Current Usefulness of Transesophageal Echocardiography in Patients Undergoing Transcatheter Aortic Valve Replacement

This review article describes in depth the current usefulness of transesophageal echocardiography in patients who undergo transcatheter aortic valve replacement. Pre-intervention, 3D-transesophageal echocardiography allows us to accurately evaluate the aortic valve morphology and to measure the valve annulus, helping us to choose the appropriate size of the prosthesis, especially useful in cases where the computed tomography is not of adequate quality. Although it is not currently used routinely during the intervention, it remains essential in those cases of greater complexity, such as for patients with greater calcification and bicuspid valve, mechanical mitral prosthesis, and "valve in valve" procedures. Three-dimensional transesophageal echocardiography is the best technique to detect and quantify paravalvular regurgitation, a fundamental aspect to decide whether immediate valve postdilation is needed. It also allows to detect early any immediate complications such as cardiac tamponade, aortic hematoma or dissection, migration of the prosthesis, malfunction of the prosthetic leaflets, or the appearance of segmental contractility disorders due to compromise of the coronary arteries ostium. Transesophageal echocardiography is also very useful in follow-up, to check the proper functioning of the prosthesis and to rule out complications such as thrombosis of the leaflets, endocarditis, or prosthetic degeneration.

Coronary microvascular dysfunction is associated with impaired cognitive function: the Cerebral-Coronary Connection study (C3 study)

BACKGROUND

It remains unknown whether the presence of coronary microcirculatory dysfunction (CMD) correlates with its equivalent condition in the brain, cerebral small vessel disease (CSVD). The cerebral-coronary connection (C3), a prospective blinded study, investigated the prevalence of CMD in patients with coronary artery disease (CAD) and its association with CSVD and cognitive function.

METHODS AND RESULTS

Patients with documented CAD fulfilling inclusion criteria underwent physiological assessment of epicardial vessels and the microcirculation using intracoronary pressure and Doppler. Coronary microcirculation-related indices included coronary flow reserve (CFR) and hyperaemic microvascular resistance. Brain magnetic resonance imaging, transcranial Doppler (TCD), and neurocognitive examination were performed. Overall, 67 patients were included in the study (mean age 66 years, 73% female). Patients with abnormal CFR (<2.0) (55.2%) showed higher burden of white-matter hyperintensities: 43.2 vs. 20.0% (P = 0.044). After statistical adjustment, low CFR was associated with lower grey matter volume (P = 0.024) and with parameters of white-matter microstructural damage in diffusion-tensor imaging (lower fractional anisotropy and higher mean diffusivity, P = 0.029 and P = 0.032, respectively). Low CFR was associated with higher resistive (P = 0.027) and pulsatility (P = 0.043) values on TCD, and worse neurocognitive test scores (lower mini mental state examination, P = 0.025, and slower Trail Making Test A, P = 0.034).

CONCLUSIONS

Coronary microcirculatory dysfunction is frequent in patients with CAD and correlates with CSVD, abnormal cerebral flow haemodynamics, and significant cognitive impairment. These findings support the hypothesis that microvascular dysfunction in the heart and the brain are part of a single pathological process affecting microcirculation in patients with CAD.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT04131075.

Discongruence Index - Simple Indicator to Predict Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement

BACKGROUND

Prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) remains an important issue. The aim of this study was to assess the value of a new discongruence index, to predict PPM after TAVR.Methods and Results: A total of 185 patients with severe aortic stenosis who underwent TAVR with the Edwards Sapien prosthesis or CoreValve Revalving system were included (Edwards valve, n=119; Core Valve Revalving system, n=66). Discongruence index was calculated pre-procedurally as the ratio of selected transcatheter valve size (mm) to body surface area (cm²). PPM was defined as effective orifice area (EOA) ≤0.85 cm²/m² on transthoracic echocardiography before hospital discharge. Mean age was 82±5 years and 72 patients (38.9%) were men. The overall incidence of post-TAVR PPM was 35.1% (n=65). Discongruence index correlated with post-TAVR indexed EOA (y=0.18+0.057x; P<0.001). On multivariate logistic regression analysis, discongruence index was the only independent predictor of post-TAVR PPM (OR, 0.15; 95% CI: 0.03-0.66; P=0.012), and the area under the receiver operating characteristic curve was 0.62 (95% CI: 0.54-0.70, P=0.003), with an optimal cut-off point of 15.02 (sensitivity, 86.2%; specificity, 72.5%; positive predictive value, 74.3%; negative predictive value, 83.4%).

CONCLUSIONS

The new discongruence index may be useful tool to predict PPM after TAVR.

Dronedarone produces early regression of myocardial remodelling in structural heart disease

Background and aims

Left ventricular hypertrophy (LVH) in hypertension is associated with a greater risk of sustained supraventricular/atrial arrhythmias. Dronedarone is an antiarrhythmic agent that was recently approved for the treatment of atrial fibrillation. However, its effect on early regression of LVH has not been reported. We tested the hypothesis that short-term administration of dronedarone induces early regression of LVH in spontaneously hypertensive rats (SHR_s).

Methods

Ten-month-old male SHR_s were randomly assigned to an intervention group (SHR-D), where animals received dronedarone treatment (100 mg/kg) for a period of 14 days, or to a control group (SHR) where rats were given vehicle. A third group with normotensive control rats (WKY) was also added. At the end of the treatment with dronedarone we studied the cardiac anatomy and function in all the rats using transthoracic echocardiogram, cardiac metabolism using the PET/CT study (2-deoxy-2[18F]fluoro-D-glucose) and cardiac structure by histological analysis of myocyte size and collagen content.

Results

The hypertensive vehicle treated SHR rats developed the classic cardiac pattern of hypertensive cardiomyopathy as expected for the experimental model, with increases in left ventricular wall thickness, a metabolic shift towards an increase in glucose use and increases in myocyte and collagen content. However, the SHR-D rats showed statistically significant lower values in comparison to SHR group for septal wall thickness, posterior wall thickness, ventricular mass, glucose myocardial uptake, size of left ventricular cardiomyocytes and collagen content. All these values obtained in SHR-D rats were similar to the values measured in the normotensive WKY control group.

Conclusion

The results suggest by three alternative and complementary ways (analysis of anatomy and cardiac function, metabolism and histological structure) that dronedarone has the potential to reverse the LVH induced by arterial hypertension in the SHR model of compensated ventricular hypertrophy.

Echocardiographic reference ranges for normal cardiac Doppler data: results from the NORRE Study

AIMS

Reference values for Doppler parameters according to age and gender are recommended for the assessment of heart physiology, specifically for left ventricular (LV) diastolic function. In this study, we report normal reference ranges for Doppler parameters obtained in a large group of healthy volunteers. Echocardiographic data were acquired using state-of-the-art cardiac ultrasound equipment following Doppler acquisition and measurement protocols approved by the European Association of Cardiovascular Imaging.

METHODS AND RESULTS

A total of 449 (mean age: 45.8 ± 13.7 years) healthy volunteers (198 men and 251 women) were enrolled at the collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. A comprehensive echocardiographic examination was obtained from all subjects following predefined protocols. The majority of the Doppler diastolic parameters (e', E/e') as well as right ventricle systolic s' wave velocity were similar in men and women. Left ventricle s' wave velocity was higher in men than in women. E wave and e' were higher in younger subjects and decreased progressively in the older ones. E/e' ratio increased with ageing. Septal e' <8 cm/s was present in 19.7% of the subjects in the 40-60 year group and in 55% of those in the ≥60 year group. However, the cut-off value of average E/e' or lateral E/e' remained <15 or 13, respectively, in the majority of patients.

CONCLUSION

The NORRE study provides the reference values for the most useful Doppler parameters in the evaluation of heart physiology. These data highlight the need of using age-specific reference values especially for the diagnosis of LV systolic and diastolic dysfunction and for the estimation of LV filling pressures.

Giant and thrombosed left ventricular aneurysm

Left ventricular aneurysms are a frequent complication of acute extensive myocardial infarction and are most commonly located at the ventricular apex. A timely diagnosis is vital due to the serious complications that can occur, including heart failure, thromboembolism, or tachyarrhythmias. We report the case of a 78-year-old male with history of previous anterior myocardial infarction and currently under evaluation by chronic heart failure. Transthoracic echocardiogram revealed a huge thrombosed and calcified anteroapical left ventricular aneurysm. Coronary angiography demonstrated that the left anterior descending artery was chronically occluded, and revealed a big and spherical mass with calcified borders in the left hemithorax. Left ventriculogram confirmed that this spherical mass was a giant calcified left ventricular aneurysm, causing very severe left ventricular systolic dysfunction. The patient underwent cardioverter-defibrillator implantation for primary prevention.

Proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography applied for tricuspid regurgitation quantification

BACKGROUND

The two-dimensional (2D) proximal isovelocity surface area (PISA) method has known technical limitations, mainly the geometric assumptions of PISA shape required to calculate effective regurgitant orifice area (EROA). Recently developed single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions and has already been validated for mitral regurgitation assessment. The aim of this study was to apply this novel method in patients with chronic tricuspid regurgitation (TR).

METHODS

Ninety patients with chronic TR were enrolled. EROA and regurgitant volume (Rvol) were assessed using transthoracic 2D and 3D PISA methods. Quantitative Doppler and 3D transthoracic planimetry of EROA were used as reference methods.

RESULTS

Both EROA and Rvol assessed using the 3D PISA method had better correlations with the reference methods than using conventional 2D PISA, particularly in the assessment of eccentric jets. On the basis of 3D planimetry-derived EROA, 35 patients had severe TR (EROA ≥ 0.4 cm(2)). Among these 35 patients, 25.7% (n = 9) were underestimated as having nonsevere TR (EROA ≤ 0.4 cm(2)) using the 2D PISA method. In contrast, the 3D PISA method had 94.3% agreement (33 of 35) with 3D planimetry in classifying severe TR. Good intraobserver and interobserver agreement for 3D PISA measurements was observed, with intraclass correlation coefficients of 0.92 and 0.88 respectively.

CONCLUSIONS

TR quantification using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Successful transcatheter closure of a postmyocardial infarction ventricular septal rupture in a patient rejected for cardiac surgery: usefulness of transesophageal echocardiography

Acute ventricular septal rupture is a high-risk complication of myocardial infarction. Although early surgical treatment improves the prognosis of this condition, hospital mortality after emergency surgery ranges from 10% to 60%. Transcatheter closure is an established method of treating selected congenital septal defects; less experience exists regarding its usefulness for postmyocardial infarction ventricular septal defect. We report a case of successful transcatheter closure of a postmyocardial infarction ventricular septal defect with a septal occluder in a 71-year-old patient rejected for surgery.