Association of Echocardiographic Left Ventricular End-Systolic Volume and Volume-Derived Ejection Fraction With Outcome in Asymptomatic Chronic Aortic Regurgitation

Prognostic value of fully-automated left atrial strain in patients with asymptomatic chronic severe aortic regurgitation

BACKGROUND

To examine whether left atrial (LA) strain was associated with adverse outcomes in asymptomatic chronic aortic regurgitation (AR).

METHODS

Asymptomatic patients with ≥moderate-severe AR were retrospectively identified from 2008 through 2022 from a university hospital. Apical 4-chamber left ventricular longitudinal strain (A4C-LVLS), LA reservoir (LASr), conduit (LAScd), and contractile strain (LASct) were measured using fully-automated software. Primary endpoint was all-cause death (ACD); secondary endpoints were heart failure (HF) development or aortic valve surgery (AVS).

RESULTS

Of 352 patients (59 ± 17 years; 19 % female), the mean LV ejection fraction (LVEF) was 60 ± 8 %. The median follow-up during medical surveillance was 4.7 (interquartile range: 1.8-9.0) years; during which 68 patients died. Multivariable analysis adjusted for covariates showed that larger maximal LA volume index (iLAVmax), lower LASr and LASct were independently associated with ACD (all P ≤ 0.047); A4C-LVLS and LAScd were not (P ≥ 0.15). Besides, iLAVmax, LASr, and LASct provided incremental prognostic value over A4C-LVLS in terms of ACD (all P ≤ 0.048). HF symptoms occurred in 126 patients at a median of 2 years. Multivariable determinants for HF development included larger minimal LAV index, lower LASr and LASct (all P ≤ 0.03). Adjusted spline curves showed LASr <38-40 % and LASct <20-24 % were associated with increased risks of ACD and HF development, respectively. Using abovementioned LASr and LASct cutoffs, adjusted Kaplan-Meier curves risk-stratified patients for ACD successfully (P ≤ 0.02). Lower LASr was also independently associated with AVS (Hazard ratio per 1 % increase: 0.98)(P = 0.02).

CONCLUSIONS

In patients with asymptomatic AR, fully-automated LASr and LASct were robust markers for outcome determination; these markers may identify those who need timely surgical referral.

Impact of early versus class I-triggered surgery on postoperative survival in severe aortic regurgitation: An observational study from the Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry

OBJECTIVES

Class I triggers for severe and chronic aortic regurgitation surgery mainly rely on symptoms or systolic dysfunction, resulting in a negative outcome despite surgical correction. Therefore, US and European guidelines now advocate for earlier surgery. We sought to determine whether earlier surgery leads to improved postoperative survival.

METHODS

We evaluated the postoperative survival of patients who underwent surgery for severe aortic regurgitation in the international multicenter registry for aortic valve surgery, Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry, over a median follow-up of 37 months.

RESULTS

Among 1899 patients (aged 49 ± 15 years, 85% were male), 83% and 84% had class I indication according to the American Heart Association and European Society of Cardiology, respectively, and most were offered repair surgery (92%). Twelve patients (0.6%) died after surgery, and 68 patients died within 10 years after the procedure. Heart failure symptoms (hazard ratio, 2.60 [1.20-5.66], P = .016) and either left ventricular end-systolic diameter greater than 50 mm or left ventricular end-systolic diameter index greater than 25 mm/m2 (hazard ratio, 1.64 [1.05-2.55], P = .030) predicted survival independently over and above age, gender, and bicuspid phenotype. Therefore, patients who underwent surgery based on any class I trigger had worse adjusted survival. However, patients who underwent surgery while meeting early imaging triggers (left ventricular end-systolic diameter index 20-25 mm/m2 or left ventricular ejection fraction 50% to 55%) had no significant outcome penalty.

CONCLUSIONS

In this international registry of severe aortic regurgitation, surgery when meeting class I triggers led to postoperative outcome penalty compared with earlier triggers (left ventricular end-systolic diameter index 20-25 mm/m2 or ventricular ejection fraction 50%-55%). This observation, which applies to expert centers where aortic valve repair is feasible, should encourage the global use of repair techniques and the conduction of randomized trials.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Aortic regurgitation: from mechanisms to management

Aortic regurgitation (AR) is a common clinical disease associated with significant morbidity and mortality. Investigations based largely on non-invasive imaging are pivotal in discerning the severity of disease and its impact on the heart. Advances in technology have contributed to improved risk stratification and to our understanding of the pathophysiology of AR. Surgical aortic valve replacement is the predominant treatment. However, its use is limited to patients with an acceptable surgical risk profile. Transcatheter aortic valve implantation is an alternative treatment. However, this therapy remains in its infancy, and further data and experience are required. This review article on AR describes its prevalence, mechanisms, diagnosis and treatment.

Noninvasive Imaging for Native Aortic Valve Regurgitation

Aortic regurgitation (AR) is associated with left ventricular (LV) volume and pressure overload, resulting in eccentric LV remodeling and enlargement. This condition may be well tolerated for years before the onset of myocardial dysfunction and symptoms. Echocardiography plays a crucial role in the diagnosis of AR, assessing its mechanism and severity, and detecting LV remodeling. The assessment of AR severity is challenging and frequently requires the integration of information from multiple different measurements to assess the severity. Recent data suggest that echocardiographically derived LV volumes (end-systolic volume index > 45 mL/m2), an ejection fraction threshold of <60%, and abnormal global longitudinal strain may help identify early dysfunction and may be used to improve clinical outcomes. Consequently, these parameters can identify candidates for surgery. Cardiac magnetic resonance imaging is emerging as a valuable tool for assessing severity when it remains unclear after an echocardiographic evaluation. This review emphasizes the importance of imaging, particularly echocardiography, in the evaluation of AR. It focuses on various echocardiographic parameters, including technical details, and how to integrate them for assessing the mechanism and severity of AR as well as LV remodeling.

2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults

Transthoracic echocardiography (TTE) is the most widely available and utilised imaging modality for the screening, diagnosis, and serial monitoring of all abnormalities related to cardiac structure or function. The primary objectives of this document are to provide (1) a guiding framework for treating clinicians of the acceptable indications for the initial and serial TTE assessments of the commonly encountered cardiovascular conditions in adults, and (2) the minimum required standard for TTE examinations and reporting for imaging service providers. The main areas covered within this Position Statement pertain to the TTE assessment of the left and right ventricles, valvular heart diseases, pericardial diseases, aortic diseases, infective endocarditis, cardiac masses, pulmonary hypertension, and cardiovascular diseases associated with cancer treatments or cardio-oncology. Facilitating the optimal use and performance of high quality TTEs will prevent the over or under-utilisation of this resource and unnecessary downstream testing due to suboptimal or incomplete studies.

Clinical and prognostic implications of left ventricular dilatation in heart failure

AIMS

To assess the agreement between left ventricular end-diastolic diameter index (LVEDDi) and volume index (LVEDVi) to define LV dilatation and to investigate the respective prognostic implications in patients with heart failure (HF).

METHODS AND RESULTS

Patients with HF symptoms and LV ejection fraction (LVEF) < 50% undergoing cardiac magnetic resonance were evaluated retrospectively. LV dilatation was defined as LVEDDi or LVEDVi above the upper normal limit according to published reference values. Patients were followed up for the combined endpoint of cardiovascular death or HF hospitalization during 5 years. A total of 564 patients (median age 64 years; 79% men) were included. LVEDDi had a modest correlation with LVEDVi (r = 0.682, P < 0.001). LV dilatation was noted in 84% of patients using LVEDVi-based definition and in 73% using LVEDDi-based definition, whereas 20% of patients displayed discordant definitions of LV dilatation. During a median follow-up of 2.8 years, patients with both dilated LVEDDi and LVEDVi had the highest cumulative event rate (HR 3.00, 95% CI 1.15-7.81, P = 0.024). Both LVEDDi and LVEDVi were independently associated with the primary outcome (hazard ratio 3.29, 95%, P < 0.001 and 2.8, P = 0.009; respectively).

CONCLUSION

The majority of patients with HF and LVEF < 50% present both increased LVEDDi and LVEDVi whereas 20% show discordant linear and volumetric definitions of LV dilatation. Patients with increased LVEDDi and LVEDVi have the worst clinical outcomes suggesting that the assessment of these two metrics is needed for better risk stratification.

Aortic Regurgitation: From Valvular to Myocardial Dysfunction

Chronic aortic regurgitation (AR) leads to volume overload in the left ventricle (LV), which is well tolerated for years. In this condition, the LV usually dilates with minimal reduction in the ejection fraction (EF), even in the absence of symptoms. Echocardiography is the primary imaging test used to quantify AR. However, no single assessment of Doppler measures is accurate and precise in individual patients; therefore, the integration of multiple parameters is necessary. Recent guidelines recommend surgical treatment for severe AR in patients who are symptomatic or have an LVEF < 55% and an end-systolic diameter > 50 mm. Nevertheless, advances in imaging technology have improved the quantification of AR and the assessment of LV subclinical dysfunction. It is widely recognized that patients who undergo aortic valve replacement/repair (AVR) due to symptoms or a low LVEF experience worse outcomes than those undergoing AVR for non-Class I indications. In fact, subclinical irreversible myocardial damage may occur in clinically well-compensated and closely monitored patients while awaiting formal surgical indications. This condition could be prevented by the use of multimodal imaging parameters, in particular longitudinal LV strain and magnetic resonance imaging. In addition, better cut-off values for mortality predictors should be established. This review aims to identify simple models that integrate several echocardiographic and cardiac magnetic resonance-derived parameters to predict the optimal timing of surgical treatment in asymptomatic patients with chronic severe AR.

Prognostic Implications of Left Atrial Strain in Bicuspid Aortic Valve With Chronic Aortic Regurgitation

BACKGROUND

Left atrial reservoir strain (LARS) is a novel imaging biomarker of left ventricular diastolic dysfunction. This study aimed to examine the prognostic implications of LARS in patients with bicuspid aortic valve and significant (moderate-severe to severe) aortic regurgitation.

METHODS AND RESULTS

A total of 220 patients with bicuspid aortic valve and significant aortic regurgitation were prospectively enrolled in our study. LARS and left ventricular global longitudinal strain were derived from speckle-tracking echocardiography. The end point was a composite of all-cause mortality, heart failure hospitalization, and aortic valve repair or replacement. The threshold value of LARS <24% was used to identify impaired left atrial mechanics based on prior results. During a median follow-up of 364 (interquartile range, 294-752) days, 46 patients (20.9%) reached the composite end points. On multivariable Cox analysis, impaired LARS (adjusted hazard ratio, 2.08 [95% CI, 1.05-4.11]; P=0.036) was a statistically significant predictor of composite end points after adjustment for other statistically significant predictors. Finally, adding impaired LARS to other statistically significant predictors (New York Heart Association functional class and left ventricular global longitudinal strain) significantly improved the global χ2 (from 32.19 to 36.56; P=0.037) and reclassification (continuous net reclassification index=0.55; P<0.001) of the prediction model.

CONCLUSIONS

In patients with bicuspid aortic valve and significant aortic regurgitation, the impairment of LARS is a strong independent prognostic predictor and confers incremental prognostic utility over clinical and other echocardiographic parameters. These findings suggest that LARS could be considered in risk stratification for such populations.

Predicting postoperative systolic dysfunction in mitral regurgitation: CT vs. echocardiography

Introduction

Volume overload from mitral regurgitation can result in left ventricular systolic dysfunction. To prevent this, it is essential to operate before irreversible dysfunction occurs, but the optimal timing of intervention remains unclear. Current echocardiographic guidelines are based on 2D linear measurement thresholds only. We compared volumetric CT-based and 2D echocardiographic indices of LV size and function as predictors of post-operative systolic dysfunction following mitral repair.

Methods

We retrospectively identified patients with primary mitral valve regurgitation who underwent repair between 2005 and 2021. Several indices of LV size and function measured on preoperative cardiac CT were compared with 2D echocardiography in predicting post-operative LV systolic dysfunction (LVEFecho <50%). Area under the curve (AUC) was the primary metric of predictive performance.

Results

A total of 243 patients were included (mean age 57 ± 12 years; 65 females). The most effective CT-based predictors of post-operative LV systolic dysfunction were ejection fraction [LVEFCT; AUC 0.84 (95% CI: 0.77-0.92)] and LV end systolic volume indexed to body surface area [LVESViCT; AUC 0.88 (0.82-0.95)]. The best echocardiographic predictors were LVEFecho [AUC 0.70 (0.58-0.82)] and LVESDecho [AUC 0.79 (0.70-0.89)]. LVEFCT was a significantly better predictor of post-operative LV systolic dysfunction than LVEFecho (p = 0.02) and LVESViCT was a significantly better predictor than LVESDecho (p = 0.03). Ejection fraction measured by CT demonstrated significantly greater reproducibility than echocardiography.

Discussion

CT-based volumetric measurements may be superior to established 2D echocardiographic parameters for predicting LV systolic dysfunction following mitral valve repair. Validation with prospective study is warranted.

Signal-to-noise of linear and volume measures of left ventricular and left atrial size

BACKGROUND

Serial echocardiographic assessments are common in clinical cardiology, e.g., for timing of intervention in mitral and aortic regurgitation. When following patients with serial echocardiograms, each new measurement is a combination of true change and confounding noise. The current investigation compares linear chamber dimensions with volume estimates of chamber size. The aim is to assess which measure is best for serial echocardiograms, when the ideal parameter will be sensitive to change in chamber size and have minimal spurious variation (noise). We present a method that disentangles true change from noise. Linear regression of chamber size against elapsed time gives a slope, being the ability of the method to detect change. Noise is the scatter of individual points away from the trendline, measured as the standard error of the slope. The higher the signal-to-noise ratio (SNR), the more reliably a parameter will distinguish true change from noise.

METHODS

LV and LA parasternal dimensions and apical biplane volumes were obtained from serial clinical echocardiogram reports. Change over time was assessed as the slope of the linear regression line, and noise was assessed as the standard error of the regression slope. Signal-to-noise ratio is the slope divided by its standard error.

RESULTS

The median number of LV studies was 5 (4-11) for LV over a mean duration of 5.9 ± 3.0 years in 561 patients (diastole) and 386 (systole). The median number of LA studies was 5 (4-11) over a mean duration of 5.3 ± 2.0 years in 137 patients. Linear estimates of LV size had better signal-to-noise than volume estimates (p < 0.001 for diastolic and p = 0.035 for systolic). For the left atrium, the difference was not significant (p = 0.214). This may be due to sample size; the effect size was similar to that for LV systolic size. All three parameters had a numerical value of signal-to-noise that favoured linear dimensions over volumes.

CONCLUSION

Linear measures of LV size have better signal-to-noise than volume measures. There was no difference in signal-to-noise between linear and volume measures of LA size, although this may be a Type II error. The use of regression lines may be better than relying on single measurements. Linear dimensions may clarify whether changes in volumes are real or spurious.

Echocardiographic assessment of aortic regurgitation: a narrative review

Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.

Assessment of the Severity of Aortic Regurgitation by Noninvasive Imaging : Non-invasive MMI for AR

PURPOSE OF THE REVIEW

The role of multimodality imaging in the evaluation of patients with aortic regurgitation is summarized in this review.

RECENT FINDINGS

The etiology (mechanism) of the aortic regurgitation and the severity of aortic regurgitation and hemodynamic consequences are key in the decision making of patients with severe aortic regurgitation. While echocardiography remains as the leading technique to assess all these parameters, other imaging techniques have become essential for the accurate assessment of aortic regurgitation severity and the timing of aortic intervention. The anatomic suitability of transcatheter aortic valve implantation in inoperable patients with severe aortic regurgitation is usually assessed with computed tomography. Aortic regurgitation is a prevalent disease with various pathophysiological mechanisms that need a personalized treatment. The evaluation of the mechanism and severity of aortic regurgitation can be initially performed with echocardiography. Three-dimensional techniques, including echocardiography, have become very relevant for accurate assessment of the regurgitation severity and its hemodynamic consequences. Assessment of myocardial tissue characteristics with cardiac magnetic resonance is key in the risk stratification of patients and in the timing of aortic intervention. Computed tomography is important in the assessment of aortic dimensions and selection of patients for transcatheter aortic valve implantation.

Imaging Methods for Evaluation of Chronic Aortic Regurgitation in Adults: JACC State-of-the-Art Review

A global multidisciplinary workshop was convened to discuss the multimodality diagnostic evaluation of aortic regurgitation (AR). Specifically, the focus was on assessment tools for AR severity and analyzing evolving data on the optimal timing of aortic valve intervention. The key concepts from this expert panel are summarized as: 1) echocardiography is the primary imaging modality for assessment of AR severity; however, when data is incongruent or incomplete, cardiac magnetic resonance may be helpful; 2) assessment of left ventricular size and function is crucial in determining the timing of intervention; 3) recent evidence suggests current cutpoints for intervention in asymptomatic severe AR patients requires further scrutiny; 4) left ventricular end-systolic volume index has emerged as an additional parameter that has promise in guiding timing of intervention; and 5) the role of additional factors (including global longitudinal strain, regurgitant fraction, and myocardial extracellular volume) is worthy of future investigation.

A Late-Detected Paraganglioma in a Young Patient with Resistant Hypertension and Severe Aortic Regurgitation-A Case Report and Review of the Literature

BACKGROUND

Paraganglioma is a rare neuroendocrine tumor derived from chromaffin cells. The overproduction of catecholamines accounts for the presenting symptoms and cardiovascular complications. The clinical presentation frequently overlaps with the associated cardiac diseases, delaying the diagnosis. Multimodality imaging and a multidisciplinary team are essential for the correct diagnosis and adequate clinical management.

CASE SUMMARY

A 37-year-old woman with a personal medical history of long-standing arterial hypertension and radiofrequency ablation for atrioventricular nodal reentry tachycardia presented with progressive exertional dyspnea and elevated blood pressure values, despite a comprehensive pharmacological treatment with six antihypertensive drugs. The echocardiography showed a bicuspid aortic valve and severe aortic regurgitation. The computed tomography angiography revealed a retroperitoneal space-occupying solid lesion, with imaging characteristics suggestive of a paraganglioma. The multidisciplinary team concluded that tumor resection should be completed first, followed by an aortic valve replacement if necessary. The postoperative histopathology examination confirmed the diagnosis of paraganglioma. After the successful resection of the tumor, the patient was asymptomatic, and the intervention for aortic valve replacement was delayed.

DISCUSSION

This was a rare case of a late-detected paraganglioma in a young patient with resistant hypertension overlapping the clinical presentation and management of severe aortic regurgitation. A multimodality imaging approach including transthoracic and transesophageal echocardiography, computed tomography, and magnetic resonance imaging had an emerging role in establishing the diagnosis and in guiding patient management and follow-up. The resection of paraganglioma was essential for the optimal timing of surgical correction for severe aortic regurgitation. We further reviewed various cardiovascular complications induced by pheochromocytomas and paragangliomas.

Aortic Regurgitation and Heart Failure: Advances in Diagnosis, Management, and Interventions

This review discusses the contemporary clinical evaluation and management of patients with comorbid aortic regurgitation (AR) and heart failure (HF) (AR-HF). Importantly, as clinical HF exists along the spectrum of AR severity, the present review also details novel strategies to detect early signs of HF before the clinical syndrome ensues. Indeed, there may be a vulnerable cohort of AR patients who benefit from early detection and management of HF. Additionally, while the mainstay of operative management for AR has historically been surgical aortic valve replacement, this review discusses alternate procedures that may be beneficial in high-risk cohorts.

Influence of Cardiac Remodeling on Clinical Outcomes in Patients With Aortic Regurgitation

BACKGROUND

Quantitative cardiac magnetic resonance (CMR) outcome studies in aortic regurgitation (AR) are few. It is unclear if volume measurements are beneficial over diameters.

OBJECTIVES

This study sought to evaluate the association of CMR quantitative thresholds and outcomes in AR patients.

METHODS

In a multicenter study, asymptomatic patients with moderate or severe AR on CMR with preserved left ventricular ejection fraction (LVEF) were evaluated. Primary outcome was development of symptoms or decrease in LVEF to <50%, development of guideline indications for surgery based on LV dimensions, or death under medical management. Secondary outcome was the same as the primary outcome, excluding surgery for remodeling indications. We excluded patients who underwent surgery within 30 days of CMR. Receiver-operating characteristic analyses for the association with outcomes were performed.

RESULTS

We studied 458 patients (median age: 60 years; IQR: 46-70 years). During a median follow-up of 2.4 years (IQR: 0.9-5.3 years), 133 events occurred. Optimal thresholds were regurgitant volume of 47 mL and regurgitant fraction of 43%, indexed LV end-systolic (iLVES) volume of 43 mL/m2, indexed LV end-diastolic volume of 109 mL/m2, and iLVES diameter of 2 cm/m2. In multivariable regression analysis, iLVES volume of ≥43 mL/m2 (HR: 2.53; 95% CI: 1.75-3.66; P < 0.001) and indexed LV end-diastolic volume of ≥109 mL/m2 were independently associated with the outcomes and provided additional discrimination improvement over iLVES diameter, whereas iLVES diameter was independently associated with the primary outcome but not the secondary outcome.

CONCLUSIONS

In asymptomatic AR patients with preserved LVEF, CMR findings can be used to guide management. CMR-based LVES volume assessment performed favorably compared to LV diameters.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Raphal Cord Rupture: A Rare Mechanism of Aortic Regurgitation in Bicuspid Aortic Valve

A 70-year-old male with chronic aortic regurgitation was referred with abrupt worsening heart failure. Late referral markers were pulmonary hypertension, mitral regurgitation, and tricuspid regurgitation. Evaluation revealed rupture of a raphal cord or fenestrated raphe from the conjoined cusp of a congenitally bicuspid aortic valve, a rare mechanism of aortic regurgitation. (Level of Difficulty: Intermediate.).

Valvular heart disease: shifting the focus to the myocardium

Adverse cardiac remodelling is the main determinant of patient prognosis in degenerative valvular heart disease (VHD). However, to give an indication for valvular intervention, current guidelines include parameters of cardiac chamber dilatation or function which are subject to variability, do not directly reflect myocardial structural changes, and, more importantly, seem to be not sensitive enough in depicting early signs of myocardial dysfunction before irreversible myocardial damage has occurred. To avoid irreversible myocardial dysfunction, novel biomarkers are advocated to help refining indications for intervention and risk stratification. Advanced echocardiographic modalities, including strain analysis, and magnetic resonance imaging have shown to be promising in providing new tools to depict the important switch from adaptive to maladaptive myocardial changes in response to severe VHD. This review, therefore, summarizes the current available evidence on the role of these new imaging biomarkers in degenerative VHD, aiming at shifting the clinical perspective from a valve-centred to a myocardium-focused approach for patient management and therapeutic decision-making.

Association of outcome with left ventricular volumes and ejection fraction measured with two- and three-dimensional echocardiography in patients referred for routine, clinically indicated studies

Objectives

We sought to analyze if left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory for routine, clinically-indicated studies.

Methods

We measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59 ± 18 years) with various clinical indications referred for a routine clinical study.

Results

LV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6 ± 1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse outcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the associations of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart disease) whose Harrel's C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC = 0.84, p < 0.001) more than 2DE LVEF (HC = 0.814, p < 0.001). The association of CD with the composite endpoint (HC = 0.64, p = 0.002) was augmented more by 3DE LV EDV (HC = 0.786, p < 0.001), end-systolic volume (HC = 0.801, p < 0.001), and EF (HC = 0.84, p < 0.001) than by the correspondent 2DE parameters (HC = 0.786, HC = 0.796, and 0.84, all p < 0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ² = 98.3 vs. χ² = 77.1; p < 0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for death than when using 2DE reference values (3DE LVEDV: χ² = 15.9, p < 0.001 vs. χ² = 10.8, p = 0.001; 3DE LVESV: χ² = 24.4, p < 0.001 vs. χ² = 17.4, p = 0.001).

Conclusion

In patients who underwent routine, clinically-indicated echocardiography, 3DE LVEF and ESV showed stronger association with outcome than the corresponding 2DE parameters.

Association of Left Ventricular Remodeling Assessment by Cardiac Magnetic Resonance With Outcomes in Patients With Chronic Aortic Regurgitation

Importance

Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload, which results in progressive LV remodeling negatively affecting outcomes. Whether cardiac magnetic resonance (CMR) volumetric quantification can provide incremental risk stratification over standard clinical and echocardiographic evaluation in patients with chronic moderate or severe AR is unknown.

Objective

To compare LV remodeling measurements by CMR and echocardiography between patients with and without heart failure symptoms and to verify the association of remodeling measurements of patients with chronic moderate or severe AR but no or minimal symptoms with clinical outcomes receiving medical management.

Design, Setting, and Participants

This multicenter retrospective cohort study included consecutive patients with at least moderate chronic native AR evaluated by 2-dimensional transthoracic echocardiography and CMR examination within 90 days from each other between January 2012 and February 2020 at Allina Health System. Data were analyzed from June 2021 to January 2022.

Exposures

Clinical evaluation and risk stratification by CMR.

Main Outcomes and Measures

The end point was a composite of death, heart failure hospitalization, or progression of New York Heart Association functional class while receiving medical management, censoring patients at the time of aortic valve replacement (when performed) or at the end of follow-up.

Results

Of the 178 included patients, 119 (66.9%) were male, 158 (88.8%) presented with no or minimal symptoms (New York Heart Association class I or II), and the median (IQR) age was 58 (44-69) years. Compared with patients with no or minimal symptoms, symptomatic patients had greater LV end-systolic volume index (LVESVi) by CMR (median [IQR], 66 [46-85] mL/m2 vs 42 [30-58] mL/m2; P < .001), while there were no significant differences by echocardiography (LVESVi: median [IQR], 38 [30-58] mL/m2 vs 27 [20-42] mL/m2; P = .07; LV end-systolic diameter index: median [IQR], 21 [17-25] mm/m2 vs 18 [15-22] mm/m2; P = .17). During the median (IQR) follow-up of 3.3 (1.6-5.8) years, 50 patients with no or minimal symptoms receiving medical management developed the composite end point, which, in multivariate analysis adjusted for age and EuroSCORE II, was independently associated with LVESVi of 45 mL/m2 or greater and aortic regurgitant fraction of 32% or greater, the latter adding incremental prognostic value to CMR volumetric assessment.

Conclusions and Relevance

In patients with chronic moderate or severe AR, patients presenting with heart failure symptoms have greater LVESVi by CMR than those with no or minimal symptoms. In patients with no or minimal symptoms, CMR quantification of LVESVi and AR severity may identify those at risk of death or incident heart failure and therefore should be considered in the clinical evaluation and decision-making of these patients.

Automated Global Longitudinal Strain Exhibits a Robust Association with Death in Asymptomatic Chronic Aortic Regurgitation

BACKGROUND

Whether automated left ventricular global longitudinal strain (LVGLS) is associated with outcomes in asymptomatic aortic regurgitation (AR) is unknown.

OBJECTIVE

To explore the impact of automated LVGLS on survival and compare it with conventional LV parameters in chronic asymptomatic AR.

METHODS

LVGLS (presented as absolute value) was measured using fully-automated two-dimensional strain software in consecutive patients with isolated chronic ≥moderate-severe AR between 2004 and 2020; incremental value of LVGLS was assessed. Limited correction of endocardial border tracking was performed if needed.

RESULTS

Of 550 asymptomatic patients (age 60±17 years; 86% men), average LVGLS was 17±3% (1^st and 2^nd tertile, 15.8% and 18.5%). In 16% cases, tracking border was partially corrected; average time for analysis was 25±5 seconds. At a median (interquartile range) of 4.8(1.5-9.9) years, 87 patients had died (19 died after aortic-valve surgery [AVS]). Separate multivariable models adjusted for age, sex, Charlson index, AR severity and time-dependent AVS demonstrated that LVEF(hazard ratio[HR] per 10%: 0.9), LV end-systolic volume index(LVESVi; HR per 5ml/m²: 1.08) and LVGLS(HR per unit: 0.87) were independently associated with death(all p≤0.018); however, LVGLS remained statistically significant (HR: 0.86-0.9; P≤0.007) as compared head-to-head to LVEF, LVESVi and LV end-systolic dimension index(LVESDi). The association of LVGLS and mortality was consistent across all subgroups (P for interaction all≥0.08). Spline curves showed that continuous risk of death rose at LVGLS <15%. Those with LVGLS <15% had 2.6-fold risk of death [95% CI 1.54-4.23] while those with LVGLS <15% plus LVESVi≥45ml/m² had 3.96-fold risk[95% CI 1.94-8.03].

CONCLUSION

In this large cohort of asymptomatic patients with ≥moderate-severe AR, automated LVGLS was feasible, efficient, and independently associated with death on head-to-head comparison with conventional LVEF, LVESDi, and LVESVi. The automated-LVGLS threshold of <15% alone or combined with LVESVi≥45ml/m², was significantly associated with increased mortality risk and may be considered in early surgery decision-making.

Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper

Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Imaging is pivotal in the evaluation of native valve regurgitation and echocardiography is the primary imaging modality for this purpose. The imaging assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy and function, and the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation largely relies on the results of imaging. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing native valve regurgitation. The present document aims to present clinical guidance for the multi-modality imaging assessment of native valvular regurgitation.