Bioprosthetic aortic valve replacement in patients aged 50 years old and younger: Structural valve deterioration at long-term follow-up. Retrospective study

Background

Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR).

Methods

We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment.

Results

The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival.

Conclusions

In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.

Safety, Efficacy and Long-Term Outcomes of Patients Treated with the Occlutech Paravalvular Leak Device for Significant Paravalvular Regurgitation

Between December 2014 and March 2021, 144 patients with aortic (Ao) or mitral (Mi) paravalvular leaks (PVLs) were enrolled at 21 sites in 10 countries. Safety data were available for 137 patients, who were included in the safety analysis fraction (SAF), 93 patients with Mi PVLs and 44 patients with Ao PVLs. The full analysis set (FAS) comprised 112 patients with available stratum (aortic/mitral leak) as well as baseline (BL), 180-day or later assessments (2 years). Procedural success (implantation of the device with a proper closure of the PVL, defined as reduction in paravalvular regurgitation of ≥one grade as assessed by echocardiography post implantation) was achieved in 91.3% of FAS patients with Mi PVLs and in 90.0% of those with Ao PVLs. The proportion of patients suffering from significant or severe heart failure (HF), classified as New York Heart Association (NYHA) class III/IV, decreased from 80% at baseline to 14.1% at 2-year follow-up (FAS). The proportion of FAS patients needing hemolysis-related blood transfusion decreased from 35.5% to 3.8% and from 8.1% to 0% in Mi patients and Ao patients, respectively. In total, 35 serious adverse events (SAEs) were reported in 27 patients (19.7%) of the SAF population. The SAEs considered possibly or probably related to the device included device embolization (three patients), residual leak (two patients) and vascular complication (one patient). During follow-up, 12/137 (8.8%) patients died, but none of the deaths was considered to be device-related. Patients implanted with the Occlutech Paravalvular Leak Device (PLD) showed long-lasting improvements in clinical parameters, including NYHA class and a reduced dependency on hemolysis-related blood transfusions.

Exercise oxygen pulse kinetics in patients with hypertrophic cardiomyopathy

OBJECTIVES

Reduced cardiac output (CO) has been considered crucial in symptoms' genesis in hypertrophic cardiomyopathy (HCM). Absolute value and temporal behaviour of O₂-pulse (oxygen uptake/heart rate (VO₂/HR)), and the VO₂/work relationship during exercise reflect closely stroke volume (SV) and CO changes, respectively. We hypothesise that adding O₂-pulse absolute value and kinetics, and VO₂/work relationship to standard cardiopulmonary exercise testing (CPET) could help identify more exercise-limited patients with HCM.

METHODS

CPETs were performed in 3 HCM dedicated clinical units. We retrospectively enrolled non-end-stage consecutive patients with HCM, grouped according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva manoeuvre (72% of patients with LVOTO <30; 10% between 30 and 49 and 18% ≥50 mm Hg). We evaluated the CPET response in HCM focusing on parameters strongly associated with SV and CO, such as O₂-pulse and VO₂, respectively, considering their absolute values and temporal behaviour during exercise.

RESULTS

We included 312 patients (70% males, age 49±18 years). Peak VO₂ (percentage of predicted), O₂-pulse and ventilation to carbon dioxide production (VE/VCO₂) slope did not change across LVOTO groups. Ninety-six (31%) patients with HCM presented an abnormal O₂-pulse temporal behaviour, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106±45 vs 130±49 W), VO₂ (21.3±6.6 vs 24.1±7.7 mL/min/kg; 74%±17% vs 80%±20%) and O₂-pulse (12 (9-14) vs 14 (11-17) mL/beat), with higher VE/VCO₂ slope (28 (25-31) vs 27 (24-31)) (p<0.005 for all). Only 2 patients had an abnormal VO₂/work slope.

CONCLUSION

None of the frequently used CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal temporal behaviour of O₂-pulse during exercise, which is strongly related to inadequate SV increase, correlates with reduced functional capacity (peak and anaerobic threshold VO₂ and workload) and increased VE/VCO₂ slope, identifying more advanced disease irrespectively of LVOTO.

ROLE OF CARDIOPULMONARY EXERCISE TEST IN THE PREDICTION OF HEMODYNAMIC IMPAIRMENT IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION

Periodic repetition of right heart catheterization (RHC) in pulmonary arterial hypertension (PAH) can be challenging. We evaluated the correlation between RHC and cardiopulmonary exercise test (CPET) aiming at CPET use as a potential noninvasive tool for hemodynamic burden evaluation. One hundred and forty‐four retrospective PAH patients who had performed CPET and RHC within 2 months were enrolled. The following analyses were performed: (a) CPET parameters in hemodynamic variables tertiles; (b) position of hemodynamic parameters in the peak end‐tidal carbon dioxide pressure (P_ETCO₂) versus ventilation/carbon dioxide output (VE/VCO₂) slope scatterplot, which is a specific hallmark of exercise respiratory abnormalities in PAH; (c) association between CPET and a hemodynamic burden score developed including mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), cardiac index, and right atrial pressure. VE/VCO₂ slope and peak P_ETCO₂ significantly varied in mPAP and PVR tertiles, while peak oxygen uptake (peak VO₂) and O₂ pulse varied in the tertiles of all hemodynamic parameters. P_ETCO₂ versus VE/VCO₂ slope showed a strong hyperbolic relationship (R² = 0.7627). Patients with peak P_ETCO₂ > median (26 mmHg) and VE/VCO₂ slope < median (44) presented lower mPAP and PVR (p < 0.005) than patients with peak P_ETCO₂ < median and VE/VCO₂ slope > median. Multivariate analysis individuated peak VO₂ (p = 0.0158) and peak P_ETCO₂ (p = 0.0089) as hemodynamic score independent predictors; the formula 11.584 − 0.0925 × peak VO₂ − 0.0811 × peak P_ETCO₂ best predicts the hemodynamic score value from CPET data. A significant correlation was found between estimated and calculated scores (p < 0.0001), with a precise match for patients with mild‐to‐moderate hemodynamic burden (76% of cases). The results of the present study suggest that CPET could allow to estimate the hemodynamic burden in PAH patients.

The Role of Multimodality Imaging in Left-Sided Prosthetic Valve Dysfunction

Prosthetic valve (PV) dysfunction (PVD) is a complication of mechanical or biological PV. Etiologic mechanisms associated with PVD include fibrotic pannus ingrowth, thrombosis, structural valve degeneration, and endocarditis resulting in different grades of obstruction and/or regurgitation. PVD can be life threatening and often challenging to diagnose due to the similarities between the clinical presentations of different causes. Nevertheless, identifying the cause of PVD is critical to treatment administration (thrombolysis, surgery, or percutaneous procedure). In this report, we review the role of multimodality imaging in the diagnosis of PVD. Specifically, this review discusses the characteristics of advanced imaging modalities underlying the importance of an integrated approach including 2D/3D transthoracic and transesophageal echocardiography, fluoroscopy, and computed tomography. In this scenario, it is critical to understand the strengths and weaknesses of each modality according to the suspected cause of PVD. In conclusion, for patients with suspected or known PVD, this stepwise imaging approach may lead to a simplified, more rapid, accurate and specific workflow and management.

229 Long-term clinical and echocardiographic outcome following TAVR in patients with severe aortic stenosis and different transvalvular flow state

Aims

Haemodynamic classifications of severe aortic stenosis (AS) have important prognostic implications, with low flow state (defined on the basis of a stroke volume index, SVi&lt;35 mL/m2) known to be a predictor of worse prognosis. As transcatheter aortic valve replacement (TAVR) has become widely used for patients with severe AS, issues were raised concerning its efficacy in patients with different haemodynamic classifications combining transvalvular flow state and pressure gradients. In fact, data on TAVR outcomes in patients with low gradient (LG) AS are limited and in some cases controversial. The aim of this study was to evaluate the efficacy and long-term clinical and echocardiographic outcome of TAVR in patients with different transvalvular flow-gradient patterns.

Methods

In this single centre study, 1078 patients (mean age 81±7 years) with severe symptomatic AS (AVA&lt;1 cm2) undergoing TAVR were categorized according to flow-gradient patterns as follow: 867 patients (80%) with normal flow-high gradient (NF-HG: mean transaortic gradient DP mean&gt;40 mmHg), 94 (9%) with paradoxical low flow LG (pLF-LG: DP mean&lt;40 mmHg, ejection fraction EF &gt; 50%, and SVi&lt;35 mL/m2), and 117 (11%) classical LF-LG (DP mean&lt;40 mmHg, EF &lt; 50%, SVi&lt;35 mL/m2).

Results

TAVR was feasible in all AS subtypes with similar rate of unsuccessful procedure (1.3% NF-HG, 1.1% pLF-LG, 0% LF-LG P=470). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group (Figure A). Overall, intraoperative (P=957) and 30-day mortality (P=817) did not differ significantly among the 3 groups. Longer follow-up showed that, compared to NF-HG patients, pLF-LG had similar all-cause mortality rate [HR 1.35(0.95–1.90), P=0.094] up to 5 years and LF-LG had a significant higher mortality rate [HR 1.89(1.43–2.49), P&lt;0.001],(Figure B). Moreover, LF-LG patients had higher rehospitalization for heart failure (NF-HG: 3%, pLF-LG: 6%, LF-LG 10%, P=0.001).

Conclusions

We provided evidence that TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. A careful haemodynamic classifications of severe AS is of utmost importance for identifying patients who benefits the most from TAVR procedure.

53 Exercise oxygen kinetic in hypertrophic cardiomyopathy: results from a multicentre cardiopulmonary exercise testing study

Aims

Reduced cardiac output (CO) has been considered crucial in symptoms’ genesis in hypertrophic cardiomyopathy (HCM). We evaluated the cardiopulmonary exercise testing (CPET) response in HCM focusing on parameters strongly associated with stroke volume (SV) and cardiac output (CO), such as oxygen uptake (VO2) and O2-pulse, considering both their absolute values and temporal behaviour during physical exercise.

Methods and results

We enrolled 312 non-end stage HCM patients, divided according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva manoeuver (72% with LVOTO &lt; 30; 10% between 30 and 49; and 18% ≥50 mmHg). Peak VO2 (percent of predicted), O2-pulse, and ventilation to carbon dioxide production (VE/VCO2) slope did not change across LVOTO groups. Ninety-six (31%) HCM patients presented an abnormal O2-pulse temporal behaviour, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106 ± 45 vs. 130 ± 49 W), VO2 (74 ± 17% vs. 80 ± 20%) and O2-pulse (12 [9–14] vs. 14 [11–17]ml/beat), with higher VE/VCO2 slope (28 [25–31] vs. 27 [24–31]) (P &lt; 0.005 for all). Only two patients had an abnormal VO2/work slope.

Conclusions

None of CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal O2-pulse exercise behaviour, which is strongly related to inadequate SV during exercise, correlates with reduced functional capacity (peak and anaerobic threshold VO2 and workload) and increased VE/VCO2 slope, helping identifying more advanced disease irrespectively of LVOTO. Adding O2-pulse kinetics evaluation to standard CPET could lead to a potential incremental benefit in terms of HCM prognostic stratification and, then, therapeutic management.

Feasibility and Accuracy of the Automated Software for Dynamic Quantification of Left Ventricular and Atrial Volumes and Function in a Large Unselected Population

We aimed to evaluate the feasibility and accuracy of machine learning-based automated dynamic quantification of left ventricular (LV) and left atrial (LA) volumes in an unselected population. We enrolled 600 unselected patients (12% in atrial fibrillation) clinically referred for transthoracic echocardiography (2DTTE), who also underwent 3D echocardiography (3DE) imaging. LV ejection fraction (EF), LV, and LA volumes were obtained from 2D images; 3D images were analyzed using dynamic heart model (DHM) software (Philips) resulting in LV and LA volume–time curves. A subgroup of 140 patients also underwent cardiac magnetic resonance (CMR) imaging. Average time of analysis, feasibility, and image quality were recorded, and results were compared between 2DTTE, DHM, and CMR. The use of DHM was feasible in 522/600 cases (87%). When feasible, the boundary position was considered accurate in 335/522 patients (64%), while major (n = 38) or minor (n = 149) border corrections were needed. The overall time required for DHM datasets was approximately 40 seconds. As expected, DHM LV volumes were larger than 2D ones (end-diastolic volume: 173 ± 64 vs. 142 ± 58 mL, respectively), while no differences were found for LV EF and LA volumes (EF: 55% ± 12 vs. 56% ± 14; LA volume 89 ± 36 vs. 89 ± 38 mL, respectively). The comparison between DHM and CMR values showed a high correlation for LV volumes (r = 0.70 and r = 0.82, p < 0.001 for end-diastolic and end-systolic volume, respectively) and an excellent correlation for EF (r = 0.82, p < 0.001) and LA volumes. The DHM software is feasible, accurate, and quick in a large series of unselected patients, including those with suboptimal 2D images or in atrial fibrillation.

Rest and exercise oxygen uptake and cardiac output changes 6 months after successful transcatheter mitral valve repair

Aims

Changes in peak exercise oxygen uptake (VO₂) and cardiac output (CO) 6 months after successful percutaneous edge‐to‐edge mitral valve repair (pMVR) in severe primary (PMR) and functional mitral regurgitation (FMR) patients are unknown.

The aim of the study was to assess the efficacy of pMVR at rest by echocardiography, VO₂ and CO (inert gas rebreathing) measurement and during cardiopulmonary exercise test with CO measurement.

Methods and results

We evaluated 145 and 115 patients at rest and 98 and 66 during exercise before and after pMVR, respectively.

After successful pMVR, significant reductions in MR and NYHA class were observed in FMR and PMR patients. Cardiac ultrasound showed reverse remodelling (left ventricular end‐diastolic volume from 158 ± 63 mL to 147 ± 64, P < 0.001; ejection fraction from 51 ± 15 to 48 ± 14, P < 0.001; pulmonary artery systolic pressure (PASP) from 43 ± 13 to 38 ± 8 mmHg, P < 0.001) in the entire population. These changes were significant in PMR (n = 62) and a trend in FMR (n = 53), except for PASP, which decreased in both groups. At rest, CO and stroke volume (SV) increased in FMR with a concomitant reduction in arteriovenous O₂ content difference [ΔC(a‐v)O₂]. Peak exercise, CO and SV increased significantly in both groups (CO from 5.5 ± 1.4 L/min to 6.3 ± 1.5 and from 6.2 ± 2.4 to 6.7 ± 2.0, SV from 57 ± 19 mL to 66 ± 20 and from 62 ± 20 to 69 ± 20, in FMR and PMR, respectively), whereas peak VO₂ was unchanged and ΔC(a‐v)O₂ decreased.

Conclusions

These data confirm pMVR‐induced clinical improvement and reverse ventricular remodelling at a 6‐month analysis and show, in spite of an increase in CO, an unchanged exercise performance, which is achieved through a ‘more physiological’ blood flow distribution and O₂ extraction behaviour. Direct rest and exercise CO should be measured to assess pMVR efficacy.

Catheter-based Closure of a Post-infective Aortic Paravalvular Pseudoaneurysm Fistula With Severe Regurgitation After Two Valve Replacement Surgeries: A Case Report

Backgsround: Infective endocarditis (IE) of prosthetic valves is a dire complication of cardiac valve replacement surgery and is associated with high rates of morbidity and mortality. Case Summary: A 72-year-old woman with multiple comorbidities underwent surgical replacement of the aortic valve with a mechanical prosthetic valve after recurrent IE. After 10 years, IE recurred and the mechanical valve was surgically replaced with a bioprosthetic valve. Ten years later, severe heart failure developed due to severe paravalvular leak (PVL) caused by an aortic annulus abscess complicated by a paravalvular pseudoaneurysm fistula (PPF). The patient was deemed at prohibitive surgical risk and a catheter-based PVL closure procedure was planned. However, the interventional procedure was delayed several months due to the Covid-19 pandemic with progressive heart failure worsening. Despite an acute satisfactory result of the PPF transcatheter closure and a significant clinical improvement, the patient died 10 months later due to multiorgan failure. It is likely that this was due, at least in part, to the long treatment delay caused by the unprecedented strain on the healthcare system. Discussion: In patients at high surgical risk, early diagnosis and prompt interventional treatment of severe PVL are crucial for improving expectancy and quality of life. However, the recent outbreak of COVID-19 caused deferral of elective and semi-elective structural heart disease procedures (SHD) as in our case. Thus, a proactive and vigilant stance on managing SHD should be a priority even in the context of the COVID-19 pandemic.

Detection of Mechanical Prosthetic Valve Dysfunction

The long-term outcome of mechanical aortic and mitral prosthetic valve (A-PV, M-PV) dysfunction (PVD) remains a serious complication associated with high morbidity and mortality. We sought to evaluate the incremental diagnostic value of combined transthoracic echocardiography (TTE) and fluoroscopy (F) in patients with suspected PVD. A total of 354 patients (178 A-PV, 176 M-PV) were imaged by TTE and F within 5 days of hospital admission. PVD was confirmed by transesophageal echocardiography, computed tomography, effective thrombolysis, or surgical inspection. PVD was confirmed in 101 patients (57%) with M-PV and 99 (55%) with A-PV. Regardless of the mechanism of PVD, TTE shows good sensitivity and specificity, with accuracy of 80% for M-PV and 91% for A-PV. F shows high specificity, but low sensitivity with accuracy of 68% for M-PV and 78% for A-PV. The integration of TTE + F significantly improved accuracy both for M-PV (83%) and A-PV (96%). At ROC analysis, the combined model of TTE + F showed the highest area under the curve for the detection of PVD compared with TTE and F alone (p < 0.001). In conclusion, in patients with a clinical suspicion of PVD, the combined model of TTE + F offers incremental value over TTE or F alone. This multimodality imaging approach overcomes limitations of TTE or F alone and provides prompt identification of patients who may require further imaging assessment and/or closer follow up.

Tricuspid annular dilation in patients undergoing early mitral valve surgery: is it an old story?

Patients with mitral valve prolapse (MVP), undergoing early surgery for severe regurgitation, are usually characterized by a low degree of right chambers' remodeling. In this selected population, the mechanisms leading to tricuspid annular (TA) dilatation (TAD) are not well understood. In this setting, we aimed to evaluate, using three-dimensional echocardiography (3DE), how right chambers affect TA size and might contribute to functional tricuspid regurgitation (FTR) progression. We studied 159 patients treated with early isolated surgery for MVP, characterized by: sinus rhythm; normal biventricular function; normal or elevated pulmonary artery pressure; tricuspid regurgitation (TR) ≤ mild; no concomitant cardiac disease. All patients reached a 3-year echocardiographic follow-up. Based on two-dimensional echocardiography, patients were divided in Group 1 (N = 68, 43%, TAD, TA ≥ 21 mm/m²) and Group 2 (N = 91, 57%, no TAD, TA < 21 mm/m²). By 3DE, Group 1 showed larger TA size, right atrial (RA) volume and right ventricular (RV) conical remodeling compared to Group 2 (p < 0.05). The multivariate analysis revealed that RA volume, RV basal diameter and function were independently correlated to TA size (p < 0.05). At the 3-year follow-up there was a low incidence of FTR, with a trend towards FTR progression in Group 1 (p = 0.07). In patients undergoing early surgery for MVP, TAD seems to result from distinctive early-onset geometrical changes of the right chambers, preceding TR, RV dilatation and pulmonary hypertension at rest. An integrated approach, including right chambers' assessment by 3DE, might help to better recognized patients at higher risk for TAD and, potentially for FTR.

Predicting Long-Term Mortality in TAVI Patients Using Machine Learning Techniques

Background: Whereas transcatheter aortic valve implantation (TAVI) has become the gold standard for aortic valve stenosis treatment in high-risk patients, it has recently been extended to include intermediate risk patients. However, the mortality rate at 5 years is still elevated. The aim of the present study was to develop a novel machine learning (ML) approach able to identify the best predictors of 5-year mortality after TAVI among several clinical and echocardiographic variables, which may improve the long-term prognosis. Methods: We retrospectively enrolled 471 patients undergoing TAVI. More than 80 pre-TAVI variables were collected and analyzed through different feature selection processes, which allowed for the identification of several variables with the highest predictive value of mortality. Different ML models were compared. Results: Multilayer perceptron resulted in the best performance in predicting mortality at 5 years after TAVI, with an area under the curve, positive predictive value, and sensitivity of 0.79, 0.73, and 0.71, respectively. Conclusions: We presented an ML approach for the assessment of risk factors for long-term mortality after TAVI to improve clinical prognosis. Fourteen potential predictors were identified with the organic mitral regurgitation (myxomatous or calcific degeneration of the leaflets and/or annulus) which showed the highest impact on 5 years mortality.

Proper Selection Does Make the Difference: A Propensity-Matched Analysis of Percutaneous and Surgical Cut-Down Transfemoral TAVR

Background. Transcatheter aortic valve replacement (TAVR) is an established technique to treat severe symptomatic aortic stenosis patients with a wide range of surgical risk. Currently, the common femoral artery is the first choice as the main access route for the procedure. The objective of this observational study is to report our experience on percutaneous and surgical cut-down transfemoral TAVRs comparing the two approaches. Methods. From January 2014 to January 2019, five hundred eleven consecutive patients underwent TAVR for severe symptomatic aortic stenosis. We analyzed only elective transfemoral procedures. After propensity score-matching based on age, sex, EuroSCORE II, mean aortic gradient, and left ventricular ejection fraction, we obtained two homogeneous populations: surgical cut-down (n = 119) and percutaneous (n = 225), which were labeled Group 1 and Group 2, respectively. Results. The main findings were that there were no significant procedural outcome differences between the two groups, but Group 2 patients had a shorter length of hospital stay and were more frequently discharged home. At follow-up, Group 1 patients had lower survival rates. Conclusions. An accurate preoperative assessment of the femoral access is mandatory to achieve satisfactory outcomes with transfemoral TAVRs. Nevertheless, the percutaneous approach allows shorter in-hospital stay and the need for rehabilitation, thus potentially decreasing the costs of the procedure.

Prosthesis-patient mismatch after aortic valve in valve procedure: incidence, predictors and clinical outcomes

Funding Acknowledgements

Type of funding sources: None.

Background. Transcatheter aortic valve-in-valve (TAVI ViV) implantation is an appealing treatment option for patients with degenerated bioprostheses. However, elevated residual gradients after TAVI ViV procedure are very common. These are an unwanted effects of prosthesis-patient mismatch (PPM). Currently, the actual incidenceof PPM, its predictors and its clinical outcomes have not been completely investigated.

Purpose. The aims of this study was to investigate the incidence, predictors and clinical outcome of PPM and therefore of elevated gradients after TAVI ViV.

Methods. 75 patients (age 78 ± 9 years, 36 male), who underwent TAVI-ViV due to failed aortic biological valve (60 stented, 15 stentless), were enrolled. Mechanism of bioprosthetic valve failure was stenosis (34 cases, 45%), regurgitation (24 cases, 32%) or combination (17 cases, 23%). Elevated residual gradients were defined as a mean DP&gt; 20 mmHg. PPM was identified by the indexed effective orifice area (EOAi) measured by echocardiography (moderate PPM if 0.65 &lt; EOAi &lt; 0.85 cm²/m²; severe PPM if EOAi &lt; 0.6 cm²/m²).

Results. ViV TAVI was feasible in all patients, 33 patients (44%) were implanted with a balloon-expandable valve and 42 (56%) with a self-expandable valve. Post-procedural post-ballooning was performed in 16 out of 42 patients (38%) receiving a self-expandable valve. Post-operative mean DP&gt; 20 mmHg was found in 35 patients (48%). Moderate PPM was found in 24 cases (33%) and severe PPM in 15 (20%). A logistic regression analyses identified small size of surgical prosthesis (size &lt; 23 mm) [OR: 6.061(2.127-17.267), p = 0.001] and failed stented valve [OR: 20.727(2.522-170.364), p = 0.005] as independent predictors for the occurrence PPM. Interestingly PPM did not affect early and 1 years mortality (1 years mortality 1.3 %), while mortality was higher in pts with stentless prostheses (9%)

Conclusions. PPM is a frequent finding after ViV procedures. Despite elevated residual gradients, TAVI ViV resolved prosthetic dysfunction and PPM did not affect mortality.  Therefore, this procedure represents a promising new option for patients with failed biological prosthetic valves.

Feasibility and accuracy of the automated software for dynamic quantification of left ventricular and atrial volumes and function in a large unselected population

Funding Acknowledgements

Type of funding sources: None.

Objective. Preliminary studies showed the accuracy of machine learning based automated dynamic quantification of left ventricular (LV) and left atrial (LA) volumes. We aimed to evaluate the feasibility and accuracy of machine learning based automated dynamic quantification of LV and LA volumes in an unselected population.

Methods. We enrolled 600 unselected patients (12% in atrial fibrillation) clinically referred for transthoracic echocardiography (2DTTE), who also underwent 3D echocardiography (3DE) imaging. LV ejection fraction (EF), LV and LA volumes were obtained from 2D images; 3D images were analysed using Dynamic Heart Model (DHM) software (Philips) resulting in LV and LA volume-time curves. A subgroup of 140 patients underwent also cardiac magnetic resonance (CMR) imaging. Average time of analysis, feasibility, and image quality were recorded and results were compared between 2DTTE, DHM and CMR.

Results. The use of DHM was feasible in 522/600 cases (87%). When feasible, the boundary position was considered accurate in 335/522 patients (64%), while major (n = 38) or minor (n = 149) borders corrections were needed. The overall time required for DHM datasets was approximately 40 seconds, resulting in physiologically appearing LV and LA volume–time curves in all cases. As expected, DHM LV volumes were larger than 2D ones (end-diastolic volume: 173 ± 64 vs 142 ± 58 mL, respectively), while no differences were found for LV EF and LA volumes (EF: 55%±12 vs 56%±14; LA volume 89 ± 36 vs 89 ± 38 mL, respectively). The comparison between DHM and CMR values showed a high correlation for LV volumes (r = 0.70 and r = 0.82, p &lt; 0.001 for end-diastolic and end-systolic volume, respectively) and an excellent correlation for EF (r= 0.82, p &lt; 0.001) and LA volumes.

Conclusions. The DHM software is feasible, accurate and quick in a large series of unselected patients, including those with suboptimal 2D images or in atrial fibrillation.

Table 1 DHM quality Adjustment Feasibility Good Suboptimal Minor Major Total of patients (n, %) 522/600 (87%) 327/522 (62%) 195/522 (28%) 149/522 (29%) 38/522 (6%) Normal subjects (n, %) 39/40 (97%) 23/39 (57%) 16/39 (40%) 9/39 (21%) 1/39 (3%) Atrial Fibrillation (n, %) 59/73 (81%)* 28/59 (47%) 31/59 (53%) 15/59 (25%) 6/59 (10%) Valvular disease (n, %) 271/312 (87%) 120/271 (%) 151/271 (%) 65/271 (24%) 16/271 (6%) Coronary artery disease (n, %) 47/58 (81%)* 26/47 (46%) 21/47 (37%) 16/47 (34%) 5/47 (11%) Miscellaneous (n, %) 24/25 (96%) 18/24 (75%) 6/24 (25%) 5/24 (21%) 3/24 (12%) Feasibility of DHM, image quality and need to adjustments in global population and in each subgroup. Abstract Figure 1

Role of the tricuspid annulus in functional tricuspid regurgitation development after early isolated mitral valve surgery: is it an old story?

Funding Acknowledgements

Type of funding sources: None.

Background. Functional Tricuspid Regurgitation (FTR) has been described as a common condition after isolated mitral valve (MV) surgery, affecting patients’ prognosis. Thus, in cases without significant tricuspid regurgitation (TR) but tricuspid annular (TA) dilatation, TV annuloplasty is currently recommended. Studies suggesting the currently used cut-off for definition of TA dilatation were based on 2D echocardiography (2DE) and included patients treated with MV surgery with heterogeneous MV disease, degree of cardiac remodeling and heart rhythm. As the management of severe MR has moved towards an earlier surgical treatment, few data are available about the incidence of FTR in the population undergoing early isolated MV surgery without TR, but 2DE satisfying criteria for TA dilatation.  

Aims. To test, in patients treated with early isolated MV surgery for MV prolapse (MVP), without TR and either normal or dilated TA (i) if the currently used 2D TA cut-off is predictive of FTR and cardiac events development (ii) how right chambers’ remodeling assessed by 3D echocardiography (3DE) affects TA dimension.

Methods. We studied 159 patients (age 61 ± 11) treated with early isolated MV surgery between 2010 and 2017. Eligible patients were those with 3DE images; normal left and right ventricular (LV and RV) function; sinus rhythm; normal or elevated right ventricular systolic pulmonary artery pressure (sPAP); normal or dilated TA by 2DE; absent TR. The decision to not perform TV annuloplasty in patients with TA dilatation was based on the surgical inspection. All patients underwent a complete 2DE, 3DE analysis was performed using custom software, including LV, RV, left atrial (LA) and right atrial (RA) assessment. 3D TA dimension were obtained using MPR. Clinical and 2DE follow-up was performed at 36 ± 6 months after surgery, major adverse cardiac events (MACEs, including cardiac hospitalization, cardiac death, arrhythmias) and FTR were recorded.

Results. Based on 2DE TA dimensions, patients were divided in group 1 (N = 68, 43%, TA≥21 mm/m²) and group 2 (N= 91, 57%, normal TA). Patients in group 1 showed larger RA volume, RV basal diameter and TA area (p &lt; 0.05) by 3DE compared to group 2 (Table). At the multivariate analysis, only the 3D RA volume, RV basal diameter and RV function were independently correlated to the TA area (p &lt; 0.05). At the follow-up, no differences were noted between groups in FTR development and MACEs at the Kaplan-Meier analysis (Fig.). At the COX analysis, 2DE TA dilatation failed to result a predictor of cardiovascular events (model’s X2, p &gt; 0.05).

Conclusions. In patients undergoing early MV surgery, the currently defined TA dilatation by 2DE may not necessarily evolve in FTR, and a larger cut-off may be needed. In this population, the evaluation of right chambers’ dimension and function may better define the probability to develop FTR.

Abstract Figure. Fig

Novelties in 3D Transthoracic Echocardiography

Cardiovascular imaging is developing at a rapid pace and the newer modalities, in particular three-dimensional echocardiography, allow better analysis of heart structures. Identifying valve lesions and grading their severity represents crucial information and nowadays is strengthened by the introduction of new software, such as transillumination, which provide detailed morphology descriptions. Chambers quantification has never been so rapid and accurate: machine learning algorithms generate automated volume measurements, including left ventricular systolic and diastolic function, which is extremely important for clinical decisions. This review provides an overview of the latest innovations in the echocardiography field, and is helpful by providing a better insight into heart diseases.

Is 3D analysis of longitudinal strain useful to predict long-term cardiac events in patients undergoing early mitral valve surgery?

Background

In patients with mitral valve prolapse (MVP) and significant mitral regurgitation (MR), the presence of reduced 3D left ventricular (LV) global longitudinal strain (GLS) has already been described. However, precise data about this finding in predicting long-term cardiac events are lacking, especially in patients after MV surgery. Particularly, few data are available about the role of 3D GLS in events prediction in patients diagnosed with Barlow or Fibro-Elastic-Deficiency (FED) disease.

Aim

To determinate whether 3D LV GLS may identify a subgroup of patients with MVP and severe MR at higher risk for cardiac events after MV surgery.

Methods

We studied 143 patients diagnosed with MVP with normal LV function, who underwent isolated MV surgery between 2011 and 2017 for severe MR. A comprehensive 2D transthoracic echocardiography (TTE) analysis was performed, degree of MR was obtained using the PISA method (Proximal Isovelocity Surface Area), degree of tricuspid regurgitation was visually estimated. 3D analysis using custom software provided measurement of left atrial (LA) and right atrial (RA) dimension, right ventricular (RV) dimension and function and LV size and function including global longitudinal strain (GLS). Cardiac events (including cardiac death, arrhythmia, hospitalization for heart failure, embolic events or arrhythmia) were recorded during a follow-up of 4.6±2 years.

Results

Study patients were diagnosed with Barlow or FED in 92 (65%) and 51 (35%) of cases, respectively. The baseline 3D analysis showed left chambers dilatation with normal LV function and normal GLS, normal right chambers and systolic pulmonary artery pressure (sPAP). Based on 3D GLS, patients were divided in Group 1 (N=84, 59%, normal GLS ≥−21%) and Group 2 (N=59, 41%, reduced GLS ≤−20%). No differences were noted at baseline between groups (Table 1). At the follow-up, 43 events were recorded, including 1 death, 12 hospitalizations (3 for heart failure, 3 for embolic events and 6 for atrial fibrillation – AF) and 30 minor arrhythmic events, mostly premature ventricular complex (PVCs) and AF. The Kaplan Meier analysis showed no differences in cardiac events between groups (Figure 1, A). Among patients with Barlow, a significant difference in events was detected between patients with reduced and normal GLS at the Kaplan Meier analysis (Figure 1, B). This finding was not found in FED patients.

Conclusions

Patients undergoing MV surgery for MVP with initial LV remodeling and normal function, seem to be characterized by a low rate of major cardiac events. Interestingly, only in the Barlow population, a reduced 3D LV GLS strain may detect cases at higher risk of minor cardiac events, mostly minor arrhythmia.

Funding Acknowledgement

Type of funding source: None

T1 mapping and cardiac magnetic resonance feature tracking in mitral valve prolapse

OBJECTIVES

T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities. We sought to demonstrate that T1-map and CMR-FT may identify the presence of subclinical myocardial structural changes in patients with mitral valve prolapse (MVP).

METHODS

Consecutive MVP patients with moderate-to-severe mitral regurgitation and comparative matched healthy subjects were prospectively enrolled and underwent CMR-FT analysis to calculate 2D global and segmental circumferential (CS) and radial strain (RS) and T1-map to determine global and segmental native T1 (nT1) values.

RESULTS

Seventy-three MVP patients (mean age, 57 ± 13 years old; male, 76%; regurgitant volume, 57 ± 21 mL) and 42 matched control subjects (mean age, 56 ± 18 years; male, 74%) were included. MVP patients showed a lower global CS (- 16.3 ± 3.4% vs. - 17.8 ± 1.9%, p = 0.020) and longer global nT1 (1124.9 ± 97.7 ms vs. 1007.4 ± 26.1 ms, p < 0.001) as compared to controls. Moreover, MVP patients showed lower RS and CS in basal (21.6 ± 12.3% vs. 27.6 ± 8.9%, p = 0.008, and - 13.0 ± 6.7% vs. - 14.9 ± 4.1%, p = 0.013) and mid-inferolateral (20.6 ± 10.7% vs. 28.4 ± 8.7%, p < 0.001, and - 12.8 ± 6.3% vs. - 16.5 ± 4.0%, p < 0.001) walls as compared to other myocardial segments. Similarly, MVP patients showed longer nT1 values in basal (1080 ± 68 ms vs. 1043 ± 43 ms, p < 0.001) and mid-inferolateral (1080 ± 77 ms vs. 1034 ± 37 ms, p < 0.001) walls as compared to other myocardial segments. Of note, nT1 values were significantly correlated with CS (r, 0.36; p < 0.001) and RS (r, 0.37; p < 0.001) but not with regurgitant volume.

CONCLUSIONS

T1-map and CMR-FT identify subclinical left ventricle tissue changes in patients with MVP. Further studies are required to correlate these subclinical tissue changes with the outcome.

KEY POINTS

• T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities. • In MVP patients, we demonstrated a longer global nT1 with associated reduced global circumferential (CS) and radial strain (RS) as compared to control subjects. • Among MVP patients, the mid-basal left ventricle inferolateral wall showed longer nT1 with reduced CS and RS as compared to other myocardial segments. Further studies are required to correlate these subclinical tissue changes with the outcome.