Pellikka, Patricia A

Abstract Background and Aims Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are intimately associated disorders; HFpEF may be overlooked in AF when symptoms are simply attributed to dysrhythmia, and incident AF may identify patients at risk for developing diastolic dysfunction (DD). This study aimed to investigate the prevalence and incidence of DD in patients with new-onset AF compared with sinus rhythm (SR). Methods Adults with new-onset AF (n = 1747) or SR (n = 29 623) and no structural heart disease were identified. Propensity score matching was performed (1:3 ratio) between AF and SR based on age, sex, body mass index, and comorbidities. Severe DD (SDD) was defined by ≥3/four abnormal parameters (medial e’, medial E/e’, tricuspid regurgitation velocity, and left atrial volume index) and ≥moderate DD (>MDD) by ≥2/4. Annualized changes in DD indices were determined. Results New-onset AF was independently associated with SDD (8% vs. 3%) and ≥MDD (25% vs. 16%); 62% of patients with AF had high-risk H2FPEF scores, and 5% had clinically recognized HFpEF. Over a median follow-up of 3.2 (interquartile range 1.6–5.8) years, DD progressed two–four-fold more rapidly in those with new-onset AF (P < .001 for all). The risk for incident DD was increased in new-onset AF [hazard ratio (95% confidence interval) 2.69 (2.19–3.32) for SDD and 1.73 (1.49–2.02) for ≥MDD]. Conclusions Patients with new-onset AF display high-risk features for HFpEF at diagnosis, emphasizing the importance of evaluating for HFpEF among symptomatic patients with AF. Patients with new-onset AF have accelerated progression in DD over time, which may identify patients with preclinical HFpEF, where preventive therapies may be tested.

Abstract Aims Atrial functional mitral regurgitation (AFMR) has been associated with atrial fibrillation (AF) and heart failure with preserved ejection fraction. However, data on incident AFMR are scarce. We aimed to study the incidence, risk factors, and clinical significance of AFMR in AF or sinus rhythm (SR). Methods and results Adults with new diagnosis of AF and adults in SR were identified. Patients with >mild MR at baseline, primary mitral disease, cardiomyopathy, left-sided valve disease, previous cardiac surgery, or with no follow-up echocardiogram were excluded. Diastolic dysfunction (DD) was indicated by ≥2/4 abnormal diastolic function parameters [mitral medial e′, mitral medial E/e′, tricuspid regurgitation velocity, left atrial volume index (LAVI)]. Overall, 1747 patients with AF and 29 623 in SR were included. Incidence rate of >mild AFMR was 2.6 per 100 person-year in new-onset AF and 0.7 per 100 person-year in SR, P < 0.001. AF remained associated with AFMR in a propensity score-matched analysis based on age, sex, and comorbidities between AF and SR [hazard ratio: 3.80 (95% confidence interval 3.04–4.76)]. Independent risk factors associated with incident AFMR were age ≥65 years, female sex, LAVI, and DD in both AF and SR, in addition to rate (vs. rhythm) control in AF. Incident AFMR was independently associated with all-cause death in both groups (both P < 0.001). Conclusions AF conferred a three-fold increase in the risk of incident AFMR. DD, older age, left atrial size, and female sex were independent risk factors in both SR and AF, while rhythm control was protective. AFMR was universally associated with worse mortality.

Abstract Background and Aims Bicuspid aortic valve (BAV) is the most common congenital heart anomaly. Lifetime morbidity and whether long-term survival varies according to BAV patient-sub-groups are unknown. This study aimed to assess lifetime morbidity and long-term survival in BAV patients in the community. Methods The authors retrospectively identified all Olmsted County (Minnesota) residents with an echocardiographic diagnosis of BAV from 1 January 1980 to 31 December 2009, including patients with typical valvulo-aortopathy (BAV without accelerated valvulo-aortopathy or associated disorders), and those with complex valvulo-aortopathy (BAV with accelerated valvulo-aortopathy or associated disorders). Results 652 consecutive diagnosed BAV patients [median (IQR) age 37 (22–53) years; 525 (81%) adult and 127 (19%) paediatric] were followed for a median (IQR) of 19.1 (12.9–25.8) years. The total cumulative lifetime morbidity burden (from birth to age 90) was 86% (95% CI 82.5–89.7); cumulative lifetime progression to ≥ moderate aortic stenosis or regurgitation, aortic valve surgery, aortic aneurysm ≥45 mm or z-score ≥3, aorta surgery, infective endocarditis and aortic dissection was 80.3%, 68.5%, 75.4%, 27%, 6% and 1.6%, respectively. Survival of patients with typical valvulo-aortopathy [562 (86%), age 40 (28–55) years, 86% adults] was similar to age-sex-matched Minnesota population (P = .12). Conversely, survival of patients with complex valvulo-aortopathy [90 (14%), age 14 (3–26) years, 57% paediatric] was lower than expected, with a relative excess mortality risk of 2.25 (95% CI 1.21–4.19) (P = .01). Conclusion The BAV condition exhibits a high lifetime morbidity burden where valvulo-aortopathy is close to unavoidable by age 90. The lifetime incidence of infective endocarditis is higher than that of aortic dissection. The most common BAV clinical presentation is the typical valvulo-aortopathy with preserved expected long-term survival, while the complex valvulo-aortopathy presentation incurs higher mortality.

Background: Left ventricular global longitudinal strain (LVGLS) has been shown to improve risk stratification in patients with LV systolic dysfunction and subsequent recovery of LV ejection fraction (LVEF) in the acquired heart disease population. The purpose of this study was to assess the relationship between LVGLS and cardiovascular events (heart failure hospitalization, sustained ventricular tachycardia/appropriate shock, heart transplant, or cardiovascular death) and deterioration in LVEF (absolute decrease in LVEF ≥10% to LVEF <50%) in adults with congenital heart disease. Methods: Retrospective cohort study of congenital heart disease patients with previous diagnosis of LV systolic dysfunction (LVEF <50%) and subsequent recovery of LVEF (absolute increase in LVEF of ≥10% to LVEF ≥50%) on subsequent echocardiogram (index echocardiogram). Based on the index echocardiogram, patients were divided into normal LVGLS (absolute LVGLS >18%) versus abnormal LVGLS (absolute LVGLS ≤18%) groups. Results: Of 193 patients with recovered LVEF, 86 (45%) had normalization of LVGLS at index echocardiogram. A higher absolute LVGLS and use of renin angiotensin aldosterone system antagonist was associated with a lower risk of cardiovascular events and subsequent deterioration in LVEF, while hypertension was associated with higher risk of cardiovascular events and deterioration in LVEF. Conclusions: These results suggest that patients with congenital heart disease with recovered LVEF remained at risk for adverse outcomes, and LVGLS can be used to identify patients at risk for adverse outcomes. Medical therapy for heart failure and treatment of hypertension may reduce the risk of adverse outcome, but these findings require empirical validation, hence the need for a clinical trial.

Abstract Background Caseous calcification of the mitral annulus is an extremely rare variant of mitral annulus calcification occurring in &lt;1% of cases. The degeneration of caseous masses could act as a source of embolic strokes and a nidus for infective endocarditis (IE). Case summary A man in his sixties presented with transient left arm weakness. His history was pertinent for bioprosthetic aortic valve replacement secondary to endocarditis and recent pneumococcal pneumonia complicated by empyema and bacteraemia. He was still on intravenous antibiotics when he presented. Evaluation including magnetic resonance imaging of the brain, transoesophageal echocardiography, and computed tomography (CT) of the chest revealed multifocal embolic strokes, degenerative bioprosthetic aortic valve dysfunction, mitral annular calcification with mobile calcific masses, and persistent empyema. 18F-fluorodeoxyglucose–positron emission tomography–CT showed indeterminate activity across a portion of the posterior mitral leaflet and no activity on the bioprosthetic aortic valve. The patient was deemed high risk for surgery and was treated with 6-week course of antibiotics both for the empyema and the possible IE of the native mitral valve. Repeat echocardiography 40 days later showed stable mitral masses. At 4 months of follow up, the patient had no evidence of recurrent clinical strokes. Discussion Caseous calcification of the mitral annulus is a rare but an increasingly recognized predisposing factor for embolic strokes and IE. Treatment ideally involves surgical resection of the calcified masses in such cases.

Background: Inferior vena cava (IVC) size and collapsibility (IVC dynamics) are used for estimating right atrial pressure (RAP). However, the diagnostic performance of the American Society of Echocardiography IVC criteria for estimating RAP in patients with congenital heart disease are unknown. The purpose of this study was to assess the role of IVC dynamics for estimating RAP in adults with congenital heart disease. Methods: We conducted a retrospective study of adults with congenital heart disease that underwent cardiac catheterization and echocardiogram at Mayo Clinic (2003–2019). IVC diameter was measured at inspiration (IVC min ) and end-expiration (IVC max ), and IVC collapsibility index (IVC CI ) was calculated. Results: Based on 918 patients, we observed a good correlation between IVC max and invasive RAP ( r =0.56, P <0.001); IVC min and RAP ( r =0.58, P <0.001); and IVC CI ( r =−0.72, P <0.001). There was excellent correlation between invasive RAP and estimated RAP using IVC CI ( r =0.80, P <0.001). We observed that IVC CI <60% had superior diagnostic performance as compared with American Society of Echocardiography criteria (IVC max >2.1 cm, area under the curve difference 0.15, P <0.001; IVC CI <50%, area under the curve difference 0.09, P =0.008; combination of IVC max >2.1 cm; and IVC CI <50%, area under the curve difference 0.06, P =0.02). Estimated RAP >10 mm Hg based on IVC CI had comparable prognostic performance as invasive RAP but superior prognostic performance as the American Society of Echocardiography criteria. Conclusions: IVC CI <60% was the best criterion to identify patients with elevated RAP. IVC CI was comparable to invasively measured RAP in its relation to prognosis. Further studies are required to determine whether the use of IVC CI in clinical decision-making will improve clinical outcomes in this population.

Background Many patients with symptomatic severe aortic stenosis do not undergo aortic valve replacement (AVR) despite clinical guidelines. This study analyzed the association of managing provider type with cardiac specialist follow‐up, AVR, and mortality for patients with newly diagnosed severe aortic stenosis (sAS). Methods and Results We identified adults with newly diagnosed sAS per echocardiography performed between January 2017 and March 2019 using Optum electronic health record data. We then selected from those meeting all eligibility criteria patients managed by a primary care provider (n=1707 [25%]) or cardiac specialist (n=5039 [75%]). We evaluated the association of managing provider type with cardiac specialist follow‐up, AVR, and mortality, as well as the independent association of cardiac specialist follow‐up and AVR with mortality, within 1 year of echocardiography detecting sAS. A subgroup analysis was limited to patients with symptomatic sAS. Patient characteristics and comorbidities at baseline were used for covariate‐adjusted cause‐specific and multivariable Cox proportional hazard models assessing group differences in outcomes by managing provider type. An adjusted Cox proportional hazard model with additional time‐dependent covariates for follow‐up and AVR was used to assess these practices' association with mortality. Within 1 year of echocardiography detecting sAS, data revealed that primary care provider management was associated with lower rates of cardiac specialist follow‐up (hazard ratio [HR], 0.47 [95% CI, 0.43–0.50], P <0.0001) and AVR (HR, 0.58 [95% CI, 0.53–0.64], P <0.0001) and with higher 1‐year mortality (HR, 1.45 [95% CI, 1.26–1.66], P <0.0001). Cardiac specialist follow‐up and AVR were independently associated with lower mortality (follow‐up: HR, 0.55 [95% CI, 0.48–0.63], P <0.0001; AVR: HR, 0.70 [95% CI, 0.60–0.83], P <0.0001). Results were similar for patients with symptomatic sAS. All analyses were adjusted for baseline patient characteristics and comorbidities. Conclusions For patients newly diagnosed with sAS, we observed differences in rates of cardiac specialist follow‐up and AVR and risk of mortality between primary care provider‐ versus cardiologist‐managed patients with sAS. In addition, a lower likelihood of receiving follow‐up and AVR was independently associated with higher mortality.

Abstract Aims Electrocardiogram (ECG)-enabled stethoscope (ECG-Scope) acquires a single-lead ECGs during cardiac auscultation and may facilitate real-time screening for pathologies not routinely identified by cardiac auscultation alone. We previously demonstrated an artificial intelligence (AI) algorithm can identify left ventricular dysfunction (LVSD) [defined as ejection fraction (EF) ≤ 40%] with an area under the curve (AUC) of 0.91 using a 12-lead ECG. Methods and results One hundred patients referred for clinically indicated echocardiography were prospectively recruited. ECG-Scope recordings with the patient supine and sitting were obtained in multiple electrode locations at the time of the echocardiogram. The AI algorithm for the detection of LVSD was retrained using single leads from ECG-12 and validated against ECG-Scope to determine accuracy for low EF detection (≤35%, &lt;40%, or &lt;50%). We evaluated the algorithm with respect to body position and lead location. Amongst 100 patients (aged 61.3 ± 13.8; 61% male, BMI: 30.0 ± 5.4), eight had EF≤40%, and six had EF 40–50%. The best single recording position was V2 with the patient supine [AUC: 0.88 (CI: 0.80–0.97) for EF≤35%, 0.85 (CI: 0.75–0.95) for EF≤40%, and 0.81 (CI: 0.71–0.90) for EF &lt; 50%]. When using an AI model to select the recording automatically, AUC was 0.91 (CI: 0.84–0.97) for EF≤35%, 0.89 (CI: 0.83–0.96) for EF≤40%, and 0.84 (CI: 0.73–0.94) for EF &lt; 50%. Conclusion An AI algorithm applied to an ECG-enabled stethoscope recording in standard auscultation positions reliably detected the presence of a low EF in this prospective study of patients referred for echocardiography. The ability to screen patients with a possible low EF during routine physical examination may facilitate rapid detection of LVSD.