Left-atrial volume reduction reflects improvement of cardiac sympathetic nervous function in patients with severe aortic stenosis after transcatheter aortic valve replacement.

Trans-catheter aortic valve replacement (TAVR) is an excellent alternative intervention for surgical aortic valve replacement. Cardiac sympathetic nervous (CSN) function and left atrial (LA) volume are both important prognostic factors in patients with aortic stenosis (AS) after TAVR. The relationship between the two clinical factors is unknown, however. This retrospective observational study aimed to assess the correlation between CSN function and LA volume in 48 symptomatic patients with severe AS (median age: 85 years, IQR 82-88 years; 81% female) before and after TAVR. CSN function was assessed by performing 123I-metaiodobenzylguanidine (MIBG) scintigraphy before and 6 months after TAVR, and the delayed heart-to-mediastinum ratio (dHMR) and washout rate (WR) were calculated. We also performed transthoracic echocardiography near the same time. TAVR improved the dHMR, WR, and LA volume index (LAVI) (dHMR: median 2.89 [IQR 2.62-3.23] vs. 2.98 [2.49-3.25], p = 0.0182; WR: 28% [24-38] vs. 23% [16-32], p < 0.0001; LAVI: 47.7 mL/m2 [37.8-56.3] vs. 41.2 mL/m2 [33.7-56.1], p = 0.0024). In multiple linear regression analysis, the percentage change in LAVI from baseline to post-TAVR (∆LAVI%) was an independent predictor of change in dHMR from baseline to post-TAVR (ß = - 0.35, p = 0.0110). In conclusion, LA volume reduction reflected CSN functional improvement after TAVR. In patients with TAVR, ∆LAVI% might be a valuable parameter for evaluating CSN functional recovery.

Impact of the distribution of epicardial and visceral adipose tissue on left ventricular diastolic function.

Although epicardial adipose tissue (EAT) and abdominal visceral adipose tissue (VAT) can contribute to left ventricular diastolic dysfunction (LVDD), the impact of these distribution has not been fully understood. A total of 235 patients who underwent cardiac computed tomography angiography and Doppler echocardiography was included in this study. We evaluated the association of indexed EAT volume and VAT area with septal and lateral early diastolic mitral annular velocity (e'). The VAT area index was significantly associated with septal and lateral e' velocity after adjusted for conventional cardiovascular risk factors and obstructive coronary artery disease (ß-estimate; - 0.015 and - 0.019, both p = 0.01). The natural logarithmic EAT volume index (ln EAT volume index) also showed a significant association with septal and lateral e' (ß-estimate; - 1.72 and - 0.99, both p < 0.01). The significant association of ln EAT volume index with septal and lateral e' was observed even after adjusting for VAT area index (ß-estimate; - 0.79 and - 1.52, both p < 0.03). In the subgroup analysis, there were significant association of ln EAT volume index with both septal and lateral e' in the lower VAT group (ß-estimate; - 1.40 and - 1.53, both p < 0.03) and with lateral e' in the higher VAT group (ß-estimate - 1.64, p = 0.006). In contrast, ln EAT volume index was not associated with septal e' in the higher VAT group (p = 0.98). EAT accumulation was significantly associated with LVDD independently of obstructive coronary artery disease and abdominal VAT. The impact of EAT on LVDD may vary depending on the amount of abdominal VAT.

Factors Influencing Cardiac Sympathetic Nervous Function in Patients With Severe Aortic Stenosis: Assessment by 123I-Metaiodobenzylguanidine Myocardial Scintigraphy.

BACKGROUND: Numerous studies have shown that 123I-metaiodobenzylguanidine (MIBG) scintigraphy, an index of cardiac sympathetic nervous (CSN) activity, is useful for predicting prognosis in patients with heart failure. However, the factors influencing the CSN activity of patients with severe aortic stenosis (AS) remain unclear. METHODS: We enrolled 91 patients with severe AS who underwent 123I-MIBG scintigraphy, coronary computed tomography (CCT), and transthoracic echocardiography. When CCT angiography (CCTA) showed an obstructive epicardial artery, invasive coronary angiography was performed within 1 week of CCTA. RESULTS: There were 21 male and 70 female patients with a mean age of 84±5 years. Eighty-five (85) patients (93%) had hypertension and 13 patients (14%) had diabetes. Two (2) patients (2%) had previous myocardial infarction and eight (9%) had a previous coronary intervention. All patients had severe AS: aortic valve area was 0.63±0.18 cm2 and the mean pressure gradient was 56±19 mmHg. Regarding 123I-MIBG parameters, early heart-to-mediastinum (H/M) ratio was 3.1±0.5, delayed H/M ratio was 2.8±0.6, and the washout rate (WR) was 35%±13%. Multivariable linear regression analysis showed that coronary artery disease (ß=-0.30, p=0.002) was an independent predictor of delayed H/M ratio, and that aortic valve area (ß=-0.20, p=0.048) was an independent predictor of WR. CONCLUSIONS: Our findings suggest that coronary artery disease is an independent predictor of delayed H/M ratio, and aortic valve area is an independent predictor of WR in patients with severe AS.

Impact of Percutaneous Edge-to-Edge Repair in Patients With Atrial Functional Mitral Regurgitation.

BACKGROUND: The aim of this study was to clarify the clinical outcomes of patients with atrial functional mitral regurgitation (FMR) who underwent the MitraClip procedure compared with those with conventional FMR and sinus rhythm (SR).Methods and Results:Of 303 patients with FMR who underwent the MitraClip procedure, 40 with "atrial-FMR" defined as FMR with permanent atrial fibrillation and normal left ventricular (LV) function/size and 115 with "sinus-FMR" defined as FMR with SR and LV dysfunction were reviewed. Transthoracic and 3D transesophageal echocardiography, and the cardiac complication rate (composite of all-cause death, heart failure admission, mitral valve (MV) surgery, and redo MitraClip procedure) during the 12-month follow-up were compared between the groups. After the MitraClip procedure, reductions in the mitral annular area and its anteroposterior dimension and in the leaflet closure area were observed in both groups. MV orifice area was smaller with greater transmitral pressure gradient (P<0.05) after the procedure in atrial-FMR patients than in those with sinus-FMR. The prevalence of residual MR was similar, but significant tricuspid regurgitation (TR) was more prevalent in the atrial-FMR group at follow-up. Cardiac complication rate was comparable between groups (20% vs. 25%, P=0.63). CONCLUSIONS: Reduction of MR occurred in atrial-FMR probably because of the increase in leaflet coaptation area. Significant TR was more common after the MitraClip procedure in patients with atrial-FMR than with sinus-FMR. However, mid-term outcomes were comparable between patients with atrial-FMR and sinus-FMR.

Effects of aging on coronary flow reserve in patients with no evidence of myocardial perfusion abnormality.

Coronary flow reserve (CFR) reflects the functional capacity of microcirculation to adapt to blood demand during increased cardiac work. We tested the hypothesis that aging had impacts on coronary flow velocities and CFR in patients with no evidence of myocardial perfusion abnormality on single photon emission computed tomography (SPECT). Seventy-six patients undergoing transthoracic Doppler echocardiography with no evidence of myocardial perfusion abnormality on SPECT were enrolled in this study. CFR was defined as the ratio of hyperemic to resting peak diastolic coronary flow velocity. Patients were divided into the three groups based on age: 17 patients aged less than 70 years (Group I), 38 patients aged 70-79 years (Group II), and 21 patients aged 80 years or more (Group III). Compared with Group I, CFR was significantly lower in Group II (p < 0.01) and Group III (p < 0.01). Multivariate linear regression analysis showed that female (ß = - 0.26, p = 0.03), cigarette smoking (ß = - 0.32, p = 0.004), hemoglobin level (ß = - 0.40, p = 0.001) and LV mass index (ß = 0.24, p = 0.03) were determinants for resting coronary flow velocity. On the other hand, age (ß = -0.30, p = 0.008), hemoglobin level (ß = -0.47, p < 0.001) and LV mass index (ß = 0.24, p = 0.04) were determinants for hyperemic coronary flow velocity. Age was only determinant for CFR (ß = -0.48, p < 0.001). Our data suggested that that aging had a decreased effect on hyperemic coronary flow velocity rather than resting coronary flow velocity, and was further associated with impaired CFR in patients with no evidence of myocardial perfusion abnormality.

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.

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.

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.

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.

Impact of the Coronary Artery Calcium Score on Mid- to Long-Term Cardiovascular Mortality and Morbidity Measured With Coronary Computed Tomography Angiography.

BACKGROUND: Although the coronary artery calcium score (CACS) is a prognostic measurement in asymptomatic individuals, it is measured in symptomatic patients using coronary computed tomography angiography (CCTA). We aimed to examine the predictive value of the CACS for mid- to long-term cardiovascular mortality and morbidity in patients who underwent CCTA. Methods and Results: We studied 736 patients with suspected coronary artery disease (CAD) who underwent CCTA. During a median follow-up period of 6.5 years, there were 39 primary outcomes (composite of cardiovascular disease death, non-fatal myocardial infarction, and non-fatal stroke). The estimated 10-year cumulative rates of the primary outcome were significantly increased across CACS classes (3.9%, 9.2%, 11.8%, and 18.2% in CACS of 0, 1-99, 100-399, and ≥400, respectively, P<0.001). These rates of cardiovascular disease death and stroke were also significantly increased across CACS classes. Multivariate Cox proportional hazard analysis showed that a CACS ≥100 was independently predictive for the primary outcome (hazard ratio [HR] 2.82, 95% confidence interval [CI] 1.40-6.00, P=0.003), as well as the presence of ≥50% stenosis on CCTA (HR 2.27, 95% CI 1.13-4.46, P=0.022). CONCLUSIONS: An elevated CACS with the use of CCTA is an independent predictor of mid- to long-term cardiovascular mortality and morbidity in patients suspected of having CAD.

Severe heart failure (NYHA Class IV) is associated with increased left ventricular mass index and short mitral deceleration time in severe aortic valve stenosis.

BACKGROUND: In aortic valve stenosis (AS), congestive heart failure (CHF) is a well-established symptom that indicates the need for surgical aortic valve replacement (SAVR). However, it is difficult to judge whether CHF symptoms such as dyspnea are caused by severe AS or other conditions, especially in elderly persons with restricted mobility or other organ complications. It is important to identify objective and noninvasive parameters associated with severe CHF symptoms in severe AS. METHODS: One hundred ninety-eight patients with severe AS without left ventricular (LV) dysfunction were retrospectively studied. CHF symptoms were classified by New York Heart Association (NYHA) functional class. Echo parameters were compared between NYHA I-III and NYHA IV. RESULTS: Patients with NYHA IV (n = 40; 20%) were older (86 ± 6 vs 82 ± 8 years; P = .001) and had a larger LV mass index (LVMI) (157 ± 43 vs 114 ± 34 g/m2 , P < .001), a higher transmitral flow velocity ratio (E/A) (1.31 ± 0.62 vs 0.93 ± 0.42; P = .001), a shorter deceleration time (DT) (202 ± 72 vs 286 ± 98 ms; P < .001), and a higher systolic pulmonary arterial pressure (SPAP) (44 ± 13 vs 35 ± 13 mm Hg; P < .001) than patients with NYHA I-III. On multivariable analysis, LVMI and DT were independently associated with NYHA IV. Receiver operating characteristic curve analysis identified LVMI ≥ 142 g/m2 and DT ≤ 194 ms as the cutoff values associated with NYHA IV in patients with severe AS. CONCLUSION: Left ventricular mass index and DT were independently associated with severe heart failure (NYHA IV). These echo parameters could be helpful to judge whether CHF symptoms are caused by severe AS.

Impact of Mitral Annular Displacement on Left Ventricular Diastolic Function Improvement After Transcatheter Aortic Valve Implantation.

BACKGROUND: The clinical significance of left ventricular (LV) diastolic function (DF) improvement after transcatheter aortic valve implantation (TAVI) is not fully elucidated. We sought to investigate the long-term clinical and hemodynamic effects of post-TAVI DF improvement and to identify its determinants.Methods and Results:Clinical and serial echocardiographic data before and after TAVI were retrospectively reviewed together with measurement of mitral annular displacement (MAD) representing longitudinal myocardial function in 98 patients with severe aortic stenosis and ejection fraction >55%. DF grade was determined as 0-III according to the current guideline. Patients with ≥1-grade improvement in DF at 1 year (n=59, 60%) showed a better recovery of New York Heart Association functional class, plasma B-type natriuretic peptide level, stroke volume index, and averaged e', and a greater decrease in systolic pulmonary artery pressure than those without DF improvement (all P<0.05). Coronary artery disease (odds ratio (OR), 0.30; 95% confidence interval (CI), 0.11-0.84; P=0.022) and averaged MAD (per 2.5 mm increase; OR, 4.11; 95% CI, 2.18-7.72; P<0.001) were predictors of post-TAVI DF improvement. An averaged MAD cutoff value of 10.7 mm discriminated cases of improvement with a sensitivity of 88% and specificity of 64%. CONCLUSIONS: Post-TAVI DF improvement may be associated with preserved LV longitudinal function and when present may be accompanied by more favorable clinical and hemodynamic changes.

Vena contracta analysis by color Doppler three-dimensional transesophageal echocardiography shows geometrical differences between prolapse and pseudoprolapse in eccentric mitral regurgitation.

AIMS: Evaluation of eccentric mitral regurgitation (MR) remains extremely difficult and the role played by its etiology, functional or degenerative, is not well understood. This study aimed to demonstrate the value of three-dimensional transesophageal echocardiography (3DTEE) in the evaluation of eccentric MR identifying geometric differences in the vena contracta area between functional and degenerative etiologies. METHODS AND RESULTS: We studied 61 patients with eccentric MR (30 functional and 31 degenerative). Regurgitant orifice area was determined by the two-dimensional proximal isovelocity surface area (2DPISA) and the 3DTEE methods. The ratio between maximum and minimum lengths of the vena contracta was calculated in each patient. Effective regurgitant orifice area by the 2DPISA method was smaller than that estimated by 3DTEE (0.56±0.21 vs 0.72±0.25 cm2 ). A better correlation between both methods was seen in degenerative mitral regurgitation (DMR; r=.83), with a mean underestimation of 8.2% by the 2DPISA method. A much worse correlation was found in functional mitral regurgitation (FMR; r=.39), where a mean underestimation by the 2DPISA method of 29.1% was observed. There was a more elongated and curved vena contracta in FMR compared to that in DMR (length ratio: 3.4±1.0 vs 2.2±0.7, P<.0001). CONCLUSION: Three-dimensional transesophageal echocardiography identifies a more elongated regurgitant orifice in eccentric FMR compared to that in eccentric DMR. This difference may explain the greater underestimation of effective regurgitant orifice area by the 2DPISA method in FMR. High-quality 3DTEE analysis of vena contracta area would be a highly recommended alternative.

Evaluation of vegetation size and its relationship with septic pulmonary embolism in tricuspid valve infective endocarditis: A real time 3DTEE study.

BACKGROUND: Tricuspid valve infective endocarditis (TVIE) causes septic pulmonary embolism (PE). However, the impact of vegetation size on PE is not fully elucidated. METHODS: In 26 consecutive patients with definite TVIE according to Duke criteria, we tested clinical, microbiological, and echocardiographic data including real time three-dimensional transesophageal echocardiography (3DTEE) as potential predictors of PE. 3DTEE measurement of maximum length of vegetation (MLV) was obtained with Advanced QLAB Quantification Software by cropping the 3D volume with the appropriate 2D plane to obtain the largest value. The standard two-dimensional transesophageal echocardiography (2DTEE) images were also evaluated to determine the MLV. RESULTS: Pulmonary embolism occurred after TVIE diagnosis with 3DTEE assessment and initiation of antibiotic therapy in 12 patients (46.2%). The 3DTEE MLV was larger than the 2DTEE value with a mean difference of 3.6 mm (95% CI, 2.5-4.6 mm). The best cutoff value for prediction of PE was MLV ≥16.4 mm with 3DTEE and MLV ≥9.5 mm with 2DTEE. The positive predictive value increased from 76.9% to 90% when 3DTEE was used. The accuracy of classification of patients with PE increased from 80.6% to 84.9% with 3DTEE. On multivariate analysis, 3DTEE MLV ≥16.4 mm (odds ratio 20.5; 95% confidence interval 1.31-322; P=.031) was independently associated with the occurrence of PE after adjustment for age, sex, complex vegetation, and the number of vegetation-attached leaflets. CONCLUSIONS: In TVIE, vegetation length is a strong predictor of the occurrence of PE. In combination with 2DTEE, 3DTEE may identify high-risk patients who will need a more aggressive therapeutic strategy.

Mitral systolic velocity at peak exercise predicts impaired exercise capacity in patients with heart failure with preserved ejection fraction.

BACKGROUND: Nearly half of patients with heart failure have normal left ventricular ejection fraction (LVEF), but their prognosis is no better than those with reduced LVEF. Although peak oxygen consumption (VO2 ) is an independent predictor of mortality in heart failure, it is unclear how cardiac function during exercise contributes to peak VO2 . Therefore, we explored the useful parameters measured by exercise stress echocardiography to predict peak VO2 in patients with heart failure with preserved LVEF (HFpEF). METHODS AND RESULTS: We assessed 80 patients being investigated for effort intolerance or dyspnea and finally analyzed 50 patients who satisfied the HFpEF criteria. Mean peak VO2 was 16.4±2.8 mL/kg/min. Twenty-three patients (46.0%) achieved a peak VO2 <16.0 mL/kg/min (Weber class C or D). There was a significant relationship between mitral systolic velocity (S') and cardiac output (CO) at rest (R=.55, P<.0001) and peak exercise (R=.64, P<.0001). The absolute increase in S' from rest to peak exercise also correlated with the absolute increase in CO (R=.32, P=.02). Multivariate logistic regression analysis showed that S' at peak exercise independently predicted peak VO2 . Receiver-operator characteristic curve analysis identified that an S' at peak exercise of ≤8.13 cm/s predicted a peak VO2 <16.0 mL/kg/min (sensitivity 95.7%, specificity 44.4%, area under curve 0.70, 95% confidence interval 0.55-0.84, P=.004). CONCLUSIONS: Mitral systolic velocity at peak exercise accurately reflects peak VO2 and may facilitate stratification of risk in patients with HFpEF.

Distant Position of Chordae from Coaptation Causes Mitral Regurgitation in Patients with Atrial Fibrillation.

BACKGROUND: The study aim was to investigate the mechanism of mitral regurgitation (MR) in lone atrial fibrillation (AF) patients using three-dimensional (3D) transesophageal echocardiography (TEE). METHODS: A retrospective analysis was conducted of 64 patients with AF and a normal left ventricle, and without prolapse of the mitral valve. Among these patients, significant MR was not identified in 33 cases (AF+MR- group) but was present in 31 cases (AF+MR+ group). The distance from the coaptation to the bending point of the anterior mitral leaflet (AML), where the chorda was attached, was termed the 'bending length'. The ratio of the bending length to the distance from coaptation to anterior mitral annulus was termed the 'bending ratio' (= bending length/coaptation-annulus length). The mitral annular area (MAA) fractional change was defined as follows: (MAA at late systole - MAA at early systole)/MAA at late systole × 100%). Other parameters relating to mitral valve morphology obtained using 3D TEE were measured with commercial software (QLAB, Phillips). RESULTS: The coaptation length (CL) was smaller in the AF+MR+ group than in the AF+MR- group (p<0.001), and correlated significantly with the anteriorposterior diameter of the mitral annulus (R = 0.286, p = -0.022), MAA at mid-systole (R = -0.269, p = 0.032), MAA fractional change (R = 0.434, p <0.001), and the bending ratio (R = -0.603, p <0.001). With a multivariable analysis, the correlating factors of significant MR in lone AF patients were a decrease in MAA fractional change (p = 0.022) and an increase of the bending ratio (p = 0.009). CONCLUSIONS: Small MAA fractional changes and the distant position of the chordae tendineae on the AML from the coaptation correlated with significant MR in AF patients with normal left ventricular systolic function.

Effects of the topographical extent of coronary artery ectasia on coronary blood flow in patients with aortic aneurysms.

Aortic aneurysms are associated with coronary artery ectasia (CAE). However, the relation between the extent of CAE and coronary blood flow in patients with aortic aneurysms is not fully understood. This study was undertaken to assess the angiographic characteristics and effects of the topographical extent of CAE on coronary blood flow in patients with aortic aneurysms. This study consisted of 93 consecutive patients with aortic aneurysms (AA group) and 79 patients without aortic aneurysms who had angiographically normal coronary arteries as the control group (Control group). Coronary flow velocity was determined using the thrombolysis in myocardial infarction frame count (TFC) and the topographical extent of CAE was assessed. In the AA group, 43 patients (46.2 %) had significant coronary artery stenosis and 37 patients (40.2 %) had diffuse CAE. TFC was significantly higher in the AA group than in the control group in all 3 coronary arteries. Furthermore, mean corrected TFC (CTFC) was significantly higher in the AA group than in the control group (40.1 ± 10.7 vs. 25.8 ± 6.5, p < 0.001). In the AA group, mean CTFC in patients with diffuse CAE was significantly higher than that in patients with segmental CAE (50.2 ± 8.7 vs. 33.6 ± 5.2, p < 0.001). The mean CTFC correlated positively with the topographical extent of CAE. Many patients with aortic aneurysms were accompanied with angiographic coronary artery stenosis and CAE. Furthermore, patients with aortic aneurysms had higher CTFC than those without aortic aneurysms and it was primarily driven by more frequent prevalence of diffuse CAE.

Significant Reduction in Mitral Regurgitation Volume Is the Main Contributor for Increase in Systolic Forward Flow in Patients with Functional Mitral Regurgitation after Transcatheter Aortic Valve Replacement: Hemodynamic Analysis Using Echocardiography.

BACKGROUND: Reduction in mitral regurgitation (MR) after transcatheter aortic valve replacement (TAVR) has previously been reported. However, the hemodynamic effects of TAVR in patients with MR have not been previously evaluated. METHODS: We analyzed 571 patients who underwent TAVR from December 2010 to December 2013. We studied 20 patients with moderate or severe preprocedural functional mitral regurgitation (FMR) who also had a follow-up transthoracic echocardiography (TTE) examination between 90 and 360 days (median 213 days) after TAVR (Significant FMR Group). We also studied age- and gender-matched 20 patients with mild or lesser MR (Nonsignificant MR Group). Left ventricular functional measurements were assessed using echocardiography before and after TAVR. Left ventricular outflow tract stroke volume measurements using pulsed-wave Doppler (SVLVOT ) were calculated as a representative of systolic forward flow, and stroke volume by the Simpson's method (SVSimpson ) was calculated as a parameter of degree of LV contraction. RESULTS: MR grade improved in 22 of 40 patients after TAVR. In both groups, BNP level decreased, left ventricular ejection fraction increased, and SVLVOT increased after TAVR. SVSimpson increased in the Nonsignificant MR Group and remained unchanged in the Significant FMR Group. Vena contracta width of MR (MRVC) decreased in the Significant FMR Group. Using multivariable analysis in the Significant FMR Group, the increase in SVLVOT significantly correlated with the decrease in MRVC (P < 0.05). CONCLUSIONS: SVLVOT increased significantly after TAVR in patients with FMR. In these patients, increase in SVLVOT after TAVR was associated with decrease in severity of MR.

Value of resting echocardiographic findings and dobutamine stress echocardiography for diagnosing myocardial ischemia in patients with suspected angina pectoris.

BACKGROUND: We evaluated the diagnostic value of resting echocardiographic findings including total heart calcification (THC) score in combination with dobutamine stress echocardiography (DSE) for detection of myocardial ischemia. METHODS: Altogether, 110 patients with suspected angina pectoris underwent resting echocardiography and DSE. On the basis of resting echocardiography, we determined the THC score, left anterior descending artery diastole-to-systole velocity ratio (LAD-DSVR), and positive myocardial velocity during isovolumic relaxation phase (VIVR ) detected by color-coded tissue Doppler imaging. Myocardial ischemia was diagnosed by a 25% or greater reduction in the internal diameter of major coronary vessels with impaired fractional flow reserve (FFR ≤0.80). RESULTS: DSE had excellent specificity (89%) but modest sensitivity (52%) for wall-motion abnormality (WMA) analysis. Multivariate analysis showed that THC score ≥2 (odds ratio and 95% confidence interval: 4.49 [2.29-10.6]; P = 0.018), LAD-DSVR ≤1.5 (6.43 [1.39-20.3], P = 0.019), and duration of positive VIVR ≥71 msec (7.93 [3.72-12.1]; P < 0.001) were independent predictors of ischemia. The combination of inducible WMA and THC score yielded significantly higher sensitivity for ischemia detection than the inducible WMA alone (80% vs. 52%, P = 0.0008). Using receiver operating characteristics analyses, adding all three resting echocardiographic findings to clinical variables plus inducible WMA further improved prediction of ischemia (P = 0.028). CONCLUSIONS: Integration of DSE and resting echocardiographic findings describing degree of heart calcification, impaired LAD flow, and extent of delayed ejection motion of the myocardium improves detection of coronary angiogram-based FFR-guided ischemia.

Insulin resistance and subclinical abnormalities of global and regional left ventricular function in patients with aortic valve sclerosis.

BACKGROUND: Insulin resistance, as a key mediator of metabolic syndrome, is thought to be associated with pathogenesis of calcific aortic valve disease and altered left ventricular (LV) function and structure. However, in patients with aortic valve sclerosis (AVS), the association between insulin resistance and subclinical impairment of LV function is not fully elucidated. METHODS: We studied 57 patients (mean age 70 ± 8 years, 22 women) with asymptomatic AVS but normal LV ejection fraction in echocardiography. LV longitudinal and circumferential strain and strain rate was analyzed using two-dimensional speckle tracking echocardiography. Patients with uncontrolled hypertension and diabetes mellitus, chronic kidney disease, and concomitant coronary artery disease were excluded. They were divided into the insulin-resistant group (AVS+IR; N = 28) and no insulin-resistant group (AVS-IR; N = 29) according to the median value of homeostatic model assessment index. Computed tomography scans were also performed to measure the aortic valve calcium score and the visceral adipose tissue (VAT) area. In addition, age- and sex- adjusted 28 control subjects were recruited for the comparison. RESULTS: There were no significant differences in LV ejection fraction or mass index among the groups. The AVS+IR group had a higher aortic valve calcium score (median 94 versus 21, P = 0.022) and a larger VAT area (113 ± 42 cm2 versus 77 ± 38 cm2, P = 0.001) than the AVS-IR group. Notably, LV global longitudinal strain, strain rate (SR), and early diastolic SR were significantly lower in the AVS+IR group than in the AVS-IR group and in control subjects (strain: -16.2 ± 1.6% versus -17.2 ± 1.2% and -18.9 ± 0.8%; SR: -1.18 ± 0.26 s(-1) versus -1.32 ± 0.21 s(-1) and -1.52 ± 0.08 s(-1); early diastolic SR: -1.09 ± 0.23 s(-1) versus -1.23 ± 0.18 s(-1) and -1.35 ± 0.12 s(-1); P < 0.05 for all comparison), whereas circumferential function were not significantly different. Multiple linear regression analyses revealed insulin resistance as an independent determinant of LV longitudinal strain (P = 0.017), SR (P = 0.047), and early diastolic SR (P = 0.049) regardless of LV mass index or VAT area. CONCLUSIONS: Insulin resistance is a powerful independent predictor of subclinical LV dysfunction regardless of concomitant visceral obesity and LV hypertrophy. Thus, it may be a novel therapeutic target to prevent subsequent heart failure in patients with AVS.