Accuracy and reproducibility of aortic annular measurements obtained from echocardiographic 3D manual and semi-automated software analyses in patients referred for transcatheter aortic valve implantation: implication for prosthesis size selection.

Aims: A 3D transoesophageal echocardiography (3D-TOE) reconstruction tool has recently been introduced. The system automatically configures a geometric model of the aortic root and performs quantitative analysis of these structures. We compared the measurements of the aortic annulus (AA) obtained by semi-automated 3D-TOE quantitative software and manual analysis vs. multislice computed tomography (MSCT) ones. Methods and results: One hundred and seventy-five patients (mean age 81.3 ± 6.3 years, 77 men) who underwent both MSCT and 3D-TOE for annulus assessment before transcatheter aortic valve implantation were analysed. Hypothetical prosthetic valve sizing was evaluated using the 3D manual, semi-automated measurements using manufacturer-recommended CT-based sizing algorithm as gold standard. Good correlation between 3D-TOE methods vs. MSCT measurements was found, but the semi-automated analysis demonstrated slightly better correlations for AA major diameter (r = 0.89), perimeter (r = 0.89), and area (r = 0.85) (all P < 0.0001) than manual one. Both 3D methods underestimated the MSCT measurements, but semi-automated measurements showed narrower limits of agreement and lesser bias than manual measurements for most of AA parameters. On average, 3D-TOE semi-automated major diameter, area, and perimeter underestimated the respective MSCT measurements by 7.4%, 3.5%, and 4.4%, respectively, whereas minor diameter was overestimated by 0.3%. Moderate agreement for valve sizing for both 3D-TOE techniques was found: Kappa agreement 0.5 for both semi-automated and manual analysis. Interobserver and intraobserver agreements for the AA measurements were excellent for both techniques (intraclass correlation coefficients for all parameters >0.80). Conclusion: The 3D-TOE semi-automated analysis of AA is feasible and reliable and can be used in clinical practice as an alternative to MSCT for AA assessment.

Optimizing the role of transthoracic echocardiography to improve the cardiovascular risk stratification: the dream of subclinical coronary artery disease detection.

Detecting coronary artery disease at a subclinical level has always been a challenging task for cardiologists. Various non-invasive echocardiographic approaches such as measurements of left ventricular hypertrophy, diastolic function, left atrial enlargement, valve sclerosis and calcification, epicardial fat thickness, and pulse wave velocity have been proposed to integrate the available risk-charts. The present review is a collection of evidence that supports the role of the above mentioned features in cardiac risk stratification, summarizing the state of the art in non-invasive echocardiographic coronary risk assessment. Each parameter is presented with its strengths and weaknesses, aiming to trace the future directions for the development of a reliable non-invasive approach.

Atrial Function as an Independent Predictor of Postoperative Atrial Fibrillation in Patients Undergoing Aortic Valve Surgery for Severe Aortic Stenosis.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common, clinically relevant, but hardly predictable complication after surgical aortic valve replacement. The aim of this study was to test the role of preoperative left atrial longitudinal strain as a predictor of POAF in clinical practice. METHODS: Sixty patients scheduled for aortic valve replacement for severe isolated aortic stenosis, in stable sinus rhythm, were prospectively enrolled and underwent full clinical, biochemical, and transthoracic echocardiographic assessment on the day before surgery. Left atrial strain-derived peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) were obtained. The occurrence of POAF was evaluated during the hospital stay after the intervention. RESULTS: POAF was present in 26 of 60 patients (43.3%). Among all clinical variables examined, age showed a significant correlation with POAF (P = .04), while no significant differences were noted regarding preoperative symptoms, cardiovascular risk factors, medications, and biochemical data. As for the echocardiographic parameters, only PALS and PACS showed strong, significant correlations with the occurrence of arrhythmia (P < .0001 on univariate analysis), with areas under the curve of 0.87 ± 0.04 (95% CI, 0.76-0.94) for PALS and 0.85 ± 0.05 (95% CI, 0.73-0.93) for PACS. In two comprehensive multivariate models, PALS and PACS remained significant predictors of POAF (odds ratio, 0.73 [95% CI, 0.61-0.88; P = .0008] and 0.72 [95% CI, 0.59-0.87; P = .0007]). No significant interaction was detected between PALS or PACS and other clinical and echocardiographic variables, including age, E/E' ratio, and left atrial enlargement. CONCLUSIONS: PALS and PACS indexes are routinely feasible and useful to predict POAF in patients with severe isolated aortic stenosis undergoing surgical aortic valve replacement.

Mitral Regurgitation and Increased Risk of All-Cause and Cardiovascular Mortality in Patients with Type 2 Diabetes.

BACKGROUND: Mitral regurgitation is the most common heart valve disease in the general population, but little is known about the prevalence and prognostic implications of mitral regurgitation in patients with type 2 diabetes. METHODS: We retrospectively analyzed the data from 814 outpatients with type 2 diabetes who had undergone a conventional echocardiography for clinical reasons during the years 1992-2007. Mitral regurgitation was evaluated by using an integrated multiparametric echocardiographic approach. The study outcomes were all-cause and cardiovascular mortality. RESULTS: At baseline, 261 (32%) patients had mitral regurgitation (25% mild, 5% moderate, and 2% severe). Over a mean follow-up of 9 years, 120 (14%) patients died, 50 of them from cardiovascular causes. Compared with those without valve disease, patients with mild mitral regurgitation had a 3.3-fold increased risk of all-cause mortality, whereas those with moderate-to-severe mitral regurgitation had a 5.1-fold increased risk of all-cause mortality. Results remained statistically significant after adjustment for multiple potential confounders. Similar results were found for cardiovascular mortality. CONCLUSIONS: Mitral regurgitation is a common pathologic condition in patients with type 2 diabetes and is independently associated with an increased risk of both all-cause and cardiovascular mortality, even if the severity of mitral regurgitation is mild.

Clinical outcomes of transcatheter aortic valve implantation: from learning curve to proficiency.

OBJECTIVE: The use of transcatheter aortic valve implantation (TAVI) is growing rapidly in countries with a predominantly elderly population, posing a huge challenge to healthcare systems worldwide. The increment of human and economic resource consumption imposes a careful monitoring of clinical outcomes and cost-benefit balance, and this article is aimed at analysing clinical outcomes related to the TAVI learning curve. METHODS: Outcomes of 177 consecutive transfemoral TAVI procedures performed in 5 years by a single team were analysed by the Cumulative Sum of failures method (CUSUM) according to the clinical events comprised in the Valve Academic Research Consortium (VARC-2) safety end point and the VARC-2 definition of device success. Margins for events acceptance were extrapolated from landmark trials that tested both balloon or self-expandable percutaneous valves. RESULTS: 30-day and 1-year survival rates were 97.2% and 89.9%, respectively. Achievement of the primary end point (number of cases needed to provide the acceptable margin of the composite end point of any death, stroke, myocardial infarction, life-threatening bleeding, major vascular complications, stage 2-3 acute kidney injury and valve-related dysfunction requiring a repeat procedure) required the performance of 54 cases, while the learning curve to achieve 'device success' identified 32 cases to reach the expected proficiency. In this experience, the baseline clinical risk as assessed by the Society of Thoracic Surgeons (STS) score determined the long-term survival rather than the adverse events related to the learning curve. CONCLUSIONS: A relatively large number of cases are required to achieve clinical outcomes comparable to those reported in high-volume centres and controlled trials. According to our national workload standards, this represents more than 2 years of continuous activity.

Risk stratification in acute coronary syndromes.

Accurate and readily available systems for risk stratification and a wide array of antithrombotic agents, on top of classical anti-ischemic drugs, provide the noninvasive cardiologist admitting the patient in the CCU with an effective and reliable armamentarium for the safe management of most patients with ACS. From the interventionalist's perspective, the immediate knowledge of the coronary anatomy yields the most valuable information to address the most appropriate treatment. The sooner angiography is performed the higher the benefit for patients at moderate to high risk, but if performed by expert teams and with the correct use of modern drugs and devices, the invasive approach has the potential to reduce costs and length of hospital stay also in low-risk patients. Although still some reluctance remains to equalize treatment strategies for patients with STEMI to those with NSTEMI, such differences will likely disappear in the near future with upcoming new evidence. Cardiac surgery may represent a life-saving alternative for patients presenting with NSTEMI evolving in cardiogenic shock or with mechanical complications, or in patients unsuitable for PCI or with failed PCI attempts. In stabilized conditions after the treatment of the culprit lesion, patients with severe multivessel disease may benefit from cardiac surgery to complete myocardial revascularization. Indications for CABG in this setting should be evaluated in the context of a local "heart team" or through prespecified protocols in centers without cardiac surgery on site.