Peak Diastolic Flow Velocity Research Articles

Determinants of right ventricular - pulmonary arterial uncoupling in hypertrophic cardiomyopathy

Abstract Background Right ventricular (RV) – pulmonary arterial (PA) coupling, assessed by echocardiography, is a non-invasive surrogate on how the RV is adapted to an increased afterload in the pulmonary circulation. In cases of exhaustion of compensatory RV remodeling, the ratio decreases and there is RV-PA uncoupling. Our objective was to identify what are the determinants of this parameter in patients with hypertrophic cardiomyopathy (HCM). Methods This prospective cohort study enrolled patients with HCM without obstructive epicardial coronary artery disease, that underwent a comprehensive evaluation. Echocardiography was used to assess RV-PA coupling as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP). In addition, coronary flow reserve in the left anterior descending artery (CFR_LAD) was also evaluated: diastolic coronary flow velocity was measured in basal conditions and in hyperemia and CFR was calculated as the ratio of hyperemic and basal peak diastolic flow velocities. This was used as a surrogate marker of coronary microvascular dysfunction. Cardiac magnetic resonance (CMR) was also performed to evaluate RV function (volumes and ejection fraction), and the extent of late gadolinium enhancement (LGE) in the left ventricle (LV). Results We enrolled 62 patients, with a mean age of 55 (15) years, 64% males. In 64% it was an asymmetrical septal hypertrophy phenotype, in 31% an apical hypertrophy, and in 27%, it was an obstructive HCM. Mean TAPSE/PASP was 0.556 (0.23) and median was 0.50. All patients had a normal LV ejection fraction. Univariable linear regression analysis showed that age, maximal wall thickness, E/E’, indexed left atrial volume (LAVi), CFR-LAD, %LGE and % hypoperfusion (by CMR) were correlated with RV-PA uncoupling. The HCM phenotype or the presence of obstruction were not associated with uncoupling. Multivariable stepwise linear regression analysis showed that the independent predictors of RV-PA uncoupling were age (b-estimate: - 0.180, p=0.009), LAVi (b-estimate: -0.645, p=<0.001), CFR-LAD (b-estimate: 0.183, p=0.011) and %LGE (b-estimate: -0.270, p=<0.001). Conclusion In patients with HCM, the presence of coronary microcirculation abnormalities and the extent of LGE in the LV are independent predictors of RV-PA uncoupling.

Non-alcoholic fatty liver disease is associated with coronary flow reserve impairment: A pilot meta-analysis.

Non-alcoholic fatty liver disease (NAFLD) is estimated to affect approximately 25% of the global population. Both, coronary artery disease and NAFLD are linked to underlying insulin resistance and inflammation as drivers of the disease. Coronary flow reserve parameters, including coronary flow reserve velocity (CFRV), baseline diastolic peak flow velocity (DPFV), and hyperemic DPFV, are noninvasive markers of coronary microvascular circulation. The existing literature contains conflicting findings regarding these parameters in NAFLD patients. A comprehensive systematic search was conducted on major electronic databases from inception until May 8, 2024, to identify relevant studies. We pooled the standardized mean differences (SMD) with 95% confidence intervals (CI) using the inverse-variance random-effects model. Statistical significance was set at P < .05. Four studies with 1139 participants (226 with NAFLD and 913 as controls) were included. NAFLD was associated with a significantly lower CFRV (SMD: -0.77; 95% CI: -1.19, -0.36; P < .0002) and hyperemic DPFV (SMD: -0.73; 95% CI: -1.03, -0.44; P < .00001) than the controls. NAFLD demonstrated a statistically insignificant trend toward a reduction in baseline DPFV (SMD: -0.09; 95% CI: -0.38, 0.19; P = .52) compared to healthy controls. Patients with NAFLD are at a higher risk of coronary microvascular dysfunction, as demonstrated by reduced CFRV and hyperemic DPFV. The presence of abnormal coronary flow reserve in patients with NAFLD provides insights into the higher rates of cardiovascular disease in these patients. Early aggressive targeted interventions for impaired coronary flow reserve in subjects with NAFLD may lead to improvement in clinical outcomes.

Echocardiographic Detection of Subclinical Left Ventricular Dysfunction in Asymptomatic Type Two Diabetes Mellitus

Background: Before systolic dysfunction and symptomatic heart, diabetic cardiomyopathy begins with left ventricular diastolic dysfunction (LVDD). Echocardiographic modalities were used to detect subclinical LV impairment in asymptomatic type 2 diabetics. This study aimed to identify subclinical left ventricular impairment in asymptomatic patients with type two diabetes using several echocardiographic techniques. Methods: In the present prospective cohort study, 30 adults over 18 having type II diabetes mellitus (DM) (Group I) and 20 normal controls (Group II) were studied. Transthoracic echocardiography and 12-lead ECG were performed on all individuals. Results: Pulsed wave Doppler techniques revealed significant variation in transmitral flow velocities between groups, including septal e', lateral mitral annulus early velocity (e'), septal early diastolic peak flow velocity (E)\e', Lateral E\e', and average E\e'. EF was significantly decreased in group I (P &lt; 0.001). With a p-value of 0.001, LVESD was significantly higher in group I. The septal, lateral, and average systolic mitral annulus (S') motions in group II were significantly larger than those in group I. When comparing groups, I and II, the first showed much longer myocardial performance index (MPI) and isovolumetric contraction time (IVCT). The ET for Group I was significantly lower than that of Group II. The study group exhibited significantly greater levels of fasting blood sugar, post-prandial blood sugar, and haemoglobin A1C (HBA1C) compared to the control group (P &lt;0.001). Conclusions: Patients having diabetes mellitus exhibited considerably greater levels of DM history fasting glucose levels, postprandial glucose levels, haemoglobin A1C (HBA1C), E/e´ ratio, LVESD, IVCT, and MPI, while having significantly lower EF and ET relative to the healthy group.

Impact of left ventricular diastolic function and direct oral anticoagulant use for predicting embolic events in patients with heart failure and atrial fibrillation

AbstractBackgroundPatients with atrial fibrillation (AF) and heart failure (HF) have high stroke risk owing to left atrial dysfunction. However, anticoagulation is a concern in patients with high bleeding risk. We aimed to identify independent predictors of stroke in HF patients with AF.MethodsWe retrospectively examined 320 patients (mean age 79 ± 12 years, 163 women) hospitalized with acute HF complicated by AF between January 2014 and December 2018. Patients were followed from admission until ischemic stroke or systemic embolism (SSE) onset or death or were censored at the last contact date or September 2023.ResultsSSE occurred in 40 patients (median follow‐up of 528 days). Multivariate Cox regression analysis identified age (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.00–1.07, p = .034), direct oral anticoagulant (DOAC) use (HR 0.26, 95% CI 0.11–0.60, p = .002), and early diastolic peak flow velocity to early diastolic peak annular velocity (E/e'; HR 1.05, 95% CI 1.02–1.08, p &lt; .001) to be independent predictors of SSE, whereas left atrial reservoir strain was not. After determining an appropriate E/e' cutoff by receiver‐operating characteristic curve analysis and adjusting the multivariate Cox model, E/e' ≥17.5 (HR 3.30, 95% CI 1.56–6.83, p = .001) independently predicted SSE. The results were consistent with no interaction in the subanalysis except for gender.ConclusionElderly patients not on DOACs with elevated E/e' may be at higher risk of stroke, suggesting that DOACs should be the first choice for patients with elevated E/e' and aggressive additional prophylaxis and careful follow‐up are needed.

FIB-4 liver fibrosis index correlates with aortic valve sclerosis in non-alcoholic population.

Hepatic fibrosis, a progressive scarring of liver tissue, is commonly caused by non-alcoholic fatty liver disease (NAFLD), which increases the risk of cardiovascular disease. The Fibrosis-4 (FIB-4) index is a non-invasive tool used to assess liver fibrosis in patients with NAFLD. Aortic valve sclerosis (AVS), a degenerative disorder characterized by thickening and calcification of valve leaflets, is prevalent in the elderly and associated with increased cardiovascular morbidity and mortality. Recent studies have suggested that AVS may also be linked to other systemic diseases such as liver fibrosis. This study aimed to investigate the relationship between the FIB-4 index and AVS in a non-alcoholic population, with the hypothesis that the FIB-4 index could serve as a potential marker for AVS. A total of 92 patients were included in this study. AVS was detected using transthoracic echocardiography, and patients were divided into groups according to the presence of AVS. The FIB-4 index was calculated for all patients and compared between the groups. A total of 17 (18.4%) patients were diagnosed AVS. Patients with AVS had higher rates of diabetes mellitus, older age, hypertension, angiotensin-converting enzyme inhibitor use, higher systolic blood pressure (BP) and diastolic BP in the office, coronary artery disease prevalence, left atrial volume index (LAVI), left ventricular mass index (LVMI), and late diastolic peak flow velocity (A) compared to those without AVS. Moreover, AVS patients had significantly higher creatinine levels and lower estimated glomerular filtration rate. Remarkably, the FIB-4 index was significantly higher in patients with AVS. In univariate and multivariate analyses, higher systolic BP in the office (OR, 1.044; 95% CI 1.002-1.080, p=.024) and higher FIB-4 index (1.46±.6 vs. .91±.46, p<.001) were independently associated with AVS. Our findings suggest that the FIB-4 index is associated with AVS in non-alcoholic individuals. Our results highlight the potential utility of the FIB-4 index as a non-invasive tool for identifying individuals at an increased risk of developing AVS.

Association between optical coherence tomography-defined culprit morphologies and changes in hyperemic coronary flow after elective stenting assessed by transthoracic Doppler echocardiography.

Stress-transthoracic Doppler echocardiography (S-TDE) provides a noninvasive assessment of coronary flow parameters in the left anterior descending artery (LAD). However, the association between morphological characteristics and coronary flow changes after elective percutaneous coronary intervention (PCI) remains unclear. We aimed to evaluate the relationships between periprocedural coronary flow changes observed on S-TDE and lesion-specific plaque characteristics obtained by optical coherence tomography (OCT) in the interrogated vessels in patients with chronic coronary syndrome (CCS). Patients with CCS who underwent pre- and post-PCI S-TDE and elective fractional flow reserve (FFR)-guided PCI under OCT guidance for de novo single LAD lesions were included. S-TDE-derived hyperemic diastolic peak flow velocity (hDPV) was used as a surrogate for coronary flow. Lesions were categorized into two groups based on the %hDPV increase or decrease. The baseline clinical, physiological, and OCT findings were compared between the groups. In total, 103 LAD lesions were studied in 103 patients. After PCI, hDPV significantly increased from 55.6 cm/s to 69.5 cm/s (P<0.01), with a median %hDPV increase of 27.2 (6.32-59.1) %, while %hDPV decreased in 20 (19.4%) patients. The FFR improved in all patients. On OCT, layered plaques were more frequently present in the culprit vessels in the %hDPV-decrease group than in the %hDPV-increase group (85.0% vs. 50.6%, P = 0.01). Multivariable logistic regression analysis showed that the presence of layered plaques and high pre-PCI hDPV were independent predictors of %hDPV decrease. In patients who underwent successful uncomplicated elective PCI for de novo single LAD lesions, the presence of layered plaques was independently associated with hyperemic coronary flow decrease as assessed by S-TDE.

Residual Microvasuclar Dysfunction (RMVD) after percutaneous coronary intervention (PCI) assessed by stress- transthoracic Doppler echocardiography (S-TDE)

Abstract Background Microvascular dysfunction (MVD) has been increasingly acknowledged as a relevant cause of myocardial ischemia and worse prognosis. Coronary flow velocity reserve (CFVR), an integrated marker of coronary circulation, can be obtained noninvasively by stress-TDE. However, limited data is available regarding residual MVD (RMVD) of the target territory after percutaneous coronary intervention (PCI) assessed by stress- transthoracic Doppler echocardiography (S-TDE). Purpose This study aimed to investigate the echocardiographic predictors for RMVD after PCI assessed by S-TDE. Methods This study prospectively included 175 patients with chronic coronary syndrome who were scheduled for elective PCI at a single tertiary-care center between April 2019 and November 2022. All patients had anginal symptoms with de novo, functionally significant, proximal left anterior descending (LAD) lesions and underwent fractional flow reserve (FFR)-guided elective single vessel PCI for LAD. Exclusion criteria were patients with reduced left ventricular (LV) systolic function (ejection fraction &amp;lt; 50%), periprocedural myocardial infarction as defined by the fourth universal definition of myocardial infarction. Eligible patients underwent pre- (1 day before) and post-procedural (3 days after) LAD coronary flow assessments by S-TDE. Coronary flow velocity reserve (CFVR) was calculated as the ratio of the hyperemic peak diastolic flow velocity to the basal peak diastolic flow velocity. We also excluded the patients with suboptimal S-TDE imaging. We defined an RMVD after PCI as a post-PCI CFVR impairment (CFVR&amp;lt;2.0). Association between RMVD and echocardiographic parameters were evaluated. Results A total of 150 patients were included in the final analysis. RMVD was observed in forty-five (30.0%) patients after successful LAD PCI. Patients with RMVD had older age (74 [67-79] versus 72 [59-76], P=0.042) and lower estimated glomerular filtration rate (eGFR) (58.4 [37.6-75.1] mL/min/1.73m2 versus 65.9 [54.3-75.5] mL/min/1.73m2, P=0.045) than those without RMVD. Univariate logistic regression analyses revealed that higher age, lower eGFR, pre-PCI higher ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity (E/e’), shorter deceleration time of diastolic coronary flow (DDT) and lower pre-PCI CFVR were associated with post-PCI RMVD. Multivariate logistic regression analyses including age and eGFR as covariates showed higher E/e’ (adjusted odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25, P=0.022), shorter DDT (OR 0.999, 95% CI 0.998-1.000, P=0.045) and lower pre-PCI CFVR (OR 0.336, 95% CI 0.165-0.683, P=0.003) were independently predictive of RMVD. Conclusions In patients with preserved LV ejection fraction who underwent successful elective FFR-guided PCI for LAD, pre-PCI LV diastolic dysfunction was associated with post-PCI residual microvascular dysfunction of LAD territory.

TDE-derived impaired post-PCI Coronary flow velocity reserve predicts MACE in patients who underwent LAD PCI

Abstract Background Coronary flow velocity reserve (CFVR) can be obtained noninvasively by stress transthoracic Doppler echocardiography (S-TDE). However, prognostic significance of S-TDE-derived CFVR after percutaneous coronary intervention (PCI) remains unknown. Purpose This study aimed to investigate the relationship between post-PCI CFVR and major adverse cardiac event (MACE). Methods This study prospectively included 200 patients with stable coronary artery disease who were scheduled for elective PCI of de novo, single, functionally significant left anterior descending (LAD) lesions at a single tertiary-care center between April 2019 and November 2022. All patients underwent fractional flow reserve (FFR)-guided elective PCI. Exclusion criteria were patients with previous coronary artery bypass graft surgery, left main coronary artery disease and periprocedural myocardial infarction as defined by the fourth universal definition of myocardial infarction. Eligible patients underwent pre- (1 day before) and post-procedural (3 days after) LAD coronary flow assessments by stress-TDE. CFVR was calculated as the ratio of the hyperemic peak diastolic flow velocity to the basal peak diastolic flow velocity. We also excluded the patients with suboptimal S-TDE imaging. Association between post-PCI physiological parameters and MACE (composite of cardiac death, myocardial infarction, heart failure and target vessel revascularization) were evaluated. Results A total of 174 patients were included in the final analysis after successful LAD PCI. MACE occurred in twenty-one (12.0%) patients during the follow-up (1.9 [0.9-2.5] years). Clinical demographics were similar in patients with versus without MACE. Post-PCI S-TDE-derived CFVR was lower in patients with versus without MACE (P = 0.023), while post-PCI FFR values tended to be lower in patients with versus without MACE, albeit not significant (P = 0.077). Receiver-operating characteristic curve analysis revealed that the optimal cut-off values of post-PCI FFR and post-PCI CFVR values to predict MACE were 0.83 and 1.70, respectively. Significant differences in the MACE were detected according to post-PCI FFR (≤ 0.83 versus &amp;gt; 0,83: 17.9 % versus 6.7 %, P = 0.035) and post-PCI CFVR (&amp;lt; 1.70 versus ≥ 1.70: 33.3% versus 8.2%, P = 0.001). On a multivariable Cox-proportional hazard analysis, patients with post-PCI CFVR &amp;lt; 1.70 had an increased risk for MACE (adjusted hazard ratio [HR] 4.75, 95% confidence interval [CI] 1.98-11.38, P &amp;lt; 0.001), along with post-PCI FFR ≤ 0.83 (adjusted HR 2.78, 95% CI 1.07-7.20, P=0.035). Conclusions In patients who underwent successful elective PCI for LAD, S-TDE-derived impaired post-PCI CFVR and post-PCI FFR were independently associated with MACE.

Cigarette smoking abolishes the mediterranean diet benefit on exercise capacity, coronary physiology and target organ damage in hypertensive males with erectile dysfunction

Abstract Background Erectile dysfunction (ED) often coexists impairing quality of life in the hypertensive aging male population. The Mediterranean diet (Med-diet) benefits cardiovascular health. Coronary flow reserve (CFR) displays the ability of the coronary circulation to increase flow. Central vascular stiffness and microalbuminuria (UMALb) represent hypertension-related target organ damage (TOD). Purpose To investigate cigarette smoking adverse effects on the Med-diet benefit in exercise capacity, coronary physiology and TOD in hypertensive males with ED. Methods We enrolled 290 hypertensive ED males (mean age: 57 yo) with no history of diabetes mellitus or overt cardiovascular disease. 121 (42%) were current cigarette smokers. Intensity of smoking referred in packs/year. All underwent a treadmill stress test (Bruce protocol), exercise capacity was validated as metabolic equivalents (METs). We measured the CFR of the LAD artery (2D echo) by performing an adenosine protocol (max dose 140μg/Kg/min over 6 min). PW Doppler measurements were achieved at the middle/distal LAD (color Doppler flow mapping). CFR was validated as ratio between peak diastolic flow velocity following drug infusion and rest. Ratios ≥ 2 indicate macro and microvascular coronary integrity. Participants were screened for the presence of UMALb (urinary albumin loss 30 – 300 mg /24 h urine volume collection). Finally a non-invasive evaluation of the carotid – femoral pulse wave velocity (PWV), estimation of central pressures and augmentation index (AIx) a parameter of wave reflection amplification were performed (Sphygmocor device). ED severity and the Med-diet adherence were assessed by the SHIM-5 (range:0-25) and the Med-diet (range:0-55) scores. Higher values indicate a better erectile ability and Med-diet compliance respectively. Results In bivariate analysis the Med-diet score was positively associated with METs, CFR and the SHIM-5 score and negatively with PWV, AIx and UMALb (p&amp;lt; 0,05). CFR, METs and the SHIM-5 score were also positively related (p&amp;lt; 0,03). In linear regression analysis the Med-diet relation remained significant after correction for age, BMI, LDL, total cholesterol and systolic blood pressure. However introducing cigarette smoking as a cofounder abolished the above relations. Packs/year were positively related to AIx, UMALb and negatively to the SHIM-5 score (p&amp;lt; 0,05). We also divided our population according to the mean Med-diet score (27) in high and low Med-diet groups .The high score group had higher METs and SHIM-5 score and lower PWV. Smokers had higher AIx and lower SHIM-5 score (pictures). Conclusion Cigarette smoking influences microvascular physiology and peripheral wave reflection and so abolishes Med-diet benefit on exercise capacity, coronary physiology, target organ damage and erectile ability in hypertensive males with ED. It is of vital importance consult this population avoiding smoking to restore cardiovascular health and quality of life.

Association between myocardial bridge with transthoracic doppler echocardiography-defined physiological indices and fractional flow reserve before and after elective percutaneous coronary intervention

Abstract Background A myocardial bridge (MB) is a coronary variant in which an epicardial coronary artery courses through myocardium. MB can be identified by computed tomographic coronary angiography (CTCA) or invasive coronary angiography (ICA), which is known to be common in left anterior descending artery (LAD). Transthoracic Doppler echocardiography (TDE) noninvasively provides coronary flow information. Purpose We aimed to investigate the physiological impact of myocardial bridge on coronary flow dynamics assessed by adenosine-induced stress-TDE before and after elective percutaneous coronary intervention (PCI). Methods We examined 93 consecutive patients treated with fractional flow reserve (FFR)-guided elective PCI who underwent pre-PCI CTCA and pre- and post-PCI stress-TDE. We compared patient characteristics, angiographic, physiological data, and stress-TDE-defined coronary flow parameters in patients with versus without MB. Results We identified MB in 40 (43.0%) and 15 (16.1%) patients by CTCA and ICA, respectively. All MBs diagnosed by ICA were identified by CTCA. Longer MB was associated with the detectability by ICA. Older age and higher frequency of diabetes mellitus were observed in patients with CTCA-defined MB compared with those without. Pre-PCI FFR was similar in patients with versus without CTCA-defined MB (0.69 [0.61-0.73] vs. 0.69 [0.61-0.75], P=0.92), while post-PCI FFR was significantly lower in patients with versus without CTCA-defined MB (0.82 [0.78-0.86] vs. 0.84 [0.82-0.88], P=0.01). Pre- and Post- PCI hyperemic systolic peak flow velocity (SPV) by stress-TDE was higher in patients with versus without MB by CTCA (36 [26-43] m/s vs. 30 [23-34] m/s, P=0.03 and 38 [32-52] m/s vs. 33 [20-39] m/s, P=0.02, respectively). Pre-PCI hyperemic diastolic peak flow velocity (DPV) by stress-TDE was not significantly different between the 2 groups (49 [39-64] m/s vs. 45 [34-55] m/s, P=0.12), while post-PCI hyperemic DPV was higher in patients with versus without CTCA-defined MB (73 [60-85] m/s vs. 63 [50-81] m/s, P=0.03). Conclusion In patients undergoing elective PCI for LAD, a presence of CTCA-defined MB was associated with higher pre- and post-PCI hyperemic SPV and an acceleration of hyperemic DPV after the PCI. Impact of systolic compression by MB on hyperemic DPV at the distal segment accelerated by the treatment of upstream stenosis may lead to lower post-PCI FFR compared with patients without MB.

Anatomical, functional and prognostic correlates of resting coronary flow velocity in patients with hypertrophic cardiomyopathy

Abstract Background The clinical significance of baseline peak diastolic coronary flow velocity (CFV) in the left anterior descending coronary artery (LAD) has not been investigated yet in patients with hypertrophic cardiomyopathy (HCM). Aim To assess the anatomical, functional and prognostic correlates of baseline LAD CFV in HCM. Methods 384 consecutive adult HCM patients (age=52+15 years, 164 [43%] females) with no known coronary artery disease from 8 centers in 5 countries were prospectively analyzed. All patients underwent comprehensive transthoracic echocardiography including CFV measurement with pulse wave Doppler in the mid-distal LAD. All patients had preserved left ventricular (LV) function. LV force was calculated as (peak instantaneous LV outflow tract gradient+systolic blood pressure)/LV end-systolic volume. Patients were followed for a median of 50 months (IQ range 18-97 months), the outcome measure was a composite endpoint of all-cause death and acute heart failure. Results The mean CFV was 36±11 cm/s. CFV was positively correlated with LV maximal wall thickness (r=0.375, p&amp;lt;0.001), LV maximal septal thickness (r=0.320, p&amp;lt;0.001), resting LV outflow tract gradient (r=0.274, p&amp;lt;0.001), LV force (r=0.227, p&amp;lt;0.001), mean E/e’ (r=0.479, p&amp;lt;0.001) and heart rate (r=0.221, p&amp;lt;0.001). During follow-up, 54 events occurred (33 all-cause deaths and 21 acute heart failures). Receiver operating characteristic analysis was used to determine the best cut-off value of CFV (&amp;gt;31 cm/s) to predict the composite endpoint. Patients with CFV &amp;gt;31 cm/s had a significantly worse 10-year event-free survival compared to those with CFV ≤31 cm/s, see Figure. Conclusion Higher resting LAD CFV is associated with greater LV wall thickness, higher LV outflow tract gradient, faster heart rate and more elevated left ventricular filling pressures in HCM. Elevated resting CFV may indicate a coronary microcirculation dysfunction either primary or secondary to anatomical (septal hypertrophy), functional (increased myocardial oxygen demand), or autonomic (increased sympathetic drive) determinants. Whatever the underlying endotype, high resting CFV is related to worse prognosis in the long term.Figure.

Abstract 13363: Echocardiographic Coronary Flow Velocity Parameters in Assessing Sub-Clinical Atherosclerosis in Inflammatory Bowel Disease Patients: A Meta-Analysis

Introduction: Chronic inflammatory diseases are linked to atherosclerosis and cardiovascular events. However, there are conflicting results in the literature regarding differences in echocardiographic Coronary Flow velocity parameters, which serve as markers of subclinical atherosclerosis, between inflammatory bowel disease (IBD) patients and healthy controls. Hypothesis: We aim to assess the Coronary Flow Velocity Reserve (CFVR), baseline Diastolic Peak Flow Velocity (DPFV), and hyperemic DPFV in IBD patients. Methods: We conducted a systematic search of databases, from January 1, 2014, to June 1, 2023, to gather relevant studies. The pooled mean differences in various parameters between IBD patients and controls were calculated using the standard mean difference with 95% confidence interval (CI), and random effect model was used when heterogeneity (I 2 ) crossed 50%. Results: 4 studies with 342 participants were included. The mean age of the IBD group was 39.25 years and of the control group was 41.25 years. Male comprised 51.46% of the study participants. IBD patients had a significantly lower CFVR (SMD; -1.12 95%CI; [-1.62, -0.61], p-value&lt;0.01) and hyperemic DPFV (SMD; -0.68, 95%CI [-1.09, -0.27], p-value&lt;0.01) than healthy controls. Whereas, Healthy controls had a lower baseline DPFV (SMD; 0.69 95%CI; [0.35, 1.04], p-value&lt;0.01) than the IBD group. Conclusions: IBD was associated with Coronary Microvascular Disease assessed as impaired CFVR and hyperemic DPFV. This suggests reduced myocardial perfusion in IBD patients and the need for regular cardiovascular risk assessment and targeted interventions to mitigate the increased risk of cardiovascular events.

Accelerated stenotic flow in the left anterior descending coronary artery explains the causes of impaired coronary flow reserve: an integrated transthoracic enhanced Doppler study.

Accelerated stenotic flow (AsF) in the entire left anterior descending coronary artery (LAD), assessed by transthoracic enhanced color Doppler (E-Doppler TTE), can reveal coronary stenosis (CS) and its severity, enabling a distinction between the microcirculatory and epicardial causes of coronary flow reserve (CFR) impairment. Eighty-four consecutive patients with a CFR <2.0 (1.5 ± 0.4), as assessed by E-Doppler TTE, scheduled for coronary angiography (CA) and eventually intracoronary ultrasounds (IVUS), were studied. CFR was calculated by the ratio of peak diastolic flow velocities: during i.v. adenosine (140 mcg/Kg/m) over resting; AsF was calculated as the percentage increase of localized maximal velocity in relation to a reference velocity. CA showed ≥50% lumen diameter narrowing of the LAD (critical CS) in 68% of patients (57/84) vs. non-critical CS in 32% (27/84). Based on the established CA/IVUS criteria, the non-critical CS subgroup was further subdivided into 2 groups: subcritical/diffuse [16/27 pts (57%)] and no atherosclerosis [11/27 pts (43%)]. CFR was similar in the three groups: 1.4 ± 0.3 in critical CS, 1.5 ± 0.4 in subcritical/diffuse CS, and 1.6 ± 0.4 in no atherosclerosis (p = ns). Overall, at least one segment of accelerated stenotic flow in the LAD was found in 73 patients (87%), while in 11 (13%) it was not. The AsF was very predictive of coronary segmental narrowing in both angio subgroups of atherosclerosis but as expected with the usage of different cutoffs. On the basis of the ROC curve, the optimal cutoff was 109% and 16% AsF % increment to successfully distinguish critical from non-critical CS (area under the curve [AUC] = 0.99, p < 0.001) and diffuse/subcritical from no CS (AUC = 0.91%, p < 0.001). Sensitivity and specificity were 96% and 100% and 82% and 100%, respectively. E-Doppler TTE is highly feasible and reliable in detecting the CS of any grade of severity, distinguishing epicardial athero from microvascular causes of a severe CFR reduction.

Ventricular dysfunction consequences of mechanical dyssynchrony in isolated complete right bundle branch block versus left bundle branch block.

Complete bundle branch block in individuals without structural heart disease is known as isolated complete bundle branch block. Isolated complete left bundle branch block (CLBBB) is correlated with ventricular dysfunction secondary to dyssynchrony; however, few studies have investigated isolated complete right bundle branch block (CRBBB), which was previously considered benign but was recently found to be associated with adverse cardiovascular outcomes. This study aimed to evaluate cardiac mechanical synchrony, and systolic and diastolic function in patients with isolated CRBBB and compare cardiac synchrony and function to patients with isolated CLBBB. This cross-sectional study was conducted at The First Hospital of China Medical University in Shenyang, China, from 2020 to 2021. A total of 44 isolated CRBBB patients, 44 isolated CLBBB patients, and 42 healthy subjects were enrolled in the study. Transthoracic echocardiography was performed in all subjects. Synchrony parameters, including the mechanical dispersion of the right ventricle [the standard deviation of time to the peak longitudinal strain of six right ventricular (RV) segments] and atrioventricular dyssynchrony parameter [the ratio of left ventricular (LV) diastolic filling time to the time interval between two adjacent R waves (RR interval) measured by tissue Doppler imaging]. RV and LV function were assessed by the global longitudinal strain (GLS) of six RV segments and 18 LV segments, and the ratio of the peak early diastolic flow velocity to annular velocity (E/e') of the tricuspid valve and mitral valve. Statistical analyses were performed, including an analysis of variance, Pearson correlation analysis, and linear regression analysis. Compared with the healthy subjects, the mechanical dispersion of the right ventricle was significantly increased, and ventricular function was impaired as evidenced by the decreased RV GLS and LV GLS, and the increased E/e' of the tricuspid valve and mitral valve in the isolated CRBBB patients (all P<0.001). Moreover, compared with the isolated CLBBB patients, the mechanical dispersion of the right ventricle and E/e' of the tricuspid valve were increased, and RV GLS was significantly reduced in the isolated CRBBB patients (all P<0.001). Mechanical dispersion of the right ventricle was independently associated with RV GLS [coefficient, 0.13; 95% confidence interval (CI): 0.004-0.26; P=0.04] in the isolated CRBBB patients. RV GLS (coefficient, 0.10; 95% CI: 0.01-0.20; P=0.03) and the ratio of the LV diastolic filling time to the RR interval measured (coefficient, -0.30; 95% CI: -0.53 to -0.07; P=0.01) were independent factors of LV GLS. The isolated CRBBB patients had impaired cardiac mechanical synchrony and ventricular function, and more decreased RV synchrony and function than the isolated CLBBB patients. Right intraventricular synchrony was independently associated with RV systolic dysfunction in patients with isolated CRBBB. Atrioventricular synchrony and RV systolic function were independently associated with the LV systolic function. Therefore, comprehensive evaluations of echocardiography results and close monitoring is required for isolated CRBBB patients.

Detection of left coronary ostial obstruction during transcatheter aortic valve replacement by coronary flow velocity measurement in the left main trunk by intraoperative transesophageal echocardiography

BackgroundCoronary obstruction is a rare but catastrophic complication of transcatheter aortic valve replacement (TAVR) and occurs mostly at the left coronary artery (LCA) ostium. However, some patients do not show any clinical findings, and thus, its detection is sometimes difficult. The peak diastolic flow velocity in left main coronary artery (LM) was reportedly increased in significant stenosis lesions. We evaluated the effectiveness of measuring blood flow velocities in LM by transesophageal echocardiography (TEE) for the detection of LCA ostial obstruction during a TAVR procedure. MethodsA total of 1105 consecutive patients who underwent TAVR in Sendai Kousei Hospital between September 2014 and December 2020 were enrolled. The LM blood flow velocity was measured at pre- and post-valve implantation. ResultsAmong the 1105 patients, 9 had LCA ostial obstruction. The peak LM blood flow velocity at post-TAVR [0.90 (0.39–1.15) vs. 0.37 (0.28–0.50) m/s; p = 0.0046) was significantly higher in 9 patients who had LCA ostial obstruction, compared with the remaining 1096 patients who had not (controls), although no significant difference was observed before the TAVR procedures between the two groups. The post- to pre-TAVR LM flow velocity ratio [2.26 (1.31–3.42) vs. 1.06 (0.82–1.36); p = 0.0030] was also significantly higher in patients with LCA obstruction, compared to the controls. Furthermore, the post- to pre-TAVR LM blood flow velocity ratio was >2.0 in all six hemodynamically stable patients with LCA obstruction, whereas <2.0 in all three patients with LCA obstruction who showed hemodynamic collapse at post-TAVR procedure. ConclusionCoronary blood flow velocity in LM significantly increased in hemodynamically stable LCA obstruction patients. The intraprocedural TEE measurement of the LM flow velocities would be potentially useful to detect asymptomatic and hemodynamically stable LCA ostial obstruction.

"Collar-like" neocommissure in mitral valve repair for extensive commissural prolapse.

ObjectivesMitral valve repair for extensive commissural prolapse is complex; several methods have been reported with variable results. To restore the leaflet area, we introduced an innovative and effective method rather than a simple folding technique through reconstructing a neocommissure with a “collar-like” plasty technique.MethodsFrom 2016 to 2021, 62 patients with mitral valve extensive commissural prolapse that received the “collar-like” plasty technique were included.ResultsThe mean age was 51.7 ± 13.8 years, and 38 (61%) were female. Postplasty transesophageal echocardiography showed the mean transvalvular pressure gradients were 3.8 ± 1.2 mm Hg, end diastolic peak flow velocity was 1.1 ± 0.3 m/s, and coaptation height was 7.9 ± 1.1 mm. During the follow-up period of 3 to 6 months, no deaths or cardiovascular-/valvular plasty-related adverse events occurred. All patients regained their heart function and returned to normal physical activities.ConclusionsThe “collar-like” plasty technique can be safely performed for patients with extensive commissural prolapse. Echocardiography revealed that the technique can restore the leaflet area of low transvalvular pressure and flow velocity.

Coronary Flow Evaluation in Heart Transplant Patients Compared to Healthy Controls Documents the Superiority of Coronary Flow Velocity Reserve Companion as Diagnostic and Prognostic Tool.

BackgroundDistinct contributions by functional or structural alterations of coronary microcirculation in heart transplantation (HT) and their prognostic role have not been fully elucidated. We aimed to identify the mechanisms of coronary microvascular dysfunction (CMD) in HT and their prognostic implications.Methods134 patients, surviving at least 5 years after HT, without evidence of angiographic vasculopathy or symptoms/signs of rejection were included. 50 healthy volunteers served as controls. All underwent the assessment of rest and hyperemic coronary diastolic peak flow velocity (DPVr and DPVh) and coronary flow velocity reserve (CFVR) and its inherent companion that is based on the adjusted quadratic mean: CCFVR = √{(DPVr)2 + (DPVh)2}. Additionally, basal and hyperemic coronary microvascular resistance (BMR and HMR) were estimated.ResultsBased on CFVR and DPVh, HT patients can be assigned to four endotypes: endotype 1, discordant with preserved CFVR (3.1 ± 0.4); endotype 2, concordant with preserved CFVR (3.4 ± 0.5); endotype 3, concordant with impaired CFVR (1.8 ± 0.3) and endotype 4, discordant with impaired CFVR (2.0 ± 0.2). Intriguingly, endotype 1 showed lower DPVr (p < 0.0001) and lower DPVh (p < 0.0001) than controls with lower CFVR (p < 0.0001) and lower CCFVR (p < 0.0001) than controls. Moreover, both BMR and HMR were higher in endotype 1 than in controls (p = 0.001 and p < 0.0001, respectively), suggesting structural microvascular remodeling. Conversely, endotype 2 was comparable to controls. A 13/32 (41%) patients in endotype 1 died in a follow up of 28 years and mortality rate was comparable to endotype 3 (14/31, 45%). However, CCFVR was < 80 cm/s in all 13 deaths of endotype 1 (characterized by preserved CFVR). At multivariable analysis, CMD, DPVh < 75 cm/s and CCFVR < 80 cm/s were independent predictors of mortality. The inclusion of CCFVR < 80 cm/s to models with clinical indicators of mortality better predicted survival, compared to only adding CMD or DPVh < 75 cm/s (p < 0.0001 and p = 0.03, respectively).ConclusionA normal CFVR could hide detection of microvasculopathy with high flow resistance and low flow velocities at rest. This microvasculopathy seems to be secondary to factors unrelated to HT (less rejections and more often diabetes). The combined use of CFVR and CCFVR provides more complete clinical and prognostic information on coronary microvasculopathy in HT.

Diagnostic Value and Clinical Performance of Cardiac Ultrasound in Patients with Chronic Heart Failure with Hypertension.

Objective To assess the diagnostic value and clinical performance of cardiac ultrasound in patients with chronic heart failure and hypertension. Methods In this prospective study, between August 2017 and January 2020, 50 patients with chronic heart failure and hypertension were recruited and assigned to the study group and 50 healthy individuals during the same period after physical examinations were included in the control group. Cardiac ultrasound examinations were performed on the participants, and the results were compared and analyzed. Results The study group had a higher left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left ventricular ejection fraction (LVEF), and late diastolic peak flow velocity (A wave) and showed lower early diastolic peak flow velocity (E wave) and late diastolic peak flow velocity/lower early diastolic peak flow velocity (E/A) ratio levels than in the control group. The study group had 15 patients with grade I cardiac function (ultrasound detection rate of 100%), 18 patients with grade II cardiac function (ultrasound detection rate of 100%), and 17 patients with grade III cardiac function (ultrasound detection rate of 100%). Grade I cardiac function patients showed the lowest LVEDD, LVESD, and E/A and the highest LVEF than grade II patients, followed by grade III patients. The study group showed higher LVEF and echocardiographic estimation of the pulmonary arterial systolic pressure (PASP) and lower right ventricular lateral wall systolic excursion velocity and tricuspid annular plane systolic excursion (TAPSE) than the control group. Chronic heart failure with hypertension was associated with high levels of right atrial total emptying volume (RAVIt), right atrial passive emptying volume (RAVIp), right atrial active emptying volume (RAVIa), and right atrial active emptying fraction (RAVIaEF) and low levels of right atrial total emptying fraction (RAVItEF) and right atrial passive emptying fraction (RAVIpEF) versus the healthy status (all P < 0.05). Conclusion Cardiac ultrasound is a noninvasive operation with low cost, high repeatability, and accurate detection, which can identify right heart function impairment at an early stage, assist clinical treatment, and improve patient prognosis, so it is worthy of promotion and application.

A Novel Patent Ductus Arteriosus Severity Score to Predict Clinical Outcomes in Premature Neonates.

Background: Patent Ductus Arteriosus (PDA) in premature neonates has been associated with comorbidities including chronic lung disease (CLD), and death. However, the treatment of PDA remains controversial. There have been several echocardiographic variables previously used to determine the hemodynamic significance of PDA but their utility in early prediction of clinical outcomes is not well studied. Objective: The objective of our study was to evaluate the use of a severity scoring system incorporating markers of systemic under perfusion, pulmonary over perfusion and left ventricular (LV) function in predicting clinical outcomes in premature neonates. Methods: It is a single center prospective observational study involving newborns < 32 weeks’ gestation. An echocardiogram was done within seven days of life to measure variables previously known to predict severity of shunting in PDA including pulmonary perfusion index (PPI). Predictors of CLD/death were identified using multivariate logistic regression. A severity score was derived and its ability to predict clinical outcomes was tested using a receiver operating characteristic curve. Results: We studied 98 infants with a mean (SD) gestation of 28.9 ± 1.91 weeks and birth weight of 1228.06 ± 318.94 g, respectively. We identified five echocardiographic variables along with gestational age that was independently associated with the outcome variable (PPI, LV output, Superior Mesenteric Artery [SMA] Velocity Time Integral [VTI], Peak diastolic flow velocity in Pulmonary Vein [PV Vd], and reversal of flow in diastole in descending aorta [DFR]). The range of severity score was 0 (low risk) to 12 (high risk). A higher score was associated with the primary outcome variable of CLD/death (7.5 [1.2] vs. 3.6 [1.5], p < 0.001). Our severity score had an area under the curve of 0.97 (95% CI 0.93–0.99, p < 0.001) for predicting CLD/death. Conclusion: Our new PDA severity score of 5.5 has a sensitivity and specificity of 94% and 93%, and positive and negative predictive values of 94% and 93%, respectively.

Blunted coronary flow velocity reserve is associated with impairment in systolic function and functional capacity in hypertrophic cardiomyopathy

BackgroundCoronary microvascular dysfunction constitutes an important pathophysiological feature in hypertrophic cardiomyopathy (HCM).We aimed to assess the association between impaired coronary flow velocity reserve (CFVR) and ventricular systolic function and functional capacity. MethodsEighty-three patients with HCM were enrolled in this prospective cohort study. Patients underwent echocardiogram to evaluate ventricular performance and CFVR in the left anterior descending artery (LAD) and posterior descending artery (PD). Diastolic coronary flow velocity was measured in basal conditions and in hyperemia. CFVR was calculated as the ratio of hyperemic and basal peak diastolic flow velocities. Functional capacity was evaluated by cardiopulmonary exercise testing (CPET). The link between CFVR and biventricular systolic function and peak VO2 was studied. ResultsAge was 55.0(14.4)years, 50 patients (60%) were male; 59 patients (71%) had nonobstructive HCM. Mean CFVR LAD was 1.81(0.49) and CFVR PD was 1.73(0.55). Lower CFVR PD was associated with impaired global longitudinal strain (GLS) 2D (β-estimate:-3.240,95%CI:-4.634;-1.846, p < 0.001), GLS 3D (β-estimate:-2.559,95%CI:-3.932;-1.186, p < 0.001) and area strain (β-estimate:-3.044,95%CI:-5.373;-0.716, p = 0.011). Lower values of CFVR PD related to worse global work index (β-estimate:267.824,95%CI:75.964;459.683, p = 0.007), global constructive work (β-estimate:217.300,95%CI:38.750;395.850, p = 0.018) and global work efficiency (β-estimate:5.656,95%CI:2.229;9.084, p = 0.002). Impaired CFVR LAD (β-estimate:2.826, 95%CI:0.913;4.739, p = 0.004) and CFVR PD (β-estimate:2.801,95%CI:0.657;4.945, p = 0.011) were associated with lower TAPSE. Lower values of CFVR LAD (β-estimate:2.580, 95%CI:0.169;4.991, p = 0.036) and CFVR PD (β-estimate:3.163, 95%CI: 0.721;5.606, p = 0.012) were associated with worse peak VO2. ConclusionLower CFVR was associated with impairment in biventricular systolic function parameters and functional capacity assessed by pVO2.