Clinical study: congestive heart failure
Determinants and prognostic value of left atrial volume in patients with dilated cardiomyopathy

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Abstract

Objectives

We aimed to investigate the determinants of left atrial (LA) volume and its prognostic value in patients with dilated cardiomyopathy (DCM).

Background

Enlargement of the LA is a marker of mortality in the general population. Patients with DCM are characterized by a wide range of LA sizes, but the clinical role of this observation has been played down.

Methods

A complete echocardiographic Doppler examination was performed in 337 patients (age 60 ± 13 years; 84% male) with the diagnosis of DCM. Left atrial maximal volume (LAmax) was measured at left ventricular (LV) end systole (four-chamber view; area–length method). Left ventricular end-diastolic and end-systolic volumes (LVEDV and LVESV) and ejection fraction (EF) were also measured. Mitral regurgitation (MR) was graded using a 5-point scale. Mitral E-wave (E) and A-wave (A) velocities, as well as their ratio (E/A), were measured off-line.

Results

Determinants of LAmax were: atrial fibrillation (r = 0.34, p < 0.0001), LVEDV (r = 0.46, p < 0.0001), EF (r = 0.40, p < 0.0001), MR (r = 0.39, p < 0.0001), and E/A ratio (r = 0.36, p < 0.0001). During follow-up (41 ± 29 months), 77 patients died and 12 underwent heart transplantation. Univariate Cox analysis showed that LAmax (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.007–1.013, p < 0.0001), LVESV (HR 1.003, CI 1.001–1.005, p = 0.0003), E/A ratio (HR 1.6, CI 1.3–2.005, p < 0.0001), and MR (HR 1.21, CI 1.03–1.44, p = 0.02) were related to the outcome. On bivariate Cox analysis, LAmax predicted the prognosis independently of each determinant. Patients with a larger LA volume (LAmax/m2 >68.5 ml/m2) had a risk ratio of 3.8 compared with those with a smaller LA volume.

Conclusions

In patients with DCM, LA volume is associated with LV remodeling, diastolic dysfunction, and the degree of MR. The maximal volume of the LA has an independent and incremental prognostic value, compared with all its determinants.

Abbreviations

AF
atrial fibrillation
CI
confidence interval
DCM
dilated cardiomyopathy
EF
ejection fraction
HR
hazard ratio
LA
left atrium/atrial
LV
left ventricle/ventricular
LVEDV and LVESV
left ventricular end-diastolic and end-systolic volume, respectively
MR
mitral regurgitation
ROC
receiver-operating characteristic

Cited by (0)

Dr. Cicoira was supported by a grant from the Italian Society of Cardiology for Cardiovascular Research. Dr. Enriquez-Sarano was supported in part by Grant HL-64928 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.