Key result
Low preoperative LA reservoir strain independently predicts adverse LA expansion and HF hospitalizations after LAA excision.
Why the study?
Eliminating the high-compliance left atrial appendage buffer may increase wall stress and heart failure risk in patients with impaired left atrial reserve, but long-term structural and clinical data after surgical excision remain limited.
Does pre-operative left atrial reservoir strain predict adverse left atrial expansion at one year and subsequent heart failure hospitalizations in patients undergoing surgical left atrial appendage excision?
Cohort (n=202)
Does pre-operative left atrial reservoir strain predict adverse left atrial expansion at one year and subsequent heart failure hospitalizations in patients undergoing surgical left atrial appendage excision?
Pre-operative left atrial reservoir strain independently predicts adverse left atrial expansion and subsequent heart failure hospitalization following surgical left atrial appendage excision, identifying high-risk patients who require closer post-operative monitoring.
Low pre-operative LASr may flag HF hospitalization risk after LAA excision; hypothesis-generating and requires prospective validation before clinical use.
Background The left atrium (LA) performs three phasic functions: reservoir, conduit, and booster pump. Left atrial reservoir strain (LASr) is a sensitive biomarker for diastolic dysfunction and cardiovascular risk, often preceding structural changes. While left atrial appendage (LAA) intervention, including surgical excision and percutaneous closure, is an established standard for stroke prophylaxis in patients with atrial fibrillation (AF), the LAA also acts as a "pressure-volume buffer" due to its 2.6-fold higher compliance compared to the LA main chamber. Eliminating this high-compliance buffer may increase wall stress and heart failure (HF) risk in patients with impaired LA reserve, although long-term structural and clinical data remain limited. Purpose To evaluate pre-operative LASr as a predictor of adverse LA expansion at one year and subsequent HF hospitalizations after surgical LAA excision. Methods We retrospectively analyzed 202 consecutive patients (62.4% male, mean age 67.5 ± 12.8 years) who underwent surgical LAA excision during cardiac surgery between March 2023 and February 2025. Transthoracic echocardiography was performed at baseline and at one-year follow-up. LA phasic function, specifically LASr, was analyzed via two-dimensional speckle-tracking (EchoPAC AFI-LA, GE Healthcare) using the R-R gating method. The patient cohort included those undergoing isolated LAA excision (5.3%), isolated CABG (21.1%), isolated valve replacement (35.1%), and other complex cardiac procedures. Subjects were categorized by baseline rhythm: sinus (73.7%), paroxysmal AF (14.0%), persistent AF (3.5%), or long-standing persistent AF (LSAF) (8.8%). Adverse remodeling was strictly defined as an absolute LA volume index (LAVI) increase ≥10 points (ml/m2) at one year. Outcomes were assessed via Kaplan-Meier analysis for unplanned HF hospitalizations. Results Pre-operative LASr declined stepwise with AF severity (Sinus > Paroxysmal > Persistent > LSAF, p < 0.001). At one year, no group showed significant LASr improvement, while LA expansion was most prominent in the LSAF group. Compared to the Non-Expansion Group, the Expansion Group (LAVI increase ≥10 points) had significantly lower baseline LASr and higher LSAF prevalence. Median follow-up was 554 days, with a 3.5% incidence of HF hospitalizations. Kaplan-Meier analysis revealed a significantly higher incidence of HF hospitalizations in the Expansion Group (p < 0.05). Multivariate analysis identified pre-operative low LASr as an independent predictor of post-operative LA expansion and subsequent HF. Conclusion LASr is a critical predictor of adverse remodeling post-LAA excision. In patients with severely impaired LASr, the LA cannot compensate for the loss of the LAA's buffer capacity, leading to structural expansion and elevated HF risk. Pre-operative LA strain assessment is essential to identify high-risk patients requiring intensive post-operative management and vigilant follow-up.
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Hada et al. (2026) conducted a cohort in Patients undergoing surgical left atrial appendage (LAA) excision during cardiac surgery (n=202). Pre-operative left atrial reservoir strain (LASr) / Post-operative LA expansion (LAVI increase >=10 ml/m2) vs. Normal/higher pre-operative LASr / Non-Expansion Group (LAVI increase <10 ml/m2) was evaluated on Adverse left atrial expansion (LAVI increase >=10 ml/m2) at one year and unplanned heart failure hospitalizations (p=< 0.05). Low pre-operative left atrial reservoir strain independently predicted 1-year LA expansion (LAVI increase >=10 ml/m2) and subsequent HF hospitalizations (3.5% overall; p<0.05) after LAA excision.
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