Left Atrial Stiffness Index as a Predictor of Effort Intolerance and Hemodynamics Evaluated by Invasive Exercise Stress Testing in Degenerative Mitral Regurgitation.

In patients with degenerative mitral regurgitation (DMR), peak oxygen consumption is the significant prognostic factor, and exercise intolerance has been considered a trigger for surgical intervention. The significant mitral regurgitation (MR) induces left atrial (LA) remodeling, but the significance of LA stiffness calculated by the ratio of E/e' to LA reservoir strain in degenerative MR has not been elucidated. A total of 30 patients with asymptomatic or minimally symptomatic grade ≥III + DMR underwent the cardiopulmonary exercising test simultaneously with invasive hemodynamic assessment. LA stiffness index significantly correlated with exercise hemodynamic deterioration, including pulmonary arterial wedge pressure (r = 0.71, p <0.01), systolic pulmonary arterial pressure at peak exercise (r = 0.73, p <0.01), and pulmonary circulatory reserve (mean pulmonary arterial pressure/cardiac output slope, r = 0.45, p = 0.012). Multiple linear regression analysis revealed that the higher LA stiffness index was significantly associated with decreased percent predicted peak oxygen consumption (per 0.1 increase, ß -4.0, 95% confidence interval -6.9 to -1.3, p <0.01) independently of MR deterioration during exercise. In conclusion, increased LA stiffness was associated with exercise intolerance through hemodynamic deterioration during exercise in patients with asymptomatic or minimally symptomatic severe DMR.

Determinants of Exercise-Induced Mitral Regurgitation Using Three-Dimensional Transesophageal Echocardiography Combined With Isometric Handgrip Exercise.

Using three-dimensional (3D) transesophageal echocardiography (TEE) and isometric handgrip exercise (IHE), we investigated the determinants of exercise-induced mitral regurgitation (MR) according to MR etiologies. Seventy-six patients with more than moderate MR, 40 patients with functional MR (FMR) and 36 patients with degenerative MR (DMR), underwent 3D TEE combined with IHE. Mitral valve (MV) geometry and 3D vena contracta area (3D VCA) were simultaneously evaluated at baseline and during IHE. With regard to exercise-induced MR, Δ3D VCA was calculated as the difference between 3D VCA at baseline and 3D VCA during IHE. IHE caused different changes in MV geometry between etiologies and led to exacerbation of 3D VCA at baseline. Larger Δ3D VCA was observed in the FMR group compared with the DMR group (15.9 ± 10.3 mm2 versus 7.3 ± 4.2 mm2; p < 0.0001). In multivariate analyses, tenting height and 3D VCA were selected as independent factors associated with Δ3D VCA in the FMR group (p = 0.0135 and p = 0.0201, respectively), while flail width was selected as an independent factor associated with Δ3D VCA in the DMR group (p = 0.0066). In conclusion, IHE alters mitral valve geometry and causes exacerbation of MR regardless of MR etiology and the determinants of exercise-induced MR differed between MR etiologies.

Impact of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement on Changes in Cardiac Sympathetic Nervous Function.

The impact of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) on changes in cardiac sympathetic nervous (CSN) function remains unclear. Using 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy, we investigated the impact of PPM after TAVR on CSN activity.We enrolled 44 of 117 patients with severe aortic stenosis who underwent TAVR for analysis in the present study. We conducted 123I-MIBG scintigraphy at baseline and at about 9 months after TAVR. Differences between baseline and post-TAVR 123I-MIBG parameters were compared between cases with and without PPM.There were 17 and 27 patients with and without PPM, respectively. Those without PPM exhibited significantly decreased left ventricular mass index (122 ± 36 g/m2 versus 108 ± 30 g/m2, P < 0.001) following TAVR, whereas those with PPM did not (117 ± 21 g/m2 versus 110 ± 17 g/m2, P = 0.09). Significant improvements in delayed heart-to-mediastinum (H/M) ratio (2.8 ± 0.4 versus 3.0 ± 0.4, P = 0.004) and washout rate (WR) (33% ± 10% versus 24% ± 12%, P < 0.001) were observed after TAVR in patients without PPM but not in those with PPM. Multivariable linear regression analysis revealed PPM to be a negative predictor of improvements in delayed H/M ratio and WR.Delayed H/M ratio and WR improve significantly after TAVR in the absence of PPM, whereas these improvements are not observed in patients with PPM. Hence, the presence of PPM is a negative predictor of improvements in delayed H/M ratio and WR in patients undergoing TAVR.

Tricuspid valve geometry and right heart remodelling: insights into the mechanism of atrial functional tricuspid regurgitation.

AIMS: We sought to investigate tricuspid valve (TV) geometry and right heart remodelling in atrial functional tricuspid regurgitation (AF-TR) as compared with ventricular functional TR with sinus rhythm (VF-TR). METHODS AND RESULTS: Transoesophageal 3D echocardiography datasets of the TV and right ventricle were acquired in 51 symptomatic patients with severe TR (AF-TR, n = 23; VF-TR, n = 28). Three-dimensional right ventricular (RV) endocardial surfaces were reconstructed throughout the cardiac cycle and then postprocessed using semiautomated integration and segmentation software to calculate position of papillary muscle (PM) tips. Compared with VF-TR, AF-TR had more dilated and posteriorly displaced annulus and less leaflet tethering angles with more prominent right atrium and smaller RV end-systolic volume. On the XY (annular) plane, the centre of annulus was getting closer towards the anterior and posterior PM tips and was going away from the medial PM tip caused by prominent annular dilatation in AF-TR. On the Z-axis, the position of each PM tip in AF-TR was not so much displaced apically as that in VF-TR. Multiple linear regression analyses revealed that right atrial volume and right atrial/RV end-systolic volume ratio were determinants of annular area and orientation in AF-TR, respectively (both P < 0.001). Additionally, the posteromedial-directed component of posterior PM tip position and the apically directed component of the position of all three PM tips were independently associated with TV tethering angles of each leaflet in AF-TR (all P < 0.02). CONCLUSION: Right heart remodelling and its association with 3D TV geometry differ entirely between AF-TR and VF-TR, which may offer distinctive therapeutic implication.

Non-Invasive Central Venous Pressure Measurement Using Enclosed-Zone Central Venous Pressure (ezCVPTM).

BACKGROUND: Central venous pressure (CVP) is measured to assess intravascular fluid status. Although the clinical gold standard for evaluating CVP is invasive measurement using catheterization, the use of catheterization is limited in a clinical setting because of its invasiveness. We developed novel non-invasive technique, enclosed-zone (ezCVPTM) measurement for estimating CVP. The purpose of this study was to assess the feasibility of ezCVP and the relationship between ezCVP and CVP measured by a catheter.Methods and Results:We conducted 291 measurements in 97 patients. Linear regression analysis revealed that ezCVP was significantly correlated with CVP (r=0.65, P<0.0001). The Bland-Altman analysis showed that ezCVP had an underestimation bias of -2.5 mmHg with 95% limits of agreement of -14.1 mmHg and 9.6 mmHg for CVP (P<0.0001). The areas under the curves of receiver operating curve with ezCVP to detect the CVP ≥12 cmH2O (8.8 mmHg) and CVP >10 mmHg were 0.81 or 0.88, respectively. The sensitivity, specificity and positive likelihood ratio of ezCVP for the CVP ≥8.8 mmHg and CVP >10 mmHg were 0.59, 0.96 and 14.8 with a cut-off value of 11.9 and 0.79, 0.97 and 26.3 with a cut-off value of 12.7. CONCLUSIONS: These findings suggest that ezCVP measurement is feasible and useful for assessing CVP.

Successful catheter ablation of persistent atrial fibrillation is associated with improvement in functional tricuspid regurgitation and right heart reverse remodeling.

Atrial fibrillation (AF) is a common disease that changes cardiac morphology, especially in the left atrium (LA). It is now known that certain categories of functional mitral regurgitation (MR) are associated with AF; however, the influence of AF on right cardiac morphology is not fully understood. Our aim in this study was to investigate the association between AF and right cardiac morphology. This was a retrospective cohort study of 86 patients with persistent AF without other cardiac disease who underwent catheter ablation (CA). Seventy-one patients had sustained sinus rhythm (SR) (SR Group) and 15 patients had sustained AF (AF Group) during the study period. We compared the changes in the right cardiac dimensions and tricuspid regurgitation (TR) between the groups 12 months after CA. Patients' baseline echocardiographic assessments revealed that the LA volume index was significantly smaller in the SR group than in the AF group (46.8 ± 11.9 ml/m2 vs 59.3 ± 12.8 ml/m2, respectively; p < 0.01). Comparing baseline data with the 12-month follow-up data, in the SR group, right atrial area (RAA, cm2), tricuspid annular diameter (mm), and tricuspid regurgitant jet area (cm2) were significantly decreased compared with the AF group (19.5 ± 4.5-15.5 ± 3.6 vs 20.7 ± 3.6-19.7 ± 2.3; 30.5 ± 4.9-26.4 ± 3.9 vs 28.7 ± 4.0-28.8 ± 3.1; and 1.4 [interquartile range (IQR) 0.7-2.6]-0.6 [IQR 0.2-1.2] vs 1.2 [IQR 1.1-1.5]-0.9 [IQR 0.4-1.3], respectively). On multivariate analysis, change in RAA correlated with the reduction in tricuspid regurgitant jet area (R = 0.51, p < 0.001). In conclusion, successful CA for persistent AF led to right heart reverse remodeling, and our findings suggested that persistent AF was associated with RAA dilatation and TR.

H2FPEF Score for the Prediction of Exercise Intolerance and Abnormal Hemodynamics in Japanese　- Evaluation by Exercise Stress Echocardiography Combined With Cardiopulmonary Exercise Testing.

BACKGROUND: Both the H2FPEF-score and nomogram-score, which consist of simple clinical parameters, can assist in diagnosing "early" heart failure with preserved ejection fraction (HFpEF) and only exertional dyspnea, but their these usefulness in Japanese remains unclear. We sought to investigate the correlation between these scores and exercise response, including the peak oxygen uptake (V̇O2), the pulmonary artery systolic pressure (PASP), the ratio of early diastolic transmitral flow velocity to early diastolic mitral annular velocity (E/e') and stroke volume (SV) using exercise stress echocardiography (ESE) combined with cardiopulmonary exercise testing (CPET).Methods and Results:In this single-center, retrospective cross-sectional study the H2FPEF-score and nomogram-score were calculated in a total of 139 patients who underwent ESE combined with CPET. The scores correlated with peak V̇O2(r=-0.48, r=-0.44), PASP (r=0.23, r=0.29) and SV (r=-0.32, r=-0.19) at peak exercise. The nomogram-score correlated with E/e' (r=0.24). The prevalence of exercise intolerance (percent predicted peak V̇O2<75% and <50%) increased as the H2FPEF-score increased and reached 88.9% and 22.2% among the patients with high H2FPEF-score (6-9 points). CONCLUSIONS: The H2FPEF-score may be useful as the initial step to diagnosing 'early' HFpEF. The nomogram-score may be more useful in Japanese because of its more universal association with exercise response than the H2FPEF-score.

Delivery balloon rupture during transcatheter heart valve alignment procedure in extreme descending aorta tortuosity.

A 79-year-old man with a history of partial resection of the lung and the bladder due to cancer, hypertension, dyslipidemia, and heart failure, underwent transcatheter aortic valve replacement with a SAPIEN 3 (S3) valve (Edwards Lifesciences, Irvine, CA, USA). Preprocedural examination showed a bicuspid aortic valve and severe calcification of the leaflets. Computed tomography showed great tortuosity of the descending aorta. A 29-mm S3 valve prosthesis was advanced into the aorta, but a high degree of resistance was encountered in the middle of the descending aorta. The prosthesis was advanced to the level of aortic valve and an attempt was made to deploy the valve. However, the valve balloon did not expand. A balloon rupture was suspected. The balloon catheter was pulled back into the eSheath (Edwards Lifesciences), and the catheter and eSheath were removed together. Rupture of the balloon was confirmed. A new eSheath and prosthesis were prepared, with delivery supported with a Lunderquist guidewire (Cook Medical, Bloomington, IN, USA). The valve alignment procedure was performed in a straighter portion of the descending aorta. The new 29-mm S3 valve was then successfully implanted. .

Comprehensive Evaluation of Tricuspid Regurgitation Location and Severity Using Vena Contracta Analysis: A Color Doppler Three-Dimensional Transesophageal Echocardiographic Study.

BACKGROUND: The clinical significance of three-dimensional (3D) vena contracta area (VCA) in tricuspid regurgitation (TR) is not fully elucidated. The aim of this study was to investigate the diagnostic accuracy of 3D VCA using 3D echocardiography-derived regurgitation volume as a reference standard. METHODS: One hundred sixteen patients with at least moderate TR underwent two-dimensional transthoracic and color Doppler 3D transesophageal echocardiography. The 3D vena contracta, which was located at the narrowest neck of the TR jet just above and toward the right atrial side of the flow convergence zone, was assessed for TR location and severity. RESULTS: As for TR location, patients with severe functional TR had the highest prevalence of central jet location among TR subgroups, whereas patients with severe primary TR showed a greater spatial extent of TR jet location involved compared with the moderate TR group (P < .05 for both). As for TR severity, a 3D VCA cutoff value of 0.61 cm2 discriminated severe TR with sensitivity of 78% and specificity of 97% in the total patient population (area under the curve = 0.93, P < .001). Multivariate analysis revealed that 3D VCA, a dilated right ventricle, and hepatic vein systolic reversal were independently associated with regurgitant volume (P < .001 for all). The χ2 value for the model that incorporated clinical and two-dimensional integrative parameters and 3D VCA > 0.61 cm2 to evaluate severe TR was significantly higher than that for the model that incorporated only clinical and two-dimensional integrative parameters (P = .001). CONCLUSIONS: Three-dimensional VCA has independent and incremental diagnostic value for evaluating severe TR. Comprehensive evaluation of TR location and severity using 3D vena contracta analysis may help in treatment selection for TR.

Early mitral inflow velocity to left ventricular global strain ratio predicts limited exercise capacity.

BACKGROUND: Estimation of left ventricular filling pressure (LVFP) is the essential part of the echocardiographic workup for exercise intolerance. The ratio of the mitral early filling velocity to the left ventricular global longitudinal strain (E/LVGLS) has emerged as a novel index of LVFP. This study aimed to investigate the relationship between E/LVGLS and exercise capacity. METHODS AND RESULTS: We retrospectively reviewed 90 patients with exertional dyspnea who underwent echocardiography and cardiopulmonary exercise test. Patients were classified into three groups according to their percent-predicted maximal oxygen consumption (ppVo2 ) (G â‰§ 75, ppVo2  > 75%, n = 20; G 50-75, ppVo2 75-50%, n = 57; G < 50, ppVo2  < 50%, n = 13). Measurements were (a) the relationship between ppVo2 and E/LVGLS and (b) the efficiency of integrated diastolic assessment using E/LVGLS, left ventricular volume, mitral annular early diastolic velocity (E'), and tricuspid regurgitation to identify the patient with impaired exercise capacity. Univariate linear regression analysis demonstrated that E/LVGLS had significant correlation with ppVo2 (ρ = 0.52, P < 0.001). The area under the ROC of E/LVGLS for ppVo2  < 50% was 0.86 (95%CI 0.75-0.97). The DeLong test showed that E/LVGLS was efficient to detect ppVo2  < 50% than E/E' (P = 0.007). When used in the integrated assessment of LVFP as the alternative for E/E', E/LVGLS improved risk classification for impaired exercise capacity. CONCLUSION: E/LVGLS may be a more efficient index than E/E' to identify exercise impairment as a single index and as a part of the integrated diastolic assessment.

Exercise-Stress Echocardiography and Effort Intolerance in Asymptomatic/Minimally Symptomatic Patients With Degenerative Mitral Regurgitation Combined Invasive-Noninvasive Hemodynamic Monitoring.

Background Effort intolerance, measured objectively by reduced peak oxygen consumption (Vo2), has been considered as an important prognosticator in degenerative mitral regurgitation (MR). However, its mechanism is unknown. Methods and Results In 25 asymptomatic/minimally symptomatic patients with grade III+ or greater degenerative MR undergoing semisupine invasive exercise testing, Doppler estimates and invasive measurement of systolic (SPAP) and mean pulmonary artery pressure (MPAP) and cardiac output (CO) were simultaneously obtained. Echocardiographic estimates of SPAP, MPAP, and CO correlated well with invasive measurement at peak exercise (bias, SPAP, -0.7±7.4 mm Hg; MPAP, 1.2±6.3 mm Hg; CO, 0.2±2.5 L/min). Heart rate reserve (ß, 3.997; 95% CI, 2.704-5.290 per 41.5% increase; P<0.001), MPAP/CO slope (ß, -3.846; 95% CI, -5.926 to -1.766 per 4.85 mm Hg/L per minute increase; P=0.001), and tricuspid annular plane systolic excursion/SPAP slope (ß, 4.094; 95% CI, 2.252-5.936 per 0.22 mm/mm Hg increase; P=0.003) were associated with peak Vo2 even after adjustment for increase in MR vena contracta during exercise and peak SPAP. The MPAP/CO slope of 4.13 had a sensitivity and a specificity for predicting effort intolerance (%predicted peak Vo2 <70%) of 57% and 91%, respectively, whereas the tricuspid annular plane systolic excursion/SPAP slope of 0.25 had a respective sensitivity and specificity of 86% and 82%. Conclusions The agreement between echocardiographic and invasive measures of pulmonary artery pressures and CO during exercise is acceptable. In patients with degenerative MR, effort intolerance is predominantly because of chronotropic incompetence, abnormal pulmonary vascular reserve, and limited right ventricular contractile reserve and not simply because of exercise-induced MR or pulmonary hypertension.

Occasionally increased 18F-fluorodeoxyglucose uptake in apical hypertrophic cardiomyopathy with mid-ventricular obstruction.

We report on a 77-year-old man who was diagnosed with apical hypertrophic cardiomyopathy (HCM) with mid-ventricular obstruction. He had a cured hepatitis C infection. We detected occasionally increased 18F-fluorodeoxyglucose (18F-FDG) uptake on whole-body positron emission tomography (PET)/computed tomography (CT) performed to examine the involvement of bladder carcinoma. 18F-FDG-PET was restudied following specific preparation involving an 18-h low-carbohydrate diet and following 15-h fasting plus heparin pre-administration. Increased uptake of 18F-FDG was observed reproducibly in the hypertrophic apical to mid left ventricular myocardium, with a maximum standardized uptake value of 6.2. In contrast, relatively lower 18F-FDG-uptake areas tended to match areas of late gadolinium enhancement on cardiac magnetic resonance (CMR). Histopathological examination of myocardial biopsy showed disarried hypertrophic myocytes with cellular infiltration. Increased uptake of 18F-FDG may reflect the phenomenon of increased glucose utilization in hypertrophied myocardium. The increasing clinical utility of whole-body PET/CT for evaluating malignancies may increase the detection of occasional abnormal 18F-FDG uptake in the heart. It is necessary to clarify that 18F-FDG myocardial PET in combination with CMR may provide a more detailed risk assessment in patients with HCM. .