Left Atrium in Heart Failure With Preserved Ejection Fraction

HeartMate 3 for Heart Failure with Preserved Ejection Fraction: In Vitro Hemodynamic Evaluation and Anatomical Fitting

Heart failure with preserved ejection fraction (HFpEF) constitutes approximately 50% of heart failure (HF) cases, and encompasses different phenotypes. Among these, most patients with HFpEF exhibit structural heart changes, often with smaller left ventricular cavities, which pose challenges for utilizing ventricular assist devices (VADs). A left atrial to aortic (LA-Ao) VAD configuration could address these challenges, potentially enhancing patient quality of life by lowering elevated mean left atrial pressure (MLAP). This study assessed the anatomical compatibility and left atrial unloading capacity using a simulated VAD-supported HFpEF patient. A HeartMate3-supported HFpEF patient in an LA-Ao configuration was simulated using a cardiovascular simulator. Hemodynamic parameters were recorded during rest and exercise at seven pump flow rates. Computed tomography scans of 14 HFpEF (NYHA II-III) and six heart failure with reduced ejection fraction patients were analysed for anatomical comparisons. HFpEF models were independently assessed for virtual anatomical fit with the HM3 in the LA-Ao configuration. Baseline MLAP was reduced from 15 to 11 mmHg with the addition of 1 L/min HM3 support in the rest condition. In an exercise simulation, 6 L/min of HM3 support was required to reduce the MLAP from 29 to 16 mmHg. The HM3 successfully accommodated six HFpEF patients without causing interference with other cardiac structures, whereas it caused impingement ranging from 4 to 14 mm in the remaining patients. This study demonstrated that the HM3 in an LA-Ao configuration may be suitable for unloading the left atrium and relieving pulmonary congestion in some HFpEF patients where size-related limitations can be addressed through pre-surgical anatomical fit analysis.

Long-term outcomes of phenoclusters in preclinical heart failure with preserved and mildly reduced ejection fraction

AIMS

The identification of subjects at higher risk for incident heart failure (HF) with preserved ejection fraction (EF) suitable for more intensive preventive programmes remains challenging. We applied phenomapping to the DAVID-Berg population, comprising subjects with preclinical HF, aiming to refine HF risk stratification.

METHODS

The DAVID-Berg study prospectively enrolled 596 asymptomatic outpatients with EF > 40% with hypertension, diabetes mellitus or known cardiovascular disease. In this cohort, we performed an unsupervised cluster analysis on 591 patients, including clinical, laboratory, electrocardiographic and echocardiographic parameters. We tested the association between each cluster and a composite outcome of HF/death.

RESULTS

The median age was 70 years, 55.5% were males and the median EF was 61.0%. Phenomapping provided three different clusters. Subjects in Cluster 3 were the oldest and had the highest prevalence of atrial fibrillation, the lowest estimated glomerular filtration rate (eGFR), the highest N-terminal pro-brain natriuretic peptide (NT-proBNP) and the largest left atrium. During a median follow-up of 5.7 years, 13.4% of subjects experienced HF/death events (N = 79). Compared with Clusters 1 and 2, Cluster 3 had the worst prognosis (log-rank test: Cluster 3 vs. 1 P < 0.001; Cluster 3 vs. 2 P = 0.008). Cluster 3 was associated with a risk of HF/death 2.5 times higher than Cluster 1 [adjusted hazard ratio (HR) = 2.46, 95% confidence interval (CI) 1.24-4.90].

CONCLUSIONS

Based on phenomapping, older patients with lower kidney function and worse diastolic function might represent a subset of preclinical HF with EF > 40% who deserve more efforts to prevent clinical HF.

Radiomics features of the cardiac blood pool to indicate hemodynamic changes in pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (PH-HFpEF)

To test the hypothesis that cine MRI-derived radiomics features of the cardiac blood pool can represent hemodynamic characteristics of pulmonary hypertension-heart failure with preserved ejection fraction (PH-HFpEF). Nineteen PH-HFpEF patients (9 male, 57.8 ± 14.7 years) and 19 healthy controls (13 male, 50.3 ± 13.6 years) were enrolled. All participants underwent a cardiac MRI scan. One hundred and seven radiomics features (7 classes) of the blood pool in the left and right ventricles/atrium (LV/RV/LA/RA) were extracted from 4-chamber cine (2D images) at the stages of systole, rapid filling, diastasis, and atrial contraction within a cardiac cycle. For PH-HFpEF patients, features acquired from LV/LA were related to the pulmonary capillary wedge pressure (PCWP); features acquired from RV/RA were related to the mean pulmonary artery pressure (mPAP) using the Pearson correlation coefficient (r). Logistic regression, receiver operating characteristic (ROC) curve and the area under the curve (AUC) were used to test the capability of radiomics features in discriminating 2 subject groups. Features acquired from different chambers at various periods present diverse properties in representing hemodynamic indices of PH-HFpEF. Multiple radiomics features blood pool were significantly related to PCWP and/or mPAP (r: 0.4-0.679, p < 0.05). In addition, multiple features of blood pools acquired at various time points within a cardiac cycle can efficiently discriminate PH-HFpEF from controls (individual AUC: 0.7-0.864). Cine MRI-derived radiomics features of the cardiac blood pool have the potential to characterize hemodynamic abnormalities in the context of PH-HFpEF.

Left Atrial Mechanics Following Preeclamptic Pregnancy

BACKGROUND

Preterm preeclampsia is a pregnancy complication associated with myocardial dysfunction and premature cardiovascular disease morbidity and mortality. Left atrial (LA) strain is a noninvasive index of left ventricular end diastolic pressure and an early marker of heart failure risk. This study aimed to evaluate LA strain during the postpartum period in participants with and without preterm preeclampsia and to assess whether this varied in the presence of hypertension, cardiac dysfunction or both.

METHODS

In this longitudinal cohort study, 321 women from 28 hospitals with preterm preeclampsia (cases) underwent cardiovascular assessment 6 months postpartum. This is a secondary analysis of the PHOEBE study (ISRCTN01879376). An uncomplicated pregnancy control group (n=30) was recruited from a single center for comparison. A full cross-sectional transthoracic echocardiogram was performed, and from these images, the myocardial strain of the left atrium, including reservoir, conduit, and contractile strain, as well as LA stiffness, were calculated.

RESULTS

At 6 months postpartum, compared with controls, prior preeclampsia was associated with a significantly attenuated LA reservoir, conduit, and contractile strain, as well as increased LA stiffness (all P<0.001). LA strain was further reduced in preeclamptic women who had and had not developed hypertension, systolic, or diastolic dysfunction at 6 months postpartum (all P<0.05).

CONCLUSIONS

LA mechanics were significantly attenuated at 6 months postpartum in participants with preterm preeclampsia, whether or not they remained hypertensive or had evidence of ventricular dysfunction. Further studies are needed to determine whether postnatal LA strain may identify women at greater risk for future cardiovascular disease.

Conduit Flow Compensates for Impaired Left Atrial Passive and Booster Functions in Advanced Diastolic Dysfunction

BACKGROUND

Quantification of left atrial (LA) conduit function and its contribution to left ventricular (LV) filling is challenging because it requires simultaneous measurements of both LA and LV volumes. The functional relationship between LA conduit function and the severity of diastolic dysfunction remains controversial. We studied the role of LA conduit function in maintaining LV filling in advanced diastolic dysfunction.

METHODS

We performed volumetric and flow analyses of LA function across the spectrum of LV diastolic dysfunction, derived from a set of consecutive patients undergoing multiphasic cardiac computed tomography scanning (n=489). From LA and LV time-volume curves, we calculated 3 volumetric components: (1) early passive emptying volume; (2) late active (booster) volume; and (3) conduit volume. Results were prospectively validated on a group of patients with severe aortic stenosis (n=110).

RESULTS

The early passive filling progressively decreased with worsening diastolic function (P<0.001). The atrial booster contribution to stroke volume modestly increases with impaired relaxation (P=0.021) and declines with more advanced diastolic function (P<0.001), thus failing to compensate for the reduction in early filling. The conduit volume increased progressively (P<0.001), accounting for 75% of stroke volume (interquartile range, 63-81%) with a restrictive filling pattern, compensating for the reduction in both early and booster functions. Similar results were obtained in patients with severe aortic stenosis. The pulmonary artery systolic pressure increased in a near-linear fashion when the conduit contribution to stroke volume increased above 60%. Maximal conduit flow rate strongly correlated with mitral E-wave velocity (r=0.71; P<0.0001), indicating that the increase in mitral E wave in diastolic dysfunction represents the increased conduit flow.

CONCLUSIONS

An increase in conduit volume contribution to stroke volume represents a compensatory mechanism to maintain LV filling in advanced diastolic dysfunction. The increase in conduit volume despite increasing LV diastolic pressures is accomplished by an increase in pulmonary venous pressure.

Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium

Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism-based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well-defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.

Remodelling of cAMP dynamics within the SERCA2a microdomain in heart failure with preserved ejection fraction caused by obesity and type 2 diabetes

AIMS

Despite massive efforts, we remain far behind in our attempts to identify effective therapies to treat heart failure with preserved ejection fraction (HFpEF). Diastolic function is critically regulated by sarcoplasmic/endoplasmic reticulum (SR) calcium ATPase 2a (SERCA2a), which forms a functional cardiomyocyte (CM) microdomain where 3',5'-cyclic adenosine monophosphate (cAMP) produced upon β-adrenergic receptor (β-AR) stimulation leads to phospholamban (PLN) phosphorylation and facilitated Ca2+ re-uptake.

METHODS AND RESULTS

To visualize real-time cAMP dynamics in the direct vicinity of SERCA2a in healthy and diseased myocytes, we generated a novel mouse model on the leprdb background that stably expresses the Epac1-PLN Förster resonance energy transfer biosensor. Mice homozygous for the leprdb mutation (db/db) developed obesity and type 2 diabetes and presented with a HFpEF phenotype, evident by mild left ventricular hypertrophy and elevated left atria filling pressures. Live cell imaging uncovered a substantial β2-AR subtype stimulated cAMP response within the PLN/SERCA2a microdomain of db/db but not healthy control (db/+) CMs, which was accompanied by increased PLN phosphorylation and accelerated calcium re-uptake. Importantly, db/db CMs also exhibited a desensitization of β1-AR stimulated cAMP pools within the PLN/SERCA2a microdomain, which was accompanied by a blunted lusitropic effect, suggesting that the increased β2-AR control is an intrinsic compensatory mechanism to maintain PLN/SERCA2a-mediated calcium dynamics and cardiac relaxation. Mechanistically, this was due to a local loss of cAMP-degrading phosphodiesterase 4 associated specifically with the PLN/SERCA2a complex.

CONCLUSION

These newly identified alterations of cAMP dynamics at the subcellular level in HFpEF should provide mechanistic understanding of microdomain remodelling and pave the way towards new therapies.

Clinical Characteristics and Rhythm Outcomes in Patients With Atrial Myopathy After Successful Catheter Ablation of Atrial Fibrillation

BACKGROUND

Although successful atrial fibrillation (AF) ablation can maintain sinus rhythm and reduce the left atrial (LA) dimension, blunted LA reverse remodeling can be observed in patients with atrial myopathy. We explored the potential mechanisms and long-term outcomes in patients with blunted LA reverse remodeling after successful AF catheter ablation.

METHODS AND RESULTS

We included 1685 patients who underwent baseline and 1-year follow-up echocardiograms, had a baseline LA dimension ≥40 mm, and did not have a recurrence of AF within a year. The patients were divided into tertile groups according to the delta value of the change in LA dimension on the preprocedure and 1-year postprocedure echocardiography. After propensity score matching for age, sex, AF type, and LA dimension, 1272 patients were finally included in the analyses (424 in each group; the least/blunted, moderate, and the most reverse remodeling group). The patients in the T1 group (blunted LA reverse remodeling) were independently associated with higher left ventricular mass index (odds ratio [OR], 1.014 [95% CI, 1.005-1.022], P=0.001), change in ΔH2FPEF score (heavy, hypertensive, atrial fibrillation, pulmonary hypertension, elder, filling pressure) score (OR, 1.445 [95% CI, 1.121-1.861], P=0.004), ventricular epicardial adipose tissue volume (OR, 1.010 [95% CI, 1.003-1.017], P=0.003), thinner LA wall thickness (OR, 0.461 [95% CI, 0.271-0.785], P=0.004), lower LA voltage (OR, 0.670 [95% CI, 0.499-0.899], P=0.008), and showed higher long-term AF recurrence (log-rank P<0.001) than other groups.

CONCLUSIONS

Blunted LA reverse remodeling after AF catheter ablation, which is suggestive of atrial myopathy, was independently associated with a larger ventricular epicardial adipose tissue volume and worsening of H2FPEF score. Blunted LA reverse remodeling after AF catheter ablation was also an independent predictor for higher recurrences of AF post-1-year AF catheter ablation.

Post-Capillary Pulmonary Hypertension: Clinical Review

Pulmonary hypertension (PH) caused by left heart disease, also known as post-capillary PH, is the most common etiology of PH. Left heart disease due to systolic dysfunction or heart failure with preserved ejection fraction, valvular heart disease, and left atrial myopathy due to atrial fibrillation are causes of post-capillary PH. Elevated left-sided filling pressures cause pulmonary venous congestion due to backward transmission of pressures and post-capillary PH. In advanced left-sided heart disease or valvular heart disease, chronic uncontrolled venous congestion may lead to remodeling of the pulmonary arterial system, causing combined pre-capillary and post-capillary PH. The hemodynamic definition of post-capillary PH includes a mean pulmonary arterial pressure > 20 mmHg, pulmonary vascular resistance < 3 Wood units, and pulmonary capillary wedge pressure > 15 mmHg. Echocardiography is important in the identification and management of the underlying cause of post-capillary PH. Management of post-capillary PH is focused on the treatment of the underlying condition. Strategies are geared towards pharmacotherapy and guideline-directed medical therapy for heart failure, surgical or percutaneous management of valvular disorders, and control of modifiable risk factors and comorbid conditions. Referral to centers with advanced heart and pulmonary teams has shown to improve morbidity and mortality. There is emerging interest in the use of targeted agents classically used in pulmonary arterial hypertension, but current data remain limited and conflicting. This review aims to serve as a comprehensive summary of postcapillary PH and its etiologies, pathophysiology, diagnosis, and management, particularly as it pertains to advanced heart failure.

The correlation of left atrial diameter with preserved ejection fraction, reduced ejection fraction, and mid-range ejection fraction

BACKGROUND

In patients with heart failure, left atrial remodeling often occurs to varying degrees. Left atrial enlargement has been proved to be an important predictor of cardiovascular-related adverse events. However, the relationship between left atrial diameter (LAD) with heart failure (HF) with preserved ejection fraction (HFpEF), reduced ejection fraction (HFrEF) and mid-range ejection fraction (HFmrEF) remains unclear.

HYPOTHESIS

We want to explore the correlation between left atrial diameter and HFpEF, HFmrEF, and HFrEF.

METHODS

A total of 210 patients with heart failure who underwent hospitalization in Ningbo Medical Center Lihuili Hospital, Zhejiang, China, from January 1, 2020, to June 31, 2021, were reviewed. The basic demographic characteristics, blood test, and the related indexes of echocardiography of the subjects were collected and analyzed.

RESULTS

There is a significant difference between HFpEF and HFrEF group in LAD (p = .007), and LAD is negatively correlated with left ventricular ejection fraction (LVEF) (p = .002, r = -.209).

CONCLUSION

LAD is negatively correlated with LVEF, which may predict the prevalence of HFrEF.

Selvester QRS Score is a Predictor of Mortality in Heart Failure with Preserved Ejection Fraction

BACKGROUND

The Selvester QRS (S-QRS) score on a 12-lead electrocardiogram (ECG) is associated with both the amount of myocardial scar and poor prognosis in myocardial infarction patients. However, its prognostic value in heart failure (HF) with preserved ejection fraction (HFpEF) is unknown.

OBJECTIVE

This study aims to investigate the predictive value of the S-QRS score for mortality in HFpEF.

METHODS

359 patients were retrospectively enrolled in this study. Electrocardiographic, echocardiographic, and laboratory features of the patients were recorded. The simplified S-QRS score was measured and recorded. The mean follow-up time of the patients was 38.1±9.5 months. Statistical significance was set at p < 0.05.

RESULTS

Of 359 patients, 270 were in the survivor group, and 89 were in the deceased group. Age, Hs-CRP, troponin, pro-BNP, left atrial (LA) diameter, LA volume index, QRS duration, Tpe, and S-QRS score were statistically high in the deceased group. In multivariate logistic regression analysis, age, Hs-CRP, NT-proBNP, LA diameter, LA volume index, Tpe, and S-QRS score were shown to be independent risk factors for mortality. In the receiver-operating characteristic (ROC) analysis, the cut-off value of the S-QRS score was 5.5, the sensitivity was 80.8%, and the specificity was 77.2% (AUC:0.880, p:0.00). In Kaplan-Meier analysis, it was found that mortality was higher in the group with S-QRS score ≥ 5.5 than in the group with S-QRS score < 5.5. (Long-rank, p:0.00).

CONCLUSIONS

We think that the S-QRS score can be used as a prognostic indicator of long-term mortality in patients with HFpEF.

Mechanisms of benefits of sodium-glucose cotransporter 2 inhibitors in heart failure with preserved ejection fraction

For decades, heart failure with preserved ejection fraction (HFpEF) proved an elusive entity to treat. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have recently been shown to reduce the composite of heart failure hospitalization or cardiovascular death in patients with HFpEF in the landmark DELIVER and EMPEROR-Preserved trials. While improvements in blood sugar, blood pressure, and attenuation of kidney disease progression all may play some role, preclinical and translational research have identified additional mechanisms of these agents. The SGLT2 inhibitors have intriguingly been shown to induce a nutrient-deprivation and hypoxic-like transcriptional paradigm, with increased ketosis, erythropoietin, and autophagic flux in addition to altering iron homeostasis, which may contribute to improved cardiac energetics and function. These agents also reduce epicardial adipose tissue and alter adipokine signalling, which may play a role in the reductions in inflammation and oxidative stress observed with SGLT2 inhibition. Emerging evidence also indicates that these drugs impact cardiomyocyte ionic homeostasis although whether this is through indirect mechanisms or via direct, off-target effects on other ion channels has yet to be clearly characterized. Finally, SGLT2 inhibitors have been shown to reduce myofilament stiffness as well as extracellular matrix remodelling/fibrosis in the heart, improving diastolic function. The SGLT2 inhibitors have established themselves as robust, disease-modifying therapies and as recent trial results are incorporated into clinical guidelines, will likely become foundational in the therapy of HFpEF.

Decreased diastolic hydraulic forces incrementally associate with survival beyond conventional measures of diastolic dysfunction

Decreased hydraulic forces during diastole contribute to reduced left ventricular (LV) filling and heart failure with preserved ejection fraction. However, their association with diastolic function and patient outcomes are unknown. The aim of this retrospective, cross-sectional study was to determine the mechanistic association between diastolic hydraulic forces, estimated by echocardiography as the atrioventricular area difference (AVAD), and both diastolic function and survival. Patients (n = 5176, median [interquartile range] 5.5 [5.0-6.1] years follow-up, 1213 events) were selected from the National Echo Database Australia (NEDA) based on the presence of relevant transthoracic echocardiographic measures, LV ejection fraction (LVEF) ≥ 50%, heart rate 50-100 beats/minute, the absence of moderate or severe valvular disease, and no prior prosthetic valve surgery. NEDA contains echocardiographic and linked national death index mortality outcome data from 1985 to 2019. AVAD was calculated as the cross-sectional area difference between the LV and left atrium. LV diastolic dysfunction was graded according to 2016 guidelines. AVAD was weakly associated with E/e', left atrial volume index, and LVEF (multivariable global R2 = 0.15, p < 0.001), and not associated with e' and peak tricuspid regurgitation velocity. Decreased AVAD was independently associated with poorer survival, and demonstrated improved model discrimination after adjustment for diastolic function grading (C-statistic [95% confidence interval] 0.644 [0.629-0.660] vs 0.606 [0.592-0.621], p < 0.001) and E/e' (0.649 [0.635-0.664] vs 0.634 [0.618-0.649], p < 0.001), respectively. Therefore, decreased hydraulic forces, estimated by AVAD, are weakly associated with diastolic dysfunction and demonstrate an incremental prognostic association with survival beyond conventional measures used to grade diastolic dysfunction.

Improvement of obstructive sleep apnea does not rescue left atrial enlargement in obese participants of a multimodal weight reduction program

The aim of our study was to investigate the effect of obstructive sleep apnea (OSA) and its weight loss related improvement on left atrial (LA) area in individuals with severe obesity participating in a multimodal weight reduction (WR) program. Participants with obesity (body mass index, BMI, 40.2 ± 7.3 kg/m2) underwent a 1-year WR program. Phenotyping was performed at baseline and after 12 months. Individuals were categorized according to their baseline apnea-hypopnea-index (AHI) into "no OSA" (AHI < 5) and "OSA" (AHI ≥ 5). From a total of 84 study participants, 69 completed the program. Average WR was 19.0 ± 15.7 kg after 12 months. Participants with obesity and OSA had a larger LA area at baseline as compared to participants with obesity but without OSA (22.4 ± 5.6 vs 18.8 ± 3.8 cm2; P = .008). Linear regression showed significant associations of AHI and BMI with LA area. In contrast, despite a significant decrease of AHI in participants with OSA as compared to those without OSA at 1 year follow up (ΔAHI was -12 ± 14) ΔLA area did not significantly differ between groups. Multivariable linear regression showed no significant association of ΔAHI or ΔBMI with ΔLA. In conclusion, the presence of obstructive sleep apnea contributes to LA enlargement on top of obesity in our study cohort. Yet, successful WR with subsequently improved OSA was not associated with an improvement of LA area.

Quantification of left atrial function by the area-length method overestimates left atrial emptying fraction

PURPOSE

The biplane area-length method is commonly used in cardiac magnetic resonance (CMR) to assess left atrial (LA) volume (LAV) and function. Associations between left atrial emptying fraction (LAEF) and clinical outcomes have been reported. However, only limited data are available on the calculation of LAEF using the biplane method compared to 3D assessment. This study aimed to compare volumetric and functional LA parameters obtained from the biplane method with 3D assessment in a large, multiethnic cohort.

METHOD

158 participants of MESA (Multi-Ethnic Study of Atherosclerosis) underwent CMR that included standard two- and four-chamber steady-state free precession (SSFP) cine imaging for the biplane method. For 3D-based assessment, short-axis SSFP cine series covering the entire LA were obtained, followed by manual delineation of LA contours to create a time-resolved 3D LAV dataset. Paired t-tests and Bland-Altman plots were used to analyze the data.

RESULTS

Standard volumetric assessment showed that LAVmin (bias: -8.35 mL, p < 0.001), LAVmax (bias: -9.38 mL, p < 0.001) and LAVpreA (bias: -10.27 mL, p < 0.001) were significantly smaller using the biplane method compared to 3D assessment. Additionally, the biplane method reported significantly higher LAEFtotal (bias: 7.22 %, p < 0.001), LAEFactive (bias: 6.08 %, p < 0.001), and LAEFpassive (bias: 4.51 %, p < 0.001) with wide limits of agreement.

CONCLUSIONS

LA volumes were underestimated using the biplane method compared to 3D assessment, while LAEF parameters were overestimated. These findings demonstrate a lack of precision using the biplane method for LAEF assessment. Our results support the usage of 3D assessment in specific settings when LA volumetric and functional parameters are in focus.

Periplocin Alleviates Cardiac Remodeling in DOCA-Salt-Induced Heart Failure Rats

Heart failure with preserved ejection fraction (HFpEF) is a common public health problem associated with increased morbidity and long-term mortality. However, effective treatment for HFpEF was not discovered yet. In the present study, we aimed to decipher the effects of Periplocin on DOCA-induced heart failure rats and explore the possible underlying mechanisms. We demonstrated that Periplocin could significantly attenuate cardiac structural remodeling and improve cardiac diastolic function. Of note, Periplocin significantly inhibited the recruitment of inflammatory and immune cells and decreased the expression of serum inflammatory cytokines. Meanwhile, Periplocin had the effect of cardiac glycosides to improve cardiomyocyte contractility and calcium transient amplitude. These findings indicate that Periplocin might be a potential medicine to treat HFpEF in patients.

Spironolactone effect on cardiac structure and function of patients with heart failure and preserved ejection fraction: a pooled analysis of three randomized trials

AIMS

Spironolactone is currently used in a large proportion of patients with heart failure and preserved ejection fraction (HFpEF), yet its effect on cardiac structure and function in a large population has not been well established. The aim of this study was to evaluate the impact of spironolactone on key echocardiographic parameters in HFpEF.

METHODS AND RESULTS

An individual-patient-data meta-analysis of three randomized trials (HOMAGE, Aldo-DHF, and TOPCAT) was performed comparing spironolactone (9-12 month exposure) to placebo (or control) for the changes in left atrial volume index (LAVi), left ventricular mass index (LVMi), interventricular septum (IVS) thickness, E/e' ratio, and left ventricular ejection fraction (LVEF) among patients with stage B (HOMAGE) or C (Aldo-DHF and TOPCAT) HFpEF. Analysis of covariance was used to test the effect of spironolactone on echocardiographic changes. A total of 984 patients were included in this analysis: 452 (45.9%) from HOMAGE, 398 (40.4%) from Aldo-DHF, and 134 (13.6%) from TOPCAT. The pooled-cohort patient's median age was 71 (66-77) years and 39% were women. Median LAVi was 29 (24-35) ml/m² , LVMi 100 (84-118) g/m² , IVS thickness 12 (10-13) mm, E/e' ratio 11 (9-13), and LVEF 64 (59-69)%. Spironolactone reduced LAVi by -1.1 (-2.0 to -0.1) ml/m² (p = 0.03); LVMi by -3.6 (-6.4 to -0.8) g/m² (p = 0.01); IVS thickness by -0.2 (-0.3 to -0.1) mm (p = 0.01); E/e' ratio by -1.3 (-2.4 to -0.2) (p = 0.02); and increased LVEF by 1.7 (0.8-2.6)% (p < 0.01). No treatment-by-study heterogeneity was found except for E/e' ratio with a larger effect in Aldo-DHF and TOPCAT (interaction p < 0.01).

CONCLUSIONS

Spironolactone improved cardiac structure and function of patients with HFpEF.

The predictive value of changes in left atrial volume index for rehospitalization in heart failure with preserved ejection fraction

AIMS

Left atrial volume index (LAVI) is an adequate analysis to predicate the left ventricle (LV) filling pressures, providing a powerful predictive marker of LV diastolic dysfunction. LAVI is a dynamic morphophysiological marker, and whether LAVI changes can predicate clinical outcomes in HF with preserved ejection fraction (HFpEF) is unknown.

METHODS

HFpEF patients were retrospectively studied from the First Affiliated Hospital of Dalian Medical University. Patients were classified into deteriorated, stable and improved groups according to the change in LAVI. Rehospitalization was defined as the main endpoint, the composite outcome of rehospitalization or all-cause death was defined as the secondary endpoint.

RESULTS

A total of 409 patients were included. In this cohort, the percentage of deteriorated, stable, and improved LAVI were 99 (24.2%), 235 (57.4%), and 75 (18.4%), respectively. During the 22 months follow-up period, 168 patients (41.1%) were rehospitalized, 31 patients (7.5%) died and 182 patients (44.5%) experienced a composite outcome. Multivariate Cox regression showed that compared to improved LAVI, those with deteriorated and stable LAVI experienced higher risk of rehospitalization. Logistic regression showed atrial fibrillation (AF) and higher creatinine were independent predictors of deteriorated LAVI, whereas the use of loop diuretics, calcium channel blockers (CCB), and high level of high-density lipoprotein cholesterol (HDL-C) were significantly associated with improved LAVI.

CONCLUSIONS

Change in LAVI provides a powerful and dynamic morphophysiological marker of LV filling status and can be used to evaluate the rehospitalization in HFpEF patients.

Defining the Phenotypes for Heart Failure With Preserved Ejection Fraction

PURPOSE OF REVIEW

Heart failure with preserved ejection fraction (HFpEF) imposes a significant burden on society and healthcare. The lack in efficacious therapies is likely due to the significant heterogeneity of HFpEF. In this review, we define various phenotypes based on underlying comorbidities or etiologies, discuss phenotypes arrived at by novel methods, and explore therapeutic targets.

RECENT FINDINGS

A few studies have used machine learning methods to uncover sub-phenotypes within HFpEF in an unbiased manner based on clinical features, echocardiographic findings, and biomarker levels. We synthesized the literature and propose three broad phenotypes: (1) young, with few comorbidities, usually obese and with low natriuretic peptide levels, (2) obese with substantive cardiometabolic burden and comorbidities and impaired ventricular relaxation, (3) old, multimorbid, with high rates of atrial fibrillation, renal and coronary artery disease, chronic obstructive pulmonary disease, and left ventricular hypertrophy. We also propose potential therapeutic strategies for these phenotypes.

Atrial Pacing Affects Left Atrial Morphological and Functional Parameters Early after Pacemaker Implantation

Background and Objectives: Chronic atrial stimulation might impair left atrial (LA) function. We aimed to assess the impact of atrial pacing burden on LA volumetric and functional parameters after implantation of a dual-chamber pacemaker. Materials and Methods: The prospective study included 121 subjects with sinus node disease (SND) or atrioventricular block (AVB) that received a dual-chamber pacemaker. After device implantation, the subjects were divided into three groups: (1) SND with a lower rate (LR) set to 60 bpm and rate response enabled; (2) AVB with an LR set to 60 bpm and no rate response; and (3) AVB with an LR set to 40 bpm and no rate response. Subjects were followed at one and three months. Two subsets of patients with high and low atrial pacing burdens accompanied by low ventricular pacing percentage were analyzed. LA function was evaluated with volumetric and strain parameters from transthoracic echocardiography. Results: The high atrial low ventricular pacing group consisted of 38 subjects, and the low atrial low ventricular group consisted of 22 subjects. When looking at the change in volumetric parameters, we observed a tendency for volumes to increase in both groups; however, only minimal LA volume reached statistical significance at three months in the high atrial pacing group. A trend towards the lowering of an active emptying fraction at one month (p = 0.076) became significant at three months (p = 0.043), and was also only observed in the same group. Moreover, a decrease in the tendency to reach statistical significance at three months for reservoir and contractile strain parameters and stiffness index was only observed in the high atrial pacing group. Meanwhile, in the low atrial pacing burden group, all parameters remained significantly unchanged. Conclusions: The burden of right atrial pacing in patients with preserved left ventricular function negatively influences functional and morphologic LA parameters. Moreover, negative effects take place soon after pacemaker implantation and appear to be sustained.

The Role of the Left Atrium: From Multimodality Imaging to Clinical Practice: A Review

In recent years, new interest is growing in the left atrium (LA). LA functional analysis and measurement have an essential role in cardiac function evaluation. Left atrial size and function are key elements during the noninvasive analysis of diastolic function in several heart diseases. The LA represents a “neuroendocrine organ” with high sensitivity to the nervous, endocrine, and immune systems. New insights highlight the importance of left atrial structural, contractile, and/or electrophysiological changes, introducing the concept of “atrial cardiomyopathy”, which is closely linked to underlying heart disease, arrhythmias, and conditions such as aging. The diagnostic algorithm for atrial cardiomyopathy should follow a stepwise approach, combining risk factors, clinical characteristics, and imaging. Constant advances in imaging techniques offer superb opportunities for a comprehensive evaluation of LA function, underlying specific mechanisms, and patterns of progression. In this literature review, we aim to suggest a practical, stepwise algorithm with integrative multimodality imaging and a clinical approach for LA geometry and functional analysis. This integrates diastolic flow analysis with LA remodelling by the application of traditional and new diagnostic imaging techniques in several clinical settings such as heart failure (HF), atrial fibrillation (AF), coronary artery disease (CAD), and mitral regurgitation (MR).

Decreased Peak Left Atrial Longitudinal Strain Is Associated with Persistent Pulmonary Hypertension Associated with Left Heart Disease

Pulmonary hypertension (PH) associated with left heart disease (PH-LHD) is the most common form of PH and has significantly higher morbidity and mortality. We estimated the prevalence of PH-LHD on the follow-up echocardiography and the role of left atrial (LA) function in PH-LHD. From the STRATS-AHF registry composed of 4312 acute heart failure (HF) patients, we analyzed peak atrial longitudinal strain (PALS) in 1729 patients with follow-up echocardiographic examinations during mean 18.1 ± 13.5 months. PH was determined by the maximal velocity of tricuspid regurgitation (TR Vmax ≥ 3.4 m/s). Persistent PH was found in 373 patients (21.6%). The PH-LHD group was significantly older, and the prevalence of atrial fibrillation (AF), hypertension, diabetes, and heart failure with preserved ejection fraction were higher compared with the no PH-LHD group. Baseline left ventricular end-systolic volume and PALS were lower, and LA diameter, mitral E/E’ ratio, and TR Vmax were higher in the PH-LHD group. In the multivariate analysis, PALS (HR = 1.024, p = 0.040) was a significant variable after adjustment of LA diameter and mitral E/E’. A decreased PALS of <12.5% was the best cutoff value in the prediction of persistent PH-LHD (AUC = 0.594, sensitivity = 65.3%, specificity = 46.1%). PH-LHD was associated with increased HF hospitalization (HR = 2.344, p < 0.001) and mortality (HR = 2.015, p < 0.001) after adjusting for age and sex. In conclusion, persistent PH-LHD was found in 21.6% in the follow-up echocardiography and was associated with decreased PALS (<12.5%). PH-LHD persistence was associated with poor clinical outcomes. Thus, AHF patients with decreased PALS, especially <12.5%, should be followed with caution.

Left atrial disease and left atrial reverse remodeling across different stages of heart failure development and progression: a new target for prevention and treatment

The left atrium is a dynamic chamber with peculiar characteristics. Stressors and disease mechanisms may deeply modify its structure and function, leading to left atrial remodelling and disease. Left atrial disease is a predictor of poor outcomes. It may be a consequence of left ventricular systolic and diastolic dysfunction and neurohormonal and inflammatory activation and/or actively contribute to the progression and clinical course of heart failure through multiple mechanisms such as left ventricular filling and development of atrial fibrillation and subsequent embolic events. There is growing evidence that therapy may improve left atrial function and reverse left atrial remodelling. Whether this translates into changes in patient's prognosis is still unknown.

In this review we report current data about changes in left atrial size and function across different stages of development and progression of heart failure. At each stage, drug therapies, lifestyle interventions and procedures have been associated with improvement in left atrial structure and function, namely a reduction in left atrial volume and/or an improvement in left atrial strain function, a process that can be defined as left atrial reverse remodelling and, in some cases, this has been associated with improvement in clinical outcomes. Further evidence is still needed mainly with respect of the possible role of left atrial reverse remodelling as an independent mechanism affecting the patient's clinical course and as regards better standardization of clinically meaningful changes in left atrial measurements. Summarizing current evidence, this review may be the basis for further studies.

Association of Left Atrial Structure and Function With Heart Failure in Older Adults

BACKGROUND

Limited data exist to characterize novel measures of left atrial (LA) structure and function in older adults without prevalent heart failure (HF).

OBJECTIVES

The aim was to assess reference range of LA measures, their associations with N-terminal pro-B-type natriuretic-peptide (NT-proBNP) and the related risk for incident HF or death.

METHODS

We analyzed LA structure (LA maximal [LAViMax] and minimal volume indexed by body surface area) and function (LA emptying fraction, LA reservoir, conduit, and contraction strain) in 4,901 participants from the ARIC (Atherosclerosis Risk In Communities) study (mean age 75 ± 5 years, 40% male, and 19% Black) without prevalent HF. We assessed sex-specific 10th and 90th percentile ARIC-based reference limits in 301 participants free of prevalent cardiovascular disease, and related LA measures to NT-proBNP and incident HF or death (median follow-up of 5.5 years) in the whole ARIC cohort.

RESULTS

Approximately 20% of the overall population had LA abnormalities according to the ARIC-based reference limit. Each LA measure was associated with NT-proBNP and, except for LAViMax, with incident HF or death after multivariable adjustment (including left ventricular function and NT-proBNP). Results were consistent in participants with normal LAViMax (P for interaction > 0.05). LA measures were prognostic for both incident HF with preserved ejection fraction or death and incident HF with reduced ejection fraction or death. When added to HF risk factors and NT-proBNP (baseline C-statistics = 0.74) all LA measures, except for LAViMax, significantly enhanced the prognostic accuracy.

CONCLUSIONS

Novel measures of LA structure and function, but not standard assessment by LAViMax, are associated with increased risk of incident HF or death regardless of measures of left ventricular function and NT-proBNP.

Impact of different degrees of left ventricular strain on left atrial mechanics in heart failure with preserved ejection fraction

Background

Impairment of left atrial (LA) function is linked to left ventricle (LV) mechanics in patients with heart failure with preserved ejection fraction (HFpEF). In this study, we set forth to determine the difference in LA mechanics compared between HFpEF patients with different degrees of LV strains using the cardiac magnetic resonance feature tracking technique.

Methods

This retrospective study enrolled 79 patients with prior heart failure event and LV ejection fraction (LVEF) ≥ 50% (HFpEF group) together with 2:1 matched controls. LV global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS); LA emptying fraction (LAEF); and, LA strains consisting of reservoir phase strain (LAS_r), conduit phase strain (LAS_cd), and contraction phase strain (LAS_ct) were derived from cine images. All LA parameters were compared between HFpEF subgroups (lower and higher LV strain stratified by the median of each LV strain value) and controls.

Results

A total of 237 subjects were included. HFpEF had a lower LAEF and LA strain values compared with controls. The mean GLS value was significantly different between HFpEF and controls (− 13.3 ± 3.4% vs. − 15.4 ± 2.2%, p < 0.001). HFpEF with lower GLS (value ≥  − 13.1%) had significantly impaired LA mechanical parameters compared with both HFpEF with higher GLS and controls independent of potential confounders, as follows: LAEF (38.8 ± 16.6% vs. 48.6 ± 15.7% and 54.2 ± 12.2%), LAS_r (14.6 ± 7.1% vs. 24.3 ± 9.6% and 26.7 ± 8.8%), and LAS_cd (− 6.6 ± 3.9% vs. − 12.9 ± 6.0% and − 14.7 ± 7.4%) (post hoc analysis of variance p < 0.05 for all comparisons). Similarly, HFpEF with lower GCS (value ≥  − 16.6%) or lower GRS (value < 27.9%) also had significant impairment of LAS_r and LAS_cd compared with the higher strain group and controls. Abnormal LAEF (< 50%) and abnormal LAS_r (< 23%) are independently associated with NYHA class ≥ II (Odds ratio [OR] 3.894 [95% CI 2.202–6.885] p < 0.001, adjusted OR 3.382 [1.791–6.389] p < 0.001 for abnormal LAEF; and OR 2.613 [1.497–4.562] p = 0.001, adjusted OR 2.064 [1.118–2.110] p = 0.021 for abnormal LAS_r).

Conclusions

Patients with HFpEF were found to have impaired LV and LA mechanics. Abnormal LA mechanics was highly prevalent in HFpEF patients with lower LV strain and significantly associated with the symptomatic status of the patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02608-7.

Utility of left atrial and ventricular strain for diagnosis of transthyretin amyloid cardiomyopathy in aortic stenosis

Aims

To clarify the usefulness of left atrial (LA) function and left ventricular (LV) function obtained by two‐dimensional (2D) speckle tracking echocardiography to diagnose concomitant transthyretin amyloid cardiomyopathy (ATTR‐CM) in patients with aortic stenosis (AS).

Methods and results

We analysed 72 consecutive patients with moderate to severe AS who underwent ^99mTc‐pyrophosphate (PYP) scintigraphy at Kumamoto University Hospital from January 2012 to September 2020. We divided these 72 patients into 2 groups based on their ^99mTc‐PYP scintigraphy positivity or negativity. Among 72 patients, 16 patients (22%) were positive, and 56 patients (78%) were negative for ^99mTc‐PYP scintigraphy. In clinical baseline characteristics, natural logarithm troponin T was significantly higher in the ^99mTc‐PYP scintigraphy‐positive than scintigraphy‐negative group (−2.9 ± 0.5 vs. −3.5 ± 0.8 ng/mL, P < 0.05). In conventional echocardiography, the severity of AS was not significantly different between these two groups. In 2D speckle tracking echocardiography, the relative apical longitudinal strain (LS) index (RapLSI) [apical LS/ (basal LS + mid LS)] was significantly higher (1.09 ± 0.49 vs. 0.78 ± 0.23, P < 0.05) and the peak longitudinal strain rate (LSR) in LA was significantly lower in the ^99mTc‐PYP scintigraphy‐positive than scintigraphy‐negative group (0.36 ± 0.14 vs. 0.55 ± 0.20 s⁻¹, P < 0.05). Multivariable logistic analysis revealed the peak LSR in LA and RapLSI were significantly associated with ^99mTc‐PYP scintigraphy positivity. Receiver operating characteristic analysis showed that the area under the curve (AUC) of the peak LSR in LA for ^99mTc‐PYP scintigraphy positivity was 0.79 and that the best cut‐off value of the peak LSR in LA was 0.47 s⁻¹ (sensitivity: 78.6% and specificity: 72.3%). The AUC of RapLSI for ^99mTc‐PYP scintigraphy positivity was 0.69, and the cut‐off value of RapLSI was decided as 1.00 (sensitivity: 43.8% and specificity: 87.5%) according to the previous report. The ^99mTc‐PYP scintigraphy positivity in patients with RapLSI ≥ 1.0 and the peak LSR in LA ≤ 0.47 s⁻¹ was 83.3% (5/6), and the ^99mTc‐PYP scintigraphy negativity in patients with RapLSI < 1.0 and the peak LSR in LA > 0.47 s⁻¹ was 96.6% (28/29).

Conclusions

Left atrial and LV strain analysis were significantly associated with ^99mTc‐PYP scintigraphy positivity in ATTR‐CM patients with moderate to severe AS. The combination of the peak LSR in LA and RapLSI might be a useful predictor of the presence of ATTR‐CM in patients with moderate to severe AS.

Exercise-induced pulmonary hypertension in HFpEF and HFrEF: Different pathophysiologic mechanism behind similar functional impairment

AIMS

Pathophysiological mechanisms behind cardio-pulmonary impairment in heart failure (HF) with reduced (HFrEF) and preserved (HFpEF) ejection fraction are likely different. We analysed them using combined cardiopulmonary-exercise stress echocardiography (CPET-ESE).

METHODS

We matched 1:1 subjects with HFrEF (n = 90) and HFpEF (n = 90) for age, sex, body mass index (BMI), peak oxygen consumption, and minute ventilation/carbon dioxide production slope. All patients underwent a symptom-limited graded ramp bicycle CPET-ESE compared with 40 age-, sex- and BMI-matched healthy controls.

RESULTS

During a median follow-up of 25 months, we observed 22 deaths and 80 HF hospitalisations, with similar distribution between HFpEF and HFrEF. Compared with HFrEF, HFpEF had a higher prevalence of metabolic syndrome (p = 0.02) with higher levels of high-sensitivity C-reactive protein and uric acid (p < 0.01). The multipoint mean pulmonary artery pressure/cardiac output (mPAP/CO) slope showed equally increased values in HFrEF and HFpEF (3.5 ± 1.8 and 3.7 ± 1.5 mmHg/L/min) compared with controls (1.8 ± 1.1 mmHg/L/min; p < 0.0001). During exercise, HFpEF displayed more adverse interaction of right ventricle-pulmonary artery (RV-PA; tricuspid annular plane systolic excursion/systolic pulmonary artery pressure: 0.40 ± 0.2 vs 0.47 ± 0.2 mm/mmHg in HFrEF; p < 0.01) and left atrium-left ventricle (LA-LV; LA reservoir strain/LV global longitudinal strain: 1.5 ± 0.8 vs 2.2 ± 1.1 in HFrEF; p < 0.01). The latter were independent predictors of mPAP/CO slope, along with hs-CRP (adjusted R2: 0.21; p < 0.0001).

CONCLUSION

Despite similar disease severity, HFpEF and HFrEF show different pathophysiological mechanisms. HFpEF is characterised by a worse LA-LV and RV-PA interaction than HFrEF, with more prevalent low-grade systemic inflammation. In HFpEF, these features may have a role in exercise-induced pulmonary hypertension.

Left atrial reservoir strain as a predictor of cardiac outcome in patients with heart failure: the HaFaC cohort study

BACKGROUND

The left atrium (LA) is a key player in the pathophysiology of systolic and diastolic heart failure (HF). Speckle tracking derived LA reservoir strain (LAS_r) can be used as a prognostic surrogate for elevated left ventricular filling pressure similar to NT-proBNP. The aim of the study is to investigate the correlation between LAS_r and NT-proBNP and its prognostic value with regards to the composite endpoint of HF hospitalization and all-cause mortality within 1 year.

METHODS

Outpatients, sent to the echocardiography core lab because of HF, were enrolled into this study. Patients underwent a transthoracic echocardiographic examination, commercially available software was used to measure LAS_r. Blood samples were collected directly after the echocardiographic examination to determine NT-proBNP.

RESULTS

We included 174 HF patients, 43% with reduced, 36% with mildly reduced, and 21% with preserved ejection fraction. The study population showed a strong inverse correlation between LAS_r and log-transformed NT-proBNP (r = - 0.75, p < 0.01). Compared to NT-proBNP, LAS_r predicts the endpoint with a comparable specificity (83% vs. 84%), however with a lower sensitivity (70% vs. 61%).

CONCLUSION

LAS_r is inversely correlated with NT-proBNP and a good echocardiographic predictor for the composite endpoint of hospitalization and all-cause mortality in patients with HF.

TRIAL REGISTRATION

https://www.trialregister.nl/trial/7268.

Early cardiac-chamber-specific fingerprints in heart failure with preserved ejection fraction detected by FTIR and Raman spectroscopic techniques

The pathophysiology of heart failure with preserved ejection fraction (HFpEF) is a matter of investigation and its diagnosis remains challenging. Although the mechanisms that are responsible for the development of HFpEF are not fully understood, it is well known that nearly 80% of patients with HFpEF have concomitant hypertension. We investigated whether early biochemical alterations were detectable during HFpEF progression in salt-induced hypertensive rats, using Fourier-transformed infrared (FTIR) and Raman spectroscopic techniques as a new diagnostic approach. Greater protein content and, specifically, greater collagen deposition were observed in the left atrium and right ventricle of hypertensive rats, together with altered metabolism of myocytes. Additionally, Raman spectra indicated a conformational change, or different degree of phosphorylation/methylation, in tyrosine-rich proteins. A correlation was found between tyrosine content and cardiac fibrosis of both right and left ventricles. Microcalcifications were detected in the left and right atria of control animals, with a progressive augmentation from six to 22 weeks. A further increase occurred in the left ventricle and right atrium of 22-week salt-fed animals, and a positive correlation was shown between the mineral deposits and the cardiac size of the left ventricle. Overall, FTIR and Raman techniques proved to be sensitive to early biochemical changes in HFpEF and preceded clinical humoral and imaging markers.

Effect of coronavirus disease-2019 infection on left atrial functions

Objective:

Left atrial (LA) dysfunction is a crucial risk factor for cardiovascular events, and various pathologies may affect LA function. Coronavirus disease-2019 (COVID-19) is an ongoing global pandemic causing morbidity and mortality. In the present study, we aimed to evaluate LA functions in patients who recovered from COVID-19.

Methods:

Sixty consecutive patients recovered from COVID-19 and 60 healthy individuals as a control group were included in the study. Blood samples and echocardiography measurements were obtained from each subject. The two groups were compared in terms of demographic and echocardiographic characteristics.

Results:

In the COVİD-19 group, LA maximum volume (LAV_max) (P = 0.040), LA pre-A volume (LAVpre-A) (P = 0.014), and LA active emptying fraction (P = 0.027) were higher, while LA passive emptying fraction (P = 0.035) was lower. In addition, left ventricular ejection fraction (P = 0.006) and isovolumetric relaxation time (P = 0.008) were decreased in this group. Although LA volume index was higher in the COVID-19 group, it does not reach statistical significance.

Conclusion:

LA functions may be impaired in patients recovered from COVID-19 infection.

Heart failure with preserved ejection fraction: An alternative paradigm to explain the clinical implications of atrial fibrillation

Atrial fibrillation (AF) is associated with exercise intolerance, stroke, and all-cause mortality. However, whether this can be solely attributable to the arrhythmia itself or alternative mechanisms remains controversial. Heart failure with preserved ejection (HFpEF) commonly coexists with AF and may contribute to the poor outcomes associated with AF. Indeed, several invasive hemodynamic studies have confirmed that patients with AF are at increased risk of underlying HFpEF and that the presence of HFpEF may have important prognostic implications in these patients.

Mechanistically, AF and HFpEF are closely linked. Both conditions are driven by the presence of common cardiovascular risk factors and are associated with left atrial (LA) myopathy, characterized by mechanical and electrical dysfunction. Progressive worsening of this left atrial (LA) myopathy is associated with both increased AF burden and worsening HFpEF. In addition, there is growing evidence to suggest that worsening LA myopathy is associated with poorer outcomes in both conditions and that reversal of the LA myopathy could improve outcomes. In this review article, we will present the epidemiologic and mechanistic evidence underlying the common coexistence of AF and HFpEF, discuss the importance of a progressive LA myopathy in the pathogenesis of both conditions, and review the evidence from important invasive hemodynamic studies. Finally, we will review the prognostic implications of HFpEF in patients with AF and discuss the relative merits of AF burden reduction vs HFpEF reduction in improving outcomes of patients with AF and HFpEF.

Left Atrial Strain and Compliance Correlate with Diastolic Dysfunction Grades and Complications during Pre-eclampsia: A Speckle-Tracking Echocardiography Study

This study aimed to investigate left atrium (LA) strain components in the assessment of cardiac function and its clinical correlates in pre-eclampsia (PE). With the use of speckle tracking echocardiography, phasic LA strain and (LASr)/(E/e'), the surrogate of LA compliance, were compared between healthy pregnant women (n = 70) and those with PE (n = 146) and among different diastolic dysfunction (DD) grades in PE. Receiver operating characteristic curves and logistic regression analysis were used to identify the role of strain components in distinguishing DD grades and predicting cardiac complications. LA reservoir strain, conduit strain and LA compliance reduced significantly in PE (p < 0.01). LASr/(E/e') gradually decreased with worsening DD and LASr/(E/e') <3.40 was the independent risk factor for cardiac events in PE (p < 0.01). This study observed significantly decreased LA strain and compliance in PE. Notably, LA compliance decreased progressively with the severity of DD, and LASr/(E/e') <3.40 is the independent risk factor for cardiac complications during PE pregnancy.

The Influence of Surgical Weight Reduction on Left Atrial Strain

BACKGROUND

Obesity increases and surgical weight reduction decreases the risk of atrial fibrillation (AF) and heart failure (HF). We hypothesized that surgically induced weight loss may favorably affect left atrial (LA) mechanical function measured by longitudinal strain, which has recently emerged as an independent imaging biomarker of increased AF and HF risk.

METHODS

We retrospectively evaluated echocardiograms performed before and 12.2 ± 2.2 months after bariatric surgery in 65 patients with severe obesity (mean age 39 [36; 47] years, 72% of females) with no known cardiac disease or arrhythmia. The LA mechanical function was measured by the longitudinal strain using the semi-automatic speckle tracking method.

RESULTS

After surgery, body mass index decreased from 43.72 ± 4.34 to 30.04 ± 4.33 kg/m2. We observed a significant improvement in all components of the LA strain. LA reservoir strain (LASR) and LA conduit strain (LASCD) significantly increased (35.7% vs 38.95%, p = 0.0005 and - 19.6% vs - 24.4%, p < 0.0001) and LA contraction strain (LASCT) significantly decreased (- 16% vs - 14%, p = 0.0075). There was a significant correlation between an increase in LASR and LASCD and the improvement in parameters of left ventricular diastolic and longitudinal systolic function (increase in E' and MAPSE). Another significant correlation was identified between the decrease in LASCT and an improvement in LA function (decrease in A').

CONCLUSIONS

The left atrial mechanical function improves after bariatric surgery. It is partially explained by the beneficial effect of weight reduction on the left ventricular diastolic and longitudinal systolic function. This effect may contribute to decreased risk of AF and HF after bariatric surgery.

Association Between Heart Failure With Preserved Left Ventricular Ejection Fraction and Impaired Left Atrial Phasic Function in Hypertrophic Cardiomyopathy: Evaluation by Cardiac MRI Feature Tracking

BACKGROUND

The majority of heart failure (HF) in hypertrophic cardiomyopathy (HCM) manifests as a phenotype with preserved left ventricular (LV) ejection fraction; however, the exact contribution of left atrial (LA) phasic function to HF with preserved ejection fraction (HFpEF) in HCM remains unresolved.

PURPOSE

To define the association between LA function and HFpEF in HCM patients using cardiac magnetic resonance imaging (MRI) feature tracking.

STUDY TYPE

Retrospective.

POPULATION

One hundred and fifty-four HCM patients (HFpEF vs. non-HF: 55 [34 females] vs. 99 [43 females]).

FIELD STRENGTH/SEQUENCE

3.0 T/balanced steady-state free precession.

ASSESSMENT

LA reservoir function (reservoir strain [ε_s ], total ejection fraction [EF]), conduit function (conduit strain [ε_e ], passive EF), booster-pump function (booster strain [ε_a ] and active EF), LA volume index, and LV global longitudinal strain (LV GLS) were evaluated in HCM patients.

STATISTICAL TESTS

Chi-square test, Student's t-test, Mann-Whitney U test, multivariate linear regression, logistic regression, and net reclassification analysis were used. Two-sided P < 0.05 was considered statistically significant.

RESULTS

No significant difference was found in LV GLS between the non-HF and HFpEF group (-10.67 ± 3.14% vs. -10.14 ± 4.01%, P = 0.397), whereas the HFpEF group had more severely impaired LA phasic strain (ε_s : 27.40 [22.60, 35.80] vs. 18.15 [11.98, 25.90]; ε_e : 13.80 [9.20, 18.90] vs. 7.95 [4.30, 14.35]; ε_a : 13.50 [9.90, 17.10] vs. 7.90 [5.40, 14.15]). LA total EF (37.91 [29.54, 47.94] vs. 47.49 [39.18, 55.01]), passive EF (14.70 [7.41, 21.49] vs. 18.07 [9.32, 24.78]), and active EF (27.19 [17.79, 36.60] vs. 36.64 [26.63, 42.71]) were all significantly decreased in HFpEF patients compared with non-HF patients. LA reservoir (β = 0.90 [0.85, 0.96]), conduit (β = 0.93 [0.87, 0.99]), and booster (β = 0.86 [0.78, 0.95]) strain were independently associated with HFpEF in HCM patients. The model including reservoir strain (Net Reclassification Index [NRI]: 0.260) or booster strain (NRI: 0.325) improved the reclassification of HFpEF based on LV GLS and minimum left atrial volume index (LAVI_min ).

DATA CONCLUSION

LA phasic function was severely impaired in HCM patients with HFpEF, whereas LV function was not further impaired compared with non-HF patients.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 3.

Left atrial structural and mechanical remodelling in heart failure with reduced ejection fraction

Aims

In patients with heart failure with reduced ejection fraction (HFrEF), an association between left atrial (LA) dilatation and dysfunction is expected, but the degree of coexistence of the two abnormalities and their relative prognostic role is not known.

Methods and results

A total of 626 HFrEF patients formed the study population. All of them underwent a comprehensive echocardiographic evaluation. LA maximal volume was indexed to body surface area (LAVi); LA function was assessed using strain analysis during the reservoir phase: peak atrial longitudinal strain (PALS) analysis. Study primary endpoint was overall mortality or hospitalization for worsening heart failure. Four groups of patients were included in this study according to LAVi (≤34 or >34 mL/m²) and PALS (≤23% or >23%); 61 (10%) patients had normal LA volume and function (Group 1), 58 (9%) had LA dilatation but normal function (Group 2), 100 (16%) had normal volume but abnormal function (Group 3), and 407 (65%) had enlarged left atrium and abnormal function (Group 4). PALS was associated with primary endpoint in patients with both normal‐size [Groups 1 and 3: hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.88–0.96; P = 0.0006] and dilated left atria (Groups 2 and 4: HR 0.93, 95% CI 0.91–0.96; P < 0.0001). In contrast, LAVi was associated with the primary endpoint in patients with abnormal LA function (Groups 3 and 4: HR 1.018, 95% CI 1.011–1.024; P < 0.00001) but not in those with normal PALS (Groups 1 and 2: HR 1.023, 95% CI 0.99–1.057; P = 0.1).

Conclusions

Left atrial dilatation and dysfunction frequently but not invariably coexist. PALS emerged as a significant prognostic parameter in HFrEF even in the absence of LA dilation.

The Central Role of Left Atrium in Heart Failure

In past cardiovascular medicine, the attention to the left ventricle-identified as the only indicator and determinant of healthy or unhealthy cardiac conditions- has systematically hidden the role of the left atrium (LA). The recent advances in cardiovascular imaging have provided a better understanding of LA anatomy, physiology, and pathology, making us realize that this functional structure is far from being an innocent spectator. We now know that the LA's mechanical and neuro-hormonal properties play a relevant part in several cardiovascular diseases, including atrial fibrillation, ischemic heart disease, valvular heart disease, and heart failure. The present review aims to describe the role of LA in the specific setting of heart failure. We provide currently available information on LA structure and function and summarize its role as a determinant of symptoms, prognosis, and potential therapeutic target in heart failure patients.

Determinants of exercise intolerance symptoms considered non-specific for heart failure in patients with stage A and B: role of the left atrium in the transition phase to overt heart failure

To assess to what extent left atrial (LA) structure and function are associated with non-specific heart failure symptoms, so that patients were classified as HF stage A and B. Mechanisms underlying the transition to overt HF in patients with stage A and B HF are unclear. Consecutive outpatients undergoing echocardiography and clinical evaluation and classified as HF stage A and B with preserved left ventricular ejection fraction (LVEF) were included. The association between LA measures [volume (LAVi), peak longitudinal-(PALS), contraction-(PACS) and conduit-strain] and non-specific HF symptoms was assessed using adjusted logistic regression analyses. The incremental value of atrial myopathy in symptoms prediction on top of clinical or echocardiographic confounders was assessed through ROC curves analyses. The cohort comprehended 185 patients (63 ± 16 years, 47% women) of whom 133 (72%) were asymptomatic, and 52 (28%) reported non-specific HF symptoms. After adjustment for clinical and echocardiographic confounders for HF symptoms, LAVi, PALS and PACS were associated with symptoms (p < 0.05). Among echocardiographic variables, only LA parameters were significantly associated with symptoms on top of clinical confounders (for LAVi OR [95% CI] 1.56 [1.21–2.00], p < 0.0001; for PALS 1.45 (1.10–1.91), p = 0.0009; for PACS 2.10 [1.33–3.30], p = 0.002). After adjustment for age, hypertension and COPD or E/E′, LV mass-i and mitral ERO, atrial myopathy added predictive value for symptoms presence compared to the clinical variables or echocardiographic parameters described (AUC increase 0.80 to 0.88, p = 0.004, and 0.79 to 0.84, p = 0.06, respectively). In patients with HF stages A–B and preserved LVEF, measures of LA structure and function were associated with non-specific HF symptoms. A comprehensive LA remodeling evaluation may help clinicians in the appropriate identification of overt HF.

Left atrial remodelling, mid-regional pro-atrial natriuretic peptide, and prognosis across a range of ejection fractions in heart failure

AIMS

Measures of structural and functional remodelling of the left atrium (LA) are emerging as useful biomarkers in heart failure (HF). We hypothesized that LA volume and its contribution to stroke volume (SV) would predict a composite endpoint of HF hospitalization or death in patients with HF.

METHODS AND RESULTS

We recruited 57 controls and 86 patients with HF, including preserved and reduced left ventricular ejection fraction (LVEF). Cardiac magnetic resonance imaging was used to evaluate LA volumes and contribution to LV SV. Plasma mid-region pro-atrial natriuretic peptide (MR-proANP) was evaluated. LA volume was negatively correlated with LVEF (P = 0.001) and positively correlated with LV mass in HFrEF (P < 0.001) but not in HFpEF. LA volume at end-diastole was associated with the composite endpoint in HFrEF (hazard ratio 1.26, 95% confidence interval 1.01-1.54; P = 0.044), but not HFpEF (1.06, 0.85-1.30; P = 0.612), per 10 mL/m increase. Active contribution to SV was negatively associated with the composite endpoint in HFpEF (0.32, 0.14-0.66; P = 0.001), but not HFrEF (0.91, 0.38-2.1; P = 0.828) per 10% increase. MR-proANP was associated with the composite endpoint in HFpEF (1.46, 1.03-1.94; P = 0.034), but not in HFrEF (1.14, 0.88-1.37; P = 0.278), per 100 pM increase.

CONCLUSION

We found different relationships between LA remodelling and biomarkers in HFrEF and HFpEF. Our results support the hypothesis that the pathophysiologic underpinnings of HFpEF and HFrEF are different, and atrial remodelling encompasses distinct components for each HF subtype.

Prognostic Value of Minimal Left Atrial Volume in Heart Failure With Preserved Ejection Fraction

Background

Maximal left atrial (LA) volume is reported by most echocardiography laboratories and is associated with clinical outcomes in patients with heart failure (HF). Recent studies suggest that minimal LA volume may better reflect left ventricular filling pressure and may be more prognostic than maximal LA volume. This study assessed the prognostic value of indexed minimal LA volume (LAVImin) in patients with HF with preserved ejection fraction.

Methods and Results

We assessed the relationship of LAVImin with a primary composite end point of cardiovascular death, aborted cardiac death, or HF hospitalization in 347 patients with HF with preserved ejection fraction enrolled from the Americas region in TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial). We compared LAVImin with indexed maximal LA volume with respect to their prognostic values. In addition, we assessed if LA functional parameters provide additional prognostic information over LAVImin. During a median follow‐up of 2.5 years, 107 patients (31%) experienced a primary composite end point. LAVImin was associated with increased risk of a primary composite outcome (hazard ratio [HR], 1.35; 95% CI, 1.12–1.61) and HF hospitalization alone (HR, 1.42; 95% CI, 1.17–1.71) after adjusting for clinical confounders and ejection fraction. In contrast, indexed maximal LA volume was not related to the primary composite outcome, but related to HF alone (HR, 1.25; 95% CI, 1.02–1.54). In comparison with indexed maximal LA volume, LAVImin was significantly more prognostic for primary composite outcome (P for comparison=0.032). Both LA emptying fraction and LA strain were prognostic of primary outcome independent of LAVImin (all P<0.05).

Conclusions

In patients with HF with preserved ejection fraction, LAVImin was more predictive of cardiovascular outcome than indexed maximal LA volume, suggesting this measure may be more physiologically relevant and might better identify patients at high risk for cardiovascular events. LA functional parameters provide prognostic information independent of LAVImin.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00094302.

Hemodynamic changes during transcatheter atrial septal defect closure predict midterm heart failure deterioration in adults

OBJECTIVES

To investigate whether hemodynamic changes during balloon occlusion test (BOT) predict future heart failure (HF) deterioration after transcatheter atrial septal defect closure (tASD-closure).

BACKGROUND

Midterm HF deterioration can sometimes occur after tASD-closure in adults. Whether hemodynamic changes during tASD-closure can help identify patients at risk is unknown.

METHODS

This prospective observational study enrolled 86 consecutive adult patients who underwent tASD-closure. Hemodynamic parameters, including pulmonary capillary wedge pressure (PCWP), were measured at baseline, during BOT, and after tASD-closure. The changes in PCWP during BOT and after tASD-closure were defined as ΔPCWP (Occ-Pre) and ΔPCWP (Post-Pre), respectively. Clinical parameters were evaluated before tASD-closure and during the 3-month follow-up. We assessed the occurrence of HF deterioration (HF requiring hospitalization or additional diuretics) during a 2-year follow-up period and categorized patients into HF (+) and HF (-) groups accordingly. The aforementioned parameters were compared between groups.

RESULTS

Midterm HF deterioration occurred in 12 patients (13.9%). Compared to the HF (-) group, the HF (+) group presented a significantly higher ΔPCWP (Occ-Pre) (9.5 ± 4.4 mmHg vs. 3.0 ± 3.3 mmHg; p < 0.001) and ΔPCWP (Post-Pre) (4.0 ± 2.8 mmHg vs. 0.6 ± 1.8 mmHg; p = 0.004). Receiver operating characteristic curve analysis showed that the ΔPCWP (Occ-Pre) cutoff value of 5.5 mmHg had excellent ability to predict HF deterioration (Area under the curve 0.886 [0.779-0.993], p < 0.001; sensitivity 0.917, specificity 0.824).

CONCLUSIONS

Increases in PCWP during BOT predict midterm HF deterioration after tASD-closure. Close surveillance may be needed in patients with a ΔPCWP (Occ-Pre) >5 mmHg.

Left Atrial Myopathy in Atrial Fibrillation and Heart Failure: Clinical Implications, Mechanisms, and Therapeutic Targets

PURPOSE OF REVIEW

This review discusses the mechanisms, clinical implications, and treatments of left atrial (LA) myopathy in comorbid atrial fibrillation (AF) and heart failure (HF) across the spectrum of ejection fraction.

RECENT FINDINGS

AF and HF are highly comorbid conditions. Left atrial (LA) myopathy, characterized by impairments in LA structure, function, or electrical conduction, plays a fundamental role in the development of both AF and HF with preserved ejection fraction (AF-HFpEF) along with AF and HF with reduced ejection fraction (AF-HFrEF). While the nature of LA myopathy in AF-HFpEF is unique from that of AF-HFrEF, LA myopathy also leads to progression of both of these conditions. There may be a vulnerable cohort of AF-HF patients who have a disproportionate degree of LA myopathy compared with left ventricular (LV) dysfunction. Further investigations are required to identify therapies to improve LA function in this cohort.

Angiotensin II and angiotensin 1-7: which is their role in atrial fibrillation?

Atrial fibrillation (AF) is a significant cause of morbidity and mortality as well as a public health burden considering the high costs of AF-related hospitalizations. Pre-clinical and clinical evidence showed a potential role of the renin angiotensin system (RAS) in the etiopathogenesis of AF. Among RAS mediators, angiotensin II (AII) and angiotensin 1-7 (A1-7) have been mostly investigated in AF. Specifically, the stimulation of the pathway mediated by AII or the inhibition of the pathway mediated by A1-7 may participate in inducing and sustaining AF. In this review, we summarize the evidence showing that both RAS pathways may balance the onset of AF through different biological mechanisms involving inflammation, epicardial adipose tissue (EAT) accumulation, and electrical cardiac remodeling. EAT is a predictor for AF as it may induce its onset through direct (infiltration of epicardial adipocytes into the underlying atrial myocardium) and indirect (release of inflammatory adipokines, the stimulation of oxidative stress, macrophage phenotype switching, and AF triggers) mechanisms. Classic RAS blockers such as angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) may prevent AF by affecting the accumulation of the EAT, representing a useful therapeutic strategy for preventing AF especially in patients with heart failure and known left ventricular dysfunction. Further studies are necessary to prove this benefit in patients with other cardiovascular diseases. Finally, the possibility of using the A1-7 or ACE2 analogues, to enlarge current therapeutic options for AF, may represent an important field of research.

Left Atrial Remodeling Mechanisms Associated with Atrial Fibrillation

Heart disease has always been one of the important diseases that endanger health and cause death. Therefore, it is particularly important to understand left atrium reconstruction and atrial fibrillation before heart image processing. The purpose of this paper is to provide an important review of the mechanisms of left atrial remodeling (LAR) associated with atrial fibrillation (AF). LAR refers to the spectrum of pathophysiological changes in (i) atrial structure and physiological function, and (ii) electric, ionic, and molecular milieu of the LA, in response to stresses imposed by conditions such as hypertension, myocardial ischemia, autonomic denervation and congestive heart failure. The main mechanisms of LAR include electrical remodeling, structural remodeling, metabolic remodeling, autonomic remodeling, neurohormones and inflammation, and other influencing factors. LAR is not only the basic mechanism of AF and heart failure, but also the pathophysiological basis of its progression. In clinical practice, AF is the most common persistent arrhythmia, and is believed to be the result of a combination of mechanisms that have triggers and maintenance mechanisms, including spontaneous ectopic pacing and multiple wavelet reentry. While LA electrophysiological, structural, and ultra-structural changes trigger AF, in turn, AF alters the LA electrical and structural properties that promote its maintenance and recurrence. Chronic AF leads to extensive changes in atrial cellular substructures, including loss of myofibrils, accumulation of glycogen, changes in mitochondrial shape and size, fragmentation of sarcoplasmic reticulum, and dispersion of nuclear chromatin. Electrical remodeling and structural remodeling of the atria during AF, involving structural changes and functional impairment of the left atrium, can lead to serious decline in left ventricular function and severe heart failure. Therefore, LAR and AF are inter-activating phenomena, and the resulting complications can cause serious disabling and fatal events. In this paper, we present (i) the mechanisms of LAR, in the form of structural, electrical, metabolic, and neurohormonal changes, and (ii) their interactive roles in initiating and maintaining AF. These in-depth understanding of the atrial remodeling mechanisms can in turn provide useful insights into the treatment of AF and heart failure.

Left atrial function and maximal exercise capacity in heart failure with preserved and mid-range ejection fraction

Aims

Exercise intolerance is the leading manifestation of heart failure with preserved or mid‐range ejection fraction (HFpEF or HFmrEF), and left atrial (LA) function might contribute to modulating left ventricular filling and pulmonary venous pressures. We aim to assess the association between LA function and maximal exercise capacity in patients with HFpEF or HFmrEF.

Methods and results

Sixty‐five patients, prospectively enrolled in the German HFpEF Registry, were analysed. Inclusion criteria were New York Heart Association functional class ≥ II, left ventricular ejection fraction > 40%, structural heart disease or diastolic dysfunction, and elevated levels of N terminal pro brain natriuretic peptide (NT‐proBNP). LA function was evaluated through speckle‐tracking echocardiography by central reading in the Charité Academic Echocardiography core lab. All patients underwent maximal cardiopulmonary exercise test and were classified according to a peak VO₂ cut‐off of prognostic value (14 mL/kg/min). NT‐pro‐BNP was measured. Twenty‐nine patients (45%) reached a peak VO₂ < 14 mL/kg/min (mean value 12.4 ± 1.5) and 36 patients (55%) peak VO₂ ≥ 14 mL/kg/min (mean value 19.4 ± 3.9). There was no significant difference in left ventricular ejection fraction (60 ± 9 vs. 59 ± 8%), left ventricular mass (109 ± 23 vs. 112 ± 32 g/m²), LA volume index (45 ± 17 vs. 47 ± 22 mL/m²), or E/e´ (13.1 ± 4.7 vs. 13.0 ± 6.0) between these groups. In contrast, all LA strain measures were impaired in patients with lower peak VO₂ (reservoir strain 14 ± 5 vs. 21 ± 9%, P = 0.002; conduit strain 9 ± 2 vs. 13 ± 4%, P = 0.001; contractile strain 7 ± 4 vs. 11 ± 6%, P = 0.02; reported lower limits of normality for LA reservoir, conduit and contractile strains: 26.1%, 12.0%, and 7.7%). In linear regression analysis, lower values of LA reservoir strain were associated with impaired peak VO₂ after adjustment for age, sex, body mass index, heart rhythm (sinus/AFib), and log‐NTproBNP [β 0.29, 95% confidence interval (CI) 0.02–0.30, P = 0.02], with an odds ratio 1.22 (95% CI 1.05–1.42, P = 0.01) for peak VO₂ < 14 mL/kg/min for LA reservoir strain decrease after adjustment for these five covariates. Adding left ventricular ejection fraction, it did not influence the results. On the other hand, the addition of LA strain to the adjustment parameters alone described above provided a significant increase of the predictive value for lower peak VO₂ values (R² 0.50 vs. 0.45, P = 0.02). With receiver operating characteristic curve analysis, we identified LA reservoir strain < 22% to have 93% sensitivity and 49% specificity in predicting peak VO₂ < 14 mL/kg/min. Using this cut‐off, LA reservoir strain < 22% was associated with peak VO₂ < 14 mL/kg/min in logistic regression analysis after comprehensive adjustment for age, sex, body mass index, heart rhythm, and log‐NTproBNP [odds ratio 95% CI 10.4 (1.4–74), P = 0.02].

Conclusions

In this HFpEF and HFmrEF cohort, a reduction in LA reservoir strain was a sensible marker of decreased peak exercise capacity. Therefore, LA reservoir strain might be of clinical value in predicting exercise capacity in patients with HFpEF or HFmrEF.

H2FPEF Score Reflects the Left Atrial Strain and Predicts Prognosis in Patients With Heart Failure With Preserved Ejection Fraction

BACKGROUND

The H₂FPEF score is a validated algorithm for the diagnosis of heart failure with preserved ejection fraction (HFpEF). We investigated the associations of the H₂FPEF score with echocardiographic parameters and prognosis in patients with HFpEF admitted for acute heart failure.

METHODS AND RESULTS

In total, 4312 patients at 3 tertiary centers were identified. Among 1335 patients with HFpEF, the H₂FPEF score was available in 1105 patients (39% male) with a median age of 77 years (interquartile range 69-82). The median H₂FPEF score was 4 (interquartile range 3-6). Patients with higher H₂FPEF scores had worse left atrial (LA) size, peak atrial longitudinal strain of the left atrium, mitral E/e' ratio, and peak tricuspid regurgitation velocity. Peak atrial longitudinal strain of the left atrium demonstrated a significant association with the H₂FPEF score, in patients without atrial fibrillation and those without atrial fibrillation. After adjustment for clinical factors and echocardiographic parameters, patients with higher H₂FPEF scores had a higher risk of mortality and hospitalization for heart failure, regardless of the presence of atrial fibrillation.

CONCLUSIONS

The H₂FPEF score reflects left atrial function in patients with HFpEF admitted for acute heart failure. This association supports the clinical usefulness of the H₂FPEF score as an indicator of diastolic dysfunction, a diagnostic algorithm for HFpEF, and a prognostic factor in patients with HFpEF.

Current Understanding of Circulating Biomarkers in Pulmonary Hypertension Due to Left Heart Disease

Pulmonary hypertension due to left heart disease (PH-LHD; Group 2), especially in the setting of heart failure with preserved ejection fraction (HFpEF), is the most frequent cause of PH. Despite its prevalence, no effective therapies for PH-LHD are available at present. This is largely due to the lack of a concise definition for hemodynamic phenotyping, existence of significant gaps in the understanding of the underlying pathology and the impact of associated comorbidities, as well as the absence of specific biomarkers that can aid in the early diagnosis and management of this challenging syndrome. Currently, B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) are guideline-recommended biomarkers for the diagnosis and prognosis of heart failure (HF) and PH. Endothelin-1 (ET-1), vascular endothelial growth factor-D (VEGF-D), and microRNA-206 have also been recently identified as new potential circulating biomarkers for patients with PH-LHD. In this review, we aim to present the current state of knowledge of circulating biomarkers that can be used to guide future research toward diagnosis, refine specific patient phenotype, and develop therapeutic approaches for PH-LHD, with a particular focus on PH-HFpEF. Potential circulating biomarkers identified in pre-clinical models of PH-LHD are also summarized here.