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Observational Study
. 2020 Jan;36(1):101-110.
doi: 10.1007/s10554-019-01684-9. Epub 2019 Aug 10.

Left atrial ejection fraction and outcomes in heart failure with preserved ejection fraction

Prathap Kanagala  1   2 , Jayanth R Arnold  3 , Adrian S H Cheng  4 , Anvesha Singh  3 , Jamal N Khan  3 , Gaurav S Gulsin  3 , Jing Yang  5 , Lei Zhao  5 , Pankaj Gupta  3 , Iain B Squire  3 , Leong L Ng  3 , Gerry P McCann  3
Affiliations
Observational Study

Left atrial ejection fraction and outcomes in heart failure with preserved ejection fraction

Prathap Kanagala et al. Int J Cardiovasc Imaging. 2020 Jan.

Abstract

The aim of this study was to determine whether left atrial ejection fraction (LAEF) quantified with cardiovascular magnetic resonance (CMR) was different between heart failure with preserved ejection fraction (HFpEF) and controls, and its relation to prognosis. As part of our single-centre, prospective, observational study, 188 subjects (HFpEF n = 140, controls n = 48) underwent phenotyping with contrast-enhanced CMR, transthoracic echocardiography, blood sampling and six-minute walk testing. LAEF was calculated using the biplane method. Atrial fibrillation (AF) was present in 43 (31%) of HFpEF subjects. Overall, LAEF (%) was lower in HFpEF patients inclusive of AF (32 ± 16) or those in sinus rhythm alone (41 ± 12) compared to controls (51 ± 11), p < 0.0001. LAEF correlated inversely with maximal and minimal left atrial volumes indexed (r = - 0.602, r = - 0.762), and plasma N-terminal pro-atrial natriuretic peptide (r = - 0.367); p < 0.0001. During median follow-up (1429 days), there were 67 composite events of all-cause death or hospitalization for heart failure (22 deaths, 45 HF hospitalizations) in HFpEF. Lower LAEF (below median) was associated with an increased risk of composite endpoints (Log-Rank: all p = 0.028; sinus p = 0.036). In multivariable Cox regression analysis, LAEF (adjusted hazard ratio [HR] 0.767, 95% confidence interval [CI] 0.591-0.996; p = 0.047) and indexed extracellular volume (HR 1.422, CI 1.015-1.992; p = 0.041) were the only parameters that remained significant when added to a base prognostic model comprising age, prior HF hospitalization, diastolic blood pressure, lung disease, NYHA, six-minute-walk-test-distance, haemoglobin, creatinine and B-type natriuretic peptide. CMR-derived LAEF is lower in HFpEF compared to healthy controls and is a strong prognostic biomarker.

Keywords: Biomarker; Cardiovascular magnetic resonance imaging; Heart failure with preserved ejection fraction; Left atrial ejection fraction; Prognosis.

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Conflict of interest statement

Lei Zhao and Jing Yang are employees of Bristol Myers Squibb which facilitated plasma NTpro-ANP analysis. All other authors declare that they have no competing interests relevant to this study. All authors also state that they have full control of all primary data and that they agree to allow the journal to review their data if requested.

Figures

Fig. 1
Fig. 1
Calculation of left atrial ejection fraction. Cine 2- and 4-chamber images illustrating contoured maximum (a) and minimum (b) left atrial areas for volume (and ejection fraction) derivation
Fig. 2
Fig. 2
Study recruitment overview. Flow chart illustrating recruitment and CMR assessments. CMR cardiovascular magnetic resonance imaging, HFpEF heart failure with preserved ejection fraction
Fig. 3
Fig. 3
Associations of left atrial ejection fraction with left atrial volumes. Scatter plot illustrating the relationship between left atrial ejection fraction (LAEF) and the inverse of: maximum left atrium volume indexed-LAVImax (left panel) or minimum left atrium volume indexed-LAVImin (right panel)
Fig. 4
Fig. 4
Survival analysis stratified according to median left atrial ejection fraction. Kaplan–Meier analysis stratified according to median left atrial ejection fraction for the composite endpoint of death and/or hospitalization with heart failure in a all subjects and b in sinus rhythm only
See this image and copyright information in PMC

Comment in

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