Left atrial structure and function and clinical outcomes in the general population

Proteomic profiles of left atrial volume and its influence on response to spironolactone: Findings from the HOMAGE trial and STANISLAS cohort

AIMS

High left ventricular filling pressure increases left atrial volume and causes myocardial fibrosis, which may decrease with spironolactone. We studied clinical and proteomic characteristics associated with left atrial volume indexed by body surface area (LAVi), and whether LAVi influences the response to spironolactone on biomarker expression and clinical variables.

METHODS AND RESULTS

In the HOMAGE trial, where people at risk of heart failure were randomized to spironolactone or control, we analysed 421 participants with available LAVi and 276 proteomic measurements (Olink) at baseline, month 1 and 9 (mean age 73 ± 6 years; women 26%; LAVi 32 ± 9 ml/m2). Circulating proteins associated with LAVi were also assessed in asymptomatic individuals from a population-based cohort (STANISLAS; n = 1640; mean age 49 ± 14 years; women 51%; LAVi 23 ± 7 ml/m2). In both studies, greater LAVi was significantly associated with greater left ventricular masses and volumes. In HOMAGE, after adjustment and correction for multiple testing, greater LAVi was associated with higher concentrations of matrix metallopeptidase-2 (MMP-2), insulin-like growth factor binding protein-2 (IGFBP-2) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) (false discovery rates [FDR] <0.05). These associations were externally replicated in STANISLAS (all FDR <0.05). Among these biomarkers, spironolactone decreased concentrations of MMP-2 and NT-proBNP, regardless of baseline LAVi (pinteraction > 0.10). Spironolactone also significantly reduced LAVi, improved left ventricular ejection fraction, lowered E/e', blood pressure and serum procollagen type I C-terminal propeptide (PICP) concentration, a collagen synthesis marker, regardless of baseline LAVi (pinteraction > 0.10).

CONCLUSION

In individuals without heart failure, LAVi was associated with MMP-2, IGFBP-2 and NT-proBNP. Spironolactone reduced these biomarker concentrations as well as LAVi and PICP, irrespective of left atrial size.

Association of left atrial enlargement with heart failure events in non-valvular atrial fibrillation patients with preserved left ventricular ejection fraction

Aims

Atrial fibrillation (AF) increases the risk of heart failure (HF); however, little is known regarding the risk stratification for incident HF in AF patients, especially with preserved left ventricular ejection fraction (LVEF).

Methods and results

The Fushimi AF Registry is a community-based prospective survey of AF patients. From the registry, 3002 non-valvular AF patients with preserved LVEF and with the data of antero-posterior left atrial diameter (LAD) at enrolment were investigated. Patients were stratified by LAD (<40, 40-44, 45-49, and ≥50 mm) with backgrounds and HF hospitalization incidences compared between groups. Of 3002 patients [mean age, 73.5 ± 10.7 years; women, 1226 (41%); paroxysmal AF, 1579 (53%); and mean CHA2DS2-VASc score, 3.3 ± 1.7], the mean LAD was 43 ± 8 mm. Patients with larger LAD were older and less often paroxysmal AF, with a higher CHA2DS2-VASc score (all P < 0.001). Heart failure hospitalization occurred in 412 patients during the median follow-up period of 6.0 years. Larger LAD was independently associated with a higher HF hospitalization risk [LAD ≥ 50 mm: hazard ratio (HR), 2.36; 95% confidence interval (CI), 1.75-3.18; LAD 45-49 mm: HR, 1.84; 95% CI, 1.37-2.46; and LAD 40-44 mm: HR, 1.34; 95% CI, 1.01-1.78, compared with LAD < 40 mm) after adjustment by age, sex, AF type, and CHA2DS2-VASc score. These results were also consistent across major subgroups, showing no significant interaction.

Conclusion

Left atrial diameter is significantly associated with the risk of incident HF in AF patients with preserved LVEF, suggesting the utility of LAD regarding HF risk stratification for these patients.

Fine tuning contractility: atrial sarcomere function in health and disease

The molecular mechanisms of sarcomere proteins underlie the contractile function of the heart. Although our understanding of the sarcomere has grown tremendously, the focus has been on ventricular sarcomere isoforms due to the critical role of the ventricle in health and disease. However, atrial-specific or -enriched myofilament protein isoforms, as well as isoforms that become expressed in disease, provide insight into ways this complex molecular machine is fine-tuned. Here, we explore how atrial-enriched sarcomere protein composition modulates contractile function to fulfill the physiological requirements of atrial function. We review how atrial dysfunction negatively affects the ventricle and the many cardiovascular diseases that have atrial dysfunction as a comorbidity. We also cover the pathophysiology of mutations in atrial-enriched contractile proteins and how they can cause primary atrial myopathies. Finally, we explore what is known about contractile function in various forms of atrial fibrillation. The differences in atrial function in health and disease underscore the importance of better studying atrial contractility, especially as therapeutics currently in development to modulate cardiac contractility may have different effects on atrial sarcomere function.

The association of plasma connective tissue growth factor levels with left ventricular diastolic dysfunction in patients with overt hyperthyroidism

Background

Left ventricular (LV) diastolic dysfunction is an independent predictor of future cardiovascular events. Early detection of patients with LV diastolic dysfunction can improve clinical outcomes through active management. However, the assessment of diastolic function is very complicated, and there are currently lack of effective biomarkers to assess the risk of LV diastolic dysfunction. Connective tissue growth factor (CTGF) plays a significant role in cardiac remodeling and dysfunction. We aimed to investigate the associations between plasma CTGF level and the risk of LV diastolic dysfunction in this study and judge its effectiveness in diagnosing LV diastolic dysfunction.

Methods

A total of 169 patients with overt hyperthyroidism were included. LV diastolic function was evaluated and the subjects were divided into normal LV diastolic function group and LV diastolic dysfunction group. Routine clinical medical data, biochemical data, thyroid related parameters and echocardiographic parameters were recorded for analysis.

Results

Compared with normal LV diastolic function group, the LV diastolic dysfunction group had higher age and BMI, as well as lower heart rate, lower serum albumin, lower eGFR, higher serum TgAb and BNP level, and the incidences of hypertension were also higher (all P <0.05). Circulating plasma CTGF levels in the LV diastolic dysfunction group were significantly higher (normal LV diastolic function group: 7.026 [5.567-8.895], LV diastolic dysfunction group: 8.290 [7.054-9.225] ng/ml, median [(Interquartile range)], P = 0.004); Compared with the lowest quartile group, the crude odds ratios (OR) of LV diastolic dysfunction in the second, third, and fourth quartile group were 3.207, 5.032 and 4.554, respectively (all P<0.05). After adjustment for the potentially confounding variables, the adjusted OR values of the third and fourth quartile group had no obvious change. The results of ROC showed that the plasma CTGF had the largest area under the ROC curve, and the value was 0.659 (P = 0.005).

Conclusion

The level of circulating plasma CTGF in the LV diastolic dysfunction group was significantly increased. Plasma CTGF level is an independent risk factor for LV diastolic dysfunction. Compared with serum BNP level, the plasma CTGF level may have auxiliary diagnostic value for LV diastolic dysfunction in hyperthyroid patients.

Ethnic differences in cardiac structure and function assessed by MRI in healthy South Asian and White European people: A UK Biobank Study

BACKGROUND

Echocardiographic studies indicate South Asian people have smaller ventricular volumes, lower mass and more concentric remodelling than White European people, but there are no data using cardiac MRI (CMR). We aimed to compare CMR quantified cardiac structure and function in White European and South Asian people.

METHODS

Healthy White European and South Asian participants in the UK Biobank Imaging CMR sub-study were identified by excluding those with a history of cardiovascular disease, hypertension, obesity or diabetes. Ethnic groups were matched by age and sex. Cardiac volumes, mass and feature tracking strain were compared.

RESULTS

121 matched pairs (77 male/44 female, mean age 58 ± 8 years) of South Asian and White European participants were included. South Asian males and females had smaller absolute but not indexed left ventricular (LV) volumes, and smaller absolute and indexed right ventricular volumes, with lower absolute and indexed LV mass and lower LV mass:volume than White European participants. Although there were no differences in ventricular or atrial ejection fractions, LV global longitudinal strain was higher in South Asian females than White European females but not males, and global circumferential strain was higher in both male and South Asian females than White European females. Peak early diastolic strain rates were higher in South Asian versus White European males, but not different between South Asian and White European females.

CONCLUSIONS

Contrary to echocardiographic studies, South Asian participants in the UK Biobank study had less concentric remodelling and higher global circumferential strain than White European subjects. These findings emphasise the importance of sex- and ethnic- specific normal ranges for cardiac volumes and function.

Natural history of echocardiographic changes in atrial fibrillation: A case-controlled study of longitudinal remodeling

BACKGROUND

Atrial fibrillation (AF) can be a cause and consequence of cardiac remodeling. The natural history of remodeling associated with AF is incompletely described.

OBJECTIVE

The purpose of this study was to describe the frequency and timing of AF-associated echocardiographic changes.

METHODS

Patients within the Duke University Health System with ≥2 transthoracic echocardiograms (TTEs) performed between 2005 and 2018 were evaluated. Patients with AF and normal baseline TTEs were matched to patients without AF on year of TTE, age, and CHA2DS2-VASc score. Frequency and timing of changes in chamber size, ventricular function, mitral regurgitation, and all-cause mortality were compared over 5 years of follow-up.

RESULTS

The cohort included 3299 patients with AF at baseline and 7613 controls without AF. Normal baseline TTEs were acquired from 730 of patients with AF; 727 of these patients were matched to controls without AF. Patients with AF had higher rates of left atrial enlargement (hazard ratio [HR] 1.53; 95% confidence interval 1.27-1.85; P < .001), left ventricular (LV) systolic dysfunction (HR 1.80; 95% confidence interval 1.00-3.26; P = .045), LV diastolic dysfunction (HR 1.51; 95% confidence interval 1.08-2.10; P = .01), and moderate or greater mitral regurgitation (HR 2.09; 95% confidence interval 1.27-3.43; P = .003) than did controls. Atrial enlargement, systolic dysfunction, and mitral regurgitation surpassed the rates seen in controls within 6-12 months, whereas differences in diastolic dysfunction emerged at 24 months. There were no differences in ventricular sizes or mortality.

CONCLUSION

AF is associated with higher rates of left atrial enlargement, LV systolic and diastolic dysfunction, and mitral regurgitation that typically manifest within 6-24 months of diagnosis. The natural history of cardiac remodeling in patients with AF may inform treatment decisions and facilitate patient-tailored care.

Left atrial remodeling in adolescents with obesity evaluated by speckle-tracking echocardiography

BACKGROUND AND AIMS

In adolescents with obesity, a left atrial (LA) enlargement has been reported. However, data regarding its function and its stiffness are missing. The aim of this study was to describe LA morphology and function, using speckle-tracking echocardiography (STE) and to explore their potential determinants in adolescents with obesity.

METHODS

Twenty-eight adolescent women with obesity (13.2 ± 1.4 yr) with an illness duration of 130 ± 27 months and 33 controls (14.1 ± 2.0 yr) underwent a resting echocardiography including an analysis of left ventricular (LV) and LA morphologies and strains. A fasting venous blood sample was performed to biochemical determinations including inflammation markers.

RESULTS

LA volume and stiffness index were increased in adolescents with obesity compared to controls. LA reservoir, conduit and booster pump functions were not different between groups. By stepwise forward multivariate regression analyses, systolic blood pressures, cardiac output and sedimentation rate were the independent determinants of LA volume (p < 0.0001, β-coefficient = 0.460) whereas only the body mass index was an independent determinant of LA stiffness (p = 0.003, β-coefficient = 0.413).

CONCLUSION

In adolescents with obesity, we observed a specific LA remodeling, including higher volume and lower stiffness, which could constitute early signs of an altered LV diastolic function.

Significant dependency of left atrial strain on left ventricular longitudinal motion

BACKGROUND

The effects of left ventricular longitudinal function on the left atrial strain, including the left atrial reservoir function, have not been adequately quantified.

METHODS

A total of 124 patients who underwent echocardiography were enrolled in this study. Left atrial strain analysis was performed using two-dimensional speckle tracking echocardiography, and the left atrial volume was derived using the modified Simpson's method. The peak left atrial strain (LAS) and left atrial expansion index (LAEI), as indices of left atrial reservoir function, were measured. The global longitudinal strain (GLS) and mitral annular plane systolic excursion (MAPSE), which are indices of contractile motion toward the left ventricular apex, were also measured. The correlation between LAS and candidate determinants, including left ventricular systolic longitudinal function, was evaluated, and multivariate regression analysis was performed.

RESULTS

A significant correlation was found between LAS and left ventricular systolic longitudinal functions, GLS (r = 0.63, p < 0.001), and MAPSE (r = 0.65, p < 0.001). Two models, which were selected by multiple regression analyses for LAS, included GLS or MAPSE as independent determinants. GLS and MAPSE were also the strongest predictors, among other factors.

CONCLUSION

LAS, when determined by evaluating the left atrial reservoir function, was significantly associated with left ventricular function, especially the systolic longitudinal function. Left ventricular function should be considered when assessing left atrial function by LAS.

Normalized Echocardiographic Values From Guideline-Directed Dedicated Views for Cardiac Dimensions and Left Ventricular Function

BACKGROUND

Continuous technologic development and updated recommendations for image acquisitions creates a need to update the current normal reference ranges for echocardiography. The best method of indexing cardiac volumes is unknown.

OBJECTIVES

The authors used 2- and 3-dimensional echocardiographic data from a large cohort of healthy individuals to provide updated normal reference data for dimensions and volumes of the cardiac chambers as well as central Doppler measurements.

METHODS

In the fourth wave of the HUNT (Trøndelag Health) study in Norway 2,462 individuals underwent comprehensive echocardiography. Of these, 1,412 (55.8% women) were classified as normal and formed the basis for updated normal reference ranges. Volumetric measures were indexed to body surface area and height in powers of 1 to 3.

RESULTS

Normal reference data for echocardiographic dimensions, volumes, and Doppler measurements were presented according to sex and age. Left ventricular ejection fraction had lower normal limits of 50.8% for women and 49.6% for men. According to sex-specific age groups, the upper normal limits for left atrial end-systolic volume indexed to body surface area ranged from 44 mL/m2 to 53 mL/m2, and the corresponding upper normal limit for right ventricular basal dimension ranged from 43 mm to 53 mm. Indexing to height raised to the power of 3 accounted for more of the variation between sexes than indexing to body surface area.

CONCLUSIONS

The authors present updated normal reference values for a wide range of echocardiographic measures of both left- and right-side ventricular and atrial size and function from a large healthy population with a wide age-span. The higher upper normal limits for left atrial volume and right ventricular dimension highlight the importance of updating reference ranges accordingly following refinement of echocardiographic methods.

Left atrial function index predicts poor outcomes in acute myocardial infarction patients treated with percutaneous coronary intervention

Background and aims

The left atrial function index (LAFI) is an index that combines the left atrial emptying fraction, adjusted left atrial volume and stroke volume. The prognostic value of LAFI in acute myocardial infarction (AMI) patients treated with percutaneous coronary intervention (PCI) is unknown. This study aims to determine whether LAFI predicts prognosis in AMI patients treated with PCI.

Methods

Patients with newly diagnosed AMI who were treated with PCI at Hunan Provincial People's Hospital from March 2020 to October 2021 were prospectively enrolled. All patients underwent transthoracic echocardiography (TTE) at baseline and follow-up. The endpoint events included rehospitalization due to unstable angina, nonfatal myocardial infarction, rehospitalization due to heart failure and cardiovascular death.

Results

A total of 368 patients with AMI (92 women; mean age, 61.45 ± 11.91 years) were studied with a median follow-up of 14 ± 6.58 months. Sixty-nine patients had endpoint events. Patients who presented with events had a significantly lower LAFI than patients without events (34.25 ± 12.86 vs. 48.38 ± 19.42, P < 0.0001). Multivariate Cox analysis demonstrated that LAFI (HR = 0.97 [95% CI: 0.95; 0.99]; P = 0.012) and the Killip classification (HR = 1.51 [95% CI: 1.03; 2.22]; P = 0.034) were independently predictive of endpoint events. Kaplan-Meier survival curves showed that patients with LAFI ≤ 40.17 cm/ml/m2 had higher events than patients with LAFI > 40.17 cm/ml/m2 (HR = 8.53 [95% CI: 4.74; 15.35]; P < 0.0001).

Conclusion

LAFI is a strong and independent predictor of adverse events and can be used for risk stratification in patients with AMI treated with PCI.

Diastology with Cardiac MRI: A Practical Guide

Diastolic filling of the ventricle is a complex interplay of volume and pressure, contingent on active energy-dependent myocardial relaxation and myocardial stiffness. Abnormal diastolic function is the hallmark of the clinical entity of heart failure with preserved ejection fraction (HFpEF), which is now the dominant type of heart failure and is associated with significant morbidity and mortality. Although echocardiography is the current first-line imaging modality used in evaluation of diastolic function, cardiac MRI (CMR) is emerging as an important technique. The principal role of CMR is to categorize the cause of diastolic dysfunction (DD) and distinguish other entities that manifest similarly to HFpEF, particularly infiltrative and pericardial disorders. CMR also provides prognostic information and risk stratification based on late gadolinium enhancement and parametric mapping techniques. Advances in hardware, sequences, and postprocessing software now enable CMR to diagnose and grade DD accurately, a role traditionally assigned to echocardiography. Two-dimensional or four-dimensional velocity-encoded phase-contrast sequences can measure flow and velocities at the mitral inflow, mitral annulus, and pulmonary veins to provide diastolic functional metrics analogous to those at echocardiography. The commonly used cine steady-state free-precession sequence can provide clues to DD including left ventricular mass, left ventricular filling curves, and left atrial size and function. MR strain imaging provides information on myocardial mechanics that further aids in diagnosis and prognosis of diastolic function. Research sequences such as MR elastography and MR spectroscopy can help evaluate myocardial stiffness and metabolism, respectively, providing additional insights on diastolic function. The authors review the physiology of diastolic function, mechanics of diastolic heart failure, and CMR techniques in the evaluation of diastolic function. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Defining Heart Failure Based on Imaging the Heart and Beyond

Water and salt retention, in other words congestion, are fundamental to the pathophysiology of heart failure and are important therapeutic targets. Echocardiography is the key tool with which to assess cardiac structure and function in the initial diagnostic workup of patients with suspected heart failure and is essential for guiding treatment and stratifying risk. Ultrasound can also be used to identify and quantify congestion in the great veins, kidneys and lungs. More advanced imaging methods might further clarify the aetiology of heart failure and its consequences for the heart and periphery, thereby improving the efficiency and quality of care tailored with greater precision to individual patient need.

Effect of Intensive Blood Pressure Control on Troponin and Natriuretic Peptide Levels: Findings From SPRINT

BACKGROUND

Given the important role of cardiac injury and neurohormonal activation in the pathways leading from hypertension to heart failure and strong associations observed between hypertension and its sequelae on hs-cTnT (high-sensitivity cardiac troponin T) and NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, we hypothesized that intensive systolic blood pressure (SBP) lowering would decrease levels of hs-cTnT and NT-proBNP.

METHODS

hs-cTnT and NT-proBNP were measured at baseline and 1 year from stored specimens in SPRINT (Systolic Blood Pressure Intervention Trial). Changes in biomarkers were evaluated continuously on the log scale and according to categories (≥50% increase, ≥50% decrease, or <50% change). The effect of intensive SBP lowering on continuous and categorical changes in biomarker levels were assessed using linear and multinomial logistic regression models, respectively. The association between changes in biomarkers on heart failure and death was assessed using multivariable-adjusted Cox proportional hazards models.

RESULTS

Randomization to intensive SBP lowering (versus standard SBP management) resulted in a 3% increase in hs-cTnT levels over 1-year follow-up (geometric mean ratio, 1.03 [95% CI, 1.01-1.04]) and a higher proportion of participants with ≥50% increase (odds ratio, 1.47 [95% CI, 1.13, 1.90]). In contrast, randomization to intensive SBP lowering led to a 10% decrease in NT-proBNP (geometric mean ratio, 0.90 [95% CI, 0.87-0.93]) and a lower probability of ≥50% increase in NT-proBNP (odds ratio, 0.57 [95% CI, 0.46-0.72]). The association of randomized treatment assignment on change in hs-cTnT was completely attenuated after accounting for changes in estimated glomerular filtration rate over follow-up, whereas the association of treatment with NT-proBNP was completely attenuated after adjusting for change in SBP. Increases in hs-cTnT and NT-proBNP from baseline to 1 year were associated with higher risk for heart failure and death, with no significant interactions by treatment assignment.

CONCLUSIONS

Intensive SBP lowering increased hs-cTnT, mediated by the effect of SBP lowering on reduced kidney filtration. In contrast, intensive SBP lowering decreased NT-proBNP, a finding that was explained by the decrease in SBP. These findings highlight the importance of noncardiac factors influencing variation in cardiac biomarkers and raise questions about the potential role of hs-cTnT as a surrogate marker for heart failure or death in SBP-lowering studies.

Spironolactone effect on cardiac structure and function of patients with heart failure and preserved ejection fraction: a pooled analysis of three randomized trials

AIMS

Spironolactone is currently used in a large proportion of patients with heart failure and preserved ejection fraction (HFpEF), yet its effect on cardiac structure and function in a large population has not been well established. The aim of this study was to evaluate the impact of spironolactone on key echocardiographic parameters in HFpEF.

METHODS AND RESULTS

An individual-patient-data meta-analysis of three randomized trials (HOMAGE, Aldo-DHF, and TOPCAT) was performed comparing spironolactone (9-12 month exposure) to placebo (or control) for the changes in left atrial volume index (LAVi), left ventricular mass index (LVMi), interventricular septum (IVS) thickness, E/e' ratio, and left ventricular ejection fraction (LVEF) among patients with stage B (HOMAGE) or C (Aldo-DHF and TOPCAT) HFpEF. Analysis of covariance was used to test the effect of spironolactone on echocardiographic changes. A total of 984 patients were included in this analysis: 452 (45.9%) from HOMAGE, 398 (40.4%) from Aldo-DHF, and 134 (13.6%) from TOPCAT. The pooled-cohort patient's median age was 71 (66-77) years and 39% were women. Median LAVi was 29 (24-35) ml/m² , LVMi 100 (84-118) g/m² , IVS thickness 12 (10-13) mm, E/e' ratio 11 (9-13), and LVEF 64 (59-69)%. Spironolactone reduced LAVi by -1.1 (-2.0 to -0.1) ml/m² (p = 0.03); LVMi by -3.6 (-6.4 to -0.8) g/m² (p = 0.01); IVS thickness by -0.2 (-0.3 to -0.1) mm (p = 0.01); E/e' ratio by -1.3 (-2.4 to -0.2) (p = 0.02); and increased LVEF by 1.7 (0.8-2.6)% (p < 0.01). No treatment-by-study heterogeneity was found except for E/e' ratio with a larger effect in Aldo-DHF and TOPCAT (interaction p < 0.01).

CONCLUSIONS

Spironolactone improved cardiac structure and function of patients with HFpEF.

Accelerated brain aging in individuals with diabetes: Association with poor glycemic control and increased all-cause mortality

BACKGROUND

Diabetes has been linked to accelerated brain aging, i.e., neuroimaging-predicted age of brain is higher than chronological age. This report evaluated whether accelerated brain aging in diabetes is associated with higher levels of glycated hemoglobin (HbA1c) and increased mortality.

METHODS

Brain age in Dallas Heart Study (n = 1949) was estimated using T1-weighted magnetic resonance imaging (MRI) scans and a previously-published Gaussian Processes Regression model. Accelerated brain aging (adjusted Δ brain age) was computed as follows: (brain age adjusted for chronological age)-minus-(chronological age). Mortality data until 12/31/2016 were obtained from the National Death Index. Associations of adjusted Δ brain age with diabetes in full sample and with HbA1c in individuals with diabetes were evaluated. Proportion of association between diabetes and all-cause mortality that was accounted for by adjusted Δ brain age were evaluated with mediation analyses. Covariates included Framingham 10-year risk score, race/ethnicity, income, body mass index, and history of myocardial infarction.

RESULTS

Diabetes was associated with] higher adjusted Δ brain age [estimate= 1.79; 95% confidence interval (CI): 0.889, 2.68]. Among those with diabetes, higher HbA1c (log-base-2-transformed) was associated with higher adjusted Δ brain age (estimate=3.88; 95% CI: 1.47, 6.30). Over a median follow-up of 97.5 months, 24/246 (9.8%) with diabetes and 63/1703 (3.7%) without diabetes died. Adjusted Δ brain age accounted for 65.3 (95% CI: 39.3, 100.0)% of the association between diabetes and all-cause mortality.

CONCLUSION

Accelerated brain aging may be related to poor glycemic control in diabetes and partly account for the association between diabetes and all-cause mortality.

Clinical implications of left atrial changes after optimization of medical therapy in patients with heart failure

AIMS

Limited data exist regarding the prognostic relevance of changes in left atrial (LA) dimensions in patients with heart failure (HF). We assessed changes in LA dimension and their relation with outcomes after optimization of guideline-directed medical therapy (GDMT) in patients with new-onset or worsening HF.

METHODS AND RESULTS

Left atrial diameter was assessed at baseline and 9 months after GDMT optimization in 632 patients (mean age 65.8 ± 12.1 years, 22.3% female) enrolled in BIOSTAT-CHF. LA adverse remodelling (LAAR) was defined as an increase in LA diameter on transthoracic echocardiography between baseline and 9 months. After the 9-month visit, patients were followed for a median of 13 further months. LAAR was observed in 247 patients (39%). Larger baseline LA diameter (odds ratio [OR] 0.90; 95% confidence interval [CI] 0.87-0.93; p < 0.001) and up-titration to higher doses of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEi/ARBs) (OR 0.56; 95% CI 0.34-0.92; p = 0.022) were independently associated with lower likelihood of LAAR. LAAR was associated with an increased risk of the composite of all-cause mortality or HF hospitalization (log-rank p = 0.007 and adjusted hazard ratio 1.73, 95% CI 1.22-2.45, p = 0.002). The association was more pronounced in patients without a history of atrial fibrillation (p for interaction = 0.009).

CONCLUSION

Among patients enrolled in BIOSTAT-CHF, LAAR was associated with an unfavourable outcome and was prevented by ACEi/ARB up-titration. Changes in LA dimension may be a useful marker of response to treatment and improve risk stratification in patients with HF.

Sex differences in arterial hypertension

There is strong evidence that sex chromosomes and sex hormones influence blood pressure (BP) regulation, distribution of cardiovascular (CV) risk factors and co-morbidities differentially in females and males with essential arterial hypertension. The risk for CV disease increases at a lower BP level in females than in males, suggesting that sex-specific thresholds for diagnosis of hypertension may be reasonable. However, due to paucity of data, in particularly from specifically designed clinical trials, it is not yet known whether hypertension should be differently managed in females and males, including treatment goals and choice and dosages of antihypertensive drugs. Accordingly, this consensus document was conceived to provide a comprehensive overview of current knowledge on sex differences in essential hypertension including BP development over the life course, development of hypertension, pathophysiologic mechanisms regulating BP, interaction of BP with CV risk factors and co-morbidities, hypertension-mediated organ damage in the heart and the arteries, impact on incident CV disease, and differences in the effect of antihypertensive treatment. The consensus document also highlights areas where focused research is needed to advance sex-specific prevention and management of hypertension.

Prognostic relevance of left atrial function and stiffness in heart failure with preserved ejection fraction patients with and without diabetes mellitus

Background

Although the left atrium (LA) plays a key role in the pathophysiology and disease progression of heart failure with preserved ejection fraction (HFpEF), the impact of type 2 diabetes mellitus (T2DM) on LA function and stiffness in HFpEF patients remains unclear. Furthermore, the prognostic value of different phases of LA function and stiffness is less well-established in HFpEF patients.

Methods

This study prospectively enrolled 164 HFpEF patients who were in sinus rhythm at the time of echocardiography, including 61 (37%) HFpEF patients with T2DM. LA reservoir, conduit, and pump function were assessed using two-dimensional volume indices and speckle tracking echocardiography. The LA stiffness was calculated as the ratio of early mitral inflow velocity-to-early annular tissue velocity (E/e’) and LA reservoir function. The primary end point was a combined outcome of heart failure hospitalization or death.

Results

Left atrium reservoir function [measured by peak LA strain (LAS-peak)] and LA pump function (measured by LAS-active) remained significantly lower in the HFpEF patients with T2DM compared with those without T2DM, even after adjustment for potential confounders. In addition, the LA stiffness of HFpEF patients with T2DM was higher than those without T2DM. After a median follow-up of 13.7 months, 46 patients (28.1%) reached the composite end point. LAS-peak (hazard ratios: 0.88; 95% confidence interval: 0.81–0.95; P = 0.001) was significantly associated with the risk of heart failure hospitalization or death after adjusting for demographic and clinical characteristics, LV global longitudinal strain, E/e’, and LA volume index. In contrast, other LA function and stiffness parameters did not independently predict the risk of adverse events. Kaplan-Meier analysis showed that HFpEF patients with T2DM and low LAS-peak (<27.2%) had a significantly increased risk of heart failure-related hospitalization or death (log-rank P < 0.001).

Conclusion

Left atrium reservoir and pump function are impaired, whereas LA stiffness is increased in HFpEF patients with T2DM compared with those without T2DM. LAS-peak is a powerful predictor of adverse clinical outcomes and may be crucial for risk stratification in HFpEF patients with and without T2DM.

Left Atrial Volumes and Function, and Long-Term Incidence of Ischemic Stroke in the General Population

Background Left atrial (LA) volumes and emptying fraction in the general population may address structural and functional aspects of atrial cardiomyopathy associated with long-term risk of ischemic stroke in the absence of atrial fibrillation or prior stroke. We investigated the association between LA volumes and function and ischemic stroke. Methods and Results In a community-based cohort, we measured LA minimal volume, LA maximal volume, and LA emptying fraction by transthoracic echocardiography. The primary end point was ischemic stroke. Participants with known atrial fibrillation or prior ischemic stroke were excluded, which resulted in 1866 participants. The mean age was 58±16 years, and 57% were women. During a median follow-up of 16.5 years (interquartile range: 11.4-16.8 years), 176 (9.4%) ischemic strokes occurred. In multivariable cause-specific regression models and competing risk models with death as a competing risk, LA emptying fraction was associated with ischemic stroke (hazard ratio [HR], 1.14 per 10% decrease [95% CI, 1.02-1.28]) and (subdistribution HR, 1.14 [95% CI, 1.01-1.29]). This association remained when adjusting for participants who developed atrial fibrillation during follow-up (HR, 1.12 per 10% decrease [95% CI, 1.00-1.26]). Indexed LA volumes were not associated with ischemic stroke in the same models. LA emptying fraction and indexed LA volumes were not associated with all-cause mortality. Conclusions Lower LA emptying fraction measured by transthoracic echocardiography was associated with future ischemic stroke independently of incident atrial fibrillation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02993172.

Quantification of Left Atrial Size and Function in Cardiac MR in Correlation to Non-Gated MR and Cardiovascular Risk Factors in Subjects without Cardiovascular Disease: A Population-Based Cohort Study

Background: In magnetic resonance imaging (MRI), the comparability of gated and non-gated measurements of the left atrial (LA) area and function and their association with cardiovascular risk factors have not been firmly established. Methods: 3-Tesla MRIs were performed on 400 subjects enrolled in the KORA (Cooperative Health Research in the Augsburg Region) MRI study. The LA maximum and minimum sizes were segmented in gated CINE four-chamber sequences (LAmax and LAmin) and non-gated T1 VIBE-Dixon (NGLA). The area-based LA function was defined as LAaf = (LAmax − LAmin)/LAmax. Inter-and intra-reader reliability tests were performed (n = 31). Linear regression analyses were conducted to link LA size and function with cardiovascular risk factors. Results: Data from 378 subjects were included in the analysis (mean age: 56.3 years, 57.7 % male). The measurements were highly reproducible (all intraclass correlation coefficients ≥ 0.98). The average LAmax was 19.6 ± 4.5 cm2, LAmin 11.9 ± 3.5 cm2, NGLA 16.8 ± 4 cm2 and LAaf 40 ± 9%. In regression analysis, hypertension was significantly associated with larger gated LAmax (β = 1.30), LAmin (β = 1.07), and non-gated NGLA (β = 0.94, all p ≤ 0.037). Increasing age was inversely associated with LAaf (β = −1.93, p < 0.001). Conclusion: LA enlargement, as measured in gated and non-gated CMR is associated with hypertension, while the area-based LA function decreases with age.

Phenotyping the hypertensive heart

Arterial hypertension remains the most frequent cardiovascular (CV) risk factor, and is responsible for a huge global burden of disease. Echocardiography is the first-line imaging method for the evaluation of cardiac damage in hypertensive patients and novel techniques, such as 2D and D speckle tracking and myocardial work, provide insight in subclinical left ventricular (LV) impairment that would not be possible to detect with conventional echocardiography. The structural, functional, and mechanical cardiac remodelling that are detected with imaging are intermediate stages in the genesis of CV events, and initiation or intensification of antihypertensive therapy in response to these findings may prevent or delay progressive remodelling and CV events. However, LV remodelling—especially LV hypertrophy—is not specific to hypertensive heart disease (HHD) and there are circumstances when other causes of hypertrophy such as athlete heart, aortic stenosis, or different cardiomyopathies need exclusion. Tissue characterization obtained by LV strain, cardiac magnetic resonance, or computed tomography might significantly help in the distinction of different LV phenotypes, as well as being sensitive to subclinical disease. Selective use of multimodality imaging may therefore improve the detection of HHD and guide treatment to avoid disease progression. The current review summarizes the advanced imaging tests that provide morphological and functional data about the hypertensive cardiac injury.

The role of cardiac magnetic resonance imaging in the assessment of heart failure with preserved ejection fraction

Heart failure (HF) is a major cause of morbidity and mortality worldwide. Current classifications of HF categorize patients with a left ventricular ejection fraction of 50% or greater as HF with preserved ejection fraction or HFpEF. Echocardiography is the first line imaging modality in assessing diastolic function given its practicality, low cost and the utilization of Doppler imaging. However, the last decade has seen cardiac magnetic resonance (CMR) emerge as a valuable test for the sometimes challenging diagnosis of HFpEF. The unique ability of CMR for myocardial tissue characterization coupled with high resolution imaging provides additional information to echocardiography that may help in phenotyping HFpEF and provide prognostication for patients with HF. The precision and accuracy of CMR underlies its use in clinical trials for the assessment of novel and repurposed drugs in HFpEF. Importantly, CMR has powerful diagnostic utility in differentiating acquired and inherited heart muscle diseases presenting as HFpEF such as Fabry disease and amyloidosis with specific treatment options to reverse or halt disease progression. This state of the art review will outline established CMR techniques such as transmitral velocities and strain imaging of the left ventricle and left atrium in assessing diastolic function and their clinical application to HFpEF. Furthermore, it will include a discussion on novel methods and future developments such as stress CMR and MR spectroscopy to assess myocardial energetics, which show promise in unraveling the mechanisms behind HFpEF that may provide targets for much needed therapeutic interventions.

Cardiac Computed Tomography-Derived Left Atrial Strain and Volume in Pediatric Patients With Congenital Heart Disease: A Comparative Analysis With Transthoracic Echocardiography

Purpose

This study aimed at exploring the feasibility and reproducibility of CCT for the measurement of Left Atrial (LA) strain and volume compared with transthoracic echocardiography (TTE) in pediatric patients with congenital heart disease (CHD).

Materials and Methods

The present study included 43 postoperative patients with CHD (7.39 ± 3.64 years, 56% male) who underwent clinically indicated CCT, and all patients underwent additional TTE on the same day. LA strain and volume parameters were measured by dedicated software. The correlation and agreement of LA strain and volume parameters were assessed using Pearson’s correlation coefficient and Bland-Altman analysis. Intra-class correlation coefficients (ICC) were used to assess CCT intra-observer and inter-observer reproducibility.

Results

All strain parameters of CCT were lower compared to TTE (reservoir strain: 28.37 ± 6.92 vs. 32.15 ± 8.15, respectively; conduit strain: 21.33 ± 6.46 vs. 24.23 ± 7.75, respectively; booster strain: 7.04 ± 2.74 vs. 7.92 ± 3.56). While the volume parameters of CCT were higher compared to TTE (LAV: 29.60 ± 19.01 vs. 25.66 ± 17.60, respectively; LAVi: 30.36 ± 22.31 vs. 28.63 ± 19.25, respectively). Both LA strain and volume measurements showed good correlation and agreement between the two modalities (r = 0.63–0.87, p < 0.001). CT-derived LA strain and volume measurements showed good intra- and inter-observer reproducibility using prototype software (ICC = 0.78–0.96).

Conclusions

CCT was feasible for measuring LA strain and volume with good correlation and high reproducibility as compared with TTE. As a complementary modality, CCT can regard as an accepted method in the evaluation of LA function in pediatric patients with CHD

Left atrial phasic function remodeling during its enlargement: a two-dimensional speckle-tracking echocardiography study

BACKGROUND

Left atrial (LA) size is often used as a surrogate marker of LA function in clinical practice, with larger atrial thought to represent a "dysfunctioning" atrium, since there is no accepted 'gold' standard to evaluate LA function. The exact relationship between LA size and phasic function, and whether LA dysfunction occur before LA enlargement (LAE) may be of clinical interest while have not been fully studied. Two-dimensional speckle-tracking echocardiography (2D STE) was showed a promising method in measuring LA physical deformation.

MATERIALS AND METHODS

A community cohort of 715 subjects at cardiovascular disease high risk accepted comprehensive echocardiography. LA longitudinal phasic strain Sa (absolute peak strain during atrial contraction), Se (peak strain at early diastole) and Stot (total atrial strain = Sa + Se), representing contractile, conduit, and reservoir function respectively, were measured using off-line 2D STE software in apical 4 chamber view, and data were compared among groups at different LA size and between subgroups in normal LA size with and without hypertension (HT).

RESULTS

With LAE (from normal size, mild, moderate to severe LAE), the Stot (21.74 ± 5.97, 20.75 ± 4.99, 20.49 ± 5.27, 17.75 ± 4.71, respectively, ANOVA P = 0.003) and Sa (11.84 ± 3.92, 11.00 ± 3.29, 10.11 ± 2.57, 8.55 ± 2.88, respectively, ANOVA P < 0.001) reduced while Se had no change. Stot of Severe LAE group was significantly lower than that of Normal LA size group (P = 0.002). Sa of the three LAE groups were all significantly lower than that of Normal LA size group (P = 0.024, P = 0.002, P < 0.001, respectively). In normal sized LA subgroups, Stot (21.35 ± 5.91 vs. 23.01 ± 6.02, P = 0.008) and Se (9.51 ± 4.41 vs. 11.17 ± 4.89, P < 0.001) reduced in subjects with HT comparing with those without.

CONCLUSION

LA phasic function remodeling occurs before LAE and continues with LAE, with reservoir, conduit and contractile function being affected unparalleled.

Left Atrial Remodeling and Stroke in Patients With Sinus Rhythm and Normal Ejection Fraction: ARIC-NCS

Background Age-related left atrial (LA) structural and functional abnormalities may be related to subclinical cerebral infarcts (SCIs) and stroke. We evaluated the association of 3-dimensional echocardiographic LA contractility parameters with SCIs and stroke across the spectrum of tertiles of age increment in elderly patients with sinus rhythm, normal ejection fraction, and no history of atrial fibrillation. Methods and Results We enrolled 407 participants (mean age, 76±8 years; 40% men) from ARIC-NCS (Atherosclerosis Risk in Communities Neurocognitive Study) undergoing a brain magnetic resonance imaging and 3-dimensional echocardiographic examinations in 2011 to 2013. The sample was analyzed among age tertiles and subgroups: no cerebral magnetic resonance imaging-detectable infarcts (n=315), magnetic resonance imaging-diagnosed SCIs (n=58), and clinically diagnosed stroke (n=34). The frequency of SCIs significantly increased over age tertiles (P trend 0.023). LA global longitudinal strain-a 3-dimensional echocardiographic index of LA reservoir function-and E/e' divided by LA global longitudinal strain-an index of LA stiffness-worsened across age tertiles (P trend 0.014 and 0.001, respectively), and only in the categories of SCIs (P trend <0.001 and 0.045, respectively) and stroke (P trend 0.001 and 0.011, respectively). LA global longitudinal strain was negatively associated with increased odds of SCIs (P=0.036, P=0.008, and P=0.001, respectively) and strokes (P=0.043, P=0.015, and P=0.001, respectively) over age tertiles, with a significant interaction between age tertiles (interaction P=0.043 and P=0.010, respectively). E/e' divided by LA global longitudinal strain was positively associated with the presence of SCIs (P=0.037, P=0.007, and P=0.001, respectively) and strokes (P=0.045, P=0.007, and P=0.003, respectively) over age tertiles, with a significant interaction only for SCIs (interaction P=0.040) and not for clinical stroke. Conclusions In a large cohort study of elderly patients, among participants with sinus rhythm, normal ejection fraction, and no history of atrial fibrillation, measures of worse age-related LA reservoir function and stiffness are associated with higher odds of SCIs and stroke.

Association of Left Atrial Structure and Function With Heart Failure in Older Adults

BACKGROUND

Limited data exist to characterize novel measures of left atrial (LA) structure and function in older adults without prevalent heart failure (HF).

OBJECTIVES

The aim was to assess reference range of LA measures, their associations with N-terminal pro-B-type natriuretic-peptide (NT-proBNP) and the related risk for incident HF or death.

METHODS

We analyzed LA structure (LA maximal [LAViMax] and minimal volume indexed by body surface area) and function (LA emptying fraction, LA reservoir, conduit, and contraction strain) in 4,901 participants from the ARIC (Atherosclerosis Risk In Communities) study (mean age 75 ± 5 years, 40% male, and 19% Black) without prevalent HF. We assessed sex-specific 10th and 90th percentile ARIC-based reference limits in 301 participants free of prevalent cardiovascular disease, and related LA measures to NT-proBNP and incident HF or death (median follow-up of 5.5 years) in the whole ARIC cohort.

RESULTS

Approximately 20% of the overall population had LA abnormalities according to the ARIC-based reference limit. Each LA measure was associated with NT-proBNP and, except for LAViMax, with incident HF or death after multivariable adjustment (including left ventricular function and NT-proBNP). Results were consistent in participants with normal LAViMax (P for interaction > 0.05). LA measures were prognostic for both incident HF with preserved ejection fraction or death and incident HF with reduced ejection fraction or death. When added to HF risk factors and NT-proBNP (baseline C-statistics = 0.74) all LA measures, except for LAViMax, significantly enhanced the prognostic accuracy.

CONCLUSIONS

Novel measures of LA structure and function, but not standard assessment by LAViMax, are associated with increased risk of incident HF or death regardless of measures of left ventricular function and NT-proBNP.

Association of Echocardiographic Measures of Left Atrial Function and Size With Incident Dementia

IMPORTANCE

Atrial myopathy-characterized by alterations in left atrial (LA) function and size-is associated with ischemic stroke, independent of atrial fibrillation (AF). Electrocardiographic markers of atrial myopathy are associated with dementia, but it is unclear whether 2-dimensional echocardiographic (2DE)-defined LA function and size are associated with dementia.

OBJECTIVE

To examine the association of LA function and size with incident dementia.

DESIGN, SETTING, AND PARTICIPANTS

The Atherosclerosis Risk in Communities (ARIC) study is a community-based prospective cohort. An exploratory, retrospective analysis was conducted. ARIC centers are located in Forsyth County, North Carolina; Jackson, Mississippi; Washington County, Maryland; and suburban Minneapolis, Minnesota. For this analysis, visit 5 (2011-2013) served as the baseline. Participants without prevalent AF and stroke and who had 2DEs in 2011-2013 were included and surveilled through December 31, 2019.

EXPOSURES

LA function (reservoir strain, conduit strain, contractile strain, emptying fraction, passive emptying fraction, and active emptying fraction), and LA size (maximal and minimal volume index) as evaluated by 2DE.

MAIN OUTCOMES AND MEASURES

Dementia cases were identified using in-person and phone cognitive assessments, hospitalization codes, and death certificates. Cox proportional hazards models were used.

RESULTS

Among 4096 participants (mean [SD] age, 75 [5] years; 60% women; 22% Black individuals), 531 dementia cases were ascertained over a median follow-up of 6 years. Dementia incidence for the lowest LA quintile was 4.80 for reservoir strain, 3.94 for conduit strain, 3.29 for contractile strain, 4.20 for emptying fraction, 3.67 for passive emptying fraction, and 3.27 for active emptying fraction per 100 person-years. After full-model adjustments, there were statistically significant associations between measures of LA function and dementia; the hazard ratios (HRs) from the lowest vs highest quintile for reservoir strain were 1.98 (95% CI, 1.42-2.75); for conduit strain, 1.50 (95% CI, 1.09-2.06); for contractile strain, 1.57 (95% CI, 1.16-2.14); for emptying fraction, 1.87 (95% CI, 1.31-2.65); and for active emptying fraction, 1.43 (95% CI, 1.04-1.96). LA passive emptying fraction was not significantly associated with dementia (HR, 1.26 [95% CI, 0.93-1.71]). Dementia incidence for the highest LA maximal volume index quintile was 3.18 per 100 person-years (HR for highest vs lowest quintile, 0.77 [95% CI, 0.58-1.02]) and for the highest minimal volume index quintile was 3.50 per 100 person-years (HR for the highest vs lowest quintile, 0.95 [95% CI, 0.71-1.28]). Both measures were not significantly associated with dementia. These findings were robust to sensitivity analyses that excluded participants with incident AF or stroke.

CONCLUSIONS AND RELEVANCE

In this exploratory analysis of a US community-based cohort, several echocardiographic measures of lower LA function were significantly associated with an increased risk of subsequent dementia. Measures of LA size were not significantly associated with dementia risk. These findings suggest that impaired LA function may be a risk factor associated with dementia.

Cardiac Structure and Function and Diabetes-Related Risk of Death or Heart Failure in Older Adults

Background Whether cardiac structure and function abnormalities associated with dysglycemia are sufficient to explain the increased risk of death or heart failure (HF) remains unclear. Methods and Results We analyzed 6059 participants (mean age, 75±5 years; 58% women; and 22% Black individuals) who attended the ARIC (Atherosclerosis Risk in Communities) study visit 5 examination (2011-2013). Participants were categorized as no diabetes, pre-diabetes, and diabetes (on the basis of medical history and glycated hemoglobin values). We assessed whether diabetes modified the association between echocardiographic measures of cardiac structure and function and the composite of all-cause death or HF hospitalization and then estimated the extent to which the increased risk of the composite outcome associated with diabetes was explained by cardiac structure and function. Diabetes was prevalent in 33.5% of the subjects. Death or HF occurred in 1111 (18%) at a rate of 3.6 per 100 person-years. Both measures of cardiac structure and function and diabetes status were significantly associated with worse prognosis after accounting for clinical confounders. While diabetes was consistently associated with a higher risk of events, it did not significantly modify the association between cardiac abnormalities and the risk of death or HF, except for subjects with higher left atrial volume who showed higher relative risk of events (P for interaction <0.001). Measures of cardiac structure and function accounted for ≈16% of the increased risk of death or HF associated with diabetes. Similar results were observed analyzing subjects without prevalent heart disease. Conclusions In a biracial cohort of older adults, the increased risk of events associated with diabetes was partially explained by cardiac structure and function abnormalities.

Anthracycline Treatment and Left Atrial Function in Children: A Real-Time 3-Dimensional Echocardiographic Study

Anthracycline (AC) therapy is associated with left ventricular (LV) dysfunction. Left atrial (LA) size and function are used to assess LV diastolic function in heart failure in adults. Data on LA size and function following AC therapy in children is limited. We hypothesized that LA size and function will be abnormal in children following AC chemotherapy. This retrospective review included patients who received AC for pediatric cancers. Controls had normal echocardiograms performed for evaluation of chest pain, murmur, or syncope. Real-time three-dimensional echocardiography was performed to evaluate LA reservoir, conduit, and booster pump function parameters. In addition to LA volume data, LV shortening fraction, spectral and tissue Doppler variables assessing diastolic function as well as myocardial performance index was obtained. Groups with and without AC therapy were compared by student t-test and chi-square test. We evaluated 136 patients, 55 (40.4%) had received AC. There was no significant difference between the groups in LV shortening fraction, diastolic as well as global function indices. LA reservoir and conduit function parameters were significantly lower in AC group compared to controls. The booster function parameters showed variable results. It is intriguing that AC-treated children have smaller LA reservoir and abnormal booster function. We speculate that these findings may reflect early changes in LA compliance associated with AC exposure. Assessment of LA volumes and function as prognostic markers of AC-induced cardiotoxicity in children is warranted.

Artificial Intelligence-Enabled Electrocardiogram Estimates Left Atrium Enlargement as a Predictor of Future Cardiovascular Disease

Background: Left atrium enlargement (LAE) can be used as a predictor of future cardiovascular diseases, including hypertension (HTN) and atrial fibrillation (Afib). Typical electrocardiogram (ECG) changes have been reported in patients with LAE. This study developed a deep learning model (DLM)-enabled ECG system to identify patients with LAE. Method: Patients who had ECG records with corresponding echocardiography (ECHO) were included. There were 101,077 ECGs, 20,510 ECGs, 7611 ECGs, and 11,753 ECGs in the development, tuning, internal validation, and external validation sets, respectively. We evaluated the performance of a DLM-enabled ECG for diagnosing LAE and explored the prognostic value of ECG-LAE for new-onset HTN, new-onset stroke (STK), new-onset mitral regurgitation (MR), and new-onset Afib. Results: The DLM-enabled ECG achieved AUCs of 0.8127/0.8176 for diagnosing mild LAE, 0.8587/0.8688 for diagnosing moderate LAE, and 0.8899/0.8990 for diagnosing severe LAE in the internal/external validation sets. Notably, ECG-LAE had higher prognostic value compared to ECHO-LAE, which had C-indices of 0.711/0.714 compared to 0.695/0.692 for new-onset HTN, 0.676/0.688 compared to 0.663/0.677 for new-onset STK, 0.696/0.695 compared to 0.676/0.673 for new-onset MR, and 0.800/0.806 compared to 0.786/0.760 for new-onset Afib in internal/external validation sets, respectively. Conclusions: A DLM-enabled ECG could be considered as a LAE screening tool and provide better prognostic information for related cardiovascular diseases.

Effect of coronavirus disease-2019 infection on left atrial functions

Objective:

Left atrial (LA) dysfunction is a crucial risk factor for cardiovascular events, and various pathologies may affect LA function. Coronavirus disease-2019 (COVID-19) is an ongoing global pandemic causing morbidity and mortality. In the present study, we aimed to evaluate LA functions in patients who recovered from COVID-19.

Methods:

Sixty consecutive patients recovered from COVID-19 and 60 healthy individuals as a control group were included in the study. Blood samples and echocardiography measurements were obtained from each subject. The two groups were compared in terms of demographic and echocardiographic characteristics.

Results:

In the COVİD-19 group, LA maximum volume (LAV_max) (P = 0.040), LA pre-A volume (LAVpre-A) (P = 0.014), and LA active emptying fraction (P = 0.027) were higher, while LA passive emptying fraction (P = 0.035) was lower. In addition, left ventricular ejection fraction (P = 0.006) and isovolumetric relaxation time (P = 0.008) were decreased in this group. Although LA volume index was higher in the COVID-19 group, it does not reach statistical significance.

Conclusion:

LA functions may be impaired in patients recovered from COVID-19 infection.

Comparison between Nondedicated and Novel Dedicated Tracking Tool for Right Ventricular and Left Atrial Strain

BACKGROUND

Recently, dedicated speckle-tracking solutions for right ventricular (RV) and left atrial (LA) strain assessment have become commercially available. The purpose of this study was to assess the level of agreement between nondedicated (left ventricular [LV] tracking software) and novel dedicated tracking software for RV and LA strain.

METHODS

In 200 patients with various cardiovascular pathologies, we measured global longitudinal strain (GLS), free wall strain (FWS), and segmental values, as well as LA strain during reservoir, conduit, and contraction phases, by using the (1) LV-tracking software and (2) the novel dedicated tracking software for RV or LA strain analysis. Agreement between corresponding measurements obtained with the LV and dedicated RV or LA software was determined by using mean absolute difference (MAD) and Bland-Altman test. The intra- and interobserver reproducibility related to the nondedicated and novel dedicated tracking software was tested in 30 randomly selected subjects.

RESULTS

The dedicated RV-tracking software provided slightly lower strain values without reaching statistical significance. The agreement between software was best for RV GLS (MAD, 2.4 ± 1.8) and significantly poorer for segmental values (MAD ranging from 4.5 ± 3.8 to 5.1 ± 4.0; analysis of variance, P < .05). The intra- and interobserver reproducibility for RV measurements was similar with both software (P > .05 for all parameters). Left atrial mean values showed no statistical difference when obtained with the two tracking tools. The use of LA dedicated tracking software increased significantly the intra- and interobserver reproducibility for LA strain during reservoir and atrial contraction (P < .01 for both).

CONCLUSIONS

Our results suggest that the choice of tracking software does not significantly impact RV strain measurements. Nonetheless, the use of the same tracking software is recommended when performing serial measurements. The use of the dedicated software for LA strain analysis significantly improved the intra- and interobserver reproducibility.

Utility of Functional and Volumetric Left Atrial Parameters Derived From Preprocedural Cardiac CTA in Predicting Mortality After Transcatheter Aortic Valve Replacement

Background: Cardiac CTA is required for preprocedural workup before transcatheter aortic valve replacement (TAVR) and can be used to assess functional parameters of the left atrium (LA). Objective: We aimed to evaluate the utility of functional and volumetric LA parameters derived from cardiac CTA to predict mortality in patients with severe aortic stenosis (AS) undergoing TAVR. Methods: This retrospective study included 175 patients with severe AS (median age 79 years; 92 male, 83 female) who underwent cardiac CTA for clinical pre-TAVR assessment. A postdoctoral research fellow calculated maximum and minimum LA volumes using biplane area-length measurements; the values were indexed to body surface area (LAVImax and LAVImin, respectively). LA emptying fraction (LAEF) was automatically calculated. All-cause mortality within a 24-month follow-up period post-TAVR was recorded. To identify parameters predictive of mortality, Cox regression was performed, and results were summarized by hazard ratio (HR) and 95% CI. Harrell's c-index was used to assess model performance. A radiology resident repeated the measurements in a random sample of 20% (n=35) of cases, and interobserver agreement was computed using the intraclass correlation coefficient (ICC). Results: Thirty-eight deaths (22%) were recorded within a median follow-up of 21 months. LAVImax (HR 1.02 [1.01-1.04]; p=.005), LAVImin (HR 1.02 [1.01-1.04]; p<.001), and LAEF (HR 0.97 [0.95-0.99]; p=.002) were predictive of mortality in univariable analysis. After adjusting for clinical parameters, only LAEF (HR 0.97 [0.94-0.99]; p=.02) independently predicted mortality. The c-index of the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) significantly increased from 0.64 to 0.68, 0.69, and 0.70 when incorporating into the model LAVImax, LAVImin, and LAEF, respectively. ICC for maximum and minimum LA volumes and LAEF ranged from 0.94 to 0.99. Conclusion: LAEF derived from preprocedural cardiac CTA independently predicts mortality in patients with severe AS undergoing TAVR. Clinical impact: Cardiac CTA-derived LA function, evaluated during pre-TAVR workup, can be used to assess preprocedural risk and may improve risk stratification in post-TAVR surveillance.

Three-dimensional echocardiography and cardiac strain imaging in women with gestational diabetes mellitus

OBJECTIVES

Gestational diabetes mellitus (GDM) is associated with premature cardiovascular disease and adverse cardiovascular outcome in the mother. Subclinical cardiac functional changes in the left ventricle have been reported during pregnancy in women with GDM using conventional echocardiography, but results are inconsistent. The aims of the current study were to assess whether GDM is associated with biventricular systolic dysfunction in the mother and whether these cardiac changes can be detected using the novel echocardiographic modalities of strain imaging and three-dimensional (3D) echocardiography.

METHODS

This was a cross-sectional study in women with GDM and controls examined at 26-40 weeks of gestation. All women underwent echocardiography, and 3D volumes of the left and right ventricles and left atrium were collected. Ejection fraction and left ventricular mass were measured using 3D echocardiography. Left ventricular mass was indexed to body surface area. Speckle-tracking echocardiography was used to assess global longitudinal strain of the left and right ventricles and strain of the left atrium.

RESULTS

The study population included 123 women with GDM and 246 controls. Women with GDM, compared to controls, were older (35.1 ± 5.2 vs 32.4 ± 5.5 years; P < 0.001), had higher body mass index (30.6 (interquartile range (IQR), 26.2-35.2) vs 27.5 (IQR, 24.7-30.7) kg/m² ; P < 0.001) and had higher systolic blood pressure (119.9 ± 11.2 vs 116.4 ± 12.0 mmHg; P = 0.007). In all women with GDM, there was good glycemic control. In women with GDM, compared to controls, there was lower global longitudinal strain of the left ventricle (-19.3% (IQR, -21.4 to -17.6%) vs -20.1% (IQR, -22.1 to -18.7%); P = 0.002) and right ventricle (-22.2% (IQR, -26.1 to -19.8%) vs -24.1% (IQR, -27.0 to -21.9%); P < 0.001). There was no significant difference between the groups in ejection fraction, left ventricular mass, diastolic function assessed by left atrial strain, or 3D functional indices.

CONCLUSIONS

Women with GDM, compared to women with uncomplicated pregnancy, have lower left and right ventricular myocardial deformation. Volumetric assessment using 3D echocardiography does not provide additional information about maternal cardiac function. Strain imaging is a sensitive echocardiographic modality to detect early cardiac functional changes in women with GDM. Further studies are needed to assess the pattern of deterioration of cardiac function with advancing age in women with a history of GDM. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Genome-wide association study identifies 18 novel loci associated with left atrial volume and function

Aims 

Left atrial (LA) volume and function impose significant impact on cardiovascular pathogenesis if compromised. We aimed at investigating the genetic architecture of LA volume and function using cardiac magnetic resonance imaging data.

Methods and results 

We used the UK Biobank, which is a large prospective population study with available phenotypic and genetic data. On a subset of 35 658 European individuals, we performed genome-wide association studies on five volumetric and functional LA variables, generated using a machine learning algorithm. In total, we identified 18 novel genetic loci, mapped to genes with known roles in cardiomyopathy (e.g. MYO18B, TTN, DSP, ANKRD1) and arrhythmia (e.g. TTN, CASQ2, MYO18B, C9orf3). We observed high genetic correlation between LA volume and function and stroke, which was most pronounced for LA passive emptying fraction (r_g = 0.40, P = 4 × 10⁻⁶). To investigate whether the genetic risk of atrial fibrillation (AF) is associated with LA traits that precede overt AF, we produced a polygenetic risk score for AF. We found that polygenetic risk for AF is associated with increased LA volume and decreased LA function in participants without AF [LA_max 0.25 (mL/m²)/standard deviation (SD), 95% confidence interval (CI) (0.15; 0.36), P = 5.13 × 10⁻⁶; LA_min 0.21 (mL/m²)/SD, 95% CI (0.15; 0.28), P = 1.86 × 10⁻¹⁰; LA active emptying fraction −0.35%/SD, 95% CI (−0.43; −0.26), P = 3.14 × 10⁻¹⁴].

Conclusion 

We report on 18 genetic loci associated with LA volume and function and show evidence for several plausible candidate genes important for LA structure.

Left Ventricular Diastolic Function Studied with Magnetic Resonance Imaging: A Systematic Review of Techniques and Relation to Established Measures of Diastolic Function

Purpose: In recent years, cardiac magnetic resonance (CMR) has been used to assess LV diastolic function. In this systematic review, studies were identified where CMR parameters had been evaluated in healthy and/or patient groups with proven diastolic dysfunction or known to develop heart failure with preserved ejection fraction. We aimed at describing the parameters most often used, thresholds where possible, and correlation to echocardiographic and invasive measurements. Methods and results: A systematic literature review was performed using the databases of PubMed, Embase, and Cochrane. In total, 3808 articles were screened, and 102 studies were included. Four main CMR techniques were identified: tagging; time/volume curves; mitral inflow quantification with velocity-encoded phase-contrast sequences; and feature tracking. Techniques were described and estimates were presented in tables. From published studies, peak change of torsion shear angle versus volume changes in early diastole (−dφ′/dV′) (from tagging analysis), early peak filling rate indexed to LV end-diastolic volume <2.1 s⁻¹ (from LV time-volume curve analysis), enlarged LA maximal volume >52 mL/m², lowered LA total (<40%), and lowered LA passive emptying fractions (<16%) seem to be reliable measures of LV diastolic dysfunction. Feature tracking, especially of the atrium, shows promise but is still a novel technique. Conclusion: CMR techniques of LV untwisting and early filling and LA measures of poor emptying are promising for the diagnosis of LV filling impairment, but further research in long-term follow-up studies is needed to assess the ability for the parameters to predict patient related outcomes.

Left Atrial Function in Different Modes of Heart-Rate Lowering Therapy with Beta-Blockers in Patients with Recurrent Atrial Fibrillation and Hypertension

Aim. To study the impact of heart rate (HR) reduction with beta-blockers (BB) on left atrial (LA) function in hypertensive patients with paroxysmal or persistent mild symptomatic atrial fibrillation.

Material and methods. In this open prospective trial we randomly assigned patients with hypertension, sinus rhythm, elevated heart rate (≥70 bpm), and recurrent atrial fibrillation (EHRA 2A or less) to receive BB with a target HR of less or greater than 70 bpm for at least 4 months. All the patients underwent an echocardiogram [left atrial (LA) function was assessed as emptying fraction]and applanation tonometry at baseline and after 4 months. Primary endpoint was median LA emptying fraction (LAEF) measurement at the end of the study.

Results. 47 patients were randomized to group with a target HR of ≤70 bpm and 44 patients to >70 bmp. Among them 44 and 41 patients completed the study. Median follow up was 4.4 months. At the end of the study (4.5 months) median HR was 62 [60; 67] bmp in ≤70 group and 73 [72; 76] bpm in >70 group. Both groups received similar antihypertensive therapy and there were no intergroup differences in systolic and diastolic blood pressure. At the end of the study, patients in ≤70 group had significantly lower LAEF compared with >70 group (37% vs 42%; p=0.01). E’avg was lower and augmentation index was higher in ≤70 group as compared to >70. In regression analysis, after E’avg and augmentation index were included in the model, the association between LAEF and randomization group lost its significance.

Conclusion. Beta blockers treatment with strict HR reduction (≤70 bpm) significantly reduced LA function as compared to lenient target HR (>70 bpm).

Left atrial expansion index is associated with recurrent stroke

OBJECTIVE

Although left atrial (LA) expansion index is associated with cardiovascular prognosis, whether it affects recurrent strokes is still unknown.

METHODS

This study enrolled 176 patients hospitalized with first ischemic stroke. Their stroke subtypes were classified as cardioembolic stroke (CE), noncardioembolic stroke (NCE), embolic stroke of undetermined source (ESUS), or transient ischemic attack. The LA expansion index was calculated as (Volmax-Volmin) × 100%/Volmin, where Volmax was defined as maximal LA volume and Volmin as minimal LA volume. The study endpoint was recurrent ischemic stroke.

RESULTS

Over a five-year (mean 4.9 years) follow-up period, 21 (11.9%) participants reached the study endpoint, including 10 with CE, five with NCE, and six with ESUS. The LA expansion index was lower in the event groups compared with the non-event group. For predicting recurrent stroke, LA expansion index <62.5% (76% sensitivity and 68% specificity) was superior to LA volume and E/e'. Kaplan-Meier curves revealed that the five-year cumulative recurrent stroke rate in patients with LA expansion index <62.5% was 23.9%, which was significantly higher than the five-year cumulative recurrent stroke rate of 4.6% in patients with LA expansion index >62.5% (log rank p<0.001). The LA expansion index was a significant independent predictor of recurrent stroke (hazard ratio=0.873; 95% confidence interval: 0.790-0.973 per 10% increase in LA expansion index; p=0.009).

CONCLUSION

The LA expansion index is useful for predicting recurrent stroke.

Development and Validation of a Risk Prediction Model for Ventricular Arrhythmia in Elderly Patients with Coronary Heart Disease

BACKGROUND

Sudden cardiac death is a leading cause of death from coronary heart disease (CHD). The risk of sudden cardiac death (SCD) increases with age, and sudden arrhythmic death remains a major cause of mortality in elderly individuals, especially ventricular arrhythmias (VA). We developed a risk prediction model by combining ECG and other clinical noninvasive indexes including biomarkers and echocardiology for VA in elderly patients with CHD.

METHOD

In the retrospective study, a total of 2231 consecutive elderly patients (≥60 years old) with CHD hospitalized were investigated, and finally 1983 patients were enrolled as the model group. The occurrence of VA within 12 months was mainly collected. Study parameters included clinical characteristics (age, gender, height, weight, BMI, and past medical history), ECG indexes (QTcd, Tp-e/QT, and HRV indexes), biomarker indexes (NT-proBNP, Myo, cTnT, CK-MB, CRP, K+, and Ca2+), and echocardiology indexes. In the respective study, 406 elderly patients (≥60 years old) with CHD were included as the verification group to verify the model in terms of differentiation and calibration.

RESULTS

In the multiparameter model, seven independent predictors were selected: LVEF, LAV, HLP, QTcd, sex, Tp-e/QT, and age. Increased HLP, Tp-e/QT, QTcd, age, and LAV were risk factors (RR > 1), while female and increased LVEF were protective factors (RR < 1). This model can well predict the occurrence of VA in elderly patients with CHD (for model group, AUC: 0.721, 95% CI: 0.669∼0.772; for verification group, AUC: 0.73, 95% CI: 0.648∼0.818; Hosmer-Lemeshow χ 2 = 13.541, P=0.095). After adjusting the predictors, it was found that the combination of clinical indexes and ECG indexes could predict VA more efficiently than using clinical indexes alone.

CONCLUSIONS

LVEF, LAV, QTcd, Tp-e/QT, gender, age, and HLP were independent predictors of VA risk in elderly patients with CHD. Among these factors, the echocardiology indexes LVEF and LAV had the greatest influence on the predictive efficiency of the model, followed by ECG indexes, QTcd and Tp-e/QT. After verification, the model had a good degree of differentiation and calibration, which can provide a certain reference for clinical prediction of the VA occurrence in elderly patients with CHD.

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.

Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling in the Community

PURPOSE OF REVIEW

Echocardiography is a noninvasive tool of choice for evaluating cardiac structure and function in numerous cardiac conditions ranging from congenital heart disease, myocardial diseases, coronary artery disease (CAD), valvulopathies, arrhythmias, and pericardial disorders. We review the prognostic significance of echocardiographic indices of cardiac remodeling in the general population.

RECENT FINDINGS

Recent meta-analyses have confirmed the prognostic significance of echocardiographic measurements (left ventricular mass/hypertrophy, systolic and diastolic dysfunction, left atrial dimensions and function, and strain rate measures) in asymptomatic people in the community for adverse clinical outcomes including CAD, stroke, heart failure, atrial fibrillation, sudden death, and all-cause mortality. The clinical utility of screening echocardiography has been examined comprehensively in hypertensive patients, where it is challenged by measurement variability. Echocardiographic measures predict cardiovascular disease outcomes consistently in multiple community-based epidemiological studies. However, the clinical utility of screening asymptomatic individuals with echocardiography in population-based settings is limited.

Left ventricular end-diastolic pressure is associated with left atrial functional measures by echocardiography

Echocardiography guidelines recommend the assessment of maximal LA volume (LAV_max). Evidence, however, suggests additional value of functional LA measures. We investigated the association between functional LA measures and left ventricular end-diastolic pressure (LVEDP). Patients suspected of coronary artery disease referred for invasive coronary angiography (ICA) underwent, in addition to ICA, invasive pressure measurements. LVEDP > 12 mmHg was considered elevated. LA measurements by echocardiography included: LAV_max, minimal LA volume (LAV_min), total LA emptying fraction (LAEF_total), passive LA emptying fraction (LAEF_passive), and active LA emptying fraction (LAEF_active). Of 43 patients, 28 (65%) had elevated LVEDP. These patients more frequently had coronary vessel disease (VD) and impaired LA mechanics for all measures except LAV_max. All LA measures except LAV_max were associated with LVEDP in unadjusted linear regression analyses. After adjustment for age and VD, only LA emptying fractions remained associated with LVEDP (2.6 (1.2-4.0) mmHg increase, p = 0.001, per 5% decrease in LAEF_total; 1.4 (0.1-2.8) mmHg increase, p = 0.040, per 5% decrease in LAEF_active; 1.8 (0.1-3.4) mmHg increase, p = 0.038, per 5% decrease in LAEF_passive). In logistic regression, only LAEF_passive was significantly associated with elevated LVEDP after adjusting for age and VD (OR = 1.11 (1.01-1.21), p = 0.023, per 1% decrease). Similar findings were made in subgroup analyses among patients without dilated LA and patients without conventional indicators of elevated filling pressure. Left ventricular end-diastolic pressure is significantly associated with LA functional measures but not LA volumes. Additionally, LAEF_passive is associated with elevated LVEDP. Future studies examining LA function should include all components of LAEF.

Variability of echocardiographic measures of left ventricular diastolic function. The HUNT study

OBJECTIVE

Investigate variability related to image acquisition and reading process for echocardiographic measures of left ventricular (LV) diastolic function, and its influence on classification of LV diastolic dysfunction (LVDD).

METHODS

Forty participants (19 women) mean age 62 (28-88) years underwent echocardiographic examinations twice by different echocardiographers and blinded analyses by four readers in a cross-sectional design. Measurements included quantification of two- (2D) and three-dimensional (3D) recordings of the left atrium (LA) (maximal) volume (LAV_max ) and spectral Doppler blood flow and tissue velocities for assessment of LV diastolic function. Variability and reproducibility measures were calculated using variance component analyses and Kappa statistics.

RESULTS

Image acquisition influenced variability more than image reading (mean 24% and 4% of variance, respectively), but variability from image reading was especially important for 2D LAV_max (16% of variance) compared to 4% for 3D LAV_max , which was reflected in better agreement for 3D measures. The variability of measures used in classification of LVDD had clinical significance, and agreement across the four raters in classification using current recommendations was only fair (Kappa 0.42), but the agreement improved when using 3D LAV_max (Kappa 0.58). Agreement and reliability measures were reported for all measures.

CONCLUSION

Performing a new image acquisition influenced variability more than a introducing a new image reader, but there were differences across the different measures. LAV_max by 3D is superior to 2D with respect to lower variability. The variability of diastolic measures influences the reliability of LVDD classification, and this should be taken into account in the everyday clinic.

Correlation between left atrial expansion index and stroke subtype: A 10-Year Follow-Up Study

PURPOSE

Although left atrial (LA) expansion index predicts cardiovascular events, its efficacy for predicting cerebral events is unknown.

METHODS

This study enrolled 2205 patients who had sinus rhythm after echocardiography in their first visit. LA expansion index was calculated as (Vol_max -Vol_min ) x100%/Vol_min , where Vol_max was defined as maximal LA volume and Vol_min as minimal LA volume. The study endpoint was ischemic stroke. Stroke subtype was classified as cardioembolic stroke (CE), noncardioembolic stroke with determined mechanism (NCE), or embolic stroke of undetermined source (ESUS).

RESULTS

Over a 10-year (mean 9.7 years) follow-up period, 128 (5.8%) participants reached endpoint, including 46 with CE, 33 with NCE, and 49 with ESUS. Regardless of stroke subtype, LA expansion index was lower in the event groups compared to the nonevent group. The lowest quartile of LA expansion index was associated with high CHA₂ DS₂ -VASc score at enrollment and more events, including CE, ESUS, atrial fibrillation (AF), heart failure, and all-cause mortality, relative to other quartiles. The LA expansion index was an independent predictor of CE (HR 0.82; 95% CI 0.723-0.912, per 10% increase in LA expansion index; P < .0001) and ESUS (HR 0.92; 95% CI 0.881-0.976, per 10% increase in LA expansion index; p 0.003). An LA expansion index <68% predicts the presence of AF after ESUS with 84% sensitivity and 70% specificity.

CONCLUSION

LA expansion index is useful for predicting CE and ESUS. It is also associated with AF, heart failure hospitalization, and all-cause mortality.

The Effects of Laparoscopic Sleeve Gastrectomy on Cardiac Diastolic Function, Aortic Elasticity, and Atrial Electromechanics Delay

BACKGROUND

Obesity is a well-known risk factor for cardiovascular diseases. The aim of this study was to prospectively investigate the short-term effects of laparoscopic sleeve gastrectomy (LSG) on cardiac functions.

METHODS

Forty-four morbidly obese patients who underwent LSG were included in the study. The aortic systolic and diastolic diameters, left ventricular (LV) diameter, LV cardiac output and cardiac index, LV ejection fraction, LV septal and lateral wall velocities, deceleration time of the E wave, the LA volume index and atrial mechanic functions, and atrial conduction times were evaluated.

RESULTS

The patients' aortic stiffness index showed a significant improvement at postoperative control: 3.23 ± 0.58, 2.49 ± 0.36; p<0.001 for preoperative and postoperative aortic stiffness index, respectively. A significant reduction was observed in the LV mass and relative wall thickness (RWT) of the patients: 182.41 ± 36.87 g, 154.85 ± 24.32 g; p<0.001 and 0.42 ± 0.07, 0.39 ± 0.05; p=0.010 for the preoperative and postoperative LV mass and RWT, respectively. A statistically significant decrease was observed in total atrial conduction time and interatrial and intraatrial conduction time in the postoperative period: 120.95 ± 22.27 ms, 106.57 ± 20.46 ms; p=0.001; 13.82 ± 8.21 ms, 10.66 ± 6.78 ms; p=0.038, and 29.64 ± 14.18 ms, 24.09 ± 10.95 ms; p=0.047 for preoperative and postoperative total atrial conduction time, intraatrial electromechanical delay, and interatrial electromechanical delay, respectively.

CONCLUSIONS

Weight loss reduced aortic stiffness, IVS and posterior wall thickness, LAV, LAVi, LA passive emptying fraction, and atrial electromechanical delays in morbidly obese patients.

A Systematic Review on the Correlations between Left Atrial Strain and Cardiovascular Outcomes in Chronic Kidney Disease Patients

Left atrial strain (LASr) represents a relatively new but promising technique for left atrial and left ventricle function evaluation. LASr was strongly linked to myocardial fibrosis and endocardial thickness, suggesting the utility of LASr in subclinical cardiac dysfunction detection. As CKD negatively impacts cardiovascular risk and mortality, underlying structural and functional abnormalities of cardiac remodeling are widely investigated. LASr could be used in LV diastolic dysfunction grading with an excellent discriminatory power. Our objectives were to assess the impact and existing correlations between LASr and cardiovascular outcomes, as reported in clinical trials, including patients with CKD. We searched PubMed, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials for full-text papers. As reported in clinical studies, LASr was associated with adverse cardiovascular outcomes, including cardiovascular death and major adverse cardiovascular events (HR 0.89, 95% CI, 0.84–0.93, p < 0.01), paroxysmal atrial fibrillation (OR 0.847, 95% CI, 0.760–0.944, p = 0.003), reduced exercise capacity (AUC 0.83, 95% CI, 0.78–0.88, p < 0.01), diastolic dysfunction (p < 0.05), and estimated pulmonary capillary wedge pressure (p < 0.001). Despite limitations attributed to LA deformation imaging (image quality, inter-observer variability, software necessity, learning curve), LASr constitutes a promising marker for cardiovascular events prediction and risk evaluation in patients with CKD.

Accuracy of Diastolic Function by Cardiac Computed Tomography Relative to Echo-Doppler: Additive Clinical and Prognostic Value

OBJECTIVES

We aimed to assess the agreement between cardiac computed tomography (CT) and echo for diagnosing advanced diastolic dysfunction (DD) and to assess the prognostic value of CT-based parameters.

METHODS

One hundred one consecutive patients who had both CT and echo-Doppler within 1 month were included. Diastolic function was assessed by CT using a previously validated method, based on left atrial volume changes, and compared with echocardiography grades 0 to 3. Patients were followed up for a combined outcome of cardiac death and hospitalization for heart failure.

RESULTS

By operating characteristic curve analysis, the best CT-based parameter for predicting advanced DD based on echo was left atrial total emptying fraction. Left atrial total emptying fraction <36% had sensitivity/specificity of 76%/86%. Agreement between echo and CT for detecting advanced (grades 2/3) DD was substantial (κ = 0.62, P < 0.0001). By Cox multivariate analysis, left atrial total emptying fraction was a powerful independent predictor of outcome at 3 years (hazard ratio, 8.0 [2.2-28.4]; P < 0.0001).

CONCLUSIONS

Computed tomography-based assessment of DD has a good agreement with echo-Doppler-based results. Left atrial total emptying fraction seems to have a strong prognostic value.

Assessment of right atrial dyssynchrony by 2D speckle-tracking in healthy young men following high altitude exposure at 4100 m

Background

High altitude exposure induces overload of right-sided heart and may further predispose to supraventricular arrhythmia. It has been reported that atrial mechanical dyssynchrony is associated with atrial arrhythmia. Whether high altitude exposure causes higher right atrial (RA) dyssynchrony is still unknown. The aim of study was to investigate the effect of high altitude exposure on right atrial mechanical synchrony.

Methods

In this study, 98 healthy young men underwent clinical examination and echocardiography at sea level (400 m) and high altitude (4100 m) after an ascent within 7 days. RA dyssynchrony was defined as inhomogeneous timing to peak strain and strain rate using 2D speckle-tracking echocardiography.

Results

Following high altitude exposure, standard deviation of the time to peak strain (SD-TPS) [36.2 (24.5, 48.6) ms vs. 21.7 (12.9, 32.1) ms, p<0.001] and SD-TPS as percentage of R–R’ interval (4.6 ± 2.1% vs. 2.5 ± 1.8%, p<0.001) significantly increased. Additionally, subjects with higher SD-TPS (%) at high altitude presented decreased right ventricular global longitudinal strain and RA active emptying fraction, but increased RA minimal volume index, which were not observed in lower group. Multivariable analysis showed that mean pulmonary arterial pressure and tricuspid E/A were independently associated with SD-TPS (%) at high altitude.

Conclusion

Our data for the first time demonstrated that high altitude exposure causes RA dyssynchrony in healthy young men, which may be secondary to increased pulmonary arterial pressure. In addition, subjects with higher RA dyssynchrony presented worse RA contractile function and right ventricular performance.

Characteristics and prognostic value of right ventricular (dys)function in patients with non-ischaemic dilated cardiomyopathy assessed with cardiac magnetic resonance imaging

Aims

In non‐ischaemic dilated cardiomyopathy (DCM), concomitant right ventricular (RV) dysfunction is frequently observed. This study sought to determine the correlation of RV dysfunction with several cardiac magnetic resonance (CMR) imaging characteristics in patients with DCM, and the prognostic value of RV dysfunction on all‐cause mortality and ventricular arrhythmias (VA) was evaluated.

Methods and results

Consecutive patients with DCM and left ventricular (LV) dysfunction (ejection fraction < 50%) on CMR were included retrospectively. Left atrial (LA), LV, and RV volumes and function were quantified. RV systolic dysfunction was defined as RVEF<45%. The presence and pattern of late gadolinium enhancement (LGE) on CMR were assessed visually. Septal midwall LGE was defined as midmyocardial stripe‐like or patchy hyperenhancement in the septal segments, and the extent was quantified using the full width at half maximum method. Primary endpoint was a composite of all‐cause mortality and VA, including resuscitated cardiac arrest, sustained VA, and appropriate implantable cardioverter defibrillator therapy. Secondary endpoints were time to all‐cause mortality alone and time to VA alone. A total of 216 DCM patients were included (42% female, age 58 ± 14 years). Mean RVEF was 46 ± 12%, and RV dysfunction was present in 38%. RVEF was moderately correlated with LA dilation (LA minimal volume ρ = −0.38, P < 0.001) and strongly correlated with LA and LV dysfunction (LA emptying fraction r = 0.58, P < 0.001 and LVEF ρ = 0.52, P < 0.001). Septal midwall LGE was more often observed in patients with RV dysfunction compared with patients with preserved RV function (respectively 40% vs. 26%, P = 0.04). No correlation was found between RVEF and the extent of septal midwall LGE (ρ = −0.12, P = 0.34). During a median follow‐up of 2.2 years [IQR 1.6–2.8], 30 patients experienced the primary endpoint. RV dysfunction was significantly associated with shorter time to the composite primary endpoint (HR 3.19 [95% CI 1.49–6.84], P < 0.01) and to the secondary endpoint of VA alone (HR 6.48 [95% CI 1.83–22.98], P < 0.01). There was a trend towards increased mortality when RV dysfunction was present (HR 2.54 [95% CI 0.99–6.57], P = 0.05).

Conclusions

Right ventricular dysfunction was predominantly observed in patients with DCM with advanced heart failure and pronounced myocardial remodelling, defined as increased LV and LA dilation and dysfunction and the presence of septal midwall LGE on CMR. During follow‐up, RV dysfunction was associated with shorter time to all‐cause mortality and ventricular arrhythmic events.

Percutaneous Left Atrial Appendage Occlusion Yields Favorable Neurological Outcomes in Patients with Non-Valvular Atrial Fibrillation

BACKGROUND AND OBJECTIVES

Prior studies have shown that stroke patients treated with percutaneous left atrial appendage occlusion (LAAO) for non-valvular atrial fibrillation (NVAF) experience better outcomes than similar patients treated with warfarin. We investigated the impact of percutaneous left atrial appendage closure on post-stroke neurological outcomes in NVAF patients, compared with non-vitamin K antagonist oral anticoagulant (NOAC) therapy.

METHODS

Medical records for 1,427 patients in multiple registries and for 1,792 consecutive patients at 6 Korean hospitals were reviewed with respect to LAAO or NOAC treatment. Stroke severity in patients who experienced ischemic stroke or transient ischemic attack after either treatment was assessed with modified Rankin Scale (mRS) scoring at hospital discharge and at 3 and 12 months post-stroke.

RESULTS

mRS scores were significantly lower in LAAO patients at 3 (p<0.01) and 12 months (p<0.01) post-stroke, despite no significant differences in scores before the ischemic cerebrovascular event (p=0.22). The occurrences of disabling ischemic stroke in the LAAO and NOAC groups were 36.7% and 44.2% at discharge (p=0.47), 23.3% and 44.2% at 3 months post-stroke (p=0.04), and 13.3% and 43.0% at 12 months post-stroke (p=0.01), respectively. Recovery rates for disabling ischemic stroke at discharge to 12 months post-stroke were significantly higher for LAAO patients (50.0%) than for NOAC patients (5.6%) (p<0.01).

CONCLUSIONS

Percutaneous LAAO was associated with more favorable neurological outcomes after ischemic cerebrovascular event than NOAC treatment.