Shifts in Clinical Characteristics, Treatment, and Outcome for Rheumatic Mitral Stenosis: Insights From a 20-Year Multicentre Registry Study in Korea.

BACKGROUND: The rapid economic development of South Korea provides a unique model to study changes in the clinical characteristics, treatment approaches, and clinical outcomes of patients with rheumatic mitral stenosis (MS) relative to socioeconomic growth. METHODS: From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, 2,337 patients diagnosed with moderate or severe rheumatic MS between January 2001 and December 2020 were analyzed. Patients were grouped into consecutive 5-year intervals based on their year of diagnosis. Clinical characteristics, echocardiographic data, and clinical outcomes were assessed. RESULTS: Over 20 years, the severity of mitral stenosis increased from 79.1% to 90.2%; similarly, the average age at diagnosis increased from 54.3 to 63.0 years (all P < 0.001). Comorbidities such as hypertension and atrial fibrillation increased (6.3% to 29.5% and 41.4% to 46.9%, respectively; all P for trend < 0.05). The rate of mitral intervention within five years after diagnosis increased from 31.2% to 47.4% (P for trend < 0.001). However, clinical outcomes of rheumatic mitral stenosis deteriorated over time in the composite outcomes (log-rank test, P < 0.001). Conversely, the incidence of stroke remained stable (60.6-73.7%; P < 0.001), which might be attributed to the increased use of anticoagulation therapy. CONCLUSION: This study observed an increase in patient age, comorbidities, and valve disease severity as the country transitioned from a developing to developed status. Despite a rise in mitral valve interventions, clinical outcomes deteriorated over 20 years, highlighting the need for modified treatment approaches to improve patient outcomes.

Assessment of aortic valve area on cardiac computed tomography in symptomatic bicuspid aortic stenosis: Utility and differences from Doppler echocardiography.

Background: In this study, we investigate the utility of geometric orifice area (GOA) on cardiac computed tomography (CT) and differences from effective orifice area (EOA) on Doppler echocardiography in patients with bicuspid aortic stenosis (AS). Methods: A total of 163 patients (age 64 ± 10 years, 56.4% men) with symptomatic bicuspid AS who were referred for surgery and underwent both cardiac CT and echocardiography within 3 months were studied. To calculate the aortic valve area, GOACT was measured by multiplanar CT planimetry, and EOAEcho was calculated by the continuity equation with Doppler echocardiography. The relationships between GOACT and EOAEcho and patient symptom scale, biomarkers, and left ventricular (LV) functional variables were analyzed. Results: There was a significant but modest correlation between EOAEcho and GOACT (r = 0.604, p < 0.001). Both EOAEcho and GOACT revealed significant correlations with mean pressure gradient and peak transaortic velocity, and the coefficients were higher in EOAEcho than in GOACT. EOAEcho of 1.05 cm2 and GOACT of 1.25 cm2 corresponds to hemodynamic cutoff values for diagnosing severe AS. EOAEcho was well correlated with the patient symptom scale and log NT-pro BNP, but GOACT was not. In addition, EOAEcho had a higher correlation coefficient with estimated LV filling pressure and LV global longitudinal strain than GOACT. Conclusion: GOACT can be used to evaluate the severity of bicuspid AS. The threshold for GOACT for diagnosing severe AS should be higher than that for EOAEcho. However, EOAEcho is still the method of choice because EOAEcho showed better correlations with clinical and functional variables than GOACT.

Assessment of multidirectional movements of the common carotid artery in atherothrombotic stroke using dimensional speckle tracking carotid ultrasonography: A prospective, controlled cohort study.

AIM: We aimed to explore the relevance of multidirectional movements of the common carotid artery in atherothrombotic stroke. METHODS AND RESULTS: We prospectively enrolled 69 patients with atherothrombotic stroke (stroke group) and 69 age-matched and sex-matched controls (control group) who underwent carotid ultrasonography. Based on the speckle tracking technique, circumferential and radial movements of the common carotid artery were analyzed from transverse and longitudinal B-mode images of the common carotid artery. Peak longitudinal and radial displacements, strain, and strain rate were measured. Mean age of the overall population was 64 ± 11 years, and 57% (78 patients) were men. In the transverse image, circumferential strain was significantly lower in the stroke group than in the control group (5.6 ± 1.6 vs 4.2 ± 1.7, P < .001). In multivariate logistic regression analysis, circumferential strain was independently associated with stroke (odds ratio: 0.60, P = .001). Compared with conventional risk factors, as well as carotid intima-media thickness and carotid plaque, the addition of a strain parameter appeared to improve discrimination of a stroke event (area under the receiver operating characteristic curve: 0.65 and 0.75 vs 0.84, respectively; P < .05 for both). CONCLUSIONS: Circumferential strain of the common carotid artery might serve as a novel surrogate marker of atherothrombotic stroke. Multidirectional strain imaging of the common carotid artery may provide more information than conventional carotid ultrasonography and identify clinical risk factors for risk stratification of an acute stroke event.

Assessment of myocardial viability based on dual-energy computed tomography in patients with chronic myocardial infarction: comparison with magnetic resonance imaging.

PURPOSE: To evaluate the diagnostic performance of dual-energy computed tomography (DECT) for the assessment of myocardial viability compared with magnetic resonance imaging (MRI) in patients with chronic myocardial infarction (CMI). METHODS AND MATERIAL: Twenty-six patients were prospectively enrolled, who underwent DECT and MRI at delayed phase. The infarct volumes for DECT and MRI were measured. RESULTS: In per-segment and per-vessel analysis, DECT showed excellent diagnostic performance compared with MRI (diagnostic accuracy: 86.2%, 81.2% respectively). In volume analysis, DECT correlated well with MRI (r=0.966, p<0.0001). CONCLUSIONS: DECT has excellent diagnostic performance for detecting CMI.

Impact of Contrast Echocardiography on Assessment of Ventricular Function and Clinical Diagnosis in Routine Clinical Echocardiography: Korean Multicenter Study.

BACKGROUND: Fundamental echocardiography has some drawbacks in patients with difficult-to-image echocardiograms. The aim of this study is to evaluate impact of contrast echocardiography (CE) on ventricular function assessment and clinical diagnosis in routine clinical echocardiography. METHODS: Two hundred sixty patients were prospectively enrolled over 3 years in 12 medical centers in Korea. General image quality, the number of distinguishable segments, ability to assess regional wall motion, left ventricular (LV) apex and right ventricle (RV) visualization, LV ejection fraction, changes in diagnostic or treatment plan were documented after echocardiography with and without ultrasound contrast agent. RESULTS: Poor or uninterpretable general image was 31% before contrast use, and decreased to 2% (p<0.05) after contrast use. The average number of visualized LV segments was 9.53 before contrast use, and increased to 14.46 (p<0.001) after contrast use. The percentage of poor or not seen LV regional wall motion was decreased from 28.4% to 3.5% (p<0.001). The percentage of poor or not seen LV apex and RV was decreased from 49.4% to 2.4% (p<0.001), from 30.5% to 10.5% (p<0.001), respectively. Changes in diagnostic procedure and treatment plan after CE were 30% and 29.6%, respectively. CONCLUSION: Compared to fundamental echocardiography, CE impacted LV function assessment and clinical decision making in Korean patients who undergo routine echocardiography.

Preclinical assessment of a modified Occlutech left atrial appendage closure device in a canine model.

BACKGROUND: LAA occlusion has a similar stroke prevention efficacy compared to anticoagulation treatment for non-valvular atrial fibrillation. OBJECTIVE: The objective of this study was to assess the feasibility and safety of a modified Occlutech® left atrial appendage (LAA) closure device in a canine model. METHODS: The device was implanted in 10 dogs (33±1kg) using fluoroscopy and transesophageal echocardiography (TEE) guidance. The modified Occlutech® LAA occlusion device was compared with the current version, the Watchman device, and the Amplazter cardiac plug (ACP). LAA occlusion and anchoring to the LAA were evaluated. All dogs were assessed using angiography, TEE, and a gross anatomy examination. RESULTS: The 10 LAA occlusion devices were to be implanted into 10 dogs (5 modified Occlutech devices, 3 current version of Occlutech devices, 1 Watchman, and 1 ACP). LAA implantation was not performed in one dog due to transeptal puncture failure. The three current version of Occlutech devices were embolized immediately after implantation, so three modified devices of the same size were implanted securely without embolization. The mean implant size was 20.1±2.0mm. The devices chosen were a mean of 23.3±10.6% larger than the measured landing zone diameters. Post-implant angiography and TEE revealed well-positioned devices without pericardial effusion or impingement on surrounding structures. CONCLUSIONS: The results of this acute animal study suggested that a modified Occlutech® LAA occlusion device was feasible and had greater anchoring performance in canines. Additional large clinical studies are needed to evaluate safety and efficacy.

Assessment of Mitral Paravalvular Leakage After Mitral Valve Replacement Using Cardiac Computed Tomography: Comparison With Surgical Findings.

BACKGROUND: The diagnostic performance of cardiac computed tomography (CT) for detection of paravalvular leakage (PVL) after mitral valve replacement has not been investigated in a large population. We aimed to investigate the diagnostic accuracy of CT for diagnosis of mitral PVL using surgical findings as the standard reference and to compare the diagnostic performance of CT with those of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). METHODS AND RESULTS: A total of 204 patients with previous mitral valve replacement who underwent cardiac CT were retrospectively included. The presence of mitral PVL was analyzed on CT, TTE, and TEE. In 78 patients who underwent redo-surgery, diagnostic performance for the detection of PVL for CT, TTE, and TEE were compared with surgical findings as the standard reference. The location of mitral PVL on CT and TEE was compared with surgical findings. Mitral PVL was present in 18.1% (37/204) on CT, in 16.2% (32/198) on TTE, and in 42.6% (29/68) on TEE. On the surgical field, PVL was identified in 41.0% (32/78). The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for detection of PVL were 96.9%, 97.8%, 96.9%, 97.8%, and 97.4% for CT; 81.3%, 95.6%, 92.9%, 87.8%, and 89.6% for TTE; and 96.2%, 95.8%, 96.2%, 95.8%, and 96.0% for TEE. CT and TEE identified the correct location of PVL in 75.9% (22/29) and 85.6% (19/23). CONCLUSIONS: Cardiac CT may have better diagnostic accuracy compared with TTE for the detection of mitral PVL and may be comparable to TEE for the detection and localization of PVL.

Differences in aortic vortex flow pattern between normal and patients with stroke: qualitative and quantitative assessment using transesophageal contrast echocardiography.

The flow in the aorta forms a vortex, which is a critical determinant of the flow dynamics in the aorta. Arteriosclerosis can alter the blood flow pattern of the aorta and cause characteristic alterations of the vortex. However, this change in aortic vortex has not yet been studied. This study aimed to characterize aortic vortex flow pattern using transesophageal contrast echocardiography in normal and stroke patients. A total of 85 patients who diagnosed with ischemic stroke and 16 normal controls were recruited for this study. The 16 normal control subjects were designated as the control group, and the 85 ischemic stroke patients were designated as the stroke group. All subjects underwent contrast transesophageal echocardiography (TEE), and particle image velocimetry was used to assess aortic vortex flow. Qualitative and quantitative analyses of vortex flow morphology, location, phasic variation, and pulsatility were undertaken and compared between the groups. In the control group, multiple irregularly-shaped vortices were observed in a peripheral location in the descending thoracic aorta. In contrast, the stroke group had a single, round, merged, and more centrally located aortic vortex flow. In the quantitative analysis of vortex, vortex depth, which represents the location of the major vortex in the aorta, was significantly higher in the control group than in the stroke group (0.599 ± 0.159 vs. 0.522 ± 0.101, respectively, P = 0.013). Vortex relative strength, which is the pulsatility parameter of the vortex itself, was significantly higher in the stroke group than in the control group (0.367 ± 0.148 vs. 0.304 ± 0.087, respectively, P = 0.025). It was feasible to visualize and quantify the characteristic morphology and pulsatility of the aortic vortex flow using contrast TEE, and aortic vortex pattern significantly differed between normal and stroke patients.

Assessment of mitral annuloplasty ring by cardiac computed tomography: Correlation with echocardiographic parameters and comparison between two different ring types.

OBJECTIVES: This study investigated computed tomographic (CT) appearance after mitral ring annuloplasty, especially comparing CT findings between patients with normal pressure gradient (PG) and patients with functional mitral stenosis (MS) and between 2 commonly used types of annuloplasty ring. METHODS: A total of 45 cardiac CT scans in patients who underwent mitral ring annuloplasty (Carpentier-Edwards ring, n = 27; Duran ring, n = 18) were retrospectively reviewed. On CT scan, presence of significant pannus around the annuloplasty ring, presence of leaflet thickening, and maximal mitral opening area were analyzed. CT findings were compared between patients with normal PG and patients with functional MS (mean diastolic PG ≥ 5 mm Hg). Incidences of functional MS and CT findings were compared between ring types. RESULTS: Significant pannus was present in 10 cases and leaflet thickening in 31 cases, and maximal opening area was 2.34 ± 0.717 cm(2). Valve opening area on CT was positively correlated with mitral valve area on transthoracic echocardiography and negatively correlated with mean diastolic PG. Mean diastolic PG was significantly elevated with increasing pannus severity. Patients with functional MS had more significant pannus than patients with normal PG. The Duran ring group had higher mean diastolic PG, smaller mitral valve area, and higher incidence of functional MS than the Carpentier-Edwards ring group (P < .05). The proportion of pannus and significant pannus was significantly higher in the Duran ring group (P < .05). CONCLUSIONS: Significant pannus around the annuloplasty ring on CT may cause functional MS after mitral ring annuloplasty. This may occur more frequently with the Duran ring.