Objectives This study sought to observe the relationship between left atrial (LA) strain and left ventricular diastolic function and determine whether LA strain could be used to detect diastolic dysfunction (DD) and classify its degree when present. Background The assessment of diastolic function is complex and multiparametric because most conventional parameters do not follow the progression of DD. Strain imaging is an emerging index of LA function, with recent data demonstrating that LA strain is diminished in diastolic heart failure. However, LA strain is not part of the standard assessment of diastolic function. We hypothesized that LA strain decreases with worsening DD in a stepwise fashion and could thus be useful in evaluating DD. Methods We performed a retrospective derivation and validation cohort study to derive and test LA strain thresholds for DD grades (0 to 3) in patients with preserved left ventricular ejection fraction (N = 229). Two-dimensional speckle tracking was used to measure peak LA strain, which was applied as a single parameter to classify DD. American Society of Echocardiography guidelines were used as the reference standard. Results In the derivation cohort (n = 90), peak LA strain was significantly different between DD groups, with gradual decreases seen with worsening DD. Receiver-operating characteristic analysis resulted in 3 distinct LA strain thresholds for categorization of DD grades, with good to excellent diagnostic utility (area under the curve: 0.86 to 0.91). In an independent validation group (n = 139) with a spectrum of diastolic function, 11 patients (8%) had indeterminate DD grades using standard criteria, whereas LA strain was measured in all patients and its cutoffs resulted in diagnostic accuracy up to 95%. Conclusions LA strain measurements are feasible and allow accurate categorization of DD, because unlike the traditional parameters, it changes progressively with severity of DD. LA strain may become a useful tool for diastolic assessment in future clinical practice.

Echocardiographic assessment of left ventricular (LV) filling pressures is performed using a multi-parametric algorithm. Left atrial (LA) strain was recently found to accurately classify the degree of diastolic dysfunction. We hypothesized that LA strain could be used as a stand-alone marker and sought to identify and test a cutoff, which would accurately detect elevated LV pressures. We studied 76 patients with a spectrum of LV function who underwent same-day echocardiogram and invasive left-heart catheterization. Speckle tracking was used to measure peak LA strain. The protocol involved a retrospective derivation group (N = 26) and an independent prospective validation cohort (N = 50) to derive and then test a peak LA strain cutoff which would identify pre-A-wave LV diastolic pressure > 15 mmHg. The guidelines-based assessment of filling pressures and peak LA strain were compared side-by-side against invasive hemodynamic data. In the derivation cohort, receiver-operating characteristic analysis showed area under curve of 0.76 and a peak LA strain cutoff < 20% was identified as optimal to detect elevated filling pressure. In the validation cohort, peak LA strain demonstrated better agreement with the invasive reference (81%) than the guidelines algorithm (72%). The improvement in classification using LA strain compared to the guidelines was more pronounced in subjects with normal LV function (91% versus 81%). In summary, the use of a peak LA strain to estimate elevated LV filling pressures is more accurate than the current guidelines. Incorporation of LA strain into the non-invasive assessment of LV diastolic function may improve the detection of elevated filling pressures.

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In PAH, TR progression was associated with worsening pulmonary hypertension and adverse RV and TV apparatus remodelling. TR progression is associated with poor outcome in PAH.

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