Prognostic and functional value of left atrial indices in advanced heart failure

Left atrial (LA) remodeling and dysfunction are increasingly recognized as important contributors to outcomes in heart failure; however, their prognostic and functional relevance in advanced heart failure (AHF) remains insufficiently defined. This study evaluated the prognostic and functional significance of echocardiographic LA indices in AHF. Between 2021 and 2023, 194 patients with left ventricular ejection fraction ≤ 25% were included. All patients were referred to our tertiary cardiovascular center for evaluation of advanced therapeutic options [left ventricular assist device (LVAD) or heart transplantation] and underwent echocardiography, right heart catheterization, and cardiopulmonary exercise testing (CPET). Kaplan–Meier and Cox regression analyses were used to assess the prognostic impact of LA strain and mechanical indices on the composite endpoint of all-cause death, LVAD implantation, or heart transplantation. Correlations with CPET parameters were examined to evaluate functional relevance. Patients with impaired LA reservoir strain (LASr < 8.35%) exhibited more advanced atrial remodeling, higher filling pressures, worse ventricular function, and reduced exercise capacity. During a median follow-up of 461 days, adverse outcomes occurred more frequently in the lower LASr group (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. LASr, LA ejection fraction (LAEF), and LA expansion index (LAEI) showed positive associations with peak VO₂ (all p < 0.001), indicating an association between atrial mechanics and exercise performance. In patients with AHF, LASr and LAVImin are independently associated with adverse clinical outcomes and reduced exercise tolerance. Incorporation of LA functional assessment into routine evaluation may help improve risk stratification and support clinical decision-making in this high-risk population.