Right vs. left ventricular longitudinal strain for mortality prediction after transcatheter aortic valve implantation

Prognostic Value of Advanced Echocardiographic Analysis for Transcatheter Aortic Valve Replacement: A Systematic Review

Transcatheter aortic valve implantation (TAVI) is the main treatment option for patients with severe aortic stenosis (AS) and older age. Improved imaging techniques have enabled better patient selection, and the main role is played by echocardiography. Methods more sensitive than LVEF in assessing cardiac function, such as global longitudinal strain (GLS) and myocardial work (MW), have become widespread, and other methods, like hemodynamic forces (HDFs), might be promising. The aim of this paper is to systematically review the parameters of GLS, MW, and HDF as predictors of reverse remodeling and their association with outcomes in patients with AS undergoing TAVI. In particular, the focus will be on the examination of the influence of TAVI on left atrial and ventricular function and right ventricular function.

Pre-interventional renal artery calcification and survival after transcatheter aortic valve implantation

The prognostic significance of renal artery calcification (RAC) is unknown in patients with severe aortic stenosis (AS) eligible for transcatheter aortic valve implantation (TAVI). RAC can be assessed by computed tomography (CT) performed during pre-interventional planning for TAVI. This study aimed at investigating the utility of RAC for predicting survival after TAVI. In this longitudinal cohort study, RAC volume was measured by CT in 268 consecutive patients with severe AS undergoing TAVI. Association of RAC with mortality was assessed using Cox regression analysis. RAC was evaluated as a binary parameter and in a supplementary analysis as a logarithmically transformed continuous variable. Over a median follow-up time of 9.6 years, 237 (88.4%) patients died, with 174 (73.4%) deaths attributable to a cardiovascular cause. RAC was highly prevalent (N = 150 (86.2%)) among patients suffering cardiovascular death. Competing risk cumulative incidence curves revealed a higher occurrence of cardiovascular death in patients with RAC (P-value = 0.008), while this was not the case for non-cardiovascular death (P-value = 0.71). RAC was independently associated with cardiovascular death (HR 1.61 [95% CI: 1.01-2.57]; P = 0.047) after adjustment for age, sex, cardiovascular risk factors, impaired renal function, and aortic valve calcification. The presence or absence of RAC rather than its volume was important in all the analyses. RAC is a strong and independent predictor of cardiovascular death in patients with severe AS undergoing TAVI. Given its favourable properties for event prediction, RAC may be considered valuable for prognostic assessment of TAVI patients.

Prognostic value of right ventricular free-wall longitudinal strain in aortic stenosis: A systematic review and meta-analysis

BACKGROUND

Assessment of right ventricular (RV) function in aortic stenosis (AS) may improve risk stratification. However, whether the prognostic value of RV free-wall longitudinal strain (RVfwLS) is better than that of other right heart or pulmonary circulation parameters remains uncertain. This study assessed and compared the prognostic value of RVfwLS with traditional parameters in the AS population using a systematic review and meta-analysis.

METHODS

We selected studies reporting the hazard ratio (HR) of RVfwLS in patients with AS. We also collected data regarding the HR of systolic pulmonary arterial pressure (SPAP), fractional area change (FAC), and tricuspid annulus plane systolic excursion (TAPSE). To ensure comparability, we standardized the HR using within-study standard deviations. The comparison between the prognostic value of RVfwLS and other parameters was conducted as a ratio of HR.

RESULTS

This meta-analysis included 9 studies comprising a total of 2547 patients, with 679 events. The pooled HR of RVfwLS was 1.56 (95 % CI: 1.39-1.75, p < 0.001). When examining the ratio of HR between RVfwLS and conventional parameters, all comparisons were statistically non-significant [RVfwLS/SPAP: 1.28 (95 % CI: 0.99-1.65, p = 0.06); RVfwLS/FAC: 1.24 (95 % CI: 0.90-1.72, p = 0.14); and RVfwLS/TAPSE:1.07 (95 % CI: 0.75-1.52, p = 0.60)].

CONCLUSIONS

This meta-analysis establishes a substantial association between RVfwLS and adverse outcomes in the AS population. However, comparative analysis between RVfwLS and SPAP, FAC, or TAPSE did not support the prognostic superiority of RVfwLS.

Preoperative right ventricular strain as an early predictor of perioperative cardiac failure in patients undergoing mitral surgery: An exploratory study

Objectives

This study's primary purpose was to demonstrate the correlation of preoperative right ventricular free-wall longitudinal strain (RVFWLS) and pre-/postsurgical variation in strain (delta strain) with the clinical and echocardiographic diagnosis of right ventricular dysfunction. Its secondary purpose was to determine the correlation of RVFWLS and delta strain with length of stay (LOS) in the intensive care unit (ICU), ventilation days, trend of natriuretic peptide test. (NT-proBNP) and lactate in the first 48 h, incidence of acute renal failure, and 28-day mortality.

Design

Prospective observational study.

Setting

Cardio-thoracic and Vascular Anaesthesia Department and ICU of the University Hospital Integrated Trust of Verona.

Participants

Patients scheduled for mitral surgery.

Interventions

None.

Measurements and Main Results

All clinical and transoesophageal echocardiographic (TEE) parameters were collected at baseline, before surgery (T1) and at admission in the ICU postsurgery (T2). During the postoperative period, the clinical and echocardiographic diagnoses of right, left, or biventricular dysfunction were evaluated. TEE parameters were evaluated by a cardiologist offline. The patients were divided into two subgroups according to the development of any type of ventricular dysfunction. No statistically significant differences emerged between the two groups. According to a logistic regression model, a T1-RVFWLS value of -15% appeared to predict biventricular dysfunction (sensitivity: 100%; specificity: 91.3%). No correlation between T1- or T2-RVFWLS and creatinine, hours of ventilation or ICU LOS was found.

Conclusions

Our study introduces a new parameter that could be used in perioperative evaluations to identify patients at risk of postoperative biventricular dysfunction.

The impact of the Naples Prognostic Score on the short- and long-term prognosis of patients undergoing transcatheter aortic valve implantation

BACKGROUND

Preoperative systemic inflammation and nutritional status have been shown to affect prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). In this study, we investigated the effect of the Naples Prognostic Score (NPS), which consists of four different parameters including these two components on short- and long-term prognosis in patients undergoing TAVI.

METHODS

In 343 patients (mean age 78.1 ± 8.4 years, 51.3% female) who underwent TAVI, the NPS score was calculated from the blood tests obtained before the procedure and the study population was divided into three according to the NPS value: those with 0 and 1 were divided into Group-1, those with 2 into Group-2, and those with 3 and 4 into Group-3. The relationship between NPS group and in-hospital adverse events and long-term survival was evaluated.

RESULTS

Systolic pulmonary artery pressure, STS score, presence of chronic lung disease and being in NPS Group-3 [adjusted odds ratio (adjOR): 3.93, 95% confidence interval (CI) (1.02-15.17), P  = 0.047] were found to be independent predictors of in-hospital mortality. According to the multivariate Cox-regression model, both Group-2 NPS [adjusted hazard ratio (adjHR): 4.81, 95% CI (1.09-21.14), P  = 0.037] and Group-3 NPS [adjHR: 10.1, 95% CI (2.31-43.36), P  = 0.002] was an independent predictor of 2-year all-cause mortality after TAVI. There was no significant difference in perioperative adverse events between the groups except for postprocedural acute kidney injury. According to receiver-operating characteristic analysis, the optimal predictive value of NPS for in-hospital and long-term mortality was 2.5.

CONCLUSION

In patients who will be candidates for TAVI, NPS is a simple and effective tool for determining both short- and long-term prognosis.

Impact of Stress Echocardiography on Aortic Valve Stenosis Management

Rest and stress echocardiography (SE) play a fundamental role in the evaluation of aortic valve stenosis (AS). According to the current guidelines for the echocardiographic evaluation of patients with aortic stenosis, four broad categories can be defined: high-gradient AS (mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, aortic valve area (AVA) ≤ 1 cm2 or indexed AVA ≤ 0.6 cm2/m2); low-flow, low-gradient AS with reduced ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, left ventricle ejection fraction (LVEF) < 50%, stroke volume index (Svi) ≤ 35 mL/m2); low-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, LVEF ≥ 50%, SVi ≤ 35 mL/m2); and normal-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, indexed AVA ≤ 0.6 cm2/m2, LVEF ≥ 50%, SVi > 35 mL/m2). Aortic valve replacement (AVR) is indicated with the onset of symptoms development or LVEF reduction. However, there is often mismatch between resting transthoracic echocardiography findings and patient's symptoms. In these discordant cases, SE and CT calcium scoring are among the indicated methods to guide the management decision making. Additionally, due to the increasing evidence that in asymptomatic severe aortic stenosis an early AVR instead of conservative treatment is associated with better outcomes, SE can help identify those that would benefit from an early AVR by revealing markers of poor prognosis. Low-flow, low-gradient AS represents a challenge both in diagnosis and in therapeutic management. Low-dose dobutamine SE is the recommended method to distinguish true-severe from pseudo-severe stenosis and assess the existence of flow (contractile) reserve to appropriately guide the need for intervention in these patients.