Andrea Sweeney

Abnormal left ventricular intracavitary flow acceleration in patients undergoing aortic valve replacement for aortic stenosis. A marker for high postoperative morbidity and mortality.

BackgroundWe examined the clinical and echocardiographic characteristics of patients undergoing aortic valve replacement for aortic stenosis whose continuous wave Doppler studies showed abnormal intracavitary flow acceleration. Methods and ResultsThe clinical and Doppler echocardiographic records of 53 consecutive patients undergoing aortic valve replacement for aortic stenosis were reviewed. Doppler echocardiography was performed at a mean of 6.6 days (range, 0–22 days) after surgery. Thirteen patients (group 1) had a dagger-shaped high-velocity systolic flow signal indicative of abnormal intracavitary flow acceleration on their postoperative Doppler study; group 2 comprised 40 aortic stenosis patients who underwent aortic valve replacement but had no postoperative evidence of abnormal intracavitary flow acceleration. Group 1 postoperative abnormal intracavitary flow velocities ranged from 1.8 to 6.8 m/sec (mean, 4.9±0.9 m/sec): Resulting dynamic gradients ranged from 10 to 184 mm Hg (mean, 104.6±32 mm Hg). Compared with group 2, group 1 patients had a distinctive ventricular geometry with more-pronounced hypertrophy, smaller cavities, and higher ejection fraction. Systolic anterior motion of the mitral valve did not accompany abnormal intracavitary flow acceleration in any patient. Six of 13 group 1 patients suflered postoperative hemodynamic compromise characterized by severe hypotension despite adequate pulmonary capillary wedge pressures; group 1 postoperative mortality was significantly greater than that seen in group 2 patients (38% versus 12%, p<0.05). ConclusionsAbnormal intracavitary flow acceleration after aortic valve replacement for severe aortic stenosis is associated with a distinctive ventricular geometry and supernormal systolic function but not systolic anterior motion of the mitral valve. Such flow acceleration appears to be a marker for increased postoperative morbidity and mortality. Preoperative and postoperative Doppler echocardiography may be useful in risk stratification and guiding therapy.

Reduced left ventricular systolic pump performance and depressed myocardial contractile function in patients > 65 years of age with normal ejection fraction and a high relative wall thickness

We studied the relation between relative wall thickness, left ventricular systolic pump performance, and myocardial contractile function in 77 older patients with normal ejection fraction who were free of valvular and myocardial ischemic disease. Group 1 comprised 49 patients with relative wall thickness > or = 0.45; group 2 (n = 28) had normal relative wall thickness. Pump performance was characterized by stroke volume index, cardiac index, and stroke work; myocardial function was characterized by midwall shortening and circumferential stress versus shortening relations. Group 1 patients had lower end-diastolic volume (83 +/- 3 vs 124 +/- 5 ml, p < 0.05), cardiac index (2.6 +/- 0.2 vs 3.5 +/- 0.1 L/min/m2, p < 0.05), and stroke work/100 g left ventricular mass (43 +/- 2 vs 53 +/- 3 g-m/100 g, p < 0.005). Although there was no significant difference with regard to ejection fraction or fractional shortening at the endocardium, fractional shortening at the midwall was significantly lower in group 1 than in group 2 (16 +/- 1% vs 19 +/- 1%, p < 0.005). This lower value for midwall shortening was observed despite lower values for endsystolic stress, implying decreased myocardial contractile function. Lower stroke volume index in group 1 patients, likely due to small chamber size, was not offset by increased heart rate, resulting in a low-normal cardiac index; in 33% of group 1 patients, cardiac index was < 2.2 L/min/m2, indicating reduced pump performance. Our data indicate an abnormality in pump performance and myocardial function in patients who have high relative wall thickness and normal ejection fraction.

Evaluation of extent of shortening versus velocity of shortening at the endocardium and midwall in hypertensive heart disease

To assess the incremental value of velocity of shortening velocity parameters compared with simpler, more widely used, extent of shortening parameters in compensated left ventricular hypertrophy, we studied 52 patients with left ventricular hypertrophy and 63 age-matched controls. Velocity parameters did not provide incremental information beyond that obtained by extent of shortening parameters.

Traumatic Intracardiac Communication: Detection by Color Flow Mapping

A previously healthy 20-year-old man underwent emergency surgery for repair of a right ventricular free wall laceration that was the result of a knife wound. A systolic murmur was first heard 1 month later, and two-dimensional echocardiography and color flow mapping demonstrated a communication between the left and right ventricle in the region of the membranous septum. The visualized turbulent flow was consistent with a ventriculoseptal defect but also appeared to extend posteriorly into the left atrium in a direct line with the septal communication. At cardiac catheterization the calculated left-to-right shunt was 1.2:1.

Color Doppler mapping of aortic regurgitation in aortic stenosis: comparison with angiography.

Color flow Doppler mapping has become the principal noninvasive method used for the qualitative grading of aortic regurgitation (AR). However, the performance of the color Doppler method in patients with AR accompanying aortic stenosis (AS) has not been studied. We therefore compared results of color Doppler and semiquantitative angiographic grading of AR in 32 patients with AS (mean valve area = 0.7 cm2) undergoing supravalvular aortography in the course of cardiac catheterization. Color Doppler demonstrated AR in all 27 patients who had AR by aortography. As expected, neither the maximal jet area nor the jet length discriminated patients by angiographic grade. The best correlation between color Doppler and aortography occurred when the ratio of maximal jet height (JH) to left ventricular outflow tract (LVOT) height was used to grade AR on a scale of 0-4. Four of 5 patients without AR by aortography had either absent or grade 1 AR by color Doppler. Although there was considerable overlap of color Doppler grades in patients with 1+ AR by aortography, grade 3 or 4 AR by color Doppler was always associated with III+ or IV+ AR by aortography. Thus, color Doppler sensitively depicts AR in patients with AS, and the ratio of JH to LVOT height by color Doppler correctly identifies patients with III+ or IV+ AR by aortography. Methods for distinguishing among milder grades require further evaluation.

TCT-738 Optimizing cost savings in minimalist transfemoral TAVR – closing the gap

METHODS Retrospective analysis of consecutive TAVR patients for whom pre procedural angles were predicted by cardiac imaging specialists using two methods: manual multiplanar reformations (MR) and the semi-automatic optimal angle graph (OAG). The distributions of predicted versus actual cranial caudal (CRA\CAU, Y axis) and right and left anterior oblique (RAO\LAO, X axis) angles are presented in scatter plots. Paired analysis was used to compare the distributions and means following definition of equal distribution as the null hypothesis. The difference between the two dimensional distributions and means were compared to a zero bivariate normal distribution and mean.