Strain rate imaging for noninvasive functional quantification of the left atrium: comparative studies in controls and patients with atrial fibrillation

Evaluation of Cardiac Function Recovery in Patients with Paroxysmal Atrial Fibrillation after Catheter Radiofrequency Ablation Using Two-Dimensional Speckle Tracking Imaging and Real-Time Three-Dimensional Echocardiography

INTRODUCTION

The aim of this study was to evaluate the utility of 2D-STI and real-time three-dimensional echocardiography (RT-3DE) in assessing changes in left atrial (LA) structure and function in patients with paroxysmal atrial fibrillation (PAF) post-radiofrequency catheter ablation (RFCA).

METHODS

A retrospective analysis was conducted on 44 PAF patients who underwent RFCA at BA Hospital from March 2022 to March 2023. An age- and gender-matched control group of 32 healthy individuals was also included. Comprehensive echocardiographic parameters including LA dimensions (LAAPD, LALRD), volumes (LAVmin, LAVmax), ejection fraction (LAEF), and tissue velocities (a', Ar) were compared between groups. Post-RFCA changes in these parameters were also assessed at 1, 3, and 6 months.

RESULTS

Pre-RFCA, PAF patients demonstrated larger LA dimensions and volumes with reduced LAEF and tissue velocities compared to controls. Post-RFCA, there was a significant improvement in LAEF and left ventricular ejection fraction at 1, 3, and 6 months, with the most pronounced changes observed at 6 months. LA dimensions increased initially but then decreased from 1 to 6 months post-RFCA. Notably, strain rate (SRS, SRE, SRA) measurements in various LA segments improved progressively, with the most significant enhancements at 6 months, suggesting improved atrial mechanics.

CONCLUSION

The application of 2D-STI and RT-3DE provides a quantitative means to evaluate the structural and functional changes in the LA of PAF patients following RFCA. The progressive improvements in LA dimensions, volumes, and strain measurements up to 6-month post-RFCA indicate the potential of these techniques in monitoring treatment efficacy and patient recovery.

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.

Ablation-induced left atrial mechanical dysfunction recovers in weeks after ablation

BACKGROUND

The immediate impact of catheter ablation on left atrial mechanical function and the timeline for its recovery in patients undergoing ablation for atrial fibrillation (AF) remain uncertain. The mechanical function response to catheter ablation in patients with different AF types is poorly understood.

METHODS

A total of 113 AF patients were included in this retrospective study. Each patient had three magnetic resonance imaging (MRI) studies in sinus rhythm: one pre-ablation, one immediate post-ablation (within 2 days after ablation), and one post-ablation follow-up MRI (≤ 3 months). We used feature tracking in the MRI cine images to determine peak longitudinal atrial strain (PLAS). We evaluated the change in strain from pre-ablation, immediately after ablation to post-ablation follow-up in a short-term study (< 50 days) and a 3-month study (3 months after ablation).

RESULTS

The PLAS exhibited a notable reduction immediately after ablation, compared to both pre-ablation levels and those observed in follow-up studies conducted at short-term (11.1 ± 9.0 days) and 3-month (69.6 ± 39.6 days) intervals. However, there was no difference between follow-up and pre-ablation PLAS. The PLAS returned to 95% pre-ablation level within 10 days. Paroxysmal AF patients had significantly higher pre-ablation PLAS than persistent AF patients in pre-ablation MRIs. Both type AF patients had significantly lower immediate post-ablation PLAS compared with pre-ablation and post-ablation PLAS.

CONCLUSION

The present study suggested a significant drop in PLAS immediately after ablation. Left atrial mechanical function recovered within 10 days after ablation. The drop in PLAS did not show a substantial difference between paroxysmal and persistent AF patients.

Antiquated ejection fraction: Basic research applications for speckle tracking echocardiography

For years, ejection fraction has been an essentially ubiquitous measurement for assessing the cardiovascular function of animal models in research labs. Despite technological advances, it remains the top choice among research labs for reporting heart function to this day, and is often overstated in applications. This unfortunately may lead to misinterpretation of data. Clinical approaches have now surpassed research methods, allowing for deeper analysis of the tiers of cardiovascular performance (cardiovascular performance, heart performance, systolic and diastolic function, and contractility). Analysis of each tier is crucial for understanding heart performance, mechanism of action, and disease diagnosis, classification, and progression. This review will elucidate the differences between the tiers of cardiovascular function and discuss the benefits of measuring each tier via speckle tracking echocardiography for basic scientists.

Left atrial reservoir and pump function after catheter ablation with persistent atrial fibrillation: a two-dimensional speckle tracking imaging study

OBJECTIVE

By using ultrasound strain rate (SR) imaging to evaluate the left atrial (LA) reservoir and pump function after catheter ablation (CA) with persistent atrial fibrillation (PAF).

METHODS

A total of 45 patients with PAF underwent echocardiography examination before and after ablation as well as during 6 months of follow-up. Peak SR was measured at each LA segment (septal, lateral, anterior, inferior and posterior) during systole (LAs) and late diastole (LAa).

RESULTS

During 6 months after CA, 30 patients were free of atrial fibrillation recurrence (AFR). left atrial area index (LAAI), left atrial maximum volume index (LAVImax), and E/Ea were obviously higher in patients with before CA, left atrial ejection fraction (LAEF), SR-LAs were lower than in normal cases, the SR-LAa was disappeared. Shortly after ablation, SR-LAa was recovered, and SR-LAs was reduced compared to those at baseline. At midterm follow-up, LAEF and SR-LAs were still lower than the control group, and LAAI and LAVImax were higher. SR-LAa was recovered slowly over time, but still lower.

CONCLUSION

LA reservoir function was seriously damaged and LA pump function disappeared in patients with PAF. LA reservoir function impairment appeared shortly after ablation, it showed improvement at midterm follow-up, but some degree of damage to the LA reservoir and pump function was still present. Speckle tracking imaging is a feasible technique for the assessment of LA function in patients with PAF, which is a potentially valuable clinical tool to assist in the early detection of atrial remodelling and reverse remodelling.

Real-time three-dimensional echocardiography and two-dimensional speckle tracking imaging in the evaluation of left atrial function in patients with triple-vessel coronary artery disease without myocardial infarction

OBJECTIVE

To evaluate left atrial function in patients with triple-vessel disease (TVD) without myocardial infarction by real-time three-dimensional echocardiography (RT-3DE) and two-dimensional speckle tracking imaging (2D-STE).

METHODS

Sixty patients with coronary artery disease (CAD) without myocardial infarction were classified into two groups in accordance with the coronary angiography results: group B (all triple-vessel stenosis ≥ 50% and < 75%) and group C (all triple-vessel stenosis ≥ 75%). Thirty healthy individuals were selected as group A. LA volume related parameters including left atrial maximum volume index (LAVImax), LA passive and active ejection fraction (LAPEF, LAAEF) and LA total ejection fraction (LATEF) were measured by RT-3DE. The global peak atrial longitudinal systolic strain (LASRs), early and late diastolic LA strain (LASRe and LASRa) rates were measured by 2D-STE.

RESULTS

We found statistically significant differences between 2D-STE and RT-3DE related parameters of these three groups. Furthermore, in groups B and C, N-terminal fragment brain natriuretic peptides (NT-pro-BNP) and left ventricular end-diastolic pressure (LVEDP) were found to be significantly correlated with LASRs and LASRa. And NT-pro-BNP had a moderate correlation with LVEDP.

CONCLUSIONS

2D-STE and RT-3DE can assess the LA function in patients with TVD without myocardial infarction. And LA strain values may provide additional information for predicting increased LVEDP and NT-pro-BNP.

Sclerodermic Cardiomyopathy—A State-of-the-Art Review

Systemic sclerosis (SSc) is a chronic autoimmune disorder with unknown triggering factors, and complex pathophysiologic links which lead to fibrosis of skin and internal organs, including the heart, lungs, and gut. However, more than 100 years after the first description of cardiac disease in SSc, sclerodermic cardiomyopathy (SScCmp) is an underrecognized, occult disease with important adverse long-term prognosis. Laboratory tests, electrocardiography (ECG) and cardiovascular multimodality imaging techniques (transthoracic 2D and 3D echocardiography, cardiac magnetic resonance (CMR), and novel imaging techniques, including myocardial deformation analysis) provide new insights into the cardiac abnormalities in patients with SSc. This state-of-the-art review aims to stratify all the cardiac investigations needed to diagnose and follow-up the SScCmp, and discusses the epidemiology, risk factors and pathophysiology of this important cause of morbidity of the SSc patient.

Left Atrial Dysfunction, Fibrosis and the Risk of Thromboembolism in Patients With Paroxysmal and Persistent Atrial Fibrillation

Background and Objectives

Left atrial (LA) fibrosis is an important component of the arrhythmogenic substrate and is related to LA dysfunction in patients with atrial fibrillation (AF). However, its relationship with functional changes and the risk of thrombus in patients with paroxysmal AF (PAF) and persistent AF (PeAF) remains unclear.

Methods

We included 139 patients with preprocedural cardiac magnetic resonance imaging (CMR) and transesophageal echocardiography (TEE) for the first AF catheter ablation. Spontaneous echo contrast (SEC) and multiple parameters of LA were measured from TEE and CMR. LA fibrosis was evaluated by late gadolinium enhancement of LA (LA-LGE) of CMR.

Results

The presence of SEC was higher in patients with PeAF than in patients with PAF (26.4% vs. 11.9%, p=0.03). The patients with SEC had more enlarged LA size and impaired function of LA and LAA, regardless of AF type. However, the area of LA-LGE was more extensive in patients with SEC in PeAF (27.5±15.9 vs. 20.1±10.3, p=0.033), not in PAF. In PAF, maximal LA volume index was closely related to the presence of SEC with marginal trend toward significance (odd ratio [OR], 1.07; 95% confidence interval [CI], 0.99–1.16; p=0.072). Whereas, a larger area of LA-LGE and lower emptying flux of LA appendage were independently related with SEC (OR, 1.10; 95% CI, 1.0–1.20; p=0.049 and OR, 0.93; 95% CI, 0.86–0.99; p=0.022, respectively) after adjusting related cardiovascular risk factors of SEC

Conclusions

In this study, we suggest that the risk of thrombus is provoked by LA enlargement with dysfunction in early-stage AF and by stiffened LA with fibrosis rather than LA size when it becomes PeAF.

Current clinical applications of speckle tracking echocardiography for assessment of left atrial function

Two-dimensional speckle tracking echocardiography (2D-STE) enables assessment of left atrial (LA) function with better reproducibility and less load dependence than those with conventional methods. Data regarding LA functions determined by 2D-STE in patients with various cardiovascular diseases have recently been accumulating. LA strain has emerged as a novel parameter with the potential of improving the diagnostic accuracy of left ventricular diastolic dysfunction and the prognostic value in patients with heart failure and stroke. Furthermore, LA dysfunction determined by 2D STE can provide incremental prognostic information to conventional echocardiographic parameters in patients with cardiovascular diseases. Hence, 2D-STE appears to be a promising technique for diagnosis and therapeutic decision-making. Data regarding LA functions determined by three-dimensional speckle tracking echocardiography (3D-STE) have also been accumulating. Here, I review recent studies, especially those published after 2016, on clinical applications of LA function assessed by 2D-STE and 3D-STE and summarize the remaining problems to be solved for improving the clinical utility of these techniques.

A Novel Approach for Predicting Atrial Fibrillation Recurrence After Ablation Using Deep Convolutional Neural Networks by Assessing Left Atrial Curved M-Mode Speckle-Tracking Images

Aims: Curved M-mode images of global strain (GS) and strain rate (GSR) provide sufficiently detailed spatiotemporal information of deformation mechanics. This study investigated whether a deep convolutional neural network (CNN) could accurately classify these images in patients with atrial fibrillation (AF) who underwent radiofrequency catheter ablation (RFCA) with different outcomes.

Methods and Results: We retrospectively evaluated 606 consecutive patients who underwent RFCA for drug-refractory AF. Patients were divided into AF-free (n = 443) and AF-recurrent (n = 163) groups. Transthoracic echocardiography was performed within 24 h after RFCA. Left atrial curved M-mode speckle-tracking images were acquired from randomly selected 163 patients in AF-free group and 163 patients in AF-recurrent group as the dataset for deep CNN modeling. We used the ReLu activation function and repeatedly performed CNN model for 32 times to evaluate the stability of hyperparameters. Logistic regression models with the left atrial dimension, emptying fraction, and peak systolic GS as predictor variables were used for comparisons. Images from the apical 2-chamber (2-C) and 4-chamber (4-C) views had distinct features, leading to different CNN performance between settings; of them, the “4-C GS+4-C GSR” setting provided the highest performance index values. All four predictor variables used for logistic regression modeling were significant; however, none of them, individually or in any combined form, could outperform the optimal CNN model.

Conclusion: The novel approach using deep CNNs for learning features of left atrial curved M-mode speckle-tracking images seems to be optimal for classifying outcome status after AF ablation.

Left Atrial Strain Identifies Increased Atrial Ectopy in Patients with Beta-Thalassemia Major

Patients with beta-thalassemia major (β-ΤΜ) may develop cardiac arrhythmias through a multifactorial mechanism. The current study evaluated the association of cardiac structure and function on echocardiography with atrial ectopic burden on 24-hour tape recording in β-ΤΜ patients. This prospective study included consecutive β-ΤΜ patients. Demographic, laboratory, echocardiographic, cardiac magnetic resonance (CMR) T2* and 24-hour tape recording data were prospectively collected. The patients were classified according to the median value of premature atrial contractions (PACs) on 24-hour tape. In total, 50 β-TM patients (37.6 ± 9.1 years old, 50% male) were divided in 2 groups; PACs ≤ 24/day and > 24/day. Patients with PACs > 24/day were treated with blood transfusion for a longer period of time (39.0 ± 8.6 vs. 32.0 ± 8.9 years, p < 0.007), compared to their counterparts. Older age (OR: 1.121, 95% CI: 1.032–1.217, p = 0.007), longer duration of blood transfusion (OR:1.101, 95% CI:1.019–1.188, p = 0.014), larger LV end-diastolic diameter (OR: 4.522, 95% CI:1.009–20.280, p = 0.049), higher values of LA peak systolic strain (OR: 0.869, 95% CI: 0.783–0.964, p = 0.008), higher MV E/E′ average (OR: 1.407, 95% CI: 1.028–1.926, p = 0.033) and higher right ventricular systolic pressure (OR: 1.147, 95% CI: 1.039–1.266, p = 0.006) were univariably associated with PACs > 24/day. LA peak systolic strain remained significantly associated with PACs > 24/day after adjusting for the duration of blood transfusions or for CMR T2*. The multivariable model including blood transfusion duration and LA peak systolic strain was the most closely associated with PACs > 24/day. Receiver operating characteristic curve analysis identified a left atrial peak systolic strain of 31.5%, as the best cut-off value (83% sensitivity, 68% specificity) for prediction of PACs > 24/day. In β-TM patients, LA peak systolic strain was associated with the atrial arrhythmia burden independently to the duration of blood transfusions and CMR T2*.

Tissue Doppler Imaging and strain rate of the left atrial lateral wall: age related variations and comparison with parameters of diastolic function

Background

Strain Rate Imaging (SRI) is one of the most used techniques to study left atrial (LA) and diastolic function. Its availability in low-income countries is diminished since it requires additional expensive software, among other limitations. In contrast, Tissue Doppler Imaging (TDI) is widely available and easy to use. We hypothesize TDI could detect changes in LA and diastolic function associated with age similarly to SRI. The aim of this study is to evaluate the effects of age on LA and diastolic function assessed by LA lateral wall TDI online by spectral pulse, and to compare them with age-related variations of LA SRI and other parameters of diastolic function in a population of healthy adults.

Materials and methods

Ninety-one healthy adults were prospectively evaluated. In apical four - chamber view the LA lateral wall was divided in three portions. Peak velocities of basal and mid portions were measured with TDI online by spectral pulse and with SRI by speckle tracking. A first positive wave (S’la and SRS) and two negative waves (E’la and SRE, and A’la and SRA respectively) were obtained. E’la/A’la ratio and SRE/SRA ratio were analyzed. The distribution of the variables by age subgroups was described and analyzed. Correlation analyses were performed.

Results

The median age was 42 years old and 54.9% were female. E’la/A’la showed a negative good correlation with age. E’la/A’la and SRE/SRA ratios changed from > 1 to < 1 in the age group of 41–50 years old, while this occurred in the group of 51–60 years old for the E/A ratio. Lateral and septal mitral annulus E´ showed decrease with age and prolongation of E-wave deceleration time was observed in the age group over 61 years old.

Conclusion

Normal values​​ according to age group of TDI of the LA lateral wall were obtained. Age-related changes in LA and diastolic function could be detected as early with TDI as with SRI. Future studies are required to explore if this method could be used to address in part LA or diastolic function in other populations with established cardiovascular disease or at risk of presenting it, which could be useful in low-income settings, where SRI is not available.

Left atrial strain imaging differentiates cardiac amyloidosis and hypertensive heart disease

Echocardiographic diagnosis of cardiac amyloidosis (CA) can be difficult to differentiate from increased left ventricular (LV) wall thickness from hypertensive heart disease. The aim of this study was to evaluate left atrial (LA) function and deformation using strain and strain rate (SR) imaging in cardiac amyloidosis. We reviewed 44 cases of CA confirmed by tissue biopsy or a combination of clinical and cardiac imaging data. Cases were classified according two subgroups: amyloid light chain (AL) or amyloid transthyretin (ATTR). These subjects underwent 2D-Speckle tracking echocardiographic derived (STE) LA strain analysis. These were compared to 25 hypertensive (HT) patients with increased LV wall thickness. The three phases of LA function were evaluated using strain and strain rate parameters. Despite a similar increase in LV wall thickness, all LA strain parameters were significantly reduced in the AL cohort compared to the HT cohort (reservoir strain/LAs: 11.0 vs. 24.8%, p < 0.05). The ATTR cohort had significantly thicker LV walls and higher atrial fibrillation burden compared to AL and HT patients but similar reduction in LA strain values compared to AL group. A reservoir strain (S-LAs) cut off value of 20% was 86.4% sensitive and 88.6% specific for detecting CA compared to HT heart disease in this cohort. LA strain parameters were able to identify LA dysfunction in all types of CA. LA function in CA is significantly worse compared with hypertensive patients despite similar increase in LV wall thickness. In combination with other clinical and imaging features, LA strain may provide incremental value in differentiating cardiac amyloidosis from increased wall thickness secondary to hypertension.

Strain imaging to assess early effects of successful percutaneous balloon mitral valvotomy on left atrium mechanics

Background

Global left atrial strain (LA) has been used as a novel assessment tool to evaluate left atrial function. However, not much has been investigated to study the effect of percutaneous balloon mitral valvotomy (BMV) in patients with rheumatic severe mitral stenosis on global LA strain. We studied the relationship between global left atrial (LA) strain and severe mitral stenosis and the effect of BMV on LA strain.

Results

A total of 29 patients satisfying the criteria for severe mitral stenosis underwent balloon mitral valvotomy (67% females; mean age, 39.53 ± 11.78 years). Global left atrial strain was assessed by speckle tracking echocardiography before and after valvuloplasty. Global LA strain was impaired in patients with severe mitral stenosis and improved 24–48 h following BMV (13.4 ± .75% vs 17.37 ± 6.95%, p < 0.001). There was a significant decrease in mitral mean gradient (MMG) (16.94 ± 6.62 mmHg vs 8.19 ± 4.01 mmHg, p < 0.001) and systolic pulmonary artery pressure (sPAP) (47.84 ± 9.07 mmHg vs 36.88 ± 7.69 mmHg, p < 0.001) after BMV. Mitral valve area (MVA) (1.045 ± 0.17 cm² vs 1.94 ± 0.22 cm², p < 0.001) significantly increased after BMV. Results were compared with 30 age- and sex-matched healthy controls.

Conclusion

Global LA strain can be taken as an indicator of left atrial function, and its improvement following valvotomy may be taken as a good indicator of successful BMV.

The role of the left atrial function in the surgical management of aortic and mitral valve disease

The right management of both mitral and aortic disease can be challenging, especially in asymptomatic patients. The current guidelines recommend valve repair or replacement when symptoms arise or when there is an evident left ventricular dysfunction. However, deciding the optimal surgical timing can be very difficult, since the line between the absence of symptoms and being minimally symptomatic, especially in the elderly, is blurred. Another relevant issue regards the second surgical criterion: operating on a patient with a reduced left ventricular ejection fraction or with a dilated left ventricle might jeopardize the possibility of a fully reverse remodeling of the heart after surgery. In this scenario, the left atrium might play an important role. In particular, left atrial deformation might be a very useful tool to detect early ultrastructural alterations, and help or support guiding a patient-tailored treatment at an early stage, optimizing the outcome in the long term.

The relationship between total atrial conduction time and left atrial global strain in patients with psoriasis vulgaris

INTRODUCTION

Psoriasis vulgaris is a chronic, multisystem disease that results in the development of atrial fibrillation (AF) over time. In this study, our goal was to assess predictors of AF in patients with psoriasis, including total atrial conduction time (TACT) and left atrial global longitudinal strain (LAGLS).

MATERIAL AND METHODS

A total of 80 individuals, including 40 psoriasis patients and 40 healthy controls, were enrolled in the study. A physical examination was performed, biochemical parameters were studied, and Holter electrocardiography was carried out. Conventional echocardiography, atrial tissue Doppler, and speckle tracking echocardiography were recorded.

RESULTS

No significant difference was observed between psoriasis patients and healthy controls with regard to age, and the average duration of psoriasis was 5.7 years. High-sensitivity C reactive protein levels were higher in the patient group compared to the control group (respectively, group 1: 1 ±0.8; group 2: 0.6 ±0.3, p < 0.05). Atrial arrhythmia was not detected in the Holter ECG monitoring. A significant moderate negative correlation between TACT and LAGLS (r = -0.57, p < 0.05) was observed, and there was a significant moderate positive correlation between the duration of disease and TACT (r = 0.52, p < 0.05).

CONCLUSIONS

In the current study, we determined that LAGLS decreased, TACT was prolonged, and P-wave dispersion increased in patients with psoriasis. The current results may improve predictions of AF risk in psoriasis patients in clinical practice.

Tissue Doppler imaging of the atrial lateral wall: Correlation with atrial strain rate and parameters of diastolic function

OBJECTIVE

To evaluate the velocity profile of the lateral wall of the left atrium (LA) using pulsed-wave color tissue Doppler imaging (TDI) on line and its correlation with two-dimensional strain rate imaging (SRI) by speckle tracking, of equal segments and phases, and other parameters of diastolic function in a population of individuals without known cardiovascular disease.

MATERIALS AND METHODS

A total of 91 adults aged 18-74 years, without cardiovascular history, hypertension, diabetes, dyslipidemia or obesity, were evaluated. A Doppler echocardiogram was performed. The lateral wall of the LA was divided subjectively into three portions, the atrial roof was excluded; the peak velocities of the basal and midportions, and their average, were measured with pulsed-wave TDI on line and SRI. Using both techniques, a first positive wave (S'la and SRS-reservoir phase) and two negative waves (E'la and SRE-conduit phase-and A'la and SRA-atrial systole-respectively) were obtained. E'la/A'la ratio and SRE/SRA ratio were analyzed.

RESULTS

The median age was 42 years, and 54.9% of the subjects were female. S'la presented moderate correlation with S' lateral mitral annulus. Both E'la and the E'la/A'la relationships showed moderate to good correlation with various diastolic dysfunction parameters evaluated and SRI. A'la did not present a statistically significant correlation with any of the variables evaluated.

CONCLUSION

Evaluation of the lateral wall of the LA by pulsed-wave color TDI on line is feasible in the vast majority of patients. In the conduit phase, E'la and the E'la/A'la relationship showed correlation with the parameters that evaluate diastolic function and SRI.

Improving performance of 3D speckle tracking in arterial hypertension and paroxysmal atrial fibrillation by using novel strain parameters

The function of left atrium (LA) is closely related to LA remodeling and one of the most important mechanisms is an increased deposition of fibrous tissue that often is the basis for LA electro-mechanical changes before the onset of atrial fibrillation (AF). This study evaluated LA shape and function, by investigating standard and novel strain parameters calculated by a new approach based on homologous times derived from 3D speckle tracking echocardiography (3DSTE) in hypertensive (HT) and paroxysmal atrial fibrillation (PAF) patients with or without left ventricular hypertrophy (LVH), compared to control (C) subjects. LA function was assessed using homologous times to compare strain variables among different individuals, acquired at different physiological time periods. Standard global longitudinal (GLS) and circumferential (GCS) strains were measured at peak of atrial diastole, while longitudinal and circumferential strains (GLSh, GCSh), strain rate (GLSr, GCSr), volume (Vh) and volume rate (Vr) were measured during the atrial telediastolic phase (fifth homologous time) and atrial pre-active phase (tenth homologous time). Using ANOVA, we found an impaired LA deformation detected by standard, interpolated strains and strain rates in both HT and PAF groups compared to C. We also performed ROC analysis to identify different performances of each parameter to discriminate groups (GLSr10 + GCSr10: C vs PAF 0.935; C vs PAF_LVH 0.924; C vs HT_LVH 0.844; C vs HT 0.756). Our study showed anatomical and functional LA remodeling in patients with PAF and HT. 3D strains and strain rates derived from the homologous times approach provide more functional information with improved performance to identify among the explored groups, in particular PAF patients.

Normal values for tissue velocity and strain rate imaging parameters of left and right atrial myocardium in normal subjects

OBJECTIVE

To determine normal values for tissue velocity imaging (TVI) and strain rate imaging (SRI) in the left atrium (LA) and right atrium (RA) in normal subjects.

METHODS

A total of 63 healthy volunteers (50.8% male, age: 20-50 years) prospectively underwent TVI and SRI. The peak systolic velocity (TVs), strain (STs) and strain rate (SRs), peak early and late diastolic velocities (TVe and TVa), strain (STe and STa), and strain rate (SRe and SRa) were measured in the base and mid of the LA and RA walls and roofs.

RESULTS

By TVI, TVs and TVe of LA walls decreased significantly from basal to mid-level and from mid to the roof. Mean Tva of LA walls reduced significantly from basal to mid-level and to the roof. By SRI, mean STs and STe of LA walls increased remarkably from basal to mid-level and to the roof and also mean SRs, SRe and SRa increased significantly from basal to mid-level and to the roof. For SRe, the changes were also significant from mid-LA wall to the roof. Mean Tvs, Tve, and Tva of the RA walls reduced significantly from base to mid and then to the RA roof. RA systolic, early, and late diastolic ST and SR increased from base to mid and to the roof.

CONCLUSION

Peak systolic and diastolic velocities of the LA and RA decreased from the base to the mid and to the roof, while systolic and diastolic ST and SR increased from the base to the mid to the roof.

Heart Failure With Preserved Ejection Fraction - Time for a Paradigm Shift Beyond Diastolic Function

At present, heart failure with preserved ejection fraction (HFpEF) is a commonly accepted condition in HF patients. In contrast to HF with reduced EF (HFrEF), HFpEF is strongly associated with aging, and vascular, metabolic, neurohormonal, and systemic inflammatory comorbidities. Two major hypotheses explain the pathophysiology of HFpEF (stages C,D in the American College of Cardiology Foundation/American Heart Association HF staging system): (1) impaired active relaxation and increased passive stiffness of the left ventricular (LV) myocardium during diastole (left atrial [LA]-LV coupling); and (2) LV and arterial stiffening during systole (LV-arterial coupling). Cardiac structural and functional abnormalities can be evaluated using non-invasive measures, such as 2-D, flow velocity Doppler, and tissue Doppler echocardiography, to estimate LV filling pressure and afterload mismatch. The clinical application of 2-D speckle-tracking echocardiography (2D-STE) is feasible for earlier diagnosis of functional abnormalities of the LA, LV, and elastic arteries in asymptomatic patients with cardiovascular risk factors (stages A,B). The goal of this review is to highlight the role of 2D-STE to detect impairment of LA-LV-arterial coupling beyond diastolic function earlier, because it may provide important information on the pathophysiology and prevention of HFpEF.

Left atrial functional response after a marathon in healthy amateur volunteers

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

Assessment of left and right atrial geometrical changes in patients with stable coronary artery disease: Left and right atrial strain and strain rate imaging study

Objective

In patients with coronary artery disease (CAD), there are several studies that assessed the left ventricular (LV) function by strain (S) and strain rate (SR) imaging. The aim of this study is to evaluate the function of both atria in patients with CAD using strain and strain rate imaging, and to correlate this with the severity of CAD.

Methods

We conducted a prospective, single center case control study for 40 consecutive patients who presented to our department with chronic stable angina and were candidates for invasive coronary angiography. We enrolled patients from December 2013 to May 2014 and each patient was subjected to echocardiographic assessment of E/e' of mitral valve, left atrial volume index (LAVI), right atrial volume index (RAVI), and peak atrial longitudinal strain (es) and strain rate (SR) during LV systole. This was followed by invasive coronary angiography for assessment of the severity of CAD using Gensini score. Patients were classified according to angiographic results into 3 groups: Group I (Gensini score = zero), Group II (Gensini score > 0 and < 20) and Group III (Gensini score ≥ 20).

Results

There was no statistically significant difference between the three groups in either LA volumes (V_min, V_max) and distensibility with p value of 0.272, 0.126, and 0.243 respectively or RA volumes and distensibility with a p value of 0.671, 0.183, and 0.259 respectively. On the other hand, LA & RA systolic S and SR were significantly lower among CAD patients in comparison with the group of normal coronaries. Mean LA S and SR was decreased in group III than group II (15.97 ± 3.73, 21.8 ± 6.75 % and 1.11 ± 0.30, 1.81 ± 1.23 s^-1) with p value of 0.005&0.041 respectively. RA systolic S and SR were significantly lower in the 2 groups with CAD than the group with normal coronaries with a p value of 0.001 and 0.002 respectively.

Conclusion

In patients with CAD and normal EF, borderline E/e' ratio and normal atrial size, there are decreased LA and RA systolic S and SR parameters with no effect on atrial volumes or distensibility. Accordingly, this could prove that atrial wall deformation occurs early in CAD even before any changes in atrial volumes or dimensions.

Left Ventricular Systolic Function Assessed by Global Longitudinal Strain is Impaired in Atrial Fibrillation Compared to Sinus Rhythm

Background

Atrial fibrillation (AF) is the most common aberrant cardiac arrhythmia. Many AF patients present with symptoms of dyspnea and fatigue, but have normal left ventricular ejection fraction (LVEF).

Purpose

To determine the reproducibility of measurements of global longitudinal strain (GLS) and strain rate in patients with AF and examine if the arrhythmia is associated with abnormal LV strain and strain rate independent of age, sex, heart rate, LVEF and LV mass. We hypothesized that AF independently reduces ventricular systolic performance.

Methods

The study was conducted as a retrospective analysis of images from 150 randomly selected patients with AF compared to an equal number of subjects with sinus rhythm (SR) matched for age, sex, heart rate, LVEF and LV mass. Half of the patients had normal LVEF (LVEF > 50%) and half had reduced LVEF (LVEF < 50%). GLS and strain rate were measured in each group, as were quantitative LV volumes and standard systolic and diastolic parameters. Results: GLS was significantly impaired in patients with AF compared to subjects with SR, both in the overall population (-12.25 ± 4.1% vs. -16.13 ± 4.7%, p<0.0001), in patients with normal LVEF (-14.41 ± 3.9% vs. -19.42 ± 3.1%, p<0.0001) and in patients with reduced LVEF (-10.10 ± 3.1% vs. -12.85 ± 3.5%, p<0.0001).Linear regression and Bland Altman analyses demonstrated good intraobserver and interobserver agreement for measurements of GLS and strain rate parameters even in patients with AF.

Early Reverse Cardiac Remodeling Effect of Laparoscopic Sleeve Gastrectomy

BACKGROUND

This study evaluated the early postoperative benefits of laparoscopic sleeve gastrectomy (LSG) on the left ventricular (LV) function and left atrial (LA) structural, mechanical, and electrical functions in severely obese patients.

METHODS

Thirty-two patients with severe obesity who were consecutively scheduled for LSG and 30 healthy controls were included in the study. LV global longitudinal strain (LGS), peak atrial longitudinal strain (PALS), and strain rates (S-Sr, E-Sr, and A-Sr) of the lateral and septal LA walls, and intra- and interatrial dyssynchrony periods for all subjects were evaluated using strain echocardiography. The measurements were repeated in patients 1 month after surgery.

RESULTS

LGS of the LV was significantly depressed in the patient group compared with the control group (p < 0.001). LA peak septal and lateral wall strain values were significantly lower in patients than in controls (both p values <0.001). LA intra- and interatrial dyssynchrony periods were longer in patients than in controls (p = 0.012 and p = 0.004, respectively). LGS significantly improved after LSG (p < 0.001). Significant reductions were noted in the LA antero-posterior diameter (p < 0.001), LA volume index (LAVI, p = 0.001), and in the mitral velocity to the early diastolic velocity of the mitral annulus ratio (E/e' ratio, p = 0.046). The PALS of the septal and lateral LA walls significantly increased (p = 0.001 and p < 0.001, respectively). S-Sr, E-Sr, and A-Sr values of the septal LA wall (p = 0.049, p < 0.001, and p = 0.001, respectively) and the lateral LA wall (p = 0.009, p = 0.007, and p = 0.002, respectively) significantly improved postoperatively. Intra- and interatrial dyssynchrony significantly decreased (p = 0.001 and p < 0.001, respectively). Weight loss positively correlated with changes in LGS (R = 0.39, p = 0.039), LAVI (R = 0.39, p = 0.034), intra-atrial dyssynchrony (R = 0.45, p = 0.021), interatrial dyssynchrony (R = 0.42, p = 0.038), septal LA wall peak strain (R = 0.44, p = 0.027), lateral LA wall peak strain (R = 0.46, p = 0.017), septal LA wall A-Sr (R = 0.43, p = 0.028), and lateral LA wall A-Sr (R = 0.46, p = 0.019). The comparison of postoperative findings of the patients with controls revealed that the LA diameter, both LA volume and volume index (LAVI), E/e' ratio, S-Sr and E-Sr of both lateral and septal LA walls, intra- and interatrial LA dyssynchrony of the patient group became similar to the control group (all p value >0.05). Postoperative A-Sr values of both LA walls (both p value <0.001) were higher in patients than controls.

CONCLUSION

The benefits of LSG on LV and LA function may be observed even in the early postoperative phase. The resulting weight loss correlates with LV and LA reverse remodeling in severely obese patients.

Assessment of left atrial mechanical function and synchrony in paroxysmal atrial fibrillation with two-dimensional speckle tracking echocardiography

BACKGROUND

The aim of this study was to investigate left atrial (LA) function and synchrony in paroxysmal atrial fibrillation (PAF) patients using two-dimensional speckle tracking echocardiography (STE).

METHODS

Forty-five PAF patients and 30 healthy controls were enrolled. LA peak ventricular systolic longitudinal strain (LA_S-S ) and strain rate (LA_SR-S ) and left atrial longitudinal strain (LA_S-A ) and strain rate (LA_SR-A ) during late diastole were determined using STE, and the standard deviation of the time to peak (TPSD) of the regional strains was calculated to quantify LA dyssynchrony. TPSD during ventricular systole and late diastole were named SDs and SDa, respectively.

RESULTS

Left atrial peak longitudinal strain during ventricular systole (LA_S-S ) (29.34±8.57 vs 36.73±6.13), LA_SR-S (1.27±0.311 vs 1.57±0.25), LA_S-A (13.11±4.91 vs 17.86±3.57), and LA_SR-A (-1.51±0.58 vs -1.90±0.30) were reduced in the PAF group compared with the controls (P<.05 for all). SDs (8.11±3.00% vs 4.67±1.48%) and SDa (5.57±2.26% vs 3.11±1.13%) were greater in PAF patients than in the controls (P<.05 for both). Furthermore, PAF patients with normal LA sizes exhibited lower LA_S-S (P<.05), LA_SR-S (P<.05), LA_S-A (P<.05), and LA_SR-A (P<.05) values and increased SDs (P<.05) and SDa (P<.05) values compared with the controls. Multivariate regression confirmed that SDs and SDa were powerful parameters for differentiating PAF patients from controls (SDs: sensitivity, 83%; specificity, 72%; SDa: sensitivity, 81%; specificity, 76%).

CONCLUSIONS

Left atrial (LA) dysfunction and dyssynchrony in PAF patients can be detected with STE even in the absence of LA enlargement. STE-derived SDs and SDa were powerful parameters for identifying PAF patients.

Acute effect of treatment of mitral stenosis on left atrium function

Aim:

Peak atrial longitudinal strain (PALS) is used to evaluate left atrium (LA) function in patients with mitral stenosis (MS), before and after percutaneous transmitral commissurotomy (PTMC) and mitral valve replacement (MVR).

Methods:

Patients with severe symptomatic MS, who were referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery or PTMC from October of 2014 to October of 2015, were included in the study.

Result:

The peak systolic global LA strain improved post-PTMC (P < 0.001) and post-MVR (P = 0.012). This difference was statistically highly significant.

Conclusion:

PALS is impaired in patients with severe symptomatic MS and improved acutely after treatment and may be a good indicator of LA function and may predict the right time for intervention on mitral valve.

Left Atrial Strain at Different Stages of Myxomatous Mitral Valve Disease in Dogs

Background

Decreased function of the left atrium (LA) is a useful prognostic indicator in dogs with myxomatous mitral valve disease (MMVD). In humans, LA strain is a novel severity indicator of mitral regurgitation, but its clinical utility in dogs has not been confirmed.

Objectives

To examine whether LA strain as evaluated with speckle‐tracking echocardiography is associated with MMVD stage in dogs.

Animals

Fifty‐two client‐owned dogs with MMVD.

Methods

Cross‐sectional study. Dogs were classified as stage B1, B2, C, or D, according to the American College of Veterinary Internal Medicine consensus. Physical examination findings and echocardiographic variables were compared among the groups. To assess the comparative accuracy of echocardiographic variables in identifying dogs with the presence or history congestive heart failure (CHF), receiver operating characteristic curves and multivariate logistic analysis were used.

Results

There were no significant differences in parameters of LA strain between B1 and B2 groups. However, LA longitudinal strain during atrial contraction (ε_A) (median, 19.1%; interquartile range, 15.3–24.3% in B1, 19.6%; 14.1–21.4% in B2, 6.2%; 3.18–11.2% in C/D) and during ventricular systole (ε_S) (32.7%; 28.9–39.2% in B1, 35.6%; 31.7–41.9% in B2, 23.6%; 16.9–26.1% in C/D) were significantly lower in stages C/D than in stages B1 and B2. In multivariate logistic regression analysis, ε_A and peak early diastolic mitral inflow velocity were identified as independent indicators of stage C/D.

Conclusions and Clinical Importance

ε_A was the best predictor of the presence or history of CHF. Further studies are needed to determine the clinical implications of these findings for treatment decisions and prognosis determination.

Acute and Chronic Response to Exercise in Athletes: The "Supernormal Heart"

During last decades, most studies have examined the exercise-induced remodeling defined as "athlete's heart". During exercise, there is an increased cardiac output that causes morphological, functional, and electrical modification of the cardiac chambers. The cardiac remodeling depends also on the type of training, age, sex, ethnicity, genetic factors, and body size. The two main categories of exercise, endurance and strength, determine different effects on the cardiac remodeling. Even if most sport comprise both strength and endurance exercise, determining different scenarios of cardiac adaptation to the exercise. The aim of this paper is to assemble the current knowledge about physiologic and pathophysiologic response of both the left and the right heart in highly trained athletes.

LA Strain for Categorization of LV Diastolic Dysfunction

OBJECTIVES

This study sought to observe the relationship between left atrial (LA) strain and left ventricular diastolic function and determine whether LA strain could be used to detect diastolic dysfunction (DD) and classify its degree when present.

BACKGROUND

The assessment of diastolic function is complex and multiparametric because most conventional parameters do not follow the progression of DD. Strain imaging is an emerging index of LA function, with recent data demonstrating that LA strain is diminished in diastolic heart failure. However, LA strain is not part of the standard assessment of diastolic function. We hypothesized that LA strain decreases with worsening DD in a stepwise fashion and could thus be useful in evaluating DD.

METHODS

We performed a retrospective derivation and validation cohort study to derive and test LA strain thresholds for DD grades (0 to 3) in patients with preserved left ventricular ejection fraction (N = 229). Two-dimensional speckle tracking was used to measure peak LA strain, which was applied as a single parameter to classify DD. American Society of Echocardiography guidelines were used as the reference standard.

RESULTS

In the derivation cohort (n = 90), peak LA strain was significantly different between DD groups, with gradual decreases seen with worsening DD. Receiver-operating characteristic analysis resulted in 3 distinct LA strain thresholds for categorization of DD grades, with good to excellent diagnostic utility (area under the curve: 0.86 to 0.91). In an independent validation group (n = 139) with a spectrum of diastolic function, 11 patients (8%) had indeterminate DD grades using standard criteria, whereas LA strain was measured in all patients and its cutoffs resulted in diagnostic accuracy up to 95%.

CONCLUSIONS

LA strain measurements are feasible and allow accurate categorization of DD, because unlike the traditional parameters, it changes progressively with severity of DD. LA strain may become a useful tool for diastolic assessment in future clinical practice.

Left atrial appendage function assessment and thrombus identification

Background

The diagnosis of thrombus in the left atrium in patients with persistent atrial fibrillation (AF) and may be inconsistent because of variability in thrombus morphology. In some cases it is challenging and requires unusual approach. New Doppler-derived methods might be helpful to identify such thrombi. We evaluated quantitative differences in mechanical function of the left atrial appendage (LAA) basal segments using tissue Doppler imaging (TDI)and speckle tracking echocardiography (STE) in patients with non-valvular AF with and without LAA thrombus and compared them with SR patients.

Methods

A total of 80 patients with normal left ventricular ejection fraction underwent transesophageal echocardiography (40 patients with SR and 40 patients with AF on oral anticoagulants including patients with LAA thrombus). We analyzed the basal segments of LAA including left lateral ridge (LLR) and baso-medial appendage segment (BMAS). Quantitative analysis was used to calculate peak velocity, average velocity, strain, strain rate and deformation.

Results

In patients with AF the lower LLR strain rate was the sole new STE significant parameter differentiating patients with and without LAA thrombi: − 0.9(− 1.2; − 0.1)s^− 1 vs. − 1.6(− 1.9; − 1.3)s^− 1, (p = 0.004). Additionally, patients in SR demonstrated significantly better peak velocity, average velocity, strain, strain rate and deformation than those with AF (p < 0.001).

Conclusions

LLR appeared to be an appropriate site for measuring Doppler derived parameters. It is possible that the strain rate in LLR area may be a novel parameter correlating with the presence of thrombus in patients with AF.

Comparisons of the underlying mechanisms of left atrial remodeling after repeat circumferential pulmonary vein isolation with or without additional left atrial linear ablation in patients with recurrent atrial fibrillation

BACKGROUND

Radiofrequency catheter ablation (RFCA) is a potentially curative treatment for atrial fibrillation (AF), however, whether or not additional left atrial (LA) linear ablation for recurrent AF adversely affects LA remodeling is unknown.

METHODS

Thirty-eight patients experiencing AF recurrence after the 1st circumferential pulmonary vein isolation (CPVI) underwent a repeat RFCA, including 20 and 18 patients receiving a repeat CPVI (group I) or CPVI plus LA linear ablation (group II), respectively. 2-D echocardiography was performed during sinus rhythm within 24h, at 1-m and 6-m after RFCA. Longitudinal strains and strain rate were measured with speckle-tracking echocardiography. The standard deviation of contraction duration was defined as LA mechanical dispersion.

RESULTS

One and two patients experienced AF recurrence after the 2nd RFCA in group I and II, respectively (P=NS). The 1st CPVI with AF recurrence did not reduce LA size significantly in two groups. After a repeat CPVI, LA diameter but not LA maximal and minimal volume was significantly reduced in group I; additional LA linear ablation significantly decreased LA diameter, maximal and minimal volume in group II. However, there was no significant difference in LA emptying function, global and segmental LA strain and strain rate among the baseline, 1-m and 6-m follow-up in two groups. RFCA did not significantly increase LA mechanical dispersion regardless of the AF ablation strategies.

CONCLUSIONS

In patients with recurrent AF, a successful repeat CPVI with or without additional LA linear ablation reduced LA size without significant deleterious effects on LA function and mechanical dispersion.

Three-Dimensional Speckle Tracking Imaging for Assessing Left Atrial Function in Hypertensive Patients With Paroxysmal Atrial Fibrillation

Hypertension (HT) is known to be the most prevalent risk factor for paroxysmal atrial fibrillation (PAF), however, its mechanisms have not been fully clarified. Our aim was to investigate the differences in left atrial (LA) function between healthy subjects, and hypertensive patients without PAF (HT-PAF(-)) and with PAF (HT-PAF(+)) using 3-dimensional (3D) speckle tracking imaging (STI). A total of 144 subjects were enrolled: 44 HT-PAF(+) (27 males; mean age 69 ± 10 years), 50 HT-PAF(-) (31 males; mean age 63 ± 11 years), and 50 controls (31 males; mean age 51 ± 14 years). All subjects were in sinus rhythm during the examination. LA volume, LA emptying fraction (LAEF), and LA wall strain were analyzed by 3D area tracking imaging. The maximal value of the global strain curve was defined as the peak global strain. The standard deviation of the time from the R-wave on the electrocardiogram to peak positive values of the segmental strain curves corrected by the R-R' interval in 6 mid LA segments (TP-SD) was calculated to assess LA dyssynchrony. LAEF and peak global strain were lower in HT-PAF(+) than in HT-PAF(-) (P < 0.01) and in the control (P < 0.01). Moreover, TP-SD was higher in HT-PAF(+) than in HT-PAF(-) (P < 0.05) and in the control (P < 0.01). Multivariate analysis revealed LA volume index, peak global strain, and TP-SD were independent determinants of HT-PAF(+). The presence of PAF is associated with diminished LA compliance and advanced mechanical dyssynchrony, as well as LA geometric deformation.

A Simple, Non-Invasive Score to Predict Paroxysmal Atrial Fibrillation

Paroxysmal atrial fibrillation (pAF) is a major risk factor for stroke but remains often unobserved. To predict the presence of pAF, we developed model scores based on echocardiographic and other clinical parameters from routine cardiac assessment. The scores can be easily implemented to clinical practice and might improve the early detection of pAF. In total, 47 echocardiographic and other clinical parameters were collected from 1000 patients with sinus rhythm (SR; n = 728), pAF (n = 161) and cAF (n = 111). We developed logistic models for classifying between pAF and SR that were reduced to the most predictive parameters. To facilitate clinical implementation, linear scores were derived. To study the pathophysiological progression to cAF, we analogously developed models for cAF prediction. For classification between pAF and SR, amongst 12 selected model parameters, the most predictive variables were tissue Doppler imaging velocity during atrial contraction (TDI, A’), left atrial diameter, age and aortic root diameter. Models for classifying between pAF and SR or between cAF and SR showed areas under the ROC curves of 0.80 or 0.93, which resembles classifiers with high discriminative power. The novel risk scores were suitable to predict the presence of pAF based on variables readily available from routine cardiac assessment. Modelling helped to quantitatively characterize the pathophysiologic transition from SR via pAF to cAF. Applying the scores may improve the early detection of pAF and might be used as decision aid for initiating preventive interventions to reduce AF-associated complications.

Atrial Strain and Strain Rate: A Novel Method for the Evaluation of Atrial Stunning

Background

Atrial fibrillation (AF) is the most common arrhythmia seen in adults. Atrial stunning is defined as the temporary mechanical dysfunction of the atrial appendage developing after AF has returned to sinus rhythm (SR).

Objectives

We aimed to evaluate atrial contractile functions by strain and strain rate in patients with AF, following pharmacological and electrical cardioversion and to compare it with conventional methods.

Methods

This study included 41 patients with persistent AF and 35 age-matched control cases with SR. All the AF patients included in the study had transthoracic and transesophageal echocardiography performed before and after. Septum (SEPsSR), left atrium (LAsSR) and right atrium peak systolic strain rate (RAsSR) were defined as the maximum negative value during atrial contraction and septum (SEPε), left atrium (LAε) and right atrium peak systolic strain (RAε) was defined as the percentage of change. Parameters of two groups were compared.

Results

In the AF group, 1st hour and 24th hour LAε, RAε, SEPε, LAsSR, RAsSR, SEPsSR found to be significantly lower than in the control group (LAε: 2.61%±0.13, 3.06%±0.19 vs 6.45%±0.27, p<0.0001; RAε: 4.03%±0.38, 4.50%±0.47 vs 10.12%±0.64, p<0.0001; SEPε: 3.0%±0.22, 3.19%±0.15 vs 6.23%±0.49, p<0.0001; LAsSR: 0.61±0.04s-¹, 0.75±0.04s-¹ vs 1.35±0.04s-¹, p<0.0001; RAsSR: 1.13±0.06s-¹, 1.23±0.07s-¹ vs 2.10±0.08s- ¹, p<0.0001; SEPsSR: 0.76±0.04s- ¹, 0.78±0.04s- ¹ vs 1.42±0.06 s- ¹, p<0.0001).

Conclusion

Atrial strain and strain rate parameters are superior to conventional echocardiographic parameters for the evaluation of atrial stunning in AF cases where SR has been achieved.

Regional quantification of left atrial early diastolic strain in two groups of patients with mitral stenosis: normal sinus rhythm vs atrial fibrillation

BACKGROUND

Strain rate imaging (SRI) is proposed for assessing atrial function. There are limited studies on the role of SRI in assessing the left atrial (LA) function in patients with mitral stenosis (MS). We decided to assess LA early diastolic strain to evaluate LA conduit function in two groups of patients with MS.

METHODS

A total of 49 patients with moderate to severe MS, scheduled for percutaneous transluminal mitral commissurotomy, were categorized into two groups: normal sinus rhythm (NSR, n=24) and persistent atrial fibrillation (AF, n=25). Early diastolic strain was measured via SRI in four mid-left atrial walls by transthoracic echocardiography.

RESULTS

Left atrial volume was significantly higher in AF group. LA early diastolic strain was significantly reduced in AF patients in three walls: interatrial septum (-6.78±6.22% vs -11.44±6.35%, P=.016), anterior wall (-4.47±4.30% vs -12.52±10.62%, P=.002), and inferior wall (-2.87±3.23% vs -9.73±9.67%, P=.003). After adjustment for age, heart rate, LA volume, LA thrombus, and LAA emptying velocity, there was a significant correlation between the presence of AF and left atrial average early diastolic strain. This correlation was also remarkable between existence of AF and two LA walls (i.e., anterior and inferior walls of the LA).

CONCLUSION

There was reduced average early diastolic strain in the presence of AF compared to NSR in MS patients regardless of LA volume and age. In AF patients, there is not only a loss of atrial late diastolic contraction, but also there is a reduction in early diastolic shortening of LA myocardium.

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.

Exercise-Induced Atrial Remodeling: The Forgotten Chamber

Cardiac changes in athletes involve the left ventricle and atrium. Mild left atrial enlargement is common among competitive athletes, possibly a physiologic adaptation to exercise conditioning. The prevalence of this remodeling and the association with supraventricular arrhythmias has not been systematically addressed. Echocardiography screens for patients with disease involving the left atrium. New techniques like speckle tracking can recognize early atrial dysfunction and assess left atrial myocardial function in patients with either physiologic or pathologic left ventricular hypertrophy. This article reviews echocardiographic techniques in delineating the athlete's morphology and functional properties of the left atrium.

Challenges for 'diastology': contributions from Japanese researchers

Diastology is a study to treat diastole of the heart. Transmitral flow and pulmonary venous flow velocities recorded by pulsed Doppler echocardiography provide more important information about left ventricular (LV) diastolic dysfunction [left atrial (LA)-LV coupling] than cardiac catheterization in clinical practice; however, these waveforms are influenced by loading conditions, particularly preload. The early diastolic mitral annular and LV wall motion indices measured by tissue Doppler echocardiography can evaluate LV relaxation abnormality and filling pressure by being relatively preload independent. In addition, the role of concomitant systolic longitudinal dysfunction is well characterized in asymptomatic patients and in patients with heart failure and preserved ejection fraction. Two-dimensional speckle tracking echocardiography is an angle-independent method, and has the potential to evaluate the contraction and relaxation abnormalities in the longitudinal, circumferential, and radial directions of the LV myocardium as well as LV torsion/untwisting and, moreover, deformation of the LA myocardium and large arterial wall. As a result, this new technique can facilitate the early detection of impaired LA-LV-arterial coupling in patients before occurrence of overt heart failure symptoms.