Left-sided Valvular Disease Research Articles

Outcome of Patient with Moderate Functional Tricuspid Regurgitation Underwent Mitral Valve Replacement without Tricuspid Valve Repair

Background: The tricuspid valve is often called the "forgotten valve" or "lost valve," because it is relatively understudied relative to the other cardiac valves. Left-sided valvular heart diseases represent the most common cause of functional tricuspid regurgitation (FTR) and the reported prevalence reached 25% to 30%. Objective: The aim of the work is to give an attention to the problem of moderate functional tricuspid valve regurgitation with mitral valve replacement and includes revision of anatomy of tricuspid valve, pathophysiology, diagnosis and management of functional tricuspid valve regurgitation. Patients and Methods: In the present retrospective study, 30 randomly selected patients with moderate functional tricuspid valve regurgitation (grade 2) underwent mitral valve replacement for the first time at Al-Hussein University Hospital without repair of their moderate functional tricuspid regurgitation. The study was approved by the medical ethics committee of Al-Azhar University Hospitals and a written informed consent is obtained from all patients. Results: In the present study and according to the sex, the females (9) represent (30%) while males (21) were (70%). Their age ranged between 40-60 years with mean 48.40 ± 6.92. The Degree of TR was mild 15 (50.0%), moderate 6 (20.0%), severe 3 (10.0%) and Trivial 6 (20.0%) of Echo data after 6 months. Conclusion: Functional tricuspid regurgitation (TR) is commonly associated with mitral valve (MV) diseases and the presence of significant TR is reported to be an indicator of poor prognosis after the surgical correction of MV diseases.

P4510Impact of secondary tricuspid regurgitation on survival in heart failure - insights from COMMIT-HF registry

Abstract Background Functional tricuspid regurgitation (fTR) is common in left sided heart disease, especially in patients with concomitant left-sided valvular diseases and can lead to functional impairment and reduced survival. However, the impact of fTR on survival in chronic heart failure with reduced left ventricular ejection fraction (HFrEF) without severe left valvular diseases (LVD) is not fully established. The aim of the present study was to observe if moderate to severe fTR may influence the survival in patients with HFrEF without severe LVD. Methods We have analyzed a large single-center registry (n=2731) of HFrEF patients treated in a large-volume cardiovascular center between 2009–2015. After exclusion of patients with severe aortic and mitral valve disease we have included 2435 patients with HFrEF (left ventricular ejection fraction (LVEF) ≤35%). Functional moderate to severe tricuspid regurgitation without severe left valvular diseases was present in 465 patients. Twelve -month vital status was available for the whole patient population. Univariate and multivariate Cox proportional hazard regression models were performed to evaluate the relationship between moderate to severe fTR and mortality in the study group. Results Comparison of clinical data of fTR and non-fTR in HFrEF patients revealed some significant differences (age 63.3±12.9 vs 61.3±12.4, p=0.002; female sex 25.8% vs 17,9%, p<0.001; chronic kidney disease stage III-V 45.3 vs 26.6%, p=0.001; atrial fibrillation 52.4% vs 28.5%, p<0.001). Twelve-month all-cause mortality was over 2-fold higher in the fTR group (21.2% vs 8.1%, p<0.001). There were no significant differences with regard to the medical treatment, implantable defibrillator or cardiac resynchronization therapy. The presence of fTR was identified as an independent echocardiographic factor impaired 12-month all-cause survival (HR 1.59, CI 1.2- 2.09, p<0.001, figure 1) Conclusion Apart from the LVEF, the presence of moderate to severe fTR may predict 12-month all-cause mortality in patients with HFrEF. Acknowledgement/Funding None

Abstract P299: Racial and Sex-Related Differences in Aortic and Mitral Valve Disease

Background: With the proliferation of echocardiography, clinicians are detecting more patients with valve disease and identifying valve disease much earlier in its natural course. Understanding the gender and racial differences in prevalence of valve disease may help guide clinicians to allocate resources in researching strategies to prevent progression of valve disease. Methods: We identified 9,625 patients from the echocardiography laboratory database between September 2013 to April 2018 who had a LV ejection fraction ≥ 50%. Data related to left-sided valvular disease, baseline demographics, and clinical history were obtained from our clinical data repository. Crude analyses by sex and race were performed to identify the prevalence of certain valve lesions. Logistic regression was used to adjust these relationships by baseline demographics. Results: Our population was 58% female, 21% African-American (AA) with a mean age of 59 ± 17 years. For moderate/severe aortic stenosis (AS), AA had 2.4% compared to 7.5% in Caucasians (CA; p<0.001), and women had 4.8% compared to 8.5% for men (p<0.001). For moderate/severe aortic regurgitation (AR), AA had 4.1% compared to 7.5% in CA (p>0.2), and women had 4.0% compared to 5.4% for men (p=0.003). For moderate/severe mitral regurgitation, AA had 6.6% vs 7.8% for CA (p=0.056), and women had 8.3% vs 6.3% for men (p=0.003). Adjusting for age, race, sex, height, and weight, AA had lower odds ratio (OR) for AS than CA (OR: 0.47; 95% CI: 0.34-0.64; p<0.001), and women had less AS than men (OR: 0.60; 95% CI: 0.50-0.72; p<0.001), less AR (OR: 0.67; 95% CI: 0.54-0.83; p<0.001), but more MR (OR: 1.29; 95% CI: 1.08-1.53; p=0.004). Conclusion: African-Americans have a lower prevalence of moderate/severe aortic stenosis than Caucasians. Compared to men, women have a lower prevalence of moderate/severe aortic stenosis, lower prevalence of moderate/severe aortic regurgitation, but a higher prevalence of mitral regurgitation.

Cardiac remodeling in aortic and mitral valve disease: a simulation study with clinical validation.

Remodeling is an important long-term determinant of cardiac function throughout the progression of heart disease. Numerous biomolecular pathways for mechanosensing and transduction are involved. However, we hypothesize that biomechanical factors alone can explain changes in myocardial volume and chamber size in valve disease. A validated model of the human vasculature and the four cardiac chambers was used to simulate aortic stenosis, mitral regurgitation, and aortic regurgitation. Remodeling was simulated with adaptive feedback preserving myocardial fiber stress and wall shear stress in all four cardiac chambers. Briefly, the model used myocardial fiber stress to determine wall thickness and cardiac chamber wall shear stress to determine chamber volume. Aortic stenosis resulted in the development of concentric left ventricular hypertrophy. Aortic and mitral regurgitation resulted in eccentric remodeling and eccentric hypertrophy, with more pronounced hypertrophy for aortic regurgitation. Comparisons with published clinical data showed the same direction and similar magnitudes of changes in end-diastolic volume index and left ventricular diameters. Changes in myocardial wall volume and wall thickness were within a realistic range in both stenotic and regurgitant valvular disease. Simulations of remodeling in left-sided valvular disease support, in both a qualitative and quantitative manner, that left ventricular chamber size and hypertrophy are primarily determined by preservation of wall shear stress and myocardial fiber stress. NEW & NOTEWORTHY Cardiovascular simulations with adaptive feedback that normalizes wall shear stress and fiber stress in the cardiac chambers could predict, in a quantitative and qualitative manner, remodeling patterns seen in patients with left-sided valvular disease. This highlights how mechanical stress remains a fundamental aspect of cardiac remodeling. This in silico study validated with clinical data paves the way for future patient-specific predictions of remodeling in valvular disease.

Estimation of Mean Left Atrial Pressure in Patients with Acute Coronary Syndromes: A Doppler Echocardiographic and Cardiac Catheterization Study

Doppler echocardiography, including the ratio of transmitral E to tissue Doppler e' velocities (E/e'), is widely used to estimate mean left atrial pressure (mLAP). This method, however, has not been validated in patients with acute coronary syndromes. Fifty-seven patients with acute coronary syndromes who underwent left heart catheterization and transthoracic echocardiography within 8hours of each other were retrospectively analyzed. Forty-two of the patients (74%) were men, with a mean age of 65±11years. Patients with known cardiomyopathy, atrial fibrillation, or left-sided valvular disease were excluded. Doppler mLAP was estimated using Nagueh's formula (1.24×[E/e']+1.9). Invasive mLAP was estimated using the formula of Yamamoto etal. (1.20×mean left ventricular diastolic pressure - 0.82), wherein we averaged left ventricular diastolic pressure starting from the isovolumic relaxation phase to the post-A inflection point. Subanalyses were performed in groups with reduced or normal left ventricular ejection fraction (EF). There was stronger agreement between the two techniques to estimate mLAP in the reduced EF group (r=0.73, r2=0.53, P<.001) compared with the normal EF group (r=0.33, r2=0.11, P=.08). The κ statistic for agreement was 0.34 for the overall study cohort, suggesting fair agreement according to partition values of mean mLAP: <8, 8 to 15, and >15mm Hg. Left atrial volume index did not correlate with invasively estimated mLAP in this cohort. In patients with acute coronary syndromes, Doppler- and catheter-derived estimates of mLAP correlate well in patients with reduced EFs. In the acute setting, echocardiographic evaluation is a reliable adjunct to clinical examination in assessment of heart failure in this subgroup of patients.

Changes in pulmonary artery systolic pressure and right ventricular function in patients with end-stage renal disease on maintenance dialysis.

Pulmonary hypertension is common in patients with end-stage renal disease, and portends a poor prognosis. There are little data in this population, and previous studies have not evaluated quantitative changes in haemodynamics over time while on maintenance dialysis. This study sought to estimate changes in pulmonary artery systolic pressure (PASP) and right ventricular function over time, and to predict PASP change using clinical variables routinely available at time of initial measurement, in patients on maintenance dialysis. We retrospectively studied patients with end-stage renal disease at a university-affiliated dialysis centre who had two separate echocardiograms 1-4 years apart. Seventy-six patients (65 haemodialysis, 11 peritoneal dialysis) were included. PASP was estimated by echocardiography. Baseline PASP was predicted by left-sided valvular disease, anaemia, COPD, left-ventricular mass index, and haemodialysis modality (P = 0.07 for modality). Average increase in PASP was 2.41 mmHg per year. Higher rates of PASP change were predicted by E/e' ratio by tissue doppler on echocardiogram, diabetes mellitus, low LV mass, and left-sided valvular heart disease (P = 0.07 for valvular disease). Patients with higher PASP had higher incidence of new-onset right ventricular dysfunction. In patients with end-stage renal disease, PASP increases over time. Changes are moderately predictable. Higher PASP predicted development of right ventricular dysfunction.

Right atrial function by speckle tracking echocardiography in atrial septal defect: Prediction of atrial fibrillation.

Most antiarrhythmic interventional therapies for atrial fibrillation (AF) have been provided with special focus on the treatment of left-sided valvular disease and enlarged left atrium but few studies have assessed AF associated with congenital heart disease and dilated right atrium. We hypothesized that right atrial (RA) function assessed by two-dimensional (2DSTE) and three-dimensional (3DSTE) speckle-tracking echocardiography in patients with atrial septal defect (ASD) before and after percutaneous trancatheter closure could predict paroxysmal atrial fibrillation (PAF) development. Seventy-three patients with hemodynamically significant secundum ASD were prospectively studied and followed up for 6 months after occluder insertion and compared with a normal age-matched group (n = 73). A subgroup of 17 patients who developed PAF after device implantation was also studied. RA peak global longitudinal strain (PS) was determined using 2DSTE. Standard deviations (SDs) of times to peak strain (TPS) were calculated as indices of dyssynchrony. RA volumes, emptying fraction (EF), and expansion index (EI) were determined using 3DSTE. RA-PS, EF, and EI (pre-closure values) were reduced in patients with atrial devices compared with controls, and further reductions were observed in patients with PAF. Pre-closure 3D-RA-EI (P = 0.009) and RA-TPS (P = 0.023) were independent predictors of PAF by multivariate analysis after adjustment for age and left atrial dysfunction. The areas under the ROC-curve (AUC) for 3D-RA-EI, RA-PS, RA-TPS (pre-closure values) showed high discriminative values(from 0.76 to 0.85) in predicting PAF. By combining 3D-RA-EI and RA-TPS, the AUC increased to 0.90. Two-dimensional and three-dimensional speckle tracking echocardiography was clinically helpful in ASD patients in revealing right atrial dilatation and dysfunction pre-existent to device closure and associated with PAF development. RA parameters had a higher association with PAF compared to both the size of the implanted device and left atrial indices.

Long-Term Results of Tricuspid Annuloplasty Using MC3 Ring for Functional Tricuspid Regurgitation.

This study aimed to evaluate the long-term results of tricuspid annuloplasty using the MC3 ring for functional tricuspid regurgitation (TR). Methods and Results: Between 2004 and 2014, 249 patients underwent tricuspid ring annuloplasty using the MC3 ring for functional TR (FTR). Main etiologies of FTR were left-sided valvular disease (n=211) and left-to-right shunt (n=34). Based on the interval between the operation and last echocardiographic scan, patients were divided into short-term and long-term follow-up groups. Mean follow-up duration was 84.4±37.1 months. Operative death occurred in 8 patients (3.2%). Predischarge echocardiography showed that both TR grade and systolic pulmonary artery pressure were significantly decreased compared with preoperative values, and these values were sustained during follow-up in both the short-term and long-term follow-up groups. There were no ring-related complications in either the postoperative or follow-up period, except for permanent pacemaker implantation in 2 patients. The freedom from TR ≥moderate and tricuspid valve (TV)-related events at 10 years were 92.1% and 92.8%, respectively. TV annular size was a risk factor for the recurrence of TR ≥moderate (P=0.001), and 42 mm was the cutoff value for predicting the recurrence of TR ≥moderate. Tricuspid annuloplasty using the MC3 ring for FTR provides satisfactory early results that are sustained during long-term follow-up. Preoperative TV annular size was associated with the recurrence of TR ≥moderate.

Outcome and undertreatment of mitral regurgitation: a community cohort study

Mitral regurgitation is the most common valve disease worldwide but whether the community-wide prevalence, poor patient outcomes, and low rates of surgical treatment justify costly development of new therapeutic interventions remains uncertain. Therefore, we did an observational cohort study to assess the clinical characteristics, outcomes, and degree of undertreatment of mitral regurgitation in a community setting. We used data from Mayo Clinic electronic health records and the Rochester Epidemiology Project to identify all cases of moderate or severe isolated single-valvular mitral regurgitation (with no other severe left-sided valvular disease or previous mitral surgery) diagnosed during a 10-year period in the community setting in Olmsted County (MN, USA). We assessed clinical characteristics, mortality, heart failure incidence, and results of cardiac surgery post-diagnosis. Between Jan 1, 2000, and Dec 31, 2010, 1294 community residents (median age at diagnosis 77 years [IQR 66-84]) were diagnosed with moderate or severe mitral regurgitation by Doppler echocardiography (prevalence 0·46% [95% CI 0·42-0·49] overall; 0·59% [0·54-0·64] in adults). Left-ventricular ejection fraction below 50% was frequent (recorded in 538 [42%] patients), and these patients had a slightly lower regurgitant volume than those with an ejection fraction of 50% or higher (mean 39 mL [SD 16] vs 45 mL [21], p<0·0001). Post-diagnosis mortality was mainly cardiovascular in nature (in 420 [51%] of 824 patients for whom the cause of death was available) and higher than expected for residents of the county for age or sex (risk ratio [RR] 2·23 [95% CI 2·06-2·41], p<0·0001). This excess mortality affected all subsets of patients, whether they had a left-ventricular ejection fraction lower than 50% (RR 3·17 [95% CI 2·84-3·53], p<0·0001) or of 50% or higher (1·71 [1·53 -1·91], p<0·0001) and with primary mitral regurgitation (RR 1·73 [95% CI 1·53-1·96], p<0·0001) or secondary mitral regurgitation (2·72 [2·48-3·01], p<0·0001). Even patients with a low comorbidity burden combined with favourable characteristics such as left-ventricular ejection fraction of 50% or higher (RR 1·28 [95% CI 1·10-1·50], p<0·0017) or primary mitral regurgitation (1·29 [1·09-1·52], p=0·0030) incurred excess mortality. Heart failure was frequent (mean 64% [SE 1] at 5 years postdiagnosis), even in patients with left-ventricular ejection fraction of 50% or higher (49% [2] at 5 years postdiagnosis) or in those with primary mitral regurgitation (48% [2]). Mitral surgery was ultimately done in only 198 (15%) of 1294 patients, of which the predominant type of surgery was valve repair (in 149 [75%] patients). Mitral surgery was done in 28 (5%) of 538 patients with left-ventricular ejection fraction below 50% and in 170 (22%) of 756 patients with ejection fraction of 50% or higher, and in 34 (5%) of 723 with secondary mitral regurgitation versus 164 (29%) of 571 with primary regurgitation. All other types of cardiac surgery combined were performed in only 3% more patients (237 [18%] patients) than the number who underwent mitral surgery. In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder. Mayo Clinic Foundation.

O2-5 - Surgical Outcome of Severe Tricuspid Valve Regurgitation Developed Long after Left-sided Valvular Surgeries

Background: Early surgical treatment for severe tricuspid regurgitation (TR) is recommended before right or left heart failure develops, however those who have developed severe TR late after left-sided valvular surgery are prone to be treated noninvasively because the risk of repeated surgery is concerned. Methods: Nine patients with severe symptomatic TR treated surgically in our hospital long after left-sided valvular disease were reviewed retrospectively. Results: Average age of the patients were 67 ± 4 years. Prior surgeries had been performed at their age of 37 ± 11 years, and heart failure symptoms had appeared 11 ± 8 years before subsequent surgeries. The second surgeries were performed with aortic valve replacement in 3, with mitral valve replacement in 4, and without left-sided valve surgery were in 2. None of the nine patients died perioperatively, however 4 patients died during a mean follow up period of 2.3 ± 1.7 years. Right heart catheterization was performed after surgery in 6 patients. Systolic regurgitant pressure of right atrium were prone to decrease (P = .66) and cardiac index increased significantly (P = .033), however mean pressure of right atrium and pulmonary artery wedge pressure increased considerably in some patients. Conclusion: Operative risk of surgical treatment for TR late after left-sided valvular surgery is not high, however long-term prognosis is poor with incomplete hemodynamic improvement in some patients.

Echocardiographic Pulmonary Hypertension Predicts Post-transplantation Renal Allograft Failure

BackgroundPulmonary hypertension in the setting of renal transplantation has been associated with early allograft dysfunction and increased mortality, but this relationship has not been extensively studied. MethodsWe performed a retrospective cohort study of adult patients who underwent their first renal transplantation in the years 2003–2009 and had pre-transplantation echocardiograms. Pulmonary hypertension was defined as right ventricular systolic pressure ≥40 mm Hg in the absence of left-sided valvular disease and/or left ventricular ejection fraction ≤50%. Eighty-two of 205 patients (40%) met the inclusion criteria. The relationship between pulmonary hypertension and death-censored allograft failure (hemodialysis dependence or retransplantation) and serum creatinine was assessed with the use of Cox hazard regression and generalized mixed models. ResultsThe presence of pulmonary hypertension was associated with a 3-fold increase in the risk of death-censored allograft failure (95% confidence interval, 1.20–7.32; P = .02). Failure rates were 19% at 24 months and 51% at 96 months for those with pulmonary hypertension versus 7% at 24 months and 20% at 86 months for those without pulmonary hypertension (P = .01). Among those without graft failure, there was an increase in creatinine levels after transplantation (P = .01). Effect estimates were unchanged by adjustment for multiple covariates and when pulmonary hypertension was defined as right ventricular systolic pressure ≥36 mm Hg. ConclusionsPulmonary hypertension before renal transplantation carries a 3-fold increased risk of death-censored allograft failure. The relationship between the pulmonary circulation and renal allograft failure warrants further study.

Comparison of Clinical and Electrocardiographic Predictors of Ischemic and Nonischemic Cardiomyopathy During the Initial Evaluation of Patients With Reduced (≤40%) Left Ventricular Ejection Fraction

Invasive coronary angiography is routinely performed during the initial evaluation of patients with suspected cardiomyopathy with reduced left ventricular function. Clinical and electrocardiographic (ECG) data may accurately predict ischemic cardiomyopathy (IC). Medical records of adults referred for coronary angiography for evaluation of left ventricular ejection fraction ≤40% from 2010 to 2014 were retrospectively reviewed. Patients with myocardial infarction (MI), previous coronary revascularization, cardiac surgery, or left-sided valvular disease were excluded. IC was defined as ≥70% diameter stenosis of the left main, proximal left anterior descending, or involvement of ≥2 epicardial coronary arteries. A risk model was developed from logistic regression coefficients, with a dichotomous cut-point based on the maximal Youden's index from the receiver-operating characteristic curve. A total of 273 patients met study inclusion criteria. Mean age was 56.8 ± 11.6 and 68.1% were men. IC was identified in 41 patients (15%). Patients with IC were more likely to have ECG evidence of Q-wave MI (34% vs 13%, p <0.001) and less likely to have left bundle branch block (2% vs 15%, p= 0.03) than non-IC. A model including age, hypertension, diabetes mellitus, tobacco use, ECG evidence of ST or T-wave abnormalities concerning for ischemia, and previous Q-wave MI, yielded a 95% negative predictive value for IC. In conclusion, at an urban referral hospital, the prevalence of IC was low. Left bundle branch block on electrocardiography was rarely associated with IC. A risk score incorporating clinical and ECG abnormalities identified patients at a low likelihood for IC.

Transcatheter treatment of functional tricuspid regurgitation: preliminary experiences.

Tricuspid regurgitation (TR) is a common finding in patients with left-sided valvular or myocardial disease. However, many patients with severe symptomatic TR are deemed inoperable or at high surgical risk, often due to comorbidities and the need for redo sternotomy. Thus, despite the poor prognosis associated with this condition, few patients undergo isolated surgical tricuspid valve repair. Therefore, there is an unmet clinical need for less invasive therapeutic options for these patients. In recent times, several transcatheter therapies have emerged for treating TR, with promising safety and preliminary efficacy results. In this review, we describe the main features of and clinical results associated with such devices, and describe the ongoing and future studies in the field.

Computational fluid dynamics modelling of left valvular heart diseases during atrial fibrillation.

Background: Although atrial fibrillation (AF), a common arrhythmia, frequently presents in patients with underlying valvular disease, its hemodynamic contributions are not fully understood. The present work aimed to computationally study how physical conditions imposed by pathologic valvular anatomy act on AF hemodynamics.Methods: We simulated AF with different severity grades of left-sided valvular diseases and compared the cardiovascular effects that they exert during AF, compared to lone AF. The fluid dynamics model used here has been recently validated for lone AF and relies on a lumped parameterization of the four heart chambers, together with the systemic and pulmonary circulation. The AF modelling involves: (i) irregular, uncorrelated and faster heart rate; (ii) atrial contractility dysfunction. Three different grades of severity (mild, moderate, severe) were analyzed for each of the four valvulopathies (AS, aortic stenosis, MS, mitral stenosis, AR, aortic regurgitation, MR, mitral regurgitation), by varying–through the valve opening angle–the valve area.Results: Regurgitation was hemodynamically more relevant than stenosis, as the latter led to inefficient cardiac flow, while the former introduced more drastic fluid dynamics variation. Moreover, mitral valvulopathies were more significant than aortic ones. In case of aortic valve diseases, proper mitral functioning damps out changes at atrial and pulmonary levels. In the case of mitral valvulopathy, the mitral valve lost its regulating capability, thus hemodynamic variations almost equally affected regions upstream and downstream of the valve. In particular, the present study revealed that both mitral and aortic regurgitation strongly affect hemodynamics, followed by mitral stenosis, while aortic stenosis has the least impact among the analyzed valvular diseases.Discussion: The proposed approach can provide new mechanistic insights as to which valvular pathologies merit more aggressive treatment of AF. Present findings, if clinically confirmed, hold the potential to impact AF management (e.g., adoption of a rhythm control strategy) in specific valvular diseases.

40-Year-Old Woman With Breathlessness and Fatigue

40-Year-Old Woman With Breathlessness and Fatigue

Abstract WMP99: Major Causes of Stroke in Children With Congenital and Acquired Heart Disease

Introduction: Heart disease is the leading cause of stroke in children; however, little is known about the distribution of cardiac conditions associated with stroke. Hypothesis: We assessed the hypothesis that patients requiring cardiac surgery, catheterization, or mechanical support account for the majority of strokes in children with heart disease. Methods: All patients admitted to Lucile Packard Children’s Hospital at Stanford were included. A new diagnosis of stroke was identified using hospital data. Descriptive statistics were used to evaluate the characteristics of the population and tabulate common causes of stroke and stroke sub-types. Results: Between September 1, 2009 and February 1, 2014, a total of 36 patients with congenital or acquired heart disease had a new diagnosis of stroke. The median age was 4.18 years (IQR 0.32 - 10.6 years); 64% were male. Overall, 50% of strokes were arterial ischemic, 17% hemorrhagic and 25% had both ischemic and hemorrhagic components. Transient ischemic attacks accounted for the remaining 8%. Patients on mechanical support accounted for the majority of strokes (33%; ECMO 22%, ventricular assist device 11%) followed by left-sided cardiac catheterization (22%). Single-ventricle palliation procedures (Norwood or Glenn) accounted for 11% and septal defect repair 8%. Associated cardiac conditions included cardiomyopathy (28%), single-ventricle physiology (28%), septal defects (14%), myo/endocarditis (11%), heart transplantation (6%), and left-sided valvular disease (5%). Overall, 47.2% of patients were receiving anticoagulant therapy at the time of their stroke. Among those patients, 32% with arterial ischemic strokes and 60% with hemorrhagic strokes were within goal anticoagulation levels. Conclusions: Mechanical circulatory support, cardiac catheterizations and single-ventricle palliation procedures account for two-thirds of strokes observed in patients with cardiac disease. Many strokes occur in patients receiving anticoagulant therapy in accordance with contemporary anticoagulation guidelines. Re-evaluation of these guidelines and studies to reduce the risk of strokes in vulnerable sub-groups of cardiac patients is warranted.

Abstract 12642: Left Atrial Diameter as a Predictor of World Health Organization Group Two Pulmonary Hypertension Severity

Objective: Left atrial (LA) enlargement and dysfunction have poor prognostic significance in heart failure and coronary artery disease. However, the correlation between LA diameter and World Health Organization (WHO) Group 2 pulmonary hypertension (PH) severity has not been well studied. Hypothesis: We hypothesized that LA enlargement as a marker of LA remodeling in response to pressure and volume overload may contribute to higher pulmonary arterial pressures (PAP) in this population, independent of comorbidities and left ventricular ejection fraction (LVEF). Methods: After exclusion for severe left-sided valvular disease, 100 patients with isolated or mixed WHO Group 2 PH defined by right heart catheterization were studied in a cross-sectional retrospective analysis at a single institution. Linear LA anteroposterior diameter was obtained from the parasternal long-axis view on two dimensional TTE. LVEF, LV E/A Ratio, and LV Mass Index were measured according to ASE guidelines. LV E/A and LV Mass Index was recorded in 80 subjects and 79 subjects, respectively. Mean PAP was assessed on RHC. TTE and RHC were performed within one year of each other. Results: LA diameter was significantly associated with mean PAP after adjustment for age, sex, body-mass index, presence of coronary artery disease, hypertension, atrial fibrillation, and LVEF in multivariable linear regression analysis. In this multivariable model, a one centimeter increase in LA diameter predicted an average increase in mean PAP of 2.78 mmHg (95% CI 0.10, 5.46, p = 0.0423). In a subset of this population, LVEF, LV E/A Ratio, and LV Mass Index were not significant predictors of mean PAP. Reduction in cardiac index was noted with increasing LA diameter but this trend did not reach statistical significance. Conclusion: LA enlargement is significantly associated with increased mean PAP in patients with WHO Group 2 PH. LA enlargement may be a proxy for LA dysfunction and our data suggests that increased LA diameter may be a predictor of WHO Group 2 PH severity. Further studies of LA dimension, volume, and function are warranted to further our understanding of the left atrium’s relationship to PH.

Surgical Treatment of Secondary Tricuspid Regurgitation: Insight Derived From Annulus Sizes and Tethering Distances

The main goal of this study was to explore the feasibility of stratifying patients with secondary tricuspid regurgitation (TR) into different risk levels, and to compare the surgical outcomes of patients within different risk levels who underwent different tricuspid valve repair (TVP) approaches. One hundred and one patients with left-sided valvular disease underwent either left-sided valvular replacement or repair, and 79 patients underwent concomitant TVP. Depending upon their tricuspid annulus diameter and tethering distances, the patients were assessed using 4 risk levels. The different surgical approaches were used in patients within different risk levels. Among the 101 patients, there were 32 patients within risk level I, 28 within risk level II, 20 within risk level III, 21 within risk level IV. In the first risk level, the patients with untreated tricuspid valves had no or mild TR after surgery. In the second and third risk levels, the patients treated with a modified De Vega procedure had mild TR at follow-up. In the fourth risk level, the patients treated with undersized annuloplasty rings exhibited an improved outcome. The evaluation of both tricuspid annular diameter and tethering distance may help clinicians to stratify patients with secondary TR into different risk levels as a means of choosing an optimal TVP approach. The application of a modified De Vega procedure or an undersized annuloplasty ring in patients within appropriate risk level could improve the treatment for secondary TR.

Abstract T P145: Incidence and Determinants of Clinical Dementia after Ischemic Stroke: a Population-based Study in Rochester, MN

Introduction: Studies have suggested a high incidence of dementia after stroke; however data regarding risk factors are conflicting and few studies are population-based. The aims of this population-based study are to determine the frequency of diagnosis and predictors of clinical dementia after ischemic stroke. Methods: The Rochester Epidemiology Project medical records linkage system was used to ascertain all first ischemic strokes (IS) occurring among Rochester, MN residents between 1990 -1994. Comprehensive medical records were reviewed. Patient and stroke characteristics, medical comorbidities, and the development of clinical dementia any time after IS were recorded. Dementia was defined as any reflection in the chart by a clinician of memory loss resulting in functional impairment. Patients with a pre-stroke diagnosis of dementia were excluded. Associations between new dementia after the index IS and other variables of interest were analyzed using univariate logistic regression. Results: First IS was detected in 490 people, 82 of whom had a prior history of dementia, and 119 (29%) of whom developed dementia during a mean follow-up of 6.5 years (range 0-23.8). The mean age at index stroke was 76.6 years (SD 12.9). Those who developed dementia were a mean 4 years older at the time of IS (p = 0.003). The odds of developing dementia were 1.7 higher in those who had at least one recurrent stroke. There was no effect of sex, stroke location (cortical, subcortical, brainstem), stroke mechanism, or premorbid stroke risk factors (coronary artery disease, atrial fibrillation/flutter, hypertension, diabetes mellitus, left-sided valvular disease) on the occurrence of dementia. Conclusions: Dementia is commonly diagnosed following ischemic stroke. While stroke risk factors did not impact the risk of diagnosis of dementia, recurrent stroke increased this risk. Stroke risk factors may indirectly increase the risk of dementia by increasing the risk of recurrent IS. This suggests that aggressive secondary stroke prevention measures may significantly decrease the risk of being diagnosed with dementia following IS.

Resolution of Whipple Disease–Induced Pulmonary Hypertension Following Antibiotic Therapy

Whipple disease is a disorder caused by Tropheryma whipplei, a ubiquitous Gram-positive bacillus. In addition to gastrointestinal manifestations, many other systems may be involved in Whipple disease. Pulmonary hypertension (PH) is a rare manifestation of Whipple disease, and its clinical course is not well established. We report a case of a 45-year-old woman who presented with typical gastrointestinal manifestations of Whipple disease, which was diagnosed by duodenal biopsy. She was also noted to have elevated pulmonary arterial pressures on transthoracic echocardiography. There was no evidence of left-sided valvular disease, hypertrophy, or dyskinesis, and there was no evidence of endocarditis. The patient was started on intravenous ceftriaxone for 6 weeks and then transitioned to oral trimethoprim-sulfamethoxazole for a year. The patient demonstrated clinical improvement, endoscopic and histologic improvement, and also resolution of PH. This is the third reported case of PH that is convincingly secondary to Whipple disease that resolved after appropriate antibiotic therapy.