Impact of Prosthesis-Patient Mismatch on Hemodynamics During Exercise in Patients With Aortic Stenosis After Transcatheter Aortic Valve Implantation With a Balloon-Expandable Valve

Background

There is no evidence of hemodynamic performance during exercise in patients with aortic stenosis (AS) after transcatheter aortic valve implantation (TAVI). This study aimed to investigate the changes in kinematic hemodynamics during exercise and determine the impact of prosthesis-patient mismatch (PPM) on the hemodynamics of transcatheter heart valves using exercise stress echocardiography (ESE) in AS patients after TAVI.

Methods and Results

This study enrolled 77 consecutive patients (mean age 82 ± 5 years, 50.6% male) who underwent ESE 3–6 months after TAVI with a balloon-expandable valve. The effective orifice area index at rest was significantly correlated with the mean pressure gradient (PG) during exercise (p <0.001). The patients were divided into two groups according to the presence of PPM (PPM and non-PPM groups). During exercise, the patients with PPM had a higher left ventricular ejection fraction (74.6 ± 6.1% vs. 69.7 ± 9.6%, p = 0.048), a lower stroke volume index (47.2 ± 14.0 ml/m² vs. 55.6 ± 14.5 ml/m², p = 0.037), a significantly higher mean transvalvular PG (21.9 ± 9.1 mmHg vs. 12.2 ± 4.9 mmHg, p = 0.01) and an increased mean PG from rest to exercise (5.7 ± 3.5 mmHg vs. 2.3 ± 2.8 mmHg, p <0.001) compared with patients without PPM. Patients with PPM had a higher pulmonary artery systolic pressure (SPAP) during exercise (57.3 ± 13.8 mmHg vs. 49.7 ± 10.9 mmHg, p = 0.021) and a higher incidence of exercise-induced pulmonary hypertension (43.8 vs. 15.0%, p = 0.037) than patients without PPM. PPM was strongly associated with exercise-induced pulmonary hypertension (hazard ratio: 3.570, p = 0.013).

Conclusions

AS patients with PPM after TAVI showed a disproportionate increase in the transvalvular PG and SPAP during exercise, and PPM was associated with exercise-induced pulmonary hypertension.

Value of Echocardiography in the Treatment of Patients With Acute Heart Failure

Heart failure (HF) is a burden in pandemic medicine resulting in high mortality and morbidity. Because acute HF is a life-threatening event, its diagnosis and choice of optimal treatment are important to improve outcomes. Furthermore, understanding the cause and hemodynamics of acute HF is important in selecting the optimal treatment for these patients. Echocardiography is widely used in daily clinical practice because of its non-invasive nature and excellent portability to understand cardiac function and hemodynamics. Echocardiography is highly recommended by guidelines in the practice of HF, but evidence is limited. In this review, I would like to share clinical value of echocardiography in the treatment of patients with acute HF and discuss the usefulness of echocardiography.

MitraClip Treatment of Moderate-to-Severe and Severe Mitral Regurgitation in High Surgical Risk Patients - Real-World 1-Year Outcomes From Japan

BACKGROUND

The MitraClip NT System was approved for marketing in Japan on October 31, 2017, and a prospective, multi-center, single-arm Post-Marketing use Surveillance (PMS) study was launched in 2018. This is the first report of the Japan PMS study with 1-year subject outcomes.Methods and Results:A total of 500 patients were registered between April 2018 and January 2019. Patients with symptomatic chronic moderate-to-severe (3+) or severe mitral regurgitation (MR; 4+), MR with a Society of Thoracic Surgery (STS) replacement score of ≥8%, or presence of 1 pre-defined risk factor were enrolled. Primary outcome measures included acute procedural success (APS), and rate of Single Leaflet Device Attachment (SLDA) at 30 days. The overall cohort was elderly (77.9±9.48 years) with functional MR etiology in 71.6% of the subjects. The majority of subjects were New York Heart Association (NYHA) class III/IV (68.9%), with mean STS replacement score of 11.95±9.66%. The APS rate was 91.13% and the 30-day SLDA rate was 1.21%. Durable MR reduction was achieved with 88.1% of subjects at MR ≤2+ at 1 year. Significant improvement in the functional capacity was observed, with 93% of subjects at NYHA class I/II at 1 year.

CONCLUSIONS

In the Japan PMS experience, the MitraClip procedure resulted in improvements in MR severity, with significantly improved functional outcomes. These results demonstrate safety and efficacy of MitraClip therapy in the eligible Japanese population.

Antithrombotic Therapy for Patients With Atrial Fibrillation and Bioprosthetic Valves - Real-World Data From the Multicenter, Prospective, Observational BPV-AF Registry

BACKGROUND

Although bioprosthetic valve (BPV) replacements are becoming more common within our aging society, there are limited prospective data on the appropriate antithrombotic therapy for East Asian patients with atrial fibrillation (AF) and BPV replacement. Antithrombotic therapy and thrombotic and hemorrhagic event rates in Japanese patients with AF and BPV replacement are investigated.Methods and Results:This multicenter, prospective, observational study enrolled patients with BPV replacement and AF. The primary efficacy outcome was stroke or systemic embolism, and the primary safety outcome was major bleeding. Of the 894 patients analyzed, 54.7%, 29.4%, and 9.6%, were treated with warfarin-based therapy, direct oral anticoagulant (DOAC)-based therapy, or antiplatelet therapy without anticoagulants, respectively; 6.3% did not receive any antithrombotic drugs. The mean observation period was 15.3±4.0 months. The event rates for stroke or systemic embolism and major bleeding were 1.95%/year and 1.86%/year, respectively. The multivariate adjusted hazard ratios for DOAC vs. warfarin were 1.02 (95% confidence intervals [CI], 0.30-3.41 [P=0.979]) for systemic embolic events and 0.96 (95% CI, 0.29-3.16 [P=0.945]) for major bleeding.

CONCLUSIONS

Approximately 30% of patients with AF and BPV replacement were treated with DOAC. The risks of major bleeding and stroke or systemic embolism were similar between warfarin- and DOAC-treated patients with AF who had BPV replacement. Treatment with DOACs could be an alternative to warfarin in this population.

Resting echocardiographic predictors for true-severe aortic stenosis in patients with low-gradient severe aortic stenosis: A dobutamine stress echocardiography study

OBJECTIVE

Dobutamine stress echocardiography (DSE) is not always feasible in patients with low-gradient severe aortic stenosis (LG-SAS), and there are limited data available on the resting echocardiographic predictors for true-severe aortic stenosis (TSAS). This study investigated resting echocardiographic predictors for TSAS.

METHODS

Clinical data of 106 LG-SAS patients who underwent DSE were retrospectively analyzed. LG-SAS was defined as an aortic valve area index (AVAi) < .6 cm² /m² , and a mean AV pressure gradient < 40 mm Hg. The velocity ratio (VR) was calculated as the peak left ventricular outflow tract velocity/peak AV velocity. TSAS was defined as a projected AVAi < .6 cm² /m² .

RESULTS

The mean age was 79.3 ± 7.3 years, and 45 (42.5%) were men. The resting AV data were as follows: AVAi, .50 ± .07 cm² /m² ; mean AV pressure gradient, 23.0 ± 7.4 mm Hg; and VR, .25 ± .05. The projected AVAi was .58 ± .09 cm² /m² , and TSAS was documented in 65 (61.3%) patients. In multivariate analysis, the independent predictors of TSAS were AVAi (p = 0.012) and VR (p = 0.004) with respective best cut-off values of .52 cm² /m² and .25 on receiver-operating characteristic curve analysis. According to incremental numbers of the predictors, correct classification percentages of TSAS significantly increased with the Cochran-Armitage trend test (16.2% in no predictors, 65.2% in one predictor, and 95.7 % in two predictors; p < 0.001).

CONCLUSIONS

Resting AVAi and VR were independent predictors of TSAS in LG-SAS patients. The true severity might be predictable using the combination of resting parameters.

Angioscopic Evaluation of Atrial Septal Defect Closure Device Neo-Endothelialization

Background

Current guidelines recommend at least 6 months of antithrombotic therapy and antibiotic prophylaxis after septal‐occluding device deployment in transcatheter closure of atrial septal defect. It has been estimated that it takes ≈6 months for complete neo‐endothelialization; however, neo‐endothelialization has not previously been assessed in vivo in humans.

Methods and Results

The neointimal coverage of septal occluder devices was evaluated 6 months after implantation in 15 patients by angioscopy from the right atrium. Each occluder surface was divided into 9 areas; the levels of endothelialization in each area were semiquantitatively assessed by 4‐point grades. Device neo‐endothelialization was sufficient in two thirds of patients, but insufficient in one third. In the comparison between patients with sufficiently endothelialized devices of average grade score ≥2 (good endothelialization group, n=10) and those with poorly endothelialized devices of average grade score <2 (poor endothelialization group, n=5), those in the poor endothelialization group had larger devices deployed (27.0 mm [25.0–31.5 mm] versus 17.0 mm [15.6–22.5 mm], respectively) and progressive right heart dilatation. The endothelialization was poorer around the central areas. Moreover, the prevalence of thrombus formation on the devices was higher in the poorly endothelialized areas than in the sufficiently endothelialized areas (Grade 0, 94.1%; Grade 1, 63.2%; Grade 2, 0%; Grade 3, 1.6%).

Conclusions

Neo‐endothelialization on the closure devices varied 6 months after implantation. Notably, poor endothelialization and thrombus attachment were observed around the central areas and on the larger devices.

Pre-clinical medical student cardiac point-of-care ultrasound curriculum based on the American Society of Echocardiography recommendations: a pilot and feasibility study

Background

Cardiac point-of-care ultrasound (POCUS) training has been integrated into medical school curricula. However, there is no standardized cardiac POCUS training method for medical students. To address this issue, the American Society of Echocardiography (ASE) proposed a framework for medical student cardiac POCUS training. The objective of this pilot study was to develop a medical student cardiac POCUS curriculum with test scoring systems and test the curriculum feasibility for a future definitive study.

Methods

Based on the ASE-recommended framework, we developed a cardiac POCUS curriculum consisting of a pre-training online module and hands-on training with a hand-held ultrasound (Butterfly iQ, Butterfly Network Inc., Guilford, CT, USA). The curriculum learning effects were assessed with a 10-point maximum skill test and a 40-point maximum knowledge test at pre-, immediate post-, and 8-week post-training. To determine the curriculum feasibility, we planned to recruit 6 pre-clinical medical students. We semi-quantitatively evaluated the curriculum feasibility in terms of recruitment rate, follow-up rate 8 weeks after training, instructional design of the curriculum, the effect size (ES) of the test score improvements, and participant satisfaction. To gather validity evidence of the skill test, interrater and test-retest reliability of 3 blinded raters were assessed.

Results

Six pre-clinical medical students participated in the curriculum. The recruitment rate was 100% (6/6 students) and the follow-up rate 8 weeks after training was 100% (6/6). ESs of skill and knowledge test score differences between pre- and immediate post-, and between pre- and 8-week post-training were large. The students reported high satisfaction with the curriculum. Both interrater and test-retest reliability of the skill test were excellent.

Conclusions

This pilot study confirmed the curriculum design as feasible with instructional design modifications including the hands-on training group size, content of the cardiac POCUS lecture, hands-on teaching instructions, and hand-held ultrasound usage. Based on the pilot study findings, we plan to conduct the definitive study with the primary outcome of long-term skill retention 8 weeks after initial training. The definitive study has been registered in ClinicalTrials.gov (Identifier: NCT04083924).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00910-3.

Transcatheter mitral valve repair with a mitraclip for severe mitral regurgitation in a patient on hemodialysis

A 55-year-old male patient undergoing hemodialysis (HD) had shortness of breath, New York Heart Association (NYHA) class IIm (moderate limitation of physical activity) due to chronic heart failure. His past medical history was remarkable for chronic heart diseases and severe functional mitral regurgitation (MR), with an ejection fraction of only 33%. The cardiologist considered this severe MR as the cause of his symptom. Due to the multiple comorbidities and low cardiac function, transcatheter mitral valve repair (TMVR) using a MitraClip was selected as an alternative to surgery. TMVR with MitraClip was successfully performed. Postoperatively, the degree of MR decreased from severe to trivial, with an obvious improvement in symptoms to NYHA class I. He was discharged without any postoperative complications. TMVR with MitraClip is an effective nonsurgical treatment for mitral valve disease in HD patients with multiple comorbidities.

Prognostic impact of transcatheter mitral valve repair in patients with exercise-induced secondary mitral regurgitation

AIMS

Although exercise-induced secondary mitral regurgitation (MR) is known to have a poor prognosis, the therapeutic strategy towards this condition remains to be investigated. In the present study, we aimed to investigate the prognostic impact of transcatheter mitral valve repair (TMVr) using the MitraClip in patients with exercise-induced secondary MR.

METHODS AND RESULTS

Of the 200 consecutive patients with secondary MR who underwent exercise stress echocardiography, 46 (23%) that presented with exercise-induced secondary MR [i.e. increase in effective regurgitant orifice area (EROA) of ≥ 0.13 cm2] were enrolled in the present investigation. The composite endpoints of all-cause mortality and hospitalization for heart failure were evaluated. Of the 46 patients included in the current cohort, 19 (41%) underwent TMVr and 27 (59%) were medically managed (control group). Although the TMVr group tended to present with a greater EROA at rest (0.26 ± 0.10 vs. 0.20 ± 0.08 cm2, P = 0.047), there were no differences in the EROA changes during exercise between the two groups (0.18 ± 0.10 vs. 0.18 ± 0.04 cm2, P = 0.940). While the TMVr group reported a higher event-free survival rate after the 13-month follow-up period (log-rank P = 0.017), the Cox proportional-hazard analysis suggested the TMVr to be associated with clinical outcomes (hazard ratio: 0.419, P = 0.044).

CONCLUSION

As opposed to the medical management, TMVr treatment was associated with a lower risk of composite endpoints in patients with exercise-induced secondary MR. Exercise stress echocardiography is considered to have played an important role in decision-making for secondary MR.

Usefulness of velocity ratio in patients with moderate aortic stenosis and reduced left ventricular ejection fraction

Background. Moderate aortic stenosis (AS) increases left ventricular afterload and results in unfavorable outcomes in patients with reduced left ventricular ejection fraction (LVEF). Velocity ratio (VR) may be appropriate for the evaluation of aortic valve (AV) hemodynamics because of the low dependence on flow. Therefore, this study investigated the usefulness of VR on the clinical outcomes of such patients. Method. Clinical data of patients with moderate AS (AV area, 0.60-0.85 cm²/m²; peak AV velocity, 2.0-4.0 m/s) and reduced LVEF (LVEF 20-50%) were analyzed during 2010-2018. VR was calculated as peak left ventricular outflow tract velocity/peak AV velocity. The primary endpoint included all-cause death, heart failure hospitalization, and AV replacement. Results. In total, 104 patients (mean age, 75.9 ± 7.0 years; 62.5% men) were included. LVEF was 39.5% ± 7.8%. The AV area was 0.72 ± 0.08 cm²/m², peak AV velocity was 2.59 ± 0.40 m/s, and VR was 0.30 ± 0.07. The follow-up period was 1.7 (0.5-3.5) years. Kaplan-Meier estimates for the endpoint were 59.9% at 3 years. Multivariable analysis revealed that VR (hazard ratio, 0.947; 95% confidence interval, 0.905-0.990; p = .018) was significantly related to this endpoint. Patients with a VR <0.25 had significantly higher incidence rates of the endpoint than those with a VR ≥0.25 (85.6% versus 47.8% at 3 years; p < .001). Conclusions. Patients with moderate AS and reduced LVEF have unfavorable clinical outcomes, particularly those with low VR.

Effect of Diastolic Flow Reversal Patterns on Clinical Outcomes Following Transcatheter Aortic Valve Implantation - An Intraprocedural Echocardiography Study

BACKGROUND

Although diastolic flow reversal (DFR) in the descending aorta, assessed via transesophageal echocardiography (TEE), is a simple and easy indicator for evaluating aortic regurgitation, the association between DFR pattern and clinical outcomes following transcatheter aortic valve implantation (TAVI) is unclear. The purpose of this study was to evaluate the effect of DFR patterns on clinical outcomes following TAVI.Methods and Results:Two-hundred and eleven patients (mean age, 83.6±5.7 years; 69% female) who underwent TAVI were retrospectively assessed via intraprocedural TEE. DFR was evaluated using pulsed-wave Doppler in the descending aorta before and after TAVI. The primary endpoint was major adverse cardio-cerebrovascular events (MACCEs). Although only 7 patients (3.3%) had moderate or severe paravalvular leak, as assessed by color Doppler echocardiography, holo-DFR (HDFR) was observed in 33 patients (16.0%) after TAVI. MACCEs occurred in 40 patients during the median follow up of 282 days (interquartile range: 160-478 days). The estimated cumulative MACCE-free survival at 1 year was significantly lower in patients with HDFR than in those without HDFR. A Cox proportional hazards analysis revealed that HDFR after TAVI was independently associated with MACCEs.

CONCLUSIONS

HDFR was associated with an increased risk of MACCEs after TAVI. DFR evaluated by intraprocedural echocardiography could serve as a simple and easy method for predicting clinical outcomes.

Asian Pacific Society of Cardiology Consensus Recommendations on the Use of MitraClip for Mitral Regurgitation

Transcatheter mitral valve repair with the MitraClip, a catheter-based percutaneous edge-to-edge repair technique to correct mitral regurgitation (MR), has been demonstrated in Western studies to be an effective and safe MR treatment strategy. However, randomised clinical trial data on its use in Asian-Pacific patients is limited. Hence, the Asian Pacific Society of Cardiology convened an expert panel to review the available literature on MitraClip and to develop consensus recommendations to guide clinicians in the region. The panel developed statements on the use of MitraClip for the management of degenerative MR, functional MR, and other less common indications, such as acute MR, dynamic MR, hypertrophic obstructive cardiomyopathy, and MR after failed surgical repair. Each statement was voted on by each panel member and consensus was reached when 80% of experts voted ‘agree’ or ‘neutral’. This consensus-building process resulted in 10 consensus recommendations to guide general cardiologists in the evaluation and management of patients in whom MitraClip treatment is being contemplated.

Influence of coronary artery disease and percutaneous coronary intervention on mid-term outcomes in patients with aortic valve stenosis treated with transcatheter aortic valve implantation

Background

A high frequency of coronary artery disease (CAD) is reported in patients with severe aortic valve stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the optimal management of CAD in these patients remains unknown.

Hypothesis

We hypothesis that AS patients with TAVI complicated by CAD have poor prognosis. His study evaluates the prognoses of patients with CAD and severe AS after TAVI.

Methods

We divided 186 patients with severe AS undergoing TAVI into three groups: those with CAD involving the left main coronary (LM) or proximal left anterior descending artery (LAD) lesion (the CAD[LADp] group), those with CAD not involving the LM or a LAD proximal lesion (the CAD[non‐LADp] group), and those without CAD (Non‐CAD group). Clinical outcomes were compared among the three groups.

Results

The CAD[LADp] group showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) and all‐cause mortality than the other two groups (log‐rank p = .001 and p = .008, respectively). Even after adjustment for STS score and percutaneous coronary intervention (PCI) before TAVI, CAD[LADp] remained associated with MACCE and all‐cause mortality. However, PCI for an LM or LAD proximal lesion pre‐TAVI did not reduce the risk of these outcomes.

Conclusions

CAD with an LM or LAD proximal lesion is a strong independent predictor of mid‐term MACCEs and all‐cause mortality in patients with severe AS treated with TAVI. PCI before TAVI did not influence the outcomes.

Weather temperature and the incidence of hospitalization for cardiovascular diseases in an aging society

Weather temperatures affect the incidence of cardiovascular diseases (CVD), but there is limited information on whether CVD hospitalizations are affected by changes in weather temperatures in a super-aging society. We aimed to examine the association of diurnal weather temperature changes with CVD hospitalizations. We included 1,067,171 consecutive patients who were admitted to acute-care hospitals in Japan between April 1, 2012 and March 31, 2015. The primary outcome was the number of CVD hospitalizations per day. The diurnal weather temperature range (DTR) was defined as the minimum weather temperature subtracted from the maximum weather temperature on the day before hospitalization. Multilevel mixed-effects linear regression models were used to estimate the association of DTR with cardiovascular hospitalizations after adjusting for weather, hospital, and patient demographics. An increased DTR was associated with a higher number of CVD hospitalizations (coefficient, 4.540 [4.310–4.765]/°C change, p < 0.001), with greater effects in those aged 75–89 (p < 0.001) and ≥ 90 years (p = 0.006) than among those aged ≤ 64 years; however, there were no sex-related differences (p = 0.166). Greater intraday weather temperature changes are associated with an increased number of CVD hospitalizations in the super-aging society of Japan, with a greater effect in older individuals.

Prognostic significance of right ventricular function during exercise in asymptomatic/minimally symptomatic patients with nonobstructive hypertrophic cardiomyopathy

BACKGROUND

The risk stratification of hypertrophic cardiomyopathy (HCM) without left ventricular outflow tract (LVOT) obstruction and the utility of exercise stress echocardiography (ESE) remains unclear. We investigated the value of right ventricular (RV) function and RV-pulmonary artery (PA) coupling during exercise in asymptomatic/minimally symptomatic patients with nonobstructive HCM (nHCM).

METHOD AND RESULTS

This retrospective study evaluated 74 HCM patients (age 63 ± 13 years, 65% men) without LVOT obstruction (≥30 mmHg) who underwent​ ESE. Eight patients (11%) suffered from HCM-related cardiac events during a median 2.5 years follow-up. During exercise, tricuspid annular plane systolic excursion (Ex-TAPSE) and Ex-TAPSE/systolic pulmonary artery pressure [SPAP] ratio were more impaired in patients with than in those without events (22 ± 4 vs 26 ± 4 mm, P = .005; and 0.45 [0.41, 0.47] vs 0.56 [0.47, 0.82] mm/mmHg, P = .002). In Cox regression analysis, Ex-TAPSE (HR: 1.397, P = .002) and the Ex-TAPSE/SPAP ratio (HR: 2.737, P = .006) were associated with cardiac events. In Kaplan-Meier analysis, patients with a low Ex-TAPSE (<24 mm) and Ex-TAPSE/SPAP ratio (<0.50 mm/mmHg) had a higher incidence of adverse outcomes than those with high Ex-TAPSE (Log rank, P < .001 and =.001, respectively).

CONCLUSIONS

A low Ex-TAPSE and Ex-TAPSE/SPAP ratio were associated with adverse outcomes in nHCM. Evaluation of RV functional performance during exercise may play a crucial role in the risk stratification of nHCM.

Association of PM2.5 exposure with hospitalization for cardiovascular disease in elderly individuals in Japan

Although exposure to particulate matter with aerodynamic diameters ≤ 2.5 µm (PM_2.5) influences cardiovascular disease (CVD), its association with CVD-related hospitalizations of super-aged patients in Japan remains uncertain. We investigated the relationship between short-term PM_2.5 exposure and CVD-related hospitalizations, lengths of hospital stays, and medical expenses. We analyzed the Japanese national database of patients with CVD (835,405) admitted to acute-care hospitals between 2012 and 2014. Patients with planned hospitalizations and those with missing PM_2.5 exposure data were excluded. We classified the included patients into five quintiles based on their PM_2.5 exposure: PM-5, -4, -3, -2, and -1 groups, in descending order of concentration. Compared with the PM-1 group, the other groups had higher hospitalization rates. The PM-3, -4, and -5 groups exhibited increased hospitalization durations and medical expenses, compared with the PM-1 group. Interestingly, the hospitalization period was longer for the ≥ 90-year-old group than for the ≤ 64-year-old group, yet the medical expenses were lower for the former group. Short-term PM_2.5 exposure is associated with increased CVD-related hospitalizations, hospitalization durations, and medical expenses. The effects of incident CVDs were more marked in elderly than in younger patients. National PM_2.5 concentrations should be reduced and the public should be aware of the risks.

Impact of perioperative change in physical function on midterm outcomes after transcatheter aortic valve implantation

Preoperative frailty diminishes the potential for functional recovery after transcatheter aortic valve implantation (TAVI). However, perioperative changes in physical status and their impact on prognosis after TAVI have not previously been reported. Therefore, this study aimed to investigate whether perioperative changes in physical function affect prognosis in patients undergoing TAVI. We retrospectively reviewed 257 patients who underwent TAVI. The Short Physical Performance Battery (SPPB), an objective physical status assessment tool, was evaluated pre- and post-TAVI. Patients were divided into two groups: (i) patients whose SPPB score declined in the perioperative period (the decline group) and (ii) patients whose SPPB score did not decline in the perioperative period (the non-decline group). The primary endpoint was unplanned hospitalization owing to heart failure or cardiovascular death following TAVI. The mean follow-up period was 385 ± 151 days, mean age was 83.2 ± 5.8 years, and 67% of the patients were women. Sixteen patients required readmission owing to heart failure, and seven experienced cardiovascular-related death. Kaplan-Meier analysis revealed that the event-free rate was significantly lower in the decline group (log-rank, p = 0.006). A stepwise multivariate logistic regression analysis showed that a perioperative change in SPPB was significantly associated with primary endpoints (odds ratio, 1.51; 95% confidence interval, 1.12-2.04). Perioperative change in physical function was an independent risk factor for heart failure, hospitalization, or cardiovascular death following TAVI.

Cerebral infarction due to dispersal of aortic atheromas detected by transoesophageal echocardiography during transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving treatment option with an inherent risk of causing cerebral infarctions. The mechanism of cerebral infarction during TAVI mainly involves embolisms from the aortic wall and valve. Transoesophageal echocardiography (TEE) is useful for detecting aortic atheromas. We present the case of a patient in whom the dispersal of aortic atheromas was monitored by TEE during TAVI. This report demonstrates the importance of preoperatively predicting embolisms from aortic atheromas in patients with severe aortic stenosis.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Effect of Immunosuppressive Therapy on Clinical Outcomes for Patients With Aortic Stenosis Following Transcatheter Aortic Valve Implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an established treatment for symptomatic patients with severe aortic stenosis (AS). Sometimes patients with severe AS taking immunosuppressants are encountered. The effect of immunosuppressive therapy on clinical outcomes in patients with AS following TAVI were investigated.Methods and Results:In total, 282 consecutive patients with severe AS who underwent transfemoral TAVI from January 2016 to December 2018 at St. Marianna University School of Medicine were reviewed. They were divided into 2 groups: the immunosuppressants group (IM group) in which patients continually used immunosuppressive drugs (n=22) and the non-immunosuppressants group (non-IM group) (n=260). The composite endpoints of a major adverse cardiovascular and cerebrovascular event (MACCE) defined as non-lethal myocardial infarction, unstable angina pectoris, heart failure requiring hospitalization, stroke, and cardiovascular death were evaluated. There were no differences in the incidence of vascular access complications (32% vs. 20%, P=0.143) and the rate of procedure success (100% vs. 93%, P=0.377) between the IM and non-IM groups. During the median follow-up period of 567 (16-1,312) days after the TAVI procedure, there were no significant differences between the IM and non-IM groups in the incidence of infectious complications (14% vs. 9%, P=0.442) or MACCE (18% vs. 20%, respectively; P=0.845).

CONCLUSIONS

The use of IM after TAVI is not associated with increased vascular access complications or mid-term MACCE in patients with severe AS treated with TAVI.

Correction to: Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

In the original publication of the article, the first and the second authors' names should be changed as follows.

Effect of PM2.5 for hospitalization of cardiovascular diseases and medical expenses by age group: a nationwide study from the Japanese Registry Of All cardiac and vascular Diseases (JROAD)

Introduction

Although particulate matter with an aerodynamic diameter less than or equal to 2.5 μm (PM2.5) exposure influences cardiovascular events, there is limited knowledge how PM2.5 exposure is associated with cardiovascular hospitalization in Japan.

Purpose

We tested the hypothesis that PM2.5 exposure was related to the number of cardiovascular hospitalizations, hospitalization period, and medical expenses.

Methods

We included 835,405 subjects who were admitted to acute care hospitals in Japan. We classified PM2.5 exposure concentration into quintile groups (from low to high in the order of “PM-1” to “PM-5” group). Multilevel mixed-effects Poisson and linear regression analysis were used to estimate the association of PM2.5 exposure concentration with the cardiovascular hospitalization events, duration and medical expenses. We also analyzed those factors classified by age.

Results

PM-2, 3, 4, 5 group were positively related to the number of cardiovascular hospitalization events compared with PM-1 group (Table 1). PM-3, 4, 5 group were positively associated with a 0.018, 0.029, and 0.029 (all p&lt;0.001) of the difference of log cardiovascular hospitalization period compared with PM-1 group (p for trend &lt;0.001). These groups were also positively associated with a 0.016, 0.023, and 0.021 (all p&lt;0.001) of the difference of log medical expenses compared with PM-1 group (p for trend &lt;0.001). Analyzed by age group, hospitalization duration was longer (p&lt;0.05) and medical expenses was lower (p&lt;0.05) significantly in super-aging group (over 90 years old) than the group under 64 years old (Figure 1).

Conclusions

PM2.5 exposure concentration has harmful effect on not only cardiovascular events but cardiovascular hospitalization period and medical expenses due to big-data in Japan. Medical costs were kept low in comparison with their hospitalization period in subjects over 90 years old.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic relevance of exercise pulmonary hypertension for new-onset atrial fibrillation in primary mitral regurgitation

Background/Introduction

New-onset of atrial fibrillation (AF) portends poor prognosis in patients with primary mitral regurgitation (MR). However less is known about prognostic indicator for new-onset AF.

Purpose

The purpose of this study was to identify the prognostic relevance of exercise pulmonary hypertension for the new-onset AF in patients with primary MR.

Methods

Total of 114 consecutive patients with primary MR who underwent symptom-limited exercise echocardiography using supine-cycle ergometer were followed for new-onset AF over mean follow-up time of 3.6±2.6 years. Those with prevalent AF and pulmonary hypertension (estimated systolic pulmonary artery pressure ≥50mmHg) prior to exercise echocardiography were excluded from our analysis. We defined exercise-induced pulmonary hypertension (ExPHT) as those with peak estimated systolic pulmonary artery pressure (SPAP) ≥60mmHg or delta SPAP defined as differences between rest and peak SPAP ≥20mmHg.

Results

The mean age was 61±15 years old and 70 (61%) were male. Of those, 8 (7.8%) had mild MR, 32 (31.1%) had moderate MR, and 63 (61.2%) had severe MR. 60 (52.2%) patients had ExPHT. A total of 27 cases of new-onset AF were found during follow-up where the ExPHT group had higher prevalence of new-onset AF than the non-ExPHT group (35% vs. 11%, p=0.002). Those with ExPHT had significantly stronger association with shorter event-free survival time of new-onset AF (log-rank p&lt;0.001, Figure). When adjusted for age, sex, body surface area, the American Society of Echocardiography MR grade, left atrial dimension, peak systolic blood pressure and heart rate, the multivariable Cox regression analysis showed that those with ExPHT had a hazard risk of 3.1 ([95% CI 1.1–9.1], p=0.039) for new-onset of AF.

Conclusions

Exercise-induced pulmonary hypertension predicted incident of new-onset AF in those with primary MR. Exercise echocardiography is expected to play an important role in decision making with regards to the optimal timing for surgical intervention in primary MR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Short-term effects of low-dose tolvaptan in acute decompensated heart failure patients with severe aortic stenosis: the LOHAS registry

Background

Tolvaptan exerts potent diuretic effects in heart failure patients without hemodynamic instability. Nonetheless, its clinical efficacy for acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) remains unclear. This study aimed to evaluate the short-term effects of tolvaptan in ADHF patients with severe AS.

Methods

The LOw-Dose Tolvaptan (7.5 mg) in Decompensated Heart Failure Patients with Severe Aortic Stenosis (LOHAS) registry is a multicenter (7 centers) prospective registry that assessed the short-term effects of tolvaptan in subjects hospitalized for ADHF with severe AS. A total of 59 subjects were enrolled between September 2014 and December 2017. The primary endpoints were changes in body weight and fluid balance measured daily from baseline up to 4 days.

Results

The median [interquartile range] patient age and aortic valve area were 85.0 [81.0–89.0] years and 0.58 [0.42–0.74] cm2, respectively. Body weight continuously decreased, and fluid balance was maintained from baseline to day 4 (p&lt;0.001, p=0.194, respectively). Median serum B-type natriuretic peptide concentration significantly decreased from 910.5 to 740.0 pg/mL by day 4 (p=0.002). However, systolic blood pressure and heart rate were non-significantly changed (p=0.250, p=0.656, respectively). Hypernatremia (&gt;150 mEq/L) and worsening renal function occurred in 2 (3.4%) and 4 (6.8%) patients, respectively.

Conclusions

Short-term treatment with low-dose tolvaptan is safe and effective, providing stable hemodynamic parameters in patients with ADHF and severe AS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This research was supported by Otsuka Pharmaceutical Co., Ltd.

Comparison in Clinical Outcomes Between Leadless and Conventional Transvenous Pacemaker Following Transcatheter Aortic Valve Implantation

OBJECTIVES

Atrioventricular block is a common complication of transcatheter aortic valve implantation (TAVI). Although conventional transvenous dual-chamber (DDD) pacemaker (PM) is ideal for atrioventricular block, leadless PM, which is less invasive, may be suitable for frail TAVI patients. Little is known about clinical outcomes of this newer device following TAVI.

METHODS

A total of 330 consecutive patients undergoing TAVI were reviewed. Of these, PM cases without atrial fibrillation were studied. Indication for leadless PM was based on heart team discussion.

RESULTS

PM implantations were performed in 30 patients (9.1%), and 24 patients (7.3%) had no atrial fibrillation. These 24 patients had 14 DDD-PMs and 10 leadless PMs, and formed the two study groups. Baseline characteristics were similar except for ejection fraction: median ages were 83.0 years (IQR, 81.0-87.0 years) vs 86.5 years (IQR, 83.5-90.3) (P=.18); 11 (78.6%) vs 8 (80%) were women (P=.67); Society of Thoracic Surgeons scores were 5.1% (IQR, 3.8%-5.9%) vs 5.3% (IQR, 3.4%-8.5%) (P=.82); and ejection fractions were 68.0% (IQR, 66.0%-70.5%) vs 59.0% (IQR, 52.8%-69.3%) (P=.049), for the DDD-PM and leadless PM groups, respectively. There was 1 case of atrial lead dislodgment in the DDD-PM group; otherwise, no complications related to the implantation procedure were found. The leadless PM group showed numerically shorter hospital stay: 12.5 days (range, 9.0-17.8 day) in the DDD-PM group vs 10.5 days (range, 7.8-15.3 days) in the leadless PM group (P=.44). Six-month follow-up revealed no significant differences in incidence of heart failure rehospitalizations or deaths: 2 (14.3%) in the DDD-PM group vs 2 (25%) in the leadless PM group (P=.47); and 2 (14.3%) in the DDD-PM group vs 0 (0%) in the leadless PM group (P=.39), respectively.

CONCLUSIONS

Patients with leadless PM following TAVI may have shorter hospital stays, and clinical outcomes can be comparable with DDD-PMs. Leadless PMs may therefore be a reasonable option for frail TAVI patients.

New-Generation Transcatheter Aortic Valves in Patients With Small Aortic Annuli - Comparison of Balloon- and Self-Expandable Valves in Asian Patients

BACKGROUND

Asian patients have smaller aortic annuli. Although 20-mm balloon-expandable (BE) transcatheter heart valves (THV) are manufactured for transcatheter aortic valve implantation (TAVI) in these cases, the supra-annular design of self-expandable (SE) THV is considered more suitable; however, real-world comparative data are scarce.Methods and Results:Consecutive TAVI cases (n=330) in a single Japanese center were reviewed. Based on the cutoff for the new-generation 20-/23-mm BE-THV, a small aortic annulus was defined as <330 mm². A considerable number of patients had small annuli: 49/302 (16%). Of these, 33 BE-THV and 13 SE-THV using new-generation valves were compared. Although the SE-THV group had smaller annulus area (median 297 (interquartile range, 280-313) vs. 309 (303-323) mm²(P=0.022)), it had more favorable post-procedural parameters; for SE-THV and BE-THV, respectively, effective orifice area (EOA), 1.5 (1.3-1.6) vs. 1.1 cm²(0.9-1.3) (P=0.002); mean pressure gradient, 7.6 (5.6-11.0) vs. 14.2 mmHg (11.2-18.8) (P=0.001); and peak velocity, 1.8 (1.6-2.4) vs. 2.7 m/s (2.3-3.1) (P=0.001). Although new left bundle branch block was higher with SE-THV (24% and 62%, P=0.02), patient-prosthesis mismatch (PPM) ≥ moderate (indexed EOA <0.85 cm²/m²) was significantly less with SE-THV than with BE-THV (8% vs. 55%; P=0.04). Hemodynamic findings were consistent up to 1 year.

CONCLUSIONS

Small annuli are often seen in Asian patients, for whom SE-THV implantation results in favorable hemodynamics with less PPM.

Prognostic value of Mini Nutritional Assessment-Short Form with aortic valve stenosis following transcatheter aortic valve implantation

Aims

Older adults at risk for malnutrition are known to have a high mortality rate. This study aimed to investigate whether the Mini Nutritional Assessment—Short Form (MNA‐SF) could predict midterm mortality in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods and results

We applied the MNA‐SF in 288 patients who had undergone TAVI from January 2016 to June 2019 at the St. Marianna University School of Medicine hospital. Using the MNA‐SF cut‐off value to indicate the risk of malnutrition, patients were divided into two groups, namely, those with an MNA‐SF score ≤11 (impaired MNA‐SF group) and those with an MNA‐SF score ≥12 (maintained MNA‐SF group). We used this value to investigate the association between the MNA‐SF and all‐cause mortality. Overall, 188 (65%) and 100 (35%) patients comprised the impaired MNA‐SF and maintained MNA‐SF groups, respectively, and 41 patients died after TAVI (mean follow‐up duration, 458 ± 315 days). Kaplan–Meier analyses showed that patients in the impaired MNA‐SF group had a significantly higher incidence of all‐cause mortality (hazard ratio 2.67; 95% confidence interval 1.29–6.21; P = 0.01). Multivariate Cox regression analyses showed that the MNA‐SF score was an independent predictor of all‐cause mortality after adjusting for the Society of Thoracic Surgeons risk score, Katz Index, and brain natriuretic peptide test results (hazard ratio 1.14; 95% confidence interval 1.01–1.28; P = 0.04).

Conclusions

The MNA‐SF was useful to screen for the risk of malnutrition in patients with TAVI and in predicting midterm prognoses in patients undergoing TAVI and could predict patient mortality after the procedure.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

"Avulsion Injury" of the Artery by a Suture-Mediated Closure System During Transcatheter Aortic Valve Implantation

We describe a cut-down method that is useful in cases with calcification restricted to the region surrounding the puncture site in transcatheter aortic valve implantation patients with severe aortic stenosis.

Calcified Nodule Protruding Into the Lumen Through Stent Struts: An In Vivo OCT Analysis

We observed a calcified nodule (CN) protruding into the coronary lumen through the stent struts of an in-stent restenosis (ISR) lesion in detail using optical coherent tomography (OCT). The patient was a 56-year-old Japanese male on regular hemodialysis for his end-stage renal disease who had multiple coronary risk factors. He previously underwent percutaneous coronary intervention (PCI) for the middle left anterior descending artery and a drug-eluting stent was implanted. OCT showed a CN in the culprit lesion. He underwent coronary angiography 9 months later, and an ISR lesion was observed. Re-PCI was done, and a drug-coated balloon was used. OCT showed a CN protruding into the coronary lumen through the stent struts in the ISR lesion. Although this phenomenon was previously reported in a pathological study, the observation of a CN protruding through stent struts by in vivo OCT has been rarely demonstrated previously. The present study provides support for the previous pathological report, and demonstrates a useful application of OCT imaging that can help in the treatment of ISR lesions.

Impact of Board-Certified Cardiologist Characteristics on Risk of In-Hospital Mortality

Background: This study examined the influence of board-certified cardiologist characteristics on the in-hospital mortality of patients with cardiovascular disease.

Methods and Results: Data were collected between 2012 and 2014 from a nationwide database of acute care hospitals in Japan. Overall, there were 1,422,703 patients, of whom 883,746 were analyzed. The primary outcome was all-cause in-hospital mortality. The association between board-certified cardiologist characteristics and in-hospital mortality was estimated using multilevel mixed-effect logistic regression modeling. Median age of cardiologists in a hospital was not related to in-hospital mortality (OR, 1.003; 95% CI: 0.998–1.008, P=0.316), but a greater cardiologist age range was associated with a lower risk of in-hospital mortality (OR, 0.992; 95% CI: 0.988–0.995 per 1-unit increment in age range, P<0.001). Meanwhile, the average years of experience of the board-certified cardiologists in a hospital was not associated with a lower risk of in-hospital mortality (OR, 1.002; 95% CI: 0.996–1.007, P=0.525), but a greater range of years of experience was (OR, 0.986; 95% CI: 0.983–0.990 per 1-unit increment in range of years of experience, P<0.001).

Conclusions: Median board-certified cardiologist age/experience at an institution is not related to in-hospital mortality, but a greater range in age/experience is associated with a lower risk of mortality.

Association between the number of board-certified cardiologists and the risk of in-hospital mortality: a nationwide study involving the Japanese registry of all cardiac and vascular diseases

OBJECTIVES

Although there are 14 097 board-certified cardiologists in Japan, it is unknown whether the number of institutional board-certified cardiologists is related to the prognosis of cardiovascular disease patients.

DESIGN

Cross-sectional analysis.

SETTING

Data were collected from the nationwide database of acute care hospitals in Japan (2371 hospitals) between 2012 and 2013.

PARTICIPANTS

A total of 1 422 703 consecutive patients were initially included in this study, but 518 610 patients were excluded due to age <18 years, missing data or prior hospitalisations; therefore, 896 171 patients comprised the final sample population.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital mortality due to any cause. For the per-hospital analysis, Poisson regression models were used to estimate the association of board-certified cardiologists with in-hospital mortality, adjusted for hospital facilitation. For the per-patient analysis, hierarchical logistic regression models were used to estimate the ORs of the number of institutional board-certified cardiologists, adjusted for patient demographics, diagnoses, therapies and hospital facilities.

RESULTS

The regression model of the per-hospital analysis indicated that the number of board-certified cardiologists was associated with a lower rate ratio of in-hospital mortality (rate ratio, 0.988; 95% CI 0.983 to 0.993; p<0.01). The per-patient analysis indicated that the median age was 73 years and the in-hospital mortality rate was 11.7%. The regression model indicated that the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality (OR, 0.980; 95% CI 0.975 to 0.986; p<0.01) after adjustments for hospital facilities, patient characteristics and treatments.

CONCLUSIONS

Among cardiovascular disease patients admitted to acute care hospitals in Japan, the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality. These results have implications for national and institutional strategies for determining the required number of board-certified cardiologists.

P304Prognostic significance of transvalvular flow rate during exercise in asymptomatic patients with aortic stenosis

Background

The optimal management of asymptomatic aortic stenosis (AS) remains controversial. The aim of this study is to investigate the prognostic value of exercise stress echocardiography (ESE) in asymptomatic patients with AS.

Purpose

To investigate the additive value of ESE in asymptomatic patients with AS.

Methods and results

We retrospectively enrolled 109 consecutive patients (mean age 73±13 years, 55 men) with AS (aortic valve area ≤1.5cm2) who underwent ESE. Of these, 10 patients referred for aortic valve replacement without symptoms were excluded; finally, 99 conservatively managed patients were enrolled. During the mean follow-up period of 14±11 months, 23 patients (23%) suffered from AS related events. Although no differences in mean pressure gradient at rest and during exercise were found between the patients with and without adverse events, transvalvular flow rate during exercise (Ex-FR) was lower in patients with adverse events than those without adverse events (236±55 ml/sec vs 274±64 ml/sec, P=0.01). Using multivariate Cox regression analysis, low Ex-FR (<270 ml/sec) was an independent predictor for adverse events in patients with asymptomatic AS (hazard ratio: 3.53, P<0.01). The Kaplan–Meier analysis showed that Ex-FR was clearly stratified the event-free survival (Figure, log-rank P<0.01).

K-M curve according to Ex-FR

Conclusion

These results suggested that Ex-FR measured by ESE should play crucial roles in risk stratification in asymptomatic patients with AS.

P1493Prognostic significance of right ventricular function during exercise in patients with non-obstructive hypertrophic cardiomyopathy

Background

Hypertrophic cardiomyopathy (HCM) is a heterogeneous condition that may present crucial complication including life-threatening arrhythmia and sudden cardiac death. However, the risk stratification of HCM without left ventricular outflow tract (LVOT) obstruction had not been fully elucidated. Moreover, although recent studies have revealed the right ventricle (RV) involvement of HCM, the prognostic importance of RV function during exercise is unclear.

Purpose

To investigate the prognostic significance of RV function in patients with non-obstructive HCM using exercise stress echocardiography (ESE).

Methods and results

This study conducted on 100 HCM patients (age 62.9±13.6 years, 63% men) with preserved left ventricular ejection fraction who underwent ESE using semi-supine bicycle ergometer. Ten patients with significant LVOT obstruction (≥30mmHg) were excluded and 9 were also excluded because of the inadequate imaging quality or insufficiency of data. Among remaining 81 non-obstructive HCM patients, 9 patients suffered from HCM related cardiac events including cardiac death, unexpected hospitalization, life-threatening arrhythmias, and new-onset of syncope during the mean follow up period of 2.6±1.6 years. A multivariate Cox Hazard analysis revealed that low tricuspid annular plane systolic excursion during exercise (Ex-TAPSE, cut-off: 24mm) was an independent predictor of cardiac events. (hazard ratio: 18.66, 95% confidence interval: 3.66–338.46, P<0.001) The estimated cumulative cardiac event free survival using the Kaplan-Meier method was significantly lower in patients with reduced Ex-TAPSE (<24mm) than those with preserved Ex-TAPSE (Log-rank, P<0.01).

K-M curve according to Ex-TAPSE

Conclusion

Ex-TAPSE had a strong predictive value of clinical outcomes in non-obstructive HCM patients. Right ventricular function during exercise may have crucial role in the risk stratification of non-obstructive HCM.

Novel Device-Based Algorithm Provides Optimal Hemodynamics During Exercise in Patients With Cardiac Resynchronization Therapy

BACKGROUND

An adaptive cardiac resynchronization therapy (aCRT) algorithm has been described for synchronized left ventricular (LV) pacing and continuous optimization of cardiac resynchronization therapy (CRT). However, there are few algorithmic data on the effect of changes during exercise.Methods and Results:We enrolled 27 patients with availability of the aCRT algorithm. Eligible patients were manually programmed to optimal atrioventricular (AV) and interventricular (VV) delays by using echocardiograms at rest or during 2 stages of supine bicycle exercise. We compared the maximum cardiac output between manual echo-optimization and aCRT-on during each phase. After initiating exercise, the optimal AV delay progressively shortened (P<0.05) with incremental exercise levels. The manual-optimized settings and aCRT resulted in similar cardiac performance, as demonstrated by a high concordance correlation coefficient between the LV outflow tract velocity time integral (LVOT-VTI) during each exercise stage (Ex.1: r=0.94 P<0.0008, Ex.2: r=0.88 P<0.001, respectively). Synchronized LV-only pacing in patients with normal AV conduction could provide a higher LVOT-VTI as compared with manual-optimized conventional biventricular pacing at peak exercise (P<0.05).

CONCLUSIONS

The aCRT algorithm was physiologically sound during exercise by patients.

Cardiogenic shock following balloon post-dilatation in transcatheter aortic valve implantation: first case report of all three stuck leaflets

Background

A stuck leaflet and frozen cusp are reported complications following transcatheter aortic valve implantation (TAVI). These complications are rare but can drastically change haemodynamics and be potentially life-threatening; thus, their awareness during TAVI is indispensable. Leaflet malfunction generally presents in one of the three leaflets of a prosthetic valve; however, we encountered a case where all three leaflets were simultaneously stuck.

Case Summary

A 94-year-old woman was referred to our cardiology department with severe aortic stenosis. She underwent transfemoral TAVI. After a 20 mm balloon was inflated, a 23 mm Sapien 3 valve was deployed. Since the delivery balloon slipped into the ventricle, the valve top was not fully expanded. Post-dilatation using a 23 mm balloon was performed, which led to cardiogenic shock. Immediate cardiopulmonary resuscitation and venoarterial extracorporeal membrane oxygenation were provided. Since aortography and haemodynamics indicated severe aortic regurgitation and transoesophageal echocardiography depicted no leaflets inside the Sapien 3, we confirmed that all leaflets were stuck. The valve-in-valve procedure using the second 23 mm valve was successfully performed, and her haemodynamics dramatically improved. The patient was discharged 20 days later.

Discussion

Only a handful of cases have been reported on a stuck leaflet following post-dilatation. Root rupture is a major concern of the abrupt change after post-dilatation, but a stuck leaflet should also be considered even when the new-generation balloon-expandable valve, Sapien 3, is used. Here we report the first case in which all three leaflets were stuck.

Endothelialization of an Amplatzer Septal Occluder Device 6 Months Post Implantation: Is This Enough Time? An In Vivo Angioscopic Assessment

The current guidelines recommend a minimum of 6 months of antithrombotic and antibiotic prophylaxis following septal occluding device placement for transcatheter closure of atrial septal defect. Full neoendothelialization is thought to be completed within 6 months of device implantation; however, there is no method available that can assess the level of neoendothelialization in vivo. This report therefore evaluates endothelialization in vivo and demonstrates that 6 months of postimplantation prophylactic therapy may not provide sufficient time for adequate endothelialization. Further investigations are warranted to determine the optimal duration of these treatments after atrial septal defect closure.

Geometry of the left ventricular outflow tract assessed by 3D TEE in patients with aortic stenosis: impact of upper septal hypertrophy on measurements of Doppler-derived left ventricular stroke volume

BACKGROUND

It is unclear how upper septal hypertrophy (USH) affects Doppler-derived left ventricular stroke volume (SV) in patients with AS. The aims of this study were to: (1) validate the accuracy of 3D transesophageal echocardiography (TEE) measurements of the left ventricular outflow tract (LVOT), (2) evaluate the differences in LVOT geometry between AS patients with and without USH, and (3) assess the impact of USH on measurement of SV.

METHODS

In protocol 1, both 3D TEE and multi-detector computed tomography were performed in 20 patients with AS [aortic valve area (AVA) ≤ 1.5 cm²]. Multiplanar reconstruction was used to measure the LVOT short and long diameters in four parts from the tip of the septum to the annulus. In protocol 2, the same 3D TEE measurements were performed in AS patients (AVA ≤ 1.5 cm², n = 129) and controls (n = 30). We also performed 2D and 3D transthoracic echocardiography in all patients.

RESULTS

In protocol 1, excellent correlations of LVOT parameters were found between the two modalities. In protocol 2, the USH group had smaller LVOT short and long diameters than the non-USH group. Although no differences in mean pressure gradient, or SV calculated with the 3D method existed between the two groups, the USH group had greater SV calculated with the Doppler method (73 ± 15 vs. 66 ± 15 ml) and aortic valve area (0.89 ± 0.26 vs. 0.73 ± 0.24 cm²) than the non-USH group.

CONCLUSIONS

3D TEE can provide a precise assessment of the LVOT in AS. USH affects the LVOT geometry in patients with AS, which might lead to inaccurate assessments of disease severity.

Novel Understanding of Takotsubo Syndrome

Takotsubo cardiomyopathy is described as a transient reversible cardiomyopathy which typically occurs in older women after emotional or physical stress. This cardiomyopathy is also recognized as a "syndrome" because it develops in conjunction with various diseases. Since the clinical presentation of takotsubo syndrome (TTS) is similar to acute coronary syndrome (ACS), TTS should be distinguished from ischemic heart disease. Although the pathophysiology of TTS has not well been established, a number of its specific features have been suggested. The predictor of mortality in TTS is still unknown. In this review article, we describe a series of treatment decisions in TTS.