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Purpose: This study quantitatively evaluated the phasic right heart morphology of candidate patients for a transcatheter tricuspid valve intervention (N=32) and of subjects with trace to no tricuspid regurgitation (N = 14). Methods: Cardiac computed tomography angiography (CCTA) and transthoracic/transesophageal echocardiography (TTE/TEE) images were analyzed using dedicated research and clinical software. Using CCTA, the phasic right atrial and ventricular volumes, annulus dimensions, annulus-to-right coronary artery (RCA) distances, circumferential topography of the annular tissue shelf, vena cava dimensions (inferior and superior), vena cava positions, axis angles, and annular excursions were quantified. Using TTE/TEE, leaflet geometry, regurgitation, hemodynamics, and heart function were quantified. Measurements within and between groups were quantitatively compared with regression analyses to explore relationships between right heart features. Results: The phasic position and orientation of the vena cava and the circumferential topography of the annular tissue shelf were quantitatively presented for the first time. The candidate patient group exhibited greater chamber dimensions, enlarged vena cava, distended vena cava positions, positional shallowing of the annular tissue shelf, geometric annular distortion, leaflet distention, moderate or greater regurgitation, and impaired ventricular function. Atrial volume correlated strongly with directional vena cava positions as well as with annular dimensions. Annulus-to-RCA distances and annular excursions were comparable between groups. Conclusions: This study provides new and further insight to the right heart morphology and functional characteristics of candidate patients for a transcatheter tricuspid valve intervention. These data provide a platform from which these patients can continue to be better understood for further improving transcatheter system design and use. [ABSTRACT FROM AUTHOR]

Aims: Clinical guidelines recommend that the exercise protocol of a stress echocardiogram is selected to induce volitional exhaustion after a target duration of at least 8 minutes. While the Bruce protocol is very commonly used for clinical stress tests, it is known to be "steep", and many patients therefore fail to reach 8 minutes. We studied predictors of failure and developed a method for identifying patients not suitable for Bruce protocol which was accurate and yet simple enough to be used as a point‐of‐care decision support tool. Methods and results: We studied data out‐patients undergoing Bruce protocol stress echocardiograms (n = 11 086) and analyzed predictors of inappropriate early termination (defined as test duration < 8 min as per current practice guidelines) using logistic regression. A prediction model was constructed as follows:.5 points were given for each of hypertension, diabetes, smoking, and E/e' > 7.9 in the resting echocardiogram;.1 point was added for each 1‐unit increment in body mass index; 1 point was added for patient age by decade; 2.0 points were subtracted for male sex (p for all < 0.001). In tests on held‐out validation data, the model was well calibrated (in plots of predicted vs actual risk) and discriminated failure versus non‐failure well (C‐statistic.86 for a score of 6.0 points; p < 0.001). Conclusion: These data may help to standardize protocol selection in stress echocardiography, by identifying patients pre‐hoc where Bruce protocol will be inappropriately steep. [ABSTRACT FROM AUTHOR]

Aims: Advances in diagnostic imaging have increased the recognition of coexisting transthyretin cardiac amyloidosis (ATTR‐CA) and severe aortic stenosis (AS), with a reported prevalence between 8–16%. In this prospective study, we aimed to evaluate the implications of ATTR‐CA on outcomes after transcatheter aortic valve replacement (TAVR). Methods and results: At two academic centres, we screened patients with severe AS undergoing TAVR for ATTR‐CA. Using Kaplan–Meier analysis, we compared survival free from death and a combined endpoint of death and first heart failure hospitalization between patients with and without ATTR‐CA. Cox proportional‐hazards models were used to determine the association of ATTR‐CA with these endpoints. The rate of heart failure hospitalization was compared amongst those with and without ATTR‐CA. Overall, 204 patients (83 years, 65% male, Society of Thoracic Surgeons score 6.6%, 72% New York Heart Association class III/IV) were included, 27 (13%) with ATTR‐CA. Over a median follow‐up of 2.04 years, there was no difference in mortality (log rank, P = 0.99) or the combined endpoint (log rank, P = 0.79) between patients with and without ATTR‐CA. In Cox proportional‐hazards models, the presence of ATTR‐CA was not associated with death. However, patients with ATTR‐CA had increased rates of heart failure hospitalization at 1 year (0.372 vs. 0.114 events/person‐year, P < 0.004) and 3 years (0.199 vs. 0.111 events/person‐year, P = 0.087) following TAVR. Conclusion: In moderate‐risk patients with severe AS undergoing TAVR, there was a 13% prevalence of ATTR‐CA, which did not affect mortality. The observed increase in heart failure hospitalization following TAVR in those with ATTR‐CA suggests the consequences of the underlying infiltrative myopathy. [ABSTRACT FROM AUTHOR]

Background: Myocardial infarction (MI) is a high‐risk condition especially when filling pressure is raised, and earlier reports have suggested that E/e' is associated with poor outcome. However, whether E/e' predicts risk better than LVEF, which is the current standard of practice, is not known. We investigated this question in the largest and most rigorous study of MI patients so far. Methods and Results: We studied 660 patients with ST‐elevation MI (STEMI) treated with primary percutaneous coronary intervention and related E/e' to short‐term mortality (in‐hospital death), as well as long‐term events at 2 years comprising (a) a composite of MI, stroke, heart failure, and death, and (b) death alone. Short‐term models were adjusted for age, sex, and LVEF. Long‐term models were adjusted for age, sex, diabetes, revascularization procedure, history of MI, hypertension, renal function, drugs on discharge, and LVEF. Elevated E/e'> 15 indicated higher risk of short‐term events (n = 19:7.0% (95% confidence interval 3.4‐10.8%) vs. 1.0% (0.3 ‐ 2.3%); adjusted odds ratio 3.7 (1.3‐10.5)). While elevated E/e' was also associated with long‐term outcomes (n = 103 composite events: 15.9% (11.9% – 21.4%) vs 6.8% (5.2% – 8.7%), P <.001; n = 38 death events: 6.0% (3.9% – 9.5%) vs 2.0% (1.3% – 3.2%), P =.001), E/e' was rendered nonsignificant for long‐term outcomes by multivariable adjustment (p = ns for both). LVEF, on the contrary, was a highly significant predictor in the adjusted long‐term model. Conclusion: E/e' is associated with poor outcome in STEMI, but LVEF is a stronger predictor of long‐term risk. [ABSTRACT FROM AUTHOR]

Aims Transthyretin cardiac amyloidosis (ATTR-CA) has been reported in patients with aortic stenosis (AS) but its prevalence and phenotype are not known. We examine elderly patients with severe symptomatic AS undergoing transcatheter aortic valve replacement (TAVR) and determine the prevalence and phenotype of ATTR-CA non-invasively. Methods and results We performed technetium-99m pyrophosphate (99mTc-PYP) cardiac scintigraphy prospectively on patients who underwent TAVR, to screen for ATTR-CA. Transthoracic echocardiography and speckle-strain imaging were performed. We assessed the association of several parameters with ATTR-CA using multivariable logistic regression and constructed receiver operating curves to evaluate the best predictors of ATTR-CA. Among 151 patients (mean age 84 ± 6 years, 68% men), 16% (n = 24) screened positive for ATTR-CA with 99mTc-PYP scintigraphy. Compared with patients without ATTR-CA, ATTR-CA patients had a thicker interventricular septum (1.3 vs. 1.1 cm, P = 0.007), higher left ventricular (LV) mass index (130 vs. 98 g/m², P = 0.002), and lower stroke volume index (30 vs. 36 mL/m², P = 0.009). ATTR-CA patients had advanced diastolic dysfunction with higher E/A ratio (2.3 vs. 0.9, P = 0.001) and lower deceleration time (176 vs. 257 ms, P < 0.0001); impairment in systolic function with lower ejection fraction (48% vs. 56%, P = 0.011), myocardial contraction fraction (26 vs. 41, P < 0.0001), and average of lateral and septal mitral annular tissue Doppler S' (4.0 vs. 6.6 cm/s, P < 0.0001). While ATTR-CA patients had more impaired global longitudinal strain (-12 vs. -16%, P = 0.007), relative apical longitudinal strain was the same regardless of ATTR-CA diagnosis (0.98 vs. 0.98, P = 0.991). Average S' best predicted ATTR-CA in multivariable logistic regression (odds ratio 16.67 per 1 cm/s decrease with AUC 0.96, 95% confidence interval 0.90-0.99, P = 0.002) with a value ≤6 conferring 100% sensitivity for predicting a positive 99mTc-PYP amyloid scan. Conclusions Transthyretin cardiac amyloidosis is prevalent in 16% of patients with severe calcific AS undergoing TAVR and is associated with a severe AS phenotype of low-flow low-gradient with mildly reduced ejection fraction. Average tissue Doppler mitral annular S' of < 6 cm/s may be a sensitive measure that should prompt a confirmatory 99mTc-PYP scan and subsequent testing for ATTR-CA. Prospective assessment of outcomes after TAVR is needed in patients with and without ATTR-CA. [ABSTRACT FROM AUTHOR]

Purpose: The left ventricle (LV) ejects blood into the proximal aorta. Age and hypertension are associated with stiffening and dilation of the aortic root, typically viewed as indicative of adverse remodeling. Based on analytical considerations, we hypothesized that a larger aortic root should be associated with lower global afterload (effective arterial elastance, EA) and larger stroke volume (SV). Moreover, as antihypertensive drugs differ in their effect on central blood pressure, we examined the role of antihypertensive drugs for the relation between aortic root size and afterload.Methods: We studied a large group of patients (n = 1250; 61 ± 12 years; 78 % males; 64 % hypertensives) from a single-center registry with known or suspected coronary artery disease. Aortic root size was measured by echocardiography as the diameter of the tubular portion of the ascending aorta. LV outflow tract Doppler was used to record SV.Results: In the population as a whole, after adjusting for key covariates in separate regression models, aortic root size was an independent determinant of both SV and EA. This association was found to be heterogeneous and stronger in patients taking a calcium channel blocker (CCB; 10.6 % of entire population; aortic root size accounted for 8 % of the explained variance of EA).Conclusion: Larger aortic root size is an independent determinant of EA and SV. This association was heterogeneous and stronger in patients on CCB therapy. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to determine the cardiovascular (CV) risk factor response in Irish patients with type 1 diabetes following simultaneous pancreas and kidney transplantation (SPK), analyzing response based on mode of immunosuppression and surgical drainage in a uniquely homogenous population. Methods: A retrospective review of SPKs carried out between 1993 and 2005 in the National Renal and Pancreatic Centre of Ireland was performed. Weight, glycated hemoglobin (HBA1c), lipid profile, and blood pressure (BP) were measured pre- and post-operatively. Results: Fifty-eight SPK patients with functioning grafts were analyzed. Thirty-two were male. Following transplantation, mean HbA1c fell from 8.1 (±1.5) to 5.2 (±0.5)% (p < 0.0001), total cholesterol from 5.2 (±1.2) to 4.5 (±1.0) mmol/L (p = 0.0004), serum triglycerides from 1.5 (±0.6) to 1.1 (±0.6) mmol/L (p < 0.0001), and serum creatinine from 699.3 (±273.4) to 162.5 (±135.8) mmol/L (p < 0.0001). Systolic and diastolic BP fell from 148.5 (±23.3) to 136.9 (±22.4) mmHg (p = 0.02), and 84.8 (±11.7) to 77.8 (±10.4) mmHg (p = 0.003), respectively. Cholesterol reduction was significantly greater in the group that received cyclosporine (n = 29) compared with a tacrolimus and mycophenolic acid mofetil (MMF) combination (1.3 ± 0.3 vs. 0.2 ± 0.2 mmol/L, p = 0.003). Choice of exocrine vs. endocrine graft drainage did not affect risk factor response. Conclusion: SPK resulted in significant improvements both in glucose control and other measured CV risk factors. [ABSTRACT FROM AUTHOR]