Systolic pulmonary regurgitation affects the outcome of patients with severe systolic heart failure

AIMS

Little is known of the impact of systolic pulmonary regurgitation (PR) on acute decompensated heart failure (HF). We assessed the prevalence and prognostic significance of systolic PR in patients with severe HF.

METHODS AND RESULTS

According to recent 10 year echocardiographic database of E-Da Hospital, 533 patients admitted for first systolic heart failure (HF) and left ventricular ejection fraction <35% were under investigation. Systolic PR was defined as the presence of pulmonary backward flow persistent after QRS in electrocardiogram. Isovolumic contraction/relaxation time and myocardial performance index were derived by tissue Doppler imaging. Right ventricular (RV) function was assessed by RV fractional area change. Estimated pulmonary vascular resistance (PVR) was assessed by the ratio of peak tricuspid regurgitation velocity to the RV outflow tract time-velocity integral. The factors associated with systolic PR were assessed by multivariate logistic regression. Cox proportional regression analyses were used to estimate the impact of cardiovascular events including HF rehospitalization and cardiovascular death. For estimated prevalence of 5480 control subjects, echocardiographic screens in those with normal left ventricular ejection fraction were performed. Of 533 systolic HF cases, 143 (26.8%) had systolic PR during indexed hospitalization. Among 143 cases, 86% systolic PR disappeared during late follow-up. In control subjects, 0.3% (18/5480) had systolic PR. Systolic PR correlated to RV dysfunction, estimated PVR, E/e', sign of low cardiac output, and pulmonary oedema. Systolic PR was associated independently with further cardiovascular events (hazard ratio 2.266, 95% confidence interval 1.682-3.089, P < 0.0001) including cardiovascular death and HF rehospitalization.

CONCLUSIONS

Systolic PR is not uncommon in systolic HF and is associated with high PVR and RV dysfunction. Systolic PR significantly impacts cardiovascular outcome.

Phantom Systole: A Failed Ejection Phenomenon between Pulsus Alternans and Systolic Aortic Regurgitation

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PA and SAR are both related to heart failure.

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The authors describe “phantom systole,” a remarkable finding of FE.

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PVCs play a key role in worsening systolic heart failure.

Systolic aortic regurgitation in rheumatic carditis: Mechanistic insight by Doppler echocardiography

Background

Aortic regurgitation (AR) usually occurs in diastole in presence of an incompetent aortic valve. Systolic AR is a rare phenomenon occurring in patients with reduced left ventricular systolic pressure and atrial fibrillation or premature ventricular contractions. Its occurrence is a Doppler peculiarity and adds to the hemodynamic burden.

Aim

Rheumatic carditis is often characterised by acute or subacute severe mitral regurgitation (MR) due to flail anterior mitral leaflet and elongated chords. In patients with acute or subacute MR, developed left ventricular systolic pressure may fall in mid and late systole due to reduced afterload and end-systolic volume and may be lower than the aortic systolic pressure, causing flow reversal in aorta and systolic AR.

Material and methods

17 patients with acute rheumatic fever were studied in the echocardiography lab during the period 2005–2015. Five patients had severe MR of which two had no AR and hence were excluded from the study. Three young male patients (age 8–24 years) who met modified Jones’ criteria for rheumatic fever with mitral and aortic valve involvement were studied for the presence of systolic AR.

Results

In presence of acute or subacute severe MR, flail anterior mitral valve and heart failure, all three showed both diastolic and late systolic AR by continuous-wave and color Doppler echocardiography.

Conclusion

Systolic AR is a unique hemodynamic phenomenon in patients with acute rheumatic carditis involving both mitral and aortic valves and occurs in presence of severe MR.

Accuracy of systolic aortic regurgitation in the diagnosis of heart failure: a predictive approach

BACKGROUND

Systolic aortic regurgitation (SAR) is a curious phenomenon that has been found to be associated with heart failure (HF). We aimed to determine de diagnostic value of SAR as a black box predictive tool in patients with suspected HF admitted to hospital with dyspnea as leading symptom.

METHODS AND RESULTS

Cross-sectional study including 269 consecutive patients admitted to hospital with dyspnea as leading symptom without definite clinical diagnosis. SAR was defined by echocardiography as the presence of blood flow from the aorta to the left ventricular outflow tract during a complete systole. The reference standard was the presence of HF diagnosis at discharge. SAR was present in 9 (3.3%) patients. Prevalence of HF was 40.3%. Specificity of SAR in the diagnosis of HF was high at 99.4% (95% CI 96.5-99.9%). Sensitivity was 7.5% (95% CI 3.9-14.2%). Positive predictive value (PPV) was 88.9% (95% CI 56.5-98.0%). Positive likelihood ratio was 11.85. Estimated PPV of SAR was significantly higher than 50% for any hypothetical prevalence of HF.

CONCLUSION

In patients admitted to hospital with dyspnea, the finding of systolic aortic regurgitation in echocardiography has a high PPV for HF diagnosis at discharge.

Imaging Aortic Regurgitation: The Incremental Benefit of Speckle Tracking Echocardiography

Aortic regurgitation (AR) affects global left ventricular mechanics. However, limited literature is available on how it may affect regional longitudinal strain.

We present a case where severe AR jet is thrashing the anterior-septal wall and reducing its overall longitudinal performance most likely secondary to increased wall shear stress in diastole. This new insight into patho-physiological process using deformation study may have supplementary impact in decision making for surgical intervention. Transthoracic echocardiography is the primary imaging modality for the assessment of AR as it offers evaluation of severity of AR, aetiology of AR, left ventricular (LV) dilatation, LV systolic function, left ventricular mass, diastolic function and global strain. This case highlights the regional disturbances in longitudinal strain in eccentric AR.

Systolic aortic regurgitation: a not-so-rare phenomenon

In a normal cardiac cycle, aortic and pulmonary regurgitation are diastolic phenomena. Aortic regurgitation has been observed in ventricular systole in patients with arrhythmias, extracorporeal circulation and palliative surgical correction of complex congenital heart disease. Systolic aortic regurgitation is explained as the inability of the ventricular beat to overcome the aortic pressure in patients with valvular incompetence. Beyond its potential as an elegant quiz about heart physiology, clinical association of systolic aortic regurgitation with heart failure and syncope has been described. Illustrative examples of both aortic and pulmonary systolic regurgitation are presented, an image of "continuous" aortic regurgitation is displayed, and technical issues on its diagnosis are briefly commented.