Left atrial enlargement is associated with pulmonary vascular disease in heart failure with preserved ejection fraction

Emma K. Gard, Anna L. Beale, Fernando Telles, Frank E. Silvestry, Thomas Hanff, Scott L. Hummel, Sheldon E. Litwin, Mark C. Petrie, Sanjiv J. Shah, Barry A. Borlaug, Dan Burkhoff, Jan Komtebedde, David M. Kaye*, Shane Nanayakkara

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Aims: Elevated left atrial (LA) pressure is a pathophysiologic hallmark of heart failure with preserved ejection fraction (HFpEF). Chronically elevated LA pressure leads to LA enlargement, which may impair LA function and increase pulmonary pressures. We sought to evaluate the relationship between LA volume and pulmonary arterial haemodynamics in patients with HFpEF. Methods and results: Data from 85 patients (aged 69 ± 8 years) who underwent exercise right heart catheterization and echocardiography were retrospectively analysed. All had symptoms of heart failure, left ventricular ejection fraction ≥50% and haemodynamic features of HFpEF. Patients were divided into LA volume index-based tertiles (≤34 ml/m2, >34 to ≤45 ml/m2, >45 ml/m2). A subgroup analysis was performed in patients with recorded LA global reservoir strain (n = 60), with reduced strain defined as ≤24%. Age, sex, body surface area and left ventricular ejection fraction were similar between volume groups. LA volume was associated with blunted increases in cardiac output with exercise (padjusted <0.001), higher resting mean pulmonary artery pressure (padjusted = 0.003), with similar wedge pressure (padjusted = 1). Pulmonary vascular resistance (PVR) increased with increasing LA volume (padjusted <0.001). Larger LA volumes featured reduced LA strain (padjusted <0.001), with reduced strain associated with reduced PVR–compliance time (0.34 [0.28–0.40] vs. 0.38 [0.33–0.43], p = 0.03). Conclusion: Increasing LA volume may be associated with more advanced pulmonary vascular disease in HFpEF, featuring higher PVR and pulmonary pressures. Reduced LA function, worse at increasing LA volumes, is associated with a disrupted PVR–compliance relationship, further augmenting impaired pulmonary haemodynamics.

Original languageEnglish (US)
Pages (from-to)806-814
Number of pages9
JournalEuropean Journal of Heart Failure
Issue number6
StatePublished - Jun 2023


  • Cardiac catheterization
  • Echocardiography
  • Exercise haemodynamics
  • Heart failure with preserved ejection fraction
  • Left atrium
  • Pulmonary hypertension

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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