Longitudinal Assessment of Left Atrial Remodeling in Patients With Chronic Severe Aortic Regurgitation

BACKGROUND

There are significant sex and age differences in left ventricular (LV) remodeling that may lead to disparity in outcomes when used to inform the timing of aortic regurgitation (AR) intervention.

OBJECTIVES

The aim of this study was to examine whether left atrial (LA) parameters might represent better criteria than LV parameters to inform the timing of AR intervention.

METHODS

Using data on patients with moderate to severe or severe AR with serial echocardiography (2010-2016), the longitudinal trends in left atrial volume index (LAVI) and left atrial reservoir strain (LAr) were evaluated by sex and age. The incremental utility of these parameters in predicting adverse events over LV parameters was also determined.

RESULTS

In 525 patients (25.7% women) with 1,687 echocardiograms over a median follow-up period of 2.0 years (Q1-Q3: 1.0-3.6 years), there was significant increase in LAVI (1.0 mL/m2 per year [95% CI: 0.76-1.2 mL/m2 per year]) and decrease in LAr (-1.3% per year [95% CI: -1.6% to -0.92%]), without a significant interaction by sex or age category (P for interaction ≥ 0.17). In addition, both LAVI and LAr were significant predictors of adverse events independent of LV parameters. The optimal discriminatory thresholds were 37 mL/m2 for LAVI and 35% for LAr. These thresholds were similar across categories of sex and age. Within the relatively short-term follow-up, surgery was associated with survival benefit among patients with LAVI ≥37 mL/m2 (HR: 0.33 [95% CI: 0.15-0.72]; P = 0.006) but was not statistically significant among patients with LAVI <37 mL/m2 (HR: 0.46 [95% CI: 0.18-1.17]; P = 0.09). Similarly, surgery was associated with survival for the subgroup with LAr ≤35% but not among those with LAr >35%.

CONCLUSIONS

Unlike LV remodeling, LA remodeling demonstrates a similar rate of progression between categories of sex and age among patients with AR. In addition, LA parameters provide incremental prognostic value over LV parameters.

Optimal antiplatelet strategy following coronary artery bypass grafting: a meta-analysis

OBJECTIVE

Coronary artery bypass grafting (CABG) is an established revascularisation strategy for multivessel and left main coronary artery disease. Although aspirin is routinely recommended for patients with CABG, the optimal antiplatelet regimen after CABG remains unclear. We evaluated the efficacies and risks of different antiplatelet regimens (dual (DAPT) versus single (SAPT), and dual with clopidogrel (DAPT-C) versus dual with ticagrelor or prasugrel (DAPT-T/P)) after CABG.

METHODS

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and performed a comprehensive literature search using PubMed, Ovid Medline, Ovid Embase and Cochrane Central Register of Controlled Trials. Data were extracted and pooled using random-effects models and Review Manager (V.5.4).

RESULTS

Among the 2970 article abstracts screened, 215 full-text articles were reviewed and 38 studies totaling 77 447 CABG patients were included for analyses. DAPT compared with SAPT was associated with significantly lower all-cause mortality (OR 0.65 with 95% CI 0.50 to 0.86; p=0.002), cardiovascular mortality (OR 0.53, 95% CI 0.33 to 0.84; p=0.008), and major adverse cardiac and cerebrovascular events (MACCE) (OR 0.68, 95% CI 0.51 to 0.91; p=0.01), but higher rates of major (OR 1.30, 95% CI 1.08 to 1.56; p=0.007) and minor bleeding (OR 1.87, 95% CI 1.28 to 2.74; p=0.001) after CABG. DAPT-T/P compared with DAPT-C was associated with significantly lower all-cause (OR 0.43, 95% CI 0.29 to 0.65; p≤0.0001) and cardiovascular mortality (OR 0.44, 95% CI 0.24 to 0.80; p=0.008), and no differences on other cardiovascular or bleeding outcomes after CABG.

CONCLUSION

In patients with CABG, DAPT compared with SAPT and DAPT-T/P compared with DAPT-C were associated with reduction in all-cause and cardiovascular mortality, especially in patients with acute coronary syndrome. Additionally, DAPT was associated with reduction in MACCE, but higher rates of major and minor bleeding. An individualised approach to choosing antiplatelet regimen is necessary for patients with CABG based on ischaemic and bleeding risks.

Echocardiography Versus Magnetic Resonance Imaging Quantification and Novel Algorithm for Isolated Severe Tricuspid Regurgitation

Transthoracic echocardiography (TTE) is the first-line tool to evaluate isolated tricuspid regurgitation (TR) but it has limitations and its TR quantification compared with magnetic resonance imaging (MRI) has been studied infrequently. We compared isolated severe TR quantification by TTE against MRI and developed a novel TTE-based algorithm. Isolated TR patients graded severe by TTE and who underwent MRI January 2007 to June 2019 were studied. The TTE and MRI measurements were analyzed by correlation, area under receiver-operative characteristics curve (AUC), and classification and regression tree algorithm of TTE parameters to best identify MRI-derived severe TR (regurgitant volume ≥45 ml and/or fraction ≥50%). A total of 108 of 262 (41%) that were graded as severe TR by TTE also had severe TR by MRI. There were moderate correlations between TTE and MRI in the quantification of TR severity and right atrial size (Pearson r = 0.428 to 0.645) but none to modest correlations between them in right ventricle quantification. The key TTE parameters to identify MRI-derived severe TR in the decision tree regression algorithm were right atrial volume indexed ≥47 ml/m2 and effective regurgitant orifice area ≥0.45 cm2 and especially if there is right ventricle free wall strain ≥ -9.5%. This novel algorithm has an AUC of 0.76% and 79% agreement to detect severe TR by MRI, which higher than the American Society of Echocardiography criteria with AUC 0.68% and 66% agreement (p = 0.006 and p <0.001, respectively). In conclusion, TTE-derived TR and right atrial quantification had moderate correlation and discrimination of severe TR by MRI, from which a novel TTE algorithm was derived, which had incrementally a higher accuracy than contemporary guidelines' criteria alone.

Prevalence, Characteristics, and Outcomes of Infective Endocarditis Readmissions in Patients With Variables Associated With Liver Disease in the United States

Infective endocarditis (IE) is common in patients with liver disease. Outcomes of IE in patients with liver disease are limited. We aimed to investigate IE outcomes in patients with variables associated with liver disease in the USA. We used the 2017 National Readmission Database to identify index admission of adults with IE, based on the International Classification of Disease, 10th revision codes. The primary outcome was 30-day readmission. Secondary outcomes were mortality and predictors of hospital readmission. We identified 40,413 IE admissions. Patients who were readmitted were more likely to have a history of HCV (19.4 vs 12.3%, P < .001), hyponatremia (25 vs 21%, P < .001), and thrombocytopenia (20.3 vs 16.3%, P < .001). After adjusting for age, hypertension, heart failure, diabetes mellitus, and end stage renal disease, hyponatremia (odds ratio (OR) 1.25; 95% confidence intervals [CI]: 1.17-1.35; P < .001) and thrombocytopenia (OR 1.16; 95% CI: 1.08-1.24; P < .001) correlated with higher odds of 30-day readmission. Mortality was higher among patients with hyponatremia (29 vs 22%, P < .001), thrombocytopenia (29 vs 17%, P < .001), coagulopathy (12 vs 5%, P < .001), cirrhosis (6 vs 4%, P < .001), ascites (7 vs 3%, P < .001), liver failure (18 vs 3%, P < .001), and portal hypertension (3 vs 1.5%, P < .001).

Intracardiac Thrombus in COVID-19 Inpatients: A Nationwide Study of Incidence, Predictors, and Outcomes

COronaVIrus Disease-2019 (COVID-19) is associated with a hypercoagulable state. Intracardiac thrombosis is a potentially serious complication but has seldom been evaluated in COVID-19 patients. We assessed the incidence, associated factors, and outcomes of COVID-19 patients with intracardiac thrombosis. In 2020, COVID-19 inpatients were identified from the National Inpatient Sample (NIS) database. Data on clinical characteristics, intracardiac thrombosis, and adverse outcomes were collected. Multivariable logistic regression was used to identify factors associated with intracardiac thrombosis, in-hospital mortality, and morbidities. In 2020, 1,683,785 COVID-19 inpatients (mean age 63.8 years, 32.2% females) were studied. Intracardiac thrombosis occurred in 0.10% (1830) of cases. In-hospital outcomes included 13.2% all-cause mortality, 3.5% cardiovascular mortality, 2.6% cardiac arrest, 4.4% acute coronary syndrome (ACS), 16.1% heart failure, 1.3% stroke, and 28.3% acute kidney injury (AKI). Key factors for intracardiac thrombosis were congestive heart failure history and coagulopathy. Intracardiac thrombosis independently linked to higher risks of all-cause mortality (odds ratio [OR]: 3.32 (2.42-4.54)), cardiovascular mortality (OR: 2.95 (1.96-4.44)), cardiac arrest (OR: 2.04 (1.22-3.43)), ACS (OR: 1.62 (1.17-2.22)), stroke (OR: 3.10 (2.11-4.56)), and AKI (OR: 2.13 (1.68-2.69)), but not heart failure. While rare, intracardiac thrombosis in COVID-19 patients independently raised in-hospital mortality and morbidity risks.

Impact of Bariatric Surgery on Left Ventricular Structure and Function

BACKGROUND

Obesity leads to an increased risk of cardiovascular disease morbidity and death, including heart failure. Bariatric surgery has been proven to be the most effective long-term weight management treatment. This study investigated the changes in cardiac structure and function after bariatric surgery, including left ventricular global longitudinal strain.

METHODS AND RESULTS

There were 398 consecutive patients who underwent bariatric surgery with pre- and postoperative transthoracic echocardiographic imaging at a US health system between 2004 and 2019. We compared cardiovascular risk factors and echocardiographic parameters between baseline and follow-up at least 6 months postoperatively. Along with decreases in weight postoperatively, there were significant improvements in cardiovascular risk factors, including reduction in systolic blood pressure levels from 132 mm Hg (25th-75th percentile: 120-148 mm Hg) to 127 mm Hg (115-140 mm Hg; P=0.003), glycated hemoglobin levels from 6.5% (5.9%-7.6%) to 5.7% (5.4%-6.3%; P<0.001), and low-density lipoprotein levels from 97 mg/dL (74-121 mg/dL) to 86 mg/dL (63-106 mg/dL; P<0.001). Left ventricular mass decreased from 205 g (165-261 g) to 190 g (151-236 g; P<0.001), left ventricular ejection fraction increased from 58% (55%-61%) to 60% (55%-64%; P<0.001), and left ventricular global longitudinal strain improved from -15.7% (-14.3% to -17.5%) to -18.6% (-16.0% to -20.3%; P<0.001) postoperatively.

CONCLUSIONS

This study has shown the long-term impact of bariatric surgery on cardiac structure and function, with reductions in left ventricular mass and improvement in left ventricular global longitudinal strain. These findings support the cardiovascular benefits of bariatric surgery.

Contemporary Trends in Clinical Characteristics, Therapeutic Strategies and Outcomes in Patients Aged 80 Years and Older Presenting with non-ST Elevation Myocardial Infarctions in the United States

The current guidelines for the management and treatment of acute coronary syndromes do not fully consider the role of age in guiding medical or invasive management. We investigated the characteristics, management strategies, and clinical outcomes of patients aged 80 years and older presenting with non-ST elevation myocardial infarction (NSTEMI). A cohort study using the nationwide inpatient sample database of patients aged 80 years and older presenting with NSTEMI in the United States between 2012 to 2018 was performed. About 24.2% (151,472/625,916) of NSTEMI patients were 80 years and older. Older patients (≥80 years) had higher in-hospital mortality and cardiovascular complications compared to younger patients (odds ratio (OR) 1.79, 95% confidence intervals (CI) 1.71-1.88, P < 0.001). Among older patients, conservative medical management was associated with higher inpatient mortality compared to percutaneous coronary intervention (PCI) (OR 2.3, 95% CI 2.18-2.41, P < 0.001) or coronary artery bypass graft (CABG) (OR 1.9, 95% CI 1.76-2.09, P < 0.001). The highest mortality rate was observed in older patients who underwent both PCI and CABG, followed by those treated conservatively and those undergoing coronary angiography without revascularization. This study provides valuable insights into the clinical characteristics and outcomes of elderly patients presenting with NSTEMI in the United States. The results emphasize the importance of a tailored approach to the management of ACS in elderly patients and the need for improved revascularization strategies to reduce in-hospital mortality and adverse cardiovascular outcomes. Therefore, the clinician should tailor the management of older patients presenting with NSTEMI.

Factors Associated With Maintenance of an Improved Ejection Fraction: An Echocardiogram-Based Registry Study

Background Heart failure with improved ejection fraction (EF) is increasingly recognized as a sizable and distinct entity. While the features associated with improvedEF have been explored and new guidelines have emerged, factors associated with sustaining an improved EF over time have not been defined. We aimed to assess factors associated with maintenance of an improved EF in a large real-world patient cohort. Methods and Results A total of 7070 participants with heart failure with improved EF and a subsequent echocardiogram performed after at least 9 months of follow-up were included in a retrospective cohort study conducted at the Cleveland Clinic in Cleveland, Ohio. Multiple logistic regression models, adjusted for demographics, comorbidities, and medications were built to identify characteristics and therapeutic interventions associated with maintaining an improved EF. Mean age (SD) was 64.9 (13.8) years, 62.7% were men, and 75.1% were White participants. White race and the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors were associated with maintaining the EF at least 9 months after EF improvement. In contrast, male sex or having atrial fibrillation/flutter, coronary artery disease, history of myocardial infarction, presence of an implanted cardioverter-defibrillator, and use of loop diuretics were associated with a decline in EF after previously documented improvement. Conclusions Continued use of renin-angiotensin-aldosterone system inhibitors was associated with maintaining the EF beyond the initial improvement phase.

Seasonal differences in the timing of flight between the invasive winter moth and native Bruce spanworm promotes reproductive isolation

The European winter moth, Operophtera brumata L. (Lepidoptera: Geometridae), was accidentally introduced to North America on at least 4 separate occasions, where it has been hybridizing with the native Bruce spanworm, O. bruceata Hulst, at rates up to 10% per year. Both species are known to respond to the same sex pheromones and to produce viable offspring, but whether they differ in the seasonal timing of their mating flights is unknown. Therefore, we collected adult male moths weekly along 2 transects in the northeastern United States and genotyped individuals using polymorphic microsatellite markers as males of these 2 species cannot be differentiated morphologically. Along each transect, we then estimated the cumulative proportions (i.e., the number of individuals out of the total collected) of each species on each calendar day. Our results indicate that there are significant differences between the species regarding their seasonal timing of flight, and these allochronic differences likely are acting to promote reproductive isolation between these 2 species. Lastly, our results suggest that the later flight observed by winter moth compared to Bruce spanworm may be limiting its inland spread in the northeastern United States because of increased exposure to extreme winter events.

Prognostic Power of Quantitative Assessment of Functional Mitral Regurgitation and Myocardial Scar Quantification by Cardiac Magnetic Resonance

BACKGROUND

The severity classification of functional mitral regurgitation (FMR) remains controversial despite adverse prognosis and rapidly evolving interventions. Furthermore, it is unclear if quantitative assessment with cardiac magnetic resonance can provide incremental risk stratification for patients with ischemic cardiomyopathy (ICM) or non-ICM (NICM) in terms of FMR and late gadolinium enhancement (LGE). We evaluated the impact of quantitative cardiac magnetic resonance parameters on event-free survival separately for ICM and NICM, to assess prognostic FMR thresholds and interactions with LGE quantification.

METHODS

Patients (n=1414) undergoing cardiac magnetic resonance for cardiomyopathy (ejection fraction<50%) assessment from April 1, 2001 to December 31, 2017 were evaluated. The primary end point was all-cause death, heart transplant, or left ventricular assist device implantation during follow-up. Multivariable Cox analyses were conducted to determine the impact of FMR, LGE, and their interactions with event-free survival.

RESULTS

There were 510 primary end points, 395/782 (50.5%) in ICM and 114/632 (18.0%) in NICM. Mitral regurgitation-fraction per 5% increase was independently associated with the primary end point, hazards ratios (95% CIs) of 1.04 (1.01-1.07; P=0.034) in ICM and 1.09 (1.02-1.16; P=0.011) in NICM. Optimal mitral regurgitation-fraction threshold for moderate and severe FMR were ≥20% and ≥35%, respectively, in both ICM and NICM, based on the prediction of the primary outcome. Similarly, optimal LGE thresholds were ≥5% in ICM and ≥2% in NICM. Mitral regurgitation-fraction×LGE emerged as a significant interaction for the primary end point in ICM (P=0.006), but not in NICM (P=0.971).

CONCLUSIONS

Mitral regurgitation-fraction and LGE are key quantitative cardiac magnetic resonance biomarkers with differential associations with adverse outcomes in ICM and NICM. Optimal prognostic thresholds may provide important clinical risk prognostication and may further facilitate the ability to derive selection criteria to guide therapeutic decision-making.

Impact of Age and Sex on Left Ventricular Remodeling in Patients With Aortic Regurgitation

BACKGROUND

Current guidelines for aortic regurgitation (AR) recommend the same linear left ventricular (LV) dimension for intervention regardless of age and sex.

OBJECTIVES

The purpose of this study was to evaluate the impact of age and sex on the degree of LV remodeling and outcomes.

METHODS

We included consecutive patients with severe AR who were serially monitored by echocardiogram between 2010 and 2016. The 2 main endpoints were as follows: 1) LV end-systolic volume indexed to body surface area (LVESVi) and LV end-diastolic volume indexed to body surface area; and 2) adverse events (AE). We evaluated the longitudinal rate of LV remodeling and determined the association between LV volume and AE by age and sex.

RESULTS

A total of 525 adult patients (26% women) with a median echocardiogram follow-up of 2.0 years (IQR: 1.0-3.6 years) were included. At baseline, older patients (age ≥60 years) had smaller LV volumes compared with younger patients (age <60 years), eg, the mean LVESVi was 27.3 mL/m² vs 32.3 mL/m², respectively. Similarly, women had smaller LV volumes compared with men (mean LVESVi was 23.3 mL/m² vs 32.4 mL/m²). On serial evaluation, older patients and women maintained smaller LV volumes compared with younger patients and men, respectively. There were 210 (40%) AE during follow-up. The optimal discriminatory threshold for AE varies by age and sex, eg, the LVESVi threshold was highest for young men (50 mL/m²), intermediate for older men (35 mL/m²), and lowest for women (27 mL/m²).

CONCLUSIONS

On serial evaluation, older patients and women with chronic AR maintained smaller LV volumes than younger patients and men, respectively, and develop AE at lower LV volumes.

Advances in multi-modality imaging for constrictive pericarditis and pericardial inflammation: role of imaging-guided therapy

INTRODUCTION

Constrictive pericarditis (CP) can result from uncontrolled inflammation of the pericardium. This can be due to various etiologies. CP can lead to both left- and right-sided heart failure with associated poor quality of life, so early recognition is key. The evolving role of multimodality cardiac imaging allows for earlier diagnosis and facilitates management to help mitigate this adverse outcome.

AREAS COVERED

This review discusses the pathophysiology of constrictive pericarditis, chronic inflammation and autoimmune etiologies, clinical presentation of CP, and advances in multimodality cardiac imaging for diagnosis and management. Echocardiography and cardiac magnetic resonance (CMR) imaging remain cornerstone modalities to evaluate this condition, whereas additional imaging modalities such as computed tomography and FDG-positron emission tomography can provide complementary information.

EXPERT OPINION

Advances in multimodality imaging allow for a more precision diagnosis of constrictive pericarditis. There has been a paradigm shift in pericardial disease management with advances in multimodality imaging, especially CMR, to detect subacute and chronic inflammation. This has enabled imaging-guided therapy (IGT) to both help prevent and potentially reverse established constrictive pericarditis.

Prognostic impact of left ventricular systolic dysfunction in patients with mixed aortic valve disease undergoing aortic valve replacement

BACKGROUND

The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV-GLS) and LV ejection fraction (LVEF).

METHODS

We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all-cause mortality.

RESULTS

Mean age was 65 ± 15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV-GLS. During a median follow-up period of 5.8 years, 65 patients (34%) of 192 patients with follow-up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF <50% (P < .001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV-GLS worse than -15% and those with postoperative LV-GLS better than -15% (P < .001).

CONCLUSIONS

In patients with MAVD who underwent AVR, the mean postoperative LV-GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV-GLS and LVEF were both independently associated with higher mortality in this population.

Diagnostic performance of contemporary transesophageal echocardiography with modern imaging for infective endocarditis

Background

Infective endocarditis (IE) is associated with high morbidity and mortality. Following an initial negative transesophageal echocardiogram (TEE), high clinical suspicion warrants repeat examination. We evaluated the diagnostic performance of contemporary TEE imaging for IE.

Methods

This retrospective cohort study included patients ≥18 years old undergoing ≥2 TEEs within 6 months, with confirmed diagnosis of IE based on Duke criteria, 70 in 2011 and 172 in 2019, were included. We compared the diagnostic performance of TEE for IE in 2019 versus 2011. The primary endpoint was the sensitivity of initial TEE to detect IE.

Results

Sensitivity of the initial TEE to detect endocarditis was 85.7% versus 95.3%, in 2011 and 2019, respectively (P=0.01). On multivariable analysis, initial TEE more frequently detected IE in 2019, compared to 2011 [odds ratio (OR): 4.06, 95% confidence intervals (CIs): 1.41-11.71, P=0.01]. Improved diagnostic performance was driven by improved detection of prosthetic valve infective endocarditis (PVIE), sensitivity 70.8% in 2011 versus 93.7% (P=0.009) in 2019. In 2019, TEEs more frequently utilized probes with higher frame rates/resolution, than 2011 (P<0.001). Three dimensional (3D) technology was utilized in 97.2% of initial TEEs in 2019, compared to 70.5% in 2011 (P<0.001).

Conclusions

Contemporary TEE was associated with improved diagnostic performance for endocarditis, driven by improved sensitivity for PVIE.

Novel Multi-Parametric Mitral Annular Calcification Score Predicts Outcomes in Mitral Valve Dysfunction

The objective of the study was to construct a multi-parametric mitral annular calcification (MAC) score using computed tomography (CT) features for prediction of outcomes in patients undergoing mitral valve surgery. We constructed a multi-parametric MAC score, which ranges between 2 and 12, and consists of Agatston calcium score (1 point: <1000 Agatston units (AU); 2 points: 1000-<3000 AU; 3 points: 3000-5000 AU; 4 points: >5000 AU), quantitative MAC circumferential angle (1 point: <90°; 2 points: 90-<180°; 3 points: 180-<270°; 4 points: 270-360°), involvement of trigones (1 point: 1 trigone; 2 points: both trigones), and 1 point each for myocardial infiltration and left ventricular outflow tract extension/involvement of aorto-mitral curtain. The association between MAC score and clinical outcomes was evaluated. The study cohort consisted of 334 patients undergoing mitral valve surgery (128 mitral valve repairs, 206 mitral valve replacements) between January 2011 and September 2019, who had both non-contrast gated CT scan and evidence of MAC. The mean age was 72 ± 11 years, with 58% of subjects being female. MAC score was a statistically significant predictor of total operation time (P<0.001), cross-clamp time (P = 0.001) and in-hospital complications (P = 0.003). Additionally, MAC score was a significant predictor of time to all-cause death (P = 0.046). A novel multi-parametric score based on CT features allowed systematic assessment of MAC, and predicted clinical outcomes in patients with mitral valve dysfunction undergoing mitral valve surgery.

Differences in patterns of progression of secondary mitral regurgitation

AIMS

Little data exist about the natural history and disease progression of secondary mitral regurgitation (SMR). We sought to study the temporal progression of left-sided volumes and functions in patients who progress to develop severe SMR.

METHODS AND RESULTS

We screened patients with chronic severe SMR who had at least one previous transthoracic echocardiography showing non-severe MR. Unsupervised phenotypic clustering based on baseline and rate of change in left ventricular (LV) and left atrial (LA) volumes, ejection fraction (EF), and MR severity progression identified two different phenotypes. We then compared them in terms of clinical characteristics, mechanistic and anatomical features, management, and outcomes. A total of 257 patients were included. Cluster 1 started with lower EF and LA strain and higher LV and LA volumes compared with Cluster 2, with a slower progression into severe SMR. At the onset of severe MR, Cluster 2 still had higher EF, lower LV volumes, but similar LA volumes and strain, and less proportionate SMR, compared with Cluster 1. They also had higher tenting height and more compensatory leaflet growth. On follow-up, Cluster 1 had more ventricular-directed therapies, whereas Cluster 2 received more mitral valve interventions. While the heart failure burden was higher in Cluster 1, there was no difference in mortality rates.

CONCLUSION

Based on disease progression, two distinct progression patterns of SMR exist, having different anatomical and mechanistic features with variation in management and outcomes.

Quantitative Echocardiographic Assessment and Optimal Criteria for Early Intervention in Asymptomatic Tricuspid Regurgitation

BACKGROUND

Significant tricuspid regurgitation (TR) is associated with poor outcome and high operative mortality resulting from late presentation. Yet, the optimal timing for intervention is unknown.

OBJECTIVES

The purpose of this study was to evaluate the prognostic value of echocardiographic parameters to inform early intervention in asymptomatic TR.

METHODS

Using the Cleveland Clinic echocardiography database 2004 to 2018, the authors identified a consecutive cohort of asymptomatic patients with moderate to severe (3+) or severe (4+) TR. Quantitative TR and right heart parameters were retrospectively determined, and their prognostic utility for all-cause mortality was assessed.

RESULTS

In 325 asymptomatic patients (mean age: 67.9 years; 79.4% female) with at least 3+ TR, there were 132 deaths (40.6%), with a median survival time of 9.9 years (95% CI: 7.9-12.7 years). By contrast, the median survival time in an age- and sex-matched cohort of symptomatic TR patients was 4.4 years (95% CI: 2.8-5.9 years). Among all the echocardiographic parameters evaluated, right ventricle free wall strain (RVFWS) and tricuspid regurgitant volume (RVol) were the strongest predictors of mortality in asymptomatic TR. The optimal discriminatory thresholds for these parameters were RVFWS <-19% and RVol >45 mL. The 5-year survival rates by number of risk factors (RF) were 93% (95% CI: 86%-96%), 65% (95% CI: 55%-74%), and 38% (95% CI: 26%-49%) for no RF, 1 RF, and both RFs, respectively. Compared with symptomatic TR, mortality was lower for asymptomatic TR with no RF (HR: 0.10; 95% CI: 0.04-0.29) or 1 RF (HR: 0.29; 95% CI: 0.14-0.58), but similar for asymptomatic TR with both RFs (HR: 1.11; 95% CI: 0.56-2.19).

CONCLUSIONS

RVFWS and RVol are key prognostic markers that can be serially monitored to inform optimal timing of intervention for severe asymptomatic TR.

Quantification of Significant Aortic Stenosis by Echocardiography versus Four-Dimensional Cardiac Computed Tomography: A Multi-Modality Imaging Study

Transthoracic echocardiography (TTE) grading of aortic stenosis (AS) is challenging when parameters are discrepant, and four-dimensional cardiac computed tomography (4D-CCT) is increasingly utilized for transcatheter intervention workup. We compared TTE and 4D-CCT measures contributing to AS quantification. AS patients (n = 80, age 86 ± 10 years, 71% men) referred for transcatheter replacement in 2014−2017 were retrospectively studied, 20 each with high-gradient AS (HG-AS), classical and paradoxical low-flow low-gradient AS (CLFLG-AS and PLFLG-AS), and normal-flow low-gradient AS (NFLG-AS). Correlation and Bland−Altman analyses were performed between TTE and 4D-CCT parameters. There were moderate-to-high TTE versus 4D-CCT correlations for left ventricular volumes, function, mass, and outflow tract dimensions (r = 0.51−0.88), though values were mostly significantly higher by 4D-CCT (p < 0.001). Compared with 4D-CCT planimetry of aortic valve area (AVA), TTE estimates had modest correlation (r = 0.37−0.43) but were significantly lower (by 0.15−0.32 cm2). The 4D-CCT estimate of LVSVi lead to significant reclassification of AS subtype defined by TTE. In conclusion, 4D-CCT quantified values were higher than TTE for the left ventricle and AVA, and the AS subtype was reclassified based on LVSVi by 4D-CCT, warranting further research to establish its clinical implications and optimal thresholds in severe AS management.