Objectives
T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation ...abnormalities. We sought to demonstrate that T1-map and CMR-FT may identify the presence of subclinical myocardial structural changes in patients with mitral valve prolapse (MVP).
Methods
Consecutive MVP patients with moderate-to-severe mitral regurgitation and comparative matched healthy subjects were prospectively enrolled and underwent CMR-FT analysis to calculate 2D global and segmental circumferential (CS) and radial strain (RS) and T1-map to determine global and segmental native T1 (nT1) values.
Results
Seventy-three MVP patients (mean age, 57 ± 13 years old; male, 76%; regurgitant volume, 57 ± 21 mL) and 42 matched control subjects (mean age, 56 ± 18 years; male, 74%) were included. MVP patients showed a lower global CS (− 16.3 ± 3.4% vs. − 17.8 ± 1.9%,
p
= 0.020) and longer global nT1 (1124.9 ± 97.7 ms vs. 1007.4 ± 26.1 ms,
p
< 0.001) as compared to controls. Moreover, MVP patients showed lower RS and CS in basal (21.6 ± 12.3% vs. 27.6 ± 8.9%,
p
= 0.008, and − 13.0 ± 6.7% vs. − 14.9 ± 4.1%,
p
= 0.013) and mid-inferolateral (20.6 ± 10.7% vs. 28.4 ± 8.7%,
p
< 0.001, and − 12.8 ± 6.3% vs. − 16.5 ± 4.0%,
p
< 0.001) walls as compared to other myocardial segments. Similarly, MVP patients showed longer nT1 values in basal (1080 ± 68 ms vs. 1043 ± 43 ms,
p
< 0.001) and mid-inferolateral (1080 ± 77 ms vs. 1034 ± 37 ms,
p
< 0.001) walls as compared to other myocardial segments. Of note, nT1 values were significantly correlated with CS (
r
, 0.36;
p
< 0.001) and RS (
r
, 0.37;
p
< 0.001) but not with regurgitant volume.
Conclusions
T1-map and CMR-FT identify subclinical left ventricle tissue changes in patients with MVP. Further studies are required to correlate these subclinical tissue changes with the outcome.
Key Points
•
T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities.
•
In MVP patients, we demonstrated a longer global nT1 with associated reduced global circumferential (CS) and radial strain (RS) as compared to control subjects.
•
Among MVP patients, the mid-basal left ventricle inferolateral wall showed longer nT1 with reduced CS and RS as compared to other myocardial segments. Further studies are required to correlate these subclinical tissue changes with the outcome.
A bedside-available transcatheter aortic valve implantation (TAVI)–dedicated prognostic risk score is an unmet clinical need. We aimed to develop such a risk score predicting 1-year mortality ...post-TAVI and to compare it with the performance of the logistic EuroSCORE (LES) I and LES-II and the Society of Thoracic Surgeons' (STS) score. Baseline variables of 511 consecutive patients who underwent TAVI that were independently associated with 1-year mortality post-TAVI were included in the “TAVI2 -SCORe.” Discrimination and calibration abilities of the novel score were assessed and compared with surgical risk scores. One-year mortality was 17.0% (n = 80 of 471). Porcelain thoracic aorta (hazard ratio HR 2.56), anemia (HR 2.03), left ventricular dysfunction (HR 1.98), recent myocardial infarction (HR 3.78), male sex (HR 1.81), critical aortic valve stenosis (HR 2.46), old age (HR 1.68), and renal dysfunction (HR 1.76) formed the TAVI2 -SCORe (all p <0.05). According to the number of points assigned (1 for each variable and 2 for infarction), patients were stratified into 5 risk categories: 0, 1 (HR 2.6), 2 (HR 3.6), 3 (HR 10.5), and ≥4 (HR 17.6). TAVI2 -SCORe showed better discrimination ability (Harrells' C statistic 0.715) compared with LES-I, LES-II, and STS score (0.609, 0.633, and 0.50, respectively). Cumulative 1-year survival rate was 54% versus 88% for patients with TAVI2 -SCORE ≥3 versus <3 points, respectively (p <0.001). Contrary to surgical risk scores, there was no significant difference between observed and expected 1-year mortality for all TAVI2 -SCORe risk strata (all p >0.05, Hosmer-Lemeshow statistic 0.304), suggesting superior calibration performance. In conclusion, the TAVI2 -SCORe is an accurate, simple, and bedside-available score predicting 1-year mortality post-TAVI, outperforming conventional surgical risk scores for this end point.
Background This study aimed to evaluate the impact of baseline left ventricular (LV) systolic function on clinical and echocardiographic outcomes following transcatheter aortic valve implantation ...(TAVI). Survival of patients undergoing TAVI was also compared with that of a population undergoing surgical aortic valve replacement. Methods One hundred forty-seven consecutive patients (mean age = 80 ± 7 years) undergoing TAVI in 2 centers were included. Mean follow-up period was 9.1 ± 5.1 months. Results At baseline, 34% of patients had impaired LV ejection fraction (LVEF) (<50%) and 66% had normal LVEF (≥50%). Procedural success was similar in these 2 groups (94% vs 97%, P = .41). All patients achieved improvement in transvalvular hemodynamics. At follow-up, patients with a baseline LVEF <50% showed marked LV reverse remodeling, with improvement of LVEF (from 37% ± 8% to 51% ± 11%). Early and late mortality rates were not different between the 2 groups, despite a higher rate of combined major adverse cardiovascular events (MACEs) in patients with a baseline LVEF <50%. The predictors of cumulative MACEs were baseline LVEF (HR = 0.97, 95% CI = 0.94-0.99) and preoperative frailty (HR = 4.20, 95% CI = 2.00-8.84). In addition, long-term survival of patients with impaired or normal LVEF was comparable with that of a matched population who underwent surgical aortic valve replacement. Conclusions TAVI resulted in significant improvement in LV function and survival benefit in high-risk patients with severe aortic stenosis, regardless of baseline LVEF. Patients with a baseline LVEF <50% were at higher risk of combined MACEs.
Objectives This study examined the mid-term hemodynamic and clinical impact of prosthesis–patient mismatch (PPM) in patients undergoing transcatheter aortic valve implantation (TAVI) with ...balloon-expandable valves. Background PPM can be observed after aortic valve surgery. However, little is known about the incidence of PPM in patients undergoing TAVI. Methods Echocardiography and clinical assessment were performed in 165 patients at baseline, before hospital discharge, and at 6 months after TAVI. PPM was defined as an indexed effective orifice area ≤0.85 cm2 /m2. Results Thirty patients (18.2%) showed PPM before hospital discharge. At baseline, patients with PPM had a larger body surface area (1.84 ± 0.18 m2 vs. 1.73 ± 0.18 m2 , p = 0.003) and a greater severity of aortic stenosis (indexed valve area 0.35 ± 0.09 cm2 /m2 vs. 0.40 ± 0.10 cm2 /m2 , p = 0.005) than patients without PPM. Patients with PPM demonstrated a slower and smaller reduction in mean transaortic gradient, limited left ventricular (LV) mass regression, and left atrial volume reduction over 6 months compared with patients without PPM. LV filling pressure, measured by E/e′, tended to remain elevated in patients with PPM. Importantly, a higher proportion of patients with PPM did not improve in New York Heart Association functional class compared with patients without PPM (36.7% vs. 1.5%, p < 0.001), although major adverse valve-related and cardiovascular events did not differ between the 2 groups. Conclusions PPM may be observed after TAVI and when present may be accompanied by less favorable changes in transvalvular hemodynamics, limited LV mass regression, persistent elevated LV filling pressure, and less improvement in clinical functional status.
Conventional indices of right ventricular (RV) function are known to be reduced after cardiac surgery, as a consequence of geometric rather than functional alterations. New techniques, such as ...three-dimensional (3D) transthoracic and two-dimensional speckle-tracking echocardiography, may be useful in postsurgical RV assessment. The aim of this study was to compare indices of RV function obtained using different echocardiographic modalities, before and after surgery.
Forty-two patients were screened the day before and 6 months after mitral valve repair. Twenty healthy patients were also enrolled as controls. Tricuspid annular plane systolic excursion and peak systolic velocity were calculated from Doppler tissue imaging. Longitudinal and radial strain values were obtained from speckle-tracking echocardiography. RV ejection fraction was calculated from 3D transthoracic echocardiographic RV volumes, and similarly, fractional area change was computed from RV areas.
Tricuspid annular plane systolic excursion (25 ± 4 vs 17 ± 3 mm), peak systolic velocity (17 ± 4 vs 12 ± 2 cm/sec), and fractional area change (43 ± 8% vs 39 ± 7%) significantly decreased after surgery (P < .01), while 3D RV ejection fraction was preserved (59 ± 7% vs 59 ± 6%). Speckle-tracking echocardiographic results were dependent on the considered direction, with preserved radial but decreased longitudinal strain values. All postoperative two-dimensional longitudinal indices were smaller than in controls. Preoperative parameters were not significantly correlated with RV functional changes.
Although 3D ejection fraction was preserved after surgery, in agreement with the lack of evidence of RV dysfunction, two-dimensional indices showed a functional loss in the longitudinal direction. Fractional area change, as a combination of radial and longitudinal properties, was slightly decreased. Speckle-tracking echocardiography could constitute a useful approach to relate local and space-dependent changes to the global RV function.
Abstract Background Post COVID-19 syndrome is characterized by several cardiorespiratory symptoms but the origin of patients’ reported symptomatology is still unclear. Methods Consecutive post ...COVID-19 patients were included. Patients underwent full clinical evaluation, symptoms dedicated questionnaires, blood tests, echocardiography, thoracic computer tomography (CT), spirometry including alveolar capillary membrane diffusion (DM) and capillary volume (Vcap) assessment by combined carbon dioxide and nitric oxide lung diffusion (DLCO/DLNO) and cardiopulmonary exercise test. We measured surfactant derive protein B (immature form) as blood marker of alveolar cell function. Results We evaluated 204 consecutive post COVID-19 patients (56.5 ± 14.5 years, 89 females) 171 ± 85 days after the end of acute COVID-19 infection. We measured: forced expiratory volume (FEV 1 ) 99 ± 17%pred, FVC 99 ± 17%pred, DLCO 82 ± 19%, DM 47.6 ± 14.8 mL/min/mmHg, Vcap 59 ± 17 mL, residual parenchymal damage at CT 7.2 ± 3.2% of lung tissue, peakVO 2 84 ± 18%pred, VE/VCO 2 slope 112 102–123%pred. Major reported symptoms were: dyspnea 45% of cases, tiredness 60% and fatigability 77%. Low FEV 1 , Vcap and high VE/VCO 2 slope were associated with persistence of dyspnea. Tiredness was associated with high VE/VCO 2 slope and low PeakVO 2 and FEV 1 while fatigability with high VE/VCO 2 slope. SPB was fivefold higher in post COVID-19 than in normal subjects, but not associated to any of the referred symptoms. SPB was negatively associated to Vcap. Conclusions In patients with post COVID-19, cardiorespiratory symptoms are linked to VE/VCO 2 slope. In these patients the alveolar cells are dysregulated as shown by the very high SPB. The Vcap is low likely due to post COVID-19 pulmonary endothelial/vasculature damage but DLCO is only minimally impaired being DM preserved.
Background The aim of this study was to assess the accuracy of a comprehensive multidetector computed tomography (MDCT) evaluation of the aortic annulus (AoA), coronary artery disease (CAD), and ...peripheral vessels in patients referred for transcatheter aortic valve implantation (TAVI). Methods In 60 patients referred for TAVI, the following parameters were assessed with 64-slices MDCT and compared with transesophageal echocardiography (TEE), invasive coronary angiography (ICA), and peripheral angiography: AoA maximum diameter (Max-AoA-DMDCT ), minimum diameter (Min-AoA-DMDCT ), and area; lumen morphology index (Max-AoA-DMDCT /Min-AoA-DMDCT ); length of the left, right, and non-coronary aortic leaflets; degree (grades 1-4) of aortic leaflet calcifications; distance between AoA and left main coronary ostium and between AoA and right coronary ostium CAD and peripheral vessel disease. Results The Max-AoA-DMDCT and Min-AoA-DMDCT were 25.1 ± 2.8 and 21.2 ± 2.2 mm, respectively, with high correlation versus AoA diameter measured with TEE (r = 0.82 and 0.86, respectively). The area of AoA, systolic and diastolic lumen morphology index were 410 ± 81.5 mm2 , 1.19 ± 0.1 and 1.22 ± 0.11, respectively. Aortic leaflet calcification score was 3.3 ± 0.5. The lengths of left, right, and non-coronary aortic leaflets were 14.2 ± 2.4, 13.7.1 ± 2.1, and 14.5 ± 2.6 mm, whereas distances between AoA and the left main coronary ostium and between AoA, and the right coronary ostium were 13.7 ± 2.9 and 15.8 ± 3.5 mm, respectively. Feasibility, negative predictive value, and accuracy for CAD detection versus ICA were 87%, 100% (CI 100-100), and 96% (95% CI 94-100), respectively. All patients (N = 17) who were ineligible for TAVI were correctly detected by MDCT. Conclusions A comprehensive MDCT evaluation of patients referred for TAVI is feasible, provides more accurate assessment than TEE of AoA morphology, and may replace peripheral angiography in all patients and ICA in patients without significant CAD.
Head-to-Head Comparison of Two- and Three-Dimensional Transthoracic and Transesophageal Echocardiography in the Localization of Mitral Valve Prolapse
Mauro Pepi, Gloria Tamborini, Anna Maltagliati, ...Claudia Agnese Galli, Erminio Sisillo, Luca Salvi, Moreno Naliato, Massimo Porqueddu, Alessandro Parolari, Marco Zanobini, Francesco Alamanni
The aim of this study, undertaken in 112 patients who underwent mitral valve (MV) repair surgery, was to evaluate the accuracy of 3-dimensional (3D) transthoracic (TTE) and transesophageal (TEE) echocardiography in the evaluation of MV pathology in comparison with surgical inspection. Good or optimal 3D imaging quality was obtained in the majority of cases. Three-dimensional TEE allowed more accurate identification (96%) of all MV lesions. Three-dimensional TTE and 2-dimensional (2D) TEE had similar accuracies (90% and 87%, respectively), whereas the accuracy of 2D TTE (77%) was lower. Three-dimensional TTE and TEE are useful methods in identifying MV pathology in patients undergoing MV repair.
The aim of this study, undertaken in patients who underwent mitral valve (MV) repair surgery, was to evaluate the feasibility and accuracy of 3-dimensional (3D) transthoracic (TTE) and transesophageal (TEE) echocardiography in the evaluation of MV pathology.
A pre-operative assessment of MV anatomy is essential to surgical design in patients undergoing MV repair. Although 2-dimensional (2D) echocardiography provides precise information regarding MV anatomy, 3D TTE and 3D TEE could increase the understanding of MV apparatus and individual scallop identification.
One-hundred-twelve consecutive patients with severe mitral regurgitation due to MV prolapse underwent a complete 2D and 3D TTE the day before surgery and a complete 2D and 3D TEE in the operating room. Echocardiographic data obtained by the different techniques were compared with surgical inspection.
Three-dimensional techniques were feasible in a relatively short time (3D TTE: 7 ± 4 min; 3D TEE: 8 ± 3 min), with good (3D TTE 55%; 3D TEE 35%) and optimal (3D TTE 21%; 3D TEE 45%) imaging quality in the majority of cases. Three-dimensional TEE allowed more accurate identification (95.6% accuracy) of all MV lesions in comparison with other techniques. Three-dimensional TTE and 2D TEE had similar accuracies (90% and 87%, respectively), whereas the accuracy of 2D TTE (77%) was significantly lower.
Three-dimensional TTE and TEE are feasible and useful methods in identifying the location of MV prolapse. They were superior in the description of pathology in comparison with the corresponding 2D techniques and should be regarded as an important adjunct to standard 2D examinations in decisions regarding MV repair.
BackgroundPost-procedural aortic regurgitation (AR) has been described in a large number of patients receiving transcatheter aortic valve implantation (TAVI).ObjectiveThe aim of this study was to ...examine the intraoperative 2-dimensional (2D) and 3-dimensional (3D) echocardiographic features of the aortic valve associated with significant post-procedural paravalvular AR.MethodsA total of 135 patients (81±7 years) with severe symptomatic aortic stenosis, who underwent TAVI, were imaged with comprehensive 2D and 3D transoesophageal echocardiography before the procedure and peri-procedure. Various baseline and peri-procedural echocardiographic characteristics were tested to predict paravalvular AR post-TAVI: calcifications at the aortic valve commissures and leaflets, ‘aortic annulus eccentricity index’, ‘area cover index’, overlap between aortic prosthesis and anterior mitral leaflet. Post-procedural paravalvular AR≥2 was considered significant.ResultsSuccessful TAVI was achieved in all patients. The incidence of paravalvular AR≥2 immediately after the procedure was 21% (28 patients). Commissural calcifications and, particularly, the calcification of the commissure between the right coronary and non-coronary cusps was significantly more frequent in presence of paravalvular AR; the area cover index pre-TAVI was significantly lower among patients with AR (11.1±11.8% vs 20.8±12.5%, p=0.0004). Multivariate analysis revealed that calcification of the commissure between the right coronary and non-coronary cusps (OR=2.66, 95% CI 1.39 to 5.12, p=0.001), and the area cover index pre-TAVI (OR=0.95, 95% CI 0.91 to 0.99, p=0.006) were the only independent predictors of significant paravalvular AR after TAVI.ConclusionsIntraoperative 2D and 3D transoesophageal echocardiography identified calcification of the commissure between the right coronary and non-coronary cusps and the area cover index as independent predictors of significant paravalvular AR following TAVI.
Objectives The aims of this study were to analyze in a large series of patients undergoing transcatheter aortic valve implantation (TAVI): 1) the accuracy of 3-dimensional transesophageal ...echocardiographic (3DTEE) measurement of left coronary cusp (LCC) length and of the distances from left main coronary ostium (LM) to the aortic annulus (AA) pre-operatively and to the aortic prosthesis post-operatively; and 2) the role of the 3DTEE measurements in predicting the prosthetic deployment and the association between prosthesis position and aortic regurgitation (AR) and/or prosthesis-patient mismatch (PPM). Background Coronary ostia occlusion is a possible complication in TAVI; therefore, the careful pre-operative evaluation of AA-LM and LCC length, and the post-operative analysis of the relationship between the prosthesis and LM, may influence the procedural outcomes. Even though multidetector computed tomography (MDCT) is the gold standard pre-operatively, sometimes it cannot be performed and it is rarely repeated post-operatively. Methods In 122 patients undergoing TAVI, pre-operative AA-LM and LCC measurements obtained by 3DTEE and MDCT were compared. Post-operatively, the feasibility of 3DTEE evaluation of the prosthesis-LM distance was performed. The relationship between 3DTEE overlap of the prosthesis with the anterior mitral leaflet and AR/PPM was assessed. Results Pre-operatively, 3DTEE AA-LM (r = 0.83) and LCC (r = 0.69) significantly correlated with MDCT. Post-operatively, 3DTEE prosthesis-LM distance was 2.1 ± 1.9 mm. The prosthesis reached or exceeded LM in 6 and 10 cases, respectively. Prosthesis overlap with mitral leaflet was 4.7 ± 1.8 mm. Significant correlation between the 3DTEE computed and nominal length of the prosthesis was found (r = 0.61). No correlations were found between prosthesis–mitral leaflet overlap and aortic regurgitation or PPM. Conclusions AA-LM distance and LCC length may be accurately estimated by 3DTEE, which may represent a valid alternative to MDCT. Pre- and post-3DTEE data concerning the aortic root, such as LM, aortic valve, and prosthetic morphology, give new insights into TAVI and its complications.
PDF
