Infective endocarditis after transcatheter aortic valve implantation

Introduction

Infective endocarditis (IE) is a potentially serious complication in patients with prosthetic heart valves. The objective of this study is to analyze and describe the incidence, baseline characteristics, risks factors and in-hospital evolution in IE after Transcatheter Aortic Valve Implantation (IE-TAVI).

Methods

All the TAVI implanted in our center since the beginning of the program have been included consecutively. Patients with a confirmed diagnosis of IE according to the “ESC Guidelines for the management of infective endocarditis” are identified and analyzed.

Results

331 TAVI have been implanted in our center from June 2009 to February 2021. IE-TAVI incidence in our series is 2.7% (n=9 cases). In baseline analysis, we observed that insulin dependent diabetes mellitus, Barthel Score and Pulmonary systolic pressure >50mmHg are significantly associated with the appearance of IE-TAVI (TABLE 1).

The most frequently microorganism is Enterococcus faecalis (44.4%; n=4) followed by Staphylococcus aureus (22.2%; n=2), Coagulase-negative staphylococci (22.2%; n=2) and Streptococcus viridans (11.1%; n=1).

77.8% of IE-TAVI (n=7) are Nosocomial IE or non-nosocomial healthcare-associated IE. 2 of them have been related to implantation (1 Enterococcus faecalis and 1 Coagulase-negative staphylococci) and 5 have been related to other interventions (2 after gastroscopy, 1 after percutaneous vascular intervention, 1 hemodialysis catheter infection and 2 unknown focus).

44.4% of IE-TAVI (n=4) were confirmed after performing Positron Emission Tomography (PET) scan. 3 cases (33.3%) were diagnosed with the initial Transthoracic Echocardiogram (TTE) and 2 cases (22.2%) were diagnosed after performing a Transesophageal Echocardiogram (TEE) (TABLE 2)

4 patients had an indication for surgery according to the ESC Guidelines (3 for persistent bacteremia and 1 for severe aortic regurgitation), but all were ruled out due to high surgical risk. Hospital mortality was 44.4% (n=4). The main predictor of hospital mortality was having an indication for surgery (p=0.028), which was present in 3 of the 4 deaths. The other death was due to digestive bleeding during hospitalization.

Conclusions

IE-TAVI is a serious disease with high in-hospital mortality. Insulin dependent diabetes mellitus, Barthel Score and Pulmonary systolic pressure >50mmHg are risk factors for IE-TAVI. PET-scan is the imaging test of choice when there were no echocardiographic findings. The main predictor of mortality is having an indication for surgery according to the ESC Guidelines.

Funding Acknowledgement

Type of funding sources: None.

Evaluation of left ventricular diastolic function in Marfan syndrome using speckle-tracking echocardiography

Background/Introduction

Previous studies using conventional echocardiographic measurements have reported subclinical left diastolic dysfunction in patients with Marfan syndrome (MFS). Certain speckle-tracking echocardiography (STE) derived parameters have shown good correlation with invasive measurements of LV relaxation.

Purpose

To evaluate diastolic function in Marfan patients using STE-derived parameters along with traditional diastolic measurements and compare them with healthy controls.

Methods

We consecutively included 127 MFS patients with normal LV ejection fraction and no previous cardiovascular surgery or significant valvular regurgitation. We also studied 38 healthy controls (age and sex-matched). We performed LV and LA strain analysis using 2D STE (QLAB 10, Philips). Echocardiographic parameters recommended to assess diastolic function (according to ASE/EACVI 2016 guidelines) were also considered.

Results

Reported use of BB/ARB was 28/39% in MFS patients. According to current guidelines, all participants had normal diastolic function. MFS patients showed lower TDI e' velocities (septal and lateral) and higher average E/e' ratio compared to controls, but still within normal range. Regarding STE-derived measurements, LVGLS, EDLSR and PALS were significantly reduced in MFS. E/EDLSR ratio was higher among MFS patients, reflecting impaired LV relaxation. Interestingly, E/LVGLS was not different between both groups.

Conclusion

STE-derived parameters showed impaired LV relaxation in MFS patients compared to controls. Our results suggest that STE derived parameters can be markers of early diastolic dysfunction and provide a better insight into Marfan-related cardiomyopathy.

STE derived parameters

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Programa de Actividades de I+D de la Comunidad de Madrid

Usefulness of strain imaging to determine prognosis in pulmonary hypertension

Introduction

Pulmonary hypertension (PH) is defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg at rest, measured by right heart catheterization (RHC).

Purpose

To describe classical and myocardial deformation echocardiographic parameters in patients with established PH and to identify prognostic variables

Methods

We prospectively enrolled 76 patients with mPAP ≥25 mmHg undergoing RHC between 2017 and 2018. All subjects underwent transthoracic echocardiography (TTE) according to the latest ASE/EACVI guidelines the same day of the RHC. Strain analysis was carried out by speckle-tracking echocardiography (QLAB 10.7, Philips). Clinical events during the follow-up were: acute heart failure hospitalization, cardiac transplant and all-cause mortality.

Results

Mean age was 59±12, 43.4% were women and 49 patients (64.5%) belonged to group 2 of PH. The median follow-up was 288 (ICR 92–534) days. Total number of events was 42 (55.3%, 9 deaths). Variables associated to events are shown in Table 1. All classic LV and RV systolic function and strain parameters were associated with a worse prognosis, being free-wall RV longitudinal strain (RVLS) the only one that remained as a prognostic factor in mutivariate analysis. Other variables associated with a worse prognosis were PCP>15 mmHg and NT-proBNP>1800, the latter being independent predictor of events. The attached figure shows event-free survival curves for the global population divided according to whether or not they belong to group II PH.

Conclusions

Our data highlight the prognostic value of free-wall RVLS and NT-proBNP in patients with established PH. NT-ProBNP was only useful in group II PH while free-wall RVLS identified patients with a higher risk of events in both groups, mainly in patients with heart disease

Free event survival Curves

Funding Acknowledgement

Type of funding source: None

P4372Left atrial strain: a potential marker of early diastolic dysfunction in patients with Marfan syndrome

Background/Introduction

Previous studies using conventional echocardiographic measurements have reported subclinical left diastolic dysfunction in patients with Marfan syndrome (MFS). Left atrial strain (LAS) has been shown to be an accurate predictor of left ventricular diastolic dysfunction. However, there is no evidence regarding the use of LAS in MFS.

Purpose

To assess feasibility of LAS and compare LAS derived measurements along with traditional diastolic parameters in MFS patients vs healthy controls.

Methods

46 MFS patients (normal LV ejection fraction, no previous cardiovascular surgery, no significant valvular regurgitation) vs. 20 healthy controls (age and sex-matched). We performed LAS analysis using 2D speckle-tracking (QLAB 10, Philips). LA strain was determined as the average value of the longitudinal deformation (7 segments) in the apical 4-chamber view (RR gating).

Results

LAS analysis was feasible in 40 MFS patients (87%). All participants had normal diastolic function according to current guidelines (ASE/EACVI 2016). MFS patients showed lower TDI e' velocities and higher average E/e' ratio, but still within normal range. Similarly, LVEF was normal but slightly reduced in MFS patients. LA strain and strain rate parameters during reservoir and conduit phase were significantly impaired in MFS patients compared to controls.

MFS vs controls MFS patients (n=40) Controls (n=20) p MFS patients (n=40) Controls (n=20) p Age 33.8±12.4 34.4±8.3 0.846 Septal e' (cm/s) 9.7±2.5 11.7±2.3 0.006 Male (%) 24 (60%) 12 (60%) 1.000 Average E/e' ratio 6.8±1.5 5.5±1.1 0.002 SBP (mmHg) 120.3±12.4 120.1±9.4 0.969 TR velocity (cm/s) 208.6±21.4 201.6±22.9 0.390 DBP (mmHg) 72.0±10.1 67.1±6.2 0.069 LAVi (ml/m2) 23.5±7.1 25.5±4.8 0.260 Aortic root (mm) 40.3±4.6 31.7±3.7 <0.001 LASr (%) 32.6±8.8 43.0±8.3 <0.001 LVEF (%) 60.9±5.6 64.2±4.2 0.022 LAScd (%) −20.1±8.0 −29.4±5.5 <0.001 E-wave (cm/s) 74.6±16.5 76.7±16.5 0.651 LASct (%) −12.8±6.1 −13.6±5.2 0.622 A-wave (cm/s) 55.2±10.9 52.0±12.8 0.327 LASRr 2.02±0.49 2.31±0.43 0.030 E/A ratio 1.4±0.4 1.5±0.4 0.287 LASRcd −2.22±0.61 −3.07±0.68 <0.001 Lateral e' (cm/s) 13.0±3.6 16.3±3.3 0.002 LASRct −2.24±0.90 −2.35±0.75 0.600 SBP: Systolic blood pressure. DBP: Diastolic blood pressure. LVEF: Left ventricular ejection fraction. LAVi: Left atrial volume index. LAS: Left atrial strain. LASR: Left atrial strain rate. (r): Reservoir. (cd): Conduit. (ct): Contraction.

Example of LA strain and strain rate

Conclusion

MFS patients showed a subtle impairment in diastolic function compared to controls. Although further evidence is needed, LAS derived parameters could be early markers of diastolic dysfunction in this group of patients.

Acknowledgement/Funding

Programa de Actividades de I+D de la Comunidad de Madrid

P1820New parameters for the evaluation of mechanic and elastic properties of the aortic root in Marfan Syndrome

Background

Elastic properties of the thoracic aorta in patients with Marfan Syndrome (MS) have already been evaluated with classic echocardiographic parameters. In the latest years the use of Speckle-Tracking (STE) ecocardiography has been widely extended. Our aim is to describe and provide new parameters of aortic deformation measured by STE in patients with MS.

Methods

95 unoperated adult patients with MS and 32 healthy controls were prospectively enrolled. We measured classic parameters of the aortic root using 2D echocardiography. We calculated the posterior aortic wall systolic excursion at the sinuses of Valsalva and ascending aorta using M Mode in TDI colour; with ST 2D ecocardiography we measured the aortic strain at the sinuses of Valsalva (SV) and the anterior and posterior aortic wall displacement at the SV. Aortic distensibility was calculated using the formula: 1000 * (Ds − Dd)/Dd * 1/(Ps − Pd) in mmHg–1 (Ds: systolic and Dd: diastolic diameters, Ps systolic and Pd diastolic blood pressure). Aortic stiffness index was calculated as Ln((Ps/Pd)/(Ds-Dd)/Dd)).

Results

As shown in the table bellow, patients with MS had lower aortic strain, aortic anterior and posterior wall displacement and impaired aortic distensibility and stiffness index compared to healthy controls. We found a strong negative linear correlation between aortic root diameter at the SV and aortic root strain (r=−0.56, figure 1).

Results of statistical analysis MS (n=95) Controls (n=32) p Age (years) 32.84±12.35 32.41±7.98 0.85 Aortic root diameter at the sinuses of Valsalva (mm) 38.82±5.35 30.92±3.65 <0.001 Aortic root strain (%) 4.66±2.45 9.19±2.49 <0.001 Anterior aortic wall displacement STE (mm) 10.39±3.64 13.10±2.26 <0.001 Posterior aortic wall displacement STE (mm) 9.02±2.87 11.04±1.82 <0.001 Aortic distensibility 0.98±0.46 1.37±0.72 0.01 Aortic stiffness index 3.74±0.43 3.47±0.51 0.01 MS = Marfan Syndrome; STE = Speckle Tracking Ecocardiography.

Figure 1. Dispersion plot

Conclusions

Our results suggest that aortic deformation and displacement obtained by STE echocardiography is impaired in MS, showing a reduced distensibility and an increased stiffness of the aortic wall, with a strong negative correlation between aortic root dilation and aortic strain. All these parameters may be useful as additional tools for the diagnosis and follow-up of Marfan patients, and could be useful to to improve the echocardiographic evaluation of the aortic root.

P4374Biventricular systolic function analysis in patients with Marfan Syndrome using speckle-tracking 2D ecocardiography

Background

Left Ventricular systolic disfunction has already been described in Marfan Syndrome (MS) in patients without valvular dysfunction using 2D and 3D speckle tracking echocardiography (STE). This dysfunction has been related to a more severe causal genetic mutation, which suggest the presence of a primary cardiomiopathy in these patients. Right ventricular function has been less studied so far. We sought to evaluate biventricular function in our cohort of MS patients with 2D-STE.

Methods

95 unoperated adult patients with MS and 32 healthy controls were prospectively enrolled. Patients with more than mild mitral or aortic regurgitation were excluded. Using STE we obtanied left ventricular global longitudinal strain (LVGLS) from the average of 16 segments from 4,2 and 3-chamber views and RVGLS values were obtained from the average of 6 segments from the apical 4-chamber view. We also measured classic parameters of systolic biventricular function (LVEF and TAPSE).

Results

Compared to controls, patients with MFS had significantly lower LVGLS and RVGLS (table 1). Values obtanied for LVGLS in MS patients were at the lower limit of normality stablished in the latest cuantification guidelines, while RVGLS and RV free wall LS were slightly above the limit of normality. LVEF and TAPSE were also slightly diminished in MS patients, though the differences found were clinically not relevant.

Results of statistical analysis MS (n=93) Controls (n=32) p Age (years) 32.84±12.4 32.41±7.98 0.85 Aortic Root Diameter Valsalva Sinuses (mm) 38.82±5.35 30.91±5.3 <0.001 LVGLS (%) −18.93±2.62 −21.52±2.26 <0.001 RVGLS (%) −21.25±3.54 −24.68±3.08 <0.001 RV free wall LS (%) −22.09±3.92 −25.56±3.63 <0.001 LVEF (%) 59.5±5.34 63.27±4.19 0.001 TAPSE (mm) 23.97±4.57 25.82±3.32 0.03 MS = Marfan Syndrome; LVGLS = Left ventricular global longitudinal strain; RVGLS = right ventricular global longitudinal strain.

Conclusions

Our study suggests that patients with MFS show lower biventricular strain compared with healthy controls. 2D-STE imaging may be useful to detect subclinical changes in cardiac function in patients with MFS and should be added to routine ecocardiographic evaluation in order to improve the follow-up and treatment of these patients.

P2472Two-dimensional speckle tracking echocardiography in heart transplant patients: five year follow-up of right and left ventricular function

Background

Evolution of left and right ventricular (LV and RV) function after heart transplantation (HT) has not been well described. Our objective was to evaluate the normal evolution of echocardiographic parameters of both ventricles and to explore if there is a link between the decrease of strain values and acute rejection (AR) or coronary allograft vasculopathy (CAV)

Methods

We followed 29 HT recipients with serial echocardiograms performed between 2011 and 2018, with a median follow-up of 5 years. LV global longitudinal strain (LV GLS) was analyzed by speckle tracking in 12 LV segments in 4 and 2 chamber views, and RV free wall longitudinal strain (RV free Wall LS) was measured in 4 chamber view. Acute rejection was diagnosed by EMB following our HT protocol. We take into consideration only moderate or severe rejection episodes (grade ≥2R).The presence of CAV was studied by coronariography or IVUS one year post-HT.

Results

As shown in the table below, LVEF was preserved from the begining of the follow up while LV GLS reached the normality in the 6th month, and both remained in normal ranges untill the 5th year. Regarding RV function, TAPSE was impaired in the early post-HT period and increased progressively and reached normality 1 year after HT. RV lateral wall LS rose during follow-up as well, reaching normal values 6 months after HT. Nevertheless, we noticed an impairment in this parameter at 5 years (−20.1±2.7, p=0.001), although it remained within normal ranges compared to guidelines reference parameters. We did not find any correlation between any parameter evaluated and the presence of AR or CAV at five years of follow-up.

LV and RV function parameters LVEF LV GLS TAPSE FAC RV free wall LS Basal (14 days) 63.0±7.9 −17.2±3.6 12.1±2.9* 43.7±9.8 −19.3±4.2 3 months 65.0±8.6 −17.7±2.8 14.8±3.4* 45.3±8.2 −22.0±4.6 6 months 65.8±9.6 −18.7±3.4 16.1±3.6 44.6±9.6 −24.6±4.9* 1 year 63.5±8.1 −18.1±2.2 17.1±4.1 44.0±8.1 −26.7±7.1* 2 years 63.8±6.8 −18.3±9.0 19.4±3.7 45.3±7.9 −27.6±6.3* 5 years 64.4±7.3 −18.1±3.3 17.9±3.9 46.6±12.1 −20.1±2.8 P (Anova) 0.85 0.85 <0.001 0.82 <0.001

Conclusion

As we show in this series of HT recipients with uneventful postoperative course, all LV and RV function parameters showed normal values 1 year after HT and manteined them during long-term follow-up. The presence of AR or CAV did not have any influence in ventricular function.