Edgard A. Prihadi

Feasibility, Accuracy, and Reproducibility of Aortic Annular and Root Sizing for Transcatheter Aortic Valve Replacement Using Novel Automated Three-Dimensional Echocardiographic Software: Comparison with Multi–Detector Row Computed Tomography

Background: In transcatheter aortic valve replacement (TAVR), multi–detector row computed tomography (MDCT) is currently the standard imaging modality for correct prosthesis sizing, despite risks of radiation and contrast‐induced renal injury. Three‐dimensional (3D) transesophageal echocardiography (TEE) has been proposed as a potential alternative imaging technique, and recently, automated 3D transesophageal echocardiographic software (Aortic Valve Navigator [AVN], an unreleased prototype from Philips) has been developed for assessment of the aortic annulus and root. The aim of this study was to assess the feasibility, accuracy, and reproducibility of AVN measurements in TAVR candidates by performing a comparison with MDCT. Methods: In 150 patients with severe, symptomatic aortic stenosis referred for TAVR, data on aortic annular and root dimensions prospectively acquired using 3D TEE and MDCT were retrospectively analyzed. Image quality on 3D TEE and the duration of analysis with AVN were recorded, as well as the aortic valve Agatston score on MDCT. Results: Data were obtained using 3D TEE and MDCT in 100% of patients for aortic annular dimensions and in 89% for aortic root dimensions. The mean duration of analysis using AVN was 4.2 ± 1.0 min, but it was significantly shorter with better 3D echocardiographic image quality and lower Agatston score on MDCT. Correlation of measurements between 3D TEE and MDCT was good to excellent for all anatomic locations (sinotubular junction mean diameter, R = 0.71; sinus of Valsalva mean diameter, R = 0.87; aortic annular mean diameter, R = 0.75; aortic annular perimeter, R = 0.83; aortic annular area, R = 0.91), with low inter‐ and intraobserver variability (intraclass correlation coefficient ≥ 0.93 and r ≥ 0.90 for all locations). Comparison based on conventional prosthesis sizing charts yielded excellent agreement in prosthesis size choice (&kgr; = 0.90). Conclusions: New automated 3D transesophageal echocardiographic software allows accurate modeling and reproducible quantification of aortic annular and root dimensions with high feasibility. An excellent correlation between measurements with AVN and MDCT and agreement in prosthesis sizing suggests the use of AVN in clinical practice as potential alternative to MDCT before TAVR. HighlightsNew automated 3D echocardiographic software (AVN) yields accurate measures of the aortic annulus.AVN showed excellent agreement with MDCT in choosing TAVR prosthesis size.AVN may be used for aortic root sizing in TAVR patients as an alternative to MDCT.

Development of significant tricuspid regurgitation over time and prognostic implications: new insights into natural history.

Aims To evaluate the risk factors influencing the development of significant (moderate and severe) tricuspid regurgitation (TR), and its impact on all-cause mortality in large registry of referral centre. Methods and results In 1000 patients (mean age 68 ± 13 years; 50.9% male) with documented significant TR, clinical, and echocardiographic data were retrospectively analysed when the echocardiogram showed none/mild TR. Patients with congenital heart disease were excluded. The study population was divided into quartiles according to the time interval between the two echocardiograms: Group 1: ≤1.2 years, n = 251; Group 2: 1.3-4.7 years, n = 248, Group 3: 4.8-8.9 years, n = 251; Group 4: ≥9.0 years, n = 250. Baseline age [odds ratio (OR) 1.02], presence of pacemaker and defibrillator lead (OR 1.59), presence of mild (vs. none) TR (OR 8.96), reduced tricuspid annulus plane systolic excursion (OR 0.86), and tricuspid annulus dilation (OR 1.06) were independently associated with development of significant TR in a short period of time. Any valvular surgery (without concomitant tricuspid surgery) occurring between both echocardiograms was also associated with a higher risk of fast development of significant TR (OR 1.58). During a median follow-up of 2.9 years after the second echocardiogram (with significant TR), 42.1% patients died. Patients with fast development of significant TR showed worse survival than patients with slower significant TR development (log rank P = 0.001). Fast development of significant TR was independently associated with all-cause mortality (hazard ratio per preceding year of development: 0.92, confidence interval 0.90-0.94; P < 0.001). Conclusion By identifying patients at increased risk of developing significant TR, close echocardiographic surveillance can be indicated permitting effective therapy at an earlier stage to improve survival.

Imaging Needs in Novel Transcatheter Tricuspid Valve Interventions

The advent of novel transcatheter therapies for severe tricuspid regurgitation (TR) has attracted much attention. Novel 3-dimensional imaging techniques have permitted analysis of the tricuspid valve (TV) anatomy from unparalleled views and better understanding of the underlying pathophysiology of TR. Grading TR and assessment of right ventricular function remain challenging, and although 2-dimensional echocardiography is the mainstay imaging technique to evaluate patients with severe TR the use of 3-dimensional echocardiography and cardiovascular magnetic resonance is increasing. The number of transcatheter interventions for TR is growing, and procedural success relies significantly on the pre-procedural evaluation of the anatomy of the TV, etiology and severity of TR, right ventricular size and function, and importantly, the anatomic relationships of the TV. The role of multimodality imaging in patient selection and procedural planning for transcatheter TV repair is reviewed.

Electrocardiographic Pattern of Left Ventricular Hypertrophy with Strain and Survival in Calcific Aortic Valve Disease

ABSTRACT Background: The prevalence of electrocardiographic (ECG) patterns of left ventricular (LV) hypertrophy and strain in calcific aortic valve disease has not been extensively evaluated. We sought to evaluate the prevalence of ECG-defined LV hypertrophy and strain in a large cohort of patients with various grades of calcific aortic valve disease and to correlate these ECG patterns with survival. Methods: A total of 1,437 patients (mean age 66 ± 14 years, 62.6% men) with calcific aortic valve disease were evaluated. Demographic, clinical variables and presence of ECG patterns of LV hypertrophy and strain were collected and related to occurrence of all-cause mortality, correcting for aortic valve replacement during follow-up. Results: Aortic sclerosis was diagnosed in 29% of patients, mild aortic stenosis (AS) in 13%, moderate AS in 30% and severe AS in 28%. Seventy-six patients showed ECG pattern of LV hypertrophy without strain whereas 227 showed ECG pattern of LV hypertrophy with strain. Patients with LV hypertrophy with strain pattern showed more frequently severe AS. During a mean follow-up of 7.2 ± 4.8 years (10,258 patient-years), 545 (37.9%) patients died. Compared to ECG without hypertrophy pattern, ECG strain pattern was independently associated with all-cause mortality (HR 1.36, 95% CI 1.08–1.72; p = 0.009), whereas LV hypertrophy pattern on ECG was not (HR 1.38, 95% CI 0.94–2.24; p = 0.094). Conclusions: The ECG strain pattern reflects an advanced stage of the LV remodeling process in the natural history of calcific aortic valve disease and is independently associated with worse outcome.

Prevalence and Prognostic Relevance of Ventricular Conduction Disturbances in Patients With Aortic Stenosis

The prevalence and prognostic implications of ventricular conduction disturbances in aortic stenosis (AS) have not been extensively evaluated. The present retrospective study investigated the prevalence and prognostic implications of ventricular conduction abnormalities (including the QRS morphology and duration) in AS. A total of 1,245 patients (mean age 66 ± 14 years, 62.8% men) with varying AS severity (aortic sclerosis 33.9%, mild AS 11.5%, moderate AS 29.9%, and severe AS 24.7%) were evaluated. Demographic, clinical variables, and presence of ventricular conduction abnormalities on the electrocardiogram (based on QRS morphology and duration) were related to occurrence of all-cause mortality, correcting for occurrence of aortic valve replacement. The prevalence of ventricular conduction disorders increased in parallel with AS severity, which was particularly significant for left bundle branch block (4.3% in aortic sclerosis, 2.1% in mild AS, 4.6% in moderate AS, and 8.1% in severe AS; p = 0.042). The QRS duration showed a slight prolongation with increasing AS severity (102 ± 21 ms in aortic valve sclerosis, 99 ± 18 ms in mild AS, 104 ± 22 ms in moderate AS, and 105 ± 22 ms in severe AS; p = 0.044). During a mean follow-up of 8.1 ± 4.8 years, 40.9% of patients died. Right bundle branch block morphology (hazard ratio 1.59, 95% confidence interval 1.18 to 2.13, p = 0.002) and increase of QRS duration (hazard ratio 1.06, 95% confidence interval 1.02 to 1.11; p = 0.006) were independently associated with all-cause mortality. In conclusion, ventricular conduction disorders became more prevalent with increasing severity of AS and have an impact on survival.