Peak Left Atrial Longitudinal Strain Research Articles

Left atrial volumetric-mechanical coupling index as a marker of subclinical primary heart involvement in systemic sclerosis

Abstract Background Primary heart involvement in systemic sclerosis (SSc) is a common yet often clinically silent marker of poor prognosis. Up to 80% of patients have histopathological evidence of heart involvement, highlighting the need for better screening and diagnostic methods. N-terminal pro-brain natriuretic peptide (NTproBNP), a well-established cardiac biomarker, is often increased in patients with SSc, but with a not fully understood mechanism. Meanwhile, left atrial volumetric-mechanical coupling index (LACI), a new echocardiographic parameter, has been shown to predict cardiovascular outcomes in heart failure patients and the general population, but it has not been studied in SSc. Purpose To identify new echocardiographic parameters, particularly related to left atrial volume and function, as markers of increased NTproBNP in SSc patients without overt heart involvement. Methods Consecutive SSc patients without overt heart disease referred for routine cardiac screening underwent 2D and 3D transthoracic echocardiography, including atrial and ventricular strain analysis. LACI was calculated by both 2D and 3D echocardiography as the ratio between the left atrial volume index and the tissue-Doppler-imaging septal a’ velocity. Patients with significant structural and functional changes suggestive of systolic or diastolic dysfunction or pulmonary hypertension, and those with impaired global left ventricular strain were excluded. Logistic regression, Pearson correlation coefficients, and area under the receiver-operating characteristic curve (AUC) are used to analyze the association and predictive power of LACI for elevated NTproBNP. Results A total of 36 SSc patients (55±10 years old; 34 (94%) women; mean disease duration 14±11 years) were included. Sixteen (44.4%) had diffuse cutaneous involvement (dcSSc). Seventeen (47%) patients had increased NTproBNP levels (i.e. >125 pg/mL). Among all tested variables, 3D LACI had the best correlation with NTproBNP values (r = 0.63, p<0.001). A 3D LACI of >2 associated with NTproBNP of >125 pg/mL (odds ratio 7.33 [95%CI 1.38-38.8]; p=0.01) and predicted these increased values with a sensitivity of 76.9% and a specificity of 81.2% (AUC 0.78). NTproBNP was also correlated with 2D LACI (r=0.55, p<0.001), peak left atrial longitudinal strain (r=-0.42, p=0.01), and left atrial contraction strain (r=0.48, p=0.005). Compared to patients with limited cutaneous involvement, those with dcSSc had higher NTproBNP values (250±139.6 vs 107.2±110.9 pg/mL, p=0.001), higher 3D LACI values (2.6±0.9 vs 1.9±0.5, p=0.02), with similar left atrial and ventricular strain parameters. Conclusion Left atrial volumetric-mechanical coupling index assessed by 3D echocardiography is significantly associated with and predictive of elevated NTproBNP levels in SSc patients without overt heart disease and may be a potentially useful non-invasive marker for screening for early subclinical heart involvement in SSc patients.

Assessment of Left Arterial Function by using 2-Dimensional Speckle Tracking in Obese versus Non-Obese Diabetic Patients

Both obesity and diabetes are major problems for the public's health. Both are known to contribute to the development of atrial cardiomyopathy. However, the consequences of obesity on the function of the left atrium(LA) in diabetic individuals have not been determined as of yet. The aim of this study is to compare the peak atrial longitudinal strain (PALS) measured by two-dimensional (2D) speckle tracking in obese versus non-obese diabetic Iraqi patients. For a study that was designed to be cross-sectional, the data collection period lasted for a total of ten months. In this study, the participants had to have diabetes mellitus type 2. A comparison was made between patients who were obese and patients who were not obese using 2-D speckle tracking to measure the peak left atrial longitudinal strain. Several additional factors, such as age, gender, body mass index, conventional echocardiographic parameters, and volume-derived LA function, were investigated during this study. A total of 59 patients participated in this study. The ratio of males to females was exactly 1:1.5, and the average age was (54 ± 9.4) years old. Coexistent systemic arterial hypertension was observed in 25 % of the study population. Patients with type 2 diabetes mellitus and obesity had ad higher E/e` ratio and lower PALS than patients with type 2 diabetes mellitus without obesity, whereas all other parameters were statistically non-significant (EF, E/A, S prime, LA volume index). It was found that the peak longitudinal strain of the LA, which was measured using 2-D speckle tracking, was lower in the obese diabetic individuals. This was in contrast to diabetic people, who did not have obesity issues. An evaluation of the global strain in the left atrium can help in the early detection of remodeling and dysfunction in the left atrium if it is compared to the size of the left atrium and the filling pressures of the left ventricle, both of which are respectively determined by the E/e' ratio and the left atrial volume.

Association of reduced peak left atrial strain with supraventricular arrhythmia in adults with congenital heart disease.

Atrial arrhythmias are an important cause of morbidity and mortality in adults with congenital heart disease (ACHD). In acquired heart disease, the left atrial (LA) strain has been shown to predict supraventricular tachyarrhythmias (SVT). This study aimed to investigate whether reduced LA strain is associated with SVT in ACHD patients. This retrospective, single-center cohort study collected baseline clinical and echocardiographic data of 206 ACHD patients (157 left heart defect, 49 right heart defect). Patients with sinus rhythm at baseline and a 5-year follow-up (median age 29, IQR 22-41 years) were included. Diagnosis of sustained SVT was determined from clinical reports during the follow-up period. New or recurrent sustained SVT occurred in 16 patients (7.8%, median follow-up of 6.2 years). Patients who developed SVT were older, more likely to have diastolic dysfunction, and had larger LA dimensions, left ventricular mass, and a lower peak LA longitudinal strain (PALS). Lower PALS was associated with higher risk of SVT in patients with left and right heart defects. Patients in the lowest quartile for PALS had a 15.9-fold higher hazard ratio of SVT (95% confidence interval, 4.5 to 56.0, p < 0.001) in comparison with the top three quartiles. PALS provides information about the occurrence of SVT in the ACHD population. Including measurement of LA strain in the follow-up of these patients may allow to better identify patients at risk of future atrial arrhythmias.

Correlation between Peak Left Atrial Longitudinal Strain and The Severity of Mitral Valve Disease at Haji Adam Malik General Hospital Medan

Correlation between Peak Left Atrial Longitudinal Strain and The Severity of Mitral Valve Disease at Haji Adam Malik General Hospital Medan

Associations of Circulating Vascular Cell Adhesion Molecule-1 and Intercellular Adhesion Molecule-1 With Long-Term Cardiac Function.

Although VCAM-1 (vascular cell adhesion molecule-1) and ICAM-1 (intercellular adhesion molecule-1) have been associated with incident heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF), the associations of VCAM-1 and ICAM-1 with sensitive measures of cardiac structure/function are unclear. The objective of this study is to evaluate associations between VCAM-1, ICAM-1, and measures of cardiac structure and function as potential pathways through which cellular adhesion molecules promote HFpEF and AF risk. In MESA (Multi-Ethnic Study of Atherosclerosis), we evaluated the associations of circulating VCAM-1 and ICAM-1 at examination 2 (2002-2004) with measures of cardiac structure/function on cardiac magnetic resonance imaging at examination 5 (2010-2011) after multivariable adjustment. Mediation analysis of left atrial (LA) strain on the association between VCAM-1 or ICAM-1 and AF or HFpEF was also performed. Overall, 2304 individuals (63±10 years; 47% men) with VCAM-1 or ICAM-1, cardiac magnetic resonance imaging, and covariate data were included in analysis. Higher VCAM-1 and ICAM-1 were associated with lower LA peak longitudinal strain and worse global circumferential left ventricular strain but were not associated with left ventricular myocardial scar or interstitial fibrosis. Lower LA peak longitudinal strain mediated 8% (95% CI, 2-30) of the relationship between VCAM-1 and HFpEF and 9% (95% CI, 2-21) of the relationship between VCAM-1 and AF. Higher VCAM-1 and ICAM-1 were associated with lower LA function and left ventricular systolic function but were not associated with myocardial scar or interstitial fibrosis. VCAM-1 and ICAM-1 may promote HFpEF and AF risk through impaired LA reservoir function.

Left atrial function and the risk of new-onset atrial fibrillation in cardiac amyloidosis

Abstract Background Cardiac amyloidosis (CA) is an infiltrative disease characterized by the accumulation of misfolded proteins into the extracellular matrix of the myocardium. Ventricular but also atrial myopathy are described in CA, with higher risk of atrial fibrillation (AF) and cardioembolic events even during sinus rhythm. Purpose We aimed to investigate which parameters of left atrial (LA) structure and function could predict new-onset AF (NOAF) in patients with CA, aiding in improved follow-up. Methods We prospectively included patients diagnosed with CA, both light chain (AL) and variant transthyretin (ATTRv) with no history of AF, from 2 tertiary European centers. Cardiac involvement was assessed according to current European recommendations. Comprehensive echocardiographic studies were performed at baseline with measurement of both classical structure and function parameters parameters derived from speckle tracking echocardiography measured with a vendor-dependent analysis software and the primary outcome was NOAF. Results Of the 179 patients diagnosed with CA, 86 were excluded due to history of AF, unacceptable image quality and non-AL or non-ATTRv diagnoses. Finally, 93 patients with CA were included (mean age 54.3±9.8, 58% males), and 44 patients developed NOAF during a median follow up of 11 (32.5) months. Patients with NOAF had heavier hearts (LVMi 155.5±39.6 vs. 136.6±44.3 g/m2, p= 0.03), worse global LV function (LVEF 46.7±10.9 vs. 53.8±11.2 %, p= 0.003), more LV longitudinal impairment (GLS -10.0±4.7 vs. -13.4±3.7 %, p= 0.0002), larger atria (LAVi 44.6±14.3 vs. 35.4±13.6 mL/m2, p= 0.002) and worse LA function (LA emptying fraction 28.5±15.5 vs. 44.9±14.6 %, p&amp;lt; 0.001; LA peak longitudinal strain (PALS) 13.6±11.3 vs. 20.5±10.4 %, p= 0.003). In the multivariate analysis adjusting for confounding factors, including LA diameter, LAVi and other LA function parameters, lower PALS was independently associated with higher risk for NOAF (HR: 0.874, 95% CI: 0.784-0.974, p= 0.014). Using the receiver operating characteristics curve analysis, we identified the optimal cut-off of PALS for predicting NOAF as 14.3% (Sn 71%, Sp 73%, AUC 0.75). Furthermore, PALS ≤14.3% was an independent predictor for NOAF (HR: 5.259, 95% CI: 2.653–10.423, P&amp;lt; 0.001). The Kaplan–Meier curves showed that patients with PALS ≤14.3% had a higher risk for NOAF than those with PALS &amp;gt;14.3% (P&amp;lt;0.001 by log-rank test, Figure 1). Conclusions PALS is an independent predictor for NOAF in patients with CA.Figure 1.Kaplan-Meier curves for NOAF

Abstract 11700: Left Ventricular Global Longitudinal Strain After Transcatheter Aortic Valve Implantation in Patients With Preserved Ejection Fraction

Background: Left ventricular (LV) global longitudinal strain (GLS), which could assess subtle LV dysfunction, is already deteriorated in a certain number of aortic stenosis (AS) patients with preserved ejection fraction (EF). Although GLS improves after valve replacement, detailed outcome is not well understood. Research Question: In AS patients with preserved EF undergoing transcatheter aortic valve implantation (TAVI), is there a difference in post-procedural GLS between patients with and without reduced pre-procedural GLS? Aim: To elucidate the post-procedural course of GLS after TAVI. Methods: The present study was a single-center retrospective cohort study that included 119 out of 347 consecutive patients undergoing TAVI by excluding EF &lt;50%, atrial fibrillation, inadequate echo image for analysis, and loss to follow-up echocardiography. Subjects were divided into two groups according to pre-procedural GLS: reduced GLS (r-GLS) (&gt; -15%) and preserved GLS (p-GLS) (≤ -15%), and echocardiographic parameters at baseline and changes from baseline to mid-term follow-up (6 months to 1 year) were compared. Results: There was no significant difference in baseline characteristics ( Table ). Before the procedure, higher severity of AS, higher LV mass index and E/e’, and lower EF and peak left atrial longitudinal strain were observed in r-GLS. Both EF and LV mass index improved after TAVI in r-GLS and became comparable in p-GLS ( Figure ). After TAVI, GLS improved in r-GLS, but remained significantly inferior to p-GLS (-14.7 ± 2.3% vs. -16.5 ± 2.8%, P &lt; 0.001; Figure ). Conclusions: In AS patients with preserved EF, GLS improved after TAVI in patients with r-GLS but remained inferior to those with p-GLS, suggesting underlying refractory myocardial damage presumably caused by more severe AS and consequently more severe LV hypertrophy in patients with r-GLS. It might indicate the possibility of GLS for determining optimal timing of TAVI in AS patients with preserved EF.

Left heart remodeling as a risk factor for atrial fibrillation in patients after surgery of acquired heart defects

Aim. To identify risk factors for atrial fibrillation (AF) in patients with aortic and mitral defects after surgical treatment.Material and methods. A total of 112 patients with aortic and mitral defects (excluding patients with mitral stenosis) were examined: 90 men and 22 women aged 18 to 72 years (median age, 51(35;57) years). Patients were examined initially before and after surgery (in terms of 8-14 days and after 12-36 months). The peak left atrial (LA) longitudinal strain (PALS) was determined at LA reservoir phase. The following endpoints were chosen: the presence of AF and atrial flutter (AFL) in the shortand long-term period after surgery, repeated hospitalization for arrhythmias. Patients were divided into 2 groups: group 1 — patients with a favorable prognosis, group 2 — patients with AF and AFL after surgery. The mean values were compared by the independent Student’s t test, while the rank sum — by the Mann-Whitney test. ROC analysis was used.Results. Baseline LA volume index (LAVI) &gt;44,4 ml/m2 increased the risk of AF after surgery (AUC=0,6±0,07, p&lt;0,05, relative risk (RR) — 2,34 (confidence interval (CI), 0,8-6,88). LA volumes were within the normal range in the group without arrhythmias. A decrease in the initial threshold level of LA PALS &lt;27,5% increased the risk of AF as in the shortand long-term postoperative period (AUC=0,659±0,08, p&lt;0,01, RR — 1,19 (CI, 3,38-31,4). In the AF group, PALS decreased after surgery and did not increase in the long-term period (28±7,5% at baseline, 19±6,2% after surgery, 21±8,3% in the long-term period, (p=0,04 and p=0, 23, respectively). Left ventricular ejection fraction affected the AF development only in the early period after surgery (AUC=0,71±0,049, p&lt;0,008, RR — 2,21 (CI, 1,27-3,87).Conclusion. The development of AF was influenced by LAVI, LA PALS, while in the early postoperative surgery period — ejection fraction.

Left atrial subclinical dysfunction in children with Kawasaki disease: a two-dimensional speckle-tracking echocardiography study.

Left atrial (LA) function is a very important prognostic indicator for many cardiovascular diseases. In this study, we aimed to determine whether LA function is impaired in children with Kawasaki disease (KD) and to analyze the relationships between LA deformation and conventional echocardiographic parameters and laboratory markers. A total of 50 KD patients during different disease phases and 50 age- and sex-matched controls were retrospectively analyzed. Patients in the acute phase based on coronary artery dilation (CAD) were subdivided into Group I (with CAD) and Group II (without CAD) and compared. During the acute phase, KD patients had a lower peak LA longitudinal strain (PLALS), a lower LA strain peak during LA contraction (LASct), and a lower LA strain rate peak during LA contraction (LASRct) than the controls. The PLALS, LASct and LASRct began to increase during the subacute phase, and during the convalescent phase, all LA strains in patients had recovered to normal compared with the control subjects. Subgroup analysis revealed that, compared with Group II, Group I had higher C-reactive protein (CRP) and serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels; however, there were no significant differences in LA strains. Only the PLALS during the acute phase was negatively correlated with left ventricular mass index, CRP and NT-proBNP. In patients with KD, LA function is impaired during the acute phase, and this impairment is transient. Two-dimensional speckled tracking echocardiography is a useful tool for detecting subclinical LA dysfunction.

C9 THE EFFECT OF ANTHRACYCLINE CHEMOTHERAPY ON PEAK LEFT ATRIAL LONGITUDINAL STRAIN: A METANALYSIS

Abstract Background Currently there is a limited number of studies reporting atrial function, evaluated by peak left atrial longitudinal strain (PALS), among patients undergoing anthracycline chemotherapy. Objective We investigated this issue through a meta–analysis of echocardiography studies that reported data on: A) PALS before and after anthracycline chemotherapy and B) PALS in patients who have previously received anthracycline chemotherapy versus controls. Methods The PubMed, OVID–MEDLINE and Cochrane library databases were systematically analysed to search articles and abstracts published from inception to 29th December 2022. Studies were identified by using Me–SH terms and crossing the following terms: “left atrial strain”, AND “cardiotoxicity”, “anthracycline”, “anthracycline cardiotoxicity” and “echocardiography”. Results The meta–analysis included a total of 967 patients from 10 studies. A) The metanalysis of six studies evaluating PALS before and after anthracycline chemotherapy in a total of 343 patients showed a significant PALS worsening after anthracycline (30,05±2,5 vs 26,8±3,1) with standard mean difference (SMD) being –0,27±0,06, p &amp;lt; 0.0001. Figure 1 panel A. B) Five studies evaluated PALS in 359 patients who have previously received anthracycline chemotherapy versus 356 controls. Compared with controls, PALS was significantly worse in the pooled anthracycline group (34,63±1,8 vs 37,64±2,7) with SMD being –0.35 ± 0,08, p &amp;lt; 0.0001. Figure 1 panel B. Conclusions Our metanalysis suggests a detrimental effect of anthracycline chemotherapy on atrial function evaluated by PALS.

Peak left atrial longitudinal strain is associated with all-cause mortality in patients with ventricular functional mitral regurgitation

PurposeChronic mitral regurgitation promotes left atrial (LA) remodeling. However, the significance of LA dysfunction in the setting of ventricular functional mitral regurgitation (FMR) has not been fully investigated. Our aim was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in patients with FMR and reduced left ventricular ejection fraction (LVEF).MethodsPatients with at least mild ventricular FMR and LVEF < 50% under optimized medical therapy who underwent transthoracic echocardiography at a single center were retrospectively identified in the laboratory database. PALS was assessed by 2D speckle tracking in the apical 4-chamber view and the study population was divided in two groups according to the best cut-off value of PALS, using receiver operating characteristics (ROC) curve analysis. The primary endpoint-point was all-cause mortality.ResultsA total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 – 40%) and median effective regurgitant orifice area (EROA) was 15mm2 (IQR: 9 – 22mm2). According to current European guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 – 6.6), 148 patients died. The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS. On multivariable analysis, PALS remained independently associated with all-cause mortality (adjusted hazard ratio 1.052 per % decrease; 95% CI: 1.010 – 1.095; P = 0.016), even after adjustment for several (n = 14) clinical and echocardiographic confounders.ConclusionPALS is independently associated with all-cause mortality in patients with reduced LVEF and ventricular FMR.Graphical

High liver fibrosis scores in MAFLD patients are associated with adverse atrial remodeling and related clinical outcomes

Atrial fibrillation (AF) is the most common arrhythmia in the world, linked to a remodeled left atrium. A number of epidemiological studies have suggested an association between metabolic dysfunction-associated fatty liver disease (MAFLD) and the incidence of AF. However, the pathogenesis leading to AF in the context of MAFLD remains unclear. We aimed at assessing the impact of MAFLD and liver fibrosis status on left atrium (LA) structure and function. Using two distinct cohorts, the patient's liver status is determined using validated blood biomarkers and clinical-biological scores (FLI, NFS). In the first cohort of patients undergoing AF ablation, the LA structural and functional impact of MAFLD was assessed by LA strain analysis and endocardial voltage mapping. Histopathological assessment of atrial fibrosis was performed in the second cohort of patients undergoing cardiac surgery. Finally, the impact of MAFLD on AF recurrence following catheter ablation was assessed. In the AF ablation cohort (n = 245), MAFLD patients with high risk of F3–F4 liver fibrosis presented more LA low-voltage areas compared to patients without MAFLD, impaired LA reservoir function assessed by peak left atrial longitudinal strain, and increased LA volume. Accordingly, among the MAFLD patients, those with a high risk of F3–F4 liver fibrosis presented a higher rate of AF recurrence during follow-up. These patients had permanent recurrent AF, therefore difficult to treat. In the cardiac surgery cohort (n = 20), an increase in histopathological atrial fibrosis was observed in MAFLD patients with a high risk of F3–F4 liver fibrosis. We found that liver fibrosis scoring in MAFLD patients is associated with adverse atrial remodeling and AF recurrences following catheter ablation. The impact of the management of MAFLD on LA remodeling and AF ablation outcomes should be assessed in dedicated studies. This work has been published in Frontier In Endocrinology in August 2022 (doi: 10.3389/fendo.2022.957245).

Echocardiographic Measures of Left Atrial Structure and Function and the Association with Atrial Fibrillation following Acute Coronary Syndrome

Introduction: Acute coronary syndrome (ACS) is associated with an increased risk of developing atrial fibrillation (AF). This arrhythmia is associated with adverse outcomes, making it important to identify high-risk patients. The aim was to evaluate the prognostic value of measures of left atrial (LA) structure and function in AF prediction following ACS. Methods: Three hundred and eighty-one patients who had a percutaneous coronary intervention for ACS were included in the study. Our endpoint was new-onset AF. Results: With a median follow-up time of 5.4 [3.9–6.8] years, 56 patients (14.7%) developed AF. Patients developing AF had significantly (p ≤ 0.05) increased maximal and minimal LA volumes (LAV_max and LAV_min, respectively). LAV_max and LAV_min remained significantly increased in AF patients when indexing to either body surface area (LAV_max/BSA and LAV_min/BSA, respectively), left ventricle length in end diastole (LAV_max/LVLd and LAV_min/LVLd, respectively), or late mitral annular diastolic velocity (LAV_max/a’ and LAV_min/a’, respectively), while LA expansion index (LAEi), LA emptying fraction (LAEF), and peak LA longitudinal strain (PALS) were decreased. In univariable Cox regressions, all LA measures were found to be predictors of AF. After multivariable adjustment for clinical and echocardiographic parameters, all measures reflecting atrial function (LAV_min, LAV_min/BSA, LAV_min/LVLd, LAV_min/a’, LAV_max/a’, LAEF, LAEi, and PALS) (p ≤ 0.05) but no structural measures (LAV_max, LAV_max/BSA, and LAV_max/LVLd) remained significant independent predictors of AF. Conclusion: Echocardiographic measures of LA function are independent predictors of AF following ACS. Evaluation of LA function might improve the prognostic workup, aid in risk stratification for AF, and improve selection for further examinations.

Response to 'Is the left atrium the key in the amyloid imaging lock?'

We thank Dr Bart for her commentary on our paper.1 The echocardiogram is the first-line imaging technique in patients with suspected cardiac amyloidosis (CA).2 Speckle-tracking analysis of the left ventricle should be systematically performed, as the apical sparing pattern is strongly suggestive of CA, particularly in individuals with unexplained hypertrophy.2 In patients in sinus rhythm, the left atrial (LA) function may be studies by calculating the peak LA longitudinal strain (PALS), which reflects the reservoir function, and peak LA contraction strain (PACS), which explores the contractile function of the LA. In our study, we reported that both PALS and PACS are severely depressed in patients with amyloid transthyretin (ATTR) CA.3 The mechanisms are (i) a progressive dilation and remodelling of the LA, due to diastolic dysfunction and leading to a depressed LA contractility, and (ii) amyloid deposition in the atrial walls, with an expansion of extracellular spaces and cardiomyocyte dysfunction. Structural and functional remodelling of the LA is more prominent in ATTR-CA, which is a slowly progressive disease, than in amyloid light-chain (AL)-CA, which has a more rapid progression.3 We agree with Dr Bart that this difference between ATTR- and AL-CA may be useful for the purposes of differential diagnosis. The exact role of cardiovascular magnetic resonance (CMR) in the diagnostic workup of CA has not been standardized yet, but CMR may implement baseline examination in patients with suspected CA. Several techniques (feature tracking, tagging, and tissue-phase contrast) allow to track the motion of LA throughout the cardiac cycle and represent the CMR equivalents of speckle-tracking imaging. The study cited by Dr Bart investigated the value of CMR-based LA strain in 54 patients with CA (30 AL and 24 ATTR), reporting a lower LA function in patients with ATTR vs. AL despite no significant differences in LA geometry.4 These findings are in agreement with our study.1 Echo- or CMR-based LA strain might then help differentiate AL- from ATTR-CA among patients starting the diagnostic workup for suspected CA. On the other hand, further investigations (cardiac scintigraphy with bone tracers, search for a monoclonal protein, and often histological analyses) are still needed to confirm the diagnosis of CA and its subtype, in agreement with the current algorithm.1 Beyond its possible diagnostic value, we think that LA strain might prove helpful for risk stratification and to track disease evolution. A more depressed LA strain is reasonably associated with more blood stasis and a greater risk of atrial thrombosis, and could then suggest the potential need for an anticoagulant therapy even when there is no history of atrial fibrillation.1,2 As for the second point, LA strain has a close association with disease severity and is highly reproducible, meaning that a deterioration of LA strain over time reflects disease progression, while unchanged or improved values over times may mirror the stabilizing or positive effects of disease-modifying therapies.5 In summary, LA strain could really become a ‘key in the amyloid imaging lock’.

Impact of left atrial size and strain on new atrial arrhythmias during a 5-year follow-up in adults with congenital heart disease

Abstract Introduction Atrial arrhythmias are a common and important cause of morbidity and mortality in adults with congenital heart disease (ACHD). In acquired heart disease, left atrial (LA) strain has been shown to predict supraventricular tachyarrhythmias (SVT). This study sought to investigate if LA strain is also a reliable predictor of SVT in the ACHD population. Method We retrospectively obtained baseline clinical and echocardiographic data, including LA function parameters and strain, in 206 ACHD patients. Only patients with sinus rhythm at baseline and 5-years follow-up were included (median age 29, IQR 22–41 years). 157 participants had a left heart defect (aortic stenosis or aortic coarctation, with or without correction) and 49 a right heart defect (Fallot physiology). Diagnosis of sustained SVT was determined from clinical reports during the follow-up period (standard 12-lead ECG, ECG Holter). Results During a median follow-up of 6.2 years, a new or recurrent sustained SVT occurred in 16 patients (7.8%). Patients baseline characteristics are depicted in Table 1. Patients who developed SVT were older, had larger LA dimensions and left ventricular mass, more likely diastolic dysfunction on echo, and a lower peak LA longitudinal strain (PALS). PALS was a good predictor of SVT risk in patients with left and right heart defects with an area under the receiver-operating-curve of 0.857. By Cox regression analysis, patient in the lowest quartile for PALS had a 16.7-fold higher hazard ratio of SVT (95% confidence interval, 4.7 to 59.0, p&amp;lt;0.001) in comparison with the top three quartiles. Overall freedom from arrhythmia after 1, 3 and 5 years of follow-up was 98.1%, 96.1% and 94.2%, respectively. The freedom from SVT as a function of PALS quartiles is shown in Figure 1. Conclusion PALS provides predictive information about the occurrence of SVT in the ACHD population, regardless of the type of the lesion. Including the measurement of LA strain in the follow-up of these patients may permit to better identify patients at risk of future atrial arrhythmias. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Universitätsklinik für Kardiologie, Inselspital Bern

High liver fibrosis scores in metabolic dysfunction-associated fatty liver disease patients are associated with adverse atrial remodeling and atrial fibrillation recurrence following catheter ablation.

BackgroundA number of epidemiological studies have suggested an association between metabolic dysfunction-associated fatty liver disease (MAFLD) and the incidence of atrial fibrillation (AF). However, the pathogenesis leading to AF in the context of MAFLD remains unclear. We therefore aimed at assessing the impact of MAFLD and liver fibrosis status on left atrium (LA) structure and function.MethodsPatients with a Fatty Liver Index (FLI) >60 and the presence of metabolic comorbidities were classified as MAFLD+. In MAFLD+ patients, liver fibrosis severity was defined using the non-alcoholic fatty liver disease (NAFLD) Fibrosis Score (NFS), as follows: MAFLD w/o fibrosis (NFS ≦ −1.455), MAFLD w/indeterminate fibrosis (−1.455 < NFS < 0.675), and MAFLD w/fibrosis (NFS ≧ 0.675). In the first cohort of patients undergoing AF ablation, the structural and functional impact on LA of MAFLD was assessed by LA strain analysis and endocardial voltage mapping. Histopathological assessment of atrial fibrosis was performed in the second cohort of patients undergoing cardiac surgery. Finally, the impact of MAFLD on AF recurrence following catheter ablation was assessed.ResultsIn the AF ablation cohort (NoMAFLD n = 123; MAFLD w/o fibrosis n = 37; MAFLD indeterm. fibrosis n = 75; MAFLD w/severe fibrosis n = 10), MAFLD patients with high risk of F3–F4 liver fibrosis presented more LA low-voltage areas as compared to patients without MAFLD (16.5 [10.25; 28] vs 5.0 [1; 11] low-voltage areas p = 0.0115), impaired LA reservoir function assessed by peak left atrial longitudinal strain (19.7% ± 8% vs 8.9% ± 0.89% p = 0.0268), and increased LA volume (52.9 ± 11.7 vs 43.5 ± 18.0 ml/m2 p = 0.0168). Accordingly, among the MAFLD patients, those with a high risk of F3–F4 liver fibrosis presented a higher rate of AF recurrence during follow-up (p = 0.0179). In the cardiac surgery cohort (NoMAFLD n = 12; MAFLD w/o fibrosis n = 5; MAFLD w/fibrosis n = 3), an increase in histopathological atrial fibrosis was observed in MAFLD patients with a high risk of F3–F4 liver fibrosis (p = 0.0206 vs NoMAFLD; p = 0.0595 vs MAFLD w/o fibrosis).ConclusionIn conclusion, we found that liver fibrosis scoring in MAFLD patients is associated with adverse atrial remodeling and AF recurrences following catheter ablation. The impact of the management of MAFLD on LA remodeling and AF ablation outcomes should be assessed in dedicated studies.

Feature-tracking computed tomography left atrial strain and long-term survival after transcatheter aortic valve implantation.

Aortic stenosis (AS) induces left atrial (LA) remodelling through the increase of left ventricular (LV) filling pressures. Peak LA longitudinal strain (PALS), reflecting LA reservoir function, has been proposed as a prognostic marker in patients with AS. Feature-tracking (FT) multi-detector computed tomography (MDCT) allows assessment of LA strain from MDCT data. The aim of this study is to investigate the association between PALS using FT MDCT and survival in patients with severe AS who underwent transcatheter aortic valve implantation (TAVI). A total of 376 patients (mean age 80 ± 7 years, 53% male) who underwent MDCT before TAVI and had suitable data for assessment of PALS using dedicated FT software, were included. The patients were classified into four groups according to PALS quartiles; PALS > 19.3% (Q1, highest reservoir function), 15.0-19.3% (Q2), 9.1-14.9% (Q3), and ≤9.0% (Q4, lowest reservoir function). The primary outcome was all-cause mortality. During a median of 45 (22-68) months follow-up, 148 patients (39%) died. On multivariable Cox regression analysis, PALS was independently associated with all-cause mortality [hazard ratio (HR): 1.044, 95% confidence interval (CI): 1.012-1.076, P = 0.006]. Compared with patients in Q1, patients in Q3 and Q4 were associated with higher risk of mortality after TAVI [HR: 2.262 (95% CI: 1.335-3.832), P = 0.002 for Q3, HR: 3.116 (95% CI: 1.864-5.210), P < 0.001 for Q4]. PALS assessed with FT MDCT is independently associated with all-cause mortality after TAVI.

Decreased Peak Left Atrial Longitudinal Strain Is Associated with Persistent Pulmonary Hypertension Associated with Left Heart Disease.

Pulmonary hypertension (PH) associated with left heart disease (PH-LHD) is the most common form of PH and has significantly higher morbidity and mortality. We estimated the prevalence of PH-LHD on the follow-up echocardiography and the role of left atrial (LA) function in PH-LHD. From the STRATS-AHF registry composed of 4312 acute heart failure (HF) patients, we analyzed peak atrial longitudinal strain (PALS) in 1729 patients with follow-up echocardiographic examinations during mean 18.1 ± 13.5 months. PH was determined by the maximal velocity of tricuspid regurgitation (TR Vmax ≥ 3.4 m/s). Persistent PH was found in 373 patients (21.6%). The PH-LHD group was significantly older, and the prevalence of atrial fibrillation (AF), hypertension, diabetes, and heart failure with preserved ejection fraction were higher compared with the no PH-LHD group. Baseline left ventricular end-systolic volume and PALS were lower, and LA diameter, mitral E/E’ ratio, and TR Vmax were higher in the PH-LHD group. In the multivariate analysis, PALS (HR = 1.024, p = 0.040) was a significant variable after adjustment of LA diameter and mitral E/E’. A decreased PALS of <12.5% was the best cutoff value in the prediction of persistent PH-LHD (AUC = 0.594, sensitivity = 65.3%, specificity = 46.1%). PH-LHD was associated with increased HF hospitalization (HR = 2.344, p < 0.001) and mortality (HR = 2.015, p < 0.001) after adjusting for age and sex. In conclusion, persistent PH-LHD was found in 21.6% in the follow-up echocardiography and was associated with decreased PALS (<12.5%). PH-LHD persistence was associated with poor clinical outcomes. Thus, AHF patients with decreased PALS, especially <12.5%, should be followed with caution.

The role of alcohol consumption on echocardiographic and electrophysiologic changes in atrial fibrillation.

A wealth of evidence suggests that alcohol consumption is a risk factor for atrial fibrillation (AF); however, the mechanisms underlying this association are unclear. This makes it challenging to develop therapeutic strategies in patients with AF attributed to alcohol consumption. To investigate the echocardiographic and electrophysiologic changes caused by alcohol consumption in patients with AF. The study was registered in Chinese Clinical Trial Registry (Registration number ChiCTR2000041575). Data on 134 consecutive non-valvular AF patients who underwent radiofrequency catheter ablation in our center was collected from April 1, 2019 to June 30, 2020. Patients were divided into no-alcohol (72) and alcohol groups [categorized into light (34), moderate (11) and heavy (17) alcohol consumption]. All patients underwent echocardiographic and electrophysiologic examinations for the assessment of left atrial (LA) strain, inter-atrial conduction, intra-atrial conduction, and atrial effective refractory period (ERP). Overall, the mean age was 61 ± 11 years and 87 (65%) were males. Compared with the no-alcohol group, impaired peak LA longitudinal strain, obvious inter-atrial conduction delay and increasing ERP dispersion were observed in the alcohol group. Intra-atrial conduction delay and ERP dispersion increased with increasing amounts of alcohol consumption. Alcohol consumption was associated with substantial abnormal echocardiographic and electrophysiologic changes in AF patients. These changes may contribute to the occurrence and progression of AF attributed to alcohol consumption, which may help in the development of new strategies for the prevention and management of AF. However further investigation is required.

C42 MULTI–CHAMBER SPECKLE TRACKING IMAGING AND DIAGNOSTIC VALUE OF LEFT ATRIAL STRAIN IN CARDIAC AMYLOIDOSIS

Abstract Background Amyloid deposits in all cardiac chambers, impairing their function. We investigated for the first time if a speckle–tracking echocardiography (STE) analysis extended to all 4 chambers might hold additive diagnostic value for CA and its subtypes (amyloid transthyretin [ATTR–] and light–chain [AL]–CA). Methods We evaluated 423 consecutive patients undergoing a diagnostic workup for CA in 2 referral centres from 2015 to 2020. Results CA was diagnosed in 261 patients (62%; ATTR–CA, n = 144, 34%; AL–CA, n = 117, 28%). Patients with CA had an impaired function of all cardiac chambers, particularly those with ATTR–CA. Peak left atrial longitudinal strain (LA–PALS) was the only STE parameter that predicted CA and ATTR–CA independent of laboratory and standard echocardiographic variables (Model 1). It also predicted ATTR–CA among patients with unexplained hypertrophy regardless of a diagnostic score (IWT score). Patients with either LA–PALS or LA–peak atrial contraction strain (PACS) in the first quartile (LA–PALS &amp;lt;6.65% or LA–PACS &amp;lt;3.62%) had an almost 4–fold higher likelihood of CA and ATTR–CA regardless of Model 1. Among patients with unexplained hypertrophy, those with LA–PALS or LA–PACS in the first quartile had an almost 9–fold higher likelihood of ATTR–CA irrespective of Model 1, and a 2–fold higher likelihood of ATTR–CA beyond the IWT score. Conclusions STE measures of all 4 chambers are abnormal in patients with CA, particularly in those with ATTR–CA. LA strain holds independent diagnostic significance. Among patients screened for CA, those with LA–PALS &amp;lt;6.65% and/or LA–PACS &amp;lt;3.62% have a high likelihood of CA and ATTR–CA.