Elena Galli

Prevalence and prognostic value of right ventricular dysfunction in severe aortic stenosis

AIMS Systolic pulmonary artery pressure (sPAP) is a well-known outcome predictor in patients with valvular heart disease. Limited data are available regarding the evaluation of right ventricular (RV) performance, particularly in patients with aortic stenosis (AS). The aim of this study was to evaluate the prevalence, determinants, and prognostic significance of RV dysfunction in severe AS independently from the strategy of treatment chosen. METHODS AND RESULTS Two hundred patients (mean age: 79.9 ± 8.8 years) with severe AS underwent two-dimensional and speckle tracking echocardiography for the evaluation of left ventricular (LV) and RV functions, aortic valve gradients, and sPAP. A tricuspid annular plane systolic excursion (TAPSE) ≤17 mm defined RV dysfunction. RV dysfunction was detected in 48 patients (24%). At multivariable regression analysis, LV global longitudinal strain (r = -0.29, P = 0.001), mean aortic gradient (r = 0.25, P = 0.002), and LV ejection fraction (r = 0.18, P = 0.02) were well correlated with TAPSE. After a median 16-month follow-up, cardiovascular death occurred in 17 patients. At multivariate Cox regression analysis, biventricular dysfunction (TAPSE ≤17 mm and LVEF ≤50%) emerged as the strongest predictor of prognosis (hazard ratio 4.08, 95% confidence interval 1.36-12.22; P = 0.012). CONCLUSIONS RV dysfunction is common in AS patients, and this finding can likely be accounted for by the RV-LV interdependence. Given that biventricular function impairment was a strong predictor of mortality in our population, we suggest that RV dysfunction should be systematically looked for in AS patients.

Pre- and postoperative tricuspid regurgitation in patients with severe symptomatic aortic stenosis: importance of pre-operative tricuspid annulus diameter

Aims Secondary tricuspid regurgitation (STR) is commonly found in patients with aortic stenosis and is associated with increased morbidity. The study sought to evaluate the prevalence of pre-operative STR and its progression after surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). Also, it sought to analyse the predictors of post-operative changes in STR. Methods and results We prospectively evaluated 116 patients (aged 75.1 ± 9.8 years, predominantly male) who undergo SAVR or TAVI for severe aortic stenosis (AS) from September 2013 to April 2015. Patients with associated valve disease requiring intervention, significant coronary artery disease or left ventricular ejection fraction (LVEF) <50% were excluded. Clinical and echocardiographic data, including TR grade and right ventricular (RV) size and function, were assessed at baseline and at the 1-year follow-up. At baseline, significant TR was documented in 13 patients (11.1%) and non-significant TR was documented in 103 patients (88.9%). Atrial fibrillation (AF) was more prevalent in patients with a tricuspid annulus diameter ≥40 mm (P < 0.0051). At the 1-year follow-up, the TR grade had improved in 17 patients (14.7%), was unchanged in 68 patients (58.6%) and had worsened in 31 patients (26.7%). Moderate to severe TR was found in 30 patients (25.8%). Tricuspid annulus diameter >40 mm was the only echocardiographic predictor of significant postoperative TR (relative risk (RR) = 2.12 [1.26-3.54], P = 0.004). Right heart function and size were not independent predictors. Conclusion Significant TR was present pre-operatively in 11.1% of patients. Post-operative progression was observed in 26.7% of patients. Only tricuspid annulus size >40 mm was an independent echocardiographic predictor of moderate to severe TR at the 1-year follow-up.

Echocardiographic reference ranges for normal left atrial function parameters: results from the EACVI NORRE study

Aims To obtain the normal ranges for echocardiographic measurements of left atrial (LA) function from a large group of healthy volunteers accounting for age and gender. Methods and results A total of 371 (median age 45 years) healthy subjects were enrolled at 22 collaborating institutions collaborating in the Normal Reference Ranges for Echocardiography (NORRE) study of the European Association of Cardiovascular Imaging (EACVI). Left atrial data sets were analysed with a vendor-independent software (VIS) package allowing homogeneous measurements irrespective of the echocardiographic equipment used to acquire data sets. The lowest expected values of LA function were 26.1%, 48.7%, and 41.4% for left atrial strain (LAS), 2D left atrial emptying fraction (LAEF), and 3D LAEF (reservoir function); 7.7%, 24.2%, and -0.53/s for LAS-active, LAEF-active, and LA strain rate during LA contraction (SRa) (pump function) and 12.0% and 21.6% for LAS-passive and LAEF-passive (conduit function). Left atrial reservoir and conduit function were decreased with age while pump function was increased. All indices of reservoir function and all LA strains had no difference in both gender and vendor. However, inter-vendor differences were observed in LA SRa despite the use of VIS. Conclusion The NORRE study provides contemporary, applicable echocardiographic reference ranges for LA function. Our data highlight the importance of age-specific reference values for LA functions.

Atrial function is altered in lone paroxysmal atrial fibrillation in male endurance veteran athletes

Aims Intensive endurance sport practice is associated with an increased risk of atrial fibrillation (AF) in male veteran athletes. Paroxysmal AF (PAF) is the very beginning step of this disease. The description of atrial remodelling occurring at this early stage might enable to depict predictive factors of AF in veteran athletes in order to give them personalized recommendation according to their sport practice. Methods and results Twenty-seven male endurance veteran athletes with documented PAF were retrospectively enrolled and compared with 30 control endurance athletes without documented AF, with similar training level, age, and cardiovascular risk factors. All subjects underwent a resting-electrocardiogram (ECG) to assess the electric remodelling of P-waves as well as an echocardiography, to evaluate the left and right atrial (LA, RA) anatomical and functional (assessed by 2D strain) remodelling. No difference was noted between groups for the ECG P-wave parameters. Atrial function was decreased in the PAF group, particularly the peak atrial longitudinal strain (L-ɛ-Max) of LA (29.3 ± 7.9% vs. 49.1 ± 7.8% respectively in the PAF group and in controls, P < 0.0001) and RA (36.5 ± 7.0% vs. 50.6 ± 10.2%, P < 0.0001). LA and RA volumes were also larger in the PAF group. Receiver operating characteristic analysis demonstrated that L-ɛ-Max of LA [area under curve (AUC): 0.957 ± 0.023] and RA (AUC: 0.901 ± 0.042) had the best ability to identify the athletes with PAF, far better than the anatomical parameters (AUC < 0.75 in all). Conclusion Atrial function analysed by strain in echocardiography is strongly associated with PAF and might enable to identify male endurance veteran athletes at risk to develop AF.

Role of myocardial constructive work in the identification of responders to CRT

Aims Cardiac resynchronization therapy (CRT) plays a pivotal role in the management of patients with heart failure (HF) and wide QRS complex. However, the treatment is plagued by numerous non-responders. Aim of the study is to evaluate the role myocardial work estimated by pressure-strain loops (PSLs) in the comprehension of physiological mechanisms associated with CRT and in the prediction of CRT response. Methods and results Ninety-seven patients with symptomatic HF (ejection fraction: 27 ± 6%, QRS duration 164 ± 18 ms) undergoing CRT implantation according to current recommendations were retrospectively included in the study. Standard 2D and speckle tracking echocardiography were performed before CRT and at the 6-month follow-up (FU). PSL analysis allowed the calculation of global and regional myocardial constructive work (CW) and wasted work (WW). A > 15% reduction in left ventricular (LV) end-systolic volume at FU defined CRT-positive response (CRT-PR). At FU, 63 (65%) patients responded to CRT. Global CW (CWtot) was significantly increased in CRT-responders. At multivariate analysis, CWtot > 1057 mmHg% (OR 14.69, P = 0.005) and septal flash (OR 8.05, P = 0.004) were the only significant predictors of CRT-PR. CWtot was associated with the entity of CRT-induced myocardial remodelling in both ischaemic (r = -0.55, P < 0.0001) and non-ischaemic patients (r = 0.65, P < 0.0001). A CWtot < 1057 mmHg% identified 85% of non-responders with a positive predictive value of 88%. Conclusion Patients with higher CWtot exhibit a favourable response to CRT. These data encourage further studies for the assessment of the myocardial substrate related to the functional response to CRT.

New indices of left ventricular function: let's move from ejection fraction to more physiological parameters

The assessment of myocardial function in the context of valvular heart disease (VHD) remains highly challenging. This article is protected by copyright. All rights reserved

Left ventricular non-compaction and idiopathic dilated cardiomyopathy: the significant diagnostic value of longitudinal strain

Left ventricular non-compaction (LV NC) is characterized by abnormal trabeculations that are mainly at the LV apex. Distinction between LV NC and non-specific dilated cardiomyopathies (DCMs) remains often challenging. We sought to find additive tools comparing the longitudinal strain characteristics of LVNC versus idiopathic DCM in a cohort of patients. 48 cases of LVNC (derivation cohort) were compared with 45 cases of DCM. Global and regional multi-layer (sub-endocardial, mid-wall, and sub-epicardial) LV longitudinal strain analysis was performed. Results were compared to define the best tool for distinguishing LVNC from DCM. A validation cohort (41 LVNC patients) was then used to assess the performance of the proposed diagnostic tools. In the derivation cohort, longitudinal deformation (strain) was greater in LVNC than in DCM patients. Longitudinal shortening was greater in the non-compacted segments than in the compacted ones. A mid-wall strain base-apex gradient had 88.4 % sensitivity and 66.7 % specificity in distinguishing LVNC from DCM (AUC = 0.83; cut-off of −23 or |0.23|%). In a multivariable model, the base-apex mid-wall gradient in an apical 4-chamber view was the only independent echocardiographic criteria (OR = 0.76, CI 95 % [0.66; 0.90], p = 0.0010) allowing the distinction between LVNC and DCM. In the validation cohort, the base-apex mid-wall gradient of strain had 88.4 % sensitivity, 85.7 % negative predictive values for the diagnosis of LVNC. Longitudinal strain, especially the base-apex longitudinal gradient of strain, appears as an additive valuable tool for distinguishing LVNC from DCM.

Non‐invasive estimation of left heart filling pressures: another nail in the coffin for E/e'?

The non-invasive diagnosis of left ventricular (LV) filling pressures is important in the management of heart failure (HF) patients with reduced as well as preserved LV ejection fraction (LVEF). To that end, a new expert consensus has proposed a diagnostic algorithm based on the ratio of the early diastolic velocities of mitral inflow and mitral annular motion (E/e’; abnormal when >14), the indexed left atrial volume (LAVi; abnormal when >34 mL/m2), and the maximal velocity of tricuspid regurgitation (TR; abnormal when >2.8 m/s).1 The recommendations have now been tested in two multicentre studies of heterogeneous populations. The first enrolled 450 patients, with a mean LVEF of 47%, including 209 with LVEF <50%. It demonstrated that the echocardiographic algorithm diagnosed elevated LV filling pressure [defined as either mean pulmonary capillary wedge pressure (PCWP) or pre-‘a’ LV diastolic pressure >12 mmHg] with an accuracy of 87%.2 The second, called Euro-Filling, was designed and conducted by the European Association of Cardiovascular Imaging (EACVI) and enrolled 159 patients undergoing elective coronary arteriography, including 39 with LVEF <50%. The new algorithm identified patients with LV end-diastolic pressure (LVEDP) ≥15 mmHg with sensitivity 75%, specificity 74%, positive predictive value 39%, and negative predictive value 93%; the area under the receiver-operating characteristic curve (C statistic) was 0.78, compared with 0.68 using the 2009 recommendations.3 The respective authors concluded that the algorithm had ‘good accuracy’ and was ‘fairly reliable’. This is the context in which Hummel et al. now report their commendably detailed retrospective analysis of 98 patients with HF and preserved LVEF (>45%), including 30% with atrial fibrillation.4

Prognostic value of BNP in heart failure with preserved or reduced ejection fraction

Heart failure (HF) is a growing concern for the public healthcare, especially among elderly patients where diagnosis, treatment and prevention of re-hospitalisation are challenging. HF with preserved EF (HFpEF) incidence has steadily increased over time without significant improvement in treatment and survival. Natriuretic peptides (NP), including B-type NP (BNP) and N-terminal-proBNP (NT-proBNP), are primarily upregulated by increased atrial or ventricular diastolic wall stress and have emerged as powerful predictors of adverse cardiovascular outcomes (death or hospitalisation) in patients with HF, which had mainly been demonstrated in HF with reduced EF (HFrEF). Consequently, European Society of Cardiology (ESC) guidelines published in 2012 have incorporated BNP as a tool for diagnosis and prognosis (class of recommendation IIa, level C). American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines proposed these biomarkers for guided HF therapy in selected patients (class IIa, level B). These recommendations are also considering that evidence of BNP-guided management in HF to reduce mortality or hospitalisation rates is insufficient for being used systematically (class IIb, level B). Thus, NP might help clinician but does not seem to provide robust enough information to be strongly recommended. New approaches like combination with biomarkers like ST21 or imaging tools such as echocardiography would have to be considered. In their Heart publication, Kang …

Right ventricular exercise contractile reserve and outcomes after early surgery for primary mitral regurgitation

Objective To assess if the lack of development of right ventricular (RV) contractile reserve during exercise echocardiography (ex-echo) might be a predictor of postoperative major adverse cardiovascular events (MACEs) in patients with primary mitral regurgitation (pMR) undergoing early surgery. Methods Comprehensive resting and ex-echo were performed in 142 asymptomatic patients (58±21 years, 68% men, New York Heart Association functional class ≤2) with isolated severe pMR and preserved left ventricular (LV) function (LV ejection >60%, LV end-systolic diameter <45 mm) undergoing mitral valve replacement (n=20) or repair. Postoperative MACEs were defined as occurrence of atrial fibrillation, stroke, cardiac-related hospitalisation or death. RV function was evaluated at rest in every patient during ex-echo by measuring their tricuspid annular plane systolic excursion (TAPSE) value. Results After median follow-up of 30 months (IQR 16–60 months), MACEs occurred in 48 (34%) patients. Using Bayesian model averaging, among all the characteristics including the type of surgery, exercise TAPSE (ex-TAPSE) emerged as the most likely predictor of prognosis (HR 0.91, 95% CI 0.86 to 0.96). Other probable predictors were exercise fractional area change (HR 0.02, 95% CI 0.00 to 0.80), male gender (HR 0.40, 95% CI 0.21 to 0.75) and RV basal diameter (HR 1.06, 95% CI 0.98 to 1.14). In the receiver operating characteristic curve analysis, an ex-TAPSE value of <26 mm (sensitivity 73% (95% CI 61 to 84) and specificity of 86% (95% CI 77% to 93%)) defined RV dysfunction. Event-free survival at 5 years was significantly lower in the patient group that exhibited no development of RV contractile reserve during exercise: 43.9% (95% CI 31.3 to 61.4) vs 75.8% (95% CI 64.8 to 88.7). Conclusion Lack of development of exercise-induced RV contractile reserve is a prognostic predictor in patients with severe pMR undergoing early mitral valve surgery.