Assessment of Adult Patients with Long COVID Manifestations Suspected as Cardiovascular: A Single-Center Experience.

Background: Persistent symptoms affect a subset of coronavirus disease 2019 (COVID-19) survivors. Some of these may be cardiovascular (CV)-related. Objective: To assess the burden of objective CV morbidity among, and to explore the short-term course experienced by, COVID-19 patients with post-infectious symptomatology suspected as CV. Methods: This was a single-center, retrospective analysis of consecutive adult patients with new-onset symptoms believed to be CV following recovery from COVID-19, who had been assessed at a dedicated 'Cardio'-COVID clinic between June 2020 and June 2021. All participants were followed for 1 year for symptomatic course and the occurrence of new CV diagnoses and major adverse cardiovascular events (MACE). Results: A total of 96 patients (median age 54 (IQR, 44-64) years, 52 (54%) females) were included in the final analysis. Initial visits occurred within a median of 142 days after the diagnosis of acute COVID. Nearly all (99%) patients experienced a symptomatic acute illness, which was graded as severe in 26 (27%) cases according to the National Institutes of Health (NIH) criteria. Long-COVID symptoms included mainly dyspnea and fatigue. While the initial work-up was mostly normal, 45% of the 11 cardiac magnetic resonance studies performed revealed pathologies. New CV diagnoses were made in nine (9%) patients and mainly included myocarditis that later resolved. An abnormal spirometry was the only variable associated with these. No MACE were recorded. Fifty-two (54%) participants felt that their symptoms improved. No association was found between CV morbidity and symptomatic course. Conclusions: In our experience, long-COVID symptoms of presumed CV origin signified actual CV disease in a minority of patients who, irrespective of the final diagnosis, faced a fair 1-year prognosis.

Comparison of Simultaneous Transthoracic Versus Transesophageal Echocardiography for Assessment of Aortic Stenosis.

Transthoracic echocardiography (TTE) is the gold standard for aortic stenosis (AS) assessment. Transesophageal echocardiography (TEE) provides better resolution, but its effect on AS assessment is unclear. To answer this question, we studied 56 patients with ≥moderate AS. Initial TTE (TTE1) was followed by conscious sedation with simultaneous TEE and TTE2. Based on conservative versus actionable implication, AS types were dichotomized into group A, comprising moderate and normal-flow low-gradient, and group B, comprising high gradient, low ejection fraction low-flow low-gradient, and paradoxical low-flow low-gradient AS. Paired analysis of echocardiographic variables and AS types measured by TEE versus TTE2 and by TEE versus TTE1 was performed. TEE versus simultaneous TTE2 comparison demonstrated higher mean gradients (31.7 ± 10.5 vs 27.4 ± 10.5 mm Hg) and velocities (359 ± 60.6 vs 332 ± 63.1 cm/s) with TEE, but lower left ventricular outflow velocity-time-integral (VTI1) (18.6 ± 5.1 vs 20.2 ± 6.1 cm), all p <0.001. This resulted in a lower aortic valve area (0.8 ± 0.21 vs 0.87 ± 0.28 cm2), p <0.001, and a net relative risk of 1.86 of group A to B upgrade. TEE versus (awake state) TTE1 comparison revealed a larger decrease in VTI1 because of a higher initial awake state VTI1 (22 ± 5.6 cm), resulting in similar Doppler-velocity-index and aortic valve area decrease with TEE, despite a slight increase in mean gradients of 0.8 mm Hg (confidence interval -1.44 to 3.04) and velocities of 10 cm/s (confidence interval -1.5 to 23.4). This translated into a net relative risk of 1.92 of group A to B upgrade versus TTE1. In conclusion, TEE under conscious sedation overestimates AS severity compared with both awake state TTE and simultaneous sedation state TTE, accounted for by different Doppler insonation angles obtained in transapical versus transgastric position.

Echocardiographic Assessment of Aortic Stenosis under Sedation Underestimates Stenosis Severity.

BACKGROUND: Sedation can impact aortic stenosis (AS) classification, which depends on left ventricular ejection fraction (<≥ [less than or greater than and/or equal to] 50%), aortic valve area (AVA<≥ 1 cm2), mean pressure gradient (<≥ 40 mm Hg), peak velocity <≥ 400 cm/sec, and stroke volume index (SVI <≥35 mL/m2). We compared AS classification by transthoracic echo (TTE) during wakefulness versus sedation. METHODS: Immediately following a baseline TTE performed during wakefulness, another TTE was done during sedation delivered for a concomitant transesophageal study in 69 consecutive patients with AS (mean age 78 ± 7 years, 32 males). AVA was calculated through the continuity equation using the relevant hemodynamic parameters measured by each TTE study and same left ventricular outflow tract. AS class was defined as moderate, severe high gradient (HG), low ejection fraction low flow low gradient (LF-LG), paradoxical LF-LG (PLFLG), and normal flow low gradient (NF-LG). Based on conservative versus invasive treatment implication, AS classes were aggregated into group A (moderate AS and NFLG) and group B (HG, low-EF LF-LG, and PLFLG). RESULTS: During sedation, systolic and diastolic blood pressure decreased by 14.3 ± 29 and 8 ± 22 mm Hg, respectively, mean pressure gradient from 30.4 ± 10.9 to 27.2 ± 10.8 mm Hg, peak velocity from 345.3 ± 57.7 to 329.3 ± 64.8 cm/m2, and SVI from 41.5 ± 11.3 to 38.3 ± 11.8 mL/m2 (all P < .05). Calculated AVA was similar (delta = -0.009 ± 0.15 cm2). Individual discrepancies in hemodynamic parameters between the paired TTE studies resulted in an overall 17.4% rate of AS intergroup misclassification with sedation, with a relative risk of 1.09 of downgrade misclassification from group B to A versus upgrade misclassification (P < .001). CONCLUSIONS: Sedation TTE assessment downgrades AS severity in a significant proportion of patients, with a conversely smaller proportion of patients being upgraded, and therefore cannot be a substitute for wakefulness assessment.

Incremental Value of Transesophageal Echocardiography Integrated with Transthoracic Echocardiography in the Assessment of Aortic Stenosis Severity.

BACKGROUND: Transthoracic echocardiography (TTE) is the standard method for evaluating the severity of aortic stenosis (AS), while transesophageal echocardiography (TEE) is useful for morphologic characterization. The study aim was to assess the impact of complementary TEE to TTE in refining hemodynamic assessment of AS severity. METHODS: A retrospective analysis was conducted of sequential TTE and TEE studies performed in 100 patients with moderate or severe AS confirmed on prior TTE. The left ventricular outflow tract (LVOT) velocity-time-integral (VTI1) and the aortic valve velocity-time integral (VTI2) were measured for both modalities. The highest values of VTI1 and VTI2 and mean gradients and peak velocities were selected from the sequential TTE/TEE study for indexed aortic valve area (AVAi) calculation and AS severity determination through an integrated assessment. RESULTS: AVAi determined by TTE was not significantly different from that determined by TEE (mean difference -0.008 cm2; p = 0.38). The dimensionless velocity index (DVI) was higher when assessed by TTE than by TEE (mean difference 0.0126 ± 0.04; p = 0.003). Using the integrated AS assessment, six of 13 patients with a TTE-based diagnosis of moderate AS were re-classified as severe AS. A slight lowering of the recommended TTE-derived DVI threshold for severe AS, from 0.25 to 0.24, improved the ability to discriminate moderate versus severe AS, as determined by the integrated assessment. CONCLUSIONS: TEE integrated with TTE may improve the detection of severe AS, particularly in patients with moderate AS criteria assessed by TTE, but with a DVI ratio ≤0.24.

Comprehensive prospective cognitive and physical function assessment in elderly patients undergoing transcatheter aortic valve implantation.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) is occasionally associated with stroke and silent cerebral ischemia, which may affect cognitive and functional performance. The aim of this study was to evaluate the changes in cognitive performance and functional status following TAVI. METHODS: We performed a comprehensive prospective functional, cognitive and quality of life (QOL) evaluation in consecutive patients who underwent TAVI using the CoreValve device (Medtronic Inc.). The evaluation was performed at baseline and 1 month after the procedure and included the 36-item Short-Form Health Survey for QOL assessment, Mini-Mental State Examination (MMSE), quantitative clock drawing test (Rouleau), color trails test, Cognistat evaluation, Barthel Index and Duke Activity Status Index. RESULTS: A total of 36 patients completed the full pre- and post-TAVI evaluation. Mean age was 82.2 ± 4.2 years (52.8% men); 94.5% of patients had low functional class (New York Heart Association III/IV), and 13.9% had prior stroke. After the procedure, all patients had improved functional status and valve hemodynamics. At 1 month, there was a significant improvement in the MMSE and Cognistat evaluations (from 25.9 ± 3.3 to 27.6 ± 2.4, p < 0.001, and from 5 ± 1 to 5.7 ± 0.7, p = 0.001, respectively). CONCLUSIONS: Our preliminary results of a comprehensive assessment of patients undergoing TAVI indicate favorable results for both functional performance and cognitive function early after the procedure.