Association with left atrial volume index and long-term prognosis in patients without systolic dysfunction nor atrial fibrillation: an observational study.

The prognostic impact of left atrial size in patients without systolic dysfunction nor atrial fibrillation (AF) has not been fully elucidated in Japan. We retrospectively analyzed data obtained from 4444 consecutive patients who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in our hospital. Those who presented with a history of myocardial infarctions, severe and moderate valvular diseases, low ejection fraction (< 50%), and documented AF, and without data on LA volume index (LAVI) or tissue Doppler early diastolic mitral annular velocity were excluded. We defined high LAVI as a value > 34 ml/m2. The primary outcome measure was a composite of all-cause death and major adverse cardiac events. A total of 2792 patients were categorized into two groups: 2627 with normal LAVI (94.1%), 165 with high LAVI (5.9%). The median age of patients in the normal and high LAVI groups were 67, and 77 years, respectively (p < 0.001). Prevalence of diabetes mellitus, hypertension, and chronic kidney disease, and left ventricular mass index was higher in the high-LAVI group than normal-LAVI group. After adjusting for confounders, the excess 3-year risk of primary outcome of high-LAVI related to normal-LAVI was significant (hazard ratio 1.44; 95% confidence interval 1.03-1.97, p = 0.032). High-LAVI should be considered a marker of a worse long-term follow-up in patients without systolic dysfunction nor AF.

Age- and Body Size-Adjusted Left Ventricular End-Diastolic Dimension in a Japanese Hospital-Based Population.

BACKGROUND: Using the normal values for the East Asian population, we evaluated age- and body size-adjusted left ventricular end-diastolic dimension (LVEDD) and its prognostic impact in a hospital-based population in Japan. Methods and Results: We retrospectively analyzed data obtained from 4,444 consecutive patients who had undergone both transthoracic echocardiography and electrocardiography at Kitano Hospital in 2013. Those who presented with a history of previous episodes of myocardial infarction and severe or moderate valvular disease or with low ejection fraction (<50%) were excluded from the analysis. We calculated LVEDD adjusted by age and body surface area. A total of 3,474 patients were categorized into 3 groups: 401 with large adjusted LVEDD, 2,829 with normal adjusted LVEDD, and 244 with small adjusted LVEDD. Mean patient age in the large, normal, and small adjusted LVEDD groups was 66.6±18.4, 65.6±15.7, and 62.1±15.5 years, respectively (P<0.001). After adjusting for confounding factors, the excess adjusted 3-year risk of primary outcome of large adjusted LVEDD relative to normal LVEDD was significant (HR, 1.40; 95% CI: 1.08-1.78). The risk for primary outcomes of small adjusted LVEDD relative to normal adjusted LVEDD was significantly lower (HR, 0.55; 95% CI: 0.34-0.85). CONCLUSIONS: Adjusted large LVEDD has a deleterious impact on long-term mortality, whereas small LVEDD carried a significantly lower risk.

Association between abnormal myocardial scintigraphy findings and long-term outcomes for elderly patients 85 years or older: a retrospective cohort study.

BACKGROUND: Normal findings of cardiac scintigraphy predict good outcomes. However, a paucity of the data exists for elderly patients 85 years or older. In the present study, we aimed to demonstrate the association between the abnormal findings of cardiac scintigraphy and the risk of all cause death in patients 85 years or older. METHODS: We enrolled 143 consecutive patients 85 years or older with known or suspected coronary artery disease who underwent stress scintigraphy under adenosine or an exercise test and a 99mTechnetium (Tc)-labeled tracer or thallium 201 (201Tl), dual tracer rest scintigraphy using 201Tl and 123I-ß-methyl iodophenyl pentadecanoic acid (123I-BMIPP), or 123I-BMIPP single tracer scintigraphy. Ischemia was defined by an induced perfusion abnormality according to a provocation test with recovery at rest or decreased uptake of 123I-BMIPP despite normal perfusion at rest. Infarction was defined by perfusion abnormalities assessed by images at rest on 201Tl or 99mTc-labeled tracer. We defined these findings as abnormal when at least one of these aforementioned characteristics was observed. RESULTS: Patients in the abnormal findings group (N = 62) were more likely to have undergone prior coronary angiography and to have decreased ejection fraction than those in the normal findings group (N = 81). The median follow-up duration was 797 days (interquartile range, 635-1045 days), with follow-up rates of 90% at 1 year and 73% at 2 years. The 2-year mortality rate were significantly higher in the abnormal findings group than in the normal findings group (26.8% vs. 10.9%; p = 0.01). The risk of abnormal findings relative to normal findings remained significant for the mortality (adjusted hazard ratio, 5.99; 95% CI, 1.37-42.8; P = 0.015). CONCLUSION: Abnormal myocardial scintigraphy findings were associated with the increased risk for mortality, even for patients 85 years or older.

The Accuracy of a Large V Wave in the Pulmonary Capillary Wedge Pressure Waveform for Diagnosing Current Mitral Regurgitation.

BACKGROUND: Large V waves in the pulmonary capillary wedge pressure (PCWP) waveform traditionally indicate severe mitral regurgitation (MR). However, our understanding of MR etiology and hemodynamics has changed in recent decades. OBJECTIVES: We aimed to reevaluate the association between large V waves and current MR to determine whether traditional large V wave criteria remain optimal. METHOD: We reviewed 1,964 right heart catheterizations (RHCs) performed at our institution from 2010 to 2017, and retrospectively selected 126 patients with sinus rhythm who underwent echocardiography within 2 days (0.3 ± 0.5 days) of the RHC. The diagnostic accuracy of 3 traditional criteria for large V waves was assessed, and the optimal cut-off points were determined as those with the maximal Youden indices. RESULTS: Severe MR was observed on echocardiography in 26 (21%) patients, including 15 (58%) with Carpentier classification type II MR and 11 (42%) with type IIIB MR. Large V waves, defined as a difference between the peak V wave and mean PCWP ≥10 mm Hg, had a high specificity of 94% (95% confidence interval: 87-98%), but a low sensitivity of 27% (12-48%) for diagnosing severe MR. The optimal cut-off point for the V wave was 3 mm Hg above the mean PCWP, with a sensitivity of 73% (52-88%) and a specificity of 64% (54-73%). CONCLUSIONS: For diagnosing current MR, the cut-off point for a large V wave should be reduced from that previously employed for rheumatic valvular heart disease. This information may be useful in guiding contemporary transcatheter therapies for MR under RHC monitoring.

Prognostic significance of moderate primary mitral regurgitation and concomitant paroxysmal atrial fibrillation.

BACKGROUND: Severe primary mitral regurgitation [degenerative MR (DMR)] is associated with poor outcomes, including cardiac death and hospitalization due to worsening heart failure. However, little information is available regarding the characteristics of moderate DMR and their impacts on prognostic outcome. The aim of the present study was to investigate the prognosis and its determinants in patients with moderate DMR. METHODS: We retroactively reviewed 13,700 consecutive patients who underwent transthoracic echocardiography and selected those with moderate DMR but without other underlying cardiac diseases. We assessed the characteristics and event-free rate of patients with moderate DMR compared with those of age- and gender-matched patients with mild or no MR. RESULTS: The cohort included 182 (1%) patients with moderate DMR, and these were compared with 182 age- and gender-matched patients with mild or no MR. During the follow-up period of 1376 ± 652 days, 30 patients (8%) met the composite endpoint defined as cardiac death or hospitalization due to worsening heart failure. Kaplan-Meier analysis showed that patients with moderate DMR were significantly associated with a poor outcome compared to patients with mild or no MR (log-rank test p < 0.0001). Cox proportional hazard ratio revealed that moderate DMR and paroxysmal atrial fibrillation (PAF) were the independent predictors of the composite endpoint. CONCLUSIONS: Patients with moderate DMR and concomitant PAF had a significantly worse outcome compared to those with mild or no MR. Active surveillance and some intervention for patients with PAF and moderate DMR may be required.

Association of the low e' and high E/e' with long-term outcomes in patients with normal ejection fraction: a hospital population-based observational cohort study.

OBJECTIVE: We aimed to evaluate the association of the severity of left ventricular (LV) diastolic dysfunction with long-term outcomes in patients with normal ejection fraction. DESIGN: Retrospective study. SETTING: A single centre in Japan. PARTICIPANTS: We included 3576 patients who underwent both scheduled transthoracic echocardiography and ECG between 1 January and 31 December 2013, in a hospital-based population after excluding valvular diseases or low ejection fraction (<50%) or atrial fibrillation and categorised them into three groups: septal tissue Doppler early diastolic mitral annular velocity (e')≥7 (without relaxation disorder, n=1593), e'<7 and early mitral inflow velocity (E)/e'≤14 (with relaxation disorder and normal LV end-diastolic pressure, n=1337) and e'<7 and E/e'>14 (with relaxation disorder and high LV end-diastolic pressure, n=646). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was a composite of all-cause death and major adverse cardiac events (MACE). The secondary outcome measure were all-cause death and MACE, separately. RESULTS: The cumulative 3-year incidences of the primary outcome measures were significantly higher in the e'<7 and E/e'≤14 (19.0%) and e'<7 and E/e'>14 group (23.4%) than those for the e'≥7 group (13.0%; p<0.001). After adjusting for confounders, the excess 3-year risk of primary outcome for the groups with e'<7 and E/e'≤14 related to e'≥7 (HR: 1.24; 95% CI 1.02 to 1.52) and e'<7 and E/e'>14 related to e'<7 (HR: 1.57; 95% CI 1.28 to 1.94) were significant. The severity of diastolic dysfunction was associated with incrementally higher risk for primary outcomes (p<0.001). CONCLUSION: The severity of LV diastolic dysfunction using e'<7 and E/e'>14 was associated with the long-term prognosis in patients with normal ejection fraction in an incremental fashion.

Staging Cardiac Damage in Patients With Hypertension.

Ventricular and extraventricular response to pressure overload may be a common process in aortic stenosis and hypertension. We aimed to evaluate the association of a newly defined staging classification characterizing the extent of cardiac damage, originally developed for aortic stenosis, with long-term outcomes in patients with hypertension. We retrospectively analyzed 1639 patients with hypertension who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in a Japanese hospital, after excluding severe and moderate aortic stenosis, aortic regurgitation, mitral stenosis, previous myocardial infarction, or cardiomyopathy. We classified patients according to the presence or absence of cardiac damage as detected on echocardiography as follows: stage 0, no cardiac damage (n=858; 52.3%); stage 1, left ventricular damage (n=358; 21.8%); stage 2, left atrial or mitral valve damage (n=360; 22.0%); or stage 3 and 4, pulmonary vasculature, tricuspid valve, or right ventricular damage (n=63; 3.8%). The primary outcome was a composite of all-cause death and major adverse cardiac events. Cumulative 3-year incidence of the primary outcome was 15.5% in stage 0, 20.7% in stage 1, 31.8% in stage 2, and 60.6% in stage 3. After adjusting for confounders, the stage was incrementally associated with higher risk of the primary outcome (per 1-stage increase: hazard ratio, 1.46 [95% CI, 1.31-1.61]; P<0.001). The staging classification characterizing the extent of cardiac damage, originally developed for aortic stenosis, was associated with long-term outcomes in patients with hypertension in a stepwise manner.

Isolated Tricuspid Regurgitation and Long-Term Outcome in Patients With Preserved Ejection Fraction.

Background: The aim of this study was to evaluate the association of isolated tricuspid regurgitation (TR) with long-term outcome in patients with preserved left ventricular ejection fraction (LVEF). Methods and Results: We retrospectively analyzed 3,714 patients who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in a hospital-based population, after excluding severe and moderate left-side valvular disease and LVEF <50%. We classified patients into 2 groups: moderate to severe TR (n=53) and no moderate to severe TR (n=3,661). Next, we generated a propensity score (PS)-matched cohort: the moderate to severe TR group and the no moderate to severe TR group (n=41 in each group). The primary outcome was a composite of all-cause death and major adverse cardiac events. In the moderate to severe TR group, patients were older, and more likely to have higher left atrial volume index and E/e' than those in the no moderate to severe TR group. In the PS-matched cohort, cumulative 3-year incidence of the primary outcome was 61.5% in the moderate to severe TR group and 24.3% in the no moderate to severe TR group (log-rank P=0.043; hazard ratio, 2.86; 95% CI: 1.37-6.37). Conclusions: Isolated moderate to severe TR is associated with poor clinical outcome in patients with preserved LVEF.

Impact of stroke volume on prognostic outcome in patients with atrial fibrillation and concomitant heart failure with preserved ejection fraction.

BACKGROUND: Atrial fibrillation (AF) can lead to a decrease in stroke volume (SV) despite a preserved left ventricular ejection fraction (LVEF). However, no previous studies have evaluated the prognostic importance of the decreased SV in patients with AF and concomitant heart failure with preserved ejection fraction (HFpEF). METHODS: We retrospectively studied the cases of 1520 consecutive patients who had undergone right heart catheterization. HFpEF (New York Heart Association functional class ≥II and LVEF ≥50%) was observed in 574 patients. We selected 47 patients with persistent AF with a heart rate of 40-110bpm and HFpEF without other underlying heart diseases. RESULTS: Among a total of 47 patients, 16 (34%) had normal SV [SV index (SVI) >35ml/m2 and 31 (66%) patients had low SV (SVI≤35ml/m2)]. During the follow-up period of 1115±305 days, 14 patients (30%) met the composite endpoint defined as cardiac death and admission due to worsening heart failure. Cox proportional hazard ratio analysis showed that SVI was a predictor of the endpoint, independently of the cardiac index and other parameters. Kaplan-Meyer analysis showed that low SVI was significantly associated with a poor prognosis, with an event-free rate of 58% at the mean follow-up period of 991 days (log-rank p=0.02). In the multiple regression analysis, a high systemic vascular resistance index and a high heart rate were independent determinants of low SVI. CONCLUSIONS: Our findings suggest that low SV had a significant impact on prognosis in patients with AF despite the preserved LVEF. The SVI depended on the heart rate and SVRI.

Impact of left ventricular concentricity on long-term mortality in a hospital-based population in Japan.

BACKGROUND: The prognostic impact of relative wall thickness (RWT), ventricular concentricity, is controversial. METHODS: We retrospectively analyzed data obtained from 4444 consecutive patients who had undergone both transthoracic echocardiography and electrocardiography at our hospital in 2013. Those who presented with a history of previous episodes of myocardial infarctions and severe or moderate valvular disease were excluded from the analysis. We calculated RWT as follows: (2 x diastolic posterior wall thickness) / (the diastolic LV dimension). We defined high RWT as a ratio > 0.42. A total of 3654 patients were categorized into two groups: 492 with high RWT, and 3162 with normal RWT. RESULTS: The mean ages of those in the normal and high RWT groups were 64.6 (±standard deviation 16.3) and 71.6 (± 12.7) years, respectively (p<0.001). Prevalence of male sex, history of diabetes, hypertension, and chronic kidney disease, and the left atrium volume index was higher for the high RWT group than for the normal RWT group. The median follow-up period was 1274 days (interquartile range, 410-1470). The Kaplan-Meier curves showed a constant increase in all-cause death, with cumulative 3-year incidences of 18.3% and 10.8% for the high RWT and normal RWT groups, respectively (log-rank p<0.001). After adjusting for confounders, the increased mortality risk for those with high RWT relative to normal RWT was significant (hazard ratio, 1.64; 95% confidence interval, 1.27-2.10). This trend was consistent for the composite of deaths and major adverse cardiac events. CONCLUSION: High RWT has a deleterious impact on long-term mortality.

Temporal pattern of strokes after on-pump and off-pump coronary artery bypass graft surgery.

BACKGROUND: The incidence of strokes has not decreased after coronary artery bypass graft surgery (CABG). The purpose of this study is to identify incidence, risk factors, and temporal pattern of strokes after on-pump and off-pump CABG. METHODS: We analyzed 2,516 consecutive patients who underwent first elective isolated CABG. The primary endpoint was strokes within 30 days. The temporal onset of the deficits was classified by consensus as either an "early stroke," which is present just after emergence from anesthesia, or a "delayed stroke," which is present after first awaking from surgery without a neurologic deficit. RESULTS: More than half of strokes (29 of 46; 63%) were delayed strokes. Patients undergoing off-pump CABG had significantly lower risk of early stroke (0.1% versus 1.1%, p = 0.0009), whereas the incidence of delayed strokes was not different significantly (0.9% versus 1.4%, p = 0.3484) between patients undergoing on-pump and off-pump CABG. In multivariate analyses, undergoing off-pump CABG was an independent protective factor for all strokes (relative risk 0.29, 95% confidence interval: 0.14 to 0.56, p = 0.0005) and early strokes (relative risk 0.05, 95% confidence interval: 0.003 to 0.24, p < 0.0001), but it was not an independent protective factor for delayed strokes (relative risk 0.54, 95% confidence interval: 0.24 to 1.17, p = 0.1210). CONCLUSIONS: Undergoing off-pump CABG reduces the incidence of perioperative stroke mainly by minimizing early strokes; however, the risk of delayed strokes is not different between patients undergoing on-pump and off-pump CABG.