Importance and significance of left atrial reverse remodelling in the follow-up of patients with heart failure
L B F Silva, S R Furquim, M T S S Lira, D S P Belfort, B Biselli, P R Chizzola, R T Munhoz, E A Bocchi, S M Ayub-FerreiraAbstract
Background
Heart failure (HF) phenotypes are clinically classified based on left ventricular ejection fraction (LVEF). While cardiac reverse remodelling is a well-established marker of favourable outcome, clinical focus remains predominantly on the left ventricle (LV), which may underestimate significant structural changes in other chambers. The left atrium (LA) is a sensitive marker of haemodynamic burden and filling pressures; however, consensus is lacking regarding the prevalence and prognostic impact of left atrial reverse remodelling (LARR) in relation to left ventricular reverse remodelling (LVRR).
Purpose
To simultaneously analyse atrial and ventricular reverse remodelling to classify recovery phenotypes in patients with HF and evaluate the impact of structural dissociation on 10-year survival.
Methods
A retrospective cohort study (2006–2019) included 7,981 patients with baseline LVEF <40%. Subjects were stratified by functional recovery (Total: LVEF ≥50%; Partial: LVEF 40–49%) and by diameter normalisation patterns: combined (LV/LA), isolated (LV or LA only), and absent. Statistical analysis included Pearson correlation and Kaplan–Meier survival curves with log-rank tests.
Results
In the total functional recovery group (n=1,005), isolated ventricular normalisation (LV only) was predominant (40.8%), surpassing the combined LV/LA profile (30.9%). A weak correlation was found between LVEF gain and atrial reduction (r=0.169). In the partial recovery group (n=1,494), absent structural improvement predominated (44.2%), with near-zero atrial variation (0.12%). Survival analysis at 5 and 10 years revealed that LA normalisation significantly reduces mortality: in the total functional recovery group, mortality decreased from 20.2% (isolated LV) to 8.0% (combined LV/LA); in the partial recovery group, it fell from 31.1% (isolated LV) to 16.5% (combined LV/LA) (p < 0.001).
Conclusion
Functional recovery is frequently independent of structural recovery; thus, current definitions of reverse remodelling may underestimate patient prognosis. Persistent atrial dilatation in patients with normalised LVEF suggests residual cardiac impairment, which maintains elevated mortality rates.