Stroke volume index and transvalvular flow rate trajectories in severe aortic stenosis treated with TAVR

AIMS

The prognostic impact of flow trajectories according to stroke volume index (SVi) and transvalvular flow rate (FR) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) remains poorly assessed. We evaluated and compared SVi and FR prior and after TAVR for severe AS.

METHODS AND RESULTS

Patients were categorized according to SVi (<35 mL/m2) and FR (<200 mL/s). The association of pre- and post-TAVR SVi and FR with all-cause mortality up to 3 years was assessed with multivariable Cox regression models. Among 980 patients with pre-TAVR flow assessment, SVi was reduced in 41.3% and FR in 48.1%. Baseline flow status was not an independent mortality predictor [SVi: hazard ratio (HR) 1.22, 95% confidence interval (CI) 0.85-1.82, FR: HR 0.78, 95% CI 0.48-1.27]. Among 731 patients undergoing early (5 days, interquartile range 2-29) post-TAVR flow assessment, SVi recovered in 40.1% and FR in 49.0% patients with baseline low flow. Reduced FR following TAVR was an independent predictor of mortality (HR 1.67, 95% CI 1.02-2.74), whereas SVi was not (HR 0.97, 95% CI 0.53-1.78). Three-year estimated mortality in patients with recovered FR was lower than that in patients with reduced FR (13.3 vs. 37.7% vs, P = 0.003) and similar to that in patients with normal baseline FR (P = 0.317).

CONCLUSION

Baseline flow status was not an independent predictor of mid-term mortality among all-comers with severe AS undergoing TAVR. Flow recovery early after TAVR was frequent. Post-TAVR FR, but not SVi, was independently associated with mid-term all-cause mortality. By impacting flow status, AV replacement modifies the association of flow status with outcomes.

Relevance of subclinical right ventricular dysfunction measured by feature-tracking cardiac magnetic resonance in non-ischemic dilated cardiomyopathy

BACKGROUND

Right ventricular (RV) dysfunction in patients with non-ischemic dilated cardiomyopathy (NICM) is associated with cardiovascular events. To analyze the feasibility of assessing RV myocardial deformation by feature tracking (FT)-cardiac magnetic resonance (CMR), and its usefulness as a prognostic marker.

METHODS

Retrospective study of NICM patients undergoing CMR. Longitudinal FT-RV free wall (LFT-RVFW) and fractional area change (FAC) were obtained. Correlation with standard RV parameters was studied. An association with combined event (heart failure (HF), ICD implantation or cardiovascular death) was assessed using a logistic regression model.

RESULTS

98 patients (64 ± 13 years) were included. Left ventricular (LV) systolic function (LVEF 29.5 ± 9.6%, 47% with LVEF ≥ 30%) and RV (RVEF 52.2 ± 14.6%, 72% with RVEF ≥ 45%). Follow-up of 38 ± 17 months, 26.5% presented at least one admission for HF. An excellent correlation of LFT-RVFW (r = 0.82) and FAC (r = 0.83) with RVEF was evident. No association of RV-FT parameters with prognosis entire study population was found. However, in patients with LVEF ≥ 30%, admissions for HF were associated with lower LFT-RVFW (-21.6 ± 6.6% vs -31.3 ± 10%; p = 0.006) and FAC (36.6 ± 9.6% vs 50.5 ± 13.4%; p < 0.001) values. Similar differences were observed when only patients with RVEF ≥ 45% were considered. An LFT-RVFW cut-off point of -19.5% and FAC of 36.5% showed good prognostic performance. Decreased LFT-RVFW or FAC represented an independent predictor of combined event in patients with LVEF ≥ 30%.

CONCLUSIONS

In NICM patients without severe LV dysfunction, decreased values of LFT-RVFW and/or FAC were associated with HF admissions, independently of RVEF.

Development of a new score to predict left ventricular reverse remodelling in patients with nonischemic cardiomyopathy

Background and purpose

Implantable cardioverter-defibrillator is indicated in patients with dilated non-ischemic cardiomyopathy (DCM) and severely depressed left ventricular ejection fraction (LVEF) after a wait-and-see period of 3–9 months under optimised medical therapy. However, in the first 6 months after the disease debut, around 2% of patients might suffer life-threatening arrhythmias.

The appearance of left ventricular reverse remodelling (LVRR) in patients with DCM is associated with a lower incidence of ventricular tachyarrhythmias. Therefore, it is relevant an early identification of the patients who will experience LVRR during the follow-up.

Our aim was to develop a score to predict the appearance of LVRR in patients with DCM.

Methods

From 2014 to 2021, 201 patients with DCM and LVEF ≤45% were prospectively evaluated in our tertiary care hospital. All patients underwent a transthoracic echocardiogram and 1.5 Tesla scanner cardiac magnetic resonance (MR) as part of the diagnostic workup. LVRR was defined as an increase in LVEF ≥10 points or absolute LVEF ≥50% associated with a reduction in left ventricular end-diastolic diameter ≥10%.

Results

The median age of our cohort (n=201) was 61.6 (14.7) years, and 68% were male. Most patients (&gt;90%) were treated with beta-blockers or RASS blockers, and 72% with mineralocorticoid receptor antagonists.

During a mean follow-up period of 37.6 (33.9) months 45% of patients had LVRR.

Patients with LVRR had a lower cardiovascular mortality (3.33 vs 9.59%; p=0.153), lower mortality due to heart failure (0% vs 8.22%; p=0.023), and a lower incidence of ventricular tachyarrhythmias (1.67% vs 19.18%; p=0.001).

Table 1 shows the echocardiographic, MR and clinical characteristics of patients who experienced LVRR.

Variables significantly associated with LVRR in the univariable analysis and considered clinically relevant were included in a multivariable logistic regression analysis. The final model included the presence of right ventricular end systolic volume index (RVESVi) &gt;50 ml/m2 (2 points), left bundle brach block (LBBB) echo pattern (1 point), female gender (1 point) and tachycardiomyopathy/idiopathic/alcoholic/chemotherapy induced cardiomyopathy as the potencial cause of DCM (1 point).

The score showed a good discrimination, with an area under the ROC curve of 0.82 (95% CI 0.69 to 0.94), 84% sensitivity and 80% specificity. The presence of 3 or more points was associated with a high probability to had LVRR (0 points: 1%; 1 points: 17%; 2 points: 38%; 3 points: 64%; 4 points: 84%%; 5 points: 94% and 6 points: 98%) (Figure 1).

Conclusion

A new score with four variables (RVESV, LBBB echo pattern, female gender and tachycardiomyopathy/idiopatic/alcoholic/chemotheapy induced cardiomyopathy as potential cause) accurately predicts the probability of LVRR. Considering patients who experience LVRR have less cardiovascular events, this score may be a helpful tool for patients' risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Global and regional left ventricular deformation evaluation with feature tracking in transthyretin cardiac amyloidosis. Comparison with echocardiographic findings

Background

Diagnosis of cardiac amyloidosis (CA) is basically based on imaging techniques. Transthoracic echocardiography (TTE) is crucial to raise suspicion of this disease through detection of the classical features. An specific left ventricular (LV) deformation pattern with apical sparing (“cherry on top”) has been described on speckle tracking (ST) TTE. However, there is no data regarding the role of the LV global and regional analysis with the new tool feature tracking (FT) of cardiac magnetic resonance (CMR) in CA.

Purpose

Our aim is to analyze the concordance of LV deformation between ST-TTE and FT-CMR.

Methods

Consecutive patients with definitive diagnosis of transthyretin (TTR) CA, based on DPD scintigraphy, and imaging evaluation with TTE and CMR were retrospectively included. LV volumes and ejection were calculated from both TTE and CMR following the ongoing recommendations. Global and segmental longitudinal strain values were obtained from apical 2-, 3- and 4-chambers projections on TTE, while the same parameters were calculated on the same cine views of CMR using a dedicated software of FT analysis. Student t-test was used to compared mean measurements derived from both imaging techniques. Apical index was calculated as the ratio between apical and basal-mid longitudinal values. Moreover, agreement was established using Passing-Bablok regression analysis.

Results

27 patients (80 years-old, 88% men) with definitive diagnosis of TTR CA from our tertiary hospital were included. Regarding echocardiographic findings, 80% showed concentric LV hypertrophy with low normal ejection fraction in the majority (52±10%). When longitudinal LV strain parameters were compared (Table 1), no differences were noted in global and apical values whereas basal and mid measurements were higher from CRM resulting in different apical indexes. Although 42% showed a typical “cherry on top” pattern in ST analysis, in only 18% of the FT apical sparing was detected. Consistently, decremental pattern was observed in 60% of TTE and in 20% of CMR. Concordance analysis with Passing-Bablok showed no constant or proportional differences, meaning both techniques were comparable.

Conclusions

Among patients with TTR CA there were no differences in global longitudinal LV strain analysis between ST-TTE and FT-CMR. Nevertheless, discordance in regional parameters resulted in a less frequent detection of apical sparing in CMR.

Funding Acknowledgement

Type of funding sources: None.

Impact of diabetes mellitus in non-ischemic dilated cardiomyopathy: focus on diastolic dysfunction

Introduction

In patients with diabetes mellitus (DM), the presence of myocardial dysfunction in the absence of coronary artery disease, valvular disease and other conventional cardiovascular risk factors has been defined as diabetic cardiomyopathy. Left ventricle concentric hypertrophy and myocardial fibrosis are the structural hallmarks that lead to overt diastolic dysfunction.

The impact of DM in imaging features and clinical outcomes of patients with non-ischaemic dilated cardiomyopathy (DCM) has not been completely elucidated yet.

Purpose

We aim to describe advance imaging and clinical characteristics of DCM's patients with DM, and its potential impact on cardiac morphology and function in comparison to non-diabetic patients.

Methods

From 2014 to 2021, all patients with DCM were prospectively evaluated in our tertiary care hospital.

All patients underwent a transthoracic echocardiogram and 165 patients underwent a 1.5 Tesla scanner cardiac magnetic resonance (CMR) as part of the diagnostic workup. Left ventricle ejection fraction (LVEF), mechanical dyssynchrony, and diastolic function were analyzed according to current guidelines. Late gadolinium enhancement (LGE) was assessed visually and its extent was calculated as the number of affected myocardial segments.

Heart failure (HF) hospitalizations, arrhythmic events and mortality were assessed during follow-up.

Results

The median age of our cohort (n=227) was 61.6 (14.7) years, 66% were male, and DM was present in 57 patients (25.1%). Mean follow-up was 37.6 (33.9) months. Diabetic patients were significantly older, more frequently male, and with more comorbidity. Left bundle branch block was more frequent in patients with DM. The use of SGLT2 inhibitors was higher in diabetic patients (47.4% vs 21.1%; p&lt;0.05). No significant differences were observed regarding other guideline-recommended HF drugs.

With regard to imaging features, no significant differences were found in LVEF and global longitudinal strain between the two groups. There was a trend toward a higher left ventricle mass index measured by CMR in diabetic patients (p=0.364). Parameters of mechanical dyssynchrony and diastolic dysfunction were worse in diabetic patients (Table 1). High-risk LGE pattern (defined as the presence of epicardial, transmural or septal plus free-wall LGE) was more frequently observed in the diabetes group (p&lt;0.05).

Finally, the diabetic group had a higher incidence of HF hospitalization (45.61% vs 22%, p&lt;0.001) and all-cause mortality (24.6% vs 11.8%, p&lt;0.05), as shown in Figure 1. There was also a trend toward a higher cardiovascular mortality (12.3% vs 6.5%, p=0.164) in this group.

Conclusion

DM confers a high-risk profile to DCM patients, explained by extracardiac (more comorbidities) and cardiac (more diastolic dysfunction and high-risk LGE pattern) reasons. These patients may benefit from a close monitoring, and new therapies should be developed to improve their prognosis.

Funding Acknowledgement

Type of funding sources: None.

Cardiac damage staging in patients undergoing TAVR. Incremental value of global longitudinal strain and right ventricular-arterial coupling

Background

Transcatheter aortic valve replacement (TAVR) is nowadays a safe and increasingly frequent option to treat severe aortic stenosis (AS). Cardiac damage staging has been proposed and validated in some studies as a prognostic tool; however, many patients continue to undergo aortic valve replacement only after there is evidence of cardiac damage. The aim of this study is to assess the potential incremental value of global longitudinal strain (GLS) and right ventricular-arterial coupling (RV-VAc) in the prognostic performance of the cardiac damage staging.

Methods

Consecutive patients with AS and undergoing TAVR were included in our hospital registry. Baseline echocardiography was performed before TAVR according to current guidelines. For this study, patients were classified based on the following stage of cardiac damage: Stage 0: no cardiac damage; Stage 1: left ventricular (LV) damage (LV ejection fraction (LVEF) &lt;50%, LV mass index &gt;95 g/m2 for women, &gt;115 g/m2 for men); Stage 2: left atrial (LA) or mitral valve damage (LA volume index &gt;34 ml/m2, mitral regurgitation moderate-severe, or presence of atrial fibrillation); Stage 3: pulmonary vasculature or tricuspid valve damage (systolic pulmonary artery pressure 60 mmHg, or tricuspid regurgitation moderate-severe); Stage 4: RV damage (TAPSE &lt;1.7 cm, S' &lt;9.5 cm/s).

Results

496 patients were studied. Mean age of the cohort was 81.9±6.2 years, mean aortic valve area was 0.86±0.6 cm2, mean LVEF was 57.9±12.3%, mean LV-GLS was −15.6±3.5% and RV-Vac was 0.61±0.34. Table 1 shows clinical and echo characteristics of patients. Only one patient (0.2%) met criteria for stage 0; 38 (7.7%) patients were in stage 1; 159 (32.1%) patients in stage 2, 157 (31.7%) patients in stage 3 and 141 (28.4%) patients in stage 4. 1-year mortality for stage 1 was (10.5%), for stage 2 (13.7%), for stage 3 (32.2%) and for stage 4 (19.5%). The area under the ROC curve (AUC) for 1-year mortality for the cardiac damage staging system was 0.622, CI (0.539–0.705); the best cut-off value for LV-GLS to predict 1-year mortality was −14% with an AUC of 0.634 CI (0.487–0.781) and RV-VAc had an AUC of 0.748 CI (0.638–858). Finally, the model that included the staging system, LV-GLS and RV-VAc had an AUC ROC of 0.875, CI (0.780–0.971) (Figure 1).

Conclusions

Cardiac damage staging is a good prognostic tool and it has been validated in several studies, however, the addition of feasible and widely available echo parameters such as LV-GLS and RV-VAc can significantly increase its prognostic yield.

Funding Acknowledgement

Type of funding sources: None.

Center Valve Preference and Outcomes of Transcatheter Aortic Valve Replacement: Insights From the AMTRAC Registry

BACKGROUND

Data on outcomes of transcatheter aortic valve replacement (TAVR) using balloon-expandable valves (BEVs) or self-expandable valves (SEVs) as well as the impact of center valve preference on these outcomes are limited.

OBJECTIVES

The aim of this study was to compare outcomes of TAVR procedures using third-generation BEVs and SEVs stratified by center valve preference.

METHODS

In a multicenter registry (n = 17), 13 centers exhibited valve preference (66.6%-90% of volume) and were included. Outcomes were compared between BEVs and SEVs stratified by center valve preference.

RESULTS

In total, 7,528 TAVR procedures (3,854 with SEVs and 3,674 with BEVs) were included. The mean age was 81 years, and the mean Society of Thoracic Surgeons score was 5.2. Baseline characteristics were similar between BEVs and SEVs. Need for pacemaker implantation was higher with SEVs at BEV- and SEV-dominant centers (17.8% vs 9.3% [P < 0.001] and 12.7% vs 10.0% [P = 0.036], respectively; HR: 1.51; P for interaction = 0.021), risk for cerebrovascular accident was higher with SEVs at BEV-dominant but not SEV-dominant centers (3.6% vs 1.1% [P < 0.001] and 2.2% vs 1.4% [P = 0.162]; HR: 2.08; P for interaction < 0.01). Aortic regurgitation greater than mild was more frequent with SEVs at BEV-dominant centers and similar with BEVs regardless of center dominance (5.2% vs 2.8% [P < 0.001] and 3.4% vs 3.7% [P = 0.504], respectively). Two-year mortality was higher with SEVs at BEV-dominant centers but not at SEV-dominant centers (21.9% vs 16.9% [P = 0.021] and 16.8% vs 16.5% [P = 0.642], respectively; HR: 1.20; P for interaction = 0.032).

CONCLUSIONS

Periprocedural outcomes, aortic regurgitation greater than mild, and 2-year mortality are worse when TAVR is performed using SEVs at BEV-dominant centers. Outcomes are similar regardless of valve type at SEV-dominant centers. The present results stress the need to account for this factor when comparing BEV and SEV outcomes. (The Aortic+Mitral Transcatheter [AMTRAC] Valve Registry; NCT04031274).

Mitochondrial Oxidative Stress Promotes Cardiac Remodeling in Myocardial Infarction through the Activation of Endoplasmic Reticulum Stress

We have evaluated cardiac function and fibrosis in infarcted male Wistar rats treated with MitoQ (50 mg/kg/day) or vehicle for 4 weeks. A cohort of patients admitted with a first episode of acute MI were also analyzed with cardiac magnetic resonance and T1 mapping during admission and at a 12-month follow-up. Infarcted animals presented cardiac hypertrophy and a reduction in the left ventricular ejection fraction (LVEF) and E- and A-waves (E/A) ratio when compared to controls. Myocardial infarction (MI) rats also showed cardiac fibrosis and endoplasmic reticulum (ER) stress activation. Binding immunoglobulin protein (BiP) levels, a marker of ER stress, were correlated with collagen I levels. MitoQ reduced oxidative stress and prevented all these changes without affecting the infarct size. The LVEF and E/A ratio in patients with MI were 57.6 ± 7.9% and 0.96 ± 0.34, respectively. No major changes in cardiac function, extracellular volume fraction (ECV), or LV mass were observed at follow-up. Interestingly, the myeloperoxidase (MPO) levels were associated with the ECV in basal conditions. BiP staining and collagen content were also higher in cardiac samples from autopsies of patients who had suffered an MI than in those who had died from other causes. These results show the interactions between mitochondrial oxidative stress and ER stress, which can result in the development of diffuse fibrosis in the context of MI.

Prognostic implications of impaired longitudinal left ventricular systolic function assessed by tissue Doppler imaging prior to transcatheter aortic valve implantation for severe aortic stenosis

Change in longitudinal left ventricular (LV) systolic function serves as an early marker of the deleterious effect of aortic stenosis (AS) and other cardiac comorbidities on cardiac function. We explored the prognostic value of tissue Doppler imaging (TDI)-derived longitudinal LV systolic function, defined by the peak systolic average of lateral and septal mitral annular velocities (average S') among symptomatic patients with severe AS undergoing transcatheter aortic valve implantation (TAVI). 297 consecutive patients with severe AS undergoing TAVI at three european centers with available average S' at preprocedural echocardiography were retrospectively included. The primary endpoint was the Kaplan Meier estimate of all-cause mortality. After a median 18 months (IQR 12-18) follow-up, 36 (12.1%) patients had died. Average S' was associated with all-cause mortality (per 1 cm/sec decrease: HR 1.29, 95%CI 1.03-1.60, p = 0.025), the cut-off of 6.5 cm/sec being the most accurate. Patients with average S' < 6.5 cm/sec (55.2%) presented characteristics of more advanced LV remodeling and functional impairment along with higher burden of cardiac comorbidities, and experienced higher all-cause mortality (17.6% vs. 7.5%, p = 0.007), also when adjusted for in-study outcome predictors (adj-HR: 2.69, 95%CI 1.22-5.93, p = 0.014). Results were consistent among patients with preserved ejection fraction, normal-flow AS, high-gradient AS and in those without LV hypertrophy. Longitudinal LV systolic function assessed by average S' is independently associated with long-term all-cause mortality among TAVI patients. An average S' below 6.5 cm/sec best defines clinically meaningful reduced longitudinal systolic function and may aid clinical risk stratification in these patients.

A new method for ECG recording in the prone position

Introduction

Prone ventilation is frequently used in critical patients. ECG is usually recorded transposing the precordial positions to the back (Fig. 1A). The resultant precordial leads are unpredictably different from the supine ECG and difficult to interpret.

According to the dipole theory and the concept of mirror image electrocardiogram, each precordial point has an antipodal area where a mirror precordial lead can be recorded. Fig. 1B shows the location of the antipodal areas for the precordial points

Purpose

Based on this theoretical background we propose to use these antipodal areas to record inverted precordial leads (mirror leads M1 – M6) with diagnostic and monitoring potential.

Patients and methods

We have placed the precordial electrodes in the corresponding antipodal area for each precordial point (Fig. 1B) and we have recorded prone ECG in 20 subjects (10 healthy volunteers, 10 cardiac patients) The resultant ECGs (leads M1-M6) were compared with the standard supine ECGs (v1-V6).

Results

Mirror leads show low amplitude (especially V2-V4) compared to standard precordials, but are qualitatively quite similar (but inverted) to the supine precordial leads (Fig. 2).

Conclusion

We proposed a new method to obtain ECGs in prone patients. The resultant precordial leads are comparable to the standard precordial leads.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Impact of mitral valve anatomy suitability in echocardiographic and clinical evolution in patients referred for percutaneous edge-to-edge repair

Background

Percutaneous edge-to-edge mitral repair has become an effective therapeutic alternative to surgery in high-risk patients with moderate-to-severe mitral regurgitation (MR). A traffic light system has been proposed to evaluate echocardiographic suitability for this therapy. However, few data is available regarding prognostic impact of these criteria.

Purpose

To study the impact of imaging eligibility classification in echocardiographic and clinical evolution.

Methods

We evaluated all the consecutive patients who underwent percutaneous mitral repair with the MitraClip system between 2010 and 2020 in our tertiary university hospital, excluding the redo procedures (n=1). Imaging eligibility classification was blindly made by two experts in structural heart disease. Pre and posprocedural echocardiographic measurements were reassessed and clinical events were collected from medical records.

Results

87 patients (65.5% males) with a mean age of 76±10 years were finally included. Regarding mitral valve disease, 13 (14.9%) was graded as moderate-to-severe whereas 74 (85.1%) was considered severe. MR etiology was: functional 44.8%, organic 34.5% and mixed 20.7%. Prior to the procedure the NYHA class was III or higher in 88.5% and LVEF was 44.4±15.4%. Eligibility criteria was: green (44, 50.6%), yellow (39, 44.8%) and red (4, 4.6%). The later patients, with theorical contraindication for the procedure, were excluded from analysis. Although less number of clips were needed in green morphology (1.14 vs 1.46; p=0.01), pulmonary vein flow improved more markedly (Table) in these patients. This resulted only in a slightly greater reduction in MR grade at 6 months (−2.5 vs −1.9; p=0.008). No differences were noted in follow up absolute MR grade or changes in ventricular volumes, LVEF or pulmonary artery systolic pressure. Moreover, there was no impact in MACE during the evolution.

Conclusion

Excluding contraindicated group, no relevant echocardiographic or clinical impact was noted regarding eligibility criteria for percutaneous edge-to-edge mitral repair. Thus, suboptimal patients may equally benefit from this therapy even in moderate-volume centers.

Funding Acknowledgement

Type of funding sources: None. Table 1. Postprocedural pulmonary vein flow pattern in relation with eligibility criteria

The discongruence index, a simple predictor of cardiac remodeling after transcatheter aortic valve replacement

Background

Aortic stenosis causes several changes in left ventricular (LV) geometry and function; cardiac remodeling after transcatheter aortic valve replacement (TAVR) is variable among patients and it is not clearly defined. The aim of this study is to identify factors associated with LV functional and structural recovery.

Methods

428 patients were retrospectively studied; all patients underwent transthoracic echocardiography prior to TAVR; specific measurements such as maximum internal diameter of the prosthetic valve, nominal loss and percentage of nominal loss regarding to valve size, as well as the discongruence index (Prosthesis size/BSA) were evaluated at discharge and 1-year follow up. Positive cardiac remodeling (PCR) was considered if patients had a reduction of ≥20% of left ventricle mass index (LVMi) and ≥10% of end-diastolic volume index (LVEDVi).

Results

Mean age of the cohort was 83±5.6 years, 55% were female (n=236), mean aortic valve area was 0.7±0.2cm2; mean LVMi and LVEDVi were 129.4±35.4gr/m2 and 54.5±22ml/m2 respectively. LVMi reduction ≥20% was observed in 30% (n=128) of patients; LVEDVi reduction ≥10% was observed in 44% (n=188) of patients. A total of 107 patients (25%) showed PCR. Female patients showed more PCR (p=0.04). Discongruence index was significantly higher in patients with PCR (15.5±1.9 vs 14.5±1.8, p=0.01) and was significantly associated to LVMi (121.5±28.9 vs 150.8±41.1g/m2) and LVEDVi individually (55.1±17.2 vs 42.7±16.7ml/m2; p&lt;0.01). Left ventricular ejection fraction (LVEF) had a statistically significant increase among patients with PCR (53.2±14.9 vs 56.7±11.5, p=0.04) global longitudinal strain showed improvement at 1-year follow-up as well, although not statistically significant (−17.3±3.7 vs −18.3±3.4 p=0.53).

Conclusions

The discongruence index is a simple and feasible parameter that can predict positive cardiac remodeling after TAVR which can have a significant impact in clinical outcome of patients.

Funding Acknowledgement

Type of funding sources: None.

Discongruence Index: predictor of prosthesis size loss after transcatheter aortic valve replacement

Introduction

Prosthesis under-expansion has been associated with higher rates of complications and worse long term outcome after transcatheter aortic valve replacement (TAVR). The objective of the current study was to assess the value of a new “Discongruence index”, to predict the percentage of prosthesis size loss (compared to its nominal size). The “discongruence index” is obtained from the relation between transcatheter valve size and the patient body surface area.

Methods

A total of 247 consecutive patients with severe aortic stenosis that underwent TAVR with balloon expandable Edwards-Sapiens prosthesis or CoreValve Revalving system at our institution were included. The “Discongruence index” was calculated pre-procedurally as the ratio: selected transcatheter valve size (mm) / body surface area (cm2). Two-dimensional transesophageal echocardiography images were studied in the 120–135° plane after the prosthesis deployment, and the maximum anteroposterior diameter was measured (in millimeters). From this measurement was obtained the percentage of prosthesis size loss (compared to the prosthesis nominal size).

Results

Mean age was 82±6 years and 102 patients (41.3%) were men. Mean aortic valvular area before TAVR was 0,87±3,8 cm2, (indexed 0,36±0,1 cm2) and the mean aortic gradient 49,1±16,9 mmHg. Mean prosthesis maximum deployment was 18,9±2,7 mm; absolute loss of prosthesis size compared to nominal 6,5±2,8 mm and the percentage loss of prosthesis size 25.1±9,5%. The “Discongruence index” was predictor of the percentage of prosthesis size loss (y = 5,7650 + 1,3010x, p&lt;0,001), see figure.

Conclusions

The “Discongruence index” is a useful tool to predict the percentage of prosthesis size loss after TAVR. This new index should be taken into consideration in the selection of transcatheter valve sizes to avoid prosthesis under-expansion.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Ventricular-arterial coupling in hypertensive patients after TAVR. It is not all about the valve

Background

In severe aortic stenosis, the left ventricle faces the challenge of the valvular load and the arterial load caused by abnormalities in systemic arterial compliance and systemic vascular resistance. The aim of this study is to assess the effect of hypertension control on left ventricular performance in patients that underwent TAVR.

Methods

68 consecutive patients who underwent TAVR were analyzed; all patients were evaluated to confirm severe aortic stenosis with transthoracic echo (TTE). Conventional echo parameters were assessed as well as left ventricular mechanics parameters and vascular parameters such as arterial elastance (Ea), ventricular elastance (Ees) and V/Ac; besides all patients underwent TTE prior to TAVR, at discharge and 90 days follow-up visit.

Results

Mean age was 82±5; mean aortic valve area was 0.69±0.19, mean left ventricular ejection fraction was 58.3±12.1 and mean ventricular-arterial coupling was 1.6±0.9. At 90 days follow up we observed a significant worsening in V/Ac in those patients with poor control of blood pressure (&gt;140/90mmHg), (1.8±0.5 vs 2.1±0.3, p=0.03). Aortic impedance was significantly higher (4.4±1.4 vs 3.5±1.2, p=0.05); Ea and Ees were also significantly higher in hypertensive patients (2.3±0.8 vs 1.7±0.6, p=0.05) and (1.4±0.7 vs 0.9±0.6, p=0.01) respectively. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) showed a slightly reduction in hypertensive patients, although not statistically significant.

Conclusions

Control of blood pressure seems to be an important factor that contributes to a better or rather worse LV performance and could have a potential role in systolic function and clinical outcome of patients after TAVR.

Funding Acknowledgement

Type of funding sources: None.

Impact of frailty on elderly patients with infective endocarditis

Introduction

Frailty studies focused on patients with infective endocarditis (IE) are scarce and its potential impact on patient outcomes is not well known.

The aim of this study is to describe the clinical profile and prognosis of elderly patients with IE, comparing patients who met the frailty criteria versus those who did not.

Methods

A total of 121 cases of confirmed IE were consecutively collected in three tertiary hospitals between 2017 and 2019. The patients were classified into two groups: Group I (n=49), patients with IE who met the Frail criteria for frailty, and Group II (n=72), those patients without frailty by this scale.

Results

The median age of our cohort was 77 years (69–82), and 62.8% were men. Frail patients were older than those in Group II, as shown in Table 1.

Regarding comorbidity, chronic anemia (40.8% vs 25%; p&lt;0.060) was more common in Group I, as well as rheumatic manifestations at admission (12.2% vs 1.4%; p=0.014).

The most frequently isolated microorganisms were S. aureus (n=25), coagulase negative staphylococci (n=25), viridans group streptococci (n=14), and enterococci (n=14). Enterococci (16.3% vs 8.3%, p=0.177) and non-viridans streptococci (10.2% vs 2.8%); p=0.086) were more frequent in frail patients.

Vegetation (79.6% vs 80.6%; p=0.896) and periannular complications (24.5% vs 29.2%; p=0.571) were similar in both groups. No significant differences were found regarding the location of the infection.

The incidence of in-hospital complications was similar between both groups. Frail patients underwent surgery less frequently than those in Group II, and had higher predicted mortality on surgical risk scale scores. However, the percentage of patients who met the surgical criteria and were considered inoperable was similar (33.3% vs 26.2%; p=0.415). In-hospital mortality was similar in both groups. When analyzing in-hospital mortality according to the therapeutic strategy in Group I, a mortality of 34.5% was observed in frail patients with conservative medical treatment, compared to 47.1% in those patients who underwent surgery in the same group.

One third of our patients received outpatient antibiotic treatment, being significantly more frequent in Group I (39.6% vs 29.0%; p=0.232).

Conclusions

The elderly patients with IE and frailty criteria were older and more frequently had rheumatic symptoms at admission. Enterococci and non-viridans streptococci were isolated more frequently than in non-frailty patients. Surgery was less performed among frail patients, who had a higher predicted surgical risk. Although complications and in-hospital mortality were similar between both groups, in the group of frail patients, those with conservative management showed lower mortality compared to surgery.

Funding Acknowledgement

Type of funding sources: None.

Correlation between cardiac magnetic resonance feature tracking derived left ventricular strain and morphological characteristics of non-ischemic dilated cardiomyopathy at baseline and follow-up

Background

Left ventricular (LV) strain from echocardiography is a known useful predictor of LVEF recovery in non-ischemic dilated cardiomyopathy (NIDCM). More recently, feature tracking (FT) has allowed LV myocardial deformation analysis using conventional cardiac magnetic resonance (CMR) cine sequences.

Purpose

Our aim is to establish the correlation between LV strain values from CMR-FT at diagnosis and morphological parameters at baseline and during follow-up.

Methods

Consecutive patients with NIDCM who underwent CMR were retrospectively collected. All the studies were performed in a 1.5 Tesla magnet following a standard acquisition protocol of conventional SSFP cine sequences in long and short axis. Global longitudinal, circumferential and radial strain (GLS, GCS and GRS, respectively) were obtained with a dedicated FT software. Correlation with CMR morphological parameters at baseline were evaluated. Likewise, in the cases with follow-up echocardiogram association between FT LV strain and evolution of morphofunctional variables was explored.

Results

CMR-FT strain analysis was performed in 98 patients (age 68±13 years, 72% males) with NIDCM. They showed severe LV dilatation (LVEDVi= 133.6±33.4 mL/m2) and systolic dysfunction (LVEF= 29.5±9.6%) at baseline. Myocardial fibrosis was detected in 38.8% of the patients with late gadolium enhancement (LGE) sequence. All the basal CMR morphological characteristics were significantly correlated with FT strain analysis (Table), even more markedly for GCS. However, there was no association of baseline morphofunctional parameters with LGE. An echocardiogram was performed in 85.7% of the patients during the follow-up (2.4 [1.8–3.4] years), with an LVEF &gt;50% in the 25.5% of the cases. These patients with preserved LVEF in the evolution showed better GCS (−9 vs −7.1%; p=0.019) at baseline, with no differences in the other FT LV strain parameters. Despite less fibrosis in LGE (16.1% vs 37.7%; p=0.037), none of the baseline morphofunctional CMR parameters (LVEF, LVEDVi...) were associated with systolic function restoration. In multivariate analysis, GCS was the only independent predictor (OR 1.16; p=0.045) of LVEF recovery among imaging variables.

Conclusions

All the FT derived LV strain values were correlated with the degree of basal morphofunctional involvement in NIDCM. Furthermore, GCS emerged as an independent imaging predictor of LV systolic function restoration in our series.

Funding Acknowledgement

Type of funding sources: None. Table 1. Correlation between myocardial deformation values by feature tracking and morphofunctional variables in basal CMR.

Clinical relevance of cardiac magnetic resonance feature tracking derived left ventricular strain in nonischemic dilated cardiomyopathy

Background

Left ventricular (LV) myocardial deformation analysis with echocardiography has shown an additive value for risk stratification in nonischemic dilated cardiomyopathy (NIDCM). However, scarce data is available with the new cardiac magnetic resonance (CMR) technique feature tracking, which allows strain evaluation from conventional cine sequences.

Purpose

Our aim is to analyze prognostic relevance of FT in NIDCM

Methods

Consecutive patients with NIDCM diagnosis and CMR at diagnosis were retrospectively included. LV global longitudinal, circumferential and radial strain (GLS, GCS and GRS, respectively) were obtained from standard CMR cine sequences with a dedicated FT software. Their association with a composite endpoint (heart failure admission, implantable cardioverter defibrillator in secondary prevention, and death) was evaluated.

Results

FT derived strain was obtained in 98 patients (68±13 years, 72% males) with NIDCM, mostly idiopathic (75.5%). The vast majority showed a severely dilated LV (LVEDVi= 133.6±33.4 mL/m2) with severely impaired systolic function (LVEF= 29.5±9.6%), and in 38.8% of the cases fibrosis was demonstrated in late gadolium enhancement (LGE). During a 3.2 [2.2–4] years follow-up 25.5% had an admission due to heart failure, 5.1% received an implantable cardioverter defibrillator in secondary prevention, and 10.2% died. Only a trend towards worse GCS values (−7.1 vs −8.5%; p=0.10) was noted among patients with heart failure hospitalization. Mortality was associated with poorer GCS (−5.9 vs −7.9%; p=0.012) and GLS (−6.9 vs −9.6%; p=0.051) values, whereas GRS was not related with any prognostic variable. Exclusively GCS was associated with the composite endpoint (−6.7 vs −8.2%; p=0.035). Considering other morphological parameters with prognostic relevance (LVEF and LVEDVi), GCS was the only independent predictor (OR 1.15; p=0.038). A cut-off point &lt;−8.2% was able to identify those patients with a worse clinical evolution (Figure, Log Rank 4.6; p=0.032)

Conclusions

In our series LV myocardial deformation analysis with FT has shown prognostic relevance in NIDCM, especially GCS determination.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Cardiac mechanics as predictors of left ventricular reverse remodelling in patients with dilated non-ischemic cardiomyopathy

Background and purpose

The appearance of left ventricular reverse remodelling (LVRR) is associated with a better prognosis in patients with dilated non-ischemic cardiomyopathy (DCM).

Our aim was to identify cardiac imaging parameters, including speckle tracking by transthoracic echocardiography (TTE) and feature tracking by CMR, associated with LVRR in a prospective cohort of patients with DCM.

Methods

From 2014 to 2021, 182 patients with DCM and left ventricle ejection fraction (LVEF) &lt;40% were prospectively evaluated in our hospital.

LVRR was defined as an increase in LVEF ≥10 points or absolute LVEF ≥50%, associated with a reduction in left ventricular end- diastolic diameter ≥10%.

Patients underwent multimodality imaging evaluation including CMR with a 1.5 Tesla scanner, and TTE. Cardiac mechanics, including global longitudinal strain (GLS), strain rate (SR) and mechanical dispersion (MD) were measured.

Results

Median age of our cohort was 62.3 (14.4) years, and 67.7% were male.

Most patients (&gt;90%) were treated with beta-blockers or RASS blockers, and 67% with mineralocorticoid receptor antagonists. 30% had cardiac resynchronization therapy (CRT) and 37% had ICD as primary prevention. Mean LVEF was 31.3%. During a mean follow-up period of 35.9 (35.4) months, 38.3% of patients had LVRR.

Age and gender distribution were similar in both groups. Regarding cardiovascular risk factors and pharmacological treatment, no differences were found between patients with and without LVRR. Baseline CRT therapy was not associated with LVRR (22.6% vs 34.7%; p=0.249). However, there was a trend towards higher LVRR in those who received CRT during follow-up 18.8% vs 0%; p=0.069).

Patients who experienced LVRR had lower basal LVEF (23.4% vs 29%; p&lt;0.008), as well as poorer RV function, including lower RVEF (40.5% vs 51%; p=0.006) and lower TAPSE (16 mm vs 19 mm; p=0.021). Regarding cardiac mechanics, those patients with lower GLS (−9% vs −12%; p=0.001), and higher MD (73 mm vs 55 mm; p=0,050) had LVRR more frequently during follow-up. The presence of a left bundle branch block (LBBB) contraction pattern by strain was associated with higher rate of LVRR (83.3% vs 30.4%; p=0.011). The burden of fibrosis measured by LGE with CMR was not associated with LVRR (14% vs 12%; p=NS).

Patients with LVRR had a lower cardiovascular mortality (3.3 vs 14.3%; p=0.117), lower mortality due to heart failure (0% vs 12.2%; p=0.046), less heart failure hospitalizations (20% vs 46.9%; p=0.016), and a lower incidence of ventricular tachyarrhythmias (3.3% vs 18.4%; p=0.051).

Conclusions

LVRR in patients with DCM receiving optimized medical therapy is associated with a better prognosis. Imaging parameters, including a lower basal LVEF, RVEF, GLS and higher MD, as well as LBBB echo pattern, were associated with a higher frequency of LVRR, and might help to identify patients who could benefit from CRT/and may be helpful to stratify patients's risk.

Funding Acknowledgement

Type of funding sources: None.

Managing the patient undergoing transcatheter aortic valve replacement with ongoing mitral regurgitation

INTRODUCTION

Significant mitral regurgitation (MR) frequently coexists in patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). These patients have worse clinical outcomes than those with non-significant MR, especially if MR persists after treatment of the aortic stenosis. The optimal treatment approach for this challenging high-risk population is not well defined.

AREAS COVERED

This review aims to present the current literature on concomitant significant MR in the TAVR population, and to provide a comprehensive algorithmic approach for clinical decision-making in this challenging cohort of patients.

EXPERT OPINION

Concomitant mitral and aortic valve disease is a complex clinical entity. An exhaustive and comprehensive assessment of patient's clinical characteristics and mitral valve anatomy and function is required in order to assess the surgical risk, predict the MR response after AVR and evaluate the feasibility of percutaneous MV treatment if necessary. Further developments in transcatheter techniques will expand the indications for double valve treatment in operable and inoperable patients with concomitant significant MR and aortic stenosis.

Effect of Transcatheter Aortic Valve Replacement on Concomitant Mitral Regurgitation and Its Impact on Mortality

OBJECTIVES

The purpose of this study was to examine the impact of residual mitral regurgitation (MR) on mortality in patients undergoing transcatheter aortic valve replacement (TAVR).

BACKGROUND

MR is common in patients undergoing TAVR. Data on optimal management of patients with significant MR after TAVR are limited.

METHODS

The registry consisted of 16 TAVR centers (n = 7,303). Outcomes of patients with ≥ moderate versus lesser grade MR after TAVR were compared.

RESULTS

In 1,983 (27.2%) patients, baseline MR grade was ≥ moderate. MR regressed in 874 (44.1%) patients and persisted in 1,109 (55.9%) after TAVR. Four-year mortality was higher for those with MR persistence, but not for those with MR regression after TAVR, compared with nonsignificant baseline MR (43.8% vs. 35.1% vs. 32.4%; hazard ratio [HR]: 1.38; p = 0.008; HR: 1.02; p = 0.383, respectively). New York Heart Association functional class III to IV after TAVR was more common in those with MR persistence vs. regression (14.4% vs. 3.9%; p < 0.001). In a propensity score-matched cohort (91 patients' pairs), with significant residual MR after TAVR who did or did not undergo staged mitral intervention, staged intervention was associated with a better functional class through 1 year of follow-up (82.4% vs. 33.3% New York Heart Association functional class I or II; p < 0.001), and a numerically lower 4-year mortality, which was not statistically significant (64.6% vs. 37.5%; HR: 1.66; p = 0.097).

CONCLUSIONS

Risk stratification based on improvement in MR and symptoms after TAVR can identify patients at increased mortality risk after TAVR. These patients may benefit from a staged transcatheter mitral intervention, but this requires further proof from future studies. (Transcatheter Treatment for Combined Aortic and Mitral Valve Disease. The Aortic+Mitral TRAnsCatheter [AMTRAC] Valve Registry [AMTRAC]; NCT04031274).

Multivariate analysis of right ventricle echocardiographic function parameters for the prediction of outcomes in significant functional tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Functional tricuspid regurgitation is a common disease that significantly impairs survival and quality of life. The role of echocardiographic right ventricular (RV) function parameters to detect patients with worse prognosis that may benefit from invasive treatment is still under debate.

Methods

121 consecutive patients with grade III and IV functional tricuspid regurgitation were evaluated. RV function parameters and clinical variables were assessed at baseline, and then patients were prospectively followed-up. The primary endpoint was the combination of death or heart failure (HF) admissions. Comparison of imaging parameters was done using receiver-operating characteristics (ROC) curves. Multivariate logistic regression analysis was preformed to establish independent predictors of outcomes.

Results

Median follow up was 27.3 months. 73.6% of the patients were female, and mean age was 80.4 years. 63.6% were grade IV tricuspid regurgitation.

In the univariate analysis using the area under the ROC curve (AUC), RV-free wall strain (RVS, AUC = 0.633) and pulmonary artery systolic pressure (PASP, AUC = 0.605) were the best predictors of death and HF admissions, showing better diagnostic performance than tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC) and tricuspid S’ (p &lt; 0.001 for each comparison) (graph 1A).

In the multivariate analysis including either clinical and echocardiographic variables, independent predictors of death and HF admissions were Age (OR 1.07, p = 0.029), RVS&gt;-16 (OR 5.0, p = 0.001), Diabetes mellitus (OR 3.0, p = 0.011), eGFR (ml/min, OR 0.96, p = 0.001) and Hemoglobin (g/dL, OR = 0.74, p = 0.048) (table 1). The model including these variables was superior than RVS and PASP alone (AUC 0.884, p &lt; 0.001) (graph 1B), showing high sensitivity (78.8%) and moderate specificity (67.3%).

Conclusions

In patients with significant functional tricuspid regurgitation, RVS and PASP show the best performance for the detection of death and HF admissions. A multivariate model including age, diabetes, eGFR, hemoglobin and RVS was superior than the individual imaging parameters.

Table 1 Variable OR 95% CI P value Age (years) 1.07 1.01-1.13 0.029 Diabetes Mellitus 3.00 1.29-7.00 0.011 RV free wall strain &gt;-16 5.01 1.87-13.4 0.001 Hemoglobin (d/dL) 0.74 0.55-1.00 0.048 eGFR (ml/min) 0.96 0.94-0.98 0.001 OR odds ratio. CI: confidence interval. eGFR: estimated glomerular filtration rate (CKD-EPI formula). Abstract Figure. Graph 1

Transcatheter aortic valve replacement in patients with paradoxical low-flow, low-gradient aortic stenosis: Incidence and predictors of treatment futility

BACKGROUND

Few and controversial data exist on the outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLFLG-AS) following transcatheter aortic valve replacement (TAVR). This study aims to better characterize clinical outcomes and predictors of treatment futility in PLFLG-AS patients undergoing TAVR.

METHODS

In this multicenter study, 318 patients with PLFLG-AS undergoing TAVR were categorized according to treatment futility, defined as all-cause mortality, poor functional status (NYHA class III-IV) or deterioration in functional class at 1-year follow-up. Clinical outcomes and the factors associated with treatment futility were assessed.

RESULTS

The mean age of the patients was 81.0 ± 8.3 years and 50.3% were women. At 1-year follow-up, 17.6% died and 12.9% had heart failure hospitalization. Residual impaired functional capacity (NYHA ≥ II) was present in 54.4% of patients who were alive at 1-year, and 9.8% remained in NYHA III/IV. The primary endpoint was observed in 103 (32.4%) patients, of which 54% died and 46% had a poor or worsening functional class. Factors independently associated with treatment futility were the presence of atrial fibrillation (AF) (OR:1.79, 95%CI, 1.04-3.10), chronic obstructive pulmonary disease (COPD) (OR:2.66, 95%CI, 1.50-4.74) and a lower SVi (OR per each decrease in 10 ml/m²:1.89, 95%CI, 1.06-3.45). The risk of treatment futility of patients with AF, COPD and a SVi < 30 ml/m² was 66.38% (95%CI, 54.29%-78.48%).

CONCLUSION

Close to one-third of patients with PLFLG-AS failed to derive a benefit from TAVR. The presence of AF, COPD and a low SVi were predictors of treatment futility. Being able to identify patients less likely to improve after the procedure may help to guide management and improve outcomes in patients with PLFLG-AS.

P4352Usefulness of speckle tracking echocardiography in the detection of ventricular mechanics changes after percutaneous intervention of coronary chronic total occlusions

Background

Previous studies show contradictory results of the effect of chronic total occlusions (CTO) revascularization on LVEF. Deformation parameters based on speckle tracking (2D-ST) echo allows the evaluation of the systolic regional function.

Purpose

To examine the usefulness of 2D-ST to detect changes in regional ventricular mechanics in a consecutive cohort of patients with successful CTO percutaneous revascularization.

Methods

Prospective study that included 13 consecutive patients (72±8 y, 85% men). Revascularization was justified based on the evidence of viability of the underlying territory. 2D-ST was performed before, one and three months after of the procedure. Based on 16 segments model (n: 208), these were classified in two groups (dependent/non-dependent) according to their relationship with the treated CTO. Strain rate (Sr) and Strain (S) of the three myocardial layers were measured.

Results

208 segments analyzed. 62 (30%) perfusion dependent, (mean 5 segments/patient), non-dependent: 146 (70%). During follow-up (median: 3.3 m), there were no significant differences with respect to LVEF (56±6 vs. 59±6, p: 0.2). Although non-dependent segments showed no significant changes of deformation parameters after the procedure, dependent segments showed an increase (Δ) of both the S and Sr, being statistically significant the Δ of the three layers S at 3 months vs. non-dependent.

Table 1 PRE POST p Δ Non-Dependent segments (N: 146)   S-epicardial −16.6±4.9 −16.0±4.0 0.06 0.6±4.0   S-mesocardiac −17.4±4.8 −16.8±4.2 0.08 0.6±3.9   S-endocardial −18.1±5.1 −17.7±4.9 0.337 0.4±4.5   Sr −1.15±0.4 −1.09±0.4 0.080 0.07±0.47 Dependent segments (N: 62)   S-epicardial −13.7±5.8 −16.3±4.5 <0.001 −2.6±5.2*   S-mesocardiac −14.7±6.1 −17.0±4.5 <0.05 −2.3±5.2*   S-endocardial −15.8±6.7 −17.9±4.9 <0.05 −2.1±5.6*   Sr −0.98±0.4 −1.03±0.4 0.353 −0.05±0.42 *p<0.05 ΔNon-dependents vs. ΔDependents.

S (%) improvement post RCA CTO treatment

Conclusions

This study shows that CTO treatment improves regional myocardial function in LV segments dependent on CTO at three months of follow-up, without changes in LVEF. 2D-ST allows to examine the effect of flow restoration, providing new information on the potential short-term benefits of this strategy

P6456Role of cardiac imaging in the prediction of ventricular arrythmias, heart failure and death in dilated non-ischemic cardiomyopathy with severe left ventricular systolic disfunction

Background and purpose

Dilated non-ischemic cardiomyopathy (DCM) is associated with an increased risk of cardiac events. Implantable Cardioverter Defibrillator (ICD) is recommended in DCM with severe left ventricular ejection fraction impairment, but the evidence of its usefulness is somewhat controversial. We evaluated the predictive value of myocardial fibrosis measured by cardiac magnetic resonance (CMR) and of global longitudinal strain (GLS) in the incidence of adverse cardiac events.

Methods

From 2009 to 2019, sixty-six patients with DCM were evaluated. CMR with a 1.5 Tesla scanner was performed, and the presence and extent of late gadolinium enhancement (LGE) was blindly assessed. GLS was measured using speckle-tracking 2D echocardiography. We examined the incidence of sustained ventricular arrhythmias (SVA, including appropriate anti-tachycardia pacing and shocks), admissions due to heart failure (HF) and all-cause mortality.

Results

62.1% of the patients were male, with a median age of 63.8 years. 50.0% had cardiac resynchronization therapy and 73.9% had ICD as primary prevention therapy. Median LVEF was 25.7%.

Median follow-up was 32 months. In that period, 10.6% of patients died, 25.8% had hospital admissions due to HF, and 9.2% had SVA. A burden of LGE over 14% was independently associated with higher risk of SVA (3.0% vs 19.2%, p=0.041). This cut-off value had a sensitivity of 83.3% and a negative predictive value of 97.0%. LGE was not associated with higher risk of HF admissions (27.3% vs 23.1%, p=0.731) or death (9.1% vs 11.5%, p=0.757).

On the other hand, GLS was not associated with higher risk of SVA (8.7% vs 4.55% for a cut-off value of −10.6%, p=0.577), HF admissions (26.1% vs 30.4%, p=0.743) or death (8.7% vs 8.7%, p=1.00).

Table 1. Main etiologies of DCM Causes N (%) Idiopathic 43 (65.2) Alcoholic 6 (9.1) Chemotherapy 4 (6.1) Non-compaction 4 (6.1) Familiar 3 (4.6) Thoracic radiotherapy 2 (3.0) Chagas disease 2 (3.0)

Conclusions

The burden of myocardial fibrosis measured by LGE is a high sensitive marker for the development of SVA. However, is not a predictive tool for HF admissions or all-cause mortality. GLS was not associated with the incidence of cardiac events in this population.

Discongruence Index - Simple Indicator to Predict Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement

BACKGROUND

Prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) remains an important issue. The aim of this study was to assess the value of a new discongruence index, to predict PPM after TAVR.Methods and Results: A total of 185 patients with severe aortic stenosis who underwent TAVR with the Edwards Sapien prosthesis or CoreValve Revalving system were included (Edwards valve, n=119; Core Valve Revalving system, n=66). Discongruence index was calculated pre-procedurally as the ratio of selected transcatheter valve size (mm) to body surface area (cm²). PPM was defined as effective orifice area (EOA) ≤0.85 cm²/m² on transthoracic echocardiography before hospital discharge. Mean age was 82±5 years and 72 patients (38.9%) were men. The overall incidence of post-TAVR PPM was 35.1% (n=65). Discongruence index correlated with post-TAVR indexed EOA (y=0.18+0.057x; P<0.001). On multivariate logistic regression analysis, discongruence index was the only independent predictor of post-TAVR PPM (OR, 0.15; 95% CI: 0.03-0.66; P=0.012), and the area under the receiver operating characteristic curve was 0.62 (95% CI: 0.54-0.70, P=0.003), with an optimal cut-off point of 15.02 (sensitivity, 86.2%; specificity, 72.5%; positive predictive value, 74.3%; negative predictive value, 83.4%).

CONCLUSIONS

The new discongruence index may be useful tool to predict PPM after TAVR.

Transcatheter Aortic Valve Implantation in Patients With Paradoxical Low-Flow, Low-Gradient Aortic Stenosis

Controversial data exist on clinical outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLF-LG-AS) undergoing valve replacement. The objective of this study was to determine the clinical outcomes and treatment futility in patients with paradoxical low-flow (PLF), low-gradient (LG) severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). A total of 493 patients with severe symptomatic AS and preserved ejection fraction (>50%) undergoing TAVI were included. Patients were divided in two groups: high gradient AS group (HG-AS; mean gradient ≥40 mm Hg and stroke volume index >35 ml/m², n = 396); and PLF, LG AS group (PLF-LG-AS; mean AV gradient <40 mm Hg and indexed stroke volume ≤35 ml/m², n = 97). The primary endpoint was treatment futility defined as death or poor functional status (New York Heart Association class III and/or IV) at 6-month follow-up. There were no differences in mortality between groups (PLF-LG-AS: 5%, HG: 8%; adjusted odds ratio (OR): 0.85, 95% confidence interval (CI):0.29 to 2.46), but PLF-LG-AS patients remained more frequently in New York Heart Association class III to IV (20% vs 8% in the HG group, adjusted OR: 2.46, 95% CI:1.19 to 5.07). TAVI treatment futility was more frequent in the PLF-LG-AS group (24% vs 14%, adjusted OR: 1.90 [1.01 to 3.57]), and patients with PLF-LG-AS exhibited a higher rate of rehospitalization for cardiovascular causes (9% vs 5%, adjusted OR: 2.95, 95% CI:1.08 to 8.09). Previous myocardial infarction and chronic obstructive pulmonary disease were associated with treatment futility (p< 0.03 for both). In conclusion, TAVI was a futile treatment in one fourth of patients with PLF-LG-AS. These results underscore the complexity and need for improving the clinical decision-making process and management of patients with PLF-LG-AS.

Mitral Regurgitation After Transcatheter Aortic Valve Replacement: Prognosis, Imaging Predictors, and Potential Management

OBJECTIVES

This study sought to analyze the clinical impact of the degree and improvement of mitral regurgitation in TAVR recipients, validate the main imaging determinants of this improvement, and assess the potential candidates for double valve repair with percutaneous techniques.

BACKGROUND

Many patients with severe aortic stenosis present with concomitant mitral regurgitation (MR). Cardiac imaging plays a key role in identifying prognostic factors of MR persistence after transcatheter aortic valve replacement (TAVR) and for planning its treatment.

METHODS

A total of 1,110 patients with severe aortic stenosis from 6 centers who underwent TAVR were included. In-hospital to 6-month follow-up clinical outcomes according to the degree of baseline MR were evaluated. Off-line analysis of echocardiographic and multidetector computed tomography images was performed to determine predictors of improvement, clinical outcomes, and potential percutaneous alternatives to treat persistent MR.

RESULTS

Compared with patients without significant pre-TAVR MR, 177 patients (16%) presented with significant pre-TAVR MR, experiencing a 3-fold increase in 6-month mortality (35.0% vs. 10.2%; p < 0.001). After TAVR, the degree of MR improved in 60% of them. A mitral annular diameter of >35.5 mm (odds ratio: 9.0; 95% confidence interval: 3.2 to 25.3; p < 0.001) and calcification of the mitral apparatus by multidetector computed tomography (odds ratio: 11.2; 95% confidence interval: 4.03 to 31.3; p < 0.001) were independent predictors of persistent MR. At least 14 patients (1.3% of the entire cohort, 13.1% of patients with persistent MR) met criteria for percutaneous mitral repair with either MitraClip (9.3%) or a balloon-expandable valve (3.8%).

CONCLUSIONS

Significant MR is not uncommon in TAVR recipients and associates with greater mortality. In more than one-half of patients, the degree of MR improves after TAVR, which can be predicted by characterizing the mitral apparatus with multidetector computed tomography. According to standardized imaging criteria, at least 1 in 10 patients whose MR persists after TAVR could benefit from percutaneous mitral procedures, and even more could be treated with MitraClip after dedicated pre-imaging evaluation.

Galectin-3 Participates in Cardiovascular Remodeling Associated With Obesity

Remodeling, diastolic dysfunction, and arterial stiffness are some of the alterations through which obesity affects the cardiovascular system. Fibrosis and inflammation are important mechanisms underlying cardiovascular remodeling, although the precise promoters involved in these processes are still unclear. Galectin-3 (Gal-3) induces inflammation and fibrosis in the cardiovascular system. We have investigated the potential role of Gal-3 in cardiac damage in morbidly obese patients, and we have evaluated the protective effect of the Gal-3 inhibition in the occurrence of cardiovascular fibrosis and inflammation in an experimental model of obesity. Morbid obesity is associated with alterations in cardiac remodeling, mainly left ventricular hypertrophy and diastolic dysfunction. Obesity and hypertension are the main determinants of left ventricular hypertrophy. Insulin resistance, left ventricular hypertrophy, and circulating levels of C-reactive protein and Gal-3 are associated with a worsening of diastolic function in morbidly obese patients. Obesity upregulates Gal-3 production in the cardiovascular system in a normotensive animal model of diet-induced obesity by feeding for 6 weeks a high-fat diet (33.5% fat). Gal-3 inhibition with modified citrus pectin (100 mg/kg per day) reduced cardiovascular levels of Gal-3, total collagen, collagen I, transforming and connective growth factors, osteopontin, and monocyte chemoattractant protein-1 in the heart and aorta of obese animals without changes in body weight or blood pressure. In morbidly obese patients, Gal-3 levels are associated with diastolic dysfunction. In obese animals, Gal-3 blockade decreases cardiovascular fibrosis and inflammation. These data suggest that Gal-3 could be a novel therapeutic target in cardiac fibrosis and inflammation associated with obesity.

Screening for Rheumatic Heart Disease among Peruvian Children: A Two-Stage Sampling Observational Study

BACKGROUND

The objective of the study was to evaluate the implications of different classifications of rheumatic heart disease on estimated prevalence, and to systematically assess the importance of incidental findings from echocardiographic screening among schoolchildren in Peru.

METHODS

We performed a cluster randomized observational survey using portable echocardiography among schoolchildren aged 5 to 16 years from randomly selected public and private schools in Arequipa, Peru. Rheumatic heart disease was defined according to the modified World Health Organization (WHO) criteria and the World Heart Federation (WHF) criteria.

FINDINGS

Among 1395 eligible students from 40 classes and 20 schools, 1023 (73%) participated in the present survey. The median age of the children was 11 years (interquartile range [IQR] 8-13 years) and 50% were girls. Prevalence of possible, probable and definite rheumatic heart disease according to the modified WHO criteria amounted to 19.7/1000 children and ranged from 10.2/1000 among children 5 to 8 years of age to 39.8/1000 among children 13 to 16 years of age; the prevalence of borderline/definite rheumatic heart disease according to the WHF criteria was 3.9/1000 children. 21 children (2.1%) were found to have congenital heart disease, 8 of which were referred for percutaneous or surgical intervention.

CONCLUSIONS

Prevalence of RHD in Peru was considerably lower compared to endemic regions in sub-Saharan Africa, southeast Asia, and Oceania; and paralleled by a comparable number of undetected congenital heart disease. Strategies to address collateral findings from echocardiographic screening are necessary in the setup of active surveillance programs for RHD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02353663.

Proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography applied for tricuspid regurgitation quantification

BACKGROUND

The two-dimensional (2D) proximal isovelocity surface area (PISA) method has known technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions and has already been validated for mitral regurgitation assessment. The aim of this study was to apply this novel method in patients with chronic tricuspid regurgitation (TR).

METHODS

Ninety patients with chronic TR were enrolled. EROA and regurgitant volume (Rvol) were assessed using transthoracic 2D and 3D PISA methods. Quantitative Doppler and 3D transthoracic planimetry of EROA were used as reference methods.

RESULTS

Both EROA and Rvol assessed using the 3D PISA method had better correlations with the reference methods than using conventional 2D PISA, particularly in the assessment of eccentric jets. On the basis of 3D planimetry-derived EROA, 35 patients had severe TR (EROA ≥ 0.4 cm(2)). Among these 35 patients, 25.7% (n = 9) were underestimated as having nonsevere TR (EROA ≤ 0.4 cm(2)) using the 2D PISA method. In contrast, the 3D PISA method had 94.3% agreement (33 of 35) with 3D planimetry in classifying severe TR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.92 and 0.88 respectively.

CONCLUSIONS

TR quantification using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.