The Kansas City Cardiomyopathy Questionnaire in Relation to New York Heart Association Class.

BACKGROUND: In order to identify candidacy and treatment response for patients with obstructive hypertrophic cardiomyopathy (oHCM), clinicians need an accurate means of assessing symptoms, function, and quality of life. While the New York Heart Association (NYHA) Classification is most often used, the Kansas City Cardiomyopathy Questionnaire (KCCQ-23) is more accurate and sensitive to change, although less familiar to practicing clinicians. To support interpreting the KCCQ, we describe cross-sectional and changes in KCCQ scores in the context of the NYHA. METHODS: Participants from the EXPLORER-HCM trial (NCT03470545) completed the KCCQ-23 and clinicians assigned NYHA classes at study visits. Participants were included if they had baseline and week 30 data for cross-sectional and longitudinal changes. Median KCCQ-23 scores were compared by NYHA class at baseline and week 30 and by change in NYHA class from baseline to week 30. RESULTS: Cross-sectionally, the KCCQ-23 Overall Summary Scores (KCCQ-23 OSS) and Clinical Summary Scores (KCCQ-23 CSS) had an inverse relationship with NYHA at baseline and 30 weeks, with marked variations in KCCQ-23 scores among patients assigned to the same NYHA class. When improving from NYHA class II to I, the median changes in KCCQ-23 OSS and KCCQ-23 CSS were 10 (IQR 4, 22) and 8 (IQR 2, 20), respectively. The changes were larger when improving from NYHA class III to II and from NYHA class III to I. CONCLUSION: KCCQ-23 scores are inversely related to NYHA classes, with significant variability within classes. Changes in scores are not linear, suggest greater differences when patients move between NYHA Class II and III than Class I and II. These insights may help clinicians better understand cross-sectional and changes in KCCQ scores.

Sex differences in the diagnostic algorithm of screening for heart failure by symptoms and NT-proBNP in patients with type 2 diabetes.

OBJECTIVES: This study aimed to assess the guideline recommended diagnostic tools NT-proBNP and NYHA classification, with a focus on sex-specific differences. BACKGROUND: Patients with Type 2 Diabetes (T2D) face a heart failure (HF) risk up to four times higher than those without T2D, particularly affecting women more than twice as much as men. Despite distinct pathophysiological differences between men and women, there are currently no sex-specific recommendations for the diagnostic algorithm of HF in diabetic patients. METHODS: A total of 2083 patients with T2D were enrolled, and the primary endpoint was heart failure during hospitalization within a 5-year timeframe. The secondary endpoint was all-cause death. RESULTS: In female patients, frequency of HF diagnosis prior to or during hospitalization and mortality did not differ significantly between NYHA II and III, in contrast to male patients. Additionally, there was no notable difference in mean NT-proBNP levels between NYHA stage II and III only in female patients. The multivariable regression analysis highlighted NYHA classification not to be a predictor of NT-proBNP levels in female but solely in male patients. On multivariable Cox regression NYHA score was also no significant risk factor for occurence of HF in female patients. Furthermore, there was no significant disparity in mortality between men with NT-proBNP levels between 125 and 400 pg/ml and those below 125 pg/ml, whereas in women mortality was significantly higher in the group with NT-proBNP levels between 125 and 400 pg/ml than below 125 pg/ml. CONCLUSION: These findings suggest that NYHA classification may not be the most suitable tool for assessing the diagnosis of HF in female patients with T2D. Moreover, the need for consideration of a more symptom-independent screening for HF in female patients with T2D and re-evaluation of current guidelines especially regarding sex-specific aspects is highlighted.

Correlation of Serum Laminin Levels with Cardiac Function and In-Hospital Prognosis in Patients with Atrial Fibrillation.

We aimed to investigate the correlation between serum laminin (LN) levels and cardiac function in patients with atrial fibrillation (AF) and its predictive value for in-hospital prognosis. This study included 295 patients with AF who were admitted to the Second Affiliated Hospital of Nantong University from January 2019 to January 2021. The patients were divided into three groups according to the New York Heart Association (NYHA) functional classification (I-II, III, and IV); the LN levels increased with increasing NYHA class (P < 0.05). Spearman's correlation analysis revealed a positive correlation between LN and NT-proBNP (r = 0.527, P < 0.001). Of the patients, 36 had in-hospital major adverse cardiac events (MACEs), of whom 30 had acute heart failure, 5 had malignant arrhythmias, and one had stroke. The area under the ROC curve for predicting the in-hospital MACEs by LN was 0.815 (95% CI: 0.740-0.890, P < 0.001). Multivariate logistic regression analysis revealed that LN could be an independent predictor of in-hospital MACEs (odds ratio: 1.009, 95% confidence interval: 1.004-1.015, P = 0.001). In conclusion, LN may serve as a potential biomarker to evaluate the severity of cardiac function and predict in-hospital prognosis in AF patients.

Sex Differences in the Relationship between New York Heart Association Functional Classification and Survival in Cardiovascular Disease Patients: A Mediation Analysis of Exercise Capacity with Regular Care Data.

Background: The New York Heart Association (NYHA) functional class has extensively been used for risk stratification in patients suspected of heart failure, although its prognostic value differs between sexes and disease entities. Functional exercise capacity might explain the association between NYHA functional class and survival, and can serve as an objective proxy for the subjective nature of the NYHA classification. Therefore, we assessed whether sex-differences in exercise capacity explain the association between NYHA functional class and survival in patients suspected of cardiovascular disease. Methods: Electronic health record data from 7259 patients with cardiovascular symptoms, a documented NYHA functional class and cardiac stress electrocardiogram (ECG), was analysed. Follow-up for all-cause mortality was obtained through linkage with Statistics Netherlands. A sex-stratified mediation analysis was performed to assess to what extent the proportional heart rate and -workload during ECG stress testing explain the association between NYHA functional class and survival. Results: In men, increments in NYHA functional class were related to higher all-cause mortality in a dose-response manner (NYHA II vs III/IV: hazard ratio [HR] 1.59 vs 3.64, referenced to NYHA I), whilst in women those classified as NYHA functional class II and III/IV had a similar higher mortality risk (HR 1.49 vs 1.41). Sex-stratified mediation analysis showed that the association between NYHA and survival was mostly explained by proportional workload during stress ECG (men vs women: 22.9%, 95% CI: 18.9%-27.3% vs 40.3%, 95% CI: 28.5%-68.6%) and less so by proportional heart rate (men vs women: 2.5%, 95% CI: 1.3%-4.3% vs 8.0%, 95% CI: 4.1%-18.1%). Post-hoc analysis showed that NYHA classification explained a minor proportion of the association between proportional workload and all-cause mortality (men vs women: 15.1%, 95% CI: 12.0%-18.3% vs 4.4%, 95% CI: 1.5%-7.4%). Conclusions: This study showed a significant mediation in both sexes on the association between NYHA functional class and all-cause mortality by proportional workload, but the effect explained by NYHA classification on the association between survival and proportional workload is small. This implies that NYHA classification is not a sole representation of a patient's functional capacity, but might also incude other aspects of the patient's overall health status.

Pulmonary perfusion and NYHA classification improve after cardiac resynchronization therapy.

BACKGROUND: Evaluation of cardiac resynchronization therapy (CRT) often includes New York Heart Association (NYHA) classification, and echocardiography. However, these measures have limitations. Perfusion gradients from ventilation/perfusion single-photon emission computed tomography (V/P SPECT) are related to left-heart filling pressures and have been validated against invasive right-heart catheterization. The aim was to assess if changes in perfusion gradients are associated with improvements in heart failure (HF) symptoms after CRT, and if they correlate with currently used diagnostic methods in the follow-up of patients with HF after receiving CRT. METHODS AND RESULTS: Nineteen patients underwent V/P SPECT, echocardiography, NYHA classification, and the quality-of-life scoring system "Minnesota living with HF" (MLWHF), before and after CRT. CRT caused improvement in perfusion gradients from V/P SPECT which were associated with improvements in NYHA classification (P = .0456), whereas improvements in end-systolic volume (LVESV) from echocardiography were not. After receiving CRT, the proportion of patients who improved was lower using LVESV (n = 7/19, 37%) than perfusion gradients (n = 13/19, 68%). Neither change in perfusion gradients nor LVESV was associated with changes in MLWHF (P = 1.0, respectively). CONCLUSIONS: Measurement of perfusion gradients from V/P SPECT is a promising quantitative user-independent surrogate measure of left-sided filling pressure in the assessment of CRT response in patients with HF.

Worsening effect of testosterone deficiency on males with heart failure with preserved ejection fraction.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF)is challenging. Patients usually have normal LV size and ejection fraction. This clinical syndrome develops from a complex interaction of several risk factors that cause organ dysfunction and clinical symptoms. There's evidence that testosterone deficiency is associated with a worse cardiometabolic profile and increased inflammatory markers. We thought that these changes might have an impact on heart failure pathogenesis. We aimed to study the relationship between testosterone level and symptoms in HFpEF. METHODS: We studied 120 male patients with HFpEF. According to New York Heart Association (NYHA), patients were classified into I, II and III classes; class IV patients were excluded. All patients were subjected to clinical and echocardiographic examinations. In addition, we measured serum testosterone, cardio-metabolic profile, intracellular adhesive molecule-1(ICAM-1), P-selectin and nitric oxide (NO) levels. RESULTS: Patients with testosterone deficiency had worse NYHA class and higher BNP P = (0.001). Additionally, they had a significantly worse metabolic profile; higher total cholesterol, triglycerides, LDL cholesterol, fasting insulin and HOMA-IR P = (0.005, 0.001, 0.001, 0.001), respectively. Also, they had higher inflammatory markers and worse endothelial functional parameters; (ICAM-1, NO and P- selectin) P = (0.001). Age, BNP and testosterone deficiency can be used as independent predictors of NYHA class III symptoms with a Testosterone cutoff value of 2.7 ng/ml. CONCLUSION: Testosterone deficiency could be used as an independent predictor of symptom severity in HFpEF, and it aggravates systemic inflammation and endothelial dysfunction in these patients.

Influence of Iron Deficiency on Clinical and Haemodynamic Parameters in Pulmonary Arterial Hypertension Cohorts.

BACKGROUND: Iron deficiency (Fedef) has been shown to be common in patients with group 1 or pulmonary arterial hypertension (PAH). Several studies have shown a negative impact of Fedef on clinical and haemodynamic parameters of the disease, but data from individual studies have not been strong enough to lead to incorporation of the finding of Fedef into prognostic or therapeutic algorithms. The goal of this meta-analysis was to combine data from available studies to better define any associations between Fedef and established variables of prognostic importance in PAH. METHODS: A literature search identified nine studies with extractable data relevant to the study questions. The impact of Fedef upon the following parameters was evaluated: 6-minute walk distance (6MWD), WHO-functional class, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, echocardiography, and findings from right heart catheterisation (RHC). Pooled results were reported as mean difference or risk difference with 95% confidence intervals utilising a random effects modeling approach. RESULTS: Fedef in the PAH population was common (47% of cases) and was associated with cardiovascular dysfunction (lower tricuspid annular plane systolic excursion [TAPSE], elevated NT-proBNP, and lower mixed venous oxygen saturation) and with reduction in functional capacity (lower 6MWD and higher functional class). CONCLUSION: This meta-analysis strengthens the relationships between Fedef and several markers of poor outcome in PAH. Fedef in patients with PAH warrants further scrutiny and merits consideration as a cause of clinical deterioration. Even though causation and longitudinal relationships between Fedef and PAH could not be identified, effect of Fedef on factors that affect disease prognosis is noteworthy and worthy of more focussed studies.

Application Value of Systemic Inflammatory Indexes in the Clinical Evaluation of Patients with Heart Failure with Preserved Ejection Fraction (HFpEF).

Background: In areas where medical resources are scarce, an economical and convenient way to assess patients' condition so that treatment plans can be adjusted in a timely manner makes sense. The clinical value of systemic inflammatory indexes (SII) such as neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), albumin-to-gamma-glutamyl-transferase ratio (AGR), white-blood-cell-count-to-mean-platelet-volume ratio (WMR), high-density-lipoprotein-cholesterol-to-C-reactive-protein ratio (HCR), etc. were explored in heart failure (HF) with preserved ejection fraction (HFpEF) because of their easy availability and clinical value in the diagnosis, therapy and prognosis of cardiovascular diseases. Methods: 189 inpatients (including 48 patients with New York Heart Association (NYHA) I in the control group, and 141 patients with NYHA II-IV in the study group) from The First Affiliated Hospital of Jinan University, during the period July 2018 to March 2022, were included by retrieving electronic medical records. Logistic regression analysis, Spearman's correlation coefficient, operating characteristic curve, etc. were used to analyze the data. Results: In patients with HFpEF, LMR (OR = 0.463, 95% CI 0.348−0.617, p = 0.000), NLR and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were independent predictors for the presence of HF, and LMR (OR = 2.630, 95% CI 2.016−3.435, p = 0.000), NLR, FAG, MHR, AGR and NT-proBNP were independent predictors for increased NYHA functional classification. There were good correlations (r > 0.4) between LMR (r = −0.667, p = 0.000), NLR, WMR, HCR, NT-proBNP (r = −0.681, p = 0.000) and NYHA functional classification, and LMR (AUC = 0.803, 95% CI 0.729−0.849, p = 0.0001), NLR and NT-proBNP (AUC = 0.805, 95% CI 0.738−0.861, p = 0.0001) had good diagnostic values (AUC > 0.7) for HF in patients with HFpEF. In addition, there were certain correlations between LMR, NT-proBNP and echocardiography indicators of cardiac structural. Conclusions: SII have a potential application value in the clinical evaluation of patients with HFpEF in the follow-up, especially in areas with limited medical resources, as they are more convenient and cost effective. Among different SII, LMR is probably the most promising metric. However, large-scale clinical trials are needed in the future to confirm these findings.

LIPCAR Is Increased in Chronic Symptomatic HF Patients. A Sub-Study of the GISSI-HF Trial.

BACKGROUND: The long noncoding RNA LIPCAR (Long Intergenic noncoding RNA Predicting CARdiac remodeling) has emerged as a promising biomarker in cardiac disease and cardiac remodeling. To determine whether LIPCAR levels help for a molecular phenotyping of chronic heart failure (HF) patients, this study assessed the association of LIPCAR with severity of the disease and its progression, and with risk of death or hospitalization in HF patients. METHODS: LIPCAR was measured in plasma of 967 HF patients with symptomatic heart failure participating in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Insufficienza Cardiaca - Heart Failure (GISSI-HF) biohumoral sub-study. RESULTS: Plasma levels of LIPCAR were significantly associated with functional impairment as assessed by the New York Heart Association (NYHA) class, kidney function as reflected by estimated glomerular filtration rate, and creatinine, hemoglobin and mitral insufficiency. In females, these associations were more marked as compared to males. LIPCAR plasma levels were significantly related to the two cardiac markers, N-terminal pro-B type natriuretic peptide and high-sensitivity cardiac troponin T, but not to inflammatory markers such as high sensitivity C-reactive protein and pentraxin-3, nor to patient reported outcomes such as depression and quality of life. HF patients with high LIPCAR levels univariately showed significantly higher incidence of cardiovascular hospitalizations but not of death; after adjusting for covariates, no significant effects of LIPCAR were found for cardiovascular hospitalizations. CONCLUSION: The circulating long noncoding RNA LIPCAR was increased in HF patients with higher NYHA class, impaired kidney function, and lower hemoglobin, which are indicators of patients' overall state.

Implications of concomitant obstructive or restrictive pulmonary diseases on functional and clinical results after MitraClip.

OBJECTIVES: We investigated the impact of underlying pulmonary limitations (PL) on symptoms and clinical outcomes after transcatheter mitral valve repair (TMVr). BACKGROUND: Patients with pulmonary disease and patients with symptomatic mitral regurgitation (MR) suffer common symptoms like dyspnea and reduced exercise capacity. METHODS: Datasets from the TMVr Ulm registry were retrospectively analyzed by a blinded specialist in pneumology. Patients were dichotomized according to an unambiguous manifestation of concomitant pulmonary disease in a PL-group and a non-PL-group and were analyzed regarding baseline characteristics and clinical follow-up. RESULTS: Overall, 483 patients were included in the study of which 32.3% (n = 156) showed an underlying pulmonary disease. Patients in the PL-group were similar to patients in the non-PL-group, including Euro SCORE II (8.2 vs. 8.4, p = 0.39), New York Heart Association (NYHA) classification (3.2 ± 0.7 in both groups, p = 0.65) and the incidence of moderate-to-severe or severe MR after TMVr (5.8 vs. 8.3%, p = 0.32). Equal and significant symptom relief after TMVr was experienced in both cohorts according to NYHA functional class (2.24 ± 0.84 vs. 2.24 ± 0.86, p = 0.93) and rate of hospitalization during 2 years of follow-up decreased comparably from 61.1 to 19.3%. However, all-cause mortality for 2 year follow-up was significantly higher in the PL-group compared to the non-PL-group (31.4 vs. 21.4%, p = 0.018). CONCLUSION: In patients with MR and concomitant pulmonary disorders, a significant increase of exercise capacity and a significant decrease of rehospitalization rate were observed after TMVr. Nevertheless, all-cause mortality remains significantly increased within a follow-up period of 2 years compared to patients without pulmonary disorders.

Galectin-3 is associated with severe heart failure and death: A hospital-based study in Chinese patients.

Heart failure (HF) is a serious disease syndrome characterized by elevated pro-inflammatory cytokines and inflammatory mediators presume to have significant contribution on disease progression. Galectins are carbohydrate-binding proteins responsible of various physiological functions. Role of galectins in heart failure has been ill-defined. In the present case-controls study, 136 patients clinically diagnosed with heart failure and 125 healthy Chinese controls were recruited. Levels of galectins (Gal-1, 3 and 9) and cytokines (IFN-γ, IL-17A, IL-4 and TGF-ß) were quantified by ELISA. Increased levels of galectin-1 and 3 was observed in HF patients and associated with clinical severity. In addition, pro-inflammatory cytokines such as IFN-γ and IL-17A were increased in patients whereas, anti-inflammatory TGFß was decreased. Galectin-3 was positively correlated with IFN-γ, IL-17A and inversely with TGF-ß. Furthermore, ROC curve analysis suggested galectin-3 as a promising biomarker for diagnosis and HF and clinical severity. Interestingly, a two-year follow-up indicated significant association of elevated galectin-3 with mortality due to HF. In conclusion, galectin-3 associated with HF and clinical manifestations possibly by inducing pro-inflammatory cytokines and could be a possible biomarker of HF and severe clinical conditions.

Increased plasma level of apelin with NYHA grade II and III but not IV.

The change in plasma apelin level in heart failure (HF) patients is controversial. We investigated the change in plasma apelin level in HF patients versus control and non-HF patients. The plasma level of apelin was measured by ELISA and plasma level of B-type natriuretic peptide (BNP) by fluorescence immunoassay. We included 101 patients with HF, 32 patients without HF and 20 controls. The three groups did not differ in general and clinical characteristics. Plasma levels of apelin and BNP were both higher in HF patients than non-HF patients and controls. Plasma levels of apelin and BNP were not correlated. Plasma level of BNP was increased with increasing New York Heart Association grade and apelin level was decreased. Apelin level was lower in HF patients with NYHA grade IV than in controls and non-HF patients. Apelin level had 75% diagnostic value for HF, and BNP level had 96.8% diagnostic value. At a cutoff of 6.44 ng/mL apelin level, sensitivity was 69.3%, and specificity 97.1%. However, the diagnostic of apelin for NYHA II patients was higher than that of BNP (99.6% vs. 96.1%). These results suggested that apelin might be particularly useful in association with BNP in mild HF patients.

Cross-lagged analyses of the bidirectional relationship between depression and markers of chronic heart failure.

BACKGROUND: Depression is common in patients with chronic heart failure (CHF) and is a predictor of rehospitalization and mortality. However, the complex bidirectional relationships between these two conditions are barely understood. We investigated the course of depression and markers of CHF (New York Heart Association [NYHA] functional class, N-terminal-prohormone B-type natriuretic peptide [NT-proBNP], and left ventricular ejection fraction [LVEF]) in a longitudinal study over a period of 2 years, using three assessment points. METHODS: Data of n = 446 patients with documented CHF were analyzed using structural equation modeling. Specifically, a Bayesian cross-lagged structural equation model was applied. RESULTS: Our study revealed that an aggravation of depression predicted an increase in NYHA functional class (significant cross-lagged effect γh = 0.103, 95% confidence interval [CI] [0.017; 0.194]), whereas an increase in NYHA functional class did not predict an aggravation of depression (γd = 0.002 95% CI [-0.057; 0.194]). This association was found only for NYHA functional class and depression-not for NT-proBNP and LVEF. CONCLUSIONS: Experiencing depression and associated symptoms, such as lack of energy and fatigue, may lead to a further decrease of functional capacity, and consequently to a higher NYHA functional class in CHF patients. As NYHA functional class is associated with higher mortality, this may be a critical development for affected patients. Further studies are required to investigate whether or not this association could be an essential key that explains the pathway from depression to increased mortality in heart failure patients.

The relationship between galectin-3 levels and fragmented QRS (fQRS) in patients with heart failure with reduced left ventricular ejection fraction.

BACKGROUND: Fragmented QRS (fQRS) complex is an electrocardiographic pattern which reflects myocardial scarring. We aimed to investigate the relationship between the presence of fragmented QRS (fQRS) on electrocardiogram (ECG) and plasma galectin-3 levels in patients with heart failure (HF) and severely decreased left ventricular ejection fraction (LVEF ≤ 35%). METHODS: We prospectively enrolled 125 symptomatic HF patients (NYHA class II-III) with severely reduced LVEF (≤35%). fQRS was identified in ECG. Galectin-3 and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were measured. Patients were divided into two groups based on the presence (n = 40) or absence (n = 85) of a fQRS on ECG. RESULTS: Majority of patients were male (87.70%), and mean age was 65.1 ± 11.6. Galectin-3 and NT-proBNP levels were found to be significantly higher in the fQRS (+) group compared with the fQRS (-) group (NT-proBNP 5,362 ± 701 pg/ml vs. 4,452 ± 698 pg/ml; p < 0.001, galectin-3 607 ± 89.8 pg/ml vs. 509.4 ± 63.5 pg/ml; p < 0.001). Multivariate analyses revealed galectin-3 and NT-proBNP levels are the presence of fQRS on ECG (p < 0.001 and p < 0.001, respectively). The area under the curve using the galectin-3 level for fQRS was 0.819. CONCLUSIONS: fQRS and serum galectin-3 levels are associated with myocardial fibrosis and are associated with poor prognosis in heart failure. In our study, a positive correlation was found between serum galectin-3 levels and fQRS on ECG.

2D/3D Echocardiographic features of patients with reverse remodeling after cardiac resynchronization therapy.

PURPOSE: To describe clinical and echocardiographic characteristics associated with reverse left ventricular (LV) remodeling after 6 months of cardiac resynchronization therapy (CRT) in patients with nonischemic dilated cardiomyopathy. METHODS: Twenty-four consecutive patients underwent 2D and 3D echocardiography before and after 6 months of CRT implant. Several echocardiographic parameters including global longitudinal strain (GLS) and 3D mechanical dyssynchrony (MD) index were calculated. CRT response was defined as a decrease in LV end-systolic volume (LVESV) of at least 10% at follow-up. Patients were divided in two groups according to CRT response. RESULTS: Cardiac resynchronization therapy responder (CRTR+) rate was 50%. Nonresponder (CRTR-) patients showed a less significant improvement in NYHA class at follow-up. At baseline, CRTR- presented with higher LV end-diastolic volume (LVEDV) (P = 0.031), LVESV (P = 0.024), lower left ventricular ejection fraction (LVEF) (P = 0.002) and less negative GLS (P = 0.03), and with higher diastolic dysfunction, more impaired right ventricle (RV), and higher pulmonary artery systolic pressure (PASP) (P = 0.002). No significant differences in echocardiographic parameters of MD were found. Univariate determinants of CRTR+ were LVEF (OR = 1.59, CI 95% = 1.13-2.22, P = 0.007) and TAPSE (OR 1.21, CI 95% = 1.024-1.429, P = 0.025). A ROC curve analysis showed a cutoff value of LVEF of 22.15% significantly related to CRTR+ (SE 80%, SP 50%). CONCLUSIONS: Our findings suggest that end-stage HF patients, presenting before CRT with LVEF <22.15%, may not benefit from the procedure after 6 months. Mechanical dyssyncronicity did not provide additional information to improve candidate selection.

The role of surgical transcatheter valve implantation for the treatment of severe mitral annular calcification.

With a rise in the aging population, mitral annular calcification is increasingly encountered with an incidence of 10% in over 70 years old. This with increasing patient comorbidities presents a technical challenge due to the risk of atrioventricular disruption which is associated with high operative mortality of up to 75%. We describe two cases of severe mitral disease with marked annular calcification successfully treated with a balloon expandable transcatheter valve which was deployed on cardiopulmonary bypass via a trans-atrial approach.

Moderate Chronic Ischemic Mitral Regurgitation.

The benefits of concomitant mitral valve procedure (MVP) for treating moderate chronic ischemic mitral regurgitation (IMR) during coronary artery bypass grafting (CABG) have not been clearly established. This study aimed to determine the incidence of moderate or more residual mitral regurgitation (MR) following CABG plus MVP for moderate chronic IMR, and to evaluate the impacts of concomitant MVP vs. CABG alone on clinical outcomes based on propensity-matched data.All eligible patients were entered into either the MVP group (CABG plus MVP, n = 184) or CABG group (CABG alone, n = 162). Moderate or more residual MR rate was investigated, and in-hospital and follow-up outcomes between the groups were compared after matching.Moderate or more residual MR rate was 11.4% at 1 year and 22.9% at 2 years after CABG plus MVP, respectively. Patients in the MVP group as compared with the CABG group had significantly lower moderate or more residual MR rates at various postoperative time points (all P < 0.001). Grouping was not an independent risk factor for in-hospital adverse events in multivariate logistic regression analysis. Also, grouping was a significant variable related to moderate or more residual MR rate and NYHA class III-IV at the latest follow-up in Cox regression analysis (HR = 0.391, 95% CI 0.114-0.628; HR = 0.419, 95% CI 0.233-0.819, respectively).Concomitant MVP as compared with CABG alone for treating moderate chronic IMR was associated with a reduction in moderate or more residual MR rate and an improvement in NYHA functional status, with no increase in in-hospital adverse events or follow-up death.

Multifractal Spectrum Curvature of RR Tachograms of Healthy People and Patients with Congestive Heart Failure, a New Tool to Assess Health Conditions.

We calculate the multifractal spectra of heartbeat RR-interval time series (tachograms) of healthy subjects and patients with congestive heart failure (CHF). From these time series, we obtained new subseries of 6 h durations when healthy persons and patients were asleep and awake respectively. For each time series and subseries, we worked out the multifractal spectra with the Chhabra and Jensen method and found that their graphs have different shapes for CHF patients and healthy persons. We suggest to measure two parameters: the curvature around the maximum and the symmetry for all these multifractal spectra graphs, because these parameters were different for healthy and CHF subjects. Multifractal spectra of healthy subjects tend to be right skewed especially when the subjects are asleep and the curvature around the maximum is small compared with the curvature around the maximum of the CHF multifractal spectra; that is, the spectra of patients tend to be more pointed around the maximum. In CHF patients, we also have encountered differences in the curvature of the multifractal spectra depending on their respective New York Heart Association (NYHA) index.

Severe heart failure (NYHA Class IV) is associated with increased left ventricular mass index and short mitral deceleration time in severe aortic valve stenosis.

BACKGROUND: In aortic valve stenosis (AS), congestive heart failure (CHF) is a well-established symptom that indicates the need for surgical aortic valve replacement (SAVR). However, it is difficult to judge whether CHF symptoms such as dyspnea are caused by severe AS or other conditions, especially in elderly persons with restricted mobility or other organ complications. It is important to identify objective and noninvasive parameters associated with severe CHF symptoms in severe AS. METHODS: One hundred ninety-eight patients with severe AS without left ventricular (LV) dysfunction were retrospectively studied. CHF symptoms were classified by New York Heart Association (NYHA) functional class. Echo parameters were compared between NYHA I-III and NYHA IV. RESULTS: Patients with NYHA IV (n = 40; 20%) were older (86 ± 6 vs 82 ± 8 years; P = .001) and had a larger LV mass index (LVMI) (157 ± 43 vs 114 ± 34 g/m2 , P < .001), a higher transmitral flow velocity ratio (E/A) (1.31 ± 0.62 vs 0.93 ± 0.42; P = .001), a shorter deceleration time (DT) (202 ± 72 vs 286 ± 98 ms; P < .001), and a higher systolic pulmonary arterial pressure (SPAP) (44 ± 13 vs 35 ± 13 mm Hg; P < .001) than patients with NYHA I-III. On multivariable analysis, LVMI and DT were independently associated with NYHA IV. Receiver operating characteristic curve analysis identified LVMI ≥ 142 g/m2 and DT ≤ 194 ms as the cutoff values associated with NYHA IV in patients with severe AS. CONCLUSION: Left ventricular mass index and DT were independently associated with severe heart failure (NYHA IV). These echo parameters could be helpful to judge whether CHF symptoms are caused by severe AS.

Atrial deformation correlated with functional capacity in mitral stenosis patients.

BACKGROUND: Left atrial (LA) dysfunction, expressed as impaired LA deformation using two-dimensional (2D) strain imaging, has been observed in association with rheumatic mitral stenosis (MS). However, the clinical role of speckle tracking echocardiography (STE)-derived LA strain has rarely been studied in MS. AIM: This study aimed to identify the determinants of New York Heart Association (NYHA) functional class in patients with mitral stenosis and to investigate the relationship between left atrial deformation as measured by two-dimensional STE-derived LA strain and heart failure symptoms. METHODS: Sixty-nine consecutive patients (20 males and 49 females; mean age: 61 ± 14 years) with rheumatic MS were evaluated using comprehensive 2D and color Doppler echocardiography including STE-derived LA strain (LAS) and peak positive filling strain rate (LASRr) during the LA reservoir phase. Those results were then correlated with NYHA functional class. RESULTS: There were 15 (22%) patients in functional class I, 42 (61%) in functional class II, and 12 (17%) in functional class III. There were no significant differences in mitral valve area, pressure gradient, pulmonary artery pressure, LA emptying fraction, or left ventricular ejection fraction between functional classes. Upon multivariate analysis (controlling for diuretics usage), LAS (ß = -0.233, P = .045) and LASRr (ß = -0.277, P = .014) were independent factors in determining NYHA functional class. CONCLUSIONS: In stable patients with MS, NYHA functional class independently correlated with LAS and LASRr. Left atrial (LA) deformation correlated with heart failure symptoms in patients with MS.