Validation of TRI-SCORE for Outcome Prediction After Isolated Tricuspid Valve Surgery in Asian Patients

BACKGROUND

TRI-SCORE was recently developed in Europe as a risk model for predicting in-hospital death after isolated tricuspid valve surgery. We aimed to validate TRI-SCORE in an Asian population and investigate its value for predicting long-term outcomes.

METHODS AND RESULTS

The TRI-SCORE was calculated for 202 patients (65±11 years, 61% women, 81% functional tricuspid regurgitation) who underwent isolated tricuspid valve surgery for severe tricuspid regurgitation at 2 Korean centers and was based on 8 parameters: age, New York Heart Association class, right-sided heart failure signs, furosemide daily dose, glomerular filtration rate, bilirubin, left ventricular ejection fraction, and moderate/severe right ventricular dysfunction. The primary outcome was all-cause death during follow-up; the secondary outcome was in-hospital death. During a median follow-up duration of 50 (interquartile range, 21-82) months after isolated tricuspid valve surgery, 23 (11.4%) patients experienced the primary outcome, and 7 (3.5%) patients experienced the secondary outcome. Observed all-cause death and in-hospital death increased by up to 50% in those with higher scores. Patients with the primary outcome had a higher TRI-SCORE (4.5±2.4 versus 2.9±2.1; P=0.001) than those without. The TRI-SCORE showed a significant association with the primary outcome (concordance index, 0.77, cutoff value, 4) and in-hospital death (area under the curve, 0.84; cutoff value, 3). Using the Kaplan-Meier analysis, patients with a high TRI-SCORE exhibited a poor outcome for all-cause death at follow-up (log-rank P<0.001) and in-hospital death (log-rank P=0.004).

CONCLUSIONS

TRI-SCORE was validated in an Asian population and helped predict long-term outcomes after isolated tricuspid valve surgery.

Effects of intensive blood pressure control on left ventricular hypertrophy in aortic valve disease

BACKGROUND

Hypertension adds to the pressure overload on the left ventricle (LV) in combination with aortic valve (AV) disease, but the optimal blood pressure (BP) targets for patients with AV disease remain unclear. We tried to investigate whether intensive BP control reduces LV hypertrophy in asymptomatic patients with aortic stenosis (AS) or aortic regurgitation (AR).

METHODS

A total of 128 hypertensive patients with mild to moderate AS (n = 93) or AR (n = 35) were randomly assigned to intensive therapy, targeting a systolic BP <130 mm Hg, or standard therapy, targeting a systolic BP <140 mm Hg. The primary end point was the change in LV mass from baseline to the 24-month follow-up. Secondary end points included changes in severity of AV disease, LV volumes, ejection fraction and global longitudinal strain (GLS).

RESULTS

The treatment groups were generally well balanced regarding the baseline characteristics. The mean (±SD) age of the patients was 68 ± 8 years and 48% were men. The mean BP was 145 ± 12/81 ± 10 mm Hg at baseline. Medication at baseline was similar between the 2 groups. The 2 treatment strategies resulted in a rapid and sustained difference in systolic BP (P < .05). At 24-month, the mean systolic BP was 129 ± 12 mm Hg in the intensive therapy group and 135 ± 14 mm Hg in the standard therapy group. No patient died or underwent AV surgery during follow-up in either of the groups. LV mass was changed from 189.5 ± 41.3 to 185.6 ± 41.5 g in the intensive therapy group (P = .19) and from 183.8 ± 38.3 to 194.0 ± 46.4 g in the standard therapy group (P < .01). The primary end point of change in LV mass was significantly different between the intensive therapy and the standard therapy group (-3.9 ± 20.2 g vs 10.3 ± 20.4 g; P = .0007). The increase in LV mass index was also significantly greater in the standard therapy group (P = .01). No significant differences in secondary end points (changes in severity of AV disease, LV volumes, ejection fraction and GLS) were observed between the treatment groups.

CONCLUSIONS

Among hypertensive patients with AV disease, intensive hypertensive therapy resulted in a significant reduction in LV hypertrophy, although progression of AV disease was similar between the treatment groups.

CLINICAL TRIAL REGISTRATION

http://ClinicalTrials.gov (Number NCT03666351).

Comparison of Intracardiac Echocardiography Versus Transesophageal Echocardiography for Guidance During Transcatheter Aortic Valve Replacement

BACKGROUND AND OBJECTIVES

Evidence regarding the efficacy and safety of intracardiac echocardiography (ICE) for guidance during transcatheter aortic valve replacement (TAVR) is limited. This study aimed to compare the clinical efficacy and safety of ICE versus transesophageal echocardiography (TEE) for guiding TAVR.

METHODS

This prospective cohort study included patients who underwent TAVR from August 18, 2015, to June 31, 2021. Eligible patients were stratified by echocardiographic modality (ICE or TEE) and anesthesia mode (monitored anesthesia care [MAC] or general anesthesia [GA]). Primary outcome was the 1-year composite of all-cause mortality, rehospitalization for cardiovascular cause, or stroke, according to the Valve Academic Research Consortium-3 (VARC-3) definition. Propensity score matching was performed, and study outcomes were analyzed for the matched cohorts.

RESULTS

Of the 359 eligible patients, 120 patients were matched for the ICE-MAC and TEE-GA groups, respectively. The incidence of primary outcome was similar between matched groups (18.3% vs. 20.0%; adjusted hazard ratio, 0.94; 95% confidence interval [CI], 0.53-1.68; p=0.843). ICE-MAC and TEE-GA also had similar incidences of moderate-to-severe paravalvular regurgitation (PVR) (4.2% vs. 5.0%; adjusted odds ratio, 0.83; 95% CI, 0.23-2.82; p=0.758), new permanent pacemaker implantation, and VARC-3 types 2-4 bleeding.

CONCLUSIONS

ICE was comparable to TEE for guidance during TAVR for the composite clinical efficacy outcome, with similar incidences of moderate-to-severe PVR, new permanent pacemaker implantation, and major bleeding. These results suggest that ICE could be a safe and effective alternative echocardiographic modality to TEE for guiding TAVR.

Pericardiocentesis versus window formation in malignant pericardial effusion: trends and outcomes

OBJECTIVES

Malignant pericardial effusion (MPE) in patients with cancer is associated with poor prognosis. This study aimed to compare clinical outcomes in patients with cancer who underwent pericardiocentesis versus pericardial window formation.

METHODS

In the present study, 765 consecutive patients with cancer (mean age 58.4 years, 395 men) who underwent pericardial drainage between 2003 and 2022 were retrospectively analysed. All-cause death and MPE recurrence were compared based on the drainage method (pericardiocentesis vs pericardial window formation) and time period (period 1: 2003-2012; period 2: 2013-2022).

RESULTS

Pericardiocentesis was performed in 639 (83.5%) patients and pericardial window formation in 126 (16.5%). There was no difference in age, sex distribution, proportion of metastatic or relapsed cancer, and chemotherapy status between the pericardiocentesis and pericardial window formation groups. Difference was not found in all-cause death between the two groups (log-rank p=0.226) regardless of the period. The pericardial window formation group was associated with lower MPE recurrence than the pericardiocentesis group (6.3% vs 18.0%, log-rank p=0.001). This advantage of pericardial window formation was more significant in period 2 (18.1% vs 1.3%, log-rank p=0.005). In multivariate analysis, pericardial window formation was associated with lower MPE recurrence (HR: 0.31, 95% CI: 0.15 to 0.63, p=0.001); younger age, metastatic or relapsed cancer, and positive malignant cells in pericardial fluid were associated with increased recurrence.

CONCLUSION

In patients undergoing pericardial drainage for MPE, pericardial window formation showed mortality outcomes comparable with pericardiocentesis and was associated with lower incidence of MPE recurrence.

Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty

BACKGROUND

This study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm2).

METHODS

From the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm2 < MVA ≤ 1.5 cm2 and MVA ≤ 1.0 cm2, respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention.

RESULTS

Among 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012).

CONCLUSIONS

PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Early Aortic Valve Replacement in Symptomatic Normal-Flow, Low-Gradient Severe Aortic Stenosis: A Propensity Score-Matched Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Aortic valve replacement (AVR) is considered a class I indication for symptomatic severe aortic stenosis (AS). However, there is little evidence regarding the potential benefits of early AVR in symptomatic patients diagnosed with normal-flow, low-gradient (NFLG) severe AS.

METHODS

Two-hundred eighty-one patients diagnosed with symptomatic NFLG severe AS (stroke volume index ≥35 mL/m², mean transaortic pressure gradient <40 mmHg, peak transaortic velocity <4 m/s, and aortic valve area <1.0 cm²) between January 2010 and December 2020 were included in this retrospective study. After performing 1:1 propensity score matching, 121 patients aged 75.1±9.8 years (including 63 women) who underwent early AVR within 3 months after index echocardiography, were compared with 121 patients who received conservative care. The primary outcome was a composite of all-cause death and heart failure (HF) hospitalization.

RESULTS

During a median follow-up of 21.9 months, 48 primary outcomes (18 in the early AVR group and 30 in the conservative care group) occurred. The early AVR group demonstrated a significantly lower incidence of primary outcomes (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.29-0.93; p=0.028); specifically, there was no significant difference in all-cause death (HR, 0.51; 95% CI, 0.23-1.16; p=0.110), although the early AVR group showed a significantly lower incidence of hospitalization for HF (HR, 0.43; 95% CI, 0.19-0.95, p=0.037). Subgroup analyses supported the main findings.

CONCLUSIONS

An early AVR strategy may be beneficial in reducing the risk of a composite outcome of death or hospitalization for HF in symptomatic patients with NFLG severe AS. Future randomized studies are required to validate and confirm our findings.

Echocardiographic Imaging in Transcatheter Structural Intervention: An AAE Review Paper

Transcatheter structural heart intervention (TSHI) has gained popularity over the past decade as a means of cardiac intervention in patients with prohibitive surgical risks. Following the exponential rise in cases and devices developed over the period, there has been increased focus on developing the role of "structural imagers" amongst cardiologists. This review, as part of a growing initiative to develop the field of interventional echocardiography, aims to highlight the role of echocardiography in myriad TSHIs available within Asia. We first discuss the various echocardiography-based imaging modalities, including 3-dimensional echocardiography, fusion imaging, and intracardiac echocardiography. We then highlight a selected list of structural interventions available in the region-a combination of established interventions alongside novel approaches-describing key anatomic and pathologic characteristics related to the relevant structural heart diseases, before delving into various aspects of echocardiography imaging for each TSHI.

Prognostic value of functional tricuspid regurgitation quantified by cardiac magnetic resonance in heart failure

AIMS

Quantitative assessment of tricuspid regurgitation (TR) is challenging, and the prognostic implications of cardiac magnetic resonance (CMR)-quantified measures of TR remain unclear in patients with heart failure with reduced ejection fraction (HFrEF). This study investigated the prognostic value of functional TR quantified by CMR in patients with HFrEF.

METHODS AND RESULTS

A total of 262 patients with HFrEF who underwent CMR were analysed. Patients who had primary TR, who had acute HF, or for whom cardiac surgery was planned were excluded. TR volume and fraction were indirectly calculated via subtracting methods. The primary outcome was defined as a composite of all-cause death and hospitalization for HF. Renal outcome was defined as a composite of a decrease in estimated glomerular filtration rate ≥50% or progression to end-stage renal disease. During the follow-up period (median 921 days), 62 primary outcomes and 48 renal outcomes occurred. When divided into two or three groups based on TR fraction in Kaplan-Meier analysis, patients with higher TR fractions showed worse primary outcomes and renal outcomes than those with lower TR fractions. In Cox regression analysis, a 10% increase in TR fraction was significantly associated with primary outcome [hazard ratio (HR) 1.49, 95% confidence interval (CI) 1.29-1.73, P < 0.001] and renal outcome (HR 1.31, 95% CI 1.12-1.55, P = 0.001). TR fraction exhibited a strong positive linear relationship with primary outcomes and renal outcomes in restricted cubic spline curves.

CONCLUSION

CMR-quantified measures of TR were independently associated with adverse clinical outcomes in patients with HFrEF.

Reclassification of moderate aortic stenosis based on data-driven phenotyping of hemodynamic progression

The management and follow-up of moderate aortic stenosis (AS) lacks consensus as the progression patterns are not well understood. This study aimed to identify the hemodynamic progression of AS, and associated risk factors and outcomes. We included patients with moderate AS with at least three transthoracic echocardiography (TTE) studies performed between 2010 and 2021. Latent class trajectory modeling was used to classify AS groups with distinctive hemodynamic trajectories, which were determined by serial systolic mean pressure gradient (MPG) measurements. Outcomes were defined as all-cause mortality and aortic valve replacement (AVR). A total of 686 patients with 3093 TTE studies were included in the analysis. Latent class model identified two distinct AS trajectory groups based on their MPG: a slow progression group (44.6%) and a rapid progression group (55.4%). Initial MPG was significantly higher in the rapid progression group (28.2 ± 5.6 mmHg vs. 22.9 ± 2.8 mmHg, P < 0.001). The prevalence of atrial fibrillation was higher in the slow progression group; there was no significant between-group difference in the prevalence of other comorbidities. The rapid progression group had a significantly higher AVR rate (HR 3.4 [2.4-4.8], P < 0.001); there was no between-group difference in mortality (HR 0.7 [0.5-1.0]; P = 0.079). Leveraging longitudinal echocardiographic data, we identified two distinct groups of patients with moderate AS: slow and rapid progression. A higher initial MPG (≥ 24 mmHg) was associated with more rapid progression of AS and higher rates of AVR, thus indicating the predictive value of MPG in management of the disease.

Effects of continuous positive airway pressure therapy on left ventricular performance in patients with severe obstructive sleep apnea

We investigated myocardial performance concerning obstructive sleep apnea (OSA) severity and the benefits of continuous positive airway pressure (CPAP) therapy. In this randomized sham-controlled trial, 52 patients (mean age, 49 years; 92%, males; mean AHI, 59) with severe OSA were randomly assigned to receive either CPAP or sham treatment for 3 months. The severity of OSA was determined using the apnea/hypopnea index (AHI), oxygen desaturation index (ODI), percentage of sleep time below 90% oxygen saturation (T90), and average O₂ saturation during sleep (mean SpO₂). We compared the changes in myocardial work after 3 months of CPAP (n = 26) versus the sham group (n = 26) at rest and during an exercise stress test. Unlike AHI or ODI, indices of hypoxemia including T90 and mean SpO₂ were significantly correlated with global constructive work, as defined by work of left ventricle (LV) that contributes to LV ejection during systole (T90, β = 0.393, p = 0.012; mean SpO₂, β = 0.331, p = 0.048), and global wasted work (GWW), as defined by work of LV that does not contribute to LV ejection (T90, β = 0.363, p = 0.015; mean SpO₂, β =  - 0.370, p = 0.019). After 3 months, GWW decreased (80.0 ± 49.2 to 60.8 ± 26.3, p = 0.009) and global work efficiency increased (94.0 ± 4.5 to 95.7 ± 2.0, p = 0.008) in the CPAP group compared to those in the sham group. At the 3-month follow-up exercise stress echocardiography, worsening of GWW during exercise was significantly decreased in the CPAP group compared to that in the sham group (p = 0.045 at 50 W). Hypoxemia indices were closely associated with myocardial performance in patients with severe OSA. CPAP treatment for 3 months improved left ventricular myocardial performance by decreasing wasted work and increasing work efficacy compared to the sham treatment.

Nationwide trends of gatekeeper to invasive coronary angiography in suspected coronary artery disease

Funding Acknowledgements

Type of funding sources: None.

Background and Objectives

Real-world trends in the utility and type of gatekeeping studies in invasive coronary angiography (ICA) requires further investigation.

Methods

We identified outpatients who underwent noninvasive cardiac tests or directly ICA for suspected coronary artery disease (CAD) from the nationwide Korea Health Insurance Review and Assessment Service-National Patient Sample database between 2012 and 2018.

Results

Among 71,401 patients, the percentage of patients who were evaluated for suspected CAD was 34.7% for treadmill test (TMT), 4.2% for single-photon emission computed tomography (SPECT), 24.2% for coronary computed tomography angiography (CCTA), 1.6% for multiple gatekeepers, and 32.3% for directly ICA without noninvasive studies (Figure 1). The proportion of CCTA as a gatekeeper showed linear increase, (18.6% in 2012 and 28.8% in 2018; p &lt; 0.001), while those of TMT, SPECT, and direct ICA have decreased (p &lt; 0.001, p = 0.03, and p &lt; 0.001, respectively). The overall incidence of downstream ICA after gatekeeper was 13.8% (6,662/48,346), and SPECT showed higher ICA rate in pairwise comparison with TMT and CCTA (p &lt; 0.001). Patients who performed gatekeepers before ICA showed higher rate of subsequent PCI (34.7% vs. 32.3%; p &lt; 0.001) and CABG (3.5% vs. 1.0%; p &lt; 0.001), compared to those who directly underwent ICA, and CCTA was associated with higher revascularization rate after ICA in pairwise comparison with TMT and SPECT (p &lt; 0.001).

Conclusion

Nationwide database demonstrated that CCTA is utilized increasingly as a gatekeeper for ICA and is associated with high revascularization rate after ICA in outpatients with suspected CAD.

The ratio of measured and reference effective orifice areas for discriminating prosthetic aortic valve obstruction

AIMS

We aimed to evaluate the efficacy of the measured effective orifice area (EOA)/reference EOA ratio in discriminating mechanical prosthetic aortic valve (PAV) obstruction.

METHODS AND RESULTS

This is a retrospective study of 193 mechanical PAV patients with an elevated mean transprosthetic pressure gradient (PG) over 20 mmHg or peak velocity over 3 m/s. Of those, 143 patients were objectively proven PAV obstruction with cardiac computed tomography or surgical inspection. The EOA was measured using the continuity equation, and the reference EOA values were obtained from previous guidelines. The measured/reference EOA ratio was significantly lower in the obstruction group (0.63 ± 0.18 vs. 0.86 ± 0.17; P < 0.001). The EOA ratio added incremental value for discriminating obstruction from the conventional parameters recommended in the guidelines. Receiver operating characteristic curve analysis revealed that the measured/reference EOA ratio discriminated PAV obstruction from those without obstruction [area under the curve (AUC), 0.840; 95% confidence interval, 0.783-0.898; P < 0.001]. A cutoff of 0.71 had 73.4% sensitivity and 82.0% specificity. The novel diagnostic algorithm adding the EOA ratio had similar accuracy to previous guideline algorithms, including reference EOA, and conventional Doppler parameters (AUC, 0.763 vs. 0.731; P = 0.309). In patients with a large PAV (≥23 mm), the novel algorithm had higher accuracy than the previous algorithm (AUC, 0.788 vs. 0.642; P = 0.019).

CONCLUSION

The ratio of measured/reference EOA adds incremental value over conventional Doppler parameters and might be helpful for distinguishing PAV obstruction.

Effects of radiofrequency catheter ablation for premature ventricular complexes originating from the right ventricular outflow tract on right ventricular function

INTRODUCTION

This study aimed to elucidate the relationship between premature ventricular complexes (PVCs) and right ventricular (RV) dysfunction, and the effects of radiofrequency catheter ablation (RFCA) on RV function.

METHODS

A total of 110 patients (age, 50.8 ± 14.4 years; 30 men) without structural heart disease who had undergone RFCA for RV outflow tract (RVOT) PVCs were retrospectively included. RV function was assessed using fractional area change (FAC) and global longitudinal strain (GLS) before and after RFCA. Clinical data were compared between the RV dysfunction (n = 63) and preserved RV function (n = 47) groups. The relationship between PVC burden and RV function was analyzed. Change in RV function before and after RFCA was compared between patients with successful and failed RFCA.

RESULTS

PVC burden was significantly higher in the RV dysfunction group than in the preserved RV function group (p < .001). FAC and GLS were significantly worse in proportion to PVC burden (p < .001 and p < .001, respectively). The risk factor associated with RV dysfunction was PVC burden [odds ratio (95% confidence interval), 1.092 (1.052-1.134); p < .001]. Improvement in FAC (13.0 ± 8.7% and -2.5 ± 5.6%, respectively; p < .001) and GLS (-6.8 ± 5.7% and 2.1 ± 4.2%, respectively; p < .001) was significant in the patients with successful RFCA, compared to the patients in whom RFCA failed.

CONCLUSIONS

Frequent RVOT PVCs are associated with RV dysfunction. RV dysfunction is reversible by successful RFCA.

Efficacy and safety of edoxaban in patients early after surgical bioprosthetic valve implantation or valve repair: A randomized clinical trial

OBJECTIVE

Early warfarin anticoagulation is recommended in patients undergoing surgical bioprosthetic valve implantation or valve repair. It is unclear whether non-vitamin K antagonist oral anticoagulants can be a full alternative to warfarin. This study aimed to compare efficacy and safety of edoxaban with warfarin in patients early after surgical bioprosthetic valve implantation or valve repair.

METHODS

The Explore the Efficacy and Safety of Edoxaban in Patients after Heart Valve Repair or Bioprosthetic Valve Replacement study was a prospective, randomized (1:1), open-label, clinical trial conducted from December 2017 to September 2019. Patients were randomly assigned to receive edoxaban (60 mg or 30 mg once daily) or warfarin for the first 3 months after surgical bioprosthetic valve implantation or valve repair. The primary efficacy outcome was a composite of death, clinical thromboembolic events, or asymptomatic intracardiac thrombosis. The primary safety outcome was the occurrence of major bleeding.

RESULTS

Of 220 participants, 218 (109 per group) were included in the modified intention-to-treat analysis. The primary efficacy outcome occurred in 4 patients (3.7%) taking warfarin and none taking edoxaban (risk difference, -0.0367; 95% confidence interval, -0.0720 to -0.0014; P < .001 for noninferiority). The primary safety outcome occurred in 1 patient (0.9%) taking warfarin and 3 patients (2.8%) taking edoxaban (risk difference, 0.0183; 95% confidence interval, -0.0172 to 0.0539; P = .013 for noninferiority).

CONCLUSIONS

Edoxaban is noninferior to warfarin for preventing thromboembolism and is potentially comparable for risk of major bleeding during the first 3 months after surgical bioprosthetic valve implantation or valve repair.

Changes in Cardiac Structure and Function After Kidney Transplantation: A New Perspective Based on Strain Imaging

BACKGROUND

We aimed to investigate left ventricular (LV) global longitudinal strain (GLS) in end-stage renal disease patients and its change after kidney transplantation (KT).

METHODS

We retrospectively reviewed patients who underwent KT between 2007 and 2018 at two tertiary centers. We analyzed 488 patients (median age, 53 years; 58% male) who had obtained echocardiography both before and within 3 years after KT. Conventional echocardiography and LV GLS assessed by two-dimensional speckle-tracking echocardiography were comprehensively analyzed. Patients were classified into three groups according to the absolute value of pre-KT LV GLS (|LV GLS|). We compared longitudinal changes of cardiac structure and function according to pre-KT |LV GLS|.

RESULTS

Correlation between pre-KT LV EF and |LV GLS| were statistically significant, but the constant was not high (r = 0.292, p < 0.001). |LV GLS| was widely distributed at corresponding LV EF, especially when the LV EF was > 50%. Patients with severely impaired pre-KT |LV GLS| had significantly larger LV dimension, LV mass index, left atrial volume index, and E/e' and lower LV EF, compared to mildly and moderately reduced pre-KT |LV GLS|. After KT, the LV EF, LV mass index, and |LV GLS| were significantly improved in three groups. Patients with severely impaired pre-KT |LV GLS| showed the most prominent improvement of LV EF and |LV GLS| after KT, compared to other groups.

CONCLUSIONS

Improvements in LV structure and function after KT were observed in patients throughout the full spectrum of pre-KT |LV GLS|.

Assessment of aortic valve area on cardiac computed tomography in symptomatic bicuspid aortic stenosis: Utility and differences from Doppler echocardiography

Background

In this study, we investigate the utility of geometric orifice area (GOA) on cardiac computed tomography (CT) and differences from effective orifice area (EOA) on Doppler echocardiography in patients with bicuspid aortic stenosis (AS).

Methods

A total of 163 patients (age 64 ± 10 years, 56.4% men) with symptomatic bicuspid AS who were referred for surgery and underwent both cardiac CT and echocardiography within 3 months were studied. To calculate the aortic valve area, GOA_CT was measured by multiplanar CT planimetry, and EOA_Echo was calculated by the continuity equation with Doppler echocardiography. The relationships between GOA_CT and EOA_Echo and patient symptom scale, biomarkers, and left ventricular (LV) functional variables were analyzed.

Results

There was a significant but modest correlation between EOA_Echo and GOA_CT (r = 0.604, p < 0.001). Both EOA_Echo and GOA_CT revealed significant correlations with mean pressure gradient and peak transaortic velocity, and the coefficients were higher in EOA_Echo than in GOA_CT. EOA_Echo of 1.05 cm² and GOA_CT of 1.25 cm² corresponds to hemodynamic cutoff values for diagnosing severe AS. EOA_Echo was well correlated with the patient symptom scale and log NT-pro BNP, but GOA_CT was not. In addition, EOA_Echo had a higher correlation coefficient with estimated LV filling pressure and LV global longitudinal strain than GOA_CT.

Conclusion

GOA_CT can be used to evaluate the severity of bicuspid AS. The threshold for GOA_CT for diagnosing severe AS should be higher than that for EOA_Echo. However, EOA_Echo is still the method of choice because EOA_Echo showed better correlations with clinical and functional variables than GOA_CT.

Risk factors and outcomes with surgical bioprosthetic mitral valve dysfunction

BACKGROUND

There are insufficient data regarding the risk factors associated with valve dysfunction of bioprosthetic valves in the mitral position This study aimed to investigate the factors associated with bioprosthetic mitral valve (MV) dysfunction (MVD).

METHODS

A total of 245 patients (age 67.2±11.2 years, 74.9% women) who were followed up for more than 5 years after surgical bioprosthetic MV replacement were analysed in the setting of retrospective study design. MVD was defined as an increased mean gradient of >5 mm Hg with limited leaflet motion and/or newly developed MV regurgitation of at least moderate severity on follow-up echocardiography. The clinical outcome was defined as a composite of cardiovascular mortality, redo MV surgery or intervention and heart failure-related hospitalisations.

RESULTS

During a median of 96.0 months (IQR 67.0-125.0 months), bioprosthetic MVD occurred in 66 (27.6%) patients. Factors associated with bioprosthetic MVD detected by multivariate regression analysis were age at surgery (HR 0.98, 95% CI 0.96 to 0.99, p<0.001), chronic kidney disease (HR 3.27, 95% CI 1.74 to 6.12, p<0.001), elevated mean diastolic pressure gradient >5.5 mm Hg across the bioprosthetic MV early after operation (HR 2.02, 95% CI 1.08 to 3.78, p=0.028) and average haemoglobin level after surgery (HR 0.80, 95% CI 0.67 to 0.96, p=0.015). Patients with bioprosthetic MVD showed significantly poorer clinical outcomes than those without bioprosthetic MVD (log-rank p<0.001).

CONCLUSIONS

Young age at operation, chronic kidney disease, elevated pressure gradient across the bioprosthetic MV early after surgery and postsurgical anaemia are associated with bioprosthetic MVD. Bioprosthetic MVD is associated with poor clinical outcomes.

Clinical significance of right ventricular–pulmonary arterial coupling in patients with tricuspid regurgitation before closure of atrial septal defect

Background

Functional tricuspid regurgitation (TR) usually decreases after atrial septal defect (ASD) closure; however, it may persist and cause heart failure that requires treatment. We aimed to investigate clinical and echocardiographic factors predicting persistent TR after ASD closure.

Methods

Among 348 adults who underwent isolated ASD closure between January 2010 and September 2020, 91 (26.1%) patients with significant TR (at least moderate degree) before ASD closure were included. Persistent TR was defined as significant TR on echocardiography at 6 months to 1 year after ASD correction. We comprehensively analyzed the echocardiogram before ASD closure, including speckle-tracking imaging. Right ventricular (RV)–pulmonary arterial (PA) (RV–PA) coupling was assessed by the ratio of RV global longitudinal strain (RV GLS) and tricuspid annular S' velocity to PA systolic pressure (PASP).

Results

Persistent TR was observed in 22 (24.2%) patients. Patients with persistent TR were significantly older and had larger TR jet areas and lower RV–PA coupling parameters than those without persistent TR. On multivariable regression, persistent TR was independently associated with age [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.01–1.14, p = 0.030) and |RV GLS|/PASP (OR 0.001, 95% CI 0.00–0.017, p = 0.012). ROC curves analysis showed that |RV GLS|/PASP's best cut-off for persistent TR was 0.46 (cut-off 0.46, the area under the curve 0.789, p &lt; 0.001).

Conclusion

Persistent TR after ASD closure is not rare. Old age and RV–PA uncoupling could be associated with persistent TR after ASD closure. In older patients with abnormal RV–PA coupling, careful evaluation and concomitant or subsequent TR intervention may be considered.

Left atrial strain and clinical outcome in patients with significant mitral regurgitation after surgical mitral valve repair

Background

This study aimed to investigate the prognostic value of left atrial (LA) strain in patients with significant mitral regurgitation (MR) after surgical mitral valve (MV) repair.

Methods

A total of 169 patients (age 55 ± 15 years, 88 men) with moderate or severe MR on echocardiogram at least 6 months after surgical MV repair for primary MR were studied. Two-dimensional, Doppler, and speckle tracking echocardiography including MR quantitative measures, chamber size, and LA strain were comprehensively analyzed. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, and MV reoperation.

Results

During a median of 44.4 months [interquartile range (IQR): 18.7-70.3 months] of follow-up, 44 patients (26%) experienced clinical events; these patients had greater MR volume, elevated mean diastolic pressure gradient and pulmonary artery systolic pressure, and enlarged chamber size compared with patients who did not experience events. Patients with events showed significantly lower LA strain [13.3% (IQR: 9.3-23.8%) vs. 24.0% (IQR: 13.1-31.4%), p = 0.003] and higher MR volume/LA strain [3.09 ml/% (IQR: 2.06-5.80 ml/%) vs. 1.57 ml/% (IQR: 1.04-2.72 ml/%), p < 0.001] than those without events. MR volume/LA strain was a good predictor of clinical outcomes (cut-off 1.57 ml/%, area under the curve 0.754, p < 0.001). On multivariable Cox proportional analysis, MR volume/LA strain was independently associated with clinical outcomes (hazard ratio: 1.269, 95% confidence interval: 1.109-1.452, p < 0.001) along with pulmonary artery systolic pressure.

Conclusion

A measure of LA mechanical function relative to MR volume is associated with clinical outcomes in patients with significant MR after surgical MV repair.

Determinants of exercise-induced pulmonary hypertension in rheumatic mitral stenosis: a study with exercise stress and speckle tracking echocardiography

Backgrounds

Exercise stress echocardiography is helpful in assessing hemodynamic consequence of mitral stenosis (MS) and in guiding treatment. Exercised-induced pulmonary hypertension (PH) is result of severity of MS, but myocardial function of left ventricle and clinical factors can also have effect.

Purpose

We aimed to evaluate the associated factors with the pulmonary artery systolic pressure (PASP) in exercise stress echocardiography through 2D, Doppler, and speckle tracking imaging in patients with rheumatic MS.

Methods

A total of 164 patients with rheumatic MS underwent a graded, symptom-limited, supine bicycle exercise with echocardiography. After exclusion of patients who had very severe MS (valve area &lt;1.0 cm2), a history of surgery or recent percutaneous mitral valvotomy, combined significant aortic valve dysfunction, left ventricular (LV) ejection fraction &lt;50%, we analyzed 113 patients (77.6% female; mean age, 56±9 years). Echocardiographic parameters at rest, each stage (25 watt increment every 3 minutes), and peak exercise were obtained. Exercised induced PH was defined as present if PASP &gt;60 mmHg at peak exercise. LV global longitudinal strain (LV-GLS) and left atrial (LA) strain were analyzed by software. The subjects were divided into 4 groups according to mean transmitral pressure gradient (MG) (15 mmHg) and PASP (60 mmHg) at peak exercise (Group 1, MG &lt;15 mmHg and PASP &lt;60 mmHg, n=29; Group 2, MG &lt;15 mmHg and PASP ≥60 mmHg, n=9; Group 3, MG ≥15 mmHg and PASP &lt;60 mmHg, n=23; Group 4, MG ≥15 mmHg and PASP ≥6 0mmHg, n=52).

Results

The mean mitral valve area was 1.30±0.23 cm2. PASP increased from 30.0±8.0 mmHg at rest to 61.0±14.8 mmHg at peak exercise, along with increase MG. 61 (53.9%) subjects had PASP&gt;60 mmHg at peak exercise. Compared to group 1, group 2 had higher incidence of diabetes mellitus (DM) and significantly elevated PASP at baseline and impaired LV-GLS. However, there was no statical difference in LA strain between the two groups. In subjects with MG above 15 mmHg (Group 3 and 4), a similar trend was observed in occurrence of exercise-induced PH. On logistic multivariate regression, exercised induced PH was independently associated with female (HR: 5.35, 95% CI: 1.51–24.95; p=0.032), DM (HR: 10.05, 95% CI, 1.35–74.45; p=0.024), MG at peak exercise (HR: 1.17, 95% CI, 1.02–1.34; p=0.002), PASP at rest (HR: 1.17, 95% CI, 1.05–1.30; p=0.002), and LV-GLS (HR: 1.45, 95% CI, 1.09–1.91; p=0.009), but not with LA strain. The predictive value for exercised induced PH was highest when adding LV-GLS to the clinical factor (age, sex, DM) and echocardiographic parameters (Figure 1).

Conclusions

Exercised induced PH is affected by not only hemodynamic consequence of MS, but also myocardial function of left ventricle and clinical factors. Therefore, when determining the optimal timing of intervention based on exercise-induced PH in rheumatic MS patients, LV-GLS should be evaluated comprehensively along with MS characteristics.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): Yonsei University College of Medicine

Assessment of aortic valve area on cardiac computed tomography and doppler echocardiography: differences and clinical significance in symptomatic bicuspid aortic stenosis

Backgrounds

This study aimed to investigate the differences and clinical significance of effective orifice area (EOA) on Doppler echocardiography and geometric orifice area (GOA) on cardiac computed tomography (CT) in bicuspid aortic stenosis (AS).

Methods

One-hundred sixty-three consecutive patients (age 64±10 years, 56.4% men) with symptomatic bicuspid AS who were referred for surgery and underwent both cardiac CT and echocardiography within 3 months were studied. For the aortic valve area, GOACT was measured by multiplanar CT planimetry, and EOAEcho was calculated by continuity equation with Doppler echocardiography. The associations of GOACT and EOAEcho with the patients' symptom scale, biomarkers, and left ventricular (LV) functional variables were comprehensively analyzed.

Results

There was a significant but modest correlation between EOAEcho and GOACT (r=0.604, p&lt;0.001). Both EOAEcho and GOACT revealed significant correlations with mean pressure gradient and peak transaortic velocity and the coefficients were higher in EOAEcho than GOACT. EOAEcho of 1.05 cm2 and GOACT of 1.25 cm2 correspond to the hemodynamic cut-off values for diagnosing severe AS. EOAEcho was well correlated with patients' symptom scale and log NT-pro BNP, but GOACT was not. In addition, EOAEcho showed higher correlation coefficient with estimated LV filling pressure and LV global longitudinal strain than GOACT.

Conclusions

Both EOAEcho and GOACT can be used to evaluate the severity of bicuspid AS, however, the threshold for GOACT for diagnosing severe AS should be applied higher than that for EOAEcho. EOAEcho tends to be more correlated with the patients' symptom degree, biomarkers, and LV functional variables than GOACT.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Korean Cardiac Research Foundation

Identification of distinct subgroups in moderately severe rheumatic mitral stenosis using data-driven phenotyping of longitudinal hemodynamic progression

Background

Rheumatic mitral stenosis (MS) is a significant cause of valvular heart disease. Pulmonary artery systolic pressure (PASP) reflects the hemodynamic consequences of MS and is used to determine treatment strategies. However, PASP progression and expected outcomes in patients with moderately severe MS remain unclear.

Purpose

We aimed to examine the impact of progression rate of PASP in moderately severe MS.

Methods

A cohort of 866 consecutive patients with moderately severe rheumatic MS (1.0 cm2.

Results

Data-driven phenotyping identified two distinct trajectories based on PASP progression: a rapid progression group (N=38, 8.7%) and a slow progression group (N=398, 91.3%). Patients in the rapid progression group were older and had more comorbidities than patients in the slow progression group, including diabetes, and atrial fibrillation (all P&lt;0.05). The initial mean diastolic pressure gradient and PASP were higher in the rapid progression group than in the slow progression group (6.2±2.4 mmHg vs. 5.1±2.0 mmHg, P=0.001, and 42.3±13.3 mmHg vs. 33.0±9.2 mmHg, P&lt;0.001, respectively). During a mean follow-up of 7.0±3.0 years, the event-free survival rate was significantly lower in the rapid progression group than in the slow progression group (log-rank P&lt;0.001). Rapid PASP progression was a significant risk factor for composite outcomes even after adjusting for comorbidities (hazard ratio: 3.08, 95% confidence interval (CI): 1.68–5.64, P&lt;0.001). Multivariate regression analysis revealed that PASP&gt;40 mmHg was independently associated with the probability of rapid progression group allocation (odds ratio: 4.95, 95% CI: 2.08–11.99, P&lt;0.001).

Conclusions

Two groups with distinct patterns of PASP progression were identified. Rapid PASP progression was associated with a significantly higher risk of the composite outcomes. The main independent echocardiographic predictor for rapid progression group allocation was initial PASP&gt;40 mmHg.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): This study was supported by a Severance Hospital Research fund for Clinical excellence (SHRC) (C-2020-0041) and a faculty research grant of Yonsei University College of Medicine (6-2020-0156).

Characteristics and clinical implications of premature summation of early and late diastolic filling in patients without tachycardia

Backgrounds

The summation of early (E) and late diastolic filling (A) on mitral inflow Doppler even in the absence of tachycardia is often found during assessments of left ventricular (LV) diastolic function. We evaluated the echocardiographic characteristics and clinical implications of premature E-A summation.

Methods

We identified 1,014 subjects who showed E-A summation and normal LV ejection fraction between January 2019 and June 2021 in two tertiary hospitals. Among these, 105 (10.4%) subjects showed premature E-A summation at heart rates less than 100 beats per minute (bpm). The conventional echocardiographic parameters and LV global longitudinal strain (GLS) were compared with 1:1 age, sex, and heart rate matched controls without E-A summation.

Results

The premature E-A summation group had a heart rate of 96.4±3.7 bpm. Only 4 (3.8%) subjects were classified as having LV diastolic dysfunction according to the current guidelines. That group showed prolonged isovolumic relaxation time (107.2±25.3 vs. 61.6±15.6 msec, p&lt;0.001), increased Tei index (0.76±0.19 vs. 0.48±0.10, p&lt;0.001), lower LVEF (63.8±7.0 vs. 67.3±5.6%, p&lt;0.001) and lower absolute LV GLS (|LV GLS|) (17.0±4.2 vs. 19.7±3.3%, p&lt;0.001) than controls. As the E-A summation occurred at lower heart rate, the |LV GLS| was also lower (p for trend=0.002).

Conclusions

The premature E-A summation at heart rates less than 100 bpm is associated with subclinical LV dysfunction. Time-based indices and LV GLS are helpful for evaluating this easily overlooked population.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of liver stiffness in patients with tricuspid regurgitation

Background

It has been known that liver stiffness (LS) assessed by transient elastography is associated with right heart dysfunction and the severity of the tricuspid regurgitation. However, the predictive value of LS for adverse outcome in patients with tricuspid regurgitation (TR) is uncertain.

Objectives

The aim of this study was to identify the prognostic value of LS in patients with moderate or greater degree of TR.

Methods

A total of 257 patients with moderate or severe TR who underwent both echocardiography and liver transient elastography were retrospectively analysed. Patients who have congenital heart disease or chronic liver disease including, viral hepatitis, alcoholic liver disease, autoimmune hepatitis, hepatocellular carcinoma were excluded. Severe LS was defined as elevated kilopascal (kPa) ≥11 (High kPa). Primary outcome was defined as the composite of all-cause death and unplanned admission for heart failure.

Results

One hundred forty-one patients had moderate TR and 116 patients had severe TR. One hundred twenty-eight (50%) patients had severe liver stiffness. During a follow-up period (median 637 days, IQR 1317), 116 (45.1%) primary outcomes occurred. In Kaplan-Meier analysis, patients who had severe TR with high kPa showed the worst outcome. Moreover, patients who had high kPa were associated with worse clinical outcome both moderate TR group and severe TR group than patients with low kPa. In multivariate Cox regression analysis, severe liver stiffness was independently associated with primary outcomes (HR=1.66, 95% CI: 1.28–2.16), p&lt;0.001).

Conclusions

LS is independently associated with adverse clinical outcomes in both patients with moderate and severe TR. The degree of liver fibrosis measured by transient elastography may be a useful marker of cardiac hepatopathy related to TR, and this may contribute to predict the prognosis of TR.

Funding Acknowledgement

Type of funding sources: None.

Dapagliflozin attenuates diabetes-induced diastolic dysfunction and cardiac fibrosis by regulating SGK1 signaling

BACKGROUND

Recent studies have reported improved diastolic function in patients administered sodium-glucose cotransporter 2 inhibitors (SGLT2i). We aimed to investigate the effect of dapagliflozin on left ventricular (LV) diastolic function in a diabetic animal model and to determine the molecular and cellular mechanisms underlying its function.

METHODS

A total of 30 male New Zealand white rabbits were randomized into control, diabetes, or diabetes+dapagliflozin groups (n = 10/per each group). Diabetes was induced by intravenous alloxan. Cardiac function was evaluated using echocardiography. Myocardial samples were obtained for histologic and molecular evaluation. For cellular evaluation, fibrosis-induced cardiomyoblast (H9C2) cells were obtained, and transfection was performed for mechanism analysis (serum and glucocorticoid-regulated kinase 1 (SGK1) signaling analysis).

RESULTS

The diabetes+dapagliflozin group showed attenuation of diastolic dysfunction compared with the diabetes group. Dapagliflozin inhibited myocardial fibrosis via inhibition of SGK1 and epithelial sodium channel (ENaC) protein, which was observed both in myocardial tissue and H9C2 cells. In addition, dapagliflozin showed an anti-inflammatory effect and ameliorated mitochondrial disruption. Inhibition of SGK1 expression by siRNA decreased and ENaC and Na+/H+ exchanger isoform 1 (NHE1) expression was confirmed as significantly reduced as siSGK1 in the diabetes+dapagliflozin group.

CONCLUSIONS

Dapagliflozin attenuated left ventricular diastolic dysfunction and cardiac fibrosis via regulation of SGK1 signaling. Dapagliflozin also reduced macrophages and inflammatory proteins and ameliorated mitochondrial disruption.

Associations between Subclinical Myocardial Dysfunction and Premature Fusion of Early and Late Diastolic Filling with Uncertain Cause

PURPOSE

The fusion of early (E) and late diastolic filling (A) on mitral inflow Doppler, even in the absence of tachycardia, is often found during assessment of left ventricular (LV) diastolic function. We evaluated the echocardiographic characteristics and clinical implications of premature E-A fusion of uncertain cause in the absence of tachycardia.

MATERIALS AND METHODS

We identified 1014 subjects who showed E-A fusion and normal LV ejection fraction (LVEF) between January 2019 and June 2021 at two tertiary hospitals. Among these, 105 (10.4%) subjects showed premature E-A fusion at heart rates less than 100 beats per minute (bpm). The conventional echocardiographic parameters and LV global longitudinal strain (GLS) were compared with 1:1 age-, sex-, and heart rate-matched controls without E-A fusion.

RESULTS

The premature E-A fusion group had a heart rate of 96.4±3.7 bpm. Only 4 (3.8%) subjects were classified as having LV diastolic dysfunction according to current guidelines. The group showed prolonged isovolumic relaxation time (107.2±25.3 msec vs. 61.6±15.6 msec, p<0.001), increased Tei index (0.76±0.19 vs. 0.48±0.10, p<0.001), lower LVEF (63.8±7.0% vs. 67.3±5.6%, p<0.001) and lower absolute LV GLS (|LV GLS|) (17.0±4.2% vs. 19.7±3.3%, p<0.001) than controls. As the E-A fusion occurred at lower heart rate, the |LV GLS| was also lower (p for trend=0.002).

CONCLUSION

Premature E-A fusion at heart rates less than 100 bpm is associated with subclinical LV dysfunction. Time-based indices and LV GLS are helpful for evaluating this easily overlooked population.

Prognostic Implications of Biventricular Global Longitudinal Strain in Patients With Severe Isolated Tricuspid Regurgitation

Background

Isolated TV surgery can be performed in patients with symptoms caused by severe isolated tricuspid regurgitation (TR), preferably before the onset of significant right ventricular (RV) dysfunction. In patients with severe TR, intrinsic RV dysfunction tends to be masked and promotes left ventricular (LV) mechanical dysfunction. This study investigated the prognostic implications of biventricular global longitudinal strain (GLS) in patients receiving isolated tricuspid valve (TV) surgery.

Methods

Among 1,670 patients who underwent TV surgery between January 2000 and December 2020, 111 patients with severe isolated TR who underwent echocardiography before and after TV surgery were analyzed. We assessed LV, RV, and biventricular GLS using speckle tracking echocardiography. Biventricular GLS was defined as the sum of LV-GLS and RV free-wall strain. The primary outcomes were cardiovascular death, heart failure hospitalization, re-done TV surgery, and heart transplantation.

Results

During 3.9 ± 3.8 years of follow-up after the postoperative echocardiography, 24 (21.6%) patients experienced a primary outcome. Those patients had more comorbidities and more impaired preoperative RV-GLS and biventricular GLS than those who did not experience a primary outcome, although the two groups did not differ in preoperative LV-GLS. Patients with a primary outcome also showed significantly impaired postoperative RV-GLS, biventricular GLS, and LV-GLS compared those without a primary outcome. In multivariate analyses, both pre- and postoperatively assessed RV-GLS [preoperative; hazard ratio (HR) 0.86, confidence interval (CI) 0.79–0.93, p < 0.001, postoperative; HR 0.89, CI 0.82–0.96, p = 0.004] and biventricular GLS [preoperative; HR 0.96, CI 0.91–1.00, p = 0.048, postoperative; HR 0.94, CI 0.89–0.99, p = 0.023] were independently associated with the primary outcomes.

Conclusion

In patients with severe isolated TR undergoing TV surgery, the absolute value of RV-GLS under 17.2% is closely associated with a poor prognosis, and that of biventricular GLS under 34.0%, mainly depending on the RV-GLS, is related to the poor prognosis. Further prospective multicenter studies are warranted to establish the risk stratification of isolated TV surgery.

Identification of Distinct Subgroups in Moderately Severe Rheumatic Mitral Stenosis Using Data-Driven Phenotyping of Longitudinal Hemodynamic Progression

Background

Rheumatic mitral stenosis is a significant cause of valvular heart disease. Pulmonary arterial systolic pressure (PASP) reflects the hemodynamic consequences of mitral stenosis and is used to determine treatment strategies. However, PASP progression and expected outcomes based on PASP changes in patients with moderately severe mitral stenosis remain unclear.

Methods and Results

A total of 436 patients with moderately severe rheumatic mitral stenosis (valve area 1.0–1.5 cm²) were enrolled. Composite outcomes included all‐cause mortality and hospitalization for heart failure. Data‐driven phenotyping identified 2 distinct trajectory groups based on PASP progression: rapid (8.7%) and slow (91.3%). Patients in the rapid progression group were older and had more diabetes and atrial fibrillation than those in the slow progression group (all P<0.05). The initial mean diastolic pressure gradient and PASP were higher in the rapid progression group than in the slow progression group (6.2±2.4 mm Hg versus 5.1±2.0 mm Hg [P=0.001] and 42.3±13.3 mm Hg versus 33.0±9.2 mm Hg [P<0.001], respectively). The rapid progression group had a poorer event‐free survival rate than the slow progression group (log‐rank P<0.001). Rapid PASP progression was a significant risk factor for composite outcomes even after adjusting for comorbidities (hazard ratio, 3.08 [95% CI, 1.68–5.64]; P<0.001). Multivariate regression analysis revealed that PASP >40 mm Hg was independently associated with allocation to the rapid progression group (odds ratio, 4.95 [95% CI, 2.08–11.99]; P<0.001).

Conclusions

Rapid PASP progression was associated with a higher risk of the composite outcomes. The main independent predictor for rapid progression group allocation was initial PASP >40 mm Hg.

Impact of New-Onset Persistent Left Bundle Branch Block on Reverse Cardiac Remodeling and Clinical Outcomes After Transcatheter Aortic Valve Replacement

Background

The clinical implication of new-onset left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) remains controversial. We investigated the impact of new-onset persistent LBBB on reverse cardiac remodeling and clinical outcomes after TAVR.

Methods

Among 478 patients who had undergone TAVR for symptomatic severe aortic stenosis from 2011 to 2021, we analyzed 364 patients after excluding patients with pre-existing intraventricular conduction disturbance or a pacing rhythm before or during the indexed hospitalization for TAVR. Echocardiographic variables of cardiac remodeling at baseline and 1 year after TAVR were comprehensively analyzed. The primary outcome was a composite of cardiovascular death and hospitalization for heart failure. Secondary outcomes were all-cause death and individual components of the primary outcome.

Result

New-onset persistent LBBB occurred in 41 (11.3%) patients after TAVR. The no LBBB group showed a significant increase in the left ventricular (LV) ejection fraction and decreases in LV dimensions, the left atrial volume index, and LV mass index 1 year after TAVR (all p < 0.001). However, the new LBBB group showed no significant changes in these parameters. During a median follow-up of 18.1 months, the new LBBB group experienced a higher incidence of primary outcomes [hazard ratio (HR): 5.03; 95% confidence interval (CI): 2.60–9.73; p < 0.001] and all-cause death (HR: 2.80; 95% CI: 1.38–5.69; p = 0.003). The data were similar after multivariable regression analysis.

Conclusion

New-onset persistent LBBB after TAVR is associated with insufficient reverse cardiac remodeling and increased adverse clinical events.

Cancer Therapy-Related Cardiac Dysfunction in Patients Treated with a Combination of an Immune Checkpoint Inhibitor and Doxorubicin

Backgrounds: There are scarce data on whether immune checkpoint inhibitors (ICIs) increase the risk of cardiac dysfunction when used with cardiotoxic agents. Thus, we evaluated cardiac dysfunction in patients with sarcoma receiving doxorubicin with or without ICI using echocardiography and left ventricular global longitudinal strain (LVGLS). Methods: A total of 95 patients were included in this study. Echocardiography and LVGLS were evaluated at baseline and follow-up (at 3 and 6 months of chemotherapy) and compared with the doxorubicin (Dox; n = 73) and concomitant ICI with doxorubicin (Dox-ICI; n = 22) groups. Cancer therapy-related cardiac dysfunction (CTRCD) was defined as a left ventricular ejection fraction (LVEF) drop of >10% and LVEF of <50% (definite CTRCD), LVEF drop of >10%, LVEF of ≥50%, and LVGLS relative reduction of >15% (probable CTRCD) at six months. Results: There were no significant differences in age, cumulative dose of doxorubicin, and cardiovascular risk factors between the two groups. At baseline, the LVEF was similar in the Dox and Dox-ICI groups (p = 0.493). In the Dox group, LVEF decreased to 59 ± 6% (Δ −7 ± 1.3%, p < 0.001) and LVGLS decreased from −17.3 ± 3.2% to −15.4 ± 3.2% (Δ −10.1 ± −1.9%, p < 0.001) at six months. In the Dox-ICI group, LVEF decreased to 55 ± 9% (Δ −9 ± 2.1%, p < 0.001), along with a significant decrease in LVGLS (from −18.6 ± 1.9% to −15.3 ± 3.6%, Δ −12.4 ± −2.4%, p < 0.001). Over a median follow-up of 192 days, there were no cases with clinical manifestations of fulminant myocarditis. In the Dox group, definite and probable CTRCD were observed in seven (10.1%) and five (7.4%) patients, respectively. In the Dox-ICI group, definite and probable CTRCD were observed in four (19%) and four (19%) patients, respectively. The total number of patients who developed CTRCD was significantly higher in the Dox-ICI group than in the Dox group (38.1% vs. 17.4%, p = 0.042). Serum troponin-T level was significantly higher in the Dox-ICI group than in the Dox group (53.3 vs. 27.5 pg/mL, p = 0.023). Conclusions: ICIs may increase the risk of CTRCD when used with cardiotoxic agents. CTRCD should be monitored in patients treated with ICIs by cardiac biomarkers and echocardiography, including LV-GLS.

Noninvasive Aortic Ultrafast Pulse Wave Velocity Associated With Framingham Risk Model: in vivo Feasibility Study

Background

Aortic pulse wave velocity (PWV) enables the direct assessment of aortic stiffness, which is an independent risk factor of cardiovascular (CV) events. The aim of this study is to evaluate the association between aortic PWV and CV risk model classified into three groups based on the Framingham risk score (FRS), i.e., low-risk (&lt;10%), intermediate-risk (10~20%) and high-risk (&gt;20%).

Methods

To noninvasively estimate local PWV in an abdominal aorta, a high-spatiotemporal resolution PWV measurement method (&gt;1 kHz) based on wide field-of-view ultrafast curved array imaging (ufcPWV) is proposed. In the ufcPWV measurement, a new aortic wall motion tracking algorithm based on adaptive reference frame update is performed to compensate errors from temporally accumulated out-of-plane motion. In addition, an aortic pressure waveform is simultaneously measured by applanation tonometry, and a theoretical PWV based on the Bramwell-Hill model (bhPWV) is derived. A total of 69 subjects (aged 23–86 years) according to the CV risk model were enrolled and examined with abdominal ultrasound scan.

Results

The ufcPWV was significantly correlated with bhPWV (r = 0.847, p &lt; 0.01), and it showed a statistically significant difference between low- and intermediate-risk groups (5.3 ± 1.1 vs. 8.3 ± 3.1 m/s, p &lt; 0.01), and low- and high-risk groups (5.3 ± 1.1 vs. 10.8 ± 2.5 m/s, p &lt; 0.01) while there is no significant difference between intermediate- and high-risk groups (8.3 ± 3.1 vs. 10.8 ± 2.5 m/s, p = 0.121). Moreover, it showed a significant difference between two evaluation groups [low- (&lt;10%) vs. higher-risk group (≥10%)] (5.3 ± 1.1 vs. 9.4 ± 3.1 m/s, p &lt; 0.01) when the intermediate- and high-risk groups were merged into a higher-risk group.

Conclusion

This feasibility study based on CV risk model demonstrated that the aortic ufcPWV measurement has the potential to be a new approach to overcome the limitations of conventional systemic measurement methods in the assessment of aortic stiffness.

Mitral and Aortic Regurgitation in Patients Undergoing Kidney Transplantation: The Natural Course and Factors Associated With Progression

Background

Valve regurgitation can decrease with resolution of hemodynamic loads on the left ventricle (LV) after kidney transplantation (KT). We aimed to investigate the natural course of left-side valve regurgitation after KT and factors associated with progression.

Methods

Among patients who underwent KT in two tertiary centers, 430 (224 men, mean age 50 ± 13 years) were examined by echocardiography within 3 months before KT and between 6 and 36 months after KT. Mitral regurgitation (MR) and aortic regurgitation (AR) were graded according to the current guidelines. Regression was defined as a decrease in regurgitation by one or more steps, and progression was an increase in one or more steps after KT. Clinical and echocardiographic factors associated with progression of MR and AR were analyzed.

Results

Mild or greater MR was observed in 216 (50%) patients before KT, and mild or greater AR was observed in 99 (23%). During the follow-up period of 23.4 ± 9.9 months, most patients experienced regression or no change in regurgitation after KT, but 34 patients (7.9%) showed MR progression and 37 (8.6%) revealed AR progression. Patients who showed MR progression were more likely to receive a second KT, have mitral annular calcifications, and show a smaller decrease in LV end-systolic dimension. Patients who showed AR progression were more likely to have persistent hypertension after KT, aortic valve calcifications, and a smaller reduction of LV end-systolic dimension.

Conclusions

Risk factors for progression of MR after KT include a second KT, MAC and a smaller decrease in LV end-systolic dimension after KT. Risk factors for progression of AR include valve calcification, persistent hypertension and a smaller decrease in LV end-systolic dimension after KT. Further echocardiographic surveillance and risk factor management after KT are warranted in these patients.

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.

The impact of cardiopulmonary exercise-derived scoring on prediction of cardio-cerebral outcome in hypertrophic cardiomyopathy

Background

Sudden cardiac death (SCD) and stroke-related events accompanied by atrial fibrillation (AF) can affect morbidity and mortality in hypertrophic cardiomyopathy (HCM). This study sought to evaluate a scoring system predicting cardio-cerebral events in HCM patients using cardiopulmonary exercise testing (CPET).

Methods

We investigated the role of a previous prediction model based on CPET, the HYPertrophic Exercise-derived Risk score for Heart Failure-related events (HyperHF), which is derived from peak circulatory power ventilatory efficiency and left atrial diameter (LAD), for predicting a composite of SCD-related (SCD, serious ventricular arrhythmia, death from cardiac cause, heart failure admission) and stroke-related (new-onset AF, acute stroke) events. The Novel HyperHF risk model using left atrial volume index (LAVI) instead of LAD was proposed and compared with the previous HCM Risk-SCD model.

Results

A total of 295 consecutive HCM patients (age 59.9±13.2, 71.2% male) who underwent CPET was included in the present study. During a median follow-up of 742 days (interquartile range 384–1047 days), 29 patients (9.8%) experienced an event (SCD-related event: 14 patients (4.7%); stroke-related event: 17 patients (5.8%)). The previous model for SCD risk score showed fair prediction ability (AUC of HCM Risk-SCD 0.670, p = 0.002; AUC of HyperHF 0.691, p = 0.001). However, the prediction power of Novel HyperHF showed the highest value among the models (AUC of Novel HyperHF 0.717, p<0.001).

Conclusions

Both conventional HCM Risk-SCD score and CPET-derived HyperHF score were useful for prediction of overall risk of SCD-related and stroke-related events in HCM. Novel HyperHF score using LAVI could be utilized for a better prediction power.

Predictors of Subsequent Heart Failure After Left Atrial Appendage Closure

BACKGROUND

Left atrial appendage occlusion (LAAO) plays an important role in preventing stroke in patients with atrial fibrillation. However, LAAO may interact unfavorably with left atrial (LA) compliance and reservoir function and thus increase the risk of heart failure (HF). The purpose of this study was to identify predictors of subsequent HF after successful LAAO.Methods and Results:A total of 98 patients (mean age 70±9 years, 68% male) who had undergone LAAO were included. The primary endpoint was unexpected HF admission after LAAO. During a mean period of 36±26 months, 16 of the 98 patients (16%) experienced hospital HF admission. In multivariate analysis, higher E/e' (hazard ratio [HR] 1.11, 95% confidence interval [CI] 1.02-1.20, P=0.014), higher left ventricular mass index (HR 1.02, 95% CI 1.00-1.03, P=0.023), history of HF (HR 4.78, 95% CI 1.55-14.7, P=0.006), and lower LA strain (HR 0.80, 95% CI 0.70-0.93, P=0.003) were independently associated with hospital HF admission. Patients with LAAO had a significantly higher incidence of subsequent HF than the control group after propensity score matching (P=0.046).

CONCLUSIONS

LAAO increases the occurrence of HF, and it is not uncommon after successful LAAO. A previous history of HF, left ventricular mass index, E/e', and abnormal LA strain are independently associated with the development of HF. These parameters should be considered before attempting LAAO.

Temporal Trends in Diagnosis, Treatments, and Outcomes in Patients With Bicuspid Aortic Valve

Background: The population is aging and advances in multimodal imaging and transcatheter valve intervention have been prominent in the past two decades. This study investigated temporal trends in demographic characteristics, use of multimodal imaging, treatments, and outcomes in patients with bicuspid aortic valve (BAV). Methods and Results: A total of 1,497 patients (male 71.7%, 57 ± 14 years old) first diagnosed with BAV between January 2003 and December 2020, in a single tertiary center were divided into three groups according to year of diagnosis: group 1 (2003-2008, n = 269), group 2 (2009-2014, n = 594), and group 3 (2015-2020, n = 634). The patients' demographic characteristics, comorbidities, BAV morphology, BAV function, BAV-related disease, use of multimodal diagnostic imaging, treatment modality for BAV, and clinical outcomes were compared among the three groups. The ages at diagnosis and at the time of surgery/intervention increased considerably from group 1 to 3. The patients' comorbidity index also increased progressively. The proportion of non-dysfunctional BAV and significant AS increased, while that of significant AR decreased. The frequency of infective endocarditis as an initial presentation significantly decreased over time. Additionally, the use of multimodal imaging increased markedly in the most recent group. The results also indicated increasing trends in the use of bioprosthetic valves and transcatheter aortic valve replacement. Overall and cardiovascular survival rates improved from group 1 to 3 (log rank p < 0.001). Conclusions: For the past two decades, remarkable temporal changes have occurred in patient characteristics, use of multimodal diagnostic imaging, choice of treatment modality, and clinical outcomes in patients with BAV.

Usefulness of cardiac magnetic resonance images for prediction of sudden cardiac arrest in patients with mitral valve prolapse: a multicenter retrospective cohort study

Background

An association has been identified between mitral valve prolapse (MVP) and sudden cardiac arrest (SCA), and ventricular arrhythmias (VA). This study aimed to elucidate predictive factors for SCA or VA in MVP patients.

Methods

MVP patients who underwent cardiac magnetic resonance (CMR) were retrospectively included. Patients with other structural heart disease or causes of aborted SCA were excluded. Clinical characteristics (sex, age, body mass index, histories of diabetes, hypertension, and dyslipidemia) and electrocardiographic (PR interval, QRS duration, corrected QT interval, inverted T wave in the inferior leads, bundle branch block, and atrial fibrillation), echocardiographic [mitral regurgitation grade, prolapsing mitral leaflet, and right ventricular systolic pressure (RVSP)], and CMR [left atrial volume index, both ventricular ejection fractions, both ventricular end-diastolic and systolic volume indexes, prolapse distance, mitral annular disjunction, systolic curling motion, presence of late gadolinium enhancement (LGE), LGE volume and proportion] parameters were analyzed.

Results

Of the 85 patients [age, 54.0 (41.0–65.0) years; 46 men], seven experienced SCA or VA. Younger age and wide QRS complex were observed more often in the SCA/VA group than in the no-SCA/VA group. The SCA/VA group exhibited lower RVSP, more systolic curling motion and LGE, greater LGE volume, and higher LGE proportion. The presence of LGE [hazard ratio (HR), 19.8; 95% confidence interval (CI) 2.65–148.15; P = 0.004], LGE volume (HR 1.08; 95% CI 1.02–1.14; P = 0.006) and LGE proportion (HR 1.32; 95% CI 1.08–1.60; P = 0.006) were independently associated with higher risk of SCA or VA in MVP patients together with systolic curling motion in each model.

Conclusions

The presence of systolic curling motion, high LGE volume and proportion, and the presence of LGE on CMR were independent predictive factors for SCA or VA in MVP patients.

Sex Differences in Mitral Annular Calcification and the Clinical Implications

Background: Heterogeneous mechanisms may contribute to the occurrence of mitral annular calcification (MAC), however, little is known about the sex differences in MAC and the clinical implications of these differences. This study aimed to investigate clinical and imaging differences of MAC according to sex.

Methods: In total, 537 patients (221 men) with MAC were identified by transthoracic echocardiography at a single center from January 2012 to June 2016. Moderate-to-severe MAC was defined as calcification extent ≥120° of the mitral annulus. Significant functional mitral stenosis (MS) was defined as a transmitral mean diastolic pressure gradient ≥5 mmHg.

Results: Women more frequently had moderate-to-severe MAC and concomitant mitral regurgitation than men; however, significant functional MS was comparable between sexes. In the logistic regression analysis, old age, uncontrolled hypertension, end-stage renal disease (ESRD), and obstructive hypertrophic cardiomyopathy were significantly associated with moderate-to-severe MAC in women, whereas ESRD and moderate-to-severe aortic stenosis were in men. In the Cox regression analysis, significant functional MS was associated with all-cause death in both sexes, although an independent association was found in only women.

Conclusion: Women had more extended MAC than men. Significant functional MS was independently associated with unfavorable clinical outcomes in patients with MAC, which was more pronounced in women than in men.

Transcatheter Aortic Valve Replacement with Minimal Contrast Dye in Patients with Renal Insufficiency

PURPOSE

Concerns have been consistently raised in regards to the considerable amount of contrast dye used during transcatheter aortic valve replacement (TAVR) in patients with renal insufficiency. In the present study, we introduced minimal contrast TAVR and compared its 30-day clinical outcomes with conventional TAVR.

MATERIALS AND METHODS

We retrospectively investigated 369 patients who underwent TAVR between July 2011 and April 2020 in our institute. Among them, 93 patients with severe aortic stenosis and renal insufficiency (estimated glomerular filtration rate ≤50 mL/min/1.73 m²) were included and divided into a conventional TAVR group (n=56) and a minimal contrast TAVR group (n=37). In the minimal contrast TAVR group, the total amount of contrast was <10 mL during the entire TAVR procedure. Thirty-day major adverse clinical events (MACE), including death, stroke, implantation of permanent pacemaker, and initiation of hemodialysis, were investigated.

RESULTS

The incidence of MACE was significantly lower in the minimal contrast TAVR group than the conventional TAVR group (16.2% vs. 42.9%, p=0.010). Death occurred in 9 patients (16.1%) in the conventional TAVR group and in 0 patients in the minimal contrast group (p=0.011). Hemodialysis was initiated in 2 patients (5.4%) in the minimal contrast TAVR group and in 7 patients (12.5%) in the conventional TAVR group (p=0.256). Multivariate regression analysis showed that the minimal contrast TAVR procedure was an independent predictor for reducing MACE (hazard ratio 0.208, 95% confidence interval: 0.080-0.541, p=0.001).

CONCLUSION

Minimal contrast TAVR is feasible and shows more favorable short-term clinical outcomes than conventional TAVR in patients with renal insufficiency.

Differential characteristics associated with progression of mitral and aortic regurgitation in patients undergoing kidney transplantation

Background

Heart valve regurgitation is common in patients with end-stage renal disease (ESRD). However, there are no data on the fate of mitral regurgitation (MR) and aortic regurgitation (AR) after kidney transplantation (KT). In this study, we sought to investigate regression or progression rates of MR and AR after KT in patients with ESRD. Moreover, we aimed to explore clinical and echocardiographic factors associated with the progression of MR and AR in patients undergoing KT.

Methods

Among 1,734 patients who underwent KT from 2005 to 2018 at a single tertiary hospital, 674 patients (407 men; mean 48±12 years) who underwent both pre- and post-KT echocardiography were analyzed comprehensively. Pre-KT echocardiography was performed within three months of KT, and post-KT echocardiography was done between 6 months and 24 months after KT. Severities of MR and AR were graded as no/trivial, mild, moderate, and severe according to the current guidelines. Regression was defined if the severity decreased by one or more grades, while progression was defined if the severity increased by one or more grades.

Results

Figure 1 shows the regression or progression of MR and AR after KT. 78 (11%) patients showed MR regression, but 41 (6%) experienced MR progression. 13 (2%) revealed AR regression, while 23 (4%) presented AR progression. In patients with MR progression, there were more cases of receiving a second KT, having mitral annular calcification, and showing lesser reduction of left atrial volume after KT. Patients with AR progression showed a longer hemodialysis duration, persistent hypertension after KT, and aortic root dilatation. Factors related to the progression of MR and AR showed statistically meaningful predictive values in a stepwise manner (Figure 2)

Conclusions

In patients undergoing KT, MR and AR may progress in patients with certain distinct characteristics. Different clinical and echocardiographic characteristics before KT, and reduction of hemodynamic loads after KT determine the progression of MR and AR. Further echocardiographic surveillances after KT are needed in patients with clinical and echocardiographic factors for progression of valve regurgitation.

Funding Acknowledgement

Type of funding sources: None.

Factors determining mitral valve dysfunction in patients who underwent surgical mitral valve replacement with bio-prosthetic valves

Background

There is increasing Interest in bio-prosthetic MVD as recent advances in transcatheter MV interventions, but there is limited data.

Objectives

The aim of this study was to identify the factors determining mitral valve (MV) dysfunction (MVD) in patients who underwent MV replacement with bio-prosthetic valves. Also, we sought to investigate clinical outcomes in patients with bio-prosthetic MVD.

Methods

A total of 233 patients underwent surgical bio-prosthetic MV replacement between June 1996 and May 2015. Finally, 226 patients (mean age 66.9±11.5 years, 74.3% of women) were analyzed, excluding patients who followed-up for less than 5 years and patients whose baseline or follow-up echocardiography could not be analyzed. Clinical, echocardiographic, and laboratory data were collected early after the surgery and during follow-up. MVD was defined as an increase in mean gradient ≥5 mmHg with leaflet motion limitation and/or newly developed MV regurgitation during follow-up. Clinical outcome was defined as a composite of cardiovascular death, redo MV surgery or intervention, and hospitalization for heart failure.

Results

During a median of 102.0 months (interquartile range 72.0 to 132.0 months), 65 patients (28.8%) revealed MVD. 8 (12.3%) patients revealed predominant MV obstruction, and 57 (87.7%) showed predominant MV regurgitation. Factors associated with bio-prosthetic MVD by multivariate regression analysis were young age at operation (hazard ratio 0.97, 95% CI 0.95–0.99, p=0.001), end-stage renal disease (hazard ratio 4.29, 95% CI 1.45–12.71, p=0.007), elevated mean diastolic pressure gradient&gt;5.5 mmHg across the bio-prosthetic MV early after operation (hazard ratio 1.86, 95% CI 0.97–3.74, p=0.063) and anemia after operation (hazard ratio 0.84, 95% CI 0.74–0.95, p=0.007). However, the presence of hypertension, dyslipidemia, or porcine bio-prosthesis was not related to the bio-prosthetic MVD. Kaplan-Meier curves revealed significant differences in event-free survivals for the occurrence of bio-prosthetic MVD according to each factor (Figure 1). Patients with bio-prosthetic MVD showed significantly poor clinical outcomes compared with those without bio-prosthetic MVD (event-free survival 43.1% vs. 91.9%, log-rank p&lt;0.001) during the follow-up.

Conclusions

Young age at operation, end-stage renal disease, elevated mean pressure gradient early after the operation, and anemia after operation were associated with bio-prosthetic MVD in patients who underwent bio-prosthetic MV replacement.

Funding Acknowledgement

Type of funding sources: None.

Transcatheter Aortic Valve Replacement versus Sutureless Aortic Valve Replacement: A Single Center Retrospective Cohort Study

PURPOSE

This study sought to compare clinical outcomes between transcatheter aortic valve replacement (TAVR) and sutureless aortic valve replacement (SU-AVR).

MATERIALS AND METHODS

In total, 320 patients with symptomatic severe aortic stenosis who underwent TAVR (n=254) or SU-AVR (n=66) at Severance Cardiovascular Hospital between July 2011 and September 2019 were included for analysis. Propensity score matching and inverse probability weighted adjustment were performed to adjust for confounding baseline characteristics. Outcomes defined by the Valve Academic Research Consortium-2 in 62 patients pairs were compared.

RESULTS

Device success (79.0% vs. 79.0%, p>0.999) and 30-day mortality (4.8% vs. 0.0%, p=0.244) did not differ between the TAVR and SU-AVR groups. The TAVR group developed more frequent mild or moderate paravalvular leakage (59.7% vs. 8.1%, p<0.001), whereas SU-AVR was associated with higher rates of major or life-threatening bleeding (9.7% vs. 22.6%, p=0.040), acute kidney injury (8.1% vs. 21.0%, p=0.041), and new-onset atrial fibrillation (4.8% vs. 32.3%. p<0.001) at 30 days, along with longer stays in the intensive care unit (ICU) (1.9±1.6 days vs. 5.9±9.2 days, p=0.009) and hospital (7.1±7.9 days vs. 13.1±8.8 days, p<0.001). The TAVR group showed a trend towards a higher 1-year all-cause mortality, compared with the SU-AVR group (7.0% vs 1.7%, p=0.149). Cardiovascular mortality, however, did not differ significantly (1.6% vs 1.7%, p=0.960).

CONCLUSION

TAVR achieved a similar 1-year survival rate free from cardiovascular mortality as SU-AVR and was associated with a lower incidence of complications, except for paravalvular leakage, and shorter stays in the ICU and hospital.

Early percutaneous mitral commissurotomy or conventional management for asymptomatic mitral stenosis: a randomised clinical trial

OBJECTIVE

The decision to perform percutaneous mitral commissurotomy (PMC) on asymptomatic patients requires careful weighing of the potential benefits against the risks of PMC, and we conducted a multicentre, randomised trial to compare long-term outcomes of early PMC and conventional treatment in asymptomatic, severe mitral stenosis (MS).

METHODS

We randomly assigned asymptomatic patients with severe MS (defined as mitral valve area between 1.0 and 1.5 cm²) to early PMC (84 patients) or to conventional treatment (83 patients). The primary endpoint was a composite of major cardiovascular events, including PMC-related complications, cardiovascular mortality, cerebral infarction and systemic thromboembolic events. The secondary endpoints were death from any cause and mitral valve (MV) replacement during follow-up.

RESULTS

In the early PMC group, there were no PMC-related complications. During the median follow-up of 6.4 years, the composite primary endpoint occurred in seven patients in the early PMC group (8.3%) and in nine patients in the conventional treatment group (10.8%) (HR 0.77; 95% CI 0.29 to 2.07; p=0.61). Death from any cause occurred in four patients in the early PMC group (4.8%) and three patients in the conventional treatment group (3.6%) (HR 1.30; 95% CI 0.29 to 5.77). Ten patients (11.9%) in the early PMC group and 17 patients (20.5%) in the conventional treatment group underwent MV replacement (HR 0.59; 95% CI 0.27 to 1.29).

CONCLUSIONS

Compared with conventional treatment, early PMC did not significantly reduce the incidence of cardiovascular events among asymptomatic patients with severe MS during the median follow-up of 6 years.

TRIAL REGISTRATION NUMBER

NCT01406353.