Optimal Analysis of Left Atrial Strain by Speckle Tracking Echocardiography: P-wave versus R-wave Trigger

Strain Measures of Atrial and Ventricular Diastolic Function in Pediatric Fontan Patients: Comparisons to Controls and Between Ventricular Morphology Types

BACKGROUND

Fontan patients may have abnormal diastolic function, but this is poorly characterized using conventional echocardiography. Herein, we describe atrial function and other diastolic strain measurements in a cohort of pediatric Fontan patients, with comparisons to healthy controls and between right ventricle (RV) and left ventricle (LV) types.

METHODS

This is a single-institution, cross-sectional study of healthy controls (n = 50) and patients with a Fontan circulation (n = 50, 29 RV type, 21 LV type). Parameters of atrial function and ventricular systolic and diastolic function derived from speckle-tracking echocardiography (STE) were retrospectively obtained from apical four-chamber images. These included three phases of atrial strain (Ɛ) and strain rate (SR): contraction (ac), conduit (con), and reservoir (res), and diastolic SR for passive (E-SR) and active (A-SR) filling.

RESULTS

Fontan patients had lower Ɛcon (13.4% vs. 28.2%, p < 0.01) and Ɛres (22.8% vs. 37.7%, p < 0.01) compared to controls. They had a longer time to peak atrial filling (450 ms vs. 399 ms, p < 0.01) and a greater reliance on atrial contraction for ventricular filling (atrial contraction fraction 41% vs. 26%, p < 0.01). RV type Fontan patients had longer time to peak atrial filling (461 ms vs. 406 ms, p = 0.02) and lower E-SR (1.0 %/s vs. 1.4%/s, p = 0.01) compared to LV type.

CONCLUSIONS

Several atrial and diastolic strain parameters in pediatric Fontan patients are altered compared to controls. Additionally, some metrics are more deranged in RV type Fontan patients. This highlights the need for population-specific normal values in patients with a Fontan circulation. Study of the clinical correlations and prognostic value of these STE-derived parameters is also warranted.

Left atrial stiffness index - an early marker of left ventricular diastolic dysfunction in patients with coronary heart disease

AIMS

To evaluate the correlation between left atrial stiffness index (LASI) and left ventricular diastolic function in patients with coronary heart disease (CHD) by Autostrain LA technique.

METHODS

This was a retrospective analysis that included a total of 82 CHD patients who had suitable image quality for left atrial strain measurement. According to the 2016 ASE/EACVI guidelines for the echocardiographic assessment of diastolic dysfunction, the patients were divided into three groups: normal left ventricular diastolic function group (n = 26), indeterminate left ventricular diastolic function (n = 36), and left ventricular diastolic dysfunction (LVDD) (n = 20). The left atrial conduit strain (LAScd), Left atrial contractile strain (LASct), left atrial reservoir strain (LASr) and its derived parameters, including LASI and left atrial filling index (LAFI), were compared among the three groups. Furthermore, we conduct a correlation analysis between LASI and left ventricular diastolic function in patients with CHD.

RESULTS

LASr and LAScd in normal group were higher than those in indeterminate group, LASr and LAScd in indeterminate group were higher than those in LVDD group, LASI in normal group was lower than that in indeterminate group, and LASI in indeterminate group was lower than that in LVDD group (P < 0.001). LASct in both normal and indeterminate groups was higher than that in LVDD group (P < 0.05). The LAFI of normal group was lower than that of indeterminate group and LVDD group (P < 0.001). LASI was positively correlated with E/e'(r = 0.822) (P < 0.001). LASr and E/e' were negatively correlated (r = -0.637) (P < 0.001).

CONCLUSION

LASI is closely related to the changes of left ventricular diastolic function in CHD patients.

Myocardial strain of the left ventricle by speckle tracking echocardiography: From physics to clinical practice

Speckle tracking echocardiography (STE) is a reliable imaging technique of recognized clinical value in several settings. This method uses the motion of ultrasound backscatter speckles within echocardiographic images to derive myocardial velocities and deformation parameters, providing crucial insights on several cardiac pathological and physiological processes. Its feasibility, reproducibility, and accuracy have been widely demonstrated, being myocardial strain of the various chambers inserted in diagnostic algorithms and guidelines for various pathologies. The most important parameters are Global longitudinal strain (GLS), Left atrium (LA) reservoir strain, and Global Work Index (GWI): based on large studies the average of the lower limit of normality are -16%, 23%, and 1442 mmHg%, respectively. For GWI, it should be pointed out that myocardial work relies primarily on non-invasive measurements of blood pressure and segmental strain, both of which exhibit high variability, and thus, this variability constitutes a significant limitation of this parameter. In this review, we describe the principal aspects of the theory behind the use of myocardial strain, from cardiac mechanics to image acquisition techniques, outlining its limitation, and its principal clinical applications: in particular, GLS have a role in determine subclinical myocardial dysfunction (in cardiomyopathies, cardiotoxicity, target organ damage in ambulatory patients with arterial hypertension) and LA strain in determine the risk of AF, specifically in ambulatory patients with arterial hypertension.

Myocardial function including estimates of myocardial work in young adults born very preterm or with extremely low birthweight - a cohort study

BACKGROUND

Preterm birth and low birthweight have been associated with increased risk of heart failure and cardiovascular disease in young adulthood. However, results from clinical studies of myocardial function are not consistent. Echocardiographic strain analyses allow detection of early stages of cardiac dysfunction, and non-invasive estimates of myocardial work can provide additional information on cardiac function. We aimed to evaluate left ventricular (LV) myocardial function including measures of myocardial work in young adults born very preterm (gestational age < 29 weeks) or with extremely low birthweight (< 1000 g) (PB/ELBW), compared with term-born age- and sex matched controls.

METHODS

63 PB/ELBW and 64 controls born in Norway in the periods 1982-1985, 1991-1992, and 1999-2000 were examined with echocardiography. LV ejection fraction (EF) and LV global longitudinal strain (GLS) were measured. Myocardial work was estimated from LV pressure-strain loops after determination of GLS and construction of a LV pressure curve. Diastolic function was evaluated by determination of the presence or absence of elevated LV filling pressure, including measures of left atrial longitudinal strain.

RESULTS

The PB/ELBW with mean birthweight 945 (standard deviation (SD) 217) grams, mean gestational age 27 (SD 2) weeks, and mean age 27 (SD 6) years had LV systolic function mainly within normal range. Only 6% had EF < 50% or impaired GLS >-16%, but 22% had borderline impaired GLS between - 16% and - 18%. Mean GLS in PB/ELBW (-19.4% (95% confidence interval (CI) -20.0, -18.9)) was impaired compared to controls (-20.6% (95% CI -21.1, -20.1)), p = 0.003. Lower birthweight was associated to more impaired GLS (Pearson correlation coefficient - 0.2). Means of EF, measures of diastolic function including left atrial reservoir strain, global constructive and wasted work, global work index and global work efficiency was similar in PB/ELBW and controls.

CONCLUSION

The young adults born very preterm or with extremely low birthweight had impaired LV-GLS compared to controls, although systolic function mainly within normal range. Lower birthweight was associated with more impaired LV-GLS. These findings could indicate an elevated lifetime risk of developing heart failure in preterm born individuals. Measures of diastolic function and myocardial work were similar compared to controls.

Right ventricular and atrial strain in patients with advanced melanoma undergoing immune checkpoint inhibitor therapy

AIMS

While immune checkpoint inhibitor (ICI) therapy significantly improves survival rates in advanced melanoma, ICI can evoke severe immune-related cardiovascular adverse events. Right ventricular (RV) dysfunction negatively impacts the outcomes in cardiovascular diseases and may be an early sign for overall cardiotoxicity. We aimed to assess RV function in melanoma patients undergoing ICI therapy using conventional echocardiographic and strain imaging techniques.

METHODS AND RESULTS

We retrospectively examined 30 patients (40% women, age 59 ± 13 years) with advanced melanoma (stage III/IV) before and 4 weeks after the start of ICI therapy (follow-up at 39 ± 15 days); n = 15 of the patients received nivolumab, and n = 15 received the combination therapy nivolumab/ipilimumab. Two-dimensional echocardiography with assessment of RV longitudinal strain of the free wall (RV-LSFW) and assessment of right atrial (RA) strain from speckle tracking was performed at baseline and after the start of ICI therapy. Short-term ICI therapy caused a reduction of RV-LSFW (-25.5 ± 6.4% vs. -22.4 ± 4.3%, P = 0.002) and of RA strain during contraction phase (-10.6 ± 3.5% vs. -7.7 ± 3.1%, P = 0.001). Conventional parameters including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and pulmonary artery systolic pressure were not different between the two time points (TAPSE 26 ± 5 vs. 25 ± 5 mm, P = 0.125; FAC 38 ± 13% vs. 38 ± 14%, P = 0.750; and pulmonary artery systolic pressure 27 ± 10 vs. 25 ± 8 mmHg, P = 0.268).

CONCLUSIONS

Analysis of RV and RA strain shows alterations even in a short-term follow-up, while changes in RV function are not visible by conventional RV parameters. Alterations in RV and RA strain could be early signs of cardiotoxicity and therefore should be assessed in patients undergoing ICI therapy.

Assessment of the Left Atrial Reservoir Function and Left Atrial Volume After Percutaneous Balloon Mitral Valvuloplasty Using Peak Atrial Longitudinal Strain

Objective To evaluate the impact of successful percutaneous balloon mitral valvuloplasty (BMV) on left atrial (LA) reservoir function and LA volume in patients with severe mitral stenosis (MS) using peak atrial longitudinal strain (PALS). Method This was a prospective, non-randomized observational study conducted at the Laxmipat Singhania (LPS) Institute of Cardiology, Kanpur from August 2018 to February 2020 among patients with severe rheumatic MS undergoing BMV to assess LA reservoir function and its volume after BMV using PALS. Inclusion criteria were symptomatic severe rheumatic MS (NYHA ≥II), normal ventricular systolic function, and suitable valve morphology. Exclusion criteria were the coexistence of aortic valve involvement, left atrial appendage clot, mitral leak more than mild, pregnancy, hypertension, diabetes, and coronary artery disease. To assess LA reservoir function and its volume after BMV, PALS was used. LA was divided into six regions of interest and longitudinal strain curves of individual segments together with global strain were recorded. PALS was calculated at baseline 24 hours following the intervention, and at three months of follow-up. Result Successful BMV was performed in 260 patients (109 or 41.9% males and 151 or 58.1% females), resulting in significant improvement in mitral valve area (MVA) (0.89±0.11 cm2 vs. 1.83±0.3 cm2; p<0.001). The mean age of patients was 26.7±4.7 years; 214 (82.3%) patients were in normal sinus rhythm (NSR) while 46 (17.7%) had atrial fibrillation (AF). Significant improvement in PALS was noted immediately following the procedure (6.5±11.6% vs. 7.7±10.5%; p< 0.001) and it continued to improve at three months of follow-up (6.5±11.6% vs. 11.3±12.5%; p<0.001), which was 24% and 74% improvement from baseline respectively. Significant reduction in indexed left atrial (LA) volume was observed immediately following the procedure (56.8±14.3 ml/m2 vs 48.4±12.5 ml/m2; p=0.003), and at three months of follow-up (56.8±14.3 ml/m2 vs. 45.4±13.3 ml/m2; p=0.002). Those with AF had lesser improvement in PALS in comparison to those with NSR (60% vs. 84%; p=0.044) at three months of follow-up. At three months, the increase in PALS was also lower in patients with a history of stroke as compared to those without it (55% vs 80%; p=0.039). Both LA volume and indexed LA volume reduced significantly immediately at 24 hours and during follow-up. Conclusion LA reservoir function, as assessed by PALS, is reduced in patients with severe MS. It improved significantly within 24 hours following BMV and continued to improve at three months of follow-up. It is an underutilized modality among patients of MS for decision-making prior to intervention and to assess the effect of the intervention.

Echocardiographic predictors of new-onset atrial arrhythmias in patients undergoing hematopoietic stem cell transplantation

BACKGROUND

Atrial arrhythmias following hematopoietic stem cell transplantation (HSCT) have been associated with increased length of stay, need for intensive care, and increased mortality within one-year post-transplant. We sought to identify echocardiographic parameters that may predict the development of new atrial arrhythmias post-HSCT.

METHODS

We performed a retrospective chart review of 753 consecutive patients who underwent HSCT at the University of Chicago from January 2015 through December 2019. Patients with baseline echocardiogram within 6 months prior to transplantation were included. Those with prior transplants, history of atrial arrhythmias, or unavailable echocardiographic images were excluded, resulting in 187 patients included for final analysis. Baseline clinical and demographic variables, as well as echocardiographic parameters, were compared between patients who developed new atrial arrhythmias post-HSCT versus those who did not.

RESULTS

Of the 187 patients included for analysis, 25 (13%) developed new atrial arrhythmias, with 13 of these occurring within 30 days of transplantation. Despite no significant difference in left atrial (LA) end-systolic volume between those with and without new arrhythmia following HSCT (OR 1.04; 95% CI 0.91-1.09, p = 0.233), univariable analysis demonstrated that patients who developed atrial arrhythmias had reduced LA function, as reflected by lower LA emptying fraction (OR 0.94; 95% CI 0.91-0.98, p = 0.003) and lower LA reservoir strain (OR 0.95; 95% CI 0.92-0.99, p = 0.009).

CONCLUSIONS

Echocardiographic indices of LA function, namely LA emptying fraction and LA reservoir strain, can identify patients at risk for developing new atrial arrhythmias post-HSCT, prior to the development of morphologic changes in the LA.

Echocardiographic Measurement of Left Atrial Strain - A Key Requirement in Clinical Practice

Unlike the left ventricle (LV), the left atrium (LA) has a thin-walled structure and has been regarded as a simple conduit chamber. However, the unique function of the LA to modulate LV filling has recently drawn much attention. Because LA structure and function are directly influenced by the LV filling pressure, LA assessment is an essential step in the diagnosis of diastolic dysfunction that can help predict new-onset atrial fibrillation, assess the risk of further embolic events, and identify high-risk patients for adverse cardiovascular events. Even in the recent era of multimodality imaging, 2-dimensional (2D) echocardiography is the most common imaging method and the central modality for evaluation of LA function. LA strain derived from 2D echocardiography can help assess LA function objectively and demonstrates the 3 distinct phasic motions of the LA cycle. Further, LA strain provides invaluable pathophysiologic information and helps to predict clinical prognosis in various cardiovascular diseases. In this review article, we focus on LA strain: basic concepts, advantages over conventional parameters, and some unresolved issues. Additionally, we present a brief history of the clinical evidence for LA strain. Through this review, we suggest echocardiography for LA strain assessment in clinical practice.

Quantification of left atrial contractile function using two-dimensional speckle tracking echocardiography in horses after conversion of atrial fibrillation to sinus rhythm

INTRODUCTION/OBJECTIVES

In horses, persistent atrial dysfunction is a prognostic indicator of recurrence of atrial fibrillation (AF). The objective of this study was to quantify left atrial (LA) contractile function in Warmblood horses after successful cardioversion of AF to sinus rhythm, using standard two-dimensional echocardiography (2DE) and two-dimensional speckle tracking (2DST) analyses, and to provide proof-of-concept for use of 2DST to detect LA contractile dysfunction in horses.

ANIMALS, MATERIALS, AND METHODS

Nineteen Warmblood horses with AF and successful transvenous electrical cardioversion (TVEC) or medical cardioversion using quinidine sulfate (QS) were included. Echocardiography was performed at 24 hr, 72 hr, and 1-6 months after cardioversion. Conventional 2DE-derived indices of LA size and function and global longitudinal strain (S_L) and longitudinal strain rate (SR_L) during LA contractile function were measured to detect differences in LA size and function over time and between treatment modalities. The association between 2DE-derived indices and global S_L and SR_L, respectively, and the agreement of the variables to detect LA dysfunction were assessed.

RESULTS

Global S_L and SR_L, as well as active LA fractional area change (FAC) identified cases with LA dysfunction after TVEC and QS cardioversion and proved useful to demonstrate LA functional recovery over time. Agreement between active LA FAC and S_L and SR_L, respectively, to diagnose atrial dysfunction was substantial to fair at 24 hr after cardioversion and decreased with time.

CONCLUSION

This study shows that 2DST is useful to quantify LA contractile dysfunction in horses after cardioversion of AF.

Assessing the atria in pediatric sickle cell disease: Beyond the dilation

BACKGROUND

Diastolic dysfunction (DD) and pulmonary hypertension (PH) are common causes of mortality for sickle cell disease (SCD) patients in developed countries. We hypothesized that left and right atrial strain (LAS-Ɛ, RAS-rƐ) are decreased in SCD adolescents, and that worsening values correlate with laboratory markers of disease severity.

METHODS

Prospective cohort study of patients with HbSS genotype of SCD was compared with healthy controls. LAS and RAS were measured from 4- and 2-chamber views by a blinded reader. Peak strain and strain rate values were obtained for atrial contraction (ac), reservoir (res), and conduit (con) phases. Mitral/tricuspid Doppler velocities, left atrial volume, right atrial area were obtained. Laboratory variables were obtained from the electronic record with the three prior values being averaged. Differences in variables were assessed with Wilcoxon rank sum test, and correlations assessed with Spearman's coefficient.

RESULTS

There were 33 SCD patients compared to 35 healthy controls of similar age, gender, and size. SCD patients had increased left atrial volume and right atrial area. For LAS, Ɛres was significantly lower in SCD patients. For RAS, RƐcon was significantly lower. Neither measurement correlated with clinical markers. The majority of SCD patients had relatively normal atrial strain values. Those with markedly lower values had similar atrial size.

CONCLUSIONS

A sub-set of SCD patients have markedly low Ɛres and rƐcon. No correlation with clinical markers was identified. Larger, longitudinal studies may determine utility of atrial strain as a screening tool in this at-risk population.

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume-pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference.

Assessing the left atrium of childhood cancer survivors

Survivors of childhood cancer are at risk of cancer therapy-related cardiac dysfunction (CTRCD) characterized by systolic impairment, with little known about diastolic function. Left atrial strain (LAS) is a surrogate measure of left ventricular filling. We hypothesized that survivors (1) have lower LAS versus controls, and (2) survivors exposed to higher anthracycline dosage have even lower LAS. Cross-sectional study of 45 survivors exposed to anthracyclines ≥ 1 year after chemotherapy and 45 healthy controls. Echo variables included mitral spectral and tissue Doppler, left ventricular ejection fraction (LV EF), LV dimension, LA volume, LV global longitudinal strain (GLS), and LAS. Peak strain (Ɛ) and strain rate (SR) at three phases were obtained: atrial contraction (ac), reservoir (res), and conduit (con). Two sub-analyses of cancer survivors were performed: (1) those with anthracycline dosage ≥ 250 mg/m², and (2) those with Ɛres in the lowest quartile. On the whole, survivors had lower Ɛres and Ɛcon values. The majority of survivors had relatively normal LAS, while a subset had very low LAS values and were more likely to be older. Survivors exposed to ≥ 250 mg/m² anthracycline also had lower Ɛres than those < 250 mg/m². There were no differences in mitral spectral/tissue Doppler, LV dimension, left atrial volume, or GLS. A subset of childhood cancer survivors have lower LAS than their healthy counterparts, while most are essentially normal. Those exposed to higher anthracycline dosage have even lower Ɛres. Longitudinal study of LAS may prove useful in monitoring for CTRCD.

Quantification of left atrial wall motion in healthy horses using two-dimensional speckle tracking

INTRODUCTION

The mechanical function of the left atrium (LA) plays a pivotal role in modulation of left ventricular filling. Assessment of LA function might be a clinically useful prognostic tool for horses with mitral regurgitation or atrial fibrillation. However, the most accurate, reliable, and clinically useful methods to assess LA myocardial function are yet to be determined. The objective of this study was to describe the methods for quantification of LA wall motion using two-dimensional speckle tracking (2DST) echocardiography in healthy Warmblood horses to quantify measurement variability, to calculate reference intervals for 2DST variables, and to investigate their relationship to sex, age, body weight, and heart rate.

ANIMALS, MATERIALS, AND METHODS

Twenty-six healthy Warmblood horses were included. 2DST analyses of LA wall motion were performed on digitally stored cine-loop recordings of a standardized right-parasternal four-chamber view focusing on the LA. Longitudinal strain, longitudinal strain rate, and time to peak LA contraction were measured to characterize LA contractile, reservoir, and conduit function. Intraobserver and interobserver measurement variability was quantified, and reference intervals were calculated.

RESULTS

The coefficient of variation for intraobserver and interobserver measurement variability ranged between 2.0-11.1% and 5.1-15.4%, respectively, for global strain, strain rate, and time to peak LA contraction. Reference intervals for healthy Warmblood horses were reported.

CONCLUSION

This study shows that 2DST is a feasible and reliable method to quantify LA wall motion throughout the cardiac cycle in healthy Warmblood horses. Further studies are required to establish the clinical value of 2DST for assessment of LA function.

Left Atrial Strain Correlates with Elevated Filling Pressures in Pediatric Heart Transplantation Recipients

BACKGROUND

Noninvasive assessment of diastolic function in pediatric heart transplantation (PHTx) patients is important for monitoring of rejection, cardiac allograft vasculopathy, and nonspecific graft failure. We hypothesized that left atrial strain (LAS) would correlate with pulmonary capillary wedge pressure (PCWP) and that cutoff values to identify elevated left ventricular (LV) filling pressure could be derived for clinical practice and future testing.

METHODS

This was a secondary analysis of a prospectively collected cohort of PHTx patients undergoing same-day cardiac catheterization with biopsy and transthoracic echo. There were 70 patients with 85 clinical encounters. Traditional mitral inflow Doppler, LAS, LV diastolic strain and strain rate, and ratios for mitral E to LV diastolic strain and strain rate were assessed. Correlation with PCWP was performed, and receiver operator characteristic curves were generated for an elevated mean PCWP, acute rejection, and cardiac allograft vasculopathy.

RESULTS

Decreased LAS during the atrial reservoir phase (Ɛres) correlated with higher invasively measured PCWP (r = -0.40, P < .001). An Ɛres cutoff of 14.5% had good discriminatory ability for an elevated PCWP (sensitivity 75%, specificity 82%), and Ɛres > 22.0% had 100% negative predictive value; Ɛres was superior to other measures of diastolic function. Subanalyses for recent acute rejection (n = 9) showed good discriminatory ability for Ɛres of 14.5% (sensitivity 89%, specificity 74%).

CONCLUSIONS

LAS correlates with invasively measured PCWP and can identify elevated pressures better than traditional and other advanced diastolic function parameters. Use of LAS in PHTx patients may aid in noninvasive monitoring for rejection and nonspecific graft dysfunction.

Left atrial functional response after a marathon in healthy amateur volunteers

Middle-aged marathon runners have an increased risk of developing atrial fibrillation (AF). A previous study described that repetitive marathon running was associated with left atrial (LA) dysfunction. However, whether this change is common in marathon runners and which runners are at risk of LA dysfunction remain unknown. The purpose of this study was to determine which factors could predict LA dysfunction. We prospectively examined 12 healthy amateur volunteers (9 males, 31 ± 8 years old) who participated in a full marathon. All echocardiographic measurements and speckle-tracking echocardiography were performed before and after the marathon. The endpoint was defined as reduced LA reservoir strain 1 day after the marathon (non-responder group). Seven participants were in the non-responder group. Age (35 ± 9 vs. 26 ± 2 years, p = 0.020), augmentation index (76 ± 12 vs. 55 ± 8, p = 0.002), and diastolic blood pressures (83 ± 11 vs. 70 ± 7 mmHg, p = 0.021) in the non-responder group were significantly higher compared with the responder group. In multivariate linear regression analysis, only the augmentation index was an independent predictor of reduced LA reservoir function after the marathon (β = - 0.646, p = 0.023). The augmentation index was a predictive marker for reduction in LA reservoir function after a marathon in healthy amateur volunteers.

Left atrial strain - an early marker of left ventricular diastolic dysfunction in patients with hypertension and paroxysmal atrial fibrillation

BACKGROUND

2D strain imaging of the left atrium (LA) is a new echocardiographic method which allows us to determine contractile, conduit and reservoir functions separately. This method is particularly useful when changes are subtle and not easily determined by traditional parameters, as it is in arterial hypertension and atrial fibrillation (AF).

THE AIMS OF OUR STUDY WERE

to determine LA contractile, conduit and reservoir function by 2D strain imaging in patients with mild arterial hypertension and paroxysmal AF; to assess LA contractile, conduit and reservoir functions' relation with LV diastolic dysfunction (DD) parameters.

METHODS

LA contractile, conduit and reservoir functions together with echocardiographic signs of LV DD were assessed in 63 patients with arterial hypertension and paroxysmal AF. Patients were grouped according to number of signs showing LV DD (annular e' velocity: septal e' < 7 cm/s, lateral e' < 10 cm/s, average E/e' ratio > 14, LA volume index > 34 ml/m², peak tricuspid regurgitation velocity > 2.8 m/s) present. Number of patients with 0 signs - 17, 1 sign - 26, 2 signs - 19. Contractile, conduit and reservoir functions were compared between the groups.

RESULTS

Mean contractile, conduit and reservoir strains in all the patients were - 14.14 (± 5.83) %, 15.98 (± 4.85) % and 31.03 (± 7.64) % respectively. Contractile strain did not differ between the groups. Conduit strain was higher in patients with 0 signs compared with other groups (p = 0.016 vs 1 sign of LV DD and p = 0.001 vs 2 signs of LV DD). Reservoir strain was higher in patients with 0 signs compared with other groups (p = 0.014 vs 1 sign of LV DD and p < 0.001 vs 2 signs of LV DD).

CONCLUSIONS

The patients with paroxysmal AF and primary arterial hypertension have decreased reservoir, conduit and pump LA functions even in the absence of echocardiographic signs of LV DD. With increasing number of parameters showing LV DD, LA conduit and reservoir functions decrease while contractile does not change. LA conduit and reservoir functions decrease earlier than the diagnosis of LV DD can be established according to the guidelines in patients with primary arterial hypertension and AF.

In-depth echocardiographic analysis of left atrial function in healthy adults using speckle tracking echocardiography and volumetric analysis

Purpose

Left atrial (LA) dilatation is predictive for complications in a multitude of cardiac diseases; therefore, adequate assessment is essential. Technological advances have made it possible to quantify LA function with Speckle Tracking Echocardiography (STE); however, there are currently no recommendations for normal values with regard to LA function. We aimed to assess LA myocardial and volumetric function in a healthy cohort and investigate correlations with baseline characteristics.

Methods

This prospective cohort study included 147 (aged 20–72) healthy individuals and assessed LA volumetric function using maximum, minimum and pre‐a‐wave volumes and myocardial function using reservoir function using peak strain in LA relaxation (LA‐strain), conduit function using peak strain rate in early LA contraction (LA‐SRe) and pump function using peak strain rate in late LA contraction (LA‐SRa).

Results

Mean LA‐strain was 39.7 ± 6.2%, LA‐SRe −2.78 ± 0.62 s⁻¹ and LA‐SRa −2.56 ± 0.62 s⁻¹. Subjects were divided into 5 age decades (each 50% female). LA‐strain and LA‐SRe were lower in the oldest groups, whereas LA‐SRa was higher. LA‐SRa was higher in males(−2.69 ± 0.68 s⁻¹ vs −2.42 ± 0.52 s⁻¹). Age‐specific values are provided. Age proved to be an independent predictor for LA‐SRa after correction for blood pressure and heart rate. LA expansion index and passive emptying fraction decreased with age, while active emptying fraction increased with age. LA maximum volume did not increase with age.

Conclusion

This study provides normal values for the three phasic functions of the LA, assessed with STE and volumetric function. Our results suggest the need for age‐specific reference ranges, and normal values for this cohort have been calculated.

Left atrium function and deformation in very preterm infants with and without volume load

BACKGROUND

Left atrium (LA) function can be assessed by volumetric measurements, conventional and tissue Doppler, and more recently, deformation imaging using two-dimensional speckle tracking echocardiography (2DSTE). 2DSTE allows for measurement of volume and deformation and can quantify the contribution of the reservoir, conduit, and contraction phase. A common cause for LA dysfunction in very preterm infants is volume overload with a patent ductus arteriosus (PDA). The aim of this study was to explore the feasibility and reliability of LA 2DSTE in preterm infants, and describe LA function with and without PDA volume load.

METHODS

We prospectively recruited preterm infants <30 weeks of gestation referred for assessment of a possible PDA. A cardiac ultrasound was performed at day 3 and in week 4 of life and analyzed using conventional techniques and 2DSTE.

RESULTS

Forty-eight infants (32 with PDA) were included. LA 2DSTE analysis was feasible in 96% of measurements with good reliability of strain and volume parameters. Strain rate was less reliable. Poorer LA contraction and reservoir function was associated with larger LA volume index, higher inflow over the mitral valve at early diastole, higher EA ratio, and higher Ee' ratio. Poorer conduit function was associated with higher Ee' ratio. A larger PDA diameter was found to be an independent contributor to deteriorating LA contraction and reservoir function.

CONCLUSION

LA 2DSTE analysis is feasible in preterm infants and provides detailed information on atrium mechanics. Further studies are needed to explore the clinical value of these new parameters in this population.

Effects of vitamin D deficiency on left atrial function as evaluated by 2D speckle-tracking echocardiography

PURPOSE

Vitamin D deficiency is prevalent the world over, and some of its effects on the cardiovascular system have been previously demonstrated. We evaluated left atrial (LA) function via 2D speckle-tracking echocardiography (2DSTE) in subjects with and without vitamin D deficiency.

METHODS

Ninety-seven consecutive patients without significant coronary artery disease on selective coronary angiography were incorporated in our study and divided according to their serum level of vitamin D into 2 groups: with and without vitamin D deficiency.

RESULTS

The early diastolic strain rate, as a marker of LA conduit function, was increased in patients with vitamin D deficiency (P = .008) and after adjustment for age (P = .046). However, after adjustment for all the confounding factors, vitamin D deficiency showed only a trend to be the independent determinant of LA early diastolic longitudinal strain rate (SRE, P = .065).

CONCLUSIONS

Our findings indicated that LA function, as evaluated by 2DSTE, was not different between subjects with and without vitamin D deficiency after adjustment for the confounding factors.

Left atrial function: evaluation by strain analysis

The left atrium has an important role in modulating left ventricular filling and is an important biomarker of cardiovascular disease and adverse cardiovascular outcomes. While previously left atrial (LA) size was utilised, the role of LA function as a biomarker is increasingly being evaluated, both independently and also in combination with LA size. Strain analysis has been utilised for evaluation of LA function and can be measured throughout the cardiac cycle, thereby enabling the evaluation of LA reservoir, conduit and contractile function. Strain evaluates myocardial deformation while strain rate examines the rate of change in strain. This review will focus on the various types of strain analysis for evaluation of LA function, alterations in LA strain in physiological and pathologic states that alter LA function and finally evaluate its utility as a prognostic marker.

Left atrial strain assessed by three-dimensional speckle tracking echocardiography predicts atrial fibrillation recurrence after catheter ablation in patients with paroxysmal atrial fibrillation

BACKGROUND

Several studies have shown the utility of left atrial (LA) function determined by two-dimensional or three-dimensional speckle tracking echocardiography (2D- or 3D-STE) for identifying patients with paroxysmal atrial fibrillation (AF). However, whether 3D-STE is applicable for prediction of the recurrence of AF after catheter ablation (CA) remains unknown. We examined whether any 3D-STE parameters are better than 2D-STE parameters for the prediction of AF recurrence.

METHODS

Forty-two patients with paroxysmal AF (58 ± 10 years old, 69% male) underwent 2D- and 3D-STE within 3 days before first-time CA. The global peak LA longitudinal, circumferential, and area strains during systole (3D-GLSs, -GCSs, and -GASs, respectively) and those just before atrial contraction (3D-GLSa, -GCSa, and -GASa, respectively) were determined by 3D-STE and standard deviations of times to peaks of regional LA strains were calculated as indices of LA dyssynchrony. In 2D-STE, global LA longitudinal strains during systole and just before atrial contraction (2D-GLSs and -GLSa) were determined.

RESULTS

During follow-up of 441 ± 221 days, 12 patients (29%) had AF recurrence. In the univariate Cox proportional hazard analysis, age [hazard ratio (HR): 1.08, p = 0.04], 3D-GCSs (HR: 0.91, p = 0.03), and 3D-GASs (HR: 0.95, p = 0.01) were predictors of AF recurrence, though associations of recurrence with 2D-STE parameters, indices of LA synchrony, and LA volume were not significant. Multivariable analysis showed that 3D-GASs was an independent predictor of AF recurrence (HR: 0.96, p = 0.048).

CONCLUSIONS

LA strain determined by 3D-STE is a novel and better predictor of AF recurrence after CA than that determined by 2D-STE or other known predictors.