BACKGROUND:Non-invasive assessment of left atrial pressure (LAP) remains difficult in patients with atrial fibrillation (AF). The American Society of Echocardiography (ASE) updated the Recommendations for the Evaluation of Left Ventricular Diastolic Function and introduced a specific algorithm for LAP estimation in AF. We retrospectively investigated the prognostic value of the new algorithm-based LAP assessment in patients with heart failure with preserved ejection fraction (HFpEF) and persistent AF. METHODS:This study included 363 patients hospitalized for acutely decompensated HFpEF who had persistent AF at discharge. LAP was categorized as normal, elevated, or indeterminate using echocardiography at discharge, according to the algorithm in the 2025 ASE guidelines. Multivariable Cox proportional hazards models were constructed to assess associations between LAP classification and clinical outcomes such as death, heart failure (HF) hospitalization and stroke during follow-up of 574 days. RESULTS:LAP was classified as elevated in 93 patients (25.6%) and normal in 165 (45.5%), while it was indeterminate in 105 (28.9%) cases due to missing variables recommended in the 2025 guidelines. Elevated LAP was independently associated with HF hospitalization during follow-up period (HR 1.57, 95% CI 1.05-2.37, p=0.03), whereas it was not identified as an independent predictor for death or stroke after adjustment. This association remained significant after accounting for the competing risk of death and was largely preserved across multiple imputation and sensitivity analyses using different assumptions for indeterminate cases. The incremental value of LAP estimation for predicting HF hospitalization over natriuretic peptides was modest and not statistically significant. CONCLUSIONS:In patients hospitalized for HFpEF with persistent AF, LAP classification was associated with HF hospitalization, implying clinical relevance of the 2025 algorithm-based approach in this challenging population.
BACKGROUND:Ventricular functional mitral regurgitation (VFMR) is a heterogeneous disease with widely variable outcomes, yet current risk stratification relies predominantly on left ventricular (LV) indices. This study aims to evaluate the incremental value of right ventricular free-wall longitudinal strain (RVfwLS) beyond conventional LV parameters and LV longitudinal strain (LVLS) in an unselected VFMR population. METHODS:This multicenter retrospective cohort included consecutive patients with moderately severe or greater VFMR diagnosed between 2010 and 2022. Right ventricular free-wall longitudinal strain and apical 4-chamber LVLS (A4C-LVLS) were quantified using automated software. The primary end point was cardiovascular death or death equivalent (LV assist device implantation or heart transplantation) during the longest available follow-up. Optimal cutoff for RVfwLS was derived from regression tree analysis and maximal selective rank statistics. Incremental prognostic value was assessed using likelihood ratio tests comparing nested models. RESULTS:Among the 487 patients included, 156 (32%) patients experienced the primary end point over a median follow-up of 2.6 (interquartle range, 0.85.9) years. Compared with event-free patients, those with events had larger LV volumes, but lower LV ejection fraction, A4C-LVLS, RV fractional area change (RVFAC), and RVfwLS (all P ≤ .005). Right ventricular free-wall longitudinal strain was independently associated with the primary end point on top of conventional LV indices, A4C-LVLS, and RVFAC (all P ≤ .047). Patients with A4C-LVLS < 8.7% and RVfwLS < 14% exhibited markedly worse 6-year event-free survival (48%) than those with higher biventricular strain (A4C-LVLS ≥ 8.7% and RVfwLS ≥ 14%; 72%; P < .001). Moreover, RVfwLS provided incremental prognostic value beyond A4C-LVLS, conventional LV indices, and RVFAC (all P ≤ .046). CONCLUSIONS:Right ventricular free-wall longitudinal strain is a robust determinant of adverse outcomes beyond conventional LV indices and A4C-LVLS in VFMR. A cutoff near 14% reliably identified the highest-risk subgroup. These results might support incorporating RVfwLS into routine evaluation to improve risk stratification in VFMR.
Background Diagnosis of heart failure with preserved left ventricular ejection fraction (HFpEF) remains a significant clinical challenge, particularly in patients with atrial fibrillation (AF). Recently, the HFA-PEFF score was introduced to aid in the diagnostic work-up of HFpEF. This study aimed to investigate the distribution of the HFA-PEFF score and its relationship with left atrial (LA) function, pressure, and reverse remodeling in patients with AF. Methods We investigated 155 AF patients who underwent their first catheter ablation (CA). Echocardiography was performed before CA, and the HFA-PEFF score was calculated. Direct LA pressure (LAP) was measured at CA. Echocardiography was repeated 6 months after CA to evaluate LA reverse remodeling. Results High (5-6), intermediate (2-4) and low (0-1) HFA-PEFF scores were observed in 19 (12.3%), 99 (63.9%) and 37 (23.9%) patients, respectively. Higher HFA-PEFF scores were associated with worse LA function and LA stiffness (both P<0.05). Elevated LAP was detected in 31.6%, 19.2%, and 5.4% of the high, intermediate, and low HFA-PEFF score groups, respectively. In the intermediate HFA-PEFF score group, LA stiffness was a good predictor of elevated LAP, whereas left ventricular global longitudinal strain was more predictive in the high HFA-PEFF score group. Six months after CA, all groups exhibited LA reverse remodeling, while the high-score group retained larger LA size and worse LA function. Conclusions Higher HFA-PEFF scores were associated with advanced LA functional remodeling and elevated LAP in AF patients. Persistent LA remodeling after CA in the high-score group demonstrates the need for careful follow-up.
INTRODUCTION:Diagnosing heart failure with preserved ejection fraction (HFpEF) remains challenging in patients with exertional dyspnea and inconclusive resting echocardiography. The left atrial stiffness index (LASI), calculated as E/e' divided by left atrial reservoir strain (LARS), reflects the relationship between estimated left ventricular filling pressure and left atrial compliance. OBJECTIVES:We aimed to evaluate the performance of the LASI for predicting a positive diastolic stress test (DST) response, its incremental value beyond the HFA-PEFF algorithm, and its potential role as a resting pre-test triage tool within the intermediate HFA-PEFF group. METHODS:We retrospectively analyzed 376 patients in a derivation cohort and 141 patients in an external validation cohort who underwent noninvasive DST at two tertiary referral centers. Patients with baseline septal E/e' ≥15 were excluded. A positive DST was defined as exercise septal E/e' ≥15, a guideline-based surrogate of exercise-induced elevation in LV filling pressure. Machine-learning models ranked predictors of a positive DST, followed by logistic regression and receiver operating characteristic analysis; the LASI was then examined within the intermediate HFA-PEFF group. RESULTS:Positive DST occurred in 49 patients (13.0%) in the derivation cohort and 25 patients (17.7%) in the external validation cohort. LASI ranked among the stronger variables associated with positive DST and remained independently associated with positive DST after multivariable adjustment (adjusted odds ratio per 1 SD, 1.81 in the derivation cohort and 1.96 in the validation cohort). At the study-defined cutoff of 0.333, LASI showed high sensitivity and negative predictive value for positive DST in both cohorts (derivation, 80% and 96%; validation, 84% and 94%), although specificity was modest. Within the intermediate HFA-PEFF group, the LASI cutoff separated patients into higher- and lower-yield strata, with only 5% of patients below the cutoff having a positive DST. CONCLUSION:LASI is a resting echocardiographic marker associated with positive DST and may help refine pre-test selection for DST among patients with suspected HFpEF, particularly those with intermediate HFA-PEFF scores. Rather than serving as a stand-alone diagnostic gatekeeper, LASI may serve as a rule-out triage aid to refine selection for DST.
BACKGROUND:Current risk scores for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) have limited ability to identify high-risk subgroups. We aimed to investigate the prognostic value of left atrial reservoir strain (LARS) for SCD-related events and its utility for risk stratification. METHODS:This retrospective cohort study included 1,761 patients with HCM from two referral centers. The primary outcome was SCD-related events, including SCD, aborted SCD, and appropriate implantable cardioverter-defibrillator shocks. Explainable machine learning approaches were used to explore the importance of LARS and identify a clinically relevant threshold. The prognostic value of LARS was evaluated using Cox regression analyses, particularly among patients classified as low-to-intermediate risk (HCM Risk-SCD score<6%). RESULTS:During a median follow-up of 6.8 years (IQR: 3.0-10.7 years), 69 (3.9%) SCD-related events occurred. Decreased LARS was independently associated with a higher risk of SCD-related events (per 1% decrease, adjusted HR 1.11, 95% CI, 1.07-1.15, p<0.001). SHAP analysis identified LARS as the top-ranked predictor and a clinically relevant threshold of <21%. LARS <21% was significantly associated with a higher risk of SCD-related events (adjusted HR 5.01, 95% CI 2.77-9.03, p<0.001), even among patients without atrial fibrillation. Adding LARS to the HCM Risk-SCD score significantly improved risk discrimination in the low-to-intermediate risk population (5-year time-dependent AUC 0.73 vs. 0.63, p=0.005). Among low-to-intermediate risk patients, LARS <21% was associated with a significantly higher risk of SCD-related events (adjusted HR 6.13, 95% CI 3.13-12.03, p<0.001), whereas the original low- and intermediate-risk categories showed limited risk discrimination. CONCLUSIONS:LARS was an independent predictor of SCD-related events and effectively stratified risk among patients classified as low-to-intermediate risk by the HCM Risk-SCD score. Integrating LARS into the HCM Risk-SCD score may enhance risk stratification and guide preventive strategies.
