Objectives The aim of this study was to assess the long-term prognostic role of multidetector computed tomography coronary angiography (CTA) in patients with suspected coronary artery disease (CAD). ...Background Use of CTA is increasing in patients with suspected CAD. Although there is a large body of data supporting the prognostic role of CTA for major adverse cardiac events in the intermediate term, its long-term prognostic role in patients with suspected CAD is not well studied. Methods Between February 2005 and March 2008, 1,304 consecutive patients were prospectively studied with CTA for detecting the presence and assessing extent of CAD (disease extension and coronary plaque scores). Patients were classified according to the presence of normal coronaries and nonobstructive (<50%) and obstructive (>50%) coronary lesions. The composite rates of hard cardiac events (cardiac deaths and nonfatal myocardial infarctions) and all cardiac events (including late revascularization) were the endpoints of the study. Results Seventy patients were excluded because their CTA data were uninterpretable. Of the remaining 1,234 patients, clinical follow-up (mean 52 ± 22 months) was obtained for 1,196 (97%). A total of 475 events were recorded, with 136 hard events (18 cardiac deaths and 118 nonfatal myocardial infarctions) and 123 late revascularizations. A total of 216 patients with early elective revascularizations were excluded from the survival analysis. Significant independent predictors of events in multivariate analysis were multivessel disease and left main CAD. Cumulative event-free survival was 100% for hard and all events in patients with normal coronary arteries, 88% for hard events and 72% for all events in patients with nonobstructive CAD, and 54% for hard events and 31% for all events in patients with obstructive CAD. Multivessel CAD was associated with a higher rate of hard cardiac events. Conclusions CTA provides prognostic information in patients with suspected CAD and unknown cardiac disease, showing excellent long-term prognosis when there is no evidence of atherosclerosis and allowing risk stratification when CAD is present.
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.
Background Multidetector computed tomography (MDCT) provides detailed assessment of valve annulus and iliofemoral vessels in transcatheter aortic valve replacement (TAVR) patients. However, data on ...diagnostic performance of MDCT coronary angiography (MDCT-CA) are scarce. The aim of the study is to assess diagnostic performance of MDCT for coronary artery evaluation before TAVR. Methods A total of 325 consecutive patients (234 without previous myocardial revascularization, 49 with previous coronary stenting, and 42 with previous coronary artery bypass graft CABG) underwent invasive coronary angiography and MDCT before TAVR. MDCT-CA was performed using the same data set dedicated to standard MDCT aortic annulus evaluation. Multidetector computed tomography-CA evaluability and diagnostic accuracy in comparison with invasive coronary angiography as criterion standard were assessed. Results The MDCT-CA evaluability of native coronaries was 95.6%. The leading cause of unevaluability was beam-hardening artifact due to coronary calcifications. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for detecting ≥50% stenosis of 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. The MDCT-CA evaluability of coronary stents was 82.1%. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy for detecting ≥50% in-stent restenosis of 94.1%, 86.7%, 66.7%, 98.1%, and 88.3%, respectively. All CABGs were correctly assessed by MDCT-CA. In a patient-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy of 89.7%, 90.8%, 80.6%, 95.4%, and 90.5%, respectively. Conclusions Multidetector computed tomography–CA allows to correctly rule out the presence of significant native coronary artery stenosis, significant in-stent restenosis, and CABG disease in patients referred for TAVR.
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.
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.
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.
Aortic dilation is an independent predictor of cardiovascular disease. The association between hypertension and aortic dilation is still controversial. Also, most previous research has investigated ...this relationship regarding only the aortic root, and no information is available for the ascending aorta (AscAo).
To assess AscAo dimensions in hypertensive patients, 1,027 patients with hypertension and 1,002 healthy volunteers were prospectively enrolled. Aortic diameters at four levels were measured using the leading edge-to-leading edge convention at end-diastole: the sinuses of Valsalva, sinotubular junction (STJ), AscAo, and aortic arch (AoArch), using two-dimensional echocardiography.
All four diameters were significantly larger in hypertensive patients than in control subjects, with positive correlations with age, body size, and male sex. On multivariate analysis, gender and body surface area were independently associated with aortic diameters. The general linear model showed that after adjusting for age, sex, and body surface area, hypertension was positively associated (P < .01) with higher aortic diameter at every level. Hypertension was associated with increases of 1.7 mm (95% CI, 1.2-2.1 mm) at the sinuses of Valsalva, 4.1 mm (95% CI, 3.6-4.6 mm) at the STJ, 1.6 mm (95% CI, 1.1-2.1 mm) at the AscAo, and 2.2 mm (95% CI, 1.7-2.6 mm) at the AoArch. On the basis of nomograms, an abnormally high prevalence of aortic dilation in hypertensive patients was observed for the STJ (14%) and the AoArch (7%).
Systematic analysis of the AscAo in hypertensive patients showed that, together with age, sex, and body surface area, hypertension is an independent factor associated with increases in all four aortic diameters and that aortic dilation occurred more frequently at the level of the STJ and AoArch.
Factors correlating to mitral annulus calcification (MAC) include risk factors predisposing to atherosclerosis. In patients with mitral valve (MV) prolapse (MVP), other anatomic or mechanical factors ...have been supposed to facilitate MAC. The aims of this study were, in patients with MVP undergoing MV repair, (1) to describe the prevalence and characteristics of MAC, (2) to correlate MAC with clinical risk factors, coronary involvement, and aortic valve disease, and (3) to describe prevalence, site, and extension of MAC in fibroelastic deficiency (FED) versus Barlow's disease (BD) and correlate MAC to surgical outcomes (repair vs replacement). In 410 consecutive patients with MVP suitable for surgical MV repair, detailed clinical and echocardiographic data were collected to characterize MAC in BD and FED. MAC was found in 99 patients (24%). Age, female gender, coronary artery disease, and cardiovascular risk factors were correlated with MAC. MAC was equally distributed in FED and BD groups despite patients with FED being older with more cardiovascular risk factors. The most common localization of MAC was annular involvement adjacent to P2 (75%), P1 (31%), and P3 (35%). The presence of MAC affected surgical outcomes in both groups (8% patients with MAC underwent replacement after a first attempt of repair vs 3% without MAC). MAC is a common finding in patients undergoing MV repair, and several clinical characteristics correlate with MAC either in FED or BD. In conclusion, despite very high percentage of repairability, MAC influences surgical outcomes and very detailed echo evaluation is advocated.
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