Mitral regurgitation severity correlates with symptoms and extent of left atrial dysfunction: Effect of mitral valve repair.

PURPOSE: We aimed to assess the relationship between mitral regurgitation (MR) severity, symptoms, and left atrial (LA) structure and function, before and after mitral valve repair (MVR). METHODS: Global peak atrial longitudinal strain (PALS) was evaluated in 37 patients with severe symptomatic MR and preserved left ventricular (LV) ejection fraction (60.4% ± 4.6%) before and 3 months after MVR and was compared with values from 30 age- and gender-matched controls. RESULTS: Before surgery, PALS was worse in patients than in controls and indexed LA volume was greater (P < .0001 for both). After MVR, PALS deteriorated further and LA volume decreased (P = .001 and P = .05, respectively) as did LV ejection fraction, longitudinal strain (P = .05 and P < .001, respectively), and LV mass (P < .0001). Before surgery, LA volume correlated modestly with LV end-diastolic volume (R = 0.51; P = .01); effective regurgitant orifice area (EROA) correlated with PALS (R = -0.69, P < .001) and with LV longitudinal strain (R = 0.54, P = .01), and New York Heart Association class correlated with PALS (R = -0.69, P < .001), EROA (R = 0.69, P < .001), and LA volume (R = 0.51, P = .04). LA volume was the strongest predictor of global PALS reduction (P < .001), whereas global PALS was the main predictor of postoperative atrial fibrillation (AF) (P < .001). CONCLUSIONS: In patients with severe MR, EROA correlate with symptoms and LA PALS, which itself predicts the occurrence of postoperative AF. Strain values were superior to 2D data for the prediction of postoperative AF.

Sacubitril/Valsartan in an Elderly Patient with Heart Failure: A Case Report.

Sacubitril/valsartan has recently been approved for the treatment of heart failure with reduced ejection fraction. Given its recent introduction in the armamentarium for the treatment of heart failure (HF), "field-practice" evidence is required to deepen the clinical management of sacubitril/valsartan therapy. We report a relevant case of an elderly patient who achieved major clinical benefits after only 3 months of sacubitril/valsartan therapy. Importantly, in our assessment, we employed speckle tracking echocardiography (STE), a recent echocardiography technique that is non-Doppler and not angle dependent, which analyzes deformations of heart chambers from standard images and allows a fast, reliable, and reproducible assessment of heart function. After 3 months of therapy, NHYA class decreased from III to I-II and hypertension was controlled. Echocardiography examination also showed a marked improvement, with a reduction of left ventricular diameter, improved diastolic function (E = 0.39 m/s; A 0.69 m/s; E/A 0.55), normalized diastolic function index (E/E' TDI = 6.93), normalized atrial volume (63 mL), and improved atrial strain (15.44%). This case report documents the fast clinical and symptom improvement with sacubitril/valsartan in an elderly patient with HF; comprehensive echocardiographic assessment, including STE, also revealed a marked functional improvement with this compound.

The prognostic role of different renal function phenotypes in patients with acute heart failure.

OBJECTIVE: Worsening renal function (WRF) is common in patients treated for acute heart failure (AHF) and might be associated with a significant increase in blood nitrogen urea (BUN). Although many patients develop WRF during hospitalisation, its prognostic role is still unclear. Thus, we aimed to evaluate the prognostic relevance of WRF according to BUN changes during hospitalization. METHODS: We studied patients with AHF screened for Diur-HF Trial (NCT01441245). WRF was defined as an in-hospital rise in serum creatinine ≥0.3 mg/dl or estimated glomerular filtration rate (GFR) reduction ≥20%. BUN increase was defined as a rise in BUN ≥20% during admission. Effective decongestion was defined as complete resolution of two, or more, signs of HF, or absence of clinical signs of congestion at discharge. RESULTS: Of 247 patients enrolled, 59 (23%) patients experienced WRF, 107 (43%) had a BUN increase ≥20%, and 111 (45%) were effectively decongested during hospitalization. During 180 days of follow-up, 136 patients died or were re-hospitalised for AHF. An increase in BUN was an independent predictor of adverse outcome, regardless of WRF (HR = 2.19 [1.35-3.54], p = 0.002 and 1.71 [1.14-2.59], p = 0.010; with and without WRF, respectively) or congestion at discharge. WRF was not an independent predictor of outcome if BUN did not increase or when congestion was effectively relieved. CONCLUSIONS: an increase in BUN≥20% during hospitalization for AHF predicts a poor outcome independently from renal function deterioration and decongestion. WRF predicts adverse outcome only if BUN increases substantially or clinical congestion persists.

Prognostic value of left atrial strain in patients with moderate asymptomatic mitral regurgitation.

For patients with asymptomatic mitral regurgitation (MR), the criteria identifying the groups at higher-risk and their clinical outcome are still uncertain. Therefore, in these patients, optimal time of surgery remains controversial. The purpose of this study was to compare left atrial (LA) strain to other echocardiographic left ventricular (LV) and LA parameters for the prediction of cardiovascular outcomes in patients with moderate asymptomatic MR. We enrolled 395 patients with primary degenerative moderate asymptomatic MR. Exclusion criteria were: history of atrial fibrillation, myocardial infarction, heart failure, cardiac surgery or heart transplantation, severe MR, mitral valve surgery during follow-up. Patients were prospectively followed for 3.5 ± 1.6 years for the development of cardiovascular events i.e. atrial fibrillation, stroke/transient ischaemic attack, acute heart failure, cardiovascular death. Of 276 patients (mean age 66 ± 8 years) who met eligibility criteria, 108 patients had 141 new events. Patients who developed cardiovascular events presented reduced global peak atrial longitudinal strain (PALS), reduced LA emptying fraction, larger LA volume indexed and lower LV strain at baseline (p < 0.0001). With receiving operating characteristics (ROC) curve analysis, global PALS < 35% showed the greatest predictive performance (AUC global PALS: 0.87). Bland-Altman analysis demonstrated good intra- and interobserver agreement with small bias and Kaplan-Meier analysis showed a graded association between PALS and event-free-survival rates. Speckle tracking imaging could provide a useful index, global PALS, to estimate LA function in asymptomatic moderate MR in order to optimize timing of surgery before the development of irreversible myocardial dysfunction.

Role of BNP and echo measurement for pulmonary hypertension recognition in patients with interstitial lung disease: An algorithm application model.

BACKGROUND: This study evaluated the role of echocardiography and BNP in patients with interstitial lung disease (ILD), to identify those with PH and RV dysfunction. The aims of this study were: 1-to evaluate the accuracy of an algorithm including BNP, DLCO and echocardiographic measurements to identify PH and RV dysfunction; 2- to evaluate BNP and Echo values concordance in relation to right catheterization measurement. METHODS: We analyzed 113 patients with diagnosis of ILD. Echo examination included: Pulmonary systolic, diastolic and mean Arterial Pressure (PAPs, PAPd, PAP mean), End-Diastolic and End-Systolic right ventricle diameters, Inferior Caval Vein diameter, and Tricuspid Annular Plane Systolic Excursion (TAPSE). Patients revealing increased PAPs at echocardiography underwent to catheterization. RESULTS: Patients with PAPs > 40 mm Hg (37 patients), PAPmean ≥ 25 mm Hg (23 patients) and PAPd ≥ 20 mm Hg showed BNP increased (157 ± 96 vs 16 ± 14 pg/ml p = 0.004; 201 ± 120 vs 28 ± 17 pg/mL; 124 ± 88 vs 23 ± 18 pg/ml p < 0.001) as patients with TAPSE ≤16 mm (25 patients) (145 ± 104 vs 26 ± 21 pg/ml p < 0.001). In catheterized patients (37 patients) BNP was increased in patients with invasive PAPs > 40 mm Hg (165 ± 112 vs 29 ± 14 pg/ml p < 0.02), as well as in patients with Wedge pressure > 14 mm Hg (199 + 153 vs 54 + 39 pg/mL; p = 0.01). ROC Curve analysis showed that elevated values of BNP, PAPs, PAP mean are able to assess PH. On the other hand, lower values of DLCO (<40%) and TAPSE (≤16 mm) detect PH. Logistic regression analysis of the previous parameters, confirmed their diagnostic role in PH detection. CONCLUSIONS: In patients with ILD, an algorithm including BNP, DLCO and echocardiography could be useful for non invasive screening of PH. CLINICAL TRIAL REGISTRATION NAME AND NUMBER: ARTEMIS-HP trial; ID number: NCT00879229.

Usefulness of atrial deformation analysis to predict left atrial fibrosis and endocardial thickness in patients undergoing mitral valve operations for severe mitral regurgitation secondary to mitral valve prolapse.

In patients with severe mitral regurgitation (MR) referred for cardiac surgery, left atrial (LA) remodeling and enlargement are accompanied by mechanical stress, mediated cellular hypertrophy, and interstitial fibrosis that finally lead to LA failure. Speckle tracking echocardiography is a novel non-Doppler-based method that allows an objective quantification of LA myocardial deformation, becoming useful for LA functional analysis. We conducted a study to evaluate the relation between the traditional and novel atrial indexes and the extent of ultrastructural alterations, obtained from patients with severe MR who were undergoing surgical correction of the valvular disease. The study population included 46 patients with severe MR, referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery. The global peak atrial longitudinal strain (PALS) was measured in all subjects by averaging all atrial segments. LA tissue samples were obtained from all patients. Masson's trichrome staining was performed to assess the extent of the fibrosis. The LA endocardial thickness was measured. A close negative correlation between the global PALS and grade of LA myocardial fibrosis was found (r = -0.82, p <0.0001), with poorer correlations for the LA indexed volume (r = 0.51, p = 0.01), LA ejection fraction (r = 0.61, p = 0.005), and E/E' ratio (0.14, p = NS). Of these indexes, global PALS showed the best diagnostic accuracy to detect LA fibrosis (area under the curve 0.89), and it appears to be a strong and independent predictor of LA fibrosis. Furthermore, we also demonstrated an inverse correlation between the global PALS and LA endocardial thickness (r = -0.66, p = 0.0001). In conclusion, in patients with severe MR referred for cardiac surgery, impairment of LA longitudinal deformation, as assessed by the global PALS, correlated strongly with the extent of LA fibrosis and remodeling.