Temporary oral anticoagulation after MitraClip - a strategy to lower the incidence of post-procedural stroke?

Background: Incidence of stroke within 30 days after percutaneous mitral valve repair using the MitraClip varies from 0.7% and 2.6% between registries. Standard medical treatment after the MitraClip procedure, in the absence of risk factors requiring antithrombotic therapy such as atrial fibrillation, is dual antiplatelet therapy using aspirin and clopidogrel. ESC/EACTS and ACC/AHA surgical guidelines show a Class IIa indication for temporary antithrombotic therapy after mitral valve repair/bioprosthetic valve replacement within the first three months even in patients with no additional risk factors.Methods: 470 patients were treated with the MitraClip receiving oral anticoagulation (Coumadin: INR 2.0-3.0) instead of dual antiplatelet therapy for at least 30 days after the procedure. The incidence of stroke, as well as major adverse events such as bleeding, were analysed in comparison to large registries and multi-centre studies.Results: Incidence of stroke within 30 days was significantly reduced as compared to comparative cohorts (0.2% vs. Median 1.3% [0.7-2.6%]; p < .05). Cardiovascular risk factors such as age, atrial fibrillation, hypertension, diabetes, STS score and prior stroke did not differ significantly between cohorts (ns). Bleeding complications were not increased due to 30 days oral anticoagulation treatment (4.6% vs. Median 7.4% [3.4-13.6%]; ns).Conclusions: Temporary oral anticoagulation might be a strategy to reduce the incidence of stroke within the first 30 days after the MitraClip procedure. Bleeding events were not significantly altered due to temporary oral anticoagulation.

Unidimensional Longitudinal Strain: A Simple Approach for the Assessment of Longitudinal Myocardial Deformation by Echocardiography.

BACKGROUND: Impaired left ventricular (LV) longitudinal function (LF) is a known predictor of cardiac events in patients with heart failure, but two-dimensional strain imaging, the reference method to measure myocardial deformation, is not always feasible or available. Therefore, reliable and reproducible alternatives are needed. The aim of the present study was to evaluate unidimensional longitudinal strain (ULS) as a simple echocardiographic parameter for the assessment of LV LF. METHODS: Two hundred two patients with dilated cardiomyopathy who had their first presentation in the authors' cardiology department, as well as the same number of age- and gender-matched control subjects, were prospectively included in this study. ULS was compared with global longitudinal strain (GLS), the current gold standard for LV LF assessment by echocardiography. Uni- and multivariate Cox regression analyses were conducted to evaluate the prognostic value of ULS. RESULTS: LV LF was higher in the control group compared with patients: GLS -19.5 ± 1.7% versus -12.6 ± 4.8% and ULS -16.3 ± 1.5% versus -10.2 ± 3.9% (P < .001 for each). Correlation between ULS and GLS was excellent (r = 0.94), while Bland-Altman plots revealed lower values for ULS (bias -2.76%, limits of agreement ±3.31%). During a mean follow-up time of 39 months, the combined end point of cardiovascular death or hospitalization for acute cardiac decompensation was reached by 28 patients (13.9%). GLS (hazard ratio, 1.21; 95% CI, 1.10-1.34; P < .001) and ULS (hazard ratio, 1.24; 95% CI, 1.12-1.39; P < .001) had comparable prognostic impact on patient outcomes. CONCLUSIONS: ULS might be an alternative echocardiographic method for the assessment of LV LF, with similar diagnostic and prognostic value compared with GLS.

Assessment of global longitudinal strain using standardized myocardial deformation imaging: a modality independent software approach.

BACKGROUND: Myocardial deformation measurement is superior to left ventricular ejection fraction in identifying early changes in myocardial contractility and prediction of cardiovascular outcome. The lack of standardization hinders its clinical implementation. The aim of the study is to investigate a novel standardized deformation imaging approach based on the feature tracking algorithm for the assessment of global longitudinal (GLS) and global circumferential strain (GCS) in echocardiography and cardiac magnetic resonance imaging (CMR). METHODS: 70 subjects undergoing CMR were consecutively investigated with echocardiography within a median time of 30 min. GLS and GCS were analyzed with a post-processing software incorporating the same standardized algorithm for both modalities. Global strain was defined as the relative shortening of the whole endocardial contour length and calculated according to the strain formula. RESULTS: Mean GLS values were -16.2 ± 5.3 and -17.3 ± 5.3 % for echocardiography and CMR, respectively. GLS did not differ significantly between the two imaging modalities, which showed strong correlation (r = 0.86), a small bias (-1.1 %) and narrow 95 % limits of agreement (LOA ± 5.4 %). Mean GCS values were -17.9 ± 6.3 and -24.4 ± 7.8 % for echocardiography and CMR, respectively. GCS was significantly underestimated by echocardiography (p < 0.001). A weaker correlation (r = 0.73), a higher bias (-6.5 %) and wider LOA (± 10.5 %) were observed for GCS. GLS showed a strong correlation (r = 0.92) when image quality was good, while correlation dropped to r = 0.82 with poor acoustic windows in echocardiography. GCS assessment revealed only a strong correlation (r = 0.87) when echocardiographic image quality was good. No significant differences for GLS between two different echocardiographic vendors could be detected. CONCLUSIONS: Quantitative assessment of GLS using a standardized software algorithm allows the direct comparison of values acquired irrespective of the imaging modality. GLS may, therefore, serve as a reliable parameter for the assessment of global left ventricular function in clinical routine besides standard evaluation of the ejection fraction.

Reliability of noninvasive assessment of systolic pulmonary artery pressure by Doppler echocardiography compared to right heart catheterization: analysis in a large patient population.

BACKGROUND: Pulmonary artery pressure (PAP) is an important marker in cardiovascular disorders, being closely associated with morbidity and mortality. Noninvasive assessment by Doppler echocardiography is recommended by current guidelines. So far, the reliability of this method has been assessed only in small studies with contradictory results. Therefore, the aim of this study was to analyze the reliability of noninvasive PAP assessment by Doppler echocardiography compared to invasive measurements in a large patient population. METHODS AND RESULTS: We retrospectively analyzed data from a large tertiary cardiology department over 6 years in order to compare invasively measured PAP to estimated PAP from echocardiography examinations. N=15 516 patients fulfilled inclusion criteria and n=1695 patients with timely matched examinations (within 5 days) were analyzed. In n=1221 (72%) patients, pulmonary hypertension (PH) was diagnosed invasively (postcapillary PH: n=1122 [66%]; precapillary PH: n=99 [6%]). Systolic pulmonary artery pressure (sPAP) was 45.3±15.5 mm Hg by Doppler echocardiography and 47.4±16.4 mm Hg by right heart catheterization. Pearson's correlation coefficient was r=0.87 (P<0.0001). Mean right atrial pressure (RAP) was 12.0±5.7 mm Hg by right heart catheterization and was estimated to be 12.1±6.6 mm Hg by echocardiography (r=0.82, P<0.0001). Bland-Altman analysis showed a bias of -2.0 mm Hg for sPAP (95% limits of agreement -18.1 to +14.1 mm Hg) and +1.0 mm Hg for RAP (95% limits of agreement +0.1 to +1.9 mm Hg). Noninvasive diagnosis of pulmonary hypertension with Doppler echocardiography had a good sensitivity (87%) and specificity (79%), positive and negative predictive values (91% and 70%), as well as accuracy (85%) for a sPAP cut-off value of 36 mm Hg (AUC 0.91, P<0.001, CI 0.90 to 0.93). CONCLUSIONS: In this study, Doppler echocardiography proved to be a reliable method for the assessment of sPAP, being well suited to establish the noninvasive diagnosis of pulmonary hypertension in patients with cardiac diseases.

Assessment of left ventricular volumes with echocardiography and cardiac magnetic resonance imaging: real-life evaluation of standard versus new semiautomatic methods.

BACKGROUND: Routine quantitative assessment of left ventricular (LV) volumes with echocardiography is hindered by time-consuming methods requiring a manual trace of the LV cavity from two apical two-dimensional planes. Thus, the aim of this study was to evaluate faster new semiautomatic echocardiographic methods that could represent a feasible alternative for the assessment of LV volumes and ejection fraction (EF) in clinical practice. METHODS: Two semiautomatic methods, the automated EF (Auto-EF) for two-dimensional echocardiography and the 4D Auto LVQ tool for three-dimensional echocardiography (3DE), were compared with the biplane modified Simpson's method and cardiac magnetic resonance (CMR) imaging in 47 patients. To evaluate the accuracy of volumetry, additional in vitro measurements using water-filled latex balloons were performed with both modalities. RESULTS: Results of balloon volumetry by echocardiography and CMR measurements were in good agreement with real balloon volumes. The mean LV EF was 45 ± 11% by Auto-EF, 45 ± 11% by 3DE, 48 ± 11% by Simpson's method, and 54 ± 12% by CMR. Linear regression and Bland-Altman analyses showed good associations for semiautomatic methods with Simpson's method (Auto-EF, r = 0.85, bias = 3%, limits of agreement [LOA] = 12%; 3DE, r = 0.79, bias = 3%, LOA = 14%), as well as with CMR (Auto-EF, r = 0.74, bias = 9%, LOA = 17%; 3DE, r = 0.73, bias = 9%, LOA = 17%). Intra- and interobserver variability were 6% and 12% with Auto-EF and 8% and 11% with 3DE, respectively. CONCLUSIONS: Good correlations between semiautomatic echocardiographic parameters for assessment of LV volumes and EF could be observed when compared with Simpson's method or CMR. However, intertechnique agreement analysis of absolute LV volumes revealed considerable differences, with significant underestimation of volumes and EF with respect to CMR.

Dobutamine stress cardiac magnetic resonance versus echocardiography for the assessment of outcome in patients with suspected or known coronary artery disease. Are the two imaging modalities comparable?

PURPOSE: To compare the value of Dobutamine stress echocardiography (DSE) with that provided by Dobutamine Cardiac Magnetic Resonance (DCMR) for the non-invasive risk stratification of patients with suspected or known coronary artery disease (CAD). METHODS: Patients with suspected or known CAD underwent either DSE or DCMR using the same standardized protocol. Patient matching was then performed retrospectively for age, gender and risk factors. Outcome data including cardiac death and non-fatal myocardial infarction (defined as hard cardiac events) and 'late' revascularization performed >90days after the diagnostic procedures were collected during at least 6months. RESULTS: Follow-up data were available in 1852 patients who completed either DSE (n=884) or DCMR (n=884) during a mean follow-up duration of 4.1±2.4 and 3.9±1.9years, respectively (p=NS). Matched patients exhibited an overall high risk profile (69±9years; 69% male, 70% history of CAD and 26% diabetes mellitus in both groups). Using multivariable analysis, both modalities successfully identified patients with inducible ischemia at higher risk for subsequent hard cardiac events, surpassing the value of conventional risk factors like age, male gender and diabetes (HR=9.2; 95%CI=5.6-14.9 for DCMR versus 2.5; 95%CI=1.7-3.7 for DSE). By testing for interaction the predictive capacity of DCMR was higher than that provided by DSE (p=0.02). Patients with negative DCMR exhibited lower event rates compared to those with negative DSE (annual hard cardiac event rate of 0.8% versus 3.2%, p=0.002). CONCLUSIONS: DSE & DCMR aid the risk stratification of CAD patients. However, inducible WMA during DCMR are associated with a higher risk for subsequent cardiac events. Patients with negative DCMR on the other hand, exhibited a lower event rate compared to those with negative DSE.

Rapid assessment of longitudinal systolic left ventricular function using speckle tracking of the mitral annulus.

BACKGROUND: Evaluation of left ventricular function (LV) is one of the most important tasks of echocardiography. Left ventricular longitudinal function has been recognized to differentiate myocardial disorders better than ejection fraction (EF) alone. But recent parameters are still dependent on image quality and time consuming. METHODS: Transthoracic echocardiography, tissue Doppler imaging, strain imaging and assessment of longitudinal function with a tissue motion annular displacement (TMAD) tracking algorithm were performed in 152 patients with various cardiac pathologies and 47 healthy volunteers in a clinical routine setting. RESULTS: Measures of longitudinal function such as LV peak systolic strain (SR, r² = 0.88, p < 0.001) and peak systolic strain rate (SRR, r² = 0.78, p < 0.001) correlated highly with TMAD. Tissue motion annular displacement was ultrafast and less time-consuming compared to strain imaging (8.2 ± 2.2 s, p < 0.001). Significantly more patients with reduced image quality could be analyzed compared to strain imaging (p < 0.001). The intra- and inter-observer variabilities were very low with 1.3 ± 1% and 1.7 ± 1.2%. Tissue motion annular displacement correlated well with clinical parameters (NYHA, r = -0.71, p < 0.001) as well as NT-proBNP (r = -0.73, p < 0.001) and identified patients with structural heart disease with a significantly higher sensitivity 92.1% and specificity 95.7% than did EF, SR, SRR or NT-proBNP (Cut-off:14.2%, p < 0.01). In a subgroup of patients with systemic light chain amyloidosis and preserved EF (>50%, n = 54), TMAD was significantly reduced, especially in those without any signs of cardiac involvement and was superior to other parameters of longitudinal function (p < 0.05). CONCLUSIONS: Tissue motion annular displacement is a rapid, sensitive and reproducible method for the assessment of LV longitudinal function, which is less dependent on image quality.

Assessment of pulmonary artery systolic pressures by stress Doppler echocardiography after bilateral lung transplantation.

BACKGROUND: Even after successful single-lung transplantation (SLTx) or bilateral lung transplantation (BLTx), patients continue to have peripheral muscle weakness and exercise impairment. After SLTx, exercise limitation is also attributed to persistent or recurrent pulmonary vascular abnormalities with elevated pulmonary arterial pressures at rest or during exercise. Therefore, the aim of this study was to evaluate systolic pulmonary artery pressures (PASPs) at rest and during supine bicycle exercise, exercise capacity and cardiopulmonary function in post-BLTx patients. METHODS: Nine patients underwent BLTx due to end-stage pulmonary arterial hypertension (PAH) and 37 age- and gender-matched control subjects underwent a physical examination, electrocardiographic (ECG) test, a 6-minute walk test, a lung function test, a cardiopulmonary exercise test and echocardiographic assessment at rest and during exercise. RESULTS: Exercise capacity was significantly reduced in the BLTx group, with an impaired 6-minute walk test and maximal oxygen uptake and workload. Ventilatory factors did not appear to limit exercise capacity. Right and left ventricular size and pump function and PASP values at rest were normal in both groups, but exceeded 40 mm Hg in 3 of 9 BLTx recipients and in 1 of 37 controls during exercise at low workloads. Mean PASP during exercise was only slightly higher in the BLTx group (40 +/- 5 vs 36 +/- 4 mm Hg, p = not statistically significant). CONCLUSIONS: Reduced exercise capacity of patients after BLTx due to end-stage pulmonary hypertension is not attributed to persistent or recurrent manifest pulmonary hypertension or cardiopulmonary dysfunction. Nevertheless, latent pulmonary hypertension with exaggerated pulmonary artery pressures during exercise may occur in some patients.

Value of MR phase-contrast flow measurements for functional assessment of pulmonary arterial hypertension.

Goals of our study were to compare the pulmonary hemodynamics between healthy volunteers and patients with pulmonary arterial hypertension (PAH) and correlate MR flow measurements with echocardiography. Twenty-five patients with PAH and 25 volunteers were examined at 1.5 T. Phase-contrast flow measurements were performed in the ascending aorta and pulmonary trunk, resulting in the following parameters: peak velocity (cm/s), average blood flow (l/min), time to peak velocity (ms), velocity rise gradient and pulmonary distensibility (cm(2)). The bronchosystemic shunt was calculated. In PAH patients transthoracic echocardiography and right-heart catheterization (RHC) served as the gold standard. In comparison to volunteers, the PAH patients showed significantly reduced pulmonary velocities (P = 0.002), blood flow (P = 0.002) and pulmonary distensibility (P = 0.008). In patients, the time to peak velocity was shorter (P<0.001), and the velocity rise gradient was steeper (P = 0.002) than in volunteers. While in volunteers the peak velocity in the aorta was reached earlier, it was the reverse in patients. Patients showed a significant bronchosystemic shunt (P = 0.01). No meaningful correlation was found between MRI measurements and echocardiography or RHC. MRI is a feasible technique for the differentiation between PAH and volunteers. Further studies have to be conducted for the absolute calculation of pressure estimates.

Prognostic value of serial cardiac assessment and familial screening in patients with dilated cardiomyopathy.

OBJECTIVES: This prospective study was performed to analyse whether routine clinical follow-up investigations at 12+/-6 months add to risk stratification and improve survival rates in patients with a first diagnosis of dilated cardiomyopathy (DCM). METHODS: Four hundred and eighty consecutive patients (mean age 53.4+/-12.3 years, 369 males, mean NYHA class 2.4+/-0.8) with invasively confirmed DCM were included and followed for 3.9+/-3.5 years. Patients were requested to adhere to a follow up investigation within 6-18 months either at the referring physicians or at our out patient department. Two hundred and eighty-one of the 480 patients presented for follow up which consisted of a detailed evaluation of symptoms, standardized physical examination, 12-lead-electrocardiogram recording and echocardiography. Seventeen patients were lost for follow up, 182 did not seek specialized medical follow up. Patients outcome was assessed by structured telephone interviews. RESULTS: Independent predictors of death or transplantation at initial diagnosis were LV-ejection fraction <30% (P=0.0001, risk ratio 2.25), LV-end diastolic pressure >or=15 mmHg (P=0.002, risk ratio 2.0), age >or=54 years, (P=0.04, risk ratio 1.55), and presence of left bundle branch block (P=0.046, risk ratio 1.53). On follow up investigations only deterioration of clinical status by at least one NYHA-class (P=0.001, risk ratio 2.6) and new onset or worsening of mitral regurgitation (P=0.02, risk ratio 1.8), remained independent prognostic factors for cardiac death. Patients who presented for routine follow up revealed significant better 5-year survival rates (n=281, 70%) than those who did not (n=153, 55%, P=0.005). CONCLUSIONS: Routine clinical follow up investigations within 6-18 months after first diagnosis of DCM adds to risk stratification and improves survival rates.