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Catheter ablation (CA) is commonly used to obtain rhythm control in patients with atrial fibrillation (AF), yet AF recurrence is frequent. In this study, we hypothesized that measures of left atrial (LA) structure and function modified the treatment effect of amiodarone to prevent AF recurrence, which has otherwise not proven beneficial. This was a post hoc analysis of the double-blinded AMIO-CAT trial. Patients undergoing CA were randomized to short-term amiodarone treatment or placebo. All patients underwent echocardiography to assess LA volumes and strain. The primary endpoint was AF recurrence at 6-months. Secondary endpoints were cardioversion and AF-related hospitalization during follow-up. Of 212 patients, 108 were randomized to amiodarone and 104 to placebo. 206 patients were eligible for analyses of the primary endpoint, of whom 90 (44%) developed AF recurrence. No measure of LA size or function significantly modified the effect of amiodarone for preventing AF recurrence (p for interaction >0.05 for all measures). However, abnormal LA strain (<22.7%) significantly modified the treatment effect for the secondary outcomes of cardioversions (p for interaction = 0.013) and AF-related hospitalization (p for interaction = 0.014). In patients with abnormal LA strain, amiodarone significantly reduced the risk of cardioversions (OR 0.35 [0.15 to 0.80], p = 0.013) and AF-related hospitalization (OR 0.31 [0.14 to 0.73], p = 0.007) compared to placebo. In conclusion, LA measures did not modify the treatment effect of amiodarone versus placebo for preventing AF recurrence at 6 months in patients undergoing CA. However, in patients with abnormal LA strain, amiodarone may reduce cardioversions and AF-related hospitalizations as compared to placebo. Clinical trial registration: Clinicaltrials.gov unique identifier: NCT00826826 [Display omitted]

Cardiovascular magnetic resonance (CMR) is the gold standard method for the assessment of cardiac structure and function. Reference ranges permit differentiation between normal and pathological states. To date, this study is the largest to provide CMR specific reference ranges for left ventricular, right ventricular, left atrial and right atrial structure and function derived from truly healthy Caucasian adults aged 45–74. Five thousand sixty-five UK Biobank participants underwent CMR using steady-state free precession imaging at 1.5 Tesla. Manual analysis was performed for all four cardiac chambers. Participants with non-Caucasian ethnicity, known cardiovascular disease and other conditions known to affect cardiac chamber size and function were excluded. Remaining participants formed the healthy reference cohort; reference ranges were calculated and were stratified by gender and age (45–54, 55–64, 65–74). After applying exclusion criteria, 804 (16.2%) participants were available for analysis. Left ventricular (LV) volumes were larger in males compared to females for absolute and indexed values. With advancing age, LV volumes were mostly smaller in both sexes. LV ejection fraction was significantly greater in females compared to males (mean ± standard deviation [SD] of 61 ± 5% vs 58 ± 5%) and remained static with age for both genders. In older age groups, LV mass was lower in men, but remained virtually unchanged in women. LV mass was significantly higher in males compared to females (mean ± SD of 53 ± 9 g/m2 vs 42 ± 7 g/m2). Right ventricular (RV) volumes were significantly larger in males compared to females for absolute and indexed values and were smaller with advancing age. RV ejection fraction was higher with increasing age in females only. Left atrial (LA) maximal volume and stroke volume were significantly larger in males compared to females for absolute values but not for indexed values. LA ejection fraction was similar for both sexes. Right atrial (RA) maximal volume was significantly larger in males for both absolute and indexed values, while RA ejection fraction was significantly higher in females. We describe age- and sex-specific reference ranges for the left ventricle, right ventricle and atria in the largest validated normal Caucasian population.

BackgroundObstructive sleep apnoea (OSA) can cause left atrial (LA) and left ventricular (LV) remodelling, which is linked to atrial fibrillation (AF). Whether continuous positive airway pressure (CPAP) can reverse LA and LV remodelling in patients with OSA and paroxysmal AF (PAF) has yet to be studied. We assessed the impact of CPAP treatment on LA and LV size and function in patients with OSA and PAF before and after catheter ablation.MethodsIn a randomised controlled trial, we screened patients with PAF for OSA. We enrolled patients with an Apnoea–Hypopnoea Index ≥15/hour. The burden of AF was monitored by an implantable loop recorder in all patients. Patients were then randomised to CPAP treatment or standard care. Transthoracic echocardiography was performed at baseline and after 6 and 12 months to assess LV and LA function and remodelling with advanced echocardiographic imaging techniques.ResultsWe enrolled 109 patients (63±7 years, body mass index 29.6±4.3, 76% men). 83 patients were scheduled for pulmonary vein isolation (PVI) and 26 for clinical follow-up only. 55 patients were randomised to CPAP and 54 to standard care. The burden of AF decreased significantly in patients who underwent PVI irrespective of treatment with CPAP (p for difference ≤0.001). Patients in the study group had LV ejection fraction (LVEF) and LV global longitudinal strain (GLS) within the normal range, increased LA Volume Index (LAVI), LA volume (by speckle tracking) and decreased LA reservoir strain at baseline. We did not observe any improvement in LVEF, GLS, LAVI, LA volume or LA reservoir strain in either group during the 12 months of follow-up.ConclusionsIn patients with PAF and OSA, treatment with CPAP was not associated with reverse LA remodelling within 12 months of follow-up.

Background Sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated reduction in heart failure outcomes in patients with type 2 diabetes mellitus, although the exact mechanism of benefit remains unclear. Alteration in left atrial (LA) function due to chronic pressure or volume overload is a hallmark of heart failure. Objective To evaluate the effect of the SGLT2 inhibitor empagliflozin on LA volume and function. Methods 90 patients with coronary artery disease and type 2 diabetes (T2DM) were randomized to empagliflozin ( n  = 44) or placebo ( n  = 46), and underwent cardiac magnetic resonance (CMR) imaging at baseline and after 6 months. The main outcome was change in LA volume; LA function, including active and passive components, was also measured by a blinded reader. Results At baseline, there was no significant difference in LA volumes between the empagliflozin (indexed maximum LA volume 26.4 ± 8.4mL/m 2 , minimum LA volume 11.1 ± 5.7mL/m 2 ) and placebo (indexed maximum LA volume 28.7 ± 8.2mL/m 2 , minimum LA volume 12.6 ± 5.0mL/m 2 ) groups. After 6 months, changes in LA volumes did not differ with adjusted difference (empagliflozin minus placebo): 0.99 mL/m 2 (95% CI: -1.7 to 3.7 mL/m 2 ; p  = 0.47) for indexed maximum LA volume, and 0.87 mL/m 2 (95% CI: -0.9 to 2.6 mL/m 2 ; p  = 0.32) for indexed minimum LA volume. Changes in total LA emptying fraction were also similar, with between-group adjusted mean difference − 0.01 (95% CI: -0.05 to 0.03, p  = 0.59). Conclusion SGLT2 inhibition with empagliflozin for 6 months did not have a significant impact on LA volume and function in patients with T2DM and coronary artery disease. (Effects of Empagliflozin on Cardiac Structure in Patients with Type 2 Diabetes [EMPA-HEART]; NCT02998970).

Radiofrequency current (RFC) catheter ablation for patients with paroxysmal atrial fibrillation (AF) has been shown to be safe and effective in first-line therapy. Recent data demonstrates that RFC ablation provides better clinical outcomes compared to antiarrhythmic drug (AAD) in the treatment of early AF disease. Furthermore, studies comparing RFC and cryoballoon have established comparable efficacy and safety of pulmonary vein isolation (PVI) for patients with symptomatic paroxysmal AF. The Cryo-FIRST trial was designed to compare AAD treatment against cryoballoon PVI as a first-line therapy in treatment naïve patients with AF. Efficacy and safety will be compared between the two cohorts and amongst subgroups. The primary hypothesis is that cryoablation is superior to AAD therapy. To test this hypothesis, patients will be randomized in a 1:1 design. Using a 90-day blanking period, primary efficacy endpoint failure is defined as (at least) one episode of atrial arrhythmia with a duration >30 sec (documented by 7-day Holter or 12-lead ECG). Secondary endpoints (Quality-of-Life, rehospitalization, arrhythmia recurrence rate, healthcare utilization, and left atrial function) and adverse events will also be evaluated. Study enrollment will include 218 patients in up to 16 centers. This study will be a multi-national randomized controlled trial comparing cryoablation against AAD as a first-line treatment in patients with paroxysmal AF. The results may help guide the selection of patients for early AF disease therapy via cryoballoon ablation. [Display omitted]

Objectives A strong association exists between left atrial (LA) structural remodeling and the development of atrial fibrillation (AF). The role of LA function in AF prediction remains unclear. We studied the relationship between LA function and incident AF using cardiac CT. Materials and methods We retrospectively analyzed patients who underwent multiphasic cardiac CT. LA volumes and parameters of LA global, reservoir and booster function were calculated. The association between measures of LA function and incident AF was analyzed using multivariable Cox regression adjusting for clinical variables, LA volume and left ventricular function. Results 1025 patients (age 64 years ± 14) were evaluated. Over a median of 3.9 years, 90 patients developed AF. There was a significant association between LA total emptying fraction (adjusted hazard ratio (HR) 1.05; 95% CI: 1.02–1.05 per 1% decrease, p  < 0.001), LA reservoir function (HR 1.04; 95% CI: 1.02–1.06 per 1 mL/m 2 decrease in LA expansion index, p  < 0.001) and passive LA emptying (HR 1.08; 95% CI: 1.03–1.13 per 1% decrease in LA passive emptying fraction, p  < 0.001) with incident AF, but no association with LA booster function. Incorporating LA function into predictive models improved risk stratification beyond clinical variables and LA volume. Mediation analysis demonstrated that 46% of the effect of LA volume on AF was mediated via LA dysfunction. Conclusion LA functional impairment is common even in patients with normal LA volume and provides additional prognostic information for AF risk. The findings underscore the significance of LA mechanical dysfunction in the pathogenesis of AF. Key Points Question A strong association exists between left atrial structural remodeling and incident atrial fibrillation. The role of left atrial function in atrial fibrillation prediction remains unclear. Findings Left atrial reservoir and passive emptying function (but not booster function) predict incident atrial fibrillation independent of left atrial volume and clinical risk factors. Clinical relevance Left atrial functional impairment precedes the development of atrial fibrillation. Measures of left atrial reservoir and passive emptying function are independent predictors of incident atrial fibrillation. Graphical Abstract

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are 2 cardiovascular conditions that often coexist. Strain phases of both the left and right atria are more impaired in paroxysmal AF patients with HFpEF than those without HFpEF in spite of comparable global longitudinal strain of the left ventricle. Atrial function may differentiate paroxysmal AF patients with HFpEF from those without HFpEF.

The extent of improvement in left atrial (LA) function after radiofrequency catheter ablation (RFCA) in patients with paroxysmal atrial fibrillation (PxAF) and its association with heart failure with preserved ejection fraction (HFpEF) remain unclear. This study aims to explore whether there is a difference in the improvement of LA function after RFCA in patients with PxAF combined with HFpEF compared to those without HFpEF. Patients with PxAF receiving RFCA were enrolled. LA volume index (LAVI), LA emptying fraction (LAEF), and LA peak reservoir strain (LA RS) were assessed using echocardiography at baseline and three months after RFCA. Changes in these parameters were compared between patients with a high probability of HFpEF (hp-HFpEF) and those with a medium or low probability of HFpEF (lp-HFpEF), as determined by the H2FPEF score. A total of 147 patients (mean age 62.6 years; 63.3% males) were recruited (hp-HFpEF = 30). Baseline LA function differed significantly between patients with hp-HFpEF and those with lp-HFpEF. Differences included LAVI, LAEF, and LA RS (all P  < 0.01). The improvement in LA function 3 months after RFCA was significantly different between the two groups, even after adjusting for confounding factors. Specifically, patients with hp-HFpEF experienced greater reductions in LAVI, more improvement in LAEF, and greater improvement in LA RS compared to patients with lp-HFpEF. A high probability of HFpEF was correlated with greater improvement in LA function following RFCA in patients with PxAF. The clinical trial registration number: ClinicalTrials.gov NCT05266144. Graphical Abstract

Purpose Left atrial (LA) function has emerged as an important marker of LA compliance and has been associated with adverse outcomes in patients with heart failure with reduced ejection fraction (HFrEF). This study aimed to evaluate the association between impaired LA function and the risk of incident atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). Hypothesis Impaired LA function is associated with an increased risk of incident AF and HFpEF. Methods A total of 268 patients without a prior diagnosis of heart failure or atrial fibrillation were prospectively enrolled according to predefined inclusion and exclusion criteria. Results During a mean follow-up of 36 ± 3 months, 79 patients (29.48%) developed AF and 69 patients (25.75%) developed HFpEF, including 23 patients (8.6%) who developed both conditions. Compared with patients who remained free of both conditions, those who developed AF and/or HFpEF exhibited impaired LA function, reflected by lower LATEF, LAPEF, LAAEF, and LAEI, as well as a higher E/e′ ratio (all P  < 0.05). In multivariable Cox regression analyses, LAD, E/e′ ratio, interventricular septal thickness (IVS), and LATEF were independently associated with incident AF. Similarly, E/e′ ratio, LATEF, LAAEF, and IVS were independently associated with incident HFpEF. Patients with lower LATEF had higher risks of all-cause mortality and stroke during follow-up. Conclusion Impaired LA function is associated with an increased risk of AF and HFpEF. Reduced LATEF is independently associated with these outcomes and is further associated with adverse clinical events.