Predicting mortality for patients with heart failure beyond oxygen consumption: a prognostic risk score.

Cardiopulmonary exercise test (CPET) is a crucial tool for the functional evaluation of cardiac patients. We hypothesized that maximal oxygen consumption (V̇o2max) and ventilatory efficiency-minute ventilation to carbon dioxide production (V̇e/V̇co2) slope are not the only parameters of CPET able to predict major cardiac events (mortality or cardiac transplantation urgently or elective). We aimed to identify the best CPET predictors of major cardiac events in patients with severe chronic heart failure and to propose an integrated score that could be applied for their prognostic evaluation. We evaluated 140 patients with chronic heart failure who underwent CPET between 2011 and 2019. Major cardiac events were evaluated during follow-up. Univariate and multivariate logistic regression analyses were applied to study the predictive value of different clinical, echocardiographic, and CPET parameters in relation to the major cardiac events. A score was generated, and c-statistic was used for the comparisons. Thirty-nine patients (27.9%) died or underwent cardiac transplantation over a median follow-up of 48 mo. Five parameters (maximal workload, breathing reserve, left ventricular ejection fraction, diastolic dysfunction, and nonidiopathic cardiomyopathy) were used to generate a risk score that had better risk discrimination than the New York Heart Association dyspnea scale, V̇o2max, V̇e/V̇co2 slope > 35 alone, and combined V̇o2max and V̇e/V̇co2 slope (P = 0.009, 0.004, <0.001, and 0.005, respectively) in predicting major cardiac events. A composite score of CPET and clinical/echocardiographic data is more reliable than the single use of V̇o2max or combined with V̇e/V̇co2 slope to predict major cardiac events.NEW & NOTEWORTHY This is a cohort study with a follow-up of maximum of 8 years of patients with chronic heart failure that demonstrates a simple integrated score consisting of CPET (breathing reserve, workload at maximal exercise), echocardiographic (LVEF, diastolic dysfunction), and clinical (etiology of cardiac disease) data. The generated score was a better predictor of major cardiac events (mortality or cardiac transplantation) than Weber classification (V̇o2max classification) or NYHA functional class as single factors.

Impact of Sacubitril-Valsartan Treatment on Diastolic Function in Patients with Heart Failure and Reduced Ejection Fraction.

INTRODUCTION: Sacubitril/valsartan (S-V) has been shown to reduce clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). This benefit has been mostly attributed to an improvement in systolic function. AIM: This study aimed to evaluate longitudinal changes in several echocardiographic parameters of diastolic function in a cohort of patients with HFrEF receiving S-V. METHODS: Echocardiographic parameters of consecutive patients receiving S-V, such as diastolic dysfunction (DD) grade and other individual diastolic and systolic function parameters, were prospectively collected at baseline and at 6-month follow-up. New York Heart Association (NYHA) functional class was also recorded. RESULTS: 65 patients (73.9% males; 61.5 ± 13 years) with HFrEF in NYHA class II-IV were evaluated. There was a significant reduction in DD grade after treatment with maximal tolerated doses (p < 0.001). Patients with advanced DD showed the most significant improvements: 75% and 60% of patients with initial grade 3 and 2, respectively, had better grade after 6 months of S-V. Moreover, there was a reduction in E/e' ratio (p = 0.004), left atrial longitudinal strain (p = 0.002), and an improvement of left ventricle ejection fraction (p < 0.001) and NYHA functional class (p = 0.001). Among those subjects who improved their functional class, a higher percentage improved their DD grade (39.3%, p = 0.025) in comparison with those not improving their NYHA class (25%, p = 0.434). CONCLUSIONS: In addition to an improvement in systolic function parameters, patients with HFrEF receiving S-V improved their diastolic function. This echocardiographic improvement is particularly relevant in those patients with better NYHA class at 6-month follow-up.

Aortic coarctation endarteritis: The importance of a systematic echocardiographic study.

Aortic coarctation determines a favorable anatomical condition for the development of endocarditis-endarteritis due to the presence of an alteration in blood flow dynamics that favors the appearance of endothelial damage and the adhesion of microorganisms. At present, endarteritis of aortic coarctation is a rare entity due to early detection and surgical treatment of patient carriers of aortic coarctation. We present a case of a patient affected with a previously unknown aortic coarctation, who developed infective endarteritis with secondary formation of mycotic aneurysm. The echocardiography techniques proved determinant in establishing the diagnosis of aortic coarctation, as well as the associated infectious complications. .

Changes in the severity of aortic regurgitation at peak effort during exercise.

BACKGROUND: Chronic aortic regurgitation can be well tolerated for a long time. Some patients with normal ventricular function can even reach high levels of sporting performance. How the severity of regurgitation may change during exercise, however, is little known, although some studies suggest it diminishes. The present work examines, during exercise, the functional capacity, ventricular function, and regurgitation fraction (RF) in asymptomatic subjects with moderate or severe aortic regurgitation with preserved ejection fraction. METHODS: The study subjects (n=32; 23 men, 9 women) were patients referred to our echocardiography laboratory with moderate or severe aortic regurgitation, preserved left ventricular systolic function, and sinus rhythm into NYHA functional class I. All underwent transthoracic echocardiography at rest and at peak effort during an exercise protocol involving an inclined cycloergometer. Left atrial and ventricular volume indices were recorded, along with diastolic and systolic function, cardiac index, peripheral resistance, and RF. RESULTS: The mean age of the subjects was 43.8±18.2years; 59% suffered moderate regurgitation, 41% severe aortic regurgitation, and 84% had a dilated left ventricle. All subjects managed exercise loads adequate for their age. Peak effort was associated with a significant reduction (mean 44.5% [range 10-95%]) in the RF (21.8±13.2 vs. 39.3%±14.7% at rest; p=0.0001). The absolute reduction in the RF at peak effort was greater among the subjects with severe aortic regurgitation (21.2% vs. 13.3% in those with moderate regurgitation; p=0.018). CONCLUSIONS: The RF becomes smaller during exercise in asymptomatic subjects with moderate or severe aortic regurgitation and preserved ventricular function.

Real-time three-dimensional transesophageal echocardiographic imaging of cor triatriatum and persistent left superior vena cava.

The authors describe the case of a 54-year-old woman with the association of two rare congenital cardiac anomalies: cor triatriatum and persistent left superior vena cava with the special characteristic of direct drainage to the right atrium. Real-time three-dimensional transesophageal echocardiography offered a comprehensive anatomic and functional evaluation of these infrequent entities.