Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice

Prognostic value of aortic valve calcification in non-severe aortic stenosis with preserved ejection fraction

AIMS

Aortic valve calcification (AVC) is prognostic in patients with aortic stenosis (AS). We assessed the AVC prognostic value in non-severe AS patients.

METHODS AND RESULTS

We conducted a retrospective study of 395 patients with non-severe AS, LVEF ≥ 50%. The Agatston method was used for CT AVC assessment. The log-rank test determined the best AVC cut-offs for survival under medical surveillance: 1185  arbitrary unit (AU) in men and 850 AU in women, lower than the established cut-offs for severe AS (2064 AU in men and 1274 AU in women). Patients were divided into 3 AVC groups based on these cut-offs: low (<1185 AU in men and <850 AU in women), sub-severe (1185-2064 AU in men and 850-1274 AU in women), and severe (>2064 AU in men and >1274 AU in women). Of 395 patients (mean age 73 ± 12 years, 60.5% men, aortic valve area 1.23 ± 0.30 cm2, mean pressure gradient 28 ± 8 mmHg), 218 underwent aortic valve intervention (AVI) and 158 deaths occurred during follow-up, 82 before AVI. Median survival time under medical surveillance was 2.1 (0.7-4.9) years. Compared with the low AVC group, both sub-severe and severe AVC groups had higher risk for all-cause death under medical surveillance after comprehensive adjustment including echocardiographic AS severity and coronary artery calcium score (all P ≤ 0.006); while mortality risk was similar between sub-severe and severe AVC groups (all P ≥ 0.2). This mortality risk pattern persisted in the overall survival analysis after adjustment for AVI. AVI was protective of all-cause death in the sub-severe and severe AVC (all P ≤ 0.01), but not in the low AVC groups.

CONCLUSION

Sub-severe AVC is a robust risk stratification parameter in patients with non-severe AS and may inform AVI timing.

Cardiac Damage in Early Aortic Stenosis: Is the Valve to Blame?

BACKGROUND

Despite the close association between aortic stenosis (AS) and cardiac damage (CD), it is unclear if CD is limited to patients with moderate and severe AS and which factors affect its progression. Although altered valvular hemodynamic status may drive the development of CD in AS, commonly occurring comorbidities may contribute.

OBJECTIVES

The aim of this study was to determine the prevalence of and factors associated with CD in mild AS.

METHODS

This retrospective study included 9,611 patients with mild AS (peak aortic valve velocity [Vmax] 2-3 m/s and description of abnormal aortic valve) from 2010 through 2021. CD was staged using the Genereux classification.

RESULTS

All but 20% (n = 1,901; stage 0) of patients with mild AS demonstrated CD: 1,613 (17%) stage 1, 4,843 (50%) stage 2, 891 (9%) stage 3, and 363 (4%) stage 4. Patients with higher stages had more comorbidities (hypertension, heart failure, ischemic heart disease, stroke, peripheral arterial disease, chronic kidney disease, chronic pulmonary disease, and diabetes mellitus) but had valvular hemodynamic status similar to those without CD. CD stage did not worsen with higher Vmax range (stage >1 in 64% with Vmax <2.5 m/s vs 61% with Vmax ≥2.5 m/s) but increased with the number of comorbidities, with stage >1 occurring in 50%, 53%, 60%, 66%, 72%, and 73% in the presence of 0, 1, 2, 3, 4, and 5 or more comorbidities, respectively.

CONCLUSIONS

CD was highly prevalent in patients with mild AS. Among patients with mild AS, there was no relationship between the degree of CD and AS severity; instead, CD was highly associated with comorbidities.

Hemodynamic Comparison of the On-X and Top Hat Mechanical Aortic Valve Prostheses

BACKGROUND

There are limited data comparing hemodynamic valve function in mechanical aortic valve prostheses. This study compared the hemodynamic function of 2 commonly used mechanical aortic valve (AV) prostheses, the On-X (Artivion) and Top Hat (CarboMedics Inc) valves.

METHODS

This study was a retrospective analysis of 512 patients who underwent AV replacement with the On-X (n = 252; 49%) or Top Hat (n = 260; 51%) mechanical valves between 2011 and 2019. Patients were matched on the basis of selected variables. Echocardiographic data were collected preoperatively and postoperatively over a median follow-up of 1.39 years.

RESULTS

A total of 320 patients were matched, 160 patients in each group. Despite being matched for left ventricular outflow tract diameter, patients in the Top Hat group received a greater prevalence of smaller tissue annulus diameter valves (≤21 mm) (83% vs 38%; P < .001). Patients in the On-X group had longer aortic cross-clamp times (78 minutes vs 64 minutes; P < .001) during isolated aortic valve replacement. Discharge echocardiography showed no difference in the AV area index between both groups (1.00 cm2/m2 vs 1.02 cm2/m2; P = .377). During longer-term echocardiographic follow-up, the AV area index remained stable for both valves within their respective tissue annulus diameter groups (P = .060).

CONCLUSIONS

There was no difference between the 2 valves with respect to the AV area index at discharge, and hemodynamic function was stable during longer-term follow-up. The longer aortic cross-clamp time observed in the On-X group may indicate increased complexity of implantation compared with the Top Hat group.

Macrophage Migration Inhibitory Factor Promotes Thromboinflammation and Predicts Fast Progression of Aortic Stenosis

BACKGROUND

Aortic stenosis (AS) is driven by progressive inflammatory and fibrocalcific processes regulated by circulating inflammatory and valve resident endothelial and interstitial cells. The impact of platelets, platelet-derived mediators, and platelet-monocyte interactions on the acceleration of local valvular inflammation and mineralization is presently unknown.

METHODS

We prospectively enrolled 475 consecutive patients with severe symptomatic AS undergoing aortic valve replacement. Clinical workup included repetitive echocardiography, analysis of platelets, monocytes, chemokine profiling, aortic valve tissue samples for immunohistochemistry, and gene expression analysis.

RESULTS

The patients were classified as fast-progressive AS by the median ∆Vmax of 0.45 m/s per year determined by echocardiography. Immunohistological aortic valve analysis revealed enhanced cellularity in fast-progressive AS (slow- versus fast-progressive AS; median [interquartile range], 247 [142.3-504] versus 717.5 [360.5-1234]; P<0.001) with less calcification (calcification area, mm2: 33.74 [27.82-41.86] versus 20.54 [13.52-33.41]; P<0.001). MIF (macrophage migration inhibitory factor)-associated gene expression was significantly enhanced in fast-progressive AS accompanied by significantly elevated MIF plasma levels (mean±SEM; 6877±379.1 versus 9959±749.1; P<0.001), increased platelet activation, and decreased intracellular MIF expression indicating enhanced MIF release upon platelet activation (CD62P, %: median [interquartile range], 16.8 [11.58-23.8] versus 20.55 [12.48-32.28], P=0.005; MIF, %: 4.85 [1.48-9.75] versus 2.3 [0.78-5.9], P<0.001). Regression analysis confirmed that MIF-associated biomarkers are strongly associated with an accelerated course of AS.

CONCLUSIONS

Our findings suggest a key role for platelet-derived MIF and its interplay with circulating and valve resident monocytes/macrophages in local and systemic thromboinflammation during accelerated AS. MIF-based biomarkers predict an accelerated course of AS and represent a novel pharmacological target to attenuate progression of AS.

Disproportionately high aortic valve calcium scores in atrial fibrillation: implications for transcatheter aortic valve replacement

AIMS

Doppler mean gradient (MG) can underestimate aortic stenosis (AS) severity in patients with atrial fibrillation (AF) compared with patients with sinus rhythm (SR), potentially delaying intervention in AF. This study compared outcomes in patients with AF and SR following transcatheter aortic valve replacement (TAVR) and investigated delay in TAVR based on computed tomography aortic valve calcium score (AVCS).

METHODS AND RESULTS

Patients who underwent TAVR from 2013 to 2017 for native valve severe AS were identified from an institutional database. Baseline characteristics and overall survival were compared between those with SR and AF. There were 820 patients (mean age 81 years; 41.6% females) included in this study. AF was present in 356 patients. Patients with AF were older (82.2 vs. 80.5, P = 0.003) and had a lower MG compared with patients with SR (42.0 vs. 44.9, P = 0.002) with similar indexed aortic valve area (0.4 vs. 0.4, P = 0.17). Median AVCS was higher in AF (males: AF 2850.0 vs. SR 2561.0, P = 0.044; females: AF 1942.0 vs. SR 1610.5, P = 0.025). Projected AVCS, assuming the same age of diagnosis, was similar between AF and SR. Median survival post-TAVR was worse in AF compared with SR (3.2 vs. 5.4 years, log rank P < 0.001). AF, lower MG, higher right ventricular systolic pressure, dialysis, diabetes, and significant tricuspid regurgitation were associated with higher mortality (P < 0.05 for all).

CONCLUSION

Older age and higher AVCS in patients with AF compared with those with SR suggest that AS was both underestimated and more advanced at TAVR referral.

A novel functional index, aortic-valve-coefficient, for assessing aortic-stenosis in patients undergoing TAVR: A prospective-pilot study

BACKGROUND

Evaluating the severity of aortic stenosis (AS) can be challenging, particularly in patients with low-gradient (LG, Δp < 40 mmHg) AS.

OBJECTIVE

This study aims to improve the accuracy of assessing severity of AS using a novel functional index- Aortic Valve Coefficient (AVC). The AVC is defined as ratio of mean transvalvular pressure-drop (Δp) to the proximal dynamic pressure (1/2 × blood density × VLVOT2; VLVOT: left ventricular outflow tract peak velocity).

HYPOTHESIS

AVC, developed from fundamental fluid dynamic principles, is a better index for accessing AS severity as it incorporates square of VLVOT and downstream pressure recovery.

METHODS

This pilot prospective study enrolled 47 patients undergoing TAVR for AS. Using cardiac-catheterization-measured Δp and echocardiography-Doppler-derived VLVOT, AVC was evaluated. Pre- and post-TAVR pressure-velocity measurements were obtained, resulting in a dataset with 78 data points, including 32 data points specifically linked to LG AS. Linear regression analysis was performed to correlate AVC with Δp, VLVOT and aortic-valve-area. Welch 2-sample t-test was carried out to compare the means of AVC against aortic-valve-area.

RESULTS

Moderate correlation (r = 0.85) was observed between AVC and aortic-valve-area indicating AVC could be a prospective index. However, correlation decreased (r = 0.75) in LG AS patients, indicating increased discordancy. Comparing AVC and aortic-valve-area in LG AS patients with left ventricular ejection fraction (LVEF) < 50 % and LVEF ≥50 %, t-test showed that AVC values are significantly different (p < 0.05) as compared to aortic-valve-area (p = 0.48).

CONCLUSION

AVC, a novel index, has the potential to improve assessment of AS severity and clinical decision making for treating patients with AS.

CONDENSED ABSTRACT

Complex hemodynamics, such as paradoxical "low-flow low-gradient (LG)" Aortic stenosis (AS) can be difficult to diagnose. Currently, mean transvalvular pressure-drop and flow-derived aortic-valve-area assess AS severity. Aortic valve coefficient (AVC) is a novel index which combines both pressure-drop and flow measurements to assess the severity of AS. A total of 47 patients (72 data points) were studied undergoing TAVR. In LG AS patients, t-test comparing left ventricular ejection fraction (LVEF) < 50 % and LVEF ≥50 % showed that AVC are significantly different (p < 0.05) as compared to aortic-valve-area (p = 0.48). Therefore, AVC could be a better index.

Impact of Procedural Success Definitions on Long-Term Outcomes in Patients With Rheumatic Mitral Stenosis Treated With Percutaneous Balloon Mitral Valvuloplasty: A Multicenter, Retrospective Cohort Study

BACKGROUND

It is uncertain which percutaneous balloon mitral valvuloplasty (PBMV) success definitions should be used because there are no studies comparing the effects of these definitions on subsequent outcomes. We evaluated the association between 3 success definitions and long-term clinical outcomes in patients with rheumatic mitral stenosis who underwent PBMV.

METHODS AND RESULTS

This multicenter retrospective study included patients with severe rheumatic mitral stenosis who underwent PBMV. Three definitions were used as follows: (A) post-PBMV mitral valve area (MVA) ≥1.5 cm2 or ≥50% increase in MVA with MR <3+; (B) post-PBMV MVA ≥1.5 cm2 and MR ≤2+; and (C) post-PBMV MVA ≥1.5 cm2 or ≥50% increase in MVA, with no more than 1-grade increment in MR. Multivariable Cox regression analyses were performed to evaluate the associations between PBMV success and the composite of all-cause mortality, mitral surgery, and repeat PBMV. Successful PBMV, according to definitions A, B, and C was associated with a lower risk of the composite outcomes (definition A-hazard ratio [HR], 0.55 [95% CI, 0.43-0.69], definition B-HR, 0.55 [95% CI, 0.43-0.69], definition C-HR, 0.55 [95% CI, 0.44-0.69]). Patients meeting all 3 success definitions had the lowest risk compared with those who did not meet any definition or met 1 or 2 definitions.

CONCLUSIONS

All 3 success definitions had a prognostic impact on outcomes. Patients who achieved post-PBMV MVA ≥1.5 cm2, irrespective of the percentage increase in MVA, and MR ≤grade 2, with no more than a 1-grade increment in MR, had the most favorable outcomes.

Left Ventricular Remodeling in Patients with Low Flow Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Low-flow (LF) aortic stenosis (AS) is common among older adults and associated with worse outcomes than AS with normal stroke volume. It is unknown whether left ventricular (LV) remodeling identifies patients with LF AS at higher risk of complications. LV remodeling was evaluated in 463 patients with severe LF AS referred for transcatheter aortic valve replacement (TAVR) and classified as adaptive (normal geometry and concentric remodeling) or maladaptive (concentric and eccentric hypertrophy) using the American Society of Echocardiography gender-specific criteria. Of these, the 390 patients who underwent TAVR were followed for the end points of heart failure (HF) hospitalization and all-cause mortality. The mean patient age was 79 (74.5 to 84) years. LV remodeling was adaptive in 57.4% (62 normal geometry, 162 concentric remodeling) and maladaptive in 42.6% (127 concentric hypertrophy, 39 eccentric hypertrophy). During a median follow-up of 3 years, 45 patients (11.5%) were hospitalized for HF and 73 (18.7%) died. After adjustment for widely used echocardiographic parameters, maladaptive remodeling was independently associated with HF hospitalization and death (adjusted hazard ratio 1.75, confidence interval 1.03 to 3.00). There was no significant difference between men and women in the association of maladaptive LV remodeling with the composite outcome (p = 0.40 for men and p = 0.06 for women). In conclusion, in patients with LF AS, maladaptive LV remodeling before TAVR is independently associated with higher incidences of postprocedural HF rehospitalization and death in both men and women. Assessment of LV remodeling has prognostic value over and above LV ejection fraction and may improve risk stratification for patients with LF AS.

Prevalence and prognosis of aortic valve diseases in patients hospitalized with heart failure with mildly reduced ejection fraction

AIMS

Data regarding the characterization and outcomes of patients with heart failure (HF) with mildly reduced ejection fraction (HFmrEF) is scarce. This study investigates the characteristics and prognostic impact of native aortic valve diseases (AVD) in patients with HFmrEF.

METHODS AND RESULTS

Consecutive patients hospitalized with HFmrEF (i.e. left ventricular ejection fraction 41-49% and signs and/or symptoms of HF) were retrospectively included at one institution from 2016 to 2022. The prognostic impact of native aortic valve stenosis (AS), aortic valve regurgitation (AR) and mixed AVD (MAVD) was investigated for the primary endpoint of long-term all-cause mortality during a median follow-up of 30 months. Kaplan-Meier, univariable and multivariable Cox proportional analyses were applied. From a total of 2106 patients hospitalized with HFmrEF, the prevalence of AS and AR was 16.5% and 31.2%, respectively (MAVD 7.8%). The presence of moderate/severe AS was associated with a higher risk of long-term all-cause mortality (44.8% vs. 28.7%; p = 0.001) and HF-related rehospitalization (18.6% vs. 12.0%; p = 0.001), even after multivariable adjustment (mortality: hazard ratio [HR] 1.320; 95% confidence interval [CI] 1.035-1.684; p = 0.025; HF-related rehospitalization: HR 1.570; 95% CI 1.101-2.241; p = 0.013). Interestingly, even mild AS was associated with increased risk of long-term all-cause mortality compared to patients without AS (HR 1.477; 95% CI 1.101-1.982; p = 0.009). In contrast, the presence of AR was not associated with long-term outcomes after multivariable adjustment.

CONCLUSIONS

The presence of AS, but not AR, was independently associated with increased risk of all-cause mortality and HF-related rehospitalization in patients with HFmrEF. Even milder stages of AS were associated with impaired prognosis.

Validation of Yeo's index in assessing severity of rheumatic mitral stenosis in mixed valve lesions

Introduction

Yeo's Index, product of the mitral leaflet separation index and dimensionless index, is a novel measure of the severity of rheumatic mitral stenosis (MS). We assess Yeo's index in patients with rheumatic MS with or without mixed valve disease.

Methods

In a retrospective cohort study, Yeo's index was measured in 237 cases of rheumatic MS - 124 in a transthoracic echocardiography validation cohort using mitral valve area (MVA) by pressure half-time and planimetry as comparator and 113 in a transesophageal echocardiography (TEE) validation cohort using TEE three-dimensional MVA as comparator. Patients were considered to have mixed valve disease if they had MS and concomitant mitral regurgitation or aortic valve disease.

Results

There were 113 patients with isolated MS and 124 patients with mixed valve disease. Overall, Yeo's index ≤ 0.26 cm showed 93.0 % sensitivity and 87.5 % specificity for identifying severe MS (MVA ≤ 1.5 cm2). In isolated MS, Yeo's index ≤ 0.26 cm showed sensitivity of 94.6 % and specificity of 90.0 % for identifying severe MS, while in mixed valve disease sensitivity was 90.6 % and specificity 86.7 %. Overall, Yeo's index ≤ 0.15 cm showed 83.6 % sensitivity and 94.3 % specificity for very severe MS (MVA ≤ 1.0 cm2). In isolated MS, the threshold of ≤0.15 cm showed sensitivity of 84.4 % and specificity of 92.6 % for very severe MS, while in mixed valve disease sensitivity was 81.3 % and specificity 95.3 %. The presence of atrial fibrillation did not influence the performance of Yeo's index.

Conclusion

Yeo's Index accurately differentiates severity of rheumatic MS with or without mixed valve disease.

Prognostic value of extraaortic-valvular cardiac damage in patients with moderate aortic stenosis and reduced left ventricular ejection fraction

PURPOSE

The extraaortic-valvular cardiac damage (EVCD) Stage has shown potential for risk stratification for patients with aortic stenosis (AS). This study aimed to examine the usefulness of the EVCD Stage in risk stratification of patients with moderate AS and reduced left ventricular ejection fraction (LVEF).

METHODS

Clinical data from patients with moderate AS (aortic valve area, .60-.85 cm2/m2; peak aortic valve velocity, 2.0-4.0 m/s) and reduced LVEF (LVEF 20%-50%) were analyzed during 2010-2019. Patients were categorized into three groups: EVCD Stages 1 (LV damage), 2 (left atrium and/or mitral valve damage), and 3/4 (pulmonary artery vasculature and/or tricuspid valve damage or right ventricular damage). The primary endpoint included a composite of cardiac death and heart failure hospitalization, with non-cardiac death as a competing risk.

RESULTS

The study included 130 patients (mean age 76.4 ± 6.8 years; 62.3% men). They were categorized into three groups: 26 (20.0%) in EVCD Stage 1, 66 (50.8%) in Stage 2, and 48 (29.2%) in Stage 3/4. The endpoint occurred in 54 (41.5%) patients during a median follow-up of 3.2 years (interquartile range, 1.4-5.1). Multivariate analysis indicated EVCD Stage 3/4 was significantly associated with the endpoint (hazard ratio 2.784; 95% confidence interval 1.197-6.476; P = .017) compared to Stage 1, while Stage 2 did not (hazard ratio 1.340; 95% confidence interval .577-3.115; P = .500).

CONCLUSION

The EVCD staging system may aid in the risk stratification of patients with moderate AS and reduced LVEF.

Cardiopulmonary haemodynamics in Tibetans and Han Chinese during rest and exercise

During sea-level exercise, blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) in humans without a patent foramen ovale (PFO) is negatively correlated with pulmonary pressure. Yet, it is unknown whether the superior exercise capacity of Tibetans well adapted to living at high altitude is the result of lower pulmonary pressure during exercise in hypoxia, and whether their cardiopulmonary characteristics are significantly different from lowland natives of comparable ancestry (e.g. Han Chinese). We found a 47% PFO prevalence in male Tibetans (n = 19) and Han Chinese (n = 19) participants. In participants without a PFO (n = 10 each group), we measured heart structure and function at rest and peak oxygen uptake (V ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ ), peak power output (W ̇ p e a k ${{\dot{W}}_{peak}}$ ), pulmonary artery systolic pressure (PASP), blood flow through IPAVA and cardiac output (Q ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ ) at rest and during recumbent cycle ergometer exercise at 760 Torr (SL) and at 410 Torr (ALT) barometric pressure in a pressure chamber. Tibetans achieved a higherW peak ${W}_{\textit{peak}}$ than Han, and a higherV ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ at ALT without differences in heart rate, stroke volume orQ ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ . Blood flow through IPAVA was generally similar between groups. Increases in PASP and total pulmonary resistance at ALT were comparable between the groups. There were no differences in the slopes of PASP plotted as a function ofQ ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ during exercise. In those without PFO, our data indicate that the superior aerobic exercise capacity of Tibetans over Han Chinese is independent of cardiopulmonary features and more probably linked to differences in local muscular oxygen extraction. KEY POINTS: Patent foramen ovale (PFO) prevalence was 47% in Tibetans and Han Chinese living at 2 275 m. Subjects with PFO were excluded from exercise studies. Compared to Han Chinese, Tibetans had a higher peak workload with acute compression to sea level barometric pressure (SL) and acute decompression to 5000 m altitude (ALT). Comprehensive cardiac structure and function at rest were not significantly different between Han Chinese and Tibetans. Tibetans and Han had similar blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) during exercise at SL. Peak pulmonary artery systolic pressure (PASP) and total pulmonary resistance were different between SL and ALT, with significantly increased PASP for Han compared to Tibetans at ALT. No differences were observed between groups at acute SL and ALT.

Incidence and predictors of adverse outcomes in patients with rheumatic mitral stenosis following percutaneous balloon mitral valvuloplasty: a study from a tertiary center in Thailand

BACKGROUND

Rheumatic mitral stenosis (MS) remains a common and concerning health problem in Asia. Percutaneous balloon mitral valvuloplasty (PBMV) is the standard treatment for patients with symptomatic severe MS and favorable valve morphology. However, studies on the incidence and predictors of adverse cardiac outcomes following PBMV in Asia have been limited. This study aims to evaluate the incidence and predictors of adverse outcomes in patients with rheumatic MS following PBMV.

METHODS

A retrospective cohort study was conducted on patients with symptomatic severe MS who underwent successful PBMV between 2002 and 2020 at a tertiary academic institute in Thailand. Patients were followed up to assess adverse outcomes, defined as a composite of cardiac death, heart failure hospitalization, repeat PBMV, or mitral valve surgery. Univariable and multivariable analyses were performed to identify predictors of adverse outcomes. A p-value of < 0.05 was considered statistically significant.

RESULTS

A total of 379 patients were included in the study (mean age 43 ± 11 years, 80% female). During a median follow-up of 5.9 years (IQR 1.7-11.7), 74 patients (19.5%) experienced adverse outcomes, with an annualized event rate of 2.7%. Multivariable analysis showed that age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.008-1.05, p = 0.006), significant tricuspid regurgitation (HR 2.17, 95% CI 1.33-3.56, p = 0.002), immediate post-PBMV mitral valve area (HR 0.39, 95% CI 0.25-0.64, p = 0.01), and immediate post-PBMV mitral regurgitation (HR 1.91, 95% CI 1.18-3.07, p = 0.008) were independent predictors of adverse outcomes.

CONCLUSIONS

In patients with symptomatic severe rheumatic MS, the incidence of adverse outcomes following PBMV was 2.7% per year. Age, significant tricuspid regurgitation, immediate post-PBMV mitral valve area, and immediate post-PBMV mitral regurgitation were identified as independent predictors of these adverse outcomes.

Impact of Net Atrioventricular Compliance on Mitral Valve Area Assessment-A Perspective Considering Three-Dimensional Mitral Valve Area by Transesophageal Echocardiography

BACKGROUND

Net atrioventricular compliance (Cn) can affect the accuracy of mitral valve area (MVA) assessment. We assessed how different methods of MVA assessment are affected by Cn, and if patients with abnormal Cn may be identified by clinical and/or echocardiographic parameters.

METHODS

We studied 244 patients with rheumatic MS. The concordance between mitral valve area (MVA) by 2D planimetry, pressure half-time (PHT), continuity equation (CE), Yeo's index, and 3-dimensional mitral valve area assessed by transesophageal echocardiography (TEE 3DMVA) in patients with normal and abnormal Cn (Cn ≤ 4 mL/mmHg) were evaluated in the 110 patients with both transesophageal echocardiogram (TEE) and transthoracic echocardiogram (TTE). Variables that were associated with abnormal Cn were validated in the remaining 134 patients with only TTE.

RESULTS

Except for MVA by CE, concordance with TEE 3DMVA was poorer for all other methods of MVA assessment in patients with abnormal Cn. But, the difference in concordance was only statistically significant for MVA by PHT. Patients with MVA ≤ 1.5 cm2 by 2D planimetry and PHT ≤ 130 ms were likely to have an abnormal Cn. (specificity 98.5%). This finding was validated in the remaining 134 patients (specificity 93%).

CONCLUSIONS

MVA assessment by PHT is significantly affected by Cn. Abnormal Cn should be suspected when 2D planimetry MVA is ≤1.5 cm2 together with an inappropriately short PHT that is ≤130 ms. In this scenario, MVA by PHT is inaccurate.

Bioimpedance analysis predicts worsening events in outpatients with heart failure and reduced ejection fraction

AIMS

Heart failure (HF) with reduced left ventricle ejection fraction (LVEF) is an entity with poor prognosis characterized by decompensations. Bioelectrical impedance analysis (BIA) is used to assess volume overload (VO) and may be useful to identify apparently stable HF outpatients at risk of decompensation. The aim of this study is to analyse whether VO assessed by BIA is associated with worsening heart failure (WHF) in stable outpatients with HF and reduced LVEF (HFrEF).

METHODS AND RESULTS

This is a prospective single-centre observational study. Consecutive stable HF outpatients with LVEF below 40% underwent BIA, transthoracic echocardiography, blood sampling, and physical examination and were followed up for 3 months. VO was defined as the difference between the measured weight and the dry weight assessed by BIA. Demographic, clinical, anthropometric, echocardiographic, and analytical parameters were recorded. The primary endpoint was WHF, defined by visits to the emergency department for HF or hospitalization for HF. A total of 100 patients were included. The median VO was 0.5 L (interquartile range 0-1.6 L). Eleven patients met the primary endpoint. Univariate binary logistic regression analysis showed that left ventricle filling pressures assessed by E/e', N-terminal pro B-type natriuretic peptide, inferior vena cava dilatation (≥21 mm), signs of congestion, and VO were associated with the primary endpoint. Binary logistic regression multivariate analysis showed that VO was the only independent predictor for the primary endpoint (adjusted OR 2.7; 95% CI 1.30-5.63, P = 0.008). Multivariate Cox regression analysis also showed an adjusted hazard ratio (HR) for VO of 2.03; 95% CI 1.37-3.02, P < 0.001. Receiver-operating characteristic curve analysis showed an area under the curve for VO of 0.88 (95% CI 0.79-0.97, P < 0.001) with an optimal cut-off of 1.2 L.

CONCLUSIONS

VO assessed by BIA is independently associated with WHF in stable outpatients with HFrEF at 3 months.

Pro-angiogenic cytokine features of left ventricular remodeling in patients with bicuspid aortic valve

OBJECTIVE

Bicuspid aortic valve (BAV) is prone to promote left ventricular remodeling (LVR), which is associated with adverse clinical outcomes. Although the association between angiogenic activity and LVR has been established, pro-angiogenic cytokine features and potential biomarker candidates for LVR in patients with BAV remain to be clarified.

METHODS

From November 2018 to May 2019, patients with BAV diagnosed by transthoracic echocardiography at our institution were included. LVR was diagnosed on the basis of echocardiographic calculations of relative wall thickness (RWT) and left ventricular mass index (LVMI). A multiplex ELISA array was used to measure the plasma levels of 60 angiogenesis-related cytokines.

RESULTS

Among 103 patients with BAV, 71 were categorized into the LVR group and 32 into the normal left ventricular (LV) geometry group. BAV patients with LVR demonstrated increased LVMI, elevated prevalence of moderate to severe aortic stenosis and aortic regurgitation, and decreased LV ejection fraction (LVEF). Plasma levels of angiopoietin-1 were elevated in BAV patients with or without LVR compared with healthy controls (P = 0.001, P < 0.001, respectively), and were negatively correlated with RWT (r = -0.222, P = 0.027). Plasma levels of angiopoietin-2 were elevated in the LVR group (P = 0.001) compared with the normal LV geometry group, and were negatively correlated with LVEF (r = -0.330, P = 0.002).

CONCLUSION

Decreased angiogenesis plays a crucial role in the occurrence and progression of LVR in patients with BAV. Disturbance in the pro- and anti-angiogenesis equilibrium in BAV patients with LVR may reflect the aggravation of endothelial injury and dysfunction.

Myocardial transcriptomic analysis of diabetic patients with aortic stenosis: key role for mitochondrial calcium signaling

BACKGROUND

Type 2 diabetes (T2D) is a frequent comorbidity encountered in patients with severe aortic stenosis (AS), leading to an adverse left ventricular (LV) remodeling and dysfunction. Metabolic alterations have been suggested as contributors of the deleterious effect of T2D on LV remodeling and function in patients with severe AS, but so far, the underlying mechanisms remain unclear. Mitochondria play a central role in the regulation of cardiac energy metabolism.

OBJECTIVES

We aimed to explore the mitochondrial alterations associated with the deleterious effect of T2D on LV remodeling and function in patients with AS, preserved ejection fraction, and no additional heart disease.

METHODS

We combined an in-depth clinical, biological and echocardiography phenotype of patients with severe AS, with (n = 34) or without (n = 50) T2D, referred for a valve replacement, with transcriptomic and histological analyses of an intra-operative myocardial LV biopsy.

RESULTS

T2D patients had similar AS severity but displayed worse cardiac remodeling, systolic and diastolic function than non-diabetics. RNAseq analysis identified 1029 significantly differentially expressed genes. Functional enrichment analysis revealed several T2D-specific upregulated pathways despite comorbidity adjustment, gathering regulation of inflammation, extracellular matrix organization, endothelial function/angiogenesis, and adaptation to cardiac hypertrophy. Downregulated gene sets independently associated with T2D were related to mitochondrial respiratory chain organization/function and mitochondrial organization. Generation of causal networks suggested a reduced Ca2+ signaling up to the mitochondria, with the measured gene remodeling of the mitochondrial Ca2+ uniporter in favor of enhanced uptake. Histological analyses supported a greater cardiomyocyte hypertrophy and a decreased proximity between the mitochondrial VDAC porin and the reticular IP3-receptor in T2D.

CONCLUSIONS

Our data support a crucial role for mitochondrial Ca2+ signaling in T2D-induced cardiac dysfunction in severe AS patients, from a structural reticulum-mitochondria Ca2+ uncoupling to a mitochondrial gene remodeling. Thus, our findings open a new therapeutic avenue to be tested in animal models and further human cardiac biopsies in order to propose new treatments for T2D patients suffering from AS.

TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov ; Unique Identifier: NCT01862237.

Combining 2D Planimetry and Yeo's Index Can Help Accurately Identify Patients with Severe Rheumatic Mitral Stenosis-A Perspective from a 3D Assessment Using Transoesophageal Echocardiography

BACKGROUND

Yeo's index is a novel measure of the severity of rheumatic mitral valve stenosis (MS). It is derived from the product of the mitral leaflet separation index and dimensionless index. This study aims to validate Yeo's index using a transesophageal echocardiogram (TEE) three-dimensional (3D) mitral valve area (MVA) as a comparator and to compare the concordance of existing echocardiographic measures of the MVA with TEE 3DMVA.

METHODS AND RESULTS

We studied 111 patients with rheumatic MS who underwent both transthoracic echocardiography (TTE) and a TEE assessment of MS severity. Yeo's index, the MVA determined by 2D planimetry, pressure half-time (PHT) and continuity equation (CE) measured on TTE were compared with the TEE 3DMVA. With a linear correlation, Yeo's index showed the best correlation with TEE 3DMVA (r2 = 0.775), followed by 2D planimetry (r2 = 0.687), CE (r2 = 0.598) and PHT (r2 = 0.363). Using TEE 3DMVA as comparator, Yeo's index (ρc = 0.739) demonstrated the best concordance, followed by 2D planimetry (ρc = 0.632), CE (ρc = 0.464) and PHT (ρc = 0.366). When both Yeo's index and 2D planimetry suggested significant MS, the positive predictive value was high (an AUC of 0.966 and a PPV of 100.00% for severe MS, and an AUC of 0.864 and a PPV of 85.71% for very severe MS). When both measures suggested the absence of significant MS, the negative predictive value was also high (an AUC of 0.940 and an NPV of 88.90% for severe MS, and an AUC of 0.831 and an NPV of 88.71% for very severe MS).

CONCLUSIONS

Yeo's index performed well in identifying severe MS when compared with TEE 3DMVA and may be a useful adjunct to existing methods of measuring MS severity. Combining it with 2D planimetry could further enhance its accuracy.

Mid-term outcomes of tricuspid annuloplasty using the Tri-Ad Adams tricuspid annuloplasty ring

OBJECTIVES

The Tri-Ad Adams tricuspid annuloplasty ring is a recent innovative prosthesis characterized by a semi-rigid central component and fully flexible extremities. The goal of this study was to assess the short-term and mid-term results following implantation of the Tri-Ad Adams ring.

METHODS

A retrospective analysis was conducted on patients who underwent tricuspid annuloplasty using the Tri-Ad Adams ring between August 2016 and October 2021.

RESULTS

Our study enrolled a total of 248 participants. The median age was 64.0 (interquartile range: 56.0-71.5) years. The median EuroSCORE II was 4.3% (2.7-7.5%), with 37 patients (14.9%) having a history of cardiac operations. Tricuspid regurgitation of grade 2-3 was observed in 63.7% of cases, and the median tricuspid annular diameter was 3.3 (2.8-3.6) cm. Concurrent procedures included mitral valve replacement (n = 160, 64.5%), mitral valve repair (n = 75, 30.2%), aortic valve replacement (n = 72, 29.0%) and the maze procedure (n = 170, 68.5%). Immediate postoperative tricuspid regurgitation≥moderate was present in 1 patient (0.4%). Early death occurred in 14 patients (5.6%). Major complications included low cardiac output syndrome (n = 18, 0.3%), acute kidney injury (n = 14, 5.6%) and permanent pacemaker placement (n = 15, 6.0%). According to the Kaplan-Meier analysis, the 4-year rates of freedom from overall mortality and moderate-to-severe tricuspid regurgitation were 96.9% and 91.6%, respectively. There were no incidents of tricuspid valve reoperations, ring detachment or significant tricuspid stenosis (trans-tricuspid valve gradient ≥ 5 mmHg).

CONCLUSIONS

Tricuspid annuloplasty utilizing the Tri-Ad Adams ring demonstrated favourable outcomes in both the early and midterm periods. Further studies are warranted to confirm the long-term results.

Mitral regurgitation carries greater prognostic significance than mitral stenosis in patients undergoing transcatheter aortic valve replacement

AIMS

This study assessed the outcomes of concomitant mitral valve disease and severe aortic stenosis in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Echocardiographic data of 813 patients with severe aortic stenosis undergoing transfemoral TAVR were collected, and clinical outcomes were analyzed for individuals with mitral stenosis and mitral regurgitation.

RESULTS

The final cohort includes 788 patients with severe calcific aortic stenosis. Among single parameters of mitral stenosis, a smaller baseline mitral valve area (MVA) by the continuity equation and higher postprocedural mean mitral gradients (MMG) were associated with an increased risk of death at 1 year (P-values 0.02 and <0.01, respectively), but no correlation with outcomes was demonstrated after multivariate adjustment for major prognosticators. Mitral stenosis (based on MVA + MMG) was not associated with complications or mortality. Mitral regurgitation was present in 94.6% of the population at baseline and regressed by at least one grade post-TAVR in 28% of the patients. The improvement in mitral regurgitation was associated with a greater prosthetic effective orifice area (P-value 0.03). Significant (at least moderate) residual mitral regurgitation was correlated with short-term complications and shown to be an independent predictor of 1-year mortality (P-value 0.02, odds ratio (OR) 5.37, confidence interval 1.34-21.5).

CONCLUSION

Mitral regurgitation has a greater impact on TAVR patients than mitral stenosis as assessed by functional methods.

Handmade Bicuspid Valved Polytetrafluoroethylene Conduit for Right Ventricular Outflow Tract Reconstruction

Background: Excellent outcomes of right ventricle to pulmonary artery conduits with polytetrafluoroethylene (PTFE) valves have been reported. The purpose of this study was to analyze the short-term results of our handmade PTFE bicuspid valved conduit (VC) for right ventricular outflow tract reconstruction. Methods: Between September 2019 and May 2023, bicuspid PTFE-VC was implanted in 17 patients at a median age of 2.5 years (range, 3 months to 13.6 years). The PTFE-VC was fashioned from a commercially available PTFE tube graft (14 mm in three patients, 16 mm in three patients, 18 mm in one patient, 20 mm in three patients, and 22 mm in seven patients) and 0.1 mm thick PTFE membrane for the leaflet material. Valve function was assessed by echocardiogram after the implantation. The conduit reoperation and the conduit dysfunction were analyzed. There were no early deaths, but there was one late death. Results: There were no postoperative in-hospital deaths. Follow-up echocardiograms were available for 14 of 17 patients. The median follow-up was 21 months (range, 7-49 months). Conduit stenosis was none or trivial in 11 patients while it was mild in two and moderate in one patient and severe in 0 patients. Conduit insufficiency was mild or trivial in all 14 patients. By the end of the study period, freedom from reoperation/reintervention was 100%. There were no episodes of aneurysmal dilatation of the conduit or endocarditis. Conclusions: Handmade bicuspid PTFE VC shows good short-term outcome, with no significant valve dysfunction and no reintervention. A longer follow-up is necessary to evaluate the long-term advantages of using the handmade bicuspid PTFE VC.

Association Between Vegetation Size and Outcome in the Partial Oral Antibiotic Endocarditis Treatment Trial

Step-down oral antibiotic therapy is associated with a non-inferior long-term outcome compared with continued intravenous antibiotic therapy in the treatment of left-sided infective endocarditis. We aimed to analyze whether step-down oral therapy compared with continued intravenous antibiotic therapy is also associated with a non-inferior outcome in patients with large vegetations (vegetation length ≥ 10 mm) or among patients who underwent surgery before step-down oral therapy. We included patients without presence of aortic root abscess at diagnosis from the POET (Partial Oral Antibiotic Endocarditis Treatment) study. Multivariable Cox regression analyses were used to find associations between large vegetation, cardiac surgery, step-down oral therapy, and the primary end point (composite of all-cause mortality, unplanned cardiac surgery, embolic event, or relapse of positive blood cultures during follow-up). A total of 368 patients (age 68 ± 12, 77% men) were included. Patients with large vegetations (n = 124) were more likely to undergo surgery compared with patients with small vegetations (n = 244) (65% vs 20%, p <0.001). During a median 1,406 days of follow-up, 146 patients reached the primary end point. Large vegetations were not associated with the primary end point (hazard ratio 0.74, 95% confidence interval 0.47 to 1.18, p = 0.21). Step-down oral therapy was non-inferior to continued intravenous antibiotic in all subgroups when stratified by the presence of a large vegetation at baseline and early cardiac surgery. Step-down oral therapy is safe in the presence of a large vegetation at diagnosis and among patients who underwent early cardiac surgery.

Modified Clover Technique Using Automated Suture Placement and Securing Technology in a Passive Beating Heart Model

Tricuspid regurgitation (TR) is a prevalent finding in echocardiography and in case of severe disease is associated with impaired patient outcome. Clover repair offers a surgical solution that can be applied for the treatment of primary and secondary TR. An ex vivo passive beating porcine heart model was created to test a modified clover technique using automated suturing devices and to compare this approach to standard ring annuloplasty. Secondary TR was induced in 10 porcine hearts and the backflow of fluid was assessed. The primary endpoint of this study was regurgitant volume measured in mL at the site right atrial cannula. The baseline regurgitation was 43.3 ± 10.8 mL. The mean regurgitant volume was significantly reduced after all repair procedures to 22.2 ± 5.9 mL with isolated ring annuloplasty, 12 ± 3.9 mL with the modified clover, and 7.6 ± 3.4 mL with the combined procedure (p < 0.0001). The modified clover technique shows how to effectively reduce TR in an ex vivo model. This method may be suitable to facilitate tricuspid repair, especially for totally endoscopic valve surgery.

2023 Korean Society of Echocardiography position paper for the diagnosis and management of valvular heart disease, part II: mitral and tricuspid valve disease

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the diagnosis and management of valvular heart diseases with referring to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee sought to reflect national data on the topic of valvular heart diseases published to date through a systematic literature search based on validity and relevance. In the part II of this article, we intend to present recommendations for diagnosis and treatment of mitral valve disease and tricuspid valve disease.

One-Year Outcome of an Ongoing Pre-Clinical Growing Animal Model for a Tissue-Engineered Valved Pulmonary Conduit

Objectives: A self-constructed valved pulmonary conduit made out of a de-cellularized porcine small intestinal submucosal extracellular matrix biological scaffold was tested in a chronic growing lamb model. Methods: The conduit was implanted in pulmonary valve position in 19 lambs. We monitored clinical, laboratory, and echocardiographic findings until 12 months after surgery. In two animals, euthanasia was planned at nine and twelve months. Pre-mortem chest computed tomography and post-mortem pathologic work up were performed. Data are presented as frequency and percentage, median and range, or mean and standard deviation. Results: Twelve (63.2%) animals survived the perioperative period. Three unexpected deaths occurred during the follow-up period: one due to aspiration pneumonia at 23 days after surgery, and two due to early and late infective endocarditis of the conduit at 18 and 256 days. In the two animals with planned scarification, the pre-mortem CT scan revealed mild or no calcification within the conduit or valve leaflets. In the echocardiographic examination at 12 months, peak and mean systolic pressure gradients across the conduit valve were 6.5 (3-21) mmHg and 3 (2-12) mmHg, while valve regurgitation was none (n = 2), trivial (n = 5), moderate (n = 1), or severe (n = 1). No clinical or laboratory signs of hemolysis were seen. After 12 months of follow-up, the animals' body weights had increased from 33 (27-38) kg to 53 (38-66) kg (p = 0.010). Conclusions: Implantation of a valved pulmonary conduit in our growing lamb model was feasible. Infective endocarditis of the implanted valved conduit remained a significant complication.

Myocardial Blood Flow Reserve, Microvascular Coronary Health, and Myocardial Remodeling in Patients With Aortic Stenosis

BACKGROUND

Coronary microvascular function and hemodynamics may play a role in coronary circulation and myocardial remodeling in patients with aortic stenosis (AS). We aimed to evaluate the relationship between myocardial blood flow and myocardial function in patients with AS, no AS, and aortic valve sclerosis.

METHODS AND RESULTS

We included consecutive patients who had resting transthoracic echocardiography and clinically indicated positron emission tomography myocardial perfusion imaging to capture their left ventricular ejection fraction, global longitudinal strain (GLS), and myocardial flow reserve (MFR). The primary outcome was major adverse cardiovascular event (all-cause mortality, myocardial infarction, or late revascularization). There were 2778 patients (208 with aortic sclerosis, 39 with prosthetic aortic valve, 2406 with no AS, and 54, 49, and 22 with mild, moderate, and severe AS, respectively). Increasing AS severity was associated with impaired MFR (P<0.001) and GLS (P<0.001), even when perfusion was normal. Statistically significant associations were noted between MFR and GLS, MFR and left ventricular ejection fraction, and MFR and left ventricular ejection fraction reserve. After a median follow-up of 349 (interquartile range, 116-662) days, 4 (7.4%), 5 (10.2%), and 6 (27.3%) patients experienced a major adverse cardiovascular event in the mild, moderate, and severe AS groups, respectively. In a matched-control analysis, patients with mild-to-moderate AS had higher rates of impaired MFR (52.9% versus 39.9%; P=0.048) and major adverse cardiovascular event (11.8% versus 3.0%; P=0.002).

CONCLUSIONS

Despite lack of ischemia, as severity of AS increased, MFR decreased and GLS worsened, reflecting worse coronary microvascular health and myocardial remodeling. Positron emission tomography-derived MFR showed a significant independent correlation with left ventricular ejection fraction and GLS. Patients with prosthetic aortic valve showed a high prevalence of impaired MFR.

Severe aortic stenosis: secular trends of incidence and outcomes

BACKGROUND AND AIMS

Severe aortic stenosis (AS) is the guideline-based indication for aortic valve replacement (AVR), which has markedly increased with transcatheter approaches, suggesting possible increasing AS incidence. However, reported secular trends of AS incidence remain contradictory and lack quantitative Doppler echocardiographic ascertainment.

METHODS

All adults residents in Olmsted County (MN, USA) diagnosed over 20 years (1997-2016) with incident severe AS (first diagnosis) based on quantitatively defined measures (aortic valve area ≤ 1 cm2, aortic valve area index ≤ 0.6 cm2/m2, mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, Doppler velocity index ≤ 0.25) were counted to define trends in incidence, presentation, treatment, and outcome.

RESULTS

Incident severe AS was diagnosed in 1069 community residents. The incidence rate was 52.5 [49.4-55.8] per 100 000 patient-year, slightly higher in males vs. females and was almost unchanged after age and sex adjustment for the US population 53.8 [50.6-57.0] per 100 000 residents/year. Over 20 years, severe AS incidence remained stable (P = .2) but absolute burden of incident cases markedly increased (P = .0004) due to population growth. Incidence trend differed by sex, stable in men (incidence rate ratio 0.99, P = .7) but declining in women (incidence rate ratio 0.93, P = .02). Over the study, AS clinical characteristics remained remarkably stable and AVR performance grew and was more prompt (from 1.3 [0.1-3.3] years in 1997-2000 to 0.5 [0.2-2.1] years in 2013-16, P = .001) but undertreatment remained prominent (>40%). Early AVR was associated with survival benefit (adjusted hazard ratio 0.55 [0.42-0.71], P < .0001). Despite these improvements, overall mortality (3-month 8% and 3-year 36%), was swift, considerable and unabated (all P ≥ .4) throughout the study.

CONCLUSIONS

Over 20 years, the population incidence of severe AS remained stable with increased absolute case burden related to population growth. Despite stable severe AS presentation, AVR performance grew notably, but while declining, undertreatment remained substantial and disease lethality did not yet decline. These population-based findings have important implications for improving AS management pathways.

Beyond prevalence: significance and differential impact of echocardiographic abnormalities in dialysis patients

BACKGROUND

Echocardiography is commonly used to assess hydratation status and cardiac function in kidney failure patients, but the impact of structural or functional abnormalities on the prognosis of kidney failure patients was yet to be investigated. This study aimed to investigate the prevalence and clinical significance of echocardiographic abnormalities in kidney failure patients.

METHODS

This study included 857 kidney failure patients who underwent echocardiography at dialysis initiation. Patients were followed up for a median of 4.2 years for the occurrence of major adverse cardiovascular events (MACE) and all-cause mortality.

RESULTS

Among the 857 patients studied, 77% exhibited at least one echocardiographic abnormality. The most common abnormalities were left ventricular hypertrophy and left atrial enlargement, but they were not significantly correlated with poor outcomes. Instead, the primary predictors of both major adverse cardiovascular events and mortality in kidney failure patients were left ventricular systolic function, right ventricular systolic function, left ventricular volume index, and valvular abnormalities. Although diastolic dysfunction was linked to major adverse cardiovascular events, it was not associated with mortality. Furthermore, the study revealed that increased left ventricular volume index and left ventricular systolic dysfunction had a more significant impact on peritoneal dialysis (PD) patients than on hemodialysis (HD) patients.

CONCLUSION

This study provides insights into the echocardiographic abnormalities and their association with adverse outcomes in kidney failure patients, which can help clinicians optimize the management of patients and closely monitor possible high-risk populations.

A Multimodal Video-Based AI Biomarker for Aortic Stenosis Development and Progression

Importance

Aortic stenosis (AS) is a major public health challenge with a growing therapeutic landscape, but current biomarkers do not inform personalized screening and follow-up. A video-based artificial intelligence (AI) biomarker (Digital AS Severity index [DASSi]) can detect severe AS using single-view long-axis echocardiography without Doppler characterization.

Objective

To deploy DASSi to patients with no AS or with mild or moderate AS at baseline to identify AS development and progression.

Design, Setting, and Participants

This is a cohort study that examined 2 cohorts of patients without severe AS undergoing echocardiography in the Yale New Haven Health System (YNHHS; 2015-2021) and Cedars-Sinai Medical Center (CSMC; 2018-2019). A novel computational pipeline for the cross-modal translation of DASSi into cardiac magnetic resonance (CMR) imaging was further developed in the UK Biobank. Analyses were performed between August 2023 and February 2024.

Exposure

DASSi (range, 0-1) derived from AI applied to echocardiography and CMR videos.

Main Outcomes and Measures

Annualized change in peak aortic valve velocity (AV-Vmax) and late (>6 months) aortic valve replacement (AVR).

Results

A total of 12 599 participants were included in the echocardiographic study (YNHHS: n = 8798; median [IQR] age, 71 [60-80] years; 4250 [48.3%] women; median [IQR] follow-up, 4.1 [2.4-5.4] years; and CSMC: n = 3801; median [IQR] age, 67 [54-78] years; 1685 [44.3%] women; median [IQR] follow-up, 3.4 [2.8-3.9] years). Higher baseline DASSi was associated with faster progression in AV-Vmax (per 0.1 DASSi increment: YNHHS, 0.033 m/s per year [95% CI, 0.028-0.038] among 5483 participants; CSMC, 0.082 m/s per year [95% CI, 0.053-0.111] among 1292 participants), with values of 0.2 or greater associated with a 4- to 5-fold higher AVR risk than values less than 0.2 (YNHHS: 715 events; adjusted hazard ratio [HR], 4.97 [95% CI, 2.71-5.82]; CSMC: 56 events; adjusted HR, 4.04 [95% CI, 0.92-17.70]), independent of age, sex, race, ethnicity, ejection fraction, and AV-Vmax. This was reproduced across 45 474 participants (median [IQR] age, 65 [59-71] years; 23 559 [51.8%] women; median [IQR] follow-up, 2.5 [1.6-3.9] years) undergoing CMR imaging in the UK Biobank (for participants with DASSi ≥0.2 vs those with DASSi <.02, adjusted HR, 11.38 [95% CI, 2.56-50.57]). Saliency maps and phenome-wide association studies supported associations with cardiac structure and function and traditional cardiovascular risk factors.

Conclusions and Relevance

In this cohort study of patients without severe AS undergoing echocardiography or CMR imaging, a new AI-based video biomarker was independently associated with AS development and progression, enabling opportunistic risk stratification across cardiovascular imaging modalities as well as potential application on handheld devices.

Insights into calcific aortic valve stenosis: a comprehensive overview of the disease and advancing treatment strategies

Aortic valve stenosis is a disease characterized by thickening and narrowing of the aortic valve (AV), most commonly due to calcification, which leads to left ventricular outflow obstruction called calcific aortic valve disease (CAVD). CAVD presents as a progressive clinical syndrome with cardiorespiratory symptoms, often with rapid deterioration. The modern-day pathophysiology of CAVD involves a complex interplay of genetic factors, chronic inflammation, lipid deposition, and valve calcification, with early CAVD stages resembling atherosclerosis. Various imaging modalities have been used to evaluate CAVD, with a recent trend of using advanced imaging to measure numerous AV parameters, such as peak jet velocity. Significant improvements in mortality have been achieved with transcatheter AV repair, but numerous therapeutics and modalities are being researched to delay the progression of CAVD. This article aims to provide a comprehensive review of CAVD, explore recent developments, and provide insights into future treatments with various novel modalities.

Congenitally Corrected Transposition of the Great Arteries in Utero: Morphological Spectrum, Outcomes and Pitfalls in Fetal Diagnosis

Congenitally corrected transposition of the great arteries (ccTGA) is a rare malformation with diverse morphology. We assessed features of fetuses with ccTGA and evaluated neonatal and pediatric outcomes. This was a retrospective review of fetuses with ccTGA at Birmingham Women's and Children's Hospital born from 2005 to 2019. Of thirty-six fetuses identified, six had unavailable prenatal data, one was postnatally diagnosed with isomerism and 29 fetuses were evaluated. ccTGA without associated cardiac lesions was found in 28% (8/29), ccTGA with significant VSD in 31% (9/29), ccTGA with pulmonary obstruction in 24% (7/29) and ccTGA with complex anomalies in 17% (5/29). Tricuspid regurgitation (TR) was observed in 17% (5/29) and heart block (HB) in 10% (3/29) prenatally. Six, that is 21% underwent genetic testing of which one was abnormal. Five extra-cardiac anomalies were reported prenatally and postnatally. Pregnancy was discontinued in five, of which two had moderate TR. There were thirty-one liveborn. Coarctation of the aorta was found in five postnatally but not suspected prenatally. In one, pulmonary stenosis was underestimated; otherwise, prenatal morphology was confirmed. Cardiac interventions were performed in 77% (24/31) liveborn with 39% (12/31) undergoing neonatal intervention. Overall, 6/31 liveborn died including all three with prenatal heart block and one with TR. Estimated survival for all liveborn at 1, 5 and 10 years was 87% (95% CI 76-100%), 83% (95% CI 72-98%) and 80% (95% CI 66-96%) respectively. Accurate prenatal diagnosis of ccTGA is critical for counseling. Early outcomes are favorable with 77% of liveborn undergoing surgery. Fetuses with prenatal diagnosis of complex associated abnormalities, HB and TR appear to do less well.

Energy Loss Index and Dimensionless Index Outperform Direct Valve Planimetry in Low-Gradient Aortic Stenosis

Background/Objectives: Among patients with suspected severe aortic stenosis (AS), discordance between effective orifice area (EOA) and transvalvular gradients is frequent and requires a multiparametric workup including flow assessment and calcium-scoring to confirm true severe AS. The aim of this study was to assess direct planimetry, energy loss index (Eli) and dimensionless index (DI) as stand-alone parameters to identify non-severe AS in discordant cases. Methods: In this prospective cohort study, we included consecutive AS patients > 70 years with EOA < 1.0 cm2 referred for valve replacement between 2014 and 2017. AS severity was retrospectively reassessed using the multiparametric work-up recommended in the 2021 ESC/EACTS guidelines. DI and ELi were calculated, and valve area was measured by direct planimetry on transesophageal echocardiography. Results: A total of 101 patients (mean age 82 y; 57% male) were included. Discordance between EOA and gradients was observed in 46% and non-severe AS found in 24% despite an EOA < 1 cm2. Valve planimetry performed poorly, with an area under the ROC curve (AUC) of 0.64. At a cut-off value of >0.82 cm2, sensitivity and specificity to identify non-severe AS were 67 and 66%, respectively. DI and ELi showed a higher diagnostic accuracy, with an AUC of 0.77 and 0.76, respectively. Cut-off values of >0.24 and >0.6 cm2/m2 identified non-severe AS, with a high specificity of 79% and 91%, respectively. Conclusions: Almost one in four patients with EOA < 1 cm2 had non-severe AS according to guideline-recommended multiparametric assessment. Direct valve planimetry revealed poor diagnostic accuracy and should be interpreted with caution. Usual prognostic cut-off values for DI > 0.24 and ELI > 0.6 cm2/m2 identified non-severe AS with high specificity and should therefore be included in the assessment of low-gradient AS.

Diagnostic Challenges in Aortic Stenosis

Aortic stenosis (AS) is the most prevalent degenerative valvular disease in western countries. Transthoracic echocardiography (TTE) is considered, nowadays, to be the main imaging technique for the work-up of AS due to high availability, safety, low cost, and excellent capacity to evaluate aortic valve (AV) morphology and function. Despite the diagnosis of AS being considered straightforward for a very long time, based on high gradients and reduced aortic valve area (AVA), many patients with AS represent a real dilemma for cardiologist. On the one hand, the acoustic window may be inadequate and the TTE limited in some cases. On the other hand, a growing body of evidence shows that patients with low gradients (due to systolic dysfunction, concentric hypertrophy or coexistence of another valve disease such as mitral stenosis or regurgitation) may develop severe AS (low-flow low-gradient severe AS) with a similar or even worse prognosis. The use of complementary imaging techniques such as transesophageal echocardiography (TEE), multidetector computed tomography (MDTC), or cardiac magnetic resonance (CMR) plays a key role in such scenarios. The aim of this review is to summarize the diagnostic challenges associated with patients with AS and the advantages of a comprehensive multimodality cardiac imaging (MCI) approach to reach a precise grading of the disease, a crucial factor to warrant an adequate management of patients.

Performance and outcomes of the SAPIEN 3 Ultra RESILIA transcatheter heart valve in the OCEAN-TAVI registry

BACKGROUND

Data on the performance of the latest-generation SAPIEN 3 Ultra RESILIA (S3UR) valve in patients who undergo transcatheter aortic valve replacement (TAVR) are scarce.

AIMS

We aimed to assess the clinical outcomes, including valve performance, of the S3UR.

METHODS

Registry data of 618 consecutive patients with S3UR and of a historical pooled cohort of 8,750 patients who had a SAPIEN 3 (S3) valve and underwent TAVR were collected. The clinical outcomes and haemodynamics, including patient-prosthesis mismatch (PPM), were compared between the 2 groups and in a propensity-matched cohort.

RESULTS

The incidence of in-hospital death, vascular complications, and new pacemaker implantation was similar between the S3UR and the S3 groups (allp>0.05). However, both groups showed significant differences in the degrees of paravalvular leakage (PVL) (none-trivial: 87.0% vs 78.5%, mild: 12.5% vs 20.5%, ≥moderate: 0.5% vs 1.1%; p<0.001) and the incidence of PPM (none: 94.3% vs 85.1%, moderate: 5.2% vs 12.8%, severe: 0.5% vs 2.0%; p<0.001). The prevalence of a mean pressure gradient ≥20 mmHg was significantly lower in the S3UR group (1.6% vs 6.2%; p<0.001). Better haemodynamics were observed with the smaller 20 mm and 23 mm S3UR valves. The results were consistent in a matched cohort of patients with S3UR and with S3 (n=618 patients/group).

CONCLUSIONS

The S3UR has equivalent procedural complications to the S3 but with lower rates of PVL and significantly better valve performance. The better valve performance of the S3UR, particularly in smaller valve sizes, overcomes the remaining issue of balloon-expandable valves after TAVR.

Shifts in Clinical Characteristics, Treatment, and Outcome for Rheumatic Mitral Stenosis: Insights From a 20-Year Multicentre Registry Study in Korea

BACKGROUND

The rapid economic development of South Korea provides a unique model to study changes in the clinical characteristics, treatment approaches, and clinical outcomes of patients with rheumatic mitral stenosis (MS) relative to socioeconomic growth.

METHODS

From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, 2,337 patients diagnosed with moderate or severe rheumatic MS between January 2001 and December 2020 were analyzed. Patients were grouped into consecutive 5-year intervals based on their year of diagnosis. Clinical characteristics, echocardiographic data, and clinical outcomes were assessed.

RESULTS

Over 20 years, the severity of mitral stenosis increased from 79.1% to 90.2%; similarly, the average age at diagnosis increased from 54.3 to 63.0 years (all P < 0.001). Comorbidities such as hypertension and atrial fibrillation increased (6.3% to 29.5% and 41.4% to 46.9%, respectively; all P for trend < 0.05). The rate of mitral intervention within five years after diagnosis increased from 31.2% to 47.4% (P for trend < 0.001). However, clinical outcomes of rheumatic mitral stenosis deteriorated over time in the composite outcomes (log-rank test, P < 0.001). Conversely, the incidence of stroke remained stable (60.6-73.7%; P < 0.001), which might be attributed to the increased use of anticoagulation therapy.

CONCLUSION

This study observed an increase in patient age, comorbidities, and valve disease severity as the country transitioned from a developing to developed status. Despite a rise in mitral valve interventions, clinical outcomes deteriorated over 20 years, highlighting the need for modified treatment approaches to improve patient outcomes.

Transthoracic echocardiographic Doppler metrics in evaluating bioprosthetic tricuspid valve dysfunction

PURPOSE

There is currently limited information on the utility of transthoracic echocardiography (TTE)-derived Doppler parameters for assessing bioprosthetic tricuspid valve (BTV) dysfunction. Our study aimed to establish the precision and appropriate reference ranges for routinely collected transthoracic Doppler parameters in the assessment of BTV dysfunction.

METHODS

We retrospectively evaluated 100 BTV patients who underwent TTE. Based on redo surgical confirmation or more than 2 repeat TTE or transesophageal echocardiography (TEE) examinations, patients were allocated to normal (n = 61), regurgitant (n = 24), or stenotic (n = 15) BTV group. Univariate and multivariate binary logistic regression were performed to identify TTE Doppler parameters that detected BTV dysfunction.

RESULTS

The VTI ratio (VTITV/VTILVOT) was the most accurate Doppler parameter for detecting BTV dysfunction, with a ratio of >2.8 showing 84.6% sensitivity and 90.2% specificity. VTI ratio > 3.2, mean gradient (MGTV) > 6.2 mmHg and pressure half-time > 218 ms detected significant BTV stenosis, with sensitivities of 100%, 93.3% and 93.3% and specificities of 82.4%, 75.3% and 87.1%, respectively. After multivariate analysis, the VTI ratio > 2.8 (OR = 9.00, 95% CI = 2.13-41.61, p = .003) and MGTV > 5.1 mmHg (OR = 6.50, 95% CI = 1.69-27.78, p = .008) were the independent associations of BTV dysfunction. With these cutoff values, 75.0%-92.2% of normal and 62.5%-96.0% of dysfunctional BTV were identified.

CONCLUSIONS

Doppler parameters from TTE can accurately identify BTV dysfunction, particularly with VTI ratio > 2.8 and MGTV > 5.1 mmHg, to assess the need for additional testing with TEE.

Acute Heart Valve Emergencies

Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory remodeling. Within this context, optimal medical management, considerations for temporary mechanical circulatory support and decisive treatments strategies are addressed. Fundamental concepts include an appreciation for how sudden changes in flow and pressure gradients between cardiac chambers can impact hemodynamic and echocardiographic findings differently compared to similarly severe chronic lesions, as well as understanding the main causes for decompensated heart failure and cardiogenic shock for each valvular abnormality.

Posterior Annulus Elevation Technique in Reducing Residual Regurgitation During Mitral Valve Repair in Children: A Randomized Controlled Trial

Background: The current technique used in severe mitral regurgitation in children can occasionally lead to residual regurgitation. To address this issue, the posterior annulus elevation technique was developed to enhance coaptation and reduce residual lesions. This study aims to evaluate the effectiveness of this technique in reducing residual regurgitation during mitral valve repair in children. Methods: A total of 64 patients aged <18 years old undergoing mitral valve repair were randomized into two groups: the intervention (with posterior annulus elevation) group and the control group, which underwent conventional repair techniques. Various parameters, including coaptation area, residual mitral regurgitation, clinical outcomes, metabolic, and hemolytic markers, were measured on days 0, 5, 2 weeks, and 3 months after surgery. Results: The intervention group (n = 32) showed a significant reduction in residual mitral regurgitation compared with the control group (n = 32) on each evaluation. At three months after surgery, we found that the posterior annulus elevation technique could be a protective factor that reduces the chance of residual regurgitation compared with the control group (RR = 0.31; confidence interval: 0.18-0.54; P ≤ .001). Coaptation length and index were also found to be significantly higher in the intervention group (P ≤ .001). Clinical outcomes, metabolic markers, and hemolysis marker did not show any significant differences between the two groups. Conclusions: The posterior annulus elevation technique demonstrated effectiveness in reducing residual mitral regurgitation and improving coaptation area in pediatric mitral valve repair. This technique showed better short-term surgical outcomes in children with mitral regurgitation compared with the conventional technique.

Echocardiographic Parameters and Complication Profiles Among Adult Patients with Rheumatic Heart Disease at Jimma Medical Center

Background

Despite the fact that patients with rheumatic heart disease (RHD) need early medical attention and follow-up, most patients in developing countries tend to present with debilitating complications. The objective of this study was to evaluate the echocardiographic features of adult individuals diagnosed with RHD and examine the associated complications among patients who started follow-up at Jimma Medical Center's (JMC) cardiac follow-up clinic.

Methods

A prospective cross-sectional study was conducted at JMC between January 5 and April 15, 2023. Echocardiographic patterns were taken by senior cardiologists; socio-demographic variables, anthropometric measurements, and behavioral factors were collected through a structured questioner.

Results

The study recruited a total of 115 participants, of whom 86 (74.8%) were female and 29 (25.2%) were male. The mean age of the patients was 32.31 (SD± 12.16) years. The mitral valve was affected in 98.26% of cases, while the aortic and tricuspid valve abnormalities were diagnosed in 49.5% and 21.7%, respectively. The most frequent combinations of valve lesions were mitral regurgitation (MR) + mitral stenosis (MS) + aortic regurgitation (AR) (15.7%), followed by MR + AR + TR (8.7%). The occurrence of MR+MS+AR was higher in females (17.4%) compared to males (10.3%), whereas the occurrence of MS+MR was higher in males (24.1%) compared to females (20.9%). Females have a severely reduced ejection fraction compared to males (84.8% vs 15.2%, P = 0.044). Nearly two-thirds (63.5%) of individuals experienced RHD-related complications; the most commonly encountered complications were pulmonary hypertension (26.1%) and atrial fibrillation (19.1%).

Conclusion

RHD predominantly affects individuals in their active and productive years, particularly females. Most patients have multiple-valve lesions.

Early outcomes following transatrial transcatheter mitral valve replacement in patients with severe mitral annular calcification

OBJECTIVE

Implantation of a transcatheter valve-in-mitral annular calcification (ViMAC) has emerged as an alternative to traditional surgical mitral valve (MV) replacement. Previous studies evaluating ViMAC aggregated transseptal, transapical, and transatrial forms of the procedure, leaving uncertainty about each technique's advantages and disadvantages. Thus, we sought to evaluate clinical outcomes specifically for transatrial ViMAC from the largest multicenter registry to-date.

METHODS

Patients with symptomatic MV dysfunction and severe MAC who underwent ViMAC were enrolled from 12 centers across the United States and Europe. Clinical characteristics, procedural details, and clinical outcomes were abstracted from the electronic record. The primary end point was all-cause mortality.

RESULTS

We analyzed 126 patients who underwent ViMAC (median age 76 years [interquartile range {IQR}, 70-82 years], 28.6% female, median Society of Thoracic Surgeons score 6.8% [IQR, 4.0-11.4], and median follow-up 89 days [IQR, 16-383.5]). Sixty-one (48.4%) had isolated mitral stenosis, 25 (19.8%) had isolated mitral regurgitation (MR), and 40 (31.7%) had mixed MV disease. Technical success was achieved in 119 (94.4%) patients. Thirty (23.8%) patients underwent concurrent septal myectomy, and 8 (6.3%) patients experienced left ventricular outflow tract obstruction (7/8 did not undergo myectomy). Five (4.2%) patients of 118 with postprocedure echocardiograms had greater than mild paravalvular leak. Thirty-day and 1-year all-cause mortality occurred in 16 and 33 patients, respectively. In multivariable models, moderate or greater MR at baseline was associated with increased risk of 1-year mortality (hazard ratio, 2.31; 95% confidence interval, 1.07-4.99, P = .03).

CONCLUSIONS

Transatrial ViMAC is safe and feasible in this selected, male-predominant cohort. Patients with significant MR may derive less benefit from ViMAC than patients with mitral stenosis only.

Outcomes and care quality metrics for people living with rheumatic heart disease and atrial fibrillation in Uganda

Background

Atrial fibrillation (AF) is a common complication of rheumatic heart disease (RHD) and is challenging to treat in lower-resourced settings in which RHD remains endemic.

Objective

We characterized demographics, treatment outcomes, and factors leading to care retention for participants with RHD and AF in Uganda.

Methods

We conducted a retrospective analysis of the Uganda national RHD registry between June 2009 and May 2018. Participants with AF or atrial flutter were included. Demographics, survival, and care metrics were compared with participants without AF. Multivariable logistic regression was used to identify factors associated with retention in care among participants with AF.

Results

A total of 1530 participants with RHD were analyzed and 293 (19%) had AF. The median age was 24 (interquartile range 14-38) years. Mortality was similar in both groups (adjusted hazard ratio 1.183, P = .77) over a median follow-up of 203 (interquartile range 98-275) days. A total of 79% of AF participants were prescribed anticoagulation, and 43% were aware of their target international normalized ratio. Retention in care was higher in participants with AF (18% vs 12%, P < .01). Factors associated with decreased retention in care include New York Heart Association functional class III/IV (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.30-0.76) and distance to nearest health center (adjusted OR 0.94, 95% CI 0.90-0.99). Anticoagulation prescription was associated with enhanced care retention (adjusted OR 1.86, 95% CI 1.24-2.79).

Conclusion

Participants with RHD and AF in Uganda do not experience higher mortality than those without AF. Anticoagulation prescription rates are high. Although retention in care is poor among RHD participants, those with concurrent AF are more likely to be retained.

Pulmonary Artery Stenosis After an Orthotopic Heart Transplantation: A Case Report With Cardiac Imaging Findings and a Literature Review

Pulmonary artery stenosis is a rare complication of heart transplantation. It is typically a congenital condition or can be secondary to rheumatic fever, systemic vasculitis like Behcet's disease, or Takayasu's arteritis. It can also occur as a rarity of a delayed complication post-heart transplant. In this report, we describe the imaging findings of pulmonary artery stenosis in a patient who underwent an orthotopic heart transplant more than 10 years prior. Dynamic cardiac magnetic resonance imaging (MRI), phase contrast imaging, and MR angiography in the management of pulmonary artery stenosis helped in heart and pulmonary circulation. Functional evaluation can be achieved with current multichannel transmit-receive coils. Cardiac gated pre- and dynamic contrast-enhanced MR was performed with phase-contrast imaging for further evaluation confirming the diagnosis of pulmonary artery stenosis.

Imaging of the Mitral Valve

Echocardiographic imaging is the foundation for the evaluation of mitral valve dysfunction. Both transthoracic and transesophageal echocardiography provide insight into the anatomy, pathology, and classification mitral valve dysfunction. Echocardiography also provides a multi-parametric approach with semi-quantitative and quantitative parameters to assess the severity of mitral regurgitation and mitral stenosis. Transesophageal imaging is essential in the assessment of patients considered for surgical or transcatheter interventional strategies to treat mitral valve dysfunction. Cardiac computed tomography (CT) and cardiac MRI are useful adjunctive imaging techniques in mitral valve disease with CT providing detailed procedural specificity and MRI providing detailed ventricular and regurgitant flow analysis.

Diastolic dysfunction and clinical outcomes after transcatheter or surgical aortic valve replacement in patients with atypical aortic valve stenosis

BACKGROUND

Diastolic dysfunction is a predictor of poor outcomes in many cardiovascular conditions. At present, it is unclear whether diastolic dysfunction predicts adverse outcomes in patients with atypical aortic stenosis who undergo aortic valve replacement (AVR).

METHODS

Five hundred and twenty-three patients who underwent transcatheter AVR (TAVR) (n = 303) and surgical AVR (SAVR) (n = 220) at a single institution were included in our analysis. Baseline left and right heart invasive hemodynamics were assessed. Baseline transthoracic echocardiograms were reviewed to determine aortic stenosis subtype and parameters of diastolic dysfunction. Aortic stenosis subtype was categorized as typical (normal flow, high-gradient) aortic stenosis, classical, low-flow, low-gradient (cLFLG) aortic stenosis, and paradoxical, low-flow, low-gradient (pLFLG) aortic stenosis. Cox proportional hazard models were utilized to examine the relation between invasive hemodynamic or echocardiographic variables of diastolic dysfunction, aortic stenosis subtype, and all-cause mortality. Propensity-score analysis was performed to study the relation between aortic stenosis subtype and the composite outcome [death/cerebrovascular accident (CVA)].

RESULTS

The median STS risk was 5.3 and 2.5% for TAVR and SAVR patients, respectively. Relative to patients with typical aortic stenosis, patients with atypical (cLFLG and pLFLG) aortic stenosis displayed a significantly higher prevalence of diastolic dysfunction (LVEDP ≥ 20mmHg, PCWP ≥ 20mmHg, echo grade II or III diastolic dysfunction, and echo-PCWP ≥ 20mmHg) and, independently of AVR treatment modality, had a significantly increased risk of death. In propensity-score analysis, patients with atypical aortic stenosis had higher rates of death/CVA than typical aortic stenosis patients, independently of diastolic dysfunction and AVR treatment modality.

CONCLUSION

We demonstrate the novel observation that compared with patients with typical aortic stenosis, patients with atypical aortic stenosis have a higher burden of diastolic dysfunction. We corroborate the worse outcomes previously reported in atypical versus typical aortic stenosis and demonstrate, for the first time, that this observation is independent of AVR treatment modality. Furthermore, the presence of diastolic dysfunction does not independently predict outcome in atypical aortic stenosis regardless of treatment type, suggesting that other factors are responsible for adverse clinical outcomes in this higher risk cohort.

Is the Corrected Carotid Flow Time a Clinically Acceptable Surrogate Hemodynamic Parameter for the Left Ventricular Ejection Time?

OBJECTIVE

The corrected left ventricular ejection time (cLVET) comprises the phase from aortic valve opening to aortic valve closure corrected for heart rate. As a surrogate measure for cLVET, the corrected carotid flow time (ccFT) has been proposed in previous research. The aim of this study was to assess the clinical agreement between cLVET and ccFT in a dynamic clinical setting.

METHODS

Twenty-five patients with severe aortic valve stenosis (AS) were selected for transcatheter aortic valve replacement (TAVR). The cLVET and ccFT were derived from the left ventricular outflow tract (LVOT) and the common carotid artery (CCA), respectively, using pulsed wave Doppler ultrasound. Bazett's (B) and Wodey's (W) equations were used to calculate cLVET and ccFT. Measurements were performed directly before (T1) and after (T2) TAVR. Correlation, Bland-Altman and concordance analyses were performed.

RESULTS

Corrected LVET decreased from T1 to T2 (p < 0.001), with relative reductions of 11% (B) and 9% (W). Corrected carotid flow time decreased (p < 0.001), with relative reductions of 12% (B) and 10% (W). The correlation between cLVET and ccFT was strong for B (ρ = 0.74, p < 0.001) and W (ρ = 0.81, p < 0.001). The bias was -39 ms (B) and -37 ms (W), and the upper and lower levels of agreement were 19 and -98 ms (B) and 5 and -78 ms (W), respectively. Trending ability between cLVET and ccFT was good (concordance 96%) for both B and W.

CONCLUSION

In TAVR patients, the clinical agreement between cLVET and ccFT was acceptable, indicating that ccFT could serve as a surrogate measure for cLVET.

Valvular Prostaglandins Are Elevated in Severe Human Aortic Valve Stenosis

BACKGROUND

Aortic valve stenosis (AVS) is the most common valvular disease in the developed world. AVS involves the progressive fibrocalcific remodeling of the aortic valve (AV), which impairs function and can ultimately lead to heart failure. Due to gaps in our understanding of the underlying mechanisms of AVS, there are no pharmacological treatments or dietary interventions known to slow AVS progression. Recent studies have begun to suggest oxylipins-a class of bioactive lipids-may be dysregulated in the valves of patients with AVS.

METHODS

We utilized high-performance liquid chromatography-tandem mass spectrometry to conduct a targeted oxylipin analysis on human AV tissue and plasma from a cohort of 110 patients undergoing AV surgery.

RESULTS

We identified 36 oxylipins in human AV tissue with all showing significant increase in patients with severe AVS. A multivariate model including patient characteristics and valvular oxylipins identified the arachidonic acid-COX (cyclooxygenase) pathway-derived prostanoids to be the most associated with AVS severity. Plasma oxylipin levels were measured in a subset of AV surgery patients and compared with a control group of healthy participants, showing distinct oxylipin profiles between control and disease.

CONCLUSIONS

Our comprehensive analysis of oxylipins in the human AV identified the inflammatory and osteogenic regulating prostanoids to be positively correlated with AVS severity. This elucidation of prostanoid dysregulation warrants further research into COX inhibition to mitigate AVS.

Prevalence of valvular heart disease in cardiac amyloidosis and impact on survival

BACKGROUND

Limited data exists on the prognostic impact of valvular heart disease in cardiac amyloidosis (CA). We therefore sought to define the prevalence of valvular disease in patients with CA and assess the effects of significant valve disease on survival.

METHODS

This multi-center retrospective cohort study included consecutive patients with confirmed transthyretin (TTR) or light chain (AL) amyloidosis. Echocardiographic data closest to the date of amyloid diagnosis was reviewed, and severity was graded according to ASE guidelines. Kaplan-Meier survival analysis was performed to compare survival between patients with moderate or greater valve disease against those with mild or less disease.

RESULTS

We included 345 patients (median age 76 years; 73 % men; 110 AL, 235TTR). The median survival for the total patient cohort with cardiac amyloidosis was 2.92 years, with 30 % of patients surviving at five years after their diagnosis. Median survival comparing AL vs ATTR was 2.58 years vs 2.82 years (p = 0.67) The most common valvular abnormalities in the total cohort were mitral (62 %) and tricuspid (66 %).regurgitation There was a statistically significant difference in median survival between patients with no or mild MR compared to those with moderate or severe MR (2.92 years vs 3.35 years, p = 0.0047) (Fig. 5). There was a statistically significant difference in median survival in patients with no or mild TR compared to those with moderate or severe TR (3.35 years vs 2.3 years, p = 0.015).

CONCLUSION

Our study demonstrates a significant prevalence of mitral and tricuspid regurgitation in CA, with patients with moderate to severe MR and TR having a poorer prognosis.

Predictive machine learning models for ascending aortic dilatation in patients with bicuspid and tricuspid aortic valves undergoing cardiothoracic surgery: a prospective, single-centre and observational study

OBJECTIVES

The objective of this study was to develop clinical classifiers aiming to identify prevalent ascending aortic dilatation in patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV).

DESIGN AND SETTING

A prospective, single-centre and observational cohort.

PARTICIPANTS

The study involved 543 BAV and 491 TAV patients with aortic valve disease and/or ascending aortic dilatation, excluding those with coronary artery disease, undergoing cardiothoracic surgery at the Karolinska University Hospital (Sweden).

MAIN OUTCOME MEASURES

Predictors of high risk of ascending aortic dilatation (defined as ascending aorta with a diameter above 40 mm) were identified through the application of machine learning algorithms and classic logistic regression models.

EXPOSURES

Comprehensive multidimensional data, including valve morphology, clinical information, family history of cardiovascular diseases, prevalent diseases, demographic details, lifestyle factors, and medication.

RESULTS

BAV patients, with an average age of 60.4±12.4 years, showed a higher frequency of aortic dilatation (45.3%) compared with TAV patients, who had an average age of 70.4±9.1 years (28.9% dilatation, p <0.001). Aneurysm prediction models for TAV patients exhibited mean area under the receiver-operating-characteristic curve (AUC) values above 0.8, with the absence of aortic stenosis being the primary predictor, followed by diabetes and high-sensitivity C reactive protein. Conversely, prediction models for BAV patients resulted in AUC values between 0.5 and 0.55, indicating low usefulness for predicting aortic dilatation. Classification results remained consistent across all machine learning algorithms and classic logistic regression models.

CONCLUSION AND RECOMMENDATION

Cardiovascular risk profiles appear to be more predictive of aortopathy in TAV patients than in patients with BAV. This adds evidence to the fact that BAV-associated and TAV-associated aortopathy involves different pathways to aneurysm formation and highlights the need for specific aneurysm preventions in these patients. Further, our results highlight that machine learning approaches do not outperform classical prediction methods in addressing complex interactions and non-linear relations between variables.