An alternative method of indexation in aortic stenosis: height-adjusted effective orifice area : An observational prospective study.

BACKGROUND: Although indexing effective orifice area (EOA) by body surface area (BSA) is recommended, this method has several disadvantages, since it corrects by acquired fatty tissue. Our aim was to analyze the value of EOA normalized by height for predicting cardiovascular outcome in patients with aortic stenosis (AS). METHODS: Patients with AS (peak velocity > 2 m/s) evaluated in our echocardiography laboratory between January 2015 and June 2018 were prospectively enrolled. EOA was indexed by BSA and height. A composite primary endpoint was defined as cardiac death or aortic valve replacement. A receiver operating characteristic curve was plotted to determine the best cutoff value of EOA/height for predicting cardiovascular events. RESULTS: Four-hundred and fifteen patients were included (52% women, mean age 74.8 ± 11.6 years). Area under the curve was similar for EOA/BSA (AUC 0.75, p < 0.001) and EOA/height (AUC 0.75, p < 0.001). A cutoff value of 0.60 cm2/m for EOA/height had a sensitivity of 84%, specificity of 61%, positive predictive value of 60% and negative predictive value of 84%. One-year survival from primary endpoint was significantly lower in patients with EOA/height ≤ 0.60 cm2/m (48 ± 5% vs 91 ± 4%, log-rank p < 0.001) than EOA/height > 0.60 cm2/m. The excess of risk of cardiovascular events seen in univariate analysis persists even after adjustment for other demonstrated adverse prognostic variables (HR 5.91, 95% CI 3.21-10.88, p < 0.001). In obese patients, there was an excess of risk in patients with EOA/height < 0.60 cm2/m (HR 10.2, 95% CI 3.5-29.5, p < 0.001), but not in EOA/BSA < 0.60 cm2/m2 (HR 0.14, 95% CI 0.14-1.4, p = 0.23). CONCLUSIONS: We could identify a subgroup of patients with AS at high risk of cardiovascular events. Consequently, we recommend using EOA/height as a method of indexation in AS, especially in obese patients, with a cutoff of 0.60 cm2/m for identifying patients with higher cardiovascular risk.

Early recruitable coronary collaterals preserve miocardial viability in late presentation infarctions.

BACKGROUND: Previous studies showed conflicting results regarding the contribution of coronary collateral circulation (CCC) to myocardial perfusion and function in the setting of myocardial infarction (MI). In the primary angioplasty era, the role of CCC in these studies may have been influenced by the effect of early reperfusion. The true impact of CCC could be clarified by studying its effect on nonreperfused patients. The aim of our study was to evaluate the effect of CCC on myocardial viability of late presentation MI. METHODS AND RESULTS: Between 2008 and 2019, we included 167 patients with a late presentation MI who had a complete angiographic occlusion in a major coronary artery in which myocardial viability of the culprit territory was assessed. Patients were divided according to the presence of angiographic early recruited CCC (ERCC) (Rentrop 2-3) or poor CCC (PCC) (Rentrop 0-1). A lower left ventricular ejection function (LVEF) at discharge (54.2 ± 9 vs. 47.9 ± 12; <0.01) and a more severe left ventricular wall motion abnormalities in the culprit territory were observed in PCC patients. The presence of ERCC was the main independent predictor of myocardial viability in late presentation MI (hazard ratio, 4.24; 95% confidence interval, 1.68-10.6; P < 0.001). At follow-up, wall motion score increased significantly (2.05 ± 0.16; P = 0.02) in patients with ERCC but not in PCC patients (0.07 ± 0.16; P = 0.4), and LVEF improvement was significantly higher in ERCC than in PCC patients (9.7 ± 2.6 vs. 3.8 ± 4.2; P = 0.02). CONCLUSION: The presence of ERCC was the main independent predictor of myocardial viability in late presentation MI.

Effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors on left ventricular remodelling and longitudinal strain: a prospective observational study.

BACKGROUND: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) lower cardiovascular events in type 2 diabetes mellitus (T2DM) patients, although the mechanisms underlying these benefits are not clearly understood. Our aim was to study the effects of SGLT2i on left ventricular remodelling and longitudinal strain. METHODS: Between November 2019 and April 2020, we included 52 patients with T2DM ≥ 18 years old, with HbA1c between 6.5 and 10.0%, and estimated glomerular filtration ≥ 45 ml/min/1.73 m2. Patients were classified into SGLT2i group and control group, according to prescribed treatment by their referring physician. Conventional and speckle tracking echocardiography were performed by blinded sonographers, at baseline and after 6 months of treatment. RESULTS: Among the 52 included patients (44% females, mean age 66.8 ± 8.6 years, mean HbA1c was 7.40 ± 0.7%), 30 patients were prescribed SGLT2i and 22 patients were classified as control group. Mean change in indexed left ventricular mass (LVM) was - 0.85 ± 3.31 g/m2 (p = 0.003) in the SGLT2i group, and + 2.34 ± 4.13 g/m2 (p = 0.58) in the control group. Absolute value of Global Longitudinal Strain (GLS) increased by a mean of 1.29 ± 0.47 (p = 0.011) in the SGLT2i group, and 0.40 ± 0.62 (p = 0.34) in the control group. We did not find correlations between changes in LVM and GLS, and other variables like change in HbA1c. CONCLUSIONS: Among patients with T2DM, SGLT2i were associated with a significant reduction in indexed LVM and a significant increment in longitudinal strain measured by speckle tracking echocardiography, which may explain in part the clinical benefits found in clinical trials.

Prognostic value of aortic valve area normalized to body size in native aortic stenosis.

INTRODUCTION AND OBJECTIVES: Although guidelines recommend the use of a cutoff value of 0.60 cm2/m2 for aortic valve area (AVA) normalized to body surface area (BSA) for severe aortic stenosis, there is little evidence of its prognostic value. Our aim was to test the value of AVA normalized to body size for outcome prediction in aortic stenosis. METHODS: One-hundred and ninety patients with at least moderate aortic stenosis (AVA <1.50 cm2) were prospectively enrolled. AVA was normalized to BSA and height. The primary endpoint was cardiovascular death under medical management. A receiver operating characteristic curve was plotted to determine the best cutoff value for predicting cardiovascular death. RESULTS: An AVA/BSA cutoff value of 0.50 had a sensitivity of 96% and specificity of 51%. An AVA/height cutoff value of 0.49 showed a sensitivity of 96% and a specificity of 52%. During a mean follow-up of 247±190 days, there were 24 cardiovascular deaths, with higher cardiovascular mortality in patients with AVA/BSA <0.50 cm2/m2 (21% vs 2.5%, P <.001) and AVA/height <0.49 cm2/m (25% vs 12%, P <.001). Two-year survival was 95±5% in patients with AVA/BSA> 0.50 cm2/m2 and was 37±5% in patients with AVA/BSA <0.50 cm2/m2 (P <.001). Cardiovascular death risk was higher in patients with AVA/BSA <0.50 cm2/m2 (adjusted 10.9 [1.2-103.7], P=.037), but cardiovascular mortality was not significantly higher in multivariate analysis for patients with AVA/height <0.49 cm2/m (2.0 [0.6-6.0], P=.22). CONCLUSIONS: We could identify a subgroup of patients at high risk of cardiovascular death when they were medically treated. Consequently we recommend using an AVA/BSA cutoff value of 0.50 cm2/m2 to identify a subgroup of patients with higher cardiovascular risk.

Acceleration Time and Ratio of Acceleration Time to Ejection Time in Aortic Stenosis: New Echocardiographic Diagnostic Parameters.

BACKGROUND: Inconsistencies between gradients and aortic valve area are frequent in the echocardiographic evaluation of aortic stenosis (AS). Assessing AS severity is essential for the correct management of the disease. The aim of this study was to evaluate whether ejection dynamics, particularly acceleration time (AT) and the ratio of AT to ejection time (ET), could be diagnostic parameters in patients with AS. METHODS: Patients with AS (aortic peak velocity > 2 m/sec) were prospectively enrolled. Quantitative echocardiographic Doppler parameters including ejection dynamics (AT, ET, and AT/ET ratio) as well as conventional and clinical parameters were analyzed. AT, ET, and AT/ET ratio were calculated in different stages of AS. A receiver operating characteristic curve was plotted to determine the best cutoff value to identify severe AS. RESULTS: Two hundred sixty-two patients were included (mean age, 75 ± 8 years; 54% women), of whom 109 (42%) had severe AS, 99 (38%) had moderate AS, 22 (8%) had mild AS, 24 (9%) had classical low-flow, low-gradient severe AS, and eight (3%) had paradoxical low-flow, low-gradient severe AS. AT was higher in patients with higher levels of severity of AS (65 ± 16 vs 82 ± 19 vs 109 ± 23 msec, P < .001) as well as AT/ET ratios (0.22 ± 0.05 vs 0.29 ± 0.07 vs 0.37 ± 0.06, P < .001). Using a cutoff of 94 msec, AT had sensitivity of 71% and specificity of 81% for severe AS; using a cutoff of 0.35, the AT/ET ratio had sensitivity of 59% and specificity of 86%. On multivariate analysis, AT was associated with effective orifice area (B = -0.64, P < .001) and ET with heart rate (B = -0.62, P < .001) and age (B = 0.30, P = .04). CONCLUSIONS: Ejection dynamics parameters, such as AT and AT/ET, can help evaluate AS severity.

Insuficiencia aórtica aguda traumática tras intervención coronaria percutánea: una causa poco frecuente / Percutaneous coronary intervention: a rare cause of acute traumatic aortic regurgitation

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Invasive assessment of coronary flow reserve impairment in severe aortic stenosis and ecochadiographic correlations.

OBJECTIVES AND BACKGROUND: Patients with aortic stenosis (AS) may have impaired coronary flow reserve (CFR) despite angiographically normal coronary arteries. This is the first report of invasive thermodilution-derived CFR and IMR in patients with AS and their associations with echocardiographic parameters for AS assessment. METHODS: Thirty-six consecutive severe AS patients and ten patients without AS underwent prospectively cardiac catheterization and coronary physiological parameters were determined in the left anterior descending (LAD). Mean transit time (Tmn), a surrogate of absolute coronary flow, was obtained from the coronary thermodilution curve. RESULTS: In AS patients we found a high LAD flow at rest (Tmn rest 0.55±0.3 vs 0.99±0.4, p=0.01) and a low flow at hyperemia (Tmnhyp 0.44±0.2 vs 27.7±0.1, p=0.02) and consequently a severe CFR impairment (1.4±0.4 vs 3.8±1.4, p<0.001) compared with controls. An elevated index of microvascular resistance (IMR) (32.7±16 vs 17.8±6.5, p=0.01) and a low baseline microvascular coronary resistance (48.1±29 vs 84±34, p=0.02) were also found. In AS patients there were significant correlations between CFR and left ventricular mass index (r=-0.32; p=0.02), and the ratio of acceleration time to ejection time (AT/ET) (r=-0.4; p=0.01) a non-flow dependent echocardiographic parameter for AS assessment. Multiple linear stepwise regression analysis showed that AT/ET (ß=-0.441, p=0.019) was the only independently variable associated with CFR CONCLUSIONS: In severe AS, invasive CFR shows a progressive decrease with AS severity and a good correlation with echocardiographic parameters of AS, especially with flow-independent ones.

Invasive assessment of coronary microvascular dysfunction in hypertrophic cardiomyopathy: the index of microvascular resistance.

We present a review of microvascular dysfunction in hypertrophic cardiomyopathy (HCM) and an interesting case of a symptomatic familial HCM patient with inducible ischemia by single photon emission computed tomography. Coronary angiography revealed normal epicardial arteries. Pressure wire measurements of fractional flow reserve (FFR), coronary flow reserve (CFR) and index of microvascular resistance (IMR) demonstrated a significant microcirculatory dysfunction. This is the first such case that documents this abnormality invasively using the IMR. The measurement of IMR, a novel marker of microcirculatory dysfunction, provides novel insights into the pathophysiology of this condition.

Dolor torácico en urgencias: otra posibilidad diagnóstica a valorar / Chest pain in the emergency department: another diagnosis to consider

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Ratio of Acceleration Time to Ejection Time for Assessing Aortic Stenosis Severity.

BACKGROUND: Inconsistencies in the grading of aortic valve stenosis are frequent (24-38%). Guidelines highlight the waveform shape when discrepancies are present. Our aim was to evaluate the severity of aortic stenosis by the ratio of acceleration time to ejection time (AT/ET). METHODS: Between January 2011 and January 2013, patients with at least moderate aortic stenosis (valve area < 1.5 cm(2) ) evaluated in our echocardiography laboratory were enrolled. Clinical data were recorded including symptoms attributable to aortic stenosis. Quantitative echocardiographic Doppler parameters as ejection dynamics (ejection time and acceleration time) and conventional parameters, and usual laboratory test including natriuretic peptides (NT-proBNP) were analyzed. RESULTS: One hundred eight patients with aortic valve stenosis were recruited (mean age 77 ± 7 years; 57% women). Comorbidity of the patients was frequent: 85% hypertension, 59% diabetes, 31% chronic renal failure, 26% smokers, mean body mass index 30.0 ± 6.6 kg/m(2) . Ninety-six patients (90%) were symptomatic at the index visit. Using a cutoff of 0.35, AT/ET had a sensitivity of 77% and a specificity of 100% to discriminate symptomatic patients. Serum value of NT-proBNP was higher in patients with AT/ET > 0.35 (9885 ± 3111 vs. 2600 ± 1175, P < 0.001). This ratio showed a good correlation with indexed left ventricle mass (r = 0.60, P < 0.001), DVI (r = -0.56, P < 0.001), and AVA (r = -0.49, P < 0.001). CONCLUSIONS: Ejection dynamics through aortic valve, particularly AT/ET ratio, is a useful tool for assessing aortic stenosis severity, with a good correlation with flow-independent parameters in aortic stenosis.

Cardiac troponin-T in acute pericarditis.

INTRODUCTION: The long-term outcome of acute pericarditis with high cardiac troponin-T (cTnT) is unknown. Our purpose was to investigate the prognostic and clinical value of cTnT in myopericardial inflammatory syndromes. METHODS: Between January 2001 and September 2011, 107 patients hospitalized for acute pericarditis or myopericarditis were enrolled. Postinfarction pericarditis and neoplastic pericarditis were excluded. Physical examination, ECG, echocardiography and blood tests were performed. RESULTS: Among the 105 patients (89% men, mean age 36 ±â€Š15 years-old), a cTnT rise was detectable in 64 patients (60.9%). Only younger age was found as an independent factor for higher values of cTnT in multivariate analysis (P = 0.03). After a mean follow-up of 51 months, a similar rate of complications was found in patients with a positive or a negative cTnT test: recurrent pericarditis (11 vs. 19%, P = 0.23) and cardiac tamponade (2 vs. 5%, P = 0.56). No cases of constrictive pericarditis, residual left ventricular dysfunction or hospital death were detected. The left ventricular ejection fraction remained unchanged during the follow-up (62.6 ±â€Š6.5 vs. 61.9 ±â€Š5.8, P = 0.89). CONCLUSION: In acute pericarditis, a cTnT rise is a frequent finding and commonly found in younger patients. However, unlike acute coronary syndrome, cTnT rise is not a negative prognostic marker.