Degree Of Mitral Regurgitation Research Articles

Long-term results of catheter ablation of atrial fibrillation in patients with a reduced left ventricular ejection fraction

Abstract Objective This study aims to evaluate long-term results after catheter ablation of atrial fibrillation (AF) in patients with reduced left ventricular ejection fraction (LVEF) and to evaluate sinus rhythm (SR) maintenance, clinical status, and echocardiographic parameters in the long-term follow-up period. Material and methods The study included 112 patients (75.5% men, age 59.5±11.5 years) with LV EF <50% underwent radiofrequency catheter ablation for paroxysmal (24%) or persistent (76%) AF. Patients after ablation were followed up for 38.4 (17.7–54.5) months for AF recurrence, functional class, and echocardiographic parameters. Results All patients underwent complete antral isolation of the pulmonary veins, and 95 (84.8%) underwent additional linear ablations in the left atrium. During the follow-up period, 48 (42.8%) patients experienced arrhythmia recurrence in the form of AF, atrial flutter, or ectopic atrial tachycardia. Repeated ablations were required in 35 (31.2%) patients. After ablation, antiarrhythmic drugs continued to be taken in 75 (66.9%) patients. During follow-up, NYHA class improved at least one class more often among patients in stable sinus rhythm than patients with recurrences (77.5% vs 51.2%, p=0.003). LV EF improved in patients maintaining sinus rhythm (36.6% vs 19.4%; P=0.016), and the degree of mitral regurgitation was significantly reduced (P<0.001) only in these patients. On multivariate analysis, maintenance of sinus rhythm was an independent predictor (odds ratio 4.56, 95% CI 1.69–9.94, P=0.002) of long-term clinical improvement (reduction in NYHA class ≥1 and relative improvement in LVEF ≥10%). Conclusions In patients with reduced LV EF, maintenance of sinus rhythm after ablation is associated with more significant clinical improvement. In the long-term period, the effectiveness of AF ablation in patients with reduced LVEF, as an improvement in the NYHA class and an increase in LVEF, is affected by a high rate of long-term recurrences. Funding Acknowledgement Type of funding sources: None.

Trajectory of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction and association with cardiac structure and function

Abstract Background The PARADISE-MI trial examined the efficacy of sacubitril/valsartan in patients with acute myocardial infarction (AMI) complicated by reduced left ventricular ejection fraction (LVEF), pulmonary congestion or both. Little is known about the trajectory and echocardiographic correlates of pulmonary congestion in this population. Purpose We sought to assess the trajectory of pulmonary congestion using lung ultrasound (LUS) and its association with cardiac structure and function in a subset of patients enrolled in PARADISE- MI. Methods Participants underwent 8-zone LUS at baseline and 8 months. B-lines were quantified offline, blinded to treatment group, clinical findings, timepoint and outcomes by a core laboratory. Paired t-tests, chi-squared tests, and linear regression analyses were conducted. Results Among 152 patients (median age 65 years, 32% women, 35% obese, mean LVEF 41%), any B-lines were detectable in 87%, the median sum of B-lines in 8 zones was 4 [IQR 2–8], and 67% had ≥3 B-lines indicative of congestion. Greater number of B-lines at baseline was associated with larger left atrial (LA) size, higher E/e' and E/A ratios, greater degree of mitral regurgitation, worse right ventricular (RV) systolic function, and higher tricuspid regurgitation velocity (P trend <0.05 for all) (Figure 1). Among 115 patients with 8-month LUS data, there was a significant decline in number of B-lines from baseline (mean ± SD: −1.6±7.3; p=0.018). Adjusted for baseline, B-lines at follow-up were on average 6 (95% CI: 3, 9) higher in a patient who experienced an intercurrent heart failure (HF) event than a non-HF patient (p=0.001). Among 75 patients with ≥3 B-lines at baseline, a decrease in B-lines to <3, indicating decongestion, occurred in 37% and was similar in the sacubitril/valsartan and ramipril groups (36% vs. 39%, p=0.83). Conclusions In this post-AMI cohort, sonographic B-lines, indicating pulmonary congestion, were common at baseline and were significantly higher at follow-up in those who developed HF. Worse pulmonary congestion at baseline was associated with prognostically important echocardiographic markers of LV filling pressure, pulmonary pressure, and RV function. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Novartis

Pre-operative evaluation and mid-term outcomes of anomalous origin of the left coronary artery from the pulmonary artery based on left ventricular ejection fraction.

ObjectiveThe purpose of this study was to evaluate the prognosis of patients with anomalous left coronary artery originating from pulmonary artery with varying cardiac function after surgical correction.MethodsThis was a single-center retrospective cohort study including 51 patients with anomalous left coronary artery originating from pulmonary artery, all of whom underwent surgery at our center.ResultsAll 5 deaths occurred in the pre-operative low cardiac function group (n = 39). After corrected by body surface area, parameters such as left coronary artery, right coronary artery, left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and main pulmonary artery diameter, were lower in patients in the normal cardiac function group than in the low cardiac function group. The rate of collateral circulation formation was higher in the normal cardiac function group. The proportion of changes of T wave was higher in the low cardiac function group (P = 0.005), and the duration of vasoactive drugs (dopamine, milrinone, epinephrine, nitroglycerin.) was longer in the low cardiac function group. Left ventricular end-diastolic diameter, left ventricular end-systolic diameter, main pulmonary artery diameter, and left atrial diameter were smaller than those pre-operatively (P < 0.05). Left ventricular ejection fraction was higher than that pre-operatively (P = 0.003). The degree of mitral regurgitation in the low cardiac function group was reduced post-operatively (P < 0.001).ConclusionThere was a significant difference between the pre-operative baseline data of the low cardiac function group and the normal cardiac function group. After surgical repair, cardiac function gradually returned to normal in the low cardiac function group. The low cardiac function group required vasoactive drugs for a longer period of time. The left ventricular end-diastolic diameter, left ventricular end-systolic diameter, left atrial diameter, and main pulmonary artery diameter decreased and gradually returned to normal after surgery. The degree of mitral regurgitation in the low cardiac function group was reduced after surgery.

Primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension for hypertrophic obstructive cardiomyopathy

The transaortic Morrow procedure is the current gold standard for hypertrophic obstructive cardiomyopathy (HOCM) patients who are resistant to maximum drug therapy. It is controversial whether concomitant mitral valve intervention is necessary. Only a few centers apply for concomitant anterior mitral leaflet extension with a bovine or autologous pericardial patch to further decrease systolic anterior motion. Our aim is to assess the primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension (TTM-AMLE) in symptomatic HOCM patients. Between April 2019 and November 2020, 18 consecutive HOCM patients who underwent TTM-AMLE were enrolled in this study. Preoperative, postoperative, and follow-up outcomes were compared and statistically analyzed. The mean age was (50.17 ± 6.18) years and 10 (55.56%) were males. 18 (100%) patients had mitral regurgitation preoperatively, and they all successfully underwent TTM-AMLE with a median cardiopulmonary bypass and aortic cross-clamp time of 200.0 (150.8, 232.0), and 127.5 (116.0, 149.0) min, respectively. The median length of ICU stay was 2.7 (1.4, 5.2) days. The interventricular septum thickness was significantly reduced (from 18.03 ± 3.02 mm to 11.91 ± 1.66 mm, p < .001). There was no perioperative mortality, perforation of ventricular septum, or conversion to sternotomy observed. During a median follow-up of 18 months (IQR, 5-24 months), 1 (5.56%) patient had severe mitral regurgitation due to patch detachment and received reoperation. Moderate degree of mitral regurgitation and more than 50 mmHg in left ventricular outflow tract gradient were found in 2 (11.11%), and 1 (5.56%) patients, respectively. 1 (5.56%) patient who had second-degree atrioventricular block received permanent pacemaker implantation postoperatively. Overall, the maximum left ventricular outflow tract gradient (88.50 [59.50, 112.75] mmHg vs. 10.50 [7.00, 15.50] mmHg, p = .002), left ventricular outflow tract velocity (4.70 [3.86, 5.33] m/s vs. 1.60 [1.33, 1.95] m/s, p < .001) and the degree of mitral regurgitation (6.99 ± 4.47 cm2 vs. 2.22 ± 1.51 cm2 , p = .001) were significantly decreased, with a significant reduction in the proportion of systolic anterior motion (94.44% vs. 16.67%, p < .001). The TTM-AMLE is a safe and effective surgical approach for selected patients with HOCM. In our series, it provides excellent relief of left ventricular outflow tract obstruction, while significantly eliminating mitral regurgitation. The early outcomes of TTM-AMLE are satisfactory, but further studies and longer follow-ups are awaited.

Systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: a narrative review.

Background and ObjectiveThe prevalence of hypertrophic cardiomyopathy (HCM) is estimated to be 1 in 200 to 500 individuals, with systolic anterior motion (SAM) of the mitral valve (MV) and left ventricular outflow tract (LVOT) obstruction present in 60% to 70%. In this narrative review, we aim to elucidate the pathophysiology of SAM-septal contact and LVOT obstruction in HCM by presenting a detailed review on the anatomy of the MV apparatus in HCM, examining the various existing theories pertaining to the SAM phenomenon as supported by cardiac imaging, and providing a critical assessment of management strategies for SAM in HCM.MethodsA literature review was performed using PubMed, EMBASE, Ovid, and the Cochrane Library, of all scientific articles published through December 2021. A focus was placed on descriptive studies, reports correlating echocardiographic findings with pathologic diagnosis, and outcomes studies.Key Content and FindingsThe pathophysiology of SAM involves the complex interplay between HCM morphology, MV apparatus anatomic abnormalities, and labile hemodynamic derangements. Echocardiography and cardiac magnetic resonance (CMR) vector flow mapping have identified drag forces, as opposed to the “Venturi effect”, as the main hydraulic forces responsible for SAM. The degree of mitral regurgitation with SAM is variable, and its severity is correlated with degree of LVOT obstruction and outcomes. First line therapy for the amelioration of SAM and LVOT obstruction is medical therapy with beta-blockers, non-dihydropyridine calcium-channel blockers, and disopyramide, in conjunction with lifestyle modifications. In refractory cases septal reduction therapy is performed, which may be combined with a ‘resect-plicate-release’ procedure, anterior mitral leaflet extension, surgical edge-to-edge MV repair, anterior mitral leaflet retention plasty, or secondary chordal cutting.ConclusionsRecent scientific advances in the field of HCM have allowed for a maturation of our understanding of the SAM phenomenon. Cardiac imaging plays a critical role in its diagnosis, treatment, and surveillance, and in our ability to apply the appropriate therapeutic regimens. The increasing prevalence of HCM places an emphasis on continued basic and clinical research to further improve outcomes for this challenging population.

C34 INDIRECT MITRAL ANNULOPLASTY USING THE CARILLON CONTOUR SYSTEM, SINGLE CENTER EXPERIENCE

Abstract Mitral Regurgitation (MR) is both the most common and the most underdiagnosed valvulopathy in Western countries. When MR’s entity is moderate to severe it is highly burdened by incident heart failure causing an important impact on prognosis, in terms of mortality and re–hospitalization. Unfortunately a lot of symptomatic patients are not elegible to reparative or replacement surgery also due to the high procedural risks. Hence, the need for a less invasive treatment has grown, so endovascular repair techniques have been developed such as the CARILLON Mitral Contour System, a percutaneous procedure for reshape the mitral annulus reducing its dilation and mitral regurgitation. This technique is indicated for patients with secondary mitral regurgitation. The CARILLON is a simple and fast procedure with a right jugular approach that requires neither general anesthesia nor anticoagulant/antiplatelet therapy. Four patients including 3 men, aged 37–64 years, suffering from heart failure and moderate to severe secondary mitral regurgitation who were symptomatic in optimal medical therapy, NYHA II – III class, were admitted to our Cardiological Intensive Care Unit from April to September 2021. All patients underwent coronary angiography and three patients had no obstructive coronary artery disease (CAD). All patients underwent transthoracic and transesophageal echocardiography showing severely dilated left ventricles (DTD 70 ± 10mm, DTS 46 ± 21mm, VTD 264 ± 6ml, VTS 204 ± 6ml), severe reduction in ejection fraction (mean EF 24 ± 5%), severely dilated left atrium, mean volume values 47 ± 13ml/m2, moderate to severe mitral regurgitation (vena contracta 6 ± 2mm, EROA 34 ± 9mm2, regurgitation volume 37 ± 12 ml, regurgitation fraction mean 54 ± 4%). After implantation of the Carillon no complications were observed. In the 3–month follow–up, patients reported improvement in symptoms, exercise capacity and NYHA class. At the echocardiographic evaluation we saw improvement in contractile function and left ventricular size, reduction in the degree of mitral regurgitation to mild–moderate. There were no further hospitalizations for heart failure during the follow–up. The data, albeit limited to our little experience, show how the Carillon reduces mitral regurgitation and improves clinical outcomes in terms of exercise tolerance, quality of life and reduction of hospital admissions, which have social and economic relevance.

Prognostic value of left atrial strain quantification from 2D ultrasound imaging in post-ischemic heart failure patients: evidence from the REMODEL-HF study

Background. Left atrial (LA) function can be effectively assessed by measuring longitudinal LA strain (LAS) via two-dimensional speckle tracking echocardiography (2DSTE). Here, we test 2DSTE-based LAS as marker of different left ventricle (LV) remodeling patterns and as prognostic index in ischemic heart failure (HF) candidates to surgical ventricular reconstruction.Methods. We retrospectively considered ischemic HF patients with anterior (group A, n=130) or posterior (group P, n=48) LV remodeling. Based on 2D ultrasound, LV and LA morpho-functional parameters were quantified including reservoir (LASRes), conduit (LASCond) and booster (LASBoost) LAS. We tested their capability to discriminate between groups A and P, and their group-specific prognostic significance for the composite end-point of death or HF re-hospitalization at follow-up (mean follow-up time=40 months, range 3-101 months).Results. Group A and group P displayed similar end-diastolic (p=0.89) and end-systolic (p=0.33) LV volume index, and LA volume index LAVi (p=0.44) corrected for the degree of mitral regurgitation. As compared to group P, group A revealed a significant reduction in LASBoost (9.2±0.4% vs. 11.1±0.7%, p=0.04) and a non-significant reduction in LASRes (16.9±0.7% vs. 19.3±1.1%, p=0.06).Kaplan-Meier curves showed that the median LASRes and LASBoost values effectively stratified patients based on their prognosis in the overall study population (Log-rank p=0.002 and Log_rank p<0.0001) and in group A, where the association was stronger for LASBoost (Log-rank p<0.001) than for LASRes (Log-rank p=0.013).Conclusions. 2DSTE-based LAS assessment is affordable, repeatable and non-invasive, and could add clinically-relevant mechanistic insight and prognostic value in the stratification of ischemic HF patients.

Effects of Metoprolol on Exercise Hemodynamics in Patients With Obstructive Hypertrophic Cardiomyopathy

BackgroundThe relationship between exercise hemodynamics, loading conditions, and medical treatment in patients with obstructive hypertrophic cardiomyopathy (HCM) is incompletely understood. ObjectivesThis study aimed to investigate the effect of metoprolol on invasive hemodynamic parameters at rest and during exercise in patients with obstructive HCM. MethodsThis randomized, double-blind, placebo-controlled crossover trial enrolled 28 patients with obstructive HCM and New York Heart Association functional class ≥II. Patients were randomized to initiate either metoprolol 150 mg or placebo for 2 consecutive 2-week periods. Right-heart catheterization and echocardiography were performed at rest and during exercise at the end of each treatment period. The primary outcome was the difference in pulmonary capillary wedge pressure (ΔPCWP) between peak exercise and rest. ResultsNo treatment effect on ΔPCWP was observed between metoprolol and placebo treatment (21 ± 9 mm Hg vs 23 ± 9 mm Hg; P = 0.12). At rest, metoprolol lowered heart rate (P < 0.0001), left ventricular outflow tract (LVOT) gradient (P = 0.01), and increased left ventricular end-diastolic volume (P = 0.02) and stroke volume (SV) (+6.4; 95% CI: 0.02-17.7; P = 0.049). During peak exercise, metoprolol was associated with a lower heart rate (P < 0.0001), a lower LVOT gradient (P = 0.0005), lesser degree of mitral regurgitation (P = 0.004), and increased SV (+9 mL; 95% CI: 2-15 mL; P = 0.008). ConclusionsIn patients with obstructive HCM, exercise was associated with an abnormal rise in PCWP, which was unaffected by metoprolol. However, metoprolol increased SV at rest and peak exercise following changes in end-diastolic volume, LVOT gradient, and degree of mitral regurgitation. (The Effect of Metoprolol in Patients With Hypertrophic Obstructive Cardiomyopathy [TEMPO]; NCT03532802)

Characteristics and long-term outcome for congenital left main coronary artery atresia.

The prevalence of congenital left main coronary artery atresia is very low. We report the characteristics and long-term outcomes of four children with left main coronary artery atresia. Three patients had heart murmurs due to mitral regurgitation at less than 1year old. Their myocardial ischaemia worsened on exercise with aging. In the fourth patient, hypertrophic cardiomyopathy and Noonan syndrome were suspected at 1year old. The development of communicating arteries between the conus branch and the left anterior descending artery was detected at 7years old. The left main coronary artery atresia was confirmed by a selective coronary angiogram at 15years old. Congenital left main coronary artery atresia could not be diagnosed by two-dimensional echocardiography; however, the left coronary arteries were small. Two patients underwent coronary artery bypass grafting of the left anterior descending artery using the left internal thoracic artery at 3years and 6years old, respectively. Two patients had an angioplasty with a cut back at the orifice of the left coronary artery at 2years old and 17years old, respectively. Two patients had no cardiac events without medication for more than 30years after the operation. We must differentiate the diagnosis of left main coronary artery atresia in the small left coronary arteries with mitral regurgitation during the first year. Coronary artery revascularisation and mitral annuloplasty are needed. The long-term outcome of both coronary artery bypass grafting and angioplasty were good. The degree of mitral regurgitation after surgery may affect the prognosis.

Histopathological maladaptive changes in the explanted human mitral leaflets correlate with changes in echocardiographic leaflet morphology and the severity of ischaemic mitral regurgitation.

Several changes of the mitral valve (MV) morphology have been previously documented in ischaemic mitral regurgitation (IMR) upon macro and microscopic examination. This study aimed to correlate echocardiographic MV thickening with IMR severity and to delineate the histopathological basis of valve thickening from the explanted leaflets. Two hundred and fifty patients were included in the echo-group; of these, 48 patients (19.2%) underwent surgical mitral valve replacement (MVR), including them in the histology-group. By echocardiography, the thickness of the anterior and posterior leaflet was more extensive in moderate to severe IMR, P < 0.001. Histology-group: patients were divided into two groups based on the median thickness: those with cusp thickness <0.42 cm in Group 1, and ≥0.42 cm in Group 2. The thickness of the base and cusp was more significant in Group 2, P < 0.05 in both. Group 2 biopsies were characterized by involvement of the three leaflet segments, myxoid tissue, and fibrosis deposition. Thicker leaflets were associated with a greater degree of mitral regurgitation (MR), P < 0.0001. In the echo-group, a median leaflet thickness of 3.5 mm of the anterior and posterior MV was independently associated with moderate to severe ischaemic MR [odds ratio (OR) 2.88, P < 0.01] and (OR 10.8, P < 0.001), respectively. In ischaemic MR, the thicker the cusps, the worse the MR. Leaflet thickening was due to the myxoid and fibrosis deposition and was detected by echocardiography. Therefore, this method can be helpful in the evaluation of valve remodelling.

Outcomes of Coronary Artery Disease Patients with Severe Left Ventricular Dysfunction Undergoing Surgical Management.

Surgical revascularization by coronary artery bypass grafting (CABG) is the gold standard treatment for coronary artery disease. But, in patients with severe left ventricular dysfunction (ischemic cardiomyopathy), the result of CABG is different from those with normal left ventricular function. The coronary artery disease pattern in the Indian subconti-nent is different from the western world, due to the diffuse nature of coronary involvement, the smaller size of native vessels, increased prevalence of diabetes mellitus and other risk factors, and more prevalence of severe left ventricular dysfunction. Most of the studies regarding the surgical outcomes in ischemic cardiomyopathy come from western countries. This study attempts to assess the outcomes of surgical management of ischemic cardiomyopathy in the Indian subcontinent. A single-center retrospective cohort study was conducted at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. The data of CAD pa-tients, who underwent surgical coronary revascularization for severe LV dysfunction from January 2010 to December 2014, were collected from the hospital records and through tele-phonic interviews in a structured study proforma. A total of 146 patients satisfied the criteria and were followed up for a period of 5 years. The mean age of the study population was 55.6 (8.8) years. Male preponderance was observed (94.52%; N = 138). CABG alone was done in 62.3% (N = 91) of the study partici-pants. CABG with linear plication was done in 23.3% (N = 34), CABG with MV repair in 7.5% (N = 11), and CABG with DORS in 6.8% (N = 10). The majority of patients (N = 54, 37%) received 4 grafts. Thirty-day mortality observed in the study population was 11 (7.5%). The causes documented were cardiac causes in 9 (82%), cerebrovascular events in one (9%), and septicemia in one (9%). The mean of 5-year survival of the study population was 94.2 (3.5) months with 95% CI 87.32, 101.13. There was a substantial improvement in the degree of mitral regurgitation. Ejection fraction (EF) also showed improvement. The mean preoperative EF was 29.51 (4.84%) and that of post-op was 39.92 (9.0%). Despite the challenges of diffusely diseased coronary arteries, severe LV dysfunction, addressing associated significant MR and ventricular aneurysms, the outcome of surgical management of CAD with severe LV dysfunction, in the Indian population can be done with acceptable results. Randomized control studies in this subset can provide more solid evidence in this regard.

Impact of severe mitral annular calcification on mitral regurgitation after transcatheter aortic valve implantation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who are at intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequent in patients with aortic stenosis, and its presence is associated with increased cardiovascular morbidity and mortality. Not infrequently, it is associated with significant morphologic and functional abnormalities of the mitral valve apparatus. Purpose The aim of this work is to evaluate the relationship between severe MAC and the presence and development of significant mitral regurgitation after TAVI. Methods We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019. Clinical, echocardiographic and procedure-related data were collected until a follow-up of 6 months. Statistical analysis was conducted on IBM SPSS® Statistics software. Descriptive statistics were calculated for all variables. Sample T-test, Chi-square and Wilcoxon sign test were used. A p-value &amp;lt; 0.05 was considered significant. The presence and severity of MAC was defined according to echocardiographic data. Severe MAC was defined by the presence of calcification of more than half of the mitral annular circumference. Results A total of 343 patients were enrolled in the study. The mean age of the population was 80 ± 8 years, 45% were male. Mean functional area was 0.75 ± 0.18 cm2, mean transvalvular pressure gradient was 48 ± 15 mmHg and the mean left ventricular ejection fraction (LVEF) was 54 ± 14%. MAC was detected in 231 (67%) patients. In 44 (19%) of these patients, MAC was graded as severe. Patients with severe MAC tended to have higher prevalence of moderate (27.3 vs 20.4%, p = 0.30) as well as severe (4.5 vs 1.8%, p = 0.24) mitral regurgitation at baseline. After TAVI, the prevalence of moderate mitral regurgitation at 6 months was similar between both groups (22.5 vs 20.4%, p = 0.76). Although not reaching statistical significance, patients with severe MAC had higher prevalence of severe mitral regurgitation at 6 months post-procedure (12.2 VS 5.0%, p = 0.07) as well as higher incidence of worsening of mitral regurgitation (34.2 vs 23.7%, p = 0.16). The proportion of patients that had improvement (13.2 vs 15.0%, p = 0.76) or no change (52.6 vs 61.3%, p = 0.31) in the degree of mitral regurgitation was similar in both groups. Conclusion The presence of severe MAC at baseline echocardiography in patients undergoing TAVI may be associated with worsening of mitral regurgitation after the procedure. These patients tend to have higher prevalence of severe mitral regurgitation post-TAVI. Further studies are needed in order to further elucidate this association.

Abstract 10270: Association Between Hypertension and Aortic Stenosis Mortality in a Large Unselected Hospital Population

Introduction: Hypertension (HTN) is common for patients with AS. However, whether it is a sign of a healthy ventricle and therefore a good prognostic sign, or a risk factor remains unclear. We sought to evaluate the effect of HTN on survival in AS patients at a large referral center. Methods: Echocardiograms conducted at Tufts Medical Center (Boston, MA) were screened and parameters were extracted from a central database. NLP was used on unstructured clinical visit notes to fill in missing data. AS severity was defined as [mild (Vmax: 2.5- 2.9 m/s, MG: 10-20 mmHg, AVA: &gt; 1.5 cm2), moderate (Vmax: 3.0-3.9, MG: 20-40, AVA: 1.0-1.5) or severe (Vmax: &gt; 4.0, MG: &gt; 40, AVA: &lt; 1.0)]. Cox proportional hazard regression models assessed the association between hypertension stage [Normotensive: SBP &lt; 120 mmHg, Elevated: SBP 120-129 mmHg, Stage 1: 130-139 mmHg, Stage 2: &gt; 140 mmHg] taken at the time of the echocardiographic exam and death. Models were adjusted for age, sex, ejection fraction, BMI, and degree of mitral regurgitation. The last echocardiographic time point prior to death or being censored alive was used for modeling. Results: Of the 160,491 echocardiographic exams performed between 2006-2021 2,699 had mild AS or greater. Patients were followed for a median of 533 days for mild (N = 319), 593 days for moderate (N = 1070), and 76 days for severe (N = 1310). Overall mortality was lowest for moderate and severe AS (log-rank test: P &lt; 0.001). HTN was associated with decreased mortality relative to a normotensive state at moderate (HR: Elevated 0.67 CI: 0.35-1.26, Stage 1 0.35 CI: 0.19-0.63, Stage 2 0.52 CI: 0.31-0.87) and severe stenosis (HR: Elevated 0.64 CI: 0.25-1.59, Stage 1 0.29 CI: 0.12-0.66, Stage 2 0.42 CI: 0.22-0.81). Conclusions: Contrary to other cardiovascular diseases HTN was associated with decreased mortality for this large cohort with significant AS. This observation raises questions about whether traditional HTN treatment targets are appropriate for patients with AS.

Sacubitril/Valsartan in heart failure with reduced ejection fraction: clinical and echocardiographic insights from a real world population

Abstract Background Following the PARADIGM trial, some studies have identified cardiac remodeling as major background for hard end point benefits of Sacubitril/Valsartan (S/V), but few adopted a well described definition in the literature. Purpose We aimed at a comprehensive evaluation of the effects of S/V on echo-derived measures of cardiac remodeling along with clinical and laboratory data over a medium-term follow-up pointing to a real-world HFrEF population. Methods This is a prospective observational study of HFrEF patients on optimal medical therapy (OMT) initiated with S/V at Heart Failure Clinic of our institute (January 2017-January 2020). In 62 HFrEF, echocardiographic, laboratory and clinical data were collected at baseline and over 10 (Q1-Q3 8–13) months after S/V initiation. Mean age was 68±12 years, 79% men. Left ventricular reverse remodeling (LVRR) was defined as: 1) an absolute increase in LVEF ≥10 points or a LVEF ≥50% at follow-up and 2) a relative decrease in indexed left ventricular end-diastolic diameter of at least 10% or an indexed left ventricular end-diastolic diameter ≤33 mm/m2. Results Compared to baseline, S/V promoted a significant improvement of LV ejection fraction (LVEF, from 30% to 37%; p&amp;lt;0,0001) with an absolute median increase in LVEF of 8 points. Parallel significant reductions in left ventricular and atrial volumes, lower mitral regurgitation degree and a better diastolic dysfunction along with clinical improvement (NYHA class and NT-proBNP values) were observed at follow up. sPAP (systolic Pulmonary Arterial Pressure) was significantly decreased at follow-up evaluation (37 mmHg vs 31 mmHg p=0,005) (Table 1). Overall, LVRR as defined above was observed in 30% of patients. Younger age (64 vs 74 years, p=0,007), a shorter duration of the disease (7 vs 23 months, p=0,009), and non ischaemic etiology (79% vs 33% p=0,003), along with a smaller baseline LAESVi (Left Atrial End Systolic Volume, 41 vs 48 ml/m2 p=0,012) were more common in patients with LVRR. sPAP and Right Ventricular (RV) function estimated by tricuspid annular plane systolic excursion (TAPSE) were significantly better in LVRR patients along with TAPSE/sPAP ratio (Table 2). Conclusions Our data point to a remarkable medium-term reverse remodeling effect by S/V in HFrEF. Findings reinforce the concept that the main benefits of S/V on hard end-points are mediated by its cardiac-related effects. Both a left and right reverse remodeling occur in HFrEF patients who start S/V in the most adaptable phase of the disease supporting an early administration. Funding Acknowledgement Type of funding sources: None.

Experience of using intra-aortic balloon counterpulsation during coronary bypass surgery and coronary stenting in patients with reduced left ventricular ejection fraction and mitral regurgitation of ischemic genesis

AIM: To analyze the changes in the degree of mitral regurgitation (MR) of ischemic origin and of clinical outcomes in patients with reduced left ventricular ejection fraction (LVEF) and multi-vascular coronary artery disease during use of intra-aortic balloon counterpulsation (IABC).&#x0D; MATERIALS AND METHODS: The results of the treatment of 186 patients with ischemic mitral insufficiency who underwent intra-aortic balloon counterpulsation as a preoperative preparation in connection with a low LVEF were outlined in this manuscript. The patients were divided into 2 groups. Group 1 included 132 patients who underwent coronary bypass surgery while Group 2 included 54 patients who underwent coronary artery stenting. The dynamics of MR and LVEF before and after left ventricular revascularization were studied on the basis of echocardiographic data.&#x0D; RESULTS: In group 1, there was a decrease in the degree of mitral regurgitation by 58% using IABC (p 0.05) in the early postoperative period (based on the measurement of vena contracta, v.c., the width of the regurgitation jet on the valve), and by 54% (p 0.05) in more than 6 months following surgical treatment. In group 2, there was a significant decrease in the degree of MR (based on v.c.) by 42% (p 0.05) in the early postoperative period and by 41% (p 0.05) in more than 6 months following surgical treatment.&#x0D; CONCLUSION: The use of intra-aortic balloon counterpulsation in patients with low LVEF, moderate and severe MI, and with significant coronary artery pathology, led to the reduction in the duration of surgical treatment and the time of using artificial blood circulation through by excluding the need for the correction of MI, both directly during surgical revascularization and in the long-term period (more than 6 months).

Earlysurgical treatment of acu te coronary syndrome in patients with ST -segm ent elevation (at &lt; h24), arrhy thm iccomp lications and severe mitral regu rgitation

Treatment outcomes of acute coronary syndrome in 108 patients with ST-segment elevation (after more than 24 hours) complicated by arrhythmias (atrial fibrillation and atrial flutter) and subsequently developed severe (degrees 2 and 3) mitral insufficiency were analyzed. We elaborated an algorithm for the sequence of interventions. All the patients had coronary angiography and stenting of the symptom-dependent artery during the first 2 days after the admission. Depending on the localization of the left ventricular myocardial infarction zone, the patients were divided into 3 groups: 68 (63%) patients with anterior wall and apex infarction; 23 (21.3%) patients with posterior wall infarction; 17 (15.7%) patients with lower wall infarction. It was revealed that patients, who had undergone revascularization in the early stages, had a statistically significant increase in the main indicators of myocardial contractility, in contrast to patients receiving only conservative therapy. In the observation group, sinus rhythm was restored in all patients 1–4 days after hospitalization. 12 patients underwent emergency electrical cardioversion on the day of admission. In 31 patients, sinus rhythm was restored within the first 24 hours during therapy prior to revascularization. In 39 patients, sinus rhythm was restored during therapy on days 3–5 after primary revascularization. In 26 patients, sinus rhythm was restored 2–4 days after complete revascularization. Based on the study, several conclusions can be drawn: in conditions of heart failure, revascularization is best to perform at the earliest possible stage. The optimal values of vital functions for performing revascularization can be considered: systolic blood pressure ≥ 80 mm Hg; heart rate ≤ 110 beats per minute. In primary surgical treatment, it is most optimal to revascularize only the symptom-dependent artery. Reintervention for complete revascularization is most effective and safe 10–14 days after the initial intervention. The use of emergency electrical cardioversion in those patients in the preoperative period is fully justified, despite the existing risks. Application of our algorithm helps to restore sinus rhythm, reduce the degree of mitral regurgitation and reduce mortality.

Mitral regurgitation severity at left ventricular assist device implantation is associated with distinct myocardial transcriptomic signatures

ObjectivesWe examined for differences in pre–left ventricular assist device (LVAD) implantation myocardial transcriptome signatures among patients with different degrees of mitral regurgitation (MR). MethodsBetween January 2018 and October 2019, we collected left ventricular (LV) cores during durable LVAD implantation (n = 72). A retrospective chart review was performed. Total RNA was isolated from LV cores and used to construct cDNA sequence libraries. The libraries were sequenced with the NovaSeq system, and data were quantified using Kallisto. Gene Set Enrichment Analysis (GSEA) and Gene Ontology analyses were performed, with a false discovery rate <0.05 considered significant. ResultsComparing patients with preoperative mild or less MR (n = 30) and those with moderate-severe MR (n = 42), the moderate-severe MR group weighted less (P = .004) and had more tricuspid valve repairs (P = .043), without differences in demographics or comorbidities. We then compared both groups with a group of human donor hearts without heart failure (n = 8). Compared with the donor hearts, there were 3985 differentially expressed genes (DEGs) for mild or less MR and 4587 DEGs for moderate-severe MR. Specifically altered genes included 448 DEGs for specific for mild or less MR and 1050 DEGs for moderate-severe MR. On GSEA, common regulated genes showed increased immune gene expression and reduced expression of contraction and energetic genes. Of the 1050 genes specific for moderate-severe MR, there were additional up-regulated genes related to inflammation and reduced expression of genes related to cellular proliferation. ConclusionsPatients undergoing durable LVAD implantation with moderate-severe MR had increased activation of genes related to inflammation and reduction of cellular proliferation genes. This may have important implications for myocardial recovery.

Real-World Outcomes of Revascularization Strategies in Patients With Left Ventricular Dysfunction and Three-Vessel Coronary Disease Stratified by Mitral Regurgitation.

Aims: Limited information exists regarding optimal revascularization options for patients with triple-vessel coronary artery disease (TVD), heart failure (HF), and different degrees of mitral regurgitation (MR). Thus, we aimed to compare the effect of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) surgery in the indicated patients.Methods and Results: In the real-world prospective study, 1190 patients with multi-vessel disease and decreased left ventricular systolic function but without severe MR, who underwent PCI or CABG, were enrolled and followed-up for 4.7 ± 1.8 years. The primary endpoint was a composite of cardiovascular death and HF hospitalization. Secondary endpoints were the individual components of the primary outcome. Risk of the primary endpoint was higher in the PCI than in the CABG group (HR = 1.38, 95%CI: 1.14–1.67, and P < 0.01), particularly in patients with moderate MR (HR = 1.85, 95%CI: 1.35–2.55, and P < 0.01). In patients with no-mild MR, the risk of the primary endpoint did not differ significantly between PCI and CABG (P = 0.09). Treatment with PCI was associated with an increased risk for cardiovascular death and HF hospitalization in the moderate MR cohort, while PCI was comparable to CABG in the no-mild MR cohort.Conclusions: In this real-world study, for patients with HF and TVD, CABG was related to lower adverse outcome rates compared to PCI. Assessment of MR can aid in selecting optimal revascularization therapies and in risk stratification.

Ecoestresse Físico na Cardiomiopatia Hipertrófica: Como, Quando e Por Quê?

Historically, the role of exercise stress echocardiography in the management of hypertrophic cardiomyopathy has been neglected in clinical practice according to the analysis of the 2002 Guidelines of the American College of Cardiology/ American Heart Association, which recommended caution use of this methodology in patients with hypertrophic cardiomyopathy due to the risk of both cardiac arrhythmia and hemodynamic collapse on exertion. Exercise stress testing in patients with hypertrophic cardiomyopathy is currently part of the routine assessment of symptomatic patients with or without a resting left ventricular outflow tract gradient &lt; 50 mmHg. For this group, it is a safe and reliable method for measuring the left ventricular outflow tract gradient during exertion and a solid differentiator of patients with nonobstructive hypertrophic cardiomyopathy (absent gradient, both at rest and on exertion) from those with labile gradients (absent gradient at rest and present on exertion). Therefore, in the assessment of hypertrophic cardiomyopathy, exercise stress is equally useful for quantifying the degree of mitral regurgitation and left ventricular segmental contractility changes as well as assessing left ventricular diastolic function on exertion and is able to predict the future development of heart failure symptoms. The method is also important for determining different treatment strategies for each patient, from surgical myomectomy or alcohol septal ablation for those with a labile gradient, limiting symptoms, and who refractory to drug treatment to heart transplantation for those without a gradient.

The impact of mild ischemic mitral regurgitation in the occurrence of congestive heart failure

Ischemic mitral regurgitation (IMR) is a common complication of myocardial infarction, leading to left ventricular (LV) dysfunction and remodeling. Its presence is associated with an increased risk for death and heart failure. The aim of this study was to evaluate the impact of a mild degree (effective regurgitant orifice area < 20 mm 2 ) of IMR on heart failure (HF). This is a retrospective, study including 210 patients who had been hospitalized in a cardiology intensive care unit for myocardial infarction from September 2018 to March 2020, 36 patients with mild IMR were compared to 40 patients without IMR (controls), measuring LV volumes, ejection-fraction, and the degree of mitral regurgitation and incidence of HF events. The main age was 59.3 ± 7.02 sex ratio: 2.86 (74.1% male, 25.9% female) 32.3% of patients had de novo heart failure of which 29.2% with mild IMR. Patients with IMR had a significantly higher incidence of HF than controls (72% vs. 34%, P = 0.001), a significant increase in LV end-diastolic and end-systolic volumes, ( P = 0.004) and lower ejection-fractions ( P = 0.0002). The culprit artery was left anterior descending artery in 54.4%. The presence of IMR, even mild in degree, has an impact on the progression of the post-infarction ventricular dysfunction and a higher rate of HF.