Sarcopenia in cardiac surgery: Dual X-ray absorptiometry study from the McGill frailty registry.

BACKGROUND: To determine the prevalence and prognostic value of sarcopenia measured by dual x-ray absorptiometry (DXA) and physical performance tests in patients undergoing coronary artery bypass surgery or heart valve procedures. METHODS: Adults undergoing cardiac surgery were prospectively enrolled and completed a questionnaire, physical performance battery, and a DXA scan (GE Lunar) to measure appendicular muscle mass indexed to height2 (AMMI). Patients were categorized as sarcopenic based on European Working Group 2 guidelines if they had low AMMI defined as <7 kg/m2 for men or <5.5 kg/m2 for women, and low muscle strength defined as 5 chair rise time ≥15 seconds. Cox proportional hazards regression was used to test the association between sarcopenia and all-cause mortality over a median follow-up of 4.3 years. RESULTS: The cohort consisted of 141 patients with a mean age of 69.7 ± 10.0 years and 21% females. The prevalence rates of low AMMI, slow chair rise time, and sarcopenia (low AMMI and slow chair rise time) were 24%, 57%, 13%, respectively. The 4-year survival rate was 79% in the non-sarcopenic group as compared to 56% in the sarcopenic group (Log-rank P = 0.01). In the multivariable model, each standard deviation of decreasing AMMI and increasing chair rise time was associated with a hazard ratio for all-cause mortality of 1.84 (95% CI 1.18, 2.86) and 1.79 (95% CI 1.26, 2.54), respectively. CONCLUSION: Lower-extremity muscle strength and DXA-based muscle mass are objective indicators of sarcopenia that are independently predictive of all-cause mortality in older cardiac surgery patients.

A multicentric quality-control study of exercise Doppler echocardiography of the right heart and the pulmonary circulation. The RIGHT Heart International NETwork (RIGHT-NET).

PURPOSE: This study was a quality-control study of resting and exercise Doppler echocardiography (EDE) variables measured by 19 echocardiography laboratories with proven experience participating in the RIGHT Heart International NETwork. METHODS: All participating investigators reported the requested variables from ten randomly selected exercise stress tests. Intraclass correlation coefficients (ICC) were calculated to evaluate the inter-observer agreement with the core laboratory. Inter-observer variability of resting and peak exercise tricuspid regurgitation velocity (TRV), right ventricular outflow tract acceleration time (RVOT Act), tricuspid annular plane systolic excursion (TAPSE), tissue Doppler tricuspid lateral annular systolic velocity (S'), right ventricular fractional area change (RV FAC), left ventricular outflow tract velocity time integral (LVOT VTI), mitral inflow pulsed wave Doppler velocity (E), diastolic mitral annular velocity by TDI (e') and left ventricular ejection fraction (LVEF) were measured. RESULTS: The accuracy of 19 investigators for all variables ranged from 99.7 to 100%. ICC was > 0.90 for all observers. Inter-observer variability for resting and exercise variables was for TRV = 3.8 to 2.4%, E = 5.7 to 8.3%, e' = 6 to 6.5%, RVOT Act = 9.7 to 12, LVOT VTI = 7.4 to 9.6%, S' = 2.9 to 2.9% and TAPSE = 5.3 to 8%. Moderate inter-observer variability was found for resting and peak exercise RV FAC (15 to 16%). LVEF revealed lower resting and peak exercise variability of 7.6 and 9%. CONCLUSIONS: When performed in expert centers EDE is a reproducible tool for the assessment of the right heart and the pulmonary circulation.

The role of echocardiography in amniotic fluid embolism: a case series and review of the literature.

PURPOSE: Amniotic fluid embolism (AFE) is a rare, but often fatal condition characterized by sudden hemodynamic instability and coagulopathy occurring during labour or in the early postpartum period. As the mechanisms leading to shock and the cardiovascular effects of AFE are incompletely understood, the purpose of this case series is to describe how AFE presents on echocardiography and review limited reports in the literature. CLINICAL FEATURES: We describe three cases of AFE at the Jewish General Hospital, a tertiary care centre in Montreal, Canada. All cases met the Clark diagnostic criteria, which comprise 1) sudden cardiorespiratory arrest or both hypotension and respiratory compromise, 2) disseminated intravascular coagulation, 3) clinical onset during labour or within 30 min of delivery of the placenta, and 4) absence of fever. Two patients had a cardiac arrest and the third developed significant hypotension and hypoxia. In all patients, point-of-care echocardiography at the time of shock revealed signs of right ventricular failure including a D-shaped septum, acute pulmonary hypertension, and right ventricular systolic dysfunction. CONCLUSION: This case series and literature review of AFE emphasizes the importance of echocardiography in elucidating the etiology of maternal shock. The presence of right ventricular failure may be considered an important criterion to diagnose AFE.

RéSUMé: OBJECTIF: L'embolie de liquide amniotique (ELA) est une complication rare mais souvent fatale caractérisée par une instabilité hémodynamique et une coagulopathie soudaines survenant pendant le travail obstétrical ou au début de la période postpartum. Étant donné que les mécanismes menant au choc et les effets cardiovasculaires de l'ELA ne sont que partiellement compris, le but de cette série de cas était de décrire comment l'ELA apparaît à l'échocardiographie et de passer en revue les rares comptes rendus dans la littérature. CARACTéRISTIQUES CLINIQUES: Nous décrivons trois cas d'ELA survenus à l'Hôpital général juif, un centre tertiaire de soins à Montréal, au Canada. Tous les cas remplissaient les critères diagnostiques de Clark, qui comportent 1) un arrêt cardiorespiratoire soudain ou une hypotension accompagnée d'une détresse respiratoire, 2) une coagulation intravasculaire disséminée, 3) une apparition clinique pendant le travail obstétrical ou dans un délai de 30 minutes suivant la délivrance du placenta, et 4) l'absence de fièvre. Deux patientes ont subi un arrêt cardiaque et le tiers des patientes ont manifesté une hypotension et une hypoxie significatives. Chez toutes les patientes, l'échocardiographie au chevet au moment du choc a révélé des signes d'insuffisance ventriculaire droite, y compris un septum en forme de D, une hypertension pulmonaire aiguë et une dysfonction systolique ventriculaire droite. CONCLUSION: Cette série de cas et revue de littérature de l'ELA souligne l'importance de l'échocardiographie pour élucider l'étiologie du choc maternel. La présence d'une insuffisance ventriculaire droite peut être considérée un critère important pour diagnostiquer une ELA.

Optimal Echocardiographic Approach to the Evaluation of Tricuspid Regurgitation.

PURPOSE OF REVIEW: To summarize the most recent literature on the optimal echocardiographic approach to the evaluation of tricuspid regurgitation (TR). RECENT FINDINGS: Severe TR is increasingly recognized as an independent adverse prognostic marker. TR severity grading has been mainly based on qualitative and semiquantitative parameters according to the 2017 ASE guidelines, but new data emerging from 3D echocardiography and MRI will likely provide insights into more quantitative measurements of TR severity. The tricuspid valve's anatomy and physiology is complex and unique. TR can be primary or secondary to tricuspid annular dilatation. Commonly used echocardiographic parameters to define severe TR are severe valve lesions, a large color flow jet area, a vena contracta width of ≥ 7 cm, a PISA radius of ≥ 0.9 cm, a dense and triangular continuous wave Doppler jet shape, and hepatic vein systolic flow reversal. Complementary imaging modalities such as 3D echocardiography and MRI should be utilized if the 2D echocardiographic evaluation is suboptimal.

Malnutrition and Mortality in Frail and Non-Frail Older Adults Undergoing Aortic Valve Replacement.

BACKGROUND: Older adults undergoing aortic valve replacement (AVR) are at risk for malnutrition. The association between preprocedural nutritional status and midterm mortality has yet to be determined. METHODS: The FRAILTY-AVR (Frailty in Aortic Valve Replacement) prospective multicenter cohort study was conducted between 2012 and 2017 in 14 centers in 3 countries. Patients ≥70 years of age who underwent transcatheter or surgical AVR were eligible. The Mini Nutritional Assessment-Short Form was assessed by trained observers preprocedure, with scores ≤7 of 14 considered malnourished and 8 to 11 of 14 considered at risk for malnutrition. The Short Performance Physical Battery was simultaneously assessed to measure physical frailty, with scores ≤5 of 12 considered severely frail and 6 to 8 of 12 considered mildly frail. The primary outcome was 1-year all-cause mortality, and the secondary outcome was 30-day composite mortality or major morbidity. Multivariable regression models were used to adjust for potential confounders. RESULTS: There were 1158 patients (727 transcatheter AVR and 431 surgical AVR), with 41.5% females, a mean age of 81.3 years, a mean body mass index of 27.5 kg/m2, and a mean Society of Thoracic Surgeons-Predicted Risk of Mortality of 5.1%. Overall, 8.7% of patients were classified as malnourished and 32.8% were at risk for malnutrition. Mini Nutritional Assessment-Short Form scores were modestly correlated with Short Performance Physical Battery scores (Spearman R=0.31, P<0.001). There were 126 deaths in the transcatheter AVR group (19.1 per 100 patient-years) and 30 deaths in the surgical AVR group (7.5 per 100 patient-years). Malnourished patients had a nearly 3-fold higher crude risk of 1-year mortality compared with those with normal nutritional status (28% versus 10%, P<0.001). After adjustment for frailty, Society of Thoracic Surgeons-Predicted Risk of Mortality, and procedure type, preprocedural nutritional status was a significant predictor of 1-year mortality (odds ratio, 1.08 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.01-1.16) and of the 30-day composite safety end point (odds ratio, 1.06 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.001-1.12). CONCLUSIONS: Preprocedural nutritional status is associated with mortality in older adults undergoing AVR. Clinical trials are needed to determine whether pre- and postprocedural nutritional interventions can improve clinical outcomes in these vulnerable patients.

Pulmonary capillary surface area in supine exercising humans: demonstration of vascular recruitment.

In exercising humans, cardiac output (CO) increases, with minor increases in pulmonary artery pressure (PAP). It is unknown if the CO is accommodated via distention of already perfused capillaries or via recruitment of nonconcomitantly perfused pulmonary capillaries. Ten subjects (9 female) performed symptom-limited exercise. Six had resting mean PAP (PAPm) <20 mmHg, and four had PAPm between 21 and 24 mmHg. The first-pass pulmonary circulatory metabolism of [3H]benzoyl-Phe-Ala-Pro (BPAP) was measured at rest and at peak exercise, and functional capillary surface area (FCSA) was calculated. Data are means ± SD. Mean pulmonary arterial pressure rose from 18.8 ± 3.3 SD mmHg to 28.5 ± 4.6 SD mmHg, CO from 6.4 ± 1.6 to 13.4 ± 2.9 L/min, and pulmonary artery wedge pressure from 14 ± 3.3 to 19.5 ± 5 mmHg (all P ≤ 0.001). Percent BPAP metabolism fell from 74.7 ± 0.1% to 67.1 ± 0.1%, and FCSA/body surface area (BSA) rose from 2,939 ± 640 to 5,018 ± 1,032 mL·min-1·m-2 (all P < 0.001). In nine subjects, the FCSA/BSA-to-CO relationship suggested principally capillary recruitment and not distention. In subject 10, a marathon runner, resting CO and FCSA/BSA were high, and increases with exercise suggested distention. Exercising humans demonstrate pulmonary capillary recruitment and distention. At moderate resting CO, increasing blood flow causes principally recruitment while, based on one subject, when exercise begins at high CO, further increases appear to cause distention. Our findings clarify an important physiologic question. The technique may provide a means for further understanding exercise physiology, its limitation in pulmonary hypertension, and responses to therapy.

Right ventricular strain: measurement and clinical application.

PURPOSE OF REVIEW: Right ventricular (RV) assessment has long been challenging and technically difficult using echocardiography. This is mainly the result of the asymmetrical shape of the RV making it difficult to visualize on one-or-two dedicated views, thus requiring multiple integrated views and subjective assessment. Measurement of tricuspid annular systolic plane excursion and RV tissue Doppler velocity have become relied-upon methods of objective assessments; however, have limitations for characterizing true RV physiology. RECENT FINDINGS: Studies suggest that two-dimensional RV free wall longitudinal systolic strain (RVFWS) using speckle-tracking echocardiography has emerged as a reproducible, feasible and highly prognostic technique for quantifying RV function. This has been demonstrated for patients with heart failure, ischemic heart disease, pulmonary hypertension, infiltrative disease and many other types of cardiovascular disease. SUMMARY: The current review outlines the clinical use of RVFWS, and its integration with other commonly used echocardiographic measurements to more accurately assess RV function, cause and prognosis to guide and improve patient care decision making.

Invasive and Noninvasive Evaluation for the Diagnosis of Pulmonary Hypertension: How to Use and How to Combine Them.

The etiologic diagnosis of pulmonary hypertension (PH) may be very challenging. Right-heart catheterization (RHC) in isolation cannot classify a precapillary PH patient into group 1, 3, 4, or 5. Moreover, RHC may be not sufficient for reaching a definitive differential diagnosis of precapillary or postcapillary PH if hemodynamic data are not integrated in clinical context and combined with information gleaned from noninvasive imaging. Therefore, only the integration of risk factors, clinical evaluation, invasive and noninvasive tests allows the physician to distinguish between different forms of PH.

The Right Heart International Network (RIGHT-NET): Rationale, Objectives, Methodology, and Clinical Implications.

The Right Heart International Network is a multicenter international study aiming to prospectively collect exercise Doppler echocardiography tests of the right heart pulmonary circulation unit (RHPCU) in large cohorts of healthy subjects, elite athletes, and individuals at risk of or with overt pulmonary hypertension. It is going to provide standardization of exercise stress echocardiography of RHPCU and explore the full physiopathologic response.

Early improvement in serial echocardiographic studies in heart failure patients predicts long term survival-a pilot study.

BACKGROUND: Several echocardiographic measures have prognostic value in heart failure (HF). However, no definitive data exist on how changes in these parameters with treatment affect survival in this patient population. We hypothesized that early improvement on echocardiography could predict long-term survival. METHODS AND RESULTS: We conducted a retrospective review of 404 patients seen in the HF clinic from 2002 to 2008 (6.5 years). Patients had one echocardiogram ≤1 year before and another ≥1 month (10 ± 7 months) after treatment onset. We studied changes in standard echocardiographic parameters, including left (LV) and right (RV) ventricular size and/or function (systolic and/or diastolic), valvular (mitral and tricuspid) function, and pulmonary artery pressure. Survival curves and hazard ratios were generated for patients showing improvement on the 2nd echocardiogram versus those who did not. Multivariable analyses were performed adjusting for age, sex, ischemic etiology, and significant baseline echocardiographic parameters. Average follow-up was 2.9 ± 1.5 years. Improvement in LV end-systolic dimension, RV function, and mitral regurgitation were independent predictors of 5-year survival (P < .05) and, importantly, more predictive than baseline values of these parameters alone (higher hazard ratios). CONCLUSIONS: Early echocardiographic improvement is strongly associated with 5-year survival in patients with HF. Serial echocardiography may aid in stratifying patient care.

Complications Associated With Nitrate Use in Patients Presenting With Acute Pulmonary Edema and Concomitant Moderate or Severe Aortic Stenosis.

STUDY OBJECTIVE: We evaluate the incidence of complications associated with the use of nitrates in patients presenting with acute pulmonary edema and concomitant moderate or severe aortic stenosis compared with patients without aortic stenosis. Nitrates are contraindicated in severe aortic stenosis because of the theoretical yet unproven risk of precipitating profound hypotension. METHODS: A cohort design with retrospective chart review study was conducted at two Canadian hospitals. Patients with aortic stenosis (moderate or severe) and without aortic stenosis were included if they presented with acute cardiogenic pulmonary edema, received intravenous or sublingual nitroglycerin, and had an echocardiography report available. The primary outcome was clinically relevant hypotension, defined as hypotension leading to any of the following predefined events: nitroglycerin discontinuation, intravenous fluid bolus, vasopressor use, or cardiac arrest. The secondary outcome was sustained hypotension, defined as a systolic blood pressure less than 90 mm Hg and lasting greater than or equal to 30 minutes. RESULTS: The cohort consisted of 195 episodes of acute pulmonary edema, representing 65 episodes with severe aortic stenosis (N=65) and an equal number of matched episodes with moderate aortic stenosis (N=65) and no aortic stenosis (N=65). Nitroglycerin was administered intravenously only in 70% of cases, intravenously and sublingually in 25%, and sublingually only in the remaining 5%. After adjustment for sex, initial systolic blood pressure, furosemide dose, and use of noninvasive ventilation, moderate and severe aortic stenosis were not associated with clinically relevant hypotension after receipt of nitroglycerin (adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.40 to 2.37 for moderate aortic stenosis; adjusted OR 0.99, 95% CI 0.41 to 2.41 for severe aortic stenosis). The incidence of clinically relevant hypotension was 26.2% for moderate and severe aortic stenosis and 23.1% in the no aortic stenosis reference group. The secondary outcome of sustained hypotension occurred in 29.2% of patients with severe aortic stenosis, 16.9% with moderate aortic stenosis, and 13.8% in the no aortic stenosis group (adjusted OR for severe aortic stenosis 2.34; 95% CI 0.91 to 6.01). CONCLUSION: In this retrospective study, neither moderate nor severe aortic stenosis was associated with a greater risk of clinically relevant hypotension requiring intervention when nitroglycerin was used for acute pulmonary edema. Future studies should investigate safety and efficacy of nitroglycerin for patients with aortic stenosis because this study was limited by a small sample size and design limitations. Cautious use of nitroglycerin in patients with moderate or severe aortic stenosis and presenting with acute pulmonary edema may be a safer strategy than traditionally thought.

Echocardiographic evaluation of the right ventricle: a 2014 perspective.

The ability to properly evaluate the right ventricular size and function can have important consequences for clinical management and prognosis. Echocardiography is and will remain the leading method of right ventricle (RV) assessment due to its ease of use and wealth of diagnostic information provided. Understanding the various strengths and limitations of the diverse echocardiographic methods of RV assessment can allow a systematic approach to resolve situations where one's quantitative parameters are not necessarily concordant. Quantification of RV volume can be done by two-dimensional (2D) and three-dimensional (3D) echocardiography. Measurements of RV systolic function include fractional area change (FAC), right-sided index of myocardial performance (RIMP), RV ejection fraction (RVEF), tricuspid annular plane excursion by M-Mode (TAPSE), tricuspid annular systolic longitudinal velocity by tissue Doppler (S'), and regional strain and strain rate. RVEF can also be assessed volumetrically by 3D echocardiography. This article will review the current methods used in contemporary echocardiography laboratories, with an emphasis on a guideline-based approach as well as emerging techniques.

Incremental value of the preoperative echocardiogram to predict mortality and major morbidity in coronary artery bypass surgery.

BACKGROUND: Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. METHODS AND RESULTS: Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. CONCLUSIONS: Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.

Tricuspid Regurgitation: From Imaging to Clinical Trials to Resolving the Unmet Need for Treatment.

Tricuspid regurgitation (TR) is a highly prevalent and heterogeneous valvular disease, independently associated with excess mortality and high morbidity in all clinical contexts. TR is profoundly undertreated by surgery and is often discovered late in patients presenting with right-sided heart failure. To address the issue of undertreatment and poor clinical outcomes without intervention, numerous structural tricuspid interventional devices have been and are in development, a challenging process due to the unique anatomic and physiological characteristics of the tricuspid valve, and warranting well-designed clinical trials. The path from routine practice TR detection to appropriate TR evaluation, to conduction of clinical trials, to enriched therapeutic possibilities for improving TR access to treatment and outcomes in routine practice is complex. Therefore, this paper summarizes the key points and methods crucial to TR detection, quantitation, categorization, risk-scoring, intervention-monitoring, and outcomes evaluation, particularly of right-sided function, and to clinical trial development and conduct, for both interventional and surgical groups.

High prevalence of occult left heart disease in scleroderma-pulmonary hypertension.

Our study aimed to determine the prevalence of occult left-heart disease in patients with scleroderma and pulmonary hypertension. In patients with pulmonary hypertension (mean pulmonary artery pressure (mean PAP)≥25 mmHg), differentiation between pre- and post-capillary pulmonary hypertension has been made according to pulmonary artery wedge pressure (PAWP) less than or more than 15 mmHg, respectively. We performed a retrospective chart review of 107 scleroderma patients. All patients with suspected pulmonary hypertension had routine right or left heart catheterisation with left ventricular end-diastolic pressure (LVEDP) measurement pre-/post-fluid challenge. We extracted demographic, haemodynamic and echocardiographic data. Patients were classified into one of four groups: haemodynamically normal (mean PAP<25 mmHg); pulmonary venous hypertension (PVH) (mean PAP≥25 mmHg, PAWP>15 mmHg); occult PVH (mean PAP≥25 mmHg, PAWP≤15 mmHg, LVEDP>15 mmHg before or after fluid challenge); and pulmonary arterial hypertension (PAH) (mean PAP≥25 mmHg, PAWP≤15 mmHg and LVEDP≤15 mmHg before or after fluid challenge). 53 out of 107 patients had pulmonary hypertension. Based on the PAWP-based definition, 29 out of 53 had PAH and 24 out of 53 had PVH. After considering the resting and post-fluid-challenge LVEDP, 11 PAH patients were reclassified as occult PVH. The occult PVH group was haemodynamically, echocardiographically and demographically closer to the PVH group than the PAH group. PVH had high prevalence in our scleroderma-pulmonary hypertension population. Distinguishing PAH from PVH with only PAWP may result in some PVH patients being misclassified as having PAH.

De-frailing intervention for hospitalized cardiovascular patients in the TARGET-EFT randomized clinical trial.

AIMS: Frailty is disproportionately prevalent in cardiovascular disease patients and exacerbated during hospital admissions, heightening the risk for adverse events and functional decline. Using the Essential Frailty Toolset (EFT) to target physical weakness, cognitive impairment, malnourishment, and anaemia, we tested a multicomponent targeted intervention to de-frail older adults with acute cardiovascular conditions during their hospital admission. METHODS AND RESULTS: The TARGET-EFT trial was a single-center randomized clinical trial at the Jewish General Hospital, Montreal, Canada. We compared a multicomponent de-frailing intervention with usual clinical care. Intervention group patients received exercise, cognitive stimulation, protein supplementation, and iron replacement, as required. In this study, the primary outcome was frailty, as assessed by the SPPB score (Short Physical Performance Battery) at discharge, and the secondary outcome was the SARC-F score (Strength, Assistance walking, Rising from chair, Climbing, Falls) assessed 30 days later. The analysis consisted of 135 patients (mean age of 79.3 years; 54% female) who survived and completed the frailty assessments.Compared with control patients, intervention group patients had a 1.52-point superior SPPB score and a 0.74-point superior SARC-F score. Subgroup analysis suggested that patients with low left ventricular ejection fraction may have attenuated benefits, and that patients who underwent invasive cardiac procedures had the greatest benefits from the intervention. CONCLUSION: We achieved our objective of de-frailing older cardiac inpatients on a short-term basis by improving their physical performance and functioning using a pragmatic multicomponent intervention. This could have positive impacts on their clinical outcomes and ability to maintain independent living in the future. ONE SENTENCE SUMMARY: The multicomponent intervention targeted to the deficits of vulnerable older adults hospitalized with acute cardiovascular diseases successfully de-frailed them on a short-term basis, which can have positive implications on their post-discharge health outcomes.

Multicomponent intervention for frail and pre-frail older adults with acute cardiovascular conditions: The TARGET-EFT randomized clinical trial.

BACKGROUND: Hospitalization for cardiovascular disease (CVD) may be complicated by hospital-acquired disability (HAD) and subsequently poor health-related quality of life (HRQOL). While frailty has been shown to be a risk factor, it has yet to be studied as a therapeutic target to improve outcomes. OBJECTIVES: This trial sought to determine the effects of an in-hospital multicomponent intervention targeting physical weakness, cognitive impairment, malnutrition, and anemia on patient-centered outcomes compared to usual care. METHODS: A single-center parallel-group randomized clinical trial was conducted in older patients with acute CVD and evidence of frailty or pre-frailty as measured by the Essential Frailty Toolset (EFT). Patients were randomized to usual care or a multicomponent intervention. Outcomes were HRQOL (EQ-5D-5L score) and disability (Older Americans Resources and Services score) at 30 days post-discharge and mood disturbances (Hospital Anxiety and Depression Scale) at discharge. RESULTS: The trial cohort consisted of 142 patients with a mean age of 79.5 years and 55% females. The primary diagnosis was heart failure in 29%, valvular heart disease in 28%, ischemic heart disease in 14%, arrhythmia in 11%, and other CVDs in 18%. The intervention improved HRQOL scores (coefficient 0.08; 95% CI 0.01, 0.15; p = 0.03) and mood scores (coefficient -1.95; 95% CI -3.82, -0.09; p = 0.04) but not disability scores (coefficient 0.18; 95% CI -1.44, 1.81; p = 0.82). There were no intervention-related adverse events. CONCLUSION: In frail older patients hospitalized for acute CVDs, an in-hospital multicomponent intervention targeted to frailty was safe and led to modest yet clinically meaningful improvements in HRQOL and mental well-being. The downstream impact of these effects on event-free survival and functional status remains to be evaluated in future research, as does the generalizability to other healthcare systems. CLINICAL REGISTRATION NUMBER: NCT04291690.

Exercise Stress Echocardiography of the Right Ventricle and Pulmonary Circulation.

BACKGROUND: Exercise echocardiography is used for assessment of pulmonary circulation and right ventricular function, but limits of normal and disease-specific changes remain insufficiently established. OBJECTIVES: The objective of this study was to explore the physiological vs pathologic response of the right ventricle and pulmonary circulation to exercise. METHODS: A total of 2,228 subjects were enrolled: 375 healthy controls, 40 athletes, 516 patients with cardiovascular risk factors, 17 with pulmonary arterial hypertension, 872 with connective tissue diseases without overt pulmonary hypertension, 113 with left-sided heart disease, 30 with lung disease, and 265 with chronic exposure to high altitude. All subjects underwent resting and exercise echocardiography on a semirecumbent cycle ergometer. All-cause mortality was recorded at follow-up. RESULTS: The 5th and 95th percentile of the mean pulmonary artery pressure-cardiac output relationships were 0.2 to 3.5 mm Hg.min/L in healthy subjects without cardiovascular risk factors, and were increased in all patient categories and in high altitude residents. The 5th and 95th percentile of the tricuspid annular plane systolic excursion to systolic pulmonary artery pressure ratio at rest were 0.7 to 2.0 mm/mm Hg at rest and 0.5 to 1.5 mm/mm Hg at peak exercise, and were decreased at rest and exercise in all disease categories and in high-altitude residents. An increased all-cause mortality was predicted by a resting tricuspid annular plane systolic excursion to systolic pulmonary artery pressure <0.7 mm/mm Hg and mean pulmonary artery pressure-cardiac output >5 mm Hg.min/L. CONCLUSIONS: Exercise echocardiography of the pulmonary circulation and the right ventricle discloses prognostically relevant differences between healthy subjects, athletes, high-altitude residents, and patients with various cardio-respiratory conditions. (Right Heart International NETwork During Exercise in Different Clinical Conditions; NCT03041337).

Pulmonary arterial hypertension in the elderly-clinical characteristics and long-term survival.

BACKGROUND: Recent registries describe a significant prevalence of pulmonary arterial hypertension (PAH) in the elderly, but little is known of their characteristics. We aimed to examine the features and prognostic factors of long-term survival in elderly (≥65 years) PAH patients. METHODS: Clinical, echocardiographic, angiographic, hemodynamic, treatments, and survival data were reviewed in consecutive patients over the course of 20 years. Elderly PAH patients (n = 47) were compared to younger PAH patients (n = 107). RESULTS: At presentation, elderly patients were more likely to have hypertension, diabetes, dyslipidemia, coronary disease, and PAH associated with scleroderma (42.6 vs. 24.3 %; p = 0.02) than younger patients. Prior to PAH therapy, elderly patients had better right ventricular myocardial performance index (RV-MPI; 0.48 ± 0.20 vs. 0.62 ± 0.23, p = 0.006) and lower mean pulmonary arterial pressure (PAP; 45.0 ± 11.1 vs. 49.2 ± 11.8 mmHg, p = 0.04). Elderly patients were treated less often with epoprostenol (8.5 vs. 29 %, p = 0.006) or trepostinil (8.5 vs. 23.4 %, p = 0.04). The 1, 3, and 5 year survival rates of elderly patients were estimated to be 76.4, 50.5, and 37.6 %, respectively. In comparison, younger patients had survival estimates of 92.2, 74.2 and 64.0 % (p = 0.002). Baseline right atrial pressure, mean PAP, cardiac index, and RV-MPI were associated with survival in elderly patients; however in these patients, survival was not affected by any PAH subgroup or age (per year) by itself. CONCLUSIONS: The diagnosis of PAH in elderly patients is associated with poorer survival which is in part explained by a greater vulnerability to the hemodynamic disturbances of PAH.

Echocardiographic assessment and clinical implication of functional tricuspid regurgitation in heart failure with reduced or preserved ejection fraction (ECLIPSE-HF) : Rationale and design of the study.

PURPOSE: Functional tricuspid regurgitation (FTR) has been shown to be associated with increased morbidity and mortality in several clinical conditions, including heart failure (HF) with reduced left ventricular ejection fraction as well as pulmonary arterial hypertension (PAH). We have designed a study aiming at: characterizing the echocardiographic morphology of the tricuspid valve apparatus and the pathophysiology of FTR in heart failure with reduced, mid-range or preserved left ventricular ejection fraction (HFrEF, HFmrEF, HFpEF) and in PAH patients; correlating the morphologic characteristics of tricuspid valve apparatus with hemodynamic severity of FTR; correlating the severity of FTR with the clinical condition and outcome. METHODS: The study will be a non-interventional, prospective, international, multicenter, longitudinal study (ClinicalTrials.gov Identifier NCT05209919). The minimum number of patients which are expected to be enrolled is 300 HF patients, including HFrEF, HFmrEF and HFpEF patients, whereas 100 PAH patients will serve as control. The patients will be enrolled in 20 centers in Europe, North America and Saudi Arabia. Standard echocardiographic parameters will be analyzed by local investigators; strain measurements will be performed in a single central core-lab. CONCLUSIONS: This study has been designed to improve our understanding of pathophysiological mechanisms and clinical relevance of FTR across all HF phenotypes. The results could potentially allow a more appropriate selection of heart failure patients with FTR for tricuspid valve intervention by percutaneous or surgical repair or replacement.