LA Emptying Fraction Research Articles

Association between left atrial dysfunction and adverse outcomes after tricuspid valve surgery for atrial functional tricuspid regurgitation

Abstract Objectives To identify factors associated with clinical outcomes in patients undergoing tricuspid valve (TV) surgery for atrial functional tricuspid regurgitation (AF- TR). Methods Among 1,670 patients who underwent TV surgery between January 2000 and December 2020, we included 83 AF-TR patients (69.1±9.2 years, 50 women) who had severe TR without any cause other than atrial fibrillation. A comprehensive analysis of right ventricular (RV) and left atrial (LA) function on preoperative and postoperative echocardiography was performed. LA function was evaluated by LA emptying fraction (LAEF), LA reservoir strain, and LA stiffness index. The primary outcome was a composite of all-cause death and heart failure hospitalization during follow up after surgery. Results For a median of 39.9 (interquartile range 19.9 to 55.8) months, the primary outcome occurred in 20 (24.1%) patients. Patients with a primary outcome showed significantly lower LAEF (9.7±7.3 vs. 21.8±6.7 %, p<0.001) and LA reservoir strain, and higher LA stiffness index than those without. However, there was no difference in RV chamber size and functional parameters according to the occurrence of a primary outcome. The restricted cubic spline plot exhibited a significant relationship between LAEF and primary outcome. The low baseline LAEF (<17%) group showed a poorer outcome than the high LAEF group (log rank p<0.001). In the Cox regression analysis, the low LAEF (<17%) was independent predictor for primary outcome (adjusted hazard ratio 13.5, 95% confidence interval 3.1–58.6). Conclusion In patients undergoing TV surgery with AF-TR, preoperative LA dysfunction was independently associated with adverse outcomes.Figure1

Measures of left atrial structure and function predict cardiovascular death in patients with heart failure with reduced ejection fraction

Abstract Background The role of the left atrium (LA) is increasingly recognized as a predictor of cardiovascular health outcomes. This study aimed to investigate the prognostic value of LA strain in relation to cardiovascular (CV) death in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Methods In this retrospective cohort analysis, patients diagnosed with stable HFrEF and free from atrial fibrillation at baseline were included. All patients had a Left Ventricular Ejection Fraction (LVEF) of 45% or below at the time of referral. Baseline clinical and echocardiographic parameters were collected from the database of the HF outpatient clinic, and data on CV death was gathered through the Danish National Patient Registry. LA function was assessed by means of LA emptying fraction (LAEF), peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA conduit strain (LACS). Uni- and multivariable Cox regression models adjusted for clinical and echocardiographic baseline characteristics were used to determine the association between LA parameters and CV death. Cubic splines were used to identify cutoff values for LA parameters corresponding to a HR of 1. Results The study population consisted of 495 patients (mean age 66 ±11.5 years, 71% males). During a follow-up of 10.9 years [IQR: 6.2; 13.4], 134 (27%) patients reached the outcome of CV death. At baseline, patients who died of CV death were generally older (70.7±9.7 years vs. 64.2±11.7, p<0.001), had a higher prevalence of diabetes (25.4% vs. 13.9%, p=0.004), and a higher prevalence of moderate or severe valve disease (11.2% vs. 3.9%, p=0.004), as well as a lower LVEF (25.1%±8.5 vs. 29.4±8.9, p<0.001). Among LA parameters, the patients who met the outcome had a significantly lower LAEF (30.5% [IQR: 18.0; 42.0] vs. 38.9% [IQR: 29.0; 49.3], p<0.001), PALS (18.2% [IQR: 12.7; 24.4] vs. 23.0% [IQR: 18.3; 29.9], p<0.001), PACS (7.7% [IQR: 2.9; 13.6] vs. 11.7% [IQR: 7.9; 16.4], p<0.001), and LACS (9.4% [IQR: 7.2 ; 12.4] vs. 11.9% [IQR: 8.8; 15.0], p<0.001). Lower levels of all LA parameters were associated with an increased risk of CV death in univariable analysis (p<0.0001 for all parameters). However, in multivariable analysis, only LAEF (HR 0.99 per 1% increase, 95% CI 0.973-0.999, p=0.039), PALS (HR 0.96 per 1% increase, 95% CI 0.931–0.991, p=0.011), and PACS (HR 0.94 per 1% increase, 95% CI 0.90–0.98, p=0.002) remained significant. Splines for LAEF, PALS, and PACS were constructed with identified cutoff points for higher CV death risk (Figure 1), which were utilized to generate Kaplan-Meier curves (Figure 2). Conclusion Lower LA parameters, including LAEF, PALS, and PACS, are associated with increased risk of CV death in patients with HFrEF.Spline curves for LAEF, PALS, and PACS.Kaplan-Meier survival estimates for CVD

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

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

Echocardiographic Parameters of Left Atrial Structure and Function and Clinical Outcomes at 2 Years in Elderly Patients With Atrial Fibrillation - The ANAFIE Echocardiographic Substudy.

This prospective ANAFIE Registry substudy investigated the relationship between the echocardiographic parameters of left atrial (LA) structure and function and clinical outcomes at 2 years among atrial fibrillation (AF) patients aged ≥75 years. Outcomes of 1,474 elderly non-valvular AF (NVAF) patients who underwent transthoracic echocardiography at baseline were analyzed by categories of maximum LA volume index (max. LAVi) and LA emptying fraction (LAEF) total. Baseline mean±standard deviation LAEF total and max. LAVi were 28.2±14.9% and 54.2±25.9 mL/m2, respectively. Proportions of oral anticoagulant (OAC), direct OAC, and warfarin use were 92.7%, 68.7%, and 24.0%, respectively. Patients with LAEF total ≤45.0% (n=1,213) vs. >45.0% (n=224) were at higher risk of cardiovascular events (hazard ratio [HR]: 2.19, P=0.021) and heart failure (HF) hospitalization (HR: 2.25, P=0.045). Risk of all-cause death was higher with max. LAVi >48.0 mL/m2(n=656) vs. ≤48.0 mL/m2(n=621) (HR: 1.69, P=0.048). Subgroups with abnormal LA function and structure had increased incidence of cardiac/cardiovascular events and HF hospitalization. No significant interaction was observed between echocardiographic parameters and OAC type. Elderly Japanese patients with NVAF and LAEF total ≤45.0% were at higher risk of cardiovascular events and HF hospitalization, and those with max. LAVi >48.0 mL/m2were at higher risk of all-cause death.

Effects of sacubitril/valsartan versus olmesartan on left atrial structure in hypertensive patients without HFrEF: a randomized controlled trial

Background and purpose: Treatment with sacubitril plus valsartan attenuates cardiac remodeling in patients with heart failure with reduced ejection fraction (HFrEF). Evidence for potential effects of sacubitril/valsartan on left atrial remodeling in hypertensive patients without HFrEF, however, is limited. Therefore, we aimed to compare the effects of sacubitril/valsartan and olmesartan on the left atrial structure in Chinese hypertensive patients. Methods: This single-center randomized controlled trial was conducted at Nanjing First Hospital from June 2021 to February 2022. Adult patients (18–80 years of age) with essential hypertension but no HFrEF were randomized at a 1:1 ratio to receive sacubitril/valsartan or olmesartan. Initial dosage was 100 mg/day for sacubitril/valsartan and 20 mg/day for olmesartan. In patients who did not reach the target blood pressure (&lt;140/90 mmHg) within a week, dosage was increased to 200 to 400 mg/day for sacubitril/valsartan and 40 mg/day for olmesartan. In patients who failed to reach the target blood pressure at 4 weeks, other antihypertensive drugs were used at physician’s discretion. The patients should reach the target blood pressure at 8 weeks. The primary endpoint was the change of left atrial volume index (LAVI) from baseline to 24 weeks. Secondary endpoints included the changes of left atrial diameter (LAD), left atrial emptying fraction (LAEF), left ventricular ejection fraction (LVEF), and left ventricular end-diastolic diameter (LVEDD) from baseline to 24 weeks. Results are shown as median and interquartile range (IQR). Results: A total of 153 patients were enrolled. The final analysis included 145 patients who completed the 24-week assessment: 71 and 74 in the sacubitril/valsartan and olmesartan groups, respectively. Demographic and key baseline characteristics (e.g., blood pressure) were comparable between the 2 groups. Target blood pressure was achieved in all 145 patients at 8 weeks. In comparison to the olmesartan group, the sacubitril/valsartan group had significantly greater change in LAVI (−4.19 [−2.87, −5.43] vs. −0.61 [−0.53, −1.13] mL/m2, P &lt; 0.001), LAEF (1.00% [2.00%, 0%] vs. 0% [1.00%, −1.00%], P = 0.014), LVEDD (−2.00 [0, −3.00]mm vs. −1.00 [0, −1.00]mm, P &lt; 0.001), and LVEF (1.00% [3.00%, 1.00%] vs. 0% [1.00%, 0%], P &lt; 0.001), but not LAD, LAVI, LAEF, LVEDD, and LVEF at 24 weeks relative to the baseline. Conclusions: In comparison to olmesartan, sacubitril/valsartan resulted in more robust improvements in left atrial and ventricular structure and function in hypertensive patients without HFrEF.

Left atrial reservoir longitudinal strain and its incremental value to the left ventricular global longitudinal strain in predicting anthracycline-induced cardiotoxicity.

Left ventricular global longitudinal strain (LVGLS) has been recommended by current guidelines for diagnosing anthracycline-induced cardiotoxicity. However, little is known about the early changes in left atrial (LA) morphology and function in this population. Our study aimed to evaluate the potential usefulness of LA indices and their incremental value to LVGLS with three-dimensional echocardiography (3DE) in the early detection of subclinical cardiotoxicity in patients with lymphoma receiving anthracycline. A total of 80 patients with diffuse large B-cell lymphoma who received six cycles of anthracycline-based treatment were enrolled. Echocardiography was performed at baseline (T0), after four cycles (T1), and after the completion of six cycles of chemotherapy (T2). Left ventricular ejection fraction (LVEF), LVGLS, LA volumes, LA emptying fraction (LAEF), LA active emptying fraction (LAAEF), and LA reservoir longitudinal strain (LASr) were quantified with 3DE. Left atrioventricular global longitudinal strain (LAVGLS) was calculated as the sum of peak LASr and the absolute value of peak LVGLS (LAVGLS=LASr+|LVGLS|). LV cardiotoxicity was defined as a new LVEF reduction by ≥10 percentage points to an LVEF of ≤50%. Fourteen (17.5%) patients developed LV cardiotoxicity at T2. LA volumes, LAEF, and LAAEF remained stable over time. Impairment of LASr (28.35±5.03vs. 25.04±4.10, p<.001), LVGLS (-22.77±2.45vs. -20.44±2.62, p<.001), and LAVGLS (51.12±5.63vs. 45.61±5.22, p<.001) was observed by the end of the fourth cycle of chemotherapy (T1). Statistically significant declines in LVEF (61.30±4.73vs. 57.08±5.83, p<.001) were only observed at T2. The relative decrease in LASr (ΔLASr), LVGLS (ΔLVGLS), and LAVGLS (ΔLAVGLS) from T0 to T1 were predictors of LV cardiotoxicity. A ΔLASr of>19.75% (sensitivity, 71.4%; specificity, 87.9%; area under the curve (AUC),.842; p<.001), a ΔLVGLS of>13.19% (sensitivity, 78.6%; specificity, 74.2%; AUC,.763; p<.001), and a ΔLAVGLS of>16.80% (sensitivity, 78.6%; specificity, 93.9%; AUC,.905; p<.001) predicted subsequent LV cardiotoxicity at T2, with the AUC of ΔLAVGLS significantly larger than that of ΔLVGLS (.905vs..763, p=.027). Compared to ΔLVGLS, ΔLAVGLS showed improved specificity (93.9%vs. 74.2%, p=.002) and maintained sensitivity in predicting LV cardiotoxicity. LASr could predict anthracycline-induced LV cardiotoxicity with excellent diagnostic performance. Incorporating LASr into LVGLS (LAVGLS) led to a significantly improved specificity and maintained sensitivity in predicting LV cardiotoxicity.

Normal values for left atrial strain, volume, and function derived from 3D echocardiography: the Copenhagen City Heart Study.

3D echocardiographic (3DE) assessment of the left atrium (LA) is a new modality of potential clinical value. Age- and sex-based normative values are needed to benchmark these parameters for clinical use. Of 4466 participants in the 5th Copenhagen City Heart Study, a prospective longitudinal cohort study on the general population, 2082 participants underwent 3DE of the LA. Healthy participants were included to establish normative values for LA strain, volume, and function by 3DE. The effects of age and sex were also evaluated. After excluding participants with comorbidities, 979 healthy participants (median age 44 years, 39.6% males) remained. The median and limits of normality (2.5th and 97.5th percentiles) for functional and volumetric measures were as follows: LA reservoir strain (LASr) 30.8% (18.4-44.2%), LA conduit strain (LAScd) 19.1% (6.8-32.0%), LA contractile strain 11.7% (4.3-22.2%), total LA emptying fraction (LAEF) 61.4% (47.8-71.0%), passive LAEF 37.7% (17.4-53.9%), active LAEF 37.4% (22.2-52.5%), LA minimum volume index (LAVimin) 10.2 (5.9-18.5) mL/m2, and LA maximum volume index (LAVimax) 26.8 (16.5-40.1) mL/m2. All parameters changed significantly with increasing age (P value for all <0.001). Significant sex-specific differences were observed for all parameters except active LAEF and LAVimax. Sex significantly modified the association between age and LASr (P for interaction < 0.001), LAScd (P for interaction < 0.001), LAVimin (P for interaction = 0.037), and total LAEF (P for interaction = 0.034) such that these parameters deteriorated faster with age in females than males. We present age- and sex-specific reference material including limits of normality for LA strain, volume, and function by 3DE.

Assessment of left atrial function in patients with metabolic syndrome by four-dimensional automatic left atrial quantification

ObjectiveThis study aimed at assessing the changes of left atrial (LA) volume and strain function in metabolic syndrome (MS) patients using four-dimensional automatic left atrial quantification (4D-LAQ) and exploring independent correlative factors for LA function. MethodsA total of 110 MS patients and 70 normal controls were selected and assigned into the MS group and the control group, respectively. Echocardiogram parameters were routinely examined and the thickness of epicardial adipose tissue (EAT) were measured with a parasternal long axis of left ventricle(LV). The LA volume and strain parameters were determined using 4D-LAQ. The independent correlation factors for LA strain parameters in MS patients were investigated through linear regression analysis. ResultsCompared with the control group, LA volume parameters were increased in the MS group, LA strain parameters and LA emptying fraction (LAEF) were decreased (all P < 0.05). EAT thickness is associated with LA reservoir longitudinal strain (LASr), conduit longitudinal strain (LAScd), reservoir circumferential strain (LASr-c), and conduit circumferential strain (LAScd-c) (all P < 0.05). LA contraction longitudinal (LASct) and circumferential strain (LASct-c) were not statistically significant. Regression analysis results show that systolic blood pressure (SBP) and triglyceride (TG) are independent correlative factors. Intra-observer and inter-observer repeatability test showed that the LA parameters examined by 4D-LAQ had good agreement. Conclusions4D-LAQ is capable of effectively assessing the LA function in MS patients and providing a useful reference for clinical diagnosis. SBP and TG serve as the independent correlative factors for LA function.

Exercise echocardiography to assess left atrial function in patients with symptomatic AF

BackgroundLeft atrial (LA) function contributes to the augmentation of cardiac output during exercise. However, LA response to exercise in patients with atrial fibrillation (AF) is unknown. We explored the LA mechanical response to exercise and the association between LA dysfunction and exercise intolerance. MethodsWe recruited consecutive patients with symptomatic AF and preserved left ventricular ejection fraction (LVEF). Participants underwent exercise echocardiography and cardiopulmonary exercise testing (CPET). Two-dimensional and speckle-tracking echocardiography were performed to assess LA function at rest and during exercise. Participants were grouped according to presenting rhythm (AF vs sinus rhythm). The relationship between LA function and cardiorespiratory fitness in patients maintaining SR was assessed using linear regression. ResultsOf 177 consecutive symptomatic AF patients awaiting AF ablation, 105 met inclusion criteria; 31 (29.5 %) presented in AF whilst 74 (70.5 %) presented in SR. Patients in SR augmented LA function from rest to exercise, increasing LA emptying fraction (LAEF) and LA reservoir strain. In contrast, patients in AF demonstrated reduced LAEF and reservoir strain at rest, with failure to augment either parameter during exercise. This was associated with reduced VO2Peak compared to those in SR (18.4 ± 5.6 vs 22.5 ± 7.7 ml/kg/min, p = 0.003). In patients maintaining SR, LAEF and reservoir strain at rest and during exercise were associated with VO2Peak, independent of LV function. ConclusionThe maintenance of SR in patients with AF is associated with greater LA reservoir function at rest and greater augmentation with exercise compared to patients in AF. In patients in SR, reduced LA function is associated with reduced exercise tolerance, independent of LV function.

Spironolactone improves left atrial function and atrioventricular coupling in patients with resistant hypertension.

To determine the blood pressure independent effects of spironolactone on left atrial (LA) size and function in patients with resistant hypertension (RHTN). Patients with RHTN (n = 36, mean age 55 ± 7) were prospectively recruited. Spironolactone was initiated at 25mg/day and increased to 50mg/day after 4 weeks. Other antihypertensives were withdrawn to maintain constant blood pressure. Cardiac magnetic resonance imaging was performed at baseline and after 6 months of spironolactone treatment and changes in LA functional metrics were assessed. LA size and function parameters were improved (p < 0.05) from baseline to month-6: LA volumes indexed to body surface area (LAVI) were reduced (LAVImaximum 41.4±12 vs. 33.2±9.7 mL/m2; LAVIpre-A 32.6±9.8 vs. 25.6±8.1 mL/m2; median LAVIminimum 18.5 [13.9-24.8] vs. 14.1 [10.9-19.2] mL/m2); left atrioventricular coupling index was reduced (28.2±11.5 vs. 22.7±9.2%); LA emptying fractions (LAEF) were increased (median total LAEF 52.4 [48.7-60.3] vs. 55.9 [50.3-61.1] %; active LAEF 40.2±8.6 vs. 43.1±7.8%). LA global longitudinal strain in the active phase was increased (16.3±4.1 vs. 17.8±4.2%). The effect of spironolactone was similar in patients with high (N = 18) and normal (N = 18) aldosterone status (defined by plasma renin activity and 24-h urine aldosterone). Treatment of RHTN with spironolactone is associated with improvements in LA size and function, and atrioventricular coupling, regardless of whether aldosterone levels were normal or high at baseline. This study suggests the need for larger prospective studies examining effects of mineralocorticoid receptor antagonists on atrial function and atrioventricular coupling.

Evaluation of Left Atrial Function in Patients with Paroxysmal Atrial Fibrillation Using Left Atrial Automatic Myocardial Functional Imaging Ultrasonography.

To evaluate volume and strain of the left atrium (LA) in people suffering from paroxysmal atrial fibrillation which is not valvular (NVPAF) using the new technology of left atrial automatic myocardial function imaging (AFILA) and to analyze prognostic factors in patients with NVPAF by follow-up. Between August 2019 and August 2022, a total of 80 NVPAF patients and 60 normal control patients who were hospitalized in the Department of Cardiology were included in the study. The LA volume and strain parameters of the two groups were analyzed. The differences in LA function (LAF) parameters were compared between the two groups to generate the receiver operating characteristic curve (ROC) and calculate the area under the curve (AUC), sensitivity, and specificity of each parameter. Follow-up was conducted on the 80 NVPAF patients included, their treatment methods after admission and their rehospitalization due to heart events were recorded, and independent risk factors influencing the prognosis of NVPAF were obtained. A total of 140 patients participated in the study, including 80 in the NVPAF group and 60 in the normal control group. There was no statistically significant difference in age and sex between the two groups. Compared to the normal group, the LA minimum volume (LAVmin), LA maximum volume (LAVmax), and volume at onset of LA contraction (LAVpreA) in the NVPAF group were significantly increased. The LA emptying fraction (LAEF) was significantly decreased, and LA reservoir strain (S_R), LA conduit strain (S_CD), and LA contractile strain (S_CT) were significantly compromised (P < 0.05). There was no significant difference in LA evacuation volume (LAEV) reduction (P > 0.05). Logistic regression analysis of LAF parameters in NVPAF patients showed that LAEF and S_R were independently correlated with NVPAF (odds ratio values: 0.883 (0.827-0.943), P < 0.001; 0.916 (0.569-1.474), P = 0.047). The ROC curve results showed that LAEF had a high efficiency in the diagnosis of NVPAF, with P < 0.001, AUC of 0.843, sensitivity of 0.788, and specificity of 0.867. For the LA strain parameters, the S_R test efficiency was higher, with P < 0.001, AUC of 0.762, sensitivity of 0.713, and specificity of 0.783. There was a strong correlation between S_R and LAEF in patients with no end event and those with end event. The ROC curve revealed that the S_R was better than LAEF in predicting prognosis of patients with AF (AUC = 0.914, P < 0.0001 vs. AUC = 0.876, P < 0.0001). S_R of 10.5 and LAEF of 21 were the cut-off values for endpoint events in NVPAF patients, with sensitivity of 0.909 and 0.727 and specificity of 0.904 and 0.901, respectively. AFILA ultrasound technology comprehensively evaluated the LA size and function in patients with NVPAF. The LAEF and S_R were independently correlated with NVPAF and can determine the prognosis of patients with NVPAF.

Normal values for left atrial strain, volume and function derived from three-dimensional echocardiography in the general population

Abstract Background Three-dimensional echocardiographic (3DE) assessment of the left atrium (LA) is a new modality of potential clinical value. Age- and sex-based normative values are needed to benchmark these parameters for clinical use. Methods The study included 4,466 participants from a prospective longitudinal cohort study in the general population, among these 2,082 participants underwent 3DE of the LA. Exclusion criteria were hypertension, diabetes, ischemic heart disease, history of stroke, atrial fibrillation, heart failure, use of heart medication, chronic kidney disease, use of pacemaker, significant valve regurgitation or valve stenosis. Healthy participants were included to establish normative values for LA strain, volume, and function by 3DE. The effects of age and sex on 3DE parameters were also evaluated. Mean volumes per second for included participants was 62.4±5.7. Results After excluding participants with comorbidities, the final study population constituted of 979 healthy participants, median age was 44 years (interquartile range 32-56 years), 40% men. The median and limits of normality (2.5th and 97.5th percentiles) for functional and volumetric measures were: LA reservoir strain (LASr) 30.8% (18.4-44.2%), LA conduit strain (LAScd) 19.1% (6.8-32.0%), LA contractile strain (LASct) 11.7% (4.3-22.2%) (Figure 1) total LA emptying fraction (LAEF) 61.4% (47.8-71.0%), passive LAEF 37.7% (17.4-53.9%), active LAEF 37.4% (22.2-52.5%), LA minimum volume index (LAVimin) 10.2 (5.9-18.5) ml/m2, and LA maximum volume index (LAVimax) 26.8 (16.5-40.1) ml/m2 (Figure 2). All parameters changed significantly with increasing age (p value for all &amp;lt;0.001). Significant sex-specific differences were observed for all parameters except for active LAEF. Sex significantly modified the association between age and LASr (p for interaction&amp;lt;0.001), LAScd (p for interaction&amp;lt;0.001), LAVimin (p for interaction=0.037), and total LAEF (p for interaction=0.034). Conclusion We present age- and sex specific reference material including limits of normality for LA strain, volume, and function by 3DE.

The impact of extensive ablation strategy for persistent atrial fibrillation on left atrial function and cardiovascular events: Insights from EARNEST-PVI randomized controlled trial

Abstract Background Left atrial (LA) function is paid attention as the marker for several cardiovascular events. In catheter ablation for persistent atrial fibrillation (AF), extensive ablation strategy, such as linear ablation and/or complex fractionated atrial electrogram ablation in addition to pulmonary vein isolation (PVI-plus), could impair LA function more severely than PVI-alone strategy. Purpose The aim of this study is to investigate the impact of PVI-plus strategy on LA function and an incidence of cardiovascular events. Methods This study is a post-hoc subanalysis of the EARNEST-PVI randomized controlled trial (NCT03514693), which investigated the efficacy of the PVI-alone strategy in comparison with PVI-plus strategy for persistent AF. From the 497 participants of EARNEST-PVI trial, we enrolled 191 patients with full datasets of pre- and post-ablation cardiac computed tomography (CT). Patients were divided into PVI-alone and PVI-plus groups. Within one month before and 3 months after ablation, LA volume index (LAVI) and LA emptying fraction (LAEF) were calculated. We assessed (i) post-ablation LAEF (LAEFpost), (ii) AF/AT -free rate after final session, and (iii) association between PVI-plus strategy and composite cardiovascular events; all-cause death, embolic stroke, and heart failure (HF) hospitalization. Results The baseline LAVI and LAEF were not different between PVI-alone (N=96) and PVI-plus groups (N=95) [LAVI: 71.4(57.8, 82.0) vs. 68.7(61.0, 78.1), P=0.92, LAEF: 13.7(10.0, 17.4) vs. 13.0(10.0, 16.9), PVI-alone vs. PVI-plus, P=0.78]. In overall patients, LAEFpost did not differ [34.4 (26.1, 40.7) vs. 31.6 (26.0, 37.4), P=0.13]. In the analysis of patients showing sinus rhythm during the CT study, however, LAEFpost was significantly higher in PVI-alone (N=87) than in PVI-plus group (N=93) [35.7(29.0, 41.0) vs. 31.7(26.1, 37.5), P=0.011] (Figure 1). AF/AT-free survival rate after final session during median follow-up of 44 months tended to be higher in PVI-plus (72.9% vs. 84.2%, P=0.053) (Figure 2). The composite cardiovascular events-free rate were not different among two groups (94.8% vs. 96.8%, P=0.42) (Figure 3). LAEFpost was significantly lower in patients with composite events (N=8) than those without (N=183) [18.7(11.5, 28.1) vs. 33.1 (27.0-38.1), P=0.0051]. In multivariate Cox regression model adjusted with age≥75, gender and pre-LAVI, PVI-plus did not show association with composite events (HR: 0.90, 95%CI: 0.18-4.47, P=0.89), while LAEFpost showed strong association (HR:0.88, 95%CI: 0.80-0.96, P=0.0039). Conclusion Compared with PVI-alone strategy, PVI-plus strategy impaired LA function more severely, but tended to have higher ablation success rate, and did not increase cardiovascular events. LAEFpost was independently associated with cardiovascular events. Regardless of ablation strategy, patients with reduced post-ablation LA function should be observed carefully.Post-ablation LA function and recurrenceCardiovascular events and LA function

Lower cardiorespiratory fitness is associated with left atrial structural, functional and electrical remodelling in patients with symptomatic atrial fibrillation

Abstract Background Preserved cardiorespiratory fitness (CRF) is associated with improved rhythm control in patients with symptomatic atrial fibrillation (AF). However, the pathophysiological features associated with low cardiorespiratory fitness are not well described. Purpose Evaluate the association between cardiorespiratory fitness and structural, functional and electroanatomical features of the left atrium (LA) amongst patients with symptomatic AF. Methods Consecutive patients with symptomatic paroxysmal or persistent AF undergoing AF ablation were recruited. CRF was assessed objectively by peak oxygen consumption (VO2peak) assessed during maximal cycle ergometry. Invasive assessment of LA remodelling involved direct assessment of resting LA pressures (LAP), LA stiffness during saline infusion and LA electrical function using high-density electroanatomical maps. Non-invasive assessment involved 2D transthoracic echocardiography at rest and during exercise. The association between VO2PEAK and atrial parameters were determined using multivariable linear regression models adjusted for age and sex. Results In total, 110 participants were recruited. Mean age was 63±11 and 74.5% of the cohort was male. In adjusted analyses, higher VO2PEAK was associated with lower mean LAP (p&amp;lt;0.001) and invasively assessed LA stiffness (p=0.005). On non-invasive testing, VO2PEAK was positively associated with left atrial emptying fraction (LAEF) (p=0.001) and reservoir strain (p&amp;lt;0.001) at rest. During exercise, VO2PEAK remained associated with LAEF (p&amp;lt;0.001) and LA reservoir strain (p=0.007). Higher VO2peak was positively associated with LA bipolar voltages (p=0.035) but not LA conduction velocities (p=0.131) or LA fractionation (p=0.452) Conclusions In patients with symptomatic AF, lower cardiorespiratory fitness is independently associated with extensive LA remodelling involving impaired LA haemodynamics, increased LA stiffness, LA mechanical dysfunction and LA electrical remodeling.

3D atrial stiffness in chronic mitral regurgitation: impact of sex, regurgitation mechanism and valve geometry - the 3D-PRIME study

Abstract Background Chronic mitral regurgitation (MR) is both a cause and a consequence of progressive left atrial (LA) remodeling. The degree of LA stiffness in relation to clinical risk factors as well as atrio-valvular remodeling has not been reported in patients with MR. Aims To assess the severity and determinants of 3D LA stiffness in chronic MR. Methods In the prospective 3D-PRIME (3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation) study, 100 patients with chronic MR (70±13years, 38% women, 55% with a history of atrial fibrillation (AF), 42% with severe MR) recruited at one heart valve center were investigated with 2D and 3D transthoracic and transesophageal echocardiography. MR severity was quantified by the regurgitant fraction and MR classified as primary (54%), atrial functional (26%) or ventricular functional (20%). 3D LA volume (LAV) was measured at end-diastole (min LAV) and end-systole (max LAV), and 3D LA function assessed in by the emptying fraction (EF) and the peak strain in the reservoir phase (LASr). LA stiffness was estimated from the ratio: mitral peak E-wave velocity divided by the mitral annular e’ velocity (E/e´) / LASr and classified as high for age if ≥ 0.55. Results High LA stiffness for age was present in 58% of patients and more often in those with a history of AF (73% vs. 45%) and in severe vs moderate MR (70% vs. 42%) (both p &amp;lt;0.01). Patients with high LA stiffness had larger LAVs with lower LA EF, lower right ventricular ejection fraction, increased mitral annulus area, and larger mitral valve leaflets (all p&amp;lt;0.05). Men had considerably larger LAVs in all MR subgroups, and highly stiff LAs in atrial functional MR compared to women (p &amp;lt;0.05, Figure) despite similar MR severity (regurgitation fraction 50% vs 52%, respectively). In multiple regression analysis, after stepwise removal of the following factors: MR severity, mitral leaflet to ring area ratio, and right ventricular ejection fraction, increased LA stiffness was independently associated with male sex, history of AF, lower LA EF and lower mitral intertrigonal diameter (R2 0.40, p &amp;lt;0.001, Table). Conclusion LA is stiff for age in over half of patients with chronic MR, excessively stiff in men with atrial functional MR, and associated with specific changes in mitral valve geometry and LA function. This gives mechanistic insights into the complex atrio-valvular interplay in chronic MR.Figure.Table.

Abstract 12930: Atrial Myopathy and the Risk of Incident Atrial Fibrillation in People With Newly Diagnosed Cavotricuspid Isthmus-Dependent Atrial Flutter

Background New cavotricuspid isthmus-dependent atrial flutter (AFL) is associated with increased risk of incident atrial fibrillation (AF). It is unclear which patients with AFL will develop AF. Hypothesis: Patients with new AFL who have co-existing atrial myopathy, detected by measuring left atrial emptying fraction (LAEF) and left atrial reservoir strain (LARS), may be at increased risk for developing AF. Methods: There were 210 patients who received an ablation or cardioversion for AFL at a tertiary care medical center between 2015-2022. Patients were excluded for prior AF (118), congenital heart disease (16), valve surgery and heart transplant (9), no echocardiogram available (9), and less than 6 months of follow up (9). Data was obtained by retrospective chart review. Covariates included coronary heart disease, heart failure, diabetes, age, sex, vascular disease, and stroke. Exposure variables included LAEF and LARS. We used Cox proportional hazards models to estimate the risk of AF for LAEF and LARS. Results: 49 patients (mean age 62.3 years, 18.3% female) met criteria for inclusion, and 18 developed atrial fibrillation over a mean follow up period of 29.9 months (19.7 months). Those who developed AF had lower LAEF and LARS compared to those who did not. For every 5% decrease in LAEF and LARS, there was a 1.79 (1.33, 2.38) and 5.26 (1.75, 16.67)-fold increase in risk of AF after adjustment for covariates. Conclusion: Co-existing atrial myopathy, measured by decreased LAEF and LARS, is associated with increased risk of AF in people with new AFL.

Abstract 17781: Spironolactone Improves Left Atrial Function and Atrioventricular Coupling in Resistant Hypertension

Purpose: To determine the blood pressure independent effects of spironolactone on left atrial (LA) size and function in patients with resistant hypertension (RHTN). Methods: Patients with RHTN (N=36, 55±7 years) were prospectively recruited. Spironolactone was initiated at 25 mg/day and increased to 50 mg/day after four weeks. Other antihypertensives were withdrawn to maintain constant blood pressure. Cardiac magnetic resonance imaging was performed at baseline and after six months of spironolactone treatment and changes in LA functional metrics were assessed (Figure 1). The statistical analysis was conducted using two-sided tests of significance. Results: LA size and function parameters improved from baseline to month-six: LA volumes indexed to body surface area (LAVI) were reduced (LAVI max 41.4±12 vs 33.2±9.7 ml/m 2 ; LAVI pre-A 32.6±9.8 vs 25.6±8.1 ml/m 2 ; LAVI min 18.5 [13.9 - 24.8] vs 14.1 [10.9 - 19.2] ml/m 2 ; all p &lt; 0.05); left atrioventricular coupling index was reduced (28.2±11.5 vs 22.7±9.2 %, p &lt; 0.05); LA emptying fractions (LAEF) were increased (total LAEF 52.4 [48.7 - 60.3] vs 55.9 [50.3 - 61.1] %; active LAEF 40.2±8.6 vs 43.1±7.8 %, both p &lt; 0.05). There was a substantial increase in reservoir strain (29.1 ± 8.5 % vs 30.9 ± 5.5 %, p = 0.068) whereas active strain was significantly increased from baseline (16.3 ± 4.1 % vs 17.8 ± 4.2 %, p &lt; 0.05). Changes in passive strain and strain rates were not statistically significant (p &gt; 0.1). The effect of spironolactone was similar in patients with high (N = 18) and normal (N = 18) aldosterone status (defined by plasma renin activity and 24-hour urine aldosterone). Conclusion: Treatment of RHTN with spironolactone is associated with improvements in LA size and function regardless of whether aldosterone levels were normal or high. This study suggests the need for larger prospective studies examining effects of mineralocorticoid receptor antagonists on atrial function and atrioventricular coupling.

Abstract 18826: Atrial Fibrillation, Atrial Myopathy, and the Risk of Recurrent Stroke or Transient Ischemic Attack After Cryptogenic Stroke

Background: The annual risk of recurrent stroke after cryptogenic stroke (CS) is estimated at 3-6%. Atrial myopathy, characterized by left atrial structural and electrophysiological remodeling, is associated with atrial fibrillation (AF) and stroke. Hypothesis: Atrial myopathy is associated with an increased risk of recurrent stroke or transient ischemic attack (rCVA) within one year. Methods: Patients with interpretable echocardiograms who received an implantable loop recorder for CS at a tertiary care medical center (2015-22) were included and followed for at least 1 year. Left atrial emptying fraction (LAEF) and reservoir strain (LARS) were calculated from two-dimensional transthoracic echocardiograms. Covariates including congestive heart failure, hypertension, age, diabetes, sex, stroke/transient ischemic attack, vascular disease, carotid artery stenosis, and rCVA were ascertained by review of hospital medical records. Incident AF post CS was obtained from review of loop recorder data. Odds ratios were calculated using logistic regression models. Two-sided student's T-test was used to compare means of continuous variables. Results: 159 patients (mean age 74.4 years, 52.1% female) were followed for at least one-year post CS. Patients with rCVA had significantly lower LAEF (p=0.012) and near-significantly lower LARS (p=0.088) compared to those who did not. The odds of rCVA were 4.82 (2.22, 7.11)-fold greater in those found to have new AF independent of LAEF, LARS, and remaining covariates including carotid artery stenosis. Patients on anticoagulation at time of rCVA had trends towards reduced stroke severity (p=0.184). Conclusions: Atrial myopathy characterized by AF or reduced LA function is associated with rCVA post CS.

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 13576: Long-Term Serial Changes in Echocardiographic Parameters in Patients With Heart Failure With Preserved Ejection Fraction After Catheter Ablation for Atrial Fibrillation

Background: Heart failure with preserved ejection fraction (HFpEF) is frequently complicated by atrial fibrillation (AF). Catheter ablation for AF is an effective method for restoring and maintaining sinus rhythm (SR). However, there is limited data on the serial changes in echocardiographic parameters in patients with HFpEF after ablation. Hypothesis: The serial changes in echocardiographic parameters after ablation for AF depend not only on baseline rhythm but also on the presence of HFpEF. Methods: A retrospectively review was conducted on 1109 out of 2123 patients who had serial echocardiographic data available before the ablation procedure and at 1-year, 2-year, and 3-year follow-ups. The changes in echocardiographic parameters were assessed using repeated measures ANOVA with a Greenhouse-Geisser correction and Bonferroni tests in four groups, which were divided according to baseline rhythm and HFpEF. HFpEF was defined as an HFA-PEFF score ≥ 5 or 2-4 and left atrial pressure ≥ 15 mmHg at the time of catheter ablation. Results: The prevalence of HFpEF was 51.9%, and paroxysmal AF was present in 65%. Left atrial volume index (LAVI) was larger at baseline in patients with AF and significant decreased after ablation in all groups. The trend of left atrial emptying fraction (LAEF) increased in patients with baseline AF until 1year later, while in patients with baseline SR and HFpEF, LAEF gradually declined even after catheter ablation. The trend of left ventricular ejection fraction increased in patients with baseline AF. The trend of mean E/E’ mildly increased after ablation in all groups. There were significant differences between HFpEF and non-HFpEF. (Figure) Conclusions: Catheter ablation was associated with changes of LA size, function and left ventricular function. Baseline rhythm and the presence of HFpEF play a complex role in the course of cardiac function after ablation.