Left atrial volume: a powerful predictor of survival after acute myocardial infarction

Independent prognostic value of left atrial function by two-dimensional speckle tracking imaging in patients with non -ST-segment-elevation acute myocardial infarction

Background

The objective of this study is to evaluate left atrial(LA) function and its prognostic value by two-dimensional speckle tracking echocardiography (STE) in patients with non-ST-segment-elevation acute myocardial infarction (NSTEAMI).

Methods

Global longitudinal LA S/SR data obtained by 2D speckle imaging with automated software (Echo PAC, GE Medical).

Results

Clinical variables and angiographic, echocardiographic, and STE parameters were studied in 65 patients with NSTEAMI (51 males and 14 females; mean age of 60.7 ± 9.8 years) who underwent elective PCI. The final study population consisted of 51 individuals (43 males and 8 females; mean age of 62.9 ± 11.1 years) and a 12 ± 3 months follow-up was performed. A total of 22 combined cardiovascular events(20 patients) occurred. With the use of Univariable Cox regression, all parameters were evaluated in the prediction of cardiac events, ischemic events, and/or cardiac death. According to ROC analysis, baseline mean global left atrial SRs (ROC area 0.82, p = 0.001) and baseline mean global left atrial SRe (ROC area 0.68, p = 0.036) were the only predictive variables.

Conclusions

In patients with NSTEAMI, we found that the novel global strain parameter of left atrial function is a valuable predictor of combined cardiovascular events over conventional echocardiography and may therefore be an important clinical tool for risk stratification in the acute phase of NSTEAMI.

Prediction of All-Cause Mortality by the Left Atrial Volume Index in Patients With Normal Left Ventricular Filling Pressure and Preserved Ejection Fraction

OBJECTIVE

To describe the prevalence of left atrial (LA) enlargement (LAE) and its association with all-cause mortality in 10,719 patients with an early diastolic transmitral flow velocity (E) to early diastolic mitral annular velocity (e') ratio-determined normal left ventricular (LV) filling pressure and preserved LV ejection fraction (LVEF).

METHODS

We evaluated 10,719 patients (deceased patients: n = 479; mean [SD] age, 65 [14] years; 60% male; surviving patients: n = 10,240; mean (SD) age, 54 (16) years; 48% male) with estimated normal LV filling pressure (E/e' ratio ≤ 8) and preserved LVEF (≥ 50%) to determine the impact of LA volume index (LAVi) on all-cause mortality during a mean (SD) follow-up of 2.2 (1.0) years.

RESULTS

In the univariate analysis, with every milliliter per square meter increase in LAVi, all-cause mortality risk increased by 3% (hazard ratio [HR], 1.03; 95% CI, 1.02-1.04; P < .001). After adjusting for covariates, LAVi (as a continuous variable) was an independent predictor of all-cause mortality (HR, 1.015; 95% CI, 1.005-1.026; P = .01). When LAVi was assessed as a categorical variable with normal LAVi (≤ 28 mL/m(2)) as the reference group, moderate LAVi (34-39 mL/m(2)) and severe LAVi (≥ 40 mL/m(2)) were independent predictors of all-cause mortality (HR, 1.34; 95% CI, 1.01-1.79; P = .04; and HR, 1.65; 95% CI, 1.18-2.29; P = .003, respectively).

CONCLUSION

LAE was independently associated with an increased risk of all-cause mortality in our large cohort of 10,719 patients with normal LV filling pressure and preserved LVEF.

New insights into symptomatic or silent atrial fibrillation complicating acute myocardial infarction

Atrial fibrillation (AF) is the most frequent heart rhythm disorder in the general population and contributes not only to a major deterioration in quality of life but also to an increase in cardiovascular morbimortality. The onset of AF in the acute phase of myocardial infarction (MI) is a major event that can jeopardize the prognosis of patients in the short-, medium- and long-term, and is a powerful predictor of a poor prognosis after MI. The suspected mechanism underlying the excess mortality is the drop in coronary flow linked to the acceleration and arrhythmic nature of the left ventricular contractions, which reduce the left ventricular ejection fraction. The principal causes of AF-associated death after MI are linked to heart failure. Moreover, the excess risk of death in these heart failure patients has also been associated with the onset of sudden death. Whatever its form, AF has a major negative effect on patient prognosis. In recent studies, symptomatic AF was associated with inhospital mortality of 17.8%, to which can be added mortality at 1year of 18.8%. Surprisingly, silent AF also has a negative effect on the prognosis, as it is associated with an inhospital mortality rate of 10.4%, which remains high at 5.7% at 1year. Moreover, both forms of AF are independent predictors of mortality beyond traditional risk factors. The frequency and seriousness of silent AF in the short- and long-term, which were until recently rarely studied, raises the question of systematically screening for it in the acute phase of MI. Consequently, the use of continuous ECG monitoring could be a simple, effective and inexpensive solution to improve screening for AF, even though studies are still necessary to validate this strategy. Finally, complementary studies also effect of oxidative stress and endothelial dysfunction, which seem to play a major role in triggering this rhythm disorder.

Aldosterone, mortality, cardiovascular events and reverse epidemiology in end stage renal disease

BACKGROUND

Plasma aldosterone is markedly increased in end stage renal disease (ESRD). The relationship between aldosterone, all-cause and cardiovascular (CV) mortality in observational studies performed so far is controversial.

DESIGN

We investigated the relationship between aldosterone, mortality and CV events in multivariate analyses including nutrition status, inflammation, LV function and fluids volume biomarkers in 278 ESRD patients without heart failure at baseline.

RESULTS

In univariate analyses aldosterone was an inverse predictor of death (3rd tertile vs. 1st tertile Hazard ratios (HR): 0·58; 95% confidence interval (CI) 0·38-0·90. P = 0·01) and CV events (HR: 0·63; 95% CI 0·41-0·96; P = 0·03). Data adjustment for inflammation and malnutrition biomarkers substantially reduced the inverse relationship between aldosterone, mortality and CV events to be largely not significant (P = 0·31 and P = 0·36, respectively). The same was true by adjusting for volume expansion and LV dysfunction (left atrial volume and atrial natriuretic peptide) biomarkers (P = 0·30 for both outcomes). In a model adjusting for the full set of biomarkers of protein energy wasting/inflammation and volume expansion/LV dysfunction the inverse relationship between aldosterone and death and CV events was nullified (HR for death 0·98, P = 0·93; HR for CV events 0·96, P = 0·87).

CONCLUSIONS

Aldosterone is an inverse predictor of mortality and CV events in ESRD patients. This seemingly paradoxical relationship is abolished by statistical adjustment for inflammation, protein energy malnutrition, and volume expansion biomarkers indicating that it is the mere expression of the confounding effect of these factors. A clinical trial is needed to establish if aldosterone antagonism may improve clinical outcomes in ESRD.

Echocardiographic measurement of left atrial volume: Does the method matter?

BACKGROUND

Four two-dimensional echocardiographic methods (cube, ellipsoid, Simpson's and area-length) can be used to assess left atrial volume (LAV).

AIMS

To compare absolute LAV measurements and evaluate agreement regarding the semiquantitative assessment of degree of left atrial (LA) enlargement, between methods.

METHODS

We prospectively measured LAV in 51 healthy volunteers using the four methods, and defined thresholds for moderate (mean+2 standard deviations [SDs]) and severe (mean+4 SDs) LA enlargement for each method. In 372 patients referred for echocardiography, we compared absolute LAV measurements and agreement between methods.

RESULTS

LAV was significantly different between methods in the healthy volunteer group (11 ± 4, 17 ± 3, 26 ± 6 and 28 ± 7 mL/m(2), respectively; P<0.0001), resulting in different thresholds for moderate and severe LA enlargement. LAV was also significantly different in the 372 patients (30 ± 20, 47 ± 27, 61 ± 34 and 65 ± 36 mL/m(2), respectively; P<0.0001). Agreement regarding degree of LA enlargement (none, moderate, severe), using the area-length method as reference, was modest with the cube method (kappa=0.41), correct with the ellipsoid method (kappa=0.60) and excellent with Simpson's method (kappa=0.83).

CONCLUSION

The choice of the method had a major effect on assessment of degree of LA enlargement. Our results suggest that the cube and ellipsoid methods, which significantly underestimated LAV and provided modest agreement, should be disregarded. In contrast, Simpson's method and the area-length method were slightly different, but showed close agreement, and should be preferred, using dedicated thresholds (50 and 56 mL/m(2) respectively).

Beyond ejection fraction: an integrative approach for assessment of cardiac structure and function in heart failure

Left ventricular ejection fraction (LVEF) has been the central parameter used for diagnosis and management in patients with heart failure. A good predictor of adverse outcomes in heart failure when below ∼45%, LVEF is less useful as a marker of risk as it approaches normal. As a measure of cardiac function, ejection fraction has several important limitations. Calculated as the stroke volume divided by end-diastolic volume, the estimation of ejection fraction is generally based on geometric assumptions that allow for assessment of volumes based on linear or two-dimensional measurements. Left ventricular ejection fraction is both preload- and afterload-dependent, can change substantially based on loading conditions, is only moderately reproducible, and represents only a single measure of risk in patients with heart failure. Moreover, the relationship between ejection fraction and risk in patients with heart failure is modified by factors such as hypertension, diabetes, and renal function. A more complete evaluation and understanding of left ventricular function in patients with heart failure requires a more comprehensive assessment: we conceptualize an integrative approach that incorporates measures of left and right ventricular function, left ventricular geometry, left atrial size, and valvular function, as well as non-imaging factors (such as clinical parameters and biomarkers), providing a comprehensive and accurate prediction of risk in heart failure.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Relationship between increased left atrial volume and microvascular complications in patients with type 2 diabetes

AIMS

We assessed whether left atrial volume index (LAVI) was associated with the presence of microvascular complications in patients with type 2 diabetes, and whether this association was independent of hemodynamic and non-hemodynamic factors.

METHODS

We studied 157 consecutive outpatients with type 2 diabetes with no previous history of ischemic heart disease, chronic heart failure and valvular diseases. A transthoracic echocardiography and myocardial perfusion scintigraphy were performed in all participants. Presence of microvascular complications was also recorded.

RESULTS

Overall, 51 patients had decreased estimated glomerular filtration rate and/or abnormal albuminuria, 24 had diabetic retinopathy, 22 had lower-extremity sensory neuropathy, and 67 (42.7%) patients had one or more of these microvascular complications (i.e., combined endpoint). After stratifying patients by LAVI, those with LAVI ≥32 ml/m(2) had a greater prevalence of microvascular complication, lower left ventricular (LV) ejection fraction, higher LV mass index and higher E/e' ratio than those with LAVI <32 ml/m(2). Logistic regression analyses revealed that microvascular complications (singly or in combination) were associated with increased LAVI, independently of age, sex, diabetes duration, hemoglobin A1c, hypertension, LV-ejection fraction, LV mass index and the E/e' ratio.

CONCLUSIONS

These results indicate that microvascular diabetic complications are associated with increased LAVI in well-controlled type 2 diabetic patients with preserved systolic function and free from ischemic heart disease, independently of multiple potential confounders.

The Role of Magnetic Resonance Imaging and Cardiac Computed Tomography in the Assessment of Left Atrial Anatomy, Size, and Function

In the last decade, there has been increasing evidence that comprehensive evaluation of the left atrium is of utmost importance. Numerous studies have clearly demonstrated the prognostic value of left atrial volume for long-term outcome. Furthermore, advances in catheter ablation procedures used for the treatment of drug-refractory atrial fibrillation require the need for detailed knowledge of left atrial and pulmonary venous morphology as well of atrial wall characteristics. This review article discusses the role of cardiac magnetic resonance and computed tomography in assessment of left atrial size, its normal and abnormal morphology, and function. Special interest is paid to the utility of these rapidly involving noninvasive imaging methods before and after atrial fibrillation ablation.

Usefulness of traditional echocardiographic parameters in assessment of left ventricular function in patients with normal ejection fraction early after acute myocardial infarction: results from a large consecutive cohort

AIMS

The aim of this study was to assess the frequency of left ventricular (LV) systolic function impairment using classical echocardiographic parameters and their relation to myocardial damage in patients hospitalized for acute myocardial infarction (MI) with normal LV ejection fraction (LVEF ≥52% in males or ≥54% in females).

METHODS AND RESULTS

All 421 consecutive patients with MI included in the REBUS (RElevance of Biomarkers for future risk of thromboembolic events in UnSelected post-myocardial infarction patients) study underwent two-dimensional and Doppler echocardiography within 72 h after admission. A normal LVEF was present in 262 (73.8%) of the 355 patients ultimately enrolled in the study. Patients with normal LVEF more often presented with non-ST-elevation myocardial infarction and had less comorbidities when compared with those with impaired LVEF. No differences in demographic factors or relevant medications were observed. Higher value of mean annular plane systolic excursion (MAPSE), lower wall motion score index (WMSI), lower LV as well as left atrial volumes characterized patients with normal LVEF. Impaired MAPSE was present in 64.4%, WMSI >1 in 72.1%, and dilated left atrium in 33.6% of those patients. Maximal cardiac troponin concentration reflecting infarct size showed the strongest association with WMSI (β = 0.35), followed by LVEF (β = -0.29), MAPSE (β = -0.25), and indexed LV end-systolic volume (β = 0.19; P < 0.001 for all the models).

CONCLUSION

In two-third of patients with MI and normal LVEF, at least one of the other markers of systolic function was outside of the normal range. WMSI reflected the size of MI better than global LV function parameters as LVEF or MAPSE.

Role of echocardiography in clinical hypertension

Hypertension is a major and correctable cardiovascular risk factor. The correct diagnosis of hypertension and precise assessment of cardiovascular risk are essential to give proper treatment in patients with hypertension. Although echocardiography is the second-line study in the evaluation of hypertensive patients, it gives many clues suggesting bad prognosis associated with hypertension, including increased left ventricular (LV) mass, decreased LV systolic function, impaired LV diastolic function, and increased left atrial size and decreased function. Along with conventional echocardiographic methods, tissue Doppler imaging, three-dimensional echocardiography, and strain echocardiography are newer echocardiographic modalities in the evaluation of hypertensive patients in the current echocardiographic laboratories. Understanding conventional and newer echocardiographic parameters is important in the diagnosis and assessment of cardiovascular risk in hypertensive patients.

Effect of acute sleep deprivation on left atrial mechanics assessed by three-dimensional echocardiography

BACKGROUND

Although sleep deprivation (SD) affects cardiovascular system in many ways, physio-pathological changes in cardiac chamber volume and function have not been described well. The aim of the present study was to investigate the effect of SD on left atrial (LA) and ventricular function with three-dimensional (3D) echocardiography.

METHODS

Thirty-two healthy individuals (12 females, mean age 33.25 ± 8.18) were evaluated. Echocardiographic examination was performed once after a night of regular sleep and a night of sleep debt. Beside conventional parameters, 3D phasic volumes and function were measured using a commercially available 3D echocardiography system and offline analysis software.

RESULTS

Mean sleep duration of the study group was 8.15 ± 2.19 h in the day of regular sleep and 2.56 ± 2.25 h in the day of sleep deprivation. There was a significant prolongation in deceleration time (180.83 ± 15.34 vs. 166.44 ± 26.12; p = 0.044) and increase in E/e' (6.95 ± 1.26 vs. 6.38 ± 0.85; p = 0.005). Among 3D measurements, the difference in left ventricular ejection fraction (EF), LA EF, LA reservoir function and LA active EF were not significant. Mean LA passive EF of the individuals was significantly lower after night shift (24.10 ± 7.66 vs. 31.49 ± 7.75; p = 0.006).

CONCLUSION

Acute SD is associated with a reduction in LA passive emptying function in healthy adults. 3D-derived indices were sufficient to show subclinical diastolic dysfunction according to impairment in passive phase of LA ejection. Prospective large-scale studies are needed to enlighten this issue.

Single breath-hold 3D measurement of left atrial volume using compressed sensing cardiovascular magnetic resonance and a non-model-based reconstruction approach

BACKGROUND

Left atrial (LA) dilatation is associated with a large variety of cardiac diseases. Current cardiovascular magnetic resonance (CMR) strategies to measure LA volumes are based on multi-breath-hold multi-slice acquisitions, which are time-consuming and susceptible to misregistration.

AIM

To develop a time-efficient single breath-hold 3D CMR acquisition and reconstruction method to precisely measure LA volumes and function.

METHODS

A highly accelerated compressed-sensing multi-slice cine sequence (CS-cineCMR) was combined with a non-model-based 3D reconstruction method to measure LA volumes with high temporal and spatial resolution during a single breath-hold. This approach was validated in LA phantoms of different shapes and applied in 3 patients. In addition, the influence of slice orientations on accuracy was evaluated in the LA phantoms for the new approach in comparison with a conventional model-based biplane area-length reconstruction. As a reference in patients, a self-navigated high-resolution whole-heart 3D dataset (3D-HR-CMR) was acquired during mid-diastole to yield accurate LA volumes.

RESULTS

Phantom studies. LA volumes were accurately measured by CS-cineCMR with a mean difference of -4.73 ± 1.75 ml (-8.67 ± 3.54%, r2 = 0.94). For the new method the calculated volumes were not significantly different when different orientations of the CS-cineCMR slices were applied to cover the LA phantoms. Long-axis "aligned" vs "not aligned" with the phantom long-axis yielded similar differences vs the reference volume (-4.87 ± 1.73 ml vs. -4.45 ± 1.97 ml, p = 0.67) and short-axis "perpendicular" vs. "not-perpendicular" with the LA long-axis (-4.72 ± 1.66 ml vs. -4.75 ± 2.13 ml; p = 0.98). The conventional bi-plane area-length method was susceptible for slice orientations (p = 0.0085 for the interaction of "slice orientation" and "reconstruction technique", 2-way ANOVA for repeated measures). To use the 3D-HR-CMR as the reference for LA volumes in patients, it was validated in the LA phantoms (mean difference: -1.37 ± 1.35 ml, -2.38 ± 2.44%, r2 = 0.97). Patient study: The CS-cineCMR LA volumes of the mid-diastolic frame matched closely with the reference LA volume (measured by 3D-HR-CMR) with a difference of -2.66 ± 6.5 ml (3.0% underestimation; true LA volumes: 63 ml, 62 ml, and 395 ml). Finally, a high intra- and inter-observer agreement for maximal and minimal LA volume measurement is also shown.

CONCLUSIONS

The proposed method combines a highly accelerated single-breathhold compressed-sensing multi-slice CMR technique with a non-model-based 3D reconstruction to accurately and reproducibly measure LA volumes and function.

Galectin-3 as a new biomarker of diastolic dysfunction in hemodialysis patients

BACKGROUND

Galectin-3 (gal-3) is an emerging prognostic biomarker in heart failure (HF). Clinical and experimental studies suggest that gal-3 is an important mediator of HF. Here we aimed to examine the relationship between gal-3 and diastolic dysfunction in patients undergoing maintenance hemodialysis (HD).

METHODS

We examined the relationship between plasma gal-3 levels and left ventricular diastolic function. Plasma gal-3 was measured in 87 subjects with chronic HD and in 45 healthy controls using biochemical evaluations. Conventional echocardiography and pulsed tissue Doppler assessment were performed in all patients. Left ventricular diastolic dysfunction (LVDD) was defined as E' < 8 cm/s. The E/E' ratio was used as the main determinant of LVDD grade.

RESULTS

The mean gal-3 concentrations were: 16.05 ng/ml (13.89-19.75) in healthy controls; 14.54 ng/ml (10.85-17.65) in HD patients with normal diastolic function; and 23.30 ng/ml (20.12-26.87) in HD patients with LVDD (p  < 0.01). Plasma gal-3 levels correlated with E/E' (r = 0.933, p  < 0.01), left atrial volume index (r = 0.713, p  < 0.01), and E' (r = -0.685, p  < 0.01). ROC analysis showed that the best gal-3 cut-off point for the diagnosis of LVDD was 20.12 ng/ml with a sensitivity of 67.6 % and specificity of 84.6 % (AUC = 0.803).

CONCLUSION

We suggest that gal-3 may be a promising biomarker for the detection of LVDD in HD patients.

Prognostic significance of NT-proBNP, 3D LA volume and LV dyssynchrony in patients with acute STEMI undergoing primary percutaneous intervention

OBJECTIVES

The aim of the present study was to assess the short term prognostic significance of N-terminal pro BNP (NT-proBNP), 3D left atrial volume (LAV) and left ventricular (LV) dyssynchrony in patients of acute ST-elevation myocardial infarction (STEMI) who underwent primary Percutaneous intervention (PCI).

BACKGROUND

NT-proBNP, LV dyssynchrony and LAV in patients with acute coronary syndrome have been associated with PCI outcomes and predict the short and long-term prognosis.

METHODS

This study consisted of 142 patients with a first STEMI who underwent primary PCI. Baseline echocardiographic data was collected at admission and at 6 months follow up. Left ventricular dyssynchrony was measured by tissue Doppler imaging and LAV by real time 3D-echocardiography, plasma NT-proBNP levels were estimated between 72 and 96 h of admission.

RESULTS

During study period 3 patients expired and 4 developed congestive heart failure (CHF). Baseline NT-proBNP and LV dyssynchrony correlated with LV size and LV ejection fraction (LVEF) at baseline and during follow up. Patients with higher NT-proBNP levels and higher LV dyssynchrony showed significant increase in LV size with decrease in LVEF during follow-up. Baseline Left atrial volume index (LAVI) showed significant correlation with LV size but no association with LVEF at baseline and during follow-up.

CONCLUSIONS

Higher levels of NT-proBNP and higher LV dyssynchrony can predict patients with increase in LV size, worsening of LV systolic and diastolic function during follow-up. Patients with higher NT-proBNP levels at baseline developed CHF during follow-up.

Left atrium function in patients with coronary artery disease

PURPOSE OF REVIEW

The left atrial cavity has recently been identified as a potential biomarker for cardiac and cerebrovascular accidents. This review examines the potential of left atrial size and function in predicting cardiovascular disease in the general population and outcomes in coronary artery disease (CAD) patients.

RECENT FINDINGS

The atrium is perfused primarily by branches of the proximal left circumflex coronary artery (LCx), and depression of the cavity mechanical performance has been demonstrated in experimental studies during LCx occlusion. Thus, left atrial volume and function assessment may have prognostic relevance, particularly in CAD patients. Such a line of thinking, however, is challenged by the widespread notion that the contribution by left atrial chamber morphology and functional quantitation to the risk stratification process after a first cardiovascular event is not adequately considered. However, a number of studies have shown that left atrial volume predicts survival and major adverse events after an acute myocardial infarction. Left atrial remodeling also provides an important overall prognostic information and correlates with brain natriuretic peptide after primary percutaneous coronary interventions.

SUMMARY

Evaluation of left atrial size and function is currently of great interest and it will be more so in the very near future, given its potential for insights into the pathophysiology of the ischemic heart, which makes it an important clinical risk identifier in CAD patients.

Principles of transthoracic echocardiographic evaluation

Transthoracic echocardiography is the most widely used imaging test in cardiology. Although completely noninvasive, transthoracic echocardiography has a well-established role in the diagnosis of numerous cardiovascular diseases, and also provides critical qualitative and quantitative information on their prognosis and pathophysiological processes. The aim of this Review is to outline the broad principles of transthoracic echocardiography, including the traditional techniques of two-dimensional, colour, and spectral Doppler echocardiography, and newly developed advances including tissue Doppler, myocardial deformation imaging, torsion, stress echocardiography, contrast and three-dimensional echocardiography. The advantages and disadvantages, clinical application, prognostic value, and salient research findings of each modality are described. Advances in complex imaging techniques are expected to continue unabated, and this Review highlights technical improvements that will influence the diagnosis and improve our understanding of cardiovascular function and disease.

Left atrial volume assessment in atrial fibrillation using multimodality imaging: a comparison of echocardiography, invasive three-dimensional CARTO and cardiac magnetic resonance imaging

Left atrial size in atrial fibrillation is a strong predictor of successful ablation and cardiovascular events. Cardiac magnetic resonance multislice method (CMR-MSM) is the current gold standard for left atrial volume (LAV) assessment but is time consuming. We investigated whether LAV with more rapid area-length method by echocardiography (Echo-AL) or cardiac magnetic resonance (CMR-AL) and invasive measurement by 3D-CARTO mapping during ablation correlate with the CMR-MSM. We studied 250 consecutive patients prior to atrial fibrillation ablation. CMR images were acquired on 3T scanner to measure LAV by MSM and biplane area-length method. Standard echocardiography views were used to calculate LAV by biplane area-length method. LAV during ablation was measured by 3D-CARTO mapping. LAV was compared using intra-class correlation (ICC), Pearson's correlation and Bland-Altman plots. CMR-MSM was used as the reference standard. Mean LAV using CMR-MSM was 112.7 ± 36.7 ml. CMR-AL method overestimated LAV by 13.3 ± 21.8 ml (11.2%, p < 0.005) whereas 3D-CARTO and Echo-AL underestimated LAV by 8.3 ± 22.6 and 24.0 ± 27.6 ml respectively (8.7% and 20.0% respectively, p < 0.005). There was no significant difference between paroxysmal and persistent atrial fibrillation. CMR-AL and 3D-CARTO correlated and agreed well with CMR-MSM (r = 0.87 and 0.74, ICC = 0.80 and 0.77 respectively). However, Echo-AL had poor correlation and agreement with CMR-MSM (r = 0.66 and ICC = 0.48). Bland-Altman plots confirmed these findings. CMR-AL method may be used as an alternative to CMR-MSM, as it is non-invasive, rapid, and correlates well with CMR-MSM. LAV by different modalities should not be used interchangeably.

How to identify hypertensive patients at high cardiovascular risk? The role of echocardiography

Scientific authorities recommend that patients with arterial hypertension should be managed not only on the basis of blood pressure (BP) levels, but also on the assemement of total cardiovascular risk. In particular, evaluation of target organ damage (TOD) is of major relevance for identifying hypertensive individuals at high cardiovascular risk independently of clinic BP levels. Evidence of cardiac and extra-cardiac TOD has been consistently associated with worse cardiovascular prognosis. Unfortunately, detection of TOD markedly depends on sensitivity of diagnostic tools, at difference from evaluation of risk factors and associated diseases, usually reliably provided by accurate clinical examination and routine investigation. The purpose of this paper was to provide an updated, comprehensive review on the role of echocardiography in identifying hypertensive patients apparently uncomplicated, but exposed to a high cardiovascular risk due to the presence of subclinical structural and functional cardiac alterations of adverse prognostic significance.

Diastolic dysfunction is an independent predictor of cardiovascular events in incident dialysis patients with preserved systolic function

Background

Diastolic heart failure (HF), the prevalence of which is gradually increasing, is associated with cardiovascular (CV) morbidity and mortality in the general population and, more specifically, in patients with end-stage renal disease (ESRD). However, the impact of diastolic dysfunction on CV outcomes has not been studied in incident dialysis patients with preserved systolic function.

Methods

This prospective observational cohort study investigates the clinical consequence of diastolic dysfunction and the predictive power of diastolic echocardiographic parameters for CV events in 194 incident ESRD patients with normal or near normal systolic function, who started dialysis between July 2008 and August 2012.

Results

During a mean follow-up duration of 27.2 months, 57 patients (29.4%) experienced CV events. Compared to the CV event-free group, patients with CV events had a significantly higher left ventricular (LV) mass index, ratio of early mitral flow velocity (E) to early mitral annulus velocity (E’) (E/E’), LA volume index (LAVI), deceleration time, and right ventricular systolic pressure, and a significantly lower LV ejection fraction and E’. In multivariate Cox proportional hazard analysis, E/E’>15 and LAVI>32 mL/m² significantly predicted CV events (E/E’>15: hazard ratio [HR] = 5.40, 95% confidence interval [CI] = 2.73–10.70, P< .001; LAVI>32 mL/m²: HR = 5.56, 95% CI = 2.28–13.59, P< .001]. Kaplan-Meier analysis revealed that patients with both E/E’>15 and LAVI>32mL/m² had the worst CV outcomes.

Conclusion

An increase in E/E’ or LAVI is a significant risk factor for CV events in incident dialysis patients with preserved LV systolic function.

Relationship of ischemic times and left atrial volume and function in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

Little is known about the impact of duration of ischemia on left atrial (LA) volumes and function during acute phase of myocardial infarction. We investigated the relationship of ischemic times, echocardiographic indices of diastolic function and LA volumes in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). A total of 433 consecutive STEMI patients underwent echocardiographic examination within 48 h of primary PCI, including the measurement of LA volumes and the ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity (E/e'). Time intervals from onset of chest pain to hospital admission and reperfusion were collected and magnitude of Troponin I release was used to assess infarct size. Patients with LA volume index (LAVI) ≥28 ml/m(2) had longer total ischemic time (410 ± 347 vs. 303 ± 314 min, p = 0.007) and higher E/e' ratio (15 ± 5 vs. 10 ± 3, p < 0.001) than those with LAVI <28 ml/m(2), while the indices of LA function were similar between the study groups (p > 0.05, for all). Significant correlation was found between E/e' and LA volumes at all stages of LA filling and contraction (r = 0.363-0.434; p < 0.001, for all) while total ischemic time along with E/e' and restrictive filling pattern remained independent predictor of LA enlargement. Increased LA volume is associated with longer ischemic times and may be a sensitive marker of increased left ventricular filling pressures in STEMI patients treated with primary PCI.

Changes in echocardiographic parameters according to the rate of residual renal function decline in incident peritoneal dialysis patients

Residual renal function (RRF) is associated with left ventricular (LV) hypertrophy as well as all-cause and cardiovascular (CV) mortality in patients with end-stage renal disease. However, no studies have yet examined the serial changes in echocardiographic findings according to the rate of RRF decline in incident dialysis patients. A total of 81 patients who started peritoneal dialysis (PD) between 2005 and 2012 at Yonsei University Health System, Seoul, South Korea, and who underwent baseline and follow-up echocardiography within the first year of PD were recruited. Patients were dichotomized into "faster" and "slower" RRF decline groups according to the median values of RRF decline slope (-1.60 mL/min/y/1.73 m(2)). Baseline RRF and echocardiographic parameters were comparable between the 2 groups. During the first year of PD, there were no significant changes in LV end-diastolic volume index (LVEDVI), left atrial volume index (LAVI), or LV mass index (LVMI) in the "faster" RRT decline group, while these indices decreased in the "slower" RRT decline group. The rate of RRF decline was a significant determinant of 1-year changes in LVEDVI, LAVI, and LVMI. The linear mixed model further confirmed that there were significant differences in the changes in LVEDVI, LAVI, and LVMI between the 2 groups (P = 0.047, 0.048, and 0.001, respectively). During a mean follow-up duration of 31.9 months, 4 (4.9%) patients died. Compared with the "slower" RRF decline group, CV composite (20.29/100 vs 7.18/100 patient-years [PY], P = 0.098), technique failure (18.80/100 vs 4.19/100 PY, P = 0.006), and PD peritonitis (15.73/100 vs 4.95/100 PY, P = 0.064) developed more frequently in patients with "faster" RRF decline rate. On multivariate Cox regression analysis, patients with "faster" RRF decline rate showed 4.82-, 4.44-, and 7.37-fold higher risks, respectively, for each clinical outcome. Preservation of RRF is important for conserving cardiac performance, resulting in an improvement in clinical outcomes of incident PD patients.

Impact of atrial fibrillation ablation on left ventricular filling pressure and left atrial remodeling

BACKGROUND

Left ventricular (LV) diastolic dysfunction is associated with new-onset atrial fibrillation (AF), and the estimation of elevated LV filling pressures by E/e' ratio is related to worse outcomes in patients with AF. However, it is unknown if restoring sinus rhythm reverses this process.

OBJECTIVE

To evaluate the impact of AF ablation on estimated LV filling pressure.

METHODS

A total of 141 patients underwent radiofrequency (RF) ablation to treat drug-refractory AF. Transthoracic echocardiography was performed 30 days before and 12 months after ablation. LV functional parameters, left atrial volume index (LAVind), and transmitral pulsed and mitral annulus tissue Doppler (e' and E/e') were assessed. Paroxysmal AF was present in 18 patients, persistent AF was present in 102 patients, and long-standing persistent AF in 21 patients. Follow-up included electrocardiographic examination and 24-h Holter monitoring at 3, 6, and 12 months after ablation.

RESULTS

One hundred seventeen patients (82.9%) were free of AF during the follow-up (average, 18 ± 5 months). LAVind reduced in the successful group (30.2 mL/m(2) ± 10.6 mL/m(2) to 22.6 mL/m(2) ± 1.1 mL/m(2), p < 0.001) compared to the non-successful group (37.7 mL/m(2) ± 14.3 mL/m(2) to 37.5 mL/m(2) ± 14.5 mL/m(2), p = ns). Improvement of LV filling pressure assessed by a reduction in the E/e' ratio was observed only after successful ablation (11.5 ± 4.5 vs. 7.1 ± 3.7, p < 0.001) but not in patients with recurrent AF (12.7 ± 4.4 vs. 12 ± 3.3, p = ns). The success rate was lower in the long-standing persistent AF patient group (57% vs. 87%, p = 0.001).

CONCLUSION

Successful AF ablation is associated with LA reverse remodeling and an improvement in LV filling pressure.

Associations of electrocardiographic P-wave characteristics with left atrial function, and diffuse left ventricular fibrosis defined by cardiac magnetic resonance: The PRIMERI Study

BACKGROUND

Abnormal P-terminal force in lead V1 (PTFV1) is associated with an increased risk of heart failure, stroke, atrial fibrillation, and death.

OBJECTIVE

Our goal was to explore associations of left ventricular (LV) diffuse fibrosis with left atrial (LA) function and electrocardiographic (ECG) measures of LA electrical activity.

METHODS

Patients without atrial fibrillation (n = 91; mean age 59.5 years; 61.5% men; 65.9% white) with structural heart disease (spatial QRS-T angle ≥105° and/or Selvester QRS score ≥5 on ECG) but LV ejection fraction >35% underwent clinical evaluation, cardiac magnetic resonance, and resting ECG. LA function indices were obtained by multimodality tissue tracking using 2- and 4-chamber long-axis images. T1 mapping and late gadolinium enhancement were used to assess diffuse LV fibrosis and presence of scar. P-prime in V1 amplitude (PPaV1) and duration (PPdV1), averaged P-wave-duration, PR interval, and P-wave axis were automatically measured using 12 SLTM algorithm. PTFV1 was calculated as a product of PPaV1 and PPdV1.

RESULTS

In linear regression after adjustment for demographic characteristics, body mass index, maximum LA volume index, presence of scar, and LV mass index, each decile increase in LV interstitial fibrosis was associated with 0.76 mV*ms increase in negative abnormal PTFV1 (95% confidence interval [CI] -1.42 to -0.09; P = .025), 15.3 ms prolongation of PPdV1 (95% CI 6.9 to 23.8; P = .001) and 5.4 ms prolongation of averaged P-duration (95% CI 0.9-10.0; P = .020). LV fibrosis did not affect LA function. PPaV1 and PTFV1 were associated with an increase in LA volumes and decrease in LA emptying fraction and LA reservoir function.

CONCLUSION

LV interstitial fibrosis is associated with abnormal PTFV1, prolonged PPdV1, and P-duration, but does not affect LA function.

Left atrial function assessed by left atrial strain in patients with left circumflex branch culprit acute myocardial infarction

INTRODUCTION

Although left atrium (LA) has played an important role in diastole, ischemic insult of atrium in acute myocardial infarction (AMI) has not been clearly evaluated.

METHODS

We hypothesized that LA function would be further decreased in AMI patients with a culprit lesion in the left circumflex branch (LCX). This was an observational cohort study in a single university hospital. Echocardiography was performed to evaluate left ventricular diastolic function, LA volume, and LA function. Systolic (LAS ) and late diastolic (LAA ) LA strain were measured using speckle tracking echocardiography.

RESULTS

Sixty-eight AMI patients treated with emergent or urgent percutaneous coronary intervention were enrolled. Global LAS strain was significantly lower in patients with a culprit lesion in the LCX than culprit lesions in other vessels (left anterior descending, 27.3 ± 6.8%; left circumflex, 20.1 ± 8.9%; right coronary artery, 23.3 ± 6.5%; P = 0.007). LA volume index did not differ significantly (P = 0.093). Other clinical and conventional echocardiographic parameters, including Doppler measurements, did not differ significantly.

CONCLUSIONS

Global LAS strain was lower in AMI patients with a culprit lesion in the LCX than those with culprit lesions in other vessels, without any significant difference in LA volume index. The lower global LAS strain might suggest decreased LA function resulting from ischemic insult by AMI with culprit lesions in the LCX.

Relationship of left atrial global peak systolic strain with left ventricular diastolic dysfunction and brain natriuretic peptide level in patients presenting with non-ST elevation myocardial infarction

Background

In patients presenting with non-ST elevation myocardial infarction, we investigated the relationship of left atrial deformational parameters evaluated by 2-dimensional speckle tracking imaging (2D-STI) with conventional echocardiographic diastolic dysfunction parameters and brain natriuretic peptide level.

Material/Methods

We enrolled 74 non-ST segment elevation myocardial infarction patients who were treated with percutaneous coronary intervention and 58 healthy control subjects. Non-ST segment elevation myocardial infarction patients had echocardiographic examination 48 h after the percutaneous coronary intervention procedure and venous blood samples were drawn simultaneously. In addition to conventional echocardiographic parameters, left atrial strain curves were obtained for each patient. Average peak left atrial strain values during left ventricular systole were measured.

Results

BNP values were higher in non-ST segment elevation myocardial infarction patients compared to controls. Mean left atrium peak systolic global longitudinal strain in Group 2 (the control group) was higher than in the non-ST segment elevation myocardial infarction group. Left atrium peak systolic global longitudinal strain was significantly correlated with left ventricular ejection fraction. There was a significant inverse correlation between left atrium peak systolic global longitudinal strain and brain natriuretic peptide level, left atrium volume maximum, and left atrium volume minimum.

Conclusions

Our study shows that Left atrium peak systolic global longitudinal strain values decreased consistently with deteriorating systolic and diastolic function in non-ST segment elevation myocardial infarction patients treated with percutaneous coronary intervention. Left atrium peak systolic global longitudinal strain measurements may be helpful as a complimentary method to evaluate diastolic function in this patient population.

Influence of renal impairment on myocardial function in outpatients with systolic heart failure: an echocardiographic and cardiac biomarker study

BACKGROUND

Renal dysfunction (RD) is associated with poor outcome in systolic heart failure (HF). Left ventricular ejection fraction (LVEF) is not depressed to a greater extent in patients with RD compared to patients with normal renal function, but it is relatively unknown whether other measures of myocardial function are impaired by RD. The objective of the present study is to evaluate whether RD in systolic HF is associated with excessive impairment of myocardial function, evaluated by strain analysis and cardiac biomarkers.

METHODS

Patients with LVEF <0.45% were enrolled from an outpatient HF clinic. The patients underwent advanced echocardiography. Glomerular filtration rate was estimated by the CKD-EPI equation (eGFR) and patients grouped by eGFR: eGFR group-I, ≥ 90 ml/min/1.73 m(2); eGFR group-II, 60-89 ml/min/1.73 m(2); and eGFR group-III, ≤ 59 ml/min/1.73 m(2). Multivariate regression models were developed to evaluate the associations between eGFR groups, echocardiographic measures and cardiac biomarkers.

RESULTS

A total of 149 patients participated in the study. Median age was 69 years, 26% were female; LVEF was 33%. Patients with a low eGFR were older (P < 0.001), but there were no differences in frequency of atrial fibrillation, hypertension, diabetes and ischemic heart disease between eGFR groups (P > 0.05 for all). RD was associated with impaired global longitudinal strain (P = 0.018), increased E/e' (P = 0.032), larger left atria (P = 0.038) and increased levels of proANP (P < 0.001), NT-proBNP (P < 0.001) and troponin I (P = 0.019) after adjustment for traditional confounders.

CONCLUSIONS

Echocardiographic measures and biomarkers reflecting different aspects of myocardial function are impaired in systolic HF patients with RD and the increased mortality risk in these patients may partly be explained by a depressed cardiac function.

Left atrial passive emptying function is preserved in patients with permanent atrial fibrillation--a 320-slice multidetector computed tomography study

OBJECTIVE

Left atrial (LA) mechanical function is thought to be virtually inexistent in patients with permanent atrial fibrillation (AF). Due to recent advances in multidetector computed tomography (MDCT) technology, it is now possible to acquire images of the entire heart in a single heartbeat. The objective of this study was to compare individual components of LA function assessed by MDCT in patients with permanent AF and patients in sinus rhythm (SR).

METHODS

320-slice MDCT was performed in 30 patients with permanent AF. Measurements of LA volumes during the cardiac cycle were compared to 30 patients in SR, who were matched with respect to age, sex, left ventricular ejection fraction and body surface area.

RESULTS

LA volumes were significantly larger in patients with AF than SR patients at all times during the cardiac cycle (LA maximal volume; 82 vs. 55 ml/m(2), p < 0.0001, LA minimal volume; 71 vs. 30 ml/m(2), p < 0.0001). However, except for the absence of active LA emptying, the overall trend of the LA time-volume curve was similar in patients with AF and SR.

CONCLUSION

Compared to SR patients, patients with permanent AF have significantly increased LA volumes throughout the cardiac cycle. Yet, a residual hemodynamic role of LA function may be maintained during permanent AF.

Impact of gout on left atrial function: a prospective speckle-tracking echocardiographic study

The purpose of our study was to evaluate the left ventricular (LV) and left atrial (LA) function in patients with gout. A total of 173 patients underwent a comprehensive Doppler-echocardiography examination. Participants were divided into four groups–Stage 0: control (n = 35), Stage I: asymptomatic hyperuricemia (n = 30), Stage II: gouty arthritis without tophi (n = 58), and Stage III: tophaceous gout (n = 50). Serum uric acid levels were not significantly different between stage I, II and III. Stage III patients demonstrated a higher ratio of the transmitral and myocardial peak early diastolic velocities (E/Em) (10.50±3.18 vs. 8.58±2.07; P = 0.008), and larger maximal LA volume index (LAVi) (29.60±9.89 vs. 20.07±4.76 ml/m²; P<0.001) compared with controls. Stage III patients had decreased LV global longitudinal systolic strain (LVε) compared with controls (−20.2±3.06 vs. −21.79±2.27; P = 0.002). Stage III patients also had decreased peak atrial longitudinal strain rate during ventricular systole (ALSR_syst), peak atrial longitudinal strain rate during ventricular early diastole (ALSR_early), and peak atrial longitudinal strain rate during ventricular late diastole (ALSR_late) compared with controls (1.73±0.48 vs. 2.05±0.55 1/s, −1.44±0.53 vs. −2.07±0.84 1/s, −2.07±0.7 vs. −2.66±0.91 1/s, respectively; all P<0.005). Multiple regression analysis revealed severity of gout had an independent negative impact on LA pump function (ALSR_late). In conclusion, gout caused LV diastolic dysfunction, LV subclinical systolic dysfunction and LA reservoir, conduit, and booster pump dysfunction.

Association of left atrial booster-pump function with heart failure symptoms in patients with severe aortic stenosis and preserved left ventricular ejection fraction

BACKGROUND

Identification of heart failure (HF) symptoms in patients with severe aortic stenosis (AS) and preserved left ventricular (LV) ejection fraction (EF) is clinically important, but assessment of HF symptoms is challenging. It was recently reported that resting left atrium (LA) functions are related to exercise performance and are also important prognostic markers for patients with HF. The aim of this study was to assess the association of the HF symptoms with LA function in patients with severe AS and preserved LVEF.

METHODS

We retrospectively studied 40 patients with severe AS and preserved LVEF (all ≥50%) who were referred for aortic valve replacement (AVR). LA reservoir (SR-LAs), conduit (SR-LAe), and booster-pump (SR-LAa) functions were determined as the averaged global LA speckle tracking longitudinal strain rate from apical four- and two-chamber views. Twenty patients were symptomatic and 20 asymptomatic.

RESULTS

Aortic stenosis severity was similar for the 2 groups. Symptomatic status was associated with age, LV mass index, hemoglobin, B-type natriuretic peptide, LV end-systolic volume index, LVEF, LA volume index, SR-LAs, SR-LAe, and SR-LAa. Importantly, multivariate logistic regression analysis revealed that SR-LAa was the only independent determinant of symptomatic status (OR = 0.242, P = 0.002). Furthermore, significant improvement of SR-LAa was observed along with the reduction in LA volume index and LV mass index after AVR.

CONCLUSIONS

SR-LAa was found to be associated with the HF symptoms. Characterization of LA booster-pump function may be useful for the assessment of the symptomatic status in patients with severe AS patients and limited physical activity.

Echocardiographic assessment of maximum and minimum left atrial volumes: a population-based study of middle-aged and older subjects without apparent cardiovascular disease

The aim of the present study was to obtain reference values of maximum and minimum left atrial volumes (maxLAV and minLAV, respectively) in a population-based subset without apparent cardiovascular disease or other factors potentially associated with left atrial enlargement. Because left ventricular diastolic dysfunction is commonly found in elderly subjects, we also tried to identify the presence of possible preclinical diastolic dysfunction in the study population. A population-based sample of 168 subjects (127 men and 41 women) underwent two-dimensional echocardiography using the single-plane disc method to determine maxLAV and minLAV. maxLAV and minLAV were indexed to body surface area (maxLAVi and minLAVi, respectively). maxLAVi was independent of age and sex, and produced reference limits (mean ± 1.96 SD) of 15–37 mL/m². minLAVi was correlated with age, and produced estimated reference limits of 3–15 and 7–23 mL/m² in 40- and 80-year-old subjects, respectively. Based on the age-dependent reference values from the European Association of Cardiovascular Imaging, <5 % of the study population had possible preclinical left ventricular diastolic dysfunction. The present study established normal ranges for maxLAVi and minLAVi in a well-characterized population-based subset without apparent cardiovascular disease or other factors potentially associated with left atrial volume enlargement.

Imaging techniques in the evaluation of post-infarction function and scar

Imaging techniques are essential in the clinical evaluation of patients with a myocardial infarction. They are of value for both initial assessment of the ischemic injury and for detection of the subgroup of patients at higher risk of developing cardiovascular events during follow-up. Echocardiography remains the technique of choice for the initial evaluation, owing to its bedside capability to determine strong predictors, such as ventricular volumes, global and regional systolic function, and valvular regurgitation. New techniques for evaluating ventricular mechanics, mainly assessment of ventricular deformation, are revealing important aspects of post-infarction ventricular adaptation. The main alternative to echocardiography is cardiac magnetic resonance imaging. This technique is highly accurate for determining ventricular volumes and ventricular function and has the additional advantage of being able to characterize the myocardium and demonstrate changes associated with the ischemic insult such as necrosis/fibrosis, edema, microvascular obstruction, and intramyocardial hemorrhage. These features not only allow detection and quantification of the infarct size, but also reveal additional characteristics of the scar tissue with prognostic value.

Risk factors and genetics of atrial fibrillation

Atrial fibrillation (AF) is by far the most common sustained tachyarrhythmia, affecting 1% to 2% of the general population. AF prevalence and the total annual cost for treatment are alarming, emphasizing the need for an urgent attention to the problem. Thus, having up-to-date information on AF risk factors and appreciating how they promote maintenance of AF maintenance are essential. This article presents a simplified examination of AF risk factors, including emerging genetic risks.

Left atrial volume index and prediction of events in acute coronary syndrome: Solar Registry

Background

According to some international studies, patients with acute coronary syndrome (ACS) and increased left atrial volume index (LAVI) have worse long-term prognosis. However, national Brazilian studies confirming this prediction are still lacking.

Objective

To evaluate LAVI as a predictor of major cardiovascular events (MCE) in patients with ACS during a 365-day follow-up.

Methods

Prospective cohort of 171 patients diagnosed with ACS whose LAVI was calculated within 48 hours after hospital admission. According to LAVI, two groups were categorized: normal LAVI (≤ 32 mL/m²) and increased LAVI (> 32 mL/m²). Both groups were compared regarding clinical and echocardiographic characteristics, in- and out-of-hospital outcomes, and occurrence of ECM in up to 365 days.

Results

Increased LAVI was observed in 78 patients (45%), and was associated with older age, higher body mass index, hypertension, history of myocardial infarction and previous angioplasty, and lower creatinine clearance and ejection fraction. During hospitalization, acute pulmonary edema was more frequent in patients with increased LAVI (14.1% vs. 4.3%, p = 0.024). After discharge, the occurrence of combined outcome for MCE was higher (p = 0.001) in the group with increased LAVI (26%) as compared to the normal LAVI group (7%) [RR (95% CI) = 3.46 (1.54-7.73) vs. 0.80 (0.69-0.92)]. After Cox regression, increased LAVI increased the probability of MCE (HR = 3.08, 95% CI = 1.28-7.40, p = 0.012).

Conclusion

Increased LAVI is an important predictor of MCE in a one-year follow-up.

Multi-ethnic study of atherosclerosis: association between left atrial function using tissue tracking from cine MR imaging and myocardial fibrosis

PURPOSE

To investigate the association between left atrial ( LA left atrium ) function and left ventricular myocardial fibrosis using cardiac magnetic resonance (MR) imaging in a multi-ethnic population.

MATERIALS AND METHODS

For this HIPAA-compliant study, the institutional review board at each participating center approved the study protocol, and all participants provided informed consent. Of 2839 participants who had undergone cardiac MR in 2010-2012, 143 participants with myocardial scar determined with late gadolinium enhancement and 286 age-, sex-, and ethnicity-matched control participants were identified. LA left atrium volume, strain, and strain rate were analyzed by using multimodality tissue tracking from cine MR imaging. T1 mapping was applied to assess diffuse myocardial fibrosis. The association between LA left atrium parameters and myocardial fibrosis was evaluated with the Student t test and multivariable regression analysis.

RESULTS

The scar group had significantly higher minimum LA left atrium volume than the control group (mean, 22.0 ± 10.5 [standard deviation] vs 19.0 ± 7.8, P = .002) and lower LA left atrium ejection fraction (45.9 ± 10.7 vs 51.3 ± 8.7, P < .001), maximal LA left atrium strain ( Smax maximum LA strain ) (25.4 ± 10.7 vs 30.6 ± 10.6, P < .001) and maximum LA left atrium strain rate ( SRmax maximum LA strain rate ) (1.08 ± 0.45 vs 1.29 ± 0.51, P < .001), and lower absolute LA left atrium strain rate at early diastolic peak ( SRE LA strain rate at early diastolic peak ) (-0.77 ± 0.42 vs -1.01 ± 0.48, P < .001) and LA left atrium strain rate at atrial contraction peak ( SRA LA strain rate at atrial contraction peak ) (-1.50 ± 0.62 vs -1.78 ± 0.69, P < .001) than the control group. T1 time 12 minutes after contrast material injection was significantly associated with Smax maximum LA strain (β coefficient = 0.043, P = .013), SRmax maximum LA strain rate (β coefficient = 0.0025, P = .001), SRE LA strain rate at early diastolic peak (β coefficient = -0.0016, P = .027), and SRA LA strain rate at atrial contraction peak LA strain rate at atrial contraction peak (β coefficient -0.0028, P = .01) in the regression model. T1 time 25 minutes after contrast material injection was significantly associated with SRmax maximum LA strain rate (β coefficient = 0.0019, P = .016) and SRA LA strain rate at atrial contraction peak (β coefficient = -0.0022, P = .034).

CONCLUSION

Reduced LA left atrium regional and global function are related to both replacement and diffuse myocardial fibrosis processes. Clinical trial registration no.: NCT00005487

Left atrial expansion index is an independent predictor of diastolic dysfunction in patients with preserved left ventricular systolic function: a three dimensional echocardiography study

In the absence of mitral valve disease left atrial (LA) volume is a marker of diastolic dysfunction and its severity. This study investigated the relationship between left ventricular (LV) end diastolic pressure (LVEDP) and LA volumes and phasic atrial functions detected by real-time full volume three-dimensional echocardiography (RT3DE), in a patient population with preserved LV systolic function. Seventy-two (39 female and 33 male; mean age 56.1 ± 9.0 years) stable patients with normal LV ejection fraction (EF) undergoing cardiac catheterization were studied. All patients underwent comprehensive echocardiographic examination just before catheterization and LVEDP was obtained. In addition to conventional echocardiographic measurements and Doppler indices; by using RT3DE LA maximum, minimum and pre-a-wave volumes were measured; LA total, passive and active emptying volumes and fractions were calculated. LV systolic function was assessed by EF and global longitudinal strain by speckle tracking. RT3DE minimum LA volume index, RT3DE active LAEF and LA expansion index (EI) were statistically significant univariate predictors of LVEDP ≥ 16 mmHg. When age and hypertension adjusted multivariate analysis was performed EI [β = -1.741, p = 0.015; OR 0.175; 95 % CI (0.043-0.717)] was an independent predictor of elevated LVEDP. RT3DE evaluation of LA function during entire cardiac cycle has incremental value for the diagnosis of diastolic dysfunction in patients with preserved EF. We suggest that RT3DE evaluation of LA may find clinical application in this field.