Indexed Left Ventricular End-systolic Dimension Research Articles

Clinical journey for patients with aortic regurgitation: A retrospective observational study from a multicenter database.

Data using real-world assessments of aortic regurgitation (AR) severity to identify rates of Heart Valve Team evaluation and aortic valve replacement (AVR), as well as mortality among untreated patients, are lacking. The present study assessed these trends in care and outcomes for real-world patients with documented AR. Using a deidentified data set (January 2018-March 2023) representing 1,002,853 patients >18 years of age from 25 US institutions participating in the egnite Database (egnite, Inc.) with appropriate permissions, patients were classified by AR severity in echocardiographic reports. Rates of evaluation by the Heart Valve Team, AVR, and all-cause mortality without AVR were examined using Kaplan-Meier estimates and compared using the log-rank test. Within the data set, 845,113 patients had AR severity documented. For moderate-to-severe or severe AR, respectively, 2-year rates (95% confidence interval) of evaluation by the Heart Valve Team (43.5% [41.7%-45.3%] and 65.4% [63.3%-67.4%]) and AVR (19.4% [17.6%-21.1%] and 46.5% [44.2%-48.8%]) were low. Mortality at 2 years without AVR increased with greater AR severity, up to 20.7% for severe AR (p < 0.001). In exploratory analyses, 2-year mortality for untreated patients with left ventricular end-systolic dimension index > 25 mm/m2 was similar for moderate (34.3% [29.2%-39.1%]) and severe (37.2% [24.9%-47.5%]) AR. Moderate or greater AR is associated with poor clinical outcomes among untreated patients at 2 years. Rates of Heart Valve Team evaluation and AVR were low for those with moderate or greater AR, suggesting that earlier referral to the Heart Valve Team could be beneficial.

Automated Global Longitudinal Strain Exhibits a Robust Association with Death in Asymptomatic Chronic Aortic Regurgitation

Whether automated left ventricular global longitudinal strain (LVGLS) is associated with outcomes in patients with asymptomatic aortic regurgitation (AR) is unknown. The aim of this study was to explore the impact of automated LVGLS on survival and compare it with conventional left ventricular (LV) parameters in patients with chronic asymptomatic AR. LVGLS (presented as an absolute value) was measured using fully automated two-dimensional strain software in consecutive patients with isolated chronic moderate to severe or greater AR between 2004 and 2020; the incremental value of LVGLS was assessed. Limited correction of endocardial border tracking was performed if needed. Of 550 asymptomatic patients (mean age, 60±17years; 86% men), average LVGLS was 17±3% (first and second tertiles, 15.8% and 18.5%). In 16% of cases, tracking border was partially corrected; average time for analysis was 25±5sec. At a median of 4.8years (interquartile range, 1.5-9.9years), 87 patients had died (19 died after aortic valve surgery). Separate multivariable models adjusted for age, sex, Charlson index, AR severity, and time-dependent aortic valve surgery demonstrated that LV ejection fraction (hazard ratio [HR] per 10%, 0.9), LV end-systolic volume index (LVESVi; HR per 5mL/m2, 1.08) and LVGLS (HR per unit, 0.87) were independently associated with death (P≤.018 for all); however, LVGLS remained statistically significant (HR: 0.86-0.9; P≤.007) when compared head-to-head with LV ejection fraction, LVESVi, and LV end-systolic dimension index. The association of LVGLS and mortality was consistent across all subgroups (P for interaction ≥ .08 for all). Spline curves showed that continuous risk for death rose at LVGLS < 15%. Those with LVGLS < 15% had a 2.6-fold risk for death (95% CI, 1.54-4.23) while those with LVGLS < 15% plus LVESVi ≥ 45mL/m2 had 3.96-fold risk (95% CI, 1.94-8.03). In this large cohort of asymptomatic patients with moderate to severe or greater AR, automated LVGLS was feasible, efficient, and independently associated with death in head-to-head comparisons with conventional LV ejection fraction, LV end-systolic dimension index, and LVESVi. An automated LVGLS threshold of <15% alone or combined with LVESVi ≥ 45mL/m2 was significantly associated with increased mortality riskand may be considered in early surgery decision-making.

The left ventricular remodeling assessment by cardiac magnetic resonance in chronic aortic regurgitation; implications for outcome

Abstract Background Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload resulting in progressive LV remodeling, which negatively affect clinical outcome. Clinical Guidelines recommend assessment of LV remodeling by echocardiography, but little is known about comparative remodeling quantification by cardiac magnetic resonance (CMR) and association with outcomes. Purpose To assess LV remodeling in AR by CMR, compared with echocardiographic measures and determine its impact on clinical outcome. Methods Patients with native, ≥moderate, chronic AR by echocardiography who underwent CMR exam within 90 days of diagnosis from January 2012 to February 2020 were enrolled. The endpoint was a composite of death, heart failure hospitalization, and heart failure symptom exacerbation during follow-up. Results The 178 patients included had median age (IQR) of 58 years (44–69), and most (88%, n=158) presented with no or minimal symptoms (NYHA class I/II). At diagnosis symptomatic vs. no/minimal symptoms patients presented with much more advanced LV remodeling by CMR (EDVI 133 [83–151] vs. 96 [80–123] p=0.024, ESVI 66 [46–85] vs. 42 [30–58], P=0.001) while echocardiography showed limited differences (EDVI 76 [57–93] vs. 65 [54–87] p=0.507, ESVI 38 [30–58] vs. 27 [20–42], p=0.072). During follow-up (3.3 years [1.6–5.8]), aortic valve replacement (AVR) was performed in 49 patients. In patients with no/minimal symptoms, the composite endpoint occurred in 54 (34%) patients including eight deaths and 30 heart failure hospitalizations. Patients with LV end-systolic volume index (LVESVi) &amp;gt;45 ml/m2 by CMR had higher likelihood for composite endpoint (Panel A) confirmed in multivariate models, adjusting for age, sex, AVR (time-dependent), EuroSCORE2, and LV End-systolic-dimension-index (LVESDi) &amp;gt;25 mm/2, with adjusted hazard ratio 1.84 [1.02–3.33], p&amp;lt;0.044 (Panel B). LVESVi by CMR was at least as powerful in determining clinical outcomes as guideline-recommended Doppler-Echocardiographic variables. Conclusion Assessment of LV remodeling by CMR in patients with clinically significant AR is feasible in routine clinical practice, detects with high sensitivity LV remodeling associated with development of HF symptoms and is independently predictive of clinical outcome. Hence, CMR provides a powerful tool for evaluation and risk stratification of patients with AR. Funding Acknowledgement Type of funding sources: None. Panel APanel B

Sex Differences in Outcomes of Patients With Chronic Aortic Regurgitation: Closing the Mortality Gap

ObjectiveTo examine contemporary clinical differences between men and women with hemodynamically significant chronic aortic regurgitation (AR). Patients and MethodsWe retrospectively identified 1072 consecutive patients with moderate to severe or severe AR diagnosed between February 21, 2004, and April 29, 2019. Echocardiographic data, aortic valve surgical intervention (AVS), and all-cause death were analyzed. ResultsAt baseline, the 189 women in the study group were older than the 883 men (mean ± SD age, 64±18 years vs 58±17 years), had more advanced symptoms, and had larger left ventricular end-systolic dimension index (LVESDi) (all P<.001) despite similar AR severity. An LVESDi of greater than 20 mm/m2 was noted in 60 of 92 asymptomatic women (65%) vs 225 of 559 asymptomatic men (40%) (P<.001). Median follow-up was 5.6 years (interquartile range, 2.5 to 10.0 years). Female sex was associated with less AVS (P=.009), and overall 10-year survival was better in men (76%±2%) than in women (64%±5%) (P=.004). However, 10-year post-AVS survival was similar between the sexes (P=.86), and women had better left ventricular reverse remodeling than men regarding end-diastolic dimension (P=.02). Multivariable independent predictors of death were age, advanced symptoms, LVESDi, ejection fraction, and AVS (all P≤.03) but not female sex. When compared with the age-matched US population, women exhibited a 1.3-fold increased relative risk of death (P=.0383) while men had similar survival (P=.11). ConclusionIn contemporary practice, women with AR continue to exhibit an overall survival penalty not related to female sex but to late referral markers, including more advanced symptoms, larger LVESDi, and less AVS. Nonetheless, women in our study exhibited outstanding post-AVS left ventricular remodeling and had good post-AVS survival, a step forward toward closing the sex-related mortality gap. The high percentage of LVESDi of 20 mm/m2 or greater in asymptomatic women represents a window of opportunity for advanced-symptom prevention and timely AR surgical correction that may close the mortality gap.

Reverse remodelling after aortic valve replacement for chronic aortic regurgitation.

This study aimed to assess the long-term outcomes and investigate the factors related to left ventricular (LV) reverse remodelling after aortic valve replacement (AVR) in patients with chronic aortic regurgitation (AR). A total of 246 patients who underwent AVR for chronic AR at our institution were included in this retrospective study. Primary end-points included all-cause mortality, cardiac mortality and major adverse cerebral and cardiovascular events. Secondary end-points included cardiac function on echocardiography 1 year after surgery. We explored the predictive factors for reverse remodelling 1 year after surgery. The 10-year survival rate was 86.0%, with no cardiac deaths in 93.8% and no major adverse cerebral and cardiovascular events in 79.9% of patients. Postoperative LV function and symptoms were significantly improved 1 year after surgery, but 34 patients (13.8%) did not recover normal function and structure. A significant negative correlation was found between the incidence of cardiac death and major adverse cerebral and cardiovascular events and reverse remodelling. Multivariate logistic regression identified preoperative LV ejection fraction (P = 0.001, odds ratio = 1.057) and LV end-systolic dimension index (P = 0.038, odds ratio = 0.912) as significant predictive factors of reverse remodelling 1 year after surgery. Preoperative LV ejection fraction and LV end-systolic dimension index were predictive factors for reverse remodelling after surgery, which was associated with late outcomes. Earlier surgery may thus help to restore normal LV function and achieve better late outcomes after AVR for AR.

Preoperative left ventricular end-systolic dimension predicts occurrence of aortic insufficiency following aortic valve preservation and repair surgery

BackgroundPreoperative left ventricular (LV) end-systolic dimension (LVESD) ≥5.0 cm is a class IIa indication for surgical intervention for aortic insufficiency (AI); however, the effect of LV dilatation on the longevity of the aortic valve (AV) has not yet been investigated. This study aimed to assess the impact of preoperative LV dimension on the long-term outcome of AV preservation surgery. MethodsBetween 2009 and 2019, 256 patients underwent AV preservation surgery at a single center. The median duration of follow-up was 5 years. The primary outcome was the development of >1+ AI at 6 years; secondary outcomes include long-term mortality, freedom from >2+ AI, and freedom from AV reoperation. Cox proportional hazard analysis was performed to identify predictors of AV deterioration. ResultsIn-hospital mortality was 0.8%, and mean survival at 8 years was 85.5 ± 3.4%. Mean freedom from >1+ AI at 6 years was 71.1 ± 3.4%. Patients with preoperative indexed LVESD (LVESDi) ≥2.0 cm/m2 were at greater risk of developing >1+ AI at 6 years compared with patients with preoperative LVESDi of 1.5 to 1.9 cm/m2 and ≤1.4 cm/m2 (50.3 ± 0.1% vs 80.9 ± 0.1% vs 92.2 ± 0.1%, respectively; P < .01). On risk-adjusted multivariable analysis, preoperative LVESDi was an independent predictor for recurrence of >1+ AI (hazard ratio, 2.2; 95% confidence interval, 1.5-3.4). ConclusionsPreoperative LVESDi ≥2 cm/m2 is associated with increased risk of recurrent >1+ AI following AV preservation surgery. Further investigation of the appropriate operative threshold for AI may be warranted.

Association of Left Ventricular Volume in Predicting Clinical Outcomes in Patients with Aortic Regurgitation

Aortic regurgitation (AR) is a common valvular lesion associated with increased mortality once the left ventricle enlarges significantly or develops systolic dysfunction (ejection fraction<50%). Valve guidelines recommend aortic valve repair or replacement (AVR) for left ventricular (LV) linear end-systolic dimension≥50mm or end-diastolic dimension≥65mm. However, chamber quantification guidelines recommend using LV volume for LV size determination because linear measurements may not accurately reflect LV remodeling. The aim of this study was to evaluate the correlation of LV volumes with linear dimensions, interobserver variability in the estimation of volumes, and the association of volumes with outcomes in patients with AR. A total of 1,100 consecutive patients with chronic moderate to severe and severe AR on echocardiography between 2004 and 2019 were retrospectively analyzed. The modified Simpson disk summation method was used for LV volume estimation. The primary outcome was all-cause mortality; the secondary outcome was mortality censored at AVR. Patients' age was 60±17years, and 198 were women (18%). Volumes were measured using the biplane method in 939 patients (85%) and the monoplane method in 161 (15%); end-systolic volume was normal in 169 (11%). Correlations between volumes and linear dimensions were 0.5 for end-diastolic volume and 0.6 for end-systolic volume. At median follow-up of 5.4years (interquartile range, 2.4-10.0years), 216 patients had died and 539 had undergone AVR. Indexed LV end-systolic volume (iLVESV) and indexed left ventricular end-systolic dimension were both associated with mortality and symptoms, but the association of iLVESV was stronger. iLVESV, age, male gender, Charlson comorbidity index, New York Heart Association functional class III or IV, and time-dependent AVR were independently associated with all-cause mortality. Interobserver variability in the estimation of LV volumes in 200 patients included intraclass coefficients of 0.94 (95% CI, 0.92-0.95) for end-diastolic volume and 0.88 (95% CI, 0.78-0.93) for end-systolic volume. Patients with iLVESV ≥ 45mL/m2 had lower survival and a higher prevalence of symptoms than those with volumes < 45mL/m2. Echocardiographic LV volume assessment had good reproducibility in patients with moderate to severe and severe AR. The correlation between linear dimensions and volumes was limited. Both iLVESV and indexed left ventricular end-systolic dimension were associated with worse outcomes, but the association of iLVESV was stronger. iLVESV ≥ 45mL/m2 was associated with worse outcomes.

Age-Related Development of Cardiac Remodeling and Dysfunction in Young Black and White Adults: The Coronary Artery Risk Development in Young Adults Study

Little is known about the timing of preclinical heart failure (HF) development, particularly among blacks. The primary aims of this study were to delineate age-related left ventricular (LV) structure and function evolution in a biracial cohort and to test the hypothesis that young-adult LV parameters within normative ranges would be associated with incident stage B-defining LV abnormalities over 25years, independent of cumulative risk factor burden. Data from the Coronary Artery Risk Development in Young Adults study were analyzed. Participants (n=2,833) had a mean baseline age of 30.1years; 45% were black, and 56% were women. Generalized estimating equation logistic regression was used to estimate age-related probabilities of stage B LV abnormalities (remodeling, hypertrophy, or dysfunction) and logistic regression to examine risk factor-adjusted associations between baseline LV parameters and incident abnormalities. Cox regression was used to assess whether baseline LV parameters associated with incident stage B LV abnormalities were also associated with incident clinical (stage C/D) HF events over >25years' follow-up. Probabilities of stage B LV abnormalities at ages 25 and 60years were 10.5% (95% CI, 9.4%-11.8%) and 45.0% (95% CI, 42.0%-48.1%), with significant race-sex disparities (e.g., at age 60, black men 52.7% [95% CI, 44.9%-60.3%], black women 59.4% [95% CI, 53.6%-65.0%], white men 39.1% [95% CI, 33.4%-45.0%], and white women 39.1% [95% CI, 33.9%-44.6%]). Over 25years, baseline LV end-systolic dimension indexed to height was associated with incident systolic dysfunction (adjusted odds ratio per 1 SD higher, 2.56; 95% CI, 1.87-3.52), eccentric hypertrophy (1.34; 95% CI, 1.02-1.75), concentric hypertrophy (0.69; 95% CI, 0.51-0.91), and concentric remodeling (0.68; 95% CI, 0.58-0.79); baseline LV mass indexed to height2.7 was associated with incident eccentric hypertrophy (1.70; 95% CI, 1.25-2.32]), concentric hypertrophy (1.63; 95% CI, 1.19-2.24), and diastolic dysfunction (1.24; 95% CI, 1.01-1.52). Among the entire cohort with baseline echocardiographic data available (n=4,097; 72 HF events), LV end-systolic dimension indexed to height and LV mass indexed to height2.7 were significantly associated with incident clinical HF (adjusted hazard ratios per 1 SD higher, 1.56 [95% CI, 1.26-1.93] and 1.42 [95% CI, 1.14-1.75], respectively). Stage B LV abnormalities and related racial disparities were present in young adulthood, increased with age, and were associated with baseline variation in indexed LV end-systolic dimension and mass. Baseline indexed LV end-systolic dimension and mass were also associated with incident clinical HF. Efforts to prevent the LV abnormalities underlying clinical HF should start from a young age.

Association of Echocardiographic Left Ventricular End-Systolic Volume and Volume-Derived Ejection Fraction With Outcome in Asymptomatic Chronic Aortic Regurgitation

Volumetric measurements by transthoracic echocardiogram may better reflect left ventricular (LV) remodeling than conventional linear LV dimensions. However, the association of LV volumes with mortality in patients with chronic hemodynamically significant aortic regurgitation (AR) is unknown. To assess whether LV volumes and volume-derived LV ejection fraction (Vol-LVEF) are determinants of mortality in AR. This cohort study included consecutive asymptomatic patients with chronic moderately severe to severe AR from a tertiary referral center (January 2004 through April 2019). Clinical and echocardiographic data were analyzed retrospectively. Aortic regurgitation severity was graded by comprehensive integrated approach. De novo disk-summation method was used to derive LV volumes and Vol-LVEF. Associations between all-cause mortality under medical surveillance and the following LV indexes: linear LV end-systolic dimension index (LVESDi), linear LVEF, LV end-systolic volume index (LVESVi), and Vol-LVEF. Of 492 asymptomatic patients (mean [SD] age, 60 [17] years; 425 men [86%]), ischemic heart disease prevalence was low (41 [9%]), and 453 (92.1%) had preserved linear LVEF (≥50%) with mean (SD) LVESVi of 41 (15) mL/m2. At a median (interquartile range) of 5.4 (2.5-10.1) years, 66 patients (13.4%) died under medical surveillance; overall survival was not different than the age- and sex-matched general population (P = .55). Separate multivariate models, adjusted for age, sex, Charlson Comorbidity Index, and AR severity, demonstrated that in addition to linear LVEF and LVESDi, LVESVi and Vol-LVEF were independently associated with mortality under surveillance (all P < .046) with similar C statistics (range, 0.83-0.84). Spline curves showed that continuous risks of death started to rise for both linear LVEF and Vol-LVEF less than 60%, LVESVi more than 40 to 45 mL/m2, and LVESDi above 21 to 22 mm/m2. As dichotomized variables, patients with LVESVi more than 45 mL/m2 exhibited increased relative death risk (hazard ratio, 1.93; 95% CI, 1.10-3.38; P = .02) while LVESDi more than 20 mm/m2 did not (P = .32). LVESVi more than 45 mL/m2 showed a decreased survival trend compared with expected population survival. In this large asymptomatic cohort of patients with hemodynamically significant AR, LVESVi and Vol-LVEF worked equally as well as LVESDi and linear LVEF in risk discriminating patients with excess mortality. A LVESVi threshold of 45 mL/m2 or greater was significantly associated with an increased mortality risk.

Contemporary differences between bicuspid and tricuspid aortic valve in chronic aortic regurgitation

ObjectiveTo comprehensively explore contemporary differences between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with chronic haemodynamically significant aortic regurgitation (AR).MethodsConsecutive patients with chronic ≥moderate-severe AR from a...

Left Ventricular End-Systolic Dimension and Outcome in Patients With Heart Failure Undergoing Percutaneous MitraClip Valve Repair for Secondary Mitral Regurgitation

Recent MitraClip heart failure (HF) trials suggest that baseline left ventricular (LV) remodeling may be critical for patient selection. We, therefore, investigated whether baseline LV remodeling affects safety, efficacy, and clinical outcomes in HF patients with symptomatic secondary mitral regurgitation (MR) undergoing percutaneous mitral valve repair using MitraClip. LV remodeling was assessed by LV end-systolic dimension index (LVESDi) on transthoracic baseline echocardiography. Early and late outcome was reported using Mitral Valve Academic Research Consortium-criteria. A total of 107 consecutive HF patients (73 ± 10 years, 70% male) who underwent MitraClip intervention for secondary MR were studied. The study population was stratified by median LVESDi between nonadvanced (<28 mm/m², n = 49) and advanced LV remodeling (≥28 mm/m², n = 58). Both groups had similar acute procedural success, in hospital bleeding and nonbleeding complications and significant improvement in MR severity and symptoms, sustained up to 36 months (all p >0.05). LVESDi, but not LV end-diastolic diameter index nor LV ejection fraction, independently related to HF hospitalization (hazard ratio 1.11, 95% confidence interval 1.05 to 1.16, p <0.001) and mortality (hazard ratio 1.11, 95% confidence interval 1.06 to 1.17, p <0.001). At 1 and 3 years, survival free of HF hospitalization was higher in patients without versus with advanced LV remodeling (89% vs 66% and 65% vs 37%, p = 0.002) and mortality was lower (9% vs 24% and 36% vs 47%, p = 0.074), respectively. Annual HF hospitalization rate only decreased in the nonadvanced LV remodeling group (-43%, p = 0.025). Advanced LV remodeling, assessed by LVESDi, in HF patients who underwent MitraClip therapy does not influence therapeutic safety nor efficacy, but implies increased HF hospitalization and mortality risk. This parameter may be valuable for MitraClip therapy patient selection.

Predictors of Progression in Patients With Stage B Aortic Regurgitation

BackgroundThe natural history of stage B aortic regurgitation (AR) is unknown. ObjectivesThis study sought to examine determinants, rate, and consequences of progression of AR. MethodsConsecutive patients with ≤moderate chronic AR quantified by effective regurgitant orifice area (EROA) and regurgitant volume (RVol) from 2004 to 2017 who had ≥1 subsequent echocardiogram with quantitation were included. ResultsOf 1,077 patients (66 ± 15 years of age), baseline trivial/mild AR was noted in 196 (18%), mild-to-moderate AR in 465 (43%), and moderate AR in 416 (39%); 10-year incidence of progression to ≥moderate-severe AR (stage C/D; progressors) was 12%, 30%, and 53%, respectively. At 4.1-year follow-up (interquartile range: 2.1 to 7.2 years), there were 228 progressors (21%), whose annualized progression rates within 3 years before diagnosis of ≥moderate-severe AR were 4.2 mm2/year for EROA and 9.9 ml/year for RVol. Baseline AR severity and dimensions of sinotubular junction and annulus were associated with progression (all p ≤ 0.007); hypertension and systolic blood pressure were not. Progressors had faster chamber remodeling, functional class decline, and more aortic valve/aortic surgery. At medium-term follow-up, 242 patients (22%) died; poor survival was linked to age, comorbidities, functional class, resting heart rate, and left ventricular (LV) ejection fraction (p ≤ 0.003), not LV end-systolic dimension index. Survival after progression to stage C/D AR was associated with LV end-systolic dimension index (adjusted p = 0.02). ConclusionsProgression from stage B to stage C/D AR was observed in 21% patients. Repeat echocardiography for trivial/mild, mild-to-moderate, and moderate AR at every 5, 3, and 1 years, respectively, was reasonable. EROA, RVol, annulus, and sinotubular junction should be routinely measured to estimate progression rates and identify patients at high risk of progression, which was associated with adverse consequences.

Outcomes in Chronic Hemodynamically Significant Aortic Regurgitation and Limitations of Current Guidelines

BackgroundFew data exist on the contemporary profiles and outcomes of patients with significant aortic regurgitation (AR). ObjectivesThis study sought to assess the benefits of aortic valve repair or replacement (AVR) and the prognostic value of left ventricular (LV) dimensions in significant AR. MethodsFrom 2006 to 2017, consecutive patients with ≥moderate-severe chronic AR without prior heart surgery, myocardial infarction, or overt coronary artery disease were included. ResultsOf 748 participants (58 ± 17 years of age; 82% men), 387 (52%) were medically treated, and 361 (48%) had AVR. Of 361 patients having AVR, 334 (93%) met guideline criteria: Class I indications in 284 (79%) patients, which included symptoms in 236, and Class II indications in 50 (14%). The remaining 27 (7%) opted for surgery without Class I or II indications. At a median follow-up of 4.9 years (interquartile range: 2.3 to 8.3 years), 125 (17%) patients had died. Age, comorbidities, baseline symptoms, and higher LV end-systolic dimension index (LVESDi) were associated with all-cause mortality (all p ≤ 0.01). Compared with patients having LVESDi <20 mm/m2, those with LVESDi 20 to 25 mm/m2 (hazard ratio: 1.53; 95% confidence interval: 1.01 to 2.31) and ≥25 mm/m2 (HR: 2.23; 95% confidence interval: 1.32 to 3.77) had increased risks of death. AVR was associated with better survival (p < 0.0001). Patients with Class I indications for surgery had inferior post-operative survival (p < 0.003). ConclusionsClass I indications for surgery, mainly symptoms, are the most common triggers for AVR. Class II indications were associated with better post-operative outcome and thus merit more attention. LVESDi was the only LV parameter independently associated with all-cause mortality and the ideal cutoff seems to be lower than previously recommended.

Incremental Prognostic Utility of Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Chronic Aortic Regurgitation and Preserved Left Ventricular Ejection Fraction

ObjectivesThis study sought to examine the prognostic utility of left ventricular (LV) global longitudinal strain (GLS) in asymptomatic patients with ≥III+ aortic regurgitation (AR), an indexed LV end-systolic dimension of <2.5 cm/m2, and preserved left ventricular ejection fraction (LVEF). BackgroundManagement of asymptomatic patients with severe chronic AR and preserved LVEF is challenging and is typically based on LV dimensions. MethodsWe studied 1,063 such patients (age 53 ± 16 years; 77% men) seen between 2003 and 2010 (excluding those with symptoms, obstructive coronary artery disease, acute AR/dissection, aortic/mitral stenosis, more than moderate mitral regurgitation, and previous cardiac surgery). Society of Thoracic Surgeons (STS) score was calculated. The primary endpoint was mortality. Average resting LV-GLS was measured offline on 2-, 3-, and 4-chamber views using Velocity Vector Imaging (Siemens, Malvern, Pennsylvania). ResultsMean STS score, LVEF, LV-GLS, and right ventricular systolic pressure were 4.4 ± 5.0%, 57.0 ± 4.0%, −19.5 ± 0.2%, and 31.0 ± 9.0 mm Hg, respectively. In total, 671 patients (63%) underwent aortic valve surgery at a median of 42 days after the initial evaluation. At 6.8 ± 3.0 years, 146 patients (14%) had died. On multivariable Cox survival analysis, LV-GLS (hazard ratio [HR]: 1.11), STS score (HR: 1.51), indexed LV end-systolic dimension (HR: 0.50), right ventricular systolic pressure (HR: 1.33), and aortic valve surgery (HR: 0.35) were associated with longer term mortality (all p < 0.001). Sequential addition of LV-GLS and aortic valve surgery improved the C-statistic for longer term mortality for the clinical model (STS score + right ventricular systolic pressure + indexed LV end-systolic dimension) from 0.61 (95% confidence interval [CI]: 0.51 to 0.72) to 0.67 (95% CI: 0.54 to 0.87) and to 0.77 (95% CI: 0.63 to 0.90), respectively (p < 0.001 for both). A significantly higher proportion (log-rank p = 0.01) of patients with LV-GLS worse than median (−19.5%) died versus those with an LV-GLS better than median (86 of 513 [17%] vs. 60 of 550 [11%]). The risk of death at 5 years significantly increased with an LV-GLS of worse than −19%. ConclusionsIn asymptomatic patients with ≥III+ chronic AR and preserved LVEF, worsening LV-GLS was associated with longer term mortality, providing incremental prognostic value and improved reclassification.

Prognostic Impact of Segmental Wall Motion Abnormality in Patients With Idiopathic Dilated Cardiomyopathy.

The clinical impact of left ventricular (LV) segmental wall motion abnormalities (SWMA) in patients with idiopathic dilated cardiomyopathy (IDCM) has not been well elucidated.Among 100 consecutive IDCM patients with follow-up visits, we enrolled 85 after excluding those with left bundle branch block and/or ventricular pacemaker implantation. LV wall motion was assessed using left ventriculography scored for 7 segments according to the American Heart Association classification as follows: 0, normokinesis; 1, hypokinesis; 2, akinesis; and 3, dyskinesis. SWMA were defined as a score dispersion of more than 1 degree among the segments.SWMA was exhibited by 26 patients. Kaplan-Meier curves demonstrated that the patients with SWMA (SWMA+) had a significantly higher cardiac event-free rate than the patients without SWMA (P < 0.001). Cox proportional hazards analysis showed that SWMA+ was an independent predictor of cardiac events (P = 0.03; hazard ratio = 3.38; 95% confidence interval [CI], 1.11-10.8). Furthermore, multiple regression analysis showed that SWMA+ was an independent predictor of decreased LV end-systolic dimension index after optimal pharmacotherapy (β = -0.24; 95%CI, -9.12 to -0.73; P = 0.02).SWMA is common in patients with IDCM and is independently associated with a poor prognosis and less morphometric and functional improvement of LV in response to pharmacotherapy.

Global and Regional Longitudinal Strains Predict Left Ventricular Dysfunction after Mitral Valve Repair: A Two Dimensional Speckle Tracking Study

Abstract Background: It has been well documented that reduced left ventricular ejection fraction (LVEF) has adverse effect on the outcome of patients with severe mitral regurgitation (MR) after mitral valve repair (MVr). However, the best method for early detection of LV dysfunction in asymptomatic or mildly symptomatic patients with MR still has not been established. Recently two dimensional speckle tracking echocardiography (2DSTE) has been used to identify subclinical alterations of myocardial deformation in many clinical settings. Objectives: Our aim was to assess the value of regional and global LV two dimensional strains to predict postoperative LV dysfunction after MVr. Methods: Twenty six patients with severe MR were evaluated. Patients were divided into two groups according to their postoperative LVEF difference, those with a post-op LVEF reduction of < 10% at 3 months (Group 1), and those with post-op LVEF reduction of  10% at 3 months (Group 2). All data were measured after 3 months follow-up and compared with pre-operative measures. Results: The occurrence of post-operative LV dysfunction was significantly related to left ventricular end-systolic dimension index (LVESDI), NYHA functional class and global longitudinal strain (GLS). A cut-off value of 19% for GLS could predict post-op LV dysfunction with a sensitivity of 89% and specificity of 77%. In addition a cut-off value of - 17.7% for long axis strain with a sensitivity of 78% and specificity of 77% and a cut off value of -20% for 2-chamber strain with a sensitivity of 77% and specificity 83% could predict LV dysfunction after MVr. Conclusions: Among all measured data LV global longitudinal strain seems to be the most sensitive predictor of postoperative LV dysfunction in patients with severe MR and normal LVEF after surgical repair.

Preoperative ejection fraction determines early recovery of left ventricular end-diastolic dimension after aortic valve replacement for chronic severe aortic regurgitation

BackgroundIn patients with chronic severe aortic regurgitation (AR), aortic valve replacement (AVR) has been proved to promote left ventricular (LV) remodeling, especially LV end-diastolic dimension (LVEDD) reduction. However, there is little research whether postoperative LVEDD could return to normal parameter after AVR. The objective of this study was to determine predictors for the recovery of dilated LVEDD early after AVR. MethodsThe echocardiographic data of 105 patients, who underwent AVR for chronic pure AR between January 2005 and December 2011, were analyzed at the preoperative (3–7 d), early (6–8 mo), and late (2-y) postoperative stages, retrospectively. According to the baseline level, LVEDD >70 mm or LV end-systolic dimension (LVESD) >50 mm or LVESD index >25 mm/m2 were defined as severe LV dilation. Patients were then categorized into two groups (group 1: severe LV dilation; group 2: nonsevere LV dilation). ResultsIn all patients, four-fifth of the reduction in LV dimension occurred at early (6–8 mo) postoperative stage. The patients in both groups had significant decreases in the LVEDD and LVESD early after AVR, with an additional but insignificant reduction at late postoperative stage. The ejection fraction (EF) in both groups significantly increased at either early or late stage. However, the LVEDD and LVESD in group 1 were larger than those in group 2, and the EF in group 1 was lower than that in group 2 at early postoperative stage. By multivariate analysis, we found that the preoperative EF was a good predictor for the recovery of dilated LVEDD early after AVR (P = 0.009). Receiver-operating characteristics analysis showed that EF >52% was the best cut-off value for the recovery of LVEDD. ConclusionsIn patients with chronic pure AR, preoperative EF may be a good predictor for successful recovery of dilated LVEDD early after AVR.

Predictors of Long-Term Outcomes in Patients With Significant Myxomatous Mitral Regurgitation Undergoing Exercise Echocardiography

Significant myxomatous mitral regurgitation leads to progressive left ventricular (LV) decline, resulting in congestive heart failure and death. Such patients benefit from mitral valve surgery. Exercise echocardiography aids in risk stratification and helps decide surgical timing. We sought to assess predictors of outcomes in such patients undergoing exercise echocardiography. This is an observational study of 884 consecutive patients (age, 58 ± 14 years; 67% men) with grade III+ or greater myxomatous mitral regurgitation who underwent exercise echocardiography between January 2000 and December 2011 (excluding functional mitral regurgitation, prior valvular surgery, hypertrophic cardiomyopathy, rheumatic valvular disease, or greater than mild mitral stenosis). Clinical and echocardiographic data (mitral regurgitation, LV ejection fraction, LV dimensions, right ventricular systolic pressure) and exercise variables (metabolic equivalents, heart rate recovery at 1 minute after exercise) were recorded. Composite events of death, myocardial infarction, stroke, and progression to congestive heart failure were recorded. Mean LV ejection fraction, indexed LV end-systolic dimension, resting right ventricular systolic pressure, peak stress right ventricular systolic pressure, metabolic equivalents achieved, and heart rate recovery were 58 ± 5%, 1.6 ± 0.4 mm/m(2), 31 ± 12 mm Hg, 46 ± 17 mm Hg, 9.6 ± 3, and 33 ± 14 beats, respectively. During 6.4 ± 4 years of follow-up, there were 87 events. On stepwise multivariable Cox analysis, percent of age/sex-predicted metabolic equivalents (hazard ratio, 0.99; 95% confidence interval, 0.98-0.99; P=0.005), heart rate recovery (hazard ratio, 0.29; 95% confidence interval, 0.17-0.50; P<0.001), resting right ventricular systolic pressure (hazard ratio, 1.03; 95% confidence interval, 1.004-1.05; P=0.02), atrial fibrillation (hazard ratio, 1.91; 95% confidence interval, 1.07-3.41; P=0.03), and LV ejection fraction (hazard ratio, 0.96; 95% confidence interval, 0.92-0.99; P=0.04) predicted outcomes. In patients with grade III+ or greater myxomatous mitral regurgitation undergoing exercise echocardiography, lower percent of age/sex-predicted metabolic equivalents, lower heart rate recovery, atrial fibrillation, lower LV ejection fraction, and high resting right ventricular systolic pressure predicted worse outcomes.

Prognostic predictors in pericardiectomy for chronic constrictive pericarditis

Prognosis after pericardiectomy remains to be clearly elucidated, especially in Asian countries, where the causes of constrictive pericarditis differ from those in Western countries. We aimed to investigate the preoperative prognostic factors and clinical outcomes after pericardiectomy in patients with chronic constrictive pericarditis. Preoperative clinical and imaging characteristics were evaluated in 85 consecutive patients with chronic constrictive pericarditis without other valvular or ischemic heart diseases who underwent pericardiectomy. Causes were idiopathic in 49 patients (57.6%) and tuberculous in 36 patients (42.4%). All-cause death was observed for a median of 38.5 months. Of 85 patients, 15 (17.6%) died during follow-up. These 15 patients who died during follow-up had higher aspartate aminotransferase, smaller left ventricular end-systolic dimension index, and higher early diastolic mitral inflow velocity before pericardiectomy than the 70 patients who survived. Multivariate Cox proportional analysis showed that diabetes mellitus (hazard ratio, 4.610; P = .024) and high early diastolic mitral inflow velocity (hazard ratio, 1.050/cm/s; P = .002) before pericardiectomy were independent predictors of mortality after pericardiectomy. The preoperative cutoff value for early diastolic mitral inflow velocity in predicting mortality after pericardiectomy was 71 cm/s (sensitivity of 84.6% and specificity of 52.2%), and there was a significant difference in survival between groups divided by this cutoff value of early diastolic mitral inflow velocity (P = .029). Preoperative high early diastolic mitral inflow velocity and diabetes mellitus were predictors of poor prognosis after pericardiectomy in patients with chronic constrictive pericarditis. These results suggest that preoperative Doppler echocardiographic evaluation may be valuable not only for diagnosing constrictive pericarditis but also for predicting prognosis after pericardiectomy.

Contractile Reserve Determined on Exercise Echocardiography in Patients With Severe Aortic Regurgitation

The aim of this study was to assess contractile reserve (CR) in patients with severe aortic regurgitation (AR), and potential clinical applications of CR in minimally symptomatic patients. Symptom-limited treadmill exercise echocardiography was performed in 58 asymptomatic or mildly symptomatic patients with chronic severe AR (male 69%, 50±14 years). Patients with increased ejection fraction (EF) after exercise were denoted as having CR (+) and those without increased EF were categorized as CR (-). CR (+) was found in 31 and CR (-) in 27 patients. Compared with CR (+), the CR (-) group had lower EF, larger effective regurgitant orifice, regurgitant volume, left ventricular (LV) end-diastolic dimension, LV end-systolic dimension (LVESD), and LV mass index. On multiple logistic regression analysis LVESD index (LVESDI; odds ratio -0.354, P<0.0001) was an independent predictor of CR. One-third of patients with LVESD >50mm, however, were found to be CR (+), while one-third of patients with smaller LVESD were CR (-). Although CR is best related to baseline resting LVESDI, one-third of patients were found to have discordance between the presence of CR and the LV dimension recommended for aortic valve replacement (AVR) in minimally symptomatic patients with severe AR, suggesting that exercise test may be able to further stratify the current guideline for AVR.