Journal of the American Society of Echocardiography最新文献

Background: In patients with secondary tricuspid regurgitation (STR), right ventricular ejection fraction (RVEF) may not accurately reflect the actual RV systolic performance since a considerable amount of the RV stroke volume (SV) is regurgitated back into the right atrium. To overcome this limitation, we explored the association with the outcome of the effective RVEF (eRVEF), which accounts for the tricuspid regurgitant volume (RegVol).

Methods: 513 patients with STR (mean age 75±13 years, 39% atrial STR, 58% severe) underwent complete two-, three-dimensional, and Doppler echocardiography. eRVEF was computed as RV forward SV/RV end-diastolic volume, where forward SV was obtained by subtracting the tricuspid RegVol from the total RVSV. The endpoint was a composite of all-cause death and heart failure hospitalization.

Results: After a mean follow-up of 18±15 months, 195 patients (38%) reached the composite endpoint. At time-dependent receiver operating characteristic analysis, eRVEF (AUC 0.72, 95%CI 0.68-0.77) showed a stronger association with outcome than RVEF (AUC 0.65, 95%CI 0.59-0.70, p=0.006), tricuspid annular plane systolic excursion (AUC 0.64, 95%CI 0.59-0.69, p= 0.01), RV free-wall longitudinal strain (AUC 0.63, 95%CI 0.58-0.68, p= 0.003), and RV fractional area change (AUC 0.55, 95%CI 0.50-0.60, p<0.001). The eRVEF cut-off associated with an excess event rate was 20% on spline curve modeling. Patients with eRVEF <20% demonstrated a higher rate of events at 2 years (65 ± 6%) than those having an eRVEF ≥20% (22 ±7%, log-rank <0.0001). eRVEF <20% was associated with a 3-fold increased risk of experiencing the composite endpoint (HR: 3.54 [2.61-4.79], p<0.001). On different models of multivariable analysis, eRVEF as a continuous variable remained independently associated with the combined endpoint (HR: 0.96; 95% CI= 0.94-0.98; p<0.001).

Conclusions: In patients with STR, eRVEF was more closely associated with all-cause mortality and heart failure hospitalizations than RVEF and other conventional echocardiographic indices of RV function.

Background: Left ventricular ejection fraction (LVEF) is relatively indiscriminate for prognosis in patients with preserved or mildly reduced LVEF (>40%) following myocardial infarction (MI). This study sought to determine the value of guideline-based assessment of diastolic dysfunction (DD) in predicting long-term all-cause and cardiac mortality in patients with a first-ever MI and LVEF>40%.

Methods: A retrospective single centre study involving 2234 patients with a first-ever MI (STEMI or NSTEMI) with LVEF>40% was performed. Clinical, angiographic, echocardiographic and outcomes data were obtained from prospectively maintained institutional and state-wide databases. Echocardiography was performed early post-admission for all patients. Significant diastolic dysfunction (DD) was defined was grade 2&3 diastolic dysfunction.

Results: The mean age of patients was 61.4+12.3 years, 70.7% were males, and 12.1% had 3-vessel disease. The mean LVEF was 55.8+7.2% and 14.1% had significant DD. At a median follow up of 4.5 years, there were 219 deaths (46 cardiac deaths). On Cox proportional-hazards multivariable analyses incorporating significant clinical, angiographic, and echocardiographic variables, significant DD was an independent predictor of both all-cause (HR 2.01, 95%CI 1.37-2.94, p<0.001) and cardiac (HR 3.97, 95%CI 1.98-7.99, p<0.001) mortality. Bootstrapping and calculation of Harrel's C confirmed the independent association of significant DD with outcomes.

Conclusions: Significant DD is an independent predictor of all-cause and cardiac mortality following MI in patients with preserved or mildly reduced LVEF and thus effectively re-classifies prognosis in a subgroup where the LVEF is relatively indiscriminate for survival. The benefit of further investigation and/or treatment in this subgroup needs further study.

Background: Abnormalities of left ventricular diastolic function are established independent predictors of heart failure and mortality. The aim of this study was to determine whether the association of diastolic function with all-cause mortality is driven by cardiovascular or noncardiovascular death and if impaired relaxation mitral inflow filling pattern is a risk marker.

Methods: Diastolic function was graded by the Mayo Clinic algorithm using the well-characterized prospective Olmsted County Heart Function Study. Those with reduced left ventricular ejection fraction, moderate or greater valve disease, clinical diagnosis of heart failure, or indeterminate diastolic function were excluded. Notably, all patients with an impaired relaxation pattern (E/A ratio < 0.8) were classified as abnormal (grade 1) regardless of ejection fraction and clinical or other echocardiographic abnormalities. Individuals were followed for a median of 19.7 years (interquartile range, 18.9-20.6 years) for mortality outcomes.

Results: In a community cohort of 1,005 subjects 63 years (interquartile range, 57-71 years) of age, grade 1 diastolic function was common (26%) and associated with all-cause mortality (hazard ratio [HR], 4.05; 95% CI, 3.22-5.09; P < .0001). This association persisted in a subgroup of those with impaired myocardial relaxation and no other clinical or echocardiographic abnormalities (HR, 2.71; 95% CI, 1.89-3.88; P < .0001). The association of diastolic function with noncardiovascular death was not significant after adjustment for age, sex, and comorbidities, though there was an association with grade 1 diastolic function and risk for death of dementia (age- and sex-adjusted HR, 2.30; 95% CI, 1.54-3.45; P < .001). The association of diastolic function and cardiovascular mortality persisted in multivariable model, including for grade 1 diastolic function (HR, 2.43; 95% CI, 1.16-5.05; P = .02).

Conclusions: Impaired relaxation mitral inflow pattern (grade 1) is common in older adults in the community and found to be associated with cause-specific death, highlighting this simple echocardiographic finding as a potential biomarker of cardiovascular and cognitive risk and not necessarily a benign finding that is normal with age.

Background: Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous entity including different phenotypes of near normal, normal, and supernormal left ventricular (LV) function. The aim of this study was to assess the value of resting LV elastance (also known as force) using transthoracic echocardiography to identify HFpEF phenotypes.

Methods: In a prospective, observational, multicenter study, 2,380 patients with HFpEF were recruited from July 2016 to May 2024. Systolic blood pressure (SBP) was measured. LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction, force (SBP/LVESV), stroke volume (SV), arterial elastance, ventricular-arterial coupling, and left atrial volume index were assessed. Global longitudinal strain was available in 1,164 patients (48.9%). Six hundred eighty patients finished follow-up with a composite endpoint of major adverse cardiac events (MACEs). Patients were divided into three groups: group 1, low force (<25th percentile, <3.24 mm Hg/mL); group 2, intermediate force (≥25th percentile and ≤75th percentile, 3.24-5.48 mm Hg/mL); and group 3, high force (>75th percentile, >5.48 mmHg/mL).

Results: The three groups showed a gradient with descending values (group 3 > group 2 > group 1) for SBP, LV ejection fraction, global longitudinal strain, arterial elastance, and ventricular-arterial coupling, with the opposite gradient (group 1 > group 2 > group 3) for LVEDV, LVESV, SV, and left atrial volume index values (P < .01 for all). After a median follow-up period of 16 months, 205 MACEs occurred in 138 patients. The cumulative MACE rate was lowest in group 2 (14.7% person-years) and higher in groups 1 (16.1% person-years) and 3 (22.9% person-years; log-rank P = .036).

Conclusions: Patients with HFpEF present with different LV contractile phenotypes, easily identified with resting LV force and volumetric transthoracic echocardiography. The dominant hemodynamic feature of hypocontractile phenotype is a preload recruitment with larger LVEDV and normal SV, while the hypercontractile phenotype is characterized by a small left ventricle with reduced SV. The hypercontractile and hypocontractile phenotypes are associated with a higher risk for subsequent events.

Background: Aortic stenosis (AS) is a complex condition with various hemodynamic subtypes, each with distinct clinical profiles and outcomes. The aim of this study was to assess the characteristics and outcomes of different AS phenotypes on the basis of flow and gradient patterns.

Methods: In this retrospective cohort study, 930 patients who underwent transcatheter aortic valve replacement for severe symptomatic AS at Mayo Clinic sites from 2012-2017 were included. Patients were classified into three groups: high gradient (HG), low-flow low-gradient (LFLG), and normal-flow low-gradient (NFLG). Baseline clinical, echocardiographic, and computed tomographic characteristics, including aortic valve area, aortic valve calcium score, left ventricular ejection fraction, and the prevalence of tricuspid regurgitation, and atrial fibrillation were analyzed. One- and 5-year all-cause mortality outcomes were compared using Kaplan-Meier analysis and Cox proportional-hazards models.

Results: The final cohort included 273 patients in the NFLG group (29.4%), 563 in the HG group (60.5%), and 94 in the LFLG group (10.1%). After reevaluation and careful review of the echocardiograms, 41 patients with NFLG AS were reclassified into the LFLG group. Patients with LFLG AS had the highest prevalence of atrial fibrillation or flutter (60%) and tricuspid regurgitation (17%). Aortic valve calcium score was significantly lower in the NFLG group compared with the HG and LFLG groups. One-year mortality was highest in the LFLG group (17.4%), followed by the HG (13.9%) and NFLG (10.9%) groups, but the difference was not statistically significant (P = .20). The 5-year mortality rate was higher in the LFLG group (55.6%) compared with the NFLG (47.2%) and HG (47.9%) groups but did not reach statistical significance (P = .20).

Conclusions: LFLG AS was associated with more comorbidities and higher mortality compared with HG and NFLG AS, though differences in mortality were not statistically significant. The NFLG group, after close review and reclassification, showed the least significant AS. Randomized trials are needed to clarify the prognosis and management of NFLG AS.

Background: Newborns with transposition of the great arteries (TGA) are at risk of severe hypoxia from inadequate atrial mixing, closure of the arterial duct and/or pulmonary hypertension (PPHN). Acute maternal hyperoxygenation (AMH) might assist in identifying at-risk fetuses. We report pulmonary vasoreactivity to AMH in TGA fetuses and its relationship to early postnatal hypoxia and requirement for emergency balloon atrial septostomy (e-BAS).

Methods: Standard fetal echocardiographic (FE) assessment of the foramen ovale (FO): total septal length and morphology of flap valve of FO were used to predict need for e-BAS. Following prospective recruitment, additional assessments were performed in fetuses with TGA at baseline and repeated after 10minutes of 10L/min of 100% oxygen delivered via non-rebreather mask to the pregnant mother. Analysis included measurement of atrial septal excursion, branch pulmonary artery pulsatility index (PA-PI), middle cerebral artery (MCA) PI and cardiac output. Delivery and newborn status were reviewed. Hypoxia was defined as preductal oxygen saturations <75% and e-BAS when undertaken within two hours of birth. Area under receiver operating characteristics curves (AUROC) were calculated.

Results: 30 cases underwent FE at 34.6weeks' gestation (IQR: 34.6-35.6). All 7 predicted to require e-BAS based on standard FE were correctly identified prenatally. 3/30 were hypoxic without FO restriction and treated with nitric oxide (PPHN). Change in PA-PI < 15% was associated with PPHN (p=0.001), but not with e-BAS. The MCA-PI response to AMH varied according to newborn condition, a mean reduction occurred in the non-hypoxic newborns (-7.8 ± 18.3, p=0.05). Increase in MCA-PI Z score AUROC 0.837 (95% CI: 0.663-1.00, p=0.01); reduction in right ventricular cardiac output 0.811 (95% CI: 0.623-0.998, p=0.04), reduction in combined cardiac output (0.851 (95% CI: 0.699-1.0, p=0.01)) were moderately associated with e-BAS. Changes in atrial septal excursion and FO flow direction with AMH did not correlate with newborn condition.

Conclusions: PA-PI change < 15% to AMH was associated with postnatal hypoxia due to PPHN. Increase in right and combined cardiac output and reduced MCA resistance with AMH are seen in those who do not require e-BAS.