial function is impaired in SS patients and serves as an early marker of subclinical cardiac involvement.

Left atrial volume and function assessed by cardiac magnetic resonance imaging are markers of subclinical atrial fibrillation as detected by continuous monitoring.

We aimed to investigate whether left atrial (LA) markers from cardiovascular magnetic resonance (CMR) were able to predict atrial fibrillation (AF) in elderly patients with risk factors for stroke. At baseline, 203 participants with stroke risk factors but without history of AF underwent advanced CMR and received an implantable loop recorder. During a median of 40 (37-42) months of continuous monitoring, incident AF was detected in 79 patients (39%). With regards to CMR markers, a steep increase in incidence rate of AF was seen with LA maximum volume (LAmax) above 55 mL/m2, LA minimum volume (LAmin) above 30 mL/m2, LA total emptying fraction (LA TEF) below 45%, LA active emptying fraction (LA AEF) below 37%, LA strain S below 25%, LA strain A below 17%, and LA strain rate A above -1.7 s-1. After multivariate adjustment, the above-mentioned CMR markers remained associated with AF incidence: hazard ratio (95% confidence interval) 1.25 (1.06-1.48) and 1.51 (1.22-1.87) per 10 mL/m2 increase of LAmax and LAmin, respectively, 1.49 (1.26-1.76) and 1.46 CI (1.25-1.71) per 5% decrease in LA TEF and LA AEF, respectively, 1.23 (1.05-1.44) and 1.56 (1.18-2.06) per 5% decrease in LA strain S and A, respectively, and 2.06 (1.31-3.23) per s-1 increase in LA strain rate A. In prediction analyses, LA functional indices increased area under the receiver operating characteristic curve significantly. The risk of AF, including asymptomatic AF, increases significantly with increasing LA volumes and worsening LA function.

LEFT ATRIAL STRUCTURE AND FUNCTION OF THE AMYLOIDOGENIC V122I TRANSTHYRETIN VARIANT IN ELDERLY AFRICAN AMERICANS

AIMS African-American carriers of the transthyretin (TTR) valine-to-isoleucine substitution (V122I) are at increased risk of heart failure, yet many have relatively subtle abnormalities of left ventricular (LV) function. We sought to explore the influence of this mutation on left atrial (LA) structure and function in this population. METHODS AND RESULTS We assessed 1225 genotyped African-Americans (age range, 67-89 years) participating in the Atherosclerosis Risk in Communities study who underwent echocardiography and were in sinus rhythm at study Visit 5 (2011 to 2013). Six LA parameters [LA maximum/minimum volume index, ejection fraction, and LA reservoir, conduit, and contractile longitudinal strains (LS)] were compared between V122I TTR variant carriers (n = 46) and non-carriers (n = 1179). LA minimum volume index was significantly greater and LA contractile LS was worse in carriers than non-carriers (19.5 ± 10.6 mL/m2 vs. 16.3 ± 8.4 mL/m2 ; 15.0 ± 5.8% vs. 16.8 ± 5.7%, respectively, both P < 0.05). Carriers had a significantly higher number of LA abnormalities than non-carriers (1.8 ± 2.2 vs. 1.1 ± 1.6, P = 0.009). The number of subjects with at least four LA abnormalities was significantly increased among carriers compared with non-carriers (27% vs. 12%; odds ratio 2.43; 95% confidence interval 1.06-5.58 after adjusting for age, sex, body mass index, and LV wall thickness and global LS). CONCLUSIONS Left atrial enlargement and dysfunction were common in V122I TTR carriers with sinus rhythm than non-carriers, suggesting that abnormalities of LA function may represent early markers of subclinical disease in these individuals.

Incremental value of three-dimensional echocardiography for evaluating left atrial function in patients with coronary slow flow phenomenon: a case control study

BackgroundCoronary slow flow phenomenon (CSFP) involves the delayed opacification of the coronary distal vessel, in the absence of an obstructive lesion in the epicardial coronary artery during angiography. Since the link between left atrial (LA) function and decreased left ventricular function is still unclear, we evaluated LA function using real-time three-dimensional echocardiography (RT3DE) in patients with CSFP, and subsequently determined the incremental value of RT3DE.MethodsThis study enrolled 60 patients with CSFP and 45 control subjects. CSFP was diagnosed based on thrombolysis in myocardial infarction frame count (TFC). The LA phasic volume and function was evaluated by both two-dimensional echocardiography (2DE) and RT3DE.ResultsThe LA maximal volume (Volmax), pre-systolic volume (Volp), and minimal volume (Volmin) increased, but LA total and active ejection fraction decreased in patients with CSFP. Based on our results, Volmax, Volp, Volmin, and LA total and active ejection fraction correlated with TFC, and with the number of arteries involved. The LA total ejection fraction by RT3DE was the only independent predictor for CSFP (odds ratio, 0.64 [95% confidence interval, 0.49–0.83]; P = 0.001). Also, the LA total ejection fraction by RT3DE demonstrated good predictive power for CSFP, with a cut-off value of 54.15% (area under curve, 0.85; sensitivity, 84%; specificity, 83%).ConclusionsThe LA reservoir and contractile function decreased in the patients with CSFP and correlated with coronary flow rate and with the number of arteries involved. The LA total ejection fraction by RT3DE can independently predict CSFP, and RT3DE demonstrated incremental value for evaluating LA phasic function in the patients with CSFP compared to 2DE.

Sex differences and higher upper normal limits for left atrial end-systolic volume in individuals in their mid-60s: data from the ACE 1950 Study.

The current study aimed to describe normal values of left atrial (LA) volumes and LA emptying fraction (LAEF) in a large sample in their mid-60s from the general population and to explore sex differences. In the Akershus Cardiac Examination (ACE) 1950 Study, body surface area-indexed LA maximum (LAVimax) and minimum (LAVimin) volumes and LAEF were measured in 3489 individuals aged 63.9 ± 0.6 years from the general population. A healthy group of 832 individuals was defined. Data are presented as mean ± standard deviation (SD) and a normal range of mean ± 2 SD. T-tests were used for comparisons. In the healthy group, mean LAVimax was 25.5 ± 6.2 mL/m2 and the normal range was 13.1-37.9 mL/m2. Men had significantly larger body surface area-indexed volumes than women, but there was no difference in LAEF. The mean LAVimax for healthy men was 26.4 ± 6.5 mL/m2, for healthy women 24.9 ± 5.8 mL/m2 (P < 0.001) and the upper normal limits were 39.4 and 36.5 mL/m2, respectively. In the healthy group, 13.0% of all men and 5.4% of all women had LAVimax above the current upper normal limit of 34 mL/m2. A large proportion of healthy individuals, in particular men, had LAVimax >34 mL/m2. Our findings suggest that the recommended cut-off may be too low at the age of 65 years and above and that sex-specific cut-offs should be considered.

Atrial premature activity detected after an ischaemic stroke unveils atrial myopathy

Recent publications suggest that left atrial (LA) myopathy is a potential source of thromboembolism, independent of atrial fibrillation. We sought to investigate whether the presence of atrial premature activity after an ischaemic stroke is associated with LA remodelling and dysfunction, and might be a surrogate marker of LA myopathy. After an ischaemic stroke or a transient ischaemic attack, patients without known atrial fibrillation or overt heart disease were included prospectively in the study. All patients had a standard workup, including ambulatory Holter electrocardiogram monitoring and transthoracic echocardiography. In some patients, transoesophageal echocardiography was also performed. Anatomical and functional LA remodelling were assessed using minimal and maximal volumes and LA emptying fraction in two-dimensional and three-dimensional echocardiography. Patients were separated into two groups according to the burden of atrial premature complexes (APCs), measured by Holter electrocardiography. Among 148 eligible patients recruited from October 2015 to May 2016, 93 were included in the group with non-frequent APCs (nf-APC:<100 APCs/24hours) and 43 in the group with frequent APCs (f-APC:>100 APCs/24hours). Twelve patients had paroxysmal atrial fibrillation, and were not included in the statistical analysis. Maximal and minimal indexed LA volumes were significantly higher in the f-APC group than in the nf-APC group (P<0.01). LA emptying fraction was worse in the f-APC group than in the nf-APC group. In addition, LA appendage emptying velocity was impaired in the f-APC group, and was correlated with LA remodelling variables, especially LA emptying fraction (r=0.621). After an ischaemic stroke or a transient ischaemic attack, excessive APCs are associated with LA remodelling. Thus, LA dilatation and dysfunction reflect early LA myopathy, which might itself be responsible for cardioembolic stroke.