Objectives This study sought to observe the relationship between left atrial (LA) strain and left ventricular diastolic function and determine whether LA strain could be used to detect diastolic dysfunction (DD) and classify its degree when present. Background The assessment of diastolic function is complex and multiparametric because most conventional parameters do not follow the progression of DD. Strain imaging is an emerging index of LA function, with recent data demonstrating that LA strain is diminished in diastolic heart failure. However, LA strain is not part of the standard assessment of diastolic function. We hypothesized that LA strain decreases with worsening DD in a stepwise fashion and could thus be useful in evaluating DD. Methods We performed a retrospective derivation and validation cohort study to derive and test LA strain thresholds for DD grades (0 to 3) in patients with preserved left ventricular ejection fraction (N = 229). Two-dimensional speckle tracking was used to measure peak LA strain, which was applied as a single parameter to classify DD. American Society of Echocardiography guidelines were used as the reference standard. Results In the derivation cohort (n = 90), peak LA strain was significantly different between DD groups, with gradual decreases seen with worsening DD. Receiver-operating characteristic analysis resulted in 3 distinct LA strain thresholds for categorization of DD grades, with good to excellent diagnostic utility (area under the curve: 0.86 to 0.91). In an independent validation group (n = 139) with a spectrum of diastolic function, 11 patients (8%) had indeterminate DD grades using standard criteria, whereas LA strain was measured in all patients and its cutoffs resulted in diagnostic accuracy up to 95%. Conclusions LA strain measurements are feasible and allow accurate categorization of DD, because unlike the traditional parameters, it changes progressively with severity of DD. LA strain may become a useful tool for diastolic assessment in future clinical practice.

Background Recent American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines for echocardiographic evaluation of left ventricular (LV) diastolic function provide a practical, simplified diagnostic algorithm for estimating LV filling pressure. The aim of this study was to test the accuracy of this algorithm against invasively measured pressures and compare it with the accuracy of the previous 2009 guidelines in the same patient cohort. Methods Ninety patients underwent transthoracic echocardiography immediately before left heart catheterization. Mitral inflow E/A ratio, E/e′, tricuspid regurgitation velocity, and left atrial volume index were used to estimate LV filling pressure as normal or elevated using the ASE/EACVI algorithm. Invasive LV pre-A pressure was used as a reference, with >12 mm Hg defined as elevated. Results Invasive LV pre-A pressure was elevated in 40 (44%) and normal in 50 (56%) patients. The 2016 algorithm resulted in classification of 9 of 90 patients (10%) as indeterminate but estimated LV filling pressures in agreement with the invasive reference in 61 of 81 patients (75%), with sensitivity of 0.69 and specificity of 0.81. The 2009 algorithm could not definitively classify 4 of 90 patients (4.4%), but estimated LV filling pressures in agreement with the invasive reference in 64 of 86 patients (74%), with sensitivity of 0.79 and specificity of 0.70. Conclusions The 2016 ASE/EACVI guidelines for estimation of filling pressures are more user friendly and efficient than the 2009 guidelines and provide accurate estimates of LV filling pressure in the majority of patients when compared with invasive measurements. The simplicity of the new algorithm did not compromise its accuracy and is likely to encourage its incorporation into clinical decision making.

Hepatic hydrothorax (HH) is an example of a porous diaphragm syndrome. Portal hypertension results in the formation of ascitic fluid which moves across defects in the diaphragm and accumulates in the pleural space. Consequently, the treatment approach to HH consists of measures to reduce the formation of ascitic fluid, prevent the movement of ascitic fluid across the diaphragm, and drain or obliterate the pleural space. Approximately 21-26% of cases of HH are refractory to salt and fluid restriction and diuretics and warrant consideration of additional treatment measures. Ideally, liver transplantation is the best treatment option; however, most of the patients are not candidates and most of those who are eligible die while waiting for a transplant. Treatment measures other than liver transplantation may not only provide relief from dyspnea but also improve patient survival and serve as a bridge to liver transplantation.

Echocardiographic assessment of left ventricular (LV) filling pressures is performed using a multi-parametric algorithm. Left atrial (LA) strain was recently found to accurately classify the degree of diastolic dysfunction. We hypothesized that LA strain could be used as a stand-alone marker and sought to identify and test a cutoff, which would accurately detect elevated LV pressures. We studied 76 patients with a spectrum of LV function who underwent same-day echocardiogram and invasive left-heart catheterization. Speckle tracking was used to measure peak LA strain. The protocol involved a retrospective derivation group (N = 26) and an independent prospective validation cohort (N = 50) to derive and then test a peak LA strain cutoff which would identify pre-A-wave LV diastolic pressure > 15 mmHg. The guidelines-based assessment of filling pressures and peak LA strain were compared side-by-side against invasive hemodynamic data. In the derivation cohort, receiver-operating characteristic analysis showed area under curve of 0.76 and a peak LA strain cutoff < 20% was identified as optimal to detect elevated filling pressure. In the validation cohort, peak LA strain demonstrated better agreement with the invasive reference (81%) than the guidelines algorithm (72%). The improvement in classification using LA strain compared to the guidelines was more pronounced in subjects with normal LV function (91% versus 81%). In summary, the use of a peak LA strain to estimate elevated LV filling pressures is more accurate than the current guidelines. Incorporation of LA strain into the non-invasive assessment of LV diastolic function may improve the detection of elevated filling pressures.