Usefulness of left atrial volume as a predictor of mortality in patients with ischemic cardiomyopathy

Atrial Fibrillation, Atrial Myopathy, and Thromboembolism: The Additive Value of Echocardiography and Possible New Horizons for Risk Stratification

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, and it is associated with increased stroke and dementia risk. While the established paradigm attributes these complications to blood stasis within the atria and subsequent thrombus formation with cerebral embolization, recent evidence suggests that atrial myopathy (AM) may play a key role. AM is characterized by structural and functional abnormalities of the atria, and can occur with or without AF. Moving beyond classifications based solely on episode duration, the 4S-AF characterization has offered a more comprehensive approach, incorporating patient's stroke risk, symptom severity, AF burden, and substrate assessment (including AM) for tailored treatment decisions. The "ABC" pathway emphasizes anticoagulation, symptom control, and cardiovascular risk modification and emerging evidence suggests broader benefits of early rhythm control strategies, potentially reducing stroke and dementia risk and improving clinical outcomes. However, a better integration of AM assessment into the current framework holds promise for further personalizing AF management and optimizing patient outcomes. This review explores the emerging concept of AM and its potential role as a risk factor for stroke and dementia and in AF patients' management strategies, highlighting the limitations of current risk stratification methods, like the CHA2DS2-VASc score. Echocardiography, particularly left atrial (LA) strain analysis, has shown to be a promising non-invasive tool for AM evaluation and recent studies suggest that LA strain analysis may be a more sensitive risk stratifier for thromboembolic events than AF itself, with some studies showing a stronger association between LA strain and thromboembolic events compared to traditional risk factors. Integrating it into routine clinical practice could improve patient management and targeted therapies for AF and potentially other thromboembolic events. Future studies are needed to explore the efficacy and safety of anticoagulation in AM patients with and without AF and to refine the diagnostic criteria for AM.

Evaluation of left atrial and left ventricular functions with 3D speckle-tracking echocardiography in patients with coronary artery tortuosity

BACKGROUND

Tortuosity in the coronary arteries is a very common entity encountered during angiography. The effect of coronary artery tortuosity (CAT) on the myocardium has not been completely investigated. The aim of the current study was to assess the effects of CAT on left atrial (LA) and left ventricular (LV) myocardial functions by 3D speckle-tracking echocardiography (3D-STE).

METHODS

Seventy-five patients with CAT and 80 age- and gender-matched controls who proved to have normal coronary angiograms (CAG) were enrolled into the study. Following CAG, the 2D images were obtained first, and then 3D images were obtained for strain analysis.

RESULTS

The LAS-r, LAS-active, and LV-GLS were significantly depressed in the CAT (+) group (p < .001, p < .001, p = .012, respectively). The multivariate regression models demonstrated that LAS-r (p < .001), LAS-active (p = .009), and LV-GLS (p = .024) were found to be independent factors predicting CAT.

CONCLUSION

The current study is the first to focus on the assessing both LA and LV myocardial dynamics in CAT (+) patients by strain echocardiography. The results of our study support the patients with CAT may have subclinical LA and LV myocardial involvements.

Left atrial reverse remodeling predicts long-term survival after cardiac resynchronization therapy

BACKGROUND

Left ventricular (LV) reverse remodeling has been identified as a strong predictor of long-term survival in patients receiving CRT. Interestingly, CRT induces reverse remodeling in the left atrium (LA) as well. It is currently unknown to what extent LA reverse remodeling is correlated to long-term survival after CRT. This study aims to assess the long-term prognostic value of left atrium (LA) reverse remodeling in patients undergoing cardiac resynchronization therapy (CRT).

METHODS

Baseline and 3-months follow-up echocardiograms after CRT implantation were prospectively assessed to determine changes in left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), left atrial volume (LAV), and left atrial reservoir strain (LAS_r). Multivariate Cox regression analysis was performed to identify predictors for long-term survival.

RESULTS

In our study population of 99 patients with a mean follow-up of 6.3 ± 2.1 years, 43 patients (43%) reached the end-point of all-cause mortality. More extensive LA reverse remodeling, as measured by a relative increase in LAS_r, was observed in survivors compared to non-survivors (43 [29-64] % vs. 8 [2-28] %, P < 0.001, respectively). After multivariate analysis, delta LAS_r remained the only significant predictor of mortality [HR per 5%: 0.90 (0.86-0.95); AUC 0.78 (0.68-0.88)].

CONCLUSION

An increase in LAS_r is associated with favorable long-term outcome after CRT. The observed clinical importance of LA reverse remodeling after CRT asks for further validation in larger prospective cohorts.

Feasibility and Accuracy of the Automated Software for Dynamic Quantification of Left Ventricular and Atrial Volumes and Function in a Large Unselected Population

We aimed to evaluate the feasibility and accuracy of machine learning-based automated dynamic quantification of left ventricular (LV) and left atrial (LA) volumes in an unselected population. We enrolled 600 unselected patients (12% in atrial fibrillation) clinically referred for transthoracic echocardiography (2DTTE), who also underwent 3D echocardiography (3DE) imaging. LV ejection fraction (EF), LV, and LA volumes were obtained from 2D images; 3D images were analyzed using dynamic heart model (DHM) software (Philips) resulting in LV and LA volume–time curves. A subgroup of 140 patients also underwent cardiac magnetic resonance (CMR) imaging. Average time of analysis, feasibility, and image quality were recorded, and results were compared between 2DTTE, DHM, and CMR. The use of DHM was feasible in 522/600 cases (87%). When feasible, the boundary position was considered accurate in 335/522 patients (64%), while major (n = 38) or minor (n = 149) border corrections were needed. The overall time required for DHM datasets was approximately 40 seconds. As expected, DHM LV volumes were larger than 2D ones (end-diastolic volume: 173 ± 64 vs. 142 ± 58 mL, respectively), while no differences were found for LV EF and LA volumes (EF: 55% ± 12 vs. 56% ± 14; LA volume 89 ± 36 vs. 89 ± 38 mL, respectively). The comparison between DHM and CMR values showed a high correlation for LV volumes (r = 0.70 and r = 0.82, p < 0.001 for end-diastolic and end-systolic volume, respectively) and an excellent correlation for EF (r = 0.82, p < 0.001) and LA volumes. The DHM software is feasible, accurate, and quick in a large series of unselected patients, including those with suboptimal 2D images or in atrial fibrillation.

Left atrial contractile longitudinal strain determines intrinsic left atrial function regardless of load status and left ventricular deformation

PURPOSE

Left atrial (LA) longitudinal strain (S) has been proposed as a superior, non-invasive parameter over LA volumetric assessment. LAS has diagnostic and prognostic value in many cardiovascular pathologies. Nevertheless, the acute effect of hemodynamic changes on LAS indices is not well-established. We sought to identify volume independent physiomechanical changes in LA and interrelation between LA and left ventricular (LV) strain indices following a large amount of fluid loss provided by hemodialysis.

METHODS

Seventy-five patients between 18 and 85 years of age under hemodialysis therapy were included. The echocardiographic images were obtained before and after hemodialysis. Phasic LAS and LV global longitudinal strain (GLS) were calculated. The impact of volume depletion on echocardiographic measurements and their temporal correlation were calculated.

RESULTS

LV and LA dimensions,volumes and LV, LA reservoir, and conduit deformation showed a significant decrease after hemodialysis. No significant change was observed for LAS_contraction (p = 0.203). The ultrafiltrated volume was significantly correlated with the changes in LVGLS (r = 0.75, p < 0.001), and LAS_reservoir (r = 0.81, p < 0.001) and LA total emptying volume (r = 0.80, p < 0.001). Absolute changes in LAS_reservoir and LVGLS were strongly correlated (r = 0.83, p < 0.001). There was no correlation between absolute changes in LAS_contraction and LVGLS or ultrafiltrated volume (p = NS, both).

CONCLUSION

LA reservoir and conduit LS are highly volume dependent strain parameters and are strongly correlated with LV deformation along with ultrafiltrated volume. Acute excessive volume depletion or LV deformation have no influence on LAS_contraction. It is important to identify independent easily accessible functional parameters for the LA which would improve clinical evaluation.

The clinical value of the apex beat as a marker of left atrial enlargement

BACKGROUND

The palpation of the apex beat, one of the most fundamental physical examinations, provides a clue to left ventricular (LV) dilatation and hypertrophy; however, its relation to left atrial (LA) volume has rarely been investigated.

METHODS

The clinical value of the apex beat, especially in relation to LA volume was studied in 138 consecutive patients. Patients were examined in the supine position for a palpable apex beat. When an apex beat was felt, the apex beat distance, defined as the distance from the mid-clavicular line to the lateral border of the apex beat, was measured. The LA and LV geometry were assessed using echocardiography.

RESULTS

Of the 138 patients, an apex beat was palpable in 52 (38%) patients and the apex distance of these 52 patients ranged from -2 to 8 cm. The parameters of LV dilatation or hypertrophy were significant according to univariate but not to multivariate analysis. Only LA volume index was significant both for the palpability of the apex beat (p=0.0042) and the apex distance (p=0.0017) by multivariate analysis. The best cut-off point for the apex distance was -1 cm for LA enlargement (sensitivity 61%, specificity 92%, p<0.0001).

CONCLUSIONS

The LA volume is the most significant factor for the palpability and leftward deviation of the apex beat. Palpation of the apex beat is a crucial diagnostic tool for the detection of not only LV dilatation or hypertrophy but also of LA enlargement.

Novelties in 3D Transthoracic Echocardiography

Cardiovascular imaging is developing at a rapid pace and the newer modalities, in particular three-dimensional echocardiography, allow better analysis of heart structures. Identifying valve lesions and grading their severity represents crucial information and nowadays is strengthened by the introduction of new software, such as transillumination, which provide detailed morphology descriptions. Chambers quantification has never been so rapid and accurate: machine learning algorithms generate automated volume measurements, including left ventricular systolic and diastolic function, which is extremely important for clinical decisions. This review provides an overview of the latest innovations in the echocardiography field, and is helpful by providing a better insight into heart diseases.

Identification of Circular RNA-MicroRNA-Messenger RNA Regulatory Network in Atrial Fibrillation by Integrated Analysis

BACKGROUND

Circular RNA (circRNA) is a noncoding RNA that forms a closed-loop structure, and its abnormal expression may cause disease. We aimed to find potential network for circRNA-related competitive endogenous RNA (ceRNA) in atrial fibrillation (AF).

METHODS

The circRNA, miRNA, and mRNA expression profiles in the heart tissue from AF patients were retrieved from the Gene Expression Omnibus database and analyzed comprehensively. Differentially expressed circRNAs (DEcircRNAs), differentially expressed miRNAs (DEmiRNAs), and differentially expressed mRNAs (DEmRNAs) were identified, followed by the establishment of DEcircRNA-DEmiRNA-DEmRNA regulatory network. Functional annotation analysis of host gene of DEcircRNAs and DEmRNAs in ceRNA regulatory network was performed. In vitro experiment and electronic validation were used to validate the expression of DEcircRNAs, DEmiRNAs, and DEmRNAs.

RESULTS

A total of 1611 DEcircRNAs, 51 DEmiRNAs, and 1250 DEmRNAs were identified in AF. The DEcircRNA-DEmiRNA-DEmRNA network contained 62 circRNAs, 14 miRNAs, and 728 mRNAs. Among which, two ceRNA regulatory pairs of hsa-circRNA-100053-hsa-miR-455-5p-TRPV1 and hsa-circRNA-005843-hsa-miR-188-5p-SPON1 were identified. In addition, six miRNA-mRNA regulatory pairs including hsa-miR-34c-5p-INMT, hsa-miR-1253-DDIT4L, hsa-miR-508-5p-SMOC2, hsa-miR-943-ACTA1, hsa-miR-338-3p-WIPI1, and hsa-miR-199a-3p-RAP1GAP2 were also obtained. MTOR was a significantly enriched signaling pathway of host gene of DEcircRNAs. In addition, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, and hypertrophic cardiomyopathy were remarkably enriched signaling pathways of DEmRNAs in DEcircRNA-DEmiRNA-DEmRNA regulatory network. The expression validation of hsa-circRNA-402565, hsa-miR-34c-5p, hsa-miR-188-5p, SPON1, DDIT4L, SMOC2, and WIPI1 was consistent with the integrated analysis.

CONCLUSION

We speculated that hsa-circRNA-100053-hsa-miR-455-5p-TRPV1 and hsa-circRNA-005843-hsa-miR-188-5p-SPON1 interaction pairs may be involved in AF.

Assessment of left atrial mechanics and left ventricular functions using 3D speckle-tracking echocardiography in patients with inappropriate sinus tachycardia

PURPOSE

Inappropriate sinus tachycardia (IST) is defined as a sinus heart rate > 100 bpm at rest (with a mean 24-h heart rate > 90 bpm not due to primary causes) and is associated with distressing symptoms of palpitations. The effect of IST on left atrial (LA) and left ventricular (LV) myocardial dynamics is uncertain. Thus, the aim of this study was to identify early changes in LA mechanics and LV myocardial functions in patients with IST using 3D-STE.

METHODS

Sixty patients with IST and 65 age- and gender-matched controls were enrolled into the study. Conventional 2D echocardiography and 3D-STE were performed, and LAS-r, LAS-active, LAS-passive, LAEF, LAEF-active, LAEF-passive, LV-GLS, LV-GCS, LV-GAS, and LV-GRS were obtained for every patient.

RESULTS

The LAS-r and LAS-active were significantly decreased in the IST group than in the control group (p < 0.001, p = 0.004, respectively). The multivariate logistic regression models revealed that LAS-r (p = 0.008, Odds ratio (OR) 5.98, 95% confidence interval (CI) 2.36-11.18), and LAS-active (p = 0.032, OR 2.16, 95% CI 1.97-4.69) were found to be independent factors for predicting IST.

CONCLUSIONS

The present study is the first to evaluate the left atrial mechanics and left ventricular functions in the patients with IST using 3D-STE. We found that IST had a negative effect on left atrial mechanics. According to our findings, we can say that IST is not a completely innocent, benign clinical condition, but rather, it causes subclinical left atrial dysfunction.

Normal reference intervals for cardiac dimensions and function for use in echocardiographic practice: a guideline from the British Society of Echocardiography

This guideline presents reference limits for use in echocardiographic practice, updating previous guidance from the British Society of Echocardiography. The rationale for change is discussed, in addition to how the reference intervals were defined and the current limitations to their use. The importance of interpretation of echocardiographic parameters within the clinical context is explored, as is grading of abnormality. Each of the following echo parameters are discussed and updated in turn: left ventricular linear dimensions and LV mass; left ventricular volumes; left ventricular ejection fraction; left atrial size; right heart parameters; aortic dimensions; and tissue Doppler imaging. There are several important conceptual changes to the assessment of the heart’s structure and function within this guideline. New terminology for left ventricular function and left atrial size are introduced. The British Society of Echocardiography has advocated a new approach to the assessment of the aortic root, the right heart, and clarified the optimal methodology for assessment of LA size. The British Society of Echocardiography has emphasized a preference to use, where feasible, indexed measures over absolute values for any chamber size.

Left Heart Dysfunction in Acromegaly Revealed by Novel Echocardiographic Methods

Background: Acromegaly is a rare disease that requires modern treatment to decrease the risk of mortality, mainly from vascular diseases. Identifying acromegalic patients with increased cardiovascular risk is challenging. Speckle-tracking echocardiography (STE) is a modern, well-validated, and reproducible method of assessing left ventricular longitudinal deformation and providing a sensitive assessment of myocardial contractility. We hypothesized that STE may be useful in evaluating subclinical dysfunction of the left heart in acromegalic patients, especially when a left ventricle (LV) assessment is completed with STE of the left atrium (LA). Purpose: To assess the diagnostic value of speckle-tracking echocardiography in identifying the occurrence of LV and LA functional impairment in patients with acromegaly, in comparison to patients without this rare pituitary disease. Methods: Echocardiographic assessments of LV and LA function using the new STE method were performed in 60 subjects: 30 acromegalic (ACRO group) patients and a CONTROL group with 30 patients matched in terms of age, gender, systolic/diastolic pressure, and history of hypertension for at least 12 months. Results: The ACRO group, compared to the CONTROL group, presented: (1) higher left ventricular mass (left ventricular mass index: 132 vs. 108 g/m², p < 0.001) and, in consequence, more frequent LV hypertrophy (80.0 vs. 53.3%; p = 0.028); (2) impaired LV systolic function measured by both left ventricular ejection fraction (LVEF) (63.4 vs. 66.9%, p < 0.001) and global longitudinal strain (GLS) (-18.1 vs. -19.4%, p = 0.023); (3) greater LA anteroposterior diameter (40.3 vs. 36.9 mm, p = 0.003) and indexed left atrial volume (37.9 vs. 27.6 ml/m², p < 0.001); and (4) impaired echocardiographic strain parameters corresponding with LA function. Conclusions: Acromegaly, even in young patients with good blood pressure control, may be associated with left ventricular hypertrophy and subclinical impairment of the left ventricular and left atrial mechanical function, which may be identified by speckle-tracking echocardiography. Further research in this area is necessary to clarify the prognostic value of these phenomena.

Left atrial volume index: Can it provide additional prognostic information in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention?

INTRODUCTION

We sought to assess the prognostic impact of left atrial (LA) size on long-term outcomes of ST-segment elevation myocardial infarction (STEMI).

METHODS

We studied 200 consecutive patients admitted to a single center between January 2010 and December 2014 with non-fatal STEMI treated with primary percutaneous coronary intervention (pPCI) who underwent a comprehensive echocardiographic examination at discharge. LA volume was estimated by the area-length method. The left atrium was classified as normal, mildly, moderately or severely enlarged by LA volume index (LAVI). The endpoints were defined as all-cause mortality, a cardiac composite endpoint (all-cause mortality, reinfarction, unplanned revascularization and hospitalization for heart failure) and a cardiovascular composite endpoint (cardiac endpoint plus atrial fibrillation and ischemic stroke) during follow-up.

RESULTS

In this STEMI population, 58% had normal LA size, 22.5% had mild LA enlargement, 10% had moderate LA enlargement and 9.5% had severe LA enlargement. During a median follow-up of 28 (IQR 21-38) months, 14 (7.0%) patients died, 53 (26.5%) had the cardiac and 58 (29%) the cardiovascular composite endpoints. There was a stepwise increase in the incidence of all-cause mortality (p=0.020) and both cardiac (p<0.001) and cardiovascular (p<0.001) endpoints with each increment of LAVI class. In multivariate analysis, severe LA enlargement by LAVI was an independent predictor of all-cause mortality (HR: 11.153; 95% CI: 1.924-64.642, p=0.007) and the cardiac (HR: 4.351; 95% CI: 1.919-9.862, p<0.001) and cardiovascular (HR: 4.351; 95% CI: 1.919-9.862, p<0.001) endpoints during follow-up.

CONCLUSIONS

This contemporary study confirms the prognostic effect of LA size at discharge, applying the most recent reference values in STEMI patients treated with pPCI.

Load Dependency of Left Atrial Strain in Normal Subjects

BACKGROUND

Left atrial (LA) longitudinal strain is a novel parameter used for the evaluation of LA function, with demonstrated prognostic value in several cardiac diseases. However, the extent of load dependency of LA strain is not well known. The aim of this study was to evaluate the impact of acute changes in preload on LA strain, side by side with LA volume, in normal subjects.

METHODS

Twenty-five healthy volunteers (13 men; mean age, 31 ± 2 years) were prospectively enrolled, who underwent two-dimensional and three-dimensional echocardiographic imaging during acute stepwise reductions in preload using a tilt maneuver: baseline at 0°, followed by 40° and 80°. Left ventricular and LA size and function parameters were measured using standard methodology, and LA strain-time curves were obtained using speckle-tracking software (TomTec), resulting in reservoir, conduit, and contractile strain components. All parameters were compared among the three loading conditions using one-way analysis of variance for repeated measurements.

RESULTS

Although there were no significant changes in blood pressure, heart rate increased significantly with tilt. As expected, LA volumes, left ventricular volumes, and left ventricular ejection fraction, as well as E wave, A wave, and e' significantly decreased with progressive inclination. In parallel, LA reservoir, conduit, and contractile strain values decreased with reduction in preload (reservoir: 42.9 ± 3.9% to 27.5 ± 3.8%, P < .001; conduit: 29.3 ± 2.7% to 20.2 ± 5.0%, P < .001; contractile: 13.6 ± 2.9% to 7.3 ± 3.5%, P < .001). Paired post hoc analysis showed that all LA strain values were significantly different among all three tilt phases. Of note, percentage change in LA reservoir strain was significantly smaller than that in LA maximum volume.

CONCLUSIONS

In normal subjects, LA strain is preload dependent but to a lesser degree than LA volume. This difference underscores the relative advantage of LA strain over maximum volume, when LA assessment is used as part of the diagnostic paradigm.

Current role of echocardiography in cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure and left ventricular systolic dysfunction. Patients are usually assessed by echocardiography, which provides a number of anatomical and functional information used for cardiac dyssynchrony assessment, prognostic stratification, identification of the optimal site of pacing in the left ventricle, optimization of the CRT device, and patient follow-up. Compared to other cardiac imaging techniques, echocardiography has the advantage to be non-invasive, repeatable, and safe, without exposure to ionizing radiation or nefrotoxic contrast. In this article, we review current evidence about the role of echocardiography before, during, and after the implantation of a CRT device.

Left atrial remodeling, hypertrophy, and fibrosis in mouse models of heart failure

Left ventricular dysfunction increases left atrial pressures and causes atrial remodeling. In human subjects, increased left atrial size is a powerful predictor of mortality and adverse events in a broad range of cardiac pathologic conditions. Moreover, structural remodeling of the atrium plays an important role in the pathogenesis of atrial tachyarrhythmias. Despite the potential value of the atrium in assessment of functional endpoints in myocardial disease, atrial pathologic alterations in mouse models of left ventricular disease have not been systematically investigated. Our study describes the geometric, morphologic, and structural changes in experimental mouse models of cardiac pressure overload (induced through transverse aortic constriction), myocardial infarction, and diabetes. Morphometric and histological analysis showed that pressure overload was associated with left atrial dilation, increased left atrial mass, loss of myofibrillar content in a subset of atrial cardiomyocytes, atrial cardiomyocyte hypertrophy, and atrial fibrosis. In mice undergoing nonreperfused myocardial infarction protocols, marked left ventricular systolic dysfunction was associated with left atrial enlargement, atrial cardiomyocyte hypertrophy, and atrial fibrosis. Both infarcted animals and pressure overloaded mice exhibited attenuation and perturbed localization of atrial connexin-43 immunoreactivity, suggesting gap junctional remodeling. In the absence of injury, obese diabetic db/db mice had diastolic dysfunction associated with atrial dilation, atrial cardiomyocyte hypertrophy, and mild atrial fibrosis. Considering the challenges in assessment of clinically relevant functional endpoints in mouse models of heart disease, study of atrial geometry and morphology may serve as an important new tool for evaluation of ventricular function.

The Role of Left Atrial Volume Index in Patients with a First-ever Acute Ischemic Stroke

BACKGROUND

Although an enlarged left atrium has recently emerged as a marker of adverse outcomes in various diseases, its discriminatory value and prognostic role in acute ischemic stroke (AIS) are not well studied. We studied whether left atrial volume index (LAVI) predicts mortality and discriminates stroke subtypes after AIS.

METHODS

We prospectively followed 310 consecutive first-ever AIS patients aged 50 years or older who were admitted to the hospital within 24 hours of the onset of stroke symptoms. The type of AIS was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. All of the patients underwent transthoracic echocardiography within the first 24 hours. LAVI was measured with the biplane area-length method and categorized as 28 mL/m² or lower (normal), 28.1-32 mL/m², 32.1-36 mL/m², and >36 mL/m². The patients were followed for 1 year or until death, whichever came first.

RESULTS

The LAVI of the cardioembolic group was significantly higher than that of the noncardioembolic group (32.4 ± 4.0 versus 29.7 ± 3.4 mL/m², respectively; P < .001). The optimal cutoff value, sensitivity, and specificity of LAVI to distinguish cardioembolic stroke from noncardioembolic stroke were 30 mL/m², 81%, and 64%, respectively. Mortality in each LAVI category was 4%, 7.8%, 25.9%, and 70.9%, respectively (P = .026). Kaplan-Meier analysis showed that there was a stepwise increase in risk of mortality with each increment of LAVI category.

CONCLUSIONS

The LAVI can distinguish cardioembolic stroke from noncardioembolic stroke and provides an independent information over clinical and other echocardiographic variables for predicting mortality in patients with first-ever AIS.

Abnormal echocardiography in patients with type 2 diabetes and relation to symptoms and clinical characteristics

OBJECTIVES

We aimed to determine the prevalence of echocardiographic abnormalities and their relation to clinical characteristics and cardiac symptoms in a large, contemporary cohort of patients with type 2 diabetes.

RESULTS

A total of 1030 patients with type 2 diabetes participated. Echocardiographic abnormalities were present in 513 (49.8%) patients, mainly driven by a high prevalence of diastolic dysfunction 178 (19.4%), left ventricular hypertrophy 213 (21.0%) and left atrial enlargement, 200 (19.6%). The prevalence increased markedly with age from 31.1% in the youngest group (<55 years) to 73.9% in the oldest group (>75 years) (p < 0.001) and was equally distributed among the sexes (p = 0.76). In univariate analyses, electrocardiographic abnormalities, age, body mass index, known coronary heart disease, hypertension, albuminuria, diabetes duration and creatinine were associated with abnormal echocardiography along with dyspnoea and characteristic chest pain (p < 0.05 for all). Neither of the cardiac symptoms nor clinical characteristics had sufficient sensitivity and specificity to accurately identify patients with abnormal echocardiography.

CONCLUSION

Echocardiographic abnormalities are very common in outpatients with type 2 diabetes, but neither cardiac symptoms nor clinical characteristics are effective to identify patients with echocardiographic abnormalities.

The differences in left atrial function between ischemic and idiopathic dilated cardiomyopathy patients: A two-dimensional speckle tracking imaging study

PURPOSE

To evaluate left atrial (LA) function in patients with ischemic (ICM) or idiopathic dilated (DCM) cardiomyopathy via two-dimensional speckle-tracking imaging.

METHODS

We measured the LA maximum volume, minimum volume, and volume before the atrial systole, and calculated total emptying volume, expansion index, active emptying volume, and fraction. We measured strain and strain rate during systole and late diastole using two-dimensional speckle-tracking imaging, and analyzed correlations between variables.

RESULTS

We found no significant differences in LA size, left ventricle (LV) end-diastole diameter, LV ejection fraction (EF), E/A, E/e', deceleration time of the E wave, and effective mitral regurgitant orifice area between the DCM and the ICM group. However, the LA expansion index, active EF, systolic and late diastolic strain, and strain rate were lower in the ICM group (p < 0.05). The expansion index and active EF were positively correlated with the systolic strain rate and the absolute value of the late diastolic strain rate, respectively.

CONCLUSIONS

LA basic echocardiographic variables did not reflect the differences between ICM and DCM patients, but the systolic and late diastolic strain, as well as the strain rate, were lower in DCM patients. Two-dimensional speckle-tracking imaging is a promising method to differentiate these patients. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:437-445, 2016.

Atrial Functions and Aortic Elasticity in Children with Aortic Coarctation

BACKGROUND

Coarctation of the aorta (CoA) is a chronic vascular disease characterized by a persistence of myocardial and vascular alterations. We aimed to evaluate children who have had successful coarctation surgery or balloon dilatation to evaluate the elasticity of the aorta, left atrial ejection force (AEF) and myocardial performance collectively at midterm follow-up.

METHODS

Nineteen patients (7.15 ± 0.9 years of age) and 21 age-sex matched healthy children were included in this study. Left AEF index is defined as the product of mass and acceleration of blood expelled from the left atrium. Aortic stiffness and distensibility were estimated using ascending and descending aorta diameters.

RESULTS

The left atrial force index [(g∙cm/s(2))/m(2)] in the patient group was found to be significantly higher (12.69 ± 7.29, 5.74 ± 2.59, respectively, p = 0.001). Distensibility of the ascending aorta (cm(2)/dynes 10(-6)) was significantly lower in the patient group than in the control group (42.13 ± 24.02, 78.79 ± 20.49, respectively, p < 0.001). The stiffness index of the ascending aorta was significantly higher in the patient group (p < 0.001). We also documented that atrial force index is associated with peak E velocity, right arm systolic blood pressure and left ventricular mass index.

CONCLUSIONS

Our investigation showed that AEF is higher in children who have had successful coarctation surgery or balloon dilatation, and AEF is associated with systolic blood pressure, peak E velocity and left ventricular mass index. Distensibility of the ascending aorta was lower, and stiffness index was higher in children with corrected CoA than in healthy subjects.

KEY WORDS

Atrial ejection force; Balloon dilatation; CoA; Coarctation surgery; Distensibility; Stiffness index.

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.

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.

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.

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.

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.

Role of echocardiography in the contemporary management of chronic heart failure

Echocardiography is an excellent noninvasive tool for the assessment of ventricular size and both systolic and diastolic function, and it is routinely used in patients with heart failure. This review will discuss the role of echocardiography in heart failure diagnosis, prognostic assessment and in the management of heart failure patients.

Left Atrial Volume and the Benefit of Cardiac Resynchronization Therapy in the MADIT-CRT Trial

Background—

Left atrial volume (LAV) is an important marker of heart failure (HF) severity. We hypothesized that LAV independently correlates with clinical outcomes in patients who receive cardiac resynchronization therapy with a defibrillator (CRT-D) and can be used for improved risk assessment in this population.

Methods and Results—

The benefit of CRT-D versus defibrillator-only therapy in reducing the risk of HF or death was assessed by LAV (dichotomized at the upper quartile >52 mL/m 2 ) among 1785 patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) study. Landmark analysis was used to evaluate the relationship between LAV response to CRT-D and subsequent clinical outcomes. Multivariable analysis showed that patients with a higher baseline LAV experienced 69% ( P <0.001) and 59% ( P =0.02) increased hazard for HF or death and for all-cause mortality, respectively, independently of baseline left ventricular volume. CRT-D was associated with a significant reduction in LAV compared with defibrillator-only therapy (−28% versus −10%, respectively; P <0.001). Landmark analysis showed that after CRT-D implantation each 1% reduction in LAV was independently associated with a corresponding 4% reduction in the hazard of subsequent HF or death ( P <0.001). The assessment of LAV change after CRT implantation improved prediction of clinical response to the device compared with assessment of the corresponding changes in left ventricular volume.

Conclusions—

LAV is an independent correlate of clinical outcomes in mildly symptomatic HF patients treated with CRT-D. CRT exerts pronounced reverse remodeling effects on the left atrium that independently correlate with improved clinical outcomes after device implantation.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00180271.

Real-time 3D echocardiographic quantification of left atrial volume: multicenter study for validation with CMR

OBJECTIVES

We studied in a multicenter setting the accuracy and reproducibility of 3-dimensional echocardiography (3DE)-derived measurements of left atrial volume (LAV) using new, dedicated volumetric software, side by side with 2-dimensional echocardiography (2DE), using cardiac magnetic resonance (CMR) imaging as a reference.

BACKGROUND

Increased LAV is associated with adverse cardiovascular outcomes. Although LAV measurements are routinely performed using 2DE, this methodology is limited because it is view dependent and relies on geometric assumptions regarding left atrial shape. Real-time 3DE is free of these limitations and accordingly is an attractive alternative for the evaluation of LAV. However, few studies have validated 3DE-derived LAV measurements against an accepted independent reference standard, such as CMR imaging.

METHODS

We studied 92 patients with a wide range of LAV who underwent CMR (1.5-T) and echocardiographic imaging on the same day. Images were analyzed to obtain maximal and minimal LAV: CMR images using standard commercial tools, 2DE images using a biplane area-length technique, and 3DE images using Tomtec LA Function software. Intertechnique comparisons included linear regression and Bland-Altman analyses. Reproducibility of all 3 techniques was assessed by calculating the percentage of absolute differences in blinded repeated measurements. Kappa statistics were used to compare 2DE and 3DE classification of normal/enlarged against the CMR reference.

RESULTS

3DE-derived LAV values showed higher correlation with CMR than 2DE measurements (r = 0.93 vs. r = 0.74 for maximal LAV; r = 0.88 vs. r = 0.82 for minimal LAV). Although 2DE underestimated maximal LAV by 31 ± 25 ml and minimal LAV by 16 ± 32 ml, 3DE resulted in a minimal bias of -1 ± 14 ml for maximal LAV and 0 ± 21 ml for minimal LAV. Interobserver and intraobserver variability of 2DE and 3DE measurements of maximal LAV were similar (7% to 12%) and approximately 2 times higher than CMR (4% to 5%). 3DE classified enlarged atria more accurately than 2DE (kappa: 0.88 vs. 0.71).

CONCLUSIONS

Compared with CMR reference, 3DE-derived LAV measurements are more accurate than 2DE-based analysis, resulting in fewer patients with undetected atrial enlargement.

Effects of Age and Gender on Left Atrial Ejection Force and Volume from Real-Time Three-Dimensional Echocardiography

Introduction: This study was carried out to (i) provide the methodology for determining left atrial (LA) volume, emptying fraction and ejection force (LAEF), from real-time 3-dimensional echocardiography (RT3DE), and (ii) evaluate the effects of age and gender on LA volume and LAEF in a wide age range of healthy participants. Materials and Methods: RT3DE was performed in 102 healthy participants (age range, 20 to 80 years). From full-volume data sets, LA endocardial borders were automatically traced and LA volumes were determined. LAEF was calculated as 1/3×mitral annular area × (blood density) × (peak velocity of A wave)2 according to Newton’s law of motion and hydrodynamics; wherein the mitral annular area (MVA) is traced using RT3DE and A is the peak Doppler-derived blood velocity at atrial systole with the sample volume placed at the mitral annulus level. Results: ANOVA analysis revealed that LA volume indices were significantly correlated with age (r = 0.366, P <0.0001 for maximal volume index and r = 0.288, P <0.005 for minimal volume index). LAEF was also significantly positively correlated with age (r = 0.49, P <0.0001). The LA emptying fraction was maintained across ages. LA volume indices and LAEF did not differ significantly with gender. Conclusion: Our data can be used as normal reference values for LA volumes and LAEF. We have demonstrated that age is positively related to LA volume indices and LAEF, which suggests that age-dependent cut-off values should be considered in those with heart disease. Key words: Age, LA Ejection Force, RT3DE, Volume

Left atrial volume is an independent predictor of all-cause mortality in chronic hemodialysis patients

OBJECTIVE

An enlarged left atrium (LA) has recently been identified as a risk factor for adverse cardiovascular outcomes in various pathologic conditions. However, few studies have evaluated its prognostic value in hemodialysis (HD) patients.

METHODS

We conducted an observational study to investigate whether an enlarged LA predicted all-cause mortality in 174 HD patients. Patients were stratified into two groups based on the LA volume index (LAVI) value of 32 mL/m².

RESULTS

An increased left atrial volume index (LAVI >32 mL/m(2)) was present in 28 (16.1%) of the HD patients. During the follow-up period (50.1 ± 22.4 months), 77 patients (44.3%) died. A Kaplan-Meier analysis revealed that the 7-year survival rate was significantly lower in the group whose LAVI was >32 mL/m(2) than in the group whose LAVI was ≤ 32 mL/m(2) (p=0.0033). Multivariate analyses adjusted for echocardiographic parameters and clinical and laboratory data showed that increased LAVI was an independent predictor of all-cause mortality (hazard ratio 1.030, 95% confidence interval 1.004-1.056, p=0.0260). Moreover, increased LAVI had a higher predictive value for all-cause mortality (area under the receiver operating characteristic curve=0.612, p=0.0059) among the measured echocardiographic parameters.

CONCLUSION

The results of the present study suggested that measurement of LAVI may be helpful in the risk stratification of HD patients and in providing therapeutic direction for their management.

Left atrial size and risk for all-cause mortality and ischemic stroke

BACKGROUND

Limited data are available on the relation between left atrial size and outcome among patients referred for clinically indicated echocardiograms. Our aim was to assess the association of left atrial size with all-cause mortality and ischemic stroke in a large cohort of patients referred for echocardiography.

METHODS

Left atrial diameter was measured in 52 639 patients aged 18 years or older (mean age 61.8 [standard deviation (SD) 16.3] years; 52.9% men) who underwent a first transthoracic echocardiogram for clinical reasons at our institution between April 1990 and March 2008. The outcomes were all-cause mortality and nonfatal ischemic stroke.

RESULTS

Based on the criteria of the American Society of Echocardiography, 50.4% of the patients had no left atrial enlargement, whereas 24.5% had mild, 13.3% had moderate and 11.7% had severe left atrial enlargement. Over a mean follow-up period of 5.5 (SD 4.1) years, 12 527 patients died, and 2314 patients had a nonfatal ischemic stroke. Cumulative 10-year survival was 73.7% among patients with normal left atrial size, 62.5% among those with mild enlargement, 54.8% among those with moderate enlargement and 45% among those with severe enlargement (p < 0.001). After adjustment in multivariable Cox proportional hazard analysis, left atrial diameter remained a predictor of all-cause mortality in both sexes (hazard ratio [HR] per 1-cm increment in left atrial size 1.17, 95% confidence interval [CI] 1.12-1.22, p < 0.001 in women, and HR 1.09, 95% CI 1.05-1.13, p < 0.001 in men) and of ischemic stroke in women (HR 1.25, 95% CI 1.14-1.37, p < 0.001).

INTERPRETATION

Left atrial diameter has a graded and independent association with all-cause mortality in both sexes and with ischemic stroke in women.

Left atrial volume is an independent predictor of mortality in CAPD patients

BACKGROUND

Echocardiography is an established technique to estimate the risk for cardiovascular complications in patients with end-stage renal disease (ESRD). An enlarged left atrium (LA) has recently emerged as a marker of adverse cardiovascular outcomes in various pathologic conditions. However, there have been few studies to evaluate its prognostic value in patients with ESRD, particularly those receiving continuous ambulatory peritoneal dialysis (CAPD).

METHODS

We conducted an observational cohort study to investigate whether enlarged LA can predict patient outcome in 216 patients with CAPD. Study outcomes were all-cause and cardiovascular mortality.

RESULTS

Increased left atrium volume index (LAVI > 32 mL/m(2)) was observed in 99 (45.8%) of the CAPD patients. During the follow-up (26.3 ± 18.6 months), 20 patients (9.3%) died. Kaplan-Meier analysis revealed that the 5-year survival rate was significantly lower in patients with LAVI > 32 mL/m(2) than those with LAVI ≤ 32 mL/m(2) (69 versus 82%, P = 0.024). In multivariate analyses adjusted for echocardiographic parameters and clinical and laboratory data, increased LAVI was an independent predictor of all-cause mortality [hazard ratio (HR) 1.05, 95% confidence interval (CI) 1.01-1.10, P = 0.03] and cardiovascular mortality (HR 1.08, 95% CI 1.02-1.14, P = 0.006). Furthermore, increased LAVI provided the highest predictive value for all-cause mortality [area under the receiver operating characteristic curve (AUC) = 0.766, P < 0.001] and cardiovascular mortality (AUC = 0.836, P < 0.001) among the measured echocardiographic parameters.

CONCLUSIONS

We showed that increased LAVI predicted adverse outcomes better than other echocardiographic parameters in patients with CAPD.

Left atrial volume and index by multi-detector computed tomography: comprehensive analysis from predictors of enlargement to predictive value for acute coronary syndrome (ROMICAT study)

OBJECTIVES

We aimed to identify the predictors of left atrial (LA) enlargement by multi-detector computed tomography (CT) and determine its association and predictive value for acute coronary syndrome (ACS).

BACKGROUND

LA enlargement is associated with myocardial ischemia and coronary artery disease (CAD) and is a strong predictor for cardiovascular events. These studies were performed primarily with echocardiography. With the rise of cardiac CT, LA volume can be readily measured.

METHODS

In 377 emergency department patients with chest pain, we performed 64-slice CT for coronary artery assessment. We derived LA volumes (LAV(max), LAV(min)) and indices (LAVI(max), LAVI(min)) using a threshold-based volumetric method.

RESULTS

Subjects, with cardiac risk factors or CAD by CT, had larger LA (ΔLAV(max) 9.1 ml, p=0.004; ΔLAV(min) 8.1 ml, p=0.001; ΔLAVI(max) 3.3 ml/m(2), p=0.03; ΔLAVI(min) 3.4 ml/m(2), p=0.006) than controls. Predictors of LA enlargement were related to risk factors for diastolic dysfunction. ACS risk was greater in patients with top quartile LAV(max) (odds ratio [OR] 3.4, p=0.02) and LAV(min) (OR 4.7, p=0.01) than lowest quartile, but not when indexed. Similarly, the predictive values of LA volumes were incrementally better when added to CT finding of indeterminate stenosis (LAV(max): C statistic 0.62 to 0.70, p=0.046; LAV(min): C statistic 0.65 to 0.73, p=0.008), but not when indexed.

CONCLUSIONS

Risk factors related to diastolic dysfunction are independent predictors of LA enlargement. LA enlargement by volumes are associated with a 3-5 fold increase risk for ACS and have incremental value for predicting ACS when added to the CT finding of indeterminate stenosis.

Assessment of left atrial volume: a focus on echocardiographic methods and clinical implications

Left atrial enlargement is an important predictor of cardiovascular events such as atrial fibrillation, stroke, heart failure and mortality. A number of methods of left atrial size assessment by echocardiography have been reported, from the simple antero-posterior diameter in the parasternal long axis view to the more complex ellipsoid, area-length and Simpson's method of estimating left atrial volume. These different methods of left atrial size assessment, their clinical implications and some common pitfalls are discussed in this review.