Left ventricular outflow tract velocity-time integral improves outcome prediction in patients with secondary mitral regurgitation.

AIMS: Left ventricular outflow velocity-time integral (LVOT-VTI) has been shown to improve outcome prediction in different patients' subsets, with or without heart failure (HF). Nevertheless, the prognostic value of LVOT-VTI in patients with HF and secondary mitral regurgitation (MR) has never been investigated so far. Therefore, in the present study, we aimed to assess the prognostic value different metrics of LV forward output, including LVOT-VTI, in HF patients with secondary MR. METHODS AND RESULTS: Consecutive patients with HF and moderate-to-severe/severe secondary MR and systolic dysfunction (i.e., left ventricular ejection fraction [LVEF] <50%) were retrospectively selected and followed-up for the primary endpoint of cardiac death. Out of the 287 patients analyzed (aged 74 ± 11 years, 70% men, 46% ischemic etiology, mean LVEF 30 ± 9%, mean LVOT-VTI 20 ± 5 cm), 71 met the primary endpoint over a 33-month median follow-up (16-47 months). Patients with an LVOT-VTI ≤17 cm (n = 96, 32%) showed the greatest risk of cardiac death (Log Rank 44.3, p < 0.001) and all-cause mortality (Log rank 8.6, p = 0.003). At multivariable regression analysis, all the measures of LV forward volume (namely LVOT-VTI, stroke volume index, cardiac output, and cardiac index) were predictors of poor outcomes. Among these, LVOT-VTI was the most accurate in risk prediction (univariable C-statistics 0.70 [95%CI 0.64-0.77]). CONCLUSION: Left ventricular forward output, noninvasively estimated through LVOT-VTI, improves outcome prediction in HF patients with low LVEF and secondary MR.

Valve disease in cardiac amyloidosis: an echocardiographic score.

Cardiac amyloidosis (CA) may affect all cardiac structures, including the valves. From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR-) or light-chain (AL-) CA, and age- and sex-matched controls. We chose 31 echocardiographic items related to the mitral, aortic and tricuspid valves, giving a value of 1 to each abnormal item. Patients with ATTR-CA displayed more often a shortened/hidden and restricted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL-CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (13.6-17.4) in ATTR-CA, 11.0 (9.3-14.9) in AL-CA, 12.8 (11.1-14.4) in ATTR-CA controls, and 11.0 (9.1-13.0) in AL-CA controls (p = 0.004 for ATTR- vs. AL-CA, 0.009 for ATTR-CA vs. their controls, and 0.461 for AL-CA vs. controls). Area under the curve values to diagnose ATTR-CA were 0.782 in patients with ATTR-CA or matched controls, and 0.773 in patients with LV hypertrophy. Patients with ATTR-CA have a prominent impairment of mitral valve structure and function, and higher score values. The valve score may help identify patients with ATTR-CA among patients with CA or unexplained hypertrophy.

Multi-chamber speckle tracking imaging and diagnostic value of left atrial strain in cardiac amyloidosis.

AIMS: Cardiac amyloidosis (CA) affects the four heart chambers, which can all be evaluated through speckle-tracking echocardiography (STE). METHODS AND RESULTS: We evaluated 423 consecutive patients screened for CA over 5 years at two referral centres. CA was diagnosed in 261 patients (62%) with either amyloid transthyretin (ATTR; n = 144, 34%) or amyloid light-chain (AL; n = 117, 28%) CA. Strain parameters of all chambers were altered in CA patients, particularly those with ATTR-CA. Nonetheless, only peak left atrial longitudinal strain (LA-PALS) displayed an independent association with the diagnosis of CA or ATTR-CA beyond standard echocardiographic variables and cardiac biomarkers (Model 1), or with the diagnosis of ATTR-CA beyond the validated IWT score in patients with unexplained left ventricular (LV) hypertrophy. Patients with the most severe impairment of LA strain were those most likely to have CA or ATTR-CA. Specifically, LA-PALS and/or LA-peak atrial contraction strain (PACS) in the first quartile (i.e. LA-PALS <6.65% and/or LA-PACS <3.62%) had a 3.60-fold higher risk of CA, and a 3.68-fold higher risk of ATTR-CA beyond Model 1. Among patients with unexplained LV hypertrophy, those with LA-PALS or LA-PACS in the first quartile had an 8.76-fold higher risk for CA beyond Model 1, and a 2.04-fold higher risk of ATTR-CA beyond the IWT score. CONCLUSIONS: Among STE measures of the four chambers, PALS and PACS are the most informative ones to diagnose CA and ATTR-CA. Patients screened for CA and having LA-PALS and/or LA-PACS in the first quartile have a high likelihood of CA and ATTR-CA.

Prognostic value of lung ultrasound in patients hospitalized for heart disease irrespective of symptoms and ejection fraction.

AIMS: Lung ultrasound B-lines are the sonographic sign of pulmonary congestion and can be used in the differential diagnosis of dyspnoea to rule in or rule out acute heart failure (AHF). Our aim was to assess the prognostic value of B-lines, integrated with echocardiography, in patients admitted to a cardiology department, independently of the initial clinical presentation, thus in patients with and without AHF, and in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF). METHODS AND RESULTS: We enrolled consecutive patients admitted for various cardiac conditions. Patients were classified into three groups: (i) acute HFrEF; (ii) acute HFpEF; and (iii) non-AHF. All patients underwent an echocardiogram coupled with lung ultrasound at admission, according to standardized protocols. We followed up 1021 consecutive inpatients (69 ± 12 years) for a median of 14.4 months (interquartile range 4.6-24.3) for death and rehospitalization for AHF. During the follow-up, 126 events occurred. Admission B-lines > 30, ejection fraction < 50%, tricuspid regurgitation velocity > 2.8 m/s, and tricuspid annular plane systolic excursion < 17 mm were independent predictors at multivariable analysis. B-lines > 30 had a strong predictive value in HFpEF and non-AHF, but not in HFrEF. CONCLUSIONS: Ultrasound B-lines can detect subclinical pulmonary interstitial oedema in patients thought to be free of congestion and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is more robust in patients with HFpEF compared with HFrEF.

Prognostic value of reverse remodelling criteria in heart failure with reduced or mid-range ejection fraction.

AIMS: Reverse remodelling (RR) is the recovery from left ventricular (LV) dilatation and dysfunction. Many arbitrary criteria for RR have been proposed. We searched the criteria with the strongest prognostic yield for the hard endpoint of cardiovascular death. METHODS AND RESULTS: We performed a systematic literature search of diagnostic criteria for RR. We evaluated their prognostic significance in a cohort of 927 patients with LV ejection fraction (LVEF) < 50% undergoing two echocardiograms within 12 ± 2 months. These patients were followed for a median of 2.8 years (interquartile interval 1.3-4.9) after the second echocardiogram, recording 123 cardiovascular deaths. Two prognostic models were defined. Model 1 included age, LVEF, N-terminal pro-B-type natriuretic peptide, ischaemic aetiology, cardiac resynchronization therapy, estimated glomerular filtration rate, New York Heart Association, and LV end-systolic volume (LVESV) index, and Model 2 the validated Cardiac and Comorbid Conditions Heart Failure score. We identified 25 criteria for RR, the most used being LVESV reduction ≥15% (12 studies out of 42). In the whole cohort, two criteria proved particularly effective in risk reclassification over Model 1 and Model 2. These criteria were (i) LVEF increase >10 U and (ii) LVEF increase ≥1 category [severe (LVEF ≤ 30%), moderate (LVEF 31-40%), mild LV dysfunction (LVEF 41-55%), and normal LV function (LVEF ≥ 56%)]. The same two criteria yielded independent prognostic significance and improved risk reclassification even in patients with more severe systolic dysfunction, namely, those with LVEF < 40% or LVEF ≤ 35%. Furthermore, LVEF increase >10 U and LVEF increase ≥1 category displayed a greater prognostic value than LVESV reduction ≥15%, both in the whole cohort and in the subgroups with LVEF < 40% or LVEF ≤ 35%. For example, LVEF increase >10 U independently predicted cardiovascular death over Model 1 and LVESV reduction ≥15% (hazard ratio 0.40, 95% confidence interval 0.18-0.90, P = 0.026), while LVESV reduction ≥15% did not independently predict cardiovascular death (P = 0.112). CONCLUSIONS: Left ventricular ejection fraction increase >10 U and LVEF increase ≥1 category are stronger predictors of cardiovascular death than the most commonly used criterion for RR, namely, LVESV reduction ≥15%.

A novel echocardiographic method for estimation of pulmonary artery wedge pressure and pulmonary vascular resistance.

AIMS: This study aimed to evaluate a novel echocardiographic algorithm for quantitative estimation of pulmonary artery wedge pressure (PAWP) and pulmonary vascular resistance (PVR) in patients with heart failure and pulmonary hypertension (PH) scheduled to right heart catheterization (RHC). METHODS AND RESULTS: In this monocentric study, 795 consecutive patients (427 men; age 68.4 ± 12.1 years) undergoing echocardiography and RHC were evaluated. Multiple regression analysis was performed to identify echocardiographic predictors of PAWP and PVR measured by RHC in the derivation group (the first 200 patients). The diagnostic accuracy of the model was then tested in the validation group (the remaining 595 patients). PH was confirmed by RHC in 507 (63.8%) patients, with 192 (24.2%) cases of precapillary PH, 248 (31.2%) of postcapillary PH, and 67 (8.4%) of combined PH. At regression analysis, tricuspid regurgitation maximal velocity, mitral E/e' ratio, left ventricular ejection fraction, right ventricular fractional area change, inferior vena cava diameter, and left atrial volume index were included in the model (R = 0.8, P < 0.001). The model showed a high diagnostic accuracy in estimating elevated PAWP (area under the receiver operating characteristic curve = 0.97, 92% sensitivity, and 93% specificity, P < 0.001) and PVR (area under the receiver operating characteristic curve = 0.96, 89% sensitivity, and 92% specificity, P < 0.001), outperforming 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations (P < 0.001) and Abbas' equation (P < 0.001). Bland-Altman analysis showed satisfactory limits of agreement between echocardiography and RHC for PAWP (bias 0.7, 95% confidence interval -7.3 to 8.7) and PVR (bias -0.1, 95% confidence interval -2.2 to 1.9 Wood units), without indeterminate cases. CONCLUSIONS: A novel quantitative echocardiographic approach for the estimation of PAWP and PVR has high diagnostic accuracy in patients with heart failure and PH.

Cardiac calcification by transthoracic echocardiography in patients with known or suspected coronary artery disease.

OBJECTIVES: To estimate the correlation between the total heart calcification score index (CSI), assessed by echocardiography, left ventricle mass index (LVMI), Framingham risk score (FRS), and angiographically assessed coronary artery disease (CAD). BACKGROUND: Aortic valve and root sclerosis (AVS, ARS) and mitral annular calcium (MAC) detected by echocardiography have been associated with atherosclerosis. FRS is recommended for estimation of total coronary heart disease risk over the course of 10 years. The anatomic extent of CAD can be assessed with coronary angiography. Total and cardiovascular mortality risk increases with increasing LVMI. METHODS: 167 consecutive in-hospital patients (mean age 66.6+/-9.7 yrs, 119 men) underwent: 1) complete transthoracic echocardiography (TTE), with CSI assessment (from 0=normal to 10=diffuse calcification of aortic valve, mitral annulus and aortic root), 2) the FRS evaluation (FRSor=11 and or=21=high risk), and 3) coronary angiography (with Duke score evaluation, from 0=normal to 100=severe left main disease). RESULTS: The mean CSI of the entire population was 3.94+/-2.1, with a mean of 2.75+/-2 in patients at low risk, with a progressive increase in patients at average risk (4.11+/-2.2), at high risk (4.7+/-1.7), respectively. CSI was associated with the presence of CAD (p=0.003) and the presence of abnormal LVMI (p=0.002). CONCLUSIONS: Echocardiographically assessed CSI is correlated to FRS, Duke score and LVMI and can provide a simple, radiation-free index of cardiovascular risk.

[Radiotherapy and cardiovascular toxicity]. / Radioterapia e tossicità cardiovascolare.

The authors describe the case of a 41-year old patient, with multiple cardiovascular risk factors and past radiotherapic treatment at the chest and cervical region which developed a waste coronary and carotid atherosclerosis associated with aortic and mitralic valvular disease. The role of radiotherapy in developing cardiovascular diseases, in particular about valvular disease is discussed.

A system for real-time measurement of the brachial artery diameter in B-mode ultrasound images.

The measurement of the brachial artery diameter is frequently used in clinical studies for evaluating the flow-mediated dilation and, in conjunction with the blood pressure value, for assessing arterial stiffness. This paper presents a system for computing the brachial artery diameter in real-time by analyzing B-mode ultrasound images. The method is based on a robust edge detection algorithm which is used to automatically locate the two walls of the vessel. The measure of the diameter is obtained with subpixel precision and with a temporal resolution of 25 samples/s, so that the small dilations induced by the cardiac cycle can also be retrieved. The algorithm is implemented on a standalone video processing board which acquires the analog video signal from the ultrasound equipment. Results are shown in real-time on a graphical user interface. The system was tested both on synthetic ultrasound images and in clinical studies of flow-mediated dilation. Accuracy, robustness, and intra/inter observer variability of the method were evaluated.

The elusive prognostic value of systemic endothelial function in patients with chest pain syndrome.

The prognostic value of systemic endothelial dysfunction still remains uncertain in ischemic heart disease. The aim of the study was to establish the prognostic value of ultrasonically assessed systemic endothelial dysfunction in patients with chest pain syndrome and to assess whether this information was incremental to that already provided by simple parameters derived from echocardiography, such as left ventricular mass index or ejection fraction. One hundred ninety-five in-hospital patients (age=60+/-10 years; 63 females) with known or suspected CAD have been enrolled. All of the patients underwent, on different days, coronary angiography, endothelium-dependent FMD testing of the brachial artery by high-resolution ultrasound and resting 2D-echocardiography evaluation. The result of the FMD has been defined as the percent change in the internal diameter of the brachial artery during reactive hyperemia related to baseline. All patients were followed-up for a median of 27 months. During follow-up there were 17 deaths (9 cardiac), 4 non-fatal myocardial infarction (MI), and 18 late clinically-driven revascularization procedures. By a multivariate analysis, echocardiographically assessed ejection fraction (odds ratio: 2.32; 95% confidence interval: 1.24-4.33; p=0.008) and angiographically assessed CAD (odds ratio: 2.82; 95% confidence interval: 1.40-5.67; p=0.003), were independent prognostic predictors of events. In patients with known or suspected CAD, systemic endothelial dysfunction did not show a significant prognostic value. Echocardiographic indices of structural left ventricular damage appear to have a stronger prognostic value than functional indices of peripheral vascular damage in risk stratifying ischemic patients.

Aortic valve sclerosis is associated with systemic endothelial dysfunction.

OBJECTIVES: We sought to examine the association between aortic valve sclerosis (AVS) and systemic endothelial manifestations of the atherosclerotic process. BACKGROUND: Clinical and experimental studies suggest that AVS is a manifestation of the atherosclerotic process. Systemic endothelial dysfunction is an early sign of the atherosclerotic process and can be assessed by ultrasonography of the brachial artery. METHODS: A total of 102 in-hospital patients (76 men; mean age 63.5 +/- 9.7 years) referred to the stress echocardiography laboratory underwent: 1) transthoracic echocardiography, with specific assessment of AVS (thickened valve leaflets with a transaortic flow velocity <2.5 m/s); 2) stress echocardiography; 3) coronary angiography, with evaluation of the Duke score (from 0 [normal] to 100 [most severe disease]); and 4) an endothelial function study, with assessment of endothelium-dependent, post-ischemic, flow-mediated dilation (FMD). RESULTS: Aortic valve sclerosis was present in 35 patients (group I) and absent in 67 (group II). Groups I and II were similar in terms of the frequency of stress-induced wall motion abnormalities (35.3% vs. 19.4%, p = NS) and the angiographic Duke score (33.8 +/- 28.6 vs. 35.2 +/- 29.1, p = NS). Patients with AVS showed a markedly lower FMD than those without AVS (2.2 +/- 3.5% vs. 5.3 +/- 5.3%, p < 0.01). On multivariate analysis, only FMD was highly predictive of AVS, with an odds ratio of 1.18 for each percent decrease in FMD (95% confidence interval 1.05 to 1.32; p = 0.01). CONCLUSIONS: Aortic valve stenosis is associated with systemic endothelial dysfunction. This observation may provide a mechanistic insight into the emerging association between AVS and cardiovascular events.