Chronic Aortic Regurgitation Patients Research Articles

Abstract 12123: Descending Aortic Diastolic Flow Reversal in Aortic Regurgitation: Optimizing Definitions and Assessment on Cardiac Magnetic Resonance

Introduction: Holodiastolic flow reversal (HDR) in the descending aorta (DA) may indicate hemodynamically significant aortic regurgitation (AR). However, the optimal definition and quantification of flow reversal on cardiac magnetic resonance (CMR) is unknown. Methods: We studied 346 chronic AR patients with regurgitant volume (RegVol) ≥30 mL or regurgitant fraction (RegF) ≥30%. The presence of HDR and quantitation of reverse volume in the DA (DA-RVol) was performed by a blinded observer. The threshold for DA-RVol that identified ≥ moderate-severe AR (RegVol ≥45 mL and RegF ≥40%) was established by derivation (50% random sample), validation (50% remaining sample), and ROC curve analysis. Multivariable logistic regression models adjusting for age, gender, NYHA Class, and indexed left ventricular end-diastolic volume were performed to compare HDR and DA-RVol. Results: The median age was 61 (IQR 50-70) years, 79.2% men, and 30.3% with bicuspid aortic valve. The median RegF was 37% (IQR 32-44) and DA-RVol was 12 mL (IQR 5-27). HDR was observed in 150 (43.2%), with 63% sensitivity and 77% specificity for detecting ≥ moderate-severe AR. The threshold of DA-RVol which identified ≥ moderate-severe AR was 17 mL (AUC 0.82, sensitivity 68%, and specificity 87%). The ROC curve analysis revealed a higher AUC for DA-RVol ≥17 mL relative to HDR (0.78 vs 0.70, P <0.001) for predicting ≥ moderate-severe AR. On multivariable analysis models, DA-RVol ≥17 mL was superior to HDR (AUC 0.83 vs 0.80, P =0.008). Conclusion: Quantitation of flow reversal in the descending aorta is a more reliable method to identify hemodynamically significant AR compared to simple presence of holodiastolic flow reversal.

Left ventricle reverse remodeling in chronic aortic regurgitation patients with dilated ventricle after aortic valve replacement

BackgroundAortic valve replacement (AVR) for chronic aortic regurgitation (AR) with a severe dilated left ventricle and dysfunction leads to left ventricle remodeling. But there are rarely reports on the left ventricle reverse remodeling (LVRR) after AVR. This study aimed to investigate the LVRR and outcomes in chronic AR patients with severe dilated left ventricle and dysfunction after AVR.MethodsWe retrospectively analyzed the clinical datum of chronic aortic regurgitation patients who underwent isolated AVR. The LVRR was defined as an increase in left ventricular ejection fraction (LVEF) at least 10 points or a follow-up LVEF ≥ 50%, and a decrease in the indexed left ventricular end-diastolic diameter of at least 10%, or an indexed left ventricular end-diastolic diameter ≤ 33 mm/m2. The changes in echocardiographic parameters after AVR, survival analysis, the predictors of major adverse cardiac events (MACE), the association between LVRR and MACE were analyzed.ResultsSixty-nine patients with severe dilated left ventricle and dysfunction underwent isolated AVR. LV remodeling in 54 patients and no LV remodeling in 15 patients at 6–12 months follow-up. The preoperative left ventricular dimensions and volumes were larger, and the EF was lower in the LV no remodeling group than those in the LV remodeling group (all p < 0.05). The adverse LVRR was the predictor for MACE at follow-up. The mean follow-up period was 47.29 months (range 6 to 173 months). The rate of freedom from MACE was 94.44% at 5 years and 92.59% at 10 years in the remodeling group, 60% at 5 years, and 46.67% at 10 years in the no remodeling group.ConclusionsThe left ventricle remodeling after AVR was the important predictor for MACE. LV no remodeling may not be associated with benefits from AVR for chronic aortic regurgitation patients with severe dilated LV and dysfunction.

Analysis of chronic aortic regurgitation by 2D and 3D echocardiography and cardiac MRI

Purpose: The study compares the feasibility of the quantitative volumetric and semi-quantitative approach for quantification of chronic aortic regurgitation (AR) using different imaging modalities.Methods: Left ventricular (LV) volumes, regurgitant volumes (RVol) and regurgitant fractions (RF) were assessed retrospectively by 2D, 3D echocardiography and cMRI in 55 chronic AR patients. Semi-quantitative parameters were assessed by 2D echocardiography.Results: 22 (40%) patients had mild, 25 (46%) moderate and 8 (14%) severe AR. The quantitative volumetric approach was feasible using 2D, 3D echocardiography and cMRI, whereas the feasibility of semi-quantitative parameters varied considerably. LV volume (LVEDV, LVESV, SVtot) analyses showed good correlations between the different imaging modalities, although significantly increased LV volumes were assessed by cMRI. RVol was significantly different between 2D/3D echocardiography and 2D echocardiography/cMRI but was not significantly different between 3D echocardiography/cMRI. RF was not statistically different between 2D echocardiography/cMRI and 3D echocardiography/cMRI showing poor correlations (r < 0.5) between the different imaging modalities. For AR grading by RF, moderate agreement was observed between 2D/3D echocardiography and 2D echocardiography/cMRI and good agreement was observed between 3D echocardiography/cMRI.Conclusion: Semi-quantitative parameters are difficult to determine by 2D echocardiography in clinical routine. The quantitative volumetric RF assessment seems to be feasible and can be discussed as an alternative approach in chronic AR. However, RVol and RF did not correlate well between the different imaging modalities. The best agreement for grading of AR severity by RF was observed between 3D echocardiography and cMRI. LV volumes can be verified by different approaches and different imaging modalities.

Value of Three Dimensional Strain Imaging on Assessing Left Ventricular Systolic Function and Predicting Short-Term Outcome in Chronic Aortic Regurgitation Undergoing Valve Replacement Surgery

This study aimed to evaluate the subtle left ventricular function change in chronic aortic regurgitation (AR) patients using three dimensional strain imaging (3D STI) and to investigate its perioperative prognostic value. 3D STI were analyzed in 30 controls, 31 chronic AR patients with preserved LV function (AR+PEF group, LVEF≥55%), and 36 patients with LV dysfunction (AR+REF group, LVEF<55%). Among them, 32 patients underwent aortic valve replacement surgery (AVR). (1) Comparing controls, global longitudinal strain (GLS, -19.93±1.82% vs. -17.87±2.43%), global radial strain (GRS, 43.63±3.28% vs. 39.80±4.51% ), and torsion (2.31±0.60°/cm vs. 1.65±0.41°/cm) were reduced in AR+PEF, with global circumferential strain (GCS, -32.47±3.53%vs. -20.74±4.82%), GLS (-19.93±1.82% vs. -12.56±2.62 %), GRS (43.63±3.28% vs. 27.13±5.90 %), and torsion (2.31±0.60 °/cm vs. 1.17±0.46°/cm) reduced in AR+REF. (2) Strains in middle segments (LS -18.44±3.34%vs. -15.21±3.50%, CS -37.03±5.51%vs-33.67±4.09%, RS 46.02±5.82% vs. 40.22±4.34%, respectively), in apical segments (LS -21.73±5.27 % vs. -19.18±7.85%, CS -39.07±5.32 %vs. -35.08±4.64 %, RS 50.73±6.74 % vs. 45.20±9.24 %, respectively), and apical rotation (10.42±2.92°vs. 8.47±3.07°) were all reduced in AR+PEF, with basal segmental strains and rotation preserved. (3) Preoperative GLS was the unique independent predictor of perioperative cardiac adverse events. The receiver operating characteristic curves showed that optimal cut-off point was -15.65% with the area under the curve 0.765. 3D STI can detect subclinical left ventricular dysfunction in AR patients. For patients with preserved LVEF, GCS, basal strains and rotation were important in maintaining normal LEVF. GLS can predict perioperative cardiac adverse events in AVR.

Exercise echocardiography predicts postoperative left ventricular remodeling in aortic regurgitation

Objective. We aimed to investigate if preoperative left ventricular (LV) function assessed by exercise echocardiography could predict late postoperative LV function in aortic regurgitation (AR) patients and to evaluate how LV long-axis function is affected late after aortic valve surgery. Design. A total of 21 male chronic AR patients, aged 49 () years, accepted for surgery were examined preoperatively, 6 months-, and 4 years postoperatively, at rest and during exercise. Besides conventional echocardiographic parameters, the atrioventricular plane displacement (AVPD) by M-mode and peak systolic velocity (s’) in the basal LV by color tissue Doppler were measured. Results. Preoperatively EFrest and EFexercise, were 55()% and 54()%, respectively, and ∆EF 0()%. LV dimensions and volumes indexed to BSA had decreased at the 6-month follow-up and were stable at late follow-up. s'rest, s'exercise, AVPDrest, and AVPDexercise were unchanged at both the postoperative examinations (all P ≥ 0.05). Preoperative EFexercise and AVPDexercise showed inverse correlation to late postoperative indexed LV enddiastolic volume (r = –0.68, p < 0.004 and r = –0.86, P < 0.001) and indexed LV endsystolic volume (r = –0.68, P = 0.004 and r = –0.81, P < 0.001), while there was no correlation to preoperative EFrest and AVPDrest (all r < 0.2). Conclusions. Preoperative exercise echocardiography can detect AR patients with suboptimal LV remodeling late postoperatively.

Subendocardial dysfunction in patients with chronic severe aortic regurgitation and preserved ejection fraction detected with speckle-tracking strain imaging and transmural myocardial strain profile

It remains difficult to detect subtle left ventricular (LV) myocardial dysfunction in chronic aortic regurgitation (AR) patients with the preserved ejection fraction (EF). We studied 36 chronic severe AR patients undergoing surgical correction with the EF of 58 ± 6% (all ≥ 50%). Echocardiography was performed before and 12 ± 8 months after surgical correction. We used two-dimensional speckle-tracking strain imaging to evaluate global radial strain in the inner-half (GRSinner), outer-half (GRSouter), and total (GRStotal) layer from the mid-LV short-axis view. We also evaluated the transmural strain profile in the LV posterior wall by using myocardial tissue Doppler radial strain, and the location of peak strain was determined as the percentage of the distance from the endocardium to the epicardium accounted for by the wall thickness. Fifteen EF-matched normal volunteers were studied for comparison. GRSinner for AR patients was significantly smaller than that for controls (28.9 ± 12.9 vs. 37.1 ± 9.1%, P = 0.032), and the location of peak strain had significantly shifted to the epicardial side compared with that in controls (27.1 ± 14.0-13.2 ± 4.8%, P = 0.001). In contrast, GRStotal and GRSouter were similar for the two groups. After surgical correction, EF increased from 58 ± 6 to 62 ± 7% (P = 0.018), GRSinner from 27.8 ± 12.5 to 37.7 ± 14.6% (P < 0.0001), and the location of peak strain significantly shifted to the endocardial side (26.9 ± 13.9-19.1 ± 11.9%, P = 0.028). However, GRStotal and GRSouter did not change. The LV endocardium side, impaired in chronic AR patients with the preserved EF, improved after surgical correction. Our observations may prove useful for evaluating subtle early changes in such patients.

Strain Value in the Assessment of Left Ventricular Function and Prediction of Heart Failure Markers in Aortic Regurgitation

This study aimed to examine the relationship between biochemical heart failure markers and conventional left ventricular (LV) measurements and strain assessed by speckle-tracking echocardiography in chronic aortic regurgitation (AR) patients. LV strain, rotation assessed by speckle-tracking echocardiography, LV measurements, mitral annular plane excursion measured by M-mode, and systolic annular plane velocity measured by tissue Doppler echocardiography were analyzed in 64 controls and 65 chronic AR patients. Reduced LV longitudinal strain with increased apical rotation was seen in normal plasma NT-proBNP patients. Increased NT-proBNP (>400 pg/mL) was associated with reduced longitudinal and circumferential strain, diminished mitral annular plane excursions and systolic annular plane velocity. Global systolic longitudinal strain was an indepentent predictor of NT-proBNP level. Longitudinal strain less than 16.0% was the cutoff value for NT-proBNP>400 pg/mL (P<0.05). LV strain analysis in conjunction with NT-proBNP evaluation is a useful tool in assessing LV function in AR patients.

Increased Thrombolysis in Myocardial Infarction Frame Counts in Patients with Chronic Aortic Regurgitation

Aim: The effects of chronic aortic regurgitation (AR) on coronary blood flow of systolic/diastolic phase and phase and coronary reserve have been shown. Whereas thrombolysis in myocardial infarction (TIMI) frame count, which incorporates coronary blood flow and a higher TIMI frame count (TFC) is reflect disordered resistance vessel function, has not yet been evaluated in chronic AR. Method: 33 patients with isolated chronic AR diagnosed by echocardiography and angiography, and 22 control groups with no coronary or valvular disease who underwent angiography for atypical chest pain were included in our study. Coronary blood flow was measured using TFC. Result: Coronary blood flow, echocardiographic and demographic parameters were compared between the two groups. The mean TFC is found to be higher in AR patients when compared to the control group. (left anterior descending coronary artery (LAD) TFC, 43±7.3 vs. 30±5.9 frames/s, p<0.001; Corrected LAD (cLAD) TFC, 25.0±4.3 vs. 17.6 ± 3.5 frames/s, p< 0.001; Left circumflex artery (LCx) TFC, 27.0±6.4 vs. 19.9±3.4 frames/s, p<0.001; and Right coronary artery (RCA) TFC, 25.8±5.5 vs. 19.9±4.7 frames/s, p<0.001; mean TFC, 26.3±5.4 vs.19.1±3.9 frames/s, p<0.001). Conclusion: This is the first study showing increase of TFC in chronic AR patients without CAD. It is thought to show impaired coronary blood flow, and may explain angina symptoms in chronic AR patients. At the same time, it could be used as a parameter showing severe AR.