Left atrial (LA) remodeling and dysfunction are increasingly recognized in heart failure, yet their role in advanced heart failure (AHF) remains less defined. In a study published in the Cardiovascular Ultrasound, the researchers assessed echocardiographic left atrial indices for prognostic and functional value in AHF. Between 2021 and 2023, 194 patients with left ventricular ejection fraction ≤25% referred for evaluation of advanced therapies (left ventricular assist device [LVAD] or heart transplantation) underwent echocardiography, right heart catheterization, and cardiopulmonary exercise testing.

Patients with impaired LA reservoir strain (LASr <8.35%) demonstrated more advanced atrial remodeling, higher filling pressures, worse ventricular function, and reduced exercise capacity. Over a median follow-up of 461 days, adverse events (all-cause death, LVAD implantation, or heart transplantation) occurred more frequently in patients with lower LASr (35.1% vs 14.4%; p=0.002). Both LASr and LA minimum volume index (LAVImin) independently predicted the composite endpoint and provided incremental prognostic value.

Functional associations were observed between LA indices and exercise capacity. LASr, LA ejection fraction (LAEF), and LA expansion index (LAEI) were positively associated with peak VO₂ (all p<0.001).

Limitations include retrospective single-center design, selection of patients with advanced disease, vendor-dependent strain analysis, exclusion of certain cardiac conditions, indirect Fick cardiac output estimation, and non-standardized therapies.

In this AHF cohort, LASr and LAVImin were independently associated with adverse outcomes and reduced exercise tolerance. Prospective multicenter validation is needed to clarify broader clinical applicability.