Left atrial roof enlargement is a distinct feature of Heart Failure with preserved Ejection Fraction

Sören Jan Backhaus (Göttingen)1, A. Nasopoulou (London)2, T. Lange (Göttingen)1, A. Schulz (Göttingen)1, R. Evertz (Göttingen)1, J. Kowallick (Göttingen)3, G. Hasenfuß (Göttingen)1, P. Lamata (London)2, A. Schuster (Göttingen)1

1Universitätsmedizin Göttingen Herzzentrum, Klinik für Kardiologie und Pneumologie Göttingen, Deutschland; 2King's College London Department of Biomedical Engineering London, Großbritannien; 3Universitätsmedizin Göttingen Institut Diagnostische und Interventionelle Radiologie Göttingen, Deutschland


It remains unknown to what extent intrinsic atrial cardiomyopathy or left ventricular (LV) diastolic dysfunction drive atrial remodelling and functional failure in heart failure with preserved ejection fraction (HFpEF). Computational 3D models fitted to cardiovascular magnetic resonance (CMR) allows state-of-the-art anatomical and functional assessment and we hypothesised to identify a phenotype linked to HFpEF.

Patients with exertional dyspnoea and diastolic dysfunction on echocardiography (E/e’ >8) were prospectively recruited and classified as HFpEF or non-cardiac dyspnoea (NCD) based on right heart catheterisation (RHC). All patients underwent rest and exercise-stress RHC and CMR. Computational 3D anatomical left atrial (LA) models were generated based on short axis cine sequences. A fully automated pipeline was developed to segment CMR images and build 3D statistical models of LA shape and find the 3D patterns discriminant between HFpEF and NCD. In addition, atrial morphology and function were quantified by conventional volumetric analyses and deformation imaging. A clinical follow-up was conducted after 24 months for the evaluation of cardiovascular hospitalisation.

Beyond atrial size, the 3D LA models revealed roof dilation as the main feature found in masked HFpEF (diagnosed during exercise-stress only) preceding a pattern shift to overall atrial size in overt HFpEF (diagnosed at rest). Characteristics of the 3D model were integrated into the Left Atrial HFpEF Shape (LAHS) score, a biomarker to characterise the gradual remodelling between dyspnoea and HFpEF. The LAHS score was able to discriminate HFpEF (n=34) to NCD (n=34) (AUC 0.81 and was associated with a risk for atrial fibrillation occurrence (HR 1.02, 95% CI 1.01-1.04, p=0.003) as well as cardiovascular hospitalization (HR 1.02, 95% CI 1.00-1.04, p=0.043).

LA roof dilation is an early remodelling pattern in masked HFpEF advancing to overall LA enlargement in overt HFpEF. These distinct features predict occurrence of atrial fibrillation and cardiovascular hospitalisation.

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