Pre- and Post-Operative Diastolic Dysfunction in Patients With Valvular Heart Disease

Using Electrocardiogram to Assess Diastolic Function and Prognosis in Mitral Regurgitation

BACKGROUND

The determination of left ventricular diastolic function (LVDF) in patients with significant (≥moderate) mitral regurgitation (MR) poses a complex challenge. We recently validated an artificial intelligence-enabled electrocardiogram (AI-ECG) algorithm to estimate LVDF.

OBJECTIVES

This study sought to evaluate the risk of all-cause mortality across AI-ECG LVDF-derived myocardial disease (MD) grades in MR.

METHODS

This was a retrospective study including all patients in the AI-ECG LVDF study testing group who underwent comprehensive transthoracic echocardiography confirming significant MR and electrocardiogram within 14 days of each other at the Mayo Clinic between September 2001 and April 2023. AI-ECG LVDF status was determined based on the index electrocardiogram and used to categorize patients into 3 stages of MD: MD-1, normal or grade 1 LVDF; MD-2, grade 2 LVDF; and MD-3, grade 3 LVDF.

RESULTS

Of 4,019 patients with significant MR (mean age 69.8 years; 49.0% women), 1,175 (29.2%), 1,881 (46.8%), and 963 (24.0%) were classified by AI-ECG as MD-1, MD-2, and MD-3, respectively. The median mitral effective regurgitant orifice area was 26 mm2 (Q1-Q3: 20-36 mm2). Over a median follow-up of 3.5 years, 1,636 (40.7%) patients died. In multivariable survival analysis adjusted for multiple risk factors, a higher diastolic function grade was independently associated with an increased death risk (MD-2, adjusted HR [aHR]: 1.99; 95% CI: 1.62-2.45; MD-3, aHR: 2.65; 95% CI: 2.11-3.34). These findings were consistent when accounting for mitral valve intervention and across various sensitivity and subgroup analyses.

CONCLUSIONS

In patients with significant MR, the grading of LVDF by AI-ECG is independently associated with all-cause mortality.

Left ventricular diastolic dysfunction in non-myocardial disorders

This article reviews and discusses non-myocardial disorders that represent diagnostic challenges when evaluating patients for suspected heart failure with preserved left ventricular ejection fraction. This includes pre-capillary pulmonary hypertension, which is important to differentiate from post-capillary hypertension caused by left-sided heart disease. The impact of electrical disorders on LV diastolic function is also reviewed, and includes a discussion of left bundle branch, which has both a direct effect on LV diastolic function, as well as a long-term effect due to remodelling. Furthermore, evaluation of diastolic function in patients with atrial fibrillation is discussed. Pericardial diseases are reviewed as well as effects of a normal pericardium on diastolic function in failing hearts. Finally, the article reviews how valvular diseases impact LV diastolic function.

Echocardiographic Assessment of Left Atrial Mechanics in Patients with Atrial Fibrillation Undergoing Electrical Cardioversion: A Systematic Review

Background: To date, only a few studies have evaluated left atrial (LA) mechanics in patients with atrial fibrillation (AF) scheduled for electrical cardioversion (ECV). The present systematic review has been primarily designed to summarize the main findings of these studies and to examine the overall effect of AF on left atrial reservoir strain (LASr) in patients undergoing ECV. Methods: All the echocardiographic studies evaluating the effect of AF on LA mechanics in patients scheduled for ECV, selected from the PubMed and EMBASE databases, were included. There was no limitation of time period. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: The full texts of 12 studies with 880 AF patients were analyzed. The pooled ECV success rate was 91.5% (range 65.8-100%). Over a median follow-up of 5.4 months (range 0.3-12 months), 35.2% of the patients (range 5-68.8%) experienced AF recurrence. At baseline, the average LASr was 11.4% (range 6.2-17.7%). A reduced LASr before ECV was strongly correlated with reduced left atrial appendage (LAA) flow velocities and/or thrombosis. The main independent predictors of cardioversion failure were impaired LASr and previous AF history. A severe LASr deterioration was independently correlated with AF recurrence after ECV. The other independent predictors of AR relapses were LA asynchrony, reduced difference between post- and pre-ECV LASr, and reduced right atrial reservoir strain. Conclusions: LASr assessment before ECV may provide useful prognostic information about AF relapses and improve the refinement of the thromboembolic risk of AF patients scheduled for ECV.

Mitral Annular Tissue Velocity Predicts Survival in Patients With Primary Mitral Regurgitation

BACKGROUND AND OBJECTIVES

Early diastolic mitral annular tissue (e') velocity is a commonly used marker of left ventricular (LV) diastolic function. This study aimed to investigate the prognostic implications of e' velocity in patients with mitral regurgitation (MR).

METHODS

This retrospective cohort study included 1,536 consecutive patients aged <65 years with moderate or severe chronic primary MR diagnosed between 2009 and 2018. The primary and secondary outcomes were all-cause and cardiovascular mortality, respectively. According to the current guidelines, the cut-off value of e' velocity was defined as 7 cm/s.

RESULTS

A total of 404 individuals were enrolled (median age, 51.0 years; 64.1% male; 47.8% severe MR). During a median 6.0-year follow-up, there were 40 all-cause mortality and 16 cardiovascular deaths. Multivariate analysis revealed a significant association between e' velocity and all-cause death (adjusted hazard ratio [aHR], 0.770; 95% confidence interval [CI], 0.634-0.935; p=0.008) and cardiovascular death (aHR, 0.690; 95% CI, 0.477-0.998; p=0.049). Abnormal e' velocity (≤7 cm/s) independently predicted all-cause death (aHR, 2.467; 95% CI, 1.170-5.200; p=0.018) and cardiovascular death (aHR, 5.021; 95% CI, 1.189-21.211; p=0.028), regardless of symptoms, LV dimension and ejection fraction. Subgroup analysis according to sex, MR severity, mitral valve replacement/repair, and symptoms, showed no significant interactions. Including e' velocity in the 10-year risk score improved reclassification for mortality (net reclassification improvement [NRI], 0.154; 95% CI, 0.308-0.910; p<0.001) and cardiovascular death (NRI, 1.018; 95% CI, 0.680-1.356; p<0.001).

CONCLUSIONS

In patients aged <65 years with primary MR, e' velocity served as an independent predictor of all-cause and cardiovascular deaths.

Non-invasive assessment of left ventricular filling pressure in aortic stenosis

BACKGROUND

The assessment of left ventricular (LV) filling pressure (FP) is important for the management of aortic stenosis (AS) patients. Although, it is often restricted for predict LV FP in AS because of mitral annular calcification and a certain left ventricular hypertrophy. Thus, we tested the predictive ability of the algorithm for elevated LV FP in AS patients and also applied a recently-proposed echocardiographic scoring system of LV FP, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score.

METHODS

We enrolled consecutive 116 patients with at least moderate AS in sinus rhythm who underwent right heart catheterization and echocardiography within 7 days. Mean pulmonary artery wedge pressure (PAWP) was measured as invasive parameter of LV FP. LV diastolic dysfunction (DD) was graded according to the ASE/EACVI guidelines. The VMT score was defined as follows: time sequence of opening of mitral and tricuspid valves was scored to 0-2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). When the inferior vena cava was dilated, one point was added and VMT score was finally calculated as 0-3.

RESULTS

Of the 116 patients, 29 patients showed elevated PAWP. Ninety patients (93%) and 67 patients (63%) showed increased values for left atrium volume index (LAVI) and E/e', respectively when the cut-off values recommended by the guidelines were applied and thus the algorism predicted elevated PAWP with a low specificity and positive predictive value (PPV). VMT ≥ 2 predicted elevated PAWP with a sensitivity of 59%, specificity of 90%, PPV of 59%, and negative predictive value of 89%. An alternative algorithm that applied tricuspid regurgitation velocity and VMT scores was tested, and its predictive ability was markedly improved.

CONCLUSION

VMT score was applicable for AS patients. Alternative use of VMT score improved diagnostic accuracy of guideline-recommended algorism.

Systolic Heart Failure is Associated with Higher Mortality Among Patients Undergoing Transcatheter Aortic Valve Replacement: A Nationwide Analysis

Heart failure (HF) is prevalent among patients with aortic stenosis and presents a poor prognosis. In order to better portray outcomes for HF patients undergoing transcatheter aortic valve replacement (TAVR), we evaluated clinical outcomes in patients with systolic vs diastolic heart failure who underwent TAVR in a large nationwide database. We searched the National Inpatient Sample (NIS) for hospitalized adult patients who underwent TAVR with coexisting history of systolic (SHF) or diastolic heart failure (DHF) as a secondary diagnosis using the ICD-10 codes. The primary outcome was in-hospital mortality, with secondary outcomes of cardiac arrest (CA), cardiogenic shock (CS), respiratory failure (RF), Non-ST elevation myocardial infarction (NSTEMI), acute kidney injury (AKI), use of cardiac and respiratory assist device, and health care utilization defined as length of stay, average hospital cost (AHC) and patient charge (APC). Both univariate and multivariate logistic, generalized linear, and Poisson regression analyses were used to evaluate and test the outcomes. A P-value of <0.05 was significant. A total of 106,815 patients were admitted to acute care hospitals for TAVR, and 73% had a secondary diagnosis of heart failure (41% had SHF and 59% DHF). SHF group were older (mean age of 78.9 years [SD ± 8.9] vs 79.9 years [SD ± 8.3]) with more males (61.8% vs 48.2%) and white predominant (whites [85.9% vs 87.9%]). Compared to DHF, SHF had higher inpatient mortality (1.75% vs 1.14%, P = 0.003), CA (1.31% vs 0.81%, P = 0.01), NSTEMI (2.52% vs 1.0%, P = 0.001), RF (10.87% vs 8.01%, P = 0.001), and CS (3.94% vs 1.14%, P = 0.001). In addition, SHF had greater LOS (5.1 days vs. .3.9, P = 0.0001) & AHC ($52,901 vs $48,070, P = 0.0001). HF is common among patients admitted for TAVR. SHF had worse CV outcomes, greater use of hospital resources, and higher acute care hospital mortality compared to those with DHF.

Hemodynamics and Diastolic Function after Native Aortic Valve Preserving vs. Replacing Surgery

BACKGROUND

 Alterations in left ventricular (LV) diastolic function following native tissue-preserving aortic valve (AV) procedures have not been systematically investigated. Furthermore, no comparisons have been made between these changes and those observed after prosthetic AV replacement.

METHODS

 From October 2017 to August 2020, 74 patients aged <65 years were referred to our institution for elective AV surgery. Preoperative and postoperative (i.e., discharge, 3-month and 1-year follow-up) transthoracic echocardiography was analyzed.

RESULTS

 Native tissue-preserving surgery was performed in 55 patients (AV repair: n = 42, Ross procedure: n = 13). The remaining 19 patients underwent prosthetic AV replacement. Preoperatively and at discharge, transvalvular hemodynamics and LV diastolic function were comparable in both groups. At 1-year follow-up, native valve (NV) patients showed significantly lower mean transvalvular gradient (7 ± 5 vs. 9 ± 3 mmHg, p = 0.046) and peak velocity (1.74 ± 0.51 vs. 2.26 ± 0.96 m/s, p = 0.004), and significantly better septal e' (9.1 ± 2.7 vs. 7.7 ± 2.5 cm/s, p = 0.043) and lateral e' (14.7 ± 3.1 vs. 11.7 ± 3.7 cm/s, p = 0.001). From preoperatively to 1-year postoperatively, septal and lateral e' and E/e' improved markedly after NV preservation (septal e': +0.7 cm/s, p = 0.075; lateral e': +2.3 cm/s, p < 0.001; E/e': -1.5, p = 0.001) but not after AV replacement (septal e': +0.2 cm/s, p = 0.809; lateral e': +0.8 cm/s, p = 0.574; E/e': -1.2, p = 0.347). Significant negative linear correlations between postoperative transvalvular gradients and absolute changes in lateral e' and E/e' were detected during follow-up.

CONCLUSION

 Preservation of native tissue in AV surgery results in superior transvalvular hemodynamics compared with prosthetic AV replacement. This may induce faster LV reverse remodeling and may explain more pronounced improvement in LV diastolic function.

Risk factors for atrial arrhythmia recurrence after atrial arrhythmia surgery with pulmonary valve replacement

Objectives

Atrial arrhythmias are a significant cause of late morbidity and mortality in patients after tetralogy of Fallot repair. However, reports on their recurrence following atrial arrhythmia surgery are limited. We aimed to identify the risk factors for atrial arrhythmia recurrence after pulmonary valve replacement (PVR) and arrhythmia surgery.

Methods

We reviewed 74 patients with repaired tetralogy of Fallot who underwent PVR for pulmonary insufficiency at our hospital between 2003 and 2021. Twenty-two patients (mean age, 39 years) underwent PVR and atrial arrhythmia surgery. A modified Cox-maze III was performed in 6 patients with chronic atrial fibrillation, and a right-sided maze was performed in 12 with paroxysmal atrial fibrillation, 3 with atrial flutter, and 1 with atrial tachycardia. Atrial arrhythmia recurrence was defined as any documented sustained atrial tachyarrhythmia requiring intervention. The influence of preoperative parameters on recurrence was assessed with the Cox proportional-hazards model.

Results

The median follow-up period was 9.2 years (interquartile range, 4.5-12.4). Cardiac death and redo-PVR due to prosthetic valve dysfunction were not observed. Eleven patients had atrial arrhythmia recurrence after discharge. Atrial arrhythmia recurrence-free rates were 68% at 5 years and 51% at 10 years after PVR and arrhythmia surgery. Multivariable analysis revealed that right atrial volume index (hazard ratio, 1.04; 95% confidence interval, 1.01-1.08, P = .009) was a significant risk factor for atrial arrhythmia recurrence after arrhythmia surgery and PVR.

Conclusions

Preoperative right atrial volume index was associated with atrial arrhythmia recurrence, which may assist in planning the timing of atrial arrhythmia surgery and PVR.

Different heart failure phenotypes of valvular heart disease: the role of mitochondrial dysfunction

Valvular heart disease (VHD)-related heart failure (HF) is a special subtype of HF with an increasingly concerned heterogeneity in pathophysiology, clinical phenotypes, and outcomes. The mechanism of VHD-related HF involves not only mechanical damage to the valve itself but also valve lesions caused by myocardial ischemia. The interactions between them will lead to the occurrence and development of VHD-related HF subtypes. Due to the spatial (combination of different valvular lesions) and temporal effects (sequence of valvular lesions) of valvular damages, it can make the patient's condition more complicated and also make the physicians deal with a dilemma when deciding on a treatment plan. This indicates that there is still lack of deep understanding on the pathogenic mechanism of VHD-related HF subtypes. On the other hand, mitochondrial dysfunction (MitD) is not only associated with the development of numerous cardiac diseases such as atherosclerosis, hypertension, diabetes, and HF but also occurs in VHD. However, the role of MitD in VHD-related HF is still not fully recognized. In this comprehensive review, we aim to discuss the current findings and challenges of different valvular damages derived from HF subtypes as well as the role of MitD in VHD-related HF subtypes.

Incidence and Risk Factors for Long-Term Persistence of Diastolic Dysfunction after Aortic Valve Replacement for Aortic Stenosis Compared with Aortic Regurgitation

(1) Background: Severe left ventricular (LV) diastolic dysfunction with a restrictive diastolic pattern (LVDFP) is generally associated with a worse prognosis. Its evolution and reversibility in the short- and medium-term after aortic valve replacement (AVR) has been little-studied. We aimed to evaluate the evolution of LV remodeling and LV systolic and diastolic function after AVR in aortic stenosis (AS) patients compared to aortic regurgitation (AR). Moreover, we tried to identify the main predictive parameters for postoperative evolution (cardiovascular hospitalization or death and quality of life) and the independent predictors for the persistence of restrictive LVDFP after AVR. (2) Methods: A five-year prospective study on 397 patients undergoing AVR for AS (226 pts) or AR (171 pts), evaluated clinically and by echocardiography preoperatively and until 5 years postoperatively. (3) Results: 1. In patients with AS, early post AVR, LV dimensions decreased and diastolic filling and LV ejection fraction (LVEF) improved more rapidly compared to patients with AR. At 1 year postoperatively, persistent restrictive LVDFP was found especially in the AR group compared to the AS group (36.84% vs. 14.16%). 2. Cardiovascular event-free survival at the 5-year follow-up was lower in the AR group (64.91% vs. 87.17% in the AS group). The main independent predictors of short- and medium-term prognosis after AVR were: restrictive LVDFP, severe LV systolic dysfunction, severe pulmonary hypertension (PHT), advanced age, severe AR, and comorbidities. 3. The persistence of restrictive LVDFP after AVR was independently predicted by: preoperative AR, the E/Ea ratio > 12, the LA dimension index > 30 mm/m², an LV endsystolic diameter (LVESD) > 55 mm, severe PHT, and associated second-degree MR (p < 0.05). (4) Conclusions: AS patients had an immediate postoperative evolution in terms of LV remodeling, and LV systolic and diastolic function were more favorable compared to those with AR. The restrictive LVDFP was reversible, especially after the AVR for AS. The main prognostic predictors were the presence of restrictive LVDFP, advanced age, preoperative AR, severe LV systolic dysfunction, and severe PHT.

Managing Diastolic Dysfunction Perioperatively

Preoperative cardiac evaluation is a cornerstone of the practice of anesthesiology. This consists of a thorough history and physical attempting to elucidate signs and symptoms of heart failure, angina or anginal equivalents, and valvular heart disease. Current guidelines rarely recommend preoperative echocardiography in the setting of an adequate functional capacity. Many patients may have poor functional capacity and/or have medical history such that echocardiographic data is available for review. Much focus is often placed on evaluating major valvular abnormalities and systolic function as measured by ejection fraction, but a key impactful component is often overlooked-diastolic function. A diagnosis of diastolic heart failure is an independent predictor of mortality and is not uncommon in patients with normal systolic function. This narrative review addresses the clinical relevance and management of diastolic dysfunction in the perioperative setting.

Non-invasive evaluation of pulmonary capillary wedge pressure using the left atrial expansion index in mitral valve stenosis, prosthesis and repair

Pulmonary capillary wedge pressure (PCWP) non-invasive evaluation is limited in patients with mitral valve (MV) stenosis, prosthesis, and surgical repair. This study aimed to assess the left atrial expansion index (LAEI) measured through transthoracic echocardiography (TTE) as a novel parameter for estimating PCWP in these challenging cardiac conditions. We performed a retrospective, cross-sectional study, including chronic cardiac patients receiving within 24 h a clinically indicated right heart catheterization (RHC) and transthoracic echocardiographic (TTE) exam. PCWP measured during RHC was used as the reference. TTE measurements were performed offline, blinded to RHC results. LAEI was calculated as LAEI = [(LAmaxVolume-LAminVolume)/LAminVolume] × 100. We included 167 patients (age = 73 ± 11.5 years; PCWP = 18 ± 7.7 mmHg) with rheumatic mitral valve (MV) stenosis (16.2%), degenerative MV stenosis (51.2%), MV prosthesis (18.0%), and MV surgical repair (13.8%). LAEI correlated logarithmically with PCWP, and the log-transformed LAEI (lnLAEI) showed a good linear association with PCWP (r = - 0.616; p < 0.001). lnLAEI was an independent PCWP determinant, providing added predictive value over conventional clinical (age, atrial fibrillation, heart rate, MV subgroups) and echocardiographic variables (LVEF, MV effective orifice area, MV mean gradient, net atrioventricular compliance, and pulmonary arterial systolic pressure). lnLAEI identified PCWP > 12 mmHg with AUC = 0.870, p < 0.001; and PCWP > 15 mmHg with AUC = 0.797, p < 0.001, with an optimal cut-off of lnLAEI < 3.69. The derived equation PCWP = 36.8-5.5xlnLAEI estimated the invasively measured PCWP ± 6.1 mmHg. In this cohort of patients with MV stenosis, prosthesis, and surgical repair, lnLAEI resulted in a helpful echocardiographic parameter for PCWP estimation.

Association of renin-angiotensin system inhibitors use with short- and long-term mortality in patients with aortic stenosis: A systematic review and meta-analysis

Purpose

The present study aimed to investigate the association of renin-angiotensin system inhibitors (RASi) with short- and long-term mortality in patients with aortic stenosis (AS).

Methods

A systematic search was performed in PubMed, Embase, and Cochrane library databases for relevant studies published before March 2022. Studies meeting the inclusion criteria were included to assess the effect of RASi on short-term (≤30 days) and long-term (≥1 year) mortality in patients with AS.

Results

A total of 11 studies were included in the meta-analysis. Our results demonstrated that RASi reduced short-term mortality (OR = 0.76, 95% CI 0.63-0.93, p = 0.008) after aortic valve replacement (AVR). Subgroup analysis revealed that RASi was still associated with lower short-term mortality after transcatheter aortic valve replacement (TAVR); however, the association was relatively weak in patients who underwent surgical aortic valve replacement (SAVR). For long-term mortality, the pooled OR was 1.04 (95% CI 0.88-1.24, p = 0.63) after sensitivity analysis in patients who did not undergo AVR. In addition, our study confirmed that RASi significantly reduced long-term mortality (OR = 0.57, 95% CI 0.44-0.74, p < 0.0001) in patients who underwent AVR. Subgroup analysis showed that both TAVR and SAVR groups treated with RASi had lower long-term mortality.

Conclusion

Renin-angiotensin system inhibitors did not change long-term mortality in AS patients who did not undergo AVR. However, RASi reduced short- and long-term mortality in patients who underwent AVR.

Molecular Approaches and Echocardiographic Deformation Imaging in Detecting Myocardial Fibrosis

The pathological remodeling of myocardial tissue is the main cause of heart diseases. Several processes are involved in the onset of heart failure, and the comprehension of the mechanisms underlying the pathological phenotype deserves special attention to find novel procedures to identify the site of injury and develop novel strategies, as well as molecular druggable pathways, to counteract the high degree of morbidity associated with it. Myocardial fibrosis (MF) is recognized as a critical trigger for disruption of heart functionality due to the excessive accumulation of extracellular matrix proteins, in response to an injury. Its diagnosis remains focalized on invasive techniques, such as endomyocardial biopsy (EMB), or may be noninvasively detected by cardiac magnetic resonance imaging (CMRI). The detection of MF by non-canonical markers remains a challenge in clinical practice. During the last two decades, two-dimensional (2D) speckle tracking echocardiography (STE) has emerged as a new non-invasive imaging modality, able to detect myocardial tissue abnormalities without specifying the causes of the underlying histopathological changes. In this review, we highlighted the clinical utility of 2D-STE deformation imaging for tissue characterization, and its main technical limitations and criticisms. Moreover, we focalized on the importance of coupling 2D-STE examination with the molecular approaches in the clinical decision-making processes, in particular when the 2D-STE does not reflect myocardial dysfunction directly. We also attempted to examine the roles of epigenetic markers of MF and hypothesized microRNA-based mechanisms aiming to understand how they match with the clinical utility of echocardiographic deformation imaging for tissue characterization and MF assessment.

Unsupervised Machine Learning for Assessment of Left Ventricular Diastolic Function and Risk Stratification

BACKGROUND

The 2016 American Society of Echocardiography (ASE) guidelines have been widely used to assess left ventricular diastolic function. However, limitations are present in the current classification system. We aimed to develop a data-driven, unsupervised machine learning approach for diastolic function classification and risk stratification using the left ventricular diastolic function parameters recommended by the 2016 ASE guidelines; the guideline grading was used as the reference standard.

METHODS

Baseline demographics, heart failure hospitalization and all-cause mortality data were obtained for all adult patients who underwent transthoracic echocardiography at Mayo Clinic Rochester in 2015. Patients with prior mitral valve intervention, congenital heart disease, cardiac transplant, or cardiac assist device were excluded. Nine left ventricular diastolic function variables (mitral E and A wave peak velocities, E/A, deceleration time, medial and lateral annulus e' and E/e', and tricuspid regurgitation peak velocity) were used for an unsupervised machine learning algorithm to identify different phenotype clusters. The cohort average of each variable was used for imputation. Patients were grouped according to the algorithm-determined clusters for Kaplan-Meier survival analysis.

RESULTS

Among 24,414 patients, age 63.6 ±16.2 years, all-cause mortality occurred in 4,612 (18.9%) patients during median follow-up 3.1 years. The algorithm determined 3 clusters with echocardiographic measurement characteristics corresponding to normal diastolic function (n= 8,312), impaired relaxation (n=11,779) and increased filling pressure (n =4,323), with 3-year cumulative mortality of 11.8%, 19.9% and 33.4%, respectively (p<0.0001). All 10,694 (43.8%) patients classified as indeterminate were reclassified into the 3 clusters (3,324, 5,353, and 2,017, respectively) with 3-year mortality of 16.6%, 22.9% and 34.4%, respectively. The clusters also outperformed guideline-based grade for prognostication (c-index: 0.607 vs. 0.582, p=0.013).

CONCLUSIONS

Unsupervised machine learning identified physiologically and prognostically distinct clusters based on 9 diastolic function Doppler variables. The clusters can be potentially applied in echocardiography laboratory practice and future clinical trials for simple, replicable diastolic function related risk stratification.

Elevated N-terminal pro C-type natriuretic peptide is associated with mortality in patients undergoing transcatheter aortic valve replacement

Background

Unlike N-terminal pro-B-type natriuretic peptide (NT-proBNP), which have been extensively studied, little is known about the role of N-terminal pro-C-type natriuretic peptide (NT-proCNP) for predicting survival post transcatheter aortic valve replacement (TAVR).

Methods

A total of 309 patients were included in the analysis. Patients were grouped into quartiles (Q1–4) according to the baseline NT-proCNP value. Blood for NT-proCNP analysis was obtained prior to TAVR procedure. The primary endpoint was mortality after a median follow-up of 32 months. Multivariable Cox proportional hazards regression models analyzed prognostic factors. The predictive capability was compared between NT-proBNP and NT-proCNP using receiver operator curve (ROC) analysis.

Results

A total of 309 subjects with the mean age of 76.8 ± 6.3 years, among whom 58.6% were male, were included in the analysis. A total of 58 (18.8%) patients died during follow-up. Cox multivariable analyses indicated society of thoracic surgeons (STS)-score was a strong independent predictor for mortality (hazard ratio (HR) 1.08, 95% confidential interval (CI) 1.05–1.12, P < 0.001). Elevated NT-proCNP was associated with a higher risk of cardiovascular mortality (HR 1.02, 95% CI 1.00–1.03, P = 0.025) and All-cause mortality (HR 1.01, 95% CI 1.00–1.03, P = 0.027), whereas NT-proBNP showed a small effect size on mortality. ROC analysis indicated that NT-proCNP was superior to NT-proBNP for TAVR risk evaluation in patients with left ventricular ejection fraction (LVEF) < 50% [(Area under the curve (AUC)-values of 0.79 (0.69; 0.87) vs. 0.59 (0.48; 0.69), P = 0.0453].

Conclusions

NT-proCNP and STS-Score were the independent prognostic factors of mortality among TAVR patients. Furthermore, NT-proCNP was superior to NT-proBNP for TAVR risk evaluation in patients with LVEF < 50%.

Trial registration NCT02803294, 16/06/2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02615-8.

Prognostic Implications of Left Ventricular Global Longitudinal Strain in Patients With Surgically Treated Mitral Valve Disease and Preserved Ejection Fraction

Background

This study investigated whether left ventricular (LV) global longitudinal strain (LV-GLS), as an LV function parameter less affected by mitral valve (MV) repair or prosthesis, is associated with clinical outcomes in patients with surgically treated MV disease.

Methods

Among 750 patients who underwent MV surgery, we assessed LV-GLS by speckle tracking echocardiography in 344 patients (148 men, mean age 58 ± 13 years) who showed preserved LV ejection fraction on echocardiography between 6 months and 2 years after MV surgery and who did not undergo aortic valve surgery. The assessed clinical events included admission for worsening of heart failure and cardiac death.

Results

During a period of 42.4 ± 26.0 months, 32 (9.3%) patients were hospitalized for worsening heart failure, and 3 (0.8%) died due to cardiac causes. The absolute value of LV-GLS (|LV-GLS|) was significantly lower in patients with clinical events than in those without (12.1 ± 3.1 vs. 15.0 ± 3.2%, p < 0.001) despite comparable LV ejection fraction between groups. |LV-GLS| showed predictive value for clinical events (cut-off 13.9%, area under the curve 0.744, p < 0.001). Patients with |LV-GLS| ≤14.0% had poorer outcomes than those with |LV-GLS| >14.0% (log-rank p < 0.001). Prognosis was worse in patients with |LV-GLS| ≤14.0% and pulmonary hypertension than among those who with |LV-GLS| ≤14.0% without pulmonary hypertension (log rank p < 0.001). In nested Cox proportional hazard regression models, reduced |LV-GLS| was independently associated with the occurrence of clinical events.

Conclusions

In patients with surgically treated MV and preserved LV ejection fraction, assessment of LV-GLS provides functional information associated with cardiovascular outcomes.

Left atrial volume index predicts adverse events in asymptomatic moderate or severe aortic stenosis

OBJECTIVE

In aortic stenosis (AS), chronic pressure overload on left ventricle (LV) leads to LV hypertrophy, impaired relaxation, increased chamber stiffness, fibrosis and left atrial (LA) dilatation. An enlarged LA may be a marker of longstanding diastolic dysfunction (DD) and more advanced disease in AS. We aimed to assess the impact of LA volume index (LAVI) on events in patients with moderate or severe AS.

METHODS

A total of 324 patients (mean age 69 ± 13 years, 61% men) were included. LA volume was measured by biplane Simpson's method using apical four- and two-chamber views and indexed to body surface area. An increased LAVI was defined as > 34 ml/m² .

RESULTS

The mean EF was 64 ± 8%, LAVI 35 ± 14 ml/m² and flow rate 244 ± 70 ml/s. The number of total events was 275 (85%): 243 (75%) aortic valve replacement and 32 (10%) deaths. Mean follow-up 23.7 ± 23.8 months (median 15.2 months). An increased LAVI (45% [n = 145]) was associated with adverse events (HR 1.86; 95% CI 1.24-2.82, p = 0.003) independent of age, smoking, diabetes, atrial fibrillation, LV ejection fraction, LV mass, aortic valve area, and low flow rate (<200 ml/s). In the same multivariate model, when increased LAVI was replaced by E/e' ratio ≥14 cm, no association was found between E/e' ratio ≥14 cm and adverse events (HR 1.18; 95% CI .78-1.78, p = 0.430).

CONCLUSION

LAVI was an independent predictor of adverse events in patients with moderate or severe AS and preserved ejection fraction. Including LAVI in the risk assessment of AS patients may further improve risk stratification.

Long-term implications of left atrial appendage thrombus identified incidentally by pre-procedural cardiac computed tomography angiography in patients undergoing transcatheter aortic valve replacement

AIMS

The prevalence and prognostic implications of left atrial appendage (LAA) thrombus (LAAT) in patients considered for transcatheter aortic valve replacement (TAVR) are incompletely defined. We, therefore, studied pre-procedural cardiac computed tomography angiography (CCTA) scans of TAVR candidates to determine the prevalence of LAAT and its association with late outcomes.

METHODS AND RESULTS

Baseline clinical variables and CCTA findings from a prospective TAVR registry were analysed for the prevalence of pre-procedural LAAT and its impact on in-hospital outcomes and late mortality. LAAT was differentiated from LAA filling defects (LAAFD) reflecting stasis without clot. Patients (n = 561) with complete in-hospital and late mortality data were included in the study (median follow-up 31.6 months). LAAT and LAAFD were evidenced on pre-procedural CCTA in 24 (4.3%) and 26 (4.6%) patients, respectively. One hundred fourteen (20.3%) patients died during the study period. Though in-hospital adverse event rates (including stroke) did not differ among groups, mortality at long-term follow-up was higher among LAAT patients compared with those with or without LAAFD (58.3% vs. 11.5% vs. 19.0%, respectively; P < 0.003). By multivariable analysis, LAAT (but not LAAFD) was independently associated with all-cause mortality [hazard ratio (HR) = 3.33 (1.83-6.00), P < 0.001]. In patients with LAAT, oral anticoagulation at discharge was associated with lower mortality risk, independently of atrial fibrillation status.

CONCLUSIONS

LAAT visualized by pre-procedural CCTA is an independent predictor of late mortality following TAVR, but not peri-procedural stroke. When reporting TAVR-CCTA, particular note should be made of LAA features and presence of LAAT which may have prognostic and management implications.

Outcomes After Transcatheter Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Diastolic Dysfunction

OBJECTIVES

Left ventricular diastolic dysfunction (LVDD) in patients undergoing transcatheter aortic valve replacement (TAVR) is associated with poor outcomes; however, the effect of its severity is controversial. We sought to assess the impact of diastolic dysfunction on hospital outcomes and survival after TAVR and identify prognostic factors.

METHODS

We included patients who underwent TAVR for severe aortic stenosis with preexisting LVDD from 2009 to 2018 (n = 325). Patients with prior mitral valve surgery (n = 4), atrial fibrillation (n = 39), missing or poor baseline diastolic dysfunction assessment (n = 36) were excluded. The primary endpoint was all-cause mortality. 246 patients were included in the study.

RESULTS

The median age was 80 years (25th and 75th percentiles:75-86.7), 154 (62.6%) were males and the median EuroSCORE II was 4.3 (2.2-8). Patients with severe LVDD had significantly higher EuroSCORE, and lower ejection fraction (p < 0.001). There was no difference in post-TAVR new atrial fibrillation (p = 0.912), pacemaker insertion (p = 0.528), stroke (p = 0.76), or hospital mortality (p = 0.95). Patients with severe LVDD had longer hospital stay (p = 0.036). The grade of LVDD did not affect survival (log-rank = 0.145) nor major adverse cardiovascular events (log-rank = 0.97). Predictors of mortality were; low BMI (HR: 0.95 (0.91-0.99); p = 0.019), low sodium (0.93 (0.82-2.5); p = 0.021), previous PCI (HR: 1.6 (1.022-2.66); p = 0.04), E-peak (HR: 1.01 (1.002-1.019); p = 0.014) and implantation of more than one device (HR: 3.55 (1.22-10.31); p = 0.02).

CONCLUSION

Transcatheter aortic valve replacement is feasible in patients with diastolic dysfunction, and the degree of diastolic dysfunction did not negatively affect the outcome. Long-term outcomes in those patients were affected by the preoperative clinical state and procedure-related factors.

THAP11 down-regulation may contribute to cardio-protective effects of sevoflurane anesthesia: Evidence from clinical and molecular evidence

This study aimed to explore the potential target of the cardio-protective effect induced by sevoflurane anesthesia based on evidence from clinical samples and in vitro model. Forty patients undergoing mitral valve replacement were randomly allocated to receive sevoflurane or propofol-based anesthesia. Atrial muscle specimens were collected from all patients, of which 5 were used to perform transcriptomics analysis. The cTn-I concentration was tested before, at the end of, and 24 h after surgery. In in vitro study, the expression level of the identified target gene, i.e., THAP11, was studied in H9C2 cells treated with sevoflurane or propofol. Then, we studied cell viability using CCK-8 staining, apoptosis by using flow cytometry, and cell death by lactic acid dehydrogenase (LDH) detection in H9C2 cells exposed to oxygen glucose deprivation/reoxygenation (OGD/R) injury. THAP11 was the most significantly down-regulated gene in the transcriptomics analysis (P < 0.001), as confirmed in validation samples (P = 0.006). THAP11 mRNA levels in atrial muscle specimens were positively associated with cTn-I levels at 24-h postoperatively (determination coefficient = 0.564; P < 0.001). Sevoflurane treatment down-regulated THAP11 in H9C2 cell models, which promoted cell viability, inhibited cell apoptosis, and death in the OGD/R injury cell model. Up-regulation of THAP11 reduced the protective effect of sevoflurane treatment against OGD/R injury. Sevoflurane anesthesia down-regulates the expression of THAP11, which contributes to a cardio-protective effect. THAP11 down-regulation promotes cell viability, and inhibits cell apoptosis and death, thereby protecting again myocardial injury; it may therefore be a novel target for perioperative cardio-protection.

Pre- and postoperative left atrial and ventricular volumetric and deformation analyses in severe aortic regurgitation

Background

The impact of volume overload due to aortic regurgitation (AR) on systolic and diastolic left ventricular (LV) indices and left atrial remodeling is unclear. We assessed the structural and functional effects of severe AR on LV and left atrium before and after aortic valve replacement.

Methods

Patients with severe AR scheduled for aortic valve replacement (n = 65) underwent two- and three-dimensional echocardiography, including left atrial strain imaging, before and 1 year after surgery. A control group was selected, and comprised patients undergoing surgery for thoracic aortic aneurysm without aortic valve replacement (n = 20). Logistic regression analysis was used to assess predictors of impaired left ventricular functional and structural recovery, defined as a composite variable of diastolic dysfunction grade ≥ 2, EF < 50%, or left ventricular end-diastolic volume index above the gender-specific normal range.

Results

Diastolic dysfunction was present in 32% of patients with AR at baseline. Diastolic LV function indices and left atrial strain improved, and both left atrial and LV volumes decreased in the AR group following aortic valve replacement. Preoperative left atrial strain during the conduit phase added to left ventricular end-systolic volume index for the prediction of impaired LV functional and structural recovery after aortic valve replacement (model p < 0.001, accuracy 70%; addition of left atrial strain during the conduit phase to end-systolic volume index p = 0.006).

Conclusions

One-third of patients with severe AR had signs of diastolic dysfunction. Aortic valve surgery reduced LV and left atrial volumes and improved diastolic indices. Left atrial strain during the conduit phase added to the well-established left ventricular end-diastolic dimension for the prediction of impaired left ventricular functional and structural recovery at follow-up. However, long-term follow-up studies with hard endpoints are needed to assess the value of left atrial strain as predictor of myocardial recovery in aortic regurgitation.

Incremental prognostic role of left atrial reservoir strain in asymptomatic patients with moderate aortic stenosis

Left atrial (LA) mechanics assessed by two-dimensional speckle tracking echocardiography (2D-STE) have not been extensively studied and clearly characterized in patients with moderate aortic stenosis (AS). Accordingly, we aimed to evaluate the usefulness of LA reservoir strain for risk stratification of asymptomatic patients with moderate AS. This retrospective study included all consecutive asymptomatic patients with moderate AS who underwent transthoracic echocardiography implemented with 2D-STE analysis of LA myocardial strain and strain rate indices at our Institution, between February 2011 and September 2019. During the follow-up period, we evaluated the occurrence of any of the following: (1) CV hospitalization; (2) The recourse to AS surgery; (3) Cardiac death or sudden death. A total of 186 patients (mean age 71.9 ± 12.7 years, 61.8% men) were included in the present study. During a mean follow-up of 2.3 ± 1.9 years, no patients died and 63 adverse CV events were recorded: 48 patients were hospitalized because of heart failure (28 patients), acute coronary syndrome (10 patients), arrhythmias (10 patients) and 15 patients underwent AS surgery. At the multivariate Cox regression analysis, type 2 diabetes mellitus (OR 1.87, 95%CI 1.05-3.34, p = 0.03), NT-proBNP (OR average 1.14, 95%CI 1.02-1.27, p = 0.02), average E/e' ratio (OR 1.07, 95%CI 1.01-1.15, p = 0.04) and most of all left atrial positive global strain (LA-GSA+) (OR 0.85, 95%CI 0.81-0.90, p < 0.0001) were independently associated with the outcome. LA-GSA+ (optimal cut-off ≤ 19%, AUC = 0.94, 87% sensitivity, 99% specificity, positive predictive value 99%, negative predictive value 88%) showed the highest diagnostic performance. An impaired LA reservoir strain can contribute to identify a subset of asymptomatic patients with moderate AS at higher risk, who may benefit from closer echocardiographic follow-up and/or early surgery.

Impact of Loop Diuretic Use on Outcomes Following Transcatheter Aortic Valve Implantation

The use of LDT may signify significant hemodynamic changes and left ventricular remodeling in severe aortic stenosis (AS). Therefore, we sought to determine whether loop diuretic therapy (LDT) is associated with adverse outcomes following transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic AS. Subjects undergoing TAVI at a single institution from June 2008 to December 2017 were analyzed. LDT doses were normalized to oral furosemide daily equivalents. All outcomes were adjudicated using VARC2 criteria. Descriptive statistics, multivariate logistic regression, and propensity score matching were used. Of the 804 subjects studied, 48.3% were on pre-TAVI LDT with a mean dose of 51.1 mg furosemide dose-equivalents. Subjects on LDT were higher risk, frail patients with more co-morbidities including chronic kidney disease, coronary artery disease requiring prior bypass grafting, peripheral arterial disease, atrial fibrillation or flutter, and diabetes with more severe heart failure symptoms. Those on LDT also had worse left ventricular systolic function, lower transvalvular gradients, and markers of adverse left ventricular remodeling, including increased left ventricular mass index and higher rates of concentric and eccentric hypertrophy. On propensity-score matching, death within one year post-TAVI was borderline significantly higher in the pre-LDT as compared with no-LDT group (16.9% vs 10.4 %, p = 0.068). In conclusion, use of pre-TAVI LDT for severe symptomatic AS is associated with a trend towards worse 1-year mortality and is a marker of high-risk, frail individuals with advanced left ventricular remodeling.

Atrial-ventricular function in rheumatic mitral regurgitation using strain imaging

Background

Chronic mitral regurgitation (MR) historically has been shown to primarily affect left ventricular (LV) function. The impact of increased left atrial (LA) volume in MR on morbidity and mortality has been highlighted recently, yet the LA does not feature as prominently in the current guidelines as the LV. Thus, we aimed to study LA and LV function in chronic rheumatic MR using traditional volumetric parameters and strain imaging.

Methods

Seventy-seven patients with isolated moderate or severe chronic rheumatic MR and 40 controls underwent echocardiographic examination. LV and LA function were assessed with conventional echocardiography and 2D strain imaging.

Results

LA stiffness index was greater in chronic rheumatic MR than controls (0.95 ± 1.89 vs 0.16 ± 0.13, P = 0.009). LA dysfunction was noted in the reservoir, conduit, and contractile phases compared with controls (P < 0.05). LA peak reservoir strain (Ɛ_R), LA peak contractile strain, and LV peak systolic strain were decreased in chronic rheumatic MR compared with controls (P < 0.05). Eighty-six percent of patients had decreased LA Ɛ_R and 58% had depressed LV peak systolic strain. Decreased Ɛ_R and normal LV peak systolic strain were noted in 42%. Thirteen percent had normal Ɛ_R and LV peak systolic strain. One patient had normal Ɛ_R with decreased LV peak systolic strain.

Conclusions

In chronic rheumatic MR, there is LA dysfunction in the reservoir, conduit, and contractile phases. In this study, LA dysfunction with or without LV dysfunction was the predominant finding, and thus, LA dysfunction may be an earlier marker of decompensation in chronic rheumatic MR.

Higher preoperative left atrial volume index predicts lack of mitral regurgitation improvement after transcatheter aortic valve replacement

BACKGROUND

Moderate-to-severe mitral regurgitation is present in 20-35% of patients undergoing transcatheter aortic valve replacement (TAVR) and the current literature lacks simple echocardiographic parameters, which can predict post-TAVR changes in mitral regurgitation. The aim of this study is to investigate the echocardiographic predictors of improvement or worsening of mitral regurgitation in patients undergoing TAVR with moderate-to-severe mitral regurgitation.

METHODS

This retrospective study included 113 patients who underwent TAVR with preoperative mitral regurgitation grade at least 2. Patients with concomitant coronary artery disease requiring treatment were excluded. Mitral regurgitation was related to the annular dilatation or tethering mechanism in all patients. Preoperative and postoperative echocardiographies were compared in terms of mitral regurgitation and other commonly measured parameters.

RESULTS

After TAVR, a reduction in mitral regurgitation was observed in 62.8% of cases. On the basis of the difference between postoperative and preoperative echocardiograms, 71 patients had improved mitral regurgitation, whereas 42 patients had stable or worsened mitral regurgitation. After analyzing preoperative echocardiographic parameters with regard to this group difference, left atrial volume index (LAVI) was the only variable that was different between groups (33.4 ± 4.8 ml/m in improved mitral regurgitation vs. 39.8 ± 3.0 ml/m in not improved mitral regurgitation, P < 0.001). In a multivariable logistic regression model, a LAVI increase was associated with lack of an acute reduction in mitral regurgitation (odds ratio = 1.41, P < 0.001) after adjustment for age and preoperative serum creatinine.

CONCLUSION

Higher preoperative LAVI is a determinant predictor of lack of an acute reduction in mitral regurgitation after TAVR, and LAVI could be used as a stratifying tool to tailor the treatment strategy and the timing of the procedures. However, validation of these results and long-term outcomes are warranted to support those conclusions.

Association Between Diastolic Dysfunction and Health Status Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVES

The aim of this study was to assess the association of baseline left ventricular diastolic dysfunction (LVDD) with health status outcomes of patients undergoing transcatheter aortic valve replacement (TAVR).

BACKGROUND

Although LVDD in patients with aortic stenosis is associated with higher mortality after TAVR, it is unknown if it is also associated with health status recovery.

METHODS

In a cohort of 304 patients with interpretable echocardiograms, undergoing TAVR, LVDD was categorized at baseline as absent (grade 0), mild (grade 1), moderate (grade 2), or severe (grade 3). Disease-specific health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) at baseline and at 1-month and 12-month follow-up. Association of baseline LVDD with health status at baseline and follow-up after TAVR was assessed using a linear trend test, and association with health status recovery (change in KCCQ-OS) was examined using a linear mixed model adjusting for baseline KCCQ-OS.

RESULTS

Twenty-four (7.9%), 54 (17.8%), 186 (61.2%), and 40 (13.2%) patients had LVDD grades of 0, 1, 2, and 3, respectively. Baseline KCCQ-OS was 61.3 ± 22.7, 51.0 ± 26.1, 44.7 ± 25.7, and 44.4 ± 21.9 (p = 0.004) in patients with LVDD grades of 0, 1,2 and 3. At 1 and 12 months after TAVR, LVDD was not associated with KCCQ-OS. Recovery in KCCQ-OS after TAVR was substantial and similar in patients across all severities of LVDD.

CONCLUSIONS

Although LVDD is associated with health status prior to TAVR, patients across all severities of LVDD have similar recovery in health status after TAVR.

Impact of diastolic dysfunction on long-term mortality and quality of life after transcatheter aortic valve replacement

BACKGROUND

There is conflicting data as to whether diastolic dysfunction (DD) affects the prognosis of patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Consecutive patients undergoing TAVR underwent assessment of DD with preoperative echocardiography and NT-pro BNP. Long-term survival was ascertained every 6 months by clinic visits or phone. DD was graded according to the new American Society of Echocardiography recommendations. Health status was assessed at baseline and 30 days post-procedure using the KCCQ-12 questionnaire. Long-term survival was displayed using Kaplan-Meier curves according to NT-pro BNP levels and DD grades.

RESULTS

We included 222 patients, mean age 78 (±8) years, median STS score 4 (interquartile range = 3-7), median follow-up time 385 days (IQR = 180-640). DD was absent in 25, Grade I in 13, Grade II in 74, Grade III in 24, and indeterminate in 86 patients. Advanced (Grades II-III) DD was associated with higher pre-procedural NT-pro BNP levels (p < .001), worse quality of life (p < .001) but similar surgical risk (p = .43). Advanced and indeterminate DD were associated with increased long-term mortality (25-28% vs. 5%, p = .02) and elevated NT-pro BNP levels (26.4% vs. 9.8%, p = .05). Improvements in quality of life measures were seen in all DD groups (median change in KCCQ score no or Grade I DD:14 [3-21] vs. Grades II-III DD: 15 [16-26; p = .37]).

CONCLUSION

Preoperative NT-pro BNP levels and echocardiographic indices of indeterminate or advanced DD are associated with increased long-term mortality after TAVR but similar improvements in quality of life.

Impact of High Baseline Left Ventricular Filling Pressure on Transcatheter Aortic Valve Replacement Outcomes in Patients with Significant Mitral Annular Calcification

BACKGROUND

Left ventricular filling pressure (LVFP) has been demonstrated to be a major predictor of poor cardiovascular outcomes. However, estimation of LVFP in patients with aortic stenosis is limited by the high prevalence of significant mitral annular calcification. The aim of this study was to investigate the effect of transcatheter aortic valve replacement on LVFP and the relationship of LVFP to mortality and hospitalization.

METHODS

This was a single-center, retrospective study of 140 consecutive patients in sinus rhythm with significant mitral annular calcification who underwent transcatheter aortic valve replacement for severe aortic stenosis from May 2011 to June 2015. Mean follow-up duration was 3.06 ± 1.48 years (minimum, 2.4 years; maximum, 6.5 years). Diastolic function was assessed using recently proposed criteria for those with significant mitral annular calcification. High LVFP was defined as a mitral E/A ratio > 1.8 or a ratio of 0.8 to 1.8 and isovolumic relaxation time < 80 msec.

RESULTS

At baseline, the proportion of patients with high LVFP was 40.7%, similar to 1 month (39.7%) (P = .86). However, the proportion of patients with high LVFP was significantly decreased at 1 year compared with those at baseline (26.9% vs 40.7%, P = .02). Multivariate analysis showed that high LVFP at baseline significantly increased risk for all-cause mortality compared with patients with normal LVFP (hazard ratio, 2.84; 95% confidence interval, 1.33-6.05; P = .007).

CONCLUSIONS

High baseline LVFP was associated with a significantly increased all-cause mortality, and LVFP does not improve in the short term but only at 1 year after transcatheter aortic valve replacement.

Left Ventricular Diastolic Dysfunction and Transcatheter Aortic Valve Replacement Outcomes: A Review

Aortic stenosis (AS) is the most common valvular disease that can lead to increased afterload, left ventricular (LV) remodeling, and myocardial fibrosis. We reviewed the literature addressing the impact of transcatheter aortic valve replacement (TAVR) on LV remodeling and patients' outcomes by elimination of AS-related high afterload. TAVR reduces afterload and improves LV remodeling recovery. However, myocardial fibrosis may not completely reverse after the TAVR. The LV diastolic dysfunction (LVDD) induced by AS is an independent predictor of post-TAVR mortality, and mortality increases with severity of LVDD. The impact of diastolic dysfunction on patient outcomes emerges at 30 days but continues to persist during mid-term follow-up. Based on severity of the baseline LVDD, some patients may tolerate post-TAVR aortic regurgitation (AR), but even minimal post-TAVR AR in patients with severe baseline LVDD can have an additive negative impact on survival. It is crucial to consider TAVR prior to development of advanced LVDD. Appropriate device selection and deployment technique are important in improvement of TAVR outcomes via elimination of AR.

Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement

IMPORTANCE

Data are lacking on the effect of a renin-angiotensin system (RAS) inhibitor prescribed after transcatheter aortic valve replacement (TAVR). Treatment with a RAS inhibitor may reverse left ventricular remodeling and improve function.

OBJECTIVE

To investigate the association of prescription of a RAS inhibitor and outcomes after TAVR.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of TAVR procedures performed in the United States (using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry) between July 2014 and January 2016 that were linked to Medicare claims data (final date of follow-up: March 31, 2017). To account for differences in demographics, echocardiographic findings, and in-hospital complications, 1:1 propensity matching was performed.

EXPOSURES

Initial hospital discharge prescription of a RAS inhibitor after TAVR.

MAIN OUTCOMES AND MEASURES

Primary outcomes were all-cause death and readmission due to heart failure at 1 year after discharge, which were considered separately. The secondary outcome was health status assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ; score range: 0-100, with a higher score indicating less symptom burden and better quality of life; a small effect size was defined as 5 points) at 1 year.

RESULTS

Among 21 312 patients who underwent TAVR at 417 US sites, 8468 patients (39.7%) were prescribed a RAS inhibitor at hospital discharge. After propensity matching, 15 896 patients were included (mean [SD] age, 82.4 [6.8] years; 48.1% were women; mean [SD] left ventricular ejection fraction [LVEF], 51.9% [11.5%]). Patients with a prescription for a RAS inhibitor vs those with no prescription had lower mortality rates at 1 year (12.5% vs 14.9%, respectively; absolute risk difference [ARD], -2.4% [95% CI, -3.5% to -1.4%]; hazard ratio [HR], 0.82 [95% CI, 0.76 to 0.90]) and lower heart failure readmission rates at 1 year (12.0% vs 13.8%; ARD, -1.8% [95% CI, -2.8% to -0.7%]; HR, 0.86 [95% CI, 0.79 to 0.95]). When stratified by LVEF, having a prescription for a RAS inhibitor vs no prescription was associated with lower 1-year mortality among patients with preserved LVEF (11.1% vs 13.9%, respectively; ARD, -2.81% [95% CI, -3.95% to -1.67%]; HR, 0.78 [95% CI, 0.71 to 0.86]), but not among those with reduced LVEF (18.8% vs 19.5%; ARD, -0.68% [95% CI, -3.52% to 2.20%]; HR, 0.95 [95% CI, 0.81 to 1.12]) (P = .04 for interaction). Of 15 896 matched patients, 4837 (30.4%) were included in the KCCQ score analysis and improvements at 1 year were greater in patients with a prescription for a RAS inhibitor vs those with no prescription (median, 33.3 [interquartile range, 14.2 to 51.0] vs 31.3 [interquartile range, 13.5 to 51.1], respectively; difference in improvement, 2.10 [95% CI, 0.10 to 4.06]; P < .001), but the effect size was not clinically meaningful.

CONCLUSIONS AND RELEVANCE

Among patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge compared with no prescription was significantly associated with a lower risk of mortality and heart failure readmission. However, due to potential selection bias, this finding requires further investigation in randomized trials.

Diastolic dysfunction is common and predicts outcome after cardiac surgery

Background

Diastolic dysfunction (DD) identified on echocardiography predicts mortality after cardiac surgery, however the most useful diastolic parameters for assessment and the association of DD with prolonged mechanical ventilation, ICU re-admission, and hospital length of stay are not established.

Methods

We included patients that underwent coronary artery bypass grafting (CABG), aortic valve replacement (AVR) or a combined procedure (CAB-AVR) from 2010 to 2016, and who had preoperative transthoracic echocardiography (TTE) at our institution within 6 months of the operation. Diastolic function was graded using the transmitral E and A waves and the septal tissue Doppler velocity. We performed logistic regression to assess the association of grade of DD with a composite endpoint of death, prolonged mechanical ventilation, ICU readmission during hospitalization, and hospital length of stay longer than 14 days.

Results

Between 2010 and 2016, 577 patients were eligible for inclusion. DD was common, with 42% of the cohort manifesting grade II or grade III DD. Rates of death and prolonged ventilation increased across grades of DD and across quartiles of increasing LV filling pressure, assessed by the E/e’ ratio. Adjusting for age, sex, procedure, systolic and diastolic function, both systolic (odds ratio 0.68 95% CI 0.55–0.85 per inter-quartile increase in LVEF) and diastolic function (odds ratio 1.31 95% CI 1.04–1.66 per increasing DD grade) both independently predicted outcome.

Conclusion

Diastolic dysfunction is common among patients undergoing cardiac surgery and is associated with death, prolonged mechanical ventilation, and prolonged hospital and ICU length of stay independent of systolic dysfunction.

Adverse effects of left ventricular electrical dyssynchrony on cardiac reverse remodeling and prognosis after aortic valve surgery

BACKGROUND

Electrical dyssynchrony (ED) is one of the important contributing mechanisms in the progression of heart failure. We hypothesized that ED would interfere with cardiac reverse remodeling and affect prognosis after aortic valve surgery.

METHODS

A total of 411 consecutive patients (233 males, mean age 65±11 years) who underwent aortic valve surgery were retrospectively analyzed. The patients were divided into two groups according to the presence of ED [Group 1: no ED (n=382, 93%), Group 2: ED (n=29, 7%)]. ED was defined as either left ventricular bundle branch block, or electrical pacing rhythm. Cardiac reverse remodeling was assessed at 1 year after surgery by the changes in left ventricular ejection fraction (LVEF), LV end-systolic volume (LVESV), and left atrial volume index (LAVI). The primary endpoint was a composite of hospitalization for heart failure, and all-cause mortality.

RESULTS

At 1 year after surgery, group 2 showed lower LVEF (58±15% vs. 64±9%, p=0.044), and higher LAVI (42±18ml/m² vs. 33±13ml/m², p=0.018) than group 1. However, LVESV values (55±38ml vs. 42±24ml, p=0.076) were not significantly different. In particular, in patients with reduced preoperative LVEF, the LVEF was markedly increased in group 1 but not in group 2 after 1 year. During a median follow-up of 39 months, group 2 showed a worse clinical outcome than group 1 (20.7% vs. 7.6%, p=0.031). After adjusting for confounding factors in the multivariate analyses, age [hazard ratio (HR) 1.11, 95% confidence interval (CI) 1.06-1.16, p<0.001] and the presence of ED (HR 2.43, 95% CI 1.01-5.89, p=0.046) were found to be independent predictors of clinical outcomes.

CONCLUSIONS

ED after aortic valve surgery negatively affected cardiac remodeling and prognosis.

Feature Tracking Cardiac MRI Reveals Abnormalities in Ventricular Function in Patients With Bicuspid Aortic Valve and Preserved Ejection Fraction

Subclinical systolic and diastolic left ventricular (LV) dysfunction has been reported in previous echocardiographic studies on congenital bicuspid aortic valve (BAV). Patients with BAV commonly undergo evaluation with magnetic resonance imaging, and feature-tracking cardiovascular magnetic resonance (CMR-FT) is an emerging technique that assesses myocardial strain using standard cine sequences. This study investigated differences in myocardial strain between patients with BAV with preserved ejection fraction (EF) and controls using CMR-FT. Patients with isolated BAV and preserved EF, who had previously undergone CMR (n = 42; mean age, 41.2 ± 13.9) were compared with controls (n = 19; 36.6 ± 9.8; P = .2). Investigational CMR-FT strain analysis software was used to measure circumferential systolic and diastolic strain values, as well as standard LV volumetric and functional parameters. The majority of patients with BAV had mild or no valve dysfunction, and LV myocardial mass end-diastolic volume indices were similar between groups. Peak diastolic circumferential strain rate was lower in patients with BAV than in controls (0.89 ± 0.27 vs 1.21 ± 0.21 s-1, P = .003). After adjusting for covariates, only myocardial mass index was independently associated with peak circumferential systolic strain and diastolic strain rate. Feature-tracking CMR can identify abnormalities of LV strain in a clinical cohort of asymptomatic patients with BAV with preserved EF. Decreases in circumferential diastolic strain rate in patients with BAV suggest evidence of early diastolic dysfunction.

Hyaluronidase 2 Deficiency Causes Increased Mesenchymal Cells, Congenital Heart Defects, and Heart Failure

Supplemental Digital Content is available in the text.

Background—

Hyaluronan (HA) is required for endothelial-to-mesenchymal transition and normal heart development in the mouse. Heart abnormalities in hyaluronidase 2 (HYAL2)–deficient (Hyal2^−/−) mice and humans suggested removal of HA is also important for normal heart development. We have performed longitudinal studies of heart structure and function in Hyal2^−/− mice to determine when, and how, HYAL2 deficiency leads to these abnormalities.

Methods and Results—

Echocardiography revealed atrial enlargement, atrial tissue masses, and valvular thickening at 4 weeks of age, as well as diastolic dysfunction that progressed with age, in Hyal2^−/− mice. These abnormalities were associated with increased HA, vimentin-positive cells, and fibrosis in Hyal2^−/− compared with control mice. Based on the severity of heart dysfunction, acute and chronic groups of Hyal2^−/− mice that died at an average of 12 and 25 weeks respectively, were defined. Increased HA levels and mesenchymal cells, but not vascular endothelial growth factor in Hyal2^−/− embryonic hearts, suggest that HYAL2 is important to inhibit endothelial-to-mesenchymal transition. Consistent with this, in wild-type embryos, HYAL2 and HA were readily detected, and HA levels decreased with age.

Conclusions—

These data demonstrate that disruption of normal HA catabolism in Hyal2^−/− mice causes increased HA, which may promote endothelial-to-mesenchymal transition and proliferation of mesenchymal cells. Excess endothelial-to-mesenchymal transition, resulting in increased mesenchymal cells, is the likely cause of morphological heart abnormalities in both humans and mice. In mice, these abnormalities result in progressive and severe diastolic dysfunction, culminating in heart failure.

Preoperative Invasive Hemodynamic Determinants of Survival Among Patients Undergoing Aortic or Mitral Valve Surgery

OBJECTIVES

To evaluate the association of preoperative invasive hemodynamic parameters with mortality in valvular heart surgery.

DESIGN

Retrospective cohort study.

SETTING

Single tertiary academic medical center.

PARTICIPANTS

A total of 382 patients who underwent preoperative right and/or left heart catheterization before open aortic valve replacement (AVR), open mitral valve repair/replacement (MVR), or combined AVR and MVR, from July 2009 to December 2014.

INTERVENTIONS

Retrospective chart review.

MEASUREMENTS AND MAIN RESULTS

Common hemodynamic indices derived from direct catheterization measurements were assessed, including pulmonary artery systolic pressure (PASP), pulmonary artery pulse pressure (PPP), mean pulmonary capillary wedge pressure (mPCWP), pulmonary artery pulsatility index, diastolic pressure gradient, left ventricular work index, and right ventricular work index. Bivariable and multivariable associations of these measures with survival were determined using Cox proportional hazards regression. Kaplan-Meier survival curves were generated using the log-rank test. The median age of the cohort was 69 years (interquartile range 60-79 years), and 162 (42.4%) of the patients were female. Elevated PASP (hazard ratio [HR] 1.32 per 10 mmHg, p < 0.0001), elevated PPP (HR 1.48 per 10 mmHg, p < 0.0001), and elevated mPCWP (HR 1.95 per 10 mmHg, p < 0.0001) were all associated with decreased survival, as was decreased diastolic blood pressure (DBP) (p = 0.005). The combination of elevated PPP and decreased DBP was associated with the worst outcomes.

CONCLUSIONS

PASP, PPP, mPCWP, and DBP were significantly associated with mortality in valvular heart surgery patients. These hemodynamic parameters may be useful in risk stratification of this population subset.

B-type natriuretic peptide and echocardiography reflect volume changes during pregnancy

OBJECTIVE

To evaluate B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac structure and function in normal women through pregnancy and the postpartum.

METHODS

In this prospective observational study, we obtained serial transthoracic echocardiograms, BNP, and NT-proBNP at seven intervals from 6 weeks' gestation through 12 months postpartum. Women with hypertension or cardiac disease were excluded. Using 6-12 months postpartum as reference for non-pregnant levels, echocardiogram measurements and BNP/NT-proBNP were compared over time using linear mixed models with Tukey-Kramer adjustment for multiple comparisons.

RESULTS

Of 116 patients, data was available for 78-114 healthy pregnant or postpartum women within each time interval, and 102 patients provided data for ≥4 intervals. Compared to 6-12 months postpartum, BNP and NT-proBNP remained stable through pregnancy and delivery, increased within 48 h postpartum (P<0.0001), then returned to baseline. Left ventricular volume increased within 48 h postpartum (P=0.021) while left atrial volume increased at 18-24 weeks (P=0.0002), 30-36 weeks (P<0.0001) and within 48 h postpartum (P=0.002). The transmitral early/late diastolic velocity (E/A) ratio, transmitral early/peak mitral annulus diastolic velocity (E/E') ratio, isovolumic relaxation times, and mitral valve deceleration times were similar within 48 h and 6-12 months postpartum.

CONCLUSION

In normal women, BNP/NT-proBNP, left atrial, and left ventricular volumes increase within 48 h postpartum without indications of altered diastolic function.

Diastolic Function and Transcatheter Aortic Valve Replacement

BACKGROUND

Little is known about baseline diastolic dysfunction and changes in diastolic dysfunction grade after transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) and its impact on overall outcomes. The aim of this study was to describe baseline diastolic dysfunction and changes in diastolic dysfunction grade that occur with TAVR and their relationship to mortality and rehospitalization.

METHODS

This was a single-center study evaluating all TAVRs from January 2012 to June 2014. We compared parameters of diastolic dysfunction grade on pre-TAVR and 1 month post-TAVR echocardiograms for all patients undergoing the procedure. Descriptive statistics, Kaplan-Meier time-to-event analysis, and multivariate logistic regression were used.

RESULTS

Of a sample size of 120 patients undergoing TAVR for symptomatic severe AS, 90 were included in the final analysis after excluding significant mitral valve disease. There were improvements in individual parameters of diastolic dysfunction grade such as lateral e' velocity, E/lateral e', and left atrial volume index (nonsignificant trend) in the setting of improvement in aortic valve area and gradients and functional class pre- and post-TAVR. Multivariate analysis revealed that baseline diastolic dysfunction grade, but not post-TAVR or changes in diastolic dysfunction grade, was associated with 1-year death (hazard ratio, 1.163; 95% CI, 1.049-1.277, P = .005) and combined death/cardiovascular hospitalization (hazard ratio, 1.174; 95% CI, 1.032-1.318; P = .018).

CONCLUSIONS

In this single-center retrospective study of patients with symptomatic severe AS who underwent TAVR, several diastolic function parameters improved on echocardiography, but baseline diastolic dysfunction grade remained the most important echocardiographic factor associated with adverse 1-year outcomes.

Determinants and Prognostic Significance of Symptomatic Status in Patients with Moderately Dysfunctional Bicuspid Aortic Valves

Background

We aimed to identify the clinical and echocardiographic determinants of symptoms and their prognostic implications in patients with moderately dysfunctional bicuspid aortic valves (BAVs).

Methods

Among 1,019 subjects in the BAV registry treated in a single tertiary care center, the records of 127 patients (85 men, age 58±13 years) with moderately dysfunctional BAVs were comprehensively reviewed. The patients were divided into two groups based on symptom status: asymptomatic (n = 80) vs. symptomatic (n = 47). The primary end-point was defined as a composite of aortic valve surgery, hospitalization for heart failure, and any cause of death.

Results

The symptomatic group had a higher proportion of females, hypertension, aortic stenosis, and aortopathy than did the asymptomatic group. The symptomatic group showed lower e′ (5.5±1.7 vs. 6.5±2.2 cm/s, p = 0.003), higher E/e′ (13.3 ± 4.9 vs. 10.9±3.7, p = 0.002), and larger left atrial volume index (29.9±11.4 vs. 24.6±9.1 ml/m², p = 0.006) than did the asymptomatic group. In multivariate logistic regression analysis, female gender (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.10–7.36, p = 0.031), hypertension (OR 3.07, 95% CI 1.20–7.82, p = 0.019), moderate aortic stenosis (OR 5.33 5.78, 95% CI 1.99–16.83, p = 0.001), E/e′ >15 (OR 3.82, 95% CI 1.03–11.19, p = 0.015), and aortopathy (OR 2.76, 95% CI 1.07–7.10, p = 0.035) were independently correlated with symptom status. The symptomatic group showed a significantly lower rate of event-free survival during the 8-year follow-up period (54±9% vs. 68±10%, p = 0.001).

Conclusions

In patients with moderately dysfunctional BAVs, the presence of moderate aortic stenosis, aortopathy, and diastolic dysfunction determines symptom status, along with female gender and hypertension. Symptom status was associated with clinical outcomes.

Short-Term Effects and Safety Analysis of Retrograde Autologous Blood Priming for Cardiopulmonary Bypass in Patients with Cardiac Valve Replacement Surgery

This randomized, double-blind study evaluated the short-term effects and safety of perioperative retrograde autologous priming (RAP) for cardiopulmonary bypass (CPB) in patients with cardiac replacement surgery to determine if this approach is a better substitute for crystal liquids priming in patients with valvular heart disease. We observed that RAP significantly decreased the actual priming volume, preserved the hematocrit and hemoglobin level during CPB to a certain degree, and decreased lactate accumulation in CPB period. Moreover, RAP lowered the volume of transfusion and dosage blood products. Thus, our results showed that RAP approach effectively improved tissue perfusion and lowered intraoperative Lac levels, by reducing the hemodilution, which safely and reliably improve the microcirculation perfusion.

Early Transthoracic Echocardiography after Cardiac Surgery Predicts Postoperative Atrial Fibrillation

PURPOSE

Postoperative atrial fibrillation (POAF) is frequent after cardiac surgery. We aimed to establish a predictive model of POAF based on postoperative transthoracic echocardiography (TTE) findings.

METHODS

This study included 147 patients (aged 67 ± 11 years; 109 men) undergoing coronary artery bypass grafting and/or aortic valve replacement. TTE and Doppler tissue imaging were performed on intensive care unit arrival after surgery. All patients were continuously monitored during hospitalization. The end point was the appearance of POAF.

RESULTS

POAF appeared in 37 patients (25.2%). These patients were older (69 ± 16 vs. 65 ± 12 years; P < 0.001) and had increased long axis of the left atrium (LA) dimension (5.4 ± 1 vs. 4.8 ± 0.9 cm, P = 0.02), lower early diastolic velocity of the mitral annulus (e') (6.9 ± 2.1 vs. 8 ± 1.8 cm/sec; P < 0.01), and higher early diastolic pulsed Doppler mitral ratio (E)/e' (E/e') (17.4 ± 6.8 vs. 13.8 ± 6; P = 0.01). Left ventricle diastolic dysfunction grade (DFG) of 2 or 3 relative to grade 0 was significant: odds ratio (OR) 22.5, 95% confidence interval (CI) 4.52-57.2; P < 0.001, and OR: 23.6, 95% CI: 3.57-60.1; P = 0.001), respectively. On multivariate analysis, the independent predictors of POAF were age (OR: 1.10, 95% CI: 1.01-1.18; P < 0.05), long-axis LA dimension (OR: 6.24, 95% CI: 1.97-8.23; P = 0.0017), DFG-2 (OR: 4.1, 95% CI: 1.57-15.81; P < 0.001), and DFG-3 (OR: 8.3, 95% CI: 4.11-25.37; P < 0.001).

CONCLUSIONS

Apart from age, the simple determination by postoperative TTE of long-axis LA dimension and DFG after cardiac surgery proved to be powerful independent predictors of POAF and may be useful for risk stratification of these patients.

Maternal Cardiovascular Function in Normal Pregnancy

The aim of this study was to investigate cardiac functional status in pregnancy using a comprehensive approach taking into account the simultaneous changes in loading and geometry, as well as maternal age and anthropometric indices. This was a prospective cross-sectional study of 559 nulliparous pregnant women assessed at 4 time points during pregnancy and at 1 year postpartum. All women underwent conventional echocardiography and tissue Doppler velocities and strain rate analysis at multiple cardiac sites. Mean arterial pressure and total vascular resistance index significantly decreased (both P <0.001) during the first 2 trimesters of pregnancy and increased thereafter. Stroke volume index and cardiac index showed the opposite trend compared with mean arterial pressure and total vascular resistance index (both P <0.05). Myocardial and ventricular function were significantly enhanced in the first 2 trimesters but progressively declined thereafter. By the end of pregnancy, significant chamber diastolic dysfunction and impaired myocardial relaxation was evident in 17.9% and 28.4% of women, respectively, whereas myocardial contractility was preserved. There was full recovery of cardiac function at 1 year postpartum. Cardiovascular changes during pregnancy are thought to represent a physiological adaptation to volume overload. The findings of a drop in stroke volume index, impaired myocardial relaxation with diastolic dysfunction, and a tendency toward eccentric remodeling in a significant proportion of cases at term are suggestive of cardiovascular maladaptation to the volume-overloaded state in some apparently normal pregnancies. These unexpected cardiovascular findings have important implications for the management of both normal and pathological pregnancy states.