Unmasking Myocardial Dysfunction in Patients Hospitalized for Community-Acquired Pneumonia Using a 4-Chamber 3-Dimensional Volume/Strain Analysis.

Lower respiratory infection was reported as the most common fatal infectious disease. Community-acquired pneumonia (CAP) and myocardial injury are associated; yet, true prevalence of myocardial injury is probably underestimated. We assessed the rate and severity of myocardial dysfunction in patients with CAP. Admitted patients diagnosed with CAP were prospectively recruited. All the patients had C-reactive protein (CRP), brain natriuretic peptide (BNP), and high-sensitivity cardiac troponin (hs-cTnl) tests added to their routine workup. 2D/3D Doppler echocardiography was done on a Siemens Acuson SC2000 machine ≤ 24 h of diagnosis. 3D datasets were blindly analyzed for 4-chamber volumes/strains using EchobuildR 3D-Volume Analysis prototype software, v3.0 2019, Siemens-Medical Solutions. Volume/strain parameters were correlated with admission clinical and laboratory findings. The cohort included 34 patients, median age 60 years (95% CI 55-72). The cohort included 18 (53%) patients had hypertension, 9 (25%) had diabetes mellitus, 7 (21%) were smokers, 7 (21%) had previous myocardial infarction, 4 (12%) had chronic renal failure, and 1 (3%) was on hemodialysis treatment. 2D/Doppler echocardiography findings showed normal ventricular size/function (LVEF 63 ± 9%), mild LV hypertrophy (104 ± 36 g/m2), and LA enlargement (41 ± 6 mm). 3D volumes/strains suggested bi-atrial and right ventricular dysfunction (global longitudinal strain RVGLS = - 8 ± 4%). Left ventricular strain was normal (LVGLS = - 18 ± 5%) and correlated with BNP (r = 0.40, p = 0.024). The patients with LVGLS > - 17% had higher admission blood pressure and lower SaO2 (144 ± 33 vs. 121 ± 20, systolic, mmHg, p = 0.02, and 89 ± 4 vs. 94 ± 4%, p = 0.006, respectively). hs-cTnl and CRP were not different. Using novel 3D volume/strain software in CAP patients, we demonstrated diffuse global myocardial dysfunction involving several chambers. The patients with worse LV GLS had lower SaO2 and higher blood pressure at presentation. LV GLS correlated with maximal BNP level and did not correlate with inflammation or myocardial damage markers.

Left atrial minimal volume: association with diastolic dysfunction and heart failure in patients in sinus rhythm or atrial fibrillation with preserved ejection fraction.

BACKGROUND: Evidence of diastolic dysfunction (DD) required for the diagnosis of heart failure with preserved ejection fraction (HFpEF) is elusive in atrial fibrillation (AF). Left ventricular (LV) and left atrial (LA) speckle-tracking echocardiography (STE) may provide rhythm independent indications of DD. We aimed to find common LV/LA myocardial mechanics parameters to demonstrate DD, using STE in patients with AF. METHODS: 176 echocardiographic assessments of patients were studied retrospectively by STE. 109 patients with history of AF were divided in three groups: sinus with normal diastolic function (n = 32, ND), sinus with DD (n = 35, DD) and patients with AF during echocardiography (n = 42). These assessments were compared to 67 normal controls. Demographic, clinical, echocardiographic and myocardial mechanic characteristics were obtained. RESULTS: The patients with DD in sinus rhythm and patients with AF were similar in age, mostly women, and had cardiovascular risk factors as well as higher dyspnea prevalence compared to either controls or patients with ND. In the AF group, LV ejection fraction (LVEF) (p = 0.008), global longitudinal strain and LA emptying were lower (p < 0.001), whereas LA volumes were larger (p < 0.001) compared to the other groups. In a multivariable analysis of patients in sinus rhythm, LA minimal volume indexed to body surface area (Vmin-I) was found to be the single significant factor associated with DD (AUC 83%). In all study patients, Vmin-I correlated with dyspnea (AUC 80%) and pulmonary hypertension (AUC 90%). CONCLUSIONS: Vmin-I may be used to identify DD and assist in the diagnosis of HFpEF in patients with AF.

Acute Kidney Injury Following Transcatheter Aortic Valve Implantation: Association with Contrast Media Dosage and Contrast Media Based Risk Predication Models.

The effect of contrast media (CM), delivered prior to- and during transcatheter aortic valve implantation (TAVI), on kidney function, following the procedure, is debatable. Consequently, the performance of CM-based, acute kidney injury (AKI) risk prediction models is also questionable. We retrospectively studied 210 patients that underwent TAVI. We recorded the dose of CM used prior and during TAVI, calculated the results of different AKI risk assessment models containing a CM module, and tested their association with AKI after the procedure. AKI was diagnosed in 38 patients (18.1%). The baseline estimated glomerular filtration rate (eGFR) was lower in the AKI+ group compared to AKI- group (51 ± 19.3 versus 64.5 ± 19 mL/min/1.73 mr2, respectively). While the dose of CM delivered prior to TAVI, during TAVI or the cumulative amount of both did not differ between the groups, the results of all tested risk models were higher in AKI+ patients. However, by multivariable analysis, only eGFR had a consistent independent association with AKI. We suggest that the dose of CM delivered prior or during TAVI is not associated with AKI and that the predictive power of CM based AKI risk models is, in all probability, limited to eGFR alone.

Clinical and echocardiographic characteristics of patients with preserved versus mid-range ejection fraction.

A wide range of ejection fraction (EF) thresholds have been used to categorize patients with heart failure (HF) with "preserved" EF. Our goal was to characterize the clinical and echocardiographic differences among patients with cardiac structural/functional alterations and mid-range EF (mrEF) (EF 40-49%) compared to preserved EF (pEF) (EF ≥ 50%), irrespective of HF. Patients with an EF ≥ 40% and echocardiographic evidence of structural alterations (left atrial enlargement and/or left ventricular hypertrophy) and/or functional alterations (evidence of diastolic dysfunction) were retrospectively selected. Patients with acute coronary syndromes and ≥ moderate left sided valvular diseases were excluded. Patients were divided according to EF to pEF group (n = 578) and mrEF (n = 86). Patients with mrEF were twice as likely to be men, had higher prevalence of hyperlipidemia, diabetes and smoking, compared to patients with pEF. History of coronary artery disease (CAD) was more frequent among mrEF (50% vs. 28%, p < 0.0001, respectively), and highest among the subgroup of patients with HF (83% vs. 35%, p < 0.0001, respectively). Patients with mrEF had increased LV mass index (131 ± 35 vs. 120 ± 26 g/m2, p < 0.001), LV end diastolic diameter (55 ± 5 vs 51 ± 3, p < 0.0001), mitral E to e' ratio (16 ± 7 vs. 14 ± 5, p = 0.001), and left atrial systolic diameter (44 ± 5 mm vs. 42 ± 4 mm, p = 0.01. respectively). Patients with mrEF demonstrated worse structural and functional echocardiographic alterations and were more likely to be men and to have CAD compared to patients with pEF.

Immediate Post-Procedural and Discharge Assessment of Mitral Valve Function Following Transcatheter Edge-to-Edge Mitral Valve Repair: Correlation and Association with Outcomes.

The correlation between residual mitral regurgitation (rMR) grade or mitral valve pressure gradient (MVPG), at transcatheter edge-to-edge mitral valve repair (TEEMr) completion and at discharge, is unknown. Furthermore, there is disagreement regarding rMR grade or MVPG from which prognosis diverts. We retrospectively studied 82 patients that underwent TEEMr. We tested the correlation between rMR or MVPG and evaluated their association, with outcomes. Moderate or less rMR (rMR ≤ 2) at TEEMr completion was associated with improved survival, whereas mild or less rMR (rMR ≤ 1) was not. Patients with rMR ≤ 1 at discharge demonstrated a longer time of survival, of first heart failure hospitalization and of both. The correlation for both rMR grade (r = 0.5, p < 0.001) and MVPG (r = 0.51, p < 0.001), between TEEMr completion and discharge, was moderate. MR ≤ 2 at TMEER completion was the strongest predictor for survival (HR 0.08, p < 0.001) whereas rMR ≤ 1 at discharge was independently associated with a lower risk of the combined endpoint (HR 4.17, p = 0.012). MVPG was not associated with adverse events. We conclude that the assessments for rMR grade and MVPG, at the completion of TEEMr and at discharge, should be distinctly reported. Improved outcome is expected with rMR ≤ 2 at TEEMr completion and rMR ≤ 1 at discharge. Higher MVPG is not associated with unfavorable outcomes.

Serum BNP levels are associated with malignant pericardial effusion.

INTRODUCTION: The development of malignant pericardial effusion indicates a poor prognosis and is the leading cause of cardiac tamponade. The objectives of the study were to examine the levels of BNP in traumatic, malignant and non-malignant pericardial effusion etiologies, and to assess the value of serum and pericardial fluid BNP levels in the prognosis of malignant pericardial effusion. METHODS: A of 56 patients with clinical and echocardiographic diagnosis of pre-tamponade or tamponade who required pericardiocentesis were included in the study. BNP levels were assessed in the serum and within the pericardial fluid. The diagnostic value of BNP levels in discriminating between malignant and non- malignant etiology of pericardial effusion was examined using a receiver-operating characteristic (ROC). RESULTS: Pericardial fluid BNP levels were similar across all etiology groups. In patients with malignant etiology, the amount of pericardial fluid was high and their serum BNP levels were relatively low. BNP levels were strong predictors of malignant pericardial effusion, and the cut-off point of BNP ≤ 250 pg/ml demonstrated the highest sensitivity (90.0%) for malignant etiology. CONCLUSIONS: Low serum BNP levels were significantly associated with malignancy in patients undergoing pericardiocentesis for pericardial effusions. Serum BNP levels <250 pg/ml may trigger more extensive diagnostic testing for malignant pericardial effusion in patients with small pericardial effusion who are not considered for pericardiocentesis due to small effusion, in whom the etiology is unclear.