Left Atrial Reservoir Function Research Articles

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

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

LA Mechanics in Decompensated Heart Failure: Insights From Strain Echocardiography With Invasive Hemodynamics

ObjectivesThe aim of this study was to assess the effect of congestion and decongestive therapy on left atrial (LA) mechanics and to determine the relationship between LA improvement after decongestive therapy and clinical outcome in immediate or chronic heart failure with reduced ejection fraction (HFrEF). BackgroundLA mechanics are affected by volume/pressure overload in decompensated HFrEF. MethodsA total of 31 patients with HFrEF and immediate heart failure (age 64 ± 15 years, 74% male, left ventricular ejection fraction 20 ± 12%) underwent serial echocardiography during decongestive therapy with simultaneous hemodynamic monitoring. LA function was assessed by strain (rate) imaging. Patients were re-evaluated 6 weeks after discharge and prospectively followed up for the composite endpoint of heart failure readmission and all-cause mortality. ResultsLA reservoir function was markedly reduced at baseline and improved with decongestion (peak atrial longitudinal strain from 6.4 ± 2.2% to 8.8 ± 3.0% and strain rate from 0.29 ± 0.11 s–1 to 0.38 ± 0.13 s–1), independent of changes in left ventricular global longitudinal strain, LA end-diastolic volume, and mitral regurgitation severity (p < 0.001). Both measures continued to rise at 6 weeks (up to 13.4 ± 6.1% and 0.50 ± 0.19 s–1, respectively; p < 0.001). LA pump strain rate only increased 6 weeks after discharge (–0.25 ± 0.12 s–1 to –0.55 ± 0.29 s–1; p < 0.010). Changes in LA mechanics correlated with changes in wedge pressure (r = –0.61; p < 0.001). Lower peak atrial longitudinal strain values after decongestion were associated with increased risk for the composite endpoint of heart failure and mortality (p < 0.019). ConclusionsLA reservoir and booster function, while severely impaired during immediate decompensation, significantly improve during and after decongestive therapy. Poor LA reservoir function after decongestion is associated with worse outcome.

P324 Left atrial deformation analysis by 2D speckle tracking echocardiography in liver cirrhosis is a potential new tool for a better characterization of cirrhotic cardiomyopathy

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 Cirrhotic cardiomyopathy (CCM) is defined as a cardiac dysfunction that includes mainly diastolic dysfunction (DD), generated by liver cirrhosis (LC). Its present diagnosis is based mostly on 2D conventional transthoracic echocardiography (TTE), with focus on diastolic dysfunction. However, there is no standardized algorithm for diagnosis of CCM. Role of the new methods, such as speckle tracking echocardiography (STE), for the diagnosis of CCM is still controversial. Aim. To assess left atrial (LA) function by STE in LC, on top of conventional TTE, in order to establish role of LA function for the diagnosis of CCM. Methods 107 subjects were assessed by TTE and STE: 52 patients with LC (57 ± 9 yrs, 23 males), free of any cardiovascular disease or diabetes, and 55 age-matched normal subjects. TTE was used to measure LV indexed volumes and ejection fraction (LVEF), E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP); STE to measure global longitudinal strain (GLS) and 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), LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct) (Figure). NTproBNP was measured in all patients. Results LC patients vs. controls had lower SBP (112 ± 15 vs. 122 ± 12, P &amp;lt; 0.001), higher LV volumes and NTproBNP, but similar LVEF. They had lower GLS, and higher E/E’, LAVi, and sPAP, suggesting higher LV filling pressure (Table). Meanwhile, they had lower LA reservoir, conduit, and pump functions(Table). By using current algorithm for the diagnosis of DD, 21% of LC patients had DD, 48% had no DD, and 31% had indeterminate grade. By adding assessment of LA reservoir function by STE (LASr &amp;lt; 35%) to the DD algorithm, 50% of patients had DD, without any indeterminate cases. Conclusion LC patients have longitudinal systolic LV dysfunction, diastolic dysfunction with higher estimated LV filling pressure, and lower LA reservoir, conduit, and pump functions. By adding LA deformation analysis by STE to the current diagnosis algorithm, better characterization of CCM is possible. Table Group (N) NTproBNP ng/ml GLS (%) E/E’ LAVi (ml/m2) sPAP (mmHg) LASr (%) LASRr LAScd (%) LASRcd LASRct LC (52) 215 ± 258 -20.8 ± 3 8.5 ± 2.3 44 ± 14 27 ± 9 28 ± 9 1.29 ± 0.4 14.7 ± 8.1 -1.2 ± 0.42 -1.64 ± 0.47 Controls (55) 44 ± 43 -22 ± 2 7.6 ±2.3 28 ±6.5 21 ± 8 35 ± 4 1.54 ± 0.4 18.3 ± 6.7 -1.7 ± 0.61 -1.93 ± 0.44 P value &amp;lt;0.001 0.05 0.05 0.001 0.003 0.011 0.002 0.014 0.001 0.002 Abstract P324 Figure

P1743 The contribution of left atrial dysfunction to exercise intolerance in early heart failure with preserved left ventricular ejection fraction

Abstract Background Diagnosis of early heart failure with preserved ejection fraction (HFpEF) may be challenging because exertional dyspnea is not specific for heart failure, and biomarkers and indicators of volume overload may be absent at rest. We aimed to characterize the contribution of abnormal left atrial (LA) mechanical properties to exercise intolerance in early HFpEF (normal left ventricular filling pressures at rest but elevated during exercise). Methods Diastolic stress testing (DST) was performed in 104 patients with left ventricular ejection fraction ≥50%, in sinus rhythm, and no more than LV diastolic dysfunction grade I, referred for assessment of exertional dyspnoea. Patients exercised supine cycle ergometry at 60 rpm starting with a 3-min period of low-level 25-W workload followed by 25-W increments in 3-minute stages to maximum tolerated levels. According to DST, 43 patients were diagnosed with HFpEF (average mitral E-to-annular e′ ratio [E/e′] &amp;gt; 14, and peak TR velocity &amp;gt;2.8 m/sec at maximal exertion) and 61 as non-cardiac dyspnea (NCD). During the test, two-dimensional images, mitral E/e′, peak tricuspid regurgitation (TR) velociry, and two-dimensional LA mechanical parameters (longitudinal LA strain [LASR] and strain rate [LASRR] during reservoir phase and LA stiffness assessed as a ratio of mitral E/e′ ratio to LASR) were analysed at baseline, and at peak. Results HFpEF and NCD patients were similar in regard to the LA volume index (34.4 [30.2;39.4] vs. 33.6 [28.4;37.1] ml/m2), and NT-proBNP level (132 [80;238] vs. 129 [80;197] pg/ml). As compared with NCD patients, HFpEF patients displayed reduced LA reservoir function assessed by LASR (22.3 [18.9;25.6] vs. 24.2 [21.2;29.8] % at rest, and 25.3 [21.4;30.2] vs. 29.0 [24.2;33.3] % with exercise) and LASRR (0.78 [0.58;0.96] vs. 0.90 [0.68;1.12] /s at rest, and 1.10 [0.79;1.31] vs. 1.24 [1.03;1.56] s–1 with exercise) with increased LA stiffness (0.57 [0.44;0.70] vs. 0.42 [0.30;0.49] mmHg/% at rest, and 0.61 [0.46;0.74] vs. 0.40 [0.32;0.51] mmHg/% with exercise, all P &amp;lt; 0.05). Additionally, HFpEF patients showed smaller exercise elevation in LASRR (+31 [-5;77] vs. +47 [12;85] % as compared with resting values, P &amp;lt; 0.05). Exercised LA stiffness and reservoir strain correlated with exercise LV filling pressures estimated by mitral E/e′ ratio (r = 0.72 and r =–0.35, P &amp;lt; 0.001). LA stiffness showed a good diagnostic accuracy (area under the curve 0.75), and LA stiffness &amp;gt; 0.46 mmHg/% demonstrated reasonable sensitivity (79%) and specificity (71%) to diagnose HFpEF. Neither LV global longitudinal strain and ejection fraction at rest nor their exercise-induced elevation differed between HFpEF and NCD. Conclusion Impaired LA reservoir function and increased stiffness are associated with exercise intolerance in patients with early HFpEF, while LV systolic function seems preserved in this stage of the disease. LA stiffness provides HFpEF diagnostic potential in ambulatory patients with dyspnea

Atrial Deformation Correlated with Functional Capacity in Mitral Stenosis Patients

<i>Background</i>: Mitral stenosis (MS) is the most common valve disease seen as a sequel of rheumatic fever and usually presents with exertional dyspnea, right sided heart failure and pulmonary arterial hypertension. <i>Aim</i>: To determine the functional class of dyspnea in patients with MS and to investigate the relationship between Left Atrial (LA) deformation as measured by two-dimensional Speckle Tracking Echocardiography (STE)-derived LA strain and heart failure symptoms. <i>Patients and methods</i>: This was a prospective study carried out on 25 patients referred for evaluation of MS using echocardiography and 25 control subjects, who were evaluated using 2D and color Doppler echocardiography, including STE-derived LA strain (LAS) and peak positive filling strain rate (LASRr) during the LA reservoir phase. Those results were then correlated with New York Heart Association (NYHA) functional class. <i>Results</i>: There was a statistically significant difference between the patients and the control groups in the LAS in the apical 4 chamber view (LAS A4) (64.240±15.271, 40.360±21.785, respectively; p=0.001), LASRr A4 (2.504±0.358, 1.740±0.716, respectively; p=0.001) and LASRc A4 (-2.796±0.226, -1.820±0.928, respectively; p=0.001). also, there was a highly significant relation between NYHA class and LAS A4, LASRr A4 and Peak Negative Conduit Strain Rate (LASRc A4), with P<0.001 with all data. <i>Conclusion</i>: This study showed that all left atrial (LA) reservoir, conduit and contractile functions showed prominent impairment in mitral stenosis patients. Speckle tracking strain and strain rate were useful in pointing out the different effects of MS on left atrial functions. The assessment of LA dimension and function can provide further insights in patients with MS, LA dimension and volume in patients with MS had a positive significant correlation with NYHA classes (heart failure symptoms). In stable patients (NYHA classes I & II) with MS, NYHA functional class independently correlated with LAS and LASRr as LAS and LASRr values of stable patients and control aspects were normal. While LA deformation (LAS and LASRr) was significantly correlated with heart failure symptoms (NYHA Classes III & IV) in patients with MS.

P374 Prediction of an adverse cardiovascular response to physical exercise from resting echocardiography imaging in young adults with suboptimal blood pressure

Abstract Funding Acknowledgements British Heart Foundation (BHF) grants (PG/13/58/30397) Background Young adults with mildly elevated blood pressure are less likely to engage with physical activity. This may be because early hypertension alters myocardial response to moderate exercise, leading to greater perceived exertion and lower levels of enjoyment. As atrial and ventricular function are closely coupled we investigated whether subclinical atrial changes at rest may identify this myocardial response. Purpose To identify whether subclinical changes in left atrial function at rest predict response to exercise by performing left atrial deep-phenotyping in a cohort of young adults with a range of blood pressures. Methods Seventy-one full-term born young adults (25.25 ± 5.13 years) were enrolled in the Young Adult Cardiovascular Health sTudy (YACHT) to undergo baseline clinical and cardiovascular phenotyping including detailed blood pressure measurement. Cardiopulmonary exercise testing combined with echocardiography imaging was performed to assess the myocardial response to physical exercise at 40%, 60% and 80% of peak exercise load for all participants. Left ventricular ejection fraction and global longitudinal strain were measured from an apical four chamber view at each exercise load, and resting left atrial phasic function was assessed by conventional and speckle tracking echocardiography from apical four and two chamber views (figure 1). Results In this young cohort with a range of blood pressure (120.9 ± 12.96/70.85 ± 9.78 mmHg), resting left atrial reservoir and conduit function, but not left atrial structural measures, showed good correlation with left ventricular ejection fraction and global longitudinal strain during 40%, 60% and 80% of peak exercise. The association between resting left atrial conduit with left ventricular deformation at 60% of peak exercise intensity remained significant when adjusted for age, sex and mean arterial pressure (P = 0.007). Conclusion Left atrial phasic function at rest predicts left ventricular responses to physical exercise in this cohort of young adults, which may relate to early subclinical left atrial remodelling in early hypertension. These findings require validation in other cohorts and investigation of whether this exercise limitation can be overcome in young hypertensives. Abstract P374 Figure 1

P667 Protein supplementation improves left ventricular systolic functions in athletes by 2D speckle tracking echocardiography

Abstract Funding Acknowledgements none Background Exercise induced left ventricular remodelling is known for many years. Left ventricular enlargement, hypertrophy, left atrial dilatation are adaptive responsive mechanisms of myocardial tissue to increased physiological demand by exercise. In recent years, strain and strain rate have been used for the assessment of myocardial adaptation in athletes’. In literature, left ventricular and right ventricular deformation is decreased in athletes’, compared to normal healthy individuals. Also left atrial reservoir and contractile functions, which can be measured by speckle tracking echocardiography, decrease in endurance athletes with atrial fibrillation. Athletes have been using protein supplementation frequently in recent years however cardiac effects are largely unknown. There is limited data in the literature about cardiac effects of protein supplementation. Purpose In our study, we aim to evaluate the effects of protein supplementation on cardiac functions in athletes with 2D speckle tracking echocardiography. This is the first study in the literature evaluating the effects of protein supplements on echocardiographic parameters. Methods Eighty-three athletes (mean age = 29.7 ± 7.9) without history of cardiac disease or other chronic diseases such as hypertension, diabetes mellitus, kidney failure were prospectively included in our study. 73.5% (n = 61) of them were male. Participants were divided into two groups; participants who use protein supplementation regularly was defined as group 1 (n = 33); did not use protein supplementation was defined as group 2 (n = 50). In addition to Standard 2D echocardiographic measurements, left ventricle global longitidunal strain (LvGLS), right ventricle global longitidunal strain (RvGLS), right ventricle free wall strain (RvFWS), left atrium strain and strain rate were analyzed with Vivid E9, offline using a customized software package (Echo Pac for PC, GE Vingmed) (Figure 1). Results Diameter of interventricular wall was higher in group 1 (10.1 ± 1.0 vs 9.5 ± 1.2, p = 0.022). Systolic peak ejection velocity of the mitral valve medial annulus is higher in group 1 than group 2 (0.09 ± 0.1 vs 0.08 ± 0.1, p &amp;lt; 0.001). Late diastolic velocity of the mitral valve medial annulus is higher in the group 1 (0.09 ± 0.02 vs 0.08 ± 0.02, p = 0.015). LvGLS which was the indicator of left ventricular deformation was significantly higher in the group 1 (-19.49 ± 1.9 vs -18.45 ± 2.2, p = 0.030). Although RvGLS was higher in the group 1, there was no statistically significant difference (-22.93 ± 4.52 vs -21.07 ± 5.02, p = 0.083). Conclusion In recent years protein supplementation usage increases in young adults and athletes. In our study, although there was no statistically significant difference with left ventricular ejection fraction, LvGLS which is the early indicator of LV systolic functions better in the athletes who used protein supplementation. Further studies are needed to evaluate the long term effects of protein supplements on the heart.

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 &amp;lt; 0.001), but not with LAVi. By multiple regression analysis, best predictor for NTproBNP &amp;gt; 125pg/ml was LASRct (r = 0.60, r2 =0.30, p &amp;lt; 0.001). LASRct &amp;lt; -1.29 (AUC = 0.82, sensitivity 75%, specificity 81%) was the only predictor of NTproBNP &amp;gt; 125pg/ml (Figure). Conclusion LA pump function is the only predictor of NTproBNP &amp;gt; 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 &amp;lt;0.001 &amp;lt;0.001 0.7 0.4 0.8 0.7 0.4 &amp;lt;0.001 Abstract 409 Figure.

564 Cardiac magnetic resonance myocardial feature tracking for optimized risk assessment after acute myocardial infarction in patients with type 2 diabetes

Abstract Objective Type 2 diabetes mellitus (T2DM) associates with worse cardiovascular outcome following acute myocardial infarction (AMI) as compared to non-diabetic patients. Since the mechanisms behind these observations are not fully understood we aimed to quantify the underlying pathophysiology on ventricular and atrial levels and study their prognostic implications using cardiovascular magnetic resonance (CMR) quantitative feature-tracking (FT) and tissue characterization. Research Design and Methods: A total of 1147 consecutive patients with AMI (n = 265 with diabetes; n = 882 without diabetes) undergoing cardiac magnetic resonance (CMR) imaging in median 3 days after AMI were included in this multicenter study. Left ventricular (LV) function and volumetry included LV ejection fraction (LV-EF), global longitudinal (GLS), radial (GRS) and circumferential strain (GCS) as well as left atrial (LA) strain and strain rate parameters of LA reservoir, conduit and booster pump function. LV damage assessment included infarct size (IS), edema and microvascular obstruction (MO). The clinical study endpoint was the rate of major adverse cardiovascular events (MACE) at 12 months. Results T2DM patients had impaired LA reservoir (19.8 vs. 21.2%, p &amp;lt; 0.01) and conduit strains 7.6 vs. 9.0%, p &amp;lt; 0.01) but no differences in ventricular function or myocardial damage. They were at higher risk of MACE than non-diabetic patients (10.2% vs. 5.8%, p &amp;lt; 0.01) with the majority of MACE occurring in patients with LVEF ≥ 35%. Whilst LVEF was an independent predictor of adverse events in non-diabetic patients (p = 0.04 on multivariable analysis), LV GLS as well as LA strain emerged as independent predictors of poor prognosis in patients with diabetes (p &amp;lt; 0.02 on multivariable analysis). Considering patients with diabetes and LVEF ≥35% (n = 237), GLS and LA reservoir strain below median were significantly associated with higher 12-month event rates. Conclusions In patients with diabetes, LA and LV longitudinal strain permit optimized risk assessment early after reperfused AMI with incremental prognostic value over and above LVEF.

Echocardiographic Evaluation of Left Atrial Function to Discriminate Non-Valvular Atrial Fibrillation Development in Patients with Apical Hypertrophic Cardiomyopathy.

Data is limited on baseline left atrial (LA) myocardial mechanics between apical hypertrophic cardiomyopathy (ApHCM) patients who develop non-valvular atrial fibrillation (NVAF) during follow-up and those who do not. This retrospective study investigated the clinical outcomes of consecutive patients newly diagnosed with ApHCM between August 2011 and July 2014 who were followed-up for at least 3 years. The patients underwent 12-lead surface electrocardiography and/or 24-hour Holter electrocardiography at least once a year. The patients were divided into two groups, namely those who did or did not exhibit NVAF during follow-up, respectively. The baseline clinical and echocardiographic data of the two groups were compared. Twenty patients were studied, five of whom were lost to follow-up. Of the remaining 15 ApHCM patients, seven developed NVAF. No differences were observed in the clinical characteristics of the two groups. However, for the echocardiographic data, the NVAF development group exhibited a larger LA volume and impaired LA reservoir, conduit and booster functions. The NVAF development group also showed lower peak LA strain and stiffer left atrium. The LA volume, function, global strain and stiffness were all statistically associated with NVAF development. Among these parameters, a LA conduit function of ≤ 24.9% was found to be the best parameter to discriminate NVAF development. The baseline LA function was impaired in the ApHCM patients who subsequently developed NVAF during follow-up. A LA conduit function of ≤ 24.9% was strongly associated with NVAF development.

100 Association of age-related left atrial remodeling with ischemic stroke in patients with normal sinus rhythm

Abstract OnBehalf The ARIC Study Background Age-related left atrial (LA) structural/functional abnormalities in elderly patients with normal sinus rhythm and preserved ejection fraction may precede the development of overt atrial fibrillation, and also may be related to stroke. Purpose To evaluate the association of 3-dimensional echocardiographic (3DE) atrial contractility parameters with subclinical cerebral infarcts (SCIs), as assessed by brain MRI, and clinically diagnosed stroke Methods We studied 407 participants (mean age 76 ± 5 years, 40.5% male) from the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS) without AF and who underwent a brain MRI and a 3DE examination in 2011-13. We defined 3 groups: those with no cerebral infarcts on brain MRI (NCIs, N = 315); those with MRI-diagnosed SCIs (N = 58); and those with clinically diagnosed stroke (N = 34). Results While still within the normal range, LA indexed volume significantly increased across the 3 groups (P-trend = 0.01).This was accompanied by an increase in the LA global longitudinal strain (GLS), an echocardiographic index of LA reservoir function (P-trend = 0.004). E/e’ divided by LA GLS—index of atrial stiffness—worsened across groups (P-trend = 0.005) and was independently associated with SCIs and Stroke, pooled together, [OR per 1 %-1, 1.97; 95% CI (1.24, 3.11), P = 0.004], and Stroke [OR per 1 %-1, 2.30; 95% CI (1.23, 4.30), P = 0.009]. LA GLS was marginally associated with an increased odd of SCIs [OR per 1 %, 1.07; 95% CI (1.01, 1.13), P = 0.014]. Conclusions Among elderly participants with normal sinus rhythm and preserved ejection fraction in a large cohort study, markers of LA function and stiffness are associated with increased odds of subclinical infarcts and stroke. These data suggest that even subtle LA dysfunction, which may contribute to LA stasis, may predispose to subclinical cerebral infarcts and stroke.

Impact of left atrial appendage occlusion on left atrial function-The LAFIT Watchman study.

Left atrial (LA) strain and strain rate (SR) analysis by two-dimensional speckle tracking echocardiography is a novel way of LA function assessment. From prior study, we know that LA appendage closure with LARIAT appears to improve LA function. The purpose of this study was to assess the impact of LAA closure via Watchman device on LA function via strain and volumetric analyses using two-dimensional speckle tracking echocardiography(2D-STE). Twenty-five patients who underwent Watchman device implantation (WDI) were included. LA function parameters (volumetric, strain indices) were calculated from apical four chamber views with the reference point set at QRS using 2D-STE before and after WDI. LA expansion index, strain and strain rate during ventricular systole represent LA reservoir function. Passive emptying fraction, strain and strain rate during early ventricular diastole represent LA conduit function. Mean age was 76 ± 6.9years with 60% males. There was significant improvement in conduit function (LA passive emptying fraction; post 28.6 (21.9-35.9) vs pre 21.0 (13.8-34.7), p= 0.032), reservoir function (LA expansion index; post 75.3 (52.3-98.0) vs pre 58.1 (37.8-85.2), p= 0.026), and booster function (LA active emptying fraction; post 13.3 (9.7-29.9) vs pre 12.6 (8.8-25.5), p= 0.04) by volumetric indices. No significant improvement was noted with strain indices in conduit function (SRe; post - 0.56 (0.43-0.93) vs pre - 0.58 (0.46-0.87); p= 0.518) and reservoir function (SRs; post + 0.58 (0.28-0.40) vs pre + 0.52 (0.35-0.86); p= 0.851). WDI resulted in discrepancy of volumetric and strain indices in LA function assessment.

Strain de la aurícula izquierda por speckle tracking: evaluación de su reproducibilidad global y segmentaria

Objetivos: evaluar la reproducibilidad intra e interobservador en la medicion del strain auricular izquierdo funcion reservorio mediante speckle tracking, usando un protocolo para su analisis global y segmentario.Metodos y resultados: se establecio un protocolo para la adquisicion y medicion del strain de la auricula izquierda (SAI), para un analisis global y segmentario, utilizando un modelo tipo “ojo de buey”. Se evaluo su reproducibilidad mediante eln coeficiente de correlacion intraclase (CCI) en 20 participantes de la cohorte GEnotipo, Fenotipo y Ambiente de la HiperTension arterial en el UruguaY (GEFA-HT-UY). Se obtuvo una excelente reproducibilidad global intraobservador de 0,92 (IC: 0,81-0,97) y buena reproducibilidad interobservador de 0,82 (IC: 0,59-0,92). El analisis segmentario de SAI no fue reproducible. Los valores promedio de SAI fueron 31,0% (± 7,5) para la vista de 4 camaras; 34,6% (± 9,9) para la vista de 2 camaras, y 36,8% (± 13,9) para la vista de 3 camaras. El valor global de SAI tomando las tres vistas fue de 34,1% (± 7,8) y de 32,8% (± 6,5) considerando las vistas de 4 y 2 camaras.Conclusion: el protocolo de adquisicion y analisis de SAI para la funcion de reservorio fue reproducible para su analisis global, no asi para su analisis segmentario.

P5432Invasive assessment by atrial volume-pressure loops of the acute changes in left atrial function induced by pulmonary vein antral isolation

Abstract Background Atrial volume-pressure loops are considered the best method to assess left atrium (LA) function. Changes in atrial function induced by pulmonary vein (PV) antral isolation of atrial fibrillation (AF) have not been documented thus far using this approach. Purpose We aimed to evaluate changes in LA function in patients with paroxysmal atrial fibrillation (PAF) undergoing catheter ablation by atrial volume-pressure loops. Methods Patients undergoing for the first time catheter ablation of PAF by PV antral isolation and PV-LA junction ablation, as clinically indicated, were enrolled from 2 centers. Each center enrolled consecutive patients undergoing PV antral isolation using the same method i.e. radiofrequency or cryoballoon ablation. Patients with severe mitral stenosis or regurgitation, any prosthetic valve, left atrial thrombus or severe systolic or diastolic dysfunction of the left ventricle were excluded. Before and after the procedure, all patients underwent real-time three-dimensional transthoracic echocardiogram to evaluate volume changes of the LA during an entire cardiac cycle, while simultaneously recording LA pressure by a 6F angiographic catheter following transseptal puncture. After the procedure, LA volume and pressure recordings were gated offline by ECG, and were used to plot the LA pressure as a function of LA volume, thus creating a volume-pressure loop. The A loop area is a measure of the booster pump function of the LA. The V loop area expresses the reservoir function of the LA. Pressure and volume data at the clockwise ascending limb of the volume-pressure loop were fitted to the exponential function P = bxea·V, where P = instantaneous LA pressure; V = LA volume; a is the passive elastic chamber stiffness constant (cm–3) that determines the slope of the exponential curve, and b is the elastic constant (mm Hg). Results 34 patients with PAF were analysed, 12 treated with radiofrequency ablation and 22 with cryoablation. The procedure was uneventful in all cases. Mean LA pressure, A-wave amplitude, and V-wave amplitude were all significantly increased post-procedurally (p&lt;0.001 for all). The area of the A-loop decreased (Post: 40.69 ml·mm Hg [IQR 13.7–71.3] vs. Pre: 64.2 ml·mm Hg [IQR 30.9–86.9]; p=0.001), whereas the area of the V-loop increased (Post: 96.5 ml·mm Hg [IQR 45.1–230.5] vs. Pre: 79.2 ml·mm Hg [IQR 46.9–149.7]; p=0.016). Although the elastic constant increased (p&lt;0.001), there was no significant difference in the passive chamber elastic constant (p=0.30). Conclusion Volume-pressure loops can assess procedural changes in LA function. Catheter ablation of AF is associated with a decrease the LA booster pump function of the LA, and in increase in the left atrial reservoir function. Moreover, there is an increase in LA pressures that is observed in the absence of change in LA stiffness.

P660The effect of hypertension and metabolic syndrome on left atrial function in patients with paroxysmal atrial fibrillation undergoing catheter ablation

Abstract Background Hypertension and metabolic risk factors are associated with increased risk of atrial fibrillation (AF) and heart failure. Previous studies assessing the efficacy of catheter ablation in patients with metabolic syndrome have shown conflicting data. Purpose We thought to assess the impact of hypertension and other metabolic risk factors on left atrial (LA) phasic function in patients with paroxysmal AF undergoing the first catheter ablation. Methods We prospectively enrolled 112 consecutive patients (age: 63±21 years; 32% female) with symptomatic paroxysmal AF and preserved left ventricular ejection fraction (≥50%) undergoing the first catheter ablation during sinus rhythm, and 23 healthy controls. Patients with valvular AF or in AF at the time of ablation were excluded. All patients underwent comprehensive echocardiography at one day pre and at one day post ablation, and after three months. The LA reservoir, conduit and contractile strain and strain rate (SR) were assessed using the two-dimensional speckle tracking echocardiography as average of segmental values in apical views. Results A total of 51 (45.5%) patients had history of treated hypertension while 61 (54.5%) patients had normal arterial blood pressure, and 27 (24.1%) patients of hypertensive group and 17 (15.1%) patients of normotensive group have dyslipidemia and/or diabetes. All groups of patients had been adjusted by age and sex. Pre-ablation, hypertensive patients with metabolic risk factors showed significantly lower magnitude of reservoir and contractile strain and SR compared with other groups of patients (all p&lt;0.05). Hypertensive patients compared with normotensive patients had significantly increase in LA volume index (39±1% vs. 34±7%, p: 0.01) and decrease in LA emptying fraction (49.5±11% vs. 54.8±9.8%, p: 0.02). Post-ablation, LA strain and SR significantly decreased in all patients regardless of the history of hypertension or other metabolic risk factors (all p&lt;0.05). At three-month follow-up, LA strain and SR showed almost complete recovery to pre-ablation values in both groups of patients. Yet, LA function in groups of patients with metabolic risk factors remained lower compared with individuals without risk factors. Of note, hypertensive individuals showed similar improvement of LA contractile function to normotensive patients (p: 0.4) but LA reservoir function remained to be lower (p&lt;0.05) (figure 1,2). The intra- and the inter-observer variability for the LAS and LASR assessment were below 5% and significantly lower (p&lt;0.05) than that of the conventional LA indices. Conclusion Both reservoir and contractile LA strain are simultaneously affected by dyslipidemia and/or diabetes. LA reservoir function is affected earlier in hypertensive patients than contractile function. Reservoir LA strain appears to be the most useful parameter to monitor LA function in hypertensive patients with/without metabolic risk factors.

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&lt;0.01 and PACS OR=0.92 p&lt;0.05), but only PALS predicted HF admissions (PALS OR=0.86 p&lt;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&lt;0.05) and HF admissions (OR=0.85 p&lt;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&lt;0.05) and a PALS value of &lt;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.

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&lt;0.001; Figure), whereas weakly, but positively correlated with LA volume index and pump strain (r=0.12 and 0.09, both p&lt;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&lt;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 (&lt;31.4%) and conduit (&lt;12.4%) strain (adjusted odds ratio = 2.63 and 3.71 vs. normal CAVI, both p&lt;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.

P2445Prognostic values of left ventricular reservoir functional indices measured by three dimensional speckle tracking analysis

Abstract Background Left atrial functional indices measured by two dimensional echocardiography (2DE) have prognostic significance for major cardiovascular events (MACE). Retrospective analysis using propensity score matching to assess the prognostic values of left atrial reservoir function measured by three dimensional speckle tracking analysis (3DSTA) was performed. Methods Two hundred sixty-four patients (Male 60%, 65±15yo) who underwent both clinically indicated 2DE and 3DSTA for various underlying heart diseases from January 4, 2013 to February 28, 2016 were followed to record MACE. Patients with significant mitral valve disease, history of pulmonary vein isolation and persistent atrial fibrillation were excluded. Maximum and minimum left atrial volume (LAVImax and LAVImin), left atrial emptying fraction (LAEmpF), peak global LA area ratio (LAAC), circumferential strain (LACS) and longitudinal strain (LALS) were measured using 3DSTA. Standard indices including peak global LVLS (2DLVLS) and left ventricular ejection fraction (LVEF) and LA volume index were also assessed by 2DE. Cutoff line for LA reservoir functional indices and 2DLVLS was determined using ROC analysis. Average treatment effect for the treated (ATT), Average treatment effect (ATE) for each index were calculated after propensity score matching for clinical indices (age, sex, coronary artery disease, hypertension, diabetes, eGFR &lt;45 ml/min/1.73m2, LVEF &lt;40%) Results During a mean follow-up of 547±435 days, MACE developed in 30 patients (7 cardiac death 6 stroke, 1 nonfatal MI, 22 admission for heart failure). Age, coronary artery disease (CAD), diabetes mellitus (DM), chronic kidney disease (CKD: eGFR&lt; 45ml/min/1.73m2), LVEF, 2DLVLS, LAVImax and LAVImin by 2DE and all LA indices by 3DSTA had significant prognostic value by univariate analysis. LAEmpF and LALS by 3DSTA had higher ATT, ATE and Log rank χ2 than other LA indices and 2DLVLS. The model added LALS or LAEmpF by 3DSTA had higher prognostic value (LALS &lt;10.6%: AUC; 0.82, HR; 5.57 CI: 2.32–14.06, LAEmpF &lt;33.0%: AUC; 0.82, HR; 6.59 CI; 2.60–20.18) than LA volume indices by 2DE and also tended to be better than 2DLVLS (LVLS &lt;6.04%: AUC; 0.77, HR; 5.37 CI; 2.06–13.73). propensity score matching Conclusion LALS and LAEmpF by 3DSTA showed additive prognostic value for MACE.

P1483Serial changes in peak left atrial strain predicts diastolic remodelling following percutaneous revascularisation for ST-segment elevation myocardial infarction

Abstract Background Echocardiographic 2D speckle tracking peak left atrial (LA) strain reflects LA reservoir function. Limited studies have reported the relationship between peak LA strain and diastolic dysfunction. In addition, adverse diastolic remodeling (ADR) has been reported, to have better prognostic value than single diastolic function assessment following ST-elevation myocardial infarction (STEMI). Purpose We examined the relationship between serial changes in echocardiographic peak LA strain and diastolic function in STEMI patients. Methods 186 percutaneously revascularized first presentation STEMI patients (87% male, 56.9±10.6 years) underwent serial TTE at baseline (2–7 days) and at follow-up (8–10 weeks) post-STEMI. Peak LA reservoir strain measurements were analysed from apical 2-, 3- and 4- chamber views. Diastolic function was graded as per 2016 guidelines: normal, grade 1, grade 2 and grade 3. ADR was defined as worsening of diastolic function grade (≥1) from baseline to follow-up, or persistent grade 3. Results Lower baseline peak LA strain was associated with grade 2 and grade 3 diastolic dysfunction compared to normal and grade 1 function at follow-up (p&lt;0.05, see figure and table). Change in LA strain was less with worsening grades of diastolic function (see table). ADR was seen in 33 patients. Lower baseline peak LA strain predicted ADR (B=0.86 (0.80–0.92), p&lt;0.0001). In addition, a reduction in peak LA strain at follow up was independently associated with ADR (B=0.91 (0.84–0.97), p=0.007) (see figure). Diastolic function grades with LA strain Follow-up diastolic function Baseline peak LA strain (%) Follow-up peak LA strain (%) Change in peak LA strain (%) Normal (n=91) 35.70±6.38 40.97±8.10 5.26±6.07 Grade 1 (n=61) 30.70±6.97 34.54±8.77 3.84±6.32 Grade 2 (n=17) 23.95±6.11 25.49±5.93 1.54±4.70 Grade 3 (n=17) 23.66±8.07 23.49±10.64 −0.17±7.44 Data presented as mean ± SD. Peak LA strain vs diastolic function Conclusion Peak LA strain is associated with diastolic function following STEMI and differentiates normal diastolic function from diastolic dysfunction. Serial changes in peak LA strain correlated with diastolic remodelling. Longer-term follow-up is required to determine the prognostic value of changes in peak LA strain, and diastolic remodelling.

Left Atrial Function with MRI Enables Prediction of Cardiovascular Events after Myocardial Infarction: Insights from the AIDA STEMI and TATORT NSTEMI Trials.

Background The role of left atrial (LA) performance in acute myocardial infarction (AMI) remains controversial. Cardiac MRI myocardial feature tracking (hereafter, MRI-FT) is a method used to quantify myocardial function that enables reliable assessment of atrial function. Purpose To assess the relationship between LA function assessed with MRI-FT and major adverse cardiovascular events (MACE) after AMI. Materials and Methods This secondary analysis of two prospective multicenter cardiac MRI studies (AIDA STEMI [NCT00712101] and TATORT NSTEMI [NCT01612312]) included 1235 study participants with ST-elevation myocardial infarction (n = 795) or non-ST-elevation myocardial infarction (n = 440) between July 2008 and June 2013. All study participants underwent primary percutaneous coronary intervention. MRI-FT analyses were performed in a core laboratory by researchers blinded to clinical status to determine LA performance using LA reservoir function peak systolic strain (εs), LA conduit strain (εe), and LA booster pump function active strain (εa). The relationship of LA performance to a MACE within 12 months after AMI was evaluated by using Cox proportional hazards models and area under the receiver operating characteristic curve (AUC). Results Study participants with MACE had worse LA performance parameters compared with study participants without MACE (εs = 21.2% vs 16.2%, εe = 8.8% vs 6.9%, εa = 11.8% vs 10%; P < .001 for all). All atrial parameters were strongly associated with MACE (hazard ratio [HR], εs = 0.9, εe = 0.88, εa = 0.89; P < .001 for all). For εs, a cutoff of 18.8% was identified as the only independent atrial parameter with which to predict MACE after accounting for confounders and established prognostic markers in adjusted analysis (HR, 0.95; P = .02). The εs yielded incremental prognostic value above left ventricular ejection fraction, global longitudinal strain, microvascular obstruction, and infarct size (AUC comparisons, P < .04 for all). Conclusion Feature tracking of cardiac MRI to derive left atrial peak reservoir strain provided incremental prognostic value for major adverse cardiovascular events prediction versus established cardiac risk factors after acute myocardial infarction. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Almeida in this issue.