Prevalence and prognostic implications of moderate or severe mitral regurgitation in patients with bicuspid aortic valve

Abstract Background Significant (≥ moderate) mitral regurgitation (MR) could augment the hemodynamic effects of aortic valvular disease in patients with bicuspid aortic valve (BAV), imposing a greater hemodynamic burden on left ventricle and atrium, possibly culminating in a faster onset of left ventricular (LV) dilation and/or symptoms. Purpose To determine the prevalence and prognostic implications of significant MR in patients with BAV. Methods In this large, multicenter, international registry, a total of 2,932 patients (48±18 years, 71% male) with BAV were identified. All patients were evaluated for the presence of significant primary or secondary MR by transthoracic echocardiography and were followed-up for the endpoint of all-cause mortality and a combined endpoint of all-cause mortality or aortic valve surgery. Results Overall, 147 patients (5.0%) had significant primary (1.5%) or secondary (3.5%) MR. Significant MR was associated with all-cause mortality (HR 2.80, 95% CI 1.91 to 4.11, p<0.001, Figure A) and reduced event-free survival (HR 1.97, 95% CI 1.58 to 2.46, p<0.001) on univariable analysis. However, MR was not associated with all-cause mortality (HR 1.33, 95% CI 0.85 to 2.07, p=0.21, Figure B) or event-free survival (HR 1.10, 95% CI 0.85 to 1.42, p=0.46) after multivariable adjustment. Subgroup analyses demonstrated an independent association between significant MR and all-cause mortality for individuals with significant aortic regurgitation (HR 2.04, 95% CI 1.03 to 4.05, p=0.042), although this association was not observed for subgroups with significant aortic stenosis or without significant aortic valve dysfunction. Conclusions Significant MR is uncommon in patients with BAV. Following adjustment for confounding variables, significant MR was not associated with event-free or overall survival. FUNDunding Acknowledgement Type of funding sources: None. Survival curves for all-cause mortality

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Abstract 16772: Aerobic Capacity (VO 2peak ) in Congenital Heart Disease: Prognostic Implications

Circulation ◽

10.1161/circ.142.suppl_3.16772 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Andrea Soares ◽

Emily Mansour ◽

Alyssa Puritz ◽

Min Zhao ◽

chao cao ◽

...

Keyword(s):

Congenital Heart Disease ◽

Heart Disease ◽

Survival Time ◽

Cardiac Disease ◽

Congenital Heart ◽

Left Ventricular ◽

Event Free Survival ◽

Free Survival ◽

Congenital Cardiac Disease ◽

Prognostic Implications

Introduction: Cardiopulmonary exercise testing provides information about functional capacity via direct measurement of respiratory gas exchange. Whether peak oxygen consumption during exercise (VO 2peak ) is predictive of outcomes in patients with congenital heart disease is controversial. Hypothesis: VO 2peak has prognostic implications for death, left ventricular assist device (LVAD) placement, and cardiac transplant in adult patients with congenital cardiac diseases. Methods: Congenital heart disease patients were selected from a registry of cardiac patients who completed a VO 2peak exercise test at Washington University School of Medicine between May 1993 and October 2012. Diagnoses were verified by chart review and classified according to American Heart Association guidelines. Outcome data were verified via medical record, Social Security Death Index, or phone interview. A Cox proportional-hazard regression analysis was used to investigate the association between patient survival time and one or more predictor variables. Survival time was defined as the time elapsed between VO 2peak test and the earliest outcome of death, heart transplant, or LVAD placement. Results: The sample included 149 patients (49% women, mean ± SD age of 33.4 ± 11.5 years and body mass index of 25.7 ± 5.4 kg/m 2 ). Mean follow-up time was 11.8 ± 3.2 years. Mean VO 2peak was 23.0 ± 7.3 mL/kg/min for men and 20.0 ± 6.4 mL/kg/min for women. Age was comparable between men and women in the sample. In the univariate analysis, higher VO 2peak was associated with longer event-free survival time (HR 0.91, 95% CI 0.85-0.98, p= 0.01). In the multivariable analysis, higher VO 2peak was shown to be protective, independent of age and sex (HR 0.90, 95% CI 0.83-0.97, p=0.004). Conclusions: Among patients with congenital cardiac disease, higher VO 2peak independently predicted longer event-free survival. VO 2peak is a valuable clinical prognostic tool for patients with congenital cardiac disease.

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1227 Risk stratification of patients with asymptomatic moderate mitral regurgitation: the prognostic value of left atrial strain

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.689 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

M Cameli ◽

M C Pastore ◽

F M Righini ◽

G E Mandoli ◽

F D"ascenzi ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Mitral Regurgitation ◽

Risk Stratification ◽

Left Atrial ◽

Longitudinal Strain ◽

Left Ventricular ◽

Event Free Survival ◽

Free Survival

Abstract Background In asymptomatic moderate mitral regurgitation (MR), the criteria for risk stratification are still uncertain. Therefore, in these patients, optimal time of surgery remains controversial. Purpose Our aim was to compare left atrial (LA) strain to other echocardiographic parameters for the prediction of cardiovascular (CV) events in patients with asymptomatic moderate MR. Methods 401 patients with primary degenerative asymptomatic moderate MR was enrolled and prospectively followed for the development of CV events (i.e. atrial fibrillation, stroke/transient ischemic attack, acute heart failure, CV death). Patients with history of atrial fibrillation, myocardial infarction, heart failure, cardiac surgery or heart transplantation, severe MR, mitral valve surgery during follow-up were excluded. Results During a mean follow up of 3.4 ± 2 years, of the 326 patients eligible (mean age 65 ± 9 years), 122 patients had 149 new events. There were no significative differences in mean age and sex, clinical and therapeutic characteristics between the two groups. The event-group presented reduced global peak atrial longitudinal strain (PALS), LA emptying fraction, LV strain at baseline, and larger LA volume indexed (p <0.0001). Receiver operating characteristics curves proved the greatest predictive performance for global PALS < 35% (AUC 0.88). Bland-Altman analysis demonstrated good intra- and inter-observer agreement and Kaplan Meier analysis showed a graded association between PALS and event-free-survival. Conclusions Speckle tracking echocardiography could provide a useful index, global PALS, to estimate LA function in patients with asymptomatic moderate MR in order to optimize surgical timing before the development of irreversible myocardial dysfunction. Echo-data of our study population Variable No CV events (n = 204) CV events (n = 122) LV ejection fraction (%) 59 ± 9 58 ± 10 LV global longitudinal strain (%) - 18.5 ± 3.4 -17.6 ± 3.6* LA volume indexed (ml/m2) 32.5 ± 6.7 36.4 ± 7.1* LA emptying fraction (%) 68 ± 13 62 ± 15* Mitral E/A ratio 0.94 ± 0.14 0.95 ± 0.16 Mitral E/E’ ratio 11.2 ± 6.5 12.4 ± 7.1 Mitral regurgitant fraction (%) 38.9 ± 8.1 39.1 ± 9.4 End regurgitation orifice area (cm2) 0.34 ± 0.05 0.34 ± 0.06 Global PALS (%) 32.5 ± 8.5 19.7 ± 8.1* *Significative variation between groups. Cardiovascular, CV; Left atrial, LA; Left ventricular, LV; Peak atrial longitudinal strain, PALS Abstract 1227 Figure. Event-free survival according to PALS

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Outcome and durability of mitral valve annuloplasty in atrial secondary mitral regurgitation

Heart ◽

10.1136/heartjnl-2021-319045 ◽

2021 ◽

pp. heartjnl-2021-319045

Author(s):

Sébastien Deferm ◽

Philippe B Bertrand ◽

David Verhaert ◽

Jeroen Dauw ◽

Jan M Van Keer ◽

...

Keyword(s):

Mitral Valve ◽

Mitral Regurgitation ◽

Patient Characteristics ◽

Left Ventricular ◽

Type I ◽

Therapeutic Implications ◽

Mitral Valve Annuloplasty ◽

All Cause Mortality ◽

Secondary Mitral Regurgitation ◽

Secondary Mr

ObjectivesAtrial secondary mitral regurgitation (ASMR) is a clinically distinct form of Carpentier type I mitral regurgitation (MR), rooted in excessive atrial and mitral annular dilation in the absence of left ventricular dysfunction. Mitral valve annuloplasty (MVA) is expected to provide a more durable solution for ASMR than for ventricular secondary MR (VSMR). Yet data on MR recurrence and outcome after MVA for ASMR are scarce. This study sought to investigate surgical outcomes and repair durability in patients with ASMR, as compared with a contemporary group of patients with VSMR.MethodsClinical and echocardiographic data from consecutive patients who underwent MVA to treat ASMR or VSMR in an academic centre were retrospectively analysed. Patient characteristics, operative outcomes, time to recurrence of ≥moderate MR and all-cause mortality were compared between patients with ASMR versus VSMR.ResultsOf the 216 patients analysed, 97 had ASMR opposed to 119 with VSMR and subvalvular leaflet tethering. Patients with ASMR were typically female (68.0% vs 33.6% in VSMR, p<0.001), with a history of atrial fibrillation (76.3% vs 33.6% in VSMR, p<0.001), paralleling a larger left atrial size (p<0.033). At a median follow-up of 3.3 (IQR 1.0–7.3) years, recurrence of ≥moderate MR was significantly lower in ASMR versus VSMR (7% vs 25% at 2 years, overall log-rank p=0.001), also when accounting for all-cause death as competing risk (subdistribution HR 0.50 in ASMR, 95% CI 0.29 to 0.88, p=0.016). Moreover, ASMR was associated with better overall survival compared with VSMR (adjusted HR 0.43 95% CI 0.22 to 0.82, p=0.011), independent from baseline European System for Cardiac Operative Risk Evaluation II surgical risk score.ConclusionPrognosis following MVA to treat ASMR is better, compared with VSMR as reflected by lower all-cause mortality and MR recurrence. Early distinction of secondary MR towards underlying ventricular versus atrial disease has important therapeutic implications.

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Prognostic implications of left atrial dilation in aortic regurgitation due to bicuspid aortic valve

Heart ◽

10.1136/heartjnl-2020-318907 ◽

2021 ◽

pp. heartjnl-2020-318907

Author(s):

Steele C Butcher ◽

Federico Fortuni ◽

William Kong ◽

E Mara Vollema ◽

Francesca Prevedello ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Bicuspid Aortic Valve ◽

Left Atrial ◽

Valve Surgery ◽

Volume Index ◽

Aortic Valve Surgery ◽

Event Free Survival ◽

Free Survival

ObjectiveTo investigate the prognostic value of left atrial volume index (LAVI) in patients with moderate to severe aortic regurgitation (AR) and bicuspid aortic valve (BAV).Methods554 individuals (45 (IQR 33–57) years, 80% male) with BAV and moderate or severe AR were selected from an international, multicentre registry. The association between LAVI and the combined endpoint of all-cause mortality or aortic valve surgery was investigated with Cox proportional hazard regression analyses.ResultsDilated LAVI was observed in 181 (32.7%) patients. The mean indexed aortic annulus, sinus of Valsalva, sinotubular junction and ascending aorta diameters were 13.0±2.0 mm/m2, 19.4±3.7 mm/m2, 16.5±3.8 mm/m2 and 20.4±4.5 mm/m2, respectively. After a median follow-up of 23 (4–82) months, 272 patients underwent aortic valve surgery (89%) or died (11%). When compared with patients with normal LAVI (<35 mL/m2), those with a dilated LAVI (≥35 mL/m2) had significantly higher rates of aortic valve surgery or mortality (43% and 60% vs 23% and 36%, at 1 and 5 years of follow-up, respectively, p<0.001). Dilated LAVI was independently associated with reduced event-free survival (HR=1.450, 95% CI 1.085 to 1.938, p=0.012) after adjustment for LV ejection fraction, aortic root diameter, LV end-diastolic diameter and LV end-systolic diameter.ConclusionsIn this large, multicentre registry of patients with BAV and moderate to severe AR, left atrial dilation was independently associated with reduced event-free survival. The role of this parameter for the risk stratification of individuals with significant AR merits further investigation.

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Novel staging classification of primary mitral regurgitation based on the presence of cardiac damage

European Heart Journal ◽

10.1093/ehjci/ehaa946.1998 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A.L Van Wijngaarden ◽

Y.L Hiemstra ◽

P Van Der Bijl ◽

V Delgado ◽

N Ajmone Marsan ◽

...

Keyword(s):

Mitral Regurgitation ◽

Kidney Function ◽

Left Ventricular ◽

Prognostic Impact ◽

Cardiac Damage ◽

Stage 4 ◽

All Cause Mortality ◽

Primary Mitral Regurgitation ◽

Stage 1 ◽

Staging Classification

Abstract Background The indication for surgery in patients with severe primary mitral regurgitation (MR) is currently based on the presence of symptoms, left ventricular (LV) dilatation and dysfunction, atrial fibrillation and pulmonary hypertension. The aim of this study was to evaluate the prognostic impact of a new staging classification based on cardiac damage including the known risk factors but also including global longitudinal strain (GLS), severe left atrial (LA) dilatation and right ventricular (RV) dysfunction. Methods In total 614 patients who underwent surgery for severe primary MR with available baseline transthoracic echocardiograms were included. Patients were classified according to the extent of cardiac damage (Figure): Stage 0-no cardiac damage, Stage 1-LV damage, Stage 2-LA damage, Stage 3-pulmonary vasculature or tricuspid valve damage and Stage 4-RV damage. Patients were followed for all-cause mortality. Results Based on the proposed classification, 172 (28%) patients were classified as Stage 0, 102 (17%) as Stage 1, 134 (21%) as Stage 2, 135 (22%) as Stage 3 and 71 (11%) as Stage 4. The more advanced the stage, the older the patients were with worse kidney function, more symptoms and higher EuroScore. Kaplan-Meier curve analysis revealed that patients with more advanced stages of cardiac damage had a significantly worse survival (log-rank chi-square 35.2; p<0.001) (Figure). On multivariable analysis, age, male, chronic obstructive pulmonary disease, kidney function, and stage of cardiac damage were independently associated with all-cause mortality. For each stage increase, a 22% higher risk for all-cause mortality was observed (95% CI: 1.064–1.395; p=0.004). Conclusion In patients with severe primary MR, a novel staging classification based on the extent of cardiac damage, may help refining risk stratification, particularly including also GLS, LA dilatation and RV dysfunction in the assessment. Funding Acknowledgement Type of funding source: None

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New onset left bundle branch block after transcatheter aortic valve implantation and the effect on long-term survival – a UK wide experience

European Heart Journal ◽

10.1093/ehjci/ehaa946.2607 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S.S Arri ◽

A Myat ◽

I Malik ◽

N Curzen ◽

A Baumbach ◽

...

Keyword(s):

Aortic Valve ◽

Transcatheter Aortic Valve Implantation ◽

Left Bundle Branch Block ◽

Left Ventricular ◽

Bundle Branch Block ◽

Transcatheter Aortic Valve ◽

All Cause Mortality ◽

Aortic Valve Implantation ◽

Valve Implantation ◽

New Onset

Abstract Introduction New onset left bundle branch block (LBBB) is the most common conduction disturbance associated with transcatheter aortic valve implantation (TAVI). It has been shown to adversely affect cardiac function and increase re-hospitalisation, although its impact on mortality remains contentious. Methods We conducted an observational cohort analysis of all TAVI procedures performed by 13 heart teams in the United Kingdom from inception of their structural programmes until 31st July 2013. The primary outcome was 1-year all-cause mortality. Secondary outcomes included left ventricular ejection fraction (LVEF) at 30 days and need for a post-TAVI permanent pacemaker (PPM). Results 1785 patients were eligible for inclusion to the study. The primary analysis cohort was composed of 1409 patients with complete electrocardiographic (ECG) data pre- and post-TAVI. Pre-existing LBBB was present in 200 (14.2%) patients. New LBBB occurred in 323 (22.9%) patients post TAVI, which resolved in 99 (7%) patients prior to discharge. A balloon-expandable device was implanted in 968 (69%) patients, whilst 421 (30%) patients received a self-expandable valve. New LBBB was observed in 120 (12.4%) and 192 (45.6%) patients receiving a balloon- or self-expandable prosthesis respectively. Overall 1-year all-cause mortality post TAVI was 18.7%. New onset LBBB was not associated with an increase in 1-year all-cause mortality (p=0.416). Factors that were associated with mortality included an increasing logistic EuroScore (p=0.05), history of previous balloon aortic valvuloplasty (p=0.001), renal impairment (p=0.003), previous myocardial infarction with pre-existing LBBB (p=0.028) and atrial fibrillation (p=0.039). Lower baseline peak and mean AV gradients were also associated with greater mortality at 1 year (p=0.001), likely reflecting underlying left ventricular dysfunction. In the majority of patients, LVEF remained unchanged following TAVI. Interestingly, the presence or absence of new onset LBBB did not affect LVEF improvement at 30 days. 10% of patients required a PPM post TAVI. Predictors of PPM included new LBBB (OR 2.6, p<0.001), pre-TAVI left ventricular systolic impairment (OR 1.2, p=0.037), a self-expandable device (p<0.001), and pre-existing RBBB (OR 4.0, p<0.001). Conclusions These findings suggest that new onset LBBB post TAVI does not increase mortality at 1 year or adversely affect LVEF at 30 days. Funding Acknowledgement Type of funding source: None

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Abstract 16154: Baseline Left Ventricular Diameter Predicts Recovery in New Systolic Heart Failure Syndromes

Circulation ◽

10.1161/circ.142.suppl_3.16154 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Daniel Gold ◽

Nathan Kong ◽

Matthew Gold ◽

Tess Allan ◽

Anand Shah ◽

...

Keyword(s):

Left Ventricular ◽

Medical Decision ◽

Left Ventricular Ejection ◽

Internal Diameter ◽

Event Free Survival ◽

Short Term Treatment ◽

Ventricular Ejection Fraction ◽

Free Survival ◽

Advanced Therapies

Introduction: It is unknown how often patients with very advanced left ventricular (LV) dilation at initial presentation demonstrate meaningful recovery with medical therapy. Understanding short term treatment outcomes may impact medical decision making and counseling. Hypothesis: Patients with left ventricular end diastolic internal diameter (LVEDD) > 6.5cm will be less likely to recover left ventricular ejection fraction (LVEF) as compared to patients with LVEDD < 6.5cm. Methods: Patients were retrospectively identified by a database search of echocardiogram studies obtained at the University of Chicago between 2008-2018. Manual review was performed to ensure new diagnosis of systolic dysfunction with LVEF ≤ 35% and follow up echocardiogram study within 3 to 9 months of index study. LVEDD was determined from parasternal long axis views per routine. LVEF recovery was specified as LVEF > 35%. Chart review was done to assess for composite death, hospice, transplant, left ventricular assist device, and sustained ventricular tachycardia. Chi-square, multivariable logistic regression, and Kaplan-Meier survival were used for analysis. Results: Out of 100 patients included for analysis, mean age was 59.7 years, 41 were female and 82 were African American. 17.7% of patients’ with LVEDD > 6.5 cm had LVEF recovery compared to 53.0% of patients’ with LVEDD ≤ 6.5 cm (p = 0.008). LVEDD > 6.5 cm was associated with less LVEF recovery even when adjusted for age, gender, hypertension, and diabetes (adjusted odds ratio 0.18, 95% CI 0.04 to 0.65). LVEDD > 6.5cm was associated with worse event free survival (p = 0.004) with a median follow-up time of 2.4 years. Conclusions: An LVEDD of > 6.5cm is associated with diminished LVEF recovery and event free survival when compared to those patients with an LVEDD ≤ 6.5cm. Delaying consideration for advanced therapies and device based therapies in hopes of recovery may be inappropriate for many such patients.

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Outcomes of Participants with Diabetes in the ISCHEMIA Trials

Circulation ◽

10.1161/circulationaha.121.054439 ◽

2021 ◽

Author(s):

Jonathan D. Newman ◽

Rebecca Anthopolos ◽

G. B. John Mancini ◽

Sripal Bangalore ◽

Harmony R. Reynolds ◽

...

Keyword(s):

Left Ventricular Function ◽

Ventricular Function ◽

Medical Therapy ◽

Left Ventricular ◽

Event Free Survival ◽

Free Survival ◽

Female Sex ◽

Patients With Diabetes ◽

Insulin Use ◽

Invasive Management

Background: Among patients with diabetes mellitus (diabetes) and chronic coronary disease (CCD), it is unclear if invasive management improves outcomes when added to medical therapy. Methods: The ISCHEMIA Trials (ISCHEMIA and ISCHEMIA CKD) randomized CCD patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, HbA1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with vs. without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease [CAD] severity or left ventricular function). Results: Of 5,900 participants with complete baseline data, the median age was 64 years interquartile range (IQR) [57-70], 24% were female, and the median estimated glomerular filtration was 80 ml/min/1.73 2 IQR [64-95]. Among the 2,553 (43%) of participants with diabetes, median percent hemoglobin A1c was 7% IQR [7-8%], and 30% were insulin treated. Participants with diabetes had a 49% increased hazard of death or MI (HR 1.49; 95% CI: 1.31-1.70, P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI: 0.48, 0.60) and 0.66 (95% bootstrapped CI: 0.61, 0.71) for patients with vs. without diabetes - a 12% (95% bootstrapped CI: 4%, 20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI: 0.42, 0.56) and 0.49 (95% bootstrapped CI: 0.42, 0.56), respectively. There was no difference in death or MI between strategies for patients with vs. without diabetes, or for clinical (female sex or insulin use) or anatomic features (CAD severity or left ventricular function) of patients with diabetes. Conclusions: Despite higher risk for death or MI, CCD patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Clinical Trial Registration: URL: http://www.clinicaltrials.gov Unique identifier: NCT01471522

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