Prognostic Value of Left Atrial Volume Index in End Stage Renal  Disease Patients

Prognostic Value of Left Atrial Volume Index in End Stage Renal Disease Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prognostic Value of Left Atrial Volume Index in End Stage Renal Disease Patients sidra saleem, Abeera Mansur, Haris Naveed, Syeda Huma Zartash, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-879662/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Cardiovascular Disease is the leading cause of death in End Stage Renal Disease patients. Left atrial volume index is an established independent risk predictor for mortality in atherosclerotic heart disease. However, Left atrial volume index has not been extensively studied in hemodialysis population. The aim of this study is to assess the impact of Left atrial volume index on mortality in hemodialysis patients. Methods: This is a descriptive cross sectional study. From January 1, 2013, through April 30, 2018, we evaluated echocardiographic findings of 91 End stage renal disease patients on maintenance hemodialysis. Patient information was collected and data analysed using SPSS version 22 for windows software package. Results :The average age of the patients was 62.85±12.4 years. The average duration of dialysis was 29.54 months as shown in Table 1. The mean Left atrial volume index of our dialysis patients was 38.993 ml/m2. The mean Left atrial volume index of 42.62±10.24 ml/m2 in expired patients as compared to 36.6 ml/m2 in alive patients with a p-value of 0.004 shows that Left atrial volume index of expired patients was significantly higher as compared to alive patients (Table 2). Area under the curve using Receiver operating characteristic curve was found 66.7% which was statistically significant with p-value 0.007, which suggests that the cutoff value of Left atrial volume index for expired patients can be at least 38.5. 61.5% patients that expired had a Left atrial volume index of more than 38.5 ml/m2, whereas 62.7% patients that were alive had a Left atrial volume index less than 38.5 ml/m2 , the p-value 0.02 suggested a significant association of Left atrial volume index with Mortality. Left atrial volume index gives positive association with mortality, for Left atrial volume index greater than 40, the odds ratio was 3.5. Mortality didn’t give any significant association with Ejection Fraction, Pulmonary artery systolic pressure and EE ratio. Conclusion : Increased Left atrial volume index is associated with higher mortality in End stage renal disease patients on maintenance hemodialysis. Increased Left atrial volume index was the best predictor of mortality among measured echocardiographic parameters in our hemodialysis population. Urology & Nephrology Left atrial volume index End Stage renal disease mortality Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Patients with End-Stage Renal Disease (ESRD) have an increased risk of premature cardiovascular disease. [ 1 ] Diagnosing Cardiovascular disease in patients on hemodialysis is challenging as patients frequently do not experience symptoms or present with atypical symptoms. Left atrial (LA) size is part of cardiac remodeling in a variety of cardiovascular diseases and a predictor of cardiovascular morbidity and mortality. [ 2 – 5 ] A dilatation occurs in a number of disease processes such as left ventricular hypertrophy and failure, aortic and mitral valve diseases and is a powerful predictor of heart failure, stroke, and mortality. [ 6 – 10 ] Increased LAVi, which is a component of the algorithm for Diastolic dysfunction of LV, was shown to predict mortality after myocardial infarction(MI) [ 8 , 11 ] The American Society of Echocardiography / European Association of Cardiovascular Imaging, recommended LA volume index (LAVI), the value of LA volume divided by body surface area, to measure LA size. [ 12 ] The most widely applied technique for measuring atrial size is two-dimensional echocardiography (2DE). [ 12 , 13 , 14 ] The method of assessing maximal end-systolic anteroposterior dimension of LA from the parasternal long-axis view in M-mode echocardiography is simple and convenient but its accuracy is rather limited by the anatomical confinement afforded by the spine and sternum and the resulting asymmetrical or pillow-shaped enlargement of the left atrium. [ 15 ] For these reasons, multiple linear dimensions or measurement of left atrial volume (LAV) especially when corrected for body surface area i.e. left atrial volume index (LAVi), is a more accurate representation of true LA size. [ 16 ] The ASE(American Society of Echocardiography) in 2005 recommended a value of 28 ml/m 2 as the upper limit for normal LAVi and a value of > 40 ml/m 2 for severe dilatation [ 12 ] ,but in 2015 Diastology Guidelines updates from the American Society of Echocardiography and the European Association of Cardiovascular Imaging, the upper normal value of LAVi on 2DE has been increased to 34 ml/m 2 . [ 17 ] We have previously studied the normal reference range of LAVi in healthy subjects and the prognostic value of LAVi in Chronic kidney disease(CKD) patients in our population. In the normal population, in the age group less than 40 years, mean LAVi was 21.7 ml/m 2 (range 10–30 ml/m 2 ). In more than 40 years of age it was 23.14 ml/m 2 (range 15–28 ml/m 2 ). [ 18 ] In another study conducted on 170 patients at our center, patients with CKD had a higher median LAVi [30.93 (range 6–69) vs 23 (range 10–35) in patients without CKD]; p-value < 0.001. [ 19 ] The mean LAVi and its correlation with other echocardiographic parameters has not been well studied in our hemodialysis population. The association of LAVi with mortality in hemodialysis(HD) patients is not well known. The aim of this study is to assess the prognostic value of LAVi in hemodialysis patients, compared with previously established clinical and Doppler echocardiographic parameters and to study the impact of increased LAVi on mortality in dialysis patients. Methods Patients From January 1, 2013, through March 31, 2018, we evaluated echocardiographic findings of 90 ESRD patients on maintenance hemodialysis with an average follow-up of 3.7±1.0 years. Patients’ demographic and clinical data such as age, gender and comorbid conditions were recorded. Patients who had the following were excluded : Underlying malignancy , Decompensated liver cirrhosis , Immunosuppressive therapy, LV EF<25%, Severe Mitral stenosis or Mitral Regurgitation, patients on peritoneal dialysis or kidney transplantation before the initiation of hemodialysis, Acute Kidney Injury, less than 3 months on hemodialysis. Echocardiography LA Measurements: The study patients underwent TransThoracic Echocardiography,(TTE) using Toshiba, Aplio 300 system, Model TUS-A300. All patients were examined in the Left lateral position.TTE is the recommended approach for assessing LA size and it was used in our study. (TEE, is not used because the entire left atrium frequently cannot fit in the image sector). LA size is measured at the end of LV systole, when the LA chamber is at its greatest dimension. Care is taken to avoid foreshortening of the left atrium. Acquisition of the left atrium from the apical approach is done. Care is taken to have the base of the left atrium at its largest size, so that the imaging plane passes through the maximal short-axis area. LA length is also maximized to ensure alignment along the true long axis of the left atrium. The lengths of the long axes measured in the two-and four-chamber views were almost similar. When tracing the borders of the left atrium, the confluences of the pulmonary veins and the LA appendage were excluded. The atrioventricular interface was represented by the mitral annulus plane and not by the tip of the mitral leaflets. LA volume is measured using the disk summation method. [20, 21] The LA endocardial borders were traced in both the apical four and two chamber views. Gender differences in LA size were accounted for by indexing to BSA. [22-30] Left atrial volume was taken as the volume of blood in left atrium at the end of the systole, just prior to the opening of Mitral valve. Standardized planimetry was used to trace the borders of left atrium and left ventricle. Left atrial volume index (LAVi) was computed by dividing the left atrial volume by the body surface area of the individuals, as shown by formula LAVI= LAV(ml)/BSA(m 2 ). Other parameters computed from the echocardiography were LV Ejection Fraction ,mitral regurgitation, left ventricular hypertrophy, E/e´ ratio and pulmonary artery systolic pressure (PASP). Statistical Analysis : Data was analysed using IBM SPSS. Data was expressed as mean ± Standard Deviation(SD), and percentages for different parameters. Quantitative variables were expressed as mean ± SD, while Qualitative variables were expressed with numbers and percentages. Effect of LAVI on Mortality was evaluated by binary Logistic Regression. ROC Curve was used to determine the cutoff value of LAVI for expired patients. Association between LAVi and mortality was assessed by Pearson Chi Square test. P value less than 0.05 was considered as significant. Relationship between LAVi and other echocardiographic parameters was assessed using scatter plots. Sampling technique was non probability purposive sampling. Results The average age of the patients was 62.68 ±12.47 years. 51/90 were males (56.7%) and 39/90(43.3%) were females. Average body surface area was 1.77 m^2 and mean height was 65.09 inches. The average duration of dialysis was 29.54 months as shown in Table 1. Table 1 Patient Demographics Age(years) 62.68 ± 12.474 Gender 51 (56.6%)males 39(43.3%) females BSA( m 2 ) 1.7718 ± 0.2446 Height(inches) 65.09± 3.802 Duration on dialysis(months) 29.54 ± 28.98 Diabetes Mellitus 74/90 Hypertension 86/90 Dyslipidemia 28/90 Smoking 27/90 PCI 9/90 CABG 11/90 Among the comorbidities, hypertension was the most prevalent with 86(95.5%) patients being hypertensive. This was followed by diabetes in 74 patients(82.2%) and dyslipidemias in 28 patients(31.1%). 27/90(30%) patients had a history of smoking. 9 patients had Percutaneous Coronary Intervention(PCI) and 11 had coronary artery bypass grafting(CABG). The mean LAVi of our ESRD patients was 38.99 ml/m 2 with minimum value of 12 ml/m 2 and highest value of 72ml/m 2 and standard deviation of ± 10.57 as shown in Table 2. Table 2 Echocardiographic Findings of patients EF(%) PASP (mm Hg) LAVI(ml/m 2 ) PCWP (mm Hg) E/e´ Mean 53.69 43.62 38.993 17.34 12.90 StandaradDeviation 13.109 14.779 10.5705 3.544 3.464 The mean LAVI of 42.62±10.24 ml/m 2 in expired patients with p-value 0.004 suggested mean LAVI of Expired patients was significantly higher as compared to alive patients (Table 3). Table 3 Comparison of Mean LAVI among Alive and Expired Patients Mortality N Mean LAVI (ml/m 2 ) Standard Deviation p-value All Patients 90 38.993 10.57 - Alive 51 36.22 10.04 0.004* Expire 39 42.62 10.24 *p<0.05 was considered significant using independent sample t-test Results of logistic regression showed that expired patients were 1.067 times more likely to be found with higher LAVI as compared to alive patients( 95% confidence interval for odds ratio was (1.018- 1.119) with significant p-value 0.007 ) as shown in Table 4. Table 4 Effect of LAVI on Mortality using Binary Logistic Regression parameters B S.E. Wald df p-value Odds ratio 95% C.I.for odds ratio Lower Upper LAVI 0.065 .024 7.260 1 0.007 1.067 1.018 1.119 Constant -2.822 .977 8.342 1 0.004 0.060 *p<0.05 was considered significant for odds ratio Logistic regression results suggested, Area under the curve using Receiver operating characteristic curve (ROC curve ) was found 66.7% statistically significant with p-value 0.007, the ROC suggested the cutoff value of LAVI for expired patients can be at least 38.5(Figure 1) Table 5 Association of LAVI with Mortality using Pearson Chi Square test LAVI Mortality Total Alive Expire LAVI 38.5 n 19 24 43 % 37.3% 61.5% 47.8% Total Count n 39 90 % within Mort % 100.0% 100.0% *p-value 0.02 obtained using Pearson Chi Square test 61.5% patients were expired and found with LAVI more than 38.5 ml/m 2 , whereas 62.7% patients were alive with LAVI less than 38.5 ml/m 2 , the p-value 0.02 suggested a significant association of LAVI with Mortality. The analysis done above showing LAVI 38.5 as best cut off also giving significant association with mortality obtained using Pearson Chi Square test. LAVi gives positive association with mortality , for LAVI greater than 40, the odds ratio was 3.5. A significant negative relationship observed between LAVI and EF, r-square showing 4.4% variation in EF was explained by the help of LAVI as shown in Figure 2. A significant positive relationship observed between LAVI and PASP as shown in Figure 3, r-square showing 20.4% variation in PASP was explained by the help of LAVI. A significant positive relationship observed between LAVI and E/e´ ratio as shown in Figure 4, r-square showing 21.3% variation in E/e´ ratio was explained by the help of LAVI. Table 6 Correlation of LAVi with mortality and other echocardiographic parameters Correlations LAVI EF% PASP EE RATIO Mortality LAVI r-value 1 p-value EF% r-value -.209 * 1 p-value .048 PASP r-value .451 ** -.243 * 1 p-value .000 .032 EE RATIO r-value .461 ** -.289 * .330 ** 1 p-value .000 .012 .007 Mortality r-value .302 ** -.176 .172 .163 1 p-value .004 .095 .132 .163 *p-value <0.05 was considered significant for correlation. Pearson Correlation analysis showed, LAVI gives 20.9% significant negative relationship with EF, 45.2% significant positive relationship with PASP, 46.1% significant positive relationship with EE ratio, and 30.2% significant positive relationship with Mortality(Table 5). Mortality didn’t give any significant association with EF, PASP and EE ratio as shown in table 6. Discussion The mean LAVi in our study population is higher than in the healthy population as well as in CKD population. The mean LAVI in our dialysis patients was 38.93+/- 10.57 ML/M2 as compared to 21.96 +/- 4.189ML/M2 in the normal population and as compared to 33.33 +/- 11.71 ML/M2in the CKD population. [ 18 – 19 ] In previous studies, LAVi has been shown to be significantly higher in dialysis patients than in healthy subjects. In a study done by Seung Jun Kim et al increased left atrium volume index (LAVI > 32 mL/m 2 ) was observed in 99 (45.8%) of the CAPD patients [ 31 ] . Our study showed that LAVi is an independent predictor of mortality in Hemodialysis patients and as LAVi increases mortality increases. Among all echocardiographic parameters, LAVi is the strongest predictor of Mortality in our ESRD patients. Similar findings were seen in a study by Mayo Clinic of a large cohort of more than 10,000 patients which showed that with every milliliter per square meter increase in LAVi, all-cause mortality risk increased by 3% (hazard ratio [HR], 1.03; 95% CI, 1.02–1.04; P < .001) [ 32 ] . Abhayaratna et al in their study showed that LAVi of 34 mL/m2 or greater was an independent predictor of death, heart failure, atrial fibrillation, and ischemic stroke. Currently most of the focus is on LA volume, which is also a component of the algorithm for Diastolic dysfunction of LV,, in addition to LVH and LV systolic and diastolic dysfunction as an indicator of CV outcomes. It is reported that LA size is a more stable indicator to reflect the severity and chronicity of diastolic dysfunction than any other echocardiographic parameter although it is largely determined by the same factors that influence diastolic LV filling. [ 33 ] The E/e’ ratio accurately reflects the filling pressures at the time of the examination. In contrast, the LAV is a reflection of the long-term exposure to LV filling pressures. It reflects the beat-to-beat interaction of LV filling pressure and ventricular compliance, making them sensitive to rapid alterations in ventricular preload and afterload In line with these findings, we demonstrated that increased LAVI was an independent risk factor for mortality, suggesting that LAVI is a more reliable predictor of mortality in patients on hemodialysis as compared to E/e’ and EF which are dependent on multiple factors including loading conditions and volume status. Using the ROC curve and Pearson chi square test we found out that the best cut off value for LAVi that gives significant association with mortality is greater than 38.5 ml/m2 in our dialysis population. LAVi had a significant positive association with mortality. The American Society of Echocardiography criterion for moderate LA dilatation is LAVI > 40 ml/m2, at which the odds ratio was 3.5 in our study. Only a few studies have evaluated the relationship of LAVi with mortality in ESRD patients. LAVi has shown to be an independent predictor of CV morbidity and mortality in the general population and, more specifically, in ESRD patients on chronic dialysis [ 30 ,, 34 , 35 , 36 ] The study conducted by Seung Jun Kim et al in 216 patients with CAPD showed that increased LAVI was an independent predictor of all-cause mortality [hazard ratio (HR) 1.05, P = 0.03] and cardiovascular mortality (HR 1.08, P = 0.006). [ 30 ] The E/e’ ratio accurately reflects the filling pressures at the time of the examination. It reflects the beat-to-beat interaction of LV filling pressure and ventricular compliance, making them sensitive to rapid alterations in ventricular preload and afterload. In contrast, the LAV is a reflection of the long-term exposure to LV filling pressures. In a Mayo Clinic Study, Left atrial enlargement was independently associated with an increased risk of all-cause mortality in a large cohort of 10,719 patients with normal Left ventricular filling pressure and preserved LVEF. [ 37 ] In the present study, we can surmise that patients with enlarged LA were volume expanded, which might explain the higher mortality rate in these patients. Therefore, more attention should be paid to better control of fluid overload in patients with enlarged LA. Limitations This study has been done in our population in Pakistan and the relationship of LAVi with mortality may not be generalised to the general population. Echocardiographic examinations were performed only at one point in time, it was difficult to determine the consequence of the changes of echocardiographic parameters on patients’ clinical outcome. Serial follow-up echocardiography examinations may be of help in understanding the natural history of LA remodeling in HD patients [ 38 ] Number of patients was not large. A larger sample size would further help to improve the significance of the statistical analysis. Conclusion Increased LAVi is associated with higher mortality in ESRD patients on maintenance hemodialysis. Increased LAVi was the best predictor of mortality among measured echocardiographic parameters in our hemodialysis population. Abbreviations ESRD -End Stage Renal Disease LA- Left atrium LAVI-Left Atrial Volume Index MI-Myocardial Infarction 2DE-2D Echocardiography ASE-American Society of Echocardiography CKD-Chronic Kidney Disease EF-Ejection Fraction TTE-Trans Thoracic Echocardiography LV-Left Ventricle BSA-Body Surface Area PASP-Pulmonary Artery Systolic Pressure SD-Standard Deviation ROC-Receiver Operating Curve Declarations Disclosure of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Disclosure of any Conflict of interest: Conflict of interest: none declared. References Baigent C., Burbury K., Wheeler D. Premature cardiovascular disease in chronic renal failure. Lancet. 2000;356(9224):147-152. DOI: http://dx.doi.org/10.1016/S014-7636(00)02456-9 Abhayaratna WP, Seward JB, Appleton CP et al. Left atrial size: physiologic determinants and clinical applications. J Am Coll Cardiol 2006; 47:2357-63. 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Left atrial volume monitoring and cardiovascular risk in patients with end-stage renal disease: a prospective cohort study. J Am Soc Nephrol. 2007;18: 1316-1322. Pmid:17360950 DOI: http://dx.doi.org/10.1681/ASN.2006080881 Kim JK, Kim SG, Kim MG et al. Left Ventricular Diastolic Dysfunction as a Echocardiographic.2012;25:411-420. pmid:22196883Predictor of Rapid Decline of Residual Renal Function in Patients with Peritoneal Dialysis. J Am Soc. DOI: http://dx.doi.org/10.1016/j.echo.2011.11.026 Patel DA, Lavie CJ, Gilliland YE, Shah SB, Dinshaw HK, Milani RV. Prediction of All-Cause Mortality by the Left Atrial Volume Index in Patients With Normal Left Ventricular Filling Pressure and Preserved Ejection Fraction. Mayo Clin Proc.2015 Nov;90(11):1499-505. DOI: http://dx.doi.org/10.1016/mayocp.2015.07.021 . Epub 2015 Oct 9. PMID: 26455887 Tripepi G, Mattace-Raso F, Mallamaci F, et al. Biomarkers of left atrial volume: a longitudinal study in patients with end stage renal disease. Hypertension 54: 818-824,2009 DOI: http://dx.doi.org/10.1161/HYPERTENSIONAHA.109.136804 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-879662","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":51696942,"identity":"740b3f32-ba96-43d7-ae13-23e86b1dedad","order_by":0,"name":"sidra saleem","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYDACZgYDECUDxOw/P1QcAAseeECEFh4QIS1x5gCYdSABvz0ILRK8bRAtDPi0yLczb/vw448dDz97d4KB5Lw7cvZihx8CbbGT023AYcVhtuKZvW3JPJI9ZzckFG57ZswjnWYA1JJsbHYAhxZmHmMG3gZmHoMbuRsOSG47nNgjnQDSciBxGw4t8s08xox//tTz2N9/u7GBdw5IS/oHvFoYDvMYM/OwHeYxkODdDLQOpCUHvy0gvzDLth3nkTiTu41Z4thhY57bOQUHEgxw+0W+//Bmxjd/quX4289uY/xQc1iOfXb65g8fKuzkcGnBBQxIUz4KRsEoGAWjABUAAOD6Xi0YuzPRAAAAAElFTkSuQmCC","orcid":"","institution":"Doctors Hospital and Medical Center, Lahore","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"sidra","middleName":"","lastName":"saleem","suffix":""},{"id":51696943,"identity":"e2960e3c-1195-4100-9288-604e621855cb","order_by":1,"name":"Abeera Mansur","email":"","orcid":"","institution":"Doctors Hospital and Medical Center, Lahore","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Abeera","middleName":"","lastName":"Mansur","suffix":""},{"id":51696944,"identity":"5bf0553c-03ae-4abf-90a6-223dfcbaddb2","order_by":2,"name":"Haris Naveed","email":"","orcid":"","institution":"Doctors Hospital and Medical Center, Lahore","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Haris","middleName":"","lastName":"Naveed","suffix":""},{"id":51696945,"identity":"06a4c2a4-3155-4dc5-9c9c-a91fc0544575","order_by":3,"name":"Syeda Huma Zartash","email":"","orcid":"","institution":"Doctors Hospital and Medical Center, Lahore","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Syeda","middleName":"Huma","lastName":"Zartash","suffix":""},{"id":51696949,"identity":"cf85cf09-f4aa-4a74-b6bc-cb4ad7e0176c","order_by":4,"name":"Asad Mahmood","email":"","orcid":"","institution":"Doctors Hospital and Medical Center, Lahore","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Asad","middleName":"","lastName":"Mahmood","suffix":""},{"id":51696950,"identity":"b62b439e-de8d-46ef-a509-5e9e795c84f4","order_by":5,"name":"Afshan Ittifaq","email":"","orcid":"","institution":"Doctors Hospital and Medical Center, Lahore","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Afshan","middleName":"","lastName":"Ittifaq","suffix":""},{"id":51696954,"identity":"b6a4fb99-8e1e-4401-9053-44cb2fd75192","order_by":6,"name":"Shahbaz Sarwar","email":"","orcid":"","institution":"Doctors Hospital and Medical Center, Lahore","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shahbaz","middleName":"","lastName":"Sarwar","suffix":""}],"badges":[],"createdAt":"2021-09-05 20:29:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-879662/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-879662/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13459543,"identity":"15b27b44-593d-4f49-b567-459a18773031","added_by":"auto","created_at":"2021-09-16 19:44:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23549,"visible":true,"origin":"","legend":"Cut off value of LAVi using ROC Curve","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-879662/v1/1bd647a0a24d28d04797175a.png"},{"id":13459542,"identity":"3ce85c1c-56d9-4ff5-a53f-8565a454c636","added_by":"auto","created_at":"2021-09-16 19:44:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28341,"visible":true,"origin":"","legend":"Relationship between LAVi and EF","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-879662/v1/58fe6f96125eef4f4971161b.png"},{"id":13459544,"identity":"78efc60a-4088-4f7b-97c1-851020af9014","added_by":"auto","created_at":"2021-09-16 19:44:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":26066,"visible":true,"origin":"","legend":"Relationship between PASP and LAVi ","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-879662/v1/0f4f78c3f08828e3ca7b6e76.png"},{"id":13459545,"identity":"1cd7bc63-c160-421b-bbe8-2b79bb8f7032","added_by":"auto","created_at":"2021-09-16 19:44:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":26541,"visible":true,"origin":"","legend":"Relationship between LAVi and E’e Ratio","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-879662/v1/38b1efe98837cf43c3523bf5.png"},{"id":14849613,"identity":"d5f383c9-510b-480a-849c-e9fd58544385","added_by":"auto","created_at":"2021-10-25 06:59:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":500743,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-879662/v1/3239ee78-6909-45bf-af72-04599db811e3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prognostic Value of Left Atrial Volume Index in End Stage Renal Disease Patients","fulltext":[{"header":"Background","content":"\u003cp\u003ePatients with End-Stage Renal Disease (ESRD) have an increased risk of premature cardiovascular disease. \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003eDiagnosing Cardiovascular disease in patients on hemodialysis is challenging as patients frequently do not experience symptoms or present with atypical symptoms. Left atrial (LA) size is part of cardiac remodeling in a variety of cardiovascular diseases and a predictor of cardiovascular morbidity and mortality. \u003csup\u003e[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e A dilatation occurs in a number of disease processes such as left ventricular hypertrophy and failure, aortic and mitral valve diseases and is a powerful predictor of heart failure, stroke, and mortality. \u003csup\u003e[\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e Increased LAVi, which is a component of the algorithm for Diastolic dysfunction of LV, was shown to predict mortality after myocardial infarction(MI) \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003eThe American Society of Echocardiography / European Association of Cardiovascular Imaging, recommended LA volume index (LAVI), the value of LA volume divided by body surface area, to measure LA size. \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe most widely applied technique for measuring atrial size is two-dimensional echocardiography (2DE). \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e The method of assessing maximal end-systolic anteroposterior dimension of LA from the parasternal long-axis view in M-mode echocardiography is simple and convenient but its accuracy is rather limited by the anatomical confinement afforded by the spine and sternum and the resulting asymmetrical or pillow-shaped enlargement of the left atrium. \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e For these reasons, multiple linear dimensions or measurement of left atrial volume (LAV) especially when corrected for body surface area i.e. left atrial volume index (LAVi), is a more accurate representation of true LA size. \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe ASE(American Society of Echocardiography) in 2005 recommended a value of 28 ml/m\u003csup\u003e2\u003c/sup\u003e as the upper limit for normal LAVi and a value of \u0026gt;\u0026thinsp;40 ml/m\u003csup\u003e2\u003c/sup\u003e for severe dilatation \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e ,but in 2015 Diastology Guidelines updates from the American Society of Echocardiography and the European Association of Cardiovascular Imaging, the upper normal value of LAVi on 2DE has been increased to 34 ml/m\u003csup\u003e2\u003c/sup\u003e. \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWe have previously studied the normal reference range of LAVi in healthy subjects and the prognostic value of LAVi in Chronic kidney disease(CKD) patients in our population.\u003c/p\u003e \u003cp\u003eIn the normal population, in the age group less than 40 years, mean LAVi was 21.7 ml/m\u003csup\u003e2\u003c/sup\u003e (range 10\u0026ndash;30 ml/m\u003csup\u003e2\u003c/sup\u003e). In more than 40 years of age it was 23.14 ml/m\u003csup\u003e2\u003c/sup\u003e (range 15\u0026ndash;28 ml/m\u003csup\u003e2\u003c/sup\u003e). \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn another study conducted on 170 patients at our center, patients with CKD had a higher median LAVi [30.93 (range 6\u0026ndash;69) vs 23 (range 10\u0026ndash;35) in patients without CKD]; p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe mean LAVi and its correlation with other echocardiographic parameters has not been well studied in our hemodialysis population. The association of LAVi with mortality in hemodialysis(HD) patients is not well known. The aim of this study is to assess the prognostic value of LAVi in hemodialysis patients, compared with previously established clinical and Doppler echocardiographic parameters and to study the impact of increased LAVi on mortality in dialysis patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003ePatients\u003c/h2\u003e\n\u003cp\u003eFrom January 1, 2013, through March 31, 2018, we evaluated echocardiographic findings of 90 ESRD patients on maintenance hemodialysis with an average follow-up of 3.7\u0026plusmn;1.0 years. Patients\u0026rsquo; demographic and clinical data such as age, gender and comorbid conditions were recorded.\u003c/p\u003e\n\u003cp\u003ePatients who had the following were excluded :\u003c/p\u003e\n\u003cp\u003eUnderlying malignancy , Decompensated liver cirrhosis , Immunosuppressive therapy, LV EF\u0026lt;25%, Severe Mitral stenosis or Mitral Regurgitation, patients on peritoneal dialysis or kidney transplantation before the initiation of hemodialysis, Acute Kidney Injury, less than 3 months on hemodialysis.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEchocardiography\u003c/h2\u003e\n\u003ch2\u003eLA Measurements:\u003c/h2\u003e\n\u003cp\u003eThe study patients underwent \u0026nbsp;TransThoracic Echocardiography,(TTE) using Toshiba, Aplio 300 system, Model TUS-A300. All patients were examined in the Left lateral position.TTE is the recommended approach for assessing LA size and it was used in our study. (TEE, is not used because the entire left atrium frequently cannot fit in the image sector). LA size is measured at the end of LV systole, when the LA chamber is at its greatest dimension. Care is taken to avoid foreshortening of the left atrium. Acquisition of the left atrium from the apical approach is done. Care is taken to have the base of the left atrium at its largest size, so that the imaging plane passes through the maximal short-axis area. LA length is also maximized to ensure alignment along the true long axis of the left atrium. The lengths of the long axes measured in the two-and four-chamber views were almost similar. \u0026nbsp;When \u0026nbsp;tracing the borders of the left atrium, the confluences of the pulmonary veins and the LA appendage were excluded. The atrioventricular interface was represented by the mitral annulus plane and not by the tip of the mitral leaflets. LA volume is measured using the disk summation method. \u003ca href=\"#twentytotwentyone\"\u003e\u003csup\u003e[20, 21]\u003c/sup\u003e\u003c/a\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThe LA endocardial borders were traced in both the apical four and two chamber views. \u0026nbsp;Gender differences in LA size were accounted for by indexing to BSA. \u003ca href=\"#twntytwotothirty\"\u003e\u003csup\u003e[22-30]\u003c/sup\u003e\u003c/a\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eLeft atrial volume was taken as the volume of blood in left atrium at the end of the systole, just prior to the opening of Mitral valve. Standardized planimetry was used to trace the borders of left atrium and left ventricle. Left atrial volume index (LAVi) was computed by dividing the left atrial volume by the body surface area of the individuals, as shown by formula\u003c/p\u003e\n\u003cp\u003eLAVI= LAV(ml)/BSA(m\u003csup\u003e2\u003c/sup\u003e).\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOther parameters computed from the echocardiography were LV Ejection Fraction ,mitral regurgitation, left ventricular hypertrophy, E/e\u0026acute; ratio and pulmonary artery systolic pressure (PASP).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eStatistical Analysis\u0026nbsp;:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eData was analysed using IBM SPSS. Data was expressed as mean \u0026plusmn; Standard Deviation(SD), and percentages for different parameters. Quantitative variables were expressed as mean \u0026plusmn; SD, while Qualitative variables were expressed with numbers and percentages. Effect of LAVI on Mortality was evaluated by binary Logistic Regression. ROC Curve was used to determine the cutoff value of LAVI for expired patients. Association between LAVi and mortality was assessed by Pearson Chi Square test. P value less than 0.05 was considered as significant. Relationship between LAVi and other echocardiographic parameters was assessed using scatter plots. Sampling technique was non probability purposive sampling.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe average age of the patients was 62.68\u0026nbsp;\u0026plusmn;12.47 years. 51/90 were males (56.7%) and 39/90(43.3%) were females. Average body surface area was 1.77 m^2 and mean height was 65.09 inches. The average duration of dialysis was 29.54 months as shown in Table 1.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Table 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003ePatient Demographics\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eAge(years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e62.68 \u0026plusmn; 12.474\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e\u0026nbsp;51 (56.6%)males 39(43.3%) females\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eBSA(\u003cstrong\u003em\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e\u0026nbsp;1.7718 \u0026plusmn; 0.2446\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eHeight(inches)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e65.09\u0026plusmn; 3.802\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eDuration on dialysis(months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e29.54 \u0026plusmn;\u0026nbsp;28.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eDiabetes Mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e74/90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e86/90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e28/90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e27/90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003ePCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e9/90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"29.623567921440262%\"\u003e\n \u003cp\u003eCABG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.893617021276595%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"55.48281505728314%\"\u003e\n \u003cp\u003e11/90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAmong the comorbidities, hypertension was the most prevalent with 86(95.5%) patients being hypertensive. This was followed by diabetes in 74 patients(82.2%) and dyslipidemias in 28 patients(31.1%). 27/90(30%) patients had a history of smoking. 9 patients had Percutaneous Coronary Intervention(PCI) and 11 had coronary artery bypass grafting(CABG).\u003c/p\u003e\n\u003cp\u003eThe mean LAVi of our ESRD patients was 38.99 ml/m\u003csup\u003e2\u003c/sup\u003e with minimum value of 12 ml/m\u003csup\u003e2\u003c/sup\u003e and highest value of \u0026nbsp;72ml/m\u003csup\u003e2\u003c/sup\u003e\u0026nbsp; and standard deviation of \u0026nbsp;\u0026plusmn; 10.57 as shown in Table 2.\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Echocardiographic Findings of patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"22.244094488188978%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.188976377952756%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEF(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"14.173228346456693%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePASP (mm Hg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"18.30708661417323%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLAVI(ml/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"16.73228346456693%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePCWP (mm Hg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"15.354330708661417%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; E/e\u0026acute;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"22.244094488188978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.188976377952756%\"\u003e\n \u003cp\u003e\u003cstrong\u003e53.69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.173228346456693%\"\u003e\n \u003cp\u003e\u003cstrong\u003e43.62\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.30708661417323%\"\u003e\n \u003cp\u003e\u003cstrong\u003e38.993\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.73228346456693%\"\u003e\n \u003cp\u003e\u003cstrong\u003e17.34\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.354330708661417%\"\u003e\n \u003cp\u003e\u003cstrong\u003e12.90\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"22.244094488188978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStandaradDeviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.188976377952756%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.109\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.173228346456693%\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.779\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.30708661417323%\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.5705\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.73228346456693%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.544\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.354330708661417%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.464\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe mean LAVI of 42.62\u0026plusmn;10.24\u0026nbsp;ml/m\u003csup\u003e2\u003c/sup\u003e in expired patients with p-value 0.004 suggested mean LAVI of Expired patients was significantly higher as compared to alive patients (Table 3).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Table 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Comparison of Mean LAVI among Alive and Expired Patients\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"14.867256637168142%\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.699115044247787%\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.876106194690266%\"\u003e\n \u003cp\u003eMean LAVI\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(ml/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.424778761061948%\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.13274336283186%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"14.867256637168142%\"\u003e\n \u003cp\u003eAll Patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.699115044247787%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.876106194690266%\"\u003e\n \u003cp\u003e38.993\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.424778761061948%\"\u003e\n \u003cp\u003e10.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.13274336283186%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"14.867256637168142%\"\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.699115044247787%\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.876106194690266%\"\u003e\n \u003cp\u003e36.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.424778761061948%\"\u003e\n \u003cp\u003e10.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"25.13274336283186%\"\u003e\n \u003cp\u003e0.004*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.858156028368793%\"\u003e\n \u003cp\u003eExpire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.64066193853428%\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.87706855791962%\"\u003e\n \u003cp\u003e42.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"32.6241134751773%\"\u003e\n \u003cp\u003e10.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e*p\u0026lt;0.05 was considered significant using independent sample t-test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Results of logistic regression showed that expired patients were 1.067 times more likely to be found with higher LAVI as compared to alive patients( 95% confidence interval for odds ratio was (1.018- 1.119) with significant p-value 0.007 ) as shown in Table 4.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Effect of LAVI on Mortality using Binary Logistic Regression\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" width=\"14.79944674965422%\"\u003e\n \u003cp\u003eparameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"9.54356846473029%\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.990318118948824%\"\u003e\n \u003cp\u003eS.E.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"9.820193637621024%\"\u003e\n \u003cp\u003eWald\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"8.71369294605809%\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"9.820193637621024%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"11.065006915629322%\"\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"27.247579529737205%\"\u003e\n \u003cp\u003e95% C.I.for odds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"35.025380710659896%\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"64.9746192893401%\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"14.79944674965422%\"\u003e\n \u003cp\u003eLAVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.54356846473029%\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.990318118948824%\"\u003e\n \u003cp\u003e.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.820193637621024%\"\u003e\n \u003cp\u003e7.260\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.71369294605809%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.820193637621024%\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.065006915629322%\"\u003e\n \u003cp\u003e1.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.54356846473029%\"\u003e\n \u003cp\u003e1.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.704011065006917%\"\u003e\n \u003cp\u003e1.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"14.79944674965422%\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.54356846473029%\"\u003e\n \u003cp\u003e-2.822\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.990318118948824%\"\u003e\n \u003cp\u003e.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.820193637621024%\"\u003e\n \u003cp\u003e8.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.71369294605809%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.820193637621024%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.065006915629322%\"\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.54356846473029%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"17.704011065006917%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e*p\u0026lt;0.05 was considered significant for odds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eLogistic regression results suggested, Area under the curve using Receiver operating characteristic curve (ROC curve ) was found 66.7% \u0026nbsp; statistically significant with p-value 0.007, the ROC suggested the cutoff value of LAVI for expired patients can be at least 38.5(Figure 1)\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Association of LAVI with Mortality using Pearson Chi Square test\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable align=\"left\" border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"bottom\" width=\"45.3125%\"\u003e\n \u003cp\u003eLAVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"36.5234375%\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" width=\"18.1640625%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003eExpire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"21.568627450980394%\"\u003e\n \u003cp\u003eLAVI \u0026lt;=38.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.725490196078432%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.25%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e62.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e38.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e52.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"21.568627450980394%\"\u003e\n \u003cp\u003eLAVI \u0026gt;38.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.725490196078432%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.25%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e37.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e61.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e47.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"21.568627450980394%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.725490196078432%\"\u003e\n \u003cp\u003eCount\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.235294117647058%\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"30.25%\"\u003e\n \u003cp\u003e% within Mort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"23.25%\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 99.8551%;\"\u003e\u003cspan style='color: rgb(0, 0, 0); font-family: \"Times New Roman\"; font-size: medium; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;'\u003e*p-value 0.02 obtained using Pearson Chi Square test\u003c/span\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e61.5% patients were expired and found with LAVI more than 38.5 ml/m\u003csup\u003e2\u003c/sup\u003e, whereas 62.7% patients were alive with LAVI less than 38.5 ml/m\u003csup\u003e2\u003c/sup\u003e, the p-value 0.02 suggested a significant association of LAVI with Mortality.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The analysis done above showing LAVI 38.5 as best cut off also giving significant association with mortality obtained using Pearson Chi Square test. LAVi gives positive association with mortality , for LAVI greater than 40, the odds ratio was 3.5.\u003c/p\u003e\n\u003cp\u003eA significant negative relationship observed between LAVI and EF, r-square showing 4.4% variation in EF was explained by the help of LAVI as shown in Figure 2.\u003c/p\u003e\n\u003cp\u003eA significant positive relationship observed between LAVI and PASP as shown in Figure 3, r-square showing 20.4% variation in PASP was explained by the help of LAVI.\u003c/p\u003e\n\u003cp\u003eA significant positive relationship observed between LAVI and E/e\u0026acute; \u0026nbsp;ratio as shown in Figure 4, r-square showing 21.3% variation in E/e\u0026acute; \u0026nbsp;ratio was explained by the help of LAVI.\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eTable 6\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eCorrelation of LAVi with mortality and other echocardiographic parameters\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCorrelations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" width=\"34.99197431781702%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003eLAVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003eEF%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003ePASP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"13.48314606741573%\"\u003e\n \u003cp\u003eEE RATIO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"14.446227929373997%\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.32263242375602%\"\u003e\n \u003cp\u003eLAVI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.669341894060995%\"\u003e\n \u003cp\u003er-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.48314606741573%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.446227929373997%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.555555555555555%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.32263242375602%\"\u003e\n \u003cp\u003eEF%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.669341894060995%\"\u003e\n \u003cp\u003er-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e-.209\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.48314606741573%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.446227929373997%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.555555555555555%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.32263242375602%\"\u003e\n \u003cp\u003ePASP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.669341894060995%\"\u003e\n \u003cp\u003er-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e.451\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e-.243\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.48314606741573%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.446227929373997%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.555555555555555%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.32263242375602%\"\u003e\n \u003cp\u003eEE RATIO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.669341894060995%\"\u003e\n \u003cp\u003er-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e.461\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e-.289\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e.330\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.48314606741573%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.446227929373997%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.555555555555555%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.32263242375602%\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.669341894060995%\"\u003e\n \u003cp\u003er-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e.302\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e-.176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.359550561797754%\"\u003e\n \u003cp\u003e.172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.48314606741573%\"\u003e\n \u003cp\u003e.163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.446227929373997%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"14.25925925925926%\"\u003e\n \u003cp\u003e.132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.555555555555555%\"\u003e\n \u003cp\u003e.163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e*p-value \u0026lt;0.05 was considered significant for correlation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePearson Correlation analysis showed, LAVI gives 20.9% significant negative relationship \u0026nbsp;with EF, 45.2% significant positive relationship with PASP, 46.1% significant positive relationship with EE ratio, and 30.2% significant positive relationship with Mortality(Table 5).\u003c/p\u003e\n\u003cp\u003eMortality didn\u0026rsquo;t give any significant association with EF, PASP and EE ratio as shown in table 6.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe mean LAVi in our study population is higher than in the healthy population as well as in CKD population. The mean LAVI in our dialysis patients was 38.93+/- 10.57 ML/M2 as compared to 21.96 +/- 4.189ML/M2 in the normal population and as compared to 33.33 +/- 11.71 ML/M2in the CKD population. \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn previous studies, LAVi has been shown to be significantly higher in dialysis patients than in healthy subjects. In a study done by Seung Jun Kim et al increased left atrium volume index (LAVI\u0026thinsp;\u0026gt;\u0026thinsp;32 mL/m 2 ) was observed in 99 (45.8%) of the CAPD patients \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur study showed that LAVi is an independent predictor of mortality in Hemodialysis patients and as LAVi increases mortality increases. Among all echocardiographic parameters, LAVi is the strongest predictor of Mortality in our ESRD patients. Similar findings were seen in a study by Mayo Clinic of a large cohort of more than 10,000 patients which showed that with every milliliter per square meter increase in LAVi, all-cause mortality risk increased by 3% (hazard ratio [HR], 1.03; 95% CI, 1.02\u0026ndash;1.04; P\u0026thinsp;\u0026lt;\u0026thinsp;.001) \u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Abhayaratna et al in their study showed that LAVi of 34 mL/m2 or greater was an independent predictor of death, heart failure, atrial fibrillation, and ischemic stroke.\u003c/p\u003e \u003cp\u003eCurrently most of the focus is on LA volume, which is also a component of the algorithm for Diastolic dysfunction of LV,, in addition to LVH and LV systolic and diastolic dysfunction as an indicator of CV outcomes. It is reported that LA size is a more stable indicator to reflect the severity and chronicity of diastolic dysfunction than any other echocardiographic parameter although it is largely determined by the same factors that influence diastolic LV filling. \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e The E/e\u0026rsquo; ratio accurately reflects the filling pressures at the time of the examination. In contrast, the LAV is a reflection of the long-term exposure to LV filling pressures. It reflects the beat-to-beat interaction of LV filling pressure and ventricular compliance, making them sensitive to rapid alterations in ventricular preload and afterload\u003c/p\u003e \u003cp\u003eIn line with these findings, we demonstrated that increased LAVI was an independent risk factor for mortality, suggesting that LAVI is a more reliable predictor of mortality in patients on hemodialysis as compared to E/e\u0026rsquo; and EF which are dependent on multiple factors including loading conditions and volume status.\u003c/p\u003e \u003cp\u003eUsing the ROC curve and Pearson chi square test we found out that the best cut off value for LAVi that gives significant association with mortality is greater than 38.5 ml/m2 in our dialysis population. LAVi had a significant positive association with mortality. The American Society of Echocardiography criterion for moderate LA dilatation is LAVI\u0026thinsp;\u0026gt;\u0026thinsp;40 ml/m2, at which the odds ratio was 3.5 in our study.\u003c/p\u003e \u003cp\u003eOnly a few studies have evaluated the relationship of LAVi with mortality in ESRD patients. LAVi has shown to be an independent predictor of CV morbidity and mortality in the general population and, more specifically, in ESRD patients on chronic dialysis \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003eThe study conducted by Seung Jun Kim et al in 216 patients with CAPD showed that increased LAVI was an independent predictor of all-cause mortality [hazard ratio (HR) 1.05, P\u0026thinsp;=\u0026thinsp;0.03] and cardiovascular mortality (HR 1.08, P\u0026thinsp;=\u0026thinsp;0.006). \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe E/e\u0026rsquo; ratio accurately reflects the filling pressures at the time of the examination. It reflects the beat-to-beat interaction of LV filling pressure and ventricular compliance, making them sensitive to rapid alterations in ventricular preload and afterload. In contrast, the LAV is a reflection of the long-term exposure to LV filling pressures. In a Mayo Clinic Study, Left atrial enlargement was independently associated with an increased risk of all-cause mortality in a large cohort of 10,719 patients with normal Left ventricular filling pressure and preserved LVEF. \u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the present study, we can surmise that patients with enlarged LA were volume expanded, which might explain the higher mortality rate in these patients. Therefore, more attention should be paid to better control of fluid overload in patients with enlarged LA.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study has been done in our population in Pakistan and the relationship of LAVi with mortality may not be generalised to the general population.\u003c/p\u003e \u003cp\u003eEchocardiographic examinations were performed only at one point in time, it was difficult to determine the consequence of the changes of echocardiographic parameters on patients\u0026rsquo; clinical outcome. Serial follow-up echocardiography examinations may be of help in understanding the natural history of LA remodeling in HD patients \u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNumber of patients was not large. A larger sample size would further help to improve the significance of the statistical analysis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIncreased LAVi is associated with higher mortality in ESRD patients on maintenance hemodialysis. Increased LAVi was the best predictor of mortality among measured echocardiographic parameters in our hemodialysis population.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eESRD -End Stage Renal Disease\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLA- Left atrium\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLAVI-Left Atrial Volume Index\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMI-Myocardial Infarction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2DE-2D Echocardiography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eASE-American Society of Echocardiography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCKD-Chronic Kidney Disease\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEF-Ejection Fraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTTE-Trans Thoracic Echocardiography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLV-Left Ventricle\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBSA-Body Surface Area\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePASP-Pulmonary Artery Systolic Pressure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSD-Standard Deviation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eROC-Receiver Operating Curve\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDisclosure of Funding:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eDisclosure of any Conflict of interest:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eConflict of interest: none declared.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBaigent C., Burbury K., Wheeler D. 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DOI: \u003ca href=\"https://dx.doi.org/10.1161/CIRCULATIONAHA.110.011031\"\u003ehttps://dx.doi.org/10.1161/CIRCULATIONAHA.110.011031\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBeinart R, Boyko V, Schwammenthal E et al. Long-term prognostic significance of left atrial volume in acute myocardial infarction. J Am Coll Cardiol. 2004;44:327-334. DOI: \u003ca href=\"https://dx.doi.org/10.1016/j.jacc.2004.03.062\"\u003ehttps://dx.doi.org/10.1016/j.jacc.2004.03.062\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLang RM, Bierig M, Devereux RB et al. Chamber Quantification Writing Group; American Society of Echocardiography\u0026apos;s Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography\u0026apos;s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440-1463. DOI: http://dx.doi.org/10.1016/j.echo.2005.10.005\u003c/li\u003e\n \u003cli\u003eKhankirawatana B, Khankirawatana S, Porter T. How should left atrial size be reported? Comparative assessment with use of multiple echocardiographic methods. Am Heart J 2004; 147:369-74. DOI: http://dx.doi.org/10/1016/j.ahj.2003.03.001\u003c/li\u003e\n \u003cli\u003eMessika-Zeitoun D, Bellamy M, Avierinos JF et al. Left atrial remodeling in mitral regurgitation\u0026mdash;methodologic approach, physiological determinants, and outcome implications: a prospective quantitative Doppler-echocardiographic and electron beam computed tomography study. Eur Heart J 2007;28;1773-81 DOI: \u003ca href=\"http://dx.doi.org/10.1093/eurheartj/ehm199\"\u003ehttp://dx.doi.org/10.1093/eurheartj/ehm199\u003c/a\u003e DOI: \u003ca href=\"http://dx.doi.org/10.1093/eurheartj/ehm199\"\u003ehttp://dx.doi.org/10.1093/eurheartj/ehm199\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKedia G, Habibzadeh MR, Kudithipudi V, Molls F, Sorrell VL. Using traditional measurement of left atrial diameter to predict the left atrial volume index. Echocardiography. 2008; 25:36-9. DOI: \u003ca href=\"http://dx.doi.org/10.1111/j.1540-8175.2007.00544.x\"\u003ehttp://dx.doi.org/10.1111/j.1540-8175.2007.00544.x\u003c/a\u003e\u003c/li\u003e\n \u003cli\u003eLester SJ, Ryan EW, Schiller NB, Foster E. Best method in clinical practice and in research studies to determine left atrial size. Am J Cardiol. 1999; 84:829-32. DOI: http://dx.doi.org/10.1016/s0002-9149(99)00446-4\u003c/li\u003e\n \u003cli\u003eRecommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Roberto M. Lang, et al (J Am Soc Echocardiography 2015;28:1-39.)\u003c/li\u003e\n \u003cli\u003eLEFT ATRIAL VOLUME INDEX IN HEALTHY SUBJECTS: CLINICAL AND ECHOCARDIOGRAPHIC CORRELATES. Sarwar Shahbaz, Shoaib Islam, Abeera Mansur, Mamoon Akbar Vol 31, issue No 4 Pakistan Heart Journal),2020\u003c/li\u003e\n \u003cli\u003eBokhari SR, Mansur A, Khan Assir MZ, lttifaq A, Sarwar S. Echocardiographic \u0026nbsp;Evaluation of Left Atrial Volume Index in Patients with Chronic Kidne Disease. Saudi J Kidne Dis Trans \u0026bull; 12020;31:750-8\u003c/li\u003e\n \u003cli\u003eThomas L, Levett K, Boyd A, Leung DYC, Schiller NB, Ross DL. Compensatory \u0026nbsp;changes in atrial volumes with normal aging: Is atrial enlargement inevitable? J Am Coll Cardiol 2002; 40:1630-5 DOI: http:/dx.doi.org/10.1016/s0735-1097(02)02371-9\u003c/li\u003e\n \u003cli\u003eYamaguchi K1, Tanabe K, Tani Tet al. Left atrial volume in normal Japanese adults. Circ J. 2006 Mar; 70(3):285-8 DOI: \u003ca href=\"http://dx.doi.org/10.1253/circj.70.285\"\u003ehttp://dx.doi.org/10.1253/circj.70.285\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKou S, Caballero L, Dulgheru R et al. Echocardiographic reference ranges for normal cardiac chamber size: results from the NORRE study.Eur Heart J Cardiovasc Imaging 2014;15:680-90. DOI: \u003ca href=\"http://dx.doi.org/10.1093/ehjci/jet284\"\u003ehttp://dx.doi.org/10.1093/ehjci/jet284\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLancellotti P, Badano LP, Lang RM et al. Normal Reference Ranges for Echocardiography: rationale, study design, and methodology (NORRE Study). Eur Heart J Cardiovasc Imaging \u0026nbsp;2013; 14:303-8. DOI: http://dx.doi.org/10.1093/ehjci/jet008\u003c/li\u003e\n \u003cli\u003eNistri S, Galderisi M, Ballo P et al. Determinants of echocardiographic left atrial volume: implications for normalcy. Eur J Echocardiogr 2011; 12:826-33. DOI: http://dx.doi.org/10.1093/ejechocard/jer137\u003c/li\u003e\n \u003cli\u003eCacciapuoti F, Scognamiglio A, Paoli VD, Romano C, Cacciaputo F. Left Atrial Volume Index as Indicator of Left Venticular Diastolic Dysfunction. J Cardiovasc Ultrasound 2012; 20:25-9 DOI: \u003ca href=\"http://dx.doi.org/10.4250/jcu.2012.20.1.25\"\u003ehttp://dx.doi.org/10.4250/jcu.2012.20.1.25\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOrban M, Bruce CJ, Pressman GS et al. Dynamic Changes of Left Ventricular Performance and Left Atrial Volume Induced by the Mueller Maneuver in Healthy Young Adults and Implications for Obstructive Sleep Apnea, Atrial Fibrillation, and Heart Failure. Am J Cardiol 2008; 102:1557-61. DOI: \u003ca href=\"http://dx.doi.org/10.1016/j.amjcard.2008.07.050\"\u003ehttp://dx.doi.org/10.1016/j.amjcard.2008.07.050\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWhitlock M, Garg A, Gelow J, Jacobson T, Broberg C. Comparison of Left and Right Atrial Volume by Echocardiography Versus Cardiac Magnetic Resonance Imaging Using the Area-Length Method. Am J Cardiol 2010; 106:1345-50. DOI: \u003ca href=\"http://dx.doi.org/10.1016/j.amjcard.2010.06.065\"\u003ehttp://dx.doi.org/10.1016/j.amjcard.2010.06.065\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eYoshida C, Nakao S, Goda A et al. Value of assessment of left atrial volume and diameter in patients with heart failure but with normal left ventricular ejection fraction and mitral flow velocity pattern. Eur J Echocardiogr 2009; 10:278-81. DOI: http://dx.doi.org/10.1093/ejechocard/jen234\u003c/li\u003e\n \u003cli\u003eIwataki M, Takeuchi M, Otani K et al. Measurement\u003cspan style=\"white-space:pre;\"\u003e\u0026nbsp;\u003c/span\u003eof left\u003cspan style=\"white-space:pre;\"\u003e\u0026nbsp;\u003c/span\u003eatrial\u003cspan style=\"white-space:pre;\"\u003e\u0026nbsp;\u003c/span\u003evolume from\u003cspan style=\"white-space:pre;\"\u003e\u0026nbsp;\u0026nbsp;\u003c/span\u003etransthoracicthree-dimensional echocardiographic datasets using the biplane Simpson\u0026apos;s technique. J Am Soc Echocardiogr 2012; 25:1319-26. DOI: http://dx.doi.org/10.1016/j.echo.2012.08.017\u003c/li\u003e\n \u003cli\u003eLang RM, Badano LP. Mor-Avi V et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging: J Am Soc Echocardiogr 2015; 28:1-39. DOI: http://dx.doi.org/10.1016/j.echo.2014.10.003\u003cspan style=\"white-space:pre;\"\u003e\u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003eSeung Jun Kim, Seung Hyeok Han, Jung Tak Park et al. Left atrial volume is an independent predictor of mortality in CAPD patients, Nephrology Dialysis Transplantation, Volume 26, Issue 11, November 2011, Pages 3732-3739, DOI: http://dx.doi.org/10.1093/ndt/gfr118)\u003c/li\u003e\n \u003cli\u003ePatel D, Lavie C, Gilliland Y, Shah S, Dinshaw H, Milani R. Prediction of All-Cause Mortality by the Left Atrial Volume Index in Patients With Normal Left Ventricular Filling Pressure and Preserved Ejection Fraction. Mayo Clinic Proceedings. 2015;90(11):1499-1505. DOI: \u003ca href=\"http://dx.doi.org/10.1016/j.mayocp.2015.07.021\"\u003ehttp://dx.doi.org/10.1016/j.mayocp.2015.07.021\u003c/a\u003e\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSimek CL, Feldman MD, Haber H L, Wu C C, Jayaweera A R, Kaul S. Relationship between left ventricular thickness and left atrial size: comparison with other measures of diastolic function, J Am Soc Echocardiogr, 1995, vol. 8 (pg.37-47) DOI:http://dx.doi.org/10.1016/s0894-7317(05)80356-6\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSharma R, Pellerin D, Gaze DC et al. Mitral peak Doppler E-wave to peak mitralannulus velocity ratio is an accurate estimate of left ventricular filling pressure and predicts mortality in end-stage renal disease. J Am Soc Echocardiogr. 2006;19: 266-273. pmid:16500488 DOI: http://dx.doi.org/10.1016/j.echo.2005.10.006\u003c/li\u003e\n \u003cli\u003eTripepi G, Benedetto FA, Mallamaci F, Tripepi R, Malatino L, Zoccali C. Left atrial volume monitoring and cardiovascular risk in patients with end-stage renal disease: a prospective cohort study. J Am Soc Nephrol. 2007;18: 1316-1322. Pmid:17360950 DOI: http://dx.doi.org/10.1681/ASN.2006080881\u003c/li\u003e\n \u003cli\u003eKim JK, Kim SG, Kim MG et al. Left Ventricular Diastolic Dysfunction as a Echocardiographic.2012;25:411-420. pmid:22196883Predictor of Rapid Decline of Residual Renal Function in Patients with Peritoneal Dialysis. J Am Soc. DOI: http://dx.doi.org/10.1016/j.echo.2011.11.026\u003c/li\u003e\n \u003cli\u003ePatel DA, Lavie CJ, Gilliland YE, Shah SB, Dinshaw HK, Milani RV. Prediction of All-Cause Mortality by the Left Atrial Volume Index in Patients With Normal Left Ventricular Filling Pressure and Preserved Ejection Fraction. Mayo Clin Proc.2015 Nov;90(11):1499-505. DOI: \u003ca href=\"http://dx.doi.org/10.1016/mayocp.2015.07.021\"\u003ehttp://dx.doi.org/10.1016/mayocp.2015.07.021\u003c/a\u003e. Epub 2015 Oct 9. PMID: 26455887\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTripepi G, Mattace-Raso F, Mallamaci F, et al. Biomarkers of left atrial volume: a longitudinal study in patients with end stage renal disease. Hypertension 54: 818-824,2009 DOI: http://dx.doi.org/10.1161/HYPERTENSIONAHA.109.136804\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Left atrial volume index, End Stage renal disease, mortality","lastPublishedDoi":"10.21203/rs.3.rs-879662/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-879662/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Cardiovascular Disease is the leading cause of death in End Stage Renal Disease\u0026nbsp;patients. Left atrial volume index is an established independent risk predictor for mortality in atherosclerotic heart disease. However, Left atrial volume index has not been extensively studied in hemodialysis population. The aim of this study is to assess the impact of Left atrial volume index on mortality in hemodialysis patients.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This is a descriptive cross sectional study. From January 1, 2013, through April 30, 2018, we evaluated echocardiographic findings of 91 End stage renal disease patients on maintenance hemodialysis.\u0026nbsp;Patient information was collected and data analysed using SPSS version 22 for windows software package. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e :The average age of the patients was 62.85±12.4 years. The average duration of dialysis was 29.54 months as shown in Table 1.\u003c/p\u003e\u003cp\u003eThe mean Left atrial volume index of our dialysis patients was 38.993 ml/m2. The mean Left atrial volume index of 42.62±10.24 ml/m2 in expired patients as compared to 36.6 ml/m2 in alive patients with a p-value of 0.004 shows that Left atrial volume index of expired patients was significantly higher as compared to alive patients (Table 2).\u003c/p\u003e\u003cp\u003eArea under the curve using Receiver operating characteristic curve was found 66.7% which was statistically significant with p-value 0.007, which suggests that the cutoff value of Left atrial volume index for expired patients can be at least 38.5.\u003c/p\u003e\u003cp\u003e61.5% patients that expired had a Left atrial volume index of more than 38.5 ml/m2, whereas 62.7% patients that were alive had a Left atrial volume index less than 38.5 ml/m2 , the p-value 0.02 suggested a significant association of Left atrial volume index with Mortality.\u0026nbsp;Left atrial volume index gives positive association with mortality, for Left atrial volume index greater than 40, the odds ratio was 3.5.\u003c/p\u003e\u003cp\u003eMortality didn’t give any significant association with Ejection Fraction, Pulmonary artery systolic pressure and EE ratio. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion : \u003c/strong\u003e\u003c/p\u003e\u003cp\u003eIncreased Left atrial volume index is associated with higher mortality in End stage renal disease patients on maintenance hemodialysis. Increased Left atrial volume index was the best predictor of mortality among measured echocardiographic parameters in our hemodialysis population.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Prognostic Value of Left Atrial Volume Index in End Stage Renal Disease Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-16 19:44:47","doi":"10.21203/rs.3.rs-879662/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9be08db7-358f-4675-b2e9-23eb2aac4866","owner":[],"postedDate":"September 16th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":7240174,"name":"Urology \u0026 Nephrology"}],"tags":[],"updatedAt":"2021-10-25T06:59:08+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-16 19:44:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-879662","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-879662","identity":"rs-879662","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}