Mitral Valve Damage Research Articles

Staging cardiac damage in aortic valve disease: one size fits all?

Abstract Background Nowadays, in patients with aortic regurgitation (AR), aortic valve surgery is indicated when severe and symptomatic or those with depressed LVEF. However, clinical outcomes of patients with significant aortic regurgitation are not influenced by these factors only. Recently, a new staging system for severe aortic stenosis has been proposed by Généreux on the basis of the extent of anatomic and functional cardiac damage. If this model could be applicable to an unselected significant AR population has not been tested. Purpose The aim of our study was to evaluate the prevalence of the different stages of extra-aortic valvular cardiac damage by the application of Généreux staging and its impact on prognosis in a large, real world cohort of significant AR patients. Methods This study retrospectively analysed the clinical, Doppler echocardiographic and outcome data in patients with grade III or greater AR between January 2014 and September 2019. According to the extent of cardiac damage on echocardiography, patients were classified as Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage) or Stage 4 (right ventricular damage). Exclusion criteria were severe aortic stenosis and previous valve repair or replacement. The primary end-point was all-cause mortality. Results A total of 572 patients, aged 70.1±13.9 years, 294 (51.3%) men were enrolled. One third of patients were in NYHA I. Based on the proposed classification, 82 patients (14.3%) were classified in stage 0, 130 (22.7%) in stage 1, 276 (48.2%) in stage 2, 68 (11.8%) in stage 3 and 17 (3.0%) in stage 4. Median follow-up time was 3.3±1.9 years. There was a progressive increase in mortality rates according to staging: 8.5% in stage 0, 10.8% in stage 1, 24.9% in stage 2, 42.6% in stage 3 and 52.9% in stage 4 (p<0.001). On multivariable analysis, the extent of cardiac damage was independently associated with excess mortality (HR 1.69, 95% CI 1.29 to 2.21) Conclusion Our study demonstrated that this new staging system studied for aortic stenosis also provides increased prognostic value to patients with significant aortic regurgitation. This staging system can be helpful to identify the degree of extra-aortic valvular cardiac damage and to optimize the time of valvular intervention. Further prospective studies are needed to confirm the benefit of the applicability of this model in clinical practice. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho Distribution of stages of cardiac damageSurvival analysis according to stage

Extent of Cardiac Damage and Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation.

(1) Aims: We sought to assess the impact of the extent of cardiac damage on survival among real-world patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). (2) Methods: A staging classification was applied to 262 patients from the EffecTAVI Registry at baseline and re-assessed within 30-days after TAVI. The primary endpoint of the study was all-cause mortality at 1-year. Secondary endpoints included cerebrovascular accident, myocardial infarction, permanent pacemaker implantation, endocarditis, and re-hospitalization for all causes. (3) Results: At baseline, 23 (8.7%) patients were in Stage 0/1 (no cardiac damage/left ventricular damage), 106 (40.4%) in Stage 2 (left atrial or mitral valve damage), 59 (22.5%) in Stage 3 (pulmonary vasculature or tricuspid valve damage) and 74 (28.3%) in Stage 4 (right ventricular damage). At 30-days after TAVI, a lower prevalence of advanced stages of cardiac damage than baseline, mainly driven by a significant improvement in left ventricular diastolic parameters and right ventricular function, was reported. At 1-year, a stepwise increase in mortality rates was observed according to staging at baseline: 4.3% in Stage 0/1, 6.6% in Stage 2, 18.6% in Stage 3 and 21.6% in Stage 4 (p = 0.08). No differences were found in secondary endpoints. (4) Conclusions: TAVI has an early beneficial impact on the left ventricular diastolic and right ventricular function. However, the extent of cardiac damage at baseline significantly affects the risk of mortality at 1-year after the procedure.

"Portrait" of patients with pulmonary hypertension, associated with mitral valve diseases before cardiac surgery

Aim. To study “the portrait” of patients with acquired mitral valve (MV) heart disease of various origins and pulmonary hypertension hospitalized for surgical correction of the defect.Methods. The study included 97 patients with acquired diseases of mitral valve and pulmonary hypertension. The assessment of demographic, clinical and anamnestic data, indicators of transthoracic echocardiography, quality of life before the correction of MV defect was carried out.Results. The studied cohort is mostly represented by female patients (n = 70; 72.2%). The most common cause of mitral valve disease was rheumatic heart disease (n = 40; 41.2%). Overweight, hypertension (n = 76; 78.4%) and atrial fibrillation (n = 62; 63.9%) were the most common comorbidities. The mean pressure level in the pulmonary artery according to echocardiography was 35.5 (29.0; 40.0) mm Hg, with no significant difference among the patients, regardless the mitral defect etiology. Less pronounced remodeling of the left ventricle was noted in patients with rheumatic heart disease, which is caused by a lesion of the MV by the type of stenosis in contrast to patients with connective tissue dysplasia syndrome or against the background of detachment of MV chords with MV damage in the form of its insufficiency. There were no significant differences in the systolic function of the right ventricle depending on the etiology of MV defect.Conclusion. The “portrait” of a patient with pulmonary hypertension associated with an acquired mitral valve defect before its correction is the predominance of female, overweight, with II or III functional class of chronic heart failure, more frequent rheumatic genesis of MV defect, the presence of concomitant pathology in the form of hypertension and persistent atrial fibrillation, and increased size of the left atrium and left ventricle, reduced systolic function of the right ventricle according to the data of Echocardiography.

Aplikasi teori katharine kolcaba pada pasien preoperasi mitral valve replacement: The application of katharine kolcaba’s theory in a preoperating mitral valve replacement patient

Mitral valve replacement (MVR) is a heart surgery procedure that is performed to replace a patient's mitral valve using an artificial heart valve among patients with moderate to severe mitral valve damage with symptomatic, or asymptomatic. Patients who undergo preoperative MVR might have experience including physical discomfort such as shortness of breath, fatigue, edema due to reduced mitral valve function. Patients also had psychological discomfort such as feeling anxious about the surgical procedure. The purpose of this study is to provide an overview of applying Katharine Kolcaba's theory of comfort to clients with preoperative MVR. The research method is a descriptive observational case study with a nursing care approach from the assessment stage, determining the diagnosis, planning, implementing actions, and evaluating one patient with preoperative MVR. The results of data analysis showed that the patient experienced physical discomfort in the form of decreased cardiac output, activity intolerance, and also psychological discomfort, namely anxiety. Comfort interventions are provided in the form of comfort standards, coaching, comfort food for the soul. The comfort theory of Katharine kolcaba is rightly applied to MVR preoperative nursing care which is characterized by a decrease in the anxiety scale, and the patient expresses his readiness to undergo surgery.

Refined staging classification of cardiac damage associated with aortic stenosis and outcomes after transcatheter aortic valve implantation.

A new staging classification of aortic stenosis (AS) characterizing the extent of cardiac damage was established and validated in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to validate an updated classification system in patients undergoing TAVI. In a prospective TAVI registry, AS patients were categorized into the following stages: no cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular (RV) damage or low-flow state (Stage 4). Stage 3 was sub-divided into Stage 3a (≤moderate pulmonary hypertension) and Stage 3b (severe pulmonary hypertension). Stage 4 was sub-divided into Stage 4a (low-flow without RV dysfunction), Stage 4b (RV dysfunction without low-flow), and Stage 4c (RV dysfunction with low-flow). The primary endpoint was all-cause death at 1 year. Among 1156 eligible patients, 14 were classified as Stage 0, 38 as Stage 1, 105 as Stage 2278 as Stage 3, and 721 as Stage 4. There was a stepwise increase in mortality according to advancing stages of cardiac damage: 3.9% (Stage 0-1), 9.6% (Stage 2), 14.1% (Stage 3), and 17.4% (Stage 4) (P = 0.002). After multivariable adjustment, only Stage 3b, Stage 4b, and Stage 4c conferred a significantly increased risk of mortality compared to Stage 0-1. More than one-third of patients had advanced cardiac damage (severe pulmonary hypertension or RV dysfunction) before TAVI, associating with a five- to seven-fold increased risk of mortality at 1 year. https://www.clinicaltrials.gov. NCT01368250.

MO715PROFILE OF INFECTIVE ENDOCARDITIS IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Infectious complications are the second leading cause of death in hemodialysis patients. This population is particularly exposed to bacteremia, on the one hand, because of the vascular access necessary for hemodialysis, which is a gateway to the various micro-organisms, and on the other hand, factors of susceptibility to infections. Infective endocarditis (IE) is the cardiac endothelium infection associated with bacteremia. It is a rare complication but its mortality remains high especially in patients on chronic hemodialysis. The aim of this study was to determine the microbiological profile, clinical and-biological profile, characteristics in the ultrasound, therapeutic modalities, and prognosis of IE in hemodialysis. Method This is a retrospective descriptive study of including chronic hemodialysis patients, admitted in the Nephrology and Internal Medicine Department A of the Charles Nicolle Hospital in Tunis for an IE during the period from 1973 to 2018. We used the modified Duke criteria to confirm the diagnosis of IE. Results Nineteen patients were included, including 12 men and 7 women (gender ratio=1.7). The average age was 49.1 years [29-66 years]. Seven of them (37%) were known to have a valvular disease, two of them had a double mitro-aortic valve replacement. Six of them (32%) were diabetic and two patients (11%) were on immunosuppressive therapy. The vascular access initially used for HD were arteriovenous fistula in 9 cases (47%), internal jugular catheter in 3 cases (16%), subclavian catheter in 1 case (5%), Canaud catheter in 3 cases (16%), and 2 patients were dialyzed by femoral catheter (11%). Clinically, all patients had an altered general condition, fever was present in 14 cases (74%) and a heart murmur in 10 cases (53%). Blood cultures were positive in 14 cases (74%). The isolated germs were Staphylococcus Aureus in 8 cases, Staphylococcus epidermidis in 4 cases, Pseudomonas aerogenosa in 3 cases, Enterobacterium in 1 case, enterococcus faecalis in 1 case, and Klebsielle oxytoca in one patient. On cardiac ultrasound, mitral valve damage was found in 10 patients, aortic sigmoid in 4 patients and tricuspid valve in 3 patients. The treatment included appropriate antibiotic therapy in all cases and a valvuloplasty was indicated in 7 patients. Nine patients (47%) died during their hospitalization. Conclusion Hemodialysis patients are particularly exposed to IE. The most appropriate preventive method is the strict observance of asepsis when handling the vascular access first and the rapid eradication of all infectious outbreaks.

Mitral Valve Disease in Thyroid Storm

Introduction: The cardiovascular effects that thyroid gland causes are widely studied. In fact, there is a known correlation between Graves’ Disease and mitral valve damage. We present the case of a patient admitted with thyroid storm and heart failure associated with severe structural damage of the mitral valve papillary muscle. Case Report: 24 year old woman with hyperthyroidism diagnosed 12 years ago, treated irregularly with thiamazole and propranolol, leaving treatment a year ago, presents dyspnea, class III functional capacity, diarrhea and logic dysphagia of a month of evolution. Heart rate over 170 bpm, respiratory rate 48 rpm and blood pressure 143/84 mmHg. Physical exam positive for exophthalmos, grade III goiter, crackles in both lung bases, pretibial myxedema and fulfilling criteria for a thyroid storm (65 points in Burch-Wartofsky Point Scale).First Lab Results: TSH<0.005µU/mL, free T4>7.7ng/dl and TRAB 37.8UI/L. Chest ray: Global cardiomegaly and pulmonary edema. EKG: Narrow complex supraventricular tachycardia. Thyroid ultrasound: Intrathoracic goiter. Transesophageal echocardiogram: Severe mitral insufficiency (Carpentier Type I and IIIB), right cavities and left ventricular enlargement, preserved right ventricular function and severe pulmonary hypertension (PSAP 71-76 mmHg).First treated with thiamazole, hydrocortisone IV, cholestyramine and sedation, falling time after into ventilatory failure and developing delirium, requiring invasive mechanical ventilation. Tested positive for COVID- 19. Starts preparation with Lugol and undergoes Total Thyroidectomy. After surgery develops severe hypocalcemia secondary to transitory hypoparathyroidism.During hospitalization presents multiple infections including pneumonia (Pseudomonas Aeruginosa), lung aspergillosis, bacteriuria (Enteroccocus Faecium) and candiduria (Candida Albicans and Glabrata), each one treated with multiple antibiotics and vasoactive drugs. Once stable, mitral valve replacement is realized, after which, the patient progresses favorably being discharged with programmed ambulatory controls. Conclusion: We report a case of a patient who was presented with positive thyroid storm criteria associated with heart failure and severe mitral valve insufficiency. The case gets complicated as multiple infections take place, including COVID-19. Fortunately, because of the early and aggressive multidisciplinary management, the patient evolved favorably, overcoming the life-threatening conditions she went through. Key Words: Thyroid storm, mitral valve insufficiency, heart failure. Bibliography: Klein I, Danzi S. Thyroid disease and the heart. Circulation. 2007 Oct 9;116(15):1725-35. doi: 10.1161/CIRCULATIONAHA.106.678326. Erratum in: Circulation. 2008 Jan 22;117(3):e18. PMID: 17923583.

Clinico-pathological classification of rheumatic mitral valve damage and surgical strategy.

BackgroundThere is a lack of established pathological indications for rheumatic valve repair. Therefore, we summarized the pathological classifications of rheumatic heart diseases and their correlations with the surgical strategies.MethodsThis observational study enrolled patients with rheumatic heart diseases who underwent mitral valve repair (MVP) or replacement at our centre between January 2017 and January 2019. Mitral leaflet, mitral commissural, and sub-valvular apparatus were classified into three grades from mild to severe, according to their degree of pathological damage. Based on certain principles and the grade of mitral leaflet, mitral commissural, and sub-valvular apparatus damage, three pathological types were identified (types I to III), based on which all patients were classified. The features of each pathological type were summarised. Differences between the three pathological types were analysed using chi-square test of tendency. These data were used to propose a clinico-pathological classification of rheumatic mitral valve damage in Chinese patients.ResultsOf 398 patients, 284 (70%) underwent MVP for rheumatic mitral valve diseases. There were 58 type I (15%) patients in the study, all of whom underwent repair (repair rate, 100%). Preoperative moderate-to-severe regurgitation with mild pathological lesions was observed in 64% of these patients. In 260 type II (65%) patients, the repair rate was 76% (197/260); preoperative moderate-to-severe stenosis was observed in 88% of these patients. In 80 type III (20%) patients, the repair rate was 36% (29/80); the preoperative rates of extremely severe stenosis and moderate-to-severe regurgitation in these patients were 50% and 40%, respectively. Several preoperative parameters show the change in trend with the increase in the pathological classification severity.ConclusionsOur clinico-pathological classification of rheumatic mitral valve damage is applicable to MVP. Considering that the classification principles are based on the possibility of mitral repair, it provides a phased and achievable target ratio for MVP and a principle of screening patients who should undergo rheumatic MVP.

Prognostic implications of cardiac damage classification based on computed tomography in severe aortic stenosis.

An echocardiographic staging system of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multidetector row computed tomography (MDCT) is key in the evaluation of AS patients undergoing TAVI and can potentially detect extra-valvular cardiac damage. This study aimed at evaluating the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI. A total of 405 patients (80 ± 7 years, 52% men) who underwent full-beat MDCT prior to TAVI were included. The extent of cardiac damage was assessed by MDCT and classified in five categories; Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (left atrium and mitral valve damage), Stage 3 (right atrial damage), and Stage 4 (right ventricular damage). Twenty-seven (7%) patients were stratified as Stage 0, 96 (24%) as Stage 1, 152 (38%) as Stage 2, 78 (19%) as Stage 3, and 52 (13%) as Stage 4. During a median follow-up of 3.7 (IQR 1.7-5.5) years, 150 (37%) died. On multivariable Cox regression analysis, cardiac damage Stage 3 (HR vs. Stage 0: 4.496, P = 0.039) and Stage 4 (HR vs. Stage 0: 5.565, P = 0.020) were independently associated with all-cause mortality. The MDCT-based staging system of cardiac damage in severe AS effectively identifies the patients who are at higher risk of death after TAVI.

Staging cardiac damage associated with aortic stenosis in patients undergoing transcatheter aortic valve implantation.

A new staging classification of aortic stenosis (AS) characterizing the extent of cardiac damage was established and validated in patients undergoing transcatheter aortic valve implantation (TAVI). The present study was aimed to refine the staging system by integrating a quantitative evaluation of right ventricular (RV) dysfunction defined by current echocardiographic guideline recommendations. In a prospective TAVI registry, patients were categorized into the stages: no cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or RV damage (Stage 4) based on baseline echocardiography. Among 1133 eligible patients undergoing TAVI, 8 (3.4%) patients were categorized as Stage 0, 113 (10.0%) as Stage 1, 397 (35.0%) as Stage 2, 239 (21.1%) as Stage 3, and 346 (30.5%) as Stage 4. There was a stepwise increase in all-cause and cardiovascular mortality rates at 1year according to increasing stages of secondary cardiac damage: 5.4% and 0% in Stage 0, 5.3% and 1.8% in Stage 1, 8.9% and 5.9% in Stage 2, 17.7% and 12.9% in Stage 3, and 25.8% and 19.9% in Stage 4, respectively. After multivariable adjustment, increasing stages of cardiac damage gradually correlated with all-cause and cardiovascular mortality. A significant number of patients with AS underwent TAVI only once cardiac damage has already occurred. Integrating a guideline-based definition of RV dysfunction increased the sensitivity of the staging system to identify patients at increased risk of death after TAVI.

Outcome of aortic stenosis according to invasive cardiac damage staging after transcatheter aortic valve replacement.

In recent studies, a 5-stage cardiac damage classification in severe aortic stenosis (AS) based on echocardiographic parameters has shown to provide predictive value regarding clinical outcome. The objective of this study was to investigate the prognostic impact of a cardiac damage classification based on invasive hemodynamics in patients with AS undergoing transcatheter aortic valve replacement (TAVR). A total of 1400 patients with symptomatic AS and full invasive hemodynamic assessment before TAVR were included. Patients were categorized according to their cardiac damage stage into five groups that are defined as: stage 0, no cardiac damage; stage 1, left ventricular damage; stage 2, left atrial and/or mitral valve damage; stage 3, pulmonary vasculature and/or tricuspid valve damage; stage 4, right ventricular damage. 9.9% patients were classified as stage 0, 23.6% as stage 1, the majority of patients as stage 2 (33.5%), 23.1% as stage 3 and 10% as stage 4. One- and 4-year mortality were 10.1%/29.5% in stage 0, 16.1%/60.6% in stage 1, 17.3%/39.4% in stage 2, 22%/54.6% in stage 3, 27.1%/62.2% in stage 4 (p = 0.001/p < 0.001). The extent of cardiac damage was independently associated with increased mortality after TAVR (HR 1.16 per each increment in stage, 95% confidence interval 1.03-1.18; p = 0.018). Cardiac damage staging in severe AS patients based on invasive hemodynamics appears to show strong association between the extent of cardiac damage and post-TAVR mortality. This staging classification provides predictive value and may improve risk stratification, therapy management and decision-making in patients with AS. Invasive Staging Classification of Cardiac Damage in Severe Symptomatic Aortic Stenosis has an Impact on Outcome after TAVR. (Top) Invasive staging criteria for cardiac damage in five stages using left ventricular end-diastolic pressure (LVEDP) for stage 1 (red), post-capillary wedge pressure (PCWP) for stage 2 (green), systolic pulmonary artery pressure (SPAP) for stage 3 (purple) and right atrial pressure (RAP) for stage 4 (yellow). The cake chart shows the distribution of the different stage in the whole cohort. (Bottom) Survival Analyses According to Stage of Cardiac Damage after Transcatheter Aortic Valve Replacement using Invasive Criteria. Kaplan-Meier plots comparing overall (left) and cardiovascular (right) 4-year survival showing with the more advancing stage a higher mortality rate.

572 Extent of cardiac damage and mortality in patients undergoing transcatheter aortic valve implantation

Abstract Aims Degenerative aortic stenosis (AS) is the most common heart valve disease among people ≥65 years in developed countries, with an increasing prevalence due to population ageing. A recently proposed staging classification of AS is based on the assumption that there is a continuum in the pathophysiology of LV structural and functional changes induced by AS. Such system showed prognostic ability among patients from the PARTNER 2 trial as well as in asymptomatic subjects with moderate to severe AS, thus challenging the current management of the disease. The aim of our study was to assess the prognostic performance of this staging classification in a real-world cohort of patients undergoing transcatheter aortic valve implantation (TAVI) and to investigate the eventual impact of the procedure on the extent of extra-aortic valve cardiac damage. Methods and results A staging classification was applied to 262 patients from the EffecTAVI Registry. The following criteria for staging classification of cardiac damage were applied at baseline (within 1 month before TAVI) and after the procedure (within 30-day): Stage 0, no extra-aortic valve cardiac damage; Stage 1, LV damage as defined by the presence of LV hypertrophy (LV mass index &amp;gt;95 g/m2 for women, &amp;gt;115 g/m2 for men), severe LV diastolic dysfunction (E/e’ &amp;gt;14) or LV systolic dysfunction (LV ejection fraction, LVEF &amp;lt;50%); Stage 2, left atrial (LA) and/or mitral valve damage as defined by the presence of LA enlargement (LA volume &amp;gt; 34 ml/m2) and/or moderate-severe mitral regurgitation and/or atrial fibrillation; Stage 3, pulmonary vasculature and/or tricuspid valve damage as defined by the presence of systolic pulmonary hypertension (systolic pulmonary arterial pressure, PAPS &amp;gt; 60 mmHg) and/or moderate/severe tricuspid valve regurgitation; Stage 4, right ventricular (RV) damage as defined by the presence of moderate-severe RV systolic dysfunction (tricuspid annular systolic excursion, TAPSE &amp;lt; 17 mm). The primary endpoint of the study was all-cause mortality at 1-year. Secondary endpoints included cerebrovascular accident, myocardial infarction, permanent pacemaker implantation, endocarditis and re-hospitalization for all causes. At baseline, 23 (8.7%) patients were in Stage 0/1 (no cardiac damage/left ventricular damage), 106 (40.4%) in Stage 2 (left atrial or mitral valve damage), 59 (22.5%) in Stage 3 (pulmonary vasculature or tricuspid valve damage) and 74 (28.3%) in Stage 4 (right ventricular damage). At 30-day after TAVI, a lower prevalence of advanced stages of cardiac damage than baseline, mainly driven by a significant improvement in left ventricular diastolic parameters and right ventricular function, was reported. At 1-year, a stepwise increase in mortality rates was observed according to staging at baseline: 4.3% in Stage 0/1, 6.6% in Stage 2, 18.6% in Stage 3 and 21.6% in Stage 4 (p = 0.08). No differences were found in secondary endpoints. Conclusion TAVI has an early beneficial impact on the left ventricular diastolic and right ventricular function. However, the extent of cardiac damage at baseline significantly affects the risk of mortality at 1-year after the procedure.

Cardiac damage grading in patients with aortic stenosis using multi-detector computed tomography and the impact on prognosis after transcatheter aortic valve intervention

Abstract Introduction A staging of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multi-detector row computed tomography (MDCT) has a central role in the evaluation of AS patients undergoing TAVI and can detect extra-valvular cardiac damage. Purpose To evaluate the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI. Methods Patients who underwent full-beat MDCT prior to TAVI were included. Patients with intra-cardiac devices, prior valvular surgery, and insufficient image quality were excluded. The extent of cardiac damage was assessed by MDCT and classified into following 5 groups; stage 0 (no cardiac damage), stage 1 (left ventricular damage), stage 2 (left atrium and mitral valve damage), stage 3 (right atrial damage), stage 4 (right ventricular damage). The primary end-point was all-cause mortality. Results A total of 405 patients (80±7 years, 52% men) were stratified according to the MDCT staging system: 27 (7%) were in stage 0, 96 (24%) in stage 1, 152 (38%) in stage 2, 78 (19%) in stage 3, and 52 (13%) in stage 4 (left panel). During follow-up (median 3.7 years, IQR: 1.7–5.5 years), 150 (37%) died (right panel). On multivariable analysis, cardiac damage stage, presence of chronic obstructive pulmonary disease, NYHA ≥3, eGFR, and transapical approach were independently associated with all-cause mortality. When evaluating each stage, stage 3 (HR: 4.725, P=0.033) and stage 4 (HR 5.678, P=0.018) were independently associated with worse outcomes as compared to the other stages. Conclusion MDCT-based staging system of severe AS identifies the patients who are at higher risk of death after TAVI. MDCT staging and the mortality Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant

Prognosis and clinical outcomes after TAVI, regarding the extravalvular cardiac damage defined by echocardiography prior the procedural

Abstract Background Recent studies have shown that the extent of extravalvular (extra-aortic valve) cardiac damage in patients with severe aortic stenosis (AS) have important prognostic implications for clinical outcomes after aortic valve replacement (AVR). Aims The aim of the present study is to evaluate the prognostic impact of a defined staging classification (“Généreux Staging Classification”) (GSC) characterizing the extent of extravalvular cardiac damage in patients with severe AS undergoing percutaneous transcatheter aortic valve implantation (TAVI). Methods A total of 102 consecutive patients, admitted in our institution between 2011–2017, with severe AS (echo-defined by peak aortic velocity, mean transvalvular gradient or aortic valve area) and symptoms related to AS (dyspnea, heart failure, angina or syncope) undergoing TAVI, were included. These patients were pooled and classified according to the presence or absence of cardiac damage as detected by echocardiography prior to TAVI, regarding the GSC: no extravalvular cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage (Stage 4). Two-year outcomes were compared using Kaplan– Meier techniques and multivariable Cox proportional hazards models were used to identify 2-year predictors of mortality. Results Out of 102 patients, 57 were male (55.9%). Mean age was 83.46±4.23 years. 2 patients (2.1%) were classified as Stage 0; 20 patients (20.3%) as Stage 1; 55 patients (54.2%) as Stage 2; 22 (21.6%) as Stage 3; and 3 patients (2.9%) as Stage 4. Two-year mortality was 0.0% in Stage 0, 5.0% in Stage 1, 5.5% in Stage 2, and 44.0% in Stages 3–4. After multivariable and univariate analysis, stage of cardiac damage was independently associated as predictor for all-cause mortality at 2-years, after TAVI (HR 2.8 [1.3±6.2], p&amp;lt;0.01). There were not another identificable predictors of 2-years death (age, sex, hypertension [78.5% of total patients], dislipemia [64.7%], diabetes [30.3%], smoking [78.5%], O2-chronic obstructive pulmonary disease [27.5% of total patients], renal insufficiency [78.5%], previous coronary artery disease [37.3%], peak aortic velocity, mean transvalvular gradient, and aortic valve area). Conclusions Given the strong association demonstrated in this study between advanced staging of cardiac damage and worse clinical outcomes after TAVI in short-middle term survival, consideration of the GSC in patients with severe AS in future recommendations for risk stratification might be useful. Two-year all-cause death in TAVI by GSC. Funding Acknowledgement Type of funding source: None

Prognostic role of global work index in asymptomatic patients with aortic stenosis

Abstract Background In asymptomatic patients with aortic stenosis (AS), the optimal timing for intervention is still challenging. Previous studies demonstrated that advanced stages of cardiac damage are associated with excess mortality. The role of myocardial work to identify cardiac dysfunction in AS and to predict prognosis has not been investigated. Purpose We aimed to evaluate the modification of myocardial work indices related to AS stages and their prognostic value. Methods This study analysed clinical, echocardiographic and outcome data of 170 patients with asymptomatic AS (aortic valve area ≤1.5 cm2) and preserved ejection fraction (LVEF ≥50%). Exclusion criteria were: significant associated cardiac valve lesion, left bundle branch block and suboptimal quality of speckle-tracking image analysis. The control group included 50 patients matched for age and sex. Global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were estimated by LV pressure-strain loops. In AS group, LV pressure was evaluated by adding trans-aortic mean gradient to systolic blood pressure. The following staging classification was used: no cardiac damage associated with the valve stenosis (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary hypertension or tricuspid valve damage (Stage 3), or right ventricular damage or subclinical heart failure (Stage 4). Results While global longitudinal strain was significantly lower in AS than in control group (18.7±2.8 vs 20.7±2.1%, p&amp;lt;0.001), increased values of GCW and GWI (respectively 2948±598 vs 2360±353 mmHg%, and 2528±521 vs 2005±302 mmHg%, p&amp;lt;0.001) were observed in patients with AS. Besides, GWW was significantly increased in AS vs controls (139±90 vs 90±49 mmHg%, p=0.001), with no changes in terms of GWE (95±4 vs 96±2%, p=0.110). When patients were stratified according the stages of cardiac damage, MW indices didn't different significantly, except for the GWI, which was significantly lower in Stage 3 to 4 compared to Stage 0 and Stage 2 (2268±469 vs 2623±503 vs 2610±503 mmHg% respectively, p=0.025). During a mean follow up of 27 months (IQ range 12–48 mo), 18 patients had a CV death. The best GWI value associated with outcome was 1866 mmHg% (sensitivity 45%, specificity 96%, AUC= 0.701, p=0.01). The presence of a GWI at baseline lower than 1866 mmHg% was associated with a higher rate of CV events at 4-year follow-up (57% vs 7%, log-rank p&amp;lt;0.001). On multivariable Cox-regression analysis, BNP values (P=0.014) and GWI &amp;lt;1866 mmHg% (P=0.033) emerged as independently associated with CV death. Conclusion In asymptomatic patients with AS, advanced stages of cardiac damage are characterized by reduced values of GWI, that are associated with increased mortality. Thus, the evaluation of MW indices may allow a better phenotyping of asymptomatic patients at higher risk of developing cardiovascular events during follow-up. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Cardiopath PhD program

External validation of a new staging system for severe aortic stenosis in a Portuguese cohort

Abstract Background Recently, a new staging system for severe aortic stenosis (AS) based upon the extent of extra-aortic-valve cardiac damage has been developed (Genereux et al. Eur Heart J 2017). The present study aimed to: 1) determine the prevalence of the different stages of extra-aortic valvular cardiac damage and its impact on prognosis in a real-world Portuguese cohort and; 2) evaluate the distribution of aortic valve calcium score (AV-CaSc) and its prognostic value. Methods Consecutive patients evaluated at a single-centre TAVI-programme between Nov/2015 and Nov/2018 were retrospective selected. The extent of extra-aortic valve cardiac damage was defined by echocardiography as stage 0 (no cardiac damage), stage 1 (left ventricular damage), stage 2 (mitral valve or left atrial damage), stage 3 (tricuspid valve or pulmonary artery vasculature damage) or stage 4 (right ventricular damage). AV-CaSc was estimated routinely at CT-angiography as per TAVI-programme protocol. The primary endpoint was 1-year all-cause mortality after CT-angiography. Survival analysis (Cox-regression hazards model and Kaplan-Meier) was performed. To account for the effect of aortic valve replacement (AVR), this variable entered the Cox-regression model as a time-dependent covariate. Results A total of 443 patients (mean age 82±7 years, 44% men, median euroSCORE II 4% [IQR 2.4–5.8]) were identified. After Heart Team discussion, 79% (n=349) underwent AVR (TAVI=307; surgical valve repair=42); 9% (n=42) await intervention; 6% (n=25) remain under medical treatment; 4% (n=19) died during the period of evaluation; and 2% (n=8) underwent palliative aortic balloon valvuloplasty. According to the proposed classification, the distribution of patients from stages 0 through 4 was: 0.2% (n=1), 7.5% (n=34), 67.8% (n=306), 14% (n=63), and 10.4% (n=47). Additionally, for each increasing stage of cardiac damage, the burden of AV-CaSc was higher (from stage 1 through 4: 1776 [IQR 1217–2448]; 2448 [1796–3442]; 2448 [1832–3622]; 2960 [1936–4878] units; p for trend = 0.002). All-cause mortality at 1-year was 14% (n=63). Mortality increased alongside with increasing extent of cardiac damage (from stage 0 through 4: 0% [n=0], 6% [n=2], 12% [n=36], 20% [n=12], and 30% [n=13]) – Fig. Multivariable analysis revealed chronic renal disease (HR 1.37 per stage [1.15–1.64], p&amp;lt;0.001), AV-CaSc (HR 1.02 per 100 units [1.01–1.03], p=0.007), AVR (HR 0.46 [0.26–0.81], p=0.007) and stage of cardiac damage (HR 1.54 per stage [1.15–2.05], p=0.004) as independent predictors of 1-year mortality. Conclusion In a real-world Portuguese cohort of severe AS patients, the extent of cardiac damage was associated with 1-year mortality. AV- CaSc grants additional prognostic information to this classification. Incorporation of this staging system into patient evaluation may be useful in the risk assessment of severe AS. Survival analysis Funding Acknowledgement Type of funding source: None

Incremental value of left ventricular global longitudinal strain in a newly proposed staging classification based on cardiac damage in patients with severe aortic stenosis.

Cardiac damage in severe aortic stenosis (AS) can be classified according to a recently proposed staging classification. The present study investigated the incremental prognostic value of left ventricular (LV) global longitudinal strain (GLS) over stages of cardiac damage in patients with severe AS. From an ongoing registry, a total of 616 severe symptomatic AS patients with available LV GLS by speckle tracking echocardiography were selected and retrospectively analysed. Patients were categorized according to cardiac damage on echocardiography: Stage 0 (no damage), Stage 1 (LV damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage), or Stage 4 (right ventricular damage). LV GLS was divided by quintiles and assigned to the different stages. The endpoint was all-cause mortality. Over a median follow-up of 44 [24-89] months, 234 (38%) patients died. LV GLS was associated with all-cause mortality independent of stage of cardiac damage. After incorporation of LV GLS by quintiles into the staging classification, Stages 2-4 were independently associated with outcome. LV GLS showed incremental prognostic value over clinical characteristics and stages of cardiac damage. In this large single-centre cohort of severe AS patients, incorporation of LV GLS by quintiles in a novel proposed staging classification resulted in refinement of risk stratification by identifying patients with more advanced cardiac damage. LV GLS was shown to provide incremental prognostic value over the originally proposed staging classification.

Study on the Correlation Between the Clinical-Pathological Classification of Rheumatic Mitral Valve Damage and Surgical Strategy in China

Objective: To analyze the correlation between the clinical-pathological classification of rheumatic mitral valve damage and surgical strategy for clinical cases in China and to summarize and analyz...

Transcatheter aortic valve replacement in patients with previous mitral valve replacement. A systematic study.

IntroductionSevere aortic stenosis (AS) is an ever-growing healthcare problem in ageing populations. Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of AS. However, TAVI in patients who have undergone mitral valve replacement (MVR) is associated with increased risk of mitral valve damage. Limited data exist on TAVI in patients with AS who underwent MVR in the past.AimTo retrospectively assess the clinical characteristics, detailed echocardiographic and computed tomography measurements, procedural and in-hospital outcome as well as any valve intervention or major adverse cardiovascular events according to VARC-2 criteria at follow-up of patients with a history of MVR, who underwent TAVI.Material and methodsSeventeen patients with a history of mitral valve operation, in whom TAVI was performed between 2010 and 2018, were identified. Of these, 15 underwent previous MVR.ResultsOverall, TAVI resulted in a decrease of mean transaortic gradient by 38.3 ±14 mm Hg (p < 0.001) and a decrease of maximal transaortic gradient by 58.6 ±27.6 mm Hg (p < 0.001). A successful immediate result was obtained in 14 (93.3%) patients. One tamponade occurred during TAVI, which was successfully treated with pericardiocentesis. Post-procedurally, no significant changes in transmitral gradients or mitral regurgitations were observed. Two patients died after hospital discharge, one due to possible internal bleeding and the other due to infection.ConclusionsTAVI in patients after MVR is feasible. Meticulous preinterventional echocardiographic and computed tomography planning is essential. Although recommended in previous reports, TEE guidance may not necessarily be obligatory during the procedure.

Intramuscular Immunization of Streptococcus pyogenes SF370 protein extract and identification of multiple virulence factors through proteomic profiling in RHD induced Balb/c mice

Group A streptococcus (GAS) and autoimmunity are associated with heart related mitral valve damage, in adults. In this study Balb/c mice were intramuscularly immunized with S. pyogenes SF370 for 4 weeks. Prior to euthanization, physiological parameters like body weight and electrical signalling of the heart were recorded. After euthanization, the heart tissue homogenate was prepared and proteomic alterations were studied using SDS-PAGE and 2D electrophoresis. The expression levels of inflammatory genes like TNFα, IFNγ and TGF-β were quantified using real time PCR. Insilico analysis was performed to identify the functions of hypothetical proteins and virulence factors involved in the induction of rheumatic carditis. The results showed a reduction in body weight, ulceration, inflammation, cardiac lesions and prolonged PR interval in mice immunized with S. pyogenes SF370, as a result of RHD. The heart related proteins like α-actinin, fatty acid binding protein-heart, myosin light chain 3, hemoglobin subunit alpha, myoglobin regulatory light chain 2, (ventricular/cardiac muscle isoform), myosin-6, troponin-1 were found to be up-regulated when compared with the control. The functional annotation of S. pyogenes (SF370) was carried out by retrieving 1696 identified proteins and 653 hypothetical protein sequences in NCBI genome database. The conserved domain was identified for 505 proteins. The pfam database documented that the super families of 279 sequences and 40 signal peptides enabled the classification of proteins in different categories like biological (20%), cellular (22%) and molecular functions (36%). Putative transcription repair coupling factor and putative lysine aminopeptidase N terminal are the two virulence factors identified by VICMPRED in S. pyogenes SF370. The two identified virulence factors are involved in altering the mice heart proteome and thereby controlling the streptococcus pyogenes infection. Thus, the results of the present study reveals the role of immunogenic proteins in induction of rheumatic carditis and to elucidate the molecular mechanisms leading to autoimmune reactions in Balb/c mice.