bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prognostic value of left atrial volume index in patients with rheumatic giant left atrium
Authors: Adrian L H , Sanjaya C R , Hutomo S A , Negari A D S 
Published: November 2023

Abstract

Background
Giant left atrium (GLA), conventionally defined as an anteroposterior diameter of more than 65 mm, is a rare condition mostly resulted from rheumatic mitral valve disease. Assessment of left atrial volume index (LAVI), in place of LA diameter, may have important prognostic implications in rheumatic GLA patients, incremental to clinical and additional imaging parameters.

Purpose
This study investigated whether initial assessment of LAVI is associated with short-term outcomes in rheumatic GLA patients who did not undergo surgery.

Methods
This was a single-center, prospective cohort study in 58 patients with definite rheumatic heart disease and echocardiographic-confirmed GLA who refused valve surgery and/or LA reduction procedure. Assessment of clinical, laboratory, echocardiography, and CT angiography thorax with contrast were performed on their first hospital admission. The study population was subdivided based on a LAVI value of 254 mL/m², following the prior ROC curve analysis. Both groups were followed for up to 17 months. The primary endpoint was all-cause mortality. The association between variables and all-cause mortality was analyzed using the Kaplan-Meier curve and Cox proportional hazard regression models.

Results
A total of 54 out of 58 patients (age 46 ± 11 years; 90.7% women) were included. At baseline, patients with LAVI ≥ 254 mL/m² exhibited significantly higher NT-proBNP level, reduced estimated glomerular filtration rate (eGFR), lower TAPSE, higher systolic pulmonary arterial pressure (sPAP), larger LA diameter, and more prone to atrial fibrillation and LA appendage aneurysm, rather than patients with LAVI &lt; 254 mL/m² (all p&lt;0.05). During a median follow-up of 12 (8–17) months, 11 (20.4%) patients died. Patients with LAVI ≥ 254 mL/m² demonstrated significantly higher mortality rates at 3-, 6-, and 12-months follow up (4%, 6%, and 16%, respectively) when compared with patients with LAVI &lt; 254 mL/m² (2%, 2% and 4%, respectively, log-rank p=0.03). LA appendage aneurysm [hazard ratio (HR): 4.17; 95% confidence interval (CI): 1.15–6.52; p=0.035] and LAVI (HR: 1.07; 95% CI: 1.05–1.1; p=0.042) were independently associated with all-cause mortality. The addition of LAVI to a clinical model (including eGFR, NT-proBNP, LA diameter, cardiogenic shock, echo signs of chambers compression, and LA appendage aneurysm by CT) was associated with significant increase in the X² value (X² difference = 7.19; p&lt;0.001), suggesting the incremental prognostic value of LAVI in patients with rheumatic GLA.

Conclusions
LAVI is independently associated with all-cause mortality in rheumatic GLA patients not undergoing surgery and provides incremental prognostic value over clinical and imaging variables for short-term survival. LAVI may therefore be useful in the risk stratification of patients with rheumatic GLA and optimize timing of surgical intervention.Baseline characteristics of the studyPrognostic value of LAVI on mortality
Risk of thromboembolic and bleeding events in patients with atrial fibrillation after valvular intervention in either aortic or mitral position
Authors: Skogseid E L , Batra G , Westerbergh J , Held C , Christersson C 
Published: November 2023

Abstract

Background
The optimal oral anticoagulant treatment (OAC) for patients with atrial fibrillation (AF) undergoing valvular intervention is uncertain. Mitral valve prostheses are believed to be more thrombogenic than the aortic due to lower flow velocity across the valves. The only randomized controlled trial of AF patients with biological valve prostheses included only patients receiving mitral valve prostheses (1). It is unclear if these findings could be extrapolated to patients receiving aortic valve prostheses.

Purpose
To describe baseline characteristics and comorbidities of patients receiving biological valve prostheses in aortic or mitral valve position and to investigate possible associations between valve position and the incidence of cardiovascular (CV) death, ischemic stroke or systemic embolism and major bleeding.

Methods
All patients in Sweden undergoing open heart surgery with aortic or mitral valve replacement with biological prostheses between 2010-2016 with known AF were included. The study cohort was identified in the SWEDEHEART registry. Information on comorbidities, drug exposure and occurrence of outcome events was collected from SWEDEHEART and other national registries. Association between the position of valve prosthesis (mitral and aortic) and incidence of outcome events was investigated using Cox regression analysis. Multivariable adjustments were made for comorbidities.

Results
In total, 2359 patients with AF underwent aortic (n=2103) or mitral (n=256) valve replacement. The median age was 75 and 73 years, respectively. Hypertension, diabetes mellitus and previous TIA were more common in the aortic valve group, whereas heart failure and previous major bleeding was more frequently observed in the mitral group. In both groups, about 50% of the patients were not on OAC treatment at time of discharge from valve intervention, despite that the mean CHA2DS-VASc score was 3.3 and 3.2, respectively. Mitral valve prostheses were associated with similar risk of CV death (hazard ratio (HR) 1.09; 95% confidence interval (CI), 0.77 – 1.56), ischemic stroke and systemic embolism (HR 1.27; 95% CI, 0.85-1.92) compared to aortic valve prostheses. In contrast, receiving mitral valve prosthesis was associated with lower risk of major bleeding compared to aortic prosthesis (HR 0.58; 95% CI 0.38 – 0.88).

Conclusion(s)
The study indicated similar risk of CV death, ischemic stroke and systemic embolism among patients with AF undergoing valve replacement with biological prostheses in either aortic or mitral position. Mitral valve replacement was associated with lower risk of major bleeding.
Left ventricular remodeling in chronic aortic regurgitation: both age and sex matter
Authors: Hanet V , Altes A , De Azevedo D , Vanoverschelde J L , Pasquet A , Vancraeynest D , Gerber B 
Published: November 2023

Abstract

Background
For chronic and severe aortic regurgitation (AR), both European and American guidelines recommend surgery in the setting of dilated left ventricle (LV). However, normal LV volumes are described according to age and gender (1) and differences in remodeling according to gender have been described in AR (2) and late referral bias has been suggested as a cause for outcome penalty in female patients with AR (3).

Objective and methods
To clarify the interactions of age and gender on LV volumes in the setting of AR with cardiac magnetic resonance (CMR). This is a single-center study performed in a referral center for cardiac surgery and aortic valve repair. Patients were adults identified or referred for an at least moderate AR (grade II) by transthoracic echocardiogram (TTE) and were invited to perform a CMR. Exclusion criteria were acute AR caused by bacterial infection or dissection, dilated cardiomyopathy from another identified cause, concomitant more than moderate left heart valve disease or intra-cardiac devices.

Results
Among 296 patients included (51+/-16 years, 56 (19%) females and 129 (44%) bicuspid), mean regurgitant fraction (RF) was 33%. Age was similar among men and women (50+/-16 vs 54+/-16; p=0.142) but RF was higher among men (35+/-18 vs 25+/-15%, p&lt;0.001). Both LV end-diastolic (iLVEDV) and end-systolic (iLVESV) were moderately correlated to regurgitant fraction (Pearson R of respectively 0.605 and 0.569). Women had lower iLVEDV and iLVESV than men after correction for AR severity (respectively 105+/-24 vs 136+/-43ml/m²; p&lt;0.001 and 48+/-17 vs 66+/-30ml/m²; p=0.007). Female gender was associated with a significantly lower susceptibility to dilate both iEDV and iESV in the setting of an increasing AR severity (p for interaction of respectively 0.048 and 0.041). Similarly, advancing age was associated with a continuous decrease in iEDV and iESV dilatation ability (p for interaction of respectively 0.006 and 0.048).

Conclusion
Sex and age are significant determinants for LV volumes in AR. Furthermore, both female sex and aging independantly lead to a decreased capability of LV dilatation, suggesting sex and aged-based CMR thresholds for LV dilatation should be further developed to avoid possible late referral bias for surgery in female or elderly population.Gender interaction on LV dilatationLV volumes prediction models
Moderate mixed aortic valve disease -evaluation, treatment and prognosis of patients referred to heart valve center
Authors: Lupinek P , Kotrc M , Marek T , Kockova R , Pecenkova V , Dorazilova Z , Blaha M , Benes J , Praveckova A , Kroupova K , Capkova V , Podzimkova M , Kettner J , Kautzner J 
Published: November 2023

Abstract

Background
Indications for valve intervention in mixed aortic valve disease (MAVD) are not clearly defined. Decision is usually based on predominant lesion, extrapolated from guidelines for isolated aortic stenosis (AS) or aortic regurgitation (AR). However, data have been published suggesting that the prognosis of patients who have both moderate AS and moderate AR is not benign and may be similar to the prognosis of isolated severe AS.
Goal: To assess diagnostic process, decision making and prognosis in patients with MAVD and moderate stenosis and regurgitation examined in a tertiary referral centre.

Methods
Patients with MAVD and EF ≥50% examined at tertiary referral center in years 2010-2021 were retrospectively identified. MAVD was defined as moderate AS by aortic valve area &gt;1,0 cm2 and ≤1,5 cm2 and moderate AR by integrative assessment. Patients with more than mild to moderate disease of other valves were excluded.

Results
A total of 85 patients were eligible, mean age 66,4±7,9 years, males/females 58/27, 40 (47.1%) with bicuspid or monocuspid aortic valve, 50 asymptomatic. During a mean follow-up (F-U) of 5.9±3.6 years, 20 patients died and 46 underwent aortic valve replacement (AVR). At 1, 2, and 5 years of F-U, the mortality rate was 3.5%, 7.1% and 15.3% and the rate of AVR reached 23.5%, 30.6% and 43.5%, respectively. At 1, 2 and 5 years 61 (71.7%), 54 (63.5.%) and 40 (47.1%) patients were alive and free of AVR.
In 10/13 patients who died within 5 years, MAVD was classified as nonsevere. Therefore, these patients were treated conservatively and eight of them died without AVR. Except one, all had peak velocity at aortic orifice &lt;4 m/s. In all 6 patients who died within 2 years, MAVD was classified as nonsevere on index examination, AVR was indicated and performed only in 1 due to associated aortic aneurysm.

Conclusions
MAVD where both AS and AR are moderate is not a benign condition. Its overall severity is often underestimated, indication criteria for AVR are not clear and substantial proportion of patients die while being treated conservatively. These patients should be followed closely and lower threshold for aortic valve replacement/repair may be appropriate.
Left atrial strain and risk of systemic embolic event in rheumatic mitral stenosis with sinus rhythm
Authors: Lee S , Cho I S , Kim D Y , Kim I C , Hong G R , Kim H S 
Published: November 2023

Abstract

Backgrounds
Stroke and systemic embolism might be an important complication of rheumatic mitral stenosis (MS) even though patients are in sinus rhythm (SR), but the risk of embolic events in this population are not well studied.

Purpose
We aimed to evaluate the risk factors of embolic events in patients with rheumatic MS and SR.

Methods
From the multi-center retrospective registry of 2426 patients with rheumatic MS, we included patients with rheumatic MS and SR (n=583) between January 2000 and December 2021. After exclusion of patients who had history of systemic embolic events, taking the anticoagulants, combined significant aortic valve dysfunction, and a history of valve surgery. We finally analyzed 443 patients. The primary outcome was defined as composite of stroke, transient ischemic attack, noncentral nervous system embolism.

Results
Among 448 patients (77.1% female; mean age, 52.3 ± 10.1 years), systemic embolic events developed in 38 (8.4 %) patients with annual incidence rate of 4.6/100 person-year during mean follow-up period of 96.4 ± 61.1 months (median 94.2 months). Patients who had systemic embolic events were significantly older and had higher the prevalence of hypertension and diabetes than those who did not, without significant differences in left atrial (LA) dimensions, volumes, pulmonary artery systolic pressure. Instead, LA strain was significantly impaired in patients with systemic embolic events (19.1 ± 9.3 vs. 15.5 ± 8.07, p= 0.034). In the multivariate analysis, LA strain was independent predictors of systemic embolic events [HR 0.96, 95 % CI: 0.93-0.99; P = 0.021], after adjustment for confounding factors. The impaired LA strain (LA reservoir strain &lt; 16.6 %) also had incremental prognostic value for development of systemic embolic events over clinical factors and traditional echocardiographic parameters (Figure).

Conclusions
Impaired LA strain is a predictor of stroke and systemic embolism in patients with rheumatic MS in SR. Considering the risk for embolism, oral anticoagulation might be considered in patients with rheumatic MS in SR and impaired LA strain.Figure
Moderate functional mitral regurgitation: difference between atrial and ventricular mechanism of the regurgitation
Authors: Sarrazyn C , Laenens D , Chua A P , Myagmardorj R , Nabeta T , Bax J J , Ajmone Marsan N 
Published: November 2023

Abstract

Background/Introduction
In severe functional mitral regurgitation (MR), further distinction of the mechanism of MR in atrial functional MR (aFMR) and ventricular functional MR (vFMR) has shown prognostic importance. However, no data are available on moderate functional MR, whose characteristics and prognosis are largely unknown.

Purpose
To assess clinical and echocardiographic characteristics of patients with moderate aFMR and vFMR and their potential difference in outcome.

Methods
Patients with moderate functional MR were retrospectively included. aFMR was defined as isolated mitral annulus dilatation in combination with preserved left ventricular ejection fraction (LVEF≥50%) without ischemic heart disease or LV dilatation. Patients were classified as vFMR when LVEF was reduced, LV was dilated and/or wall motion abnormalities were present. Mitral valve intervention and all-cause mortality were used as combined endpoint.

Results
In total 474 patients with moderate functional MR (mean age 67 ±12, 57% male) were evaluated, of which 136 (29%) had aFMR and 338 (71%) had vFMR as underlying mechanism. Among the clinical variables, patients with aFMR had more atrial fibrillation (77% vs. 35%; p&lt;0.001), were less symptomatic (NYHA class ≥ III: 6% vs. 18%; p&lt;0.001) and had better renal function (eGFR 73 ±23 ml/min/1,73m2 vs. 65 ±23 ml/min/1,73m2; p=0.005) as compared to vFMR. In the vFMR group, 49% of patients had ischemic heart disease. Among the echocardiographic variables, as expected in aFMR, LVEF was higher (42 ±14% vs. 55 ±13%; p&lt;0.001), while LV volumes (LV end-diastolic volume index 55 ±13 mL/m2 vs. 82 ±38 mL/m2; p&lt;0.001) and E/E’ ratio were smaller (10 ±4 vs. 15 ±4; p&lt;0.001) as compared to vFMR. However left atrial (LA) volume index was similar between both groups (43 ±14 mL/m2 vs. 41 ±18 mL/m2; p=0.271). For the echocardiographic measures of the right heart, significant difference was observed only for TAPSE which was higher for the aFMR group (22 ±4mm vs. 20 ±5mm; p&lt;0.001). During a median follow-up of 74 months [IQR: 46.8-107.0], 132 (30%) patients died and 30 (6%) underwent mitral valve intervention. Event-free survival analysis for the combined endpoint was significantly better for aFMR patients (Figure 1). Based on significant variables from the univariable Cox regression analysis, multivariable Cox regression analysis showed that the mechanism of functional MR (with aFMR being protective as compared to vFMR), age, male gender, impaired renal function, NYHA class, severe LA dilatation and TAPSE were independently associated with the combined endpoint (Table 1).

Conclusion
In patients with moderate functional MR, aFMR is independently associated with better event-free survival as compared to vFMR. Therefore, clear identification of the mechanism of MR implies a better risk stratification and may be helpful for the management of patients with moderate MR.
Artificial intelligence-enabled electrocardiogram in the detection of patients at risk of atrial functional mitral regurgitation
Authors: Naser J , Lee E , Michelena H I , Lin G , Pellikkka P A , Nkomo V T , Noseworthy P A , Friedman P A , Attia Z I , Pislaru S V 
Published: November 2023

Abstract

Background
Atrial functional mitral regurgitation (AFMR) is an increasingly recognized cause of functional MR thought to result from left atrial enlargement and myopathy in the setting of preserved left ventricular geometry and function. AFMR mostly occurs in patients with atrial fibrillation (AF) and/or heart failure with preserved ejection fraction.

Purpose
We investigated whether the use of an artificial intelligence-based electrocardiogram (AI-ECG) can identify patients with new-onset AF and sinus rhythm (SR) who are at highest risk of developing AFMR.

Methods
Adults with a new diagnosis of AF between 2010 and 2021 who had a transthoracic echocardiogram (TTE) within 1 month after AF diagnosis were identified. Similarly, adults in SR who never had AF diagnosis and had a TTE during the same period were identified. Exclusion criteria from both groups included &gt;mild MR at baseline, primary mitral valve disease, cardiomyopathy, ≥moderate aortic valve disease, current or previous low ejection fraction, enlarged left ventricle, cardiac devices, previous cardiac surgeries, and the absence of follow-up TTE ≥6 months from baseline. Only patients who had ECG within 10 days of the TTE were included. When multiple ECGs were available, the closest was considered. A previously trained AI-ECG algorithm to detect the probability of AF was utilized. Incident AFMR was defined as &gt;mild functional MR in the absence of &gt;mild left ventricle enlargement or dysfunction. Diastolic dysfunction was defined according to ASE/EACVI guidelines.

Results
Overall, 1,570 patients with new-onset AF (median age 67 years; 34% females) and 16,802 patients in SR (median age 59 years; 46% females) were included. The median AI ECG probability for AF was 43% (IQR 26%-59%) in the new-onset AF group and 2% (0.5%-7%) in the SR group, Figure 1. Incident AFMR occurred in 152 patients in the AF group over median 3.06 (IQR 1.5-5.2) years of follow-up and in 482 patients in the SR group over median 3.0 (1.5-5.6) years of follow-up. The probability of silent AF by the AI-ECG was associated with incident AFMR in the new-onset AF group [hazard ratio 1.19 (95% CI 1.11-1.28) per 10%, p &lt;.001] and the SR group [hazard ratio 1.19 (95% CI 1.12-1.25) per 10%, p &lt;.001]. The AI ECG-derived AF probability remained as an independent risk factor for AFMR in multivariable analysis in both AF and SR, Table 1.

Conclusion
The AI ECG for AF might be able to reflect the degree of left atrial myopathy and thus the risk of incident AFMR in patients with AF and SR.Distribution of AI ECG probability of AFMultivariable risk factors for AFMR
Mitral leaflet retraction and left ventricular reverse remodeling in patients with treated dilated cardiomyopathy
Authors: Kang Y , Liu K Y , Yang Z X , Qu N , Zhong X K , Chen X J , Wang M , Zhang Q 
Published: November 2023

Abstract

Background
Enlargement of the mitral leaflets (MLs) adaptive to mechanical stress caused by dilated left ventricle (LV) was recognized, but their changes after the stimuli withdrawn remained unexplored.

Aims
To observe morphological changes in the MLs along with LV reverse remodeling (LVRR) occurred after standard care.

Methods
Patients with recent-onset dilated cardiomyopathy (RODCM) were prospectively enrolled (n=82), as well as a group of age, sex and body surface area matched normal controls (NC) (n=50). Two-dimensional transthoracic echocardiography was performed at baseline and 6-month follow-up with special interests in the length of anterior and posterior mitral leaflet (AML and PML), mitral annular dimension (MAD) and tenting height (TH). LVRR was measured as a reduction in the LV end-diastolic volume (LVEDV) of ≥15%.

Results
At the 6-month follow-up, LVRR was achieved in 69.5% patients and there were 26.9% patients who reported ≥1 grade reduction in secondary mitral regurgitation that related to LVRR. The AML (28±3 vs. 26±3mm, p=0.004) and PML (19±4 vs. 17±3mm, p&lt;0.001) were decreased, as well as the MAD (31±5 vs. 28±5mm, p=0.001) and TH (10±3 vs. 8±2mm, p&lt;0.001), but all remained larger than that of the NC group (all p&lt;0.05). When compared with the control group, the AML and PML of the RODCM group was 16.7% and 35.7% longer at baseline, which remained 8.3% and 21.2% longer at the follow-up, respectively. The change in the AML (△AML) or PML (△PML) correlated moderately to the change in the LVEDV (△LVEDV) (r=0.487, p&lt;0.001; r=0.516, p &lt;0.001, respectively) (Figure 1). When compared between the subgroups stratified by LVRR, both the AML and PML decreased in the patients who had LVRR (+) (AML, 28±3 vs. 26±3, p=0.001; PML, 20±4 vs. 16±3, p&lt;0.001), but remained the same length in those with LVRR (-) (AML, 27±4 vs. 28±4, p=0.318; PML, 17±3 vs. 17±3, p=0.790). The comparison in the △AML and △PML between the two subgroups is shown in Figure 2.

Conclusion
The enlarged MLs could retract with different behavior in the AML and PML, accompanied by LV reverse remodeling. This study conducted in patients with RODCM who received standard therapy provided the other facet of mitral leaflet plasticity adaptive to mechanical stretch.correlation between △MLs and △LVEDVCompare △MLs between LVRR subgroups