Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography

The assessment of valvular pathologies in multiple valvular heart disease by echocardiography remains challenging. Data on echocardiographic assessment-especially in patients with combined aortic and mitral regurgitation-are rare in the literature. The proposed integrative approach using semi-quantitative parameters to grade the severity of regurgitation often yields inconsistent findings and results in misinterpretation. Therefore, this proposal aims to focus on a practical systematic echocardiographic analysis to understand the pathophysiology and hemodynamics in patients with combined aortic and mitral regurgitation. The quantitative approach of grading the regurgitant severity of each compound might be helpful in elucidating the scenario in combined aortic and mitral regurgitation. To this end, both the individual regurgitant fraction of each valve and the total regurgitant fraction of both valves must be determined. This work also outlines the methodological issues and limitations of the quantitative approach by echocardiography. Finally, we present a proposal that enables verifiable assessment of regurgitant fractions. The overall interpretation of echocardiographic results includes the symptomatology of patients with combined aortic and mitral regurgitation and the individual treatment options with respect to their individual risk. In summary, a reproducible, verifiable, and transparent in-depth echocardiographic investigation might ensure consistent hemodynamic plausibility of the quantitative results in patients with combined aortic and mitral regurgitation.

Driveline infections in left ventricular assist devices-Incidence, epidemiology, and staging proposal

BACKGROUND

Driveline infections (DLI) are a serious complication in patients with left ventricular assist devices (LVAD). Apart from the differentiation between superficial and deep DLI, there is no consensus on the classification of the severity of DLI. Little is known about risk factors and typical bacteria causing DLI in centrifugal-flow LVADs.

METHODS

In this single-center study with 245 patients, DLI were classified by their local appearance using a modification of a score suggested by the Sharp Memorial group. The driveline exit site was inspected routinely every 6 months.

RESULTS

Severe DLI were detected in 34 patients (15%) after 6 months and in 24 patients (22%) after 24 months. The proportion of patients with DLI increased significantly during the follow-up (p = 0.0096). The most common bacteria in local smears were Corynebacterium, coagulase-negative Staphylococcus, and Staphylococcus aureus. Fifty-nine patients were hospitalized more than once for DLI. In these patients, S. aureus was the most common bacterium. It was also the most common bacterium in blood cultures. Higher BMI, no partnership, and a HeartMate 3 device were identified as risk factors for DLI in a multivariable cause-specific Cox regression.

CONCLUSION

This study is a standardized analysis of DLI in a large cohort with centrifugal-flow LVADs.

Supervised exercise training in patients with advanced heart failure and left ventricular assist device: A multicentre randomized controlled trial (Ex-VAD trial)

AIMS

Small studies and observations suggested that exercise training may improve peak oxygen consumption (peakVO2 ) in patients with advanced heart failure and left ventricular assist device (LVAD). We investigated whether in this patient group a supervised exercise training can improve exercise capacity.

METHODS AND RESULTS

In this multicentre, prospective, randomized, controlled trial, patients with stable heart failure and LVAD were randomly assigned (2:1) to 12 weeks of supervised exercise training or usual care, with 12 weeks of follow-up. The primary endpoint was the change in peakVO2 after 12 weeks (51 patients provided a power of 90% with an expected group difference in peakVO2 of 3 ml/kg/min). Secondary endpoints included changes in submaximal exercise capacity and quality of life. Among 64 patients enrolled (97% male, mean age 56 years), 54 were included in the analysis. Mean difference in the change of peakVO2 after 12 weeks was 0.826 ml/min/kg (95% confidence interval [CI] -0.37, 2.03; p = 0.183). There was a positive effect of exercise training on 6-min walk distance with a mean increase in the intervention group by 43.4 m (95% CI 16.9, 69.9; p = 0.0024), and on the Kansas City Cardiomyopathy Questionnaire physical domain score (mean 14.3, 95% CI 3.7, 24.9; p = 0.0124), both after 12 weeks. The overall adherence was high (71%), and there were no differences in adverse events between groups.

CONCLUSION

In patients with advanced heart failure and LVAD, 12 weeks of exercise training did not improve peakVO2 but demonstrated positive effects on submaximal exercise capacity and physical quality of life.

Insights into the daily life of ventricular assist device coordinators: Outcome of an international questionnaire

BACKGROUND

As the incidence of heart failure in developed countries is on the rise, mechanical circulatory support (MCS) often remains the only treatment option for patients with end-stage heart failure and is well established worldwide. Even though VAD coordinators play a key role in VAD programs, their responsibilities and daily duties are not clearly defined and characterized. Recently published data from the first 5-year multicenter clinical trial assessing experience with the HeartMate 3 left ventricular system (Abbott, Abbott Park, IL) show an overall survival of 61% at 5 years. When it comes to possible improvements to these systems, it is necessary for developers not only to know the status quo but also to determine and consider the visions and wishes of those individuals who take care of patients, provide education and deal with possible complications. This would be helpful a meaningful effort towards implementing a standard of care.

METHODS

To fill this knowledge gap, we conducted an online survey using the SurveyMonkey tool, addressing representatives of programs implanting VADs worldwide. Representatives answered a standardized block of 14 questions and were asked to provide responses within 3 months.

RESULTS

A total of 91 VAD coordinators from centers of various regions of the world completed the survey. The majority came from European countries. The numbers of patients followed up by the centers ranged from <20 to 390 patients. The majority of VAD coordinators had a nursing background (68%). Seventy-seven percent of the centers operate a 24-h hotline and 3-monthly visits to the outpatient department are most common. Fifty-nine percent of the centers do not use an infection scoring system for driveline wound care. The majority of the centers indicated that an optimized follow-up concept including wound care, medication, and social care is crucial and the key issue for an improved outcome. Smaller components and intensified psychosocial support ranked highest in questions about how to improve quality of life. Surprisingly, the future prospects of telemetric monitoring were not rated high in significance.

CONCLUSIONS

There is a wide variability in the composition and tasks of VAD programs worldwide. Implementing a standard of care and improving psychosocial care as well as equipment is regarded most important to improve outcomes and quality of life. From the point of view of those responsible, the significance of telemetric monitoring seemed overrated.

Expert proposal to characterize cardiac diseases with normal or preserved left ventricular ejection fraction and symptoms of heart failure by comprehensive echocardiography

Currently, the term "heart failure with preserved left ventricular ejection fraction (HFpEF)" is based on echocardiographic parameters and clinical symptoms combined with elevated or normal levels of natriuretic peptides. Thus, "HFpEF" as a diagnosis subsumes multiple pathophysiological entities making a uniform management plan for "HFpEF" impossible. Therefore, a more specific characterization of the underlying cardiac pathologies in patients with preserved ejection fraction and symptoms of heart failure is mandatory. The present proposal seeks to offer practical support by a standardized echocardiographic workflow to characterize specific diagnostic entities associated with "HFpEF". It focuses on morphological and functional cardiac phenotypes characterized by echocardiography in patients with normal or preserved left ventricular ejection fraction (LVEF). The proposal discusses methodological issues to clarify why and when echocardiography is helpful to improve the diagnosis. Thus, the proposal addresses a systematic echocardiographic approach using a feasible algorithm with weighting criteria for interpretation of echocardiographic parameters related to patients with preserved ejection fraction and symptoms of heart failure. The authors consciously do not use the diagnosis "HFpEF" to avoid misunderstandings. Central illustration: Scheme illustrating the characteristic echocardiographic phenotypes and their combinations in patients with "HFpEF" symptoms with respect to the respective cardiac pathology and pathophysiology as well as the underlying typical disease.

Six years of continuous mechanical circulatory support following chronic graft failure

Re-transplantation is the preferred treatment for patients with chronic heart transplant failure. If re-transplantation is not a viable option due to the patient's comorbidities, left ventricle assist device can be used as the destination treatment. An interdisciplinary approach with thorough follow-up can help in the early detection and treatment of complications associated with LVAD.

Results of non-elective withdrawal of continuous-flow left ventricular assist devices in selected patients

BACKGROUND

Protocols have been developed to identify patients for elective withdrawal of continuous-flow left ventricular device (cfLVAD) support. However, little is known about non-elective explantation or decommissioning of cfLVADs.

METHODS

A retrospective analysis of all patients who underwent left ventricular assist device (LVAD) explantation or decommissioning at a single center between 2002 and 2021 was performed.

RESULTS

Sixty-one patients underwent withdrawal of a cfLVAD (HeartMate II [Abbott] n = 17, HeartMate 3 [Abbott] n = 2, HeartWare HVAD [Medtronic] n = 36, INCOR [Berlin Heart] n = 6). The median follow-up after withdrawal was 1,039 days. The survival at 5 years was 76.1% (95% CI: 64.2%-95.2%). Predictors of worse outcomes in univariate regressive analysis were the duration of heart failure and the age at LVAD implantation. Of the 61 patients, 40 underwent elective withdrawal following a specific protocol. The other twenty-one patients underwent non-elective withdrawal of the cfLVAD because of device infection (n = 12), device thrombosis (n = 6), device malfunction (n = 2) or due to acute intracerebral bleeding (n = 1), also with an excellent survival at 5 years of 81.3%. (95% CI: 63.8-1). The withdrawal was performed in these patients even though they did not fulfill established criteria for successful explantation or decommissioning like clinical stability (n = 21), left ventricular end-diastolic diameter ≤ 55 mm (n = 3), performance of right heart catheterization (n = 6), or pulmonary artery wedge pressure ≤ 15 mm Hg (n = 3).

CONCLUSION

Non-elective withdrawal is possible in selected patients after discussion in a team of experienced cardiac surgeons, cardiologists, technicians, and VAD coordinators. The appropriate preoperative assessment before decommissioning or explantation of a cfLVAD warrants further investigation.

Left Ventricular Assist Device Implantation in Cancer-Therapy-Related Heart Failure

Objectives: Cancer-therapy-related heart failure (CTrHF) due to cardiotoxic drugs or radiation is a growing cause of end-stage heart failure. Limited knowledge is available concerning the use of continuous-flow left-ventricular-assist devices (cfLVAD) in this setting. Methods: The files of all 1334 patients who underwent cfLVAD implantation between December 2008 and December 2020 were screened for the cause of heart failure. All patients with CTrHF were included in the analysis. Results: A total of 32 patients with a median age of 58 years (IQR: 46–65) were included in the study; 15 (47%) were male. The median time from the first diagnosis of heart failure (HF) to cfLVAD implantation was 6 months (IQR 2–24), and from cancer treatment to cfLVAD implantation 40 months (IQR 5–144). Malignancies comprised non-Hodgkin lymphoma (n = 12, 37%), breast cancer (n = 9, 28%), sarcoma (n = 5, 16%), leukemia (n = 5, 16%), and others (n = 1, 3%). In 24 patients, chemotherapy included anthracyclines (others n = 2, unknown n = 6). Chest radiation was performed in 13 patients (39%). Moreover, 71% were classified as INTERMACS profile 1 or 2. The 30-day survival rate after LVAD implantation was 88%. Rethoracotomy was necessary in nine (29%), and a temporary right ventricular assist device in seven (21%) patients. The median survival was 29 months. There was no significant difference in survival or right HF between patients with CTrHF and a matched control group. Conclusions: CfLVAD implantation is feasible in high-risk patients with CTrHF with or without prior chest radiation.

Lived experiences of patients implanted with left ventricular assist devices

BACKGROUND

Besides survival, improvement in quality of life (QoL) is a major aim of left ventricular assist device (LVAD) implantation. QoL assessment tools in current use are effective in the gathering of standardized metrics but are limited in their ability to elucidate everyday lived patient experiences that also affect overall patient wellbeing.

OBJECTIVE

To describe and understand the lived experiences of patients undergoing long-term circulatory support with LVAD.

METHODS

A phenomenological approach was used. Purposive sampling of consecutive willing inpatients and outpatients living with an LVAD for longer than 6 months was conducted until theme saturation. There were a total of 21 patients interviewed and this was then recorded and transcribed.

RESULTS

A total of eight themes emerged from the data. Overall, the patients' quality of life was affected by: (1) whether they had experienced improvements or setbacks in their recent health condition, (2) experiencing burdens from their device such as weight and handling, (3) limitations in their physical ability such as participating in sports, their inability to work; or reduced sleep, (4) reduced social interactions; (5) reduction in sexual activity and performance; (6) experiencing emotional and psychological problems and experiencing anxiety. Patients highlighted the value of obtaining (7) support from family and friends. The interviews also revealed that some patients experienced the feeling of (8) optimism and obtaining "a second chance" at life.

CONCLUSIONS

LVAD patients have unique concerns and lived experiences. Some themes emerging from this interview series such as having to give up work, having reduced social contact, reduced sexual activity and emotional problems, family support structures demand careful attention during the pre-implantation counselling and post implantation ongoing care. These aspects also deserve more attention in quality of life studies among LVAD patients. Patients with recent improvements in health reported a more positive outlook. Overall the majority of patients reported feeling that they obtained a second chance at life.

Cardiac remodeling in patients with centrifugal left ventricular assist devices assessed by serial echocardiography

AIM

The aim of the study was to characterize the remodeling process in a large cohort of patients supported with a centrifugal left ventricular assist device (cfLVAD) by standardized serial echocardiography.

METHODS AND RESULTS

From 3/2018 all cfLVAD patients underwent transthoracic echocardiography at 6 and 12 months after implantation using a standardized protocol. A total of 512 echocardiograms were reviewed (216 preoperative, 156 at 6 months, 140 at 12 months). While on cfLVAD support, left ventricular (LV) diameter decreased (p < .001). LV ejection fraction (LVEF) and LV fractional area change improved (p < .001). Potential for cfLVAD explantation (as defined by an LVEF ≥45% and opening of the aortic valve [AV]) was seen in nine patients at 6 and 21 patients at 12 months. The tricuspid annular excursion decreased significantly, while the right ventricular fractional area change did not change. Tricuspid regurgitation (TR) and mitral regurgitation (MR) improved significantly during LVAD support. Opening of the AV was seen in >64% of the patients at 6 months and in 66% at 12 months. Moderate aortic regurgitation (AR) was rare with 3.8% at 6 months but increased with the duration of cfLVAD support (8.5% at 12 months). We found no significant difference in echocardiographic parameters between patients supported with a HeartWare HVAD™ or a HeartMate 3™ device.

CONCLUSION

LVAD therapy can lead to reverse LV remodeling and improvement of MR and TR. However, right ventricular function does not improve and prevalence of AR progressively increases during mechanical support.

Predictive Value of Two-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Ventricular Restoration

Objectives

Parameters of left ventricular (LV) mechanics, obtained from speckle-tracking echocardiography (STE), were found to be of prognostic value in patients with heart failure and those who underwent cardiac surgery. This study aimed to assess the value of STE in patients scheduled to undergo surgical ventricular restoration (SVR).

Methods

A total of 158 consecutive patients with baseline STE who underwent SVR due to an LV anteroapical aneurysm were included in the analysis. Preoperative longitudinal STE parameters were evaluated for their association with an outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation. The echocardiographic follow-up to assess the change in the regional function of the segments remote from the aneurysm was performed in 43 patients at a median of 10 months [interquartile range (IQR): 6–12.7 months] after SVR.

Results

During a median follow-up of 5.1 years (IQR: 1.6–8.7 years), events occurred in 68 patients (48%). Less impaired mean basal end-systolic longitudinal strain (BLS) with a cutoff value ≤ −10.1 % demonstrated a strong association with event-free survival, also in patients with an LV shape corresponding to an intermediate shape between aneurysmal and globally akinetic. Initially hypo- or akinetic basal segments with preoperative end-systolic strain ≤ −7.8% showed a greater improvement in wall motion at the short-term follow up.

Conclusion

Patients with less impaired preoperative BLS exhibited a better event-free survival after SVR, also those with severe LV remodeling. The preserved preoperative segmental longitudinal strain was associated with a greater improvement in regional wall motion after SVR. BLS assessment may play a predictive role in patients with an LV anteroapical aneurysm who are scheduled to undergo SVR.

The value of diastolic speckle-tracking parameters in predicting outcome after surgical ventricular restoration

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): DZHK (German Centre for Cardiovascular Research) BMBF (German Ministry of Education and Research)

Background. Parameters of speckle-tracking echocardiography (STE) are incorporated into the integrative assessment of left ventricular (LV) diastolic function 1. In this study we aimed to evaluate both established and novel STE parameters of LV diastolic function and their prognostic role in patients with LV anteroapical aneurysm planned for surgical ventricular restoration (SVR).

Methods. We retrospectively examined data of 137 patients (60 ± 11 years, 25% women) with anteroapical LV aneurysm who underwent SVR and for whom preoperative echocardiography was available and feasible for STE and for conventional assessment of LV diastolic function by transmitral flow. STE parameters evaluated were: left atrial reservoir strain (LAS), early and late global diastolic strain rate (GLSRe and GLSRa), ratio of early-to-late diastolic strain rate (GLSRe/GLSRa), and ratio of early diastolic transmitral flow velocity (E) to GLSRe and to GLSRa. In 24 patients we evaluated an association of diastolic echocardiographic parameters with mean pulmonary artery pressure (PAPm) and mean pulmonary capillary wedge pressure (PCWPm) obtained invasively within 6 days of echocardiography. Preoperative echocardiographic parameters were assessed in whole cohort of patients for the association with an outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation.

Results. During a median follow-up of 4.7 years (IQR: 1.4-8.1 years) events occurred in 59 patients. GLSRa, E/GLSRa and LAS demonstrated significant correlation with PAPm and PCWPm (Table 1). GLSRa with optimal cut-off value of ≤ 0.41 s-1 was able to detect PAPm &gt;30 mmHg with sensitivity of 0.8 and specificity of 0.8 (AUC 0.85; 95% CI 0.68-1.0; p = 0.008). E/GLSRa ≥1.24 m was able to detect PAPm &gt;30 mmHg with sensitivity of 1.0 and specificity of 0.8 (AUC 0.87; 95%CI 0.7-1.0; p = 0.005). There was significant difference in event-free survival between groups stratified by cut-offs for GLSRa (Fig. 1A) and E/GLSRa (Fig. 1B). After adjustment for important clinical (age, sex, plasma creatinine, atrial fibrillation) and echocardiographic parameters (fractional shortening and LV end-systolic volume index) GLSRa and E/GLSRa remained an independent predictors of events (HR 0.16; 95% CI: 0.03-0.86; p = 0.032 and HR 1.22; 95% CI: 1.03-1.43; p = 0.018) and demonstrated higher prognostic value compared to LAS, other STE parameters and conventional parameters of LV diastolic function.

Conclusion. Late diastolic longitudinal strain rate and ratio of early diastolic transmitral flow velocity to late diastolic longitudinal strain rate demonstrated association with hemodynamic parameters in patients with LV anteropaical aneurysm and might be used for the evaluation of LV diastolic function. These parameters showed prognostic value for patients underwent SVR and could be implemented for preoperative evaluation of these patients. Abstract Table 1. Correlation data  Abstract Figure 1. Survival curves

Comparison of feasibility and results of frailty assessment methods prior to left ventricular assist device implantation

AIMS

Assessing frailty and sarcopenia is considered a valuable cornerstone of perioperative risk stratification in advanced heart failure patients. The lack of an international consensus on a diagnostic standard impedes its implementation in the clinical routine. This study aimed to compare the feasibility and prognostic impact of different assessment tools in patients undergoing continuous-flow left ventricular assist device (cf-LVAD) implantation.

METHODS AND RESULTS

We prospectively compared feasibility and prognostic values of six frailty/sarcopenia assessment methods in 94 patients prior to cf-LVAD implantation: bioelectrical impedance analysis (BIA), computed tomography (CT)-based measurement of two muscle areas/body surface area [erector spinae muscle (TMESA/BSA) and iliopsoas muscle (TPA/BSA)], physical performance tests [grip strength, 6 min walk test (6MWT)] and Rockwood Clinical Frailty Scale (RCFS). Six-month mortality and/or prolonged ventilation time >95 h was defined as the primary endpoint. BIA and CT showed full feasibility (100%); physical performance and RCFS was limited due to patients' clinical status (feasibility: 87% grip strength, 62% 6MWT, 88% RCFS). Phase angle derived by BIA showed the best results regarding the prognostic value for 6 month mortality and/or prolonged ventilation time >95 h (odds ratio (OR) 0.66 [95% confidence interval (CI): 0.46-0.92], P = 0.019; area under the curve (AUC) 0.65). It provided incremental value to the clinical risk assessment of EuroSCORE II: C-index of the combined model was 0.75 [95% CI; 0.651-0.848] compared with C-index of EuroSCORE II alone, which was 0.73 (95% CI: 0.633-0.835). Six-month survival was decreased in patients with reduced body cell mass derived by BIA or reduced muscle area in the CT scan compared with patients with normal values: body cell mass 65% (95% CI: 51.8-81.6%) vs. 83% (95% CI: 74.0-93.9%); P = 0.03, TMESA/BSA 65% (95% CI: 51.2-82.2%) vs. 82% (95% CI: 73.2-93.0%); P = 0.032 and TPA/BSA 66% (95% CI: 53.7-81.0%) vs. 85% (95% CI: 75.0-95.8%); P = 0.035.

CONCLUSIONS

Bioelectrical impedance analysis parameters and CT measurements were shown to be suitable to predict 6-month mortality and/or prolonged ventilation time >95 h in patients with advanced heart failure prior to cf-LVAD implantation. Phase angle had the best predictive capacity and sarcopenia diagnosed by reduced body cell mass in BIA or muscle area in CT was associated with a decreased 6 month survival.

Diagnostic and Prognostic Value of a TDI-Derived Systolic Wall Motion Analysis as a Screening Modality for Allograft Rejection after Heart Transplantation

Background: Despite the risk for complications, allograft surveillance after orthotopic heart transplantation (OHT) is performed by cardiac catheterization and biopsies. We investigated the diagnostic and prognostic value of a TDI-derived systolic wall motion analysis of the posterobasal wall of the left ventricle (Sm) as a screening modality in OHT aftercare. Methods: We examined data of 210 eligible patients who underwent OHT between 2010 and 2020. Forty-four patients who had died within the initial hospital stay were excluded. For 166 patients, baseline and follow-up data were analyzed. The mean age at OHT was 46.2 (±11.4) years; 76.5% were male. Results: Within the observational period, 22 (13.3%) patients died. In total, 170 episodes of acute cellular or humoral rejections occurred (84 ISHLT1R; 13 ISHLT2R; 8 ISHLT3R; 65 AMR), and 29 catheterizations revealed cardiac allograft vasculopathy (5 CAV1; 4 CAV2; 20 CAV3). Individual Sm radial/longitudinal remained stable within the follow-up period (11.5 ± 2.2 cm/s; 10.9 ± 2.1 cm/s). Patients with acute rejections and CAV3 showed significant Sm radial/longitudinal reductions (AMR1: 1.6 ± 1.9 cm/s, confidence interval (CI) 0.77–0.243, p < 0.001; 1.8 ± 2.0 cm/s, CI 0.92–0.267, p < 0.001. ISHLT1R: 1.7 ± 1.8 cm/s, CI 1.32–2.08, p < 0.001; 2.0 ± 1.6 cm/s, CI 1.66–2.34, p < 0.001. CAV3: 1.3 ± 2.5 cm/s, CI 0.23–2.43, p < 0.017; 1.4 ± 2.8 cm/s, CI 0.21–2.66, p < 0.021). Lower Sm was associated with a threefold increase in all-cause mortality (hazard ratio (HR) 3.24, CI 1.2–8.76, p = 0.020; HR 2.92, CI 1.19–7.18, p = 0.019). Overall, Sm-triggered surveillance led to 0.75 invasive diagnostics per patient post-OHT year. Conclusions: Sm remained stable in the post-OHT course. Reductions indicated ISHLT1R, AMR1 and CAV3 and were associated with higher all-cause mortality. Sm-triggered surveillance may be referred to as a safe, high-yield screening modality in OHT aftercare.

Impact of Muscle Mass as a Prognostic Factor for Failed Waiting Time Prior to Heart Transplantation

Objectives: Clinical deterioration during the waiting time impairs the prognosis of patients listed for heart transplantation. Reduced muscle mass increases the risk for mortality after cardiac surgery, but its impact on resilience against deterioration during the waiting time remains unclear.

Methods: We retrospectively analyzed data from 93 patients without a VAD who were listed in Eurotransplant status “high urgent (HU)” for heart transplantation between January 2015 and October 2020. The axial muscle area of the erector spinae muscles at the level of thoracic vertebra 12 indexed to body surface area (TMESA/BSA) measured in the preoperative thoracic computed tomography scan was used to measure muscle mass.

Results: Forty patients (43%) underwent emergency VAD implantation during the waiting time and four patients (4%) died during the waiting time. The risk of emergency VAD implantation/death during the waiting time decreased by 10% for every cm²/m² increase in muscle area [OR 0.901 (95% CI: 0.808–0.996); p = 0.049]. After adjusting for gender [OR 0.318 (95% CI: 0.087–1.073); p = 0.072], mean pulmonary artery pressure [OR 1.061 (95% CI: 0.999–1.131); p = 0.060], C-reactive protein [OR 1.352 (95% CI: 0.986–2.027); p = 0.096], and hemoglobin [OR 0.862 (95% CI: 0.618–1.177); p = 0.360], TMESA/BSA [OR 0.815 (95% CI: 0.698–0.936); p = 0.006] remained an independent risk factor for emergency VAD implantation/death during the HU waiting time.

Conclusion: Muscle area of the erector spinae muscle appears to be a potential, easily identifiable risk factor for emergency VAD implantation or death in patients on the HU waiting list for heart transplantation. Identifying patients at risk could help optimize the outcome and the timing of VAD support.

Manual zur Indikation und Durchführung spezieller echokardiographischer Anwendungen

Das zweite Manual zur Indikation und Durchführung der Echokardiographie bezieht sich auf spezifische Anwendungen der Echokardiographie und besondere Fragestellungen bei speziellen Patientengruppen. Dabei stehen v. a. praktische Aspekte im Vordergrund. Methodisch etabliert sind die transösophageale Echokardiographie, die Stressechokardiographie und die Kontrastechokardiographie. Bei nahezu allen echokardiographischen Untersuchungen spielen aktuell 3‑D-Echokardiographie und Deformationsbildgebung eine Rolle. Das gesamte Spektrum der echokardiographischen Möglichkeiten wird derzeit in Notfall- und Intensivmedizin, bei der Überwachung und Führung von Katheterinterventionen, bei strukturellen Herzerkrankungen, bei herzchirurgischen Operationen, bei der Nachsorge von kardialen Unterstützungssystemen, bei kongenitalen Vitien im Erwachsenenalter und bei der Versorgung von hochinfektiösen Patienten in Pandemiezeiten angewandt. Die diagnostischen Fortschritte der konventionellen und modernen echokardiographischen Anwendungen stehen im Fokus dieses Manuals. Die 3‑D-Echokardiographie zur Charakterisierung der kardialen Morphologie und die Deformationsbildgebung zur Objektivierung der kardialen Funktion sind bei vielen Indikationen im klinischen Alltag etabliert. Die Stressechokardiographie zur Ischämie‑, Vitalitäts- und Vitiendiagnostik, die Bestimmung der koronaren Flussreserve und die Kontrastechokardiographie bei der linksventrikulären Wandbewegungsanalyse und kardialen Tumordetektion finden zunehmend klinische Anwendung. Wie für die konventionelle Echokardiographie im ersten Manual der Echokardiographie 2009 beschrieben, erfordert der Einsatz moderner echokardiographischer Verfahren die standardisierte Dokumentation und Akquisition bestimmter Bildsequenzen bei optimierter Geräteeinstellung, da korrekte und reproduzierbare Auswertungen nur bei guter Bildqualität möglich sind.

Safety of Contemporary Heart Failure Therapy in Patients with Continuous-Flow Left Ventricular Assist Devices

BACKGROUND

Limited data are available concerning the safety, optimal administration and benefits of contemporary heart failure therapy in patients after left ventricular assist device (LVAD) implantation.

METHODS

Between 2015 and 2019, 257 patients underwent LVAD implantation and were included in this observational study. Oral heart failure therapy was initiated and uptitrated during the further course. After propensity matching and excluding patients with immediate postoperative treatment in an affiliated center with different medical standards, hospitalization rates and mortality within 12 months after LVAD implantation were compared between 83 patients who received medical therapy including an angiotensin receptor neprilysin inhibitor (ARNI) and 83 patients who did not receive an ARNI.

RESULTS

The overall use of heart-failure medications after 12 months was high: prescriptions: beta-blockers, 85%; angiotensin inhibiting drugs, 90% (angiotensin-converting-enzyme inhibitors 30%, angiotensin receptor blockers 23%, ARNI 37%); mineralocorticoid receptor antagonists, 80%. No serious drug-related adverse events occurred. The conditional 1-year survival in the group with ARNIs was 97% (95% CI: 94%-100%) compared to 88% in the group without an ARNI (95% CI: 80%-96%); P = 0.06.

CONCLUSIONS

Contemporary heart failure therapy is safe in patients with LVADs. No increase in serious adverse events was seen in patients receiving ARNIs. No significant difference in the conditional 1-year survival was seen between the ARNI group and the nonARNI group.

Myocardial Work Assessment for the Prediction of Prognosis in Advanced Heart Failure

Objectives: The aim of this study was to investigate whether echocardiographic assessment of myocardial work is a predictor of outcome in advanced heart failure.

Background: Global work index (GWI) and global constructive work (GCW) are calculated by means of speckle tracking, blood pressure measurement, and a normalized reference curve. Their prognostic value in advanced heart failure is unknown.

Methods: Cardiopulmonary exercise testing and echocardiography with assessment of GWI and GCW was performed in patients with advanced heart failure caused by ischemic heart disease or dilated cardiomyopathy (n = 105). They were then followed up repeatedly. The combined endpoint was all-cause death, implantation of a left ventricular assist device, or heart transplantation.

Results: The median patient age was 54 years (interquartile range [IQR]: 48–59.9). The mean left ventricular ejection fraction was 27.8 ± 8.2%, the median NT-proBNP was 1,210 pg/ml (IQR: 435–3,696). The mean GWI was 603 ± 329 mmHg% and the mean GCW was 742 ± 363 mmHg%. The correlation between peak oxygen uptake and GWI as well as GCW was strongest in patients with ischemic cardiomyopathy (r = 0.56, p = 0.001 and r = 0.53, p = 0.001, respectively). The median follow-up was 16 months (IQR: 12–18.5). Thirty one patients met the combined endpoint: Four patients died, eight underwent transplantation, and 19 underwent implantation of a left ventricular assist device. In the multivariate Cox regression analysis, only NYHA class, NT-proBNP and GWI (hazard ratio [HR] for every 50 mmHg%: 0.85; 95% CI: 0.77–0.94; p = 0.002) as well as GCW (HR for every 50 mmHg%: 0.86; 95% CI: 0.79–0.94; p = 0.001) were identified as independent predictors of the endpoint. The cut-off value for predicting the outcome was 455 mmHg% for GWI (AUC: 0.80; p < 0.0001; sensitivity 77.4%; specificity 71.6%) and 530 mmHg% for GCW (AUC: 0.80; p < 0.0001; sensitivity 74.2%; specificity 78.4%).

Conclusions: GWI and GCW are powerful predictors of outcome in patients with advanced heart failure.

Development of tricuspid regurgitation and right ventricular performance after implantation of centrifugal left ventricular assist devices

Background

Tricuspid regurgitation (TR) after left ventricular assist device (LVAD) implantation is associated with a poor prognosis. This study evaluates the development of TR and right ventricular (RV) performance after LVAD implantation.

Methods

Retrospective analysis of patients who underwent LVAD implantation between March 2018 and June 2019. Patients who underwent concomitant tricuspid valve surgery and patients with congenital heart disease were excluded.

Results

A total of 155 patients underwent LVAD implantation. Fourteen patients were excluded. Of the remaining patients, thirty-one died during the first six months, six were lost to follow-up and two underwent transplantation. 102 patients presented at 6.3 months (5.8 to 7.0). Patients were supported with HeartWare HVAD (74%) or HeartMate 3 (26%). 50.4% were rated as INTERMACS profile 1 or 2. At six months, systolic pulmonary artery pressure dropped from 36 to 21 mmHg (P<0.001). Tricuspid annular plane systolic excursion decreased from 17.3 to 14.3 mm (P<0.001), RV fractional area change did not change (P=0.839). Twenty-two patients (22%) presented with moderate-to-severe or severe (ms-s) TR pre-operatively. Of these, eighteen (81%) showed improvement to ≤ moderate TR. At follow-up twelve patients presented with ms-s TR. Of these, only four patients (33%) had been diagnosed with ms-s TR pre-operatively. There were no differences in pre-operative echocardiographic or clinical parameters between the twelve patients with ms-s late TR and the other ninety patients in the cohort.

Conclusions

TR can show an impressive improvement with LVAD support. Longitudinal RV function decreases; this appears to be compensated by transverse shortening. Late TR can develop independently from pre-operative parameters including TR.

Feasibility of two-dimensional speckle-tracking echocardiography of aortic valve in patients with calcific aortic valve disease

Calcific aortic valve (AV) disease is associated with increased stiffness and reduced motion of AV leaflets, has a progressive course, and can develop into aortic stenosis (AS). Our aim was to evaluate whether two-dimensional speckle-tracking echocardiography (STE) may be used for the assessment of AV stiffness. We applied STE to AV leaflets in patients with various degrees of degenerative changes of AV and measured strain as an absolute value of the radial deformation of AV leaflets. Deformation of AV expressed as averaged AV strain was greatest in patients with a normal AV (23.4 ± 6.4%), compared to those with aortic sclerosis (12.9 ± 3.2%), moderate-to-severe AS (11.9 ± 4%), and severe AS (10.9 ± 3.5%) (p < 0.01). A non-linear relationship and moderate correlation of AV strain with transvalvular hemodynamic parameters was observed. In patients with mild-to-moderate AS, the strain of AV leaflets also correlated negatively with AV calcification (r = -0.59, p = 0.008). Good inter-observer agreement was obtained for averaged AV strain with a coefficient of variation of 0.15 and an interclass correlation coefficient of 0.94 (p < 0.0001). In this study we demonstrated that deformation of AV leaflets as assessed by STE might be a potential method for a non-invasive evaluation of AV biomechanical properties and of the progression of calcific aortic disease. Further development of the two-dimensional speckle tracking technique specifically for valve structures is needed to enable a better quantification of leaflet deformation.

Validity of the 6-Minute Walk Test in Patients with End-Stage Lung Diseases Wearing an Oronasal Surgical Mask in Times of the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

The 6-minute walk test (6MWT), as a clinical assessment tool for functional exercise capacity, is an integral component of lung allocation scores (LASs). In times of the coronavirus disease (COVID-19) pandemic, patients underwent 6MWTs wearing a surgical mask in ambulatory care. We investigated the impact of wearing a mask on 6-minute walk distances (6MWDs).

METHOD

6MWDs of 64 patients with end-stage lung diseases wearing an oronasal surgical mask were retrospectively compared to previously investigated 6MWDs of the same cohort, in a pre-COVID-19 pandemic era, without wearing a mask. Four patients were excluded due to a primary vascular disease, 29 patients due to clinically unstable pulmonary functions, and 1 patient due to a psychiatric disorder.

RESULTS

The median age of the patients included was 55 (46-58) years; 15 (48%) were male. Ten (32.2%) were on the Eurotransplant lung transplant waiting list with a median LAS of 34.3 (31.9-36.2). Twenty (64.5%) patients had chronic obstructive pulmonary diseases, 7 (22.6%) had interstitial lung diseases, and 4 (12.9%) had other end-stage lung diseases. The mean 6MWD without versus with wearing a mask was 306.9 (101.9) versus 305.7 (103.8) m, with a mean difference of -1.19 m (95% confidence interval -13.4 to 11.03). The observed difference is statistically equivalent to zero (p < 0.001). No significant differences in 6MWDs were observed between the clinical groups.

CONCLUSION

Wearing an oronasal surgical mask did not affect the 6MWDs of patients with advanced lung diseases. Therefore, a masked 6MWT appears to provide a reliable examination of functional exercise capacity in this cohort.

Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness

The echocardiographic assessment of mitral valve regurgitation (MR) by characterizing specific morphological features and grading its severity is still challenging. Analysis of MR etiology is necessary to clarify the underlying pathological mechanism of the valvular defect. Severity of mitral regurgitation is often quantified based on semi-quantitative parameters. However, incongruent findings and/or interpretations of regurgitation severity are frequently observed. This proposal seeks to offer practical support to overcome these obstacles by offering a standardized workflow, an easy means to identify non-severe mitral regurgitation, and by focusing on the quantitative approach with calculation of the individual regurgitant fraction. This work also indicates main methodological problems of semi-quantitative parameters when evaluating MR severity and offers appropriateness criteria for their use. It addresses the diagnostic importance of left-ventricular wall thickness, left-ventricular and left atrial volumes in relation to disease progression, and disease-related complaints to improve interpretation of echocardiographic findings. Finally, it highlights the conditions influencing the MR dynamics during echocardiographic examination. These considerations allow a reproducible, verifiable, and transparent in-depth echocardiographic evaluation of MR patients ensuring consistent haemodynamic plausibility of echocardiographic results.

Assessment of 10-Year Left-Ventricular-Remodeling by CMR in Patients Following Aortic Valve Replacement

Aims: Aortic valve replacement (AVR) may result in reverse cardiac remodeling. We aimed to assess long-term changes in the myocardium following AVR by Cardiac Magnetic Resonance Imaging (CMR).

Methods: We prospectively observed the long-term left ventricular (LV) function and structure of 27 patients with AVR [n = 19 with aortic stenosis (AS); n = 8 with aortic regurgitation (AR)] by CMR. Patients underwent CMR before, as well as 1, 5, and 10 years after AVR. We evaluated clinical parameters, LV volumes, mass, geometry, ejection fraction (EF), global myocardial longitudinal strain (MyoGLS), global myocardial circular strain (MyoGCS), hemodynamic forces (HemForces), and Late Gadolinium Enhancement (LGE).

Results: The median of LVMI, EDVI, and ESVI decreased in both groups. Patients with AR had higher initial values of EDVI and ESVI and showed a more prominent initial reduction. In AS, MyoGLS improved already after 1 year and remained constant afterward, whereas, in AR no improvement of MyoGLS was found. MyoGCS remained unchanged in the AS group but deteriorated in the AR group over 10 years. Ejection fraction (EF) was higher in AS patients compared to AR 10 years post-AVR. Late gadolinium enhancement (LGE) could be found more frequently in AS patients.

Conclusion: CMR was well suited to investigate myocardial changes over a 10-year follow up period in patients with aortic valve disease. Regarding the long-term functional changes following AVR, patients with AR seemed to benefit less from AVR compared to AS patients. Fibrosis was more common in AS, but this did not reflect functional evolution in these patients. Close monitoring seems indispensable to avoid irreversible structural damage of the heart and to perform AVR at an appropriate stage.

Two-dimensional echocardiography compared to cardiac computed tomography for assessment of left ventricular volume and function in patients with anteroapical aneurysm

Funding Acknowledgements

Type of funding sources: None.

Background. Two-dimensional (2D) echocardiography is widely accepted method for the assessment of left ventricular (LV) morphology and function after myocardial infarction and for initial preoperative evaluation of patients planned for surgical ventricular repair (SVR). Magnetic resonance imaging and cardiac computer tomography (CT) provide more accurate measurements, but not always available.

Purpose. The aim of this study was to compare 2D-echocardiography and CT for preoperative assessment of patients with LV aneurysm in order to optimize the perioperative management in SVR.

Methods. Patients (n = 179, mean age 62.6 ± 11 years, 23.5% women) with LV anteroapical aneurysm due to myocardial infarction were examined by echocardiography and CT before SVR. LV end-diastolic and end-systolic volumes (LVEDV and LVESV) and ejection fraction (EF) obtained by two methods were compared pairwise. Prognostic role for the prediction of all-cause death was assessed for preoperative parameters in multivariate Cox regression model adjusted for patient age, sex, NYHA class, diabetes mellitus, renal failure, atrial fibrillation and arterial hypertension.

Results. There was a strong correlation for preoperative LVEDV and LVESV measured by echocardiography and CT (r = 0.85, r = 0.87, p &lt; 0.0001), however volumes obtained by echocardiography were smaller compared to those by CT (Table) with higher difference in patients with more dilated LV, as demonstrated by Bland-Altman analysis (Fig.). No significant difference in mean preoperative EF was observed with moderate correlation between two methods (r = 0.67, p &lt; 0.0001). In total 68 patients died during median follow up of 5.3 years (IQR: 1.7-8.7 years) after SVR. Comparable predictive value was demonstrated for LVEDV measured by CT and echocardiography (for 10 ml increase HR = 1.04, p = 0.004 and HR = 1.06, p = 0.0001), as well as for LVESV (for 10 ml increase HR = 1.04, p = 0.001 and HR = 1.07, p = 0.0001) and for EF (for 5% increase HR = 0.83, p = 0.004 and HR = 0.81, p = 0.004).

Conclusion. In patients with LV aneurysm 2D-echocardiography may be used for the assessment of LV volumes and function and have similar prognostic role compared to CT in patients evaluated for SVR. Underestimation of LV volumes by echocardiography must be considered, especially in patients with more dilated LV.

Comparison of CT and echocardiography Parameter CT Echo Mean difference p-value LVEDV, ml LVESV, ml EF, % 289 ± 104 198 ± 97 34 ± 12 222 ± 81 149 ± 67 35 ± 9 67 ± 56 49 ± 51 -0.9 ± 9.2 &lt;0.0001 &lt;0.0001 0.215 Abstract Figure. Bland-Altman plots for LVEDV and LVESV

Experience with a standardized protocol to predict successful explantation of left ventricular assist devices

OBJECTIVE

Patients with a continuous-flow left ventricular assist device may show recovery of myocardial function with unloading. Identifying candidates for and predicting clinical and hemodynamic stability after left ventricular assist device explantation remain challenging.

METHODS

Retrospective analysis of patients who underwent evaluation for left ventricular assist device explantation following a standardized protocol from January 2016 to March 2020. Patients who met screening criteria underwent echocardiography under "baseline," "minimal net flow," and "pump stop" conditions. If the protocol criteria were met, right heart catheterization with left ventricular assist device stoppage and occlusion of the outflow graft with a balloon catheter were performed. In patients with pulmonary capillary wedge pressure less than 16 mm Hg, explantation was performed under "pump stop" conditions.

RESULTS

A total of 544 patients were screened. Of these, 57 (10.5%) underwent a total of 73 echocardiography under "baseline" "minimal net flow" and "pump stop" conditions and 46 underwent left ventricular assist device stoppage and occlusion of the outflow graft with balloon catheter maneuvers. Complications during the procedure were rare. Ultimately, 21 patients (3.9%) underwent explantation. The left ventricular ejection fraction at baseline was 55.5% ± 6.5%. The mean pulmonary capillary wedge pressure was 8.1 ± 2.6 mm Hg and increased to 10.7 ± 2.9 mm Hg under left ventricular assist device stoppage and occlusion of the outflow graft with a balloon catheter. A nonischemic cause of cardiomyopathy was more likely to be found in patients who underwent explantation (20/21 patients [95%], P = .020). The survival 1 year after explantation was 95.2%, with 1 death occurring 222 days after left ventricular assist device explantation. At follow-up (median 24.9 months [interquartile range, 16.4-43.1 months]), patients were in New York Heart Association class 1 (61.9%), 2 (28.6%), and 3 (9.5%).

CONCLUSIONS

Our 4-year experience with a standardized protocol for left ventricular assist device explantation showed a low rate of adverse events. If all criteria are met, explantation can be performed safely and with an excellent survival and functional class.

Minimally invasive left ventricular reconstruction of a postinfarction, anterior left ventricular scar (BioVentrix Revivent TC procedure)

Surgical ventricular reconstruction is a proven option for treating patients who have heart failure due to a postinfarction scar or an aneurysm of the left ventricle. The BioVentrix Revivent TC System offers a reliable alternative to the conventional, more invasive surgical ventricular restoration. The system requires no sternotomy, no heart-lung machine, and no cardioplegic arrest.  In this video tutorial, we present our technique for using the Revivent TC System to reconstruct the normal left ventricular shape and volume in a patient with a postinfarction, anteroapical scar.

Prognostic role of left ventricular diastolic function assessed by speckle tracking echocardiography in patients after surgical ventricular repair

Background

Assessment of left ventricular (LV) diastolic function brings important prognostic information for patients with heart failure and could be evaluated by speckle tracking echocardiography (STE). Less known about its role in patients planned for surgical ventricular repair due to LV aneurysm.

Purpose

The aim of this study was to evaluate the prognostic role of STE parameters of LV diastolic function for prediction of all-cause mortality in patients after surgical ventricular repair.

Methods

We retrospectively evaluated data of 163 consecutive pts (mean age 62.3±11.5 years, 74.8% males) with anteroapical LV aneurysm who underwent surgical ventricular repair combined with coronary artery bypass surgery (71.8%) Prognostic role for prediction of all-cause mortality was assessed for various STE parameters, including left atrial strain (LAS) measured as peak reservoir strain and for the ratio of early to late global longitudinal strain rate (GLSRe/GLSRa).

Results

During a median follow-up of 4.7 years (IQR: 1.6–8.9 years) there were 65 deaths, 5 year survival rate was 73.8 (95% CI 67–79%). Baseline ejection fraction, end-diastolic and end-systolic volumes of LV did not differ between pts who died and survived at 5 year after the surgery, whereas LAS was significantly higher and GLSRe/GLSRa was significantly lower in survivors. Cox proportional hazard model adjusted to demographic and clinical variables demonstrated that LAS and GLSRe/GLSRa were independent predictors of all-cause death, with HR of 0.79 (95% CI 0.66–0.95, p=0.012) for each 5% increase of LAS and HR of 1.24 (95% CI 1.1–1.4, p=0.001) for each 0.5 increase of GLSRe/GLSRa. Moreover, GLSRe/GLSRa remained an independent predictor after additional adjustment for LV end-systolic volume, sphericity index and presence of mitral insufficiency of grade 2 and higher. A significant difference in median survival time was demonstrated according to the following cut-offs: LAS ≥16.7% (12.1 vs. 6.4 years, p=0.01), GLSRe/GLSRa ratio ≥2.3 (3.3 years vs. 10.2 years, p=0.0005) (Figure). The classification and regression tree analysis with the application of all two-dimensional, Doppler and various speckle-tracking echocardiographic parameters revealed that GLSRe/GLSRa and LAS were the most important echocardiographic variables for risk stratification for 5-year mortality.

Conclusion

This study demonstrates that STE parameters of LV diastolic function are important predictors of all-cause mortality after surgical ventricular repair due to anteroapical aneurysm of LV and could be used in the preoperative decision-making process.

Funding Acknowledgement

Type of funding source: None

Validity of visual assessment of aortic valve morphology in patients with aortic stenosis using two-dimensional echocardiography

The diagnostic value of a visual assessment of aortic valve (AV) morphology for grading aortic stenosis (AS) remains unclear. A visual score (VS) for assessing the AV was developed and its reliability with respect to Doppler measurements and the calcium score (ctCS) derived by multislice computed tomography was evaluated. 99 Patients with AS of various severity and 38 patients without AS were included in the analysis. Echocardiographic studies were evaluated using the new VS which includes echogenicity, thickening, localization of lesions and leaflet mobility, with a total score ranging from 0 to 11. The association of VS with ctCS and the severity of AS was analyzed. There was a significant correlation of VS with AV hemodynamic parameters and with ctCS. The cut-off value for the detection of AS of any grade was a VS of 6 (sensitivity 95%, specificity 85% for women; sensitivity 85%, specificity 88% for men). A VS of 9 for women and of 10 for men was able to predict severe AS with a high specificity (96% in women and 94% in men, AUC 0.8 and 0.86, respectively). The same cut-off values were identified for the detection of ctCS of ≥ 1600 AU and ≥ 3000 AU with a specificity of 77% and 82% (AUC 0.69 and 0.81, respectively). Assessment of aortic valve morphology can serve as an additional diagnostic tool for the detection of AS and an estimation of its severity.

Transcatheter Restoration of the Left Ventricular Outlet in a Patient With an Implanted Apicoaortic Conduit

We describe the transcatheter management of severe aortic regurgitation in a middle-aged patient with a porcelain aorta who underwent implantation of an apicoaortic valved conduit 12 years ago. Instantaneous relief of heart failure symptoms was achieved by restoring antegrade blood flow to the ascending aorta. (Level of Difficulty: Advanced.)

Safety of bioelectrical impedance analysis in advanced heart failure patients

BACKGROUND

Cardiac cachexia and frailty are major complications of advanced heart failure (AHF). Bioelectrical impedance analysis (BIA) may provide valuable information regarding fluid balance, muscle mass and prognosis. The main concerns regarding the use of BIA in AHF patients remain arrhythmias and electromagnetic interferences with cardiac implantable electronic devices (CIEDs). Reliable data regarding patients on continuous-flow ventricular assist device (cf-VAD) remain scarce. The aim of this study is to evaluate the safety of BIA in AHF patients on pro-arrhythmogenic therapy with an implanted CIED and/or with a cf-VAD.

METHODS

We prospectively performed 217 BIA measurements in 143 AHF patients at risk of severe arrhythmias due to inotropic support/a history of ventricular arrhythmias and/or treated with CIED, including 104 patients with an ICD, CRT or pacemaker and 95 patients with a cf-VAD. All patients were under continuous Electrocardiogram (ECG) monitoring and clinical surveillance for 24 hours.

RESULTS

No adverse events were observed during the 217 BIA measurements: No rhythm disturbances were documented in the telemetric monitoring during or within 30 minutes after the measurement. CIEDs showed no malfunction, regardless of the location measured or the device manufacturer. In particular, no inappropriate shocks were observed. No alarms, flow disturbances, or malfunctions of the cf-VAD occurred during or after the measurements.

CONCLUSION

We consider BIA a safe measurement with major clinical relevance in our cohort of AHF patients, despite an increased arrhythmic potential on inotropic support or the presence of implanted electronic devices (ICD, CRT, pacemaker and cf-VAD).

Transcatheter aortic valve implantation and its impact on mitral valve geometry and function

BACKGROUND

The aim of this study was to evaluate the impact of transcatheter aortic valve implantation (TAVI) on mitral valve geometry and function.

METHODS

Eighty-four patients underwent TAVI. Forty-four (52%) patients received a balloon-expandable valve and 40 (48%) were implanted with a self-expandable valve. All patients underwent three-dimensional-volumetric transesophageal echocardiography of the mitral valve before and immediately after TAVI. A dedicated software was used for assisted semiautomatic measurement of mitral annular geometry.

RESULTS

During systole, the anterior to posterior (AP) diameter was significantly reduced after the procedure (3.4 ± 0.5 cm vs 3.2 ± 0.5 cm; P < .05). The mitral annular area (10.8 ± 2.8cm² vs 9.9 ± 2.6cm² ; P < .05) as well as the tenting area (1.6 ± 0.7 cm² vs 1.2 ± 0.6 cm² ; P < .001) measured at mid-systole were reduced after TAVI. Diastolic measures were similar. Patients treated with balloon-expandable valves showed a significantly larger reduction in the AP diameter compared to self-expandable valves (-0.25 cm vs -0.11 cm; P < .05). The reduction of the annular area was higher in the balloon-expandable group (-1.2 ± 1.59 vs -0.22 ± 1.41; P < .05). Grade of mitral regurgitation did improve or remained stable after TAVI.

CONCLUSION

TAVI significantly impacts the mitral valve and mitral annular geometry and morphology. The choice of the prosthesis (balloon- vs self-expandable) may be relevant for those changes.

Global work index correlates with established prognostic parameters of heart failure

AIM

Identification of patients with heart failure and a poor prognosis is paramount to ensure timely and adequate treatment. We investigated the relationship between the new measures of noninvasive pressure-strain analysis, such as the global work index (GWI), and established prognostic parameters of echocardiography, cardiopulmonary exercise test (CPX), and N-terminal pro-B-type natriuretic peptide (NT-pro-BNP).

METHODS AND RESULTS

We retrospectively analyzed data of 51 patients with heart failure. Echocardiography and CPX were performed, and NT-pro-BNP was determined. Patients with a GWI < 500 mm Hg% had a mean LVEDV of 286.1 ± 100.8 mL, an LVEF of 21.3 ± 5.7%, and a stroke volume (SV) of 45.9 ± 11.6 mL, and patients with a GWI > 1000 mm Hg% had an LVEDV of 147.9 ± 39.6 mL, an LVEF of 42.6 ± 4.8%, and a SV of 70.9 ± 14.3 mL. The GWI also showed a significant correlation with peak oxygen consumption (peak VO₂ ) (r = .521; P < .001) and with NT-pro-BNP (r = .635; P < .001). Patients with a GWI of <500 mm Hg% had a significantly higher NT-pro-BNP (median 2415 pg/mL [IQR 1071, 5933]) and a lower peak VO₂ (9.5 mL/min/kg ± 2.6) compared to patients with a GWI of >1000 mm Hg% (NT-pro-BNP median 253 pg/mL [IQR 150, 549]; peak VO₂ 15.6 ± 4.2 mL/min/kg).

CONCLUSION

GWI correlates with known prognostic markers of heart failure. A GWI of <500 mm Hg% was a predictor of severely impaired ejection fraction, very low exercise capacity, and strongly elevated NT-pro-BNP, indicating a poor prognosis.

1036 Prognostic role of left ventricle longitudinal strain for the prediction of survival after surgical ventricular repair

Background

Surgical ventricular repair (SVR) in patients with ischemic cardiomyopathy is aimed to reshape left ventricle (LV) and reduce its volume in order to improve prognosis and quality of life. There are controversies regarding benefit of SVR, especially in patients with severely enlarged LV.

Purpose

Our purpose was to investigate prognostic value of LV longitudinal strain for survival and for the improvement of LV function after SVR in patients with anteroapical LV aneurysm.

Methods

218 pts (2005-2018, mean age 63.6 ± 11.2y, 73.9% males) with anteroapical LV aneurysm due to myocardial infarction underwent SVR combined with coronary bypass grafting (77.5%), mitral valve repair (18.3%) and LV thrombectomy (22.0%). Preoperative strain analysis was done retrospectively for 146 patients. Prognostic value of strain was tested in pts according to the LV end systolic volume index (LVESVI) with the cut-off value of 60ml/m². In 17 pts 1-year follow-up with strain quantification was done.

Results

During a median follow-up of 3.9 years (IQR: 1.0-6.8 years) there were 68 deaths and 1 patient was lost to follow-up. 30-days survival rate was 93.5% (95%CI: 90.3; 96.9%), 5 year survival – 72.5% (95%CI: 66.0-79.6%). Pts who died were significantly older, with higher proportion of diabetes (DM), peripheral artery disease, renal failure (RF) and atrial fibrillation (AF). Baseline ejection fraction (EF) and global longitudinal strain (GLS) did not differ significantly. Whereas basal longitudinal strain (BLS) was higher (more negative) in pts who survived (-11.4 ± 3% vs. -10.1 ± 4%, p = 0.027). Risk stratification by tertiles revealed that BLS was a significant predictor of survival. The risk of dying was 3 times higher for pts in the lowest tertile compared to those in the highest tertile (HR: 2.94, 95%CI:1.37-6.25, p = 0.013). When adjusted to age, AF, DM, RF, and previous heart surgery, BLS was an independent predictor of death (HR = 1.14, 95%CI:1.03;1.26, p = 0.032). At 1-year follow-up (12.7 ± 5.1 months) there was significant decrease of LV end-diastolic and end-systolic volume indices, from 102.8 ± 24.1 ml/m² to 77.9 ± 24 ml/m² (p &lt; 0.001) and from 67 ± 23.2 ml/m² to 44.3 ± 7.6 ml/m² (p &lt; 0.001), correspondingly, and increase of EF from 36.3 ± 9.4% to 44.4 ± 7.6% (p = 0.001). The mean systolic GLS improved from -6.6 ± 2.6% to -8.7 ± 3.2%, p = 0.008. Among 81 segments with baseline hypokinesia, 44 segments (54.3%) recovered their contractility, 36 segments (44.4%) remained hypokinetic and 1 segment deteriorated to akinesia. Mean systolic strain of segments which showed recovery was -6.6 ± 4.0% compared to -3.8 ± 4.5% with no improvement (p = 0.005). Cut-off value of systolic strain for prediction of recovery was -5.4 % (AUC = 0.69, p = 0.004; PPV = 0.73, NPV = 0.61).

Conclusion

Our study demonstrates that BLS is an independent predictor of survival after SVR in patients with LV anteroapical aneurysm. Furthermore, higher systolic strain predicts recovery of LV regional function at 1-year after SVR.

Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation

According to recent recommendations on echocardiographic assessment of aortic valve stenosis direct measurement of transvalvular peak jet velocity, calculation of transvalvular mean gradient from the velocities using the Bernoulli equation and calculation of the effective aortic valve area by continuity equation are the appropriate primary key instruments for grading severity of aortic valve stenosis. It is obvious that no gold standard can be declared for grading the severity of aortic stenosis. Thus, conclusions of the exclusive evaluation of aortic stenosis by Doppler echocardiography seem to be questionable due to the susceptibility to errors caused by methodological limitations, mathematical simplifications and inappropriate documentation. The present paper will address practical issues of echocardiographic documentation to satisfy the needs to analyze different scenarios of aortic stenosis due to various flow conditions and pressure gradients. Transesophageal and multidimensional echocardiography should be implemented for reliable measurement of geometric aortic valve area and of cardiac dimensions at an early stage of the diagnostic procedure to avoid misinterpretation due to inconsistent results.

Adjusting preoperative risk models of post heart transplant survival to a European cohort in the age of a new cardiac allocation score in Europe

Background Several risk models target the issue of posttransplant survival, but none of them have been validated in a large European cohort. This aspect is important, in a time of the planned change of the Eurotransplant allocation system to a scoring system. Material and Methods Data of 761 heart transplant recipients from the Eurotransplant region with a total follow up of 5027 patient-years were analyzed. We assessed 30-day to 10-year freedom from graft failure. Existing post-transplant mortality risk models, IMPACT, Meld-XI and Columbia Risk Stratification Score were (RSS) were evaluated. A new risk model was created and the predictive accuracy was compared with the existing risk scores, with a focus on LVAD patients. Results Thirty-day, 1-year, 5-year and 10-year rates of freedom from graft failure were 78.3±1.5%, 68.8±1.71%, 59.1±1.8% and 44.1±1.9. The 1-year incidence of graft failure varied from 14.1% to 50% (RSS), from 22.9% to 57.1 (IMPACT) and from 24.9% to 42.6% using MELD-XI. Our newly adjusted risk score showed an improved area under the curve (AUC) of 0.69 (95% CI 0.64-0.72) with better discrimination in the intermediate to moderate risk cohort (CABDES Score). Conclusion IMPACT, Meld-XI and RSS were suitable to predict posttransplant graft failure only in a high and low risk cohort. CABDES Score, might be an alternative scoring system, with donor age and eGFR beeing the strongest predictors. Implementation of the IMPACT score within the new Eurotransplant Cardiac Allocation Score for patient prioritization for heart transplantation, should be reevaluated.

Outcomes from a recovery protocol for patients with continuous-flow left ventricular assist devices

BACKGROUND

In this retrospective analysis we evaluated a standardized echocardiographic assessment and an invasive technique for patient selection for successful continuous-flow left ventricular assist device (CF-LVAD) explantation.

METHODS

Inclusion criteria for LVAD recovery assessment were: clinically stable condition; LVAD support for >6 months; physical activity; normal echocardiography findings; and no more than mild valvular disease and aortic valve opening. In a second step, echocardiography was performed under CF-LVAD reduction and stop conditions (PStopE). In the third step, patients who presented with stable parameters underwent right heart catheterization under CF-LVAD stoppage and occlusion of the outflow graft with a balloon catheter. Criteria for explantation were normal pulmonary artery pressure and pulmonary capillary wedge pressure <16 mmHg.

RESULTS

Thirty-three of 424 patients entered the second step of evaluation and 20 entered the third step. Fourteen presented positive results and the pump was successfully explanted. The PCWP at baseline was 8.5 (2.8) mmHg in the explantation group and 10.6 (2.8) mmHg in the non-explantation group (p = 0.105). It increased to 10.9 (3.0) mmHg vs 20.8 (4.9) mmHg under outflow graft occlusion. The wedge pressure was significantly higher in the non-explantation group (p < 0.001). Median duration of follow-up after explantation was 9.74 (interquartile range 4.3 to 20.60) months, with survival of 93%.

CONCLUSIONS

The protocol presented is feasible and safe. The criteria applied provide good patient selection for sustained mid-term myocardial recovery after LVAD explantation.