1
|
Luong CL, Anand V, Padang R, Oh JK, Arruda-Olson AM, Bird JG, Pislaru C, Thaden JJ, Pislaru SV, Pellikka PA, McCully RB, Kane GC. Prognostic Significance of Elevated Left Ventricular Filling Pressures with Exercise: Insights from a Cohort of 14,338 Patients. J Am Soc Echocardiogr 2024; 37:382-393.e1. [PMID: 38000684 DOI: 10.1016/j.echo.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 10/22/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Exercise echocardiography can assess for cardiovascular causes of dyspnea other than coronary artery disease. However, the prevalence and prognostic significance of elevated left ventricular (LV) filling pressures with exercise is understudied. METHODS We evaluated 14,338 patients referred for maximal symptom-limited treadmill echocardiography. In addition to assessment of LV regional wall motion abnormalities (RWMAs), we measured patients' early diastolic mitral inflow (E), septal mitral annulus relaxation (e'), and peak tricuspid regurgitation velocity before and immediately after exercise. RESULTS Over a mean follow-up of 3.3 ± 3.4 years, patients with E/e' ≥15 with exercise (n = 1,323; 9.2%) had lower exercise capacity (7.3 ± 2.1 vs 9.1 ± 2.4 metabolic equivalents, P < .0001) and were more likely to have resting or inducible RWMAs (38% vs 18%, P < .0001). Approximately 6% (n = 837) had elevated LV filling pressures without RWMAs. Patients with a poststress E/e' ≥15 had a 2.71-fold increased mortality rate (2.28-3.21, P < .0001) compared with those with poststress E/e' ≤ 8. Those with an E/e' of 9 to 14, while at lower risk than the E/e' ≥15 cohort (hazard ratio [HR] = 0.58 [0.48-0.69]; P < .0001), had higher risk than if E/e' ≤8 (HR = 1.56 [1.37-1.78], P < .0001). On multivariable analysis, adjusting for age, sex, exercise capacity, LV ejection fraction, and presence of pulmonary hypertension with stress, patients with E/e' ≥15 had a 1.39-fold (95% CI, 1.18-1.65, P < .0001) increased risk of all-cause mortality compared with patients without elevated LV filling pressures. Compared with patients with E/e' ≤ 15 after exercise, patients with E/e' ≤15 at rest but elevated after exercise had a higher risk of cardiovascular death (HR = 8.99 [4.7-17.3], P < .0001). CONCLUSION Patients with elevated LV filling pressures are at increased risk of death, irrespective of myocardial ischemia or LV systolic dysfunction. These findings support the routine incorporation of LV filling pressure assessment, both before and immediately following stress, into the evaluation of patients referred for exercise echocardiography.
Collapse
Affiliation(s)
- Christina L Luong
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Jared G Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
2
|
Bapat V, Weiss E, Bajwa T, Thourani VH, Yadav P, Thaden JJ, Lim DS, Reardon M, Pinney S, Adams DH, Yakubov SJ, Modine T, Redwood SR, Walton A, Spargias K, Zhang A, Mack M, Leon MB. 2-Year Clinical and Echocardiography Follow-Up of Transcatheter Mitral Valve Replacement With the Transapical Intrepid System. JACC Cardiovasc Interv 2024:S1936-8798(24)00527-2. [PMID: 38639690 DOI: 10.1016/j.jcin.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/15/2024] [Accepted: 02/27/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Thirty-day outcomes with the investigational Intrepid transapical (TA) transcatheter mitral valve replacement (TMVR) system have previously demonstrated good technical success, but longer-term outcomes in larger cohorts need to be evaluated. OBJECTIVES The authors sought to evaluate the 2-year safety and performance of the Intrepid TA-TMVR system in patients with symptomatic, ≥moderate-severe mitral regurgitation (MR) and high surgical risk. METHODS Patient eligibility was determined by local heart teams and approved by a central screening committee. Clinical events were adjudicated by an independent clinical events committee. Echocardiography was evaluated by an independent core laboratory. RESULTS The cohort included 252 patients that were enrolled at 58 international sites before February 2021 as part of the global Pilot Study (n = 95) or APOLLO trial (primary cohort noneligible + TA roll-ins, n = 157). Mean age was 74.2 years, mean STS-PROM was 6.3%, 60.3% were male, and 80.6% were in NYHA functional class III/IV. Most presented with secondary MR (70.1%), and nearly all had ≥moderate-severe MR (98.4%). All-cause mortality was 13.1% (30-day), 27.3% (1-year), and 36.2% (2-year). The 30-day ≥major bleeding event rate was 22.3%. Heart failure rehospitalization was 9.6% (30-day) and 36.2% (2-year). At 2 years, >50% of patients were alive with improvement in NYHA functional class (82.1%, class I/II), and all patients with available echocardiograms had ≤mild MR. CONCLUSIONS This analysis represents the largest reported TA-TMVR experience with the longest follow-up in high-risk ≥moderate-severe MR patients. Early mortality and heart failure rehospitalizations were significant, exacerbated by early TA-related bleeding events; however, meaningful improvements in clinical outcomes and marked reductions in MR severity were observed through 2 years.
Collapse
Affiliation(s)
- Vinayak Bapat
- St. Thomas' Hospital, London, United Kingdom; New York Presbyterian/Columbia University Medical Center, New York, New York, USA.
| | - Eric Weiss
- Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Tanvir Bajwa
- Aurora St. Luke's Medical Center, Milwaukee, Wisconsin, USA
| | | | | | | | - D Scott Lim
- University of Virginia Health System Hospital, Charlottesville, Virginia, USA
| | - Michael Reardon
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Sean Pinney
- Mount Sinai Medical Center, New York, New York, USA
| | | | | | - Thomas Modine
- Department of Heart Valve Therapy, CHU Bordeaux, Bordeaux, France
| | | | - Antony Walton
- Cardiology Department, The Alfred, Melbourne, Australia
| | | | | | - Michael Mack
- Baylor Scott and White Heart Hospital, Plano, Texas, USA
| | - Martin B Leon
- New York Presbyterian/Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
3
|
Danielson AP, Collins JD, Pislaru SV, Padang R, Kane GC, Foley TA, Williamson EE, Eleid MF, Thaden JJ. Comparison of Tricuspid Annular Dimension Measurements Using Automated Three-Dimensional Transthoracic Echocardiography and Computed Tomography in Patients Evaluated for Transcatheter Tricuspid Valve Intervention. J Am Soc Echocardiogr 2024:S0894-7317(24)00105-6. [PMID: 38452828 DOI: 10.1016/j.echo.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Alex P Danielson
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas A Foley
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
4
|
Ali MT, Johnson M, Irwin T, Henry S, Sugeng L, Kansal S, Allison TG, Bremer ML, Jones VR, Martineau MD, Wong C, Marecki G, Stebbins J, Michelena HI, McCully RB, Svatikova A, Padang R, Scott CG, Kanuga MJ, Arsanjani R, Pellikka PA, Kane GC, Thaden JJ. Incidence of Severe Adverse Drug Reactions to Ultrasound Enhancement Agents in a Contemporary Echocardiography Practice. J Am Soc Echocardiogr 2024; 37:276-284.e3. [PMID: 37879379 DOI: 10.1016/j.echo.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/02/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Prior data indicate a very rare risk of serious adverse drug reaction (ADR) to ultrasound enhancement agents (UEAs). We sought to evaluate the frequency of ADR to UEA administration in contemporary practice. METHODS We retrospectively reviewed 4 US health systems to characterize the frequency and severity of ADR to UEA. Adverse drug reactions were considered severe when cardiopulmonary involvement was present and critical when there was loss of consciousness, loss of pulse, or ST-segment elevation. Rates of isolated back pain and headache were derived from the Mayo Clinic Rochester stress echocardiography database where systematic prospective reporting of ADR was performed. RESULTS Among 26,539 Definity and 11,579 Lumason administrations in the Mayo Clinic Rochester stress echocardiography database, isolated back pain or headache was more frequent with Definity (0.49% vs 0.04%, P < .0001) but less common with Definity infusion versus bolus (0.08% vs 0.53%, P = .007). Among all sites there were 201,834 Definity and 84,943 Lumason administrations. Severe and critical ADR were more frequent with Lumason than with Definity (0.0848% vs 0.0114% and 0.0330% vs 0.0010%, respectively; P < .001 for each). Among the 3 health systems with >2,000 Lumason administrations, the frequency of severe ADR with Lumason ranged from 0.0755% to 0.1093% and the frequency of critical ADR ranged from 0.0293% to 0.0525%. Severe ADR rates with Definity were stable over time but increased in more recent years with Lumason (P = .02). Patients with an ADR to Lumason since the beginning of 2021 were more likely to have received a COVID-19 vaccination compared with matched controls (88% vs 75%; P = .05) and more likely to have received Moderna than Pfizer-Biotech (71% vs 26%, P < .001). CONCLUSION Severe and critical ADR, while rare, were more frequent with Lumason, and the frequency has increased in more recent years. Additional work is needed to better understand factors, including associations with recently developed mRNA vaccines, which may be contributing to the increased rates of ADR to UEA since 2021.
Collapse
Affiliation(s)
- Mays T Ali
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark Johnson
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Timothy Irwin
- University of South Dakota, Yankton Medical Clinic, Yankton, South Dakota
| | - Sonia Henry
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Lissa Sugeng
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Sarita Kansal
- WellStar Center for Cardiovascular Medicine, WellStar Health System, Atlanta, Georgia
| | - Thomas G Allison
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Merri L Bremer
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Victoria R Jones
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael D Martineau
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Connie Wong
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Gregory Marecki
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Julie Stebbins
- WellStar Center for Cardiovascular Medicine, WellStar Health System, Atlanta, Georgia
| | - Hector I Michelena
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert B McCully
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anna Svatikova
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Mansi J Kanuga
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Reza Arsanjani
- Division of Cardiac Imaging and Stress Testing, Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
5
|
Alexandrino FB, Sandhu S, Oguz D, Nkomo VT, Eleid MF, Rihal CS, Guerrero M, Alkhouli M, Pislaru SV, Thaden JJ. Estimating Mitral Valve Area Post-Transcatheter Edge-to-Edge Repair: As Simple as 50-40. JACC Cardiovasc Interv 2023; 16:2948-2950. [PMID: 38092507 DOI: 10.1016/j.jcin.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/14/2023] [Accepted: 10/03/2023] [Indexed: 12/18/2023]
|
6
|
Zahr F, Song HK, Chadderdon S, Gada H, Mumtaz M, Byrne T, Kirshner M, Sharma S, Kodali S, George I, Merhi W, Yarboro L, Sorajja P, Bapat V, Bajwa T, Weiss E, Thaden JJ, Gearhart E, Lim S, Reardon M, Adams D, Mack M, Leon MB. 1-Year Outcomes Following Transfemoral Transseptal Transcatheter Mitral Valve Replacement: Intrepid TMVR Early Feasibility Study Results. JACC Cardiovasc Interv 2023; 16:2868-2879. [PMID: 37902145 DOI: 10.1016/j.jcin.2023.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND High surgical risk may preclude mitral valve replacement in many patients. Transcatheter mitral valve replacement (TMVR) using transfemoral transseptal access is a novel technology for the treatment of mitral regurgitation (MR) in high-risk surgical patients. OBJECTIVES This analysis evaluates 30-day and 1-year outcomes of the Intrepid TMVR Early Feasibility Study in patients with ≥moderate-severe MR. METHODS The Intrepid TMVR Early Feasibility Study is a multicenter, prospective, single-arm study. Clinical events were adjudicated by a clinical events committee; endpoints were defined according to Mitral Valve Academic Research Consortium criteria. RESULTS A total of 33 patients, enrolled at 9 U.S. sites between February 2020 and August 2022, were included. The median age was 80 years, 63.6% of patients were men, and mean Society of Thoracic Surgeons Predicted Risk of Mortality for mitral valve replacement was 5.3%. Thirty-one (93.9%) patients were successfully implanted. Median postprocedural hospitalization length of stay was 5 days, and 87.9% of patients were discharged to home. At 30 days, there were no deaths or strokes, 8 (24.2%) patients had major vascular complications and none required surgical intervention, there were 4 cases of venous thromboembolism all successfully treated without sequelae, and 1 patient had mitral valve reintervention for severe left ventricular outflow tract obstruction. At 1 year, the Kaplan-Meier all-cause mortality rate was 6.7%, echocardiography showed ≤mild valvular MR, there was no/trace paravalvular leak in all patients, median mitral valve mean gradient was 4.6 mm Hg (Q1-Q3: 3.9-5.3 mm Hg), and 91.7% of survivors were in NYHA functional class I/II with a median 11.4-point improvement in Kansas City Cardiomyopathy Questionnaire overall summary scores. CONCLUSIONS The early benefits of the Intrepid transfemoral transseptal TMVR system were maintained up to 1 year with low mortality, low reintervention, and near complete elimination of MR, demonstrating a favorable safety profile and durable valve function.
Collapse
Affiliation(s)
- Firas Zahr
- Oregon Health and Science University, Portland, Oregon, USA.
| | - Howard K Song
- Oregon Health and Science University, Portland, Oregon, USA
| | | | - Hemal Gada
- UPMC Pinnacle Harrisburg Campus, Harrisburg, Pennsylvania, USA
| | - Mubashir Mumtaz
- UPMC Pinnacle Harrisburg Campus, Harrisburg, Pennsylvania, USA
| | - Timothy Byrne
- Abrazo Arizona Heart Hospital, Phoenix, Arizona, USA
| | | | - Samin Sharma
- Mount Sinai Medical Center, New York, New York, USA
| | - Susheel Kodali
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Isaac George
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - William Merhi
- Spectrum Health Hospitals, Grand Rapids, Michigan, USA
| | - Leora Yarboro
- University of Virginia Health System Hospital, Charlottesville, Virginia, USA
| | - Paul Sorajja
- Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Vinayak Bapat
- Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Tanvir Bajwa
- Aurora Saint Luke's Medical Center, Milwaukee, Wisconsin, USA
| | - Eric Weiss
- Aurora Saint Luke's Medical Center, Milwaukee, Wisconsin, USA
| | | | | | - Scott Lim
- University of Virginia Health System Hospital, Charlottesville, Virginia, USA
| | - Michael Reardon
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - David Adams
- Mount Sinai Medical Center, New York, New York, USA
| | - Michael Mack
- Baylor Scott and White Heart Hospital, Plano, Texas, USA
| | - Martin B Leon
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
7
|
Tunthong R, Salama AA, Lane CM, Fine NM, Anand V, Padang R, Thaden JJ, Pislaru SV, Kane GC. Right ventricular systolic strain in patients with pulmonary hypertension: clinical feasibility, reproducibility, and correlation with ejection fraction. J Echocardiogr 2023; 21:105-112. [PMID: 36451073 DOI: 10.1007/s12574-022-00593-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/22/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Right ventricular (RV) systolic function is the major determinant of prognosis in patients with pulmonary hypertension (PH) with quantitative assessment by speckle-tracking strain echocardiography emerging as a viable candidate measure. METHOD We evaluated a prospective cohort of 231 patients with known or suspected PH referred for clinical echocardiography. All underwent measurement of RV free-wall systolic strain by sonographer staff. Digital images were recorded for blinded offline assessment by an expert echocardiographer. Reproducibility was assessed using the analysis methods of Bland-Altman and the Cohen's-Kappa coefficient. RESULTS RV strain was feasible in 213 (92%). The average RV systolic pressure was 59 ± 22 mmHg. RV systolic strain correlated with functional class, NT-proBNP, and the degree of RV enlargement. The average free-wall systolic strain was - 20 ± 7% (range - 2 to - 37%). The RV strain measures (clinical practice versus blinded expert) had an excellent correlation with a normal distribution (R2 0.87, p < 0.0001). By Bland-Altman analysis, the mean difference in measurement was - 1.7% (95% CI - 1.4 to - 2.1) with a correlation of 0.93, p value of < 0.0001. The reproducibility of RV strain for clinically relevant thresholds was also excellent (Kappa coefficients 0.68-0.83). There was no effect on the variability of strain measures across body mass, pulmonary pressures, or rhythm. RV strain correlated with RV diastolic volumes and ejection fraction with RV free wall strain being the best echo predictor for a reduction in ejection fraction. CONCLUSION Here RV systolic strain was found to be highly feasible and reproducible in clinical practice with excellent levels of agreement for clinically relevant thresholds.
Collapse
Affiliation(s)
- Ramaimon Tunthong
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Non-Invasive Cardiology Department, Bangkok Hospital Headquarters, BDMS, Bangkok, Thailand
| | - Abdalla A Salama
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Conor M Lane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nowell M Fine
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Vidhu Anand
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jeremy J Thaden
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sorin V Pislaru
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Garvan C Kane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
8
|
Oguz D, Huntley GD, El-Am EA, Scott CG, Thaden JJ, Pislaru SV, Fabre KL, Singh M, Greason KL, Crestanello JA, Pellikka PA, Oh JK, Nkomo VT. Impact of atrial fibrillation on outcomes in asymptomatic severe aortic stenosis: a propensity-matched analysis. Front Cardiovasc Med 2023; 10:1195123. [PMID: 37408654 PMCID: PMC10318187 DOI: 10.3389/fcvm.2023.1195123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Background Atrial fibrillation (AF) portends poor prognosis in patients with aortic stenosis (AS). Objectives This study aimed to study the association of AF vs. sinus rhythm (SR) with outcomes in asymptomatic severe AS during routine clinical practice. Methods We identified 909 asymptomatic patients from 3,208 consecutive patients with aortic valve area ≤1.0 cm2 and left ventricular ejection fraction ≥50% at a tertiary academic center. Patients were grouped by rhythm at the time of transthoracic echocardiogram [SR: 820/909 (90%) and AF: 89/909 (10%)]. Propensity-matched analyses (2 SR:1 AF) matching 174 SR to 89 AF patients by age, sex, and clinical comorbidities were used to compare outcomes. Results In the propensity-matched cohort, median age (82 ± 8 vs. 81 ± 9 years, p = 0.31), sex distribution (male 58% vs. 52%, p = 0.30), and Charlson comorbidity index (4.0 vs. 3.0, p = 0.26) were not different in AF vs. SR. Median follow-up duration was 2.6 (IQR: 1.0-4.4) years. The 1-year rate of aortic valve replacement (AVR) was not different (AF: 32% vs. SR: 37%, p = 0.31). All-cause mortality was higher in AF [hazard ratio (HR): 1.68 (1.13-2.50), p = 0.009]. Independent predictors of mortality were age [HR: 1.92 (1.40-2.62), p < 0.001], Charlson comorbidity index [1.09 (1.03-1.15), p = 0.002], aortic valve peak velocity [HR: 1.87 (1.20-2.94), p = 0.006], stroke volume index [HR: 0.75 (0.60-0.93), p = 0.01], moderate or more mitral regurgitation [HR: 2.97 (1.43-6.19), p = 0.004], right ventricular systolic dysfunction [HR: 2.39 (1.29-4.43), p = 0.006], and time-dependent AVR [HR: 0.36 (0.19-0.65), p = 0.0008]. There was no significant interaction of AVR and rhythm (p = 0.57). Conclusions Lower forward flow, right ventricular systolic dysfunction, and mitral regurgitation identified increased risk of subsequent mortality in asymptomatic patients with AF and AS. Additional studies of risk stratification of asymptomatic AS in AF vs. SR are needed.
Collapse
Affiliation(s)
- Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Geoffrey D. Huntley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Edward A. El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Christopher G. Scott
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Jeremy J. Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Sorin V. Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Katarina L. Fabre
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kevin L. Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Patricia A. Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jae K. Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Vuyisile T. Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
9
|
Ibrahim H, Thaden JJ, Fabre KL, Scott CG, Greason KL, Pislaru SV, Nkomo VT. Corrigendum to 'Impact of Atrial Fibrillation on Outcomes in Very Severe Aortic Valve Stenosis' The American Journal of Cardiology Volume 189, 15 February 2023, Pages 64-69. Am J Cardiol 2023; 195:107. [PMID: 37012182 DOI: 10.1016/j.amjcard.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Affiliation(s)
- Hossam Ibrahim
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Katarina L Fabre
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
10
|
Huntley GD, Michelena HI, Thaden JJ, Alkurashi AK, Pislaru SV, Pochettino A, Crestanello JA, Maleszewski JJ, Brown RD, Nkomo VT. Cerebral and Retinal Infarction in Bicuspid Aortic Valve. J Am Heart Assoc 2023; 12:e028789. [PMID: 36942747 PMCID: PMC10122894 DOI: 10.1161/jaha.122.028789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Background Description of cerebral and retinal infarction in patients with bicuspid aortic valve (BAV) is limited to case reports. We aimed to characterize cerebral and retinal infarction and examine outcomes in patients with BAV. Methods and Results Consecutive patients from 1975 to 2015 with BAV (n=5401) were retrospectively identified from the institutional database; those with confirmed cerebral or retinal infarction were analyzed. Infarction occurring after aortic valve replacement was not included. Patients were grouped according to infarction pathogenesis: embolism from a degenerative calcific BAV (BAVi); non-BAV, large artery atherosclerotic or lacunar infarction (LAi); and non-BAV, non-large artery embolic infarction (nLAi). There were 83/5401 (1.5%) patients, mean age 54±12 years and 28% female, with confirmed cerebral or retinal infarction (LAi 23/83 [28%]; nLAi 30/83 [36%]; BAVi 26/83 [31%]; other 4/83 [5%]). Infarction was embolic in 72/83 (87%), and 35/72 (49%) were cardioembolic. CHA2DS2-VASc score was 1.4±1.2 in BAVi (P=0.188 versus nLAi) and 2.3±1.2 in LAi (P=0.005). Recurrent infarction occurred in 41% overall (50% BAVi, P=0.164 and 0.803 versus LAi and nLAi). BAVi was more commonly retinal (39% BAVi versus 13% LAi, P=0.044 versus 0% nLAi, P=0.002). Patients with BAVi and LAi were more likely to have moderate-to-severe aortic stenosis and undergo aortic valve replacement compared with patients with nLAi. Conclusions Cardioembolism, often from degenerative calcification of the aortic valve, is a predominant cause of cerebral and retinal infarction in patients with BAV and is frequently recurrent. Cerebral and retinal infarction should be regarded as a complication of BAV.
Collapse
Affiliation(s)
| | | | - Jeremy J Thaden
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Sorin V Pislaru
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | | | | | | | | |
Collapse
|
11
|
Ibrahim H, Thaden JJ, Fabre KL, Scott CG, Greason KL, Pislaru SV, Nkomo VT. Impact of Atrial Fibrillation on Outcomes in Very Severe Aortic Valve Stenosis. Am J Cardiol 2023; 189:64-69. [PMID: 36508765 DOI: 10.1016/j.amjcard.2022.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/28/2022] [Accepted: 11/17/2022] [Indexed: 12/13/2022]
Abstract
The prevalence and impact of atrial fibrillation (AF) versus sinus rhythm (SR) on outcomes in very severe aortic stenosis (vsAS) of the native valve is unknown. The aim of the study was to determine the prognostic significance of AF in vsAS. A total of 563 patients with vsAS (transaortic valve peak velocity ≥5 m/s) and left ventricular ejection fraction ≥50% were identified retrospectively. Patients were divided by rhythm at the time of index transthoracic echocardiogram (AF: n = 50 [9%] vs SR: n = 513 [91%]). Patients with AF were older (83.1 ± 7.5 vs 72.5 ± 12.2 y, p <0.001) and had no difference in gender distribution (p = 0.49) but had a higher Charlson co-morbidity index (2 [1,3] vs 1 [0,2], p = 0.01). There was no difference in transaortic peak velocity (5.3 ± 0.3 m/s vs 5.4 ± 0.4 m/s, p = 0.13) and left ventricular ejection fraction was comparable (63 ± 7 vs 66 ± 7%, p = 0.01). Age-, gender-, Charlson co-morbidity index-, and time-dependent aortic valve replacement (AVR)-adjusted overall mortality at 5 years was significantly higher in patients with AF than patients with SR (hazard ratio [HR] 1.88 [1.23 to 2.85], p = 0.003). AVR was associated with improved survival (HR = 0.30 [0.22 to 0.42], p <0.001), with no statistically significant interaction of AVR and rhythm (p = 0.36). Outcomes were also compared in the 2 SR:1 AF propensity-matched analyses (100 SR: 50 AF), with matching done according to age, gender, clinical co-morbidities, and year of echocardiogram. In the propensity-matched analysis, age-, gender-, and time-dependent AVR-adjusted all-cause mortality was higher in AF (HR 2.32 [1.41 to 3.82], p <0.001). In conclusion, AF was not uncommon in vsAS and identified a subset of patients at a much higher risk of mortality without AVR.
Collapse
Affiliation(s)
- Hossam Ibrahim
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Katarina L Fabre
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
12
|
Salama AA, Padang R, Thaden JJ, Kane CJ, Elwazir MY, Anand V, McCully RB, Pislaru C, Pislaru SV, Kane GC. Value of a Right Ventricular-Specific Longitudinal Systolic Strain Software Package in Risk Prediction in Patients With Known or Suspected Pulmonary Hypertension. J Am Soc Echocardiogr 2023:S0894-7317(23)00018-4. [PMID: 36669594 DOI: 10.1016/j.echo.2022.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/26/2022] [Accepted: 12/31/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Abdalla A Salama
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Conor J Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; School of Medicine, University College Dublin, Dublin, Ireland
| | - Mohamed Y Elwazir
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
13
|
Alkurashi AK, Thaden JJ, Naser JA, El-Am EA, Pislaru SV, Greason KL, Negrotto SM, Clavel MA, Pellikka PA, Maleszewski JJ, Nkomo VT. Underestimation of Aortic Stenosis Severity by Doppler Mean Gradient during Atrial Fibrillation: Insights from Aortic Valve Weight. J Am Soc Echocardiogr 2023; 36:53-59. [PMID: 36228839 DOI: 10.1016/j.echo.2022.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 08/01/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Doppler mean gradient (MG) can underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) compared with sinus rhythm (SR). Aortic valve weight (AVW) is a flow-independent measure of AS severity. The objective of this study was to determine whether AVW or AVW/MG ratio was increased in AF versus SR in patients with AS. METHODS Excised native aortic valves from 495 consecutive patients (median age, 77 years; interquartile range [IQR], 71-82 years; 40% women), with left ventricular ejection fractions ≥50% who underwent surgical aortic valve replacement for native valve severe AS (aortic valve area ≤ 1 cm2 or indexed aortic valve area ≤ 0.6 cm2/m2) were weighed. Excised AVW/MG ratios were compared in AF versus SR in patients with high-gradient AS (aortic peak velocity ≥ 4 m/sec or MG ≥ 40 mm Hg) and low-gradient AS (aortic peak velocity < 4 m/sec and MG < 40 mm Hg) in sex-specific analyses. RESULTS AF was present in 51 patients (10%; 11 of 51 [22%] had low-gradient AS) and SR in 444 (90%; 23 of 444 [5%] had low-gradient AS). There was no difference in sex distribution between AF and SR. Aortic valve area was not different, but forward stroke volume index and transaortic valve flow rate were lower in AF (P ≤ .002 for all); MG was lower in AF versus SR (median, 46 mm Hg [IQR, 37-50 mm Hg] vs 50 mm Hg [IQR, 44-61 mm Hg]; P < .0001). Overall AVW was not different (median, 2,290 mg [IQR, 1,830-3,063 mg] vs 2,140 mg [IQR, 1,530-2,958 mg]; P = .31), but overall AVW/MG ratio was higher in AF (median, 55 [IQR, 41-67] vs 42 [IQR, 30-55]; P = .001). In sex- and MG-specific analyses, the AVW/MG ratio was higher in AF compared with SR in men with high-gradient AS (median, 58 [IQR, 41-75] vs 51 [IQR, 39-61]; P = .03), but the differences were not statistically significant between AF and SR in other groups. CONCLUSIONS AVW was discordant to Doppler MG in AF compared with SR in men with high-gradient AS. Additional studies of the relationship of MG to other measures of AS severity, such as leaflet fibrosis, are needed.
Collapse
Affiliation(s)
- Adham K Alkurashi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jwan A Naser
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sara M Negrotto
- Department of Cardiology, Parkwest Medical Center, Knoxville, Tennessee
| | - Marie-Annick Clavel
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
14
|
Reddy YNV, Thaden JJ, Nishimura RA. Insights from Simultaneous Echo and Cath Gradients in Rheumatic Compared to Calcific Mitral Stenosis. J Am Soc Echocardiogr 2023; 36:124-125. [PMID: 36414981 DOI: 10.1016/j.echo.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
15
|
Kronzer EK, Eleid MF, Alkhouli MA, Thaden JJ, Padang R, Nkomo VT, Rihal CS, Pislaru SV, Kane GC. Rates of Oropharyngeal and Esophageal Complications During Structural Heart Disease Procedures Under Transesophageal Echocardiography Guidance. J Am Soc Echocardiogr 2022; 36:431-433. [PMID: 36368437 DOI: 10.1016/j.echo.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Ellen K Kronzer
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
16
|
Bi X, Yeung DF, Thaden JJ, Nhola LF, Schaff HV, Pislaru SV, Pellikka PA, Pochettino A, Greason KL, Nkomo VT, Villarraga HR. Characterization of myocardial mechanics and its prognostic significance in patients with severe aortic stenosis undergoing aortic valve replacement. Eur Heart J Open 2022; 2:oeac074. [PMID: 36540107 PMCID: PMC9760549 DOI: 10.1093/ehjopen/oeac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/25/2022] [Accepted: 11/02/2022] [Indexed: 06/17/2023]
Abstract
AIMS Aortic stenosis (AS) induces characteristic changes in left ventricular (LV) mechanics that can be reversed after aortic valve replacement (AVR). We aimed to comprehensively characterize LV mechanics before and after AVR in patients with severe AS and identify predictors of short-term functional recovery and long-term survival. METHODS AND RESULTS We prospectively performed comprehensive strain analysis by 2D speckle-tracking echocardiography in 88 patients with severe AS and LV ejection fraction ≥50% (mean age 71 ± 12 years, 42% female) prior to and within 7 days after AVR. Patients were followed for up to 5.2 years until death from any cause or last encounter. Within days after AVR, we observed an absolute increase in global longitudinal strain (GLS) (-16.0 ± 2.0% vs. -18.5 ± 2.1%, P<0.0001) and a decrease in apical rotation (10.5 ± 4.0° vs. 8.3 ± 2.8°, P = 0.0002) and peak systolic twist (18.2 ± 5.0° vs. 15.5 ± 3.8°, P = 0.0008). A baseline GLS is less negative than -16.2% was 90% sensitive and 67% specific in predicting a ≥ 20% relative increase in GLS. During a median follow-up of 3.8 years, a global circumferential systolic strain rate (GCSRs) less negative than -1.9% independently predicted lower survival. CONCLUSION In patients with severe AS, a reversal in GLS, apical rotation, and peak systolic twist abnormalities towards normal occurs within days of AVR. Baseline GLS is the strongest predictor of GLS recovery but neither was associated with long-term survival. In contrast, abnormal baseline GCSRs are associated with worse outcomes.
Collapse
Affiliation(s)
| | | | - Jeremy J Thaden
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Lara F Nhola
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Alberto Pochettino
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | | |
Collapse
|
17
|
Chao C, Seri A, Fortuin FD, Sweeney JP, Thaden JJ, Eleid M, Alkhouli M, Rihal CR, Holmes DR, Pollak PM, Elsabbagh A, Lester SJ, Oh JK, Banerjee I, Arsanjani R. Topological data analysis identified prognostically-distinct phenotypes in MitraClip patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Topological data analysis (TDA) is the state-of-the-art unsupervised machine learning framework that can provide insight into the dataset and visualize condensed information via the topological network graph. This robust approach was never used to assess the heterogeneous MitraClip population.
Purpose
We aim to develop a TDA model that will identify prognostically-distinct phenogroups in MitraClip patients without a priori knowledge of the population and their outcomes.
Method
Patients who underwent MitraClip (June 2014-September 2020) at Mayo Clinic sites were identified from the institutional database for baseline and follow-up data. Thirteen variables were used for TDA. The topological network graph was created using the Python Scikit-TDA Kepler-Mapper package (v. 2.0.1), and clustering was performed at the graph level with Louvain's modularity method. Kaplan-Meier survival analysis was used to assess the all-cause mortality endpoint of each cluster identified in an unsupervised manner. The dataset with cluster labels was also used to train a Light Gradient Boosted Machine model, and SHapley Additive exPlanations (SHAP) analysis was applied to determine the feature importance.
Results
A total of 389 consecutive patients were included in the final analysis and two major clusters consisting of 384 patients were identified. The mean age was 80.3±8.7 years; 256 (65.8%) were male. The mean Society of Thoracic Surgeons Mitral Valve Replacement risk score was 9.6±6.9%. Fifty-five (14.5%) patients died during the mean follow duration (185 days). Kaplan-Meier analysis showed significant survival differences among the two clusters (HR: 2.38; 95% CI: 1.39–4.06, p=0.001; Figure 1). Clusters 1 (n=195) was associated with > mild residual mitral regurgitation and worse survival performance and was characterized with worse tricuspid regurgitation severity, a higher proportion of patients with atrial fibrillation/flutter, anterior leaflet prolapse, and mitral annular/leaflet calcification, as summarized in Table 1.
Conclusion
TDA can identify distinct phenotype clusters with prognostic significance in MitraClip patients based on mitral valve morphology and clinical risk factors. This simple model can facilitate clinical risk stratification for MitraClip patients regarding procedural success and survival performance.
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- C Chao
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - A Seri
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - F D Fortuin
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - J P Sweeney
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - J J Thaden
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - M Eleid
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - M Alkhouli
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - C R Rihal
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - D R Holmes
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - P M Pollak
- Mayo Clinic , Jacksonville , United States of America
| | - A Elsabbagh
- Mayo Clinic , Jacksonville , United States of America
| | - S J Lester
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - J K Oh
- Mayo Clinic, Cardiovascular Diseases , Rochester , United States of America
| | - I Banerjee
- Mayo Clinic Arizona , Scottsdale , United States of America
| | - R Arsanjani
- Mayo Clinic Arizona , Scottsdale , United States of America
| |
Collapse
|
18
|
Chadderdon SM, Eleid MF, Thaden JJ, Makkar R, Nakamura M, Babaliaros V, Greenbaum A, Gleason P, Kodali S, Hahn RT, Koulogiannis KP, Marcoff L, Grayburn P, Smith RL, Song HK, Lim DS, Gray WA, Hawthorne K, Deuschl F, Narang A, Davidson C, Zahr FE. Three-Dimensional Intracardiac Echocardiography for Tricuspid Transcatheter Edge-to-Edge Repair. Struct Heart 2022; 6:100071. [PMID: 37288338 PMCID: PMC10242583 DOI: 10.1016/j.shj.2022.100071] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/08/2022] [Accepted: 06/17/2022] [Indexed: 06/09/2023]
Abstract
Patients with severe symptomatic tricuspid regurgitation face a significant dilemma in treatment options, as the yearly mortality with medical therapy and the surgical mortality for tricuspid repair or replacement are high. Transcatheter edge-to-edge repair (TEER) for the tricuspid valve is becoming a viable option in patients, although procedural success is dependent on high-quality imaging. While transesophageal echocardiography remains the standard for tricuspid TEER procedures, intracardiac echocardiography (ICE) with three-dimensional (3D) multiplanar reconstruction (MPR) has many theoretical and practical advantages. The aim of this article was to describe the in vitro wet lab-based imaging work done to facilitate the best approach to 3D MPR ICE imaging and the procedural experience gained with 3D MPR ICE in tricuspid TEER procedures with the PASCAL device.
Collapse
Affiliation(s)
- Scott M. Chadderdon
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Mackram F. Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy J. Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Vasilis Babaliaros
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia, USA
| | - Adam Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia, USA
| | - Patrick Gleason
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia, USA
| | - Susheel Kodali
- Structural Heart & Vascular Center, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA
| | - Rebecca T. Hahn
- Structural Heart & Vascular Center, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA
| | - Konstantinos P. Koulogiannis
- Department of Cardiovascular Medicine, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Leo Marcoff
- Department of Cardiovascular Medicine, Morristown Medical Center/Atlantic Health System, Morristown, New Jersey, USA
| | - Paul Grayburn
- Baylor Scott & White The Heart Hospital, Plano, Texas, USA
| | | | - Howard K. Song
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - D. Scott Lim
- Division of Cardiology, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - William A. Gray
- Department of Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Katie Hawthorne
- Department of Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania, USA
| | | | - Akhil Narang
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Charles Davidson
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Firas E. Zahr
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
19
|
Abstract
Background Many patients with symptomatic severe aortic stenosis do not undergo aortic valve replacement (AVR) despite clinical guidelines. This study analyzed the association of managing provider type with cardiac specialist follow-up, AVR, and mortality for patients with newly diagnosed severe aortic stenosis (sAS). Methods and Results We identified adults with newly diagnosed sAS per echocardiography performed between January 2017 and March 2019 using Optum electronic health record data. We then selected from those meeting all eligibility criteria patients managed by a primary care provider (n=1707 [25%]) or cardiac specialist (n=5039 [75%]). We evaluated the association of managing provider type with cardiac specialist follow-up, AVR, and mortality, as well as the independent association of cardiac specialist follow-up and AVR with mortality, within 1 year of echocardiography detecting sAS. A subgroup analysis was limited to patients with symptomatic sAS. Patient characteristics and comorbidities at baseline were used for covariate-adjusted cause-specific and multivariable Cox proportional hazard models assessing group differences in outcomes by managing provider type. An adjusted Cox proportional hazard model with additional time-dependent covariates for follow-up and AVR was used to assess these practices' association with mortality. Within 1 year of echocardiography detecting sAS, data revealed that primary care provider management was associated with lower rates of cardiac specialist follow-up (hazard ratio [HR], 0.47 [95% CI, 0.43-0.50], P<0.0001) and AVR (HR, 0.58 [95% CI, 0.53-0.64], P<0.0001) and with higher 1-year mortality (HR, 1.45 [95% CI, 1.26-1.66], P<0.0001). Cardiac specialist follow-up and AVR were independently associated with lower mortality (follow-up: HR, 0.55 [95% CI, 0.48-0.63], P<0.0001; AVR: HR, 0.70 [95% CI, 0.60-0.83], P<0.0001). Results were similar for patients with symptomatic sAS. All analyses were adjusted for baseline patient characteristics and comorbidities. Conclusions For patients newly diagnosed with sAS, we observed differences in rates of cardiac specialist follow-up and AVR and risk of mortality between primary care provider- versus cardiologist-managed patients with sAS. In addition, a lower likelihood of receiving follow-up and AVR was independently associated with higher mortality.
Collapse
Affiliation(s)
| | | | | | | | | | - Jeremy J Thaden
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| |
Collapse
|
20
|
Simard T, Reddy YNV, Thaden JJ, Padang R, Michelena HI, Nkomo VT, Lloyd JW, El Sabbagh A, Nishimura RA, Reeder GS, Guerrero M, Alkhouli M, Rihal CS, Eleid MF. Atrial mitral regurgitation: Characteristics and outcomes of transcatheter mitral valve edge-to-edge repair. Catheter Cardiovasc Interv 2022; 100:133-142. [PMID: 35535629 DOI: 10.1002/ccd.30224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/28/2022] [Accepted: 04/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mitral transcatheter edge-to-edge repair (MTEER) is an established therapeutic approach for mitral regurgitation (MR). Functional mitral regurgitation originating from atrial myopathy (A-FMR) has been described. OBJECTIVES We sought to assess the clinical, echocardiographic and hemodynamic considerations in A-FMR patients undergoing MTEER. METHODS From 2014 to 2020, patients undergoing MTEER for degenerative MR (DMR), functional MR (FMR), and mixed MR were assessed. A-FMR was defined by the presence of MR > moderate in severity; left ventricular (LV) ejection fraction (LVEF) ≥ 50%; and severe left atrial (LA) enlargement in the absence of LV dysfunction, leaflet pathology, or LV tethering. The diagnosis of A-FMR (vs. ventricular-FMR [V-FMR]) was confirmed by three independent echocardiographers. Baseline characteristics, procedural outcomes as well as clinical and echocardiographic follow-up are reported. Device success was defined as final MR grade ≤ moderate; MR reduction ≥1 grade; and final transmitral gradient <5 mmHg. RESULTS 306 patients underwent MTEER, including DMR (62%), FMR (19%), and mixed MR (19%). FMR cases included 37 (63.8%) V-FMR and 21 (36.2%) A-FMR. Tricuspid regurgitation (≥ moderate) was higher in A-FMR (80.1%) compared to V-FMR (54%) and DMR (42%). Device success did not significantly differ between A-FMR and V-FMR (57% vs. 73%, p = 0.34) or DMR (57% vs. 64%, p = 1.0). The A-FMR cohort was less likely to achieve ≥3 grades of MR reduction compared to V-FMR (19% vs. 54%, p = 0.01) and DMR (19% vs. 49.7%, p = 0.01). Patients with V-FMR and DMR demonstrated significant reductions in mean left atrial pressure (LAP) and peak LA V-wave, though A-FMR did not (LAP -0.24 ± 4.9, p = 0.83; peak V-wave -1.76 ± 9.1, p = 0.39). In follow-up, echocardiographic and clinical outcomes were similar. CONCLUSIONS In patients undergoing MTEER, A-FMR represents one-third of FMR cases. A-FMR demonstrates similar procedural success but blunted acute hemodynamic responses compared with DMR and V-FMR following MTEER. Dedicated studies specifically considering A-FMR are needed to discern the optimal therapeutic approaches.
Collapse
Affiliation(s)
- Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - James W Lloyd
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Abdallah El Sabbagh
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Jacksonville, Florida, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
21
|
Hassan AH, Alkhouli MA, Thaden JJ, Guerrero ME. 3D Intracardiac Echo-Guided Transseptal Mitral Valve-in-Valve Under Conscious Sedation: Minimalistic Approach TMVR for Same-Day Discharge. JACC Cardiovasc Interv 2022; 15:e103-e105. [PMID: 35430170 DOI: 10.1016/j.jcin.2022.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Abdalla H Hassan
- Mayo Clinic College of Medicine and Science, Department of Cardiovascular Medicine, Rochester, Minnesota, USA.
| | - Mohamad A Alkhouli
- Mayo Clinic College of Medicine and Science, Department of Cardiovascular Medicine, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Mayo Clinic College of Medicine and Science, Department of Cardiovascular Medicine, Rochester, Minnesota, USA
| | - Mayra E Guerrero
- Mayo Clinic College of Medicine and Science, Department of Cardiovascular Medicine, Rochester, Minnesota, USA
| |
Collapse
|
22
|
Naser JA, Crestanello JA, Nkomo VT, Luis SA, Thaden JJ, Geske JB, Anderson JH, Sinak LJ, Michelena HI, Pislaru SV, Padang R. Immobile Leaflets at Time of Bioprosthetic Valve Implantation: A Novel Risk Factor for Early Bioprosthetic Failure: A Novel Risk Factor for Early Bioprosthetic Failure. Heart Lung Circ 2022; 31:1166-1175. [PMID: 35339372 DOI: 10.1016/j.hlc.2022.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/18/2022] [Accepted: 02/16/2022] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The clinical implications of finding immobile leaflet(s) at the time of bioprosthetic valve implantation but with acceptable prosthetic haemodynamics are uncertain. We sought to determine the characteristics of such patients and their impact on outcome. METHODS Patients with immobile leaflet at the time of surgical bioprosthetic valve implantation were identified retrospectively by a systematic search of an institutional echocardiography database (2010-2020). Intraoperative echocardiograms were reviewed de-novo to confirm immobile leaflet(s) at the time of implantation. Cases were matched 1:2 to controls with normal bioprosthetic leaflets motion for age, sex, prosthesis position, prosthesis model, size, year of implantation, and pre-implantation left ventricular ejection fraction. Proportional hazards method was used to analyse the composite endpoint of stroke, valve thrombosis or re-intervention. RESULTS Immobile leaflet at the time of bioprosthetic valve implantation were found in 26 patients (median age 71 ys 39% males) following tricuspid (n=13), mitral (n=11) and aortic (n=2) valve replacements; 96% received porcine prostheses; prosthesis size was 27 mm or larger in 92%. Immobile leaflet were recorded on intraoperative reports in 16 (62%) cases. It resulted in elevated gradient or mild-moderate prosthetic regurgitation in three (12%), but none led to immediate corrective action intraoperatively. At median follow-up of 21 (4-50) months, presence of immobile leaflet was associated with composite clinical endpoint of stroke, valve thrombosis or re-intervention (hazard ratio 6.8 95% CI 1.8-25.2 p<0.01) compared to controls. CONCLUSION Immobile leaflet immediately post-bioprosthetic valve implantation is frequently under-recognised intraoperatively and appears to be associated with early bioprosthetic dysfunction and worse clinical outcome.
Collapse
Affiliation(s)
- Jwan A Naser
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lawrence J Sinak
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
23
|
Kronzer EK, Thaden JJ, Alkhouli MA, Eleid MF, Nkomo VT, Pislaru SV, Kane G. Rate of transesophageal echocardiography related complications during 1229 TEE-guided structural heart disease procedures. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background/Introduction: Transesophageal echocardiography (TEE) has long provided excellent diagnostic imaging of left-sided valvular pathology with an excellent safety profile; however, recent data has suggested an increased risk of injury related to TEE guidance.
Purpose
This study aims to evaluate the incidence and nature of TEE-related oropharyngeal or esophageal complications in patients undergoing TEE-guided structural heart procedures and identify associated risk factors.
Methods
We reviewed consecutive patients undergoing TEE-guided structural heart procedures from 2005-2020. All procedures were performed under general anesthesia. TEE-related oropharyngeal or esophageal complications were defined as those occurring within 30 days of the procedure resulting in i) persistent dysphagia, odynophagia, or upper gastrointestinal bleeding requiring prolonged endotracheal intubation, therapeutic endoscopic or surgical intervention, or diagnostic imaging that demonstrated oropharyngeal or esophageal injury. ii) upper gastrointestinal bleed requiring transfusion, hemodynamic compromise warranting mechanical or pharmacologic support; or iii) oropharyngeal or esophageal complications leading to death. For multivariate analysis, all variables with a p < 0.15 at univariate analysis were included in the model.
Results
Among 1229 adult patients undergoing TEE-guided structural heart procedures between 2005-2020, 274 underwent a transcatheter aortic valve replacement (TAVR) with the remaining 955 undergoing either mitral valve transcatheter edge-to-edge repair (mTEER, n = 278), mitral paravalvular leak closure (PVLC, n = 354), mitral valve-in-valve replacement (VIV, n = 41), or left atrial appendage closure (LAAO, n = 282). Of these, 6 (0.5 %) had TEE-related complications; 0% TAVR, 0% VIV, 0.36% LAAO, 0.28% PVLC, 1.41% mTEER (p = 0.14). Of the six patients with complications 3 required at least one day of prolonged tracheal intubation and one a blood transfusion. None required surgical repair. Factors associated with increased complication risk (Table) included a prior history of gastrointestinal bleed (Odds ratio 5.44 [0.98-30.04; p = 0.05]) and longer procedural time (OR per 30 min 1.15 [1.01-1.31, p = 0.03]). Patients undergoing mTEER had an increased risk of complication (OR 6.76 [1.23-37.1 p = 0.03]) and longer procedural time (OR per 30 mins 1.15[1.01-1.31, p = 0.04]) compared to other all other procedures.
Conclusion(s): In a large series of patients undergoing cardiac structural interventions under general anesthesia with TEE-guidance, rates of TEE-induced injury were low. Risk of oropharyngeal or esophageal complications was increased with longer procedure times, prior gastrointestinal bleeding history, increased age, increased pre-procedural creatinine, procedural type being mTEER and in male patients, lower height. Abstract Table
Collapse
Affiliation(s)
- EK Kronzer
- Mayo Clinic, Rochester, United States of America
| | - JJ Thaden
- Mayo Clinic, Rochester, United States of America
| | - MA Alkhouli
- Mayo Clinic, Rochester, United States of America
| | - MF Eleid
- Mayo Clinic, Rochester, United States of America
| | - VT Nkomo
- Mayo Clinic, Rochester, United States of America
| | - SV Pislaru
- Mayo Clinic, Rochester, United States of America
| | - G Kane
- Mayo Clinic, Rochester, United States of America
| |
Collapse
|
24
|
Roslan AB, Naser JA, Nkomo VT, Padang R, Lin G, Pislaru C, Greason KL, Pellikka PA, Eleid MF, Thaden JJ, Miller FA, Pislaru SV. Performance of Echocardiographic Algorithms for Assessment of High Aortic Bioprosthetic Valve Gradients. J Am Soc Echocardiogr 2022; 35:682-691.e2. [DOI: 10.1016/j.echo.2022.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 01/28/2022] [Accepted: 01/30/2022] [Indexed: 11/26/2022]
|
25
|
Simard T, Lloyd J, Crestanello J, Thaden JJ, Alkhouli M, Guerrero M, Rihal CS, Eleid MF. Five-year outcomes of transcatheter mitral valve implantation and redo surgery for mitral prosthesis degeneration. Catheter Cardiovasc Interv 2022; 99:1659-1665. [PMID: 35019211 DOI: 10.1002/ccd.30059] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 12/05/2021] [Accepted: 12/20/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Transcatheter mitral valve replacement (TMVR) has emerged as a feasible alternative to redo surgical mitral valve replacement (SMVR) in patients with degenerated mitral prostheses, with limited comparative data. METHODS We compared mid-term outcomes in patients with degenerated mitral valve prostheses treated with TMVR or redo SMVR. The primary endpoint was survival at 5 years of follow-up. RESULTS From 2014 to 2020, 215 patients presented with degenerated mitral valve prostheses. Of whom 86 (40%) were treated with TMVR (75[87%] valve-in-valve and 11[13%] valve-in-ring), while 129 patients (60%) underwent SMVR. The TMVR cohort was older (p < 0.0001), more symptomatic (p = 0.0003) and had more chronic lung disease (p = 0.02), worse renal function (p = 0.02) and higher right ventricular systolic pressures (p < 0.0001). Thirty-day mortality was lower with TMVR versus SMVR (2.4% vs. 10.2%, OR4.69 [95% CI 1.25-30.5], p = 0.04) with probability of mortality at 1, 2, and 5 years being 14.7% versus 17.5%, 24.5% versus 20.7%, and 49.9% versus 34.0%, respectively. Mode of prosthesis degeneration, baseline hemodynamics, and valve selection did not appreciably impact outcomes. CONCLUSIONS TMVR for degenerated mitral prostheses is associated with better early survival compared to SMVR despite a greater burden of comorbidities. In contrast, 5 year survival rates appear more favorable with SMVR, which may reflect the lower baseline risk of this population. Clinical, hemodynamic, and echocardiographic follow-up support the mid-term durability of TMVR for degenerated mitral prostheses. Further dedicated studies, however, are required to optimize outcomes in this challenging patient cohort and to navigate the choice of approach for each individual patient.
Collapse
Affiliation(s)
- Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - James Lloyd
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Juan Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
26
|
Mahowald MK, Nishimura RA, Pislaru SV, Mankad SV, Nkomo VT, Padang R, Thaden JJ, Alkhouli M, Guerrero M, Rihal CS, Eleid MF. Reduction in Right Atrial Pressures Is Associated With Hemodynamic Improvements After Transcatheter Edge-to-Edge Repair of the Tricuspid Valve. Circ Cardiovasc Interv 2021; 14:e010557. [PMID: 34814697 DOI: 10.1161/circinterventions.121.010557] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Investigational transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR) has shown promise as an alternative to surgery, but factors influencing outcomes, optimal patient selection, and procedural timing remain incompletely defined. Given the limitations of determining TR severity by conventional echocardiography, our objectives were to determine whether invasive right atrial (RA) pressures performed during the procedure are related to patient outcomes. METHODS This study was a retrospective review of patients who underwent off-label tricuspid TEER using MitraClip (Abbott Vascular, Menlo Park, CA) for significant TR at a single institution. Intraprocedural mean RA pressure, RA peak V-wave, RA pressure nadir, and systolic increase in RA pressure (XV height) were recorded. RESULTS Thirty-eight patients underwent tricuspid TEER; 33 underwent concomitant mitral TEER for mitral regurgitation. The study cohort was 39% female with a mean age of 78.6±14.3 years. Median follow-up was 339 days (interquartile range, 100-601). Any reduction in mean RA pressure, RA peak V-wave, RA nadir, and XV height occurred in 74%, 82%, 45%, and 87% of patients, respectively. At 1 year, event-free survival was 47%. Postprocedure XV height correlated with TR severity as determined by echocardiography (P<0.0001). The highest quartile of postprocedure XV height (>8 mm Hg) had worse event-free survival compared with those who had concluding XV height ≤8 mm Hg (P=0.02). Attainment of a concluding XV height less than or equal to median value was associated with a lower creatinine the next day (1.27±0.47 versus 1.64±0.47 mg/dL, P=0.04). CONCLUSIONS Intraprocedural XV height correlates with TR severity after tricuspid TEER, and lower concluding pressures are associated with improved outcomes. Analysis of RA pressures may serve as a complementary tool for the evaluation of disease severity and procedural guidance.
Collapse
Affiliation(s)
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | | |
Collapse
|
27
|
Kato N, Thaden JJ, Miranda WR, Scott CG, Sarano ME, Greason KL, Pellikka PA. Impact of aortic valve replacement for severe aortic stenosis on organic and functional mitral regurgitation. ESC Heart Fail 2021; 8:5482-5492. [PMID: 34652057 PMCID: PMC8712890 DOI: 10.1002/ehf2.13649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/26/2021] [Accepted: 09/25/2021] [Indexed: 11/10/2022] Open
Abstract
Aims Concurrent mitral regurgitation (MR) influences treatment considerations in patients with severe aortic stenosis (sAS). Limited information exists regarding haemodynamic effects of sAS on MR severity and outcome of these patients. We assessed the impact of aortic valve replacement (AVR) on MR according to mechanism in patients with sAS and MR. Methods and results In patients with sAS who received surgical or transcatheter AVR from 2008 to 2017, those with effective mitral regurgitant orifice area (ERO) ≥ 10 mm2 prior to AVR were evaluated. The change in MR after AVR was considered significant when there was at least one grade difference. We compared the all‐cause mortality of patients with and without improvement in MR. Of 234 patients with sAS and MR (age 80 ± 9 years, 52% male, ERO 19 ± 7 mm2), organic and functional MR were present in 166 (71%) and 68 (29%), respectively. MR improved in 136 (58%); improvement occurred with similar frequency in organic versus functional MR (59% and 57%, P = 0.88). Associated determinants were absence of atrial fibrillation in organic MR [odds ratio (OR) 2.09, 95% confidence interval (CI) 1.00–4.37; P = 0.049] and indexed aortic valve area (iAVA) ≤ 0.40 cm2 in functional MR (OR 3.28, 95% CI 1.13–9.47; P = 0.028). In the overall cohort, mitral annulus diameter < 3 cm (OR 1.74, 95% CI 1.02–2.97; P = 0.041) and QRS duration < 115 ms (OR 1.73, 95% CI 1.00–2.98; P = 0.049) were independently associated with improvement in MR. During median follow‐up of 3.5 years, lack of improvement in MR was not associated with higher mortality in the overall cohort of patients with ERO ≥ 20 mm2 [adjusted hazard ratio (HR) 1.71, 95% CI 0.90–3.27; P = 0.10, adjusted for age, New York Heart Association III or IV, diabetes, and creatinine ≥ 2.0 mg/dL]. Lack of improvement in organic MR was associated with higher mortality (adjusted HR 3.36, 95% CI 1.40–8.05; P < 0.01). In patients with functional MR, change in MR was not associated with mortality (HR 1.24, 95% CI 0.44–3.47; P = 0.68). Conclusions In nearly 60% of patients with sAS and MR, MR improved after AVR, even in the majority of patients with organic MR. Absence of atrial fibrillation in organic MR, iAVA ≤ 0.40 cm2 in functional MR, and mitral annulus diameter < 3 cm and QRS duration < 115 ms in the overall population were associated with MR improvement. Post‐operative improvement in organic MR was associated with better survival.
Collapse
Affiliation(s)
- Nahoko Kato
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | | | - Maurice E Sarano
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| |
Collapse
|
28
|
Alkurashi AK, Pislaru SV, Thaden JJ, Collins JD, Foley TA, Greason KL, Eleid MF, Sandhu GS, Alkhouli MA, Asirvatham SJ, Cha YM, Williamson EE, Crestanello JA, Pellikka PA, Oh JK, Nkomo VT. Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2021; 35:116-123. [PMID: 34506919 DOI: 10.1016/j.echo.2021.08.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/17/2021] [Accepted: 08/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography. RESULTS Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76-86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm2/m2 [IQR, 0.39-0.47 cm2/m2] vs 0.46 cm2/m2 [IQR, 0.41-0.51 cm2/m2], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803-4,030 AU] vs 2,722 AU [IQR, 2,180-3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS. CONCLUSIONS AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.
Collapse
Affiliation(s)
- Adham K Alkurashi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Thomas A Foley
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet S Sandhu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
29
|
Eleid MF, Alkhouli M, Thaden JJ, Zahr F, Chadderdon S, Guerrero M, Reeder GS, Rihal CS. Utility of Intracardiac Echocardiography in the Early Experience of Transcatheter Edge to Edge Tricuspid Valve Repair. Circ Cardiovasc Interv 2021; 14:e011118. [PMID: 34474586 DOI: 10.1161/circinterventions.121.011118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Firas Zahr
- Department of Cardiovascular Medicine, Oregon Health and Sciences University, Portland (F.Z., S.C.)
| | - Scott Chadderdon
- Department of Cardiovascular Medicine, Oregon Health and Sciences University, Portland (F.Z., S.C.)
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| |
Collapse
|
30
|
Welle GA, El-Sabawi B, Thaden JJ, Greason KL, Klarich KW, Nkomo VT, Alkhouli MA, Guerrero ME, Crestanello JA, Gulati R, Rihal CS, Eleid MF. Effect of eliminating pre-discharge transthoracic echocardiogram on outcomes after TAVR. Catheter Cardiovasc Interv 2021; 99:861-866. [PMID: 34388299 DOI: 10.1002/ccd.29929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 07/12/2021] [Accepted: 08/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The aim of this study was to determine the safety of eliminating the pre-discharge transthoracic echocardiogram (TTE) on 30-day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND TTE is utilized before, during, and after TAVR. Post-procedural, pre-discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR. METHODS Patients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre-discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post-TAVR. RESULTS A total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre-discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre-discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre-discharge TTE group and none in the group without pre-discharge TTE at 30-day follow-up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre-discharge TTE and those without (28.1% vs. 25.3%, P = 0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P = 0.71). CONCLUSIONS Elimination of the pre-discharge TTE is safe and associated with comparable 30-day outcomes to routine pre-discharge TTE. These findings have implication for TAVR practice cost-efficiency and health care utilization.
Collapse
Affiliation(s)
- Garrett A Welle
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota, USA
| | - Bassim El-Sabawi
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Kevin L Greason
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Kyle W Klarich
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mayra E Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
31
|
Alsidawi S, Khan S, Pislaru SV, Thaden JJ, El-Am EA, Scott CG, Morant K, Oguz D, Luis SA, Padang R, Lane CE, McCully RB, Pellikka PA, Oh JK, Nkomo VT. High Prevalence of Severe Aortic Stenosis in Low-Flow State Associated With Atrial Fibrillation. Circ Cardiovasc Imaging 2021; 14:e012453. [PMID: 34250815 DOI: 10.1161/circimaging.120.012453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a low-flow state and may underestimate aortic stenosis (AS) severity. Single-high Doppler signals (HS) consistent with severe AS (peak velocity ≥4 m/s or mean gradient ≥40 mm Hg) are averaged down in current practice. The objective for the study was to determine the significance of HS in AF low-gradient AS (LGAS). METHODS One thousand five hundred forty-one patients with aortic valve area ≤1 cm2 and left ventricular ejection fraction ≥50% were identified and classified as high-gradient AS (HGAS) (≥40 mm Hg) and LGAS (<40 mm Hg), and AF versus sinus rhythm (SR). Available computed tomography aortic valve calcium scores (AVCS) were retrieved from the medical record. Outcomes were assessed. RESULTS Mean age was 76±11 years, female 47%. Mean gradient was 51±12 in SR-HGAS, 48±10 in AF-HGAS, 31±5 in SR-LGAS, and 29±7 mm Hg in AF-LGAS, all P≤0.001 versus SR-HGAS; HS were present in 33% of AF-LGAS. AVCS were available in 34%. Compared with SR-HGAS (2409 arbitrary units; interquartile range, 1581-3462) AVCS were higher in AF-HGAS (2991 arbitrary units; IQR1978-4229, P=0.001), not different in AF-LGAS (2399 arbitrary units; IQR1817-2810, P=0.47), and lower in SR-LGAS (1593 arbitrary units; IQR945-1832, P<0.001); AVCS in AF-LGAS were higher when HS were present (P=0.048). Compared with SR-HGAS, the age-, sex-, comorbidity index-, and time-dependent aortic valve replacement-adjusted mortality risk was higher in AF-HGAS (hazard ratio=1.82 [1.40-2.36], P<0.001) and AF-LGAS with HS (hazard ratio=1.54 [1.04-2.26], P=0.03) but not different in AF-LGAS without HS or SR-LGAS (both P=not significant). CONCLUSIONS Severe AS was common in AF-LGAS. AVCS in AF-LGAS were not different from SR-HGAS. AVCS were higher and mortality worse in AF-LGAS when HS were present.
Collapse
Affiliation(s)
- Said Alsidawi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,Minneapolis Heart Institute, Minneapolis, MN (S.A.)
| | - Sana Khan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,University of Minnesota, Minneapolis, MN (S.K.)
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,Department of Medicine, Indiana University School of Medicine, Indianapolis (E.A.E.-A.)
| | | | - Kareem Morant
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,North York General Hospital, Toronto, ON, Canada (K.M.)
| | - Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Colleen E Lane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| |
Collapse
|
32
|
Oguz D, Padang R, Pislaru SV, Nkomo VT, Mankad SV, Alkhouli M, Guerrero M, Reeder GS, Eleid MF, Rihal CS, Thaden JJ. Clinical predictors and impact of postoperative mean gradient on outcome after transcatheter edge-to-edge mitral valve repair. Catheter Cardiovasc Interv 2021; 98:E932-E937. [PMID: 34245208 DOI: 10.1002/ccd.29867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/31/2021] [Accepted: 07/01/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The predictors and clinical significance of increased Doppler-derived mean diastolic gradient (MG) following transcatheter edge-to-edge mitral valve repair (MVTEER) remain controversial. OBJECTIVE We sought to examine baseline correlates of Doppler-derived increased MG post-MVTEER and its impact on intermediate-term outcomes. METHODS Patients undergoing MVTEER were analyzed retrospectively. Post-MVTEER increased MG was defined as >5 mmHg or aborted clip implantation due to increased MG intraprocedurally. Baseline MG and 3D-guided mitral valve area (MVA) by planimetry were retrospectively available in 233 and 109 patients. RESULTS 243 patients were included; 62 (26%) had MG > 5 mmHg post-MVTEER or aborted clip insertion, including 7 (11%) that had aborted clip implantation. Mortality occurred in 63 (26%) during a median follow up of 516 days (IQR 211, 1021). Increased post-MVTEER MG occurred more frequently in females (44% vs. 16%, p < 0.001), those with baseline MVA <4.0 cm2 (71% vs. 16%), baseline MG ≥4 mmHg (61% vs. 20%), or multiple clips implanted (33% vs. 21%, p = 0.04). Increased post-MVTEER MG was associated with increased subsequent mortality compared to those with normal gradient (HR 1.91 95% CI 1.15-3.18 p = 0.016) as was aborted clip insertion compared to all others (HR 5.23 95% CI 2.06-13.28 p < 0.001). CONCLUSIONS Smaller baseline MVA and increased baseline MG are associated with increased MG post-MVTEER and patients with a Doppler-derived post-MVTEER MG >5 mmHg suffered excess subsequent mortality. In high risk patients considered for MVTEER, identification of those at risk of iatrogenic mitral stenosis with MVTEER is important as they may be optimally treated with alternate surgical or transcatheter therapies.
Collapse
Affiliation(s)
- Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
33
|
Oguz D, Padang R, Rashedi N, Pislaru SV, Nkomo VT, Mankad SV, Malouf JF, Guerrero M, Reeder GS, Eleid MF, Rihal CS, Thaden JJ. Risk for Increased Mean Diastolic Gradient after Transcatheter Edge-to-Edge Mitral Valve Repair: A Quantitative Three-Dimensional Transesophageal Echocardiographic Analysis. J Am Soc Echocardiogr 2021; 34:595-603.e2. [DOI: 10.1016/j.echo.2021.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 01/22/2021] [Accepted: 01/22/2021] [Indexed: 02/08/2023]
|
34
|
Lane CE, Thaden JJ, Eleid MF. The Dynamic Duo: Intracardiac and Transesophageal Echocardiography in Transcatheter Edge-to-Edge Tricuspid Valve Repair. JACC Cardiovasc Interv 2021; 14:e125-e126. [PMID: 33933388 DOI: 10.1016/j.jcin.2021.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Colleen E Lane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
35
|
Naser JA, Kucuk HO, Ciobanu AO, Jouni H, Oguz D, Thaden JJ, Pislaru C, Pellikka PA, Foley TA, Eleid MF, Muraru D, Nkomo VT, Pislaru SV. Atrial fibrillation is associated with large beat-to-beat variability in mitral and tricuspid annulus dimensions. Eur Heart J Cardiovasc Imaging 2021:jeab033. [PMID: 33724363 DOI: 10.1093/ehjci/jeab033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS Beat-to-beat variability in cycle length is well-known in atrial fibrillation (Afib); whether this also translates to variability in annulus size remains unknown. Defining annulus maximal size in Afib is critical for accurate selection of percutaneous devices given the frequent association with mitral and tricuspid valve diseases. METHODS AND RESULTS Images were obtained from 170 patients undergoing 3D echocardiography [100 (50 sinus rhythm (SR) and 50 Afib) for mitral annulus (MA) and 70 (35 SR and 35 Afib) for tricuspid annulus (TA)]. Images were analysed for differences in annular dynamics with a commercially available software. Number of cardiac cycles analysed was 567 in mitral valve and 346 in tricuspid valve. Median absolute difference in maximal MA area over four to six cycles was 1.8 cm2 (range 0.5-5.2 cm2) in Afib vs. 0.8 cm2 (range 0.1-2.9 cm2) in SR, P < 0.001. Maximal MA area was observed within 30-70% of the R-R interval in 81% of cardiac cycles in SR and in 73% of cycles in Afib. Median absolute difference in maximal TA area over four to six cycles was 1.4 cm2 (range 0.5-3.6 cm2) in Afib vs. 0.7 cm2 (range 0.3-1.7 cm2) in SR, P < 0.001. Maximal TA area was observed within 60-100% of the R-R interval in 81% of cardiac cycles in SR, but only in 49% of cycles in Afib. CONCLUSION MA and TA reach maximal size within a broad time interval centred around end-systole and end-diastole, respectively, with significant beat-to-beat variability. Afib leads to a larger beat-to-beat variability in both timing of occurrence and values of annulus size than in SR.
Collapse
Affiliation(s)
- Jwan A Naser
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Hilal Olgun Kucuk
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Andrea O Ciobanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- University and Emergency Hospital Bucharest, Bucharest, Romania
| | - Hayan Jouni
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Thomas A Foley
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Denisa Muraru
- IRCCS, Instituto Auxologico Italiano, S. Luca Hospital, University of Milano-Bicocca, Milan, Italy
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| |
Collapse
|
36
|
Anand V, Thaden JJ, Pellikka PA, Kane GC. Safe Operation of an Echocardiography Practice During the COVID-19 Pandemic: Single-Center Experience. Mayo Clin Proc 2021; 96:531-536. [PMID: 33673905 PMCID: PMC7768215 DOI: 10.1016/j.mayocp.2020.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/22/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
37
|
Bi X, Yeung DF, Salah HM, Arciniegas Calle MC, Thaden JJ, Nhola LF, Schaff HV, Pislaru SV, Pellikka PA, Pochettino A, Greason KL, Nkomo VT, Villarraga HR. Dissecting myocardial mechanics in patients with severe aortic stenosis: 2-dimensional vs 3-dimensional-speckle tracking echocardiography. BMC Cardiovasc Disord 2020; 20:33. [PMID: 32000672 PMCID: PMC6993452 DOI: 10.1186/s12872-020-01336-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/09/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Aortic stenosis (AS) causes left ventricular (LV) pressure overload, leading to adverse LV remodeling and dysfunction. Identifying early subclinical markers of LV dysfunction in patients with significant AS is critical as this could provide support for earlier intervention, which may result in improved long-term outcomes. We therefore examined the impact of severe AS and its consequent increase in LV afterload on myocardial deformation and rotational mechanics by 2-dimensional (2D) and 3-dimensional (3D) speckle-tracking echocardiography.
Methods
We prospectively measured various strain parameters in 168 patients (42% female, mean age 72 ± 12 years) with severe AS and LV ejection fraction (EF) ≥50%, and compared them to normal values found in literature. 2D and 3D images were analyzed for global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), basal rotation, apical rotation, and peak systolic twist. We further assessed the degree of concordance between 2D and 3D strain, and examined their association with measures of LV preload and afterload.
Results
Patients with severe AS exhibited significantly lower GLS and GRS but higher GCS, apical rotation, and twist by 2D and 3D echocardiography compared with published normal values (P = 0.003 for 3D twist, P < 0.001 for all others). Agreement between 2D- and 3D-GLS by concordance correlation coefficient was 0.49 (95% confidence interval: 0.39–0.57). GLS was correlated with valvulo-arterial impedance, a measure of LV afterload (r = 0.34, p < 0.001 and r = 0.23, p = 0.003, respectively).
Conclusion
Patients with severe AS demonstrated lower-than-normal GLS and GRS but appear to compensate with higher-than-normal GCS, apical rotation, and twist in order to maintain a preserved LVEF. GLS showed a modest correlation with valvulo-arterial impedance.
Collapse
|
38
|
Welle GA, El-Sabawi B, Thaden JJ, Greason KL, Klarich KW, Nkomo VT, Alkhouli MA, Guerrero ME, Crestanello JA, Holmes DR, Rihal CS, Eleid MF. Effect of a fourth-generation transcatheter valve enhanced skirt on paravalvular leak. Catheter Cardiovasc Interv 2020; 97:895-902. [PMID: 33022117 DOI: 10.1002/ccd.29317] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 09/26/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this study was to assess the 30 day incidence of paravalvular leak (PVL) and need for aortic valve reintervention of a fourth generation balloon expandable transcatheter valve with enhanced skirt (4G-BEV) (SAPIEN 3 Ultra) compared with a third generation balloon expandable transcatheter valve (3G-BEV) (SAPIEN 3). BACKGROUND The incidence of PVL has steadily declined with iterative improvements in transcatheter aortic valve replacement (TAVR) technology and implantation strategies. METHODS Patients who underwent TAVR at Mayo Clinic from 7/2018 to 7/2019 were included in a prospective institutional registry. 4G-BEV has been utilized since 2/2019, and, after this date, 3G-BEV and 4G-BEV were simultaneously used. 4G-BEV had three sizes (20, 23, and 26 mm) while 3G-BEV included four sizes (20, 23, 26, and 29 mm). Both cohorts were evaluated at 30 days post-TAVR with a transthoracic echocardiogram to assess for PVL. RESULTS A total of 260 consecutive patients were included. Of these, 101 patients received a 4G-BEV and 159 patients received a 3G-BEV. There were more females (p = .0005) and a lower aortic valve calcium score (p = .02) in the 4G-BEV cohort at baseline. Age, STS risk score, NYHA Class, and aortic valve mean gradient did not differ between groups. 4G-BEV was associated with a lower incidence of mild PVL (10.8 vs. 36.5%; p < .0001) and moderate PVL (0 vs. 5.8%) compared to the 3G-BEV at 30 days. There was no association between PVL and valve size in either cohort. CONCLUSIONS Utilization of 4G-BEV is associated with reduced PVL at 30 days post-TAVR compared with 3G-BEV.
Collapse
Affiliation(s)
- Garrett A Welle
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota, USA
| | - Bassim El-Sabawi
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Kevin L Greason
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Kyle W Klarich
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mayra E Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
39
|
Ali MA, Hepinstall MJ, Cassidy CS, Lane CM, Pellikka PA, Thaden JJ, Pislaru SV, Kane GC. Agitated Blood-Saline Rather Than Agitated Air-Saline for Echocardiographic Shunt Studies. J Am Soc Echocardiogr 2020; 33:1032-1033. [DOI: 10.1016/j.echo.2020.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 11/29/2022]
|
40
|
Olgun Kucuk H, Jouni H, Oguz D, Thaden JJ, Nkomo VT, Pislaru C, Foley TA, Muraru D, Pellikka PA, Pislaru SV. Large, Unpredictable Beat-To-Beat Variability of Mitral Annulus Size in Atrial Fibrillation: Implications for Percutaneous Interventions. JACC Cardiovasc Interv 2020; 13:1387-1389. [PMID: 32061605 DOI: 10.1016/j.jcin.2019.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/21/2019] [Accepted: 12/17/2019] [Indexed: 10/25/2022]
|
41
|
Xia H, Yeung DF, Di Stefano C, Cha SS, Pellikka PA, Ye Z, Thaden JJ, Villarraga HR. Ventricular strain analysis in patients with no structural heart disease using a vendor-independent speckle-tracking software. BMC Cardiovasc Disord 2020; 20:274. [PMID: 32503490 PMCID: PMC7275339 DOI: 10.1186/s12872-020-01559-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/28/2020] [Indexed: 12/30/2022] Open
Abstract
Background Ventricular strain measurements vary depending on cardiac chamber (left ventricle [LV] or right ventricle [RV]), type of strain (longitudinal, circumferential, or radial), ventricular level (basal, mid, or apical), myocardial layer (endocardial or epicardial), and software used for analysis, among other demographic factors such as age and gender. Here, we present an analysis of ventricular strain taking all of these variables into account in a cohort of patients with no structural heart disease using a vendor-independent speckle-tracking software. Methods LV and RV full-thickness strain parameters were retrospectively measured in 102 patients (mean age 39 ± 15 years; 62% female). Within this cohort, we performed further layer-specific strain analysis in 20 subjects. Data were analyzed for global and segmental systolic strain, systolic strain rate, early diastolic strain rate, and their respective time-to-peak values. Results Mean LV global longitudinal, circumferential, and radial strain values for the entire cohort were − 18.4 ± 2.0%, − 22.1 ± 4.1%, and 43.9 ± 12.1% respectively, while mean RV global and free wall longitudinal strain values were − 24.2 ± 3.9% and − 26.1 ± 5.2% respectively. Women on average demonstrated higher longitudinal and circumferential strain and strain rate than men, and longer corresponding time-to-peak values. Longitudinal strain measurements were highest at the apex compared with the mid ventricle and base, and in the endocardium compared with the epicardium. Longitudinal strain was the most reproducible measure, followed closely by circumferential strain, while radial strain showed suboptimal reproducibility. Conclusions We present an analysis of ventricular strain in patients with no structural heart disease using a vendor-independent speckle-tracking software.
Collapse
Affiliation(s)
- Hongmei Xia
- Department of Ultrasound, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Darwin F Yeung
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, 200 First St SW, Rochester, MN, 55905, USA
| | - Cristina Di Stefano
- Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Stephen S Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, 200 First St SW, Rochester, MN, 55905, USA
| | - Zi Ye
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, 200 First St SW, Rochester, MN, 55905, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, 200 First St SW, Rochester, MN, 55905, USA
| | - Hector R Villarraga
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, 200 First St SW, Rochester, MN, 55905, USA.
| |
Collapse
|
42
|
Thaden JJ, Malouf JF, Rehfeldt KH, Ashikhmina E, Bagameri G, Enriquez-Sarano M, Stulak JM, Schaff HV, Michelena HI. Adult Intraoperative Echocardiography: A Comprehensive Review of Current Practice. J Am Soc Echocardiogr 2020; 33:735-755.e11. [DOI: 10.1016/j.echo.2020.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 01/19/2020] [Accepted: 01/20/2020] [Indexed: 12/15/2022]
|
43
|
Thaden JJ, Balakrishnan M, Sanchez J, Adigun R, Nkomo VT, Eleid M, Dahl J, Scott C, Pislaru S, Oh JK, Schaff H, Pellikka PA. Left ventricular filling pressure and survival following aortic valve replacement for severe aortic stenosis. Heart 2020; 106:830-837. [PMID: 32066613 DOI: 10.1136/heartjnl-2019-315908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/24/2020] [Accepted: 01/24/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To determine whether echocardiography-derived left ventricular filling pressure influences survival in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). METHODS We retrospectively reviewed 1383 consecutive patients with severe AS, normal ejection fraction and interpretable filling pressure undergoing AVR. Left ventricular filling pressure was determined according to current guidelines using mitral inflow, mitral annular tissue Doppler, estimated right ventricular systolic pressure and left atrial volume index. Cox proportional hazards regression was used to assess the influence of various parameters on mortality. RESULTS Age was 75±10 years and 552 (40%) were female. Left ventricular filling pressure was normal in 325 (23%), indeterminate in 463 (33%) and increased in 595 (43%). Mean follow-up was 7.3±3.7 years, and mortality was 1.2%, 4.2% and 18.9% at 30 days and 1 and 5 years, respectively. Compared with patients with normal filling pressure, patients with increased filling pressure were older (78±9 vs 70±12, p<0.001), more often female (45% vs 35%, p=0.002) and were more likely to have New York Heart Association class III-IV symptoms (35% vs 24%, p=0.004), coronary artery disease (55% vs 42%, p<0.001) and concentric left ventricular hypertrophy (63% vs 37%, p<0.001). After correction for other factors, increased left ventricular filling pressure remained an independent predictor of mortality after successful AVR (adjusted HR 1.45 (95% CI 1.16 to 1.81), p=0.005). CONCLUSIONS Preoperative increased left ventricular filling pressure is common in patients with AS undergoing AVR and has important prognostic implications, regardless of symptom status. Future prospective studies should consider whether patients with increased filling pressure would benefit from earlier operation.
Collapse
Affiliation(s)
- Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mahesh Balakrishnan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jose Sanchez
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rosalyn Adigun
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jordi Dahl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher Scott
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
44
|
Ryu AJ, Kane GC, Pislaru SV, Lekhakul A, Geske JB, Luis SA, Michelena HI, Nkomo VT, Thaden JJ, Sinak LJ. Bleeding Complications of Ultrasound-Guided Pericardiocentesis in the Presence of Coagulopathy or Thrombocytopenia. J Am Soc Echocardiogr 2020; 33:399-401. [PMID: 31959530 DOI: 10.1016/j.echo.2019.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
Affiliation(s)
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Annop Lekhakul
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Faculty of Medicine, Ramathibodhi Hospital, Mahidol University, Bangkok, Thailand
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Lawrence J Sinak
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
45
|
Oguz D, Padang R, Pislaru SV, Nkomo VT, Mankad SV, Malouf JF, Guerrero M, Reeder GS, Eleid MF, Rihal CS, Thaden JJ. P1798 Determinants of increased mitral mean diastolic gradient after transcatheter edge-to-edge mitral valve repair. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.1153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Transcatheter edge-to-edge mitral valve repair (TMVR; MitraClip, Abbott Vascular) is clinically approved for treatment of severe, symptomatic mitral regurgitation (MR) in high or prohibitive surgical risk patients. Iatrogenic mitral stenosis is a known complication of TMVR, but determinants of increased post-procedure mean diastolic gradient are not well defined.
Purpose
We aimed to investigate the determinants of increased mitral mean diastolic gradient after TMVR.
Methods
We retrospectively reviewed 59 patients. 2D and 3D TEE data sets acquired before and immediately after procedure were analyzed. 4D Cardio-View and 4D MV-Assessment (TomTec, Germany) were used for the analysis of the 3D volume data set. Quantitative mitral valve analysis was done at the end of systole. Increased mitral mean diastolic gradient after TMVR was correlated with pre-procedure 2D and 3D echocardiographic data.
Results
34 patients had primary MR, 25 patients had mixed/secondary MR. Baseline mean mitral diastolic gradient was 2.0 ± 0.9mmHg and increased to 3.9 ± 1.8mmHg post-TMVR and the mean 3D planimetric mitral valve area decreased from 5.3 ± 1.5cm2 to 2.6 ± 1.0cm2. Implantation of multiple clips was performed less frequently in patients with smaller baseline mitral valve area; 8% vs 47% in the lowest quartile vs all others (p = 0.006). 12(20%) of patients had a mean diastolic gradient >5mmHg post-TMVR and 15(25%) of patients had a post-TMVR mitral valve area <2.0 cm2. There was no significant difference in post-procedure heart rate between patients with mean diastolic gradient ≤5mmHg vs >5mmHg (p = 0.08). Patient characteristics according to post-TMVR mean diastolic gradient are shown in the Table. Post-TMVR mean diastolic gradient >5mmHg was more common in patients with increased pre-procedure mean diastolic gradient(p = 0.006), post-TMVR mitral valve area <2.0 cm2(40% vs 14%, p = 0.03), and ≥moderate residual mitral regurgitation(38% vs 11%, p = 0.02). Post-TMVR mitral valve area <2.0cm2 was present in 50% vs 19% of patients with vs without a mean gradient >5mmHg(p = 0.04).
Conclusions
Elevated post-TMVR mean diastolic gradient is multifactorial and related to mitral stenosis, but residual mitral regurgitation also appears to be an important contributor to increased gradients in some patients. Larger cohorts are likely needed to assess the concurrent impact of mitral annular calcification, leaflet calcification, and other variables on post-TMVR mean gradient.
Abstract P1798 Figure. 2D and 3D Echocardiographic Parameters
Collapse
Affiliation(s)
- D Oguz
- Mayo Clinic, Rochester, United States of America
| | - R Padang
- Mayo Clinic, Rochester, United States of America
| | - S V Pislaru
- Mayo Clinic, Rochester, United States of America
| | - V T Nkomo
- Mayo Clinic, Rochester, United States of America
| | - S V Mankad
- Mayo Clinic, Rochester, United States of America
| | - J F Malouf
- Mayo Clinic, Rochester, United States of America
| | - M Guerrero
- Mayo Clinic, Rochester, United States of America
| | - G S Reeder
- Mayo Clinic, Rochester, United States of America
| | - M F Eleid
- Mayo Clinic, Rochester, United States of America
| | - C S Rihal
- Mayo Clinic, Rochester, United States of America
| | - J J Thaden
- Mayo Clinic, Rochester, United States of America
| |
Collapse
|
46
|
Oguz D, Eleid MF, Dhesi S, Pislaru SV, Mankad SV, Malouf JF, Nkomo VT, Oh JK, Holmes DR, Reeder GS, Rihal CS, Thaden JJ. Quantitative Three-Dimensional Echocardiographic Correlates of Optimal Mitral Regurgitation Reduction during Transcatheter Mitral Valve Repair. J Am Soc Echocardiogr 2019; 32:1426-1435.e1. [DOI: 10.1016/j.echo.2019.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 12/24/2022]
|
47
|
Kato N, Thaden JJ, Miranda WR, Sarano ME, Greason KL, Pellikka PA. P1786Impact of surgery for mitral regurgitation at the time of aortic valve replacement. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Functional mitral regurgitation (MR) is expected to improve after aortic valve replacement (AVR) in patients with severe aortic stenosis (sAS) and MR. However, little is unknown about the impact of AVR on organic MR and whether concomitant mitral valve surgery (MVS) improves outcomes in patients with sAS and MR.
Purpose
We assessed the impact of AVR on MR severity according to MR mechanism. We also assessed the clinical outcomes in patients with sAS and MR that underwent AVR with vs without MVS.
Methods
We retrospectively investigated patients who received surgical AVR or transcatheter aortic valve implantation (TAVI) from 2008 to 2017. We identified patients with effective mitral regurgitant orifice area (ERO) ≥10 mm2 by the proximal isovelocity surface area method with transthoracic echocardiography. The change in MR after AVR was considered significant when there was at least one grade difference. We compared the all-cause mortality of patients with sAS and MR that underwent AVR with vs without MVS according to MR mechanism and patient age.
Results
We included 326 patients with sAS and MR (age 80 [Interquartile range 72–85] years, 53% male, 21% history of myocardial infarction). Organic and functional MR were present in 69% and 31%, respectively. Of these, 240 underwent AVR alone (AVR group) including TAVI in 112 while 86 underwent AVR and MVS (MVS group) including mitral valve replacement in 38 and mitral valve repair in 48. The median ERO at baseline was 17 (14–21) mm2 in AVR and 24 (19–33) mm2 in MVS (p<0.001). Improvement in MR was observed in 58% of AVR and 91% of MVS (p<0.001). In AVR group, organic MR improved as frequently as functional MR (58% vs. 59%, p=0.96). Predictors for improvement in organic MR were absence of atrial fibrillation and moderate or greater MR, and in functional MR, the only predictor was decrease in LV end-systolic diameter after AVR. During mean follow-up of 2.4±2.3 years, moderate or greater MR was observed in 23% of AVR and 7% of MVS (p=0.002). All-cause mortality was similar in AVR and MVS groups for organic and functional MR (hazard ratio for MVS group 0.68, 95% CI: 0.40–1.10, p=0.13 in organic MR and 0.62, 95% CI 0.29–1.22, p=0.68 in functional MR). All-cause mortality was lower in MVS group compared with AVR group in patients <80 years, and was similar in patients ≥80 years (Figure).
Conclusion
In patients with sAS and MR, MR improves after AVR, even in the majority of patients with organic MR. Compared with isolated AVR, concomitant MVS was associated with better prognosis in patients <80 years.
Collapse
Affiliation(s)
- N Kato
- Mayo Clinic, Rochester, United States of America
| | - J J Thaden
- Mayo Clinic, Rochester, United States of America
| | - W R Miranda
- Mayo Clinic, Rochester, United States of America
| | - M E Sarano
- Mayo Clinic, Rochester, United States of America
| | - K L Greason
- Mayo Clinic, Rochester, United States of America
| | - P A Pellikka
- Mayo Clinic, Rochester, United States of America
| |
Collapse
|
48
|
Zhang H, El-Am EA, Thaden JJ, Pislaru SV, Scott CG, Krittanawong C, Chahal AA, Breen TJ, Eleid MF, Melduni RM, Greason KL, McCully RB, Enriquez-Sarano M, Oh JK, Pellikka PA, Nkomo VT. Atrial fibrillation is not an independent predictor of outcome in patients with aortic stenosis. Heart 2019; 106:280-286. [PMID: 31439661 DOI: 10.1136/heartjnl-2019-314996] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/21/2019] [Accepted: 07/22/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). METHODS 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed. RESULTS Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- and sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. CONCLUSION AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.
Collapse
Affiliation(s)
- Hongju Zhang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Christopher G Scott
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Anwar A Chahal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Thomas J Breen
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Rowlens M Melduni
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
| |
Collapse
|
49
|
Wang Z, Ayoub C, Thaden JJ, Alsidawi S, Miller FA, Sinak LJ, Rihal CS, Melduni RM. Echocardiographic mimicker of thrombus on a mechanical aortic valve prosthesis due to cavitation: A paradoxical phenomenon of pressure recovery. Echocardiography 2019; 36:1397-1400. [DOI: 10.1111/echo.14403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/19/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Zhenzhen Wang
- Department of Cardiovascular Medicine; Mayo Clinic; Rochester Minnesota
| | - Chadi Ayoub
- Department of Cardiovascular Medicine; Mayo Clinic; Rochester Minnesota
| | - Jeremy J. Thaden
- Department of Cardiovascular Medicine; Mayo Clinic; Rochester Minnesota
| | - Said Alsidawi
- Department of Cardiovascular Medicine; Mayo Clinic; Rochester Minnesota
| | | | - Lawrence J. Sinak
- Department of Cardiovascular Medicine; Mayo Clinic; Rochester Minnesota
| | | | | |
Collapse
|
50
|
Affiliation(s)
- Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| |
Collapse
|