Quantitation of mitral regurgitation

Mitral regurgitation (MR) is the most frequent valve disease. Nevertheless, evaluation of MR severity is difficult because standard color flow imaging is plagued by considerable pitfalls. Modern surgical indications in asymptomatic patients require precise assessment of MR severity. MR severity assessment is always comprehensive, utilizing all views and methods. Determining trivial/mild MR is usually easy, based on small jet and flow convergence. Specific signs of severe MR (pulmonary venous flow systolic reversal or severe mitral lesion) are useful but insensitive. Quantitative methods, quantitative Doppler (measuring stroke volumes) and flow convergence (aka PISA method), measure the lesion severity as effective regurgitant orifice (ERO) and volume overload as regurgitant volume (RVol). Interpretation of these numbers should be performed in context of specific MR type. In organic MR (intrinsic valve lesions) ERO 65 0.40 cm2 and RVol 65 60 mL are associated with poor outcome, while in functional MR ERO 65 0.20 cm2 and RVol 65 30 mL mark reduced survival. While MR assessment should always be comprehensive, quantitative assessment of MR provides measures that are strongly predictive of outcome and should be the preferred approach. The ERO and RVol measured by these methods require interpretation in causal context to best predict outcome and determine MR management

Morphologic Types of Tricuspid Regurgitation Characteristics and Prognostic Implications

Tricuspid regurgitation (TR) is classified according to different morphologic types based on the underlying mechanisms: primary, secondary, and isolated TR. Primary TR is caused by an anatomical abnormality of the tricuspid valve apparatus. Secondary TR is caused by dilation of the tricuspid valve annulus, related to right ventricular (RV), or right atrial remodeling and increased RV pressures (often secondary to left-sided heart disease). Isolated TR can exist in patients without increased RV pressures and is frequently associated with atrial fibrillation. Two-dimensional echocardiography plays a pivotal role in the assessment of the etiology and severity of TR. Views from 3-dimensional techniques have significantly increased the understanding of the pathophysiology of each morphologic type of TR (leaflet damage, annular dilation, and distinct patterns of right-heart remodeling). The following review will describe the etiology, anatomical and functional characteristics, and outcomes of each morphologic type of TR, and furthermore addresses challenging pitfalls in the referral for tricuspid valve intervention. (C) 2019 by the American College of Cardiology Foundation.Cardiolog

The prognostic value of right ventricular strain and mechanical dispersion on mortality in patients with normal left ventricle function.

AIMS: We aimed to assess if right ventricular (RV) 4-chamber longitudinal strain (RV4CLS), RV free wall longitudinal strain (RVFWLS) and RV mechanical dispersion index (RVMDI) have prognostic independent value in patients with preserved ejection fraction (pEF), without clearly elevated LV filling pressure. METHODS: Retrospective analysis of Peak RV4CLS, RVFWLS, RVMDI and comprehensive echocardiographic assessment including left ventricle (LV), atrium (LA) strain and RV parameters in patients with pEF (EF ≥ 50%; E/e' < 14). Multivariate Cox regression hazards model were used to determine the independent association between RV strain parameters to all-cause mortality and cardiovascular events. RESULTS: We analyzed 224 consecutive patients with pEF (age 65.2 ± 19.8, 44% female, Charlson Comorbidity Index median = 3.8), with all-cause mortality of 64 patients and 28 cardiovascular events, during a median follow-up of 8.2 years (interquartile range: 6.8 to 8.4 years). The best strain univariate predictors of mortality were RV4CSL [1.16 (1.07-1.26); p = 0.0001] and RVMDI [1.01 (1.001-1.02); p = 0.02] being superior to LV and LA strain, or other RV functional indices. Moreover, after adjustment for clinical (age, gender, Charlson Comorbidity Index), conventional echocardiographic parameters (LA volume, E/e' average, LVEDD, routine RV functional indices), LV and LA STE, RV4CLS and RVFWLS remained statistically significant associates of all-cause mortality and cardiac events. RV4CLS, or RVFWLS remained statistically significant associated for all-cause mortality, after additional adjustment for RVFAC and RVMDI. CONCLUSIONS: RV4CSL and RVMDI provide significant prognostic additive value in patients with preserved ejection fraction with excellent reproducibility, incremental to routine clinical, hemodynamic and LV and LA STE parameters

Impact of right ventricular dysfunction and end-diastolic pulmonary artery pressure estimated from analysis of tricuspid regurgitant velocity spectrum in patients with preserved ejection fraction

AIMS: We aimed to analyse the association between right haemodynamic parameters, right ventricular (RV) dysfunction parameters, and outcomes in patients with preserved ejection fraction (EF). METHODS AND RESULTS: Retrospective analysis of right haemodynamic (systolic pulmonary pressure and end-diastolic pulmonary pressure based on tricuspid regurgitation (TR) velocity at pulmonary valve opening time), and RV parameters including size (end-diastolic and end-systolic area), function (RV fractional area change, Tei index, Tricuspid Annular Plane Systolic Excursion, and speckle tracking derived free wall strain), from 557 consecutive patients with preserved EF [EF >/= 50%; age 64.9 + 20; 52% female; co-morbidity Charlson index 4.7 (2.9, 6.4)]. All cause and cardiac mortality were retrospectively analysed and correlated to echo haemodynamic and co-morbid parameters. TR velocity at pulmonary valve opening time and calculated end-diastolic pulmonary artery pressure were obtainable in 71% of patients. The best haemodynamic univariate predictor of mortality was calculated end-diastolic pulmonary artery pressure [hazard ratio 1.06 (1.04-1.07); P < 0.0001], superior to TR peak velocity and systolic pulmonary artery pressure. Elevated end-diastolic pulmonary artery pressure was associated with all cause and cardiac mortality even when adjusted for all significant clinical (age, gender, and Charlson index), and echo (stroke volume index, left atrial volume index, systolic pulmonary pressure, E/e', and Tei index) parameters. Tei index was superior to all other RV functional parameters (P < 0.05 for all parameters). CONCLUSION: TR velocity at pulmonary valve opening time and calculated end-diastolic pulmonary artery pressure are obtainable in most patients, and add prognostic information on top of clinical and routine haemodynamic and diastolic parameters

High neutrophil-to-lymphocyte ratio as an early sign of cardiotoxicity in breast cancer patients treated with anthracycline.

BACKGROUND: Cardiotoxicity, defined mainly as left ventricle (LV) dysfunction, is a significant side effect of anthracyclines (ANT) therapy. The need for an early simple marker to identify patients at risk is crucial. A high neutrophil-to-lymphocyte ratio (NLR) has been associated with poor prognosis in cancer patients; however, its role as a predictor for cardiotoxicity development is unknown. OBJECTIVE: Evaluating whether elevated NLR, during ANT exposure, plays a predictive role in the development of cardiotoxicity as defined by LV global longitudinal strain (LV GLS) relative reduction (≥10%). METHODS AND RESULTS: Data were prospectively collected as part of the Israel Cardio-Oncology Registry. A total of 74 female patients with breast cancer, scheduled for ANT therapy were included. NLR levels were assessed at baseline (T1) and during ANT therapy (T2). All patients underwent serial echocardiography at baseline (T1) and after the completion of ANT therapy (T3). NLR ≥ 2.58 at T2 was found to be the optimal predictive cutoff for LV GLS deterioration. A relative LV GLS reduction ≥10% was significantly more common among patients with high NLR (50% vs. 20%, p = .009). NLR ≥ 2.58 at T2 increases the risk for LV GLS reduction by fourfold (odds ratio [OR]: 4.63, 95% confidence interval [CI]: 1.29-16.5, p = .02), with each increase of 1-point NLR adding an additional 15% risk (OR: 1.15, 95% CI: 1.01-1.32, p = .046). CONCLUSIONS: Our study provides novel data that high NLR levels, during ANT exposure, have an independent association with the development of LV dysfunction. Routine surveillance of NLR may be an effective means of risk-stratifying

Longitudinal diastolic strain slope as an early sign for systolic dysfunction among patients with active cancer

BACKGROUND: Diastolic dysfunction is a common finding in patients receiving cancer therapy. This study evaluated the correlation of diastolic strain slope (Dss) with routine echocardiography diastolic parameters and its role in early detection of systolic dysfunction and cardiovascular (CV) mortality within this population. METHODS: Data were collected from the Israel Cardio-Oncology Registry (ICOR), a prospective registry enrolling adult patient receiving cancer therapy. All patients performed at least three echocardiography exams (T1, T2, T3), including left ventricle Global Longitudinal Strain (LV GLS) and Dss. Systolic dysfunction was determined by either LV GLS relative reduction of ≥ 15% or LV ejection fraction reduction > 10% to < 53%. Dss was assessed as the early lengthening rate, measured by the diastolic slope (delta%/sec). RESULTS: Among 144 patients, 114 (79.2%) were female with a mean age of 57.31 ± 14.3 years. Dss was significantly correlated with e' average. Mid segment Dss change between T1 and T2 showed significant association to systolic dysfunction development (Odds Ratio (OR) = 1.04 [1.01,1.06]. p = 0.036). In multivariate prediction, Dss increase was a significant predictor for the development of systolic dysfunction (OR = 1.06 [1.03,1.1], P < 0.001).An 8% increase in Dss between T1 and T2 was associated with a trend in increased CV mortality (HR = 3.4 [0.77,15.4], p = 0.085). CONCLUSIONS: This study is the first to use the novel measurement of Dss in patients treated with cancer therapies and to show significant correlation between routine diastolic dysfunction parameters and Dss. Changes in the mid segment were found to have significant independent early predictive value for systolic dysfunction development in univariate and multivariate analyses

The prevalence of abnormal right ventricle speckle strain in the setting of acute myocarditis and preserved left ventricle function.

BACKGROUND: Acute myocarditis has a wide spectrum of clinical presentation, from subclinical disease to acute heart failure, and sudden cardiac death. Two-dimensional speckle tracking echocardiography (2D-STE) has been proven effective in early diagnosis of subclinical cardiac injury, however, there is a limited data regarding the right ventricle (RV) involvement among patients with acute myocarditis. PURPOSE: We evaluated the prevalence of early subclinical RV injury assessed by 2D-STE, among patients with acute myocarditis and preserved left ventricle (LV) function. METHODS: We performed a retrospective single-center study at Tel-Aviv Sourasky Medical Center, including all adult patients hospitalized with acute myocarditis, who presented with preserved LV function. 2D-STE analysis of the RV was performed offline, assessing both the RV four-chamber longitudinal strain peak systolic (RV4CLS PK) and the free wall longitudinal strain peak systolic (RVFWLS PK). The myocarditis group was compared to a healthy control group. RESULTS: From 2011 to 2020, a total of 90 patients included in the study and were compared to 70 healthy subjects. RV 2D-STE emerged as significantly lower for both the RV4CLS PK (-21.8 ± 4.2 vs. -24.9 ± 4.8, P < 0.001) and RVFWLS PK (-24.7 ± 4.9 vs. -28.4 ± 5, P < 0.001), and remained significant in a multivariate analysis. CONCLUSION: We presented for the first time the presence of subclinical RV dysfunction, assessed by 2D-STE, in patients diagnosed with acute myocarditis, in the presence of preserved LV function. Further studies are needed to evaluate its' role in the development of LV dysfunction, heart failure and mortality