Resting echocardiographic parameters to detect patients with less symptomatic primary mitral regurgitation who require exercise stress echocardiography.

Objectives: We aimed to identify which resting echocardiographic parameters can detect asymptomatic or mildly symptomatic patients with primary mitral regurgitation (MR) who require exercise stress echocardiography (ESE) to determine their suitability for surgery. Methods: We examined 56 consecutive patients with primary moderate/severe MR who underwent ergometer-based ESE. Patients who met the surgical indications at rest were excluded. Eligible patients were divided into Group I (pulmonary artery systolic pressure [PASP] during exercise >60 mmHg; n=11) and Group II (PASP during exercise ≤60 mmHg; n=30). Results: Forty-one patients were included. Group I was significantly older (65±12 vs. 54±14 years, P=0.042) and had significantly higher serum N-terminal pro-B-type natriuretic peptide concentrations than Group II (351±278 vs. 125±163 pg/mL, P=0.002). The univariate analysis demonstrated that peak E wave velocity (Group I vs. Group II: 125±45 vs. 101±24 cm/sec, P=0.050), left ventricular (LV) end-diastolic diameter index (32±4 vs. 30±3 mm/m2, P=0.035), and left atrial volume index (LAVI; 45±14 vs. 30±11 mL/m2, P=0.008) were predictors of increased PASP during exercise. In the multivariate analysis, resting LAVI best predicted exercise-induced pulmonary hypertension (hazard ratio 1.081 [95% confidence interval 1.009-1.158], P=0.028), with a cutoff value of 37 mL/m2. Conclusions: In asymptomatic or mildly symptomatic patients with primary moderate/severe MR, increased resting LAVI indicates the requirement for ESE, even without LV dilatation.

Association of resting left ventricular global longitudinal strain with myocardial perfusion abnormalities evaluated by 13 N-ammonia positron emission tomography in patients with stable angina pectoris and normal left ventricular ejection fraction.

AIMS: Little is known about whether resting left ventricular global longitudinal strain (GLS) impairment is associated with myocardial perfusion abnormalities evaluated using 13 N-ammonia positron emission tomography (13 N-NH3 -PET)-myocardial perfusion imaging (MPI). This study aimed to investigate the correlation between resting GLS and myocardial perfusion parameters in patients with a normal left ventricular ejection fraction (LVEF). We evaluated whether resting GLS can predict myocardial perfusion abnormalities in these patients. METHODS AND RESULTS: We selected 157 patients with suspected stable angina pectoris who underwent both ATP-stress NH3 -PET-MPI and 2-dimentional speckle tracing echocardiography. All subjects had a preserved LVEF and no known history of myocardial infarction. Patients were stratified into Group N (normal perfusion; summed stress score [SSS], 0-3; n = 101), Group M (mildly to moderately abnormal perfusion; SSS, 4-11; n = 41), or Group S (severely abnormal perfusion; SSS, 12+; n = 15). GLS was more impaired as myocardial perfusion abnormality severity increased (-17.9 ± 2.9% for Group N, -16.8 ± 3.1% for Group M, and -14.2 ± 3.5% for Group S; p < .001). GLS was weakly but significantly correlated with SSS (R = .32, p < .001), summed difference score (R = .32, p < .001), and myocardial blood flow during stress (R = -0.27, p < .001). Multivariate logistic regression analysis showed that male sex, diabetes mellitus, systolic blood pressure, and GLS were independent predictors of myocardial perfusion abnormality defined as Groups M and S. Additionally, the area under the curve for GLS for detecting myocardial perfusion abnormality was .65, and the optimal cutoff value for GLS was -16.5%, with sensitivity and specificity of 59% and 66%, respectively. CONCLUSION: In patients with suspected angina pectoris, resting GLS impairment despite a normal LVEF might aid the detection of hemodynamically significant coronary artery disease.

Age-related etiologies of aortic regurgitation with moderate or greater severity and coronary cusp bending: evaluation using transesophageal echocardiography.

PURPOSE: The prevalence of valvular heart disease has been rising, especially among those ≥ 65 years of age, because of age-related valvular degeneration resulting in an increase in the number of patients diagnosed with aortic regurgitation (AR). We analyzed transesophageal echocardiography (TEE) images in AR patients to identify the etiologies and investigate any differences in them according to age. METHODS: We studied 146 consecutive patients with chronic moderate or severe AR who underwent TEE. AR etiology was evaluated based on the TEE images in all the patients, as well as in each group separated by age. RESULTS: The total number of patients eligible was 126 (mean age 67 ± 12 years), consisting of an older group (n = 85, mean age 74 ± 5 years) and younger group (n = 41, mean age 52 ± 11 years). In total, the most common etiology of AR was cusp bending (33.0%). In the older group, it was the most frequent as well (48.2%), with the right coronary cusp being the most commonly affected site (90.2%). In the younger group, bicuspid aortic valve was the most common (36.5%). Subsequently, all the study subjects were re-classified into two groups according to the presence/absence of cusp bending. Multivariate analysis revealed that age was the only factor associated with cusp bending. CONCLUSION: Cusp bending was the most frequent etiology of AR in the elderly. Preoperative detection of cusp bending by TEE would expand the therapeutic strategy for AR, including aortic valvuloplasty.

Prognostic significance of oscillatory ventilation at rest in patients with advanced heart failure undergoing cardiopulmonary exercise testing.

BACKGROUND: Among heart failure patients diagnosed as having exertional oscillatory ventilation (OV), some present with OV at rest that persists during exercise, and others develop OV only after the onset of exercise during cardiopulmonary exercise (CPX) testing. We tested whether or not there was any difference in the prognostic significance between the two abnormal breathing patterns. METHODS: Patients with New York Heart Association class III-heart failure were categorized into the following 3 groups according to their ventilation pattern during the CPX: patients with an OV pattern at rest that persisted for ≥60% of the exercise test at an amplitude of ≥15% of the average resting value (group 1), patients with the same abnormal ventilatory pattern as group 1 that was observed only during exercise (group 2), and patients without any OV (group 3). The patients were followed-up for at least 2 years to assess the composite outcome of cardiac death or hospitalization for worsening heart failure. RESULTS: The occurrence of the composite outcome differed significantly across the groups with its highest occurrence in group 1 (21/29 [72.4%], 15/38 [39.5%] and 48/167 [28.7%]; log-rank P < 0.001). In multivariate hazard analyses, an N-terminal pro-brain natriuretic peptide of >900 pg/mL (hazard ratio [HR] = 1.72, P = 0.04), and group 1 (HR 2.03, P = 0.02) were independently associated with the composite outcome. CONCLUSIONS: Checking for the resting OV prior to incremental exercise during CPX testing may be helpful in risk-stratification among subjects with advanced heart failure.

Evaluation of end-tidal CO2 pressure at the anaerobic threshold for detecting and assessing pulmonary hypertension.

Cardiopulmonary exercise testing (CPET) is useful for the evaluation of patients with suspected or confirmed pulmonary hypertension (PH). End-tidal carbon dioxide pressure (PETCO2) during exercise is reduced with elevated pulmonary artery pressure. However, the utility of ventilatory parameters such as CPET for detecting PH remains unclear. We conducted a review in 155 patients who underwent right heart catheterization and CPET. Fifty-nine patients had PH [mean pulmonary arterial pressure (mPAP) ≥25 mmHg]. There was an inverse correlation between PETCO2 at the anaerobic threshold (AT) and mPAP (r = -0.66; P < 0.01). Multiple regression analysis showed that PETCO2 at the AT was independently associated with an elevated mPAP (P = 0.04). The sensitivity and specificity of CPET for PH were 80 and 86%, respectively, when the cut-off value identified by receiver operating characteristic curve analysis for PETCO2 at the AT was ≤34.7 mmHg. A combination of echocardiography and CPET improved the sensitivity in detecting PH without markedly reducing specificity (sensitivity 87%, specificity 85%). Evaluation of PETCO2 at the AT is useful for estimating pulmonary pressure. A combination of CPET and previous screening algorithms for PH may enhance the diagnostic ability of PH.

Prognostic Factors for Survival in Pulmonary Hypertension Due to Left Heart Disease.

BACKGROUND: The epidemiological data of pulmonary hypertension (PH) due to left heart disease (LHD) are limited. This study investigated hemodynamic and clinical factors associated with mortality in patients with PH due to LHD. METHODS AND RESULTS: We conducted a retrospective review in 243 patients with PH due to LHD, defined as mean pulmonary arterial pressure ≥25 mmHg and pulmonary wedge pressure >15 mmHg at rest in right heart catheterization. Kaplan-Meier and Cox proportional hazard regression analyses were performed. Seventy-five patients died during an average follow-up of 52 months (range, 20-73 months). On multivariate analysis, only diastolic pulmonary vascular pressure gradient (DPG) ≥7 mmHg among hemodynamic measurements was a predictor of mortality. Elevated N-terminal pro-brain natriuretic peptide (NT-pro BNP), more severe New York Heart Association (NYHA) class, anemia, and renal dysfunction were more strongly associated with mortality. Mean right atrial pressure (RAP) and currently available markers of pulmonary vascular remodeling including transpulmonary pressure gradient (TPG) and pulmonary vascular resistance (PVR) had no effect on survival. CONCLUSIONS: DPG is weakly associated with mortality in PH due to LHD. Clinical factors such as NT-pro BNP, NYHA class, anemia and renal dysfunction are superior predictors. The prognostic ability of hemodynamic factors such as mean RAP, TPG, PVR and DPG is limited.

Clinical value of regression of electrocardiographic left ventricular hypertrophy after aortic valve replacement.

Electrocardiographic left ventricular hypertrophy (ECG-LVH) gradually regressed after aortic valve replacement (AVR) in patients with severe aortic stenosis. Sokolow-Lyon voltage (SV1 + RV5/6) is possibly the most widely used criterion for ECG-LVH. The aim of this study was to determine whether decrease in Sokolow-Lyon voltage reflects left ventricular reverse remodeling detected by echocardiography after AVR. Of 129 consecutive patients who underwent AVR for severe aortic stenosis, 38 patients with preoperative ECG-LVH, defined by SV1 + RV5/6 of ≥3.5 mV, were enrolled in this study. Electrocardiography and echocardiography were performed preoperatively and 1 year postoperatively. The patients were divided into ECG-LVH regression group (n = 19) and non-regression group (n = 19) according to the median value of the absolute regression in SV1 + RV5/6. Multivariate logistic regression analysis was performed to assess determinants of ECG-LVH regression among echocardiographic indices. ECG-LVH regression group showed significantly greater decrease in left ventricular mass index and left ventricular dimensions than Non-regression group. ECG-LVH regression was independently determined by decrease in the left ventricular mass index [odds ratio (OR) 1.28, 95 % confidence interval (CI) 1.03-1.69, p = 0.048], left ventricular end-diastolic dimension (OR 1.18, 95 % CI 1.03-1.41, p = 0.014), and left ventricular end-systolic dimension (OR 1.24, 95 % CI 1.06-1.52, p = 0.0047). ECG-LVH regression could be a marker of the effect of AVR on both reducing the left ventricular mass index and left ventricular dimensions. The effect of AVR on reverse remodeling can be estimated, at least in part, by regression of ECG-LVH.