Department of Cardiology, Campus Kerckhoff of the Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany (S.J.B.).
German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany (S.J.B.).
Circ Cardiovasc Imaging. 2024 Jul;17(7):e016424. doi: 10.1161/CIRCIMAGING.123.016424. Epub 2024 Jul 16.
It remains unknown to what extent intrinsic atrial cardiomyopathy or left ventricular diastolic dysfunction drive atrial remodeling and functional failure in heart failure with preserved ejection fraction (HFpEF). Computational 3-dimensional (3D) models fitted to cardiovascular magnetic resonance allow state-of-the-art anatomic and functional assessment, and we hypothesized to identify a phenotype linked to HFpEF.
Patients with exertional dyspnea and diastolic dysfunction on echocardiography (E/e', >8) were prospectively recruited and classified as HFpEF or noncardiac dyspnea based on right heart catheterization. All patients underwent rest and exercise-stress right heart catheterization and cardiovascular magnetic resonance. Computational 3D anatomic left atrial (LA) models were generated based on short-axis cine sequences. A fully automated pipeline was developed to segment cardiovascular magnetic resonance images and build 3D statistical models of LA shape and find the 3D patterns discriminant between HFpEF and noncardiac dyspnea. 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 hospitalization.
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 LA HFpEF shape score, a biomarker to characterize the gradual remodeling between noncardiac dyspnea and HFpEF. The LA HFpEF shape score was able to discriminate HFpEF (n=34) to noncardiac dyspnea (n=34; area under the curve, 0.81) and was associated with a risk for atrial fibrillation occurrence (hazard ratio, 1.02 [95% CI, 1.01-1.04]; =0.003), as well as cardiovascular hospitalization (hazard ratio, 1.02 [95% CI, 1.00-1.04]; =0.043).
LA roof dilation is an early remodeling pattern in masked HFpEF advancing to overall LA enlargement in overt HFpEF. These distinct features predict the occurrence of atrial fibrillation and cardiovascular hospitalization.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03260621.
目前尚不清楚内在心房心肌病或左心室舒张功能障碍在射血分数保留的心力衰竭（HFpEF）中对心房重构和功能衰竭的影响程度。拟合心血管磁共振的计算三维（3D）模型允许进行最先进的解剖和功能评估，我们假设可以确定与 HFpEF 相关的表型。
前瞻性招募因运动呼吸困难和超声心动图（E/e'，>8）存在舒张功能障碍的患者，并根据右心导管检查将其分类为 HFpEF 或非心源性呼吸困难。所有患者均接受静息和运动负荷右心导管检查及心血管磁共振检查。基于短轴电影序列生成计算的 3D 解剖左心房（LA）模型。开发了一个全自动流水线，用于分割心血管磁共振图像并构建 LA 形状的 3D 统计模型，以找到区分 HFpEF 和非心源性呼吸困难的 3D 模式。此外，通过常规容积分析和变形成像来量化心房形态和功能。在 24 个月时进行临床随访，以评估心血管住院情况。
除了心房大小外，3D LA 模型还显示房顶扩张是隐匿性 HFpEF（仅在运动负荷时诊断）的主要特征，随后在显性 HFpEF（在静息时诊断）中出现整体心房大小的模式转变。3D 模型的特征被整合到 LAHFpEF 形状评分中，这是一种用于描述非心源性呼吸困难和 HFpEF 之间逐渐重构的生物标志物。LAHFpEF 形状评分能够区分 HFpEF（n=34）和非心源性呼吸困难（n=34；曲线下面积，0.81），并与心房颤动发生风险相关（风险比，1.02[95%CI，1.01-1.04]；=0.003），以及心血管住院（风险比，1.02[95%CI，1.00-1.04]；=0.043）。
LA 房顶扩张是隐匿性 HFpEF 的早期重构模式，在显性 HFpEF 中进展为整体 LA 增大。这些独特的特征预测了心房颤动和心血管住院的发生。
