Left Atrial Deformation Imaging and Atrial Fibrillation in Patients with Rheumatic Mitral Stenosis

BackgroundAtrial fibrillation (AF) is a frequent complication of rheumatic mitral stenosis (MS) and is associated with worse outcomes. Prediction of new-onset AF by assessing left atrial (LA) mechanics with speckle-tracking echocardiography might be useful for risk stratification and guiding therapeutic strategies. Therefore, the aim of this study was to assess the association of LA reservoir strain (LASr) and strain rate (LASRr) with AF at follow-up in patients with rheumatic MS.MethodsLeft atrial reservoir strain and LASRr measured by speckle-tracking echocardiography were assessed in 125 patients (mean age, 50 ± 15 years; 80.8% female) with rheumatic MS and without a history of AF. Patients were followed up for the occurrence of a first episode of AF after the index echocardiogram.ResultsDuring a median follow-up of 32 (9.5-70) months, 41 patients (32.8%) developed new-onset AF. Patients who developed AF had significantly more impaired LASr (13.4% ± 5.2% vs 18.9% ± 8.2%; P -1 vs 0.98 ± 0.36 s-1;P -1 were independently associated with the development of AF at follow-up (hazard ratio = 7.03, 95% CI, 2.08-23.77, P = .002; and hazard ratio = 3.42, 95% CI, 1.59-7.34, P = .002, respectively).ConclusionsLASr and LASRr are impaired in patients with rheumatic MS, and the degree of impairment is associated with new-onset AF at follow-up.</p

Left Atrial Reservoir Function and Outcomes in Secondary Mitral Regurgitation

BackgroundLeft atrial (LA) size is a marker of disease severity and is related to worse outcomes in secondary mitral regurgitation (MR). The prognostic value of LA function assessed by LA reservoir strain (LARS), however, remains unknown. The aim of this study was to investigate the prognostic implications of LARS in patients with significant secondary MR.MethodsLARS was evaluated using speckle-tracking echocardiography in patients with more than mild (grade ≥ 2) secondary MR. The population was divided into two groups according to the median LARS value (9.8%). The primary end point was all-cause mortality.ResultsA total of 666 patients (mean age, 66 ± 11 years; 68% men) were included. On multivariable analysis, more severe MR was independently associated with more impaired LARS (LARS P = .001). During a median follow-up period of 5 years (interquartile range, 2-10), 383 patients (58%) died. Patients with LARS P P ConclusionsLARS is independently associated with all-cause mortality in patients with significant secondary MR and has incremental prognostic value over LA volume and left ventricular global longitudinal strain. LARS may improve risk stratification of patients with secondary MR.</p

Extramitral Valvular Cardiac Involvement in Patients With Significant Secondary Mitral Regurgitation

Patients with secondary mitral regurgitation (SMR) often have extramitral valve cardiac involvement, which can influence the prognosis. SMR can be defined according to groups of extramitral valve cardiac involvement. The prognostic implications of such groups in patients with moderate and severe SMR (significant SMR) are unknown. A total of 325 patients with significant SMR were classified according to the extent of cardiac involvement on echocardiography: left ventricular involvement (group 1), left atrial involvement (group 2), tricuspid valve and pulmonary artery vasculature involvement (group 3), or right ventricular involvement (group 4). The primary end point was all-cause mortality. The prevalence of each cardiac involvement group was 17% in group 1, 12% in group 2, 23% in group 3%, and 48% in group 4. Group 3 and group 4 were independently associated with all-cause mortality (hazard ratio 1.794, 95% confidence interval 1.067 to 3.015, p = 0.027 and hazard ratio 1.857, 95% confidence interval 1.145 to 3.012, p = 0.012, respectively). In conclusion, progressive extramitral valve cardiac involvement (group 3 and group 4) was independently associated with all-cause mortality in patients with significant SMR.</p

An integrated framework for outsourcing using balanced score card and ELECTRE III

During the past few decades, many organizations have attempted to increase their productivity through outsourcing parts of their responsibilities. Outsourcing helps firms reduce their low value added activities and focus on their high value added activities. It also helps organization save their time and energy which leads to more efficient units. The idea of outsourcing is more important for project based organizations where the nature of works is different from a particular project to another one. This paper presents an integrated balanced score card system with an adaptation of ELECTRE III method to select suitable resources for outsourcing. The proposed model of the paper is implemented for a case study of subway system in Iran and the results are discussed

Regurgitant Volume/Left Ventricular End-Diastolic Volume Ratio

International audienceObjectives :The purpose of this study was to investigate the prognostic implications of the ratio of mitral regurgitant volume (RVol) to left ventricular (LV) end-diastolic volume (EDV) in patients with significant secondary mitral regurgitation (MR).Background : Quantification of secondary MR remains challenging, and its severity can be over- or underestimated when using the proximal isovelocity surface area method, which does not take LV volume into account. This limitation can be addressed by normalizing mitral RVol to LVEDV.Methods :A total of 379 patients (mean age 67 ± 11 years; 63% male) with significant (moderate and severe) secondary MR were divided into 2 groups according to the RVol/EDV ratio: RVol/EDV ≥20% (greater MR/smaller EDV) and <20% (smaller MR/larger EDV). The primary endpoint was all-cause mortality.Results :During median (interquartile range) follow-up of 50 (26 to 94) months, 199 (52.5%) patients died. When considering patients receiving medical therapy only, patients with RVol/EDV ratio ≥20% tended to have higher mortality rates than those with RVol/EDV ratio <20% (5-year estimated rates 24.1% vs. 18.4%, respectively; p = 0.077). Conversely, when considering the entire follow-up period including mitral valve interventions, patients with a higher RVol/EDV ratio (≥20%) had lower rates of all-cause mortality compared with patients with RVol/EDV ratio <20% (5-year estimated rates 39.0% vs. 44.8%, respectively; p = 0.018). On multivariable analysis, higher RVol/EDV ratio (per 5% increment as a continuous variable) was independently associated with lower all-cause mortality (0.93; p = 0.023).Conclusions :In patients with significant secondary MR treated medically, survival tended to be lower in those with a higher RVol/EDV ratio. Conversely, a higher RVol/EDV ratio was independently associated with reduced all-cause mortality. when mitral valve interventions were taken into consideration

Changes in Left Ventricular Global Longitudinal Strain in Patients With Heart Failure and Secondary Mitral Regurgitation: The COAPT Trial

Background Left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information over LV ejection fraction in patients with heart failure (HF) and secondary mitral regurgitation. We examined the prognostic impact of LV GLS improvement in this population. Methods and Results The COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial randomized symptomatic patients with HF with severe (3+/4+) mitral regurgitation to transcatheter edge‐to‐edge repair with the MitraClip device plus maximally tolerated guideline‐directed medical therapy (GDMT) versus GDMT alone. LV GLS was measured at baseline and 6‐month follow‐up. The relationship between the improvement in LV GLS from baseline to 6 months and the composite of all‐cause death or HF hospitalization between 6‐ and 24‐month follow‐up were assessed. Among 383 patients, 174 (45.4%) had improved LV GLS at 6‐month follow‐up (83/195 [42.6%] with transcatheter edge‐to‐edge repair+GDMT and 91/188 [48.4%] with GDMT alone; P=0.25). Improvement in LV GLS was strongly associated with reduced death or HF hospitalization between 6 and 24 months (P<0.009), with similar risk reduction in both treatment arms (Pinteraction=0.40). By multivariable analysis, LV GLS improvement at 6 months was independently associated with a lower risk of death or HF hospitalization (hazard ratio [HR], 0.55 [95% CI, 0.36–0.83]; P=0.009), death (HR, 0.48 [95% CI, 0.29–0.81]; P=0.006), and HF hospitalization (HR, 0.50 [95% CI, 0.31–0.81]; P=0.005) between 6 and 24 months. Conclusions Among patients with HF and severe mitral regurgitation in the COAPT trial, improvement in LV GLS at 6‐month follow‐up was associated with improved outcomes after both transcatheter edge‐to‐edge repair and GDMT alone between 6 and 24 months. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079