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

Maffeis, Caterina; Morris, Daniel A.; Belyavskiy, Evgeny; Kropf, Martin; Radhakrishnan, Aravind Kumar; Zach, Veronika; Conceicao, Cristina Rozados da; Trippel, Tobias Daniel; Pieske‐Kraigher, Elisabeth; Rossi, Andrea; Pieske, Burkert; Edelmann, Frank

doi:10.1002/ehf2.13143

Cited by 28 publications

(22 citation statements)

References 54 publications

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“…All patients were stable and fully recompensated before inclusion into this study. One hundred thirty-one consecutive patients with a diagnosis of HF with preserved ejection fraction (HFpEF) or mid-range ejection fraction (HFmrEF) were evaluated at the Charité University Hospital, Berlin, Germany, and prospectively enrolled in the German HFpEF Registry (data previously published 7 ); 116 consecutive patients with HF evaluated at the Cardiac Rehabilitation Centre, Veruno, Italy, in the same time frame were retrospectively enrolled.…”

Section: Methodsmentioning

confidence: 99%

“…Inclusion criteria of the German HFpEF Registry have been previously published. 7 Inclusion criteria for patients included at the Veruno Centre were (i) known LV systolic dysfunction (LVEF ≤ 50%); (ii) age ≥ 18 years; and (iii) New York Heart Association (NYHA) functional class ≥ II. For both populations, patients were ineligible in the presence of acute coronary syndrome or cardiac surgery/percutaneous intervention during the past 3 months, haemodynamic relevant pericardial disease, significant mitral annular calcification, congenital heart disease, previous cardiac transplantation, restrictive cardiomyopathy, severe chronic obstructive pulmonary disease, severe kidney disease, or severe liver disease.…”

Section: Methodsmentioning

confidence: 99%

“…However, LA function has been found to be closely related to functional capacity in patients with HF both with reduced and preserved EF. [4][5][6][7] In the present study, we analysed the influence of LA function on exercise capacity, as recognized marker of prognosis in chronic HF, in a cohort of HF patients with a broad spectrum of EF. Indeed, LA function plays a role in exercise capacity through its influence on LV filling, because it buffers flow and pressure fluctuations during the cardiac cycle, so that on the one hand it affects LV output and on the other hand it influences pressures in the pulmonary circulation.…”

Section: Introductionmentioning

confidence: 99%

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Left atrial strain predicts exercise capacity in heart failure independently of left ventricular ejection fraction

et al. 2022

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AimsWe hypothesized that left atrial (LA) remodelling and function are associated with poor exercise capacity as prognostic marker in chronic heart failure (CHF) across a broad range of left ventricular ejection fraction (LVEF). Methods and resultsOne hundred seventy-one patients with CHF were analysed [age 65 ± 11 years, 136 males (80%); 86 heart failure with reduced ejection fraction (HFrEF), 27 heart failure with mid-range ejection fraction (HFmrEF), 58 heart failure with preserved ejection fraction (HFpEF)]. All patients underwent echocardiography and maximal cardiopulmonary exercise testing and were classified according to a prognostic cut-off of peak VO 2 (pVO 2 ; 14 mL/kg/min). Seventy-seven (45%) patients reached pVO 2 < 14 and 94 (55%) pVO 2 ≥ 14 mL/kg/min. Between the two groups, there was a considerable difference in both left atrial volume (LAVi, 53 ± 24 vs. 44 ± 18 mL/m 2 , P = 0.005) and function (LA reservoir strain 12 ± 5 vs. 20 ± 10%, P < 0.0001). Receiver-operating characteristic curves identified LA reservoir strain (area under the curve: 0.73 [0.65-0.80], P < 0.0001) as strong predictor for impaired pVO 2 among all echocardiographic variables; LA reservoir strain < 23% had 37% specificity but a very high sensitivity (96%) in identifying a severely reduced pVO 2 . In logistic regression analysis, LA reservoir strain < 23% was associated with a highly increased risk of pVO 2 < 14 mL/kg/min (odds ratio 16.0 [4.7-54.6]; P < 0.0001). The multivariate analysis showed that a reduced LA reservoir strain was associated with pVO 2 < 14 mL/kg/min after adjustment for age, body mass index (BMI), and clinical variables, that is, New York Heart Association class, atrial fibrillation, haemoglobin, and creatinine (b 0.22 [95% confidence interval, CI, 0.12-0.31]; P < 0.0001), and after adjustment for echocardiographic variables, that is, LVEF or left ventricular global longitudinal strain (LVGLS) and tricuspid annular plane systolic excursion (TAPSE) (b 0.16 [95% CI 0.08-0.24]; P < 0.0001). Patients with HFrEF, HFmrEF, and HFpEF were separately analysed. Among LA reservoir strain, LAVi, LVEF, LVGLS, and TAPSE, LA reservoir strain was the only one significantly associated with pVO 2 in all subgroups (after adjustment for sex and BMI, P = 0.003, 0.04, and 0.01, respectively). Conclusions In patients with CHF, an impaired LA reservoir function is independently associated with a severely reduced pVO 2 . LA dysfunction represents a marker of poor prognosis across LVEF borders in the CHF population.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Left atrial strain predicts exercise capacity in heart failure independently of left ventricular ejection fraction

et al. 2022

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“…108 However, exercise intolerance is also a classical feature of HFpEF and has been shown to be closely associated with LA function in HFpEF patients without AF. 109,110 Furthermore, in a large cohort of patients with AF, cardiopulmonary exercise testing showed that diastolic function rather than cardiac rhythm predicted maximal VO 2 . 111 These studies suggest that LA myopathy and HFpEF play critical roles in the development of exercise intolerance in patients with AF.…”

Section: Exercise Intolerancementioning

confidence: 99%

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

et al. 2021

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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.

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“…There is increasing evidence that LA dysfunction contributes to cardiorespiratory symptoms and exercise capacity [22,23]. A strong association between reduced LALSr and impaired exercise capacity was observed in patients with HF with preserved or mid-range ejection fraction [24]. Impaired LALSr and LALSct have also been linked to abnormal exercise dynamics and elevated pulmonary pressure in these patients [11,25].…”

Section: Mechanism For La Function and Exercise Capacitymentioning

confidence: 99%

Left Atrial Reservoir Longitudinal Strain is a Resting Marker of Exercise Capacity in Chronic Heart Failure: A Cross-sectional Study

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et al. 2021

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Background: Left atrial (LA) function is an important parameter for assessing left ventricular performance. This study investigated the relationship between LA function as determined by strain analysis and exercise capacity in patients with chronic heart failure (CHF). Methods: A total of 51 patients with CHF were prospectively recruited from the Baduanjin-eight-silken-movement With Self-efficacy Building for Patients With Chronic Heart Failure study. Resting echocardiographic parameters including the ratio of transmitral E velocity to tissue Doppler mitral annulus e′ velocity (E/e′), minimum left atrial volume index (LAVI min ), maximum left atrial volume index (LAVI max ), and left atrial empty fraction (LAEF) as well as global phasic longitudinal strain (reservoir strain [LALSr], conduit strain [LALScd], and contractile strain [LALSct]) were measured and compared with maximum oxygen uptake (VO 2max ) in terms of performance in predicting reduced exercise capacity. Results: Mean age of study patients was 60.18 ± 10.41 years, mean left ventricular ejection fraction was 32.8 ± 14.2%, and mean VO 2max was 17.02 ± 4.64 mL/kg/min. Eleven (21.57%) patients were women, and 32 (62.75%) had coranary heart disease. Univariate linear regression analysis identified age and N-terminal prohormone of brain natriuretic peptide level as independent clinical parameters associated with VO 2max (both P<0.05); independent resting echocardiographic parameters included LALSRr (P<0.001); average late diastolic velocity of septal and lateral wall annulus, LAVI max , LAVI min , LALSRr, LALSRct, and LAEF (all P<0.01); and E and E/e′ (both P<0.05). The multivariate linear regression analysis revealed 4 independent clinical predictors of VO 2max including (β = 0.351; P = 0.007), age (β = -0.271; P = 0.027), body mass index (β = -0.260; P = 0.032) and N-terminal prohormone of brain natriuretic peptide (β = -0.257; P = 0.041). Conclusions: LALSr is a marker of decreased LA compliance and an independent correlate of VO 2max with high diagnostic value in patients with CHF. Thus, LALSr can be used for risk stratification of CHF patients with reduced exercise capacity and poor cardiovascular outcome. Trial registration: NCT03180320 (ClinicalTrials.gov). Registered 8 June 2017, https://clinicaltrials.gov/ct2/show/NCT03180320?term=Baduanjin-eight-silken-movement&draw=2&rank=1.

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

Cited by 28 publications

References 54 publications

Left atrial strain predicts exercise capacity in heart failure independently of left ventricular ejection fraction

Left atrial strain predicts exercise capacity in heart failure independently of left ventricular ejection fraction

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

Left Atrial Reservoir Longitudinal Strain is a Resting Marker of Exercise Capacity in Chronic Heart Failure: A Cross-sectional Study

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