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Review

Assessment of Left Atrial Structure and Function by Echocardiography in Atrial Fibrillation

by
Mengmeng Ji
1,2,3,†,
Lin He
1,2,3,†,
Lang Gao
1,2,3,
Yixia Lin
1,2,3,
Mingxing Xie
1,2,3,4,5,* and
Yuman Li
1,2,3,*
1
Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
2
Clinical Research Center for Medical Imaging in Hubei Province, Wuhan 430022, China
3
Hubei Province Key Laboratory of Molecular Imaging, Wuhan 430022, China
4
Shenzhen Huazhong University of Science and Technology Research Institute, Shenzhen 518057, China
5
Tongji Medical College and Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan 430022, China
*
Authors to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Diagnostics 2022, 12(8), 1898; https://doi.org/10.3390/diagnostics12081898
Submission received: 29 June 2022 / Revised: 30 July 2022 / Accepted: 2 August 2022 / Published: 5 August 2022
(This article belongs to the Special Issue Imaging Cardiac Arrhythmia/Sudden Cardiac Death 2.0)
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Abstract

:
Atrial fibrillation (AF) is the most common arrhythmia with significant morbidity and mortality. Exacerbated by the aging population, the prevalence of AF is gradually increasing. Accurate evaluation of structure and function of left atrium (LA) has important prognostic significance in patients with AF. Echocardiography is the imaging technique of first choice to assess LA structure and function due to its better availability, accessibility and safety over cardiac computed tomography and cardiac magnetic resonance. Therefore, the aim of this review is to summarize the recent research progress of evaluating LA size by three-dimensional echocardiography and LA function by speckle tracking echocardiography (STE) in predicting the occurrence and recurrence of AF and determining the risk of stroke in AF. In addition, we summarized the role of traditional echocardiography in detecting AF patients that are at high risk of heart failure or cardiovascular death.

1. Introduction

Atrial fibrillation (AF), with significant morbidity and mortality, is the most common arrhythmia around the world [1,2,3]. It is also an epidemic, with an estimated 33 million patients worldwide [4,5]. The incidence of AF is expected to increase as the elderly population with chronic cardiovascular conditions increases [4,6,7,8,9,10,11]. In addition, AF is independently associated with stroke, heart failure (HF) and cardiovascular death, and consequently, it contributes to a significant public health burden [7,12,13,14]. The left atrium (LA) is seen as a critical indicator of adverse outcomes of cardiovascular diseases, especially in patients with AF [15]. LA enlargement and subsequent dysfunction are usually obvious in patients with AF [16,17], and indicate that LA cannot adapt to the onset of rapid atrial tachyarrhythmias or the status of pressure or volume overload. Such LA enlargement is usually considered LA remodeling [15], an important mechanism of AF and also the main pathophysiological basis of AF progression [18]. Prompt treatment can attenuate this pathophysiologic process to a degree, and subsequent reverse remodeling leads to a decrease in LA size and improvement in LA function [15]. Several studies have demonstrated that the accurate evaluation of LA structure and function plays a critical role in characterizing the population with or at high risk of AF, predicting the AF recurrence and assessing the risk for stroke and other cardiovascular diseases [8,19,20]. Nowadays, LA multimodality imaging including echocardiography, cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) can comprehensively assess the size and function of LA by a variety of parameters. However, the image quality of CCT can be deteriorated when heart rate exceeds 60 beats per minute or arrhythmia occurs. Other disadvantages of CCT are its lower temporal resolution, low dose of radiation exposure and contraindications in patients with renal insufficiency and contrast hypersensitivity [12,21,22,23]. CMR is considered the gold standard for assessing LA size and function [8,12], and it can provide accurate endocardial border definition [24,25,26]. In addition, the detailed anatomic definition of the pulmonary vasculature can be evaluated by CMR, which can benefit AF ablation [15]. However, it has several limitations, including a longer scan time, high expense, and the relative contraindication with metal implant or claustrophobia, which limit the wide clinical application of CMR [27].
The aim of this review is to summarize the recent research evaluating LA structure and function by real-time three-dimensional (3D) echocardiography (RT-3DE) and 3D speckle tracking echocardiography (3D-STE) in identifying patients with or at high risk of AF and predicting AF recurrence. In addition, because RT-3DE and 3D-STE have not been widely applied in clinical practice, we also summarize the application of LA strain by two-dimensional STE (2D-STE) in predicting the new onset of AF and assessing the risk of stroke, as well as the role of traditional echocardiography in predicting HF and cardiovascular death in AF.
We used the keywords, “LA structure and function”, “LA strain”, “STE”, “AF”, and “stroke”, to search the literature on PubMed and Web of Science from inception to 2022, mainly selecting the literature published in the last five years.

2. LA Structure and Function in AF

2.1. LA Structural Assessment in AF

LA structural remodeling is a result of increased interstitial fibrosis, which results in cardiac structural alterations including LA dilatation [15,28,29]. LA enlargement and LA fibrosis are not only the hallmark initiating factors of AF, but are also the critical reason for AF maintenance and progression. AF can be evaluated by LA size and myocardial fibrosis, and echocardiography is usually considered the most extensive and established method of evaluating cardiac structure [12]. LA dilatation is a significant indicator for predicting the morbidity and mortality of cardiovascular diseases [30]. However, it is difficult to accurately quantify the size of LA because of its complex and asymmetric geometry, intricate fiber alignment, and influence of LA appendage and pulmonary vein. Though the antero-posterior diameter (APD) of LA is widely used in clinical practice due to its high repeatability, the APD of LA cannot precisely reflect the practical size of LA due to asymmetric remodeling during dilation [18,20]. Previous studies have demonstrated that LA volume (LAV) could reflect the changes of LA in all directions when LA is remodeled [31]. The maximum LA volume index (LAVi) remains the only officially recommended predictor that is independently associated with cardiovascular adverse events in the current guidelines [32]. The full name and calculations of LA structural parameters are depicted in Table 1.
LA fibrosis is the basis of the occurrence and maintenance of AF and is closely related to the recurrence of AF after ablation [33]. Additionally, LA fibrosis is a critical factor associated with the outcome in patients with AF [4]. The degree of LA fibrosis can be evaluated by delayed enhancement CMR (DE-CMR), however, the high cost, complex operation and time consumption of CMR limit its wide use in clinical practice [34]. At present, echocardiography is still the most practical and convenient imaging tool. The degree of LA fibrosis can be noninvasively evaluated by integrated backscatter (IBS), which can characterize tissue structure based on tissue ultrasound reflectivity [15]. Previous studies have confirmed the excellent relation between IBS and the extent of collagen deposition [35]. In recent years, myocardial strain and strain rate analysis have become a new noninvasive method for indirect evaluation of LA fibrosis [36]. Several studies have demonstrated that the extent of atrial fibrosis is negatively correlated with LA strain and strain rate on DE-CMR [36,37]. Therefore, LA strain analysis plays a significant role in assessing LA fibrosis in patients with AF. Peak LA longitudinal strain (PALS) is negatively associated with the extent of LA fibrosis and is a critical indicator of the recurrence of AF after successful ablation [38]. It is usually measured at the end of LA filling and precisely predicts LV filling pressures [39], consequently, PALS can provide important significance in patients with AF [40].

2.2. LA Function Assessment in AF

Under normal physiological conditions, the primary function of LA includes filling and emptying. LA function can be further divided into three aspects. LA respectively serves as a reservoir for pulmonary venous flow during ventricular systole, a conduit for pulmonary venous flow during early ventricular diastole, and a booster pump that increases ventricular filling during late ventricular diastole [41]. The booster pump function is the most important mechanical function of LA, which significantly contributes to approximately 20% to 30% of the left ventricular (LV) stroke volume at the end of LV diastole [27]. LA reservoir function is affected by atrial compliance, LV systolic function and LA contraction and relaxation. While LA conduit function is influenced by atrial compliance during ventricular diastole, it is closely associated with preload and LV relaxation and stiffness. LA booster pump function largely depends on the intrinsic LA contractility, but is also influenced by venous return, LV end-diastolic pressures, and LV systolic reserve [20,42,43].
LA functional remodeling is significantly related to LA structural remodeling, and the vicious circle of “AF-induced AF” can be caused by structural remodeling and electrical remodeling of the LA [44]. In these circumstances, both the frequency and duration of AF increase, which are the main reasons for AF maintenance and the conversion to persistent AF. LA booster pump function and reservoir function are usually damaged due to LA structural remodeling in patients with AF, which are manifested as LA dysfunction. Additionally, recent research has demonstrated that LA dysfunction may precede LA structure changes [45,46], and therefore, the evaluation of LA function can provide more prognostic value [47,48,49]. In conclusion, LA function evaluation also plays a crucial role in AF.

3. Echocardiographic Assessment of LA Structure and Function in AF

3.1. Real-Time Three-Dimensional Echocardiography

LAV is typically evaluated by standard 2D echocardiography. However, traditional 2D echocardiography is usually limited by its poor image quality, higher intra-observer and inter-observer variability, 2D image plane and geometric assumptions, which can underestimate the true LAV. In recent years, the advent of RT-3DE has improved the accuracy and reproducibility of LV volume assessment. Three-dimensional echocardiography can better define the complex anatomy of LA in tri-plane with less geometric assumptions, and it can make up for the error caused by shortening of biplanar volume measurement in 2D plane. Additionally, LAV assessment by 3DE is more closely associated with CMR, the gold standard of LAV assessment [15,20,50,51,52,53,54]. A major shortcoming of 3DE is the comparatively low frame rate for 3D image acquisition and the low spatial resolution, though LAV by 3DE has demonstrated prognostic value [15]. RT-3DE can also assess LA dysfunction by LAVi, maximum LAV and minimum LAV (Figure 1), which can provide independent and incremental prognostic value compared with those above parameters evaluated by 2D traditional echocardiography [55,56,57].

3.2. Speckle Tracking Echocardiography

Myocardial strain and strain rate are quantifications of the magnitude and rate of myocardial deformation. LA strain and strain rate can be evaluated by tissue doppler imaging (TDI) and STE. STE can compensate for the limitations of TDI, which including angle-dependence and susceptible to reverberations, sidelobes and drop out artifacts [58,59,60,61]. In recent years, LA strain and strain rate derived from STE have been seen as the gold standard for LA function assessment [62]. LA strain is presented in the form of a time–strain curve and is divided into three phases. The task force of European Society of Cardiology recommends using the QRS complex as the zero baseline for patients with AF, and the ventricular end-diastole as the zero reference. LA myocardial deformation is usually evaluated as global longitudinal strain, which is defined as the strain in the direction tangential to the endocardial atrial border in the apical four-chamber view. Peak LA global longitudinal strain during reservoir phase (LASr) is assessed as the difference of the strain value at mitral valve opening minus ventricular end-diastole. The peak LA global longitudinal strain during conduit phase (LAScd) is evaluated as the difference of the strain value at the onset of atrial contraction minus mitral valve opening. The peak LA global longitudinal strain during contraction phase (LASct) is estimated as the difference of the strain value at the ventricular end-diastole minus onset of atrial contraction. Since the atrial wall lengthens during the reservoir phase, LASr is usually characterized by a positive value. Due to the shortening of the LA wall during the other two phases, LAScd and LASct are usually considered as negative values. In addition, LAScd has the same value as LASr in patients with AF, however the sign is negative [63,64]. Under the atrial cycle, the first negative peak strain of the LA strain curve represents the contraction function of LA (LASct), the positive peak strain corresponds to the conduit function (LAScd), and the sum of the two peaks represents the reservoir function (LASr). PALS also be used to represent LA reservoir function in other studies, and stands for the same significance as LASr. In the same way, peak LA contraction strain (PACS) represents the LA contraction function, the same as LASct, and the difference between PALS and PACS reflects LA conduit function.
LA function can also be evaluated by volumetric function parameters derived from STE. Total LA emptying fraction (LAEF) indicates the LA reservoir function and can be further divided into passive LAEF and active LAEF, representing conduit function and pump function, respectively [65]. The full name and calculations of LA functional parameters are depicted in Table 1.

3.2.1. Two-Dimensional Speckle Tracking Echocardiography

At present, 2D-STE is the most commonly used technique in evaluating myocardial strain and strain rate [40]. It is a developing ultrasonic technique, and myocardial deformation can be evaluated through acoustic backscatter (speckles) generated by the reflected ultrasound beam. It is preferable to obtain the region of interest (ROI) from a non-foreshortened apical four-chamber or two-chamber view, and the complete ROI of LA is defined as the endocardial border and the epicardial border. The endocardial border of LA usually starts the tracing at the endocardial border of the mitral annulus in the apical four-chamber, and traces the LA endocardial border, extrapolating across the pulmonary veins, and/or LA appendage orifices, up to the opposite mitral annulus side [64]. 2D LASr and LASct in subjects with sinus rhythm and AF are shown in Figure 2. Strain analysis by 2D-STE is a method of myocardial deformation in 2D plane, and that may lead to the out-of-plane motion of speckles. In addition, LA strain assessed by 2D-STE mainly reflects the motion of longitudinal myocardial fibers, which cannot comprehensively describe the complete myocardial function and may overlook LA dysfunction.

3.2.2. Three-Dimensional Speckle Tracking Echocardiography

Three-dimensional STE (3D-STE) is a new technique that combines 3D echocardiography and speckle tracking imaging. It can overcome the shortcomings of 2D-plane tracking and track the motion of myocardium more comprehensively, objectively and accurately in 3D space. Three-dimensional STE can compensate for the limitation of 2D-STE that merely reflects the motion of longitudinal myocardial fibers, and evaluates not only longitudinal strain but also circumferential and area strain [66]. Therefore, 3D-STE can more precisely assess the LA function with excellent reproducibility [67]. However, 3D-STE is largely dependent on image quality and temporal resolution [32,68]. These aspects are the reasons that LA strain by 3D-STE is a better parameter but with lower clinical application rate.

4. LA Structure and Function to Predict the Occurrence of AF

Early prediction of AF in patients with sinus rhythm is of significance to prevent thromboembolism, the major complication and the first clinical manifestation of AF, and other adverse outcomes. LAV has been considered as a significant indicator of the occurrence of AF. Bruun Pedersen et al. [69] assessed the LAVi and maximum and minimum LAV by 2D and 3D echocardiography in 110 patients with transient ischemic attack (TIA) and without the history of AF or stroke. Fourteen patients developed AF during a mean follow-up of 2.2 years. They demonstrated that LAVi derived from both 2D and 3D images was larger in patients with AF, and those patients also had larger maximum and minimum LAV on both 2D and 3D echocardiography. However, only 3D LAVi, not 2D LAVi, was statistically significant in relation to the occurrence of AF.
The morbidity of AF in patients with Chagas disease is twice that of patients without Chagas disease, and in addition, AF is associated with the incremental mortality of Chagas disease [70,71]. Thus, the predictors of AF in patients with this disease play an important role in early prediction of the outcome of Chagas disease. Saraiva et al. [54] evaluated 392 adult patients with chronic Chagas disease using 3D echocardiography and 2D-STE. They found that 3D total and passive LAEF and 2D LASct had independent predictive value of the occurrence of AF. This study suggested that LA function parameters could provide superior prognostic value to predict new-onset AF in patients with Chagas disease compared with LAV parameters. In addition, this study demonstrated that the LA reservoir function is the best component of LA function that is associated with the occurrence of AF. However, 2D LASct representing LA contractile function was the only 2D LA strain parameter with incremental prognostic value. The above conflicting results may be due to the limitations of a biplane analysis of 2D-STE, far field, LA thin walls, pulmonary veins and LA appendage orifices of LA strain analysis. Therefore, it is necessary to apply 3D-STE to quantify LA function in clinical practice.
Hirose et al. [72] evaluated LAEF, LA strain rate and LAV by STE in 580 consecutive adults without a history of atrial arrhythmias. They demonstrated that, compared to subjects with non-AF at baseline, those without new-onset AF had higher active LAEF and higher LA strain rate during LA systole, but lower maximum LAVi. In addition, only reduced active LAEF was independently associated with new-onset AF in multivariate logistic regression analysis, therefore, active LAEF evaluated by STE was an independent predictor of the risk of new-onset AF. This study demonstrated that LA function parameters could provide superior prognostic value over LA size.
LA strain can predict the new onset of AF not only in the general population, but also in patients with heart failure (HF). Park et al. [73] researched PALS in 2461 acute HF patients with sinus rhythm, and confirmed that patients with reduced PALS had higher new-onset AF compared to subjects with relatively higher PALS during a 5-year follow-up. PALS could be seen as a significant parameter to predict the risk of new-onset AF in patients with acute HF and sinus rhythm, which could help clinicians to timely adjust treatment decisions. Jasic-Szpak et al. [74] researched PALS, PACS by 2D-STE and LAVi by 2D traditional echocardiography in 170 patients with symptomatic HF with preserved ejection fraction (HFpEF), without baseline AF. They found that PACS, PALS, and LAVi could provide the best predictive value for AF. They demonstrated that predictive value of PACS and PALS was independent from clinical data, LAVi and other conventional LA function parameters, and in addition, PALS and PACS could offer incremental predictive value. Therefore, involving PALS and PACS in the diagnostic algorithm was able to detect the HFpEF patients with high risk of AF, contributing to guiding clinical management.
A single center cross-sectional study [65] showed that LA enlargement, LA reservoir and pump function, but not conduit function, were independently related to AF. The parameters that derived from 3D-STE, particularly minimum LAV, total LAEF, active LAEF, LASrc and LASctc, were able to distinguish paroxysmal AF subjects from patients without AF. This study demonstrated the relationship between LA strain and LA volumetric function parameters for the first time. They confirmed that the peak LA global circumferential strain during reservoir phase (LASrc), peak LA global circumferential strain during conduit phase (LAScdc) and peak LA global circumferential strain during contraction phase (LASctc) are more significantly associated with total LAEF, passive LAEF and active LAEF, respectively, over LASr, LAScd and LASct. In addition, that may be attributed to the more significant impacts of circumferential myocardial deformation of LA on LA global hemodynamic function. Thus, they assumed that LA circumferential strain might offer greater value. They also hold the opinion that 3D-STE can be used as an accurate tool to determine patients with paroxysmal AF even before structural changes, and therefore it can guide the determination of treatment strategy in daily clinical practice. The researchers reckoned that LASrc, the parameter of LA reservoir function, was of the most outstanding clinical value, because LA pump function of patients with AF disappeared and LA conduit function was less influenced by AF.
Hypertension (HT) is considered the most common risk factor for paroxysmal AF. Furukawa et al. [75] investigated the relationship between LA function and the occurrence of AF by 3D-STE in 44 hypertensive patients with paroxysmal AF, 50 hypertensive patients without paroxysmal AF, and 50 healthy controls without HT or paroxysmal AF. They demonstrated that peak LA global strain and LAEF in patients with paroxysmal AF were obviously lower compared to those without paroxysmal AF and controls. Maximum LAVi and peak LA global strain were independent predictors of paroxysmal AF in patients with HT by multivariate analysis. They confirmed that LA dysfunction is related to the occurrence of AF in patients with HT by using 3D-STE.
Paroxysmal AF is seen as the most common reason of severe stroke and one of the most widespread covert reasons of cryptogenic stroke [76]. The more time spent in paroxysmal AF each day is associated with higher risk of thromboembolism [77]. Pagola et al. [78] demonstrated that PALS and N-terminal pro b-type natriuretic peptide (NT-proBNP) as LA dysfunction indicators could provide significant predictive value for the occurrence of paroxysmal AF with high risk of embolization (HpAF) despite LA size and the age of patients. In addition, the combination of PALS with NT-proBNP could independently predict the occurrence of HpAF with increased predictive power, which was superior to traditional surrogates as age or LAVi.

5. LA Structure and Function to Predict the Recurrence of AF after Catheter Ablation

The critical management of AF is to identify and improve predisposing conditions, restore the normal heart rate and sinus rhythm, and predict and reduce the risk of systemic thromboembolism and stroke. Catheter ablation (CA) is a well-established treatment for restoring and maintaining sinus rhythm in patients with AF [79], and pulmonary vein isolation by radiofrequency or cryoablation is the most common ablation technique [12,80,81]. The Scale for the Assessment and Rating of Ataxia (SARA) research has confirmed that CA was obviously more effective than antiarrhythmic drug treatment in maintaining sinus rhythm for patients with persistent AF, and it decreased the recurrence of 24 hours of sustained episodes of AF by 47.4% [82]. Guidelines increasingly support the use of CA in AF as an early therapeutic approach to symptom control, particularly for symptomatic drug-refractory AF [83]. Whereas LA fibrosis can be aggravated by the energy of CA, the LA structural remodeling and dysfunction can be exacerbated by the scar after ablation. Therefore, after successful ablation, in approximately one-third of patients AF may recur. In addition, AF cannot be eliminated in around 10% of AF patients [84,85,86]. In sum, the determination of parameters of LA remodeling for predicting patients with high risk of recurrence after CA plays a significant role in assisting clinicians in making more specific therapeutic strategy. LA size can determine the risk of recurrence of AF in patients after CA [87]. Additionally, LA strain evaluated by 2D-STE has been demonstrated as an independent predictor of AF recurrence after CA [88,89,90], however, 2D-STE is limited by its dependency on image quality and the out-of-plane motion of some speckles, which may overestimate LA function [68].
Montserrat et al. [91] found that LAV evaluated by 3D echocardiography was a superior predictor of the outcome after first radiofrequency catheter ablation (RFCA) when compared with 2D LAV. They also demonstrated that only the higher LA expansion index (LAEi) was related to non-recurrence of AF after the first RFCA in the multivariate analysis. Additionally, 3D maximum LAV was significantly associated with the non-recurrence of AF in the younger patients than aged 54 or younger after a second RFCA. All in all, this research confirmed that 3D LA function parameter was superior to 3D LA size in predicting the non-recurrence of CA. They recommended the combination of LA function parameters evaluated by 3D echocardiography and that clinical characteristics including age and hypertension were able to improve the predictive ability of the outcome of RFCA.
Yang et al. [92] established a predictive model by using LA reservoir function parameters that measured by RT-3DE, LAEi and diastolic ejection index (DEI), and the blood B-type natriuretic peptide (BNP) level before circular pulmonary vein ablation (CPVA) in 215 patients with early persistent AF after CPVA. LA appendage peak emptying velocity (LAAV) was also evaluated by pulse Doppler imaging in all patients. They found that patients with AF recurrence displayed higher minimum LAVi, DEI and BNP, however, patients with sinus rhythm had higher LAEi and LAAV. The above four parameters, BNP, LAAV, minimum LAVi and DEI, were the optimal predicators after single-factor ROC curve analysis, and a predictive model for recurrence was constructed by DEI, BNP and LAAV after multivariate logistic regression analysis. They demonstrated that the combined predictive model was superior to the best single-factor indicator (BNP) in predicting AF recurrence after CPVA with significantly excellent precision, efficiency and specificity.
Mochizuki et al. [66] estimated LA strain by 2D-STE and 3D-STE in forty-two paroxysmal AF patients undergoing first-time CA. They demonstrated that 3D global peak LA area strain during systole (3D-GASs) was independently associated with AF recurrence and it was demonstrated to be a better predictor of AF recurrence after CA compared with LA strains evaluated by 2D-STE or other clinical predictors, such as LAV, age and so on. This study also explained that it is possible that the single longitudinal myocardial evaluation of 2D-STE and the differences of clinical characteristics (age, gender distribution, LAV and the values of 2D-GLSs) between this study and previous research may be the reasons that 2D LA strain is inferior to 3D LA strain for predicting AF recurrence after CA. In short, this research proved that LA strain derived from 3D-STE is of better prognostic value in predicting the recurrence after CA for patients with paroxysmal AF compared with 2D LA strain parameters and other relevant indicators.

6. LA Structure and Function to Predict the Risk of Other Cardiovascular Diseases in AF

6.1. Ischemic Stroke

LA enlargement is common in patients with AF and indicates the presence of adverse LA structure remodeling, which is related to electrical instability and easily contributes to thromboembolism formation [93]. AF can increase the risk of ischemic stroke by four- to five-fold by contributing to a prothrombotic status and abnormal endothelial function [2,94]. Thus, early recognition of AF patients at high-risk of stroke plays an imperative role in guiding antithrombotic treatment. However, previous risk stratification schemes were mainly based on baseline demographics and clinical illnesses and ignored the effect of abnormal LA structure and function [95,96]. The increased LAV and damaged function are associated with a relatively higher clinical risk of thromboembolic stroke events. Currently, 2D-STE is emerging as one of the commonly used imaging tools for risk stratification of stroke in patients with AF [17,97]. PALS is the most frequently used indicator for increased risk of ischemic stroke among all LA deformation parameters [98,99], which is increasingly recognized in clinical practice.
Though 2D-STE is a useful tool in evaluating LA function in AF, it is limited by an irregular heart cycle in patients with AF to a great extent. Liao et al. [100] studied the predictive value of PALS by 2D-STE and the repeatability and feasibility of it by three-beat average method compared with 10-s average, and index-beat measurement among 1457 AF participants. This study confirmed that PALS and LA longitudinal strain rate (LASR) by averaged three-beat method during AF were significantly correlated with other measurements with excellent feasibility and repeatability. They also demonstrated that PALS, LA longitudinal systolic strain rate (LASRs) at the reservoir phase and the absolute value of LA longitudinal early diastolic SR (LASRe) at the conduit phase were associated with the decreased risk of stroke adjusted for clinical covariates or CHA2DS2-VASc score and traditional echocardiography parameters. However, only PALS was still independently associated with ischemic stroke after further adjusting LV global longitudinal strain (LVGLS) and LAVi. Therefore, the employment of PALS was able to offer incremental predictive value of ischemic stroke risk classification in patients with low and high CHA2DS2-VASc score.
Liao et al. [101] studied the predictive ability of the decreased PALS in 1364 patients with AF. They found that PALS was significantly impaired in patients developing stroke compared with those without stroke. In addition, all patients were classified into five groups according to the standard score of PALS (ZLA): Z0, Z − 1, Z − 2, Z − 3, and Z − 4. During the mean follow-up period of 3.1 ± 1.6 years, the morbidity of patients with Z − 2 to Z − 4 was gradually increased. When the Z − 2 group was defined as a reference, the Z − 3 and Z − 4 groups demonstrated a higher risk of ischemic stroke after adjusting clinical and echocardiographic variables. This study demonstrated that the decreased PALS could be presented in a stratified way, and the classification of PALS was related to the risk of ischemic stroke, which was independent of the baseline covariates, CHA2DS2-VASc score, and traditional echocardiographic parameters.

6.2. Heart Failure or Cardiovascular Death

AF can contribute to LA structural and functional remodeling, which is also correlated with the increased risk for HF and cardiovascular death in addition to stroke [102]. Therefore, it is also crucial to determine AF patients with high risk of HF or cardiovascular death. Wen et al. [103] found that higher LAVs (maximum LAVi and minimum LAVi) and lower LA reservoir function (LAEF and LAEi) at three months after CA were strongly associated with higher risk for HF and cardiovascular death during a median of 7.5 years of follow-up, which was independent of age, atrial tachyarrhythmia recurrence, and clinical and conventional echocardiographic parameters of LV structure and function. In addition, increased minimum LAVi could help determine the patients with high risk of adverse outcome in those with normal LA size. This study also demonstrated that minimum LAVi was the best predictor that related to HF or cardiovascular death compared with maximum LAVi, LAEF and LAEi.
A prospective echocardiographic study [104] demonstrated that increased LAVi and decreased LAEF and LAEi were related to the higher level of risk for HF and cardiovascular death alone in the unadjusted analysis and only impaired LA function indicators, LAEF and LAEi, were significantly associated with HF and cardiovascular death after adjusting clinical and echocardiographic parameters. This study also found that around half of patients with normal LA structure had LA dysfunction, and that was consistent with the results of previous studies that LA dysfunction may occur prior to LA structural abnormality. LA dysfunction was able to increase the risk of HF and cardiovascular death in spite of normal LAV, indicating that LA function parameters could provide incremental prognostic value compared with LAV.
The temporal changes of LA structure and function are of important significance in patients with HF and AF, which may predict the treatment response and prognosis. Many previous studies have researched the prognostic value of LA structure and function parameters in patients with HF and with AF. Mathias et al. [105] studied the response to cardiac resynchronization therapy with a defibrillator (CRT-D) in 533 patients with CRT-D and left bundle branch block (LBBB). The changes of both LAV and left ventricular end-systolic volume (LVESV) were above median changes in patients with complete left-sided reverse remodeling, and only LAV or LVESV changed above the median change in patients with discordant reverse remodeling. They demonstrated that the risk of HF and death, HF alone and death alone in patients with complete left-sided reverse remodeling was significantly lower compared with patients with discordant or lesser reverse remodeling during long-term follow-up.
Park et al. [106] demonstrated that PALS was a significant predictor of death and HF hospitalization in patients with acute HF and AF. However, PALS was not associated with death and HF hospitalization in patients with AF when they divided patients according to the presence of AF. PALS could predict the adverse outcome when patients were divided according to the type of HF, HF with reduced ejection fraction (HFrEF), HF with mid-range ejection fraction (HFmrEF), or HFpEF, but the prognostic power of PALS was same among the above three subgroups.
Moon et al. [107] evaluated the time trajectories of the left ventricular global longitudinal strain (LVGLS) and LASr in 409 patients with HFrEF prescribed sacubitril/valsartan. They demonstrated that both the LVGLS and LASr improved over time during follow-up, and the prominent improvements in LAGLS and LASr occurred within six months of sacubitril/valsartan treatment. Larger improvements were associated with death and HF hospitalization, and the improvement in the LVGLS to ≥ 13% and LARS to ≥12.5% could better predict the lower risk of cardiovascular death and HF hospitalization compared with other traditional echocardiographic parameters. This study confirmed that the improvement of LVGLS and LASr, defined as complete left heart reverse remodeling, could be seen as a significant predictor to reflect the treatment response and prognosis.

7. Conclusions

LA enlargement and dysfunction can predict the occurrence of AF in patients with sinus rhythm; it was also significantly associated with the adverse outcome of AF. Currently, implementation of RT-3DE and STE has provided a novel imaging technique to assess the LA size and function in AF with more accuracy, sensitivity and repeatability. However, there is lack of relevant studies about the role of 3D-STE in predicting stroke, HF and cardiovascular death in AF and more research is essential to be implemented in the future.

Author Contributions

Writing—original draft preparation, M.J. and L.H.; resources, L.G. and Y.L. (Yixia Lin); validation, L.G. and Y.L. (Yuman Li); writing—review and editing, M.J., L.H. and Y.L. (Yuman Li); supervision, Y.L. (Yuman Li) and M.X.; funding acquisition, Y.L. (Yuman Li), and M.X. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the National Natural Science Foundation of China (Grant Nos. 81727805, 81922033, 81771851, 82001852), the Key Research and Development Program of Hubei (Grant Nos. 2020DCD015, 2021BCA138), and the Shenzhen Science and Technology under Grant (Grant No. SGDX20190917094601717).

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Hindricks, G.; Potpara, T.; Dagres, N.; Arbelo, E.; Bax, J.J.; Blomström-Lundqvist, C.; Boriani, G.; Castella, M.; Dan, G.A.; Dilaveris, P.E.; et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur. Heart J. 2021, 42, 373–498. [Google Scholar] [CrossRef] [PubMed]
  2. Chao, T.F.; Liu, C.J.; Tuan, T.C.; Chen, T.J.; Hsieh, M.H.; Lip, G.Y.H.; Chen, S.A. Lifetime Risks, Projected Numbers, and Adverse Outcomes in Asian Patients With Atrial Fibrillation: A Report From the Taiwan Nationwide AF Cohort Study. Chest 2018, 153, 453–466. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  3. Sørensen, E.; Myrstad, M.; Solberg, M.G.; Øie, E.; Tveit, A.; Aarønæs, M. Left atrial function in male veteran endurance athletes with paroxysmal atrial fibrillation. Eur. Heart J. Cardiovasc. Imaging 2021, 23, 137–146. [Google Scholar] [CrossRef] [PubMed]
  4. Ma, J.; Chen, Q.; Ma, S. Left atrial fibrosis in atrial fibrillation: Mechanisms, clinical evaluation and management. J. Cell Mol. Med. 2021, 25, 2764–2775. [Google Scholar] [CrossRef] [PubMed]
  5. Iwasaki, Y.K.; Nishida, K.; Kato, T.; Nattel, S. Atrial fibrillation pathophysiology: Implications for management. Circulation 2011, 124, 2264–2274. [Google Scholar] [CrossRef] [Green Version]
  6. Leong, D.P.; Dokainish, H. Left atrial volume and function in patients with atrial fibrillation. Curr. Opin. Cardiol. 2014, 29, 437–444. [Google Scholar] [CrossRef]
  7. Chugh, S.S.; Havmoeller, R.; Narayanan, K.; Singh, D.; Rienstra, M.; Benjamin, E.J.; Gillum, R.F.; Kim, Y.H.; McAnulty, J.H., Jr.; Zheng, Z.J.; et al. Worldwide epidemiology of atrial fibrillation: A Global Burden of Disease 2010 Study. Circulation 2014, 129, 837–847. [Google Scholar] [CrossRef] [Green Version]
  8. Guglielmo, M.; Baggiano, A.; Muscogiuri, G.; Fusini, L.; Andreini, D.; Mushtaq, S.; Conte, E.; Annoni, A.; Formenti, A.; Mancini, E.M.; et al. Multimodality imaging of left atrium in patients with atrial fibrillation. J. Cardiovasc. Comput. Tomogr. 2019, 13, 340–346. [Google Scholar] [CrossRef]
  9. Benjamin, E.J.; Muntner, P.; Alonso, A.; Bittencourt, M.S.; Callaway, C.W.; Carson, A.P.; Chamberlain, A.M.; Chang, A.R.; Cheng, S.; Das, S.R.; et al. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019, 139, e56–e528. [Google Scholar] [CrossRef]
  10. Staerk, L.; Sherer, J.A.; Ko, D.; Benjamin, E.J.; Helm, R.H. Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Circ. Res. 2017, 120, 1501–1517. [Google Scholar] [CrossRef] [Green Version]
  11. Miyasaka, Y.; Barnes, M.E.; Gersh, B.J.; Cha, S.S.; Bailey, K.R.; Abhayaratna, W.P.; Seward, J.B.; Tsang, T.S. Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence. Circulation 2006, 114, 119–125. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  12. Walters, T.E.; Ellims, A.H.; Kalman, J.M. The role of left atrial imaging in the management of atrial fibrillation. Prog Cardiovasc. Dis 2015, 58, 136–151. [Google Scholar] [CrossRef] [PubMed]
  13. Li, X.; Tse, V.C.; Au-Doung, L.W.; Wong, I.C.K.; Chan, E.W. The impact of ischaemic stroke on atrial fibrillation-related healthcare cost: A systematic review. Europace 2017, 19, 937–947. [Google Scholar] [CrossRef] [PubMed]
  14. Arnăutu, S.F.; Morariu, V.I.; Arnăutu, D.A.; Tomescu, M.C.; Dan, T.F.; Dragos Jianu, C. Left Atrial Strain Helps Identifying the Cardioembolic Risk in Transient Ischemic Attacks Patients with Silent Paroxysmal Atrial Fibrillation. Ther. Clin. Risk. Manag. 2022, 18, 213–222. [Google Scholar] [CrossRef]
  15. Thomas, L.; Abhayaratna, W.P. Left Atrial Reverse Remodeling: Mechanisms, Evaluation, and Clinical Significance. JACC Cardiovasc. Imaging 2017, 10, 65–77. [Google Scholar] [CrossRef]
  16. Zhang, Q.; Yip, G.W.; Yu, C.M. Approaching regional left atrial function by tissue Doppler velocity and strain imaging. Europace 2008, 10, iii62–iii69. [Google Scholar] [CrossRef]
  17. Di Salvo, G.; Caso, P.; Lo Piccolo, R.; Fusco, A.; Martiniello, A.R.; Russo, M.G.; D’Onofrio, A.; Severino, S.; Calabró, P.; Pacileo, G.; et al. Atrial myocardial deformation properties predict maintenance of sinus rhythm after external cardioversion of recent-onset lone atrial fibrillation: A color Doppler myocardial imaging and transthoracic and transesophageal echocardiographic study. Circulation 2005, 112, 387–395. [Google Scholar] [CrossRef] [Green Version]
  18. MA, X.X. Application of echocardiography in left atrial remodeling. Chin. J. Med. Imaging Technol. 2015, 31, 1915–1918. [Google Scholar] [CrossRef]
  19. Zhuang, J.; Wang, Y.; Tang, K.; Li, X.; Peng, W.; Liang, C.; Xu, Y. Association between left atrial size and atrial fibrillation recurrence after single circumferential pulmonary vein isolation: A systematic review and meta-analysis of observational studies. Europace 2012, 14, 638–645. [Google Scholar] [CrossRef]
  20. Delgado, V.; Di Biase, L.; Leung, M.; Romero, J.; Tops, L.F.; Casadei, B.; Marrouche, N.; Bax, J.J. Structure and Function of the Left Atrium and Left Atrial Appendage: AF and Stroke Implications. J. Am. Coll. Cardiol. 2017, 70, 3157–3172. [Google Scholar] [CrossRef]
  21. Chen, C.M.; Liu, Y.C.; Chen, C.C.; Wen, M.S.; Hung, C.F.; Wan, Y.L. Radiation dose exposure of patients undergoing 320-row cardiac CT for assessing coronary angiography and global left ventricular function. Int. J. Cardiovasc. Imaging 2012, 28, 1–5. [Google Scholar] [CrossRef] [PubMed]
  22. Chinnaiyan, K.M.; Bilolikar, A.N.; Walsh, E.; Wood, D.; DePetris, A.; Gentry, R.; Boura, J.; Abbara, S.; Al-Mallah, M.; Bis, K.; et al. CT dose reduction using prospectively triggered or fast-pitch spiral technique employed in cardiothoracic imaging (the CT dose study). J. Cardiovasc. Comput. Tomogr. 2014, 8, 205–214. [Google Scholar] [CrossRef] [PubMed]
  23. To, A.C.; Flamm, S.D.; Marwick, T.H.; Klein, A.L. Clinical utility of multimodality LA imaging: Assessment of size, function, and structure. JACC Cardiovasc. Imaging 2011, 4, 788–798. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  24. Aquaro, G.D.; Di Bella, G.; Castelletti, S.; Maestrini, V.; Festa, P.; Ait-Ali, L.; Masci, P.G.; Monti, L.; di Giovine, G.; De Lazzari, M.; et al. Clinical recommendations of cardiac magnetic resonance, Part I: Ischemic and valvular heart disease: A position paper of the working group ’Applicazioni della Risonanza Magnetica’ of the Italian Society of Cardiology. J. Cardiovasc. Med. 2017, 18, 197–208. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  25. Pontone, G.; Di Bella, G.; Castelletti, S.; Maestrini, V.; Festa, P.; Ait-Ali, L.; Masci, P.G.; Monti, L.; di Giovine, G.; De Lazzari, M.; et al. Clinical recommendations of cardiac magnetic resonance, Part II: Inflammatory and congenital heart disease, cardiomyopathies and cardiac tumors: A position paper of the working group ’Applicazioni della Risonanza Magnetica’ of the Italian Society of Cardiology. J. Cardiovasc. Med. 2017, 18, 209–222. [Google Scholar] [CrossRef]
  26. Aquaro, G.D.; Camastra, G.; Monti, L.; Lombardi, M.; Pepe, A.; Castelletti, S.; Maestrini, V.; Todiere, G.; Masci, P.; di Giovine, G.; et al. Reference values of cardiac volumes, dimensions, and new functional parameters by MR: A multicenter, multivendor study. J. Magn. Reson. Imaging 2017, 45, 1055–1067. [Google Scholar] [CrossRef]
  27. Hoit, B.D. Assessment of Left Atrial Function by Echocardiography: Novel Insights. Curr. Cardiol. Rep. 2018, 20, 96. [Google Scholar] [CrossRef]
  28. Kallergis, E.M.; Manios, E.G.; Kanoupakis, E.M.; Mavrakis, H.E.; Arfanakis, D.A.; Maliaraki, N.E.; Lathourakis, C.E.; Chlouverakis, G.I.; Vardas, P.E. Extracellular matrix alterations in patients with paroxysmal and persistent atrial fibrillation: Biochemical assessment of collagen type-I turnover. J. Am. Coll. Cardiol. 2008, 52, 211–215. [Google Scholar] [CrossRef] [Green Version]
  29. Yoshihara, F.; Nishikimi, T.; Sasako, Y.; Hino, J.; Kobayashi, J.; Minatoya, K.; Bando, K.; Kosakai, Y.; Horio, T.; Suga, S.; et al. Plasma atrial natriuretic peptide concentration inversely correlates with left atrial collagen volume fraction in patients with atrial fibrillation: Plasma ANP as a possible biochemical marker to predict the outcome of the maze procedure. J. Am. Coll. Cardiol. 2002, 39, 288–294. [Google Scholar] [CrossRef] [Green Version]
  30. Olsen, F.J.; Johansen, N.D.; Skaarup, K.G.; Lassen, M.C.H.; Ravnkilde, K.; Schnohr, P.; Jensen, G.B.; Marott, J.L.; Søgaard, P.; Møgelvang, R.; et al. Changes in left atrial structure and function over a decade in the general population. Eur. Heart J. Cardiovasc. Imaging 2021, 23, 124–136. [Google Scholar] [CrossRef]
  31. Abhayaratna, W.P.; Seward, J.B.; Appleton, C.P.; Douglas, P.S.; Oh, J.K.; Tajik, A.J.; Tsang, T.S. Left atrial size: Physiologic determinants and clinical applications. J. Am. Coll. Cardiol. 2006, 47, 2357–2363. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  32. Lang, R.M.; Badano, L.P.; Mor-Avi, V.; Afilalo, J.; Armstrong, A.; Ernande, L.; Flachskampf, F.A.; Foster, E.; Goldstein, S.A.; Kuznetsova, T.; et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J. Am. Soc. Echocardiogr. 2015, 28, 1–39.e14. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  33. Rossi, V.A.; Krizanovic-Grgic, I.; Steffel, J.; Hofer, D.; Wolber, T.; Brunckhorst, C.B.; Ruschitzka, F.; Duru, F.; Breitenstein, A.; Saguner, A.M. Predictors of left atrial fibrosis in patients with atrial fibrillation referred for catheter ablation. Cardiol. J. 2022, 29, 413–422. [Google Scholar] [CrossRef]
  34. Lee, D.K.; Shim, J.; Choi, J.I.; Kim, Y.H.; Oh, Y.W.; Hwang, S.H. Left Atrial Fibrosis Assessed with Cardiac MRI in Patients with Paroxysmal and Those with Persistent Atrial Fibrillation. Radiology 2019, 292, 575–582. [Google Scholar] [CrossRef]
  35. Wang, G.D.; Shen, L.H.; Wang, L.; Li, H.W.; Zhang, Y.C.; Chen, H. Relationship between integrated backscatter and atrial fibrosis in patients with and without atrial fibrillation who are undergoing coronary bypass surgery. Clin. Cardiol. 2009, 32, E56–E61. [Google Scholar] [CrossRef] [PubMed]
  36. Kuppahally, S.S.; Akoum, N.; Burgon, N.S.; Badger, T.J.; Kholmovski, E.G.; Vijayakumar, S.; Rao, S.N.; Blauer, J.; Fish, E.N.; Dibella, E.V.; et al. Left atrial strain and strain rate in patients with paroxysmal and persistent atrial fibrillation: Relationship to left atrial structural remodeling detected by delayed-enhancement MRI. Circ. Cardiovasc. Imaging 2010, 3, 231–239. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  37. Marrouche, N.F.; Wilber, D.; Hindricks, G.; Jais, P.; Akoum, N.; Marchlinski, F.; Kholmovski, E.; Burgon, N.; Hu, N.; Mont, L.; et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: The DECAAF study. JAMA 2014, 311, 498–506. [Google Scholar] [CrossRef]
  38. Moreno-Ruiz, L.A.; Madrid-Miller, A.; Martínez-Flores, J.E.; González-Hermosillo, J.A.; Arenas-Fonseca, J.; Zamorano-Velázquez, N.; Mendoza-Pérez, B. Left atrial longitudinal strain by speckle tracking as independent predictor of recurrence after electrical cardioversion in persistent and long standing persistent non-valvular atrial fibrillation. Int. J. Cardiovasc. Imaging 2019, 35, 1587–1596. [Google Scholar] [CrossRef] [Green Version]
  39. Katbeh, A.; De Potter, T.; Geelen, P.; Di Gioia, G.; Kodeboina, M.; Balogh, Z.; Albano, M.; Vanderheyden, M.; Bartunek, J.; Barbato, E.; et al. Heart failure with preserved ejection fraction or non-cardiac dyspnea in paroxysmal atrial fibrillation: The role of left atrial strain. Int. J. Cardiol 2021, 323, 161–167. [Google Scholar] [CrossRef]
  40. Shen, Y.Z.; Du, X.; Cai, H. Echcardiography on Left Atrial Function in Atrial Fibrillation. Adv. Cardiovas. Dis. 2021, 42, 332–336. [Google Scholar] [CrossRef]
  41. Olsen, F.J.; Bertelsen, L.; de Knegt, M.C.; Christensen, T.E.; Vejlstrup, N.; Svendsen, J.H.; Jensen, J.S.; Biering-Sørensen, T. Multimodality Cardiac Imaging for the Assessment of Left Atrial Function and the Association With Atrial Arrhythmias. Circ. Cardiovasc. Imaging 2016, 9, e004947. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  42. Triposkiadis, F.; Xanthopoulos, A.; Parissis, J. Risk in atrial fibrillation: Left atrial function matters. Eur. J. Heart Fail 2019, 21, 1584–1585. [Google Scholar] [CrossRef] [PubMed]
  43. Hoit, B.D. Left atrial size and function: Role in prognosis. J. Am. Coll. Cardiol. 2014, 63, 493–505. [Google Scholar] [CrossRef] [PubMed]
  44. Wijffels, M.C.; Kirchhof, C.J.; Dorland, R.; Allessie, M.A. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 1995, 92, 1954–1968. [Google Scholar] [CrossRef] [PubMed]
  45. Kojima, T.; Kawasaki, M.; Tanaka, R.; Ono, K.; Hirose, T.; Iwama, M.; Watanabe, T.; Noda, T.; Watanabe, S.; Takemura, G.; et al. Left atrial global and regional function in patients with paroxysmal atrial fibrillation has already been impaired before enlargement of left atrium: Velocity vector imaging echocardiography study. Eur. Heart J. Cardiovasc. Imaging 2012, 13, 227–234. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  46. Eshoo, S.; Boyd, A.C.; Ross, D.L.; Marwick, T.H.; Thomas, L. Strain rate evaluation of phasic atrial function in hypertension. Heart 2009, 95, 1184–1191. [Google Scholar] [CrossRef]
  47. Oka, T.; Tanaka, K.; Ninomiya, Y.; Hirao, Y.; Tanaka, N.; Okada, M.; Inoue, H.; Takayasu, K.; Kitagaki, R.; Koyama, Y.; et al. Impact of baseline left atrial function on long-term outcome after catheter ablation for paroxysmal atrial fibrillation. J. Cardiol. 2020, 75, 352–359. [Google Scholar] [CrossRef]
  48. Kusunose, K.; Takahashi, H.; Nishio, S.; Hirata, Y.; Zheng, R.; Ise, T.; Yamaguchi, K.; Yagi, S.; Fukuda, D.; Yamada, H.; et al. Predictive value of left atrial function for latent paroxysmal atrial fibrillation as the cause of embolic stroke of undetermined source. J. Cardiol. 2021, 78, 355–361. [Google Scholar] [CrossRef] [PubMed]
  49. Leung, M.; Abou, R.; van Rosendael, P.J.; van der Bijl, P.; van Wijngaarden, S.E.; Regeer, M.V.; Podlesnikar, T.; Ajmone Marsan, N.; Leung, D.Y.; Delgado, V.; et al. Relation of Echocardiographic Markers of Left Atrial Fibrosis to Atrial Fibrillation Burden. Am. J. Cardiol. 2018, 122, 584–591. [Google Scholar] [CrossRef]
  50. Sugeng, L.; Mor-Avi, V.; Weinert, L.; Niel, J.; Ebner, C.; Steringer-Mascherbauer, R.; Schmidt, F.; Galuschky, C.; Schummers, G.; Lang, R.M.; et al. Quantitative assessment of left ventricular size and function: Side-by-side comparison of real-time three-dimensional echocardiography and computed tomography with magnetic resonance reference. Circulation 2006, 114, 654–661. [Google Scholar] [CrossRef] [Green Version]
  51. Mor-Avi, V.; Yodwut, C.; Jenkins, C.; Kühl, H.; Nesser, H.J.; Marwick, T.H.; Franke, A.; Weinert, L.; Niel, J.; Steringer-Mascherbauer, R.; et al. Real-time 3D echocardiographic quantification of left atrial volume: Multicenter study for validation with CMR. JACC Cardiovasc. Imaging 2012, 5, 769–777. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  52. Salerno, M.; Sharif, B.; Arheden, H.; Kumar, A.; Axel, L.; Li, D.; Neubauer, S. Recent Advances in Cardiovascular Magnetic Resonance: Techniques and Applications. Circ. Cardiovasc. Imaging 2017, 10, e003951. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  53. Dorosz, J.L.; Lezotte, D.C.; Weitzenkamp, D.A.; Allen, L.A.; Salcedo, E.E. Performance of 3-dimensional echocardiography in measuring left ventricular volumes and ejection fraction: A systematic review and meta-analysis. J. Am. Coll. Cardiol. 2012, 59, 1799–1808. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  54. Saraiva, R.M.; Pacheco, N.P.; Pereira, T.; Costa, A.R.; Holanda, M.T.; Sangenis, L.H.C.; Mendes, F.; Sousa, A.S.; Hasslocher-Moreno, A.M.; Xavier, S.S.; et al. Left Atrial Structure and Function Predictors of New-Onset Atrial Fibrillation in Patients with Chagas Disease. J. Am. Soc. Echocardiogr. 2020, 33, 1363–1374.e1. [Google Scholar] [CrossRef]
  55. Caselli, S.; Canali, E.; Foschi, M.L.; Santini, D.; Di Angelantonio, E.; Pandian, N.G.; De Castro, S. Long-term prognostic significance of three-dimensional echocardiographic parameters of the left ventricle and left atrium. Eur. J. Echocardiogr. 2010, 11, 250–256. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  56. Wu, V.C.; Takeuchi, M.; Kuwaki, H.; Iwataki, M.; Nagata, Y.; Otani, K.; Haruki, N.; Yoshitani, H.; Tamura, M.; Abe, H.; et al. Prognostic value of LA volumes assessed by transthoracic 3D echocardiography: Comparison with 2D echocardiography. JACC Cardiovasc. Imaging 2013, 6, 1025–1035. [Google Scholar] [CrossRef] [Green Version]
  57. Russo, C.; Jin, Z.; Homma, S.; Rundek, T.; Elkind, M.S.V.; Sacco, R.L.; Di Tullio, M.R. LA Phasic Volumes and Reservoir Function in the Elderly by Real-Time 3D Echocardiography: Normal Values, Prognostic Significance, and Clinical Correlates. JACC Cardiovasc. Imaging 2017, 10, 976–985. [Google Scholar] [CrossRef]
  58. Berglund, F.; Piña, P.; Herrera, C.J. Right ventricle in heart failure with preserved ejection fraction. Heart (British Cardiac Society) 2020, 106, 1798–1804. [Google Scholar] [CrossRef]
  59. Ikonomidis, I.; Aboyans, V.; Blacher, J.; Brodmann, M.; Brutsaert, D.L.; Chirinos, J.A.; De Carlo, M.; Delgado, V.; Lancellotti, P.; Lekakis, J.; et al. The role of ventricular–arterial coupling in cardiac disease and heart failure: Assessment, clinical implications and therapeutic interventions. A consensus document of the European Society of Cardiology Working Group on Aorta & Peripheral Vascular Diseases, European Association of Cardiovascular Imaging, and Heart Failure Association. Eur. J. Heart Fail. 2019, 21, 402–424. [Google Scholar] [CrossRef] [Green Version]
  60. Hassanin, M.; Ong, G.; Connelly, K.A. Right Ventricle Longitudinal Strain: A New Tool in Functional Tricuspid Regurgitation Prognostication. Can. J. Cardiol. 2021, 37, 945–948. [Google Scholar] [CrossRef]
  61. Cameli, M.; Righini, F.M.; Lisi, M.; Mondillo, S. Right ventricular strain as a novel approach to analyze right ventricular performance in patients with heart failure. Heart Fail. Rev. 2013, 19, 603–610. [Google Scholar] [CrossRef] [PubMed]
  62. Mandoli, G.E.; Borrelli, C.; Cameli, M.; Mondillo, S.; Ghiadoni, L.; Taddei, C.; Passino, C.; Emdin, M.; Giannoni, A. Speckle tracking echocardiography in heart failure development and progression in patients with apneas. Heart Fail. Rev. 2021. online ahead of print. [Google Scholar] [CrossRef] [PubMed]
  63. Saad, A.K.; Aladio, J.M.; Yamasato, F.; Volberg, V.I.; Gonzalez Ballerga, E.; Sordá, J.A.; Daruich, J.; Perez de la Hoz, R.A. Analysis of The Left Atrial Function Using Two-Dimensional Strain in Patients with Recent Diagnosis of Hereditary Hemochromatosis. Curr. Probl. Cardiol. 2022, 47, 100903. [Google Scholar] [CrossRef] [PubMed]
  64. Badano, L.P.; Kolias, T.J.; Muraru, D.; Abraham, T.P.; Aurigemma, G.; Edvardsen, T.; D’Hooge, J.; Donal, E.; Fraser, A.G.; Marwick, T.; et al. Standardization of left atrial, right ventricular, and right atrial deformation imaging using two-dimensional speckle tracking echocardiography: A consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur. Heart J. Cardiovasc. Imaging 2018, 19, 591–600. [Google Scholar] [CrossRef] [PubMed]
  65. Bao, L.; Cheng, L.; Gao, X.; Yan, F.; Fan, H.; Shan, Y.; Li, Y.; Shi, H.; Huang, G.; Bao, L. Left atrial morpho-functional remodeling in atrial fibrillation assessed by three dimensional speckle tracking echocardiography and its value in atrial fibrillation screening. Cardiovasc. Ultrasound 2022, 20, 13. [Google Scholar] [CrossRef] [PubMed]
  66. Mochizuki, A.; Yuda, S.; Fujito, T.; Kawamukai, M.; Muranaka, A.; Nagahara, D.; Shimoshige, S.; Hashimoto, A.; Miura, T. Left atrial strain assessed by three-dimensional speckle tracking echocardiography predicts atrial fibrillation recurrence after catheter ablation in patients with paroxysmal atrial fibrillation. J. Echocardiogr. 2017, 15, 79–87. [Google Scholar] [CrossRef]
  67. Mochizuki, A.; Yuda, S.; Oi, Y.; Kawamukai, M.; Nishida, J.; Kouzu, H.; Muranaka, A.; Kokubu, N.; Shimoshige, S.; Hashimoto, A.; et al. Assessment of left atrial deformation and synchrony by three-dimensional speckle-tracking echocardiography: Comparative studies in healthy subjects and patients with atrial fibrillation. J. Am. Soc. Echocardiogr. 2013, 26, 165–174. [Google Scholar] [CrossRef]
  68. Amzulescu, M.S.; De Craene, M.; Langet, H.; Pasquet, A.; Vancraeynest, D.; Pouleur, A.C.; Vanoverschelde, J.L.; Gerber, B.L. Myocardial strain imaging: Review of general principles, validation, and sources of discrepancies. Eur. Heart J. Cardiovasc. Imaging 2019, 20, 605–619. [Google Scholar] [CrossRef] [Green Version]
  69. Bruun Pedersen, K.; Madsen, C.; Sandgaard, N.C.F.; Hey, T.M.; Diederichsen, A.C.P.; Bak, S.; Brandes, A. Left atrial volume index and left ventricular global longitudinal strain predict new-onset atrial fibrillation in patients with transient ischemic attack. Int. J. Cardiovasc. Imaging 2019, 35, 1277–1286. [Google Scholar] [CrossRef]
  70. Benchimol-Barbosa, P.R. Predictors of mortality in Chagas’ disease: The impact of atrial fibrillation and oral transmission on infected population. Int. J. Cardiol. 2009, 133, 275–277. [Google Scholar] [CrossRef]
  71. Rojas, L.Z.; Glisic, M.; Pletsch-Borba, L.; Echeverría, L.E.; Bramer, W.M.; Bano, A.; Stringa, N.; Zaciragic, A.; Kraja, B.; Asllanaj, E.; et al. Electrocardiographic abnormalities in Chagas disease in the general population: A systematic review and meta-analysis. PLoS Negl. Trop. Dis. 2018, 12, e0006567. [Google Scholar] [CrossRef] [PubMed]
  72. Hirose, T.; Kawasaki, M.; Tanaka, R.; Ono, K.; Watanabe, T.; Iwama, M.; Noda, T.; Watanabe, S.; Takemura, G.; Minatoguchi, S. Left atrial function assessed by speckle tracking echocardiography as a predictor of new-onset non-valvular atrial fibrillation: Results from a prospective study in 580 adults. Eur. Heart J. Cardiovasc. Imaging 2012, 13, 243–250. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  73. Park, J.J.; Park, J.H.; Hwang, I.C.; Park, J.B.; Cho, G.Y.; Marwick, T.H. Left Atrial Strain as a Predictor of New-Onset Atrial Fibrillation in Patients With Heart Failure. JACC Cardiovasc. Imaging 2020, 13, 2071–2081. [Google Scholar] [CrossRef] [PubMed]
  74. Jasic-Szpak, E.; Marwick, T.H.; Donal, E.; Przewlocka-Kosmala, M.; Huynh, Q.; Gozdzik, A.; Woznicka, A.K.; Jankowska, E.A.; Ponikowski, P.; Kosmala, W. Prediction of AF in Heart Failure With Preserved Ejection Fraction: Incremental Value of Left Atrial Strain. JACC Cardiovasc. Imaging 2021, 14, 131–144. [Google Scholar] [CrossRef]
  75. Furukawa, A.; Ishii, K.; Hyodo, E.; Shibamoto, M.; Komasa, A.; Nagai, T.; Tada, E.; Seino, Y.; Yoshikawa, J. Three-Dimensional Speckle Tracking Imaging for Assessing Left Atrial Function in Hypertensive Patients With Paroxysmal Atrial Fibrillation. Int. Heart J. 2016, 57, 705–711. [Google Scholar] [CrossRef] [Green Version]
  76. Steger, C.; Pratter, A.; Martinek-Bregel, M.; Avanzini, M.; Valentin, A.; Slany, J.; Stöllberger, C. Stroke patients with atrial fibrillation have a worse prognosis than patients without: Data from the Austrian Stroke registry. Eur. Heart J. 2004, 25, 1734–1740. [Google Scholar] [CrossRef]
  77. Glotzer, T.V.; Hellkamp, A.S.; Zimmerman, J.; Sweeney, M.O.; Yee, R.; Marinchak, R.; Cook, J.; Paraschos, A.; Love, J.; Radoslovich, G.; et al. Atrial high rate episodes detected by pacemaker diagnostics predict death and stroke: Report of the Atrial Diagnostics Ancillary Study of the MOde Selection Trial (MOST). Circulation 2003, 107, 1614–1619. [Google Scholar] [CrossRef]
  78. Pagola, J.; Juega, J.; Francisco-Pascual, J.; Bustamante, A.; Penalba, A.; Pala, E.; Rodriguez, M.; De Lera-Alfonso, M.; Arenillas, J.F.; Cabezas, J.A.; et al. Predicting Atrial Fibrillation with High Risk of Embolization with Atrial Strain and NT-proBNP. Transl. Stroke Res. 2021, 12, 735–741. [Google Scholar] [CrossRef]
  79. Hakalahti, A.; Biancari, F.; Nielsen, J.C.; Raatikainen, M.J. Radiofrequency ablation vs. antiarrhythmic drug therapy as first line treatment of symptomatic atrial fibrillation: Systematic review and meta-analysis. Europace 2015, 17, 370–378. [Google Scholar] [CrossRef]
  80. Nielsen, A.B.; Skaarup, K.G.; Djernæs, K.; Hauser, R.; San José Estépar, R.; Sørensen, S.K.; Ruwald, M.H.; Hansen, M.L.; Worck, R.H.; Johannessen, A.; et al. Left atrial contractile strain predicts recurrence of atrial tachyarrhythmia after catheter ablation. Int. J. Cardiol. 2022, 358, 51–57. [Google Scholar] [CrossRef]
  81. Koca, H.; Demirtas, A.O.; Kaypaklı, O.; Icen, Y.K.; Sahin, D.Y.; Koca, F.; Koseoglu, Z.; Baykan, A.O.; Guler, E.C.; Demirtas, D.; et al. Decreased left atrial global longitudinal strain predicts the risk of atrial fibrillation recurrence after cryoablation in paroxysmal atrial fibrillation. J. Interv. Card Electrophysiol. 2020, 58, 51–59. [Google Scholar] [CrossRef] [PubMed]
  82. Wynn, G.J.; Das, M.; Bonnett, L.J.; Gupta, D. Quality-of-life benefits of catheter ablation of persistent atrial fibrillation: A reanalysis of data from the SARA study. Europace 2015, 17, 222–224. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  83. January, C.T.; Wann, L.S.; Calkins, H.; Chen, L.Y.; Cigarroa, J.E.; Cleveland, J.C., Jr.; Ellinor, P.T.; Ezekowitz, M.D.; Field, M.E.; Furie, K.L.; et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019, 140, e125–e151. [Google Scholar] [CrossRef] [PubMed]
  84. Cosedis Nielsen, J.; Johannessen, A.; Raatikainen, P.; Hindricks, G.; Walfridsson, H.; Kongstad, O.; Pehrson, S.; Englund, A.; Hartikainen, J.; Mortensen, L.S.; et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N. Engl. J. Med. 2012, 367, 1587–1595. [Google Scholar] [CrossRef] [Green Version]
  85. Gerstenfeld, E.P.; Duggirala, S. Atrial fibrillation ablation: Indications, emerging techniques, and follow-up. Prog. Cardiovasc. Dis. 2015, 58, 202–212. [Google Scholar] [CrossRef]
  86. Prystowsky, E.N.; Padanilam, B.J.; Fogel, R.I. Treatment of Atrial Fibrillation. JAMA 2015, 314, 278–288. [Google Scholar] [CrossRef]
  87. Matei, L.L.; Ghilencea, L.N.; Bejan, G.C.; Stoica, S.; Dragoi-Galrinho, R.; Siliste, C.; Vinereanu, D. Minimum Left Atrial Volume Evaluated by 3D Echocardiography Predicts Atrial Fibrillation Recurrences After a First Radiofrequency Catheter Ablation for Paroxysmal Episodes. Maedica 2021, 16, 345–352. [Google Scholar] [CrossRef]
  88. Liżewska-Springer, A.; Dąbrowska-Kugacka, A.; Lewicka, E.; Drelich, Ł.; Królak, T.; Raczak, G. Echocardiographic predictors of atrial fibrillation recurrence after catheter ablation: A literature review. Cardiol. J. 2020, 27, 848–856. [Google Scholar] [CrossRef] [Green Version]
  89. Sarvari, S.I.; Haugaa, K.H.; Stokke, T.M.; Ansari, H.Z.; Leren, I.S.; Hegbom, F.; Smiseth, O.A.; Edvardsen, T. Strain echocardiographic assessment of left atrial function predicts recurrence of atrial fibrillation. Eur. Heart J. Cardiovasc. Imaging 2016, 17, 660–667. [Google Scholar] [CrossRef]
  90. Yasuda, R.; Murata, M.; Roberts, R.; Tokuda, H.; Minakata, Y.; Suzuki, K.; Tsuruta, H.; Kimura, T.; Nishiyama, N.; Fukumoto, K.; et al. Left atrial strain is a powerful predictor of atrial fibrillation recurrence after catheter ablation: Study of a heterogeneous population with sinus rhythm or atrial fibrillation. Eur. Heart J. Cardiovasc. Imaging 2015, 16, 1008–1014. [Google Scholar] [CrossRef]
  91. Montserrat, S.; Gabrielli, L.; Borras, R.; Poyatos, S.; Berruezo, A.; Bijnens, B.; Brugada, J.; Mont, L.; Sitges, M. Left atrial size and function by three-dimensional echocardiography to predict arrhythmia recurrence after first and repeated ablation of atrial fibrillation. Eur. Heart J. Cardiovasc. Imaging 2014, 15, 515–522. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  92. Yang, Z.; Xu, M.; Zhang, C.; Liu, H.; Shao, X.; Wang, Y.; Yang, L.; Yang, J. A predictive model using left atrial function and B-type natriuretic peptide level in predicting the recurrence of early persistent atrial fibrillation after radiofrequency ablation. Clin. Cardiol. 2021, 44, 407–414. [Google Scholar] [CrossRef] [PubMed]
  93. Gupta, D.K.; Shah, A.M.; Giugliano, R.P.; Ruff, C.T.; Antman, E.M.; Grip, L.T.; Deenadayalu, N.; Hoffman, E.; Patel, I.; Shi, M.; et al. Left atrial structure and function in atrial fibrillation: ENGAGE AF-TIMI 48. Eur. Heart J. 2014, 35, 1457–1465. [Google Scholar] [CrossRef] [PubMed]
  94. Wolf, P.A.; Abbott, R.D.; Kannel, W.B. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke 1991, 22, 983–988. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  95. Lip, G.Y.; Nieuwlaat, R.; Pisters, R.; Lane, D.A.; Crijns, H.J. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: The euro heart survey on atrial fibrillation. Chest 2010, 137, 263–272. [Google Scholar] [CrossRef] [PubMed]
  96. Avgil Tsadok, M.; Berliner Senderey, A.; Reges, O.; Leibowitz, M.; Leventer-Roberts, M.; Hoshen, M.; Haim, M. Comparison of Stroke Risk Stratification Scores for Atrial Fibrillation. Am. J. Cardiol. 2019, 123, 1828–1834. [Google Scholar] [CrossRef]
  97. Habibi, M.; Lima, J.A.C.; Gucuk Ipek, E.; Zimmerman, S.L.; Zipunnikov, V.; Spragg, D.; Ashikaga, H.; Rickard, J.; Marine, J.E.; Berger, R.D.; et al. The association of baseline left atrial structure and function measured with cardiac magnetic resonance and pulmonary vein isolation outcome in patients with drug-refractory atrial fibrillation. Heart Rhythm 2016, 13, 1037–1044. [Google Scholar] [CrossRef]
  98. Leung, M.; van Rosendael, P.J.; Abou, R.; Ajmone Marsan, N.; Leung, D.Y.; Delgado, V.; Bax, J.J. Left atrial function to identify patients with atrial fibrillation at high risk of stroke: New insights from a large registry. Eur. Heart J. 2018, 39, 1416–1425. [Google Scholar] [CrossRef] [Green Version]
  99. Obokata, M.; Negishi, K.; Kurosawa, K.; Tateno, R.; Tange, S.; Arai, M.; Amano, M.; Kurabayashi, M. Left atrial strain provides incremental value for embolism risk stratification over CHA₂DS₂-VASc score and indicates prognostic impact in patients with atrial fibrillation. J. Am. Soc. Echocardiogr. 2014, 27, 709–716.e704. [Google Scholar] [CrossRef]
  100. Liao, J.N.; Chao, T.F.; Kuo, J.Y.; Sung, K.T.; Tsai, J.P.; Lo, C.I.; Lai, Y.H.; Su, C.H.; Hung, C.L.; Yeh, H.I. Global Left Atrial Longitudinal Strain Using 3-Beat Method Improves Risk Prediction of Stroke Over Conventional Echocardiography in Atrial Fibrillation. Circ. Cardiovasc. Imaging 2020, 13, e010287. [Google Scholar] [CrossRef]
  101. Liao, J.N.; Chao, T.F.; Hung, C.L.; Chen, S.A. The decrease in peak atrial longitudinal strain in patients with atrial fibrillation as a practical parameter for stroke risk stratification. Heart Rhythm 2021, 18, 538–544. [Google Scholar] [CrossRef] [PubMed]
  102. Santhanakrishnan, R.; Wang, N.; Larson, M.G.; Magnani, J.W.; McManus, D.D.; Lubitz, S.A.; Ellinor, P.T.; Cheng, S.; Vasan, R.S.; Lee, D.S.; et al. Atrial Fibrillation Begets Heart Failure and Vice Versa: Temporal Associations and Differences in Preserved Versus Reduced Ejection Fraction. Circulation 2016, 133, 484–492. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  103. Wen, S.; Pislaru, S.V.; Lin, G.; Scott, C.G.; Lee, A.T.; Asirvatham, S.J.; Pellikka, P.A.; Kane, G.C.; Pislaru, C. Association of Postprocedural Left Atrial Volume and Reservoir Function with Outcomes in Patients with Atrial Fibrillation Undergoing Catheter Ablation. J. Am. Soc. Echocardiogr. 2022. online ahead of print. [Google Scholar] [CrossRef]
  104. Inciardi, R.M.; Giugliano, R.P.; Claggett, B.; Gupta, D.K.; Chandra, A.; Ruff, C.T.; Antman, E.M.; Mercuri, M.F.; Grosso, M.A.; Braunwald, E.; et al. Left atrial structure and function and the risk of death or heart failure in atrial fibrillation. Eur. J. Heart Fail. 2019, 21, 1571–1579. [Google Scholar] [CrossRef]
  105. Mathias, A.; Moss, A.J.; McNitt, S.; Zareba, W.; Goldenberg, I.; Solomon, S.D.; Kutyifa, V. Clinical Implications of Complete Left-Sided Reverse Remodeling With Cardiac Resynchronization Therapy: A MADIT-CRT Substudy. J. Am. Coll. Cardiol. 2016, 68, 1268–1276. [Google Scholar] [CrossRef]
  106. Park, J.H.; Hwang, I.C.; Park, J.J.; Park, J.B.; Cho, G.Y. Prognostic power of left atrial strain in patients with acute heart failure. Eur. Heart J. Cardiovasc. Imaging 2021, 22, 210–219. [Google Scholar] [CrossRef] [PubMed]
  107. Moon, M.-G.; Hwang, I.-C.; Lee, H.-J.; Kim, S.-H.; Yoon, Y.E.; Park, J.-B.; Lee, S.-P.; Kim, H.-K.; Kim, Y.-J.; Cho, G.-Y. Reverse Remodeling Assessed by Left Atrial and Ventricular Strain Reflects Treatment Response to Sacubitril/Valsartan. JACC. Cardiovasc. Imaging 2022. online ahead of print. [Google Scholar] [CrossRef]
Diagnostics 12 01898 g001 550
Figure 1. Representative measurements of LAV by three-dimensional echocardiography. Standard apical four-chamber view images of 20 consecutive cardiac cycles were stored, and LAV was measured in one of the cardiac cycles. (A) Reference points setting, LA endocardial border tracking and acquisition of 3D LAV curve in a subject with sinus rhythm; (B) Reference points setting, LA endocardial border tracking and acquisition of 3D LAV curve in a subject with AF.
Figure 1. Representative measurements of LAV by three-dimensional echocardiography. Standard apical four-chamber view images of 20 consecutive cardiac cycles were stored, and LAV was measured in one of the cardiac cycles. (A) Reference points setting, LA endocardial border tracking and acquisition of 3D LAV curve in a subject with sinus rhythm; (B) Reference points setting, LA endocardial border tracking and acquisition of 3D LAV curve in a subject with AF.
Diagnostics 12 01898 g001
Diagnostics 12 01898 g002 550
Figure 2. Representative measurements of LA strain by two-dimensional echocardiography. Standard apical four-chamber view images of 20 consecutive cardiac cycles were stored, and LA strain was measured in one of the cardiac cycles. (A) LASr and LASct in a subject with sinus rhythm; (B) LASr and LASct in a subject with AF.
Figure 2. Representative measurements of LA strain by two-dimensional echocardiography. Standard apical four-chamber view images of 20 consecutive cardiac cycles were stored, and LA strain was measured in one of the cardiac cycles. (A) LASr and LASct in a subject with sinus rhythm; (B) LASr and LASct in a subject with AF.
Diagnostics 12 01898 g002
Table
Table 1. The full name and calculations of LA structural and functional parameters.
Table 1. The full name and calculations of LA structural and functional parameters.
AbbreviationFull NameCalculations
LAVLeft atrium volumeMaximum LAV and minimum LAV are measured using the modified Simpson biplane method at the end-systolic frame preceding mitral valve opening and the end-diastolic frame preceding mitral valve closure, respectively
LAViLeft atrium volume indexMaximum LAVi and minimum LAVi are measured using the modified Simpson biplane method at the end-systolic frame preceding mitral valve opening and the end-diastolic frame preceding mitral valve closure, respectively, and indexed to body surface area
LAEiLeft atrium expansion index(Maximum LAV–Minimum LAV)/Minimum LAV
Total LAEFTotal left atrium emptying fraction(Maximum LAV–Minimum LAV)/Maximum LAV
Active LAEFActive left atrium emptying fraction(LAVpreA–Minimum LAV)/LAVpreA
Positive LAEFPositive left atrium emptying fraction(Maximum LAV–LAVpreA)/Maximum LAV
LASr
(PALS)		Peak left atrium global longitudinal strain during reservoir phase
(peak left atrium longitudinal strain)		The difference of the strain value at mitral valve opening minus ventricular end-diastole (the peak value of longitudinal strain during LV systole)
LASct
(PACS)		Peak left atrium global longitudinal strain during contraction phase
(peak left atrial contractile strain)		The difference of the strain value at the ventricular end-diastole minus onset of atrial contraction (the value of strain at the onset of P-wave in electrocardiogram)
LAScdPeak left atrium global longitudinal strain during the conduit phaseThe difference of the strain value at the onset of atrial contraction minus mitral valve opening (LASct minus LASr)
LASrcPeak left atrium global circumferential strain during reservoir phaseThe peak value of circumferential strain during LV systole
LASctcPeak left atrium global circumferential strain during contraction phaseThe difference of the strain value at the ventricular end-diastole minus onset of atrial contraction
LAScdcPeak left atrium global circumferential strain during conduit phaseThe difference of the strain value at the onset of atrial contraction minus mitral valve opening (LASctc minus LASrc)
LASRLeft atrium longitudinal strain rateLASR: LASR ≈ (V2 − V1)/d, where V2 and V1 are instantaneous velocities measured in two regions of interest, and d is the distance between the two regions of interest;
LASRs (Left atrium longitudinal systolic strain rate): the peak positive longitudinal strain rate during LV systole in strain rate curve;
LASRe (Left atrium longitudinal early diastolic strain rate): the negative strain rate during early diastole in strain rate curve;
LASRa (Left atrium longitudinal late diastolic strain rate): the negative strain rate during late diastole in strain rate curve
LAVpreA: presystolic volume of LA at the beginning of P wave on electrocardiogram.
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Ji, M.; He, L.; Gao, L.; Lin, Y.; Xie, M.; Li, Y. Assessment of Left Atrial Structure and Function by Echocardiography in Atrial Fibrillation. Diagnostics 2022, 12, 1898. https://doi.org/10.3390/diagnostics12081898

AMA Style

Ji M, He L, Gao L, Lin Y, Xie M, Li Y. Assessment of Left Atrial Structure and Function by Echocardiography in Atrial Fibrillation. Diagnostics. 2022; 12(8):1898. https://doi.org/10.3390/diagnostics12081898

Chicago/Turabian Style

Ji, Mengmeng, Lin He, Lang Gao, Yixia Lin, Mingxing Xie, and Yuman Li. 2022. "Assessment of Left Atrial Structure and Function by Echocardiography in Atrial Fibrillation" Diagnostics 12, no. 8: 1898. https://doi.org/10.3390/diagnostics12081898

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