Laura Sanchis

Left atrial dysfunction relates to symptom onset in patients with heart failure and preserved left ventricular ejection fraction

AIMS Pathophysiology of heart failure (HF) with preserved ejection fraction (HFPEF) remains unclear. Left atrial (LA) function has been related to HF symptoms. Our purpose is to analyse LA function in outpatients with new onset symptoms of HF. METHODS AND RESULTS An observational study was performed including 138 consecutive outpatients with suspected HF referred to a one-stop clinic. Final diagnosis [HF with reduced EF (HFREF), HFPEF, or non-HF] was established according to current recommendations. Echocardiography was performed in all patients. LA function was analysed using strain derived from speckle tracking in sinus rhythm patients (n = 83). Results were analysed with ANOVA and Bonferroni statistical tests. Receiver operating characteristic (ROC) curves were constructed to investigate the predictive ability of LA parameters for the final diagnosis of HF. Patients were 75 ± 9 years and 63% women. Final diagnosis was 23.2% HFREF, 45.7% HFPEF, and 31.2% non-HF. Left ventricular strain rate showed no differences between non-HF and HFPEF groups, but both groups showed differences with the HFREF group. LA strain rate (A- and S-waves) was significantly reduced in both HF groups (without differences among them) when compared with the non-HF group. LA strain rate and indexed volume showed significant accuracy for HF diagnosis in ROC curves. CONCLUSIONS In outpatients with new-onset symptoms of HF, LA dysfunction was observed. It might be the initial mechanism in the development of symptoms in HFPEF patients. These findings support the relationship of LA dysfunction with HFPEF, suggesting that the analysis of LA function may be useful in sinus rhythm patients with new-onset dyspnoea.

Lung Function Abnormalities are Highly Frequent in Patients with Heart Failure and Preserved Ejection Fraction

BACKGROUND Heart failure with preserved ejection fraction (HFPEF) is the most prevalent form of heart failure in outpatients. Yet, the pathophysiology of this syndrome is unclear and pharmacological treatment does not improve prognosis. Because breathlessness during activities of daily living is the most frequent complaint of patients with HFPEF, we hypothesised that lung function may be often abnormal in these patients due to either a direct effect of HFPEF and/or shared risk factors. In this study we explore the frequency, type and severity of lung function abnormalities in HFPEF. METHODS We measured forced spirometry, static lung volumes, pulmonary diffusing capacity (DL(CO)) and arterial blood gases in 69 outpatients with newly diagnosed symptomatic HFPEF. RESULTS We found that 94% of the patients showed abnormalities in at least one of the lung function measurements obtained: spirometry was abnormal in 59%, DL(CO) in 83% and arterial hypoxaemia was present in 62%. Their severity varied between patients, they were more prevalent in patients with NYHA functional class III/IV, and most often they were undiagnosed and untreated. CONCLUSIONS Lung function abnormalities are very frequent in HFPEF patients. A greater awareness among clinicians may contribute to improve their management and health status.

Diagnóstico de la insuficiencia cardíaca con fracción de eyección preservada o reducida mediante una consulta de alta resolución

Resumen Objetivos a) Valorar la aplicabilidad de una consulta de alta resolución (CAR) para el diagnóstico de pacientes ambulatorios con insuficiencia cardíaca (IC) de inicio; b) caracterizar a los pacientes con IC y fracción de eyección preservada (ICFE-P) comparados con los de fracción de eyección reducida (ICFE-R), y c) determinar el nivel de péptido natriurético tipo B (PNB) para identificar la IC en esta población. Diseño Estudio longitudinal observacional descriptivo. Emplazamiento Atención primaria especializada. Participantes y mediciones Ciento cuarenta y tres pacientes con síntomas iniciales de IC fueron incluidos en una CAR-IC con evaluación clínica, electrocardiograma, radiografía de tórax, PNB y ecocardiograma. Resultados Se diagnosticó IC en 65,7% de los pacientes: 67% ICFE-P y 33% ICFE-R. La mayoría de pacientes con ICFE-P eran mujeres (71,4 versus 38,7%; p = 0,002), con más edemas maleolares (61,9% versus 35,5%; p = 0,016) e índice de masa corporal (29,8 ± 5,1 versus 27,2 ± 5,0; p = 0,021). Ambos presentaron signos ecocardiográficos de disfunción diastólica e hipertensión pulmonar, con PNB (153,3 ± 123,1 versus 400,8 ± 579,8; p = 0,025) y troponina I (0,024 ± 0,019 versus 0,071 ± 0,12; p = 0,037) más elevados en ICFE-R. Resultaron predictores de ICFE-P el sexo femenino y los edemas maleolares, mientras que la onda Q, los valores elevados de PNB y la frecuencia cardíaca lo fueron de ICFE-R. El punto de corte de PNB = 60,12 pg/ml identificó IC con sensibilidad del 83% y especificidad del 84% (ABC = 0,898; IC 95% [0,848-0,948]; p < 0,001). Conclusiones La CAR-IC permitió el diagnóstico rápido y la caracterización de la IC de inicio, con mayor prevalencia de ICFE-P, en pacientes ambulatorios. El valor de PNB 60,12 pg/ml ofreció una sensibilidad y especificidad elevadas para identificar la IC en esta población.OBJECTIVES a) To assess the usefulness of a one-stop clinic for the diagnosis of outpatients with new onset heart failure; b) to characterize these patients comparing preserved (HF-PEF) versus reduced ejection fraction (HF-REF), and c) to determine brain natriuretic peptide (BNP) cut-off limit to identify HF in outpatients. DESIGN Observational descriptive study. SETTING Primary care. PARTICIPANTS AND MEASUREMENTS A total of 143 outpatients with new onset HF were assessed in a one-stop clinic. A cardiologist evaluation, electrocardiogram, chest X-ray, BNP, and echocardiography (diastolic and systolic study) were performed. RESULTS Almost two-thirds (65.7%) were diagnosed with HF: 67% with HF-PEF and 33% HF-REF. Women (71.4% versus 38.7%, P=.002), presence of swelling ankles (61.9% versus 35.5%, P=.016) and higher body mass index (29.8±5.1 versus 27.2±5.0 P=.021) were more frequent in the first group of patients. Echocardiographic signs of diastolic dysfunction and pulmonary hypertension were found in both groups, with higher values of BNP (153.3±123.1 versus 400.8±579.8 P=.025) and troponin I (0.024±0.019 versus 0.071±0.12, P=.037) in HF-REF patients. Female gender and swelling ankles were predictors of HF-PEF in the multivariate analysis, while Q waves and higher values of BNP and heart rate were predictors of HF-REF. A cut-off value of 60.12 pg/ml for BNP provided 83% sensitivity, 84% specificity (AUC=0.898; 95% CI; 0.848-0.948; P <.001). CONCLUSIONS The one-stop HF clinic has diagnosed and characterized outpatients with new onset HF and high prevalence of HF-PEF. The cut-off value of 60.12 pg/ml for BNP provides high sensitivity and specificity to identify HF in this population.

Prognosis of new-onset heart failure outpatients and collagen biomarkers

Prognosis of heart failure patients has been defined in hospital‐based or retrospective studies. This study aimed to characterize prognosis of outpatients with new‐onset preserved or reduced ejection fraction heart failure; to explore the role of collagen turnover biomarkers (MMP2, MMP9, TIMP1) in predicting prognosis; and to analyse their relationship with echocardiographic parameters and final diagnosis.

Gender influence on the adaptation of atrial performance to training

Abstract Background: High-intensity training has been associated with atrial remodelling and arrhythmias in men. Our purpose was to analyse atrial performance in female endurance athletes, compared to male athletes and controls. Methods: This was a cross-sectional study. We included four groups: female athletes, females controls, male athletes and male controls. Left (LA) and right atrial (RA) volumes and function were assessed using 2D and speckle-tracking echocardiography to determine peak atrial strain-rate at atrial (SRa) and ventricular contraction (SRs), as surrogates of atrial contractile and reservoir function, respectively. ANOVA and Bonferroni’s statistical tests were used to compare variables among groups. Results: We included 82 subjects, 39 women (19 endurance athletes, 20 controls) and 43 men (22 endurance athletes, 21 controls). Mean age was similar between groups (36.6 ± 5.6 years). Athletes had larger bi-atrial volumes, compared to controls (women, LA 27.1 vs. 15.8 ml/m2, p < 0.001; RA 22.31 vs. 14.2 ml/m2, p = 0.009; men, LA: 25.0 vs. 18.5 ml/m2, p = 0.003; RA 30.8 vs. 21.9 ml/m2, p < 0.001) and lower strain-rate (women, LASRa −1.60 vs. −2.18 s−1, p < 0.001; RASRa −1.89 vs. −2.38 s−1, p = 0.009; men, LASRa −1.21 vs. −1.44 s−1, p = 1; RASRa −1.44 vs. −1.60 s−1, p = 1). However, RA indexed size was lower and bi-atrial deformation greater in female athletes, compared to male athletes. Conclusions: The atria of both male and female athletes shows specific remodelling, compared to sedentary subjects, with larger size and less deformation at rest, particularly for the RA. Despite a similar extent of remodelling, the pattern in women had greater bi-atrial myocardial deformation and smaller RA size.

Cardiovascular Imaging in the Electrophysiology Laboratory

In recent years, rapid technological advances have allowed the development of new electrophysiological procedures that would not have been possible without the parallel development of imaging techniques used to plan and guide these procedures and monitor their outcomes. Ablation of atrial fibrillation is among the interventions with the greatest need for imaging support. Echocardiography allows the appropriate selection of patients and the detection of thrombi that would contraindicate the intervention; cardiac magnetic resonance imaging and computed tomography are also essential in planning this procedure, by allowing a detailed anatomical study of the pulmonary veins. In addition, in cardiac resynchronization therapy, echocardiography plays a central role in both patient selection and, later, in device adjustment and in assessing the effectiveness of the technique. More recently, ablation of ventricular tachycardias has been established as a treatment option; this would not be possible without planning using an imaging study such as cardiac magnetic resonance imaging of myocardial scarring.

Left Atrial Function Is Impaired in Some Patients With Stroke of Undetermined Etiology: Potential Implications for Evaluation and Therapy

INTRODUCTION AND OBJECTIVES Stroke etiology remains undetermined in up to 30% of cases. Paroxysmal atrial fibrillation is found in 20% to 28% of patients with stroke initially classified as being of undetermined etiology. The aim of our study was to analyze left atrial function in ischemic stroke patients to identify patterns associated with cardioembolic etiology and to determine whether the patterns identified can be found in individuals initially classified as having a stroke of undetermined etiology. METHODS We studied a cohort of in-hospital ischemic stroke patients referred for transthoracic echocardiography. Treating neurologists determined stroke etiology based on the TOAST classification. Left atrial contractile function was assessed using 2-dimensional echocardiography to determine their ejection fraction and speckle tracking to measure left atrial strain rate: a-wave. Left atrial function was compared between stroke etiology subgroups and healthy controls. RESULTS Ninety-seven patients (aged 67±15 years) with ischemic stroke (16.5% large-artery atherosclerosis, 15.5% small-vessel occlusion, 11.3% cardioembolic, 5.1% other determined etiology, 51.1% undetermined etiology) and 10 healthy volunteers (aged 63±7 years) were included. Left atrial ejection fraction was significantly decreased only in patients with stroke of cardioembolic and undetermined etiology compared with the control group (31.5±17.2%, 40.2±17.1%, and 59.1±8.4%, respectively; P=.004). The left atrial strain rate was significantly lower in patients with stroke caused by cardioembolic or undetermined etiology, or large-artery atherosclerosis compared with controls (-0.86±0.49, -1.31±0.56, -1.5±0.47, -2.37±1.18, respectively; P<.001). CONCLUSIONS Patients with stroke of undetermined etiology with left atrial function (ejection fraction and strain) similar to that of cardioembolic stroke patients may be misclassified and could potentially benefit from prolonged electrocardiography monitoring. Left atrial function analysis (ejection fraction and strain) might help to identify potential cardioembolic sources in patients with stroke of undetermined etiology.

Minimally Invasive Transradial Percutaneous Closure of Aortic Paravalvular Leaks: Following the Steps of Percutaneous Coronary Intervention

Two patients with severe aortic paravalvular leaks (PVLs) in a mechanical prosthesis were percutaneously treated. Procedures were performed with mild sedation, angiographic guidance, and a 6-French right radial artery approach with good final results. Percutaneous PVL treatment is routinely performed with general anaesthesia, transesophageal echocardiographic guidance, and femoral access. Although another case of radial aortic PVL closure has been previously reported, it was performed with an 8-French radial sheath, transesophageal echocardiographic guidance, and general anaesthesia. According to our initial experience, aortic PVLs could be treated in a minimally invasive way. Larger studies should be conducted to confirm these observations.

Differential Clinical Implications of Current Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography

Background: Classification of left ventricular diastolic function (LVDF) by echocardiography is controversial. The aim of this study was to evaluate the impact of the last 2016 recommendations for LVDF evaluation on brain natriuretic peptide (BNP) levels, proportion of final heart failure (HF) diagnosis, and cardiovascular outcomes. Methods: Outpatients with first consultation at a one‐stop HF clinic (2009–2014) were screened. The initial visit included echocardiography with LVDF evaluation and determination of BNP level. HF diagnosis was confirmed or ruled out at the end of the visit. Cardiovascular events during follow‐up were recorded. LVDF classification was originally performed with the 2009 recommendations and reevaluated using the 2016 recommendations. Results: A total of 157 patients (mean age 73.24 ± 10.3 years; 70.1% women) were included. Originally (2009 recommendations), most of the patients were classified with grade I diastolic dysfunction (DD; 67.5%). After the reanalysis using the 2016 recommendations, 49% were reclassified with normal LVDF. These subjects showed lower BNP levels (40.8 pg/mL) and a lower proportion of HF diagnosis (9.6%). Another part of the initial grade I DD group (31.1%) was reclassified with indeterminate LVDF; they had intermediate BNP levels, proportion of HF, and rate of cardiovascular events. Lower reclassification rates were observed in the other groups of DD. Kaplan‐Meier survival curves showed significantly better prognostic stratification after the reclassification (P = .539 vs P = .003). Conclusions: Current recommendations for the evaluation of LVDF by echocardiography resulted in more accurate classification of patients, according to their BNP levels, HF diagnosis, and cardiovascular outcomes, especially for those patients previously classified with grade I DD. HIGHLIGHTSClassification of diastolic function by echocardiography is controversial.The 2009 recommendations overestimated the prevalence of grade I DD in our population.The 2016 recommendations better classified patients according to clinical outcomes.Indeterminate LVDF seems to have intermediate outcomes between normal and grade I DD.

Tricuspid Percutaneous Repair With the MitraClip System: First Implant in Spain

Severe tricuspid regurgitation (TR) can have a poor long-term prognosis. Given that its isolated surgical treatment has been associated with increased mortality, the need for minimally invasive techniques has prompted the development of the percutaneous treatment of this valve. In recent years, several percutaneous techniques have been proposed for the correction of TR. Although little evidence is available, implantation of the MitraClip system (Abbott Vascular, Santa Clara, United States) in the tricuspid position appears to be the most commonly-used technique at present. In this article, we present the first case of percutaneous tricuspid repair performed in Spain. The intervention was performed in a 65-year-old woman with symptomatic severe primary TR (extreme fatigue and lower limb edema), with right ventricular dilatation but no pulmonary hypertension. Transesophageal echocardiography (TEE) showed severe TR with a central jet, probably secondary to restriction of the septal leaflet (Figure 1), but with an anatomy favorable for clip implantation, as leaflet length was > 10 mm, with adequate thickness and no areas of calcification. Because surgery was contraindicated due to morbid obesity, we decided to perform a percutaneous repair with MitraClip. The technical details of the procedure have been described previously, but, briefly, 2 clips were implanted between the anterior and septal leaflets, as after release of the first clip we observed a partial detachment of the septal leaflet, which was stabilized with the effective implantation of a second clip in a more central position (Figure 2). The patient was discharged at 48 hours with a transthoracic echocardiogram (TTE) that showed a reduction in TR from grade 4/4 to grade 2/4. At follow-up at 4 months postimplantation, the patient reported clear symptomatic improvement. Follow-up TTE demonstrated the stability of the result at discharge, with grade 2/4 residual TR, and normalization of the right ventricular diameters and a mean tricuspid gradient of 2 mmHg (Figure 1). In recent years, percutaneous intervention on the cardiac valves has undergone rapid growth.While interventional treatment of the aortic, pulmonary and mitral valves has the advantage of more available clinical evidence, interventional treatment of the tricuspid valve is still in a very early phase. With various degrees of success, numerous conceptually distinct techniques have been proposed, such as percutaneous implantation of an aortic valve on top of degenerative tricuspid prostheses, percutaneous annuloplasty devices, and even balloon-type devices with the aim of occupying space in the valve and thus reducing the regurgitant orifice. However, despite the scarcity of the available evidence, MitraClip appears to be the most frequently-used system with the largest number of presented cases to date. The largest series published so far is that of Nickenig et al. which had 64 patients. In that series, 1 clip was implanted in 48% of patients and 2 to 4 clips were implanted in 42%. In 78% of the patients, the clip was positioned between the anterior and septal leaflets. In addition, in 97% of patients, at least 1 clip could be implanted, in 91% TR was reduced by at least 1 grade, and no periprocedural deaths were recorded. After reviewing the literature and presenting our impressions after this first implantation, we believe that the use of MitraClip in the tricuspid position has 3 inherent challenges: a) the use of a system that can only attach 2 leaflets in a valve with 3 leaflets (anterior, posterior and septal); in this regard, after studying several ex vivo models, we concluded that the attachment of the anterior and septal leaflets appears to be the combination that is Rev Esp Cardiol. 2018;71(11):976–990