Evaluation of the Truncated Cone-Rhomboid Pyramid Formula for Simplified Right Ventricular Quantification: A Cardiac Magnetic Resonance Study.

Background/Objective: Cardiac magnetic resonance (CMR) is the reference method for right ventricular (RV) volume and function analysis, but time-consuming manual segmentation and corrections of imperfect automatic segmentations are needed. This study sought to evaluate the applicability of an echocardiographically established truncated cone-rhomboid pyramid formula (CPF) for simplified RV quantification using CMR. Methods: A total of 70 consecutive patients assigned to RV analysis using CMR were included. As standard method, the manual contouring of RV-short axis planes was performed for the measurement of end-diastolic volume (EDV) and end-systolic volume (ESV). Additionally, two linear measurements in four-chamber views were obtained in systole and diastole: basal diameters at the level of tricuspid valve (Dd and Ds) and baso-apical lengths from the center of tricuspid valve to the RV apex (Ld and Ls) were measured for the calculation of RV-EDV = 1.21 × Dd2 × Ld and RV-ESV = 1.21 × Ds 2 × Ls using CPF. Results: RV volumes using CPF were slightly higher than those using standard CMR analysis (RV-EDV index: 86.2 ± 29.4 mL/m2 and RV-ESV index: 51.5 ± 22.5 mL/m2 vs. RV-EDV index: 81.7 ± 24.1 mL/m2 and RV-ESV index: 44.5 ± 23.2 mL/m2) and RV-EF was lower (RV-EF: 41.1 ± 13.5% vs. 48.4 ± 13.7%). Both methods had a strong correlation of RV volumes (ΔRV-EDV index = -4.5 ± 19.0 mL/m2; r = 0.765, p < 0.0001; ΔRV-ESV index = -7.0 ± 14.4 mL/m2; r = 0.801, p < 0.0001). Conclusions: Calculations of RV volumes and function using CPF assuming the geometrical model of a truncated cone-rhomboid pyramid anatomy of RV is feasible, with a strong correlation to measurements using standard CMR analysis, and only two systolic and diastolic linear measurements in four-chamber views are needed.

Echocardiographic determination of right ventricular volumes and ejection fraction: Validation of a truncated cone and rhomboid pyramid formula.

BACKGROUND: Echocardiographic assessment of right ventricular (RV) measurements may be challenging. The aim of this study was to develop a formula for calculation of RV volumes and function based on measurements of linear dimensions by 2-dimensional (2D) transthoracic echocardiography (TTE) in comparison to cardiovascular magnetic resonance (CMR). METHODS: 129 consecutive patients with standard TTE and RV analysis by CMR were included. A formula based on the geometric assumptions of a truncated cone minus a truncated rhomboid pyramid was developed for calculations of RV end-diastolic volume (EDV) and RV end-systolic volume (ESV) by using the basal diameter of the RV (Dd and Ds) and the baso-apical length (Ld and Ls) in apical 4-chamber TTE views: RV EDV = 1.21 * Dd2 * Ld, and RV ESV = 1.21 * Ds2 * Ls. RESULTS: Calculations of RV EDV (ΔRV EDV = 10.2±26.4 ml to CMR, r = 0.889), RV ESV (ΔRV ESV = 4.5±18.4 ml to CMR, r = 0.921) and RV EF (ΔRV EF = 0.5±4.0% to CMR, r = 0.905) with the cone-pyramid formula (CPF) highly agreed with CMR. Impaired RV function on CMR (n = 52) was identified with a trend to higher accuracy by CPF than by conventional echocardiographic parameters (tricuspid annular plane systolic excursion (TAPSE) and fractional area change (FAC)). CONCLUSION: Calculations of RV volumes and RV function by 2D TTE with the newly developed CPF were in high concordance to measurements by CMR. Accuracy for detection of patients with reduced RV function were higher by the proposed 2D TTE CPF method than by conventional echocardiographic parameters of TAPSE and RV FAC.

Transcatheter mitral valve repair is feasible and effective in oldest-old patients: results from real-world cohort.

OBJECTIVE: To evaluate the safety and efficacy of transcatheter mitral valve repair (TMVR) using MitraClip® devices in oldest-old patients compared to younger patients. METHODS: The study retrospectively included 340 consecutive patients who underwent TMVR. Patients were classified according to age into the oldest-old (age ≥ 85 years) patient group or the younger (age < 85 years) patient group. Immediate results of the procedure, intrahospital outcomes and one-year outcomes were compared. RESULTS: Oldest-old patients represented 15.9% (n = 54) of all patients. Procedure success was comparable for the oldest-old patient group and the younger patient group (92.6% vs. 95.8%, P = 0.30), and there was no difference in intrahospital mortality (9.2% vs. 4.2%, P = 0.12). At a one-year follow-up (interquartile range: 6-16 months), there was no significant difference in rehospitalization due to decompensated heart failure (25.5% vs. 34.3%, P = 0.24) or all-cause mortality (29.8% vs. 22.2%, P = 0.26) between the oldest-old patient group and the younger patient group. In patients with available echocardiographic follow-up, severity of residual mitral regurgitation was also comparable between the oldest-old patient group and the younger patient group. CONCLUSIONS: TMVR seems to be feasible and effective in oldest-old patients and should be considered for oldest-old patients presenting with symptomatic severe mitral regurgitation and high surgical risk.

Outcome of transcatheter edge-to-edge mitral valve repair in patients with diabetes mellitus: Results from a real-world cohort.

BACKGROUND: There are only limited data on patients with diabetes undergoing transcatheter edge-to-edge repair (TEER) in real-world settings. Previous data indicated patients with diabetes to have a worse prognosis. This study sought to evaluate safety and efficacy of TEER in patients with diabetes in a real-world cohort. METHODS: In this monocentric study 340 consecutive patients with severe primary and secondary mitral regurgitation (MR) undergoing TEER were included. Immediate results of the procedure, intrahospital and one-year outcome were compared between patients with and without diabetes. RESULTS: Diabetes was present in 109 patients (32%). Patients with diabetes were younger (77 y (71, 81) vs. 79 y (74, 83); p = 0.003), had more often ischemic cardiomyopathy (68% vs. 48%; p<0.001), previous coronary-artery bypass graft (35% vs. 20%; p = 0.002) and arterial hypertension (89% vs. 75%; p<0.001) compared to those without diabetes. Baseline NYHA class, type of MR (primary vs. secondary), left ventricular dimensions and function (ejection fraction: 37% (28, 50) vs. 40% (29, 55); p = 0.10) as well as severity of MR were not different between both groups. Success of the procedure (95% vs. 95%; p = 0.84), intrahospital mortality (5.5% vs. 4.8%; p = 0.98) and one-year follow-up regarding all-cause mortality (24.2% vs. 23.0%; p = 0.72), hospitalization for heart failure (37.4% vs. 31.0%, p = 0.23), NYHA class (p = 0.14) or MR severity (p = 0.59) did not differ between both groups. CONCLUSION: Our real-world data suggest that TEER seems to be similarly safe and effective in patients with severe MR and diabetes compared to those without diabetes.

Safety and efficacy of transcatheter mitral valve repair in patients with COPD; results from real-world cohort.

OBJECTIVE: To evaluate the safety and efficacy of transcatheter mitral valve repair (TMVR) in patients with chronic obstructive pulmonary disease (COPD). BACKGROUND: Heart failure and COPD share many clinical features and commonly coexist. Data about the safety and efficacy of TMVR in patients with COPD is not conclusive. METHODS: Three hundred and forty consecutive patients undergoing TMVR were retrospectively included. COPD diagnosis was based on pulmonary function tests (PFTs). Intra-hospital, 30-day- and 1-year outcomes were compared between both groups. RESULTS: Eighty-two patients had COPD (24%). There was no difference in intra-hospital mortality between patients with and without COPD (both 5%, p = 0.95). Among patients who had a successful procedure and survived to discharge there was a trend toward more rehospitalization due to decompensated heart failure at 30-day follow-up in patients with COPD (12.9% vs. 6.8%, p = 0.08) with no difference in mortality. At median follow-up of 1 year, New York heart association (NYHA) category was comparable among both groups and there was no significant difference in rehospitalization (COPD: 29.9% vs. non-COPD: 34%, p = 0.5). There was a trend toward increased 1-year mortality in COPD patients (31.2% vs. 20.6%, p = 0.06). However, a composite endpoint of rehospitalization or death at 1 year did not differ between both groups (48% vs. 42.5%, p = 0.4). Regression analysis showed no correlation between COPD severity and worse TMVR outcomes. CONCLUSIONS: COPD is highly prevalent among patients undergoing TMVR. However, TMVR seems to be safe and effective in COPD patients. COPD severity and PFT impairment alone should not be considered as a contraindication for TMVR.

Effects of COPD on Left Ventricular and Left Atrial Deformation in Patients with Acute Myocardial Infarction: Strain Analysis Using Speckle-Tracking Echocardiography.

Myocardial strain analysis, which describes myocardial deformation (shortening or lengthening), provides more detailed information about left ventricular (LV) and atrial (LA) functions than conventional echocardiography and delivers prognostic information. To analyze the effects of COPD on left heart function upon acute myocardial infarction (AMI), consecutive AMI patients were retrospectively screened, and patients were included if a post-AMI echocardiography and results of recent pulmonary function tests (PFTs) were available. Strain analysis was performed by a cardiologist who was blinded to clinical information. Overall, 109 AMI patients were included (STEMI: 38%, non-STEMI: 62%). COPD patients (41%) had significantly more impaired LV "global-longitudinal-strain" (LV-GLS) compared to non-COPD patients (−15 ± 4% vs. −18 ± 4%; p < 0.001, respectively), even after adjusting for LV-ejection-fraction (LVEF) and age (mean estimated difference: 1.7%, p = 0.009). Furthermore, COPD patients had more impaired LA strain (LAS) than non-COPD patients in all cardiac cycle phases (estimated mean differences after adjusting for LVEF and age: during reservoir phase: −7.5% (p < 0.001); conduit phase: 5.5% (p < 0.001); contraction phase: 1.9% (p = 0.034)). There were no correlations between PFT variables and strain values. In conclusion, the presence of COPD was associated with more impaired LV and LA functions after AMI, as detected by strain analysis, which was independent of age, LVEF, and PFT variables.

Chronic Subdural Hematoma.

BACKGROUND: Chronic subdural hematoma (cSDH) is typically a disease that affects the elderly. Neurosurgical evacuation is generally indicated for hematomas that are wider than the thickness of the skull. The available guidelines do not address the common clinical issue of the proper management of antithrombotic drugs that the patient has been taking up to the time of diagnosis of the cSDH. Whether antithrombotic treatment should be stopped or continued depends on whether the concern about spontaneous or postoperative intracranial bleeding, and a presumably higher rate of progression or recurrence, with continued medication outweighs the concern about a possibly higher rate of thrombotic complications if it is stopped. METHODS: In this article, we review publications from January 2015 to October 2020 addressing the issue of the management of antithrombotics in patients with cSDH that were retrieved by a selective search in the Pubmed and EMBASE databases, and we present the findings of a cohort study of 395 patients who underwent surgery for cSDH consecutively between October 2014 and December 2019. RESULTS: The findings published in the literature are difficult to summarize concisely because of the heterogeneity of study designs. Among the seven studies in which a group of patients on antithrombotics was compared with a control group, four revealed significant differences with respect to the risk of thromboembolic complications depending on previous antithrombotic use and the duration of discontinuation, while three others did not. In our own cohort, discontinuation of antithrombotics (including both plasmatic and antiplatelet drugs) was associated with thrombotic complications in 9.1% of patients. CONCLUSION: These findings imply that the management of antithrombotics should be dealt with critically on an individual basis. In patients with cSDH who are at elevated risk, an early restart of antithrombotic treatment or even an operation under continued antithrombotic therapy should be considered.

Prediction of procedural success of transcatheter mitral valve repair with normal and extended clip arms.

TMVR using different clip sizes is a treatment option for selected patients with mitral regurgitation (MR). This study sought to identify predictors of successful transcatheter mitral valve repair (TMVR) by 3-dimensional (3D) echocardiography and to compare different effects of the larger XTR and the smaller NT/NTR devices. 3D transesophageal echocardiography was performed on 54 patients with secondary MR undergoing TMVR with one clip (55.6% NT/NTR, 44.4% XTR). All NT/NTR and 96% of XTR patients had MR reduction ≤ 2+. Despite more severe baseline MR (3D vena contracta area (VCA): 0.67 ± 0.34 cm2 vs. 0.43 ± 0.19 cm2, p = 0.004) and greater mitral valve area (MVA) (6.8 ± 2.1 cm2 vs. 5.1 ± 1.6 cm2, p = 0.001) in the XTR group, MR severity after TMVR was not different between XTR and NT/NTR patients (3D VCA: 0.19 ± 0.14 vs. 0.17 ± 0.10, p = 0.51). Baseline 3D VCA > 0.45 cm2 in NT/NTR (AUC = 0.802, 95% CI 0.602 to 1.000) and 3D VCA > 0.54 cm2 in XTR devices (AUC = 0.868, 95% CI 0.719 to 1.000) were associated with ineffective MR reduction defined as residual VCA ≤ 0.2 cm2. Baseline MVA ≤ 4.2 cm2 in NT/NTR (AUC = 0.920, 95% CI 0.809 to 1.000) and MVA ≤ 6.0 cm2 in XTR devices (AUC = 0.865, 95% CI 0.664 to 1.000) were associated with postprocedural transmitral pressure gradient (TMPG) ≥ 5 mmHg. TMVR using the XTR device resulted in an equally effective reduction of MR despite of a greater baseline MR. Distinct cut-off values of baseline 3D VCA and MVA for prediction of successful MR reduction and postprocedural increase of TMPG were identified for the different devices.

Protected Percutaneous Coronary Intervention of Unprotected Left Main Using Impella Ventricular Assist Device Before Transcatheter Aortic Valve Implantation: A Single-Center Experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is nowadays the optimal therapeutic strategy in patients with severe aortic valve stenosis (AS). Consequently, percutaneous coronary intervention (PCI) of concomitant complex coronary artery disease (CAD) has increased in the last decade to optimize patients with severe AS before TAVI. Although the Impella ventricular assist device (Abiomed) was considered as a relative contraindication in patients with AS, its usage has demonstrated promising results in selected patients. METHODS: All consecutive patients with severe AS who underwent staged approach with high-risk PCI of unprotected left main (ULM) using the Impella ventricular assist device before TAVI were retrospectively included. The primary endpoint was 30-day all-cause mortality, and secondary endpoints were peri-interventional mortality, vascular complication, and 30-day stroke rates. Due to the exploratory, observational intent of the study, no statistical analysis was performed. RESULTS: Twenty-one consecutive patients (14 men; age, 80 ± 6 years; log EuroScore, 17 ± 7; SYNTAX score, 27 ± 10) were included. All patients (21/21) survived to 30-day follow-up exam. Three patients (14%) had PCI of ULM and TAVI at the same session. Eighteen patients (86%) underwent TAVI in a staged approach after previous PCI (10 ± 10 days). No patient suffered from stroke up to 30-day follow-up. One patient (5%) developed Valve Academic Research Consortium-2 major vascular complication after PCI. TAVI was successfully performed in all patients. CONCLUSION: Temporary hemodynamic support with the Impella device during staged approach with high-risk protected PCI appears to be safe and technically feasible in patients with severe AS before undergoing TAVI.

General Anesthesia Leads to Underestimation of Regurgitation Severity in Patients With Secondary Mitral Regurgitation Undergoing Transcatheter Mitral Valve Repair.

OBJECTIVES: To evaluate the effect of general anesthesia (GA) on severity of mitral regurgitation (MR) in patients undergoing transcatheter mitral valve repair (TMVR). DESIGN: Retrospective cohort study. SETTING: Tertiary care university hospital. PARTICIPANTS: Fifty consecutive patients with symptomatic severe MR and extremely high surgical risk. INTERVENTION: TMVR under GA. MEASUREMENTS AND RESULTS: Transesophageal echocardiography was performed during the preprocedural workup under conscious sedation and during TMVR under GA. After the parameters of MR were assessed, color-flow jet area (CJA), vena contracta (VC), effective regurgitant orifice area (EROA), regurgitant volume (RVOL), three-dimensional (3D) vena contracta area (VCA), and severity of MR were compared between the two examinations. In patients with primary MR (n = 11), there were no significant differences in CJA, VC, EROA, RVOL, or 3D-VCA between pre- and intraprocedural transesophageal echocardiography. In patients with secondary MR (n = 39), GA led to significant decreases of CJA (10 ± 7 v 7 ± 3 cm², p < 0.001), VC (5.5 ± 1.6 v 4.7 ± 1.5 mm, p = 0.002), EROA (30 ± 11 v 24 ± 10 mm², p < 0.001), and RVOL (47 ± 17 v 34 ± 13 mL/beat, p < 0.001). Consequently, GA led to a downgrade of regurgitation severity classification in 44% of patients when assessed by two-dimensional analysis. When evaluated by 3D analysis, GA also led to a significant but less extensive decrease of MR (3D-VCA: 66 ± 27 v 60 ± 29 mm², p = 0.002), and subsequent downgrade of MR classification in 20% of patients. CONCLUSIONS: GA underestimates regurgitation severity in patients with secondary, but not primary MR, undergoing TMVR. This effect must be considered when evaluating the immediate result of the procedure.

Incidence and clinical relevance of persistent iatrogenic atrial septal defect after percutaneous mitral valve repair.

Percutaneous mitral valve repair (PMVR) requires transseptal puncture and results in iatrogenic atrial septal defect (iASD). The impact of persistent iASD was previously investigated. However, data were diverse and inconclusive. 53 patients who underwent MITRACLIP were retrospectively included. Based on the presence of iASD in transesophageal echocardiography (TEE) after 6 months, patients were divided in two groups (iASD group vs. non-iASD group). Impact of iASD on outcome at 6 months and at two years was evaluated. Persistent iASD was detected in 62% of patients. Independent predictors for persistent iASD were female gender and reduced left ventricular ejection fraction. At 6-month follow-up, there was no difference in reduction of NYHA class (ΔNYHA = 1.3 ± 1 in iASD group vs. 0.9 ± 1 in non-iASD group, p = 0.171). There was a significant difference in right ventricular end diastolic diameter (RVEDd) (42 ± 8 mm in iASD-group vs. 39 ± 4 mm in non-iASD group, p = 0.047). However, right ventricular systolic function (TAPSE) (14 ± 7 mm in iASD group vs. 16 ± 8 mm in non-iASD group, p = 0.176) and right ventricular systolic pressure (RVSP) (40 ± 12 mmHg in iASD group vs. 35 ± 10 mmHg in non-iASD group, p = 0.136) were still comparable between both groups. At 2 years follow-up, there was no significant difference regarding rate of rehospitalization (24% vs 15%, p = 0.425) or mortality (12% vs 10%, p = 0.941) between both groups. Incidence of persistent iASD after MITRACLIP is markedly high. Despite the increase in right ventricular diameter in patients with persistent iASD, these patients were not clinically compromised compared to patients without persistent iASD.

Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness.

The echocardiographic assessment of mitral valve regurgitation (MR) by characterizing specific morphological features and grading its severity is still challenging. Analysis of MR etiology is necessary to clarify the underlying pathological mechanism of the valvular defect. Severity of mitral regurgitation is often quantified based on semi-quantitative parameters. However, incongruent findings and/or interpretations of regurgitation severity are frequently observed. This proposal seeks to offer practical support to overcome these obstacles by offering a standardized workflow, an easy means to identify non-severe mitral regurgitation, and by focusing on the quantitative approach with calculation of the individual regurgitant fraction. This work also indicates main methodological problems of semi-quantitative parameters when evaluating MR severity and offers appropriateness criteria for their use. It addresses the diagnostic importance of left-ventricular wall thickness, left-ventricular and left atrial volumes in relation to disease progression, and disease-related complaints to improve interpretation of echocardiographic findings. Finally, it highlights the conditions influencing the MR dynamics during echocardiographic examination. These considerations allow a reproducible, verifiable, and transparent in-depth echocardiographic evaluation of MR patients ensuring consistent haemodynamic plausibility of echocardiographic results.

Empagliflozin does not change cardiac index nor systemic vascular resistance but rapidly improves left ventricular filling pressure in patients with type 2 diabetes: a randomized controlled study.

BACKGROUND: In the EMPA-REG OUTCOME trial (Empagliflozin Cardiovascular Outcome Event Trial) treatment with the sodium-glucose cotransporter-2 (SGLT2) inhibitor empagliflozin significantly reduced heart failure hospitalization (HHF) in patients with type 2 diabetes mellitus (T2D) and established cardiovascular disease. The early separation of the HHF event curves within the first 3 months of the trial suggest that immediate hemodynamic effects may play a role. However, hitherto no data exist on early effects of SGLT2 inhibitors on hemodynamic parameters and cardiac function. Thus, this study examined early and delayed effects of empagliflozin treatment on hemodynamic parameters including systemic vascular resistance index, cardiac index, and stroke volume index, as well as echocardiographic measures of cardiac function. METHODS: In this placebo-controlled, randomized, double blind, exploratory study patients with T2D were randomized to empagliflozin 10 mg or placebo for a period of 3 months. Hemodynamic and echocardiographic parameters were assessed after 1 day, 3 days and 3 months of treatment. RESULTS: Baseline characteristics were not different in the empagliflozin (n = 22) and placebo (n = 20) group. Empagliflozin led to a significant increase in urinary glucose excretion (baseline: 7.3 ± 22.7 g/24 h; day 1: 48.4 ± 34.7 g/24 h; p < 0.001) as well as urinary volume (1740 ± 601 mL/24 h to 2112 ± 837 mL/24 h; p = 0.011) already after one day compared to placebo. Treatment with empagliflozin had no effect on the primary endpoint of systemic vascular resistance index, nor on cardiac index, stroke volume index or pulse rate at any time point. In addition, echocardiography showed no difference in left ventricular systolic function as assessed by left ventricular ejections fraction and strain analysis. However, empagliflozin significantly improved left ventricular filling pressure as assessed by a reduction of early mitral inflow velocity relative to early diastolic left ventricular relaxation (E/e') which became significant at day 1 of treatment (baseline: 9.2 ± 2.6; day 1: 8.5 ± 2.2; p = 0.005) and remained apparent throughout the study. This was primarily attributable to reduced early mitral inflow velocity E (baseline: 0.8 ± 0.2 m/s; day 1: 0.73 ± 0.2 m/sec; p = 0.003). CONCLUSIONS: Empagliflozin treatment of patients with T2D has no significant effect on hemodynamic parameters after 1 or 3 days, nor after 3 months, but leads to rapid and sustained significant improvement of diastolic function. Trial registration EudraCT Number: 2016-000172-19; date of registration: 2017-02-20 (clinicaltrialregister.eu).

Dynamic handgrip exercise for the evaluation of mitral valve regurgitation: an echocardiographic study to identify exertion induced severe mitral regurgitation.

Handgrip exercise (HG) has been occasionally used as a stress test in echocardiography. The effect of HG on mitral regurgitation (MR) is not well known. This study aims to evaluate this effect and the possible role of HG in the echocardiographic evaluation of MR. 722 patients with MR were included (18% primary, 82% secondary disease). We calculated effective regurgitant orifice area (EROA) and regurgitant volume (RVOL) at rest and during dynamic HG. Increase in MR was defined as any increase in EROA or RVOL. We analyzed the data to identify possible associations between clinical or echocardiographic parameters and the effect of HG on MR. MR increased during dynamic HG in 390 of 722 patients (54%) (∆EROA = 25%, ∆RVOL = 27%). Increase of regurgitation occurred in 66 of 132 patients with primary MR (50%) and in 324 of 580 patients with secondary MR (55%). This increase was associated with larger baseline EROA and RVOL, but it was independent from other clinical or echocardiographic parameters. In secondary MR, dynamic HG led to a reclassification of regurgitation severity from non-severe at rest to severe MR during HG in 104 of 375 patients (28%). There was a significant association between this upgrade in MR classification and higher New York Heart Association (NYHA) class (OR 1.486, 95%-CI 1.138-1.940, p = 0.004). Dynamic HG exercise increases MR in about half of patients independent of the etiology. Dynamic HG may be used to identify symptomatic patients with non-severe secondary MR at rest but severe MR during exercise.

Quantification of tricuspid regurgitation area by 3-dimensional color Doppler echocardiography considering different clinical settings.

PURPOSE: The precise assessment of tricuspid regurgitation (TR) using 2D imaging techniques may be associated with significant difficulties due to the nonround regurgitation area. Direct analysis of the regurgitation area by 3D color Doppler echocardiography at the vena contracta (3D VCA) has the potential to adequately quantify even complex TR. This study compared 3D VCA for quantification of the TR with the regurgitant area determined by proximal isovolumetric convergence method (PISA-EROA) considering different clinical settings. METHODS: In 95 patients with TR of different severity, the regurgitant orifice area was determined by 3D color Doppler echocardiography and by PISA-EROA. Using 3D color Doppler echocardiography, the regurgitant orifice area was determined three times in each patient considering 3 datasets. RESULTS: Mean 3D VCA was 0.27 ± 0.14, 0.27 ± 0.13, and 0.29 ± 0.14 cm2 , respectively, as determined by three separate measurements in each of the 95 patients. There was a mean relative deviation between the three measurements in each patient of 12.4 ± 14.9%. The regurgitant orifice area using the PISA method was 0.28 ± 0.14 cm2 . There was a mean difference of 0.07 cm2 (95% CI -0.124 to 0.138 cm2 ) between 3D VCA and PISA-EROA. The correlation between 3D VCA and PISA-EROA was r = .88 (P < .001). Considering a grading of TR severity in grade I (regurgitant area < 0.2 cm2 ), grade II (area 0.2-0.4 cm2 ), and grade III (area > 0.4 cm2 ), there was a good agreement between severity grade determined by 3D VCA and severity grade determined by PISA-EROA (kappa 0.71). CONCLUSION: The analysis of the VCA of a TR using 3D color Doppler echocardiography is an alternative method to determine the regurgitant severity with good agreement to the PISA method.

Distinct pressure half-time values by transthoracic echocardiography for grading of paravalvular regurgitation after transcatheter aortic valve replacement.

Postprocedural aortic regurgitation (AR) has negative impact on patient outcome after transcatheter aortic valve replacement (TAVR). Standard assessment of AR severity by echocardiography is hampered after TAVR. Measurement of pressure half-time (PHT) by echocardiography is not limited in these patients but it may be affected by concomitant left ventricular hypertrophy (LVH). This study sought to evaluate distinct cut-off values of PHT differentiating between patients without and with more than mild LVH for grading of AR after TAVR with cardiac magnetic resonance (CMR) as the reference method for comparison. 71 patients (age 81 ± 6 years) with severe aortic stenosis undergoing TAVR were included into the study. Transthoracic echocardiography (TTE) and CMR were performed after TAVR. Left ventricular mass index was calculated by TTE. PHT was measured by continuous-wave Doppler echocardiography of aortic regurgitation jet. In 18 patients (25%) PHT could not be obtained due to no or very faint Doppler signal. Aortic regurgitant volume and regurgitant fraction were calculated by CMR by flow analysis of the ascending aorta. In 14 of 53 patients (26%) AR after TAVR was moderate or severe as categorized by CMR analysis. More than mild LVH was present in 27 of 53 patients (51%). PHT correlated inversely less to regurgitant fraction by CMR analysis in patients with LVH (r = -0.293; p = 0.138) than in patients without LVH (r = -0.455; p = 0.020). In patients without relevant LVH accuracy of PHT to predict moderate or severe paravalvular regurgitation AUC was 0.813 using a cut-off value of 347 ms and AUC was 0.729 in patients with more than mild LVH using a cut-off value of 420 ms. Analysis of PHT by TTE with distinct cut-off values for patients without and with more than mild LVH allows detection of moderate or severe AR after TAVR as defined by CMR. In none of the patients in which PHT could not be measured AR was categorized as more than trace by CMR analysis.

Hemodynamic support with Impella ventricular assist device in patients undergoing TAVI: A single center experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become a well-established therapeutic option for patients with severe aortic stenosis (AS) at high to intermediate surgical risk. Although TAVI is associated with low mortality of 1.2-6.5%, cardiogenic shock (CS) as a peri-interventional complication remains a challenging problem with very high morbidity and mortality. AIM: This study evaluated the clinical outcome of the use of Impella ventricular assist device in patients undergoing TAVI. METHODS: Between 11/2015 and 08/2018, all patients undergoing TAVI requiring temporary circulatory during the same index hospitalization were included. Primary endpoint was 30-day all-cause mortality. Secondary endpoints were peri-interventional mortality and 30-day stroke rate. RESULTS: Of the 390 patients undergoing TAVI, 13 (3%) required hemodynamic support with an Impella device. Of these, 3 (23%) underwent protected high-risk PCI before TAVI and 10 patients (77%) needed emergency periprocedural hemodynamic support due to cardiogenic shock. Mortality at 30 days was 0% in Impella-protected PCI and 40% with Impella use for periprocedural CS. No stroke occurred in the cohort up to 30 days. Insertion of the Impella device in the setting of TAVI was fast with a mean insertion time of 10 min. Eight patients (80%) in the periprocedural CS group required cardiopulmonary resuscitation prior to Impella use. There was only one device-related complication. CONCLUSIONS: Temporary hemodynamic support with the Impella device in patients with severe aortic valve stenosis or in CS secondary to complicated TAVI was technically doable and allowed stabilization and treatment of salvageable patients.

Outcome predictors of patients with out of hospital cardiac arrest and immediate coronary angiography.

BACKGROUND: Out of hospital cardiac arrest (OHCA) is common and associated with low survival rates. Guidelines propose a fast work-up after OHCA including coronary angiography (CA) but little is known about the actual outcome of those patients who undergo immediate CA after OHCA with suspected cardiac origin. AIM: The aim of this retrospective single-center study was to evaluate the short-term outcomes and predictors of in-hospital mortality in patients who underwent immediate CA after OHCA with suspected cardiac origin. METHODS: We included all consecutive patients with OHCA who underwent immediate CA between January 2011 and December 2015. We defined immediate CA after OHCA as angiography within 2 hr after admission. RESULTS: Two hundred and nineteen consecutive patients with OHCA were included. Fifty six patients (26%) underwent CA without previous return of spontaneous circulation (ROSC) and with ongoing CPR using the LUCAS-device. One hundred and forty nine patients (67%) died in hospital. Of the 56 patients with CA with ongoing CPR, 55 died and only 1 patient survived to hospital discharge. In a multivariate analysis, older age (OR = 2.03, 95%CI 1.35-3.03; p = .001), initial shockable rhythm (OR = 0.28, 95%CI 0.07-1.13; p = .076), CA with ongoing CPR (OR = 11.63, 95%CI 1.20-122.55; p = .035), and initial arterial pH (OR = 0.008, 95%CI 0.00-0.228; p < .005) remained as independent predictors for in-hospital mortality. CONCLUSIONS: In this study older age, metabolic derangement on admission, initial nonshockable rhythm and failure to achieve ROSC before admission predicted in-hospital mortality. While CA with ongoing CPR with the LUCAS-device was feasible, mortality in patients without previous ROSC was extremely high, questioning whether this approach is medically useful.