AIMS:Left atrial reverse remodelling (LARR) following restoration of sinus rhythm is associated with favourable outcomes in patients with atrial fibrillation (AF). Female patients have a higher risk of recurrent AF after ablation therapy than males. This study evaluated sex-specific differences in LARR after successful ablation of AF. METHODS AND RESULTS:We examined 153 AF patients who underwent two-dimensional echocardiography before and 6 months after successful ablation without recurrent arrhythmia. LA reservoir strain (LARS) was assessed by speckle-tracking echocardiography, and LA stiffness was calculated using the ratio of E/e' to LARS. Clinical characteristics, type of AF, and baseline LA size and function were similar between males and females. At 6 months after ablation, LA parameters were improved in both sexes (all P < 0.05). Sex-specific differences in the changes of LA measures were assessed by linear mixed-effect model, and females showed significantly less improvement in LARS than males (ΔLARS: + 5.2% vs. + 9.2%, P = 0.011). In multivariable analyses for post-procedural LA indices, female sex was independently associated with larger LA volume index [unstandardized coefficient (B) = 1.35, P = 0.029], decreased LARS [unstandardized coefficient (B) = -1.33, P = 0.012] and greater LA stiffness [unstandardized coefficient (B) = 0.03, P = 0.003]. Despite similar B-type natriuretic peptide (BNP) levels at baseline, female patients had higher BNP concentration at follow-up (median 33.9 vs. 20.3 pg/mL, P = 0.004). CONCLUSION:LARR was attenuated in female AF patients, which might be related to unfavourable outcomes after ablation therapy. The relatively small number of female patients and short follow-up period in this study require further investigations.

Background Atrial fibrillation (AF) is a predominant risk factor for heart failure, even in patients with preserved left ventricular ejection fraction. Emerging evidence suggests the significance of right ventricular‐pulmonary artery (RV‐PA) uncoupling in heart failure occurrence. We aimed to elucidate the prevalence and associated factors of RV‐PA uncoupling and the efficacy of catheter ablation (CA) for RV‐PA adaptation in patients with AF without history of heart failure. Methods We studied 164 patients with AF free of heart failure who had normal left ventricular ejection fraction and underwent first CA. Echocardiography was performed before and 6 months after CA. RV‐PA coupling was calculated from the ratio of tricuspid annular plane systolic excursion to PA systolic pressure. Abnormal RV‐PA coupling was defined as tricuspid annular plane systolic excursion/PA systolic pressure <0.70 mm/mm Hg. Results Among the participants, 32 (19.5%) patients were classified as having abnormal RV‐PA coupling. The abnormal RV‐PA coupling group was older, and had higher prevalence of persistent AF, higher CRP (C‐reactive protein) and B‐type natriuretic peptide levels than the normal RV‐PA coupling group. Multivariable analysis demonstrated that an elevated CRP level was significantly associated with RV‐PA uncoupling (P=0.004). At 6 months after CA, tricuspid annular plane systolic excursion/PA systolic pressure was significantly improved but was still lower in the abnormal RV‐PA coupling group than in the normal RV‐PA coupling group (P=0.047). Furthermore, improvement of tricuspid annular plane systolic excursion/PA systolic pressure after CA was observed only in patients without recurrent AF. Conclusions Approximately 20% of patients with AF with preserved left ventricular ejection fraction had abnormal RV‐PA coupling, and CA improved RV‐PA coupling status, whereas its benefits were observed in patients free from recurrent AF.

BACKGROUND:Mitral annular calcification (MAC)-related mitral stenosis is associated with increased mortality, but robust long-term outcomes remain unclear. OBJECTIVES:The aim of this study was to investigate 5-year outcomes, including causes of death and valve-related prognostic factors, in patients with MAC-related mitral stenosis. METHODS:The retrospective, multicenter JAMAC (Japan Multicenter Mitral Annular Calcification) study included adult patients from 11 Japanese centers who underwent echocardiography between 2016 and 2017 and had MAC with a transmitral mean gradient ≥5 mm Hg. Mitral stenosis etiology, mitral valve area (MVA), and anterior MAC in the parasternal long-axis view were evaluated. Posterior MAC was graded as mild (less than one-third), moderate (one-third to two-thirds), or severe (more than two-thirds) of the posterior mitral annular circumference in the parasternal short-axis view. The primary outcome was all-cause mortality; secondary outcomes were cardiac and noncardiac death. To determine valve-related prognostic factors, multivariable analysis was performed including key clinical variables. RESULTS:Among 264 patients (median age 78 years; 73% female), 201 (76%) had calcific mitral stenosis and 63 (24%) had rheumatic mitral stenosis. Median MVA was 1.40 cm2, transmitral mean gradient was 6.1 mm Hg, and 63% had anterior MAC. Posterior MAC was severe in 47% and moderate in 25%. Five-year survival was 57%; cardiac and noncardiac mortality was 16% and 24%, respectively. Calcific mitral stenosis showed higher mortality compared with rheumatic mitral stenosis (cardiac death: 18% vs 11%; noncardiac death: 28% vs 13%). Anterior and severe posterior MAC were associated with increased mortality. MVA <1.5 cm2 predicted mortality in calcific mitral stenosis. On multivariable analysis, MVA remained associated with mortality (adjusted HR: 1.56; 95% CI: 1.03-2.38), independent of age and chronic kidney disease, both strong predictors of death. CONCLUSIONS:The prognosis of MAC-related mitral stenosis was poor, with a 5-year survival of 57%, mainly driven by noncardiac mortality in calcific mitral stenosis. Severity of mitral stenosis was one of the independent predictors in this high-risk population.

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.

BackgroundCancer therapy-related cardiac dysfunction (CTRCD) has become an important clinical issue with advances in cancer treatment and improved patient survival. The Japanese Society of Echocardiography previously published practice guidance in 2020. The present document provides an updated revision reflecting recent developments in cardio-oncology.MethodsThis guidance was developed based on contemporary evidence, including the 2022 European Society of Cardiology cardio-oncology guidelines, recent clinical studies, and advances in echocardiographic and multimodality imaging technologies.ResultsLeft ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) are emphasized as essential parameters for diagnosing and monitoring CTRCD. The document provides standardized protocols for echocardiographic evaluation before, during, and after cancer drug therapy, as well as recommendations for long-term surveillance following radiotherapy. It also addresses cardiovascular complications associated with immune checkpoint inhibitors, particularly myocarditis, and highlights the importance of measurement accuracy, quality control, artificial intelligence, and three-dimensional echocardiography in clinical practice.ConclusionsThis updated guidance offers practical and evidence-based recommendations for echocardiographic assessment in cardio-oncology, aiming to facilitate early detection of cardiotoxicity and optimize multidisciplinary management.

Right ventricular–pulmonary artery (RV–PA) coupling is an indicator of the degree to which the right ventricle can adapt to afterload. The ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) (TAPSE/PASP ratio) has been proposed as a non-invasive measure of RV–PA coupling. RV–PA coupling is a key prognostic predictor of heart failure (HF); however, HF with mildly reduced left ventricular ejection fraction (HFmrEF) is difficult to predict. This study aimed to determine the prognostic significance of the TAPSE/PASP ratio in HFmrEF. This retrospective cohort study selected eligible patients from two previous cohorts of patients who were hospitalized for HF and discharged with HFmrEF diagnosed by echocardiography: one cohort from August 2015 to September 2019 and one from April 2020 and March 2023. The primary indicator was the TAPSE/PASP ratio, and the primary endpoint was a composite of all-cause mortality and HF rehospitalization. Patients were categorized into two groups based on the median TAPSE/PASP ratio, and the high and low TAPSE/PASP ratio groups were compared. Multivariate analysis was performed using the Cox proportional hazards model. This study included 391 patients (median age, 72 [60–80] years; 70

Background Recently developed Predicting Risk of cardiovascular disease EVENTs (PREVENT) risk model has shown excellent performance for cardiovascular risk stratification, but its relationship with body fat distribution and left ventricular (LV) mechanics is unknown. Methods We investigated 517 participants free of overt cardiac disease who underwent an extensive cardiovascular health examination. The PREVENT risk score was calculated in each participant, and the study population was categorized into three groups based on the tertiles of the risk score. Body fat distribution was assessed using computed tomography and quantitatively assessed as visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus. All participants also underwent two-dimensional transthoracic echocardiography, and LV global longitudinal strain (LVGLS) was obtained with speckle-tracking analysis. Univariable and multivariable logistic regression models were constructed to investigate the association between the PREVENT risk model and abnormal LVGLS (<17.0% for male and <18.0% for female) adjusting for the clinically relevant covariates. Results Individuals with high PREVENT score had the largest VFA (160.0 [109.7-194.4] cm2), followed by intermediate and low score groups (138.6 [92.0-176.4] cm2 and 89.4 [50.6-123.9] cm2, p<0.001), while SFA was comparable among the three groups (p=0.480). LVGLS was significantly lower with increasing PREVENT risk score (20.4±3.3% vs. 18.9±2.8% vs. 18.1±2.7%, p<0.001). Multivariable logistic regression analysis showed that the PREVENT risk score carried an independent risk for abnormal LVGLS (adjusted odds ratio per 1% increase 1.06, p=0.006). Conclusion The PREVENT risk model was associated with abdominal visceral fat accumulation and subclinical LV dysfunction.

Background:Left atrial (LA) reservoir strain (LARS) is emerging as an early marker of cardiac remodelling, providing significant prognostic information. The present study investigated the prevalence of LA dysfunction and its association with pulmonary hemodynamics and cardiovascular (CV) outcomes in systemic sclerosis (SSc) patients. Methods:We included 52 patients who had SSc without structural cardiac disease. All patients underwent 2-dimensional transthoracic echocardiography and right heart catheterization. LARS was assessed by using speckle-tracking analysis. The study outcome was a composite of heart failure or pulmonary hypertension (PH)-related hospitalization, lung transplantation, and CV death. Results:Abnormal LARS (< 24%) was present in 18 patients (34.6%). Despite the similar prevalence of PH between groups with abnormal vs normal LARS (P = 0.322), patients with LA dysfunction had significantly higher pulmonary vascular resistance (3.5 Wood Units [1.9-5.2] vs 2.0 Wood Units [1.3-2.9], P = 0.029) and reduced pulmonary artery compliance (2.4 [2.1-4.1] ml/mm Hg vs. 3.9 [2.5-5.0] ml/mm Hg, p=0.024) than those with normal LARS. During a median follow-up of 3.2 years, patients with LA dysfunction displayed worse event-free survival than their counterparts (log-rank P = 0.036). The combination of LA function and PH status provided better risk stratification for composite CV outcome, as the highest incidence of adverse outcome was observed in patients with LA dysfunction and PH (40.0%), followed by those with LA dysfunction or PH alone (13.6%), and finally those without LA dysfunction and PH (0%, P = 0.008). Conclusions:LA dysfunction was related to unfavourable pulmonary artery remodelling and adverse outcomes in SSc patients without structural cardiac disease.

Background: Catheter ablation (CA) leads to the recovery of left atrial (LA) function in patients with atrial fibrillation (AF), although the degree varies substantially among individuals. PA-TDI duration, the time delay between the P-wave on the electrocardiogram to the peak A'-wave on tissue-Doppler imaging of the lateral LA wall is an echocardiographic measure that reflects structural and electrical LA remodeling. Objectives: The objective of the study was to investigate whether the preprocedural PA-TDI duration could predict LA functional recovery after CA. Methods: We studied 109 AF patients in sinus rhythm at preprocedural echocardiography, who underwent their first CA. PA-TDI duration was measured by tissue Doppler imaging from the apical four-chamber view. Speckle-tracking echocardiography was performed before and 6 months after CA to evaluate LA reservoir strain (LARS). Results: The median (25th–75th percentile) PA-TDI duration was 144 (128-162) ms. There was no significant difference in age, sex, and AF risk factors between patients with longer PA-TDI duration (≥144 ms) and those with shorter PA-TDI duration (<144 ms). The median follow-up was 465 (273-746) days. LARS was significantly improved at 6 months after CA (29.7% ± 7.9% to 32.1% ± 6.7%; P < 0.001). Preprocedural PA-TDI duration was significantly associated with LARS at 6 months after CA independent of AF type, baseline LARS, and recurrent AF (standardized beta −0.20; 95% CI: −0.10 to −0.01; P = 0.013). Combination of baseline LARS and PA-TDI duration provided enhanced predictive value for postprocedural LA function (P < 0.001). Conclusions: The measurement of PA-TDI duration provided valuable information for LA functional recovery in AF patients who underwent CA.

Although recent epidemiological studies identified albuminuria as an independent risk for atrial fibrillation (AF), even in individuals with a preserved or mildly reduced estimated glomerular filtration rate (eGFR), the prevalence of albuminuria and its association with left atrial (LA) remodelling in patients with AF remains unknown. This study aimed to investigate the association of albuminuria with LA structure and mechanics before and after catheter ablation (CA) in AF patients. We examined 133 AF patients with an eGFR ≥60 mL/min/1.73 m2 who underwent first CA. Conventional and speckle-tracking echocardiography was performed before and 6 months after CA to assess the LA volume index, LA reservoir strain, and LA stiffness. The median eGFR was 70 mL/min/1.73m2, and 21 (15.8%) patients had albuminuria. The difference between the eGFR values of patients with and without albuminuria was not significant (P = 0.709). Patients with albuminuria had a larger LA volume index, reduced LA reservoir strain and increased LA stiffness compared with patients without albuminuria (all P < 0.001). The presence of albuminuria was associated with reduced LA reservoir strain and increased LA stiffness, independent of age, AF type, and AF risk factors. After CA, there was significant improvement in LA size and function in both groups, while albuminuria group still had a larger LA volume index and increased LA stiffness (both P < 0.05). Approximately 16% of AF patients with preserved or mildly reduced eGFR had albuminuria. The presence of albuminuria was related to unfavourable LA remodelling and its persistence even after restoration of sinus rhythm.

BACKGROUND:Left heart abnormalities are risk factors for heart failure. However, echocardiography is not always available. Electrocardiograms (ECGs), which are now available from wearable devices, have the potential to detect these abnormalities. Nevertheless, whether a model can detect left heart abnormalities from single Lead I ECG data remains unclear. METHODS AND RESULTS:We developed Lead I ECG models to detect low ejection fraction (EF), wall motion abnormality, left ventricular hypertrophy (LVH), left ventricular dilatation, and left atrial dilatation. We used a dataset comprising 229,439 paired sets of ECG and echocardiography data from 8 facilities, and validated the model using external verification with data from 2 facilities. The area under the receiver operating characteristic curves of our model was 0.913 for low EF, 0.832 for wall motion abnormality, 0.797 for LVH, 0.838 for left ventricular dilatation, and 0.802 for left atrial dilatation. In interpretation tests with 12 cardiologists, the accuracy of the model was 78.3% for low EF and 68.3% for LVH. Compared with cardiologists who read the 12-lead ECGs, the model's performance was superior for LVH and similar for low EF. CONCLUSIONS:From a multicenter study dataset, we developed models to predict left heart abnormalities using Lead I on the ECG. The Lead I ECG models show superior or equivalent performance to cardiologists using 12-lead ECGs.