Detecting aortic valve bicuspidy in patients with severe aortic valve stenosis: high diagnostic accuracy of colour Doppler transoesophageal echocardiography.

OBJECTIVES: The diagnostic accuracy of multiplane bi-dimensional transoesophageal echocardiography (TEE) in detecting aortic valve bicuspidy is good, but is less reliable when the leaflets are moderately or severely calcified. We hypothesized that systolic colour Doppler analysis might improve the accuracy of diagnosing aortic bicuspidy by TEE in patients with severe symptomatic aortic stenosis (AS). METHODS: Two colour Doppler images of a stenotic aortic valve were defined in a preliminary study using multiplane TEE. In type I, the valve opening had a linear, angular or 'hanger-like' configuration and in type II it was more star-like or 'stellar'. The accuracy of this classification in detecting bicuspidy was evaluated. Fifty-one patients (mean age 71 years (range 40-90 years); 52% male) with severe symptomatic AS (defined as aortic valve area ≤1 cm(2)), requiring surgical aortic valve replacement, were included in this prospective study. The surgical findings were compared with the echocardiographic data. RESULTS: The incidence of aortic bicuspidy was 43%. The presence of type I colour Doppler configuration was significantly higher for bicuspid than for tricuspid aortic valves (95.5 vs 3.5%, respectively; P < 0.001). Diagnostic accuracy in detecting bicuspidy was high (sensitivity 95.5%; specificity 96.5%; positive predictive value 95.5%). Intra- and inter-observer agreements were excellent (Kappa coefficient = 0.88 and 0.92, respectively). CONCLUSIONS: Aortic valve bicuspidy may be accurately diagnosed by colour Doppler valve analysis during TEE in patients with severe AS. Larger prospective studies are required to confirm our results.

Functional decline in elderly patients presenting with acute coronary syndromes: impact on midterm outcome.

BACKGROUND: Elderly patients with an acute coronary syndrome (ACS) are less likely to be enrolled into randomized, controlled trials or receive guideline-recommended therapies, because of a higher burden of comorbidity, including functional decline. AIM: To assess the prognostic value of functional decline in a prospective, observational cohort of elderly ACS patients. METHODS: ACS patients aged > or = 70 years were enrolled. The ACS definition included ST- and non-ST-segment elevation myocardial infarction, and unstable angina pectoris. Clinical admission and laboratory data and echocardiographic variables were recorded. Functional decline was defined as needing assisted care in daily life. The study endpoint was all-cause mortality. RESULTS: Overall, 151 patients were enrolled (mean age 78 + or - 5 years; 52% men). Twenty-eight (19%) patients had functional decline. No significant difference in therapeutic management was observed between patients with functional decline and those living independently. Twenty-seven (18%) patients died during follow-up (median 447 days). Functional decline correlated with poor outcome (p = 0.008; hazard ratio [HR] 2.87 [1.31-6.25]). Other prognostic markers were diabetes, Killip class > or = II, elevated E/Ea ratio, C-reactive protein, B-type natriuretic peptide, haemoglobin, glycaemia and no coronary angiography. By multivariable analysis, C-reactive protein >13 mg/L correlated with poor outcome (p = 0.007; HR 4.77 [1.52-14.96]). There was a trend towards correlation between functional decline and poor outcome (p = 0.051; HR = 2.77 [0.99-7.72]). CONCLUSION: Functional decline seems to portend poor prognosis in elderly ACS patients. Larger, community-based studies are needed to confirm these findings in a multivariable model.

Exercise does not enhance the prognostic value of Doppler echocardiography in patients with left ventricular systolic dysfunction and functional mitral regurgitation at rest.

BACKGROUND: Functional mitral regurgitation (MR) is a powerful predictor of poor prognosis in patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD). However, severity of MR varies with dynamic exercise. Accordingly, we sought to assess the prognostic value of exercise-induced changes in functional MR in patients with LVSD and functional MR at rest. METHODS: One hundred four patients with chronic heart failure due to LVSD (ejection fraction [EF] < 45%) and functional MR at rest underwent conventional continuous 2-dimensional Doppler echocardiography at rest and during maximal symptom-limited exercise. The primary end point of the study was all-cause mortality. The median follow-up period was 20 months. RESULTS: Fifty-six patients (54%) had ischemic cardiomyopathy. When feasible, all 56 patients with ischemic cardiomyopathy had undergone revascularization procedures before enrollment into the study. In the whole patient cohort, resting LV end-diastolic volume was 205 +/- 76 mL and EF was 26% +/- 9%. Univariate predictors of death were functional class (New York Heart Association), LV EF, LV end-diastolic volume, resting mitral effective regurgitant orifice, mitral E deceleration time, tricuspid annular plane systolic excursion < or = 14 mm, systolic blood pressure, LV EF, and trans-tricuspid pressure gradient response to exercise. Exercise-induced change in mitral effective regurgitant orifice did not predict survival (HR 0.99, 95% CI 0.94-1.04, P = .63). By Cox multivariate analysis, resting LV end-diastolic volume and tricuspid annular plane systolic excursion < or = 14 mm were the independent predictors of death. CONCLUSIONS: Exercise Doppler echocardiography does not refine the predictive value of resting Doppler echocardiography in patients with LVSD and functional MR at rest.

Cardiac correlates of exercise induced pulmonary hypertension in patients with chronic heart failure due to left ventricular systolic dysfunction.

BACKGROUND: Patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD) may develop pulmonary hypertension at rest and during exercise. The cardiac correlates of pulmonary hypertension have been ascertained in the resting state, but seldom during exercise in these patients. AIMS: We sought to determine the cardiac correlates of exercise induced pulmonary hypertension in patients with LVSD by monitoring the estimated pulmonary artery systolic pressure (PASP) by continuous Doppler echocardiography during semirecumbent bicycle exercise. METHODS: Eighty-five patients (mean age 57 +/- 13 years, 75% male) with CHF due to LVSD (LV ejection fraction [EF] <45%, mean LVEF 26 +/- 8%) were studied. RESULTS: Mitral effective regurgitant orifice area and E-wave were independent predictors of resting PASP. Resting PASP and exercise induced changes in PASP were unrelated (r =-0.08, P = 0.45). Decrease in LV end-systolic volume, increase in left atrial (LA) area, resting LV asynchrony, and decreased tricuspid annular plane systolic excursion (TAPSE) were independent predictors of exercise PASP. CONCLUSIONS: Resting LV asynchrony, impaired LV contractile reserve, and increase in LA dilatation correlate with the severity of exercise induced pulmonary hypertension in patients with CHF due to LVSD, while right ventricular systolic dysfunction is inversely related to the severity of exercise induced pulmonary hypertension.