Left-atrial long-axis shortening allows effective quantification of atrial function and optimized risk prediction following acute myocardial infarction

Sören J Backhaus, Simon F Rösel, Thomas Stiermaier, Jonas Schmidt-Rimpler, Ruben Evertz, Alexander Schulz, Torben Lange, Johannes T Kowallick, Shelby Kutty, Boris Bigalke, Matthias Gutberlet, Gerd Hasenfuß, Holger Thiele, Ingo Eitel, Andreas Schuster, Sören J Backhaus, Simon F Rösel, Thomas Stiermaier, Jonas Schmidt-Rimpler, Ruben Evertz, Alexander Schulz, Torben Lange, Johannes T Kowallick, Shelby Kutty, Boris Bigalke, Matthias Gutberlet, Gerd Hasenfuß, Holger Thiele, Ingo Eitel, Andreas Schuster

Abstract

Aims: Deformation imaging enables optimized risk prediction following acute myocardial infarction (AMI). However, costly and time-consuming post processing has hindered widespread clinical implementation. Since manual left-ventricular long-axis strain (LV LAS) has been successfully proposed as a simple alternative for LV deformation imaging, we aimed at the validation of left-atrial (LA) LAS.

Methods and results: The AIDA STEMI and TATORT-NSTEMI trials recruited 795 patients with ST-elevation myocardial infarction and 440 with non-ST-elevation myocardial infarction. LA LAS was assessed as the systolic distance change between the middle of a line connecting the origins of the mitral leaflets and either a perpendicular line towards the posterior atrial wall (LAS90) or a line connecting to the LA posterior portion of the greatest distance irrespective of a predefined angle (LAS). Primary endpoint was major adverse cardiac event (MACE) occurrence within 12 months. There were no significant differences between LA LAS and LAS90, both with excellent reproducibility. LA LAS correlated significantly with LA reservoir function (Es, r = 0.60, P < 0.001). Impaired LA LAS resulted in higher MACE occurrence [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.82-0.88, P < 0.001]. LA LAS (HR 0.90, 95% CI 0.83-0.97, P = 0.005) and LV global longitudinal strain (GLS, P = 0.025) were the only independent predictors for MACE in multivariate analyses. C-statistics demonstrated incremental value of LA LAS in addition to GLS (P = 0.016) and non-inferiority compared with FT Es (area under the receiver operating characteristic curve 0.74 vs. 0.69, P = 0.256).

Conclusion: Left-atrial LAS provides fast and software-independent approximations of quantitative LA function with similar value for risk prediction compared with dedicated deformation imaging.

Clinical trial registration: ClinicalTrials.gov: NCT00712101 and NCT01612312.

Keywords: Atrial physiology; Left-atrial long-axis strain; Myocardial infarction; Prognosis.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Left-atrial long-axis strain assessment. The figure illustrates the assessment of left-atrial long-axis strain in the two- and four-chamber view. It was assessed between the middle of a line connecting the origins of the mitral leaflets and either a perpendicular line towards the posterior atrial wall (left-atrial long-axis strain90, blue, perpendicular line) or a line connecting to the left-atrial posterior portion of the greatest distance in regards to the middle of the mitral reference line (left-atrial long-axis strain, red, non-perpendicular line).
Figure 2
Figure 2
Study flow chart.
Figure 3
Figure 3
Left-atrial strain for major adverse cardiac event prediction. The graphs show the association of left-atrial long-axis strain dichotomized at the median of 17.48% as well as according to the Youden index at 12.23% on the rate of major adverse clinical events including associated 95% confidence intervals as well as the patients’ number at risk.
Figure 4
Figure 4
Incremental value of left-atrial long-axis strain. The graphs demonstrate the impact of additional left-atrial long-axis strain analysis over (top) left-ventricular ejection fraction above and below a cut-off at 35% as well as (bottom) left-ventricular global longitudinal strain above or below the median of 16.4%. The cut-off for left-atrial long-axis strain was identified with the Youden index at 12.23%. The graph shows the rate of major adverse clinical events including associated 95% confidence intervals as well as the patients’ number at risk.

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