Mitral valve prolapse: arrhythmic risk during pregnancy and postpartum.

BACKGROUND AND AIMS: Arrhythmic mitral valve prolapse (AMVP) is linked to life-threatening ventricular arrhythmias (VAs), and young women are considered at high risk. Cases of AMVP in women with malignant VA during pregnancy have emerged, but the arrhythmic risk during pregnancy is unknown. The authors aimed to describe features of women with high-risk AMVP who developed malignant VA during the perinatal period and to assess if pregnancy and the postpartum period were associated with a higher risk of malignant VA. METHODS: This retrospective international multi-centre case series included high-risk women with AMVP who experienced malignant VA and at least one pregnancy. Malignant VA included ventricular fibrillation, sustained ventricular tachycardia, or appropriate shock from an implantable cardioverter defibrillator. The authors compared the incidence of malignant VA in non-pregnant periods and perinatal period; the latter defined as occurring during pregnancy and within 6 months after delivery. RESULTS: The authors included 18 women with AMVP from 11 centres. During 7.5 (interquartile range 5.8-16.6) years of follow-up, 37 malignant VAs occurred, of which 18 were pregnancy related occurring in 13 (72%) unique patients. Pregnancy and 6 months after delivery showed increased incidence rate of malignant VA compared to the non-pregnancy period (univariate incidence rate ratio 2.66, 95% confidence interval 1.23-5.76). CONCLUSIONS: The perinatal period could impose increased risk of malignant VA in women with high-risk AMVP. The data may provide general guidance for pre-conception counselling and for nuanced shared decision-making between patients and clinicians.

Prognostic significance of echocardiographic deformation imaging in adult congenital heart disease.

BACKGROUND: Due to medical and surgical advancements, the population of adult patients with congenital heart disease (ACHD) is growing. Despite successful therapy, ACHD patients face structural sequalae, placing them at increased risk for heart failure and arrhythmias. Left and right ventricular function are important predictors for adverse clinical outcomes. In acquired heart disease it has been shown that echocardiographic deformation imaging is of superior prognostic value as compared to conventional parameters as ejection fraction. However, in adult congenital heart disease, the clinical significance of deformation imaging has not been systematically assessed and remains unclear. METHODS: According to the Preferred Reporting Items for Systematic Reviews checklist, this systematic review included studies that reported on the prognostic value of echocardiographic left and/or right ventricular strain by 2-dimensional speckle tracking for hard clinical end-points (death, heart failure hospitalization, arrhythmias) in the most frequent forms of adult congenital heart disease. RESULTS: In total, 19 contemporary studies were included. Current data shows that left ventricular and right ventricular global longitudinal strain (GLS) predict heart failure, transplantation, ventricular arrhythmias and mortality in patients with Ebstein's disease and tetralogy of Fallot, and that GLS of the systemic right ventricle predicts heart failure and mortality in patients post atrial switch operation or with a congenitally corrected transposition of the great arteries. CONCLUSIONS: Deformation imaging can potentially impact the clinical decision making in ACHD patients. Further studies are needed to establish disease-specific reference strain values and ranges of impaired strain that would indicate the need for medical or structural intervention.

The value of serial echocardiography in risk assessment of patients with paroxysmal atrial fibrillation.

Progression from paroxysmal to persistent atrial fibrillation (AF) is associated with increased morbidity and mortality. We examined the association of left atrial (LA) remodeling by serial echocardiography, and AF progression over an extended follow-up period. Two-hundred ninety patients (mean age 61  ±  11 years, 73% male) who underwent transthoracic echocardiography performed at first presentation for non-valvular paroxysmal AF (PAF) and repeat echocardiogram 1-year later, were followed for progression to persistent AF. LA and left ventricular (LV) dimensions, volumes, LA reservoir, conduit and booster pump strains, LV global longitudinal systolic strain (GLS) assessed by 2D speckle tracking, and PA-TDI (time delay between electrical and mechanical LA activation- reflecting the extent of LA fibrosis) were compared on serial echocardiography. Sixty-nine (24%) patients developed persistent AF over a mean follow-up period of 6.3 years. At baseline, patients with subsequent persistent AF had larger LA dimensions (46 mm vs. 42 mm, p < 0.001), indexed LA volumes (41 ml/m2 vs. 34 ml/m2, p < 0.001), lower LA reservoir and conduit strain (17.6% vs. 27.6%, p < 0.001; 10.5% vs. 16.3%, p < 0.001; respectively) and longer PA-TDI (155 ms vs. 132 ms, p < 0.001) compared to the PAF group. Patients with subsequent persistent AF showed over time significant enlargement in LA volumes (from 37.7 ml/m2 to 42.4 ml/m2, p < 0.001), lengthening of PA-TDI (from 142.2 ms to 162.2 ms, p = 0.002), and decline in LA reservoir function (from 21.9% to 18.1%, p = 0.024) after adjusting for age, gender, diabetes and LV GLS. There were no changes in LA diameter, LA conduit or booster pump function. Conversely, the PAF group showed no decline in LA function. Patients who developed persistent AF had larger LA size and impaired LA function and atrial conduction times at baseline, compared to patients who remained PAF. Over the 1-year time course of serial echocardiographic evaluation, there was progression of LA remodeling in patients who subsequently developed persistent AF, but not in patients who remained in PAF.

Association between left atrial epicardial fat, left atrial volume, and the severity of atrial fibrillation.

AIMS: Left atrial (LA) volume and LA epicardial fat are both substrates for atrial fibrillation (AF), but may relate with AF at different (early vs. late) stages in the AF disease process. We evaluated associations between LA epicardial fat and LA volume in patients with sinus rhythm (SR), paroxysmal AF (PAF), and persistent/permanent AF. METHODS AND RESULTS: In total, 300 patients (100 with SR, 100 with PAF, and 100 with persistent/permanent AF) who underwent cardiac computed tomography angiography (CTA) were included. The epicardial fat mass posterior to the LA and the LA volume were quantified from CTA and compared between patients with SR, PAF, and persistent/permanent AF. Furthermore, four groups were created by classifying LA epicardial fat and LA volume into large or small according to their median. The mean age of the population was 58.9 ± 10.5 years and 69.7% was male. Left atrial epicardial fat mass was larger in patients with PAF compared with SR, but did not further increase from PAF to persistent/permanent AF. Left atrial volume increased significantly from SR to PAF and to persistent/permanent AF. Left atrial epicardial fat and LA volume were both concordantly large or small in 184 (61%) patients, and discordant in 116 (39%). When both were small, 65.2% of the patients had SR, 23.9% PAF, and 10.9% persistent/permanent AF. When the LA epicardial fat mass was large and the LA volume small (compared with both being small), patients were significantly more often in PAF (55.2 vs. 23.9, P < 0.05), less frequently in SR (32.8% vs. 65.2%, P < 0.05) but showed comparable rates of persistent/permanent AF (12.0% vs. 10.9%, P < 0.05). When the LA volume was large, most patients had persistent/permanent AF. CONCLUSION: Left atrial epicardial fat mass was larger in PAF vs. SR, possibly indicating a marker of early disease, while large LA volumes were associated with a high prevalence of persistent/permanent AF. Elevated LA epicardial fat mass without large LA volume may reflect the early AF disease process.

Association between computed tomography-derived tricuspid annular dimensions and prognosis: insights from whole-beat computed tomography assessment.

AIMS: Tricuspid regurgitation (TR) has been associated with outcome in patients treated with transcatheter aortic valve implantation (TAVI). Tricuspid annulus (TA) dimensions are associated with TR. However, the TA is highly dynamic during the cardiac cycle, and the interaction between the TA dimensions, TR, and patient prognosis has never been evaluated. This study aimed to characterize the dynamics of the TA along with the cardiac cycle and its association with prognosis in patients undergoing TAVI. METHODS AND RESULTS: Patients with severe aortic stenosis who underwent whole-beat computed tomography (n = 393, mean age 80 ± 7 years, 53% male) were included. The ratio between anterior-posterior (AP) and septal-lateral (SL) diameter of the TA was calculated at end-systole (ES), mid-diastole (MD), and end-diastole (ED) to characterize the TA shape throughout the cardiac cycle. The primary endpoint was all-cause mortality. During a median follow-up of 3.6 (1.7-5.5) years, 146 patients died. While all the TA parameters at ES and MD were not associated with all-cause mortality, a low AP/SL ratio at ED (more circular geometry) was independently related with all-cause mortality (hazard ratio: 4.717, 95% confidence interval: 1.481-15.152; P = 0.009). In addition, a more circular TA shape at ED (AP/SL ratio < 1.20) was also associated with more right atrial and ventricular dilation, more frequently significant TR, and a higher prevalence of atrial fibrillation. CONCLUSION: Circular remodelling of the TA shape at ED is associated with more right atrial and ventricular dilation, and a higher long-term mortality after TAVI. The evaluation of the TA shape at ED may be a useful parameter in the risk stratification of patients undergoing TAVI.

Anatomical Characteristics of the Left Atrium and Left Atrial Appendage in Relation to the Risk of Stroke in Patients With Versus Without Atrial Fibrillation.

[Figure: see text].

The Clinical Spectrum of Kommerell's Diverticulum in Adults with a Right-Sided Aortic Arch: A Case Series and Literature Overview.

BACKGROUND: Kommerell's diverticulum is a rare vascular anomaly characterized as an outpouch at the onset of an aberrant subclavian artery. In the variant of a right-sided aortic arch, the trachea and esophagus are enclosed dorsally by the arch. In the configuration of an aberrant left subclavian artery, a Kommerell's diverticulum and persisting ductus arteriosus or ductal ligament enclose the lateral side, forming a vascular ring which may result in (symptomatic) esophageal or tracheal compression. Spontaneous rupture of an aneurysmatic Kommerell's diverticulum has also been reported. Due to the rarity of this condition and underreporting in the literature, the clinical implications of a Kommerell's diverticulum are not well defined. CASE SUMMARY: We describe seven consecutive adult patients with a right-sided aortic arch and an aberrant course of the left subclavian artery (arteria lusoria), and a Kommerell's diverticulum, diagnosed in our tertiary hospital. One patient had severe symptoms related to the Kommerell's diverticulum and underwent surgical repair. In total, two of the patients experienced mild non-limiting dyspnea complaints and in four patients the Kommerell's diverticulum was incidentally documented on a computed tomography (CT) scan acquired for a different indication. The size of the Kommerell's diverticulum ranged from 19 × 21 mm to 30 × 29 mm. In the six patients that did not undergo surgery, a strategy of periodic follow-up with structural imaging was pursued. No significant growth of the Kommerell's diverticulum was observed and none of the patients experienced an acute aortic syndrome to date. DISCUSSION: Kommerell's diverticulum in the setting of a right-sided aortic arch with an aberrant left subclavian artery is frequently associated with tracheal and esophageal compression and this may result in a varying range of symptoms. Guidelines on management of Kommerell's diverticulum are currently lacking. This case series and literature overview suggests that serial follow-up is warranted in adult patients with a Kommerell's diverticulum with small dimensions and no symptoms, however, that surgical intervention should be considered when patients become symptomatic or when the diameter exceeds 30 mm in the absence of symptoms.

Comparison of the Usefulness of Strain Imaging by Echocardiography Versus Computed Tomography to Detect Right Ventricular Systolic Dysfunction in Patients With Significant Secondary Tricuspid Regurgitation.

Assessment of right ventricular (RV) systolic function in patients with significant secondary tricuspid regurgitation (STR) remains challenging. In patients with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI), STR and RV enlargement have been associated with poor outcomes. In these patients, speckle tracking echocardiography (STE) may detect RV systolic dysfunction better than 3-dimensional (3D) RV ejection fraction (EF). The purpose of this study was to investigate the prevalence of RV dysfunction when assessed with STE in patients with significant STR (≥3+) compared with patients without significant STR (<3+) matched for 3D RV dimensions and RVEF on dynamic computed tomography (CT). Patients with dynamic CT data before TAVI were evaluated retrospectively. To assess the performance of RV-free wall strain (RVFWS) for identifying patients with impaired RV systolic function, patients were subsequently matched 1:1 based on age, gender, indexed RV end-diastolic volume (RVEDVi), indexed RV end-systolic volume (RVESVi), RVEF, and left ventricular ejection fraction (LVEF). In a total 267 patients (80 ± 8 years, 48% male), significant STR (≥3+) was observed in 67 patients. Patients with STR≥3+ had larger RVEDVi, larger RVESVi, lower LVEF, and more impaired RVFWS compared with patients with STR<3+ (n = 200). After propensity score matching, patients with STR≥3+ (n = 53) had significantly more impaired RVFWS compared with patients with STR<3+ (n = 53): -18.2 ± 5.0% versus -21.1 ± 3.7%, p = 0.001. In conclusion, patients with significant STR have more pronounced RV systolic dysfunction as assessed with STE than the patients without significant STR despite having similar 3D RV dimensions and RVEF on dynamic CT.

Relation of Echocardiographic Markers of Left Atrial Fibrosis to Atrial Fibrillation Burden.

In patients with atrial fibrillation (AF), left atrial (LA) fibrosis is a major determinant of the progression to, and burden of AF. LA reservoir strain and total atrial conduction time (PA-TDI) reflect LA fibrotic content. We aimed to investigate the relation between LA reservoir strain and PA-TDI in AF patients and control subjects. Six-hundred two patients (mean age 56 years, 53% men) with first episode of AF and 342 controls (mean age 64 years, 71% men) without structural heart disease underwent echocardiography. LA volumes, PA-TDI, LA reservoir strain, and left ventricular global longitudinal strain (GLS) were compared. Compared with controls, patients with paroxysmal AF and patients with persistent AF had longer PA-TDI (128 ± 25 millisecond, 140 ± 31 millisecond, and 154 ± 33 millisecond, respectively; p <0.001) and a progressive decline in LA reservoir strain (36.9 ± 11.6%, 29.8 ± 13.4%, 24.2 ± 12.3%, respectively; p <0.001). LA reservoir strain was negatively correlated with PA-TDI (r = -0.43, p <0.001). On multivariate analyses, LA reservoir strain, diabetes mellitus, and burden of AF were independent correlates of PA-TDI (R2 = 0.23, p <0.001); whereas only PA-TDI was an independent correlate of LA reservoir strain (R2 = 0.43, p <0.001); controlling for age, hypertension, coronary artery disease, body mass index, severity of mitral regurgitation, left ventricular global longitudinal strain, and LA volume. In conclusion, PA-TDI and LA reservoir strain are negatively correlated in all subjects, irrespective of the presence or burden of AF. Patients with persistent AF have longer PA-TDI and impaired LA reservoir strain compared with paroxysmal AF and controls, suggesting increasing burden of fibrosis and LA structural remodeling in the progression of AF.

The Impact of Atrial Fibrillation Clinical Subtype on Mortality.

OBJECTIVES: This study sought to investigate the prognostic implications of the clinical subtype of atrial fibrillation (AF): paroxysmal or persistent. BACKGROUND: Underlying structural abnormalities of the left atrium may be responsible for the initial clinical presentation of AF in either paroxysmal or persistent form, yet the prognostic implications of the clinical subtype on presentation are unknown. METHODS: Over a median of 7 years, 1,773 patients (age 64 ± 12 years, 74% males) with nonvalvular AF with index presentations for paroxysmal or persistent AF were followed for the occurrence of all-cause mortality. Clinical information including cardiovascular risk factors, comorbid diseases associated with AF, and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 [double weight], diabetes, stroke [double weight], vascular disease, age 65-74, and sex category [female]) score was collected and analyzed. RESULTS: In this study, 1,005 patients (57%) had persistent AF. Eighty patients (10%) with paroxysmal AF and 174 patients (17%) with persistent AF died during the follow-up period. Persistent AF compared with paroxysmal AF upon initial AF diagnosis was independently associated with worse survival independent of the CHA2DS2-VASc score and other high-risk cardiovascular risk factors (hazard ratio: 1.24; 95% confidence interval: 1.11 to 1.38). CONCLUSIONS: In patients with nonvalvular AF, persistent AF compared with paroxysmal AF upon first diagnosis is independently associated with increased mortality.

Pacemaker implantation rate after transcatheter aortic valve implantation with early and new-generation devices: a systematic review.

Aims: The incidence of new-onset conduction abnormalities requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) with new-generation prostheses remains debated. This systematic review analyses the incidence of PPI after TAVI with new-generation devices and evaluates the electrical, anatomical, and procedural factors associated with PPI. In addition, the incidence of PPI after TAVI with early generation prostheses was reviewed for comparison. Methods and results: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, this systematic review screened original articles published between October 2010 and October 2017, reporting on the incidence of PPI after implantation of early and new-generation TAVI prostheses. Of the 1406 original articles identified in the first search for new-generation TAVI devices, 348 articles were examined for full text, and finally, 40 studies (n = 17 139) were included. The incidence of a PPI after the use of a new-generation TAVI prosthesis ranged between 2.3% and 36.1%. For balloon-expandable prostheses, the PPI rate remained low when using an early generation SAPIEN device (ranging between 2.3% and 28.2%), and with the new-generation SAPIEN 3 device, the PPI rate was between 4.0% and 24.0%. For self-expandable prostheses, the PPI rates were higher with the early generation CoreValve device (16.3-37.7%), and despite a reduction in PPI rates with the new Evolut R, the rates remained relatively higher (14.7-26.7%). When dividing the studies according to the highest (>26.0%) and the lowest (<12.1%) quintile of PPI rate, patients within the highest quintile were more frequently women when compared with the lowest quintile group (50.9% vs. 46.3%, P < 0.001). Pre-existent conduction abnormalities (electrical factor), calcification of the left ventricular outflow tract (anatomical factor), and balloon valvuloplasty and depth of implantation (procedural factors) were associated with increased risk of PPI. Conclusion: The rate of PPI after TAVI with new-generation devices is highly variable. Specific recommendations for implantation of each prosthesis, taking into consideration the presence of pre-existent conduction abnormalities and anatomical factors, may be needed to reduce the risk of PPI.

Left atrial function to identify patients with atrial fibrillation at high risk of stroke: new insights from a large registry.

Aims: Atrial fibrillation (AF) is an independent risk factor for ischaemic stroke. The CHA2DS2-VASc is the most widely used risk stratification model; however, echocardiographic refinement may be useful, particularly in low risk AF patients. The present study examined the association between advanced echocardiographic parameters and ischaemic stroke, independent of CHA2DS2-VASc score. Methods and results: One thousand, three hundred and sixty-one patients (mean age 65±12 years, 74% males) with first diagnosis of AF and baseline transthoracic echocardiogram were followed by chart review for the occurrence of stroke over a mean of 7.9 years. Left atrial (LA) volumes, LA reservoir strain, P-wave to A' duration on tissue Doppler imaging (PA-TDI, reflecting total atrial conduction time), and left ventricular (LV) global longitudinal strain (GLS) were evaluated in patients with and without stroke. The independent association of these echocardiographic parameters with the occurrence of ischaemic stroke was evaluated with Cox proportional hazard models. One-hundred patients (7%) developed an ischaemic stroke, representing an annualized stroke rate of 0.9%. The incident stroke rate in the year following the first diagnosis of AF was 2.6% in the entire population and higher than the remainder of the follow-up period. Left atrial reservoir (14.5% vs. 18.9%, P = 0.005) and conduit strains were reduced (10.5% vs. 13.5%, P = 0.013), and PA-TDI lengthened (166 ms vs. 141 ms, P < 0.001) in the stroke compared with non-stroke group, despite similar LV dimensions, LV ejection fraction, GLS, and LA volumes. Left atrial reservoir strain and PA-TDI were independently associated with risk of stroke in a model including CHA2DS2-VASc score, age, and anticoagulant use. Conclusion: The assessment of LA reservoir strain and PA-TDI on echocardiography after initial CHA2DS2-VASc scoring provides additional risk stratification for stroke and may be useful to guide decisions regarding anticoagulation for patients upon first diagnosis of AF.

Mitral valve repair for secondary mitral regurgitation in non-ischaemic dilated cardiomyopathy is associated with left ventricular reverse remodelling and increase of forward flow.

Aims: It remains unclear whether surgical or transcatheter mitral valve repair for secondary mitral regurgitation (MR) in patients with non-ischaemic cardiomyopathy reverse the underlying left ventricular (LV) pathophysiology. We hypothesized that mitral valve repair improves LV systolic function and forward flow and induces LV reverse remodelling in this group of patients. Methods and results: Seventy-six patients (65 ± 14 years old, 43% male) with non-ischaemic cardiomyopathy and moderate to severe chronic secondary MR treated successfully with transcatheter or surgical mitral valve repair were evaluated. Transthoracic echocardiography was performed at baseline, discharge and 6 months post-repair. After mitral valve repair, LVEF, and LV global longitudinal strain (GLS) corrected for LV end-diastolic volume remained unchanged over time (P = 0.90 and P = 0.96, respectively). In contrast, LV forward flow increased significantly over time (stroke volume index: from 20 ± 7 to 29 ± 8 and 26 ± 8 mL/m2, P < 0.001; cardiac index: from 1.50 ± 0.44 to 2.36 ± 0.60 and 2.01 ± 0.48 L/min/m2, P < 0.001). In addition, LV end-diastolic and end-systolic volume index significantly reduced over time (from 87 ± 42 to 70 ± 33 and 75 ± 39 mL/m2, P < 0.001; and from 60 ± 35 to 50 ± 30 and 53 ± 36 mL/m2, P = 0.004, respectively). These changes were independent of the type of repair. Conclusion: Surgical and transcatheter mitral valve repair for secondary MR in patients with non-ischaemic dilated cardiomyopathy improved LV forward flow and induced LV reverse remodelling but did not change LV systolic function.

Feasibility, Accuracy, and Reproducibility of Aortic Annular and Root Sizing for Transcatheter Aortic Valve Replacement Using Novel Automated Three-Dimensional Echocardiographic Software: Comparison with Multi-Detector Row Computed Tomography.

BACKGROUND: In transcatheter aortic valve replacement (TAVR), multi-detector row computed tomography (MDCT) is currently the standard imaging modality for correct prosthesis sizing, despite risks of radiation and contrast-induced renal injury. Three-dimensional (3D) transesophageal echocardiography (TEE) has been proposed as a potential alternative imaging technique, and recently, automated 3D transesophageal echocardiographic software (Aortic Valve Navigator [AVN], an unreleased prototype from Philips) has been developed for assessment of the aortic annulus and root. The aim of this study was to assess the feasibility, accuracy, and reproducibility of AVN measurements in TAVR candidates by performing a comparison with MDCT. METHODS: In 150 patients with severe, symptomatic aortic stenosis referred for TAVR, data on aortic annular and root dimensions prospectively acquired using 3D TEE and MDCT were retrospectively analyzed. Image quality on 3D TEE and the duration of analysis with AVN were recorded, as well as the aortic valve Agatston score on MDCT. RESULTS: Data were obtained using 3D TEE and MDCT in 100% of patients for aortic annular dimensions and in 89% for aortic root dimensions. The mean duration of analysis using AVN was 4.2 ± 1.0 min, but it was significantly shorter with better 3D echocardiographic image quality and lower Agatston score on MDCT. Correlation of measurements between 3D TEE and MDCT was good to excellent for all anatomic locations (sinotubular junction mean diameter, R = 0.71; sinus of Valsalva mean diameter, R = 0.87; aortic annular mean diameter, R = 0.75; aortic annular perimeter, R = 0.83; aortic annular area, R = 0.91), with low inter- and intraobserver variability (intraclass correlation coefficient ≥ 0.93 and r ≥ 0.90 for all locations). Comparison based on conventional prosthesis sizing charts yielded excellent agreement in prosthesis size choice (κ = 0.90). CONCLUSIONS: New automated 3D transesophageal echocardiographic software allows accurate modeling and reproducible quantification of aortic annular and root dimensions with high feasibility. An excellent correlation between measurements with AVN and MDCT and agreement in prosthesis sizing suggests the use of AVN in clinical practice as potential alternative to MDCT before TAVR.

Influence of the Quantity of Aortic Valve Calcium on the Agreement Between Automated 3-Dimensional Transesophageal Echocardiography and Multidetector Row Computed Tomography for Aortic Annulus Sizing.

Accurate aortic annulus sizing is key for selection of appropriate transcatheter aortic valve implantation (TAVI) prosthesis size. The present study compared novel automated 3-dimensional (3D) transesophageal echocardiography (TEE) software and multidetector row computed tomography (MDCT) for aortic annulus sizing and investigated the influence of the quantity of aortic valve calcium (AVC) on the selection of TAVI prosthesis size. A total of 83 patients with severe aortic stenosis undergoing TAVI were evaluated. Maximal and minimal aortic annulus diameter, perimeter, and area were measured. AVC was assessed with computed tomography. The low and high AVC burden groups were defined according to the median AVC score. Overall, 3D TEE measurements slightly underestimated the aortic annulus dimensions as compared with MDCT (mean differences between maximum, minimum diameter, perimeter, and area: -1.7 mm, 0.5 mm, -2.7 mm, and -13 mm2, respectively). The agreement between 3D TEE and MDCT on aortic annulus dimensions was superior among patients with low AVC burden (<3,025 arbitrary units) compared with patients with high AVC burden (≥3,025 arbitrary units). The interobserver variability was excellent for both methods. 3D TEE and MDCT led to the same prosthesis size selection in 88%, 95%, and 81% of patients in the total population, the low, and the high AVC burden group, respectively. In conclusion, the novel automated 3D TEE imaging software allows accurate and highly reproducible measurements of the aortic annulus dimensions and shows excellent agreement with MDCT to determine the TAVI prosthesis size, particularly in patients with low AVC burden.

Inter-ethnic differences in valve morphology, valvular dysfunction, and aortopathy between Asian and European patients with bicuspid aortic valve.

Background: Transcatheter aortic valve replacement (TAVR) has been shown safe and feasible in patients with bicuspid aortic valve (BAV) morphology. Evaluation of inter-ethnic differences in valve morphology and function and aortic root dimensions in patients with BAV is important for the worldwide spread of this therapy in this subgroup of patients. Comparisons between large European and Asian cohorts of patients with BAV have not been performed, and potential differences between populations may have important implications for TAVR. Aim: The present study evaluated the differences in valve morphology and function and aortic root dimensions between two large cohorts of European and Asian patients with BAV. Methods and results: Aortic valve morphology was defined on transthoracic echocardiography according to the number of commissures and raphe: type 0 = no raphe and two commissures, type 1 = one raphe and two commissures, type 2 = two raphes and one commissure. Aortic stenosis and regurgitation were graded according to current recommendations. For this study, aortic root dimensions were manually measured on transthoracic echocardiograms at the level of the aortic annulus, sinus of Valsalva (SOV), sinotubular junction (STJ), and ascending aorta (AA). Of 1427 patients with BAV (45.2 ± 18.1 years, 71.9% men), 794 (55.6%) were Europeans and 633 (44.4%) were Asians. The groups were comparable in age and proportion of male sex. Asians had higher prevalence of type 1 BAV with raphe between right and non-coronary cusps than Europeans (19.7% vs. 13.6%, respectively; P < 0.001), whereas the Europeans had higher prevalence of type 0 BAV (two commissures, no raphe) than Asians (14.5% vs. 6.8%, respectively; P < 0.001). The prevalence of moderate and severe aortic regurgitation was higher in Europeans than Asians (44.2% vs. 26.8%, respectively; P < 0.001) whereas there were no differences in BAV with normal function or aortic stenosis. After adjusting for demographics, comorbidities, and valve function, the dimensions of the aortic annulus [mean difference 1.17 mm/m2, 95% confidence interval (CI) 0.96-1.39], SOV (mean difference 1.86 mm/m2, 95% CI 1.47-2.24), STJ (mean difference 0.52 mm/m2, 95% CI 0.14-0.90) and AA (mean difference 1.05 mm/m2, 95% CI 0.57-1.52) were significantly larger among Asians compared with Europeans. Conclusions: This large multicentre registry reports for the first time that Asians with BAV showed more frequently type 1 BAV (with fusion between right and non-coronary cusp) and have larger aortic dimensions than Europeans. These findings have important implications for prosthesis type and size selection for TAVR.

Restrictive Mitral Valve Annuloplasty: Prognostic Implications of Left Ventricular Forward Flow.

BACKGROUND: Surgical mitral valve repair for severe secondary mitral regurgitation (MR) remains controversial. The association of MR reduction and changes in left ventricular (LV) hemodynamics with survival has not been investigated. We investigated the independent associates of outcomes in heart failure patients with severe secondary MR who underwent surgical mitral valve repair. METHODS: Patients (n = 130, 62 ± 12 years old, 55% men) with chronic severe secondary MR and impaired LV ejection fraction (<0.50, mean 0.31 ± 0.10) treated with surgical mitral valve repair were included. Echocardiographic LV forward stroke volume and LV forward ejection fraction were measured at baseline and at discharge. All-cause mortality was the primary endpoint, and the combination of major adverse cardiac-related events and all-cause mortality was the secondary endpoint. RESULTS: At hospital discharge, 77% of patients showed no residual MR and 23% showed mild MR. LV volumes reduced significantly, whereas LV ejection fraction remained unchanged. In contrast, LV forward stoke volume (53 ± 24 mL versus 64 ± 22 mL, p < 0.001) and LV forward ejection fraction (0.32 ± 0.16 versus 0.48 ± 0.24, p < 0.001) significantly increased at discharge. During a median follow-up of 3.44 years, 33 patients (29%) died and 40 had major adverse cardiac-related events. On multivariable analysis, LV forward stroke volume after repair was independently associated with all-cause mortality (hazard ratio 0.98, p = 0.047) and with the combined endpoint (hazard ratio 0.98, p = 0.045) after correcting for other baseline, procedural, and postrepair characteristics. CONCLUSIONS: In patients with severe secondary MR treated with surgical repair, LV forward flow was independently associated with better survival and lower risk of the combined endpoint.

Different manifestation of irradiation induced coronary artery disease detected with coronary computed tomography compared with matched non-irradiated controls.

BACKGROUND AND PURPOSE: Patients who received chest irradiation for treatment of a malignancy are at increased risk for the development of coronary artery atherosclerosis. Little is known about the anatomical coronary artery plaque characteristics of irradiation induced coronary artery disease (CAD). This study aimed to evaluate potential differences in the presence, extent, severity, composition and location of CAD in patients treated with mediastinal irradiation compared with non-irradiated controls matched on age, gender and cardiovascular risk factors. MATERIAL AND METHODS: Seventy-nine asymptomatic Hodgkin and non-Hodgkin lymphoma survivors, all treated with mediastinal irradiation with or without chemotherapy, who underwent coronary computed tomography angiography (CTA) to exclude or detect CAD were included. Patients were 1:3 matched with non-irradiated controls (n=237) for age, gender, diabetes, hypertension, hypercholesterolemia, family history of CAD and currently smoking. Mean age at cancer diagnosis was 26±9years and age at the time of coronary CTA was 45±11years. RESULTS: More patients had an abnormal CTA (defined as any coronary artery atherosclerosis): 59% vs. 36% (P<0.001) and significantly more patients had two vessel CAD: 10% vs. 6% and three vessel/left main CAD: 24% vs. 9% compared with controls (overall P<0.001). The maximum stenosis severity among patients was less often <30% (53% vs. 68%) and more often >70% (7% vs. 0%) (overall P=0.001). Patients had more coronary artery plaques in proximal coronary artery segments: left main (17% vs. 6%, P=0.004), proximal left anterior descending artery (30% vs. 16%, P=0.004), proximal right coronary artery (25% vs 10%, P<0.001) and proximal left circumflex artery (14% vs 6%, P=0.022), whereas the number of plaques in non-proximal segments did not differ between groups. CONCLUSIONS: Hodgkin and non-Hodgkin lymphoma survivors treated with mediastinal irradiation with or without chemotherapy showed a higher presence, greater severity, larger extent and more proximally located CAD compared with age, gender and risk factor matched non-irradiated controls. These findings represent features of higher risk CAD and may explain the worse cardiovascular outcome after chest irradiation.

Transcatheter aortic valve thrombosis: the relation between hypo-attenuated leaflet thickening, abnormal valve haemodynamics, and stroke.

AIMS: The presence of hypo-attenuated leaflet thickening (HALT) and/or reduced leaflet motion on multi-detector row computed tomography (MDCT) has been proposed as a possible marker for early transcatheter aortic valve thrombosis. However, its association with abnormal valve haemodynamics on echocardiography (another potential marker of thrombosis) and clinical outcomes (stroke) remains unclear. The present study evaluated the prevalence of HALT on MDCT and abnormal valve haemodynamics on echocardiography. In addition, the occurrence of ischemic stroke and/or transient ischemic attack (TIA) was assessed. METHODS AND RESULTS: A total of 434 patients (mean age 80 ± 7 years, 51% male) who underwent transcatheter aortic valve replacement (TAVR) were evaluated. Transcatheter valve haemodynamics were assessed on echocardiography at discharge, 6 months, and thereafter yearly (up to 3 years post-TAVR). The presence of HALT and/or reduced leaflet motion was assessed on MDCT performed 35 days [interquartile range 19-210] after TAVR in 128 of these 434 patients. Possible TAVR valve thrombosis was defined by mean transvalvular gradient ≥20 mmHg and aortic valve area (AVA) ≤1.1cm2 on echocardiography or by the presence of HALT or reduced leaflet motion on MDCT. The occurrence of ischemic stroke/TIA at follow-up was recorded. HALT and/or reduced leaflet motion was present in 12.5% of 128 patients undergoing MDCT, and was associated with a slightly higher mean transvalvular gradient (12.4 ± 8.0 mmHg vs. 9.4 ± 4.3 mmHg; P = 0.026) and smaller AVA (1.49 ± 0.39 cm2 vs. 1.78 ± 0.45 cm2, P = 0.017). Only one patient with HALT on MDCT revealed abnormal valve haemodynamics on echocardiography. At 3-year follow-up, abnormal valve haemodynamics on echocardiography were observed in 3% of patients. HALT on MDCT and abnormal valve haemodynamics on echocardiography were not associated with increased risk of ischemic stroke/TIA. CONCLUSION: On MDCT, 12.5% of patients showed HALT or reduced leaflet motion, whereas only one of these patients had abnormal valve haemodynamics on echocardiography. Neither HALT nor increased transvalvular gradient were associated with stroke/TIA.