心肌做功技术对LVEF保留的AMI患者左心室整体收缩功能降低的诊断价值

目的探讨心肌做功技术对左心室射血分数(LVEF)保留的急性心肌梗死(AMI)患者左心室整体收缩功能降低的诊断价值。方法本研究为前瞻性病例-对照设计的诊断性试验。选取2019年5—10月在河南省人民医院确诊为AMI且LVEF>50%的患者为AMI(LVEF>50%)组,并选取同期健康体检者作为对照组。收集所有研究对象的年龄、性别等一般临床资料,采用二维超声采集其心尖二腔、三腔及四腔长轴切面连续3个心动周期动态图像,测量并比较两组间常规超声心动图指标及心肌做功各参数的差异。采用组内相关系数(ICC)评价观察者内及观察者间心肌做功各参数的重复性。采用受试者工作特征(ROC)曲线分析左心室整体有用功(GCW)、整体无用功(GWW)、整体做功效率(GWE)、整体做功指数(GWI)对于LVEF保留的AMI患者左心室整体收缩功能降低的诊断价值。结果AMI(LVEF>50%)组30例,年龄(67.3±9.7)岁,女性14例(46.7%)。对照组30例,年龄(68.1±8.6)岁,女性12例(40.0%)。AMI(LVEF>50%)组左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)、室间隔厚度(IVSD)、左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)、二尖瓣口舒张早期峰值流速比二尖瓣后叶瓣环组织多普勒速度(E/e)、左心室质量(LVM)、左心室质量指数(LVMI)较对照组大,E、e较对照组低,差异均有统计学意义(P<0.05)。与对照组相比,AMI(LVEF>50%)组GCW[(1145.9±440.1)mmHg%(1 mmHg=0.133 kPa)比(1425.7±355.4)mmHg%]、GWE[(80.9±9.5)%比(87.3±5.5)%]、GWI[(1001.3±416.2)mmHg%比(1247.6±341.7)mmHg%]低,长轴整体应变(GLS)绝对值低[(8.5±3.4)%比(11.4±3.7)%],峰值应变离散度(PSD)高[(101.3±66.4)ms比(74.7±31.9)ms],差异均有统计学意义(P<0.05);AMI(LVEF>50%)组GWW高[(177.2±71.1)mmHg%比(155.7±64.6)mmHg%],但差异无统计学意义(P>0.05)。GCW、GWW、GWE、GWI在观察者内及观察者间的重复性良好(ICC均>0.75)。ROC曲线分析显示,GCW、GWW、GWE、GWI 4个参数曲线下面积分别为0.896、0.929、0.808、0.862,均可用于AMI(LVEF>50%)患者左心室收缩功能降低的诊断。结论心肌做功技术对于LVEF保留的AMI患者左心室整体收缩功能降低具有一定的诊断价值。     

心肌做功技术对LVEF保留的AMI患者左心室整体收缩功能降低的诊断价值

目的探讨心肌做功技术对左心室射血分数(LVEF)保留的急性心肌梗死(AMI)患者左心室整体收缩功能降低的诊断价值。方法本研究为前瞻性病例-对照设计的诊断性试验。选取2019年5—10月在河南省人民医院确诊为AMI且LVEF>50%的患者为AMI(LVEF>50%)组,并选取同期健康体检者作为对照组。收集所有研究对象的年龄、性别等一般临床资料,采用二维超声采集其心尖二腔、三腔及四腔长轴切面连续3个心动周期动态图像,测量并比较两组间常规超声心动图指标及心肌做功各参数的差异。采用组内相关系数(ICC)评价观察者内及观察者间心肌做功各参数的重复性。采用受试者工作特征(ROC)曲线分析左心室整体有用功(GCW)、整体无用功(GWW)、整体做功效率(GWE)、整体做功指数(GWI)对于LVEF保留的AMI患者左心室整体收缩功能降低的诊断价值。结果AMI(LVEF>50%)组30例,年龄(67.3±9.7)岁,女性14例(46.7%)。对照组30例,年龄(68.1±8.6)岁,女性12例(40.0%)。AMI(LVEF>50%)组左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)、室间隔厚度(IVSD)、左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)、二尖瓣口舒张早期峰值流速比二尖瓣后叶瓣环组织多普勒速度(E/e)、左心室质量(LVM)、左心室质量指数(LVMI)较对照组大,E、e较对照组低,差异均有统计学意义(P<0.05)。与对照组相比,AMI(LVEF>50%)组GCW[(1145.9±440.1)mmHg%(1 mmHg=0.133 kPa)比(1425.7±355.4)mmHg%]、GWE[(80.9±9.5)%比(87.3±5.5)%]、GWI[(1001.3±416.2)mmHg%比(1247.6±341.7)mmHg%]低,长轴整体应变(GLS)绝对值低[(8.5±3.4)%比(11.4±3.7)%],峰值应变离散度(PSD)高[(101.3±66.4)ms比(74.7±31.9)ms],差异均有统计学意义(P<0.05);AMI(LVEF>50%)组GWW高[(177.2±71.1)mmHg%比(155.7±64.6)mmHg%],但差异无统计学意义(P>0.05)。GCW、GWW、GWE、GWI在观察者内及观察者间的重复性良好(ICC均>0.75)。ROC曲线分析显示,GCW、GWW、GWE、GWI 4个参数曲线下面积分别为0.896、0.929、0.808、0.862,均可用于AMI(LVEF>50%)患者左心室收缩功能降低的诊断。结论心肌做功技术对于LVEF保留的AMI患者左心室整体收缩功能降低具有一定的诊断价值。     

无创左心室压力-应变环定量评价冠心病患者冠状动脉狭窄

目的 探讨无创左心室压力-应变环（LVPSL）对冠状动脉不同程度狭窄的冠心病（CAD）患者心肌做功的评价。 方法 回顾性选择2019年12月～2021年10月就诊于湖南中医药高等专科学校附属第一医院心血管内科临床诊断为疑似CAD且行冠状动脉造影检查的患者130例,所有患者均行常规超声心动图、二维斑点追踪（2D-STI）和LVPSL检查。根据冠状动脉造影结果将其分为冠状动脉无狭窄组（n=33）,冠状动脉有狭窄组（n=97）。依据冠状动脉Gensini评分将冠状动脉有狭窄组分为三个亚组,轻度狭窄组（Gensini评分<25,n=37）,中度狭窄组[Gensini评分（25～50）,n=32],重度狭窄组（Gensini评分>50,n=28）。采集常规超声心动参数的同时,取左心室心尖四腔心、三腔心、两腔心切面三个心动周期在二维斑点追踪（2D-STI）模式下获得左心室整体纵向应变（GLS）。输入实时血压,进入LVPSL模式,可获得左心室整体做功指数（GWI）、整体有效做功（GCW）、整体无效做功（GWW）和整体做功效率（GWE）参数。比较不同程度冠状动脉狭窄对心肌做功的影响。 结果 与冠状动脉无狭窄组相比,冠状动脉轻度狭窄组GLS的减低、GWI减低、GCW减低、GWE减低和GWW增加（均P<0.01）;冠状动脉中度狭组GLS减低、GWI减低、GCW减低、GWE减低和GWW增加（均P<0.01）;冠状动脉重度狭窄组GLS减低、GWI减低、GCW减低、GWE减低和GWW增加（均P<0.01）。与冠状动脉轻度狭窄相比,冠状动脉中度狭窄组GLS减低、GWI减低、GCW减低、GWE减低和GWW增加（均P<0.01）;冠状动脉重度狭组GLS减低、GWI减低、GCW减低、GWE减低和GWW增加（均P<0.01）;与冠状动脉中度狭窄相比,冠状动脉重度狭窄组GLS减低、GWI减低、GCW减低、GWE减低和GWW增加（均P<0.01）。冠状动脉狭窄组的Gensini评分与GLS的绝对值、GWI、GCW、GWE呈负相关（r=?0.554, ?0.661, ?0.619, ?0.829）,与GWW呈正相关（r=0.718）,其中与GWE的相关性最高。 结论 LVPSL技术测得的GWI、GCW、GWE和GWW可定量分析不同程度冠状动脉狭窄的CAD患者心肌做功情况,心肌做功参数GWE与Gensini评分的相关性最高。     

左室压力-应变环对冠心病患者心肌做功评价的初步研究

目的 应用左室压力-应变环（LVPSL）评价冠状动脉狭窄患者心肌做功的改变情况,探讨心肌做功参数在诊断冠心病中的临床价值。 方法 疑诊冠心病患者111例,根据冠脉造影结果分为两组:对照组（冠脉无狭窄或狭窄<50%）33例;冠心病组（至少一支冠脉狭窄≥50%）78例,将冠心病组分为有节段性室壁运动异常组26例,无节段性室壁运动异常组52例;分别采集心尖四腔、两腔、左室长轴切面动态图像,应用Echo PAC工作站获取左室整体纵向应变(GLS),进入心肌做功分析模式,得出LVPSL,最终获取长轴整体做功指数（GWI）、整体有效功（GCW）、整体无效功（GWW）、整体做功效率（GME）。 结果 与对照组相比,冠心病组GLS、GWI、GCW、GME均显著减低,GWW显著升高（均P<0.01）,冠心病有节段性室壁运动异常组GLS、GWW显著升高（P<0.01）,冠心病无节段性室壁运动异常组GWI、GCW、GME均显著减低（P<0.01）,GLS显著减低、GWW显著升高（P<0.01）。ROC曲线显示GWI、GCW、GWW、GME的曲线下面积分别为0.36、0.40、0.75、0.27;GWW截断值为70.5%,预测冠心病的灵敏度、特异度分别为67%、97%,约登指数0.64。 结论 LVPSL可量化分析冠心病患者心肌做功,其中GWW是反映冠心病患者心肌做功和心室功能改变的较敏感指标。     

Diagnostic and Prognostic Value of Myocardial Work Indices for Identification of Cancer Therapy–Related Cardiotoxicity

BackgroundEchocardiographic global longitudinal strain (GLS) is a useful measure for detection of cancer treatment–related cardiac dysfunction (CTRCD) but is influenced by blood pressure changes. This limitation may be overcome by assessment of myocardial work (MW), which incorporates blood pressure into the calculation.ObjectivesThis work aims to determine whether myocardial work indices (MWIs) can help diagnose or prognosticate CTRCD.MethodsIn this prospective cohort study, 136 women undergoing anthracycline and trastuzumab treatment for HER2+ breast cancer, underwent serial echocardiograms and cardiac magnetic resonance pre- and post-anthracycline and every 3 months during trastuzumab. GLS, global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency were measured. CTRCD was defined with cardiac magnetic resonance. Generalized estimating equations quantified the association between changes in GLS and MWIs and CTRCD at the current (diagnosis) and subsequent visit (prognosis). Regression tree analysis was used to explore the combined use of GLS and MW for the diagnostic/prognostic assessment of CTRCD.ResultsBaseline left ventricular ejection fraction (LVEF) was 63.2 ± 4.0%. Thirty-seven (27.2%) patients developed CTRCD. An absolute change in GLS (standardized odds ratio [sOR]: 1.97 [95% CI: 1.07-3.66]; P = 0.031) and GWI (sOR: 1.73 [95% CI: 1.04-2.85]; P = 0.033) were associated with concurrent CTRCD. An absolute change in GLS (sOR: 1.79 [95% CI: 1.22-2.62]; P = 0.003), GWI (sOR: 1.67 [95% CI: 1.20-2.32]; P = 0.003), and GCW (sOR: 1.65 [95% CI: 1.17-2.34]; P = 0.005) were associated with subsequent CTRCD. Change in GWI and GCW demonstrated incremental value over GLS and clinical factors for the diagnosis of concurrent CTRCD. In a small group with a GLS change <3.3% (absolute), and a >21 mm Hg reduction in systolic blood pressure, worsening of GWI identified patients with higher probability of concurrent CTRCD (24.0% vs 5.2%). MWIs did not improve identification of subsequent CTRCD beyond knowledge of GLS change.ConclusionsGLS can be used to diagnose and prognosticate cardiac magnetic resonance (CMR) defined CTRCD, with additional value from MWIs in selected cases. (Evaluation of Myocardial Changes During Breast Adenocarcinoma Therapy to Detect Cardiotoxicity Earlier With MRI [EMBRACE-MRI]; NCT02306538)     

Predictors and Effects of Persistent Hypertension after Successful Treatment of Coarctation of the Aorta

Background: Coarctation of the aorta is a congenital heart disease that sometimes remains clinically silent until adulthood, usually presenting with arterial hypertension. It is well known that after coarctation treatment, many patients remain hypertensive despite successful repair. In this study we approached the predictors and effects of residual hypertension after successful coarctation therapy. Methods: It was a cross sectional observational study involving 50 patients who underwent Coarctation repair/angioplasty in Ain Shams university hospitals. We divided the patients into two groups (hypertensive and normotensive) and we studied their demographic data (e.g., age, gender, age at first repair, follow up period, etc.) to conclude the possible predictors of persistent hypertension in such cases. We also performed full echocardiographic assessment including 3D speckle tracking echocardiography to detect subtle changes in left ventricular systolic functions. Results: Hypertensive patients had significantly higher BMI (29.1 kg/m²) as compared to normotensives (24 kg/m²), p < 0.0001. Age at first CoA intervention was significantly higher in hypertensive patients. Hypertensive patients had significantly lower 3D left ventricular strain measures (Global area strain, global circumferential strain and global longitudinal strain). The incidence of bicuspid aortic valve was significantly higher in the hypertensive group, yet it was not an independent predictor of persistent hypertension. Conclusions: The predictors for residual hypertension post successful CoA repair were late intervention and higher BMI. Bicuspid aortic valve was more common in the hypertensive group. Regarding the effects of such disease domain, treated CoA patients with persistent hypertension tended to have higher LV mass index and lower values of LV deformation.     

Impact of Bicuspid Aortic Valve on Complications and Death in Infective Endocarditis of Native Aortic Valves

We retrospectively investigated the impact of bicuspid aortic valve on the prognosis of patients who had definite infective endocarditis of the native aortic valve.Of 51 patients, a bicuspid aortic valve was present in 22 (43%); the other 29 had tricuspid aortic valves. On average, the patients who had bicuspid valves were younger than those who had tricuspid valves. Patients with a tricuspid valve had larger left atrial diameters and were more likely to have severe mitral regurgitation.Periannular complications, which we detected in 19 patients (37%), were much more common in the patients who had a bicuspid valve (64% vs 17%, P = 0.001). The presence of a bicuspid valve was the only significant independent predictor of periannular complications. The in-hospital mortality rate in the bicuspid group was lower than that in the tricuspid group; however, this figure did not reach statistical significance (9% vs 24%, P = 0.15). In multivariate analysis, left atrial diameter was the only independent predictor associated with an increased risk of death (hazard ratio, 2.19; 95% confidence interval, 1.1–4.5; P = 0.031).In our study, patients with infective endocarditis in a bicuspid aortic valve were younger and had a higher incidence of periannular complications. Although a worse prognosis has been reported previously, we found that infective endocarditis in a native bicuspid aortic valve is not likely to increase the risk of death in comparison with infective endocarditis in native tricuspid aortic valves.Key words: Aortic valve/abnormalities/pathology/ultrasonography, aortic valve insufficiency/classification/diagnosis, echocardiography/methods, endocarditis, bacterial/complications/mortality/pathology/ultrasonography, heart defects/congenital, heart diseases/complications, heart valve diseases/classification/complications/congenital/pathology, hospital mortality, retrospective studies, risk factorsBicuspid aortic valve is the most common congenital cardiac malformation, affecting 1% to 2% of the population.¹ The incidence of infective endocarditis (IE) in the bicuspid aortic valve population ranges from 10% to 30%. Twenty-five percent of IE cases occur in a bicuspid aortic valve.^2,3Few data exist about IE in persons who have a bicuspid aortic valve, in contrast with the large amount of data involving other IE populations. Risk stratification is an important objective in the evaluation of patients who have IE, especially IE of the aortic valve. In patients with IE of the native valve, acute heart failure occurs more frequently in association with aortic valve infection (29%) than mitral valve infection (20%).⁴ In view of these factors, we sought to evaluate the impact of bicuspid aortic valve on complications and death related to IE that occurs in a native aortic valve.     

Dynamics of Left Ventricular Myocardial Work in Patients Hospitalized for Acute Heart Failure

BackgroundThe left ventricular ejection fraction (LVEF) is the most commonly used measure describing pumping efficiency, but it is heavily dependent on loading conditions and therefore not well-suited to study pathophysiologic changes. The novel concept of echocardiography-derived myocardial work (MyW) overcomes this disadvantage as it is based on LV pressure–strain loops. We tracked the in-hospital changes of indices of MyW in patients admitted for acute heart failure (AHF) in relation to their recompensation status and explored the prognostic utility of MyW indicesMethods and ResultsWe studied 126 patients admitted for AHF (mean 73 ± 12 years, 37% female, 40% with a reduced LVEF [<40%]), providing pairs of echocardiograms obtained both on hospital admission and prior to discharge. The following MyW indices were derived: global constructive and wasted work (GCW, GWW), global work index (GWI), and global work efficiency. In patients with HF with reduced ejection fraction with decreasing N-terminal prohormone B-natriuretic peptide levels during hospitalization, the GCW and GWI improved significantly, whereas the GWW remained unchanged. In patients with HF with preserved ejection fraction, the GCW and GWI were unchanged; however, in patients with no decrease or eventual increase in N-terminal prohormone B-natriuretic peptide, we observed an increase in GWW. In all patients with AHF, higher values of GWW were associated with a higher risk of death or rehospitalization within 6 months after discharge (per 10-point increment hazard ratio 1.035, 95% confidence interval 1.005–1.065).ConclusionsOur results suggest differential myocardial responses to decompensation and recompensation, depending on the HF phenotype in patients presenting with AHF. The GWW predicted the 6-month prognosis in these patients, regardless of LVEF. Future studies in larger cohorts need to confirm our results and identify determinants of short-term and longer term changes in MyW.     

The Impact of a Bicuspid Aortic Valve on Aortic Geometry and Function in Patients with Aortic Coarctation: A Comprehensive CMR Study

Background: An isolated bicuspid aortic valve (BAV) is associated with structural and functional abnormalities of the aorta and the left ventricle (LV). Although ~50% of patients with aortic coarctation (CoA) have a BAV, less is known about its impact on LV function and aortic geometry and function in CoA patients. In this cardiovascular magnetic resonance imaging (CMR) study, we analysed markers of LV and aortic function as well as aortic geometry in a large cohort of CoA patients with a BAV and compared them with CoA patients with a tricuspid aortic valve (TAV). Methods: We included 48 patients with a BAV (18.4 ± 9.3 years) and 45 patients with TAV (20.7 ± 9.9 years). LV volumes, mass and ejection fraction as well as aortic distensibilty, pulse wave velocity (PWV) were measured from standard cine CMR and phase-contrast CMR images. 2-dimensional CMR feature tracking (2DCMR-FT) was performed to measure longitudinal, circumferential and radial strain and strain rate of the LV. Aortic arch geometry was classified as romanic, gothic and crenel. Results: LV volumes, mass and ejection fraction as well as aortic distensibility and PWV did not significantly differ between the BAV and the TAV group. There was also no significant difference for LV global longitudinal, radial and circumferential strain and strain rate between both groups. Patients with a BAV had more commonly a gothic aortic arch compared to TAV patients, but this difference was not statistically significant (22 vs. 14, p = 0.2). Ascending and descending aortic distensibility correlated with LV mass in the entire patient group (p < 0.001). Global longitudinal, circumferential and radial strain (GLS, GCS, GRS) and global longitudinal and circumferential strain rate (GLSR, GCSR) correlated with LV ejection fraction (p < 0.001). Conclusion: Our data suggest that the presence of a BAV does not adversely impact LV and aortic function in children and young adults with CoA. The correlation of global circumferential, longitudinal and radial strain values with LV ejection fraction demonstrates that 2D-CMR-FT might provide additional information related to ventricular function in CoA patients.     

Temporal Trends and Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement for Bicuspid Aortic Valve Stenosis

ObjectivesThe purpose of this study was to assess the temporal trends of transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic stenosis (AS), and to compare the outcomes between TAVR and surgical aortic valve replacement (SAVR) in this population.BackgroundRandomized trials comparing TAVR to SAVR in AS with bicuspid valve are lacking.MethodsThe study queried the National Inpatient Sample database (years 2012 to 2016) to identify hospitalizations for bicuspid AS who underwent isolated aortic valve replacement. A propensity-matched analysis was used to compare outcomes of hospitalizations for TAVR versus SAVR for bicuspid AS and TAVR for bicuspid AS versus tricuspid AS.ResultsThe analysis included 31,895 hospitalizations with bicuspid AS, of whom 1,055 (3.3%) underwent TAVR. TAVR was increasingly utilized during the study period for bicuspid AS (p_trend = 0.002). After matching, TAVR and SAVR had similar in-hospital mortality (3.1% vs. 3.1%; odds ratio: 1.00; 95% confidence interval: 0.60 to 1.67). There was no difference between TAVR and SAVR in the rates of cardiac arrest, cardiogenic shock, acute kidney injury, hemopericardium, cardiac tamponade, or acute stroke. TAVR was associated with lower rates of acute myocardial infarction, post-operative bleeding, vascular complications, and discharge to nursing facility as well as a shorter length of hospital stay. On the contrary, TAVR was associated with a higher incidence of complete heart block and permanent pacemaker insertion. TAVR for bicuspid AS was associated with similar in-hospital mortality compared with tricuspid AS.ConclusionsThis nationwide analysis showed similar in-hospital mortality for TAVR and SAVR in patients with bicuspid AS. TAVR for bicuspid AS was also associated with similar in-hospital mortality compared with tricuspid AS. Further studies are needed to evaluate long-term outcomes of TAVR for bicuspid AS.     

Aortic stenosis severity is not a risk factor for poststenotic dilatation of the ascending aorta.

BACKGROUND: Dilatation of the ascending aorta in aortic stenosis may be partly explained by intrinsic wall structure changes, but the relative contribution of altered hemodynamics is unclear. The aim of this study was to assess the association between ascending aortic dimensions and valve stenosis severity. METHODS AND RESULTS: An analysis of echocardiographic examinations was conducted in 296 patients with aortic stenosis (179 males, mean age 71 years), 57 with bicuspid and 239 with tricuspid aortic valve, mean transaortic gradient 43+/-20 mmHg, and not more than moderate aortic regurgitation. Aortic dimensions at the level of annulus, sinuses of Valsalva, sinotubular junction and proximal ascending aorta were measured. Only height (p<0.001), degree of aortic regurgitation (p<0.01) and presence of bicuspid aortic valve (p<0.001) were independent predictors of ascending aortic dimensions. CONCLUSIONS: An independent association between aortic pressure gradients and proximal ascending aortic dimensions was not observed in patients with bicuspid or tricuspid aortic valve stenosis. Therefore, the poststenotic dilatation of the ascending aorta is not explained by aortic stenosis severity itself. Possible nonhemodynamic causes deserve detailed study at the time of diagnosis.     

Transcatheter Aortic Valve Replacement in Bicuspid Versus Tricuspid Aortic Valves From the STS/ACC TVT Registry

ObjectivesThis study sought to compare outcomes in patients with bicuspid versus tricuspid anatomy undergoing transcatheter aortic valve replacement (TAVR).BackgroundTAVR has shown excellent safety and efficacy in patients with tricuspid aortic valve stenosis, but limited data are available on the use of self-expanding valves in patients with bicuspid valves.MethodsThe Society of Thoracic Surgeons/American College of Cardiology TVT Registry was used to analyze patients who underwent TAVR with the Evolut R or Evolut PRO valves. Clinical and echocardiographic outcomes were analyzed through 1-year follow-up.ResultsBetween July 2015 and September 2018 a total of 932 patients with bicuspid aortic valve stenosis underwent elective TAVR with the self-expanding Evolut R or Evolut PRO valve. These patients were compared with a group of 26,154 patients with tricuspid aortic stenosis who underwent TAVR during that same time period. At baseline, patients with bicuspid valves were younger, had fewer cardiac comorbidities, and had lower Society of Thoracic Surgeons Predicted Risk of Mortality scores (5.3 ± 4.2% vs. 6.9 ± 4.8%; p < 0.001). To account for these differences, propensity matching was performed, which resulted in 929 matched pairs. Within these match groups, the rates of all-cause mortality at 30 days (2.6% vs. 1.7%; p = 0.18) and 1 year (10.4% vs. 12.1%; p = 0.63), as well the rate of stroke at 30 days (3.4% vs. 2.7%; p = 0.41) and 1 year (3.9% vs. 4.4%; p = 0.93), were comparable.ConclusionsAll-cause mortality, stroke, and valve hemodynamics did not differ at 30 days or 1 year between patient groups. In patients at increased surgical risk, TAVR for bicuspid aortic valve stenosis indicates acceptable safety outcomes with low complications rates.     

Transcatheter Aortic Valve Replacement in Low-Risk Patients With Symptomatic Severe Bicuspid Aortic Valve Stenosis

ObjectivesThe aim of this study was to evaluate clinical outcomes and transcatheter heart valve hemodynamic parameters after transcatheter aortic valve replacement (TAVR) in low-risk patients with bicuspid aortic stenosis (AS).BackgroundTAVR is approved for low-risk patients in the United States. However, patients with bicuspid AS were excluded from the randomized cohorts of the pivotal low-risk trials.MethodsThe LRT (Low Risk TAVR) trial was an investigator-initiated, prospective, multicenter study and was the first and only U.S. Food and Drug Administration–approved investigational device exemption trial to evaluate the feasibility of TAVR with either balloon-expandable or self-expanding valves in low-risk patients with bicuspid AS. The primary endpoint was all-cause mortality at 30 days. Baseline and follow-up echocardiography and computed tomography to detect leaflet thickening were analyzed in an independent core laboratory.ResultsSixty-one low-risk patients with symptomatic, severe AS and bicuspid aortic valves (78.3% Sievers type 1 morphology) underwent TAVR at 6 centers from 2016 to 2019. The mean age was 68.6 years, and 42.6% were men. At 30 days, there was zero mortality and no disabling strokes. The rate of new permanent pacemaker implantation was 13.1%; just 1 patient had a moderate paravalvular leak at 30 days. Hypoattenuated leaflet thickening was observed in 10% of patients at 30 days.ConclusionsTAVR appears to be safe in patients with bicuspid AS, with short length of hospital stay, zero mortality, and no disabling strokes at 30 days. Subclinical leaflet thrombosis was observed in a minority of patients at 30 days but did not appear to be associated with clinical events.     

The PARTNER 3 Bicuspid Registry for Transcatheter Aortic Valve Replacement in Low-Surgical-Risk Patients

ObjectivesThe study compared 1-year outcomes between transcatheter aortic valve replacement (TAVR) patients with bicuspid aortic valve (BAV) morphology and clinically similar patients having tricuspid aortic valve (TAV) morphology.BackgroundThere are limited prospective data on TAVR using the SAPIEN 3 device in low-surgical-risk patients with severe, symptomatic aortic stenosis and bicuspid anatomy.MethodsLow-risk, severe aortic stenosis patients with BAV were candidates for the PARTNER 3 (Placement of Aortic Transcatheter Valves 3) (P3) bicuspid registry or the P3 bicuspid continued access protocol. Patients treated in these registries were pooled and propensity score matched to TAV patients from the P3 randomized TAVR trial. Outcomes were compared between groups. The primary endpoint was the 1-year composite rate of death, stroke, and cardiovascular rehospitalization.ResultsOf 320 total submitted BAV patients, 169 (53%) were treated, and most were Sievers type 1. The remaining 151 patients were excluded caused by anatomic or clinical criteria. Propensity score matching with the P3 TAVR cohort (496 patients) yielded 148 pairs. There were no differences in baseline clinical characteristics; however, BAV patients had larger annuli and they experienced longer procedure duration. There was no difference in the primary endpoint between BAV and TAV (10.9% vs 10.2%; P = 0.80) or in the rates of the individual components (death: 0.7% vs 1.4%; P = 0.58; stroke: 2.1% vs 2.0%; P = 0.99; cardiovascular rehospitalization: 9.6% vs 9.5%; P = 0.96).ConclusionsAmong highly select bicuspid aortic stenosis low-surgical-risk patients without extensive raphe or subannular calcification, TAVR with the SAPIEN 3 valve demonstrated similar outcomes to a matched cohort of patients with tricuspid aortic stenosis.     

Estimated left ventricular pressure-myocardial strain loop as an index of cardiac work predicts all-cause mortality in patients receiving regular hemodialysis

BackgroundA non-invasive method for left ventricular pressure-strain analysis has recently been introduced to provide information on cardiac work and detect subtler changes in cardiac function. This study aims to verify and construct a novel index that could accurately and independently predict the prognosis of patients with end-stage kidney disease (ESRD) receiving regular hemodialysis.MethodsPatients with end-stage kidney disease (ESRD) receiving maintenance hemodialysis (4-h sessions, 3 times weekly for 3 months or more) and who underwent echocardiography between 2009 and 2014 in China Medical University Hospital, Taichung, Taiwan, were enrolled. Conventional (left ventricular ejection fraction, LVEF) and strain echocardiography parameters (global longitudinal strain, GLS; cardiac work index, CWI) in 102 eligible patients were analyzed and compared. CWI was calculated from estimated LV pressure-myocardial strain loop area.ResultsResults show that, while no significant differences were found between LVEF (0.57 ± 0.12 vs. 0.59 ± 0.09, P = 0.27) and GLS (?16.12 ± 6.57% vs. -18.44 ± 5.54%, P = 0.07), deceased patients had significantly lower CWI (1339 ± 683.05 mmHg% vs. 1883.38 ± 640.99 mmHg%, P = 0.0002) than surviving patients. The predictive values defined by area under the curve (AUC) of LVEF, GLS and CWI were 0.499, 0.619 and 0.724, respectively.ConclusionIn conclusion, CWI is an accurately independent predictor of all-cause mortality in ESRD patients receiving regular hemodialysis and may superior to the current predictors such as LVEF and GLS.     

左室压力-应变环评价不同剂量蒽环类药物对乳腺癌患者左室心肌的做功

目的 探讨采用无创性左室压力-应变环（left ventricular pressure-strain loops,LVPSL）技术评价乳腺癌患者在不同剂量蒽环类药物作用时左室心肌做功的变化情况。 方法 选取拟接受蒽环类药物化疗的新发乳腺癌术后患者36例,健康对照者30例,分别采集并存储左室心尖四腔、三腔、二腔至少（3~5）个心动周期,使用工作站脱机分析图像,获得数据包括左室舒张末期内径(LVDd)、左室收缩末期内径(LVds)、左室射血分数（LVEF）、左室收缩末期容积(LVESV)、左室舒张末期容积(LVEDV)、整体做功指数 (GWI)、整体有用功 (GCW )、 整体无用功(GWW)、整体做功效率(GWE)。 结果 在蒽环类药物累计剂量达240 mg/m2及360 mg/m2时,GLS及GWI较化疗前明显减低,GWW较化疗前升高,差异有统计学意义（P<0.05）;随蒽环类药物累计剂量的增加,GLS及GWI呈逐渐减低趋势,GWW呈逐渐升高趋势;相关分析发现:GLS与蒽环类药物剂量累计剂量显著相关（r = 0.653）,GWI及GWW与蒽环类药物累计剂量低度相关（r = ?0.485,r = 0.308）（P<0.05）。 结论 LVPSL的整体做功指数和整体无用功可评价乳腺癌患者蒽环类药物治疗所致的轻微的左心室心肌功能障碍,且有蒽环类药物剂量依赖性。     

Valve preserving surgery in patients with bicuspid aortic valve

Bicuspid aortic valve can be associated with clinically important aortic regurgitation and dilatation of ascending aorta. Aortic valve repair seems to be optimal therapeutic option how to avoid valve-related and anticoagulation-related complications. We have analyzed midterm outcomes of patients after bicuspid aortic valve repair.MethodsBetween January 2008 and December 2015, 91 patients (mean age 40.9 ± 12.2) with bicuspid aortic valve (type 0 or 1) underwent valve-sparing surgery for aortic valve insufficiency or aortic aneurysm. Urgent procedures and patients of age more than 65 were not included. The cohort of patients was retrospectively divided into two groups. Forty-nine patients underwent aortic valve-sparing procedure with root replacement (group 1). Forty-two patients underwent aortic valve repair without root replacement (group 2). The mean length of follow-up was 57.5 months.ResultsThere was no death in connection with aortic valve repair during follow up. Three patients from group 2 required in-hospital reoperation for early repair failure. Another seven patients (4 from group 1 and 3 from group 2) were reoperated for recurrent aortic insufficiency during follow-up period. Freedom from aortic valve reoperation at 5 years was 90% in group 1 and 87% in group 2. Freedom from recurrent aortic insufficiency (>2°) at 5 years was 85% in group 1 and 78% in group 2.ConclusionBicuspid aortic valve repair is a safe procedure, which can be performed with acceptable midterm results. Risk of repair failure depends on preoperative valve morphology and choice of repair technique. Repair technique needs to be tailored to the specific anatomy of the valve.     

Predictors of aneurysmal formation after surgical correction of aortic coarctation

OBJECTIVES: We sought to identify the predictors of aneurysmal formation after surgical correction of aortic coarctation. BACKGROUND: In 9% of patients, aneurysms develop late after corrective surgery of coarctation of the aorta, with a 36% mortality rate if left untreated. However, the predictors of postsurgical aneurysmal formation are unknown. METHODS: Of 25 aortic aneurysms requiring corrective surgery 152 +/- 78 months after the initial coarctation repair, 8 were located in the ascending aorta (type A) and 17 at the site of previous repair (local type). Seventy-four patients without progression of the aortic diameter within 189 +/- 71 months after coarctation repair were used for categorical data analysis in an attempt to identify the predictors of postsurgical aneurysmal formation. RESULTS: Advanced age at coarctation repair (p = 0.004) and patch graft technique (p < 0.0005) independently predicted local aneurysmal formation. Type A aneurysm was univariately associated with the presence of a bicuspid aortic valve (p = 0.02), advanced age at coarctation repair (p = 0.044) and a high preoperative peak systolic pressure gradient of 74 +/- 21 mm Hg (p = 0.041). Conversely, multivariate analysis confirmed only the presence of a bicuspid aortic valve (p = 0.015) as an independent predictor of type A aneurysm. Receiver operating characteristic curve analysis revealed that 72% of patients with a postsurgical aneurysm had an operation at age 13.5 years or more, whereas 69% with no postsurgical aneurysm had an operation at a younger age. CONCLUSIONS: Use of the patch graft technique and late correction of coarctation can predict aneurysmal formation at the site of coarctation repair, although patients with a bicuspid aortic valve may be at risk for an aneurysm developing in the ascending aorta, particularly after late repair of aortic coarctation with high preoperative pressure gradients.     

Propensity-Matched 1-Year Outcomes Following Transcatheter Aortic Valve Replacement in Low-Risk Bicuspid and Tricuspid Patients

ObjectivesThe aim of this study was to compare 1-year outcomes after transcatheter aortic valve replacement (TAVR) in low surgical risk patients with bicuspid aortic stenosis to patients with tricuspid aortic stenosis.BackgroundThe pivotal TAVR trials excluded patients with bicuspid aortic valves. The Low Risk Bicuspid Study 30-day primary endpoint of death or disabling stroke was 1.3%.MethodsThe Low Risk Bicuspid Study is a prospective, single-arm, TAVR trial that enrolled patients from 25 U.S. sites. A screening committee confirmed bicuspid anatomy and valve classification on computed tomography using the Sievers classification. Valve sizing was by annular measurements. An independent clinical events committee adjudicated all serious adverse events, and an independent core laboratory assessed all echocardiograms. The 150 patients from the Low Risk Bicuspid Study were propensity matched to the TAVR patients in the randomized Evolut Low Risk Trial using the 1:1 5- to-1-digit greedy method, resulting in 145 pairs.ResultsAll-cause mortality or disabling stroke at 1 year was 1.4% in the bicuspid and 2.8% in the tricuspid group (P = 0.413). A pacemaker was implanted in 16.6% of bicuspid and 17.9% of tricuspid patients (P = 0.741). The effective orifice area was similar between groups at 1 year (2.2 ± 0.7 cm² vs 2.3 ± 0.6 cm², P = 0.677) as was the mean gradient (8.7 ± 3.9 mm Hg vs 8.5 ± 3.1 mm Hg, P = 0.754). Fewer patients in the bicuspid group had mild or worse paravalvular leak (21.3% vs 42.6%, P < 0.001).ConclusionsThere were no significant differences in clinical or forward flow hemodynamic outcomes between the propensity-matched groups at 1 year.     

The bicuspid aortic valve: Still a toothy problem

• Transcatheter aortic valve replacement (TAVR) is an acceptable treatment alternative to surgical aortic valve replacement in selected patients with a bicuspid aortic valve.
• TAVR appears to have acceptable mid‐term outcomes in patients with bicuspid aortic stenosis.
• A large‐scale, randomized, clinical trial is necessary to better define the role of TAVR for patients with bicuspid aortic stenosis.