Case report : posterior thoracic window in the presence of pleural effusion in critical care medicine : one more chance to image the aortic valve

Good quality echocardiographic images in the setting of critical care medicine may be difficult to obtain for many reasons. We present a case of an 85-year-old woman with acute pulmonary edema and pleural effusion, where transthoracic bedside echocardiographic examination raised a suspicion for significant aortic valve disease. However, given the orthopneic decubitus of the patients, the quality of images was poor. To increase the accuracy of diagnosis, a posterior thoracic view through the pleural effusion in the sitting position was used. This view allowed the diagnosis of mixed aortic valve disease (aortic stenosis and regurgitation) and the quantification of valve disease through multiparametric criteria as recommended by current guidelines. The posterior thoracic view, when feasible, may provide a useful option in the assessment of cardiac structures and further diagnostic information in technically difficult echocardiographic examinations

440 Assessing cardiac output by echocardiography: is contrast always better?

Abstract Aims Contrast echocardiography is very useful in clinical cardiology. It is mainly performed for the assessment of global left ventricular (LV) function, left ventricular ejection fraction (LVEF), and stroke volume (SV), thanks to improved visualization of endocardial LV borders. Contrast echocardiography, however, is not always easily available, it is more expensive than an ordinary echocardiography and it can be contraindicated in some situations (e.g. in the presence of egg allergy). This study aimed to compare the estimation of cardiac output during traditional transthoracic echocardiography and after the injection of (Sonovue) contrast. Methods and results Patients who underwent an echocardiography with and without injection of (Sonovue) contrast between April 2019 and September 2021 were enrolled in the study. A complete transthoracic echocardiography was performed and Sonovue contrast was then injected. End-diastolic and end-systolic left ventricular volume in apex 4 and 2 chamber views, biplane LVEF with Simpson's formula, end-diastolic and end-systolic left ventricular diameters in parasternal long axis were measured prior and after injecting contrast. Left ventricular outflow tract diameter (LVOTd) was measured and LV outflow tract velocity time integral was traced in order to calculate LVOT VTI SV, as the product of LVOT cross sectional area (assuming that LVOT is circular) to the LVOT VTI. LVOT VTI SV obtained during traditional echocardiography was compared to LVEF SV, calculated as the difference between end-diastolic and end-systolic volume traced after injecting Sonovue contrast. Seventy-eight patients were enrolled in the study. Forty-two had history of CAD, 22 presented dilatative cardiomyopathy, 2 hypertrophic cardiomyopathy (HMC), 1 arrhythmogenic right ventricular dysplasia; 16 had atrial fibrillation, 66 arterial hypertension, and 20 diabetes. The main indications for contrast echocardiography were measurement of EF (39 cases) and exclusion of thrombi in LV apex (18 cases). Other indications were suspect of HCM, atrial myxoma or LV non-compaction. LVOT VTI stroke volume was calculated in 64 patients (LVOT diameter was not well visualized in 8 patients and LVOT VTI could not be measured in 14 patients due to poor acoustic windows). In the same patients LVEF Stroke Volume was also calculated. A strong correlation (P-value < 0.0001) between LVOT stroke volume and LVEF Stroke Volume was found (Figure 1). Conclusions Contrast echocardiography is very useful in clinical practice, however, requires trained physicians and its use is not widespread. This study demonstrates that estimating cardiac output through LVOT VTI SV, in patients with suboptimal echo images can be equally accurate as measuring LVEF SV with contrast echocardiography. This could be particularly useful in the acute settings when contrast echocardiography isn't always feasible and knowing cardiac output can be important for therapeutic implications

322 Atrial morphological and functional parameters in hypertrophic cardiomyopathy: cardiovascular outcome implication

Abstract Aims The impact of atrial function measured by standard and advanced echocardiographic techniques is emerging in various clinical settings but remains poorly explored in patients with hypertrophic cardiomyopathy (HCM). Methods and results Consecutive patients with HCM referred to the heart failure outpatient clinic were prospectively enrolled. Complete clinical and echocardiographic evaluation was performed, including fully automated 2D speckle tracking analysis software (AutoStrain, TomTec). Atrial function was assessed by means of left atrial (LA) volume, LA diameter, a'-TDI, and global peak atrial longitudinal strain (PALS). The primary endpoint was a composite of cardiovascular (CV) events (cardiovascular death or hospitalization, new-onset atrial fibrillation, surgical myectomy, sustained ventricular tachycardia or ventricular fibrillation) during the follow-up. A total of 40 patients with confirmed HCM diagnoses and complete follow-up were included, mean age was 61 ± 14 years, 62% male, ejection fraction 64 ± 8%. LA was frequently enlarged (indexed LA volume 43 ± 14 ml/m2, LA diameter 39 ± 7 mm), and dysfunctional (a'-TDI 7.1 ± 2.2 cm/s, PALS 21 ± 7%). During a mean follow-up of 460 ± 300 days, seven patients had a CV event. Among LA parameters, septal a'-TDI seems to characterize patients with events the most (5.5 ± 2.1 vs. 7.5 ± 2.3, P = 0.03). This was confirmed in an age-adjusted survival model [HR: 0.62 (0.39–0.92), P = 0.03]. The spline curve in the Figure illustrates the relationship between a'-TDI and the age-adjusted probability of CV events; the association began at about 7 cm/s and increased steeply for lower values. Of note, the association between PALS and CV events was highly significant in younger patients (<70 years, P < 0.001). Conclusions According to our pilot study, a'-TDI can be considered a simple, feasible, and routinely available parameter of left atrial function, which can help to identify HCM patients at higher risk of CV events

Myocardial fibrosis and steatosis in patients with aortic stenosis: roles of myostatin and ceramides

Aortic stenosis (AS) involves progressive valve obstruction and a remodeling response of the left ventriculum (LV) with systolic and diastolic dysfunction. The roles of interstitial fibrosis and myocardial steatosis in LV dysfunction in AS have not been completely characterized. We enrolled 31 patients (19 women and 12 men) with severe AS undergoing elective aortic valve replacement. The subjects were clinically evaluated, and transthoracic echocardiography was performed pre-surgery. LV septal biopsies were obtained to assess fibrosis and apoptosis and fat deposition in myocytes (perilipin 5 (PLIN5)), or in the form of adipocytes within the heart (perilipin 1 (PLIN1)), the presence of ceramides and myostatin were assessed via immunohistochemistry. After BMI adjustment, we found a positive association between fibrosis and apoptotic cardiomyocytes, as well as fibrosis and the area covered by PLIN5. Apoptosis and PLIN5 were also significantly interrelated. LV fibrosis increased with a higher medium gradient (MG) and peak gradient (PG). Ceramides and myostatin levels were higher in patients within the higher MG and PG tertiles. In the linear regression analysis, increased fibrosis correlated with increased apoptosis and myostatin, independent from confounding factors. After adjustment for age and BMI, we found a positive relationship between PLIN5 and E/A and a negative correlation between septal S', global longitudinal strain (GLS), and fibrosis. Myostatin was inversely correlated with GLS and ejection fraction. Fibrosis and myocardial steatosis altogether contribute to ventricular dysfunction in severe AS. The association of myostatin and fibrosis with systolic dysfunction, as well as between myocardial steatosis and diastolic dysfunction, highlights potential therapeutic targets

Mitral Regurgitation and Increased Risk of All-Cause and Cardiovascular Mortality in Patients with Type 2 Diabetes

Mitral regurgitation is the most common heart valve disease in the general population, but little is known about the prevalence and prognostic implications of mitral regurgitation in patients with type 2 diabetes

Proof of concept study on coronary microvascular function in low flow low gradient aortic stenosis

ObjectivesWe hypothesised that low flow low gradient aortic stenosis (LFLGAS) is associated with more severe coronary microvascular dysfunction (CMD) compared with normal-flow high-gradient aortic stenosis (NFHGAS) and that CMD is related to reduced cardiac performance. MethodsInvasive CMD assessment was performed in 41 consecutive patients with isolated severe aortic stenosis with unobstructed coronary arteries undergoing transcatheter aortic valve implantation (TAVI). The index of microcirculatory resistance (IMR), resistive reserve ratio (RRR) and coronary flow reserve (CFR) were measured in the left anterior descending artery before and after TAVI. Speckle tracking echocardiography was performed to assess cardiac function at baseline and repeated at 6 months. ResultsIMR was significantly higher in patients with LFLGAS compared with patients with NFHGAS (24.1 (14.6 to 39.1) vs 12.8 (8.6 to 19.2), p=0.002), while RRR was significantly lower (1.4 (1.1 to 2.1) vs 2.6 (1.5 to 3.3), p=0.020). No significant differences were observed in CFR between the two groups. High IMR was associated with low stroke volume index, low cardiac output and reduced peak atrial longitudinal strain (PALS). TAVI determined no significant variation in microvascular function (IMR: 16.0 (10.4 to 26.1) vs 16.6 (10.2 to 25.6), p=0.403) and in PALS (15.9 (9.9 to 26.5) vs 20.1 (12.3 to 26.7), p=0.222). Conversely, left ventricular (LV) global longitudinal strain increased after TAVI (-13.2 (8.4 to 16.6) vs -15.1 (9.4 to 17.8), p=0.047). In LFLGAS, LV systolic function recovered after TAVI in patients with preserved microvascular function but not in patients with CMD. ConclusionsCMD is more severe in patients with LFLGAS compared with NFHGAS and is associated with low-flow state, left atrial dysfunction and reduced cardiac performance

Ischemic mitral regurgitation: a multifaceted syndrome with evolving therapies

Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR

Watchful surgery in asymptomatic mitral valve prolapse

The most common organic etiology of mitral regurgitation is degenerative and consists of mitral valve prolapse (MVP). Volume overload because of mitral regurgitation is the most common complication of MVP. Advocating surgery before the consequences of volume overload become irreparable restores life expectancy, but carries a risk of mortality in patients who are often asymptomatic. On the other hand, the post-surgical outcome of symptomatic patients is dismal and life expectancy is impaired. In the present article, we aim to bridge the gap between these two therapeutic approaches, unifying the concepts of watchful waiting and early surgery in a “watchful surgery approach”

Genome-wide association study reveals novel genetic loci:a new polygenic risk score for mitral valve prolapse

AIMS: Mitral valve prolapse (MVP) is a common valvular heart disease with a prevalence of >2% in the general adult population. Despite this high incidence, there is a limited understanding of the molecular mechanism of this disease, and no medical therapy is available for this disease. We aimed to elucidate the genetic basis of MVP in order to better understand this complex disorder. METHODS AND RESULTS: We performed a meta-analysis of six genome-wide association studies that included 4884 cases and 434 649 controls. We identified 14 loci associated with MVP in our primary analysis and 2 additional loci associated with a subset of the samples that additionally underwent mitral valve surgery. Integration of epigenetic, transcriptional, and proteomic data identified candidate MVP genes including LMCD1, SPTBN1, LTBP2, TGFB2, NMB, and ALPK3. We created a polygenic risk score (PRS) for MVP and showed an improved MVP risk prediction beyond age, sex, and clinical risk factors. CONCLUSION: We identified 14 genetic loci that are associated with MVP. Multiple analyses identified candidate genes including two transforming growth factor-beta signalling molecules and spectrin beta. We present the first PRS for MVP that could eventually aid risk stratification of patients for MVP screening in a clinical setting. These findings advance our understanding of this common valvular heart disease and may reveal novel therapeutic targets for intervention. KEY QUESTION: Expand our understanding of the genetic basis for mitral valve prolapse (MVP). Uncover relevant pathways and target genes for MVP pathophysiology. Leverage genetic data for MVP risk prediction. KEY FINDING: Sixteen genetic loci were significantly associated with MVP, including 13 novel loci. Interesting target genes at these loci included LTBP2, TGFB2, ALKP3, BAG3, RBM20, and SPTBN1. A risk score including clinical factors and a polygenic risk score, performed best at predicting MVP, with an area under the receiver operating characteristics curve of 0.677. TAKE-HOME MESSAGE: Mitral valve prolapse has a polygenic basis: many genetic variants cumulatively influence pre-disposition for disease. Disease risk may be modulated via changes to transforming growth factor-beta signalling, the cytoskeleton, as well as cardiomyopathy pathways. Polygenic risk scores could enhance the MVP risk prediction

Multicentric Atrial Strain COmparison between Two Different Modalities: MASCOT HIT Study

Two methods are currently available for left atrial (LA) strain measurement by speckle tracking echocardiography, with two different reference timings for starting the analysis: QRS (QRS-LASr) and P wave (P-LASr). The aim of MASCOT HIT study was to define which of the two was more reproducible, more feasible, and less time consuming. In 26 expert centers, LA strain was analyzed by two different echocardiographers (young vs senior) in a blinded fashion. The study population included: healthy subjects, patients with arterial hypertension or aortic stenosis (LA pressure overload, group 2) and patients with mitral regurgitation or heart failure (LA volume–pressure overload, group 3). Difference between the inter-correlation coefficient (ICC) by the two echocardiographers using the two techniques, feasibility and analysis time of both methods were analyzed. A total of 938 subjects were included: 309 controls, 333 patients in group 2, and 296 patients in group 3. The ICC was comparable between QRS-LASr (0.93) and P-LASr (0.90). The young echocardiographers calculated QRS-LASr in 90% of cases, the expert ones in 95%. The feasibility of P-LASr was 85% by young echocardiographers and 88% by senior ones. QRS-LASr young median time was 110 s (interquartile range, IR, 78-149) vs senior 110 s (IR 78-155); for P-LASr, 120 s (IR 80-165) and 120 s (IR 90-161), respectively. LA strain was feasible in the majority of patients with similar reproducibility for both methods. QRS complex guaranteed a slightly higher feasibility and a lower time wasting compared to the use of P wave as the reference