Left Atrial Pump Research Articles

409 Left atrial pump function assessed by speckle tracking echocardiography adds important value for the diagnosis of heart failure with preserved ejection fraction

Abstract Funding Acknowledgements “This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number PN-III-P1-1-TE-2016-0669, within PNCDI III” Background Differentiation between heart failure with preserved ejection fraction (HFpEF) and isolated diastolic dysfunction (DD) at rest is crucial, since the prognosis is different. Symptoms are often non-specific, while NTproBNP might not be available. Increased NTproBNP is predicted by none of the currently used transthoracic echocardiographic (TTE) parameters. However, assessment of left atrial (LA) function by speckle tracking echocardiography (STE) might be a potential new marker of increased LV filling pressure. Aim. To assess LA function by STE in HFpEF and DD, on top of the currently used TTE parameters, in order to establish the added value of LA deformation in the diagnosis of HFpEF. Methods 70 patients were enrolled prospectively: 40 with HFpEF (68 ± 9 yrs) and 30 with DD (60 ± 10 yrs). TTE was used to assess LV ejection fraction (LVEF), E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP). STE was used to assess LA functions: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), and LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct). NTproBNP was measured in all patients. Results HFpEF patients had significantly higher LVEF, NTproBNP, E/E’ ratio, and sPAP, but similar LAVi compared to DD, suggesting higher LV filling pressure (Table). LA reservoir and conduit function were similar. However, LA pump function was significantly lower in HFpEF, expressed by LASRct (Tabel). NTproBNP correlated with E/E’ ratio, sPAP, and LASRct (all r = 0.44, p < 0.001), but not with LAVi. By multiple regression analysis, best predictor for NTproBNP > 125pg/ml was LASRct (r = 0.60, r2 =0.30, p < 0.001). LASRct < -1.29 (AUC = 0.82, sensitivity 75%, specificity 81%) was the only predictor of NTproBNP > 125pg/ml (Figure). Conclusion LA pump function is the only predictor of NTproBNP > 125pg/ml. This parameter should be incorporated in the current protocols for the diagnosis of HFpEF. Group (N) NTproBNP ng/ml LVEF (%) E/E’ sPAP (mmHg) LAVi (ml/m2) LASr (%) LASRr LAScd (%) LASRcd LASRct HFpEF (40) 329 ± 383 62 ± 6 10.4 ± 2.7 34 ± 11 40 ± 9 25 ± 4 1.28 ± 0.3 11.6 ± 5.5 -1.37 ± 0.5 -1.07 ± 0.6 DD (30) 37 ± 26 57 ± 8 7.5 ± 1.8 23 ± 7 39 ± 11 26 ± 6 1.26 ± 0.3 11.2 ± 3.6 -1.5 ± 0.6 -1.76 ± 0.7 P value 0.001 0.008 <0.001 <0.001 0.7 0.4 0.8 0.7 0.4 <0.001 Abstract 409 Figure.

P1358 New insights into cardiac dysfunction assessed by left atrial function in patients with type 1 diabetes mellitus

Abstract BACKGROUND There have been many reports of heart failure due to diabetic cardiomyopathy and decreased left ventricular (LV) function with increasing age in patients with type 1 diabetes mellitus (T1DM). Recently, although left atrial (LA) function has been occasionally reported to be a more useful prognostic indicator than LV function in acquired heart diseases, LA function in patients with T1DM has not yet been studied. PURPOSE To investigate LA dysfunction in patients with T1DM. METHODS Fifty patients with T1DM were recruited (age, 5–41 years). We excluded patients who had a history of heart disease, hypertension, and those taking cardioprotective agents. The patients and 50 age-matched controls were classified into 3 age groups (D1, C1, 5–14 years; D2, C2, 15–29 years; D3, C3, 30–41 years). The LA phasic function serving as the reservoir, conduit, and pump strains; the LA strain rate (SR) in the systole, early diastole, and late diastole; and the LV global longitudinal strain (LV-LS) as determined via 2-dimensional speckle tracking imaging were measured from the apical four- and two-chamber views. We also calculated the LA stiffness index as the ratio of E/e’ to the LA reservoir strain. RESULTS There was no significant difference in left ventricular ejection fraction in each age group. The LA reservoir strains in D2 and D3 were significantly lower than those in C2 (40.8 ± 5.7% vs. 47.2 ± 5.5%, p = 0.005) and C3 (39.2 ± 5.5% vs. 47.3 ± 5.7%, p = 0.004), respectively. The LA conduit strain in D2 was significantly lower than that in C2 (28.9 ± 5.8% vs. 35.0 ± 5.0%, p = 0.006). The LA pump strain and the three phases of LA SR were not significantly different among the age groups. The LA stiffness index in D3 increased significantly compared to that in N3 (0.18 ± 0.05 vs. 0.13 ± 0.01, p <0.001). The LV-LS in D2 and D3 was significantly lower than that in C2 (-15.7 ± 1.7% vs. -18.7 ± 2.1%, p <0.001) and C3 (-15.3 ± 1.8% vs. -19.3 ± 2.0%, p <0.001), respectively. The LA reservoir strain significantly correlated with LV-LS (r = -0.468, p < 0.001). Both the LA reservoir strain and LV-LS in patients with T1DM decreased significantly (p = 0.028, p < 0.042, respectively) and correlated with increasing age (r = -0.323, r = 0.286, respectively). The LV stiffness index did not correlate with age or LV-LS. CONCLUSIONS The LA reservoir strain might be as useful as LV-LS as an early marker of cardiac dysfunction in patients with T1DM. The correlation coefficient between the LA reservoir strain and LV-LS was not strong. Therefore, although LV-LS might affect the LA reservoir strain, it might represent other aspects of cardiac dysfunction. The increase of LA stiffness might represent the changes in LA wall properties and could be another useful indicator of cardiac dysfunction during long-term follow-ups, which is independent of LV-LS. Overall, these findings provide new insights into cardiac dysfunction in patients with T1DM.

Use of echocardiography to stratify the risk of atrial fibrillation: comparison of left atrial and ventricular strain.

Although both left atrial (LA) and ventricular (LV) dysfunction has been accepted as an important risk factor of atrial fibrillation (AF), usefulness of LA and LV strain has not been fully compared for prediction of AF. The aims of this study were to clarify the associations of both LA and LV strain with AF and to compare their predictive values in the risk stratification for AF. We evaluated 531 consecutive patients (median age 67 years, 56% male), with no history of AF who underwent echocardiography after cryptogenic stroke. Standard echocardiographic parameters were measured, and speckle-tracking was used to measure LA (reservoir, pump, and conduit strain) and LV strain (global longitudinal strain, GLS). The baseline clinical and echocardiographic parameters of the patients who developed AF and those who did not were compared. Median 36 months of follow-up, 61 patients (11%) had newly diagnosed AF. LA pump strain and GLS were significantly and independently associated with AF and provided incremental predictive value over clinical and standard echocardiographic parameters. Areas under the receiver-operating curves for GLS (0.841) were comparable to LA pump (0.825) and reservoir (0.851) strain. However, predictive value of both strains was different between patients with and without LA enlargement at the time of transthoracic echocardiography screening. LA strain was more useful than LV strain in patients with normal LA volumes, while LV strain was more useful than LA strain in patients with abnormal LA volumes. Both LA and LV strain are significantly and independently associated with AF and provide incremental predictive value over clinical and standard echocardiographic parameters. However, priorities of strain assessment are different depends on patients' condition at the time of echocardiography.

2140Association of arterial stiffness with left atrial structure and phasic function: a community-based cohort study

Abstract Background Increased arterial stiffness is recognized as an independent risk factor for atrial fibrillation, although the pathophysiological mechanisms remain unclear. Cardio-ankle vascular index (CAVI) is emerging as an important tool to assess arterial stiffness noninvasively which is derived from the concept of stiffness β index and is less dependent on blood pressure at the time of measurement than pulse wave velocity. Purpose This study aimed to investigate the association of arterial stiffness with left atrial (LA) volume and phasic function in a community-based cohort. Methods We included 1,156 participants without overt cardiovascular disease who underwent extensive cardiovascular examination. Arterial stiffness was evaluated by CAVI. Speckle-tracking echocardiography was employed to evaluate LA phasic function including reservoir, conduit and pump strain as well as left ventricular global longitudinal strain (LVGLS). Results CAVI was negatively correlated with reservoir and conduit strain (r=−0.37 and −0.45, both p<0.001; Figure), whereas weakly, but positively correlated with LA volume index and pump strain (r=0.12 and 0.09, both p<0.01). In multivariable analysis, CAVI was significantly associated with reservoir and conduit strain independent of traditional cardiovascular risk factors, pertinent laboratory parameters and LV morphology and function including LVGLS (standardized β=−0.22 and −0.26, respectively, both p<0.001), whereas there was no independent association with LA volume index and pump strain. In the categorical analysis, the abnormal CAVI (≥9.0) carried the significant risk of impaired reservoir (<31.4%) and conduit (<12.4%) strain (adjusted odds ratio = 2.63 and 3.71 vs. normal CAVI, both p<0.01) in a fully-adjusted model including laboratory and echocardiographic parameters. Figure 1 Conclusion Arterial stiffness was independently associated with LA reservoir and conduit function, even in the absence of overt cardiovascular disease. This association may explain the higher incidence of atrial fibrillation in individuals with increased arterial stiffness.

P4379Pathophysiology of left atrial filling in mitral regurgitation. A new volumetric flow rate index describing disturbed left atrial filling behavior in mitral regurgitation by 3D TTE

Abstract Background In chronic mitral regurgitation (MR) the left atrium (LA) is one of the first cardiac structures involved in remodeling by progressive volume overload. Real-time three-dimensional echocardiography is able to monitor volumetric changes of the left atrium during the heart cycle. Purpose We hypothesized that chronic volume overload due to MR leads to detectable changes in the LA filling behavior described by mean and maximum filling flow rates and their relation called volumetric flow rate index. Methods We prospectively analyzed data of 36 patients in different stages of chronic MR and 13 patients without MR. Transthoracic echocardiography was conducted using the Epiq 7G Ultrasound System. Standard 2D- and 3D apical 4-chamber views were recorded and stored for offline analysis. We generated volume-time-curves by 3D volume analysis to derive mean and maximum volumetric flow rates during LA reservoir, conduit and pump phase. Volumetric flow rate index was calculated as the quotient of mean flow rate/maximum flow rate. Results Average MR severity, calculated with the MR Scoring system introduced from Buck et al. and implicated in the ESC Guidelines, was 6.2 points (±2.5) according to Grade I-II. We included 13 patients without MR, 18 with mild MR, 12 patients with moderate MR, 6 patients with severe MR. Left ventricular ejection fraction was similar in the different groups (51,2±12,3%). Maximum and mean flow rate showed no significant correlation with MR severity. Correlation of MR severity with LA dilation (ml/m2 BSA) was r=0.41; p<0.001. Flow rate index showed strong significant correlation with MR severity in left atrial reservoir phase (r=−0.75; p<0.001). There was no statistically relevant difference of volumetric flow rate parameters in left atrial pump and conduit phase. Line chart Conclusions We observed a significant correlation of the volumetric flow rate index to MR severity in the left atrial reservoir phase with stronger correlation than MR severity to left atrial dilation. The results of this work encourage further investigations to establish the presented volumetric flow rate index as a progression marker of MR and to evaluate its prognostic value.

P2457Left atrial strain parameters predict clinical outcomes in patients with HFmrEF and HFpEF

Abstract Background Heart failure with preserved ejection fraction (HFpEF) and with mid-range ejection fraction (HFmrEF) are conditions sharing similar diagnostic criteria and symptoms. Left ventricular (LV) diastolic dysfunction has often been considered central to the pathophysiology of both, as determined by current conventional echocardiographic measures of elevated filling pressure and/or an increased in left atrial (LA) volume. However, the independent prognostic importance of LA function, beyond clinical predictors and LV features, in those groups remains unclear. Aims To evaluate the prognostic value of LA function measured by speckle tracking echocardiography in patients with new diagnosis of HFpEF and HFmrEF. Methods A total of 171 consecutive patients diagnosed with HFpEF with an Ejection Fraction (EF) ≥50%, or HFmrEF with an EF of 40–49% were prospectively enrolled and followed up. Follow-up was completed in 134 patients with HFpEF (n=100) and HFmrEF (n=34) for a median period of 57 months. Baseline characteristic and comorbidities were recorded, as well as conventional resting echocardiographic parameters of systolic and diastolic function. Left atrial phasic function was analysed using 2D-Specle Tracking. Peak-atrial longitudinal strain (PALS) and peak-atrial contraction strain (PACS) were measured, reflecting LA reservoir and pump function respectively. We looked at the relationship of traditional parameters of systolic and diastolic function and LA strain, with the following cardiovascular (CV) events: acute coronary syndromes, new atrial fibrillation, cerebrovascular events, HF-related admissions and cardiac deaths. Results During a median follow up period of 57 months (range 11.10), of 134 patients, 42 (31%) had at least one CV event, 10 (8%) out of whom had at least one HF-related hospitalization and 5 (4%) had cardiac death. 92 patients (69%) remained event-free. In univariate analysis, lower PALS and PACS were associated with increased risk for the composite endpoint of all CV-events (PALS OR=0.92 p<0.01 and PACS OR=0.92 p<0.05), but only PALS predicted HF admissions (PALS OR=0.86 p<0.05). In multivariate analysis after adjusting for LV EF, E/e' and LAVi, PALS remained significant at predicting CV-events (OR=0.91 p<0.05) and HF admissions (OR=0.85 p<0.05), but PACS did not. Amongst all echocardiographic parameters measured, PALS had the greatest Area Under the Curve at Receiver Operating Characteristics analysis (AUC=0.78 p<0.05) and a PALS value of <23% best predicted future HF-related admissions (sensitivity 0.9, specificity 0.6). Conclusion LA dysfunction in HFpEF and HFmrEF is associated with a higher risk of CV events and HF hospitalizations. The association of LA strain with HF hospitalization remained significant after adjustment for systolic and diastolic parameters.

Left Atrial Mechanical Dispersion Assessed by Strain Echocardiography as an Independent Predictor of New-Onset Atrial Fibrillation: A Case-Control Study

Left atrial (LA) enlargement is associated with atrial fibrillation (AF), but new-onset AF often occurs in the absence of LA enlargement. AF may be related to myocardial fibrosis, and even though left ventricular fibrosis is associated with mechanical dispersion, this phenomenon is not well studied in AF. We hypothesized that detection of LA dysfunction and mechanical dispersion using strain echocardiography is useful for predicting new-onset AF. Baseline echocardiography was performed at entry in 576 community-based participants at risk of heart failure or AF. In this case-control study, we compared 35 individuals with new-onset AF (age 70±4years; 57% men) over 2years of follow-up with 35 age- and sex-matched individuals who did not develop AF from the same cohort. Using speckle-tracking echocardiography, we measured the LA strain in each of 12 segments in the two- and four-chamber views. LA mechanical dispersion was defined as the SD of time to peak positive strain corrected by the R-R interval (SD-TPS, %). There was no significant difference in LA volume index (32.5±9.2mL/m2 vs 29.5±8.3mL/m2; P=.16); patients with new-onset AF had significantly worse LA pump strain (16.6%±4.3% vs 20.6%±4.3%; P<.01) and reservoir strain (31.4%±7.7% vs 38.0%±7.3%; P<.01) than those without AF. SD-TPS was significantly higher in patients with AF than in those without it (6.3%±2.3% vs 3.9%±1.6%; P<.01). SD-TPS was independently associated with new-onset AF after adjustment for patient characteristics, LA volume, and strain (hazard ratio=1.26; 95% CI, 1.10-1.45; P<.01). In the nested Cox models, the model based on the LA volume and strain for predicting new onset AF was significantly improved by adding SD-TPS (P<.01). LA dispersion obtained from strain echocardiography seems to provide incremental information about LA volume and function in the prediction of new-onset AF and warrants testing in a larger study.

Left atrial phasic function in hypertensive patients with significant aortic stenosis and preserved ejection fraction.

The purpose of this investigation was to evaluate the influence of hypertension on left atrial (LA) function in patients with moderate and severe AS. This cross-sectional study included 121 patients with moderate and severe AS and preserved left ventricular (LV) ejection fraction ( > 50%) and 79 age-matched controls who underwent a comprehensive echocardiographic examination. LA phasic function was determined by both volumetric and strain methods. Our findings showed that the LV ejection fraction was similar between hypertensive and normotensive AS patients. Maximal, minimal, and pre-A LA volume indexes gradually increased from controls to moderate-to-severe AS patients. The total, passive and active LA emptying fraction (EF) gradually decreased in the same direction. LA phasic function estimated with strain analysis showed that reservoir, conduit, and pump LA phasic functions were lower in all AS patients than in normotensive controls. However, there was no significant difference between moderate and severe AS except in LA pump function, which was lower in severe AS. Differences in LA phasic function were more prominent in volumetric than in strain analyses. Blood pressure, LV mass index, and AS severity were independent of other clinical and echocardiographic parameters associated with LA phasic function in patients with AS. In conclusion, hypertension has an additive impact on LA phasic function in patients with moderate and severe AS. Blood pressure and AS severity were independently associated with LA phasic function parameters in AS patients. Volumetric assessment of LA phasic function should not be completely replaced with strain analysis.

Evaluation of Left Atrial Functions by 2-dimensional Speckle-Tracking Echocardiography During Healthy Pregnancy.

We aimed to determine the effects of normal pregnancy on left atrial (LA) mechanics using 2-dimensional speckle-tracking echocardiography. A total of 47 healthy women with singleton pregnancies were prospectively enrolled in this study. A total of 4 visits, including each trimester and postpartum at 6 months, were planned. Echocardiographic studies were performed with a Vivid 7 device equipped with a 2.5-MHz transducer (GE Vingmed Ultrasound AS, Horten, Norway). Although the LA reservoir phase strain showed a gradual decrease from the first trimester to the third trimester during pregnancy, the measurements in the postpartum period were found to return to initial levels (mean ± SD: first trimester, 40.3% ± 11.7%; second trimester, 37.5% ± 12.9%; third trimester, 33.5% ± 9.0%; postpartum, 42.1% ± 11.1%; P < .001). The LA pump function strain was also parallel to the LA reservoir strain and gradually decreased from the first trimester to the third trimester during pregnancy, and it was observed that rose to the initial level in the postpartum period (first trimester, 16.7% ± 7.4%; second trimester, 14.8% ± 5.5%; third trimester, 12.7% ± 4.3%; postpartum, 15.8% ± 5.5%; P < .001). We prospectively determined normal reference values for LA deformation parameters using speckle-tracking echocardiography in each trimester and the postpartum period in healthy pregnancy. These reference values may help identify subclinical LA dysfunction in several cardiovascular or systemic conditions. According to this study, these parameters decreased toward the third trimester during pregnancy and recovered in the postpartum period.

Left Atrial Dynamics During Exercise in Mitral Regurgitation of Primary and Secondary Origin: Pathophysiological Insights by Exercise Echocardiography Combined With Gas Exchange Analysis

ObjectivesThe aim of this study was to identify the pattern of exercise left atrial (LA) dynamics, its gas exchange correlates, and prognosis in mitral regurgitation (MR) of primary and secondary origin. BackgroundThe adaptive response and clinical significance of LA function during exercise in MR is undefined. MethodsA total of 196 patients with MR (81 with primary MR, 115 with secondary MR) and 54 control subjects underwent exercise stress echocardiography and cardiopulmonary exercise testing with LA function assessment. Patients with MR were divided into 4 groups according to etiology and severity using a cutoff of 3+. ResultsLA dynamics was studied using speckle-tracking echocardiography. Compared with control subjects, patients with MR had a lower LA strain and strain rate at rest. Exercise LA strain and LA strain rate progressively worsened from primary MR <3+ through secondary MR ≥3+. In primary MR, some reserve in exercise LA strain and LA strain rate was observed, but not in secondary MR. In secondary MR, LA strain at rest and during exercise (18.1 ± 5.7 s−1, 18.3 ± 6.9 s−1, 18.6 ± 5.5 s−1, 13.9 ± 3.8 s−1) and peak oxygen consumption (11.7 ± 3 ml/min/kg) were decreased compared with the other groups. In secondary MR ≥3+, the slope of ventilation versus carbon dioxide was higher compared with the other groups: 35.1 (interquartile range [IQR]: 29.0 to 44.2) compared with control subjects: 26.5 (IQR: 24.4 to 29.0); patients with primary MR <3+ (26.9; IQR: 24.0 to 31.9); those with primary MR >3+ (25.5; IQR: 23.4 to 29.0); and those with secondary MR <3+ (29.5; IQR: 26.5 to 33.7) (p < 0.05 for all). A progressive impairment in exercise LA mechanics combined with limited cardiac output increase and right ventricular–to–pulmonary circulation uncoupling was observed from primary to secondary MR. LAS during exercise was predictive of all-cause mortality and hospitalization for heart failure. ConclusionsIn MR of any origin, exercise LA reservoir and pump function are impaired. For similar MR extent, secondary MR exhibits worse atrial function, resulting in the lowest exercise performance, limited cardiac output increase, impaired right ventricular–to–pulmonary circulation coupling, and the highest event rate.

Impaired left atrial strain predicts abnormal exercise haemodynamics in heart failure with preserved ejection fraction.

Elevated left atrial (LA) pressure, particularly during exercise, is associated with symptomatic status and survival in patients with heart failure with preserved ejection fraction (HFpEF). We aimed to characterize the contribution of abnormal LA mechanical properties to exercise haemodynamics in HFpEF. Simultaneous echocardiography and right heart catheterization were performed in 71 subjects with left ventricular ejection fraction ≥ 50% referred for assessment of exertional dyspnoea. According to haemodynamic evaluation, 49 patients were diagnosed with HFpEF [pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg at rest and/or ≥ 25 mmHg at maximal exertion] and 22 as non-cardiac dyspnoea. Apical two- and four-chamber views were used for blinded two-dimensional LA speckle tracking analysis. HFpEF was characterized by impaired LA reservoir (24.3 ± 9.6 vs. 36.7 ± 8.4%, P < 0.001) and pump strain (-11.5 ± 3.2 vs. -17.0 ± 3.4%, P < 0.001); and increased stiffness (0.8 ± 0.7 vs. 0.2 ± 0.1 mmHg/%, P < 0.001). Reservoir and pump strain correlated with exercise PCWP (r = -0.64 and r = 0.72, P < 0.001), and remained independent predictors after adjusting for left ventricular mass index, LA volume index, mean E/e' and systolic blood pressure (B = -0.66 and B = 1.41, respectively, P < 0.001). LA stiffness was strongly related to B-type natriuretic peptide levels (r = 0.73, P < 0.001; B = 173.0, P < 0.001). Reservoir strain at cut-off of ≤ 33% predicted invasively verified HFpEF diagnosis with 88% sensitivity and 77% specificity, providing a net reclassification improvement of 12% in comparison to the 2016 European Society of Cardiology criteria for non-invasive diagnosis of HFpEF. Impaired LA reservoir and pump function and increased stiffness are associated with abnormal exercise haemodynamics in HFpEF. These markers provide significant HFpEF diagnostic utility in elderly ambulatory patients with dyspnoea.

Evaluation of Left Atrial Electromechanical Delay and Left Atrial Phasic Functions in Surgical Early Menopause Patients.

BACKGROUNDThis study evaluated the atrial electromechanical delay (AEMD) and the left atrial (LA) mechanical functions in patients with surgical early menopause.METHODSA total of 62 patients were included in the study: 33 patients with surgical early menopause and 29 age- and sex-matched healthy controls. The duration distance from the start of the P wave to the beginning of the A wave for the lateral mitral annulus, septal mitral annulus, and lateral tricuspid annulus was assessed by tissue Doppler echocardiography. The differences in these durations were used to calculate the inter- and intra-atrial mechanical delays. LA volumes were evaluated using the biplane area-length technique, and LA mechanical function values were measured.RESULTSThe baseline laboratory and clinical characteristics were similar between the two groups. Surgical early menopause patients displayed increased static atrial electromechanical connection (PA′) times for the septal mitral annulus and lateral tricuspid annulus compared to the controls. However, the lateral mitral annulus, the inter-atrial, the intra-LA, and the right atrial EMD PA′ times were not significantly altered in surgical early menopause patients compared to controls. Importantly, the LA volume index (28.1 ± 8.17 vs. 24.89 ± 7.96 mL/m2, p = 0.019), the maximal LA volume (49.6 ± 14.1 vs. 42.9 ± 16.1 mL, p = 0.004), the minimal LA volume (18.4 ± 7.0 vs. 15.2 ± 9.0 mL, p = 0.022), and the atrial precontraction LA volume (31.0 ± 10.9 vs. 24.9 ± 10.1 mL, p = 0.006) were higher in the patients with surgical early menopause compared to the controls. The LA reservoir, conduit and pumping functions and the total, passive, and active emptying volumes were all comparable between the two groups (p = 0.09; 0.06; 0.68; 0.06; 0.48; 0.07, respectively).CONCLUSIONSPatients with surgical early menopause demonstrated impaired atrial electrical delay and electromechanical functions.

Left atrial function in heart failure with mid-range ejection fraction differs from that of heart failure with preserved ejection fraction: a 2D speckle-tracking echocardiographic study.

Heart failure (HF) with mid-range ejection fraction (HFmrEF) shares similar diagnostic criteria to HF with preserved ejection fraction (HFpEF). Whether left atrial (LA) function differs between HFmrEF and HFpEF is unknown. We, therefore, used 2D-speckle-tracking echocardiography (2D-STE) to assess LA phasic function in patients with HFpEF and HFmrEF. Consecutive outpatients diagnosed with HF according to current European recommendations were prospectively enrolled. There were 110 HFpEF and 61 HFmrEF patients with sinus rhythm, and 37 controls matched by age. LA phasic function was analysed using 2D-STE. Peak-atrial longitudinal strain (PALS), peak-atrial contraction strain (PACS), and PALS-PACS were measured reflecting LA reservoir, pump, and conduit function, respectively. Among HF groups, most of left ventricular (LV) diastolic function measures, and LA volume were similar. Both HF groups had abnormal LA phasic function compared with controls. HFmrEF patients had worse LA phasic function than HFpEF patients even among patients with LA enlargement. Among patients with normal LA size, LA reservoir, and pump function remained worse in HFmrEF. Differences in LA phasic function between HF groups remained significant after adjustment for confounders. Global PALS and PACS were inversely correlated with brain natriuretic peptide, LA volume, E/A, E/e', pulmonary artery systolic pressure, and diastolic dysfunction grade in both HF groups. LA phasic function was worse in HFmrEF patients compared with those with HFpEF regardless of LA size, and independent of potential confounders. These differences could be attributed to intrinsic LA myocardial dysfunction perhaps in relation to altered LV function.

Atrial Dysfunction in Arrhythmogenic Right Ventricular Cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy that is predominantly known to affect the ventricles. Evidence for atrial involvement remains limited. Therefore, we aimed to characterize atrial involvement in ARVC using functional cardiac magnetic resonance, define the extent of atrial size and function variation attributable to ventricular variables, and identify cardiac magnetic resonance-based predictors of atrial arrhythmias (AA) in ARVC. We analyzed cine cardiac magnetic resonance images of 66 definite ARVC patients without a history of AA or severe heart failure and 24 healthy controls. Using tissue tracking, we evaluated phasic biatrial volumes, ejection fractions (EFs), peak longitudinal strain, and strain rates (SRs). The primary outcome was the occurrence of AA during 6.8 years [3.0-10.8 years] of follow-up. Compared with controls, ARVC patients had higher biatrial volumes, reduced right atrial (RA) conduit function (passive EF [RAEFpassive] and peak early-diastolic SR), reduced RA and left atrial (LA) reservoir function (peak systolic SR), and reduced RA and LA pump function (peak late-diastolic SR; P<0.05). Using multivariable analysis, predictors of increased risk of AA during follow-up were higher atrial volumes (RAVmin and LAVmin), decreased LA reservoir function (total LAEF and LA peak longitudinal strain), and decreased RA conduit function (passive RAEF and RA early-diastolic SR). Compared with controls, patients with ARVC were found to have enlarged atria with decreased function on functional cardiac magnetic resonance examination. RA and LA parameters predict incident AA after adjusting for clinical and ventricular characteristics which suggests atrial involvement in ARVC.

Left atrial deformation as a potent predictor for paroxysmal atrial fibrillation in patients with end-stage renal disease.

It is widely known that various factors contribute to left atrial (LA) mechanical dysfunction in patients with end stage renal disease (ESRD). However, the connection between atrial dysfunction and arrhythmic events such as paroxysmal atrial fibrillation (PAF), in this group of patients, remains unclear. The purpose of our study was to evaluate prospectively the association between LA deformation indices and PAF in ESRD patients. 79 patients (41 men, mean age 57 ± 17) with ESRD and preserved left ventricular systolic function comprised the study population. All patients underwent a baseline comprehensive echocardiography study and were followed for a mean period of 16 ± 5 months. PAF episodes, first and the following events, were reported. LA longitudinal strain reflecting LA reservoir function and LA longitudinal strain rate reflecting LA pump function were specifically evaluated as LA deformation indices of interest, using 2D speckle tracking echocardiography. At the end of follow up period nine patients died. 15 of the rest 70 reported one or more episodes of PAF. LA indexed volumes were significantly higher in patients with PAF (32 ± 26 vs. 21.5 ± 9ml/m2, p = 0.002), mean LA strain was significantly reduced (17 ± 7 vs. 27 ± 9%, p < 0.001) as well as mean LA stain rate (- 1.19 ± 0.5 vs. - 1.95 ± 0.5 1/s, p < 0.001). Multivariate analysis showed that LA strain rate when adjusted with age together with PAF history remained the single most significant echocardiographic parameter for PAF prediction. Impaired LA strain and LA strain rate are associated with PAF in ESRD patients. LA strain rate might be a better independent predictor of PAF, compared to standard echocardiographic indices. Further prospective studies are needed to validate its relevance in routine clinical practice.

Структурно-функциональные особенности сердца у пациентов с «констриктивным», «псевдонормальным» и «рестриктивным» типами нарушения диастолической функции левого желудочка

to study structural functional characteristics of the heart in patients with various types of abnormalities of diastolic function (DF) based on data obtained at stress echocardiography (stress EchoCG) and echocardiographic indexes of myocardial deformation. We included in this study 110 patients with hypertensive disease (HD), clinically manifest chronic heart failure (CHF), and abnormal DF of the left ventricle (LV) in the absence of coronary artery stenosis. All patients underwent standard clinical and laboratory examination, EchoCG with measurement of 3‑dimensional global longitudinal strain (GLS), and stress EchoCG on treadmill with evaluation of DF parameters. In the group with abnormal relaxation in patients with Е/e' >13 left atrial (LA) passive emptying fraction and distensibility index (27.1±14.5 and 127.8±96.1 %, respectively) were significantly smaller than in other patients of this group (34.8±14.2 и 207.7±86.8 %, respectively; р13 during exercise had lower LA passive emptying fraction and distensibility index (р13 during exercise, degree of reduction of LV contractility was similar irrespective of type of DF abnormality. In patients with different degrees of DF derangements (abnormal relaxation, transitional or restrictive type) Е/e' >13 during exercise was accompanied by similar lowering of mitral annular systolic velocity at rest (7.1±1.58, 6.9±1.13, and 6.79±0.93 cm / s, respectively). There were also no significant differences between these groups in values of 3‑dimensional GLS (-11.2±1.5, -10.4±0.94, and -11.8±1.97 %, respectively). Elevation of LV filing pressure during stress EchoCG evidence for non-homogeneity of groups of patients with different degrees of DF abnormalities, presence of deeper structural-functional changes of the cardiovascular system, accompanied by reduction of myocardial contractility as well as LA reservoir and pump function. The use of stress EchoCG for evaluation of parameters of myocardial deformation allows to improve diagnostics of CHF in patients with preserved LV ejection fraction and directs to determination of criteria of preclinical manifestations of CHF.

Association between left atrial phasic conduit function and early atrial fibrillation recurrence in patients undergoing electrical cardioversion

BackgroundDiastolic dysfunction promotes atrial fibrillation (AF) inducing left atrial (LA) remodeling, with chamber dilation and fibrosis. Predominance of LA phasic conduit (LAC) function should reflect not only chamber alterations but also underlying left ventricular (LV) filling impairment. Thus, LAC was tested as possible predictor of early AF relapse after electrical cardioversion (EC).Methods96 consecutive patients, who underwent EC for persistent non-valvular AF, were prospectively enrolled. Immediately after successful EC (3 h ± 15 min), an echocardiographic apical four-chamber view was acquired with transmitral velocities, annular tissue Doppler and simultaneous LV and LA three-dimensional full-volume datasets. Then, from LA–LV volumetric curves we computed LAC as: [(LV maximum − LV minimum) − (LA maximum − LA minimum) volume], expressed as % LV stroke volume. LA pump, immediately post-EC, was assumed and verified as being negligible. Sinus rhythm persistence at 1 month was checked with ECG-Holter monitoring.ResultsAt 1 month 62 patients were in sinus rhythm and 34 in AF. AF patients presented pre-EC higher E/é values (p = 0.012), no major LA volume differences (p = NS), but a stiffer LV cavity (p = 0.012) for a comparable LV capacitance (p = 0.461). Conduit contributed more (p < 0.001) to LV stroke volume in AF subpopulation. Multiple regression revealed LAC as the most significant AF predictor (p = 0.013), even after correction for biometric characteristics and pharmacotherapy (p = 0.008).ConclusionOur data suggest that LAC larger contribution to LV filling soon after EC reflects LA–LV stiffening, which skews atrioventricular interaction leading to AF perpetuation and makes conduit dominance a powerful predictor of early AF recurrence.

Acute Impact of Balloon Mitral Valvotomy on Left Atrial Functions in Mitral Stenosis

Background: Rheumatic mitral stenosis (MS) is associated with progressive impairment of left atrial (LA) mechanical functions. This study was conducted to assess the acute impact of Balloon Mitral Valvotomy (BMV) on these functions. Methods: This single centre observational study included 25 patients with severe MS (aged 34.1 ± 7.1 years, with mean mitral valve area of 0.74 ± 0.13 cm²), in sinus rhythm, who underwent successful BMV at our hospital. Phasic LA volumes (Vmax: maximal LA volume, Vmin: minimal LA volume, and Vp: LA volume at the onset of P-wave) were measured by modified Simpson’s method. Parameters of LA reservoir function i.e. LA total emptying fraction (LATEF) and LA expansion index (LAEI); conduit function i.e. LA passive emptying fraction (LAPEF); and pump function i.e. LA active emptying fraction (LAAEF) were calculated from these volumes. All these parameters were evaluated before and 24-48 hours after BMV. Results: Successful BMV led to significant reduction in Vmax (p < 0.001), Vmin (p < 0.001), and Vp (p < 0.001). There was a significant increase in LATEF (p= 0.001) and LAEI (p= 0.002). LAPEF increased insignificantly (p= 0.057), while there was no significant change in LAAEF (p =0.127) after BMV. Conclusion: Successful BMV leads to early improvement in left atrial reservoir and conduit functions, without significantly affecting left atrial pump function. Whether these acute changes translate into long term left atrial reverse remodelling and clinical benefits thereof needs to be established by further studies.

The relationship between nighttime hypertension and left atrial function.

The authors sought to investigate the association between different hypertensive phenotypes and left atrial (LA) function assessed by the volumetric method and the strain method in patients with untreated hypertension. This cross-sectional study involved 236 untreated patients who underwent 24-hour ambulatory blood pressure monitoring and two-dimensional echocardiographic examination. Our findings showed that LA function gradually deteriorated from patients with normotension, across patients with daytime hypertension, to patients with night- and day-nighttime hypertension. LA reservoir and conduit functions were particularly deteriorated in patients with nighttime and day-nighttime hypertension compared with patients with normotension and patients with daytime hypertension, whereas LA pump function was compensatorily increased only in the participants with day-nighttime hypertension. Only nighttime hypertension and day-nighttime hypertension were independently associated with the reduced reservoir and conduit LA function. The difference between patients with daytime and nighttime hypertension was found in reservoir and conduit LA but not LA pump function.

Association of the Active and Passive Components of Left Atrial Deformation with Left Ventricular Function

Left atrial (LA) strain imaging enables the quantitative assessment of LA function. The clinical relevance of these measurements is dependent on the provision of information incremental to the left ventricular (LV) evaluation. The aim of this study was to test the hypothesis that LA pump function but not reservoir function is independent of measurement of LV mechanics. Echocardiography was undertaken in a community-based study of 576 participants ≥65years of age with one or more risk factors (e.g., hypertension, diabetes mellitus, obesity). Strain analysis was conducted using a dedicated software package, using R-R gating. LV function was classified as normal in the presence of global longitudinal strain (GLS) (≤-18%) or global circumferential strain (GCS) (≤-22%). The associations between GLS or GCS and LA reservoir, conduit, and pump strain were assessed using univariate and multivariate linear regression. Patients (mean age 71±5years, 54% women) with reduced GLS had higher blood pressure and rates of diabetes and obesity (P<.05). LA reservoir strain and conduit strain were lower in the group with impaired GLS (38.2±7.3% vs 39.9±6.4% [P=.004] and 18.7±5.7% vs 20.5±5.1% [P<.001], respectively), but there was no difference in LA pump strain (19.5±5.5% vs 19.3±4.6%, P=.72). GLS was independently associated with LA reservoir and conduit strain (P<.05) but not independently associated with LA pump strain (P=.91). Reduced GCS was associated with a larger body mass index, male sex, and diabetes (P<.05). There were no differences in LA reservoir, conduit, and pump strain in patients with normal and abnormal GCS (P>.05). The application of LA strain is specific to the component measured. LA pump strain is independent of LV mechanics.