Prognostic value of left atrial strain in patients with moderate asymptomatic mitral regurgitation.

For patients with asymptomatic mitral regurgitation (MR), the criteria identifying the groups at higher-risk and their clinical outcome are still uncertain. Therefore, in these patients, optimal time of surgery remains controversial. The purpose of this study was to compare left atrial (LA) strain to other echocardiographic left ventricular (LV) and LA parameters for the prediction of cardiovascular outcomes in patients with moderate asymptomatic MR. We enrolled 395 patients with primary degenerative moderate asymptomatic MR. Exclusion criteria were: history of atrial fibrillation, myocardial infarction, heart failure, cardiac surgery or heart transplantation, severe MR, mitral valve surgery during follow-up. Patients were prospectively followed for 3.5 ± 1.6 years for the development of cardiovascular events i.e. atrial fibrillation, stroke/transient ischaemic attack, acute heart failure, cardiovascular death. Of 276 patients (mean age 66 ± 8 years) who met eligibility criteria, 108 patients had 141 new events. Patients who developed cardiovascular events presented reduced global peak atrial longitudinal strain (PALS), reduced LA emptying fraction, larger LA volume indexed and lower LV strain at baseline (p < 0.0001). With receiving operating characteristics (ROC) curve analysis, global PALS < 35% showed the greatest predictive performance (AUC global PALS: 0.87). Bland-Altman analysis demonstrated good intra- and interobserver agreement with small bias and Kaplan-Meier analysis showed a graded association between PALS and event-free-survival rates. Speckle tracking imaging could provide a useful index, global PALS, to estimate LA function in asymptomatic moderate MR in order to optimize timing of surgery before the development of irreversible myocardial dysfunction.

Systematic Left Ventricular Assist Device Implant Eligibility with Non-Invasive Assessment: The SIENA Protocol.

In patients with end-stage left ventricular (LV) heart failure who receive LV assist device (LVAD) implantation, right ventricular (RV) failure represents a possible critical complication that heavily affects morbidity and mortality. Several clinical, laboratory, hemodynamic, and echocardiographic variables have been found to be associated with RV failure occurrence after surgery. Different models and risk scores have been proposed, with poor results. No accordance has ever been reached about RV pre-operative evaluation, and time has come to introduce a standardized systematic protocol for LVAD suitability assessment according to RV function. We analyzed imaging parameters associated with LVAD implantation-related RV failure, in order to identify the minimum number for pre-operative reliable prediction of post-operative RV failure. A few echocardiographic parameters have been identified as the most reliable, or promising, and reproducible tools in this field: free-wall RV longitudinal strain, RV fractional area change, RV sphericity index, and RV ejection fraction with 3D-echocardiography. We propose the Systematic LVAD Implant Eligibility with Non-invasive Assessment protocol-the SIENA protocol-as a new and simple way of pre-operative evaluation of patients candidates to LVAD implantation.

Left atrial strain: A useful index in atrial fibrillation.

Left atrial (LA) strain is a speckle tracking echocardiography (STE)-derived parameter applied to the analysis of chamber function that provides highly reproducible measures of LA deformation by a non-Doppler, angle-independent quantification. In recent years, data regarding accuracy and clinical application of LA strain are rapidly increasing. This review describes the main features of LA strain and examines the role of STE in the evaluation of various aspects of AF, as the risk of developing the arrhythmia in general population, the evaluation of LA fibrosis and LA impairment, the quantification of cardioembolic risk and of recurrence after cardioversion or ablation therapies.

Correlation of Left Atrial Strain and Doppler Measurements with Invasive Measurement of Left Ventricular End-Diastolic Pressure in Patients Stratified for Different Values of Ejection Fraction.

BACKGROUND: This study aimed at exploring the correlation of left atrial longitudinal function by speckle tracking echocardiography (left atrial strain) and Doppler measurements (E/E' ratio) with direct measurements of left ventricular (LV) end-diastolic pressure (LVEDP) in patients stratified for different values of ejection fraction. METHODS: The study population was 80 stable patients with sinus rhythm undergoing cardiac catheterization. This population was selected in order to have four groups of 20 patients each with different LV ejection fraction (>55%, 45-54%, 30-44%, and <30%). LVEDP was obtained during cardiac catheterization; peak atrial longitudinal strain (PALS) and mean E/E' ratio were measured in all subjects. RESULTS: Similar correlations with LVEDP of global PALS and E/E' ratio were recorded in patients with preserved (r = -0.79 vs. r = 0.72, respectively; P < 0.0001 for both) or mildly reduced ejection fraction (r = -0.75 vs. r = 0.73, respectively; P < 0.0001 for both). A closer correlation of global PALS compared to E/E' ratio was evident in patients with moderate (r = -0.78 P < 0.0001; vs. r = 0.47 P = 0.01, respectively) and severe reduction (r = -0.74 P < 0.0001; vs. r = 0.19 ns, respectively) of LV ejection fraction. In multivariate analysis of all measurements, global PALS emerged as a determinant of the LVEDP, independent on other confounding factors and, with the cutoff value of 18.0% presented the best diagnostic accuracy to predict a LVDP above 12 mmHg (AUC 0.87). CONCLUSIONS: In patients with preserved or mildly reduced LV ejection fraction, global PALS and mean E/E' ratio presented good correlations with LVEDP. In patients with moderate or severe reduction of ejection fraction, E/E' ratio correlated poorly with invasively obtained LV filling pressures. Global PALS provided an overall better estimation of LV filling pressures.

Left atrial deformation analysis by speckle tracking echocardiography for prediction of cardiovascular outcomes.

The incremental value of left atrial (LA) deformation analysis by speckle tracking echocardiography compared with LA volume or LA ejection fraction as a cardiovascular risk marker has not been evaluated prospectively. We sought to compare LA function by speckle tracking echocardiography to other conventional LA parameters for prediction of adverse cardiovascular outcomes. This prospective study included 312 adults (mean age 71 ± 6 years, 56% men) in sinus rhythm who were followed for development of first atrial fibrillation, congestive heart failure, stroke, transient ischemic attack, myocardial infarction, coronary revascularization, and cardiovascular death. Global peak atrial longitudinal strain (PALS) by speckle tracking echocardiography was measured in all subjects by averaging all atrial segments. Left atrium was assessed with biplane LA volume, LA ejection fraction, 4-chamber LA area, and M-mode dimension. Of 312 subjects at baseline, 43 had 61 new events during a mean follow-up of 3.1 ± 1.4 years. All LA parameters, traditional parameters, and parameters derived by speckle tracking echocardiography were independently predictive of combined outcomes (p <0.0001 for all comparisons). Overall performance for prediction of cardiovascular events was greatest for global PALS (area under receiver operator characteristic curve: global PALS 0.83, indexed LA volume 0.71, LA ejection fraction 0.69, LA area 0.64, LA diameter 0.59). A graded association between degree of LA enlargement and risk of cardiovascular events was evident only for global PALS and indexed LA volume. In conclusion, global PALS is a strong and independent predictor of cardiovascular events and appears to be superior to conventional parameters of LA analysis.