Right Atrial Reservoir Strain Research Articles

Improvement in right heart function following kidney transplantation in esrd patients: insights from speckle tracking echocardiography analysis.

Chronic kidney disease (CKD) is commonly associated with unfavorable cardiovascular outcomes and remains the leading cause of mortality in individuals with end-stage renal disease (ESRD). Despite substantial knowledge about the impact of CKD on the left heart, the right heart, which holds significant clinical relevance, has often been overlooked and inadequately assessed in ESRD patients who have undergone kidney transplant (KTx). This study aimed to evaluate the effects of KTx on the right heart chambers in ESRD patients. 57 adult KTx candidates were enrolled in this prospective longitudinal study, while 49 of them were included in the final assessment. Patients underwent a comprehensive cardiac assessment, including conventional echocardiography, speckle tracking echocardiography, and three-dimensional heart modeling both before and after surgery. Echocardiographic assessments showed significant increases in right ventricular (RV) ejection fraction, RV fractional area change (RVFAC), tricuspid annular plain systolic excursion, RV fractional shortening, right atrial (RA) reservoir, conduit, and booster strains, and RV global longitudinal strain (RVGLS). Moreover, significant reductions in RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), RV stroke volume, RV end-diastolic diameter (RVEDD) in mid-cavity view, systolic pulmonary artery pressure was observed (all P values < 0.05). However, no significant difference was found in S velocity, as well as RVEDD in basal and apex-to-annulus view. Moreover, pre-KTx measurements of RVGLS, RVEDD (apex-to-annulus diameter), RV fractional shortening, and S velocity were predictors of RVGLS after KTx. RA conduit strain was also identified as a predictor of RA conduit strain after KTx. Additionally, age, RVEDV, RVESV, RVFAC, and RA reservoir strain before KTx were identified as independent predictors of RA reservoir strain after KTx. The findings of this study demonstrate a significant improvement in right heart function following KTx. Furthermore, strain analysis can provide valuable insights for predicting right heart function after KTx.

The Added Value of Advanced Echocardiography for the Morpho-Functional and Prognostic Evaluation of the Right Heart in Dilated Cardiomyopathy: Do Not Forget about the Right Atrium.

(1) Introduction and Aims: Right ventricular (RV) remodeling significantly impacts the prognosis of dilated cardiomyopathy (DCM) patients, and right atrial (RA) size and function are still often neglected in DCM patients. Accordingly, our aims were to (i) evaluate right heart subclinical changes and (ii) the prognostic value of RA compared to left atrial (LA) size and function in patients with DCM by advanced echocardiography. (2) Materials and Methods: Sixty-eight patients with DCM (with a mean age of 60 years; 35 men) were evaluated by comprehensive transthoracic echocardiography, compared to 62 age- and sex-matched healthy controls (with a mean age of 61 years; 32 men), and followed up for 12.4 ± 5 months. (3) Results: DCM patients have RV and RA global longitudinal dysfunction by 2DSTE, higher RA minimum volumes and tricuspid annulus areas despite having normal RV volumes, ejection fractions, and RA maximum volumes by 3DE compared to the controls. The RA strain and RV strain are correlated with each other. The RA reservoir strain (with an AUC = 0.769) has an increased value for outcome prediction compared to that of the LA strain. (4) Conclusion: Patients with DCM have RV longitudinal dysfunction and decreased RA function, in the absence of clinical RV involvement or atrial arrhythmias, and the RA strain is associated with an increased risk of hospitalization and cardiac death.

Liver stiffness is associated with right heart dysfunction, cardiohepatic syndrome, and prognosis in pulmonary hypertension

BackgroundPulmonary hypertension (PH) can lead to congestive hepatopathy, known as cardiohepatic syndrome (CHS). Hepatic congestion is associated with increased liver stiffness, which can be quantified using shear wave elastography. We aimed to investigate whether hepatic shear wave elastography detects patients at risk in the early stages of PH. MethodsSixty-three prospectively enrolled patients undergoing right heart catheterization (52 diagnosed with PH and 11 with invasive exclusion of PH) and 52 healthy volunteers underwent assessments including echocardiography and hepatic shear wave elastography. CHS was defined as increased levels of ≥ 2 of the following: gamma-glutamyl transferase, alkaline phosphatase, and bilirubin. Liver stiffness was defined as normal (≤ 5.0 kPa) or high (> 5.0 kPa). ResultsCompared with normal liver stiffness, high liver stiffness was associated with impaired right ventricular (RV) and right atrial (RA) function (median [interquartile range] RV ejection fraction: 54 [49; 57]% vs. 45 [34; 51]%, p < 0.001; RA reservoir strain: 49 [41; 54]% vs. 33 [22; 41]%, p < 0.001), more severe tricuspid insufficiency (p < 0.001), and higher prevalence of hepatovenous backflow (2% vs 29%, p < 0.001) and CHS (2% vs. 10%, p = 0.038). In the patient subgroup with precapillary PH (n = 48), CHS and high liver stiffness were associated with increased European Society of Cardiology/European Respiratory Society 2022 risk scores (p = 0.003). ConclusionsShear wave liver elastography yields important information regarding right heart function and may complement risk assessment in patients with (suspected) PH.

Assessment of Bi-Atrial Mechanical Function in Patients with Isolated Atrial Septal Aneurysm.

Atrial mechanical dysfunction may be an alternative mechanism underlying the increased risk of systemic embolism in patients with atrial septal aneurysm (ASA). This study aimed to evaluate left atrial (LA) and right atrial (RA) function using two-dimensional speckle tracking echocardiography (2D STE) in patients with isolated ASA. Fifty-four patients with ASA (mean age 50.3 ± 12.48, 37% male) and 48 healthy individuals of similar age and gender (mean age 48.3 ± 10.84, 39.6% male) were included in the study. To assess atrial mechanical function, measurements of left and right atrial reservoir strain (RS), peak contraction strain (PCS), and conduit strain (CS) were conducted using 2D STE, in addition to conventional evaluation with transthoracic echocardiography. LA RS and PCS values were significantly lower in the ASA group than in the controls (37.52 ± 2.89 vs. 40.16 ± 2.68%, P < 0.001 and 17.29 ± 2.5 vs. 19.18 ± 2.23%, P < 0.001, respectively). Similarly, RA RS and RA PCS were significantly lower in patients with ASA (36.97 ± 2.19 vs. 39.77 ± 2.36%, P < 0.001 and 16.78 ± 2.10 vs. 18.54 ± 2.43%, P < 0.001, respectively). A multivariate regression analysis revealed a strong independent association between ASA and the measures LA RS, LA PCS, RA RS, and RA PCS. Our findings indicate that bi-atrial function are diminished in patients with isolated ASA. This may be a possible cause for the increased risk of arterial embolism in this patient group, aside from atrial arrhythmias and patent foramen ovale. Validating these results with larger studies may influence the treatment and follow-up strategies for patients with isolated ASA.

Biatrial myopathy in heart failure with preserved ejection fraction.

Left atrial (LA) myopathy is increasingly recognized as an important phenotypic trait in heart failure (HF) with preserved ejection fraction (HFpEF). Right atrial (RA) remodelling and dysfunction also develop in HFpEF, but little data are available regarding the clinical characteristics and pathophysiology among patients with isolated LA, RA, or biatrial myopathy. Patients with HFpEF underwent invasive haemodynamic exercise testing, comprehensive imaging including speckle tracking strain echocardiography, and clinical follow-up at Mayo Clinic between 2006 and 2018. LA myopathy was defined as LA volume index >34 ml/m2 and/or LA reservoir strain ≤24% and RA myopathy by RA volume index >39 ml/m2 in men and >33 ml/m2 in women and/or RA reservoir strain ≤19.8%. Of 476 consecutively evaluated patients with HFpEF defined by invasive exercise testing with evaluable atrial structure/function, 125 (26%) had no atrial myopathy, 147 (31%) had isolated LA myopathy, 184 (39%) had biatrial myopathy, and 20 (4%) had isolated RA myopathy. Patients with HFpEF and biatrial myopathy had more atrial fibrillation, poorer left ventricular systolic and diastolic function, more severe pulmonary vascular disease, tricuspid regurgitation, ventricular interdependence and right ventricular dysfunction, and poorer cardiac output reserve with exercise. There were 94 patients with events over a median follow-up of 2.9 (interquartile range 1.4-4.6) years. Individuals with biatrial myopathy had an 84% higher risk of HF hospitalization or death as compared to those with isolated LA myopathy (hazard ratio 1.84; 95% confidence interval 1.16-2.92, p = 0.01). Biatrial myopathy identifies patients with more advanced HFpEF characterized by more severe pulmonary vascular disease, right HF, poorer cardiac reserve, and a greater risk for adverse outcomes. Further study is required to define optimal strategies to treat and prevent biatrial myopathy in HFpEF.

Clinical utility and prognostic value of right atrial function in severe tricuspid regurgitation. One more piece of the puzzle

Abstract Background Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. Purpose This study aimed to describe RA function by 2D speckle tracking echocardiography (STE) in at least severe TR and to evaluate its potential association with cardiovascular outcomes. Methods Consecutive patients with at least (≥) severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent isolated AF were included for comparison (control and AF group respectively). RA function was measured with 2D-STE and RA reservoir strain (RASr) was calculated in all subjects (figure 1, AutoStrain, Philips Medical Systems the EPIQ system). The interobserver variability of RA strain was assessed in 30 randomly selected subjects (20 TR+5 AF+5 controls). A combined endpoint of hospital admission due to heart failure (HF) or all cause mortality was defined. Results A total of 227 patients with severe TR, 20 AF patients and 20 controls subjects were included in this study. Patients with at least severe TR showed lower RASr compared to controls and to AF patients (p&amp;lt;0,05). After a median follow-up of 26 months (IQR: 15-48 months), n=83 patients with severe TR (37%) reached the combined endpoint. Patients with events showed lower values of RASr (p&amp;lt;0,01 for both). RASr was an independent predictor of heart failure and all cause mortality adjusted by additional imaging prognostic parameters in a multivariable analysis (biplane vena contracta, RV end-diastolic area, and RV- free wall longitudinal strain [LR Chi2 : 49,7, p&amp;lt;0,001]). RA area or volume was not associated with outcomes. A cut-off value of RASr of &amp;lt;10% held the best accuracy to predict outcomes (adjusted HR 3,8 (2,4-6,1), p&amp;lt;0,001, figure 2). Inter-observer agreements for RA strain values across the whole cohort were high (intraclass correlation coefficient for RASr, RAScd and RASct, r= 0,95, r=0,86, r=0,92 respectively). Conclusions Evaluation of RA function by 2D-STE is feasible, reproducible and is an independent predictor of heart failure and all-cause mortality in patients with at least severe TR.LA STRAINKaplan Meier Curves

Early deterioration of right ventricular strain in patients undergoing transcatheter tricuspid valve intervention

Abstract Background Severe tricuspid regurgitation (TR) leads to volume overload and increased wall stress causing detrimental right ventricular (RV) remodelling and dysfunction and is associated with excess mortality. Transcatheter tricuspid valve interventions (TTVI) emerged to treat patients with severe TR and high surgical risk, but predictors of outcome remain largely unknown. RV free wall longitudinal strain (RVFWLS) is a sensitive parameter for RV dysfunction and has shown prognostic value in patients with functional TR treated conservatively. Periinterventional changes in RVFWLS and right atrial (RA) strain have not been evaluated in patients undergoing TTVI. Purpose To analyse the effect of transcatheter tricuspid valve annuloplasty (TTVA) and transcatheter edge-to-edge repair (TEER) on RVFWLS and RA strain, assessed by speckle tracking echocardiography, and their association with outcome. Methods We retrospectively analysed consecutive patients with severe TR that underwent TTVI at our centre between 2020 and 2022. 126 patients were included (n=48 underwent TTVA with the Cardioband system, n=78 underwent TEER with the PASCAL system). Established parameters for RV function (TAPSE, FAC) as well as RVFWLS and RA reservoir strain (RASR) were analysed at baseline and one month after TTVI. Results All patients (median age 80 years, 69% female, 79% in NYHA III/IV functional class) were at prohibitive surgical risk. RV function at baseline was slightly reduced according to FAC (34% [29-39]) and preserved according to TAPSE (18mm [15-20]), whereas RVFWLS (-18.6±5.7%) and RASR (10.0% [7.0-14.0]) were severely reduced in markedly dilated right heart chambers (RV basal 45mm [41-49], RA area 34 cm2 [28-41]). TR reduction following TTVI to TR grade ≤ 2 was achieved in 77%. Right heart chamber size significantly decreased after one month (RV basal 41mm [38-45], RA area 29cm2 [25-38], P&amp;lt;0.001), with no improvement of FAC (37% [30-40], P=0.668) or RASR (10% [7-13], P=0.143) but deterioration of RV longitudinal function (TAPSE 17mm [13-20], P=0.002; RFWLS -16.1±5.7%, P=0.001) compared to baseline. RVFWLS reduction occurred irrespective of the procedure performed (TEER [-9.2±41.4] vs. TTVA [-7.0±31.3], P=0.783). RVFWLS deterioration occurred in 63%, whereas it improved in 37% of patients. Symptomatic and clinical outcome did not differ in patients with deteriorated vs. improved RVFWLS (improvement of at least one NYHA class 61.9% vs. 58.3%, P=0.569, one-year mortality 13.7% vs. 12.3%, P=0.940, one-year heart failure rehospitalization 10.8% vs. 17.1%, P=0.701). Conclusion Deterioration of RVFWLS after TTVI possibly reflects the decreased wall stress due to TR and consecutive preload reduction. However, symptomatic and clinical outcomes did not differ in patients with deteriorated RVFWLS vs. patients with improved RVFWLS. Reduction of RA size after TTVI did not translate into improvement of RASR, indicating an already advanced pre-existing RA dysfunction.

Right heart function in isolated severe tricuspid regurgitation. a new stratification approach by Speckle tracking echocardiography

Abstract Background Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular (RV) systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown. Purpose to evaluate the clinical utility of combining RV and RA strain by Speckle-tracking echocardiography to assess RV and RA function for prediction of cardiovascular outcomes. Methods Consecutive patients with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were prospectively included following a comprehensive clinical protocol. Consecutive control subjects and patients with permanent atrial fibrillation were included for comparison. An independent cohort of patients was included for external validation. RA and RV mechanics analysis was performed using a novel, automated 2D strain analytical software. A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined. Results 176 patients with at least severe TR, 20 AF patients and 20 control subjects were included in this study. Patients with TR showed lower RA reservoir strain (RASr) and RV-free wall longitudinal strain (RV-FWLS) compared to controls and to AF patients (p&amp;lt;0,001). After a median follow-up of 2,2 years (IQR: 12-41 months), 38% reached the combined endpoint. Reservoir RA strain (RASr) and RV-FWLS were predictors of outcomes independently of TR severity and RV dimensions in a multivariate Cox analysis (table, model 1). RA strain showed incremental value to RV strain. Conventional parameters of RV function were not predictive of events. RV-FWLS&amp;gt;-20% and RASr &amp;lt;10% identified patients with a higher event rate (p&amp;lt;0,001). The combination of abnormal values of RA and RV strain (STREI stratification) stratified 4 different groups of risk independently of TR severity, RV dimensions and clinical status (adj HR per stratum 1,89 (1,4-2,34), p&amp;lt;0,001) (table-model 2 and figure). Pre-defined cut-off values achieved similar prognostic performance in the validation cohort (n=50). Conclusion Clinical outcomes demonstrate that strain parameters are superior to conventional indices of RV function in patients with at least severe TR. The combination of RA and RV strain stratify better patients’ risk, reflecting a broader effect of TR on right heart chambers.STREI STRATIFICATION.Cox regression analysis

Right atrial strain predicts collagen mRNA levels in human right atrium

Abstract Background Structural remodelling, which includes increased fibrosis and collagen production, is a hallmark of atrial cardiomyopathy. Echocardiographic strain measurements allow detailed assessment of atrial function. We investigated the association between right atrial (RA) strain and collagen mRNA levels in human RA. Methods RA biopsies were collected from 21 patients undergoing elective coronary artery bypass grafting in the prospective observational study CONSIDER-AF. Tissue mRNA levels of collagen type I (Col1A) and of collagen type III (Col3A) were quantified using real-time qPCR on ViiA 7 real-time PCR system. Echocardiographic RA strain (reservoir, conduit, and booster function) was measured in the four-chamber view using the designated software Philips QLAB. We performed uni- and multivariable linear regression analysis to elucidate the relationship between RA strain and collagen mRNA levels. Results There was a strong correlation between RA reservoir strain and Col1A mRNA levels (p=0.0152, r²=0.2608, Fig A) and Col3A mRNA levels (p=0.0058, r²=0.3374, Fig B) as well as between RA conduit strain and Col1A mRNA levels (p=0.0301, r²=0.2141, Fig C) and Col3A mRNA levels (p=0.0232, r²=0.2430, Fig D). However, there was no correlation between RA booster function and Col1A levels (p=0.5572, Fig E) or Col3A levels (p=0.3426, Fig F). Multivariate regression analysis revealed that RA conduit and RA reservoir function are predictors for Col1A and Col3A mRNA levels independent from clinical covariates (age, sex, body-mass index, systolic blood pressure). Discussion Our findings show that RA strain measurements are associated with RA collagen mRNA levels in humans and therefore highlight the potential of strain analysis to identify structural remodelling in atrial cardiomyopathy.FigureTable

Abstract 11758: Right Atrial Dysfunction is Associated With Atrial Arrhythmias in Adults With Repaired Tetralogy of Fallot

Introduction: Adults with repaired tetralogy of Fallot (TOF) have right atrial (RA) remodeling and dysfunction, and RA function can be measured using speckle-tracking echocardiography. There is limited data about the role of RA strain imaging in risk stratification in this population. Hypothesis: We hypothesized that RA reservoir strain could identify TOF patients at risk of developing atrial arrhythmia. We assessed the relationship between RA reservoir strain and atrial arrhythmias in adults with repaired TOF to test this hypothesis. Methods: Retrospective cohort study of adults with repaired TOF, and no prior history of atrial arrhythmias. Atrial arrhythmia was defined as atrial fibrillation, atrial flutter/atrial tachycardia, and categorized as new onset versus recurrent atrial arrhythmias. Results: We identified 426 patients (age 33±12 years; males 208 (49%)) that met the inclusion criteria. The mean RA reservoir, conduit, and booster strains were 34±11%, 20±9%, and 15±12%, respectively. Of 426 patients, 73 (17%) developed new-onset atrial arrhythmias (atrial flutter/tachycardia n=42; atrial fibrillation n=31); annual incidence 1.9%. RA reservoir strain was associated with new-onset atrial arrhythmias (adjusted HR 0.95, 95% CI 0.93-0.97) after multivariable adjustment. Of 73 patients with new-onset atrial arrhythmia, 41 (56%) had recurrent atrial arrhythmia (atrial flutter/tachycardia n=18; atrial fibrillation n=23); annual incidence 11.2%. Similarly, RA reservoir strain was associated with recurrent atrial arrhythmias (adjusted HR 0.92, 95% CI 0.88-0.96) after multivariable adjustment. Conclusions: RA strain indices can identify patients at risk for atrial arrhythmias, and this can, in turn, be used to guide the type/intensity of therapy in such patients.

Right Atrial Phasic Function in Heart Failure with Preserved Ejection Fraction: Cardiac Magnetic Resonance Feature Tracking and Outcomes.

This study sought to investigate the prognostic impact of right atrial (RA) size and function in patients with heart failure with preserved ejection fraction (HFpEF) in sinus rhythm (SR) and atrial fibrillation (AF). Consecutive HFpEF patients were enrolled and indexed RA volumes and emptying fractions (RA-EF) were assessed by cardiac magnetic resonance imaging (CMR). For patients in SR, feature tracking of the RA wall was performed during CMR. In addition, all patients underwent right and left heart catheterization and 6 min walk distance (6MWD) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) evaluations. We prospectively followed patients and used Cox regression models to determine the association of RA size and function with a composite endpoint of heart failure hospitalization and cardiovascular death. A total of 188 patients (71% female patients, 70 ± 8 years old) were included. Ninety-two patients (49%) were in persistent AF. Eighty-five patients reached the combined endpoint during a follow-up of 69 (42-97) months. After a multivariate cox regression analysis, the impaired RA reservoir strain (HR 0.949; 95% CI [0.909-0.990], p = 0.016), the RA reservoir strain rate (HR 0.991; 95% CI [0.983-0.999], p = 0.028), the RA conduit strain (HR 0.932; 95% CI [0.879-0.988], p = 0.019), and the RA conduit strain rate (HR 0.989; 95% CI [0.881-0.997], p = 0.011) were significantly associated with a worse outcome for patients in SR. In persistent AF, no RA imaging parameter was related to outcome after a multivariate regression analysis. In HFpEF patients in SR, CMR parameters of impaired RA conduit and reservoir function are associated with dismal cardiovascular outcomes. In persistent AF, RA parameters lose their prognostic ability.

Prognostic value of right atrial strain in patients with isolated severe tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Moderate or severe isolated Tricuspid regurgitation (TR) can lead to right ventricular (RV) dysfunction and adverse outcome. Only few patients with significant TR undergo intervention, and the optimal timing for intervention remains elusive. The right atrium (RA) is the receiving chamber of the tricuspid regurgitant volume. Changes in RA function has been described in chronic severe TR, specifically reduction in right atrial reservoir strain (RARS). The aim of this study was to evaluate the prognostic value of RA function in a cohort of patients with isolated severe TR. Materials and Methods Clinical, laboratory and echocardiographic data from 105 consecutive patients with isolated moderate-severe TR (grade≥+3) were analyzed. RARS was evaluated by two-dimensional speckle-tracking echocardiography using a semi-automated software (TOMTEC, Philips). The cohort was divided into two groups: RARS value above or below 10.9%, according to an optimal threshold obtained by a receiver operating characteristic (ROC) curve. Results and discussion A total of 105 patients (mean age 79Y, 59% female) were included. Compared with patients with higher RARS, patients with RARS≤10.9% had higher rate of atrial fibrillation and worse RV function. Lower RARS was also associated with larger inferior vena cava diameter, abnormal cholestatic liver enzymes and higher rate of diuretic use. During a median follow-up period of 19 months (IQR:8–25), 39 (37%) patients died. Patients with RARS ≤10.9% had significantly lower survival rates compared with patients with RARS&amp;gt;10.9 (60% vs. 20%; P&amp;lt;.001). A multivariable analysis (including age, RV longitudinal strain, systolic pulmonary artery pressure and atrial fibrillation) showed that lower RARS was independently associated with higher all-cause mortality (OR 2.47, 95%CI [1.07–6.06]; P=0.03). Conclusions Impaired RA function assessed by echocardiographic RA reservoir strain is independently associated with all-cause mortality in patients with isolated severe TR. Serial measurement of RARS can potentially aid in optimizing timing for intervention in patients with TR.

Characterization of right-sided strain parameters in atrial and ventricular functional tricuspid regurgitation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial functional tricuspid regurgitation (A-FTR), defined as TR due to prominent right atrial (RA) dilatation without significant right ventricular (RV) remodelling, has recently emerged as a distinct subtype of FTR, and can be distinguished from ventricular FTR (V-FTR), defined by significant RV remodelling leading to annular dilatation and leaflet tethering. However, so far no data has been reported on the values of RV and RA strain in these patients. Purpose To evaluate potential differences in right-sided strain parameters in patients diagnosed with severe atrial and ventricular FTR. Methods Patients with severe FTR, without a cardiac implantable electronic device, were categorized as V-FTR when in sinus rhythm and either having left-sided cardiac disease, pulmonary hypertension, or moderate/severe RV dysfunction. Patients, in sinus rhythm or atrial fibrillation, with no other cause of annular dilatation and impaired leaflet coaptation than RA dilatation were classified as A-FTR. Extensive echocardiographic assessment was performed, including 2D-speckle-tracking strain analysis. Results A total of 525 patients with severe FTR (mean age 66 ± 15 years, 42% male) were included, of which 401 patients (76%) were classified as V-FTR and 124 patients (24%) as A-FTR. Baseline clinical and echocardiographic characteristics are shown in Figure 1. Patients presented with mild RV dilatation (RV end-diastolic area 12.9 ± 4.0cm2/m2) and RV dysfunction (RV free wall longitudinal strain [FWLS] 18.3 ± 6.8%), and with moderate-to-severe RA dilatation (RA max volume 36.8 [26.9 – 52.2] ml/m2) and moderate-to-severe RA dysfunction (RA reservoir strain 17.0 [11.0 – 27.0] %). Corresponding to the phenotype, patients with A-FTR presented with significantly smaller RV size and better RV function (Figure 1). However, despite overall normal values of RV function by RV fractional area change, tricuspid annular plane systolic excursion (TAPSE) and RV FWLS, 27% of A-FTR patients showed reduced RV FWLS based on cut-off value of −20%. In addition, patients with A-FTR showed more dilated RA, as compared to patients with V-FTR, but with better RA function assessed by 2D-strain values (Figure 1). Notwithstanding, still 73% of the A-FTR-patients showed reduced RA strain values, when using the cut-off reported for normality of 34%. Conclusion Approximately 25% of patients diagnosed with severe FTR presented with A-FTR. These patients presented with significantly better right-sided strain parameters as compared to patients with V-FTR, despite more pronounced RA dilatation.

Incremental value of right atrial strain analysis to predict atrial fibrillation recurrence after electrical cardioversion

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is the most frequent cardiac arrhythmia, associated with elevated risks of cardiovascular events and death. The assessment of left atrial (LA) mechanics has been reported to refine AF risk prediction, however it does not completely predict AF relapse. The potential added role of right atrial (RA) function in this setting is unknown. Purpose This study sought to evaluate the added value of RA longitudinal reservoir strain (RARS), on top of LA longitudinal reservoir strain (LARS) analysis, for the prediction of AF recurrence after electrical cardioversion (ECV). Methods We retrospectively studied 132 consecutive adult patients (men 55%, 72±10 years) with persistent AF undergoing ECV in hospital setting. Exclusion criteria were: pregnancy, previous cardiac surgery, pacemaker or implantable cardioverter defibrillator, severe valvular regurgitation/stenosis, ventricular systolic dysfunction, poor apical acoustic window, unsuccessful ECV, early recurrent AF and lack of follow-up. LA and RA size and function were analyzed by conventional 2D and speckle-tracking echocardiography before ECV. The endpoint was AF recurrence. Results After a total follow-up of 12 months, 63 patients (48%) showed AF recurrence. Both LA and RA reservoir strain were significantly lower in patients experiencing AF recurrence than in patients with persistent sinus rhythm (LARS 10±6 vs 13±7%, RARS 14±10 vs 20±9 %, respectively, p&amp;lt;0.001 for both). By receiving operating curve (ROC) analysis, the best cut-offs associated to AF recurrence after ECV were 15% for RARS [AUC 0.77 (95%CI 0.69–0.84), p&amp;lt;0.0001] and 10% for LARS [AUC 0.69 (95%IC 0.60–0.77), p&amp;lt;0.0001]. Kaplan-Meier curves showed that patients with both LARS≤10% and RARS ≤15% had a significant risk for AF recurrences (log-rank, p&amp;lt;0.001) (Figure 1). However, at multivariable Cox regression, RARS [HR 3.26, 95%CI (1.73–6.13), p&amp;lt; 0.001] was the only parameter independently associated with the AF recurrence. RARS provided incremental prognostic value over LARS, LA and RA volumes concerning the prediction of AF relapse after ECV (Figure 2). Conclusions RARS was independently associated with AF recurrence after ECV and provided an incremental prognostic value over LARS. This study highlights the importance of assessing the functional remodeling of both RA and LA in patients with persistent AF. Figure 1. Atrial fibrillation recurrence freedom according to left and right atrial reservoir longitudinal strain. Kaplan-Meier plots of patients grouped according to the threshold levels of left (left panel) and right (right panel) values of reservoir longitudinal strain identified by the Receiver Operating Curve analyses.

Right atrial dysfunction is associated with atrial arrhythmias in adults with repaired tetralogy of fallot

Adults with repaired tetralogy of Fallot (TOF) have right atrial (RA) remodeling and dysfunction, and RA function can be measured using speckle tracking echocardiography. There are limited data about the role of RA strain imaging for risk stratification in this population. We hypothesized that RA reservoir strain can identify TOF patients at risk of developing atrial arrhythmia. To test this hypothesis, we assessed the relationship between RA reservoir strain and atrial arrhythmias in adults with repaired TOF. Retrospective cohort study of adults with repaired TOF, and no prior history of atrial arrhythmias. Atrial arrhythmia was defined as atrial fibrillation, atrial flutter/atrial tachycardia, and categorized as new-onset versus recurrent atrial arrhythmias. We identified 426 patients (age 33 ± 12 years; males 208 (49%)) that met the inclusion criteria. The mean RA reservoir strain, conduit strain, and booster strain were 34 ± 11%, 20 ± 9%, and 15 ± 12%, respectively. Of 426 patients, 73 (17%) developed new-onset atrial arrhythmias (atrial flutter/tachycardia n=42; atrial fibrillation n=31); annual incidence 1.9%. RA reservoir strain was associated with new-onset atrial arrhythmias (adjusted HR 0.95, 95% CI 0.93-0.97) after multivariable adjustment. Of 73 patients with new-onset atrial arrhythmia, 41 (56%) had recurrent atrial arrhythmia (atrial flutter/tachycardia n=18; atrial fibrillation n=23); annual incidence 11.2%. Similarly, RA reservoir strain was associated with recurrent atrial arrhythmias (adjusted HR 0.92, 95% CI 0.88-0.96) after multivariable adjustment. RA strain indices can identify patients at risk for atrial arrhythmias, and this can in turn, be used to guide the type/intensity of therapy in such patients.

511 INCREMENTAL VALUE OF RIGHT ATRIAL STRAIN ANALYSIS TO PREDICT ATRIAL FIBRILLATION RECURRENCE AFTER CARDIOVERSION

Abstract Background In patients with paroxysmal atrial fibrillation (AF), left atrial (LA) mechanics has been reported to be important to predict recurrences after cardioversion. However, the potential additive role of right atrial (RA) function in this setting remains to be tested. Accordingly, the aims of our study was to assess the added role of right atrial reservoir longitudinal strain (RARS) for prediction of AF recurrence after electrical cardioversion. Methods we prospectively studied 130 (mean age 69±14, 55% men) consecutive patients with persistent AF who underwent electrical cardioversion, acquired between June 2020 and December 2021. Exclusion criteria were: presence of pacemaker, more than moderate mitral and tricuspid regurgitation, left or right ventricular dysfunction, prior cardiac surgery, and, inadequate acoustic window. LA and RA 2D-speckle-tracking echocardiography analyses were obtained from dedicated, non-foreshortened 4-ch and RV-focused apical 4-ch views respectively, using a dedicated software package (AFI LA, EchoPAC 204, GE Vingmed, Horten, Norway). The primary endpoint was AF recurrence. Results after a follow-up period of 12 months, 60 patients (45%) reached the primary endpoint. The mean left ventricular ejection fraction (LVEF) was 56.5±8%, for all patients. No significant difference in LA (98±31 vs 94±30 mL, p= 0.333) and RA (68±26 vs 65±26 mL, p=0.286) volumes was detected between patients with and without AF recurrence, while left atrial reservoir strain (LARS, 10±6 vs 14±7%, p&amp;lt;0.001) and RA reservoir strain (RARS, 14±10 vs 16±8%, p&amp;lt;0.001) were significantly lower in patients with recurrent AF. Receiving operator characteristics curve analysis showed that the predictive power of LARS (AUC 0.68 [IC 95% 0.58-0.78]), was lower than RARS (AUC 0.75 [IC 95% 0.66-0.84]) (p&amp;lt;0.001, for all), with cut-off of 10.5% (sensitivity 62%, specificity 70%) and, 15.5% (sensitivity 75%, specificity 75%), respectively. Kaplan-Meier curve for time to primary endpoint showed that patients with LARS≤10.5% and RARS ≤15.5% had a significant risk for AF recurrences (log rank,p&amp;lt;0.001), even after correcting for confounding variables. However, at multivariable Cox regression RARS (HR 3.42 [CI 95% 1.72-6.8], p&amp;lt; 0.001) was the only parameter independently associated with the primary endpoint. Conclusions RARS is an independent predictor of the recurrences of AF after electrical cardioversion and provides an incremental prognostic value over LARS. This study highlights the pivotal role of the assessment of bi-atrial remodeling in patients with AF.

Cardiac remodeling after tricuspid valve repair in Ebstein's anomaly: a magnetic resonance study.

We aimed to evaluate immediate and midterm cardiac remodeling after surgery by cardiac magnetic resonance (CMR) in Ebstein's anomaly (EA), and also to investigate preoperative predictors of right ventricular (RV) normalization. We retrospectively analyzed CMR parameters of the whole heart in adult patients with EA before surgery, at discharge and follow-up. A total of 26 patients were included and performed CMR at 7 days (interquartile range, 3-13 days) before surgery. Immediate postoperative CMR was finished at discharge (median: 8 [7-9] days; n = 18) and follow-up CMR at 187 days (interquartile range, 167-356 days; n = 17). RV and right atrial (RA) volumes promptly decreased immediately after surgery and at follow-up (all p < 0.05). RV ejection fraction decreased significantly at discharge (p < 0.05) but recovered at follow-up (p = 0.18). However, RV global longitudinal strain and RA reservoir strain were significantly impaired immediately and midterm after surgery (all p < 0.05). Indexed left ventricular (LV) end-diastolic volume, stroke volume, as well as global longitudinal strain increased from preoperative to follow-up (all p < 0.05). Patients who achieved normalization of RV volumes after surgery had smaller severity index and RV and RA volumes and higher LV ejection fraction and RA reservoir strain at baseline than patients without RV normalization (all p < 0.05). Reverse biventricular remodeling took place in EA after tricuspid valve surgery. Tricuspid valve reconstruction should be performed before deterioration of RV volume overload and LV function to achieve reverse RV remodeling. Key Points • After removing the volume load of tricuspid regurgitation in Ebstein's anomaly, reverse remodeling was detected by CMR in both left and right heart at midterm follow-up. • Tricuspid valve reconstruction should be performed before deterioration of RV volume overload and LV function to achieve reverse RV remodeling.

Normal Ranges of Right Atrial Strain: A Systematic Review and Meta-Analysis

BackgroundStandard measures for the clinical assessment of right atrial (RA) function are lacking. ObjectivesIn this systematic review and meta-analysis, the authors sought to report a reference range for RA deformation parameters in healthy subjects and to identify factors that contribute to reported variations. MethodsThe authors conducted a comprehensive search of MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase; Scopus; and the Cochrane Central Register of Controlled Trials from database inception through October 2021. Studies were included if they reported RA strain or strain rate (SR) using 2-dimensional speckle-tracking echocardiography in healthy volunteers or apparently healthy control patients. Data were extracted by 1 reviewer and then reviewed by 2 independent reviewers. Conflicts were resolved through consensus. Data were combined using the method developed by Siegel and adjusted using the restricted maximum likelihood random-effects model. The normal range was defined as the 95% CI of the mean. Heterogeneity was assessed by the Cochran Q-statistic and the inconsistency index (I2). The quality of the included studies and publication bias were assessed. Effects of clinical variables were sought in a metaregression. ResultsThe search identified 4,111 subjects from 21 studies. The average RA reservoir strain was 44% (95% CI: 25%-63%), contractile strain was 17% (95% CI: 2%-32%), and conduit strain was 18% (95% CI: 7%-28%), with significant between-study heterogeneity and inconsistency. The systolic SR was 2.1 s-1 (95% CI: 0.9-3.4 s-1), early-diastolic SR was −2.0 s-1 (95% CI: −3.3 to −0.8 s-1), and late-diastolic SR was −1.9 s-1 (95% CI: −2.4 to −1.3 s-1), with nonsignificant heterogeneity and inconsistency. Ranges remained wide in healthy volunteers. The metaregression identified only age as significantly associated with systolic SR and no other significant determinants of variation among normal ranges of strain. ConclusionsThere are wide reference ranges for RA deformation, and these may limit the utility of this test in clinical practice.

Effect of Bi-Atrial Size and Function in Patients With Paroxysmal or Permanent Atrial Fibrillation

Atrial fibrillation (AF) remains the most common arrhythmia in clinical practice. The choice between a rate-control and rhythm-control strategy depends on various factors, including the anatomical and functional substrate. This study investigates the anatomical and functional characteristics of both atria in patients with AF and explores the potential therapeutic implications. From an ongoing registry of patients with paroxysmal or permanent AF, those who underwent cardiac computed tomography (CCT) were included. Left atrial (LA) and right atrial (RA) sizes were measured on CCT, whereas bi-atrial function was quantified with speckle tracking strain echocardiography. The mean LA volume index was 41.6 ± 5.6 ml/m2, and the mean RA volume index was 71.0 ± 21.6 ml/m2. Mean LA reservoir strain was 24.3 ± 15.1%, compared with the mean RA reservoir strain of 21.6 ± 13.2%. Patients with smaller LA volumes had higher LA reservoir strain values than those with larger LA volumes (24.6% [interquartile range (IQR) 15.8 to 35.8] vs 16.5% [IQR 11.2 to 25.0], p <0.001). Patients with permanent AF had larger LA volumes (44.0 [IQR 33.7 to 55.2] ml/m2 vs 36.9 [IQR 30.1 to 47.1] ml/m2, p=0.025) compared with paroxysmal AF. Patients with permanent AF had more impaired LA reservoir strain (15.5% [IQR 11.6 to 22.7] vs 26.9% [IQR 17.4 to 35.6], p <0.001) compared with paroxysmal AF. Similar trends were observed in the RA. In conclusion, atrial substrate characterization by CCT and speckle tracking strain echocardiography may have therapeutic implications, especially for choosing between a rate-control and rhythm-control strategy.

Right atrial reservoir strain and right ventricular strain improves in patients recovered from hospitalisation for non-severe COVID-19

Purpose Those hospitalised with coronavirus disease 2019 (COVID-19) have recently been shown to have impaired right ventricular (RV) strain, but data about the course of heart function after discharge are limited. Our aim was to compare right ventricular strain and right atrial reservoir strain (RASr) associated with COVID-19 between acute disease (during hospitalisation) and follow-up (after discharge). Methods In this retrospective single-center study, we analysed the echocardiograms of 43 patients hospitalised for non-severe COVID-19 between December 2020 and March 2021, undergoing echocardiography both during and after hospitalisation. In addition to conventional echocardiographic parameters, we applied 2-dimensional speckle tracking to obtain RV global longitudinal strain (RV-GLS), RV free wall strain (RV-FWS), and RASr. Results Mean (standard deviation) age of the study population was 50 (9) years, and 18 (42%) of the participants were women. Median duration between exams was 6 months (range, 5–7 months). Both mean RV-GLS and mean RV-FWS significantly increased at follow-up (−20.8 [3.8] vs. −23.5 [2.8], p < 0.001 and −23.3 [4.2] vs. −28.2 [2.8], p < 0.001; respectively), and RASr significantly improved as well (−32.3 [6.6] vs. −41.9 [9.8], p < 0.001). Conclusion In patients hospitalised for non-severe COVID-19 pneumonia, RV-GLS, RV-FWS, and RASr improved significantly between acute disease and 6 months after discharge.