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This study assessed whether left atrial (LA) strain imaging could non-invasively predict LAA contractile dysfunction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results<\/jats:title>\n                    <jats:p>We prospectively enrolled 138 patients with severe rheumatic MS in sinus rhythm who underwent transthoracic and transoesophageal echocardiography. Left atrial appendage inactivity was defined as LAA emptying velocity &amp;lt; 25\u2005cm\/s. Left atrial reservoir strain (LASr), conduit, and contractile strain were quantified using speckle-tracking echocardiography. Multivariable logistic regression and receiver operating characteristic analyses were performed to evaluate predictors of LAA inactivity. Left atrial appendage inactivity was observed in 108 patients (78.2%), and LAA thrombus was detected in eight patients (5.8%)\u2014all in sinus rhythm. In multivariate analysis, LASr was the strongest independent predictor of LAA inactivity [odds ratio: 0.61 per 1% increase; 95% confidence interval (CI): 0.50\u20130.75; P &amp;lt; 0.0001]. Left atrial reservoir strain yielded an area under the ROC curve of 0.950 (95% CI: 0.911\u20130.989), with a threshold of \u226422.95% showing a sensitivity of 93.5% and specificity of 90% for predicting LAA inactivity. Impaired LA strain identified patients with elevated fibrinogen, D-dimer, and the presence of LAA thrombus.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Left atrial strain imaging provides a robust non-invasive predictor of LAA dysfunction in severe rheumatic MS patients in sinus rhythm. These findings support the potential clinical utility of LA strain in improving risk stratification and guiding anticoagulation decisions in this under-recognized high-risk population.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ehjopen\/oeag130","type":"journal-article","created":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T11:36:35Z","timestamp":1787052995000},"source":"Crossref","is-referenced-by-count":0,"title":["Prediction of left atrial appendage dysfunction by atrial strain imaging in patients with rheumatic mitral stenosis in sinus rhythm"],"prefix":"10.1093","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0621-1509","authenticated-orcid":false,"given":"Jamal","family":"Yusuf","sequence":"first","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3013-8070","authenticated-orcid":false,"given":"Gaurav","family":"Sharma","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ankit","family":"Bansal","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3762-2618","authenticated-orcid":false,"given":"Vimal","family":"Mehta","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ankur","family":"Gautam","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lovedeep","family":"Singh","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohit D","family":"Gupta","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rajat","family":"Chaudhary","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5583-7743","authenticated-orcid":false,"given":"Vishal","family":"Batra","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Girish M","family":"Palleda","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Safal","family":"Safal","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arima","family":"Nigam","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sumod","family":"Kurian","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research , Room No. 127, First Floor, Academic Block, New Delhi, Delhi 110002 ,","place":["India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2291-5001","authenticated-orcid":false,"given":"Partho P","family":"Sengupta","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Medicine, Mayo Clinic Health System , Mayo Clinic, 200 First Street SW, Rochestser, MNRochestser, MN 55905 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clot in patients with mitral stenosis and normal sinus rhythm","volume":"90","author":"Saidi","year":"2004","journal-title":"Heart"},{"key":"2026100816023430000_oeag130-B4","first-page":"417","article-title":"Left atrial appendage function in mitral stenosis: is it determined by cardiac rhythm?","volume":"20","author":"Saygi","year":"2011","journal-title":"J Heart Valve Dis"},{"key":"2026100816023430000_oeag130-B5","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1016\/S0167-5273(00)00235-7","article-title":"Clinical and echocardiographic predictors of left atrial clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis","volume":"73","author":"Goswami","year":"2000","journal-title":"Int J Cardiol"},{"key":"2026100816023430000_oeag130-B6","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1016\/S0002-9149(00)01007-9","article-title":"Predictors of left atrial spontaneous echo contrast and thrombi in patients with mitral stenosis and atrial fibrillation","volume":"86","author":"Gonz\u00e1lez-Torrecilla","year":"2000","journal-title":"Am J Cardiol"},{"key":"2026100816023430000_oeag130-B7","doi-asserted-by":"crossref","first-page":"1860","DOI":"10.1111\/echo.15223","article-title":"Prevalence and predictors of left atrial appendage inactivity in patients of rheumatic mitral stenosis in sinus rhythm","volume":"38","author":"Mukhopadhyay","year":"2021","journal-title":"Echocardiography"},{"key":"2026100816023430000_oeag130-B8","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1161\/01.CIR.94.3.331","article-title":"Determinants of increased regional left atrial coagulation activity in patients with mitral stenosis","volume":"94","author":"Peverill","year":"1996","journal-title":"Circulation"},{"key":"2026100816023430000_oeag130-B9","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1016\/S0894-7317(14)80009-6","article-title":"Left atrial spontaneous echo contrast and thrombus in patients referred for balloon mitral valvotomy","volume":"7","author":"Rittoo","year":"1994","journal-title":"J Am Soc Echocardiogr"},{"key":"2026100816023430000_oeag130-B10","first-page":"573","article-title":"Predictive factors of thromboembolic complications in mitral stenosis in sinus rhythm","volume":"45","author":"Khatouri","year":"1996","journal-title":"Ann Cardiol Angeiol (Paris)"},{"key":"2026100816023430000_oeag130-B11","doi-asserted-by":"crossref","first-page":"593","DOI":"10.1177\/000331970305400509","article-title":"Increased systemic and regional coagulation activity in patients with mitral stenosis and sinus rhythm","volume":"54","author":"Atak","year":"2003","journal-title":"Angiology"},{"key":"2026100816023430000_oeag130-B12","doi-asserted-by":"crossref","first-page":"795","DOI":"10.1016\/S0002-9149(97)01025-4","article-title":"Activation of blood coagulation in patients with mitral stenosis and sinus rhythm","volume":"81","author":"Ileri","year":"1998","journal-title":"Am J 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thrombus","volume":"30","author":"Karabay","year":"2013","journal-title":"Echocardiography"},{"key":"2026100816023430000_oeag130-B20","first-page":"472","article-title":"Atrial myocardial deformation after cardioversion for atrial fibrillation","volume":"9","author":"Kaya","year":"2008","journal-title":"Eur J Echocardiogr"},{"key":"2026100816023430000_oeag130-B21","doi-asserted-by":"crossref","first-page":"87","DOI":"10.5603\/CJ.a2017.0069","article-title":"Left atrial strain predicts appendage stasis in non-valvular atrial fibrillation","volume":"25","author":"Zhu","year":"2018","journal-title":"Cardiol J"},{"key":"2026100816023430000_oeag130-B22","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.echo.2022.10.009","article-title":"Recommendations for echocardiography in rheumatic heart disease","volume":"36","author":"Pandian","year":"2023","journal-title":"J Am Soc 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