2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Strain echocardiography to describe left ventricular function pre- and postexercise in elite basketball athletes: A feasibility study.

BACKGROUND: Elite athletes show structural cardiac changes as an adaptation to exercise. Studies examining strain in athletes have largely analyzed images at rest only. There is little data available regarding the change in strain with exercise. Our objectives were: to investigate the feasibility of strain analysis in athletes at peak exercise, to determine the normal range of left ventricular (LV) global longitudinal strain (GLS) within this population postexercise, to describe how LV GLS changes with exercise, and to determine whether any clinical characteristics correlate with the change in GLS that occurs with exercise. METHODS: We conducted a cross-sectional study on elite athletes who participated in the 2016-2018 National Basketball Association Draft Combines. Echocardiograms were obtained at rest and after completing a treadmill stress test to maximal exertion or completion of Bruce protocol. Primary outcomes included GLS obtained at rest and peak exercise. Secondary outcome was the change in GLS between rest and exercise. Univariate relationships between various clinical characteristics and our secondary outcome were analyzed. RESULTS: Our final cohort (n = 111) was all male and 92/111 (82.9%) were African American. Mean GLS magnitude increased in response to exercise (-17.6 ± 1.8 vs -19.2 ± 2.6, P < .0001). Lower resting heart rates (r = .22, P = .02) and lower heart rates at peak exercise (r = .21, P = .03) correlated with the increase in LV GLS from exercise. CONCLUSIONS: Strain imaging is technically feasible to obtain among elite basketball athletes at peak exercise. Normative strain response to exercise from this study may help identify abnormal responses to exercise in athletes.

Three-dimensional echocardiography for the assessment of the tricuspid valve.

Tricuspid valve pathology is increasingly recognized as an important contributor to patient morbidity. Accordingly, interest in transcatheter interventions for tricuspid valve disease has continued to grow. Echocardiographic imaging of the tricuspid valve has therefore become an integral component of patient assessment and the essential imaging modality for interventional procedures. The need for improved tricuspid valve imaging has highlighted the variability in tricuspid valve anatomy and the difficulties of using two-dimensional (2D) echocardiography alone to determine the location and type of tricuspid valve disease. Here, three-dimensional (3D) imaging using tools such as biplane imaging, multiplanar reconstruction and live 3D acquisition allow a more accurate and efficient evaluation of the tricuspid valve. The 3D imaging of the tricuspid valve is often focused on transesophageal echocardiography, but the more anterior location of the tricuspid valve also lends itself to assessment with transthoracic echocardiography. In this review, we will examine how 3D imaging can complement and enhance the information obtained from 2D echocardiography, and present novel applications for the quantitation of valvular disease and its utility in intraprocedural imaging.

Left atrial size and strain in elite athletes: A cross-sectional study at the NBA Draft Combine.

INTRODUCTION: Atrial dilatation is common but of unclear physiologic significance in high-performance athletes. Myocardial deformation analysis utilizing speckle-tracking echocardiography has emerged as a promising tool to evaluate atrial function. In a cohort of elite basketball players attending the National Basketball Association (NBA) Draft Combine, we investigate changes in left atrial (LA) size as well as function as measured by strain. METHODS AND RESULTS: From 2013 to 2018, all male athletes who attended the NBA Draft Combine in Chicago, IL, received a cardiac evaluation including a comprehensive transthoracic echocardiogram. Using the P-wave as the reference point, speckle-tracking was utilized to measure LA booster, conduit, and reservoir strain over one cardiac cycle. Left atrial volume index (LAVI) of ≥34 mL/m2 was considered enlarged. 307 athletes received cardiac evaluation including a transthoracic echocardiogram, with 272 studies amenable for atrial strain analysis. Mean age was 21.0 years. Mean LAVI was 34.5 mL/m2 and LAVI was enlarged in 131 (48.2%) athletes. Comparing LA strain in those with enlarged vs normal sized atria, reservoir strain was significantly reduced (32.1% [SD 6.0%] vs 35.2% [SD 8.2%], P < .001), as was conduit strain (22.9% [SD 5.2%] vs 25.7% [SD 7.4%], P < .001), with no difference seen in booster strain (9.2% [SD 2.1%] vs 9.4% [SD 2.7%], P = .45). CONCLUSION: In this group of elite basketball players, LA enlargement was common and associated with reduced LA reservoir and conduit strain, with no difference in LA booster strain.

Two-dimensional speckle-tracking strain detects subclinical cardiotoxicity in older patients treated for acute myeloid leukemia.

BACKGROUND: Patients with acute myeloid leukemia (AML) are surviving longer. There are no data on changes in myocardial mechanics from standard of care low-dose anthracycline-based induction chemotherapy in older patients with AML. The aim of this study was to demonstrate the potential utility of strain imaging in detecting early changes in left ventricular function in this patient population after induction chemotherapy. METHODS: Thirty two patients enrolled in the ECOG-ACRIN E2906 study (cytarabine and daunorubicin vs clofarabine [Genzyme/Sanofi]) from 2011 to 2014 were evaluated retrospectively. Two-dimensional transthoracic echocardiography (TTE) imaging with Doppler and two-dimensional speckle-tracking echocardiography (2DSTE) using EchoInsight software (Epsilon imaging) were performed before and after induction chemotherapy. RESULTS: Eighteen patients received cytarabine and daunorubicin (7 + 3) and 14 received clofarabine. The clofarabine group was older than the 7 + 3 cohort (67.8 ± 4.0 vs 63.7 ± 3.8, P = .007). There were no other significant differences in cardiac risk factors between groups. The 7 + 3 group had a decrease in average peak systolic global longitudinal (-19.1 ± 2.8 to -17.2 ± 3.0, P = .01) and circumferential strain (-29.4 ± 6.3 to -23.9 ± 4.3, P = .011). These changes were not demonstrated in the clofarabine group and were not associated with a decline in left ventricular ejection fraction (LVEF). CONCLUSIONS: In older AML patients, standard cytarabine and daunorubicin chemotherapy causes early changes in global longitudinal and circumferential strain not seen with clofarabine therapy. These findings demonstrate subclinical left ventricular dysfunction after exposure to low cumulative doses of anthracycline-based induction chemotherapy and may help us better identify those patients at risk for adverse long-term cardiovascular outcomes.

Three-dimensional echocardiography in the evaluation and management of paravalvular regurgitation.

Paravalvular regurgitation is an uncommon but serious complication that can be encountered after either surgical or percutaneous valve replacement and is associated with increased morbidity and mortality. Early detection and accurate assessment of paravalvular regurgitation are crucial to identify those who would benefit from intervention. Recent advances in 3-dimensional echocardiography have increased the feasibility of percutaneous approaches for the management of paravalvular regurgitation. Percutaneous closure of paravalvular regurgitation has emerged as a favorable alternative for redo surgery in selected cases. This article will review the role of 3-dimensional echocardiography in the assessment and management of paravalvular regurgitation.

Identification of prolapsing mitral valve scallops by a three-dimensional multiplanar reconstruction method.

BACKGROUND: The objectives of this study were twofold: to assess the diagnostic utility of three-dimensional (3D) multiplanar reconstruction (MPR) in identifying prolapsing mitral valve (MV) scallops, and (2) to compare two-dimensional (2D) transthoracic echocardiography (TTE) and 3DMPR to (2D) transesophageal echocardiography (TEE) approaches among patients with mitral valve prolapse (MVP). METHODS: Fifty-five patients with MVP who underwent MV repair or replacement were retrospectively analyzed using 3 types of echocardiographic studies (2DTEE, 2DTTE, 3DMPR). The operative (OR) findings were considered the gold standard. RESULTS: When 3DMPR was combined with 2DTTE, the agreement with the OR findings was moderately strong for the A2 scallop (P < 0.001) and strong for the A3 scallop (P = 0.001), entire anterior leaflet (P < 0.001), P2 scallop (P < 0.001) and the entire posterior leaflet (P < 0.001). In comparison to the OR findings, 2DTEE demonstrated moderately strong agreement for the A2 scallop (P = 0.010) and the entire anterior leaflet (P < 0.001), and strong agreement for the P2 scallop (P < 0.001) and entire posterior leaflet (P < 0.001). CONCLUSIONS: Three-dimensional MPR should be added to the armamentarium of complementary echo techniques in the evaluation of MVP. There is increased benefit in combining 3DMPR with 2DTTE findings as part of the preoperative evaluation of patients with MVP.

Two and three dimensional echocardiography for pre-operative assessment of mitral valve regurgitation.

Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. As the repair techniques for mitral valve disease evolved, so has the need for detailed and accurate imaging of the mitral valve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation. In patients with significant mitral valve disease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. However, a comprehensive TEE in a patient with complex mitral valve disease requires great experience and skill. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitral valve surgery. In the following sections, we review some of the crucial 2D and 3D echo images necessary for evaluation of MR based on the Carpentier classification.

Prevalence and Prognostic Implications of Pulmonary Hypertension in Patients With Severe Aortic Regurgitation.

Background: Pulmonary hypertension (PH) has been shown to be associated with worse outcomes in patients with aortic regurgitation (AR) in small older studies. Objectives: The authors sought to evaluate the prevalence of PH in patients with severe AR, its impact on mortality and symptoms, and regression after aortic valve replacement (AVR). Methods: A total of 821 consecutive patients with chronic ≥ moderate-severe AR on echocardiography from 2004 to 2019 were retrospectively analyzed. PH was defined as right ventricular systolic pressure (RVSP) >40 mm Hg on transthoracic echocardiogram (mild-moderate PH: RVSP 40-59 mm Hg, severe PH: RVSP > 60 mm Hg). Clinical and echocardiographic data were extracted from the electronic medical record and echocardiographic reports. The diastolic function and filling pressures were manually assessed and checked, and the left ventricular (LV) volumes were traced by a level 3-trained echocardiographer. The primary objectives were prevalence of PH in patients with ≥ moderate-severe AR, its risk associations and impact on all-cause mortality as the primary outcome. Secondary outcomes were impact of PH on symptoms and change in RVSP at discharge post-AVR. Logistic and Cox proportional hazards regression were used to analyze these outcomes. Results: The mean age was 61.2 ± 17 years, and 162 (20%) were women. Mild-moderate PH was present in 91 (11%) patients and severe PH in 27 (3%). Larger LV size, elevated LV filling pressures, and ≥ moderate tricuspid regurgitation were associated with PH. During follow-up of 7.3 (6.3-7.9) years, 188 patients died. Compared to those without PH, risk of mortality was higher in mild-moderate PH (adjusted HR: 1.59 (95% CI: 1.07-2.36) (P = 0.021)) and severe PH (adjusted HR: 2.90 (95% CI: 1.63-5.15) (P < 0.001)). Symptoms were also more prevalent in those with PH (P = 0.004). Of 396 patients who underwent AVR during the study period, 57 had PH. AVR similarly improved survival in patients without and with PH (P for interaction = 0.23), and there was regression in RVSP (≥8 mm Hg drop) at discharge post-AVR in 35/57 (61%) patients with PH. Conclusions: PH was present in 14% of patients with AR and was associated with higher mortality and symptoms. The survival benefit of AVR was similar in patients without and with PH.