Left Ventricle Reverse Remodeling Research Articles

Predictors of persistence of functional mitral regurgitation after cardiac resynchronization therapy: Review of literature.

Functional mitral regurgitation is a common finding among heart failure patients with ischemic and non-ischemic dilated cardiomyopathies. The presence of moderate or severe mitral regurgitation is associated with higher morbidity and mortality. Heart failure patients meeting electrocardiogram and left ventricle function criteria are good candidates for cardiac resynchronization therapy, which may reduce the degree of functional mitral regurgitation in the short and long term, specifically targeting myocardial dyssynchrony and inducing left ventricle reverse remodeling. In this article, we analyze data from the literature about predictors of mitral regurgitation improvement after cardiac resynchronization therapy implantation.

Mid-Term Outcome of Left Ventricle Reverse Remodeling After Atrial Septal Defect Closure: A Comparison Between Surgical and Device Groups.

Right ventricular (RV) volume overload occurs in patients with significant atrial septal defect (ASD II) shunts, which can impair left ventricle (LV) filling, thus decreasing LV indices. However, after ASD II closure, the left ventricle regains near normal dimensions. The purpose of this study was to compare the long-term outcomes of LV reverse remodeling between device and surgical closure. We retrospectively reviewed the echocardiographic data of 222 patients with isolated ASD II who underwent surgical (95 patients) or device closure (127 patients) between January 2012 and December 2017. The ASD II was significantly larger in the surgical closure group (p < 0.001.) leading to a higher degree of paradoxical interventricular septal (IVS) movement. In contrast, the LV volume was larger in the device closure group (p < 0.001). After a median follow-up period of 19.5months, the maximum LV systolic and diastolic volumes were reached at 1year in the device closure group and 2years in the surgical closure group. IVS motion normalized in 91% of the device closure group compared to 57% of the surgical closure group (p = < 0.001). There was significant improvement in left ventricular indices and IVS motion after ASD II closure in both groups but more favorable in patients after device closure.

Left ventricle reverse remodeling in chronic aortic regurgitation patients with dilated ventricle after aortic valve replacement

BackgroundAortic valve replacement (AVR) for chronic aortic regurgitation (AR) with a severe dilated left ventricle and dysfunction leads to left ventricle remodeling. But there are rarely reports on the left ventricle reverse remodeling (LVRR) after AVR. This study aimed to investigate the LVRR and outcomes in chronic AR patients with severe dilated left ventricle and dysfunction after AVR.MethodsWe retrospectively analyzed the clinical datum of chronic aortic regurgitation patients who underwent isolated AVR. The LVRR was defined as an increase in left ventricular ejection fraction (LVEF) at least 10 points or a follow-up LVEF ≥ 50%, and a decrease in the indexed left ventricular end-diastolic diameter of at least 10%, or an indexed left ventricular end-diastolic diameter ≤ 33 mm/m2. The changes in echocardiographic parameters after AVR, survival analysis, the predictors of major adverse cardiac events (MACE), the association between LVRR and MACE were analyzed.ResultsSixty-nine patients with severe dilated left ventricle and dysfunction underwent isolated AVR. LV remodeling in 54 patients and no LV remodeling in 15 patients at 6–12 months follow-up. The preoperative left ventricular dimensions and volumes were larger, and the EF was lower in the LV no remodeling group than those in the LV remodeling group (all p < 0.05). The adverse LVRR was the predictor for MACE at follow-up. The mean follow-up period was 47.29 months (range 6 to 173 months). The rate of freedom from MACE was 94.44% at 5 years and 92.59% at 10 years in the remodeling group, 60% at 5 years, and 46.67% at 10 years in the no remodeling group.ConclusionsThe left ventricle remodeling after AVR was the important predictor for MACE. LV no remodeling may not be associated with benefits from AVR for chronic aortic regurgitation patients with severe dilated LV and dysfunction.

652 Myocardial work in patients undergoing transcatheter aortic valve implantation: clinical value and implications for outcome

Abstract Aims Non-invasive myocardial work (MW) quantification has emerged in the last years as an alternative echocardiographic tool for myocardial function assessment. This new parameter provides a less loading-dependent evaluation of myocardial performance through the combined assessment of global longitudinal strain (GLS) and non-invasive left ventricle (LV) pressures. The role of MW as a marker of cardiac dysfunction and reverse remodelling in patients with severe aortic stenosis (AS) after aortic valve implantation (TAVI) has not been adequately investigated. This study aims to evaluate MW indices as early echocardiographic markers of LV reverse remodelling within a month after TAVI and their prognostic value. Methods and results We conducted a single-centre prospective study, enrolling 70 consecutive patients (mean age 80.1 ± 5.5 years) with severe AS undergoing TAVI between 2018 and 2020, selected from the EffecTAVI registry. Exclusion criteria were prior valve surgery, severe mitral stenosis, permanent atrial fibrillation, left bundle branch block (LBBB) at baseline, and suboptimal quality of speckle-tracking image analysis. Echocardiographic assessment was performed before TAVI and at 30-day follow-up. Clinical, demographic, and resting echocardiographic data were recorded, including quantification of 2D global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). LV peak systolic pressure was estimated non-invasively from the sum of systolic blood pressure and trans-aortic mean gradient. One month after the procedure, there was a significant improvement of LV GLS (−17.94 ± 4.24% vs. −19.35 ± 4.31%, before and after TAVI respectively, P = 0.002), as well as a significant reduction of GWI (2430 ± 586 mmHg% vs. 1908 ± 472 mmHg%, P &amp;lt; 0.001), GCW (2828 ± 626 mmHg% vs. 2206 ± 482 mmHg%, P &amp;lt; 0.001), and GWW (238 ± 207 mmHg% vs. 171 ± 118 mmHg%, P = 0.006). Conversely, MWE did not significantly change early after intervention (90.53 ± 6.05% vs. 91.45 ± 5.05%, P = 0.204). After TAVI, 30 patients (42.8%) developed LV dyssynchrony due to LBBB or pacemaker implantation. When the population was divided according to the presence or absence of LV dyssynchrony at 30-day follow-up, a significant reduction in GWW was found only in those without dyssynchrony (244 ± 241 vs. 141 ± 110 mmHg% with and without dyssynchrony respectively, P = 0.002). Consistently, in this subgroup, MWE significantly improved post-TAVI (90 ± 7 vs. 93 ± 5%, P = 0.002), while a trend of MWE reduction was observed in patients who developed dyssynchrony post-TAVI (91 ± 4 vs. 89 ± 5%, P = 0.164). In the overall population, a baseline value of MWE&amp;lt; 92% was associated with an increased rate of cardiovascular events (composite of all-cause death and rehospitalization for heart failure) at 1-year follow-up (22.2 vs. 3.1%, long rank, P = 0.016). Conclusions In patients with severe AS undergoing TAVI a significant reduction of GWW and improvement of MWE can be detected only in those who did not develop LV dyssynchrony. In this setting, MWE lower than 92% at baseline is associated with poor outcome. Thus, MWE could represent an alternative tool for myocardial function assessment in patients receiving TAVI.

Evaluation of relationship between interlead electrical delay time and reverse remodeling of left ventricle in patients with quadripolar cardiac resynchronization therapy for long-term follow-up

Abstract Background Cardiac resynchronization therapy (CRT) has undoubtedly shown a high role in the treatment of advanced heart failure (HF). The effectiveness of CRT is individual and variable in each case. It is associated with the functional and structural features of heart as well as the dynamics of these features over time. Despite the quadripolar left ventricle (LV) lead widespread use, the problem of low response to CRT in the early and long-term remains actual. The search for predictors of the CRT response is an important scientific and practical issue. Purpose To determine the relationship between the interlead electrical delay time and the CRT response during 24 month postoperative period. Materials and methods We evaluated the clinical status, the quality of life and echocardiographic response of 37 patients with HF treated for 2 years with quadripolar LV lead CRT devices implanted according to guidelines: 25 males/12 females with age 62±10 years, 25 pts with history of ischemic cardiac disease, LVEF 26±7%; QRS duration 184±31 ms. The response to CRT was defined as 15% decrease of LV end-systolic volume (ESV). Interlead electrical delay time (EDT) was calculated automatically during CRT implantation, and subsequent 3–6-12–18–24 month follow-up. Results The dynamic changes EDT and ESV were assessed for 24 months after CRT. There was a significantly higher average percentage of decrease of ESV in patients (n=18), in whom the stimulation of the LV lead was carried out from a pole having a maximum EDT, in 3 months (12±8% versus 10±6% p=0.021) and in 6 months (23±9% versus 18±9% p=0.003) after CRT. That was the dynamic of reverse remodeling is significantly higher in such patients for the first 6 months. Using logistic regression, it was shown that the relative decrease EDT in the first 3 months after CRT can be a predictor of outcomes in18 and 24 months after CRT with an accuracy of 71% and 77%, respectively. The greater the relative decrease EDT between 0 and 3 months, the greater the probability of a respond in 18 and 24 months after CRT. The cut-off threshold for determining the outcomes in 18 months was 18% on the balance of specificity and sensitivity equal to 80% and in 24 months was 15% on the balance of specificity and sensitivity equal to 90%. There were no differences between the HF etiology (ischemic/ non-ischemic) and baseline rhythm. Conclusion The relationship between EDT and LV reverse remodeling have been investigated for 24 months. The rate of reverse remodeling is higher in patients in whom the stimulation of the LV lead was carried out from a pole having a maximum EDT. Relative decrease EDT in early period after CRT may be a predictor of the CRT outcomes in longtime period. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Russian Science Foundation

Determinants of worse prognosis in patients with cardiac resynchronization therapy defibrillators. Are ventricular arrhythmias an adjunctive risk factor?

Cardiac resynchronization therapy (CRT) is indicated in patients with systolic heart failure (HF), severe left ventricle (LV) dysfunction and interventricular dyssynchrony.In prospective observational research, we aimed to evaluate whether CRT-induced LV reverse remodelling and occurrence of ventricular arrhythmias (VT/VF) independently contribute to prognosis in patients with CRT defibrillators (CRT-D). In 95 Italian cardiological centres, after a screening period of 6 months, patients were categorized according to VT/VF occurrence and CRT response, defined as LV end-systolic volume relative reduction >15% or LV ejection fraction absolute increase >5%. The main endpoint was death or HF hospitalizations. Among 1308 CRT-D patients (80% male, mean age 66 years), at 6 months, follow-up 71% were identified as CRT responders and 12% experienced appropriate VT/VF detections. The main endpoint was significantly and independently associated with previous myocardial infarction, New York Heart Association Class, VT/VF occurrence and with CRT response. CRT nonresponder patients who suffered VT/VF in the screening period had a risk of death or HF hospitalizations [HR = 7.82, 95% confidence interval (CI) = 3.95-15.48] significantly (P < 0.001) higher than CRT responders without VT/VF occurrence. This risk is mitigated without VT/VF occurrence (HR = 3.47, 95% CI = 2.03-5.91, P < 0.001) or in case of CRT response (HR = 3.11, 95% CI = 1.44-6.72, P = 0.004). Our data show that both CRT response and occurrence of VT/VF independently contribute to the risk of death or HF-related hospitalizations in CRT-D patients. Early VT/VF occurrence may be identified as a marker of disease severity than can be mitigated by CRT response both in terms of all-cause mortality and long-term VT/VF onset. URL: https://www.clinicaltrials.gov. Unique identifier: NCT00147290 and NCT00617175.

Effect of Neprilysin Inhibition for Ischemic Mitral Regurgitation after Myocardial Injury.

Angiotensin receptor neprilysin inhibitor (ARNI) treatment reduces functional mitral regurgitation (MR) to a greater extent than angiotensin receptor blocker (ARB) treatment alone, but the mechanism is unclear. We evaluated the mechanisms of how ARNI has an effect on functional MR. After inducing functional MR by left circumflex coronary artery occlusion, male Sprague Dawley rats (n = 31) were randomly assigned to receive the ARNI LCZ696, the ARB valsartan, or corn oil only (MR control). Excised mitral leaflets and left ventricle (LV) were analyzed, and valvular endothelial cells were evaluated focusing on molecular changes. LCZ696 significantly attenuated LV dilatation after 6 weeks when compared with the control group (LV end-diastolic volume, 461.3 ± 13.8 µL versus 525.1 ± 23.6 µL; p < 0.05), while valsartan did not (471.2 ± 8.9 µL; p > 0.05 to control). Histopathological analysis of mitral leaflets showed that LCZ696 strongly reduced fibrotic thickness compared to the control group (28.2 ± 2.7 µm vs. 48.8 ± 7.5 µm; p < 0.05). Transforming growth factor-β and downstream phosphorylated extracellular-signal regulated kinase were also significantly lower in the LCZ696 group. Consequently, excessive endothelial-to-mesenchymal transition (EndoMT) was mitigated in the LCZ696 group compared to the control group and leaflet area was higher (11%) in the LCZ696 group than in the valsartan group. Finally, the MR extent was significantly lower in the LCZ696 group and functional improvement was observed. In conclusion, neprilysin inhibitor has positive effects on LV reverse remodeling and also attenuates fibrosis in MV leaflets and restores adaptive growth by directly modulating EndoMT.

10-Year Results of Mitral Repair and Coronary Bypass for Ischemic Regurgitation: A Randomized Trial

BackgroundThe decision to treat moderate ischemic mitral regurgitation (IMR) at the time of coronary artery bypass surgery (CABG) remains controversial. We previously conducted a prospective randomized trial that showed a benefit of adding restricted annuloplasty to bypass surgery (CABG-Ring group) in terms of IMR grade, New York Heart Association classification, and left ventricle reverse remodeling. Here, we present the long-term (>10 years) follow-up data from this randomized trial. MethodsThe original trial arms accounted for 54 patients in the CABG-alone and 48 in the CABG-Ring group; patients were re-contacted for follow-up to obtain relevant clinical and echocardiographic information. ResultsThe mean follow-up was 160.4 ± 45.5 months. Survival probabilities in the CABG-alone and CABG-Ring groups were 96% vs 93% at 3 years, 85% vs 89% at 6 years, 79% vs 85% at 9 years, 77% vs 83% at 12 years, and 72% vs 80% at 15 years, respectively (P = .18) Freedom from at least moderate IMR or reintervention at last follow-up was also higher in the CABG-Ring group (P < .001). Compared with the CABG-alone group, the CABG-Ring group had a higher degree of left ventricular reverse remodeling (54.7 ± 6.9 mm vs 51.6 ± 6 mm, respectively; P = .03), lower New York Heart Association class (P < .001), and a lower rate of rehospitalization (P = .002). ConclusionsLong-term follow-up data from our randomized trial further support the utility of performing restricted annuloplasty at the time of CABG to prevent further progression of IMR, mitral reintervention, and left ventricle remodeling. Untreated IMR was associated with significantly higher New York Heart Association class and rehospitalization.

Bicuspid aortic valve repair: outcomes after 17 years of experience.

OBJECTIVESThis study presents the results of 17 years of experience with bicuspid aortic valve (BAV) repair and the analysis of factors associated with repair failure and early echocardiographic outcome. METHODSBetween 2003 and 2020, a total of 206 patients [mean age: 44.5 ± 15.2 years; 152 males (74%)] with BAV insufficiency with or without aortic dilatation underwent elective aortic valve repair performed by a single surgeon with a mean follow-up of 5 ± 3.5 years. The transthoracic echocardiography examinations were reported.RESULTSThere were no deaths during the hospital stay, and all but 1 patient survived the follow-up period (99.5%). Overall, 10 patients (5%) developed severe insufficiency and 2 (1%) developed aortic dilatation requiring reoperation. Freedom from reoperation at 7 years reached 91.8%. Type 2 BAV configuration [hazard ratio (HR) 3.9; 95% confidence interval (CI): 1.01–60; P = 0.049], no sinotubular junction remodelling (HR 7; 95% CI: 1.7–23; P = 0.005), no circumferential annuloplasty (HR 3.9; 95% CI: 1.01–64; P = 0.047) and leaflet resection (HR 5.7; 95% CI 1.2–13. P = 0.017) have been identified as a risk factor of redo operation. Parameters of the postoperative left ventricle reverse remodelling improved significantly early after the operation and later at 2 years evaluation.CONCLUSIONSThe repair of BAV offers good short- and mid-term results providing a significant reverse left ventricular remodelling. Type 0 BAV preoperative configuration, circumferential annuloplasty and sinotubular junction remodelling are associated with better repair durability.

Abstract 16096: Successful Pulmonary Vein Isolation Improve Diastolic Dysfunction and Sympathetic Nerve Activity in Atrial Fibrillation Patients

Introduction: Atrial fibrillation (AF) is associated with diastolic dysfunction (DD) at a high rate and the presence of left ventricular DD is also associated with increased muscle sympathetic nerve activity (MSNA). Catheter ablation (CA) of AF was reported to improve cardiac function, including the reverse remodeling of left ventricle and atrium. However, little is known about the effect of CA on MSNA and DD in AF patients. Purpose: The purpose of this study was to evaluate the effect of CA on MSNA and DD and the difference in therapeutic effect between two groups with and without DD. Methods: This study was conducted as a prospective, observational study. AF patients who were scheduled for CA were enrolled. The patients were divided into two groups, E/e’ ratio≧11 and &lt;11. We measured blood pressure, HR, body weight, echocardiogram parameters, and MSNA before and 12 weeks after CA. Results: 28 AF patients participated in this study. After CA, in the patients with DD(the group of E/e’≧11, n=12), E/e’ ratio, the MSNA burst incidence(BI) and frequency(BF) were significantly decreased (13.4±2.1 to 10.6±3.0, p&lt;0.01. 64.4±15.8 to 34.0±12.0 bursts/100beats, P&lt;0.01, 39.7±9.3 to 23.5±9.2 bursts/min, p&lt;0.01 respectively). In the patients without DD (the group of E/e’&lt;11, n=16), the BI and BF were significantly decreased (59.7±11.8 to 43.5±11.7 bursts/100beats, P&lt;0.01, 38.1±10.5 to 29.2±8.4 bursts/min, p&lt;0.01 respectively) while there was no difference in E/e’ ratio. Interestingly, in the patients with DD, decrease in BI and BF were more pronounced compared in the patients without DD(-30.4±15.9 to -16.2±11.5 bursts/100beats, P&lt;0.05. -16.3±11.5 to -8.9±13.8 bursts/min, P=0.145 respectively). In both groups, no significant changes were observed in EF and peak acceleration rate of mitral E velocity. Conclusion: CA reduced MSNA in AF patients. In the patients with DD, the reduction of MSNA tended to be more remarkable than without DD. These findings suggest that changes of MSNA might reflect the improvement of DD and reduction of AF burden.

Determinants of left ventricular hypertrophy and dysfunction in adults with coarctation of aorta

Abstract Background Several coarctation of aorta (COA) severity indices are used for timing of COA intervention, and to define severity of residual coarctation post-intervention. However, it is unclear how many of these COA indices are required in order to recommend intervention, and what degree of residual coarctation results in suboptimal recovery of the left ventricle (LV). Our aim was to assess the correlation between different COA indices and effects of chronic LV pressure overload (LV hypertrophy, diastolic and systolic dysfunction), and to determine the effect of residual coarctation on LV reverse remodeling after COA intervention. Methods COA severity indices were defined as Doppler COA gradient, systolic blood pressure, upper-to-lower-extremity systolic blood pressure gradient, aortic isthmus ratio. LV remodeling indices were defined as LV mass index (LVMI), LV global longitudinal strain (LVGLS), e' and E/e'. LV reverse remodeling was defined as the difference between indices obtained pre-intervention and 5-years post-intervention (delta LVMI, e', E/e', LVGLS). Results Of the COA indices analyzed in 546 adult COA patients, aortic isthmus ratio had the strongest correlation with LVMI (β±standard error −28.3±14.1, p&amp;lt;0.001), LVGLS (1.51±0.42, p=0.005), e' (3.11±1.10, p=0.014), and E/e' (−13.4±6.67, p=0.008). Residual aortic isthmus ratio also had the strongest correlation with LV reverse remodeling, and residual aortic isthmus ratio &amp;lt;0.7 was predictive of suboptimal LV reverse remodeling post-intervention. Conclusion Considering the known prognostic implications of LV remodeling and reverse remodeling in response to pressure overload, these results support the use of aortic isthmus ratio for timing of COA intervention, and for prognostication post-intervention. Funding Acknowledgement Type of funding source: None

Minimaly invasive mitral valve repair with Neochord system in patients with degenerative mitral disease: echocardiographic assessment and predictors for mid-term outcome

Abstract Introduction Various minimally invasive mitral valve (MV) repair techniques are available to treat degenerative mitral regurgitation (MR). Transapical implantation of artificial chordae on a beating heart is performed using the NeoChord DS1000 device with real-time TEE guidance. Purpose 1)To assess preoperative and the mid-term follow-up echocardiographic data in patients after MV repair using the NeoChord DS1000 device; 2)to investigate the changes of left ventricle (LV), left atrium (LA) and mitral annulus dimensions during the follow-up period; 3)to assess the difference of baseline echocardiographic parameters between successful and not-successful (severe residual MR) MV repair groups; 4)to identify the preoperative echocardiographic variables that may be associated with recurrence of MR at mid-term follow. Methods All patients after transapical MV repair with Neochord implantation in Vilnius University hospital were prospectively entered into the study. The acquired preoperative and follow-up echocardiographic datasets were analysed. According to the residual MR at follow-up, patients were stratified to 2 groups: group A – successful durable MV repair (residual MR ≤2); group B – MV repair failure (recurrence of severe MR or reintervention). Values were expressed as Mean±SD. Univariable regression analysis was used to identify anatomical predictors of residual MR. Results 53 (70.67%) patients had a residual MR ≤2 (Group A) and 22 (29.33%) residual MR≥2+ (Group B) at 26±6 months follow-up. At baseline, Group B patients had significantly larger left ventricle end diastolic diameter (LVEDD) (mean difference 5.67±1.29mm, p&amp;lt;0.0001) left ventricle end systolic diameter (LVESD) (mean difference 4.08±1.57mm, p=0.012), LA volume index (mean difference 21.57±5.003 p&amp;lt;0.0001) and higher systolic pulmonary pressure values (mean difference 10.46±3.34, p&amp;lt;0.003) compared with group A. Overall, a significant reduction in LA volume index (mean change 15.69±4.15ml/m2, p&amp;lt;0.001), LA diameter (mean change 3.15±1.24, p=0.012), LV diameter (mean change in LVEDD 4.78±0.88mm p&amp;lt;0.000) was observed at 24 months follow up. There was no significant changes in MV annular parameters at follow up. Left atrium volume (OR 1.018; 95% CI 1.006–1.035; p=0.009), left atrium volume index (OR 1.038; 95% CI 1.013–1.072; p=0.010), LVEDD (OR 1.201; 95% CI 1.088–1.353; p=0.0008), LVESD (OR 1.122; 95% CI 1.02–1.248); p=0.0236) and sPAP (OR 1.418; 95% CI 1.139–2.016; p=0.0014) were all significantly associated with the worse outcome (MR &amp;gt;2) after mini-invasive MV repair in univariable regression analysis. Conclusions Minimaly invasive MV repair with Neochord system on beating heart is effective in patients with degenerative MR. Baseline echocardiographic characteristics predictive for a worse middle term outcome are mainly related to LV and LA remodeling. Reverse remodeling of LV and LA is observed during the follow-up period with no significant changes in MV annulus. Funding Acknowledgement Type of funding source: None

Predictors of left ventricular reverse remodelling after coarctation of aorta intervention.

Several coarctation of aorta (COA) severity indices are used for timing of COA intervention, and to define severity of residual coarctation post-intervention. However, it is unclear how many of these COA indices are required in order to recommend intervention, and what degree of residual coarctation results in suboptimal recovery of the left ventricle (LV). Our aim was to assess the correlation between different COA indices and effects of chronic LV pressure overload (LV hypertrophy, diastolic, and systolic dysfunction), and to determine the effect of residual coarctation on LV reverse remodelling after COA intervention. COA severity indices were defined as Doppler COA gradient, systolic blood pressure (SBP, upper-to-lower-extremity SBP gradient, aortic isthmus ratio. LV remodelling indices were defined as LV mass index (LVMI), LV global longitudinal strain (LVGLS), e' and E/e'. LV reverse remodelling was defined as the difference between indices obtained pre-intervention and 5-year post-intervention (delta LVMI, e', E/e', LVGLS).Of the COA indices analysed in 546 adult COA patients, aortic isthmus ratio had the strongest correlation with LVMI (β ± standard error -28.3 ± 14.1, P < 0.001), LVGLS (1.51 ± 0.42, P = 0.005), e' (3.11 ± 1.10, P = 0.014), and E/e' (-13.4 ± 6.67, P = 0.008). Residual aortic isthmus ratio also had the strongest correlation with LV reverse remodelling, and residual aortic isthmus ratio <0.7 was predictive of suboptimal LV reverse remodelling post-intervention. Considering the known prognostic implications of LV remodelling and reverse remodelling in response to pressure overload, these results support the use of aortic isthmus ratio for timing of COA intervention, and for prognostication post-intervention.

The Prospects of Secondary Moderate Mitral Regurgitation after Aortic Valve Replacement -Meta-Analysis.

Aortic valve replacement for aortic stenosis represents one of the most frequent surgical procedures on heart valves. These patients often have concomitant mitral regurgitation. To reveal whether the moderate mitral regurgitation will improve after aortic valve replacement alone, we performed a systematic review and meta-analysis. We identified 27 studies with 4452 patients that underwent aortic valve replacement for aortic stenosis and had co-existent mitral regurgitation. Primary end point was the impact of aortic valve replacement on the concomitant mitral regurgitation. Secondary end points were the analysis of the left ventricle reverse remodeling and long-term survival. Our results showed that there was significant improvement in mitral regurgitation postoperatively (RR, 1.65; 95% CI 1.36–2.00; p < 0.00001) with the average decrease of 0.46 (WMD; 95% CI 0.35–0.57; p < 0.00001). The effect is more pronounced in the elderly population. Perioperative mortality was higher (p < 0.0001) and long-term survival significantly worse (p < 0.00001) in patients that had moderate/severe mitral regurgitation preoperatively. We conclude that after aortic valve replacement alone there are fair chances but for only slight improvement in concomitant mitral regurgitation. The secondary moderate mitral regurgitation should be addressed at the time of aortic valve replacement. A more conservative approach should be followed for elderly and high-risk patients.

Clinical Outcomes of a Customized Mitral Valve Plasty for Functional Mitral Regurgitation with a Low Ejection Fraction and Implications for Preoperative Right Ventricular Function.

Purpose: To evaluate clinical outcomes of customized mitral valve plasty (MVP) for the treatment of functional mitral regurgitation (FMR) with a low ejection fraction (EF) and to determine which preoperative factors affected the clinical outcome.Methods and Results: MVP was adjusted according to the degree of left ventricle (LV) remodeling. We performed mitral annuloplasty (MAP) alone in 14 patients and added subvalvular procedures (SVPs) in 22 patients at a high risk of recurrent MR. During follow-up, reverse LV remodeling was obtained and the 3-year and 5-year non-recurrence rates of MR grade ≥2 were 94% and 89%, respectively. Two patients died during their hospital stay, and four more patients died of cardiac causes during follow-up. The 3-year and 5-year rates of freedom from cardiac-related mortality were 86% and 81%, respectively; no significant difference was observed between the two treatment groups. Right ventricular fractional area change (RVFAC) was a significant predictor of cardiac mortality. Patients with an RVFAC of <26% had significantly poorer cardiac-related mortality (71% at 3 years) than those with an RVFAC of ≥26% (95% at 3 years).Conclusion: Customized MVP provided durable mitral competence and reverse LV remodeling. Preoperative RV function was associated with cardiac-related mortality.

Mild Ischemic Mitral Regurgitation: Is Revascularization Enough for Every Patient?

The progress of mild ischemic mitral regurgitation (MR) after isolated coronary artery bypass is not clear. We aimed to determine the proportion of patients with mild ischemic MR undergoing isolated coronary artery bypass grafting (CABG) presenting with regression of or persistent MR one year after CABG and to identify the significantly different echocardiographic variables between regressing and persistent MR. Sixty-three patients with preoperative mild ischemic MR were categorized into an MR- regression or an MR-persistence group one year after isolated CABG. The echocardiographic indices, indicating mitral leaflet configuration and remodeling of the left ventricle (LV), were measured before and one year after the surgery. One year after CABG, MR regressed in 60% (38/63) and persisted in 40% (25/63) of the patients. The left ventricular diameter, volume, and sphericity and anteroposterior diameter of the mitral annulus improved only in the MR-regression group, while the ejection fraction improved in both groups (47.7% ± 12.4% from 40.1% ± 11.3%, P < .001 in the regression group and 43.2% ± 14.0% from 39.3% ± 11.6%, P = .035 in the persistence group). A >15% decrease in the LV end-systolic volume was noted more frequently in the MR-regression group (60.5% versus 30%, P = .027). The leaflet angle did not show asymmetry or significant changes in both groups. Isolated CABG improved mild MR in most patients with mild ischemic MR. These patients showed greater reverse remodeling after revascularization than the patients with persistent MR after isolated CABG. Additional tests, which can predict LV reverse remodeling, are needed to predict persistent MR.

A novel risk model for mortality and hospitalization following cardiac resynchronization therapy in patients with non-ischemic cardiomyopathy: the alpha-score

BackgroundNon-ischemic cardiomyopathy (NICM) has been associated with a better left ventricle reverse remodeling response and improved clinical outcomes after cardiac resynchronization therapy (CRT). The aims of our study were to identify the predictors of mortality and heart failure hospitalization in patients treated with CRT and design a risk score for prognosis.MethodsA cohort of 422 consecutive NICM patients with CRT was retrospectively enrolled between January 2010 and December 2017. The primary endpoint was all-cause mortality and heart transplantation.ResultsIn a multivariate analysis, the predictors of all-cause death were left atrial diameter [Hazard ratio (HR): 1.056, 95% confidence interval (CI): 1.020–1.093, P = 0.002]; non-left bundle branch block [HR: 1.793, 95% CI: 1.131–2.844, P = 0.013]; high sensitivity C-reactive protein [HR: 1.081, 95% CI: 1.029–1.134 P = 0.002]; and N-terminal pro-B-type natriuretic peptide [HR: 1.018, 95% CI: 1.007–1.030, P = 0.002]; and New York Heart Association class IV [HR: 1.018, 95% CI: 1.007–1.030, P = 0.002]. The Alpha-score (Atrial diameter, non-LBBB, Pro-BNP, Hs-CRP, NYHA class IV) was derived from each independent risk factor. The novel score had good calibration (Hosmer-Lemeshow test, P > 0.05) and discrimination for both primary endpoints [c-statistics: 0.749 (95% CI: 0.694–0.804), P < 0.001] or heart failure hospitalization [c-statistics: 0.692 (95% CI: 0.639–0.745), P < 0.001].ConclusionThe Alpha-score may enable improved discrimination and accurate prediction of long-term outcomes among NICM patients with CRT.

Combination of left ventricular reverse remodeling and brain natriuretic peptide level at one year after cardiac resynchronization therapy predicts long-term clinical outcome

IntroductionThe aim of this study was to investigate the predictors of long-term clinical outcome of heart failure (HF) patients who survived first year after initiation of cardiac resynchronization therapy (CRT).MethodsThis was a single-center observational cohort study of CRT patients implanted because of symptomatic HF with reduced ejection fraction between 2005 and 2013. Left ventricle (LV) diameters and ejection fraction, New York Heart Association (NYHA) class, and level of N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) were assessed at baseline and 12 months after CRT implantation. Their predictive power for long-term HF hospitalization and mortality, and cardiac and all-cause mortality was investigated.ResultsA total of 315 patients with left bundle branch block or intraventricular conduction delay who survived >1 year after CRT implantation were analyzed in the current study. During a follow-up period of 4.8±2.1 years from CRT implantation, 35.2% patients died from cardiac (19.3%) or non-cardiac (15.9%) causes. Post-CRT LV ejection fraction and LV end-systolic diameter (either 12-month value or the change from baseline) were equally predictive for clinical events. For NT-proBNP, however, the 12-month level was a stronger predictor than the change from baseline. Both reverse LV remodeling and 12-month level of NT-proBNP were independent and comparable predictors of CRT-related clinical outcome, while NT-proBNP response had the strongest association with all-cause mortality. When post-CRT relative change of LV end-systolic diameter and 12-month level of NT-proBNP (dichotomized at -12.3% and 1230 ng/L, respectively) were combined, subgroups of very-high and very-low risk patients were identified.ConclusionThe level of NT-proBNP and reverse LV remodeling at one year after CRT are independent and complementary predictors of future clinical events. Their combination may help to improve the risk stratification of CRT patients.

Effects of left ventricular assist device implantation on respiratory drive

Background: Patients with heart failure (HF) suffer from ventilatory abnormalities that are related to poor prognosis.Aim: The aim of the study was to investigate the respiratory drive in HF patients early after left ventricular assist device (LVAD) implantation. Methods: We enrolled eight HF patients after LVAD (HeartMate II) implantation and 8 patients with advanced HF (control group). Patients were evaluated with cardiopulmonary exercise testing, respiratory function tests and transthoracic echocardiographic examination at 1, 3 and 6 months. Respiratory drive was estimated by the mouth occlusion pressure-P0.1 and the P0.1/Pimax ratio.Results: LVAD patients at 1, 3 and 6 months after implantation had significantly improved P0.1/Pimax% ratio (4.17±0.43 vs 3.29±1.0 vs 2.56±0.35 respectively,p&lt;0.01) as well as significantly increased in Pimax. No changes where observed in the HF control group. A significant decrease in LVEDD, LVESD and an improvement in LVEF is also observed during follow up.Conclusions: Our results imply LVAD implantantion induces a progressive and significant improvement of respiratory drive and Left ventricle reverse remodeling during a 6 month follow-up period.

Comprehensive Analysis of Differential Expressed Genes Related with Myocardial Reverse Remodeling Following HeartWare Ventricular Assist Device Implantation

Purpose Clinical and experimental studies have suggested that the powerful mechanical unloading effects caused by left ventricular assist device (LVAD) may induce reverse remodeling of the failing heart. However, the detailed mechanism and process have not been fully elucidated. Recent advances in next generation sequencing has enhanced transcriptomic analysis to quantify gene expression extensively. We aimed to characterize gene expression profiling related with left ventricle (LV) reverse remodeling in failing human heart, before and after HeartWare LVAD (HVAD) implant. Methods Sequencing-based comprehensive analysis of gene expression profiling was performed through next generation sequencing in paired human failing LV samples (n=5; median age, 54 years; 4 men) collected pre- and post- HVAD, as well as non-failing human LV collected from donors (n=8, median age, 41 years; 3 men). Results Overall, mapping of sequencing reads corresponded to 48,162 genes in these human LV samples. Among them, 9,094 differentially expressed genes were found in pre- HVAD compared with non-failing LV, while 6,788 differentially expressed genes were detected in post- HVAD compared with non-failing LV (Figure). The discrepancy in the number of differentially expressed genes between pre- and post- HVAD is associated with the effect caused by HVAD. Furthermore, paired analysis performed between pre- and post- HVAD suggest serum amyloid A1 may contribute a major mechanism of LV reverse remodeling. Conclusion Our proposed analysis identified that the gene expression profiling was markedly influenced in response to HVAD. These results suggest that the altered genes expression during HVAD implantation may play important role in the pathogenesis of heart failure and reverse remodeling.