Peak left atrial strain as a single measure for the non-invasive assessment of left ventricular filling pressures

Abstract

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.

Left atrial reservoir strain combined with E/E' as a better single measure to predict elevated LV filling pressures in patients with coronary artery disease

“…However, the role of LA strain when assessing filling pressures in patients with reduced LVEF is still controversial. Melenovsky et al and Singh et al believed that LASr was less accurate in characterizing LV filling pressures in patients with LV systolic dysfunction than in patients with normal systolic function [12,15]. In contrast, Cameli et al demonstrated that in patients with advanced systolic heart failure, peak atrial longitudinal strain provided a better estimation of LV filling pressures [36].…”

“…Recent studies have shown that abnormalities in the left atrium have an important effect on the pathophysiology and disease progression of LVDD and heart failure with preserved ejection fraction (HFpEF) [10][11][12][13][14]. Moreover, several studies have implied that left atrial (LA) strain, especially LA reservoir strain (LASr), is clinically useful for the noninvasive assessment of LV filling pressures [15][16][17].…”

Correlation of left atrial strain with left ventricular end-diastolic pressure in patients with normal left ventricular ejection fraction

“…It is suggested that left atrial strain should be used in diagnosis of LVDD [7]. The previous study indicated that LA strain correlates well with LVEDP, as well as pulmonary capillary wedge pressure [7][8][9][10]. While LASct and LAScd are rarely mentioned in previous studies, cut-off value for LA strain is still undefined by invasive gold reference.…”

Left atrial function: an overlooked metrics in clinical routine echocardiography

“…As the primary function of the left atrium is to modulate LV filling ( Figure A ) with its reservoir, conduit, and contractile functions, it is not surprising that functional changes of the left atrium become evident at the earliest stages of LVDD . Moreover, LA function may provide additive value, not only in diagnosing LVDD, but also in grading its severity . In the early stages, the left atrium may compensate for LV diastolic dysfunction through its booster function, but with prolonged LV dysfunction, LA dilatation and eventually LA mechanical failure may occur …”

“…Left atrial strain globally reflects atrial function, remodelling and distensibility. All these components become progressively more impaired in the setting of chronic LVDD, as in patients with HFpEF . Therefore, LA strain represents the cumulative adverse impact of chronically impaired LV relaxation and end‐diastolic viscoelastic stiffness on the left atrium, which can result in pulmonary venous hypertension during exercise associated with HFpEF.…”