Automated left atrial strain analysis for predicting atrial fibrillation in severe COVID-19 pneumonia: a prospective study

Abstract

Background: Atrial fibrillation (AF) is the most documented arrhythmia in COVID-19 pneumonia. Left atrial (LA) strain (LAS) analysis, a marker of LA contractility, have been associated with the development of AF in several clinical situations. We aimed to assess the diagnostic ability of LA strain parameters to predict AF in patients with severe hypoxemic COVID-19 pneumonia. We conducted a prospective single center study in Amiens University Hospital intensive care unit (ICU) (France). Adult patients with severe or critical COVID-19 pneumonia according to the World Health Organization definition and in sinus rhythm were included. Transthoracic echocardiography was performed within 48 h of ICU admission. LA strain analysis was performed by an automated software. The following LA strain parameters were recorded: LA strain during reservoir phase (LASr), LA strain during conduit phase (LAScd) and LA strain during contraction phase (LASct). The primary endpoint was the occurrence of AF during ICU stay.

Results: From March 2020 to February of 2021, 79 patients were included. Sixteen patients (20%) developed AF in ICU. Patients of the AF group were significantly older with a higher SAPS II score than those without AF. LAScd and LASr were significantly more impaired in the AF group compared to the other group (- 8.1 [- 6.3; - 10.9] vs. - 17.2 [- 5.0; - 10.2] %; P < 0.001 and 20.2 [12.3;27.3] % vs. 30.5 [23.8;36.2] %; P = 0.002, respectively), while LASct did not significantly differ between groups (p = 0.31). In a multivariate model, LAScd and SOFA cv were significantly associated with the occurrence of AF. A LAScd cutoff value of - 11% had a sensitivity of 76% and a specificity of 75% to identify patients with AF. The 30-day cumulative risk of AF was 42 ± 9% with LAScd > - 11% and 8 ± 4% with LAScd ≤ - 11% (log rank test P value < 0.0001).

Conclusion: For patients with severe COVID-19 pneumonia, development of AF during ICU stay is common (20%). LAS parameters seem useful in predicting AF within the first 48 h of ICU admission.

Trial registration: NCT04354558.

Keywords: Atrial fibrillation; COVID-19; Intensive care unit; Left atrial strain; Pneumonia.

Fig. 1

Measurement of LAS parameters with an automated software. LA strain values were automatically measured during the different LA phases: LASr measured as the first peak positive deflection, LAScd measured as the difference between LASr and LASct values, LASct measured as the beginning of the P wave contraction. LAS: left atrial strain. LASr: left atrial strain reservoir phase. LAScd: left atrial strain conduit phase. LASct: left atrial strain contraction phase

Fig. 2

Flow diagram of the study group. AF: new onset atrial fibrillation; ICU: intensive care unit; TTE: transthoracic echocardiography

Fig. 3

ROC curve analysis of LAS parameters for predicting AF. AF: atrial fibrillation; LAS: left atrial strain

Fig. 4

C-statistic and receiver operating characteristics curve (ROC) of factors associated with the occurrence of AF. The ROC curve analyzed the discrimination ability of the model composed of LAScd and SOFA cv > 1 to predict AF. AF: atrial fibrillation; AUC: area under curve; CV: cardiovascular; ROC: receiver operating characteristic curve. SOFA: sequential organ failure assessment

Fig. 5

Cumulative risk of AF according to LAScd. AF: atrial fibrillation; LAScd: left atrial strain conduit phase