Javier Berdejo

Evaluation of Vegetation Size and Its Relationship With Embolism in Infective Endocarditis A Real-Time 3-Dimensional Transesophageal Echocardiography Study

Background—Two-dimensional (2D) echocardiography studies have shown that the maximum length of vegetation (MLV) ≥10 mm is a predictor of embolic events (EEs) in patients with infective endocarditis. However, 2D measurements probably underestimate the vegetation dimensions. In this study, we evaluated the feasibility of real-time 3-dimensional transesophageal echocardiography (RT3DTEE) in determining MLV and its accuracy in identifying the risk for EEs compared with 2D transesophageal echocardiography (2DTEE). Methods and Results—We analyzed 60 patients with vegetations. RT3DTEE measurement of MLV was obtained with Advanced QLAB Quantification Software by cropping the 3D volume with the appropriate 2D plane to obtain the largest value. The standard 2DTEE images were also evaluated to determine the MLV. Major EEs were registered from medical records, and a logistic regression analysis was performed to determine the association between MLV and EEs. The RT3DTEE MLV was larger than the 2DTEE value with a mean difference of 3.2 mm (95% confidence interval, 2.1–4.2 mm). The best cut-off value for prediction of EEs was MLV ≥20 mm with RT3DTEE and MLV ≥16 mm with 2DTEE. The positive predictive value increased from 59.1% to 65.2% when RT3DTEE was used. The accuracy of classification of patients with EEs increased from 65% to 70% with this new technique. Conclusions—RT3DTEE is a feasible technique for the analysis of vegetation morphology and size that may overcome the shortcoming of 2DTEE, leading to a better prediction of the embolism risk in patients with infective endocarditis.

Effect of transcatheter aortic valve replacement on the mitral valve apparatus and mitral regurgitation: real-time three-dimensional transesophageal echocardiography study.

Background—The effect of transcatheter aortic valve replacement (TAVR) on the mitral valve apparatus and factors influencing the reduction of mitral regurgitation with or without mitral leaflet tethering after TAVR are poorly understood. The present 3-dimensional (3D) transesophageal echocardiography study aimed to elucidate early changes further in the structure and function of the mitral valve apparatus after TAVR. Methods and Results—We analyzed 90 patients (nontenting group, 56 patients and tenting group, 34 patients) who underwent TAVR using the Edwards SAPIEN and had intraprocedural 3D transesophageal echocardiography evaluation of the mitral valve. Of all patients, mitral regurgitation improved in 54%, remained the same in 38%, and worsened in 8% 1 day after TAVR. There were no statistically significant differences in mitral annular 3D parameters before and after TAVR in both groups. In the tenting group, tenting area (P<0.01) and tenting height (P<0.01) were decreased, and coaptation length was increased (P<0.05) after TAVR. In a multivariable analysis, the predictors of improved mitral regurgitation were the decrease of tenting area (odds ratio, 8.15; 95% confidence interval, 1.31–50.7; P<0.05) and the decrease of valvuloarterial impedance (odds ratio, 7.57; 95% confidence interval, 1.15–49.9; P<0.05) in the tenting group and the decrease of valvuloarterial impedance (odds ratio, 6.96; 95% confidence interval, 1.24–39.2; P<0.05) in the nontenting group. Conclusions—Mitral leaflet tethering was improved immediately by TAVR in patients with mitral leaflet tenting regardless of mitral annular geometry. Acute improvement in mitral regurgitation after TAVR is predominantly related to global left ventricular hemodynamics and mitral leaflet tethering change.Background— The effect of transcatheter aortic valve replacement (TAVR) on the mitral valve apparatus and factors influencing the reduction of mitral regurgitation with or without mitral leaflet tethering after TAVR are poorly understood. The present 3-dimensional (3D) transesophageal echocardiography study aimed to elucidate early changes further in the structure and function of the mitral valve apparatus after TAVR. Methods and Results— We analyzed 90 patients (nontenting group, 56 patients and tenting group, 34 patients) who underwent TAVR using the Edwards SAPIEN and had intraprocedural 3D transesophageal echocardiography evaluation of the mitral valve. Of all patients, mitral regurgitation improved in 54%, remained the same in 38%, and worsened in 8% 1 day after TAVR. There were no statistically significant differences in mitral annular 3D parameters before and after TAVR in both groups. In the tenting group, tenting area ( P <0.01) and tenting height ( P <0.01) were decreased, and coaptation length was increased ( P <0.05) after TAVR. In a multivariable analysis, the predictors of improved mitral regurgitation were the decrease of tenting area (odds ratio, 8.15; 95% confidence interval, 1.31–50.7; P <0.05) and the decrease of valvuloarterial impedance (odds ratio, 7.57; 95% confidence interval, 1.15–49.9; P <0.05) in the tenting group and the decrease of valvuloarterial impedance (odds ratio, 6.96; 95% confidence interval, 1.24–39.2; P <0.05) in the nontenting group. Conclusions— Mitral leaflet tethering was improved immediately by TAVR in patients with mitral leaflet tenting regardless of mitral annular geometry. Acute improvement in mitral regurgitation after TAVR is predominantly related to global left ventricular hemodynamics and mitral leaflet tethering change.

Valvuloarterial Impedance, But Not Aortic Stenosis Severity, Predicts Syncope in Patients With Aortic Stenosis

Background—The presence of syncope in patients with aortic valve stenosis (AS) predicts a grave prognosis. However, the evaluation of AS severity has been limited to valve-specific factors such as aortic valve area and mean transaortic pressure gradient. Recently, valvuloarterial impedance (Zva) was proposed for the estimation of global left ventricular afterload. Therefore, because predictors of syncope in patients with AS have not been investigated in recent years, we assessed the effect of clinical characteristics and echocardiographic parameters, including Zva, on syncope in patients with AS. Methods and Results—We retrospectively studied 451 patients with moderate and severe AS without low left ventricular ejection fraction (<40%). Patients with syncope (n=79; 18%) had higher Zva (5.1±0.9 versus 4.4±0.9 mm Hg/mL per m2; P<0.001) than those without (n=372; 82%). However, no significant differences existed in the mean transaortic pressure gradient (P=0.076) or the aortic valve area (P=0.160) between the 2 groups. In the multivariable analysis, only Zva was an independent predictor of syncope in patients with AS (odds ratio, 2.02; 95% confidence interval, 1.54–2.64; P<0.001). However, systolic blood pressure, relative wall thickness, the early transmitral flow velocity to peak early diastolic mitral annular velocity ratio, and mean transaortic pressure gradient were not identified as independent predictors. Receiver operating characteristic curve analysis identified Zva ≥4.7 mm Hg/mL per m2 as the cutoff value associated with syncope in patients with AS. Conclusions—Our study suggests that high Zva, but not conventional parameters of AS, identifies AS patients with an increased risk of syncope.

Functional Tricuspid Regurgitation Caused by Chronic Atrial Fibrillation: A Real-Time 3-Dimensional Transesophageal Echocardiography Study

Background— Functional tricuspid regurgitation (TR) with a structurally normal tricuspid valve (TV) may occur secondary to chronic atrial fibrillation (AF). However, the clinical and echocardiographic differences according to functional TR subtypes are unclear. Therefore, characterization of functional TR because of chronic AF (AF-TR) remains undetermined. Methods and Results— To investigate the prevalence of AF-TR, 437 patients with moderate to severe TR underwent 3-dimensional (3D) transesophageal echocardiography. TR severity was determined by the averaged vena contracta width on apical and parasternal inflow views. The prevalence of AF-TR was 9.2%, whereas that of functional TR because of left-sided heart disease was 45.3%. Clinical features of AF-TR included advanced age, female sex, greater right atrial than left atrial enlargement and lower systolic pulmonary artery pressure compared with left-sided heart disease-TR with sinus rhythm (all P <0.05). In 3D TV assessment, patients with AF-TR had a larger TV annular area with weaker annular contraction (both P <0.001) but a smaller tethering angle ( P <0.001) despite a similar leaflet coaptation status compared with patients with left-sided heart disease-TR with sinus rhythm. On multivariable analysis, only the TV annular area in midsystole (coefficient, 0.059; 95% confidence interval, 0.041–0.078 per 100 mm2; P <0.001) was associated with TR severity in AF-TR. The annular area was more closely correlated with the right atrial volume than right ventricular end-systolic volume in AF-TR ( P <0.001). Conclusions— AF-TR is not rare and is associated with advanced age and right atrial enlargement. TV deformations and their association with right heart remodeling differ between AF-TR and left-sided heart disease-TR. Our results suggest that in patients with TR secondary to AF, TV annuloplasty should be effective because this entity has annular dilatation without leaflet deformation.Background— Functional tricuspid regurgitation (TR) with a structurally normal tricuspid valve (TV) may occur secondary to chronic atrial fibrillation (AF). However, the clinical and echocardiographic differences according to functional TR subtypes are unclear. Therefore, characterization of functional TR because of chronic AF (AF-TR) remains undetermined. Methods and Results— To investigate the prevalence of AF-TR, 437 patients with moderate to severe TR underwent 3-dimensional (3D) transesophageal echocardiography. TR severity was determined by the averaged vena contracta width on apical and parasternal inflow views. The prevalence of AF-TR was 9.2%, whereas that of functional TR because of left-sided heart disease was 45.3%. Clinical features of AF-TR included advanced age, female sex, greater right atrial than left atrial enlargement and lower systolic pulmonary artery pressure compared with left-sided heart disease-TR with sinus rhythm (all P<0.05). In 3D TV assessment, patients with AF-TR had a larger TV annular area with weaker annular contraction (both P<0.001) but a smaller tethering angle (P<0.001) despite a similar leaflet coaptation status compared with patients with left-sided heart disease-TR with sinus rhythm. On multivariable analysis, only the TV annular area in midsystole (coefficient, 0.059; 95% confidence interval, 0.041–0.078 per 100 mm2; P<0.001) was associated with TR severity in AF-TR. The annular area was more closely correlated with the right atrial volume than right ventricular end-systolic volume in AF-TR (P<0.001). Conclusions— AF-TR is not rare and is associated with advanced age and right atrial enlargement. TV deformations and their association with right heart remodeling differ between AF-TR and left-sided heart disease-TR. Our results suggest that in patients with TR secondary to AF, TV annuloplasty should be effective because this entity has annular dilatation without leaflet deformation.

Impact of Device Landing Zone Calcification on Paravalvular Regurgitation after Transcatheter Aortic Valve Replacement: A Real-Time Three-Dimensional Transesophageal Echocardiographic Study

BACKGROUND Determinants of paravalvular regurgitation after transcatheter aortic valve replacement (TAVR) remain unclear. The purpose of this study was to investigate the impact of aortic valve calcification (AVC) on paravalvular regurgitation after TAVR using real-time three-dimensional transesophageal echocardiography. METHODS A total of 227 patients with severe aortic stenosis who underwent TAVR using the Edwards SAPIEN or SAPIEN XT valve were retrospectively analyzed. Severity of AVC was assessed on a visual scale ranging from 0 to 3 at the aortic annulus, the leaflets near the nadir, and the commissure. The shape of calcification was assessed by measuring the radial and circumferential lengths of annular calcification and by focusing on the calcification protruding into the left ventricular outflow tract from the annular level. Severity of paravalvular regurgitation was determined by the sum of the cross-sectional area of the vena contracta from two-dimensional or three-dimensional color Doppler transesophageal echocardiographic data. Significant paravalvular regurgitation was defined as at least a moderate grade. RESULTS After excluding 25 patients with inadequate image quality of three-dimensional and color Doppler data for analysis, AVC could be evaluated in 202 patients. Significant paravalvular regurgitation was occurred in 37 patients (18%). The sum of the AVC scale at the annulus was significantly correlated with the grade of paravalvular regurgitation, while those at the leaflets near the nadir and the commissure were not. As assessed by receiver operating characteristic curve analysis, the radial and circumferential length of the annular calcification had good discriminatory ability for significant paravalvular regurgitation, with areas under the curve of 0.91 and 0.81, respectively. On multivariate analysis, annular calcification with radial length ≥ 3.0 mm, circumferential length ≥ 8.0 mm, and calcification protruding into the left ventricular outflow tract were independently associated with significant paravalvular regurgitation. CONCLUSIONS Assessment of AVC by real-time three-dimensional transesophageal echocardiography is feasible and has good discriminatory value for paravalvular regurgitation in patients who undergo TAVR. Significant paravalvular regurgitation after TAVR is associated with the location and size of calcification at the aortic annulus and left ventricular outflow tract, not with its severity.

Comparison of Aortic Root Geometry with Bicuspid versus Tricuspid Aortic Valve: Real-Time Three-Dimensional Transesophageal Echocardiographic Study

BACKGROUND An understanding of aortic root anatomy in bicuspid aortic valve (BAV) has not been well established. The aims of this three-dimensional transesophageal echocardiographic study were (1) to examine whether aortic root geometry differs between BAV and tricuspid aortic valve (TAV) and (2) to analyze the dynamic motion of the aortic annulus throughout cardiac cycle. METHODS A total of 66 patients with BAV (38 with severe aortic stenosis [AS]) and 66 age-, gender-, and body surface area-matched patients with TAV (36 with severe AS) who underwent three-dimensional transesophageal echocardiography were retrospectively enrolled. The dynamic motion of the aortic annulus was also analyzed in 40 selected patients (10 with BAV with severe AS, 10 with BAV without AS, 10 with TAV with severe AS, and 10 with TAV without AS). RESULTS The area of the aortic root in patients with BAV was larger than in those with TAV (aortic annulus, P < .001; sinus of Valsalva, P < .05; sinotubular junction, P < .01). There was a significant difference in circularity (4π × area/[perimeter](2)) of the sinus of Valsalva between patients with BAV and those with TAV (P < .001), although there were no differences in the shapes of the aortic annulus and the sinotubular junction between the two groups. In both patients with BAV and those with TAV, the aortic annulus in mid-systole was largest and most circular in cardiac cycle; on the other hand, in end-diastole, the aortic annulus was smallest and most elliptical (P < .001). CONCLUSIONS Three-dimensional transesophageal echocardiography successfully demonstrated significant differences in the size of the aortic root and the shape of the sinus of Valsalva between patients with BAV and those with TAV.

Vena contracta analysis by color Doppler three-dimensional transesophageal echocardiography shows geometrical differences between prolapse and pseudoprolapse in eccentric mitral regurgitation

Evaluation of eccentric mitral regurgitation (MR) remains extremely difficult and the role played by its etiology, functional or degenerative, is not well understood. This study aimed to demonstrate the value of three‐dimensional transesophageal echocardiography (3DTEE) in the evaluation of eccentric MR identifying geometric differences in the vena contracta area between functional and degenerative etiologies.

Device Landing Zone Calcification Predicts Significant Paravalvular Regurgitation after Transcatheter Aortic Valve Replacement: A Real Time Three‐Dimensional Transesophageal Echocardiography Study

Paravalvular regurgitation (PVR) after transcatheter aortic valve replacement (TAVR) is one of the major complications with negative clinical prognosis. Therefore, its prediction is important for further improvement of the outcome. We present a case with TAVR, in which we successfully evaluated aortic valve calcification protruding inward and into the left ventricular outflow tract by real time three‐dimensional transesophageal echocardiography, and predicted significant PVR after the procedure. In conclusion, device landing zone calcification protruding inward is a key for the prediction of significant PVR after TAVR.

Evaluation of vegetation size and its relationship with septic pulmonary embolism in tricuspid valve infective endocarditis: A real time 3DTEE study

Tricuspid valve infective endocarditis (TVIE) causes septic pulmonary embolism (PE). However, the impact of vegetation size on PE is not fully elucidated.

Association of postprocedural aortic regurgitation with mitral regurgitation worsened after transcatheter aortic valve replacement

There is a paucity of investigation which demonstrates a predictor of mitral regurgitation (MR) worsened after aortic valve replacement (TAVR).