Myocardial Blood Flow Quantified Using Stress Cardiac Magnetic Resonance After Mild COVID-19 Infection.

BACKGROUND: Severe COVID-19 infection is known to alter myocardial perfusion through its effects on the endothelium and microvasculature. However, the majority of patients with COVID-19 infection experience only mild symptoms, and it is unknown if their myocardial perfusion is altered after infection. OBJECTIVES: The authors aimed to determine if there are abnormalities in myocardial blood flow (MBF), as measured by stress cardiac magnetic resonance (CMR), in individuals after a mild COVID-19 infection. METHODS: We conducted a prospective, comparative study of individuals who had a prior mild COVID-19 infection (n = 30) and matched controls (n = 26) using stress CMR. Stress and rest myocardial blood flow (sMBF, rMBF) were quantified using the dual sequence technique. Myocardial perfusion reserve was calculated as sMBF/rMBF. Unpaired t-tests were used to test differences between the groups. RESULTS: The median time interval between COVID-19 infection and CMR was 5.6 (IQR: 4-8) months. No patients with the COVID-19 infection required hospitalization. Symptoms including chest pain, shortness of breath, syncope, and palpitations were more commonly present in the group with prior COVID-19 infection than in the control group (57% vs 7%, P < 0.001). No significant differences in rMBF (1.08 ± 0.27 mL/g/min vs 0.97 ± 0.29 mL/g/min, P = 0.16), sMBF (3.08 ± 0.79 mL/g/min vs 3.06 ± 0.89 mL/g/min, P = 0.91), or myocardial perfusion reserve (2.95 ± 0.90 vs 3.39 ± 1.25, P = 0.13) were observed between the groups. CONCLUSIONS: This study suggests that there are no significant abnormalities in rest or stress myocardial perfusion, and thus microvascular function, in individuals after mild COVID-19 infection.

Myocardial Injury on CMR in Patients With COVID-19 and Suspected Cardiac Involvement.

BACKGROUND: Myocardial injury in patients with COVID-19 and suspected cardiac involvement is not well understood. OBJECTIVES: The purpose of this study was to characterize myocardial injury in a multicenter cohort of patients with COVID-19 and suspected cardiac involvement referred for cardiac magnetic resonance (CMR). METHODS: This retrospective study consisted of 1,047 patients from 18 international sites with polymerase chain reaction-confirmed COVID-19 infection who underwent CMR. Myocardial injury was characterized as acute myocarditis, nonacute/nonischemic, acute ischemic, and nonacute/ischemic patterns on CMR. RESULTS: In this cohort, 20.9% of patients had nonischemic injury patterns (acute myocarditis: 7.9%; nonacute/nonischemic: 13.0%), and 6.7% of patients had ischemic injury patterns (acute ischemic: 1.9%; nonacute/ischemic: 4.8%). In a univariate analysis, variables associated with acute myocarditis patterns included chest discomfort (OR: 2.00; 95% CI: 1.17-3.40, P = 0.01), abnormal electrocardiogram (ECG) (OR: 1.90; 95% CI: 1.12-3.23; P = 0.02), natriuretic peptide elevation (OR: 2.99; 95% CI: 1.60-5.58; P = 0.0006), and troponin elevation (OR: 4.21; 95% CI: 2.41-7.36; P < 0.0001). Variables associated with acute ischemic patterns included chest discomfort (OR: 3.14; 95% CI: 1.04-9.49; P = 0.04), abnormal ECG (OR: 4.06; 95% CI: 1.10-14.92; P = 0.04), known coronary disease (OR: 33.30; 95% CI: 4.04-274.53; P = 0.001), hospitalization (OR: 4.98; 95% CI: 1.55-16.05; P = 0.007), natriuretic peptide elevation (OR: 4.19; 95% CI: 1.30-13.51; P = 0.02), and troponin elevation (OR: 25.27; 95% CI: 5.55-115.03; P < 0.0001). In a multivariate analysis, troponin elevation was strongly associated with acute myocarditis patterns (OR: 4.98; 95% CI: 1.76-14.05; P = 0.003). CONCLUSIONS: In this multicenter study of patients with COVID-19 with clinical suspicion for cardiac involvement referred for CMR, nonischemic and ischemic patterns were frequent when cardiac symptoms, ECG abnormalities, and cardiac biomarker elevations were present.

Human versus Artificial Intelligence-Based Echocardiographic Analysis as a Predictor of Outcomes: An Analysis from the World Alliance Societies of Echocardiography COVID Study.

BACKGROUND: Transthoracic echocardiography is the leading cardiac imaging modality for patients admitted with COVID-19, a condition of high short-term mortality. The aim of this study was to test the hypothesis that artificial intelligence (AI)-based analysis of echocardiographic images could predict mortality more accurately than conventional analysis by a human expert. METHODS: Patients admitted to 13 hospitals for acute COVID-19 who underwent transthoracic echocardiography were included. Left ventricular ejection fraction (LVEF) and left ventricular longitudinal strain (LVLS) were obtained manually by multiple expert readers and by automated AI software. The ability of the manual and AI analyses to predict all-cause mortality was compared. RESULTS: In total, 870 patients were enrolled. The mortality rate was 27.4% after a mean follow-up period of 230 ± 115 days. AI analysis had lower variability than manual analysis for both LVEF (P = .003) and LVLS (P = .005). AI-derived LVEF and LVLS were predictors of mortality in univariable and multivariable regression analysis (odds ratio, 0.974 [95% CI, 0.956-0.991; P = .003] for LVEF; odds ratio, 1.060 [95% CI, 1.019-1.105; P = .004] for LVLS), but LVEF and LVLS obtained by manual analysis were not. Direct comparison of the predictive value of AI versus manual measurements of LVEF and LVLS showed that AI was significantly better (P = .005 and P = .003, respectively). In addition, AI-derived LVEF and LVLS had more significant and stronger correlations to other objective biomarkers of acute disease than manual reads. CONCLUSIONS: AI-based analysis of LVEF and LVLS had similar feasibility as manual analysis, minimized variability, and consequently increased the statistical power to predict mortality. AI-based, but not manual, analyses were a significant predictor of in-hospital and follow-up mortality.

Utility of transillumination and transparency renderings in 3D transthoracic imaging.

Transillumination (TI) is a new 3D rendering tool that uses a freely movable virtual light source to enhance depth, contours, and image detail. The TI model was recently modified to allow the operator adjust the degree of transparency of both cardiac and extra-cardiac structures. While the addition of transparency was shown to significantly improve quality in 3D transesophageal imaging, this has not yet been shown for transthoracic (TTE) imaging. We prospectively studied 35 patients who underwent clinically indicated TTE with standard 3D acquisition, as well as TI with and without transparency. Six experienced echocardiographers were shown images of all three display types in random order. Each image was scored independently using a Likert Scale while assessing each of the following aspects: ability to identify anatomy or pathology, depth perception, degree of anatomic detail, and border delineation. All experts perceived an incremental value of the transparency mode, compared to TI without transparency and standard 3D rendering, in terms of ability to identify anatomy or pathology (4.15 ± 0.97 vs. 3.88 ± 0.99 vs. 2.52 ± 1.41, p < 0.01), depth perception (4.33 ± 0.78 vs. 3.88 ± 0.82 vs. 2.29 ± 1.07, p < 0.01), degree of anatomic detail (4.08 ± 1.0 vs. 3.89 ± 0.79 vs. 2.31 ± 1.08, p < 0.01), and border delineation (4.44 ± 0.80 vs. 3.90 ± 0.78 vs. 2.42 ± 1.13, p < 0.01). Compared to standard 3D and TI renderings of TTE images, the addition of transparency significantly improves both image quality and diagnostic confidence.

Ventricular Changes in Patients with Acute COVID-19 Infection: Follow-up of the World Alliance Societies of Echocardiography (WASE-COVID) Study.

BACKGROUND: COVID-19 infection is known to cause a wide array of clinical chronic sequelae, but little is known regarding the long-term cardiac complications. We aim to report echocardiographic follow-up findings and describe the changes in left (LV) and right ventricular (RV) function that occur following acute infection. METHODS: Patients enrolled in the World Alliance Societies of Echocardiography-COVID study with acute COVID-19 infection were asked to return for a follow-up transthoracic echocardiogram. Overall, 198 returned at a mean of 129 days of follow-up, of which 153 had paired baseline and follow-up images that were analyzable, including LV volumes, ejection fraction (LVEF), and longitudinal strain (LVLS). Right-sided echocardiographic parameters included RV global longitudinal strain, RV free wall strain, and RV basal diameter. Paired echocardiographic parameters at baseline and follow-up were compared for the entire cohort and for subgroups based on the baseline LV and RV function. RESULTS: For the entire cohort, echocardiographic markers of LV and RV function at follow-up were not significantly different from baseline (all P > .05). Patients with hyperdynamic LVEF at baseline (>70%), had a significant reduction of LVEF at follow-up (74.3% ± 3.1% vs 64.4% ± 8.1%, P < .001), while patients with reduced LVEF at baseline (<50%) had a significant increase (42.5% ± 5.9% vs 49.3% ± 13.4%, P = .02), and those with normal LVEF had no change. Patients with normal LVLS (<-18%) at baseline had a significant reduction of LVLS at follow-up (-21.6% ± 2.6% vs -20.3% ± 4.0%, P = .006), while patients with impaired LVLS at baseline had a significant improvement at follow-up (-14.5% ± 2.9% vs -16.7% ± 5.2%, P < .001). Patients with abnormal RV global longitudinal strain (>-20%) at baseline had significant improvement at follow-up (-15.2% ± 3.4% vs -17.4% ± 4.9%, P = .004). Patients with abnormal RV basal diameter (>4.5 cm) at baseline had significant improvement at follow-up (4.9 ± 0.7 cm vs 4.6 ± 0.6 cm, P = .019). CONCLUSIONS: Overall, there were no significant changes over time in the LV and RV function of patients recovering from COVID-19 infection. However, differences were observed according to baseline LV and RV function, which may reflect recovery from the acute myocardial injury occurring in the acutely ill. Left ventricular and RV function tends to improve in those with impaired baseline function, while it tends to decrease in those with hyperdynamic LV or normal RV function.

Comparison of clinical and echocardiographic features of first and second waves of COVID-19 at a large, tertiary medical center serving a predominantly African American patient population.

As clinicians have gained experience in treating patients with the novel SARS-CoV-2 (COVID-19) virus, mortality rates for patients with acute COVID-19 infection have decreased. The Centers for Disease Control (CDC) has identified the African American population as having increased risk of COVID-19 associated mortality, however little is known about echocardiographic markers associated with increased mortality in this patient population. We aimed to compare the clinical and echocardiographic features of a predominantly African American patient cohort hospitalized with acute COVID-19 infection during the first (March-June 2020) and second (September-December 2020) waves of the COVID-19 pandemic, and to investigate which parameters are most strongly associated with composite all-cause mortality. We performed consecutive transthoracic echocardiograms (TTEs) on 105 patients admitted with acute COVID-19 infection during the first wave and 129 patients admitted during the second wave. TTE parameters including left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (LVGLS), right ventricular global longitudinal strain (RVGLS), right ventricular free-wall strain (RVFWS), and right ventricular basal diameter (RVBD) were compared between the two groups. Clinical and demographic characteristics including underlying co-morbidities, biomarkers, in-hospital treatment regimens, and outcomes were collected and analyzed. Univariable and multivariable analyses were performed to determine variables associated with all-cause mortality. There were no significant differences between the two waves in terms of age, gender, BMI, or race. Overall all-cause mortality was 35.2% for the first wave compared to 14.7% for the second wave (p < 0.001). Previous medical conditions were similar between the two waves with the exception of underlying lung disease (41.9% vs. 29.5%, p = 0.047). Echocardiographic parameters were significantly more abnormal in the first wave compared to the second: LVGLS (- 17.1 ± 5.0 vs. - 18.9 ± 4.8, p = 0.02), RVGLS (- 15.7 ± 5.9% vs. - 19.0 ± 5.9%, p < 0.001), RVFWS (- 19.5 ± 6.8% vs. - 23.2 ± 6.9%, p = 0.001), and RVBD (4.5 ± 0.8 vs. 3.9 ± 0.7 cm, p < 0.001). Stepwise multivariable logistic analysis showed mechanical ventilation, RVFWS, and RVGLS to be independently associated with mortality. In a predominantly African American patient population on the south side of Chicago, the clinical and echocardiographic features of patients hospitalized with acute COVID-19 infection demonstrated marked improvement from the first to the second wave of the pandemic, with a significant decrease in all-cause mortality. Possible explanations include implementation of evidence-based therapies, changes in echocardiographic practices, and behavioral changes in our patient population. Mechanical ventilation and right-sided strain-based markers were independently associated with mortality.

Echocardiographic Correlates of In-Hospital Death in Patients with Acute COVID-19 Infection: The World Alliance Societies of Echocardiography (WASE-COVID) Study.

BACKGROUND: The novel severe acute respiratory syndrome coronavirus-2 virus, which has led to the global coronavirus disease-2019 (COVID-19) pandemic is known to adversely affect the cardiovascular system through multiple mechanisms. In this international, multicenter study conducted by the World Alliance Societies of Echocardiography, we aim to determine the clinical and echocardiographic phenotype of acute cardiac disease in COVID-19 patients, to explore phenotypic differences in different geographic regions across the world, and to identify parameters associated with in-hospital mortality. METHODS: We studied 870 patients with acute COVID-19 infection from 13 medical centers in four world regions (Asia, Europe, United States, Latin America) who had undergone transthoracic echocardiograms. Clinical and laboratory data were collected, including patient outcomes. Anonymized echocardiograms were analyzed with automated, machine learning-derived algorithms to calculate left ventricular (LV) volumes, ejection fraction, and LV longitudinal strain (LS). Right-sided echocardiographic parameters that were measured included right ventricular (RV) LS, RV free-wall strain (FWS), and RV basal diameter. Multivariate regression analysis was performed to identify clinical and echocardiographic parameters associated with in-hospital mortality. RESULTS: Significant regional differences were noted in terms of patient comorbidities, severity of illness, clinical biomarkers, and LV and RV echocardiographic metrics. Overall in-hospital mortality was 21.6%. Parameters associated with mortality in a multivariate analysis were age (odds ratio [OR] = 1.12 [1.05, 1.22], P = .003), previous lung disease (OR = 7.32 [1.56, 42.2], P = .015), LVLS (OR = 1.18 [1.05, 1.36], P = .012), lactic dehydrogenase (OR = 6.17 [1.74, 28.7], P = .009), and RVFWS (OR = 1.14 [1.04, 1.26], P = .007). CONCLUSIONS: Left ventricular dysfunction is noted in approximately 20% and RV dysfunction in approximately 30% of patients with acute COVID-19 illness and portend a poor prognosis. Age at presentation, previous lung disease, lactic dehydrogenase, LVLS, and RVFWS were independently associated with in-hospital mortality. Regional differences in cardiac phenotype highlight the significant differences in patient acuity as well as echocardiographic utilization in different parts of the world.

Improved Delineation of Cardiac Pathology Using a Novel Three-Dimensional Echocardiographic Tissue Transparency Tool.

BACKGROUND: Accurate visualization of cardiac valves and lesions by three-dimensional (3D) echocardiography is integral for optimal guidance of structural procedures and appropriate selection of closure devices. A new 3D rendering tool known as transillumination (TI), which integrates a virtual light source into the data set, was recently reported to effectively enhance depth perception and orifice definition. We hypothesized that adding the ability to adjust transparency to this tool would result in improved visualization and delineation of anatomy and pathology and improved localization of regurgitant jets compared with TI without transparency and standard 3D rendering. METHODS: We prospectively studied 30 patients with a spectrum of structural heart disease who underwent 3D transesophageal imaging (EPIQ system, Philips) with standard acquisition and TI with and without the transparency feature. Six experienced cardiologists and sonographers were shown randomized images of all three display types in a blinded fashion. Each image was scored independently by all experts using a Likert scale from 1 to 5, while assessing each of the following aspects: (1) ability to recognize anatomy, (2) ability to identify pathology, including regurgitant jet origin, (3) depth perception, and (4) quality of border delineation. RESULTS: TI images with transparency were successfully obtained in all cases. All experts perceived an incremental value of the transparency mode, compared with TI without transparency and standard 3D rendering, in terms of ability to recognize anatomy (respective scores: 4.5 ± 1.1 vs 4.1 ± 1.1 vs 3.6 ± 1.1, P < .05), ability to identify pathology (4.1 ± 1.1 vs 3.9 ± 1.2 vs 3.3 ± 1, P < .05), depth perception (4.6 ± 0.7 vs 4.1 ± 0.8 vs 3.2 ± 1.0, P < .05), and border delineation (4.6 ± 0.8 vs 4.1 ± 1.0 vs 3.1 ± 1.1, P < .05). CONCLUSIONS: The addition of the transparency mode to TI rendering significantly improves the diagnostic and clinical utility of 3D echocardiography and has the potential to markedly enhance echocardiographic guidance of cardiac structural interventions.

Identifying Phenogroups in patients with subclinical diastolic dysfunction using unsupervised statistical learning.

BACKGROUND: Subclinical diastolic dysfunction is a precursor for developing heart failure with preserved ejection fraction (HFpEF); yet not all patients progress to HFpEF. Our objective was to evaluate clinical and echocardiographic variables to identify patients who develop HFpEF. METHODS: Clinical, laboratory, and echocardiographic data were retrospectively collected for 81 patients without HF and 81 matched patients with HFpEF at the time of first documentation of subclinical diastolic dysfunction. Density-based clustering or hierarchical clustering to group patients was based on 65 total variables including 19 categorical and 46 numerical variables. Logistic regression analysis was conducted on the entire study population as well as each individual cluster to identify independent predictors of HFpEF. RESULTS: Unsupervised clustering identified 3 subgroups which differed in gender composition, severity of cardiac hypertrophy and aortic stenosis, NT-proBNP, percentage of patients who progressed to HFpEF, and timing of disease progression from diastolic dysfunction to HFpEF to death. Clusters that had higher percentages of women had progressively milder cardiac hypertrophy, less severe aortic stenosis, lower NT-proBNP, were diagnosed at an older age with HFpEF, and survived to an older age. Independent predictors of HFpEF for the entire cohort included diabetes, chronic kidney disease, atrial fibrillation, and diuretic use, with additional predictive variables found for each cluster. CONCLUSIONS: Cluster analysis can identify phenotypically distinct subgroups of patients with diastolic dysfunction. Clusters differ in HFpEF and mortality outcome. In addition, the variables that correlate with and predict HFpEF outcome differ among clusters.

Myocardial strain analysis of the right ventricle: comparison of different cardiovascular magnetic resonance and echocardiographic techniques.

BACKGROUND: Right ventricular (RV) strain is a useful predictor of prognosis in various cardiovascular diseases, including those traditionally believed to impact only the left ventricle. We aimed to determine inter-modality and inter-technique agreement in RV longitudinal strain (LS) measurements between currently available cardiovascular magnetic resonance (CMR) and echocardiographic techniques, as well as their reproducibility and the impact of layer-specific strain measurements. METHODS: RV-LS was determined in 62 patients using 2D speckle tracking echocardiography (STE, Epsilon) and two CMR techniques: feature tracking (FT) and strain-encoding (SENC), and in 17 healthy subjects using FT and SENC only. Measurements included global and free-wall LS (GLS, FWLS). Inter-technique agreement was assessed using linear regression and Bland-Altman analysis. Reproducibility was quantified using intraclass correlation (ICC) and coefficients of variation (CoV). RESULTS: We found similar moderate agreement between both CMR techniques and STE in patients: r = 0.57-0.63 for SENC; r = 0.50-0.62 for FT. The correlation between SENC and STE was better for GLS (r = 0.63) than for FWLS (r = 0.57). Conversely, the correlation between FT and STE was higher for FWLS (r = 0.60-0.62) than GLS (r = 0.50-0.54). FT-midmyocardial strain correlated better with SENC and STE than FT-subendocardial strain. The agreement between SENC and FT was fair (r = 0.36-0.41, bias: - 6.4 to - 10.4%) in the entire study group. All techniques except FT showed excellent reproducibility (ICC: 0.62-0.96, CoV: 0.04-0.30). CONCLUSIONS: We found only moderate inter-modality agreement with STE in RV-LS for both FT and SENC and poor agreement when comparing between the CMR techniques. Different modalities and techniques should not be used interchangeably to determine and monitor RV strain.

Stabbed Through The Heart: An Unusual VSD Presentation.

Traumatic ventricular septal defects due to penetrating cardiac injury are uncommon. Transthoracic echocardiography is an essential tool in diagnosis. Options for closure include either surgical or percutaneous repair. We present a case of a trauma-related ventricular septal defect in a young patient that was successfully repaired by using a percutaneous approach. (Level of difficulty: Intermediate.).

Echocardiographic evaluation of the effects of sacubitril-valsartan on vascular properties in heart failure patients.

Increased vascular stiffness is known to be an independent predictor of mortality in patients with heart failure with reduced ejection fraction (HFrEF). The effects of sacubitril-valsartan on vascular structure and function have not been systematically studied in this patient population. We hypothesized that aortic distensibility (AD) and fractional area change (AFAC), as assessed by 2D transthoracic echocardiography (TTE), would improve over time in HFrEF patients on sacubitril-valsartan therapy, due to the vasodilatory properties of the medication. We prospectively studied 30 patients with HFrEF (25 < EF < 40%) on optimal guideline-directed medical therapy who were subsequently started on sacubitril-valsartan. Patients underwent serial 2D TTE imaging at baseline, 3 and 6 months following therapy initiation. Ascending aortic diameters were measured 3 cm above the aortic valve in the parasternal long-axis view and used to calculate AD and AFAC, two markers of vascular compliance. For reference, we also measured AD and AFAC in 30 healthy, age and gender-matched controls at a single time point. Normal controls had significantly higher values of AD and AFAC than HFrEF patients at baseline (AD: 4.0 ± 1.1 vs. 2.2 ± 0.9 cm2dyne-110-3, p < 0.0001 and AFAC: 18.8 ± 3.7% vs. 10.3 ± 4.3%, p < 0.0001). In HFrEF patients on sacubitril-valsartan, both indices of aortic compliance progressively improved towards normal from baseline to 6 months: AD from 2.2 ± 0.9 to 3.6 ± 1.5 cm2dyne-110-3 (p < 0.0001) and AFAC from 10.3 ± 4.3 to 13.7 ± 4.1% (p < 0.0001). In conclusion, AD and AFAC are decreased in patients with HFrEF and gradually improve with sacubitril-valsartan treatment. The echocardiographic markers used in this study may become a useful tool to assess the effectiveness of sacubitril-valsartan therapy in HFrEF patients.

Contrast-enhanced echocardiographic measurement of longitudinal strain: accuracy and its relationship with image quality.

The importance of left ventricular (LV) global longitudinal strain (GLS) is increasingly recognized in multiple clinical scenarios. However, in patients with poor image quality, strain is difficult or impossible to measure without contrast enhancement. The feasibility of contrast-enhanced GLS measurement was recently demonstrated. We sought to determine: (1) whether contrast enhancement improves the accuracy of GLS measurements against cardiac magnetic resonance (CMR) reference, (2) their reproducibility compared to non-enhanced GLS, and (3) the dependence of accuracy and reproducibility on image quality. We prospectively enrolled 25 patients undergoing clinically indicated CMR imaging who subsequently underwent transthoracic echocardiography (TTE) with and without low-dose contrast injection (1-2 mL Optison/3-5 mL saline IV, GE Healthcare). GLS was measured from both non-contrast and contrast-enhanced images using speckle tracking (EchoInsight, Epsilon Imaging). These measurements were compared to each other and to CMR reference values obtained using feature tracking (SuiteHEART, NeoSoft). Inter-technique comparisons included linear regression and Bland-Altman analyses. A random subgroup of 15 patients was used to assess inter- and intra-observer variability using intra-class correlation (ICC). Contrast-enhanced GLS was in close agreement with non-enhanced GLS (r = 0.95; bias: - 0.2 ± 1.5%). Both inter-observer (ICC = 0.88 vs. 0.82) and intra-observer variability (ICC = 0.91 vs. 0.88) were improved by contrast enhancement. The agreement with CMR was better for contrast-enhanced GLS (r = 0.87; bias: 1.1 ± 2.2%) than for non-enhanced GLS (r = 0.80; bias: 1.3 ± 2.7%). In 12/25 patients with suboptimal TTE images that rendered GLS difficult to measure, contrast-enhanced GLS showed better agreement with CMR than non-enhanced GLS (r = 0.88 vs. 0.83) and also improved inter-observer (ICC = 0.83 vs. 0.76) and intra-observer variability (ICC = 0.88 vs. 0.82). In conclusion, contrast enhancement of TTE images improves the accuracy and reproducibility of GLS measurements, resulting in better agreement with CMR, even in patients with suboptimal acoustic windows. This approach may aid in the assessment of LV function in this patient population.

Asymmetric Calcification in Rheumatic Mitral Stenosis and Implications for Balloon Valvuloplasty.

A 50 year-old male with severe rheumatic mitral stenosis was deemed too high risk for surgery and referred for percutaneous balloon valvuloplasty. The valvuloplasty was successful in reducing the trans-mitral gradient and improving the patient's symptoms, however was complicated by a tear in the posteromedial commissure and moderate mitral regurgitation.

Aortic stiffening precedes onset of heart failure with preserved ejection fraction in patients with asymptomatic diastolic dysfunction.

BACKGROUND: Identifying which patients with diastolic dysfunction will progress to heart failure with preserved ejection fraction (HFpEF) remains challenging. The goal of this study is to determine whether increased vascular stiffness as identified on 2D transthoracic echocardiography (TTE) serves as a biomarker for the development of HFpEF in patients with diastolic dysfunction. METHODS: The study design is a matched retrospective case-control study. Subjects with diastolic dysfunction were divided into two groups based on whether they had a clinical diagnosis of HFpEF. The two groups were matched based on age, gender, race and body surface area, resulting in 77 matched pairs (n = 154). Data from the first TTE that documented diastolic dysfunction prior to the development of HFpEF was extracted along with baseline demographic and clinical data. Indices of vascular stiffness were measured and compared. A sub-group analysis was performed to compare diabetic subjects in Group 1 (n = 43) to those in Group 2 (n = 21). RESULTS: Group 1 had significantly decreased aortic distensibility as measured on the initial TTE when compared to Group 2 (1.9 ± 1.0 vs. 2.8 ± 1.8 cm2dyne-110-3, p = 0.01). In the diabetic subset, Group 1 had significantly less aortic strain (6.9 ± 3.3 vs. 9.7 ± 5.6%, p = 0.02) and aortic distensibility (1.8 ± 1.0 vs. 3.5 ± 2.6 cm2dyne-110-3, p = 0.02) compared to Group 2. Other indices of vascular stiffness did not differ significantly between groups. CONCLUSIONS: This study demonstrates that increased proximal aortic stiffness is associated with the development of HFpEF in patients with asymptomatic diastolic dysfunction. Larger prospective studies are needed to further investigate this relationship.