Changes in right ventricular two-dimensional echocardiographic speckle-tracking indices in adult LVAD population: a prospective clinical study

Objective

Preserved right ventricular (RV) function is crucial in patients supported with left ventricular assist devices (LVAD). The use of strain derived from speckle tracking echocardiography (STE) is recommended by recent guidelines to evaluate intricate RV contractility. The data regarding long-term RV observation in LVAD patients using STE are limited. Thus, the study aimed to determine RV systolic function by STE in the remote period after LVAD implantation.

Methods

Patients with implanted third-generation LVADs with hydrodynamic bearing were prospectively enrolled (NCT05063006). The RV STE indices were analyzed before and after LVAD implantation, both at rest and during the cycle ergometer exercise test.

Results

We included 22 patients, the mean age was 58.4±7 years, 95.5% were men, and 45.5% had dilated cardiomyopathy. Stress tests were conducted 7 months postoperatively. The RV strain analysis was feasible in all subjects both in rest and exercise. The RV free wall strain (RVFWS) worsened from −13% (IQR, −17.3 to −10.9) to −11.3% (IQR, −12.9 to −6; p=0.033) after LVAD implantation with the particular decline in the apical RV segment [−11.3% (IQR, −16.4 to −6.2) vs −7.8% (IQR, −11.7 to −3.9; p=0.012)]. The RV four-chamber longitudinal strain (RV4CSL) remained unchanged [−8.5% (IQR, −10.8 to −6.9) vs −7.3% (IQR, −9.8 to −4.7; p=0.184)]. Neither RVFWS (−11.3% (IQR, −12.9 to −6) vs −9.9% (IQR, −13.5 to −7.5; p=0.077) nor RV4CSL [−7.3% (IQR, −9.8 to −4.7) vs −7.9% (IQR, −9.8 to −6.3; p=0.548)] changed during cycle ergometer stress test.

Conclusion

The RVFWS worsens after LVAD implantation presumably due to impaired apical contractility. In LVAD-supported patients during the cycle ergometer stress test, the detailed RV strain analysis is feasible and its indices remain unchanged.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): 1. Cor Aegrum Foundation of Cardiac Surgery Development in Cracow2. Medtronic Poland sp. z o.o.

Heterogeneous and overlapping mechanisms of myocardial ischemia in patients with ischemia and non-obstructive coronary arteries. Preliminary results from the MOSAIC-COR Registry

Background

Patients with ischemia and non-obstructive coronary arteries (INOCA) account for 30–70% of all patients undergoing elective coronary angiography for angina. In these group of patients various mechanisms may be responsible for myocardial ischemia, including increased microvascular resistance, epicardial spasm or microvascular spasm. There are limited data on the prevalence and coexistence of different mechanisms in patients with INOCA.

Purpose

The primary objective was to assess the occurrence of coronary microcirculatory disease (CMD), epicardial vasospastic angina (EVSA), microvascular vasospastic angina (MVSA) and their coexistance in patients with INOCA. The secondary objective was the analysis of subgroups' clinical characteristics.

Methods

This was a single-center, prospective, observational study. In the absence of significant coronary artery stenosis, a complex functional coronary assessment was performed. Values of fractional flow reserve (FFR), RFR, coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were determined. Coronary artery and microvascular vasoreactivity was tested using the provocative acetylcholine test.

Results

We enrolled 90 consecutive patients with INOCA. Overlapping of CMD and CMD/EVSA phenomenon was observed. Accordingly, we distinguished 6 subgroups of INOCA patients in comparison to the CorMicA trial. Mixed pathophysiology (CMD+EVSA and CMD+MVSA) was diagnosed in 33% of patients. In the CMD+EVSA subgroup, 73% of subjects were male, while in the CMD+MVSA only 7.1% were male (p=0.005). Typical cardiovascular risk factors were common in the whole INOCA group.

Conclusions

The INOCA population is a heterogeneous group with various pathophysiology of myocardial ischemia. Overlapping of different pathomechanisms is a frequent phenomenon, which has to be consider for treatment optimization and future research.

Funding Acknowledgement

Type of funding sources: None.

Echo-guided left ventricular assist device speed optimisation for exercise maximisation

Objective

Current generation left ventricular assist devices (LVADs) operate with a fixed rotation speed and no automated speed adjustment function. This study evaluates the concept of physiological pump speed optimisation based on aortic valve opening (AVO) imaging during a cardiopulmonary exercise test (CPET).

Methods

This prospective crossover study (NCT05063006) enrolled patients with implanted third-generation LVADs with hydrodynamic bearing. After resting speed optimisation, patients were randomised to a fixed-modified speed or modified-fixed speed CPET sequence. Fixed speed CPET maintained baseline pump settings. During the modified speed CPET, the LVAD speed was continuously altered to preserve periodic AVO.

Results

We included 22 patients, the mean age was 58.4±7 years, 4.5% were women and 54.5% had ischaemic cardiomyopathy. Exertional AVO assessment was feasible in all subjects. Maintaining periodic AVO allowed to safely raise the pump speed from 2900 (IQR 2640–3000) to 3440 revolutions per minute (RPM) (IQR 3100–3700; p<0.001). As a result, peak oxygen consumption increased from 11.1±2.4 to 12.8±2.8 mL/kg/min (p<0.001) and maximum workload from 1.1 (IQR 0.9–1.5) to 1.2 W/kg (IQR 0.9–1.7; p=0.028). The Borg scale exertion level decreased from 15.2±1.5 to 13.5±1.2 (p=0.005).

Conclusions

Transthoracic AVO imaging is possible during CPETs in patients with LVAD. Dynamic echo-guided pump speed adjustment based on the AVO improves exercise tolerance and augments peak oxygen consumption and maximum workload.

Echo-guided LVAD speed optimization for exercise maximization

Background

Continuous-flow left ventricular assist devices (LVAD) are becoming a destination therapy in patients with end-stage left ventricular dysfunction and a competitive method for heart transplantation. Current generation pumps operate with a fixed rotation speed and do not have the automatic speed adjustment capability. However, it was shown that acceleration of the pump speed during stress test increases the maximum exercise tolerance.

Purpose

The study aimed to evaluate the concept of dynamic pump speed optimization based on the echocardiographic assessment of aortic valve opening (AVO) during the cardiopulmonary exercise test (CPET).

Methods

Patients with implanted third-generation centrifugal continuous-flow LVAD's with hydrodynamic bearing were prospectively included. Two CPET's were performed after resting speed optimization. The first one with maintained baseline pump speed settings, and the second one with gradually increased speed depending on live echocardiographic imaging. The sequence of tests was random.

Results

Exercise AVO was apparent in all 22 included patients. The resting pump speed was 2691 RPM and incremented on average by 566 RPM (20%). Pump power and flow raised from 5.6 to 9.8 Watts (p&lt;0.0001) and from 5.8 to 7.3 l/min (p&lt;0.0001), respectively. Peak VO2 increased from 11.1 to 12.8 ml/kg/min (p=0.0003) and maximum workload from 1.1 to 1.2 W/kg (p=0.03). The Borg scale exertion level decreased from 15.2 to 13.5 (p=0.0049). There was a visible trend towards longer exercise time (36s) but no statistical significance was achieved (p=0.1).

Conclusion

Ultrasonographic AVO analysis is possible during CPET's in patients supported with LVAD. Dynamic echo-guided pump speed adjustment based on the AVO improves exercise tolerance, augments peak VO2 consumption and maximal workload. An automatic speed adjustment in the next generations of LVAD controllers might improve functional capacity and requires further basic, technological and clinical research.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): 1. Cor Aegrum Foundation of Cardiac Surgery Development in Cracow2. Medtronic Poland Sp. z o.o.

Balloon Aortic Valvuloplasty for Severe Aortic Stenosis as Rescue or Bridge Therapy

The study aimed to assess procedural complications, patient flow and clinical outcomes after balloon aortic valvuloplasty (BAV) as rescue or bridge therapy, based on data from our registry. A total of 382 BAVs in 374 patients was performed. The main primary indication for BAV was a bridge for TAVI (n = 185, 49.4%). Other indications included a bridge for AVR (n = 26, 6.9%) and rescue procedure in hemodynamically unstable patients (n = 139, 37.2%). The mortality rate at 30 days, 6 and 12 months was 10.4%, 21.6%, 28.3%, respectively. In rescue patients, the death rate raised to 66.9% at 12 months. A significant improvement in symptoms was confirmed after BAV, after 30 days, 6 months, and in survivors after 1 year (p < 0.05 for all). Independent predictors of 12-month mortality were baseline STS score [HR (95% CI) 1.42 (1.34 to 2.88), p < 0.0001], baseline LVEF <20% [HR (95% CI) 1.89 (1.55-2.83), p < 0.0001] and LVEF <30% at 1 month [HR (95% CI) 1.97 (1.62-3.67), p < 0.0001] adjusted for age/gender. In everyday clinical practice in the TAVI era, there are still clinical indications to BAV a standalone procedure as a bridge to surgery, TAVI or for urgent high risk non-cardiac surgical procedures. Patients may improve clinically after BAV with LV function recovery, allowing to perform final therapy, within limited time window, for severe AS which ameliorates long-term outcomes. On the other hand, in patients for whom an isolated BAV becomes a destination therapy, prognosis is extremely poor.

Inpatient Cardiac Rehabilitation after Transcatheter Aortic Valve Replacement Is Associated with Improved Clinical Performance and Quality of Life

Cardiac rehabilitation (CR) provides multifactorial support and intervention for cardiac patients and improves quality of life (QoL). We aimed to assess clinical performance and QoL changes in patients undergoing transcatheter aortic valve replacement (TAVR) scheduled directly to inpatient CR (CR group) and those who were discharged home (DH group). The following patient-related outcomes were recorded: 5 m walk time (5MWT), 6 min walk test (6MWT), handgrip strength (HGS) with dynamometer, Katz index of Independence of Activities in Daily Living (KI of ADL), Hospital Anxiety and Depression Scores (HADS) Score. Quality of life was evaluated with Kansas City Cardiomyopathy Questionnaire (KCCQ). Baseline data, 30-day and 6- and 12-month data were assessed. The CR group consisted of 52 patients and 53 were in the discharged home (DH group). When we compared outcomes between the groups, the 5MWT, 6MWT, HGS KI of ADL, and KCCQ were significantly better in the CR group at 30 days (p = 0.03, p = 0.01, p = 0.02, p = 0.048, respectively), and no difference was found in HADS scores. At 6 months, the effect of CR was sustained for 6MWT, HGS, KI of ADL, and KCCQ (p = 0.001, p = 0.001, p = 0.03, p = 0.003, respectively) but not for 5MWT. Interestingly, at 12 months, the CR group had better performance only in 6MWT and HGS compared with the DH group (p = 0.04, p = 0.03, respectively). We showed that inpatient CR is strongly associated with better clinical performance and QoL in patients undergoing TAVR. All patients may benefit from CR after TAVR. The most important aspect of inpatient CR after TAVR from the patient’s perspective may be better performance in daily activities; however, performance was attenuated after 1 year.

Final 5-year outcomes following aortic valve replacement with a RESILIA™ tissue bioprosthesis

OBJECTIVES

Long-term durability of bioprosthetic valves is predominantly limited by structural valve deterioration. RESILIA™ tissue has exhibited reduced calcification in pre-clinical and early clinical studies. This study evaluated the 5-year clinical and haemodynamic outcomes of an aortic valve with this tissue.

METHODS

This was a prospective, non-randomized, single-arm study of 133 patients implanted with a RESILIA aortic bioprosthesis between July 2011 and February 2013 at 2 sites in Poland. Clinical outcomes and haemodynamic performance were assessed annually for 5 years post-implant. Safety events were adjudicated by a Clinical Events Committee and echocardiographic data were assessed by an independent core laboratory.

RESULTS

Mean patient age was 65.3 ± 13.5 years, with 34 patients (25.6%) ≤60. The mean follow-up was 4.2 ± 1.5 years. Early (≤30 days) and late (>30 days) all-cause mortality were 2.3% (N = 3) and 3.2%/late patients-years (N = 18) respectively. Early events included thromboembolism in 3 patients (2.3%). Late valve-related events included endocarditis in 1 patient, which led to explant, and valve thrombosis in another patient. There were no events of structural valve deterioration throughout the study. At 5 years, mean gradient was 14.8 ± 7.6 mmHg and effective orifice area was 1.4 ± 0.5 cm2, a marked improvement over baseline values. All New York Heart Association class III patients and most class II patients at baseline had improved classifications at 5 years.

CONCLUSIONS

The bioprosthesis with RESILIA tissue demonstrated a good safety profile with excellent haemodynamic performance over 5 years of follow-up. These encouraging outcomes warrant additional investigation of this novel tissue.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01651052.

P1369 Mitral regurgitation reduction after transcatheter aortic valve implantation (TAVI)

BACKGROUND

Concomitant mitral regurgitation (MR) is frequently observed in patients with severe aortic stenosis. Improvement of functional MR after TAVI has previously been reported, although influence of TAVI on organic MR remains unclear.

METHODS

We analyzed 136 patients who underwent TAVI in years 2017-2018 in our center. 16 of them had none or trivial preprocedural MR, 80 had mild preprocedural MR (nonsignificant MR group) and 40 had moderate or severe regurgitation (significant MR group). Specific etiology of each significant MR was classified as functional (11 patients), organic or mixed (29 patients). In addition, left ventricular ejection fraction (EF) was assessed using Simpson"s method. Follow-up (discharge) transthoracic echocardiographywas performed 1 to 5 days after TAVI.

RESULTS

MR diminished in 33,9% of patients undergoing TAVI (nonsignificant and significant MR group, p = 0,0118). Reduction of MR was pronounced in both: functional MR (45,4%, p = 0,0152) and organic or mixed etiology (72,4%, p = 0,0000). Left ventricular EF did not change after TAVI (p = 0,976).

CONCLUSIONS

Mitral regurgitation decreases significantly after TAVI, regardless of the etiology.

P1471 Aortic, mitral and tricuspid valve transcatheter therapy in patient with severe chronic heart failure

Introduction

The objective of this case is to present a novel approach in percutaneous treatment of complex valvular heart disease in patient disqualified from cardiac surgery.

Case Description

A 59 year-old-man with a history coronary heart disease, myocardial infarctions (in 1993, 2011), percutaneous right coronary angioplasty (2011,2012), chronic kidney disease, persistent atrial flutter, Hodgkin"s lymphoma treated with radiotherapy and chemotherapy, was admitted to hospital due to congestive heart failure in NYHA class IV, despite optimal, maximal tolerated pharmacological treatment (furosemide 40 mg tid, torasemide 20 mg qd, bisoprolol 5 mg qd, perindopril 5 mg qd, spironolactone 25 mg qd, acetylsalicylic acid 75 mg qd, atorvastatin 40 mg qd)

Physical examination showed

BMI tachycardia 110/sec, blood pressure 95/68 mmHG, systolic murmur grade 5/6 best heard at the apex, moderate leg oedema. Chest auscultation revealed crepitations.

Echocardiography revealed severe, functional mitral (MR) - 4+(VC 8/20 mm) and tricuspid (TR) regurgitation (4+); combined aortic valve disease (moderate stenosis (SA), mild regurgitation (AR) - SA max. grad. 39/23mmHg, valve area -1.3-1.4 cm2, LV end diastolic diameter (LVEDD)/LV end-systolic diameter (LVESD) 57/44 mm, LV ejection fraction 48%, both atrium enlargement (left atrium 38 cm2, right atrium 35 cm2).

Angiography didn`t show significant changes in coronary arteries.

Because of high surgical risk (Euroscore II 9,14%, STS 7,29%) and porcelain aorta confirmed in CT scan Heart Team disqualified patient from cardiac surgery (mitral and aortic valve replacement and tricuspid valve annuloplasty). Afterward he was qualified to complex, percutaneous treatment – TAVI (trans-aortic valve implantation) in first stage, and transcatheter Mitraclip and Triclip implantation in second stage.

The Portico transcatheter aortic valve (29mm) was implanted – max. grad. was 11 mmHg, residual small paravalvular leak was noted.

Two weeks later transcatheter Mitraclip and Triclip implantation was performed and significant reduction of both MR (2+/3+) and TR (2+) was observed.

Gradually after percutaneous treatment dyspnoea improved to class NYHA I/II and one month later patient was discharged to home.

Discussion

Percutaneous treatment of valvular heart diseases becomes a promising alternative for patients disqualified from cardiac surgery.

Intermediate-term outcomes after aortic valve replacement with a novel RESILIATM tissue bioprosthesis

Background

The durability of bioprosthetic heart valves is limited by structural valve deterioration (SVD) due to long-term calcification. A novel bioprosthetic tissue (RESILIA^TM) has been developed which, in preclinical studies, has shown reduced calcification. The purpose of this study was to evaluate the intermediate-term clinical outcomes and hemodynamic performance of this tissue.

Methods

A prospective, single-arm, observational trial was conducted in patients who required surgical aortic valve replacement (AVR). Between July 2011 and February 2013, 133 patients were implanted at two sites in Poland. Hemodynamic performance and clinical outcomes were assessed annually through 4 years of follow-up. All safety events were adjudicated by an independent Clinical Events Committee, and echocardiographic data were evaluated by a core laboratory.

Results

Patients were 65.3±13.5 years old and 26% were ≤60 years old. The average follow-up was 3.8±1.1 (median: 4.1; IQR, 4.0-4.3) years. Early (≤30 day) and late (>30 day) all-cause mortality rates were 2.3% (n=3) and 3.2% late patient-years (n=16), respectively. There were no cases of early or late SVD. There was one early case of major paravalvular leak (0.8%), and no late cases. At 4 years, the mean gradient was 14.5±7.4 mmHg and the effective orifice area was 1.6±0.4 cm², both markedly improved from baseline. At 4 years, the New York Heart Association functional class had improved from baseline in 54.5% of patients.

Conclusions

The aortic bioprosthesis with novel RESILIA^TM tissue demonstrated excellent hemodynamic performance and safety outcomes over 4 years. Longer follow-up will be important to confirm the durability of this bioprosthesis.

Incidence of Postoperative Delirium and Its Impact on Outcomes After Transcatheter Aortic Valve Implantation

There are limited data on the occurrence of postoperative delirium after transcatheter aortic valve implantation (TAVI). We sought to investigate the incidence of delirium after TAVI and its impact on clinical outcomes. A total of 148 consecutive patients who underwent TAVI were enrolled. Of these patients, 141 patients survived hospital stay. The incidence of delirium was assessed in these patients for the first 4 days after the index procedure. The patients were divided into 2 groups based on the presence of delirium. Baseline characteristics, procedural and long-term outcomes, and frailty and quality-of-life indexes were compared among the groups. Of the 141 patients analyzed, 29 patients developed delirium. The transapical access was more common in patients with delirium (51.7% vs 8.9%, p <0.001). A greater median contrast volume load in the delirium group was noted (75 vs 100 ml, p = 0.001). Significantly more patients with delirium were considered as frail before TAVI. Thirty-day and 12-month all-cause mortality rates were higher in the delirium group (0.0% vs 17.2%, p <0.001; and 3.6% vs 37.9%, p <0.001, respectively). Differences in mortality were significant even after adjustment for baseline characteristics. The quality of life at 12 months, assessed by the 3-level version of the EuroQol 5-dimensional questionnaire, was similar in both groups. Despite a relatively minimally invasive character of TAVI as compared with surgery, some patients experience delirium after TAVI. Importantly, the occurrence of delirium after TAVI may help to identify patients with worse short- and long-term outcomes.

Impact of frailty on mortality after transcatheter aortic valve implantation

BACKGROUND

We sought to investigate the relation between frailty indices and 12-month mortality after transcatheter aortic valve implantation (TAVI).

METHODS

We included 101 consecutive patients with severe aortic stenosis who have undergone TAVI. Frailty indices according to Valve Academic Research Consortium-2 recommendations (5-m walk test [5MWT] and hand grip strength) as well as other available scales of frailty (Katz index, Elderly Mobility Scale [EMS], Canadian Study of Health and Aging [CSHA] scale, Identification of Seniors at Risk [ISAR] scale) were assessed at baseline. The primary endpoint was 12-month all-cause mortality.

RESULTS

Twelve-month all-cause mortality was 17.8%. According to 5MWT, 17.8% were frail; hand grip test: 6.9%; Katz index: 17.8%; EMS: 7.9%; CSHA scale: 16.9%; and ISAR scale: 52.5%. Associations between frailty indices and 12-month all-cause mortality after TAVI were significant in Cox regression analysis (frail vs not frail, presented as hazard ratio[95%CI] adjusted for logistic EuroSCORE): for 5MWT, 72.38 (15.95-328.44); for EMS, 23.39 (6.89-79.34); for CSHA scale, 53.97 (14.67-198.53); for Katz index, 21.69 (6.89-68.25); for hand grip strength, 51.54 (12.98-204.74); and for ISAR scale, 15.94 (2.10-120.74). Similarly, such relationship was confirmed when 5MWT, EMS, and CSHA were used as continuous variables (hazard ratio [95%CI] adjusted for logistic EuroSCORE: for 5MWT per 1-second increase, 2.55 [1.94-3.37]; for EMS per 1-point decrease, 2.90 (1.99-4.21); and for CSHA per 1-point increase, 3.13 [2.17-4.53]).

CONCLUSIONS

Our study confirmed a strong predictive ability of most of the proposed frailty indices for 12-month mortality after TAVI. For patients scheduled for TAVI, the use of frailty indices, which are easy and quick to assess on clinical basis but with strong performance, for example, 5MWT, EMS, or hand grip test, may be advocated.

Ultrasonographic caval indices do not significantly contribute to predicting fluid responsiveness immediately after coronary artery bypass grafting when compared to passive leg raising

Background

Appropriate fluid management is one of the most important elements of early goal-directed therapy after cardiothoracic surgery. Reliable determination of fluid responsivenss remains the fundamental issue in volume therapy.

The purpose of the study was to assess the usefulness of dynamic IVC-derived parameters (collapsibility index, distensibility index) in comparison to passive leg raising, in postoperative fluid management in mechanically ventilated patients with left ventricular ejection fraction ≥ 30 %, immediately after elective coronary artery bypass grafting.

Methods

Prospective observational case series study including 35 patients with LVEF ≥ 30 %, undergoingelective coronary artery bypass grafting was conducted. Transthoracic echocardiography, passive leg raising and intravenous administration of saline were performed in all study subjects. Dynamic parameters derived from ultrasonographic assessment of the IVC diameter (collapsibility index–CI and distensibility index–DI), cardiac output

Results

There were 24 (68.57 %) responders in the study population. There were no statistical differences between the groups in relation to: clinical parameters, pre- and postoperative LVEF, fluid balance and CVP. Change in cardiac output after passive leg raising correlated significantly with that after the volume expansion (p=0.000, r=0.822). Dynamic IVC derivatives were slightly higher in fluid responders, however this trend did not reach statistical significance. None of the caval indices correlated with fluid responsiveness.

Conclusion

Dynamic IVC-derived parameters do not predict fluid responsiveness in mechanically ventilated patients with preserved ejection fraction immediately after elective coronary artery bypass grafting. Passive leg raising is not inferior to volume expansion in differentiating between fluid responders and nonresponders. Immediate fluid challenge after CABG is safe and well tolerated.

Electronic supplementary material

The online version of this article (doi:10.1186/s12947-016-0065-4) contains supplementary material, which is available to authorized users.