Pre-discharge Transthoracic Echocardiography Research Articles

Cardiovascular Risk Factors and Disparities in Management of Embolic Stroke: A Western Sydney Perspective

Ischaemic stroke remains one of the leading causes of death and disability worldwide. The population of Western Sydney has a unique demographic with lower socioeconomic status and a culturally and linguistically diverse population. This study aims to investigate the demographics and cardiovascular risk factors of patients in Western Sydney, focusing on the prevalence and profile of cardioembolic (CE) strokes and embolic strokes of undetermined source (ESUS). Prospective data were collected in 463 patients with ischaemic stroke presenting to a tertiary centre in Western Sydney, who underwent predischarge transthoracic echocardiography. Patients with haemorrhagic strokes or unclear stroke diagnosis were excluded. Analysis of stroke subtype (CE, ESUS, or non-embolic) and clinical characteristics was performed based on age, gender, and prior atrial fibrillation (AF) prevalence. Of the 463 patients, 147 (32%) had CE strokes, and 147 (32%) had ESUS. Cardioembolic (CE) strokes were associated with older age (≥65 years) and a history of congestive cardiac failure. Older patients had higher rates of hypertension, ischaemic heart disease, AF, and congestive heart failure. History of AF was present in 67 patients (14.5%); however, only 51% received anticoagulation before admission despite a low bleeding risk. The transthoracic echocardiography characteristics of ESUS/non-embolic strokes differed from those of CE strokes; 20% of patients with ESUS had an enlarged left atrium, suggesting a subset of patients with ESUS with a left atrial myopathy. Patients with ischaemic stroke in Western Sydney have a high prevalence of cardiovascular risk factors which were often undertreated. Half of the patients with prior AF did not receive anticoagulation despite low bleeding risk, indicating a gap in optimal stroke prevention. There were distinct echocardiographic characteristics among stroke subtypes. Further analysis of left atrium parameters may provide greater insights into the pathogenesis and prevention of embolic strokes.

Uncommon presentations of type A quadricuspid aortic valve in the Septuagenarian

BackgroundQuadricuspid aortic valve (QAV) is a rare congenital anomaly characterized by the presence of four cusps instead of the usual three. It is estimated to occur in less than 0.05% of the population, with Type A (four equal-sized leaflets) accounting for roughly 30% of QAV subtypes. Based on limited clinical series, the usual presentation is progressive aortic valve regurgitation (AR) with symptoms occurring in the fourth to sixth decade of life. Severe aortic valve stenosis (AS) and acute AR are very uncommon.Case presentationWe describe two cases of Type A QAV in patients who remained asymptomatic until their seventies with very uncommon presentations: one with severe AS and one with acute, severe AR and flail leaflet. In Case A, a 72-year-old patient with history of moderate AS presents to clinic with progressive exertional dyspnea. During work-up for transcatheter vs. surgical replacement pre-operative computed tomography angiogram (CTA) reveals a quadricuspid aortic valve with severe AS, and the patient undergoes surgical aortic valve replacement. Pre-discharge transthoracic echocardiography (TTE) shows good prosthetic valve function with no gradient or regurgitation. In Case B, a 76-year-old patient is intubated upon arrival to the hospital for acute desaturation, found to have wide open AR on catheterization, and transferred for emergent intervention. Intraoperative TEE reveals QAV with flail leaflet and severe AR. Repair is considered but deferred ultimately due to emergent nature. Post-operative TTE demonstrates good prosthetic valve function with no regurgitation and normal biventricular function.ConclusionsQAV can present as progressive severe AS and acute AR, with symptoms first occurring in the seventh decade of life. The optimal treatment for QAV remains uncertain. Although aortic valve repair or transcatheter option may be feasible in some patients, aortic valve replacement remains a tenable option.

Ventricular septal defect following mitral valve replacement.

Mitral valve surgery (MVS), with repair preferred to replacement, is a common procedure for the treatment of severe primary mitral regurgitation related to leaflet prolapse. Structural complications after MVS include left ventricular outflow obstruction, paravalvular leak and atrial septal defect. Intraoperative transoesophageal echocardiography and predischarge transthoracic echocardiography (TTE) specifically screen for these complications. Ventricular septal defect (VSD), a known complication after aortic valve surgery, is rarely reported after MVS. Recently, unsuccessful valvuloplasty prior to replacement was suggested as a risk factor. We present such a case and explore mechanisms with advanced cardiac imaging. In this case, the patient was found to have an elongated membranous septum that likely predisposed her to septal injury. Finally, we provide guidance on specific transoesophageal/transthoracic echocardiography views to avoid a missed diagnosis.

Acute right ventricular geometric change predicts outcomes in HeartMate 3 patients

BackgroundThe physiological response of the right ventricle (RV) following left ventricular assist device (LVAD) implantation is difficult to predict. We aimed to investigate RV geometric and functional changes after LVAD insertion and their effects on clinical outcomes. MethodsWe retrospectively reviewed 188 patients who underwent HeartMate 3 implantation at our center between November 2014 and September 2021. The RV end-diastolic diameter (RVEDD) and area (RVEDA) were measured on preoperative and pre-discharge transthoracic echocardiography. The non-adapted group included patients with increased RVEDD and RVEDA at discharge. The composite outcome was defined as death or readmission due to worsening right heart failure. ResultsThere were 82 patients (44%) who had a non-adapted and 106 (56%) who had an adapted RV. Preoperatively, the non-adapted group had smaller RVEDD (46 vs. 49 mm, p < 0.001) and RVEDA (27 vs. 31 cm2, p < 0.001). At discharge, the non-adapted group had larger RVEDD (51 vs. 43 mm, p < 0.001) and RVEDA (33 vs. 27 cm2, p < 0.001). Kaplan-Meier analysis demonstrated worse 3-year survival (77% vs. 91%, p = 0.006) and freedom from composite outcome (58% vs. 85%, p < 0.001) in the non-adapted group. A multivariable Cox proportional hazards model showed that non-adaption (HR 3.09, 95% CI 1.29–7.40 p = 0.01) and age (HR 3.73, 95% CI 1.42–9.77, p = 0.007) were independent predictors of composite outcome. ConclusionsAcute RV dimensional changes after LVAD insertion may represent intrinsic RV function and may be a useful prognostic marker.

C36 NON–CYCLIC INTERMITTENT PROSTHETIC MITRAL VALVE DYSFUNCTION: A CASE REPORT OF A DIFFICULT DIAGNOSIS CONFIRMED WITH MULTIMODALITY IMAGING

Abstract A 59–year–old man,obese,with history of hypertension, 3 years ago underwent mitral valve (MV) replacement with a mechanical prothesis(Sorin Bicarbon 31) and preservation of the native subvalvular apparatus for severe mitral regurgitation due to anterior leaflet flail. Pre–discharge transthoracic echocardiography (TTE) showed normal prothesis function (mean pressure gradient (PG) 3,2mmHg), no valvular leaks and a normal ejection fraction (EF). Lately, the patient was admitted twice to emergency department for signs of heart failure, solved with increasing dose of oral diuretics. In both cases a TTE showed a normal EF, a trans–prosthetic mean PG of 6,5mmHg and no valvular impairment/leaks. Since the suboptimal TTE acoustic windows, a transesophageal echocardiography (TEE) was recommended. TEE showed a normal motion of both MV discs and no pannus/thrombus or leaks with the use of a 2–beat acquisition protocol. However, with longer observation a pattern of non–cyclic intermittent valve dysfunction was noted: whereas some cardiac cycles showed normal discs’ motion, other cycles demonstrated an emi–disc opening delay or blockage during diastole with significant prolongation of transmitral pressure half–time and higher transvalvular gradient, suggestive of flow impairment. A cine fluoroscopy and a CT assessment were also performed, showing the visible intermittent pattern of valve dysfunction without radiological signs of thrombosis or pannus. At this point, the interference of the MV apparatus with the emidisc was considered the most probable mechanism of dysfunction. A Heart Team decision toward reintervention was taken since the risk of a sudden worsening of the mechanical valve function, with potentially lethal consequences, was considered high. The surgeon at visual inspection confirmed the interference of the subvalvular apparatus with the posterior emidisc motion. The chronic shear stress generated on the mitral remnant likely developed a progressive fibrotic response that determined the thickening of the tissue and the periodical entrapment of the disc. MV prothesis was replaced with resection of the subvalvular apparatus. At dismissal,TTE evaluation showed normal valvular function confirmed at 6 months follow–up. Intermittent prosthetic MV dysfunction is a rare but potentially serious complication of MV replacement with subvalvular apparatus preservation. TEE, cine–fluoroscopy and CT may be useful as complementary tools to detect this rare complication.

194 THROMBOEMBOLIC ACUTE ST ELEVATION MYOCARDIAL INFARCTION AFTER TRANSCATHETER VALVE IMPLANTATION

Abstract Transcatheter aortic valve implantation (TAVI) is an established treatment of severe symptomatic aortic valve stenosis and is an effective and less invasive treatment option compared with conventional surgical aortic valve replacement (SAVR) for patients considered inoperable or at high surgical risk. Thromboembolic and bleeding complications negatively impact recovery and survival after TAVI. This case describes one of the few reported TAVI-associated myocardial infarction due to thrombosis of the prosthetic aortic valve. A 82-years-old woman, suffering from severe symptomatic aortic stenosis, underwent TAVI. Before the procedure, coronary artery disease was excluded by invasive coronary angiography. Since the time of the discharge the patient didn't assume any therapy with aspirin or other antithrombotic drugs. A month after TAVI she complained persistent epigastric pain and was admitted to our department for anterior ST elevation myocardial infarction. Coronary angiography highlighted a monovascular coronary artery disease with thrombotic occlusion of the first diagonal and of the distal left anterior descending coronary artery. In consideration of the thrombotic load thyrofiban was started and it was performed a chest contrast CT which confirmed the diagnostic suspicion of bioprosthetic valve thrombosis. She was first treated with unfractionated heparin (UFH) and then oral anticoagulant therapy with warfarin was started. Echocardiograms (echo) showed a severely reduced systolic function (EF 25%) and high trans-prosthetic gradients (mean transprosthetic pressure gradient of 30 mmHg). On the 8th day after hospitalization she complained chest pain with evidence of moderate pericardial effusion. Epistenocardica pericarditis was therefore diagnosed and the patient started acetylsalicylic acid therapy with progressive clinical, instrumental and laboratory improvement. After 10 days of anticoagulation therapy, she underwent a transesophageal echocardiogram which turned out negative for bioprosthetic valve thrombosis. The predischarge transthoracic echocardiography showed severely reduced systolic function (EF 30%) with a mean transprothesic gradient of 12 mmHg; the circumferential pericardial effusion was mild-moderate but not haemodynamically significative. Therapy at discharged included warfarin and aspirin. Ten days after an echo showed a reduction of the pericardial effusion, an improved systolic function (EF 42%) and mean transprothesic gradient not changed significantly since discharge. Prosthetic valve thrombosis has been reported in up to 40% of patients after TAVI and this case hightlights the importance of antithrombotic therapy after this procedure. Therapeutic anticoagulation appears to be the only non-invasive treatment for resolving valve thrombosis but it is not clear how long this therapy should last for the prevention of prosthetic valve thrombosis.

262 AN UNUSUAL CAUSE OF PACEMAKER MALFUNCTION WITH NON-COMMON ELECTROCARDIOGRAPHIC PRESENTATION AND UNEXPECTED ECHOCARDIOGRAPHIC FINDING

Abstract This clinical case shows the diagnostic challenge and the management of a 79 y-o male with arterial hypertension, tabagism, obesity and a recent hospitalization for infero-lateral STEMI undergoing primary PCI of Right Coronary Artery with 2 DES and following DDDR MRI PM (pacemaker) implantation (through left cephalic vein) due to the development of persistent 2:1 AV block (atrio-ventricular block). One month later, admission at Emergency Department for syncope. The admission therapy included Aspirin plus Clopidogrel, Ramipril, Atorvastatin. Normal parameters were found at laboratory analyses. The electro-stimulator activity evaluation showed a PM malfunction with ventricular capture failure. Thus, the increase of PM output up to electric ventricular capture (8 Volt/120 msec) was performed, but the following Electrocardiogram (ECG) showed a PM-induced rhythm with RBBB-morphology. Then, the bedside Echocardiogram showed an apparent presence of a linear hyper-echogenic image (lead?) into left ventricle with no inter-ventricular septal defect neither inter-ventricular shunt, inter-atrial septal hypermobility with no evident inter-atrial shunt at rest; while a chest Radiography identified the atrial and ventricular leads with no accurate individuation of their position. The patient was admitted in Intensive Cardiac Care Unit with confirmation of intermittent failure to ventricular capture and RBBB-morphology during PM-induced rhythm at telemetry monitoring. Due to Electrocardiographic and (above all) Echocardiographic findings, a strong suspect of abnormal position of the ventricular lead into left ventricle through a possible PFO has been raised. A chest Computed Tomography was performed confirming the anomalous position of the ventricular lead: the atrial lead was in the right atrium whereas the ventricular lead reached the left atrium through an inter-atrial defect/patent foramen ovale (PFO), then crossing the mitral valve up to left ventricle. The PM-lead repositioning was scheduled two days after. With intra-operative fluoroscopy, a further verify of leads position was observed (the ventricular one into left ventricle through PFO and mitral valve, the atrial one mildly displaced upwards) and the leads repositioning was performed. After positioning of temporary stimulator lead in right ventricle, the ventricular lead has been withdrawn from left-side chambers and positioned into septal-apical right ventricle; furthermore, the position of right atrial lead has been optimized (because of frequent spontaneous passage to the left atrium through the PFO, during manual maneuvers). Finally, the optimal stability of the device was obtained, as well as the optimal atrial and ventricular capture during stimulation test. During the observation in Cardiology Unit in following days, the telemetry monitoring and ECG showed a PM-induced rhythm, without capture nor sensing failure. The chest Radiography confirmed the correct position of atrial and ventricular leads. Finally, the pre-discharge transthoracic Echocardiography showed a LVEF 57% with no valvular pathology nor pericardial effusion, and with atrial and ventricular leads into right-side chambers.

The Impact of Pulmonary Hypertension on the Clinical Outcomes of Acute Myocardial Infarction after Percutaneous Coronary Intervention

Background/Aims: Pulmonary hypertension (PH) in patients with heart failure contributes to a poor prognosis. However, the role of PH in the long-term clinical outcome is unclear in those with acute myocardial infarction (AMI). The clinical significance of elevated right ventricular systolic pressure (RVSP) on routine echocardiography is underestimated.Methods: This study enrolled 2,526 AMI patients (65.1 ± 12.7 years; 1,757 males [69.6%]) from the Korean AMI registry who underwent successful percutaneous coronary intervention and pre-discharge transthoracic echocardiography (TTE). The patients were divided into four groups according to the RVSP on TTE: normal RVSP (RVSP &lt; 35 mmHg, n = 1,695), mild PH (35 ≤ RVSP &lt; 45 mmHg, n = 601), moderate PH (45 ≤ RVSP &lt; 70 mmHg, n = 211), and severe PH (RVSP ≥ 70 mmHg, n = 19). Major adverse cardiac events (MACE) were compared among the four groups.Results: During the 3-year clinical follow-up period, MACE occurred in 562 patients (22.2%), including 321 (18.9%), 145 (24.1%), 83 (39.3%), and 13 patients (68.4%) in the normal RVSP and mild, moderate, and severe PH groups, respectively. On multivariate analysis, independent factors for MACE were moderate or severe PH, age ≥ 65 years, Killip class ≥ III, left ventricular ejection fraction &lt; 40%, hypertension, and diabetes.Conclusions: Measuring RVSP is useful for stratifying the risk of patients with AMI; MACE occurred in patients with moderate or severe PH.

Association of Preoperative Sleep-Disordered Breathing With Functional Status After Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy

BackgroundSleep-disordered breathing (SDB) is a risk factor for heart failure symptoms in patients with hypertrophic cardiomyopathy (HCM). However, the relationship between preoperative SDB and postoperative functional status after septal myectomy (SM) is unknown. In this study, we investigated the association of preoperative SDB with late self-reported health status among patients undergoing SM for obstructive HCM. MethodsPrior to SM, an overnight pulse oximetry test was used to measure oxygen desaturation index (ODI), which indicates the average number of desaturation episodes with at least 4% of drops in oxygen level from baseline per hour of sleep. Patients reported postoperative function through a questionnaire-based survey completed 3-5 years following SM. ResultsWe analyzed 264 patients who underwent transaortic SM from November 2005 through April 2016. On predischarge transthoracic echocardiography post-procedure, no significant difference was present in the extent of mitral valve regurgitation (P = 0.524), left ventricular outflow tract gradient (P = 0.405), or septal thickness (P = 0.744) related to ODI. At 3 to 5 years after their operation, 236 patients (89%) reported good or excellent health. Approximately 18% (n = 48) and 8% (n = 22) of the cohort continued to experience exertional dyspnea and chest tightness, respectively, on walking 2 blocks or less. A greater ODI was not an independent predictor of worse health status or residual symptoms. ConclusionsRelief of left ventricular outflow tract obstruction in patients with obstructive HCM improves symptoms, with 89% of patients reporting good or excellent health. Preoperative SDB is not significantly associated with late functional status after septal myectomy.

A Longitudinal Study of Mitral Regurgitation Detected after Acute Myocardial Infarction.

Background: Mitral regurgitation (MR) is common following myocardial infarction (MI). However, the subsequent trajectory of MR, and its impact on long-term outcomes are not well understood. This study aimed to examine the change in MR severity and associated clinical outcomes following MI. Methods: Records of patients admitted to a single centre between 2016 and 2017 with acute MI treated by percutaneous coronary intervention (PCI) were retrospectively examined. Results: 294/1000 consecutive patients had MR on baseline (pre-discharge) transthoracic echocardiography (TTE), of whom 126 (mean age: 70.9 ± 11.4 years) had at least one follow-up TTE. At baseline, most patients had mild MR (n = 94; 75%), with n = 30 (24%) moderate and n = 2 (2%) severe MR. Significant improvement in MR was observed at the first follow-up TTE (median 9 months from baseline; interquartile range: 3–23), with 36% having reduced severity, compared to 10% having increased MR severity (p < 0.001). Predictors of worsening MR included older age (mean: 75.2 vs. 66.7 years; p = 0.003) and lower creatinine clearance (mean: 60 vs. 81 mL/min, p = 0.015). Change in MR severity was significantly associated with prognosis: 16% with improving MR reached the composite endpoint of death or heart failure hospitalisation at 5 years, versus 44% (p = 0.004) with no change, and 59% (p < 0.001) with worsening MR. Conclusions: Of patients with follow-up TTE after MI, MR severity improved from baseline in approximately one-third, was stable in around half, with the remainder having worsening MR. Patients with persistent or worsening MR had worse clinical outcomes than those with improving MR.

Changes in mitral regurgitation following acute myocardial infarction: early and long-term follow-up

Abstract Background Mitral regurgitation (MR) is commonly observed following acute myocardial infarction (MI). Localised left ventricular (LV) remodelling in the region of papillary muscles together with impaired myocardial contractility promote MR. There is a paucity of long-term follow-up studies to determine whether the severity of MR observed post-MI, changes with time. Purpose This study retrospectively followed up patients with MR detected following acute MI (AMI) to investigate changes in MR severity with time and assess for pre-discharge predictors of MR regression or progression. Methods Clinical records of 1000 patients admitted with AMI between 2016 and 2017 to a single centre were retrospectively interrogated. One hundred and nine patients met the inclusion criteria of MR on pre-discharge transthoracic echocardiography (TTE) and follow-up TTE scans. Echocardiographic parameters were investigated to determine predictors of progression or regression at follow-up. Patients were divided according to those who had early follow-up TTE (within 1-year) and late follow-up TTE (beyond 1-year). Results Early follow-up TTE was performed in 73 patients at a median of 6 (IQR 3–9) months. Patients had a mean age of 69±13 years and were predominantly male 50/73 (68%). At baseline, relative MR severities were: 49/73 (67%) mild MR, 23/73 (32%) moderate MR and 1 (1%) severe MR. At follow-up, MR had completely resolved in 18/73 (23%) patients, while 39/73 (53%) had mild MR, 15/73 (21%) moderate MR and 1 (1%) severe MR. Compared to patients with no resolution of MR, those with completel resolution were younger (mean age 62±16 vs 72±11 years; p=0.015) but there were no other significant differences between the groups. Resolution at early follow-up did not significantly influence long-term mortality rates. Late follow-up TTE was performed in 69 patients at a median 2.4 (IQR 2–3.2) years. Pre-discharge, 49/69 (71%) patients had mild MR and 20/69 (29%) moderate MR. At follow-up, MR had completely resolved in 18/69 (26%), and amongst patients with persistent MR, proportion of severities were: 37/69 (54%) mild MR, 11/69 (16%) moderate MR and 3/69 (4%) severe MR. Patients with progression of mild MR were more likely to have lower left ventricular ejection fraction (LVEF: 47±15 vs 57±12%; p=0.010) and greater indexed left ventricular end-systolic volume (LVESVi: 37±23 vs 25±14 ml/m2; p&amp;lt;0.001) on pre-discharge TTE. Resolution of MR at late follow-up was associated with a reduction in long-term mortality [deaths: 2/55 (3%) vs 3/14 (21%); p=0.022] at a mean follow-up of 4.2 years from MI. Conclusion MR observed following AMI completely resolved in approximately one-quarter of patients at 6-month and 2-year follow-up. Progression of mild MR at long-term follow-up appears to be associated with increased mortality and is predicted by lower LVEF and greater LVESVi pre-discharge. Funding Acknowledgement Type of funding sources: None.

Mitral Regurgitation Following Acute Myocardial Infarction Treated by Percutaneous Coronary Intervention—Prevalence, Risk factors, and Predictors of Outcome

Mitral regurgitation (MR) following acute myocardial infarction (AMI) worsens prognosis and reports of prevalence vary significantly. The objective was to determine prevalence, risk factors, and outcomes related to MR following AMI. We identified 1000 consecutive patients admitted with AMI in 2016/17 treated by percutaneous coronary intervention with pre-discharge transthoracic echocardiography. MR was observed in 294 of 1000 (29%), graded as mild (n=224 [76%]), moderate (n=61 [21%]) and severe (n=9 [3%]). Compared with patients without MR, patients with MR were older (70 ± 12 vs 63 ± 13 years; p <0.001), with worse left ventricular ejection fraction (LVEF) (52 ± 15% vs 55 ± 11%; p <0.001) and creatinine clearance (69 ± 33 ml/min vs 90 ± 39 ml/min; p <0.001). They also had higher rates of hypertension (64% vs 55%; p=0.012), heart failure (3.4% vs 1.1%; p=0.014), previous MI (28% vs 20%; p=0.005) and severe flow-limitation in the circumflex (50% vs 33%; p <0.001) or right coronary artery (51% vs 42%; p=0.014). Prevalence and severity of MR were unaffected by AMI subtype. Revascularization later than 72 hours from symptom-onset was associated with increased likelihood of MR (33% vs 25%; p=0.036) in patients with non-ST elevation myocardial infarction (NSTEMI). After a mean of 3.2 years, 56 of 288 (19%) patients with untreated MR died. Age and LVEF independently predicted mortality. The presence of even mild MR was associated with increased mortality (p=0.029), despite accounting for confounders. In conclusion, MR is observed in over one-quarter of patients after AMI and associated with lower survival, even when mild. Prevalence and severity are independent of MI subtype, but MR was more common with delayed revascularization following NSTEMI.

Usefulness of Computed Tomography to Predict Mitral Stenosis After Transcatheter Mitral Valve Edge-to-Edge Repair

Multidetector computed tomography (MDCT) can provide valuable information for preprocedural planning of transcatheter mitral valve interventions. However, no data exists on pre-MDCT parameters predicting high transmitral pressure gradient (TMPG) post-MitraClip procedure. We analyzed the preprocedural MDCTs of 156 consecutive patients with mitral regurgitation undergoing MitraClip implantation at our institution. The mean TMPG was assessed by periprocedural transesophageal and pre-discharge transthoracic echocardiography. MDCT-derived mitral annulus area (MAA), anterior-posterior (AP) and medial-lateral (ML) mitral annulus diameters, and mitral valve orifice area (MVOA) were smaller in patients with mean TMPG ≥5 mmHg than those with mean TMPG <5 mmHg after 1-or 2-clip implantation. Small MAA, AP and ML diameters, and MVOA were moderately correlated with high TMPG post-MitraClip, in which MAA and MVOA had the highest degree of correlation after 1-clip (r=-0.46 both), whereas MAA and ML had the strongest degree of correlation after 2-clip (r=-0.39 both) and at discharge (r=-0.38 both). From the receiver-operating-characteristic curve analyses, no significant differences in the area under the curve were observed among these MDCT parameters for low TMPG after MitraClip implantation, except for those between MAA and AP diameter at discharge (p=0.026). For optimal cutoff values, MAA ≥1100 and ≥1300 mm2 had positive predictive values of 89% and 91%, while both MAA ≥750 and ≥900 mm2 had negative predictive values of 100%, for mean TMPG <5 mmHg after 1-and 2-clip implantation, respectively. In conclusion, in patients undergoing the MitraClip procedure, preprocedural MDCT parameters are useful to predict postprocedural mitral stenosis.

Approach to Mitral Valve Repair in Infective Endocarditis: Single Center, Single Surgeon, Cross Sectional Study

Objective: The traditional approach was to replace the mitral valve on infective endocarditis when the response to antibiotic therapy is poor. The decision to repair the mitral valve (MV) in this setting is more challenging. This study analysed the different approaches adopted to perform a successful repair. Methods: This retrospective cross sectional study composed of all the patients referred to a single surgeon at Kandy National Hospital, Sri Lanka over a period from June 2011 to August 2020. Repair of MV in every case was the primary approach. Different types of lesion found on direct visual assessment, techniques adopted and outcome of MV repair in native MV infective endocarditis were analysed. Results: Total number of cases was 23, (16 males, 7 females) with a mean age of 42 years. MV repair was successful in all (95%) except one case, as per the intra-operative assessment made (saline test and trans esophageal echocardiography). Vegetation or leaflet perforation were the most common lesions (Posterior mitral valve leaflet/PMVL: 18, Anterior leaflet/AMVL: 7) followed by chordal rupture (6). The table shows the repair strategies used. One death occurred on postoperative third day following MV repair due to rupture of cerebral mycotic aneurysm. 22 patients were discharged home with satisfactory pre-discharge transthoracic 2D echocardiography. Conclusions: The study shows successful repair of MV on infective endocarditis is possible in majority of cases with skilled modulation of surgical approach to individual patient pathology found at the time of surgery. Long term follow-up data requires for the assessment of durability of this approach. Procedure Number Annuloplasty ring (flexible, rigid) 22 Pericardial patchAMVLPMVL 12 Folding plasty 2 Neochords 5 Triangular resection and repairAMVLPMVL 12 Quadrangular resection and repairAMVLPMVL 50 Resection and slidingplastyAMVLPMVL 26

Ischaemic mitral regurgitation: incidence, clinical and angiographic characteristics of 1000 patients with type 1 myocardial infarction undergoing percutaneous coronary intervention

Abstract Background Previous studies of the incidence and severity of mitral regurgitation (MR) following acute myocardial infarction (MI) were limited by the study population (ST-elevation MI only), by diagnostic methods (lack of multiparametric quantification), or by the time-frame of study (late assessment post-MI). The true incidence of ischaemic MR (IMR) immediately following type 1 MI [non-ST-elevation (NSTEMI) and ST-elevation (STEMI)] patients in the modern era of universal early revascularisation remains unclear. Since even mild IMR confers a poor prognosis, factors which promote or protect against the development of MR require further evaluation. Purpose To determine the incidence, clinical and angiographic characteristics of patients with IMR following type 1 MI treated with PCI. Methods This was a single-centre study of 1000 consecutive, prospectively recruited patients admitted to the Queen Elizabeth Hospital Birmingham with type 1 MI who underwent PCI. Early inpatient transthoracic echocardiography (TTE) was performed by accredited echocardiographers using standard multiparametric quantification. Results MR was observed in 294/1000 patients (29.4%) post-MI, graded as mild (76%), moderate (21%) and severe (3%). Median time from symptom onset to PCI was 1 day (IQR 0–4) and to TTE 2 days (IQR 1–3). Compared to patients without MR (MR-), those with MR (MR+) were older (73±12 years vs 66±13 years; p&amp;lt;0.001), male (75% vs 64%; p&amp;lt;0.001) and more likely to have a history of hypertension (HTN) (63% vs 55%; p=0.0117), heart failure (HF) (3.4% vs 1.1%; p=0.0140) and previous MI (28% vs 20%; p&amp;lt;0.005). MR+ patients more frequently presented with HF (8.5% vs 4.2%; p=0.0075), lower LV ejection fraction (LVEF) (50±14% vs 55±11%; p&amp;lt;0.001) and higher peak high sensitivity troponin T (765ng/L, IQR 170–3032 vs 400ng/L, IQR 51–1966; p&amp;lt;0.0001). MR+ patients were more likely to have severe disease in the left circumflex (LCx) (50% vs 33%; p&amp;lt;0.0001) or right coronary artery (RCA) (51% vs 43%; p=0.0135). Incidence of severe disease in the left main stem and left anterior descending artery (LAD) did not significantly differ between the two groups. Incidence of MR was equal (29%) amongst STEMI (126/431) and NSTEMI (168/569) patients. While the time to revascularisation did not affect the prevalence of MR following STEMI (linear regression analysis of door-to-balloon time in MR+ and MR- patients p=0.843), NSTEMI patients were more likely to develop MR if revascularisation was delayed (linear regression analysis of symptom onset to PCI time MR+ vs MR- p=0.061). Conclusion Almost 1/3 of patients with type 1 MI undergoing revascularisation have MR evident on pre-discharge TTE. Factors promoting MR include older age, male sex, HTN, HF, larger non-LAD territory infarct, and depressed LVEF. The incidence of MR following STEMIs and NSTEMIs is equal. Earlier revascularisation is unlikely to reduce MR in STEMI patients but may improve MR prevalence following NSTEMI. Funding Acknowledgement Type of funding source: None

Mechanical Dispersion as a powerful echocardiographic predictor of outcomes after Myocardial Infarction

Abstract Introduction Several studies have addressed the importance of transthoracic echocardiography (TTE) in risk prediction of subsequent adverse events after ST elevation myocardial infarction (STEMI). While several traditional echo parameters have a well-established prognostic value, data derived from 2D-Speckle Tracking Echocardiography (2DSTE) needs further investigation. Objectives To determine if 2DSTE parameters provide additional information beyond conventional echocardiography to predict long-term adverse outcomes in patients admitted with STEMI Methods Retrospective, single-center study, that included all patients without previous cardiovascular events admitted with STEMI (who underwent primary coronary angioplasty) between 2015 and 2017. Patients with poor acoustic windows, severe valvular disease, irregular heart rhythm, and those who died during hospital stay were excluded. We reviewed all pre-discharge TTE to assess conventional parameters of LV systolic and diastolic function and data obtained by 2DSTE: global longitudinal strain (GLS) and peak strain dispersion (PSD), an index that is the standard deviation from time to peak strain of all segments over the entire cardiac cycle. Demographic and clinical data was obtained through electronic hospital records. Minimum follow-up was 2 years. The primary endpoint was a composite of all-cause mortality and cardiovascular re-admission at follow-up. Survival analysis was used to determine independent predictors of the primary endpoint. Results 377 patients were included, mean age 62±13 years, 72% male. Mean LVEF was 50±10% with 19% of patients having LVEF &amp;lt;40%. Mean indexed left atrium volume (LAVi) was 33±10 ml/m2, mean GLS was −14±4%, and PSD was 60±22 msec. Average follow-up was 36±11 months, with a combined endpoint of mortality and hospitalization of 27% (n=102) Univariate analysis of echocardiographic variables revealed an association between heart rate, LVEF, indexed LV end-systolic volume, indexed stroke volume, LAVi, GLS and PSD with the endpoint. However, on multivariate analysis only LAVi [HR 1.030 (95% CI 1.009 - 1.051), p-value = 0.005] and PSD [HR 1.011 (95% CI 1.002 - 1.020), p-value = 0.012] remained independent predictors of the primary endpoint. We determined that a PSD value higher than 52 msec has a sensitivity of 76% and a negative predictive value of 83% for mortality and hospitalization, and that this cut-off point discriminates patients at a higher risk of events in Kaplan-Meier Survival analysis with a Log-Rank p-value=0.001. Conclusion PSD derived by longitudinal strain analysis is a promising prognostic predictor after STEMI. PSD outperformed conventional echocardiographic parameters in the risk stratification of STEMI patients at discharge. Kaplan-Meier Survival Curves Funding Acknowledgement Type of funding source: None

Loop technique with ink-dot marking test: An alternative strategy to the ink test.

ObjectiveWe assessed the long-term outcomes of the loop technique with the ink-dot marking test, an alternative to the ink test for aligning the mitral valve (MV) leaflet height, during MV repair.MethodsWe retrospectively reviewed 351 patients who underwent MV repair with the loop technique via median sternotomy or right mini-thoracotomy. The ink-dot marking test involves creation of a dotted line between the rough and clear zones in the anterior leaflet and the center of the posterior leaflet by gentian violet. According to this marking, we adjusted the fixing position of the loops with or without the loop-in-loop technique and additional neochordal repair.ResultsThis study involved 141 women and 210 men (mean age, 63.7 ± 13.0 years). Forty-one patients required additional adjustment after the ink-dot marking test. No significant differences were found in the need for second arrest between patients who did and did not require additional adjustment after the ink-dot marking test (3 vs 32 patients, P = .782). Predischarge transthoracic echocardiography showed trivial residual MV regurgitation (MR) in 285 patients, mild in 64, and moderate in 2. Ten patients needed reoperations (9 MV replacements and 1 MV re-repair) because of recurrent MR during postoperative follow-up. The 3-, 5-, and 10-year postoperative cumulative incidence of moderate to severe recurrent MR was 3.6%, 6.0%, and 19.8%, respectively.ConclusionsThe loop technique with the ink-dot marking test provided good early and long-term results. This test may help to decrease residual MR, especially when using the loop technique.

The first four cases of successful NeoChord procedure in mainland China.

Transapical off-pump NeoChord procedure is a novel minimally invasive surgical repair of degenerative mitral regurgitation (MR). Here, we report the first four cases of NeoChord procedure in patients with mitral valve prolapse in mainland China. Four patients, aged 86, 84, 80 and 60 years, with severe MR due to posterior middle scallop prolapse (P2), underwent transapical off-pump artificial chordae implantation on April 9 and 10, 2019. The procedure was performed by left mini-thoracotomy under general anaesthesia and guided by 2D and 3D dimensional transoesophageal echocardiography (TEE). Mitral valve repair via NeoChord procedure was successfully performed with implantation of 3 artificial chordae in the first patient and 3, 2, and 3 artificial chordae in the following patients, respectively. Intraoperative TEE and pre-discharge transthoracic echocardiography (TTE) showed only mild to moderate MR of these four patients and no postoperative complications were noted. There were no changes of TTE finding between one-month follow-up and pre-discharge. The successful NeoChord procedures in four Chinese indicate that the valve repair using the NeoChord system for Chinese population is feasible.

Surgical myectomy versus alcohol septal ablation for obstructive hypertrophic cardiomyopathy: A propensity score–matched cohort

ObjectivesIn patients with hypertrophic cardiomyopathy, obstruction of the left ventricular outflow tract can be relieved by surgical septal myectomy or alcohol septal ablation, but uncertainty remains regarding long-term results and comparative effectiveness of alcohol septal ablation. This study aims to compare short- and long-term outcomes of the 2 procedures. MethodsBetween December 1998 and September 2016, 2407 patients underwent septal myectomy and 211 patients underwent alcohol septal ablation at our institution. After 2:1 propensity score matching, the study cohort included 334 patients who underwent myectomy and 167 patients who underwent alcohol septal ablation. ResultsMedian (interquartile range) ages of patients in the myectomy and alcohol septal ablation groups were 65 (58-71) years and 64 (56-73) years (P = .9), respectively. After intervention, median resting left ventricular outflow tract gradient at predischarge transthoracic echocardiography was 0 (0-10) mm Hg in the myectomy group (n = 288) and 21 (10-60) mm Hg in the alcohol septal ablation group (n = 63) (P < .001, tested at baseline gradients of 30 and 50 mm Hg). There were no differences in survival between the 2 groups (risk of death for alcohol septal ablation vs myectomy, hazard ratio, 1.5; 95% confidence interval, 0.9-2.6; P = .1). Survival of patients undergoing septal myectomy was better than that of an age-, sex-, and race-matched US population (82% vs 75% at 12 years, P = .01). Reintervention for left ventricular outflow tract obstruction was more likely to occur in patients who received alcohol septal ablation (hazard ratio, 33.3; 95% confidence interval, 4.4-250.6; P < .001). ConclusionsThere were no differences in survival of patients undergoing myectomy or alcohol septal ablation, but freedom from reintervention and early and late reduction of left ventricular outflow tract gradient are superior in patients undergoing septal myectomy.

Minimally Invasive Ozaki Procedure in Aortic Valve Disease: The Preliminary Results.

The Ozaki procedure for aortic valve reconstruction was reported in 2014 with low mortality, a highly reproducible rate and a good midterm result. However, the procedure still requires conventional sternotomy to be accomplished. The aim of the study was to start an initial evaluation for the feasibility of the minimally invasive approach in combination with the Ozaki technique. From January 06, 2017, to January 12, 2017, nine patients with severe aortic valve diseases underwent minimally invasive Ozaki procedure through an upper ministernotomy. The pericardium was harvested endoscopically using three trocars in different intercostal spaces. Then, a ministernotomy was performed and the Ozaki procedure was accomplished in a similar manner to the conventional technique. We analyzed the in-hospital mortality and complications of this group. The mean age was 47.4 years and 55.6% patients were female. The predominant pathology was chronic rheumatic valve disease (66.7%) and other patients were diagnosed with a bicuspid aortic valve. The mean aortic cross-clamp time was 106.8 minutes, the mean cardiopulmonary bypass time was 153.6 minutes, the mean ventilation time was 8.4 hours, and the mean intensive care unit time was 1.6 days. No mortality was recorded in our series, no conversion to full sternotomy was required, one patient experienced right hemothorax requiring drainage, and one patient required valve replacement. Intraoperative transesophageal echocardiography and predischarge transthoracic echocardiography showed five competent valves and three valves with trivial regurgitation, and no stenosis was detected. Ministernotomy combined with Ozaki procedure might be feasible, as well as an alternative to conventional sternotomy. This approach is associated with low mortality and morbidity and may be beneficial in younger populations.