Usefullness of peak mitral regurgitation velocity to left ventricular outflow tract time velocity integral ratio as a new prognostic marker for one year and long term mortality in failing heart

Background and aim

Systemic vascular resistance (SVR) is useful for risk estimation and therapy guidance in HF. It has been showed that the ratio of peak mitral regurgitation velocity (MRV) to left ventricular outflow tract velocity-time integral (LVOT VTI) correlated positively with SVR. We aimed to assess the association of MRV/LVOT VTI ratio with established prognostic markers and its prognostic role for predicting one year and long term composite end-points in patients with HF and reduced ejection fraction (HFrEF).

Material and methods

We prospectively enrolled a total of 72 patients with HFrEF and 10 control subjects. Patients were followed up patients for median 40.5 months. Primary composite endpoint (CEP) was defined as any of these outcomes including requiring mechanical circulatory support, cardiac transplantation and all-cause mortality.

Results

CEP(+) patients had higher MRV/LVOT VTI ratio than others (0.48±0.15 vs. 0.39±0.18 p=0.012). MRV/LVOT VTI ratio was positively correlated with functional status (β=0.539, p=0<001), serum BNP level (β=0.479, p<0.001),troponin I (β=0.415, p<0.001), and Uric acid level (β=0.235 p=0.018) and negatively correlated with SEATTLE score derived life expectancy (β=−0.248, p=0.032). Adjusted with other parameters, every 0.1 increase in MRV/LVOT VTI ratio increased the one-year CEP risk by 27% and long-term CEP risk by 24.6%. In Kaplan Meier analysis, patients with MRV/LVOTVTI ratio ≥0.39 had more long-term CEP compared to others.

Conclusion

MRV/LVOT VTI ratio seemed to be useful predictor of poor prognosis associated with other established HF prognostic markers.

Figure 1

Funding Acknowledgement

Type of funding source: None

Coronary sinus diameter to inferior vena cava diameter ratio in the diagnosis of cardiac tamponade: a novel approach

Background and aim

Coronary sinus (CS) as an intrapericardial, low-pressure, thin-walled structure can be easily compressed in cardiac tamponade. Whereas, inferior vena cava (IVC) is an extrapericardial structure which dilates in tamponade as opposed to the response of CS. The inverse relationship between these two venous structures may augment their role in the evaluation of tamponade imaging. Therefore, we assessed the usefullness of computerized tomographic measures of CS diameter, and also CS to IVC ratio (CS/IVC) to predict tamponade in clinically stable patients with large pericardial effusion.

Materials and methods

66 clinically stable patients who had large pericardial effusions, were included to the study. CS diameter was measured from the point at 1 cm proximal to the CS ostium11. IVC diameter was measured from the segment between its right atrial orifice and hepatic vein.

Results

Patients with tamponade had 40% smaller CS diameter (5.3±1.8 vs 8.8±2.6 mm p<0.001) and 35% lower CS/IVC ratio (20.7±5.5 vs 34.7±10.5% p<0.001).After adjusting with other parameters, only either CS diameter or CS/IVC ratio predicted tamponade respectively. (Nagelkerke r square value for CS diameter was 53.7% and 72.1% for CS/IVC ratio). 1 mm increase in CS diameter and 1% increase in CS/IVC ratio were associated with an increased odds ratio of 59% and 39% in predicting tamponade, respectively (p value <0.001).In ROC analysis, a cut of value of 6.85 mm for CS diameter, had 82.6% sensitivity and 83.7% specificity for predicting cardiac tamponade (Area under the curve 0.879, p<0.001). Additionally, a cut of value of 27% for CS / IVC ratio had 87.0% sensitivity and 86.0% specificity for predicting cardiac tamponade (Area under the curve 0.945, p<0.001).

Conclusion

The tomographic measures of both the CS diameter and the CS/IVC ratio predicted tamponade in clinically stable patients with large pericardial effusion. Compared with CS diameter, CS/IVC ratio seemed to be a more powerful predictor of tamponade

Figure 1

Funding Acknowledgement

Type of funding source: None

The Predictive Value of PRECISE-DAPT Score for the Thrombogenic Milieu in Left Atrium and Left Atrial Appendix in the Patients with Atrial Fibrillation Planned AF Ablation

Introduction and aim

Atrial fibrillation (AF) is the most common arrhythmia in the clinical practice. In AF patients, the assessment of thromboembolic risk and the initiation of anticoagulant therapy to appropriate patients play critical role in management of these patients. Current guidelines recommend to use CHA2DS2VASC score in evaluation of thromboembolic risk. However, the effectiveness of this score has been questioned recently. This situation requires new risk indicators. Although PRECISE-DAPT score was initially constituted to determine the duration of dual antiplatelet therapy in patients with PCI, current studies have reported that this score may also predict thrombotic events. In this study, we aimed to evaluate the effectiveness of PRECISE-DAPT score to predict thrombogenic milieu by comparing with CHA2DS2VASC score in non valvular AF patients whom referred TEE before AF ablation procedure.

Method

428 patients were included in the study. The presence of grade 2–3 SEC and thrombus in left atrium and/or left atrial appendage were accepted as thrombogenic milieu. The patients were divided into two groups according to the presence of thrombogenic milieu. In addition, we constituted three groups as grade 0–1 SEC group, grade 2–3 SEC group and thrombus group to evaluate the parameters in detail.

Results

Grade 2–3 SEC was found in 36 patients and thrombus was detected in 24 patients. 60 patients was included to the thrombogenic positive (artı) group while 368 patients was included to thrombogenic milieu (−) group. PRECISE-DAPT and CHA2DS2VASC scores were higher in thrombogenic positive (artı) group In multivariate logistic regression analysis, PRECISE-DAPT score was found to be an independent predictor of thrombogenic milieu (OR: 1.145, CI:1.083–1.211, p<0,001). The comparison of ROC curves was shown that PRECISE DAPT score was higher area under curve than CHA2DS2VASC score, 0,753 and 0,649 respectively.

Conclusion

In our study, in patients performed TEE before AF ablation, PRECISE-DAPT score was found to be an independent predictor for thrombogenic milieu presented as high grade SEC and thrombus, there by thromboembolic risk. PRECISE-DAPT score seems to be more effective than CHA2DS2VASC score. In AF patients, PRECISE-DAPT score may provide additional benefit in assessment of thromboembolic risk, thus enabling a more individual and accurate anticoagulation decision in these patients.

Funding Acknowledgement

Type of funding source: None

P3533The other side of the medallion in heart failure: Reverse Metabolic Syndrome

Background

As a risk factor for developing heart failure, metabolic syndrome (MetS) is associated with a reduced heart failure mortality. This paradox is also seen in most of the chronic diseases and also in the elderly population. Parameter changes representing the deteriarion of the balance in favor of catabolism including the low body mass index (BMI) and low blood pressure as well as low blood cholesterol have been associated with poor prognosis in several populations. Apart from high-density lipoprotein, which is further decreased, inverted changes in the components of MetS have been seen in heart failure population which led to the introduction of the concept of the “reverse metabolic syndrome” (RMetS).

Purpose

We aimed to investigate the effect of MetS and RMetS on hemodynamic parameters and long-term prognosis in patients with heart failure and reduced ejection fraction (HFrEF).

Methods

400 consecutive patients who were followed with HFrEF and performed right heart catheterization were examined. 96 patients with cardiac cachexia and morbid obesity were excluded and the remaining 304 patients with BMI 18–40 kg/m2 were included. The presence of MetS is defined according to the NCEP-ATP III criteria. RMetS was accepted as having BMI <22 kg/m2 with total cholesterol level <160 mg/dL and/or systolic or diastolic blood pressures <110 mmHg and <70 mmHg respectively. Composite endpoint (CEP) was defined as either of the occurrence of all-cause mortality, assist device implantation or cardiac transplantation. Endpoints were analyzed in two step approach: first we grouped patients accoding to the presence of MetS, then we added the RMetS category and stratifed patients into three groups as metabolic syndrome, reverse metabolic syndrome and metabolic healthy

Results

304 patients were followed up for a median of 16 (0–48) months. 110 patients had all-cause mortality and 148 patients had CEP. In the first step, patients with MetS (110 patients) had reduced all-cause mortality and CEP than patients without MetS (194 patients). In the second step, RMetS group had the highest all-cause mortality and CEP (chi-square: 22.187 p<0.001 and chi-square: 30.980, p<0.001, respectively) Cardiac output, cardiac index were lower and PCWP was higher in RMetS group. The endpoints were similar between MetS group and metabolically healthy patients.

Conclusion

Although individuals with MetS seem to have a better prognosis than patients without MetS, the latter group contains RMetS population, which had the poorest prognosis. This population may contribute to the false- assumption of the relative better findings of MetS population with regard to the non-MetS population. Further clinical studies are needed to clarify this pathologic phenomenon.

Right ventricular outflow tract function in chronic obstructive pulmonary disease

BACKGROUND

It is clinically important to evaluate the severity of right ventricular (RV) overload in patients with chronic obstructive pulmonary disease (COPD), which is often associated with changes in the structure and the function of the right ventricle. Noninvasive and reliable assessment of RV function would be an essential determinant of RV load and a clinically useful factor for assessing cardiovascular risk in COPD patients.

OBJECTIVE

The aim of this study was to investigate the clinical application value of right ventricular outflow tract (RVOT) systolic function measured by transthoracic echocardiography in patients with COPD.

PATIENTS AND METHODS

We prospectively investigated COPD male patients and compared them with healthy controls. In addition to RV conventional echocardiographic parameters, RVOT size and fractional shortening (RVOT-FS) parameters were also assessed.

RESULTS

Fifty-five COPD patients (all men; mean age, 62 ± 9 years) participated in the study, and were compared with a control group consisting of 21male, healthy, nonsmoking subjects with a mean age of 58 ± 11 years. The RVOT-FS was impaired in COPD patients than healthy controls (27.8 ± 15.5 vs. 57.5 ± 8.6, p < 0.001), and was correlated positively with tricuspid annular plane systolic excursion (TAPSE; r = 0.583, p < 0.001) and pulmonary acceleration time (r = 0.666, p < 0.001) and inversely with pulmonary artery systolic pressure (r = 0.605, p < 0.001) and functional capacity(r = - 0.589, p < 0.001). There was a statistically significant difference in RVOT-FS among the COPD subgroups with regard to New York Heart Association functional classification (p < 0.001).

CONCLUSION

The RVOT-FS is a noninvasive easily applicable measure of RV systolic function and is well correlated with functional capacity in COPD patients. Its combination with long-axis measurements via TAPSE and transtricuspid Doppler analysis may provide a comprehensive evaluation of the RV performance in COPD patients.

Brugada-like early repolarisation pattern associated with acute pericarditis

Two cases of acute pericarditis presented with interesting electrocardiograms resembling Brugada-like or early repolarisation patterns. This report emphasises that proper interpretation of the electrocardiogram in patients with ST-segment elevation assists the clinician in arriving at the correct diagnosis in making appropriate diagnostic and therapeutic decisions, and also that the saddleback-type ST-segment elevation cannot be a sensitive finding for the Brugada syndrome.