Mitral regurgitation severity dynamic during acute decompensated heart failure treatment

Acute decompensated heart failure (ADHF) treatment leads to significant hemodynamic changes. The aim of our study was to quantitatively analyze the dynamics of mitral regurgitation (MR) severity (evaluated by transthoracic echocardiography) which occur during the treatment of ADHF and to correlate these changes with the clinical condition of patients as well as heart failure biochemical markers. The study included 27 consecutive adult patients (40.7% females, mean age 71.19 ± 11.2 years) who required hospitalization due to signs of acute HF. Echocardiographic assessment was performed upon admission and discharge together with clinical and laboratory evaluation. Significant reduction in dyspnea intensity [0–100 scale] (81.48 ± 9.07 vs. 45.00 ± 11.04 pts, p < 0.001), body weight (84.98 ± 18.52 vs. 79.77 ± 17.49 kg, p < 0.001), and NT-proBNP level (7520.56 ± 5288.62 vs. 4949.88 ± 3687.86 pg/ml, p = 0.001) was found. The severity of MR parameters decreased significantly (MR volume 44.92 ± 22.83 vs. 30.88 ± 18.77 ml, p < 0.001; EROA 0.37 ± 0.17 vs. 0.25 ± 0.16 cm2, p < 0.001; VC 6.21 ± 1.48 vs. 5.26 ± 1.61 mm, p < 0.001). Left atrial area (35.86 ± 9.11 vs. 32.47 ± 9.37, p < 0.001) and mitral annular diameter (42.33 ± 6.63 vs. 39.72 ± 5.05. p < 0.001) also underwent statistically significant reductions. An increase in LVEF was observed (34.73 ± 13.88 vs. 40.24 ± 13.19%, p < 0.001). In 40.7% of patients, a change in MR severity class (transition from a higher class to a lower one) was observed: 6/8 (75%) patients transitioned from severe to moderate and 6/18 (33.3%) patients transitioned from moderate to mild class. Treatment of ADHF leads to a significant reduction in MR severity, together with significant reductions in left atrial and mitral annular dimensions. Quantitative measurement of MR dynamics offer valuable assistance for ADHF management.

Cardiac and aortic size measures in adult echocardiography should be indexed by body surface area regardless of body mass index

BACKGROUNDBody size indexation is a foundation of the diagnostic interpretation of cardiac size measures used in imaging assessment of cardiovascular health. Body surface area (BSA) is the most commonly used metric for body size indexation of echocardiographic measures, but its use in patients who are underweight or obese is questioned (body mass index (BMI) <18·5 kg/m2 or ≥30 kg/m2, respectively). We hypothesized that mortality can be used to identify an optimal body size indexation metric for echocardiographic measures that would be a better predictor of survival than BSA regardless of BMI.METHODSIn this big data, cohort study, adult patients with no prior valve replacement were selected from the National Echo Database Australia. Survival analysis was performed for echocardiographic measures both unindexed and indexed to different body size metrics, with 5-year cardiovascular mortality as the primary endpoint.FINDINGSIndexation of echocardiographic measures (left ventricular diameter [n=337,481] and mass [n=330,959], left atrial area [n=136,989], aortic sinus diameter [n=125,130], right atrial area [n=81,699], right ventricular diameter [n=3,575], right ventricular outflow tract diameter [n=2,841]) by BSA had better prognostic performance vs unindexed measures (healthy/overweight: C-statistic 0·656 vs 0·618, average change in Akaike Information Criteria (ΔAIC) 800; underweight: C-statistic 0·669 vs 0·654, ΔAIC 15; obese: C-statistic 0·630 vs 0·612, ΔAIC 113). Indexation by other body size metrics (lean body mass or height and/or weight raised to various powers) did not improve prognostic performance versus BSA by a clinically relevant magnitude (average C-statistic increase ≤0·01), with smaller differences in higher BMI subgroups. Similar results were obtained using sex-disaggregated analysis, for indexation of other aortic or cardiac dimension or volume measures, and for all-cause mortality.INTERPRETATIONIndexing measures of cardiac and aortic size by BSA improves prognostic performance regardless of BMI, and no other body size metric has a clinically meaningful better performance.FUNDINGThis research was supported in part by grants (PI Ugander) from New South Wales Health, Heart Research Australia, and the University of Sydney.

Echocardiographic predictors of low risk haemodynamic parameters in patients with pulmonary arterial hypertension

Background A periodic and multiparametric assessment of the risk profile of patients with pulmonary arterial hypertension (PAH) is essential for a low-risk oriented treatment strategy. Haemodynamic parameters anyway cannot be collected at each scheduled outpatients clinic follow-up visit. Purpose To evaluate echocardiographic predictors of haemodynamic low-risk parameters in patients with PAH. Methods Patients with PAH referred to our centre were included up to 31 December 2019. All patients underwent baseline demographic, clinical, WHO functional class, 6-minute walk test, brain natriuretic peptide (BNP), right cardiac catheterization and echocardiographic evaluation. Through a multivariate logistic regression analysis we evaluate the echocardiographic predictors of low risk for: 1) BNP/right atrial pressure (RAP): NT-proBNP &lt;300 ng/l/BNP &lt;50 ng/l AND RAP &lt;8 mmHg; 2) cardiac index (CI)/mixed venous oxygen saturation (SvO2): CI ≥2.5 l/min/m2 AND SvO2 &gt;65%. Echocardiographic parameters cut-offs were chosen on the basis of the ROC curves or Literature data. Results 1020 patients were included. The two analysis were performed independently. 1. Independent echocardiographic predictors of low-risk BNP/RAP were: indexed right atrial area, mitral E/A ratio, dimension and inspiratory collapse of inferior vena cava and indexed left ventricular diastolic volume. We elaborated a score utilizing these parameter cut-offs: an indexed right atrial area of 10.4–15 cm2/m2, a mitral E/A ratio of 0.8, dimension and inspiratory collapse of inferior vena cava indicative of 0–5 vs 5–10 vs 10–20 mmHg and an indexed left ventricular diastolic volume of 32 ml/m2. The score has AUC: 0.62, specificity: 92%, sensitivity: 33%, negative predictive value: 70%, positive predictive value: 69%. 2. Independent echocardiographic predictors of low-risk CI/SvO2 were: S wave at TDI, Tei index, tricuspid annular plane systolic excursion (TAPSE), indexed left ventricular diastolic volume and the severity of the tricuspid regurgitation. We elaborated a score utilizing these parameter cut-offs: an S wave at TDI of 9.5 cm/s, a Tei index of 0.4, a TAPSE of 1.7 cm, an indexed left ventricular diastolic volume of 32 ml/m2 and a mild vs more than mild tricuspid regurgitation. The score has AUC: 0.70, specificity: 89%, sensitivity: 50%, negative predictive value: 71%, positive predictive value: 77%. Conclusion Echocardiographic parameters can be used to rule out the presence of low-risk BNP/RAP values (indexed right atrial area, mitral E/A ratio, dimension and inspiratory collapse of inferior vena cava and indexed left ventricular diastolic volume) and low-risk CI/SvO2 (S wave at TDI, Tei index, TAPSE, indexed left ventricular diastolic volume and severity of tricuspid regurgitation). FUNDunding Acknowledgement Type of funding sources: None.

Mitral Regurgitation Severity Dynamic During Acute Decompensated Heart Failure Treatment.

Purpose: Acute decompensated heart failure (ADHF) treatment leads to significant hemodynamic changes. The aim of our study was to quantitatively analyze the dynamics of mitral regurgitation (MR) severity (evaluated by transthoracic echocardiography) which occur during the treatment of ADHF and to correlate these changes with the clinical condition of patients as well as heart failure biochemical markers. Methods: The study included 27 consecutive adult patients (40.7% females, mean age 71.19±11.2 years) who required hospitalization due to signs of acute HF. Echocardiographic assessment was performed upon admission and discharge together with clinical and laboratory evaluation. Results: Significant reduction in dyspnea intensity [0-100 scale] (81.48±9.07 vs. 45.00±11.04 pts, p<0.001), body weight (84.98±18.52 vs. 79.77±17.49 kg, p<0,001), and NT-proBNP level (7520.56±5288.62 vs. 4949.88±3687.86 pg/ml, p=0.001) was found. The severity of MR parameters decreased significantly (MR volume 44.92±22.83 vs. 30.88±18.77 ml, p<0.001; EROA 0.37±0.17 vs. 0.25±0.16 cm2, p<0.001; VC 6.21±1.48 vs. 5.26±1.61 mm, p<0.001). Left atrial area (35.86±9.11 vs. 32.47±9.37, p<0.001) and mitral annular diameter (42.33±6.63 vs. 39.72±5.05. p<0.001) also underwent statistically significant reductions. An increase in LVEF was observed (34.73±13.88 vs. 40.24±13.19 %, p<0.001). In 40.7% of patients, a change in MR severity class (transition from a higher class to a lower one) was observed: 6/8 (75%) patients transitioned from severe to moderate and 6/18 (33.3%) patients transitioned from moderate to mild class.Conclusions: Treatment of ADHF leads to a significant reduction in MR severity, together with significant reductions in left atrial and mitral annular dimensions. Quantitative measurement of MR dynamics offer valuable assistance for ADHF management.

Abstract P369: Cerebral Small Vessel Disease and Enlarged Cardiac Ventricles

Introduction: White matter hyperintensities (WMH) are a radiographic marker for cerebral small vessel disease (CSVD). Conditions altering cerebral venous outflow such as elevated central venous pressure and right atrial pressure in individuals with cardiac valvular disease have been implicated in the development of WMH. Hypothesis: We hypothesize that increased right-heart chamber size in individuals without significant cardiac valvular disease is associated with worse WMH. Methods: A retrospective chart review of adults with a brain MRI and a 2-dimensional transthoracic echocardiogram (TTE) was performed. Worst burden of WMH by way of Fazekas score, either periventricular or deep white matter, served as the primary outcome. Statistical analysis was performed using a multivariate ordinal logistic regression model. Results: A total of 132 individuals were included. Right atrial area (OR 0.93, 95% CI 0.87 to 1.00, p = 0.0041), right ventricular internal diameter (OR 0.48, 95%CI 0.27 to 0.83, p = 0.008) and left atrial area (OR 0.93, 95%CI 0.88 to 0.98, p = 0.007) was identified as being significant. Cardiac functional markers were not significant, including tricuspid annular plane systolic excursion (OR 0.99, 95%CI 0.93 to 1.05, p = 0.670), right ventricular ejection fraction (OR 0.99, 95%CI 0.96 to 1.02, p = 0.670) and left ventricular ejection fraction (OR 0.99, 95%CI 0.96 to 1.02, p = 0.567). Analysis of isolated DWM or PVWM Fazekas scores did not find significant predictors in relation to cardiac structure or function. Conclusions: Through non-invasive cardiac imaging, we identified that cardiac structural abnormalities as opposed to functional abnormalities were associated with worse WMH. Mechanistically this may result from altered intracerebral arteriovenous coupling or a shared pathophysiologic pathway between WMH and coronary microvascular disease.

Abstract P709: Risk Factors Associated With Atrial Fibrillation Detection by Mobile Cardiac Outpatient Telemetry Following Acute Ischemic Stroke

Background: Mobile Cardiac outpatient telemetry (MCOT) is often used for patients (pts) with cryptogenic ischemic stroke following hospital discharge to detect atrial fibrillation (AFib) but criteria for patient selection remains a subject of debate. Methods: We identified 297 pts hospitalized with acute ischemic stroke who had an inpatient transthoracic echocardiogram (TTE) and underwent MCOT upon discharge between 2016 and 2018 at a large academic comprehensive stroke center. Pts characteristics between AFib vs. no AFib were compared by Fisher’s exact test for categorical and Wilcoxon rank-sum test for continuous variables. A multivariable stepwise logistic regression model was developed to determine the predictors of AFib detection. Statistical hypotheses were tested as two-sided at 0.05 level of significance. Results: Of the 297 pts, AFib was detected in 24 (8.1%) on 30-day MCOT. Pts with AFib detected were older, white, and have had a larger left atrial area (Table). The final logistic model demonstrated that white race (vs. non-white) (OR 4.86, 1.53-15.41), left atrial area (OR 1.15, 1.05-1.25) and left ventricular internal diameter in diastole (OR 0.33, 0.16-0.67) were associated with AFib detection by MCOT. Conclusion: Although rates of AFib detection on 30-day MCOT post-discharge was low, there are important patient characteristics and TTE features that can improve patient selection. Further studies are needed to determine if this data can be used prospectively to clinically decide which pts with cryptogenic stroke should be given 30-day MCT to detect atrial fibrillation.

Plasma volume contraction reduces atrial natriuretic peptide after four days of hypobaric hypoxia exposure

We investigated whether low arterial oxygen tension (PaO2) or hypoxia-induced plasma volume (PV) contraction, which reduces central blood volume (BV) and atrial distension, explain reduction in circulating atrial natriuretic peptide (ANP) after prolonged hypoxic exposure. Ten healthy males were exposed for four days to hypobaric hypoxia corresponding to an altitude of 3,500m. PV changes were determined by carbon monoxide rebreathing. Venous plasma concentrations of mid-regional proANP (MR-ProANP) were measured before and at the end of the exposure. At the latter time-point the measurement was repeated after i. restoration of PaO2 by breathing a hyperoxic gas mixture for 30min and ii. restoration of BV by fluid infusion. Correspondingly, left ventricular end-diastolic volume (LVEDV), left atrial area (LAA) and right atrial area (RAA) were determined by ultrasound before exposure, and both pre and post fluid infusion at the end of the exposure. Hypoxic exposure reduced MR-ProANP from 37.9±18.5 to 24.5±10.3 pmol/l (p=0.034), LVEDV from 107.4±33.5 to 91.6±26.3 ml (p=0.005), LAA from 15.8±4.9 to 13.3±4.2 cm² (p=0.007) and RAA from 16.2±3.1 to 14.3±3.5 cm² (p=0.001). Hyperoxic breathing did not affect MR-ProANP (24.8±12.3 pmol/l, p=0.890). Conversely, fluid infusion restored LVEDV, LAA and RAA to near baseline values (108.0±29.3 ml, 17.2±5.7 cm² and 17.2±3.1 cm², p>0.05 vs. baseline) and increased MR-ProANP to 29.5±13.3 pmol/l (p=0.010 vs. pre-infusion and p=0.182 vs. baseline). These findings support that ANP reduction in hypoxia is at least partially attributed to plasma volume contraction, whereas reduced PaO2 does not seem to contribute.

RISK STRATIFICATION OF HEART FAILURE BY ISCHEMIC MITRAL REGURGITATION IN PATIENT WITH MYOCARDIAL INFARCTION

One of the important complications which causes the increase of mortality and economic burden on patient is the ischemic MR. Its main pathophysiology is the remodeling of the LV after MI which causes the hemodynamic load and heart failure. However, the data on relationship between ischemic MR and duration of heart failure is very few. We prospectively studied 300 patients who admitted for acute myocardial infarction in our hospital. All patients were assessed by echocardiography and graded MR as mild, moderate, and severe according to regurgitant jet area which is less than 20%, 20 – 40%, and more than 40% of the left atrial area, respectively. The median duration of follow up was 1 year (range 6-12 months). Mild and moderate or severe ischemic MR was present in 40.2 and 6.4% of patients respectively. The hazard ratios for HF were 2.9 (95% condence interval (CI), 1.9–4.3; P<.001) and 3.7 (95% condence interval (CI), 2.1-6.5; P<.001) in patients with mild and moderate or severe ischemic MR respectively, with compared to patients without ischemic MR, after adjusting for ejection fraction and other clinical variables like age, sex, Killip class, previous infarction, hypertension, diabetes mellitus, anterior wall infarction, ST elevation infarction and coronary revascularization. In patients with mild ischemic MR, the adjusted hazard ratio for death was 1.1 (95% CI 0.7-1.7; P=.42), where as in moderate or severe ischemic MR it was 2.1 (95% CI 1.3-3.5; P=.02).