Right ventricular myocardial work for the prediction of early right heart failure and long-term mortality after left ventricular assist device implant.

AIMS: Right heart failure (RHF) after left ventricular assist device (LVAD) implant is burdened by high morbidity and mortality rates and should be prevented by appropriate patient selection. Adequate right ventricular function is of paramount importance but its assessment is complex and cannot disregard afterload. Myocardial work (MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure-volume loops. The aim of this study was to evaluate the performance of right ventricular myocardial work to predict RHF and long-term mortality after LVAD implant. METHODS AND RESULTS: Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam prior to LVAD implant were excluded. MW analysis was performed. The primary endpoints were early RHF (<30 days from LVAD implant) and death at latest available follow-up. We included 23 patients (mean age 64 ± 8 years, 91% men). Median follow-up was 339 days (IQR: 30-1143). Early RHF occurred in six patients (26%). A lower right ventricular global work efficiency [RVGWE, OR 0.86, 95% confidence intervals (CI) 0.76-0.97, P = 0.014] was associated with the occurrence of early RHF. Among MW indices, the performance for early RHF prediction was greatest for RVGWE [area under the curve (AUC) 0.92] and a cut-off of 77% had a 100% sensitivity and 82% specificity. At long-term follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE > 77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group (HR 0.25, 95% CI 0.07-0.90, P = 0.033). CONCLUSION: RVGWE was a predictor of early RHF after LVAD implant and brought prognostic value in terms of long-term mortality.

Heart transplantation and anti-HLA antibodY: myocardial dysfunction and prognosis - HeartLAy study.

AIMS: The presence of anti-human leucocyte antigen (HLA) antibodies has been implicated in a higher incidence of complications as well as mortality rate in heart transplantation. The aim of the study was to identify through non-invasive parameters early signs of myocardial dysfunction in the presence of anti-HLA antibodies but without evidence of antibody-mediated rejection (AMR) and its possible prognostic impact. METHODS AND RESULTS: A total of 113 heart-transplanted patients without acute cellular rejection (ACR) and AMR or cardiac allograft vasculopathy (CAV) were prospectively enrolled and divided into two groups ['HLA+' (50 patients) and 'HLA-' (63 patients)], based on the presence of anti-HLA antibodies. Each patient was followed for 2 years after the enrolment, recording episodes of AMR, ACR, CAV, and mortality. Clinical characteristics were similar between the two groups. Among laboratory data, N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin values were significantly higher in the presence of anti-HLA antibodies (P < 0.001 and P = 0.003, respectively). The echocardiographic parameters that showed a statistically significant difference between the two groups were deceleration time of E wave (DecT E, P < 0.001), left ventricular global longitudinal strain (P < 0.001), tricuspid annular plane systolic excursion (P = 0.011), tricuspid S' wave (P = 0.002), and free wall right ventricular longitudinal strain (fwRVLS, P = 0.027), whereas left atrial strain did not differ significantly (P = 0.408). Univariate analysis showed that anti-HLA antibodies were associated with the development of CAV at both 1 and 2 year follow-up [odds ratio (OR) 11.90, 95% confidence interval (CI) 1.43-90.79, P = 0.022 and OR 3.37, 95% CI 1.78-9.67, P = 0.024, respectively]. Bivariate analysis demonstrated that both fwRVLS and DecT E were predictors of CAV development independently from HLA status. CONCLUSIONS: The presence of circulating anti-HLA antibodies is correlated with a mild cardiac dysfunction, even in the absence of AMR, and CAV development. Interestingly, reduced values of DecT E and fwRVLS were predictors of future development of CAV, independently from anti-HLA antibody.

ADONHERS (Aged DONor HEart Rescue by Stress Echo) National Protocol: Recipient's Survival after 10-Year Follow-Up.

Background: The gold-standard treatment for end-stage heart failure is heart transplantation, but the lack of organ donors remains an important limitation in this field. An accurate selection of marginal hearts is fundamental to increase organ availability. Purpose: In our study we analyzed if recipients receiving marginal donor (MD) hearts, selected by dipyridamole stress echocardiography according to the ADOHERS national protocol, had different outcomes compared to recipients with acceptable donor (AD) hearts. Methods: Data were collected and retrospectively analyzed from patients who received an orthotopic heart transplant at our institution between 2006 and 2014. Dipyridamole stress echo was performed on identified marginal donors and selected hearts were eventually transplanted. Clinical, laboratory and instrumental features of the recipients were evaluated and patients with homogenous baseline characteristics were selected. Results: Eleven recipients transplanted with a selected marginal heart and eleven recipients transplanted with an acceptable heart were included. Mean donor age was 41 ± 23. The median follow-up was 113 months (IQR 86-146 months). Age, cardiovascular risk and morpho-functional characteristics of the left ventricle were comparable between the two populations (p > 0.05). Left atrial size was significantly higher in patients with marginal hearts (acceptable atrial volume: 23 ± 5 mL; marginal atrial volume: 38 ± 5 mL; p = 0.003). Acceptable donor recipients showed a higher impact of Cardiac Allograph Vasculopathy (p = 0.019). No rejection differences were found between the two groups. Four patients deceased, three were standard donor recipients and one was from the marginal donor group. Conclusions: Our study shows how cardiac transplant (Htx) from selected marginal donor hearts through a non-invasive bedside technique can alleviate the shortage of organs without a difference in survival compared to acceptable donor hearts.

European multicenter study on the real-world use and clinical impact of extracorporeal photopheresis after heart transplantation.

BACKGROUND: Aim of this study was to describe the real-world use of extracorporeal photopheresis (ECP) and assess its impact on clinical outcomes in the modern era of heart transplantation. METHODS: Seven transplant centers from 5 European countries participated in this retrospective, observational, single-arm chart review study. All patients received ECP after heart transplantation in 2015 or later. Data were extracted from medical records between November 2020 and December 2021. RESULTS: Overall, 105 patients were enrolled and followed for an average of 2 years after initiation of ECP. Reasons to start ECP were acute cellular rejection (35.2%), rejection prevention (32.4%), mixed rejection (18.1%), and antibody-mediated rejection (14.3%). Rejection ISHLT grades improved from start to end of ECP treatment in 92% of patients treated with ECP for rejection. Of patients who started ECP to prevent rejection, 88% remained free from any rejection despite a reduction of calcineurin inhibitors. Overall survival was 95%, and no deaths were related to ECP. Safety events occurred in 18 patients, of which 13 experienced complications with venous access. CONCLUSIONS: This study, the largest European ECP study in heart transplantation, demonstrates that ECP can effectively be used to treat different rejection types and to prevent rejection in the modern era of immunosuppression. Patients with rejections who have received ECP have shown high response as measured by histological improvements in ISHLT classification. A high percentage of patients in the prevention group remained free from rejection despite reduction in immunosuppression, in particular calcineurin inhibitors.

Electromechanical delay by speckle-tracking echocardiography: A novel tool to distinguish between Brugada syndrome and isolated right bundle branch block.

BACKGROUND: The electrocardiographic (ECG) definition of Brugada syndrome (BS) can be challenging because benign ECG abnormalities, such as right bundle branch block (RBBB), may mimic pathological ECG characteristics of BrS. However, although myocardial delay and deformation can be quantified by advanced imaging, it has not yet been used to differentiate between BrS and RBBB. The aim of this study was to characterize the electro-mechanical behavior of the heart of patients with type-1 BrS and isolated complete RBBB in order to differentiate these conditions. METHODS: In this two-center study, 66 subjects were analyzed by standard and speckle-tracking echocardiography (STE): 22 type-1 BrS, 24 isolated complete RBBB, and 20 healthy subjects. The participants were not treated by any drug potentially influencing myocardial conduction. RESULTS: Standard echocardiographic parameters did not differ among the groups. The greatest right ventricular (RV) mechanical dispersion was found in RBBB. Mean absolute deviations (MADs) of time-to-peak longitudinal strain calculated for each left ventricular (LV) region were greater in patients with RBBB as compared to BrS (p < .01). No differences were found between BrS and controls (p = .36). MADs in the basal segments in RBBB group were greater than MADs found in BrS group and controls (37.3 ms vs. 26.7 ms and 29.0 ms, respectively, p < .05). The greatest differences were found in the antero-septal, anterior, lateral, and infero-septal basal segments. CONCLUSIONS: Advanced echocardiographic techniques may help to differentiate between BrS and RBBB. Indeed, STE allows to identify an electro-mechanical conduction delay in RBBB patients that is not found in patients affected by type-1 BrS.

Improving the role of echocardiography in studying the right ventricle of repaired tetralogy of Fallot patients: comparison with cardiac magnetic resonance.

Right ventricular (RV) evaluation represents one of the major clinical tasks in the follow-up of repaired tetralogy of Fallot patients (rToF) with pulmonary valve regurgitation, as both severe RV dilatation and dysfunction are key factors in defining the need of pulmonary valve replacement. The aim of our study was to report the diagnostic accuracy of echocardiography in the identification of rToF patients with severely dilated and/or depressed RV as compared to cardiac magnetic resonance (CMR). Among our patients with rToF, a subgroup of 95 (17.6 ± 6.8 years; 60% male), who underwent right ventricular qualitative and quantitative evaluation with CMR following echocardiographic suspicion of severe dilation/dysfunction, were included in the analysis. When comparing echocardiographic RV functional parameters to CMR findings, we found no association between CMR-ejection fraction (EF) and either tricuspid annulus plane systolic excursion (TAPSe) nor tissue Doppler systolic tricuspid excursion velocity (all p = ns). In contrast RVFAC was strongly associated with CMR-EF (r = 0.44; p < 0.01) as well as to longitudinal components of RV mechanics including tissue Doppler s' (r = 0.40; p < 0.01) and TAPSE (r = 0.36; p < 0.01). When comparing echocardiographic and CMR structural parameters of the RV, we found that CMR RV volume was strongly related to echocardiographic measurements of RV end diastolic area (from the 4 chamber apical view) and with proximal parasternal short axis right ventricle outflow-dimension. Accordingly a regression model was derived from multiple regression analysis, which allows a more accurate estimate of CMR RV volume from echocardiography (r2 = 0.59, p < 0.001). Our study demonstrates a significant, although imperfect, correlation between echocardiographic and CMR RV functional and geometrical parameters. Combining echocardiographic measures of RV inflow and RV outflow, we deliver a simple formula to estimate CMR-RV volume, improving the echocardiographic accuracy in RV volume quantification.

Acute and Long-Term Effects of LVAD Support on Right Ventricular Function in Children with Pediatric Pulsatile Ventricular Assist Devices.

Right ventricular failure (RVF) is a significant issue when considering left ventricular assist device (LVAD) implantation in pediatrics. The aim of this study was to evaluate the effects of LVAD on right ventricular (RV) function in children. We retrospectively reviewed clinical and echocardiographic data of children who underwent Berlin Heart EXCOR LVAD focusing on RV function before and after implantation (1, 3, and 6 month follow-up). An isolated LVAD was used in 27 patients. Median age was 11 months (interquartile range [IQR]: 5-24 months), with a median weight of 6.3 kg (IQR: 5-9 kg). Median time on ventricular assist device (VAD) support was 147 days (IQR: 86-210 days). Twenty patients were successfully bridged to orthotopic heart transplantation (OHT) (74%), six patients died (22%), and also heart function recovered in one patient (4%). Before LVAD implantation, nine patients (33%) showed a RV fractional area change (RVFAC) less than or equal to 30%. After implantation, mean RVFAC increased up until the 3 month follow-up (43.13%; p = 0.033) and then slightly decreased. In a subgroup of 18 patients, the average strain value increased after the 1 month follow-up (p = 0.022). Right ventricular failure developed in 33% of patients before the 1 month follow-up, and 7.4% experienced RVF at the 6 month follow-up. No patient required biventricular assist device (BiVAD). In our population, pulsatile-flow LVAD in children allows optimal RV decompression and function post-LVAD as measured by improvement in RV function at echo particularly at 1 and 3 month follow-up. At long-term follow-up, the beneficial effects of LVAD on RV function seem to be reduced as signs and symptoms of late RVF may develop in some patients despite LVAD support.

Training-induced right ventricular remodelling in pre-adolescent endurance athletes: The athlete's heart in children.

AIMS: Little is known about the adaptation of the right ventricle (RV) to endurance exercise in children. The aim of this study was to assess the effects of 5months of intensive training on RV morphology and function in preadolescent endurance athletes. METHODS: Ninety-four children were evaluated in this study. Fifty-seven male competitive swimmers (aged 10.8±0.2years) were evaluated before (baseline) and after 5months of the training (peak-training), and compared to 37 age- and sex-matched non-athlete children evaluated at baseline and after 5months of natural growth. All subjects were asymptomatic, with negative family history for cardiomyopathies. RESULTS: At baseline no differences were found between athletes and controls for indexed RV outflow tract (RVOT) (18.5±2.7 vs. 16.8±5.0mm/m2, p=0.18) and RV basal end-diastolic diameter (EDD) (24.9±4.1 vs. 23.6±3.0mm/m2, p=0.15). After 5months, indexed RVOT and RV basal EDD significantly increased in athletes (20.2±2.9mm/m2 and 25.4±3.3mm/m2, p<0.0001 vs. baseline) while no differences were observed in controls (p=0.84 and p=0.25). Despite the increase in RV size, RV function remained normal in athletes, with no changes in RV fractional area change (p=0.97), s' value (p=0.22), and RV longitudinal strain (p=0.28). CONCLUSIONS: Endurance training influences the growing heart of male preadolescent athletes with an addictive increase in RV dimensions, with a preserved RV function. Therefore, in children engaged in endurance sports the increase in RV size associated with normal RV function represents a physiological expression of the athlete's heart and should not be misinterpreted as an expression of incipient RV cardiomyopathy.

Right ventricular remodelling induced by exercise training in competitive athletes.

AIMS: Conflicting evidence exists concerning right ventricular (RV) morphological and functional remodelling in trained athletes, with a very few longitudinal data prospectively investigating the RV changes. The aim of this study was to assess the morphological and functional RV changes occurring during the competitive season in young athletes engaged in the most popular team sports. METHODS AND RESULTS: Twenty-nine top-level athletes (age: 20.9 ± 6.7 years), practicing basketball and volleyball, were evaluated at pre-season, mid-season, and end-season time-points, using tissue Doppler imaging and 2D speckle-tracking echocardiography. RV basal and mid-cavity end-diastolic diameters (EDDs; overall P = 0.011 and P < 0.0001, respectively), and RV diastolic area (overall P < 0.0001) increased during the season. Conversely, RV outflow tract did not vary (overall P = 0.96). During the season, no significant differences were observed in RV diastolic functional indexes and in RV fractional area change (overall P = 0.35). Global RV longitudinal strain did not significantly change (overall P = 0.52), although apical longitudinal strain significantly increased (overall P = 0.017). In association, left ventricular (LV) volume and mass increased during the season (overall P = 0.007). On multivariate analysis, LV mass was the only independent predictor of RVEDD at pre-season (ß = 0.69, P < 0.0001) and at end-season (ß = 0.82, P < 0.0001). CONCLUSIONS: Right ventricular chamber size increases during the competitive season in top-level athletes, with no significant changes in the outflow tract. RV morphological adaptation in top-level athletes practicing team sports is not associated with a reduction in RV function or in myocardial deformation and occurs in close association with changes on the left ventricle, suggesting a physiological remodelling of the right ventricle.

Training-induced dynamic changes in left atrial reservoir, conduit, and active volumes in professional soccer players.

PURPOSE: Although left atrial (LA) enlargement is a recognized component of athlete's heart, dynamic cavity changes occurring during the training period remain to be elucidated. We aimed to investigate the adaptive changes of LA reservoir, conduit, and active volumes in elite athletes vs. controls and their response to different training loads. METHODS: LA maximum, pre-P, and minimum volumes were assessed in 26 top-level athletes and 23 controls. In athletes, LA volumes were measured at pre-, mid-, end-training, and post-detraining time points using conventional 2D echocardiography. RESULTS: Athletes had larger maximum (27.5 ± 3.2 vs. 20.3 ± 5.8 mL/m(2), p = 0.001), pre-P (11.5 ± 0.9 vs. 9.8 ± 2.2 mL/m(2), p = 0.001), and minimum (6.6 ± 0.9 vs. 5.0 ± 1.2 mL/m(2), p < 0.001) LA indexed volumes, compared with controls. Total and passive emptying volume indices were also larger in athletes compared with controls (18.7 ± 3.1 vs. 15.3 ± 4.9 mL/m(2), p < 0.05 and 13.8 ± 2.9 vs. 10.5 ± 4.6 mL/m(2), p < 0.05, respectively), while active emptying volume was similar (p = 0.74). During training, LA maximum (p < 0.0001), pre-P (p < 0.0001), minimum (p < 0.0001), total (p < 0.005), and passive (p < 0.05) emptying volume indices progressively increased, while active emptying volume (p = 0.10) and E/e' ratio (p = 0.32) remained unchanged. After detraining, LA volume measurements were not different from pre-training ones. End-training left ventricular mass index was the only independent predictor of the respective maximum LA volume (ß = 0.74, p < 0.005). CONCLUSIONS: Top-level athletes exhibit a dynamic morphological and functional LA remodeling, induced by training, with an increase in reservoir and conduit volumes, but stable active volume. LA remodeling is closely associated with left ventricular adaptation to exercise and both completely regress after detraining.

Increased left atrial size is associated with reduced atrial stiffness and preserved reservoir function in athlete's heart.

Left atrial (LA) fibrosis with increased stiffness has been assumed to be the substrates for occurrence of atrial arrhythmias in athletes. However, this hypothesis has not yet been confirmed in humans. Aim of this study was, therefore, to assess LA remodeling and stiffness in competitive athletes. 150 competitive athletes and 90 age and sex-matched sedentary subjects were analyzed by speckle-tracking echocardiography to measure peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). LA stiffness was determined using E/e' ratio in conjunction with PALS. Left ventricular (LV) stiffness was also calculated. LA volume index was greater in athletes as compared with controls (24.6 ± 7.3 vs. 18.4 ± 7.8 mL/m(2), p < .0001). LA PALS, LA PACS, and E/e' ratio were lower in athletes in comparison with controls (p < .05, p ≤ .001, and p < .0001, respectively). Despite greater LA size, competitive athletes had lower LA stiffness as compared with controls (0.13 ± 0.04 vs. 0.16 ± 0.06, p ≤ .001). In addition, LV stiffness was lower in athletes (0.84 ± 0.27 vs. 1.07 ± 0.46, p ≤ .001). The only independent predictor of LA stiffness was LV stiffness (ß = 0.46, p < .0001), while the only independent predictor of LA volume index was LV end-systolic volume index (ß = 0.25, p = .002). Competitive athletes showed greater LA size associated with lower stiffness as compared with controls. Thus, LA remodeling in the context of the athlete's heart is not associated with increased LA stiffness. These findings support the benign nature of LA remodeling in athletes, occurring as a physiological adaptation to exercise conditioning.

Dynamic changes in left ventricular mass and in fat-free mass in top-level athletes during the competitive season.

BACKGROUND: Previous cross-sectional studies have demonstrated that fat-free mass (FFM) is an important determinant of left ventricular mass (LVM) in athletes. However, cross-sectional investigations have not the ability to detect the dynamic adaptation occurring with training. We hypothesized that LVM adapts concurrently with the increase of FFM induced by exercise conditioning. We sought to study the relationship between the variations of LVM and of FFM occurring in top-level soccer players during the season. METHODS: Twenty-three male top-level athletes were recruited. LVM was assessed by echocardiography and FFM by dual-energy X-ray absorptiometry. Serial measurements were performed pre-season, after 1 month, at mid- and end-season, and after 2 months of detraining. RESULTS: LVM significantly increased at mid-season versus pre-season values, reaching the highest value at the end of the season (p < 0.05). While body weight did not vary during the study period, FFM significantly increased (p < 0.05 for mid-/end-season vs. pre-season data). After the detraining, no significant differences were observed between pre-season and detraining echocardiographic data. The only independent predictors of LVM were left ventricular stroke volume and FFM (R = 0.36, p = 0.005; R = 0.35, p = 0.005, respectively). When ΔLVM index was set as dependent variable, the only independent predictor was ΔFFM (R = 0.87, p = 0.002). CONCLUSIONS: Changes in LVM occur in close association with changes in FFM, suggesting that the left ventricle adapts concurrently with the increase of the metabolically active tissue induced by training, i.e. the FFM. Therefore, the dynamic changes in FFM and LVM may reflect a physiological adaptation induced by intensive training.

Morphological and functional adaptation of left and right atria induced by training in highly trained female athletes.

BACKGROUND: Exercise is able to induce atrial remodeling in top-level athletes. However, evidence is mainly limited to men and based on cross-sectional studies. The aim of this prospective, longitudinal study was to investigate whether exercise is able to influence left and right atrial morphology and function also in female athletes. :ETHODS AND RESULTS- Two-dimensional echocardiography was performed before season and after 16 weeks of intensive training in 24 top-level female athletes. Left and right atrial myocardial deformation was assessed by two-dimensional speckle-tracking echocardiography. Left atrial volume index (24.0±3.6 versus 26.7±6.9 mL/m(2); P<0.001) and right atrial volume index (15.66±3.09 versus 20.47±4.82 mL/m(2); P<0.001) significantly increased after training in female athletes. Left atrial global peak atrial longitudinal strain and peak atrial contraction strain significantly decreased after training in female athletes (43.9±9.5% versus 39.8±6.5%; P<0.05 and 15.5±4.0% versus 13.9±4.0%; P<0.05, respectively). Right atrial peak atrial longitudinal strain and peak atrial contraction strain showed a similar, although non-significant decrease (42.8±10.6% versus 39.3±8.3%; 15.6±5.6% versus 13.1±6.1%, respectively). Neither biventricular E/e' ratio nor biatrial stiffness changed after training, suggesting that biatrial remodeling occurs in a model of volume rather than pressure overload. CONCLUSIONS: Exercise is able to induce biatrial morphological and functional changes in female athletes. Biatrial enlargement, with normal filling pressures and low atrial stiffness, is a typical feature of the heart of female athletes. These findings should be interpreted as physiological adaptations to exercise and should be considered in the differential diagnosis with cardiomyopathies.

Precompetitive assessment of heart rate variability in elite female athletes during play offs.

BACKGROUND: Heart rate variability (HRV) has been rarely applied in elite athletes prior to competition. The aim of this study was to examine the changes in HRV in elite female volleyball players before a stressful match during play offs and to evaluate the impact on sport-specific performance. METHODS: A short-term resting HRV analysis was applied right after the night sleep in ten female athletes 1 and 2 days prior to the match and the day of the competition. RESULTS: Approaching the decisive match, RR interval, resting heart rate (HR), pNN50, rMSDD and SD1 did not significantly vary. SD2 significantly increased in comparison with first-day measurement (P<0·05). HF% levels significantly decreased the prematch day and the match day (P<0·05); however, no significant changes in LF/HF% ratio were observed. A gradual increase in VLF% and in LnVLF was observed, with a significant difference between first-day and match-day measurements (P<0·01 and P<0·05, respectively). The number of positive receptions was inversely correlated with LF/HFms(2) ratio, with LF/HF% ratio (R = -0·98, P<0·05 for both) and with resting HR (R = -0·92, P<0·05). CONCLUSIONS: Elite female athletes practising team sports exhibit a slight change in HRV prior to a decisive competition, without a pronounced variation of the autonomic nervous system activity. A day-to-day HRV measurement could be a useful tool to evaluate the impact of a competition on the autonomic nervous system in athletes, also considering the relationship between sympathetic activity and athletic performance.

Characterization of right atrial function and dimension in top-level athletes: a speckle tracking study.

Although many echocardiographic studies are available about the adaptation of left ventricle to intensive training, right heart function has been poorly investigated and no data are available about the right atrial (RA) function in top-level athletes. The aim of the study was to investigate RA function and dimension by standard echocardiography and 2D speckle tracking echocardiography (STE). One hundred top-levels athletes were recruited from professional sports team and were compared with 78 normal subjects. Athletes during an off-training period or during prolonged forced rest resulting from injuries were excluded. Top-level athletes had higher BSA as compared with controls and, as expected, a lower resting heart rate (p ≤ 0.001). RA area, volume, and volume index were significantly greater in athletes than in controls (p ≤ 0.001). This increase was associated with greater right ventricular and inferior vena cava diameters (p ≤ 0.001). Peak atrial longitudinal strain and peak atrial contraction strain values were significantly lower in athletes in comparison with controls (40.92 ± 9.86% vs. 48.00 ± 12.68%, p ≤ 0.001; 13.05 ± 4.84% vs. 15.99 ± 5.74%, p ≤ 0.001, respectively). Interestingly, while athletes presented a higher E/A ratio (p ≤ 0.001) and a lower peak A velocity (p ≤ 0.001), the E/e' ratio did not differ between the two groups. In top-level athletes the RA presents a physiological adaptation to intensive exercise conditioning which determines not only a morphological but also a functional remodeling. We reported for the first time reference values of RA strain in elite athletes, demonstrating that 2D STE is a useful tool to investigate RA longitudinal myocardial deformation dynamics in athlete's heart.

Usefulness of atrial deformation analysis to predict left atrial fibrosis and endocardial thickness in patients undergoing mitral valve operations for severe mitral regurgitation secondary to mitral valve prolapse.

In patients with severe mitral regurgitation (MR) referred for cardiac surgery, left atrial (LA) remodeling and enlargement are accompanied by mechanical stress, mediated cellular hypertrophy, and interstitial fibrosis that finally lead to LA failure. Speckle tracking echocardiography is a novel non-Doppler-based method that allows an objective quantification of LA myocardial deformation, becoming useful for LA functional analysis. We conducted a study to evaluate the relation between the traditional and novel atrial indexes and the extent of ultrastructural alterations, obtained from patients with severe MR who were undergoing surgical correction of the valvular disease. The study population included 46 patients with severe MR, referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery. The global peak atrial longitudinal strain (PALS) was measured in all subjects by averaging all atrial segments. LA tissue samples were obtained from all patients. Masson's trichrome staining was performed to assess the extent of the fibrosis. The LA endocardial thickness was measured. A close negative correlation between the global PALS and grade of LA myocardial fibrosis was found (r = -0.82, p <0.0001), with poorer correlations for the LA indexed volume (r = 0.51, p = 0.01), LA ejection fraction (r = 0.61, p = 0.005), and E/E' ratio (0.14, p = NS). Of these indexes, global PALS showed the best diagnostic accuracy to detect LA fibrosis (area under the curve 0.89), and it appears to be a strong and independent predictor of LA fibrosis. Furthermore, we also demonstrated an inverse correlation between the global PALS and LA endocardial thickness (r = -0.66, p = 0.0001). In conclusion, in patients with severe MR referred for cardiac surgery, impairment of LA longitudinal deformation, as assessed by the global PALS, correlated strongly with the extent of LA fibrosis and remodeling.

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.