Left ventricular volumes by echocardiography in chronic aortic and mitral regurgitations.

Objectives Cut-off values for left ventricular (LV) dimensions indicating severe valve regurgitation have not been defined. The aim of this study was to establish echocardiographic cut-off values for LV dimensions indicating severe chronic aortic (AR) or mitral (MR) regurgitation. Design The hemodynamic significance was confirmed by documented reduction of end-diastolic volume (EDV) and symptom relief after surgery. Eighty-three patients with moderate or severe regurgitation (AR, n = 41; MR, n = 42) without other cardiac conditions underwent prospectively two-dimensional (2DE), real-time three-dimensional (RT3DE) echocardiography and cardiovascular magnetic resonance (CMR) exams within 4 h. Results The relationship between EDVCMR and EDV2DE and EDVRT3DE were strong (R 0.95 and 0.91). EDV index cut-offs for 2DE/RT3DE >87/104 ml/m(2) identified AR patients with severe regurgitation with a positive likelihood ratio (PLR) of 5.0/5.0. The corresponding in patients with MR EDV index cut-offs were >69/87 ml/m(2) with a PLR of 14.9/5.5. LV linear dimensions could not identify patients with severe regurgitation. Conclusions LV volumes by echocardiography can support the diagnosis of severe chronic regurgitation. Importantly, other causes for LV enlargement have to be considered.

Multiparametric right ventricular assessment improves risk stratification in patients with new-onset acute heart failure.

AIMS: Risk stratification of patients with new-onset acute heart failure (AHF) is important but remains challenging. In the present study, we evaluated the prognostic value of a new multiparameter right ventricular dysfunction (RVD) score. METHODS AND RESULTS: Patients (n = 210) hospitalized due to new-onset AHF between 2015 and 2018 were retrospectively included. Mean age was 56 ± 10 years, 24% were female and median left ventricular ejection fraction was 28% (interquartile range 20; 34%). The RVD score, tricuspid annular plane systolic excursion (TAPSE), and fractional area change (FAC) were determined at index hospitalization and after therapy titration. The 4-point RVD score included reduced TAPSE, right ventricular enlargement, moderate or severe tricuspid regurgitation and increased central venous pressure. The study endpoint was a composite of all-cause mortality, left ventricular assist device implantation, and heart transplantation. After 60 months median follow-up time, 53 (25%) patients met the endpoint. At index hospitalization, there were no significant differences in any echocardiographic parameter between patients with and without the endpoint. After therapy titration, there were differences in TAPSE (16 vs. 19 mm, P = 0.001), FAC (33 vs. 40%, P < 0.001) and the proportion of patients with RVD score ≥2 (36 vs. 4%, P < 0.001). The presence of RVD despite therapy titration had different impact on survival depending on the parameter considered: the proportion of patients free from events after 1 year was 87% in patients with TAPSE <17 mm, 89% in patients with FAC <35% and 65% in patients with RVD score ≥2. In a multivariable analysis, RVD score ≥2 after therapy titration, but not TAPSE <17 mm or FAC < 35%, remained associated with a higher risk of the composite endpoint (hazard ratio 3.11, 95% confidence interval 1.44-6.74). CONCLUSIONS: A novel multiparametric RVD score might improve prognostic stratification in patients with new-onset AHF. RVD after therapy titration, but not at index hospitalization is associated with a higher risk of the composite endpoint.

Pulmonary Hypertension Phenotype Can Be Identified in Heart Failure With Reduced Ejection Fraction Using Echocardiographic Assessment of Pulmonary Artery Pressure With Supportive Use of Pressure Reflection Variables.

BACKGROUND: Pulmonary hypertension (PH) is frequent in patients with heart failure and reduced ejection fraction (HFrEF) with 2 different phenotypes: isolated postcapillary PH (IpcPH) and, with the worst prognosis, combined pre- and postcapillary PH (CpcPH). The aims of the present echocardiography study were to investigate (1) the ability to identify PH phenotype in patients with HFrEF using the newly adopted definition of PH (mean pulmonary artery pressure >20 mm Hg) and (2) the relationship between PH phenotype and right ventricular (RV) function. METHODS: One hundred twenty-four patients with HFrEF consecutively referred for heart transplant or heart failure workup were included with echocardiography and right heart catheterization within 48 hours. We estimated systolic pulmonary artery pressure (sPAPDoppler) and used a method to detect increased pulmonary vascular resistance (>3 Wood units) based on predefined thresholds of 3 pressure reflection (PRefl) variables (the acceleration time in the RV outflow tract [RVOT], the interval between peak RVOT and peak tricuspid regurgitant velocity, and the RV pressure augmentation following peak RVOT velocity). RESULTS: Using receiver operator characteristic analysis in a derivation group (n = 62), we identified sPAPDoppler ≥35 mm Hg as a cutoff that in a test group (n = 62) increased the likelihood of PH 6.6-fold. The presence of sPAPDoppler >40 mm Hg and 2 or 3 positive PRefl variables increased the probability of CpcPH 6- to 8-fold. A 2-step approach with primarily assessment of sPAPDoppler and the supportive use of PRefl variables in patients with mild/moderate PH (sPAPDoppler 41-59 mm Hg) showed 76% observer agreement and a weighted kappa of 0.63. The steady-state (pulmonary vascular resistance) and pulsatile (compliance, elastance) vascular loading are increased in both IpcPH and CpcPH with a comparable degree of RV dysfunction. CONCLUSIONS: The PH phenotype can be identified in HFrEF using standard echocardiographic assessment of pulmonary artery pressure with supportive use of PRefl variables in patients with mild to moderate PH.

Cardiac sarcoidosis and giant cell myocarditis after COVID-19 infection.

Patients infected with SARS-CoV-2 have varying manifestations of cardiac involvement. We report four patients presenting with symptomatic cardiac sarcoidosis (CS) or giant cell myocarditis (GCM) 1-8 months after mild COVID-19. All patients received immunosuppressive therapy and improved gradually within the following months. The possible temporal association between the CS/GCM and COVID-19 infection might suggest that COVID-19 could be a trigger for granulomatous myocarditis.

Grading right ventricular dysfunction in left ventricular disease using echocardiography: a proof of concept using a novel multiparameter strategy.

AIMS: Grading right ventricular dysfunction (RVD) in patients with left ventricular (LV) disease has earned little attention. In the present study, we established an echocardiographic RVD score and investigated how increments of the score correspond to RVD at right heart catheterization. METHODS AND RESULTS: We included 95 patients with LV disease consecutively referred for heart transplant or heart failure work-up with catheterization and echocardiography within 48 h. The RVD score (5 points) included well-known characteristics of the development from compensated to decompensated right ventricular (RV) function: pulmonary hypertension, reduced RV strain, RV area dilatation, moderate/severe tricuspid regurgitation, and increased right atrial pressure (RAP) by echocardiography. Comparing three groups with increments of RVD score [1 (mild), 2-3 (moderate), and 4-5 (severe)] showed more advanced RVD with increasing RV end-diastolic pressure (P < 0.001) and signs of uncoupling to load (reduced ratio between RV and pulmonary artery elastance, P < 0.001) and more spherical RV shape (RV area/length, P < 0.001). Receiver operating characteristic curve analysis for detection of severe RV (RAP ≥ 10 mmHg) showed for the RVD score an area under the curve of 0.88 compared with 0.69, 0.68, and 0.64 for RV strain, tricuspid annular plane systolic excursion, and fractional area change, respectively. A patient with RVD score ≥ 4 had a 6.7-fold increase in likelihood of severe RVD, and no patient with RVD score ≤ 1 had severe RVD. CONCLUSIONS: In this proof of concept study, a novel RVD score outperformed the widely used longitudinal parameters regarding grading of RVD severity, with a potential role for refined diagnosis, follow-up, and prognosis assessment in heart failure patients.