Clinical and echocardiographic predictors of long-term outcome of a large cohort of patients with bicuspid aortic valve.

BACKGROUND AND OBJECTIVES: Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation. The aim of the present article is to determine clinical and echocardiographic prognostic factors and provide a predictive model of outcome of a large cohort of patients with BAV. METHODS: We retrospectively enrolled 337 patients consecutively assessed for echocardiography at our Cardiology Department from 1993 to 2014. We considered aortic valve replacement, aortic surgery and cardiovascular death as a clinical combined end-point. Predictors of outcome were determined by Cox regression. RESULTS: Mean age was 29.2 ±â€Š19.8 years, median 27.1 years. A total of 38.4% patients presented a history of hypertension. Mean duration of follow-up was 8.4 ±â€Š6.1 years, range 0-21 years. A total of 73 patients underwent aortic valve replacement and/or aortic surgery during follow-up. Age at surgery was 45.2 ±â€Š15.6 years. Seven patients died because of cardiovascular causes. At multivariate analysis, baseline clinical predictors were history of hypertension [hazard ratio (HR) 2.289, 95% confidence interval (CI) 1.350-3.881, P = 0.002], larger ascending aortic diameter (HR 2.537, 95% CI 1.888-3.410, P < 0.001), moderate-to-severe aortic regurgitation (HR 2.266, 95% CI 1.402-3.661, P = 0.001) and moderate-to-severe aortic stenosis (HR 2.807, 95% CI 1.476-5.338, P = 0.002). A predictive model was created by integrating these four independent covariates. It allows the calculation of calculate a risk score for each patient, which helps better tailor appropriate treatment in BAV patients. CONCLUSION: At enrolment, history of hypertension, a wider aortic diameter, moderate-to-severe aortic regurgitation and aortic stenosis were independently correlated to combined end-point. Long-term follow-up showed low cardiovascular mortality (2.1%) and a high prevalence of cardiac surgery (21.6%).

Advantages of deformation indices over systolic velocities in assessment of longitudinal systolic function in patients with heart failure and normal ejection fraction.

AIMS: Tissue Doppler imaging (TDI) systolic velocities have been used to detect impaired systolic function in patients with heart failure and normal ejection fraction (HFnEF). However, many patients do not show alterations by this technique, and furthermore, myocardial systolic velocities can be affected by tethering, translation, and loading conditions. Thus, uncertainties remain about the detection of abnormal systolic function in HFnEF patients. The aim of this study was, therefore, to compare systolic velocities vs. TDI-derived deformation indices for detection of possible abnormalities of systolic function in HFnEF patients, taking into account loading conditions. METHODS AND RESULTS: We studied 40 patients with systolic heart failure (SHF: EF ≤ 40%), 47 HFnEF patients, and 50 controls (C). Systolic velocities of the mitral annulus (pulsed-wave TDI) were measured at four sites and averaged; concomitantly, peak negative TDI-derived strain and strain rate of the four walls were measured in apical, four-, and two-chamber views. Ejection fraction was 65 ± 6% in C, 62 ± 7% in HFnEF, and 29 ± 7% in SHF (P< 0.001 vs. both). In HFnEF patients, systolic velocities and peak negative global longitudinal strain rate and strain were higher than in SHF (P< 0.0001 for all), but lower than in C (P< 0.0001 for all). After controlling for age, left ventricular mass index, end-diastolic volume index, and circumferential end-systolic stress, differences between groups remained significant for deformation indices but not for TDI velocities. By velocity/strain-stress relationship analysis, peak global longitudinal strain was more sensitive than peak systolic motion in detecting systolic dysfunction in HFnEF patients (64 vs. 40%, P< 0.05). CONCLUSION: In patients with HFnEF, TDI-derived deformation indices may more accurately detect abnormal systolic function than myocardial velocities.

Effect of revascularizing viable myocardium on left ventricular diastolic function in patients with ischaemic cardiomyopathy.

AIMS: In patients with ischaemic left ventricular (LV) dysfunction and viable myocardium, revascularization improves systolic function. Diastolic dysfunction is also present in such patients; however, whether revascularization improves diastolic function also is largely unknown. METHODS: Twenty-six patients with chronic ischaemic cardiomyopathy [ejection fraction (EF) 32 +/- 6%, wall motion score index (WMSI) 2.45 +/- 0.33] and viable myocardium (low-dose dobutamine echocardiography) were examined at baseline and > or =4 months after revascularization. Diastolic function was assessed by transmitral pulsed-wave Doppler and tissue Doppler imaging (TDI) at the mitral annulus. RESULTS: At baseline, 62% of patients showed non-restrictive filling (non-RF) pattern, and 38% restrictive filling (RF) pattern. After revascularization, along with improvement in systolic function (EF 43 +/- 10%, WMSI 1.78 +/- 0.47, P = 0.0002 for both), diastolic filling improved in most patients, with only three patients still exhibiting RF pattern (P = 0.016); furthermore, E' velocity increased (32 +/- 42%, P = 0.0028) and E/E' decreased (-19 +/- 31%, P = 0.0378) compared with baseline. Left ventricular filling pressure also decreased, from 17.5 +/- 6.8 to 13.1 +/- 6.5 mmHg (P = 0.005). Improvement of diastolic function by TDI was related to the extent of viability at baseline (P = 0.0098) and to LV reverse remodelling after revascularization (P = 0.0092). CONCLUSION: In patients with ischaemic cardiomyopathy, LV diastolic filling may largely improve after revascularization. Improvement of diastolic dysfunction is related to the amount of viable tissue and it may represent an additional advantage of revascularizing dyssinergic but viable myocardium.