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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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.
Data are limited regarding the classification and prognosis of patients with congestive heart failure (CHF) in the community.
Using the resources of the Rochester Epidemiology Project, we evaluated ...all patients receiving a first diagnosis of CHF in Olmsted County, Minnesota, in 1991 (n=216). Among these patients, 88% were >/=65 years and 49% were >/=80 years of age. The prognosis of patients with a new diagnosis of CHF was poor; survival was 86+/-2% at 3 months, 76+/-3% at 1 year, and 35+/-3% at 5 years. Of the 216 patients, 137 (63%) had an assessment of ejection fraction. In these patients, systolic function was preserved (ejection fraction >/=50%) in 59 (43%) and reduced (ejection fraction <50%) in 78 (57%). Survival adjusted for age, sex, NYHA class, and coronary artery disease was not significantly different between patients with preserved and those with reduced systolic function (relative risk, 0.80; P=0.369). ACE inhibitors were used in only 44% of the total population with CHF.
The present study reports the clinical characteristics and natural history of CHF as it presents in the community in the vasodilator era. CHF is a disease of the "very elderly," frequently occurs in the setting of normal ejection fraction, and has a poor prognosis, regardless of the level of systolic function. Diagnostic and therapeutic methods are underused in the community.
Surgical correction of mitral regurgitation in patients with no or mild symptoms remains controversial, particularly because the impact of preoperative symptoms on postoperative outcome is unknown.
...The long-term outcome of 478 patients with organic mitral regurgitation (199 in NYHA functional class I/II and 279 in class III/IV before surgery) operated on between 1984 and 1991 was analyzed. In patients in NYHA class I/II before surgery compared with those in class III/IV, postoperative long-term survival was higher (at 10 years, 76+/-5% versus 48+/-4%, P<0.0001), with lower operative mortality (0.5% versus 5.4%, P=0.003) and better late survival (P<0.0001). Comparison of observed and expected survival showed identical curves in patients in class I/II before surgery (P=0.18), whereas excess mortality was observed in patients in class III/IV before surgery (P<0.0001). Excess mortality associated with severe symptoms was also confirmed in all subgroups (all P<0.003) and in multivariate analysis (P=0.0036; adjusted hazard ratio 95% CI, 1.81 1.21 to 2.70).
In patients with organic mitral regurgitation, preoperative functional class III/IV symptoms are associated with excess short- and long-term postoperative mortality independently of all baseline characteristics. These data should lead to consideration of surgical correction of severe organic mitral regurgitation when no or minimal symptoms are present in patients at low operative risk, especially if repair is feasible.
This study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography.
In patients with mitral regurgitation (MR), valve repair is a ...major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown.
In 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined.
Compared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease.
Transesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR.
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.
Objectives. We evaluated the use and the impact of echocardiography in patients receiving an initial diagnosis of congestive heart failure in Olmsted County, Minnesota, in 1991.
Background. The ...American College of Cardiology/American Heart Association clinical practice guidelines recommend echocardiography in all patients with suspected congestive heart failure. No data are available on use and impact of echocardiography in management of congestive heart failure in a community.
Methods. The medical records linkage system of the Rochester Epidemiology Project was used to identify all 216 patients who satisfied the Framingham criteria for congestive heart failure. Of these, 137 (63%) underwent echocardiography within 3 weeks before or after the episode of congestive heart failure (Echo group), and the other 79 patients constitute the No-Echo group.
Results. The No-Echo group patients were older (p = 0.022), were more likely to be female (p = 0.072), had milder symptoms (p = 0.001) and were less often hospitalized at diagnosis (p = 0.001). Fewer patients in the No-Echo group were treated with angiotensin-converting enzyme inhibitors (p = 0.001). Advanced age (≥80 years), lower New York Heart Association functional class, absence of a fourth heart sound on examination, absence of cardiomegaly or signs of congestive heart failure on chest radiography and absence of known valve disease were independently related to the decision not to obtain an echocardiogram. Survival after adjustment for age, functional class and gender was lower in the No-Echo group than the Echo group (risk ratio = 0.607, p = 0.017).
Conclusions. The underuse of echocardiography appears to be associated with poorer survival and underuse of angiotensin-converting enzyme inhibitor therapy.
OBJECTIVE
We sought to evaluate the vena contracta width (VCW) measured using color Doppler as an index of severity of tricuspid regurgitation (TR).
BACKGROUND
The VCW is a reliable measure of mitral ...and aortic regurgitation, but its value in measuring TR is uncertain.
METHODS
In 71 consecutive patients with TR, the VCW was prospectively measured using color Doppler and compared with the results of the flow convergence method and hepatic venous flow, and its diagnostic value for severe TR was assessed.
RESULTS
The VCW was 6.1 ± 3.4 mm and was significantly higher in patients with, than those without, severe TR (9.6 ± 2.9 vs. 4.2 ± 1.6 mm, p < 0.0001). The VCW correlated well with the effective regurgitant orifice (ERO) by the flow convergence method (r = 0.90, SEE = 0.17 cm2, p < 0.0001), even when restricted to patients with eccentric jets (r = 0.93, p < 0.0001). The VCW also showed significant correlations with hepatic venous flow (r = 0.79, p < 0.0001), regurgitant volume (r = 0.77, p < 0.0001) and right atrial area (r = 0.46, p < 0.0001). A VCW ≥6.5 mm identified severe TR with 88.5% sensitivity and 93.3% specificity. In comparison with jet area or jet/right atrial area ratio, the VCW showed better correlations with ERO (both p < 0.01) and a larger area under the receiver operating characteristic curve (0.98 vs. 0.88 and 0.85, both p < 0.02) for the diagnosis of severe TR.
CONCLUSIONS
The VCW measured by color Doppler correlates closely with severity of TR. This quantitative method is simple, provides a high diagnostic value (superior to that of jet size) for severe TR and represents a useful tool for comprehensive, noninvasive quantitation of TR.
Plasma homocysteine level is a riskfactor for coronary events, stroke, and peripheral atheroscleroticdisease. However, few data are available concerning the relationshipbetween homocysteine level and ...severity of thoracic aorticatherosclerosis. We hypothesized in this multiplane transesophagealechocardiography (TEE) study that homocysteine level is a marker of thepresence and severity of thoracic aortic atherosclerosis.
Cross-sectional study.
University hospital.
Risk factors, angiographic features, and TEE findings were analyzed prospectively in82 valvular patients.
Thefollowing risk factors were recorded: age, gender, hypertension, smoking, lipid parameters, diabetes, body mass index, and familyhistory of coronary artery disease. Plasma levels of homocysteine, vitamin B12, and folic acid were measured for each patient. By univariate analysis, age, diabetes, hypertension, smoking, familyhistory of coronary artery disease, and levels of homocysteine, totalcholesterol, low-density lipoprotein cholesterol, and high-densitylipoprotein cholesterol were significant predictors of the presence ofthoracic aortic plaques. There was a positive correlation between theplasma homocysteine levels and the score of severity of thoracicatherosclerosis (r = 0.48; p = 0.0001) as well asbetween the homocysteine levels and the grades of severity of aorticintimal changes (p = 0.0008). Multivariate regression analysisrevealed that homocysteine was an independent predictor of the presenceand severity of thoracic aortic atherosclerosis.
This prospective study indicates that plasmahomocysteine level is a marker of severity of thoracic atherosclerosisdetected by multiplane TEE. These findings emphasize the role ofhomocysteine as a marker of atherosclerotic lesions in the majorarterial locations.
The width of the vena contracta (VC-W), the smallest area of regurgitant flow, reflects the degree of valvular regurgitation and is measurable by color Doppler imaging, but this method has not been ...validated in aortic regurgitation (AR).
We prospectively examined 79 patients with isolated AR and 80 patients without regurgitation. The VC-W was measured from the long-axis parasternal view and compared with 2 simultaneous reference methods (quantitative Doppler and 2D echocardiography). In patients without regurgitation, the agreement between methods was excellent. In patients with AR, good correlations (all P<0.0001) were obtained between VC-W and effective regurgitant orifice (ERO) area and regurgitant volume recorded by quantitative Doppler (r=0.89 and 0.90, respectively) and 2D echocardiographic (r=0.90 and 0.89, respectively) methods. These correlations were similar with eccentric or central jets (all P>0.60). The other methods used showed good correlations of VC-W with aortographic grading of AR (n=8, r=0.82, P=0.01), with the proximal flow convergence method (n=53, r=0.85, P<0.0001), and with left ventricular end-diastolic volume (r=0.81, P<0.0001). Sensitivity and specificity of VC-W >/=6 mm for diagnosing severe AR (ERO >/=30 mm(2)) were 95% and 90%, respectively.
For assessment of the degree of AR, VC-W shows good correlations with simultaneous quantitative measures (regardless of jet direction), shows good correlations with other methods of assessment of AR, and provides a high diagnostic value for severe AR. VC-W is a simple, reliable method that can be used clinically as part of comprehensive Doppler echocardiographic assessment of AR.
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