Outcomes of persistent pulmonary hypertension following transcatheter aortic valve replacement.

OBJECTIVES: To determine the prevalence and factors associated with persistent pulmonary hypertension (PH) following transcatheter aortic valve replacement (TAVR) and its relationship with long-term mortality. METHODS: Consecutive patients who underwent TAVR from July 2011 through January 2016 were studied. The prevalence of baseline PH (mean pulmonary artery pressure ≥25 mm Hg on right heart catheterisation) and the prevalence and the predictors of persistent≥moderate PH (pulmonary artery systolic pressure (PASP)>45 mm Hg on 1 month post-TAVR transthoracic Doppler echocardiography) were collected. Cox models quantified the effect of persistent PH on subsequent mortality while adjusting for confounders. RESULTS: Of the 407 TAVR patients, 273 (67%) had PH at baseline. Of these, 102 (25%) had persistent≥moderate PH. Mortality at 2 years in patients with no baseline PH versus those with PH improvement (follow-up PASP≤45 mm Hg) versus those with persistent≥moderate PH was 15.4%, 16.6% and 31.3%, respectively (p=0.049). After adjusting for Society of Thoracic Surgeons Predicted Risk of Mortality and baseline right ventricular function (using tricuspid annular plane systolic excursion), persistent≥moderate PH remained associated with all-cause mortality (HR=1.82, 95% CI 1.06 to 3.12, p=0.03). Baseline characteristics associated with increased likelihood of persistent≥moderate PH were ≥moderate tricuspid regurgitation, ≥moderate mitral regurgitation, atrial fibrillation/flutter, early (E) to late (A) ventricular filling velocities (E/A ratio) and left atrial volume index. CONCLUSIONS: Persistency of even moderate or greater PH at 1 month post-TAVR is common and associated with higher all-cause mortality.

Echocardiographic evaluation and guidance for MitraClip procedure.

Transcatheter mitral valve repair using the MitraClip system (Abbott, Abbott Park, Il, USA) has become a world-wide, well-established therapeutic alternative to treat symptomatic patients with severe mitral regurgitation and prohibitive surgical risk. This article offers a comprehensive review of the important clinical and imaging aspects related to the patient selection, imaging evaluation and intraprocedural guidance for optimal results using this transcatheter device therapy. This article provides an updated framework for the interested practitioners summarizing the current understanding and applications for this device based on the current literature and growing experience of this technique.

Right Ventricular Function and Prognosis in Patients with Low-Flow, Low-Gradient Severe Aortic Stenosis.

BACKGROUND: Patients with low left ventricular ejection fractions and low-flow, low-gradient aortic stenosis (AS) represent a challenging cohort with high morbidity and mortality. The prevalence and clinical impact of right ventricular dysfunction (RVD) on risk stratification and prognosis in these patients is unknown. METHODS: A retrospective analysis was performed of 65 patients with low-flow, low-gradient AS who underwent low-dose dobutamine stress echocardiography to determine AS severity and to ascertain flow reserve status (≥20% stroke volume increase). Clinical, demographic, and imaging data were prospectively collected. Per guidelines, RVD was defined as tricuspid annular plane systolic excursion < 16 mm in the apical four-chamber view and measured at baseline. Cox proportional hazards modeling was used to risk-adjust comparisons for the end point of all-cause mortality. RESULTS: The mean age was 74 ± 9 years, the mean left ventricular ejection fraction was 29 ± 10%, the mean indexed aortic valve (AV) area was 0.49 ± 0.1 cm(2)/m(2), and the mean AV gradient 22 ± 7 mm Hg. RVD was present in 37 patients (57% of the study cohort). After a median follow-up period of 13 months (interquartile range, 5-30 months), there were 29 AV replacements and 30 deaths. The presence of RVD (hazard ratio, 2.86; 95% CI, 1.21-6.75; P = .02) was an independent risk factor associated with all-cause mortality despite many adjustments for potential clinical and echocardiographic confounders such as AV replacement, Society of Thoracic Surgeons Predicted Risk of Mortality score, severity of tricuspid regurgitation, and left ventricular global longitudinal strain. CONCLUSIONS: Baseline RVD is prevalent in patients with low-flow, low-gradient AS undergoing dobutamine stress echocardiography. Quantification of right ventricular systolic function in these complex patients provides important prognostic value and risk stratification adjunctive to Society of Thoracic Surgeons Predicted Risk of Mortality score and should be incorporated into the decision-making process.

Focal monomorphic ventricular tachycardia as the first manifestation of amyloid cardiomyopathy.

52-year-old patient presented with palpitation and well tolerated monomorphic ventricular tachycardia. He had normal echocardiogram and coronary angiogram 3 months prior to presentation. Surface EKG revealed regular wide-complex tachycardia with right bundle branch block morphology and right inferior axis. In conjunction with recent negative cardiac evaluation, this suggested idiopathic focal ventricular tachycardia from anterolateral basal left ventricle. CARTO based activation mapping confirmed the presence of VT focus in that area. Radiofrequency ablation at the site of perfect pacemap resulted in a partial suppression of the focus. Echocardiogram was subsequently performed because of progressive dyspnea. It revealed asymmetrical thickening of posterolateral left ventricle, with delayed enhancement on contrast magnetic resonance imaging. Fine needle aspiration of abdominal fat stained with Congo red confirmed the diagnosis of systemic AL amyloidosis due to IgG lambda-light chain deposition. Consequently, the patient underwent placement of implantable defibrillator and hematopoetic stem cell transplantation. He remains in excellent functional status 18 months after presentation.

Constrictive pericarditis: an unusual clinical entity suggested during dobutamine stress echocardiography.

A 44-year-old female presents with disabling dyspnea and is unable to perform a regular treadmill stress test; instead a dobutamine stress echocardiogram is performed and although negative for ischemia reveals a vigorous paradoxical motion of the interventricular septum with dilatation of the inferior vena cava without respiratory variation and an increased diastolic flow signal in the hepatic veins after expiration with the infusion of dobutamine. The diagnosis of constrictive physiology is confirmed with cardiac magnetic resonance imaging (MRI) and right heart hemodynamics and the patient underwent pericardiectomy without complications with resolution of symptoms.