Feasibility and Outcome of Transjugular Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement.

Background: There are limited data on the impact of intracardiac echocardiography (ICE)-guided transcatheter aortic valve replacement (TAVR) on the new permanent pacemaker implantation (PPMI) rate. Objectives: This study investigated the feasibility and outcome of transjugular ICE (TJ-ICE) -guided TAVR, by visualizing the relationship between the membranous septum (MS) and the transcatheter aortic valve (TAV). Methods: Among patients with severe aortic stenosis who underwent TAVR between February 2017 and June 2020, this study enrolled a total of 163 patients with TJ-ICE-guided TAVR. MS length was measured by ICE. The primary endpoint of this study was the incidence of new PPMI at 30 days. Results: The mean age of the patients in this study was 84.9 ± 4.6 years, and 71.2% of the patients were female. Device success was 96.3% with TJ-ICE guidance. A TJ-ICE-related complication occurred in 1 case (0.6%). The median length of the MS was 5.8 mm (IQR: 5.0-6.9 mm). Excellent intraobserver (intraclass correlation coefficient [ICC]: 0.94; 95% CI:0.79-0.98; P < 0.001) and interobserver (ICC: 0.93; 95% CI: -0.05 to 0.98; P < 0.001) agreements were shown. The new PPMI rate was 6.7% at 30 days without a significant difference between balloon-expandable valves and self-expandable valves (3.4% vs 8.7%; P = 0.226). Patients with a TAV implantation depth less than MS length had a significantly lower incidence of new PPMI compared with patients with a TAV implantation depth greater than MS length (2.1% vs 13.4%; P = 0.005), regardless of baseline right bundle branch block presence (6.7% vs 66.7%; P = 0.004) or absence (1.2% vs 8.2%; P = 0.041). Conclusions: TJ-ICE-guided TAVR demonstrated remarkable feasibility and safety. The TJ-ICE-guided final TAV position had a significant impact on the new PPMI rate. (Tokai Valve Registry; UMIN000036671).

Incremental Value of Global Longitudinal Strain for Confirming Heart Failure-Related Symptoms in Severe Aortic Stenosis.

The indications or timing of aortic valve replacement for symptomatic aortic stenosis (AS) are based on a patient's life expectancy and symptoms. However, clinical decision-making may be difficult because symptoms are subjective and cannot be quantitatively assessed and confirmed. This study aimed to evaluate the association between heart failure (HF)-related symptoms and cardiac hemodynamic left ventricular deformations in patients with severe AS using transthoracic echocardiographic assessments of left ventricular global longitudinal strain (LV-GLS). The medical records of patients hospitalized for AS between February 2017 and September 2019 were retrospectively screened. Independent cardiologists analyzed the transthoracic echocardiographic images of a digital echocardiography database. The cohort comprised 177 hospitalized patients with severe AS and no history of HF. The subgroup with HF-related symptoms included 87 patients, whereas that without HF-related symptoms included 90 patients. In 145 patients without atrial fibrillation, the left atrial volume index (LAVI) and LV-GLS were significantly associated with HF-related symptoms (odds ratio 1.033, 95% confidence interval 1.008 to 1.059, p = 0.011 and odds ratio 1.224, 95% confidence interval 1.118 to 1.340, p <0.0001, respectively). Moreover, the combination of brain natriuretic peptide level, LAVI, and LV-GLS showed better diagnostic accuracy than the combination of brain natriuretic peptide level and LAVI (p = 0.005). However, there were no such tendencies in 32 patients with atrial fibrillation. The HF-related symptoms in patients with severe AS were strongly linked to LV-GLS. LV-GLS showed incremental value for confirming HF-related symptoms.

Mechanisms and implications of mitral regurgitation in patients with severe aortic stenosis who received transcatheter aortic valve replacement.

INTRODUCTION: This study aimed to investigate the mechanisms and clinical implications of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) who received transcatheter aortic valve replacement (TAVR). METHODS: We conducted retrospective echocardiographic analyses at baseline and 6 months after TAVR in 140 patients with symptomatic AS (85 ± 5 years) who underwent TAVR. We defined significant MR as ≥ moderate based on evaluation of transthoracic echocardiography (TTE). RESULTS: There were 48 patients (34%) with preexisting MR at the baseline. Among measured TTE parameters, end-systolic wall stress (ESWS), mitral annulus area, and mitral valve thickening index were independent factors associated with preexisting MR (odds ratio [OR]: 1.013, 95% confidence interval [CI]: 1.005-1.021; OR: 1.740, 95% CI: 1.314-2.376; OR: 2.306, 95% CI: 1.426-3.848; respectively). Six months after TAVR, there were 34 patients with post-existing MR, A history of atrial fibrillation and ESWS after TAVR were independent factors (OR: 3.013, 95% CI: 1.208-7.556; OR: 1.013, 95% CI: 1.000-1.023; respectively). The Kaplan-Meier plot indicated that preexisting MR was a risk factor for heart failure-related events within 1 year of discharge after TAVR (p = .012). CONCLUSIONS: In patients who underwent TAVR for severe AS, preexisting MR was associated with having a thickened mitral valve and large mitral annulus size induced by high ESWS. These patients may have worse prognosis after TAVR and should be closely monitored in the long term.

Nodular Pulmonary Amyloidosis Preceding Gastric Mucosa-associated Lymphoid Tissue Lymphoma, Initially Suspected to Be Lung Cancer.

Nodular pulmonary amyloidosis, a subtype of pulmonary amyloidosis, is a unique disease that can mimic lung cancer on radiographic imaging and is related to lymphoproliferative disorders. In this report, we describe a case of a 76-year-old male who presented with a solitary nodule in his left lower lung lobe on computed tomography that increased from 6 mm to 13 mm in diameter over 40 months. Lung cancer was suspected; however, transbronchial lung biopsy revealed deposition of an eosinophilic and homogeneous amorphous substance, which showed apple-green birefringence under polarized light after Congo red staining, and immunohistochemistry analysis returned positive results for immunoglobulin lambda light-chain. Upper gastrointestinal endoscopy revealed a gastric mucosa-associated lymphoid tissue (MALT) lymphoma. These findings indicated that this was a case of nodular pulmonary amyloidosis that preceded a diagnosis of MALT lymphoma.

Echocardiographic score for the screening of cardiac amyloidosis with positive 99m technetium pyrophosphate scintigraphy result.

INTRODUCTION: Speckle-tracking-derived strains in cardiac chambers may provide better solutions for transthyretin amyloid cardiomyopathy (ATTR-CM) screening. This study aimed to evaluate the efficacy of biventricular strain measurements using speckle tracking for screening 99m Tc-pyrophosphate (99m Tc-PYP) scintigraphy-positive cardiomyopathy, which is nearly equivalent to ATTR-CM. METHODS: We performed a retrospective analysis of transthoracic echocardiographic studies using vendor-independent speckle tracking analysis in older patients (≥65 years) who underwent 99m Tc-PYP scintigraphy to evaluate the etiology of suspected ATTR-CM in our institute between January 2019 and December 2022. RESULTS: The entire cohort (n = 89) was divided into two subgroups positive 99m Tc-PYP scan results (n = 34) and negative 99m Tc-PYP scan results (n = 55). In the multivariate analysis, posterior wall thickness (p = .003, odds ratio [OR]:1.48, 95% confidence interval [CI]:1.14 -1.92), left ventricular longitudinal strain apical/basal ratio (LVLSapi/bas) (p = .015, OR: 2.78, 95% CI: 1.23-6.32, and right ventricular longitudinal strain (RVLS) (p = .003, OR: 1.15, 95% CI: 1.05 -1.26) were selected to be the most representative echocardiographic findings in 99m Tc-PYP positive cardiomyopathy. The receiver operating characteristic analysis indicated that posterior wall thickness (p < .0001, area under the curve [AUC]: .821, cut-off value: 14.0 mm), LVLSapi/bas (p < .001, AUC: .802, cut-off value: 2,16), and RVLS (p < .001, AUC: .791, cut-off value: -18.7%) could significantly detect 99m Tc-PYP positive results with an excellent credibility. Echocardiographic score points calculated using the summary of these three parameters in each patient revealed that a 2-point score had a fair sensitivity (85%) and an excellent specificity (93%), while a 1-point score had an excellent sensitivity (91%) and a modest specificity (53%). CONCLUSION: Our proposed echocardiographic screening tool for 99m Tc-PYP scintigraphy-positive cardiomyopathy may help clinicians manage patients with suspected ATTR-CM.

Right ventricular free wall longitudinal strain assessment using offline speckle tracking in COVID-19 patients requiring intensive medical care.

PURPOSE: The purpose of this study was to evaluate and confirm the prognostic utility of comprehensive transthoracic echocardiography (TTE) using offline myocardial strain analyses in a Japanese coronavirus disease (COVID-19) cohort hospitalized in intensive care units. METHODS: We performed a retrospective analysis of 90 consecutive adult patients with COVID-19 who underwent clinically indicated standard two-dimensional TTE in intensive care wards. Patients on extracorporeal membrane oxygenation (ECMO) at the time of TTE were excluded. Biventricular strain assessments using vendor-independent offline speckle tracking analysis were performed. Patients with inadequate TTE image quality were also excluded. RESULTS: Among the 90 COVID-19 patients, 15 (17%) patients required venovenous or venoarterial ECMO. There were 25 (28%) in-hospital deaths. A composite event, defined as the combination of in-hospital mortality and subsequent initiation of ECMO, occurred in 32 patients. Multivariate logistic regression for composite events indicated that right ventricular free wall longitudinal strain (RV-FWLS) and mechanical ventilation at the time of TTE were independent risk factors for composite events (p = 0.01, odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01-1.18; p = 0.04, OR 3.24, 95% CI 1.03-10.20). Cumulative survival probability plots generated using the Kaplan-Meier method for composite events with log-rank tests revealed a significant difference between subgroups divided by the cutoff value of RV-FWLS (p < 0.001). CONCLUSION: Offline measurement of RV-FWLS may be a potent predictor of worse outcomes in COVID-19 requiring intensive care. Larger multicenter prospective studies are needed.

Short-term Outcomes of Urgent Transcatheter Aortic Valve Replacement in Symptomatic Aortic Stenosis That Requires Emergency Hospital Admission.

Objective This study retrospectively compared the outcomes of emergently admitted patients with aortic stenosis (AS) with or without urgent transcatheter aortic valve replacement (TAVR). Methods Patients hospitalized between February 2015 and December 2019 for symptomatic AS were retrospectively analyzed by comparing the received conservative management [continued medical therapy with or without elective surgical transcatheter replacement (SAVR) or TAVR scheduled after the index hospitalization] and urgent TAVR (TAVR during the index hospitalization). Results The cohort comprised 114 patients with symptomatic AS who required emergency admission. Urgent TAVR was performed for 37 patients, while conservative management was provided for 77 patients, including 1 who received urgent SAVR. Urgent TAVR was more likely to be performed in patients with a history of hospitalization for heart failure, high New York Heart Association class scores, a lower clinical frailty scale at admission, and a high aortic valve peak velocity (p=0.01, p<0.001, p<0.01 and p=0.02, respectively). Kaplan-Meier analyses with log-rank test revealed favorable outcomes of urgent TAVR in all-cause mortality and cardiovascular events within 60 days of admission (p<0.01, p<0.01, respectively). Conclusion Urgent TAVR had better short-term outcomes in patients with symptomatic AS who required emergency hospital admission than conservative management. When considering urgent TAVR, patients with typical heart failure symptoms due to AS with a history of heart failure hospitalization and relatively little frailty can be selected.

Value of standard echocardiography at the bedside for COVID-19 patients in intensive care units: a Japanese single-center analysis.

PURPOSE: In the era of COVID-19, those special settings or indications for which standard transthoracic echocardiography (TTE) can safely produce benefits or advantages over minimized ultrasound imaging procedures need to be identified. Thus, the purpose of this study was to conduct a retrospective analysis with offline comprehensive conventional measurement of bilateral heart function and develop an appropriate prognostic model for in-hospital death. METHODS: We performed a retrospective analysis of 37 consecutive patients with COVID-19, confirmed by real-time reverse-transcriptase polymerase chain reaction assay, who had undergone clinically indicated standard two-dimensional echocardiographic studies in intensive care wards. Offline comprehensive measurement was also performed. We further integrated the echocardiographic findings as paired evidence of vital organ involvement (possible respiratory distress assessed using right ventricular functional parameters, possible myocardial injury assessed using increased wall thickness, effusion or asynergy) and circulatory failure (suspected low flow status assessed using stroke volume index, suspected congestion assessed using elevated right or left atrial pressure). We evaluated its value for in-hospital death along with other echocardiographic findings. RESULTS: The most common features included a normal-sized left atrium and left ventricle with preserved left ventricular ejection fraction, despite deteriorated left ventricular flow volume. Less frequent findings, such as abnormalities in the right heart and left ventricular abnormalities suggesting myocarditis, were observed. Although the single echocardiographic parameters failed to show predictive values for in-hospital death, integration of the echocardiographic findings suggested predictive value (p = 0.04, odds ratio: 12.28). CONCLUSION: Standard TTE at the bedside with offline comprehensive conventional measurement may provide prognostic information that is valuable for the management of patients with COVID-19.

Predictors for non-delayed discharge after transcatheter aortic valve replacement: utility of echocardiographic parameters.

Considering that transcatheter aortic valve replacement (TAVR) procedures have become less invasive, the duration for monitoring patient care after a successful TAVR can be reduced. Therefore, this study aimed to investigate the prognostic value of baseline echocardiographic parameters for non-delayed discharge in patients after TAVR. The study group included 154 consecutive patients (mean age: 84.4 ± 4.5 years; and 101 women) who underwent a TAVR. Comprehensive echocardiograms including both side indices of myocardial performance (IMP) and blood tests were obtained prior to the TAVR procedure. The median post-TAVR length of stay was 6 days while the mode and first quartile were both 4 days. Receiver operating characteristic curve analysis showed that the optimum cut-off value of the left-sided IMP in patients with a normal left ventricular ejection fraction (LVEF, ≥ 50%) (n = 124) for non-delayed discharge (≤ 4 days) was 0.34 with an area under the curve (AUC) value of 0.71563 and p value of < 0.0001, while the optimum cut-off value in patients with reduced LVEF (< 50%) (n = 30) was 0.47 with an AUC value of 0.77778 and p value of < 0.0120. An adjusted analysis indicated the negative left-sided IMP results as the only predictor for non-delayed discharge (p < 0.0001). Furthermore, the adjusted predictors for survival without early cardiovascular re-hospitalization within 6 months after TAVR were the positive left-sided IMP result, when the cut-off value of 0.52 was used, and the presence of elevated RAP of 8 to 15 mmHg. The early discharge policy should be carefully considered in high-risk populations, but the left-sided IMP may play a significant role in the pre-screening process.

Platypnoea-orthodeoxia syndrome due to deformation of the patent foramen ovale caused by a dilated ascending aorta: a case report.

BACKGROUND: Platypnoea-orthodeoxia syndrome (POS) is characterized by dyspnoea and arterial desaturation in the sitting position. Although its pathophysiology is complex and still needed to be investigated, the disease is one of the clinical situations which should be immediately and adequately managed by health care workers from the initial presentation. CASE SUMMARY: A 66-year-old woman with a history of systemic lupus erythematosus, deep vein thrombosis, and lumbar compression fracture was admitted for evaluation of the sudden onset of dyspnoea, while in the sitting position that was relieved on placing her in the supine position. Her transoesophageal echocardiogram did reveal a deformity in the patent foramen ovale (PFO) structure with a wide gap due to aortic compression, which was markedly different from that observed in the supine position, along with massive right-to-left shunting caused by redirected venous return due to a persistent Eustachian valve. With the computed tomography and angiograms, POS was diagnosed. Then, the patient received aortic replacement and patch closure of PFO, and her symptoms were completely resolved. DISCUSSION: Platypnoea-orthodeoxia syndrome is a condition with quite unique features and needs multiple clinical measures for the diagnosis and medical management. For all health care workers, it is essential to have a high suspicion in order to detect POS in patients with unexplained dyspnoea. Echocardiography plays a major role in establishing the diagnosis and offering the choice of therapeutic options.

Cardiac sarcoidosis mimicking left ventricular noncompaction: An approach to acquired apical hypertrabeculation.

A 65-year-old asymptomatic woman, who had been pathologically diagnosed with pulmonary sarcoidosis, was admitted for further evaluation of possible cardiac involvement. Her echocardiography demonstrated the development of apical hypertrabeculation that was not observed 5 years previously. Cardiac magnetic resonance imaging revealed late gadolinium enhancement in the same region. Gallium single photon-missioned computed tomography/computed tomography revealed high uptake. Therefore, the diagnosis of active cardiac sarcoidosis was established, and subsequent treatment with corticosteroid was initiated. No study regarding acquired left ventricular hypertrabeculation associated with cardiac sarcoidosis has been reported. The integrated multi-imaging modality approach helped in earlier recognition of cardiac sarcoidosis.

Improvement of left ventricular function after successful radiofrequency catheter ablation in persistent atrial fibrillation with preserved left ventricular ejection fraction: a comprehensive echocardiographic assessment using two-dimensional speckle tracking analysis.

BACKGROUND: A limited number of studies have investigated the effects of radiofrequency catheter ablation (RFCA) on left ventricular (LV) function and the left atrial (LA) size in patients with atrial fibrillation (AF). The purpose of this study was to conduct a comprehensive assessment of LV function in patients with AF with preserved left ventricular ejection fraction (LVEF) before and after RFCA. METHOD: A total of 30 consecutive patients with no recurrences after RFCA for persistent AF (age, 57.7 ± 8.4 years) were enrolled. Transthoracic echocardiography was performed at the baseline and 6 months after the final RFCA using speckle tracking derived LV strain analysis. RESULTS: After RFCA, we measured decreases in the LA volume index (33.7 ± 10.4 ml/m2 vs. 24.6 ± 8.6 ml/m2, p < 0.0001), while we observed improvements in systolic indices such as LVEF (56.8 ± 9.8% vs. 65.1 ± 9.1%, p < 0.0001), global longitudinal strain (- 16.8 ± 4.4% vs. - 18.8 ± 3.4%, p = 0.0055) and twist (8.12 ± 3.66° vs. 12.33 ± 6.75°, p = 0.0050), and also in diastolic indices such as strain rate during early diastole (SRE) (0.73 ± 0.10 s-1 vs. 1.32 ± 0.29 s-1, p < 0.0001) and early transmitral inflow velocity (E)/SRE (1.11 ± 0.36 m vs. 0.61 ± 0.19 m, p < 0.0001). Logistic regression analysis showed that ΔE/SRE was a contributing factor for improvement in LVEF (odds ratio 126.9; p = 0.021). CONCLUSION: In persistent AF with preserved LVEF, further improvement in LVEF and reverse remodeling of the LA are achieved after RFCA. LV filling pressure may play significant roles in the mechanisms.

Observational Study of Infective Endocarditis at a Community-based Hospital: Dominance of Elderly Patients with Comorbidity.

Objective The purpose of this study was to present the recent clinical profiles and the real-world management of infective endocarditis (IE). Methods All medical records of patients with IE were reviewed retrospectively for their clinical data, including clinical presentation, laboratory results, blood cultures, echocardiographic findings, treatments and complications. Using the clinical data collected, we calculated the EuroSCORE II, the European risk score for adult cardiac surgery, the Charlson Comorbidity Index as a surrogate of comordibity, and the Katz Index as a surrogate of frailty. Results Thirty-eight patients were identified as having IE (24 men, age: 71.8±13.1 years). Congestive heart failure occurred in 16 patients (42%), stroke in 14 (50%), and systemic embolism in 5 (13%). The EuroSCORE II and Charlson Comorbidity Index were high (7.7±5.8% and 5.5±2.8%, respectively). The Katz Index was fair (5.5±1.4) before the onset but deteriorated to 2.8±2.7 at the time of establishing the diagnosis of IE (p<0.001). Early surgery was performed in 22 cases (61%). In-hospital death occurred in 10 cases (26%). A EuroSCORE II ≥9%, Staphylococcus aureus etiology, and a Charlson Comorbidity Index were suggested as determinants of in-hospital death (hazard ratios: 173.60, 9.31, 1.57, respectively). In contrast, early surgery was suggested as a determinant of the survival (hazard ratio: 0.04). The Charlson Comorbidity Index was also suggested as a determinant for selecting conservative management (odds ratio: 1.40). Conclusion Comorbidity may influence the treatment selection and outcome of elderly patients with IE.

The impact of left ventricular deformation and dyssynchrony on improvement of left ventricular ejection fraction following radiofrequency catheter ablation in Wolff-Parkinson-White syndrome: A comprehensive study by speckle tracking echocardiography.

PURPOSE: The purpose of this study was to evaluate left ventricular (LV) deformation and LV dyssynchrony in patients with Wolff-Parkinson-White (WPW) syndrome and to identify the factors that affect the efficacy of radiofrequency catheter ablation (RFCA). METHODS: Thirty patients (26 men, mean age 40 ± 12 years) with WPW syndrome were prospectively recruited for this study. They underwent 2-dimensional transthoracic echocardiography with speckle tracking analysis before RFCA and again within 48 hours after RFCA. Control group consisted of 15 age and sex-matched healthy volunteers. RESULTS: The patients had significantly lower LV ejection fraction (LVEF), global longitudinal strain (Sl ), and global circumferential strain (Sc ) compared with healthy controls (64% ± 8% vs 68% ± 5%, P = .049; -17.6% ± 3.2% vs -19.9% ± 3.3%, P = .037, -15.2% ± 2.5% vs -19.4% ± 2.5%, P < .0001, respectively). Patients had a significantly higher dyssynchrony index relative to healthy controls (58.4 ± 49.0 ms vs 36.4 ± 31.1 ms, P = .031). After RFCA, there was a significant increase in LVEF and global Sc (68% ± 8% vs 64% ± 8%, P = .005; -17.3% ± 2.0% vs -15.2% ± 2.5%, P < .0001, respectively), along with a significant decrease in the dyssynchrony index (36.9 ± 36.3 ms vs 58.4 ± ms, P < .001) relative to the baseline values. Logistic regression revealed that the baseline dyssynchrony index was a predictor of LVEF improvement after RFCA (odds ratio: 1.060, P = .038). CONCLUSION: In WPW syndrome, impaired LV circumferential deformation can be restored by RFCA with concomitant improvement in LV dyssynchrony and LVEF.

Systolic collapse of aortic composite graft after Bentall operation: A sign of pseudoaneurysm formation.

Although aortic root replacement using a composite graft including the Bentall operation is the treatment of choice for a diseased aortic valve and root dilatation, composite graft endocarditis can occur as a life-threatening complication with a high mortality rate. When aortic pseudoaneurysm occurs due to composite graft endocarditis, it usually indicates that saccular bulging of the surrounding tissue of the composite graft is present. Furthermore, another sign and a clue of the diagnosis of pseudoaneurysm is the collapse of the composite graft due to the outer compression pressure of the leaking blood flow. Additionally, right parasternal view is useful to get the clear images of this phenomenon. Echocardiographic evaluation will contribute to the early recognition of this highly critical pathology.