Determinants of left atrial reservoir and pump strain and use of atrial strain for evaluation of left ventricular filling pressure

Left atrial deformation analysis in patients with non-ischaemic dilated cardiomyopathy in atrial fibrillation

Aims

Atrial fibrillation (AF) is a common comorbidity in non-ischaemic dilated cardiomyopathy (NIDCM) affecting conventional measures of left atrial (LA) function. We aimed to determine whether LA function analysis could identify patients at higher risk of major cardiovascular events (MACEs).

Methods and results

A retrospective study of patients with NIDCM in AF referred to a single centre for transthoracic echocardiography (TTE) between 2015 and 2019. Peak atrial longitudinal strain (PALS) was measured along with LA emptying fraction and LA filling index (LAFI = E wave/PALS). Cox regression analysis was conducted. A total of 153 patients were included [median age 74 years, left ventricular ejection fraction (LVEF) 35%], and 57 (37.3%) had MACE after a median follow-up of 3.2 years. LAFI was the only independent TTE parameter associated with MACE after adjustment for age, diabetes, LVEF, left ventricular global longitudinal strain (LV-GLS), and LA volume index [adjusted hazard ratio (HR) = 1.02 per point increase, P = 0.024], with the best cut-off at ≥15. LAFI ≥15 predicted each of MACE components when separately analysed: MACE HR = 1.95, 95% confidence interval (CI) 1.16-3.30; cardiovascular death HR = 3.68, 95% CI 1.41-9.56, heart failure admission HR = 2.13, 95% CI 1.19-3.80, and ventricular arrhythmia HR = 4.72, 95% CI 1.52-14.67. Higher LAFI was associated with worsening LV-GLS, E/e', systolic pulmonary artery (PA) pressure, tricuspid annular plane systolic excursion, and right ventricular to PA coupling.

Conclusion

LA deformation analysis is feasible in patients with NIDCM presenting with AF. LAFI may identify patients at higher risk of MACE and correlates with higher pulmonary pressures and worse right ventricular function, suggesting an elevation of left-sided ventricular pressures in patients with higher LAFI.

Progress in Cardiac Magnetic Resonance Feature Tracking for Evaluating Myocardial Strain in Type-2 Diabetes Mellitus

The global prevalence of type-2 diabetes mellitus (T2DM) has caused harm to human health and economies. Cardiovascular disease is one main cause of T2DM mortality. Increased prevalence of diabetes and associated heart failure (HF) is common in older populations, so accurately evaluating heart-related injury and T2DM risk factors and conducting early intervention are important. Quantitative cardiovascular system imaging assessments, including functional imaging during cardiovascular disease treatment, are also important. The left-ventricular ejection fraction (LVEF) has been traditionally used to monitor cardiac function; it is often preserved or increased in early T2DM, but subclinical heart deformation and dysfunction can occur. Myocardial strains are sensitive to global and regional heart dysfunction in subclinical T2DM. Cardiac magnetic resonance feature-tracking technology (CMR-FT) can visualize and quantify strain and identify subclinical myocardial injury for early management, especially with preserved LVEF. Meanwhile, CMR-FT can be used to evaluate the multiple cardiac chambers involvement mediated by T2DM and the coexistence of complications. This review discusses CMR-FT principles, clinical applications, and research progress in the evaluation of myocardial strain in T2DM.

Comprehensive diagnostic workup in patients with suspected heart failure and preserved ejection fraction

Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging and it could require different tests, some of which are affected by limited availability. Nowadays, considering that new therapies are available for HFpEF and related conditions, a prompt and correct diagnosis is relevant. However, the diagnostic role of biomarker level, imaging tools, score-based algorithms and invasive evaluation, should be based on the strengths and weaknesses of each test. The aim of this review is to help the clinician in diagnosing HFpEF, overcoming the diagnostic uncertainty and disentangling among the different underlying causes, in order to properly treat this kind of patient.

Noninvasive assessment of left ventricular end-diastolic pressure using machine learning-derived phasic left atrial strain

AIMS

While transthoracic echocardiography (TTE) assessment of left ventricular end-diastolic pressure (LVEDP) is critically important, the current paradigm is subject to error and indeterminate classification. Recently, peak left atrial strain (LAS) was found to be associated with LVEDP. We aimed to test the hypothesis that integration of the entire LAS time curve into a single parameter could improve the accuracy of peak LAS in the noninvasive assessment of LVEDP with TTE.

METHODS AND RESULTS

We retrospectively identified 294 patients who underwent left heart catheterization and TTE within 24 h. LAS curves were trained using machine learning (100 patients) to detect LVEDP ≥ 15 mmHg, yielding the novel parameter LAS index (LASi). The accuracy of LASi was subsequently validated (194 patients), side by side with peak LAS and ASE/EACVI guidelines, against invasive filling pressures. Within the validation cohort, invasive LVEDP was elevated in 116 (59.8%) patients. The overall accuracy of LASi, peak LAS, and American Society of Echocardiography/European Association for Cardiovascular Imaging (ASE/EACVI) algorithm was 79, 75, and 76%, respectively (excluding 37 patients with indeterminate diastolic function by ASE/EACVI guidelines). When the number of LASi indeterminates (defined by near-zero LASi values) was matched to the ASE/EACVI guidelines (n = 37), the accuracy of LASi improved to 87%. Importantly, among the 37 patients with ASE/EACVI-indeterminate diastolic function, LASi had an accuracy of 81%, compared with 76% for peak LAS.

CONCLUSION

LASi allows the detection of elevated LVEDP using invasive measurements as a reference, at least as accurately as peak LAS and current diastolic function guideline algorithm, with the advantage of no indeterminate classifications in patients with measurable LAS.

Changes of left atrial morphology and function evaluated with four-dimensional automated left atrial quantification echocardiography in patients with coronary slow flow phenomenon and preserved left ventricular ejection fraction

BACKGROUND

Coronary slow flow phenomenon (CSFP) can cause left ventricular diastolic dysfunction (LVDD). In multiple studies, the left atrial (LA) strain has been reported to be an excellent parameter for assessing LVDD. The 4-dimensional automated LA quantification (4D Auto LAQ) dedicated to the LA was recently available. Our study aimed to evaluate subclinical changes in LA morphology and function with 4D Auto LAQ in patients with CSFP and preserved left ventricular ejection fraction (LVEF).

METHODS

Forty-eight patients with CSFP confirmed with coronary angiography and 46 age and gender-matched controls with normal coronary flow were enrolled. The thrombolysis in myocardial infarction frame count (TFC) method was used to record coronary blood flow velocities for each major coronary artery. LA volume, LA longitudinal and circumferential strains during each of the three LA phases (reservoir, conduit, and contraction), LA total emptying fraction (LATEF), LA active emptying fraction (LAAEF), and LA passive emptying fraction (LAPEF) were quantified with 4D Auto LAQ analysis.

RESULTS

Compared with controls, LA longitudinal reservoir strain (LASr), LA longitudinal strain during the conduit phase (LAScd), LA contraction strain (LASct), LA conduit circumferential strain (LAScd-c), LATEF, LAPEF decreased significantly in individuals with CSFP. Of the 4D- LAQ parameters, only LASr [odds ratio (OR): 0.773, P < 0.001] and LATEF [OR: 0.762, P < 0.001] were associated with CSFP in multivariate analysis. A LASr ≤23.00% can differentiate CSFP from controls [sensitivity, 66.7%; specificity, 93.5%; area under the curve (AUC), 0.823; P < 0.001]. A LASr of ≤19.00% could predict the elevation of LV filling pressure in the CSFP cohort [sensitivity, 76.9%; specificity, 74.3%; area under the curve (AUC), 0.792; P < 0.001]. LASr was the only index to demonstrate significant changes compared to controls in single-vessel CSFP. Compared to the right coronary artery (RCA) and left circumflex (LCX), TFC of the left anterior descending (LAD) artery was the only independent variable of LASr (Standardized Coefficients: -0.386, P = 0.037).

CONCLUSIONS

Impairment of LA reservoir function reflected by changes in LASr and LATEF can be seen in patients with CSFP. LASr could predict the elevation of LV filling pressure in CSFP individuals. LASr is more sensitive than LATEF in detecting LA reservoir dysfunction in single-vessel CSFP. CSFP in LAD exerts a more prominent influence on LASr than RCA or LCX.

Left atrial expansion index measured with cardiovascular magnetic resonance estimates pulmonary capillary wedge pressure in dilated cardiomyopathy

BACKGROUND

Pulmonary capillary wedge pressure (PCWP) assessment is fundamental for managing dilated cardiomyopathy (DCM) patients. Although cardiovascular magnetic resonance (CMR) has become the gold-standard imaging technique for evaluating cardiac chamber volume and function, PCWP is not routinely assessed with CMR. Therefore, this study aimed to validate the left atrial expansion index (LAEI), a LA reservoir function parameter able to estimate filling pressure with echocardiography, as a novel CMR-measured parameter for non-invasive PCWP estimation in DCM patients.

METHODS

We performed a retrospective, single-center, cross-sectional study. We included electively admitted DCM patients referred to our tertiary center for further diagnostic evaluation that underwent a clinically indicated right heart catheterization (RHC) and CMR within 24 h. PCWP invasively measured during RHC was used as the reference. LAEI was calculated from CMR-measured LA maximal and minimal volumes as LAEI =  ( (LAVmax-LAVmin)/LAVmin) × 100.

RESULTS

We enrolled 126 patients (47 ± 14 years; 68% male; PCWP = 17 ± 9.3 mmHg) randomly divided into derivation (n = 92) and validation (n = 34) cohorts with comparable characteristics. In the derivation cohort, the log-transformed (ln) LAEI showed a strong linear correlation with PCWP (r = 0.81, p < 0.001) and remained a strong independent PCWP determinant over clinical and conventional CMR parameters. Moreover, lnLAEI accurately identified PCWP ≥ 15 mmHg (AUC = 0.939, p < 0.001), and the optimal cut-off identified (lnLAEI ≤ 3.85) in the derivation cohort discriminated PCWP ≥ 15 mmHg with 82.4% sensitivity, 88.2% specificity, and 85.3% accuracy in the validation cohort. Finally, the equation PCWP = 52.33- (9.17xlnLAEI) obtained from the derivation cohort predicted PCWP (-0.1 ± 5.7 mmHg) in the validation cohort.

CONCLUSIONS

In this cohort of DCM patients, CMR-measured LAEI resulted in a novel and useful parameter for non-invasive PCWP evaluation.

Analysis of risk factors for changes of left ventricular function indexes in Chinese patients with gout by echocardiography

Background: Echocardiographic data investigating the association between left ventricular (LV) function and gout is still limited. Purpose: To analyze the association of echocardiographic parameters based on two-dimentional speckle tracking analysis with clinically related indicators in patients with gout, and to provide a clinical basis for the early diagnosis and treatment of cardiovascular disease in patients with gout. Methods: This study collected gout patients who visited the outpatient and inpatient departments of the first affiliated hospital of chengdu medical college from November 2019 to December 2020. Spearman correlation test was performed to analyze the correlation coefficients between the laboratorial indicators with echocardiographic parameters. And the logistic regression analysis was performed to evaluate the independent effects. Results: The results of multivariate logistic regression showed that fasting plasma glucose (FPG) was a risk factor for the decrease in absolute value of global longitudinal strain [GLS (OR = 2.34; 95% CI, 1.01-5.39; p = 0.04)], Urea was a risk factor for absolute reduction in GCS (OR = 1.40; 95% CI, 1.07-1.85; p = 0.02), age (OR = 1.09, 95% CI, 1.04-1.16; p = 0.001), and hypertension (OR = 8.35; 95% CI, 1.83-38.02; p = 0.006) were risk factors for increased E/Em. High urea levels were significantly related with high risks of LVH (OR = 1.59, 95% CI, 1.04-2.43; p = 0.03) and enlargement of LAVI (OR = 1.68, 95% CI, 1.01-2.80; p = 0.04). Conclusion: Our study found that elevated urea and FPG were risk factors for subclinical LV myocardial dysfunction in patients with gout, which might provide a theoretical basis for the early diagnosis and treatment of heart disease in clinical practice.

Atrial Strain Assessment for the Early Detection of Cancer Therapy-Related Cardiac Dysfunction in Breast Cancer Women (The STRANO STUDY: Atrial Strain in Cardio-Oncology)

Left ventricular global longitudinal strain (GLS) has an important role in the diagnosis of cancer therapy-related cardiac dysfunction (CTRCD). Little is known about the role of atrial function in diagnosing CTRCD. The aim of our study was to assess the impact of anti-cancer drugs on atrial function measured by speckle-tracking echocardiography in breast cancer women. A prospective multicenter study was conducted enrolling 169 breast cancer women treated with anthracyclines. A cardiological evaluation including an electrocardiogram and echocardiogram with an analysis of GLS, left atrial (LA) strain, and LA stiffness (LASi) was performed at baseline (T0), 3 (T1), and 6 months (T2) after starting chemotherapy. The patients were divided into two groups: patients with asymptomatic mild cardiotoxicity at T1 (with a relative reduction in GLS > 15%; Group 1) and those without (Group 2). We did not find a significant change in left ventricular ejection fraction (LVEF) at T1 and T2; we found a significant change in GLS (p-value < 0.0001) in the peak atrial longitudinal strain (PALS) and in LASi (p-value < 0.0001). Impairment of atrial function was greater in Group 1 compared to Group 2. A PALS variation > 20.8% identified patients who were most likely to develop asymptomatic mild cardiotoxicity [AUC 0.62; CI (0.51-0.73) p = 0.06, sensitivity 45%, specificity 69.5%]. Conclusions: PALS and LASi significantly change during chemotherapy in association with GLS. Atrial strain is an additional parameter that could be measured together with GLS to detect cardiotoxicity early.

Impact of enzyme replacement therapy and migalastat on left atrial strain and cardiomyopathy in patients with Fabry disease

Aims

Cardiomyopathy in Fabry disease (FD) is a major determinant of morbidity and mortality. This study investigates the effects of FD-specific treatment using enzyme replacement therapy (ERT) and chaperone therapy on left atrial (LA) function using two-dimensional speckle tracking echocardiography (2DSTE).

Methods and results

In this prospective observational single-center study, 20 FD patients [10 (50%) females] treated with migalastat, 48 FD patients [24 (50%) females] treated with ERT (agalsidase-alfa and agalsidase-beta), and 30 untreated FD patients (all females) as controls were analyzed. The mean follow-up time ranged from 26 to 81 months. 2DSTE was performed for left ventricle strain, right ventricle strain, and LA strain (LAS). FD-specific treated patients presented with increased left ventricular mass index (LVMi) and higher frequency of left ventricular hypertrophy at baseline, whereas untreated control patients showed normal baseline values. FD-specific treated (including migalastat and ERT) patients showed stabilization of LAS over time (p > 0.05). LVMi was also stable in treated FD patients during observation (p > 0.05).

Conclusion

In patients with FD, treated with either ERT or chaperone therapy, LAS values measured by echocardiographic speckle tracking were stable over time, pointing toward disease stabilization.

Left atrial strain brings new insights for evaluating early diastolic dysfunction in patients with well-functioning bicuspid aortic valve

BACKGROUND

Left atrial reservoir strain (LARS) is an early sensor of left ventricular (LV) diastolic dysfunction. Still, the clinical implications of LARS in patients with well-functioning bicuspid aortic valve (BAV) remain unknown.

MATERIALS

The study recruited 103 patients with well-functioning BAV and 50 controls with tricuspid aortic valves. LARS, LV global longitudinal strain (LVGLS) and aortic elasticity indices (aortic strain, aortic distensibility and stiffness index) were acquired. This study aimed to analyze the changes of LARS and further explore the influential factors of LARS in patients with well-functioning BAV.

RESULTS

Patients with BAV had lower LARS (34.17 ± 4.85 vs. 44.72 ± 6.06 %, P < .001) and LVGLS (20.53 ± 1.28 vs. 22.30 ± .62 %, P < .001), and abnormal aortic elasticity indices (aortic strain:7.14 ± 1.57 vs. 10.99 ± 1.03 %, aortic distensibility: 5.82 ± 1.50 vs. 8.98 ± 2.42 (10-6 cm2 dyne-1 ), and stiffness index: 6.30 ± 2.30 vs. 3.92 ± .98, all P < .05) compared with controls. LARS was associated with LVGLS (r = .799), interventricular septum index (r = -.232), lateral e' (r = .290), septal e' (r = .308), E/e' ratio (r = -.392), aortic strain (r = .829), aortic distensibility (r = .361), and stiffness index (r = -.724) (all P < .05). LVGLS, aortic strain and E/e' ratio were independent influencers of LARS in the multifactorial analysis model (all P < .05).

CONCLUSION

In patients with well-functioning BAV, decreased LARS may provide evidence of subclinical LV diastolic function impairment. LARS may be helpful for clinical risk stratification in such a population.

Cardiac amyloidosis and aortic stenosis: a state-of-the-art review

Cardiac amyloidosis is caused by the extracellular deposition of amyloid fibrils in the heart, involving not only the myocardium but also any cardiovascular structure. Indeed, this progressive infiltrative disease also involves the cardiac valves and, specifically, shows a high prevalence with aortic stenosis. Misfolded protein infiltration in the aortic valve leads to tissue damage resulting in the onset or worsening of valve stenosis. Transthyretin cardiac amyloidosis and aortic stenosis coexist in patients > 65 years in about 4-16% of cases, especially in those undergoing transcatheter aortic valve replacement. Diagnostic workup for cardiac amyloidosis in patients with aortic stenosis is based on a multi-parametric approach considering clinical assessment, electrocardiogram, haematologic tests, basic and advanced echocardiography, cardiac magnetic resonance, and technetium labelled cardiac scintigraphy like technetium-99 m (99mTc)-pyrophosphate, 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid, and 99mTc-hydroxymethylene diphosphonate. However, a biopsy is the traditional gold standard for diagnosis. The prognosis of patients with coexisting cardiac amyloidosis and aortic stenosis is still under evaluation. The combination of these two pathologies worsens the prognosis. Regarding treatment, mortality is reduced in patients with cardiac amyloidosis and severe aortic stenosis after undergoing transcatheter aortic valve replacement. Further studies are needed to confirm these findings and to understand whether the diagnosis of cardiac amyloidosis could affect therapeutic strategies. The aim of this review is to critically expose the current state-of-art regarding the association of cardiac amyloidosis with aortic stenosis, from pathophysiology to treatment.

Association between epicardial adipose tissue and cardiac dysfunction in subjects with severe obesity

AIM

Epicardial adipose tissue (EAT) plays a role in obesity-related heart failure with preserved ejection fraction. However, the association of EAT thickness with the development of cardiac dysfunction in subjects with severe obesity without known cardiovascular disease is unclear. The aim of this study was to determine the association between EAT thickness and cardiac dysfunction and describe the potential value of EAT as an early marker of cardiac dysfunction.

METHODS AND RESULTS

Subjects with body mass index ≥35 kg/m2 aged 35 to 65 years, who were referred for bariatric surgery, without suspicion of or known cardiac disease, were enrolled. Conventional transthoracic echocardiography and strain analyses were performed. A total of 186 subjects were divided into tertiles based on EAT thickness, of whom 62 were in EAT-1 (EAT <3.8 mm), 63 in EAT-2 (EAT 3.8-5.4 mm), and 61 in EAT-3 (EAT >5.4 mm). Parameters of systolic and diastolic function were comparable between tertiles. Patients in EAT-3 had the lowest global longitudinal strain (GLS) and left atrial contractile strain (LASct). Linear regression showed that a one-unit increase in EAT thickness (mm) was independently associated with a decrease in GLS (%) (β coefficient -0.404, p = 0.002), and a decrease in LASct (%) (β coefficient -0.544, p = 0.027). Furthermore, EAT-3 independently predicted cardiac dysfunction as defined by a GLS <18% (odds ratio 2.8, p = 0.013) and LASct <14% (odds ratio 2.5, p = 0.045).

CONCLUSIONS

Increased EAT thickness in subjects with obesity without known cardiac disease was independently associated with subclinical cardiac dysfunction. Our findings suggest that EAT might play a role in the early stages of cardiac dysfunction in obesity before this may progress to overt clinical disease.

Left atrial strain as a predictor of left ventricular filling pressures in coronary artery disease with preserved ejection fraction: a comprehensive study with left ventricular end-diastolic and pre-atrial contraction pressures

Assessing left ventricular (LV) filling pressure (LVFP) is challenging in patients with coronary artery disease (CAD) and preserved LV ejection fraction (LVEF). We aimed to correlate left atrial strain (LAS) with two invasive complementary parameters of LVFP and compared its accuracy to other echocardiographic data to predict high LVFP. This cross-sectional, single-center study enrolled 81 outpatients with LVEF > 50% and significant CAD from a database. Near-simultaneous echocardiography and invasive measurements of both LV end-diastolic pressure (LVEDP) and LV pre-atrial contraction (pre-A) pressure were performed in each patient, based on the definition of LVEDP > 16 mmHg and LV pre-A > 12 mmHg as high LVFP. A moderate to strong correlation was observed between LAS reservoir (LASr), contractile strain, and LVEDP (r: 0.67 and 0.62, respectively; p < 0.001); the same was true for LV pre-A (r: 0.65 and 0.63, respectively; p < 0.001). LASr displayed good diagnostic performance to identify elevated LVFP, which was higher when compared to traditional parameters. Median value of LASr was higher for an isolated increase of LVEDP than for simultaneously high LV pre-A. The cutoff found to predict high LVFP was lower for LV pre-A than that one for LVEDP. In the current study, LASr did not provide an additional contribution to the 2016 diastolic function algorithm. LAS is a valuable tool for predicting LVFP in patients with CAD and preserved LVEF. The choice of LVEDP or LV pre-A as the representative marker of LVFP leads to different cutoffs to predict high pressures. The best strategy for adding this tool to a multiparametric algorithm requires further investigation.

Relative importance of left atrial reservoir strain compared with components of the HFA-PEFF score: a cross-sectional study

Background

The relative importance of left atrial reservoir strain (LASr) regarding the Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology (HFA-PEFF) score, a diagnostic tool for patients with heart failure with preserved ejection fraction (HFpEF), remains unclear. We aimed to identify the relative importance of LASr compared with variables associated with HFpEF and HFA-PEFF scores.

Methods

Between August 2021 and July 2022, we obtained retrospective data from the participants visiting a single cardiovascular center with subjective symptoms of heart failure, such as dyspnea or chest discomfort. In total, 2,712 participants with sinus rhythm and ejection fraction of more than 50% were enrolled. Multivariable logistic regression analysis, random forest analysis, and supervised machine learning algorithms were performed to identify the relative importance of LASr to the HFA-PEFF score.

Results

The average HFA-PEFF score was 2.4 ± 1.6 points. Two hundred and thirty-eight participants had 5 or 6 points. LASr showed a moderate correlation with the HFA-PEFF score (r = -0.50, p < 0.001). Impaired LASr < 25.2% was an independent variable affecting a high HFA-PEFF score with traditional diastolic function parameters and components of the HFA-PEFF diagnostic algorithm. The odds ratio (OR) [1.74, 95% confidence interval (CI) 1.23-2.47] for LASr was higher compared to that of left ventricular global longitudinal strain (OR 1.59, 95% CI 1.14-2.21), septal E/e' (OR 1.23, 95% CI 0.85-1.77), and relative wall thickness (OR 1.20, 95% CI 0.76-1.89). LASr was also a relatively more important variable in estimating a high HFA-PEFF score than TR-Vmax, septal E/e', septal e', left ventricular mass index, and relative wall thickness, the major echocardiographic components of the HFA-PEFF score.

Conclusions

LASr is an important factor with components of the HFA-PEFF score and is a useful tool to assess patients with HFpEF.

Clinical Trial Registration

URL: https://clinicaltrials.org. Unique identifiers: NCT05638230.

Corrélation du strain atrial gauche avec les pressions de remplissage du ventricule gauche chez les patients suspects d’avoir une insuffisance cardiaque ayant une fraction d’éjection préservée

INTRODUCTION

Despite different ultrasound parameters, left ventricular filling pressures (LVFP) assessment remains inconclusive in some cases.

AIM

To determine the contribution of left atrial strain (LAS) in estimating LVFP in patients with exertional symptoms and preserved left ventricular ejection fraction.

METHODS

This was a monocentric study, carried out in the cardiology department of the Interior Security Forces Hospital, La Marsa, between October 2021 and March 2022. Patients with exertional symptoms had a physical examination, a biological assessment and an ultrasound examination at rest and, if necessary, during exercise. We investigated the performance of LAS components (Peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS) and conduit function (FnC) in predicting LVFP rising. Patients were categorized into two final groups according to LVFP: Group A= high LVFP at rest or during exercise (25 patients) and Group B= not-high LVFP at rest and during exercise (48 patients).

RESULTS

Seventy-three patients were enrolled in the study, with a mean age of 61±12 years and a majority being female (57%). The median PALS was 29.3% [21.4-32.4]. The mean PACS and FnC values were 13.4%±4.9 and 13.7%±4.7, respectively. Patients with high LVFP demonstrated lower LAS parameters and elevated NT-Pro BNP levels. LAS showed negative correlations with the E/e' ratio and NT-Pro BNP. PALS emerged as an independent predictor of LVFP elevation (HR=0.71; 95% CI: 0.513-0.986; p=0.041).

CONCLUSION

This study highlights that LAS, as a simple ultrasound parameter, can effectively predict high LVFP.

Influence of exercise training on the left atrium: implications for atrial fibrillation, heart failure, and stroke

The left atrium (LA) plays a critical role in receiving pulmonary venous return and modulating left ventricular (LV) filling. With the onset of exercise, LA function contributes to the augmentation in stroke volume. Due to the growing focus on atrial imaging, there is now evidence that structural remodeling and dysfunction of the LA is associated with adverse outcomes including incident cardiovascular disease. In patients with established disease, pathological changes in atrial structure and function are associated with exercise intolerance, increased hospital admissions and mortality, independent of left ventricular function. Exercise training is widely recommended in patients with cardiovascular disease to improve patient outcomes and maintain functional capacity. There are widely documented changes in LV function with exercise, yet less attention has been given to the LA. In this review, we first describe LA physiology at rest and during exercise, before exploring its association with cardiac disease outcomes including atrial fibrillation, heart failure, and stroke. The adaptation of the LA to short- and longer-term exercise training is evaluated through review of longitudinal studies of exercise training in healthy participants free of cardiovascular disease and athletes. We then consider the changes in LA structure and function among patients with established disease, where adverse atrial remodeling may be implicated in the disease process. Finally, we consider important future directions for assessment of atrial structure and function using novel imaging modalities, in response to acute and chronic exercise.

Phenotyping heart failure by echocardiography: imaging of ventricular function and haemodynamics at rest and exercise

Traditionally, congestive heart failure (HF) was phenotyped by echocardiography or other imaging techniques according to left ventricular (LV) ejection fraction (LVEF). The more recent echocardiographic modality speckle tracking strain is complementary to LVEF, as it is more sensitive to diagnose mild systolic dysfunction. Furthermore, when LV systolic dysfunction is associated with a small, hypertrophic ventricle, EF is often normal or supernormal, whereas LV global longitudinal strain can reveal reduced contractility. In addition, segmental strain patterns may be used to identify specific cardiomyopathies, which in some cases can be treated with patient-specific medicine. In HF with preserved EF (HFpEF), a diagnostic hallmark is elevated LV filling pressure, which can be diagnosed with good accuracy by applying a set of echocardiographic parameters. Patients with HFpEF often have normal filling pressure at rest, and a non-invasive or invasive diastolic stress test may be used to identify abnormal elevation of filling pressure during exercise. The novel parameter LV work index, which incorporates afterload, is a promising tool for quantification of LV contractile function and efficiency. Another novel modality is shear wave imaging for diagnosing stiff ventricles, but clinical utility remains to be determined. In conclusion, echocardiographic imaging of cardiac function should include LV strain as a supplementary method to LVEF. Echocardiographic parameters can identify elevated LV filling pressure with good accuracy and may be applied in the diagnostic workup of patients suspected of HFpEF.

Echocardiographic Evaluation of Diastolic Function in Special Populations

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

Peak atrial longitudinal strain represents atrial fibrillation burden in daily practice: clinical implication of routine left atrial strain measurements

BACKGROUND

Usefulness of left atrial (LA) strain measurements using speckle tracking echocardiography has been reported in various clinical settings. However, clinical implication of routine LA strain measurements in daily practice remains unclear. The purpose of this study was to evaluate clinical utility of routine LA strain measurements in daily practice.

METHODS

From January 6, 2020 to December 28, 2021, 338 consecutive patients underwent echocardiography in Takagi Cardiology Clinic, and all comers were enrolled to the study. Echocardiographic measurements including peak atrial longitudinal strain (PALS) measurement using speckle tracking echocardiography were attempted in all patients.

RESULTS

PALS was obtained in 335 patients (age 71 ± 16 years, male 43%, hypertensive 74%), and mean value was 22.3 ± 11.5%. PALS was progressively impaired with worsening atrial fibrillation (AF) burden. PALS in patients without AF, in patients with history of AF (paroxysmal AF &/or ablation therapy), and in patients with AF onsite were 26.8 ± 9.8%, 20.3 ± 7.9%, and 8.1 ± 3.3%, respectively (anova p < 0.0001). In patients without history of AF at the time of echocardiography, using cut-off value of 15.0% (i.e., mean + 2SD of PALS in AF patients), Kaplan-Meier analysis revealed that impaired PALS was associated with increased new-onset AF during follow-up period (log-rank p < 0.0001).

CONCLUSION

In daily practice, PALS represents AF burden. Furthermore, impaired PALS is associated with increased new-onset AF. Therefore, routine LA strain measurements using speckle tracking echocardiography will be useful in risk stratification of AF in daily practice.

Acute Changes on Left Atrial Function during Incremental Exercise in Patients with Heart Failure with Mildly Reduced Ejection Fraction: A Case-Control Study

BACKGROUND

the aim of this study was to assess acute changes in left atrial (LA) function during incremental aerobic exercise in patients with heart failure with mildly reduced ejection fraction (HFmrEF) in comparison to healthy subjects (HS).

METHODS

twenty patients with established HFmrEF were compared with 10 HS, age-matched controls. All subjects performed a stepwise exercise test on a cycle ergometer. Echocardiography was performed at baseline, during submaximal effort, at peak of exercise, and after 5 min of recovery.

RESULTS

HS obtained a higher value of METs at peak exercise than HFmrEF (7.4 vs. 5.6; between group p = 0.002). Heart rate and systolic blood pressure presented a greater increase in the HS group than in HFmrEF (between groups p = 0.006 and 0.003, respectively). In the HFmrEF group, peak atrial longitudinal strain (PALS) and conduit strain were both increased at submaximal exercise (p < 0.05 for both versus baseline) and remained constant at peak exercise. Peak atrial contraction strain (PACS) did not show significant changes during the exercise. In the HS group, PALS and PACS increased significantly at submaximal level (p < 0.05 for both versus baseline), but PALS returned near baseline values at peak exercise; conduit strain decreased progressively during the exercise in HS. Stroke volume (SV) increased in both groups at submaximal exercise; at peak exercise, SV remained constant in the HFmrEF, while it decreased in controls (between groups p = 0.002).

CONCLUSIONS

patients with HFmrEF show a proper increase in LA reservoir function during incremental aerobic exercise that contributes to maintain SV throughout the physical effort.

Impact of Estimated Left Atrial Pressure on Cardiac Resynchronization Therapy Outcome

BACKGROUND

We investigated the impact of baseline left atrial (LA) strain data and estimated left atrial pressure (LAP) by applying the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) guidelines on cardiac resynchronization therapy (CRT) outcomes.

METHODS

Datasets of 219 CRT patients were retrospectively analysed. All patients had full echocardiographic diastolic function assessment before CRT and were classified based on the guideline algorithm into normal LAP (nLAP = 40%), elevated LAP (eLAP = 49%) and indeterminate LAP (iLAP = 11%). All relevant baseline characteristics were analysed. CRT-induced left ventricular (LV) reverse remodeling was measured as the relative change of LV end-systolic volume (LVESV) at 12 ± 6 months after CRT compared to baseline. Patients were followed up for all-cause mortality for a mean of 4.8 years [interquartile range (IQR): 2.7-6.0 years].

RESULTS

At follow-up, CRT resulted in more pronounced reduction of LVESV in patients with nLAP than in patients with eLAP. In univariate analysis, nLAP was associated with LV reverse remodelling (p < 0.001), as well as long-term survival after CRT (p < 0.01). However, multivariable analysis showed that only the association between nLAP and LV reverse remodelling after CRT is independent (p < 0.01). Adding LA strain analysis to the guideline algorithm improved the feasibility of LAP estimation without affecting the association between estimated LAP and CRT outcome.

CONCLUSION

Normal LAP before CRT, estimated using the 2016 ASE/EACVI guideline algorithm, is associated with LV reverse remodelling and long-term survival after CRT. Albeit non-independent, it can serve as a non-invasive imaging-based predictor of effective therapy. Furthermore, the inclusion of LA reservoir strain in the guideline algorithm can enhance the feasibility of LAP estimation without affecting the association between LAP and CRT outcome.

Prognostic Impact of Left Atrial Strain in Patients Hospitalized for Acute Heart Failure With Atrial Fibrillation

BACKGROUND

Patients with atrial fibrillation (AF) and heart failure (HF) have elevated left ventricular end-diastolic pressure in addition to decreased left atrial (LA) function, but there are few reports of useful prognostic indices that can be seen on echocardiography. In this study, we investigated the association between LA reservoir strain (LARS) and prognosis in this group of patients.

METHODS AND RESULTS

We retrospectively enrolled patients with acute HF complicated by AF who were consecutively admitted to hospital between January 2014 and December 2018. A total of 320 patients (mean age 79±12 years, 163 women) were included in the analysis. During a median follow-up of 473 days, 92 cardiovascular deaths and 113 all-cause deaths occurred. In the multivariate analysis, LARS was an independent predictor of all-cause death (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.90-0.99, P=0.016). Multivariate analysis also showed that the patients in the lowest LARS tertile (<7.16%) had a significantly increased risk of cardiovascular death (HR 1.76, 95% CI 1.05-2.96; P=0.033) and all-cause death (HR 1.90, 95% CI 1.17-3.08; P=0.009) in comparison with patients in the highest LARS tertile (>10.52%).

CONCLUSIONS

We found a significant association between LARS and death in patients with AF and HF. Patients with reduced LARS had poor prognosis, suggesting the need for aggressive therapy to improve their LA dysfunction.

Left Atrial Strain Imaging by Speckle Tracking Echocardiography: The Supportive Diagnostic Value in Cardiac Amyloidosis and Hypertrophic Cardiomyopathy

Background: Left atrial (LA) function is crucial for assessing left ventricular filling in various cardiovascular conditions. Cardiac Amyloidosis (CA) is characterized by atrial myopathy and LA function impairment, with diastolic dysfunction up to restrictive filling pattern, leading to progressive heart failure and arrhythmias. This study evaluates LA function and deformation using speckle tracking echocardiography (STE) in patients with CA compared to a cohort of patients with sarcomeric Hypertrophic Cardiomyopathy (HCM) and a control group. Methods: We conducted a retrospective, observational study (from January 2019 to December 2022) including a total of 100 patients: 33 with ATTR-CA, 34 with HCMs, and 33 controls. Clinical evaluation, electrocardiograms, and transthoracic echocardiography were performed. Echocardiogram images were analyzed in post-processing using EchoPac software for LA strain quantification, including LA-reservoir, LA-conduit, and LA-contraction strain. Results: The CA group exhibited significantly impaired LA function compared to HCMs and control groups, with LA-reservoir median values of -9%, LA-conduit -6.7%, and LA-contraction -3%; this impairment was consistent even in the CA subgroup with preserved ejection fraction. LA strain parameters correlated with LV mass index, LA volume index, E/e', and LV-global longitudinal strain and were found to be associated with atrial fibrillation and exertional dyspnea. Conclusions: LA function assessed by STE is significantly impaired in CA patients compared to HCMs patients and healthy controls. These findings highlight the potential supportive role of STE in the early detection and management of the disease.

Assessment the Predictive Value of Left Atrial Strain (LAS) on Exercise Tolerance in HCM Patients with E/e' between 8 and 14 by Two-Dimensional Speckle Tracking and Treadmill Stress Echocardiography

Background

The aim of this study was to evaluate the reservoir, conduit, and contraction function of the left atrium and to evaluate the predictive value of left atrial strain (LAS) on exercise tolerance in hypertrophic cardiomyopathy (HCM) patients with an E/e' between 8 and 14 by two-dimensional speckle tracking using treadmill stress echocardiography.

Methods

This was a retrospective study in which we analyzed a total of 70 patients with HCM between 2016 and 2017. According to the resting state E/e', patients were either assigned to an HCM-1 group (E/e' > 14) or an HCM-2 group (E/e' of 8 to 14). Thirty age-matched healthy controls were included in the normal group. Analysis involved the left atrial reservoir, conduit, contraction strain and reserve function.

Results

The normal group had a higher left atrial reservoir and conduit strain than the HCM-2 group; the lowest values were in the HCM-1 group. The LAS reserve capacity of the HCM-1 and HCM-2 groups was lower than those of the normal group. The left atrial contraction strain reserve ( Δ LASct%) and global longitudinal strain reserve ( Δ GLS%) were lower in the HCM-2 and HCM-1 groups than in the normal group. We also found that the Δ LASct% and Δ GLS% in the HCM-2 group were higher than in the HCM-1 group. Furthermore, the metabolic equivalents (METS) in the HCM-2 group was greater than that in the HCM-1 group. Finally, the Rest-LASr indicated the highest differential diagnostic performance for METS < 6.0 (area under curve [AUC]: 0.759); the AUC of the composite model Rest-LASr+E/e'-rest was 0.8.

Conclusions

Analysis showed that when the E/e' was between 8 and 14, the LAS and reserve capacity of HCM patients were significantly reduced. Our findings suggest that the routine assessment of LAS +E/e' can be a strategy with which to supplement current predictive models and facilitate clinical management strategies.

Potential role of left atrial strain in estimation of left atrial pressure in patients with chronic heart failure

AIMS

In a large proportion of heart failure with reduced ejection fraction (HFrEF) patients, echocardiographic estimation of left atrial pressure (LAP) is not possible when the ratio of the peak early left ventricular filling velocity over the late filling velocity (E/A ratio) is not available, which may occur due to several potential causes. Left atrial reservoir strain (LASr) is correlated with LV filling pressures and may serve as an alternative parameter in these patients. The aim of this study was to determine whether LASr can be used to estimate LAP in HFrEF patients in whom E/A ratio is not available.

METHODS AND RESULTS

Echocardiograms of chronic HFrEF patients were analysed and LASr was assessed with speckle tracking echocardiography. LAP was estimated using the current ASE/EACVI algorithm. Patients were divided into those in whom LAP could be estimated using this algorithm (LAPe) and into those in whom this was not possible because E/A ratio was not available (LAPne). We assessed the prognostic value of LASr on the primary endpoint (PEP), which comprised the composite of hospitalization for the management of acute or worsened HF, left ventricular assist device implantation, cardiac transplantation, and cardiovascular death, whichever occurred first in time. We studied 153 patients with a mean age of 58 years of whom 76% men and 82% who were in NYHA class I-II. A total of 86 were in the LAPe group and 67 in the LAPne group. LASr was significantly lower in the LAPne group as compared with the LAPe group (15.8% vs. 23.8%, P < 0.001). PEP-free survival at a median follow-up of 2.5 years was 78% in LAPe versus 51% in LAPne patients. An increase in LASr was significantly associated with a reduced risk of the PEP in LAPne patients (adjusted hazard ratio: 0.91 per %, 95% confidence interval 0.84-0.98). An abnormal LASr (<18%) was associated with a five-fold increase in reaching the PEP.

CONCLUSIONS

In HFrEF patients in whom echocardiographic estimation of LAP is not possible due to due to unavailability of E/A ratio, assessing LASr potentially carries added clinical and prognostic value.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sacubitril/Valsartan Improves Left Atrial and Ventricular Strain and Strain Rate in Patients with Heart Failure with Reduced Ejection Fraction

BACKGROUND

Data on the impact of sacubitril/valsartan (SV) therapy on phasic left atrial (LA) and left ventricular (LV) strain in heart failure with reduced ejection fraction (HFrEF) are limited. The aim of this study was to evaluate changes in two-dimensional speckle tracking (2D-STE) parameters with SV therapy in HFrEF patients.

METHODS

Prospective evaluation of HFrEF patients receiving optimized medical therapy. Two-dimensional speckle tracking (2D-STE) parameters were assessed at baseline and after 6 months of SV therapy. LA strain and strain rate (SR) in reservoir, conduit, and contraction phases were compared with LV longitudinal, radial, and circumferential strain and SR and stratified according to heart rhythm and HFrEF etiology.

RESULTS

A total of 35 patients completed the 6-month follow-up, with a mean age of 59 ± 11 years, 40% in atrial fibrillation, 43% with ischemic etiology, and LVEF of 29 ± 6%. There were significant improvements in LA reservoir, conduit, and contractile strain and SR following SV therapy, particularly among patients in sinus rhythm. There were significant improvements in longitudinal, radial, and circumferential LV function indices.

CONCLUSION

SV therapy in HFrEF was associated with improved longitudinal, radial, and circumferential function, particularly among patients in sinus rhythm. These findings can provide insights into the mechanisms underlying the improvement of cardiac function and help assess subclinical responses to the treatment.

Speckle tracking echocardiography in early disease stages: a therapy modifier?

Echocardiography has been included as a first-line tool in several international guidelines for the management of patients with various cardiac diseases. Beyond diagnosis, echocardiographic examination helps in characterizing the severity of the condition since the very first stages. In particular, the application of second-level techniques, speckle tracking echocardiography in particular, can also reveal a subclinical dysfunction, while the standard parameters are in the normality range. The present review describes the potentialities of advanced echocardiography in different settings, including arterial hypertension, atrial fibrillation, diastolic dysfunction, and oncological patients, thus opening up potential starting points for its application as a clinical routine changer.

Left atrial strain parameters derived by echocardiography are impaired in patients with acute myocarditis and preserved systolic left ventricular function

PURPOSE

Data derived by cardiac magnetic resonance (CMR) feature tracking suggest that not only left ventricular but also left atrial function is impaired in patients with acute myocarditis. Therefore, we investigated the diagnostic value of speckle tracking echocardiography of the left ventricle and left atrium in patients with acute myocarditis and normal left ventricular ejection fraction (LVEF).

METHODS AND RESULTS

30 patients with acute myocarditis confirmed by CMR according to the Lake Louise criteria and 20 healthy controls were analyzed including global longitudinal strain (GLS) and left atrial (LA) strain parameters. Although preserved LVEF was present in both groups, GLS was significantly lower in patients with acute myocarditis (GLS - 19.1 ± 1.8% vs. GLS - 22.1 ± 1.7%, p < 0.001). Further diastolic dysfunction measured by E/e' mean was significantly deteriorated in the myocarditis group compared to the control group (E/e' mean 6.4 ± 1.6 vs. 5.5 ± 1.0, p = 0.038). LA reservoir function (47.6 ± 10.4% vs. 55.5 ± 10.8%, p = 0.013) and LA conduit function (-33.0 ± 9.6% vs. -39.4 ± 9.5%, p = 0.024) were significantly reduced in patients with acute myocarditis compared to healthy controls. Also left atrial stiffness index (0.15 ± 0.05 vs. 0.10 ± 0.03, p = 0.003) as well as left atrial filling index (1.67 ± 0.47 vs. 1.29 ± 0.34, p = 0.004) were deteriorated in patients with myocarditis compared to the control group.

CONCLUSION

In patients with acute myocarditis and preserved LVEF not only GLS but also LA reservoir function, LA conduit function and left atrial stiffness index as well as left atrial filling index were impaired compared to healthy controls indicating ventricular diastolic dysfunction and elevated LV filling pressures.

Subclinical left ventricular systolic dysfunction and incident stroke in the elderly: long-term findings from Cardiovascular Abnormalities and Brain Lesions

AIMS

Heart disease is associated with an increased risk for ischaemic stroke. However, the predictive value of reduced left ventricular ejection fraction (LVEF) for stroke is controversial and only observed in patients with severe reduction. LV global longitudinal strain (LV GLS) can detect subclinical LV systolic impairment when LVEF is normal. We investigated the prognostic role of LV GLS for incident stroke in a predominantly elderly cohort.

METHODS AND RESULTS

Two-dimensional echocardiography with speckle tracking was performed in the Cardiac Abnormalities and Brain Lesions (CABL) study. Among 708 stroke-free participants (mean age 71.4 ± 9.4 years, 60.9% women), abnormal LV GLS (>-14.7%: 95% percentile of the subgroup without risk factors) was detected in 133 (18.8%). During a mean follow-up of 10.8 ± 3.9 years, 47 participants (6.6%) experienced an ischaemic stroke (26 cardioembolic or cryptogenic, 21 other subtypes). The cumulative incidence of ischaemic stroke was significantly higher in participants with abnormal LV GLS than with normal LV GLS (P < 0.001). In multivariate stepwise logistic regression analysis, abnormal LV GLS was associated with ischaemic stroke independently of cardiovascular risk factors including LVEF, LV mass, left atrial volume, subclinical cerebrovascular disease at baseline, and incident atrial fibrillation [hazard ratio (HR): 2.69, 95% confidence interval (CI): 1.47-4.92; P = 0.001]. Abnormal LV GLS independently predicted cardioembolic or cryptogenic stroke (adjusted HR: 3.57, 95% CI: 1.51-8.43; P = 0.004) but not other subtypes.

CONCLUSION

LV GLS was a strong independent predictor of ischaemic stroke in a predominantly elderly stroke-free cohort. Our findings provide insights into the brain-heart interaction and may help improve stroke primary prevention strategies.

Echo-Doppler and strain assessment of filling pressures in adults with congenitally corrected transposition and systemic right ventricles

AIMS

Systolic dysfunction of the systemic right ventricle (sRV) is common in adults with transposition of the great arteries and sRV. In acquired disease, diastology analysis for assessment of filling pressures (FP) is paramount in patient care.

METHODS AND RESULTS

Retrospective analysis of 47 adults with sRV without prior systemic tricuspid valve surgery undergoing catheterization and echocardiography within 7 days (median -2 [-1, -3]) from January 2000 to February 2021 at our institution. Median age was 48 (31, 55) years, and 16 (34.0%) patients were female. FPs were normal in 21 patients (44.7%). Left atrial size was enlarged in most patients (83.0%) with mean indexed value 58.3 ± 23.4 mL/m2. Tissue Doppler e' was not significantly different between those with high FPs vs. normal (medial 0.07 ± 0.03 vs. 0.08 ± 0.03 m/s, P = 0.63; lateral 0.08 ± 0.04 vs. 0.08 ± 0.04 m/s, P = 0.88). E velocity and subpulmonic mitral regurgitant velocity were higher in those with high FPs (0.9 ± 0.3 vs. 0.6 ± 0.2 m/s, P = 0.005; 3.8 ± 1.1 vs. 2.8 ± 0.9 m/s, P = 0.004). Left atrial reservoir strain, sRV global longitudinal strain, and subpulmonic left ventricular strain were worse in those with high FP (18.0 ± 7.6 vs. 27.9 ± 10.2%, P = 0.0009; -13.0 ± 4.4 vs. -17.9 ± 5.0%, P = 0.002; -16.8 ± 5.7 vs. -23.0 ± 3.8%, P = 0.001).

CONCLUSION

Despite the complex anatomy, FPs can be assessed non-invasively in adults with sRV without prior systemic tricuspid valve surgery. The current guideline algorithm for diastolic dysfunction in acquired heart disease has limited applicability in this population. Given the limitations of Doppler in this heterogeneous population, strain analysis can be a helpful adjunct for estimation of FPs.

Left atrial dysfunction can independently predict exercise capacity in patients with chronic heart failure who use beta-blockers

BACKGROUND

Beta-blockers are first-line clinical drugs for the treatment of chronic heart failure (CHF). In the guidelines for cardiac rehabilitation, patients with heart failure who do or do not receive beta-blocker therapy have different reference thresholds for maximal oxygen uptake (VO_2max). It has been reported that left atrial (LA) strain can be used to predict VO_2max in patients with heart failure, which can be used to assess exercise capacity. However, most existing studies included patients who did not receive beta-blocker therapy, which could have a heterogeneous influence on the conclusions. For the vast majority of CHF patients receiving beta-blockers, the exact relationship between LA strain parameters and exercise capacity is unclear.

METHODS

This cross-sectional study enrolled 73 patients with CHF who received beta-blockers. All patients underwent a thorough resting echocardiogram and a cardiopulmonary exercise test to obtain VO_2max, which was used to reflect exercise capacity.

RESULTS

LA reservoir strain, LA maximum volume index (LAVI_max), LA minimum volume index (LAVI_min) (P < 0.0001) and LA booster strain (P < 0.01) were all significantly correlated with VO_2max, and LA conduit strain was significantly correlated with VO_2max (P < 0.05) after adjusting for sex, age, and body mass index. LA reservoir strain, LAVI_max, LAVI_min (P < 0.001), and LA booster strain (P < 0.05) were significantly correlated with VO_2max after adjusting for left ventricular ejection fraction, the ratio of transmitral E velocity to tissue Doppler mitral annulus e' velocity (E/e'), and tricuspid annular plane systolic excursion. LA reservoir strain with a cutoff value of 24.9% had a sensitivity of 74% and specificity of 63% for the identification of patients with VO_2max < 16 mL/kg/min.

CONCLUSION

Among CHF patients receiving beta-blocker therapy, resting LA strain is linearly correlated with exercise capacity. LA reservoir strain is a robust independent predictor of reduced exercise capacity among all resting echocardiography parameters.

CLINICAL TRIAL REGISTRATION

This study is a part of the Baduanjin-Eight-Silken-Movement with Self-efficacy Building for Patients with Chronic Heart Failure (BESMILE-HF) trial NCT03180320 (ClinicalTrials.gov, registration date: 08/06/2017).

Heart Failure with Preserved Ejection Fraction in Children

Diastolic dysfunction (DD) refers to abnormalities in the mechanical function of the left ventricle (LV) during diastole. Severe LVDD can cause symptoms and the signs of heart failure (HF) in the setting of normal or near normal LV systolic function and is referred to as diastolic HF or HF with preserved ejection fraction (HFpEF). Pediatric cardiologists have long speculated HFpEF in children with congenital heart disease and cardiomyopathy. However, understanding the risk factors, clinical course, and validated biomarkers predictive of the outcome of HFpEF in children is challenging due to heterogeneous etiologies and overlapping pathophysiological mechanisms. The natural history of HFpEF varies depending upon the patient's age, sex, race, geographic location, nutritional status, biochemical risk factors, underlying heart disease, and genetic-environmental interaction, among other factors. Pediatric onset HFpEF is often not the same disease as in adults. Advances in the noninvasive evaluation of the LV diastolic function by strain, and strain rate analysis with speckle-tracking echocardiography, tissue Doppler imaging, and cardiac magnetic resonance imaging have increased our understanding of the HFpEF in children. This review addresses HFpEF in children and identifies knowledge gaps in the underlying etiologies, pathogenesis, diagnosis, and management, especially compared to adults with HFpEF.

Left atrial strain evaluation to assess left ventricle diastolic dysfunction and heart failure with preserved ejection fraction: a guide to clinical practice : Left atrial strain and diastolic function

Although frequently unrecognized, left atrium (LA) function plays a key role in global cardiac performance as it modulates left ventricle (LV) filling through three main functions: the LA reservoir, conduit and booster pump. Given the interdependence between the LA and the LV, it is known that LA dimension and/or LA function can be used as a surrogate for LV diastolic function.Recently, LA deformation analysis using 2-dimensional (2D) speckle tracking echocardiography (STE) strain emerged as a promising non-invasive technique that can help to estimate LV filling pressures (LVFP) and diagnose heart failure with preserved ejection fraction (HFpEF), as recently proposed in the recent 2022 European Association of Cardiovascular Imaging (EACVI) consensus which included LA reservoir strain as an additive parameter to estimate LVFP.This article aims to review the latest evidence regarding the role of LA strain in the assessment and management of LV diastolic dysfunction (LVDD) and HFpEF, providing a clinical guide with tips and tricks to use LA strain as a new technique to help to estimate LVFP.

Relation of Left Ventricular Diastolic Function to Global Fibrosis Burden: Implications for Heart Failure Risk Stratification

BACKGROUND

Left ventricular (LV) diastolic function is primarily assessed by means of echocardiography, which has limited utility in detecting fibrosis. Cardiac magnetic resonance (CMR) readily detects and quantifies fibrosis.

OBJECTIVES

In this study, the authors sought to determine the association of LV diastolic function by to echocardiography with CMR-determined global fibrosis burden and the incremental value of fibrosis with diastolic function grade in prediction of total mortality and heart failure hospitalizations.

METHODS

A total of 549 patients underwent comprehensive echocardiography and CMR within 30 days. Echocardiography was used to assess LV diastolic function, and CMR was used to determine LV volumes, mass, ejection fraction, replacement fibrosis, and percentage extracellular volume fraction (ECV).

RESULTS

Normal diastolic function was present in 142 patients; the rest had diastolic dysfunction grades I to III, except for 18 (3.3%) with indeterminate results. The event rate was higher in patients with diastolic dysfunction compared with patients with normal diastolic function (33.4% vs 15.5; P < 0.001). The model including LV diastolic function grades II and III predicted composite outcome (C-statistic: 0.71; 95% CI: 0.67-0.76), which increased by adding global fibrosis burden (C-statistic: 0.74, 95% CI: 0.70-0.78; P = 0.02). For heart failure hospitalizations, the competing risk model with LV diastolic function grades II and III was good (C-statistic: 0.78; 95% CI: 0.74-0.83) and increased significantly with the addition of global fibrosis burden (C-statistic: 0.80; 95% CI: 0.76-0.85; P = 0.03).

CONCLUSIONS

Higher grades of diastolic dysfunction are seen in patients with replacement fibrosis and increased ECV. Fibrosis burden as determined with the use of CMR provides incremental prognostic information to echocardiographic evaluation of LV diastolic function.

Assessment of left atrial deformation in patients with total anomalous pulmonary venous connection by two-dimensional speckle-tracking echocardiography

BACKGROUND

Total anomalous pulmonary venous connection (TAPVC) is a rare congenital heart disease of newborns characterized by impaired left ventricle growth and diastolic dysfunction. We hypothesized that the patients with TAPVC reduced blood flow into the left heart prenatally could affect left atrium (LA) not just growth but function. We compared the age-related changes in LA deformation using two-dimensional speckle-tracking echocardiography (2DSTE) in Patients with TAPVC.

METHOD

This single-center, retrospective cohort study was conducted on consecutive isolated TAPVC patients who underwent neonatal surgery between January 1, 2009 and January 1, 2022. The LA datasets in TAPVC patients were analyzed before surgery (n = 28) and follow-ups at 1-2 (n = 24) and 5-7 years of age (n = 13) and compared with those of age-matched healthy controls (January 2009-2022). The LA strain (ε), indicating LA function, was analyzed using QLAB represented by reservoir (εR), conduit (εCD), and contractile (εCT) strains. LA pressure was evaluated by periodic follow-up catheterization after repair.

RESULTS

Compared to the controls, the TAPVC patients had significantly smaller LA maximum volume preoperatively, and with age, the LA maximal volumes reached normal levels, while the LA minimal volumes were larger. All 2DSTE-determined LA strains showed significant reductions at all time points in the TAPVC group compared to those in the control (median εR, εCD, and εCT; before surgery: 17.0% vs. 26.0%, 12.9% vs. 15.9%, and 6.3% vs. 10.4%; follow-up at 1-2 years: 30.0% vs. 45.7%, 23.2% vs. 29.6%, and 6.1% vs. 16.3%; follow-up at 5-7 years: 31.2% vs. 43.1%, 25.0% vs. 31.2%, and 5.2% vs. 10.8%, respectively; p < 0.05). Only εCT did not represented a significant change over time even though after correction of blood flow (median εCT: 6.0% → 5.9%). Patients with pulmonary venous obstruction (PVO) at birth showed significantly decreased εR and εCD and higher LA pressure compared to those without PVO.

CONCLUSION

This study showed that nevertheless maximum volume of LA was recovered within the normal range, reduced LA strains, especially contractile function lasted from birth even after repair in Patients with TAPVC.

Left atrial reservoir strain as a novel predictor of new-onset atrial fibrillation in light-chain-type cardiac amyloidosis

AIMS

To investigate whether left arterial reservoir strain (LASr) could predict new-onset atrial fibrillation (NOAF) in patients with light-chain-type cardiac amyloidosis (ALCA).

METHODS AND RESULTS

This study enrolled 427 patients with CA from two tertiary centres between 2005 and 2019. LASr was measured using a vendor-independent analysis programme. The primary outcome was NOAF. A total of 287 patients with ALCA were included [median age 63.0 (56.0-70.0) years, 53.3% male]. The median LASr was 13.9% (10.5-20.8%). During the median follow-up of 0.85 years, AF occurred in 34 patients (11.8%). In the receiver operating characteristics curve analysis, the optimal cut-off of LASr for predicting NOAF was 14.4%. Patients with LASr ≤14.4% had a higher risk of NOAF than those with LASr >14.4% (18.1% vs. 5.1%, P < 0.010). In the multivariate analysis adjusting for confounding factors, including left arterial volume index and left ventricular global longitudinal strain (LV-GLS), higher LASr (%) was independently associated with lower risk for NOAF [adjusted hazard ratio (aHR): 0.936, 95% confidence interval (95% CI): 0.879-0.997, P = 0.039]. Furthermore, LASr ≤14.4% was an independent predictor for NOAF (aHR: 3.370, 95% CI: 1.337-8.492, P = 0.010). This remained true after accounting for all-cause death as a competing risk. Compared with Model 1 (LV-GLS) and Model 2 (LV-GLS plus LAVI), Model 3, including LASr showed a better reclassification ability for predicting NOAF (net reclassification index = 0.735, P < 0.001 compared with Model 1; net reclassification index = 0.514, P = 0.003 compared with Model 2).

CONCLUSION

LASr was an independent predictor of NOAF in patients with ALCA.

The loss of left atrial contractile function predicts a worse outcome in HFrEF patients

Background

In chronic heart failure, high intracardiac pressures induce a progressive remodeling of small pulmonary arteries up to pulmonary hypertension. At the end of left atrial conduit function, pulmonary and left heart end-systolic pressures equalization might affect left atrial systole. In this single-center prospective study, we aimed to investigate whether peak atrial contraction strain (PACS), measured by speckle tracking echocardiography, was independently associated with prognosis in heart failure with reduced ejection fraction (HFrEF).

Materials and methods

Outpatients with HFrEF and sinus rhythm referred to our echo-labs were enrolled. After clinical and echocardiographic evaluation, off-line speckle tracking echocardiography analysis was performed. Primary and secondary endpoint were cardiovascular death and heart failure hospitalization, respectively. Spline knotted survival model identified the optimal prognostic cut-off for PACS.

Results

The 152 patients were stratified based on PACS <8% (n = 76) or PACS ≥8% (n = 76). Patients with PACS <8% had lower left ventricle and left atrial reservoir strain and higher New York Heart Association (NYHA) class and left atrial volume index (LAVI). Over a mean follow-up of 3.4 ± 2 years, 117 events (51 cardiovascular death, 66 heart failure hospitalizations) were collected. By univariate and multivariate Cox analysis, PACS emerged as a strong and independent predictor of cardiovascular death and heart failure hospitalization, after adjusting for age, sex, left ventricle strain, and E/e', LAVI (HR 0.6 per 5 unit-decrease in PACS). Kaplan-Meier curves showed a sustained divergence in event-free survival rates for the two groups.

Conclusion

The reduction of PACS significantly and independently affects cardiovascular outcome in HFrEF. Therefore, its assessment, although limited to patients with sinus rhythm, could offer additive prognostic information for HFrEF patients.

Prognostic Significance of Cardiac Magnetic Resonance in Left Atrial and Biventricular Strain Analysis during the Follow-Up of Suspected Myocarditis

To assess the variation in left atrial (LA) and biventricular strain and its prognostic value in the course of suspected myocarditis, this retrospective study included 55 patients with clinically suspected myocarditis who underwent cardiac magnetic resonance (CMR) examinations at baseline and follow-up periods. Cine images were used for feature tracking analysis. Paired Student's t test, McNemar's test, and Cox proportional hazard regression were used for statistical analysis. The LA total emptying fraction was the only functional index that showed a statistically significant improvement. The initial LA peak's late negative strain rate (SRa) was the only parameter with a significant predictive power of major adverse cardiac events under univariable (hazard ratio [HR] 2.396, 95% confidence interval [CI] 1.044-5.498, p = 0.039) and multivariable Cox survival analysis when adjusted by LA strain parameters (HR 5.072, 95% CI 1.478-17.404, p = 0.010), LA strain and functional parameters (HR 7.197, 95% CI 1.679-30.846, p = 0.008), and LA and biventricular strain and functional parameters (HR 10.389, 95% CI 2.250-47.977, p = 0.003). Thus, our findings indicate that CMR strain is useful for monitoring LA and ventricular function in suspected myocarditis, that LA function may recover preceding ventricular function changes, and that LA strain may serve as an incremental tool to predict adverse outcomes.

Prognostic Value of Left Atrial Strain in Aortic Stenosis: A Competing Risk Analysis

BACKGROUND

The role of left atrial (LA) strain as an imaging biomarker in aortic stenosis is not well established. The aim of this study was to investigate the prognostic performance of phasic LA strain in relation to clinical and echocardiographic variables and N-terminal pro-B-type natriuretic peptide in asymptomatic and minimally symptomatic patients with moderate to severe aortic stenosis and left ventricular ejection fraction > 50%.

METHODS

LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were measured using speckle-tracking echocardiography. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, progression to New York Heart Association functional class III or IV, acute coronary syndrome, or syncope. Secondary outcomes 1 and 2 comprised the same end points but excluded acute coronary syndrome and additionally syncope, respectively. The prognostic performance of phasic LA strain cutoffs was evaluated in competing risk analyses, aortic valve replacement being the competing risk.

RESULTS

Among 173 patients (mean age, 69 ± 11 years; mean peak transaortic velocity, 4.0 ± 0.8 m/sec), median LASr, LAScd, and LASct were 27% (interquartile range [IQR], 22%-32%), 12% (IQR, 8%-15%), and 16% (IQR, 13%-18%), respectively. Over a median of 2.7 years (IQR, 1.4-4.6 years), the primary outcome and secondary outcomes 1 and 2 occurred in 66 (38%), 62 (36%), and 59 (34%) patients, respectively. LASr < 20%, LAScd < 6%, and LASct < 12% were identified as optimal cutoffs of the primary outcome. In competing risk analyses, progressing from echocardiographic to echocardiographic-clinical and combined models incorporating N-terminal pro-B-type natriuretic peptide, LA strain parameters outperformed other key echocardiographic variables and significantly predicted clinical outcomes. LASr < 20% was associated with the primary outcome and secondary outcome 1, LAScd < 6% with all clinical outcomes, and LASct < 12% with secondary outcome 2. LAScd < 6% had the highest specificity (95%) and positive predictive value (82%) for the primary outcome, and competing risk models incorporating LAScd < 6% had the best discriminative value.

CONCLUSIONS

In well-compensated patients with moderate to severe aortic stenosis and preserved left ventricular ejection fractions, LA strain was superior to other echocardiographic indices and incremental to N-terminal pro-B-type natriuretic peptide for risk stratification. LAScd < 6%, LASr < 20%, and LASct < 12% identified patients at higher risk for adverse outcomes.

Multi-chamber speckle tracking imaging and diagnostic value of left atrial strain in cardiac amyloidosis

AIMS

Cardiac amyloidosis (CA) affects the four heart chambers, which can all be evaluated through speckle-tracking echocardiography (STE).

METHODS AND RESULTS

We evaluated 423 consecutive patients screened for CA over 5 years at two referral centres. CA was diagnosed in 261 patients (62%) with either amyloid transthyretin (ATTR; n = 144, 34%) or amyloid light-chain (AL; n = 117, 28%) CA. Strain parameters of all chambers were altered in CA patients, particularly those with ATTR-CA. Nonetheless, only peak left atrial longitudinal strain (LA-PALS) displayed an independent association with the diagnosis of CA or ATTR-CA beyond standard echocardiographic variables and cardiac biomarkers (Model 1), or with the diagnosis of ATTR-CA beyond the validated IWT score in patients with unexplained left ventricular (LV) hypertrophy. Patients with the most severe impairment of LA strain were those most likely to have CA or ATTR-CA. Specifically, LA-PALS and/or LA-peak atrial contraction strain (PACS) in the first quartile (i.e. LA-PALS <6.65% and/or LA-PACS <3.62%) had a 3.60-fold higher risk of CA, and a 3.68-fold higher risk of ATTR-CA beyond Model 1. Among patients with unexplained LV hypertrophy, those with LA-PALS or LA-PACS in the first quartile had an 8.76-fold higher risk for CA beyond Model 1, and a 2.04-fold higher risk of ATTR-CA beyond the IWT score.

CONCLUSIONS

Among STE measures of the four chambers, PALS and PACS are the most informative ones to diagnose CA and ATTR-CA. Patients screened for CA and having LA-PALS and/or LA-PACS in the first quartile have a high likelihood of CA and ATTR-CA.

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

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

Heart failure: an update from the last years and a look at the near future

In the last years, major progress occurred in heart failure (HF) management. Quadruple therapy is now mandatory for all the patients with HF with reduced ejection fraction. Whilst verciguat is becoming available across several countries, omecamtiv mecarbil is waiting to be released for clinical use. Concurrent use of potassium-lowering agents may counteract hyperkalaemia and facilitate renin-angiotensin-aldosterone system inhibitor implementations. The results of the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trial were confirmed by the Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) trial, and we now have, for the first time, evidence for treatment of also patients with HF with preserved ejection fraction. In a pre-specified meta-analysis of major randomized controlled trials, sodium-glucose co-transporter-2 inhibitors reduced all-cause mortality, cardiovascular (CV) mortality, and HF hospitalization in the patients with HF regardless of left ventricular ejection fraction. Other steps forward have occurred in the treatment of decompensated HF. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload (ADVOR) trial showed that the addition of intravenous acetazolamide to loop diuretics leads to greater decongestion vs. placebo. The addition of hydrochlorothiazide to loop diuretics was evaluated in the CLOROTIC trial. Torasemide did not change outcomes, compared with furosemide, in TRANSFORM-HF. Ferric derisomaltose had an effect on the primary outcome of CV mortality or HF rehospitalizations in IRONMAN (rate ratio 0.82; 95% confidence interval 0.66-1.02; P = 0.070). Further options for the treatment of HF, including device therapies, cardiac contractility modulation, and percutaneous treatment of valvulopathies, are summarized in this article.

The Role of Novel Cardiac Imaging for Contemporary Management of Heart Failure

Heart failure is becoming the central problem in cardiology. Its recognition, differential diagnosis, and the monitoring of therapy are intimately coupled with cardiac imaging. Cardiac imaging has witnessed an explosive growth and differentiation, with echocardiography continuing as the first diagnostic step; the echocardiographic exam itself has become considerably more complex than in the last century, with the assessment of diastolic left ventricular function and strain imaging contributing important information, especially in heart failure. Very often, however, echocardiography can only describe the fact of functional impairment and morphologic remodeling, whereas further clarification of the underlying disease, such as cardiomyopathy, myocarditis, storage diseases, sarcoidosis, and others, remains elusive. Here, cardiovascular magnetic resonance and perfusion imaging should be used judiciously to arrive as often as possible at a clear diagnosis which ideally enables specific therapy.

Left atrial dysfunction as the major driver of heart failure with preserved ejection fraction syndrome

Left atrial (LA) dysfunction seems to play a central role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF), is associated with disease severity and poor outcomes and potentially impacts management. Identifying LA myopathy can help guide tailored therapy for HFpEF. Echocardiography allows the accurate measurement of atrial size and function, where LA strain appears to be a sensitive measure of intrinsic LA myopathy. Several therapies and devices that decompress of left atrium are being tested for HFpEF. Further investigation is required to understand the specific atrial effects of statins, mineralocorticoid receptor antagonists, and other therapies.