Pulmonary Vein Flow Morphology after Transcatheter Mitral Valve Edge-to-Edge Repair as Predictor of Survival

BACKGROUND

Data on the prognostic factors after mitral valve transcatheter edge-to-edge repair (MV-TEER) are limited. Pulse-wave Doppler interrogation of pulmonary vein flow (PVF) is a convenient method to assess the hemodynamic burden of residual mitral regurgitation (MR), which could be of utility as a predictor of outcomes.

METHODS

Patients that underwent MV-TEER between May 2014 and December 2021 at our institution were evaluated. PVF patterns post-MV-TEER were reviewed on the procedural transesophageal echocardiogram and classified as normal (systolic dominant or codominant) or abnormal (systolic blunting or reversal). PVF pattern was correlated with all-cause mortality at follow up.

RESULTS

265 patients had diagnostic PVF post-MV-TEER, with 73 (27.5%) categorized as normal and 192 (72.5%) categorized as abnormal. Patients with abnormal PVF morphology were more likely to have atrial fibrillation (70% vs 42%, p<0.001) and >moderate residual MR (16% vs 3%, p=0.01) and had higher mean left atrial pressure (18.1±5.0 vs 15.9±4.2 mmHg, p=0.002) and left atrial V-wave (26.6±8.5 vs 21.4±7.3 mmHg, p<0.001) post-procedure. In multivariable analysis, abnormal PVF morphology post MV-TEER was independently associated mortality at follow up (HR 1.70, 95% CI 1.06-2.74, p=0.03) after correction for end-stage renal disease, atrial fibrillation, and residual MR. Results were similar in subgroups of patients with moderate or less and those with mild or less residual MR.

CONCLUSIONS

PVF morphology is a simple and objective tool to assess MR severity immediately post MV-TEER and offers important prognostic information to optimize procedural results. Additional studies are needed to determine whether patients with abnormal PVF pattern post MV-TEER would benefit from more intensive goal-directed medical therapy post-procedure.

Don't Tear My Heart: Sternal Wire Pericardial Injury After Aortic Valve Replacement

•TTE is a valuable cardiac imaging tool given its availability. •TTE can be used for the evaluation of cardiothoracic surgical complications. •Imaging modalities aid in supplementing information in postoperative patients. •Sternal wire fracture may cause a cardiac laceration.

How do cardiovascular risk factors and cardiac remodeling type affect left ventricular global longitudinal strain and right ventricular free wall strain in patients with obesity

Background

Obesity, defined by the World Health Organization (WHO) as a BMI greater than 30k g/m2, has reached epidemic proportions worldwide, related to approximately 2.8 million deaths/year as of June 2021. WHO sub-classifies obesity based on BMI in Class 1: 30–34.9 kg/m2, Class 2: 35–39.9 kg/m2, and Class 3: ≥40 kg/m2. This state of increased body weight is associated with an increased risk of cardiovascular disease. Cardiac remodeling can be affected by obesity and/or other cardiovascular risk factors (CVRF) as an adaptive physiological response. The remodeling patterns, Normal Geometry (NG), Concentric Remodeling (CR), Concentric Hypertrophy (CH), and Eccentric Hypertrophy, are classified by changes in Relative Wall Thickness (RWT), ≤ or &gt;0.42, and/or Left Ventricular Mass Index (LVMI g/m2), ≤ or &gt;88 for women and ≤ or &gt;102 for men. Left Ventricular Ejection Fraction (LVEF) can remain within normal limits in patients with obesity with multiple CVRF and cardiac remodeling. Left Ventricular Global Longitudinal Strain (LV-GLS) and Right ventricular free wall strain (RV-FWS) can be useful to detect subclinical myocardial dysfunction. The aim of this study was to evaluate if these strain variables are affected in patients with obesity associated to other CVRF in relation to cardiac remodeling type when compared to controls.

Methods

2859 patients with BMI ≥30 kg/m2 and 2616 normal-weight controls (BMI between 18.5 and 24.9 kg/m2), with normal and abnormal cardiac geometry, and normal ejection fraction by echocardiography performed between 01/01/2008 and 12/31/2018, were compared. Obesity was classified based on the World Health Organization. CVRF included were Hypertension (HTN), Diabetes Mellitus (DM), Dyslipidemia, history of Vascular Event (myocardial infarction and/or stroke), and Obstructive sleep apnea (OSA).

Results

BMI, cardiac geometry, CVRF, and the number of comorbidities independently affected GLS and RV-FWS (Figure 1 and Figure 2). LV-GLS and RV-FWS values [mean (SD)] in obesity classes 1, 2, and 3 were −19 (2.9), −18.9 (2.9), −18.7 (2.9) & −24.2 (5.2), −23.8 (6.2), −24.5 (5.9), respectively. In the control group LV-GLS and RV-FWS values [mean (SD)] were −20.1 (3.0) & −27 (5.6), respectively. CH was associated with the greatest decrease in LV-GLS and RV-FWS in males and females, regardless of BMI (Figure 2). LV-GLS values [mean (SD)] associated to CH for obesity class 1, 2, and 3, and controls in females were −18.4 (3.4), −18 (3.1) −17.6 (3.6), and −17.8 (4), respectively, and for obesity class 1, 2, and 3, and controls in males were −16.1 (3.5), 16.5 (3.2), −14.4 (2.7), and −16.6 (4.7), respectively (Figure 1).

Conclusion

Obesity associated to CVRF and CH have the lowest values of GLS in patients with normal ejection fraction. These values were exceedingly below average compared to other groups. These parameters should be used as reference values for this population.

Funding Acknowledgement

Type of funding sources: None.

Impact of proportionate versus disproportionate mitral regurgitation on acute procedural changes and clinical outcomes following transcatheter mitral valve repair

Background

Transcatheter mitral edge-to-edge repair (TEER) with MitraClip offers a less invasive alternative for patients with severe, symptomatic mitral regurgitation (MR) who are considered high risk for surgery. However, patient selection for TEER remains challenging given the variability in underlying MR pathology and current discordance among studies regarding predictors of procedural efficacy and clinical outcomes.

Purpose

This study aimed to assess acute procedural changes and long-term outcomes in patients who underwent TEER according to the proportionality of MR, defined as the ratio of the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV).

Methods

We analyzed patients who underwent TEER at our institution between 2014 and 2020 with available biplane left ventricular volume measurement. Relevant clinical comorbidities, demographics, and anthropometrics, along with pertinent pre- and post-procedural echocardiogram measurements, were obtained by review of the electronic medical record. The EROA to LVEDV index was calculated for all patients who were then stratified by quartiles. Patients with an EROA/LVEDV index in the lowest quartile were defined as having the most proportionate MR and those with an index in the highest quartile were defined as the most disproportionate MR. Baseline and post-TEER parameters were used to assess acute procedural and longitudinal outcomes.

Results

Baseline clinical and echocardiographic parameters of the 230 subjects according to quartile are shown in the table. Following TEER, there was a larger reduction in the left ventricular end-diastolic diameter and increased MR reduction with increasingly disproportionate MR (p=0.03 and p=0.05, respectively). The change in ejection fraction pre- versus post-TEER did not significantly differ across groups (p=0.64). Median follow up time was 1.7 (0.7–3.5) years; mortality occurred in 77 patients (33.5%) and heart failure hospitalizations occurred in 20 patients (8.7%) during follow up. No significant difference in all-cause mortality or post-procedural heart failure hospitalizations was identified across groups.

Conclusions

In our series, patients with proportionate MR were similarly symptomatic to those with disproportionate MR but had less severe MR with increased comorbidities. Post-TEER MR grade was similar between groups. Longer-term follow up in larger groups of patients is needed to determine the clinical implications.

Funding Acknowledgement

Type of funding sources: None.

Incremental Prognosis by Left Atrial Functional Assessment: The Left Atrial Coupling Index in Patients With Floppy Mitral Valves

Background

Emerging data suggest important prognostic value to left atrial (LA) characteristics, but the independent impact of LA function on outcome remains unsubstantiated. Thus, we aimed to define the incremental prognostic value of LA coupling index (LACI), coupling volumetric and mechanical LA characteristics and calculated as the ratio of left atrial volume index to tissue Doppler imaging a′, in a large cohort of patients with isolated floppy mitral valve.

Methods and Results

All consecutive 4792 patients (61±16 years, 48% women) with isolated floppy mitral valve in sinus rhythm diagnosed at Mayo Clinic from 2003 to 2011, comprehensively characterized and with prospectively measured left atrial volume index and tissue Doppler imaging a′ in routine practice, were enrolled, and their long‐term survival analyzed. Overall, LACI was 5.8±3.7 and was <5 in 2422 versus ≥5 in 2370 patients. LACI was independently higher with older age, more mitral regurgitation (no 3.8±2.3, mild 5.1±3.0, moderate 6.5±3.8, and severe 7.8±4.3), and with diastolic (higher E/e′) and systolic (higher end‐systolic dimension) left ventricular dysfunction (all P≤0.0001). At diagnosis, higher LACI was associated with more severe presentation (more dyspnea, more severe functional tricuspid regurgitation, and elevated pulmonary artery pressure, all P≤0.0001) independently of age, sex, comorbidity index, ventricular function, and mitral regurgitation severity. During 7.0±3.0 years follow‐up, 1146 patients underwent mitral valve surgery (94% repair, 6% replacement), and 880 died, 780 under medical management. In spline curve analysis, LACI ≥5 was identified as the threshold for excess mortality, with much reduced 10‐year survival under medical management (60±2% versus 85±1% for LACI <5, P<0.0001), even after comprehensive adjustment (adjusted hazard ratio, 1.30 [95% CI, 1.10–1.53] for LACI ≥5; P=0.002). Association of LACI ≥5 with higher mortality persisted, stratifying by mitral regurgitation severity of LA enlargement grade (all P<0.001) and after propensity‐score matching (P=0.02). Multiple statistical methods confirmed the significant incremental predictive power of LACI over left atrial volume index (all P<0.0001).

Conclusions

LA functional assessment by LACI in routine practice is achievable in a large number of patients with floppy mitral valve using conventional Doppler echocardiographic measurements. Higher LACI is associated with worse clinical presentation, but irrespective of baseline characteristics, LACI is strongly, independently, and incrementally determinant of outcome, demonstrating the crucial importance of LA functional response to mitral valve disease.

Tricuspid annulus dynamics in atrial fibrillation compared to sinus rhythm using 3-D echocardiography: relation with tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is known to cause dilation in both the mitral (MA) and the tricuspid (TA) annuli. Few studies have investigated MA dynamics and function in AF compared to sinus rhythm (SR). However, no study addressed this issue in TA. Hence, we set forth to describe TA dynamics in AF and SR and its relationship with severity of tricuspid regurgitation (TR).

Methods

3D echocardiographic imaging data were acquired from adult patients in AF or SR with varying degrees of TR between 2018 and 2020. TA was automatically tracked throughout the cardiac cycle using a commercially available software (TomTec 4MV software; Figure 1) over 4-6 cardiac cycles per patient. Time to minimal area as percentage of the R-R interval was recorded in each of the cycles. Absolute change in TA area was calculated as the difference between maximal and minimal TA area in each cardiac cycle and was averaged over 4-6 cycles per patient. This measurement was used to reflect the dynamic range of TA deformation during the cardiac cycle. Right atrial (RA) and right ventricular (RV) volumes and longitudinal strain were also measured (speckle tracking, 4-ch view).

Results

A total of 70 patients were studied (35 AF; 35 SR; 54% males in each group). Patients with AF were older [median (IQR) of 81 (72-86) years vs. 69 (59-78) years in SR, p &lt; 0.001], had larger maximal TA area and circumference (p &lt; 0.001 for both), larger RA size (p &lt; 0.001), lower RA reservoir strain  (p &lt; 0.001) and RV free-wall strain (p &lt; 0.001). Absolute change in TA area was significantly decreased in AF [2.3 (1.7-2.7) cm2] vs. 3.1 (2.3-3.5) cm2 in SR, p = 0.002. Patients with ≥ moderate TR (n = 41, 59%) had lower absolute change in TA area [2.4 (1.7-3.1) cm2 vs. 2.8 (2.2-3.5) cm2 in &lt; moderate TR, p = 0.05]. Female sex was associated with lower absolute change in TA area [2.3 (1.7-3.2) cm2 vs. 2.7 (2.2-3.6) cm2 in males, p = 0.02] on univariate analysis. AF patients had more frequently ≥ moderate TR [28 AF vs. 13 SR, p &lt; 0.001]. On multivariate analysis including sex, rhythm, TR severity, RA and RV strains, and averaged maximal TA area, independent factors associated with lower absolute change in TA area were AF, ≥ moderate TR, and larger maximal TA area (p &lt; 0.05 for all).  Time to minimal TA size was achieved in (0-40%) of the R-R interval in 70% of patients in SR compared to only 41% of patients in AF (Figure 2) and in 73% in patients with &lt; moderate TR compared to 43% in patients with ≥ moderate TR.

Conclusion

AF is associated with blunted TA dynamics resulting in lower decrease in TA size and with a heterogenous timing of minimal TA size throughout the cardiac cycle. The blunted and discoordinated annular contraction may reduce systolic tricuspid valve competence and be involved in the pathophysiology of functional TR. Future studies are needed to confirm this hypothesis and evaluate the effect of restoration of SR on TA dynamics and time to minimal TA size. Abstract Figure 1Abstract Figure 2

Incidence, risk factors, natural history and outcomes of heart failure in patients with Graves' disease

OBJECTIVE

Graves' disease (GD) can both aggravate pre-existing cardiac disease and cause de novo heart failure (HF), but large-scale studies are lacking. We aimed to investigate the incidence, risk factors and outcomes of incident GD-related HF.

METHODS

Patients with GD (2009-2019) were retrospectively included. HF with reduced ejection fraction (HFrEF) was defined by left ventricular ejection fraction <50% and Framingham criteria, while HF with preserved ejection fraction (HFpEF) was defined according to the HFA-PEFF criteria. HF due to ischaemia, valve disorder or other structural heart disease was excluded. Proportional hazards regression was used to analyse risk factors and outcomes.

RESULTS

Of 1371 patients with GD, HF occurred in 74 (5.4%) patients (31 (2.3%) HFrEF; 43 (3.1%) HFpEF). In HFrEF, atrial fibrillation (AF) (HR 10.5 (3.0-37.3), p<0.001) and thyrotropin receptor antibody (TRAb) level (HR 1.05 (1.01-1.09) per unit, p=0.007) were independent risk factors. In HFpEF, the independent risk factors were chronic obstructive pulmonary disease (HR 7.2 (3.5-14.6), p<0.001), older age (HR 1.5 (1.2-2.0) per 10 years, p=0.001), overt hyperthyroidism (HR 6.4 (1.5-27.1), p=0.01), higher body mass index (BMI) (HR 1.07 (1.03-1.10) per unit, p=0.001) and hypertension (HR 3.1 (1.3-7.2), p=0.008). The risk of cardiovascular hospitalisations was higher in both HFrEF (HR 10.3 (5.5-19.4), p<0.001) and HFpEF (HR 6.7 (3.7-12.2), p<0.001). However, only HFrEF was associated with an increased risk of all-cause mortality (HR 5.17 (1.3-19.9), p=0.02) and ventricular tachycardia/fibrillation (HR 64.3 (15.9-259.7), p<0.001).

CONCLUSION

De novo HF occurs in 5.4% of patients with GD and is associated with increased risk of cardiovascular hospitalisations and mortality. Risk factors include AF, higher TRAb, higher BMI and overt hyperthyroidism.

Predictors of Use and Outcomes of Mechanical Valve Replacement in the United States (2008-2017)

Background

Contemporary nationwide data on the use, predictors, and outcomes of mechanical valve replacement in patients less than 70 years of age are limited.

Methods and Results

We identified hospitalizations for aortic valve replacement (AVR) or mitral valve replacement (MVR) in the Nationwide Inpatient Sample between January 1, 2008, and December 31, 2017. The study's end points included predictors of mechanical valve replacement and risk‐adjusted in‐hospital mortality. Among 253 100 hospitalizations for AVR, the use rate of mechanical prosthesis decreased from 45.3% in 2008 to 17.0% in 2017. Among 284 962 hospitalizations for MVR, mechanical prosthesis use decreased from 59.5% in 2008 to 29.2% in 2017 (P for trend<0.001). In multilogistic regression analyses, female sex, prior sternotomy, prior defibrillator, and South/West geographic location were predictive of mechanical valve use. The presence of bicuspid valve was a negative predictor of mechanical AVR (odds ratio [OR], 0.68; 95% CI, 0.66–0.69; P<0.001), whereas mitral stenosis was associated with higher mechanical MVR (OR, 1.28; 95% CI, 1.22–1.33; P<0.001). Unadjusted in‐hospital mortality decreased over time with AVR but not with MVR, regardless of prosthesis choice. Using years 2008 and 2009 as a reference, risk‐adjusted mortality also decreased over time with AVR but did not decrease after MVR.

Conclusions

There is a substantial decline in the use of mechanical valve replacement among patients aged ≤70 years in the United States. Long‐term durability data on bioprosthetic valve replacement are needed to better define the future role of mechanical valves in this age group.

Intraoperative finding of immobile leaflet(s) following freshly implanted bioprosthetic valves: clinical characteristics and impact on outcomes

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Detection of immobile leaflets immediately following bioprosthetic valve implantation is a rare but important intraoperative finding. Restriction of leaflet movement can occur in the closed or open position, leading to abnormal prosthesis function. We sought to determine the clinical implications of immobile leaflets seen on intraoperative echocardiography.

METHODS

Patients with immobile leaflets identified on intra-operative/procedure echocardiography immediately post implantation between 2009-2020 were identified from an institutional database. All echocardiograms were reviewed de-novo to confirm immobile leaflets in the immediate post-implantation period. Identified cases were matched 1:2 to controls for age; sex; prosthesis position, model and size; and implantation approach (surgical vs. transcatheter).  Nominal logistic regression and proportional hazards were used to analyze outcomes.

RESULTS

Thirty patients with immobile leaflets immediately post-bioprosthesis implantation were included. Clinical characteristics are summarized in the Table. Immobile leaflets were documented in procedural reports in only 18 (60%) patients. Moderate stenosis was present intraoperatively in 1 patient, none demonstrated ≥moderate regurgitation, and none resulted in immediate corrective action. In 3 (10%), valve re-intervention was required within 30 days due to symptomatic prosthesis dysfunction. Presence of restricted leaflet motion was associated with higher need for post-operative extracorporeal membrane oxygenation use (odds-ratio 7.3, p = 0.02) and composite end-point of death, valve re-replacement, prosthesis thrombosis, or cardiac hospitalizations (risk ratio 2.1, p = 0.03, Figure).

CONCLUSION

Immobile leaflet(s) immediately post-bioprosthetic valve implantation is an uncommon, under-reported, and under-treated phenomenon. Even in the absence of significant prosthetic valve dysfunction, it can be associated with worse post-operative course as well as worse outcomes.

Baseline characteristics Age 76 (67-84) Sex, male 10 (33%) Surgical approach 25 (83%) Aortic 5 (17%) Mitral 12 (40%) Tricuspid 12 (40%) Pulmonary 1 (3%) Re-intervention within 10 days 3 (10%) Numbers are presented as median (interquartile range) or number (percentage). Abstract Figure. Clinical outcome of stuck leaflets

Defining echocardiographic reference values of LV volume indices and biventricular strain in obese patients with normal ejection fraction in different cardiac remodeling patterns – a single center study

Background

The left ventricle (LV) in obese patients undergoes different patterns of remodeling in order to normalize wall stress. However, little is known about how LV volume indices, LV global longitudinal strain and right ventricular free wall strain (GLS) vary according to the pattern of LV remodeling.

Aim

To define the echocardiographic reference values of LV volumes and biventricular GLS across the different LV remodeling patterns in obese patients with a preserved ejection fraction.

Methods

2393 adult obese patients (1428 females, 965 males) with a normal ejection fraction who underwent echocardiography from January 2008 to December 2018 were selected. They were categorized according to 4 cardiac remodeling groups defined by LV mass index (102g/m2 in males, 88g/m2 in females) and relative ventricular wall thickness (0.42): normal geometry (NG), eccentric hypertrophy (EH), concentric remodeling (CR) and concentric hypertrophy (CH). Obese subjects were further categorized by BMI class (30–35, 35–40, &gt;40 kg/m2). Obese subjects were gender matched to controls with a normal BMI (18.5–25 kg/m2) and normal cardiac geometry. Mean ± SD, One-way Anova and Tukey- Kramer HSD were applied. P&lt;0.05 is considered significant.

Results

The mean age of controls and obese patients' were 50±16 and 57±13.6 years respectively (P&lt;0.0001). LV GLS for controls compared to obese subjects with NG, EH, CR and CH was −21.1±2 vs. −20.2±1.9, −19.6±2.8, −18.5±2.9, −17.5±3.4 respectively (p&lt;0.0001 for all), and for RV GLS it was −27.9±4 vs −26.7±3.9, −25.1±5, −23.5±5.5, −24.1±5.2 respectively (p&lt;0.01 for all, except for NG where p=0.2). The distribution of LV indices according to cardiac remodeling subtypes is shown in the figure. Indexed end diastolic and end systolic volumes were smaller in NG, CH and CR compared to controls (p&lt;0.001 for each respectively). LV GLS and ejection fraction were higher in females, while indexed LV volumes were higher in males within each remodeling category (P&lt;0.0001). No significant difference in LV GLS or indexed LV volume was seen across BMI categories within each remodeling pattern (P&gt;0.05). Obese subjects with CH had the highest incidence of the cardiovascular risk factors hyperlipidemia, hypertension and history of myocardial infarction or stroke, compared to those with other remodeling patterns (p&lt;0.0001 for each, vs. NG, EH and CR).

Conclusion

To our knowledge, this is the largest study to define LV volumes and left and right ventricular GLS according to LV remodeling pattern and BMI category. The Lowest GLS was noted in CH. Ejection fraction was similar across the LV remodeling patterns. There were no differences in GLS and LV indexed volumes across BMI categories within each remodeling group. These results can be applied as a reference values for the obese population with a normal LV ejection fraction.

Funding Acknowledgement

Type of funding source: None

Beat-to-beat variability in the tricuspid annulus dimensions and dynamics is markedly increased in atrial fibrillation

Background

Atrial fibrillation (Afib) leads to beat-to-beat variability in cycle length; however, whether there is associated beat-to-beat variability in the tricuspid annulus (TA) dimensions or variability in the time in cardiac cycle when TA reaches maximal size is unknown.

Purpose

We aim to assess the beat-to-beat variability in the TA dimensions in Afib compared with sinus rhythm (SR).

Methods

Images were obtained from 58 patients (29 in Afib, 29 in SR) undergoing either 3D TTE or TEE examination. We measured TA in 3–6 cardiac cycles per patient using commercially available software (TomTec 4MV).

Results

Median absolute difference in maximal TA area over 3–6 cardiac cycles was 1.60 cm2 (range 0.35 cm2 to 4.08 cm2) in Afib vs. 1.17 cm2 (range 0.32 cm2 to 2.19 cm2) in SR, p=0.0063. Median absolute difference in the maximal circumference was 0.79 cm (range 0.09 cm to 2.2 cm) in Afib vs 0.54 cm (range 0.12 cm to 1.43 cm) in SR, p=0.0175. A total of 118 cardiac cycles were analyzed in patients in SR and 147 in Afib. Timing of maximal TA area was most commonly recorded at end-diastole (80–100% of the R-R interval) in 62% of cycles in SR; however, it was distributed over a broad range in Afib, p&lt;0.0001, [Figure].

Conclusion

Afib leads to significant beat-to-beat variability in the maximal TA area, minimal TA area, maximal TA circumference, and in the time of maximal TA area. These findings suggest that accurate assessment of TA dimensions should be based on continuous tracking of the TA over several cardiac cycles, especially in patients with Afib. These observations have significant implications for device sizing in percutaneous tricuspid valve interventions.

Timing of Maximal TA Area

Funding Acknowledgement

Type of funding source: None

Left ventricular filling pressure and survival following aortic valve replacement for severe aortic stenosis

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.

1049 High single-beat Doppler signals in low-gradient aortic stenosis are associated with higher aortic valve calcium

Funding Acknowledgements

Mayo Clinic

Background

Variability in Doppler signals is common in patients with atrial fibrillation (AF) and AF is common in low-gradient AS (LGAS). Presence of high single beat Doppler signals (peak velocity ≥4m/s or mean gradient ≥40mmHg) is not factored into decision-making in low-gradient aortic stenosis (LGAS).

Objective

Determine prevalence of at least one high Doppler signal in AF LGAS and its relationship to computed tomography aortic valve calcium score (AVCS) versus sinus rhythm (SR) high-gradient aortic stenosis (HGAS).

Methods

Consecutive patients with aortic valve area ≤1cm2 and left ventricular ejection fraction ≥50% during echo were identified (January 1, 2012-December 31, 2016). At least three consecutive Doppler signals were averaged in sinus rhythm (SR) and five in atrial fibrillation (AF).

Results

Of 1,854 patients, age 76± 11 years, male 52%, 301/1,854 (16%) were in AF and LGAS was present in 122/301 (41%). At least one high Doppler signal in AF LGAS was present in 43/122 (35%). AVCS within 1 year of echo was available for 36% of patient with SR HGAS and 34% of AS LGAS. Median AVCS was not different in SR HGAS 2424 (IQR 1623, 3445) vs AF LGAS with at least one high Doppler signal 2509 [IQR1547, 3119], p =0.10 AVCS threshold for severe AS (men &gt;2000 women &gt;1200) was met in 80% SR HGAS vs 86% AF LGAS with high signals.

Conclusions

High Doppler signals in AF LGAS are associated with high AVCS more frequently exceeding thresholds for severe AS. Single-beat high Doppler signals instead of the average correlate better with AVCS and classic HGAS.

A Dangerous Dilemma: Thrombus in Transit During Pregnancy

Pregnancy is associated with venous thromboembolism. Occasionally, thrombus can become entrapped across a patent foramen ovale, with risk of systemic embolism. This report presents a case of a pregnant woman who had thrombus in transit diagnosed by echocardiography, which was successfully removed by surgical thrombectomy. (Level of Difficulty: Intermediate.)

P2447Defining the values of left ventricular ejection fraction, volumes and strain by 2-dimensional echocardiography in subjects with normal cardiac geometry - a single center study

Background

Left ventricular ejection fraction (LVEF), end diastolic, end systolic volumes (EDV, ESV) and global longitudinal strain (GLS) are very important parameters that are frequently reported in cardiology. Normal cardiac geometry was not considered in articles that published normal values. It is important to know normal parameters for population studies. Our hypothesis is to analyze how EF, volumes and GLS may vary by age groups, gender and BMI in a population with normal cardiac geometry.

Purpose

To define the values in EF, volumes and GLS measurements in a healthy population with normal cardiac geometry stratified by age groups, gender and body mass index (BMI).

Methods

This is a single center retrospective study conducted from 2008 to 2018. We selected 4557 subjects (2605 females, 1952 males) >18 years with ≤ mild valvular heart disease, who underwent 2D-echocardiography (2DE) at Mayo clinic, Rochester. All selected subjects had normal LV geometry (i.e., LV mass index≤88g/m2 in females and ≤102g/m2 in males and relative wall thickness ≤0.42 measured by 2DE) and without any cardiovascular risk factors or structural or functional abnormality determined by 2DE. Based on age groups, gender and BMI, we assessed the variability in volumes indexed to body surface area, EF and GLS by Mean ± SD and two sample t-test.

Results

Mean age was 54±15 years (females = 53±15, males = 56±16), body surface area was 1.9 m2±0.2 (females = 1.8±0.2, males = 2.1±0.2), LV GLS −20.7% ±2 SD (females = −21.2±2, males= −20.2±1.9) ranging −16.1 to −27.6 in both genders (Figure); LVEF by Biplane volume method 62.6% ± 4 SD (females = 63±4.3, males=62±4.5). The end diastolic volume 63.6±11.7 cc/m2 (female = 59.9±10.3, males = 68.1±11.8) and end systolic volume 23.9 cc/m2±5.4 (female = 22.3±4.8, males = 25.9±5.5). LV GLS, Biplane EF values were higher in females and EDV and ESV values were higher in males. LV GLS values decreased with age in females (P<0.0001). While EF increased with age in both genders (P<0.0001), EDV and ESV values decreased with age (P<0.0001). When each gender is sub-divided based on their BMI (<25 and ≥25), GLS, EDV and ESV values were higher in population with BMI <25 (P<0.0001).

Normal geometry variables

Conclusion

To our knowledge, this is the biggest single center study to evaluate LV GLS values, LV EF, ED, ES volumes. These results can be used as reference values in a normal population.

Acknowledgement/Funding

None

3260Prognostic value of cardiac power reserve in patients with normal left ventricular ejection fraction undergoing exercise stress echocardiography

Background

Cardiac power output-to-mass (CPOM) ratio is a measure of myocardial performance that incorporates both pressure and flow output, normalized to left ventricular (LV) mass generating that cardiac work. Prior small studies have shown that CPOM predicts outcomes in patients with ischemic cardiomyopathy and reduced LV ejection fraction (EF). We sought to evaluate the prognostic significance of peak exercise CPOM and power reserve (increase from rest to peak exercise) in patients with normal EF.

Methods and results

Retrospective study in 24,783 patients (age 59±13 years, 45% females) with EF≥50% and no significant valve disease or right ventricular (RV) dysfunction, undergoing exercise stress echocardiography between 2004–2018. CPOM was calculated as previously described (0.222 x cardiac output x mean blood pressure / LV mass) and expressed in Watts/100g myocardium. Power reserve was calculated as difference in CPOM between peak stress and rest. All-cause mortality was the primary endpoint. Patients were divided into quartiles of power reserve. Patients with higher power reserve were younger, had higher blood pressure and heart rate, lower LV mass, and lower prevalence of prior myocardial infarction. (Table). During follow-up (median (IQR) 3.9 (0.6–8.3) years), 931 (3.8%) patients died. Progressively lower power reserve was associated with increasing mortality (Figure A). Compared to patients with abnormal stress test, patients with the lowest power reserve but otherwise normal stress test had the same survival as those with infarction/cardiomyopathy or ischemia on stress test (Figure B). Resting CPOM had lower predictive value. After adjusting for age, sex, METs achieved, ischemia/infarction on stress test results, and diastolic function grade, both peak exercise CPOM and power reserve were independent predictors of mortality (p<0.0001), incremental to conventional measures.

Conclusion

Cardiac power output and reserve measured during exercise stress echo provides independent prognostic information in patients with normal resting EF and no significant valve disease or RV dysfunction. The survival of patients with low power reserve but normal stress test was similar to patients with prior infarction/ cardiomyopathy or ischemia on stress test.

6098The role of diastolic function in risk stratification of patients with moderate aortic stenosis

Background

Currently data on the risk stratification of patients with moderate aortic stenosis (AS) are very limited.

Method

Patients diagnosed with moderate AS in 2012 (aortic valve area [AVA]: >1 and ≤1.5cm2) were identified. Patients were stratifying by LV diastolic function (normal vs high filling pressure), left ventricular ejection fraction (LVEF ≥50 vs <50%) and stroke volume index (SVI ≥35 vs <35 ml/m2). High filling pressure was defined as average E/e' ≥14 or septal E/e' ≥11 when atrial fibrillation was present. The prognosis was compared to age- and sex-matched general population.

Results

898 patients were included (age 74 years, 58% male, AVA 1.25 cm2). During a median follow-up of 2.9 years, there were 346 deaths. In patients with moderate AS, mortality was higher than expected (P<0.001, Fig 1A). LV high filling pressure, LVEF<50% and SVI<35ml/m2 were present in 416 (55%), 140 (17%) and 81 (9%) patients, respectively. Those with normal filling pressure had similar prognosis when compared to controls (Fig 1C, P=0.35); whereas mortality rates remained higher than reference even when LVEF≥50% or SVI≥35ml/m2 (Fig 1E, 1G, P<0.001). Amongst all groups, mortality rates were the highest in patients with LVEF <50% or SVI <35 ml/m2 (Fig 1D, 1F, P<0.001); mortality ratios were 3.78 (95% CI 3.01–4.67) and 6.91 (95% CI 5.13–9.11), respectively. Noteworthy, high filling pressure allowed further risk stratification when LVEF or SVI was preserved (Fig 2, P<0.001).

Figures 1 & 2

Conclusions

Patients with moderate AS showed poor survival. A clinical trial examining role of aortic valve replacement would be beneficial not only in patients with reduced LVEF or SVI but also in those with high LV filling pressures.

P323Haemodynamic implications of mitral regurgitation in heart failure with preserved ejection fraction

Background

Mild to moderate mitral regurgitation (MR) is a common finding in heart failure with preserved ejection fraction (HFpEF). MR is often considered to be an innocent bystander, yet little data is available regarding its implications.

Aim

Determine the pathophysiologic correlates of MR in HFpEF

Methods

We retrospectively studied 280 patients with invasively proven HFpEF. MR was absent (None or trivial) in 163 subjects (Non-MR-HFpEF), and present in 117 (MR-HFpEF; 78 mild and 39 moderate MR). 247 subjects also underwent invasive cardiopulmonary exercise testing.

Results

At rest, MR-HFpEF subjects displayed higher pulmonary artery pressures (PAP), PCWP, and pulmonary vascular resistance (PVR; Table). During exercise, PAP and PCWP were not significantly different among groups, but MR-HFpEF displayed reduced ability to enhance cardiac output (CO) in response to heightened metabolic demand (oxygen consumption, VO2; Figure).

Baseline characteristics and haemodynamic characterization at baseline and peak exercise Baseline characteristics Non-MR-HFpEF (N=163) MR-HFpEF (N=117) p value Age 66±11 71±10 0.0002 Female (%) 56 69 0.02 AFib (%) 13 38 <0.0001 Nt proBNP 192 [66, 557] 870 [401, 2135] <0.0001 E/E' 12.3±5.5 15.6±7.2 0.0006 LVEF (%) 64±6 62±6 0.0001 RV fractional area change (%) 51±9 47±10 0.0001 Mean PA (mmHg) 25±7 28±9 0.001 Mean PCWP (mmHg) 15±5 17±6 0.0002 PVR (Woods) 2.0±1.1 2.5±1.4 0.015 CO (L/min) 5.5±1.6 4.8±1.3 0.12 Peak exercise hemodynamics Non-MR-HFpEF (N=152) MR-HFpEF (N=95) p value Mean PA (mmHg 45±10 46.5±10 0.07 Mean PCWP (mmHg) 32±6 31±6 0.6 PVR (Woods) 1.8±1.6 2.7±2.4 0.002 CO (L/min) 9.1±3 7.2±3 0.01 P value adjusted for age, gender and BMI.

CO change in response to VO2 increase

Conclusion

The presence of even mild MR in HFpEF is associated with more adverse hemodynamics, greater pulmonary vascular dysfunction and impaired CO reserve with exercise. Further study is required to better understand the natural history and treatment for MR in HFpEF.

Acknowledgement/Funding

None