Right Atrial Research Articles

Right atrial strain measured by 2D speckle-tracking echocardiography is associated with poor cardiac outcomes in patients with heart failure.

Right heart failure (HF) is a poor prognostic factor in patients with HF. The right atrial (RA) function has attracted less attention than the right ventricular (RV) function. The association of RA reservoir strain evaluated by 2D speckle-tracking echocardiography (2DSTE) with clinical outcomes in patients with HF remains unclear. We prospectively enrolled patients with HF admitted to our hospital. We measured the RA, RV, left atrial (LA), and left ventricular (LV) strain using 2DSTE before discharge. The RA reservoir strain (RASr) was measured in the global right atrium. The primary endpoints were cardiac death and worsening of HF requiring rehospitalization or intravenous diuretics. Among 226 patients with HF, 72 primary endpoints were recorded during a median follow-up period of 1081days. Kaplan-Meier analysis showed a higher cardiac event rate in the low RASr group than in the high RASr group (P = 0.0089). Multivariate Cox hazard analysis showed that RASr was independently associated with cardiac events after adjusting for confounding factors [hazard ratio (HR) 0.71; 95% confidence interval (CI) 0.51-0.96; P = 0.0347]. Decreased RASr could be a feasible marker of cardiac events in patients with HF.

Abstract 4136316: BMP10 as novel marker for right atrial dilatation and pressure in precapillary pulmonary hypertension

Introduction: Precapillary pulmonary hypertension (precPH) leads to increased right atrial (RA) stretch and pressure. The right atrium is the major source of bone morphogenetic protein 10 (BMP10) in adults. Aim: This study aims to investigate BMP10 in relation to RA dilatation and pressure overload. Methods: We studied BMP10 mRNA in fresh RA tissue of N=5 Chronic Thromboembolic Pulmonary Hypertension (CTEPH) patients and N=9 controls and protein expression in paraffin-embedded RA tissue of N=4 Pulmonary Arterial Hypertension (PAH) patients and N=6 controls. We prospectively included 48 precPH patients (N=22 idiopathic PAH, N=14 hereditary PAH and N=12 CTEPH, and N=16 controls. To study BMP10-induced transcriptional activity, we assayed serum samples in human microvascular endothelial cells (HMEC) with a BMP-responsive transcriptional luciferase assay. BMP10 activity was calculated by subtracting BMP activity after incubation with antibodies for Alk1Fc and bone morphogenetic protein 9 (BMP9). We assessed correlations between BMP10 activity and RA dilatation (RA max volume>79 ml/m 2 for male or >69 ml/m 2 for female) and right ventricular (RV) dilatation (RV end-diastolic volume>108 ml/m 2 for male and >96 ml/m 2 for female). In a cohort of CTEPH patients that underwent pulmonary endarterectomy (PEA) we assessed the effect of pressure unloading on BMP10 activity. Normality of data was checked and statistical differences between groups were tested using an independent sample t-test or Wilcoxon rank-sum test. Results: BMP10 mRNA, protein and downstream activity were higher in the precPH RA tissue (Figure 1A-F). High systemic BMP10 activity was associated with RA dilatation and high RA pressure, but not RV dilatation in precPH (Figure 2A-C). Finally, pressure unloading after PEA in CTEPH patients results in a reduction in BMP10 activity (figure 2D). Conclusions: Local RA BMP10 expression and activity is increased in precPH. Increased systemic BMP10 activity was related to RA dilatation and pressure. Pressure unloading of the right heart leads to a reduction of systemic BMP10 activity. Future studies are needed to determine whether increased BMP10 release is an adaptative mechanism or can be used as therapeutic target.

Abstract 4136169: Phenotypic clustering of right heart dilatation in pulmonary arterial hypertension

Introduction: Right ventricular (RV) and right atrial (RA) dilatation are important hallmarks of disease severity in patients with pulmonary arterial hypertension (PAH). To obtain more insights on the clinical significance of RA dilatation, we phenotypically characterized patients with right heart dilatation. Aim: Description of different RV/RA phenotypes in PAH Methods: 203 incident, treatment naïve PAH patients with cardiac magnetic resonance (CMR) imaging were included. Phenotypic clustering was based on RA and RV dilatation. Conform literature, RA dilatation was defined by a RA index maximal area >15 cm 2 /m 2 . RV dilatation was defined by an RVEDV/LVEDV ratio >1.3 and >2.4 for extreme dilatation. Results: Four phenotypic patient clusters were identified: no dilatation (n=48), RV dilatation (n=78), RV+RA dilatation (n=53) and extreme RV dilatation + RA dilatation (n=23), Figure 1A. To unravel the additive clinical value of RA dilatation, we mainly compared patients with RV dilatation and patients with RV+RA dilatation. Intriguingly, patients with RV+RA dilatation demonstrated lower 3- and 5-year survival rates (58% and 43% vs. 75% and 55%) (Figure 1B) and were less likely to reverse RV dilatation after treatment initiation than patients with RV dilatation only. Despite the consequences of RA dilatation, we could not identify an explanation for the difference in RA dilatation between both groups. No difference in afterload was observed, shown by comparable pulmonary vascular resistance (9.9 [6.8-13] WU vs. 10 [7.5-12.3] WU, p>0.05). RV function was similarly impaired (RV ejection fraction: 36±9% vs. 33±9%, p>0.05). End-diastolic elastance (0.73 [0.39-1.11] mmHg/mL vs. 0.58 [0.40-0.94] mmHg/mL, p>0.05) and severity of tricuspid regurgitation did not differ. Finally, diuretic use (40% vs. 40%, p>0.05), age (54±16 vs. 57±19 yrs, p>0.05), female gender (70% vs. 60%, p>0.05) and iPAH diagnoses was similar (69% vs. 59%, p>0.05). Conclusion: PAH-patients with both RA and RV dilatation have a worse clinical profile than patients with only RV dilatation. However, no clear trigger for RA dilatation was found and future mechanistic studies should unravel factors explaining these differences in right heart adaptation.

Induction of supraventricular tachycardias in patients undergoing pulmonary vein isolation for paroxysmal atrial fibrillation is safe and reasonable.

Patients with atrial fibrillation (AF) may experience other supraventricular tachycardias (SVT) that can trigger AF and cause similar symptoms. The aim of this study was to assess the safety and effectivity of inducing SVT in patients undergoing catheter ablation (CA) for AF. In 61 patients with paroxysmal AF undergoing CA between January 2022 and March 2023, an electrophysiological study was performed after pulmonary vein isolation (PVI) to induce SVT. Induced arrhythmias were mapped and ablated. All patients were followed up at 3, 6, and 12 months after the procedure; seven-day ECG Holter monitoring was carried out 6 and 12 months after the procedure. In 24 patients (39%) an SVT was induced during the stimulation protocol. There was no significant difference in procedure time (P=0.408) or fluoroscopy dose (P=0.458) between patients with and without inducible arrhythmia. Further, none of the echocardiographic variables such as left atrial volume index (LAVI) (P=0.936), left ventricular ejection fraction (LVEF) (P=0.586), or right atrial (RA) area (P=0.716), differed significantly in these subgroups. Age was a significant factor in patients with arrhythmia inducibility compared with those without (64.5 ± 7.6 and 58.2 ± 10.5, P=0.04). SVT inducibility after successful PVI was 39%. Ablation of nonclinical arrhythmia is safe and did not prolong the total procedure or fluoroscopy time.

Abstract 4144530: IL-37 promotes resolution of Right Heart Disease-induced inflammation and atrial fibrillation.

INTRODUCTION: Atrial Fibrillation (AF) is the most common cardiac arrhythmia. Hypertension, obesity, diabetes or right heart disease (RHD) are important risk factors for AF. Inflammation stands as a common denominator among most AF risk factors. Studies have shown that patients with AF present high levels of circulating IL-18. Our group recently described that inflammation-resolution may prevent AF in RHD, however, the mechanism remains unclear. To inhibit IL-18-induced inflammation, IL37, a specific antagonist of IL-18-receptor was shown to attenuate cardiac fibrosis in a mice model of myocardial infarction, but little is known about its efficacy to prevent AF. HYPOTHESIS: IL-37 curbs RHD-induced atrial inflammation and AF vulnerability. METHODS: To induce right-sided cardiac hypertrophy and dilation, pulmonary artery banding (PAB) was performed in male and female Wistar rats (250-300g). Sham animals did not receive the ligation. Animals were randomized into four groups: Sham and PAB treated or not with IL37 (100 ng/ml/kg). Electrophysiological studies and echocardiography were performed in vivo before sacrifices at day (D)0, D7, D14 and D21. To analyze the atrial conduction, right atrial (RA) optical mapping was performed on Langendorff-perfused hearts. Histology, western blot, and qPCR were performed to study the expression of proteins and genes involved in atrial inflammation, fibrosis, and electrical remodeling. RESULTS: Twenty-one days after surgery, PAB rats were more vulnerable to AF and developed severe right-sided hypertrophy and dilation compared to Sham. Reliable to clinical evidence, female rats might be more resistant to AF than males. AF was associated with increased RA levels of inflammatory biomarkers including IL18, IL1β, and IL6. IL37 treatment was associated with decreased atrial expression of inflammatory markers. CONCLUSION: IL37 is a potential new therapeutic strategy to reduce atrial inflammation and prevent AF vulnerability in RHD.

MYH6 Variants Are Associated with Atrial Dysfunction in Neonates with Hypoplastic Left Heart Syndrome

Background: MYH6 variants are the most well-known genetic risk factor (10%) for hypoplastic left heart syndrome (HLHS) and are associated with decreased cardiac transplant-free survival. MYH6 encodes for α-myosin heavy chain (α-MHC), a contractile protein expressed in the neonatal atria. We therefore assessed atrial function in HLHS patients with MYH6 variants. Methods: We performed a retrospective, blinded assessment of pre-stage I atrial function using 2D speckle-tracking echocardiography (2D-STE). Variant carriers were control-matched based on AV valve anatomy, sex, and birth year. Studies were obtained postnatally from awake patients prior to surgical intervention. Right atrial (RA) and right ventricular (RV) strain and strain rate (SR) were measured from the apical four-chamber view. Results: A total of 19 HLHS patients with MYH6 variants had echocardiograms available; 18 were matched to two controls each, and one had a single control. RA active strain (ASct) was decreased in variant carriers (−1.41%, IQR −2.13, −0.25) vs. controls (−3.53%, IQR −5.53, −1.28; p = 0.008). No significant differences were identified in RV strain between the groups. RA reservoir strain (ASr) and conduit strain (AScd) positively correlated with heart rate (HR) in MYH6 variant carriers only (ASr R = 0.499, p = 0.029; AScd R = 0.469, p = 0.043). RV global longitudinal strain (GLS) as well as RV systolic strain (VSs) and strain rate (VSRs) correlated with HR in controls only (GLS R = 0.325, p = 0.050; VSs R = 0.419, p = 0.010; VSRs R = 0.410, p = 0.012). Conclusions: We identified functional consequences associated with MYH6 variants, a known risk factor for poor outcomes in HLHS. MYH6 variant carriers exhibit impaired RA contractility despite there being no differences in RV function between variant carriers and controls. MYH6 variants are also associated with an ineffective RA reservoir and conduit function at high heart rates, despite preserved RV diastolic function. RA dysfunction and reduced atrial “kick” may therefore be a significant contributor to RV failure and worse clinical outcomes in HLHS patients with MYH6 variants.

Prognostic Significance of Right Atrial Volume and Interval Changes in Patients with Idiopathic Pulmonary Arterial Hypertension

Idiopathic pulmonary arterial hypertension (IPAH) is a severe condition characterized by a poor prognosis, rapid deterioration, and high mortality in the absence of lung transplantation. However, non-invasive prognostic markers in assessing IPAH remain uncertain. We aimed to investigate the prognostic significance of chest CT and alterations in heart contours on chest radiography (CXR) in predicting adverse outcomes in IPAH patients. A retrospective study analyzed medical records of IPAH patients who underwent right heart catheterization and chest CT at a tertiary center between 2001 and 2023. Clinical, hemodynamic, and CT findings, and changes (Δ) in heart contours on CXR were assessed. Adverse events were defined as IPAH-related death or lung transplantation. Cox regression models evaluated the predictive power of these parameters. In 80 patients with IPAH (mean age 42.6 years; 75% females), the 3- and 5-year survival rates were 65.8% and 55.1%, respectively. Adverse events were associated with a history of cardiac arrest (Hazard ratio [HR], 11.67, p=0.02), mean pulmonary artery pressure (HR, 1.04, p=0.001), creatinine (HR, 4.12, p<0.001), 6-min walk distance (HR, 0.997, p=0.03), CT-derived right atrial (RA) volume index (HR, 1.01, p=0.02), and ΔRA contour on CXR (HR, 1.27, p<0.001). Combined clinical, CT, and CXR findings showed a 3-year event-free survival predictive accuracy of 82.2% (95% CI, 69.8-94.7), outperforming clinical factors alone. Rapid increases in RA contour on CXR and CT-derived RA volume index were associated with adverse outcomes in IPAH. Assessing these parameters may be helpful in identifying patients who require proactive treatments.

The added value of advanced echocardiography in dilated cardiomyopathy: looking at the right heart

Abstract Introduction and aims Right ventricular (RV) dilation and dysfunction significantly impact the prognosis of dilated cardiomyopathy (DCM) patients, and early detection of subclinical changes is mandatory. Furthermore, right atrial (RA) size and function are still often neglected in DCM patients. Accordingly, our aims were to evaluate (i) right heart chambers and tricuspid annulus (TA) subclinical remodeling, and (ii) the prognostic value of RA compared to left atrial (LA) size and function in patients with DCM without clinical RV involvement, RV pressure/volume overload or sustained atrial tachyarrhythmias by advanced echocardiography techniques. Materials and methods Sixty-eight patients out of a cohort of 106 patients with DCM (mean age 60 years, 35 men) were evaluated by comprehensive transthoracic two- (2DE) and three-dimensional (3DE) and speckle-tracking (2DSTE) echocardiography, were compared to 62 age- and sex-matched healthy controls (mean age 61 years, 32 men), and were followed-up for 37 ± 16.6 months. Results DCM patients have RV and RA global longitudinal dysfunction by 2DSTE, and higher RA minimum volumes (Vmin) and TA areas despite having normal RV volumes and ejection fraction (EF) and RA maximum volumes (Vmax) by 3DE compared to controls (Table). RA and RV strain correlate with each other (r=0.360, p=0.013 for RA reservoir and r=0.347, p=0.017 for conduit strain). TA area correlates with RA contractile strain (r=-.293, p=0.046) and RV free-wall strain (r=0.373, p=0.008), RA Vmax (r=0.513, p&amp;lt;0.001), RV (r=0.404, p=0.004 for end-diastolic and r=0.444, p=0.001 for end-systolic) and left ventricular (LV) volumes (r=0.394, p=0.016) and LV EF (r=-.361, p=0.028). RA reservoir strain (AUC=0.769) has higher value for outcome prediction compared to LA strain (p=0.02 between them). Conclusion Patients with DCM have RV longitudinal dysfunction and decreased RA function, in the absence of clinical RV involvement or atrial arrhythmias, and decreased RA strain is associated with an increased risk of hospitalization and cardiac death.Comparison of right heart parametersPrognostic value of atrial function

The impact of preoperative four-chamber strain on failure of the maze IV procedure for atrial fibrillation: insights from conventional and speckle-tracking echocardiography

Abstract Background Prior studies have linked decreased left atrial (LA) and left ventricular (LV) function to the failure of both catheter ablation and surgery for atrial fibrillation (AF). Yet, the effects of right atrial (RA) and right ventricular (RV) function on the failure of interventional therapy remain unexplored. This study evaluates four-chamber strain parameters using conventional echocardiography and speckle-tracking analysis to evaluate the contributions of preoperative left heart and right heart function to the failure of surgery for atrial fibrillation. Methods We retrospectively analyzed 821 patients who had surgical AF ablation, using pre- and postoperative data from electronic records to assess AF recurrence and thromboembolic events. Of these, 531 had LA ablation only and 290 had bi-atrial Maze-IV procedures. Four-chamber strain was evaluated via speckle-tracking on preoperative echos with TomTec Arena, excluding low-quality images. Univariate and multivariate logistic regression analyses were conducted to assess the influence of AF duration, LV ejection fraction, age, and gender on post-PAF surgery AF recurrence, thromboembolic events with results shown as odds ratios (ORs) in the table. An OR over 1.00 indicates a higher recurrence risk per variable increment. SAS software was used for all statistical analysis. Results In our cohort with a median age of 67.4±11.0 (46.2% female), unadjusted analyses revealed that increased LA and RA volumes and decreased RV free wall strain were significantly associated with AF recurrence post-surgical ablation. Conversely, each unit decrease in LA and RA peak reservoir strain corresponded to a 6% increase in the risk of AF recurrence, indicating an inverse relationship. Adjusted analyses for LA and RA end diastolic volumes and strain values showed a similar direction of association with AF recurrence, though these were not statistically significant. Similarly, lower LA and RA peak strains and larger atrial volumes were suggestive of an increased risk for postoperative thromboembolic stroke, but did not reach statistical significance, potentially due to the low event rate (1.8% of the cohort). Conclusion Conventional echocardiography offers a practical tool for identifying patients at high risk for AF recurrence and potential thromboembolic events after AF ablation surgery. Our study confirms that reduced preoperative LA, RA and RV strain values and enlarged volumes of LA and RA are strongly associated with AF recurrence following surgical ablation. Additionally, RA strain and volume are as predictive as LA metrics, underscoring their importance in risk stratification. These echocardiographic parameters may also hold value in forecasting the likelihood of postoperative stroke.

Functional status is associated with mean right atrial pressure derived from cardiac MRI

Abstract Background Right atrial pressure (RAP) is a key metric in haemodynamic assessment. Elevated RAP is associated with poor prognosis in heart failure and pulmonary hypertension and physiologically with fluid overload. RAP can be measured invasively or non-invasively, but Cardiac MRI (CMR) currently cannot estimate RAP. Purpose To develop a model to estimate RAP from CMR from paired right heart catheter (RHC) and CMR assessments. Assess correlation to WHO functional status prior to prospective clinical validation studies. Methods Patients were recruited to a registry of those referred for assessment of dyspnoea between 2012 and 2020. Inclusion criteria were age &amp;gt;18 years, signs and symptoms of heart failure and adequate CMR image quality. Patients diagnosed with pulmonary arterial hypertension were excluded. RHC and CMR were performed on the same day. CMR 2- and 4- chamber cines were used to measure chamber dimensions, strain, ejection fraction and stroke volume with operator reviewed AI contours in MASS research software. Pearson’s product-moment correlation coefficient (r ) was used to assess relationships between CMR metrics and invasive mRAP. Variables were then included in stepwise multiple linear regression models to predict mRAP. These were compared with receiver-operator curve analysis and DeLong’s test. Kruskal-Wallis test compared median mRAP between WHO functional class groups. Results The cohort of 672 patients was divided based upon invasive mRAP ≤ 8mmHg (44%) and mRAP &amp;gt; 8mmHg (56%). Higher mRAP was associated with increased age, male sex and a higher diastolic blood pressure but there was no difference in rates of heart failure types although the majority had preserved ejection fraction (51% vs 52%) with few having reduced ejection fraction (4.1% vs 8%). Right atrial (RA) dimensions, strain and ejection fraction had the strongest correlation with mRAP with moderate correlation to right ventricular (RV) measurements. Multivariable models contained simple RA dimensions (model 1), RA dimensions and strain (model 2), RA and RV dimensions (model 3) and RA end systolic volume corrected for body mass index and sex (model 4). All models had similar predictive capability (Figure 1 Panel A). RA end systolic volume was isolated in model 1 as the only variable required for mRAP prediction (coefficient = 0.06, p &amp;lt; 0.001). Using a threshold of mRAP &amp;gt;8mmHg ROC analysis demonstrated an area under the curve of 0.78 (95% Confidence interval 0.75 to 0.81) (Figure 1 Panel B). Worse WHO functional Class at time of assessment was significantly associated with increased CMR derived mRAP (P&amp;lt;0.001) (Figure 2). Conclusions mRAP can be estimated with moderate confidence from CMR RA end systolic volume. Limited available clinical data suggest functional status may be predicted by CMR derived mRAP. Further studies on wider populations are required to validate this model externally, refine it and determine its prognostic clinical significance.

Study of right atrial and right ventricular function in dual chamber pacemaker patients

Abstract Background Unlike left ventricular function, right ventricular (RV) function in pacemaker patients is less well studied with less studies comparing septal versus apical pacing effects on the RV function and almost none on the right atrial (RA) function. Purpose To assess the effect of RV pacing on the echocardiographic and clinical parameters of the RV and RA function and their correlation with the site of right ventricular lead implantation. Methods The study assessed 59 patients in need of permanent dual chamber pacemaker implantation using clinical and echocardiographic data of the RV and RA size and function using tricuspid annular plane systolic excursion (TAPSE), S wave velocity of the tricuspid annulus and fractional area change (FAC), free wall strain (FWSL), global longitudinal strain (GLS) of the RV, RA strain including reservoir, conduit and contraction phases and 3D ejection fraction of the RV using Epiq 7 Ultrasound machine (Philips Healthcare) by the same echocardiographer before implantation and 6 months after. All programming parameters were recorded postoperative and 6 months later. Results 31 patients had the RV lead in the RV apex whereas 28 had it in the septum and all patients had their RA lead in the right atrial appendage, with no significant difference between both groups regarding baseline demographic, clinical nor echocardiographic data. At 6 months, there was a significant decline of the 3D RVEF from a mean of (58.57% ± 6.35%) to (56.41% ± 6.17%), TAPSE from (2.61 cm ± 0.51) to (2.35 cm ± 0.52) and S wave from (13.73 cm/sec ± 2.84) to (12.64 cm/sec ± 2.61) but none showed a significant difference between septal and apical pacing, on the other hand, the RV strain showed a significant decline 6 months after implantation in both the FWSL from (-31.75% ± 5.39) to (-27.82% ± 5.73) and the GLS from (-25.89% ± 5.17) to (-21.65% ± 4.51) with more decline in the septal group compared to the apical (-20.33% ± 4.70 versus -22.84% ± 4.04 regarding the GLS and -26.11% ± 6.41 versus -29.37% ± 4.62 in the FWSL, respectively). There was no difference in the FAC, tricuspid regurgitation severity, gradient nor the estimated pulmonary artery pressure at 6 months. The RA size showed a significant decline at 6 months but no difference in any of the strain parameters. No clinical RV failure symptoms nor signs were observed. Programming revealed a mean percentage of ventricular pacing of (97.92% ± 2.67%) with a minimum of 91% and atrial pacing of (10.41% ± 12.52%), and the thresholds, impedance and atrial high-rate episodes were comparable postoperatively and 6 months after, with no difference between the septal and apical groups. Conclusion At 6 months follow-up after pacemaker implantation, right ventricular function starts to show decline in both the septal and apical groups with only the right ventricular strain more affected in the septal group compared to the apical.3D right ventricular ejection fraction3D right ventricular strain

Right atrial and ventricular function in risk stratification of patients with pulmonary artery hypertension

Abstract Background Right atrial (RA) phasic function was proved to be impaired in individuals with pulmonary arterial hypertension (PAH), the awareness of the nonnegligible involvement of RA in the clinical course of PAH was raised. However, evidence for the clinical significance of the RA strain in prognostication and risk stratification for PAH patients was limited. Method Participants diagnosed with PAH from June 2013 to December 2022 in West China Hospital were prospectively and continuously recruited. The primary endpoint was all-cause mortality, and the second endpoint was a combination of all-cause mortality and heart failure-related repeat hospitalization. Cox regression analysis and Kaplan Meier survival analysis were performed to identify the association between variables and outcomes. C-index, 1-year mortality, and annual event rate were performed to confirm the value of RA strain in PAH patients’ risk stratification. Result A total of 283 participants (mean age, 38 ± 14 years, 84 male) were finally included, following a median follow-up duration of 31.5 months (interquartile range: 15.1-53.9 months). Significant decreases in RA reservoir (p&amp;lt;.001), conduit (p&amp;lt;.001), booster pump function (p&amp;lt;.001), right ventricular global longitudinal strain (RVGLS, p&amp;lt;.001), and free-wall longitudinal strain (RV-FWLS, p&amp;lt;.001) were observed in participants with all-cause mortality than those who survived. Using 16.1% and 23.6% as thresholds for RA reservoir strain, PAH patients could be divided into low-, intermediate, and high-risk groups well, with calculated 1-year mortality of 1.8%, 6.9%, and 21.4%. Moreover, RA reservoir strain presented with better 1-year mortality predictive performance than RV-FWLS (C-index, 0.82 [0.72-0.92] vs 0.72 [0.62-0.82], p&amp;lt;.001). The addition of RA reservoir strain had significantly increased the power of both REVEAL Lite2 and Comparative, Prospective Registry of Newly initiated Therapies for Pulmonary Hypertension (COMPERA) models (both p&amp;lt;.001). Conclusion RA reservoir strain was an independent predictor of all-cause mortality in individuals with pulmonary arterial hypertension and could be used to stratify participants into different risk stratification stratum.

Right-sided exercise-induced cardiac remodelling is more pronounced in white than in black elite football players

Abstract Background Most echocardiography studies investigating exercise-induced cardiac remodelling (EICR) in athletes have predominantly focused on left ventricular end-diastolic volume (LVEDV) and wall thickness. Moreover, studies investigating right-sided EICR in individuals with different ethnic backgrounds are scarce, but are needed to assist clinicians in the differentiation between EICR and pathology. Purpose To investigate differences in right-sided EICR between Caucasian (white) and Sub-Saharan (black) male elite football players. Methods We included all male elite football players with echocardiography data from the Evaluation of Lifetime participation in Intensive Top-level sports and Exercise (ELITE) cohort. ELITE collects data from standardised cardiovascular screenings of elite level athletes in the Netherlands, including (but not limited to) standardised resting transthoracic echocardiograms (TTE). Athletes with known cardiovascular disease were excluded. Our primary metrics of interest were right ventricular end-diastolic diameter (RVEDD), maximal dimension of the inferior vena cava (IVC) and right atrial (RA) reservoir, conduit and contractile strain (measured using 2D-Speckle tracking). Secondary metrics of interest included LV ejection fraction (LVEF), LV mass index (LVMi) and left atrial reservoir strain. All metrics of interest were stratified by ethnicity, and indexed for body surface area (BSA) if appropriate. Results A total of 74 elite football players were included (black n = 37; white n = 37), with similar age (18 [2.0] vs 19 [3.0], p = 0.013) and BSA (2 [0.1] vs 2 [0.2] m2, p = 0.268) across ethnicities. There were no differences in indexed LA (35 [10.0] vs 33 [10.0] ml/m2, p = 0.417) and RA volumes (27 [7.4] vs 27 [6.6] ml/m2,p = 0.953). However, black athletes demonstrated smaller max IVC (18 [5.0] vs 25 [5.0] cm, p = &amp;lt;0.001) and RVEDD (40 [2.0] vs 43 [6.0] mm,p = 0.001). Moreover, black athletes demonstrated less RA deformation in the reservoir (31 [8.0] vs 36 [8.0] %, p = 0.003) and contractile phases (9 [4.0] vs 11 [4.0] %, p = 0.017) than white athletes. There were no ethnic-specific differences in RA conduit strain (23 [7.0] vs 25 [6.0] %, p = 0.076). We found no statistically significant differences in LVEF (55 [6.0] vs 55 [6.0] %, p = 0.914), LVMi (92 [15.0] vs 88 [26.8] g/m2, p = 0.236) or LA reservoir strain (32 [7.0] vs 33 [7.0] %, p = 0.157) in black vs white athletes. Conclusion Male elite football players with a Sub-Saharan ethnic background demonstrate less pronounced right-sided EICR than athletes with a Caucasian ethnic background. Our findings emphasize the need for ethnic-specific reference ranges for right-sided EICR to aid in the differentiation between EICR and pathology.

Right atrio-ventricular strain as a predictor of death in left-sided heart failure

Abstract Background Right ventricular (RV) strain is an established outcome predictor in heart failure (HF). However, the role of right atrial (RA) strain in the setting of left-sided HF is incompletely understood. Purpose We sought to evaluate the RV, RA and combined right atrio-ventricular (RAV) strain using speckle-tracking echocardiography in a cohort of patients with left-sided HF and to assess their prognostic role. Methods 121 consecutive patients (mean age 59±14 years, 74% men) with HF with reduced ejection fraction (HFrEF) referred to our echocardiography department were prospectively enrolled. The main endpoint was all-cause death. RV strain was measured as the average longitudinal strain of the basal, mid, and apical segments of the RV free wall and was reported as a positive value, thus a lower RV strain reflecting a greater longitudinal dysfunction. RA strain was defined as the maximal longitudinal displacement of the atrial wall at end-systole, corresponding to atrial reservoir function. RAV strain was defined as the sum of RV strain and RA strain. Results During a median follow-up of 19±11 months, 26 patients (21%) died. Patients who reached the endpoint had lower left ventricular ejection fraction (LVEF) (21±7% vs. 26±7%, p=0.001), lower tricuspid annular plane systolic excursion (16±3 vs. 18±5, p=0.02) and lower RA strain (13± 10% vs. 18±11%, p=0.03). In univariable Cox regression, RV, RA and RAV strain were all predictors of death: HR=1.05 [95% CI, 1.00-1.11], p=0.045 for RV strain, HR=0.95 [95% CI, 0.91-0.99], p=0.02 for RA strain, HR=0.97 [95% CI, 0.94-0.99], p=0.01 for RAV strain. We constructed a multivariable model with well-established event predictors in HFrEF and one strain index at a time. After adjustment for LVEF, maximal left atrial volume, tricuspid regurgitation severity and pulmonary artery systolic pressure, only RAV strain remained an independent predictor of death (HR=0.97 [95% CI, 0.94-1.00], p=0.04), while RV strain and RA strain did not (p=0.07 for both). LVEF did not emerge as a predictor of death in multivariable regression (p=0.57). Conclusion In left-sided HF, RV and RA strain were predictors of death. Combining the longitudinal strain of both right heart chambers might improve risk stratification, since RAV strain remained the only independent predictor of adverse outcome after adjustment for confounders.

Echocardiographic predictors of mortality in cardiac intensive care unit patients with pulmonary hypertension

Abstract Background Pulmonary Hypertension (PH) is a diverse condition associated with elevated mortality. We sought to determine the association of Transthoracic Echocardiography (TTE) parameters with in-hospital mortality in patients with PH admitted to Cardiac Intensive Care Unit (CICU). Methods We included 1 Clinic CICU admissions from 2007 to 2018, with available TTE parameters within the first day of CICU admission who had PH defined as an estimated right ventricular systolic pressure (RVSP) ≥36 mmHg. The primary outcome was in-hospital mortality, evaluated using logistic regression. Results We included 3085 unique CICU patients with PH, predominantly WHO group 2 and 3. Median age was 73.7 (63.8, 82.4) years, and 1343 (43.5%) were females. Heart failure (65.6%) and respiratory failure (34.0%) were the most common admission diagnoses. The median RVSP was 47 (41, 56) mmHg, and 1314 (42.6%) had RVSP ≥50 mmHg. A total of 337 (10.9%) patients died during hospitalization. In-hospital deaths had higher RVSP (51 versus 47 mmHg, p &amp;lt;0.001), reflecting higher right atrial (RA) pressure (14 versus 10 mmHg, p &amp;lt;0.001) (Figure). In-hospital mortality increased with worse TTE parameters reflecting Right Ventricle-Pulmonary Artery (RV-PA) coupling, such as Tricuspid Annular Plane Systolic Excursion/ Right Ventricular Systolic Pressure (RVSP), Tricuspid Annular Systolic Velocity (TASV)/RVSP and TASV/ Tricuspid Regurgitation velocity ratios. Conclusion In CICU patients with PH, we have identified the specific Doppler TTE parameters with strong associations with outcomes. Specifically, RA pressure and parameters of RV-PA coupling had the highest discrimination for in-hospital mortality. Comprehensive Doppler TTE is valuable for identification of high-risk PH patients to facilitate further investigation plans, management, and prognostication. Figure: In-hospital mortality in association with right ventricular (RV) function and right atrial pressure (RAP).In-hospital mortality in association wit

Right ventricular myocardial work predicts heart failure hospitalizations irrespective of ejection fraction

Abstract Hospitalization for heart failure worsening (HFW) associates with increased subsequent rehospitalization rate and mortality irrespective of left ventricular ejection fraction (EF). However there’s little evidence regarding predictors of HFW to timely apply preventive measurements. Since right ventricular (RV) dysfunction often associates with more advanced stages of HF we assumed that RV myocardial work (MW) assessment might be used in prediction of HFW. Methods 158 patients with HF (48% female) 58±7 years on guideline directed medical therapy in sinus rhythm and with at least one hospitalization in the last 6 months were enrolled in the study. Patients with HFrEF, HFmrEF and HFpEF were evenly represented. All patients were appropriately decongested prior to the study. The primary outcome was rehospitalization, HFW or cardiovascular death. RVMW was derived from RV global strain, including interventricular septum, and noninvasively estimated pulmonary arterial pressure (PAP). Systolic PAP (sPAP) was measured as the sum of maximum RV and right atrial (RA) pressure gradient (PGmax) from tricuspid regurgitation (TR) jet peak velocity and mean right atrial pressure (RAP) estimated from diameter and collapsing of inferior vena cava. Mean PAP (mPAP) was measured as the sum of PGmean RV-RA by tracing TR jet and RAP. Diastolic PAP was estimated as dPAP = 1.5 × [mPAP − (sPAP/3)]. Then RV global work index (RVGWI), constructive (RVGCW), and efficient work (RVGWE) were derived by the software dedicated for left ventricular MW. Left ventricular global longitudinal strain, left atrial (LA) reservoir strain (LAS), LA pump strain, LA volume index (LAVi), B lines, inferior vena cava, NT-pro-BNP, TAPSE/sPAP and RVMW were also measured. Patients followed up for 12 months. Results 53 events were registered at 12 months of which 42 rehospitalizations due to HFW and 11 CV deaths. Among all parameters in the multivariate analysis lower RVGCW was associated with HFW (HR 0.978, 95% CI 0.973–0.998, p = 0.014). RVGCW was the most powerful predictor of CV events (AUC 0.91) with cut off value of 148 mmHg% that had 96% sensitivity and 88% specificity. Number of patients who died with RVGCW &amp;lt; 148 mmHg% was 8 of 11 (73%) total deaths (HR 0.421, 95% CI 0.083–0.986, p = 0.028). Conclusion RVGCW was a predictor of HFW and 1 year mortality in patients with HF irrespective of EF.

Predictive factors for recurrent tricuspid regurgitation after tricuspid annuloplasty: 3D echocardiography study

Abstract Introduction There is growing concern about the recurrence of tricuspid regurgitation (TR) after tricuspid annuloplasty (TA) in individuals with functional tricuspid regurgitation (FTR). While TA is effective in treating FTR, a comprehensive understanding of the echocardiographic factors influencing TR recurrence is crucial. Aim This study aims to employ multivariate regression analysis to investigate the prognostic significance of tricuspid valve (TV) geometry and echocardiographic parameters associated with both RV geometry and function. The focus is on comprehending these relationships in the context of recurrent TR subsequent to TA. Methods This prospective observational cohort study aimed to explore factors contributing to recurrent tricuspid regurgitation (TR) after tricuspid annuloplasty (TA). The focus was on patients with moderate or severe functional TR due to left heart valvular disease, particularly severe mitral regurgitation, excluding those with ischemic heart disease. The cohort included 66 individuals undergoing preoperative assessments with 2D and 3D echocardiography, quantifying RV and right atrial (RA) geometry, functional, and tricuspid valve (TV) parameters. TR severity followed ESC guidelines. Patients were categorized into effective TA (50 patients) and recurrent TR (16 patients) groups, defined by mild-moderate TR and significant moderate-severe TR one year post-surgery, respectively. SPSS software facilitated statistical analysis, with adjusted logistic regression considering parameters such as age and gender. Results Among the patients (54% male, mean age 68±9 years), no significant differences were found in gender, left ventricular and atrial parameters, or preoperative TV orifice area between groups (recurrent TR vs. effective TA: 38 [33] mm2 vs. 29 [15] mm2, p=0.117). Univariate logistic regression analysis identified Septal-Lateral Systolic TA Diameter (OR 1.62), Septal-Lateral Diastolic TA Diameter (OR 1.99), and Major Axis Diastolic TA Diameter (OR 1.59) as key predictors. For diagnostic efficacy, ROC analysis revealed Major Axis Diastolic TA Diameter (AUC 0.848; cut-off 52.5 mm), TV Leaflet Tenting Volume (AUC 0.778; cut-off 5.1 ml), and RV Basal Diameter (AUC 0.763; cut-off 47.5 mm) as the most predictive parameters. The combined use of predefined RV basal diameter and Major Axis Diastolic TA Diameter showed the highest odds ratio for recurrent TR. Conclusion Key predictors, including Septal-Lateral Systolic and Diastolic TA Diameters, and Major Axis Diastolic TA Diameter, were identified, emphasizing their significance in understanding TR recurrence after tricuspid annuloplasty. The combination of predefined RV basal diameter and Major Axis Diastolic TA Diameter showed the highest odds ratio for recurrent TR, offering valuable insights for clinical assessment and preventive strategies.

Cardiac MRI traits linked to cardiomyopathy mutations in phenotype naive carriers

Abstract Hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM) are prevalent forms of cardiomyopathies, characterised by changes in cardiac structure and function, associated with an increased risk of atrial fibrillation (AF), heart failure (HF), and sudden cardiac death (SCD). Due to these potential life-threatening consequences close monitoring of genetic mutation carriers of HCM and DCM, is important. However, disease onset in these subjects is highly variable, with a substantial subset of people only developing disease late-in-life, or not at all, making risk stratification challenging. We set out to identify cardiac MRI (CMR) based imaging biomarkers of HCM and DCM carriership in phenotype naïve individuals, which were benchmarked against associations with AF and HF. CMR and whole genome sequencing (n: 42,723) data were sourced from a UK biobank sample free of heart failure at the time of CMR measurements. A previously validated deep learning(DL) network was used to derive 22 CMR traits(1). Adjusted cox regression models were used to determine the CMR associations with the onset of heart failure and atrial fibrillation, providing empirical validation of the DL CMR network. Univariable and multivariable generalised linear models were employed to identify associations with genetic carriership conditional on cardiac risk factors. 14 and 19 CMR measurements were associated with the time until HF (274 cases), AF (704 cases), respectively. These variables included left-ventricle (LV) ejection fraction (EF), LV end systolic volume (ESV), Right-ventricular (RV) EF and right atrial (RA) EF. Using WGS data we identified 154 people with an HCM mutation and 220 with a DCM mutation, where HCM carriership associated with five and DCM with four CMR traits. This included RA-EF (OR 1.26 95%CI 1.10; 1.45), and RV-EF (OR 1.41 95%CI 1.23;1,63) for HCM, and LV-EF (OR 0.72 95%CI 0.62; 0.84), and RV stroke volume (OR 0.75 95CI 0.62; 0.91) for DCM. By combining deep learning of CMR with large sample size WGS we were able to identify cardiac imaging biomarkers of HCM and DCM carriership in apparently healthy subjects. This could prove relevant for early identification and monitoring of phenotype naïve people.

Genotype-phenotype correlation of transthyretin cardiomyopathy in patients with stage C/D heart failure: atrial and myocardial mechanics and fibrosis

Abstract Objectives We sought to investigate: (1) the relationship between transthyretin (TTR) pathogenic variants and their corresponding echocardiographic atrial and ventricular strains in patients with TTR cardiomyopathy (TTR-CM) and clinical evidence of heart failure (HF), and (2) the relationship between TTR pathogenic variants and atrial fibrosis assessed by cardiac MRI. Methods and results Fifty Asian patients with biopsy or scintigraphy proven TTR-CM and stage C or D (C/D) HF were identified from an advanced HF clinic in a tertiary-care university hospital. Genetic testing for the pathogenic variants in the TTR genes associated with hereditary TTR-CM (hTTR-CM) was available in 22 patients (67 ±13 years; 77% were male). Of these, 3 different mutations were identified. The most prevalent pathogenic variant was Ala97Ser (67%) followed by Val30Met (27%), and Gly67Glu (6%). Wild-type TTR-CM was diagnosed in 32% of the cohort. Strain analysis was performed using the TomTec Arena 2D-cardiac performance analysis (CPA) software. Atrial and left ventricular (LV) late gadolinium enhancement (LGE) was quantified using a 9-segment and a 17-segment model, respectively. Patients with hTTR-CM had less impaired longitudinal strain (LS) (more negative strain values) than those with wild-type TTR-CM in the regional basal right ventricular free wall (RV-FW) (-21 ± -8.3 % vs.-12.6 ± -8.1%, p = 0.048) and LV basal inferoseptum (-7.3 ± -4.1 % vs.-3.1 ± -3.0 %, p = 0.045). In univariate analysis, more negative LS values in the basal LV inferoseptum and basal RV-FW were significant predictors of hTTR-CM (OR 5.1 and 2.3; p &amp;lt;0.05, respectively). However, MRI findings revealed similar regional LGE extent involving basal inferolateral segments between hTTR-CM and wild-type TTR-CM (38.3 ± 7.9 vs. 52.5 ± 34.5%, p =0.314). Left atrial (LA) and right atrial (RA) LGE was present in 90% and 81% of patients, respectively. Patients with hTTR-CM had reduced RA LGE when compared to those with wild-type TTR-CM (41% vs 67%, p =0.039). Conclusions In patients with TTR-CM and stage C/D HF, a reduced RA LGE extent and/or more preserved myocardial deformation in specific regions of basal LV and RV segments (basal LV inferoseptum and basal RV free wall) assessed by 2-D speckle tracking echocardiography were significantly more prevalent in patients with hTTR-CM than in wild-type TTR-CM. These echocardiographic and/or MRI findings may facilitate genotype testing in patients with TTR-CM, particularly in resource-limited settings. Further validation of these novel findings in patients with TTR-CM with HF is needed.

Anemia and 4 cavities myocardial strain in acute heart failure

Abstract Background Anemia is a frequent comorbidity in heart failure (HF) in elderly patients. Few data are available concerning the correlation between anemia and echocardiographic morphologic, functional and hemodynamic markers in acute HF. Purpose The aim of the study was to evaluate 4 cavities myocardial strain in elderly patients hospitalized with acute HF and to evaluate the influence of the presence of concomitant anemia. Methods One hundred and seven patients aged 70 years or older, hospitalized for acute HF were prospectively analyzed. Left ventricle longitudinal strain (LVGLS), left atrial (LA) reservoir, right atrial (RA) reservoir and right ventricle (RV) free wall strain were measured using speckle tracking transthoracic echocardiography (TTE) at admission. The population was divided into 2 groups, with (N = 47) or without (N = 60) of anemia. Results Mean age was 81.2 ± 6.6 years; 67 (62.6%) patients were men. Anemia was documented in 60 (56.1%) patients. Patients with anemia, compared to those without anemia, had more frequently history of hypertension, diabetes, renal insufficiency, and iron deficiency (Table 1). Patients with anemia, compared to those without anemia, had higher indexed cardiac output, LV ejection fraction and tricuspid annular plane systolic excursion, TAPSE (Table 1). Myocardial strain analysis found that patients with anemia, compared to those without anemia, had significantly higher LVGLS, LA and RA reservoir strain (Figure 1). Conclusion Anemia is common in elderly patients with decompensated HF. Patients suffering from both anemia and acute HF exhibited significantly higher myocardial strain (except free wall RV strain), suggesting a possible compensatory mechanism. Further investigations are necessary to understand the pathophysiologic links between HF, anemia and myocardial strain as well as their implications for prognosis.