Classification of aortic stenosis by flow and gradient patterns provides insights into the pathophysiology of disease

Different patterns of flow and valve gradients can lead to diagnostic uncertainty about the severity of aortic stenosis (AS). Consecutive patients with severe AS (valve area <1 cm2) underwent echocardiography and computed tomography. Patients were classified into 4 groups (high-gradient/normal flow [HGNF], high-gradient/low flow [HGLF], low-gradient/normal flow [LGNF], and low-gradient/low flow [LGLF]). Low flow was defined as stroke volume index <35 mL/m2 and low gradient as a mean aortic gradient <40 mm Hg. Aortic valve calcification (AVC) was calculated using the Agatston score. Of 181 patients, 56, 30, 46, and 49 had HGNF, HGLF, LGNF and LGLF with median AVC of 2048, 2015, 1366, and 1178 AU/m2 (P < .0001) and valvuloarterial impedance of 4.5, 6.4, 4.2, and 5.9, respectively (P < .0001). Among those with LGLF, AVC was lower in patients with preserved compared to reduced left ventricular ejection fraction (1018 vs 2550 AU/m2; P < .0001), but valvuloarterial impedance was similar (P = .33). The LGLFAS with preserved ejection fraction is associated with lower AVC and may identify patients with less severe AS in association with an adaptive ventricular response to high afterload

Classification of Aortic Stenosis by Flow and Gradient Patterns Provides Insights into the Pathophysiology of Disease

Different patterns of flow and valve gradients can lead to diagnostic uncertainty about the severity of aortic stenosis (AS). Consecutive patients with severe AS (valve area <1 cm2) underwent echocardiography and computed tomography. Patients were classified into 4 groups (high-gradient/normal flow [HGNF], high-gradient/low flow [HGLF], low-gradient/normal flow [LGNF], and low-gradient/low flow [LGLF]). Low flow was defined as stroke volume index <35 mL/m2 and low gradient as a mean aortic gradient <40 mm Hg. Aortic valve calcification (AVC) was calculated using the Agatston score. Of 181 patients, 56, 30, 46, and 49 had HGNF, HGLF, LGNF and LGLF with median AVC of 2048, 2015, 1366, and 1178 AU/m2 (P < .0001) and valvuloarterial impedance of 4.5, 6.4, 4.2, and 5.9, respectively (P < .0001). Among those with LGLF, AVC was lower in patients with preserved compared to reduced left ventricular ejection fraction (1018 vs 2550 AU/m2; P < .0001), but valvuloarterial impedance was similar (P = .33). The LGLFAS with preserved ejection fraction is associated with lower AVC and may identify patients with less severe AS in association with an adaptive ventricular response to high afterload

Rate-adaptive AV delay and exercise performance following cardiac resynchronization therapy.

BACKGROUND: Physiological shortening of the atrioventricular (AV) interval with increasing heart rate is well documented in normal human beings and is an established component of dual-chamber pacing for bradycardia. OBJECTIVES: To assess the effect of exercise on optimal AV delay and the impact of a patient-specific rate-adaptive AV delay (RAAVD) on exercise capacity in patients with heart failure following cardiac resynchronization therapy. METHODS: Phase 1: We performed iterative AV optimization at rest and exercise in 52 cardiac resynchronization therapy patients in atrial-sensed mode (mean age 71.6 ± 9.2 years, 25% females). Phase 2: Subsequently, 20 consecutive volunteers from this group (mean age 69.2 ± 9.6 years, 15% females) underwent cardiopulmonary exercise testing with RAAVD individually programmed ON (RAAVD-ON) or OFF (RAAVD-OFF). RESULTS: Phase 1: In 94% of the patients, there was a marked reduction (mean 50%) in optimal AV delay with exercise. The optimal resting vs exercise AV delay was 114.2 ± 29 ms at a heart rate of 64.4 ± 7.1 beats/min vs 57 ± 31 ms at a heart rate of 103 ± 13 beats/min (P < .001). No patients required an increase in AV delay with exercise, and 3 (6%) showed no change. Phase 2: With RAAVD-ON, significantly better exercise times were achieved (8.7 ± 3.2 minutes) compared with RAAVD-OFF (7.9 ± 3.2 minutes; P = .003), and there was a significant improvement in Vo(2)max (RAAVD-ON 16.1 ± 4.0 vs RAAVD-OFF 14.9 ± 3.7 mL/(kg · min); P = .024). CONCLUSIONS: There was a dramatic reduction in optimal AV delay with physiological exercise in the majority of this heart failure cardiac resynchronization therapy cohort. Replicating this physiological response with a programmable RAAVD translated into a 10% improvement in exercise capacity

Ischaemia as a cause of LVOT gradient reversal in HCM

We present the case of a previously fit 84-year-old female with long-standing systemic hypertension and the echo phenotype of hypertrophic cardiomyopathy (HCM) – asymmetrical septal hypertrophy, significant resting left ventricular (LV) outflow obstruction and mitral regurgitation (MR) secondary to systolic anterior motion (SAM) of the mitral valve. Valsalva provocation caused an increase in LVOT dynamic gradient and MR severity. The patient presented with a progressive decrease in exercise capacity along with chest pain relieved by rest or sublingual GTN. Exercise stress echo demonstrated a paradoxical response with reduction of both LVOT gradient and severity of MR. There was evidence of inducible regional wall motion abnormalities associated with no change in LV cavity size. Coronary angiogram revealed significant triple vessel disease

Is it time to change? Portable echocardiography demonstrates high prevalence of abnormalities in self-presenting members of a rural community in Kyrgyzstan

Objectives Cardiovascular disease accounts for 42% of male and 51% of female mortality within Europe. Kyrgyzstan, population of almost 6 million, has amongst the highest rates within Europe, second only to Uzbekistan for female cardiovascular disease mortality (588 per 100,000). We attempted to identify established cardiovascular disease prevalence within a rural community in Kyrgyzstan using portable echocardiography. Design Free open access echocardiography (VIVID-I, GE, USA) was offered to all adults in Batken district. Routine echocardiographic views were obtained and analysis performed using EchoPac Clinical Workstation (GE, USA). Mild valvular regurgitation, mild LV hypertrophy, patent foramen ovales and mild atrial enlargement were considered mild abnormalities; compensated ischaemic or valvular heart disease – moderate abnormalities, and decompensated congenital, ischaemic or valvular disease – severe abnormalities. Results One hundred and twenty five adults (48 male, 77 female), mean age 53 ± 16 years, underwent echocardiography. Only 16% of participants had no significant abnormality, 46% had mild disease, 25% moderate, compensated disease and 13% had severe disease. Nine percent had congenital heart disease including one tetralogy of Fallot and one Ebstein’s anomaly. Average LV function was normal, however, 19 participants had EF < 50%. Forty percent of participants had a new diagnosis warranting formal follow-up, 12% a new diagnosis of heart failure. Conclusion Using portable echocardiography, we identify a higher than reported prevalence of cardiovascular disease in rural Kyrgyzstan. Absence of portable tools and specialists for early diagnosis might lead to presentation in an advanced stage of disease when little can be done to improve mortality. Embracing remote access diagnostics is essential for disease identification within rural communities

The shape of the aortic outflow velocity profile revisited: is there a relation between its asymmetry and ventricular function in coronary artery disease?

AIMS: Myocardium contracts in the beginning of ejection causing outflow acceleration, resulting in asymmetric outflow velocity profiles peaking around one-third of ejection and declining when force development declines. This article aimed to demonstrate that decreased contractility in coronary artery disease (CAD) changes outflow timing and profile symmetry. ----- METHODS AND RESULTS: Seventy-nine patients undergoing routine full dose dobutamine stress-echo (DSE) were divided into two groups based on resting wall motion and DSE response: DSE negative (DSE(neg)) (35 of 79 patients) and positive (DSE(pos)) (44 of 79 patients) which were compared with 32 healthy volunteers. Aortic CW-Doppler traces at rest were analysed semi-automatically; time-to-peak (T(mod)), ejection-time (ET(mod)), rise-time (t(rise)), and fall-time (t(fall)) were quantified. Asymmetry (asymm) was calculated as the normalized difference of left and right half of the spectrum. Normal curves were triangular, early-peaking, whereas patients showed more rounded shapes and later peaks. T(rise) was longest in DSE(pos). T(fall) was shortest in DSE(pos), followed by controls and DSE(neg). Asymm was lowest in DSE(pos), followed by controls and DSE(neg). Abnormally symmetric profiles (asymm <0.25) were found in none of the controls, 2.9% DSE(neg), and 27.3% DSE(pos). A good correlation was found between assym and ejection fraction (EF) and T(mod)/ET(mod) and EF. Notably, an LV dynamic gradient was induced in 71.4% DSE(neg) and in 18.2% DSE(pos), associated with LV hypertrophy and supernormal (very asymmetric) traces. ----- CONCLUSION: Decreased myocardial function results in a more symmetrical outflow, while very asymmetrical traces suggest increased contractility, potentially inducing intra-cavity gradients during DSE. Therefore, including outflow symmetry as a clinical measurement provides additional information on patients with CAD

Tricuspid Regurgitation in Acute Heart Failure: Predicting Outcome Using Novel Quantitative Echocardiography Techniques

Background: The prognostic impact of tricuspid regurgitation (TR) in acute heart failure (AHF) remains uncertain. Methods: We retrospectively assessed 418 consecutive AHF patients who underwent comprehensive echocardiographic assessment within 24 h of study recruitment. TR was quantitatively assessed with 3 guideline-directed measures: regurgitant volumes (RgVol), effective regurgitant orifice area (ERO) and vena contracta (VC) diameter. Disproportionate TR was assessed by the ratio of the VC diameter to the tricuspid annulus diameter (VC/TA) ≥ 0.24. Results: The prevalence of significant (i.e., >mild) TR differed when various standard assessment parameters were applied to quantification: RgVol 50.3% (173/344), ERO 75.6% (260/344) and VC diameter 94.6% (335/354). None were able to delineate those at excess risk of all-cause 2-year mortality using guideline-directed cut-offs of mild, moderate and severe TR. Using a cut-off of VC/TA ≥ 0.24, we identified that 36.9% (130/352) had “disproportionate” TR. Disproportionate TR was associated with an excess risk of mortality at 2 years compared to proportionate TR; HR 1.48 (95% CI 1.06–2.06 [p = 0.02]) which was not significant on multivariate assessment (p = 0.94). Conclusions: TR was not associated with outcome in AHF using guideline measures. A new assessment of “Disproportionate” TR carries a higher risk than proportionate TR but was not related to outcome based on multivariate analysis. Further research is needed to quantify TR more effectively to identify cut-offs for future guidelines and disproportionate TR may be an important part of Heart Failure 2.0

The shape of the aortic outflow velocity profile revisited: is there a relation between its asymmetry and ventricular function in coronary artery disease?

Aims Myocardium contracts in the beginning of ejection causing outflow acceleration, resulting in asymmetric outflow velocity profiles peaking around one-third of ejection and declining when force development declines. This article aimed to demonstrate that decreased contractility in coronary artery disease (CAD) changes outflow timing and profile symmetry. Methods and results Seventy-nine patients undergoing routine full dose dobutamine stress-echo (DSE) were divided into two groups based on resting wall motion and DSE response: DSE negative (DSE neg ) (35 of 79 patients) and positive (DSE pos ) (44 of 79 patients) which were compared with 32 healthy volunteers. Aortic CW-Doppler traces at rest were analysed semi-automatically; time-to-peak (T mod ), ejection-time (ET mod ), rise-time (t rise ), and fall-time (t fall ) were quantified. Asymmetry (asymm) was calculated as the normalized difference of left and right half of the spectrum. Normal curves were triangular, early-peaking, whereas patients showed more rounded shapes and later peaks. T rise was longest in DSE pos . T fall was shortest in DSE pos , followed by controls and DSE neg . Asymm was lowest in DSE pos , followed by controls and DSE neg . Abnormally symmetric profiles (asymm ,0.25) were found in none of the controls, 2.9% DSE neg , and 27.3% DSE pos . A good correlation was found between assym and ejection fraction (EF) and T mod /ET mod and EF. Notably, an LV dynamic gradient was induced in 71.4% DSE neg and in 18.2% DSE pos , associated with LV hypertrophy and supernormal (very asymmetric) traces. Conclusion Decreased myocardial function results in a more symmetrical outflow, while very asymmetrical traces suggest increased contractility, potentially inducing intra-cavity gradients during DSE. Therefore, including outflow symmetry as a clinical measurement provides additional information on patients with CAD