Evaluation of the Truncated Cone-Rhomboid Pyramid Formula for Simplified Right Ventricular Quantification: A Cardiac Magnetic Resonance Study.

Background/Objective: Cardiac magnetic resonance (CMR) is the reference method for right ventricular (RV) volume and function analysis, but time-consuming manual segmentation and corrections of imperfect automatic segmentations are needed. This study sought to evaluate the applicability of an echocardiographically established truncated cone-rhomboid pyramid formula (CPF) for simplified RV quantification using CMR. Methods: A total of 70 consecutive patients assigned to RV analysis using CMR were included. As standard method, the manual contouring of RV-short axis planes was performed for the measurement of end-diastolic volume (EDV) and end-systolic volume (ESV). Additionally, two linear measurements in four-chamber views were obtained in systole and diastole: basal diameters at the level of tricuspid valve (Dd and Ds) and baso-apical lengths from the center of tricuspid valve to the RV apex (Ld and Ls) were measured for the calculation of RV-EDV = 1.21 × Dd2 × Ld and RV-ESV = 1.21 × Ds 2 × Ls using CPF. Results: RV volumes using CPF were slightly higher than those using standard CMR analysis (RV-EDV index: 86.2 ± 29.4 mL/m2 and RV-ESV index: 51.5 ± 22.5 mL/m2 vs. RV-EDV index: 81.7 ± 24.1 mL/m2 and RV-ESV index: 44.5 ± 23.2 mL/m2) and RV-EF was lower (RV-EF: 41.1 ± 13.5% vs. 48.4 ± 13.7%). Both methods had a strong correlation of RV volumes (ΔRV-EDV index = -4.5 ± 19.0 mL/m2; r = 0.765, p < 0.0001; ΔRV-ESV index = -7.0 ± 14.4 mL/m2; r = 0.801, p < 0.0001). Conclusions: Calculations of RV volumes and function using CPF assuming the geometrical model of a truncated cone-rhomboid pyramid anatomy of RV is feasible, with a strong correlation to measurements using standard CMR analysis, and only two systolic and diastolic linear measurements in four-chamber views are needed.

Chronic kidney disease is related to impaired left ventricular strain as assessed by cardiac magnetic resonance imaging in patients with ischemic cardiomyopathy.

INTRODUCTION: Chronic kidney disease (CKD) is an important cardiovascular risk factor. However, the relationship between CKD and myocardial strain as a parameter of myocardial function is still incompletely understood, particularly in patients with ischemic cardiomyopathy (ICM). Cardiac magnetic resonance imaging (CMR) feature tracking allows to analyze myocardial strain with high reproducibility. Therefore, the aim of the present study was to assess the relationship between CKD and myocardial strain as described by CMR in patients with ICM. METHODS: We retrospectively performed CMR-based myocardial strain analysis in 89 patients with ICM and different stages of CKD, classified according to the KDIGO stages. In all patients, global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) analysis of left ventricular myocardium were performed. Furthermore, segmental longitudinal (SLS), circumferential (SCS) and radial strain (SRS) according to the AHA 16/17-segment model was determined. RESULTS: Creatinine levels (GLS: r = 0.46, p < 0.001; GCS: r = 0.34, p = 0.001; GRS: r = - 0.4, p < 0.001), urea levels (GLS: r = 0.34, p = 0.001; GCS: r = 0.30, p = 0.005; GRS: r = - 0.31, p = 0.003) as well as estimated glomerular filtration rate (GLS: r = -0.40, p < 0.001; GCS: r = - 0.27, p = 0.012; GRS r = 0.34, p < 0.001) were significantly associated with global strains as determined by CMR. To further investigate the relationship between CKD and myocardial dysfunction, segmental strain analysis was performed: SLS was progressively impaired with increasing severity of CKD (KDIGO-1: - 11.93 ± 0.34; KDIGO-5: - 7.99 ± 0.38; p < 0.001 for KDIGO-5 vs. KDIGO-1; similar data for SCS and SRS). Interestingly, myocardial strain was impaired with CKD in both segments with and without scarring. Furthermore, in a multivariable analysis, eGFR was independently associated with GLS following adjustment for LV-EF, scar burden, diabetes, hypertension, age, gender, LV mass or LV mass index. CONCLUSION: CKD is related to impaired LV strain as assessed by CMR in patients with ICM. In our cohort, this relationship is independent of LV-EF, the extent of myocardial scarring, diabetes, hypertension, age, gender, LV mass or LV mass index.

Coronary microvascular dysfunction is a hallmark of all subtypes of MINOCA.

INTRODUCTION: Myocardial infarction without obstructive coronary artery disease (MINOCA) is a heterogeneous clinical condition presenting with myocardial necrosis not due to an obstruction of a major coronary artery. Recently, a relevant role of coronary microvascular dysfunction (CMD) in the pathogenesis of MINOCA has been suggested; however, data on this are scarce. Particularly, it is unclear if CMD is equally present in all subtypes of MINOCA or differentially identifies one or more of these conditions. Therefore, the aim of this study was to assess CMD in all three coronary vessels of MINOCA patients, relating it with the clinical subtype. METHODS: We retrospectively assessed coronary microvascular function in all three coronary territories by means of angiography-based index of microvascular resistance (aIMR) in 92 patients (64 with working diagnosis of MINOCA, 28 control patients). To further assess the association of CMD with MINOCA subtypes, MINOCA patients were subdivided according to clinical data in coronary cause (n = 13), takotsubo (n = 13), infiltrative or inflammatory cardiomyopathy (n = 9) or unclear (n = 29). RESULTS: Patients with working diagnosis of MINOCA showed a significantly elevated average aIMR compared to control patients (30.5 ± 7.6 vs. 22.1 ± 5.9, p < 0.001) as a marker of a relevant CMD; these data were consistent in all vessels. Among MINOCA subtypes, no significant difference in average aIMR could be detected between patients with coronary cause (33.2 ± 6.6), takotsubo cardiomyopathy (29.2 ± 6.9), infiltrative or inflammatory cardiomyopathy (28.1 ± 6.8) or unclear cause (30.6 ± 8.5; p = 0.412). Interestingly, aIMR was significantly elevated in the coronary vessel supplying the diseased myocardium compared with other vessels (31.9 ± 11.4 vs. 27.8 ± 8.2, p = 0.049). CONCLUSION: Coronary microvascular dysfunction is a hallmark of all MINOCA subtypes. This study adds to the pathophysiological understanding of MINOCA and sheds light into the role of CMD in MINOCA.

Echocardiographic determination of right ventricular volumes and ejection fraction: Validation of a truncated cone and rhomboid pyramid formula.

BACKGROUND: Echocardiographic assessment of right ventricular (RV) measurements may be challenging. The aim of this study was to develop a formula for calculation of RV volumes and function based on measurements of linear dimensions by 2-dimensional (2D) transthoracic echocardiography (TTE) in comparison to cardiovascular magnetic resonance (CMR). METHODS: 129 consecutive patients with standard TTE and RV analysis by CMR were included. A formula based on the geometric assumptions of a truncated cone minus a truncated rhomboid pyramid was developed for calculations of RV end-diastolic volume (EDV) and RV end-systolic volume (ESV) by using the basal diameter of the RV (Dd and Ds) and the baso-apical length (Ld and Ls) in apical 4-chamber TTE views: RV EDV = 1.21 * Dd2 * Ld, and RV ESV = 1.21 * Ds2 * Ls. RESULTS: Calculations of RV EDV (ΔRV EDV = 10.2±26.4 ml to CMR, r = 0.889), RV ESV (ΔRV ESV = 4.5±18.4 ml to CMR, r = 0.921) and RV EF (ΔRV EF = 0.5±4.0% to CMR, r = 0.905) with the cone-pyramid formula (CPF) highly agreed with CMR. Impaired RV function on CMR (n = 52) was identified with a trend to higher accuracy by CPF than by conventional echocardiographic parameters (tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC)). CONCLUSION: Calculations of RV volumes and RV function by 2D TTE with the newly developed CPF were in high concordance to measurements by CMR. Accuracy for detection of patients with reduced RV function were higher by the proposed 2D TTE CPF method than by conventional echocardiographic parameters of TAPSE and RV FAC.

Procedural performance between two cryoballoon systems for ablation of atrial fibrillation depends on pulmonary vein anatomy.

Background: Cryoballoon ablation is a first-line therapy for atrial fibrillation. We compared the efficacy and safety of two ablation systems and addressed the influence of pulmonary vein (PV) anatomy on performance and outcome. Methods: We consecutively enrolled 122 patients who were planned for first-time cryoballoon ablation. Patients were assigned 1:1 for ablation with the POLARx or the Arctic Front Advance Pro (AFAP) system and followed-up for 12 months. Procedural parameters were recorded during the ablation. Before the procedure, a magnetic resonance angiography (MRA) of the PVs was generated and diameter, area, and shape of each PV ostium were assessed. We applied an evaluated PV anatomical scoring system on our MRA measurement data ranging from 0 (best anatomical combination) to 5. Results: Procedures performed with POLARx were associated with shorter time to balloon temperature -30°C (p < .001), lower balloon nadir temperature (p < .001), and longer thawing time till 0°C (p < .001) in all PVs, however, time to isolation was similar. We observed a decreasing performance with each increase in the score for the AFAP, whereas the POLARx performed constant regardless of the score. At 1 year, AF recurred in 14 of 44 patients treated with AFAP (31.8%) and in 10 of 45 patients treated with POLARx (22.2%) (hazard ratio, 0.61; 95% CI 0.28 to 1.37; p = .225). There was no significant correlation between PV anatomy and clinical outcome. Conclusion: We found significant differences in cooling kinetics, especially when anatomical conditions are difficult. However, both systems have a comparable outcome and safety profile.

Computational fluid dynamics analysis of endoluminal aortic perfusion.

INTRODUCTION: In peripheral percutaneous (VA) extracorporeal membrane oxygenation (ECMO) procedures the femoral arteries perfusion route has inherent disadvantages regarding poor upper body perfusion due to watershed. With the advent of new long flexible cannulas an advancement of the tip up to the ascending aorta has become feasible. To investigate the impact of such long endoluminal cannulas on upper body perfusion, a Computational Fluid Dynamics (CFD) study was performed considering different support levels and three cannula positions. METHODS: An idealized literature-based- and a real patient proximal aortic geometry including an endoluminal cannula were constructed. The blood flow was considered continuous. Oxygen saturation was set to 80% for the blood coming from the heart and to 100% for the blood leaving the cannula. 50% and 90% venoarterial support levels from the total blood flow rate of 6 l/min were investigated for three different positions of the cannula in the aortic arch. RESULTS: For both geometries, the placement of the cannula in the ascending aorta led to a superior oxygenation of all aortic blood vessels except for the left coronary artery. Cannula placements at the aortic arch and descending aorta could support supra-aortic arteries, but not the coronary arteries. All positions were able to support all branches with saturated blood at 90% flow volume. CONCLUSIONS: In accordance with clinical observations CFD analysis reveals, that retrograde advancement of a long endoluminal cannula can considerably improve the oxygenation of the upper body and lead to oxygen saturation distributions similar to those of a central cannulation.

Diagnostic performance of 3D cardiac magnetic resonance perfusion in elderly patients for the detection of coronary artery disease as compared to fractional flow reserve.

OBJECTIVES: In patients of advanced age, the feasibility of myocardial ischemia testing might be limited by age-related comorbidities and falling compliance abilities. Therefore, we aimed to test the accuracy of 3D cardiac magnetic resonance (CMR) stress perfusion in the elderly population as compared to reference standard fractional flow reserve (FFR). METHODS: Fifty-six patients at age 75 years or older (mean age 79 ± 4 years, 35 male) underwent 3D CMR perfusion imaging and invasive coronary angiography with FFR in 5 centers using the same study protocol. The diagnostic accuracy of CMR was compared to a control group of 360 patients aged below 75 years (mean age 61 ± 9 years, 262 male). The percentage of myocardial ischemic burden (MIB) relative to myocardial scar burden was further analyzed using semi-automated software. RESULTS: Sensitivity, specificity, and positive and negative predictive values of 3D perfusion CMR deemed similar for both age groups in the detection of hemodynamically relevant (FFR < 0.8) stenosis (≥ 75 years: 86%, 83%, 92%, and 75%; < 75 years: 87%, 80%, 82%, and 85%; p > 0.05 all). While MIB was larger in the elderly patients (15% ± 17% vs. 9% ± 13%), the diagnostic accuracy of 3D CMR perfusion was high in both elderly and non-elderly populations to predict pathological FFR (AUC: 0.906 and 0.866). CONCLUSIONS: 3D CMR perfusion has excellent diagnostic accuracy for the detection of hemodynamically relevant coronary stenosis, independent of patient age. KEY POINTS: • The increasing prevalence of coronary artery disease in elderly populations is accompanied with a larger ischemic burden of the myocardium as compared to younger individuals. • 3D cardiac magnetic resonance perfusion imaging predicts pathological fractional flow reserve in elderly patients aged ≥ 75 years with high diagnostic accuracy. • Ischemia testing with 3D CMR perfusion imaging has similarly high accuracy in the elderly as in younger patients and it might be particularly useful when other non-invasive techniques are limited by aging-related comorbidities and falling compliance abilities.

Socio-demographic parameters and non-cardiac comorbidity related to self-perceived quality of life in young adults after neonatal arterial switch operation for transposition of the great arteries.

Evaluating the relation of non-cardiac comorbidity and socio-demographic factors to physical and mental health-related quality of life (QOL) which has been partially found at elevated risk in young adults after neonatal arterial switch operation (ASO) for transposition of the great arteries (TGA). In a prospective reassessment study, results of 92 unselected young adults (22.8 ± 2.6 years) having undergone evaluation of QOL (SF-36) were related to non-cardiac comorbidity with special respect to neurologic and psychiatric comorbidity and to socio-demographic parameters. Neurologic (14%) contrary to psychiatric comorbidities (6.5%) were more frequent than in the general population. The educational level was higher, the rate of unemployment was double as high compared to the average German population. Significant inverse relations (p = 0.006 to 0.033) existed between physical health domains (physical functioning and general health perception) and non-cardiac, neurologic, and psychiatric comorbidity, as well as correlations between the latter domains and socio-economic status, educational level, and worse employment status (Spearman 0.22-0.41, p < 0.0001 to 0.036). Mental health domains (vitality, social functioning, psychical health) were significantly inversely related with neurologic and psychiatric comorbidity (p = 0.002 to 0.048) and correlated with higher educational level (Spearman 0.25, p = 0.019). Neurologic and psychiatric comorbidities and socio-demographic parameters are significant risk factors for a reduced QOL concerning physical and mental health in young adults with TGA after ASO. Standardized QOL measurement should be part of routine screening programs to detect subclinical physical, neurodevelopmental, and psychosocial comorbidity.

Outcome of transcatheter edge-to-edge mitral valve repair in patients with diabetes mellitus: Results from a real-world cohort.

BACKGROUND: There are only limited data on patients with diabetes undergoing transcatheter edge-to-edge repair (TEER) in real-world settings. Previous data indicated patients with diabetes to have a worse prognosis. This study sought to evaluate safety and efficacy of TEER in patients with diabetes in a real-world cohort. METHODS: In this monocentric study 340 consecutive patients with severe primary and secondary mitral regurgitation (MR) undergoing TEER were included. Immediate results of the procedure, intrahospital and one-year outcome were compared between patients with and without diabetes. RESULTS: Diabetes was present in 109 patients (32%). Patients with diabetes were younger (77 y (71, 81) vs. 79 y (74, 83); p = 0.003), had more often ischemic cardiomyopathy (68% vs. 48%; p<0.001), previous coronary-artery bypass graft (35% vs. 20%; p = 0.002) and arterial hypertension (89% vs. 75%; p<0.001) compared to those without diabetes. Baseline NYHA class, type of MR (primary vs. secondary), left ventricular dimensions and function (ejection fraction: 37% (28, 50) vs. 40% (29, 55); p = 0.10) as well as severity of MR were not different between both groups. Success of the procedure (95% vs. 95%; p = 0.84), intrahospital mortality (5.5% vs. 4.8%; p = 0.98) and one-year follow-up regarding all-cause mortality (24.2% vs. 23.0%; p = 0.72), hospitalization for heart failure (37.4% vs. 31.0%, p = 0.23), NYHA class (p = 0.14) or MR severity (p = 0.59) did not differ between both groups. CONCLUSION: Our real-world data suggest that TEER seems to be similarly safe and effective in patients with severe MR and diabetes compared to those without diabetes.

Epicardial adipose tissue thickness assessed by CT is a marker of atrial fibrillation in stroke patients.

Epicardial adipose tissue is involved in the pathophysiology of atrial fibrillation (AF). This study aimed to analyze its relevance as a stroke etiology marker. A retrospective study of acute ischemic stroke patients with large vessel occlusion was conducted, periatrial epicardial adipose tissue thickness (pEATT) on admission computed tomography angiography was measured. One hundred and twenty-one patients with AF-related stroke and 94 patients with noncardioembolic stroke were included. Patients with AF-related stroke had increased pEATT. CT-measured left-sided pEATT was an independent predictor of AF-related stroke (adjusted odds ratio per 1 mm increase = 1.27, 95% CI = 1.05-1.53, p = 0.012). pEATT is an independent marker of AF-related stroke.

Anxiety and Depression in Adults With Congenital Heart Disease.

Introduction: Anxiety and depression can worsen outcome in patients with heart disease. We elucidate the prevalence of anxiety and depression in a cohort of adults with congenital heart disease (ACHD). Materials and Methods: Prospective screening for anxiety or depression was performed in 204 consecutive patients of the outpatient clinic of our tertiary care center using the Hospital Anxiety and Depression Scale (HADS) questionnaire and the distress thermometer (DT) as a potential ultra-short screening test. Functional data were assessed at liberty of the responsible physician. HADS scores ≥ 8 were considered doubtful and scores ≥ 11 as confirmed cases of anxiety or depression, respectively. HADS results were compared with a historical group of 100 patients with non-Hodgkin Lymphoma (NHL) as well as German reference values from the literature. Results: Patients from the ACHD cohort were 28 ± 10 years old (mean ± SD, 54% male), 34% had a simple, 51% a moderate, including 52 patients with transposition of the great arteries after arterial switch operation, and 15% a heart defect of severe complexity. Prevalence of depression in ACHD was comparable to the German normal population (5.9% ACHD vs. 5.4% control). In contrast, prevalence of anxiety was higher than expected from reference values (12.7% ACHD vs. 5.6% control). There was a positive association between psychological distress and NYHA class [anxiety: OR 2.67 (95% CI, 1.50-4.76) p = 0.001; depression: OR 2.93 (95% CI, 1.60-5.35) p = 0.0005], but not with age, gender, or heart defect severity. Percentages of patients with ACHD with anxiety were significantly higher than in a cohort of patients with indolent non-Hodgkin lymphoma (NHL) but comparable to those with aggressive NHL (HADS-A ≥ 11: ACHD 12.7%, indolent NHL 2.2%, aggressive NHL 13.2%; p = 0.037 ACHD vs. indolent NHL; p = 0.929 ACHD vs. aggressive NHL). The distress thermometer screening test had only a fair discriminatory ability (AUC 0.708; p = 0.002) and is therefore of limited usability. Conclusion: Adults with congenital heart disease exhibit an increased risk for anxiety disorders independently of the severity of the underlying heart defect. Anxiety prevalence was comparable to a historical cohort of patients with aggressive NHL underlining the importance of a routine screening for psychosocial distress in adults with congenital heart disease.

Prediction of procedural success of transcatheter mitral valve repair with normal and extended clip arms.

TMVR using different clip sizes is a treatment option for selected patients with mitral regurgitation (MR). This study sought to identify predictors of successful transcatheter mitral valve repair (TMVR) by 3-dimensional (3D) echocardiography and to compare different effects of the larger XTR and the smaller NT/NTR devices. 3D transesophageal echocardiography was performed on 54 patients with secondary MR undergoing TMVR with one clip (55.6% NT/NTR, 44.4% XTR). All NT/NTR and 96% of XTR patients had MR reduction ≤ 2+. Despite more severe baseline MR (3D vena contracta area (VCA): 0.67 ± 0.34 cm2 vs. 0.43 ± 0.19 cm2, p = 0.004) and greater mitral valve area (MVA) (6.8 ± 2.1 cm2 vs. 5.1 ± 1.6 cm2, p = 0.001) in the XTR group, MR severity after TMVR was not different between XTR and NT/NTR patients (3D VCA: 0.19 ± 0.14 vs. 0.17 ± 0.10, p = 0.51). Baseline 3D VCA > 0.45 cm2 in NT/NTR (AUC = 0.802, 95% CI 0.602 to 1.000) and 3D VCA > 0.54 cm2 in XTR devices (AUC = 0.868, 95% CI 0.719 to 1.000) were associated with ineffective MR reduction defined as residual VCA ≤ 0.2 cm2. Baseline MVA ≤ 4.2 cm2 in NT/NTR (AUC = 0.920, 95% CI 0.809 to 1.000) and MVA ≤ 6.0 cm2 in XTR devices (AUC = 0.865, 95% CI 0.664 to 1.000) were associated with postprocedural transmitral pressure gradient (TMPG) ≥ 5 mmHg. TMVR using the XTR device resulted in an equally effective reduction of MR despite of a greater baseline MR. Distinct cut-off values of baseline 3D VCA and MVA for prediction of successful MR reduction and postprocedural increase of TMPG were identified for the different devices.

Rare Case of an Adult With Double-Chambered Left Ventricle.

The rare case of an adult with a double-chambered left ventricle was revealed using multimodality imaging using echocardiography and cardiac magnetic resonance imaging in a 38-year-old asymptomatic male patient. The congenital malformation was dominated by a second, coarsely trabeculated muscular shelf dividing the left ventricle into 2 chambers without signs for left ventricular inflow or outflow tract obstruction. The partition wall did not show any signs for intramyocardial fibrosis in late gadolinium enhancement cardiovascular magnetic resonance imaging. Flow measurements excluded a relevant intracardial shunt across the additive perimembranous ventricular septal defect. There were no signs for global right and left ventricular dysfunction with left and right ventricular volumes and ejection fraction within normal limits. A conservative approach was recommended. In summary, we are able to present the case of an adult with a double-chambered left ventricle with a second muscular "septum" partially dividing the left ventricular cavity without causing a relevant impact on cardiac function or clinical signs for heart failure.

Le cas rare d'un adulte présentant un ventricule gauche à double chambre a été révélé par une imagerie multimodale utilisant l'échocardiographie et l'imagerie par résonnance magnétique cardiaque chez un homme asymptomatique de 38 ans. La malformation congénitale était dominée par une deuxième bande musculaire grossièrement trabéculaire divisant le ventricule gauche en deux chambres sans signes d'obstruction des chambres d'admission et d'éjection du ventricule gauche. La cloison de partition ne montrait aucun signe de fibrose intramyocardique à l'imagerie par résonnance magnétique cardiovasculaire avec rehaussement tardif au gadolinium. Les mesures du débit ont exclu un shunt intracardiaque significatif à travers le défaut septal ventriculaire transmembranaire supplémentaire. Il n'y avait pas de signe de dysfonction ventriculaire droite et gauche globale, les volumes ventriculaires gauche et droit et la fraction d'éjection étant dans les limites normales. Une approche conservatrice a été recommandée. En résumé, nous pouvons présenter le cas d'un adulte porteur d'un ventricule à double chambre avec une deuxième « cloison ¼ musculaire divisant partiellement la cavité ventriculaire gauche sans causer d'effet notable sur la fonction cardiaque ou de signes cliniques d'insuffisance cardiaque.

General Anesthesia Leads to Underestimation of Regurgitation Severity in Patients With Secondary Mitral Regurgitation Undergoing Transcatheter Mitral Valve Repair.

OBJECTIVES: To evaluate the effect of general anesthesia (GA) on severity of mitral regurgitation (MR) in patients undergoing transcatheter mitral valve repair (TMVR). DESIGN: Retrospective cohort study. SETTING: Tertiary care university hospital. PARTICIPANTS: Fifty consecutive patients with symptomatic severe MR and extremely high surgical risk. INTERVENTION: TMVR under GA. MEASUREMENTS AND RESULTS: Transesophageal echocardiography was performed during the preprocedural workup under conscious sedation and during TMVR under GA. After the parameters of MR were assessed, color-flow jet area (CJA), vena contracta (VC), effective regurgitant orifice area (EROA), regurgitant volume (RVOL), three-dimensional (3D) vena contracta area (VCA), and severity of MR were compared between the two examinations. In patients with primary MR (n = 11), there were no significant differences in CJA, VC, EROA, RVOL, or 3D-VCA between pre- and intraprocedural transesophageal echocardiography. In patients with secondary MR (n = 39), GA led to significant decreases of CJA (10 ± 7 v 7 ± 3 cm², p < 0.001), VC (5.5 ± 1.6 v 4.7 ± 1.5 mm, p = 0.002), EROA (30 ± 11 v 24 ± 10 mm², p < 0.001), and RVOL (47 ± 17 v 34 ± 13 mL/beat, p < 0.001). Consequently, GA led to a downgrade of regurgitation severity classification in 44% of patients when assessed by two-dimensional analysis. When evaluated by 3D analysis, GA also led to a significant but less extensive decrease of MR (3D-VCA: 66 ± 27 v 60 ± 29 mm², p = 0.002), and subsequent downgrade of MR classification in 20% of patients. CONCLUSIONS: GA underestimates regurgitation severity in patients with secondary, but not primary MR, undergoing TMVR. This effect must be considered when evaluating the immediate result of the procedure.

Proximal Aortic Dilatation and Pulmonary Valve Replacement in Patients with Repaired Tetralogy of Fallot: Is There a Relationship? A Cardiac Magnetic Resonance Imaging Study.

Aortopathy is a known complication whose incidence is growing within the population of tetralogy of Fallot (TOF) patients. Its pathology and relationship with other comorbidities remain unclear. This study was designed to determine the prevalence and predictors of proximal aortic dilatation after TOF repair. We retrospectively investigated all patients who underwent follow-up cardiac magnetic resonance imaging (CMR; at least 4 years after TOF repair) between March 2004 and December 2019. The dimensions at the ascending aorta (AAo) and sinus of Valsalva (SoV) levels were measured. Aortic dilatation was defined as an internal aortic diameter that was >2 standard deviation of the previously published normal values. We included 77 patients (mean age 28.9 ± 10.5 years, 41.5% female, mean follow-up of 24.5 ± 8.1 years). AAo and SoV were dilated in 19 (24.6%) and 43 (55.8%) patients, respectively. Patients with dilated AAo and SoV were older during the corrective surgery (p < 0.001 and p = 0.004, respectively) and during CMR (p = 0.002 and 0.024, respectively) than patients without AAo and SoV dilatation. Patients of the dilated AAo group were more likely to have prior palliative shunt (p = 0.008), longer shunt duration (p = 0.005), and a higher degree of aortic valve regurgitation (AR) fraction (p < 0.001) and to undergo pulmonary (PVR) and/or aortic valve replacement (p < 0.001 and p = 0.013, respectively). PVR (p = 0.048, odds ratio = 6.413, and 95% CI = 1.013-40.619) and higher AR fraction (p = 0.031, odds ratio = 1.194, and 95% CI = 1.017-1.403) were independent predictors for AAo dilatation. Aortopathy is a common progressive complication that may require reintervention and lifelong follow-up. Our study shows that proximal aortic dilatation may be attributed to factors that increase the volume overload across the proximal aorta, including late corrective surgery and palliative shunt. We also found that PVR and higher AR fraction are independent predictors of AAo dilatation.

Quantitative Flow Ratio Is Associated with Extent and Severity of Ischemia in Non-Culprit Lesions of Patients with Myocardial Infarction.

Quantitative flow ratio (QFR) is a novel method to assess the relevance of coronary stenoses based only on angiographic projections. We could previously show that QFR is able to predict the hemodynamic relevance of non-culprit lesions in patients with myocardial infarction. However, it is still unclear whether QFR is also associated with the extent and severity of ischemia, which can effectively be assessed with imaging modalities such as cardiac magnetic resonance (CMR). Thus, our aim was to evaluate the associations of QFR with both extent and severity of ischemia. We retrospectively determined QFR in 182 non-culprit coronary lesions from 145 patients with previous myocardial infarction, and compared it with parameters assessing extent and severity of myocardial ischemia in staged CMR. Whereas ischemic burden in lesions with QFR > 0.80 was low (1.3 ± 5.5% in lesions with QFR ≥ 0.90; 1.8 ± 7.3% in lesions with QFR 0.81-0.89), there was a significant increase in ischemic burden in lesions with QFR ≤ 0.80 (16.6 ± 15.6%; p < 0.001 for QFR ≥ 0.90 vs. QFR ≤ 0.80). These data could be confirmed by other parameters assessing extent of ischemia. In addition, QFR was also associated with severity of ischemia, assessed by the relative signal intensity of ischemic areas. Finally, QFR predicts a clinically relevant ischemic burden ≥ 10% with good diagnostic accuracy (AUC 0.779, 95%-CI: 0.666-0.892, p < 0.001). QFR may be a feasible tool to identify not only the presence, but also extent and severity of myocardial ischemia in non-culprit lesions of patients with myocardial infarction.

Lesion Geometry as Assessed by Optical Coherence Tomography Is Related to Myocardial Ischemia as Determined by Cardiac Magnetic Resonance Imaging.

INTRODUCTION: Although the relationship between the geometry of coronary stenosis and the presence of myocardial ischemia is well known, the association between stenosis geometry and severity and/or extent of ischemia is still unexplored. Thus, we investigated this relationship using optical coherence tomography (OCT) to assess stenosis parameters and cardiac magnetic resonance imaging (CMR) to determine both extent and severity of ischemia. METHODS: We analyzed 55 lesions from 51 patients with stable angina. Pre-interventionally, all patients underwent OCT-analysis of stenosis morphology as well as CMR to determine both the extent and severity of myocardial ischemia. RESULTS: Percent area stenosis (%AS) was significantly associated with ischemic burden (r = 0.416, p = 0.003). Similar results could be obtained for other stenosis parameters as well as for several other parameters assessing the extent of ischemia. Furthermore, OCT-derived stenosis parameters were associated with the product of ischemic burden and severity of ischemia (%AS: r = 0.435, p = 0.002; similar results for other parameters). A Poiseuille's-law-modelled combination of stenosis length and minimal lumen diameter yielded a good diagnostic efficiency (AUC 0.787) in predicting an ischemic burden >10%. CONCLUSIONS: Our data highlight the key role of the geometry of coronary lesions in determining myocardial ischemia.

Dynamic handgrip exercise for the evaluation of mitral valve regurgitation: an echocardiographic study to identify exertion induced severe mitral regurgitation.

Handgrip exercise (HG) has been occasionally used as a stress test in echocardiography. The effect of HG on mitral regurgitation (MR) is not well known. This study aims to evaluate this effect and the possible role of HG in the echocardiographic evaluation of MR. 722 patients with MR were included (18% primary, 82% secondary disease). We calculated effective regurgitant orifice area (EROA) and regurgitant volume (RVOL) at rest and during dynamic HG. Increase in MR was defined as any increase in EROA or RVOL. We analyzed the data to identify possible associations between clinical or echocardiographic parameters and the effect of HG on MR. MR increased during dynamic HG in 390 of 722 patients (54%) (∆EROA = 25%, ∆RVOL = 27%). Increase of regurgitation occurred in 66 of 132 patients with primary MR (50%) and in 324 of 580 patients with secondary MR (55%). This increase was associated with larger baseline EROA and RVOL, but it was independent from other clinical or echocardiographic parameters. In secondary MR, dynamic HG led to a reclassification of regurgitation severity from non-severe at rest to severe MR during HG in 104 of 375 patients (28%). There was a significant association between this upgrade in MR classification and higher New York Heart Association (NYHA) class (OR 1.486, 95%-CI 1.138-1.940, p = 0.004). Dynamic HG exercise increases MR in about half of patients independent of the etiology. Dynamic HG may be used to identify symptomatic patients with non-severe secondary MR at rest but severe MR during exercise.

Distinct pressure half-time values by transthoracic echocardiography for grading of paravalvular regurgitation after transcatheter aortic valve replacement.

Postprocedural aortic regurgitation (AR) has negative impact on patient outcome after transcatheter aortic valve replacement (TAVR). Standard assessment of AR severity by echocardiography is hampered after TAVR. Measurement of pressure half-time (PHT) by echocardiography is not limited in these patients but it may be affected by concomitant left ventricular hypertrophy (LVH). This study sought to evaluate distinct cut-off values of PHT differentiating between patients without and with more than mild LVH for grading of AR after TAVR with cardiac magnetic resonance (CMR) as the reference method for comparison. 71 patients (age 81 ± 6 years) with severe aortic stenosis undergoing TAVR were included into the study. Transthoracic echocardiography (TTE) and CMR were performed after TAVR. Left ventricular mass index was calculated by TTE. PHT was measured by continuous-wave Doppler echocardiography of aortic regurgitation jet. In 18 patients (25%) PHT could not be obtained due to no or very faint Doppler signal. Aortic regurgitant volume and regurgitant fraction were calculated by CMR by flow analysis of the ascending aorta. In 14 of 53 patients (26%) AR after TAVR was moderate or severe as categorized by CMR analysis. More than mild LVH was present in 27 of 53 patients (51%). PHT correlated inversely less to regurgitant fraction by CMR analysis in patients with LVH (r = -0.293; p = 0.138) than in patients without LVH (r = -0.455; p = 0.020). In patients without relevant LVH accuracy of PHT to predict moderate or severe paravalvular regurgitation AUC was 0.813 using a cut-off value of 347 ms and AUC was 0.729 in patients with more than mild LVH using a cut-off value of 420 ms. Analysis of PHT by TTE with distinct cut-off values for patients without and with more than mild LVH allows detection of moderate or severe AR after TAVR as defined by CMR. In none of the patients in which PHT could not be measured AR was categorized as more than trace by CMR analysis.