Left Ventricular Diastolic Dysfunction: Diagnostic and Prognostic Perspectives

The prognostic value of CMR diastolic parameters in patients with cardiac light-chain amyloidosis: a retrospective analysis

Cardiac light-chain amyloidosis (AL-CA), characterized by the accumulation of amyloid fibers in the myocardium, often results in progressive diastolic dysfunction and adverse clinical outcomes. This study aimed to explore the diastolic characteristics of AL-CA using feature tracking cardiac magnetic resonance (CMR) and determine the prognostic parameters for all-cause mortality in such patients. A total of 102 AL-CA patients who underwent CMR between January 2014 and September 2018 were retrospectively reviewed, participations were follow-up until 2021. According to the inclusion and exclusion criteria, 60 patients were ultimately included. All-cause mortality was set as the primary endpoint. Healthy subjects were selected as controls. AL-CA patients were classified as the non-survival and survival group. The baseline characteristics, as well as the CMR-derived LV diastolic strain rate and LA diastolic parameters (LA volume, phasic EF, phasic strain, and strain rate), of survivors, non-survivors, and controls were compared. The associations of diastolic parameters with clinical outcomes were assessed via Cox regression and Kaplan‒Meier analyses. At a median follow-up of 7 months (interquartile range, 2-28 months), 43 (71.6%) cases of all-cause mortality were observed. Compared with controls, non-survivors presented significantly variation for all diastolic parameters (all P < 0.05), with LA volume indexes, LSRconduit and LSRpump value significantly increased and the remaining diastolic functional values significantly decreased. Compared with survivors, non-survivors presented significantly lower LV eGLSR, eGCSR, aGLSR, and selected LA diastolic parameters, including the LA phasic ejection fraction, LA phasic longitudinal strain, and LA longitudinal reservoir strain rate (all P < 0.05); moreover, LA volume indices and LA longitudinal conduit and booster‒pump strain rate values were significantly higher in the non-survival group. Multivariate Cox regression identified LA LSR as a significant predictor of all-cause mortality (hazard ratio, 14.35; 95% CI: 1.44-142.85, p < 0.05), with an optimal cutoff of -0.28 s-1 according to Kaplan‒Meier analysis. LA LSRconduit further demonstrated additive prognostic value over conventional systolic parameters, including LVEF, the LVGCS, and LV-LGE (p < 0.05). CMR-derived diastolic parameters, particularly the LA LSRconduit, have potential as predictive biomarkers for all-cause mortality in patients with AL-CA.

The Interplay between Severe Cirrhosis and Heart: A Focus on Diastolic Dysfunction

Background/Objectives: Cardiovascular involvement in severe cirrhosis presents diagnostic challenges and carries significant prognostic implications. This study aims to evaluate the relationship between liver disease severity and portal hypertension with the burden of diastolic dysfunction. Methods: We prospectively enrolled patients with hepatic cirrhosis, classified according to the Child-Pugh criteria. Of the 102 patients included, 65 were classified as Group A (non-severe cirrhosis: Child-Pugh Classes A and B) and 37 as Group B (severe cirrhosis: Child-Pugh Class C). Portal vein and spleen diameters were assessed using abdominal ultrasound. All patients underwent echocardiographic evaluation. LV systolic function was assessed by measuring ejection fraction, while diastolic function was evaluated using three parameters: E/Em ratio, E/Vp ratio, and indexed left atrial volume. Results: We observed a significantly greater burden of diastolic dysfunction in Group B compared to Group A. Specifically, the E/Vp ratio was 2.2 ± 0.4 in Group B versus 1.9 ± 0.3 in Group A (p < 0.001); the indexed LA volume was 34.5 ± 3.2 mL/m2 in Group B versus 30.1 ± 2.9 mL/m2 in Group A (p < 0.001); and the E/Em ratio was 17.0 ± 3.0 in Group B versus 11.5 ± 2.8 in Group A (p < 0.001). Additionally, the mean diameters of the portal vein and spleen were larger in Group B, with measurements of 14.3 ± 2.1 mm versus 11.5 ± 1.6 mm for the portal vein and 15.0 ± 1.2 mm versus 11.7 ± 1.5 mm for the spleen (p < 0.001), which correlated with the extent of diastolic dysfunction. Conclusions: Diastolic dysfunction was prevalent in 55% of patients with liver cirrhosis. The burden of diastolic dysfunction was higher in patients with severe hepatic cirrhosis compared to those with milder forms, and it correlated with the severity of portal hypertension, as assessed by measuring portal vein diameter and spleen diameter.

Prognostic significance and clinical utility of left atrial reservoir strain in transcatheter aortic valve replacement

AIMS

Patients with diastolic dysfunction (DD) experience worse outcomes after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value and clinical utility of left atrial reservoir strain (LARS) in patients undergoing TAVR for aortic stenosis (AS).

METHODS AND RESULTS

All consecutive patients undergoing TAVR between January 2018 and December 2018 were included if discharge echocardiography and follow-up were available. LARS was derived from 2D-speckle-tracking. Patients were grouped into three tertiles according to LARS. DD was analysed using the ASE/EACVI-algorithm. The primary outcome was a composite of all-cause death and readmission for worsening heart failure 12 months after TAVR. Overall, 606 patients were available [age 80 years, interquartile range (IQR) 77-84], including 53% women. Median LARS was 13.0% (IQR 8.4-18.3). Patients were classified by LARS tertiles [mildly impaired 21.4% (IQR 18.3-24.5), moderately impaired 13.0% (IQR 11.3-14.6), severely impaired 7.1% (IQR 5.4-8.4), P < 0.0001]. The primary outcome occurred more often in patients with impaired LARS (mildly impaired 7.4%, moderately impaired 13.4%, and severely impaired 25.7%, P < 0.0001). On adjusted multivariable Cox regression analysis, LARS tertiles [hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.44-0.86, P = 0.005] and higher degree of tricuspid regurgitation (HR 1.82, 95% CI 1.23-2.98, P = 0.003) were the only significant predictors of the primary endpoint. Importantly, DD was unavailable in 56% of patients, but LARS assessment allowed for reliable prognostication regarding the primary endpoint in subgroups without DD assessment (HR 0.64, 95% CI 0.47-0.87, P = 0.003).

CONCLUSION

Impaired LARS is independently associated with worse outcomes in patients undergoing TAVR. LARS allows for risk stratification at discharge even in patients where DD cannot be assessed by conventional echocardiographic means.