Three-dimensional anatomic features of the mitral valve that predict systolic anterior motion occurring during dobutamine stress echocardiography.

BACKGROUND/AIM: Left ventricular outflow tract obstruction related to systolic anterior motion (SAM) of the mitral valve is a common complication of dobutamine stress echocardiography (DSE). However, the mechanisms underlying SAM have not been fully characterized. The objective of the present study was to use three-dimensional echocardiography to identify anatomic features of the mitral valve that predispose to SAM during DSE. METHODS: We retrospectively evaluated consecutive patients included prospectively in our database and who had undergone 3D echocardiography (including an assessment of the mitral valve) before DSE. Patients who had developed SAM during DSE (the SAM+ group) were matched 2:3 with patients who did not (the SAM- group). RESULTS: One hundred patients were included (mean age: 67 ± 10). Compared with SAM- patients (n = 60), SAM+ patients (n = 40) had a lower mitral annular area, a smaller perimeter, and a smaller diameter (p < .01 for all, except the anteroposterior diameter). The SAM+ group had also a narrower mitral-aortic angle (126 ± 12° vs. 139 ± 11° in the SAM- group; p < .01) and a higher posterior mitral leaflet length (1.4 ± .27 cm vs. 1.25 ± .29, respectively; p < .01). Furthermore, the mitral annulus was more spherical, more flexible, and more dynamic in SAM+ patients than in SAM- patients (p < .05 for all). In a multivariate analysis of anatomic variables, the mitral-aortic angle, the mitral annular area, and posterior leaflet length were independent predictors of SAM (p ≤ .01 for all). In a multivariate analysis of standard echo and hemodynamic variables, the presence of wall motion abnormalities at rest (p < .01) was an independent predictor of SAM. CONCLUSION: SAM during DSE is multifactorial. In addition to the pharmacologic effects of dobutamine on the myocardium, 3D echocardiographic features of the mitral valve (a smaller mitral annulus, a narrower mitral-aortic angle, and a longer posterior leaflet) appear to predispose to SAM.

Left atrial strain and distensibility in relation to left ventricular dysfunction and prognosis in aortic stenosis.

OBJECTIVE: To test the relationship between left atrial (LA) distensibility (LAD), LA strain (LAS), and left ventricular (LV) dysfunction and prognosis in aortic stenosis (AS). METHODS: Transthoracic Doppler echocardiography was performed prospectively in 102 consecutive patients with AS (77 with severe, 25 with moderate, mean age 77 years). LA volume was calculated by the area-length method in apical four- and two-chamber views, immediately before mitral valve opening (Volmax ) and at mitral valve closure (Volmin ). LAD was defined as (Volmax  - Volmin ) × 100%/Volmin . LAS (mean of maximal strain from the 4-2 chamber views) was conducted using a dedicated software package. The endpoint was hospitalization for heart failure and death from any cause. RESULTS: Left atrial strain, LAD, and LA vol/m² were significantly correlated with LV diastolic parameters, and PASP (all, P < 0.05). However, LAD and LAS but not LA vol/m² were significantly correlated with Charlson score, LV global longitudinal strain, and to transaortic mean gradient (all, P < 0.05). At a median follow-up of 25 months, 53 patients had an event. LAS, LAD, LA vol/m², and Charlson index were associated with events (all, P < 0.05). In multivariate analysis, LAD, LAS, and Charlson index (all, P < 0.01) remained independently associated with events. Using a ROC curve analysis, LAD ≤ 69% and LAS ≤ 17% were the best cutoffs associated with an event. CONCLUSION: In patients with moderate to severe AS, LAD and LAS are associated with LV dysfunction, AS severity, and are independently linked to events.

Assessment of left ventricular twist mechanics in Tako-tsubo cardiomyopathy by two-dimensional speckle-tracking echocardiography.

AIMS: To assess left ventricular (LV) twist mechanics in patients with Tako-tsubo cardiomyopathy (TTC). METHODS AND RESULTS: Two-dimensional strain and LV twist by speckle-tracking echocardiography was performed in 17 consecutive patients with typical TTC according to the Mayo clinic criteria [78 ± 8 years, 88% women, and mean left ventricular ejection fraction (LVEF) 45 ± 10%], at the acute phase (within 24 h after admission) and after recovery (1 month later). Seventeen control (C) patients matched for age and sex (mean LVEF 70 ± 7%), and 17 patients with acute anterior myocardial infarction (MI) treated by successful primary angioplasty 24 h before, matched for LVEF, age, and sex, were compared with TTC patients. LV twist was assessed using the parasternal basal and apical short-axis planes, and defined as the net difference in degrees of apical (Ar) and basal rotation (Br). Peak systolic and early diastolic, apical (As and Ad) and basal (Bs and Bd) rotation rate, and LV twisting rate (TR) and untwisting rate (UR) (in °/s) were derived from rotational and twist curves. The time sequences were normalized to the percentage of systolic duration. At the acute phase, Ar, As, Ad, Bs, LV twist (10 ± 9° vs. 23 ± 6°), LV TR, and LV UR were significantly impaired in patients with TTC when compared with controls (all, P < 0.05). Patients with MI displayed intermediate values (P = NS vs. TTC, and P < 0.05 vs. C). However, in the subgroup of patients with electrocardiogram ST-segment elevation at presentation (n = 12 TTC and 17 MI), several LV twist mechanics parameters were significantly reduced in TTC patients when compared with MI patients, LV twist, and LV TR being the most significant factors (all, P≤ 0.01). Abnormal reversed Ar (clockwise when seen from the apex) was seen in three patients (18%) with TTC vs. none in the other groups. A significant correlation between LV twist and LVEF, LV volumes, wall motion score index, and plasma NT-pro BNP was observed in the TTC group (all, P < 0.05). At follow-up, LV twist mechanics improved significantly in TTC patients (all, P < 0.05 vs. acute phase), who had final values similar to C (all, P = NS), whereas the magnitude of improvement was lower in MI patients (P ≤ 0.05 vs. TTC). CONCLUSION: LV twist mechanics is significantly impaired in patients with TTC mainly due to a severe reduction in apical function and is entirely reversible. Furthermore, in the subgroup of patients with ST-segment elevation, the early post-admission evaluation of LV twist mechanics is more severely impaired in TTC when compared with MI.

Clinical Outcomes of Adults With Bicuspid Aortic Valve: A European Perspective.

OBJECTIVE: To describe the clinical history of patients with a wide age range diagnosed with bicuspid aortic valve (BAV) and no surgical indication and to evaluate the long-term outcome of patients with BAV referred for elective surgery. PATIENTS AND METHODS: Between 2005 and 2017, 350 consecutive patients with no surgical indication (surveillance group, mean age 53±16, 71% men) and 191 with a surgical indication (surgical group, mean age 59±13, 71% men) were prospectively included. Median follow-up was 80 (32 to 115) months. RESULTS: In the surveillance group, the 5-year and 10-year survival rates were 93±1% and 89±2%, respectively, with a relative survival of patients with BAV compared with an age- and sex-matched control population of 98.7%. During follow-up, the cumulative 10-year incidence of aortic valve and aorta surgery was high; of 35±4%, the incidence of native valve infective endocarditis (IE) of 0.2% per patient-year, and no cases of aortic dissection were observed. In the surgical group, the 5-year and 10-year survival rates were 97±1% and 89±3%, respectively, with a relative survival of 99.4% compared with the general population. The incidence of IE was 0.4% per patient-year, and no cases of aortic dissection were observed. CONCLUSION: This regional cohort shows that the 10-year survival rates of patients with BAV and a wide age range, but mostly middle-aged adults, were similar to those of the general population with a very low rate of complications. Adherence to prophylactic surgical indications and younger age might have contributed to this lack of difference.

Non-invasive coronary flow reserve after successful primary angioplasty for acute anterior myocardial infarction is an independent predictor of left ventricular adverse remodelling.

AIMS: To assess the usefulness of non-invasive coronary flow reserve (CFR) to predict left ventricular adverse remodelling (LVR) after ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Sixty-five consecutive patients (mean age 58 +/- 13 years, 24 women) with a first anterior STEMI, underwent prospectively CFR in the distal part of the left anterior descending artery (LAD), using intravenous adenosine infusion (0.14 mg/kg/min, within 2 min), and a standard echocardiography during the same exam, performed within 24 h after successful primary coronary angioplasty, and 6 months later, while the patients were in stable haemodynamic situation. CFR was defined as the peak hyperaemic LAD flow velocity divided by the baseline flow velocity. LV end-systolic volume (ESV) and end-diastolic volume (EDV), and LV ejection fraction (LVEF) were measured using the biplane Simpson's rule. LVR was defined as an absolute increase of ESV > or =15%. Compared with patients without LVR, patients with LVR (n = 18) had higher peak troponin T levels, wall motion score (WMS), a worse initial angiographic TIMI flow grade, and less improved electrocardiographic ST-segment resolution (all P < 0.05), and lower CFR (1.43 +/- 0.2 vs. 1.97 +/- 0.5, P < 0.01). At 6 months, patients with LVR had higher WMS, ESV, EDV, and lower LVEF compared with patients without LVR (all P < 0.01). Furthermore, acute CFR was significantly correlated to the 6-month LVEF and ESV, and to change of LVEF and ESV (all P < 0.01). In the multivariate analysis, acute CFR and initial angiographic TIMI flow grade were the independent predictors of LVR (all P < or = 0.01). Receiver-operating characteristic curve analysis demonstrated that a cut-off value of 1.7 for CFR yields a sensitivity of 100% and a specificity of 62% to predict LVR at follow-up (P < 0.001, area under the curve 0.82). CONCLUSION: Non-invasive CFR is an independent predictor of LVR after successful primary angioplasty of anterior STEMI.

Usefulness of Noninvasive Myocardial Work to Predict Left Ventricular Recovery and Acute Complications after Acute Anterior Myocardial Infarction Treated by Percutaneous Coronary Intervention.

BACKGROUND: Predicting left ventricular recovery (LVR) after acute ST-elevation myocardial infarction (STEMI) is challenging and of prognostic importance. Our objective was to evaluate the usefulness of noninvasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LVR and in-hospital complications after STEMI. METHODS: Ninety-three patients with anterior STEMI (mean age, 59 ± 12 years) treated by percutaneous coronary intervention (PCI) were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24-48 hours after PCI and a median of 92 days at follow-up. Myocardial work is derived from the strain-pressure relation, integrating in its calculation the noninvasive arterial pressure. Segmental LVR was defined as a normalization of wall motion abnormalities of the affected segments and global recovery as an absolute improvement of left ventricular ejection fraction (LVEF) > 5% in patients with baseline LVEF ≤ 50%. In-hospital complications were defined as a composite of death, reinfarction, heart failure, and LV apical thrombus. RESULTS: Segmental MW was impaired in infarct segments, more severely in nonrecovering versus recovering segments (P < .01). Furthermore, global constructive MW was significantly correlated with follow-up LVEF (r = 0.58) and global longitudinal strain (r = -0.67; all P < .01). Constructive MW was the best index to predict segmental (P < .01 vs MW index, MW efficiency, and wasted work) and global recovery (P < .05 vs global longitudinal strain) with an independent association (odds ratio = 1.17, 95% CI, 1.13-1.20, and odds ratio = 1.43, 95% CI, 1.18-1.68, respectively; all P < .001). Moreover, global constructive MW was more severely impaired in patients with in-hospital complications (n = 16; P < .01). CONCLUSIONS: In patients with anterior STEMI treated by PCI, constructive MW is an independent predictor of segmental and global LVR and is significantly impaired in patients with in-hospital complications.

Prognostic value of transthoracic coronary flow reserve in medically treated patients with proximal left anterior descending artery stenosis of intermediate severity.

AIMS: Prognostic value of transthoracic coronary flow reserve (T-CFR) is not established in patients with left anterior descending artery (LAD) stenosis of intermediate severity. Objective is to determine the prognosis value of T-CFR>2 in medically treated patients with angiographically intermediate [50-70% QCA (quantitative coronary angiography)] proximal LAD stenosis. METHODS AND RESULTS: Among 110 consecutive patients with intermediate LAD stenosis who underwent prospectively T-CFR in the distal part of the LAD after intravenous administration of adenosine to assess the functional significance of the stenosis, 80 patients had T-CFR>2 and were treated medically without revascularization (Group 1). Among the 30 patients who had T-CFR<2, an additional dobutamine stress echocardiography (DSE) was performed: 15 had a negative DSE; were treated medically and served as a comparative group (Group 2), and 15 had a positive DSE; underwent LAD revascularization, and were excluded from further analysis. All patients completed follow-up (16+/-10 months). During the follow-up period (range 6-45 months), 76 patients (95%) remained free of death or LAD-related event in Group 1, vs. 12 patients (80%) in Group 2. By Kaplan-Meier method, at 30 months the per cent estimated survival free from death or target vessel-related events was 92+/-4% in Group 1 and 44+/-22% in Group 2 (P<0.01). By multivariate analysis, T-CFR remained the only independent predictor of death or LAD-related events. CONCLUSION: In patients with proximal LAD stenosis of intermediate severity and T-CFR>2, deferral of revascularization is associated with low event rate.

Carotid chemodectomas: long-term results of subadventitial resection with deliberate external carotid resection.

The aim of this study was to evaluate the short-term and long-term results of the subadventitial resection of carotid chemodectomas and to validate the importance of deliberate resection of the external carotid artery (ECA). From 1981 to 2006, 39 carotid chemodectomas of the carotid bifurcation or of the neighboring nerves were operated on in our department. There were 14 men and 22 women, with a mean age 44.4 +/- 5 (range 21-78) years. One of these operations was a redo surgery for local recurrence. One female patient presented with a bilateral tumor. Two tumors were secreting catecholamines. All these tumors affected the carotid body; 10 of them were also affecting the vagus nerve, and one among these last 10 affected the sympathetic nerve as well. In 11 cases, the tumor had spread into the subparotidal space and, in one case, into the skull. In two cases, the tumor had been revealed by hemispheric ischemia and in every case by tumoral syndrome. All the patients were followed up by clinical examination, duplex scan, or computed tomographic scan until the end of 2006. In 38 cases, complete resection was performed; an incomplete resection was performed in one case with cranial invasion. Under general anesthesia, and most of the time without pharmaceutical preparation, surgery consisted of a deliberate sacrifice of the ECA followed by subadventitial resection of the tumor. In one case, a previous embolization had been carried out to facilitate the cleavage, which in fact rendered it more complicated. In 22 cases, resection concerned the ECA; in seven cases, it concerned the common carotid artery and the internal carotid artery (ICA): in seven cases the superior laryngeal nerve, in nine cases the vagus nerve, in five cases the sympathetic nerve, and in four cases the jugular vein. In 13 cases, node clearing was associated. In 20 cases, an additional vascular procedure was performed: nine dilatations for spasm of the ICA, five autogenous vein grafts, two prosthetic bypasses, and one endarterectomy associated with a patch angioplasty. All patients were followed up until 2006. At 3 months, the observed complications were the sequelae of a homolateral hemispheric accident due to thrombosis of a vein graft, eight peripheral facial nerve palsies, 12 vocal palsies, seven Claude Bernard-Horner (CBH) syndromes, eight palatal paralyses, and 10 nociceptive pains. Some of these complications did persist: nine vocal cord paralyses that were successfully treated by speech therapy, three mild CBH syndromes, and nociceptive pains in 6% of the cases (15.4%), incapacitating in one case. With a follow-up of 115 +/- 27 (range 1-298) months, three local recurrences were recorded at 6 and 10 years. In two cases, local recurrence occurred when initial resection of the ECA had not been performed. Two patients presented with a contralateral lesion, at 12 and 16 years, respectively. At 40 months, one patient had to be reoperated on for an atheromatous stenosis. At 51 months, a female patient's death was not related to the operation. Subadventitial resection of carotid body tumors with deliberate resection of the ECA is a simple and efficient procedure. It is the preferential treatment for these slow-growing localized tumors.

Noninvasive Coronary Flow Reserve Predicts Response to Exercise in Asymptomatic Severe Aortic Stenosis.

BACKGROUND: In patients with asymptomatic aortic stenosis (AS), exercise stress echocardiography (ESE) provides additional prognostic information beyond baseline. The coronary flow velocity reserve (CFVR) is impaired in AS, but its link with exertion is unknown in this setting. The aim of this study was to test the hypothesis that CFVR could predict exercise capacity and abnormal exercise test results in AS. METHODS: Noninvasive CFVR and symptom-limited semisupine ESE were prospectively performed the same day in 43 patients with asymptomatic isolated severe AS (mean age, 68.5 ± 11 years; 26% women; mean aortic valve area, 0.8 ± 0.16 cm2; mean left ventricular ejection fraction, 70 ± 7%). CFVR was performed in the distal part of the left anterior descending coronary artery using intravenous adenosine infusion (140 µg/kg/min over 2 min), and ESE was performed at an initial workload of 25 W with a 20- to 25-W increase at 2-min intervals. An abnormal result on ESE was defined as onset of symptoms at <75% of maximum predicted workload, electrocardiographic ST-segment depression ≥2 mm during exercise, increase of systolic blood pressure < 20 mm Hg or decrease in blood pressure, and complex ventricular arrhythmia. Seventeen patients with isolated severe asymptomatic AS, unable to exercise because of extracardiac conditions, served as a comparative group. RESULTS: Resting, hyperemic left anterior descending coronary artery flow velocity and CFVR (2.45 ± 0.8 vs 2.4 ± 0.8) were similar between the group unable to perform ESE and the ESE group (P = NS for all). Compared with patients with normal results on ESE, those with abnormal results on ESE (n = 22) were older, had higher E/e' ratios, had higher resting left anterior descending coronary artery flow velocities (39 ± 12 vs 31 ± 8 cm/sec), and had lower CFVR (2.01 ± 0.3 vs 2.85 ± 0.7; P < .01 for all). Furthermore, CFVR was significantly correlated with age, changes in transvalvular pressure gradient and left ventricular ejection fraction with exercise, workload (in watts), and exercise duration (P < .05 for all). After adjusting for other variables, CFVR remained independently correlated with exercise duration, workload, and abnormal results on ESE (P < .01 for all). On receiver operating characteristic curve analysis, CFVR < 2.3 was the best cutoff to predict abnormal results on ESE (area under the curve = 0.88 ± 0.06, P < .01). CONCLUSIONS: In patients with asymptomatic severe AS, noninvasive CFVR is correlated with exercise duration and workload, and low CFVR predicts abnormal results on ESE with good accuracy.

Usefulness of two-dimensional longitudinal strain pattern to predict left ventricular recovery and in-hospital complications after acute anterior myocardial infarction treated successfully by primary angioplasty.

BACKGROUND: The aim of this study was to test the usefulness of two-dimensional longitudinal strain pattern in segments with wall motion abnormalities to predict left ventricular recovery and in-hospital cardiac events as well as coronary microvascular impairment (CMI) in patients with recent acute anterior myocardial infarction. METHODS: Forty-nine consecutive patients with acute myocardial infarction (mean age, 59 ± 13 years) treated successfully with primary coronary angioplasty prospectively underwent transthoracic Doppler echocardiography 24 hours after angioplasty and during follow-up (6 months). A two-dimensional strain analysis, including measurement of the duration of systolic lengthening expressed as a percentage of systolic duration (SL % duration), the lengthening-to-shortening ratio, the postsystolic shortening index in segments with wall motion abnormalities, and global longitudinal strain and left anterior descending coronary artery territory strain, was performed. Cardiac events were defined as a composite of death, reinfarction, and heart failure. CMI was assessed noninvasively by transthoracic Doppler left anterior descending coronary artery investigation <24 h after angioplasty and was defined as coronary flow velocity reserve < 1.7 and/or a no-reflow pattern (mean coronary flow velocity reserve, 1.8 ± 0.6 in the whole group). RESULTS: At the segmental level, SL % duration, lengthening-to-shortening ratio, and postsystolic shortening index were correlated with recovery (defined as normalization of wall motion abnormalities), whereas in multivariate analysis, only SL % duration independently predicted recovery (threshold level, 40%; area under the curve, 0.76; P < .01). At the patient level, in univariate analysis, SL % duration, global longitudinal strain, left anterior descending coronary artery territory strain, and troponin peak were correlated with recovery (defined as an absolute improvement of left ventricular ejection fraction of >5%). In multivariate analysis, SL % duration was independently related to recovery (area under the curve, 0.78; P < .01). Furthermore, SL % duration was independently linked to cardiac events (n = 13) and CMI (n = 24) (P < .01 for all). CONCLUSIONS: In patients with AMI treated by primary angioplasty, two-dimensional strain predicts left ventricular recovery independently of more traditional parameters and is independently linked to cardiac events and CMI.

Non-invasive detection of tako-tsubo cardiomyopathy vs. acute anterior myocardial infarction by transthoracic Doppler echocardiography.

AIMS: Typical tako-tsubo cardiomyopathy (TTC) mimics acute anterior myocardial infarction (AMI) and the differential diagnosis is challenging before coronary angiography (CA) is performed; it demonstrates reduced or absent antegrade flow in the left anterior descending artery (LAD) in AMI, whereas there is no such flow limiting in TTC. At the acute phase, we tested the usefulness of the distal LAD flow visualization by transthoracic Doppler echocardiography (TDE) to distinguish between these two diseases. For this purpose, we prospectively enrolled 28 consecutive patients with TTC (75 ± 10 years, 93% females) who were compared with 28 consecutive patients with AMI treated successfully by primary angioplasty (66 ± 12 years, 79% females). All the patients underwent the assessment of the distal LAD flow just before CA, using colour and pulsed-wave TDE. In addition, the symmetric involvement of wall motion abnormalities (WMAs) based on the extent of the disease far beyond one coronary territory in TTC was searched by TDE. Non-invasive coronary flow reserve (CFR) by TDE, in the distal LAD, was also performed within 1 day after admission. RESULTS: Before CA, the distal LAD flow was visible in 38 of 56 cases (68%) in the whole population, in all cases with TTC and in 10 cases with AMI (36%). The sensitivity (Se) and specificity (Sp) of the LAD flow visualization for the diagnosis of TTC were 100 and 64%, respectively, with a diagnostic accuracy of 82%. In comparison, the pattern of WMA yielded a Se of 75% and Sp of 86%, and a diagnostic accuracy of 80%. With the combination of both tools, the Se and Sp to detect TTC were 75 and 96% respectively, with a diagnostic accuracy of 86%. After CA, the acute CFR was less severely impaired in the TTC group when compared with the AMI group (2.2 ± 0.5 vs. 1.7 ± 0.6, P < 0.01) despite a worse LV systolic dysfunction. CONCLUSION: Non-invasive evaluation of the distal LAD flow could be helpful to differentiate TTC from AMI, and its combination with the pattern of WMA improved slightly its diagnostic accuracy. Furthermore, the acute CFR is less severely impaired in TTC compared with AMI despite poorer LV systolic dysfunction, suggesting that other mechanisms than direct microcirculatory damage are also involved in the pathogenesis of WMAs in TTC.

Factors associated with noninvasive coronary flow reserve in severe aortic stenosis.

BACKGROUND: Coronary flow reserve (CFR) is progressively impaired with aortic stenosis (AS) severity. However, there is a broad range of CFR in patients with severe AS, and the factors responsible for this variability are weakly characterized. The aim of this study was to assess the correlates of noninvasive CFR in patients with severe AS (≤1 cm(2) or ≤0.6 cm(2)/m(2)) and preserved left ventricular (LV) ejection fractions (LVEFs) (>50%). METHODS: Sixty-six consecutive patients (mean age, 74 ± 11 years; 31 women; mean LVEF, 69 ± 10%) with isolated severe AS (mean, 0.75 ± 0.2 cm(2) and 0.42 ± 0.1 cm(2)/m(2)), without coronary artery disease, underwent prospectively Doppler transthoracic echocardiography including CFR measurement in the distal part of the left anterior descending coronary artery (LAD) with intravenous adenosine infusion (140 µg/kg/min over 2 min). CFR was defined as hyperemic peak LAD flow velocity divided by baseline flow velocity. Twenty controls matched for age and gender served as a comparative group. Plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) was also assessed. RESULTS: Compared with controls, patients with AS had higher baseline LAD flow velocities (36 ± 11 vs 27 ± 6 cm/sec, P < 0.01), lower hyperemic LAD flow velocities (80 ± 20 vs 89 ± 18 cm/sec, P = .09), and consequently lower CFR (2.3 ± 0.7 vs 3.3 ± 0.7, P < .01). In patients with AS, there were significant inverse correlations between CFR and age, E/e', indexed LV mass, NT-proBNP, pulmonary artery systolic pressure (PASP), baseline LV rate-pressure product, heart rate, and indexed left atrial volume and a significant positive correlation between CFR and LVEF (all P values < .05). Furthermore, compared with patients with asymptomatic AS (n = 22), those with symptomatic AS had more severely impaired CFR (2.15 ± 0.6 vs 2.7 ± 0.65), and higher NT-proBNP values (all P values < .05). In multivariate analysis, NT-proBNP, PASP, and LV rate-pressure product were the main independent correlates of CFR (all P values ≤ .01), and PASP was independently predicted by E/e' and indexed left atrial volume (all P values < .01). CONCLUSIONS: In patients with severe AS and preserved LVEFs, there is a relatively broad range of CFR values. CFR is more severely impaired in patients with symptomatic AS and is mainly linked with NT-proBNP, a surrogate of increased LV wall stress, workload as measured by LV rate-pressure product, and PASP.

Comparison between non-invasive coronary flow reserve and fractional flow reserve to assess the functional significance of left anterior descending artery stenosis of intermediate severity.

BACKGROUND: Assessment of the functional significance of left anterior descending coronary artery (LAD) stenosis of intermediate severity (50%-70% diameter stenosis) is challenging. The aim of this study was to compare the value of noninvasive coronary flow reserve (CFR) with that of invasive fractional flow reserve (FFR) in the setting of LAD stenosis of angiographic intermediate severity. METHODS: Fifty stable consecutive patients (mean age, 63 ± 13 years; 11 women; mean left ventricular ejection fraction, 61 ± 10%) with angiographic proximal LAD stenoses of intermediate severity (55.5 ± 5% diameter stenosis on quantitative coronary angiography), no previous anterior myocardial infarction, and various vascular risk factors were prospectively studied. They underwent FFR assessment with intracoronary bolus adenosine (150 µg), and CFR assessment using intravenous adenosine (140 µg/kg/min over 2 min) in the distal part of the LAD on the same day in nearly all patients. CFR was defined as hyperemic peak diastolic LAD flow velocity divided by baseline flow velocity (normal value >2), and FFR was defined as distal pressure divided by mean aortic pressure during maximal hyperemia (normal value >0.8). RESULTS: The mean FFR and CFR were 0.84 ± 0.07 and 2.7 ± 0.75, respectively, in the whole population. Concordant results between FFR and CFR were seen in 44 patients (88%) and discordant results in six patients (12%). There was a significant correlation between CFR and FFR (r = 0.59, P < .01). A better correlation was found between FFR and percentage LAD diameter stenosis, and lesion length (all P values < .05), than between CFR and the same anatomic markers of stenosis severity (all P values = NS). The sensitivity, specificity, and positive and negative predictive values of CFR >2 to detect a nonsignificant lesion defined by normal FFR were 95%, 69%, 90%, and 82%, respectively. CONCLUSIONS: In patients with LAD stenosis of intermediate severity, discordant results between noninvasive CFR and FFR were not unusual, and the anatomic determinants of the stenosis were better correlated to FFR than to CFR. However, CFR, which is a global evaluation of the coronary tree, has very high sensitivity to detect a nonsignificant lesion, despite the high prevalence of vascular risk factors.