Victoria Delgado

Intraoperative 2D and 3D transoesophageal echocardiographic predictors of aortic regurgitation after transcatheter aortic valve implantation

Background Post-procedural aortic regurgitation (AR) has been described in a large number of patients receiving transcatheter aortic valve implantation (TAVI). Objective The aim of this study was to examine the intraoperative 2-dimensional (2D) and 3-dimensional (3D) echocardiographic features of the aortic valve associated with significant post-procedural paravalvular AR. Methods A total of 135 patients (81±7u2005years) with severe symptomatic aortic stenosis, who underwent TAVI, were imaged with comprehensive 2D and 3D transoesophageal echocardiography before the procedure and peri-procedure. Various baseline and peri-procedural echocardiographic characteristics were tested to predict paravalvular AR post-TAVI: calcifications at the aortic valve commissures and leaflets, ‘aortic annulus eccentricity index’, ‘area cover index’, overlap between aortic prosthesis and anterior mitral leaflet. Post-procedural paravalvular AR≥2 was considered significant. Results Successful TAVI was achieved in all patients. The incidence of paravalvular AR≥2 immediately after the procedure was 21% (28 patients). Commissural calcifications and, particularly, the calcification of the commissure between the right coronary and non-coronary cusps was significantly more frequent in presence of paravalvular AR; the area cover index pre-TAVI was significantly lower among patients with AR (11.1±11.8% vs 20.8±12.5%, p=0.0004). Multivariate analysis revealed that calcification of the commissure between the right coronary and non-coronary cusps (OR=2.66, 95% CI 1.39 to 5.12, p=0.001), and the area cover index pre-TAVI (OR=0.95, 95% CI 0.91 to 0.99, p=0.006) were the only independent predictors of significant paravalvular AR after TAVI. Conclusions Intraoperative 2D and 3D transoesophageal echocardiography identified calcification of the commissure between the right coronary and non-coronary cusps and the area cover index as independent predictors of significant paravalvular AR following TAVI.

Global longitudinal strain predicts left ventricular dysfunction after mitral valve repair

AIMSnDespite a successful surgical procedure and adherence to current recommendations, postoperative left ventricular (LV) dysfunction after mitral valve repair (MVr) for organic mitral regurgitation (MR) may still occur. New approaches are therefore needed to detect subclinical preoperative LV dysfunction. LV global longitudinal strain (GLS), assessed with speckle-tracking echocardiographic analysis, has been proposed as a novel measure to better depict latent LV dysfunction. The aim of this study was to investigate the value of GLS to predict long-term LV dysfunction after MVr.nnnMETHODS AND RESULTSnA total of 233 patients (61% men, 61 ± 12 years) with moderate-severe organic MR who underwent successful MVr between 2000 and 2009 were included. Echocardiography was performed at baseline and long-term follow-up (34 ± 20 months) after MVr. LV dysfunction at follow-up was defined as LV ejection fraction (EF) <50% and was present in 29 (12%) patients. A cut-off value of -19.9% of GLS showed a sensitivity and specificity of 90 and 79% to predict long-term LV dysfunction. By univariate logistic regression analysis, baseline LVEF ≤60%, LV end-systolic diameter (ESD) ≥40 mm, atrial fibrillation, presence of symptoms, and GLS >-19.9% were predictors of long-term LV dysfunction. By multivariate analysis, GLS remained an independent predictor of LV dysfunction (odds ratio 23.16, 95% confidence interval: 6.53-82.10, P < 0.001), together with LVESD.nnnCONCLUSIONnIn a large series of patients operated within the last decade, MVr resulted in a low incidence of long-term LV dysfunction. A GLS of >-19.9% demonstrated to be a major independent predictor of long-term LV dysfunction after adjustment for parameters currently implemented into guidelines.

Incremental value of 2-dimensional speckle tracking strain imaging to wall motion analysis for detection of coronary artery disease in patients undergoing dobutamine stress echocardiography

BACKGROUNDnInterpretation of dobutamine stress echocardiogram (DSE) is often subjective and requires expert training. The purposes of this study was to determine optimal cutoff values for longitudinal, circumferential, and radial strains at peak DSE for detection of significant stenoses on coronary angiography and to investigate incremental value of combining strain measurements to wall motion analysis.nnnMETHODSnIn this multicenter study, 102 patients underwent concomitant DSE and coronary angiography. Optimal cutoff values for mean global longitudinal (-20%), global circumferential (-26%), and mean radial (50%) strains at peak stress for detection of significant stenoses on coronary angiography were determined in a derivation group (n = 62) and tested in a prospectively recruited validation group (n = 40).nnnRESULTSnRespective sensitivities for longitudinal, circumferential, radial strains, and expert wall motion score index (WMSI) were 84.2%, 73.9%, 78.3%, and 76%; respective specificities were 87.5%, 78.6%, 57.1%, and 92.9%; and respective accuracies were 85.2%, 75.7%, 70.3%, and 82.1%. Longitudinal strain analysis had comparable accuracy to WMSI (P = .70). However, combination longitudinal strain and WMSI had the highest sensitivity, specificity, and accuracy (100%, 87.5%, and 96.3% respectively), and its diagnostic accuracy was incremental to either longitudinal strain (P = .034) or WMSI alone (P = .008).nnnCONCLUSIONnLongitudinal strain analysis had higher diagnostic accuracy than circumferential and radial strains and was comparable to WMSI for detection of significant coronary artery disease. However, combination longitudinal strain and WMSI resulted in significant incremental increase in diagnostic accuracy.

Outcome of Ventricular Tachycardia Ablation in Patients with Nonischemic Cardiomyopathy: The Impact of Noninducibility

Background—Ablation failure and recurrence rates after ventricular tachycardia (VT) ablation in nonischemic cardiomyopathy are high and the optimal procedural end point is not well defined. This study assessed the outcome after ablation, the impact of noninducibility, and other potential predictors of VT recurrence. Methods and Results—Forty-five patients with nonischemic cardiomyopathy (60±16 years; left ventricular ejection fraction, 44±14%) accepted for VT ablation were included. Epicardial mapping was performed in 29 (64%). A median of 2 (first-to-third quartile, 2–4) VTs (cycle length, 342±77 ms) were induced per patient. After ablation, the complete programmed electric stimulation protocol (3 drive cycle length, 3 extrastimuli ≥200 ms, and burst≥2 sites) was repeated. Complete success (noninducibility of any monomorphic VT) was achieved in 17 patients (38%), partial success (elimination of clinical VT, persistent inducibility of nonclinical VT) in 17 patients (38%), and failure (persistent inducibility of clinical VT) in 11 patients (24%). During 25±15 months of follow-up, VT occurred in 24 patients (53%), but the 6-month VT burden was reduced by ≥75% in 79%. Recurrence rates were low after complete procedural success (18%), but high after both partial success (77%) and failure (73%). Non-complete procedural success was the strongest predictor of VT recurrence (hazard ratio, 8.20; 95% confidence interval, 2.37–28.43; P=0.001). Conclusions—Although 53% of patients had VT during follow-up, the 6-month VT burden was decreased by ≥75% in 79%. Recurrence rates are low after complete procedural success, but high after both partial success and failure. Non-complete procedural success was the strongest predictor of VT recurrence.

Transcatheter Mitral Valve Replacement for Degenerated Bioprosthetic Valves and Failed Annuloplasty Rings

BACKGROUNDnLimited data exist regarding transcatheter mitral valve replacement (TMVR) for patients with failed mitral valve replacement and repair.nnnOBJECTIVESnThis study sought to evaluate the outcomes of TMVR in patients with failed mitral bioprosthetic valves (valve-in-valve [ViV]) and annuloplasty rings (valve-in-ring [ViR]).nnnMETHODSnFrom the TMVR multicenter registry, procedural and clinical outcomes of mitral ViV and ViR were compared according to Mitral Valve Academic Research Consortium criteria.nnnRESULTSnA total of 248 patients with mean Society of Thoracic Surgeons score of 8.9 ± 6.8% underwent TMVR. Transseptal access and the balloon-expandable valve were used in 33.1% and 89.9%, respectively. Compared with 176xa0patients undergoing ViV, 72 patients undergoing ViR had lower left ventricular ejection fraction (45.6 ± 17.4% vs. 55.3 ± 11.1%; pxa0< 0.001). Overall technical and device success rates were acceptable, at 92.3% and 85.5%, respectively. However, compared with the ViV group, the ViR group had lower technical success (83.3% vs. 96.0%; pxa0=xa00.001) due to more frequent second valve implantation (11.1% vs. 2.8%; pxa0=xa00.008), and lower device success (76.4% vs. 89.2%; pxa0=xa00.009) due to more frequent reintervention (16.7% vs. 7.4%; pxa0=xa00.03). Mean mitral valve gradients were similar between groups (6.4 ± 2.3xa0mmxa0Hg vs. 5.8 ± 2.7xa0mmxa0Hg; pxa0=xa00.17), whereas the ViR group had more frequent post-procedural mitral regurgitation moderate or higher (19.4% vs. 6.8%; pxa0=xa00.003). Furthermore, the ViR group had more frequent life-threatening bleeding (8.3% vs. 2.3%; pxa0=xa00.03), acute kidney injury (11.1% vs. 4.0%; pxa0=xa00.03), and subsequent lower procedural success (58.3% vs. 79.5%; pxa0=xa00.001). The 1-year all-cause mortality rate was significantly higher in the ViR group compared with the ViV group (28.7% vs. 12.6%; log-rank test, pxa0=xa00.01). On multivariable analysis, failed annuloplasty ring was independently associated with all-cause mortality (hazard ratio: 2.70; 95% confidence interval: 1.34 to 5.43; pxa0=xa00.005).nnnCONCLUSIONSnThe TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral ViR was associated with higher rates of procedural complications and mid-term mortality compared with mitral ViV.

Effect of atrioventricular and ventriculoventricular delay optimization on clinical and echocardiographic outcomes of patients treated with cardiac resynchronization therapy: a meta-analysis.

BACKGROUNDnOptimization of atrioventricular (AV) and ventriculoventricular (VV) delays of cardiac resynchronization therapy (CRT) devices maximizes left ventricular filling and stroke volume. However, the incremental value of these optimizations over empiric device programming remains unclear. The objective of this analysis was to perform a systematic review and meta-analysis of the effects of AV and VV delay optimization on clinical and echocardiographic end points of patients with heart failure treated with CRT.nnnMETHODSnA standardized search strategy was performed and identified 12 trials comparing AV and/or VV delay optimization and conventional CRT device programming and their effects on various clinical and echocardiographic outcomes. Pooled odds ratios were analyzed using random-effect meta-analysis with Mantel-Haenszel method.nnnRESULTSnCombined data from a total of 4,356 patients with heart failure treated with CRT showed no differences in clinical or echocardiographic outcomes between patients who underwent AV and/or VV delay optimization and patients who underwent empiric device programming (Mantel-Haenszel odds ratio 0.86 [95% CI 0.68-1.09], P value for overall effect = .21 by intention-to-treat analysis).nnnCONCLUSIONnThe current literature suggests that routine AV and/or VV delay optimization has a neutral effect on clinical and echocardiographic outcomes based on pooled data from randomized and nonrandomized studies. Standardization of patient selection and optimization timing and method may help to further define the role of CRT device optimization.

Lead positioning for cardiac resynchronization therapy: techniques and priorities

Although cardiac resynchronization therapy (CRT) has demonstrated to be an effective treatment for heart failure patients, up to 30-40% of the patients do not show a favourable response. Implantation of the left ventricular (LV) pacing lead is one of the determinants of CRT response. This procedure includes several challenging technical issues and strongly depends on the highly variable anatomy of the coronary sinus and tributaries. In addition, the final position of the LV pacing lead may target the latest activated areas of the left ventricle in order to obtain effective resynchronization. Furthermore, the presence of transmural myocardial scar at the region targeted by the LV lead may also determine the response to CRT. This review discusses all the issues related to LV lead implantation and the role of multimodality imaging to anticipate the implantation strategy. Finally, alternative LV pacing sites and their effect on clinical outcome and LV performance will be discussed.

Significant lead-induced tricuspid regurgitation is associated with poor prognosis at long-term follow-up

Background Although the presence of an RV lead is a potential cause of tricuspid regurgitation (TR), the clinical impact of significant lead-induced TR is unknown. Objective To evaluate the effect of significant lead-induced TR on cardiac performance and long-term outcome after cardioverter-defibrillator (ICD) or pacemaker implantation. Methods A retrospective cohort of 239 ICD (n=191) or pacemaker (n=48) recipients (age 60±14u2005years, 77% male) from a tertiary care university hospital, with an echocardiographic evaluation before and within 1–1.5u2005years after device implantation were included. Significant lead-induced TR was defined as TR worsening, reaching a grade ≥2 at follow-up echocardiography. During long-term follow-up (median 58, IQR 35–76u2005months), all-cause mortality and heart failure related events were recorded. Results Before device implantation, most patients had TR grade 1 or 2 (64.0%) or no TR (33.9%), but after lead placement, significant TR was seen in 91 patients (38%). Changes in cardiac volumes and function at follow-up were similar between patients with and without significant lead-induced TR, except for larger RV diastolic area (17±6mm2 vs 16±5mm2, p=0.009), larger right atrial diameter (39±10u2005mm vs 36±8u2005mm, p<0.001) and higher pulmonary arterial pressures (41±15u2005mmu2005Hg vs 33±10u2005mmu2005Hg, p<0.001) in patients with significant lead-induced TR. Patients with significant lead-induced TR had worse long-term survival (HR=1.687, p=0.040) and/or more heart failure related events (HR=1.641, p=0.019). At multivariate analysis, significant lead-induced TR was independently associated with all-cause mortality (HR=1.749, p=0.047) together with age, LVEF and percentage RV pacing. Conclusions Significant lead-induced TR is associated with poor long-term prognosis.

Right ventricular function and survival following cardiac resynchronisation therapy

Objectives Right ventricular (RV) function is an important prognostic marker in heart failure. However, its impact on all-cause mortality following cardiac resynchronisation therapy (CRT) independent of confounding factors has not been evaluated. Furthermore, evidence concerning the effect of CRT on RV function is limited. The studys aims were to: (1) assess the prognostic importance of RV function among CRT recipients, and (2) characterise RV functional change following CRT and its determinants. Design Retrospective observational study. Setting Single tertiary centre. Patients A total of 848 CRT recipients (median age 65u2005years, 78% male, 60% ischaemic) underwent echocardiography before and 6u2005months after CRT. RV function was evaluated using tricuspid annular plane systolic excursion (TAPSE), with a ≤14u2005mm threshold indicating severe RV impairment. The primary endpoint was long-term all-cause mortality. Results Significant baseline RV dysfunction was observed in 286 (34%) individuals. After a median 44u2005months, 288 deaths occurred. RV impairment was associated with a greater incidence of all-cause mortality (log-rank p<0.001). Independent predictors of this endpoint were functional class, ischaemic aetiology, diabetes, atrial fibrillation, renal dysfunction, bigger left ventricular (LV) end-systolic volume, less LV dyssynchrony and reduced TAPSE. Importantly, TAPSE added prognostic value to these recognised prognostic parameters (likelihood-ratio test p<0.001). Furthermore, improvement in RV function after CRT was independent of the improvement in LV systolic function but significantly associated with the improvement in LV diastolic function. Importantly, a favourable RV functional response to CRT was associated with superior survival. Conclusions RV function is an independent predictor of long-term outcome following CRT.

Effect of cardiac resynchronization therapy in patients without left intraventricular dyssynchrony

AIMSnTo evaluate the effects of cardiac resynchronization therapy (CRT) on long-term survival of patients without baseline left ventricular (LV) mechanical dyssynchrony.nnnMETHODS AND RESULTSnA total of 290 heart failure patients (age 67 ± 10 years, 77% males) without significant baseline LV dyssynchrony (<60 ms as assessed with tissue Doppler imaging) were treated with CRT. Patients were divided according to the median LV dyssynchrony measured after 48 h of CRT into two groups. All-cause mortality was compared between the subgroups. In addition, the all-cause mortality rates of these subgroups were compared with the all-cause mortality of 290 heart failure patients treated with CRT who showed significant LV dyssynchrony (≥60 ms) at baseline. In the group of patients without significant LV dyssynchrony, median LV dyssynchrony increased from 22 ms (inter-quartile range 16-34 ms) at baseline to 40 ms (24-56 ms) 48 h after CRT. The cumulative mortality rates at 1-, 2-, and 3-year follow-up of patients with LV dyssynchrony ≥40 ms 48 h after CRT implantation were significantly higher when compared with patients with LV dyssynchrony <40 ms (10, 17, and 23 vs. 3, 8, and 10%, respectively; log-rank P< 0.001). Finally, the cumulative mortality rates at 1-, 2-, and 3-year follow-up of patients with baseline LV dyssynchrony were 3, 8, and 11%, respectively (log-rank P= 0.375 vs. patients with LV dyssynchrony <40 ms). Induction of LV dyssynchrony after CRT was an independent predictor of mortality (hazard ratio: 1.247; P= 0.009).nnnCONCLUSIONnIn patients without significant LV dyssynchrony, the induction of LV dyssynchrony after CRT may be related to a less favourable long-term outcome.