Left Atrial Reservoir Strain Research Articles

Diagnostic and prognostic value of the left atrial myopathy evaluation in cardiac amyloidosis using echocardiography.

Cardiac amyloidosis (CA) is an under-recognized cause of heart failure. Left atrial (LA) myopathy contributes to a worse prognosis in heart failure and is a feature of transthyretin (ATTR) and light-chain (AL) CA. LA mechanical dispersion (LA-MD) is a novel marker of intra-atrial dyssynchrony implicated in LA myopathy and the future development of atrial fibrillation (AF). This study aimed to determine the characteristics and prognostic value of LA myopathy in ATTR and AL cardiomyopathy through a comprehensive LA echocardiographic evaluation. ATTR (n=86) and AL (n=86) CA patients were compared with hypertensive heart disease (HHT) patients (n=58). Transthoracic echocardiographic measurements including LA strain and LA-MD were obtained with patient follow-up for mortality. ATTR and AL patients had a median follow-up of 66months, with 26 mortality events. Left ventricular (LV) mass, diastolic function (average-e' and E/e'), LV global longitudinal strain, and LA volume and function (LA function index and strain) were more impaired in ATTR versus AL; these echocardiographic parameters were more impaired in both amyloid groups compared to HHT patients (P<0.05). LA-MD was increased in ATTR versus AL [median 72.2 (inter-quartile range 55-88.9) vs. 54 (43.5-64.2), respectively, P<0.001]. Multivariable logistic regression adjusted for age, presence of AF, LV mass, global and basal strain, and E/e' demonstrated that LA-MD was an independent determinant of ATTR CA (P=0.014). On multivariable analysis, LA reservoir strain was independently associated with the presence of heart failure in the CA group (P<0.001). LA minimum volume (cut-off ≥18mL/m2) was a determinant of mortality in AL CA [Cox proportional hazard ratio (HR) 1.042 (1.003-1.082), P=0.034 and Kaplan-Meier analysis, P=0.016]. Characterizing LA myopathy has significant diagnostic and prognostic utility in CA. ATTR patients have increased atrial dyssynchrony, which may have implications for AF development. LA reservoir strain was associated with heart failure in CA, whilst LA minimum volume was a predictor of mortality in AL CA.

Detection of Subclinical Cardiac Dysfunction in Patients With Sickle Cell Disease Using Speckle-Tracking Echocardiography

Sickle cell disease (SCD) is characterized by chronic anemia and recurrent ischemia-reperfusion episodes, which can lead to high-output heart failure. The impact of SCD on cardiac structure and function remains underinvestigated. We conducted a single-institution retrospective analysis of clinical and echocardiographic data from patients with hemoglobin SS SCD (SCD-SS) between January 2016 and June 2022. Patients with known heart failure, left ventricular (LV) ejection fraction <50%, moderate or severe valvular heart disease, congenital heart disease, established coronary artery disease, diabetes mellitus, hypertension, or coexistent lung disease were excluded. Compared with healthy controls (n = 28), patients with SCD-SS (n = 66) had a significantly higher left atrial (LA) volume index (35.7 vs 23.9 ml/m², p <0.001) and average E/e' (7.4 vs 6.5, p = 0.003) but lower average e' (12.3 vs 13.6 cm/s, p = 0.047) and LA reservoir strain (32.9% vs 42.4%, p <0.001). Patients with SCD-SS had higher LV end-diastolic (132.5 vs 104.1 ml, p <0.001) and LV end-systolic volumes (51.0 vs 43.8 ml, p = 0.017) with reduced LV global longitudinal strain (17.6% vs 20.0%, p <0.001). In addition, patients with SCD-SS showed reduced right ventricular (RV) global longitudinal strain (19.7% vs 22.8%, p <0.001) in the setting of normal RV tricuspid annular plane systolic excursion. Maximal systolic tricuspid regurgitation velocity (231 vs 202 cm/s, p <0.001) and right atrial area (16.6 vs 12.8 cm², p <0.001) were statistically greater in SCD-SS. Hemoglobin and hematocrit negatively correlated with LA volume index, average E/e', LV end-diastolic and LV end-systolic volumes. In conclusion, patients with SCD-SS had notable differences in cardiac chamber size and impaired LV, RV, and LA strain compared with healthy controls. Further investigations are needed to assess the impact of these variables on SCD clinical course and prognosis.

Association of central arterial stiffness with atrial myopathy: the Atherosclerosis Risk in Communities (ARIC) study.

Atrial myopathy-defined as abnormal left atrial (LA) size and function-is associated with an increased risk of atrial fibrillation, heart failure, and dementia. Central arterial stiffness is associated with increased atrial afterload and fibrosis and may be a risk factor for atrial myopathy. We examined the association of carotid-femoral pulse wave velocity (cfPWV) with LA function and assessed potential causal relationships. We included 2825 Atherosclerosis Risk in Communities (ARIC) study participants from Visit 5 (2011-2013). cfPWV was related to echocardiographic LA function continuously per 1-SD and categorically in quartiles. Mendelian randomization (MR) analysis was performed using U.K. Biobank-derived genetic variants associated with arterial stiffness index and cardiac magnetic resonance measures of LA function. When analyzed per SD increment (297.6 cm/s), higher cfPWV was significantly associated with lower LA reservoir and conduit strain (β = -0.53%, 95% CI [-0.81, -0.25] and β = -0.46%, 95% CI [-0.68, -0.25], respectively) after adjusting for demographics, clinical characteristics, systolic blood pressure, and left ventricular (LV) morphology and function. In MR analyses there was a non-significant inverse association of arterial stiffness index with LA total, passive, and active emptying fractions. Higher cfPWV is associated with lower LA reservoir and conduit strain, independent of systolic blood pressure and LV morphology and function. No evidence for a causal relationship between arterial stiffness index and alterations in LA function was found. Future studies should examine the prospective association of central arterial stiffness with LA function alterations.

The impact of diabetes mellitus on cardiac function assessed by magnetic resonance imaging in patients with hypertrophic cardiomyopathy

BackgroundThe adverse prognostic impact of diabetes on hypertrophic cardiomyopathy (HCM) is poorly understood. We sought to explore the underlying mechanisms in terms of structural and functional remodelling in HCM patients with coexisting diabetes (HCM-DM).MethodsA total of 45 HCM-DM patients were retrospectively included. Isolated HCM controls (HCM patients without diabetes) were matched to HCM-DM patients in terms of maximal wall thickness, age, and gender distribution. Left ventricular (LV) and atrial (LA) performance were evaluated using cardiac magnetic resonance feature tracking strain analyses. The associations between diabetes and LV/LA impairment were investigated by univariable and multivariable linear regression.ResultsCompared with the isolated HCM controls, the HCM-DM patients had smaller end-diastolic volume and stroke volume, lower ejection fraction, larger mass/volume ratio and impaired strains in all three directions (all P < 0.05). In terms of the LA parameters, HCM-DM patients presented impaired LA reservoir and conduit strain/strain rate (all P < 0.05). Among all HCM patients, comorbidity with diabetes was independently associated with a low LV ejection fraction (β = − 6.05, P < 0.001) and impaired global longitudinal strain (β = 1.40, P = 0.007). Moreover, compared with the isolated HCM controls, HCM-DM patients presented with more myocardial fibrosis according to late gadolinium enhancement, which was an independent predictor of impaired LV global radial strain (β = − 45.81, P = 0.008), LV global circumferential strain (β = 18.25, P = 0.003), LA reservoir strain (β = − 59.20, P < 0.001) and strain rate (β = − 2.90, P = 0.002).ConclusionsDiabetes has adverse effects on LV and LA function in HCM patients, which may be important contributors to severe manifestations and outcomes in those patients. The present study strengthened the evidence of the prevention and management of diabetes in HCM patients.

Left atrial strain by cardiac MRI feature tracking in mitral stenosis before and after balloon valvuloplasty.

The aim was to investigate LA strain by feature tracking cardiac MRI in mitral stenosis (MS) patients before and after percutaneous balloon mitral valvuloplasty (PBMV). Patients underwent cardiac MRI before and after successful PBMV (n = 18). Mitral valve area, transmitral velocity and gradients, LA volumes and ejection fraction (LAEF) were measured. LA strain feature tracking analysis was used to calculate LA reservoir, conduit, and booster strain. LA strain, LA volumes, LAEF and mitral valve severity indices were compared before and after PBMV. Correlations between LA strain and other cardiac MRI parameters were assessed. After PBMV, mitral valve area increased from 1.18 ± 0.25 cm2 to 2.26 ± 0.27 cm2, p < 0.001. Transmitral peak velocity decreased from 1.7 ± 0.37m/s to 1.3 ± 0.27m/s, p < 0.001. Transmitral peak gradient decreased from 12.4 ± 4.8 mmHg to 6.8 ± 2.9 mmHg, p < 0.001, and mean gradient decreased from 6.9 ± 3.8 mmHg to 2.9 ± 1.4 mmHg, p < 0.001. Maximal LA volume decreased from 73.1 ± 14.2 ml/m2 to 62.7 ± 16.3 ml/m2, p = 0.018; corrected p value = 0.054. LAEF increased from 36.3 ± 8.7% to 44.4 ± 9.5%, p = 0.010. Reservoir strain increased from 11.7 ± 3.1% to 14.9 ± 3.6% after PBMV, p = 0.009, and conduit strain from 3.8 ± 2% to 6 ± 2.3%, p = 0.005. Booster strain insignificantly increased after PBMV. Cardiac MRI feature tracking provides information on the 3 LA functional phases. Significant improvement was observed in reservoir and conduit functions after successful PBMV.

Impaired Left Atrial Reserve Function in Heart Failure With Preserved Ejection Fraction.

Left atrial (LA) dysfunction is common in heart failure (HF) with preserved ejection fraction. However, data on the pathophysiologic impacts of impaired LA functional reserve remained limited. We sought to determine the association of abnormal LA dynamics during exercise with cardiovascular reserve, exercise capacity, and clinical outcomes. Patients with HF with preserved ejection fraction (n=231) and controls without HF (n=219) underwent exercise stress echocardiography with simultaneous expired gas analysis. LA function was assessed at rest and during exercise using speckle-tracking echocardiography. Patients with HF with preserved ejection fraction demonstrated less increase in LA reservoir and booster pump strain during exercise than those in controls. The degree of LA dilation was more closely related to exercise LA reservoir strain than to resting LA strain (Meng test, P=0.002). The presence of impaired LA reservoir strain during exercise was associated with poorer biventricular systolic reserve and cardiac output augmentation, more severe right ventricular-pulmonary artery uncoupling, and lower peak oxygen consumption. Patients with a lower exercise LA reservoir strain had a 2.7-fold increased risk of HF events (hazard ratio, 2.66 [95% CI, 1.32-5.38]; P=0.006). Among patients with follow-up echocardiography, initiation of guideline-directed medical therapy or atrial fibrillation ablation showed significant improvements in LA reservoir (P<0.001 and P=0.022) and booster pump strain (P=0.011 and 0.028) at rest and during exercise, respectively. Impaired LA reservoir function during exercise in HF with preserved ejection fraction is associated with biventricular reserve limitations, exercise intolerance, and increased risks of HF events.

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.

Importance of fourth heart sound and preserved left atrial function in wild-type transthyretin amyloidosis.

A fourth heart sound (S4) was reported to be almost never present in patients with amyloid light-chain cardiomyopathy. There have been no reports on S4 in patients with wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM). This study aimed to clarify the clinical implications of S4 in patients with ATTRwt-CM. Seventy-six patients with ATTRwt-CM (mean age: 80.4±5.4years, 68 males) who had undergone phonocardiography (PCG) were retrospectively assessed. We measured S4 amplitude on digitally recorded PCG. S4 was considered to be present when its amplitude was 1.0mm or greater on the PCG. Distinct S4 was defined as S4 with an amplitude of 2.0mm or greater, which is usually recognizable by auscultation. According to the rhythm and presence or absence of S4, the patients were divided into three groups, namely, sinus rhythm (SR) with S4, SR without S4, and non-SR. Non-SR consisted of atrial fibrillation, atrial flutter, and atrial tachycardia. Thirty-six patients were in SR and the remaining 40 patients were in non-SR. In the 36 patients in SR, S4 was shown by PCG to be present in 17 patients (47%), and distinct S4 was recognized in 7 patients (19%) by auscultation. In patients who were in SR, those with S4 had higher systolic blood pressure (124±15 vs. 99±8mmHg, P<0.001), lower level of plasma B-type natriuretic peptide (308 [interquartile range (IQR): 165, 354] vs. 508 [389, 765] pg/mL, P=0.034) and lower level of high-sensitivity cardiac troponin T (0.068 [0.046, 0.089] vs. 0.109 [0.063, 0.148] ng/mL, P=0.042) than those without S4. There was no significant difference in left atrium (LA) volume index or LA reservoir strain between patients with S4 and without S4. Patients with S4 had more preserved LA systolic function than those without S4 (peak atrial filling velocity: 53±25 vs. 34±9cm/s, P=0.033; LA contractile strain: 4.1±2.1 vs. 1.6±2.0%, P=0.012). Patients in SR without S4 had worse short-term prognosis compared with the other two groups (generalized Wilcoxon test, P=0.033). S4 was present in 47% of the patients in SR with ATTRwt-CM. Patients in SR without S4 had more impaired LA systolic function than those in SR with S4. The absence of S4 portends a poor short-term prognosis in patients with ATTRwt-CM.

The effects of SGLT-2 inhibitors on echocardiographic indices and antioxidative properties in patients with heart failure with reduced ejection fraction and diabetes mellitus.

Sodium-glucose co-transporter-2 inhibitors (SGLT-2i) are a new class of drugs that lower blood glucose and reduce mortality in heart failure patients with reduced ejection fraction (HFrEF). They also have antioxidant effects. The exact mechanism of SGLT-2i is unknown. This study investigated the effects of SGLT-2i on asprosin, matrix metalloproteinase (MMP), and tissue inhibitor of MMP (TIMP-1) concentrations and echocardiographic measurements of strain in the left heart chamber. This prospective follow-up study included 56 patients with HFrEF and diabetes mellitus (DM) who did not initially receive SGLT-2 inhibitors. The control group consisted of 30 healthy individuals. Patients with HFrEF were administered either empagliflozin (n=28) or dapagliflozin (n=28) in addition to their treatment. The patient group was evaluated for left ventricular global longitudinal strain (LVGLS), left atrial (LA) strain, and LA volumes at the beginning and third month of the study. The control group had blood collected once, while the patient group had it twice: at the start of the trial, on the same day as the echocardiographic evaluation, and at the end of the third month after starting an SGLT-2i. Serum levels of asprosin, MMP-1 and TIMP-1 were assessed. LVGLS increased significantly in HFrEF patients at the third-month assessment compared to baseline (-8.6±2.3% vs. -9±2.5%, respectively; p<0.001), but there was no significant difference in LVEF (p=0.593). A substantial increase was observed in the left atrial ejection fraction (LAEF) compared to baseline values (36.3±9.4% vs. 42.1±8.7%, respectively; p<0.001), driven by a reduction in minimal LA volume [32.5 (19-96) ml vs. 32 (20-86) ml, respectively; p=0.018]. Compared to baseline evaluation, LA reservoir [13 (6-25) vs. 16.5 (2-26), respectively; p<0.001] and contraction strain (7.7±4.3 vs. 9.4±5.6, respectively; p=0.014) values were also enhanced at the third month. Between the baseline and the 3rd month, the patient group's LA conduit strain (p=0.122) and LA maximum volume (p=0.716) remained unchanged. Serum asprosin significantly increased (11.7±5.1 ng/mL vs. 14±9.4 ng/mL, respectively; p=0.032); however, no statistically significant alteration was detected in MMP (p=0.278) and TIMP-1 levels (p=0.401). SGLT-2i are associated with elevated levels of LVGLS, LAEF, LA contraction strain, and LA reservoir strain. SGLT-2i medications may improve plasma asprosin levels to boost energy metabolism, reduce oxidative stress and reactive oxygen radicals.

Usefulness of exercise stress echocardiography for predicting cardiovascular events and atrial fibrillation in hypertrophic cardiomyopathy

BackgroundIn hypertrophic cardiomyopathy (HCM), the determinants of exercise tolerance and the usefulness of exercise stress echocardiography (ESE) for predicting hard endpoints have not been fully investigated. We aimed to assess the key parameters of ESE for exercise tolerance and the factors predictive of cardiovascular events and new-onset atrial fibrillation (AF) in patients with HCM. MethodsSeventy-four consecutive patients with HCM who underwent ESE and with an ejection fraction ≥50 % were enrolled. The primary endpoint was a composite of cardiovascular death, heart failure hospitalization, ventricular fibrillation or tachycardia, and ventricular assist device implantation. The secondary endpoint was new-onset AF. ResultsThe primary endpoint occurred in 13 patients. The left and right ventricular functions during exercise were responsible for decreased exercise tolerance. Peak exercise e′ and tricuspid annular plane systolic excursion (TAPSE) significantly predicted increased primary outcome risk (hazard ratio 1.35, 95 % confidence interval 1.10–1.76, p = 0.003; hazard ratio 1.19, 95 % confidence interval 1.07–1.32, p = 0.002, respectively), and the results were consistent even after adjustment by maximum workload. These ESE parameters improved the prognostic model containing estimated glomerular filtration rate (eGFR) and left atrial (LA) volume index. In AF-naive patients (n = 58), LA volume, peak exercise LA reservoir strain, and left ventricular outflow tract (LVOT) pressure gradient predicted new-onset AF. ConclusionsIn patients with HCM, ESE parameters related to left and right ventricular function were responsible for low exercise tolerance. Furthermore, e′ and TAPSE at peak workload could be useful for predicting cardiovascular events in addition to eGFR and LA volume index. LVOT pressure gradient and LA function during exercise predicted new-onset AF.

Myocardial hypertrophy: the differentiation of uremic, hypertensive, and hypertrophic cardiomyopathies by cardiac MRI

ObjectivesTo apply cardiac magnetic resonance imaging (CMR) for detailed myocardial characterization in uremic cardiomyopathy (UC), hypertensive cardiomyopathy (HTN), and hypertrophic cardiomyopathy (HCM) aiming to enrich the understanding of UC’s etiology and further support the development of therapeutic strategies.MethodsA total of 152 patients (age: 49.2 ± 9.9 years; 65.8% male) underwent routine CMR from June 2016 to March 2023. Retrospectively, 53 patients with UC, 39 patients with HTN, 30 patients with HCM, and 30 healthy controls were included. Functional analysis, feature tracking of the left ventricle and left atrium, and myocardial T1, T2, and T2* mapping were performed. Statistical analysis included Pearson correlation and ROC analysis to define correlations and discriminators between groups.ResultsUC patients demonstrated significantly higher native T1 (p < 0.001 for all) and T2 (p < 0.002 for all) values compared with the other three groups. UC patients revealed higher left atrial reservoir strain rate (p < 0.001 for all) and left atrial conduit strain rate (p < 0.001 for all) absolute values as compared with HTN and HCM patients. A significant correlation between T1 and T2 values in UC patients (r = 0.511, p < 0.001) was found. The combination of T1 values and strain parameters was the best discriminator between UC and HTN patients (AUC = 0.872, 95% CI: 0.801–0.943) and between UC and HCM patients (AUC = 0.840, 95% CI: 0.746–0.934).ConclusionUC reveals distinguishing tissue characteristics as evidenced by T1 and T2 mapping, as well as distinguishing functional strain parameters as compared with other hypertrophic phenotypes such as HTN and HCM.Critical relevance statementThe use of CMR imaging in UC patients offers incremental information to elucidate its complex etiology, contributing to ongoing discourse on effective treatment pathways.Key PointsThis study investigated uremic, hypertensive, and hypertrophic cardiomyopathies using cardiac MRI.UC patients have higher T1 and T2 values and better preserved cardiac function.Combined strain and T1 values distinguish UC from other cardiomyopathies.Graphical

Exploring the Uncertainty - Is Left Atrial Reservoir Strain the Missing Piece?

Exploring the Uncertainty - Is Left Atrial Reservoir Strain the Missing Piece?

Impact of left atrial strain on clinical outcomes in patients with permanent pacemaker implantation.

This study aimed to investigate the clinical impact of pre-procedural left atrial strain (LAS) in patients undergoing permanent pacemaker implantation (PPI). This single-centre retrospective study enrolled 434 patients who were admitted for transvenous PPI between 2010 and 2020. After excluding patients with persistent atrial fibrillation, PPI for complete atrioventricular block, severe valvular disease, history of open-heart surgery and those without LAS data, 172 patients were analysed. The LAS was measured using commercially available software to calculate the average strain value of the apical four- and two-chamber views before PPI. The primary composite endpoint was hospitalization due to heart failure or cardiovascular death. Cox proportional hazard models were used to evaluate risk factors for the primary composite endpoint. The mean patient age was 78±8years, and 42% of the patients were men. PPI was performed for sick sinus syndrome in 64% and second-degree atrioventricular block in 36% of the patients. The pre-procedure left atrial reservoir strain (LASr) was 28±11%. The median follow-up period was 4.7years, and the primary endpoint was observed in 23 (13%) patients. In multivariate Cox proportional risk analysis, LASr was independently associated with the primary composite endpoint (hazard ratio, 1.08 per 1% decrease; 95% confidence interval, 1.02-1.15; P=0.007). The receiver operating characteristic curve of the LASr for the primary composite endpoint showed a cutoff value of 21% (area under the curve 0.657, P=0.004). The prognostic impact of LASr was consistent with that of sick sinus syndrome and atrioventricular block. A decreased pre-procedure LASr was associated with long-term adverse outcomes after PPI use.

Correlation of left atrial strain with invasively measured left ventricular end-diastolic pressure; determining LA strain cut-off value.

Left atrium longitudinal strain (LAS) with speckle tracking method has been proposed as a non-invasive method for the assessment of left ventricular filling pressure and diastolic dysfunction. This study aimed to investigate left atrial strain compared to invasively measured left ventricular filling pressure. All Patients candidates for coronary angiography were consecutively recruited. LAS measured by transthoracic echocardiography. Left ventricular end-diastolic pressure (LVEDP) pressure was invasively measured. Current echocardiographic modalities for diastolic function evaluated. A total of 125 people were included. 45 patients had preserved ejection fraction (EF ≥ 50%) and 85 patients had reduced EF (EF < 50%) and compared two groups. LVEDP was significantly higher in reduced EF compared to preserved EF (p-value < 0.001). LA-reservoir and LA-booster strains were significantly lower in patients with reduced EF compared to preserved EF (p-value = 0.008, mean Reservoir = 16.4% ± 6.4, mean Reservoir = 19.5% ± 5.6, respectively) and (p-value = 0.009, mean Booster = 9.09% ± 4.0, mean Booster =11. 9% ± 4.3, respectively). LA 4ch-reservoir strain <14.4%, and LA 2ch-reservoir strain <14.1% were related to LVEDP≥20 mmHg (sensitivity 63.5% and specificity 75%) (sensitivity 77.9% and specificity of 60%) respectively. LAS is significantly lower in patients with elevated LVEDP (≥ 20mmHg). LAS is significantly lower in patients with reduced EF. Both LA-reservoir and LA-booster strains have a significant relation to predicting LVFP but LA-reservoir strain is more accurate. The mean LA-reservoir strain less than 12.4% is associated with LVEDP ≥ 20mmHg.

Beyond Blood Sugar: How Left Atrium Strain Predicts Cardiac Outcomes in Type 2 Diabetes.

Speckle tracking echocardiography is an innovative imaging technique that evaluates myocardial motion, including the function of the left atrium (LA). The assessment of the left atrium's function across its dimensions can have diagnostic and prognostic roles in various cardiovascular conditions. Left atrial strain has been recognized as a valuable predictor of mortality and cardiovascular incidents in the general population across various conditions. For individuals with type 2 diabetes mellitus (T2DM), left atrial dysfunction, as gauged by speckle tracking echocardiography, appears particularly prognostic. Parameters such as peak atrial longitudinal strain (PALS) and left atrial stiffness have been linked with heightened risks of severe cardiovascular events, including atrial fibrillation (AF), heart failure (HF) hospitalizations, or mortality. Consequently, recognizing left atrial dysfunction early is crucial for accurate diagnosis, guiding treatment choices, comprehensive patient management, and prognosis evaluation. Using two-dimensional (2D) speckle tracking echocardiography, results from recent studies report that treatment with empagliflozin significantly enhanced LA function in patients with type 2 diabetes mellitus, improving left atrial strain (LAS) contraction and reservoir values. Furthermore, treatments with glucagon-like peptide-1 (GLP)-1 receptor agonists and sodium-glucose cotransporter-2 (SGLT-2) inhibitors were shown to improve LA reservoir strain more effectively than insulin alone, suggesting their potential in reducing cardiovascular complications in T2DM patients. This narrative review further addresses ongoing challenges and potential enhancements needed to boost the clinical value of left atrium strain, emphasizing its significance in managing and improving outcomes for diabetic patients.

Left Atrial Reservoir Strain as a Predictor of Exercise Tolerance

Left Atrial Reservoir Strain as a Predictor of Exercise Tolerance

Prognostic value of left atrial size and function by cardiac magnetic resonance in non-ischemic cardiomyopathy.

To evaluate left atrial (LA) function and strain parameters by cardiac magnetic resonance imaging (CMR) in patients with non-ischemic cardiomyopathy (NICM) and evaluate the association of these parameters with long-term clinical outcomes. We retrospectively included 92 patients with NICM and 50 subjects with no significant cardiovascular disease (control group). We calculated LA volumes using the Simpson area-length method to derive LA ejection fraction and expansion index. LA reservoir (ƐR), conduit (ƐCD), and contractile strain (ƐCT) were measured using dedicated CMR software (cvi42, Circle Cardiovascular Imaging Inc., version 5.14). An adjusted multivariate regression analysis was performed to determine the association of LA parameters with death and heart failure hospitalization (HFH). NICM patients were older with male preponderance. The mean age for NICM patients was 59.6 ± 15.9 years, 64% males, and 73% whites versus 52.2 ± 12.4 years, 34% male and 64% white for controls. LA strain patterns were significantly lower in NICM patients when compared to controls. During a median follow-up of 58.9 months, 12 patients (13%) died and 33(35.9%) had a HFH. None of the clinical or CMR factors were significantly associated with death. On multivariate analysis, after adjusting for age and significant univariate variables, ƐR was the only variable significantly associated with the HFH (OR 0.98, CI 0.96-1.0). Unadjusted and adjusted Cox proportional hazard models divided by the median ƐR (~ 18%) showed a significant difference in HFH over time (χ2 statistic = 21.1; P value = 0.03). In NICM patients, all LA strain components were reduced. ƐR was found to be significantly associated with HFH.

The LATE score: A novel framework for echocardiographic evaluation of left ventricular filling pressure

BackgroundThe LATE score (LATE: Left Atrial reservoir strain (LASr), Tricuspid regurgitation maximum velocity (TR Vmax), and E/e’ average) is a novel framework for echocardiographic assessment of left ventricular filling pressure (LVFP). LATE = 0 indicates normal LVFP. LATE = 1 indicates resting LVFP is borderline elevated, and the patient may be at risk of pathological elevation of LVFP during exertion. LATE ≥2 indicates LVFP is severely elevated. MethodsThe LATE score was derived from reported thresholds of LASr and conventional echocardiographic parameters for predicting LVFP. The LATE score was prospectively evaluated in a cross-sectional study of 63 patients undergoing transthoracic echocardiography immediately prior to cardiac catheterization with invasive assessment of LVFP. Accuracy of the LATE score was compared to 2016 ASE diastology algorithms. ResultsMean patient age was 62.9 ± 13.6 years with 22% female. LATE = 0 in 29 patients, of which 24 (83%) had normal LVFP (mean LVFP 9 mmHg, SD ±3 mmHg). LATE = 1 in 23 patients, of which 11 (48%) had elevated LVFP (mean LVFP 12 mmHg, SD ± 4 mmHg). LATE was ≥2 in 11 patients, all of which had elevated LVFP (100%) (mean LVFP 16 mmHg, SD ±3 mmHg). The LATE score showed greater agreement with invasive assessment than the 2016 algorithms (LATE kappa = 0.73, 2016 kappa = 0.37). ConclusionsThe LATE score is a simple and effective tool for evaluation of LVFP that is more accurate than the 2016 algorithms. The LATE score provides insight beyond binary classification of normal versus elevated LVFP.

Left atrial stiffness index – an early marker of left ventricular diastolic dysfunction in patients with coronary heart disease

AimsTo evaluate the correlation between left atrial stiffness index (LASI) and left ventricular diastolic function in patients with coronary heart disease (CHD) by Autostrain LA technique.MethodsThis was a retrospective analysis that included a total of 82 CHD patients who had suitable image quality for left atrial strain measurement. According to the 2016 ASE/EACVI guidelines for the echocardiographic assessment of diastolic dysfunction, the patients were divided into three groups: normal left ventricular diastolic function group (n = 26), indeterminate left ventricular diastolic function (n = 36), and left ventricular diastolic dysfunction (LVDD) (n = 20). The left atrial conduit strain (LAScd), Left atrial contractile strain (LASct), left atrial reservoir strain (LASr) and its derived parameters, including LASI and left atrial filling index (LAFI), were compared among the three groups. Furthermore, we conduct a correlation analysis between LASI and left ventricular diastolic function in patients with CHD.ResultsLASr and LAScd in normal group were higher than those in indeterminate group, LASr and LAScd in indeterminate group were higher than those in LVDD group, LASI in normal group was lower than that in indeterminate group, and LASI in indeterminate group was lower than that in LVDD group (P < 0.001). LASct in both normal and indeterminate groups was higher than that in LVDD group (P < 0.05). The LAFI of normal group was lower than that of indeterminate group and LVDD group (P < 0.001). LASI was positively correlated with E/e’(r = 0.822) (P < 0.001). LASr and E/e’ were negatively correlated (r = -0.637) (P < 0.001).ConclusionLASI is closely related to the changes of left ventricular diastolic function in CHD patients.

Left atrial reservoir strain is a marker of atrial fibrotic remodeling in patients undergoing cardiovascular surgery: Analysis of gene expression.

Left atrial strain (LAS) measured by two-dimensional speckle tracking echocardiography (2DSTE) is considered to be a marker of LA structural remodeling, but it remains unsettled. We investigated the potential usefulness and clinical relevance of LAS to detect atrial remodeling including fibrosis by analyzing gene expression in cardiovascular surgery patients. Preoperative 2DSTE was performed in 131 patients (92 patients with sinus rhythm [SR] patients including paroxysmal AF [PAF], 39 atrial fibrillation [AF]) undergoing cardiovascular surgery. Atrial samples were obtained from the left atrial appendages, and mRNA expression level was analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) in 59 cases (24 PAF, 35 AF). Mean value of left atrial reservoir strain (mLASr) correlated with left atrial volume index (LAVI), and left atrial conduit strain (mLAScd). mLASr also correlated with left atrial contractile strain (mLASct) in SR patients including PAF. mLASr was significantly lower, and LAVI was higher, in the AF group, compared with SR patients including PAF. The expression of COL1A1 mRNA encoding collagen type I α1 significantly increased in AF patients (p = 0.031). mLASr negatively correlated with COL1A1 expression level, and multivariate regression analysis showed that mLASr was an independent predictor of atrial COL1A1 expression level, even after adjusting for age, sex, and BMI. But, neither mLAScd / mLASct nor LAVI (bp) correlated with COL1A1 gene expression. The expression level of COL1A1 mRNA strongly correlated with ECM-related genes (COL3A1, FN1). It also correlated ECM degradation-related genes (MMP2, TIMP1, and TIMP2), pro-fibrogenic cytokines (TGFB1 encoding TGFβ1, END1, PDGFD, CTGF), oxidant stress-related genes (NOX2, NOX4), ACE, inflammation-related genes (NLRP, IL1B, MCP-1), and apoptosis (BAX). Among the fibrosis-related genes examined, univariable regression analysis showed that log (COL1A1) was associated with log (TGFB1) (adjusted R2 = 0.685, p<0.001), log (NOX4) (adjusted R2 = 0.622, p<0.001), log (NOX2) (adjusted R2 = 0.611, p<0.001), suggesting that TGFB1 and NOX4 was the potent independent determinants of COL1A1 expression level. mLASr negatively correlated with the ECM-related genes, and fibrosis-related gene expression level including TGFB1, NOX2, and NLRP3 in PAF patients. PAF patients with low mLASr had higher expression of the fibrosis-related gene expression, compared with those with high mLASr. These results suggest that LASr correlates with atrial COL1A1 gene expression associated with fibrosis-related gene expression. Patients with low LASr exhibit increased atrial fibrosis-related gene expression, even those with PAF, highlighting the utility of LAS as a marker for LA fibrosis in cardiovascular surgery patients.