Prediction of left atrial appendage dysfunction by atrial strain imaging in patients with rheumatic mitral stenosis in sinus rhythm

Figures

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  Figure 1. The pulse wave Doppler on TEE showing LAAEV (+). Pulse-wave Doppler tracing from the left atrial appendage (LAA) shows the positive wave that follows the P-wave on the ECG, representing LAA emptying, showing its contractile function (A). Transoesophageal echocardiography mid-oesophageal two-chamber view (ME-AV SAX view) showing LAA thrombus (B). The image highlights typical features of rheumatic mitral stenosis related atrial stasis, with thrombogenic LAA and absent appendage contraction consistent with mechanical inactivity. The strain curve shows two distinct peaks: the first positive peak before mitral valve opening represents LASr, while the second negative deflection before atrial contraction indicates LASct. The difference between these two peaks defines LAScd (C).

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  Figure 2. Scatter plot showing the correlation of left atrial reservoir strain with serum fibrinogen, D-dimer, and LAAEV. Each point represents an individual patient, illustrating an inverse association between LASr and both fibrinogen, D-dimer levels, conduit, and contractile strain.

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  Figure 3. Composite violin plots demonstrating left atrial functional parameters and LAAEV stratified by fibrinogen status. Composite violin plots showing LAAEV, LASr, LAScd, and LASct in patients with normal and elevated fibrinogen levels. Colour-coded violins represent individual parameters. LAVI, left atrial volume indices; LASr, left atrial reservoir strain; LAScd, left atrial conduit strain; LASct, left atrial contractile strain; LVEDV, left ventricular end diastolic volume; MVA 2D, mitral valve area by planimetry; MVA PHT, mitral valve area by pressure half time; MVMG, mitral valve mean gradient; MVPG, mitral valve peak gradient.

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  Figure 4. Forest plot showing univariate analysis of echocardiographic parameters to predict LAA inactivity (A). Comparison of ROC curve showing the discriminative ability of the LASr (AUC-0.950), MVA-2D (AUC-0.600), MVMG (AUC-0.683), and LAVI (AUC-0.620) for LAA inactivity (B). AUC, area under curve; LAAEV, left atrial appendage emptying velocity; LAScd, left atrial conduit strain; LASct, left atrial contractile strain; LASr, left atrial reservoir strain; ROC, receiver operating characteristics.