Clinical and hemodynamic results after direct transcatheter aortic valve replacement versus pre-implantation balloon aortic valvuloplasty: A case-matched analysis.

OBJECTIVES: To evaluate the safety and midterm hemodynamic results of direct transcatheter aortic valve replacement (TAVR) without pre-implantation balloon aortic valvuloplasty (BAV). BACKGROUND: BAV was considered a mandatory previous step in TAVR procedures. METHODS: A total of 339 consecutive patients who underwent transfemoral TAVR were prospectively selected. A 1:1 matching was conducted, pairing age, prosthesis type (self-expandable or balloon expandable) and size, and valve calcification grade (48% with moderate to severe valve calcification). Finally, 102 pairs (102 patients with previous BAV and 102 without BAV) were obtained. RESULTS: Direct TAVR was feasible in all patients without any crossover to BAV group. Device success was achieved in 91.2% and 90.2% of cases in direct TAVR and pre-BAV groups (P = 0.810), respectively, without any differences in balloon postdilation rate and residual aortic regurgitation. The amount of contrast agent, acute kidney injury and myocardial injury was significantly lower in the direct implantation group (P < 0.05). No differences were found in 30-day and 1-year mortality between both groups (4.9% vs. 9.8%, P = 0.177 and 14.0% vs. 23.8%, P = 0.771, respectively). Hemodynamic parameters remained stable after 1-year follow-up in both groups. CONCLUSIONS: Direct transfemoral TAVR without prior BAV was safe in patients with calcified severe aortic stenosis. Pre-implantation BAV could be omitted in patients undergoing TAVR, without influence in procedure success rate, and subsequent patients' clinical course and valve hemodynamic performance. © 2016 Wiley Periodicals, Inc.

Thromboembolic risk in atrial fibrillation: association between left atrium mechanics and risk scores. A study based on 3D wall-motion tracking technology.

BACKGROUND/OBJECTIVES: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a significantly high risk of stroke and systemic embolism. The aim of our study was to assess the association between left atrium (LA) mechanics measured by 3D wall-motion tracking (3DWMT) technology and the most common thromboembolic risk scores (CHADS2, CHA2DS2-VASc). METHODS: A total of 101 consecutive patients with permanent AF referred were included. Conventional bidimensional (2D) LA parameters, and LA mechanics by means of 3DWMT were studied. Association between LA 2D and 3DWMT parameters and both risk scores was evaluated as well as its correlation with every component of the score individually. RESULTS: Mean age was 78 ± 10 years. Mean CHADS2 was 2.7 ± 1.3 and mean CHA2DS2-VASc was 4.4 ± 1.7. Values of 2D and 3DWTM LA parameters were: 2D area 26.4 ± 9.7 cm(2) , 2D volume index 49.4 ± 10.1 mL/m(2) , 3DWMT left atrial emptying fraction (LAEF) 15.9 ± 8.4%, longitudinal strain 9.1 ± 4.5% and area strain 14.9 ± 8.8%. Linear regression analysis showed statistically significant correlation between LA longitudinal strain and LAEF with CHADS2 and CHA2DS2-VASc scores. For each 10% variation in longitudinal strain, CHADS2 and CHA2DS2-VASc scores change in 0.7 and 0.8 points, respectively. CONCLUSIONS: Left atrial longitudinal strain and emptying fraction assessed by 3D WMT technology have correlation with both CHADS2 and CHA2DS2-VASc scores. Each 10% of variation in longitudinal strain represents a 0.7 and 0.8 points change in those risk scores. LA mechanics evaluation might provide additional value to risk scores and could be considered to be a predictor of stroke in patients with AF.

Transfemoral implantation of Edwards Sapien XT aortic valve without previous valvuloplasty: role of 2D/3D transesophageal echocardiography.

BACKGROUND: Balloon valvuloplasty (BAV) has been considered a mandatory step before TAVI. However, it might be related to cerebrovascular microembolizations, atrioventricular conduction disturbances, and hemodynamic instability. The aim of this study is to describe transesophageal echocardiography characteristics of patients that could benefit from direct transfemoral transcatheter aortic valve implantation (TAVI) of Edwards SAPIEN XT, without previous BAV. METHODS AND RESULTS: A total of 16 patients with direct implantation of an Edwards SAPIEN XT valve are included. Preprocedural echocardiographic findings were exhaustively analyzed and described. From 32 patients elected for transfemoral TAVI with an Edwards SAPIEN XT, 16 of them (50%) were selected for direct implantation using the Edwards SAPIEN XT valve of size 23 mm (n = 5), 26 mm (n = 8), or 29 mm (n = 3). Patients selection for direct TAVI presented three echocardiographic conditions: central effective orifice, moderate to severe calcification of the aortic valve apparatus preserving leaflets movement, and symmetric distribution of calcium with absent to moderate central aortic regurgitation. Mean age was 81.4 ± 7.4, 75% female, with a mean logistic Euroscore 18.2 ± 11.2. Preprocedural mean valve gradient was 43.6 ± 16.3. Mean effective orifice area was 0.7 ± 0.2. There was no valve embolization and the success rate was 100%. Postdilation was performed in one patient (6.25%). New permanent pacing was needed in two patients (12.5%). CONCLUSIONS: TAVI without previous BAV is feasible and safe. 2D/3D TEE is an essential tool to select the patients that could benefit from this technique.

Feasibility and safety of transfemoral implantation of Edwards SAPIEN XT prosthesis without balloon valvuloplasty in severe stenosis of native aortic valve.

OBJECTIVES: Balloon valvuloplasty (BV) before transcatheter aortic implantation has been thought to be mandatory before the valve is implanted. We have explored the feasibility and safety of direct implantation of balloon expandable Edwards SAPIEN XT valve without prior balloon dilatation. BACKGROUND: Some complications after transcatheter aortic valve replacement (TAVR) have been associated with unwanted effects of BV, mainly the contribution to stroke and severe aortic regurgitation (AR) before the valve is implanted. Direct implantation with a self-expanding aortic valve has been recently reported. METHODS: From November 2011 to April 2012, ten patients were selected that met the following criteria in the transesophageal echocardiography (TEE): moderate calcification, homogeneous distribution of calcium, symmetrical opening of the valve, and some degree of aortic insufficiency. RESULTS: All patients had symptomatic aortic stenosis of a native valve and high surgical risk; six patients had the valve mildly calcified, in four patients the degree of calcification was moderate. The native valve was crossed and the prosthetic aortic valve was properly positioned in all cases and implanted in the correct position. No patient underwent post-dilatation and trivial AR was present in four patients. There were no adverse events (death, need for pacemaker, myocardial infarction, or stroke). At 30 days post-procedure, all patients were alive and had significant clinical improvement. CONCLUSIONS: Direct implantation of Edwards SAPIEN XT without prior BV in selected cases is feasible and safe. The number of patients in whom this technique would be applicable, and their impact on reducing complications has to be determined.

Determinants of clinical improvement after surgical replacement or transcatheter aortic valve implantation for isolated aortic stenosis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) and high surgical risk. Hemodynamic performance after TAVI is superior, but the impact of reverse remodeling on clinical improvement is controversial. We aim to address the differences in hemodynamic changes between SAVR and TAVI, and its correlation with LV remodeling and clinical improvement at 6 months follow-up. METHODS: Forty-two patients treated by TAVI were compared with 45 SAVR patients with a stented bioprosthesis. Clinical, 2D and 3D echocardiographic data were prospectively obtained before and six months after intervention. RESULTS: Patients had similar distribution for sex, body surface area and AS severity. TAVI patients were older, more symptomatic and had more comorbidities. They also had higher LV filling pressures, larger 3D indexed left atrium volume, but similar 3D indexed LV mass. At 6 months, TAVI patients had greater clinical improvement and higher effective orifice area index (EAOI), but only SAVR patients already had a significant decrease in 3D indexed LV mass and diastolic volume. In univariate analysis older age, NYHA class ≥ III, increase in EAOI and TAVI were related with functional class improvement. After multivariate analysis only NYHA class ≥ III (OR 8.81, CI:2.13-36.52; p=0.003) and an increase in EAOI ≥ 105% (OR 3.87, CI:1.02-14.70; p=0.04) were predictors of clinical improvement. CONCLUSIONS: At 6 months, functional class improvement was greater after TAVI. Higher initial NYHA class and an increase in EAOI ≥ 105% were independently associated with functional enhancement. It is debatable if left ventricular remodeling is determinant for functional class improvement.

Double bifurcation lesion treated with double Tryton Sidebranch Stent: first case report.

The optimal percutaneous treatment strategy for coronary bifurcation lesions is still unknown. Several dedicated coronary bifurcation stents, such as the Tryton Side Branch Stent™ (Tryton Medical, Durham, NC) have been developed to improve clinical outcomes. We presented a double bifurcation lesion case treated with two Tryton sidebranch stents, with a single drug eluting stent covering the main vessel and both bifurcations.

Acute left ventricle diastolic function improvement after transcatheter aortic valve implantation.

AIMS: Data regarding the effects of TAVI on LV after are scarce and conflicting results have been reported immediately after aortic valvuloplasty. This study aimed to determine the acute haemodynamic effects of transcatheter aortic valve implantation (TAVI) in left ventricle (LV) diastolic performance, immediately after aortic valvuloplasty and prosthesis deployment. METHODS AND RESULTS: Sixty-one patients with severe aortic valve stenosis, and preserved LV systolic function submitted to successful TAVI, were included. All procedures were guided through transoesophageal echocardiography, and parameters of diastolic function were evaluated before and minutes after TAVI. The mean age was 83.5±6 years and mean log EuroSCORE was 18.2±9.4. Before the procedure, all patients presented LV diastolic dysfunction. Immediately after TAVI, fewer patients presented a restrictive pattern [27 (44.3%), before the procedure, vs. 20 (34.4%), after TAVI (P=0.047)], and an increase in E wave deceleration time (211.2±75.5 vs. 252.7±102.3 cm/s, P=0.001), in E wave velocity (109.5±41.2 vs. 120.3±43.6 cm/s, P=0.025), and in isovolumetric relaxation time (83±36.5 vs. 97.1±36.0 ms, P=0.013) was observed. On multivariate analysis of covariance (ANCOVA), adjusting to LV systolic function, heart rate, blood pressure, and haematocrit values, the results remained significant. Patients referred to percutaneous approach had invasive haemodynamic data collected, showing a decrease in LV end-diastolic pressure after valve implantation [18.8±5.7 vs. 14.7±4.7, mean difference -4.1 (95% CI: -5.9; -2.9)]. Patients with a restrictive pattern immediately after TAVI presented a smaller decrease in LV end diastolic pressure (-3.3±4.7) than those with diastolic dysfunction grade I or II (-9.5±4.7; P=0.017). CONCLUSION: This is the first study describing LV diastolic performance during TAVI. Our results show improvement in diastolic function parameters in patients with preserved LV systolic function, immediately after successful TAVI.

Myocardial strain characterization in different left ventricular adaptative responses to high blood pressure: a study based on 3D-wall motion tracking analysis.

BACKGROUND: High blood pressure increases left ventricular (LV) after-load. Furthermore, LV response to that high blood pressure varies among different subjects. Nevertheless, myocardial deformation behavior in these different adaptative responses has not been analyzed until now. METHODS: Prospective study in which 66 consecutive hypertensive patients were enrolled in between May and August 2009. Every patient underwent a standard echocardiographic study and a three-dimensional-wall motion tracking (3D-WMT) study. The patients were classified according to parameters derived from echocardiography in four different groups: normal geometry, concentric remodelling, concentric hypertrophy, and eccentric hypertrophy. RESULTS: Mean age was 68 years (57-74.25; 51.5% male). Comparing the four groups, significant differences were found for the five 3D-WMT-derived parameters. When patients were compared with hypertensive patients with normal geometry, our finding show that: (a) LV average torsion is the only impaired parameter that is found in the LV concentric remodelling group (P < 0.05 vs. group 1); (b) there is a trend for an increase (P = 0.055) in LV average radial strain in the group with concentric hypertrophy and this increase is accompanied by a significant decrease in the remaining studied parameters (P < 0.05); and (c) in the LV eccentric hypertrophy group, there is a significant impairment in all the studied parameters (P < 0.05). CONCLUSIONS: LV adaptative response to hypertension is accompanied by a modification or even impairment, in LV myocardial deformation evaluated by 3D-WMT. This assessment might be useful to detect early and subtle deformation impairments in hypertensive patients and it could help optimize their clinical management.

Huge tricuspid valve abscess.

A 60-year-old woman with colorectal adenocarcinoma underwent surgical mass resection in 2003; hepatic segmentectomy due to hepatic metastasis was performed in 2005. A port-a-cath for the administration of chemotherapy was cannulated. In April 2007, the patient developed fever and shivering, and the catheter was removed. Catheter and blood cultures were positive for methicillin-sensitive Staphylococcus aureus. TEE showed a very mobile mass (3 x 2 cm) at the junction of the posterior and anterior leaflets of the tricuspid valve. The mass had large echolucent areas inside, exhibiting an appearance like a 'ball of wool' (Panel B). Cardiac MRI confirmed the presence of a mass attached to the tricuspid valve, as shown in the delayed enhancement sequence. At surgery, a ruptured tendinous cord as well as a large abscess within the septal leaflet of the tricuspid valve was found.

Usefulness of 3D transoesophageal echocardiography for guiding wires and closure devices in mitral perivalvular leaks.

Sixty-three-year-old male patient. Previous history of rheumatic valvular disease. He underwent multiple mitral and aortic valve replacements. Nowadays, he presents a periprosthetic mitral leak. He underwent a leak closure by using a percutaneous approach. During the procedure, the superiority of 3D TEE over 2D TEE was confirmed for wires and device positioning, excluding interference with the prosthesis discs and evaluating the residual periprosthetic regurgitation.

What to do with an atrial thrombus?

This case report is about an 84-year-old woman admitted with right atrial thrombus attached to a pacemaker lead, diagnosed by transesophageal echocardiography. Surgical treatment was rejected due to the high operative risk, and percutaneous stenting was performed with success; unfortunately, the outcome was fatal and the patient died. We review here the clinical features of right atrial thrombi, including the epidemiology, clinical manifestations, diagnosis, and treatment, which is sometimes controversial.

[Associated factors to increased sensitivity in the transthoracic echocardiogram for the diagnosis of infective endocarditis]. / Factores asociados a aumento de la sensibilidad del ecocardiograma transtorácico en el diagnóstico de la endocarditis infecciosa.

INTRODUCTION AND OBJECTIVES: Echocardiography is considered a basic tool in the diagnosis and management of infective endocarditis. Transesophageal echocardiography is more sensitive than transthoracic echocardiography. Our aim was to describe which factors are related to the ability of transthoracic echocardiography to establish the diagnosis of infective endocarditis. The presence of this factors in a patient with a normal transthoracic echocardiography would make unnecessary to perform a transesophageal echocardiography and would suggest to seek for other diagnostic possibilities. METHODS: 127 consecutive patients admitted to our hospital with the diagnosis of infective endocarditis and a complete transthoracic echocardiography and transesophageal echocardiography comprised our study group. Predisposing factors and clinical, echocardiographic and microbiological variables were studied. RESULTS: The presence of a cardiac murmur, the presence of an optimal acoustic window, degenerative valvular disease as the predisposing factor for infective endocarditis and positive blood cultures were related to the ability of transthoracic echocardiography to diagnose the existence of signs of infective endocarditis on its own. Nevertheless, only the presence of a cardiac murmur (RR 2.724; 95% CI 1.071-6.926; p 0,035) and the presence of an optimal acoustic window (RR 5.538; 95% IC 2.75-11.15; p < 0.001) were found as independent factors to detect those patients in which transthoracic echocardiography is able to diagnose signs of infective endocarditis on its own. CONCLUSIONS: The diagnostic accuracy of transthoracic echocardiography to detect echocardiographic signs of infective endocarditis is high in those patients with cardiac murmur and optimal acoustic window. In those patients with these characteristics, without prosthetic heart valves and a negative transthoracic echocardiography for infective endocarditis other diagnostic possibilities should be ruled out before performing of a transesophageal echocardiography.

Comparison of left ventricular volumes and ejection fractions measured by three-dimensional echocardiography versus by two-dimensional echocardiography and cardiac magnetic resonance in patients with various cardiomyopathies.

End-diastolic volume and end-systolic volume were measured in 35 consecutive patients with cardiomyopathy using 2-dimensional (2-D) and 3-dimensional (3-D) echocardiography (2, 4, and 8 planes) and cardiac magnetic resonance imaging. Three-dimensional echocardiography correlates better with magnetic resonance imaging than does 2-D echocardiography. Its accuracy improves with the increase in the number of planes used. Two-dimensional echocardiography underestimates volumes, mainly in the subgroup with an ejection fraction of <50%, whereas 3-D echocardiography does not, if enough planes are used. However, in patients with an end-diastolic volume > or =150 ml, the underestimation of 3-D echocardiography is statistically significant. Increasing the number of planes to 8 reduces this bias. Conversely, patients with an end-diastolic volume <150 ml are accurately studied with just 4 planes.

Identification of stunned myocardium with parametric imaging-based, quantitative myocardial contrast echocardiography after acute myocardial infarction.

Microvascular integrity demonstrated by myocardial contrast echocardiography (MCE) predicts functional recovery after an acute myocardial infarction (AMI). Recently, parametric imaging-based quantitative MCE has been developed. Our aim was to assess the usefulness of parametric imaging-based quantitative MCE parameters to predict the functional recovery of akinetic segments after primary percutaneous transluminal coronary angioplasty (PTCA). Fifty-three consecutive patients with a first AMI were enrolled. They underwent primary PTCA. Standard echocardiography and real-time MCE were performed. Qualitative analysis and parametric imaging-based quantitative parameters were measured offline by different blinded investigators. Dobutamine stress echocardiography was performed 1 month later. A new standard echocardiogram to assess the functional status of the akinetic segments and coronary angiography to evaluate the presence of restenosis at the level of the culprit lesion were performed 6 months later. The mean patient age was 62.9 +/- 14 years, and 42 were men (79%); 170 segments were akinetic. Of these, 105 (62%) recovered their function. The best parameter to predict functional recovery was the myocardial blood flow velocity (beta). These results were better than those obtained using dobutamine stress echocardiography and qualitative MCE to predict functional recovery. In conclusion, parametric imaging-based quantitative MCE is an accurate diagnostic tool to detect stunned myocardium after AMI. Its diagnostic accuracy in predicting the functional recovery of akinetic segments after primary PTCA is better than the accuracy of dobutamine stress echocardiography and qualitative MCE.

Long-term prognostic importance of transient left ventricular dilation during pharmacologic stress echocardiography.

OBJECTIVES: We sought to evaluate the prognostic significance of left ventricular (LV) transient ischemic dilation (TID) for patients with a positive stress echocardiogram (SE). BACKGROUND: TID during SE has been related to the presence of extensive coronary artery disease, but its long-term prognostic implications have not been reported. METHODS: In all, 99 consecutive patients with a positive SE comprised the study group. LV volumes were evaluated according to the modified Simpson's rule. TID during SE was defined as the presence of an increase in LV end-diastolic volume during the stress test. A clinical history was fulfilled for each patient and all of them were followed up. RESULTS: Of 99 patients, 32 (32.3%) showed TID. Mean age was 65.8 +/- 9.8 years for non-TID group and 70.2 +/- 8.4 for TID group (P = .048). Baseline characteristics and subsequent treatment were similar in both groups. Mean follow-up was 21.4 +/- 15.8 months. In non-TID group the mean survival free of acute myocardial infarction was 47.28 months and 39.7 months in TID group (log rank = 0.012). In the univariate and multivariate analysis only TID and the wall motion score index were found as independent predictors related to long-term prognosis (risk ratio = 6.9; 95% confidence interval = 0.8-59.6; P = .042; and risk ratio = 0.4; 95% confidence interval = 0.18-0.89; P = .047, respectively). CONCLUSIONS: LV TID during SE is an easy and independent prognostic marker. It helps to select patients with increased risk.

Prognostic significance of ischemic mitral regurgitation after non-Q-wave acute myocardial infarction.

BACKGROUND AND AIM OF THE STUDY: The development of mitral regurgitation (MR) soon after acute myocardial infarction (AMI) is a recognized and frequent complication. Its negative impact on survival has been observed after Q-wave AMI, even when of a mild degree, and independently of left ventricular systolic function. Few data exist regarding MR after non-Q-wave AMI (nQ AMI), however. Hence, the study aim was to investigate the incidence, clinical predictors and prognostic implications of MR in the setting of nQ AMI. METHODS AND RESULTS: A total of 99 consecutive patients (37 men, 62 women; mean age 72 +/- 13 years) who suffered a nQ AMI was studied. All patients underwent echocardiography during the first week after the nQ AMI. MR was detected in 34 patients (17 men, 17 women; mean age 76 +/- 10 years). Events during follow up were coded as death, AMI, unstable angina, or heart failure. The in-hospital outcome was not significantly different between patients with and without MR. The mean follow up period was 663 +/- 574 days. In the univariate analysis, freedom from hospital survival was significantly greater in patients without MR. However, multivariate analysis showed that MR was not an independent predictor of cardiovascular hospitalization or death. CONCLUSION: The incidence of MR is high among patients with nQ AMI but, unlike results found with Q-wave AMI, its presence does not add any prognostic significance to other known negative factors in the setting of nQ AMI.

Infective endocarditis: mid-term prognosis in patients with good in-hospital outcome.

BACKGROUND AND AIM OF THE STUDY: The study aim was to analyze the mid-term prognosis of infective endocarditis (IE) in patients managed with medical therapy during the in-hospital phase and who had a good initial outcome. Comparison was made with the prognosis of patients treated surgically during this period. METHODS: A total of 151 patients diagnosed with IE was studied, and in-hospital outcome, clinical characteristics and mid-term follow up data were analyzed. The main end-point was a composite of death and need for surgical repair. RESULTS: Among 151 patients, 84 (56%) underwent surgery or died during the in-hospital phase, while 67 patients (44%) received medical treatment and were discharged clinically stable with a final diagnosis of healed infective endocarditis. A better baseline profile was seen in the medically treated group, but outcome in this group showed extensive mid-term morbidity/mortality. In total, 52.2% of patients underwent surgery to correct complications and 60% died as a consequence of the disease. The event-free survival rate was 20% at five years. CONCLUSION: Despite a favorable in-hospital clinical course and successful medical treatment, patients with IE are at risk of late complications that result in a need for surgical repair, or in death. A close follow up should be made in order to treat late complications.