Asunto(s)

Presión Arterial/fisiología , Enfermedades Asintomáticas , Ejercicio Físico/fisiología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/fisiología , Anciano , Enfermedades Asintomáticas/terapia , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Estudios Prospectivos

RESUMEN

BACKGROUND: The timing of mitral valve surgery in asymptomatic patients with primary mitral regurgitation (MR) is controversial. We hypothesized that the forward left ventricular (LV) ejection fraction (LVEF; ie, LV outflow tract stroke volume divided by LV end-diastolic volume) is superior to the total LVEF to predict outcomes in MR. The objective of this study was to examine the association between echocardiographic parameters of MR severity and LV function and outcomes in patients with MR. METHODS AND RESULTS: The clinical and Doppler-echocardiographic data of 278 patients with ≥mild MR and no class I indication of mitral valve surgery at baseline were retrospectively analyzed. The primary study end point was the composite of mitral valve surgery or death. During a mean follow-up of 5.4±3.2 years, there were 147 (53%) events: 96 (35%) MV surgeries and 66 (24%) deaths. Total LVEF and global longitudinal strain were not associated with the occurrence of events, whereas forward LVEF (P<0.0001) and LV end-systolic diameter (P=0.0003) were. After adjustment for age, sex, MR severity, Charlson probability, coronary artery disease, and atrial fibrillation, forward LVEF remained independently associated with the occurrence of events (adjusted hazard ratio: 1.09, [95% confidence interval]: 1.02-1.17 per 5% decrease; P=0.01), whereas LV end-systolic diameter was not (P=0.48). CONCLUSIONS: The results of this study suggest that the forward LVEF may be superior to the total LVEF and LV end-systolic diameter to predict outcomes in patients with primary MR. This simple and easily measurable parameter may be useful to improve risk stratification and select the best timing for intervention in patients with primary MR.

Asunto(s)

Insuficiencia de la Válvula Mitral/fisiopatología , Válvula Mitral/fisiopatología , Volumen Sistólico , Función Ventricular Izquierda , Anciano , Anciano de 80 o más Años , Enfermedades Asintomáticas , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Supervivencia sin Enfermedad , Ecocardiografía Doppler , Femenino , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/cirugía , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/fisiopatología

RESUMEN

AIMS: The objective of this study was to examine the association between the different patterns of left ventricular (LV) remodelling/hypertrophy on all-cause and cardiovascular mortality in patients with aortic stenosis (AS). METHODS AND RESULTS: In total, 747 consecutive patients (69 ± 14 years, 57% men) with AS and preserved LV ejection fraction were included in this study. According to LV mass index and relative wall thickness, patients were classified into four LV patterns: normal, concentric remodelling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH). One hundred and sixteen patients (15%) had normal pattern, 66 (9%) had EH, 169 (23%) had CR, and 396 (53%) had CH. During a median follow-up of 6.4 years, 339 patients died (242 from cardiovascular causes). CH was associated with higher risk of all-cause mortality compared with the three other LV patterns (all P < 0.05). After multivariable adjustment, CH remained associated with higher risk of mortality (HR = 1.27, 95% CI 1.01-1.61, P = 0.046). There was a significant interaction (P < 0.05) between sex and CH with regards to the impact on mortality: CH was associated with worse outcome in women (P = 0.0001) but not in men (P = 0.22). In multivariable analysis, CH remained associated with higher risk of worse outcome in women (HR = 1.56, 95% CI 1.08-2.24, P = 0.018). CONCLUSIONS: This study shows that CH was independently associated with increased risk of mortality in AS patients with preserved ejection fraction. This association was observed in women but not in men. The pattern of LV remodelling/hypertrophy should be integrated in the risk stratification process in patients with AS.

Asunto(s)

Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Causas de Muerte , Hipertrofia Ventricular Izquierda/mortalidad , Volumen Sistólico/fisiología , Remodelación Ventricular/fisiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/fisiopatología , Estudios de Cohortes , Ecocardiografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/fisiopatología , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Quebec , Estudios Retrospectivos , Medición de Riesgo , Factores Sexuales , Tasa de Supervivencia

RESUMEN

OBJECTIVES: This study sought to assess the survival benefit associated with aortic valve replacement (AVR) according to different strata of echocardiographic parameters of aortic stenosis (AS) severity, and especially in patients with an aortic valve area (AVA) comprised between 0.8 cm(2) and 1 cm(2). BACKGROUND: Discordant findings between AVA (≤1.0 cm(2)) and mean gradient (MG) (<40 mm Hg) raise uncertainty regarding the actual severity of AS. Some studies suggested that the AVA threshold value to define severe AS should be decreased to 0.8 cm(2) to reconcile these discordances. METHODS: A total of 1,710 patients with documented moderate to severe AS by Doppler echocardiography were separated into 4 strata of AS severity based alternatively on AVA, indexed AVA, MG, or peak aortic jet velocity (Vpeak). We compared the survival rates of medically versus surgically treated patients. To eliminate covariate differences that may lead to biased estimates of treatment effect, a propensity matching with a greedy 5-to-1 digit-matching algorithm was used. RESULTS: Mean AVA was 0.9 ± 0.3 cm(2), mean MG 33 ± 18 mm Hg, and mean Vpeak 3.6 ± 0.9 m/s. A total of 1,030 (60%) patients underwent AVR within 3 months following echocardiographic evaluation. During a mean follow-up of 4.4 ± 3.0 years there were 469 deaths. Patients with an AVA between 0.8 cm(2) and 1.0 cm(2) had a significant observed survival benefit with AVR (hazard ratio: 0.37 [95% confidence interval: 0.21 to 0.63]; p = 0.0002). AVR was also associated with improved survival in patients with MG between 25 mm Hg and 40 mm Hg or Vpeak between 3 m/s and 4 m/s, but only in patients with concomitant AVA ≤1 cm(2) (p = 0.001 vs. p = 0.46 in patients with AVA >1 cm(2)). CONCLUSIONS: These results do not support decreasing the AVA threshold value for severity to 0.8 cm(2) and they confirm that AVR is associated with improved survival in a substantial number of patients with discordant aortic grading.

Asunto(s)

Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Implantación de Prótesis Vascular , Ecocardiografía Doppler , Anciano , Anciano de 80 o más Años , Algoritmos , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Femenino , Hemodinámica , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

OBJECTIVE: The study purpose was to assess the usefulness of echocardiographic parameters of aortic stenosis (AS) severity and left ventricular (LV) systolic function to predict mortality in AS. The main hypothesis is that parameters of LV systolic function are the most important independent predictors of mortality, whereas parameters of stenosis severity are not. METHODS: 1065 consecutive patients with AS referred to the echocardiography laboratory and meeting the inclusion/exclusion criteria were included and followed during 5.7 years. The end points were aortic valve replacement (AVR) (n=584), composite of AVR or death (n=932), all-cause mortality (n=550) and cardiovascular mortality (n=398). RESULTS: The most powerful echocardiographic predictors of valve-related events were parameters of AS severity, such as peak aortic jet velocity (VPeak), mean gradient (MG) and aortic valve area (AVA) (all p<0.001). Regarding mortality, the main predictors were LV ejection fraction (LVEF) and stroke volume index (SVi) (p<0.05). After multivariable adjustment, LVEF (p<0.001) and SVi (p=0.02) remained the only echocardiographic predictors of mortality, even after adjustment for symptomatic status. AVA was also associated with mortality, whereas VPeak and MG were not. CONCLUSIONS: The most powerful echocardiographic predictors of mortality are low LVEF and low flow, whereas AS severity parameters predict valve-related events but not overall mortality. Hence, low flow should be integrated in the risk stratification and therapeutic decision-making in patients with AS.

Asunto(s)

Estenosis de la Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/diagnóstico por imagen , Ecocardiografía Doppler , Anciano , Anciano de 80 o más Años , Válvula Aórtica/fisiopatología , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Área Bajo la Curva , Causas de Muerte , Distribución de Chi-Cuadrado , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Volumen Sistólico , Sístole , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular Izquierda

RESUMEN

BACKGROUND: Right ventricular (RV) failure is the most important factor of both morbidity and mortality in pulmonary arterial hypertension (PAH). However, the underlying mechanisms resulting in the failed RV in PAH remain unknown. There is growing evidence that angiogenesis and microRNAs are involved in PAH-associated RV failure. We hypothesized that microRNA-126 (miR-126) downregulation decreases microvessel density and promotes the transition from a compensated to a decompensated RV in PAH. METHODS AND RESULTS: We studied RV free wall tissues from humans with normal RV (n=17), those with compensated RV hypertrophy (n=8), and patients with PAH with decompensated RV failure (n=14). Compared with RV tissues from patients with compensated RV hypertrophy, patients with decompensated RV failure had decreased miR-126 expression (quantitative reverse transcription-polymerase chain reaction; P<0.01) and capillary density (CD31(+) immunofluorescence; P<0.001), whereas left ventricular tissues were not affected. miR-126 downregulation was associated with increased Sprouty-related EVH1 domain-containing protein 1 (SPRED-1), leading to decreased activation of RAF (phosphorylated RAF/RAF) and mitogen-activated protein kinase (MAPK); (phosphorylated MAPK/MAPK), thus inhibiting the vascular endothelial growth factor pathway. In vitro, Matrigel assay showed that miR-126 upregulation increased angiogenesis of primary cultured endothelial cells from patients with decompensated RV failure. Furthermore, in vivo miR-126 upregulation (mimic intravenous injection) improved cardiac vascular density and function of monocrotaline-induced PAH animals. CONCLUSIONS: RV failure in PAH is associated with a specific molecular signature within the RV, contributing to a decrease in RV vascular density and promoting the progression to RV failure. More importantly, miR-126 upregulation in the RV improves microvessel density and RV function in experimental PAH.

Asunto(s)

Regulación hacia Abajo/fisiología , Insuficiencia Cardíaca/metabolismo , Hipertensión Pulmonar/metabolismo , MicroARNs/metabolismo , Disfunción Ventricular Derecha/metabolismo , Adulto , Anciano , Animales , Células Cultivadas , Femenino , Insuficiencia Cardíaca/diagnóstico , Humanos , Hipertensión Pulmonar/diagnóstico , Masculino , Persona de Mediana Edad , Ratas , Ratas Sprague-Dawley , Disfunción Ventricular Derecha/diagnóstico

RESUMEN

OBJECTIVE: Low flow (LF), defined as stroke volume index (SVi) <35 mL/m(2), prior to the procedure has been recently identified as a powerful independent predictor of early and late mortality in patients undergoing transcatheter aortic valve replacement (TAVR). The objectives of this study were to determine the evolution of SVi following TAVR and to assess the determinants and impact on mortality of early postprocedural SVi (EP-SVi). METHODS: We retrospectively analysed the clinical, Doppler echocardiographic and outcome data prospectively collected in 255 patients who underwent TAVR. Echocardiograms were performed before (baseline), within 5 days after procedure (early post procedure) and 6 months to 1 year following TAVR (late post procedure). RESULTS: Patients with EP-SVi <35 mL/m(2) (n=138; 54%) had increased mortality (HR 1.97, p=0.003) compared with those with EP-SVi ≥35 mL/m(2) (n=117; 46%). Furthermore, patients with baseline SVi (B-SVi) <35 mL/m(2) and EP-SVI ≥35 mL/m(2), that is, normalised flow, had better survival (HR 0.46, p=0.03) than those with both B-SVi and EP-SVi <35 mL/m(2), that is, persistent LF, and similar survival compared with those with both B-SVi and EP-SVi ≥35 mL/m(2), that is, maintained normal flow. In a multivariable model analysis, EP-SVi was independently associated with increased risk of mortality (HR 1.41 per 10 mL/m(2) decrease, p=0.03). The preprocedural/intraprocedural factors associated with lower EP-SVi were lower B-SVi (standardised ß [ß] 0.36, p<0.001) atrial fibrillation (ß -0.13, p=0.02) and transapical approach (ß -0.22, p<0.001). CONCLUSIONS: The measurement of EP-SVi is useful to assess the immediate haemodynamic benefit of TAVR and to predict the risk of late mortality.

Asunto(s)

Estenosis de la Válvula Aórtica/terapia , Válvula Aórtica/fisiopatología , Cateterismo Cardíaco , Implantación de Prótesis de Válvulas Cardíacas , Hemodinámica , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/mortalidad , Distribución de Chi-Cuadrado , Ecocardiografía Doppler , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Estimación de Kaplan-Meier , Modelos Lineales , Masculino , Análisis Multivariante , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Volumen Sistólico , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular Izquierda

RESUMEN

BACKGROUND: The mechanisms of improvement of left ventricular (LV) function with cardiac resynchronization therapy (CRT) are not yet elucidated. The aim of this study was to describe a new tool based on automatic quantification of the integrals of regional longitudinal strain signals and evaluate changes in LV strain distribution after CRT. METHODS: This was a retrospective observational study of 130 patients with heart failure before CRT device implantation and after 3 to 6 months of follow-up. Integrals of regional longitudinal strain signals (from the beginning of the cardiac cycle to strain peak [IL,peak] and to the instant of aortic valve closure [IL,avc]) were analyzed retrospectively with custom-made algorithms. Response to CRT was defined as a decrease in LV end-systolic volume of ≥15%. RESULTS: Responders (61%) and nonresponders (39%) showed similar baseline values of regional IL,peak and IL,avc. At follow-up, significant improvements of midlateral IL,peak and of midlateral IL,avc were noted only in responders. Midlateral IL,avc showed a relative increase of 151 ± 276% in responders, whereas a decrease of 33 ± 69% was observed in nonresponders. The difference between IL,avc and IL,peak (representing wasted energy of the LV myocardium) of the lateral wall showed a relative change of -59 ± 103% in responders between baseline and CRT, whereas in nonresponders, the relative change was 21 ± 113% (P = .009). CONCLUSIONS: Strain integrals revealed changes between baseline and CRT in the lateral wall, demonstrating the beneficial effects of CRT on LV mechanics with favorable myocardial reverse remodeling.

Asunto(s)

Desfibriladores Implantables , Ecocardiografía/métodos , Interpretación de Imagen Asistida por Computador/métodos , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/prevención & control , Anciano , Algoritmos , Módulo de Elasticidad , Femenino , Humanos , Aumento de la Imagen/métodos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Volumen Sistólico , Resultado del Tratamiento

RESUMEN

The valve-in-valve (ViV) procedure is an option for patients with symptomatic structural degeneration of a bioprosthesis and excessive reoperative risk. The risk of coronary obstruction appears to be increased if ViV is performed for certain pericardial prostheses in which the leaflets are mounted outside the stent posts. Herein is described a successful ViV for a degenerated Trifecta aortic bioprosthesis, and the technical considerations for performing a ViV procedure within such types of prosthesis are considered. Emphasis is placed on the importance of preoperative investigations (computed tomography scan-based measurements of coronary ostial height and of sinus of Valsalva diameters), and on the precise deployment of the valve (transapical approach with transesophageal echocardiography control) to minimize the risk of major complications. The presence of a failing Trifecta bioprosthesis should not be considered an absolute contraindication to ViV on the basis of the risk of coronary obstruction.

Asunto(s)

Insuficiencia de la Válvula Aórtica/terapia , Válvula Aórtica/cirugía , Bioprótesis , Cateterismo Cardíaco/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Falla de Prótesis , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Aortografía , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/métodos , Ecocardiografía Doppler en Color , Ecocardiografía Transesofágica , Estudios de Factibilidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Diseño de Prótesis , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

AIMS: The management of asymptomatic patients with mitral regurgitation (MR) remains controversial. Exercise-induced pulmonary hypertension (ExPHT) was recently reported as a strong predictor of rapid onset of symptoms. We hypothesised that ExPHT is a predictor of postoperative cardiovascular events in patients with primary MR. METHODS AND RESULTS: One hundred and two patients with primary MR, no or mild symptoms (New York heart association (NYHA) ≤2), and no LV dysfunction/dilatation, were prospectively recruited in 3 centres and underwent exercise-stress echocardiography. The presence of ExPHT was defined as an exercise systolic pulmonary arterial pressure >60 mm Hg. All patients were closely followed up and operated on when indication for surgery was reached. Postoperative events were defined as the occurrence of atrial fibrillation (AF), stroke, cardiac-related hospitalisation or death. Among the 102 patients included, 59 developed ExPHT (58%). These patients were significantly older than those without ExPHT (p=0.01). During a mean postoperative follow-up of 50±23 months, 28 patients (26%) experienced a predefined cardiovascular event. Patients with ExPHT had significantly higher rate of postoperative events (39% vs 12%, p=0.005); the rate of events was still higher in these patients (32% vs 9%, p=0.013), even when excluding early postoperative AF (ie, within 48 h). Event-free survival was significantly lower in the ExPHT group (all events: 5-year: 60±8% vs 88±5%, p=0.007, events without early AF: 5-year: 67±7% vs 90±4%, p=0.02). Using Cox multivariable analysis, ExPHT remained independently associated with higher risk of postoperative events in all models (all p≤0.04). CONCLUSIONS: ExPHT is associated with increased risk of adverse cardiac events following mitral valve surgery in patients with primary MR.

Asunto(s)

Ecocardiografía de Estrés , Hipertensión Pulmonar/epidemiología , Insuficiencia de la Válvula Mitral/cirugía , Complicaciones Posoperatorias/epidemiología , Factores de Edad , Anciano , Enfermedades Asintomáticas , Fibrilación Atrial/epidemiología , Bélgica/epidemiología , Femenino , Estudios de Seguimiento , Francia/epidemiología , Atrios Cardíacos/diagnóstico por imagen , Insuficiencia Cardíaca/mortalidad , Ventrículos Cardíacos/diagnóstico por imagen , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/epidemiología , Análisis Multivariante , Estudios Prospectivos , Quebec/epidemiología , Accidente Cerebrovascular/epidemiología

RESUMEN

BACKGROUND: The transthoracic echocardiographic (TTE) evaluation of the severity of residual aortic regurgitation (AR) following transcatheter aortic valve implantation (TAVI) has been controversial and lacks validation. OBJECTIVES: This study sought to compare TTE and cardiac magnetic resonance (CMR) for assessment of AR in patients undergoing TAVI with a balloon-expandable valve. METHODS: TTE and CMR exams were performed pre-TAVI in 50 patients and were repeated postprocedure in 42 patients. All imaging data were analysed in centralised core laboratories. RESULTS: The severity of native AR as determined by multiparametric TTE approach correlated well with the regurgitant volume and regurgitant fraction determined by CMR prior to TAVI (Rs=0.79 and 0.80, respectively; p<0.001 for both). However, after TAVI, the correlation between the prosthetic AR severity assessed by TTE and regurgitant volume and fraction measured by CMR was only modest (Rs=0.59 and 0.59, respectively; p<0.001 for both), with an underestimation of AR severity by TTE in 61.9% of patients (1 grade in 59.5%). The TTE jet diameter in parasternal view and the multiparametric approach (Rs=0.62 and 0.59, respectively; both with p<0.001) showed the best correlation with CMR regurgitant fraction post-TAVI. The circumferential extent of prosthetic paravalvular regurgitation showed a poor correlation with CMR regurgitant volume and fraction (Rs=0.32, p=0.084; Rs=0.36, p=0.054, respectively). CONCLUSIONS: The severity of AR following TAVI with a balloon-expandable valve was underestimated by echocardiography as compared with CMR. The jet diameter, but not the circumferential extent of the leaks, and the multiparametric echocardiography integrative approach best correlated with CMR findings. These results provide important insight into the evaluation of AR severity post-TAVI.

Asunto(s)

Insuficiencia de la Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano , Insuficiencia de la Válvula Aórtica/patología , Estenosis de la Válvula Aórtica/cirugía , Valvuloplastia con Balón/métodos , Ecocardiografía Doppler en Color/métodos , Ecocardiografía Transesofágica/métodos , Femenino , Humanos , Angiografía por Resonancia Magnética/métodos , Imagen por Resonancia Cinemagnética/métodos , Masculino , Variaciones Dependientes del Observador , Estudios Prospectivos

RESUMEN

A 38-year-old farmer was hospitalized for fever, chills, cough, and chest pain lasting for 7 days. Due to persistent symptoms, patient was referred to hospital. Blood cultures identified oxacillin-sensitive Staphylococcus aureus (OSSA). Transthoracic echocardiography (TTE) showed large pericardial effusion, a mobile heterogeneous mass originating from the coronary sinus ostium, no sign of valvular endocarditis. Pericardiocentesis was done carrying out purulent fluid, microbiological culture isolating an OSSA. Parenteral penicillin M was administered for 6 weeks. At the end of this antibiotherapy regimen, TTE showed no coronary sinus mass with complete vacuity of the coronary sinus vein and no pericardial effusion.

Asunto(s)

Bacteriemia/diagnóstico por imagen , Seno Coronario/diagnóstico por imagen , Penicilinas/uso terapéutico , Derrame Pericárdico/diagnóstico por imagen , Infecciones Estafilocócicas/diagnóstico por imagen , Tromboflebitis/diagnóstico por imagen , Adulto , Bacteriemia/tratamiento farmacológico , Bacteriemia/microbiología , Seno Coronario/microbiología , Ecocardiografía/métodos , Estudios de Seguimiento , Humanos , Infusiones Intravenosas , Masculino , Derrame Pericárdico/microbiología , Derrame Pericárdico/terapia , Pericardiocentesis/métodos , Índice de Severidad de la Enfermedad , Infecciones Estafilocócicas/tratamiento farmacológico , Tromboflebitis/tratamiento farmacológico , Tromboflebitis/microbiología , Resultado del Tratamiento

RESUMEN

BACKGROUND: The operative risk of cardiac surgery is ascertained preoperatively on the basis of scores validated in multinational studies. However, the value they add to a simple bedside clinical evaluation (CE) remains controversial. AIMS: To compare operative mortality (defined as death from all causes before the 31st postoperative day) predicted by CE with that predicted by additive and logistic EuroSCOREs, EuroSCORE II and Society of Thoracic Surgeons (STS), Ambler and age-creatinine-ejection fraction (ACEF) scores in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis. METHODS: Overall, 314 consecutive patients were included who underwent AVR between October 2009 and November 2011 (22% with coronary artery bypass graft); mean age 73.4 ± 9.7 years (29% aged>80 years). Based on CE, patients were divided into four predefined groups of increasing estimated mortality risk: I ≤ 3.9%; II 4-6.9%; III 7-9.9%; IV ≥ 10%. The positive and negative predictive values of the six scores and CE were compared. RESULTS: The observed overall operative mortality was 5.7%. The distribution of the four predicted mortality groups by each score was highly variable. The positive predictive value, calculated for the 64 patients classified at highest risk by CE (groups III or IV) or each score, was 17.2% for EuroSCORE II, 14.1% for CE and STS scores, 10.9% for additive and logistic EuroSCOREs, 10.6% for ACEF and 10.2% for Ambler. The positive predictive value of each score in the low-risk groups (I and II) ranged from 2.8% to 4.4%. CONCLUSION: A simple bedside CE appears as reliable as the various established scores for predicting operative risk in patients undergoing surgical aortic valve replacement. The development and validation of more comprehensive risk stratification tools, including risk factors thus far neglected, seems warranted.

Asunto(s)

Estenosis de la Válvula Aórtica/cirugía , Técnicas de Apoyo para la Decisión , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/sangre , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Biomarcadores/sangre , Distribución de Chi-Cuadrado , Creatinina/sangre , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Volumen Sistólico , Resultado del Tratamiento , Adulto Joven

RESUMEN

BACKGROUND: Hypertrophic cardiomyopathy (HCM) and aortic stenosis (AS) may influence left ventricular (LV) systolic function, despite preservation of LV ejection fraction. The aim of this study was to determine the relative importance of cardiac afterload and myocardial hypertrophy in the potential dysfunction of myocardial deformation, at rest and during standardized exercise. METHODS: Patients with moderate to severe (≤ 1.5 cm(2)) asymptomatic AS and patients with HCM in sinus rhythm were prospectively studied using resting and exercise echocardiography during submaximal exercise. Myocardial deformations were assessed using two-dimensional strain. Exclusion criteria were altered LV ejection fraction (<50%), coronary artery disease, intra-LV obstruction > 30 mm Hg at rest, diastolic LV thickness ≥ 30 mm, and New York Heart Association class > II. Thus, 50 patients (25 with AS, 25 with HCM) were selected and matched for age, sex, rest and exercise blood pressure, degree of LV hypertrophy (defined by maximal wall thickness), and LV ejection fraction. RESULTS: Mean resting global longitudinal strain (GLS) was -14.9 ± 4.7% in patients with AS and -16.1 ± 3.9% in those with HCM (P = .30). During exercise (mean heart rate, 110 ± 10 beats/min), mean GLS was -13.9 ± 4.2% in patients with AS and -18.1 ± 5.4% in those with HCM (P = .004). GLS decreased in patients with AS but increased in those with HCM (ΔGLS, 0.9 ± 3.1% and -1.9 ± 3.2%, respectively, P = .003). The same results were observed for global circumferential strain. Mean resting global circumferential strain was -16.4 ± 5.8% in patients with AS and -17.9 ± 4.5% in those with HCM (P = .36). During exercise, mean global circumferential strain was -13.8 ± 4.1% in patients with AS and -18.6 ± 5.3% in those with HCM (P = .011). Afterload was higher, particularly during exercise, in patients with AS than in those with HCM. CONCLUSIONS: Longitudinal and circumferential LV deformation during exercise was lower in patients with AS compared with those with HCM, despite similar resting characteristics. The greater afterload observed in patients with AS led to reduced contractile reserve.

Asunto(s)

Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Ejercicio Físico/fisiología , Ventrículos Cardíacos/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/diagnóstico por imagen , Adolescente , Adulto , Ecocardiografía Doppler/métodos , Femenino , Humanos , Hipertrofia Ventricular Izquierda/etiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto Joven

RESUMEN

OBJECTIVES: The study sought to describe a specific syndrome characterized by isolated left bundle branch block (LBBB) and a history of progressive left ventricular (LV) dysfunction, successfully treated by cardiac resynchronization therapy (CRT). BACKGROUND: Isolated LBBB in animals causes cardiac remodeling due to mechanical dyssynchrony, reversible by biventricular stimulation. However, the existence of LBBB-induced cardiomyopathy in humans remains uncertain. METHODS: Between 2007 and 2010, 375 candidates for CRT were screened and retrospectively included in this study if they met all criteria of a pre-defined syndrome, including: 1) history of typical LBBB for >5 years; 2) LV ejection fraction (EF) >50%; 3) decrease in LVEF to <40% and development of heart failure (HF) to NYHA functional class II to IV over several years; 4) major mechanical dyssynchrony; 5) no known etiology of cardiomyopathy; and 6) super-response to CRT with LVEF >45% and decrease in NYHA functional class at 1 year. RESULTS: The syndrome was identified in 6 patients (1.6%), 50.5 years of age on average at the time of LBBB diagnosis. HF developed over a mean of 11.6 years. At the time of referral, Doppler echocardiograms showed major mechanical dyssynchrony at left atrioventricular, interventricular, and left intraventricular levels. During CRT, NYHA functional class decreased, LV dimensions normalized and mechanical dyssynchrony was nearly resolved in all patients, and mean LVEF increased from 31 ± 12% to 56 ± 8% (p = 0.027). CONCLUSIONS: These observations support the existence of a specific LBBB-induced cardiomyopathy resolved by CRT. Its prevalence, time course, and risk factors need to be prospectively studied.

Asunto(s)

Bloqueo de Rama/complicaciones , Bloqueo de Rama/terapia , Terapia de Resincronización Cardíaca , Cardiomiopatías/etiología , Cardiomiopatías/terapia , Adulto , Ecocardiografía Doppler , Electrocardiografía , Femenino , Insuficiencia Cardíaca/terapia , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Volumen Sistólico

RESUMEN

BACKGROUND: Cardiac resynchronization therapy (CRT) decreases mortality, improves functional status, and induces reverse left ventricular remodeling in selected populations with heart failure. We aimed to assess the impact of baseline QRS duration and morphology and the change in QRS duration with pacing on CRT outcomes in mild heart failure. METHODS AND RESULTS: Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) was a multicenter randomized trial of CRT among 610 patients with mild heart failure. Baseline and CRT-paced QRS durations and baseline QRS morphology were evaluated by blinded core laboratories. The mean baseline QRS duration was 151±23 milliseconds, and 60.5% of subjects had left bundle-branch block (LBBB). Patients with LBBB experienced a 25.3-mL/m(2) mean reduction in left ventricular end-systolic volume index (P<0.0001), whereas non-LBBB patients had smaller decreases (6.7 mL/m(2); P=0.18). Baseline QRS duration was also a strong predictor of change in left ventricular end-systolic volume index with monotonic increases as QRS duration prolonged. Similarly, the clinical composite score improved with CRT for LBBB subjects (odds ratio, 0.530; P=0.0034) but not for non-LBBB subjects (odds ratio, 0.724; P=0.21). The association between clinical composite score and QRS duration was highly significant (odds ratio, 0.831 for each 10-millisecond increase in QRS duration; P<0.0001), with improved response at longer QRS durations. The change in QRS duration with CRT pacing was not an independent predictor of any outcomes after correction for baseline variables. CONCLUSION: REVERSE demonstrated that LBBB and QRS prolongation are markers of reverse remodeling and clinical benefit with CRT in mild heart failure. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00271154.

Asunto(s)

Terapia de Resincronización Cardíaca , Insuficiencia Cardíaca/terapia , Anciano , Bloqueo de Rama/complicaciones , Electrocardiografía , Femenino , Corazón/fisiopatología , Insuficiencia Cardíaca/etiología , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/complicaciones , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/terapia , Remodelación Ventricular/fisiología

RESUMEN

BACKGROUND: Because of the lack of reliable echocardiographic parameters to predict recovery after surgery, the optimal timing of surgery for severe mitral regurgitation remains controversial. The aim of this study was to determine whether global longitudinal strain (GLS) recorded preoperatively could help in predicting left ventricular (LV) ejection fraction (LVEF) postoperatively. METHODS: A total of 88 patients (mean age, 63 ± 13 years; 59 men) with severe degenerative mitral regurgitation were included prospectively in this study. Rest echocardiography was performed before and 6 ± 1 months after mitral valve surgery. Patients were divided into two groups: group A (postoperative LVEF ≥ 50%) and group B (postoperative LVEF < 50%). RESULTS: In group B, patients had larger preoperative LV end-systolic diameters (21.6 ± 2.6 vs 19.2 ± 3.7 mm/m(2), P = .02) and impaired preoperative GLS (-17 ± 2.8% vs -19.6 ± 3.6%, P = .01), whereas there was no difference in preoperative LVEF. Preoperative LV end-systolic diameter ≥ 22 mm/m(2) and GLS < -18% were independent predictors of postoperative LV dysfunction. CONCLUSIONS: LV end-systolic diameter is a well-recognized prognostic marker. In addition, this study demonstrates the additive and independent predictive value of preoperative GLS for predicting postoperative LV dysfunction.

Asunto(s)

Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/cirugía , Módulo de Elasticidad , Diagnóstico por Imagen de Elasticidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/complicaciones , Pronóstico , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Resultado del Tratamiento , Disfunción Ventricular Izquierda/etiología

RESUMEN

AIMS: Left ventricular (LV) end-systolic diameter and LV ejection fraction (LVEF) are correlated with postoperative LVEF and prognosis in patients with organic mitral regurgitation (MR). However, in some patients, the LVEF does not return to normal 6 months postoperatively, despite normal preoperative diameters. Thus, our study aimed to evaluate whether preoperative LV strain values assessed by echocardiography at rest and during exercise were predictors of postoperative LVEF at 6-month follow-up in patients undergoing surgery for severe organic MR. METHODS AND RESULTS: In total, 88 patients with severe organic MR (mean age 62.6 ± 1.4 years) were prospectively recruited. All patients underwent an echocardiogram at rest and submaximal exercise (110 ± 10 bpm) prior to surgery and then at rest 6 months after surgery. Exclusion criteria were significant coronary artery disease, other organic valvular diseases, uncontrolled arrhythmia, and haemodynamic instability. Among the 88 patients, 77 had complete data sets with rest and exercise echocardiograms and underwent isolated mitral valve surgery (repaired, n= 72). Global longitudinal strain (GLS) at rest (R= -0.42, P= 0.011) and during exercise (R= -0.36, P= 0.034) correlated with postoperative LVEF. When normalized for LV end-systolic diameter, GLS during exercise was more closely correlated with postoperative LVEF and was its best predictor based on a multivariate linear regression model. At a cut-off of -5.7%/cm, sensitivity was 0.83, specificity 0.70, negative predictive value 0.64, and positive predictive value 0.86 for predicting a 6-month postoperative LVEF of <50%. CONCLUSION: In patients undergoing surgery for severe organic MR, GLS normalized for LV end-systolic diameter at submaximal exercise may be used as a predictor of postoperative LVEF.

Asunto(s)

Prueba de Esfuerzo , Insuficiencia de la Válvula Mitral/cirugía , Complicaciones Posoperatorias , Volumen Sistólico , Ultrasonografía Doppler , Función Ventricular Izquierda , Progresión de la Enfermedad , Femenino , Indicadores de Salud , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/patología , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Estadística como Asunto , Factores de Tiempo

RESUMEN

BACKGROUND: Heart failure (HF) with a preserved (P) left ventricular (LV) ejection fraction (EF) is common, though its diagnosis and physiopathology remains unclear. We sought to analyse the myocardial characteristics at rest and during a sub-maximal exercise test in patients with HFPEF. METHODS AND RESULTS: Standardized sub-maximal exercise stress echocardiography was performed in (i) 21 patients from the Karolinska Rennes Prospective Study of Heart Failure with Preserved Left Ventricular Ejection Fraction HFPEF registry, whose LVEF was ≥45% and (ii) 15 control patients free of any manifestations of HF. During a sub-maximal exercise test, LV systolic function measured as a global four-chamber longitudinal strain was -17±5% in patients with HFPEF vs. -22±4% in controls (P<0.001), LV longitudinal diastolic relaxation, expressed as e' (septal and lateral walls averaged) was 9±2 cm/s in patients vs. 15±4 cm/s in controls (P<0.001), and RV longitudinal systolic function, expressed as RV s', was 14±3 cm/s in patients vs. 18±1 cm/s in controls (P=0.03). LV afterload (arterial elastance) was 2.7±1 mmHg/mL and was correlated with a decrease in LV longitudinal strain (R=0.51, P<0.01) during exercise. CONCLUSION: The assessment of longitudinal systolic and diastolic LV and RV functions is valuable during a sub-maximal exercise stress echocardiography to confirm the heart dysfunction related to the HFPEF symptoms. It might be used as a diagnostic test for difficult clinical situations. ClinicalTrials.gov identifier: NCT01091467.

Asunto(s)

Ecocardiografía de Estrés , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/fisiopatología , Anciano , Estudios de Casos y Controles , Electrocardiografía , Femenino , Humanos , Masculino , Estudios Prospectivos , Sistema de Registros

RESUMEN

OBJECTIVES: The objective of this study is to ascertain the effects of the left (LV) and right (RV) ventricular lead tip position in response to cardiac resynchronization therapy (CRT). BACKGROUND: The REVERSE randomized trial examined the effects of CRT in patients with asymptomatic or mildly symptomatic heart failure (HF). METHODS: We analysed data collected from the active group (CRT-ON) of REVERSE in whom the precise locations of the LV and RV ventricular lead tips were determined from postoperative chest roentgenograms as part of a prespecified sub-study. LV position was classified as lateral or non-lateral, and apical or non-apical. RV position was classified as apical or non-apical. Echocardiographic LV end-systolic volume index (LVESVi), QRS duration, and clinical outcomes at 12-24 months of follow-up were evaluated with respect to the lead tip position. The primary trial endpoint was the proportion of patients with a worsened HF clinical composite response, scored as improved, unchanged, or worsened. RESULTS: Totally 346 patients included in this analysis were followed for a median of 12.6 months (interquartile range: 11.9-23.9 months). The proportion of worsened HF clinical composite response did not correlate with lead position, whereas a significantly greater decrease in the powered secondary endpoint of LVESVi was observed with the non-apical vs. the apical LV lead positions. CRT-paced QRS duration was significantly shorter than at baseline in patients with lateral vs. non-lateral LV position, as well non-apical vs. apical LV position. The incidence of composite endpoint of death and first hospitalization for HF was lower in the LV lateral than in the non-lateral (HR 0.44; 95% CI 0.19-0.99; P= 0.04), and in the LV non-apical than in the apical group (HR 0.27; 95% CI 0.11-0.63; P= 0.001). No significant differences were observed between RV apical and non-apical positions of the lead tip. CONCLUSIONS: A more favourable outcome of CRT with regard to LV reverse remodelling and the composite of time to death or first HF hospitalization was observed when the LV lead tip was implanted in the lateral wall, away from the apex, while the position of the RV lead tip was indifferent. The long-term change in QRS duration was significantly associated with the position of the LV lead tip. ClinicalTrials.gov Identifier: NCT00271154.

Asunto(s)

Dispositivos de Terapia de Resincronización Cardíaca , Desfibriladores Implantables , Insuficiencia Cardíaca/terapia , Implantación de Prótesis/métodos , Terapia de Resincronización Cardíaca/métodos , Método Doble Ciego , Electrocardiografía , Femenino , Ventrículos Cardíacos , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento