Mean Left Atrial Volume Index Research Articles

Abstract 4123899: Stroke Risk in Patients with an Isolated Interventricular Membranous Septal Aneurysm

Aim: This study investigates the prevalence of isolated interventricular membranous septal (IVMS) aneurysms detected via echocardiography and assesses the associated stroke risk without other classical risk factors. Methods: We searched the echocardiography database at Mount Sinai Morningside from January 2017 to September 2023. Identified echocardiograms were reviewed to confirm IVMS aneurysms and exclude sinus of Valsalva aneurysms. Patients with concurrent structural heart anomalies were excluded. Medical records were examined for baseline characteristics, risk factors, and cortical brain infarcts. Results: From 51,732 subjects, 18 were identified with IVMS aneurysms, yielding a prevalence of 0.04%. Four patients with significant structural heart disease were excluded, resulting in a final sample size of 14. Of these, 9 (64%) were female with a mean age of 59.6, and 5 (36%) were male with a mean age of 55.4. The mean BMI was 27.9 kg/m 2 , with 4 classified as obese. All patients were nonsmokers; 2 had a family history of stroke. One patient had diabetes, 8 had hyperlipidemia, and 9 had hypertension. Only one patient had paroxysmal atrial fibrillation, with a CHA2DS2-VASc score of 0. Echocardiography revealed structurally normal hearts with a mean left ventricular ejection fraction of 61% and a mean left atrial volume index of 24.8 mL/m 2 . The mean neck diameter of the aneurysm was 8.7 mm, and the mean diameter was 11.9 mm. Two patients had inter-atrial septal aneurysms, and one had a patent foramen ovale. Out of the 14 patients, 5 had a history of ischemic stroke (4) or transient ischemic attacks (1), all of whom were 64 years or younger with a mean RoPE Score of 6 and a mean CHA2DS2-VASc score of 1.6 at the time of their first neurologic event. All patients were treated with aspirin and statin therapy. Two patients had recurrent strokes, one of whom had four recurrent strokes, all cortical infarcts. These patients were switched to clopidogrel after 3 months of dual antiplatelet therapy. No anticoagulation was used. Conclusion: This retrospective study highlights a notable association between isolated IVMS aneurysms and an increased risk of ischemic stroke (36%) and recurrent ischemic stroke (14%). Despite their rarity, these anomalies should be considered in unexplained strokes. Optimal management strategies remain ambiguous, but anticoagulation may be favored based on presumed stroke mechanisms. Large-scale multicenter studies are needed for validation.

Serial changes in left atrial strain in symptomatic obstructive hypertrophic cardiomyopathy treated with mavacamten: insights from VALOR-HCM trial

Abstract Background In severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM), the VALOR-HCM phase 3 randomized, double-blind, placebo-controlled clinical trial demonstrated that mavacamten, a cardiac myosin inhibitor, reduces the eligibility for septal reduction therapy with sustained improvement in left ventricular (LV) outflow tract gradients and symptoms. Mavacamten also resulted in favorable cardiac remodeling, including improvement in left atrial volume index (LAVI), LV diastolic function, and biomarkers (NT-proBNP and troponin T). However, the impact of mavacamten on LA function is not known. Objective We sought to assess serial changes in LA strain measures in patients enrolled in the VALOR-HCM trial. Methods VALOR-HCM included 112 symptomatic obstructive HCM patients (mean age 60 years, 51% male). Patients assigned to mavacamten at baseline (n=56) continued therapy for 56 weeks and those assigned to placebo crossed over to mavacamten (n=52) from week 16-56 (40-week exposure). Echocardiographic LA strain assessment was performed according to the current American and European guideline recommendations, using a vendor-neutral post processing software. For assessment of LA strain components (reservoir, conduit, and contraction), the non-foreshortened apical 4-chamber view was utilized. The zero reference was set at end-diastole. Results Serial changes in LAVI and all components of mean LA strain from baseline to week 56 are shown in the Figure. At baseline, LAVI and all mean LA strain values were worse than reported normal mean thresholds. There was a continued and significant improvement in all 3 LA strain values, from baseline to week 56, along with a significant reduction in LAVI. Improvement in LAVI was seen earlier than improvements in LA strain. There was a significant inverse correlation between change in mean LAVI and LA reservoir strain from baseline to week 56 (r= -0.42, p<0.001). Conclusions In the VALOR-HCM trial, average LAVI and baseline LA strain values were significantly worse than reported normal thresholds. Treatment with mavacamten resulted in an improvement in LAVI and LA strain values from baseline through week 56 suggesting a sustained favorable impact on cardiac remodeling. The advantageous cardiac remodeling associated with long-term treatment with mavacamten may in turn have a favorable impact on the observed high burden of atrial tachyarrhythmias in HCM.Serial changes in LA strain in VALOR-HCM

Mavacamten-Associated Temporal Changes in Left Atrial Function in Obstructive HCM: Insights From the VALOR-HCM Trial

BackgroundIn severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM), the VALOR-HCM (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) trial showed that mavacamten reduced the eligibility for septal reduction therapy with sustained improvement in left ventricular outflow tract gradients. Mavacamten also resulted in favorable cardiac remodeling, including improvement in biomarkers (eg, N-terminal pro–B-type natriuretic peptide and troponin T). However, the impact of mavacamten on left atrial (LA) function is unknown. ObjectivesThe aim of this study was to assess serial changes in LA strain measures in patients enrolled in the VALOR-HCM trial. MethodsVALOR-HCM included 112 symptomatic patients with obstructive HCM (mean age 60 years; 51% male). Patients assigned to receive mavacamten at baseline (n = 56) continued therapy for 56 weeks and those assigned to placebo transitioned to mavacamten (n = 52) from week 16 to week 56. Echocardiographic LA strain (reservoir, conduit, and contraction) was measured by using a vendor-neutral postprocessing software. ResultsAt baseline, the mean LA volume index (LAVI) and LA strain values (conduit, contraction, and reservoir) were 41.3 ± 16.5 mL/m2, −11.8% ± 6.5%, −8.7% ± 5.0%, and 20.5% ± 8.7%, respectively (all worse than reported normal). LAVI significantly improved by −5.6 ± 9.7 mL/m2 from baseline to week 56 (P < 0.001). There was a significant (P < 0.05) improvement in absolute LA strain values from baseline to week 56 (conduit [−1.7% ± 6%], contraction [−1.2% ± 4.5%], and reservoir [2.8% ± 7.7%]). Patients originally receiving placebo had no differences in LA measurements up to week 16. There was no significant improvement in LA strain values (conduit [−0.9% ± 3.8%], contraction [−0.4% ± 3.4%], and reservoir [1.4% ± 6.1%]; all; P = NS) from baseline to week 56 in patients with history of atrial fibrillation. ConclusionsIn VALOR-HCM, mavacamten resulted in an improvement in LAVI and LA strain at week 56, suggesting sustained favorable LA remodeling and improved function, except in the atrial fibrillation subgroup. Whether the advantageous LA remodeling associated with long-term treatment with mavacamten results in a favorable impact on the observed high burden of atrial tachyarrhythmias in HCM remains to be proven. (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy [VALOR-HCM]; NCT04349072)

Left Atrial Volume Index Predicts Atrial Fibrillation Recurrence after Catheter Ablation Only in Obese Patients-Brief Report.

It has been shown that obesity and a higher body mass index (BMI) are associated with a higher recurrence rate of atrial fibrillation (AF) after successful catheter ablation (CA). The same has been proven for the left atrial volume index (LAVI). It has also been shown that there is a correlation between LAVI and BMI. However, whether the LAVI's prognostic impact on AF recurrence is BMI-independent remains unclear. We prospectively included 62 patients with paroxysmal AF who were referred to our institution for CA. All patients underwent radiofrequency CA with standard pulmonary veins isolation. Transthoracic 2-D echocardiography was performed one day after CA to obtain standard measures of cardiac function and morphology. Recurrence was defined as documented AF within 6 months of the follow-up period. Patients were also instructed to visit our outpatient clinic earlier in case of symptoms suggesting AF recurrence. We observed AF recurrence in 27% of patients after 6 months. The mean BMI in our cohort was 29.65 ± 5.08 kg/cm2 and the mean LAVI was 38.04 ± 11.38 mL/m2. We further divided patients into two groups according to BMI. Even though the LAVI was similar in both groups, we found it to be a significant predictor of AF recurrence only in obese patients (BMI ≥ 30) and not in the non-obese group (BMI < 30). There was also no significant difference in AF recurrence between both cohorts. The significance of the LAVI as an AF recurrence predictor in the obesity group was also confirmed in a multivariate model. According to our results, the LAVI tends to be a significant predictor of AF recurrence after successful catheter ablation in obese patients, but not in normal-weight or overweight patients. This would suggest different mechanisms of AF in non-obese patients in comparison to obese patients. Further studies are needed in this regard.

Atrial Fibrillation Substrate and Catheter Ablation Outcomes in MYBPC3- and MYH7-Mediated Hypertrophic Cardiomyopathy

BackgroundThe effects of disease-causing MYBPC3 or MYH7 genetic variants on atrial myopathy, atrial fibrillation (AF) clinical course, and catheter ablation efficacy remain unclear. ObjectivesThe aim of this study was to characterize the atrial substrate of patients with MYBPC3- or MYH7-mediated hypertrophic cardiomyopathy (HCM) and its impact on catheter ablation outcomes. MethodsA retrospective single-center study of patients with HCM who underwent genetic testing and catheter ablation for AF was performed. Patients with MYBPC3- or MYH7-mediated HCM formed the gene-positive cohort; those without disease-causative genetic variants formed the control cohort. High-density electroanatomical mapping was performed using a 3-dimensional mapping system, followed by radiofrequency ablation. ResultsTwelve patients were included in the gene-positive cohort (mean age 55.6 ± 9.9 years, 83% men, 50% MYBPC3, 50% MYH7, mean ejection fraction 59.3% ± 13.7%, mean left atrial [LA] volume index 51.7 ± 13.1 mL/m2, mean LA pressure 20.2 ± 5.4 mm Hg) and 15 patients in the control arm (mean age 61.5 ± 12.6 years, 60% men, mean ejection fraction 64.9% ± 5.1%, mean LA volume index 54.1 ± 12.8 mL/m2, mean LA pressure 19.6 ± 5.41 mm Hg). Electroanatomical mapping demonstrated normal voltage in 87.7% ± 5.03% of the LA in the gene-positive cohort and 94.3% ± 3.58% of the LA in the control cohort (P < 0.001). Of the abnormal regions, intermediate scar (0.1-0.5 mV) accounted for 6.33% ± 1.97% in the gene-positive cohort and 3.07% ± 2.46% in the control cohort (P < 0.01). Dense scar (<0.1 mV) accounted for 5.93% ± 3.20% in the gene-positive cohort and 2.61% ± 2.19% in the control cohort (P < 0.01). Freedom from AF at 12 months was similar between the gene-positive (75%) and control (73%) cohorts (P = 0.92), though a greater number of procedures were required in the gene-positive cohort. ConclusionsPatients with MYBPC3- or MYH7-mediated HCM undergoing AF ablation have appreciably more low-amplitude LA signals, suggestive of fibrosis. However, catheter ablation remains an effective rhythm-control strategy.

Prognostic Significance of Left Atrial Volume Index in Patients with Acute Coronary Syndrome

Background: Patients with acute coronary syndrome (ACS) and increased left atrial volume index (LAVI) have worse long-term prognosis. The present study was designed to evaluate the association between LAVI and the clinical characteristics of the patients with ACS at admission and at follow-up. Materials and Methods: A prospective cohort study was conducted at a tertiary care center in India between April 2018 and December 2019. A total of 80 patients (aged &gt;18 years) having chest pain or its equivalent with a diagnosis of ACS were enrolled as the case group and 30 healthy controls (aged &gt;18 years) were enrolled as the control group. The case group was further classified into two groups based on LAVI values (i.e., LAVI &lt;31 mL/m2 and LAVI ≥31 mL/m2). Baseline demographics, clinical characteristics, and echocardiographic characteristics were recorded of all the patients at admission. The patients were followed up at 1 month and 6 months. Results: The mean age of the case group was 54.7 ± 11.6 years and males were predominant (78.8%). Mean LAVI was 31.1 ± 9.0 mL/m2 in the case group and 24.2 ± 3.1 mL/m2 in the control group. Grade II (30%) and Grade III diastolic dysfunction (30%) were predominant in patients with LAVI ≥31 mL/m2. At 1-month follow-up, mortality was reported in 2 (5%) patients with LAVI &lt;31 mL/m2 and in 5 (12.5%) patients with LAVI ≥31 mL/m2, whereas there was no mortality at 6-months follow-up. A positive correlation was observed between LAVI and E/e’ (P = 0.001), left ventricular end-diastolic diameter (P = 0.001), and left ventricular end-systolic diameter (P = 0.001). The area under the curve for detection of mortality based on LAVI values was 0.776 (95% confidence interval of 0.692–0.860; P = 0.001). Conclusion: The present study demonstrated that LAVI acts as a prognostic marker of adverse events and mortality in patients with ACS.

EPLERENONE VS IRBESARTAN AS FIRST LINE THERAPY IN OBESE HYPERTENSIVE PATIENTS: PRELIMINARY RESULTS OF HEBRO TRIAL IN ECHOCARDIOGRAPHIC DIASTOLIC FUNCTION INDEXES

Objective: Obesity is significantly associated with hypertension and cardiovascular outcomes. However, little is known about the impact of aldosterone blockade using eplerenone on hypertensive obese patients as first line therapy. The aim of this study is to compare the efficacy between eplerenone-based strategy and irbesartan-based strategy in obese hypertensive individuals, regarding blood pressure reduction and change of echocardiographic diastolic function parameters. Design and method: HEBRO (antiHypertensive treatment with Eplerenone vs. irBesartan in hypeRtensive Obese patients) is a prospective, randomized, open-labeled, multicenter trial enrolled 112 obese hypertensive patients aged 30-75 years old, evaluated by office and out-of-office BP measurements. Patients were randomized to either 25 mg eplerenone twice (59) or 150 mg irbesartan (53) once daily. The primary endpoint is the difference in ambulatory BP measurements after 6 months follow-up period and secondary endpoint is difference in diastolic function parameters. Results: We enrolled 112 patients, 54.6 years old, 53% female, mean BMI 34.4 kg/m2 and mean eGFR 82.5 ml/min/1.73m2. Diastolic function was assessed at baseline and 6 months, by calculating left ventricular mass index (LVMI) and left atrial volume index (LAVI). At baseline, mean LVMI was 102.9 g/m2 ± 18.1 in the irbesartan group vs. 110.1 g/m2 ± 30.5 in the eplerenone group, p=0.237. The change of LVMI was – 5.6 ± 17.8 vs. -4.5 ± 22.6, p=0.843. At baseline, mean LAVI was 30.6 ml/m2 ± 16.9 in the irbesartan group vs. 30.7 ml/m2 ± 11.1 in the eplerenone group, p=0.979. The change of LAVI in the two study arms was +0.9 ± 6.7 vs. -3.6 ± 11.5, p=0.063, respectively. Although, the result was not statistically significant, there was a numerical trend towards the eplerenone arm. Conclusions: There were no statistically significant differences at baseline and follow-up evaluation of changes in left ventricular and left atrial geometry, though there is a numerical trend towards eplerenone arm, regarding reduction of LAVI after 6 months follow-up period. Patients are currently still enrolled and data on larger pool are anticipated.

Correlation between circulating fibrosis biomarkers with left atrial function and left atrial volume index in rheumatic mitral stenosis.

Mitral stenosis is the most common rheumatic heart disease (RHD) disorder worldwide, including in Indonesia. This pathological condition causes left atrial pressure, leading to left atrial fibrosis that affects the structure and function of the left atrial as well as the clinical condition. The aim of this study was to assess the correlation between circulating fibrosis biomarkers with net atrioventricular compliance (Cn) as a parameter of left atrial function, and left atrial volume index (LAVI) as a parameter left atrium structure of changes. A cross-sectional study was conducted at Panti Rahayu Hospital and Permata Bunda Hospital, Purwodadi, Central Java, with a total of 40 RHD patients with severe mitral stenosis. The ELISA was used to measure the levels of carboxy-terminal propeptide of type I procollagen (PICP), matrix metalloproteinase I (MMP-1), tissue inhibitor matrix metalloproteinase 1 (TIMP-1), and transforming growth factor-β1 (TGF-β1). The left atrial function was assessed by measuring Cn, and the LAVI parameters were measured to assess left atrium structure/size. The mean levels of circulating fibrosis biomarkers were as follows: PICP 153.96±89.12 ng/mL; MMP-1 1.44±2.12 ng/mL; MMP-1/TIMP-1 ratio 0.38±0.54 and TGF-β1 2.66±1.96 pg/mL. From the echocardiographic evaluation, the mean Cn was 5.24±1.93 mL/mmHg and the mean LAVI was 152.55±79.36 mL/m2. There were significant correlation between MMP-1 and MMP-1/TIMP-1 ratio with Cn (r=0.345 and r=0.333, respectively; both had p<0.05). PICP and TGF-β1 biomarkers did not significantly correlate with Cn (p>0.05). Meanwhile, none of the biomarkers had a significant correlation with LAVI (p>0.05). This study highlights that MMP-1 and MMP-1/TIMP-1 ratio are potentially to be used as markers to determine the Cn in RHD patients with severe mitral stenosis. However, further studies with a higher sample size are needed to confirm this finding.

Prognostic significance of left atrial volume index after myocardial infarction

Abstract Background Left atrial (LA) volume has been characterized as a strong predictive factor of cardiovascular and cerebrovascular occurrences after myocardial infarction (MI). Purpose The aim of our study was to examine the prognostic significance of the left atrial volume index (LAVI) in the occurrence of atrial fibrillation, heart failure and stroke after MI. Methods Our study is prospective and includes one hundred patients with acute MI, who underwent primary percutaneous angioplasty immediately after admission to the hospital.. LA volume was measured 48 hours after admission to the hospital, using the Biplane Simson method, which was indexed to body surface area. The patients were followed for 12 months on average. Results The average value of LAVI was higher in patients who had heart failure, atrial fibrillation and stroke after MI. AMI patients who developed heart failure during the observed period had a mean LAVI of 29.9ml/m2 ±6.7, and patients without heart failure had a mean LAVI of 24.0ml/m2 ± 2.0 (p &amp;lt;0.001). Mean LAVI in patients with atrial fibrillation was 33.6ml/m2 ±8.1, and without atrial fibrillation 25.1ml/m2 ± 2.9 (p &amp;lt;0.001). Patients who had a stroke during the observed period had a mean LAVI 35ml/m2 ± 6.9, and patients without a stroke had a mean LAVI 26.3ml/m2 ±5.2 (p &amp;lt;0.001). The results of the univariable logistic regression are presented. Conclusion LAVI value has a statistically significant effect on predicting the occurrence of heart failure, atrial fibrillation and stroke after MI. LAVI is a strong predictive factor after myocardial infarction.

Abstract 15132: Proteomic Signatures of Human Immunodeficiency Virus-Associated Subclinical Left Atrial Dilation

Introduction: Persons living with HIV (PLWH) receiving combination antiretroviral therapy (cART) are at higher risk of heart failure (HF) and preceding cardiac abnormalities, including left atrial (LA) dilation, compared to persons without HIV (PWOH). Mechanisms of this excess risk are unclear. We assessed whether plasma proteomic signatures of immune activation are cross-sectionally associated with LA volume index (LAVi) and augmented among PLWH. Methods: We performed Olink proteomics on plasma obtained concurrently with cardiac magnetic resonance among PLWH and PWOH. Proteins were analyzed individually and as clusters agnostically defined using weighted gene co-expression network analysis. Associations with HIV serostatus and LAVi were estimated using multivariable linear regression with robust variance. We explored protein relationships using annotated enrichment analysis. Results: Among 352 participants (age 55±6 years; 25% female; 70% Black), mean LAVi was 29±9 mL/m 2 and 60% were PLWH (88% on cART; 73% with undetectable plasma HIV RNA). Of 2594 proteins, 104 were independently associated with LAVi (false discovery rate, FDR&lt;0.05). We identified 49 of these as candidate contributors to the association between HIV seropositivity and higher LAVi (36 when excluding PLWH with detectable HIV RNA), enriched in T-cell activation and leukocyte cell adhesion regulators. We identified one protein cluster positively associated with LAVi and HIV seropositivity regardless of HIV suppression status, enriched in TNF signaling, ephrin signaling and extracellular matrix (ECM) organization. Conclusion: Proteomic signatures that may in part account for HIV-associated elevation in LAVi are enriched in pathways of immune activation, cytokine signaling and ECM organization, even among virally suppressed PLWH on cART. These findings support a link between persistent immune activation and subclinical LA dilation which may portend future risk for HF among PLWH.

Abstract 19134: Association Between CHA 2 DS 2 -VASc and LA Volume Index: Insights From DECAAF II

Introduction: LA Volume is strongly associated with atrial fibrillation (AF) and underlying atrial myopathy. The CHA 2 DS 2 -VASc score predicts stroke risk in patients with AF. The aim of this study is to investigate the relationship between the two. Methods: In this subanalysis of the DECAAF II trial, patients with persistent AF undergoing first-time catheter ablation underwent a baseline late gadolinium enhancement magnetic resonance imaging (LGE-MRI) within one month prior to ablation. LA Volume Index (LAVI) was defined as LA Volume on the MRI prior to ablation divided by body surface area ( mL/m2 ). The CHA2 DS2 -VASc score was also calculated at baseline prior to ablation. Analysis of Variance (ANOVA) test and linear regression were used to study the association between the two. Results: 815 patients were included, (78.9% males, mean age 62.7 ± 9.1 years) (table). The mean LAVI was 62.2 ± 18.9 mL/m2, and mean CHA2 DS2 -VASc score was 1.7 ± 1.27. The ANOVA test showed significant differences between group (F = 7.71, p &lt;0.001). For every point increase in CHA2 DS2 -VASc score, LAVI increases by 3 (LAVI = 2.99 * CHA2 DS2 -VASc + 57; p &lt;0.001) (figure). Conclusions: Our data suggests that structural remodeling in patients with AF is likely driven by multiple factors. There was a clear association between CHA2 DS2 -VASc score and higher LAVI. Serial analysis of LA Volume at different time points is needed to further understand the impact of individual comorbidities on LA volume dilation.

Racial Disparities in Atrial Fibrillation After Coronary Artery Bypass: Impact of Left Atrial Volume

BackgroundPrior studies have demonstrated a lower prevalence of postoperative atrial fibrillation (POAF) in Black, Hispanic, Asian, and Native American patients compared with White cohorts after coronary artery bypass grafting. We hypothesized that preoperative differences in left atrial size may explain this disparity. MethodsWe assessed the incidence of new POAF in 1218 patients (215 minority patients and 1003 White patients) undergoing isolated, first-time coronary artery bypass grafting from January 2017 through September 2022. Preoperative left atrial volume index (LAVi) was assessed by transthoracic echocardiography. ResultsMinority patients were younger and more likely to be female, with more comorbidities, including diabetes, prior stroke, and dialysis. There was no difference in postoperative mortality, stroke, renal failure, or reoperation for bleeding between minority and White patients. Whereas minority patients had higher blood product use and longer intensive care unit and postoperative lengths of stay, they experienced a lower incidence of new POAF (19.5% [42/215] vs 29.5% [292/1003]; P = 0.02). Mean LAVi was similar between minority and White patients (30.3 ± 12.6 mL/m2 vs 29.9 ± 10.1 mL/m2; P = .64). However, for White patients, LAVi was higher for patients with POAF than for patients without POAF (31.3 ± 10.9 mL/m2 vs 29.3 ± 9.7 mL/m2; P = .007), whereas for minority patients, LAVi was similar for patients with and without POAF (30.7 ± 26.0 mL/m2 vs 30.3 ± 11.7 mL/m2; P = .84). ConclusionsDespite more comorbidities, higher transfusion rates, and longer length of stay, minority patients had a significantly lower incidence of POAF compared with White patients but no difference in preoperative LAVi. Larger LAVi may be predictive of POAF in White patients but not in minority patients.

SEPTAL AND LEFT ATRIAL VOLUME INDEX AS PREDICTORS FOR HFPEF AMONGST TYPE 2 DIABETES MELLITUS PATIENTS

Objective: The aim of this study is to determine the prevalence and determination of risk factors of heart failure with preserved ejection fraction (HFpEF) diagnosed based on the consensus recommendation from the Heart Failure Association (HFA) and European Society of Cardiology (ESC) 2019 in type 2 diabetes mellitus (T2DM) patients in Malaysia. Design and method: We conducted a cross sectional study on patients with T2DM of more than 18 years old that were under Hospital UiTM follow-up from December 2021 until May 2021 (6 month). The participants were chosen via simple random sampling. Data's on demographic data, comorbid profile, symptoms and clinical examination including vitals sign, chemical profile and proceed with echocardiography and NTproBNP test to diagnosed HFpEF. Results: 201 diabetic patients were recruited and screened for HFpEF. 40 patients were confirmed with the diagnosis of HFpEF. Mean age was 61 ± 5.4 years. A significant difference in mean septal e’ was found between diabetic patients with HFpEF (5.5 ± 1.5 cm/s) and non-heart failure subjects (7.6 ± 1.0 cm/s)(p&lt;0.001, 95% CI -2.40,-1.49). There was also significant difference in mean left atrial volume index (LAVI) between diabetic patients with HFpEF (35.5 ± 1.5 ml/m2) and non-heart failure subjects (28.6 ± 1.0 ml/m2)(p&lt;0.001, 95% CI -2.50,-1.33). A stepwise increase in cortisol level corresponding to NTproBNP was observed(p&lt;0.061). Basal septal hypertrophy was seen in 30% of HFpEF diabetic patients (p&lt;0.081). Multiple linear regression analysis revealed septal e’ and LAVI as independent predictors of HFpEF in diabetic patients (r2 = 0.249, p&lt;0.001). Conclusions: One fifth of diabetic population had HFpEF and specific echocardiography parameters including septal e’ and LAVI were predictors for HFpEF. Emerging early imaging and chemical biomarkers for HFpEF such as basal septal hypertrophy and cortisol should be further studied.

PO-02-077 HYBRID CONVERGENT PROCEDURE FOR THE TREATMENT OF PERSISTENT AND LONG-STANDING PERSISTENT ATRIAL FIBRILLATION: A SINGLE CENTER EXPERIENCE

Pulmonary vein isolation by endocardial ablation is an effective treatment strategy for paroxysmal atrial fibrillation (AF). However, its effectiveness for treatment of persistent forms of AF is limited. In patients with advanced AF, there are extra-pulmonary vein foci that initiate and perpetuate AF. The left atrial posterior wall has been shown to have the highest proportion of such triggers. The Hybrid Convergent procedure is a novel procedure that combines epicardial and endocardial ablation to obtain isolation of the left atrial posterior wall and pulmonary veins. There is paucity of real world and long-term outcomes data regarding the Hybrid Convergent procedure. The purpose of this study is to describe the outcomes of Hybrid Convergent procedures for treatment of persistent and long standing persistent atrial fibrillation at 1 and 3 year follow up. A retrospective review of prospectively maintained single center Hybrid Convergent database was performed. Demographics, clinical, procedural, and outcomes data were collected on all patients. Atrial fibrillation burden was tracked using ECGs, wearable monitors, ICDs/pacemakers, implantable recorders and Holter monitors. Fifty patients with persistent and long-standing persistent AF underwent Hybrid Convergent procedure (age 62.6 ±9.1; male: 78%). Prior to ablation, the mean number of failed antiarrhythmic drugs was 2.3, mean number of previous ablations was 1.7, and mean left atrial volume index was 47.5 ± 17.9 ml/m2. 29 of 41 (71%) patients were free from AF recurrence at one year and 16 of 32 (50%) were free from AF at 3 years. The mean pre-operative AF burden for the group was 65.6 ± 40.2% on antiarrhythmics. Postoperatively, the total AF burden at 1 and 3 years were 23. 8 ± 40.9%, and 27.9 ± 41.1%, respectively. The Hybrid Convergent procedure is effective for the treatment of persistent and long-standing persistent AF with a 1- and 3-year freedom from AF recurrence of 71% and 50%, respectively. In this patient population, this procedure was able to reduce the mean burden of AF by 63.7% (41.8% absolute) at 1 year and by 57.4% (37.7% absolute) at 3 years. Our single center experience is consistent with the success rate from the Converge randomized trial at one year and provides additional 3 year follow up data.

Aetiology and Clinical Profile of Giant Left Atrium – An Observational Study

Background: The predominant cause of giant left atrium (GLA) is rheumatic mitral valvular disease. GLA is commonly defined echocardiographically by measuring the left atrial diameter (LAD). In the context of changing epidemiology of rheumatic heart disease (RHD) globally, and introduction of left atrial volume index (LAVI), the aetiology of GLA and utility of LAVI for defining GLA may be necessary. Methods: The prospective observational study was carried out at a dedicated tertiary care cardiac centre of a developing country to know the aetiology and clinical pattern of GLA over 8 years. GLA was defined echocardiographically as a left atrium (LA) having a diameter ≥80 mm in the left parasternal long-axis view. Follow-up was made over the telephone. Results: Thirty cases of GLA were diagnosed over 8 years from 2013 to 2021. Twenty two were due to rheumatic heart disease (RHD), 7 due to MVP, and 1 due to flail anterior mitral leaflet. Mean LAD was 92.13 ± 16.72 mm, and the mean LAVI was 288.77 ± 134.40 ml/m2. LA thrombus was present in 5 patients, 6 had spontaneous echo contrast (SEC) in LA, 2 had both LA thrombus and SEC. Mean follow-up was 0.99 ± 1.06 years. Out of 15 patients, 5 died, while 10 were alive. Mean survival was 1.8 ± 1.17 years, ranging from less than 1 year to 4 years. Conclusion: RHD continues to be the predominant cause of GLA; however, MVP is also important. The cut-off value of LAVI for defining GLA needs further study. Cardiovasc j 2023; 15(2): 151-158

The Role of Advanced Echocardiographic Parameters of the Left Atrial Function in the Incidence of Cryptogenic Ischemic Stroke: A Review.

Stroke is one of the primary causes of morbidity and mortality worldwide, including a large proportion of cryptogenic strokes. Long-term electrocardiographic monitoring is beneficial in prospective studies for detecting atrial fibrillation in patients with cryptogenic stroke. This review aimed to evaluate the advanced echocardiographic parameters and their roles in assessing left atrial (LA) function in the incidence of cryptogenic and ischemic strokes. Main resources, including PubMed, Scopus, and ISI Web of Science databases, were evaluated for articles published in English from 2010 until May 2021. LA echocardiographic parameters such as LA strain and strain rate, isovolumetric relaxation time (IVRT), the mean left atrial volume index (LAVI), LA reservoir volume, systole strain rate (SSR) of left atrial appendage, and lack of LA function response to maximal exercise as measured by the LA ejection fraction during rest and exercise could be considered for assessing the risk of cryptogenic strokes and ischemic strokes. The results indicated that increased LA volumes and reduced LA strain rate were correlated with cryptogenic stroke. Advanced parameters of LA function, measured by speckle tracking echocardiography, such as strain and strain rate values in different parts of the cardiac cycle, in addition to standard measures of LA function such as LA ejection fraction and LAVI, will define an excellent understanding regarding LA myopathy and risk assessment of cryptogenic stroke, independent of considering conventional cardiovascular risk factors.

Initial experience with pulsed field ablation for atrial fibrillation.

Pulsed field ablation (PFA) was recently introduced for the treatment of symptomatic atrial fibrillation (AF) with the claim of selectively ablating the myocardium while sparing surrounding tissues. We present our initial experience with a PFA catheter for pulmonary vein isolation (PVI) and describe procedural findings and peri-procedural safety of the first 100 patients. We investigated 100 patients treated for symptomatic AF using the FARAWAVE PFA catheter (Farapulse, Menlo Park, CA, USA) between July 2021 and March 2022. Procedure workflow and electrophysiological findings at the time of ablation, peri-procedural complications, and operator learning curves are described. The mean age of patients was 62.9 ± 9.4 years, 62% were male subjects and 80% had paroxysmal AF. The median CHA2DS2-VASc score was 1.5 (IQR: 1.0-2.0) and the mean left atrial volume index was 35.7 ± 9.6 ml/m2. In 88 (88%) patients, PVI alone was performed and in 12 (12%) patients additional ablation of the posterior wall was performed. 3D-electroanatomic mapping was performed in 18 (18%) patients. Procedures without mapping lasted for 52.3 ± 16.6 min. The mean number of applications per pulmonary vein (PV) was 8.1 ± 0.6. In all patients (100%), all PVs were confirmed to be isolated. The learning curves of the two operators who performed > 20 procedures showed a negligible variation of performance over time and practice did not significantly predict procedure time [Operator 1 (senior): R 2 = 0.034, p = 0.35; Operator 2 (junior): R 2 = 0.004, p = 0.73]. There was no difference between the procedure times between senior and junior operators (Operator 1: 46.9 ± 9.7 min vs. Operator 2: 45.9 ± 9.9 min; p = 0.73). The only complications observed were two cases of bleeding at the site of percutaneous access. Our initial experience shows that use of the PFA catheter for pulmonary vein isolation (PVI) is safe, fast, and easy to learn.

Left Atrial Reverse Remodeling in Dilated Cardiomyopathy

Left atrial (LA) dilation is associated with a worse prognosis in several cardiovascular settings, but therapies can promote LA reverse remodeling. The aim of this study was to characterize and define the prognostic implications of LA volume index (LAVI) reduction in patients with dilated cardiomyopathy (DCM). Consecutive patients with DCM from two tertiary care centers, with available echocardiograms at baseline and at 1-year follow-up, were retrospectively analyzed. LA dilation was defined as LAVI > 34mL/m2, and change in LAVI (ΔLAVI) was defined as the 1-year relative LAVI reduction. The outcome was a composite of death, heart transplantation (HTx), or heart failure hospitalization (HFH). Five hundred sixty patients were included (mean age, 54±13years; mean left ventricular ejection fraction, 31±10%; mean LAVI, 45±18mL/m2). Baseline LAVI had a non-linear association with the risk for death, HTx, or HFH, independent of age, left ventricular ejection fraction, mitral regurgitation, and medical therapy (P<.01). At 1-year follow-up, LAVI decreased in 374 patients (67%; median ΔLAVI, -24%; interquartile range, -37% to -11%). Factors independently associated with ΔLAVI were higher baseline LAVI and lower baseline left ventricular ejection fraction. After multivariable adjustment, ΔLAVI showed a linear association with the risk for death, HTx, or HFH (hazard ratio, 0.96 per 5% decrease; 95% CI, 0.93-0.99; P=.042). At 1-year follow-up, patients with reductions in LAVI of >10% and LAVI normalization (i.e., follow-up LAVI≤34mL/m2; 31% of the overall cohort) were at lower risk for death, HTx, or HFH (hazard ratio, 0.37; 95% CI, 0.35-0.97; P=.028). In a large cohort of patients with DCM, 1-year reduction in LAVI was observed in a number of patients. The association between reduction in LAVI and death, HTx, or HFH suggests that LA structural reverse remodeling might be considered an additional parameter useful in the individualized risk stratification of patients with DCM.

Diastolic stress echocardiography in patients with normal resting diastolic function: prognostic utility in presence and absence of myocardial ischemia

Abstract Background Abnormal diastolic response to exercise is reportedly associated with worse cardiovascular events. However, this has not been well studied in patients with normal diastolic function at rest. Purpose We sought to study diastolic response to exercise in patients referred for exercise stress echocardiography (ExE) and to explore its association with adverse outcomes in the presence and absence of exercise-induced myocardial ischemia. Methods In a retrospective study, patients referred for ExE to assess myocardial ischemia between April 2017 and December 2018 were enrolled. Patients were included if they had guideline-defined normal diastolic function at rest and availability of a full set of post exercise diastolic variables (post exercise tissue Doppler derived septal mitral annular early diastolic velocity (e'), ratio of pulsed Doppler derived mitral forward flow early diastolic velocity (E) over e' (E/e') and continuous wave Doppler derived maximum tricuspid regurgitation velocity (TRV)). The patients were followed for a median of 3.4 years for the occurrence of composite death, acute coronary syndrome, cardiac hospitalization, and need of follow-up ischemia testing. Abnormal exercise diastolic variables were defined as e' &amp;lt;7 cm/s, E/e' &amp;gt;15, and TRV &amp;gt;2.8 m/s. Results We studied 492 patients [age: 55.7±12.9 year, 268 (54%) women, EF: 61±5.8%]. Mean achieved metabolic equivalents of tasks (METs) was 9.7±3.1, and a total of 49 (10%) patients had evidence of exercise-induced ischemia. At rest, mean left atrial volume index was 25.4±12 ml, e' was 8±2 cm/s, E/e' was 9.5±2.4, and TRV was 2.1±0.44 m/s. Post exercise e' was 10±3 cm/s [&amp;lt;7cm/s in 63 (13%)], E/e' was 11.1±3.9 [&amp;gt;15 in 95 (19%)], and TRV was 2.37±0.68 m/s [&amp;gt;2.8 m/s in 152 (31%)]. Ischemic ExE was found to be strongly associated with the outcome (HR: 4.46, 95% CI: 2.8 to 7.1, p&amp;lt;0.001). In addition, all diastolic variables predicted the outcome in isolation if they were abnormal (e': 2.28, 95% CI: 1.4 to 3.7, p=0.001, E/e': 1.81; 95% CI: 1.15 to 2.84, p=0.01; TRV: 1.58, 95% CI: 1.17 to 2.13, p=0.003). When combined, however, association with the outcome was seen only when 2 or 3 of these variables were abnormal simultaneously (Figure 1A). When patients were stratified by ischemia and abnormal diastolic variables (figure 1B), patients with 2 or 3 abnormal variables were more likely to experience the outcome compared to patients with 0 or 1 abnormal variables in both absence of ischemia (p&amp;lt;0.001) and presence of ischemia (p=0.016). The stratified groups were different in their clinical and exercise profiles, with worse profiles in patients with both ischemia and 2 or 3 abnormal variables, and best profiles in patients with no ischemia and 0 or 1 abnormal variables. Conclusions In patients referred for ExE to assess ischemia with normal baseline diastolic function, exercise can unmask abnormal diastolic properties and stratify patients' risk regardless of the overt myocardial ischemia. Funding Acknowledgement Type of funding sources: None.

Evaluating the value of the timing of recurrence during blanking period after atrial fibrillation ablation

Abstract Introduction In the first weeks after atrial fibrillation (AF) ablation, the arrythmia may recur theoretically due to transient local inflammation and not due to treatment failure. This is defined as the blanking period, with a proposed duration of 3 months. Recently, this time period has been brought into question. The aim of this work was to evaluate the correlation between the timing of blanking recurrence and late AF recurrence. Methods This was a single-centre retrospective study including patients without structural heart disease that underwent first AF ablation and were subsequently enrolled in the post ablation structured program between 2018 and 2021. Patients were excluded if they had &amp;lt;6 months follow-up. Appointment with ECG and Holter monitoring was performed at 1, 3, 6 and 12 months after ablation. Results We included a total of 193 patients (56% male, mean age 63±12 years). Of these, 79% had paroxysmal AF and mean left atrial volume index was 58±18 mL/m2. During the 3-month blanking period, there were 39 (21%) recurrences, 18 (9%) of which in the first month. After blanking period, at 6 months, 25 (13%) patients had AF recurrence, 56% of which had already recurred during blanking period. AF recurrence in the 2nd and 3rd month of blanking increased the odd of recurrence at 6-month by more than 5-fold (odds ratio (OR) 8,944; CI 95% 2,817–28,400, p&amp;lt;0.001 and OR 5,591; 95% CI 1,173–26,651; p=0.031). On the other hand, recurrence of AF during the 1st month of blanking was not associated with increased chance of 6-month AF recurrence (OR 2,095, 95% CI 0,630–6,964, p=0.227) (figure 1). There were no significant differences in clinical variables, including LA volume, between patients with 1-month recurrence and patients without recurrences. However, patients with AF recurrence in the 2nd and 3rd month of blanking had significantly increased LA volume. Conclusion Our study suggests that patients with AF recurrence in the 2nd and 3rd month of blanking have structurally different atria and are at a significantly higher risk of post blanking AF recurrence, in contrast with patients with AF recurrence in the 1st month of blanking, thus questioning the appropriate duration of the blanking period. Funding Acknowledgement Type of funding sources: None.