Left Atrial Pressure Overload Research Articles

Acute Effect of Atrial Fibrillation on Circulating Natriuretic Peptides: The Influence of Heart Rate, Rhythm Irregularity, and Left Atrial Pressure Overload

Plasma natriuretic peptides (NPs) are increased in patients with atrial fibrillation (AF) compared with the patients with sinus rhythm. This study investigated whether this phenomenon is intrinsic to heart rhythm irregularity and independent of the heart rate and left atrial pressure (LAP) overload. We investigated 46 patients (age: 59 ± 10years, male gender: 77%) with non-valvular paroxysmal AF who were scheduled for catheter ablation and had documented stable sinus rhythm for at least 18hours before the procedure. All patients underwent direct measurement of right atrial pressure and LAP, simultaneously with assessment of plasma B-type NP, N-terminal pro-brain NP, and mid-regional pro-atrial NP. The baseline measurement was followed by induction of AF by rapid atrial pacing in the first 24 patients and by regular pacing from the coronary sinus at 100/min (corresponding to the mean heart rate during induced AF) in the latter 22 patients. Hemodynamic assessment and blood sampling were repeated after 20min of the ongoing AF or fast regular paging. The baseline characteristics and hemodynamic measurements were comparable between study groups; however, patients in the regular atrial pacing group had a higher body mass index and a larger left atrial diameter compared with the induced AF group. Plasma levels of all 3 NPs increased significantly during induced AF but not during fast regular pacing, and the increase of NPs was independent of right atrial pressure and LAP. Baseline concentrations of NPs and heart rhythm irregularity were the only independent predictors of increased NPs.

Impact of Sex in Left Atrial Indices for Prognosis of Heart Failure with Preserved Ejection Fraction.

Objective: We aim to clarify the differences in the association between re-admission for heart failure (HF) and left atrial (LA) overload indices by sex in heart failure and a preserved ejection fraction (HFpEF). Methods: We analyzed 898 HFpEF patients hospitalized for acute decompensated HF. Blood tests and transthoracic echocardiography were performed before discharge. The primary endpoint was re-admission for HF during the first year. Results: The ratio of diastolic elastance to arterial elastance (p = 0.014), a relative index of LA pressure overload, in men and LA volume index (LAVI, p = 0.020) in women were significant for re-admission for HF during the first year in the multivariable Fine–Gray analysis. Stroke volume (SV)/LA volume (LAV), another index for LAV overload, was not a significant prognostic factor of re-admission for HF during this time. Conclusion: LA overload was an important prognostic factor for HF re-readmission during the first year after enrolment in patients with HFpEF, but the indices relating to LA overload differed by sex.

Relation of left atrial overload indices with prognostic endpoints in heart failure and preserved ejection fraction

AimsConsiderable variation in the relationships between the indices of left atrial (LA) volume and pressure could possibly affect the selection of medications or efforts to improve the prognoses of patients with heart failure and preserved ejection fraction (HFpEF). We aimed to clarify the association between the prognostic endpoint and LA overload indices in elderly patients with HFpEF.Methods and resultsWe analysed 898 patients with HFpEF hospitalized for acute decompensated heart failure (men/women: 406/492). Blood tests and transthoracic echocardiography were performed before discharge. The primary endpoint was re‐admission for heart failure or all‐cause mortality. Stroke volume (SV)/left atrial volume (LAV), an index for LA volume overload, was a significant prognostic factor of re‐admission for heart failure in the multivariable Cox hazard analysis adjusted for comorbidities [hazard ratio (HR) 0.616, 95% confidence interval (CI) 0.430–0.882, P = 0.008]. Additionally, the ratio of diastolic elastance (Ed) to arterial elastance (Ea), an index for LA pressure overload, was also significant (HR 1.444, 95% CI 1.014–2.058, P = 0.041). Furthermore, Ed/Ea, but not SV/LAV, was a significant prognostic factor of all‐cause mortality (HR 1.594, 95% CI 1.102–2.306, P = 0.013).ConclusionsThe index of LA overload for prognosis may differ according to the different endpoints in elderly patients with HFpEF.

Left atrial pressure overload and prognosis in elderly patients with heart failure and preserved ejection fraction: a prospective multicenter observational study

ObjectivesThe severity of diastolic dysfunction is assessed using a combination of several indices of left atrial (LA) volume overload and LA pressure overload. We aimed to clarify which overload is...

Abstract 14456: Left Atrial Pressure Overload in Relation to N-terminal Pro-brain Natriuretic Peptide Level on Prognosis in Patients With Heart Failure With Preserved Ejection Fraction With and Without Atrial Fibrillation

Objective: We aimed to clarify the differences in the significance of the ratio of diastolic elastance (Ed) to arterial elastance (Ea), [Ed/Ea=(E/e’)/(0.9 х systolic blood pressure)], a relative index of left atrial (LA) pressure overload, in relation to N-terminal pro-brain natriuretic peptide (NT-proBNP) level on prognosis between patients with heart failure with preserved ejection fraction (HFpEF) with and without atrial fibrillation (AF). Methods: We studied 297 HFpEF patients hospitalized for acute decompensated heart failure (sinus rhythm/AF: 192/105). Blood testing and transthoracic echocardiography were performed before discharge. All-cause mortality was evaluated at >1 year after discharge. Results: During a median follow-up of 626 days, 47 patients (sinus rhythm/AF: 30/17) had all-cause mortality. In the subgroup with sinus rhythm, but not AF, Ed/Ea was significantly higher in patients with than without all-cause mortality. In a multivariate Cox hazard analysis, Ed/Ea was significantly associated with all-cause mortality independent of NT-proBNP in patients with sinus rhythm, but not with AF. Among patients with higher NT-proBNP levels, the effect of higher Ed/Ea on prognosis was prominent only in those with sinus rhythm (p=0.037). Conclusions: Ed/Ea provides additional prognostic information to serum NT-proBNP level for predicting all-cause mortality only in HFpEF patients with sinus rhythm. The prognostic risk factors differed between elderly HFpEF patients with and without AF.

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study.

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume–pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference.

Considerable scatter in the relationship between left atrial volume and pressure in heart failure with preserved left ventricular ejection fraction

The index for a target that can lead to improved prognoses and more reliable therapy in each heterogeneous patient with heart failure with preserved ejection fraction (HFpEF) remains to be defined. We examined the heterogeneity in the cardiac performance of patients with HFpEF by clarifying the relationship between the indices of left atrial (LA) volume (LAV) overload and pressure overload with echocardiography. We enrolled patients with HFpEF (N = 105) who underwent transthoracic echocardiography during stable sinus rhythm. Relative LAV overload was evaluated using the LAV index or stroke volume (SV)/LAV ratio. Relative LA pressure overload was estimated using E/e’ or the afterload-integrated index of left ventricular (LV) diastolic function: diastolic elastance (Ed)/arterial elastance (Ea) ratio = (E/e’)/(0.9 × systolic blood pressure). The logarithmic value of the N-terminal pro-brain natriuretic peptide was associated with SV/LAV (r = −0.214, p = 0.033). The pulmonary capillary wedge pressure was positively correlated to Ed/Ea (r = 0.403, p = 0.005). SV/LAV was negatively correlated to Ed/Ea (r = −0.292, p = 0.002), with no observed between-sex differences. The correlations between the LAV index and E/e’ and Ed/Ea and between SV/LAV and E/e’ were less prominent than the abovementioned relationships. SV/LAV and Ed/Ea, showing relative LAV and LA pressure respectively, were significantly but modestly correlated in patients with HFpEF. There may be considerable scatter in the relationships between these indices, which could possibly affect the selection of medications or efforts to improve the prognoses of patients with HFpEF.

P321A single factor related to left atrial pressure overload is useful for prognosis in elderly patients with heart failure with preserved ejection fraction: PURSUIT HFpEF study

Abstract Background E/e' and the ratio of diastolic elastance (Ed)/arterial elastance (Ea) = (E/e')/(0.9 × systolic blood pressure), indices of left atrial (LA) pressure overload, are elevated in elderly women with heart failure with preserved ejection fraction (HFpEF). The severity of diastolic dysfunction is assessed by a combination of several indices of LA volume and pressure overload. However, which overload is more important as a single factor for the prognosis of these patients remains undefined. Methods We enrolled patients with HFpEF showing sinus rhythm (n=145; left ventricular ejection fraction >50%; men/women, 56/89; mean age, 80.5 years). Blood examination and transthoracic echocardiography were performed before discharge. All-cause mortality and admission for cardiac events were evaluated after more than 1 year (mean, 370 days). Results The all-cause mortality rate was 11% (16/145). There were significant differences in age (p=0.005), serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level (p<0.001), LA volume index (p=0.018), E/e' (p=0.022), and Ed/Ea (p=0.016) between patients with and without all-cause mortality. When cutoff points for mortality by receiver operating characteristic curve analysis were examined, the area under the curve in LA volume index (0.564) was slightly smaller than that in age (0.734), NT-proBNP level (0.732), E/e' (0.695), and Ed/Ea (0.709). Kaplan-Meier survival analysis clearly showed that age >85 years (p<0.001), NT-proBNP level >888 pg/mL (p=0.003), E/e' >14.4 (p=0.020), and Ed/Ea >0.153 (p<0.001) were determinant factors for mortality. Cox hazard ratios were also significant in these indices (p=0.002, p=0.012, p=0.028, and p=0.001, respectively). In the case of all-cause mortality or admission for cardiac events, the results were nearly similar as those in the case of all-cause mortality. Ed/Ea exhibited a larger Cox hazard ratio for prognosis than E/e' in the multivariate analysis. Conclusions LA pressure overload compared to volume overload was a useful marker for prognosis in elderly patients with HFpEF. As a single index for LA pressure overload in noninvasive echocardiographic findings, Ed/Ea may be more suitable than E/e'.

197 Left Atrial Remodelling and Atrioventricular Coupling in a Canine Model of Early Heart Failure with Preserved Ejection Fraction

Background Left atrial (LA) compliance and contractility are key determinants of left ventricular (LV) stroke volume. LA remodelling and dysfunction in heart failure with preserved ejection fraction (HFpEF) are considered to be late presenting features, secondary to hypertension-induced LV diastolic dysfunction and chronic LA pressure overload. However, a recent unifying hypothesis has stipulated that systemic and coronary microvascular inflammation drive HFpEF pathophysiology. Considering this paradigm, we hypothesised that diminished LA compliance and contractile function occur early during HFpEF development and further impair cardiac performance. Methods Cardiac magnetic resonance imaging, echocardiography, invasive LV and LA pressure volume (PV) analysis and tissue analysis were performed in an experimental model of early-stage HFpEF (elderly dogs with renal wrap induced hypertension and exogenous aldosterone; n = 9) and young control dogs (sham surgery; n = 13). Results Early HFpEF was associated with LA enlargement, LA myocyte hypertrophy, and enhanced LA contractile function (LA active emptying fraction 18 ± 6 vs 12 ± 2%, p = 0.03; LA end-systolic PV relationship slope: 2.7 ± 0.9 HFpEF vs 1.5 ± 0.6 mmHg/mL controls, p = 0.01). However left atrioventricular systolic coupling was impaired (ratio of LV to LA end-systolic PV relationship slope 1.3 ± 0.4 HFpEF vs 0.8 ± 0.4 Controls, p 2 , p = 0.07) and inversely correlated with LA s (r=-0.66, p = 0.006). Titin isoform composition (N2BA/N2B ratio) was similar between groups, but titin hyperphosphorylation was seen in HFpEF LA and LV tissue. LA titin hyperphosphorylation correlated with LA s (r = 0.54, p = 0.03). LA microvascular reactivity was also diminished in HFpEF versus controls. Conclusions Maladaptive LA remodelling is present in early-stage experimental HFpEF and compromises overall cardiac performance. Reduced LA compliance in HFpEF may relate to contributions from LA ischaemia and titin-based cardiomyocyte stiffening. Thus, pathophysiological mechanisms involved in the development of HFpEF directly affect both atrial and ventricular myocardium.

Left atrial function in volume versus pressure overloaded left atrium

Left atrial (LA) pressure and volume overload both result in cavity enlargement and complications. LA volume has been shown to predict such complications, but it does not reflect myocardial function, which can be accurately assessed using myocardial deformation measurements. We hypothesized that volume overloaded LA have maintained myocardial function compared to pressure overloaded ones. We tested this hypothesis in 44 patient (mean age 62 ± 12 years) with LA volume overload (LAVOL) due to severe mitral regurgitation (MR) with no indirect signs of elevated left ventricular (LV) filling pressures based on Doppler measured isovolumic relaxation time >60 ms. We compared them with 24 (mean age 64 ± 12 years) patient with LA pressure overload (LAPOL) who proved to have PCWP >15 mmHg on right heart catheterization. Twenty-seven healthy controls (mean age 57 ± 10 years) constituted a control group. Patients with LAVOL had larger LA volumes, higher LV ejection fraction, global LV strain (LVGLS) and transmitral and pulmonary veins flow velocities (p < 0.05) and better LA atrial strain rate (LASR) function compared to LAPOL (p < 0.001). In LAVOL, the LASR during atrial contraction (LASRa) was lower than in controls (p < 0.05) indicating LA mechanical disturbances. LVGLS correlated with peak atrial longitudinal systolic strain in the whole group (r = -0.65, p < 0.001) and less so with LASRa (r = -0.43, p < 0.001) CONCLUSION: Irrespective of a smaller LA volume, LAVOL had less negative effect on LA myocardial function than LAPOL. Thus, monitoring atrial myocardial contraction might be useful in following patients with significant MR.

Noninvasive assessment of filling pressure and left atrial pressure overload in severe aortic valve stenosis: Relation to ventricular remodeling and clinical outcome after aortic valve replacement

One of the hemodynamic consequences of aortic valve stenosis is pressure overload leading to left atrial dilatation. Left atrial size is a known risk factor providing prognostic information in several cardiac conditions. It is not known if this is also the case in patients with aortic valve stenosis after aortic valve replacement. A total of 119 patients with severe aortic valve stenosis scheduled for aortic valve replacement were evaluated preoperatively and divided into 2 groups according to left atrial volume index (≥40 mL/m(2)). Echocardiography was repeated 12 months after surgery. Patients were followed up for 24 months. The primary end point was the composite end point overall mortality and hospitalization due to congestive heart failure. Preoperative left atrial dilation was associated with left ventricular hypertrophy and increased filling pressure. Preoperative left atrial volume index was associated with persistent abnormalities in left ventricular filling pressure and left ventricular mass index at 1 year after surgery. Event-free survival in patients with left atrial volume index of 40 mL/m(2) or more at 1 year was 71% compared with 88% in patients with left atrial volume index less than 40 mL/m(2) (P = .002). Patients with preoperative increased E/e' ratio and left ventricular hypertrophy were at increased risk. In Cox regression analysis after correcting for standard risk factors, left atrial volume index was found to be the only significant predictor of the composite end point. In a forward conditional multivariable model, left atrial volume index 40 mL/m(2) or greater (hazard ratio, 4.2 [1.6-10.7]; P = .003) remained an independent predictor, whereas E/e' was borderline significant (P = .06). In patients with symptomatic severe aortic valve stenosis undergoing aortic valve replacement, left atrial volume provides important prognostic information beyond standard risk factors.