Treatment-Relevant Findings in Transesophageal Echocardiography After Stroke: A Prospective Multicenter Cohort Study.

BACKGROUND AND PURPOSE: Cardiac ultrasound to identify sources of cardioembolism is part of the diagnostic workup of acute ischemic stroke. Recommendations on whether transesophageal echocardiography (TEE) should be performed in addition to transthoracic echocardiography (TTE) are controversial. We aimed to determine the incremental diagnostic yield of TEE in addition to TTE in patients with acute ischemic stroke with undetermined cause. METHODS: In a prospective, observational, pragmatic multicenter cohort study, patients with acute ischemic stroke or transient ischemic attack with undetermined cause before cardiac ultrasound were studied by TTE and TEE. The primary outcome was the rate of treatment-relevant findings in TTE and TEE as defined by a panel of experts based on current evidence. Further outcomes included the rate of changes in the assessment of stroke cause after TEE. RESULTS: Between July 1, 2017, and June 30, 2019, we enrolled 494 patients, of whom 492 (99.6%) received TTE and 454 (91.9%) received TEE. Mean age was 64.7 years, and 204 (41.3%) were women. TEE showed a higher rate of treatment-relevant findings than TTE (86 [18.9%] versus 64 [14.1%], P<0.001). TEE in addition to TTE resulted in 29 (6.4%) additional patients with treatment-relevant findings. Among 191 patients ≤60 years additional treatment-relevant findings by TEE were observed in 27 (14.1%) patients. Classification of stroke cause changed after TEE in 52 of 453 patients (11.5%), resulting in a significant difference in the distribution of stroke cause before and after TEE (P<0.001). CONCLUSIONS: In patients with undetermined cause of stroke, TEE yielded a higher number of treatment-relevant findings than TTE. TEE appears especially useful in younger patients with stroke, with treatment-relevant findings in one out of seven patients ≤60 years. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03411642.

Tricuspid regurgitation is a predictor of mortality after percutaneous mitral valve edge-to-edge repair.

AIMS: The aim of this study was to determine the impact of tricuspid regurgitation (TR) on mortality after edge-to-edge percutaneous mitral valve repair (PMVR), and also to analyse whether there is a difference in outcome between patients with improvement of TR after PMVR compared to patients without. METHODS AND RESULTS: Out of 197 consecutive patients who underwent PMVR, 139 patients with available follow-up (mean 428±386 days) were included in the study. Concomitant moderate/severe TR was present in 58.3% of patients. Kaplan-Meier analysis showed significantly reduced overall survival for patients with moderate/severe TR, compared to patients with none/mild TR (p=0.003). Cox multivariate regression analysis revealed severe TR at baseline as the strongest independent predictor of mortality (HR 4.367, p=0.003). An improvement of the baseline moderate/severe TR was observed in 45.5% of patients at 30-day follow-up. Patients with no improvement of TR after PMVR had a higher midterm mortality compared to patients in whom TR improved (40.5% versus 11.4%, p=0.005). CONCLUSIONS: More than half of patients undergoing PMVR have concomitant moderate/severe TR, which is associated with a worse outcome. Among predictors of mortality after edge-to-edge PMVR, severe TR at baseline is the most important. Patients with no improvement of TR at 30 days after PMVR have a significantly higher mortality at follow-up.

First-in-human transcatheter tricuspid valve repair in a patient with severely regurgitant tricuspid valve.

BACKGROUND: Severe tricuspid regurgitation is associated with poor prognosis; however, there are limited Class I indications for intervention, and high-surgical risk patients may go untreated. We report the first-in-human successful transcatheter tricuspid valve repair for severe tricuspid regurgitation. OBJECTIVES: The objective of this study was to show the feasibility of a transcatheter tricuspid annular repair. METHODS: Compassionate-use approval for the procedure was obtained from the regulatory organization in Germany. To perform the transcatheter bicuspidization of the tricuspid valve, the Mitralign system was used to place pledgeted sutures by means of a trans-jugular venous approach. Insulated radiofrequency wires were positioned 2 to 5 mm from the base of the posterior leaflet, 2.6 cm apart. The sutures were drawn together and locked, plicating the posterior annulus. RESULTS: Reconstruction of the 3-dimensional transesophageal echocardiographic dataset at baseline revealed a tricuspid valve annular area of 14.1 cm(2), and effective regurgitant orifice area was 1.35 cm(2). There was a significant reduction in annular area (57%) and effective regurgitant orifice area (53%) measured with 3-dimensional transesophageal echocardiography, at 6.05 cm(2) and 0.63 cm(2), respectively. Hemodynamic parameters also improved with a reduction in right atrial pressure from 22 mm Hg at baseline, to 9 mm Hg and an increase in left ventricular stroke volume from 42 ml at baseline to 72 ml. CONCLUSIONS: Transcatheter tricuspid valve repair could become an effective treatment for high-surgical risk patients who are non-responsive to optimal medical therapy.

Comparison of quantitative coronary angiography and first-pass perfusion magnetic resonance imaging for the detection of an impaired coronary perfusion in nonsevere coronary stenosis.

PURPOSE: To compare quantitative coronary angiography (QCA) and first-pass perfusion magnetic resonance imaging (FPP-MRI) in symptomatic patients with nonsevere coronary stenosis to detect a reduced coronary flow velocity reserve (CFVR). MATERIALS AND METHODS: In 35 patients, FPP-MRI and CFVR measurements were performed in 40 coronary arteries with a diameter stenosis (DS) <70% by QCA. From FPP-MRI a myocardial perfusion reserve index (MPRI) was calculated. CFVR was calculated as the ratio of the average peak flow velocity during infusion of adenosine and at rest and was considered reduced if <2. Diagnostic performance of MPRI and DS to detect a reduced CFVR was compared by receiver operating characteristic (ROC) curve analysis. RESULTS: CFVR was reduced in 16 coronary arteries (40%). Mean DS did not differ in coronary arteries with a reduced CFVR (41.0% +/- 13.3) and a normal CFVR (36.5% +/- 12.3; P = 0.281). Mean MPRI was lower in coronary arteries with a reduced CFVR (1.12 +/- 0.12) compared to a normal CFVR (1.33 +/- 0.2; P < 0.001). Sensitivity, specificity, and area under the ROC curve (AUC) were higher for MPRI (81%, 79%, 0.84) than for DS (56%, 58%, 0.60). CONCLUSION: FPP-MRI detects impaired CFVR in symptomatic patients with nonsevere coronary stenosis more accurately than QCA and can identify patients with symptomatic ischemia.

Contrast-enhanced cardiac MR imaging in the detection of reduced coronary flow velocity reserve.

PURPOSE: To prospectively evaluate the accuracy of contrast material-enhanced cardiac magnetic resonance (MR) imaging for determining impaired coronary flow velocity reserve (CFR) by using Doppler flow measurement as the reference standard. MATERIALS AND METHODS: The study was approved by the institutional ethics committee, and all patients gave written informed consent. Eligible patients underwent contrast-enhanced cardiac MR imaging and invasive measurement of CFR. For contrast-enhanced MR imaging, a three-section single-shot saturation recovery gradient-recalled echo sequence with steady-state free precession was used. Sections were divided into six segments. For each segment, a transmural and subendocardial myocardial perfusion reserve index (MPRI) was calculated by using the upslope of the signal intensity-time curve during the first pass of contrast material at rest and during adenosine infusion (140 microg per kilogram body weight per minute). MPRIs of vascular regions were compared with the corresponding CFR. Receiver operating characteristic (ROC) analysis was performed to find the number of segments needed for best diagnostic accuracy of MPRI and to find a cutoff value for MPRI in the detection of a reduced CFR. RESULTS: Thirty-five patients were evaluated (male-to-female ratio, 27:8; mean age +/- standard deviation, 63.5 years +/- 8.2; mean body mass index, 28.8 kg/m(2) +/- 3.8), and 43 vascular regions were analyzed. A linear correlation was found between the MPRI and CFR (r = 0.44, P < .05). The MPRI was significantly lower in vascular regions with a CFR of less than 2.00 than in regions with a CFR of 2.00 or greater (P < .05). Detection of a CFR of less than 2.00 was more accurate with subendocardial MPRI measurements than with transmural measurements. The mean subendocardial MPRI of the segments with the three lowest MPRIs of a vascular region showed the best diagnostic performance in the detection of a CFR of less than 2.00 (area under the ROC curve, 0.85; sensitivity, 84%; specificity, 75%) by using a cutoff value of 1.21. CONCLUSION: The diagnostic accuracy of subendocardial perfusion analysis in contrast-enhanced cardiac MR imaging is higher than that of transmural analysis.