Valvular Function Research Articles

Unicuspid unicommissural aortic valves: A surgical pathology analysis.

The unicuspid unicommisural aortic valve is an uncommon congenital malformation that often manifests as stenosis with or without regurgitation in adults in their third to fifth decades of life. This report characterizes the morphological features of surgically excised unicuspid valves in adults with clinical correlation. Among the surgically excised aortic valves over a period of 10 years, the clinical data and morphological features of unicuspid aortic valves were analyzed. The patients were grouped by the type of valvular function. Pathological features noted were the shape of the orifice, the status of the commissure and raphe, presence of fibrous thickening, calcification, and other complications. Twenty-three UAVs, excised over a 10-year period, represented 4.16% of the excised diseased aortic valves. There was a male preponderance with a mean age of 47.7 years. Majority of the patients (22 cases) had moderate to severe stenosis with varying degrees of regurgitation, and the valvular disease had been clinically attributed to rheumatic heart disease, bicuspid aortic valve, or senile degenerative changes. Most of the valves (18) had been cut at their commissural regions, and 2 rudimentary commissures or raphes were seen in 21 valves. Cuspal fibrosis/calcification was often associated with complications like ulceration, hemorrhage, and bland vegetations. Aneurysm of the ascending aorta had been present in 1 patient. The unicuspid unicommisural aortic valve while rare is usually clinically classified with the more common, congenitally bicuspid aortic valve. Clinical or imaging diagnosis can be challenging since calcification may obscure the morphology creating difficulties in distinguishing such valves from other congenital or acquired valvular pathologies, especially in older patients. Often it is only the gross examination that leads to the differentiation as was our observation.

Hemangioma of the Mitral Valve and Aortomitral Curtain in an Adolescent.

A hemangioma of the mitral valve and aortomitral curtain was incidentally discovered in an adolescent. The lesion was surgically excised, and the mitral valve was reconstructed with complete preservation of valvular function. Pertinent principles of multimodality imaging-based diagnosis and nuances of operative management of this rare, vascular tumor are discussed.

Predictors of adverse cardiac events in a large cohort of patients with antiphospholipid syndrome

Abstract Background Non-valvular cardiac disease in antiphospholipid syndrome (APS) has been modestly evaluated. Aim We wanted to assess the prevalence and evolution of major adverse cardiovascular events(MACE) in a cohort of APS patients. Material and Methods From a large cohort of 181 APS patients included in a study from 2011-2012.year data for the occurrence of MACE in 10 years of follow-up were evaluated in 82 patients (86.6% females, 62.2% with primary (PAPS), and 37.8% patients with APS associated with systemic lupus erythematosus (SLE) (sAPS)). At the inclusion in all patients, a transthoracic echocardiography study for the assessment of dimensions and functionality of the left and right heart along with valvular functions and morphology. Standard atherosclerotic risk factors prevalence was analyzed. Antiphospholipid antibodies(aPL) analysis included the detection of aCL (IgG/IgM), ß2GPI (IgG/IgM), and LA, and all patients were treated according to the valid guidelines by the rheumatologist. Data regarding the occurrence of new myocardial infarction (MI), cerebrovascular events (CVI), arterial and/or venous thrombosis, heart failure (HF), and cardiovascular death (considered as MACE) have been collected 10 years after inclusion. Results The prevalence of standard atherosclerotic risk factors was less than 40% in both study groups. Left ventricle ejection fraction(LVEF) was over 45% in more than 90% of patients in both groups (p=0.246) with valvular dysfunction present in 49% of PAPS and 58.1% of sAPS patients (p=0.426). 9.8% PAPS and 12.9% sAPS had coronary artery disease(CAD) (p=0.724) and HF was present in 7.8% PAPS and 3.2% sAPS (p=0.645). MACE occurred in 17.6% of PAPS and 22.6% of sAPS (p=0.585). The new MI occurred in 9.8% of PAPS and 9.7% of sAPS (p=1.000), CVI in 5.9% of PAPS and 3.2% of sAPS (p=1.000), HF in 5.9% of PAPS and 3.2% of sAPS (p=1.000) and cardiovascular death in 9.8% of PAPS and 12.9% of sAPS (p=0.724). New thrombotic events (arterial and/or venous) occurred in 15.7% of PAPS and 17.2% of sAPS (p=1.000). During the follow-up period, 66.7% of PAPS and 55.2% of SAPS (p=0.313) were treated with aspirin, 25.5% of PAPS and 25.0% of sAPS with warfarin, and chloroquine was administered in 46.8% of PAPS and 53.6% of sAPS (p=0.571). Age (p=0.008), gender (p=0.034), thrombotic APS (p=0.033), hypertension (p=0.003), diabetes mellitus (p=0.043), and cardiovascular manifestations present at the time of APS diagnosis (p=0.035), namely CAD (p=0.001) and HF (p=0.005) were significantly associated with 10y MACE. aPL type and category were not associated with 10y MACE. In a multivariate logistic model, age. hypertension, and HF were independent predictors for 10y MACE. Conclusions APS patients develop new cardiovascular events despite optimal medical therapy. Cardiovascular evaluation at the time of diagnosis and proper cardiologist follow-up with the rigorous treatment of standard atherosclerotic risk factors is of utmost importance.

A novel murine wire injury based infectious endocarditis model aggravates aortic valve stenosis

Abstract Background With mortality rates up to 40% under optimal medical treatment, infectious endocarditis (IE) remains one of the deadliest infectious diseases worldwide. In the early stages of IE, diagnosis and treatment initiation are often difficult and research is limited due to unreliable models. Most murine IE models rely on permanent prosthetic wire placement and i.v. bacterial injection, thus making it inadequate to study IE pathophysiology with the aim to reflect the course of disease in humans. Purpose To develop a reproducible murine IE model, based on aortic valve injury preceding intravenous S. aureus bacterial challenge. Methods Using a wire-injury model we induced endothelial lesions. 72h after wire injury (WI), we performed intravenous bacterial challenge using S. aureus. Echocardiography was performed to confirm bacterial vegetations and assess valvular function. Cross sections of valvular leaflets were prepared for scanning electron microscopy (SEM). Macrophage, neutrophil and S. aureus-specific immunofluorescence staining was performed and visualized by immunofluorescence microscopy. Bacterial cultivation was performed from peripheral blood and valve tissue. Systemic immune response was analyzed using flow cytometry. Results WI induced endothelial damage in all mice verified using scanning electron microscopy imaging. The combination of wire injury and injection of 10^5 and 10^6 colonies-forming-units (CFU) S. aureus reliably caused IE validated via in vivo echocardiography as well as S.aureus immunofluorescence staining and SEM imaging. Mice undergoing bacterial challenge responded with significant neutrophilia in the blood. Using 10^6 CFU S. aureus was associated with an increased mortality, liver and kidney abscess formation due to systemic bacterial spreading compared to 10^5 CFU. Peak velocity across the aortic valve and aortic valve leaflet thickness as markers for aortic valve stenosis were increased in IE compared to WI only mice. Aortic regurgitation was more prevalent after bacterial challenge mediating increased left ventricular volumes, meanwhile ejection fraction was not altered. Immunofluorescence staining revealed a pro-inflammatory milieu including increased macrophage and neutrophil infiltration in IE compared to WI only mice. Conclusion In vivo echocardiography and ex vivo histological staining revealed reliable IE induction using our new model with S. aureus concentrations of 10^5 CFU. The additional bacterial challenge causes a more severe aortic valve stenosis compared to WI only mice, potentially due to an observed increase in valvular inflammation.Fig 1 Scanning electron microscopy after

Echocardiographic assessment of atrial, ventricular, and valvular function in patients with atrial fibrillation-an expert proposal by the german working group of cardiovascular ultrasound.

Echocardiography in patients with atrial fibrillation is challenging due to the varying heart rate. Thus, the topic of this expert proposal focuses on an obvious gap in the current recommendations about diagnosis and treatment of atrial fibrillation (AF)-the peculiarities and difficulties of echocardiographic imaging. The assessment of systolic and diastolic function-especially in combination with valvular heart diseases-by echocardiography can basically be done by averaging the results of echocardiographic measurements of the respective parameters or by the index beat approach, which uses a representative cardiac cycle for measurement. Therefore, a distinction must be made between the functionally relevant status, which is characterized by the averaging method, and the best possible hemodynamic status, which is achieved with the most optimal left ventricular (LV) filling according to the index beat method with longer previous RR intervals. This proposal focuses on left atrial and left ventricular function and deliberately excludes problems of echocardiography when assessing left atrial appendage in terms of its complexity. Echocardiography of the left atrial appendage is therefore reserved for its own expert proposal.

Sport PRactice and its Effects on aortic size and valve function in bicuspid Aortic valve Disease: a cross-sectional report from the SPREAD study

ObjectiveConcerns exist about the possible detrimental effects of exercise training on aortic size and valve function in individuals with bicuspid aortic valve (BAV). This multicentre international study aimed to determine...

Assessment of Tricuspid Regurgitation by Cardiac Magnetic Resonance Imaging: Current Role and Future Applications.

Tricuspid regurgitation (TR) is a prevalent valvular disease with a significant mortality rate. The evaluation of TR severity and associated right heart remodeling and dysfunction is crucial to determine the optimal therapeutic strategy and to improve prognosis. While echocardiography remains the first-line imaging technique to evaluate TR, it has many limitations, both operator- and patient-related. Cardiovascular magnetic resonance imaging (CMR) has emerged as an innovative and comprehensive non-invasive cardiac imaging technique with additional value beyond routine echocardiographic assessment. Besides its established role as the gold standard for the evaluation of cardiac volumes, CMR can add important insights with regard to valvular anatomy and function. Accurate quantification of TR severity, including calculation of regurgitant volume and fraction, can be performed using either the well-known indirect volumetric method or novel 4D flow imaging. In addition, CMR can be used to assess the impact on the right heart, including right heart remodeling, function and tissue characterization. Several CMR-derived parameters have been associated with outcome, highlighting the importance of multi-modality imaging in patients with TR. The aim of this review is to provide an overview of the current role of CMR in the assessment and management of patients with TR and its future applications.

Abstract 1058: Effects Of Soluble Guanylate Cyclase Activation On Progression Of Fibrocalcific Aortic Valve Stenosis (avs), Its Molecular Drivers, And Downstream Pathological Cardiac Electrical Remodeling

Objective: We recently discovered that activation of oxidized soluble guanylate cyclase with ataciguat (ATA) slows valve calcification and dysfunction in mice and humans with moderate aortic valve stenosis (AVS). We examined if ATA would attenuate multiple mechanisms contributing to AVS and end organ dysfunction associated with AVS, and hypothesized: 1) ATA attenuates osteogenic signaling in valve tissue from mice with AVS, thereby attenuating calcification and valve dysfunction, 2) AVS increases rates of sudden cardiac death in our model, and 3) treatment with ATA prevents QT prolongation and deleterious electrical remodeling commonly observed in AVS. Methods: Functional, molecular, and histopathological changes in valve tissue along with QT interval duration were measured in 3 independent groups of mice: non-AVS, AVS, and AVS+ATA (WD for 6 months then WD+ATA for 3 months (AVS+ATA). We gave 5 mg/kg isoproterenol (ISO, i.p.) to ldlr -/- /ApoB100-only mice fed normal chow (non-AVS) or western diet (AVS, fed WD for 9 months) to assess risk for malignant arrhythmias. Retrospective analysis of QT interval was also done on data from our recent Phase 1 clinical trial. Results: AVS+ATA mice had less valve calcification and slower progression of valve dysfunction through attenuation of canonical BMP signaling and reductions in Runx2 and SPP1 compared to AVS mice. QT prolongation was evident in AVS mice, and was significantly attenuated by treatment with ATA (p= 0.001) and coarsely associated with severity of valvular or ventricular function. While all non-AVS mice survived for 24 hours after ISO, 40% of mice with AVS reached a moribund equivalent within 4 hours. Retrospective analyses also showed reductions in QT interval duration in patients treated with 200 mg/day ATA for 14 days (p < 0.05). Conclusion: Collectively, this is the first study reporting increased propensity for malignant arrhythmias in our mouse model of AVS, QT prolongation as a likely underlying mechanism, and restoration of cardiac conduction dynamics with targeted restoration of nitric oxide signaling. Future studies focused on the role of sGC in the evolution and prevention of AVS and consequent deleterious electrical remodeling/malignant arrhythmia risk is warranted.

Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation.

Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.

Long-term outcome and cardiac function after anatomic repair of congenitally corrected transposition.

There is limited information on long-term outcomes and trajectories of ventricular and valvular functions in patients with congenitally corrected transposition of the great arteries after anatomic repair according to the operative strategy with a median follow-up period of more than 10 years. Twenty-nine patients who underwent anatomic repair in Okayama University Hospital between January 1994 and December 2020 were reviewed. Outcomes were compared between patients who underwent a double switch operation (DS group) and patients with an atrial switch with a Rastelli operation (Rastelli-Senning/Mustard group). Fifteen (52%) were in the DS group and 14 (48%) were in the Rastelli-Senning/Mustard group. The median follow-up period after anatomic repair was 12.7 (interquartile range 4.2-18.8) years. There were 3 (10%) early deaths and 3 (10%) late deaths. Survival rates for the entire cohort at 10 and 20 years were 86% and 71%, respectively, and were not different between the 2 groups. Using competing risk analysis, risks of heart failure, cardiac rhythm device implantation and atrial arrhythmia showed no significant differences between the 2 groups, whereas risk of reoperation was higher in the Rastelli-Senning/Mustard group than that in the DS group. Four patients after a DS operation and 1 patient after a Rastelli technique developed more than moderate aortic regurgitation. During a median follow-up period of more than 10 years, mortality rate and ventricular and valvular functions after anatomic repair were acceptable, though the incidences of late complications were relatively high, especially in the Rastelli-Senning/Mustard group.

Progression of Mild Mitral Annulus Calcification to Mitral Valve Dysfunction and Impact on Mortality

Mitral annulus calcification (MAC) represents a degenerative process resulting in calcium deposition in the mitral valve apparatus. Mitral annulus calcification is associated with adverse clinical outcomes. We sought to examine the long-term significance of mild MAC and its relationship to subsequent mitral valve dysfunction (MVD) and mortality in patients without MVD on the initial echocardiogram. A total of 1,420 patients with mild MAC and no MVD at baseline and 1 or more follow-up echocardiograms at least 1year after the baseline echocardiogram were included in the analysis. For patients with >1 echocardiogram during follow-up, the last echocardiogram was used. The same criteria were used to identify 6,496 patients without MAC. Mitral valve dysfunction was defined as mitral regurgitation (MR) and/or mitral stenosis (MS) of moderate or greater severity. Mixed disease was defined as the concurrent presence of bothmoderate or greater MS and MR. The primary end point was development of MVD, and the secondary end point was all-cause mortality. For patients with mild MAC, age was 74±10years and 528 (37%) were female. Over a median follow-up of 4.7 (interquartile range, 2.7-6.9) years, 215 patients with mild MAC developed MVD, including MR in 170 (79%), MS in 37 (17%), and mixed disease in 8 (4%). In a multivariable regression model compared to patients without MAC, the presence of mild MAC was independently associated with increased mortality (hazard ratio= 1.43; 95% CI 1.24, 1.66; P<.001). Kaplan-Meier 4-year survival rates were 80% and 90% for patients with mild MAC and no MAC, respectively. Mild MAC observed on transthoracic echocardiography is an important clinical finding with prognostic implications for both valvular function and mortality.

Associations of Lifelong Exercise Characteristics With Valvular Function and Aortic Diameters in Patients With a Bicuspid Aortic Valve.

The potential impact of exercise on valvular function and aortic diameters in patients with a bicuspid aortic valve remains unclear. Therefore, we assessed the association between lifelong exercise characteristics, valvular dysfunction, and aortic dilatation in patients with a bicuspid aortic valve. In this cross-sectional study, exercise volume (metabolic equivalent of task minutes per week), exercise intensity, and sport type were determined from the age of 12 years to participation using a validated questionnaire. Echocardiography was used to assess aortic stenosis or aortic regurgitation and to measure diameters at the sinuses of Valsalva and ascending aorta. Aortic dilatation was defined as a Z-score ≥2. Four hundred and seven patients (42±17 years, 60% men) were included, of which 133 were sedentary (<500 metabolic equivalent of task minutes per week), 94 active (500-1000 metabolic equivalent of task minutes per week), and 180 highly active (≥1000 metabolic equivalent of task minutes per week). Moderate-to-severe aortic stenosis or aortic regurgitation was present in 23.7% and 20.0%, respectively. Sinuses of Valsalva and ascending aorta diameters were 34.8±6.6 and 36.5±8.1 mm, whereas aortic dilatation was found in 21.6% and 53.4%, respectively. Exercise volume was not associated with valve dysfunction or aortic dilatation. Vigorous intensity and mixed sports were associated with a lower prevalence of aortic stenosis (adjusted odds ratios, 0.43 [0.20-0.94] and adjusted odds ratios, 0.47 [0.23-0.95]). Exercise intensity and sport type were not associated with aortic regurgitation and aortic dilatation. We found no deleterious associations between lifelong exercise characteristics, valvular dysfunction, and aortic dilatation in patients with a bicuspid aortic valve. Vigorous intensity and exercise in mixed sports were associated with a lower prevalence of moderate-to-severe aortic stenosis. These observations suggest that lifelong exercise does not appear to induce adverse cardiovascular effects in patients with a bicuspid aortic valve.

Hemodynamics, anatomy, and outcomes of quadricuspid aortic valves: Multimodality imaging assessment

BackgroundQuadricuspid aortic valve (QAV) is a rare congenital heart disease with a limited body of literature. This retrospective cohort study investigates QAV morphology, function, and clinical outcomes. MethodsEchocardiography was used to assess valvular function. Morphological characteristics such as phenotypes, raphe, regurgitant orifice area (ROA), and aortic dilation (diameter >40 ​mm) were assessed by cardiac CT. Patients were followed up for the combined event of all-cause death and aortic valve replacement (AVR). ResultsNinety QAV patients (screened from 322385 CT scans) were included (mean age 55.2 ​± ​13.6 years, 61.1 ​% male). Isolated significant aortic regurgitation (AR) was present in 75.6 ​% of patients. The cohort was dominated by type I (four equal leaflets, 37.8 ​%) and type II (3 larger and 1 smaller leaflets, 42.2 ​%) QAV. Fused raphe was present in 26.7 ​% of patients. ROACT was correlated with AR severity and aortic dilation (41.1 ​%, n ​= ​37). Among patients without AVR at baseline (n ​= ​60), one died and 17 underwent AVR during a median follow-up of 35.0 months (IQR:17.3–62.8). ROACT was associated with an increasing risk of combined event (as a categorical variable with a cut-off of 21.4 ​mm2, HR ​= ​4.25, 95%CI 1.49–12.17, p ​= ​0.007; as a continuous variable (per mm2 increment), HR ​= ​1.04, 95%CI 1.01–1.07, p ​= ​0.003). Additionally, ROACT had incremental prognostic value when added to the AR severity model (area under the receiver-operating characteristic curve increased from 86.8 to 88.4, p ​= ​0.004). ConclusionQAV is characterized by variable anatomy, progressive AR, concomitant cusp fusion and aortic enlargement. ROACT may be a potential ancillary prognostic marker in patients with QAV.

Diagnostic value of papillary muscle hypertrophy and mitral valve thickness to discriminate cardiac amyloidosis and Fabry disease

BackgroundCardiac amyloidosis (CA) and Fabry disease (FD) cause myocardial damage but may also affect the valvular and subvalvular apparatus. We aimed to evaluate the diagnostic accuracy of new echocardiographic indices including mitral valve thickness and papillary muscle (PM) hypertrophy to differentiate CA and FD. MethodsIn patients with confirmed CA and FD, a detailed assessment of valvular function, mitral valve leaflet thickness and PM area as well as PM left ventricular area ratio (PM/LV-ratio) was performed in offline analyses. Receiver operating characteristic curve analyses were conducted to determine the diagnostic accuracy of mitral valve thickness, PM hypertrophy, and PM/LV-ratio to distinguish CA from FD. ResultsWe retrospectively analyzed a cohort of 129 patients (FD n = 49, CA n = 80). CA patients showed significantly more thickened mitral valve leaflets (4.1 ± 1.3 mm vs. 2.9 ± 1.1 mm, p < 0.001) and a higher PM area [4.0 (3.1–4.6) mm2 vs. 2.8 (2.1–4.6) mm2, p = 0.009] with a comparable PM/LV-ratio in both groups. Mitral valve thickness showed the highest diagnostic accuracy to discriminate CA [AUC 0.77 (95% CI 0.67–0.87)]. The prevalence of aortic, tricuspid, and pulmonary valve regurgitation was significantly higher in CA (aortic regurgitation ≥ II° 13% vs. 4%, tricuspid regurgitation≥ II° 19% vs. 8%, p < 0.001). ConclusionOur results suggest that the assessment of mitral valve thickness may be a new useful echocardiographic parameter to differentiate CA and FD, whereas papillary muscle hypertrophy and PM/LV-ratio showed a limited diagnostic performance to discriminate CA.German clinical trials registry: DRKS00027403.

The role of duplex ultrasound in the diagnosis of pelvic venous disease

Recently there is an increased awareness of the possibility of pelvic venous disorders in patients with phlebological disease. The pathophysiology involves venous reflux or obstruction or a combination of both. It has been recommended that valvular function should be determined by the duration of reflux with the patient in an upright position. However the term ‘reflux’ is being used avidly by those assessing magnetic resonance imaging and computer tomography where patients are in a supine position. Venous compression is a common finding when the patient is supine and does not necessarily mean pathology. Duplex ultrasound is probably the only diagnostic tool which allows for examination in both supine and upright positions.

Treatment of severe symptomatic aortic valve stenosis using non-invasive ultrasound therapy: a cohort study

Calcific aortic stenosis is commonly treated using surgical or transcatheter aortic valve replacement; however, many patients are not considered suitable candidates for these interventions due to severe comorbidities and limited life expectancy. As such, non-invasive therapies might offer alternative therapeutic possibilities in these patients. This study aimed to assess the safety of non-invasive ultrasound therapy and its ability to improve valvular function by softening calcified valve tissue. This prospective, multicentre, single-arm series enrolled 40 adult patients with severe symptomatic aortic valve stenosis at three hospitals in France, the Netherlands, and Serbia between March 13, 2019, and May 8, 2022. Patients were treated with transthoracically delivered non-invasive ultrasound therapy. Follow-ups were scheduled at 1, 3, 6, 12, and 24 months. The primary endpoints were procedure-related deaths within 30 days and improved valve function. We report the 6-month data. This study is registered at ClinicalTrials.gov, NCT03779620 and NCT04665596. 40 high-risk patients with a mean Society of Thoracic Surgeons score of 5·6% (SD 4·4) and multiple severe comorbidities were included. The primary endpoint, procedure-related mortality, did not occur; furthermore, no life-threatening or cerebrovascular events were reported. Improved valve function was confirmed up to 6 months, reflected by a 10% increase in mean aortic valve area from 0·58 cm2 (SD 0·19) at baseline to 0·64 cm2 (0·21) at follow-up (p=0·0088), and a 7% decrease in mean pressure gradient from 41·9 mm Hg (20·1) to 38·8 mm Hg (17·8; p=0·024). At 6 months, the New York Heart Association score had improved or stabilised in 24 (96%) of 25 patients, and the mean Kansas City Cardiomyopathy Questionnaire score had improved by 33%, from 48·5 (SD 22·6) to 64·5 (21·0). One serious procedure-related adverse event occurred in a patient who presented with a transient decrease in peripheral oxygen saturation. Non-serious adverse events included pain, discomfort during treatment, and transient arrhythmias. This novel, non-invasive ultrasound therapy for calcified aortic stenosis proved to be safe and feasible. Cardiawave.

Associations of Lifelong Exercise Characteristics with Valvular Function and Aortic Diameters in Subjects with a Bicuspid Aortic Valve

Abstract Background Whether exercise-induced hemodynamic stress accelerates the development of valvular dysfunction and aortic dilatation in subjects with a bicuspid aortic valve (BAV) is unclear. Purpose To examine the association between lifelong exercise characteristics (i.e. exercise volume, exercise intensity and type of exercise), valvular dysfunction and aortic dilatation in subjects with BAV. Methods Adults with BAV were classified as inactive (&amp;lt;500 metabolic equivalent of task minutes per week [MET-min/wk]), active (500-1000 MET-min/wk) or highly active (≥1000 MET-min/wk) based on their reported lifetime exercise characteristics. Subjects’ lifelong predominant exercise intensity was classified as moderate (3-6 MET) or vigorous (≥6 MET) and predominant sport type as skill, power, mixed or endurance. Transthoracic echocardiography was used to assess the presence of aortic stenosis (AS) or regurgitation (AR) and to measure aortic diameters at the sinus of Valsalva (SV) and in the ascending aorta (AA). Aortic dilatation was defined as a Z-score ≥ 2. Results 407 subjects (42±17 years old, 60% male) were included of which 133 were inactive, 94 active and 180 highly active. 61 subjects did not perform exercise, whereas 136 and 207 subjects predominantly participated in moderate or vigorous intensity exercise, respectively. Subjects performing sports were allocated to the skill (n=12), power (n=41), mixed (n=218), endurance (n=75) or non-dominant (n=24) exercise type group. Moderate-to-severe AS or AR was present in 96 (23.6%) and 81 (19.9%) subjects, respectively. SV and AA diameters were 34.8±6.6 and 36.5±8.1 mm, whereas 74 (18.2%) and 194 (47.7%) subjects had a Z-score ≥ 2. Exercise volume was not associated with valve dysfunction or aortic dilatation. Vigorous intensity exercise and mixed sports were associated with lower odds ratios for the risk of moderate-to-severe AS (ORadjusted: 0.43 (0.20-0.94) and ORadjusted: 0.47 (0.23-0.95), respectively). Exercise intensity and sport type were not associated with AR and aortic dilatation (Figure 1). Conclusions We found no deleterious associations between lifelong exercise characteristics, valvular dysfunction and aortic dilatation in subjects with BAV. In contrast, vigorous intensity and mixed sports were associated with a lower risk for moderate-to-severe AS. These observations suggest that lifelong exercise does not appear to induce deleterious cardiovascular effects in subjects with BAV.Figure 1.

Artificial intelligence-assisted examination of cardiac health status through electrocardiogram

Abstract Background Cardiac diseases are the main causes of death. Echocardiogram is the standard testing tool of heart diseases but it is inconvenient and expensive. This study aims at developing an artificial intelligence (AI)-assisted method to interpret electrocardiograms (ECG) for cardiac health status. Method A total of 70757 subjects undergoing concomitant ECG and echocardiography were enrolled. ECG was analyzed by using Philips DXL algorithm to obtain 512 parameters, and a healthy heart is defined by normal cardiac chamber size, myocardial thickness, systolic function, diastolic function, and valvular function. A multi-layer perceptron (MLP) and Long short term memory (LSTM) were developed with hold-out validation (training dataset 80% and testing dataset 20%). Three categories of input data are made based on the percentage of healthy data of 30.6%. Death of the participants were confirmed via linking database to the National Death Registry A Kaplan-Meier survival curve analysis was conducted in the testing dataset stratified by AI-determined cardiac health status. Results The testing results of the proposed methods on an independent dataset are shown in Table 1. It is interesting that using MLP has similar performance as the LSTM model. Furthermore, the 30-layer MLP model has a F1 value of 83.8% and the 50-layer MLP model has a F1 value of 83.8, while the F1 value of 2-layer LSTM_0.2 is 85.2% and 2-layer LSTM_0.2 is 84.6%. In addition, AI-determined healthy hearts were associated with better long-term survival. Conclusion An AI-assisted analysis on ECG can act as a preliminary examination of cardiac diseases to facilitate the arrangement of echocardiograms for early detections.

Outcomes of Transcatheter Aortic Valve Replacement Patients With Different Transvalvular Flow-Gradient Patterns

Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (LVEF). Both situations represent the most challenging subset of patients to manage and generally have a poor prognosis. Few and controversial data exist on the outcomes of these patients compared with normal flow-high gradient (NF-HG) AS after transcatheter aortic valve replacement (TAVR). We sought to characterize different transvalvular flow-gradient patterns and to examine their prognostic value after TAVR. We enrolled 1,208 patients with severe AS and categorized as follow: 976 patients NF-HG (mean aortic pressure gradient [MPG] ≥40mm Hg), 107 paradoxical LF-LG (pLF-LG, MPG <40mm Hg, LVEF ≥50%, stroke volume index <35ml/m2), and 125 classical LF-LG (cLF-LG) (MPG <40mm Hg, LVEF <50%, stroke volume index <35ml/m2). When compared with NF-HG and pLF-LG, cLF-LG had a worse symptomatic status (New York Heart Association III to IV 86% vs 62% and 67%, p <0.001), a higher prevalence of eccentric hypertrophy and a higher level of LV global afterload reflected by a higher valvuloarterial impedance. Valvular function after TAVR was excellent over time in all patients. While 30-day mortality (p=0.911) did not differ significantly among groups, cLF-LG had a lower 5-year survival rate (LF-LG 50% vs pLF-LG 62% and NF-HG 68%, p <0.05). cLF-LG was associated with a hazard ratio for mortality of 2.41 (95% confidence interval 1.65 to 3.52, p <0.001). In conclusion, TAVR is an effective procedure regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rates than patients with NF-HG, whereas cLF-LG is associated with a twofold increased risk of mortality at 5-year follow-up.

Evaluation of cardiac findings in mucopolysaccharidosis.

Mucopolysaccharidoses (MPS) are a group of rare genetic diseases and heart involvement is one of the important conflicts in most types, which may cause serious complications. We used M-Mode and two-dimensional speckle tracking echocardiography (2D-STE) to explore cardiovascular involvements in MPS patients. The present cross-sectional study investigated the frequency of cardiac involvements in MPS patients. Included participants were MPS types I, II, III, IV, and VI who underwent specialized echocardiography exams to assess valvular function, systolic and diastolic function, left ventricular ejection fraction (LVEF), and global longitudinal strain (GLS). 35 patients were enrolled in this study. The total mean age of patients was 9.58 ± 5.11 years and 71.4% were male. Type IV (40%) and type III (31.4%) were the most frequent MPS. Although LVEF did not differ notably among MPS types, GLS was significantly different (p = 0.029). Mitral regurgitation was observed remarkably more in MPS type III (p = 0.001) while mitral stenosis was more common in type III (p = 0.007). There was a significant association between LVEF and GLS (β= -0.662; p = 0.025) and between LVEF and MPS type (β = 1.82; p = 0.025) when adjusted for GLS. Cardiac complications are very common and are one of the most important causes of death in MPS patients. 2D-STE seems to be superior to M-Mode for detection of early and subclinical cardiac dysfunction in MPS patients.