Secondary mitral regurgitation: Maintaining coherence with the American Society of Echocardiography grading guidelines, which proportionality concept best predicts prognosis in the real world?

INTRODUCTION

Proportionality of secondary mitral regurgitation (sMR) may be a key factor in deciding whether a patient may benefit from mitral intervention. The aim of this study was to evaluate the prognostic value of two different concepts of proportionality and assess their ability to improve MR stratification proposed by the American Society of Echocardiography (ASE) guidelines.

METHODS

We conducted a retrospective analysis in patients with reduced left ventricular ejection fraction (LVEF) (<50%) and at least mild sMR. Proportionality status was calculated using formulas proposed by a) Grayburn et al. - disproportionate sMR defined as EROALVEDV >0.14; b) Lopes et al. - disproportionate sMR whenever measured EROA>theoretical EROA (determined as 50%×LVEF×LVEDVMitralVTI). Primary endpoint was all-cause mortality.

RESULTS

A total of 572 patients (69±12 years; 76% male) were included. Mean LVEF was 33±9%, with a median left ventricular end-diastolic volume of 174 mL [136;220] and a median effective regurgitant orifice area of 14 mm² [8;22]. During mean follow-up of 4.1±2.7 years, there were 254 deaths. There was considerable disagreement (p<0.001) between both formulas: of 96 patients with disproportionate sMR according to Lopes' criteria, 46 (48%) were considered proportionate according to Grayburn's; and of 62 patients with disproportionate sMR according to Grayburn's, 12 (19%) were considered proportionate according to Lopes' formula. In multivariate analysis, only Lopes' definition of disproportionate sMR maintained independent prognostic value (hazard ratio 1.5; 95% confidence interval 1.07-2.1, p=0.018) and improved the risk stratification of ASE sMR classification.

CONCLUSION

Of the two formulas available to define disproportionate sMR, Lopes' model emerged as the only one with independent prognostic value while improving the risk stratification proposed by the ASE guidelines.

Prevalence of RV dysfunction in patients under cardiotoxic chemoterapy: a preliminary analysis

Background

Chemotherapy-induced cardiotoxicity is a serious complication often leading to heart failure. While the left ventricle (LV) has been thoroughly implicated in this process, data is scarce on right ventricular (RV) function following cardiotoxic chemotherapies. Our goal was to determine the prevalence and clinical significance of RV dysfunction in a cohort of patients who had received these drugs.

Methodology

Single-center retrospective study of cancer patients performing 2D transthoracic echocardiogram between January 2020 and December 2021. Those previously exposed to anthracyclines and/or anti-HER2 agents (≥6 months prior to echocardiogram) were included. Patients with known coronary artery disease or cardiomyopathy were excluded. LV function was assessed through LV ejection fraction (LVEF) and global longitudinal strain (GLS). LV cardiotoxicity was defined as per 2020 ESMO guidelines. RV function was considered abnormal if the following criteria were met: tricuspid annular plane systolic excursion (TAPSE) &lt;17 mm, peak systolic velocity of the tricuspid annulus by pulsed wave TDI (S'VD) &lt;12 cm/s, fraction area change (FAC) &lt;35% and mean free wall longitudinal strain (FWLS) &gt;−20%.

Results

Forty patients were included (58±13 years; 95% female; 93% with breast cancer; 30%, 20% and 50% previously treated with anthracyclines, anti-HER2 or both, respectively). Mean LVEF and GLS were 56±7% and −17±3%. Overall, 13 patients had current LV cardiotoxicity. RV dysfunction was documented in 15 (38%) patients (7 [18%] with isolated RV dysfunction), most often detected through FWLS (14 [35%], 7 [18%], 6 [15%] and 5 [13%] patients with abnormal FWLS, TAPSE, FAC and S'VD, respectively) – Figure 1. Seven patients (18%) and one patient (3%) had ≥2 and ≥3 abnormal RV parameters. Those with RV dysfunction were more often symptomatic (NYHA class ≥2: 53% vs. 16%; p=0.013), had higher NT-proBNP levels (516 [204–2400] vs. 66 [46–191] pg/mL; p=0.003) and most often had LV cardiotoxicity (62% vs. 26%, p=0.029); pulmonary artery systolic pressures were similar between both groups.

Conclusion

In our cohort of patients treated with cardiotoxic anti-neoplastic drugs, RV dysfunction was observed in two out of every five patients, most often detected by RV 2D strain and associated with worse symptoms and higher NT-proBNP levels. This data suggests that RV cardiotoxicity may be common and clinically impactful in those under cardiotoxic chemotherapies.

Funding Acknowledgement

Type of funding sources: None.

A preliminary analysis regarding functional mitral regurgitation grading with echocardiography and CMR: in search of similarities and resolving discordances

Background

Functional mitral regurgitation (fMR) severity grading by 2D transthoracic echocardiography (TTE) can be a complex task, especially in patients where PISA assumptions are not met (eg. non-circular orifice or multiple jets). Cardiac magnetic resonance (CMR) can provide further insight on the hemodynamic burden of fMR by accurately determining mitral regurgitant fraction (RegFrac). Our goal was to investigate the concordance and disagreement between the two modalities in assessing fMR.

Methodology

Single-center prospective study of fMR patients performing same-day TTE and CMR from Feb to Dec 2021. MR severity was classified according to 2020 ACC consensus: grade I (mild; EROA &lt;0.20 cm2), grade II (moderate; EROA 0.20–0.29 cm2), grade III (moderate-to-severe; EROA 0.30–0.39 cm2) and grade IV (severe; EROA ≥0.40 cm2). MR assessment by CMR was determined through regurgitant volume (RVol) and RegFrac quantification. A RegFrac ≥35% (recently shown as the best cut-off for prognostication) was considered hemodynamically significant.

Results

A total of 36 patients were included (age 65±14y; 74% male; left ventricle [LV] ejection fraction by TTE and CMR 35±13% and 34±11%, respectively). Mean RVol and EROA by TTE were 28±11mL and 0.18±0.8 cm2. Mean RVol and Regfrac by CMR were 20±13 mL and 25±12%, respectively. A moderate correlation between RVol by TTE and CMR was found (Pearson's R 0.58, p=0.001). According to TTE, there were 20 patients (56%) with grade I fMR, 12 patients (33%) with grade II fMR and 4 patients (11%) with grade III fMR. All patients considered to have mild (grade I) fMR by TTE had a RegFrac &lt;35% at CMR. However, amongst those with moderate and moderate-to-severe (grades II and III) fMR, there were 8 patients (50%) with hemodynamic significant fMR (RegFrac ≥35%) at CMR – see Figure 1. Those with RegFrac ≥35% by CMR had higher indexed LV diastolic (165±24 vs 139±48 mL/m2) and systolic (116±31 vs 95±48 mL/m2) volumes and higher pulmonary artery systolic pressures (48±14 vs 41±16 mmHg) when compared with patients whose RegFrac was &lt;35%, even though statistically significance was not reached.

Conclusion

Using the criterion of RegFrac ≥35%, CMR re-classifies (half for each side) the patients with moderate and moderate-to-severe regurgitations by TTE. Recognizing, overcoming and resolving the disagreements between the techniques is the way forward to reach excellence.

Funding Acknowledgement

Type of funding sources: None.

Severe rheumatic mitral stenosis – analysis of clinical and echocardiographic very long-term outcomes after percutaneous mitral balloon valvuloplasty

Introduction

Mitral balloon valvuloplasty (MBV) is the guideline recommended treatment for symptomatic severe mitral stenosis (MS) with suitable anatomy, but is often deemed transitory. However, data on very-long term echocardiographic follow-up is scarce. The aim of our study was to describe clinical and echocardiographic outcomes in patients previously submitted to MBV for rheumatic MS.

Methods

We conducted a single-centre retrospective study enrolling patients previously submitted to MBV for rheumatic MS from 1990 until 2021. Follow-up was considered until last registered echocardiographic re-evaluation. Patients without electronic health records available were excluded. The primary endpoint was a composite of all-cause death or need of surgery.

Results

A total of 193 patients were included (15.5% male, with a mean age of 52±15 years at the time of MBV, 60.6% with permanent atrial fibrillation). During a mean follow-up of 11±8 years, 87 (45.1%) patients implanted a mitral valve prosthesis, 4 (2.1%) were submitted to surgical mitral valvuloplasty and 30 (15.5%) died without being reinterventioned. Moreover, a total of 23 (11.9%) embolic events were registered – 21 strokes, 1 pulmonary embolism and 1 acute lower limb embolism.

Overall, 133 patients (68.9%) survived more than 5 years, 95 (49.2%) more than 10 years and 56 (26.9%) more than 15 years since MBV without meeting the primary endpoint. The maximum follow-up without intervention was 32 years. Concerning patients submitted to surgery, the mean time from MBV until operation was 9.4±7.3 years (minimum 8 days; maximum 29.3 years).

In regard to echocardiographic long-term outcomes on alive non-operated patients (mean follow-up of 12±9 years), 52.8% remain with mild MS, 91.6% with mild or no mitral regurgitation and 77.6% with mild or no tricuspid regurgitation. Furthermore, only 20.4% have right ventricle dysfunction (defined as a TAPSE &lt;17 mm), 18.3% have pulmonary hypertension (pulmonary artery systolic pressure &gt;45 mmHg), and 6.8% have residual interatrial communication.

Conclusion

MBV is a minimally invasive procedure that has an important benefit in a very significant proportion of patients with rheumatic mitral stenosis, with potential benefit that may last more than three decades without need for another invasive intervention.

Funding Acknowledgement

Type of funding sources: None.

Light chain cardiac amyloidosis - a rare cause of heart failure in a young adult

Cardiac amyloidosis is an infiltrative cardiomyopathy, resulting from amyloid deposition within the myocardium. In primary systemic (AL-type) amyloidosis, the amyloid protein is composed of light chains resulting from plasma-cell dyscrasia, and cardiac involvement occurs in up to 50% of the patients We present a case of a 43-year-old man, with complaints of periodical swollen tongue and xerostomia, bleeding gums and haematuria for two months. His blood results showed normocytic anaemia, thrombocytopenia and a high spontaneous INR, therefore he was referred to the Internal Medicine clinic. In the first visit, he showed signs and symptoms of overt congestive heart failure and was referred to the emergency department. The electrocardiogram showed sinus tachycardia and low voltage criteria. Echocardiography showed biventricular hypertrophy with preserved ejection fraction, restrictive physiology with elevated filling pressures, thickened interatrial septum and atrioventricular valves, small pericardial effusion and relative "apical sparing" on 2D longitudinal strain. Cardiac MRI showed diffuse subendocardial late enhancement. Serum protein electrophoresis was inconclusive, however urine analysis revealed nephrotic range proteinuria, positive Bence Jones protein and an immunofixation test with a monoclonal lambda protein band. Abdominal fat biopsy was negative for Congo red stain, nevertheless a bone marrow biopsy was performed, revealing lambda protein monoclonal plasmocytosis, confirming the diagnosis of primary systemic amyloidosis. This case represents a rare cause of heart failure in a young adult. Low-voltage QRS complexes and typical echocardiography features should raise the suspicion for cardiac amyloidosis. Prognosis is dictated by the level of cardiac involvement; therefore, early diagnosis and treatment are crucial.

Native aortic valve pneumococcal endocarditis--fulminant presentation

Pneumococcal endocarditis is a rare entity, corresponding to 1 to 3% of native valve endocarditis cases. It has a typically adverse prognosis, with high mortality. There is a reported predilection for the aortic valve; thus, a common presentation is acute left heart failure. We present a case of a 60-year-old woman with a history of sinusitis, who was admitted with the diagnosis of pneumonia. She rapidly deteriorated with signs of septic shock and was transferred to the critical care unit. The transesophageal echocardiogram revealed severe aortic regurgitation due to valve vegetations. Blood cultures were positive for Streptococcus pneumoniae. She underwent cardiac surgery and had multiple postoperative complications. Nonetheless, the patient made a slow and complete recovery. Infectious endocarditis should be ruled out if any suspicion arises, and echocardiography should be performed in an early stage in patients with poor response to vasopressors and inotropes. Patients with pneumococcal endocarditis benefit from an aggressive approach, with performance of early surgery.

Effusive-constrictive pericarditis as the manifestation of an unexpected diagnosis

Constrictive pericarditis is a clinical condition characterized by the appearance of signs and symptoms of right heart failure due to loss of pericardial compliance. Cardiac surgery is now one of the most frequent causes in developed countries, while tuberculosis remains the most prevalent cause in developing countries. Malignancy is a rare cause but usually has a poor prognosis. The diagnosis of constrictive pericarditis remains a clinical challenge and requires a combination of noninvasive diagnostic methods (echocardiography, cardiac magnetic resonance and computed tomography); in some cases, cardiac catheterization is needed to confirm the diagnosis. The authors present the case of a 51-year-old man, hospitalized due to cardiac tamponade. Diagnostic investigation was suggestive of tuberculous etiology. Despite directed medical therapy, the patient developed effusive-constrictive physiology. He underwent pericardiectomy and anatomopathologic study suggested a neoplastic etiology. The patient died in the postoperative period from biventricular failure.

Epicardial ablation for prevention of ventricular fibrillation in a patient with Brugada syndrome

We present the case of a 60-year-old woman with Brugada syndrome, permanent type 1 electrocardiographic pattern, who had previously received an implantable cardioverter-defibrillator. She suffered frequent syncopal episodes and multiple appropriate shocks (around five per month) due to polymorphic ventricular tachycardia/ventricular fibrillation, refractory to quinidine therapy. Combined epicardial and endocardial electroanatomical mapping was performed with a view to substrate ablation. An area of abnormal fractionated electrograms, lasting up to 370 ms and up to 216 ms after the end of the surface QRS, was identified in the epicardium in the lower anterior part of the right ventricular outflow tract. Extensive epicardial ablation of this area, which eliminated the fractionated electrograms, led to the disappearance of the Brugada electrocardiographic pattern six weeks after ablation. Despite discontinuation of quinidine, no further ventricular arrhythmias occurred during follow-up, which is still of short duration.