Left Atrial Reverse Remodeling Research Articles

Prognostic impact of left atrial reverse remodeling in patients with ADHF-HFpEF regardless of atrial fibrillation -PURSUIT-HFpEF Registry-

Abstract Background Left atrial (LA) dilatation is associated with increased mortality in patients with cardiovascular disease including heart failure (HF) and LA reverse remodeling (LARR) was reported to be associated with favorable outcomes in patients with HF. However, it remains to be clarified whether LARR could have prognostic value in patients with HF with preserved ejection fraction (HFpEF). Purpose The purpose of this study is to elucidate whether LARR is associated with clinical outcome in patients with HFpEF in relation to the presence of atrial fibrillation (AF). Methods We prospectively studied 492 patients with acute decompensated heart failure with preserved ejection fraction (ADHF-HFpEF) without the poor outcome during the first year postdischarge. Echocardiography was performed just before discharge and at 1 year after discharge. LARR was defined as the reduction of 15% or more in left atrial end-systolic volume (LAV). The primary outcome was rehospitalization for worsening heart failure. Results All study patients were divided into 2 groups according to the presence of AF at discharge (AF group, n=182 and non-AF group, n=310). During a mean follow-up period of 1.4±1.2 years, 78 patients were rehospitalized for worsening heart failure (37 patients in AF group and 41 in non-AF group). ΔLAV, the degree of reduction in LAV during the first year postdischarge, was significantly independently associated with primary outcome after multivariable adjustment both in AF group (p=0.033, HR 0.992 [0.984-0.999]) and non-AF group (p=0.021, HR 0.986 [0.974-0.998]). Kaplan-Meier analysis revealed that patients with LARR had significantly lower risk for primary outcome than those without LARR not only in the whole study patients (8% vs 20%, p=0.001) but also both in AF group (9% vs 24% p=0.013) and in non-AF group (8% vs 16% p=0.043). Among clinical characteristics during the index hospitalization, the presence of AF and prior HF hospitalization were significantly independently associated with LARR at multivariate Cox logistic regression analysis (p=0.006, OR 0.554 [0.364-0.843] and p=0.007, OR 0.491 [0.292-0.826], respectively). Conclusion(s) The left atrial reverse remodeling could have the prognostic impact in patients with ADHF-HFpEF regardless of the presence of atrial fibrillation.Kaplan-Meier curves in AF and non-AF

Comparison of pulsed field ablation versus cryoballon and radiofrequency ablation for pulmonary vein isolation in atrial fibrillation patients with heart failure

Abstract Background Pulmonary vein isolation (PVI) is the gold standard for atrial fibrillation (AF) ablation and can be achieved by a variety of technical methodes. While thermal ablation modalities (TA), such as cryoballon (CB) and radiofrequency ablation (RF) have been established as the standard approaches, PFA has been introduced as a nvel non-thermal modality showing comparable safety and procedural efficiency. Despite the high incidence of AF in heart failure (HF) patients, data comparing outcomes of HF patients undergoing PVI by either PFA or thermal ablation (RFA/CB) are limited. Purpose This study’s aim was to compare the efficacy and safety of PFA for AF ablation versus CB/RFA in HF patients. Methods Consecutive HF patients with preserved (HFpEF), mildly reduced (HFmrEF) and reduced (HFrEF) ejection fraction undergoing PVI for AF by either PFA or CB/RFA at our institution were included. The primary end-point was time to death or recurrence of AF. Secondary end-points were periprocedural complications and clinical and echocardiographic parameters. Results We included 140 HF patients who underwent PVI either by PFA (PFA group, 76 patients) or thermal ablation approaches (TA group, 64 patients). Our patients had a mean age of 69 years and were predominantly male (62%). There was no significant difference in the baseline characteristics and in the type of AF between both groups (42% with ParAF, 45% with PersAF) and 13% LSPersAF). The distribution of heart failure types was similar between both groups: HFpEF (PFA: 71%, TA: 75%), HFmrEF (PFA: 21%, TA: 20%) and HFrEF (PFA: 8 %, TA: 5%). After the 365-days follow-up period we observed no significant difference for the primary end-point between both groups (HR: 0.79, 95% CI 0.35-1.78; p=0.575). In total 58% of the PFA patients and 59% of the TA group were still free from AF. While symptom improvement was documented in both groups, patients in the PFA group showed significant improvement of left atrial volume index (p = 0.014), NT-pro BNP levels (p = 0.046), and left ventricular ejection fraction (LVEF) (p = 0.005). Conclusion In this study, PFA and thermal ablation modalities showed comparable results in terms of safety and procedural efficiency in patients with heart failure. Since previous studies have shown that HF patients with AF benefit from PVI using thermal ablation modalities, our results suggest that PFA might also be a promising ablation method in this vulnerable population, inducing left atrial reverse remodeling and thereby contributing to improvement of left ventricular systolic function.

Changes in epicardial adipose tissue volume before and after cryoballoon ablation in patients with atrial fibrillation: Supporting the “AF begets EAT” theory

BackgroundEpicardial adipose tissue (EAT) is closely associated with atrial fibrillation (AF), suggesting that it may be 1 of the causes of AF progression. However, it is unclear whether AF affects EAT. ObjectiveThis study aimed to demonstrate that sinus rhythm restoration reduces EAT volume (EATV) through left atrial reverse remodeling (LARR). MethodsWe analyzed data from 247 patients who underwent cryoballoon ablation for AF. EATV was assessed by contrast-enhanced computed tomography with a 3-dimensional analysis workstation, evaluating EATV surrounding the entire heart (total-EATV) and left atrium (LA-EATV) at baseline and 6 months after cryoballoon ablation. ResultsAt 6 months, all patients but 1 with persistent AF were in sinus rhythm. Total-EATV and LA-EATV were both significantly decreased in patients with persistent AF (n = 33; total-EATV: 148.8 ± 53.3 mL to 142.9 ± 53.5 mL [P = .01]; LA-EATV: 26.8 ± 11.3 mL to 25.2 ± 10.7 mL [P = .01]). No changes were observed in patients with paroxysmal AF (n = 214). Persistent AF was more strongly associated with LARR than paroxysmal AF (odds ratio, 2.34; 95% confidence interval, 1.01–5.44; P = .05). LARR showed an independent correlation with both total-EATV and LA-EATV reduction (odds ratio, 1.78 [P = .04] and 2.80 [P < .001], respectively). ConclusionThese findings suggest a novel “AF begets EAT” theory, complementing the previously accepted role of EAT as a cause of AF and supporting the “AF begets AF” mechanism.

Prognostic value of left atrial reverse remodelling in patients hospitalized with acute decompensated heart failure.

Left atrial (LA) volume index (LAVI) in chronic heart failure (HF) predicts cardiovascular outcomes. However, the association between LAVI reduction during acute decompensated HF (ADHF) and its prognostic potential is limited. We hypothesized that LA reverse remodelling (LARR) after ADHF therapy would be associated with better clinical outcomes. This retrospective study analysed clinical outcomes and the LAVI reduction rate of 363 out of 861 patients hospitalized for ADHF who underwent two-point echocardiography at admission and discharge between January 2015 and December 2019. The mean age was 74.3±13.6years, and the mean ejection fraction (EF) was 38.9±15.2%. The follow-up echocardiogram was performed 13.0 [9.5, 20] days after admission. As the median LAVI reduction rate was 7.02%, the LARR was defined as an LAVI reduction rate >7%. During the 34.0±20.2months of follow-up, 117 patients (32.2%) reached the primary endpoint defined as cardiovascular death and rehospitalization for ADHF. Kaplan-Meier survival analysis showed that patients with LARR had a better prognosis. Multivariate analysis indicated that LARR was an independent predictor of cardiovascular events. Similar findings were observed in the subgroup analyses of patients with persistent/permanent atrial fibrillation and those with non-HF with reduced EF. Among patients who were brain natriuretic peptide (BNP) responders, defined as a relative reduction of >70% in BNP from admission to discharge, non-LARR was observed in 41.6%. BNP responders without LARR experienced worse prognoses. LARR in the early vulnerable phase after hospitalization for ADHF was associated with better long-term clinical outcomes.

Left Atrium Reverse Remodeling in Fusion CRT Pacing: Implications in Cardiac Resynchronization Response and Atrial Fibrillation Incidence.

Background: When compared to biventricular pacing, fusion CRT pacing was linked to a decreased incidence of atrial fibrillation (AF). There is a gap in the knowledge regarding exclusive fusion CRT without interference with RV pacing, and all the current data are based on populations of patients with intermittent fusion pacing. Purpose: To assess left atrium remodeling and AF incidence in a real-life population of permanent fusion CRT-P. Methods: Retrospective data were analyzed from a cohort of patients with exclusive fusion CRT-P. Device interrogation, exercise testing, transthoracic echocardiography (TE), and customized medication optimization were all part of the six-monthly individual follow-up. Results: Study population: 73 patients (38 males) with non-ischemic dilated cardiomyopathy aged 63.7 ± 9.3 y.o. Baseline characteristic: QRS 159.8 ± 18.2 ms; EF 27.9 ± 5.1%; mitral regurgitation was severe in 38% of patients, moderate in 47% of patients, and mild in 15% of patients; 43% had type III diastolic dysfunction (DD), 49% had type II DD, 8% had type I DD. Average follow-up was 6.4 years ± 27 months: 93% of patients were responders (including 31% super-responders); EF increased to 40.4 ± 8.5%; mitral regurgitation decreased in 69% of patients; diastolic profile improved in 64% of patients. Paroxysmal and persistent AF incidence was 11%, with only 2% of patients developing permanent AF. Regarding LA volume, statistically significant LA reverse remodeling was observed. Conclusions: Exclusive fusion CRT-P was associated with important LA reverse remodeling and a low incidence of AF.

Early left atrial reverse remodelling in patients with hypertrophic obstructive cardiomyopathy receiving transapical beating-heart septal myectomy.

This study aims to investigate the short-term effects of transapical beating-heart septal myectomy (TA-BSM) on left atrial (LA) anatomy and function and its association with clinical indicators in patients with hypertrophic obstructive cardiomyopathy (HOCM). A total of 105 HOCM patients who received TA-BSM were included. Clinical and comprehensive echocardiographic data were obtained before surgery, at discharge, and 3 months after myectomy. LA reverse remodelling was defined as LA maximum volume index (LAVI) ≤34 ml/m2 and a change of ≥10%. At 3 months after TA-BSM, New York Heart Association (NYHA) functional class and 6-min walking test were significantly improved, N-terminal pro-B-type natriuretic peptide (NT-proBNP) decreased, left ventricular outflow tract (LVOT) peak gradient and mitral regurgitation were significantly reduced. LAVI decreased in 76%, with a median change of 20%, and the criteria for LA reverse remodelling were met in 48%. LA strain parameters were improved at 3 months after TA-BSM. Moreover, left ventricular (LV) diastolic function was significantly improved, but LV global longitudinal strain was not significantly changed at 3 months after operation. Improvement in LVOT peak gradient, LAVI, LA reservoir strain (LASr) and conduit strain (LAScd) were associated with reduction in NT-proBNP. Along with effectively relieving the obstruction of the LVOT and mitral regurgitation, TA-BSM could significantly improve LA size and function during the short-term follow-up for HOCM patients. The indicators of LA reverse remodelling were associated with reduction in a biomarker of myocardial wall stress, indicating the early recovery of LV relaxation and clinical status for patients.

Clinical and pathophysiologic determinants of catheter ablation outcome in hypertrophic cardiomyopathy with atrial fibrillation

AbstractBackgroundHypertrophic cardiomyopathy (HCM) is frequently associated with atrial fibrillation (AF). We compared clinical, echocardiographic, and electrophysiological parameters between HCM subtypes and those without HCM at AF catheter ablation (AFCA) and analyzed post‐AFCA reverse remodeling and AF recurrence based on HCM presence and subtype.MethodsAmong 5161 consecutive patients who underwent de novo AFCA, we included HCM patients and control patients who were age‐, gender‐, and AF type‐matched. Between AF‐HCM patients and controls, we compared baseline values for left atrium (LA) wall thickness (LAWT), reverse remodeling at 1‐year follow‐up, and procedural outcomes over the course of follow‐up between two groups.ResultsA total of 122 AF‐HCM patients and 318 control patients were included. AF‐HCM patients had more frequent heart failure and higher LA diameter, E/Em, and LA pressure (all, p &lt; .001). However, LAWT did not differ from control group. A year after AFCA, degree of LA reverse remodeling was significantly lower in AF‐HCM than in control group (ΔLA dimension, p = .025). Nonapical HCM (HR 1.71; 95% CI 1.05–2.80), persistent AF (HR 1.46; 95% CI 1.05–2.04), and LA dimension (HR 1.04; 95% CI 1.01–1.06) were independent risk factors for AF recurrence. During 78.0 months of follow‐up, nonapical HCM patients showed higher AF recurrence rate than both apical HCM (log‐rank p = .005) and control patients (log‐rank p = .002).ConclusionsThe presence of HCM, particularly nonapical HCM, displayed increased LA hemodynamic loading with diastolic dysfunction and had poorer rhythm outcomes after AFCA compared to both apical HCM and control group.

How to Predict Left Atrial Reverse Remodeling Following Catheter Ablation for Atrial Fibrillation.

How to Predict Left Atrial Reverse Remodeling Following Catheter Ablation for Atrial Fibrillation.

Clinical Characteristics and Rhythm Outcomes in Patients With Atrial Myopathy After Successful Catheter Ablation of Atrial Fibrillation.

Although successful atrial fibrillation (AF) ablation can maintain sinus rhythm and reduce the left atrial (LA) dimension, blunted LA reverse remodeling can be observed in patients with atrial myopathy. We explored the potential mechanisms and long-term outcomes in patients with blunted LA reverse remodeling after successful AF catheter ablation. We included 1685 patients who underwent baseline and 1-year follow-up echocardiograms, had a baseline LA dimension ≥40 mm, and did not have a recurrence of AF within a year. The patients were divided into tertile groups according to the delta value of the change in LA dimension on the preprocedure and 1-year postprocedure echocardiography. After propensity score matching for age, sex, AF type, and LA dimension, 1272 patients were finally included in the analyses (424 in each group; the least/blunted, moderate, and the most reverse remodeling group). The patients in the T1 group (blunted LA reverse remodeling) were independently associated with higher left ventricular mass index (odds ratio [OR], 1.014 [95% CI, 1.005-1.022], P=0.001), change in ΔH2FPEF score (heavy, hypertensive, atrial fibrillation, pulmonary hypertension, elder, filling pressure) score (OR, 1.445 [95% CI, 1.121-1.861], P=0.004), ventricular epicardial adipose tissue volume (OR, 1.010 [95% CI, 1.003-1.017], P=0.003), thinner LA wall thickness (OR, 0.461 [95% CI, 0.271-0.785], P=0.004), lower LA voltage (OR, 0.670 [95% CI, 0.499-0.899], P=0.008), and showed higher long-term AF recurrence (log-rank P<0.001) than other groups. Blunted LA reverse remodeling after AF catheter ablation, which is suggestive of atrial myopathy, was independently associated with a larger ventricular epicardial adipose tissue volume and worsening of H2FPEF score. Blunted LA reverse remodeling after AF catheter ablation was also an independent predictor for higher recurrences of AF post-1-year AF catheter ablation.

Pulsed field ablation and cryoballoon ablation for pulmonary vein isolation: insights on efficacy, safety and cardiac function.

Pulmonary vein isolation (PVI) has become the cornerstone treatment of atrial fibrillation (AF). While in cryoablation cell damage is caused by thermal effects, lately, pulsed field ablation (PFA) has been established as a novel non-thermal tissue-specific ablation modality for PVI. However, data comparing outcomes of patients undergoing either PFA or cryoballoon ablation (CBA) for primary PVI are sparse. Consecutive patients with AF undergoing PVI by either CBA or PFA were included in the analysis. The primary outcome was the time to AF/AT recurrence. For secondary outcomes, clinical and periprocedural parameters were compared. In total, outcomes of 141 AF patients treated by PFA (94 patients) or CBA (47 patients) were compared. After 365 days, 70% of patients in the PFA group and 61% of patients in the CBA group were free from AF/AT (HR 1.35, 95% CI 0.60-3.00; p = 0.470). No deaths occurred. While symptoms alleviated in both groups, only after PFA, we observed significant improvement of left atrial volume index (PFA group baseline: 40 [31;62] ml/m2, PFA group follow-up: 35 [29;49] ml/m2; p = 0.015), NT-pro BNP levels (PFA group baseline: 1106 ± 2479 pg/ml, PFA group follow-up: 1033 ± 1742 pg/ml; p = 0.048), and left ventricular ejection fraction (LVEF) (PFA group baseline: 55 [48;60] %, PFA group follow-up: 58 [54;63] %; p = 0.006). PVI by PFA was the only independent predictor of LVEF improvement. In our study, we show that CBA and PFA for PVI are of similar efficacy when it comes to AF recurrence. However, our findings suggest that PFA rather than CBA might induce left atrial reverse remodeling thereby contributing to left ventricular systolic function.

Kiosk 4R-FB-06 - Contemporary Heart Failure Medical Therapy Results in Significant Left Ventricular and Left Atrial Reverse Remodelling in Patients with Severe Left Ventricular Systolic Dysfunction

Kiosk 4R-FB-06 - Contemporary Heart Failure Medical Therapy Results in Significant Left Ventricular and Left Atrial Reverse Remodelling in Patients with Severe Left Ventricular Systolic Dysfunction

Outcomes of Concomitant Maze Procedure in Tricuspid Repair for Severe Tricuspid Regurgitation.

We aimed to analyze the impact of concomitant Maze procedure on the clinical and rhythm outcomes, and echocardiographic parameters in tricuspid repair for patients with severe tricuspid regurgitation (TR) and persistent atrial fibrillation (AF). Patients who had severe TR and persistent AF and underwent tricuspid valve (TV) repair were included in the study. Both primary TR and secondary TR were included in the current study. The study population was stratified according to Maze procedure. The primary outcome was major adverse cardiovascular and cerebrovascular event (MACCE) at 15 years post-surgery. Propensity-score matching analyses was performed to adjust baseline differences. Three hundred seventy-one patients who underwent tricuspid repair for severe TR and persistent AF from 1994 to 2021 were included, and 198 patients (53.4%) underwent concomitant Maze procedure. The maze group showed 10-year sinus rhythm (SR) restoration rate of 55%. In the matched cohort, the maze group showed a lower cumulative incidence of cardiac death (4.6% vs. 14.4%, P = 0.131), readmission for heart failure (8.1% vs. 22.2%, P = 0.073), and MACCE (21.1% vs. 42.1%, P = 0.029) at 15 years compared to the non-maze group. Left atrial (LA) diameter significantly decreased in the maze group at 5 years (53.3 vs. 59.6 mm, P < 0.001) after surgery compared to preoperative level, and there was a significant difference in the change of LA diameter over time between the two groups (P = 0.013). The Maze procedure during TV repair in patients with severe TR and persistent AF showed acceptable SR rates and lower MACCE rates compared to those without the procedure, while also promoting LA reverse remodeling.

Association of Atrial Fibrillation Progression With Left Atrial Functional Reserve and Its Reversibility.

Atrial fibrillation (AF) progression is closely related to heart failure occurrence, and catheter ablation carries a beneficial effect for heart failure prevention. Recently, particular attention has been given to left atrial (LA) function and functional reserve in the pathogenesis linking AF and heart failure, although its significance and reversibility is not well studied. We prospectively investigated 164 patients with AF with normal left ventricular systolic function and free from heart failure who underwent first catheter ablation and pre-/postprocedural echocardiography. Conventional and speckle-tracking echocardiography were performed at rest and during passive leg lifting to assess LA size, LA reservoir strain (LARS), and functional reserve calculated as passive leg lifting-LARS - rest-LARS. Patients were categorized into 3 AF subtypes: paroxysmal AF (N=95), persistent AF (PeAF; N=50), and long-standing persistent AF (LS-PeAF; N=19). The PeAF and LS-PeAF groups had larger LA size and reduced LARS compared with the paroxysmal AF group (all P<0.05). LA functional reserve was significantly impaired in the LS-PeAF group (P=0.003). In multivariable analysis, LS-PeAF and advanced age were significantly associated with impaired LA functional reserve. Among 149 patients with sinus rhythm 1 to 2 days after catheter ablation, LARS was significantly improved in both PeAF and LS-PeAF groups but was still lower than that in the paroxysmal AF group. Sinus rhythm restoration also led to amelioration of LA functional reserve in patients with LS-PeAF. AF progression was related to impaired LARS and LA functional reserve, and restoration of sinus rhythm might contribute to early LA reverse remodeling.

Echocardiographic parameters indicating left atrial reverse remodeling after catheter ablation for atrial fibrillation.

The echocardiographic parameters total atrial conduction time (PA-TDI duration), left atrial (LA) volume index (LAVI), and LA strain reflect adverse atrial remodeling and predict atrial fibrillation (AF). The aim of this study was to investigate echocardiographic parameters indicating reverse LA remodeling and potential associations with AF recurrence after pulmonary vein isolation (PVI). This prospective observational study consecutively enrolled patients scheduled for PVI for symptomatic AF. Electrocardiogram (ECG) test and transthoracic echocardiography were performed the day before and after PVI and again 3 months later. AF recurrence was determined by Holter ECG at 3 months, and telephone follow-up at 12 months, after PVI. The parameters of LA remodeling [PA-TDI, LAVI, and LA strain analysis: reservoir strain (LASr), conduit strain (LAScd), contraction strain (LASct)] were determined by transthoracic echocardiography. A total of 48 patients were included in the study (mean age: 61.4 ± 12.2 years). PA-TDI significantly decreased the day after PVI compared with the baseline (septal PA-TDI 103 ± 13 vs. 82 ± 14.9 ms, p ≤ 0.001; lateral PA-TDI 122.4 ± 14.8 vs. 106.9 ± 14.4 ms, p ≤ 0.001) and at the 3-month follow-up (septal PA-TDI: 77.8 ± 14.5, p ≤ 0.001; lateral PA-TDI 105.2 ± 16.1, p ≤ 0.001). LAVI showed a significant reduction at the 3-month follow-up compared with the baseline (47.7 ± 14.4 vs. 40.5 ± 9.7, p < 0.05). LASr, LAScd, and LASct did not change after PVI compared with the baseline. AF recurred in 10 patients after PVI (21%). Septal PA-TDI, septal a', and LAVI/a' determined the day after PVI were associated with AF recurrence. Changes in echocardiographic parameters of LA remodeling and function indicate that functional electromechanical recovery preceded morphological reverse remodeling of the left atrium after PVI. Furthermore, these changes in echocardiographic parameters indicating LA reverse remodeling after PVI may identify patients at high risk of AF recurrence.

Effects of canagliflozin on cardiac remodeling and hemodynamic parameters in patients with type 2 diabetes mellitus

Sodium-glucose cotransporter type 2 (SGLT2) inhibitors have demonstrated to reduce cardiovascular risk in patients with type 2 diabetes mellitus (T2DM) in large trials independent of glycemic control. The mechanisms of this cardioprotective property remain uncertain. Evidence suggests positive hemodynamic changes and favorable cardiac remodeling contributing to the clinical outcomes but results were conflicting. We aim to investigate the potential impact on hemodynamic parameters, cardiac structure and functions. This prospective observational study included T2DM patients receiving canagliflozin 100 mg per day in addition to their antidiabetic treatment. We analyzed hemodynamic parameters assessed by echocardiographic measurements and impedance cardiography (ICG) to evaluate systolic and diastolic functions from baseline to 24 weeks after treatment. A total of 47 patients (25 males and 22 females) averaging 64.6 ± 10.9 years had a significant reduction in HbA1c, body weight, and systolic blood pressure. Hematocrit increased significantly, while NT-proBNP remained unchanged. E/e′, left atrium (LA) volume, and LA stiffness were reduced, while left ventricle (LV) global longitudinal strain (GLS) and LA strain rates increased at 24 weeks by conventional and speckle tracking echocardiography. LV mass and ejection fraction showed no differences. ICG suggested significant improvement in hemodynamic parameters with increased stroke volume index and cardiac output index and decreased systemic vascular resistance index at 12 and 24 weeks. Canagliflozin improved hemodynamic parameters and had a favorable impact on LA and LV reverse remodeling. These changes may explain the beneficial effect on cardiovascular outcomes in large clinical trials.

Prognostic value of left atrial reverse remodelling in heart failure with preserved ejection fraction.

Left atrial reverse remodelling (LARR) reflects an improvement in the function or structure. However, it is unclear whether the presence of LARR is associated with better outcomes in patients with heart failure with preserved ejection fraction (HFpEF). The study was a monocentric retrospective cohort one. Consecutive HFpEF patients admitted to the hospital between 1 January 2018 and 30 June 2020 were included. This cohort was divided into LARR and non-LARR groups based on the recovery of the left atrium. The primary endpoints were all-cause mortality, rehospitalization for heart failure, and the composite of death or readmission. Significant predictors of LARR were examined. A total of 409 patients were enrolled, including 90 cases in the LARR group and 319 in the non-LARR group. Kaplan-Meier analysis showed that compared with the non-LARR group, the LARR group had a lower incidence of rehospitalization for heart failure and the composite of death or readmission but not all-cause mortality. Similar results were observed in a subgroup analysis of patients with and without atrial fibrillation. Cox regression analysis demonstrated that the non-LARR group experienced higher risks of heart failure-related readmission [hazard ratio: 1.785, 95% confidence interval (CI) 1.236-3.215, P = 0.037] and the composite outcome (hazard ratio: 1.684, 95% CI 1.254-2.865, P = 0.044), but not all-cause mortality (hazard ratio: 1.475, 95% CI: 0.481-3.527, P = 0.577) compared with the LARR group after adjusting for significant confounders. Logistic regression analysis showed that mild mitral regurgitation and the use of loop diuretics were two positive predictors of LARR in patients with HFpEF. LARR is an effective echocardiographic index that can be used to predict heart failure-related readmission in HFpEF. Therefore, regular assessment of left atrial size can provide a useful marker for risk stratification of heart failure.

The Atrial Natriuretic Peptide-to-brain Natriuretic Peptide Ratio Predicts Left Atrial Reverse Remodeling after Rhythm Control Therapy in Patients with Persistent Atrial Fibrillation.

Objective The association between natriuretic peptide levels in atrial fibrillation (AF) patients with advanced left atrial (LA) remodeling and reverse remodeling after rhythm control therapy has not been clarified. The present study assessed the role of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) measurements to predict LA reverse remodeling after catheter ablation (CA) in persistent AF patients with LA enlargement. Methods This study included 88 persistent AF patients with LA enlargement (volume index >48 mL/m2) who underwent CA. Plasma ANP and BNP levels were analyzed before CA in all patients. The study population was divided into 2 groups according to the extent of decrease in the LA volume index (LAVI) at 6 months after CA: responders were those with a ≥15% reduction in the LAVI, and all others were non-responders. Results At follow-up, 58 patients (66%) were classified as responders. The preprocedural ANP level was significantly higher in the responders than in the non-responders (p=0.03). Furthermore, the ANP-to-BNP ratio (ANP/BNP) was significantly higher in the responders than in the non-responders (p<0.01). The ANP/BNP was correlated with the percentage decrease in the LAVI (r = 0.391, p<0.01). A multivariate linear regression analysis revealed that the ANP/BNP before CA was an independent predictor of LA reverse remodeling (p<0.01). Conclusions The preprocedural ANP/BNP was a robust predictor of reverse remodeling of the enlarged LA after sinus rhythm restoration by rhythm control therapy in persistent AF patients.

Canagliflozin improves hemodynamic parameters by impedance cardiography and left ventricular diastolic function in patients with type 2 diabetes mellitus

Abstract Background Sodium-glucose cotransporter type 2 (SGLT2) inhibitors have been shown to reduce cardiovascular risk in patients with type 2 diabetes mellitus (T2DM) in large trials, independent of glycemic control. The mechanisms behind this cardioprotective effect remain uncertain, although evidence suggests that positive hemodynamic changes and favorable cardiac remodeling may contribute to the clinical outcomes. However, results have been conflicting. The aim of this study was to investigate the potential impact of canagliflozin on hemodynamic parameters, cardiac structure, and function. Methods This prospective observational study included T2DM patients receiving canagliflozin 100mg per day in addition to their antidiabetic treatment. We analyzed hemodynamic parameters assessed by impedance cardiography (ICG) and echocardiographic measurements to evaluate systolic and diastolic functions from baseline to 24 weeks after treatment. Results A total of 47 patients (25 males and 22 females) with an average age of 64.4±10.8 years experienced a significant reduction in HbA1c, hematocrit, body weight, and systolic blood pressure. NT-proBNP levels remained the same. ICG suggested significant improvement in hemodynamic parameters, with increased stroke volume index and cardiac output index and decreased systemic vascular resistance index at 12 and 24 weeks. E/e’, left atrial (LA) volume, and LA stiffness were reduced, while left ventricular (LV) global longitudinal strain (GLS) and LA strain rates increased at 24 weeks, as measured by conventional and speckle tracking echocardiography. LV mass and ejection fraction showed no differences. Conclusions Canagliflozin improved hemodynamic parameters and had a favorable impact on LA and LV reverse remodeling. These changes may explain the beneficial effect on cardiovascular outcomes seen in large clinical trials.

Abstract 15053: Distinct Effects of Sacubitril/Valsartan on Left Atrial Function Between Heart Failure With Preserved and Reduced Ejection Fraction

Background: Although Sacubitril/Valsartan(S/V) could ameliorate left ventricular (LV) function, it was recently reported that S/V worsened the left atrial (LA) remodeling in pre-heart failure with preserved ejection fraction (pre-HFpEF). However, the effects of S/V on LA function remains controversial in heart failure. Accordingly, this study investigated the effects of S/V on LA function and remodeling in both HFpEF and HFrEF. Methods: This was a single-center retrospective study of patients with HF hospitalized at our hospital. Patients with HF underwent clinical evaluation and echocardiography at baseline and after administration with S/V. LA volume index (LAVI) , LA emptying fraction (LAEF), transmitral peak E wave velocity (E), pulsed-wave TDI e’ velocity (e’), and E/e` were measured by echocardiography. Results: A total of 71 consecutive patients (71 ± 13 years, 70% male) were enrolled in this study. Among them, 29 were patients with HFpEF (LVEF 55 ± 7%), and 42 were HFrEF (LVEF 28 ± 7%). S/V administration significantly reduced the serum brain natriuretic protein level in HFpEF and HFrEF (279 ± 343 to 155 ± 214 pg/ml, 638 ± 642 to. 218 ± 288 pg/ml, p&lt;0.05, respectively). LAVI was also significantly decreased after S/V administration in HFpEF and HFrEF (41 ± 11 to 38 ± 12 ml/m 2 , 50 ± 19 to. 41 ± 21 ml/m 2 , p&lt;0.05, respectively), implicating its effects on LA reverse remodeling. Furthermore, the significant decrease in the velocity of E wave and E/e’ were observed in HFpEF and HFrEF. However, LAEF were significantly improved in HFrEF, but not in HFpEF, while e’ were improved in HFpEF, but not in HFrEF. These results indicated that the effects of S/V might be attributable to LV relaxation in HFpEF and to LA reservoir function in HFrEF. Conclusions: This study demonstrated that treatment with Sacubitril/Valsartan could lead to LA reverse remodeling in both HFpEF and HFrEF, possibly due to the distinct mechanisms of Sacubitril/Valsartan for improving the LA function. Further studies should be needed to be clarified.

Abstract 18428: Effect of Continuous Positive Airway Pressure on Atrial Remodeling in Patients With Obstructive Sleep Apnea and Paroxysmal Atrial Fibrillation; a Randomized Controlled Trial

Introduction: Obstructive sleep apnea (OSA) is known to cause left atrial (LA) remodeling. The effect of continuous positive airway pressure (CPAP) on LA remodeling in patients with OSA and paroxysmal atrial fibrillation (AF) has not been assessed. Hypothesis: We aimed to assess the impact of CPAP treatment on reverse LA deformation and volume in patients with AF and OSA. Methods: In this secondary analysis of a prospective randomized controlled trial, we screened patients with AF for OSA. The majority of patients were referred for pulmonary vein isolation (PVI). We included AF patients with OSA defined as apnea-hypopnea index (AHI) &gt; 15/h. Patients were randomized to CPAP treatment or standard care. Transthoracic echocardiography was performed to assess atrial remodeling by two-dimensional speckle tracking LA reservoir strain (by AFI LA) and LA volume index (LAVI) in apical 2- and 4-chamber views in sinus rhythm at baseline and at 12 months’ follow-up by an investigator blinded to allocated arm. AF burden was monitored by an implantable loop recorder in all patients. Results: We included 104 patients (62 ±7 years old, 77% men, BMI 30 ± 4) of whom 50 were randomized to CPAP and 54 to standard care. PVI was performed in 83 patients six months after the baseline exam. There was no clear improvement in LA reservoir strain in either group from baseline to follow up (CPAP: 30 ± 8 % vs 32 ± 9 %, p = 0.15; standard care: 28 ± 7 % vs 30 ± 6 %, p = 0.11), and there was no difference between the groups (p=0.41). Similarly, LAVI did not change in the CPAP group (38±8 mL/m 2 vs 36± 10ml/m 2 , p= 0.16) or in the standard care group (39± 10 mL/m 2 vs 37 ± 12 ml/m 2 , p= 0.20) during follow-up, with no difference between the two groups (p =0.62). In patients who underwent PVI, the AF burden decreased in both treatment arms, with no between-group difference (p = 0.69). Conclusions: In AF patients with OSA, treatment with CPAP did not improve reverse left atrial remodeling within 12 months. Although the trial was relatively small, these results suggest that CPAP is unlikely to have a major impact on normalization of LA function after atrial fibrillation ablation in this patient group.