Left Atrial Work in Patients with Stable Chronic Heart Failure: Factors Associated and Prognostic Role

Mazzone, Carmine; Cioffi, Giovanni; Faganello, Giorgio; Cherubini, Antonella; Tarantini, Luigi; Lenarda, Andrea Di; Russo, T.; Selmi, Alessandro; Stefenelli, Carlo; Furlanello, F

doi:10.1111/echo.12325

Cited by 19 publications

(10 citation statements)

References 30 publications

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“…LAKE is five times higher in patients with chronic HF (CHF) than in healthy controls. It depends on LV performance and renal function, and it is a strong predictor of cardiovascular events and hospitalisation for HF . Independently of HF aetiology, diastolic dysfunction is the strongest stimulus to increase LA size and work.…”

Section: Integrated Imaging Evaluationmentioning

confidence: 99%

The importance of integrated left atrial evaluation: From hypertension to heart failure with preserved ejection fraction

et al. 2017

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SummaryAim: Functional analysis and measurement of left atrium are an integral part of cardiac evaluation, and they represent a key element during non-invasive analysis of diastolic function in patients with hypertension (HT) and/or heart failure with preserved ejection fraction (HFpEF). However, diastolic dysfunction remains quite elusive regarding classification, and atrial size and function are two key factors for left ventricular (LV) filling evaluation. Chronic left atrial (LA) remodelling is the final step of chronic intracavitary pressure overload, and it accompanies increased neurohormonal, proarrhythmic and prothrombotic activities. In this systematic review, we aim to purpose a multi-modality approach for LA geometry and function analysis, which integrates diastolic flow with LA characteristics and remodelling through application of both traditional and new diagnostic tools. Methods:The most important studies published in the literature on LA size, function and diastolic dysfunction in patients with HFpEF, HT and/or atrial fibrillation (AF) are considered and discussed. Results:In HFpEF and HT, pulsed and tissue Doppler assessments are useful tools to estimate LV filling pressure, atrio-ventricular coupling and LV relaxation but they need to be enriched with LA evaluation in terms of morphology and function. An integrated evaluation should be also applied to patients with a high arrhythmic risk, in whom eccentric LA remodelling and higher LA stiffness are associated with a greater AF risk. Conclusion:Evaluation of LA size, volume, function and structure are mandatory in the management of patients with HT, HFpEF and AF. A multi-modality approach could provide additional information, identifying subjects with more severe LA remodelling.Left atrium assessment deserves an accurate study inside the cardiac imaging approach and optimised measurement with established cut-offs need to be better recognised through multicenter studies.

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Section: Integrated Imaging Evaluationmentioning

confidence: 99%

The importance of integrated left atrial evaluation: From hypertension to heart failure with preserved ejection fraction

et al. 2017

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“…The sheer number of measures of LA function (.20) generates confusion and hinders comparability of published studies. The reproducibility of these measures may also be an issue that threatens the robustness of these B (Asymptomatic structural heart disease) † LA peak reservoir strain measured within 48 h of admission for acute myocardial infarction is associated with the composite outcome of death and HF 13 † LA function independently predicts HF hospitalization among patients with coronary artery disease and preserved LVEF 14 † LA pump function is the strongest predictor of major adverse cardiac events and all-cause mortality in patients with chronic hypertension 15 † LAEF is associated with risk of new-onset AF independent of clinical risk factors, LV systolic/diastolic function, and LA volume in elderly persons referred for echocardiography 16 † LA ejection force is associated with risk of cardiovascular events independent of age, risk factors, LV geometry, and LV diastolic function in a population with pre-clinical risk factors such as hypertension and diabetes 17 † LA strain occurs in hypertensive and diabetic patients even prior to development of overt LA dilatation 18 C (Symptomatic HF) HFpEF † LA kinetic energy predicts cardiovascular death and HF hospitalization in chronic HF regardless of EF, and has an incremental prognostic value over LA size 19 † Blunted increase in mitral annular A' velocity during exercise distinguishes HFpEF from asymptomatic hypertensive patients 20 † LAEF at rest and blunted LA systolic reserve with isometric handgrip distinguish HFpEF from asymptomatic hypertensive LV hypertrophy 21 † LA dysfunction relates to symptom onset in HFpEF 22 and occurs even in the absence of overt LA enlargement 23 † LA strain is independently associated with exercise capacity in HFpEF 24 † LA pump function is an independent correlate of HF symptoms in hypertrophic cardiomyopathy 5 …”

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confidence: 99%

Function over form? Assessing the left atrium in heart failure

Shah

Lam

2014

European Heart Journal

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This editorial refers to 'Left atrial function measured by cardiac magnetic resonance imaging in patients with heart failure: clinical associations and prognostic value' † , by P. Pellicori et al., on page 733.The understanding of heart failure (HF) haemodynamics has traditionally focused on left ventricular (LV) structure and function, with the left atrium being viewed simply as a passive transport chamber that empties into the left ventricle. Over the last decade, there has been increasing recognition of the importance of left atrial (LA) structure and function in the pathophysiology of HF. LA volume was first to be established as a biomarker integrating the magnitude and duration of LV diastolic function, and a predictor of cardiovascular outcomes in HF. More recently, LA function has emerged as a novel determinant of clinical status and outcomes in HF, and perhaps an even more robust prognostic marker than LA volume ( Table 1). Pellicori et al. have now explored the prognostic relevance of one summary measure of LA function-LA emptying fraction (LAEF)-by magnetic resonance imaging (MRI) in HF.1 In this single-centre study of 759 patients with suspected HF and in sinus rhythm undergoing cardiac MRI, LAEF was lower on average among 664 patients with the confirmed diagnosis of HF. Lower LAEF correlated with larger LA maximal and conduit volumes, smaller LA reservoir volume, lower LV and right ventricular (RV) ejection fraction, greater LV and RV remodelling, and higher circulating N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. Over a median follow-up of 3-4 years, LAEF, but not LA volume, was independently associated with incident HF hospitalization, cardiovascular mortality, all-cause mortality, and atrial fibrillation in multivariable models that included clinical predictors and NT-proBNP level. Importantly, LAEF provided incremental value in predicting these outcomes, beyond clinical variables alone but not in addition to NT-proBNP levels. The left atrium modulates LV filling and cardiovascular performance by three distinct functions: (i) as a reservoir for pulmonary venous return during LV systole; (ii) as a conduit for passive flow of blood from the pulmonary veins into the ventricle during early LV diastole and diastasis, and (iii) as a pump during late LV diastole that augments LV stroke volume (by 15-30% in healthy individuals and more in the presence of abnormal LV relaxation) (Figure 1). LA reservoir function is influenced by LA compliance as well as LV contraction via descent of the LV base during systole, and RV systolic pressure transmitted via the pulmonary circulation. LA conduit function is inversely related to reservoir function and strongly modulated by LV relaxation and compliance. LA pump function reflects LA contractility and is also dependent on both LA preload (venous return) and LA afterload (LV end-diastolic pressure). Of note, the Frank -Starling mechanism applies to LA mechanics (as with LV mechanics), wherein LA ejection volume increases as LA filling volume increases, ...

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“…Previous studies on patients with mild-to-moderate heart failure symptoms have shown that higher LA contractile or ejection force and greater kinetic energy may exist in these patients compared with healthy people ( 17 , 30 ), possibly as compensation for maintaining resting cardiac output ( 31 , 32 ). Our study showed that greater fat depots surrounding LA, especially interatrial fat, was accompanied by decreased reservoir function though augmented LA kinetic energy and ejection force.…”

Section: Discussionmentioning

confidence: 98%

Excessive interatrial adiposity is associated with left atrial remodeling, augmented contractile performance in asymptomatic population

Lai

Yun

et al. 2016

Echo Res Pract

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PurposePericardial adipose tissue had been shown to exert local effects on adjacent cardiac structures. Data regarding the mechanistic link between such measures and left atrial (LA) structural/functional remodeling, a clinical hallmark of early stage heart failure (HF) and atrial fibrillation (AF) incidence, in asymptomatic population remain largely unexplored.MethodsThis retrospective analysis includes 356 subjects free from significant valvular disorders, atrial fibrillation, or clinical HF. Regional adipose tissue including pericardial and periaortic fat volumes, interatrial septal (IAS), and left atrioventricular groove (AVG) fat thickness were all measured by multidetector computed tomography (MDCT) (Aquarius 3D Workstation, TeraRecon, San Mateo, CA, USA). We measured LA volumes, booster performance, reservoir capacity as well as conduit function, and analyzed their association with adiposity measures.ResultsAll four adiposity measures were positively associated with greater LA volumes (all P < 0.05), while IAS and AVG fat were also related to larger LA kinetic energy and worse reservoir capacity (both P < 0.01). In multivariate models, IAS fat thickness remained independently associated with larger LA volumes, increased LA kinetic energy and ejection force (β-coef: 0.17 & 0.15, both P < 0.05), and impaired LA reservoir and conduit function (β-coef: −0.20 & −0.12, both P < 0.05) after adjusting for clinical variables.ConclusionAccumulated visceral adiposity, especially interatrial fat depots, was associated with certain LA structural/functional remodeling characterized by impaired LA reservoir and conduit function though augmented kinetic energy and ejection performance. Our data suggested that interatrial fat burden may be associated with certain detrimental LA functions with compensatory LA adaptation in an asymptomatic population.

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Left Atrial Work in Patients with Stable Chronic Heart Failure: Factors Associated and Prognostic Role

Cited by 19 publications

References 30 publications

The importance of integrated left atrial evaluation: From hypertension to heart failure with preserved ejection fraction

The importance of integrated left atrial evaluation: From hypertension to heart failure with preserved ejection fraction

Function over form? Assessing the left atrium in heart failure

Excessive interatrial adiposity is associated with left atrial remodeling, augmented contractile performance in asymptomatic population

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