Correlation of left atrial strain with left ventricular end-diastolic pressure in patients with normal left ventricular ejection fraction

Myocardial Dysfunction and Risk of Long COVID in Patients Recovered From Mild and Moderate COVID-19

PURPOSE

Numerous recovered COVID-19 patients exhibit persistent cardiovascular symptoms. However, the degree of myocardial dysfunction and its associated risk factors remain unclear. This study aims to evaluate myocardial dysfunction in recovered patients and pinpoint predictors of persistent cardiovascular symptoms.

METHODS

We reviewed the echocardiograms of patients who recovered from mild or moderate COVID-19 and presented with cardiovascular symptoms during the Omicron surge. Myocardial strain was analyzed in 546 patients before and after infection, and in 351 prepandemic healthy controls. Clinical follow-up at 12 months post-infection was used to evaluated symptom persistence, and multivariable logistic regression was used to identify independent predictors.

RESULTS

Baseline characteristics showed no significant differences between patients and controls (all p > 0.05). Although the left ventricle global longitudinal strain (LVGLS) remained stable post-infection, significant reductions emerged in regional left ventricle longitudinal strains (LVLS) and all left atrial strains (LAS) (all p < 0.05). Persistent cardiovascular symptoms affected 16.5% (90/546) of patients at 1-year follow-up. Multivariate analysis showed that only LA conduit strain (OR = 0.919, 95% CI: 0.857, 0.985, p = 0.017) and basal inferoseptal LVLS (OR = 0.883, 95% CI: 0.792, 0.986, p = 0.026) correlated with persisting cardiovascular symptoms.

CONCLUSION

Our findings demonstrate that subclinical but persistent COVID-19-associated myocardial dysfunction is characterized by regional LVLS impairment and LAS reduction. The identified strain parameters (LAScd and basal inferoseptal LVLS) serve as novel imaging markers for stratifying patients at risk of persistent cardiovascular symptoms. These results advocate for targeted echocardiographic surveillance and early intervention strategies in post-COVID care pathways.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT06170307.

Characteristics of atrial ventricular coupling and left atrial function impairment in early Fabry disease patients using two-dimensional speckle tracking echocardiography

AIMS

The study was designed to investigate the characteristics of atrial ventricular coupling and left atrial (LA) function impairment in patients with Fabry disease (FD), especially those in the early stages of the condition.

METHODS

A total of 65 patients with Fabry disease who completed echocardiographic examinations from January 2018 to May 2024 were ultimately included. Among them, 25 patients with FD did not have left ventricular (LV) hypertrophy (LVH). Additionally, 65 healthy controls were matched to the overall FD population by gender and age, from which 25 controls were selected to match 25 FD patients without LVH based on gender and age. The differences in left atrioventricular coupling index (LACI) and left atrial function between the total FD patients and the healthy control group, as well as between the FD patients without LVH and the healthy control group, were compared. The effect of age on the evolution of LA strain and LACI in FD patients without LVH was examined by adding an interaction term (FD × age) to the models. The correlation between LA and LV parameters in early and total FD patients was evaluated using the Pearson's correlation.

RESULTS

For early Fabry disease patients without LVH, LA reservoir function, contractile function, and LACI were all impaired compared to the control group. LACI in early FD patients increased by 0.007 more per year than in healthy controls (P = 0.004). This increase was mainly due to the faster increase in the minimum LA volume in early Fabry disease patients (P = 0.001). In early FD patients, LACI was positively correlated with age and E/e', and negatively correlated with LASr.

CONCLUSION

This study found that both LA function and LACI were impaired in early FD patients, with LACI exhibiting a faster upward trend in early-stage FD compared to the control group, further highlighting its value in Fabry disease.

Left Atrial Strain Value Versus Tissue Doppler Echocardiography and the Left Atrium Volume Index in the Evaluation of Left Ventricular Diastolic Function in Patients with Chronic Kidney Disease

Background: In heart failure with preserved ejection fraction (HFpEF) and decreased ejection fraction (HFrEF), LA strain, an indicator of the filling and discharge of the left atrium (LA), was recently identified as a sign of diastolic dysfunction. Our objective was to examine the significance of left atrial (LA) strain relative to tissue Doppler echocardiography and the left atrial volume index (LAVI) in evaluating left ventricular (LV) diastolic performance in individuals with chronic kidney disease (CKD). Methods: A prospective cross-sectional study was conducted on 220 outpatients with CKD who fulfilled the inclusion criteria and were referred to the cardiology clinic at Tanta University for routine echocardiographic assessment during a period of 6 months (April to September 2024). Based on their estimated glomerular filtration rate (eGFR), patients were divided into five groups: GFR ranges from 90 to 120 mL/min/1.73 m2 in Group 1, 60 to 90 mL/min/1.73 m2 in Group 2, 30 to 60 mL/min/1.73 m2 in Group 3, 15 to 29 mL/min/1.73 m2 in Group 4, and less than 15 mL/min/1.73 m2 in Group 5. All participants were evaluated using echocardiographic measurements, such as the E/e ratio, left ventricular systolic and diastolic volumes, left atrial strain, left atrial volume index (LAVI), and ejection fraction (EF). Results: LA strain conduit and reservoir strain can significantly diagnose LV diastolic function in CKD patients (p < 0.001; AUC = 0.819 and 0.869, respectively) using cutoffs of ≤36 and ≥23, with 86% and 95.5% sensitivity, 65% and 60% specificity, 96.1% and 96% PPV, and 31.7% and 57.1%, NPV respectively. An AUC = 0.926 was observed with LAVI among grade 1 vs. grade 0 (0.9 is considered excellent in diagnosing patients with and without the disease). Other markers had AUC values of 0.5-0.6 among the grades of the diastolic function, suggesting no discrimination in diagnosing the disease. Conclusions: LA conduit strain and reservoir strain are independent markers that represent a superior and more sensitive approach than LAVI and tissue Doppler echocardiography for evaluating LV diastolic dysfunction in patients with CKD, even in the early stages.

Cardiovascular remodelling and reverse remodelling during pregnancy and postpartum: Looking at the right side

BACKGROUND

Considering the limited information available on right cardiac remodelling during gestation, we aimed to characterise the right cardiovascular (CV) remodelling and reverse remodelling (RR) induced by pregnancy and postpartum, respectively, and the impact of perinatal CV risk (CVR) factors on these processes.

METHODS

This prospective cohort was recruited at two tertiary centres during 2019-2022, including 51 healthy pregnant women and 79 with perinatal CVR factors. Participants were evaluated by transthoracic echocardiography during pregnancy (1st[1T] and 3rd[3T] trimesters) and postpartum (one-month[PP1], six-months[PP2], and one-year postpartum[PP3]). Generalised linear mixed-effects models were used for statistical analysis.

RESULTS

Similar enlargement of the right atrium (RA) and right ventricle (RV) dimensions was observed throughout pregnancy, normalising at PP2 values similar to PT1. This anatomical postpartum recovery was accompanied by an increase of RV global longitudinal strain, being statistically significant in perinatal CVR group. Interestingly, at 3T, this group revealed lower RV and RA strain compared to healthy participants. Despite both groups maintained preserved RV systolic function from 1T to PP3, a significant reduction of TAPSE and tricuspid S' velocity was observed at PP1. Concomitantly, all participants showed a significant increase of E/A at the same time-point, suggesting the recovery of diastolic deterioration seen from 1T to 3T that was persistingly higher in the perinatal CVR group througout the postpartum. Constant pulmonary artery systolic pressure (PASP) was documented throughout follow-up time, showing consistently higher values in the perinatal CVR group. All these echocardiographic index changes were within the normality range.

CONCLUSION

This study described subtle right cardiac changes within the normal/physiological range, recovering six-months after delivery. Coexisting perinatal CVR factors seem to affect the magnitude of RV diastolic function changes, PASP and myocardial deformation without any impact on other RV systolic function indexes.

Determinants of invasive left atrial pressure in patients with atrial fibrillation

AIMS

Estimation of left ventricular (LV) filling pressures in patients with a history of atrial fibrillation (AF) is challenging due to lack of reliable parameters. This study investigates the association between cardiac structure and function and invasive mean left atrial pressure (LAP).

METHODS AND RESULTS

This is a multi-centre prospective study enrolling patients undergoing transcatheter ablation for AF. The invasive measurement of LAP was performed at the time of the procedure while the echocardiography within the previous 24 h. A mean LAP ≥ 15 mmHg was considered as increased. Overall, 101 patients were included (mean age 65.8 ± 8.5 years, 68% male, mean LV ejection fraction 56.6 ± 8.0%). No significant differences regarding clinical characteristics were detected between the group of patients with normal (n = 47) or increased LAP (n = 54). The latter showed lower values of LV global longitudinal strain, larger left atrial volumes (LAVs) and worse right ventricular (RV) function. After multivariable adjustment, higher E/e' ratio (P = 0.041) and minimal LAV index (LAVI min) (P = 0.031), lower peak atrial longitudinal strain (P = 0.030), and RV free wall longitudinal strain (P = 0.037), but not maximal LAV index (LAVI max) (P = 0.137), were significantly associated with mean LAP. The associations were not modified by cardiac rhythm. Overall, LAVI min showed the best diagnostic accuracy to predict elevated LAP (area under the curve 0.703).

CONCLUSION

LA structure and function assessment well correlates with mean LAP in patients with a history of AF. These measures may be used in the assessment of filling pressure in these patients.

The Prognostic Value of Left Atrial Function in Patients with Acute Myocardial Infarction

The prognostic value of left atrial (LA) volume is well-established in acute myocardial infarction (AMI) patients. LA strain provides further patophysological insights. In the present study, we evaluated LA volume and LA strain in AMI patients including those with atrial fibrillation (AF). The aim of the study was to determine if LA strain provide additional prognostic value. Patients with AMI underwent two-dimensional echocardiography within 72 h of admission. The primary outcome was a composite of all-cause mortality and major adverse cardiovascular events. Cox regression analyses were performed. We included 501 patients and during follow-up, 132 patients (26.4%) met the primary outcome. Left ventricular (LV) global longitudinal strain (GLS) (HR 0.94 [95% CI 0.88-0.99], p = 0.029), indexed LA volume (LAVi) (HR 1.02 [95% CI 1.00-1.04], p = 0.015), and LA reservoir strain (HR 0.96 [95% CI 0.93-0.99], p = 0.017) were all independently associated with the primary outcome. A univariate Cox model conducted on the AF patients (n = 32) revealed that LA reservoir strain remained significantly associated with the primary outcome, while LV GLS and LAVi were not significant. The prognostic value of LA reservoir strain was comparable to LA volume and LV GLS, and might even be better in AF patients.

Left atrial strain parameters to predicting elevated left atrial pressure in patients with atrial fibrillation

OBJECTIVES

To assess the ability of left atrial (LA) strain parameters to discriminate patients with elevated left atrial pressure (LAP) from patients with atrial fibrillation (AF).

METHODS AND RESULTS

A total of 142 patients with non-valvular AF who underwent first catheter ablation (CA) between November 2022 and November 2023 were enrolled in the study. Conventional and speckle-tracking echocardiography (STE) were performed in all patients within 24 h before CA, and LAP was invasively measured during the ablation procedure. According to mean LAP, the study population was classified into two groups of normal LAP (LAP < 15 mmHg, n = 101) and elevated LAP (LAP ≥ 15 mmHg, n = 41). Compared with the normal LAP group, elevated LAP group showed significantly reduced LA reservoir strain (LASr) [9.14 (7.97-11.80) vs. 20 (13.59-26.96), p < .001], and increased LA filling index [9.60 (7.15-12.20) vs. 3.72 (2.17-5.82), p < .001], LA stiffness index [1.13 (.82-1.46) vs. .47 (.30-.70), p < .001]. LASr, LA filling index and LA stiffness index were independent predictors of elevated LAP after adjusted by the type of AF, EDT, E/e', mitral E, and peak acceleration rate of mitral E velocity. The receiver-operating characteristic curve (ROC) analysis showed LA strain parameters (area under curve [AUC] .794-.819) could provide similar or greater diagnostic accuracy for elevated LAP, as compared to conventional echocardiographic parameters. Furthermore, the novel algorithms built by LASr, LA stiffness index, LA filling index, and left atrial emptying fraction (LAEF), was used to discriminate elevated LAP in AF with good accuracy (AUC .880, accuracy of 81.69%, sensitivity of 80.49%, and specificity of 82.18%), and much better than 2016 ASE/EACVI algorithms in AF.

CONCLUSION

In patients with AF, LA strain parameters could be useful to predict elevated LAP and non-inferior to conventional echocardiographic parameters. Besides, the novel algorithm built by LA strain parameters combined with conventional parameters would improve the diagnostic efficiency.

Arrhythmogenesis in Fabry Disease

PURPOSE OF REVIEW

Fabry Disease (FD) is a rare lysosomal storage disorder characterised by multiorgan accumulation of glycosphingolipid due to deficiency in the enzyme α-galactosidase A. Cardiac sphingolipid accumulation triggers various types of arrhythmias, predominantly ventricular arrhythmia, bradyarrhythmia, and atrial fibrillation. Arrhythmia is likely the primary contributor to FD mortality with sudden cardiac death, the most frequent cardiac mode of death. Traditionally FD was seen as a storage cardiomyopathy triggering left ventricular hypertrophy, diastolic dysfunction, and ultimately, systolic dysfunction in advanced disease. The purpose of this review is to outline the current evidence exploring novel mechanisms underlying the arrhythmia substrate.

RECENT FINDINGS

There is growing evidence that FD cardiomyopathy is a primary arrhythmic disease with each stage of cardiomyopathy (accumulation, hypertrophy, inflammation, and fibrosis) contributing to the arrhythmia substrate via various intracellular, extracellular, and environmental mechanisms. It is therefore important to understand how these mechanisms contribute to an individual's risk of arrhythmia in FD. In this review, we outline the epidemiology of arrhythmia, pathophysiology of arrhythmogenesis, risk stratification, and cardiac therapy in FD. We explore how advances in conventional cardiac investigations performed in FD patients including 12-lead electrocardiography, transthoracic echocardiography, and cardiac magnetic resonance imaging have enabled early detection of pro-arrhythmic substrate. This has allowed for appropriate risk stratification of FD patients. This paves the way for future work exploring the development of therapeutic initiatives and risk prediction models to reduce the burden of arrhythmia.

Left Atrium: A New Prognostic Marker and Therapeutic Target in Secondary Mitral Regurgitation?

Mitral regurgitation (MR) is one of the most common valvular abnormalities worldwide and can be subdivided into primary and secondary causes. Atrial MR consists of a novel type of secondary MR (SMR), most often observed in patients with AF and heart failure with preserved ejection fraction. The main pathophysiological mechanism of atrial MR is mitral valve annular dilatation. Recently published studies have highlighted the clinical significance of left atrium (LA) evaluation in the early diagnosis and prognosis of patients with primary MR. However, there are little data regarding the role of the LA in SMR. The present literature review aims to elucidate the use of the echocardiographic parameters regarding LA evaluation in the prognosis prediction and therapeutic strategy of patients with SMR.

Alterations in Left Atrial Strain in Breast Cancer Patients Immediately Post Anthracycline Exposure

AIMS

With improved diagnosis and treatments, a greater percentage of breast cancer patients are achieving long-term survival. Consequently, long-term cardiotoxicity secondary to chemotherapy has become more prevalent, warranting improved cardiac surveillance. We evaluated changes in left atrial (LA) strain in breast cancer patients immediately post anthracycline (AC) therapy to assess its utility as a marker of diastolic dysfunction.

METHODS

This was a prospective cohort study of 128 consecutive human epidermal growth factor receptor 2 (HER2)-negative breast cancer patients who underwent transthoracic echocardiography prior to and immediately post AC treatment. Traditional left ventricular (LV) systolic and diastolic parameters and LA volumes were evaluated; additionally, LV global longitudinal strain (LV GLS) and LA phasic strain were measured.

RESULTS

All patients had normal LV ejection fraction (>53%) post AC, though LV GLS was significantly reduced. Peak E and é velocities were reduced post AC, with no change in LA volumes. LA reservoir strain (LASRES 34.8% vs 31.5%, p<0.001) and conduit strain (LASCD 17.2% vs 14.4%, p<0.001) were significantly lower post AC and correlated modestly with LV diastolic parameters. Reduction in LA strain post AC was evident even in patients with preserved LV systolic and diastolic function. More patients demonstrated alteration in diastolic function (≥15% reduction in LASRES from baseline) (32%) compared to alteration in systolic function (≥15% reduction in LV GLS) (23%).

CONCLUSIONS

LA strain is a promising marker of early diastolic dysfunction. We demonstrate its potential utility in surveillance of breast cancer patients treated with AC.

Incremental diagnostic and prognostic utility of left atrial deformation in heart failure using speckle tracking echocardiography

Left atrium (LA) is a very important component of cardiovascular performance. The assessment of LA function has gathered the interest with expanding research supporting the utility as a biomarker for outcomes in heart failure (HF). Echocardiography is the main imaging modality which helps in a qualitative and quantitative assessment of the LA size and function. Recent advances in probe technology and software analysis have provided a better understanding of LA anatomy, physiology, pathology, and function. A variety of parameters have been defined as markers of LA function but there is no single parameter that best defines LA function. Speckle tracking echocardiography-derived analysis of LA deformation provides a window on all phases of LA function (reservoir, conduit, and booster pump). There is accumulative published data that supported the diagnostic and prognostic values of LA deformation integration during echo assessment of LA in HF. This review article summarized the clinical utility of LA deformation that may help in prediction, diagnosis, categorization, risk stratification, and guiding the proper selection of therapy in HF patients in daily practice.

Effect of volume infusion on left atrial strain in acute circulatory failure

BACKGROUND

Left atrial strain (LAS) is a measure of atrial wall deformation during cardiac cycle and reflects atrial contribution to cardiovascular performance. Pathophysiological significance of LAS in critically ill patients with hemodynamic instability has never been explored. This study aimed at describing LAS and its variation during volume expansion and to assess the relationship between LAS components and fluid responsiveness.

METHODS

This prospective observational study was performed in a French ICU and included patients with acute circulatory failure, for whom the treating physician decided to proceed to volume expansion (rapid infusion of 500 mL of crystalloid solution). Trans-thoracic echocardiography was performed before and after the fluid infusion. LAS analysis was performed offline. Fluid responsiveness was defined as an increase in velocity-time integral (VTI) of left ventricular outflow tract ≥ 10%.

RESULTS

Thirty-eight patients were included in the final analysis. Seventeen (45%) patients were fluid responders. LAS analysis had a good feasibility and reproducibility. Overall, LAS was markedly reduced in all its components, with values of 19 [15 - 32], -9 [-19 - -7] and - 9 [-13 - -5] % for LAS reservoir (LASr), conduit (LAScd) and contraction (LASct), respectively. LASr, LAScd and LASct significantly increased during volume expansion in the entire population. Baseline value of LAS did not predict fluid responsiveness and the changes in LAS and VTI during volume expansion were not significantly correlated.

CONCLUSIONS

LAS is severely altered during acute circulatory failure. LAS components significantly increase during fluid administration, but cannot be used to predict or assess fluid responsiveness.

Left Atrial Function in Patients with Titin Cardiomyopathy

BACKGROUND

Truncating variants in titin (TTNtv) are the most prevalent genetic etiology of dilated cardiomyopathy (DCM). Although TTNtv has been associated with atrial fibrillation, it remains unknown whether and how left atrial (LA) function differs between patients with DCM with and without TTNtv. We aimed to determine and compare LA function in patients with DCM with and without TTNtv and to evaluate whether and how left ventricular (LV) function affects the LA using computational modeling.

METHODS AND RESULTS

Patients with DCM from the Maastricht DCM registry that underwent genetic testing and cardiovascular magnetic resonance (CMR) were included in the current study. Subsequent computational modeling (CircAdapt model) was performed to identify potential LV and LA myocardial hemodynamic substrates. In total, 377 patients with DCM (n = 42 with TTNtv, n = 335 without a genetic variant) were included (median age 55 years, interquartile range [IQR] 46-62 years, 62% men). Patients with TTNtv had a larger LA volume and decreased LA strain compared with patients without a genetic variant (LA volume index 60 mLm-2 [IQR 49-83] vs 51 mLm-2 [IQR 42-64]; LA reservoir strain 24% [IQR 10-29] vs 28% [IQR 20-34]; LA booster strain 9% [IQR 4-14] vs 14% [IQR 10-17], respectively; all P < .01). Computational modeling suggests that while the observed LV dysfunction partially explains the observed LA dysfunction in the patients with TTNtv, both intrinsic LV and LA dysfunction are present in patients with and without a TTNtv.

CONCLUSIONS

Patients with DCM with TTNtv have more severe LA dysfunction compared with patients without a genetic variant. Insights from computational modeling suggest that both intrinsic LV and LA dysfunction are present in patients with DCM with and without TTNtv.

Analysis of bi-atrial function using CMR feature tracking and long-axis shortening approaches in patients with diastolic dysfunction and atrial fibrillation

OBJECTIVES

Atrial function can be assessed using advancing cardiovascular magnetic resonance (CMR) post-processing methods: atrial feature tracking (FT) strain analysis or a long-axis shortening (LAS) technique. This study aimed to first compare the two FT and LAS techniques in healthy individuals and cardiovascular patients and then investigated how left (LA) and right atrial (RA) measurements are related to the severity of diastolic dysfunction or atrial fibrillation.

METHODS

Sixty healthy controls and 90 cardiovascular disease patients with coronary artery disease, heart failure, or atrial fibrillation, underwent CMR. LA and RA were analyzed for standard volumetry as well as for myocardial deformation using FT and LAS for the different functional phases (reservoir, conduit, booster). Additionally, ventricular shortening and valve excursion measurements were assessed with the LAS module.

RESULTS

The measurements for each of the LA and RA phases were correlated (p < 0.05) between the two approaches, with the highest correlation coefficients occurring in the reservoir phase (LA: r = 0.83, p < 0.01, RA: r = 0.66, p < 0.01). Both methods demonstrated reduced LA (FT: 26 ± 13% vs 48 ± 12%, LAS: 25 ± 11% vs 42 ± 8%, p < 0.01) and RA reservoir function (FT: 28 ± 15% vs 42 ± 15%, LAS: 27 ± 12% vs 42 ± 10%, p < 0.01) in patients compared to controls. Atrial LAS and FT decreased with diastolic dysfunction and atrial fibrillation. This mirrored ventricular dysfunction measurements.

CONCLUSION

Similar results were generated for bi-atrial function measurements between two CMR post-processing approaches of FT and LAS. Moreover, these methods allowed for the assessment of incremental deterioration of LA and RA function with increasing left ventricular diastolic dysfunction and atrial fibrillation. A CMR-based analysis of bi-atrial strain or shortening discriminates patients with early-stage diastolic dysfunction prior to the presence of compromised atrial and ventricular ejection fractions that occur with late-stage diastolic dysfunction and atrial fibrillation.

KEY POINTS

• Assessing right and left atrial function with CMR feature tracking or long-axis shortening techniques yields similar measurements and could potentially be used interchangeably based on the software capabilities of individual sites. • Atrial deformation and/or long-axis shortening allow for early detection of subtle atrial myopathy in diastolic dysfunction, even when atrial enlargement is not yet apparent. • Using a CMR-based analysis to understand the individual atrial-ventricular interaction in addition to tissue characteristics allows for a comprehensive interrogation of all four heart chambers. In patients, this could add clinically meaningful information and potentially allow for optimal therapies to be chosen to better target the dysfunction.

Coronary artery disease is associated with impaired atrial function regardless of left ventricular filling pressure

BACKGROUND

Left atrial (LA) strain is impaired in left ventricular (LV) diastolic dysfunction, associated with increased LV end diastolic pressure (LVEDP). In patients with preserved LV ejection fraction (LVEF), coronary artery disease (CAD) is known to impair LV diastolic function. The relationship of LVEDP with CAD and impact on LA strain is not well studied.

METHODS AND RESULTS

Patients with LVEF >50% (n = 37, age 61 ± 7 years) underwent coronary angiography, high-fidelity LV pressure measurements and cardiac magnetic resonance imaging. LA volumes, LA emptying fraction (LAEF), LA reservoir strain (LARS) and LA long-axis shortening (LALAS) were measured. By coronary angiography, patients were assigned into 3 groups: severe-CAD (n = 19, with obstruction of major coronary arteries >70% and/or history of coronary revascularization), mild-to-moderate-CAD (n = 10, obstruction of major coronary arteries 30-60%), and no-CAD (n = 8, obstruction of major coronary arteries and branches <30%). Overall, LVEF was 65 ± 8% and LVEDP was 14.4 ± 5.6 mmHg. Clinical characteristics, LVEDP and LV function measurements were similar in 3 groups. Severe-CAD group had lower LAEF, LALAS and LARS than those in no-CAD group (P < 0.05 all). In regression analysis, LARS and LALAS were associated with CAD severity and treatment with Nitrates, whereas LAEF and LAEFactive were associated with CAD severity, treatment with Nitrates and LA minimum volume (P < 0.05 all). LAEFpassive was associated with LVED volume (P < 0.05).

CONCLUSIONS

LA functional impairment may be affected by coexistent CAD severity, medications, in particular, Nitrates, and loading conditions, which should be considered when assessing LA function and LA-LV interaction. Our findings inspire exploration in a larger cohort.

Echocardiographic Evaluation of Diastolic Function in Special Populations

Left ventricular (LV) diastolic dysfunction results from a combination of impaired relaxation, reduced restoring forces, and increased chamber stiffness. Noninvasive assessment of diastology uses a multiparametric approach involving surrogate markers of increased filling pressures, which include mitral inflow, septal and lateral annular velocities, tricuspid regurgitation velocity, and left atrial volume index. However, these parameters must be used cautiously. This is because the traditional algorithms for evaluating diastolic function and estimation of LV filling pressures (LVFPs), as recommended by the American Society of Echocardiography and European Association of Cardiovascular Imaging 2016 guidelines, do not apply to unique patients with underlying cardiomyopathies, significant valvular disease, conduction abnormalities, arrhythmias, LV assist devices, and heart transplants, which alter the relation between the conventional indexes of diastolic function and LVFP. The purpose of this review is to provide solutions for evaluating LVFP through illustrative examples of these special populations, incorporating supplemental Doppler indexes, such as isovolumic relaxation time, mitral deceleration time, and pulmonary venous flow analysis, as needed to formulate a more comprehensive approach.

The effect of urgent blood pressure reduction on left atrial strain in patients with hypertensive attack : Blood pressure lowering affects LA strain

BACKGROUND

Left atrial (LA) strain is a robust measure of LA function and is a useful parameter to assess left ventricular filling pressure. While initially considered as a "load-independent" parameter of LA function, later studies have found that acute changes in LA preload may affect LA reservoir and contractile strains. Acute alterations in blood pressure (BP) induces a change in left ventricular (LV) filling pressure without imposing a volume load, thus providing an opportunity to assess the effects of the change in LA afterload on LA mechanics. This study aims to understand the effect of acute BP changes on LA strain.

METHODS

A total of 40 patients admitted to the emergency department with hypertensive urgency were included. All patients underwent a comprehensive echocardiographic examination including measurement of LA reservoir, conduit and contractile strains. A repeat set of measurements were obtained after BP lowering.

RESULTS

Average drop in mean BP following intervention was 18.1 ± 5.4%. LV end-systolic and end-diastolic volumes, as well as maximum and minimum LA volumes were decreased significantly after BP reduction. The absolute increases in reservoir and contractile strains were 2.3 ± 4.7% (7.9% ± 13.8% relative to baseline) and 2.5 ± 3.3% (13.5 ± 19.0% relative to baseline), respectively, with both changes being statistically significant (p = 0.003 for reservoir and p < 0.001 for contractile strains). There were no significant changes in conduit strain after BP intervention (p = 0.79). The change in both LA reservoir and contractile strains were more evident in those with a previous diagnosis of hypertension and those with a smaller degree of change in mean BP after intervention.

CONCLUSION

In patients with an acute hypertension, lowering BP leads to an acute improvement in LA reservoir and contractile strains. Thus, acute changes in systemic BP should be considered when LA mechanics are evaluated.

Functional outcomes in post Covid-19 patients with persistent dyspnea: multidisciplinary approach

BACKGROUND

Post-acute sequelae of SARS-CoV-2 (PASC) have emerged as a major health issue in patients who have previously been infected with Covid-19 virus.

PURPOSE

we aimed at the assessment of functional outcomes in post Covid-19 patients with persistent dyspnea using a multidisciplinary approach including clinical assessment, laboratory investigations, exercise ECG, and different echo-Doppler modalities, including left atrial functions.

METHODS

The current observational randomized controlled study conducted on 60- patients one month after recovery from Covid-19 infection presented with persistent dyspnea compared to 30 healthy volunteers. All participants were subjected to evaluation of dyspnea by different scores, laboratory investigations, stress ECG, and echo-Doppler examination to measure LV dimensions, volumes, systolic and diastolic functions by M-mode, 2D, and tissue Doppler imaging in addition to 2-D speckle tacking LA strain.

RESULTS

Post Covid-19 patients had persistent elevation of inflammatory markers, low functional capacity (evidenced by a higher NYHA class, m MRC score, PCFS scale) and decreased METs by stress ECG compared to control group. Post Covid-19 patients showed LV diastolic dysfunction and impairment of 2D-STE LA functions compared to control group. We found negative correlations between LA strain with NYHA class, mMRC scale, LAVI, ESR and CRP; meanwhile, there were significant positive correlations between LA strain with exercise duration and METs.

CONCLUSION

post Covid patients presented with persistent dyspnea demonstrated low functional capacity evidenced by different scores and stress ECG. Moreover, patients with post Covid syndrome showed elevated inflammatory biomarkers, LV diastolic dysfunction in addition to impaired LA strain functions. Impairment of LA strain was closely correlated to different functional scores, inflammatory biomarkers, exercise duration, and METs suggesting that these could to be the possible etiologies for the persistence of post Covid symptoms.

Left Atrial Strain in the Assessment of Diastolic Function in Heart Failure: A Machine Learning Approach

BACKGROUND

Diastolic dysfunction (DD) assessment in heart failure is still challenging. Peak atrial longitudinal strain (PALS) is strongly related to end-diastolic pressure and prognosis, but it is still not part of standard DD assessment. We tested the hypothesis that a machine learning approach would be useful to include PALS in DD classification and refine prognostic stratification.

METHODS

In a derivation cohort of 864 heart failure patients in sinus rhythm (age, 66.6±12 years; heart failure with reduced ejection fraction, n=541; heart failure with mildly reduced ejection fraction, n=129; heart failure with preserved ejection fraction, n=194), machine learning techniques were retrospectively applied to PALS and guideline-recommended diastolic variables. Outcome (death/heart failure rehospitalization) of the identified DD-clusters was compared with that by guidelines-based classification. To identify the best combination of variables able to classify patients in one of the identified DD-clusters, classification and regression tree analysis was applied (with DD-clusters as dependent variable and PALS plus guidelines-recommended diastolic variables as explanatory variables). The algorithm was subsequently validated in a prospective cohort of 189 heart failure outpatients (age, 65±13 years).

RESULTS

Three distinct echocardiographic DD-clusters were identified (cluster-1, n=212; cluster-2, n=376; cluster-3 DD, n=276), with modest agreement with guidelines-recommended classification (kappa=0.40; P<0.001). DD-clusters were predicted by a simple algorithm including E/A ratio, left atrial volume index, E/e' ratio, and PALS. After 36.5±29.4 months follow-up, 318 events occurred. Compared to guideline-based classification, DD-clusters showed a better association with events in multivariable models (C-index 0.720 versus 0.733, P=0.033; net reclassification improvement 0.166 [95% CI, 0.035-0.276], P=0.013), without interaction with ejection fraction category. In the validation cohort (median follow-up: 18.5 months), cluster-based classification better predicted outcome than guideline-based classification (C-index 0.80 versus 0.78, P=0.093).

CONCLUSIONS

Integrating PALS by machine learning algorithm in DD classification improves risk stratification over recommended current criteria, regardless of ejection fraction status. This proof of concept study needs further validation of the proposed algorithm to assess generalizability to other populations.

Decreased left atrial function in obesity patients without known cardiovascular disease

Obesity is a risk factor for heart failure with preserved ejection fraction (HFpEF). We hypothesized that assessment of left atrial (LA) strain may be useful to reveal precursors of HFpEF in obesity patients. Echocardiograms of obesity patients without known cardiovascular disease who underwent bariatric surgery, and echocardiograms of age- and gender matched controls were analyzed. The echocardiogram was repeated 1 year after bariatric surgery. LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were measured. 77 Obesity patients were compared with 46 non-obese controls. Obesity patients showed a significantly decreased LA function compared with non-obese individuals (LASr 32.2% ± 8.8% vs. 39.6% ± 10.8%, p < 0.001; LAScd 20.1% ± 7.5% vs. 24.9% ± 8.3%, p = 0.001; LASct 12.1% ± 3.6% vs. 14.5% ± 5.5%, p = 0.005). There was no difference in prevalence of diastolic dysfunction between the obesity group and controls (9.1% vs. 2.2%, p = 0.139). One year after bariatric surgery, LASr improved (32.1% ± 8.9% vs. 34.2% ± 8.7%, p = 0.048). In the multivariable linear regression analysis, BMI was associated with LASr, LAScd, and LASct (β =  - 0.34, CI - 0.54 to - 0.13; β =  - 0.22, CI - 0.38 to - 0.06; β =  - 0.10, CI - 0.20 to - 0.004). Obesity patients without known cardiovascular disease have impairment in all phases of LA function. LA dysfunction in obesity may be an early sign of cardiac disease and may be a predictor for developing HFpEF. LASr improved 1 year after bariatric surgery, indicating potential reversibility of LA function in obesity.

Conventional and two-dimensional strain echocardiography in predicting postoperative atrial fibrillation after coronary artery bypass grafting surgery

Background

Atrial fibrillation (AF) is a common complication after heart surgeries. Advances in imaging technologies and an understanding of the pathophysiology of preoperative left atrial (LA) dysfunction can lead to more definitive potential therapeutic approaches. This study aimed to determine the role of conventional echocardiography and LA two-dimensional (2D) strain echocardiography in assessing LA function and predicting POAF after CABG surgery.

Methods

All patients with sinus rhythm who underwent CABG surgery were enrolled. All the patients had undergone conventional echocardiography and LA 2D-strain echocardiography 24 hours before surgery. In addition to demographic, clinical, and perioperative features, electrocardiogram (ECG) and Holter monitoring were recorded.

Results

Of the 105 patients included, 85 patients (81%) were men with a mean age of 60.26±10.61 years. POAF was seen in 22.9% of patients during hospitalization, and AF duration was 10 hours (median; IQR: 2.0-19.5). AF patients had a higher LA volume index (LAVI) than patients with sinus rhythm (p=0.018). Patients with sinus rhythm had higher rates of LA reservoir (26.97±6.87 VS. 20.46±4.27, p<0.001), LA contractile (14.98±3.68 VS. 12.76±3.72, p =0.012) and LA global strain (24.28±6.57 VS. 17.71±4.11, p<0.001) than AF patients. The results of the multivariate logistic regression showed that LAVI (p=0.014) and LA global strain (p=0.027) were independent predictors of AF detection.

Conclusion

Compared to conventional echocardiography, 2D-strain echocardiography is a more effective diagnostic method to predict the possibility of post-CABG AF.

Left Atrial Strain for Assessment of Left Ventricular Diastolic Function: Focus on Populations with Normal LVEF

Left atrial (LA) strain has emerged as a useful parameter for the assessment of left ventricular (LV) diastolic function and the estimation of LV filling pressures. Some have advocated using LA strain by itself, mainly reservoir strain, as a single stand-alone measurement for this objective. Recent data indicate several challenges for this application in patients with normal left ventricular ejection fraction (LVEF) because of the wide range for normal values and the load dependency of LA strain. Both findings can result in reduced left atrial reservoir strain (LARS) values in normal subjects that overlap those seen in patients with diastolic dysfunction. LARS for the estimation of LV filling pressures is most accurate in patients with depressed LVEF. It is less accurate in patients with normal ejection fraction. In this group of patients, LARS <18% has high specificity for increased LV filling pressures. There are promising data showing the association of LARS with outcome events in patients with normal ejection fraction, and additional data are needed to confirm that it provides incremental information over clinical and other echocardiographic measurements.

Clinical Utility of Three-Dimensional Speckle-Tracking Echocardiography in Heart Failure

Heart failure (HF) is an extremely major health problem with gradually increasing incidence in developed and developing countries. HF may lead to cardiac remodeling; thus, advanced imaging techniques are required to comprehensively evaluate cardiac mechanics. Recently, three-dimensional speckle-tracking echocardiography (3D-STE) has been developed as a novel imaging technology that is based on the three-dimensional speckle-tracking on the full volume three-dimensional datasets. Three-dimensional speckle-tracking echocardiography allows a more accurate evaluation of global and regional myocardial performance, assessment of cardiac mechanics, detection of subclinical cardiac dysfunction, and prediction of adverse clinical events in a variety of cardiovascular diseases. Therefore, this review summarizes the clinical usefulness of 3D-STE in patients with HF.

The validation of left atrial strain imaging for the assessment of diastolic functions in patients with ST-segment elevation myocardial infarction

Assessment of left ventricular filling pressure (LVFP) is crucial in patients with ST-segment elevation myocardial infarction (STEMI). Since current guideline recommended echocardiographic parameters have limited value, more comprehensive assessment methods are required in this patient subset.In this study, we aimed to investigate the clinical utility of left atrial reservoir strain (LARS) imaging in patients treated with primary percutaneous coronary intervention (pPCI). Patients who underwent successful pPCI were included. Left ventricular end-diastolic pressure (LVEDP) was measured invasively following pPCI. Left atrial strain imaging was performed following pPCI within 24 h of pPCI. Normal LARS value was accepted as above 23%. We prospectively enrolled 69 patients; there were 18 patients with LARS below 23% who were included into group 1 and rest of the study population included into group 2. There was no significant difference between groups in terms of comorbidities.Troponin and pro-BNP levels were significantly higher in group 1 (p: 0.036 and 0.047 respectively). Left atrial volume and tricuspid regurgitation velocity were similar between groups (p: 0.416 and p: 0.351 respectively). Septal tissue velocity was higher (p: 0.001) and Septal E/e' ratio was lower (p: 0.004) in group 2. Left ventricular (LV) global longitudinal strain value was higher in group 1 which is consistent with observed lower ejection (LVEF) fraction in group 1 (p: 0.001 for LV strain and p: 0.001 for LVEF). Estimated mean LVFP was also higher in group 1 (p: 0.003).Correlation analyses revealed moderate correlation between LARS and LVEDP (r: - 0.300). Our results indicate that left atrial strain imaging is a promising tool for the assessment of left atrial pressure in patients with STEMI.

The impact of lifestyle intervention on left atrial function in type 2 diabetes: results from the DIASTOLIC study

Aerobic exercise training and low energy diets have been shown to improve left ventricular remodelling and diastolic function in adults with type 2 diabetes (T2D), albeit with differential effects. The impact of these lifestyle interventions on left atrial (LA) function, however, has not previously been reported. The DIASTOLIC study was a prospective, randomised, open-label, blind endpoint trial, in which 90 people with obesity and T2D and no prevalent cardiovascular disease were randomised to a 12-week intervention of: (i) routine care, (ii) aerobic exercise training, or (iii) low energy (≈ 810 kcal/day) meal replacement plan (MRP). Cardiac magnetic resonance (CMR) imaging was performed pre- and post-intervention. Image analysis included LA volumes (LAV), emptying fraction (LAEF), and LA strain (LAS) corresponding to LA reservoir (LAS-r), conduit (LAS-cd), and booster pump (LAS-bp) function. 73 participants with T2D (mean age 50 ± 6 years, 62% male, body mass index (BMI) 36.1 ± 5.3 kg/m2) completed the trial and had analysable LA images. There was no significant change in CMR measured LA volumetric function (LAV/LAEF) in any group. The routine care group showed no significant change in BMI or LAS. In the MRP group, there were significant reductions in BMI (4.5 kg/m2) and a significant increase in LAS-r and LAS-bp (29.9 ± 7.0 to 32.3 ± 7.0%, p = 0.036 and 14.6 ± 5.3 to 17.2 ± 3.7%, p = 0.034). The exercise group showed a small reduction in BMI (0.49 kg/m2), with no significant change in LAS. Compared to routine care, weight loss via a 12-week MRP, led to improvements in LA filling and contractile function in adults with T2D and obesity. However, these within-group changes were not statistically significant on between-group comparison. ClinicalTrials.gov Identifier: NCT02590822.

Left Atrial Reservoir Strain-Based Left Ventricular Diastolic Function Grading and Incident Heart Failure in Hypertrophic Cardiomyopathy

BACKGROUND

The echocardiographic assessment of left ventricular (LV) diastolic dysfunction (LVDD) in patients with hypertrophic cardiomyopathy is complex and not well-established. We investigated whether the left atrial reservoir strain (LARS) could be used to categorize LVDD and whether this grading is predictive of heart failure (HF) events in hypertrophic cardiomyopathy.

METHODS

A total of 414 patients with hypertrophic cardiomyopathy (aged 58.3±12.8 years; 65.7% male) were categorized using LARS-defined LVDD (LARS-DD) grades: ≥35% (grade 0), ≥24% to <35%, ≥19% to <24%, and <19% (grade 3). Patients were followed for a median of 6.9 years to assess hospitalization for HF or HF-related death.

RESULTS

An increase in LARS-DD grade was associated with worse conventional echocardiographic parameters of LVDD, such as lower e', higher E/e' ratio, greater maximum tricuspid regurgitation velocity, and restrictive mitral inflow pattern. Higher LARS-DD grade was also associated with parameters reflecting increased LV filling pressure, such as greater LV wall thickness, greater extent of fibrosis, obstructive physiology, and decreased LV longitudinal strain. Furthermore, higher LARS-DD grade was associated with worse HF-free survival (log-rank P<0.001). Patients with LARS-DD grades 0, 1, 2, and 3 showed 10-year HF-free survival of 100%, 91.6%, 84.1%, and 67.5%, respectively. LARS-DD grade was an independent predictor of HF events after adjusting for clinical and echocardiographic variables (hazard ratio, 1.53 [95% CI, 1.03-2.28], per 1-grade increase). The LARS-DD grade also had incremental prognostic value for incident HF events over the traditional echocardiographic LVDD parameters and grading system. The prognostic value of advanced LARS-DD grade was consistent in sensitivity analyses and various patient subgroups.

CONCLUSIONS

LARS can be used as a simple single or supplemental index to categorize LV diastolic function and predict HF events in hypertrophic cardiomyopathy.

A systematic review and meta-analysis of the normal reference value of the longitudinal left atrial strain by three dimensional speckle tracking echocardiography

The normal reference value of the global longitudinal left atrial strain during the reservoir phase (LASr) by 3D speckle-tracking echocardiography (3DSTE) is needed to define the abnormal and normal spectra and to compare and interpret the obtained values. The present study is a meta-analysis of 3DSTE-derived normal reference value of the longitudinal LASr and an attempt to determine probable contributing factors in the variations of reported ranges. The databases of PubMed, Scopus, and Embase were searched for the following keywordS: "Left atrial/left atrium" and "strain/speckle/deformation" and "three-dimensional/3-dimensional/three dimensional/3 dimensional/three dimension/3 dimension/three-dimension/3-dimension/3D/3-D". The studies selected included those on adult healthy subjects without cardiovascular risk factors. A random-effect model was used to calculate the global 3DSTE-derived longitudinal LASr, and meta-regression was applied to determine inter-study heterogeneity. Our search yielded 316 adult subjects from 5 studies. The mean value of the global 3DSTE-derived longitudinal LASr was 27.5% (95% CI, 25.2-29.8%). There was significant heterogeneity between the studies. The meta-regression analysis revealed the publication year, the heart rate, and systolic and diastolic blood pressure as the sources of heterogeneity. The current meta-analysis determined a normal reference value of the global 3DSTE-derived longitudinal LASr of 27.5% (95% CI, 25.2-29.8%). The heterogeneity between studies may be explained by the publication year, the heart rate, and systolic and diastolic blood pressure.

The novel left atrial strain parameters in diagnosing of heart failure with preserved ejection fraction

Objectives

We sought to evaluate the ability of the novel LA strain parameters to discriminate patients with heart failure with preserved ejection fraction (HFpEF) from individuals with risk factors of HFpEF.

Methods and results

A total of n = 389 patients with risk factors for HFpEF finally was prospectively enrolled into the study, 66 of them were diagnosed with HFpEF by the 2021 ESC HF guidelines. Fifty‐five patients were undergone left ventricular catheterization and simultaneous transthoracic echocardiography was performed, 35 of them with elevated left ventricular end‐diastolic pressure (LVEDP). Left atrial reservoir strain (LASr) was measured in all patients. LA filling index was defined as the ratio of mitral E and LASr and LA stiffness index was calculated as E/e′/LASr. Compared with the patients in the normal LVEDP subgroup, those in the elevated LVEDP subgroup showed significantly higher LA filling index, LA stiffness index, and LAVI/LASr. The receiver‐operating characteristic curve (ROC) analysis showed LASr (area under curve [AUC] .840), LA filling index (AUC .843), LA stiffness index (AUC .766), and LAVI/LASr (AUC .755) had good diagnostic accuracy for elevated LVEDP. Inter‐technique agreement analysis showed the novel algorithms with LA strain parameters had good agreement with the invasive LVEDP measurement, better than the 2016 ASE/SCAI algorithms (kappa .711 vs. .101). Furthermore, compared with patients without HFpEF, LASr was lower in HFpEF, LA filling index, LA stiffness index, and LAVI/LASr was higher in patients with HFpEF. ROC analysis showed the novel LA strain parameters with good accuracy (AUC .756 to .821) non‐inferior to conventional echocardiographic parameters could identify HFpEF, and LA stiffness index (AUC .821) was the best one.

Conclusion

The novel LA strain parameters could be of potential usefulness in estimating LVEDP and incorporated into the 2016 EACVI/ASE criteria would improve the diagnostic efficiency. The novel LA strain parameters with good accuracy non‐inferior to conventional echocardiographic parameters could discriminate HFpEF from patients with risk factors of HFpEF.

Determinants of the Volumetric Markers of Left Atrial Contraction Function in Coronary Artery Disease: A Cross-sectional Study

BACKGROUND

A body of research advocates the prognostic role and usefulness of the volumetric markers of left atrial (LA) phasic functions in the diagnosis of LA dysfunction. We aimed to determine the independent determinants of the volumetric markers of LA contraction function in candidates for coronary artery bypass graft (CABG) surgery.

METHODS

This cross-sectional study enrolled 516 candidates for CABG. The biplane maximal, minimal, and pre-P volumes of the LA were measured with two-dimensional echocardiography, and LA active emptying fraction was calculated. The standardized correlation coefficient for the correlation between each factor and LA active emptying fraction was calculated by using univariate and backward multivariable regression analyses.

RESULTS

The multivariable regression analysis demonstrated that the heart rate (β = 0.15; p = 0.001), S (β = 0.09; p = 0.036), E/e′ ratio (β = −0.11; p = 0.014), left ventricle (LV) ejection fraction (β = 0.15; p = 0.001), and LA enlargement (β = −0.19; p < 0.001) were the independent determinants of LA active emptying fraction.

CONCLUSIONS

The independent determinants of LA contraction function were the heart rate, S, LV ejection fraction, LA enlargement, and E/e′ ratio in candidates for CABG surgery.

Automated left atrial strain analysis for predicting atrial fibrillation in severe COVID-19 pneumonia: a prospective study

BACKGROUND

Atrial fibrillation (AF) is the most documented arrhythmia in COVID-19 pneumonia. Left atrial (LA) strain (LAS) analysis, a marker of LA contractility, have been associated with the development of AF in several clinical situations. We aimed to assess the diagnostic ability of LA strain parameters to predict AF in patients with severe hypoxemic COVID-19 pneumonia. We conducted a prospective single center study in Amiens University Hospital intensive care unit (ICU) (France). Adult patients with severe or critical COVID-19 pneumonia according to the World Health Organization definition and in sinus rhythm were included. Transthoracic echocardiography was performed within 48 h of ICU admission. LA strain analysis was performed by an automated software. The following LA strain parameters were recorded: LA strain during reservoir phase (LASr), LA strain during conduit phase (LAScd) and LA strain during contraction phase (LASct). The primary endpoint was the occurrence of AF during ICU stay.

RESULTS

From March 2020 to February of 2021, 79 patients were included. Sixteen patients (20%) developed AF in ICU. Patients of the AF group were significantly older with a higher SAPS II score than those without AF. LAScd and LASr were significantly more impaired in the AF group compared to the other group (- 8.1 [- 6.3; - 10.9] vs. - 17.2 [- 5.0; - 10.2] %; P < 0.001 and 20.2 [12.3;27.3] % vs. 30.5 [23.8;36.2] %; P = 0.002, respectively), while LASct did not significantly differ between groups (p = 0.31). In a multivariate model, LAScd and SOFA cv were significantly associated with the occurrence of AF. A LAScd cutoff value of - 11% had a sensitivity of 76% and a specificity of 75% to identify patients with AF. The 30-day cumulative risk of AF was 42 ± 9% with LAScd > - 11% and 8 ± 4% with LAScd ≤ - 11% (log rank test P value < 0.0001).

CONCLUSION

For patients with severe COVID-19 pneumonia, development of AF during ICU stay is common (20%). LAS parameters seem useful in predicting AF within the first 48 h of ICU admission.

TRIAL REGISTRATION

NCT04354558.

Left atrial reservoir strain provides incremental value to left atrial volume index for evaluation of left ventricular filling pressure

BACKGROUND

Left atrial analysis is employed in diastolic assessment with left atrial volume index (LAVI) incorporated in the 2016 ASE/EACVI diastology guideline algorithm. LAVI has sub-optimal correlation with invasive left ventricular filling pressure (LVFP) and incorporation of left atrial reservoir strain (LASr) may improve diastolic assessment.

METHODS

A cross-sectional prospective study of 139 patients was undertaken with all patients undergoing transthoracic echocardiography immediately prior to cardiac catheterization with invasive evaluation of LVFP. LASr by speckle tracking echocardiography and conventional echocardiographic parameters were assessed in relation to invasive LVFP. Modification of the 2016 guideline algorithm was performed with incorporation of LASr in place of LAVI (LASr ≤23% indicating elevated LVFP). Accuracy of the modified and conventional algorithm were assessed for predicting invasive LVFP.

RESULTS

The mean age was 63±12 years with 27% female. LASr demonstrated superior correlation and receiver operator characteristic for predicting LVFP than LAVI (LASr: r -.46 (p < 0.01), AUC: .82 vs LAVI: r .19 (p 0.02), AUC: .66). LASr of ≤23% was the optimal cut-off for discriminating elevated LVFP (sensitivity 80%, specificity 77%). Modification of the 2016 algorithm with incorporation of LASr in place of LAVI reclassified 12% of the patient cohort and improved concordance of echocardiographic and invasive LVFP assessment (modified algorithm κ .47 vs 2016 algorithm κ: .33). No patients were incorrectly reclassified by modified algorithm assessment.

CONCLUSIONS

LASr better predicts invasive LVFP than LAVI. Modification of the 2016 guideline algorithm with incorporation of LASr in place of LAVI improves accuracy of echocardiographic assessment of LVFP.

Multi-modality assessment and role of left atrial function as an imaging biomarker in cardiovascular disease

The left atrium (LA) plays a vital role in maintaining normal cardiac function. LA volume and function have been utilised as important imaging biomarkers, with their prognostic value demonstrated in multiple cardiac conditions. More recently, there has been a sharp increase in the number of publications utilising LA strain by echocardiography and cardiac magnetic resonance (CMR) imaging. However, little is known about its prognostic value or reproducibility as a technique. In this review, we aim to highlight the conventional and novel imaging techniques available for LA assessment, using echocardiography and CMR, their role as an imaging biomarker in cardiovascular disease, the reproducibility of the techniques and the current limitations to their clinical application. We identify a need for further standardisation of techniques, with establishment of ‘normal’ cut-offs before routine clinical application can be made.

Clinical relevance of spectral tissue Doppler-derived E/e' in older patients with preserved ejection fraction

BACKGROUND

The E/e' index measured in spectral tissue Doppler is included in the recommendations for the diagnosis by transthoracic Doppler echocardiography of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction. While E/e' is influenced by age in healthy individuals, no studies have evaluated this index in elderly patients. This study addressed the clinical relevance of E/e' in assessment of left ventricular diastolic function in elderly patients with preserved ejection fraction and its relevance from both a diagnostic and prognostic perspective based on the existing literature.

METHODS

A total of 76 patients≥70years of age were prospectively included. The analysis of left ventricular diastolic function was adapted from the 2016 ASE/EACVI recommendations without consideration of E/e'.

RESULTS

The mean age was 85years. In all, 42 patients had moderate-to-severe diastolic dysfunction (elevated left atrial pressure). Mean E/e' was significantly correlated with diastolic function (r=0.58, P<0.001). Mean E/e'>13.3 had a sensitivity of 86% and a specificity of 91% in the diagnosis of moderate-to-severe diastolic dysfunction (AUC: 0.92). E/(e'xs') (AUC: 0.89) and NT pro-BNP (AUC: 0.80) did not perform better than E/e'. The existing literature offers large body of evidence that E/e' provides essential diagnostic and prognostic information in older patients with cardiovascular disease.

CONCLUSION

E/e' is accurate in the diagnosis of significant diastolic dysfunction, in the diagnosis of heart failure with preserved ejection fraction and in risk stratification in older patients with cardiovascular disease.

Mitral early-diastolic inflow peak velocity (E)-to-left atrial strain ratio as a novel index for predicting elevated left ventricular filling pressures in patients with preserved left ventricular ejection fraction

OBJECTIVES

We sought to explore the relationship between an index of left ventricular diastolic function parameters combined with left atrial strain and the diastolic function of patients with preserved ejection fraction.

METHODS

We prospectively enrolled 388 patients with left ventricular ejection fraction (LVEF) ≥ 50%, 49 of whom underwent left heart catherization. Transthoracic echocardiography was performed within 12 h before or after the procedure. Left atrial (LA) strain was obtained by speckle tracking echocardiography. These patients served as the test group. The remaining patients (n = 339) were used to validate the diagnostic performance of the mitral early-diastolic inflow peak velocity (E)-to-left atrial reservoir strain ratio (E/LASr) in left ventricular diastolic dysfunction.

RESULTS

Invasive measurements of LV end-diastolic pressure (LVEDP) demonstrated that the E/LASr ratio was increased in patients with elevated LVEDP [ 2.0 (1.8-2.2) vs 3.0 (2.6-4.0), p < 0.001] in the test group (n = 49). After adjusting for age, mitral A, E/e' ratio and β-blocker use, the E/LASr ratio was an independent predictor of elevated LVEDP and showed good diagnostic performance in determining elevated LVEDP [area under the curve (AUC) 0.903, cutoff value 2.7, sensitivity 74.2%, specificity 94.4%]. In the validation group (n = 339), the E/LASr ratio also performed well in diagnosing elevated left atrial pressure (LAP) (AUC 0.904, cutoff value 3.2, sensitivity 76.5%, specificity 89.0%), while with a cut-off value of 2.7, the E/LASr ratio showed high accuracy in discriminating elevated LAP. In addition, E/LASr was a good index of excellent diagnostic utility (AUC: 0.899 to 0.996) in the categorization of diastolic dysfunction grades. Regarding the clinical relevance of this index, the E/LASr ratio could accurately diagnose HF with preserved ejection fraction (HFpEF) (0.781), especially in patients with "indeterminate" status (AUC: 0.829). Furthermore, an elevated E/LASr ratio was significantly associated with the risk of rehospitalization due to major adverse cardiac events (MACEs) within one year (odds ratio: 1.183, 95% confidence interval: 1.067, 1.312).

CONCLUSIONS

In patients with EF preservation, the E/LASr ratio is a novel index for assessing elevated left ventricular filling pressure with high accuracy.

Current clinical applications of speckle tracking echocardiography for assessment of left atrial function

Two-dimensional speckle tracking echocardiography (2D-STE) enables assessment of left atrial (LA) function with better reproducibility and less load dependence than those with conventional methods. Data regarding LA functions determined by 2D-STE in patients with various cardiovascular diseases have recently been accumulating. LA strain has emerged as a novel parameter with the potential of improving the diagnostic accuracy of left ventricular diastolic dysfunction and the prognostic value in patients with heart failure and stroke. Furthermore, LA dysfunction determined by 2D STE can provide incremental prognostic information to conventional echocardiographic parameters in patients with cardiovascular diseases. Hence, 2D-STE appears to be a promising technique for diagnosis and therapeutic decision-making. Data regarding LA functions determined by three-dimensional speckle tracking echocardiography (3D-STE) have also been accumulating. Here, I review recent studies, especially those published after 2016, on clinical applications of LA function assessed by 2D-STE and 3D-STE and summarize the remaining problems to be solved for improving the clinical utility of these techniques.

Incremental prognostic role of left atrial reservoir strain in asymptomatic patients with moderate aortic stenosis

Left atrial (LA) mechanics assessed by two-dimensional speckle tracking echocardiography (2D-STE) have not been extensively studied and clearly characterized in patients with moderate aortic stenosis (AS). Accordingly, we aimed to evaluate the usefulness of LA reservoir strain for risk stratification of asymptomatic patients with moderate AS. This retrospective study included all consecutive asymptomatic patients with moderate AS who underwent transthoracic echocardiography implemented with 2D-STE analysis of LA myocardial strain and strain rate indices at our Institution, between February 2011 and September 2019. During the follow-up period, we evaluated the occurrence of any of the following: (1) CV hospitalization; (2) The recourse to AS surgery; (3) Cardiac death or sudden death. A total of 186 patients (mean age 71.9 ± 12.7 years, 61.8% men) were included in the present study. During a mean follow-up of 2.3 ± 1.9 years, no patients died and 63 adverse CV events were recorded: 48 patients were hospitalized because of heart failure (28 patients), acute coronary syndrome (10 patients), arrhythmias (10 patients) and 15 patients underwent AS surgery. At the multivariate Cox regression analysis, type 2 diabetes mellitus (OR 1.87, 95%CI 1.05-3.34, p = 0.03), NT-proBNP (OR average 1.14, 95%CI 1.02-1.27, p = 0.02), average E/e' ratio (OR 1.07, 95%CI 1.01-1.15, p = 0.04) and most of all left atrial positive global strain (LA-GSA+) (OR 0.85, 95%CI 0.81-0.90, p < 0.0001) were independently associated with the outcome. LA-GSA+ (optimal cut-off ≤ 19%, AUC = 0.94, 87% sensitivity, 99% specificity, positive predictive value 99%, negative predictive value 88%) showed the highest diagnostic performance. An impaired LA reservoir strain can contribute to identify a subset of asymptomatic patients with moderate AS at higher risk, who may benefit from closer echocardiographic follow-up and/or early surgery.

Left Atrial Strain as a Single Parameter to Predict Left Ventricular Diastolic Dysfunction and Elevated Left Ventricular Filling Pressure in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

OBJECTIVE

Left ventricular diastolic dysfunction (LVDD) is very common among patients undergoing cardiac surgery and is associated with increased mortality and morbidity. The present study tested the hypothesis of whether left atrial strain (LAS) can be used as a single parameter to predict LVDD (per 2016 LVDD evaluation guidelines) and elevated left ventricular filling pressure (LVFP) (ie, LVDD grades II and III) in patients scheduled for off-pump coronary artery bypass grafting (OPCABG) surgery.

DESIGN

A prospective observational study.

SETTINGS

Tertiary-care level hospital.

PARTICIPANTS

The study comprised 60 patients undergoing elective OPCABG.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Transthoracic echocardiography was performed within 24 hours of surgery by an anesthesiologist. LVDD was graded per American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations for 2016 LVDD guidelines. Left atrial (LA) function was evaluated using two-dimensional strain measurements obtained with the speckle-tracking echocardiography technique. Receiver operating characteristic curves were constructed, and the area under the curve was derived for the prediction of elevated LVFP by LAS. Fourteen (23.3%) patients had elevated LVFP. Global LA reservoir strain (LAS_r) reduced significantly as the LVDD grade worsened (28.9% ± 8.3%, 21.8% ± 7.2%, 15.6% ± 4.5% and 11.9% ± 1.3%, respectively, for normal LV diastolic function and grades I, II, and III LVDD; p < 0.0001). Similar trends were noted for other components of LAS; namely, global LA conduction, global LA contraction strain, and LAS rate. The ability to predict high LVFP with LAS_r was statistically significant, with an area under the receiver operating characteristic curve of 0.92 (confidence interval 0.82-0.97; p < 0.001), and a Youden's index for LAS_r of 19% was obtained with 85.71% sensitivity and 84.78% specificity. The ability of LAS and its components to predict increased LVFP in various subpopulations (normal v reduced ejection fraction) yielded statistically significant results.

CONCLUSIONS

In patients scheduled for OPCABG, cardiac anesthesiologists successfully could measure LAS with speckle-tracking echocardiography in the preoperative period. LAS as a single parameter was significantly associated with the grade of LVDD. LAS_r decreased significantly with worsening grade of LVDD. Furthermore, an LAS_r value <19% significantly predicted a high LVFP, and LAS_r predicted high LVFP in both preserved and reduced ejection fraction equally well.