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Mitral regurgitation (MR) is common in ischemic heart disease and contributes to symptoms and mortality. This report compares the results of baseline transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) imaging of the mechanism and severity of functional MR in patients with ischemic cardiomyopathy in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Independent core laboratories measured both TTE and TEE images on 196 STICH participants. Common measurements to both models included MR grade, mitral valve tenting height and tenting area, and mitral annular diameter. For each parameter, correlations were assessed using Spearman rank correlation coefficients. A modest correlation was present between TEE and TTE for overall MR grade (n = 176, r = 0.52). For mechanism of MR, modest correlations were present for long-axis tenting height (n = 152, r = 0.35), tenting area (n = 128, r = 0.27), and long-axis mitral annulus diameter (n = 123, r = 0.41). For each measurement, there was significant scatter. Potential explanations for the scatter include different orientation of the imaging planes between TEE and TTE, a mean temporal delay of 6 days between TEE and TTE, and statistically significant differences in heart rate and blood pressure and weight between studies. In conclusion, TEE and TTE measurements of MR mechanism and severity correlate only modestly with enough scatter in the data that they are not interchangeable. [ABSTRACT FROM AUTHOR]

The mechanisms underlying functional mitral regurgitation (MR) and the relation between mechanism and severity of MR have not been evaluated in a large, multicenter, randomized controlled trial. Transesophageal echocardiography (TEE) was performed in 215 patients at 17 centers in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Both 2-dimensional (n = 215) and 3-dimensional (n = 81) TEEs were used to assess multiple quantitative measurements of the mechanism and severity of MR. By 2-dimensional TEE, leaflet tenting area, anterior and posterior leaflet angles, mitral annulus diameter, left ventricular (LV) end-systolic volume index, LV ejection fraction (LVEF), and sphericity index (p <0.05 for all) were significantly different across MR grades. By 3-dimensional TEE, mitral annulus area, leaflet tenting area, LV end-systolic volume index, LVEF, and sphericity index (p <0.05 for all) were significantly different across MR grades. A multivariate analysis showed a trend for annulus area (p = 0.069) and LV end-systolic volume index (p = 0.071) to predict effective regurgitant orifice area and for annulus area (p = 0.018) and LV end-systolic volume index (p = 0.073) to predict vena contracta area. In the STICH trial, multiple quantitative parameters of the mechanism of functional MR are related to MR severity. The mechanism of functional MR in ischemic cardiomyopathy is heterogenous, but no single variable stands out as a strong predictor of quantitative severity of MR. [ABSTRACT FROM AUTHOR]

We sought to determine the differential prognosis of patients with a normal single-photon emission computed tomographic (SPECT) perfusion study by type of stress modality. Even with a normal SPECT perfusion study, patients selected for adenosine stress have a worse survival than those selected for exercise stress. In patients who are able, low-level treadmill exercise is commonly performed during adenosine infusion (“walking” adenosine). The adjusted differential prognosis of patients performing walking adenosine is unknown. Our historical cohort underwent adenosine or treadmill stress with SPECT imaging during 2003 and 2004. Adenosine studies were classified as walking or adenosine only (no low-level exercise). Patients with an abnormal single-photon emission computed tomogram or missing demographic information were excluded. All-cause mortality was determined through July 2008. In total 3,479 patients were included, of which 1,451 (41.7%) were stressed with adenosine only, 201 (5.8%) with walking adenosine, and 1,827 (52.5%) with treadmill exercise. Over an average of 4.3 ± 1.0 years of follow-up, 307 (8.8%) died. Mortality was greatest for adenosine only, intermediate for walking adenosine, and least for exercise (p <0.001 by log-rank test), even after accounting for covariates (adjusted hazard ratio for walking adenosine 0.57, p = 0.044). In conclusion, patients with a normal SPECT perfusion scan who are able to undergo an adenosine protocol in conjunction with exercise have an intermediate prognosis between those who cannot perform low-level exercise and patients able to undergo full treadmill exercise. This differential survival remains significant after adjustment, perhaps because of differences in baseline functional capacity. [ABSTRACT FROM AUTHOR]

The relative impact of body mass index (BMI) and exercise capacity on mortality in patients with an intermediate to high likelihood of coronary artery disease (CAD) is not clear. Thus, the effect of BMI and exercise capacity on all-cause mortality in patients referred for stress myocardial perfusion imaging was investigated. The outcome of 2,119 patients undergoing exercise stress myocardial perfusion imaging from 1995 to 1999 was assessed. Patients lacked known CAD, but were at intermediate to high risk. Mortality outcome data were obtained from the Social Security Administration Death Master File. There were 183 deaths during an average follow-up of 8.4 ± 1.4 years. A Cox proportional hazards model identified age, Bruce protocol exercise time, BMI, male gender, and diabetes mellitus as significant predictors of all-cause mortality. In multivariate analysis, both exercise capacity and BMI correlated inversely with mortality, with higher chi-squared impact related to exercise capacity than BMI. In conclusion, both increased exercise capacity and BMI were associated with lower mortality in patients with an intermediate to high likelihood of CAD after controlling for confounding variables, supporting an inverse impact of BMI on mortality. The origin for this “obesity paradox” is unclear. [Copyright &y& Elsevier]

Frailty is a syndrome of older adults associated with increased morbidity and mortality. We aimed to assess the impact of frailty status on outcomes after transcatheter aortic valve implantation (TAVI). We reviewed all 191 patients who underwent a modified Fried frailty assessment before TAVI between February 2012 and September 2015 at a single academic medical center, and we assessed the impact of preoperative frailty status on morbidity, mortality, and health care utilization after TAVI. Frailty, pre-frailty, and nonfrailty were present in 33% (n = 64), 37% (n = 70), and 30% (n = 57) of patients, respectively. Slowness (75% vs 54%, p = 0.003) and low physical activity (55% vs 31%, p = 0.001) were more common in women than men. With increasing frailty status, the proportion of women increased (35% nonfrail, 44% pre-frail, and 66% frail, p = 0.002) and stature decreased (1.68 ± 0.11 m nonfrail, 1.66 ± 0.11 m pre-frail, 1.62 ± 0.12 m frail, p = 0.028). There was no difference in post-TAVI 30-day mortality, stroke, major vascular injury, major or life-threatening bleeding, respiratory failure, mean hospital length of stay, 30-day hospital re-admission, or overall survival between groups. The rate of discharge to a rehabilitation facility increased with increasing frailty status (14% nonfrail, 22% pre-frail, and 39% frail, p = 0.005). Frailty was independently associated with discharge to a rehabilitation facility (odds ratio 4.80, 95% confidence interval 1.66 to 13.85, p = 0.004). In conclusion, the safety of TAVI is not affected by frailty status, but patients with frailty are less likely to be discharged directly home after TAVI., (Copyright © 2016 Elsevier Inc. All rights reserved.)