Regurgitant Jet Research Articles

Pulmonary valve acceleration fraction as a novel echo parameter to evaluate systolic pulmonary artery pressure during exercise echocardiography

Abstract Background/Introduction Long-COVID is a disabling chronic condition. Some patients have features of exercise-induced pulmonary hypertension (PHT) but non-invasive assessment during exercise stress echo (SE) is often limited by absence of reliable jet of tricuspid regurgitation (TR). We aimed to investigate novel Doppler echo parameters elicited from right ventricular (RV) outflow tract to aid diagnosis of exercise induced PHT among patients referred to our centre with Long-COVID symptoms. Purpose We investigated the ratio of the pulmonary valve acceleration time (PV AccT) to RV ejection time (RV ET) to calculate the pulmonary acceleration fraction (PV AccT/RV ET), thereby adjusting to heart rate. To identify its utility to estimate pulmonary artery pressure (PASP) during SE we correlated the PV AccT/RV ET and the TR-estimated RV systolic pressure (RVSP) in patients referred for evaluation of exercise-induced PHT in Long-Covid patients. Methods We developed a dedicated Covid-19 SE protocol to assess RV and pulmonary hemodynamics. From November 2022 to February 2023 all consecutive patients with Long-COVID symptoms underwent supine bike exercise with 3-min increments of workload of 25W. We did not evaluate the inferior vena cava during exercise, therefore estimated pressures from maximal TR jet velocities only. Results We enrolled 93 consecutive patients. The mean age was 50.1 years, 42.9% were female. No patients had RV impairment or RVSP >40mmHg at baseline. The average exercise time was 12.4 minutes, only 33% achieved the sub-maximum target heart rate (THR), in 50/93 (53.7%) reasons for termination were recorded as shortness of breath. The pulmonary acceleration fraction could be recorded in every patient at rest and at stress, while 20/92 (21.7%) patients had insufficient spectral Doppler profile of TR to estimate RVSP. The PV acceleration fraction was correlated with the available RVSPs during exercise (Spearman’s ϱ -0.446 (95% CI -0.606- -0.251[p<0.0001]). ROC analysis indicated a pulmonary acceleration fraction ≤0.44 was associated with the maximum Youden index to discriminate an increase in RVSP >20mmHg during exercise (AUC =0.731 [p<0.001]) with a sensitivity and specificity of 70.0% and 80.0%. In logistic regression analysis, a PV acceleration fraction ≤0.44 was independently associated with an increase in RVSP>20mmHg during exercise independently of age, gender and baseline LVEF, LVEDV, TAPSE and baseline RVSP (p<0.001). Conclusions Significant proportion of Long-COVID patients are limited by symptoms and not able to achieve THR during exercise. PV Acc T/ PV ET correlates well to RVSP and can be used to estimate PA pressure. A threshold of 0.44 appears independently associated with a benchmark of PA systolic pressure increase of >20mmHg. Further studies needed to evaluate this new marker of pulmonary hypertension in other group of patients.

Right ventricular myocardial work predicts heart failure hospitalizations irrespective of ejection fraction

Abstract Hospitalization for heart failure worsening (HFW) associates with increased subsequent rehospitalization rate and mortality irrespective of left ventricular ejection fraction (EF). However there’s little evidence regarding predictors of HFW to timely apply preventive measurements. Since right ventricular (RV) dysfunction often associates with more advanced stages of HF we assumed that RV myocardial work (MW) assessment might be used in prediction of HFW. Methods 158 patients with HF (48% female) 58±7 years on guideline directed medical therapy in sinus rhythm and with at least one hospitalization in the last 6 months were enrolled in the study. Patients with HFrEF, HFmrEF and HFpEF were evenly represented. All patients were appropriately decongested prior to the study. The primary outcome was rehospitalization, HFW or cardiovascular death. RVMW was derived from RV global strain, including interventricular septum, and noninvasively estimated pulmonary arterial pressure (PAP). Systolic PAP (sPAP) was measured as the sum of maximum RV and right atrial (RA) pressure gradient (PGmax) from tricuspid regurgitation (TR) jet peak velocity and mean right atrial pressure (RAP) estimated from diameter and collapsing of inferior vena cava. Mean PAP (mPAP) was measured as the sum of PGmean RV-RA by tracing TR jet and RAP. Diastolic PAP was estimated as dPAP = 1.5 × [mPAP − (sPAP/3)]. Then RV global work index (RVGWI), constructive (RVGCW), and efficient work (RVGWE) were derived by the software dedicated for left ventricular MW. Left ventricular global longitudinal strain, left atrial (LA) reservoir strain (LAS), LA pump strain, LA volume index (LAVi), B lines, inferior vena cava, NT-pro-BNP, TAPSE/sPAP and RVMW were also measured. Patients followed up for 12 months. Results 53 events were registered at 12 months of which 42 rehospitalizations due to HFW and 11 CV deaths. Among all parameters in the multivariate analysis lower RVGCW was associated with HFW (HR 0.978, 95% CI 0.973–0.998, p = 0.014). RVGCW was the most powerful predictor of CV events (AUC 0.91) with cut off value of 148 mmHg% that had 96% sensitivity and 88% specificity. Number of patients who died with RVGCW < 148 mmHg% was 8 of 11 (73%) total deaths (HR 0.421, 95% CI 0.083–0.986, p = 0.028). Conclusion RVGCW was a predictor of HFW and 1 year mortality in patients with HF irrespective of EF.

Longitudinal echocardiographic parameters for evaluation of pulmonary hypertension in preterm infants with very low birth weight.

Echocardiography is essential for the evaluation of pulmonary hypertension. We determined the feasible quantitative parameter for screening and monitoring pulmonary hypertension in preterm infants. This secondary analysis of a prospective cohort single-centre study was conducted between August 2019 and September 2020. Serial echocardiography was performed 7 and 28 days after birth and at 36 weeks postmenstrual age. The data of infants who developed pulmonary hypertension at 36 weeks postmenstrual age were compared with those without pulmonary hypertension. We also modelled the parameters' trend and performed an interaction test using multi-level Gaussian regression. Out of 30 infants enrolled in the study, 79 echocardiograms were analysed. Left ventricular eccentric index was obtainable in all infants, while tricuspid jet velocity was measurable in 44.1%. Left ventricular eccentric index correlated well with tricuspid regurgitation jet velocity (r = 0.77, P < 0.001). Six infants were diagnosed with newly developed or persistent pulmonary hypertension at 36 weeks postmenstrual age. Serial left ventricular eccentric index showed a significantly different increasing trend in the pulmonary hypertension group (change per day: +0.004; P = 0.090) from the decreasing trend among a non-pulmonary hypertension group (change per day: -0.001; P = 0.041) (P for interaction = 0.007). Right ventricular systolic function and right ventricular isovolumic systolic velocity revealed a reducing trend in the pulmonary hypertension group, which was different from the improving trend in non-pulmonary hypertension infants. Infants with low current weight, low postmenstrual age, and requiring high-flow oxygen therapy at day 28 of life trended to increase the risk of late pulmonary hypertension. Left ventricular eccentric index and right ventricular isovolumic systolic velocity were feasible for assessing pulmonary hypertension and should be incorporated into pulmonary hypertension evaluation. Serial left ventricular eccentric index and right ventricular isovolumic systolic velocity may help predict late pulmonary hypertension and early detection of right ventricular dysfunction.

Flow quantification within the aortic ejection tract using 4D flow cardiac MRI in patients with bicuspid aortic valve: Implications for the assessment of aortic regurgitation

PurposeThe purpose of this study was to evaluate the performance of four-dimensional (4D) flow cardiac MRI in quantifying aortic flow in patients with bicuspid aortic valve (BAV). Materials and methodsPatients with BAV who underwent transthoracic echocardiography (TTE) and 4D flow cardiac MRI were prospectively included. Aortic flow was quantified using two-dimensional phase contrast velocimetry at the sinotubular junction and in the ascending aorta and using 4D flow in the regurgitant jet, in the left ventricular outflow tract, at the aortic annulus, the sinotubular junction, and the ascending aorta, with or without anatomical tracking. Flow quantification was compared with ventricular volumes, pulmonary flow using Pearson correlation test, bias and limits of agreement (LOA) using Bland Altman method, and with multiparametric transthoracic echocardiography quantification using weighted kappa test. ResultsEighty-eight patients (63 men, 25 women) with a mean age of 50.5 ± 14.8 (standard deviation) years (age range: 20.8–78.3) were included. Changes in flow with or without tracking were modest (< 5 mL). The best correlation was obtained at the aortic annulus for forward volume (r = 0.84; LOA [-28.4; 25.3] mL) and at the regurgitant jet and sinotubular junction for regurgitant volume (r = 0.68; LOA [-27.8; 33.8] and r = 0.69; LOA [-28.6; 24.2] mL). A combined approach for regurgitant fraction and net volume calculations using forward volume measured at ANN and regurgitant volume at sinotubular junction performed better than each level taken separately (r = 0.90; LOA [-20.7; 10.0] mL and r = 0.48, LOA [-33.8; 33.4] %). The agreement between transthoracic echocardiography and 4D flow cardiac MRI for aortic regurgitation grading was poor (kappa, 0.13 to 0.42). ConclusionIn patients with BAV, aortic flow quantification by 4D flow cardiac MRI is the most accurate at the annulus for the forward volume, and at the sinotubular junction or directly in the jet for the regurgitant volume.

Coanda Effect Displayed in a Giant Intracranial Aneurysm.

The Coanda effect is a fluid dynamics phenomenon in which a fluid jet adheres to a convex or flat surface. This effect occurs when a liquid or gas jet emerging from an orifice clings to an adjacent surface and entrains the surrounding fluid, creating a lower-pressure region along its path that maintains its attachment to the surface. The Coanda effect accounts for the behavior of blood flow in the fetal right atrium and the dispersion of eccentric mitral regurgitation jets along atrial walls. This series of interesting images depicting a large 4 × 3.75 cm saccular intracranial aneurysm suggests that the Coanda effect may play a role in the pathophysiology of intracranial aneurysms and could be an underlying factor in their formation, progression, or rupture.

Regional impairment of left ventricular longitudinal strain in aortic regurgitation

BackgroundAortic regurgitation (AR) has an important impact on myocardial mechanics and recent studies have proved the value of global longitudinal strain (GLS) in the assessment of its severity and prognosis. Our purpose was to assess if the direct impact of the regurgitant jet on the myocardial wall could affect regional longitudinal strain.MethodsEighty patients with chronic moderate/severe AR were retrospectively studied. Patients were considered to have a jet-related longitudinal strain reduction when the myocardial segments directly impacted by the jet had their longitudinal strain reduced by at least 30% compared to nonaffected segments. AR severity, left ventricular (LV) size and function were compared according to the presence/absence of this regional pattern. For those who underwent surgery, postoperative regional and global LV function was also analyzed.ResultsA pattern of regional longitudinal strain impairment was identified in 43% of patients, with a regional reduction (in median) of 10 percentage points in absolute strain values in the segments impacted by the jet, compared to nonaffected segments. In the subgroup who underwent surgery, this pattern became attenuated after surgery. Patients with regional longitudinal strain impairment were less likely to improve GLS after surgery (10% vs. 38% improved GLS by at least 2.5%, P = 0.049).ConclusionsTo our knowledge, this study identifies for the first time, a link between the location of the impact of the regurgitant jet in AR and regional longitudinal strain impairment. The presence of this regional pattern might be associated with worse postoperative LV recovery.

Prognostic significance of exercise stress echocardiography using two and three diastolic variable approaches

BackgroundThe prognostic utility of comprehensive, guideline-defined assessment of diastolic measures during routine exercise echocardiography remains unclear. ObjectivesThe purpose of the study was to pragmatically assess the prognostic role of obtainable Doppler-derived diastolic variables during treadmill exercise echocardiography. MethodsIn this retrospective study, the authors included 1910 patients undergoing exercise echocardiography. The guideline-defined diastolic measures included resting septal e’ velocity, post-exercise E/e’ ratio and post-exercise tricuspid regurgitant jet velocity. Since tricuspid regurgitant jet velocity is not routinely obtainable, the authors examined 2 approaches: 2 variable approach using only resting septal e’ velocity and post-exercise E/e’ ratio and 3 variable approach with all diastolic variables. ResultsThe mean age of study subjects was 57.6 ± 16 years and 1068 (56 %) were women. The tricuspid jet velocity was not reliably obtained in 501(26 %) of patients. All 3 diastolic variables were associated with the hard outcomes (mortality, acute coronary syndrome, cardiac hospitalization), soft outcomes (subsequent revascularization and cardiac testing), as well as the composite outcome. In the 2-variable approach, the presence of 2 abnormal variables was associated with a worse composite outcome. In the 3 variable approach, the presence of 2 or 3 abnormal variables was associated with a worse composite outcome. The associations persisted after multivariable adjustment and in the propensity matched subgroups. ConclusionsGuideline-defined diastolic variables during treadmill exercise echocardiography offer prognostic utility when used in combination, especially if all 3 variables are obtainable.

Efficacy of early administration of sacubitril/valsartan after coronary artery revascularization in patients with acute myocardial infarction complicated by moderate-to-severe mitral regurgitation: a randomized controlled trial.

Effects of angiotensin receptor/neprilysin inhibitors (ARNI) on ventricular remodeling in patients with heart failure, especially heart failure with reduced ejection fraction (HFrEF), are better than those of angiotensin-converting enzyme inhibitors (ACEI). Acute myocardial infarction (AMI) complicated by mitral regurgitation exacerbates ventricular remodeling and increases the risk of heart failure. There is limited evidence on the effects of early administration of ARNI in patients with AMI complicated by mitral regurgitation. The aim of this trial was to examine the effectiveness and the safety of early administration of sacubitril/valsartan after coronary artery revascularization in patients with AMI complicated by moderate-to-severe mitral regurgitation. This was a randomized, single-blind, parallel-group, controlled trial. From June 2021 to June 2022, we enrolled 142 consecutive patients with AMI complicated by moderate-to-severe mitral regurgitation and followed them for 12months. The patients received standard treatment for AMI and were randomly assigned to receive ARNI or benazepril. The primary efficacy end points were the differences in mitral regurgitant jet area (MRJA), mitral regurgitant volume (MRV), concentration of n-terminal pro-brain natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), and left ventricular end-diastolic volume and end-systolic volume (LVEDV and LVESV) between groups and within groups at baseline, 1, 3, 6, and 12months. Secondary end points included the rates of heart failure hospitalization, all-cause mortality, refractory angina, malignant arrhythmias, recurrent myocardial infarction, and stroke. Safety end points included the rates of hyperkalemia, renal dysfunction, hypotension, angioedema, and cough. The ARNI group had significantly lower NT-proBNP levels than the benazepril group at 1month and later (P < 0.001). MRJA and MRV significantly improved in the ARNI group compared with the benazepril group at 12months (MRJA: - 3.21 ± 2.18 cm2 vs. - 1.83 ± 2.81 cm2, P < 0.05; MRV: - 27.22 ± 15.22mL vs. - 13.67 ± 21.02mL, P < 0.001). The ARNI group also showed significant reductions in LVEDV and LVESV (P < 0.05) and improvement in LVEF (P < 0.05). Secondary end point analysis showed a significantly higher rate of heart failure hospitalization in the benazepril group compared with the ARNI group (HR = 2.03, 95% CI 1.12-3.68, P = 0.021). Safety end point analysis showed a higher rate of hypotension in the ARNI group (P < 0.05). Early use of sacubitril/valsartan after coronary artery revascularization in patients with AMI complicated by moderate-to-severe mitral regurgitation can significantly reduce mitral regurgitation, improve ventricular remodeling, and decrease heart failure hospitalization. Nevertheless, caution is needed to avoid hypotension. Chinese Clinical Trial Registry (ChiCTR2100054255) registered on December 11, 2021.

Peak Tricuspid Regurgitation Jet Velocity and Kidney Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

IntroductionAlthough venous congestion secondary to elevated pulmonary artery pressure (PAP) has been hypothesized to worsen kidney function, the association of peak tricuspid regurgitation jet velocity (pTRV), a surrogate of PAP, with kidney outcomes remains uncertain in heart failure with preserved ejection fraction (HFpEF). MethodsThis post-hoc analysis of the TOPCAT trial analyzed participants with a left ventricular ejection fraction (LVEF) of ≥45% who had pTRV measured by echocardiography at baseline. For the cross-sectional analysis, the association of baseline pTRV with baseline estimated glomerular filtration rate (eGFR) was assessed using linear regression. For the longitudinal analysis, the association of baseline pTRV with decline in eGFR of ≥30% and doubling of serum creatinine was assessed using Cox proportional hazards models. ResultsAmong 450 participants, the mean (SD) baseline age, LVEF, pTRV, and eGFR were 72.3 (9.6) years, 58.2 (7.4) %, 2.8 (0.5) m/s, and 62.1 (18.7) mL/min/1.73 m2, respectively. Each 1 SD higher pTRV was associated with a lower baseline eGFR (Coefficient, -1.79; 95% CI, -3.48 to -0.10 mL/min/1.73 m2). Over a median (IQR) follow-up of 3.0 (2.0–4.4) years, 203 (45%) patients experienced ≥30% eGFR decline, and 48 (11%) experienced creatinine doubling. Each 1 SD higher pTRV was associated with a 20%-higher risk of ≥30% eGFR decline (HR, 1.20; 95% CI, 1.04–1.39) and a 45%-higher risk of creatinine doubling (HR, 1.45; 95% CI, 1.09–1.94). ConclusionsHigher pTRV was associated with lower eGFR at baseline, and higher risk of ≥30% eGFR decline and creatinine doubling among patients with HFpEF.

Right ventricular function indices and platelet parameters for early prediction value of bronchopulmonary dysplasia: a retrospective study

BackgroundTo examine the value of early echocardiographic indices for the right ventricular function combined with platelet(PLT) parameters for predicting bronchopulmonary dysplasia (BPD) in preterm infants.MethodsThis retrospective study included infants with gestational age (GA) below 32 weeks, who were admitted to the neonatal intensive care unit(NICU). The detection rate of tricuspid regurgitation jet velocity (TRVJ), ventricular septal flattening, pulmonary artery widening, right ventricular dilation, and right atrial enlargement on the 7th day of life (DOL 7) were compared between BPD and non-BPD infants. Echocardiographic indices of the right ventricular function including tricuspid annular plane systolic excursion (TAPSE) and right ventricular index of myocardial performance (RIMP) were measured on 1 day of life (DOL 1)、on DOL 7 and on 14 day of life (DOL 14) respectively. The PLT parameters including the PLT count, mean platelet volume (MPV), platelet hematocrit (PCT) level, and platelet distribution width (PDW) were measured on the DOL 1,DOL 7, and DOL 14. Multivariate logistic regression was used to analyze the relationship between these parameters and BPD. Receiver operating characteristic curve analysis was performed to assess the predictive value of the right ventricular function indices and PLT parameters for BPD.ResultsA total of 220 preterm infants were included in this study, and of these, 85 infants developed BPD among them. The RIMP of the BPD group on DOL 14 was higher than that of the non-BPD group (P < 0.05). The TAPSE of the BPD group on DOL 14 was lower than that of the non-BPD group (P < 0.05). The PLT count of the BPD group on DOL 1 was lower than that of the non-BPD group (P < 0.05), and the MPV of the BPD group on DOL 1 was higher than that of the non-BPD group (P < 0.05). Using multivariate logistic regression, GA、invasive mechanical ventilation duration ≥ 7 days、 PLT、 MPV、 TAPSE and RIMP were found to be independent risk factors for BPD. The area under the receiver operating characteristic curve was 0.846 (95CI: 0.794∼0.899), which improved when using right ventricular function indices combined with platelet parameters.ConclusionTAPSE and RIMP combined with PLT count and MPV can help identify preterm infants at an increased risk of developing BPD.

Pre- and post-hemodialysis differences in heart failure diagnosis by current heart failure guidelines in patients with end-stage renal disease

BackgroundPatients with end-stage renal disease (ESRD) who are on hemodialysis (HD) have reduced vascular compliance and are likely to develop heart failure (HF). In this study, we estimated the prevalence of HF pre- and post-HD in ESRD using the current guidelines.MethodsWe prospectively investigated HF in ESRD patients on HD using echocardiography pre- and post-HD. We used the structural and functional abnormality criteria of the 2021 European Society of Cardiology guidelines.ResultsA total of 54 patients were enrolled. The mean age was 62.6 years, and 40.1% were male. Forty-five patients (83.3%) had hypertension, 28 (51.9%) had diabetes, and 20 (37.0%) had ischemic heart disease. The mean N-terminal-pro brain natriuretic peptide BNP (NT-proBNP) level was 12,388.8 ± 2,592.2 pg/dL. The mean ideal body weight was 59.3 kg, mean hemodialysis time was 237.4 min, and mean real filtration was 2.8 kg. The mean left ventricular ejection fraction (LVEF) was 62.4%, and mean left ventricular end-diastolic diameter was 52.0 mm in pre-HD. Post-HD echocardiography showed significantly lower left atrial volume index (33.3 ± 15.9 vs. 40.6 ± 17.1, p = 0.030), tricuspid regurgitation jet V (2.5 ± 0.4 vs. 2.8 ± 0.4 m/s, p < 0.001), and right ventricular systolic pressure (32.1 ± 10.3 vs. 38.4 ± 11.6, p = 0.005) compared with pre-HD. There were no differences in LVEF, E/E′ ratio, or left ventricular global longitudinal strain. A total of 88.9% of pre-HD patients and 66.7% of post-HD patients had either structural or functional abnormalities in echocardiographic parameters according to recent HF guidelines (p = 0.007).ConclusionsOur data showed that the majority of patients undergoing hemodialysis satisfy the diagnostic criteria for HF according to current HF guidelines. Pre-HD patients had a 22.2% higher incidence in the prevalence of functional or structural abnormalities as compared with post-HD patients.

Right Atrial Strain in Pediatric Pulmonary Hypertension-A Prospective Observational Study.

Right ventricular (RV) afterload due to elevated pulmonary arterial (PA) pressure in pulmonary hypertension (PH) causes long-term right atrial (RA) remodeling and dysfunction. RA function has been shown to correlate with PA pressures and outcome in both adult and pediatric patients with PH. We studied the role of RA strain in estimating PA pressures in congenital heart disease (CHD)-associated PH. Children below 12years undergoing elective repair of CHD with left-to-right shunts and echocardiographic evidence of PH were included. RA reservoir, conduit and contractile strain along with conventional measures of RV function and PA pressure were measured using transthoracic echocardiography after induction of anaesthesia. Pre-and post-repair invasive PA pressures were measured after surgical exposure. 51 children with a median age of 24months (range 4-144months) were included, most of whom were undergoing VSD closure. Contractile RA strain showed good correlation with pre-repair systolic PA pressure in mmHg (r = 0.59, 95%CI 0.37-0.75) or expressed as a percentage of SBP (r = 0.67, 95%CI 0.49-0.80). It also predicted persistent postoperative PH as well as pre-repair pulmonary artery acceleration time and right ventricular systolic pressure measured from tricuspid regurgitation jet. The trends of correlation observed suggest a possible prognostic role of RA strain in ACHD with PH and potential utility in its echocardiographic assessment. The observed findings merit deeper evaluation in larger cohorts.

Novel Noninvasive Index Combining Echocardiography and Computed Tomography for Screening for Pulmonary Hypertension in Patients With Systemic Sclerosis

BackgroundIn patients with systemic sclerosis (SSc), early detection of pulmonary hypertension (PH) improves survival. This study aimed to investigate whether a combination index (cPAT) of the tricuspid regurgitation jet peak gradient and the ratio of pulmonary artery (PA) diameter to aortic diameter measured by computed tomography (CT; PA ratio) can estimate the mean PA pressure (mPAP) and detect PH more accurately than conventional parameters in SSc patients. MethodsA total of 36 SSc patients who underwent PH screening were retrospectively analyzed. All patients were screened for PH between 2013 and 2017 by echocardiography, CT, and right heart catheterization. Patients with mPAP > 20 mm Hg by right heart catheterization were diagnosed as having PH. Additionally, patients with an mPAP > 20 mm Hg, pulmonary vascular resistance > 2 Wood units, and PA wedge pressure ≤ 15 mm Hg, for whom other causes were ruled out, including group 2-5, were defined as having pulmonary atrial hypertension. ResultsOf 36 patients, 29 patients were female (81%), and the average duration of SSc was 7.5 years. The mPAP was significantly correlated with the tricuspid regurgitation jet peak gradient (r = 0.734), the PA ratio (r = 0.584), and the cPAT (r = 0.848). In receiver operating characteristic analysis to identify PH, the cPAT showed the highest area under the curve, 0.906, among the 3 parameters. Additionally, in receiver operating characteristic analysis to identify pulmonary atrial hypertension, the cPAT also showed the highest area under the curve, 0.851, among the 3 parameters. ConclusionsThe cPAT is a new index combining echocardiogram and CT results that provides the most accurate noninvasive assessment of mPAP in SSc patients. The cPAT can also help detect PH early in SSc patients, thereby allowing for earlier treatment.

DIASTOLIC DYSFUNCTION EVALUATION IN CARDIAC AMYLOIDOSIS: BEYOND TRADITIONAL PARAMETERS TO DISCRIMINATE BETWEEN TRUE HEART FAILURE WITH PRESERVED EJECTION FRACTION AND MIMICS

Abstract Background Diastolic dysfunction in cardiac amyloidosis (CA), according to current guidelines, can be classified using mitral flow velocities, mitral annular e’ velocity, E/e’ ratio, tricuspid regurgitation jet and left atrial (LA) maximal volume. However, LA minimal volume and the ratio between LA and left ventricular (LV) volumes at end–diastole, known as left atrio–ventricular coupling index (LACI), have recently been proposed to refine prognosis and peak atrial longitudinal strain (PALS) has been demonstrated to better stratify diastolic dysfunction. Aim of the Study To evaluate, in patients with CA: 1) the role of LACI as marker of LV diastolic dysfunction; 2) whether LACI could discriminate cardiomyopathy from normal cardiac function; 3) whether LACI and/or PALS could help discriminate between true heart failure with preserved ejection fraction (HFpEF) and amyloidotic cardiomyopathy (HFpEF–mimic). Methods We retrospectively analyzed 63 patients with CA and compared them with 80 true HFpEF patients and 70 healthy people; echocardiography was performed at the time of the diagnosis and diastolic function was characterized according to current guidelines. Results In patients with CA, LACI significantly increased as diastolic dysfunction worsened (P for trend &amp;lt; 0.0001) and significantly correlated with LV filling pressures estimated by E/e’ ratio (beta = 0.65, P &amp;lt; 0.0001) and pulmonary artery systolic pressure (beta = 0.63, P &amp;lt; 0.0001). LACI, after adjustment for age, gender and body mass index (BMI), was significantly higher in CA [0.62 (95%CI 0.52–0.70)] and in HFpEF [0.61 (95%CI 0.55–0.68)] than in controls [0.29 (95%CI 0.19–0.39)], while the difference between the two diseased populations was not statistically significant; a cut–off value of 0.45 was able to discriminate between controls and diseased patients (sensitivity = 95%, specificity = 94%, area under ROC curve = 0.98). PALS, after adjustment for age, gender and BMI, was significantly lower in CA [11.1 (95%CI 8.4–13.8%) and 8.4 (95%CI 3.5–13.3%) respectively in ATTR and AL] than in HFpEF [17.4 (95%CI 15.6–19.3%)], and a cut–off value of 9.9% was able to discriminate between them (sensitivity = 89%, specificity = 73%, area under ROC curve = 0.86). Conclusions LACI is a novel index able to discriminate between normal and diseased patients. In CA, it shows good correlation with diastolic dysfunction and LV filling pressures. PALS can be used to discriminate between true HFpEF and CA.

Predictors of post-operative left atrioventricular valve regurgitation in pediatric patients with complete atrioventricular canal defects.

In infants with complete atrioventricular canal (CAVC) defects, post-operative left atrioventricular valve regurgitation (LAVVR) is a known major cause of morbidity and mortality and a common indication for re-operation. However, there is scarce data to identify risk factors for poor outcomes. Our study aims to find echocardiographic characteristics that predict post-operative LAVVR at discharge and 1-year follow-up. Retrospective cohort study of patients with initial CAVC repair at our hospital who were followed for 1 year between 2013 and 2022. Patients with major co-morbid conditions were excluded. Serial echocardiograms were reviewed. Anatomic details, quantitative and qualitative measure of LAVVR including the number of regurgitant jets, regurgitant jet length and vena contracta width, and ventricular function were collected. The time points measured include pre-operative transthoracic echocardiogram (TTE), post-operative transesophageal echocardiogram (PO-TEE), routine protocol based post-operative day 1 (POD1) TTE, discharge TTE and 1-year post-operative (1yPO) TTE. Paired t-tests, chi-square analysis, and linear regression analysis were performed comparing measured variables to LAVVR outcomes. Fifty-two patients were included; 92% had Trisomy 21. The majority were classified as Rastelli A (71%), others Rastelli C (29%). Only two patients had moderate or greater LAVVR pre-operatively. The mean age at repair was 125 ± 44 days. Pre-operative LAVVR was the only significant predictor of LAVVR severity at 1 year after backward stepwise regression. Of those with<moderate LAVVR on PO-TEE, 20% had worsening to≥moderate at discharge, but only 9% remained that way at 1 year. Of those with≥moderate LAVVR on PO-TEE, 40% improved to<moderate by 1 year. Two patients who worsened at 1 year, both secondary to likely cleft suture dehiscence. Only one patient required reoperation in the immediate post-operative period secondary to severe LAVVR due to suture dehiscence. Routine protocol-based POD1 echo did not have any association with altered outcomes. Pre-operative LAVVR was the only significant predictor of LAVVR severity at 1 year. A significant percentage (40%) of patient with≥moderate LAVVR on PO-TEE improved to<moderate by 1 year. Furthermore, routine protocol-based POD1 echo did not have any association with altered outcomes.

The Influence of Pericardial Fat on Left Ventricular Diastolic Function.

Heart failure is a major cause of morbidity and mortality worldwide; left ventricular diastolic dysfunction plays a leading role in this clinical context. Diastolic dysfunction may be predisposed by increased abdominal fat and, consequently, increased pericardial and epicardial adiposity. This study aimed to determine whether pericardial fat (PF) and epicardial fat (EF) are associated with left ventricular diastolic function. A total of 82 patients had their abdominal circumference measured and underwent transthoracic echocardiography to measure the thickness of PF and EF and assess the left ventricular diastolic function. Two groups were created based on mean pericardial fat (PF) thickness (4.644 mm) and were related to abdominal circumference and echocardiographic parameters. Subjects in the PF High group showed a significant decrease in septal e' (p < 0.0001), lateral e' (p < 0.0001), and E/A ratio (p = 0.003), as well as a significant increase in E/e' ratio (p < 0.0001), E wave deceleration time (p = 0.013), left atrial volume (p < 0.0001), the left ventricle mass (p = 0.003), tricuspid regurgitant jet velocity (p < 0.0001), and the left ventricle diameter (p = 0.014) compared to the PF Low group. Correlations were found between pericardial fat and nine echocardiographic parameters in the study, while epicardial fat (EP) only correlated with eight. Measurement of abdominal circumference, PF, and EF is an early indicator of diastolic changes with transthoracic echocardiography being the gold standard exam.

Fact or Artifact: A prospective study on diagnostic value of a new echocardiographic parameter of Color Doppler Horizontal Splay width in assessment of mitral regurgitation severity

Objective. 1. To evaluate the diagnostic value of the echocardiographic parameter of Color Doppler Horizontal Splay width (CDHSW) in assessment the of mitral regurgitation (MR) severity.2. To determine the cut-off values of CDHSW for the diagnosis of severe MR.Material and methods. A prospective data collection of 81 patients with presence of CDHS on echocardiography was carried out. Transesophageal echocardiography was performed in all of them to clarify the etiology and severity of MR, and in addition, 33 (40%) patients underwent phase-contrast magnetic resonance imaging.Results. After multiparametric examination severe MR was found in 32 (39%) patients, moderate MR in 47 (58%) and mild MR in 2 (3%). Regurgitation jet was eccentric in 79 (98%) patients, and sharply eccentric in 58 (71%) of them. The values of CDHSW (measured in 4-chamber, 2-chamber view, and mean CDHSW values) were significantly higher in the group of severe MR in comparison with the group of moderate MR. A statistically significant strong correlation was revealed between the CDHSW (measured in the 4- and 2-chamber view, and mean CDHSW values) with the values of MR volume, regurgitant fraction, size of effective regurgitant orifice, and a moderate correlation with the values of vena contracta width, left ventricle end-diastolic velocity and left atrium volume. ROC analysis showed the highest diagnostic value (AUC 0,93 ± 0,5, p &lt; 0,001) of mean CDHSW in diagnosis of severe MR in comparison with CDHSW. Optimal cutoff value for mean CDHSW for severe MR diagnosis was &gt;30 mm with a sensitivity of 88% and specificity of 71%.Conclusions. 1. CDHSW is an echocardiographic parameter that provides additional opportunities in the diagnosis of latent moderate and severe eccentric MR.2. It is reasonable to use mean values for the increase of diagnostic sensitivity of CDHSW.3. The mean value of CDHSW &gt;30 mm is highly suggestive to severe MR.

Entire Mitral Valve Reconstruction Using Porcine Extracellular Matrix: Adding a Ring Annuloplasty

PurposeThis study investigated the implications of inserting a flexible annuloplasty ring after reconstructing the entire mitral valve in a porcine model using a previously investigated tube graft design made of 2-ply small intestinal submucosa extracellular matrix (CorMatrix®).MethodsAn acute model with eight 80-kg pigs, each acting as its own control, was used. The entire mitral valve was reconstructed with a 2-ply small intestinal submucosa extracellular matrix tube graft (CorMatrix®). Subsequently, a Simulus® flexible ring was inserted. The characterization was based on mitral annular geometry and valvular dynamics with sonomicrometry and echocardiography.ResultsAfter adding the ring annuloplasty, the in-plane annular dynamics were more constant throughout the cardiac cycle compared to the reconstruction alone. However, the commissure–commissure distance was statistically significantly decreased [35.0 ± 3.4 mm vs. 27.4 ± 1.9 mm, P < 0.001, diff = − 7.6 mm, 95% CI, − 9.8 to (−5.4) mm] after ring insertion, changing the physiological annular D-shape into a circular shape which created folds at the coaptation zone resulting in a central regurgitant jet on color Doppler.ConclusionWe successfully reconstructed the entire mitral valve using 2-ply small intestinal submucosal extracellular matrix (CorMatrix®) combined with a flexible annuloplasty. The annuloplasty reduced the unphysiological systolic widening previously found with this reconstructive technique. However, the Simulus flex ring changed the physiological annular D-shape into a circular shape and hindered a correct unfolding of the leaflets. Thus, we do not recommend a flexible ring in conjunction with this reconstructive technique; further investigations are needed to discover a more suitable remodelling annuloplasty.

A tissue-silicone integrated simulator for right ventricular pulsatile circulation with severe functional tricuspid regurgitation

There is a great demand for development of a functional tricuspid regurgitation (FTR) model for accelerating development and preclinical study of tricuspid interventional repair devices. This study aimed to develop a severe FTR model by creating a tissue-silicone integrated right ventricular pulsatile circulatory simulator. The simulator incorporates the porcine tricuspid annulus, valve leaflets, chordae tendineae, papillary muscles, and right ventricular wall as one continuous piece of tissue, thereby preserving essential anatomical relationships of the tricuspid valve (TV) complex. We dilated the TV annulus with collagenolytic enzymes under applying stepwise dilation, and successfully achieved a severe FTR model with a regurgitant volume of 45 ± 9 mL/beat and a flow jet area of 15.8 ± 2.3 cm2 (n = 6). Compared to a normal model, the severe FTR model exhibited a larger annular circumference (133.1 ± 8.2 mm vs. 115.7 ± 5.5 mm; p = 0.009) and lower coaptation height (6.6 ± 1.0 mm vs. 17.7 ± 1.3 mm; p = 0.003). Following the De-Vega annular augmentation procedure to the severe FTR model, a significant reduction in regurgitant volume and flow jet area were observed. This severe FTR model may open new avenues for the development and evaluation of transcatheter TV devices.

Novel percutaneous technique for creation of porcine model of tricuspid regurgitation via two routes.

To develop an experimental porcine model of tricuspid regurgitation using two induction routes: the inferior vena cava and superior vena cava. Tricuspid regurgitation was generated using the loop wire cutting method. The tricuspid regurgitation jet direction was controlled by accessing the valve through the inferior (n = 7) or superior (n = 6) vena cava. The occurrence, direction, and progression of tricuspid regurgitation were assessed postoperatively, and echocardiography was performed at 4 to 6 weeks. Right heart dilatation was assessed using computed tomography after 6 weeks. Moderate to severe or torrential tricuspid regurgitation occurred immediately after the procedure in 12 of 13 animals. The jet was directed toward the septum in five of seven animals in the inferior vena cava group and toward the posterolateral side in four of six animals in the superior vena cava group. The dimensions of the right heart (right atrium, ventricle, and tricuspid valve annulus) were significantly enlarged at the 4- to 6-week follow-up echocardiographic examination and confirmed to be enlarged by computed tomography, independent of the route used. The loop wire cutting method successfully induced a disease model of tricuspid regurgitation while controlling the regurgitation jet direction via two procedural routes.