Transcatheter aortic valve implantation in patients with severely reduced left ventricular systolic function: a single-center experience

Aims

Current guidelines consider severe systolic left ventricular dysfunction [ejection fraction (EF) ≤20 %; left ventricular dysfunction (LVD)] a contraindication for transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the efficacy and safety of TAVI in this extreme risk subset of patients.

Methods and Results

The study population (253 patients) was divided into two groups; the LVD group [21 patients with left ventricular ejection fraction (LVEF) ≤20 %] and the control group (232 patients with LVEF >20 %). TAVI was generally performed transfemorally under analgosedation without mechanical circulatory support. Clinical and hemodynamic variables, as well as procedural and follow-up outcomes, were compared, and all events were defined according to the Valve Academic Research Consortium criteria for event definition. Mean EF in the LVD group was 18.3 ± 2.9 % compared to 50.9 ± 11.3 % in the control group. Patients in the LVD group were younger, more commonly males, had higher logistic EuroSCORE and lower mean aortic pressure gradients. Immediate procedural mortality was low and similar in both groups (0 vs. 2.2 % in the LVD and control group, respectively, p = 0.49). At 30 days, post-procedural vascular and bleeding complications as well as strokes were similar, but all-cause mortality was higher in the LVD group (14.3 vs. 3.4 %, p = 0.05). In the survivors of the LVD group, New York Heart Association functional class and LVEF significantly improved at 30 days and 6 months. Survival at 1 and 2 years was 70.2 vs. 86.0 % and 56.1 vs. 78.3 % in the LVD and control group, respectively (log-rank p = 0.03).

Conclusions

TAVI without mechanical circulatory support appears feasible, safe and effective in patients with severe aortic stenosis and severe LVD, but short- and long-term mortality remain high. TAVI should be considered a viable treatment option in this subset of extremely compromised patients.     

Tei指数评价三尖瓣反流胎儿左心室功能

目的 采用Tei指数评估三尖瓣反流（TR）胎儿左心室功能,观察其预测不良妊娠结局的价值。方法 纳入78胎TR胎儿,根据反流程度分为轻度组（n=54）及中度组（n=24）;同期纳入60胎正常胎儿作为对照组。比较组间左心室等容收缩时间（ICT）、等容舒张时间（IRT）及射血时间（ET）,计算Tei指数。绘制受试者工作特征（ROC）曲线,计算曲线下面积（AUC）,评价Tei指数预测不良妊娠结局的效能。结果 轻度组各参数与对照组差异均无统计学意义（P均>0.05）;中度组左心室Tei指数、ICT+IRT明显高于对照组（P均<0.05）。轻、中度组胎儿出生孕周均小于对照组（P均<0.05）,不良妊娠结局发生率均高于对照组（P均<0.05）。左心室Tei指数预测轻度组及中度组不良结局的AUC分别为0.52及0.65,敏感度分别为36.80%及58.30%,特异度分别为75.00%及83.30%。结论 Tei指数可用于评价单纯性TR胎儿左心室功能,进而预测TR胎儿不良结局,为临床干预提供重要依据。     

Tei指数评价左心室心尖球形综合征患者左心室功能

目的 探讨定量组织速度成像(QTVI)技术测量Tei指数评价左心室心尖球形综合征(LVABS)患者左心室整体功能的价值。 方法 收集7例LVABS患者(LVABS组)及20名健康体检者(对照组),于入院时、4周末、8周末行超声心动图检查,应用QTVI技术测算左心室Tei指数及舒张早期峰值速度/舒张晚期峰值速度(Ea/Aa),以双平面Simpson法测算左心室射血分数(EF)。 结果 LVABS组患者入院时、4周末、8周末左心室Tei指数逐渐降低,平均Tei指数(Tei_M)与对照组的差异均具有统计学意义(P均<0.05);LVABS组4周末、8周末时EF逐渐升高,与入院时相比较差异均具有统计学意义(P均<0.05);Tei_M与EF呈负相关(入院时、4周末、8周末:r=-0.913、-0.932、-0.946; P均<0.05);LVABS组4周末、8周末时Ea/Aa逐渐升高,与入院时相比较差异均具有统计学意义(P均<0.05);Tei_M与Ea/Aa呈负相关(入院时、4周末、8周末:r=-0.779、-0.821、-0.853;P均<0.05)。 结论 QTVI技术测量Tei指数能有效地综合评价LVABS患者左心室整体功能,其中前壁及前侧壁测值尤为敏感。     

Association of aortic distensibility and left ventricular function in patients with stenotic bicuspid aortic valve and preserved ejection fraction: a CMR study

The International Journal of Cardiovascular Imaging - To determine the relationship between aortic distensibility and left ventricular (LV) remodeling, myocardial strain and blood biomarkers in...     

心肌分层应变评估二叶式主动脉瓣畸形左室收缩功能的可行性研究

目的探讨超声心动图心肌分层应变评估二叶式主动脉瓣畸形患者亚临床心肌损害的可行性。方法选择左室射血分数(LVEF)正常的二叶式主动脉瓣畸形患者104例,根据是否伴有瓣膜功能异常分为瓣膜功能正常者44例(A组)和瓣膜功能异常者60例(B组),另选50例健康志愿者为对照组。比较各组一般资料、常规超声心动图参数及心肌分层应变参数。随机选取20例患者进行观察者内和观察者间的重复性分析。结果 B组平均年龄明显高于A组,差异有统计学意义(P<0.05);B组左室舒张末内径和升主动脉内径均较A组及对照组明显增大,差异均有统计学意义(均P<0.05)。A组全层心肌收缩期整体纵向应变峰值(LSavg)、外层心肌收缩期纵向应变峰值(LSepi)、内层心肌收缩期纵向应变峰值(LSendo)均较对照组明显减小,差异均有统计学意义(均P<0.05);B组LSavg、LSepi、中层心肌收缩期纵向应变峰值、全层心肌收缩期整体圆周应变峰值、外层心肌收缩期圆周应变峰值、中层心肌收缩期圆周应变峰值均较对照组和A组明显减小,差异均有统计学意义(均P<0.05);B组LSendo、内层心肌收缩期圆周应变峰值均较对照组明显减小,差异均有统计学意义(均P<0.05)。心肌分层应变评估左室心肌整体全层、各层心动周期纵向应变峰值及圆周应变峰值观察者内部和观察者间一致性限度为-6.0%~5.0%,组内相关系数均≥0.80。结论应用超声心动图心肌分层应变评估LVEF正常的二叶式主动脉瓣畸形左室外层及内层纵向应变峰值,有利于早期检出亚临床心肌损害。     

超声心动图Tei指数对自发性高血压大鼠左心室功能的研究

目的探讨超声心动图Tei指数对自发性高血压大鼠左室心功能的应用价值。方法经胸超声检测高血压大鼠与正常大鼠（各20只）左室容积、内径及室壁厚度,了解其心功能指标左室射血分数（LVEF）、左室缩短分数（LVFS）变化以及二尖瓣口E峰、A峰流速、E/A比值,测量射血时间（ET）、等容收缩时间（ICT）、等容舒张时间（IRT）,计算Tei指数。结果高血压大鼠左室心肌较正常对照组明显肥厚,以左室后壁为主,左室腔缩小,Tei指数（0.59±0.19）较正常对照组（0.35±0.10）增大,P〈0.05,而二尖瓣口E峰、A峰流速,LVEF、LVFS与正常组无明显差别。结论超声心动图Tei指数评价高血压大鼠左心室功能较常规指标更有效。     

Global longitudinal strain: a novel index of left ventricular systolic function.

BACKGROUND: Echocardiographic estimation of global left ventricular (LV) function is subjective and time consuming. Our aim was to develop a novel approach for assessment of global LV function from 2-dimensional echocardiographic images METHODS: Novel computer software for tissue tracking was developed and applied as follows: digital loops were acquired from apical 2-, 3-, and 4-chamber views and a line was loosely traced along the LV endocardium at the frame wherein it was best defined. Around this line, the software selected natural acoustic markers moving with the tissue. Automatic frame-by-frame tracking of these markers during the heart cycle yielded a measure of contractility along the selected region of interest. Global longitudinal strain (GLS) and GLS rate (GLSR) were calculated for the entire U-shaped length of LV myocardium (basal, mid, and apical segments of 2 opposite walls in each view). To test this software, computer-derived GLS and GLSR were analyzed by a nonechocardiographer, blinded to the echocardiographic interpretation, in 27 consecutive patients after myocardial infarction (MI) (age 64.4 +/- 12.9 years; 19 men; mean wall-motion score index of 1.79 +/- 0.44) and compared with those obtained in 12 consecutive control patients (age 59.0 +/- 9.7 years; 8 women), with a normal echocardiographic study. RESULTS: GLS and GLSR, averaged from the 3 apical views, differed significantly in patients post-MI compared with control patients (GLS -14.7 +/- 5.1% vs -24.1 +/- 2.9% and GLSR -0.57 +/- 0.21/s vs -1.02 +/- 0.09/s for patients post-MI vs control patients, respectively; both P <.0001). There was a good linear correlation between the wall-motion score index and the GLS and GLSR (R = 0.68 and R = 0.67, respectively; both P <.0001). A cut-off value for GLS of -21% had 92% sensitivity and 89% specificity and a cut-off value for GLSR -0.9/s had 92% sensitivity and 96% specificity for the detection of patients post-MI. CONCLUSIONS: GLS and GLSR are novel indices for assessment of global LV function from 2-dimensional echocardiographic images. Early validation studies with the method are suggestive of high sensitivity and specificity in the detection of LV systolic dysfunction in patients post-MI.     

Improvement of left ventricular longitudinal systolic function after transcatheter aortic valve implantation: a speckle-tracking prospective study

Transcatheter aortic valve implantation (TAVI) is able to determine a significant improvement of left ventricular ejection fraction (LVEF). The variations of LV global longitudinal strain (GLS) have not been yet investigated in TAVI patients with reduced LVEF. The aim of this study was to determine the effects of TAVI on LV function by 2D speckle-tracking echocardiography (STE) in patients with reduced LVEF. Eighteen consecutive patients undergoing TAVI in our centre were prospectively enrolled. Echocardiography was performed pre-procedurally the day of TAVI and at 40-day and 3-month follow-up (FU). The mean age of TAVI patients was 79.75 ± 7.68 years. The mean EuroSCORE was 26.59 ± 14.62 %. A significant decrease of mean trans-aortic gradient was observed 40 days after TAVI (51.69 ± 18.82 vs. 9.62 ± 3.28 mmHg, p < 0.0001). LV mass index significantly decreased at 40-day FU (165.72 ± 37.75 vs. 145.52 ± 31.32 g/m², p < 0.001) with a further reduction at 3-month FU (136.91 ± 26.91 g/m², p < 0.05 in comparison with 40-day FU). The mean pre-procedural LVEF was 45.87 ± 7.95 %. LVEF significantly increased at 40-day FU (55.20 ± 5.91 %, p < 0.05) and remained stable at 3-month FU (55.58 ± 6.14 %). Interestingly, an early improvement of LV GLS was observed at 40-day FU (?11.09 ± 3.40 vs. ?14.40 ± 3.68 %, p < 0.001) with a slight further increase at 3-month FU (?14.71 ± 3.56 %). Our results indicate that significant improvements of LVEF and LV GLS can be observed in patients undergoing TAVI with impaired LVEF. Two-dimensional STE was able to detect the reverse remodeling of LV function, adding further insights into the assessment of LV mid-term recovery after TAVI.     

Preoperative diastolic function predicts the onset of left ventricular dysfunction following aortic valve replacement in high-risk patients with aortic stenosis

Introduction  

Left ventricular (LV) dysfunction frequently occurs after cardiac surgery, requiring inotropic treatment and/or mechanical circulatory support. In this study, we aimed to identify clinical, surgical and echocardiographic factors that are associated with LV dysfunction during weaning from cardiopulmonary bypass (CPB) in high-risk patients undergoing valve replacement for aortic stenosis.     

Tei指数对高血压不同左室构型左右心室整体功能的研究

已有研究认为Tei指数可客观有效地评价心室收缩及舒张整体功能的损害情况p[1-3].本文将应用Tei指数评价高血压不同左室构型左、右心室整体功能的变化,探讨高血压患者左、右心室整体功能的变化与不同左室构型的关系.     

Tei指数综合评估正常胎儿心室功能的定量研究

目的　建立正常胎儿左、右心室Tei指数范围 ,并探讨孕龄及心率对Tei指数的影响。方法应用多普勒超声心动图测量 13 1名孕龄在 15～ 40周的胎儿左、右心室多普勒时间间期 ,获得左、右心室Tei指数范围 ,分析孕龄、心率对此指数的影响。结果　正常胎儿左室Tei指数为 0 .3 7± 0 .12 ,右室Tei指数为 0 .3 6± 0 .12 ,两者之间具有相关性 (r =0 .41,P <0 .0 1) ,不同孕龄、不同心率胎儿之间的Tei指数差异均无显著性意义 (P >0 .0 5 )。结论　Tei指数是一种简单可靠的定量综合评价心脏收缩和舒张功能的多普勒指数 ,不受心室几何形态、心率及孕龄的影响 ,与传统评价方法比较 ,具有更好的可靠性和重复性。Tei指数对于先天性心脏病和心律失常胎儿的心功能评价具有潜在的应用价值 ,有待进一步研究。     

Noncompaction of the ventricular myocardium associated with mitral regurgitation and preserved ventricular systolic function.

Noncompaction of the ventricular myocardium is an embryonic cardiomyopathy that is increasingly being recognized. Mitral regurgitation, when present, is usually a result of the associated left ventricular systolic dysfunction. We report 4 patients with noncompaction of the ventricular myocardium in whom ventricular systolic function was preserved. Mitral regurgitation was associated with changes in the mitral valve leaflets and an abnormal coaptation pattern. This association of noncompaction of the ventricular myocardium with mitral regurgitation has not, to our knowledge, been reported.     

Treatment of arrhythmias in patients with chronic cardiac insufficiency with preserved left ventricular systolic function

It is known that disturbances in neurohumoral systems in chronic heart failure (CHF) do not only result in myocardial dysfunction, but also can lead to sudden arrhythmic death. The review is devoted to one of pathophysiological approaches to treatment of patients with CHF with a preserved left ventricular function providing maintenance of neurohumoral systems balance. The author considers literature data on possibilities provided by such pharmaceuticals as ACE inhibitors, angiotensin II antagonists, beta-adrenoblockers, and calcium channel blockers in treatment and prophylaxis of arrhythmic events.     

Tei指数评价原发性高血压病患者左室舒张功能

目的探讨Tei指数评价原发性高血压病左室不同构型的舒张功能的临床价值。方法原发性高血压病患者115例,以Ganau分类法分为4组:正常构型组36例,向心性重构组36例,向心性肥厚组31例,离心性肥厚组12例;另选择体检健康者35例为对照组。应用M型超声测量左室的舒张末期内径(LVEDD)、后壁厚度(LVPWT)、室间隔厚度(IVST);改良Simpson法测量左室射血分数(LVEF);脉冲多普勒测量二尖瓣舒张早期血流峰值流速(E)、舒张晚期血流峰值流速(A)、E峰减速时间(EDT),计算E/A;测量肺静脉血流频谱收缩期肺静脉血流峰值(PVS)、舒张早期血流峰值(PVD),计算PVS/PVD,组织多普勒测量左室Tei指数。结果高血压病组左室舒张功能均减低。正常构型组、向心性重构组、向心性肥厚组E/A1,EDT延长;离心性肥厚组E/A1,其EDT较正常构型组、向心性重构组、向心性肥厚组缩短,收缩功能减低,LVEF与对照组比较差异有统计学意义(P0.05);对照组、高血压病各组Tei指数依次增加,组间差异均有统计学意义(均P0.05);左室Tei指数与LVEF、A峰呈负相关,与IVST、LVPWT、LVEDD、RWT、LVMI、E峰、E/A呈正相关;Tei指数ROC曲线下面积为0.986,以Tei指数为0.425鉴别有无左室舒张功能不全的敏感性为97%,特异性为83%。结论 Tei指数与原发性高血压病患者左室不同构型具有良好的相关性,原发性高血压病早期Tei指数即发生改变,随舒张功能不全的加重而增高;Tei指数可作为评价鉴别二尖瓣血流"假性正常化"的参考指标之一。     

组织多普勒心肌综合指数对风湿性二尖瓣狭窄患者左心室功能的研究

目的运用脉冲型组织多普勒技术(PW-TDI)测算心肌综合指数(Tei指数)以评价风湿性心脏病二尖瓣狭窄(MS)患者左心室功能。方法测量30例MS患者及25例健康对照者的常规超声心动图指标,在PW-TDI条件下测算左心室二尖瓣环四个位点(后间隔、侧壁、前壁、下壁)的Tei值及其均值(t-Tei),对两组值进行对比分析。结果与正常对照组相比,MS患者左室Tei值明显增大(P<0.001);二尖瓣环四个位点等容舒张时间延长(P<0.001)、射血时间缩短(P<0.01或P<0.05),前壁、下壁等容收缩时间延长(P<0.05)。结论MS患者左心室在收缩功能正常时舒张功能已减退,采用PW-TDI技术测算Tei指数来评价风湿性心脏病MS患者左心室功能具有重要的临床价值。     

Tei指数评价肥厚型心肌病患者左心功能的临床价值

目的：探讨Tei指数评价肥厚型心肌病患者左心功能的临床价值。方法：检测18例肥厚型梗阻性心肌病患者(H()CM组)、15例肥厚型非梗阻性心肌病患者(HNCM组)、20例健康体检者(对照组)左心常规超声指标,记录二尖瓣及主动脉瓣血流频谱,计算Tei指数。结果：与对照组比较,HOCM组与HNCM组E峰减速时间增高,E/A比值降低,Tei值明显增大(P＜0.05);HOCM组与HNCM组间差异无统计学意义(P＞0.05)。结论：Tei指数能早期、敏感、综合评价HCM患者左心功能变化。     

Tei指数评价非体外循环冠状动脉搭桥术后心功能的变化

目的　应用Tei指数评价非体外循环冠状动脉搭桥术 (OPCAB)后心功能的变化。方法　选取 46例行OPCAB的冠心病患者 ,分别于术前 ,术后即刻、1周、1个月、3个月、6个月应用经胸超声多普勒技术测量患者的左室射血分数 (LVEF)、二尖瓣口舒张早期和舒张晚期血流峰值之比 (E/A)、E峰减速时间(EDT)、左室等容舒张时间 (IVRT)、肺静脉血流图收缩波和舒张波之比 (S/D)、肺静脉反向血流a波峰值(a)及Tei指数。结果　在各时间点间Tei指数逐渐减小 ,差异均具有显著性意义 ( P <0 .0 1～ 0 .0 5 )。其余指标各时间点间也存在不同程度的差异。结论　Tei指数是综合检测左室收缩和舒张功能的可靠指标。OPCAB术后心功能得到明显改善 ,这种恢复从术后即刻就已开始 ,到 6个月时还在继续     

Differences in left ventricular diastolic dysfunction between eccentric and concentric left ventricular hypertrophy in hypertensive patients with preserved systolic function

Left ventricular (LV) hypertrophy (LVH) may be eccentric or concentric (2 × LV posterior wall thickness relative to LV end-diastolic dimension ≤ 0.42 or > 0.42, respectively). The LV diastolic function between age-matched hypertensive patients with eccentric and concentric LVH was compared in the present study. Echocardiography was used to measure LV mass index (LV mass/body surface area; LVMI) as an index of LVH. LV diastolic function was assessed by measurements of peak early transmitral flow velocity (E)/peak late transmitral flow velocity (A) (the E/A ratio), peak early diastolic mitral annular velocity (e') and the E/e' ratio. Although LVMI, E/A and e' did not differ between the two groups, E/e' was significantly higher (worse) in patients with concentric LVH (13.4 ± 5.4) than in those with eccentric LVH (11.1 ± 3.6). Among hypertensive patients with LVH, those with concentric LVH may, therefore, have more severe LV diastolic dysfunction than those with eccentric LVH even if their LVMIs, which reflect the degree of LVH, are similar.     

Comparison of preoperative left ventricular function with postoperative left ventricular response to exercise in patients with chronic aortic regurgitation and aortic stenosis

The relation between preoperative left ventricular (LV) systolic function at rest and postoperative LV response to exercise was assessed in 13 patients with aortic regurgitation (AR) and nine patients with aortic stenosis (AS). Preoperative end-systolic volume index (ESVI) and ejection fraction (EF) determined by LV angiography were compared with postoperative exercise-induced changes of LV fractional shortening (delta %FS) and mean velocity of fiber shortening (delta mVcf) assessed by echocardiography. Preoperative EF and ESVI in 13 patients with AR correlated well with postoperative delta %FS and delta mVcf. Similarly, preoperative EF and ESVI in nine patients with AS correlated well with postoperative delta %FS and delta mVcf. Our study demonstrated that preoperative LV systolic function in AR and AS patients closely reflected postoperative LV response to exercise. Preoperative smaller ESVI will be warranted to expect a favorably good postoperative LV response to exercise.