Could echocardiographic left atrial characterization have additive value for detecting risks of atrial arrhythmias and stroke in patients with hypertrophic cardiomyopathy?

Background

Atrial arrhythmia (AA) is considered a turning point for prognosis in hypertrophic cardiomyopathy (HCM) patients. Prediction of AA and associated stroke risk in patients with HCM is an important clinical challenge as these events can occur in young subjects and significantly impact their quality of life. (1) (2)

Purpose

We sought to assess whether an echocardiographic evaluation focused on the left atrial (LA) characterization could estimate the occurrence of AA and stroke in HCM patients.

Methods

216 HCM-patients (52±16 years old) were enrolled between 2016 and 2019. All patients underwent transthoracic echocardiography for the evaluation of left atrial volume (LAV), left ventricular global longitudinal strain (LV-GLS), peak left atrial strain (PLAS) and peak atrial contraction strain (PACS) by speckle-tracking imaging. A composite endpoint was defined as a history of AA and/or a history of stroke or peripheral embolism and/or occurrence of AA.

Results

The patients were followed for 2.9 years. Among the 216 patients, 78 (36%) met the composite endpoint. These patients were older (50.3±16.7 vs. 57.1±14.4 years, p=0.0035), had a higher prevalence of arterial hypertension (42.3% vs. 62.3%; p=0.005) and had higher NT-proBNP levels. LAV (37.2±15.7 vs. 47±20 ml/m2, p=0.0001) was significantly higher in patients who met the composite endpoint, whereas PLAS and PACS were significantly impaired (26.6±9.12 vs. 19.3±9.54%; p<0.0001 and 13.1±6.3% vs. 8.8±6.5%; p<0.0001, respectively). After adjustment, PLAS and PACS remained independently associated with events with an odds ratio (OR) of 0.42 for PLAS (95% CI, [0.29–0.61]; p<0.0001). Stroke occurred in 67% of the patients without any clinical AA. PLAS with a cut-off of under 15.5% provided event detection with 91% specificity and demonstrated a predictive value for new-onset of AA. Although there was a high correlation between PLAS and LV-GLS, LV-GLS was not associated with the events.

Conclusion

The impairment of LA function assessed by 2D speckle-tracking echocardiography was strongly associated with AA and the risk of stroke, even in patients without any documented AA. Its value for guiding the management of HCM-patients requires further investigation.

Funding Acknowledgement

Type of funding sources: None.

Functional tricuspid regurgitation : a clustering analysis and prognostic validation of 3 phenotypes on an external cohort

Funding Acknowledgements

Type of funding sources: None.

Background

Functional tricuspid regurgitation (FTR) ≥ moderate is an independent risk factor of morbidity and mortality. FTR could be classified into 2 categories: "atrial functional-TR" (AF-TR) and "ventricular functional-TR" (VF-TR). Percutaneous procedures increase interest in best understanding and selecting patients eligible for intervention. We aim to study echocardiographic criteria associated with the prognosis in patients with severe TR, using a clustering method on a retrospective monocentric cohort that we applied to an external validation prospective multicentric cohort.

Methods and results: Ninety-two patients with severe TR (mean age 77.9 ± 13 years, 48.9% female, atrial fibrillation in 68.5%) were enrolled. A hierarchical clustering analysis was conducted. Four parameters explained the clustering categorization (right ventricular (RV) end-diastolic mid-cavity diameter, RV free-wall Strain, right atrial (RA) volume index, RA Strain; p = 0,0039). Three clusters were identified: Cluster 1 with better right ventricular, left ventricular, and right atrial function (related to AF-TR) compared with Cluster 2 (related to VF-TR). Cluster 3 includes patients with severely dilated heart chambers, and RV and RA dysfunction. When applying the 3 clusters in the validation cohort (149 patients), the primary endpoint (hospitalization for Heart failure and/or death from any cause) was significantly better in cluster 1 in 30.8% versus 48% and 58.8% in clusters 2 and 3 respectively (p < 0.05).

Conclusion

Three phenotypes of FTR were built.  Significant TR assessment should include RV and RA characteristics. AF-TR seems to have a better prognosis than VF-TR (under non interventional management). Abstract Figure. survival according to clusters

prognostic evaluation of patients benefiting from a trans aortic valve replacement according to the type of aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic Stenosis (AS) is a common condition in patients over 75 years.  Latest ESC recommendations differentiate 4 types of AS according to: Indexed Stroke Volume (SVi), mean gradient and left ventricular ejection fraction (LVEF). The aim of our study is to evaluate prognosis of patients who have had a transcatheter aortic valve replacement (TAVR), in terms of mortality, according  to the 4 types of AS.

Methods

This study compares prognosis of 620 patients who had TAVR between January 1, 2015 and December 31, 2018. Patients were classified into 4 groups according to AS type: high gradient; low gradient, low flow, low LVEF; low gradient, low flow, normal LVEF; low gradient, normal flow.

Results

69 patients (11.1%) died within 12 months of the procedure: 49 in the high gradient group (9.4%); 13 in the low gradient, low flow, low LVEF group (47.1%); 1 in the low gradient, low flow, normal LVEF group (5%); 6 in the low gradient, normal flow, normal LVEF group (18.2%). All-cause mortality at one year follow-up is higher in low-gradient, low-flow, altered LVEF group (p = 0.0004) than in other groups. Patients in this group were significantly more often admitted for heart failure than patients in high-gradient group (p = 0.009).

Conclusion

A complete echocardiography evaluation is needed to evaluate AS, its severity and type. Patients in the low gradient, low flow, low LVEF group have an independent risk of mortality at 12 months higher than other groups and are more hospitalized than patients in the high gradient group.