Search

Transthoracic echocardiography (TTE) is the first-line tool to evaluate isolated tricuspid regurgitation (TR) but it has limitations and its TR quantification compared with magnetic resonance imaging (MRI) has been studied infrequently. We compared isolated severe TR quantification by TTE against MRI and developed a novel TTE-based algorithm. Isolated TR patients graded severe by TTE and who underwent MRI January 2007 to June 2019 were studied. The TTE and MRI measurements were analyzed by correlation, area under receiver-operative characteristics curve (AUC), and classification and regression tree algorithm of TTE parameters to best identify MRI-derived severe TR (regurgitant volume ≥45 ml and/or fraction ≥50%). A total of 108 of 262 (41%) that were graded as severe TR by TTE also had severe TR by MRI. There were moderate correlations between TTE and MRI in the quantification of TR severity and right atrial size (Pearson r = 0.428 to 0.645) but none to modest correlations between them in right ventricle quantification. The key TTE parameters to identify MRI-derived severe TR in the decision tree regression algorithm were right atrial volume indexed ≥47 ml/m 2 and effective regurgitant orifice area ≥0.45 cm 2 and especially if there is right ventricle free wall strain ≥ -9.5%. This novel algorithm has an AUC of 0.76% and 79% agreement to detect severe TR by MRI, which higher than the American Society of Echocardiography criteria with AUC 0.68% and 66% agreement (p = 0.006 and p <0.001, respectively). In conclusion, TTE-derived TR and right atrial quantification had moderate correlation and discrimination of severe TR by MRI, from which a novel TTE algorithm was derived, which had incrementally a higher accuracy than contemporary guidelines' criteria alone., Competing Interests: Declaration of Competing Interest Dr. Desai has research and consultant agreements with Myokardia Inc, Medtronic, and Silence therapeutics. Dr. Gillinov is a consultant for AtriCure, Medtronic, Edwards, CryoLife, Abbott, Johnson and Johnson, and ClearFlow and has right to equity in ClearFlow. The remining authors have no competing interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Controversies remain in the management strategy for isolated tricuspid regurgitation (TR) because of adverse prognosis and uncertainties regarding the benefits of tricuspid valve surgery. We compared the characteristics and outcomes of a large cohort of patients with isolated TR, based on downstream tricuspid valve surgery versus medical management. Consecutive patients with isolated TR graded at least moderate-to-severe by echocardiography identified between January 2004 and December 2018 (n = 9,031, age 70 ± 15 years, 60% women) were retrospectively studied. The primary end point was time to all-cause mortality during follow-up. Outcomes were compared by management strategy using unadjusted and adjusted survival and multivariable regression analyses. Tricuspid valve surgery was performed in 632 of 9,031 of the cohort (7%), including 514 valve repairs and 118 valve replacements, with in-hospital mortality in 19 patients (2.9%). Overall, there were 3,985 all-cause deaths (44%) over mean follow-up of 2.6 ± 3.3 years. Tricuspid valve surgery was independently associated with lower mortality rate during follow-up, with hazard ratios (HRs) of 0.53 (95% confidence interval [CI] 0.45 to 0.64), and the association persisted in both primary and secondary TR subgroups. Tricuspid valve surgery also had a significantly higher rate of infective endocarditis and heart failure hospitalizations rates during follow-up, at HRs of 5.55 (95% CI 4.00 to 7.71) and 1.29 (95% CI 1.16 to 1.43), respectively. In conclusion, tricuspid valve surgery is rarely performed in isolated TR, but it is independently associated with greater survival for the overall cohort and both primary and secondary etiology subgroups. Increasing the utilization of this surgery at specialized centers is encouraged to try to improve the clinical outcomes for this challenging clinical entity., Competing Interests: Disclosures Dr. Desai has research and consultant agreements with Myokardia Inc, Medtronic, Silence therapeutics, and Caristo Diagnostics. Dr. Gillinov is consultant to AtriCure, Medtronic, Edwards, CryoLife, Abbott, Johnson and Johnson, and ClearFlow and has right to equity for ClearFlow. The other authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

To evaluate the temporal relations of cardiovascular disease in oncology patients referred to cardio-oncology and describe the impact of cardiovascular disease and cardiovascular risk factors on outcomes. All adult oncology patients referred to the cardio-oncology service at the Cleveland Clinic from January 2011 to June 2018 were included in the study. Comprehensive clinical information were collected. The impact on survival of temporal trends of cardiovascular disease in oncology patients were assessed with a Cox proportional hazards model and time-varying covariate adjustment for confounders. In total, 6,754 patients were included in the study (median age, 57 years; [interquartile range, 47 to 65 years]; 3,898 women [58%]; oncology history [60% - breast cancer, lymphoma, and leukemia]). Mortality and diagnosis of clinical cardiac disease peaked around the time of chemotherapy. 2,293 patients (34%) were diagnosed with a new cardiovascular risk factor after chemotherapy, over half of which were identified in the first year after cancer diagnosis. Patients with preexisting and post-chemotherapy cardiovascular disease had significantly worse outcomes than patients that did not develop any cardiovascular disease (p < 0.0001). The highest 1-year hazard ratios (HR) of post-chemotherapy cardiovascular disease were significantly associated with male (HR 1.81; 95% confidence interval 1.55 to 2.11; p < 0.001] and diabetes [HR 1.51; 95% confidence interval 1.26 to 1.81; p < 0.001]. In conclusion, patients referred to cardio-oncology, first diagnosis of cardiac events peaked around the time of chemotherapy. Those with preexisting or post-chemotherapy cardiovascular disease had worse survival. In addition to a high rate of cardiovascular risk factors at baseline, risk factor profile worsened over course of follow-up., (Copyright © 2020 Elsevier Inc. All rights reserved.)

We sought to study the incremental prognostic impact of baseline valvuloarterial impedance (Zva) and left ventricular global longitudinal strain (LV-GLS) in patients with severe aortic stenosis and preserved left ventricular ejection fraction (LVEF) treated with surgical aortic valve replacement (AVR). We included 961 consecutive patients (68 ± 13 years; 63% men) with severe aortic stenosis (indexed aortic valve area <0.6 cm 2 ) and LVEF >50% who underwent surgical AVR at our institution between January 2007 and December 2008. The analysis is based on derivation (n = 637) and validation (n = 324) subgroups. Society of Thoracic Surgeons (STS) score was calculated. Zva (systolic arterial pressure + mean aortic valve gradient)/left ventricular stroke volume index and LV-GLS (measured offline using Velocity Vector Imaging; Siemens Medical Solutions, Mountain View, California) were calculated. The primary outcome was death. Median Zva and LV-GLS were 4.5 mm Hg × ml -1  × m 2 and -14.5%, respectively. AVR was performed at a median of 34 days from initial evaluation (isolated AVR in 46%, bioprosthetic AVR in 93%). At 7.5 ± 3 years, 320 patients died (33%; 30 days/in-hospital death in 0.5%). In the derivation subgroup, on multivariate Cox survival analysis, higher STS score (hazard ratio [HR] 1.06), higher Zva (HR 1.13), and worse LV-GLS (HR 1.07) were independently associated with long-term survival (all p <0.01). When Zva and LV-GLS were sequentially added to STS score, the c-statistic improved from 0.63 [0.55 to 0.77] to 0.70 [0.60 to 0.81] and 0.78 [0.69 to 0.83], respectively, all p <0.001). Findings were confirmed in the validation subgroup. In conclusion, in patients with severe aortic stenosis and preserved LVEF treated with surgical AVR, baseline Zva and LV-GLS provide improved risk stratification with synergistic prognostic value., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Global longitudinal strain (GLS) by speckle-tracking echocardiography is a sensitive measure of regional left and right ventricular (LV and RV) dysfunction, before onset of overt systolic dysfunction. We sought to evaluate the prognostic utility of measuring LV-GLS and RV free wall strain (FWS) in low risk patients at 1 year after orthotopic heart transplantation (OHT). We retrospectively studied 96 OHT recipients (age 52 ± 14 years, 64% men) free of antibody-mediated rejection or moderate to severe coronary allograft vasculopathy (CAV, grade 2 to 3) at 1 year after transplant. LV-GLS and RV-FWS were calculated using EchoPAC software. Cox models were developed after adjusting for the Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score (post-transplant risk score), with the primary outcome of death, moderate to severe CAV, or treated rejection. At 1 year after transplant, LV ejection fraction and RV fractional area change (FAC) were 58 ± 7% and 42 ± 10%, respectively. LV-GLS was -17.0 ± 3.3% and RV-FWS -16.4 ± 4.5%. At an average follow-up of 4.5 years, 28 patients met the primary end point (10 death, 5 vasculopathy, 17 rejection). In sequential Cox models, markers of RV function were associated with the primary outcome (RV-FAC, p = 0.012; RV-FWS, p = 0.022), while LV ejection fraction and LV-GLS were not. We conclude that in low risk patients 1 year after OHT, markers of RV function (RV-FAC and RV-FWS) are independently associated with incident rejection, CAV, and death. Markers of RV dysfunction could potentially be incorporated into risk scores and future prospective studies to risk stratify patients after OHT., (Copyright © 2017. Published by Elsevier Inc.)

Framingham risk score is an office-based tool used for long-term coronary heart disease risk stratification. Most acute coronary events occur in association with proximal nonobstructive atherosclerotic plaque. Multislice computed tomography detects both obstructive coronary artery disease (CAD) and proximal atherosclerotic plaque with high accuracy. The association of Framingham risk score with obstructive CAD and proximal atherosclerotic plaque was tested. Coronary multislice computed tomography was performed in 295 patients (61% men, mean age 54 +/- 13 years) without documented CAD referred for evaluation of cardiac symptoms. Framingham risk score was computed and patients were stratified according to 10-year risk (n = 213 [72%] low, n = 74 [25%] intermediate, and n = 8 [3%] high). Obstructive CAD was defined as > or =50% stenosis in > or =1 epicardial coronary artery. Proximal atherosclerotic plaque was defined as calcified or noncalcified plaque in the left main or proximal left anterior descending artery. In the low- and intermediate-Framingham risk score groups, there was a high frequency of proximal atherosclerotic plaque (44% and 75%) and obstructive CAD (16% and 34%), although both findings were more prevalent in the high-Framingham risk score group (63% for atherosclerotic plaque, 88% for obstructive CAD), respectively. Proximal atherosclerotic plaque was noncalcified in approximately 13 of patients. In women (n = 114) and younger (<55 years) patients (n = 148), most (93% and 91%, respectively) had a low Framingham risk score. There were 48 women and 51 younger patients with proximal atherosclerotic plaque, of whom only 40% (in each group) were on statin therapy. In conclusion, of patients with a low and intermediate Framingham risk score, a significant proportion had proximal atherosclerotic plaque or obstructive CAD.

Healthy aging results in changes in Doppler measures of diastolic function. It is unclear whether these alterations are a specific manifestation of the aging process or reflect a cardiac adaptation to a more sedentary lifestyle. It was hypothesized that healthy, but sedentary, aging would result in slowing of diastolic filling and myocardial relaxation, whereas lifelong endurance training would prevent such changes. Doppler data were measured in young subjects and sedentary and fit seniors across a broad range of loading conditions. Thirteen sedentary healthy (70+/-4 years) and 12 fit Masters athlete (68+/-3 years) seniors were recruited. Twelve young healthy (32+/-9 years) subjects were used for comparison. Pulmonary capillary wedge pressure and Doppler variables were measured at the 6 loading conditions of baseline (twice), -15 and -30 mm Hg lower body negative pressure, and 2 levels of saline solution infusion. Doppler variables consisted of early and late mitral inflow velocity (E/A) ratio, isovolumetric relaxation time (IVRT), tissue Doppler velocities (TDI Emean), and propagation velocity of mitral inflow. Aging resulted in a decrease in E/A ratio (p<0.001), TDI Emean (p<0.001), and propagation velocity of mitral inflow (p<0.001) and an increase in IVRT (p=0.001). Lifelong endurance training did not completely prevent the changes in E/A ratio (p=0.212), IVRT (p=0.546), or propagation velocity of mitral inflow (p=1.00). Fit seniors were able to achieve E/A ratios of 1.0 during baseline and saline solution infusion. TDI Emean was higher in fit versus sedentary seniors at baseline (p=0.012) and during maximal lower body negative pressure (p=0.036), but not during saline solution infusion (p=0.493). In conclusion, age-associated abnormalities in Doppler measures of myocardial filling and relaxation are only partially minimized by lifelong endurance training and therefore may be more specific to the aging process than secondary to years of deconditioning.

The optimal pacing site in cardiac resynchronization therapy (CRT) remains controversial. Tissue synchronization imaging is a novel echocardiographic technique that color-codes for areas of maximal delay in myocardial velocities. This study aimed to identify whether the left ventricular (LV) pacing lead position in CRT should be guided by a patient's area of maximal mechanical delay. Fifty-four patients with advanced heart failure were assessed echocardiographically before and 6 months after CRT. Response was analyzed according to the relation between the LV lead position and the area of maximal delay to peak velocity by tissue synchronization imaging in the first half of the ejection phase: group 1 (n = 22) had lead placement corresponding to the segment of maximal delay; group 2 (n = 13) had lead placement 1 segment adjacent; and group 3 (n = 19) had lead placement remote from this site. Evidence of LV reverse remodeling and improved systolic function was documented in group 1 (mean percentage decrease in end-systolic volume 23%) more than in group 2 (mean decrease 15%), and more than in group 3 (mean increase 8.9%, p <0.0001 compared with groups 1 and 2). In group 1, 16 of 22 patients had reverse remodeling (>15% decrease in end-systolic volume); reverse remodeling was seen in 7 of 13 patients in group 2 and 1 of 19 in group 3. The placing of the lead position proximal to the site of maximal delay by tissue synchronization imaging was correlated with reverse remodeling (r = 0.449, p = 001). Of 7 patients with delay confined to the septum and anterior wall only, none had evidence of reverse remodeling after CRT. In conclusion, pacing at the site of maximal mechanical delay was associated with reverse remodeling. Individually tailored LV lead positioning should be considered before CRT.