Vericiguat and transcatheter edge-to-edge mitral valve repair for combined post- and pre-capillary pulmonary hypertension due to left ventricular low ejection fraction and functional mitral regurgitation.

A 66-year-old female was diagnosed with combined post- and pre-capillary pulmonary hypertension due to heart failure with reduced ejection fraction (47 %) and functional mitral regurgitation [mean pulmonary arterial wedge pressure: 27 mmHg; pulmonary arterial pressure: 91/30 (56) mmHg; pulmonary vascular resistance: 12.9 Wood units; and cardiac index: 1.77 L/min/m2]. Following treatment with vericiguat (a novel oral soluble guanylate cyclase stimulator), hemodynamics improved [mean pulmonary arterial wedge pressure: 27 mmHg; pulmonary arterial pressure: 54/26 (35) mmHg; pulmonary vascular resistance: 2.2 Wood units; and cardiac index: 2.80 L/min/m2]. Therefore, transcatheter edge-to-edge repair for functional mitral regurgitation was performed. One month later, further improvement in hemodynamics was confirmed. Learning objective: Vericiguat (a novel oral soluble guanylate cyclase stimulator) and transcatheter edge-to-edge mitral valve repair may improve combined post- and pre-capillary pulmonary hypertension due to low ejection fraction of the left ventricle and functional mitral regurgitation.

Feasibility and Outcome of Transjugular Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement.

Background: There are limited data on the impact of intracardiac echocardiography (ICE)-guided transcatheter aortic valve replacement (TAVR) on the new permanent pacemaker implantation (PPMI) rate. Objectives: This study investigated the feasibility and outcome of transjugular ICE (TJ-ICE) -guided TAVR, by visualizing the relationship between the membranous septum (MS) and the transcatheter aortic valve (TAV). Methods: Among patients with severe aortic stenosis who underwent TAVR between February 2017 and June 2020, this study enrolled a total of 163 patients with TJ-ICE-guided TAVR. MS length was measured by ICE. The primary endpoint of this study was the incidence of new PPMI at 30 days. Results: The mean age of the patients in this study was 84.9 ± 4.6 years, and 71.2% of the patients were female. Device success was 96.3% with TJ-ICE guidance. A TJ-ICE-related complication occurred in 1 case (0.6%). The median length of the MS was 5.8 mm (IQR: 5.0-6.9 mm). Excellent intraobserver (intraclass correlation coefficient [ICC]: 0.94; 95% CI:0.79-0.98; P < 0.001) and interobserver (ICC: 0.93; 95% CI: -0.05 to 0.98; P < 0.001) agreements were shown. The new PPMI rate was 6.7% at 30 days without a significant difference between balloon-expandable valves and self-expandable valves (3.4% vs 8.7%; P = 0.226). Patients with a TAV implantation depth less than MS length had a significantly lower incidence of new PPMI compared with patients with a TAV implantation depth greater than MS length (2.1% vs 13.4%; P = 0.005), regardless of baseline right bundle branch block presence (6.7% vs 66.7%; P = 0.004) or absence (1.2% vs 8.2%; P = 0.041). Conclusions: TJ-ICE-guided TAVR demonstrated remarkable feasibility and safety. The TJ-ICE-guided final TAV position had a significant impact on the new PPMI rate. (Tokai Valve Registry; UMIN000036671).

Incremental Value of Global Longitudinal Strain for Confirming Heart Failure-Related Symptoms in Severe Aortic Stenosis.

The indications or timing of aortic valve replacement for symptomatic aortic stenosis (AS) are based on a patient's life expectancy and symptoms. However, clinical decision-making may be difficult because symptoms are subjective and cannot be quantitatively assessed and confirmed. This study aimed to evaluate the association between heart failure (HF)-related symptoms and cardiac hemodynamic left ventricular deformations in patients with severe AS using transthoracic echocardiographic assessments of left ventricular global longitudinal strain (LV-GLS). The medical records of patients hospitalized for AS between February 2017 and September 2019 were retrospectively screened. Independent cardiologists analyzed the transthoracic echocardiographic images of a digital echocardiography database. The cohort comprised 177 hospitalized patients with severe AS and no history of HF. The subgroup with HF-related symptoms included 87 patients, whereas that without HF-related symptoms included 90 patients. In 145 patients without atrial fibrillation, the left atrial volume index (LAVI) and LV-GLS were significantly associated with HF-related symptoms (odds ratio 1.033, 95% confidence interval 1.008 to 1.059, p = 0.011 and odds ratio 1.224, 95% confidence interval 1.118 to 1.340, p <0.0001, respectively). Moreover, the combination of brain natriuretic peptide level, LAVI, and LV-GLS showed better diagnostic accuracy than the combination of brain natriuretic peptide level and LAVI (p = 0.005). However, there were no such tendencies in 32 patients with atrial fibrillation. The HF-related symptoms in patients with severe AS were strongly linked to LV-GLS. LV-GLS showed incremental value for confirming HF-related symptoms.

Mechanisms and implications of mitral regurgitation in patients with severe aortic stenosis who received transcatheter aortic valve replacement.

INTRODUCTION: This study aimed to investigate the mechanisms and clinical implications of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) who received transcatheter aortic valve replacement (TAVR). METHODS: We conducted retrospective echocardiographic analyses at baseline and 6 months after TAVR in 140 patients with symptomatic AS (85 ± 5 years) who underwent TAVR. We defined significant MR as ≥ moderate based on evaluation of transthoracic echocardiography (TTE). RESULTS: There were 48 patients (34%) with preexisting MR at the baseline. Among measured TTE parameters, end-systolic wall stress (ESWS), mitral annulus area, and mitral valve thickening index were independent factors associated with preexisting MR (odds ratio [OR]: 1.013, 95% confidence interval [CI]: 1.005-1.021; OR: 1.740, 95% CI: 1.314-2.376; OR: 2.306, 95% CI: 1.426-3.848; respectively). Six months after TAVR, there were 34 patients with post-existing MR, A history of atrial fibrillation and ESWS after TAVR were independent factors (OR: 3.013, 95% CI: 1.208-7.556; OR: 1.013, 95% CI: 1.000-1.023; respectively). The Kaplan-Meier plot indicated that preexisting MR was a risk factor for heart failure-related events within 1 year of discharge after TAVR (p = .012). CONCLUSIONS: In patients who underwent TAVR for severe AS, preexisting MR was associated with having a thickened mitral valve and large mitral annulus size induced by high ESWS. These patients may have worse prognosis after TAVR and should be closely monitored in the long term.

Echocardiographic score for the screening of cardiac amyloidosis with positive 99m technetium pyrophosphate scintigraphy result.

INTRODUCTION: Speckle-tracking-derived strains in cardiac chambers may provide better solutions for transthyretin amyloid cardiomyopathy (ATTR-CM) screening. This study aimed to evaluate the efficacy of biventricular strain measurements using speckle tracking for screening 99m Tc-pyrophosphate (99m Tc-PYP) scintigraphy-positive cardiomyopathy, which is nearly equivalent to ATTR-CM. METHODS: We performed a retrospective analysis of transthoracic echocardiographic studies using vendor-independent speckle tracking analysis in older patients (≥65 years) who underwent 99m Tc-PYP scintigraphy to evaluate the etiology of suspected ATTR-CM in our institute between January 2019 and December 2022. RESULTS: The entire cohort (n = 89) was divided into two subgroups positive 99m Tc-PYP scan results (n = 34) and negative 99m Tc-PYP scan results (n = 55). In the multivariate analysis, posterior wall thickness (p = .003, odds ratio [OR]:1.48, 95% confidence interval [CI]:1.14 -1.92), left ventricular longitudinal strain apical/basal ratio (LVLSapi/bas) (p = .015, OR: 2.78, 95% CI: 1.23-6.32, and right ventricular longitudinal strain (RVLS) (p = .003, OR: 1.15, 95% CI: 1.05 -1.26) were selected to be the most representative echocardiographic findings in 99m Tc-PYP positive cardiomyopathy. The receiver operating characteristic analysis indicated that posterior wall thickness (p < .0001, area under the curve [AUC]: .821, cut-off value: 14.0 mm), LVLSapi/bas (p < .001, AUC: .802, cut-off value: 2,16), and RVLS (p < .001, AUC: .791, cut-off value: -18.7%) could significantly detect 99m Tc-PYP positive results with an excellent credibility. Echocardiographic score points calculated using the summary of these three parameters in each patient revealed that a 2-point score had a fair sensitivity (85%) and an excellent specificity (93%), while a 1-point score had an excellent sensitivity (91%) and a modest specificity (53%). CONCLUSION: Our proposed echocardiographic screening tool for 99m Tc-PYP scintigraphy-positive cardiomyopathy may help clinicians manage patients with suspected ATTR-CM.

Right ventricular free wall longitudinal strain assessment using offline speckle tracking in COVID-19 patients requiring intensive medical care.

PURPOSE: The purpose of this study was to evaluate and confirm the prognostic utility of comprehensive transthoracic echocardiography (TTE) using offline myocardial strain analyses in a Japanese coronavirus disease (COVID-19) cohort hospitalized in intensive care units. METHODS: We performed a retrospective analysis of 90 consecutive adult patients with COVID-19 who underwent clinically indicated standard two-dimensional TTE in intensive care wards. Patients on extracorporeal membrane oxygenation (ECMO) at the time of TTE were excluded. Biventricular strain assessments using vendor-independent offline speckle tracking analysis were performed. Patients with inadequate TTE image quality were also excluded. RESULTS: Among the 90 COVID-19 patients, 15 (17%) patients required venovenous or venoarterial ECMO. There were 25 (28%) in-hospital deaths. A composite event, defined as the combination of in-hospital mortality and subsequent initiation of ECMO, occurred in 32 patients. Multivariate logistic regression for composite events indicated that right ventricular free wall longitudinal strain (RV-FWLS) and mechanical ventilation at the time of TTE were independent risk factors for composite events (p = 0.01, odds ratio [OR] 1.09, 95% confidence interval [CI] 1.01-1.18; p = 0.04, OR 3.24, 95% CI 1.03-10.20). Cumulative survival probability plots generated using the Kaplan-Meier method for composite events with log-rank tests revealed a significant difference between subgroups divided by the cutoff value of RV-FWLS (p < 0.001). CONCLUSION: Offline measurement of RV-FWLS may be a potent predictor of worse outcomes in COVID-19 requiring intensive care. Larger multicenter prospective studies are needed.

Short-term Outcomes of Urgent Transcatheter Aortic Valve Replacement in Symptomatic Aortic Stenosis That Requires Emergency Hospital Admission.

Objective This study retrospectively compared the outcomes of emergently admitted patients with aortic stenosis (AS) with or without urgent transcatheter aortic valve replacement (TAVR). Methods Patients hospitalized between February 2015 and December 2019 for symptomatic AS were retrospectively analyzed by comparing the received conservative management [continued medical therapy with or without elective surgical transcatheter replacement (SAVR) or TAVR scheduled after the index hospitalization] and urgent TAVR (TAVR during the index hospitalization). Results The cohort comprised 114 patients with symptomatic AS who required emergency admission. Urgent TAVR was performed for 37 patients, while conservative management was provided for 77 patients, including 1 who received urgent SAVR. Urgent TAVR was more likely to be performed in patients with a history of hospitalization for heart failure, high New York Heart Association class scores, a lower clinical frailty scale at admission, and a high aortic valve peak velocity (p=0.01, p<0.001, p<0.01 and p=0.02, respectively). Kaplan-Meier analyses with log-rank test revealed favorable outcomes of urgent TAVR in all-cause mortality and cardiovascular events within 60 days of admission (p<0.01, p<0.01, respectively). Conclusion Urgent TAVR had better short-term outcomes in patients with symptomatic AS who required emergency hospital admission than conservative management. When considering urgent TAVR, patients with typical heart failure symptoms due to AS with a history of heart failure hospitalization and relatively little frailty can be selected.

Value of standard echocardiography at the bedside for COVID-19 patients in intensive care units: a Japanese single-center analysis.

PURPOSE: In the era of COVID-19, those special settings or indications for which standard transthoracic echocardiography (TTE) can safely produce benefits or advantages over minimized ultrasound imaging procedures need to be identified. Thus, the purpose of this study was to conduct a retrospective analysis with offline comprehensive conventional measurement of bilateral heart function and develop an appropriate prognostic model for in-hospital death. METHODS: We performed a retrospective analysis of 37 consecutive patients with COVID-19, confirmed by real-time reverse-transcriptase polymerase chain reaction assay, who had undergone clinically indicated standard two-dimensional echocardiographic studies in intensive care wards. Offline comprehensive measurement was also performed. We further integrated the echocardiographic findings as paired evidence of vital organ involvement (possible respiratory distress assessed using right ventricular functional parameters, possible myocardial injury assessed using increased wall thickness, effusion or asynergy) and circulatory failure (suspected low flow status assessed using stroke volume index, suspected congestion assessed using elevated right or left atrial pressure). We evaluated its value for in-hospital death along with other echocardiographic findings. RESULTS: The most common features included a normal-sized left atrium and left ventricle with preserved left ventricular ejection fraction, despite deteriorated left ventricular flow volume. Less frequent findings, such as abnormalities in the right heart and left ventricular abnormalities suggesting myocarditis, were observed. Although the single echocardiographic parameters failed to show predictive values for in-hospital death, integration of the echocardiographic findings suggested predictive value (p = 0.04, odds ratio: 12.28). CONCLUSION: Standard TTE at the bedside with offline comprehensive conventional measurement may provide prognostic information that is valuable for the management of patients with COVID-19.

Late-onset atrioventricular block after transcatheter aortic valve replacement.

BACKGROUND: Conduction disturbances leading to permanent pacemaker implantation (PPI) rarely occur late after transcatheter aortic valve replacement (TAVR). The clinical features of this phenomenon and its association with periprocedural conduction disturbances remain uncertain. OBJECTIVES: We aimed to determine the incidence and characteristics of late-onset atrioventricular block (AVB) after TAVR. METHODS: This single-center study included 246 patients undergoing TAVR. Late-onset AVB was defined as AVB ≥1 month after the TAVR. RESULTS: Periprocedural AVB (periAVB) occurred in 43 patients (17%). Patients with periAVB had a higher rate of right bundle branch block (47% vs 7%, P < .0001). Of the 43 patients with periAVB, 15 underwent PPI (35%) at a median duration of 6 days, whereas 1 of the remaining 203 patients without periAVB underwent PPI within 1 month (0.5%). During a median follow-up duration of 365 days, late-onset AVB occurred in 10 of 230 patients without PPI within 1 month (4%) at a median duration of 76 days. All 10 patients presented transient periprocedural atrioventricular conduction disturbances, including 8 patients with periAVB (80%), all of whom recovered within 1 month, and 9 patients underwent self-expanding valve implantation (90%). The mortality rate in patients with PPI within 1 month was higher than in those without, although the difference was not statistically significant (hazard ratio 2.68, 95% confidence interval 0.97-9.05, log-rank P = .09). CONCLUSION: Late-onset AVB occurred in a minority of patients undergoing TAVR. Greater vigilance is warranted, particularly in patients with transient conduction disturbances during the periprocedural period following self-expanding valve implantation.

Predictors for non-delayed discharge after transcatheter aortic valve replacement: utility of echocardiographic parameters.

Considering that transcatheter aortic valve replacement (TAVR) procedures have become less invasive, the duration for monitoring patient care after a successful TAVR can be reduced. Therefore, this study aimed to investigate the prognostic value of baseline echocardiographic parameters for non-delayed discharge in patients after TAVR. The study group included 154 consecutive patients (mean age: 84.4 ± 4.5 years; and 101 women) who underwent a TAVR. Comprehensive echocardiograms including both side indices of myocardial performance (IMP) and blood tests were obtained prior to the TAVR procedure. The median post-TAVR length of stay was 6 days while the mode and first quartile were both 4 days. Receiver operating characteristic curve analysis showed that the optimum cut-off value of the left-sided IMP in patients with a normal left ventricular ejection fraction (LVEF, ≥ 50%) (n = 124) for non-delayed discharge (≤ 4 days) was 0.34 with an area under the curve (AUC) value of 0.71563 and p value of < 0.0001, while the optimum cut-off value in patients with reduced LVEF (< 50%) (n = 30) was 0.47 with an AUC value of 0.77778 and p value of < 0.0120. An adjusted analysis indicated the negative left-sided IMP results as the only predictor for non-delayed discharge (p < 0.0001). Furthermore, the adjusted predictors for survival without early cardiovascular re-hospitalization within 6 months after TAVR were the positive left-sided IMP result, when the cut-off value of 0.52 was used, and the presence of elevated RAP of 8 to 15 mmHg. The early discharge policy should be carefully considered in high-risk populations, but the left-sided IMP may play a significant role in the pre-screening process.

Optimizing self-expandable transcatheter heart valve sizing in patients with small sinus of Valsalva.

OBJECTIVES: To evaluate the feasibility and efficacy of transcatheter aortic valve replacement (TAVR) in patients with small sinus of Valsalva (SOV). BACKGROUND: Patients with small SOV are considered unfavorable for TAVR since it carries risk of coronary obstruction after valve implantation. Therefore, these patients with small SOV were excluded from previous clinical trials. METHODS: Between February 2017 and February 2019, a total of 139 consecutive patients with severe aortic stenosis (AS) undergoing TAVR were prospectively enrolled in the Tokai Valve Registry. Patients with small SOV who were treated with smaller size of self-expandable transcatheter heart valve (THV) than expected by perimeter-based sizing were included in this study. Eleven patients (7.9%) were included. RESULTS: Mean age was 86.5 ± 3.8 years and median STS Score was 8.5% (interquartile range: 6.3-12.3%). Device success was accomplished in all patients and no coronary obstruction was observed. No moderate/severe paravalvular leakage, new onset conduction disturbance, and new permanent pacemaker implantation were noted. At 30-day follow-up, mean aortic valve gradient was 6.9 ± 1.7 mmHg and mean indexed aortic valve area was 0.95 ± 0.16 cm2 /m2 . Prosthetic valve performance was stable at 12-month follow-up. No severe prosthesis patient mismatch was documented at any time point. No in-hospital, 30-day, and 12-month mortality were observed. The median follow-up was 711 days (IQR: 547-803 days), and no patient was lost to follow-up. CONCLUSIONS: Our preliminary experience suggests favorable safety and efficacy of TAVR utilizing self-expandable THV with intentional down-sizing in patients with severe AS and small SOV in a mid-term follow-up.

Cardiac sarcoidosis mimicking left ventricular noncompaction: An approach to acquired apical hypertrabeculation.

A 65-year-old asymptomatic woman, who had been pathologically diagnosed with pulmonary sarcoidosis, was admitted for further evaluation of possible cardiac involvement. Her echocardiography demonstrated the development of apical hypertrabeculation that was not observed 5 years previously. Cardiac magnetic resonance imaging revealed late gadolinium enhancement in the same region. Gallium single photon-missioned computed tomography/computed tomography revealed high uptake. Therefore, the diagnosis of active cardiac sarcoidosis was established, and subsequent treatment with corticosteroid was initiated. No study regarding acquired left ventricular hypertrabeculation associated with cardiac sarcoidosis has been reported. The integrated multi-imaging modality approach helped in earlier recognition of cardiac sarcoidosis.

Transcatheter closure of atrial septal defect protects from pulmonary edema: septal occluder device gradually reduces LR shunt.

A 56-year-old woman was diagnosed as atrial septal defect (ASD) with pulmonary hypertension; pulmonary blood flow/systemic blood flow (Qp/Qs) of 2.3, pulmonary artery pressure (PAP) of 71/23(39) mmHg and diastolic dysfunction of left ventricle. PAP was improved after medical therapy; therefore, transcatheter ASD closure was performed. Seven days later, left-sided heart failure occurred, however, the improvement of Qp/Qs (1.7) and PAP of 51/21(32) was confirmed. Diuretic therapy was introduced which led to further decrease of PAP 40/12(25) and Qp/Qs (1.1). Because of gradual decrease of Qp/Qs, this patient appeared to be protected from acute pulmonary edema.