Patients with high left ventricular filling pressure may be missed applying 2016 echo guidelines: a pilot study.

2016 guidelines for the echographic evaluation of left ventricular filling pressure (LVFP) proposed a single algorithm with limited number of criteria (E/A ratio, tricuspid regurgitation velocity, left atrial volume index and average E/e') mainly related to left atrial pressure. Pulmonary venous flow analysis, evaluating more specifically left ventricular end diastolic pressure (LVEDP) has been withdrawn. We aim to evaluate the proportion of patients diagnosed with normal LVFP according to 2016 recommendations, despite an abnormal pulmonary venous flow profile suggesting high LVEDP. We prospectively studied patients with stable ischemic cardiomyopathy and aortic stenosis, before cardiac surgery. Extensive echocardiography was performed including pulmonary and mitral A wave durations. We included 76 patients (mean age 72 ± 10 years, 78% were men), 37 (49%) with aortic stenosis and 22 (29%) with ischemic cardiomyopathy. Mean left ventricular ejection fraction was 67 ± 11%. Applying recommendations, 58 patients had normal LVFP and 15 patients had high LVFP. Among the 58 patients with normal LVFP, 26 patients had Apd-Amd duration > 30 ms highly suggestive of high LVEDP. These patients had higher LV mass (112 ± 30 g/m2 vs. 86 ± 20 g/m2, p = 0.004) and shorter A wave duration (120 ± 13.6 ms vs. 132 ± 16.5 ms, p = 0.006) as compared to the remaining 15 patients with concordant evaluation (normal LVFP and normal Apd-Amd). In the present study, we found that 26/58 patients with low LVFP according to the 2016 recommendations had Apd-Amd suggestive of high LVEDP. Pulmonary venous flow should be added to the algorithm, particularly in patients with unexplained symptom, high LV mass or truncated mitral A wave.

Preoperative right ventricular dysfunction is a strong predictor of 3 years survival after cardiac surgery.

BACKGROUND: Prognostic value of right ventricular (RV) systolic function is well established in valvular disease, heart failure but has not been evaluated in patients undergoing cardiac surgery. OBJECTIVES: The aim of the present study was to evaluate the prognostic value of preoperative RV dysfunction extensively evaluated on the basis of a large set of echocardiographic parameters [S', RV fractional area change (RVFAC), right myocardial performance index (RMPI), isovolumic acceleration (IVA), RV dP/dt and basal longitudinal strain (BLS)] in a large population of unselected patient awaiting cardiac surgery. METHODS: We prospectively studied 400 consecutive patients referred for cardiac surgery, in a single surgical center. Echocardiography was performed 24 h before surgery and phone interview assessed the survival status (overall and cardiovascular death) 3-years after surgery. RESULTS: Among 400 patients, 271 were male, mean age was 70.3 ± 10.2. At 3-years the overall and cardiovascular mortality was, respectively, 10.5 and 6.8%. The univariate Cox analysis identified all RV function parameters excepted BLS as predictive factors of overall mortality, with the strongest value for RVFAC < 35% (HR 4.8), S' < 10 cm/s (HR 3.8) and IVA < 1.8 m/s2 (HR 3.2) (all P < 0.001). All parameters were associated to cardiovascular mortality. In multivariate analysis, RVFAC, S', dP/dt and IVA were significantly associated to 3-years overall mortality whatever the EuroSCORE. Abnormal RVFAC, S', IVA and BLS were associated to cardiovascular mortality. CONCLUSIONS: The presence of RV dysfunction before cardiac surgery assessed by echo significantly predicts postoperative mortality, and this is true whatever the EuroSCORE level. This result demonstrates the need of adding the assessment of echographic RV function before cardiac surgery.

Echocardiographic assessment of right ventricular systolic function in a population of unselected patients before cardiac surgery: a multiparametric approach is necessary.

BACKGROUND: According to recent USA guidelines, right ventricular (RV) dysfunction can be diagnosed on the basis of a single parameter, such as tricuspid lateral annular systolic velocity (S')<10 cm/s or RV fractional area change (RVFAC)<35%. AIMS: To assess these recommendations in a large unselected cohort of patients awaiting cardiac surgery and evaluate less validated RV function criteria. METHODS: Among the consecutive patients, 413 were prospectively enrolled and underwent comprehensive echocardiography, including S', RVFAC and other RV parameters (right myocardial performance index; acceleration time, isovolumic velocity and isovolumic acceleration [IVA]; RV dP/dt; isovolumic relaxation time; two-dimensional [2D] strain). We defined subgroups of highly probable RV dysfunction (S'<10 cm/s and RVFAC<35%) and highly probable normal RV function (S'≥10 cm/s and RVFAC≥35%) as reference groups. Indices of preload and afterload were also recorded. RESULTS: Of 413 patients, 320 (77.5%) had normal RV function. In 93 patients, S' and/or RVFAC were abnormal; both were abnormal in 39 (42%) patients. Using our reference groups, IVA≤1.8 m/s2 and basal 2D strain≥-17% were of most value in diagnosing RV dysfunction. IVA was least load dependent while basal 2D strain appeared to be afterload and preload dependent. CONCLUSION: In this large population, S' and RVFAC were sometimes discrepant, supporting the need for a multiparametric approach when evaluating RV function. Among seven less validated criteria, IVA and 2D strain had the best diagnostic value. Unlike 2D strain, IVA was not influenced by loading conditions.

Outcomes of pseudo-severe aortic stenosis under conservative treatment.

AIMS: In the setting of low-flow/low-gradient aortic stenosis (LF/LGAS), outcomes of pseudo-severe aortic stenosis (AS) remain poorly described. This study was aimed to assess the outcome of patients with pseudo-severe AS under conservative treatment. METHODS AND RESULTS: Among 305 patients from the European Registry of LF/LGAS, the outcomes of the 107 patients followed under conservative treatment were analysed. Based on the results of dobutamine echocardiography, patients were divided into group IA [left ventricular (LV) contractile reserve present with true-severe AS, n = 43], group IB [pseudo-severe AS (n = 29) defined as LV contractile reserve with a final aortic valve area ≥1.2 cm(2) and a mean transaortic pressure gradient <40 mmHg at peak dobutamine infusion], or group II (exhausted LV contractile reserve, n = 35). The rate of death within 5 years was significantly lower in the group IB (43 ± 11%, n = 10), when compared with the group IA (91 ± 6%, n = 33; P = 0.001) and the group II (100%, n = 23; P < 0.001). The Cox proportional hazard model analysis demonstrated that the hazard ratio for death in the group IB remained significantly lower than in the other groups, even after adjustment for currently established risk factors. Furthermore, the 5-year survival of pseudo-severe AS patients was comparable with that of propensity-matched patients with systolic heart failure and no evidence of valve disease. CONCLUSION: In patients with pseudo-severe AS, the 5-year survival under conservative treatment is better than in true-severe AS and comparable with that of propensity-matched patients with LV systolic dysfunction and no evidence of valve disease. Further studies are needed to define optimal therapeutic management in these patients.

Improving stress echocardiography accuracy for detecting left circumflex artery stenosis: a new echocardiographic sign?

BACKGROUND: The accuracy and reproducibility of stress echocardiography (SE) for the detection of coronary artery lesions requires improvement, particularly in the left circumflex artery (LCx). AIMS: To evaluate the feasibility and diagnostic value of a new sign: Rise of the Apical lateral wall and/or Horizontal displacement of the Apex toward the septum ("RA-HA") in apical echocardiographic views. METHODS: Consecutive patients with normal left ventricular function at rest, positive SE and an indication for coronary angiography were included. SEs were analysed blindly by three independent cardiologists: two seniors (S1 and S2) and one junior (J). RESULTS: Of 81 patients, 58 had an exercise SE and 23 had a dobutamine SE. Significant coronary stenosis was found in 59 of 77 patients who underwent coronary angiography (76.6%). Interobserver reproducibility for the presence of RA-HA was very good between S1 and S2 (κ = 0.86), and good between S1 and J (0.67) and S2 and J (0.70). The sensitivity, specificity and positive and negative predictive values of RA-HA for the detection of significant coronary artery stenosis were, respectively, 39-41%, 83-89%, 88-92% and 29-31% for S1/S2; and 29%, 83%, 85% and 26% for J. To predict LCx stenosis (single or multivessel): 67-70%, 89%, 80-81% and 80-82% for S1/S2, respectively, and 50%, 89%, 75% and 74% for J. CONCLUSION: With a short learning curve, RA-HA is easily diagnosed with a very good interobserver reproducibility. It has high specificity and PPV for the detection of a coronary artery stenosis, particularly in the LCx artery, during exercise or dobutamine SE.

Valvuloarterial impedance does not improve risk stratification in low-ejection fraction, low-gradient aortic stenosis: results from a multicentre study.

OBJECTIVES: In a multicentre series of patients with low-ejection fraction/low-gradient aortic stenosis (LEF/LGAS), we evaluated the prognostic impact of valvuloarterial impedance (Zva). BACKGROUND: Zva in AS, a measure of global afterload taking into account systemic arterial compliance, has been proposed for risk stratification in paradoxical LGAS. We hypothesized that Zva could help risk stratification in LEF/LGAS. METHODS AND RESULTS: We retrospectively calculated Zva (5.6 ± 1.7 mmHg/mL/m(2)) of 184 consecutive patients (mean age: 71 ± 10 years) with severe symptomatic LEF/LGAS (valve area ≤1 cm2;, EF ≤40%, mean transaortic pressure gradient ≤40 mmHg) included between 1995 and 2005 in a multicentre registry. Zva was higher in patients with LVEF at rest ≤20% (6.6 ± 2.3 vs. 5.5 ± 1.6; P = 0.05) and correlated negatively with LVEF at rest (R = -0.25; P = 0.001). Zva was lower in patients without contractile reserve (CR) on dobutamine stress echocardiography (DSE) compared with patients with true severe AS (5.3 ± 1.3 vs. 5.8 ± 1.8 mmHg/mL/m(2); P = 0.048). Zva and the variation in stroke volume during DSE were positively correlated (P = 0.0001) but Zva did not allow distinction between true and pseudo-severe AS (5.8 ± 1.8 vs. 5.3 ± 1.8 mm Hg/mL/m(2); P = 0.30). In the total population, Zva was not predictive of long-term mortality. In the 128 patients who underwent aortic valve replacement, Zva was not predictive of operative death and of long-term mortality. CONCLUSIONS: Increased Zva is related to low LVEF and more frequent CR on DSE in LEF/LGAS. However, Zva did not allow an accurate distinction between true and pseudo-severe AS and failed to predict operative and long-term mortality after aortic valve replacement, in LEF/LGAS.

Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography.

OBJECTIVES: This study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE). BACKGROUND: Patients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial. METHODS: Eighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area or=20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55). RESULTS: Five-year survival was higher in AVR patients compared with medically managed patients (54 +/- 7% vs. 13 +/- 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12-3.16 to 0.21-8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 +/- 11% vs. 11 +/- 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG

Clinical value of exercise Doppler echocardiography in patients with cardiac-valvular disease.

Besides its usefulness for the detection of exercise-induced ischemia, conventional exercise testing may help to predict the onset of clinical events and the need for surgery in asymptomatic patients with cardiac-valvular disease. Doppler echocardiography examination during exercise recently emerged as a new stress testing modality that may add useful information regarding dynamism of LV function, valve disease severity and pulmonary circulation. Few studies have demonstrated a correlation between the results of exercise Doppler echocardiography and clinical outcome. Preliminary experience needs to be confirmed to warrant routine use of Doppler echocardiography examination during exercise in the evaluation of patients with cardiac-valve disease.

Aortic valve replacement for low-flow/low-gradient aortic stenosis operative risk stratification and long-term outcome: a European multicenter study.

OBJECTIVES: We evaluated a large multicenter series of patients operated on for low-flow/low-gradient aortic stenosis (LF/LGAS) to stratify the operative risk, assess whether perioperative mortality has decreased over recent years, and analyze the post-operative outcome. BACKGROUND: Although LF/LGAS is classically associated with a high operative risk, few data are available concerning the results of surgery in this setting. METHODS: A total of 217 consecutive patients (168 men, 77%) with severe aortic stenosis (area <1 cm(2)), low ejection fraction (EF) (

Effects of surgery on ischaemic mitral regurgitation: a prospective multicentre registry (SIMRAM registry).

AIMS: Functional ischaemic mitral regurgitation (IMR) is common in patients with ischaemic left ventricular dysfunction undergoing coronary artery bypass surgery. Although the presence of IMR negatively affects prognosis, the additional benefit of valve repair is debated, particularly with mild IMR at rest. Exercise echocardiography may help identify a subset of patients at higher risk of cardiovascular events by revealing the dynamic component of IMR. METHODS: A large prospective, multicentre, non-randomized registry is designed to evaluate the effects of surgery on IMR at rest and on its dynamic component at exercise (z). SIMRAM will enrol approximately 550 patients with IMR in up to 17 centres with clinical and exercise follow-up for 1 year. Three sets of outcomes will be prospectively assessed and several hypotheses will be tested including determinants of adverse outcome and progressive left ventricular remodeling, efficacy of treatment and role of ischaemia on the dynamic consequences of IMR. Enrolment began in November 2006 and is expected to end by early 2008.

Low-gradient aortic stenosis: impact of prosthesis-patient mismatch on survival.

AIMS: To assess the prognostic impact of prosthesis-patient mismatch (PPM) in a large consecutive series of patients operated for low-gradient aortic stenosis (AS). METHODS AND RESULTS: Outcomes after surgery for low-gradient AS were prospectively assessed in 152 consecutive patients from seven institutions. There were 113 men (74%); mean age was 72 years (64-76); valve area, 0.7 cm(2) (0.6-0.8); left ventricular (LV) ejection fraction 0.31 (0.25-0.37) and baseline mean transaortic pressure gradient (MPG), 30 mmHg (25-35) Among 139 patients with available prosthetic valve effective orifice area (EOA), PPM (defined by an indexed EOA < or = 0.85 cm(2)/m(2)) was present in 79 patients (57%) and had no significant impact on post-operative mortality. Independent predictors of overall mortality were LV contractile reserve [hazard ratio (HR) 0.52; 95% confidence interval (CI) 0.35-0.78; P = 0.002], associated coronary artery bypass grafting (HR 1.87; 95% CI 1.24-2.82; P =0.003), baseline MPG (per 1 mmHg decrease to 10 mmHg; HR 1.03; 95% CI 1.01-1.06; P = 0.021), previous cancer (HR 2.13; 95% CI 1.05-4.29; P = 0.037), and logistic EuroSCORE (per 1% increase; HR 1.02; 95% CI 1.01-1.04; P = 0.040). CONCLUSION In this large multicentre series of patients with low-gradient AS, we found that PPM (moderate in most cases) had no influence on post-operative mortality. Therefore, the performance of more complex interventions in order to avoid moderate PPM may not be justified in the setting of low-gradient AS, because their higher risk probably outweighs the expected benefit.

Influence of preoperative left ventricular contractile reserve on postoperative ejection fraction in low-gradient aortic stenosis.

BACKGROUND: Dobutamine stress hemodynamics (DSH) has the potential to stratify operative risk in low-gradient aortic stenosis (AS), but little is known about the relation between left ventricle contractile reserve and postoperative left ventricular ejection fraction (LVEF). We sought to assess the value of DSH to predict postoperative improvement in LVEF. METHODS AND RESULTS: Sixty-six consecutive patients with symptomatic severe AS (aortic valve area < or =1 cm2), LVEF < or =40%, and mean pressure gradient < or =40 mm Hg prospectively enrolled in the French multicenter study on low-gradient AS and who survived to aortic valvular replacement (AVR) were included. Preoperative contractile reserve was present in 46 patients (group I; 70%) and absent in 20 patients (group II; 30%). In the overall sample, 58% of patients improved by 2 New York Heart Association (NYHA) classes after AVR. Mean LVEF improved from 29+/-6% to 47+/-11% (P<0.0001). LVEF improved by > or =10 EF units in 38 patients (83%) in group I and in 13 patients (65%) in group II. Mean LVEF improvement was similar in the 2 groups (19+/-10% versus 17+/-11%; P=0.54). On multivariable analysis, multivessel coronary artery disease (P=0.05) and baseline mean transaortic pressure gradient (P=0.01) were related to LVEF improvement, whereas contractile reserve was not. CONCLUSIONS: LVEF increases in the majority of patients with low-gradient AS who survive after AVR. Although the absence of contractile reserve on DSH is related to high operative mortality, it does not predict the absence of LVEF recovery in patients surviving to AVR. These data further support the concept that surgery should not be contraindicated on the basis of absence of contractile reserve alone.

Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis.

BACKGROUND: In patients with asymptomatic valvular aortic stenosis, exercise testing may help to stratify the clinical risk. However, data are limited, and the role of quantitative exercise Doppler echocardiography has never been investigated. METHODS AND RESULTS: Sixty-nine consecutive patients with severe asymptomatic aortic stenosis (aortic valve area <1 cm2) who prospectively underwent quantitative Doppler echocardiographic measurements at rest and during semisupine exercise test were followed up for 15+/-7 months. Of these, 26 had an abnormal response to exercise [occurrence of > or =1 of the following findings: angina, dyspnea, > or =2 mm ST segment depression, or fall or small (<20 mm Hg) rise in systolic blood pressure during the test] and 18 presented cardiac events during follow-up (symptoms in 2 patients, acute pulmonary edema in 2, aortic valve replacement in 12, and cardiac death in 2). In univariate analysis, patients who had cardiac events exhibited a higher increase in both peak (29+/-16 versus 22+/-14 mm Hg; P=0.019) and mean (23+/-8 versus 12+/-7 mm Hg; P=0.000003) transvalvular pressure gradients, whereas the left ventricular ejection fraction reached at peak stress was lower. These patients experienced more frequently symptoms during exercise (14 of 18 versus 12 of 51; P=0.0008). By multivariate Cox regression analysis, independent predictors of cardiac events were as follows: an increase in mean transaortic pressure gradient by > or =18 mm Hg during exercise (P=0.0015), an abnormal exercise test (P=0.0026), and an aortic valve area <0.75 cm2 (P=0.0031). Exercise Doppler echocardiographic findings provided incremental prognostic value over resting echocardiographic and exercise electrocardiographic parameters. CONCLUSIONS: Quantitative Doppler exercise echocardiography could be useful to identify a high-risk subset of patients with asymptomatic valvular aortic stenosis and help for clinical decision making.

Functional assessment of mitral regurgitation by transthoracic echocardiography using standardized imaging planes diagnostic accuracy and outcome implications.

OBJECTIVES: We sought to assess the value of transthoracic echocardiography (TTE) using standardized imaging planes for the functional analysis of mitral regurgitation (MR) as well as for postoperative outcome implications. BACKGROUND: The feasibility of mitral valve repair is based on functional assessment of MR, mainly by transesophageal echocardiography (TEE). Considering the recent advances in TTE imaging, the incremental value of TEE in this setting needs to be re-examined. METHODS: Consecutive patients (n = 279; 181 men; median age 68 years [quartiles, 61 to 74]) who underwent surgery for MR were enrolled prospectively in two tertiary care centers. The accuracy of TTE (harmonic imaging) versus TEE for functional assessment of MR was evaluated against surgical findings. RESULTS: Valve repair (n = 237 patients, 85%) or replacement (n = 42) was predicted accurately by TTE in 97% of cases; TEE added significant information for only two patients. In the subgroup of degenerative MR (n = 190), agreement with surgical findings for the localization of prolapsed segments was 91% for TTE (kappa, 0.81) and 93% for TEE (kappa, 0.85) without incremental value of TEE (p = 0.40). Patients with single prolapse of the middle posterior scallop (P2) had a better postoperative outcome as compared with patients who had non-P2 lesions (p = 0.008). Furthermore, mitral replacement predicted by TTE was an independent predictor for postoperative long-term mortality (odds ratio 5.7, 95% confidence interval 1.97 to 16.4, p = 0.001). CONCLUSIONS: In experienced hands, functional assessment of MR by TTE can predict accurately valve repairability and has a strong influence on postoperative outcome. Thus, in most cases preoperative TEE is not mandatory, provided intraoperative TEE is performed.

Native aortic valve thrombosis: a rare cause of acute ischemia of the lower limb.

Spontaneous native aortic valve thrombosis is an uncommon event occurring after heart valve disease, during cardiac catheterization, bacterial endocarditis, or as a hypercoagulative state as in antiphospholipid antibody syndrome. We report the case of a 55-year-old woman in whom thrombi developed on a native aortic valve with no predisposing cause. The thrombi were responsible for recurrent lower limb ischemia. Eighteen months after aortic valve replacement, the patient is doing well.

Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics.

BACKGROUND: The prognostic value of dobutamine stress hemodynamic data in the setting of low-gradient aortic stenosis has been addressed in small, single-center studies. Larger studies are needed to define the criteria for selecting the patients who will benefit from valve replacement. METHODS AND RESULTS: Six centers prospectively enrolled 136 patients with aortic stenosis (96 men; median age, 72 years [range, 65 to 77 years]; median aortic valve area, 0.7 cm2 [range, 0.6 to 0.8]; mean transaortic gradient, 29 mm Hg [range, 23 to 34 mm Hg]; cardiac index, 2.11 L x min(-1) x m(-2) [range, 1.75 to 2.55 L x min(-1) x m(-2)]). Left ventricular contractile reserve on the dobutamine stress Doppler study was present in 92 patients (group I) and absent in 44 patients (group II). Operative mortality was 5% (3 of 64 patients) in group I compared with 32% (10 of 31 patients) in group II (P=0.0002). Predictors for operative mortality were the lack of contractile reserve (odds ratio, 10.9; 95% confidence interval [CI], 2.6 to 43.4; P=0.001) and a mean transaortic gradient < or =20 mm Hg (odds ratio, 4.7; 95% CI, 1.1 to 21.0; P=0.04). Predictors for long-term survival were valve replacement (hazard ratio, 0.30; 95% CI, 0.17 to 0.53; P=0.001) and left ventricular contractile reserve (hazard ratio, 0.40; 95% CI, 0.23 to 0.69; P=0.001). CONCLUSIONS: In the setting of low-gradient aortic stenosis, surgery seems beneficial for most of the patients with left ventricular contractile reserve. In contrast, the postoperative outcome of patients without reserve is compromised by a high operative mortality. Thus, dobutamine stress Doppler hemodynamics may be factored into the risk-benefit analysis for each patient.