Prognostication of Poor Survival After Cardiac Resynchronization Therapy.

Background and Objectives: Cardiac resynchronization therapy (CRT) is a successful treatment option for appropriately selected patients. However, one-third of recipients do not experience any positive outcome or their condition even declines. We aimed to assess preimplantation factors associated with worse survival after the CRT. Materials and Methods: This was a retrospective unicenter trial. The study cohort included 183 consecutive CRT-treated patients. Baseline demographic, clinical, electrocardiographic, and echocardiographic characteristics were analyzed. Results: After the median follow-up of 15.6 months (9.3-26.3), 20 patients had died (11%). In multivariate Cox regression analysis, ischemic origin of heart failure (HF) was a significant predictor of poor survival (adjusted hazard ratio (aHR) 15.235, 95% confidence interval (CI) (1.999-116.1), p = 0.009). In univariate Cox regression, tricuspid annular plane systolic excursion (TAPSE) <15.5 mm (sensitivity 0.824, specificity 0.526; HR 5.019, 95% CI (1.436-17.539), p = 0.012), post-implantation prescribed antiplatelet agents (HR 2.569, 95% CI (1.060-6.226), p = 0.037), statins (HR 2.983, 95% CI (1.146-7.764), p = 0.025), and nitrates (HR 3.694, 95% CI (1.342-10.171), p = 0.011) appeared to be related with adverse outcome. Conclusions: ischemic etiology of HF is a significant factor associated with worse survival after the CRT. Decreased TAPSE is also related to poor survival.

Changes in right ventricular longitudinal function: primary mitral and concomitant tricuspid valve repair.

OBJECTIVES: To evaluate the impact of concomitant tricuspid valve (TV) repair on the right ventricular (RV) function postoperatively and within the 6 months following degenerative mitral valve (MV) repair. METHODS: The prospective study included 37 patients (mean age 57.32 ± 2.13 years) with severe MV regurgitation due to primary MV prolapse. Nineteen underwent successful MV repair (TV(-) group). Additional TV repair due to moderate-to-severe TV regurgitation was performed in 18 (TV(+) group). Two-dimensional (2D) speckle-tracking and tissue Doppler echocardiography was performed for all patients before surgery and 7 days and 6 months after surgery. RESULTS: Preoperative dimensions and indices of RV longitudinal function did not differ between the groups (right ventricle end-diastolic diameter (RVEDD) was 33.53 ± 0.94 mm vs. 34.67 ± 1.72 mm, tricuspid annular systolic motion (S') was 15.06 ± 0.85 cm/s vs. 16.0 ± 1.27 cm/s, tricuspid annular plane systolic excursion (TAPSE) was 24.02 ± 1.06 mm vs. 22.4 ± 1.36 mm, respectively; p>0.05). RVEDD decreased significantly and did not change within the follow-up in the TV(-) group. In the TV(+) group, RVEDD decreased early after surgery and more markedly six months later in comparison to the TV(-) group. Indices of RV systolic longitudinal function decreased early after surgery and had a tendency to increase after six months in both groups. Regional longitudinal strains of the lateral RV wall decreased early after surgery and improved within the six months in the TV(-) group and did not change significantly in the TV(+) group. CONCLUSIONS: Additional TV repair in degenerative MV repair more markedly reduces RV dimensions and does not have a negative impact on RV systolic function in comparison to an isolated MV repair although these conclusions are of limited value due to the lack of a control group.

Determinants of reduced tricuspid annular plane systolic excursion in patients with severe systolic left ventricular dysfunction.

OBJECTIVE: Right ventricular (RV) dysfunction is associated with poor exercise tolerance and prognosis, regardless of left ventricular (LV) function. Tricuspid annular plane systolic excursion (TAPSE) is a non-invasive parameter of RV longitudinal function which can predict outcome in heart failure (HF) patients (pts). Our aim was to investigate the relation of TAPSE to clinical and echocardiographic parameters in severe LV dysfunction. METHODS AND RESULTS: The study included 119 pts with non-ischaemic dilated cardiomyopathy (n = 46) and ischaemic heart disease (n = 73) in stable HF with severe LV systolic dysfunction (LV ejection fraction (EF) < 30%). In pts with different LV dysfunction severity the higher NYHA class correlated with lower TAPSE dimensions: NYHA class IV 12.7 +/- 2.9 mm vs. NYHA class III 15.9 +/- 4.2 mm and NYHA class II 18.8 +/- 4.2 mm, P < 0.001. The presence of atrial arrhythmias in 16% of pts was related to lower values of TAPSE (12.9 +/- 3.6 mm vs. 15.4 +/- 4.2 mm, P < 0.05). Pts with non-ischaemic HF aetiology were found to have lower values of TAPSE compared to ischaemic aetiology (12.5 +/- 2.8 mm vs. 16.6 +/- 4.1 mm, P = 0.001) and increased odds of low TAPSE (< or = 14 mm)--odds ratio (OR) [95% confidence interval] = 9.8 [3.8-25.6], P < 0.001. Multivariate analysis revealed that LVEF, deceleration time (DT) of early mitral inflow E wave and the RV end-diastolic diameter are independent determinants of reduced TAPSE (< or = 14 mm) in pts with severe LV systolic dysfunction. CONCLUSION: The lower TAPSE values are related to higher NYHA functional class, presence of atrial arrhythmias and non-ischaemic aetiology in HF pts. The LVEF, DT of LV filling and RV end-diastolic diameter are independent predictors of reduced TAPSE (< or = 14 mm) in pts with severe systolic LV dysfunction.

The impact of unrepaired versus repaired mitral regurgitation on functional status of patients with ischemic cardiomyopathy at one year after coronary artery bypass grafting.

BACKGROUND AND AIM OF THE STUDY: The issues regarding the appropriate management of patients with ischemic mitral regurgitation (MR) and advanced left ventricular (LV) dysfunction are controversial and limited. The present study was undertaken to evaluate the mid-term dynamics of MR, LV dimensions, function and NYHA functional class in patients with ischemic cardiomyopathy (ICM) and MR who underwent coronary artery bypass grafting (CABG) either alone or combined with mitral valve (MV) repair. METHODS: A total of 199 patients with LV ejection fraction (LVEF) <35% were included in the study. Of these patients, 73 had MR grade 2+ (group 1), 66 had 0 or 1+ MR (group 2) and underwent isolated CABG, and 60 had MR > 2+ and underwent CABG with MV repair (group 3). RESULTS: At one year after surgery, the severity of MR was unchanged from preoperative grade in group 1 (2.1 +/- 0.5 vs. 1.97 +/- 0.8), and increased in group (0.76 +/- 0.43 vs. 1.44 +/- 0.77; p < 0.05), but was significantly lower in group (2.8 +/- 0.5 vs. 1.6 +/- 0.7; p <0.05). In group 1, the LV end-systolic volume index (LVESVI) tended to increase, the LV end-diastolic volume index (LVEDVI) increased from 69.6 +/- 22.6 to 79.6 +/- 23.2 ml/m2 with an increase in LVEF (from 27.9 +/- 5.9 to 31.3 +/- 9.4%), and pulmonary artery pressure (PAP) increased from 31.9 +/- 7.0 to 39.5 +/- 17.4 mmHg. In group 2, the LV volumes tended to increase, LVEF increased from 30. 3 +/- 4.1 to 34.9 +/- 9.1%, and PAP remained unchanged. In group 3, the LVESVI decreased from 55.4 +/- 16.9 to 47.1 +/- 21.7 ml/m2, LVED-VI tended to decrease, LVEF increased from 31.4 +/- 8.6 to 36.5 +/- 11.3%, and PAP decreased from 35.5 +/- 6.0 to 32.8 +/- 8.3 mmHg. CONCLUSION: Isolated CABG in patients with ICM had no favorable effect on MR reduction, and did not prevent its development. MR grade 2+ in patients with ICM at one year after isolated CABG had a deleterious effect on LV functional status, with progression of LV dilatation and increased PAP. A significant reduction or elimination of MR after combined surgery had a marked positive impact on reverse LV remodeling, including regression of LV dilatation, an increased LVEF, and decreased PAP.

Ischemic mitral valve repair: predictive significance of restrictive left ventricular diastolic filling.

AIM: The aim of the present study was to evaluate the impact of left ventricular (LV) diastolic filling impairment on postoperative results in patients with low LV ejection fraction (EF) undergoing combined coronary artery bypass grafting (CABG) and mitral valve (MV) repair. METHODS AND RESULTS: Study population consisted of 53 patients with ischemic MV incompetence and LV systolic dysfunction (mean EF-26.1 +/- 6%), who underwent CABG with MV repair. Patients were divided into three groups according to the LV diastolic filling pattern. Study protocol included evaluation of perioperative mortality (30 days inhospital mortality), NYHA functional class, and two-dimensional Doppler echocardiographic examination preoperatively, 10-14 days, and 12 months after surgery. The highest perioperative mortality rate (33.3%), unimproved functional status (in 78.5% of the patients, NYHA functional class remained unchanged late after surgery), and hemodynamic deterioration (LV dilatation, progression of mitral regurgitation (MR) was observed in the restriction group). Though early after surgery, MR reduction was significant in this group, at even one year after surgery 85.7% of patients presented with >grade 1 of MR (P < 0.05). Logistic regression analysis showed that restrictive LV diastolic filling is an important independent preoperative marker (P = 0.035) of progression of MR late after MV repair. CONCLUSION: In patients with severe LV dysfunction undergoing combined CABG and MV repair, restrictive LV diastolic filling pattern is an important preoperative marker of high perioperative mortality rate, further negative remodeling of LV, and progression of mitral regurgitation late after MV repair.

[Comparative analysis of myocardial revascularisation and combined surgery impact on left ventricular function in patients with ischemic cardiomyopathy]. / Ligoniu, serganciu isemine kardiomiopatija, izoliuotos miokardo revaskulizacijos ir kompleksiniu operaciju poveikio kairiojo skilvelio funkcijos kitimui lyginamoji analize.

UNLABELLED: The aim of study was to evaluate the impact of isolated myocardial revascularisation (MR) and combined surgery (MR) with mitral valve (MV) repair) on early and late postoperative changes of left ventricular ( LV) function. The study group consisted of 133 CAD pts with low LV ejection fraction (28.6+/-4.1%) and = II degrees MV incompetence, including 73 pts who underwent isolated MR (1 gr.) and 60 pts - MR with MV repair (2 gr.). Echocardiographic investigations performed preoperatively, early (10-14 th day) and late (following 1 year) after surgery, included evaluation of 1) LV morphometry, 2) systolic function indices, 3) pulmonary artery pressure (PAP) and 4) severity of MV incompetence. RESULTS: At late follow up severity of MV incompetence did not differ from the preoperative in 1 gr., but was significantly lower in 2 gr. (2.8+/-0.5 versus 1.6+/-0.7, p<0.05). Preferable LV function changes were noted in 1 gr. at early follow up, but at late follow up - LV end diastolic diameter index increased and exceeded preoperative values (from 29.6+/-4.4 to 31.3+/-4.1 mm/m(2), p<0.05), as well as segmental contraction index and PAP (from 31.9+/-7.0 to 39.5+/-17.4 mmH, p<0.05). Early LV function improvement in 2 gr. remained stable at late follow up. CONCLUSIONS: Combined surgery (MR with MV repair) in pts with ischemic cardiomyopathy and = II degrees MV incompetence has marked positive impact on LV remodelling: late follow up revealed no progression of LV dilation and significantly reduced severity of mitral regurgitation. One year following isolated MR severity of MV incompetence remained unchanged with progression of LV dilation and increase in PAP.