Left Atrial Pressure In Patients Research Articles

LA reservoir strain predicts elevated left atrial pressure in patients with Veno-Arterial (VA) extracorporeal membrane oxygenator (ECMO) support for cardiogenic shock

Abstract Background Veno-arterial (VA) extracorporeal membrane oxygenator (ECMO) is not a left ventricular (LV) support system as it increases aortic pressure and LV afterload due to retrograde blood flow in the aorta. This can lead to complications such as increased LV volume (LV distention), increased LV and left atrial (LA) pressures, and pulmonary edema. We sought to investigate the correlation between LA strain and invasive LA pressure (LAP) in patients with ECMO support for cardiogenic shock undergoing atrial septostomy with stenting. Methods and Results A total of 24 consecutive patients (52±20 years; 83% were male) undergoing atrial septostomy with stenting while being on ECMO support for cardiogenic shock for left heart decompression were analyzed. LAP was measured immediately after transeptal puncture and before deployment of interatrial septal stent. A comprehensive echocardiogram was performed in all patients prior to atrial septostomy. Median time difference between echocardiogram and LAP measurement was 3.5 (0.5-20) hours. LA strain analysis was performed using the TomTec Arena 2D-cardiac performance analysis (CPA) software. LA reservoir strain was measured at peak systole during the reservoir phase in a single apical 4-chamber view. Intraclass correlation coefficients between 2 different investigators were excellent (All> 0.95). Median LA reservoir strain and LAP were 3.2 (0.5-1) % and 23 (8-53) mmHg, respectively. LA reservoir strain significantly correlated with LAP (r=0.53, p=0.034). LA reservoir strain of < 1.5% can effectively predict markedly elevated LAP (LA> 30 mmHg) (OR =9.9, p =0.0016). Conclusions LA reservoir strain significantly correlated with invasive LAP. With the advent of strain imaging software, LA reservoir strain is a feasible, reproducible, noninvasive, and straightforward method to predict the need for left heart decompression and/or to guide optimal afterload management in patients with VA-ECMO for cardiogenic shock. Further a prospective simultaneous echocardiographic and invasive LAP study is needed.

Abstract Mo039: Risk of Structural and Hemodynamic changes in Left Atrium in Patients with Heart Failure undergoing Percutaneous Left Atrial Appendage Occlusion: A Retrospective Analysis

Background: Exclusion of left atrial appendage (LAA) in animals reduces compliance and increases left atrial pressure. We hypothesize that percutaneous left atrial appendage occlusion (LAAO) would lead to structural and hemodynamic changes in left atrium and assess the risk using echocardiographic cut-offs used for evaluating left atrial pressure in heart failure patients. Methods: We queried TriNetx database for adult patients with heart failure undergoing percutaneous LAAO. We excluded those who underwent surgical or alternative percutaneous procedures pertaining to LAA, procedures pertaining to mitral valve (MV), mitral valvular pathologies, mechanical circulatory support placement, pacemaker placement, and those with left bundle branch block. We calculated risk of meeting echocardiographic cut-offs used in evaluation of left atrial pressure; MV maximum E-wave velocity ≥50cm/s, left atrial end systolic volume index (LAESVI) indexed to body surface area ≥34 ml/m2, Tricuspid Regurgitation systolic jet velocity ≥ 2.8 m/s, Pulmonary vein Systole/Diastole ratio ≤ 1, mitral valve lateral annulus E/e' ≥ 13 and Mitral valve E/A ratio ≥2. Those meeting the respective cut-off before LAAO were excluded. All diagnoses, procedures, and echocardiographic parameters were identified using International Classification of Diseases, Current Procedural Terminology, and Logical Observation Identifiers Names and Codes. Results: We identified 4,046 patients with heart failure undergoing percutaneous LAAO. Baseline demographics and diagnosis were; mean (SD) age 75.4 (8.1) years, 37% females, 92% hypertension, 67% ischemic heart disease, 42% diabetes mellitus, 41% chronic kidney disease, and 42% were overweight or obese. Risk of meeting echocardiographic cut-offs used in evaluating left atrial pressure was low with 0.24% (10) patients having LAESVI indexed to body surface area ≥34 ml/m2, Tricuspid Regurgitation systolic jet velocity ≥ 2.8 m/s, Pulmonary vein Systole/Diastole ratio ≤ 1, and Mitral valve E/A ratio ≥ 2. Risk of having MV maximum E-wave velocity ≥50cm/s was 0.58% and no patients had mitral valve lateral annulus E/e' ≥ 13. (Figure 1) Conclusion: Risk of meeting echocardiographic cut-offs used in evaluation of left atrial pressure in patients with heart failure undergoing percutaneous LAAO is low.

Determinants of invasive left atrial pressure in patients with atrial fibrillation.

Estimation of left ventricular (LV) filling pressures in patients with atrial fibrillation (AF) is challenging due to lack of reliable parameters. This study investigates the association between cardiac structure and function and invasive mean left atrial pressure (LAP). This is a multi-center prospective study enrolling patients undergoing transcatheter ablation for AF. The invasive measurement of LAP was performed at the time of the procedure while the echocardiography within the previous 24 hours. A mean LAP ≥ 15 mmHg was considered as increased. Overall, 101 patients were included (mean age 65.8 ± 8.5 years, 68% male, mean LV ejection fraction 56.6 ± 8.0%). No significant differences regarding clinical characteristics were detected between the group of patients with normal (n=47) or increased LAP (n=54). The latter showed lower values of LV global longitudinal strain, larger left atrial volumes (LAV) and worse right ventricular (RV) function. After multivariable adjustment, higher E/e' ratio (p=0.041) and minimal LAV index (LAVI min) (p=0.031), lower peak atrial longitudinal strain (PALS) (p=0.030) and RV free wall strain (p=0.037), but not maximal LAV index (LAVI max) (p=0.137), were significantly associated with mean LAP. The associations were not modified by cardiac rhythm. Overall, LAVI min showed the best diagnostic accuracy to predict elevated LAP (AUC 0.703). LA structure and function assessment well correlates with mean LAP in patients with AF. These measures may be used in the assessment of filling pressure in these patients.

Remote dielectric sensing predicts elevated left atrial pressure in patients with atrial fibrillation

BackgroundThere are currently no established non-invasive indices of echocardiography for elevated left atrial pressure (LAP) especially in patients with atrial fibrillation (AF). Remote dielectric sensing (ReDS) is a novel non-invasive electromagnetic energy-based technology that quantifies total lung fluid, enabling the monitoring of volume status in patients with heart failure. The utility of ReDS for estimating LAP in patients with AF remains unknown. MethodsWe prospectively investigated patients with AF in whom LAP was directly measured during catheter ablation for AF, and ReDS measurements were conducted the day before ablation. Elevated LAP was defined as LAP ≥ 15 mmHg. ResultsA total of 61 patients were included (median age 66 years, 38 % female). Among them, 26 patients had elevated LAP. There was a positive correlation between ReDS and LAP (r = 0.363, P = 0.004). Receiver operating characteristic curve analysis for the prediction of elevated LAP demonstrated that the best cut-off value of ReDS was 30 %, with a sensitivity of 65 %, specificity of 69 %, and an area under the curve of 0.703 (95 % confidence interval 0.568–0.837). Multivariate logistic regression analysis revealed that ReDS was an independent predictor of elevated LAP, among covariates including left ventricular ejection fraction, the ratio of early transmitral flow velocity to septal mitral annular early diastolic velocity, and left atrial volume index. ConclusionsOur results suggest ReDS could be a valuable marker of elevated LAP even in patients with AF. Further studies are needed to elucidate the effectiveness of a ReDS-guided decongestive strategy in patients with heart failure.

Left atrial strain parameters to predicting elevated left atrial pressure in patients with atrial fibrillation.

To assess the ability of left atrial (LA) strain parameters to discriminate patients with elevated left atrial pressure (LAP) from patients with atrial fibrillation (AF). A total of 142 patients with non-valvular AF who underwent first catheter ablation (CA) between November 2022 and November 2023 were enrolled in the study. Conventional and speckle-tracking echocardiography (STE) were performed in all patients within 24h before CA, and LAP was invasively measured during the ablation procedure. According to mean LAP, the study population was classified into two groups of normal LAP (LAP<15mmHg, n=101) and elevated LAP (LAP≥15mmHg, n=41). Compared with the normal LAP group, elevated LAP group showed significantly reduced LA reservoir strain (LASr) [9.14 (7.97-11.80) vs. 20 (13.59-26.96), p<.001], and increased LA filling index [9.60 (7.15-12.20) vs. 3.72 (2.17-5.82), p<.001], LA stiffness index [1.13 (.82-1.46) vs..47 (.30-.70), p<.001]. LASr, LA filling index and LA stiffness index were independent predictors of elevated LAP after adjusted by the type of AF, EDT, E/e', mitral E, and peak acceleration rate of mitral E velocity. The receiver-operating characteristic curve (ROC) analysis showed LA strain parameters (area under curve [AUC].794-.819) could provide similar or greater diagnostic accuracy for elevated LAP, as compared to conventional echocardiographic parameters. Furthermore, the novel algorithms built by LASr, LA stiffness index, LA filling index, and left atrial emptying fraction (LAEF), was used to discriminate elevated LAP in AF with good accuracy (AUC.880, accuracy of 81.69%, sensitivity of 80.49%, and specificity of 82.18%), and much better than 2016 ASE/EACVI algorithms in AF. In patients with AF, LA strain parameters could be useful to predict elevated LAP and non-inferior to conventional echocardiographic parameters. Besides, the novel algorithm built by LA strain parameters combined with conventional parameters would improve the diagnostic efficiency.

2-Year Outcomes of an Atrial Shunt Device in HFpEF/HFmrEF: Results From REDUCE LAP-HF II

BackgroundThe REDUCE LAP-HF II (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure II) trial found that, compared with a sham procedure, the Corvia Atrial Shunt did not improve outcomes in heart failure with preserved or mildly reduced ejection fraction. However, after 12-month follow-up, “responders” (peak-exercise pulmonary vascular resistance <1.74 WU and absence of a cardiac rhythm management device) were identified. ObjectivesThis study sought to determine: 1) the overall efficacy and safety of the atrial shunt vs sham control after 2 years of follow-up; and 2) whether the benefits of atrial shunting are sustained in responders during longer-term follow-up or are offset by adverse effects of the shunt. MethodsThe study analyzed 2-year outcomes in the overall REDUCE LAP-HF II trial, as well as in responder and nonresponder subgroups. The primary endpoint was a hierarchical composite of cardiovascular death or nonfatal ischemic/embolic stroke, total heart failure events, and change in health status. ResultsIn 621 randomized patients, there was no difference between the shunt (n = 309) and sham (n = 312) groups in the primary endpoint (win ratio: 1.01 [95% CI: 0.82-1.24]) or its individual components at 2 years. Shunt patency at 24 months was 98% in shunt-treated patients. Cardiovascular mortality and nonfatal ischemic stroke were not different between the groups; however, major adverse cardiac events were more common in those patients assigned to the shunt compared with sham (6.9% vs 2.7%; P = 0.018). More patients randomized to the shunt had an increase in right ventricular volume of ≥30% compared with the sham control (39% vs 28%, respectively; P < 0.001), but right ventricular dysfunction was uncommon and not different between the treatment groups. In responders (n = 313), the shunt was superior to sham (win ratio: 1.36 [95% CI: 1.02-1.83]; P = 0.037, with 51% fewer HF events [incidence rate ratio: 0.49 [95% CI: 0.25-0.95]; P = 0.034]). In nonresponders (n = 265), atrial shunting was inferior to sham (win ratio: 0.73 [95% CI: 0.54-0.98]). ConclusionsAt 2 years of follow-up in REDUCE LAP-HF II, there was no difference in efficacy between the atrial shunt and sham groups in the overall trial group. The potential clinical benefit identified in the responder group after 1 and 2 years of follow-up is currently being evaluated in the RESPONDER-HF (Re-Evaluation of the Corvia Atrial Shunt Device in a Precision Medicine Trial to Determine Efficacy in Mildly Reduced or Preserved Ejection Fraction Heart Failure) trial. (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure II [REDUCE LAP-HF II]; NCT03088033)

Invasive hemodynamic characteristics in patients with mitral annular calcification related mitral stenosis and chest radiation.

Quantification of invasive hemodynamics and mitral annular calcification-related mitral stenosis remains underexplored in patients exposed to chest radiation. We sought to explore invasive hemodynamic parameters via transseptal catheterization in patients with and without chest radiation who had a diagnosis of mitral annular calcification-related mitral stenosis. After excluding patients with more than moderate mitral regurgitation, we found that there was no difference in mitral valve area on hemodynamic testing in patients with and without radiation with an elevated baseline transmitral gradient on transthoracic echocardiography in the setting of mitral annular calcification-related mitral stenosis. There was a higher transmitral gradient and left atrial pressure in patients with prior radiation consistent with left atrial noncompliance, suggesting that treatment mitral valve stenosis may not relieve symptoms in this cohort of patients.

Atrial Shunt Device Effects on Cardiac Structure and Function in Heart Failure With Preserved Ejection Fraction

Although the results of A Study to Evaluate the Corvia Medical Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure (REDUCE LAP-HF II) trial were neutral overall, atrial shunt therapy demonstrated potential efficacy in responders (no latent pulmonary vascular disease and no cardiac rhythm management device). Post hoc analyses were conducted to evaluate the effect of shunt vs sham stratified by responder status. To evaluate the effect of atrial shunt vs sham control on cardiac structure/function in the overall study and stratified by responder status. This was a sham-controlled randomized clinical trial of an atrial shunt device in heart failure with preserved ejection fraction (HFpEF)/HF with mildly reduced EF (HFmrEF). Trial participants with evaluable echocardiography scans were recruited from 89 international medical centers. Data were analyzed from April 2023 to January 2024. Atrial shunt device or sham control. Changes in echocardiographic measures from baseline to 1, 6, 12, and 24 months after index procedure. The modified intention-to-treat analysis of the REDUCE LAP-HF II trial included 621 randomized patients (median [IQR] age, 72.0 [66.0-77.0] years; 382 female [61.5%]; shunt arm, 309 [49.8%]; sham control arm, 312 [50.2%]). Through 24 months, 212 of 217 patients (98%) in the shunt arm with evaluable echocardiograms had patent shunts. In the overall trial population, the shunt reduced left ventricular (LV) end-diastolic volume (mean difference, -5.65 mL; P <.001), left atrial (LA) minimal volume (mean difference, -2.8 mL; P =.01), and improved LV systolic tissue Doppler velocity (mean difference, 0.69 cm/s; P <.001) and LA emptying fraction (mean difference, 1.88 percentage units; P =.02) compared with sham. Shunt treatment also increased right ventricular (RV; mean difference, 9.58 mL; P <.001) and right atrial (RA; mean difference, 9.71 mL; P <.001) volumes but had no effect on RV systolic function, pulmonary artery pressure, or RA pressure compared with sham. In the shunt arm, responders had smaller increases in RV end-diastolic volume (mean difference, 5.71 mL vs 15.18 mL; interaction P =.01), RV end-systolic volume (mean difference, 1.58 mL vs 7.89 mL; interaction P =.002), and RV/LV ratio (mean difference, 0.07 vs 0.20; interaction P <.001) and larger increases in transmitral A wave velocity (mean difference, 5.08 cm/s vs -1.97 cm/s; interaction P =.02) compared with nonresponders randomized to the shunt, suggesting greater ability to accommodate shunted blood through the pulmonary circulation enabling LA unloading. In this post hoc analysis of the REDUCE LAP-HF II trial, over 2 years of follow-up, atrial shunting led to reverse remodeling of left-sided chambers and increases in volume of right-sided chambers consistent with the shunt flow but no change in RV systolic function compared with sham. Changes in cardiac structure/function were more favorable in responders compared with nonresponders treated with the shunt, supporting the previously identified responder group hypothesis and mechanism, although further evaluation with longer follow-up is needed. ClinicalTrials.gov Identifier: NCT03088033.

Validation of E/e′ Using the Index-Beat Method as an Estimate of Left Atrial Pressure in Patients with Atrial Fibrillation

Introduction: Echocardiographic assessment of diastolic function during atrial fibrillation (AF) remains challenging due to the irregular cardiac cycle length. We sought to assess whether the index-beat method, the beat following two preceding cardiac cycles of equal duration, could provide a more reliable measurement of E/e′ (mitral E wave/diastolic tissue Doppler velocity) than the conventional averaging of consecutive beats and hence facilitate the noninvasive estimation of elevated left atrial pressure (LAP) in patients with AF. Methods: We prospectively studied 35 patients with persistent AF who had preserved left ventricular ejection fraction and underwent radiofrequency ablation. LAP was measured in conjunction with transseptal puncture during catheter ablation. Echocardiography was performed 24 h before ablation and E/e′ was determined using the recommended averaging of 10 beats and the index-beat method, with the observers blinded to the clinical details and LAP measurements. Results: Correlation analysis showed a strong positive correlation between two methods in terms of both septal E/e′ (r = 0.841, p < 0.001) and lateral E/e′ (r = 0.930, p < 0.001). Bland-Altman analysis also showed a good agreement between the two measurement methods in terms of E/e′. E/e′ determined using both conventional averaging and the index-beat method was significantly correlated with LAP (p < 0.05). After Fisher Z transformation, we found that the index-beat septal E/e′ had a better correlation with LAP than did the conventional averaging E/e′ (r = 0.736 vs. r = 0.392, Zr = −2.110, p = 0.035). Furthermore, the index-beat method took significantly less time to measure E/e′ (mean 33.6 s; 95% confidence intervals [CIs]: 32.1 s–36.2 s) than did conventional averaging method (mean 96.2 s; 95% CI: 90.2 s–102.3 s; p < 0.001). Receiver operating characteristic curve analysis revealed that the optimal cut-off for predicting mean LAP >12 mm Hg was 11 (sensitivity 100%; specificity 77.3%) for index-beat septal E/e′ and 16 (sensitivity 61.5%; specificity 95.5%) for index-beat lateral E/e′. Conclusions: Good correlations were found between E/e′ and LAP in patients with AF, particularly with the index-beat method. Moreover, the index-beat method can easily measure E/e′ at an accuracy similar to that for the conventional averaging of consecutive beats, which can therefore be applied to assess the diastolic dysfunction and potentially improve the diagnosis of heart failure in patients with AF.

Atrial Fibrillation Burden and Atrial Shunt Therapy in Heart Failure With Preserved Ejection Fraction

BackgroundAtrial fibrillation (AF) is a common comorbidity in patients with heart failure with preserved ejection fraction (HFpEF) and in heart failure with mildly reduced ejection fraction (HFmrEF). ObjectivesThis study sought to describe AF burden and its clinical impact among individuals with HFpEF and HFmrEF who participated in a randomized clinical trial of atrial shunt therapy (REDUCE LAP-HF II [A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure]) and to evaluate the effect of atrial shunt therapy on AF burden. MethodsStudy investigators characterized AF burden among patients in the REDUCE LAP-HF II trial by using ambulatory cardiac patch monitoring at baseline (median patch wear time, 6 days) and over a 12-month follow-up (median patch wear time, 125 days). The investigators determined the association of baseline AF burden with long-term clinical events and examined the effect of atrial shunt therapy on AF burden over time. ResultsAmong 367 patients with cardiac monitoring data at baseline and follow-up, 194 (53%) had a history of AF or atrial flutter (AFL), and median baseline AF burden was 0.012% (IQR: 0%-1.3%). After multivariable adjustment, baseline AF burden ≥0.012% was significantly associated with heart failure (HF) events (HR: 2.00; 95% CI: 1.17-3.44; P = 0.01) both with and without a history of AF or AFL (P for interaction = 0.68). Adjustment for left atrial reservoir strain attenuated the baseline AF burden-HF event association (HR: 1.71; 95% CI: 0.93-3.14; P = 0.08). Of the 367 patients, 141 (38%) had patch-detected AF during follow-up without a history of AF or AFL. Atrial shunt therapy did not change AF incidence or burden during follow-up. ConclusionsIn HFpEF and HFmrEF, nearly 40% of patients have subclinical AF by 1 year. Baseline AF burden, even at low levels, is associated with HF events. Atrial shunt therapy does not affect AF incidence or burden. (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure [REDUCE LAP-HF II]; NCT03088033)

The prognostic value of non-invasively estimated left atrial pressure in patients undergoing cardiac resynchronization therapy

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovative program under the Marie Sklodowska -Curie grant agreement No. 860745. Background The impact of non-invasively estimated left atrial pressure (LAP) on cardiac resynchronization therapy (CRT) outcome has been previously investigated, yet with inconsistent results. Aim We aim at investigating the association between baseline LAP and CRT outcome applying both the standard guideline approach (Nagueh et al 2016) and the integrated guideline + LA strain approach. Methods Datasets of 219 CRT patients were retrospectively analyzed. All patients had full echocardiographic diastolic function assessment before CRT and were classified based on the guidelines approach for estimation of LAP into normal LAP (nLAP = 40%), elevated LAP (eLAP = 49%) and undetermined LAP (uLAP = 11%, when classification was not possible due to missing data, Figure A, solid bars). All baseline characteristics, comorbidities, and ECG data in addition to LA strain components before CRT were collected and analyzed. The amount of CRT-induced LV reverse remodeling was assessed at 12±6 months after CRT and was defined as percentage decrease of LV end-systolic volume (LVESV) compared to baseline. Patients were followed up for a mean of 4.8 years (interquartile range (IQR): 2.7–6.0) for all-cause mortality. Results Compared to patients with eLAP, patients with nLAP were more of female sex (40% vs. 21%) and they had lower serum creatinine (1.1 ± 0.4 vs. 1.5 ± 0.6 mg/dl). ECG data showed that they had less prevalence of AF (9 vs. 15%). All LA strain indices were better in patients with nLAP (23 ± 9 vs. 12 ± 7% for reservoir strain, 10 ± 4 vs. 7 ± 5% for conduit strain and 11 ± 7 vs. 4 ± 4% for pump strain, P &amp;lt; 0.01 for all comparisons). At follow-up, LVESV was reduced more in patients with nLAP than in patients with eLAP (47 ± 28 vs. 30 ± 30%, P &amp;lt; 0.01, figure B solid bars). Survival rates of patients with nLAP was significantly higher than patients with eLAP (Hazard ratio (HR): 0.40; confidence interval (CI): 0.22–0.27; P &amp;lt; 0.01, figure C solid lines). In the subgroup of uLAP an LA reservoir strain was used to further identify patients with nLAP (LA reservoir strain ≥ 18%). Accordingly, the integrated guideline+LA strain approach improved the feasibility for classification from 89% to 97%, where the percentage of the uLAP dropped from 11% to 3% (only patients with no baseline LA strain remained classified as uLAP, figure A). Patients with nLAP according to the integrated approach showed very similar CRT-induced LV reverse remodeling (figure B dashed bars) and long-term survival as compared to patients with nLAP according to the standard approach (figure C dashed lines). Conclusion Applying the standard guideline approach for LAP, patients with nLAP before CRT show more LV reverse remodeling and better long-term survival after CRT, as compared to patients with eLAP. The guideline + LA strain approach markedly improves the feasibility of LAP estimation, while not influencing the association between LAP and outcome after CRT.

Correlation of NT-proBNP and left atrial pressure in patients with atypical atrial flutter after cardiac surgery and previous catheter ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atypical atrial flutter (AFL) is often associated with cardiac surgery or extensive catheter ablation (CA) for the treatment of atrial fibrillation (AF). Therefore, the increase in the number of cardiac surgery procedures leads to the development of substrates for atypical AFL onset. Described several prognostic factors for the development of AF in the long-term period after cardiac interventions. To our knowledge, the prognostic factors of atypical AFL in patients after cardiac surgery are not described. Objective the aim of our study was to determine the relationship between increased left atrial pressure and the NT-proBNP biomarker in patients after cardiac surgery and catheter ablation. Methods Sixty-five adult patients with AFL after cardiac surgery and catheter ablation were included in a single-center prospective study. The patients' age varied from 18 to 76 years, and the mean age was 57.1±12.2 years. Of these, 36 patients were male (55.4%) and 29 women (49.3%), respectively. Patients were observed for NT-proBNP before index radiofrequency ablation (RFA). All patients underwent RFA of atypical AFL in the left atrium (LA) and measurement of LA pressure. The patients were discharged safely and were monitored for 12 months. Results According to basic characteristics of patients with atypical AFL cardiac surgery for valvular heart disease was performed in 30 (46.1%) cases, for ischemic and congenital heart diseases occurred with the same frequency, 8 (12.3%). Atypical AFL occurred in 20 (30.8%) cases after cryoballoon pulmonary veins isolation (PVI), after RFA of a typical AFL in 14 (21.3%) cases, and radiofrequency PVI in 13 (20%) cases. The mean invasive LA pressure before index RFA was 22.3±5 mm. Hg, mean LA size on transthoracic echocardiography was 42.3±6.9mm. The parameters of the left ventricle: mean EDV 93.3±26.1ml, mean ESV 41.7±16.9ml, and mean EF 56±7.6%. Mean NT-proBNP was 974.8±440.5 pg/ml. In our cohort of patients, we identified a positive correlation between NT-proBNP and LA pressure (p&amp;lt;0.001, r=0.761), as well as a positive relationship between NT-proBNP and LA diameter (r=0.512, p&amp;lt;0.001), between LA pressure and LA diameter (r=0.438, p&amp;lt;0.001). Additionally, a correlation was found between the pulmonary artery systolic pressure and LA diameter (r=0.314, p=0.011). Conclusions Our study demonstrates a strong direct linear relationship of NT-proBNP with an increase of LA pressure in patients with atypical AFL in patients previously undergone cardiac surgery and catheter ablation. Thus, these parameters can serve as possible prognostic criteria for the development of complex cardiac arrhythmias such as atypical AFL.

Echocardiographic and invasive evaluation of left atrial pressure in patients undergoing catheter ablation for atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. AIMS Estimation of left ventricle (LV) filling pressure is one of the most important parameters to provide information in clinical practice. However, the challenging in investigating this parameter through invasive methods makes it difficult to be used. The study aims to investigate the association between cardiac structure and function derived by transthoracic echocardiography (TTE) and left atrial (LA) invasive pressure (LAP). Methods The study was a multi-center prospective study enrolling 73 patients (mean age 65 ± 8, 27% female) undergoing primary catheter ablation for AF. Patients were evaluated and enrolled from June 2021 to April 2022. Complete TTE assessing measures of LV, LA and right ventricle (RV) structure and function including speckle tracking echocardiography, was performed at baseline. Echocardiographic data have been assessed the same day of the invasive measurement of the LAP during AF ablative procedure. Linear regression analysis has been performed to assess the relationship between measures of cardiac structure and function and LAP. Logistic regression analysis assessed the parameters associated with elevated LAP (≥ 15mmHg). Results Baseline clinical characteristics of the study population did not differ according to elevated LAP vs. non-elevated LAP. Patients with elevated LAP showed instead abnormal measures of LV global longitudinal strain, measures of LA structure and function, except for LA maximal volume, and RV structure and function. After multivariable adjustment, including demographic factors and comorbidities, E/e`(p = 0,024), LA minimal volume (p = 0,009), LA emptying fraction (LAEF) (p = 0,012), LA Reservoir (p = 0,039), TAPSE (p= 0,010) and RV free wall strain (p= 0,028), but not LA maximal volume (p=0,11), were significantly associated with LAP. Similarly, these measures, but nor LA maximal volume, were significant determinants of elevated LAP. Overall, LA minimal volume and LAEF showed the best diagnostic accuracy to predict elevated LAP (AUC 0.72 and 0.73, respectively). Conclusions Novel measures of LA structure and function, but not standard assessment by LA maximal volume, were significantly associated with LAP in patients affected by AF. These measures, along with measures of LV and RV function may be used in the diagnostic assessment of filling pressure in ambulatory settings.

Potential role of left atrial strain in estimation of left atrial pressure in patients with chronic heart failure.

In a large proportion of heart failure with reduced ejection fraction (HFrEF) patients, echocardiographic estimation of left atrial pressure (LAP) is not possible when the ratio of the peak early left ventricular filling velocity over the late filling velocity (E/A ratio) is not available, which may occur due to several potential causes. Left atrial reservoir strain (LASr) is correlated with LV filling pressures and may serve as an alternative parameter in these patients. The aim of this study was to determine whether LASr can be used to estimate LAP in HFrEF patients in whom E/A ratio is not available. Echocardiograms of chronic HFrEF patients were analysed and LASr was assessed with speckle tracking echocardiography. LAP was estimated using the current ASE/EACVI algorithm. Patients were divided into those in whom LAP could be estimated using this algorithm (LAPe) and into those in whom this was not possible because E/A ratio was not available (LAPne). We assessed the prognostic value of LASr on the primary endpoint (PEP), which comprised the composite of hospitalization for the management of acute or worsened HF, left ventricular assist device implantation, cardiac transplantation, and cardiovascular death, whichever occurred first in time. We studied 153 patients with a mean age of 58years of whom 76% men and 82% who were in NYHA class I-II. A total of 86 were in the LAPe group and 67 in the LAPne group. LASr was significantly lower in the LAPne group as compared with the LAPe group (15.8% vs. 23.8%, P<0.001). PEP-free survival at a median follow-up of 2.5years was 78% in LAPe versus 51% in LAPne patients. An increase in LASr was significantly associated with a reduced risk of the PEP in LAPne patients (adjusted hazard ratio: 0.91 per %, 95% confidence interval 0.84-0.98). An abnormal LASr (<18%) was associated with a five-fold increase in reaching the PEP. In HFrEF patients in whom echocardiographic estimation of LAP is not possible due to due to unavailability of E/A ratio, assessing LASr potentially carries added clinical and prognostic value.

Exercise-Induced Left Atrial Hypertension in Heart Failure With Preserved Ejection Fraction

BackgroundMany patients with heart failure and preserved ejection fraction have no overt volume overload and normal resting left atrial (LA) pressure. ObjectivesThis study sought to characterize patients with normal resting LA pressure (pulmonary capillary wedge pressure [PCWP] <15 mm Hg) but exercise-induced left atrial hypertension (EILAH). MethodsThe REDUCE LAP-HF II (A Study to Evaluate the Corvia Medical, Inc. IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure) trial randomized 626 patients with ejection fraction ≥40% and exercise PCWP ≥25 mm Hg to atrial shunt or sham procedure. The primary trial outcome, a hierarchical composite of death, heart failure hospitalization, intensification of diuretics, and change in health status was compared between patients with EILAH and those with heart failure and resting left atrial hypertension (RELAH). ResultsPatients with EILAH (29%) had similar symptom severity, but lower natriuretic peptide levels, higher 6-minute walk distance, less atrial fibrillation, lower left ventricular mass, smaller LA volumes, lower E/e′, and better LA strain. PCWP was lower at rest, but had a larger increase with exercise in EILAH. Neither group as a whole had a significant effect from shunt therapy vs sham. Patients with EILAH were more likely to have characteristics associated with atrial shunt responsiveness (peak exercise pulmonary vascular resistance <1.74 WU) and no pacemaker (63% vs 46%; P < 0.001). The win ratio for the primary outcome was 1.56 (P = 0.08) in patients with EILAH and 1.51 (P = 0.04) in those with RELAH when responder characteristics were present. ConclusionsPatients with EILAH had similar symptom severity but less advanced myocardial and pulmonary vascular disease. This important subgroup may be difficult to diagnose without invasive exercise hemodynamics, but it has characteristics associated with favorable response to atrial shunt therapy. (A Study to Evaluate the Corvia Medical, Inc. IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure [REDUCE LAP-HF TRIAL II]; NCT03088033)

Abstract 12468: Hemodynamic Validation of Echocardiographic Left Ventricular to Left Atrial Volumes Ratio Indices in Heart Failure With Preserved Ejection Fraction

Introduction: The assessment of mean left atrial (LA) pressure rather than Left Ventricular (LV) end-diastolic pressure reflects more accurately filling pressure which is pathophysiological landmark of Heart Failure with preserved Ejection Fraction (HFpEF). Hypothesis: We sought to test whether the measurement of LV to LA volume ratio at the specific cardiac phases can estimate resting LA pressure in patients with HFpEF. Methods: Fifty-three HFpEF patients (mean age 71+-10 years) who underwent cardiac catheterization including direct, at rest, retrograde LA pressure, were analysed. Echocardiographic data was obtained 1.5+-1.0 hours off cardiac catheterization. Patients were divided into: Group 1 (normal filling pressure) and Group 2 (elevated filling pressure, mean LA pressure &gt;12mmHg and/or pulmonary capillary wedge pressure 14mmHg). The ratio of LV/LA volume was measured in end-systole (LV ES /LA max ), end-diastole (LV ED /LA min ), diastasis (LV dias /LA dias ), and as both maximum (LV ED /LA max ), and minimum (LV ES /LA min ). Results: All measured LV/LA ratios were lower in Group 2 as compared to Group 1 and correlated inversely with an increased LA pressure (LV ED /LA min , r=-0.54, p&lt;0.001; LV ES /LA min , r=-0.53, p&lt;0.001; LV ED /LA max , r=-0.52, p&lt;0.001; LV dias /LA dias , r=-0.50, p&lt;0.001; LV ES /LA max , r=-0.37, p=0.013. The following ratios, LV dias /LA dias , LV ED /LA max , LV ED /LA min , and LV ES /LA min , were the most accurate echocardiographic indices to differentiate HFpEF patients between Group 2 and Group 1 (independently off the presence atrial fibrillation), with the area under the curve &gt;0.75 and statistically noninferior to the following a new LA function parameters such as: LA reservoir strain, index LA reservoir strain, LA total emptying fraction and LA active emptying fraction. The cut-off values for LV ES /LA min &lt;1.45 and LV dias /LA dias &lt;1.30 had the sensitivity 78%, 74% and specificity 71%, 71%, respectively, to differentiate patients between Group 2 and Group 1. Conclusions: Among all studied echocardiographic indices the LV ES /LA min and LV dias /LA dias were the most accurate parameters to assess the level of LA pressure in HFpEF.

Potential role of bolus-tracking data of carotid CT angiography for atrial fibrillation prediction.

Atrial fibrillation (AF), a significant cause of ischemic stroke, often goes undetected because of its asymptomatic nature. This study investigated whether the total bolus-tracking time (TTT) and average slope (AS) of a bolus-tracking graph could be used to predict AF. This single-center, retrospective study included patients who underwent carotid CTA and a 24-h Holter test. TTT and the average degree of enhancement during bolus-tracking, derived from carotid CTA, were defined as variables of interest. All patients underwent transthoracic echocardiography. Left ventricular diastolic dysfunction and elevated left atrial pressure (LAP) were identified according to the guidelines of the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging. The final cohort comprised 716 patients, 80 of whom presented with AF. The TTT of the AF group was significantly longer (23.8 ± 5.2 s) than that of the non-AF group (18.7 ± 2.8 s); p < 0.001. The AS of the bolus-tracking graph of the AF group was 0.80 ± 0.24, which was significantly lower than that of the non-AF group 1.38 ± 0.21 (p < 0.001). TTT was associated with a significantly higher risk of AF (odds ratio [OR]: 1.36; p < 0.001) and elevated LAP (OR: 1.46; p < 0.001). In contrast, the AS of the bolus-tracking graph was not significantly associated with either AF or an elevated LAP. TTT derived from bolus-tracking carotid CTA is an effective adjuvant tool for detecting AF related to left ventricular diastolic dysfunction and elevated LAP, confirmed using echocardiography. • Atrial fibrillation is not only a significant cause of ischemic stroke but is also often masked because of its atypical and asymptomatic features. • The total tracking time, derived from bolus tracking of carotid computed tomography angiography, may be an effective adjuvant tool for detecting undiagnosed atrial fibrillation and elevated left atrial pressure in patients.

Relationship between left ventricular diastolic function and the risk of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation.

In patients with nonvalvular atrial fibrillation (NVAF), the impact of left ventricular diastolic function on the risk of left atrial appendage (LAA) thrombus has rarely been studied. This prospective study aimed to investigate the relationship between diastolic function and the risk of LAA thrombus in patients with NVAF. Seventy-six patients with NVAF admitted to receive radiofrequency catheter ablation were prospectively enrolled. All the patients underwent transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in 24h before ablation. Diastolic function was estimated by TTE including left atrial volume index (LAVI) and E/e', as well as invasive left atrial pressure (LAP) measured during the ablation procedure. LAA peak emptying velocity (LAA-PEV) and the intensity of spontaneous echo contrast (SEC) were determined by TEE. Average E/e', LAVI and mean LAP had a significant positive correlation with the intensity of SEC, the coefficient of correlation were 0.344 (p = 0.002), 0.416 (p < 0.001) and 0.402 (p < 0.001), respectively. After adjustment for CHA2DS2-VASc score and type of AF, multivariate regression analysis revealed that increased LAP (OR 1.144, 95% CI 1.012-1.293, p = 0.031) independently correlated with the risk of LAA thrombus (SEC ≥ Grade 2). LAA-PEV showed a significantly inverse relationship with mean LAP in patients with AF (r = - 0.525, p < 0.001), and in the assessment of elevated LAP with TEE, the LAA-PEV cut-off of 0.40m/s had a sensitivity of 80%, specificity of 81%. Left ventricular diastolic dysfunction may constitute a potential risk for LAA thrombus and stroke. Furthermore, evaluation of LAA emptying with use of TEE is helpful for assessing the LAP status of patients with AF.

The validation of left atrial strain imaging for the assessment of diastolic functions in patients with ST-segment elevation myocardial infarction.

Assessment of left ventricular filling pressure (LVFP) is crucial in patients with ST-segment elevation myocardial infarction (STEMI). Since current guideline recommended echocardiographic parameters have limited value, more comprehensive assessment methods are required in this patient subset.In this study, we aimed to investigate the clinical utility of left atrial reservoir strain (LARS) imaging in patients treated with primary percutaneous coronary intervention (pPCI). Patients who underwent successful pPCI were included. Left ventricular end-diastolic pressure (LVEDP) was measured invasively following pPCI. Left atrial strain imaging was performed following pPCI within 24 h of pPCI. Normal LARS value was accepted as above 23%. We prospectively enrolled 69 patients; there were 18 patients with LARS below 23% who were included into group 1 and rest of the study population included into group 2. There was no significant difference between groups in terms of comorbidities.Troponin and pro-BNP levels were significantly higher in group 1 (p: 0.036 and 0.047 respectively). Left atrial volume and tricuspid regurgitation velocity were similar between groups (p: 0.416 and p: 0.351 respectively). Septal tissue velocity was higher (p: 0.001) and Septal E/e’ ratio was lower (p: 0.004) in group 2. Left ventricular (LV) global longitudinal strain value was higher in group 1 which is consistent with observed lower ejection (LVEF) fraction in group 1 (p: 0.001 for LV strain and p: 0.001 for LVEF). Estimated mean LVFP was also higher in group 1 (p: 0.003).Correlation analyses revealed moderate correlation between LARS and LVEDP (r: − 0.300). Our results indicate that left atrial strain imaging is a promising tool for the assessment of left atrial pressure in patients with STEMI.

Latent Pulmonary Vascular Disease May Alter the Response to Therapeutic Atrial Shunt Device in Heart Failure.

In REDUCE LAP-HF II (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure), implantation of an atrial shunt device did not provide overall clinical benefit for patients with heart failure with preserved or mildly reduced ejection fraction. However, prespecified analyses identified differences in response in subgroups defined by pulmonary artery systolic pressure during submaximal exercise, right atrial volume, and sex. Shunt implantation reduces left atrial pressures but increases pulmonary blood flow, which may be poorly tolerated in patients with pulmonary vascular disease (PVD). On the basis of these results, we hypothesized that patients with latent PVD, defined as elevated pulmonary vascular resistance during exercise, might be harmed by shunt implantation, and conversely that patients without PVD might benefit. REDUCE LAP-HF II enrolled 626 patients with heart failure, ejection fraction ≥40%, exercise pulmonary capillary wedge pressure ≥25 mm Hg, and resting pulmonary vascular resistance <3.5 Wood units who were randomized 1:1 to atrial shunt device or sham control. The primary outcome-a hierarchical composite of cardiovascular death, nonfatal ischemic stroke, recurrent HF events, and change in health status-was analyzed using the win ratio. Latent PVD was defined as pulmonary vascular resistance ≥1.74 Wood units (highest tertile) at peak exercise, measured before randomization. Compared with patients without PVD (n=382), those with latent PVD (n=188) were older, had more atrial fibrillation and right heart dysfunction, and were more likely to have elevated left atrial pressure at rest. Shunt treatment was associated with worse outcomes in patients with PVD (win ratio, 0.60 [95% CI, 0.42, 0.86]; P=0.005) and signal of clinical benefit in patients without PVD (win ratio, 1.31 [95% CI, 1.02, 1.68]; P=0.038). Patients with larger right atrial volumes and men had worse outcomes with the device and both groups were more likely to have pacemakers, heart failure with mildly reduced ejection fraction, and increased left atrial volume. For patients without latent PVD or pacemaker (n=313; 50% of randomized patients), shunt treatment resulted in more robust signal of clinical benefit (win ratio, 1.51 [95% CI, 1.14, 2.00]; P=0.004). In patients with heart failure with preserved or mildly reduced ejection fraction, the presence of latent PVD uncovered by invasive hemodynamic exercise testing identifies patients who may worsen with atrial shunt therapy, whereas those without latent PVD may benefit.