Left atrial enlargement is frequent in degenerative mitral regurgitation (DMR), but its link to outcomes remains unproven in routine clinical practice.
The purpose of this study was to assess whether ...left atrial volume index (LAVI) measured in routine clinical practice of multiple sonographers/cardiologists is associated independently with DMR survival.
A cohort of 5,769 (63 ± 16 years, 47% women) consecutive patients with degenerative mitral valve disease, in whom LAVI was prospectively measured, was enrolled and the long-term survival was analyzed.
LAVI (43 ± 24 ml/m2) was widely distributed (<40 ml/m2 in 3,154 patients, 40 to 59 ml/m2 in 1,606, and ≥60 ml/m2 in 1,009). Overall survival throughout follow-up (10-year 66 ± 1%) was strongly associated with LAVI (79 ± 1% vs. 65 ± 2% and 54 ± 2% for LAVI <40, 40 to 59, and ≥60 ml/m2, respectively; p < 0.0001) even after comprehensive adjustment, including for DMR severity (adjusted hazard ratio HR: 1.05 95% confidence interval (CI): 1.03 to 1.08 per 10 ml/m2; p < 0.0001). Mortality under medical management was profoundly affected by LAVI (adjusted HR: 1.07 95% CI: 1.04 to 1.10 per 10 ml/mm2 and 1.55 95% CI: 1.31 to 1.84 for LAVI ≥60 ml/m2 vs. <40 ml/m2; both p < 0.0001) incrementally to adjusting variables (p < 0.0001) and in all subgroups, particularly sinus rhythm (adjusted HR: 1.25 95% CI: 1.21 to 1.28) or atrial fibrillation (adjusted HR: 1.10 95% CI: 1.06 to 1.13 per 10 ml/m2; both p < 0.0001). Thresholds of excess mortality in spline curve analysis were approximated at 40 ml/m2 in all subgroups. Survival markedly improved after mitral surgery (time-dependent adjusted HR: 0.43 95% CI: 0.36 to 0.53; p < 0.0001) but remained modestly linked to LAVI (10-year survival 85 ± 3% vs. 86 ± 2% and 75 ± 3% for LAVI <40, 40 to 59, and ≥60 ml/m2, respectively; p < 0.0001).
The frequent left atrial enlargement of DMR as measured by LAVI in routine practice displays, overall and in all subsets, a powerful, incremental, and independent link to excess mortality, which is partially alleviated by mitral surgery. Hence, LAVI measurement should be part of routine DMR evaluation and the clinical decision-making process.
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Cardiac output (CO) monitoring is a valuable tool for the diagnosis and management of critically ill patients. In the critical care setting, few studies have evaluated the level of agreement between ...CO estimated by transthoracic echocardiography (CO-TTE) and that measured by the reference method, pulmonary artery catheter (CO-PAC). The objective of the present study was to evaluate the precision and accuracy of CO-TTE relative to CO-PAC and the ability of transthoracic echocardiography to track variations in CO, in critically ill mechanically ventilated patients.
Thirty-eight mechanically ventilated patients fitted with a PAC were included in a prospective observational study performed in a 16-bed university hospital ICU. CO-PAC was measured via intermittent thermodilution. Simultaneously, a second investigator used standard-view TTE to estimate CO-TTE as the product of stroke volume and the heart rate obtained during the measurement of the subaortic velocity time integral.
Sixty-four pairs of CO-PAC and CO-TTE measurements were compared. The two measurements were significantly correlated (r = 0.95; p < 0.0001). The median bias was 0.2 L/min, the limits of agreement (LOAs) were -1.3 and 1.8 L/min, and the percentage error was 25%. The precision was 8% for CO-PAC and 9% for CO-TTE. Twenty-six pairs of ΔCO measurements were compared. There was a significant correlation between ΔCO-PAC and ΔCO-TTE (r = 0.92; p < 0.0001). The median bias was -0.1 L/min and the LOAs were -1.3 and +1.2 L/min. With a 15% exclusion zone, the four-quadrant plot had a concordance rate of 94%. With a 0.5 L/min exclusion zone, the polar plot had a mean polar angle of 1.0° and a percentage error LOAs of -26.8 to 28.8°. The concordance rate was 100% between 30 and -30°. When using CO-TTE to detect an increase in ΔCO-PAC of more than 10%, the area under the receiving operating characteristic curve (95% CI) was 0.82 (0.62-0.94) (p < 0.001). A ΔCO-TTE of more than 8% yielded a sensitivity of 88% and specificity of 66% for detecting a ΔCO-PAC of more than 10%.
In critically ill mechanically ventilated patients, CO-TTE is an accurate and precise method for estimating CO. Furthermore, CO-TTE can accurately track variations in CO.
Background Moderate aortic stenosis ( MAS ) has not been extensively studied and characterized, as no published study has been specifically devoted to this condition. Methods and Results We aimed to ...describe the characteristics of patients with MAS and to evaluate their long-term survival compared with that of the general population. This study included 508 patients (mean±SD age, 75±11 years) with MAS (aortic valve area between 1 and 1.5 cm
; mean±SD aortic valve area, 1.2±0.15 cm
) and preserved left ventricular ejection fraction. Patients were mostly (86.4%) asymptomatic or minimally symptomatic, 78.3% had hypertension, 36.2% were diabetics, and 48.3% had dyslipidemia. Each patient with MAS was matched for the average survival (per year) of all patients of the same age and same sex from our region (Somme department, north of France). During follow-up (median 47 months), 113 patients (22.2%) underwent aortic valve replacement for severe AS. The mean±SD time between inclusion and surgery was 37±22 months. During follow-up, 255 patients (50.2%) died. The 6-year survival of patients with MAS was lower than the expected survival (53±2% versus 65%). In multivariate analysis, age (hazard ratio, 1.04 95% CI, 1.02-1.05; P<0.001), prior atrial fibrillation (hazard ratio, 1.35 95% CI, 1.05-1.73; P=0.019), and Charlson comorbidity index (hazard ratio, 1.11 95% CI, 1.05-1.18; P=0.002) were associated with increased mortality. Aortic valve replacement was associated with better survival (hazard ratio, 0.38 95% CI, 0.27-0.54; P<0.001). Conclusions The results of this study show that patients with MAS present many cardiovascular risk factors, a high rate of surgery during follow-up, and increased mortality compared with the general population mainly related to associated comorbidities. Patients with MAS should, therefore, be managed for their cardiovascular risk factors and comorbidities. They require close follow-up, especially when the aortic valve area is close to 1 cm
, as aortic valve replacement performed when patients transition to severe AS and develop indications for surgery during follow-up is associated with better survival.
Objectives This study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without ...contractile reserve (CR) on dobutamine stress echocardiography (DSE). Background Patients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial. Methods Eighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area ≤1 cm2 , left ventricular ejection fraction ≤40%, mean pressure gradient MPG ≤40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of ≥20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55). Results Five-year survival was higher in AVR patients compared with medically managed patients (54 ± 7% vs. 13 ± 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time 95% confidence interval: 0.12–3.16 to 0.21–8.50, p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 ± 11% vs. 11 ± 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG ≤20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 ± 8% at 5 years. Conclusions In patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.
IMPORTANCE The optimal management of severe mitral valve regurgitation in patients without class I triggers (heart failure symptoms or left ventricular dysfunction) remains controversial in part due ...to the poorly defined long-term consequences of current management strategies. In the absence of clinical trial data, analysis of large multicenter registries is critical. OBJECTIVE To ascertain the comparative effectiveness of initial medical management (nonsurgical observation) vs early mitral valve surgery following the diagnosis of mitral regurgitation due to flail leaflets. DESIGN, SETTING, AND PARTICIPANTS The Mitral Regurgitation International Database (MIDA) registry includes 2097 consecutive patients with flail mitral valve regurgitation (1980-2004) receiving routine cardiac care from 6 tertiary centers (France, Italy, Belgium, and the United States). Mean follow-up was 10.3 years and was 98% complete. Of 1021 patients with mitral regurgitation without the American College of Cardiology (ACC) and the American Heart Association (AHA) guideline class I triggers, 575 patients were initially medically managed and 446 underwent mitral valve surgery within 3 months following detection. MAIN OUTCOMES AND MEASURES Association between treatment strategy and survival, heart failure, and new-onset atrial fibrillation. RESULTS There was no significant difference in early mortality (1.1% for early surgery vs 0.5% for medical management, P=.28) and new-onset heart failure rates (0.9% for early surgery vs 0.9% for medical management, P=.96) between treatment strategies at 3 months. In contrast, long-term survival rates were higher for patients with early surgery (86% vs 69% at 10 years, P < .001), which was confirmed in adjusted models (hazard ratio HR, 0.55 95% CI, 0.41-0.72, P < .001), a propensity-matched cohort (32 variables; HR, 0.52 95% CI, 0.35-0.79, P = .002), and an inverse probability–weighted analysis (HR, 0.66 95% CI, 0.52-0.83, P < .001), associated with a 5-year reduction in mortality of 52.6% (P < .001). Similar results were observed in relative reduction in mortality following early surgery in the subset with class II triggers (59.3 after 5 years, P = .002). Long-term heart failure risk was also lower with early surgery (7% vs 23% at 10 years, P < .001), which was confirmed in risk-adjusted models (HR, 0.29 95% CI, 0.19-0.43, P < .001), a propensity-matched cohort (HR, 0.44 95% CI, 0.26-0.76, P = .003), and in the inverse probability–weighted analysis (HR, 0.51 95% CI, 0.36-0.72, P < .001). Reduction in late-onset atrial fibrillation was not observed (HR, 0.85 95% CI, 0.64-1.13, P = .26). CONCLUSION AND RELEVANCE Among registry patients with mitral valve regurgitation due to flail mitral leaflets, performance of early mitral surgery compared with initial medical management was associated with greater long-term survival and a lower risk of heart failure, with no difference in new-onset atrial fibrillation.
Objectives The aim of this study was to develop and validate a simple calculator to quantify the embolic risk (ER) at admission of patients with infective endocarditis. Background Early valve surgery ...reduces the incidence of embolism in high-risk patients with endocarditis, but the quantification of ER remains challenging. Methods From 1,022 consecutive patients presenting with definite diagnoses of infective endocarditis in a multicenter observational cohort study, 847 were randomized into derivation (n = 565) and validation (n = 282) samples. Clinical, microbiological, and echocardiographic data were collected at admission. The primary endpoint was symptomatic embolism that occurred during the 6-month period after the initiation of treatment. The prediction model was developed and validated accounting for competing risks. Results The 6-month incidence of embolism was similar in the development and validation samples (8.5% in the 2 samples). Six variables were associated with ER and were used to create the calculator: age, diabetes, atrial fibrillation, embolism before antibiotics, vegetation length, and Staphylococcus aureus infection. There was an excellent correlation between the predicted and observed ER in both the development and validation samples. The C-statistics for the development and validation samples were 0.72 and 0.65, respectively. Finally, a significantly higher cumulative incidence of embolic events was observed in patients with high predicted ER in both the development (p < 0.0001) and validation (p < 0.05) samples. Conclusions The risk for embolism during infective endocarditis can be quantified at admission using a simple and accurate calculator. It might be useful for facilitating therapeutic decisions.
Pulmonary hypertension is an established outcome predictor in patients with aortic stenosis (AS), but the prognostic impact of right ventricular dysfunction has not been well studied.
We included ...2181 patients (50.4% men; mean age, 77 years) with aortic valve area <1.3 cm
and analyzed the occurrence of all-cause death during follow-up according to tricuspid annular plane systolic excursion (TAPSE) quartiles.
Patients in the lowest quartile (TAPSE <17 mm) were at a high risk of death, whereas survival was comparable for the 3 other quartiles. Five-year survival was 55±2% for TAPSE <17 mm, 72±2% for TAPSE of 17 to 20 mm, 71±2% for TAPSE of 20 to 24 mm, and 73±2% for TAPSE >24 mm (overall
<0.001). TAPSE <17 mm was associated with increased mortality after adjustment for established prognostic factors (adjusted hazard ratio HR, 1.55 95% CI, 1.21-1.97) and after further adjustment for aortic valve replacement (AVR; adjusted HR, 1.47 95% CI, 1.15-1.87). The excess mortality risk associated with TAPSE <17 mm was noticed in both patients managed initially conservatively (adjusted HR, 1.46 95% CI, 1.20-1.76) and patients who underwent early (within 3 months after diagnosis) AVR (adjusted HR, 1.61 95% CI, 1.03-2.52). In asymptomatic patients with severe AS and preserved ejection fraction, TAPSE <17 mm was independently predictive of mortality (adjusted HR, 2.14 95% CI, 1.31-3.51). Early AVR was associated with similar survival benefit in TAPSE <17 and ≥17 mm (adjusted HR, 0.23 95% CI, 0.16-0.34 for TAPSE <17 mm, adjusted HR, 0.26 95% CI, 0.19-0.35 for TAPSE ≥17 mm;
for interaction, 0.97).
Right ventricular dysfunction is an important and independent predictor of mortality in AS. TAPSE <17 mm at the time of AS diagnosis is a marker of poor survival under conservative management and after AVR even in asymptomatic patients with severe AS. AVR was associated with a pronounced reduction in mortality independent of TAPSE suggesting that AVR should be discussed before right ventricular dysfunction occurs in severe AS.
Background Normal-flow, low-gradient severe aortic stenosis (NF-LG-SAS), defined by aortic valve area <1 cm
, mean gradient <40 mm Hg, and indexed stroke volume >35 mL/m
, is the most prevalent form ...of low-gradient aortic stenosis (AS). However, the true severity of AS and the management of NF-LG-SAS are controversial. The aim of this study was to evaluate the outcome of patients with NF-LG-SAS compared with moderate AS (MAS) and with high-gradient severe-AS (HG-SAS). Methods and Results A total of 154 patients with NF-LG-SAS, 366 with MAS (aortic valve area between 1.0 and 1.3 cm
), and 1055 with HG-SAS were included. On multivariate analysis, after adjustment for covariates of prognostic importance, NF-LG-SAS patients did not exhibit an excess risk of mortality compared with MAS patients under medical management (hazard ratio=1.13 95% CI, 0.82-1.56;
=0.45) and under medical and surgical management (hazard ratio 1.06 95% CI, 0.79-1.43;
=0.70), even after further adjustment for aortic valve replacement (hazard ratio=1.09 95% CI, 0.81-1.48;
=0.56). The 6-year cumulative incidence of aortic valve replacement (performed in accordance with guidelines) was comparable between the 2 groups (39±4% for NF-LG-SAS and 35±3% for MAS,
=0.10). After propensity score matching (n=226), NF-LG-SAS and MAS patients also had comparable outcomes under medical (
=0.41) and under medical and surgical management (
=0.52). NF-LG-SAS had better outcomes than HG-SAS patients (adjusted hazard ratio 1.84 95% CI, 1.18-2.88;
<0.001). Conclusions This study shows that patients with NF-LG-SAS have a comparable outcome to those with MAS when aortic valve replacement is performed during follow-up according to guidelines, mostly at the stage of HG-SAS. Rigorous echocardiographic assessment to rule out measurement errors and close follow-up are essential to detect progression to true severe AS in NF-LG-SAS.
Left ventricular (LV) outflow tract (LVOT) obstruction (LVOTO) is not unusual in ICU patients particularly with septic shock.
LVOT was first described in patients with hypertrophic cardiomyopathy and ...was defined as LV wall thickness at least 15 mm. LVOT is usually because of systolic anterior motion of the mitral valve. By convention, LVOTO is defined as an instantaneous peak Doppler LVOT pressure gradient at least 30 mmHg at rest or during physiological provocation such as Valsalva maneuver. Recently, it has been demonstrated that LVOT can be present in patients with severe hypovolemia or hyperkinesia with or without LV hypertrophy and can lead to hemodynamic compromise. LVOT is because of a combination of precipitating factors, which may or may not be associated with anatomical abnormalities. Decreased preload because of hypovolemia or decreased afterload because of septic shock, increased heart rate, and LV hyperkinesis produced by dobutamine infusion can induce a change of LV shape and induce LVOTO.
LVOTO is not uncommon in ICU patients and can be observed at the early phase of septic shock. Treatment should include discontinuation of dobutamine infusion and fluid infusion. β blockers can be useful in this clinical situation.
Background Although women represent half of the population burden of aortic stenosis (AS), little is known whether sex affects the presentation, management, and outcome of patients with AS. Methods ...and Results In a cohort of 2429 patients with severe AS (49.5% women) we aimed to evaluate 5-year excess mortality and performance of aortic valve replacement (AVR) stratified by sex. At presentation, women were older (
<0.001), with less comorbidities (
=0.030) and more often symptomatic (
=0.007) than men. Women had smaller aortic valve area (
<0.001) than men but similar mean transaortic pressure gradient (
=0.18). The 5-year survival was lower compared with expected survival, especially for women (62±2% versus 71% for women and 69±1% versus 71% for men). Despite longer life expectancy in women than men, women had lower 5-year survival than men (66±2% expected-75% versus 68±2% expected-70%,
<0.001) after matching for age. Overall, 5-year AVR incidence was 79±2% for men versus 70±2% for women (
<0.001) with male sex being independently associated with more frequent early AVR performance (odds ratio, 1.49; 1.18-1.97). After age matching, women remained more often symptomatic (
=0.004) but also displayed lower AVR use (64.4% versus 69.1%;
=0.018). Conclusions Women with severe AS are diagnosed at later ages and have more symptoms than men. Despite prevalent symptoms, AVR is less often performed in women and 5-year excess mortality is noted in women versus men, even after age matching. These imbalances should be addressed to ensure that both sexes receive equivalent care for severe AS.
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