bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prevalence and prognostic value of significant mitral regurgitation development after pacemaker implantation
Authors: Nabeta T , Galloo X , Stassen J , Delgado V , Marsan N A , Bax J J 
Published: November 2023

Abstract

Background
Mitral regurgitation (MR) is one of the complications after pacemaker (PM) implantation. However, the underlying mechanism leading to MR progression after PM implantation is not yet fully understood. There is also a lack of information on the clinical impact of the development of MR after PM implantation.

Purpose
This study aims to evaluate the prevalence and mechanism of MR progression after PM implantation and to determine its prognostic value.

Methods
Patients who underwent de novo PM implantation at our university medical centre between 2010 and 2020 were included. Patients with previous mitral valve surgery, transcatheter edge-to-edge repair, or MR severity ≥ moderate before device implantation were excluded. The development of significant MR was defined as a worsening of MR severity ≥ moderate within five years after PM implantation. Clinical endpoints were defined as a composite of all-cause mortality or heart failure hospitalization.

Results
A total of 451 patients (mean age 69 ± 15 years, 61% male) were included. High-degree atrioventricular block (76%) was the main indication for PM implantation. Dual-chamber PM was implanted in 370 (82%) patients. The development of significant MR occurred in 131 (29%) patients at a median of 2.4 years [interquartile range (IQR): 1.0-3.8 years] after PM implantation. Multivariate logistic regression analysis demonstrated that implanted single-chamber PM, LV end-systolic volume index (LVESVI), and mild MR (vs no MR) at baseline were independently associated with the development of significant MR. Prespecified endpoints occurred in 143 patients (31.7%) during median follow-up of 5.4 years [IQR: 3.0-8.1 years] after PM implantation. The Kaplan-Meier analysis showed that patients with significant MR after PM implantation had a significantly higher incidence of endpoints than those without. (Figure) Multivariate Cox regression analysis demonstrated that the development of significant MR, age, male gender, and diabetes mellitus were independently associated with the occurrence of the combined endpoints. The development of significant MR had significant incremental prognostic value for the composite endpoints over the multivariate models including a decrease in LV ejection fraction of ≥ 10% (p = 0.008) or an increase in LVESVI of ≥ 20% (p = 0.016) after PM implantation.

Conclusions
The development of significant MR occurred in 131 patients after PM implantation. The development of significant MR was independently associated with cardiac events, and its prognostic value was also significant even when included in models including a decrease in LV ejection fraction or an increase in LVESVI after PM implantation.Figure:Kaplan-Meier Curve
Influence of device generations on alternations of mitral annulus after transcatheter edge-to-edge repair: a real-time three-dimensional transesophageal echocardiography study
Authors: Ohmori M , Hirasawa K , Izumo M , Ochida M , Satou Y , Kobayashi Y , Kuwata S , Okuyama K , Arima H , Akashi Y , Sasano T 
Published: November 2023

Abstract

Background
Alternation of the mitral annulus (MA) after transcatheter edge-to-edge mitral valve repair (TEER) is reported to be associated with a reduction of mitral regurgitation (MR). However, the influence of the new device system with 4 device size options (MitraClip G4) on MA geometry compared to the conventional device (G2) remains unknown.

Methods and results
A total of 129 patients (mean age 79±10 years, male 66%) including 38 primary MR and 91 secondary MR who underwent TEER guided with three-dimensional (3D) transesophageal echocardiography (TEE) were included. MA area, anterior-posterior (AP) diameter, inter-commissure (CC) diameter, and MA ellipticity before and after MitraClip implantation were measured using 3D TEE images assessed by dedicated software. MitraClip G4 was used in 54 cases (42%). In patients with secondary MR, greater changes in MA area, AP diameter, and MA ellipticity were observed in patients treated with G4 compared to G2 (P=0.001, 0.003, and 0.39, respectively). In contrast, patients with primary MR had no differences in the change of MA parameters between G2 and G4. Patients with significant residual MR had less increase of MA ellipticity after device implantation in secondary MR (P=0.014), but not in primary MR (P=0.062).

Conclusion
In patients with secondary MR, MitraClip G4 made greater changes in MAA, AP diameter, and MA ellipticity compared to MitraClip G2, but not in CC diameter. The change of ellipticity was associated with a reduction of MR after device implantation in secondary MR. These findings indicated that MitraClip G4 may lead favorable MA alternation than G2, especially in secondary MR.
Handgrip echocardiography improves risk stratification in patients with atrial functional mitral regurgitation
Authors: Spieker M , Sidabras J , Lagarden H , Fallack D , Christian L , Zweck E , Bejianriu A , Veulemans V , Akhyari A , Horn P , Westenfeld R , Kelm M , Rana O 
Published: November 2023

Abstract

Background
In the last years, cardiologist increasingly recognize "atrial functional mitral regurgitation" (AFMR) frequently associated with heart failure with persevered ejection fraction and atrial fibrillation. Exercise echocardiography is recommended by current guidelines in patients with secondary mitral regurgitation (MR) in several clinical scenarios. However, there are no data on the prognostic impact of exercise induced AFMR yet. We hypothesise that handgrip exercise during echocardiography unravels dynamic changes of MR severity that may impact further clinical decision making.

Purpose
We aimed to assess the prognostic impact of isometric exercise-induced changes in patients with AFMR.

Methods
Patients with atrial fibrillation and at least mild AFMR who underwent handgrip exercise echocardiography between January 2019 and September 2021 were included. Patients were followed-up for one year to assess clinical outcomes. The combined endpoint included all-cause mortality, heart failure hospitalisation and mitral valve surgery/intervention.

Results
We included 80 patients with AFMR (median age was 80 (77-83) years; 53.8%were female). Echocardiography at rest showed mild MR in half of the patients (53.8%), moderate MR in 20 patients (25.0%), and severe MR in 17 patients (21.2%). In nearly every fifth patient (17.5%) with non-severe MR at rest, the MR became severe during exercise. Median follow-up duration was 12 months (IQR: 4-17 months). Follow-up was completed in 78 of the 80 patients (97.5%). Thirty-five patients (44.9%) experienced adverse events. Kaplan-Meier survival analysis revealed adverse clinical outcomes more often in patients with severe MR during exercise (76.9%) compared to patients with non-severe MR during exercise (33.3%)(p&lt;0.001). Addition of handgrip exercise testing to echocardiographic assessment at rest improved the global chi-square (from 21.2 to 30.2) and the Harrell’s c-index (from 0.69 to 0.78) for prediction of mitral valve surgery/interventions during follow-up.

Conclusions
Isometric handgrip exercise testing unmasks severe MR in a significant proportion of patients with non-severe MR at rest and improves further risk stratification in these patients.
3D atrial stiffness in chronic mitral regurgitation: impact of sex, regurgitation mechanism and valve geometry - the 3D-PRIME study
Authors: Cramariuc D , Berg-Hansen C E , Persson R M , Urheim S , Hung J 
Published: November 2023

Abstract

Background
Chronic mitral regurgitation (MR) is both a cause and a consequence of progressive left atrial (LA) remodeling. The degree of LA stiffness in relation to clinical risk factors as well as atrio-valvular remodeling has not been reported in patients with MR.

Aims
To assess the severity and determinants of 3D LA stiffness in chronic MR.

Methods
In the prospective 3D-PRIME (3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation) study, 100 patients with chronic MR (70±13years, 38% women, 55% with a history of atrial fibrillation (AF), 42% with severe MR) recruited at one heart valve center were investigated with 2D and 3D transthoracic and transesophageal echocardiography. MR severity was quantified by the regurgitant fraction and MR classified as primary (54%), atrial functional (26%) or ventricular functional (20%). 3D LA volume (LAV) was measured at end-diastole (min LAV) and end-systole (max LAV), and 3D LA function assessed in by the emptying fraction (EF) and the peak strain in the reservoir phase (LASr). LA stiffness was estimated from the ratio: mitral peak E-wave velocity divided by the mitral annular e’ velocity (E/e´) / LASr and classified as high for age if ≥ 0.55.

Results
High LA stiffness for age was present in 58% of patients and more often in those with a history of AF (73% vs. 45%) and in severe vs moderate MR (70% vs. 42%) (both p &lt;0.01). Patients with high LA stiffness had larger LAVs with lower LA EF, lower right ventricular ejection fraction, increased mitral annulus area, and larger mitral valve leaflets (all p&lt;0.05).
Men had considerably larger LAVs in all MR subgroups, and highly stiff LAs in atrial functional MR compared to women (p &lt;0.05, Figure) despite similar MR severity (regurgitation fraction 50% vs 52%, respectively).
In multiple regression analysis, after stepwise removal of the following factors: MR severity, mitral leaflet to ring area ratio, and right ventricular ejection fraction, increased LA stiffness was independently associated with male sex, history of AF, lower LA EF and lower mitral intertrigonal diameter (R2 0.40, p &lt;0.001, Table).

Conclusion
LA is stiff for age in over half of patients with chronic MR, excessively stiff in men with atrial functional MR, and associated with specific changes in mitral valve geometry and LA function. This gives mechanistic insights into the complex atrio-valvular interplay in chronic MR.Figure.Table.
Right heart remodeling and outcomes of patients with tricuspid regurgitation
Authors: Bombace S , Fortuni F , Viggiani G , Meucci M C , Esposito G , Condorelli G , Von Roeder M , Thiele H , Lurz P , Grayburn P A , Sannino A 
Published: November 2023

Abstract

Background
Albeit long neglected, significant (at least moderate, ≥ 2+) tricuspid regurgitation (TR) is currently known to be associated with increased mortality, and has thus become a relevant therapeutic target [1-3]. Recent and somewhat preliminary evidence has shown, however, that different subtypes of TR might respond differently to current therapeutic options [4-5]. In fact, secondary TR, rather than being a single entity, can develop because of either right ventricular (RV) remodelling (i.e functional TR) or tricuspid annulus (TA) dilation secondary to right atrial (RA) dilation (i.e isolated TR).

Purpose
The aim of this meta-analysis was to study the association between right heart remodeling and long-term all-cause mortality in a population of patients with significant TR, independent of the treatment option.

Methods
MEDLINE, ISI Web of Science, and SCOPUS databases were searched for studies published up to July 2022. Studies reporting data on at least one echocardiographic RV anatomic and/or functional parameter and outcome in patients with significant TR were included. This study was designed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) requirements. The primary endpoint was long-term all-cause mortality.

Results
Out of 3152 studies, a total of 14 were included in the final analytic synthesis, enrolling 4394 subjects. The median follow-up was 33 [24–51] months. Overall, long-term all-cause mortality was 31% (95% confidence interval [CI]: 20-41%, p = &lt;0.001; Figure 1); however, a significant difference was noted in the medical subgroup vs. the surgery subgroup (43% [32-53%] vs 11% [20-41%]). By means of a meta-regression analysis, a significant and inverse relation was found between tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RV-FAC) and mortality (11 studies enrolling 3551 subjects, coefficient -0.063 [-0.111 to -0.014], p = 0.011; 9 studies, 2975 subjects, coefficient -0.044 [-0.059 to -0.029], p &lt; 0.001, respectively; Figure 2A and 2B), whereas a significant and concordant relation was found between TA dimension, RA area and mortality (7 studies, 2986 subjects, coefficient 0.003 [0.002 to 0.005], p &lt; 0.001; 6 studies, 1920 subjects, coefficient -0.019 [-0.025 to -0.013], p &lt; 0.001, respectively; Figure 2C and 2D).

Conclusions
The higher mortality associated with right ventricular dysfunction and reduced mortality with increasing right atrial dilatation suggest a better prognostic outcome for isolated TR than functional TR. Careful assessment of right heart anatomy and function is warranted, as it might foster the identification of different subtypes of TR with unique prognoses.Forest plot all-cause mortalityResult of the meta-regression analysis
Left ventricular fibrosis influences the time to recovery in patients with arrhythmia-induced cardiomyopathy
Authors: Schach C , Lavall D , Vosshage N , Koertl T , Muehleck F , Baum P , Uecer E , Hamer O , Maier L , Wachter R , Sossalla S 
Published: November 2023

Abstract

Background
The hallmark of arrhythmia-induced cardiomyopathy (AIC) is reversibility of left ventricular systolic dysfunction (LVSD) following rhythm restoration. Atrial fibrillation and LVSD very frequently co-exist and hence AIC is likely to be under recognized in daily practice. We tested the hypothesis, that left ventricular fibrosis has an influence on the time to recovery (TTR) in patients with AIC.

Method
We prospectively screened patients hospitalized for newly diagnosed and otherwise unexplainable LVSD (i.e. left ventricular ejection fraction (LVEF) &lt;50%) and coexisting tachyarrhythmia (atrial fibrillation/flutter + heart rate (HR) &gt;100/min). Causes other than tachyarrhythmic for LVSD had to be excluded (e.g. valvular, ischaemic, inflammatory). Left ventricular function was assessed by echocardiography at presentation and at follow-up visits 2, 4, and 6 months after rhythm control. Left ventricular (LV) late gadolinium enhancement (LGE) was measured via magnetic resonance imaging after rhythm restoration. Patients were classified AIC, if LVEF significantly recovered after 6 months (increase by ≥15% or above 50% with an increase of ≥10%) and then correlated with LGE as an indicator for fibrosis.

Results
39 patients were included in the LGE analysis, 31 of them recovered and were classified AIC. Although we found no difference in LGE content in AIC vs. non-AIC patients (mean ± SEM 7.7 ± 0.9% vs. 6.5 ± 1.4%; p = 0.542) and contingency analysis of AIC/non-AIC vs. LGE-positive/LGE-negative patients revealed no difference between the groups (p = 0.682), there was a negative correlation of ΔLVEF (month 2 minus baseline) with LGE (Fig. 1) and a positive correlation of the TTR with LGE (Fig. 2) in LGE-positive patients, suggesting an influence of LV fibrosis on the speed of recovery.

Conclusion
Reliable criteria for recovery of LVEF in patients with newly diagnosed LVSD and coexisting arrhythmia are lacking. We found, that LV LGE correlated with the time to recovery of LVEF in patients with AIC. These results may help to estimate the recovery period and thereby optimize the diagnostic and therapeutic strategy for patients with AIC.Figures 1 and 2.
Comparing clinical outcomes in bicuspid versus trileaflet aortic valve endocarditis
Authors: Chatrath N , Dargan J , Hampal R , Kaza N , Bhatia R , Fyyaz S , Maclachlan H , Breathnatch A , Sharma S , Papadakis M , Tome Esteban M , Marciniak A 
Published: November 2023

Abstract

Background
The incidence of bicuspid aortic valve infective endocarditis (BAV-IE) has been reported at 2% in contemporary BAV cohorts with an estimated risk of developing BAV-IE 11 times that of the general population with a trileaflet aortic valve (TAV).

Purpose
To characterise BAV-IE from a clinical and microbiological perspective and compare clinical outcomes with a cohort of individuals with trileaflet aortic valve infective endocarditis (TAV-IE).

Methods
The clinical records of all patients (&gt;16 years old) admitted to a large tertiary referral centre in the United Kingdom between 2015 and 2022 with a definitive diagnosis of native aortic valve IE by Duke’s criteria were included. Clinical, echocardiographic and microbiological data were obtained. The primary outcomes were death or surgical aortic valve intervention during the indexed hospital admission. Secondary outcomes included the incidence of cardiac complications (e.g. aortic root abscess or fistula formation, IE affecting another valve or high degree atrioventricular block requiring temporary or permanent pacing). Extra-cardiac complications included embolic phenomena and thrombotic events.

Results
83 patients were included (BAV-IE 34; TAV-IE 49). BAV-IE patients were significantly younger at presentation than TAV-IE patients (Table 1). There was no difference age-adjusted mortality rate between the two groups (mortality rate BAV-IE 0.20 (95% CI 0.08-0.54) versus TAV-IE 0.29 (95% CI 0.17-0.48). The rate of cardiac complications including aortic root abscess or fistula formation, and concomitant mitral valve endocarditis was greater in the BAV group, though not reaching statistical significance. Those in the BAV-IE group were more likely to develop at least moderate aortic regurgitation and have aortic valve intervention during the admission (70.6% (24/34) BAV-IE versus 46.9% (23/49) TAV-IE, p=0.03).

Conclusion
Despite an estimated prevalence of 1% in the general population, BAV accounted for 41% of all native AV IE cases at our institution. This study demonstrates that even in young, otherwise healthy individuals, BAV-IE has a poor prognosis with a high proportion developing structural complications. Age-adjusted mortality rates are similar to those with TAV-IE, who are often older with more co-morbidities. Though antibiotic prophylaxis is currently only recommended for those at the highest risk, these findings reinforce the importance of mitigating sources of infection in individuals with BAV. Prompt medical attention and treatment of suspected IE cases is of utmost importance as degeneration of a BAV and other cardiac complications, particularly aortic regurgitation, can rapidly develop.
Valvulitis: a new echocardiographic criterion for the diagnosis of prosthetic valve infective endocarditis
Authors: Zulet Fraile P , Olmos C , Pozo E , Carnero M , Saiz-Pardo M , Mahia P , Jeronimo A , Islas F , Gomez-Ramirez D , De Agustin A , San Roman J A , Vilacosta I 
Published: November 2023

Abstract

Background
Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been previously described in some patients with aortic bioprosthetic valve endocarditis (PVE). This echocardiographic finding has been termed valvulitis.

Objectives
Our aim was to estimate the prevalence of valvulitis, to precisely describe its echocardiographic characteristics, and to determine their clinical significance in patients with aortic bioprosthetic valve endocarditis.

Methods
From 2011 to 2022, 388 consecutive patients with IE admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with aortic bioprosthetic valve endocarditis (n=86) were selected, and their TEE images were thoroughly evaluated by three independent cardiologists to identify all potential cases of valvulitis. The diagnosis of valvulitis was considered to be present when all three were in complete agreement.

Results
Prevalence of isolated valvulitis in the total cohort was 12.8%, and 20.9% of patients had valvulitis accompanying other classical echocardiographic findings of IE.
A description of the main clinical and imaging findings of 11 patients with valvulitis and no other echocardiographic signs of IE is shown at the Table. Diagnosis status corresponds to the criteria for the diagnosis of IE according to the ESC 2015 IE guidelines, including 18F-FDG PET/CT.
TEE long-axis and short-axis views of a patient with bioprosthetic valvulitis (homogeneous and hypoechoic thickening of the aortic leaflets) resulting in severe aortic stenosis are shown at the Figure, Panel A. At Panel B, abnormal FDG uptake (white arrow) at the prosthetic valve is seen on PET/CT scan of the same patient. At Panel C, histology of the aortic bioprosthetic leaflet of the same patient with valvulitis is presented (hematoxylin and eosin stain of the aortic leaflet; granulation tissue is well demonstrated (red bracket) covering the aortic fibrosa (red asterisk)).
Moderate or severe valve stenosis was more common in those with valvulitis (81.8 vs 34.9%, p&lt;0.001). Patients with isolated valvulitis tended to have a lower IE-related in-hospital mortality (9.1 vs 23.3%, p=0.219) and cardiac surgery was less frequently performed than in the other subjects with aortic PVE (27.3 vs 58.1%, p=0.17), but these results were not statistically significant.

Conclusions
Valvulitis can be the only echocardiographic finding in infected biological aortic prosthesis and needs to be recognized by imagers for early patient diagnosis. The identification of this sort of lesion is important since the clinical profile and management of these patients is different from that of patients with classical PVE.TableFigure