EACVI survey on radiation exposure in interventional echocardiography

AIMS

The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey on radiation exposure in interventional echocardiography. The survey aimed to collect data on local practices for radioprotection in interventional echocardiography and to assess the awareness of echocardiography operators about radiation-related risks.

METHODS AND RESULTS

A total of 258 interventional echocardiographers from 52 different countries (48% European) responded to the survey. One hundred twenty-two (47%) participants were women. Two-thirds (76%) of interventional echocardiographers worked in tertiary care/university hospitals. Interventional echocardiography was the main clinical activity for 34% of the survey participants. The median time spent in the cath-lab for the echocardiographic monitoring of structural heart procedures was 10 (5-20) hours/month. Despite this, only 28% of interventional echocardiographers received periodic training and certification in radioprotection and 72% of them did not know their annual radiation dose. The main adopted personal protection devices were lead aprons and thyroid collars (95% and 92% of use, respectively). Dedicated architectural protective shielding was not available for 33% of interventional echocardiographers. Nearly two-thirds of responders thought that the radiation exposure of interventional echocardiographers was higher than that of interventional cardiologists and 72% claimed for an improvement in the radioprotection measures.

CONCLUSION

Radioprotection measures for interventional echocardiographers are widely variable across centres. Radioprotection devices are often underused by interventional echocardiographers, portending an increased radiation-related risk. International scientific societies working in the field should collaborate to endorse radioprotection training, promote reliable radiation dose assessment, and support the adoption of radioprotection shielding dedicated to interventional echocardiographers.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

ODP109 PARATHYROID HORMONE AND 25 OH VITAMINA D IN PREGNANCY: DATA FROM AN ARGENTINEAN COHORT SUPPORTING SUPPLEMENTATION

 

Vitamin D (Vit D) deficiency has become a global health care issue, as it affects a great number of women during pregnancy and lactation. Vit D levels are critical during pregnancy, being the mother the only source of them for the developing fetus; an enzymatic system for conversion of 25OH VitD into 1-25(OH) 2 VitD is present in the placenta, thus reinforcing the importance of VitD during gestation. VitD deficiency has been associated with obstetric complications and adverse outcomes in offspring, affecting skeletal, immunological and respiratory systems. It is known that prenatal supplements available do not contain enough VitD to fulfil requirements. It is generally accepted that elevated PTH is an indicator of VitD deficiency, and Hysaj O et al (2021) showed that 25OH VitD is a statistically significant determinant of PTH levels in early and late pregnancy.

Aim

To evaluateVitD status and its relationship to parathyroid hormone (PTH) in a cohort of pregnant women representative of multiple Argentinian regions.

Subjects and Methods

Data from samples of 423 pregnant women in 1st and 2nd trimester were collected between 2016 and 2021. VitD was measured in different platforms: DiaSorin Liaison CLIA (n=184), Roche COBAS ECLIA (n=166), Abbott ARCHITECT CMIA (n=33), Biomérieux VIDAS ELFA (n=18) and Siemens CENTAUR CLIA (n=16). PTH (ng/L) was measured in 162 samples by SIEMENS IMMULITE CLIA and Roche COBAS ECLIA. As VitD is light-exposure dependent, we considered warm and high light-exposure season period from December to March and cold and low light season from April to September. VITD (ng/L) levels were classified as Deficient (<20), Insufficient (between 21 and 29) and Sufficient (>30) (Endocrine Society, 2014).

Results

From 423 data collected, 102 were excluded because of lacking information on VitD supplementation. From the remaining non supplemented 321 samples, 48% resulted insufficient, 30% deficient and 22% sufficient for VitD (groups comparison: p< 0. 05, Kruskal Wallis-Dunn test). The seasonal period and pregnancy trimester distributions didn't show significant differences. Similar results of VitD insufficiency were found in the major used platforms, regardless the seasonal period considered. PTH results expressed as median and interquartile range were (ng/L): 32. 0 (13.7-169. 0) in Deficient pregnancies (N=92), 23.7(13.3-88. 0) in Insufficient (n=50) and 18.7 (9.8-55.7) in Sufficient (n=20).

Conclusions

This study shows VitD inadequate levels in 78% in non-supplemented pregnancies, regardless season or measurement platform. Relative elevated levels of PTH were associated to pregnancies with VitD deficiency, evidenciating a regulatory role according to published data. To improve VitD status during pregnancy it would be advisable to pose new strategies for prenatal supplements developed by a multidisciplinary professional team.

Presentation: No date and time listed

Epicardial adipose tissue in patients with systemic sclerosis

Background

Cardiac involvement is a major cause of death in patients with systemic sclerosis (SSc). Epicardial adipose tissue (EAT) has recently emerged as a mediator between systemic inflammatory disorders and cardiovascular disease, and may therefore play a role in the pathophysiology of cardiac involvement in SSc.

Purpose

To assess the correlation between EAT mass and left ventricular (LV) function, and to determine the prognostic value of EAT in patients with SSc.

Methods

Consecutive patients with SSc who underwent non-contrast thorax computed tomography and echocardiography were included. EAT mass was quantified using dedicated software (Figure A). The study endpoint was all-cause mortality.

Results

A total of 230 SSc patients [age 53±15 years, 14% male] were included. The median value of EAT mass was 67g (IQR: 45–101g). Patients with increased EAT mass (≥67g) showed specifically more impaired LV diastolic function as compared to patients with less EAT mass (&lt;67g). After adjusting for age and comorbidities, EAT remained independently associated with LV diastolic function parameters including left atrial volume index (B=0.031, P=0.025), LV mass index (B=0.139, P=0.036), E/E$'$ (B=0.025, P&lt;0.001) and E' (B=−0.012, P&lt;0.001). During a median follow-up of 8 years 42 patients died, and by Kaplan-Meier analysis patients with increased EAT mass showed higher all-cause mortality rate as compared to patients with less EAT mass (log-rank p&lt;0.001, Figure B). On multivariate analysis, EAT mass was independently associated with all-cause mortality (HR: 1.006; 95% CI: 1.001–1.010; p=0.010).

Conclusion

In patients with SSc, EAT mass is independently associated with LV diastolic dysfunction and higher mortality rate.

Funding Acknowledgement

Type of funding sources: None.

The impact of chronic obstructive pulmonary disease on right ventricular dysfunction and remodeling after aortic valve replacement

Background

Chronic obstructive pulmonary disease (COPD) is one of the most common comorbidities in patients with aortic stenosis (AS) and has been associated with a poor prognosis after both transcatheter and surgical aortic valve replacement (AVR). Since COPD is associated with an increase in right ventricular (RV) afterload, some studies already suggested that COPD causes RV dysfunction (RVD) and dilatation. On the other hand, RVD and remodeling can also occur due to chronic pressure overload secondary to the AS itself. However, there is no data that studied RVD and remodeling in AVR recipients in terms of COPD severity.

Purpose

We aimed to evaluate the impact of COPD on RVD and remodeling in patients with severe AS undergoing AVR before AVR and at 1-year follow-up, as well as the association between COPD severity and all-cause mortality.

Methods

Patients with severe AS who received either transcatheter or surgical AVR were included. Patients' demographic data, medical history and documented spirometry data were carefully collected, while two-dimensional and speckle tracking echocardiography measurements were performed according to recommended guidelines to evaluate RV systolic function and RV size. RVD was defined as tricuspid annular plane systolic excursion (TAPSE) ≤17mm. RV dilatation was defined by RV mid cavity &gt;35 mm, RV basal diameter &gt;42mm, and RV longitudinal diameter &gt;83mm. RV wall thickness above 5mm was considered as RV hypertrophy. Diagnosis of COPD was determined by the Society of Thoracic Surgeons' definition based on forced expiratory volume in first second (FEV 1&lt;75%, cut-off for COPD). The primary outcome was all-cause death at 1-year.

Results

A total of 293 patients (78.0 years, 58.4% male) were included. RVD was detected in 54 (18.4%) patients, while 55 (18.8%) patients had mild COPD and 43 (14.7%) patients had moderate or severe COPD. At 1-year follow-up, the prevalence of RVD significantly increased (18.4% versus 23.6%, p=0.004). Compared to baseline, RV free wall strain of lateral basal segment (p=0.046), TAPSE (p&lt;0.0001) and tricuspid regurgitation gradient (p=0.018) impaired whereas RV wall thickness (p=0.014), RV diameter index of lateral basal segment (p&lt;0.0001), and RV diameter index of lateral mid segment (p&lt;0.0001) increased, respectively. At 1-year follow-up, 33 patients died (Figure 1). On multivariate cox regression analysis, RVD (hazard ratio (HR) 2.781, 95% confidence interval (CI) 1.172–6.598; p=0.020) as well as mild (HR 4.695, 95% CI 1.787–12.336; p=0.002) and moderate-severe COPD (HR 4.725, 95% CI 1.717–13.006; p=0.003) were significantly associated with the endpoint (Table 1).

Conclusions

The prevalence of RVD significantly increased and it deteriorated at 1-year after AVR. RV remodeling observed more at lateral basal and mid segments of RV as well as wall thickness. RV dysfunction and COPD were the strongest predictors of mortality in this population.

Funding Acknowledgement

Type of funding sources: None.

Ratio between left and right ventricular end-diastolic volumes and outcomes in patients with heart failure and preserved ejection fraction

Background

Reference left and right ventricular (LV/RV) volumes normalized to age and gender have been published. However, the relative dilation of the LV compared to the RV in patients with heart failure (HF) symptoms and its prognostic association have not been evaluated.

Purpose

The present study investigated the relative dilation of the LV compared to the RV among patients with HF and preserved LV ejection fraction (HFpEF). We explored the association between LV/RV ratio (defined as the ratio between LV end-diastolic volume index [LVEDVi] and RV end-diastolic volume index [RVEDVi]) and outcomes.

Methods

Clinical and imaging data from consecutive ambulatory patients diagnosed with HFpEF between April 2011 and November 2021, and undergoing a cardiac magnetic resonance examination were retrieved. The endpoints were 1) all-cause death or first HF hospitalization, and 2) cardiovascular death or first HF hospitalization, 3) repeated HF hospitalizations.

Results

A total of 159 patients (median age 58 years [interquartile range 49–69], 64% men) were included. Median LVEF was 60% (54–70%), and the LV/RV ratio was 1.21 (1.07–1.40). Over a 3.5-year follow-up (1.5–5.0), all-cause death or first HF hospitalization occurred in 23 patients (15%) and cardiovascular death or first HF hospitalization in 22 (14%). Spline curve analysis showed a bimodal relationship between LV/RV and both outcomes, with a steep increase in risk &lt;1.0 and ≥1.4 (Figure 1). Accordingly, patients with either LV/RV &lt;1.0 or ≥1.4 had a much shorter survival free from both endpoints than patients with LV/RV 1.0–1.3 (Figure 2). An LV/RV &lt;1 was associated with a higher risk of all-cause death or first HF hospitalization (hazard ratio [HR] 5.95, 95% confidence interval [CI] 1.67–21.28; p=0.006) and a higher risk of cardiovascular death or first HF hospitalization (HR 5.68, 95% CI 1.58–20.35; p=0.008). Furthermore, an LV/RV ≥1.4 was associated with a higher risk of all-cause death or first HF hospitalization (HR 4.10, 95% CI 1.58–10.61; p=0.004) and a higher risk of cardiovascular death or first HF hospitalization (HR 3.71, 95% CI 1.41–9.79; p=0.008). Nine patients (6%) had more than 1 HF hospitalization. The crude incidence of HF hospitalizations was much higher in patients with an LV/RV &lt;1.0 (16.6 per 100 patient/years) or ≥1.4 (10.29 per 100 patient/years) than in those with LV/RV 1–1.3 (1.88 per 100 patient/years). Multivariable binomial negative regression showed significant association between LV/RV and recurrent HF hospitalizations after adjustment by age, gender and New York Heart Association class: LV/RV &lt;1.0 vs. 1.0–1.3, incidence rate ratio 9.0 per 100 patient/years (4.1–19.6), p&lt;0.001; LV/RV ≥1.4 vs. 1.0–1.3, incidence rate ratio 5.3 per 100 patient/years (1.5–8.4), p=0.009.

Conclusions

Among patients with HFpEF, an RVEDVi larger than the LVEDVi, or an LVEDVi ≥40% larger than the RVEDVi were significantly associated with worse outcomes.

Funding Acknowledgement

Type of funding sources: None.

Association between chronic obstructive pulmonary disease and all-cause mortality after aortic valve replacement for aortic stenosis

Introduction

Chronic obstructive pulmonary disease (COPD) and aortic stenosis (AS) are the most common diseases in aging population that their prevalence and percental change in mortality increase over the years. In severe AS, aortic valve replacement (AVR) is the only treatment that has demonstrated to improve survival, however the presence of comorbidities increases the operative risk and influences negatively on the outcomes after AVR. Therefore, the definition of COPD varies across the studies and is not always based on the use of pulmonary functional tests. Accordingly, the aim of the present study is to evaluate the association between pulmonary functional parameters and all-cause mortality after AVR in a large cohort of patients with severe AS.

Methods

Total of 400 patients (78.0 year-old, 56.7% men) with severe AS and documented preoperative pulmonary functional test (PFT) were retrospectively analyzed. Demographic and clinical characteristics were collected from electronic medical records while echocardiography was performed and measured according to the recommendations. PFTs were performed prior to AVR and categories defined in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database: normal pulmonary function was defined by an FEV1 &gt;75% of predicted; mild COPD if FEV1 was 60–75% of predicted; moderate COPD if FEV1 was 50–59% of predicted and severe COPD when FEV1 &lt;50% of predicted.

Results

Mild, moderate and severe COPD were documented in 75 (19%), 31 (8%) and 22 (5%) while the remaining 68% had normal PFTs. Patients with moderate and severe COPD had significantly larger LV mass and LV end-systolic volume whereas LV ejection fraction was significantly lower. The FVC, FEV1, Tiffeneau index, VC, PEF, and IC were the worst among patients with moderate and severe COPD (per definition) (p&lt;0.0001). Over a median follow-up of 32 months, 92 (23%) patients died. The survival rates were significantly lower in patients with moderate and severe COPD (Log rank p=0.003, Figure 1). In multivariable Cox regression analysis, some clinical factors and COPD were independently associated with all-cause mortality (table 1). Remarkably, any grade of COPD was associated with 2-fold increased risk of all cause-mortality (HR 1.933; 95% CI 1.166–3.204; p=0.011 for mild COPD and HR 2.028; 95% CI 1.154–3.564; p=0.014 for moderate/ severe COPD, separately).

Conclusion

Patients with moderate and severe COPD had higher LV hypertrophy and reduced LV ejection fraction while PFT parameters were the worst among these patients. The survival rates were significantly lower in patients with moderate and severe COPD compared with patients without COPD. In addition to other clinical factors, any grade of COPD was associated with 2-fold increased risk of all cause-mortality.

Funding Acknowledgement

Type of funding sources: None.

Mesenchymal stromal cell therapy with early tacrolimus withdrawal prevents left atrial remodelling in renal transplant recipients: an analysis of the TRITON trial

Background

After renal transplantation, there is a need for immunosuppressive regimens that effectively prevent allograft rejection, while minimizing cardiovascular side effects. The TRITON study is the first randomized clinical trial that tested a strategy with autologous bone marrow derived mesenchymal stromal cell (MSC) therapy and complete withdrawal of calcineurin inhibitors (CNIs). The combination of MSC therapy and CNIs discontinuation was associated with improved blood pression control and regression of left ventricular hypertrophy. Nevertheless, the impact of this immunosuppressive strategy on left atrial (LA) structural and functional remodelling, which has been proven as an independent predictor of cardiovascular outcomes, has not been investigated.

Purpose

To assess the effects of MSC therapy combined with CNIs withdrawal on longitudinal changes of LA structure and function, evaluated by two-dimensional transthoracic echocardiography.

Methods

The TRITON trial randomized renal transplant recipients to MSC therapy – infused at week 6 and 7 after transplantation, with complete withdrawal at week 8 of tacrolimus (MSC group) – or standard tacrolimus dose (control group). Patients who underwent transthoracic echocardiography with speckle-tracking analysis at week 4 and 24 after renal transplantation were included in this sub-analysis. Changes in echocardiographic variables between 4 and 24 weeks post-transplantation were evaluated and compared between randomization arms using an analysis of covariance model, adjusted for baseline variable.

Results

54 patients (MSC group =27; control group =27) were included. Between 4 and 24 weeks after transplantation, an increase in indexed minimal LA volume (LAVImin) was observed in the control group, whereas in the MSC group there were no changes in LAVImin over the time, leading to a significant difference between groups (p=0.021). Moreover, patients randomized to MSC therapy showed a benefit in LA function, assessed by a significant interaction between changes in LA emptying fraction (LAEF) and LA reservoir strain and the treatment group (p=0.012 and p=0.027, respectively) (Table 1).

The association between changes in LA structural and functional parameters and the randomization arm remained significant after adjustment for changes in systolic blood pressure, diastolic blood pressure and estimated glomerular filtration rate over the time (Figure 1).

Conclusion

The combination of MSC therapy and early CNIs withdrawal prevents LA structural and functional remodelling in the first six months after renal transplantation. MSC therapy appears a promising approach in renal transplant recipient, effective in the prevention of graft rejection, while exerting potential cardioprotective effects.

Funding Acknowledgement

Type of funding sources: None.

Assessment of left atrial function and diastolic dysfunction in patients with Becker muscular dystrophy

Background

Becker muscular dystrophy (BMD) is frequently characterized by myocardial involvement1 but little is known about the prevalence of left ventricular (LV) diastolic dysfunction (DD) in these patients, particularly when using more recently proposed measure of left atrial (LA) function.

Purpose

Purpose of our study was to assess LVDD in patients with BMD using the currently recommended echocardiographic multiparametric approach and adding LA reservoir strain as advanced measure of LVDD.

Methods

A total of 33 BMD patients (38±13 years) were analyzed including standard and advanced echocardiography at the time of their first visit and at 24 months follow-up. A control group consisted of 20 age- and gender-matched healthy subjects.

Results

18% of BMD patients showed an e'lateral &lt;10, 0% an E/e' &gt;14, 22% a LAVI &gt;34ml/m2 and 11% a tricuspid velocity &gt;2.8m/s. When applying the currently recommended multiparametric approach, 83% of BMD patients showed normal DD and 17% showed indeterminate LV diastolic dysfunction (50% positive parameters); no BMD patient had &gt;50% positive DD parameters for confirmed DD. LA reservoir strain was significantly lower in BMD patients as compared to controls (28±10% vs. 42±11%; p&lt;0.001) (Figure), while LA indexed volume (LAVI) was not (26±19 ml/m2 vs. 21±6 ml/m2; p=0.142). When using the reported median value of LA reservoir strain (47%) for normal subjects with comparable age2, 31 (94%) BMD patients had impaired LA strain, but when using the cut-off value of &lt;19% for increased LV filling pressure, 6 (18%) patients showed affected LA reservoir strain. Patients with more impaired six minute walk test (6MWT), defined as in the 1st tertile (1st tertile 0–309m; 2nd tertile 310–523m; 3rd tertile &gt;523m) had significantly lower LA reservoir strain (1st tertile, 22±6% vs. 2nd tertile, 29±14% vs. 3rd tertile, 33±5%; p=0.022). LA reservoir strain tended to deteriorate at 1 year follow-up but not significantly (from 29±10% to 26±12%; p=0.200).

Conclusions

LVDD is not highly prevalent in BMD patients but LA dysfunction as assessed by LA reservoir strain is reduced and may improve detection of myocardial involvement in these patients, also over time.

Funding Acknowledgement

Type of funding sources: None.

Prognostic relevance of left ventricular global longitudinal strain in patients with heart failure and reduced ejection fraction

Background

Patients with heart failure (HF) and reduced ejection fraction (HFrEF) are complex patients who often have a high prevalence of comorbidities and cardiovascular risk factors. However, risk stratification and treatment decision in these patients mainly depend on simple measurements of left ventricular (LV) ejection fraction (EF). In the present study, we investigated the prognostic significance of LV global longitudinal strain (GLS) along with important clinical and echocardiographic risk factors in patients with HFrEF.

Methods

Patients who had a first echocardiographic diagnosis of LV systolic dysfunction, defined as LVEF ≤45%, were identified. LV GLS was measured with speckle-tracking echocardiography and represented by a positive value. To divide the study population into 2 groups, spline curve analysis was used to derive the optimal threshold value of LV GLS (i.e. where the predicted hazard ratio for the endpoint was ≥1) (Figure 1). Patients were followed up for worsening HF, as well as the composite endpoint of worsening HF and all-cause mortality.

Results

A total of 2394 patients (mean age 63±12 years, 75% men) were analyzed. During a median follow-up of 60 months (interquartile range [IQR] 31–60 months), 306 patients (13%) experienced worsening HF and the composite endpoint of worsening HF and all-cause mortality occurred in 673 patients (28%). The 5-year event-free survival rates for the primary and secondary endpoint were significantly lower in the patients who had LV GLS ≤10% compared to the patients who had LV GLS &gt;10% (Figure 2A for worsening HF and Figure 2B for the composite endpoint of worsening HF and all-cause mortality). After adjustment for important clinical and echocardiographic risk factors, including HF treatments and baseline LVEF, baseline LV GLS remained independently associated with a higher risk of worsening HF (HR=0.95, 95% CI 0.90–0.99, p=0.029) and the composite of worsening HF and all-cause mortality (HR=0.94, 95% CI 0.90–0.97, p=0.001).

Conclusions

Baseline LV GLS is associated with long-term prognosis in patients with HFrEF, independently from various clinical and echocardiographic risk factors.

Funding Acknowledgement

Type of funding sources: None.

Prevalence and prognostic implications of discordant grading and flow-gradient patterns in moderate aortic stenosis

Background

The prognostic implications of discordant grading in severe aortic stenosis (AS) are well known. However, the prevalence of different flow-gradient patterns and their prognostic implications in moderate AS are unknown.

Purpose

To investigate the occurrence and prognostic implications of different flow-gradient patterns in patients with moderate AS.

Methods

Patients with moderate AS (aortic valve area 1.0–1.5 cm2) were divided in 4 groups, based on transvalvular mean gradient (MG), stroke volume index (SVi) and left ventricular ejection fraction (LVEF): concordant moderate AS (MG ≥20 mmHg); normal-flow, low-gradient discordant moderate AS (MG &lt;20 mmHg, SVi ≥35 ml/m2); “classical” low-flow, low-gradient discordant moderate AS (MG &lt;20 mmHg, SVi &lt;35 ml/m2 and LVEF &lt;50%) and “paradoxical” low-flow, low-gradient discordant moderate AS (MG &lt;20 mmHg, SVi &lt;35 ml/m2 and LVEF ≥50%). The primary endpoint was all-cause mortality.

Results

Of 1974 patients (age 73±10 years, 51% men) with moderate AS, 788 (40%) had discordant grading. Patients with discordant grading showed significantly higher mortality rates than patients with concordant grading (p&lt;0.001), even in the subgroup of patients having preserved LVEF (p=0.028) or preserved SVi (p=0.002). Of the patients with discordant grading, 71% had normal-flow, low-gradient moderate AS, 14% had “classical” low-flow, low-gradient moderate AS, and 14% had “paradoxical” low-flow, low-gradient moderate AS (Figure 1). Patients with normal-flow, low-gradient moderate AS, “classical” low-flow, low-gradient moderate AS, and “paradoxical” low-flow, low-gradient moderate AS had worse survival rates than patients with concordant grading (p&lt;0.001) (Figure 2). On multivariable analysis “paradoxical” low-flow, low-gradient (HR: 1.533; 95% CI: 1.133–2.075; p=0.006) and “classical” low-flow, low-gradient (HR: 1.926; 95% CI: 1.442–2.572; p&lt;0.001) but not normal-flow, low-gradient moderate AS were independently associated with all-cause mortality.

Conclusion

Discordant grading is frequently (40%) observed in patients with moderate AS. Low-flow, low-gradient patterns account for an important proportion of the discordant cases and are associated with increased mortality. These findings underline the need for better phenotyping patients with discordant moderate AS.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Prognostic value of left ventricular myocardial work indices in patients undergoing transcatheter aortic valve replacement

Introduction

Left ventricular myocardial work (LVMW) is a novel echocardiographic-based method to assess LV function using pressure-strain loops taking LV afterload into account. In patients with aortic stenosis (AS), this approach was shown to improve assessment of LV performance as compared to conventional and advanced parameters of LV systolic function, but data on its prognostic value are lacking.

Purpose

To evaluate the prognostic value of LVMW indices in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR).

Methods

LVMW indices, including LV global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were calculated in 281 patients with severe AS (age 82, IQR 78–85 years, 52% male) prior to the TAVR procedure. As previously validated, LV systolic pressure was derived non-invasively by adding the mean aortic gradient to the brachial systolic pressure. LV global longitudinal strain and LV systolic pressure were then incorporated to construct pressure-strain loops to determine the LVMW indices. The study endpoint was all-cause mortality.

Results

In the total population average GWI was 1872±753 mmHg%, GCW 2240±797 mmHg%, GWW 200 (IQR 127–306) mmHg% and GWE 89 (IQR 84–93)%. During a median follow-up of 52 (IQR 41–67) months, 64 patients died. These patients showed lower values of GWI (1644 vs 1940 mmHg%, p=0.006) and GCW (2010 vs 2307 mmHg%, p=0.009) as compared to patients who survived while GWW (197 vs 200 mmHg%, p=0.794) and GWE (88% vs 90%, p=0.102) were similar. While LV GCW, GWW and GWE did not show a significant association with the study endpoint, GWI was independently associated with all-cause mortality (HR per-tertile-increase 0.639; 95% CI 0.463–0.883; P=0.007), and the patients in the lowest GWI tertile showed the worst survival rates (Figure 1). Of interest, patients in the lowest GWI tertile were more likely to be male (63% vs 56% and 37% from the lowest to the highest tertile, P=0.001), had a higher prevalence of atrial fibrillation (26% vs 19% and 8% from the lowest to the highest tertile, P=0.006), worse renal function (53 mL/min/1.73 m2 vs 64 mL/min/1.73 m2 and 62 mL/min/1.73 m2 from the lowest to the highest tertile, P=0.038) and larger LV dimension (LVEDD 52 mm vs 47 mm and 46 mm from lowest through highest tertile, p&lt;0.001). Importantly, when added to a basal model, LVGWI yielded a higher increase in predictivity compared to both conventional and advanced parameters of LV systolic function (Figure 2). Also, in a model corrected for the hemodynamic class of AS (high-gradient, low-flow low-gradient), GWI also showed a significant independent association (P=0.003) with all-cause mortality.

Conclusions

LVGWI is independently associated with all-cause mortality in patients undergoing TAVR and has a higher prognostic value compared to both conventional and advanced parameters of LV systolic function.

Funding Acknowledgement

Type of funding sources: None.

Left atrial reservoir strain and long-term prognosis in patients with heart failure and reduced ejection fraction

Background

Cardiac damage in heart failure (HF) with reduced ejection fraction (HFrEF) often involves structural and functional left atrial (LA) abnormalities. Speckle-tracking echocardiography derived LA reservoir strain (LARS) is a sensitive measurement for early detection of LA dysfunction. However, the prognostic value of LARS is not well established in patients with HFrEF.

Methods

LARS was measured with speckle tracking echocardiography in patients who had a first echocardiographic diagnosis of reduced LVEF (≤45%). Patients with prior history of atrial fibrillation (AF) were excluded. The primary endpoint was newly onset AF, while the composite endpoint of newly onset AF and all-cause mortality was chosen as the secondary endpoint. The study population was divided into two groups according to the optimal threshold value of baseline LARS (derived from spline curve analysis) (Figure 1) and event-free survival rates were compared by the Kaplan-Meier method.

Results

A total of 997 patients (mean age 62±13 years, 73% men) were analyzed. At baseline, LA volume index was significantly larger (41±17 vs. 32±12 ml/m2, p&lt;0.001), and LA reservoir function significantly more impaired (9±3.1 vs. 21±6.3%, p&lt;0.001) in patients with LARS ≤14% compared to patients with LARS &gt;14%. During a median follow-up of 60 months (interquartile range [IQR] 29–60 months), newly onset AF occurred in 75 patients (7.5%), while 254 patients (25.5%) experienced the composite endpoint of newly onset AF and all-cause mortality. The 5-year event-free survival rates for both endpoints were significantly lower in the LARS ≤14% group compared to LARS &gt;14% group (Figure 1A for new onset AF and Figure 2B for the composite endpoint of newly onset AF and all-cause mortality). After adjustment for important risk factors, including HF treatments and echocardiographic predictors, baseline LARS remained independently associated with a higher risk of development of AF (HR=0.89, 95% CI 0.85–0.94, p&lt;0.001) and the composite of newly onset AF and all-cause mortality (HR=0.93, 95% CI 0.91–0.96, p&lt;0.001).

Conclusions

Baseline LARS is associated with long-term prognosis in patients with HFrEF and the association is independent from various clinical and echocardiographic predictors.

Funding Acknowledgement

Type of funding sources: None.

Prognostic implications of left ventricular diastolic dysfunction in moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Although left ventricular (LV) diastolic dysfunction (DDF) has shown to carry an unfavorable prognosis in severe AS, the prognostic value of LV DDF in MAS has not been investigated.

Purpose

To investigate the prognostic impact of LV DDF in patients with MAS and preserved LV ejection fraction (EF).

Methods

LV diastolic function was evaluated in patients with MAS (aortic valve area &gt;1.0 and ≤1.5cm2)  and preserved LVEF (≥50%) using echocardiography according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement (AVR).

Results

Of 1247 patients (age 74 ± 10 years, 47% men) with MAS and preserved LVEF, 396 (32%) had normal diastolic function, 316 (25%) had indeterminate diastolic function and 535 (43%) had DDF. Patients with DDF were more likely to be female, had more comorbidities (hypertension, atrial fibrillation, chronic kidney disease) and were more symptomatic (NYHA ≥2) than patients with normal diastolic function. Patients with DDF also had smaller aortic valve area and higher peak aortic velocities than patients with normal/indeterminate diastolic function. During a median follow-up of 53 (26 – 81) months, 484 (39%) patients died. For the composite endpoint, 770 patients (62%) underwent AVR (n = 376) or died (n = 394) during a median follow-up of 37 (IQR 15 – 62) months. Patients with DDF had significantly lower survival rates (p &lt;0.001) and event-free survival rates (p = 0.015) compared to patients with normal/indeterminate diastolic function (Figure 1). On multivariable analysis, DDF was independently associated with all-cause mortality (HR: 1.368; 95% CI: 1.085 – 1.725; p = 0.008) and the composite endpoint of all-cause mortality and AVR (HR: 1.241; 95% CI: 1.035 – 1.488; p = 0.020) (Figure 2).

Conclusion

LV DDF is associated with worse outcomes in patients with MAS. Assessment of LV diastolic function may contribute significantly to risk stratification of patients with MAS. Abstract Figure.  Abstract Figure.

Prognostic value of left ventricular global longitudinal strain in patients with moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Impaired left ventricular (LV) global longitudinal strain (GLS) is associated with worse outcomes in patients with severe aortic stenosis, but its prognostic value in patients with moderate aortic stenosis (MAS) is largely unknown.

Purpose

To investigate the prognostic implications of LV GLS in patients with MAS and preserved LV ejection fraction (EF).

Methods

LV GLS was evaluated by speckle tracking echocardiography in 621 patients (age 71 ± 12 years, 59% men) with MAS (aortic valve area 1.0 – 1.5cm2) and preserved LVEF (≥50%). Impaired LV GLS was defined as an LV GLS value &lt;16%, based on spline curve analysis (i.e. where the hazard ratio for all-cause mortality was ≥1). Clinical outcomes were defined as all-cause mortality and a composite endpoint of all-cause mortality and aortic valve replacement.

Results

Patients with LV GLS &lt;16% (n = 282) were significantly older, more likely to be male and had more comorbidities (diabetes mellitus, atrial fibrillation, more impaired renal function) compared to patients with LV GLS ≥16% (n = 339). In terms of echocardiographic data, patients with LV GLS &lt;16% had larger LV volumes, lower LVEF and higher E/e’. During a median follow-up of 53 (27 – 102) months, 199 (32%) patients died. For the composite endpoint, 409 patients (66%) underwent AVR (n = 290) or died (n = 119) during a median follow-up of 29 (IQR 14 – 54) months. Patients with LV GLS &lt;16% experienced significantly lower survival rates (p &lt; 0.001) and event-free survival rates (p = 0.001) compared to patients with LV GLS ≥16% (Figure 1). On multivariable analysis, LV GLS was independently associated with all-cause mortality (HR 2.442; 95% CI: 1.762 – 3.384; p &lt; 0.001) and the composite endpoint of all-cause mortality and aortic valve replacement  (HR 1.862; 95% CI: 1.498 – 2.315; p = 0.040) (Figure 2).

Conclusions

In patients with MAS and preserved LVEF, reduced LV GLS is associated with an increased risk of all-cause mortality and the composite endpoint of all-cause mortality and AVR. Assessment of LV GLS may be useful in the risk stratification of these patients. Abstract Figure. Kaplan-Meier curves  Abstract Figure. Cox regression analysis

Non-invasive left ventricular myocardial work in patients with chronic aortic regurgitation and preserved left ventricular ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

 Left ventricular global longitudinal strain (LV GLS) has been proposed as sensitive marker of myocardial damage in patients with chronic severe aortic regurgitation (AR) and preserved left ventricular ejection fraction (LVEF). However, LV GLS does not take into account the afterload.

Non-invasive LV myocardial work is a novel parameter of LV myocardial performance, which integrates measurements of myocardial deformation and non-invasive blood pressure (afterload).

Purpose

The aims of this study were: 1) to assess non-invasive LV myocardial work in patients with chronic AR and preserved LVEF and its correlation with other echocardiographic parameters, 2) to evaluate changes of LV myocardial work after aortic valve replacement or repair (AVR) and 3) to assess the relationship between LV myocardial work and post-operative LV reverse remodeling.

Methods

This retrospective study included fifty patients (53 ± 16 years; 68% men) with moderate or severe chronic AR and preserved LVEF, who underwent AVR. Non-invasive LV myocardial work indices were measured at baseline and post-operatively (between 2 and 12 months after surgery) and compared with previously reported normal reference ranges.

Results

Based on normal reference values, patients with chronic AR and preserved LVEF had preserved or increased values of LV global work index (LV GWI) (84% and 16%, respectively) and LV global constructive work (LV GCW) (78% and 22%, respectively) (Figure 1). In addition, LV global work efficiency (LV GWE) was preserved in all patients, despite 16 (32%) subjects had impaired values of LV GLS (&lt;16.7.% in men and &lt;17.8% in women). LV GWI and GCW showed a positive correlation with markers of AR severity and parameters of LV systolic function. AVR results in a significant reduction of myocardial work indices (p &lt; 0.0001), with the exception of LV global wasted work, that did not change (p = 0.29). According to normal reference ranges, 15 (30%) patients had impaired values of LV GWI and LV GCW post-operatively, while LV GLS was impaired in 37 (74%) patients. The post-operative impairment of LV GWI demonstrated a stronger association with reduced LV reverse remodeling, as compared to the impairment of LV GLS (Figure 2).

Conclusions

Compared to afterload-dependent echocardiographic parameters, non-invasive LV myocardial work indices allow a better understanding of myocardial performance and energetics in the setting of chronic AR with preserved LVEF and could improve risk stratification. Abstract Figure.  Abstract Figure.

Right ventricular remodelling in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Inconsistent changes in right ventricular (RV) dimensions and function have been observed after tricuspid valve (TV) surgery and their associations with long-term outcomes have not been explored.

Purpose

To evaluate RV remodelling and RV function in patients with significant (moderate or severe) tricuspid regurgitation (TR) undergoing TV surgery and their association with outcome.

Methods

A total of 121 patients (mean age 63 ± 12 years, 47% male) with significant TR treated with TV surgery and who had an echocardiogram between 3 months and 1 year of follow-up, were included for this analysis. Remodelling was assessed by comparing dimensions and function at follow-up to baseline values. The population was stratified by tertiles of percentage reduction of RV end-systolic area (RVESA) and absolute change of RV fractional area change (RVFAC). Five-year mortality rates were compared across the tertiles of RV remodelling and the independent associates of mortality were investigated.

Results

Reduction in RVESA and improvement in RVFAC were significantly associated with better survival after TV surgery, whereas reduction in RV end-diastolic area was not (Figure 1). One third of the patients presented with a reduction in RVESA of at least 17.2% and improvement in RVFAC of at least 2.3%, constituting the third tertiles for comparison. Kaplan-Meier curves for overall survival according to RVESA- and RVFAC-tertiles are shown in Figure 2. Cumulative survival rates were significantly better in patients in the third tertile of RVESA reduction: 49%, 69%, and 90% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 12.526; p = 0.002); as well as according to RVFAC improvement: 57%, 65%, and 87% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 7.784; p = 0.02). Tertile 3 of RVESA-reduction as well as tertile 3 of RVFAC-change were both independently associated with better survival after TV surgery compared to tertile 1 (hazard ratio: 0.221 [95% CI: 0.074 to 0.658] and 0.327 [95% CI: 0.118 to 0.907], respectively).

Conclusion

The magnitude of RV reverse remodelling (based on reduction in RVESA) and improvement in RVFAC were associated with better survival at 5 years’ follow-up after TV surgery for significant TR. Abstract Figure 1: Spline curves  Abstract Figure 2: KM curves for overal survival

Left atrioventricular coupling index in hypertrophic cardiomyopathy and risk of new-onset atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

 In patients with hypertrophic cardiomyopathy (HCM) accurate risk stratification for new onset atrial fibrillation (AF) has important prognostic implications. Left atrioventricular coupling index (LACI) has been recently associated with the occurrence of AF in patients without history of cardiovascular disease.

Purpose

The objective of this study was to investigate the association between LACI and new onset AF in HCM patients and its incremental value over conventional left atrial (LA) parameters.

Methods

A total of 373 HCM patients without history of AF (48 ± 17 years, 66% men) were evaluated by transthoracic echocardiography. LACI was defined by the ratio of the LA end-diastolic volume divided by the LV end-diastolic volume. The cut-off value for LACI (≥40%) to identify LA-left ventricular (LV) uncoupling was chosen based on the risk excess of new-onset AF described with a spline curve analysis. Cox proportional hazard models were used to evaluate the association between LACI and the occurrence of AF.

Results

The median LACI was 38% (interquartile range: 24-56) and LA-LV uncoupling (LACI ≥40%) was observed in 171 (45.8%) patients. During a mean follow-up of 11.0 ± 5.6 years, 118 subjects (31.6%) developed new-onset AF. The cumulative event-free survival at 10 years was 53% for patients with LA-LV uncoupling (LACI ≥40%) versus 94% for patients without LA-LV uncoupling (LACI &lt;40%) (p &lt; 0.0001; Figure 1). Multivariable analysis showed an independent association between new-onset AF  and LA maximum volume indexed (LAVImax) (hazard ratio [HR], 1.03; 95% CI, 1.02–1.04), LA minimum volume indexed (LAVImin) (HR, 1.04; 95% CI, 1.03–1.05), LA emptying fraction (HR, 0.97; 95% CI, 0.96–0.98) and LACI (HR, 1.02; 95% CI, 1.01–1.02; all p &lt; 0.0001). The inclusion of LACI in the multivariate model provided larger improvement in the risk stratification for new-onset AF, as compared to conventional LA parameters (Figure 2). Furthermore, the likelihood ratio test demonstrated incremental value of LACI assessment on the top of the multivariate model including LAVImin to predict new-onset AF (p = 0.02), while the addition of LAVImin did not improve the risk discrimination of the multivariate model including LACI (p = 0.36).

Conclusion

Greater LACI, indicative of LA-LV uncoupling, was independently associated with the occurrence of new-onset AF in patients with HCM and demonstrated a stronger risk discrimination power compared to conventional LA parameters. This simple ratio may be easily implemented in clinical practice to improve risk stratification for new-onset AF in HCM. Abstract Figure. Incident AF according to LACI  Abstract Figure.

Let atrial dysfunction is an independent predictor of mortality in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt

Funding Acknowledgements

Type of funding sources: None.

Background

 Transjugular intrahepatic portosystemic shunt (TIPS) is widely used to treat portal hypertension-related complications in patients with liver cirrhosis. Left ventricular diastolic dysfunction (LVDD) is associated with an increased risk of cardiac decompensation after TIPS, but its predictive value on long-term survival of TIPS candidates is currently unknown. In addition, the assessment of left atrial (LA) reservoir function, which recently emerged as sensitive marker of LVDD, has never been studied in this population.

Purpose

The main objectives were 1) to evaluate the association between LVDD, assessed according to the algorithm proposed by the Cirrhotic Cardiomyopathy Consortium (revised from the 2016 ASE/EACVI guidelines), and long-term survival in cirrhotic patients undergoing TIPS 2) to investigate the additive prognostic value of LA reservoir strain, measured by speckle-tracking echocardiography.

Methods

Patients with liver cirrhosis treated by TIPS were retrospectively evaluated. All subjects received an echocardiographic examination few weeks before the procedure. Threshold for LA reservoir strain (≤35%) to identify LA dysfunction was chosen based on the median value in the current population and on previously suggested cut-off value from the literature. The primary endpoint of the study was all-cause mortality.

Results

A total of 129 patients (61 ± 12 years; 61 % men) were included. According to the algorithm of the Cirrhotic Cardiomyopathy Consortium, 65 (50%) patients had normal diastolic function, 26 (20%) patients had grade 1 LVDD, 21 (16%) patients had grade 2 LVDD and 17 (13%) patients had indeterminate diastolic function. Additionally, LA dysfunction (LA reservoir strain ≤35%) was found in 67 (52%) patients. After a median follow-up of 36 months (interquartile range: 12-80), 65 (50%) patients died. Kaplan–Meier analysis for all-cause mortality at 4 years demonstrated a significant reduction in survival for more advanced grades of LVDD (log-rank p = 0.007) (Figure 1A). Furthermore, patients with LA dysfunction (LA reservoir strain ≤35%) had a higher cumulative event rate versus patients with preserved LA function (log-rank p = 0.001) (Figure 1B). Multivariable Cox regression analysis identified MELD (model for end-stage liver disease) score (Hazard ratio:1.06; p = 0.003), hemoglobin (Hazard ratio:0.74; p = 0.022) and LA reservoir strain (Hazard ratio:0.96; p = 0.005) as independent predictor of mortality (Figure 2). Excluding LA reservoir strain from the model, more advanced grades of LVDD (grade 2 and indeterminate function) became associated with the outcome. Of note, LA reservoir strain provided incremental prognostic value to the model including MELD score, hemoglobin and grades of LVDD (p = 0.004).

Conclusions

LA dysfunction, assessed by LA reservoir strain with speckle-tracking echocardiography, is an independent predictor of long-term mortality in in cirrhotic patients treated with TIPS. Abstract Figure.  Abstract Figure.

The MIDA quantitative international registry: prognostic implications of moderately elevated pulmonary artery pressure

Funding Acknowledgements

Type of funding sources: None.

Background

  Pulmonary hypertension is a frequent complication of severe degenerative mitral regurgitation (DMR) associated with major outcome implications. However, whether pulmonary hypertension is linked with worse outcome in less that severe MR is uncertain and even more unsubstantiated is the link of elevated systolic pulmonary artery pressure (sPAP) &lt; 50mmHg with clinical presentation and outcome.

Purpose

To assess the outcome implication of sPAP elevation, even moderate, among mitral regurgitation severity subgroups.

Methods

The MIDA-Quantitative (MIDA-Q) unprecedented registries included 7373 consecutive patients (age 64 ± 17 years, 45% women, follow-up 5.5 ± 3.4 years) with isolated DMR diagnosed at tertiary (European/North-American/Middle East) centers in which systolic pulmonary artery pressure (sPAP) was measured prospectively at baseline. Long-term survival overall, under medical management and post-mitral surgery was analyzed.

Results

 Elevated pulmonary pressure (sPAP &gt;50mmHg) was observed in 1371 patients (19%, mean 63 ± 13mmHg) and moderate increase in pulmonary pressure (35&lt; sPAP &lt; 50mmHg) in 1874 patients (25%, mean 41 ± 14mmHg), with no/mild MR in 4067 (50%), moderate in 2073 (25%), and severe or above in 2047 (25%), mean ERO 0.24 ± 24cm2, RVol 37 ± 35mL and posterior leaflet prolapse in 34%. sPAP severe but also moderate both strongly and independently linked to more severe clinical presentation, with more dyspnea, more AFib, and impaired renal function (P ≤ 0.0001). &lt;SPAP&lt; &gt;By sPAP categories,  35 &lt; sPAP&lt; 50mmHg (vs. 35mmHg) was independently associated with worse outcome under medical management adjusted-HR 1.62[1.40-1/87], with considerable excess-mortality for sPAP &gt; 50mmHg (vs. &lt;35mmHg) adjusted-HR 2.54[2.17-2.96], all P &lt; 0.0001. As continuous variable, sPAP was associated with worse outcome adjusted-HR 1.25[1.21-1.29], P &lt; 0.0001 per 10mmHg-increase. Mitral valve surgery (performed in 2378 patients, 32%) improved outcome without alleviating completely higher mortality associated with sPAP &gt; 50mmHg (P &lt; 0.0001).

Conclusion

In this very large international cohort of patients with DMR of all range and prospective sPAP grading, higher sPAP is associated at diagnosis with more severe clinical presentation. Long term, sPAP &gt; 50mmHg but also 35-50mmHg is independently of all confounders, associated with worse mortality. Thus careful assessment and consideration for mitral surgery/transcatheter therapy is warranted even in patients with sPAP &lt;50mmHg.&lt;/SPAP&lt; &gt; Abstract Figure. Survival stratified by sPAP Categories  Abstract Figure. Postop survival by sPAP Categories

Left ventricular remodeling patterns in patients with moderate aortic stenosis

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Background

Moderate aortic stenosis (MAS) is associated with an increased risk of adverse events. Although left ventricular (LV) adverse remodeling is associated with worse outcomes in patients with severe AS, the prognostic significance of different patterns of LV remodeling in MAS has not been investigated.

Purpose

To investigate the association between different patterns of LV remodeling on outcomes in patients with MAS.

Methods

Patients with MAS (aortic valve area &gt;1.0 and ≤1.5cm2) were stratified into 4 groups according to the pattern of LV remodeling: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH) or eccentric hypertrophy (EH). Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR).

Results

Of 1931 patients (age 73 ± 10 years, 52% men) with MAS, 344 (18%) had NG, 469 (24%) CR, 698 (36%) CH and 420 (22%) EH. Patients with CH were more likely to be female, had more hypertension, were more symptomatic (NYHA ≥III) and had more pronounced LV diastolic dysfunction, whereas patients with EH had more coronary artery disease, were more symptomatic (NYHA ≥III) and had lower LV ejection fraction than patients with NG. Patients with CH had higher aortic mean pressure gradients and peak aortic jet velocities than patients with NG. During a median follow-up of 51 (IQR 25 - 83) months, 833 (43%) patients died. For the composite endpoint, 1286 (67%) patients underwent AVR (n = 613) or died (n = 673) during a median follow-up of 35 (IQR 14 - 60) months. Patients with CH and EH had significantly lower survival rates (p &lt; 0.001; Figure 1) and event-free survival rates (p = 0.004) compared to patients with NG/CR. On multivariable analysis, CH was independently associated with all-cause mortality (HR:1.267; 95% CI:1.024 – 1.568; p = 0.029), whereas both CH (HR:1.293; 95% CI:1.090 – 1.533; p = 0.003) and EH (HR:1.222; 95% CI:1.013 – 1.474; p = 0.036) were associated with the composite endpoint of AVR and all-cause mortality (Figure 2).

Conclusions

In patients with MAS, different patterns of LV remodeling are observed with CH being independently associated with an increased risk of all-cause mortality. Risk stratification according to the different patterns of LV remodeling may help to identify patients with MAS who are at increased risk of adverse events and may benefit from closer follow-up. Abstract Figure. Kaplan-Meier curves  Abstract Figure. Cox regression analysis

Delayed Iatrogenic Left Ventricular Apex Perforation Sealed With an Amplatzer Septal Occluder Device Under Transthoracic Echocardiography Guidance

High rates of spontaneous rupture and death have been described when the pseudoaneurysm is left untreated. Percutaneous closure has emerged as an alternative to surgery in patients with unacceptable surgical risk. In this case, transthoracic echocardiography allowed optimal characterization of the defect and successful procedure guidance, avoiding risks derived from more invasive intraprocedural imaging techniques.

Prognostic value of three dimensional-vena contracta area in patients with secondary mitral regurgitation

Background

Effective regurgitant orifice area (EROA) is an important quantitative measurement for mitral regurgitation (MR) grading. Yet, the accuracy of this method is limited in patients with secondary mitral regurgitation (SMR). Three-dimensional (3D) color Doppler echocardiography allows for the direct assessment of the vena contracta area (VCA). The prognostic value of 3D-VCA in patients with secondary MR has not been investigated.

Purpose

The aim of the present study was to assess the association between 3D-VCA and prognosis of patients with SMR.

Methods

A total of 218 patients (69% men, median age 74 years) with significant SMR were retrospectively analyzed. 3D-VCA was measured offline with dedicated software, from restored 3D color Doppler full volume datasets of the mitral valve (Figure 1). The population was divided according to the American College of Cardiology expert recommendation for the grading of severe MR (VCA ≥50 mm2 and VCA &lt;50 mm2). Patients were followed up for the combined end point of all-cause mortality or heart failure hospitalization.

Results

Of the total population, 63% had an ischemic etiology, 60% had atrial fibrillation and 25% cardiac resynchronization therapy. Patients with 3D-VCA ≥50 mm2 needed more diuretic therapy, had a larger left ventricle and atrium, and had more post-procedural residual MR. A total of 82% of patients underwent MitraClip device implantation, 17% had mitral valve repair and 1% had mitral valve replacement. During a median follow-up of 28 months, 130 (60%) met the combined end point (101 (46%) patients died and 81 (37%) were hospitalized due to heart failure). When dividing the population according to the cut-off of 3D-VCA, patients with a 3D-VCA≥50 mm2 had a worse prognosis compared with their counterparts (Figure 2). In a multivariable Cox regression analysis, 3D-VCA≥50 mm2 remained independently associated with the composite endpoint of all-cause mortality or heart failure hospitalization (HR=1.454, 95% CI 1.020–2.072, p=0.038).

Conclusion

In patients with SMR, a 3D-VCA ≥50 mm2 was independently associated with a combined endpoint of death or heart failure hospitalization.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Method of 3D-VCA measurementFigure 2. Kaplan-Meier survival curve

Sex differences in left ventricular remodeling in patients with severe aortic valve stenosis

Background

Women with severe aortic valve stenosis (AS) have better long-term outcomes after transcatheter aortic valve implantation (TAVI) but worse survival after surgical aortic valve replacement compared to men. Whether this is related to sex differences in left ventricular (LV) remodeling is unknown.

Purpose

To examine sex differences in LV remodeling and outcomes in patients with severe AS undergoing TAVI.

Methods

Patients with severe AS who underwent TAVI between 2007 and 2018 with a pre-procedural multidetector row computed tomography (MDCT) scan were included. LV volumes, mass and function were analyzed with MDCT. Patients were classified into 4 LV remodeling patterns based on LV mass index and LV mass-to-volume ratio: 1) normal geometry, 2) concentric remodeling, 3) concentric hypertrophy and 4) eccentric hypertrophy. The primary endpoint was all-cause mortality after TAVI.

Results

A total of 289 patients (age 80±6 years, 54% male) were included. Women showed smaller LV volumes and mass compared to men. Concentric hypertrophy (50%) was the most frequent pattern of LV remodeling followed by eccentric hypertrophy (33%), normal geometry (13%) and concentric remodeling (4%). Concentric remodeling was more frequently observed in men compared to women (91% vs. 9% respectively, p=0.011). However, no sex differences were observed in the remaining LV remodeling patterns (Figure 1). During a median follow-up of 3.8 (IQR 2.2–5.1) years after TAVI, 87 patients died. Women demonstrated better outcome after TAVI compared to men (log-rank χ2=4.29, p=0.038). The survival benefit of women over men was mainly present among patients with concentric hypertrophy (log-rank χ2=4.91, p=0.027, Figure 2).

Conclusion

LV concentric and eccentric hypertrophy are similarly observed in men and women with severe AS. Women demonstrated better outcome after TAVI as compared to men, particularly among those with LV concentric hypertrophy. However, the outcome benefit of females after TAVI seems not to be related to sex-differences in LV remodeling.

Funding Acknowledgement

Type of funding sources: None. Distribution of sex in LV remodelingAll-cause mortality after TAVI

Right ventricular remodeling and prognostic relevance after ST-segment elevation myocardial infarction in patients treated with primary percutaneous coronary intervention

Background

ST-segment elevation myocardial infarction (STEMI) often involves changes in right ventricular (RV) function and size over time. However, the prognostic implications of RV remodeling after STEMI are unknown. The aim of current study was to characterize RV remodeling in post-STEMI patients and to investigate it's prognostic relevance.

Methods

RV remodeling in post-STEMI patients who underwent primary percutaneous coronary intervention (PCI) was defined by RV end-systolic area (RV ESA) change at 6 months after STEMI, compared to baseline. The optimal threshold of RV ESA change (≥40%) to define RV remodeling was derived from spline curve analysis (Figure 1A). The primary endpoint was the composite of all-cause mortality and heart failure (HF) hospitalization. Long term outcomes were compared between patients with and without RV remodeling by means of a log rank test.

Results

A total of 2280 patients were analyzed (mean age 60±11 years, 76% male) and RV remodeling was present in 320 patients (14%). After a median follow-up of 75 months (interquartile range 50–106 months), the composite endpoint of all-cause mortality and HF hospitalization occurred in 292 patients (13%). After adjustment for various risk factors, including tricuspid annular plane systolic excursion (TAPSE), post-STEMI RV remodeling was independently associated with a higher risk of all-cause mortality and HF hospitalization (HR=1.37, 95% CI 1.00–1.87, p=0.049. Finally, patients with RV remodeling were had a significantly lower event-free survival rate compared with patients without RV remodeling during follow-up (log-rank test p=0.009) (Figure 1B).

Conclusion

RV post-infarct remodeling is associated with mortality and HF hospitalization, independent of RV systolic function.

Funding Acknowledgement

Type of funding sources: None. Figure 1. A) Spline and B) Kaplan-Meier curve

Right ventricular myocardial work characterisation in patients with pulmonary hypertension: association with invasive haemodynamic parameters

Background

Non-invasive evaluation of indices of right ventricular (RV) myocardial work derived from RV pressure-strain loops may provide novel insights into RV function in pre-capillary pulmonary hypertension.

Purpose

This study was designed to evaluate the association between the indices of RV myocardial work and invasive haemodynamic parameters in a patient cohort with pulmonary arterial hypertension (Group I) or chronic thromboembolism pulmonary hypertension (Group IV).

Methods

The non-invasive analysis of echocardiography-derived RV myocardial work (Figure 1, upper panel) was completed in 51 patients (mean age 58.1±12.7 years, 31% male) with Group I (78%) or Group IV (22%) pulmonary hypertension. Conventional echocardiographic measurements of RV systolic function, RV global work index (RV GWI), RV global constructive work (RV GCW), RV global wasted work (RV GWW) and RV global work efficiency (RV GWE) were compared with parameters derived invasively during right heart catheterisation (RHC).

Results

The median RV GWI, RV GCW, RV GWW and RV GWE were 620 (443 to 857) mmHg%, 830 (650 to 1206) mmHg%, 105 (54 to 169) mmHg% and 87 (82 to 93)%, respectively. Compared to pulmonary artery systolic pressure and conventional echocardiographic parameters of RV systolic function (RV global longitudinal strain [GLS], tricuspid annular plane systolic excursion and RV fractional area change), RV GCW and RV GWI correlated more closely with invasively-derived RV stroke work index (R=0.63, P&lt;0.001 and R=0.60, P&lt;0.001, respectively) (Figure 1, lower panels). Invasively-derived pulmonary vascular resistance (PVR) correlated with RV GWW (R=0.63, P&lt;0.001), RV GWE (R=0.48, P&lt;0.001) and RV GLS (R=0.58, P&lt;0.001). RV GLS correlated more closely with invasively-derived stroke volume index (R=−0.57, P&lt;0.001) than RV GCW, RV GWI and RV GWE (R=0.34, P=0.016, R=0.48, P&lt;0.001 and R=0.47, P&lt;0.001, respectively).

Conclusions

In a patient cohort with Group I and Group IV pulmonary hypertension, indices of RV myocardial work were more closely correlated with invasively-derived RV stroke work index and PVR than conventional echocardiographic parameters of RV systolic function.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Method and correlations

Prognostic value of left atrial function in patients with severe primary mitral regurgitation undergoing mitral valve repair

Background

Timing of mitral valve surgery for primary mitral regurgitation (MR) remains challenging. Since MR has a significant hemodynamic impact on the left atrium (LA), assessment of LA function may have prognostic value in these patients which is incremental to LA volume and left ventricular (LV) remodeling parameters.

Purpose

This study sought to investigate whether preoperative assessment of LA reservoir strain (LASr) by speckle tracking echocardiography is associated with long-term outcome in patients undergoing mitral valve repair for severe primary MR.

Methods

Echocardiography was performed prior to mitral valve surgery in 566 patients (age 64±12 years, 66% men) with severe primary MR. Complete clinical information was collected and the endpoint was all-cause mortality after operation. The study population was divided based on a cut-off value of LASr (22%) derived from a spline curve analysis (hazard ratio for all-cause mortality &gt;1).

Results

Patients with LASr ≤22% (n=277) were significantly older, had more impaired renal function and were more symptomatic (NYHA functional class III to IV) compared to patients with LASr &gt;22% (n=289). In terms of echocardiographic data, patients with LASr ≤22% had significantly lower LV ejection fraction and LV global longitudinal strain (LV-GLS) and significantly higher systolic pulmonary artery pressures and LA volume index compared with patients with LASr &gt;22%.

During a median follow-up of 95 (56 – 147) months, 129 patients (22.8%) died. Patients with LASr ≤22% experienced significantly higher mortality rates compared to patients with LASr &gt;22% (log rank chi-square 35.1; p&lt;0.001) (Figure). On multivariable analysis, age (hazard ratio (HR): 1.06; 95% confidence interval (CI): 1.03 to 1.09; p&lt;0.001), LV-GLS (HR: 1.08; 95% CI: 1.02 to 1.15; p=0.014) and LASr (HR: 0.96; 95% CI: 0.93 to 0.99; p=0.014) were independently associated with all-cause mortality. The addition of LASr to a clinical model (including: age, coronary artery disease, estimated glomerular filtration rate, NYHA class III-IV, atrial fibrillation, LV end-diastolic volume index, LV ejection fraction, LV-GLS, LA volume index and systolic pulmonary artery pressure) showed a significant increase in the chi-square value (chi-square differences = 6.9; p=0.011), demonstrating the incremental prognostic value of LASr in patients with primary MR.

Conclusions

Preoperative LASr is independently associated with all-cause mortality in patients undergoing mitral valve repair for primary MR, has incremental prognostic value over LA volume and LVEF and might therefore be helpful to guide surgical timing.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Jan Stassen has received an ESC training grant (Appehab724.011364741) Association of LASr and outcome

Prognostic implications of staging right heart failure in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Introduction

Mortality of tricuspid valve (TV) surgery for severe secondary tricuspid regurgitation (TR) remains relatively high. Current guidelines advise surgery in patients with symptomatic severe TR as a concomitant procedure to left-sided valve surgery. Right ventricular (RV) dysfunction is an important prognostic marker and may appear late in the natural history of TR. How a staging algorithm of right heart failure (RHF) may impact on TV surgery outcomes has not been evaluated.

Purpose

To evaluate the impact of staging RHF on survival of patients with significant TR undergoing TV surgery.

Methods

Patients diagnosed with significant (moderate and severe) TR who subsequently underwent TV surgery, were staged into 4 groups of progressive disease according to the diagnosis of RV dysfunction and the presence of RHF: stage 1, at risk for RHF; stage 2, RV dysfunction without clinical symptoms of RHF; stage 3, RV dysfunction with symptoms of RHF, and stage 4, RV dysfunction with refractory symptoms of RHF (Figure 1). The study endpoint was all-cause mortality.

Results

A total of 279 patients (mean age 64±12 years, 49% male), were included in the analysis, of which 20 patients (7%) were in stage 1, 14 patients (5%) were in stage 2, 141 patients (51%) were in stage 3 and 104 patients (37%) were in stage 4.

The majority of the patients (266 patients, 95%) underwent TV annuloplasty. Most patients had TV surgery concomitant to left-sided valve surgery or coronary artery bypass grafting (254 patients, 91%). In per-group analysis, patients in stage 4 had significantly larger left ventricular (LV) and RV dimensions, lower LV ejection fraction and more severe diastolic dysfunction than patients in other RHF stages.

During a median follow-up of 65 [15 - 106] months after TV surgery, 145 deaths (52%) occurred. The cumulative survival rates were 88%, 77% and 60% at 1 month, 1 year and 5 years, respectively. The Kaplan-Meier curves for overall survival according to RHF stage are shown in Figure 2. Survival rates at 5 years were significantly worse in more advanced stages of RHF: 71% (stage 1 and 2), 66% (stage 3) and 49% (stage 4); log-rank chi-square: 11.302; p=0.004. Right heart failure stage was independently associated with all-cause mortality following adjustment for age, gender, LV ejection fraction, kidney function, TV annulus diameter, concomitant mitral valve surgery and time delay from diagnosis until surgery (p=0.021).

Conclusion

Patients diagnosed with significant TR may benefit from earlier referral for surgical intervention, before presenting with RV dysfunction and before the onset of symptoms of RHF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Stages of right heart failureFigure 2. Kaplan-Meier curves for overall survival

Prevalence, echocardiographic profile and clinical outcomes of patients with paradoxical low-gradient rheumatic mitral stenosis

Introduction

Rheumatic mitral stenosis (MS) has been conventionally defined by the mitral valve area (MVA), and associated with an elevated mean pressure gradient (PG) across the valve. However, there may be discrepancies between MVA and PG. We compared the clinical and echocardiographic parameters, as well asoutcomes of those with consistent (normal-gradient, NG) versus discrepant (Low-gradient, LG) grading between MVA and PG.

Methods

Consecutive patients (n=452) with index echocardiographic diagnosis of rheumatic MS (MVA &lt;1.5cm2) were examined. Patients were matched by MVA and divided based on mean PG (LG &lt;10mmHg or HG ≥10mmHg). The groups were compared using appropriate univariable, multivariable and survival analyses. Patients were followed up prospectively for clinical outcomes (admission for congestive heart failure, stroke or death).

Results

There were 226 patients (50.0%) with LGMS despite MVA&lt;1.5cm2. They had similar age and body mass index. The LG group had higher prevalence of atrial fibrillation (62.4% vs 45.1%, p&lt;0.001), hypertension (31.4% vs 18.8%, p&lt;0.001) and lower heart rate during echocardiography (74.3±16.6 vs 82.5±20.2 beats per minute, p&lt;0.001). LG MS patients had lower incidence of adverse events (log-rank 4.62, p=0.032). On multivariable Cox regression adjusting for age, left ventricular ejection fraction, MVA, pulmonary artery systolic pressure and mitral valve procedure, LG MS remained protective for adverse events (adjusted HR 0.58, 95% CI 0.38–0.89, p=0.013).

Conclusions

There was significant prevalence of paradoxical LG MS. Despite similar MVA, these patients had lower PASP and had fewer adverse outcomes on follow-up.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Dr Jan Stassen is supported by an ESC Training Grant (Appehab724.169164741)

Impact of left atrial strain assessed with feature-tracking computed tomography on long-term mortality after transcatheter aortic valve implantation

Background

Aortic stenosis (AS) induces left atrial (LA) remodeling through the increase of left ventricular (LV) filling pressure. Peak left atrial longitudinal strain (PALS) has been proposed as a prognostic marker in patients with AS. Novel feature-tracking (FT) software allows to assess LA strain from multidetector computed tomography (MDCT) dataset.

Purpose

To investigate the association between PALS using FT MDCT and moratlity in patients who underwent transcatheter aortic valve implantation (TAVI).

Methods

A total of 369 Patients (mean 80±7 years, 51% male) who underwent preprocedual MDCT before TAVI and had suitable data for measureing PALS using dedicated FT software were included. Patients were classified into 4 groups according to PALS quartiles; PALS more than 19.3% (Q1), 19.3% or less to more than 15.0% (Q2), 15.0% or less to more than 9.1% (Q3), and 9.1% or less (Q4). The primary outcome was all-caurse mortality.

Results

During median follow-up of 45 [22 - 68] months, 124 patients (34%) were died. On multivariable Cox regression analysis, PALS is an independently associated with all-cause mortality (HR: 0.958 [95% CI: 0.925–0.993], P=0.006). Kaplan-Meier analysis showed the worse outcome of the quatile with more impaired PALS (Logrank P&lt;0.001). Compared to Q1, Q3 and Q4 had higher risk of mortality after TAVI (HR: 2.475 [95% CI: 1.411–4.340] for Q3, HR: 3.253 [95% CI: 1.878–5.633] for Q4).

Conclusion

In this retrospective study, PALS measured with FT MDCT was strongly associated with all-cause mortality after TAVI. LA functial assessment using MDCT may have a importan role for risk stratification in patients referred to TAVI.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant 2018 K-M curve according to PALS quartiles

The MIDA quantitative mortality risk score: prognostic model in floppy mitral valves

Background

The Mitral Regurgitation International Database (MIDA) score is a validated tool for Degenerative Mitral Regurgitation (DMR) management, being able to position a given patient within a continuous spectrum of short and long term mortality. However, whether this score may be applicable and incremental in the entire span of Floppy Mitral Valves (FMV), regardless of DMR severity, remains unsubstantiated.

Methods

The MIDA-Quantitative (MIDA-Q) unprecedented registries include 8187 consecutive patients (age 64±17 years, 45% women, follow-up 5.5±3.4 years) with isolated degenerative mitral valve disease diagnosed at tertiary (European/ North-American/ Middle Eastern) centers in whom DMR severity used both integrative and quantitative grading. The MIDA-Q Score ranged from 0 to 15 depending on accumulating risk factors. Long-term survival overall, under medical management and post-mitral surgery was analysed.

Results

By quantitative grading, MR was no/trivial in 1938 (24%), mild in 1423 (17%), moderate in 2027 (25%) and severe in 2799 (34%), with ERO 0.24±24cm2, RVol 37±35mL, and posterior leaflet prolapse in 49%. MIDA-Q Scores stratified in 8 categories were 0 (score 0, n=851), 1 (score 1–2, n=1301), 2 (score 3–4, n=2043), 3 (score 5–6, n=1581), 4 (score 7–8, n=1273), 5 (score 9–10, n=718), 6 (score 11–12, n=331) and 7 (score 13–15, n=89). In the whole MIDA-Q population (n=8187 patients), 5-year survival under medical management with Scores categories 0–1, 2–4, and 5–7 was 96±1%, 73±1%, and 61±3% respectively (P&lt;0.0001). Five-year mortality ranged from 3% with MIDA Q-score 0 to 95% with MIDA Q-score 13–15 (P&lt;0.0001). After mitral surgery, 1-year mortality with Scores categories 0–1, 2–4, and 5–7 was 0%, 1%, and 6% respectively and 5-year post-operative survival was 99±1%, 94±1%, and 82±2% (all P&lt;0.0001). In models including age, sex and all guideline-provided prognostic markers, the EuroScoreII and the MIDA Score without DMR severity, the MIDA-Q Score provided incremental prognostic information (P&lt;0.001).

Conclusion

This unheard international cohort of patients with FMV and prospective mitral severity quantitative grading, enables for the first time the calculation of a MIDA-Q Score, highly determinant of survival after diagnosis of FMV with any degree of DMR, that may be very useful for mitral valve prolapse management.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Mayo Fundation Figure 1

Sex-differences in left ventricular remodeling and mechanics after aortic valve surgery in patients with severe aortic valve disease

Background

Sex-differences in left ventricular (LV) remodeling in patients with aortic valve disease have been reported. However, sex-differences in LV remodeling and mechanics in response to aortic valve replacement (AVR) remained largely unexplored.

Purpose

The present study aimed to evaluate the sex-differences during the time course of LV remodeling and LV mechanics (by LV global longitudinal strain (GLS)) after aortic valve replacement.

Methods

Patients with severe aortic valve disease (aortic stenosis (AS) or aortic regurgitation (AR)) undergoing AVR with echocardiographic follow-up at 1,2, and/or 5 years were evaluated. LV mass index, LV ejection fraction, LV GLS and stroke volume (SV) were measured. Linear mixed models analyses were used to assess changes in LV mass index, LVEF, LV GLS and SV between time points. The models were corrected for age, LV end-diastolic diameter at baseline and time between echocardiograms.

Results

A total of 211 patients (61±14 years, 61% male) with severe aortic valve disease (AS 63% or AR 39%) were included. Before AVR, men had larger LV mass index and higher SV compared to women. Both men and women had a preserved LV ejection fraction (54±12 and 56±9, P=0.102, respectively), but moderately impaired LV GLS (14.6±4.1 and 16.1±4.1, P=0.009, respectively). After AVR, both groups showed LV mass regression, improvement in LV ejection fraction and LV GLS. LV mass index and SV remained higher in men. During follow-up women showed significantly better LV GLS compared to men (P=0.030, figure 1).

Conclusion

In men and women with severe aortic valve disease undergoing AVR, the time course of changes in LV mass regression, LV ejection fraction, LV GLS and SV are similar. During follow-up LV mass index remained larger in men and women showed significantly better LV GLS.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The department of Cardiology received unrestricted research grants from Abbott Vascular, Bayer, Bioventrix, Biotronik, Boston Scientific, Edwards Lifesciences, GE Healthcare and Medtronic. Victoria Delgado received speaker fees from Abbott Vascular, Edwards Lifesciences, GE Healthcare, MSD and Medtronic. Nina Ajmone Marsan received speakers fees from Abbott Vascular and GE healthcare. Jeroen J Bax received speaker fees from Abbott Vascular. The remaining authors have nothing to disclose.

Impact of tricuspid annular shape on late worsening tricuspid regurgitation after transcatheter aortic implantation: insight from multidetector row computed tomography assessment

Background

Worsening of tricuspid regurgitation (TR) in patients undergoing transcatheter aortic valve implantation (TAVI) is associated with adverse clinical outcomes. The geometrical factors that determine the occurrence of significant TR after TAVI are uncertain. Multi-detector row computed tomography (MDCT) may provide additional geometrical insights in the pathophysiology of worsening TR after TAVI.

Purpose

To investigate the impact of right atrial and tricuspid annular (TA) geometryassessed by MDCT on the occurrence of significant TR (≥ moderate) at 1-year after TAVI.

Methods

Patients without significant TR who had undergone a full-beat MDCT prior to TAVI were included. Right and left atrial and ventricular volumes and TA parameters including the anterior-posterior (AP) and septal-lateral (SL) diameters, area and circularity (AP/SL ratio) were measured and correlated to the occurrence of significant TR at 1-year after TAVI.

Results

A total of 205 patients (80±7 years, 51% male) who underwent TAVI for severe aortic stenosiswere included. Moderate or severe TR at 1-year follow-up occurred in 59 patients (29%). Patients who developed significant TR were more likely to have atrial fibrillation and lower left ventricular (LV) volumes, but larger right and left atrial volumes and TA dimensions at baseline. After adjusting for atrial fibrillation and LV and right atrial volumes, larger end-diastolic TA SL diameter (odds-ratio 1.182 95% CI 1.047–1.334, P=0.007) and more circular TA shape were independently associated with the occurrence of significant TR.

Conclusion

In patients without significant TR prior to TAVI, TA dilation and loss of the elliptical shape of the TA at baseline are associated with of the occurrence of significant TR 1-year after TAVI.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant 2018 Representative cases

Sex-specific difference in cardiac function in patients with systemic sclerosis: association with cardiovascular outcomes

Background

Cardiac involvement is an important cause of hospitalization and mortality in patients with systemic sclerosis (SSc) and advanced echocardiographic measures such as left ventricular (LV) global longitudinal strain (GLS) have already demonstrated to improve risk-stratification. However, possible sex differences in echocardiographic parameters including LV GLS have not been explored so far.

Purpose

To compare standard and advanced echocardiographic parameters between men and women with SSc and evaluate their association with cardiovascular outcomes.

Methods

A total of 746 SSc patients from four different centers were included of which 628 (84%, 54±13 years) women and 118 (16%, 55±15 years) men. Baseline transthoracic echocardiographic (TTE) data with standard and advanced (LV GLS) measurements as well as clinical characteristics were analysed. The study endpoint was the composite of all-cause mortality and cardiovascular hospitalisations.

Results

Men and women showed several differences in terms of disease characteristics: greater modified Rodnan skin score, higher prevalence of diffuse cutaneous SSc, lung fibrosis and myositis, more impaired pulmonary function (DLCO) and higher creatine phosphokinase were observed in men, while women were characterized by longer disease duration, higher NT-proBNP and lower glomerular filtration rate. By TTE, men showed larger LV indexed volumes, lower LV ejection fraction and more impaired LV GLS [−19% (IQR −20% to −17%) vs. −21% (IQR: −22% to −19%, p&lt;0.001)]. Considering the significant differences in clinical characteristics between men and women, a propensity matching score was applied to explore whether sex-differences in TTE parameters were maintained. The matching was performed according to age, disease duration, presence of diffuse SSc, lung fibrosis, DLCO and NT-proBNP (n=140); after matching, LV GLS still showed significant difference between men and women [−19% (IQR −20% to −18%) vs. −20% (IQR −22% to −18%, p=0.03)] while LV volumes and ejection fraction did not. After a median follow-up of 48 months (IQR: 26–80), the combined endpoint occurred in 182 patients and Kaplan-Meier survival analysis (Figure) showed that men experienced higher cumulative event rates as compared to women (Chi-square 8.648; Log rank 0.003) even after matching for clinical characteristics (Chi-square 7.211; Log rank 0.007); however, sex difference in outcomes was neutralized after matching groups according to LV GLS. Furthermore, LV GLS showed a significant association with prognosis in the overall group (HR: 1.173; 95% CI: 1.106–1.244, p&lt;0.001) without significant interaction with sex (p=0.373), indicating a consistent prognostic value of LVGLS for both men and women.

Conclusions

Among patients with SSc, LV GLS is more impaired in men as compared to women even after matching for clinical characteristics, and its impairment is associated with higher prevalence of death and cardiovascular hospitalization.

Funding Acknowledgement

Type of funding sources: None.

Left atrial remodeling after mitral valve repair for primary mitral regurgitation: evolution over time and prognostic significance

Background

Although preoperative left atrial (LA) dilation is a well-known predictor of adverse cardiovascular events in patients with severe, primary mitral regurgitation (MR), little is known about LA reverse remodeling after mitral valve (MV) surgery and its prognostic value.

Purpose

This study sought to systematically investigate the changes in LA volume in patients undergoing MV repair for severe, primary MR and the association between LA volume after surgery and long-term outcome.

Methods

In patients undergoing MV repair for severe, primary MR, echocardiography was evaluated at three different time points: pre-operatively, immediate postoperatively (5 [4–6] days) and within 1–3 years (19 [14–24] months) follow-up. Outcome was all-cause mortality happening after the third echocardiographic evaluation.

Results

A total of 226 patients (mean age 62±13 years, 66% male) were included. Mean pre-operative LA volume index (LAVi) was 56±28 ml/m2 and significantly decreased immediately after surgery (to 38±21 ml/m2; p&lt;0.001) as well as at long-term follow-up (to 32±17 ml/m2; p&lt;0.001). Significant correlations were found between reduction in LAVi at long-term follow-up and age (R=−0.139; p=0.037), pre-operative left ventricular end-diastolic volume index (R=0.199; p=0.003), preoperative LAVi (R=0.498; p&lt;0.001), preoperative effective regurgitant orifice area (R=0.205; p=0.004), preoperative regurgitant volume (R=0.222; p=0.002) and postoperative transmitral mean pressure gradient at long-term follow-up (R=−0.150; p=0.026). Patients were subsequently divided into 3 groups: patients with a preoperative LAVi &lt;42 ml/m2 (n=68), based on the definition of moderately dilated LA; patients with a LAVi 42–59 ml/m2 (n=88) and patients with a LAVi ≥60 ml/m2 (n=70), based on the current class IIaC indication for intervention in primary MR. Although patients with a LAVi ≥60 ml/m2 at baseline showed the most pronounced reduction in LAVi, their values of LAVi at long-term follow-up remained above the range of normality (figure 1). During a median follow-up of 72 (40–114) months, 43 (19.0%) patients died. Patients who had a LAVi ≥42 ml/m2 at long-term follow-up (3rd echocardiographic evaluation) showed significantly higher mortality rates as compared to patients with a LAVi &lt;42 ml/m2 (p&lt;0.001) (figure 2). Multivariable Cox regression analysis showed that, after adjusting for age, sex and coronary artery disease, postoperative LAVi ≥42ml/m2 at long-term follow-up remained independently associated with all-cause mortality (HR 2.494; CI 1.292 to 4.815; p=0.006).

Conclusions

In patients with severe primary MR, LA reverse remodeling occurs immediately after MV repair, with a further reduction in LAVi during follow-up. Patients in whom LAVi does not remodel to normal values present worse long-term prognosis as compared to patients who achieve normal LAVi values.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC Training Grant (Appehab724.011664741). Changes in LA volume over timeKM curve for all-cause mortality

Echocardiographic global longitudinal strain as a marker of myocardial fibrosis predicts outcomes in aortic stenosis

Background

Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) reflects intrinsic myocardial function, influenced by interstitial abnormalities. Cardiovascular magnetic resonance (CMR) detects myocardial fibrosis non-invasively, but it is limited for widespread use. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on CMR and validate the prognostic value of LV-GLS thresholds associated with fibrosis.

Methods

LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57±10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR for replacement myocardial fibrosis. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71±12 years; 58% males; NYHA functional class I-II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, myocardial infarction and cerebrovascular events.

Results

In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74; 95% confidence interval: 0.66–0.83; P&lt;0.001) and calibration (Hosmer-Lemeshow X2=6.37; P=0.605) for replacement fibrosis. In the outcome cohort, 52 events occurred over 16 [3.1, 42.0] months of follow-up. Patients with LV-GLS &gt;−15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS &lt;−21.0% (corresponding to 95% sensitivity to rule-out myocardial fibrosis) and those between −21.0 and −15.0% (log-rank P&lt;0.001; Figure 1). Furthermore, LV-GLS offered independent prognostic value over clinical variables, AS severity, echocardiographic LVEF and E/e' (hazard ratio 1.18; 95% confidence interval: 1.07 to 1.30; P=0.001).

Conclusions

LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF (Figure 2).

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Figure 1Figure 2

Renal function in patients with significant tricuspid regurgitation: pathophysiological mechanisms and prognostic implications

BACKGROUND

The pathophysiological mechanisms linking tricuspid regurgitation (TR) and chronic kidney disease (CKD) remain unknown. This study aimed to determine which pathophysiological mechanisms related to TR are independently associated with renal dysfunction and to evaluate the impact of renal impairment on long-term prognosis in patients with significant (≥ moderate) secondary TR.

METHODS

A total of 1234 individuals (72 [IQR 63-78] years, 50% male) with significant secondary TR were followed up for the occurrence of all-cause mortality and the presence of significant renal impairment (eGFR of <60 mL min-1  1.73 m-2 ) at the time of baseline echocardiography.

RESULTS

Multivariable analysis demonstrated that severe right ventricular (RV) dysfunction (TAPSE < 14 mm) was independently associated with the presence of significant renal impairment (OR 1.49, 95% CI 1.11 to 1.99, P = 0.008). Worse renal function was associated with a significant reduction in survival at 1 and 5 years (85% vs. 87% vs. 68% vs. 58% at 1 year, and 72% vs. 64% vs. 39% vs. 19% at 5 years, for stage 1, 2, 3 and 4-5 CKD groups, respectively, P < 0.001). The presence of severe RV dysfunction was associated with reduced overall survival in stage 1-3 CKD groups, but not in stage 4-5 CKD groups.

CONCLUSIONS

Of the pathophysiological mechanisms identified by echocardiography that are associated with significant secondary TR, only severe RV dysfunction was independently associated with the presence of significant renal impairment. In addition, worse renal function according to CKD group was associated with a significant reduction in survival.

Orientation of the right superior pulmonary vein affects outcome after pulmonary vein isolation

Funding Acknowledgements

Type of funding sources: None.

Aims

Controversial results have been published regarding the influence of pulmonary vein (PV) anatomical variations on outcomes after pulmonary vein isolation (PVI). However, no data is available on the impact of PV orientation on the long-term success rates of point-by-point PVI. We sought to determine the impact of PV anatomy and orientation on atrial fibrillation (AF)-free survival in patients undergoing PVI using the radiofrequency point-by-point technique.

Methods and results

We retrospectively included 448 patients who underwent initial point-by-point radiofrequency ablation for AF at our department. Left atrial CT-angiography (CTA) was performed before each procedure. PV anatomical variations, ostial parameters (area, effective diameter and eccentricity), orientation and their associations with 24-month AF-free survival were analyzed. PV anatomical variations and ostial parameters were not predictive for AF-free survival (all p &gt; 0.05). Univariate analysis showed that female sex (p = 0.025) was associated with higher rates of AF recurrence, ventral-caudal (p = 0.002), dorsal-cranial (p = 0.034) and dorsal-caudal (p = 0.042) orientation of the right superior PV (RSPV), on the other hand, showed an association with lower rates of AF recurrence, as compared to the reference ventral-cranial orientation. On multivariate analysis, both female sex [odds ratio(OR) 1.83, 95% CI 1.15-2.93, p = 0.011] and ventral-caudal RSPV orientation, compared with ventral-cranial orientation, proved to be independent predictors of 24-month AF recurrence (OR 0.37, 95% CI 0.19-0.71, p = 0.003).

Conclusion

  Female sex and ventral-caudal RSPV orientation have an impact on long-term arrhythmia-free survival. Assessment of PV orientation may be a useful tool in predicting AF-free survival and may contribute to a more personalized management of AF.

A matter of proportions: a novel framework to classify functional tricuspid regurgitation

Background

Current approaches for the assessment of tricuspid regurgitation (TR) severity do not correct for right ventricular (RV) size. Similarly to what recently proposed for the left heart, we hypothesized that TR severity can be proportional or disproportional to RV dilation.

Purpose

To characterize the clinical features and the prognosis of patients with disproportionate vs proportionate functional TR (FTR).

Methods

A total of 345 patients (mean age: 70±12 years; 40% male) with significant (≥ moderate) FTR, preserved left ventricular systolic function and who did not undergo tricuspid valvular repair during follow-up were included. Proportional and disproportional FTR were defined according to the ratio between TR severity (vena contracta [VC] width) and RV size (tricuspid annulus [TA] diameter). A prognostic relevant cut-off for VC/TA was identified with spline curve analysis. The primary end-point was all-cause mortality and the event rates were compared between patients with proportionate and disproportionate FTR.

Results

The cut-off for disproportionate FTR associated with an increase in all-cause mortality was identified at 0.24 (Figure 1: left panel). According to this cut-off, 172 (50%) patients showed disproportionate FTR, while the remaining had proportionate FTR. Patients with disproportionate FTR were more frequently symptomatic, had smaller RV basal diameter, higher TR severity, greater left atrial volume, higher prevalence of mitral regurgitation, and higher pulmonary artery pressures compared to those with proportionate FTR. During a median follow-up of 61 (interquartile range, 28–101) months, 135 (39%) patients died. The cumulative 5-year survival rate was significantly worse in patients with disproportionate FTR (57% vs 74%, P=0.001; Figure 1: right panel) and on multivariable Cox regression analysis disproportionate FTR was independently associated with poor outcome (HR 1.56; 95% CI 1.06–2.29; P=0.023) together with age, coronary artery disease, renal impairment, reduced RV systolic function, and increased pulmonary artery pressures. Importantly, this novel framework outperformed the TR grading system recommended by current guidelines, which in this population was not able to effectively stratify the prognosis (HR for severe FTR vs moderate FTR 1.09; 95% CI 0.72–1.64; P=0.694).

Conclusions

In patients with significant FTR, characterization of TR severity in relation to RV size significantly improves risk-stratification since disproportionate FTR if left untreated is associated with worse prognosis compared with proportionate FTR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Comparison of global left ventricular myocardial work indices at baseline and after 3 months of st-segment elevation myocardial infarction

Background

Global left ventricular myocardial work indices (GLVMWI) are derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure recordings. Global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) are derived from these measures. GLVMWI in ST-segment elevation myocardial infarction (STEMI) remains unexplored and comparison between measures of GLVMWI at index event (baseline) and follow-up is unknown.

Purpose

To assess the evolution in GLVMWI in STEMI patients from baseline (index infarct) to 3 months' follow-up.

Methods

This retrospective study included 350 patients (265 men, mean age: 61±10 years) with STEMI treated with primary percutaneous coronary intervention and optimal, guideline-based medical therapy. Clinical variables, echocardiographic measures and GLVMWI were recorded at baseline and 3 months follow-up.

Results

Left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), GWI, GCW and GWE improved significantly at 3 months follow-up with no significant difference in GWW (Table). These findings suggest that the impaired values of GLVMWI at baseline are related to stunning after STEMI and they recover at 3 months follow-up without further deterioration in GWW, which probably reflects irreversible myocardial damage.

Conclusions

In STEMI patients treated with primary percutaneous coronary intervention and optimal guideline-based medical therapy, GLVMWI assessed by speckle tracking strain echocardiography are significantly improved at 3 months follow-up, without significant changes in GWW. GLVMWI therefore have the potential to identify reversible and irreversible components of post-infarct myocardial damage.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Society of Cardiology Research Grant

Regional left ventricular myocardial work index in culprit territory predicts early left ventricular remodelling in patients with st-segment elevation myocardial infarction

Background

The association between left ventricular (LV) myocardial work index (LVMWI) derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure recordings and adverse LV dilatation i.e. remodelling has not been evaluated.

Purpose

To assess the predictive value of regional LVMWI for LV remodelling at baseline echocardiography in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

This retrospective study included 350 patients (265 men, mean age: 61±10 years) with STEMI treated with primary percutaneous coronary intervention and optimal medical therapy. Clinical variables, conventional echocardiographic parameters, global and segmental measures of LVMWI were recorded at baseline. The primary endpoint was early LV remodelling defined as increase in LV end-diastolic volume (LVEDV) ≥20% at 3 months after the index event.

Results

Eighty-seven patients (24.9%) presented with early LV remodelling. The global and regional LVMWI in the culprit territory were significantly lower in patients with early LV remodelling. Univariate and multivariate logistic regression analyses were performed to identify predictors of early LV remodelling. At the index event, troponin I peak, LVEDV and LVMWI in the culprit territory were independently associated with early LV remodelling (Table).

Conclusions

In STEMI patients treated with primary percutaneous coronary intervention and optimal medical therapy, the regional LVMWI in the culprit territory at echocardiography before discharge is independently associated with troponin I peak and LVEDV in predicting early LV remodelling.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Society of Cardiology

Non-invasive myocardial work: an echocardiographic measure of post-infarct scar on contrast-enhanced cardiac magnetic resonance imaging

Background

Late gadolinium contrast enhanced cardiac magnetic resonance (LGE CMR) imaging accurately quantifies the extent of fibrosis and transmurality in chronically infarcted left ventricular (LV) segments, and identifies viability. Moreover, CMR characterizes the remote, non-infarcted zone, which is an emerging region of interest following ST-segment elevation myocardial infarction (STEMI). Non-invasive myocardial work is a novel LV function parameter - calculated from speckle-tracking strain echocardiography and sphygmomanometrically-determined blood pressure, which has shown excellent correlation with invasively measured myocardial work.

Purpose

To explore the relation of non-invasively estimated parameters of LV myocardial work to post-infarct scar on LGE CMR, and to compare myocardial work indices between the infarct core and remote zone in STEMI patients who were treated with primary percutaneous coronary intervention (PCI).

Methods

Patients with a STEMI who underwent primary PCI and LGE CMR, in addition to echocardiographic studies where non-invasive myocardial work analysis was feasible, were included. The LV was subdivided into non-infarcted, non-transmural and transmurally infarcted segments. The remote zone was defined as the non-infarcted myocardial segment diametrically opposed to the infarct core, without any evidence of LGE. Myocardial work indices were compared with linear mixed models, ANOVA and Wilcoxon signed rank tests.

Results

53 patients (89% male, age 58±9 years) and 689 segments were analysed. The mean scar burden comprised 14±7% of the total LV mass and 76 (11%) segments showed transmural LGE. The following non-invasive myocardial work indices: myocardial work index (MWI), constructive work (CW) and myocardial work efficiency (MWE) showed a significant inverse relationship with infarct transmurality (p&lt;0.05 for all comparisons) while a positive trend was observed for wasted work (WW) (p=0.086) (Figure 1). The core zone demonstrated lesser MWI (1237±568 vs. 1514±518 mmHg%; p=0.010), CW (1331±627 vs. 1827±537 mmHg%; p&lt;0.001) and MWE (92 (84–98) vs. 98 (95–99) %; p&lt;0.001) as well as greater WW when compared to the remote zone (107 (26–196) vs. 26 (10–90) mmHg%; p=0.001).

Conclusions

In STEMI patients who underwent primary PCI, MWI, CW and MWE were significantly related to the extent of transmural infarction, while WW demonstrated a trend. MWI, CW and MWE were significantly lower, and WW higher, in the core zone compared to the remote zone. Non-invasive myocardial work indices may provide an echocardiographic method for determining post-infarct viability, as well as characterization of the remote zone.

MW and scar transmurality on LGE CMR

Funding Acknowledgement

Type of funding source: None

Insights into aortic stenosis progression: factors affecting rate of progression and its impact on survival

Background

Severe aortic stenosis (AS) is associated with adverse clinical outcomes. Little is known about the rate of progression in patients with moderate AS.

Purpose

Risk factors affecting the rate of progression from moderate to severe AS, and their impact on all-cause mortality were studied in this multicentre registry.

Methods

Based on the echocardiographic diagnosis of moderate AS (valve area &gt;1.0 and ≤1.5 cm2) at the time of first echocardiogram, 962 patients with follow-up were included. Follow-up echocardiograms were reviewed to identify those who developed severe AS (based on the current guidelines). Patients were divided into 2 groups: AS Progressors (progressed to severe AS) and Non-progressors (remained in moderate AS). Among those with AS progression, patients were subdivided into Slow versus Fast Progressors, according to the median time interval between the two echocardiograms. The clinical correlates of fast AS Progressors were analysed using the binary logistic regression. The association between rate of progression (slow versus fast) and all-cause mortality was assessed by the Kaplan-Meier method using log-rank test. A multivariate Cox proportional analysis was used to identify the independent associates of all-cause mortality, with interval of AS progression between the two echocardiograms (in years) included as a continuous variable.

Results

Of the 962 patients with moderate AS, AS progressed to severe in 62% (n=595), while 38% (n=367) remained in moderate AS, over a mean follow-up of 6.8 [IQR 4.2–9.3] years. Older age, renal impairment (eGFR&lt;30ml/min/1.73 m2), hypertension and atrial fibrillation were significantly associated with higher risk of AS progression. Left ventricular (LV) hypertrophy and higher peak aortic velocity were more prevalent in AS Progressors at baseline. Among the AS Progressors (n=595), the median time of AS progression was 2.5 [IQR 1.3–3.9] years. Based on the median time of AS progression, patients were subdivided into: Slow (n=295) versus Fast Progressors (n=300). On multivariate analysis, age, renal impairment (eGFR&lt;30ml/min/1.73 m2), betablocker use, impaired LV ejection fraction and peak aortic velocity were significantly associated with Fast progression of AS. Although the rates of AV intervention were similar between Fast versus Slow Progressors (60% vs. 54%, p=0.137), Fast AS Progressors had worse survival than Slow AS Progressors (Log rank p=0.045, Figure 1), over a mean follow-up of 4.0 [IQR 1.0–6.4] years. Importantly, on multivariable Cox proportional analysis, shorter time of progression from moderate to severe AS was independently associated with increased all-cause mortality (HR=0.92, 95% CI 0.88–0.99, p=0.047).

Conclusion

In a large real-world registry of patients with moderate AS, fast progression to severe AS is associated with worse survival. Close surveillance should be given to those patients who are at higher risk of AS progression.

AS progression and all-cause mortality

Funding Acknowledgement

Type of funding source: None

The truly forgotten chamber: prognostic value of right atrial dilation in patients with sinus rhythm and significant functional tricuspid regurgitation

Background

Functional tricuspid regurgitation (FTR) can be caused by right ventricular (RV) and/or right atrial (RA) dilation, and it leads in turn to further RV and RA remodeling. While it is known that in these patients RV dilation is associated with worse prognosis, there are no data on the prognostic value of RA enlargement.

Purpose

To assess the prognostic impact of RA dilation in patients with significant (≥ moderate) FTR taking into account the presence of atrial fibrillation (AF).

Methods

1382 patients (mean age: 69±13 year; 50% male) with moderate or severe FTR were included. Patients with congenital heart disease were excluded. Significant RA enlargement was identified by the value of RA area associated with excess of mortality according to spline curve analysis in the overall population (30 cm2 – Figure: Left Panel). The prognostic value of RA enlargement was investigated separately in patients with sinus rhythm (SR) and AF. The primary endpoint was all-cause mortality.

Results

A total of 987 (71%) patients were in SR while the remaining 395 (29%) had AF at the time of significant FTR diagnosis. Patients in SR with RA enlargement were more likely to present with RV failure symptoms and to receive diuretics compared with patients in SR with non-enlarged RA, whereas these differences were not detected in patients with AF. During a median follow-up of 53 (interquartile range, 20–89) months, 698 (51%) patients died. The survival rates of patients in SR with RA enlargement were significantly worse compared to the ones of patients in SR with normal RA size (Figure: Right Panel). In contrast, RA enlargement did not affect the prognosis of patients in AF (Log-rank χ2: 0.41; P=0.522). RA enlargement was associated with 33% increase risk of all-cause mortality in patients with SR and this association was retained on a multivariable Cox regression analysis (HR 1.27; 95% CI 1.04–1.56; P=0.022) together with older age, coronary artery disease, diabetes, severe renal impairment, reduced left ventricular or RV systolic function, and increased pulmonary artery pressures.

Conclusion

RA enlargement has an independent prognostic value for all-cause mortality in patients with FTR and SR, and therefore its evaluation might be useful to further improve their risk stratification.

Funding Acknowledgement

Type of funding source: None

Subclinical leaflet thrombosis after transcatheter aortic valve implantation: association to reverse left ventricular remodeling

Background

Hypo-attenuated leaflet thickening (HALT) of transcatheter aortic valves can be observed on multidetector computed tomography (MDCT) and is considered as an early marker of leaflet thrombosis. Preliminary data has suggested that HALT will prevent or delay reverse left ventricular (LV) remodeling after transcatheter aortic valve implantation (TAVI).

Purpose

The purpose of the present study was to assess the association of HALT to reverse LV remodeling after TAVI.

Methods

In this multicenter study, patients who underwent MDCT after TAVI were evaluated. The presence of HALT was assessed with MDCT. Transthoracic echocardiograms were performed to assess LV dimensions and function before and 12 months after TAVI; transcatheter valve hemodynamics were assessed immediately after TAVI and at 12 months follow-up.

Results

A total of 169 patients (mean age 81±7 years, 53% male) who underwent MDCT performed 35 days [IQR 32–52] after TAVI were analyzed. HALT was observed in 42 (33%) patients. Before TAVI, LV mass (LVM) and LV mass index (LVMi) did not differ between patients with or without HALT: 227±80 vs. 234±62 g (p=0.568) and 121±37 vs. 126±32 g/m2 (p=0.35), respectively. Also LV ejection fraction (LVEF) was comparable between groups, 51±10 vs. 50±12%, p=0.64. LV end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV) were lower in patients with HALT: 75 (67–115) vs. 99 (77–127) ml (p=0.030) and 39 (30–53) vs. 46 (33–65) ml (p=0.050), respectively. At 12 months follow-up, we found no differences in LVM or LVMi regression, decrease of LV volumes or transprosthetic gradients between groups (Figure 1).

Conclusion

Patients who presented with HALT had significantly lower LV volumes before TAVI. LV mass and volumes regressed significantly at 12 months after TAVI, however LV remodeling was not associated to the presence of HALT.

Funding Acknowledgement

Type of funding source: None

A novel quantitative grading system to further characterize the prognosis of patients with functional tricuspid regurgitation

Background

Recent studies have suggested that current grading of tricuspid regurgitation (TR) has significant limitations and specifically cannot identify the various grades of severe TR (such as torrential). New cut-off values for the recommended measures of vena contracta (VC) width and effective regurgitant orifice area (EROA) have been proposed but not yet validated.

Purpose

To test the prognostic utility of new cut-offs for VC width and EROA in a large registry of patients with functional TR (FTR) and to integrate them into a novel comprehensive grading system.

Methods

FTR severity was evaluated in 1148 patients (mean age: 69±13 years, 50% male) with significant FTR (≥ moderate). Patients with congenital heart disease or who underwent tricuspid valve repair during follow-up were excluded. The primary endpoint was all-cause mortality. Based on Kaplan-Meier survival analyses, VC width significantly differentiated the prognosis of patients with moderate FTR vs severe FTR (with a cut-off value of 7 mm), whereas EROA was able to further stratify patients with more than severe (torrential) FTR. Therefore these two parameters were combined into a novel grading system (Figure: Upper Panel) to define: moderate FTR (VC &lt;7 mm), severe FTR (VC ≥7 mm, EROA &lt;80 mm2) and torrential FTR (VC ≥7 mm, EROA ≥80 mm2).

Results

According to our novel grading system a total of 146 patients (13%) showed moderate FTR, 547 patients (48%) had severe FTR and 454 patients (39%) presented with torrential FTR. Patients with torrential FTR had greater right ventricular (RV) dimensions, lower RV systolic function and were more likely to receive diuretics. The cumulative 10-year survival rates were significantly different among the groups: 54% for moderate FTR, 43% for severe FTR and 32% for torrential FTR (P=0.004 Figure – Lower Panel). After adjusting for potential confounders, torrential FTR retained its association with worse prognosis compared with other FTR grades (HR 1.28; 95% CI 1.07–1.54; P=0.007) together with age, coronary artery disease, diabetes, severe renal impairment, lower RV or left ventricular systolic function, higher pulmonary artery pressures, and dilated tricuspid annulus. Differently, severe FTR graded according to current guidelines did not show any association with the primary outcome (HR for severe FTR vs moderate FTR 1.17; 95% CI 0.96–1.42; P=0.128).

Conclusion

The proposed novel grading system combining measures of VC width and EROA is able to further risk stratify patients with FTR and specifically to identify patients with torrential FTR, a new clinical condition associated with even worse mortality than severe FTR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Novel staging classification of primary mitral regurgitation based on the presence of cardiac damage

Background

The indication for surgery in patients with severe primary mitral regurgitation (MR) is currently based on the presence of symptoms, left ventricular (LV) dilatation and dysfunction, atrial fibrillation and pulmonary hypertension. The aim of this study was to evaluate the prognostic impact of a new staging classification based on cardiac damage including the known risk factors but also including global longitudinal strain (GLS), severe left atrial (LA) dilatation and right ventricular (RV) dysfunction.

Methods

In total 614 patients who underwent surgery for severe primary MR with available baseline transthoracic echocardiograms were included. Patients were classified according to the extent of cardiac damage (Figure): Stage 0-no cardiac damage, Stage 1-LV damage, Stage 2-LA damage, Stage 3-pulmonary vasculature or tricuspid valve damage and Stage 4-RV damage. Patients were followed for all-cause mortality.

Results

Based on the proposed classification, 172 (28%) patients were classified as Stage 0, 102 (17%) as Stage 1, 134 (21%) as Stage 2, 135 (22%) as Stage 3 and 71 (11%) as Stage 4. The more advanced the stage, the older the patients were with worse kidney function, more symptoms and higher EuroScore. Kaplan-Meier curve analysis revealed that patients with more advanced stages of cardiac damage had a significantly worse survival (log-rank chi-square 35.2; p&lt;0.001) (Figure). On multivariable analysis, age, male, chronic obstructive pulmonary disease, kidney function, and stage of cardiac damage were independently associated with all-cause mortality. For each stage increase, a 22% higher risk for all-cause mortality was observed (95% CI: 1.064–1.395; p=0.004).

Conclusion

In patients with severe primary MR, a novel staging classification based on the extent of cardiac damage, may help refining risk stratification, particularly including also GLS, LA dilatation and RV dysfunction in the assessment.

Funding Acknowledgement

Type of funding source: None

Right ventricular myocardial work in patients with HFrEF

Background

Right ventricular myocardial work (RVMW) is a novel method of non-invasively quantifying right ventricular (RV) systolic function. Through the use of speckle tracking echocardiography-derived RV pressure-strain loops, RVMW provides a quantitative evaluation of afterload-dependent RV systolic function.

Purpose

To investigate RVMW in patients with heart failure and reduced ejection fraction (HFrEF) and compare to that of patients without cardiovascular disease (CVD) and a structurally and functionally normal heart.

Methods

Noninvasive analysis of RVMW was performed in 23 HFrEF patients and 23 patients without cardiovascular or structural heart disease. The novel indices of RV global constructive work (RVGCW), RV global work index (RVGWI), RV wasted work (RVWW) and RV global work efficiency (RVGWE) were analysed utilizing proprietary software originally developed for the assessment of left ventricular myocardial work by speckle tracking echocardiography. Parameters of RVMW were then compared between the two patient groups.

Results

The HFrEF group had lower left ventricular (LV) ejection fraction (18.7% [±6.7] vs 60.1% [±4.6], p&lt;0.0001), LV global longitudinal strain (−3.6% [±1.6] vs −20.4% [±2.1), p&lt;0.0001) and RV global longitudinal strain (−10.0% [±4.2] vs −22.0% [±3.1], p&lt;0.0001) when compared to those with no CVD. Estimated pulmonary artery systolic pressure (42.5mm Hg [±12] vs 22.5mm Hg [±3.7], p&lt;0.0001) and estimated right atrial pressure (8mm Hg (5 to 15) vs 5mm Hg (5 to 5), p&lt;0.0001) were significantly higher in the HFrEF group. RVGWI (259.7mmHg% [±135.0] vs 385.3mmHg% [±103.1], p=0.001), RVGWW (83.7mmHg% [±58.6] vs 14.5mmHg% [8.5 to 20.5], p&lt;0.0001) and RVGWE (77.2% [11.4] vs 95.5% [93.5 to 97], p&lt;0.0001) were significantly lower in the HFrEF group when compared to those without CVD. There was no statistically significant difference in RVGCW between the two groups (353.5mmHg% [±118.4] vs 417.2 [±102.1], p=0.057).

Conclusion

The novel parameters of RVGWI, RVGWW and RVGWE were significantly reduced in patients with HFrEF when compared to those without CVD. Further exploration of the clinical role and prognostic value of these afterload dependent parameters of RV systolic function is warranted.

Funding Acknowledgement

Type of funding source: None