Unmasking Myocardial Dysfunction in Patients Hospitalized for Community-Acquired Pneumonia Using a 4-Chamber 3-Dimensional Volume/Strain Analysis.

Lower respiratory infection was reported as the most common fatal infectious disease. Community-acquired pneumonia (CAP) and myocardial injury are associated; yet, true prevalence of myocardial injury is probably underestimated. We assessed the rate and severity of myocardial dysfunction in patients with CAP. Admitted patients diagnosed with CAP were prospectively recruited. All the patients had C-reactive protein (CRP), brain natriuretic peptide (BNP), and high-sensitivity cardiac troponin (hs-cTnl) tests added to their routine workup. 2D/3D Doppler echocardiography was done on a Siemens Acuson SC2000 machine ≤ 24 h of diagnosis. 3D datasets were blindly analyzed for 4-chamber volumes/strains using EchobuildR 3D-Volume Analysis prototype software, v3.0 2019, Siemens-Medical Solutions. Volume/strain parameters were correlated with admission clinical and laboratory findings. The cohort included 34 patients, median age 60 years (95% CI 55-72). The cohort included 18 (53%) patients had hypertension, 9 (25%) had diabetes mellitus, 7 (21%) were smokers, 7 (21%) had previous myocardial infarction, 4 (12%) had chronic renal failure, and 1 (3%) was on hemodialysis treatment. 2D/Doppler echocardiography findings showed normal ventricular size/function (LVEF 63 ± 9%), mild LV hypertrophy (104 ± 36 g/m2), and LA enlargement (41 ± 6 mm). 3D volumes/strains suggested bi-atrial and right ventricular dysfunction (global longitudinal strain RVGLS = - 8 ± 4%). Left ventricular strain was normal (LVGLS = - 18 ± 5%) and correlated with BNP (r = 0.40, p = 0.024). The patients with LVGLS > - 17% had higher admission blood pressure and lower SaO2 (144 ± 33 vs. 121 ± 20, systolic, mmHg, p = 0.02, and 89 ± 4 vs. 94 ± 4%, p = 0.006, respectively). hs-cTnl and CRP were not different. Using novel 3D volume/strain software in CAP patients, we demonstrated diffuse global myocardial dysfunction involving several chambers. The patients with worse LV GLS had lower SaO2 and higher blood pressure at presentation. LV GLS correlated with maximal BNP level and did not correlate with inflammation or myocardial damage markers.

Acute Kidney Injury Following Transcatheter Aortic Valve Implantation: Association with Contrast Media Dosage and Contrast Media Based Risk Predication Models.

The effect of contrast media (CM), delivered prior to- and during transcatheter aortic valve implantation (TAVI), on kidney function, following the procedure, is debatable. Consequently, the performance of CM-based, acute kidney injury (AKI) risk prediction models is also questionable. We retrospectively studied 210 patients that underwent TAVI. We recorded the dose of CM used prior and during TAVI, calculated the results of different AKI risk assessment models containing a CM module, and tested their association with AKI after the procedure. AKI was diagnosed in 38 patients (18.1%). The baseline estimated glomerular filtration rate (eGFR) was lower in the AKI+ group compared to AKI- group (51 ± 19.3 versus 64.5 ± 19 mL/min/1.73 mr2, respectively). While the dose of CM delivered prior to TAVI, during TAVI or the cumulative amount of both did not differ between the groups, the results of all tested risk models were higher in AKI+ patients. However, by multivariable analysis, only eGFR had a consistent independent association with AKI. We suggest that the dose of CM delivered prior or during TAVI is not associated with AKI and that the predictive power of CM based AKI risk models is, in all probability, limited to eGFR alone.

Left atrial function analysis in patients in sinus rhythm, normal left ventricular function and indeterminate diastolic function.

Assessment of diastolic function by echocardiography may be indeterminate as demonstrated in previous studies where diastolic measurement is a discrepant. We aimed to assess whether left atrial (LA) function may contribute to left ventricle filling evaluation in patients with indeterminate diastolic function (IndtDFx). This retrospective study included 3 groups of patients based on diastolic function: normal diastolic function (NDFx), definite diastolic dysfunction (DDFx) and IndtDFx. All patients had sinus rhythm with left ventricular ejection fraction ≥ 45%. Diastolic function was determined according to the following echocardiographic parameters: mitral E', mitral E/E' ratio, LA maximal volume index, and pulmonary pressure. NDFx was defined as having less than 2 abnormal parameters, DDFx as more than 2 abnormal parameters, and IndtDFx as 2 abnormal parameters. LA function analysis was performed in all patients using echocardiographic 2D speckle tracking. Sixty seven patients were included in strain analysis. The DDFx group (n = 21) and IndtDFx (n = 19) were significantly different from NDFx (27) in some demographics, cardiovascular risk factors, presentation and echocardiographic parameters. Some of the phasic LA function (phasic LA volumes and strains) parameters in the IndtDFx group were similar to DDFx and significantly different from the NDFx group, while other parameters fell in between the two groups. Phasic LA minimal volume index was found to be associated with heart failure symptoms. The IndtDFx group is a heterogeneous group demonstrating clinical and echocardiographic profiles that closely resemble that of DDFx group. LA phasic function analysis may help in re-classification of patients with IndtDFx as actual DDFx or as NDFx.

Immediate Post-Procedural and Discharge Assessment of Mitral Valve Function Following Transcatheter Edge-to-Edge Mitral Valve Repair: Correlation and Association with Outcomes.

The correlation between residual mitral regurgitation (rMR) grade or mitral valve pressure gradient (MVPG), at transcatheter edge-to-edge mitral valve repair (TEEMr) completion and at discharge, is unknown. Furthermore, there is disagreement regarding rMR grade or MVPG from which prognosis diverts. We retrospectively studied 82 patients that underwent TEEMr. We tested the correlation between rMR or MVPG and evaluated their association, with outcomes. Moderate or less rMR (rMR ≤ 2) at TEEMr completion was associated with improved survival, whereas mild or less rMR (rMR ≤ 1) was not. Patients with rMR ≤ 1 at discharge demonstrated a longer time of survival, of first heart failure hospitalization and of both. The correlation for both rMR grade (r = 0.5, p < 0.001) and MVPG (r = 0.51, p < 0.001), between TEEMr completion and discharge, was moderate. MR ≤ 2 at TMEER completion was the strongest predictor for survival (HR 0.08, p < 0.001) whereas rMR ≤ 1 at discharge was independently associated with a lower risk of the combined endpoint (HR 4.17, p = 0.012). MVPG was not associated with adverse events. We conclude that the assessments for rMR grade and MVPG, at the completion of TEEMr and at discharge, should be distinctly reported. Improved outcome is expected with rMR ≤ 2 at TEEMr completion and rMR ≤ 1 at discharge. Higher MVPG is not associated with unfavorable outcomes.

Clinical and echocardiographic characteristics of patients in sinus rhythm, normal left ventricular function, and indeterminate diastolic function.

BACKGROUND: Diastolic dysfunction (DDFx) is the major underlying mechanism of heart failure with preserved left ventricular ejection fraction (EF). Yet, the echocardiographic diagnosis of DDFx in patients in sinus rhythm is challenging and up to 25% of studies have discrepant measures making assessment of DDFx indeterminate. We aimed to describe the clinical and echocardiographic characteristics of patients with indeterminate diastolic function compared to patients with definite normal and abnormal diastolic function. METHODS: One thousand six hundred seventy-four patients were identified from the echocardiography database in sinus rhythm, EF ≥ 45% without wall-motion abnormalities, valvular, congenital heart diseases, cardiomyopathies or pulmonary disease. Patients were divided according to their lateral mitral E/E' ratio and left atrial systolic diameter: normal diastolic function (DFx) (left atrial systolic diameter [LASd] <40 mm, E/E' < 10), DDFx (LASd ≥ 40 mm, E/E' ≥ 10) and indeterminate DFx (discrepant LASd diameter and E/E' ratio). RESULTS: Clinical and echocardiographic characteristics of the 3 groups, DDFx (n = 186), indeterminate diastolic function (IndtDFx) (n = 207), and normal diastolic function (NDFx) (n = 1281) were significantly different. IndtDFx demonstrated intermediate parameter abnormalities, largely overlapping with DDFx. LASd and E/E' were similarly associated with the inability to determine diastolic function. Age, female gender, renal failure, E/E' and pulmonary pressure were found to be independent predictors of heart failure symptoms (RR = 1.02, 1.5, 2.5, 1.1, 1.1, respectively, P < .0001, r = .35). CONCLUSION: Clinically and echocardiographically patients with IndtDFx are more closely related to DDfx than to NDFx. Although LAd was abnormal in IndtDFx it was not predictive of heart failure symptoms. Further study is suggested to establish whether LA function rather than its maximal size can provide additional information.