Assessment of the Severity of Aortic Regurgitation by Noninvasive Imaging : Non-invasive MMI for AR

PURPOSE OF THE REVIEW

The role of multimodality imaging in the evaluation of patients with aortic regurgitation is summarized in this review.

RECENT FINDINGS

The etiology (mechanism) of the aortic regurgitation and the severity of aortic regurgitation and hemodynamic consequences are key in the decision making of patients with severe aortic regurgitation. While echocardiography remains as the leading technique to assess all these parameters, other imaging techniques have become essential for the accurate assessment of aortic regurgitation severity and the timing of aortic intervention. The anatomic suitability of transcatheter aortic valve implantation in inoperable patients with severe aortic regurgitation is usually assessed with computed tomography. Aortic regurgitation is a prevalent disease with various pathophysiological mechanisms that need a personalized treatment. The evaluation of the mechanism and severity of aortic regurgitation can be initially performed with echocardiography. Three-dimensional techniques, including echocardiography, have become very relevant for accurate assessment of the regurgitation severity and its hemodynamic consequences. Assessment of myocardial tissue characteristics with cardiac magnetic resonance is key in the risk stratification of patients and in the timing of aortic intervention. Computed tomography is important in the assessment of aortic dimensions and selection of patients for transcatheter aortic valve implantation.

New-onset persistent left bundle branch block following sutureless aortic valve replacement

OBJECTIVE

To evaluate the incidence, predictive factors and prognostic value of new-onset persistent left bundle branch block (NOP-LBBB) in patients undergoing sutureless surgical aortic valve replacement (SU-SAVR).

METHODS

A total of 329 consecutive patients without baseline conduction disturbances or previous permanent pacemaker implantation (PPI) who underwent SU-SAVR with the Perceval valve (LivaNova Group, Saluggia, Italy) in two centres from 2013 to 2019 were included. Patients were on continuous ECG monitoring during hospitalisation and 12-lead ECG was performed after the procedure and at hospital discharge. NOP-LBBB was defined as a new postprocedural LBBB that persisted at hospital discharge. Baseline, procedural and follow-up clinical and echocardiography data were collected in a dedicated database.

RESULTS

New-onset LBBB was observed in 115 (34.9%) patients, and in 76 (23.1%) persisted at hospital discharge. There were no differences in baseline and procedural characteristics between patients with (n=76) and without (n=253) NOP-LBBB. After a median follow-up of 3.3 years (2.3-4.4 years), patients with NOP-LBBB had a higher incidence of PPI (14.5% vs 6.3%, p=0.016), but exhibited similar rates of all-cause mortality (19.4% vs 19.2%, p=0.428), cardiac mortality (8.1% vs 9.4%, p=0.805) and heart failure readmission (21.0% vs 23.2%, p=0.648), compared with the no/transient LBBB group. NOP-LBBB was associated with a decrease in left ventricular ejection fraction (LVEF) at 1-year follow-up (delta: -5.7 vs +0.2, p<0.001).

CONCLUSIONS

NOP-LBBB occurred in approximately a quarter of patients without prior conduction disturbances who underwent SU-SAVR and was associated with a threefold increased risk of PPI along with a negative impact on LVEF at follow-up.

Three-Dimensional Echocardiography for Tricuspid Valve Assessment

PURPOSE OF REVIEW

This review article provides an overview of the various roles of 3-dimensional (3D) echocardiography in the evaluation of the tricuspid valve (TV) with specific focus on tricuspid regurgitation (TR) and its treatment.

RECENT FINDINGS

The prognostic implications of TR and the advent of new transcatheter therapies have underscored the need of accurate assessment of the TV. 3D echocardiography is key to assess the anatomy and function of TV and has provided new insights that have led to new classifications of the type of TR. Furthermore, 3D echocardiography is superior to 2-dimensional echocardiography to assess the right ventricle, an important parameter to select the patients with severe TR who may benefit from intervention. Finally, the use of 3D echocardiography during the guidance of transcatheter interventions is pivotal to ensure procedural success and minimize the complications. Three-dimensional echocardiography provides the soft tissue resolution that fluoroscopy does not provide.

Impact of COVID-19 on mechanical complications in ST elevation myocardial infarction

Background

Mechanical complications (MC) give a poor prognosis for ST elevation myocardial infarction (STEMI). Its prevalence had decreased in the era of primary angioplasty, at the expense of free wall rupture (FWR).

Purpose

To analyse the prevalence of post-STEMI MC for two periods, before and after the COVID-19 pandemic.

Methods

Unicentric prospective registration of patients with STEMI admitted between January-2018 and December-2021. They are classified into two groups according to the onset of the pandemic by COVID-19: Pre-COVID: January-2018 to December-2019, and Post-COVID: January-2020 to December-2021. The prevalence of post-STEMI MC is analysed, including ventricular septal rupture (VSR), papillary muscle rupture (PMR) and FWR, and 30-day mortality.

Results

1507 consecutive patients with STEMI (Pre-COVID n=775, Post-COVID n=732) are included. Age 62.9 years vs 63.3 years (p=0.5097). Men 78.1% Vs 79.5% (p=0.493). No differences in cardiovascular risk factors, previous heart infarction or anterior wall STEMI. Primary angioplasty was similar in both groups (92%). The Post-COVID group has a higher prevalence of Killip>I (21.7% vs 17.2% p=0.025) and LVEF ≤40% (27.2% vs 20% p=0.001), and longer symptom onset to balloon dilatation interval (316 min vs 257 min p=0.0004). MC are most developed in Post-COVID (2.6% vs 1.2% p=0.039), at the expense of FWR (1.91% vs 0.3% p=0.001). No significant changes in VSR and PMR prevalence or 30-day mortality. Multivariate analysis identifies the independent predictors of FWR: Age (OR 1.05, p=0.024), Primary angioplasty (OR 0.09, p<0.001), and Post-COVID (OR 6.8, p=0.013).

Conclusions

The COVID-19 pandemic is independently associated with a higher prevalence of FWR, probably due to delayed reperfusion.

Funding Acknowledgement

Type of funding sources: None.

Incidence, Predictors and Prognostic Value of Permanent Pacemaker Implantation Following Sutureless Valve Implantation in Low-Risk Aortic Stenosis Patients

OBJECTIVES

SU-SAVR has been associated with higher rates of permanent pacemaker (PPM) compared with conventionally implanted aortic bioprostheses. The purpose of this study was to determine the incidence, predictors and mid-term prognostic impact of PPM after Perceval (Livanova, London, UK) SU-SAVR in low-risk patients.

METHODS

A total of 400 consecutive low-risk (EuroSCORE II < 4%) patients without prior pacemaker who underwent SAVR with the Perceval prosthesis from 2013 to 2019 in two centres were included. Baseline, clinical and electrocardiographic parameters, procedural characteristics, and follow-up data were collected.

RESULTS

PPM was required in 36 (9%) patients after SU-SAVR, with a median time between the procedure and PPM implantation of 7.5 (4.5-10.5) days. Older age and prior right bundle branch block (RBBB) were associated with an increased risk of PPM (p < 0.05 for all), but only baseline RBBB was found to be an independent predictor of new PPM requirement (Odds ratio: 2.60, 95% confidence interval: 1.15-5.81; p = 0.022). At a median follow-up of 3.4 (2.3-4.5) years, there were no differences between groups in mortality (PPM: 36%, no PPM: 22%, p = 0.105) or heart failure rehospitalization (PPM: 25%, no PPM: 21%, p = 0.839).

CONCLUSIONS

About 1 out of 10 low-risk patients with aortic stenosis undergoing SU-SAVR with the Perceval prosthesis required PPM implantation. Prior RBBB determined an increased risk (close to 3 times) of PPM following the procedure. PPM was not associated with a higher risk of clinical events at 3-year follow-up.

Long-term evolution of estimated glomerular filtration rate in patients with type 2 diabetes and heart failure

Background

Limited data are available on the very long-term trajectory of glomerular filtration rate (GFR) in patients with chronic heart failure (HF) and type 2 diabetes mellitus (T2D).

Purpose

To prospectively assess dynamic trajectories of GFR estimated by CKD-EPI in a real-life cohort of HF patients based on the presence or absence of T2D over a 14-year follow-up.

Methods

In a prospective observational registry of real-life HF outpatients, estimated GFR (eGFR) was calculated by CKD-EPI at baseline and on a structured schedule every 3 months up to 14 years. We included in the analysis only eGFR values that were assessed at scheduled visits, discarding urgent renal function assessments. Loess (locally weighted error sum of squares) curves were plotted for the subgroups according to baseline T2D up to 14 years of follow-up. Loess curves are useful to observe a trend or relationship on nonlinear data observed over time.

Results

2386 patients were consecutively included from August 2001 to December 2018. 43.2% of the patients had a history of T2D. Mean age was 67.0±12.6 years, 28.9% were women and 71.0% had HF with reduced ejection fraction (EF&lt;40%). 25080 eGFR values were included in the analysis with a median of 8 values per patient [IQR 4–15] and a range between 1 and 47.

Diabetic patients had a worse baseline eGFR and presented a persistent decline over time. On the contrary non-diabetic patients presented an early decrease, mid-term improvement and a late progressive decline (Figure 1).

Conclusions

eGFR long-term trajectories in diabetic and non-diabetic patients with chronic HF were significantly different.

Funding Acknowledgement

Type of funding sources: None. eGFR evolution according to baseline T2D

Long-term evolution of estimated glomerular filtration rate in heart failure

Background

Limited data are available on the very long-term trajectory of glomerular filtration rate (GFR) in patients with chronic heart failure (HF).

Purpose

To assess the GFR dynamics estimated by CKD-EPI in a real-life cohort of HF patients over a 14-year follow-up.

Methods

In a prospective observational registry of real-life HF outpatients, estimated GFR (eGFR) was calculated by CKD-EPI at baseline and on a structured schedule every 3 months up to 14 years. We included in the analysis only eGFR values that were assessed at scheduled visits, discarding urgent renal function assessments. Loess (locally weighted error sum of squares) curves were plotted for the whole cohort and subgroups according to vital status up to 14 years of follow-up. Loess curves are useful to observe a trend or relationship on nonlinear data observed over time.

Results

2423 patients were consecutively included from August 2001 to December 2018. Mean age was 67.0±12.7 years, 28,8% were women and 71.1% had HF with reduced ejection fraction (EF&lt;40%). Out of 37360 eGFR values, 25458 were included in the analysis with a median of 8 values per patient [IQR 4–15] and a range between 1 and 47.

Significant changes occurred along the whole trajectory. An initial decline in eGFR was observed during the first three years of follow-up. Subsequently, there was an upward trend during the following five years and after that period a progressive decline was seen until the end of follow-up (Figure 1). In the sub-group of patients who died during follow-up the eGFR slope showed a persistent decline over time of ∼1ml/min/1.73m2 per year. On the contrary, patients who survived to follow-up maintained a stable eGFR (Figure 2).

Conclusions

The eGFR long-term trajectory in patients with chronic HF showed a snaky pattern with an early decrease, mid-term improvement and late progressive decline. Patients who died during follow-up presented a progressive decline from the beginning.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Long-term evolution of eGFRFigure 2. eGFR evolution according to vital status