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Impact of sex on severity assessment and cardiac remodeling in primary mitral regurgitation due to valve prolapse 性别对二尖瓣脱垂致原发性二尖瓣返流严重程度评估和心脏重构的影响

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.002

A. Altes , F. Levy , V. Hanet , D. De Azevedo , P. Krug , L. Iacuzio , M. Toledano , V. Silvestri , D. Vancraeynest , A. Pasquet , A. Vincentelli , A. Eker , S. Marechaux , B. Gerber

Introduction

The current recommended cut-off values for primary mitral regurgitation (MR) quantification (Effective Regurgitant Orifice Area [EROA], regurgitant volume [RegVol]) and left ventricular (LV) remodeling in MR (end-systolic diameter [ESD]) are not sex-specific.

Method

We retrospectively evaluated 470 patients (27% women, median age 63 years) with chronic significant primary MR due to prolapse who underwent echocardiography (Echo) and cardiac magnetic resonance imaging (CMR) in 3 tertiary centers between 2005 and 2022.

Results

Women were older than men, had higher NYHA class, larger left atrial volume, higher pulmonary pressure, and more symptoms-triggered MV intervention (all P < 0.035). However, both MR EROA, Echo-RegVol and CMR-RegVol were lower in women than in men (all P < 0.003), while CMR regurgitant fraction (RegFrac) values were similar (P = 0.890). Abnormally increased CMR- (> upper limit bound of UK Biobank reference values) indexed LV end-diastolic (indLVEDV), end-systolic volume (indLVESV) were observed in 55%, 29% of patients, respectively, without sex difference (P = 1, P = 0.9). The optimal cut-off values of MR EROA, Echo-RegVol and CMR-RegVol associated with enlarged indLVEDV were lower in women (40 mm², 60 mL, 50 mL) than in men (45 mm²,77 mL, 62 mL). LVESD ≥ 40 mm showed in women and men high specificity [Sp] (91%, 79%) but poor sensitivity [Se] (40% 50%) to predict enlarged indLVESV, while the optimal threshold was slightly lower in women (35 mm, Se = 65%, Sp = 71%) than in men (37 mm, Se = 65%, Sp = 68%).

Conclusion

Despite clear hallmarks of more advanced valve disease, women with primary MR have lower mitral RegVol and lower ventricular volumes than men. Then, cut-off values of mitral RegVol, EROA and LV dimensions for predicting abnormal LV dilatation are lower in women than in men. Hence, guideline-based criteria for grading MR and timing of intervention could be sex-specific (Fig. 1).

目前推荐的初级二尖瓣反流(MR)定量(有效反流口面积[EROA]，反流容积[RegVol])和MR左心室重构(收缩末期直径[ESD])的临界值没有性别特异性。方法回顾性评估2005年至2022年间在3个三级中心接受超声心动图(Echo)和心脏磁共振成像(CMR)检查的470例因脱垂而患有慢性显著原发性MR的患者(27%为女性，中位年龄63岁)。结果女性比男性年龄大，NYHA分级高，左房容积大，肺动脉压高，症状引发的MV干预较多(P <0.035)。然而，女性的MR EROA、Echo-RegVol和CMR-RegVol均低于男性(P <0.003)，而CMR反流分数(RegFrac)值相似(P = 0.890)。CMR异常升高- (>在55%、29%的患者中分别观察到以UK Biobank参考值上限为指标的左室舒张末期容积(indLVEDV)、收缩末期容积(indLVESV)，无性别差异(P = 1, P = 0.9)。与indLVEDV增大相关的MR EROA、Echo-RegVol和CMR-RegVol的最佳临界值在女性中(40 mm2、60 mL、50 mL)低于男性(45 mm2、77 mL、62 mL)。LVESD≥40 mm在女性和男性中预测indLVESV增大的特异性[Sp]高(91%，79%)，敏感性[Se]低(40%，50%)，而女性的最佳阈值(35 mm, Se = 65%， Sp = 71%)略低于男性(37 mm, Se = 65%， Sp = 68%)。结论:尽管有更晚期瓣膜疾病的明确标志，但原发性MR女性的二尖瓣RegVol和心室容积低于男性。然后，二尖瓣RegVol、EROA和左室尺寸预测异常左室扩张的临界值在女性中低于男性。因此，基于指南的MR分级标准和干预时间可能是性别特异性的(图1)。

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引用次数: 0

Prognostic contribution of left ventricular myocardial work assessment in mitral valve prolapse 二尖瓣脱垂患者左心室心肌工作评估对预后的影响

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.004

J. Thierry, D. Stevant, N. Piriou, P.Y. Turgeon, K. Warin-Fresse, J.M. Serfaty, D. Grimault, T. Le Tourneau

Introduction

Mitral Valve Prolapse (MVP) is the leading cause of primary mitral regurgitation (MR). Due to volume overload-induced changes in severe MR, assessment of left ventricular systolic function, an important marker to refer patients to surgery, is difficult. The aim of our study was to assess cardiac mechanics based on the non-invasive evaluation of myocardial work, by analysing the left ventricular pressure-strain loop, taking into account loading conditions.

Method

In total, 321 patients (63% male) with MVP (with or without severe MR), who underwent a comprehensive echocardiography and cardiac magnetic resonance (CMR) between 2010 and 2021, were included. Myocardial work parameters were assessed using a dedicated software. The primary endpoint associated cardiovascular death, sustained ventricular arrhythmia, heart failure, new onset atrial fibrillation, or arterial embolism.

Results

Of the 321 patients 186 (58%) had a GWW (global wasted work) < 120 mmHg% and 135 (42%) a GWW ≥ 120 mmHg%. GWW < 120 mmHg% was associated with echographic and CMR parameters of abnormal filling, volume overload and more severe regurgitation. During a mean follow-up of 4.5 ± 2.8 years, censored at the time of mitral valve surgery, 36 cardiovascular events were recorded in the GWW < 120 mmHg% group versus 14 in the GWW ≥ 120 mmHg% group (19% vs. 10%; P = 0.028). Heart failure (15 vs. 6%; P = 0.011) and mitral valve intervention (69 vs. 59%; P = 0.045) rates were higher in the GWW < 120 mmHg% group. Five-year cardiovascular event-free survival was decreased in patients with GWW < 120 mmHg% (46.6 ± 7.7% vs. 59.1 ± 12.4%; P = 0.023). In multivariable analysis, MR severity, the presence of late enhancement on CMR, and GWW < 120 mmHg% (HR 1.76; 95% CI 0.93–3.34; P = 0.085) were associated with impaired event-free survival.

Conclusion

Myocardial work-up provides additional diagnostic and prognostic information to echocardiography and cardiac MRI in MV.

二尖瓣脱垂(MVP)是原发性二尖瓣反流(MR)的主要原因。由于严重MR的容量负荷引起的改变，评估左心室收缩功能是一个重要的标志，这是转介患者手术的困难。我们研究的目的是在无创心肌功评估的基础上评估心脏力学，通过分析左心室压力-应变循环，考虑到负荷条件。方法共纳入2010 - 2021年间接受全面超声心动图和心脏磁共振(CMR)检查的321例MVP(伴有或不伴有严重MR)患者(63%男性)。使用专用软件评估心肌功参数。主要终点与心血管死亡、持续性室性心律失常、心力衰竭、新发房颤或动脉栓塞相关。结果321例患者中186例(58%)出现GWW (global wasted work);120 mmHg%和135 (42%)GWW≥120 mmHg%。奢华婚礼& lt;还是再想想吧120 mmHg%与超声和CMR参数异常充盈、容量过载和更严重的反流相关。在平均4.5±2.8年的随访期间(剔除二尖瓣手术时间)，GWW <记录了36例心血管事件;GWW≥120 mmHg%组14例(19%对10%;p = 0.028)。心力衰竭(15% vs. 6%;P = 0.011)和二尖瓣介入治疗(69% vs. 59%;P = 0.045);120 mmHg%组。GWW患者的5年无心血管事件生存率降低;120 mmHg%(46.6±7.7% vs. 59.1±12.4%;p = 0.023)。在多变量分析中，MR严重程度、CMR是否存在晚期增强、GWW <120 mmHg% (HR 1.76;95% ci 0.93-3.34;P = 0.085)与无事件生存受损相关。结论心肌检查可为超声心动图和心脏MRI提供额外的诊断和预后信息。

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引用次数: 0

Aortic valve calcification of surgical bioprostheses and its impact on clinical outcome 外科生物瓣膜的主动脉瓣钙化及其对临床结果的影响

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.005

G. Guimbretiere, T. Senage, A.S. Boureau, N. Piriou, K. Warin-Fresse, J.M. Serfaty, J.C. Roussel, T. Le Tourneau

Introduction

Aortic valve calcification (AVC) of surgical valve bioprostheses (BP) has been poorly explored. We aimed to evaluate in vivo and ex vivo BP AVC and its prognosis value.

Method

Between 2011 and 2019, AVC was assessed in 361 patients with surgical BP on in vivo computed tomography (CT) scanner (6.4 ± 4.3 years after surgery). Follow-up was obtained in all patients. Ex vivo CT-scans were performed in 37 explanted BP.

Results

After exclusion of 19 (5.2%) CT-scans, mean in vivo AVC was 307 ± 500 AU in the remaining 342 BP (77 ± 9 years, 64% male). Of these, 183 (53.5%) had a structural valve degeneration (SVD) with an AVC of 562 ± 570 AU compared with 13 ± 43 AU (P < 0.0001) for non-SVD BP. Early calcification was observed in around 10% of BP (12/124) examined before the 3rd postoperative year. In explanted BP in vivo AVC correlated strongly with ex vivo AVC (r = 0.88, P < 0.0001). An in vivo AVC > 100 AU (n = 147, 43%) had an excellent specificity (96%) for diagnosing stage 2–3 SVD. Patients with AVC > 100 AU had worse survival compared with those with an AVC < 100 (n = 195, 57%). In multivariable analyses, AVC value was a predictor of overall mortality (HR = 1.16 [1.04–1.29]; P = 0.009), cardiovascular mortality (HR = 1.21 [1.03–1.41]; P = 0.021) and cardiovascular events (HR = 1.19 [1.08–1.31]; P = 0.001). After further adjustment for SVD diagnosis, AVC remained a predictor of overall mortality (HR = 1.24 [1.07–1.44]; P = 0.005), and cardiovascular events (HR = 1.16 [1.02–1.32]; P = 0.029).

Conclusion

CT-scan AVC of surgical BP is a reliable tool for assessing leaflets calcification. Whereas calcification can develop early after surgery, an AVC > 100 AU is tightly associated with SVD, and is a strong predictor of overall mortality and cardiovascular events, even after adjustment for SVD diagnosis. Hence, AVC scoring is a complementary tool to echocardiography that should be used in the follow-up of patients with surgical aortic BP.

外科生物瓣膜修复术(BP)主动脉瓣钙化(AVC)的研究很少。我们的目的是评估体内和离体BP AVC及其预后价值。方法对2011年至2019年361例外科BP患者(术后6.4±4.3年)进行AVC评估。所有患者均接受随访。对37例BP进行体外ct扫描。结果排除19例(5.2%)ct扫描后，剩余342 BP(77±9岁，男性64%)的平均体内AVC为307±500 AU。其中183例(53.5%)有结构性瓣膜变性(SVD)， AVC为562±570 AU，而AVC为13±43 AU (P <0.0001)。术后3年前检查的BP(12/124)中约有10%出现早期钙化。外植BP体内AVC与离体AVC呈显著相关(r = 0.88, P <0.0001)。体内AVC >100 AU (n = 147, 43%)诊断2-3期SVD具有极好的特异性(96%)。AVC患者;100 AU患者的生存率较AVC患者差;100 (n = 195, 57%)。在多变量分析中，AVC值是总死亡率的预测因子(HR = 1.16 [1.04-1.29];P = 0.009)，心血管死亡率(HR = 1.21 [1.03-1.41];P = 0.021)和心血管事件(HR = 1.19 [1.08-1.31];p = 0.001)。在进一步调整SVD诊断后，AVC仍然是总死亡率的预测因子(HR = 1.24 [1.07-1.44];P = 0.005)，心血管事件(HR = 1.16 [1.02-1.32];p = 0.029)。结论ct扫描AVC是评估小叶钙化的可靠工具。尽管钙化可以在手术后早期发生，但AVC >100 AU与SVD密切相关，即使在SVD诊断调整后，仍是总死亡率和心血管事件的有力预测因子。因此，AVC评分是超声心动图的补充工具，应用于手术主动脉BP患者的随访。

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引用次数: 0

Value of echocardiography in estimating functional status and event-risk in patients with hypertrophic cardiomyopathy 超声心动图在肥厚性心肌病患者功能状态和事件风险评估中的价值

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.037

M. Lacout

Introduction

The prognosis in patients with hypertrophic cardiomyopathy (HCM) remains complicated to estimate. Exercise testing is recommended. We sought to assess whether the echocardiographic evaluation could help in best understanding the clinical consequences and the event-risk of patients referred for HCM.

Method

In total, 302 HCM-patients (57.4 ± 16.8 years old) were analysed. All patients underwent transthoracic rest and stress echocardiography for the evaluation of size and function including strain measurements. A cardiopulmonary exercise test (CPET) was performed by all the patients at the time of echocardiography. The patients were followed for 3.4 years for the occurrence of a composite endpoint including heart failure requiring hospitalization, syncope, ventricular tachycardia (VT) sustained or not, atrial heart rate episode registered by pacemaker or implanted defibrillator, symptomatic supraventricular tachycardia, asymptomatic supraventricular tachycardia detected by Holter, defibrillator implantation, myomectomy/septal alcoholising, or HCM related death.

Results

Mean VO² peak for all patients was 21.57 ± 7.6 mL/kg/min. The best predictors of peak VO² were increased exercise mean E/Ea (9.17 [6.30–12.9]), decreased resting TAPSE (22.5 ± 4.99 mm) and decreased exercise LV GLS (−17.6 ± 3.97%). Among the 302 patients, 132 (43.8%) met the composite endpoint. Among clinical, CPET and echocardiographic parameters recorded, PLAS was the best predictor of event with linear association.

Conclusion

The decrease in PLAS was strongly associated with the risk of event. It takes over CPET results. On top of this prognostic value, echocardiographic evaluation was demonstrated extremely relevant for our daily evaluation of HCM-patients.

肥厚性心肌病(HCM)患者的预后仍然难以估计。建议进行运动测试。我们试图评估超声心动图评估是否有助于最好地了解HCM患者的临床后果和事件风险。方法对302例hcm患者(57.4±16.8岁)进行分析。所有患者都接受了经胸休息和应激超声心动图，以评估大小和功能，包括应变测量。所有患者在超声心动图检查时均行心肺运动试验(CPET)。对这些患者进行了3.4年的复合终点随访，包括需要住院治疗的心力衰竭、晕厥、室性心动过速(VT)持续与否、起搏器或植入除颤器记录的心房心率发作、症状性室上性心动过速、Holter检测到的无症状室上性心动过速、除颤器植入、子宫肌瘤切除术/室间隔酒精中毒或HCM相关死亡。结果所有患者的平均VO2峰值为21.57±7.6 mL/kg/min。运动平均E/Ea增加(9.17[6.30-12.9])、静息TAPSE降低(22.5±4.99 mm)和运动LV GLS降低(- 17.6±3.97%)是VO2峰值的最佳预测因子。302例患者中，132例(43.8%)达到了复合终点。在临床、CPET和超声心动图参数记录中，PLAS是事件的最佳预测因子，线性相关。结论PLAS的降低与事件发生风险密切相关。它接管CPET结果。在这种预后价值之上，超声心动图评估被证明与我们对hcm患者的日常评估非常相关。

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引用次数: 0

Ours SFC 我们的香港

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/S1878-6480(23)00213-6

引用次数: 0

Associated factors and clinical implications of dynamic changes in late gadolinium enhancement after acute myocarditis 急性心肌炎后晚期钆增强动态变化的相关因素及临床意义

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.011

Y. Bohbot , F. Sanguineti , C. Renard , T. Hovasse , I. Limouzineau , T. Unterseeh , C. Di Lena , W. Boukefoussa , C. Tawa , S. Duhamel , P. Garot , C. Tribouilloy , J. Garot

Introduction

Although follow-up cardiac magnetic resonance (CMR) is often performed after acute myocarditis (AM), the prognostic implications of dynamic changes in late gadolinium enhancement (LGE) are unknown. We aimed to determine the prognostic implications of dynamic LGE changes after acute AM.

Method

In a two-centre study, 204 consecutive hemodynamically stable patients (mean age 35 ± 16 years, 78.9% males) with a CMR-based diagnosis of AM were included and underwent repeat CMR 3–12 months after diagnosis. Quantitative LGE was expressed as percent of left ventricular (LV) myocardium. The primary endpoint was the occurrence of major adverse cardiac events (MACE) at median 7.3 [IQR: 5.7–8.7] years.

Results

Compared to index CMR, there was an increase in LV ejection fraction (EF) (59% vs. 55%, P < 0.001) and a decrease in LGE extent (7.6% vs. 12.0%, P < 0.001) at follow-up (mean 5.7 ± 2.6 months after index CMR). LGE persisted in 175 patients at follow-up (85.8%). LGE decreased by ≥ 50% from baseline in 94 patients (46%), by < 50% in 86 (42%) and increased in 24 (12%). Female gender (OR [95%CI] = 3.27 [1.17–9.12], P = 0.023), low baseline LVEF (OR [95%CI] = 0.93 [0.88–0.98] per %, P = 0.010) and LGE involving both septal and lateral walls (OR [95%CI] = 4.64 [1.77–12.17], P = 0.002) were independently associated with increased LGE. By multivariate Cox analysis, only baseline LVEF (HR [95%CI] = 0.94 [0.89–0.99] per %, P = 0.031), a < 50% LGE decrease (HR [95%CI] = 3.78 [1.04–10.70], P = 0.044) and an increase in LGE (HR [95%CI] = 8.35 [2.05–24.00], P = 0.003) were significantly associated with MACE.

Conclusion

After AM, LGE persists at 6 months in the vast majority of patients but tends to decrease. A < 50% decrease or an increase in LGE are associated with MACE, indicating that follow-up CMR is relevant for risk stratification (Fig. 1).

引言尽管急性心肌炎（AM）后经常进行心脏磁共振（CMR）随访，但晚期钆增强（LGE）的动态变化对预后的影响尚不清楚。我们旨在确定急性AM后动态LGE变化的预后影响。方法在一项双中心研究中，204名连续的血液动力学稳定的患者（平均年龄35±16岁，78.9%的男性）被纳入，并在诊断后3-12个月重复进行CMR。定量LGE表示为左心室（LV）心肌的百分比。主要终点是中位7.3年时发生的主要心脏不良事件（MACE）[IQR:5.7-8.7]年。结果与指数CMR相比，随访时左心室射血分数（EF）增加（59%对55%，P<；0.001），LGE范围减少（7.6%对12.0%，P<！0.001）（平均指数CMR后5.7±2.6个月）。随访时，175名患者（85.8%）的LGE持续存在；86例为50%（42%），24例增加（12%）。女性（OR[95%CI]=3.27[1.17–9.12]，P=0.023）、低基线左心室射血分数（OR[95%CI]=0.93[0.88–0.98]per%，P=0.010）和同时涉及间隔壁和侧壁的LGE（OR[95%nCI]=4.64[1.77–12.17]，P=0.002）与LGE增加独立相关。通过多变量Cox分析，只有基线LVEF（HR[95%CI]=0.94[0.89–0.99]per%，P=0.031），a<；50%的LGE下降（HR[95%CI]=3.78[1.04-10.70]，P=0.044）和LGE增加（HR[95%CI]=8.35[2.05-24.00]，P=0.003）与MACE显著相关。结论AM后，绝大多数患者的LGE持续6个月，但有下降的趋势。A<；LGE降低或增加50%与MACE相关，表明后续CMR与风险分层相关（图1）。

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引用次数: 0

Feasibility, efficacy and safety of PFO closure under local anesthesia with transoesophageal echocardiography microprobe: A single-center study of 383 patients 经食管超声心动图微探针局部麻醉下PFO封堵术的可行性、有效性和安全性：383例患者的单中心研究

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.029

S. Lagrange, B. Mouhat, M. Besutti, O. Zbitou, R. Chopard, N. Meneveau

Introduction

Percutaneous patent foramen ovale (PFO) closure is usually performed under general anesthesia (GA) with guidance by transesophageal echocardiograpy (TEE). Microrobe makes this procedure possible under local anesthesia (LA). Our study aimed to assess the feasibility, efficacy and safety of PFO closure under LA with microprobe guidance.

Method

The aim was to evaluate the rate of PFO closure failure in patients who underwent a procedure under LA with a TEE microprobe (micro-LA group) vs. under GA with a conventional probe (conventional-GA group). The primary endpoint was the persistence of inter-atrial shunt (> 10 microbubbles) 6 months after procedure, screened by contrast transthoracic ultrasound. The secondary objectives were: identification of risk markers for the persistence of inter-atrial shunt at 6 months, post-procedure complication rates and major cardiovascular events rate.

Results

Three hundred and eighty three patients were included: 303 (79%) in the conventional-GA group, 79 (21%) in the micro-AL group. The median follow-up was 28.0 (14.0–49.0) months. The average age was 49.9 ± 12.6 years, 61.9% of men. There was no failure of PFO closure under AL. Six months after PFO closure, there was no difference in persistence of inter-atrial shunt between the conventional-GA group and the micro-AL group (29.3% vs. 25.5%, P = 0.583). There was no difference in the occurrence of complications related to the procedure between the 2 groups. In multivariate analysis, the presence of interatrial septal aneurysm [OR 1.88 (95% CI 1.07–3.31), P = 0.029], ROPE score > 6 [OR 1.22 (1.04–1.43), P = 0.015] and the occurrence of stroke following the procedure [OR 4.48 (1.12–17.87), P = 0.034] were independently associated with the presence of a residual inter-atrial shunt at 6 months.

Conclusion

Our study identified that PFO closure under LA with TEE microprobe is feasible and safe. There was no difference in efficacy of 6-month FOP closure, regardless of conventional-GA or micro-AL method.

经皮卵圆孔未闭(PFO)通常在全身麻醉(GA)下经食管超声心动图(TEE)指导下进行。在局部麻醉(LA)下，显微技术使这一过程成为可能。我们的研究旨在评估微探针引导下LA闭合PFO的可行性、有效性和安全性。目的是评估采用TEE微探针(micro-LA组)和采用常规探针(conventional-GA组)进行手术的患者PFO关闭失败率。主要终点是房内分流的持续存在(>10个微泡)术后6个月，经胸超声造影筛查。次要目标是:确定6个月时房内分流持续存在的危险标志，术后并发症发生率和主要心血管事件发生率。结果共纳入383例患者:常规- ga组303例(79%)，微量- al组79例(21%)。中位随访时间为28.0(14.0 ~ 49.0)个月。平均年龄49.9±12.6岁，男性占61.9%。AL下无PFO关闭失败。PFO关闭6个月后，常规- ga组与micro-AL组的房间分流持续时间无差异(29.3% vs. 25.5%， P = 0.583)。两组手术并发症发生率无差异。在多因素分析中，房间隔动脉瘤的存在[OR 1.88 (95% CI 1.07-3.31)， P = 0.029]， ROPE评分>6 [OR 1.22 (1.04-1.43)， P = 0.015]和手术后卒中的发生[OR 4.48 (1.12-17.87)， P = 0.034]与6个月时残留心房分流的存在独立相关。结论TEE微探针在LA下闭合PFO是可行且安全的。无论是常规ga法还是显微al法，6个月FOP闭合的疗效均无差异。

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引用次数: 0

Analysis of therapeutic decision-making process and prognosis in patients referred to the Valvular Heart Team for management of mitral regurgitation 瓣膜心脏团队治疗二尖瓣返流患者的治疗决策过程和预后分析

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.003

M.L. Marie Luciani

Introduction

Due to the aging of the population and the diversification of treatment options, finding the right treatment for the right patient becomes a challenge, especially in patients with mitral regurgitation (MR), which is a heterogenous and complex disease, with numerous etiologies. Aims of this study are to describe the profile of patients referred to the Valvular Heart Team (VHT) for management of mitral regurgitation, to highlight the selection process and the main factors guiding allocation for different treatment options, to assess clinical outcomes after treatment.

Method

All patients with mitral regurgitation referred to the VHT between January 1st, 2014, and April 30th, 2021, in University Hospital of Tours, were included.

Results

MR patients referred to our VHT were, mostly, old (mean: 74.2 years), symptomatic (96%), at high or intermediate risk according to “European Society of Cardiology” criteria (44%). Most of them had comorbidities, 34% had LVEF < 50% and 70% a severe primary MR. In 81% of cases, invasive management was decided (surgery [44%], percutaneous edge- to-edge mitral repair [TEER] [35%], transcatheter mitral valve replacement [1.6%]) and in 19% of cases, medical treatment was decided. Distribution of treatments changed significantly (P < 0.01) over time, with a progressive increase in TEER. History of cardiac surgery (P = 0.015), EuroScore II > 4% (P = 0.012), STS score > 8% (P = 0.037), frailty according to the Katz index (P = 0.029), LVEF < 50% (P < 0.001), TAPSE < 15 mm (P < 0,01) secondary MR (P < 0.001) and leaflets calcifications (P = 0.027) were the main factors significantly associated with the choice of a conservative treatment. In 86% of cases, VHT decisions could be implemented.

Conclusion

VHT is a centerpiece in the current management of patients with MR, it opts and more and more, for percutaneous treatments. The organization and the smooth running of VHT meetings will be a real issue in the future, with the increase in patients referred and we will have to find solutions (Fig. 1).

由于人口老龄化和治疗方案的多样化，为合适的患者找到合适的治疗方法成为一项挑战，特别是对于二尖瓣反流(MR)患者，这是一种异质性和复杂的疾病，病因众多。本研究的目的是描述转介到瓣膜性心脏小组(VHT)治疗二尖瓣返流的患者概况，强调选择过程和指导分配不同治疗方案的主要因素，评估治疗后的临床结果。方法选取2014年1月1日至2021年4月30日在图尔大学医院行VHT就诊的所有二尖瓣返流患者。结果采用VHT治疗的smr患者大多为老年人(平均74.2岁)，有症状(96%)，根据欧洲心脏病学会(European Society of Cardiology)的标准(44%)具有高或中度风险。大多数患者有合并症，34%有LVEF <在81%的病例中，有创治疗被决定(手术[44%]，经皮二尖瓣边缘到边缘修复[TEER][35%]，经导管二尖瓣置换术[1.6%])，19%的病例被决定药物治疗。处理的分布发生了显著变化(P <0.01)，随着时间的推移，TEER逐渐增加。心脏手术史(P = 0.015)， EuroScore II >4% (P = 0.012)， STS评分>8% (P = 0.037)，根据Katz指数(P = 0.029)， LVEF <50% (P <0.001)， TAPSE <15mm (P <0.01)继发MR (P <0.001)和小叶钙化(P = 0.027)是选择保守治疗的主要因素。在86%的病例中，VHT判决可以得到执行。结论vht是目前MR患者治疗的核心，越来越多地选择经皮治疗。随着转诊患者的增加，未来VHT会议的组织和顺利进行将是一个真正的问题，我们必须找到解决方案(图1)。

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引用次数: 0

Echocardiographic assessment of right ventricular function and right ventriculoarterial coupling in tricuspid regurgitation 超声心动图评价三尖瓣反流的右心室功能和右心室-动脉耦合

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.032

L. Trousselle , F. Eggenspieler , L. Faroux , P. Nazeyrollas , O. Huttin , N. Pace , L. Filippetti , A. Fraix , B. Carquin , C. Selton-Suty , D. Metz

Introduction

Echographic evaluation of the cardiopulmonary unit may be difficult in the presence of TR. Purpose: To assess the variation of simple and combined echographic parameters analysing the cardiopulmonary unit according to the severity of TR.

Method

Echographic images were reviewed in 179 patients to assess TR grade according to Hahn's 5 grades classification. Classical morphological (RV end diastolic length and area), function [TAPSE, RVFAC, S’,RVFWS (RV free wall longitudinal strain)] and load [PASP,TRTVI (TR Time-velocity integral)] parameters analysing RV were assessed. Combined parameters of function and load (TAPSE/PASP, TR TVI × RVFWS), morphology and load (load adaptation index = TRTVIxRVED length/area) and morphology, load, and function [myomechanical index (MMI = RV-RA mean pressure gradient × RVFWS/indexed RAED area × 10–2) and morphology-load-function index (MLF = RVED length/area xTRTVIx RVFWS)] were calculated. We used ROC curves to analyze the diagnostic value of echocardiographic parameters to predict potential high (> 3) or low (< 6) surgical risk of mortality according to TRISCORE.

Results

Simple parameters were significatively different among groups with a nonlinear progression between the 5 levels of TR. Combined parameters were also significatively different. Among them, MMI and MLF had a linear progression (MMI: grade 1: 0.20 ± 0.09; grade 2: 0.15 ± 0.08; grade 3: 0.10 ± 0.05, grade 4: 0.09 ± 0.08; grade 5: 0.05 ± 0.04 P = 0.000; MLF: grade 1: 7.56 ± 2.06; grade 2: 6.57 ± 2.14; grade 3: 4.85 ± 2.29, grade 4: 4.79 ± 3.17; grade 5: 3.06 ± 1.82 P = 0.000) and had the best predictive value for TRISCORE (MMI: AUC = 0.889 P = 0.000 for low risk, 0.855 P = 0.000 for high risk; MLF: AUC = 0.873 P = 0.000 and 0.822 P = 0.000).

Conclusion

Combined parameters are relevant to evaluate cardiopulmonary unit in a population presenting with TR, especially when combining morphology, function and load (Fig. 1).

目的:评价单纯超声和综合超声参数的变化，根据TR的严重程度对心肺进行分析。方法回顾性分析179例患者的超声图像，根据Hahn的5级分级对TR进行分级。分析右心室的经典形态学参数(右心室舒张末端长度和面积)、功能参数[TAPSE、RVFAC、S '、RVFWS(右心室自由壁纵向应变)]和载荷参数[PASP、TRTVI(右心室时间-速度积分)]。计算功能与载荷(TAPSE/PASP, TRTVI × RVFWS)、形态与载荷(载荷适应指数= TRTVIxRVED长度/面积)、形态、载荷与功能[肌力学指数(MMI = RV-RA平均压力梯度× RVFWS/索引RAED面积× 10-2)和形态-载荷-功能指数(MLF = RVED长度/面积xTRTVIx RVFWS)]的组合参数。我们采用ROC曲线分析超声心动图参数对预测潜在高(>3)或低(<6)根据TRISCORE评估手术死亡风险。结果单纯参数组间差异有统计学意义，5个TR水平间呈非线性变化，综合参数组间差异也有统计学意义。其中，MMI与MLF呈线性进展(MMI: 1级:0.20±0.09;2级:0.15±0.08;3级:0.10±0.05,4级:0.09±0.08;5级:0.05±0.04 P = 0.000;MLF: 1级:7.56±2.06;二级:6.57±2.14;三级:4.85±2.29，四级:4.79±3.17;5级:3.06±1.82 P = 0.000)，对TRISCORE的预测值最高(MMI: AUC = 0.889 P = 0.000，低危、高危分别为0.855 P = 0.000;MLF: AUC = 0.873 P = 0.000和0.822 P = 0.000)。结论综合参数与评估TR人群的心肺功能相关，特别是结合形态学、功能和负荷时(图1)。

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引用次数: 0

Right Ventricular-Pulmonary arterial (RV-PA) coupling is load independent and accurately predicts right ventricular function 右心室-肺动脉(RV-PA)耦合与负荷无关，可准确预测右心室功能

IF 18 Q4 Medicine

Archives of Cardiovascular Diseases Supplements

Pub Date : 2023-06-01 DOI: 10.1016/j.acvdsp.2023.04.030

V.C.F.S. Chong Fah Shen , C.V. Venner , E.A. Abergel

Introduction

RV-PA coupling can be evaluated, using non-invasive surrogates such as Tricuspid annular plane systolic excursion/Systolic pulmonary artery pressure (TAPSE/SPAP) or RV free wall longitudinal strain/SPAP (RVFWLS/SPAP) emerged. The aim of the present study was: 1) Population 1: in Hemodialysis population (HD), to evaluate RV parameters during important load variations, immediately before and after HD. 2) Population 2: in routine cardiologic population, to evaluate the diagnostic value of RV-PA coupling for RV dysfunction

Method

Population 1: 85 patients (53 men), 64 ± 16 years old, had an echocardiography with RV analysis (s’, TAPSE, RVFWLS)immediately before starting HD(Pre-HD)and at the end of HD(Post-HD). Population 2: 96 patients (60 men), 64 ± 14 years old with various disease in the Department of cardiology had an echocardiography including RVFWLS,RV fractional area change(RVFAC), TAPSE,S’, Tei index, Isovolumic acceleration(IVA),and 3D RVEF. Patients were split in normal RV function (defined by 6 concordant normal indices) and RV dysfunction (defined by the presence of at least 3 abnormal indices)

Results

Population 1: TAPSE, s’, RVFWLS were significantly decreased in post-HD as compared to pre-HD; when indexing these parameters by SPAP (s’/SPAP, TAPSE/SPAP, RVFWLS/SPAP), they remain unchanged. Population 2: RVFWLS/SPAP and TAPSE/SPAP were significantly higher in normal RV function compared to dysfunction (1.02 ± 0.31 vs 0.57 ± 0.34 and 0.83 ± 0.20 vs 0.47 ± 0.21); diagnostic thresholds for RV dysfunction were 0.67 for RVFWLS/SPAP(sensitivity:95%, specificity:78%)and 0.63 for TAPSE/SPAP (sensitivity:86%, specificity:80%)

Conclusion

Surrogates of RV-PA coupling, such as TAPSE/SPAP or RVFWLS/SPAP are load independent in a HD population. Moreover, these parameters may contribute to precisely evaluate RV function.

RV- pa耦合可以评估，使用无创替代品，如三尖瓣环平面收缩漂移/收缩期肺动脉压(TAPSE/SPAP)或RV自由壁纵向应变/SPAP (RVFWLS/SPAP)出现。本研究的目的是:1)人群1:在血液透析人群(HD)中，在HD之前和之后的重要负荷变化期间评估RV参数。人群1:85例患者(男性53例)，年龄64±16岁，在HD开始前(预HD)和HD结束时(后HD)分别行超声心动图RV分析(s′、TAPSE、RVFWLS)。人群2:96例(男性60例)，64±14岁，心内科各种疾病患者，超声心动图包括RVFWLS、RV分数面积变化(RVFAC)、TAPSE、S′、Tei指数、等容积加速(IVA)和3D RVEF。患者分为左心室功能正常(以6项一致的正常指标定义)和右心室功能不全(以至少3项异常指标定义)两组。结果人群1:与hd前相比，hd后患者的TAPSE、s '、RVFWLS显著降低;当用SPAP (s ' /SPAP, TAPSE/SPAP, RVFWLS/SPAP)对这些参数进行索引时，它们保持不变。人群2:RVFWLS/SPAP和TAPSE/SPAP在正常右心室功能组中显著高于功能不全组(1.02±0.31 vs 0.57±0.34,0.83±0.20 vs 0.47±0.21);RVFWLS/SPAP的右室功能障碍诊断阈值为0.67(敏感性:95%，特异性:78%)，而TAPSE/SPAP的诊断阈值为0.63(敏感性:86%，特异性:80%)。结论:在HD人群中，TAPSE/SPAP或RVFWLS/SPAP等RV- pa耦合替代指标与负荷无关。此外，这些参数有助于准确地评估RV函数。

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引用次数: 0