Tricuspid regurgitation: frequency, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP valvular heart disease II survey

Background

Tricuspid regurgitation (TR) is frequent among patients with severe left-sided valvular heart disease (LS-VHD).

Objectives

This study sought to assess TR frequency, management and outcome in this population.

Methods

Among 6883 patients with severe LS-VHD or previous valvular intervention in the EURObservational Research Programme prospective VHD II survey, we analyzed frequency and grade of TR according to LS-VHD, and 6-month survival according to TR grade. Among 2081 patients who underwent an intervention for severe LS-VHD, we analyzed frequency and outcome of concomitant TV intervention, and concordance between Class I indications for concomitant TV surgery (patients with severe TR) and real-practice decision-making.

Results

Moderate to severe TR was very frequent among patients with severe mitral VHD (≥30%), especially in patients with secondary mitral regurgitation (46%), and rare among patients with aortic VHD (<5%). Higher TR grade was associated with a poorer 6-month survival (P<0.001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (more than 40%). Concomitant TV intervention at the time of left-sided heart valve surgery (LS-HVS) was not associated with an increase in-hospital mortality (P=0.93). Concordance between Class I indications for concomitant TV surgery at the time of LS-HVS according to guidelines and real-practice decision-making was very good (88% overall).

Conclusion

TR was frequent in patients with mitral VHD and was associated with a poorer outcome as TR grade increased. Compliance to guidelines for Class I indications for concomitant TV surgery at the time of LS-HVS was very good. With the trend toward more transcatheter treatment for left-sided VHD, there is a critical need for safe and efficient tricuspid valve transcatheter treatment for patients with concomitant TR.

Funding Acknowledgement

Type of funding sources: None.

Parameters of left atrial during stress in patients with asymptomatic primary mitral regurgitation

Introduction

Progressive volume overload caused by chronic mitral regurgitation (MR) leads to left atrium (LA) and left ventricle (LV) remodeling. Despite these structural changes, most of MR patients may remain asymptomatic for a long time. LA enlargement and reduced LA deformation parameters in asymptomatic MR patients predict a worse prognosis and may provide additional information to guide for earlier surgery.

Purpose

The aim of the study was to evaluate changes of LA size and deformation parameters in patients with asymptomatic primary MR during stress.

Methods

84 asymptomatic patients (age 59.87±13.47 years) with sinus rhythm and preserved left ventricle (LV) ejection fraction (EF) (>50%) at rest were included in the study. Resting and stress (veloergometry as per protocol 25 + 25 W every 3 minutes) echocardiography and speckle tracking off-line analyses were performed to 52 (61.9%) patients with moderate MR (MR group) and 32 (38.1%) patients without significant heart valves disease (control group). Statistical analyses were performed using the SPSS 20.0 software. The value of p<0.05 was considered as statistically significant.

Results

Volume index of LA was significantly higher in subjects with MR (picture 1). LA area was similar in MR and control groups at rest. However, during stress LA area became significantly larger in MR group (picture 1). LA myocardial deformation parameters were calculated during 3 phases of LA cycle: reservoir phase strain (LASr), conduit phase strain (LAScd), contraction phase strain (LASct). At rest, during peak stress and at recovery phase all of them were higher in controls but difference was not significant. During initial stress (25 W) LAScd was significantly higher in MR group (−16.86±−8.06% vs. −11.33 ±−6.26% p=0.034), while healthy subjects had a tendency to lower LASr (20.32±10.53% vs. 22.7±10.89%, p=0.535) (picture 1). Better LV EF at rest was related to smaller LA area (p=0.003, r – 0.390) and volume index (p=0.020, r – 0.308) during peak stress.

Conclusions

Stress provokes significant increase of LA size (volume and area) and LAScd in patients with primary mitral regurgitation. Other myocardial deformation parameters of LA were not significantly related to MR. LV EF at rest correlates with LA parameters during peak stress.

Changes of LA parameters during stress

Funding Acknowledgement

Type of funding source: None

Accurate prediction of left ventricular diastolic dysfunction in 2D echocardiography using ensemble of deep convolutional neural networks

Introduction

Deep convolutional neural networks (CNNs) have been shown to be reliable in evaluating geometrically assessed systolic heart function, however, studies evaluating diastolic heart function, which reflects hemodynamic status, are scarce. This study presents a novel CNNs approach for recognition and evaluation of different diastolic left ventricular (LV) function measurements.

Purpose

To create a new CNNs approach in the assessment of LV diastolic function and compare the results with clinicians' measurements.

Methods

A total of 4586 2D echocardiographic images were extracted from the studies of 330 patients referred with varying indications. The ensemble of four CNNs was trained (80/20% training/validation patient split) for the assessment of transmitral inflow (E and A wave peak velocities), mitral septal and lateral annular velocities (e'), tricuspid regurgitation systolic velocity (Vmax) and detection the left atrial endocardium in apical four-chamber views. Additionally, E/A ratio, average E/e' ratio and left atrial volume index (LAVi) values were calculated for the evaluation of diastolic dysfunction according to the 2016 ASE/EACVI recommendations. CNNs performance in detecting diastolic dysfunction was compared to expert cardiologists on a set of 20 separate cases.

Results

Study results on the validation data showed that CNNs accurately predicted peak E/A ratio, average E/e' ratio (R2=0.88 and R2=0.89, respectively) and tricuspid regurgitation Vmax (R2=0.82). Figure 1 illustrates different functional LV measurements among the obtained echocardiographic images. Regarding the geometrical assessment of diastolic function, the segmentation model traced the left atrial endocardial border (intersection over union = 0.94) and subsequently was used in predicting the LAVi (R2=0.92). The ensemble of four CNNs had the area under the ROC curve of 0.93 for the detection of diastolic dysfunction when compared to expert cardiologists.

Conclusion

Deep CNNs demonstrate the capacity to detect peak velocities across different Doppler imaging modes and delineate left atrial endocardium border while using a relatively small dataset. Combining multiple CNNs has the potential of performing an accurate assessment of the diastolic LV function.

Funding Acknowledgement

Type of funding source: None

Value of tissue doppler indices for prediction of early atrial fibrillation recurrence after cardioversion

Background

Spectral tissue Doppler-derived E/e' ratio has been proposed as the best parameter in the prediction of atrial fibrillation (AF). Although relaxation and contraction are equivalent parts of a continuous cardiac cycle, where systolic and diastolic abnormalities have a variable contribution to the left ventricle (LV) failure. A new doppler index, E/(e'×s') ratio, combining an index of diastolic function (E/e') and marker of systolic LV function (s'), has been confirmed as a good predictor of new-onset AF, although value of E/(e'×s') ratio to predict AF recurrence was not evaluated.

Purpose

The aim of this study was to investigate whether E/(e'×s') may be better parameter than E/e' to predict AF recurrence after the electrical cardioversion (ECV) of persistent AF in patients with normal LV function.

Methods

The prospective study included 77 patients with persistent AF with preserved LV ejection fraction (>50%) and successfully performed ECV. Plasma level of NT-proBNP was measured for all the patients before the ECV. Transthoracic echocardiography was performed within the first 24 hours after successful ECV. Primary outcome was the early (at 1 month) recurrence of AF.

Results

At 1 month follow-up, 39 patients (50.6%) were in sinus rhythm. Binary logistic regression analysis showed that LV enddiastolic diameter >50 mm (HR 3.70, 95% CI 1.29–10.58, p=0.02), NT-proBNP >2000 ng/L (HR 3.28, 95% CI 1.01–10.71, p=0.04), E/e' (HR 1.74, 95% CI 1.27–2.39, p=0.001) and E/(e'×s') ratios (HR 8.17, 95% CI 1.57–42.4, p=0.01) were significant predictors of AF early recurrence after ECV. When we developed multivariate models using these potential confounding factors. To minimize the problem of collinearity E/e'and E/(e'×s') were included in 2 separate models. Multivariate analysis identified that E/(e'×s') ratio and E/e' ratio in combination with LV enddiastolic diameter >49.3 mm and NT-proBNP >2000 ng/L are able to predict early AF recurrence after ECV in 74% and 79% cases, respectively. E/(e'×s') ratio showed higher contribution in the model to predict AF recurrence compared to E/e' ratio (for E/(e'×s') ratio HR 18.94, 95% CI 2.39–149.66, p=0.005; for E/e' ratio HR 1.95, 95% CI 1.31–2.91, p=0.001). On ROC analysis, the diagnostic accuracy of E/(e'×s') and E/e' ratios were found to have the largest areas under the curve (E/(e'×s') ratio, AUC = 0.71, p=0.002 and E/e' ratio, AUC = 0.75, p<0.0001) with an optimal E/(e'×s') ratio cut-off value of 1.15 (sensitivity 97%, specificity 58%) and E/e' ratio value of 8.79 (sensitivity 89%, specificity 41%) for predicting early recurrence of AF after ECV.

Conclusions

Spectral tissue Doppler-derived ratios (E/(e'×s') and E/e') together with higher NTproBNP level and larger LV enddiastolic diameter predicted early AF recurrence after ECV. E/(e'×s') seems to be a more powerful predictor of AF early recurrence than E/e' ratio.

Funding Acknowledgement

Type of funding source: None

P1578 The prognostic value of left ventricle longitudinal strain and cardiac biomarkers in asymptomatic patients with chronic severe aortic regurgitation

Background

Because of adaptive remodelling of the left ventricle (LV), patients with chronic severe aortic regurgitation (AR) can remain asymptomatic for prolonged periods. The main clinical challenge is to avoid irreversible damage to the myocardium and LV dysfunction, but the time of surgery should be such that the benefits of surgery outweigh the risks at that particular time. We aimed to evaluate the predictive value of global LV longitudinal strain (GLS) and natriuretic peptide in severe AR.

Methods

Comprehensive and 2D speckle tracking echocardiography was performed in 84 patients with severe AR. Patients were divided into the asymptomatic group (n = 56; 41 men; mean age 46.1 ± 15.4 years) and the group with indications for AV surgery (n = 28; 27 men; mean age 49.0 ± 14.3 years). Asymptomatic patients were followed for about 4.4 ± 2.4 years. The primary endpoint was to detect the development of HF symptoms, deterioration in the LVEF(≤50%) and/or severe LV dilatation (EDD > 70mm or ESS > 50mm).

Results

Patients with the need of AV surgery showed a significantly larger impairment in GLS and higher increase in the values of NT-proBNP compared to asymptomatic patients (-17.2 ± 2.6 vs. -19.1 ± 2.4%, and 149.4 [86.6–500] vs. 112.5 [45.3–180.8]pg/mL, P < 0.05, resp.). Of the 56 patients who were initially asymptomatic, 49 patients were prospectively monitored. The primary endpoint was reached in 16 (33%) patients with AR. Despite the preserved LVEF at baseline, patients in need of AV surgery had lower GLS compared to those who remained stable while being monitored (-17.1 ± 2.3 vs. -20.1 ± 1.8%, P < 0.05). The baseline levels of NT-proBNP were higher among patients who progressed to needing AV surgery in comparison to that in no need of AV surgery at follow-up (194 [135-421.8] vs. 75.9 [34.1-136.7]pg/ml, P < 0.05). In multivariate analysis, GLS and NT-proBNP were independent predictors of AV surgery. ROC analysis showed that the probability of primary endpoint occurrence was greater in patients with GLS >-18.5% (AUC:0.85, P < 0.05) and NT-proBNP >130pg/ml (AUC:0.81, P < 0.05).

Conclusion

GLS and NT-proBNP may be used as independent prognostic predictors of optimal timing of operation in asymptomatic severe AR during follow-up.

Multivariate analysis Variables OR (95% CI) P Age 0.97 (0.89-1.06) 0.54 LV ESD 1.02 (0.78-1.34) 0.87 LV EF 1.07 (0.74-1.56) 0.71 GLS 3.36 (1.09-10.36) 0.035 NT-proBNP 1.02 (1.0-1.04) 0.049