1
|
Kusunose K, Yamada H, Saijo Y, Nishio S, Hirata Y, Ise T, Yamaguchi K, Fukuda D, Yagi S, Soeki T, Wakatsuki T, Sata M. Clinical course and decision-making in heart failure by preload stress echocardiography: a preliminary study. ESC Heart Fail 2022; 9:4020-4029. [PMID: 36017722 PMCID: PMC9773745 DOI: 10.1002/ehf2.14127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/06/2022] [Accepted: 08/15/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS Abnormal left ventricular diastolic response to preload stress can be an early marker of heart failure (HF). The aim of this study was to assess clinical course in patients with HF with preserved ejection fraction (HFpEF) who underwent preload stress echocardiography. In the subgroup analysis, we assessed the prognosis of patients with unstable signs during preload stress classified by treatment strategies. METHODS AND RESULTS We prospectively conducted preload stress echocardiographic studies between January 2006 and December 2013 in 211 patients with HFpEF. Fifty-eight patients had abnormal diastolic reserve during preload stress (unstable impaired relaxation: unstable IR). Of 58 patients with unstable IR, 19 patients were assigned to additional therapy by increased or additional therapy and 39 patients were assigned to standard therapy. Composite outcomes were prespecified as the primary endpoint of death and hospitalization for deteriorating HF. During a median period of 6.9 years, 19 patients (33%) reached the composite outcome. Unstable group with standard therapy had significantly shorter event-free survival than stable group. Patients with uptitration of therapy had longer event-free survival than those with standard therapy group after adjustment of laboratory data (hazard ratio, 0.20, 95% confidence interval, 0.05-0.90; P = 0.036); the 10 year event-free survival in patients with and without uptitration of therapy was 93% and 51%, respectively (P = 0.023). CONCLUSIONS Patients with unstable sign had significantly shorter event-free survival than patients with stable sign. After additional therapy, the prognosis of patients with unstable signs improved. This technique may impact decision-making for improving their prognosis.
Collapse
Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| | - Hirotsugu Yamada
- Department of Community Medicine for CardiologyTokushima University Graduate School of Biomedical SciencesTokushimaJapan
| | - Yoshihito Saijo
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| | - Susumu Nishio
- Ultrasound Examination CenterTokushima University HospitalTokushimaJapan
| | - Yukina Hirata
- Ultrasound Examination CenterTokushima University HospitalTokushimaJapan
| | - Takayuki Ise
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| | - Koji Yamaguchi
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| | - Daiju Fukuda
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| | - Shusuke Yagi
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| | - Takeshi Soeki
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| | - Masataka Sata
- Department of Cardiovascular MedicineTokushima University Hospital2‐50‐1 KuramotoTokushimaJapan
| |
Collapse
|
2
|
Długosz D, Surdacki A, Zawiślak B, Bartuś S, Chyrchel B. Impaired Left Ventricular Circumferential Midwall Systolic Performance Appears Linked to Depressed Preload, but Not Intrinsic Contractile Dysfunction or Excessive Afterload, in Paradoxical Low-Flow/Low-Gradient Severe Aortic Stenosis. J Clin Med 2022; 11:2873. [PMID: 35628998 PMCID: PMC9144151 DOI: 10.3390/jcm11102873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
Paradoxical low-flow/low-gradient aortic stenosis (P-LFLG-AS) occurs in about one-third of patients with severe AS and preserved left ventricular (LV) ejection fraction (EF). Our aim was to differentiate between altered LV loading conditions and contractility as determinants of subtle LV systolic dysfunction in P-LFLG-AS. We retrospectively analyzed medical records of patients with isolated severe degenerative AS and preserved EF (30 subjects with P-LFLG-AS and 30 patients with normal-flow/high-gradient severe AS (NFHG-AS)), without relevant coexistent diseases (e.g., diabetes, coronary artery disease and chronic kidney disease) or any abnormalities which could account for a low-flow state. Patients with P-LFLG-AS and NFHG-AS did not differ in aortic valve area index and most clinical characteristics. Compared to NFHG-AS, subjects with P-LFLG-AS exhibited smaller LV end-diastolic diameter (LVd) (44 ± 5 vs. 54 ± 5 mm, p < 0.001) (consistent with lower LV preload) with pronounced concentric remodeling, higher valvulo-arterial impedance (3.8 ± 1.1 vs. 2.2 ± 0.5 mmHg per mL/m2, p < 0.001) and diminished systemic arterial compliance (0.45 ± 0.11 vs. 0.76 ± 0.23 mL/m2 per mmHg, p < 0.001), while circumferential end-systolic LV midwall stress (cESS), an estimate of afterload at the LV level, was similar in P-LFLG-AS and NFHG-AS (175 ± 83 vs. 198 ± 69 hPa, p = 0.3). LV midwall fractional shortening (mwFS) was depressed in P-LFLG-AS vs. NFHG-AS (12.3 ± 3.5 vs. 14.7 ± 2.9%, p = 0.006) despite similar EF (61 ± 6 vs. 59 ± 8%, p = 0.4). By multiple regression, the presence of P-LFLG-AS remained a significant predictor of lower mwFS compared to NFHG-AS upon adjustment for cESS (β ± SEM: −2.35 ± 0.67, p < 0.001); however, the significance was lost after further correction for LVd (β = −1.10 ± 0.85, p = 0.21). In conclusion, the association of P-LFLG-AS with a lower cESS-adjusted mwFS, an index of afterload-corrected LV circumferential systolic function at the midwall level, appears secondary to a smaller LV end-diastolic cavity size according to the Frank−Starling law. Thus, low LV preload, not intrinsic contractile dysfunction or excessive afterload, may account for impaired LV circumferential midwall systolic performance in P-LFLG-AS.
Collapse
Affiliation(s)
- Dorota Długosz
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
| | - Andrzej Surdacki
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
| | - Barbara Zawiślak
- Intensive Care Unit, Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland;
| | - Stanisław Bartuś
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
| | - Bernadeta Chyrchel
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
| |
Collapse
|
3
|
Ishii N, Kusunose K, Shono A, Matsumoto K, Nishio S, Yamaguchi N, Hirata Y, Matsuura T, Ise T, Yamaguchi K, Yagi S, Fukuda D, Yamada H, Soeki T, Wakatsuki T, Sata M. Effects of Radiofrequency Catheter Ablation on Cardiac Reserve Using Preload Stress Echocardiography in Paroxysmal and Persistent Atrial Fibrillation. Am J Cardiol 2022; 168:71-77. [PMID: 35063270 DOI: 10.1016/j.amjcard.2021.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/06/2021] [Accepted: 12/20/2021] [Indexed: 11/01/2022]
Abstract
The effects of catheter ablation on exercise tolerance and quality of life in patients with atrial fibrillation (AF) have been reported. We assessed cardiac function in more detail using the leg positive pressure (LPP) technique and found that contractile reserve is particularly important in relation to exercise tolerance and prognosis. In this study, we used the LPP technique to examine changes in contractile reserve immediately after ablation and 6 months later. We prospectively enrolled patients who underwent catheter ablation for AF at 2 institutes. We performed LPP stress echocardiography 2 to 3 days after (FU-1) and 6 months after (FU-2) ablation to examine changes in cardiac function indexes. The primary end point was improvement in contractile reserve. Ultimately, 109 patients (mean age 67.4 ± 9.6 years; 70% men) underwent 2 sessions of LPP stress echocardiography. The median CHA2DS2-VASC score was 2 (interquartile range 13). From FU-1 to FU-2, the change in the stroke volume index after the LPP maneuver increased in patients with paroxysmal and persistent AF with low CHA2DS2-VASC scores (both p <0.05). Regardless of AF subtype, contractile reserve at FU-2 improved in patients with low CHA2DS2-VASC scores compared with that at FU-1. In contrast, patients with high CHA2DS2-VASC scores had no change. In conclusion, patients with AF with a low CHA2DS2-VASC score had improved contractile reserve after ablation, whereas patients with high scores did not show any improvement. Aggressive interventions in patients with high scores may lead to better management after catheter ablation.
Collapse
|
4
|
Kusunose K, Fujiwara M, Yamada H, Nishio S, Saijo Y, Yamada N, Hirata Y, Torii Y, Ise T, Yamaguchi K, Fukuda D, Yagi S, Soeki T, Wakatsuki T, Sata M. Deterioration of biventricular strain is an early marker of cardiac involvement in confirmed sarcoidosis. Eur Heart J Cardiovasc Imaging 2021; 21:796-804. [PMID: 31566217 DOI: 10.1093/ehjci/jez235] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/19/2019] [Accepted: 08/28/2019] [Indexed: 12/20/2022] Open
Abstract
AIMS Risk assessment of developing cardiac involvement in systemic sarcoidosis can be challenging because of limited data. Recently, attention has been given to left ventricular and right ventricular (LV and RV) involvement in cardiac sarcoidosis (CS) and its prevalence, relevance, and prognostic value. The aim of this study was to assess the role of biventricular strain to predict prognosis in confirmed sarcoidosis patients. METHODS AND RESULTS LV and RV longitudinal strains (LSs) were evaluated by 2D speckle tracking in 139 consecutive confirmed sarcoidosis patients without other pre-existing structural heart diseases, and 52 age- and gender-matched control subjects. The primary endpoint was CS-related events (cardiac death or development of cardiac involvement). Sarcoidosis without cardiac involvement had significantly lower LV and RV free wall LS compared with control subjects. Basal LS had a higher area under the curve for differentiation of sarcoidosis in patients without cardiac involvement compared to control (cut-off value: -18% with 89% sensitivity and 69% specificity). During a median period of 50 months, the occurrence of CS-related events was observed in 20 patients. In a multivariate analysis, basal LV LS and RV free wall LS were associated with the events [hazard ratio (HR) 0.72, P < 0.001 and HR: 0.83, P = 0.006, respectively]. Patients with impaired biventricular function had significantly shorter event-free survival than those with preserved biventricular function (P < 0.001). CONCLUSION Deterioration of biventricular strain was associated with CS-related events. This information might be useful for clinical evaluation and follow-up in sarcoidosis.
Collapse
Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Mika Fujiwara
- Department of Community medicine for cardiology, Tokushima Graduate School of Biomedical Sciences, Tokushima University, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Hirotsugu Yamada
- Department of Community medicine for cardiology, Tokushima Graduate School of Biomedical Sciences, Tokushima University, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Susumu Nishio
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Yoshihito Saijo
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Nao Yamada
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Yukina Hirata
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Yuta Torii
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Takeshi Soeki
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, 770-8503 Tokushima, Japan
| |
Collapse
|
5
|
Kusunose K, Takahashi H, Nishio S, Hirata Y, Zheng R, Ise T, Yamaguchi K, Yagi S, Fukuda D, Yamada H, Soeki T, Wakatsuki T, Shimada K, Kanematsu Y, Takagi Y, Sata M. Predictive value of left atrial function for latent paroxysmal atrial fibrillation as the cause of embolic stroke of undetermined source. J Cardiol 2021; 78:355-361. [PMID: 34119401 DOI: 10.1016/j.jjcc.2021.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/28/2021] [Accepted: 05/05/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND In patients with embolic stroke of undetermined source (ESUS), paroxysmal atrial fibrillation (AF) is often diagnosed, however, the risk of paroxysmal AF in ESUS has not been well described. Several studies have suggested a linkage between left atrial (LA) functional parameters and risk of AF in stroke patients. The aim of this study was to assess the role of LA functional parameters as predictors of latent paroxysmal AF in ESUS on admission. METHODS Between January 2015 and December 2019, consecutive stroke patients with suspected ESUS at admission were prospectively included in this study. They were under hospital electrocardiographic monitoring for detection of new-onset AF. Various echocardiographic parameters including left atrial strain were assessed for association with new-onset AF. RESULTS We gathered 1082 consecutive patients with ischemic stroke. After exclusions, 121 patients with suspected ESUS at admission formed the study cohort. New-onset AF was detected in 46 (38%) patients during hospital electrocardiographic monitoring (median follow-up: 18 days). LA pump and reservoir strains were significantly and independently associated with new-onset AF. Receiver operating characteristic analysis for the association with new-onset AF showed that the areas under the curve (AUCs) of clinical parameters plus one of each strain (LA pump strain: AUC: 0.86±0.04 and LA reservoir strain: AUC: 0.76±0.05) models were significantly better than plus LA volume index (AUC: 0.68±0.04, compared p-values <0.05). CONCLUSIONS LA strain was significantly associated with new development of AF. Patients with impaired LA function at admission should be carefully monitored to find AF.
Collapse
Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
| | - Hironori Takahashi
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Susumu Nishio
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Yukina Hirata
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Robert Zheng
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Takeshi Soeki
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Yasuhisa Kanematsu
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Hospital, Tokushima, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| |
Collapse
|
6
|
Zheng R, Kusunose K. Review: application of current imaging modalities in the management of left-sided valvular heart disease. Cardiovasc Diagn Ther 2021; 11:793-803. [PMID: 34295706 DOI: 10.21037/cdt.2020.02.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/31/2020] [Indexed: 11/06/2022]
Abstract
In terms of valvular heart disease (VHD) imaging, transthoracic echocardiography (TTE) is the preferred first choice because of its widespread availability. Other modalities, such as transesophageal echocardiography, computed tomography and magnetic resonance imaging, have played a supplementary role in diagnosis for severity, deciding the timing/type of treatment, detection of post procedural complications, and prognostic predictions. However, there are few consensuses on how to employ these modalities, as the evidence is not extensive as that for TTE. On the other hand, these imaging modalities also have their own unique strengths. If employed properly, these modalities have the potential to play a more prominent role in clinical decision making. In this review, we focus on the potential, limitations and application of current imaging modalities in the management of left-sided VHD.
Collapse
Affiliation(s)
- Robert Zheng
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| |
Collapse
|
7
|
Left Atrial Strain Associated with Functional Recovery in Patients Receiving Optimal Treatment for Heart Failure. J Am Soc Echocardiogr 2021; 34:966-975.e2. [PMID: 33852960 DOI: 10.1016/j.echo.2021.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Heart failure with recovered ejection fraction (HFrecEF) has been reported in several previous studies to have a better prognosis than heart failure with reduced ejection fraction (HFrEF). However, the factors associated with HFrecEF have not been identified. The aim of this study was to test the hypothesis that left atrial (LA) strain could help identify patients with recovered ejection fraction (EF) among those with heart failure (HF) with low EF on admission. METHODS One hundred consecutive patients hospitalized for the first time for new-onset HF were enrolled. Patients were clinically diagnosed with HFrEF on admission (left ventricular EF < 40%) and received optimal treatment for HF. Twenty-eight patients improved to HFrecEF during 6 months of follow-up. RESULTS Regarding clinical background, there were significantly more women and a lower rate of atrial fibrillation in the HFrecEF group than in the HFrEF group. In a multivariate logistic regression analysis, LA strain was an independent predictor of HFrecEF, even after adjustment for gender and left ventricular EF (odds ratio: 4.06; 95% CI: 2.04-8.07; P < .001). A cutoff value of 10.8% for LA strain showed high sensitivity (96%) and specificity (82%) in identifying HFrecEF in patients with HF presenting with low EF on admission. During a follow-up period of 24 ± 13 months, 31 patients (31%) had cardiovascular death or readmission for HF. Patients with reduced LA strain (<10.8%) had significantly shorter event-free survival than those with preserved LA strain (P = .02). CONCLUSIONS LA strain is a useful indicator for predicting HFrecEF and should be considered as a routine measurement in patients with HFrEF on admission.
Collapse
|
8
|
Abstract
The key to understanding hemodynamics in heart failure (HF) is the relation between elevated left ventricular (LV) filling pressure and cardiac output. Some patients show abnormal response to stress in the relationship between LV filling pressure and cardiac output. In patients with preserved diastolic function, cardiac output can be increased without significantly elevated filling pressure during stress. In patients with HF, as long as the Frank-Starling mechanism operates effectively, cardiac output can increase while acquiring elevated filling pressure. In patients with decompensated HF, hemodynamic stress will lead to a much greater elevation in filling pressure and pulmonary venous hypertension.
Collapse
|
9
|
Altes A, Thellier N, Bohbot Y, Marsou W, Chadha G, Binda C, Ringle A, Mailliet A, Marotte N, Riolet C, Tribouilloy C, Maréchaux S. Prognostic Impact of the Ratio of Acceleration Time to Ejection Time in Patients With Low Gradient Severe Aortic Stenosis and Preserved Ejection Fraction. Am J Cardiol 2019; 124:1594-1600. [PMID: 31522771 DOI: 10.1016/j.amjcard.2019.07.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/17/2022]
Abstract
The clinical management of patients with low gradient severe aortic stenosis (LG-SAS) and preserved left ventricular ejection fraction (LVEF) remains challenging owing to their heterogeneity. The aim to this study was to evaluate the relation between an ejection dynamic parameter linked to AS severity and outcome, the ratio of acceleration time (AT) to ejection time (ET), in a cohort of patients with LG-SAS and preserved LVEF. Three hundred and fifty-six patients with LG-AS (defined by AVA ≤1 cm² and/or AVAi ≤0.6 cm²/m² and mean aortic pressure gradient <40 mm Hg) and preserved LVEF ≥50% were studied. The relation between AT/ET and all-cause and cardiac mortality during follow-up was studied. Median follow-up was 41 months (interquartile range, 35 to 47 months). Median AT/ET was 0.32 (interquartile range, 0.29 to 0.36). The 5-year estimates of all-cause and cardiac mortality were respectively 57 ± 7%, 36 ± 7% for patients with AT/ET >0.36 versus 43 ± 4%, 16 ± 3% for patients with AT/ET ≤0.36 (p = 0.024 and p <0.001, respectively). After adjustment on known predictors of outcome including aortic valve replacement used as a time-dependent covariate, there was a significant increase in all-cause mortality risk for patients with AT/ET >0.36 (adjusted hazard ratio 2.04 [95% confidence interval, 1.32 to 3.13]; p = 0.001) and cardiac mortality risk (adjusted hazard ratio 2.89 [95% confidence interval, 1.54 to 5.43]; p<0.001) compared with patients with AT/ET ≤0.36. The association of AT/ET >0.36 and all-cause or cardiac mortality risk was consistent in subgroups of patients with LG-SAS and preserved EF. In conclusion, an AT/ET ratio of more than 0.36 is an independent predictor of mortality in patients with LG-SAS and preserved EF.
Collapse
Affiliation(s)
- Alexandre Altes
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Nicolas Thellier
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Yohann Bohbot
- Centre Hospitalier Universitaire d'Amiens, Amiens, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Wassima Marsou
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | | | - Camille Binda
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Anne Ringle
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Amandine Mailliet
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Nathalie Marotte
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Clemence Riolet
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Christophe Tribouilloy
- Centre Hospitalier Universitaire d'Amiens, Amiens, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Sylvestre Maréchaux
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France; Laboratoire UPJCV, Université de Picardie, Amiens, France.
| |
Collapse
|
10
|
Low Gradient Aortic Stenosis: Role of Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
11
|
Chadha G, Bohbot Y, Rusinaru D, Maréchaux S, Tribouilloy C. Outcome of Normal-Flow Low-Gradient Severe Aortic Stenosis With Preserved Left Ventricular Ejection Fraction: A Propensity-Matched Study. J Am Heart Assoc 2019; 8:e012301. [PMID: 31550970 PMCID: PMC6806034 DOI: 10.1161/jaha.119.012301] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Normal‐flow, low‐gradient severe aortic stenosis (NF‐LG‐SAS), defined by aortic valve area <1 cm2, mean gradient <40 mm Hg, and indexed stroke volume >35 mL/m2, is the most prevalent form of low‐gradient aortic stenosis (AS). However, the true severity of AS and the management of NF‐LG‐SAS are controversial. The aim of this study was to evaluate the outcome of patients with NF‐LG‐SAS compared with moderate AS (MAS) and with high‐gradient severe‐AS (HG‐SAS). Methods and Results A total of 154 patients with NF‐LG‐SAS, 366 with MAS (aortic valve area between 1.0 and 1.3 cm2), and 1055 with HG‐SAS were included. On multivariate analysis, after adjustment for covariates of prognostic importance, NF‐LG‐SAS patients did not exhibit an excess risk of mortality compared with MAS patients under medical management (hazard ratio=1.13 [95% CI, 0.82‐1.56]; P=0.45) and under medical and surgical management (hazard ratio 1.06 [95% CI, 0.79‐1.43]; P=0.70), even after further adjustment for aortic valve replacement (hazard ratio=1.09 [95% CI, 0.81‐1.48]; P=0.56). The 6‐year cumulative incidence of aortic valve replacement (performed in accordance with guidelines) was comparable between the 2 groups (39±4% for NF‐LG‐SAS and 35±3% for MAS, P=0.10). After propensity score matching (n=226), NF‐LG‐SAS and MAS patients also had comparable outcomes under medical (P=0.41) and under medical and surgical management (P=0.52). NF‐LG‐SAS had better outcomes than HG‐SAS patients (adjusted hazard ratio 1.84 [95% CI, 1.18‐2.88]; P<0.001). Conclusions This study shows that patients with NF‐LG‐SAS have a comparable outcome to those with MAS when aortic valve replacement is performed during follow‐up according to guidelines, mostly at the stage of HG‐SAS. Rigorous echocardiographic assessment to rule out measurement errors and close follow‐up are essential to detect progression to true severe AS in NF‐LG‐SAS.
Collapse
Affiliation(s)
- Gagandeep Chadha
- Department of Cardiology Amiens University Hospital Amiens France
| | - Yohann Bohbot
- Department of Cardiology Amiens University Hospital Amiens France.,EA 7517 MP3CV Jules Verne University of Picardie Amiens France
| | - Dan Rusinaru
- Department of Cardiology Amiens University Hospital Amiens France.,EA 7517 MP3CV Jules Verne University of Picardie Amiens France
| | - Sylvestre Maréchaux
- EA 7517 MP3CV Jules Verne University of Picardie Amiens France.,Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de Médecine Université Lille Nord de France Lille France
| | - Christophe Tribouilloy
- Department of Cardiology Amiens University Hospital Amiens France.,EA 7517 MP3CV Jules Verne University of Picardie Amiens France
| |
Collapse
|
12
|
Adda J, Stanova V, Zenses AS, Clavel MA, Barragan P, Penaranda G, Habib G, Pibarot P, Rieu R. Discordant Grading of Aortic Stenosis Severity: New Insights from an In Vitro Study. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2019. [DOI: 10.1080/24748706.2019.1632507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Jérôme Adda
- Department of Cardiology, University Hospital Arnaud de Villeneuve, Montpellier, France
| | | | - Anne-Sophie Zenses
- Aix-Marseille University, LBA-UMRT24 IFSTTAR, Marseille, France
- Department of Cardiology, Quebec Heart and Lung Institute, Quebec, Canada
| | | | - Paul Barragan
- Department of Cardiology, Polyclinique les Fleurs, Ollioules, France
| | | | - Gilbert Habib
- Department of Cardiology, Hospital La Timone, Insuffisance Cardiaque et Valvulopathie, Marseille, France
| | - Philippe Pibarot
- Department of Cardiology, Quebec Heart and Lung Institute, Quebec, Canada
| | - Régis Rieu
- Aix-Marseille University, LBA-UMRT24 IFSTTAR, Marseille, France
| |
Collapse
|
13
|
Clinical application of stress echocardiography for valvular heart disease. J Med Ultrason (2001) 2019; 47:81-89. [PMID: 31289972 DOI: 10.1007/s10396-019-00958-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
Abstract
Stress echocardiography is widely used to assess several cardiovascular diseases, including ischemic heart disease, valvular heart disease (VHD), heart failure, congenital heart disease, and pulmonary hypertension. In valvular heart disease with asymptomatic severe or symptomatic non-severe status, stress echocardiography plays a central role in the management. As of 2017, the updated American College of Cardiology/American Heart Association and European Society of Cardiology/European Association for Cardio-Thoracic Surgery VHD guidelines recommended stress testing to (1) confirm symptoms and (2) evaluate the hemodynamic response to exercise. In patients with undetermined VHD severity in the presence of low-flow status, it can also be helpful to determine whether the VHD is severe based on flow-dependent changes in response to stress. The clinical indications of stress echocardiography in VHD have expanded with growing evidence for prognosis and being an early marker for interventions. As a result, demand has increased in major cardiology societies for the standardization of stress echocardiography in VHD. Echocardiographic centers should be aware of the clinical potential of stress echocardiography to ensure its optimal application and performance in VHD. This article reviews the clinical application of stress echocardiography, including dobutamine, semisupine bicycle, treadmill, and leg-positive pressure for VHD patient management, and focuses on the current consensus regarding the use of stress echocardiography in VHD. Stress echocardiography is safe and should be encouraged, especially in heart valve clinics, to understand the complex mechanism in asymptomatic patients.
Collapse
|
14
|
Kusunose K, Seno H, Yamada H, Nishio S, Torii Y, Hirata Y, Saijo Y, Ise T, Yamaguchi K, Fukuda D, Yagi S, Soeki T, Wakatsuki T, Sata M. Right Ventricular Function and Beneficial Effects of Cardiac Rehabilitation in Patients With Systolic Chronic Heart Failure. Can J Cardiol 2018; 34:1307-1315. [PMID: 30146462 DOI: 10.1016/j.cjca.2018.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/05/2018] [Accepted: 06/05/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND It has been recognized that a comprehensive cardiac rehabilitation (CR) program improves mortality in patients with chronic heart failure. On the other hand, the magnitude of the improvement in exercise capacity after CR differs among individuals. The aim of this study was to assess the echocardiographic determinants of responders to CR using preload stress echocardiography. METHODS We prospectively enrolled 58 chronic heart failure patients with reduced left ventricular ejection fraction (aged 62 ± 11 years; 69% male; left ventricular ejection fraction 43% ± 7%) who had received optimized medical treatment in a CR program for 5 months. We performed preload echocardiographic studies using leg positive pressure (LPP) to assess the echocardiographic parameters during preload augmentation. We defined 41 patients as a development cohort to assess the predictive value of echocardiographic variables. Next, we validated results in the remaining 17 patients as a validation cohort. RESULTS In the development cohort, significant improvement in peak oxygen uptake (VO2) (>10%) after CR was observed in 58% patients. In a multivariable logistic regression model, the significant predictor of improvement in exercise capacity was right ventricular (RV) strain during LPP (odds ratio: 3.96 per 1 standard deviation; P = 0.01). An RV strain value of -16% during LPP had a good sensitivity of 0.79 and a specificity of 0.71 to identify patients with improvement in peak VO2. In the validation cohort, an optimal cutoff value of RV strain value was the same (area under the curve: 0.77, sensitivity: 0.78, specificity: 0.65). CONCLUSIONS RV strain during LPP may be an echocardiographic parameter for assessing beneficial effects of CR.
Collapse
Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan.
| | - Hiromitsu Seno
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Hirotsugu Yamada
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Susumu Nishio
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Yuta Torii
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Yukina Hirata
- Ultrasound Examination Center, Tokushima University Hospital, Tokushima, Japan
| | - Yoshihito Saijo
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Takeshi Soeki
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| |
Collapse
|
15
|
Workup and Management of Patients With Paradoxical Low-Flow, Low-Gradient Aortic Stenosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:49. [DOI: 10.1007/s11936-018-0642-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
16
|
Clavel MA, Guzzetti E, Annabi MS, Salaun E, Ong G, Pibarot P. Normal-Flow Low-Gradient Severe Aortic Stenosis: Myth or Reality? STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2018. [DOI: 10.1080/24748706.2018.1437934] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Erwan Salaun
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Géraldine Ong
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| |
Collapse
|
17
|
Affiliation(s)
- Philippe Pibarot
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Department of Medicine, Laval University, Québec, Canada
| | - Marie-Annick Clavel
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Department of Medicine, Laval University, Québec, Canada
| |
Collapse
|