bluuebunny/crossref_metadata_2025 huggingface dataset:
Usefulness of left atrial strain in detection of left ventricular diastolic dysfunction in patients with first acute myocardial infarction.
Authors: Sikora-Frac M , Pilichowska-Paszkiet E , Smarz K , Maciejewski P , Kokowicz P , Przadka M , Budaj A , Zaborska B
Published: January 2025

Background

Left ventricular (LV) diastolic function is an important prognostic marker in acute myocardial infarction (AMI) but detection and classification of the dysfunction grade remains still difficult. The 2021 EACVI document provides recommendations on how to use left atrial (LA) strain to assess elevated LV filling pressure when HFpEF is suspected but the role of LA strain in the diagnosis of LV diastolic dysfunction (LVDD) in patients (pts) with AMI is not well documented.

Aim

The aim of this study was to analyse the usefulness of adding LA strain to the assessment of the degree of LVDD based on the 2016 ASE/ECVI guidelines in pts with first AMI.

Methods

Consecutive pts with first AMI undergoing percutaneous coronary intervention (PCI) were prospectively studied. Echocardiography was performed between 3-7th day after PCI. Assessment of LV diastolic function and classification of LVDD were based on 2016 ASE/ECAVI document. To assess systolic LV function, LV ejection fraction (LVEF) and global longitudinal strain (GLS) were calculated. LA strain in following phases: LA reservoir (LARs) and LA pump (LASp) strain and LVGLS were measured by speckle tracking echocardiography. The cut-off values for reduced LARs was based on the NORRE study results (≤27.7%) and for elevated filling pressure on the 2021 EACVI document (<18%).

Results

92 pts were included in the study (71 males, 52 STEMI pts, 42 NSTEMI pts), age 60±11 years, LVEF 52.5±9.5% (31 pts with LVEF < 50%), LVGLS -15±3.8%, NT-proBNP median 433 pg/mL (144-1416), Troponin T median 1160 ng/L (322-4586). Normal diastolic function was found in 16.3% pts, LVDD grade I in 52.2%, grade II in 7.6% pts, no patient had grade III and in 23.8% pts the degree of LVDD could not be determined based on the ASE/ECVI 2016 criteria. LARs and LASp were significantly different between groups and lower in pts with LVDD grade I, II, and indeterminate group than in normal subjects (table). Adding abnormal LARs to the diagnosing of LVDD resulted in an increase in the diagnosis of LVDD from 59.8% to 78.2% respectively without and with LARs. 24% pts had LARs <18%. LARs values presented highly statistically significant correlation with GLS, LVEF, Troponin T, and NT-proBNP (r=-0.60, r=0.58, r= -0,41 and r= -0.39, P< 0.001, respectively).

Conclusions

The findings from this study provide insights regarding the potential usefulness of adding LA strain in the detection of LVDD in pts with early phase STEMI and NSTEMI. Lower LARs values were associated with greater LV damage.

LA strain and the severity of LVDD
Influence of right ventricular function on medium and long-term mortality after percutaneous aortic valve implantation in elderly patients with severe aortic stenosis.
Authors: Ruisanchez Villar C , Perez Barquin R , Santiago Setien I , Veiga Fernandez G , Cuesta Cosgaya J M , Lerena Saenz P , Coroas Pascual C , Serrano Lozano D , Llano Cardenal M , Zarauza Navarro J M , Sainz Laso F , Lee Hwang D H , Garcia Camarero T , Gil Ongay A , De La Torre Hernandez J M
Published: January 2025

Background

Right ventricular (RV) function is a potent marker of morbidity and mortality in heart failure and other cardiovascular diseases. However, the prognostic value of right myocardial function in aortic stenosis (AS) treated with a percutaneous aortic valve implantation (TAVI) is not well defined.

Objetive

In the present study, we aim to analyze the impact of two relevant RV function parameters, TAPSE and right ventricular longitudinal strain, measured in the pre-TAVI study, on medium- and long-term mortality in elderly patients with severe AS.

Methods

We included 180 consecutive patients with severe AS who underwent TAVI implantation between February 2018 and February 2020. We analyzed the pre-TAVI echocardiogram (TTE) performed on the same day as the procedure. The variables analyzed were TAPSE and free wall right ventricular strain (FW-RVS). We studied the implications of both parameters on medium-term (the first year after the intervention) and long-term (2 years after TAVI implantation) mortality.

Results

We analyzed 180 patients (mean age 80.2 years, SD 9.02), of whom 98 (54.4%) were women. At the time of data collection, 58 deaths (32.6%) had been recorded, 17 (29.3%) of which occurred during the first year after TAVI, and 22 (37%) in the second year; 3 died immediately post-procedure and 7 before 6 months. The average TAPSE in the baseline TTE was 21.7 mm +/- 4. FW-RVS could be analyzed in 150 patients (83%), with an average value of 20.5 +/- 6 in the pre-TAVI study. Neither TAPSE nor FW-RVS showed statistical significance in 1-year mortality (p>0.5; p=0.19, respectively). However, RV strain demonstrated an impact on 2-year follow-up mortality (OR 1.14; p=0.014), while TAPSE did not reach significance (p=0.59).

Conclusions

In our study, in an elderly population of patients with severe AS treated with TAVI, free wall RV strain, a sensitive marker of subclinical myocardial dysfunction, proved to be a predictive parameter of long-term mortality, once the first year of follow-up was overcome. The poor influence of RV function within the first year of follow-up may be related to aspects of futility and other conditions of interest during this specific follow-up period (coronavirus pandemic).
Effect of apical foreshortening and transducer angulation on strain measurements: a quantitative investigation
Authors: Pasdeloup D , Ostvik A , Smistad E , Nyberg J , Jakobsen E O , Grenne B L , Holte E , Lovstakken L , Dalen H
Published: January 2025

Background

Two-dimensional echocardiographic strain measurements have limited reproducibility, hampering the ability to detect subtle changes in repeated examinations. This is partly related image acquisition, including apical foreshortening and suboptimal transducer rotation and/or tilt, resulting in non-standardized imaging planes. However, the impact of image acquisitions on measured global longitudinal strain (GLS) values has not been quantified in large studies due to the labor-intensive task of measuring apical foreshortening and characterizing the imaging plane. Recent advances in echocardiographic image analysis based on deep learning (DL) may shed new light on this problem by enabling measurements of apical foreshortening and estimation of transducer angulation without human intervention.

Purpose

To quantify the effect of apical foreshortening and transducer rotation/tilt on GLS values.

Methods

To isolate the effect of foreshortening and transducer rotation/tilt on GLS values, 1395 patients without cardiac pathology were included in the analysis. For each patient, GLS was measured in the three apical views (four chamber, two chamber, long-axis) using commercial software. The same recordings were automatically analyzed using DL to obtain indicators of apical foreshortening (apex displacement in the long axis and short axis directions) and of the transducer rotation and tilt relative to the heart. Correlations between strain values and the foreshortening/rotation/tilt indicators were calculated. When significant correlation was detected, a regression analysis was performed to quantify the absolute change in GLS that can be related to foreshortening and transducer rotation/tilt. The first and last 5% quantiles of each DL indicator were excluded from these analyses.

Results

For each view, GLS was significantly correlated (p<0.05) with at least one of the foreshortening or transducer angulation indicators (Fig. 1). The regression analyses suggested that apical foreshortening and suboptimal transducer rotation/tilt can cause GLS variations up to 1.3 percentage points, representing a relative change of 6.5%.

Conclusions

Apical foreshortening and transducer rotation/tilt quantified using automatic DL methods were related to GLS values in a large dataset. The magnitude of the relationship suggests that apical foreshortening and transducer rotation/tilt can limit the usefulness of GLS measurements, especially in the context of repeated examinations where detecting small relative changes is important. Overall, this retrospective analysis confirms the importance of minimizing apical foreshortening and of standardizing transducer angulation to reduce minimal detectable changes in GLS and improve its reproducibility.
E-point septal separation (EPSS) for diagnosing reduced left ventricular ejection fraction (LVEF): a systematic review and meta-analysis
Authors: Kirkovski A , Lee J , Lickfett L
Published: January 2025

Background/Introduction

The estimation of LVEF with the standard quantitative methods is a difficult and time-consuming process, which requires experience and relies on the ability of the physician. An alternative method for a rapid assessment of LVEF could be EPSS, which measures the distance between the anterior mitral valve leaflet and septum in early diastole, demonstrated on a parasternal long axis view with M-Mode.

Purpose

To determine how accurate EPSS is for diagnosing reduced LVEF in adult patients.

Methods

We used the Cochrane methods for diagnostic test accuracy (DTA) reviews. We searched Pubmed, Ovid, CENTRAL, OATD, ClinicalTrials.gov and WHO-ICTRP up to 21 June 2024.

We included studies that assess the accuracy of EPSS against an acceptable reference standard (Biplan Simpson’s method, angiographically determined, or visually determined ejection fraction) in adult patients.The articles were screened and data from the articles was extracted using the Metagear package in R Studio. We extracted data into a 2 x 2 table (true positives, true negatives, false positives, and false negatives). We used GetData Graph Digitizer to extract numbers from the histograms in studies where direct data wasn't available. We synthesized and summarized the data into a forest plot and a summary receiver operating characteristic (SROC) plot. We used a bivariate meta-analysis model to synthesize the meta-analysis in RevMan.

Results

We identified 757 titles and abstracts and after removal of duplicates, we assessed 730 unique studies. After exclusion, 14 studies were deemed eligible for inclusion in the meta-analysis (914 patients). EPSS with a threshold of > 7 mm showed a summary sensitivity of 84% (95% CI 81% to 88%) and a summary specificity of 88% (95% CI 77% to 85%). If we take the median prevalence of reduced LVEF in the included studies (48%) and apply it to a cohort of 1000 patients, 480 patients will have a reduced LVEF. Of these, 403 (84%) would be correctly diagnosed and 77 (16%) would be misdiagnosed and not receive appropriate treatment. 520 of the 1000 patients will have a normal LVEF. Of these, 421 (81%) would be correctly deemed to have a normal LVEF, and 99 (19%) would be falsely diagnosed with reduced LVEF and undergo inappropriate treatment.

Conclusion

The findings of this review provide evidence to suggest that EPSS is an accurate diagnostic tool compared to reference standards and it could be used to provide a quick initial assessment of the LVEF as a precursor to the standard quantitative methods.

Summary of findings

Forest plot
Oxidative stress biomarkers and myocardial dysfunction in a doxorubicin- and trastuzumab-induced rat model of cardiomyopathy
Authors: Cho D H , Kim S R , Kim M N , Park S M
Published: January 2025

Background

Chemotherapy, although improving survival rates in breast cancer patients, is associated with heightened risks of myocardial dysfunction and heart failure. This study explores the association of oxidative stress biomarkers with myocardial dysfunction in a rat model induced by doxorubicin and trastuzumab.

Methods

Forty-two rats were allocated into groups receiving various treatments including control, doxorubicin only, and doxorubicin plus trastuzumab. Doxorubicin and trastuzumab were sequentially administered over 28 days at 2-week intervals. Echocardiography with speckle-tracking was utilized to measure left ventricular end-systolic dimension and longitudinal strain (LS). Blood samples were collected from the inferior vena cava before sacrifice for biomarker analysis, focusing on oxidative stress indicators including superoxide dismutase (SOD) and glutathione (GSH). Myocardium fibrosis area was measured using Masson's trichrome staining.

Results

The combination of doxorubicin and trastuzumab significantly increased the LV end-systolic dimension and worsened LS compared to the control group (all P < .05). Levels of oxidative stress biomarkers, including SOD and glutathione, were significantly deteriorated in the chemotherapy groups. Oxidative stress biomarkers demonstrated a strong correlation with measures of myocardial dysfunction. SOD showed a correlation coefficient of 0.609 with LS (P = 0.0056). Glutathione (GSH) showed a correlation coefficient of -0.477 with LS (P = 0.0388). Additionally, LS was well correlated with fibrosis area, showing a correlation coefficient of -0.487 (P = 0.0347).

Conclusions

In a doxorubicin- and trastuzumab-induced rat model of cardiomyopathy, oxidative stress biomarkers were correlated with myocardial dysfunction, as represented by LS. The findings suggest that monitoring these biomarkers could enhance early detection and prevention strategies for chemotherapy-induced cardiomyopathy.

A representative image of strain

Correlation between parameters
Heart failure by ventricle-arterial coupling in STEMI
Authors: Garcia Villarejo M , Latapi Ruiz Esparza X , Dominguez Garciduenas B , Amaro Palomo E J , Gopar Nieto R , Araiza Garaygordobil D , Arias Mendoza M A , Sierra Lara Martinez J D
Published: January 2025

Background

Left ventricular-arterial coupling (VAC), calculated as the ratio between arterial elastance (Ea) and left ventricular end-systolic elastance (Ees), is part of contemporary non-invasive indices of left ventricular (LV) and arterial system function. It may assist in identifying post-STEMI patients at risk of major adverse cardiovascular events, including heart failure.

Purpose

To analyse the development and applicability in routine clinical practice of simplified echocardiographic methods for calculating left VAC and predicting the risk of heart failure post-STEMI.

Methods

Echocardiography was performed on 144 post-STEMI patients who were followed up for 750 days after hospitalisation. Each baseline characteristic variable was analysed using the Wilcoxon and Shapiro-Wilk tests. Kaplan-Meier methods with log-rank tests and Cox regression were employed to assess the risk of heart failure based on two main variables: VAC values within the range of 0.95-1.1, and values outside this range. VAC was measured using Chen’s method, which includes systolic and diastolic pressure, preejection time, total ejection time, ejection fraction, and stroke volume. All analyses were conducted using StataMP 14.1.

Results

We enrolled 144 patients, of whom 87% (n=125) were male, with a median age of 60 years. Initially, 76.3% (n=106) of patients had reduced ejection fraction at the first echocardiography. The most common comorbidities were hypertension (52%) and type 2 diabetes (40.3%). In our initial comparison of VAC values, Kaplan-Meier curves demonstrated significant differences in the incidence of heart failure between VAC 0.95-1.1 and values outside this range. The VAC 0.95-1.1 group showed a better prognosis (p-value < 0.0312), with no occurrences of heart failure during the 750-day follow-up.

Conclusions

Established parameters for VAC vary across different scenarios, but conclusive information is lacking for patients in acute myocardial infarction. We propose that enhancing the Ea/Ees ratio (measured by Chen’s method) and thereby VAC could provide clinicians with detailed prognostic information, potentially preventing heart failure.

Heart failure and VAC
Prognostic value of left ventricular global longitudinal strain in patients with moderate ischemic mitral regurgitation who underwent coronary revascularization
Authors: Comia M A F , Tucay E S , Mendoza-Reyes M C , Ladlad-Pua E V , Flores V B , Santos R J
Published: January 2025

Background

Patients with severe ischemic mitral regurgitation are indicated to undergo mitral valve surgery during CABG. For moderate ischemic mitral regurgitation, however, doing mitral valve intervention during revascularization is still controversial. Guidelines recommend the use of LVEF as a parameter for LV dysfunction as an indication to do intervention, but studies have showed that LV GLS is a sensitive tool to detect even subclinical left ventricular dysfunction. This study aimed to determine the prognostic value of left ventricular global longitudinal strain in patients with moderate ischemic mitral regurgitation who underwent coronary revascularization without mitral valve surgery in predicting MACE.

Methodology

Baseline clinical and echocardiographic characteristics were retrospectively studied among patients with moderate ischemic mitral regurgitation who underwent surgical revascularization without mitral valve surgery. Speckle tracking using VVI was done on pre-operative echocardiograms to determine the left ventricular global longitudinal strain and intraoperative transesophageal echocardiograms were reviewed to assess for persistence of moderate mitral regurgitation. Occurrence of major adverse cardiovascular events during the hospital stay were reviewed in the medical records as well.

Results

Among the 36 patients with moderate ischemic mitral regurgitation, 16 (44.4%) had persistent moderate mitral regurgitation. There was no statistical difference in the outcome of moderate mitral regurgitation postoperatively between LV GLS >7% and <7%. In terms of major adverse cardiovascular events, 58% (21/36) had occurrence of MACE. There was no significant difference in the occurrence of MACE between patients with LV GLS of >7% and <7%. However, it was noted that for every unit decrease in LV GLS, the odds of having MACE increases by 17.02% with crude odds ratio of 1.17 (p-value 0.041). Patients with history of ACS were 11.69 times more likely to have MACE with odds ratio of 11.69 (p-value of 0.002). Ejection fraction was not found to be a significant factor associated with MACE.

Conclusion

Left ventricular global longitudinal strain can be used as an additional parameter in prognosticating patients with moderate ischemic mitral regurgitation who will undergo revascularization. Patients with more impaired LV GLS would have higher odds of having MACE.

Methodology

Factors Associated with MACE
External validation of two different cardiac damage staging systems for aortic stenosis in a surgical cohort of patients who underwent surgical aortic valve replacement
Authors: Roman R , Olmos C , O'neill P , Gil C , Carnero M , Rivadeneira M , Luque M , Bassa R , Gil-Abizanda S , Perez-Camargo D , Pozo E , Mahia P , Montero L , De Agustin J A , Islas F
Published: January 2025

Purpose

In recent years, several cardiac damage staging systems for severe aortic stenosis (AS) have been proposed. These systems may help to stratify patients’ risk and select the adequate timing for intervention. Our aim was to perform an external validation of two staging systems (1,2) in patients who underwent surgical aortic valve replacement (SAVR).

Methods

Retrospective analysis of a prospective cohort of patients with AS who underwent SAVR in a tertiary care center from 2017 to 2022. Echocardiographic parameters measured prior to surgery were analyzed, and patients were classified into the different stages of two published staging systems.

The area under the ROC curve (AUC ROC) was used to measure the discriminatory capacity of the two staging models to predict the primary endpoint of 1-year mortality after SAVR.

Results

244 patients were analyzed. Mean age was 69 (9.5) years, and 37.7%f were female. Mean EuroSCORE II was 2.6 (3.3). The primary endpoint occurred in 11 (4.5%) patients.

The distribution of patients in the different stages of cardiac damage is displayed in Figure 1. According to Staging system 1, the majority of patients (50%) were intervened on in a Stage 1 of cardiac damage (left ventricular subclinical damage, considered when global longitudinal strain [GLS] was ≥ −17%). In the case of Staging system 2, 29% of patients were classified as left ventricular damage and 47.9% as left atrium or mitral damage.

The area under the ROC curve of Staging system 1, which incorporated cardiac mechanics, was 0.688 (95% CI: 0.510-0.865), and showed better predictive performance than Staging system 2 [0.593 (95% CI 0.432–0.736)] (Figure 2).

Conclusions

In a surgical cohort of patients with AS, a cardiac staging system that include GLS and right ventricular-arterial coupling showed better discriminatory yield for one-year mortality. Therefore, when available, assessing LV mechanics and the interrelation between right ventricular function and afterload could help in better risk stratification and prognostic assessment in this context.

Cardiac damage staging systems

AUC curve for 1-y mortality
Mechanism of mitral regurgitation in Fabry disease: a detailed study of mitral leaflet morphology and severity in a cohort of symptomatic patients
Authors: Vecerova A , Linhart A
Published: January 2025

Introduction

Fabry disease, stemming from mutations in the alpha-galactosidase A gene, manifests in the buildup of globotriaosylceramide (Gb3), inducing systemic complications, notably cardiac issues such as mitral regurgitation (MR). This research delves into the mechanisms underlying MR development in Fabry disease. A group of 38 symptomatic patients with moderate or substantial MR were monitored. Mitral leaflet morphology was classified as normal, displaying fibrodegenerative changes, or exhibiting leaflet thickening. The severity of MR varied, primarily attributed to leaflet restriction. Moreover, left ventricular outflow tract obstruction (LVOTO) and annular dilatation were identified. The study indicates that MR in Fabry disease chiefly results from leaflet restriction caused by degenerative changes or leaflet thickening. Echocardiographic assessment involved detailed measurements of various parameters, including leaflet height, annulus size, coaptation height and depth, tenting area, coaptation to septum distance, and angles of the anterior and posterior mitral leaflets.

Methods

A cohort of 38 symptomatic Fabry disease patients with moderate or significant MR were longitudinally examined. Echocardiographic evaluations were employed to assess MR severity and classify mitral leaflet morphology. Statistical analyses were conducted to explore the link between MR severity and leaflet morphology. Critical components of the mitral valve were measured, and specific angles were determined to comprehensively assess each mechanism.

Results

The study showed that the primary cause of MR in most patients was leaflet restriction, with varying severity levels. Mitral leaflet morphology was categorized as normal in 15.8%, fibrodegenerative changes in 31.5%, and leaflet thickening in 52.7%. Additionally, LVOTO was observed in 15.7%, albeit without systolic anterior motion (SAM), and annular dilatation was present in 66%.

Conclusion

The research suggests that MR in Fabry disease primarily stems from leaflet restriction, whether due to degenerative changes or leaflet thickening. The presence of anteroposterior annular dilatation, although not always anticipated, was identified in some cases, adding depth to the understanding of MR mechanisms in Fabry disease patients.

Mitral valve in systole in Fabry disease

Leaflet morfology and the degree
Evolution of primary mitral regurgitation during echocardiographic follow-up
Authors: Surakka M , Hirvonen R , Vasankari T , Airaksinen J , Ukkonen H , Saraste A
Published: January 2025

Background

Routine echocardiographic follow-up of patients with mitral regurgitation (MR) is common practice recommended by clinical practice guidelines. However, there is limited contemporary data on the natural course of primary mitral regurgitation, particularly in those without severe regurgitation at presentation.

Purpose

To evaluate outcomes in patients undergoing repeated echocardiograms due to mild, moderate and severe primary mitral regurgitation.

Methods

We identified all patients at a tertiary referral center who were in follow-up due to MR between the years 2004-2019. Patients with a history of heart failure or secondary MR were excluded. Additional age and sex matched individuals without history of cardiac disease and in whom echocardiography showed no valvular heart disease were included as a control group. Data on echocardiographic severity of mitral regurgitation, all-cause mortality, stroke, myocardial infarction, diabetes mellitus and mitral valve interventions were collected from electronic medical records. Primary endpoints were all-cause mortality and survival free from intervention.

Results

The study cohort consisted of 614 patients with a mean follow-up duration of 6.1 ± 3.8 years. At baseline, 275 (45%) had mild (age 65 years, 58% men), 221 (36%) moderate (age 68 years, 66% men) and 118 (19%) severe (age 65 years, 85% men) MR. The control group consisted of 647 individuals (age 66 years, 66% men). Compared to patients with moderate MR at baseline, significantly fewer patients with mild MR at baseline progressed to severe MR during follow-up (27% vs. 4%, p<0.001). Out of patients with mild MR at baseline, 9 (3.3%) underwent mitral valve intervention (surgical mitral valve repair in 7 and implantation of mitral valve prosthesis in 2) during follow-up. Out of these, referral for intervention was based on development of symptoms in 7 (acute heart failure in 2 and atrial fibrillation in 1), endocarditis in 1, whereas 1 patient was operated due to asymptomatic severe MR. All 9 patients had an uncomplicated course of intervention and post-operative left ventricular ejection fraction was >50%. Out of patients with moderate and severe MR at baseline, 47 (21%) and 77 (64%) underwent intervention during follow-up, respectively. Based on a Kaplan-Meier analysis adjusted for stroke, myocardial infarction and diabetes mellitus, survival of patients with mild MR did not differ from control patients without valvular heart disease (Figure).

Conclusions

Our findings indicate that only few patients with mild MR progress to severe MR during 6 years of follow-up and out of these only one asymptomatic patient had surgery. The likelihood of left ventricular function remaining normal in those who have had mitral valve intervention triggered by MR related symptoms seems high.

Survival by time in follow-up (years)
A novel staging system of cardiac damage in aortic stenosis based on multi-chamber myocardial deformation
Authors: Tomaselli M , Springhetti P , Clement A , Benfari G , Radu N , Ciceri L , Pilan M , Scarsini R , Calin A , Nitu C , Penso M , Ribichini F , Popescu B , Muraru D , Badano L P
Published: January 2025

Background

In patients with moderate-to-severe aortic stenosis (AS), the assessment of extravalvular cardiac damage has improved risk stratification and identify candidates for early intervention.

Objectives

To evaluate whether multi-chamber myocardial deformation analysis by speckle tracking echocardiography could improve the existing staging systems in moderate-to-severe.

Methods

We analyzed 2D, Doppler, and STE data obtained from two cohorts: derivation (654 patients, median age: 82 years; 51% men) and validation (237 patients, median age: 77 years; 55% men) with at least moderate AS (aortic valve area< 1.5 cm2). The receiver operator characteristic curve analysis resulted in the following cut-off values associated with outcomes: 15% for left ventricular global longitudinal strain (LVGLS), 13% for peak atrial longitudinal strain (PALS), and 19% for right ventricular free-wall strain (RVFWS). Patients have been divided into five stages: Stage 0 - no left-side damage (LVGLS ≥15% and PALS ≥13%); Stage 1 - partial left-side damage (LVGLS <15% or PALS <13%); Stage 2 - definite left-side damage, (LVGLS <15% and PALS <13%); Stage 3, right-side damage by conventional parameters, with RVFWS ≥19%; and Stage 4, right-side damage including RVFWS <19%.

Results

In a multivariable Cox regression analysis, the new staging scheme remained independently associated with an increased risk of all-cause death (adjusted hazard ratio [aHR]: 1.28; 95%CI: 1.10–1.48; p= 0.001). The new staging classification showed incremental value to conventional 2D echocardiographic variables and exhibited a significantly higher predictive power (ROC AUC: 0.67; 95%CI: 0.62-0.73) compared to those proposed by Généreux et al. (1) (AUC 0.62; 95% CI 0.56-0.67; p=0.002) and Tastet et al. (2) (AUC 0.64; 95% CI 0.58-0.70; p=0.041) at 2-years for all-cause death in the derivation cohort (Figure 1). Similar results were obtained in the validation cohort.

Conclusions

Our staging system for detecting cardiac damage, incorporating multi-chamber myocardial deformation, exhibits a stronger association with outcomes than previously validated systems.

ROC curve across stagin systems
Prognostic significance of left atrial volume index in patients with severe aortic stenosis after transcatheter aortic valve
Authors: Wei X , Yang Y Q , Li X I , Zhou W X , Zhao Z G , Feng Y , Chen M
Published: January 2025

Background

Transcatheter aortic valve replacement (TAVR) is an important approach for patients with severe aortic stenosis (AS), but its mortality remains high and its prognostic factors are not fully understood.

Methods

This single-center retrospective cohort study enrolled 553 consecutive severe AS patients who underwent TAVR between April 2012 and October 2019. Patients with biological valve decay after surgery, moderate to severe mitral stenosis, and inadequate echocardiographic image were excluded. The primary outcome was mortality at 4 years after TAVR.

Results

Over the follow-up time, 64 patients (12.8%) died. Compared to the Survivors, the Non-survivors were older, less females, higher STS scores, larger left atrial volume index (LAVi) and lower serum albumin level. Results from univariate and multivariate cox regression analysis showed that the age (HR, 1.072; 95% CI 1.023-1.124, p =0.004), the LAVi level (HR, 1.023; 95% CI 1.013-1.033, p <0.001) and the serum level of albumin (HR, 0.862; 95% CI 0.796-0.934, p <0.001) were the independent risk factors for estimation of 4-year mortality after TAVR. Moreover, the mortality in patients with the highest category of LAVi (>48 ml/m2) was significantly higher than others, and its multivariable HR was 4.796 (95% CI, 1.137-20.238). In addition, Kaplan-Meier analysis revealed a reduced survival probability according to the highest category of LAVi (p =0.003).

Conclusion

LAVi was an independent predictor of mortality in patients with severe AS after TAVR, and LAVi could be used as a risk stratificationtool for long-term clinical outcome of post-TAVR patients.
Impact of mitral regurgitation in patients undergoing transcatheter aortic valve replacement: imaging predictors and prognosis
Authors: Bravo Martinez I , Florido J , Ullate A , Urkullu A , Rodriguez I , Onaindia J J , Cacicedo A , Sanz I , Candina R , Subinas A , Sadaba M , Armendari K , Velasco M S
Published: January 2025

Backgorund

Mitral regurgitation (MR) is a frequent finding in patients with severe aortic stenosis but usually left untreated at the time of transcatheter aortic valve replacement (TAVR). There is controversial evidence on the prognostic impact of the presence of concomitant MR in patients undergoing TAVR.

Purpose

The objective of the study was to assess the evolution of MR after TAVR, imaging and clinical predictors on its evolution and the impact on the prognosis of the baseline degree of MR and its response after TAVI.

Methods

This is a retrospective observational study. Mitral regurgitation was graded by transthoracic echocardiography before and after TAVR in 67 patients with severe aortic stenosis. 1-year mortality and admissions for heart failure were related to the degree of baseline MR and improvement of MR after TAVR. Morphological echo analysis was performed to determine predictors of MR improvement.

Results

32% of patients presented with baseline moderate or severe MR (MR grade >2). MR improved in 62% of patients with moderate or severe MR. The echocardiographic parameters that were associated with an improvement in MR were left ventricular (LV) ejection fraction (45.3±16 vs. 60±12, p<0.001), LV end-diastolic (5.7±1 vs. 5.1±1cm, p=0.045) and end-systolic diameters (4.11±1 vs. 3.36±1cm, p=0.006), LV volume (128±51 vs. 98±49ml, p=0.01), LV mass (182±40 vs. 163 ±53 gr/m2, p= 0.02), mitral annulus diameter (38±6 vs 35±4mm, p= 0.01) and the functional etiology of MR (p= 0.01). Patients with improved MR had a significant reduction in admissions for heart failure (p=0.04), with no differences in mortality at one year follow-up. Significant baseline MR (MR grade >2) was not associated with a higher risk of mortality (p= 0.42) or admissions for heart failure(p=0.25) at one year of follow-up.

Conclusions

There is a high prevalence of MR associated with severe aortic stenosis. There can be an improvement in MR after TAVR. Improvement in MR was associated with significantly better survival and a lower risk of admissions for heart failure. There are echocardiographic parameters that can predict a significant reduction in MR after TAVR. The baseline grade of MR did not influence the prognosis of the patients at one year of follow-up.

Echocardiographic parameters associated

MR improvement after TAVR
Impact of TAVI on left ventricular mass and function in a cohort of elderly patients with severe aortic stenosis.
Authors: Perez Barquin R , Ruisanchez Villar C , Santiago Setien I , Veiga Fernandez G , Lerena Saenz P , Cuesta Cosgaya J M , Coroas Pascual C , Serrano Lozano D , Llano Cardenal M , Zarauza Navarro J M , Sainz Laso F , Lee Hwang D H , Garcia Camarero T , Gil Ongay A , De La Torre Hernandez J M
Published: January 2025

Introduction

TAVI implantation is currently indicated as a therapeutic alternative for an increasingly broad cohort of patients with aortic valve disease. Myocardial mass regression appears to be a constant in follow-up studies of these patients. However, there is no consensus on the evolution of systolic function in these patients after TAVI.

Purpose

The objective of our study was to analyze the 6-month effect of TAVI implantation on myocardial mass and left ventricular systolic function, measured through the usual estimation parameter—left ventricular ejection fraction (LVEF)—and left ventricular global longitudinal strain (GLS).

Methods

Patients diagnosed with symptomatic severe aortic stenosis who received a TAVI between February 2018 and February 2020 were included. Baseline echocardiogram studies (performed on the day of the implant, prior to the intervention) were analyzed and compared with examinations at medium-term follow-up, established at six months. Variables of systolic function (LVEF and GLS) as well as left ventricular mass (total and indexed) were detailed.

Results

We analyzed 180 patients (mean age 80.2 years, SD 9.02), of whom 98 (54.4%) were women. At the time of data collection, 58 deaths (32.6%) had been recorded, 17 (29.3%) of which occurred during the first year after TAVI implantation. The baseline and follow-up echocardiogram data obtained are summarized in Table 1. A statistically significant reduction (p<0.0001) in total left ventricular mass of 44.3g (33.2-55.5) and indexed mass of 24.9 g/m² (18.6-31.2) at six months post-intervention was observed. Parallel to this, left ventricular systolic function showed a significant improvement at medium-term follow-up, both estimated by left ventricular longitudinal strain (GLS -14.1 (SD±4.5) at baseline and GLS -16.1 (SD±11.6) at follow-up, p 0.0001) and by LVEF (baseline 54.9% (SD±12.9) and follow-up 58.8% (SD±11.6); p 0.0014)). Statistical significance in the analysis of this parameter had not been achieved in other studies by this working group until now.

Conclusions

Correction of aortic valve disease via percutaneous approach through TAVI implantation results in significant improvement in medium-term systolic function, as estimated by the classical parameter, LVEF, as well as in subclinical myocardial function measured through GLS. Similarly, in accordance with current evidence, the left ventricular mass (total and indexed) regresses in medium-term follow-up.

Table 1.
Utility of the average pixel intensity method for the detection of moderate-severe mitral regurgitation in comparison with the area of the regurgitant orifice
Authors: Calvo-Asensio M , Lozano-Edo S , Buendia-Fuentes F , Osa-Saez A , Rodriguez-Serrano M , Sanz-Ros J , Martinez-Dolz L , Maceira A , Calvillo-Batlles P , Fonfria-Esparcia C , Arnau-Vives M A , Aguero J
Published: January 2025

Background and purpose

The "average pixel intensity" (API) method, which is applied to the continuous Doppler spectral signal in mitral regurgitation (MR), has been proposed as a new method for automated MR grading. The objective of this study is to compare the API method with the effective regurgitant orifice area (EROA) for the detection of moderate-severe or severe MR (grades III or IV/IV) using open-source software (ImageJ).

Methods

Prospective single-center study (n=267) including patients with different degrees of MI, with a subgroup with cardiac magnetic resonance (CRM, n=55). Of the total sample, API was measured in 148 patients, and EROA in 159. Significant MR by echocardiography was defined according to a multiparameter criterion (American Society of Echocardiography - ASE algorithm), and by CRM according to regurgitant volume (≥50 ml) or regurgitant fraction (≥40%). The association between quantitative parameters (API and EROA) and the diagnosis of moderate-severe MI according to each imaging technique (echocardiography vs CMR) was evaluated using ROC curves.

Results

The prevalence of significant MR was 34.1% by echocardiography, and 21.8% by CMR. In 24% of cases the MR mechanism was functional. The median [Q1-Q3] API was 112 [141-166] units, and EROA 0.17 [0.10-0.30] cm2. The correlation between API and EROA was low (r = 0.34; p < 0.01). For the diagnosis of moderate-severe MR, EROA performed better than API taking the ASE algorithm as a reference (AUC 0.89 vs 0.75; Figure 1A), but both parameters showed a similar performance when compared to the CMR criterion ( AUC 0.80 vs 0.75; Figure 1B).

Conclusions

The low correlation between the API method and EROA raises their potential complementarity in the diagnosis of MR. Regarding the ASE multiparametric criterion by echocardiography, the EROA is superior to the API (being a key element in this algorithm). However, both methods present a similar association with the diagnosis of moderate-severe MR by CMR, and the assessment of both parameters could improve the agreement between echocardiography and CMR.
Right ventricle pulmonary artery coupling in patients with aortic stenosis.
Authors: Oikonomidis D , Tasoulis A , Tatsis E , Kouloulias I , Papadopoulos C
Published: January 2025

Right Ventricle (RV) –Pulmonary Artery (PA) Coupling refers to the relationship between RV contractility and RV afterload. It is estimated as the ratio of RV free wall tissue Doppler imaging (TDi) and Pulmonary Artery Systolic Pressure (PASP) . This index has shown a prognostic value in patients with cardiovascular diseases. The aim of the current study is to investigate the current index in patients with various grades of aortic stenosis.

We enrolled 60 subjects to our study (20 with severe aortic stenosis, 20 with symptomatic moderate aortic stenosis without other significant valve pathology, 20 contol group- aged matched). All patients underwent transthoracic echocardiography study.

Statistical analysis revealed a significant deference within 3 groups regarding RV –PA Coupling (RV-STDi /PASP, mean ± sd : 0.2595 ± 0.11718 vs 0.4305 ± 0.07416 vs 0.5820 ± 0.04275 , p – value = <0,001)

Conclusions

RV –PA Coupling index is significally associated with the grade of aortic stenosis.

RV PA coupling vs stenosis
Left ventricular pressure-strain-volume-loop and myocardial work patterns in asymptomatic severe aortic regurgitation with early disease decompensation
Authors: De Oliveira E K , Buytaert D , Moya A , Shumkova M , Mistrulli R , Ghare S , Fialova M , Medilek K , Van Camp G , Kockova R , Penicka M
Published: January 2025

Background

Severe aortic regurgitation (AR) is associated with left ventricular (LV) pressure and volume overload, leading to irreversible myocardial damage often before the onset of guidelines triggers for aortic valve surgery. Therefore, the development of sensitive imaging markers to detect the early impact of pressure-volume overload imposed by AR on LV geometry and function is needed.

Aim

To describe patterns of LV pressure-strain-volume loops, their components and myocardial work in asymptomatic patients with significant AR and preserved LV ejection fraction with early disease progression.

Methods

This multicenter study consisted of 95 consecutive patients (84.1% male, 45±14 years) with asymptomatic significant AR, in sinus rhythm, and preserved LV ejection fraction (EF) >50%, who did not have any indication for aortic valve surgery as per current guidelines. Comprehensive echocardiography was analyzed by an experienced operator blinded to clinical outcome. Pressure-strain-volume loops (PSVL), their components, and myocardial work were analyzed using customized software.

Results

During a median follow-up of 1375 [interquartile range 1041-1783] days, a total of 34 (36%) patients developed the class I indication for aortic valve surgery, i.e. either symptoms or LV dysfunction (AVsurg group). At baseline, LVEF (64±5% vs. 64±7%;p=0.748), global longitudinal strain (-17.6 ± -2.4% vs. -18.5 ± -2.4%; p=0.112), global myocardial work index (1963±429 vs.1900±340 mmHg%; p=0.429) or global constructive work (2371±495 vs. 2287±368 mmHg%; p=0.390) did not differ significantly between groups. In contrast, global wasted work was significantly higher (149[90-204] vs.106[80-152] mmHg%; p=0.031) in the Avsurg group compared to the patients without progression for AV surgery indication (CON group). Moreover, the AVsurg group showed a larger PSVL area than the CON group probability due to the larger strain-volume (234 [129-380] vs.155 [88-216] %mL; p=0.021) and pressure-volume (12504 [9318- 15073] vs. 10192 [8004-11918] mmHg.mL; p=0.002) component, while the pressure-strain loop was similar between groups (Figure 1).

Conclusions

Non-invasive pressure-strain-volume loop reflects early changes in LV geometry and function due to chronic pressure-volume overload in significant AR. Patients with early disease decompensation show larger PSVL than stable individuals. The clinical utility of this index needs to be investigated in future studies.

Figure 1
Accuracy of echocardiographic parameters in the diagnosis of severe mitral regurgitation as determined by cardiac magnetic resonance imaging.
Authors: Auberson D , Soylemez N , Arangalage D , Tzimas G , Antiochos P , Rutz T , Hugelshofer S , Monney P
Published: January 2025

Background

Echocardiographic grading of mitral regurgitation (MR) relies on the interpretation of both quantitative and qualitative parameters. Contemporary societal guidelines suggest a diagnostic approach that primarily favors quantitative parameters.1 We aimed to assess the diagnostic accuracy of such an approach in comparison to grading by cardiac magnetic resonance (CMR).

Methods

Patients with primary mitral regurgitation were assessed by transthoracic and transesophageal echocardiography (TTE, TOE), as well as cardiac magnetic resonance. Mitral regurgitation was considered severe if the regurgitant fraction by CMR was ≥40%.2

Results

A total of 77 patients were included, severe mitral regurgitation was diagnosed in 53 patients (69%) by CMR. Effective regurgitant orifice (ERO), regurgitant volume (RVol) and regurgitant fraction (RF) were assessed by TTE. ERO, RVol and 3D vena contracta area (VCA) were assessed by TOE.

On TTE, as standalone parameters, ERO ≥40mm2 (Se 72%/Sp 67%) and RVol ≥60mL (Se 65%/Sp 81%) had higher diagnostic accuracies than RF ≥50% (Se 65%/Sp 67%). On TOE, ERO (Se 85%/Sp75%) had the highest sensitivity and specificity, followed by the RVol (Se 73%/Sp71%) and VCA (Se 89%/Sp42%). When the presence of at least one quantitative parameter is considered diagnostic, the sensitivity is highest, more so by TOE than TTE (Se 94%/Sp 42% and Se 83%/Sp 56%, respectively) (Figure 1).

On the other hand, semi-quantitative parameters such as vena contracta ≥7mm (VC) and E-wave dominant mitral inflow (E >1.2m/s) had high specificities, but low sensitivities (TEE: VC Se 59%/Sp 79%, E >1.2m/s Se 49%/Sp 90%; TOE: VC Se 62%/Sp 87%, E >1.2m/s Se 24%/Sp 85%) (Figure 2).

Conclusion

For MR severity assessment, ERO and RVol by TEE and TOE exhibit the highest diagnostic accuracy as stand-alone parameters. VCA by TOE is highly sensitive for severe MR, but with a low specificity. Semi-quantitative parameters such as E-wave dominant mitral inflow and VC were highly specific of severe MR and may be used as additional parameters to confirm MR severity.
Effects of prosthetic heart valve-associated subclinical intravascular hemolysis on endothelium and cardiovascular system: a retrospective cohort study
Authors: Yamanturk Y , Ozdol C , Esenboga K , Uludag D M G
Published: January 2025

Background

Mechanical prosthetic heart valve implantation is a surgical treatment method used in the treatment of severe and symptomatic valvular disease. Regular follow-up of prosthetic valve functions, clinical and laboratory parameters is of great importance in patients who have undergone valve implantation. Chronic subclinical intravascular hemolysis is frequently seen in this patient group, but its management and long-term adverse effects are uncertain. In this study, it was aimed to determine the effects of subclinical hemolysis on the endothelium by comparing the frequency of clinical events such as pulmonary hypertension and atherosclerotic vascular events in patients with mechanical valves.

Methods

In this single-center, retrospective cohort, patients with functional mechanical prosthetic valves were evaluated. A total of 346 patients who underwent aortic and/or mitral valve replacement were included in the study according to the inclusion and exclusion criteria. The severity of mechanical intravascular hemolysis (MIH) in patients was evaluated based on serum lactate dehydrogenase (LDH) levels measured during follow-up after valve implantation. The study population was divided into two groups according to the median follow-up LDH value (fLDH) of 264.5 U/L: non-hemolysis/mild hemolysis (Group 1) and moderate hemolysis (Group 2). Study patients were evaluated for pulmonary hypertension (PHT) and major adverse cardiovascular events (MACE) during the retrospective follow-up period.

Results

The mean age of the study patients was 57.5±12.5 years, and the study population consisted of 65% male patients. The mean follow-up period of the patients was 9.4 years (±3.3). MACE (composite of non-fatal cerebrovascular event, myocardial infarction, new-onset arrhythmia, cardiovascular death, and elective coronary revascularization) were observed in 5.2% (n=18) of the study population. New-onset PHT was detected in 122 patients (35.3%) during follow-up period. When compared in terms of MACE, 1 event (0,6%) occurred in group 1, while 17 events (9,8%) occurred in group 2 (p<0.001). In the multivariate analysis performed with logistic regression method to determine statistical significance of the parameters that stand out in terms of MACE prediction, fLDH value ≥ 265 and having DM were found to be statistically significant variables (fLDH; OR = 37.18, 95% CI: 3.24-426.35, p=0.004, DM; OR = 27.14, 95% CI: 1.22-601.72, p=0.037).

Conclusion

The results of the study show that subclinical intravascular hemolysis in prosthetic heart valve patients may be associated with the development of MACE and PHT. Evaluation of the severity of hemolysis, which can be evaluated by LDH level in routine clinical practice, can be a prognostic factor in this patient group and may contribute to the appropriate management and treatment of patients.

Baseline characteristics

Critical outcomes of study