Discongruence Index　- Simple Indicator to Predict Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement.

BACKGROUND: Prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) remains an important issue. The aim of this study was to assess the value of a new discongruence index, to predict PPM after TAVR.Methods and Results: A total of 185 patients with severe aortic stenosis who underwent TAVR with the Edwards Sapien prosthesis or CoreValve Revalving system were included (Edwards valve, n=119; Core Valve Revalving system, n=66). Discongruence index was calculated pre-procedurally as the ratio of selected transcatheter valve size (mm) to body surface area (cm2). PPM was defined as effective orifice area (EOA) ≤0.85 cm2/m2 on transthoracic echocardiography before hospital discharge. Mean age was 82±5 years and 72 patients (38.9%) were men. The overall incidence of post-TAVR PPM was 35.1% (n=65). Discongruence index correlated with post-TAVR indexed EOA (y=0.18+0.057x; P<0.001). On multivariate logistic regression analysis, discongruence index was the only independent predictor of post-TAVR PPM (OR, 0.15; 95% CI: 0.03-0.66; P=0.012), and the area under the receiver operating characteristic curve was 0.62 (95% CI: 0.54-0.70, P=0.003), with an optimal cut-off point of 15.02 (sensitivity, 86.2%; specificity, 72.5%; positive predictive value, 74.3%; negative predictive value, 83.4%). CONCLUSIONS: The new discongruence index may be useful tool to predict PPM after TAVR.

Prevalence of auricular thrombosis before atrial flutter cardioversion: a 17-year transoesophageal echocardiographic study.

AIMS: Prevalence of left appendage thrombosis ranges from 6 to 18% in persistent atrial fibrillation (AF). Few and low sample size studies have assessed left and right atrial thrombosis in persistent atrial flutter (AFL) and a wide variety of frequencies, from 1 to 21%, has been reported. The aim of this study was to evaluate the prevalence of atrial appendage thrombosis in a large population of patients undergoing transoesophageal echocardiography (TEE)-guided cardioversion (CV) for recent AFL onset and compare it with AF. METHODS AND RESULTS: From 1999 to September 2014, we collected data of 1081 patients to CV: 877 affected by AF (81.1%) and 204 by AFL (18.9%). The presence of auricular thrombosis was evaluated by TEE in AF or AFL persisting for more than 48 h. The presence of appendage thrombosis, Doppler emptying velocities, and severe spontaneous echo contrast (SEC) was studied. The overall prevalence of atrial thrombosis was 9.62% (104/1081). Frequency of atrial thrombosis in AFL patients was 6.4% (13/204) vs. 10.5% among AF (92/877), P = 0.074. Comparing the two appendages, frequency of left atrial appendage thrombosis was in AFL 5.9% (12/204) vs. 9.9% (87/877) in the AF group, P = 0.07. Right atrial appendage thrombosis was present in 0.5% (1/204) in the AFL group vs. 0.8% (7/877) in the AF group, P = 0.64. Moderate to severe SEC (3+/4+) was present in 28% of AFL patients (57/204) vs. 35% of AF patients (307/877), P = 0.05. CONCLUSION: Auricular thrombosis is not an infrequent finding in AFL before CV. Our study suggests the use of TEE screening in AFL, as well as in AF, when patients arrive to clinical attention after more than 48 h from arrhythmia onset.

Exercise Intolerance in McArdle Disease: A Role for Cardiac Impairment? A Preliminary Study in Humans and Mice.

INTRODUCTION: Whether cardiac impairment can be fully discarded in McArdle disease-the paradigm of 'exercise intolerance', caused by inherited deficiency of the skeletal muscle-specific glycogen phosphorylase isoform ('myophosphorylase')-remains to be determined. METHODS: Eight patients with McArdle disease and seven age/sex-matched controls performed a 15-minute moderate, constant-load cycle-ergometer exercise bout followed by a maximal ramp test. Electrocardiographic and two-dimensional transthoracic (for cardiac dimension's assessment) and speckle tracking [for left-ventricle global longitudinal (GLS) assessments] echocardiographic evaluations were performed at baseline. Electrocardiographic and GLS assessments were also performed during constant-load exercise and immediately upon maximal exertion. Four human heart biopsies were obtained in individuals without McArdle disease, and in-depth histological/molecular analyses were performed in McArdle and wild-type mouse hearts. RESULTS: Exercise intolerance was confirmed in patients ('second wind' during constant-load exercise, -55% peak power output vs controls). As opposed to controls, patients showed a decrease in GLS during constant-load exercise, especially upon second wind occurrence, but with no other between-group difference in cardiac structure/function. Human cardiac biopsies showed that all three glycogen phosphorylase-myophosphorylase, but also liver and especially brain-isoforms are expressed in the normal adult heart, thereby theoretically compensating for eventual myophosphorylase deficiency. No overall histological (including glycogen depots), cytoskeleton, metabolic or mitochondrial (morphology/network/distribution) differences were found between McArdle and wild-type mouse hearts, except for lower levels of pyruvate kinase M2 and translocase of outer membrane 20 kDa subunit in the former. CONCLUSIONS: This study provides preliminary evidence that cardiac structure and function seem to be preserved in patients with McArdle disease. However, the role for an impaired cardiac contractility associated with the second wind phenomenon should be further explored.

Right atrial indexed volume in healthy adult population: reference values for two-dimensional and three-dimensional echocardiographic measurements.

BACKGROUND: Current guidelines do not recommend routine assessment of right atrial volume due to the lack of standardized data. Three-dimensional wall-motion tracking (3D-WMT) is a new technology that allows us to calculate volumes without any geometric assumptions. The aim of this study was to define the indexed reference values for two-dimensional echocardiography (2D-echo) and 3D-WMT in adult healthy population and to assess the intermethod, intra- and interobserver agreement. METHODS: Prospective study. Nonselected healthy subjects were enrolled. Every patient underwent a 2D-echo and a 3D-WMT examination. 2D-echo right atrial volume was obtained by using the area-length method (A-L) from four- and two-chamber view. 3D-echo volumes were assessed by 3D-WMT. Values were indexed by the patient's body surface area. RESULTS: Sixty consecutive healthy subjects were enrolled. Mean age was 57 ± 12-years old and 27 patients (45%) were male. Average indexed right atrial volume obtained by 2D-echo and 3D-echo was 16.76 ± 8.15 mL/m(2) and 19.05 ± 6.87 mL/m(2) , respectively. Univariate linear regression analysis between 2D-echo and 3D-echo right atrial volumes shows a weak correlation between right atrial volume obtained with 2D-echo compared with 3D-WMT (r = 0.29, CI 95% 0.029-0.66, P = 0.033). The agreement analysis shows a similar result (intraclass correlation coefficient [ICC] = 0.28). The intra- and interobserver agreement analysis showed a better agreement when using 3D-WMT. CONCLUSIONS: This is the first study that reports the reference indexed right atrial volume values by means of 2D-echo and 3D-echo in healthy population. 3D-WMT is a feasible and reproducible method to determine right atrial volume.

Prevalence of extra-appendage thrombosis in non-valvular atrial fibrillation and atrial flutter in patients undergoing cardioversion: a large transoesophageal echo study.

AIMS: The aim of our study was to evaluate the prevalence of left atrial cavity and appendage thrombosis in patients undergoing cardioversion for non-valvular atrial tachyarrhythmias. In persistent atrial tachyarrhythmias, 90% of thromboses are reported to be located inside the left atrial appendage. This prevalence refers to old studies and meta-analysis in a mixed population of valvular and non-valvular atrial fibrillation. Left atrial cavity thrombosis in non-valvular atrial fibrillation has not been investigated recently in large-scale studies. METHODS AND RESULTS: A total of 1,420 consecutive adult patients with paroxysmal or persistent atrial tachyarrhythmias, candidates to cardioversion, who opted for a transoesophageal echocardiography-guided strategy, were enrolled in the study. Mitral stenosis, rheumatic valve disease and mechanical prostheses were excluded. In total there were 91 thrombi in 87 patients with a prevalence of 6.13% (87/1,420). Patients with left atrial thrombosis had predisposing clinical and echo characteristics (heart failure, lower ventricular function and higher atrial volume). Except for one case in which the thrombus was located in the left atrial cavity (0.07%), and three in the right appendage, all thromboses were detected in the left atrial appendage. CONCLUSIONS: Extra-appendage thrombosis is a very rare finding in non-valvular persistent and paroxysmal atrial tachyarrhythmias and, when present, a left appendage thrombus is usually concomitant.

Cardiac dysfunction during liver transplantation: incidence and preoperative predictors.

BACKGROUND: The aim was to investigate the cardiac response during liver transplantation (LT) and analyze its relationship with clinical factors, echocardiographic, and hemodynamic findings. METHODS: All patients undergoing LT for cirrhosis from 1998 to 2004 were included. Clinical data, comprehensive echocardiography, hepatic, and right heart hemodynamic measurements were analyzed. During LT patients underwent continuous right-heart pressure monitorization. Measurements 10 min after reperfusion were compared with baseline values. Abnormal cardiac response was defined as a decrease in left ventricular stroke work index despite a rise in pulmonary wedge capillary pressure. Predictors of abnormal cardiac response were investigated using logistic regression. RESULTS: Data were available from 209 patients (mean age 52 (9) yrs; Child A 27; B 93; C 89) with a mean model for end-stage liver disease score 16.3 (4.7). Abnormal cardiac response was observed in 47 (22.5%) patients after reperfusion. Patients who developed this response had hyponatremia, lower central venous pressure, lower pulmonary artery pressure, and lower pulmonary wedged capillary pressure. Abnormal cardiac response was related to a longer postoperative intubation time. CONCLUSION: Abnormal cardiac response is observed during LT and may be a manifestation of occult cirrhotic cardiomyopathy. This finding is underestimated with usual diagnostic tools and could be related to indirect signs of circulatory dysfunction of advanced liver disease.

Usefulness of transesophageal echocardiography in percutaneous transcatheter repairs of paravalvular mitral regurgitation.

This study was conducted to assess the usefulness of transesophageal echocardiography (TEE) as a guide in the percutaneous transcatheter occlusion of paravalvular defects and in subsequent follow-up. In 27 consecutive patients with mitral paravalvular leaks with significant regurgitation considered to be poor surgical candidates who were treated with percutaneous closure of the defects, TEE was performed before and during the procedure. If the device was successfully positioned, a reevaluation was made 1 month later. Events occurring during the procedure and 1-month follow-up were recorded. The device was correctly positioned in 17 of the patients (63%). TEE enabled the detection of complications (intraprosthetic insufficiencies due to passing the guide through the prosthesis, blockade of the prosthesis, etc.). It also confirmed the correct canalization of the leak with the catheter and the position of the device. In 8 patients (47% of patients with successful implantation), the degree of regurgitation was substantially reduced after 1 month. In conclusion, TEE is a fundamental technique when considering the percutaneous treatment of paravalvular leaks in patients with high surgical risk. It provides essential information on the characteristics of the dehiscence during implantation and follow-up.

Impact of Calcium Score on Agreement Between Multidetector Computed Tomography and Invasive Coronary Angiography.

INTRODUCTION AND OBJECTIVES: Multidetector computed tomography (MDCT) has been demonstrated as a feasible alternative to invasive coronary angiography (ICA). However, contradictory results have been reported regarding the effect of coronary artery calcium score (CS) on the diagnostic accuracy of MDCT. Our aim was to assess the agreement of MDCT and ICA and to evaluate the influence of CS on this agreement. METHODS: We enrolled 266 consecutive patients who underwent evaluation with 64-slice MDCT and ICA. Standard CS software tools were used to calculate the Agatston score. Stenosis was qualitatively classified as mild, moderate, or severe by 1 blinded observer and the results were compared with those of ICA, which was used as the gold standard. RESULTS: The mean age of the patients was 65.4 ± 11.2 years, and 188 patients (70.3%) were men. A total of 484 segments with coronary stenosis ≥ mild were qualitatively evaluated and quantified with MDCT. Noninvasive measurements were concordant with ICA in 402 stenoses (83.05%; Kappa, 0.684), with no significant differences between vessels and with no statistically significant influence of CS on this agreement (OR, 0.93; 95%CI, 0.76-1.09; P = .21). Multidetector computed tomography had high sensitivity, specificity, positive predictive value, and negative predictive value on a per-segment, per-vessel, and per-patient basis. CONCLUSIONS: Non-ICA using MDCT showed good agreement with ICA in the qualitative quantification coronary stenosis and CS had no significant impact on this agreement.

Tricuspid annular plane systolic excursion inaccuracy to assess right ventricular function in patients with previous tricuspid annulopasty.

OBJETIVES: The clinical and prognostic usefulness of tricuspid annular plane systolic excursion (TAPSE) is well established. However, the ability of TAPSE to assess right ventricular (RV) function in patients with previous tricuspid valve annulopasty is controversial. This study examined the TAPSE suitability in patients with previous tricuspid valve annuloplasty using right ventricular fractional area change (RVFAC) as reference method. METHODS: We retrospectively analyzed 53 patients who underwent tricuspid valve annuloplasty at our hospital between 2013 and 2016. TAPSE and RVFAC were obtained in preoperative and postoperative periods using standard methodology. RESULTS: Mean age was 68±12years and 34 patients (64.1%) were women. TAPSE decreased significantly after surgery in comparison with pre-surgical values (17±4.2 Vs 12.9±4.1mm, p<0.001). On the contrary, RVFAC did not change significantly after surgery (37±9.2 Vs 36.2.9, p=0.25). The correlation between RVFAC and TAPSE was better in the preoperative (r=0.63, p<0.0001) than in the postoperative period (r=0.38, P=0.005). Good intra- and interobserver agreement for TAPSE and RVFAC was obtained, with intraclass correlation coefficients of 0.97 and 0.92 for TAPSE; and 0.90 and 0.85 for RVFAC, respectively. CONCLUSIONS: These findings suggest that TAPSE is not suitable after tricuspid valve annuloplasty and it leads to an underestimation of RV systolic function. It seems to be appropriate to rely on echocardiographic parameters of global RV function such as RVFAC in this context.

Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study.

OBJECTIVES: The aim of our study was to assess whether left atrial appendage (LAA) ligation in patients undergoing mitral valve replacement is associated with the risk of future embolisms. BACKGROUND: Previous studies show that the LAA plays an important role in the development of intracardiac thrombus. According to this decisive role, LAA surgical closure in patients undergoing cardiac surgery may be an attractive choice for reducing stroke. METHODS: We retrospectively studied 205 patients with previous mitral valve replacement and referred for echocardiography study. Patients were excluded if other causes of systemic embolism were found. The main outcome measure was the occurrence of an embolic event. RESULTS: Ligation of LAA was performed in 58 patients. However, an incomplete ligation was verified in six patients. During a median time from valve replacement to echocardiography study of 69.4 months (1 to 329), 27 patients had an embolism. Multivariate analysis identified the absence of LAA ligation (odds ratio [OR] 6.7 [95% confidence interval [CI] 1.5 to 31.0]; p = 0.02) and the presence of left atrial thrombus as the only independent predictors of occurrence of an embolic event. Moreover, when the identification of an incomplete LAA ligation was considered together with the absence of LAA ligation, risk of embolism increased up to 11.9 x (OR 11.9 [95% CI 1.5 to 93.6]; p = 0.02). CONCLUSIONS: Our study shows that LAA ligation during surgery of mitral valve replacement, performed in a high-risk population, is consistent with a reduction of the risk of late embolism and supports this technique if a mitral valve replacement is indicated.

Primary angioplasty reduces the risk of left ventricular free wall rupture compared with thrombolysis in patients with acute myocardial infarction.

OBJECTIVES: This study aimed to evaluate the effect of primary angioplasty (PA) over the risk of free wall rupture (FWR) in reperfused acute myocardial infarction (AMI). BACKGROUND: It has been suggested that PA reduces the risk of FWR compared with thrombolysis. However, few studies have evaluated this issue, and there are no data demonstrating this hypothesis. METHODS: A total of 1,375 patients with AMI treated with PA (n = 762, 55.4%) or thrombolysis (n = 613, 44.6%) within 12 h after symptoms onset were included. The diagnosis of FWR was made either in the presence of sudden death due to electromechanical dissociation with large pericardial effusion on an echocardiogram or when demonstrated post mortem or at surgery. A multivariable analysis was performed including type of reperfusion strategy. RESULTS: The overall incidence of FWR was 2.5% (n = 34): 1.8% and 3.3% in patients treated with PA and with thrombolysis, respectively (p = 0.686). The following characteristics were associated with a higher rate of FWR in the univariable analysis: age >70 (5.2% vs. 1.2%, p < 0.001), female gender (5.1% vs. 1.8%, p = 0.006), anterior location (3.3% vs. 1.4%, p = 0.020) and treatment >2 h after symptoms onset (3.6% vs. 1.7%, p = 0.043). In the multivariable analysis, age >70 (odds ratio [OR]: 4.12, 95% confidence interval [CI]: 2.04 to 8.62, p < 0.001) and anterior location (OR: 2.91, 95% CI: 1.36 to 6.63, p = 0.008) were independent risk factors of FWR, whereas treatment with PA was an independent protective factor (OR: 0.46, 95% CI: 0.22 to 0.96, p = 0.0371). CONCLUSIONS: In patients with AMI, PA reduces the risk of FWR in comparison with thrombolysis.

Cardiac rupture during contrast-enhanced dobutamine stress echocardiography.

Dobutamine stress echocardiography is widely used after myocardial infarction. This technique is safe and severe adverse reactions are uncommon. We report one case of cardiac rupture during contrast-enhanced dobutamine stress echocardiography.

M-mode apical systolic excursion: A new and simple method to evaluate global left ventricular longitudinal strain.

INTRODUCTION: Since M-mode measurements can assess deformation of specific regions of the left ventricle, we hypothesized that M-mode measurements like M-mode apical systolic excursion (MMASE) and mitral annular plane systolic excursion (MAPSE) may be correlated with left ventricular longitudinal strain (LVLS). METHODS: All subjects of the study underwent a full echocardiographic evaluation and MMASE and MAPSE measurement. Three-dimensional wall motion tracking (3D-WMT) was performed. RESULTS: Thirty-one patients were evaluated. Significant correlations between MAPSE and LVLS (-0.372; p=0.04) and between MMASE and LVLS (-0.398; p=0.027) were found. LVLS was linearly related to MAPSE and MMASE (in mm) as follows: ST=-10.6 -0.4 * MAPSE (r2=0.14) and ST=-13.1 -0.5 * MMASE (r2=0.16). CONCLUSIONS: Our results demonstrate that simpler and faster methods than strain based on complex speckle analysis can also have a role in predicting subclinical left ventricular systolic dysfunction.

Giant and thrombosed left ventricular aneurysm.

Left ventricular aneurysms are a frequent complication of acute extensive myocardial infarction and are most commonly located at the ventricular apex. A timely diagnosis is vital due to the serious complications that can occur, including heart failure, thromboembolism, or tachyarrhythmias. We report the case of a 78-year-old male with history of previous anterior myocardial infarction and currently under evaluation by chronic heart failure. Transthoracic echocardiogram revealed a huge thrombosed and calcified anteroapical left ventricular aneurysm. Coronary angiography demonstrated that the left anterior descending artery was chronically occluded, and revealed a big and spherical mass with calcified borders in the left hemithorax. Left ventriculogram confirmed that this spherical mass was a giant calcified left ventricular aneurysm, causing very severe left ventricular systolic dysfunction. The patient underwent cardioverter-defibrillator implantation for primary prevention.

COVID-19 y afectación cardíaca / Cardiac implications and COVID-19

The coronavirus pandemic has generated a serious global health problem. COVID-19 mainly affects the lung, but it has been seen that myocardial involvement also occurs in some patients, producing myocarditis and arrhythmias.

La pandemia por coronavirus ha generado un grave problema sanitario mundial. El COVID-19 afecta fundamentalmente el pulmón, pero se ha visto que en algunos pacientes también se produce afectación del miocardio produciendo miocarditis y arritmias.

Efficacy and learning curve of a hand-held echocardiography device in an oncology outpatient clinic: Expanding the use of echoscopic heart examination beyond cardiology.

Certain chemotherapy drugs for breast cancer may induce cardiotoxicity and these patients should be echocardiographically monitored. The performance of a focused echocardiographic evaluation (echoscopy) at the patient's location by a non-cardiologist appears to be feasible. The aim of the present study was to assess the accuracy of echoscopy performed by medical oncologists in an outpatient clinic using hand-held echocardiography devices. The study cohort comprised consecutive unselected patients who attended an oncology outpatient clinic. Two medical oncologists attended a one-week training period, which included theoretical and practical teaching by an expert cardiologist. Every subject underwent two echo examinations. The first examination was performed by an oncologist using a hand-held echo device and the second was performed by a cardiologist using a 'premium' device. Out of the 101 enrolled patients, 32 were men (31.7%) and the mean age was 56.03±16.88 years. There was a good global agreement [intra-class correlation coefficient (ICC): 0.65 for left ventricular ejection fraction (LVEF)]. When the results were analyzed depending on the period of time when the echo studies were performed, a clear and short learning curve was observed: LVEF started at ICC=0.58 and increased to 0.66 and 0.77 in the second and third period, respectively. There were extremely few clinically significant differences and a learning curve was also evident. In conclusion, cardiac echoscopy performed by an oncologist with a hand-held device may lead to a similar clinical management as a study performed by an expert cardiologist with a 'premium' system in patients under chemotherapy following a short training period.

Usefulness of contrast echocardiography in arrhythmogenic right ventricular dysplasia.

Arrhythmogenic right ventricular (RV) dysplasia or cardiomyopathy is a familiar heart muscle disease, characterized by progressive fibrofatty replacement of RV myocardium. Echocardiography can be used to evaluate the wide spectrum of abnormalities that range from a normal RV to severe RV dilation, with localized aneurysms. In the context of a positive family history, even minimal RV abnormalities represent a disease expression. This suggests the need for a careful echocardiographic investigation focusing in subtle structural changes. However, echocardiography may be limited by poor endocardial visualization in several patients. Contrast echocardiography may improve endocardial border delineation in these cases and, thus, the ability to assess arrhythmogenic RV dysplasia or cardiomyopathy at the initial stages of the disease.

Regional Left Ventricular Diastolic Dysfunction Evaluated by Pulsed-Tissue Doppler Echocardiography.

Pulsed-wave Doppler tissue imaging (DTI) allows the examination of regional wall motion at a very high temporal resolution and therefore constitutes an excellent technique for assessing diastolic motion of left ventricular walls. Regional relaxation has been well characterized in normal subjects using this technique, and physiological time intervals and motion wave profiles are described. In an experimental model of acute ischemia, local relaxation impairment was observed showing highly characteristic local diastolic abnormalities. Interestingly, these findings took place before any decrease in systolic motion was recordable. In a prospective clinical study, noninvasive regional DTI parameters were compared with coronary angiography to assess the feasibility and clinical value of the technique; the diagnostic accuracy is discussed in detail. Also, the association between regional diastolic parameters and global regional function as assessed by Doppler analysis of transmitral left ventricular filling flow was studied, stressing the impact of regional diastolic function on overall ventricular performance. Finally, the diagnostic role of pulsed-wave DTI on stress testing, identification of myocardial viability, and microvascular angina is reviewed.