Global longitudinal strain predicts left ventricular dysfunction after mitral valve repair.

AIMS: Despite a successful surgical procedure and adherence to current recommendations, postoperative left ventricular (LV) dysfunction after mitral valve repair (MVr) for organic mitral regurgitation (MR) may still occur. New approaches are therefore needed to detect subclinical preoperative LV dysfunction. LV global longitudinal strain (GLS), assessed with speckle-tracking echocardiographic analysis, has been proposed as a novel measure to better depict latent LV dysfunction. The aim of this study was to investigate the value of GLS to predict long-term LV dysfunction after MVr. METHODS AND RESULTS: A total of 233 patients (61% men, 61 ± 12 years) with moderate-severe organic MR who underwent successful MVr between 2000 and 2009 were included. Echocardiography was performed at baseline and long-term follow-up (34 ± 20 months) after MVr. LV dysfunction at follow-up was defined as LV ejection fraction (EF) <50% and was present in 29 (12%) patients. A cut-off value of -19.9% of GLS showed a sensitivity and specificity of 90 and 79% to predict long-term LV dysfunction. By univariate logistic regression analysis, baseline LVEF ≤60%, LV end-systolic diameter (ESD) ≥40 mm, atrial fibrillation, presence of symptoms, and GLS >-19.9% were predictors of long-term LV dysfunction. By multivariate analysis, GLS remained an independent predictor of LV dysfunction (odds ratio 23.16, 95% confidence interval: 6.53-82.10, P < 0.001), together with LVESD. CONCLUSION: In a large series of patients operated within the last decade, MVr resulted in a low incidence of long-term LV dysfunction. A GLS of >-19.9% demonstrated to be a major independent predictor of long-term LV dysfunction after adjustment for parameters currently implemented into guidelines.

Global longitudinal strain predicts long-term survival in patients with chronic ischemic cardiomyopathy.

BACKGROUND: Left ventricular (LV) global longitudinal strain (GLS) is a measure of the active shortening of the LV in the longitudinal direction, which can be assessed with speckle-tracking echocardiography. The aims of this evaluation were to validate the prognostic value of GLS as a new index of LV systolic function in a large cohort of patients with chronic ischemic cardiomyopathy and to determine the incremental value of GLS to predict long-term outcome over other strong and well-established prognostic factors. METHODS AND RESULTS: A total of 1060 patients underwent baseline clinical evaluation and transthoracic echocardiography. Median age was 66.9 years (interquartile range, 58.4, 74.2 years); 739 (70%) were men. The median follow-up duration for the entire patient population was 31 months. During the follow-up, 270 patients died and 309 patients reached the combined end point (all-cause mortality and heart failure hospitalization). Compared with survivors, patients who died (270, [25%]) had larger LV volumes (P<0.05), lower LV ejection fraction (P=0.004), higher wall motion score index (P=0.001), and greater impairment of LV GLS (P<0.001). After dichotomizing the population on the basis of the median value of LV GLS (-11.5%), patients with an LV GLS ≤-11.5% had superior outcome compared with patients with an LV GLS >-11.5% (log-rank χ(2), 13.86 and 14.16 for all-cause mortality and combined end point, respectively, P<0.001 for both). On multivariate analysis, GLS was independently related to all-cause mortality (hazard ratio per 5% increase, 1.69; 95% confidence interval, 1.33-2.15; P<0.001) and combined end point (1.64; 95% confidence interval, 1.32-2.04; P<0.001). CONCLUSIONS: The assessment of LV GLS with speckle-tracking echocardiography is significantly related to long-term outcome in patients with chronic ischemic cardiomyopathy.

Changes in left ventricular function after mitral valve repair for severe organic mitral regurgitation.

BACKGROUND: Limited data are available on the changes in left ventricular (LV) contractile function at long-term follow-up after mitral valve repair (MVr). Moreover, assessment of LV systolic function in patients undergoing MVr is troublesome with current methods, given that mitral regurgitation is characterized by increased preload and decreased afterload, potentially masking LV dysfunction. The aim of this study was to assess the value of LV global strain (longitudinal and circumferential) measured by speckle tracking analysis for detecting changes in contractile function after MVr. METHODS: A total of 122 patients with organic mitral regurgitation who underwent successful MVr at an early stage (LV ejection fraction>60%, LV end-systolic diameter<40 mm) were included. Echocardiography was performed at baseline and at short-term (∼7 days) and long-term (1 to 3 years) follow-up after MVr. RESULTS: At baseline, LV ejection fraction and LV global strain were higher in patients than in 40 normal control individuals. By contrast, LV forward stroke volume was higher in control individuals than in patients. At short-term follow-up, a significant decrease in LV ejection fraction and LV global strain was noted as a consequence of changes in loading conditions. At long-term follow-up, LV ejection fraction and LV global strain improved significantly. Correction of LV strain for LV size showed a subtle impairment of myocardial contractility at baseline, which significantly improved over time after MVr, together with the improvement in LV forward stroke volume. CONCLUSIONS: Mitral valve repair for organic mitral regurgitation results in a significant increase in LV myocardial contractility as measured by LV global strain corrected by LV size.

Effect of cardiac resynchronization therapy in patients without left intraventricular dyssynchrony.

AIMS: To evaluate the effects of cardiac resynchronization therapy (CRT) on long-term survival of patients without baseline left ventricular (LV) mechanical dyssynchrony. METHODS AND RESULTS: A total of 290 heart failure patients (age 67 ± 10 years, 77% males) without significant baseline LV dyssynchrony (<60 ms as assessed with tissue Doppler imaging) were treated with CRT. Patients were divided according to the median LV dyssynchrony measured after 48 h of CRT into two groups. All-cause mortality was compared between the subgroups. In addition, the all-cause mortality rates of these subgroups were compared with the all-cause mortality of 290 heart failure patients treated with CRT who showed significant LV dyssynchrony (≥60 ms) at baseline. In the group of patients without significant LV dyssynchrony, median LV dyssynchrony increased from 22 ms (inter-quartile range 16-34 ms) at baseline to 40 ms (24-56 ms) 48 h after CRT. The cumulative mortality rates at 1-, 2-, and 3-year follow-up of patients with LV dyssynchrony ≥40 ms 48 h after CRT implantation were significantly higher when compared with patients with LV dyssynchrony <40 ms (10, 17, and 23 vs. 3, 8, and 10%, respectively; log-rank P< 0.001). Finally, the cumulative mortality rates at 1-, 2-, and 3-year follow-up of patients with baseline LV dyssynchrony were 3, 8, and 11%, respectively (log-rank P= 0.375 vs. patients with LV dyssynchrony <40 ms). Induction of LV dyssynchrony after CRT was an independent predictor of mortality (hazard ratio: 1.247; P= 0.009). CONCLUSION: In patients without significant LV dyssynchrony, the induction of LV dyssynchrony after CRT may be related to a less favourable long-term outcome.

Changes in heart valve structure and function in patients treated with dopamine agonists for prolactinomas, a 2-year follow-up study.

OBJECTIVE: The use of ergot-derived dopamine agonists (DA) to treat patients with prolactinomas has not been associated with an increased risk of significant heart valve dysfunction. Accordingly, the present study evaluated whether the long-term use of DA for hyperprolactinaemia may be associated with increased risk of significant valvular heart disease. METHODS: A total of 74 patients (mean age 48 ± 1·4 years, 23% male) with prolactinoma treated with DA for at least 1 year were evaluated with 2-dimensional echocardiography at baseline. After 2 years of follow-up, a repeat echocardiography was performed to evaluate significant changes in valvular heart structure (thickening, calcifications and leaflet motion abnormalities) and function (regurgitation or stenosis). Patients were classified according to treatment: patients treated with cabergoline (group 1: n = 45), and patients not treated with cabergoline (group 2: n = 29). RESULTS: At 2-year follow-up, no significant valvular stenosis was observed in any patient. In addition, the prevalence of any significant valve regurgitation did not change significantly (from 12% to 15%, P = NS). However, there was a significant increase in the prevalence of valvular calcifications (from 48% to 58%, P = 0·004) and, particularly, in the prevalence of aortic valve calcifications (from 39% to 53%, P = 0·002). In a per-treatment-based analysis, the group of patients treated with cabergoline had significantly higher prevalence of aortic valve calcification at 2 years follow-up as compared to the group of patients not treated with cabergoline (63%vs 38%, P = 0·016). CONCLUSIONS: The long-term therapy with DA (cabergoline) of patients with prolactinoma is associated with an increased prevalence of valvular calcification. However, these structural changes were not accompanied by an increased prevalence of valvular dysfunction.

Prediction of response to cardiac resynchronization therapy combining two different three-dimensional analyses of left ventricular dyssynchrony.

Triplane tissue synchronization imaging (TSI) and real-time 3-dimensional echocardiography (RT3DE) provide different characterizations of left ventricular (LV) mechanics and dyssynchrony. Triplane TSI assesses differences in time to peak systolic segmental myocardial tissue velocities, whereas RT3DE evaluates differences in time to minimum end-systolic regional volumes. Whether an approach using the 2 3D techniques predicts better significant reverse remodeling after cardiac resynchronization therapy (CRT) remains unknown. In 166 patients (mean age 66 ± 9 years, 78% men) treated with CRT, baseline LV dyssynchrony was assessed using RT3DE and triplane TSI. LV dyssynchrony was defined by a systolic dyssynchrony index ≥6.4% when assessed with RT3DE and SD of time to peak velocity of 12 segments (Ts-SD-12) ≥33 ms with triplane TSI. CRT response was defined by ≥15% decrease in LV end-systolic volume at 6-month follow-up. Mean LV dyssynchrony using Ts-SD-12 was 48 ± 26 ms and mean systolic dyssynchrony index was 8.51 ± 3.81%. Response to CRT was observed in 86.3% of patients showing LV dyssynchrony with the 2 methods. In contrast, 97% of patients who did not show significant LV dyssynchrony with any of the techniques were nonresponders (p <0.001). Importantly, systolic dyssynchrony index and LV dyssynchrony using Ts-SD-12 were independent predictors of response to CRT (p <0.001 for each technique). Assessment of LV dyssynchrony with the 2 techniques showed incremental value for prediction of significant LV reverse remodeling over its assessment with only 1 technique (chi-square 90.18, p <0.001). In conclusion, the combined use of 2 different 3D techniques to assess LV dyssynchrony permits accurate prediction of response to CRT.

Surgical ventricular restoration for patients with ischemic heart failure: determinants of two-year survival.

BACKGROUND: Surgical ventricular restoration (SVR) improves left ventricular (LV) systolic function by partially restoring the normal geometry of the left ventricle. However, the beneficial effects of this surgical procedure on long-term clinical outcome remain controversial. The present study aimed to evaluate the independent determinants of 2-year morbidity and mortality rates after SVR. METHODS: Seventy-nine patients with ischemic heart disease and LV ejection fraction of 0.35 or less were included. All patients underwent SVR and additionally coronary artery bypass grafting or mitral valve surgery if clinically indicated. Clinical and echocardiographic examination was performed before SVR and at 6 months' follow-up. The primary end point was a composite of all-cause mortality and hospitalizations for heart failure. RESULTS: At 6 months' follow-up a significant improvement in heart failure symptoms was noted. In addition, LV ejection fraction increased from 0.27 ± 0.07 to 0.36 ± 0.10 (p < 0.001). During a median follow-up of 2.7 years, the primary end point was recorded in 22% of the patients. Baseline New York Heart Association functional class IV and a 6-month follow-up LV end-systolic volume index of at least 60 mL/m(2) were independently associated with worse outcome (hazard ratio, 5.4; 95% confidence interval, 1.9 to 15.2; p < 0.001; hazard ratio, 2.7; 95% confidence interval, 1.3 to 5.6; p < 0.001, respectively). CONCLUSIONS: Advanced heart failure status at baseline and large residual postsurgery LV end-systolic volume index were independently associated with increased mortality and heart failure hospitalization rates at 2 years' follow-up after SVR.

First-in-man implantation of a trans-catheter aortic valve in a mitral annuloplasty ring: novel treatment modality for failed mitral valve repair.

The trans-catheter valve-in-valve concept has become a feasible therapeutic option for patients with failing degenerated bioprosthesis, who are deemed inoperable. However, little is known about the feasibility of this technique in failed valve annuloplasty. We report the first-in-man implantation of a trans-catheter aortic valve within a mitral annuloplasty ring. Through a trans-apical trans-catheter approach, a 26-mm Sapien-Edwards valve was successfully implanted in a 72-year-old man with ischemic heart failure and failed mitral-valve annuloplasty. The present case report provides a critical appraisal of the procedural technique.

Longitudinal mechanics of the periinfarct zone and ventricular tachycardia inducibility in patients with chronic ischemic cardiomyopathy.

BACKGROUND: Quantification of segmental left ventricular (LV) strain by speckle-tracking echocardiography can identify transmural infarcts in patients with chronic ischemic cardiomyopathy. The aim of the study was to explore the relationship between the LV longitudinal peak systolic strain (LPSS) of the infarct, periinfarct, and remote zones and monomorphic ventricular tachycardia (VT) inducibility on electrophysiologic (EP) study. METHODS: A total of 134 patients with chronic ischemic cardiomyopathy scheduled for EP study were included. The protocol consisted of clinical, electrocardiographic, and echocardiographic evaluation, including LV longitudinal strain analysis using speckle-tracking echocardiography, immediately before EP study. An infarct segment was defined as a longitudinal strain value of greater than -5%, and a periinfarct segment was defined as immediately adjacent to an infarct segment. RESULTS: The infarct zone had the most impaired longitudinal strain (-0.5% ± 3.0%), whereas the periinfarct and remote zones had more preserved longitudinal strain (-10.8% ± 1.9% and -14.5% ± 3.0%, respectively; analysis of variance, P < .001). Seventy-two (54%) patients had inducible monomorphic VT on EP study. There was no significant difference in LV ejection fraction (31% ± 9% vs 32% ± 11%, P = .29) between inducible and noninducible patients. Longitudinal peak systolic strain of the periinfarct zone was more impaired in inducible patients (-9.8% ± 1.5% vs -11.0% ± 2.1%, P = .001), but no differences in LPSS of the infarct (-0.5% ± 3.2% vs -0.4% ± 2.7%, P = .75) and remote (-14.6% ± 2.8% vs -14.5% ± 3.4%, P = .92) zones were observed. Only LPSS of the periinfarct zone (OR 1.43, 95% CI 1.15-1.78, P = .001) was independently related to monomorphic VT inducibility on multiple logistic regression. CONCLUSIONS: Longitudinal strain analysis may be a useful imaging tool to risk stratify ischemic patients for malignant ventricular arrhythmia.

Effect of cardiac resynchronization therapy on subendo- and subepicardial left ventricular twist mechanics and relation to favorable outcome.

The analysis of left ventricular (LV) mechanics provides novel insights into the effects of cardiac resynchronization therapy (CRT) on LV performance. Currently, advances in speckle-tracking echocardiographic analysis have permitted the characterization of subendocardial and subepicardial LV twist. The aim of this study was to investigate the role of the acute changes in subendocardial and subepicardial LV twist for the prediction of midterm beneficial effects of CRT. A total of 84 patients with heart failure scheduled for CRT were recruited. All patients underwent echocardiography before and <48 hours after CRT implantation and at 6-month follow-up. The assessment of LV volumes, ejection fractions, and mechanical dyssynchrony (systolic dyssynchrony index) was performed with real-time 3-dimensional echocardiography. The assessment of subendocardial and subepicardial LV twist was performed with 2-dimensional speckle-tracking echocardiography. A favorable outcome was defined as the occurrence of a reduction > or =15% in LV end-systolic volume associated with an improvement of > or =1 New York Heart Association functional class at 6-month follow-up. At 6-month follow-up, 53% of the patients showed favorable outcomes. Ischemic cause of heart failure, baseline systolic dyssynchrony index, immediate improvement in the LV ejection fraction, immediate improvement in systolic dyssynchrony index, and immediate improvement in subendocardial and subepicardial LV twist were significantly related to favorable outcomes. However, in multivariate logistic regression analysis, only the immediate improvement of subepicardial LV twist was independently related to favorable outcomes (odds ratio 2.31, 95% confidence interval 1.29 to 4.15, p = 0.005). Furthermore, the immediate improvement of subepicardial LV twist had incremental value over established parameters. In conclusion, the immediate improvement of subepicardial LV twist (but not subendocardial LV twist) is independently related to favorable outcomes after CRT.

Impact of intravenous furosemide on flow rate characteristics and clinic waiting times.

OBJECTIVE: To assess the impact of a single dose of i.v. furosemide on clinic waiting times and urinary flow rate parameters in a group of symptomatic men. METHODS: Sixty-two consecutive men attending a prostate assessment clinic were prospectively entered into the study. They were then randomized to receive 10 mg of i.v. furosemide or to drink oral fluids only, as per standard protocol. Flow rate parameters and clinic waiting times were recorded. RESULTS: The clinic waiting time was significantly reduced by the administration of i.v. furosemide compared to oral fluid alone (81 vs 36 min; P < 0.0001) without any alteration in flow rate characteristics. Interestingly, although there was no statistically significant difference between the voided volumes in both groups (251 vs 313 mL; P = 0.115) all of the patients given furosemide voided a volume of over 150 mL, where as almost a third (10/32) of those receiving oral fluid alone did not achieve this. There were no adverse events following the administration of i.v. diuretic. CONCLUSION: A single dose of i.v. furosemide dramatically reduces the overall clinic waiting time without inducing statistically significant changes in flow rate parameters. Indeed, none of the patients receiving furosemide voided less than 150 mL. We would thus recommend this practice be considered as an alternative to standard uroflowmetry protocols.