Racial disparities in characteristics and outcomes of patients undergoing mitral transcatheter edge-to-edge repair.

Background: There are scarce data regarding the post-mitral transcatheter edge-to-edger repair (TEER) course in different racial groups. Objective: To assess the impact of race on outcomes following TEER for mitral regurgitation (MR). Methods: This is a single-center, retrospective analysis of consecutive TEER procedures performed during 2013-2020. The primary outcome was the composite of all-cause mortality or heart failure (HF) hospitalizations along the first postprocedural year. Secondary outcomes included individual components of the primary outcome, New York Heart Association (NYHA) class, MR grade, and left ventricular mass index (LVMi). Results: Out of 964 cases, 751 (77.9%), 88 (9.1%), 68 (7.1%), and 57 (5.9%) were whites, blacks, Asians, and Hispanics, respectively. At baseline, non-whites and blacks were younger and more likely be female, based in lower socioeconomic areas, not fully insured, diagnosed with functional MR, and affected by biventricular dysfunction. Intra-procedurally, more devices were implanted in blacks. At 1-year, non-whites (vs. whites) and blacks (vs. non-blacks or whites) experienced higher cumulative incidence of the primary outcome (32.9% vs. 22.5%, p = 0.002 and 38.6% vs. 23.4% or 22.5%, p = 0.002 or p = 0.001, respectively), which were accounted for by hospitalizations in the functional MR sub-cohort (n = 494). NYHA class improved less among blacks with functional MR. MR severity and LVMi equally regressed in all groups. White race (HR 0.62, 95% CI 0.39-0.99, p = 0.047) and black race (HR 2.07, 95% CI 1.28-3.35, p = 0.003) were independently associated with the primary outcome in functional MR patients only. Conclusion: Mitral TEER patients of different racial backgrounds exhibit major differences in baseline characteristics. Among those with functional MR, non-whites and blacks also experience a less favorable 1-year clinical outcome.

Comparison of echocardiographic parameters with cardiac magnetic resonance imaging in the assessment of right ventricular function.

INTRODUCTION: The right ventricle (RV) strain measured by speckle tracking (RVS) is an echocardiographic parameter used to assess RV function. We compared RVS to RV fractional area change (FAC%), tricuspid annular plane systolic excursion (TAPSE) and Doppler tissue imaging-derived peak systolic velocity (S') in the assessment of right ventricular (RV) systolic function measured using cardiac magnetic resonance imaging (MRI). METHODS: We enrolled consecutive patients who underwent cardiac MRI between Jan 2012 and Dec 2017 and a transthoracic echocardiogram (TTE) within 1 month of the MRI with no interval event. Baseline clinical characteristics and MRI parameters were extracted from chart review. Echocardiographic parameters were measured prospectively. TTE parameters including RVS, TAPSE, S', and FAC% were tested for accuracy to identify impaired RV EF (EF < 45% & <30%) using receiver operator curves. RESULTS: The study cohort included 500 patients with mean age 55 years ± 18 and peak tricuspid regurgitation velocity 2.7 ± 1.4 m/s. The area under ROC for RVS was 0.69 (95% CI 0.63-0.75) and 0.78 (95% CI 0.70-0.88) to predict RVEF < 45% & RVEF < 30%, respectively. The RV FAC% had second highest accuracy of predicting RVEF among all the TTE parameters tested in study. CONCLUSION: Right ventricular strain is the most accurate echocardiographic method to detect impaired right ventricular systolic function when using MRI as the gold standard.

Degenerative Mitral Regurgitation: Assessment, Physical Examination, and Imaging.

PURPOSE OF REVIEW: In this review, we provide a comprehensive approach to assess degenerative mitral regurgitation. RECENT FINDINGS: In the evaluation of MR, it is important to differentiate between primary (degenerative/organic) MR in which an intrinsic mitral valve lesion(s) is responsible for the occurrence of MR and secondary (functional) MR where the mitral valve is structurally normal, but alterations of the left ventricular geometry cause deterioration of the MV apparatus. Advanced imaging modalities, foremost two-dimensional and three-dimensional echocardiography, are essential for this determination. In the evaluation of degenerative MR, the exact mechanism, the extent of the disease, associated valve lesions, the grade of mitral regurgitation severity, and hemodynamic consequences require careful assessment in order to provide patients with appropriate monitoring and treatment.

Assessment of Post-Procedural Aortic Regurgitation After TAVR: An Intraprocedural TEE Study.

OBJECTIVES: The purpose of this study was to determine which echocardiographic parameters, including holodiastolic flow reversal (HDFR) in the descending aorta, were useful for grading of post-procedural aortic regurgitation (PAR) after transcatheter aortic valve replacement (TAVR) using intraprocedural transesophageal echocardiography. BACKGROUND: Reliable assessment of PAR in a catheterization laboratory is essential for an optimal outcome after TAVR; however, such an assessment has not been determined. METHODS: Three hundred eighty patients who underwent TAVR with the Edwards (Irvine, California) balloon-expandable transcatheter heart valve were retrospectively assessed by intraprocedural transesophageal echocardiography. PAR was evaluated by 2-dimensional color Doppler and pulse-wave Doppler in the descending aorta. Using 2-dimensional color Doppler, we measured the cross-sectional area of the vena contracta, the circumferential extent at the aortic annular plane, the longitudinal jet length, and the jet extent (with a mosaic pattern in the left ventricular outflow tract) compared with the location of the tip of the anterior mitral leaflet (AML). Grading of PAR was determined using the following vena contracta cutoffs: mild ≤9 mm(2); moderate 10 to 29 mm(2); and severe ≥30 mm(2). Significant PAR was defined as at least moderate grade. RESULTS: All patients with consistent HDFR had significant PAR. By multivariable analysis, consistent HDFR and the jet extent beyond the tip of AML were independent predictors of significant PAR. Consistent HDFR and jet extent beyond the tip of AML predicted significant PAR with specificities of 100% and 97%, respectively. In contrast, patients with both negative HDFR and a jet extent of less than halfway to the tip of AML had no significant PAR, with 97% specificity. CONCLUSIONS: The presence of consistent HDFR and jet extent beyond the tip of AML are indicative of significant PAR after TAVR.

Percutaneous interventions for left atrial appendage exclusion: options, assessment, and imaging using 2D and 3D echocardiography.

Percutaneous left atrial appendage (LAA) exclusion is an evolving treatment to prevent embolic events in patients with nonvalvular atrial fibrillation. In the past few years multiple percutaneous devices have been developed to exclude the LAA from the body of the left atrium and thus from the systemic circulation. Two- and 3-dimensional transesophageal echocardiography (TEE) is used to assess the LAA anatomy and its suitability for percutaneous closure to select the type and size of the closure device and to guide the device implantation procedure in conjunction with fluoroscopy. In addition, 2- and 3-dimensional TEE is also used to assess the effectiveness of device implantation acutely and on subsequent follow-up examination. Knowledge of the implantation options that are currently available along with their specific characteristics is essential for choosing the appropriate device for a given patient with a specific LAA anatomy. We present the currently available LAA exclusion devices and the echocardiographic imaging approaches for evaluation of the LAA before, during, and after LAA occlusion.

The incidence, diagnosis, and management of pulmonary vein stenosis as a complication of atrial fibrillation ablation.

PURPOSE: Pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) is associated with pulmonary vein stenosis (PVS). Although the reported incidence of PVS has fallen in recent years, the precise rate of PVS is unknown. Coherent guidelines for screening and treatment of PVS are not established. We reviewed literature to investigate the incidence, diagnosis, and management of PVS as a complication of PVI. METHODS: We reviewed 41 manuscripts that described a total of 4,615 subjects (median, 84 subjects/study). RESULTS: The incidence of PVS after PVI reported in literature from 1999 to 2004 ranges from 0 to 44% (mean, 6.3%; median, 5.4%), whereas studies after 2004 report an incidence of 0-19% (mean, 2%; median, 3.1%; p < 0.001). PVS symptoms typically occur with reduction of lung perfusion by 20-25%. Variable criteria exist for diagnosis of PVS by magnetic resonance imaging, computed tomography, and perfusion imaging. The restenosis rate for treatment with balloon angioplasty ranges from 30 to 87% (mean, 60%; median, 47%), compared with immediate stenting that ranges from 14 to 57% (mean, 34%; median, 33%). CONCLUSIONS: Recent peer-reviewed articles suggest that PVI carries a 3-8% risk of developing PVS, but they likely underestimate the incidence of PVS, as specific screening and diagnostic guidelines are not established. Imaging modalities should be used to screen patients after ablation of AF since early recognition of PVS improves treatment outcomes. Treatment with angioplasty and stent placement can improve symptoms and lung perfusion but the benefit of treatment with immediate stent placement remains controversial. It is critical to maintain a high clinical index of suspicion for PVS in at-risk individuals to ensure timely detection and treatment.

Peri-interventional echo assessment for the MitraClip procedure.

Worldwide, there have been more than 6500 MitraClip procedures performed to treat either functional or degenerative mitral regurgitation (MR). The MitraClip procedure is the only available percutaneous device available to reduce MR by creating a double mitral valve (MV) orifice and decreasing MV annular diameter. As the mitral leaflets cannot be assessed by fluoroscopy, procedural success is dependent upon echocardiographic guidance. In this review, we describe the assessment necessary to determine eligibility for the MitraClip procedure. This includes accurate assessment of MR and detailed analysis of MV morphology by 2D and 3D echocardiography. In addition, each of the intraprocedural steps involved in the deployment of this device and the guidance of these steps by 2D and 3D echo are described in detail, along with the use of echo to detect procedural complications. Thus the focus of this review is on the peri-interventional echocardiographic assessment before, during, and after the MitraClip procedure.

Three-dimensional echocardiographic assessment of patent foramen ovale in platypnea-orthodeoxia.

Platypnea-orthodeoxia is an uncommon syndrome characterized by positional dyspnea and hypoxia when upright that improves with lying down. We present a 75-year-old man with platypnea-orthodeoxia in the setting of a patent foramen ovale (PFO) and a 2.1 cm highly mobile atrial septal aneurysm with 2 cm bowing. Prior reports have established the use of three-dimensional echocardiography to facilitate percutaneous closure of PFO and atrial septal defect, but its use in patients with platypnea-orthodeoxia is unclear. We document three-dimensional echocardiographic images that accurately estimated PFO defect size and confirmed placement of the occluder device.

Assessment of the morphological features of degenerative mitral valve disease using 64-slice multi detector computed tomography.

BACKGROUND: Patients with severe mitral regurgitation may be screened for coronary artery disease with the use of cardiac computed tomography before valve surgery. OBJECTIVE: We hypothesized that dual-source multidetector computed tomography (DSCT) could effectively predict the culprit mitral valve scallop identified during surgery among patients with degenerative mitral valve disease undergoing surgical mitral valve repair. METHODS: Twenty-six patients (7 women) with known severe mitral regurgitation underwent elective mitral valve repair from September 2006 through December 2009 at our institution. An additional 10 patients underwent aortic valve replacement and had no documented history of mitral valve disease. All patients underwent transthoracic echocardiography and had retrospectively gated DSCT performed to evaluate the coronary arteries before surgery. Each mitral scallop was identified as either normal, prolapsed, or flail. CT findings were compared with operative findings, which were guided by intraoperative transesophageal echocardiography (TEE). RESULTS: In the 26 patients examined, DSCT identified flail in 23 scallops and prolapse in 48. DSCT agreed with operative findings on identification of the culprit scallop in 25 of 26 patients. On a per-patient and per-scallop basis, the observed κ statistic for agreement between DSCT and operative findings was 0.82. Of the 60 scallops in the aortic valve group, all were judged to be normal by both DSCT and TEE. CONCLUSIONS: In patients with degenerative mitral valve disease undergoing cardiac surgery, DSCT demonstrates excellent agreement with intraoperative findings. DSCT can be used to identify the affected mitral valve scallop and its structure in patients who are candidates for mitral valve repair.

Reproducibility of proximal isovelocity surface area, vena contracta, and regurgitant jet area for assessment of mitral regurgitation severity.

OBJECTIVES: The aim of this study was to evaluate the interobserver agreement of proximal isovelocity surface area (PISA) and vena contracta (VC) for differentiating severe from nonsevere mitral regurgitation (MR). BACKGROUND: Recommendation for MR evaluation stresses the importance of VC width and effective regurgitant orifice area by PISA measurements. Reliable and accurate assessment of MR is important for clinical decision making regarding corrective surgery. We hypothesize that color Doppler-based quantitative measurements for classifying MR as severe versus nonsevere may be particularly susceptible to interobserver agreement. METHODS: The PISA and VC measurements of 16 patients with MR were interpreted by 18 echocardiologists from 11 academic institutions. In addition, we obtained quantitative assessment of MR based on color flow Doppler jet area. RESULTS: The overall interobserver agreement for grading MR as severe or nonsevere using qualitative and quantitative parameters was similar and suboptimal: 0.32 (95% confidence interval [CI]: 0.1 to 0.52) for jet area-based MR grade, 0.28 (95% CI: 0.11 to 0.45) for VC measurements, and 0.37 (95% CI: 0.16 to 0.58) for PISA measurements. Significant univariate predictors of substantial interobserver agreement for: 1) jet area-based MR grade was functional etiology (p = 0.039); 2) VC was central MR (p = 0.013) and identifiable effective regurgitant orifice (p = 0.049); and 3) PISA was presence of a central MR jet (p = 0.003), fixed proximal flow convergence (p = 0.025), and functional etiology (p = 0.049). Significant multivariate predictors of raw interobserver agreement > or =80% included: 1) for VC, identifiable effective regurgitant orifice (p = 0.035); and 2) for PISA, central regurgitant jet (p = 0.02). CONCLUSIONS: The VC and PISA measurements for distinction of severe versus nonsevere MR are only modestly reliable and associated with suboptimal interobserver agreement. The presence of an identifiable effective regurgitant orifice improves reproducibility of VC and a central regurgitant jet predicts substantial agreement among multiple observers of PISA assessment.

Visual assessment of left ventricular dyssynchrony using tissue synchronization imaging.

BACKGROUND: Tissue synchronizing imaging (TSI) allows visual detection of asynchronous myocardial contraction. Although it is a screening tool for the detection of left ventricular (LV) dyssynchrony, its use as a qualitative method to assess dyssynchrony has not been studied. We evaluated the correlation of the visual assessment of dyssynchrony using TSI with quantitative assessment, the value of visual assessment to predict reverse remodeling to cardiac resynchronization therapy (CRT). METHODS: Echocardiograms from 100 consecutive patients were retrospectively evaluated. We compared visual TSI assessment with the qualitative assessment of dyssynchrony obtained by tissue Doppler imaging (TDI). The utility of visual assessment as a predictor of response to CRT was evaluated in 43 patients. RESULTS: In 86% of the cases, visual assessment was possible, and reproducibility was unrelated to observer experience. Each grade of visual dyssynchrony corresponded to a range of values of time to peak velocity (TPV) gradient (p < 0.001). Grade >or=1 dyssynchrony by visual assessment had 90% sensitivity and 95% specificity to identify >or=65 ms TPV gradient of LV opposing walls, and 93% sensitivity and 70% specificity to predict reverse LV remodeling. CONCLUSION: LV dyssynchrony may be visually assessed by TSI, which can also predict reverse LV remodeling.

Reduction in mitral regurgitation in patients undergoing cardiac resynchronization treatment: assessment of predictors by two-dimensional radial strain echocardiography.

BACKGROUND: We utilized the novel approach of 2D radial strain (2-DRS) to evaluate whether left ventricular (LV) mechanical dyssynchrony in mid-LV segments corresponding to papillary muscles insertion sites can predict early mitral regurgitation (MR) reduction post-cardiac resynchronization therapy (CRT). METHODS: We evaluated 32 patients undergoing CRT (mean age 64 +/- 17 years, 54% males) with MR grade > or =3 determined by the MR jet area/left atrial area ratio (JA/LAA). RESULTS: Fifteen (47%) patients responded to CRT (JA/LAA) < 25%). Sixty-seven percent of responders had mild or no residual MR and 33% had mild-to-moderate MR, while 70% of nonresponders had grade 3 or 4 MR (P = 0.0001) post CRT. The percent reduction in LV end-systolic volume was significantly higher in responders (P = 0.03), as was improvement in LVEF (P = 0.007). Significant delay of time-to-peak 2-DRS in the midposterior and inferior segments prior to CRT was found in responders compared with nonresponders (580 +/- 58 vs. 486 +/- 94, P = 0.002 and 596 +/- 79 vs. 478 +/- 127 ms, P = 0.005, respectively). Responders also had higher peak positive systolic 2-DRS in the posterior and inferior segments compared to nonresponders (22 +/- 13 vs. 12 +/- 7%, P = 0.01 and 17 +/- 9 vs. 9 +/- 7%, P = 0.02, respectively). Logistic regression analysis showed that the differences in pre-CRT inferoanterior time-to-peak 2-DRS of >110 ms and MRJA/LAA <40% as well as 2-DRS >18% in the posterior wall were significant predictors of post-CRT improvement in MR. CONCLUSION: The presence of a significant time-to-peak delay on 2-DRS between inferior and anterior LV segments, preserved strain of posterior wall, and MRJA/LAA <40% were found to be associated with significant MR reduction in patients post-CRT.

Assessment of aortic stenosis by three-dimensional echocardiography: an accurate and novel approach.

BACKGROUND: Accurate assessment of aortic valve area (AVA) is important for clinical decision-making in patients with aortic valve stenosis (AS). The role of three-dimensional echocardiography (3D) in the quantitative assessment of AS has not been evaluated so far. OBJECTIVES: To evaluate the reproducibility and accuracy of real-time three-dimensional echocardiography (RT3D) and 3D-guided two-dimensional planimetry (3D/2D) for assessment of AS, and compare these results with those of standard echocardiography and cardiac catheterisation (Cath). METHODS: AVA was estimated by transthoracic echo-Doppler (TTE) and by direct planimetry using transoesophageal echocardiography (TEE) as well as RT3D and 3D/2D. 15 patients underwent assessment of AS by Cath. RESULTS: 33 patients with AS were studied (20 men, mean (SD) age 70 (14) years). Bland-Altman analysis showed good agreement and small absolute differences in AVA between all planimetric methods (RT3D vs 3D/2D: -0.01 (0.15) cm(2); 3D/2D vs TEE: 0.05 (0.22) cm(2); RT3D vs TEE: 0.06 (0.26) cm(2)). The agreement between AVA assessment by 2D-TTE and planimetry was -0.01 (0.20) cm(2) for 3D/2D; 0.00 (0.15) cm(2) for RT3D; and -0.05 (0.30) cm(2) for TEE. Correlation coefficient r for AVA assessment between each of 3D/2D, RT3D, TEE planimetry and Cath was 0.81, 0.86 and 0.71, respectively. The intraobserver variability was similar for all methods, but interobserver variability was better for 3D techniques than for TEE (p<0.05). CONCLUSIONS: The 3D echo methods for planimetry of the AVA showed good agreement with the standard TEE technique and flow-derived methods. Compared with AV planimetry by TEE, both 3D methods were at least as good as TEE and had better reproducibility. 3D aortic valve planimetry is a novel non-invasive technique, which provides an accurate and reliable quantitative assessment of AS.

Comparison of transthoracic and intraoperative transesophageal color flow Doppler assessment of mitral and aortic regurgitation.

BACKGROUND: We examined the agreement between transthoracic echocardiography (TTE) and intraoperative prepump transesophageal echocardiography (TEE) in the assessment of left-sided regurgitant lesions and echocardiographic variables associated with grading discrepancies. METHODS: The TTE and prepump TEE studies of 54 patients undergoing aortic-valve replacement for aortic stenosis were reviewed. Agreement and correlation in assessment of aortic (AR) and mitral regurgitation (MR) severity were evaluated. RESULTS: There was no significant difference between mean TTE and prepump TEE grading of MR (0.23 +/- 0.19 vs. 0.21 +/- 0.15 jet area/area of the left atrium, p = 0.49), but the correlation between the two methods was weak (r = 0.40, p = 0.003), with an exact agreement of 54%. Prepump TEE tended to grade AR as more severe (mean grade 1.43 +/- 0.94 vs. 1.24 +/- 0.75, p = 0.058). The correlation between the two methods in AR assessment was fair (r = 0.70, p = 0.0001) with an agreement of 59%. For MR and AR grading, no significant correlations between valvular regurgitation severity and blood pressure differences between preoperative TTE and prepump TEE were found. In 17% of cases, discrepancies in identifying severe mitral or aortic valve regurgitation could have affected patient management. CONCLUSIONS: There is modest agreement in MR and AR assessment between TTE and prepump TEE. Cardiologists, cardiac surgeons, and anesthesiologists must be aware of differences between these methods when using prepump TEE to guide intraoperative decisions.