Myocardial work and left heart deformation parameters across primary mitral regurgitation severity

A cohort study evaluating myocardial work and right ventricle strain in sepsis in critical care

The understanding of sepsis-related changes in myocardial function is evolving. This single-centre prospective observational cohort pilot study evaluated myoCardial work and Right ventricle Strain In Sepsis (CRiSIS) with 30-day mortality in critical care patients. Measurements were recorded for 32 patients on days 1 and 3 of admission: 22 (69%) survivors and 10 (31%) non-survivors at 30 days. Survivors demonstrated a higher global work efficiency (GWE; 94%, IQR 91-96%) compared to non-survivors (88.5%, IQR 85-92%; p = 0.02, BF10 = 1.44) on day 3. No significant differences in changes between day 1 and day 3 were observed in MW or RV FWS. Bayesian analysis supported a possible difference in global work index (GWI) and global constructive work (GCW) between survivors and non-survivors on day 1 and for global work index (GWI) on day 3. GWI, GCW, and GWE strongly correlated with left ventricle ejection fraction (LVEF) and global longitudinal strain (GLS), while the relationship with global wasted work (GWW) was weaker. To the best of our knowledge, this is the first study to investigate the role of MW in critically ill patients presenting with sepsis and suggests that it may be a valuable prognostic tool in this patient population.

Prognostic impact of left ventricular myocardial work in patients undergoing surgery for primary mitral regurgitation

PURPOSE

Echocardiography-based, left ventricular myocardial work (LVMW) can assess LV function by incorporating LV afterload. This study aims to evaluate the prognostic value of LVMW indices in patients with primary mitral regurgitation (MR) undergoing mitral valve surgery.

METHODS AND RESULTS

A total of 306 patients (mean age 63 ± 12 years, 68% male) with severe, primary MR who underwent surgery, were included. All patients underwent transthoracic echocardiography and LVMW indices were assessed with commercially available ultrasound equipment before surgery. The mean LV global work index (LVGWI) was 1979 ± 537 mmHg% and 130 (42%) patients had impaired LVGWI (≤ 1900 mmHg%). During a median follow-up of 5.0 years (interquartile range, 2.5-8.9), 27 (8.8%) patients died after mitral valve surgery. Patients with impaired LVGWI or LV global longitudinal strain (LVGLS) (≤ 20%) had lower survival rates compared to the group with preserved (p < 0.01 and p = 0.02, respectively). While the likelihood ratio test suggests that LVGWI ≤ 1900 mmHg% provides additional prognostic information beyond the model including LVGLS (p < 0.05) for all-cause mortality, no significant improvement was observed in area under the curve, the C-index, or net-reclassification index.

CONCLUSIONS

In patients with severe, primary MR who underwent surgery, impaired pre-operative LVGWI was associated with a higher mortality risk, and may have incremental value beyond LVGLS, but requires further study for validation.

Prognostic Value of Advanced Echocardiographic Analysis for Transcatheter Aortic Valve Replacement: A Systematic Review

Transcatheter aortic valve implantation (TAVI) is the main treatment option for patients with severe aortic stenosis (AS) and older age. Improved imaging techniques have enabled better patient selection, and the main role is played by echocardiography. Methods more sensitive than LVEF in assessing cardiac function, such as global longitudinal strain (GLS) and myocardial work (MW), have become widespread, and other methods, like hemodynamic forces (HDFs), might be promising. The aim of this paper is to systematically review the parameters of GLS, MW, and HDF as predictors of reverse remodeling and their association with outcomes in patients with AS undergoing TAVI. In particular, the focus will be on the examination of the influence of TAVI on left atrial and ventricular function and right ventricular function.

Prediction of Cardiovascular Events and Structural and Functional Remodeling of the Heart in Patients With Severe Mitral Regurgitation of Various Genesis Underwent Transcatheter Mitral Valve Repair "Edge-To-Edge"

AIM

To search for predictors of adverse cardiovascular events after edge-to-edge transcatheter mitral valve repair (TMVR) in patients with severe mitral regurgitation (MR) of various origins with an assessment of structural and functional remodeling of the heart and left ventricular (LV) contractile function.

MATERIAL AND METHODS

The study included 73 patients (median age 71 [63; 80] years, 60.3% men) at a high surgical risk with severe MR of primary and secondary genesis, who underwent TMVR. The second-generation (58.9%) and fourth-generation (41.1%) clips were implanted. In addition to standard echocardiographic (EchoCG) indices, the parameters of left heart chamber longitudinal strain and LV myocardial function were assessed at baseline, on days 4-5, and at 6 and 12 months after the intervention. Also, the N-terminal fragment of the pro-brain natriuretic peptide (NT-proBNP) was assessed at baseline and on days 4-5 after TMVR.

RESULTS

A significant decrease in MR was achieved during 12 months of follow-up. In the group with primary mitral regurgitation (PMR), MR decreased from 4.0 [3.4; 4.0] to 2.0 [1.5; 2.5] at one year of follow-up (p<0.001). In the group with secondary mitral regurgitation (SMR), MR decreased from 3.5 [3.0; 3.9] to 2.0 [2.0; 2.5] at 12 months of follow-up (p<0.001). This effect was associated with volumetric unloading of the left heart chambers evident as a significant decrease in the volumetric indices of the left chambers and an increase in the cardiac index. In the early postoperative period, the LV function was impaired as shown by decreases in the ejection fraction (EF), global longitudinal strain (GLS), LV myocardial function parameters, and an associated increase in NT-proBNP. By 12 months of follow-up, statistically significant improvements in global constructive work (GCW) and global work index (GWI) relative to baseline values were noted in both groups without significant changes in EF and LV GLS. A strong correlation was found between LV EF and GCW (r=0.812, p<0.001) and GWI (r=0.749, p<0.001). The overall survival was 89%, not differing between groups (p=0.72); the absence of hospitalization for decompensated heart failure (HF) was 79.5%, also without significant differences between the groups (p=0.78). According to multivariate regression analysis, the baseline GCW value was the strongest predictor of rehospitalization for decompensated HF (relative risk (RR) 0.997; 95% confidence interval (CI) 0.995-1.000; p=0.021) and the composite endpoint (CEP) (hospitalization for decompensated HF + all-cause mortality) (RR 0.998; 95% CI 0.996-1.000; p=0.033) in the cohort with PMR. In the group with SMR, the initial degree of MR was related with rehospitalization and the CEP (OR 12.252; 95% CI 2.125-70.651; p=0.005 and OR 16.098; 95% CI 2.944-88.044; p=0.001, respectively). The most significant predictor of overall mortality in the study population was the preoperative value of LV stroke volume (OR 0.824; 95% CI 0.750-0.906; p<0.001).

CONCLUSION

Edge-to-edge TMVR exerts a positive effect on the prognosis and structural and functional remodeling of the heart in patients with PMR and SMR. Myocardial function indices may be useful in assessing the LV contractile function in patients with severe MR of various origins. Identification of predictors for adverse cardiovascular events, including with new EchoCG technologies, may contribute to better patient stratification.

Mitral Transcatheter Edge-to-Edge Repair and Clinical Value of Novel Echocardiographic Biomarkers: A Hypothesis-Generating Study

BACKGROUND

Longitudinal data on reverse cardiac remodeling and outcomes after transcatheter edge-to-edge repair (TEER) are limited.

METHODS

A total of 78 patients with severe mitral regurgitation (MR) were included retrospectively. All patients had echocardiography at baseline and again six months after TEER. They were monitored for a primary composite endpoint, consisting of heart failure hospitalization and cardiovascular death, over 13 months.

RESULTS

Significant decreases in the left ventricular ejection fraction (LVEF), all myocardial work indices (except global wasted work), and the left atrial reservoir were observed after TEER. Additionally, there was a decrease in the pulmonary artery systolic pressure and an increase in the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. A post-TEER TAPSE/PASP ratio of <0.47 (HR: 4.76, p-value = 0.039), and a post-TEER left atrial reservoir of <9.0% (HR: 2.77, p-value = 0.047) were associated with the primary endpoint.

CONCLUSIONS

Echocardiography post-TEER reflects impairment in ventricular performance due to preload reduction and right ventricle and pulmonary artery coupling improvement. Short-term echocardiography after TEER identifies high-risk patients who could benefit from a close clinical follow-up. The prognostic significance of LA strain and the TAPSE/PASP ratio should be validated in subsequent large-scale prospective studies.

Timing and Patient Position During Cuff Blood Pressure Measurement Affect Myocardial Work Parameters Measured by Echocardiography

BACKGROUND

Although cuff blood pressure measurement is a critical parameter to calculate myocardial work noninvasively, there is no recommendation about when and how to measure it. Accordingly, we sought to evaluate the effects of the timing during the echo study and the patient's position on the scanning bed during the cuff blood pressure measurement on myocardial work parameter calculations.

METHODS

One hundred one consecutive patients (44 women, 66 ± 14 years) undergoing clinically indicated echocardiography were prospectively enrolled. During the echocardiographic study, we measured the cuff blood pressure 4 times, using a fully automatic digital blood pressure monitor applied to the right and left arm in the same position throughout the study: BP1, before the start of the echo study, with the patient lying in the supine position; BP2, after positioning the patients on their left side to start the echo study; BP3, at the time of the acquisition of the 3 apical views (4- and 2-chamber and long-axis) used to measured left ventricular global longitudinal strain; and BP4, at the end of the echo study with the patient again in the supine position.

RESULTS

Systolic blood pressureat BP1 was 147 ± 21 mm Hg. Between BP1 and BP2, it dropped by 17 ± 9 mm Hg (P < .05). Systolic blood pressure at BP3 was significantly lower than BP2 (130 ± 20 mm Hg vs 122 ± 18 mm Hg, P < .05), and at BP4 was significantly lower than at BP1 (-9 ± 13 mm Hg, P < .05). The average global longitudinal strain was -16% ± 3%. Accordingly, the global work index was 1,929 ± 441 mm Hg% at BP1, dropped to 1,717 ± 421 at BP2, decreased to 1,602 ± 351 mm Hg% at BP3, and increased to 1,815 ± 386 mm Hg% at BP4 (P < .001).

CONCLUSIONS

The timing during the echocardiography study and the patient's position on the scanning bed are critical determinants of the measured cuff systolic blood pressure and the resulting values of myocardial work parameters.