Replacement Myocardial Fibrosis in Patients With Mitral Valve Prolapse: Relation to Mitral Regurgitation, Ventricular Remodeling, and Arrhythmia.

BACKGROUND: Mitral valve prolapse (MVP) is a frequent disease that can be complicated by mitral regurgitation (MR), heart failure, arterial embolism, rhythm disorders, and death. Left ventricular (LV) replacement myocardial fibrosis, a marker of maladaptive remodeling, has been described in patients with MVP, but the implications of this finding remain scarcely explored. We aimed at assessing the prevalence, pathophysiological and prognostic significance of LV replacement myocardial fibrosis through late gadolinium enhancement (LGE) by cardiac magnetic resonance in patients with MVP. METHODS: Four hundred patients (53±15 years of age, 55% male) with MVP (trace to severe MR by echocardiography) from 2 centers, who underwent a comprehensive echocardiography and LGE cardiac magnetic resonance, were included. Correlates of replacement myocardial fibrosis (LGE+), influence of MR degree, and ventricular arrhythmia were assessed. The primary outcome was a composite of cardiovascular events (cardiac death, heart failure, new-onset atrial fibrillation, arterial embolism, and life-threatening ventricular arrhythmia). RESULTS: Replacement myocardial fibrosis (LGE+) was observed in 110 patients (28%; 91 with myocardial wall including 71 with basal inferolateral wall, 29 with papillary muscle). LGE+ prevalence was 13% in trace-mild MR, 28% in moderate MR, and 37% in severe MR, and was associated with specific features of mitral valve apparatus, more dilated LV and more frequent ventricular arrhythmias (45% versus 26%, P<0.0001). In trace-mild MR, despite the absence of significant volume overload, abnormal LV dilatation was observed in 16% of patients and ventricular arrhythmia in 25%. Correlates of LGE+ in multivariable analysis were LV mass (odds ratio, 1.01 [95% CI, 1.002-1.017], P=0.009) and moderate-severe MR (odds ratio, 2.28 [95% CI, 1.21-4.31], P=0.011). LGE+ was associated with worse 4-year cardiovascular event-free survival (49.6±11.7 in LGE+ versus 73.3±6.5% in LGE-, P<0.0001). In a stepwise multivariable Cox model, MR volume and LGE+ (hazard ratio, 2.6 [1.4-4.9], P=0.002) were associated with poor outcome. CONCLUSIONS: LV replacement myocardial fibrosis is frequent in patients with MVP; is associated with mitral valve apparatus alteration, more dilated LV, MR grade, and ventricular arrhythmia; and is independently associated with cardiovascular events. These findings suggest an MVP-related myocardial disease. Last, cardiac magnetic resonance provides additional information to echocardiography in MVP.

Machine Learning-Based Phenogrouping in MVP Identifies Profiles Associated With Myocardial Fibrosis and Cardiovascular Events.

BACKGROUND: Structural changes and myocardial fibrosis quantification by cardiac imaging have become increasingly important to predict cardiovascular events in patients with mitral valve prolapse (MVP). In this setting, it is likely that an unsupervised approach using machine learning may improve their risk assessment. OBJECTIVES: This study used machine learning to improve the risk assessment of patients with MVP by identifying echocardiographic phenotypes and their respective association with myocardial fibrosis and prognosis. METHODS: Clusters were constructed using echocardiographic variables in a bicentric cohort of patients with MVP (n = 429, age 54 ± 15 years) and subsequently investigated for their association with myocardial fibrosis (assessed by cardiac magnetic resonance) and cardiovascular outcomes. RESULTS: Mitral regurgitation (MR) was severe in 195 (45%) patients. Four clusters were identified: cluster 1 comprised no remodeling with mainly mild MR, cluster 2 was a transitional cluster, cluster 3 included significant left ventricular (LV) and left atrial (LA) remodeling with severe MR, and cluster 4 included remodeling with a drop in LV systolic strain. Clusters 3 and 4 featured more myocardial fibrosis than clusters 1 and 2 (P < 0.0001) and were associated with higher rates of cardiovascular events. Cluster analysis significantly improved diagnostic accuracy over conventional analysis. The decision tree identified the severity of MR along with LV systolic strain <21% and indexed LA volume >42 mL/m2 as the 3 most relevant variables to correctly classify participants into 1 of the echocardiographic profiles. CONCLUSIONS: Clustering enabled the identification of 4 clusters with distinct echocardiographic LV and LA remodeling profiles associated with myocardial fibrosis and clinical outcomes. Our findings suggest that a simple algorithm based on only 3 key variables (severity of MR, LV systolic strain, and indexed LA volume) may help risk stratification and decision making in patients with MVP. (Genetic and Phenotypic Characteristics of Mitral Valve Prolapse, NCT03884426; Myocardial Characterization of Arrhythmogenic Mitral Valve Prolapse [MVP STAMP], NCT02879825).

Does Clot Burden Score on Baseline T2*-MRI Impact Clinical Outcome in Acute Ischemic Stroke Treated with Mechanical Thrombectomy?

BACKGROUND AND PURPOSE: A long clot, defined by a low (0-6) clot burden score (CBS) assessed by T2*-MR sequence, is associated with worse clinical outcome after intravenous thrombolysis (IVT) for acute ischemic stroke than is a small clot (CBS, 7-10). The added benefit of mechanical thrombectomy (MT) might be higher in patients with long clot. The aim of this pre-specified post hoc analysis of the THRombectomie des Artères CErebrales (THRACE) trial was to assess the association between T2*-CBS, successful recanalization and clinical outcome. METHODS: Of 414 patients randomized in the THRACE trial, 281 patients were included in this analysis. Associations between T2*-CBS and clinical outcome on the modified Rankin Scale (mRS) at 3 months were tested. RESULTS: High T2*-CBS, i.e., small clot, was associated with a shift toward better outcome on the mRS; proportional odds ratio (POR) per point CBS was 1.19 (95% confidence interval [CI], 1.05 to 1.34) in the whole population, 1.34 (95% CI, 1.13 to 1.59) in IVT group, and 1.04 (95% CI, 0.87 to 1.23) in IVTMT group. After adjustment for baseline prognostic variables, the effect of the full scale T2*-CBS was not statistically significant in the whole population and for the IVTMT group but remains significant for the IVT group (POR, 1.32; 95% CI, 1.11 to 1.58). CONCLUSION: s A small clot, as assessed using T2*-CBS, is associated with improved outcome and may be used as a prognostic marker. Despite the worst outcome with long clot, the relative benefit of MT over IVT seemed to increase with low T2*-CBS and longer clot.

Memory Alterations and White Matter Hyperintensities in Elderly Patients With Hypertension: The ADELAHYDE-2 Study.

OBJECTIVES: The longitudinal ADELAHYDE-2 study aims to identify the factors associated with cognitive impairment/decline and white matter hyperintensities burden. METHODS: Longitudinal single-center study comprising two visits separated by approximately 7 years. A total of 131 patients completed the two visits. The primary outcome was global memory composite scale, while the secondary outcome was white matter hyperintensities (WMH/Fazekas scale) load. RESULTS: Global memory at visit 2 (V2) was largely influenced by age, smoking status, glycated hemoglobin, and history of stroke already present at visit 1 (V1). These variables accounted for ∼51% of the memory alterations at V2. WMH at V2 was likely influenced by age, left ventricular hypertrophy, diabetes mellitus, carotid intima-media thickness, and body mass index at V1. These findings accounted for ∼37% of the WMH changes at V2. Increase in pulse wave velocity from V1 to V2 showed a trend for association with memory deterioration (adjusted estimates = 0.06; P = .067), whereas smoking and increase in systolic blood pressure (trend) were associated with an increment in WMH (adjusted estimates = 0.49; P = .047 and adjusted estimates = 0.01; P = .08, respectively). On the other hand, angiotensin-converting enzyme inhibitor/angiotensin receptor blockers and statins (trend) were likely to be protective (adjusted estimates for angiotensin-converting enzyme inhibitor/angiotensin receptor blockers = -0.49; P = .049, and adjusted estimates for statins = -0.46; P = .055). CONCLUSIONS: Several readily identifiable factors are associated with memory deterioration and WMH, many of which are potentially modifiable. Interventions aimed to control these risk factors need to be tested prospectively in order to assess their cognitive protective value.

Is High Temporal Resolution Achievable for Paediatric Cardiac Acquisitions during Several Heart Beats? Illustration with Cardiac Phase Contrast Cine-MRI.

BACKGROUND: During paediatric cardiac Cine-MRI, data acquired during cycles of different lengths must be combined. Most of the time, Feinstein's model is used to project multiple cardiac cycles of variable lengths into a mean cycle. OBJECTIVE: To assess the effect of Feinstein projection on temporal resolution of Cine-MRI. METHODS: 1/The temporal errors during Feinstein's projection were computed in 306 cardiac cycles fully characterized by tissue Doppler imaging with 6-phase analysis (from a population of 7 children and young adults). 2/The effects of these temporal errors on tissue velocities were assessed by simulating typical tissue phase mapping acquisitions and reconstructions. 3/Myocardial velocities curves, extracted from high-resolution phase-contrast cine images, were compared for the 6 volunteers with lowest and highest heart rate variability, within a population of 36 young adults. RESULTS: 1/The mean of temporal misalignments was 30 ms over the cardiac cycle but reached 60 ms during early diastole. 2/During phase contrast MRI simulation, early diastole velocity peaks were diminished by 6.1 cm/s leading to virtual disappearance of isovolumic relaxation peaks. 3/The smoothing and erasing of isovolumic relaxation peaks was confirmed on tissue phase mapping velocity curves, between subjects with low and high heart rate variability (p = 0.05). CONCLUSIONS: Feinstein cardiac model creates temporal misalignments that impair high temporal resolution phase contrast cine imaging when beat-to-beat heart rate is changing.