The Added Value of Atrial Strain Assessment in Clinical Practice

Prognostic value of left atrial strain in aortic stenosis: A systematic review

PURPOSE

Aortic stenosis (AS) is a common valvular heart disease with high morbidity and mortality. Recently, the association between peak atrial longitudinal strain (PALS) and AS clinical outcomes has been identified. This systematic review evaluates the prognostic value of PALS for adverse events in AS.

METHODS

We performed a systematic literature review to identify clinical studies that evaluated Speckle-Tracking Echocardiography (STE)-derived PALS to predict adverse outcomes in patients with AS. We excluded studies that compared echocardiography to computed tomography and studies that focused on diseases other than AS.

RESULTS

We included 18 studies reporting on 2660 patients. Patients with symptomatic AS had decreased PALS when compared to patients with asymptomatic AS. Patients with AS who had adverse events had decreased PALS when compared to patients with AS with no events. Each unit increase of PALS was independently associated with decreased risk for the primary endpoint. PALS cut-off values were associated with increased risk for the primary endpoint.

CONCLUSION

This systematic review suggests PALS as an independent predictor for cardiovascular events in patients with AS and highlights the importance of evaluating LA mechanics for AS prognosis.

The Clinical Applications of Left Atrial Strain: A Comprehensive Review

Left atrial (LA) strain imaging, which measures the deformation of the LA using speckle-tracing echocardiography (STE), has emerged recently as an exciting tool to help provide diagnostic and prognostic information for patients with a broad range of cardiovascular (CV) pathologies. Perhaps due to the LA's relatively thin-walled architecture compared with the more muscular structure of the left ventricle (LV), functional changes in the left atrium often precede changes in the LV, making LA strain (LAS) an earlier marker for underlying pathology than many conventional echocardiographic parameters. LAS imaging is typically divided into three phases according to the stage of the cardiac cycle: reservoir strain, which is characterized by LA filling during systole; conduit strain, which describes LA deformation during passive LV filling; and booster strain, which provides information on the LA atrium during LA systole in late ventricular diastole. While additional large-population studies are still needed to further solidify the role of LAS in routine clinical practice, this review will discuss the current evidence of its use in different pathologies and explore the possibilities of its applications in the future.

Moving from left ventricular ejection fraction to deformation imaging in mitral valve regurgitation

The increasing prevalence of valvular heart diseases, specifically mitral regurgitation (MR), underscores the need for a careful and timely approach to intervention. Severe MR, whether primary or secondary, when left untreated leads to adverse outcomes, emphasizing the critical role of a timely surgical or transcatheter intervention. While left ventricular ejection fraction (LVEF) remains the guideline-recommended measure for assessing left ventricle damage, emerging evidence raises concerns regarding its reliability in MR due to its volume-dependent nature. This review summarizes the existing literature on the role of LVEF and deformation imaging techniques, emphasizing the latter's potential in providing a more accurate evaluation of intrinsic myocardial function. Moreover, it advocates the need for an integrated approach that combines traditional with emerging measures, aiming to optimize the management of patients with MR. It attempts to highlight the need for future research to validate the clinical application of deformation imaging techniques through large-scale studies.

Evaluating left atrial function changes by speckle tracking echocardiography in type 2 diabetes patients in Central Vietnam: a cross-sectional comparative study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a metabolic disorder that detrimentally affects multiple systems in the body, with a particular emphasis on the vascular and nervous systems. Despite its significant impact, limited studies have explored the influence of this condition on the left atrial (LA) function. To address this gap, our study utilized speckle tracking echocardiography (STE) to assess LA function in patients with T2DM in Central Vietnam.

RESULTS

The cross-sectional comparative study enrolled 134 subjects involving 66 patients with T2DM and 68 healthy individuals meeting the selection and exclusion criteria of the study. In our study, healthy individuals demonstrated higher values for LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct), measuring 38.75% ± 5.43%, 19.58% ± 5.91%, and 19.16% ± 4.98%, respectively. In contrast, the T2DM group exhibited lower values for LASr, LAScd, and LASct, which measured 31.2% ± 4.56%, 14.77% ± 6.3%, and 16.36% ± 4.82%, respectively (p < 0.05). T2DM patients with normal LA volume index (LAVI) and normal left ventricular mass index (LVMI), LASr, LAScd, and LASct results were 32.07% ± 5.28%, 16.28% ± 6.95%, and 15.64% ± 5.32%. respectively.

CONCLUSIONS

STE of the LA reveals a noteworthy reduction in reservoir, conduit, and contractile functions within the T2DM group when compared to the control group (p < 0.05). Furthermore, these impaired functions persist in T2DM patients even in the absence of increased LAVI and LVMI.

Left Atrial Strain Predicts Cardiovascular and All-Cause Mortality

Background

Left atrial strain can usefully reflect left atrial function. The follow-up periods in previous studies assessing left atrial strain as a survival predictor have been relatively short, and few studies have examined the ability of left atrial strain to predict mortality in patients with borderline diastolic function. This study sought to investigate the survival predictive value of left atrial strain with a longer follow-up duration. In addition, we also evaluated the survival predictive value of left atrial strain in patients with borderline diastolic function.

Methods

In total, 652 participants who received routine echocardiography underwent 2-D speckle tracking echocardiography to evaluate left atrial reservoir function by peak atrial longitudinal strain. The study endpoints were all-cause and cardiovascular mortality.

Results

The mean left atrial strain was 27.6%, and the median follow-up duration was 92 months. During follow-up, 72 patients died of cardiovascular causes and 181 died of all causes. Univariable Cox regression analysis revealed that lower left atrial strain significantly predicted an increase in all-cause and cardiovascular mortality. After adjusting for common clinical and echocardiographic parameters, lower left atrial strain was still associated with a higher risk of all-cause mortality [hazard ratio (HR) = 0.942, p = 0.011] and cardiovascular mortality (HR = 0.915, p = 0.018) in multivariable Cox-regression analysis. In addition, 293 patients had borderline left ventricular diastolic function. Multivariable analysis still revealed that left atrial strain could predict cardiovascular mortality in this population.

Conclusions

Our data showed that left atrial strain could predict all-cause and cardiovascular mortality, even after adjusting for general clinical and echocardiographic parameters.

Impact of enzyme replacement therapy and migalastat on left atrial strain and cardiomyopathy in patients with Fabry disease

Aims

Cardiomyopathy in Fabry disease (FD) is a major determinant of morbidity and mortality. This study investigates the effects of FD-specific treatment using enzyme replacement therapy (ERT) and chaperone therapy on left atrial (LA) function using two-dimensional speckle tracking echocardiography (2DSTE).

Methods and results

In this prospective observational single-center study, 20 FD patients [10 (50%) females] treated with migalastat, 48 FD patients [24 (50%) females] treated with ERT (agalsidase-alfa and agalsidase-beta), and 30 untreated FD patients (all females) as controls were analyzed. The mean follow-up time ranged from 26 to 81 months. 2DSTE was performed for left ventricle strain, right ventricle strain, and LA strain (LAS). FD-specific treated patients presented with increased left ventricular mass index (LVMi) and higher frequency of left ventricular hypertrophy at baseline, whereas untreated control patients showed normal baseline values. FD-specific treated (including migalastat and ERT) patients showed stabilization of LAS over time (p > 0.05). LVMi was also stable in treated FD patients during observation (p > 0.05).

Conclusion

In patients with FD, treated with either ERT or chaperone therapy, LAS values measured by echocardiographic speckle tracking were stable over time, pointing toward disease stabilization.

Atrial Cardiomyopathy in Valvular Heart Disease: From Molecular Biology to Clinical Perspectives

This review discusses the evolving topic of atrial cardiomyopathy concerning valvular heart disease. The pathogenesis of atrial cardiomyopathy involves multiple factors, such as valvular disease leading to atrial structural and functional remodeling due to pressure and volume overload. Atrial enlargement and dysfunction can trigger atrial tachyarrhythmia. The complex interaction between valvular disease and atrial cardiomyopathy creates a vicious cycle of aggravating atrial enlargement, dysfunction, and valvular disease severity. Furthermore, atrial remodeling and arrhythmia can predispose to atrial thrombus formation and stroke. The underlying pathomechanism of atrial myopathy involves molecular, cellular, and subcellular alterations resulting in chronic inflammation, atrial fibrosis, and electrophysiological changes. Atrial dysfunction has emerged as an essential determinant of outcomes in valvular disease and heart failure. Despite its predictive value, the detection of atrial fibrosis and dysfunction is challenging and is not included in the clinical routine. Transthoracic echocardiography and cardiac magnetic resonance imaging are the main diagnostic tools for atrial cardiomyopathy. Recently published data have revealed that both left atrial volumes and functional parameters are independent predictors of cardiovascular events in valvular disease. The integration of atrial function assessment in clinical practice might help in early cardiovascular risk estimation, promoting early therapeutic intervention in valvular disease.

[Left atrium remodeling after catheter ablation of atrial fibrillation]

Atrial fibrillation (AF) is the most common cardiac arrhythmia. It has a high association with cardiovascular embolic events and heart failure. Structural and functional changes are a fundamental part of the pathophysiological process, leading to left atrial myopathy and progressive left ventricular dysfunction that modifies the prognosis of patients. We present the case of a 75-year-old patient with symptomatic paroxysmal AF with good functional class who was referred for pulmonary vein ablation after antiarrhythmic therapy failure. The initial echocardiogram showed preserved biventricular systolic function, mild diastolic dysfunction, and normal left atrium (LA) volumes. However, functional LA impairment was observed with decreased reservoir phase strain. Pulmonary vein isolation was successfully performed without evidence of new arrhythmic events, in addition to improvement in LA reservoir strain, left ventricular (LV) global longitudinal strain, and myocardial work index at three months follow-up. The patient has remained asymptomatic and is under clinical follow-up. LA and LV strain as new advanced echocardiography techniques is useful in the assessment of reverse remodeling of atrial myopathy and LV structural assessment.

Prognostic Value of Left Atrial Strain in Heart Failure: A Systematic Review and Meta-Analysis

Background

Heart failure (HF) is a global health problem with high morbidity and mortality. Recently, the association between peak atrial longitudinal strain (PALS) and clinical outcomes of HF has gained increasing attention. Our aim was to systematically assess the prognostic value of PALS for adverse events in HF.

Methods

PubMed, Embase, and Scopus databases were systematically searched from inception to 30 April 2022. Studies in which PALS was assessed to predict adverse outcomes in adult patients with HF were included. Study selection, quality assessment, and data extraction were performed independently by two authors. The primary endpoints were all-cause death and cardiac hospitalization.

Results

Among 7,787 patients in 17 included studies, 3,029 (38.9%) experienced the primary endpoint. Patients with events had lower PALS than those without events [weighted mean difference (WMD) 6.17, 95% confidence interval (CI) 3.09–9.26, p < 0.001]. Each unit increment of PALS was independently associated with decreased risk for the primary endpoint [hazard ratio (HR) 0.96, 95% CI 0.94–0.98, p < 0.001]. The addition of PALS significantly improved the predictive power of conventional risk models [net reclassification index (NRI) 0.22, 95% CI 0.06–0.39, p = 0.008].

Conclusion

Peak atrial longitudinal strain was an independent predictor for all-cause mortality and cardiac hospitalization in patients with HF, highlighting the clinical importance of left atrial (LA) deformation in the prognosis of HF.

Systematic Review Registration

[www.crd.york.ac.uk/prospero/], identifier [CRD42020185034].