Comprehensive strain assessment and mortality after acute myocardial infarction: a retrospective observational study based on the Essen Coronary Artery Disease registry

BACKGROUND AND AIMS

Current ESC guidelines on the management of patients after acute myocardial infarction only include the evaluation of left ventricular (LV) function by assessment of the ejection fraction in addition to clinical risk scores to estimate the patient's prognosis. We aimed to determine, whether comprehensive evaluation of cardiac function using LV and right ventricular (RV) global longitudinal strain (GLS) and left atrial (LA) reservoir strain improves the prediction of survival in patients with acute myocardial infarction.

METHODS

In patients with non-ST segment elevation or ST segment elevation myocardial infarction receiving echocardiography within 1 year after revascularisation, LV-GLS, RV-GLS and LA reservoir strain were quantified. In multivariable Cox regression analysis, HRs and 95% CIs were calculated per 1 SD increase in strain measure, adjusting for age, sex, systolic blood pressure, low-density lipoprotein cholesterol, smoking, diabetes and family history of premature coronary artery disease.

RESULTS

During a median follow-up of 1.5 (0.5-4.2) years, 157 (11.1%) out of 1409 patients (64.4±13.5 years, 24.7% female) died. LV-GLS (1.68 (1.37-2.06), p<0.001), RV-GLS (1.39 (1.16-1.67), p<0.001) and LA reservoir strain (0.57 (0.47-0.69), p<0.001) were associated with mortality. Adding LV ejection fraction, tricuspid annular plane systolic excursion (TAPSE) or LA volume index to these models did not alter the association of strain measures of the LV (1.41 (1.06-1.89), p=0.02), RV (1.48 (1.03-2.13), p=0.04) or LA (0.61 (0.49-0.76), p<0.001). In receiver operating characteristics, combining the three strain measures improved the prediction of mortality above risk factors (AUC: 0.67 (0.63-0.71) to 0.75 (0.70-0.80)), while further addition of LV ejection fraction, TAPSE and LA volume index did not (0.75 (0.70-0.81)).

CONCLUSION

The comprehensive evaluation of contractility of various cardiac chambers via transthoracic echocardiography using myocardial strain analysis, when routinely performed after acute myocardial infarction, may help to detect patients at increased mortality risk.

2-year results and myocardial impact of transapical mitral valve repair in patients with primary mitral regurgitation: an echocardiographic study

BACKGROUND

There is limited data on the 2-year outcomes of transapical transcatheter edge-to-edge repair (TA-TEER) using the ValveClamp in patients with severe primary mitral regurgitation (MR) and its impact on myocardial deformation.

METHODS

From July 2018 to March 2021, 53 patients with symptomatic severe primary MR underwent TA-TEER were enrolled. The endpoint was the composite of all-cause mortality, recurrent 3 + or 4 + MR, or need for mitral surgery.

RESULTS

Among the 53 patients who had successfully ValveClamp implantation, 8(15.1%) reached the composite endpoint. Significant improvement in left ventricular (LV) end-diastolic volume, pulmonary artery systolic pressure, NYHA functional class, and MR severity were observed (P < 0.05 for all). Univariate Cox's regression analysis revealed that LV end-diastolic volume index, LV end-systolic volume index, left atrial volume index, and pulmonary artery systolic pressure were associated with adverse events (P < 0.05 for all). On multivariate Cox regression analysis, left atrial volume index was independently associated with the endpoint (hazard ratio, 1.049; 95% CI, 1.009-1.091; P < 0.001) after adjustment for above echocardiographic parameters. LV global longitudinal strain and apical longitudinal strain in global and regional segments decreased at 30 days, but showed a recovery at 2 years with no significant difference compared to the baseline.

CONCLUSION

TA-TEER using the ValveClamp presented favorable safety and efficacy at 2-year. Myocardial deformation impairment was observed at 30 days post-procedure, but did not persist at 2 years.

Long-term prognostic value of changes in left ventricular global longitudinal strain in patients with heart failure with preserved ejection fraction

BACKGROUND

Left ventricular (LV) global longitudinal strain (GLS) has emerged as a more sensitive index than LV ejection fraction (LVEF) for detecting subclinical LV dysfunction. We examined whether changes in GLS values are associated with the long-term prognosis of patients with a preserved LVEF and acute decompensated heart failure (HF).

METHODS

We studied 100 consecutive patients (mean age: 71 years) who were hospitalized for HF with preserved ejection fraction (HFpEF) and had a preserved LVEF (≥ 50%) in both the acute and stable phases. We performed two-dimensional speckle-tracking echocardiography in the acute (GLS-acute) and stable (GLS-stable) phases at a median of 2 and 347 days after admission, respectively, and calculated the rate of change of the absolute value of GLS-stable with respect to that of GLS-acute. An improved GLS was defined as a rate of change in GLS ≥ 16%, and a non-improved GLS was a rate of change < 16%. The primary endpoint was the occurrence of major cardiovascular events (MACE).

RESULTS

During a mean follow-up period of 1218 days, MACE occurred in 26 patients, including 8 all-cause deaths and 18 readmissions for HF. The rate of change in GLS for patients with MACE was lower than compared to those without MACE (10.6% vs 26.0%, p < 0.001). Multivariate Cox regression analyses indicated the rate of change in GLS was an independent predictor of MACE (p < 0.001). A non-improved GLS was correlated with a high risk of MACE.

CONCLUSION

Changes in GLS values could be useful for the long-term risk stratification of patients hospitalized for HFpEF and persistently preserved LVEF.

Composite Echocardiographic Score to Predict Long-Term Survival Following Myocardial Infarction

BACKGROUND

Whilst the left ventricular ejection fraction (LVEF) remains the primary echocardiographic measure widely utilised for risk stratification following myocardial infarction (MI), it has a number of well recognised limitations. The aim of this study was to compare the prognostic utility of a composite echocardiographic score (EchoScore) composed of prognostically validated measures of left-ventricular (LV) size, geometry and function, to the utility of LVEF alone, for predicting survival following MI.

METHODS

Retrospective data on 394 consecutive patients with a first-ever MI were included. Comprehensive echocardiography was performed within 24 hours of admission for all patients. EchoScore consisted of LVEF<50%, left atrial volume index>34 mL/m², average E/e >14, E/A ratio>2, abnormal LV mass index, and abnormal LV end-systolic volume index. A single point was allocated for each measure to derive a score out of 6. The primary outcome measure was all-cause mortality.

RESULTS

At a median follow-up of 24 months there were 33 deaths. On Kaplan-Meier analysis, a high EchoScore (>3) displayed significant association with all-cause mortality (log-rank χ²=74.48 p<0.001), and was a better predictor than LVEF<35% (log-rank χ²=17.01 p<0.001). On Cox proportional-hazards multivariate analysis incorporating significant clinical and echocardiographic predictors, a high EchoScore was the strongest independent predictor of all-cause mortality (HR 6.44 95%CI 2.94-14.01 p<0.001), and the addition of EchoScore resulted in greater increment in model power compared to addition of LVEF (model χ² 56.29 vs 44.71 p<0.001, Harrell's C values 0.83 vs 0.79).

CONCLUSIONS

A composite echocardiographic score composed of prognostically validated measures of LV size, geometry, and function is superior to LVEF alone for predicting survival following MI.

Increased left atrial volume index is associated with more cardiovascular events in patients with acute coronary syndrome: HIJ-PROPER study findings

AIM

To investigate the association between the left atrial volume index (LAVI) and the incidence of cardiovascular events in patients with acute coronary syndrome (ACS) who did not have atrial fibrillation (AF).

METHODS

In this sub-analysis of the HIJ-PROPER study, 226 ACS patients who did not have a history of AF were enrolled. Participants were divided into two groups according to the LAVI cut-off level calculated by receiver operating characteristic (ROC) curve analysis to predict the primary endpoint, and cardiovascular events were compared between groups. The primary endpoint was the first occurrence of all-cause death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for heart failure.

RESULTS

ROC curve analysis for the occurrence of composite of cardiovascular events indicated a LAVI cut-off point of 34 mL/m² . Based on this, 131 patients (58.0%) were in the LAVI < 34 mL/m² group and 95 (42.0%) were in the LAVI ≥ 34 mL/m² group. Over a median follow-up period of 4.0 years [interquartile range: 3.2, 5.1], cardiovascular events were noted in 7 and 15 patients in the LAVI < 34 mL/m² and LAVI ≥ 34 mL/m² groups, corresponding to an incidence rate of 5.3% and 15.8%, respectively. Patients with a LAVI value ≥ 34 mL/m² had a significantly higher risk of cardiovascular events than those with a LAVI value < 34 mL/m² (hazard ratio: 2.93; 95% confidence interval: 1.19-7.22; P = .014). The tendency was similar after adjusting for several confounders (P = .025).

CONCLUSION

In ACS patients without AF, elevated LAVI was associated with increased cardiovascular events.

CLINICAL TRIAL REGISTRATION

International standard randomized controlled trial (URL: https://www.umin.ac.jp; UMIN000002742).

Is Indexed Left Atrial Volume (LAVi) in Indian Patients with Acute Coronary Syndrome (ACS) undergoing revascularization a predictor of cardiovascular outcomes?

Background:

Methods and Results:

Conclusion:

Effect of Cardiac Rehabilitation on Left Ventricular Diastolic Function in Patients with Acute Myocardial Infarction

Cardiac rehabilitation (CR) improves symptoms and survival in patients with acute myocardial infarction (AMI). We studied the change of diastolic function and its prognostic impact after CR. After reviewing all consecutive AMI patients from January 2012 to October 2015, we analyzed 405 patients (mean, 63.7 ± 11.7 years; 300 males) with baseline and follow-up echocardiographic examinations. We divided them into three groups according to their CR sessions: No-CR group (n = 225), insufficient-CR group (CR < 6 sessions, n = 117) and CR group (CR ≥ 6 sessions, n = 63). We compared echocardiographic parameters of diastolic dysfunction including E/e' ratio > 14, septal e' velocity < 7 cm/s, left atrial volume index (LAVI) > 34 mL/m2, and maximal TR velocity > 2.8 m/s. At baseline, there were no significant differences in all echocardiographic parameters among the three groups. At follow-up echocardiographic examination, mitral annular e' and a' velocities were higher in the CR group (p = 0.024, and p = 0.009, respectively), and mitral E/e' ratio was significantly lower (p = 0.009) in the CR group. The total number of echocardiographic parameters of diastolic dysfunction at the baseline echocardiography was similar (1.29 vs. 1.41 vs. 1.52, p = 0.358). However, the CR group showed the lowest number of diastolic parameters at the follow-up echocardiography (1.05 vs. 1.32 vs. 1.50, p = 0.017). There was a significant difference between the No-CR group and CR group (p = 0.021). The presence of CR was a significant determinant of major adverse cardiovascular events in the univariate analysis (HR = 0.606, p = 0.049). However, the significance disappeared in the multivariate analysis (HR = 0.738, p = 0.249). In conclusion, the CR was significantly associated with favorable diastolic function, with the highest mitral e' and a' velocity, and the lowest mitral E/e' ratio and total number of echocardiographic parameters of diastolic dysfunction at the follow-up echocardiographic examinations in AMI patients.

Prognostic value of left atrial volume index in acute coronary syndrome: A systematic review and meta-analysis

BACKGROUND

In the absence of mitral valve disease, increased left atrial volume (LAV) is a marker of diastolic dysfunction and long-standing elevated left ventricle (LV) pressure. The aim of this study was to assess the role of increased baseline LAV in predicting clinical outcome of patients presenting with acute coronary syndrome (ACS).

METHODS

We systematically searched all electronic databases up to September 2020 in order to select clinical trials and observational studies, which assessed the predictive role of LAV indexed (LAVI) on clinical outcome in patients with ACS. Primary clinical endpoints were as follows: major adverse cardiac events (MACE), all-cause mortality and hospitalization. Secondary endpoints were in-hospital complications.

RESULTS

A total of 2,705 patients from 11 cohort studies with a mean follow-up 18.7 ± 9.8 months were included in the meta-analysis. Patients with low LAVI had low risk for MACE (15.9% vs. 33.7%; p < .01), long-term all-cause mortality (9.14% vs. 18.1%; p < .01), short-term mortality (3.31% vs. 9.38%; p = .02) and lower hospitalization rate (11.6% vs. 25.5%; p < .01) compared to patients with increased LAVI. Atrial fibrillation and cardiogenic shock as in-hospital events were lower (p < .05 for all) in patients with low LAVI but ventricular fibrillation/tachycardia was not different between groups (p = .14).

CONCLUSION

Increased LAVI is an independent predictor of outcome in patients with ACS. Thus, assessment of LA index in these patients is important for better risk stratification and guidance towards optimum clinical management.

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.

Simultaneous Analysis of 2D Echo Views for Left Atrial Segmentation and Disease Detection

We propose a joint information approach for automatic analysis of 2D echocardiography (echo) data. The approach combines a priori images, their segmentations and patient diagnostic information within a unified framework to determine various clinical parameters, such as cardiac chamber volumes, and cardiac disease labels. The main idea behind the approach is to employ joint Independent Component Analysis of both echo image intensity information and corresponding segmentation labels to generate models that jointly describe the image and label space of echo patients on multiple apical views, instead of independently. These models are then both used for segmentation and volume estimation of cardiac chambers such as the left atrium and for detecting pathological abnormalities such as mitral regurgitation. We validate the approach on a large cohort of echoes obtained from 6,993 studies. We report performance of the proposed approach in estimation of the left-atrium volume and detection of mitral-regurgitation severity. A correlation coefficient of 0.87 was achieved for volume estimation of the left atrium when compared to the clinical report. Moreover, we classified patients that suffer from moderate or severe mitral regurgitation with an average accuracy of 82%.

Prognostic value of new left atrial volume index severity partition cutoffs after cardiac rehabilitation program in patients undergoing cardiac surgery

BACKGROUND

Previous studies showed that left atrial enlargement is an independent marker of adverse outcomes in both primary and secondary cardiovascular prevention. However, no data are available on long-term outcomes in patients undergoing valve surgery and/or coronary artery by-pass graft (CABG) surgery. Aim of the study was to evaluate long-term prognostic role of left atrial volume index (LAVi) after cardiac surgery, using the cutoff values recently proposed by the European Association of Cardiovascular Imaging and American Society of Echocardiography.

METHODS

We created a retrospective registry of 1703 consecutive patients who underwent cardiovascular rehabilitation program after cardiac surgery, including CABG, valve surgery and valve + CABG surgery. LAVi was calculated as ratio of left atrium volume to body surface area, in ml/m(2) at discharge; 563 patients with available LAVi data were included in the study.

RESULTS

In the whole population LAVi was 36 ± 14 ml/m(2) (mean ± SD) and the follow-up time was 5 ± 1.5 years. Increased LAVi (>34 ml/m(2)) predicted major adverse cardiovascular and cerebrovascular events (MACCEs) (HR = 2.1; CI95 %: 1.4-3.1; p < 0.001) and cardiovascular mortality (HR = 2.2; CI95 %: 1.0-4.5; p = 0.032). An increased LAVi remained MACCEs predictor after adjustement for age, gender, diabetes, atrial fibrillation at discharge, echocardiographic E/A ratio and left ventricular ejection fraction (HR = 1.8; CI95 %: 1.0-3.0; p = 0.036). When the study population was split according to increasing LAVi values, left atrium enlargement resulted a predictor of progressively worse adverse outcome.

CONCLUSIONS

LAVi is a predictor of long-term adverse cardiovascular outcome after cardiac surgery, even after correction for main clinical and echocardiographic variables. The recently recommended LAVi severity cutoffs appear adequate to effectively stratify outcome in patients undergoing rehabilitation after cardiac surgery.

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.

Effect of left atrium volume on patients' prognosis following acute myocardial infarction

Evaluating left atrium volume is a good way to estimate prognosis in acute myocardial infarction patients because it indicates to time and severity of diastolic dysfunction and longer-term results of acute myocardial infarction. The present study aims at evaluating the effect of left atrium volume on patients' prognosis following acute myocardial infarction. This is a cohort study conducted on 100 patients who were admitted with acute myocardial infarction. They were studied for 9 months and their one-month mortality rate was evaluated. The patients were studied considering demographic factors, risk factors, mechanical and arrhythmic complications and echocardiography indexes such as systolic and diastolic functions and left atrium volume. It was seen that mortality (27.3%, 6.22) in patients with atrium index > 32 mL m(-2) is more than cases with lower atrium index (1.3%, 1.78) (p = 0.001). There was not any meaningful difference in mortality rate of the patients considering age and gender (p > 0.05). This study indicated to lack of any meaningful difference in patients' mortality rate in terms of hypertension, diabetes, smoking and dyslipidemia. But, mortality rate was significantly higher in MI as a result of elevated-ST, diastolic dysfunction, restrictive pattern, ejection fraction of left atrium < 40%, left atrium volume index > 32 mL m(-2). High volume left atrium independently refers to bad prognosis in patients with acute myocardial infarction which is confirmed with outcome clinical predictors and common echocardiography indexes even following modification.

Left atrial enlargement and reduced physical function during aging

Diastolic dysfunction, often seen with increasing age, is associated with reduced exercise capacity and increased mortality. Mortality rates in older individuals are linked to the development of disability, which may be preceded by functional limitations. The goal of this study was to identify which echocardiographic measures of diastolic function correlate with physical function in older subjects. A total of 36 men and women from the Louisiana Healthy Aging Study, age 62-101 yr, received a complete echocardiographic exam and performed the 10-item continuous-scale physical-functional performance test (CS-PFP-10). After adjustment for age and gender, left atrial volume index (ρ = -0.59; p = .0005) correlated with the total CS-PFP-10 score. Increased left atrial volume index may be a marker of impaired performance of activities of daily living in older individuals.