Extensive intra-myocardial calcifications: Value of multimodality imaging.

BACKGROUND: Massive myocardial calcification is a very rare finding. INTRODUCTION: Accurate identification and characteriation may help the clinicians to determine the etiology and clinical significance. RESULTS: In this case, the diagnostic pathway excluded previous myocardial infarction, myocarditis, and calcium-phosphate disorders. A possible dystrophic etiology was considered. DISCUSSION: There are no standardized imaging features available to classify specific subtypes of intra-myocardial calcifications. The relative merits of computed tomography and cardiac magnetic resonance (CMR) in providing complimentary diagnostic information in the evaluation of calcific myocardial lesions are shown. CONCLUSION: Knowledge of the potential etiology and their imging patterns are important to provide a concise and accurate differential diagnosis.

Echocardiographic characteristics of non-resectional ring-only valve repair in mitral valve prolapse.

BACKGROUND: Simple mitral valve repair (MVR) using a ring-only approach (ROA) was recently proposed for some complex forms of bileaflet myxomatous mitral valve prolapse (MVP). Nevertheless, few data are available concerning the characteristics of MVP patients that may benefit from this simple repair technique. METHODS: Based on 39 consecutive patients (28 men; mean age 57 ± 15) with severe primary Mitral regurgitation (MR) caused by bileaflet MVP referred for MVR, we sought to identify the preoperative echocardiographic parameters associated with successful ROA repair. RESULTS: Twenty-three patients (59%) underwent standard resectional MVR (SMVR) while 16 (41%) underwent ROA. Cardiopulmonary bypass and cross clamp times were lower in ROA than in SMVR (74 ± 27 min vs 99 ± 42 min and 49 ± 19 min vs 70 ± 25 min, respectively, p = 0.03 and p = 0.005). ROA patients were more frequently women (50% vs 13%, p = 0.027). Echocardiographic characteristics of successful ROA were mid-late systolic MR, a paradoxical systolic papillary muscle displacement, and paradoxical systolic annulus expansion (PAE). A prolapsing depth <10 mm, the absence of flail leaflet and ruptured chordae, the presence of multiple jets, more often in the central part of the valve were also associated with ROA. Non hemodynamic systolic anterior motion and residual trivial MR tended to be more frequent in ROA than in SMVR. CONCLUSION: Simple and fast MVR using a ROA is feasible in 4/10 patients with complex forms of bileaflet MVP. Successful ROA patients were more frequently women, with mid-late systolic central multiple jet, low prolapse depth, absence of chordal rupture or flail leaflet and PAE.

Performance of a new fully automated transthoracic three-dimensional echocardiographic software for quantification of left cardiac chamber size and function: Comparison with 3 Tesla cardiac magnetic resonance.

PURPOSE: To evaluate the accuracy and reproducibility of a new fully automated fast three-dimensional (3D) transthoracic echocardiography (TTE) software for the simultaneous assessment of left atrial (LA) volumes and LA ejection fraction (EF), left ventricular (LV) volumes, LV mass, and LVEF, and to compare the results obtained with a cardiac magnetic resonance (CMR) reference. METHODS: We included retrospectively 56 patients (46 men; mean age 63 ± 13 years) in sinus rhythm who had had comprehensive 3D TTE and CMR examinations within 24 hours. RESULTS: Despite a slight underestimation of LV and LA volumes, LVEF and LAEF were similar using CMR or 3DTTE (58% ± 16% vs 58% ± 12%; P = .65 and 45% ± 14% vs 46% ± 15%; P = .38, respectively) in the total population. Despite significant correlation between TTE and CMR measurements (r = 0.78; P < .001), 3D TTE underestimated LV mass (bias = -27 ± 35 g). CONCLUSION: 3D TTE using a new-generation fully automated software is a fast and reproducible imaging modality for simultaneous extensive quantification of left heart chambers size and function in routine practice. Potential underestimation of LA volume and LV mass, and of LVEF in patients with LVEF <50%, should be taken into consideration.

Assessment of left ventricular size and function by 3-dimensional transthoracic echocardiography: Impact of the echocardiography platform and analysis software.

BACKGROUND: Whether echocardiography platform and analysis software impact left ventricular (LV) volumes, ejection fraction (EF), and stroke volume (SV) by transthoracic tridimensional echocardiography (3DE) has not yet been assessed. Hence, our aim was to compare 3DE LV end-diastolic and end-systolic volumes (EDV and ESV), LVEF, and SV obtained with echocardiography platform from 2 different manufacturers. METHODS: 3DE was performed in 84 patients (65% of screened consecutive patients), with equipment from 2 different manufacturers, with subsequent off-line postprocessing to obtain parameters of LV function and size (Philips QLAB 3DQ and General Electric EchoPAC 4D autoLVQ). Twenty-five patients with clinical indication for cardiac magnetic resonance imaging served as a validation subgroup. RESULTS: LVEDV and LVESV from 2 vendors were highly correlated (r = 0.93), but compared with 4D autoLVQ, the use of Qlab 3DQ resulted in lower LVEDV and LVESV (bias: 11 mL, limits of agreement: -25 to +47 and bias: 6 mL, limits of agreement: -22 to +34, respectively). The agreement between LVEF values of each software was poor (intraclass correlation coefficient 0.62) despite no or minimal bias. SVs were also lower with Qlab 3DQ advanced compared with 4D autoLVQ, and both were poorly correlated (r = 0.66). Consistently, the underestimation of LVEDV, LVESV, and SV by 3DE compared with cardiac magnetic resonance imaging was more pronounced with Philips QLAB 3DQ advanced than with 4D autoLVQ. CONCLUSIONS: The echocardiography platform and analysis software significantly affect the values of LV parameters obtained by 3DE. Intervendor standardization and improvements in 3DE modalities are needed to broaden the use of LV parameters obtained by 3DE in clinical practice.

The gray zone of the qualitative assessment of respiratory changes in inferior vena cava diameter in ICU patients.

INTRODUCTION: Transthoracic echocardiography (TTE) is a useful tool for minimally invasive hemodynamic monitoring in the ICU. Dynamic indices (such as the inferior vena cava distensibility index (dIVC)) can be used to predict fluid responsiveness in mechanically ventilated patients. Although quantitative use of the dIVC has been validated, the routinely used qualitative (visual) approach had not been assessed before the present study. METHODS: Qualitative and quantitative assessments of the dIVC were compared in a prospective, observational study. After operators with differing levels in critical care echocardiography had derived a qualitative dIVC, the last (expert) operator performed a standard, numeric measurement of the dIVC (referred to as the quantitative dIVC). Two groups of patients were separated into two groups: group (dIVC < 18%) and group (dIVC ≥ 18%). RESULTS: In total, 114 patients were assessed for inclusion, and 97 (63 men and 34 women) were included. The mean sensitivity and specificity values for qualitative assessment of the dIVC by an intensivist were 80.7% and 93.7%, respectively. A qualitative evaluation detected all quantitative dIVCs >40%. Most of the errors concerned quantitative dIVCs of between 15% and 30%. In the dIVC <18% group, two qualitative evaluation errors were noted for quantitative dIVCs of between 0 and 10%. The average of positive predictive values and negative predictive values for qualitative assessment of the dIVC by residents, intensivists and cardiologists were 83%, 83%, and 90%; and 92%, 94%, and 90%, respectively. The Fleiss kappa for all operators was estimated to be 0.68, corresponding to substantial agreement. CONCLUSION: The qualitative dIVC is a rather easy and reliable assessment for extreme numeric values. It has a gray zone between 15% and 30%. The highest and lowest limitations of the gray area are rather tedious to define. Despite reliability of the qualitative assessment when it comes to extreme to numerical values, the quantitative dIVC measurement must always be done within a hemodynamic assessment for intensive care patients. The qualitative approach can be easily integrated into a fast hemodynamic evaluation by using portable ultrasound scanner for out-of-hospital patients.

Impact of Sex on Severity Assessment and Cardiac Remodeling in Primary Mitral Regurgitation.

Background: Women with severe primary mitral regurgitation (MR) have lower surgery rates than men and could suffer from delayed referral for mitral valve (MV) intervention, exposing them to an increased risk of postoperative adverse outcomes. Objectives: The purpose of this study was to assess the sex-based differences in patients with primary MR. Methods: The study sample consisted of 420 patients (median age: 62 years, 26% women) with primary MR due to valve prolapse referred for preoperative assessment who underwent transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) imaging. Multiple endpoints (abnormally increased left ventricular size, NYHA functional class III/IV, severe left atrial [LA] dilatation, pulmonary hypertension) were studied using areas under the curves and logistic regression models. Results: Women were older than men, had higher NYHA functional class and larger indexed LA volumes (all P ≤ 0.031), despite displaying lower MR effective regurgitant orifice area, regurgitant volumes (RegVol), and ventricular volumes than men (all P ≤ 0.002). The optimal cut-off values of RegVol associated with abnormally increased left ventricular size according to reference normal values were lower in women (TTE: 67 ml, CMR: 50 ml) than in men (TTE: 77 ml, CMR: 65 ml). MR regurgitant fraction, but not RegVol, was associated in women and men with NYHA functional class III/IV, severe LA dilatation, and pulmonary hypertension (all areas under the curves, P ≤ 0.024). Conclusions: Despite having hallmarks of more advanced valvular heart disease, women with significant primary MR demonstrate lower mitral RegVol and ventricular volumes than men. In contrast, the systematic calculation of MR regurgitant fraction could standardize MR quantification irrespective of sex.

Computed Simulation of Transcatheter Edge-to-Edge Mitral Valve Repair - A Proof of Concept Study.

AIMS: As transcatheter mitral valve (MV) interventions are expanding and more device types and sizes become available, a tool supporting operators in preprocedural planning and the clinical decision-making process is highly desirable. We sought to develop a finite element (FE) computational simulation model to predict results of transcatheter edge-to-edge (TEER) interventions. METHODS AND RESULTS: We prospectively enrolled patients with secondary mitral regurgitation (MR) referred for a clinically indicated TEER. Three-dimensional (3D) transesophageal echocardiograms performed at the beginning of the procedure were used to perform the simulation. On the 3D dynamic model of the MV that was first obtained, we simulated the clip implantation using the same clip(s) type, size, number, and implantation location that was used during the intervention. The 3D model of the MV obtained after simulation of the clip implantation was compared to the clinical results obtained at the end of the intervention. We analyzed the degree and location of residual MR and the shape and area of the diastolic mitral valve area. We performed computational simulation on 5 patients. Overall, the simulated models predicted well the degree and location of the residual regurgitant orifice(s) but tended to underestimate the diastolic mitral orifice area. CONCLUSIONS: In this proof-of-concept study, we present preliminary results on our algorithm simulating clip implantation in 5 patients with functional MR. We show promising results regarding the feasibility and accuracy in terms of predicting residual MR and the need to improve the estimation of the diastolic mitral valve area.

Is there a role for cardiovascular magnetic resonance imaging in the assessment of biological aortic valves?

Patients with biological aortic valves (following either surgical aortic valve replacement [SAVR] or trans catheter aortic valve implantation [TAVI]) require lifelong follow-up with an imaging modality to assess prosthetic valve function and dysfunction. Echocardiography is currently the first-line imaging modality to assess biological aortic valves. In this review, we discuss the potential role of cardiac magnetic resonance imaging (CMR) as an additional imaging modality in situations of inconclusive or equivocal echocardiography. Planimetry of the prosthetic orifice can theoretically be measured, as well as the effective orifice area, with potential limitations, such as CMR valve-related artefacts and calcifications in degenerated prostheses. The true benefit of CMR is its ability to accurately quantify aortic regurgitation (paravalvular and intra-valvular) with a direct and reproducible method independent of regurgitant jet morphology to accurately assess reverse remodelling and non-invasively detect focal and interstitial diffuse myocardial fibrosis. Following SAVR or TAVI for aortic stenosis, interstitial diffuse fibrosis can regress, accompanied by structural and functional improvement that CMR can accurately assess.

The evolving role of cardiovascular magnetic resonance in the assessment of mitral valve prolapse.

Mitral valve prolapse (MVP), characterized by a displacement > 2 mm above the mitral annulus of one or both bileaflets, with or without leaflet thickening, is a common valvular heart disease, with a prevalence of approximately 2% in western countries. Although this population has a generally good overall prognosis, MVP can be associated with mitral regurgitation (MR), left ventricular (LV) remodeling leading to heart failure, ventricular arrhythmia, and, the most devastating complication, sudden cardiac death, especially in myxomatous bileaflet prolapse (Barlow's disease). Among several prognostic factors reported in the literature, LV fibrosis and mitral annular disjunction may act as an arrhythmogenic substrate in this population. Cardiac magnetic resonance (CMR) has emerged as a reliable tool for assessing MVP, MR severity, LV remodeling, and fibrosis. Indeed, CMR is the gold standard imaging modality to assess ventricular volume, function, and wall motion abnormalities; it allows accurate calculation of the regurgitant volume and regurgitant fraction in MR using a combination of LV volumetric measurement and aortic flow quantification, independent of regurgitant jet morphology and valid in cases of multiple valvulopathies. Moreover, CMR is a unique imaging modality that can assess non-invasively focal and diffuse fibrosis using late gadolinium enhancement sequences and, more recently, T1 mapping. This review describes the use of CMR in patients with MVP and its role in identifying patients at high risk of ventricular arrhythmia.

Quantification of primary mitral regurgitation by echocardiography: A practical appraisal.

The accurate quantification of primary mitral regurgitation (MR) and its consequences on cardiac remodeling is of paramount importance to determine the best timing for surgery in these patients. The recommended echocardiographic grading of primary MR severity relies on an integrated multiparametric approach. It is expected that the large number of echocardiographic parameters collected would offer the possibility to check the measured values regarding their congruence in order to conclude reliably on MR severity. However, the use of multiple parameters to grade MR can result in potential discrepancies between one or more of them. Importantly, many factors beyond MR severity impact the values obtained for these parameters including technical settings, anatomic and hemodynamic considerations, patient's characteristics and echocardiographer' skills. Hence, clinicians involved in valvular diseases should be well aware of the respective strengths and pitfalls of each of MR grading methods by echocardiography. Recent literature highlighted the need for a reappraisal of the severity of primary MR from a hemodynamic perspective. The estimation of MR regurgitation fraction by indirect quantitative methods, whenever possible, should be central when grading the severity of these patients. The assessment of the MR effective regurgitant orifice area by the proximal flow convergence method should be used in a semi-quantitative manner. Furthermore, it is crucial to acknowledge specific clinical situations in MR at risk of misevaluation when grading severity such as late-systolic MR, bi-leaflet prolapse with multiple jets or extensive leak, wall-constrained eccentric jet or in older patients with complex MR mechanism. Finally, it is debatable whether the 4-grades classification of MR severity would be still relevant nowadays, since the indication for mitral valve (MV) surgery is discussed in clinical practice for patients with 3+ and 4+ primary MR based on symptoms, specific markers of adverse outcome and MV repair probability. Primary MR grading should be seen as a continuum integrating both quantification of MR and its consequences, even for patients with presumed "moderate" MR.

Is "moderate" aortic stenosis still the right name? A review of the literature.

Current guidelines recommend aortic valve replacement for symptomatic or selected asymptomatic high-risk patients with severe aortic stenosis. Conversely, a watchful waiting attitude applies to patients with moderate aortic stenosis, regardless of their risk profile and symptoms, until the echocardiographic thresholds of severe aortic stenosis are reached. This strategy is based on data reporting high mortality in untreated severe symptomatic aortic stenosis, whereas moderate aortic stenosis has always been perceived as a non-threatening condition, with a benefit-risk balance against surgery. Meanwhile, numerous studies have reported a worrying event rate in these patients, surgical techniques and outcomes have improved significantly and the use of transcatheter aortic valve replacement has become more widespread and extended to lower-risk patients, leaving this strategy open to question, especially for patients with moderate aortic stenosis and left ventricular dysfunction. In this review, we summarize the current state of knowledge about moderate aortic stenosis progression and prognosis. We also discuss the particular case of moderate aortic stenosis associated with left ventricular dysfunction, and the ongoing trials that that might change our paradigm for the management of this "moderate" valvular heart disease.

Relationship between cutoff values of peak aortic valve velocity and those of other Doppler echocardiographic parameters of severity in patients with aortic stenosis and normal flow.

BACKGROUND: Previous studies have reported inconsistencies between echocardiographic parameters of severity in aortic valve stenosis (AS). Peak aortic valve velocity (Vmax ) strongly predicts outcome in AS patients. This study was therefore designed to identify the cutoff values of echocardiographic parameters of severity corresponding to a Vmax ≥ 3 m/sec, ≥4 m/sec, 5 m/sec, or 5.50 m/sec in a large cohort of patients with normal flow (NF) AS. METHODS AND RESULTS: We retrospectively reviewed the echocardiograms of 528 consecutive patients with normal flow (NF) AS, left ventricular (LV) ejection fraction ≥0.50, and NF (stroke volume index > 35 mL/m²). The values of mean pressure gradient (MPG), aortic valve area (AVA), and indexed aortic valve area (IAVA) corresponding to Vmax ≥ 3 m/sec obtained from receiver operating characteristic (ROC) curves analysis were 22 mmHg, 1.15 cm(2) , and 0.60 cm(2) /m(2) , respectively. While a cutoff of Vmax ≥ 4 m/sec to define severe AS was consistent with a value of 39 mmHg for MPG, corresponding values for AVA and IAVA of 0.90 cm² and 0.48 cm²/m², respectively, were substantially different from those recommended in current guidelines. MPG ≥60 and 65 mmHg, AVA ≤0.76 and ≤0.68 cm², and IAVA ≤0.41 and ≤0.35 cm(2) /m(2) were related to a Vmax ≥5 and ≥5.5 m/sec (very severe AS), respectively. CONCLUSIONS: Guidelines recommended cutoff values for AVA and IAVA are not consistent with those of Vmax and MPG. The results of this study may serve as safeguard in case of apparent inconsistencies between echocardiographic parameters of severity in NF AS.

Role of Cardiovascular Magnetic Resonance in Native Valvular Regurgitation: A Comprehensive Review of Protocols, Grading of Severity, and Prediction of Valve Surgery.

Valvular regurgitation is common in developed countries with an increasing prevalence due to the aging of the population and more accurate diagnostic imaging methods. Echocardiography is the gold standard method for the assessment of the severity of valvular heart regurgitation. Nonetheless, cardiovascular magnetic resonance (CMR) has emerged as an additional tool for assessing mainly the severity of aortic and mitral valve regurgitation in the setting of indeterminate findings by echocardiography. Moreover, CMR is a valuable imaging modality to assess ventricular volume and flow, which are useful in the calculation of regurgitant volume and regurgitant fraction of mitral valve regurgitation, aortic valve regurgitation, tricuspid valve regurgitation, and pulmonary valve regurgitation. Notwithstanding this, reference values and optimal thresholds to determine the severity and prognosis of valvular heart regurgitation have been studied lesser by CMR than by echocardiography. Hence, further larger studies are warranted to validate the potential prognostic relevance of the severity of valvular heart regurgitation determined by CMR. The present review describes, analyzes, and discusses the use of CMR to determine the severity of valvular heart regurgitation in clinical practice.

Comparison of Mitral Regurgitant Volume Assessment between Proximal Flow Convergence and Volumetric Methods in Patients with Significant Primary Mitral Regurgitation: An Echocardiographic and Cardiac Magnetic Resonance Imaging Study.

BACKGROUND: Discrepancies have been observed between transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) severity grading in primary mitral regurgitation (MR). OBJECTIVES: We sought to compare mitral regurgitant volume (RVol) determined by the TTE proximal flow convergence (proximal isovelocity surface area [PISA]) method and by volumetric methods (TTE and CMR) and to study the relationship between left ventricle (LV) size and RVol obtained by either the PISA or volumetric methods. METHODS: Two centers prospectively recruited 188 patients with at least moderate to severe primary MR due to prolapse in sinus rhythm who underwent TTE and CMR examinations. Regurgitant volume was estimated by either PISA (PISA-RVol) or volumetric methods (LV total stroke volume-systolic aortic forward outflow volume) using either CMR (CMR-RVol) or TTE (TTE-RVol). RESULTS: The PISA-RVol was weakly correlated with CMR-RVol and TTE-RVol (r = 0.29 and 0.30, respectively; P < .001 for both). On multivariable analysis, smaller CMR-left ventricular end-diastolic volume (LVEDV) and absence of mitral annular disjunction independently correlated with increased magnitude of RVol difference between PISA and volumetric methods. While PISA-RVol and LVEDV were unrelated, CMR-RVol and TTE-RVol moderately correlated with LVEDV (r = 0.66 and 0.68, respectively; P < .001 for both). In contrast, LVEDV and regurgitant fraction (RVol/LV total stroke volume), assessed with either TTE or CMR, were poorly correlated (r = 0.17, P = .02; and r = 0.12, P = .10, respectively). CONCLUSIONS: Mitral RVol values estimated by PISA and volumetric methods are not directly comparable. The expected proportional relationship between volumetric RVol and LV size, which was not observed with PISA-RVol, suggests that PISA-RVol would be inaccurate. Given that RVol assessed with volumetric methods depends on LV size, determination of a unique RVol threshold for severe MR is challenging. In contrast to RVol, calculating regurgitant fraction by volumetric methods allows the quantification of MR severity independently from LV size.

Low systolic blood pressure at admission predicts long-term mortality in heart failure with preserved ejection fraction.

BACKGROUND: Systolic blood pressure (SBP) at hospital admission predicts in-hospital and postdischarge mortality in patients with left ventricular systolic dysfunction. The relationship between admission SBP and mortality in heart failure with preserved (≥50%) ejection fraction (HFPEF) is still unclear. METHODS AND RESULTS: We aimed to investigate the relationship between admission SBP and 5-year outcome in 368 consecutive patients hospitalized for new-onset HFPEF. Five-year all-cause mortality rates according to admission SBP categories (<120, 120-139, 140-159, 160-179, and ≥180 mm Hg) were 75 ± 7%, 53 ± 6%, 52 ± 7%, 55 ± 4%, and 60 ± 7%, respectively (P = .029). Survival analysis showed an inverse relation between admission SBP and mortality with increased risk of death for SBP <120 mm Hg. SBP <120 mm Hg independently predicted 5-year all-cause mortality (adjusted hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.08-2.63) and cardiovascular mortality (adjusted HR 1.89, 95% CI 1.21-2.97). In patients discharged alive, after adjustment for medical treatment at discharge, admission SBP <120 mm Hg remained predictive of all-cause mortality (adjusted HR 1.52, 95% CI 1.04-2.43) and cardiovascular mortality (adjusted HR 1.69, 95% CI 1.06-2.73). There was no interaction between any of the therapeutic classes and outcome prediction of SBP. CONCLUSIONS: In HFPEF, low SBP (<120 mm Hg) at the time of hospital admission is associated with excess long-term mortality. Further studies are required to determine the mechanism of this association.

Valvuloarterial impedance does not improve risk stratification in low-ejection fraction, low-gradient aortic stenosis: results from a multicentre study.

OBJECTIVES: In a multicentre series of patients with low-ejection fraction/low-gradient aortic stenosis (LEF/LGAS), we evaluated the prognostic impact of valvuloarterial impedance (Zva). BACKGROUND: Zva in AS, a measure of global afterload taking into account systemic arterial compliance, has been proposed for risk stratification in paradoxical LGAS. We hypothesized that Zva could help risk stratification in LEF/LGAS. METHODS AND RESULTS: We retrospectively calculated Zva (5.6 ± 1.7 mmHg/mL/m(2)) of 184 consecutive patients (mean age: 71 ± 10 years) with severe symptomatic LEF/LGAS (valve area ≤1 cm2;, EF ≤40%, mean transaortic pressure gradient ≤40 mmHg) included between 1995 and 2005 in a multicentre registry. Zva was higher in patients with LVEF at rest ≤20% (6.6 ± 2.3 vs. 5.5 ± 1.6; P = 0.05) and correlated negatively with LVEF at rest (R = -0.25; P = 0.001). Zva was lower in patients without contractile reserve (CR) on dobutamine stress echocardiography (DSE) compared with patients with true severe AS (5.3 ± 1.3 vs. 5.8 ± 1.8 mmHg/mL/m(2); P = 0.048). Zva and the variation in stroke volume during DSE were positively correlated (P = 0.0001) but Zva did not allow distinction between true and pseudo-severe AS (5.8 ± 1.8 vs. 5.3 ± 1.8 mm Hg/mL/m(2); P = 0.30). In the total population, Zva was not predictive of long-term mortality. In the 128 patients who underwent aortic valve replacement, Zva was not predictive of operative death and of long-term mortality. CONCLUSIONS: Increased Zva is related to low LVEF and more frequent CR on DSE in LEF/LGAS. However, Zva did not allow an accurate distinction between true and pseudo-severe AS and failed to predict operative and long-term mortality after aortic valve replacement, in LEF/LGAS.

Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction.

AIMS: Left ventricular (LV) dysfunction is the first cause of late mortality after mitral valve surgery. In this retrospective analysis, we studied the association between preoperative echocardiographic LV measures and occurrence of LV dysfunction after mitral valve repair (MVR). METHODS AND RESULTS: Between 1991 and 2009, 335 consecutive patients underwent MVR for severe mitral regurgitation due to leaflet prolapse in our institution. Echocardiography was performed preoperatively and at 10.8 (9.1-12.0) months after surgery in 303 patients who represented the study population. Cardiac events were recorded during follow-up. LV ejection fraction (EF) decreased from 68 ± 9% before surgery to 59 ± 9% post-operatively (P < 0.001). Preoperative EF <64% and LV end-systolic diameter (ESD) ≥ 37 mm were the best cut-off values for the prediction of post-operative LV dysfunction (EF < 50%). On the basis of a combined analysis, the occurrence of post-operative LV dysfunction was 9% when EF was ≥ 64% and LVESD < 37 mm, 21% with EF < 64% or LVESD ≥ 37 mm, and 33% with EF < 64% and LVESD ≥ 37 mm (P for trend < 0.001). The combined variable EF < 64% and LVESD ≥ 37 mm added incremental prognostic value to the multivariable regression model (P = 0.001). CONCLUSION: Simple preoperative echocardiography measures allow the prediction of LV dysfunction after MVR in patients with leaflet prolapse. Patients with preoperative EF ≥ 64% and LVESD < 37 mm incur relatively low risk of post-operative LV dysfunction.

Influence of Prolapse Volume in Mitral Valve Prolapse.

Mitral valve prolapse (MVP) is characterized by excessive leaflet tissue leading to a wide spectrum of mitral regurgitation (MR) ranging from trivial to severe. The prolapse volume (PV) below the prolapsing leaflets in end-systole was suspected to impact both chamber remodeling and MR grading in MVP. Based on 157 consecutive patients (45 women; mean age 62±15) referred for CMR assessment of MR, either from MVP (n = 91; 58%) or fibroelastic disease (FED) (n = 66; 42%), we sought to study (i) the interaction between PV and cardiac chamber geometry (ii) to study the impact of PV on MR quantification in MVP. Despite similar left ventricular (LV) size, PV was larger in MVP (11±9ml) than in FED (2±2ml). PV progressively increased with the severity of MR in MVP but not in FED. Despite a low regurgitant volume (32±18ml), some MVP patients with less than moderate MR exhibit significant cardiac chambers remodeling compared to 52 age and sex-matched controls. PV correlated significantly (r = 0.52) with the LV dilatation in severe MR but also in less than moderate MR. In MVP, PV>14ml was associated with a significant underestimation (Bias=-26±32ml) of regurgitant volume by PISA compared to CMR. In conclusion, in MVP, PV may play a role in left cardiac chambers remodeling, even in patients without severe MR, and in discordant grading of MR between echocardiography and CMR.

Non-contrast myocardial T1 global and regional reference values at 3 Tesla cardiac magnetic resonance in aortic stenosis.

BACKGROUND: T1 mapping using cardiac magnetic resonance (CMR) was recently proposed as a promising non-contrast imaging technique for the assessment of diffuse myocardial fibrosis (MF) in aortic stenosis (AS). AIMS: To provide reference values for native T1 mapping at 3 Tesla magnetic field strength in subjects with moderate or severe AS and in control subjects; to identify factors associated with the presence of diffuse MF in severe AS; to assess the regional distribution of diffuse MF; and to compare the level of diffuse MF in the different types of AS, stratified by flow and gradient patterns. METHODS: Retrospective study based on 160 consecutive patients with moderate (n=11) to severe (n=149) AS and 47 control subjects referred for CMR. RESULTS: Mean native T1 increased progressively across controls (1221±23ms), moderate AS (1249±26ms) and severe AS (1273±43ms). T1 times correlated significantly with left ventricular (LV) remodelling (indexed LV mass and LV diastolic volume) and functional LV alterations (global longitudinal strain and LV ejection fraction). Native T1 appears to be elevated in the basal segments of the septum in moderate AS, and to extend to midventricular and apical segments in severe AS. Mean T1 time was higher in classical low-flow/low-gradient AS (1295±62ms) than in the other types of AS (P=0.006). The level of diffuse MF in paradoxical low-flow/low-gradient AS (1280±42ms) was higher than in moderate AS, but similar to that in high-gradient AS (1271±42ms) (P=0.07). CONCLUSIONS: Assessment of diffuse MF in AS using T1 mapping is feasible and reproducible in clinical practice. T1 value increases with AS severity, along with morphological and functional LV alterations, particularly in the basal segments of the septum.

Relationship Between the Ratio of Acceleration Time/Ejection Time and Mortality in Patients With High-Gradient Severe Aortic Stenosis.

Background The ratio of acceleration time/ejection time (AT/ET) is a simple and reproducible echocardiographic parameter that integrates aortic stenosis severity and its consequences on the left ventricle. No study has specifically assessed the prognostic impact of AT/ET on outcome in patients with high-gradient severe aortic stenosis (SAS) and no or mild symptoms. We sought to evaluate the relationship between AT/ET and mortality and determine the best predictive AT/ET cutoff value in these patients. Methods and Results A total of 353 patients (median age, 79 years; 46% women) with high-gradient (mean pressure gradient ≥40 mm Hg and/or aortic peak jet velocity ≥4 m/s) SAS, left ventricular ejection fraction ≥50%, and no or mild symptoms were studied. The impact of AT/ET ≤0.35 or >0.35 on all-cause mortality was retrospectively studied. During a median follow-up of 39 (25th-75th percentile, 23-62) months, 70 patients died. AT/ET >0.35 was associated with a considerable increased mortality risk after adjustment for established prognostic factors in SAS under medical and/or surgical management (adjusted hazard ratio [HR], 2.54; 95% CI, 1.47-4.37; P<0.001) or conservative management (adjusted HR, 3.29; 95% CI, 1.70-6.39; P<0.001). Moreover, AT/ET >0.35 improved the predictive performance of models including established risk factors in SAS with better global model fit, reclassification, and discrimination. After propensity matching, increased mortality risk persisted when AT/ET >0.35 (adjusted HR, 2.10; 95% CI, 1.12-3.90; P<0.001). Conclusions AT/ET >0.35 is a strong predictor of outcome in patients with SAS and no or only mild symptoms and identifies a subgroup of patients at higher risk of death who may derive benefit from earlier aortic valve replacement.