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Peer-reviewedCC BY 4.0Frontiers in Cardiovascular Medicine

Development and evaluation of a transesophageal echocardiography–derived left atrial appendage structure–function coupling index across the atrial fibrillation disease continuum

  • Jianbo Zhu1,2,3
  • Chen Ni2,3
  • Yangnan Ruan2,3
  • Yanfeng Jiang2,3
  • Lei Zhu1,2
  • Yanhua Huang1,2
  • Zhenzhen Jiang1,2,3
  • Xiatian Liu1,2,3
  1. 1Department of Echocardiography, Shaoxing People’s Hospital
  2. 2Department of Echocardiography, The First Affiliated Hospital, Shaoxing University
  3. 3School of Medicine, Shaoxing University
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Abstract

Background: Atrial fibrillation (AF) is a progressive disorder associated with atrial remodeling and thromboembolic risk. We developed a transesophageal echocardiography (TEE)-derived left atrial appendage (LAA) structure-function coupling index (LAA-SFCI), defined as LAA volumetric load relative to longitudinal deformation, and assessed its distribution along the AF disease continuum and its potential for risk re-stratification of patients without documented AF.

Methods: This single-center, prospective, cross-sectional study included 267 patients undergoing clinically indicated TEE, classified by the 2023 American College of Cardiology/American Heart Association/American College of Clinical Pharmacy/Heart Rhythm Society (ACC/AHA/ACCP/HRS) framework as Stage 1 ( n = 68), Stage 2 ( n = 65), Stage 3a ( n = 66), or Stage 3b ( n = 68). Seven candidate LAA-SFCIs were calculated as the LAA volume index (LAA-VI) divided by a functional measure, and the principal index was selected by ordinal logistic regression using the Akaike information criterion. Discrimination was compared using the DeLong test and internally validated by bootstrapping, and patients without documented AF (Stages 1–2) were stratified by the exploratory cutoff.

Results: LAA-VI/LAA-GLS (LAA global longitudinal strain) provided the best model fit and rose across AF stages from 0.33 ± 0.11 to 0.86 ± 0.36 (mL/m ² )/% ( P < 0.001). In ordinal regression with the log-transformed index, each 1-SD increase remained associated with higher AF stage after adjustment for age, sex, body mass index, left ventricular ejection fraction, and left atrial volume index (odds ratio 11.04, 95% confidence interval 7.17–16.98). For Stage 1–2 versus Stage 3a–3b, its area under the curve (0.904; optimism-corrected 0.900) was significantly higher than those of LAA-VI (0.661) and LAA-GLS (0.824) (both DeLong P < 0.001). Among 133 patients without documented AF, 18 (13.5%) exceeded the cutoff of 0.460 (mL/m ² )/%; these patients did not differ from the others in left atrial volume index or age.

Conclusion: In this cross-sectional study, LAA-VI/LAA-GLS characterized LAA structure–function uncoupling along the AF disease continuum. In patients without documented AF undergoing clinically indicated TEE, it identified a subgroup with an AF-like LAA phenotype not captured by conventional atrial size measures. These findings are hypothesis-generating and require external validation and longitudinal follow-up to determine their prognostic value.

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Cite

BibTeXRIS
BibTeX
@article{zhu2026development,
  title = {{Development and evaluation of a transesophageal echocardiography–derived left atrial appendage structure–function coupling index across the atrial fibrillation disease continuum}},
  author = {Jianbo Zhu and Chen Ni and Yangnan Ruan and Yanfeng Jiang and Lei Zhu and Yanhua Huang and Zhenzhen Jiang and Xiatian Liu},
  journal = {Frontiers in Cardiovascular Medicine},
  year = {2026},
  month = oct,
  doi = {10.3389/fcvm.2026.1951089},
  url = {https://www.frontiersin.org/articles/10.3389/fcvm.2026.1951089/full},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Development and evaluation of a transesophageal echocardiography–derived left atrial appendage structure–function coupling index across the atrial fibrillation disease continuum
AU  - Jianbo Zhu
AU  - Chen Ni
AU  - Yangnan Ruan
AU  - Yanfeng Jiang
AU  - Lei Zhu
AU  - Yanhua Huang
AU  - Zhenzhen Jiang
AU  - Xiatian Liu
PY  - 2026
DA  - 2026/10/28
JO  - Frontiers in Cardiovascular Medicine
DO  - 10.3389/fcvm.2026.1951089
UR  - https://www.frontiersin.org/articles/10.3389/fcvm.2026.1951089/full
AB  - Background: Atrial fibrillation (AF) is a progressive disorder associated with atrial remodeling and thromboembolic risk. We developed a transesophageal echocardiography (TEE)-derived left atrial appendage (LAA) structure-function coupling index (LAA-SFCI), defined as LAA volumetric load relative to longitudinal deformation, and assessed its distribution along the AF disease continuum and its potential for risk re-stratification of patients without documented AF.  Methods: This single-center, prospective, cross-sectional study included 267 patients undergoing clinically indicated TEE, classified by the 2023 American College of Cardiology/American Heart Association/American College of Clinical Pharmacy/Heart Rhythm Society (ACC/AHA/ACCP/HRS) framework as Stage 1 ( n = 68), Stage 2 ( n = 65), Stage 3a ( n = 66), or Stage 3b ( n = 68). Seven candidate LAA-SFCIs were calculated as the LAA volume index (LAA-VI) divided by a functional measure, and the principal index was selected by ordinal logistic regression using the Akaike information criterion. Discrimination was compared using the DeLong test and internally validated by bootstrapping, and patients without documented AF (Stages 1–2) were stratified by the exploratory cutoff.  Results: LAA-VI/LAA-GLS (LAA global longitudinal strain) provided the best model fit and rose across AF stages from 0.33 ± 0.11 to 0.86 ± 0.36 (mL/m ² )/% ( P < 0.001). In ordinal regression with the log-transformed index, each 1-SD increase remained associated with higher AF stage after adjustment for age, sex, body mass index, left ventricular ejection fraction, and left atrial volume index (odds ratio 11.04, 95% confidence interval 7.17–16.98). For Stage 1–2 versus Stage 3a–3b, its area under the curve (0.904; optimism-corrected 0.900) was significantly higher than those of LAA-VI (0.661) and LAA-GLS (0.824) (both DeLong P < 0.001). Among 133 patients without documented AF, 18 (13.5%) exceeded the cutoff of 0.460 (mL/m ² )/%; these patients did not differ from the others in left atrial volume index or age.  Conclusion: In this cross-sectional study, LAA-VI/LAA-GLS characterized LAA structure–function uncoupling along the AF disease continuum. In patients without documented AF undergoing clinically indicated TEE, it identified a subgroup with an AF-like LAA phenotype not captured by conventional atrial size measures. These findings are hypothesis-generating and require external validation and longitudinal follow-up to determine their prognostic value.
SN  - 2297-055X
ER  -