Global Left Ventricular Myocardial Work Efficiency in Patients With Severe Rheumatic Mitral Stenosis and Preserved Left Ventricular Ejection Fraction.

BACKGROUND: Assessment of left ventricular (LV) function plays a pivotal role in the management of patients with valvular heart disease, including those caused by rheumatic heart disease. Noninvasive LV pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate global LV systolic function, integrating longitudinal strain by speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work. The aim of this study was to characterize global LV myocardial work efficiency in patients with severe rheumatic mitral stenosis (MS) with preserved ejection fraction (EF). METHODS: We retrospectively included adult patients with severe rheumatic MS with preserved EF (> 50%) and sinus rhythm. Healthy individuals without structural heart disease were included as a control group. Global LV myocardial work efficiency was estimated with a proprietary algorithm from speckle-tracking strain analyses, as well as noninvasive blood pressure measurements. RESULTS: A total of 45 individuals with isolated severe rheumatic MS with sinus rhythm and 45 healthy individuals were included. In healthy individuals without structural heart disease, the mean global LV myocardial work efficiency was 96% (standard deviation [SD], 2), Compared with healthy individuals, median global LV myocardial work efficiency was significantly worse in MS patients (89%; SD, 4; p < 0.001) although the LVEF was similar. CONCLUSIONS: Individuals with isolated severe rheumatic MS and preserved EF, had global LV myocardial work efficiencies lower than normal controls.

Echocardiographic Imaging in Transcatheter Structural Intervention: An AAE Review Paper.

Transcatheter structural heart intervention (TSHI) has gained popularity over the past decade as a means of cardiac intervention in patients with prohibitive surgical risks. Following the exponential rise in cases and devices developed over the period, there has been increased focus on developing the role of "structural imagers" amongst cardiologists. This review, as part of a growing initiative to develop the field of interventional echocardiography, aims to highlight the role of echocardiography in myriad TSHIs available within Asia. We first discuss the various echocardiography-based imaging modalities, including 3-dimensional echocardiography, fusion imaging, and intracardiac echocardiography. We then highlight a selected list of structural interventions available in the region-a combination of established interventions alongside novel approaches-describing key anatomic and pathologic characteristics related to the relevant structural heart diseases, before delving into various aspects of echocardiography imaging for each TSHI.

Identification of Pacemaker Lead Position Using Fluoroscopy to Avoid Significant Tricuspid Regurgitation.

Permanent pacemaker implantation improves survival but can cause tricuspid valve dysfunction in the form of tricuspid regurgitation (TR). The dominant mechanism of pacemaker-mediated TR is lead impingement. This study evaluated the association between the location of the pacemaker leads crossing the tricuspid valve and the incidence of worsening TR and lead impingement using fluoroscopy. Lead positions were evaluated using perpendicular right anterior oblique (RAO) and parallel left anterior oblique (LAO) fluoroscopic angulation views of the tricuspid annulus. A two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate the maximum TR jet area-to-right atrium ratio and define regurgitation severity. A three-dimensional TTE was performed to evaluate lead impingement. A worsening of TR was observed in 23 of 82 subjects. Most leads had an inferior position in the RAO view and a septal position in the LAO view. The mid position in the RAO view and septal position in the LAO view were risk factors for lead impingement. Mid and septal positions were associated with higher risks of significant TR and lead impingement. Lead impingement was associated with a high risk of significant TR. Pacemaker-mediated TR remains a significant problem after lead implantation.

Impact of Rheumatic Process in Left and Right Ventricular Function in Patients with Mitral Regurgitation.

Background: Mitral regurgitation (MR) burdens the left and right ventricles with a volume or pressure overload that leads to a series of compensatory adaptations that eventually lead to ventricular dysfunction, and it is well known that in rheumatic heart disease (RHD) that the inflammatory process not only occurs in the valve but also involves the myocardial and pericardial layers. However, whether the inflammatory process in rheumatic MR is associated with ventricular function besides hemodynamic changes is not yet established. Purpose: Evaluate whether rheumatic etiology is associated with ventricular dysfunction in patients with chronic MR. Methods: The study population comprised patients aged 18 years or older included in the registry who had echocardiography performed at the National Cardiovascular Center Harapan Kita in Indonesia during the study period with isolated primary MR due to rheumatic etiology and degenerative process with at least moderate regurgitation. Results: The current study included 1,130 patients with significant isolated degenerative MR and 276 patients with rheumatic MR. Patients with rheumatic MR were younger and had a higher prevalence of atrial fibrillation and pulmonary hypertension, worse left ventricle (LV) ejection fraction and tricuspid annular plane systolic excursion (TAPSE) value, and larger left atrium (LA) dimension compared to patients with degenerative mitral regurgitation (MR). Gender, age, LV end-systolic diameter, rheumatic etiology, and TAPSE were independently associated with more impaired LV ejection fraction. Whereas low LV ejection fraction, LV end-systolic diameter, and tricuspid peak velocity (TR) peak velocity >3.4 m/s were independently associated with more reduced right ventricle (RV) systolic function (Table 3). Conclusions: Rheumatic etiology was independently associated with more impaired left ventricular function; however, rheumatic etiology was not associated with reduced right ventricular systolic function in a patient with significant chronic MR.

Clinical and Hemodynamic Factors Associated with Low Gradient Severe Rheumatic Mitral Stenosis.

Discrepancy between narrowed mitral valve area and transmitral gradient is not uncommon, suggesting the presence of low gradient (LG)-severe mitral stenosis (MS). Some clinical and hemodynamic factors are believed to associate with LG-severe MS. Transthoracic echocardiography reports were reviewed retrospectively to evaluate the association of all clinical and hemodynamic parameters with LG-severe MS. A 36% of total 322 patients was in the LG-severe MS group. In multivariate analysis, atrial fibrillation (95% confidence interval [CI] 4.60-16.71, odds ratio [OR] 8.77), net atrioventricular compliance > 4 mL/mm Hg (95% CI 3.96-14.25, OR 7.51), tricuspid regurgitation maximal velocity (TR Vmax) > 3.4 m/s (95% CI 0.13-0.48, OR 0.25), stroke volume index ≤ 35 mL/m 2 (95% CI 1.49-6.25, OR 3.05), female gender (95% CI 1.30-5.33, OR 2.63), and severe tricuspid regurgitation (95% CI 1.04-5.50, OR 2.39) were found to be associated with LG-severe MS. Atrial fibrillation, net atrioventricular compliance, TR Vmax, stroke volume index, female gender, and severe TR were associated with low transmitral gradient in patients with severe MS.

Recommendations for the Use of Echocardiography in the Evaluation of Rheumatic Heart Disease: A Report from the American Society of Echocardiography.

Acute rheumatic fever and its chronic sequela, rheumatic heart disease (RHD), pose major health problems globally, and remain the most common cardiovascular disease in children and young people worldwide. Echocardiography is the most important diagnostic tool in recognizing this preventable and treatable disease and plays an invaluable role in detecting the presence of subclinical disease needing prompt therapy or follow-up assessment. This document provides recommendations for the comprehensive use of echocardiography in the diagnosis and therapeutic intervention of RHD. Echocardiographic diagnosis of RHD is made when typical findings of valvular and subvalvular abnormalities are seen, including commissural fusion, leaflet thickening, and restricted leaflet mobility, with varying degrees of calcification. The mitral valve is predominantly affected, most often leading to mitral stenosis. Mixed valve disease and associated cardiopulmonary pathology are common. The severity of valvular lesions and hemodynamic effects on the cardiac chambers and pulmonary artery pressures should be rigorously examined. It is essential to take advantage of all available modalities of echocardiography to obtain accurate anatomic and hemodynamic details of the affected valve lesion(s) for diagnostic and strategic pre-treatment planning. Intraprocedural echocardiographic guidance is critical during catheter-based or surgical treatment of RHD, as is echocardiographic surveillance for post-intervention complications or disease progression. The role of echocardiography is indispensable in the entire spectrum of RHD management.

The effect of external counterpulsation on intrinsic myocardial function evaluated by speckle tracking echocardiography in refractory angina patients: a randomized controlled trial.

External Counterpulsation (ECP) is one of the therapeutic options in patients with refractory angina inadequately controlled by medical, interventional, or surgical therapy. The 2D Speckle Tracking Echocardiography (2D-STE) method is considered superior in assessing clinical improvement. We would like to evaluate any improvement of myocardial intrinsic function using 2D-STE in patients underwent standard ECP protocol (35 sessions). We conducted a double-blind randomized controlled trial. Patients with refractory angina who could not be revascularized conventionally were randomized into two groups: (1) the ECP group (300 mmHg) and (2) the Sham/control group (75 mmHg). ECP standard therapy was given for 35 sessions (1 h/day/session). The 2D-STE data, including longitudinal strain and post systolic index (PSI) were obtained before and after therapy. 43 subjects were analyzed, with 22 subjects in ECP group and 21 control subjects (Sham group). A homogenous baseline strain was found either globally (12.42 ± 4.55 vs 12.00 ± 4.92 [- %]; P = 0.774) or segmentally/regionally (12.63 (0.01-25.16) vs 12.43 (0.01-27.20) [- %]; P = 0.570). There was no statistically significant improvement between groups in the left ventricle longitudinal strain globally (P = 0.535) and segmentally/regionally (P = 0.434). PSI parameters showed improvement in the ECP group (P = 0.049), and segments with PSI ≥ 20% seemed to improve longitudinal strains in the ECP group after therapy (P = 0.042). In conclusion, 35 ECP therapy sessions did not improve either global or segmental/regional left ventricular mechanical function in patients with refractory angina. However, the mechanical function of myocardial segments with PSS tends to improve after ECP therapy.

Two Barricades in a Row Mixed Lesion of Dynamic Left Ventricular Outflow Tract Obstruction and Aortic Stenosis: Finding the Culprit for Decision Making.

Concurrent lesions of dynamic left ventricular outflow tract obstruction (DLVOTO) with aortic stenosis pose a challenge in the measurement of the pressure gradient and severity of each lesion. Determining the true culprit lesion is difficult and challenging. The establishment of true culprit lesion is crucial in deciding the future course of action. We present two cases of concurrent DLVOTO and aortic stenosis. Although the composition of lesions is similar, the severity of each lesion was different and described a variety of technical problems. Finding the culprit through the shape of the stenotic jet from the continuous wave Doppler as well as other different technical approaches is the critical point of this case report. The first patient showed nonsignificant DLVOTO with severe aortic stenosis in which transthoracic echocardiography (TTE) alone was sufficient to find the culprit. Meanwhile, the second patient concluded to have significant DLVOTO with moderate aortic stenosis based on TTE and transesophageal echocardiography examination data. Jet morphology from Doppler examination is a crucial finding to differentiate DLVOTO with aortic stenosis, along with other parameters that might help find the dominant lesion. Multiple modalities with several tailor-made technical considerations might be needed to establish a culprit lesion.

Echocardiography Screening for Latent Rheumatic Heart Disease: What Can We Do in Indonesia?

Rheumatic heart disease (RHD), a sequela of acute rheumatic fever (ARF), is a preventable disease but remains a significant health problem, especially in developing countries. It causes disability, poor quality of life, early mortality, and national economic burden. The World Heart Federation (WHF) aimed to achieve a 25% reduction in premature deaths from ARF and RHD among individuals aged <25 years by 2025. Primordial and primary prophylaxis of RHD is aimed to prevent the occurrence of ARF, while the goal of secondary and tertiary prophylaxis is to limit the progression and reduce the consequences of RHD. Early recognition of RHD is important for early prophylaxis strategies to inhibit any progression to advanced stages. In 2012, WHF introduced the latest echocardiographic criteria to recognize the early stage of RHD. This includes the evaluation of pathological regurgitation jet and morphological features of RHD based on 2D, color, and spectral Doppler criteria. In remote areas, portable echocardiography is preferable for RHD screening. Previous portable devices were only capable of producing 2D and color images. Hence, a simplified echocardiographic criterion without spectral Doppler evaluation is needed in selected areas. Indonesia is a developing country, an archipelago with a population of over 250 million. Currently, there are no data on ARF incidence and RHD prevalence nationwide. The only data available are the number of patients in advanced stages who came to referral centers for further management. The screening program has to be introduced in Indonesia as part of national RHD prophylaxis.

Association between late gadolinium enhancement and global longitudinal strain in patients with rheumatic mitral stenosis.

The correlation between the extent of myocardial fibrosis and subclinical left ventricle (LV) systolic dysfunction in rheumatic mitral stenosis (MS) has not been widely studied. We sought to evaluate the correlation between the extent of LV myocardial fibrosis quantified by late gadolinium enhancement (LGE) using cardiac magnetic resonance (CMR) and global longitudinal strain (GLS) by speckle tracking echocardiography (STE) in patients with rheumatic MS. We prospectively evaluated 36 consecutive rheumatic MS patients who were planning to undergo mitral valve surgery. Then we evaluate the correlation between the extent of LV myocardial fibrosis quantified by LGE CMR and the systolic LV function by GLS using STE. Thirty-six patients with mean age of 45.7 ± 9.9 years old, showed mean LGE was 4.9 ± 2.7%. The mean LV ejection fraction (EF) measured by CMR was 50 ± 10.8%, and the mean LV GLS was 13.5 ± 3.9%. There was a moderate correlation between GLS and LGE (r - 0.432, p = 0.009). There were no correlations between GLS with mitral valve area (MVA) with r 0.149, p = 0.385, mean mitral valve gradient (MVG) with r -0.078, p = 0.653, and LVEF (r 0.299, p = 0.076). There was a moderate correlation between LGE and GLS in patients with rheumatic MS.

Amplatzer Cardiac Plug for Stroke Prevention in Patients with Atrial Fibrillation and Bigger Left Atrial Appendix Size.

Left atrial appendage (LAA) dimensions have been shown as an independent predictor of higher risk for stroke in AF patients. Little data exist on the outcomes after LAA closure in patients with nonvalvular atrial fibrillation (NVAF) who have relatively bigger LAA size. This study aims to evaluate the results associated with LAA closure with the Amplatzer cardiac plug (ACP, AGA, St. Jude Medical, Minneapolis, MN) in bigger LAA size. A total of 25 patients with NVAF underwent LAA closure with the ACP device. All patients received short-term (up to 3 months) dual-antiplatelet therapy (clopidogrel and aspirin) after the procedure and aspirin only thereafter. A transesophageal echocardiography was performed in all patients at the 3- and 6-month follow-ups. No patient was lost to follow-up (≥ 12 months in all patients). The mean age, CHA2DS2-VASc score, and HAS-BLED score were 66.2 ± 8.79 years; 3.2 ± 1.46 and 2.4 ± 1.0, respectively. The average sizes of the LAA landing zone and ostium were 23.08 ± 5.0 and 24.9 ± 4.4 mm, respectively. The procedure was successful in 23 (92%) patients and was canceled in 2 (8%) patients due to huge LAA dimensions. In 56% of the patients "pull and release" technique is needed to appropriately implant the ACP. During a mean follow-up of 12 months, no cases of periprocedural stroke and no mortality were observed. In patients with NVAF at high risk of cardioembolic events and big LAA size, LAA closure using the ACP device is safe and effective.

The MitraClip Asia-Pacific registry: Differences in outcomes between functional and degenerative mitral regurgitation.

OBJECTIVES: The objective of this study is to describe and compare the use of the MitraClip therapy in mitral regurgitation (MR) patients with degenerative MR (DMR) and functional MR (FMR). INTRODUCTION: Percutaneous edge-to-edge repair of severe MR using the MitraClip device is approved for use in the USA for high risk DMR while European guidelines include its use in FMR patients as well. METHODS: The MitraClip in the Asia-Pacific Registry (MARS) is a multicenter retrospective registry, involving eight sites in five Asia-Pacific countries. Clinical and echocardiographic characteristics, procedural outcomes and 1-month outcomes [death and major adverse events (MAE)] were compared between FMR and DMR patients treated with the MitraClip. RESULTS: A total of 163 patients were included from 2011 to 2014. The acute procedural success rates for FMR (95.5%, n = 84) and DMR (92%, n = 69) were similar (P = 0.515). 45% of FMR had ≥2 clips inserted compared to 60% of those with DMR (P = 0.064).The 30-day mortality rate for FMR and DMR was similar at 4.5% and 6.7% respectively (P = 0.555). The 30-day MAE rate was 9.2% for FMR and 14.7% for DMR (P = 0.281). Both FMR and DMR patients had significant improvements in the severity of MR and NYHA class after 30 days. There was a significantly greater reduction in left ventricular end-diastolic diameter (P = 0.002) and end systolic diameter (P = 0.017) in DMR than in FMR. CONCLUSIONS: The MitraClip therapy is a safe and efficacious treatment option for both FMR and DMR. Although, there is a significantly greater reduction in LV volumes in DMR, patients in both groups report clinical benefit with improvement in functional class. © 2015 Wiley Periodicals, Inc.

Percutaneous mitral valve repair with the MitraClip: early results from the MitraClip Asia-Pacific Registry (MARS).

AIMS: Percutaneous MitraClip therapy has been shown to be safe and efficacious in mitral regurgitation (MR). Our aim was to describe early outcomes in patients from the Asia- Pacific region. METHODS AND RESULTS: The MitraClip Asia-Pacific Registry (MARS) includes data from eight different centres in five countries in the Asia-Pacific region. The primary efficacy outcome was reduction in MR to ≤2+ at 30 days. The safety outcome was 30-day freedom from major adverse events (MAE), defined as the composite of death, myocardial infarction, non-elective cardiac surgery, renal failure, transfusion of ≥2 units of blood, ventilation for >48 hours, septicaemia, and new onset atrial fibrillation. A total of 142 patients underwent the MitraClip procedure from February 2011 to October 2013. Fifty-three point five percent (76) of patients had functional MR, 45.8% (65) had degenerative MR and 0.7% (1) had mixed MR. The acute procedural success rate was 93.7% (133). Thirty-one point seven percent of the patients were in NYHA Class I-II at baseline, compared to 82.1% at 30 days (p<0.001). Zero percent (0) of the patients had ≤2+ MR at baseline compared to 76.8% (109) at 30 days (p<0.001). CONCLUSIONS: Results from the Asia-Pacific region show that the MitraClip procedure is effective in reducing mitral regurgitation and has favourable short-term safety outcomes.