Distinct role of minimal and maximal left atrial volumes in assessing LV filling pressures and prognosis in chronic heart failure

• Published in: The international journal of cardiovascular imaging Vol. 41; no. 8; pp. 1513 - 1522
• Main Authors: Fortuni, Federico, Biagioli, Paolo, Mengoni, Anna, Zuchi, Cinzia, Sforna, Stefano, Delgado, Victoria, Ambrosio, Giuseppe, Carluccio, Erberto
• Format: Journal Article
• Language: English
• Published: Dordrecht Springer Netherlands 01.08.2025; Springer Nature B.V
• Subjects: Aged; Atrial Function, Left; Biomarkers - blood; Blood pressure; Cardiac Imaging; Cardiology; Chronic Disease; Congestive heart failure; Diastolic pressure; Doppler effect; Echocardiography; Echocardiography, Doppler; Female; Heart Atria - diagnostic imaging; Heart Atria - physiopathology; Heart attacks; Heart failure; Heart Failure - diagnostic imaging; Heart Failure - mortality; Heart Failure - physiopathology; Heart Failure - therapy; Hospitalization; Humans; Imaging; Ischemia; Kidney diseases; Male; Medical prognosis; Medicine; Medicine & Public Health; Middle Aged; Mitral Valve Insufficiency - diagnostic imaging; Mitral Valve Insufficiency - mortality; Mitral Valve Insufficiency - physiopathology; Natriuretic Peptide, Brain - blood; Original Paper; Patients; Peptide Fragments; Predictive Value of Tests; Prognosis; Radiology; Regression analysis; Regurgitation; Retrospective Studies; Risk Factors; Stroke Volume; Time Factors; Velocity; Ventricular Dysfunction, Left - diagnostic imaging; Ventricular Dysfunction, Left - mortality; Ventricular Dysfunction, Left - physiopathology; Ventricular Dysfunction, Left - therapy; Ventricular Function, Left; Ventricular Pressure; Heart failure; Echocardiography; Prognosis; Left atrium; Left ventricle
• ISSN: 1875-8312; 1569-5794; 1875-8312; 1573-0743
• DOI: 10.1007/s10554-025-03441-7

Current guidelines recommend assessing left atrial (LA) maximal volume to grade left ventricular (LV) diastolic dysfunction. However, recent studies suggest a strong association between LA minimal volume and prognosis. The present study aims to investigate the relative merits of minimal and maximal LA volume in reflecting LV filling pressures and on prognosis in chronic heart failure (HF). We retrospectively analyzed 1135 chronic HF patients (75% men; mean age 66 ± 12 years) in sinus rhythm. LV end-diastolic pressure (EDP) ≥ 20 mmHg (estimated with echocardiography) was considered as increased LV-EDP. Patients were followed-up for the occurrence of all-cause death or HF hospitalization (primary composite endpoint). LA minimal volume (Area Under the Curve [AUC] = 0.74) demonstrated a stronger association with LV filling pressures compared to maximal volume (AUC 0.71, P-for-comparison = 0.007) and NT-proBNP. The superiority of LA minimal over maximal volume in identifying increased LV-EDP was more evident in patients with severe mitral regurgitation (MR, 12% of the cohort) or LV systolic dysfunction (LV ejection fraction < 50%, 84% of the cohort). Conversely, LA maximal volume (AUC = 0.77) performed better than minimal volume (AUC = 0.71) in identifying increased LV-EDP in patients with preserved LV ejection fraction. Multivariable Cox regression analysis revealed that both LA volumes were similarly and independently associated with the primary composite endpoint. In patients with chronic HF, although both minimal and maximal LA volumes are associated with clinical outcomes, minimal volume provides a more accurate reflection of LV filling pressures. This makes LA minimal volume a more valuable diagnostic parameter than maximal volume, especially in patients with severe mitral regurgitation and LV systolic dysfunction. Graphical abstract LA minimal volume reflects LV filling pressures better in HFrEF/secondary MR, while LA maximal volume correlates more with LV filling pressures in HFpEF. The right panel shows an algorithm based on these findings