Echocardiographic correlates of major adverse cardiac events at 1 year in patients with apical ballooning takotsubo syndrome.

INTRODUCTION: Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction and associated with considerable morbidity and mortality. We sought to evaluate the association between change in cardiac mechanics after diagnosis of TTS with 1-year incidence of major adverse cardiovascular events (MACE). METHODS: We retrospectively identified 85 patients with apical TTS based on ICD 9/10 codes and chart adjudication, who had a follow-up echocardiogram within 6 months of diagnosis. Echocardiograms were analyzed for left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), GLS ratio, global circumferential strain (GCS), and global radial strain (GRS). Multivariable logistic regression was performed to identify parameters associated with MACE (all-cause mortality, heart failure, stroke, and coronary artery disease [CAD] requiring percutaneous coronary intervention [PCI]) at 1 year. Event-free survival was assessed in patients with GLS (≤-18% vs. >18%) and LVEF (≥53% vs. <53%). RESULTS: Within 1 year of diagnosis, MACE occurred in 15 (18%) patients. Between baseline and follow-up echocardiogram (median 15 [range 1-151] days), there were significant differences in change in LVEF and GLS in patients with versus without incident MACE. In multivariate analysis, change in LVEF (odds ratio [OR] = .93 [.87, .98], p = .013) and change in GLS (OR = 1.32 [1.04, 1.67], p = .022) were independently associated with MACE; however, the association with change in GLS was attenuated (odds ratio [OR] = 1.13 [.94, 1.36], p = .21) after adjustment for baseline and change in LVEF. Among patients with normalized LVEF at follow-up, there were five (14.7%) MACE; whereas, there were no events among patients with normalized GLS. CONCLUSIONS: In patients with apical TTS, recovery in GLS and LVEF at follow-up was associated with significantly lower MACE at 1 year. Normalization of GLS at follow-up was better able to discriminate event-free survival than normalization of LVEF.

Echocardiographic parameters associated with in-hospital adverse outcomes in patients with Takotsubo syndrome.

INTRODUCTION: Takotsubo syndrome (TTS) is an acute heart failure syndrome that leads to significant morbidity and mortality. We sought to evaluate the association of cardiac mechanics on presentation with in-hospital adverse outcomes in patients with apical TTS. METHODS: We retrospectively identified 468 patients with TTS based on ICD-9/10 codes between 2006 and 2017. The association of echocardiographic parameters with a composite outcome of heart failure and all-cause mortality during the index hospitalization was analyzed. RESULTS: One hundred and forty one patients with the apical subtype and adequate imaging were included. 113 (80.1%) were female, left ventricular ejection fraction (LVEF) was 41.7% ± 12.4%, and global longitudinal strain was -10.1% ± 3.2%. The composite outcome occurred in 58 patients (41%), with heart failure occurring in 55 patients and death occurring in nine patients. Global longitudinal strain, global circumferential strain, global radial strain, right ventricular fractional area change, tricuspid annular plane systolic excursion, and right ventricular free wall strain were significantly worse in patients who experienced the composite outcome in univariate analyses. However, only LVEF was independently associated with the composite outcome in multivariable-adjusted analysis. CONCLUSIONS: In patients with apical TTS, the strain has limited prognostic utility in the acute setting compared to LVEF, which was the only echocardiographic parameter associated with in-hospital heart failure and all-cause mortality.

Three-dimensional echocardiography in the evaluation and management of paravalvular regurgitation.

Paravalvular regurgitation is an uncommon but serious complication that can be encountered after either surgical or percutaneous valve replacement and is associated with increased morbidity and mortality. Early detection and accurate assessment of paravalvular regurgitation are crucial to identify those who would benefit from intervention. Recent advances in 3-dimensional echocardiography have increased the feasibility of percutaneous approaches for the management of paravalvular regurgitation. Percutaneous closure of paravalvular regurgitation has emerged as a favorable alternative for redo surgery in selected cases. This article will review the role of 3-dimensional echocardiography in the assessment and management of paravalvular regurgitation.

Echocardiographic Outcomes With Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation in Prohibitive Surgical Risk Patients.

BACKGROUND: The CLASP IID randomized trial (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial) demonstrated the safety and effectiveness of the PASCAL system for mitral transcatheter edge-to-edge repair (M-TEER) in patients at prohibitive surgical risk with significant symptomatic degenerative mitral regurgitation (DMR). OBJECTIVES: This study describes the echocardiographic methods and outcomes from the CLASP IID trial and analyzes baseline variables associated with residual mitral regurgitation (MR) ≤1+. METHODS: An independent echocardiographic core laboratory assessed echocardiographic parameters based on American Society of Echocardiography guidelines focusing on MR mechanism, severity, and feasibility of M-TEER. Factors associated with residual MR ≤1+ were identified using logistic regression. RESULTS: In 180 randomized patients, baseline echocardiographic parameters were well matched between the PASCAL (n = 117) and MitraClip (n = 63) groups, with flail leaflets present in 79.2% of patients. Baseline MR was 4+ in 76.4% and 3+ in 23.6% of patients. All patients achieved MR ≤2+ at discharge. The proportion of patients with MR ≤1+ was similar in both groups at discharge but diverged at 6 months, favoring PASCAL (83.7% vs 71.2%). Overall, patients with a smaller flail gap were significantly more likely to achieve MR ≤1+ at discharge (adjusted OR: 0.70; 95% CI: 0.50-0.99). Patients treated with PASCAL and those with a smaller flail gap were significantly more likely to sustain MR ≤1+ to 6 months (adjusted OR: 2.72 and 0.76; 95% CI: 1.08-6.89 and 0.60-0.98, respectively). CONCLUSIONS: The study used DMR-specific echocardiographic methodology for M-TEER reflecting current guidelines and advances in 3-dimensional echocardiography. Treatment with PASCAL and a smaller flail gap were significant factors in sustaining MR ≤1+ to 6 months. Results demonstrate that MR ≤1+ is an achievable benchmark for successful M-TEER. (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial [CLASP IID]; NCT03706833).

Leadless solution for arrhythmia-related sudden unexpected death in epilepsy.

A leadless pacemaker is a recently approved pacing technology that helps mitigate lead-related complications, but it has several limitations. Careful candidate selection is needed. Here, we demonstrate leadless pacing as the solution for prolonged postictal bradycardia/asystole; there is no consensus regarding pacemaker implantation for seizure patients with such a risk of sudden cardiac death.