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Jain CC, Egbe AC, Stephens EH, Connolly HM, Hagler DJ, Hilscher MB, Miranda WR. Systemic Venous Hypertension and Low Output Are Prevalent at Catheterization in Adults with Pulmonary Atresia and Intact Ventricular Septum Regardless of Repair Strategy. Semin Thorac Cardiovasc Surg 2021; 34:1312-1319. [PMID: 34688901 DOI: 10.1053/j.semtcvs.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 12/24/2022]
Abstract
Patients with pulmonary atresia and intact ventricular septum (PA-IVS) require intervention early in life, and most survive to a definitive procedure of either Fontan circulation or right ventricle to pulmonary artery (RV-PA) repair. It remains unknown how surgical strategy impacts hemodynamics and comorbidities in adults. Retrospective analysis of adults (age ≥18 years) with PA-IVS undergoing hemodynamic catheterization at Mayo Clinic, MN between January 2000 through January 2020 was performed. 14 patients in the RV-PA group (71% biventricular, 29% 1.5 ventricle repair) and 19 post-Fontan patients [9 lateral tunnel (48%), 6 atriopulmonary (32%), and 4 extracardiac (21%)] were identified. Median age was 29 (21, 34) years. There were no differences in demographics and laboratory data (including MELD-XI) between groups. All patients assessed for liver disease had evidence of hepatic congestion or cirrhosis (14 in the Fontan group and 4 in the RV-PA group). Invasive hemodynamics were comparable between groups with the Fontan and RV-PA groups having similar systemic venous pressure (15.7±4.4 vs. 14.3±6.2, p = .44) and cardiac output (2.2±0.6 vs. 2.0±0.4 L/min/m2, p = .23). There was no difference in transplant-free survival (p = .92; 5-year transplant-free survival RV-PA 84%, Fontan 80%). Hemodynamic derangements, namely elevated systemic venous pressure and low cardiac output, are prevalent in patients with PA-IVS undergoing cardiac catheterization regardless of surgical strategy.
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Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Donald J Hagler
- Division of Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Egbe AC, Miranda WR, Oh JK, Connolly HM. Prognostic implications of left heart diastolic dysfunction in adults with coarctation of aorta. Eur Heart J Cardiovasc Imaging 2021; 22:1332-1340. [PMID: 34423358 DOI: 10.1093/ehjci/jeab165] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/06/2021] [Indexed: 12/16/2022] Open
Abstract
AIMS The prognostic implication of left atrial (LA) dysfunction and left ventricular diastolic dysfunction (LVDD) in patients with coarctation of aorta (COA) is unknown. The purpose of this study was to determine whether LA dysfunction and LVDD were associated with mortality in COA patients. METHODS AND RESULTS This is a retrospective review of adults (age ≥18 years) with repaired COA that underwent transthoracic echocardiogram (2000-18). LVDD was determined using the 2016 guidelines for LV diastolic function assessment, and LA dysfunction was assessed using LA reservoir strain. Of 721 patients, LV diastolic function could be determined in 635 (88%); and 414 (65%) had no LVDD, while 146 (23%), 53 (8%), and 22 (4%) had Grade I/II/III LVDD, respectively. The mean LA reservoir strain was 39 ± 11%, and patients were divided into quartiles: top quartile (reference group), mild LA dysfunction, moderate LA dysfunction, and severe LA dysfunction. Grade III LVDD (but not Grades I and II) was associated with death/transplant. On the other hand, there was an incremental risk of death/transplant across LA strain quartiles: mild LA dysfunction [hazard ratio (HR) 1.16, 1.04-2.06], moderate LA dysfunction (HR 1.75, 1.27-3.58), and severe LA dysfunction (HR 3.49, 1.88-7.16). Of 86 patients with indeterminate diastolic function, there was a trend towards a lower 5-year transplant-free survival in patients with LA dysfunction vs. normal LA function (83% vs. 91%, P = 0.06). CONCLUSION LA dysfunction (but not LVDD) was associated with incremental risk of mortality and thus can be used for prognostication in all patients including those with indeterminate diastolic function.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Kato N, Thaden JJ, Miranda WR, Scott CG, Sarano ME, Greason KL, Pellikka PA. Impact of aortic valve replacement for severe aortic stenosis on organic and functional mitral regurgitation. ESC Heart Fail 2021; 8:5482-5492. [PMID: 34652057 PMCID: PMC8712890 DOI: 10.1002/ehf2.13649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/26/2021] [Accepted: 09/25/2021] [Indexed: 11/10/2022] Open
Abstract
Aims Concurrent mitral regurgitation (MR) influences treatment considerations in patients with severe aortic stenosis (sAS). Limited information exists regarding haemodynamic effects of sAS on MR severity and outcome of these patients. We assessed the impact of aortic valve replacement (AVR) on MR according to mechanism in patients with sAS and MR. Methods and results In patients with sAS who received surgical or transcatheter AVR from 2008 to 2017, those with effective mitral regurgitant orifice area (ERO) ≥ 10 mm2 prior to AVR were evaluated. The change in MR after AVR was considered significant when there was at least one grade difference. We compared the all‐cause mortality of patients with and without improvement in MR. Of 234 patients with sAS and MR (age 80 ± 9 years, 52% male, ERO 19 ± 7 mm2), organic and functional MR were present in 166 (71%) and 68 (29%), respectively. MR improved in 136 (58%); improvement occurred with similar frequency in organic versus functional MR (59% and 57%, P = 0.88). Associated determinants were absence of atrial fibrillation in organic MR [odds ratio (OR) 2.09, 95% confidence interval (CI) 1.00–4.37; P = 0.049] and indexed aortic valve area (iAVA) ≤ 0.40 cm2 in functional MR (OR 3.28, 95% CI 1.13–9.47; P = 0.028). In the overall cohort, mitral annulus diameter < 3 cm (OR 1.74, 95% CI 1.02–2.97; P = 0.041) and QRS duration < 115 ms (OR 1.73, 95% CI 1.00–2.98; P = 0.049) were independently associated with improvement in MR. During median follow‐up of 3.5 years, lack of improvement in MR was not associated with higher mortality in the overall cohort of patients with ERO ≥ 20 mm2 [adjusted hazard ratio (HR) 1.71, 95% CI 0.90–3.27; P = 0.10, adjusted for age, New York Heart Association III or IV, diabetes, and creatinine ≥ 2.0 mg/dL]. Lack of improvement in organic MR was associated with higher mortality (adjusted HR 3.36, 95% CI 1.40–8.05; P < 0.01). In patients with functional MR, change in MR was not associated with mortality (HR 1.24, 95% CI 0.44–3.47; P = 0.68). Conclusions In nearly 60% of patients with sAS and MR, MR improved after AVR, even in the majority of patients with organic MR. Absence of atrial fibrillation in organic MR, iAVA ≤ 0.40 cm2 in functional MR, and mitral annulus diameter < 3 cm and QRS duration < 115 ms in the overall population were associated with MR improvement. Post‐operative improvement in organic MR was associated with better survival.
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Affiliation(s)
- Nahoko Kato
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | | | - Maurice E Sarano
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
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105
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Hassler KR, Stephens EH, Miranda WR, Foley TA, Dearani JA. Intra-atrial Pulmonary Venous Conduit Leak in Criss-Cross Heart: Role of Three-Dimensional Modeling. World J Pediatr Congenit Heart Surg 2021; 13:113-116. [PMID: 34550031 DOI: 10.1177/21501351211037626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Three-dimensional (3D) modeling has become an invaluable tool for operative planning in the continually evolving complex field of adult congenital heart surgery. We present a case of an Intra-atrial conduit leak after multiple repairs of common atrium and criss-cross morphology. 3D modeling was critical in preoperative evaluation and operative planning for complicated intracardiac anatomy after an uncommon initial approach to preserve a biventricular circulation. In the setting of complex or rare congenital cardiac anomalies, advanced imaging and 3D modeling are helpful with preoperative planning.
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Affiliation(s)
- Kenneth R Hassler
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, USA
| | - Elizabeth H Stephens
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, USA
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Thomas A Foley
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, USA
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106
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Jain CC, Miranda WR, El Sabbagh A, Nishimura RA. A Simplified Method for the Diagnosis of Constrictive Pericarditis in the Cardiac Catheterization Laboratory. JAMA Cardiol 2021; 7:100-104. [PMID: 34550314 DOI: 10.1001/jamacardio.2021.3478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Enhanced ventricular interdependence is a highly sensitive and specific criterion for the diagnosis of constrictive pericarditis (CP), but simultaneous ventricular measurements can be challenging at cardiac catheterization. Ejection times (ETs) correlate with stroke volumes and can be easily measured from arterial pressure tracings. Objective To assess respirophasic changes in pulmonary artery (PA) ETs and aorta (Ao) ETs as a marker for enhanced ventricular interdependence. Design, Setting, and Participants Retrospective analysis of simultaneous left-side and right-side heart catheterizations between January 2006 and January 2017 was performed. The data were analyzed in June 2020. All catheterizations were performed at the Mayo Clinic, Rochester, Minnesota. This study evaluated patients undergoing left-side and right-side heart catheterization for assessment of CP after noninvasive evaluation was inconclusive. Main Outcomes and Measures Measurements of the PA and Ao ETs were made during inspiration and expiration. Ventricular interaction was mainly assessed by evaluating the difference of ETs from expiration to inspiration as well as the difference in Ao minus the difference in PA. Results A total of 10 patients with surgically proven CP and 10 patients without CP (restrictive cardiomyopathy or severe tricuspid regurgitation) were identified. Of these 20 included patients, 10 (50%) were female, and the median (interquartile range) age was 59.5 (47.0-67.5) years. There were no significant differences in demographic characteristics or baseline hemodynamic measurements. In patients with CP compared with those without CP, there was a significantly greater decrease in PA ET (mean [SD], -31.8 [28.6] vs 5.1 [9.5]; P < .001) and a nonsignificantly greater increase in Ao ET (mean [SD], 19.0 [15.7] vs 10.5 [9.1]; P = 0.20) during expiration vs inspiration. Thus, the difference in Ao ET minus the difference in PA ET during expiration vs inspiration was significantly greater in those with CP compared with those without CP (mean [SD], 50.8 [22.5] milliseconds vs 5.4 [15.2] milliseconds; P < .001). Conclusions and Relevance In this study, PA and Ao measurements of ETs throughout the respiratory cycle were a simple, easily obtainable, and accurate parameter for the diagnosis of CP.
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Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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107
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Egbe AC, Miranda WR, Connolly HM. Predictors of left ventricular reverse remodelling after coarctation of aorta intervention. Eur Heart J Cardiovasc Imaging 2021; 22:1168-1173. [PMID: 33020809 DOI: 10.1093/ehjci/jeaa199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/08/2020] [Indexed: 01/04/2023] Open
Abstract
AIMS Several coarctation of aorta (COA) severity indices are used for timing of COA intervention, and to define severity of residual coarctation post-intervention. However, it is unclear how many of these COA indices are required in order to recommend intervention, and what degree of residual coarctation results in suboptimal recovery of the left ventricle (LV). Our aim was to assess the correlation between different COA indices and effects of chronic LV pressure overload (LV hypertrophy, diastolic, and systolic dysfunction), and to determine the effect of residual coarctation on LV reverse remodelling after COA intervention. METHODS AND RESULTS COA severity indices were defined as Doppler COA gradient, systolic blood pressure (SBP, upper-to-lower-extremity SBP gradient, aortic isthmus ratio. LV remodelling indices were defined as LV mass index (LVMI), LV global longitudinal strain (LVGLS), e' and E/e'. LV reverse remodelling was defined as the difference between indices obtained pre-intervention and 5-year post-intervention (delta LVMI, e', E/e', LVGLS).Of the COA indices analysed in 546 adult COA patients, aortic isthmus ratio had the strongest correlation with LVMI (β ± standard error -28.3 ± 14.1, P < 0.001), LVGLS (1.51 ± 0.42, P = 0.005), e' (3.11 ± 1.10, P = 0.014), and E/e' (-13.4 ± 6.67, P = 0.008). Residual aortic isthmus ratio also had the strongest correlation with LV reverse remodelling, and residual aortic isthmus ratio <0.7 was predictive of suboptimal LV reverse remodelling post-intervention. CONCLUSION Considering the known prognostic implications of LV remodelling and reverse remodelling in response to pressure overload, these results support the use of aortic isthmus ratio for timing of COA intervention, and for prognostication post-intervention.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
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108
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Hu JJ, Bonnichsen CR, Dearani JA, Miranda WR, Johnson JN, Cetta F, Stephens EH, Aganga DO, Van Dorn CS. Adults With Tetralogy of Fallot: Early Postoperative Outcomes and Risk Factors for Complications. Mayo Clin Proc 2021; 96:2398-2406. [PMID: 34412856 DOI: 10.1016/j.mayocp.2021.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/06/2021] [Accepted: 01/26/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To report the early postoperative outcomes in adults with tetralogy of Fallot (TOF) undergoing cardiac surgery and to identify patient factors associated with complications. PATIENTS AND METHODS We performed a single-institution retrospective review of adults with TOF who underwent cardiac surgery from January 8, 2008, through June 21, 2018. Patients' characteristics, preoperative imaging, surgical interventions, outcomes, and complications were analyzed. RESULTS There were 219 adults with TOF (mean age, 40 years; range, 18-83 years; 88 [40%] female) in the study. Surgical interventions included repair or replacement of the pulmonary valve (n=199 [91%]), tricuspid valve (n=70 [32%]), mitral valve (n=13 [5.9%]), and aortic valve (n=8 [3.7%]). Three patients (1.4%) underwent first-time TOF repair. The 30-day mortality rate was 1.4% (n=3). Early postoperative complications occurred in 66 (30%) and included arrhythmias requiring treatment, dialysis requirement, liver dysfunction, respiratory failure, infection, reoperation, cardiac arrest, mechanical circulatory support, and death. Multivariate analysis found older age at current surgery (odds ratio [OR], 1.04 per year; 95% CI, 1.01 to 1.06; P<.001), longer cardiopulmonary bypass time (OR, 1.01 per minute; 95% CI, 1.01 to 1.02; P<.001), right ventricular systolic dysfunction (OR, 1.31; 95%, CI 1.02 to 1.69; P=.03), diabetes mellitus (OR, 3.50; 95% CI, 1.20 to 10.2; P=.02), and history of initial palliative surgery (OR, 1.99; 95% CI, 1.01 to 3.91; P=.05) as independent predictors of complications. CONCLUSION Surgical interventions for adult patients with TOF can be performed with low early morbidity and mortality. Clinical characteristics and preoperative testing parameters can predict risk for complications in the postoperative period.
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Affiliation(s)
- Jessie J Hu
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Jonathan N Johnson
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Frank Cetta
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | | | - Devon O Aganga
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN; Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Charlotte S Van Dorn
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN; Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Yang JH, Miranda WR, Nishimura RA, Greason KL, Schaff HV, Oh JK. Prognostic importance of mitral e' velocity in constrictive pericarditis. Eur Heart J Cardiovasc Imaging 2021; 22:357-364. [PMID: 32514577 DOI: 10.1093/ehjci/jeaa133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Increased medial mitral annulus early diastolic velocity (e') plays an important role in the echocardiographic diagnosis of constrictive pericarditis (CP) and mitral e' velocity is also a marker of underlying myocardial disease. We assessed the prognostic implication of mitral e' for long-term mortality after pericardiectomy in patients with CP. METHODS AND RESULTS We studied 104 surgically confirmed CP patients who underwent echocardiography and cardiac catheterization within 7 days between 2005 and 2013. Patients were classified as primary CP (n = 45) or mixed CP (n = 59) based on the clinical history of concomitant myocardial disease. On multivariable analysis, medial e' velocity and mean pulmonary artery pressure were independently associated with long-term mortality post-pericardiectomy. There were significant differences in survival rates among the groups divided by cut-off values of 9.0 cm/s and 29 mmHg for medial e' and mean pulmonary artery pressure, respectively (both P < 0.001). Ninety-two patients (88.5%) had elevated pulmonary artery wedge pressure (PAWP) (≥15 mmHg); there was no significant correlation between medial E/e' and PAWP (r = 0.002, P = 0.998). However, despite the similar PAWP between primary CP and mixed CP groups (21.6 ± 5.4 vs. 21.2 ± 5.8, P = 0.774), all primary CP individuals with elevated PAWP had medial E/e' <15 as opposed to 34 patients (57.6%) in the mixed CP group (P < 0.001). CONCLUSION Increased mitral e' velocity is associated with better outcomes in patients with CP. A paradoxical distribution of the relationship between E/e' and PAWP is present in these patients but there is no direct inverse correlation between them.
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Affiliation(s)
- Jeong Hoon Yang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.,Division of Cardiology, Department of Critical Care Medicine and Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.,Division of Cardiology, Department of Critical Care Medicine and Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
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Egbe AC, Miranda WR, Dearani JA, Katta RR, Goda AY, Iftikhar M, Connolly HM. Prognostic role and hemodynamic mechanism of impaired aerobic capacity in adults with Ebstein anomaly. International Journal of Cardiology Congenital Heart Disease 2021. [DOI: 10.1016/j.ijcchd.2021.100195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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111
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Egbe AC, Miranda WR, Connolly HM, Kullo IJ. Ambulatory blood pressure data is the best approximation of central aortic pressure in coarctation of aorta. International Journal of Cardiology Congenital Heart Disease 2021. [DOI: 10.1016/j.ijcchd.2021.100142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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112
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Lim K, Yang JH, Miranda WR, Chang SA, Jeong DS, Nishimura RA, Schaff H, Soo WM, Greason KL, Oh JK. Clinical significance of pulmonary hypertension in patients with constrictive pericarditis. Heart 2021; 107:1651-1656. [PMID: 34285103 DOI: 10.1136/heartjnl-2021-319149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/08/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We investigated haemodynamics and clinical outcomes according to type of pulmonary hypertension (PH) in patients with constrictive pericarditis (CP). BACKGROUND As the prevalence of CP with concomitant myocardial disease (mixed CP) grows, PH is more commonly seen in patients with CP. However, haemodynamic and outcome data according to the presence or absence of PH are limited. METHODS 150 patients with surgically confirmed CP who underwent echocardiography and cardiac catheterisation within 7 days at two tertiary centres were divided into three groups: no-PH, isolated postcapillary PH (Ipc-PH) and combined postcapillary and precapillary PH (Cpc-PH). Primary outcome was all-cause mortality during follow-up. RESULT In this retrospective cohort study, 110 (73.3%) had PH (mean pulmonary artery pressure ≥25 mm Hg). Cpc-PH, using defined cut-offs for pulmonary vascular resistance (>3 Wood units) or diastolic pulmonary gradient (≥7 mm Hg), was seen in 18 patients (12%). The Cpc-PH group had a higher prevalence of comorbidities (diabetes and atrial fibrillation) and concomitant myocardial disease as an aetiology of CP than other groups. Pulmonary vascular resistance had a significant direct correlation with medial E/e' by Doppler echocardiography (r=0.404, p<0.001). Survival rate was significantly lower in the Cpc-PH than the no-PH (p=0.002) and Ipc-PH (p=0.024) groups. On multivariable analysis, age, New York Heart Association functional class IV, medial e' velocity, Cpc-PH and Ipc-PH were independently associated with long-term mortality. CONCLUSION Combined postcapillary and precapillary PH develops in a subset of patients with CP and is associated with long-term mortality after pericardiectomy.
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Affiliation(s)
- Kyunghee Lim
- Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea (the Republic of)
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of).,Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the republoic of)
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Sung-A Chang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of)
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Seoul, Korea (the Republic of)
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Wern Miin Soo
- Department of Cardiology, National University Hospital, Singapore
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jae K Oh
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of).,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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Egbe AC, Miranda WR, Warnes CA, Bonnichsen C, Crestanello J, Anderson JH, Connolly HM. Persistent Hypertension and Left Ventricular Hypertrophy After Repair of Native Coarctation of Aorta in Adults. Hypertension 2021; 78:672-680. [PMID: 34247510 DOI: 10.1161/hypertensionaha.121.17515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
| | - William R Miranda
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
| | - Carole A Warnes
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
| | - Crystal Bonnichsen
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
| | - Juan Crestanello
- Department of Cardiovascular Surgery (J.C.), Mayo Clinic Rochester, MN
| | - Jason H Anderson
- Division of Pediatric Cardiology (J.H.A.), Mayo Clinic Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine (A.C.E., W.R.M., C.A.W., C.B., H.M.C.), Mayo Clinic Rochester, MN
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Jain CC, Nishimura RA, Newman DB, Miranda WR. Haemodynamics of left ventricular apical pouch: is Doppler obstructing us from seeing the full story? Eur Heart J Cardiovasc Imaging 2021; 22:e138. [PMID: 34245251 DOI: 10.1093/ehjci/jeab121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Darrell B Newman
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Miranda WR, Newman DB, Eleid MF, Nishimura RA, Schaff HV. Mid-Cavitary Obstruction in Hypertrophic Cardiomyopathy: Diagnostic Findings at Catheterization. Mayo Clin Proc 2021; 96:1684-1686. [PMID: 34088429 DOI: 10.1016/j.mayocp.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/13/2021] [Indexed: 11/26/2022]
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Egbe AC, Miranda WR, Devara J, Iftikhar M, Shaik L, Katta RR, Connolly HM. Effect of Combined Ventricular-Arterial Stiffening on Exercise Hemodynamics in Adults With Repaired Coarctation of Aorta. CJC Open 2021; 3:603-608. [PMID: 34027365 PMCID: PMC8134908 DOI: 10.1016/j.cjco.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
Background Patients with coarctation of aorta (COA) have arterial stiffening, and this is associated with impaired cardiac reserve and hypertensive systolic blood pressure (SBP) response during exercise. However, whether patients with COA have concomitant left ventricular (LV) stiffening and the potential impact of combined ventricular-arterial stiffening on exercise hemodynamics are unknown. Methods We studied 174 patients with repaired COA (aged 39 ± 11 years and male 103 [59%]) and 174 matched controls. Our study hypotheses are: (1) patients with COA have higher ventricular-arterial stiffness (end-systolic elastance [Ees] and arterial elastance [Ea]) as compared with controls; (2) ventricular-arterial stiffness was associated with LV stroke volume augmentation (ΔLVSV) and SBP augmentation (ΔSBP) during exercise among patients with COA. Results Despite similar systolic SBP, patients with COA had higher Ea (1.8 ± 0.4 vs 1.4 ± 0.4 mm Hg/mL, P < 0.001), higher Ees (2.41 ± 0.65 vs 2.17 ± 0.40 mm Hg/mL, P < 0.001), but similar Ea/Ees (0.87 ± 0.29 vs 0.83 ± 0.33, P = 0.2). ΔLVSV was 6.1 ± 1.4 mL/beat. Combined ventricular-arterial stiffness had a stronger correlation with ΔLVSV as compared with Ea alone (r = −0.53 vs r = −0.41, P = 0.006) and as compared with Ees alone (r = −0.53 vs r = −0.46, P = 0.02). ΔSBP was 48 ± 21 mm Hg. Combined ventricular-arterial stiffness had a stronger correlation with ΔSBP as compared with Ea alone (r = 0.57 vs r = 0.43, P < 0.001) and as compared with Ees alone (r = 0.57 vs r = −0.39, P < 0.001). Conclusion Patients with COA had combined ventricular-arterial stiffening, and this was associated with impaired cardiac reserve and hypertensive SBP response during exercise. These findings provide foundation for further studies to determine whether drugs that reduce both ventricular and arterial stiffness will improve exercise capacity and hemodynamics in this unique population.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Janaki Devara
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Momina Iftikhar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Likhita Shaik
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Renuka Reddy Katta
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Pierre K, Adedinsewo DA, Al-Hijji M, Miranda WR, Alkhouli M, Eleid MF, Guerrero M, Pollak PM, Rihal CS, El Sabbagh A. 30-day patient reported outcomes can be predicted by change in left atrial pressure and not change in transmitral gradient following MitraClip. Catheter Cardiovasc Interv 2021; 97:1244-1249. [PMID: 33502087 DOI: 10.1002/ccd.29477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/27/2020] [Accepted: 12/13/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Change in left atrial pressure (LAP) has been shown to be associated with symptom improvement post-MitraClip; however, the association between acute procedural changes in transmitral diastolic mean gradient (MG) compared to LAP and symptom improvement is not well established. METHODS 164 consecutive patients undergoing MitraClip at Mayo Clinic between June 2014 and May 2018 were included. Preclip and postclip MG and LAP were recorded. Baseline demographics, clinical, and echocardiographic outcomes, including 30-day New York Heart Association (NYHA) functional status were obtained from patient charts. RESULTS Median age was 81.5 years (IQR: 76.3, 87), 34% were female and 94.5% had NYHA class III and IV functional status at baseline. At baseline, median MG was 4 mmHg (IQR: 3, 5) and LAP was 19 mmHg (IQR: 16, 23.5). Following MitraClip deployment, the median MG was 4 mmHg (IQR: 3, 6) and the median LAP was 17 mmHg (IQR: 14, 21), 69.5% of patients had less than moderate MR. There was no statistically significant association between change in MG and NYHA functional class at 30 days (OR = 0.95, 95% CI: 0.76-1.20). However, a reduction in LAP following MitraClip deployment was significantly associated with improvement in NYHA functional status at 30 days following adjustments for age and sex (aOR 3.36, 95% CI: 1.34-8.65). There was no significant correlation between change in mean LAP and change in MG (p = .98). CONCLUSION Unlike change in left atrial pressure, change in MG post-MitraClip was not associated with patient reported outcomes at 30 days and did not correlate with change in left atrial pressure. Long-term follow up is needed to evaluate the impact of LA pressure on symptoms.
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Affiliation(s)
- Keniel Pierre
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Mohammed Al-Hijji
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter M Pollak
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abdallah El Sabbagh
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Nkomo VT, DeSimone DC, Miranda WR. Stroke Associated With Infective Endocarditis After Transcatheter Aortic Valve Replacement Is Devastating. J Am Coll Cardiol 2021; 77:2288-2290. [PMID: 33958125 DOI: 10.1016/j.jacc.2021.03.318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 03/27/2021] [Accepted: 03/29/2021] [Indexed: 01/22/2023]
Affiliation(s)
- Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Daniel C DeSimone
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Yuan H, Medina-Inojosa JR, Lopez-Jimenez F, Miranda WR, Collazo-Clavell ML, Sarr MG, Chamberlain AM, Hodge DO, Bailey KR, Wang Y, Chen Y, Cha YM. The Long-Term Impact of Bariatric Surgery on Development of Atrial Fibrillation and Cardiovascular Events in Obese Patients: An Historical Cohort Study. Front Cardiovasc Med 2021; 8:647118. [PMID: 33928133 PMCID: PMC8076511 DOI: 10.3389/fcvm.2021.647118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/02/2021] [Indexed: 12/18/2022] Open
Abstract
Objective: To determine whether early Roux-en-Y gastric bypass surgery (RYGB) reduces the risk of Major adverse cardiovascular events (MACE) in patients with obesity. Patients and Methods: We conducted a study of patients with class II and III obesity [body mass index (BMI) > 35 kg/m2] from Olmsted County, Minnesota, who underwent obesity clinic consultation between the years 1993-2012, and had either RYGB surgery within 1 year (RYGB-1Y group), or medically managed (No-RYGB group). The composite endpoint of MACE (all-cause mortality, stroke, heart failure admission and acute myocardial infarction) was the primary endpoint, with new-onset AF as the secondary endpoint. Results: Of the 1,009 study patients, 308 had RYGB-1Y and 701 were medically managed (No-RYGB). Overall, the age was 44.0 ± 12.4 (mean ± SD) years; BMI was 45.0 ± 6.8 kg/m2. The RYGB-1Y group had a lower rate of MACE (adjusted hazard ratio (HR), 0.62; 95% CI, 0.44-0.88; P = 0.008) and lower mortality (adjusted HR, 0.51; 95% CI, 0.26-0.96; P = 0.04) than the No-RYGB group. The RYGB-1Y surgery was not associated with lower AF occurrence (HR, 0.66; 95% CI, 0.40-1.10; P = 0.11). Conclusion: An early RYGB approach for BMI reduction was associated with lower rates of MACE.
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Affiliation(s)
- Hongtao Yuan
- Department of Cardiology, Chinese People's Liberation Army General Hospital (PLAGH), Beijing, China
| | | | | | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Maria L Collazo-Clavell
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, United States
| | - Michael G Sarr
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
| | - Alanna M Chamberlain
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, United States
| | - Kent R Bailey
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
| | - Yutang Wang
- Department of Cardiology, Chinese People's Liberation Army General Hospital (PLAGH), Beijing, China
| | - Yundai Chen
- Department of Cardiology, Chinese People's Liberation Army General Hospital (PLAGH), Beijing, China
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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Egbe AC, Miranda WR, Devara J, Shaik L, Iftikhar M, Goda Sakr A, John A, Cedars A, Rodriguez F, Moore JP, Russell M, Grewal J, Ginde S, Lubert AM, Connolly HM. Recurrent sustained atrial arrhythmias and thromboembolism in Fontan patients with total cavopulmonary connection. Int J Cardiol Heart Vasc 2021; 33:100754. [PMID: 33786365 PMCID: PMC7988316 DOI: 10.1016/j.ijcha.2021.100754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 11/29/2022]
Abstract
Background Total cavopulmonary connection (TCPC) is associated with a lower risk of incident atrial arrhythmias as compared to atriopulmonary Fontan, but the risk of recurrent atrial arrhythmias is unknown in this population. The purpose of this study was to determine the incidence and risk factors for recurrent atrial arrhythmias and thromboembolic complications in patients with TCPC. Methods This is a retrospective multicenter study conducted by the Alliance for Adult Research in Congenital Cardiology (AARCC), 2000-2018. The inclusion criteria were TCPC patients (age > 15 years) with prior history of atrial arrhythmia. Results A total of 103 patients (age 26 ± 7 years; male 58 [56%]) met inclusion criteria. The mean age at initial arrhythmia diagnosis was 13 ± 5 years, and atrial arrhythmias were classified as atrial flutter/tachycardia in 85 (83%) and atrial fibrillation in 18 (17%). The median duration of follow-up from the first episode of atrial arrhythmia was 14.9 (12.1-17.3) years, and during this period 64 (62%) patients had recurrent atrial arrhythmias (atrial flutter/tachycardia 51 [80%] and atrial fibrillation 13 [20%]) with annual incidence of 4.4%. Older age was a risk factor for arrhythmia recurrence while the use of a class III anti-arrhythmic drug was associated with a lower risk of recurrent arrhythmias. The incidence of thromboembolic complication was 0.6% per year, and the cumulative incidence was 4% and 7% at 5 and 10 years respectively from the time of first atrial arrhythmia diagnosis. There were no identifiable risk factors for thromboembolic complications in this cohort. Conclusions Although TCPC provides superior flow dynamics and lower risk of incident atrial arrhythmias, there is a significant risk of recurrent arrhythmias among TCPC patients with a prior history of atrial arrhythmias. These patients may require more intensive arrhythmia surveillance as compared to other TCPC patients.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Janaki Devara
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Likhita Shaik
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Momina Iftikhar
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Ahmed Goda Sakr
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Anitha John
- Children's National Hospital, Washington DC, United States
| | - Ari Cedars
- University of Texas, Southwestern Medical Center, United States
| | - Fred Rodriguez
- Emory University Hospital and Children's Healthcare of Atlanta, GA, United States
| | - Jeremy P Moore
- Ahmanson/UCLA Adult Congenital Heart Disease Center, UCLA Medical Center, Los Angeles, CA, United States
| | - Matthew Russell
- Ahmanson/UCLA Adult Congenital Heart Disease Center, UCLA Medical Center, Los Angeles, CA, United States
| | - Jasmine Grewal
- University of British Columbia, Vancouver, United States
| | - Salil Ginde
- Children's Hospital Wisconsin, United States
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
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Egbe AC, Miranda WR, Dearani J, Connolly HM. Left Ventricular Global Longitudinal Strain Is Superior to Ejection Fraction for Prognostication in Ebstein Anomaly. JACC Cardiovasc Imaging 2021; 14:1668-1669. [PMID: 33744142 DOI: 10.1016/j.jcmg.2021.01.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/21/2021] [Accepted: 01/28/2021] [Indexed: 11/17/2022]
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Egbe AC, Miranda WR, Dearani J, Kamath PS, Connolly HM. Prognostic Role of Hepatorenal Function Indexes in Patients With Ebstein Anomaly. J Am Coll Cardiol 2021; 76:2968-2976. [PMID: 33334426 DOI: 10.1016/j.jacc.2020.10.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hepatorenal dysfunction is a risk factor for mortality in patients with chronic tricuspid regurgitation due to acquired heart disease. Ebstein anomaly is the most common cause of primary tricuspid regurgitation in adults with congenital heart disease, but the prevalence and prognostic implications of hepatorenal dysfunction are unknown in this population. OBJECTIVES The purpose of this study was to determine the risk factors and prognostic implications of hepatorenal dysfunction, as measured primarily by the use of model for end-stage liver disease excluding international normalized ratio (MELD-XI score), as well as looking at other associated factors. METHODS This was a retrospective study of adults with Ebstein anomaly who received care at Mayo Clinic from 2003 to 2018. RESULTS Of 692 patients, the median MELD-XI score was 10.2 (interquartile range: 9.4 to 13.3); 53 (8%) died and 3 (0.4%) underwent heart transplant. MELD-XI was an independent predictor of death/transplant (hazard ratio: 1.32; 95% confidence interval: 1.11 to 2.06; p < 0.001). In the subset of patients with serial MELD-XI scores (n = 416), temporal change in MELD-XI score (ΔMELD-XI) was also a predictor of death/transplant. In the subset of patients who underwent tricuspid valve surgery (n = 344), a post-operative improvement in MELD-XI score (ΔMELD-XI) was associated with improved long-term survival. Impaired right atrial (RA) reservoir strain and elevated estimated RA pressure were associated with worse baseline MELD-XI and ΔMELD-XI scores. CONCLUSIONS Hepatorenal dysfunction is a predictor of mortality in Ebstein anomaly, and RA dysfunction and hypertension are hemodynamic biomarkers that can identify patients at risk for deterioration in hepatorenal function and mortality. These data highlight the prognostic importance of noncardiac organ-system dysfunction, and provide complementary clinical risk stratification metrics for management of these patients.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Egbe AC, Miranda WR, Anderson JH, Borlaug BA. Hemodynamic and Clinical Implications of Impaired Pulmonary Vascular Reserve in the Fontan Circulation. J Am Coll Cardiol 2021; 76:2755-2763. [PMID: 33272370 DOI: 10.1016/j.jacc.2020.10.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Pulmonary vascular disease, pulmonary endothelial dysfunction, liver fibrosis, renal disease, and exercise intolerance are common in adults with Fontan physiology. Although the pathophysiologic mechanisms linking these phenomena have been studied, certain aspects are not well understood. OBJECTIVES This study hypothesized that impaired pulmonary vascular reserve (VR) plays a central role linking these abnormalities, and that patients with abnormal pulmonary VR with exercise, compared with patients with normal VR, would display poorer pulmonary endothelial function, greater liver stiffness, more renal dysfunction, and poorer exercise capacity. METHODS Symptomatic adults with the Fontan palliation (n = 29) underwent invasive cardiopulmonary exercise testing, echocardiography, and assessment of microvascular function. Abnormal pulmonary VR was defined by the slope of increase in pulmonary pressure relative to cardiac output with exercise >3 mm Hg/l/min. Pulmonary endothelial function was assessed using reactive hyperemia index. End-organ function was assessed using magnetic resonance elastography-derived liver stiffness, glomerular filtration rate, N-terminal pro-B-type natriuretic peptide, and peak oxygen consumption (Vo2). RESULTS Compared with individuals with normal VR (n = 8), those with abnormal VR (n = 21) displayed higher central and pulmonary venous pressures, and more severely impaired cardiac output and stroke volume responses to exertion, but similar pulmonary vascular resistance at rest. Patients with abnormal VR displayed more severely impaired reactive hyperemia index, increased liver stiffness, lower glomerular filtration rate, higher N-terminal pro-B-type natriuretic peptide, and lower peak Vo2. As compared to pulmonary vascular resistance at rest, slope of increase in pulmonary pressure relative to cardiac output displayed stronger correlations with reactive hyperemia index (r = -0.63 vs. r = -0.31; Meng test p = 0.009), magnetic resonance elastography-derived liver stiffness (r = 0.47 vs. r = 0.29; Meng test p = 0.07), glomerular filtration rate (r = -0.52 vs. r = -0.24; Meng test p = 0.03), N-terminal pro-B-type natriuretic peptide (r = 0.56 vs. r = 0.17; Meng test p = 0.02), and peak Vo2 (r = -0.63 vs. r = -0.26; Meng test p = 0.02). CONCLUSIONS Pulmonary vascular limitations in Fontan physiology are related to pulmonary endothelial and end-organ dysfunction, suggesting a mechanistic link between these commonly observed findings, and these abnormalities are more apparent during exercise testing, with little relationship at rest.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Egbe AC, Miranda WR, Anderson JH, Crestanello J, Warnes CA, Connolly HM. A Comparison of Hemodynamic and Clinical Outcomes After Transcatheter Versus Surgical Therapy in Adults in Coarctation of Aorta. J Invasive Cardiol 2021; 33:E191-E199. [PMID: 33570503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Transcatheter stent therapy provides similar acute reduction in coarctation of aorta (COA) gradient and systolic blood pressure (SBP) as compared with surgery. However, there are limited data comparing mid-term outcomes after transcatheter vs surgical therapy for COA. The purpose of this study was to compare temporal changes in Doppler COA gradient and SBP after transcatheter stent therapy versus surgical therapy for COA. METHODS A retrospective study of COA patients (≥18 years old) undergoing transcatheter stent therapy or surgical therapy at Mayo Clinic in Rochester, Minnesota from 2000-2018 was performed. Linear regression analyses were used to compare temporal changes in Doppler gradient and SBP between the 2 groups. Propensity matching was used to adjust for between-group differences in clinical and anatomic characteristics. RESULTS A total of 44 and 128 patients underwent transcatheter and surgical therapy, respectively; there were no significant between-group differences in the anatomy of the thoracic aorta. Both groups had similar acute reduction in Doppler peak gradient (P=.66), mean gradient (P=.41), SBP (P=.22), and upper-to-lower extremity SBP (ULE-SBP) gradient (P=.69). The median follow-up was 46 months (interquartile range, 27-81 months) and 63 months (interquartile range, 41-94 months) in the transcatheter and surgical groups, respectively. There were no significant between-group differences in the temporal change in Doppler peak gradient (P-interaction=.06), mean gradient (P-interaction=.15), SBP (P-interaction=.20), and ULE-SBP gradient (P-interaction=.51). CONCLUSIONS These favorable short- and mid-term outcome data support the use of transcatheter therapy as an alternative to surgery in adults with COA. Further studies are required to determine if these favorable outcomes are maintained on long-term follow-up.
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Affiliation(s)
- Alexander C Egbe
- Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905 USA.
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Ito S, Miranda WR, Nkomo VT, Boler AN, Pislaru SV, Pellikka PA, Crusan DJ, Lewis BR, Nishimura RA, Oh JK. Prognostic Risk Stratification of Patients with Moderate Aortic Stenosis. J Am Soc Echocardiogr 2021; 34:248-256. [DOI: 10.1016/j.echo.2020.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/12/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022]
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Egbe AC, Miranda WR, Dearani JA, Connolly HM. Hemodynamics and Clinical Implications of Occult Left Ventricular Dysfunction in Adults Undergoing Ebstein Anomaly Repair. Circ Cardiovasc Imaging 2021; 14:e011739. [PMID: 33583197 DOI: 10.1161/circimaging.120.011739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Left ventricular global longitudinal strain (LVGLS) can detect early phases of LV systolic dysfunction, but its application has not been studied in Ebstein anomaly. We hypothesized that LVGLS can detect early phases of LV systolic dysfunction and that patients with occult LV systolic dysfunction will have worse hemodynamics, end-organ dysfunction, and suboptimal postoperative LV reverse remodeling after tricuspid valve surgery in comparison to patients with normal LV systolic function. METHODS In this retrospective cohort study, 371 Ebstein patients that underwent tricuspid valve surgery were divided into 3 groups: normal LV systolic function (normal LVGLS and LV ejection fraction; n=244, 77%), occult LV systolic dysfunction (abnormal LVGLS with normal LV ejection fraction; n=44, 14%), and overt LV systolic dysfunction (abnormal LVGLS and LV ejection fraction; n=27, 9%). RESULTS Compared with the normal LV function group, the occult group had smaller LV volume and cardiac output (2.1±0.4 versus 2.9±0.6 L/min per m2, P<0.001), worse end-organ dysfunction (glomerular filtration rate, 78±14 versus 91±18 mL/min per 1.73 m2, P=0.01), and suboptimal postoperative LV reverse remodeling. Although both the occult and overt groups had a similar degree of end-organ dysfunction (glomerular filtration rate, 78±14 versus 82±16 mL/min per 1.73 m2, P=0.3), the occult group was less likely to be on heart failure therapy (48% versus 96%, P<0.001). CONCLUSIONS Abnormal LVGLS was associated with suboptimal postoperative LV reverse remodeling. These data suggest that LVGLS can potentially be used for risk stratification and provides a foundation for further studies to determine whether optimal heart failure therapy or tricuspid valve intervention can improve outcomes for LV systolic dysfunction in patients with Ebstein anomaly.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Joseph A Dearani
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Agasthi P, Miranda WR, Egbe AC. Discordance Between Measured vs Calculated Oxygen Consumption in Adults With Congenital Heart Disease: Limitations and Clinical Implications. J Invasive Cardiol 2021; 33:E100-E107. [PMID: 33531441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Oxygen consumption (VO2) is frequently estimated using derived formulas for ease of use. We performed a prospective study to assess the correlation and limits of agreement between measured and assumed VO2 (mL/min) in adults with congenital heart disease (CHD). METHODS Consecutive adults with CHD who have undergone cardiac catheterization at Mayo Clinic Rochester from January 2018 to December 2019 were retrospectively enrolled in the study. Expired gas analysis was performed to measure VO2. We estimated VO2 using LaFarge (VO2L), Dehmer (VO2D), and Bergstra (VO2B) formulas. Bland-Altman and linear-regression analyses were used to assess the correlation between measured and calculated VO2. RESULTS We enrolled 84 patients with a mean age of 43 ± 12 years; 66% were men. Linear correlation analysis showed a moderate correlation of VO2L and VO2B with VO2M (r = 0.58; P<.001 and r = 0.44; P<.01, respectively) and good correlation of VO2D with VO2M (r = 0.79; P<.001). The large spread of limits of agreement assessed using Bland-Altman analysis demonstrates poor agreement of VO2L and VO2B with VO2M (bias, -58; 95% confidence interval [CI], -258 to 48) and bias, 38; 95% CI, -91 to 167, respectively). The limits of agreement for VO2D have a large spread, demonstrating a low degree of agreement with VO2M (bias, 13; 95% CI, -64 to 89). VO2L predominantly misclassified patients as low cardiac index and VO2D and VO2B misclassified patients as normal/ high cardiac index. CONCLUSION In adults with CHD, assumed VO2 will lead to a significant error while assessing invasive intracardiac hemodynamics.
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Affiliation(s)
- Pradyumna Agasthi
- Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054 USA.
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Vaidya VR, Lyle M, Miranda WR, Farwati M, Isath A, Patlolla SH, Hodge DO, Asirvatham SJ, Kapa S, Deshmukh AJ, Foley TA, Michelena HI, Connolly HM, Melduni RM. Long-Term Survival of Patients With Left Ventricular Noncompaction. J Am Heart Assoc 2021; 10:e015563. [PMID: 33441029 PMCID: PMC7955291 DOI: 10.1161/jaha.119.015563] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background The prognosis of left ventricular noncompaction (LVNC) remains elusive despite its recognition as a clinical entity for >30 years. We sought to identify clinical and imaging characteristics and risk factors for mortality in patients with LVNC. Methods and Results 339 adults with LVNC seen between 2000 and 2016 were identified. LVNC was defined as end‐systolic noncompacted to compacted myocardial ratio >2 (Jenni criteria) and end‐diastolic trough of trabeculation‐to‐epicardium (X):peak of trabeculation‐to‐epicardium (Y) ratio <0.5 (Chin criteria) by echocardiography; and end‐diastolic noncompacted:compacted ratio >2.3 (Petersen criteria) by magnetic resonance imaging. Median age was 47.4 years, and 46% of patients were female. Left ventricular ejection fraction <50% was present in 57% of patients and isolated apical noncompaction in 48%. During a median follow‐up of 6.3 years, 59 patients died. On multivariable Cox regression analysis, age (hazard ratio [HR] 1.04; 95% CI, 1.02–1.06), left ventricular ejection fraction <50% (HR, 2.37; 95% CI, 1.17–4.80), and noncompaction extending from the apex to the mid or basal segments (HR, 2.11; 95% CI, 1.21–3.68) were associated with all‐cause mortality. Compared with the expected survival for age‐ and sex‐matched US population, patients with LVNC had reduced overall survival (P<0.001). However, patients with LVNC with preserved left ventricular ejection fraction and patients with isolated apical noncompaction had similar survival to the general population. Conclusions Overall survival is reduced in patients with LVNC compared with the expected survival of age‐ and sex‐matched US population. However, survival rate in those with preserved left ventricular ejection fraction and isolated apical noncompaction was comparable with that of the general population.
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Affiliation(s)
| | - Melissa Lyle
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | - Medhat Farwati
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Ameesh Isath
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | | | - David O Hodge
- Department of Cardiovascular Diseases Mayo Clinic Jacksonville FL
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN.,Department of Pediatrics and Adolescent Medicine Mayo Clinic Rochester MN
| | - Suraj Kapa
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
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Ito S, Dhesi S, Miranda WR, Geske JB, Anavekar NS, Morant K, Rihal CS, Eleid MF, Oh JK. Assessment of left ventricular filling pressure with Doppler velocities across the patent foramen ovale. J Echocardiogr 2021; 19:158-165. [PMID: 33438170 DOI: 10.1007/s12574-020-00509-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 12/12/2020] [Accepted: 12/24/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND The utility of Doppler velocities across the patent foramen ovale (PFO) to estimate left ventricular (LV) filling pressure is not well known. METHODS The best cut-off value of peak interatrial septal velocity across a transeptal puncture site measured by transesophageal echocardiography for estimating high mean left atrial (LA) pressure (≥ 15 mmHg) was determined in 17 patients. This cut-off value was subsequently applied to 67 patients with a PFO undergoing transthoracic echocardiography (TTE) for assessing the value of PFO velocity in determining LV filling pressure. RESULTS The peak systolic interatrial septal velocities significantly correlated with directly measured mean LA pressures during transcatheter mitral valve procedure (r = 0.77, P < 0.001). The best cut-off value was 1.7 m/s for predicting high LA pressure (AUC 0.91; sensitivity 90%, specificity 86%). When this cut-off was applied to patients undergoing TTE, peak PFO velocity ≥ 1.7 m/s correlated with reduced e', higher E/e', and higher tricuspid regurgitation velocity (P < 0.01). LV filling pressure according to the 2016 diastolic guideline was compared with peak PFO velocity in 51 patients. Among patients with high filling pressure according to the guidelines (n = 20), peak PFO velocity ≥ 1.7 m/s was present in 60% of patients. In patients with normal filling pressure per the guidelines (n = 31), PFO velocity < 1.7 m/s was present 84%. Sensitivity and specificity were 75% and 92%, respectively, in patients with sinus rhythm, but were only 50% and 57%, respectively, among patients with atrial fibrillation. CONCLUSIONS Doppler-derived peak PFO velocities could be valuable in the assessment of increased LV filling pressure using 1.7 m/s as the cut-off value.
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Affiliation(s)
- Saki Ito
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA
| | - Sumandeep Dhesi
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA
- Department of Medicine, Faculty of Medicine, Division of Cardiology at the University of British Columbia, Vancouver, BC, Canada
| | - William R Miranda
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA.
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA
| | - Kareem Morant
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, 200 First St SW, Rochester, MN, 55905, USA
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Abstract
OBJECTIVE To investigate the clinical presentation, pathophysiology, and treatment for "paroxysmal severe mitral regurgitation" (MR), which is an underappreciated cause of heart failure with preserved left ventricular ejection fraction. METHODS We retrospectively reviewed cases of transient severe MR that were evaluated at Mayo Clinic in Rochester, Minnesota, between January 1, 2006, and December 31, 2019. Paroxysmal severe MR was defined as the appearance of transient severe MR in patients with mild MR at rest, normal left ventricle (LV) size, left ventricular ejection fraction greater than 40%, and absence of obstructive coronary artery disease. RESULTS We identified 6 patients (5 women) with a median age of 68 years. There were 3 distinct mechanisms of paroxysmal severe MR, which we labeled types 1, 2, and 3. Type 1 MR was caused by LV dyssynchrony from a rate-dependent left bundle branch block, which led to apical leaflet tenting and incomplete coaptation. Type 2 MR occurred from mitral annular dilatation during maneuvers that increased left-sided volume. Type 3 MR was caused by coronary artery vasospasm with apical leaflet tenting. Treatments varied depending on the underlying cause and included cardiac resynchronization therapy for type 1, surgical valve replacement for type 2, and medical therapy for type 3. CONCLUSION Paroxysmal severe MR is a rare cause of heart failure in patients with preserved LV function. We have identified 3 distinct mechanisms that can lead to this dynamic process, with treatments varying based on the underlying cause.
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Affiliation(s)
- Thomas J Breen
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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Joseph TA, Jain CC, Miranda WR, Nishimura RA. Obstruction Before the Obstruction: Fact or Artifact? Circ Heart Fail 2020; 13:e007489. [PMID: 33070638 DOI: 10.1161/circheartfailure.120.007489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Timothy A Joseph
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Miranda WR, Jain CC, Connolly HM, DuBrock HM, Cetta F, Egbe AC, Hagler DJ. Prevalence of pulmonary hypertension in adults after atrial switch and role of ventricular filling pressures. Heart 2020; 107:heartjnl-2020-317111. [PMID: 33028672 DOI: 10.1136/heartjnl-2020-317111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/04/2020] [Accepted: 08/13/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the prevalence of elevated systemic right ventricular (sRV) end-diastolic pressure and pulmonary arterial hypertension in adults with transposition of the great arteries (TGA) who have undergone atrial switch operation. METHODS Forty-two adults (aged ≥18 years) with complete TGA and atrial switch palliation undergoing cardiac catheterisation between 2004 and 2018 at Mayo Clinic, MN, were identified. Clinical, echocardiographic and invasive haemodynamic data were abstracted from the medical charts and procedure logs. RESULTS Mean age was 37.6±7.9 years; 28 were male (67%). The Mustard operation was performed in 91% of individuals. Mean estimated sRV ejection fraction by echocardiography was 33.3%±10.9% and ≥moderate tricuspid (systemic atrioventricular valve) regurgitation was present in 15 patients (36%). Mean sRV end-diastolic pressure was 13.2±5.4 mm Hg. An sRV end-diastolic pressure >15 mm Hg was present in 35% of individuals whereas a pulmonary artery wedge pressure (PAWP) >15 mm Hg was seen in 59%. Mean pulmonary artery pressure ≥25 mm Hg was seen in 47.5% of patients with PAWP being >15 mm Hg in all but one patient. CONCLUSION In adults after atrial switch, elevated sRV end-diastolic pressure was present in only one-third of patients whereas increased PAWP was seen in almost 60%. These findings are most likely related to a combination of decreased pulmonary atrial (functional left atrium) compliance and, in a subset of patients, pulmonary venous baffle obstruction. Elevation in pulmonary pressures was highly prevalent with concomitant elevation in PAWP being present in essentially all patients.
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Affiliation(s)
- William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Frank Cetta
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Donald J Hagler
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota, USA
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Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK. Left Atrial Strain in Evaluation of Heart Failure with Preserved Ejection Fraction. J Am Soc Echocardiogr 2020; 33:1490-1499. [PMID: 32981787 DOI: 10.1016/j.echo.2020.07.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with heart failure with preserved ejection fraction (HFpEF) may have elevated left ventricular filling pressure with exercise (LVFP-ex), despite normal LVFP at rest. The aim of this study was to assess the diagnostic value of resting left atrial strain (LAS) in detecting elevated LVFP-ex in patients with dyspnea evaluated on exercise stress echocardiography. METHODS Two-dimensional speckle-tracking analysis for LAS was performed in 669 consecutive patients (mean age, 64 ± 14 years; 53% men) who underwent treadmill echocardiographic evaluation and had left ventricular ejection fractions ≥ 50%. Assessment of LVFP at rest LVFP-ex was based on the 2016 American Society of Echocardiography guidelines for diastolic function assessment. An E/e' ratio ≥ 15 after exercise is considered to indicate elevated LVFP-ex. A continuous diagnostic score of HFpEF was calculated on the basis of the European Society of Cardiology HFA-PEFF diagnostic algorithm. RESULTS LASreservoir was lowest in patients with elevated LVFP at rest (n = 81) and lower in those with normal resting filling pressure who developed elevated LVFP-ex (n = 108) compared with those who maintained normal LVFP-ex (29.0 ± 5.2% vs 33.1 ± 5.0% vs 39.3 ± 4.8%, P < .001). Lower LASreservoir was associated with worse exercise capacity as assessed by metabolic equivalents, exercise time, and functional aerobic capacity (multivariate-adjusted P values all < .05). In patients with normal or indeterminate LVFP at rest (n = 587), LASreservoir and preexercise HFA-PEFF score demonstrated areas under the curve of 0.82 and 0.7, respectively, for elevated LVFP-ex. There were 28% higher odds of developing elevated LVFP-ex per 1% decrease in LASreservoir (odds ratio, 0.78; 95% CI, 0.74-0.82). Among patients with intermediate scores (n = 461), 123 developed elevations in LVFP-ex and were classified as having HFpEF per the diagnostic algorithm. The addition of LASreservoir improved the diagnostic value of HFA-PEFF score for HFpEF (area under the curve increased from 0.71 to 0.80, P = .01). CONCLUSIONS LASreservoir has potential to identify patients with intermediate scores for HFpEF who may develop elevated LVFP-ex only and is therefore a promising alternative to aid in diagnosis when exercise testing is not feasible.
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Affiliation(s)
- Zi Ye
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darwin F Yeung
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Jain CC, Warnes CA, Egbe AC, Cetta F, DuBrock HM, Connolly HM, Miranda WR. Hemodynamics in Adults With the Shone Complex. Am J Cardiol 2020; 130:137-142. [PMID: 32703525 DOI: 10.1016/j.amjcard.2020.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/31/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022]
Abstract
Patients with Shone complex (SC) have multiple left-sided obstructive lesions and thus are at risk for left ventricular (LV) remodeling, LV diastolic dysfunction and pulmonary hypertension. Yet, to date, there has been no description of hemodynamics in adults with SC. Retrospective chart review of 25 patients with SC who underwent cardiac catheterization at Mayo Clinic, MN between 2002 and 2019 was performed. SC was defined as multiple left-sided obstructive lesions in the presence of an anatomically abnormal mitral valve. Median age was 32 years (22.5, 42) and 15 patients (60%) were female. The majority of patients (84%) had history of coarctation of the aorta, 10 (40%) had subaortic stenosis, 11 (44%) had prior aortic valve replacement, and 10 (40%) had prior mitral valve replacement. Structural disease at the time of catheterization which warranted intervention within the next year was present in 13 patients (52%). The mean LV end-diastolic pressure was 21.3 ± 9.0 mm Hg (>15 mm Hg in 71%), pulmonary artery peak systolic pressure was 55.4 ± 13.4 mm Hg, and the pulmonary artery mean pressure was 37.0 ± 9.4 mm Hg (>20 mm Hg in 96%). During a mean follow-up of 8.3 ± 4.4 years, there were 7 deaths (28%) and 3 additional patients (12%) underwent cardiac transplantation. In conclusion, adults with SC who underwent catheterization showed significant left-sided heart and pulmonary vascular remodeling. Elevated LV end-diastolic pressure and pulmonary artery pressures were highly prevalent. There were high mortality and cardiac transplant rates in our cohort.
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Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota
| | - Carole A Warnes
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota
| | | | - Frank Cetta
- Department of Cardiovascular Medicine, Mayo Clinic, Minnesota; Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Minnesota
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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Abstract
Background Thoracic aortic aneurysm is common in patients with tetralogy of Fallot (TOF); the incidence of thoracic aortic dissection (TAD) is unknown, but generally considered to be uncommon. The purpose of this study was to determine incidence and risk factors for TAD in TOF patients. Methods and Results This work is a retrospective review of the National Inpatient Sample (NIS) database for cases of ascending TAD among all hospital admissions in adults with TOF, 2000–2014. Of 18 353 admissions in TOF patients, 11 (0.06%; 6 per 10 000 admissions) of these were TAD‐related admissions. For the TAD‐related admissions, mean age was 49.8±7.2 years; aortic surgical interventions were performed during 8 of the admissions, and overall in‐hospital mortality was 45% (5 of 11). Risk factors associated with TAD‐related admission were age >60 years (odds ratio, 2.41; 95% CI, 1.23–3.25; P=0.013), male sex (odds ratio, 6.91; 95% CI, 4.85–8.54; P<0.001), and hypertension (odds ratio, 1.74; 95% CI, 1.06–3.19; P=0.037). Conclusions This is the first population‐based study of TAD outcomes in patients with TOF, and it showed a low risk of TAD in this population. This has important clinical implication with regard to surveillance and surgical intervention. Given that prevalence of thoracic aortic aneurysm is higher in TOF patients compared with the general population; therefore, making clinical decisions based on outcomes data and practice guidelines derived from patients with degenerative and bicuspid aortic valve–related aortopathies may lead to overtreatment. Further studies are required to better understand the pathobiology of this disease in order to make evidence‐based recommendations for surveillance and treatment.
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Affiliation(s)
- Alexander C Egbe
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | | | - Heidi M Connolly
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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El Sabbagh A, Reddy YNV, Barros-Gomes S, Borlaug BA, Miranda WR, Pislaru SV, Nishimura RA, Pellikka PA. Low-Gradient Severe Mitral Stenosis: Hemodynamic Profiles, Clinical Characteristics, and Outcomes. J Am Heart Assoc 2020; 8:e010736. [PMID: 30793648 PMCID: PMC6474933 DOI: 10.1161/jaha.118.010736] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Optimal management of patients with severe mitral stenosis ( MS ) and low transmitral gradient is incompletely understood. Methods and Results We examined 101 consecutive patients with severe rheumatic MS (mitral valve area ≤1.5 cm2) who underwent balloon valvuloplasty. Low gradient was defined as mean transmitral gradient <10 mm Hg and low flow as stroke volume index ≤35 mL/m2 by echocardiography. Symptoms and mortality data were collected. Systolic, diastolic, and arterial function were characterized by measuring left ventricular (LV) end-systolic elastance, LV stiffness constant (β), diastolic capacitance (predicted LV end-diastolic volume at a common LV filling pressure of 30 mm Hg), and effective arterial elastance. Low gradient (<10 mm Hg) was present in 55 patients, including low flow/low gradient in 11 and normal flow/low gradient in 44 patients, and high gradient was present in 46 patients. Participants with low-flow/low-gradient (LG) MS were older with higher rates of atrial fibrillation (64%) and subvalvular thickening, higher afterload, and decreased LV compliance with lower ejection fraction (57±10% versus 65±4% versus 63±6%, P=0.002) but similar end-systolic elastance compared with patients with normal-flow/ LG and high-gradient MS . The normal-flow/ LG group had larger mitral valve area and lower left atrial pressure by catheterization, as well as favorable long-term outcomes compared with the low-flow/ LG and high-gradient MS group. A total of 40% of patients with LG MS had no symptomatic benefit from valvuloplasty compared with 18% of patients with high-gradient MS ( P=0.02). Conclusions Presence of low gradient in patients with severe MS was associated with lesser symptomatic benefit from valvuloplasty. In the subset with low stroke volume index, this may be related to independent ventricular-vascular uncoupling, decreased LV compliance, and high prevalence of atrial fibrillation in addition to intrinsic MS .
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Affiliation(s)
| | - Yogesh N V Reddy
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Barry A Borlaug
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Sorin V Pislaru
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Rick A Nishimura
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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Egbe AC, Connolly HM, Miranda WR, Scott CG, Borlaug BA. Prognostic implications of inferior vena cava haemodynamics in ambulatory patients with tetralogy of Fallot. ESC Heart Fail 2020; 7:2589-2596. [PMID: 32588556 PMCID: PMC7524124 DOI: 10.1002/ehf2.12836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/21/2020] [Accepted: 05/29/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS Right atrial pressure (RAP) provides a composite measure of right ventricular diastolic dysfunction, right atrial compliance, and volume status, and these three variables are typically abnormal in adults with repaired tetralogy of Fallot (TOF). RAP is a well-established prognostic metric in patients with pulmonary hypertension, and recent data suggest that RAP is associated with clinical outcomes in TOF. The purpose of this study was to determine the role of inferior vena cava (IVC) haemodynamics (size and collapsibility) for the assessment of RAP and its potential application for risk stratification and prognostication in the TOF population. METHODS AND RESULTS Adult TOF patients with echocardiographic assessment of IVC haemodynamics were divided into patients with (derivation cohort, n = 256) and without (validation cohort, n = 492) cardiac catheterization data. We assessed the correlation between IVC haemodynamics, RAP, and disease severity indices [arrhythmias, peak oxygen consumption (VO2 ), and heart failure hospitalization] in derivation cohort and compared it with the correlations in the validation cohort. IVC haemodynamics correlated with RAP (r = 0.52, P < 0.001), with disease severity indices {atrial arrhythmias [area under the curve (AUC) 0.81], ventricular arrhythmias [AUC 0.67], heart failure hospitalizations [AUC 0.78], and peak VO2 [r = 0.53]}, and with transplant-free survival in the derivation cohort. Similar correlations between IVC haemodynamics, disease severity indices, and transplant-free survival were also observed in the validation cohort. CONCLUSIONS These findings suggest that IVC haemodynamics can potentially be used for risk stratification and prognostication in TOF patients and can complement the current risk models that are based predominately on right ventricular volumes and systolic function.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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139
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Affiliation(s)
- Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jared G Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, Texas.
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Egbe AC, Miranda WR, Connolly HM. Increased prevalence of left ventricular diastolic dysfunction in adults with repaired coarctation of aorta. Int J Cardiol Heart Vasc 2020; 28:100530. [PMID: 32462075 PMCID: PMC7240224 DOI: 10.1016/j.ijcha.2020.100530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 01/28/2023]
Abstract
Background Left ventricular (LV) pressure overload and coronary artery disease are common in patients with coarctation of aorta (COA), and they are risk factors for LV diastolic dysfunction. Patients with COA may have aortic vasculopathy that can result in LV pressure overload even in the absence of hemodynamically significant COA. We therefore hypothesized that patients with mild COA (without hemodynamically significant COA) will have more LV diastolic dysfunction compared to controls. Methods Adult patients with mild COA (Doppler peak velocity < 2.5 m/s) were matched 1:1 to patients without structural heart disease using propensity score method based on age, sex, body mass index, hypertension and blood pressure. The objective was to compare LV diastolic dysfunction (defined as E/e′ > 2 standard deviations above age-specific normative values) between adults with repaired COA and controls. Results Of 204 COA and 204 control patients (age 35 ± 12 years), patients with COA had higher septal and lateral E/e′ ratio (12 ± 4 vs 9 ± 4, p = 0.009) and (10 ± 3 vs 7 ± 3, p < 0.001), respectively. Compared to controls, the prevalence of LV diastolic dysfunction was higher in patients with COA for every age group: <40 years (63% vs 13%, p < 0.001); 41–60 years (87% vs 33%, p < 0.001); age > 60 years (82% vs 56%, p = 0.076). Left ventricular mass index (LVMI) was the strongest determinant of E/e′ (β = 2.71 per 10 g/m2, standard error = 1.25, p < 0.001). Conclusion LV diastolic dysfunction was common in patients with COA, and the association with LVMI suggests that patients with COA may have ongoing LV pressure overload in the absence of hemodynamically significant re-coarctation.
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Affiliation(s)
- Alexander C Egbe
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - William R Miranda
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Heidi M Connolly
- The Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Ito S, Miranda WR, Jaffe AS, Oh JK. Prognostic Value of N-Terminal Pro-form B-Type Natriuretic Peptide in Patients With Moderate Aortic Stenosis. Am J Cardiol 2020; 125:1566-1570. [PMID: 32204871 DOI: 10.1016/j.amjcard.2020.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/02/2020] [Accepted: 02/04/2020] [Indexed: 10/25/2022]
Abstract
Plasma B-type natriuretic peptide (BNP) and its N-terminal pro-form, NT-proBNP, can predict outcomes in patients with severe aortic stenosis (AS). However, their prognostic value in moderate AS is currently unknown. The present study included 261 patients diagnosed with moderate AS (1.0 <aortic valve area ≤1.5 cm2) in 2012 with serum NT-pro BNP level collected within ±3 months of the echocardiographic assessment. Patients were divided into 2 groups according to the median NT-proBNP value (888 pg/dl) and all-cause mortality compared. Median age was 78 years and 64% of patients were male. There were 131 (50%) patients with lower-median NT-pro BNP levels (≤888 pg/dl) and 130 (50%) with higher-median NT-pro BNP levels (>888 pg/dl). During a median follow up of 2.7 years, there were 136 (52%) deaths. Mortality rate was much higher in patients with higher-median NT-pro BNP compared to those with lower-median NT-pro BNP levels (p <0.001). Higher-median NT-pro BNP level was significantly associated with higher mortality rate (hazard ratio 3.11; 95% confidence interval 1.78 to 5.46, p <0.001) even after adjusting for confounders. Aortic valve replacement (AVR) was performed in 82 (31%) patients and median time to AVR was 2.1 years. Patients with higher-median NT-pro BNP had higher mortality rate compared to patients with lower-median NT-pro BNP even after AVR (p <0.01). In conclusion, higher NT-proBNP level is associated with higher mortality rates in patients with moderate AS even among those undergoing AVR.
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Egbe AC, Miranda WR, Veldtman GR, Graham RP, Kamath PS. Hepatic Venous Pressure Gradient in Fontan Physiology Has Limited Diagnostic and Prognostic Significance. CJC Open 2020; 2:360-364. [PMID: 32995721 PMCID: PMC7499375 DOI: 10.1016/j.cjco.2020.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/23/2020] [Indexed: 01/06/2023] Open
Abstract
Background Hepatic venous pressure gradient (HVPG) is measure of portal pressure and a prognostic tool in patients with viral and alcoholic cirrhosis; its utility is unknown in patients with Fontan-associated liver disease (FALD). Limited data suggest that patients with FALD have normal HVPG. On the basis of the available data, we hypothesized that there would be no association between HVPG, liver disease severity, and transplant-free survival in FALD. Methods A retrospective study of Fontan patients who had liver biopsy and HVPG assessment at Mayo Clinic was performed. HVPG was calculated as wedged HVP minus free HVP; liver disease severity was measured by histologic assessment of fibrosis and standard clinical liver disease risk scores. Results Of 56 patients (aged 28 ± 7 years), the mean Fontan pressure was 16 ± 4 and the mean HVPG was 1.4 ± 0.3 mm Hg (range, 0-3). Perisinusoidal fibrosis and periportal fibrosis were present in 56 (100%) and 54 (94%) patients, respectively; 18 (32%) met criteria for cirrhosis. There was no correlation between HVPG and degree of hepatic fibrosis. Similarly, there was no correlation between HVPG and any clinical liver disease risk score. Six (11%) patients died and 2 (4%) underwent heart transplantation during follow-up; HVPG was not associated with transplant-free survival. Conclusions HVPG is not elevated in FALD even in the setting of cirrhosis and does not correlate with liver disease severity or clinical outcomes. These results suggest the limited diagnostic and prognostic role of HVPG in the management of FALD and highlight the potential pitfalls of using HVPG in this population.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
- Corresponding author: Dr Alexander C. Egbe, Mayo Clinic and Foundation, 200 First Street SW, Rochester, Minnesota 55905, USA. Tel.: +1-507-284-2520; fax: +1-507-266-0103.
| | - William R. Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Gruschen R. Veldtman
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rondell P. Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Patrick S. Kamath
- Divison of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Egbe AC, Miranda WR, Bonnichsen CR, Warnes CA, Connolly HM. Potential Benefits of Ambulatory Blood Pressure Monitoring in Coarctation of Aorta. J Am Coll Cardiol 2020; 75:2089-2090. [PMID: 32327108 DOI: 10.1016/j.jacc.2020.02.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 02/03/2020] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
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Zhu D, Ito S, Miranda WR, Nkomo VT, Pislaru SV, Villarraga HR, Pellikka PA, Crusan DJ, Oh JK. Left Ventricular Global Longitudinal Strain Is Associated With Long-Term Outcomes in Moderate Aortic Stenosis. Circ Cardiovasc Imaging 2020; 13:e009958. [DOI: 10.1161/circimaging.119.009958] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Left ventricular global longitudinal strain (GLS) is associated with long-term outcomes of patients with severe aortic stenosis. However, its prognostic value in patients with moderate aortic stenosis remains unknown.
Methods:
Patients diagnosed with moderate aortic stenosis (1.0< aortic valve area ≤1.5 cm
2
) and left ventricular ejection fraction ≥50% were identified. GLS was assessed by 2-dimensional strain imaging using speckle-tracking method. All-cause mortality was assessed according to the median GLS value.
Results:
Two hundred eighty-seven patients were included (median age 76 years; 47% male). Mean aortic valve area was 1.25 cm
2
, left ventricular ejection fraction 62%, and median GLS −15.2%. During a median follow-up of 3.9 years, there were 103 deaths (36%). Mortality was higher in patients with GLS>−15.2% (hazard ratio 2.62 [95% CI 1.69–4.06]) compared with patients with GLS ≤−15.2% even after adjusting for confounders. Mortality rates at 1, 3, 5 years were 21%, 35%, 48%, respectively, in patients with GLS >−15.2%, and 6%, 15%, 19% in those with GLS ≤−15.2%. Even among those with left ventricular ejection fraction ≥60%, GLS discriminated higher-risk patients (
P
=0.0003). During follow-up, 106 (37%) patients underwent aortic valve replacement with median waiting-time of 2.4 years, and their survival was better than patients without aortic valve replacement. Among those patients undergoing aortic valve replacement, prognosis was still worse in patients with GLS >−15.2% (
P
=0.04). Mortality rates at 1, 3, 5 years were 2%, 10%, 20%, respectively, in patients with GLS >-15.2% and 2%, 5%, 6% in those with GLS ≤−15.2%.
Conclusions:
Impaired GLS in moderate aortic stenosis patients is associated with higher mortality rates even among those undergoing aortic valve replacement.
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Affiliation(s)
- Dan Zhu
- Department of Cardiovascular Medicine (D.Z., S.I., W.R.M., V.T.N., S.V.P., H.R.V., P.A.P., J.K.O.), Mayo Clinic, Rochester, MN
- Department of Cardiology, Peking University Third Hospital, NHFPC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Beijing, China (D.Z.)
| | - Saki Ito
- Department of Cardiovascular Medicine (D.Z., S.I., W.R.M., V.T.N., S.V.P., H.R.V., P.A.P., J.K.O.), Mayo Clinic, Rochester, MN
| | - William R. Miranda
- Department of Cardiovascular Medicine (D.Z., S.I., W.R.M., V.T.N., S.V.P., H.R.V., P.A.P., J.K.O.), Mayo Clinic, Rochester, MN
| | - Vuyisile T. Nkomo
- Department of Cardiovascular Medicine (D.Z., S.I., W.R.M., V.T.N., S.V.P., H.R.V., P.A.P., J.K.O.), Mayo Clinic, Rochester, MN
| | - Sorin V. Pislaru
- Department of Cardiovascular Medicine (D.Z., S.I., W.R.M., V.T.N., S.V.P., H.R.V., P.A.P., J.K.O.), Mayo Clinic, Rochester, MN
| | - Hector R. Villarraga
- Department of Cardiovascular Medicine (D.Z., S.I., W.R.M., V.T.N., S.V.P., H.R.V., P.A.P., J.K.O.), Mayo Clinic, Rochester, MN
| | - Patricia A. Pellikka
- Department of Cardiovascular Medicine (D.Z., S.I., W.R.M., V.T.N., S.V.P., H.R.V., P.A.P., J.K.O.), Mayo Clinic, Rochester, MN
| | - Daniel J. Crusan
- Division of Biomedical Statistics and Informatics (D.J.C.), Mayo Clinic, Rochester, MN
| | - Jae K. Oh
- Department of Cardiovascular Medicine (D.Z., S.I., W.R.M., V.T.N., S.V.P., H.R.V., P.A.P., J.K.O.), Mayo Clinic, Rochester, MN
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Egbe AC, Pellikka PA, Afzal A, Jain V, Thotamgari S, Miranda WR, Connolly HM. Prognostic Implications of Left Ventricular Cardiomyopathy in Adults With Tetralogy of Fallot. CJC Open 2020; 2:1-7. [PMID: 32159130 PMCID: PMC7063625 DOI: 10.1016/j.cjco.2019.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite the significant risk of cardiovascular mortality after tetralogy of Fallot (TOF) repair, there are limited data about left ventricular (LV) cardiomyopathy in this population, thus creating important knowledge gaps. This study aims to address some of these knowledge gaps by describing the risk and prognostic implications of LV systolic dysfunction (LVD) after TOF repair. METHODS We performed a cohort study of adult patients after TOF repair with an echocardiographic assessment of LV ejection fraction (LVEF) to determine the association between LVD and cardiovascular events, defined as sustained ventricular tachycardia, aborted sudden death, heart transplantation, or death. Prevalent and incidence LVD were defined as LVEF < 50% at baseline or new decrease in LVEF to < 50% during follow-up, respectively. RESULTS Of 574 patients (age 38 ± 13 years), the baseline LVEF was 57% ± 9% and 68 (12%) had prevalent LVD. Cardiovascular events occurred in 126 patients (22%) during 10.5 ± 6.2 years of follow-up. LVEF was an independent predictor of mortality (hazard ratio, 1.16; 95% confidence interval, 1.16-1.24; P = 0.003) per 5%-point decrease in LVEF. Among the 357 patients with preserved LVEF and echocardiographic follow-up, incident LVD occurred in 23 (6%) during 3.8 ± 1.6 years of follow-up. Event-free survival was significantly lower in patients with incident LVD compared with patients without incident LVD (87% vs 71%, P = 0.021). CONCLUSION Prevalent and incident LVD occurred in 12% and 6% of this cohort, respectively, and were associated with lower event-free survival. Incident LVD suggests the presence of subclinical LV cardiomyopathy, and further studies are required to determine optimal strategies for diagnosing and treating subclinical LV cardiomyopathy to improve outcomes in the population with TOF.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Miranda WR, El Sabbagh A, Nishimura RA, Rihal CS. Mitral Stenosis Assessment Using Left Atrial Pressure Via Radial Approach. JACC Cardiovasc Interv 2019; 12:2430-2431. [DOI: 10.1016/j.jcin.2019.07.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/23/2019] [Indexed: 11/17/2022]
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Miranda WR, Connolly HM, Hagler DJ. Suprasternal Pulmonary Artery Puncture in the Setting of Right-Sided Mechanical Prostheses: The Radner Technique Redux. JACC Cardiovasc Interv 2019; 12:2320-2321. [PMID: 31678091 DOI: 10.1016/j.jcin.2019.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/13/2019] [Accepted: 05/21/2019] [Indexed: 10/25/2022]
Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Donald J Hagler
- Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
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Egbe AC, Miranda WR, Mehra N, Ammash NM, Missula VR, Madhavan M, Deshmukh AJ, Farouk Abdelsamid M, Kothapalli S, Connolly HM. Role of QRS Fragmentation for Risk Stratification in Adults With Tetralogy of Fallot. J Am Heart Assoc 2019; 7:e010274. [PMID: 30561260 PMCID: PMC6405623 DOI: 10.1161/jaha.118.010274] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Patients with tetralogy of Fallot (TOF) remain at risk for cardiovascular events despite successful repair. Some of the current risk stratification tools require advanced imaging and invasive studies, and hence are difficult to apply to routine patient care. A recent study showed that QRS fragmentation (QRS‐f) is predictive of mortality in patients with TOF. The current study aims to validate this result by assessing whether severity of QRS‐f could predict all‐cause mortality in a different TOF population. Methods and Results The authors reviewed the Mayo Adult Congenital Heart Disease database for patients with TOF who had ECG from 1990–2017. QRS‐f was defined as notches in QRS complex in ≥2 contiguous leads on ECG, not related to bundle branch block, and classified as none, mild (≤3 leads), moderate (4 leads), or severe (≥5 leads). Of 465 patients (age 37±14 years) in the study, QRS‐f was present in 161 (35%): mild (n=43, 9%), moderate (n=77, 17%), and severe (n=41, 9%). There were 55 deaths (12%) during 13.6±8.2 years of follow‐up. Severity of QRS‐f remained an independent predictor of all‐cause mortality after adjustment for other ECG parameters, patient demographics, and atrial and ventricular arrhythmia (hazard ratio, 1.74 per class; 95% confidence interval, 1.08–2.93 [P=0.041]). Conclusions The presence of severe QRS‐f may be used as complementary data to the usual clinical indices to determine whether interventions such as invasive electrophysiology study should be performed in patients with nonsustained ventricular tachycardia or to proceed with pulmonary valve replacement in patients with severe pulmonary regurgitation with ventricular volumes below the guideline‐directed threshold for intervention.
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Affiliation(s)
- Alexander C Egbe
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Nandini Mehra
- 2 Department of Internal Medicine Mayo Clinic Rochester MN
| | - Naser M Ammash
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Malini Madhavan
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | | | | | - Heidi M Connolly
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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Kato N, Padang R, Pislaru C, Miranda WR, Hoshina M, Shibayama K, Watanabe H, Scott CG, Greason KL, Pislaru SV, Nkomo VT, Pellikka PA. Hemodynamics and Prognostic Impact of Concomitant Mitral Stenosis in Patients Undergoing Surgical or Transcatheter Aortic Valve Replacement for Aortic Stenosis. Circulation 2019; 140:1251-1260. [PMID: 31589485 DOI: 10.1161/circulationaha.119.040679] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mitral stenosis frequently coexists in patients with severe aortic stenosis. Mitral stenosis severity evaluation is challenging in the setting of combined aortic stenosis and mitral stenosis because of hemodynamic interactions between the 2 valve lesions. The impact of aortic valve replacement (AVR) for severe aortic stenosis on mitral stenosis is unknown. This study aimed to assess the effect of AVR on mitral stenosis hemodynamics and the clinical outcomes of patients with severe aortic stenosis with and without mitral stenosis. METHODS We retrospectively investigated patients who underwent surgical AVR or transcatheter AVR for severe aortic stenosis from 2008 to 2015. Mean transmitral gradient by Doppler echocardiography ≥4 mm Hg was identified as mitral stenosis; patients were then stratified according to mitral valve area (MVA, by continuity equation) as >2.0 cm2 or ≤2.0 cm2. MVA before and after AVR in patients with mitral stenosis were evaluated. Clinical outcomes of patients with and without mitral stenosis were compared using 1:2 matching for age, sex, left ventricular ejection fraction, method of AVR (surgical AVR versus transcatheter AVR) and year of AVR. RESULTS Of 190 patients with severe aortic stenosis and mitral stenosis (age 76±9 years, 42% men), 184 were matched with 362 with severe aortic stenosis without mitral stenosis. Among all mitral stenosis patients, the mean MVA increased after AVR by 0.26±0.59 cm2 (from 2.00±0.50 to 2.26±0.62 cm2, P<0.01). MVA increased in 105 (55%) and remained unchanged in 34 (18%). Indexed stroke volume ≤45 mL/m2 (odds ratio [OR] 2.40; 95% CI, 1.15-5.01; P=0.020) and transcatheter AVR (OR, 2.36; 95% CI, 1.17-4.77; P=0.017) were independently associated with increase in MVA. Of 107 with significant mitral stenosis (MVA ≤2.0 cm2), MVA increased to >2.0 cm2 after AVR in 52 (49%, pseudo mitral stenosis) and remained ≤2.0 cm2 in 55 (51%, true mitral stenosis). During follow-up of median 2.9 (0.7-4.9) years, true mitral stenosis was an independent predictor of all-cause mortality (adjusted hazard ratio, 1.88; 95% CI, 1.20-2.94; P<0.01). CONCLUSIONS MVA improved after AVR in nearly half of patients with severe aortic stenosis and mitral stenosis. MVA remained ≤2.0 cm2 (true mitral stenosis) in nearly half of patients with severe aortic stenosis and significant mitral stenosis; this was associated with worse survival among patients undergoing AVR for severe aortic stenosis.
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Affiliation(s)
- Nahoko Kato
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Ratnasari Padang
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Cristina Pislaru
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - William R Miranda
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Mizuho Hoshina
- Tokyo Bay Urayasu/Ichikawa Medical Center, Urayasu, Japan (M.H., K.S., H.W.)
| | - Kentaro Shibayama
- Tokyo Bay Urayasu/Ichikawa Medical Center, Urayasu, Japan (M.H., K.S., H.W.)
| | - Hiroyuki Watanabe
- Tokyo Bay Urayasu/Ichikawa Medical Center, Urayasu, Japan (M.H., K.S., H.W.)
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery (K.L.G.), Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
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Kato N, Thaden JJ, Miranda WR, Sarano ME, Greason KL, Pellikka PA. P1786Impact of surgery for mitral regurgitation at the time of aortic valve replacement. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Functional mitral regurgitation (MR) is expected to improve after aortic valve replacement (AVR) in patients with severe aortic stenosis (sAS) and MR. However, little is unknown about the impact of AVR on organic MR and whether concomitant mitral valve surgery (MVS) improves outcomes in patients with sAS and MR.
Purpose
We assessed the impact of AVR on MR severity according to MR mechanism. We also assessed the clinical outcomes in patients with sAS and MR that underwent AVR with vs without MVS.
Methods
We retrospectively investigated patients who received surgical AVR or transcatheter aortic valve implantation (TAVI) from 2008 to 2017. We identified patients with effective mitral regurgitant orifice area (ERO) ≥10 mm2 by the proximal isovelocity surface area method with transthoracic echocardiography. The change in MR after AVR was considered significant when there was at least one grade difference. We compared the all-cause mortality of patients with sAS and MR that underwent AVR with vs without MVS according to MR mechanism and patient age.
Results
We included 326 patients with sAS and MR (age 80 [Interquartile range 72–85] years, 53% male, 21% history of myocardial infarction). Organic and functional MR were present in 69% and 31%, respectively. Of these, 240 underwent AVR alone (AVR group) including TAVI in 112 while 86 underwent AVR and MVS (MVS group) including mitral valve replacement in 38 and mitral valve repair in 48. The median ERO at baseline was 17 (14–21) mm2 in AVR and 24 (19–33) mm2 in MVS (p<0.001). Improvement in MR was observed in 58% of AVR and 91% of MVS (p<0.001). In AVR group, organic MR improved as frequently as functional MR (58% vs. 59%, p=0.96). Predictors for improvement in organic MR were absence of atrial fibrillation and moderate or greater MR, and in functional MR, the only predictor was decrease in LV end-systolic diameter after AVR. During mean follow-up of 2.4±2.3 years, moderate or greater MR was observed in 23% of AVR and 7% of MVS (p=0.002). All-cause mortality was similar in AVR and MVS groups for organic and functional MR (hazard ratio for MVS group 0.68, 95% CI: 0.40–1.10, p=0.13 in organic MR and 0.62, 95% CI 0.29–1.22, p=0.68 in functional MR). All-cause mortality was lower in MVS group compared with AVR group in patients <80 years, and was similar in patients ≥80 years (Figure).
Conclusion
In patients with sAS and MR, MR improves after AVR, even in the majority of patients with organic MR. Compared with isolated AVR, concomitant MVS was associated with better prognosis in patients <80 years.
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Affiliation(s)
- N Kato
- Mayo Clinic, Rochester, United States of America
| | - J J Thaden
- Mayo Clinic, Rochester, United States of America
| | - W R Miranda
- Mayo Clinic, Rochester, United States of America
| | - M E Sarano
- Mayo Clinic, Rochester, United States of America
| | - K L Greason
- Mayo Clinic, Rochester, United States of America
| | - P A Pellikka
- Mayo Clinic, Rochester, United States of America
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