Undiagnosed Chronic Obstructive Pulmonary Disease is Highly Prevalent in Patients Referred for Dobutamine Stress Echocardiography with Shortness of Breath.

PURPOSE: Shortness of breath (SOB) is a common symptom referral for dobutamine stress echocardiography (DSE). Patients with SOB and a normal DSE have worse long-term outcome than the general population. This suggests multiple aetiologies are involved. The purpose of this study was to assess the prevalence and clinical significance of undiagnosed COPD amongst patients referred for a DSE with SOB. METHODS: We prospectively studied 114 patients referred for DSE with SOB without prior evidence of lung disease (mean age 64.9 ± 18.5 years, 60 male). Respiratory function testing using spirometry was performed on all patients on the day of their DSE. The study end-points were cardiac events and total mortality. RESULTS: Respiratory function testing and DSE was performed in all patients and COPD was highly prevalent (n = 93). Multivariate Cox regression analysis was used to estimate the effect of dyspnoea on non-fatal cardiac events (NFCE) and all-cause mortality. Over a mean follow-up of 4.5 ± 2.6 years, the composite end-point of NFCE and all-cause mortality occurred in 62.7% and 16.7% patients, respectively. COPD (HR 1.27; 95% CI 1.17-1.93), previous myocardial infarction (HR 1.84; 95% CI 1.06-3.2), myocardial ischaemia (HR 2.56; 95% CI 1.48-4.43), peak wall motion score index (HR 4.66; 95% CI 2.26-9.6), and mitral E/E' (HR 1.21; 95% CI 1.1-1.33) were significantly associated with a NFCE. Myocardial ischaemia (HR 4.43; 95% CI 1.24-15.81) was the only independent predictor of all-cause mortality. CONCLUSION: Undiagnosed COPD is highly prevalent and independently associated with worse outcome amongst patients with SOB referred for DSE. Symptom presentation is therefore an important consideration when interpreting DSE results.

Phenotyping Left Ventricular Obstruction With Postprandial Re-Test Echocardiography in Hypertrophic Cardiomyopathy.

Dynamic left ventricular (LV) obstruction has important clinical and therapeutic implications in patients with hypertrophic cardiomyopathy (HC). Although absent at rest, LV obstruction may be elicited using varying stressors. Meal-related hemodynamic changes may favor LV obstruction and support postprandial (PP) symptoms in HC patients. The aim of this study was to evaluate PP-LV obstruction inducibility in HC patients in comparison with fasting Valsalva maneuver and exercise test. Ninety-two HC patients without LV obstruction underwent at-rest Transthoracic Echocardiography (TTE) during Valsalva maneuver and exercise test under fasting condition followed by at-rest re-test PP-TTE 30 to 60 minutes after a standardized midday meal. LV obstruction was noted and classified as being related to systolic anterior motion (SAM) of the mitral valve (SAM-related) and/or non-SAM-related (mid-cavity or apical), and intraventricular gradient was measured. At-rest re-test PP-TTE showed significant intraventricular gradient (>30 mm Hg) in 68 patients (60 SAM-related, 8 non-SAM related, 30 combined) with a higher prevalence (74%) of HC phenotype re-classified as obstructive compared with the fasting Valsalva maneuver (23%) or exercise test (33%) (p < 0.001). At multivariate analysis, a clinical history of PP symptoms and mitral anterior leaflet length and/or LV outflow ratio >2 were independently correlated with PP-TTE obstruction. In conclusion, PP TTE re-test is a simple and effective approach to unmask latent LV dynamic obstruction in daily clinical practice over fasting Valsalva maneuver or exercise test. PP clinical phenotype refinement may be relevant in targeting and evaluating HC therapy.

Tricuspid Annular Size and Regurgitation Progression After Surgical Repair for Degenerative Mitral Regurgitation.

The late worsening of nonsevere tricuspid regurgitation (TR) after mitral valve surgery is a relevant clinical problem that can lead to high-risk reoperation. Although tricuspid annulus (TA) dilatation has been proposed for prophylactic annuloplasty to prevent TR worsening, prospective data in degenerative mitral regurgitation (MR) are lacking. The aim of this prospective cohort study was to evaluate TA dimension to predict TR progression after valve repair for degenerative MR. Clinical and echocardiographic evaluation of 706 patients with degenerative MR and no significant TR was obtained preoperatively and at follow-up after isolated mitral valve repair. Together with standard cardiac chamber and valve analysis, 3-dimensional (3D) transesophageal echocardiography was performed to evaluate TA, including the anteroposterior and septolateral diameters. After a mean follow-up of 24 ± 15 months (range 6 to 60), 2 patients died while 14 developed severe MR. Compared with preoperative values, TR decreased (≤1 degree) in 227 patients, was unchanged in 437, and increased (≥1 degree) in 39 patients, with the development of significant TR (3 to 4 degree) in 3 patients. Receiver-operating characteristic curve analysis did not identify significant TA values predicting postoperative TR worsening. On multivariate regression analysis, recurrent MR and pulmonary hypertension at follow-up emerged as significant positive predictors of TR progression. Newly developed significant TR is a rare event after successful repair of degenerative MR. Although more accurate than conventional 2D measurement, 3D analysis of TA does not predict early to midterm subsequent TR progression.

Long-term results of mitral repair in patients with severe left ventricular dysfunction and secondary mitral regurgitation: does the technique matter?

OBJECTIVES: An isolated undersized annuloplasty was used to treat mitral regurgitation (MR) secondary to dilated cardiomyopathy (DCM) if the baseline coaptation depth (CD) was <1 cm. In the presence of significant tethering of the mitral leaflets (CD ≥1 cm), the edge-to-edge (EE) technique was combined with annuloplasty to improve the durability of the repair. The long-term results of this approach are unknown and represent the objective of this study. METHODS: To obtain long-term outcome data, we included in the study population the first 105 consecutive patients with severe left ventricular dysfunction (ejection fraction 29 ± 6.6%) and secondary MR submitted to mitral valve repair. Forty patients underwent isolated undersized annuloplasty and 65 patients received the EE technique combined with annuloplasty. Preoperative and postoperative data were prospectively entered into a dedicated database. Clinical and echocardiographic follow-ups were performed in our institutional outpatient clinic. RESULTS: Follow-up was 90% complete. The median follow-up time was 7.2 years (interquartile range 4.3;10.4). The longest follow-up time was 16.5 years. A comparative analysis between the annuloplasty group and the EE group was performed. Baseline LV dimensions and function were slightly worse in the EE group, but only the severity of tethering was significantly more pronounced than in the annuloplasty group. Hospital mortality (3 vs 2.5%, P = 1.0) and 10-year overall survival (42 ± 6.7 vs 55 ± 8.5%, P = 0.2) were not significantly different in the EE and annuloplasty group, respectively. Cumulative incidence functions of cardiac death were similar as well (at 10-years, 34.3 ± 8.1 vs 37.9 ± 6.4%, respectively, P = 0.4). At 10 years, cumulative incidence function of recurrence of MR ≥3+ was lower in the EE patients (10.3 ± 4.1 vs 30.8±8.0%, P = 0.01). Isolated annuloplasty [hazard ratio (HR) 4.84, 95% confidence interval (CI) 1.46-16.1, P = 0.01] and residual MR >1+ at hospital discharge (HR 5.25, 95% CI 2.00-13.8, P < 0.001) were significantly related to the development of MR ≥3. Failure of repair was associated with recurrence of New York Heart Association III or IV symptoms (P < 0.001). CONCLUSIONS: In patients with end-stage DCM and secondary MR, the association of the EE technique to the undersized annuloplasty significantly decreases the rate of recurrent MR at long-term. This higher repair durability did not translate into a better long-term prognosis in this series.

In Vivo CT Direct Volume Rendering: A Three-Dimensional Anatomical Description of the Heart.

BACKGROUND: Since cardiac anatomy continues to play an important role in the practice of medicine and in the development of medical devices, the study of the heart in three dimensions is particularly useful to understand its real structure, function and proper location in the body. MATERIAL/METHODS: This study demonstrates a fine use of direct volume rendering, processing the data set images obtained by Computed Tomography (CT) of the heart of 5 subjects with age range between 18 and 42 years (2 male, 3 female), with no history of any overt cardiac disease. The cardiac structure in CT images was first extracted from the thorax by marking manually the regions of interest on the computer, and then it was stacked to create new volumetric data. RESULTS: The use of a specific algorithm allowed us to observe with a good perception of depth the heart and the skeleton of the thorax at the same time. Besides, in all examined subjects, it was possible to depict its structure and its position within the body and to study the integrity of papillary muscles, the fibrous tissue of cardiac valve and chordae tendineae and the course of coronary arteries. CONCLUSIONS: Our results demonstrated that one of the greatest advantages of algorithmic modifications of direct volume rendering parameters is that this method provides much necessary information in a single radiologic study. It implies a better accuracy in the study of the heart, being complementary to other diagnostic methods and facilitating the therapeutic plans.