Clinical Investigation
Ventricular and Atrial Mechanics
Left Atrial Systolic and Diastolic Dysfunction in Heart Failure with Normal Left Ventricular Ejection Fraction

https://doi.org/10.1016/j.echo.2011.02.004Get rights and content

Background

The authors hypothesized that in patients with heart failure with normal left ventricular (LV) ejection fraction (HFNEF), the same fibrotic processes that affect the subendocardial layer of the left ventricle could also alter the subendocardial fibers of the left atrium. Consequently, these fibrotic alterations, together with chronically elevated LV filling pressures, would lead to both systolic and diastolic subendocardial dysfunction of the left atrium (i.e., impaired left atrial [LA] longitudinal systolic and diastolic function) in patients with HFNEF.

Methods

Patients with HFNEF and a control group consisting of asymptomatic patients with LV diastolic dysfunction (LVDD) matched by age, gender, and LV ejection fraction were studied using two-dimensional speckle-tracking echocardiography.

Results

A total of 420 patients were included (119 with HFNEF and 301 with asymptomatic LVDD). LA longitudinal systolic (LA late diastolic strain rate) and diastolic (LA systolic strain and strain rate) function was significantly more impaired in patients with HFNEF (LA late diastolic strain rate, −1.17 ± 0.63 s−1; LA systolic strain, 19.9 ± 7.3%; LA systolic strain rate, 1.17 ± 0.46 s−1) compared with those with asymptomatic LVDD (−1.80 ± 0.70 s−1, 30.8 ± 11.4%, and 1.67 ± 0.59 s−1, respectively) (all P values < .0001). On multiple regression analysis, LV global longitudinal systolic strain and diastolic strain rate were the most important independent predictors of LA longitudinal systolic and diastolic function, in contrast to noninvasive LV filling pressures (i.e., mitral E/e′ average septal-lateral ratio), which were modestly related to LA longitudinal systolic and diastolic function. Furthermore, in patients with HFNEF, the subendocardial function of both the left atrium and the left ventricle was significantly impaired in high proportions. In that regard, in patients with HFNEF, the rate of LA longitudinal systolic and diastolic dysfunction was 65.5% and 28.5%, whereas the prevalence of LV longitudinal systolic and diastolic dysfunction was 81.5% and 58%, respectively. In addition, patients with both systolic and diastolic longitudinal dysfunction of the left atrium presented worse NYHA functional class as compared with those with normal LA longitudinal function.

Conclusions

In patients with HFNEF, LA subendocardial systolic and diastolic dysfunction is common and possibly associated with the same fibrotic processes that affect the subendocardial fibers of the left ventricle and to a lesser extent with elevated LV filling pressures. Furthermore, these findings suggest that LA longitudinal systolic and diastolic dysfunction could be related to reduced functional capacity during effort in patients with HFNEF.

Section snippets

Study Population

We enrolled consecutive patients aged ≥18 years with signs or symptoms of HF with LVEF > 50% by transthoracic echocardiography (according to the diagnostic criteria of the consensus of experts in HFNEF2 and in LV diastolic function21 of the European Society of Echocardiography and the American Society of Echocardiography) and a control group consisting of asymptomatic patients with LVDD without history of HFNEF (in accordance with the diagnostic criteria of the European Society of

Patient Characteristics and LV Echocardiographic Measurements

A total of 654 patients met the eligibility criteria during the study period (218 with HFNEF and 436 with asymptomatic LVDD). However, 89 patients (17 with HFNEF and 72 with asymptomatic LVDD) could not be enrolled, because of poor two-dimensional quality in one or more LA and LV segments for analysis by speckle-tracking echocardiography and Simpson’s method (n = 24), severe kidney disease (n = 12), cardiac pacing (n = 8), severe chronic liver disease (n = 8), NSTEMI in the past 72 hours (n =

Discussion

In the present study, we performed a comprehensive assessment of the systolic and diastolic function of the left atrium and the left ventricle in patients with HFNEF and in a control group consisting of patients with asymptomatic LVDD. Using two-dimensional speckle-tracking echocardiography at rest, we have demonstrated that patients with HFNEF have severely impaired systolic and diastolic functions of the subendocardial fibers of both the left ventricle and the left atrium (i.e., impaired LV

Conclusions

In patients with HFNEF, the subendocardial systolic and diastolic dysfunction of the left atrium (i.e., LA longitudinal systolic and diastolic dysfunction) is common and possibly associated with the same fibrotic processes that affect the subendocardial layer of the left ventricle as a consequence of comorbid conditions such as hypertension, type 2 diabetes, obesity, and history of CAD. Furthermore, our findings suggest that LA longitudinal systolic and diastolic dysfunction may be important

Acknowledgments

We are grateful to the patients and to the staff of the Department of Echocardiography for their participation in this project.

References (69)

  • W. Kosmala et al.

    Use of body weight and insulin resistance to select obese patients for echocardiographic assessment of subclinical left ventricular dysfunction

    Am J Cardiol

    (2008)
  • A.C. Ng et al.

    Findings from left ventricular strain and strain rate imaging in asymptomatic patients with type 2 diabetes mellitus

    Am J Cardiol

    (2009)
  • T. Stanton et al.

    Assessment of subendocardial structure and function

    J Am Coll Cardiol Img

    (2010)
  • H. Geyer et al.

    Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications

    J Am Soc Echocardiogr

    (2010)
  • S.F. Nagueh et al.

    Recommendations for the evaluation of left ventricular diastolic function by echocardiography

    J Am Soc Echocardiogr

    (2009)
  • R.M. Lang et al.

    Recommendations for chamber quantification

    J Am Soc Echocardiogr

    (2005)
  • F. Triposkiadis et al.

    Left atrial mechanical function in the healthy elderly: new insights from a combined assessment of changes in atrial volume and transmitral flow velocity

    J Am Soc Echocardiogr

    (1995)
  • W.P. Abhayaratna et al.

    Left atrial size: physiologic determinants and clinical applications

    J Am Coll Cardiol

    (2006)
  • R. Vianna-Pinton et al.

    Two-dimensional speckle-tracking echocardiography of the left atrium: feasibility and regional contraction and relaxation differences in normal subjects

    J Am Soc Echocardiogr

    (2009)
  • B. Khankirawatana et al.

    Peak atrial systolic mitral annular velocity by Doppler tissue reliably predicts left atrial systolic function

    J Am Soc Echocardiogr

    (2004)
  • R.M. Saraiva et al.

    Left atrial strain measured by two-dimensional speckle tracking represents a new tool to evaluate left atrial function

    J Am Soc Echocardiogr

    (2010)
  • T.B. Horwich et al.

    Glucose, obesity, metabolic syndrome, and diabetes relevance to incidence of heart failure

    J Am Coll Cardiol

    (2010)
  • C.G. Brilla et al.

    Antifibrotic effect of spironolactone in preventing myocardial fibrosis in systemic arterial hypertension

    Am J Cardiol

    (1993)
  • J.S. Gottdiener et al.

    Left atrial volume, geometry, and function in systolic and diastolic heart failure of persons ≥ 65 years of age (the Cardiovascular Health Study)

    Am J Cardiol

    (2006)
  • C.T. Tsai et al.

    Real-time three-dimensional echocardiography in the evaluation of left atrial structure and function in normal, aging, hypertensive and heart failure patients: new insights into left atrial adaptation and remodeling

    Int J Gerontol

    (2009)
  • G. Di Salvo et al.

    Atrial myocardial deformation properties in obese nonhypertensive children

    J Am Soc Echocardiogr

    (2008)
  • A.C. Boyd et al.

    Left atrial enlargement and phasic function in patients following non-ST elevation myocardial infarction

    J Am Soc Echocardiogr

    (2010)
  • S. Mehta et al.

    The clinical consequences of a stiff left atrium

    Am Heart J

    (1991)
  • H. Dokainish et al.

    Assessment of left ventricular systolic function using echocardiography in patients with preserved ejection fraction and elevated diastolic pressures

    Am J Cardiol

    (2008)
  • D.Y. Leung et al.

    Echocardiographic evaluation of left atrial size and function: current understanding, pathophysiologic correlates, and prognostic implications

    Am Heart J

    (2008)
  • K. Wakami et al.

    Correlation between left ventricular end-diastolic pressure and peak left atrial wall strain during left ventricular systole

    J Am Soc Echocardiogr

    (2009)
  • S. Yusuf et al.

    Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: The CHARM-Preserved Trial

    Lancet

    (2003)
  • A.M. Anwar et al.

    Assessment of left atrial volume and function by real-time three-dimensional echocardiography

    Int J Cardiol

    (2008)
  • C. Rivas-Gotz et al.

    Impact of left ventricular ejection fraction on estimation of left ventricular filling pressures using tissue Doppler and flow propagation velocity

    Am J Cardiol

    (2003)
  • Cited by (0)

    This work was supported by the German Competence Network Heart Failure, funded by the German Federal Ministry of Education and Research (grant FKZ-01GI0205).

    View full text