Left ventricle geometry, atrial strain, ventricle strain and hemodynamics across aortic valve before and after transcatheter aortic valve replacements

Background: Transcatheter Aortic Valve Replacements (TAVR) has become widespread throughout the world. To date there are no echocardiographic study of TAVR patients from Southeast Asia (SEA). We sought to evaluate 1) changes in echocardiographic and strain values pre and post TAVR 2) relationship between aortic stenosis (AS) severity and strain values, 3) left ventricle geometry in severe AS 4) relationship of flow rate to dimensionless index (DVI) and acceleration time (AT) and 5) effect of strains on outcome. Methods: Retrospective study of 112 TAVR patients in our center from 2009 to 2020. The echocardiographic and strain images pre (within 1 months), post (day after) and 6 months post TAVR were analyzed by expert echocardiographer. Results: The ejection fraction (EF) increased at 6 months (53.02 ± 12.12% to 56.35 ± 9.00%) (p=0.044). Interventricular septal thickness in diastole (IVSd) decreased (1.27 ± 0.21cm to 1.21 ± 0.23cm) (p=0.038) and left ventricle internal dimension in diastole (LVIDd) decreased from 4.77 ± 0.64cm to 4.49 ± 0.65cm (p = 0.001). No changes in stroke volume index (SVI pre vs 6 months p =0.187), but the flow rate increases (217.80 ± 57.61mls/s to 251.94 ± 69.59mls/s, p<0.001). Global Longitudinal Strain (GLS) improved from -11.44 ± 4.23% to -13.94 ± 3.72% (p <0.001), Left Atrial Reservoir strain (Lar-S) increased from 17.44 ± 9.16% to 19.60 ± 8.77% (p=0.033). 8 patients (7.5%) had IVSd < 1.0cm, and 4 patients (3.7%) had normal left ventricle (LV) geometry. There was linear relationship between IVSd and mean PG (r=0.208, p=0.031), between GLS to aortic valve area (AVA) and aortic valve area index (AVAi) (r = – 0.305, p=0.001 and r= – 0.316, p = 0.001). There was also relationship between AT (r=-0.20, p=0.04) and DVI (r=0.35, p< 0.001) with flow rate. Patients who died late (after 6 months) had lower GLS at 6 months. (Alive; -13.94 ± 3.72% vs Died; -12.43 ± 4.19%, p= 0.001) Conclusion: At 6 months TAVR cause reverse remodeling of the LV with reduction in IVSd, LVIDd and improvement in GLS and LAr-S. There is linear relationship between GLS and AVA and between IVSd and AVA.

The impact of cardiopulmonary exercise-derived scoring on prediction of cardio-cerebral outcome in hypertrophic cardiomyopathy

Background Sudden cardiac death (SCD) and stroke-related events accompanied by atrial fibrillation (AF) can affect morbidity and mortality in hypertrophic cardiomyopathy (HCM). This study sought to evaluate a scoring system predicting cardio-cerebral events in HCM patients using cardiopulmonary exercise testing (CPET). Methods We investigated the role of a previous prediction model based on CPET, the HYPertrophic Exercise-derived Risk score for Heart Failure-related events (HyperHF), which is derived from peak circulatory power ventilatory efficiency and left atrial diameter (LAD), for predicting a composite of SCD-related (SCD, serious ventricular arrhythmia, death from cardiac cause, heart failure admission) and stroke-related (new-onset AF, acute stroke) events. The Novel HyperHF risk model using left atrial volume index (LAVI) instead of LAD was proposed and compared with the previous HCM Risk-SCD model. Results A total of 295 consecutive HCM patients (age 59.9±13.2, 71.2% male) who underwent CPET was included in the present study. During a median follow-up of 742 days (interquartile range 384–1047 days), 29 patients (9.8%) experienced an event (SCD-related event: 14 patients (4.7%); stroke-related event: 17 patients (5.8%)). The previous model for SCD risk score showed fair prediction ability (AUC of HCM Risk-SCD 0.670, p = 0.002; AUC of HyperHF 0.691, p = 0.001). However, the prediction power of Novel HyperHF showed the highest value among the models (AUC of Novel HyperHF 0.717, p<0.001). Conclusions Both conventional HCM Risk-SCD score and CPET-derived HyperHF score were useful for prediction of overall risk of SCD-related and stroke-related events in HCM. Novel HyperHF score using LAVI could be utilized for a better prediction power.

The value of ventricular gradient for predicting pulmonary hypertension and mortality in hemodialysis patients

Pulmonary hypertension (PHT) is associated with increased mortality in hemodialysis (HD) patients. The ventricular gradient optimized for right ventricular pressure overload (VG-RVPO) is sensitive to early changes in right ventricular overload. The study aimed to assess the ability of the VG-RVPO to detect PHT and predict all-cause and cardiac mortality in HD patients. 265 selected HD patients were enrolled. Clinical, biochemical, electrocardiographic, and echocardiographic parameters were evaluated. Patients were divided into normal and abnormal VG-RVPO groups, and were followed-up for 3 years. Abnormal VG-RVPO patients were more likely to be at high or intermediate risk for PHT, were older, had longer HD vintage, higher prevalence of myocardial infarction, higher parathormone levels, shorter pulmonary flow acceleration time, lower left ventricular ejection fraction, higher values of left atrial volume index, left ventricular mass index, and peak tricuspid regurgitant velocity. Both all-cause and CV mortality were higher in abnormal VG-RVPO group. In multivariate Cox analysis, VG-RVPO remained an independent and strong predictor of all-cause and CV mortality. In HD patients, abnormal VG-RVPO not only predicts PHT, but also all-cause and CV mortality.

The Thromboembolic Predictability of CHA2DS2-VASc Scores Using Different Echocardiographic Criteria for Congestive Heart Failure in Korean Patients with Nonvalvular Atrial Fibrillation

The association between congestive heart failure (CHF) of the CHA2DS2-VASc scores and thromboembolic (TE) events in patients with atrial fibrillation (AF) is a topic of debate due to conflicting results. As the importance of diastolic impairment in the occurrence of TE events is increasingly recognized, it is crucial to evaluate the predictive power of CHA2DS2-VASc scores with C criterion integrating diastolic parameters. We analyzed 4200 Korean nonvalvular AF patients (71 years of age, 59% men) to compare multiple echocardiographic definitions of CHF. Various guideline-suggested echocardiographic parameters for systolic or diastolic impairment, including left ventricular ejection fraction (LVEF) ≤ 40%, the ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus (E/E’) ≥ 11, left atrial volume index > 34 mL/m2, and many others were tested for C criteria. Multivariate-adjusted Cox regression analysis showed that CHA2DS2-VASc score was an independent predictor for composite thromboembolic events only when CHF was defined as E/E’ ≥ 11 (hazard ratio, 1.26; p = 0.044) but not with other criteria including the original definition (hazard ratio, 1.10; p = 0.359). Our findings suggest that C criterion defined as diastolic impairment, such as E/E’ ≥ 11, may improve the predictive value of CHA2DS2-VASc scores.

Left Atrial Appendage Remodeling after Atrial Fibrillation Ablation

Introduction: Larger left atrial appendage (LAA) ostium area and greater left atrial (LA) volume have been associated with an increased risk of ischemic stroke. Catheter ablation (CA) of atrial fibrillation (AF) leads to morphological and functional changes within the LA and LAA, some of which are not well studied. Here, we present findings regarding post-ablation changes of the LAA ostia and correlate them with various LA, LAA and left ventricular (LV) functional and morphological metrics. Methods: This retrospective analysis included patients scheduled to undergo first-time radiofrequency CA for AF. Catheter ablation techniques included PVI with or without additional ablations. Cardiac magnetic resonance imaging (CMR) was used to assess LA, LAA and LV morphology and function, including LAA ostium area, LA/LAA volume and volume index, LA ejection fraction, LA strain, and LV ejection fraction. A Kruskal-Wallis test was used for correlating LAA ostial dimensions with other LA morphological and functional metrics. The t-test or two-sample Wilcoxon test were used to compare LA and LAA morphological parameters. Results: A total of 101 patients with AF were included in this study. The mean age was 60.1 ± 11.1 years, 69% were male, the average BMI was 29.22 ± 5.08. The LAA ostial area reduced significantly from 3.84 ± 1.15 cm before ablation to 3.42 ± 0.96 cm after ablation (p=0.0004). This reduction was asymmetrical, as the minor axis length decreased from 1.92 cm to 1.77 cm without significant changes in the major axis. LVEF increased from a pre-ablation average of 48.26% to a post-ablation average of 53.62% (p=0.015). Correlation of pre-ablation LVEF and LAA ostium area showed a near-significant negative trend (r=-0.21, p=0.083). LAEF correlated negatively with LAA ostial area (r=-0.289, p=0.0057), total LA strain (r=-0.248, p=0.0185), and passive LA strain (r=-0.208, p=0.049). Conclusion: There is a significant asymmetrical reduction of the LAA ostial area after AF ablation that is independent of LVEF changes. Larger LAA ostial area was associated with lower LAEF and LA strain. Remodeling of the LAA after AF ablation may help account for reduced risk of stroke and increased cardiac function.

Cardiac Magnetic Resonance Findings and Prognosis in Type 1 Myotonic Dystrophy

Purpose Cardiac involvement is a major determinant of prognosis in type 1 myotonic dystrophy (DM1), but limited information is available about myocardial remodelling and tissue changes. Aim of the study was to investigate cardiac magnetic resonance (CMR) findings and their prognostic significance in DM1. Methods We identified all DM1 patients referred from a neurology unit to our CMR laboratory from 2009 to 2020. Results Thirty-four patients were included (aged 45±12, 62% males). At CMR, 5(15%) had a left ventricular ejection fraction (LVEF)<50% and 4(12%) a right ventricular ejection fraction (RVEF)<50%. Compared to age- and sex-specific reference values, 12(35%) had a decreased end-diastolic volume index (LVEDVi), 7(21%) a decreased mass index (LVMi), and 29(85%) a reduced LVMi/LVEDVi. Nine (26%) showed mid-wall late gadolinium enhancement (LGE; 5±2% of LVM), and 14(41%) fatty infiltration. In a subset of 13(38%) patients, native T1 in the interventricular septum (1,041±53 ms) approached the upper reference limit (1,089 ms) and the extracellular volume was slightly increased (33±2%, reference<30%). Over 2.5(1.5-4.0) years, 2(6%) patients died for infectious and respiratory complications, 5(15%) underwent device implantation; 4/21(19%) with Holter developed repetitive ventricular ectopic beats (VEBs). Lower RV volumes (p=0.043), higher anteroseptal wall thickness (p=0.024) and LV fatty infiltration (p=0.029) were associated with device implantation, LGE mass was associated with VEBs (p=0.003) and death (p<0.001). Conclusion DM1 patients display structural and functional cardiac abnormalities, with variable degrees of cardiac muscle hypotrophy, fibrosis and fatty infiltration. Such changes, as evaluated by CMR, may anticipate the worsening of electrical disturbances.

Association of left atrial strain by cardiovascular magnetic resonance with recurrence of atrial fibrillation following catheter ablation

Background Atrial fibrillation (AF) is a progressive condition, which is characterized by inflammation/fibrosis of left atrial (LA) wall, an increase in the LA size/volumes, and decrease in LA function. We sought to investigate the relationship of anatomical and functional parameters obtained by cardiovascular magnetic resonance (CMR), with AF recurrence in paroxysmal AF (pAF) patients after catheter ablation. Methods We studied 80 consecutive pAF patients referred for ablation, between January 2014 and December 2019, who underwent pre- and post-ablation CMR while in sinus rhythm. LA volumes were measured using the area–length method and included maximum, minimum, and pre-atrial-contraction volumes. CMR-derived LA reservoir strain (ℇR), conduit strain (ℇCD), and contractile strain (ℇCT) were measured by computer assisted manual planimetry. We used a multivariate logistical regression to estimate the independent predictors of AF recurrence after ablation. Results Mean age was 58.6 ± 9.4 years, 75% men, mean CHA2DS2-VASc score was 1.7, 36% had prior cardioversion and 51% were taking antiarrhythmic drugs. Patients were followed for a median of 4 years (Q1–Q3 = 2.5–6.2 years). Of the 80 patients, 21 (26.3%) patients had AF recurrence after ablation. There were no significant differences between AF recurrence vs. no recurrence groups in age, gender, CHA2DS2-VASc score, or baseline comorbidities. At baseline, patients with AF recurrence compared to without recurrence had lower LV end systolic volume index (32 ± 7 vs 37 ± 11 mL/m2; p = 0.045) and lower ℇCT (7.1 ± 4.6 vs 9.1 ± 3.7; p = 0.05). Post-ablation, patients with AF recurrence had higher LA minimum volume (68 ± 32 vs 55 ± 23; p = 0.05), right atrial volume index (62 ± 20 vs 52 ± 19 mL/m2; p = 0.04) and lower LA active ejection fraction (24 ± 8 vs 29 ± 11; p = 0.05), LA total ejection fraction (39 ± 14 vs 46 ± 12; p = 0.02), LA expansion index (73.6 ± 37.5 vs 94.7 ± 37.1; p = 0.03) and ℇCT (6.2 ± 2.9 vs 7.3 ± 1.7; p = 0.04). Adjusting for clinical variables in the multivariate logistic regression model, post-ablation minimum LA volume (OR 1.09; CI 1.02–1.16), LA expansion index (OR 0.98; CI 0.96–0.99), and baseline ℇR (OR 0.92; CI 0.85–0.99) were independently associated with AF recurrence. Conclusion Significant changes in LA volumes and strain parameters occur after AF ablation. CMR derived baseline ℇR, post-ablation minimum LAV, and expansion index are independently associated with AF recurrence.

Risk prediction in patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction undergoing TAVI

ObjectivePatients with low-flow, low-gradient aortic stenosis (LFLG AS) and reduced left ventricular ejection fraction (LVEF) are known to suffer from poor prognosis after transcatheter aortic valve implantation (TAVI). This study aimed to develop a simple score system for risk prediction in this vulnerable subset of patients.MethodsAll patients with LFLG AS with reduced EF and sufficient CT data for aortic valve calcification (AVC) quantification, who underwent TAVI at five German centres, were retrospectively included. The Risk prEdiction in patients with Low Ejection Fraction low gradient aortic stenosis undergoing TAVI (RELiEF TAVI) score was developed based on multivariable Cox regression for all-cause mortality.ResultsAmong all included patients (n=718), RELiEF TAVI score variables were defined as independent predictors of mortality: male sex (HR 1.34 (1.06, 1.68), p=0.013), underweight (HR 3.10 (1.50, 6.40), p=0.0022), chronic obstructive pulmonary disease (HR 1.55 (1.21, 1.99), p=0.001), pulmonary hypertension (HR 1.51 (1.17, 1.94), p=0.0015), atrial fibrillation (HR 1.28 (1.03, 1.60), p=0.028), stroke volume index (HR 0.96 (0.95, 0.98), p<0.001), non-transfemoral access (HR 1.36 (1.05, 1.76), p=0.021) and low AVC density (HR 1.44 (1.15, 1.79), p=0.0012). A score system was developed ranging from 0 to 12 points (risk of 1-year mortality: 13%–99%). Kaplan-Meier analysis for low (0–1 points), moderate (2–4 points) and high RELiEF TAVI score (>4 points) demonstrated rates of 18.0%, 29.0% and 46.1% (p<0.001) for all-cause mortality and 23.8%, 35.9% and 53.4% (p<0.001) for the combined endpoint of all-cause mortality or heart failure rehospitalisation after 1 year, respectively.ConclusionsThe RELiEF TAVI score is based on simple clinical, echocardiographic and CT parameters and might serve as a helpful tool for risk prediction in patients with LFLG AS and reduced LVEF scheduled for TAVI.