Left Atrial Phasic Function Research Articles

Myocardial strain overrules left ventricular ejection fraction and late gadolinium enhancement extent in predicting MACE in CMR-proven acute myocarditis

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac magnetic resonance (CMR) plays a major role in both the diagnostic process and prognostic stratification in acute myocarditis. Presence of late gadolinium enhancement (LGE) and left ventricular (LV) ejection fraction (EF) are known predictors of major adverse cardiovascular events (MACE). However, in daily clinical practice it remains challenging to distinguish ‘the good from the bad’. The prognostic value of CMR feature tracking (FT) derived strain, with respect to LGE and LVEF, remains unclear. Purpose To evaluate the incremental prognostic value of left atrial (LA) phasic function, LV and right ventricular (RV) strain using CMR-FT in patients with CMR-proven acute myocarditis. Methods In this multicenter observational study, patients with CMR-proven acute myocarditis were included and followed with regard to MACE including all-cause mortality (ACM), heart-failure hospitalizations (HFH), and life-threatening arrhythmias (LTA). Using FT-derived strain, LV global longitudinal strain (GLS), circumferential strain (GCS), and radial strain (GRS), RV GLS and LA phasic function were measured. Uni- and multivariable analysis including clinical and CMR parameters were performed to assess the association with MACE. Results A total of 162 patients were included (75% male, 41 ±17 years). MACE occurred in 29 patients (18%, ACM n = 18, HFH n = 7, LTA n = 11) during a median follow-up of 5.5 (2.2-8.3) years. Forty-six percent had a STEMI-like presentation (combination of chest pain, elevated troponin, and ST-elevation, n = 74). LGE was present in 90% of patients and mean LVEF was 51 ± 12%. Patients with LVEF <50% had a significantly worse prognosis compared to patients with LVEF ≥50% (p < 0.0001, Figure A). When we categorized the study population into subgroups of quartile values of LV GLS, patients with LV GLS worse than 18% had a significant worse outcome compared to the other subgroups (p < 0.05, Figure B). Subgroups of LGE extent did not show significantly different associations with outcome (p = 0.458, Figure C). Cox regression analysis showed that LV strain and LA phasic function were univariably associated with MACE, whereas RV GLS and LGE extent were not. All univariable associated strain parameters were separately included in a multivariable model, including age, sex, STEMI-like presentation, and LVEF. LV GLS (HR 1.08, p = 0.01), LV GCS (HR 1.15, p = 0.02), and LV GRS (HR 0.98, p = 0.02) were independent predictors of MACE. Conclusions LV strain parameters are independent and incremental predictors of prognosis in patients with acute myocarditis, while RV strain and LA phasic function are not. Therefore, LV strain is a promising novel parameter for risk stratification in acute myocarditis.

Left atrial morpho-functional changes in hypertrophic cardiomyopathy and Fabry disease: a CMR-feature tracking study

Abstract Funding Acknowledgements Type of funding sources: None. Background Left ventricular (LV) diastolic dysfunction (DD) is a hallmark of hypertrophic cardiomyopathy (HCM) and its phenocopies, such as Fabry disease (FD). Together with left atrial (LA) size, LA function is emerging as a sensitive marker of the adaptive changes to backward transmission of LV cardiac filling pressure, thus implementing DD assessment. Additionally, both HCM and FD are characterized by a primitive atrial myopathy, but LA morpho-functional changes in HCM and FD have never been directly compared. More recently, LA strain by Cardiovascular Magnetic Resonance Feature Tracking (CMR-FT) has been demonstrated to be a feasible and reproducible tool to explore LA function. Purpose To compare LA morpho-functional changes in HCM and FD and to explore their correlation with tissue alterations. Methods 15 HCM and 15 sex-, age- and LV mass index-matched FD patients underwent CMR (Magnetom Aera 1.5T, Siemens) and Doppler Echocardiography for LV diastolic function assessment (E/e’ and DD grading from 0 to 3). LA phasic function was evaluated by CMR-FT strain (Qstrain Medis). The software output included passive (εe, conduit function), active (εa, booster pump function) and total strain (εs, reservoir function), along with LA volumes and ejection fraction (EF). Late gadolinium enhancement (LGE) was quantified as a percentage of LV mass using the standard deviations (SDs) method (≥ 5 SDs). Interstitial fibrosis was assessed by extracellular volume (ECV) quantification in remote myocardium. All patients were in sinus rhythm. Results In the HCM group, the proportion of patients with DD grade 2-3 was only slightly higher than in FD (p 0.26). Accordingly, no significant difference was found in E/e’ value (p 0.78). Compared to FD, HCM patients showed more severe LA morpho-functional changes, including larger LA end-systolic volume (ESV) (113 ± 35 vs 84 ± 23 ml), lower LA EF (37 ± 7 vs 44 ± 9 %) and a greater reduction of εs (-20 ± 5 vs -25 ± 6 %) and εa (-10 ± 4 vs -15 ± 4 %) (all p < 0.05). LV size and function and the burden of fibrosis (LGE quantification and ECV) were comparable between the two groups. Interestingly, in HCM population, unlike in FD, LA morpho-functional measurements significantly correlated with tissue characterization parameters (LA ESV with LGE, r 0.56, p 0.03; εs and εa with ECV, r -0.51, p 0.05 and r -0.59, p 0.02, respectively). Conclusions LA morpho-functional alterations are much more severe in HCM compared to FD with similar degree of LV hypertrophy. A more severe atrial myopathy or different mechanisms of atrial damage in the two cardiomyopathies may explain these findings. LA CMR-FT analysis may represent a sensitive tool to discriminate between HCM and FD, although larger studies are needed to confirm this finding and the possible correlation with the occurrence of atrial arrhythmias and thromboembolic risk.

Impaired left atrial reservoir and conduit strain in patients with atrial fibrillation and extensive fibrosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is associated with profound structural and functional changes in the atria. Timely interventions may decelerate and perhaps reverse this pathophysiologic process and improve clinical outcome. In this regard, detailed characterization of the atrial remodeling process, and understanding of the interplay between structural remodeling and function is essential. Purpose In the present study, we investigated the association between left atrial (LA) phasic function and the extent of LA fibrosis using advanced cardiovascular magnetic resonance (CMR) imaging techniques, including 3-dimensional (3D) late gadolinium enhancement (LGE) and Feature Tracking. Methods Patients with paroxysmal and persistent AF (n = 93) underwent CMR in sinus rhythm. LA global reservoir strain, conduit strain and contractile strain were derived from cine CMR images using Feature Tracking. The extent of LA fibrosis was assessed from 3D LGE images. Healthy volunteers underwent CMR and served as controls (n = 19). Results Significantly lower reservoir strain, conduit strain and contractile strain were found in AF patients, as compared to controls (-15.7 ± 3.9% vs. -21.1 ± 3.6% P < 0.001, -8.6 ± 2.9% vs. -12.6 ± 2.5% P < 0.001 and -7.1 ± 2.4% vs. -8.6 ± 2.2% P = 0.02, respectively) (Figure A, B, C). Patients with a high degree of LA fibrosis (dichotomized by the median value) had lower reservoir strain and conduit strain compared to patients with a low degree of LA fibrosis (-14.7 ± 4.0% vs. -16.8 ± 3.5%, P = 0.02 and -7.7 ± 2.7% vs. -9.5 ± 2.9%, P < 0.01, respectively). In contrast, no difference was found for LA contractile strain (-7.0 ± 2.3% vs. -7.3 ± 2.5%, P = 0.62) (Figure D, E, F). Conclusions This study shows impaired LA reservoir and conduit strain in AF patients with extensive atrial fibrosis. Of interest, LA contractile function was largely unaffected. Future studies are required to study the biologic nature of this association and possible therapeutic implications. Abstract Figure.

Four-Dimensional Echocardiographic Volumetric and Functional Assessment of the Left Atrium in Healthy Male Subjects in Relation to Age

Background: Four-dimensional echocardiography technique results in marked improvements in terms of quality and accuracy in assessing the size and function of heart chambers, especially the left atrium as its geometric variation has a notable impact on the results when using traditional echocardiographic techniques alone. Thus, this study aimed at investigating the probability of significant functional and morphological changes in the left atrium with advancing age using Four-dimension echocardiography. Method: Four-dimensional technique derived left atrial phasic volumes and functions were assessed in (30) healthy subjects with mean age of 73.6 (±3.6) years and (30) young subjects with mean age of 23.17 (±3.5) years. Results: Old age group showed a significant increase in maximum left atrial volume index, minimum left atrial volume index and pre-atrial contraction left atrial volume index compared to young age group (31.52±1.09 vs. 26.44±1.03, P < 0.001), (17.93±0.43 vs. 15.89±0.44, P < 0.00) and (25.73±1.003 vs. 22.34±0.77, P < 0.01), respectively. In the old age group, the passive left atrial emptying function (LAEF) significantly decreased (20.43±0.25% vs. 24.96±0.93%, p

Left atrial conduit function modulates right ventricular afterload, exercise capacity and survival in heart failure patients.

To assess if left atrial phasic function characteristics modulate functional capacity/survival by impacting on the pulsatile component of right ventricular (RV) afterload, as represented by pulmonary arterial compliance (PAC). Sixty heart failure patients (67 ± 11 years, ejection fraction 39 ± 11%, range 20--62%) underwent 6 min walk test (6MWT) and 3D transthoracic echocardiography. Left atrial conduit was computed off-line, gathering simultaneous real-time 3D multibeats (six cycles) left atrial and left ventricular (LV) volume curves, with conduit (time) = [LV (time) - LV minimum volume] - [left atrial maximum volume - left atrial (time)], expressed as % LV stroke volume. Atrial stiffness (Kla) was computed using noninvasively assessed wedge pressure divided by left atrial reservoir (maximum - minimum) volume. PAC was obtained as ratio between RV stroke volume, obtained as pulsed Doppler RV outflow tract envelope∗cross-sectional area, and pulmonary pulse pressure, obtained by transforming tricuspid regurgitant velocity in millimetres of mercury and considering diastolic pulmonary as a fixed fraction of systolic pressure. Conduit averaged 34 ± 12%, PAC 3.1 ± 1.1 ml/mmHg, 6MWT 404 ± 154 m. Conduit was independent of LV volumes and ejection fraction, showing a direct dependence on noninvasive Kla (r = 0.56; P < 0.001). Dividing patients into tertiles according to 6MWT and to PAC, the largest conduit fraction was associated with the lowest functional capacity (P < 0.001) and most deranged PAC (P < 0.001), respectively, suggesting outmost RV haemodynamic burden. Tertiles of conduit predicted survival (P = 0.01). Conduit depends on noninvasively assessed Kla and appears to be increased in heart failure patients with lowest capacity and worst survival, likely as RV pulsatile afterload, as reflected by PAC, is highest in these individuals.

Left atrial phasic transport function closely correlates with fibrotic and arrhythmogenic atrial tissue degeneration in atrial fibrillation patients: cardiac magnetic resonance feature tracking and voltage mapping.

To characterize the association of phasic left atrial (LA) transport function and LA fibrosis guided by multimodality imaging containing cardiac magnetic resonance imaging (CMR) feature tracking and bipolar voltage mapping. Consecutive patients presenting for first-time ablation of atrial fibrillation (AF) were prospectively enrolled. Each patient underwent CMR prior to the ablation procedure. LA phasic indexed volumes (LA-Vi) and emptying fractions (LA-EF) were calculated and CMR feature tracking guided LA wall motion analysis was performed. LA bipolar voltage mapping was carried out in sinus rhythm to find areas of low voltage as a surrogate for fibrosis and arrhythmogenesis. One hundred and sixty-eight patients were enrolled. Low-voltage areas (LVAs) were present in 70 patients (42%). Contrary to LA volume, CMR based LA-EF [odds ratio (OR) 0.88, 95% confidence interval (CI) 0.80-0.96, P = 0.005] and LA booster pump strain rate (SR) (OR 0.98, 95% CI 0.97-0.99, P = 0.001) significantly predicted presence and extent of LVA in multivariate logistic regression analysis for patients scanned in SR. In receiver operating characteristic analysis, LA-EF <40% carried a sensitivity of 83% and specificity of 76% (area under the curve 0.8; 95% CI 0.71-0.89) to predict presence of LVA. For patients scanned in AF only minimal LA-Vi on CMR (OR: 1.06; 95% CI: 1.02-1.10; P = 0.002) predicted presence of LVA. For patients scanned in SR LA-EF and LA booster pump SR are closely linked to the presence and extent of LA LVA.

Impaired left atrial reservoir and conduit strain in patients with atrial fibrillation and extensive left atrial fibrosis

BackgroundAtrial fibrillation (AF) is associated with profound structural and functional changes in the atria. In the present study, we investigated the association between left atrial (LA) phasic function and the extent of LA fibrosis using advanced cardiovascular magnetic resonance (CMR) imaging techniques, including 3-dimensional (3D) late gadolinium enhancement (LGE) and feature tracking.MethodsPatients with paroxysmal and persistent AF (n = 105) underwent CMR in sinus rhythm. LA global reservoir strain, conduit strain and contractile strain were derived from cine CMR images using CMR feature tracking. The extent of LA fibrosis was assessed from 3D LGE images. Healthy subjects underwent CMR and served as controls (n = 19).ResultsSignificantly lower LA reservoir strain, conduit strain and contractile strain were found in AF patients, as compared to healthy controls (− 15.9 ± 3.8% vs. − 21.1 ± 3.6% P < 0.001, − 8.7 ± 2.7% vs. − 12.6 ± 2.5% P < 0.001 and − 7.2 ± 2.3% vs. − 8.6 ± 2.2% P = 0.02, respectively). Patients with a high degree of LA fibrosis (dichotomized by the median value) had lower reservoir strain and conduit strain compared to patients with a low degree of LA fibrosis (− 15.0 ± 3.9% vs. − 16.9 ± 3.3%, P = 0.02 and − 7.9 ± 2.7% vs. − 9.5 ± 2.6%, P = 0.01, respectively). In contrast, no difference was found for LA contractile strain (− 7.1 ± 2.4% vs. − 7.4 ± 2.3%, P = 0.55).ConclusionsImpaired LA reservoir and conduit strain are present in AF patients with extensive atrial fibrosis. Future studies are needed to examine the biologic nature of this association and possible therapeutic implications.

Speckle Tracking Analysis Reveals Altered Left Atrial and Ventricular Myocardial Deformation in Patients with End-Stage Liver Disease.

Background: Cardiac function can be influenced by liver cirrhosis and should be thoroughly evaluated before liver transplantation. We investigated left ventricular (LV) and, for the first time, left atrial (LA) strain and strain rate in end-stage liver cirrhosis patients of different etiologies. Methods: This retrospective, cross-sectional study evaluated left heart function in 80 cirrhosis patients and 30 controls using standardized echocardiographic techniques and speckle tracking technology (STE) analysis. Serum markers of liver function were used for correlation analysis. Results: While conventional parameters demonstrated no alteration in systolic function, speckle tracking analysis showed a significant increase in LV longitudinal strain throughout all cardiac layers, with significant correlation to model of end-stage liver disease (MELD) score. LA reservoir and conduit strain as well as LA strain rate in all phases were significantly reduced in end-stage liver disease (ESLD) patients compared to control. STE for the evaluation of LA phasic function seemed to be more sensitive than volumetric methods. Kaplan-Meier curves showed a trend towards reduced post-transplant survival in patients with a reduced LA reservoir and conduit strain. Conclusion: STE analysis detected increased LV and decreased LA deformation in cirrhosis patients, thus proving to be highly sensitive to cardiac changes and useful for more precise cardiac evaluation.

Impaired left atrial function in clinically well heart transplant patients.

Left atrial (LA) enlargement is present in the majority of adult heart transplant (HT) recipients. We used speckle-tracking echocardiography to investigate whether LA phasic function in HT patients is altered and explored its relationship to HT-related clinical variables. This study evaluated LA function in 112 clinically well HT patients and 40 healthy controls. Clinical data included recipient age at HT, donor age, ischemia time, left ventricular function, and biochemical indicators. Atrial deformation and volume indices were measured with two-dimensional and three-dimensional speckle-tracking echocardiography, respectively. Components of phasic atrial function were calculated and correlations to clinical variables were explored. Compared with controls, HT patients had worse LA reservoir, conduit, and pump function. LA reservoir function of the bicaval group was better than the biatrial group, but differences did not persist after adjustment for potential confounders. Among patients with HT, those with lower LAS-peak had an older recipient age, larger LA volume, as well as worse left ventricular systolic function than those patients with higher LAS-peak. However, E/e', biochemical indicators and donor-related information were similar across the quartiles of LA function. In HT cohort, we observed impairment in all phases of LA function, and LA reservoir function was decreased independent of surgical technique. LAS-peak was associated with worse left ventricular systolic function, which suggested that LA function may play an important role in HT patients.

Assessment of visit-to-visit variability in systolic blood pressure over 5years and phasic left atrial function by two-dimensional speckle-tracking echocardiography.

Visit-to-visit variability in systolic blood pressure (VVV-SBP) has been associated with increased cardiac events. Hence, volume analysis by two-dimensional speckle-tracking echocardiography (2-DSTE) allows physicians to easily measure phasic left atrial (LA) function. However, the relationship of VVV-SBP and functional deformation of the left atrium with patients' clinical outcome is unclear. The aim of the study was to investigate the relationship between phasic LA function and VVV-SBP. The subjects were 70 male participants in whom 2-DSTE was performed to measure blood pressure at health check-ups every year for 5years. The standard deviation of systolic blood pressure (SBP) was calculated to assess VVV-SBP. The average SBP (Ave-SBP) was also assessed. Total emptying function (EF) (reservoir function), passive EF (conduit function), and active EF (booster pump function) of the left atrium were calculated to evaluate phasic LA function by 2-DSTE. The Pearson correlation, simple regression analysis, and multivariate logistic regression analysis were used in data analysis. Participants' mean age was 50 ± 10years, and 16 participants had hypertension. VVV-SBP correlated with total EF (r = - 0.30, p = 0.014) and active EF (r = - 0.35, p = 0.003). There was no correlation between the standard deviation of SBP and passive EF (r = - 0.10, p = 0.39). Ave-SBP had no significant relationship with total EF (r = - 0.06, p = 0.62), passive EF (r = - 0.08, p = 0.50), or active EF (r = - 0.03, p = 0.78). Active EF was also associated with VVV-SBP in multiple regression analysis. The active EF was significantly decreased in the highest quartile of VVV-SBP. Despite the small sample size of our study, the VVV-SBP showed a relationship with the phasic LA function. Our findings suggest that high VVV-SBP is noted to be associated with cardiovascular risk including a deterioration of LA function in clinical practice.

Left Atrial Phasic Function Predicts NT-proBNP in Asymptomatic Community Patients at Risk for Heart Failure

Left atrial (LA) phasic function includes Reservoir, Conduit and Booster Pump functions. Although the correlation of N-terminal pro-B-type natriuretic peptide (NT-proBNP) with non-invasive estimates of left ventricular (LV) filling pressures has been well described, the relationship between NT-proBNP and LA phasic function has not been clearly elucidated.

Determinants of the Volumetric Markers of Left Atrial Contraction Function in Coronary Artery Disease: A Cross-sectional Study.

BACKGROUNDA body of research advocates the prognostic role and usefulness of the volumetric markers of left atrial (LA) phasic functions in the diagnosis of LA dysfunction. We aimed to determine the independent determinants of the volumetric markers of LA contraction function in candidates for coronary artery bypass graft (CABG) surgery.METHODSThis cross-sectional study enrolled 516 candidates for CABG. The biplane maximal, minimal, and pre-P volumes of the LA were measured with two-dimensional echocardiography, and LA active emptying fraction was calculated. The standardized correlation coefficient for the correlation between each factor and LA active emptying fraction was calculated by using univariate and backward multivariable regression analyses.RESULTSThe multivariable regression analysis demonstrated that the heart rate (β = 0.15; p = 0.001), S (β = 0.09; p = 0.036), E/e′ ratio (β = −0.11; p = 0.014), left ventricle (LV) ejection fraction (β = 0.15; p = 0.001), and LA enlargement (β = −0.19; p < 0.001) were the independent determinants of LA active emptying fraction.CONCLUSIONSThe independent determinants of LA contraction function were the heart rate, S, LV ejection fraction, LA enlargement, and E/e′ ratio in candidates for CABG surgery.

Association of prediabetes with impaired left atrial contractility in patients with never-treated hypertension.

Prediabetes defined by HbA1c 5.7-6.4 has been shown to be associated with left ventricular (LV) hypertrophy and diastolic dysfunction in hypertensive patients. We hypothesized HbA1c prediabetes may be related to the alterations of LA contractility or volume in nondiabetic hypertension. Nondiabetic individuals on sinus rhythm were enrolled; 107 patients with never-treated hypertension, 134 patients with treated hypertension, and 71 normotensive subjects. Participants were classified as normal glucose tolerance (NGT, HbA1c<5.7), prediabetes (HbA1c 5.7-6.4) according to the ADA criteria. They underwent echocardiography to measure left atrial (LA) phasic volumes and functions, as well as mitral E/e' and mitral e'. In nondiabetic patients with never-treated hypertension, prediabetes saw lower LA total emptying fraction (53.7 ± 8.2 vs. 48.3 ± 9.9*) and mitral e' (7.38 ± 2.18 vs. 6.17 ± 1.50*) than NGT, implicating that the association of prediabetes with reduced LA contractility and LV stiffness. On the other hand, in nondiabetic patients with treated hypertension, prediabetes saw higher maximum LA volume/BSA (29.7 ± 7.1 vs. 32.9 ± 6.2* ml/mm2) and mitral E/e' (10.72 ± 3.08 vs. 12.37 ± 3.35*) than NGT, suggesting the relationship of prediabetes with increased LA preload. Prediabetes may be involved in the progression of LA structural and functional alterations in nondiabetic hypertensive patients.

Visceral fat accumulation and left atrial phasic function in the general population

Abstract Background Obesity carries independent risk for incident atrial fibrillation (AF), although the impact of abdominal fat distribution on LA morphological and functional remodeling is not fully elucidated. Speckle-tracking echocardiography is a novel and sensitive tool that allows quantification and detection of subtle alterations in left atrial (LA) phasic function. Purpose This study aimed to investigate whether increased visceral adiposity is independently associated with impaired LA phasic function in a community-based cohort. Methods We included 527 participants without overt cardiac disease who underwent laboratory testing, abdominal computed tomographic examination and speckle-tracking echocardiography. Abdominal adiposity was quantitatively assessed as visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus. Speckle-tracking echocardiography was performed to assess LA phasic function including reservoir, conduit and pump strain as well as left ventricular global longitudinal strain (LVGLS). Results Mean age was 57±10 years and 362 of the participants (69%) were men. LA reservoir and conduit strain were decreased according to the VFA quartiles (both p&amp;lt;0.05), whereas there was no significant difference in LA volume index and LA pump strain. When stratified by SFA, there was no significant differences in LA volume index and all LA phasic strain across the quartiles. In multivariable analysis, VFA as continuous variable was significantly associated with LA conduit strain, independent of traditional cardiovascular risk factors, pertinent laboratory parameters and LV morphology and function including LVGLS (standardized b=−0.146, p=0.011). Representative cases are shown in the Figure. Conclusion In a sample of the general population, VFA accumulation was independently associated with worse LA conduit strain, which may be involved in the pathophysiological mechanism of obesity-related AF. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Yamauchi Susumu Scholarship for Cardiovascular Research

Diagnosis of heart failure with preserved ejection fraction in patients with dyspnea and paroxysmal atrial fibrillation: a role of left atrial strain

Abstract Background Diagnosis of heart failure with preserved ejection fraction (HFpEF) in patients with dyspnea and paroxysmal atrial fibrillation (AF) is challenging. Speckle tracking-derived left atrial strain (LAS) provides an accurate estimate of left ventricular filling pressures and left atrial phasic function. However, data on clinical utility of LAS in patients with dyspnea and AF are scarce. Objective To assess relationship between LAS and probability of HFpEF in patients with dyspnea and paroxysmal AF. Methods The study included 205 consecutive patients (62±10 years, 58% males) with limiting dyspnea (NYHA ≥ II), paroxysmal AF and preserved LVEF (≥50%), who underwent speckle tracking echocardiography and natriuretic peptide (NT-proBNP) assessment during sinus rhythm. Patients with manifest ischemic heart or valve disease, and cardiomyopathy were excluded. Probability of HFpEF was estimated using H2FPEF and HFA-PEFF scores, which combine clinical characteristics, echocardiographic parameters and natriuretic peptides. Results A total of 61 (30%), 115 (56%) and 29 (14%) had respectively high, intermediate and low probability of HFpEF. Patients with high probability of HFpEF were significantly older, had higher body mass index, NT-proBNP, E/e', pulmonary artery pressure and larger LA volume index than patients in low-to-intermediate probability groups (all p&amp;lt;0.05). Two distinct patterns of LA phasic function were observed. Firstly, reservoir LAS showed close inverse association with increasing probability of HFpEF. Secondly, contractile LAS showed initial decrease with subsequent compensatory increase in intermediate probability category with final decrease in patients with high HFpEF probability. In contrast, LV global longitudinal strain was similar between groups (NS). In multivariable regression analysis, reservoir LAS emerged as the strongest independent predictor of HFpEF defined by using both scores. Reservoir LAS with optimal cut off value of 24% showed sensitivity of 86% and specificity of 70% to identify high probability of HFpEF. Combination of LAS with NT-proBNP did not increase the accuracy of each parameter alone. Conclusions Reservoir LAS shows a strong independent association with probability of HFpEF in patients with dyspnea and paroxysmal AF. This advocates for more liberal use of LAS assessment to distinguish cardiac from non-cardiac dyspnea in patients with history of AF. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): International PhD programme in Cardiovascular Pathophysiology and Therapeutics (CardioPaTh).

Subclinical Hypothyroidism as an Independent Determinant of Left Atrial Dysfunction in the General Population.

Although subclinical hypothyroidism (SCH) is a common clinical entity and carries independent risk for incident heart failure (HF), its possible association with subclinical cardiac dysfunction is unclear. Left ventricular global longitudinal strain (LVGLS) and left atrial (LA) phasic strain can unmask subclinical left heart abnormalities and are excellent predictors for HF. This study aimed to investigate the association between the presence of SCH and subclinical left heart dysfunction in a sample of the general population without overt cardiac disease. We examined 1078 participants who voluntarily underwent extensive cardiovascular health check-ups, including laboratory tests and 2-dimensional speckle-tracking echocardiography to assess LVGLS and LA reservoir, conduit, and pump strain. SCH was defined as an elevated serum thyroid-stimulating hormone level with normal concentration of free thyroxine. Mean age was 62 ± 12 years, and 56% were men. Seventy-eight (7.2%) participants exhibited SCH. Individuals with SCH had significantly reduced LA reservoir (37.1 ± 6.6% vs 39.1 ± 6.6%; P = 0.011) and conduit strain (17.3 ± 6.3% vs 19.3 ± 6.6%; P = 0.012) compared with those with euthyroidism, whereas there was no significant difference in left ventricular ejection fraction, LA volume index, LVGLS, and LA pump strain between the 2 groups. In multivariable analyses, SCH remained associated with impaired LA reservoir strain, independent of age, traditional cardiovascular risk factors, and pertinent laboratory and echocardiographic parameters. including LVGLS (standardized β -0.054; P = 0.032). In an unselected community-based cohort, individuals with SCH had significantly impaired LA phasic function. This association may be involved in the higher incidence of HF in subjects with SCH.

Left atrial stiffness index as a marker of early target organ damage in hypertension.

This study aimed to evaluate left atrial (LA) mechanics using two-dimensional speckle-tracking echocardiography (2DSTE) and investigate their correlations with measures of target organ damage (TOD) in hypertension. We enrolled 42 healthy controls (Group I) and 286 hypertension patients: Group II (n = 79) had an LA volume index (LAVI) <28 ml/m2; Group III (n = 92) had an LAVI ≥28 ml/m2; and Group IV (n = 115) had hypertension with left ventricular hypertrophy (LVH). We measured the following parameters: LA reservoir strain and strain rate (LAS-S, LASR-S), LA conduit strain and strain rate (LAS-E and LASR-E), and LA booster strain and strain rate (LAS-A and LASR-A). The LA stiffness index (LASI) was defined as the ratio of early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') to LAS-S. We performed correlation and regression analyses of individual TOD with LA phasic functions, the LASI, and cardiovascular risk factors. Our findings showed that there was a trend toward a gradual increase in the LASI from controls to normal LA and enlarged LA patients and finally to hypertrophic LV patients. The LASI was significantly higher in Group III [0.28 (0.20, 0.38)] than in Group I [0.20 (0.16, 0.23)] and Group II [0.22 (0.18, 0.27)] and was the highest in Group IV [0.33 (0.26, 0.43)]. The LA reservoir and conduit function gradually decreased from Group I to Group IV. Multivariate regression analysis revealed that the LASI was independently correlated with individual TOD. In conclusion, abnormal LA mechanics precede LA enlargement and LVH, and an increased LASI can be used as a marker of early TOD in hypertension.

Heart failure with preserved ejection fraction or non-cardiac dyspnea in paroxysmal atrial fibrillation: The role of left atrial strain

BackgroundDiagnosis of heart failure with preserved ejection fraction (HFpEF) in patients with dyspnea and paroxysmal atrial fibrillation (AF) is challenging. Speckle tracking-derived left atrial strain (LAS) provides an accurate estimate of left ventricular (LV) filling pressures and left atrial (LA) phasic function. However, data on clinical utility of LAS in patients with dyspnea and AF are scarce. ObjectiveTo assess relationship between the LAS and the probability of HFpEF in patients with dyspnea and paroxysmal AF. MethodsThe study included 205 consecutive patients (62 ± 10 years, 58% males) with dyspnea (NYHA≥II), paroxysmal AF and preserved LV ejection fraction (≥50%), who underwent speckle tracking echocardiography during sinus rhythm. Probability of HFpEF was estimated using H2FPEF and HFA-PEFF scores, which combine clinical characteristics, echocardiographic parameters and natriuretic peptides. ResultsPatients with high probability of HFpEF were significantly older, had higher body mass index, NT-proBNP, E/e’, pulmonary artery pressure and larger LA volume index than patients in low-to-intermediate probability groups (all p < 0.05). All components of LAS and LA strain rate showed proportional impairment with increasing probability of HFpEF (all p < 0.05). Out of the speckle tracking-derived parameters, reservoir LAS showed the largest area under the curve (AUC = 0.78, p < 0.001) and the strongest independent predictive value (OR: 1.22, 95% CI 1.08–1.38) to identify patients with high probability of HFpEF. ConclusionsReservoir LAS shows a high diagnostic performance to distinguish HFpEF from non-cardiac causes of dyspnea in symptomatic patients with paroxysmal AF.

Altered Biatrial Phasic Function after Heart Transplantation in Children

We used two-dimensional echocardiographic speckle-tracking to investigate whether left and right atrial (LA and RA) phasic function in pediatric heart transplantation (HT) patients is altered and explored the relationship to HT-related clinical variables. Eighty-six subjects (36 HT and 50 normal children) were prospectively enrolled in two centers. Clinical data included age at HT, bypass time, ischemia time, donor age, and incidence of rejection. Atrial deformation indices including strain and strain rates (SRs) were measured using two-dimensional echocardiographic speckle-tracking. Components of phasic atrial function-reservoir (εr, SRr), conduit (εcd, SRcd), and booster (εct, SRct) were calculated. Comparisons with controls were made using t test or Kruskal-Wallis test, and correlations to clinical variables were explored. The mean age and body surface area of HT subjects were 10.2±6.2years and 1.2±0.6m2, respectively. The mean heart rates were higher in HT (96±18 vs 88±21 in controls). There were reductions in RA and LA reservoir (εr, SRr), conduit (εcd, SRcd), and booster (εct, SRct) function in HT compared with controls. There was no relationship of LA and RA deformation indices with mean age at HT, bypass time, or ischemia time. The LA εcd correlated weakly with donor age (r=-0.49, P=.04) and RA SRr, and SRcd showed association with duration of HT (P<.05). Nineteen HT recipients had follow-up studies 0.24±0.18years after the first examination, and deformational indices were not significantly changed. Atrial strain determination is feasible in pediatric HT recipients and demonstrates disruption of reservoir, conduit, and booster function of both atria in this population; we speculate this may be a consequence of ventricular diastolic dysfunction.

Impact of different dipping patterns on left atrial function in hypertension.

We aimed to investigate left atrial phasic function in the recently diagnosed hypertensive patients and determine association between circadian blood pressure (BP) patterns and left atrial function. The present study involved 256 untreated hypertensive patients who underwent 24-h ambulatory BP monitoring and comprehensive echocardiographic examination. All patients were divided into four groups according to the percentage of nocturnal BP drop (dippers, extreme dippers, nondippers and reverse dippers). There was no significant difference in daytime BPs between the observed groups, whereas night-time BPs significantly and gradually increased from extreme dippers and dippers, across nondippers, to reverse dippers. Total, passive and active left atrial emptying fractions that correspond with left atrial reservoir, conduit and contractile function were lower in nondippers and reverse dippers than in dippers and extreme dippers. Reservoir and contractile left atrial strains were lower in reverse dippers than in dippers and extreme dippers, whereas conduit left atrial strain was lower in reverse dippers in comparison with extreme dippers. Nondipping and reverse dipping BP patterns were, independently of age, sex, nocturnal BPs, left ventricular mass index, E/e', associated with reduced reservoir function. Nevertheless, only reverse dipping profile was independently of other circadian BP profiles, nocturnal BP, demographic and echocardiographic parameters related with reduced conduit and contractile functions. Nondipping and reverse dipping BP patterns were related with impaired left atrial phasic function. However, reverse pattern was the only circadian profile that was independently of other clinical parameters, including night-time BP, associated with decreased reservoir, conduit and contractile function.