Thaden, Jeremy J.

Background: Tricuspid edge to edge repair (TEER) is a novel treatment for severe tricuspid regurgitation and is highly dependent on intraprocedural image quality. To date, transesophageal echocardiography (TEE) has been the primary imaging modality used to guide TEER. The role of intracardiac echocardiography (ICE) has not been assessed. The objective of this study was to describe the use and role of 2-dimensional ICE in the early experience of TEER. Methods: Consecutive patients undergoing TEER (with or without concomitant mitral repair) with off-label use of MitraClip (Abbott, Santa Clara, CA) were included in the study. Utilization of 2-dimensional ICE in comparison with TEE imaging were collected in each procedure through retrospective review of the procedural reports and images. Results: Of 42 TEER cases, ICE was used in 15 (36%) and concomitant mitral repair was performed in 37 (86%). ICE was increasingly used over time for TEER. ICE was able to visualize the tricuspid leaflets with high resolution and provided superior leaflet visualization to TEE in 40% of cases where it was used. Patients treated with ICE guidance tended to have a greater baseline severity of tricuspid regurgitation compared with patients treated with TEE guidance alone (8/15 [53%] massive or greater tricuspid regurgitation versus 6/27 [22%]; P =0.09). Degree of tricuspid regurgitation reduction was similar with TEE alone versus ICE plus TEE guidance (1.9±1.0 versus 2.1±1.1 grade reduction, P =0.28). Conclusions: ICE was increasingly used in the early experience of TEER over time. ICE facilitates leaflet visualization for grasping and is a useful adjunct to TEE during TEER.

AbstractObjectivesThe aim of this study was to determine the safety of eliminating the pre‐discharge transthoracic echocardiogram (TTE) on 30‐day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).BackgroundTTE is utilized before, during, and after TAVR. Post‐procedural, pre‐discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR.MethodsPatients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre‐discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post‐TAVR.ResultsA total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre‐discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre‐discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre‐discharge TTE group and none in the group without pre‐discharge TTE at 30‐day follow‐up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre‐discharge TTE and those without (28.1% vs. 25.3%, P = 0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P = 0.71).ConclusionsElimination of the pre‐discharge TTE is safe and associated with comparable 30‐day outcomes to routine pre‐discharge TTE. These findings have implication for TAVR practice cost‐efficiency and health care utilization.

Background: Atrial fibrillation (AF) is a low-flow state and may underestimate aortic stenosis (AS) severity. Single-high Doppler signals (HS) consistent with severe AS (peak velocity ≥4 m/s or mean gradient ≥40 mm Hg) are averaged down in current practice. The objective for the study was to determine the significance of HS in AF low-gradient AS (LGAS). Methods: One thousand five hundred forty-one patients with aortic valve area ≤1 cm 2 and left ventricular ejection fraction ≥50% were identified and classified as high-gradient AS (HGAS) (≥40 mm Hg) and LGAS (<40 mm Hg), and AF versus sinus rhythm (SR). Available computed tomography aortic valve calcium scores (AVCS) were retrieved from the medical record. Outcomes were assessed. Results: Mean age was 76±11 years, female 47%. Mean gradient was 51±12 in SR-HGAS, 48±10 in AF-HGAS, 31±5 in SR-LGAS, and 29±7 mm Hg in AF-LGAS, all P ≤0.001 versus SR-HGAS; HS were present in 33% of AF-LGAS. AVCS were available in 34%. Compared with SR-HGAS (2409 arbitrary units; interquartile range, 1581–3462) AVCS were higher in AF-HGAS (2991 arbitrary units; IQR1978–4229, P =0.001), not different in AF-LGAS (2399 arbitrary units; IQR1817–2810, P =0.47), and lower in SR-LGAS (1593 arbitrary units; IQR945–1832, P <0.001); AVCS in AF-LGAS were higher when HS were present ( P =0.048). Compared with SR-HGAS, the age-, sex-, comorbidity index-, and time-dependent aortic valve replacement-adjusted mortality risk was higher in AF-HGAS (hazard ratio=1.82 [1.40–2.36], P <0.001) and AF-LGAS with HS (hazard ratio=1.54 [1.04–2.26], P =0.03) but not different in AF-LGAS without HS or SR-LGAS (both P =not significant). Conclusions: Severe AS was common in AF-LGAS. AVCS in AF-LGAS were not different from SR-HGAS. AVCS were higher and mortality worse in AF-LGAS when HS were present.

AbstractBackgroundThe predictors and clinical significance of increased Doppler‐derived mean diastolic gradient (MG) following transcatheter edge‐to‐edge mitral valve repair (MVTEER) remain controversial.ObjectiveWe sought to examine baseline correlates of Doppler‐derived increased MG post‐MVTEER and its impact on intermediate‐term outcomes.MethodsPatients undergoing MVTEER were analyzed retrospectively. Post‐MVTEER increased MG was defined as >5 mmHg or aborted clip implantation due to increased MG intraprocedurally. Baseline MG and 3D‐guided mitral valve area (MVA) by planimetry were retrospectively available in 233 and 109 patients.Results243 patients were included; 62 (26%) had MG > 5 mmHg post‐MVTEER or aborted clip insertion, including 7 (11%) that had aborted clip implantation. Mortality occurred in 63 (26%) during a median follow up of 516 days (IQR 211, 1021). Increased post‐MVTEER MG occurred more frequently in females (44% vs. 16%, p < 0.001), those with baseline MVA <4.0 cm2 (71% vs. 16%), baseline MG ≥4 mmHg (61% vs. 20%), or multiple clips implanted (33% vs. 21%, p = 0.04). Increased post‐MVTEER MG was associated with increased subsequent mortality compared to those with normal gradient (HR 1.91 95% CI 1.15–3.18 p = 0.016) as was aborted clip insertion compared to all others (HR 5.23 95% CI 2.06–13.28 p < 0.001).ConclusionsSmaller baseline MVA and increased baseline MG are associated with increased MG post‐MVTEER and patients with a Doppler‐derived post‐MVTEER MG >5 mmHg suffered excess subsequent mortality. In high risk patients considered for MVTEER, identification of those at risk of iatrogenic mitral stenosis with MVTEER is important as they may be optimally treated with alternate surgical or transcatheter therapies.

Introduction: Accurate stroke volume (SV) calculation is critical for calculating aortic valve area by echocardiography. 2D-Doppler estimation of SV (SV 2D ) assumes uniform blood flow velocities through the left ventricular outflow tract (LVOT). Non-uniform flow through the LVOT, appreciated as spectral broadening of the LVOT Doppler signal, could result in inaccurate SV calculation. Hypothesis: Increased spectral broadening in the LVOT will result in overestimation of SV by the SV 2D method compared to 3D volumetric assessment of SV (SV 3D ). Methods: Fifty-one consecutive patients with aortic stenosis underwent comprehensive 2D-TTE and assessment of SV 3D . Patients with ≥ moderate mitral or aortic regurgitation were excluded. An LVOT pulse-wave Doppler signal with > 0.4 m/s difference between outer and inner edge of velocity spectral display (at time of peak velocity) was considered non-uniform flow (i.e., spectral broadening). Results: Spectral broadening was present in 33% of the cohort. These patients were commonly female with smaller ventricles and higher ejection fraction. Spectral broadening was associated with a significant overestimation of SV on Doppler-based measurements (101±20 ml vs 78±15 mL, SV 2D vs SV 3D , respectively; r=0.83, p<0.0001); such differences were not seen in patients with uniform flow velocities (82±15 vs 79±14 mL, r=0.83, p=0.03). Patient characteristics by spectral broadening are shown in table 1. Conclusion: In aortic stenosis patients with non-uniform flow, Doppler-based methods overestimated SV by 29.5% on average (maximum 64%) when compared to 3D methods. This results in a proportional increase in calculated valve area despite a similar mean gradient between groups. Substituting SV 3D resulted in similar SV, valve area, and mean gradient between uniform and non-uniform groups. When spectral broadening >0.40 cm/s is present, 3D volumetric assessment of SV should be considered for accurate estimation of aortic valve area.

Objective: In patients with aortic stenosis (AS), the development of left ventricular (LV) systolic dysfunction adversely affects the natural history and is associated with poor outcomes following aortic valve replacement. However, the timing and possible reasons for transition from preserved to impaired LV ejection fraction (LVEF) in patients with AS have not been described. The aim of this study was to describe the time course of development of LV dysfunction and associated conditions in patients with severe AS. Methods & Results: Between 1/1/2009 and 12/31/2012, 667 (19%) of 3528 patients with severe AS (aortic valve area (AVA) ≤1 cm2) identified from the Mayo Clinic, Rochester, MN Echocardiographic Laboratory database; had LVEF ≤50%. Of those 667 patients, 263 (39%) had previous echocardiograms (median: 71.6 months, 25 IQR: 36.3, 75:118.2) before the development of severe AS, allowing an assessment of change in LVEF over time. Among these 263 patients, 8 (3%) had dilated cardiomyopathy (DCM), 225 (86%) had ischemic heart disease (IHD), 5 (2%) had other significant valve disease, and 25 (10%) had no concomitant heart disease before the development of severe AS. The evolution of development of reduced LVEF at several time points is shown in the Figure. The initial LVEF was 34±12 % in DCM patients, 51±13% in IHD patients and 61±9 % in AS patients without other heart diseases (p<0.001, ANOVA). Patients with AS alone or AS+DCM/IHD showed a gradual decline in LVEF before AS became severe, and a more rapid decline in LVEF once the AVA reached ≤ 1 cm2. Conclusion: In patients with severe AS, a majority of the patients (86%) with reduced EF had ischemic heart disease. Although there was a gradual decline in LVEF before development of severe AS, the decline was more rapid after AS became severe in almost all patients regardless of associated cardiac condition. More frequent monitoring may be indicated in AS patients especially when AVA reaches 1cm2 and concomitant IHD.

Introduction: Excised aortic valve weight (AVW) correlates with severity of AS. There is some debate about the true severity of AS in low gradient AS (LGAS) compared to high gradient AS (HGAS). We sought to compare patient characteristics and operatively excised AVW in patients with LGAS vs HGAS vs moderate AS. Methods: 916 patients with EF ≥50% undergoing surgical aortic valve replacement for AS between 2010-2012 were included. Clinical and echocardiographic characteristics of LGAS patients (AVA≤1cm 2 , MnG<40mmHg; N=68) were compared to HGAS patients (AVA≤1cm 2 , MnG≥40mmHg; N=745) and operatively excised AVW were compared to moderate AS (AVA>1cm 2 , MnG<40mmHg; N=102). Results: Compared to HGAS, LGAS patients were older (mean age 77 ± 10 vs 73 ± 10 years; p=0.001), often female (56% vs 38%; p=0.006), but without differences in diabetes (26% vs 29%; p=0.78), hyperlipidemia (85% vs 86%, p=0.86), coronary artery disease (49% vs 44%; p=0.53), or hypertension (81% vs 76%; p=0.38). LGAS patients predominantly had trileaflet aortic valves (91% vs 71%; p<0.001), smaller LVOT diameter (2.16 ± 0.15 vs 2.25 ± 0.20 cm; p=0.002), lower stroke volume index (42.1 ± 7.3 vs 49.0 ± 8.8 cc/m 2 ; p<0.001), lower systemic compliance (0.77 ± 0.30 vs 0.93 ± 0.33 ; p<0.001), but no difference in valvulo-arterial impedance (3.96 ± 0.76 vs. 3.84 ± 0.80, p=0.24) compared to HGAS. Excised AVW were lower in patients with LGAS vs HGAS (1.77 ± 0.76 vs 2.69 ± 1.26 g, p<0.001), but not different from moderate AS (1.77 ± 0.76 vs 2.04 ± 0.94 g; p=0.1). This relationship held true when AVW was indexed to body surface area. Three-year mortality post-valve replacement was significantly higher in LGAS compared to HGAS (22% vs 11%, p=0.02). Conclusions: LGAS occurs mostly in older female patients with trileaflet aortic valves. Excised AVW in LGAS is similar to moderate AS but lower than HGAS. However, systemic compliance is higher in LGAS vs HGAS contributing to increased afterload. Poorer outcomes after surgery in LGAS patients may be attributed to noncompliant vasculature which is not corrected with valve replacement and evaluation of patients with LGAS should include assessment of peripheral resistance.

Abstract Aims Beat-to-beat variability in cycle length is well-known in atrial fibrillation (Afib); whether this also translates to variability in annulus size remains unknown. Defining annulus maximal size in Afib is critical for accurate selection of percutaneous devices given the frequent association with mitral and tricuspid valve diseases. Methods and results Images were obtained from 170 patients undergoing 3D echocardiography [100 (50 sinus rhythm (SR) and 50 Afib) for mitral annulus (MA) and 70 (35 SR and 35 Afib) for tricuspid annulus (TA)]. Images were analysed for differences in annular dynamics with a commercially available software. Number of cardiac cycles analysed was 567 in mitral valve and 346 in tricuspid valve. Median absolute difference in maximal MA area over four to six cycles was 1.8 cm2 (range 0.5–5.2 cm2) in Afib vs. 0.8 cm2 (range 0.1–2.9 cm2) in SR, P &lt; 0.001. Maximal MA area was observed within 30–70% of the R-R interval in 81% of cardiac cycles in SR and in 73% of cycles in Afib. Median absolute difference in maximal TA area over four to six cycles was 1.4 cm2 (range 0.5–3.6 cm2) in Afib vs. 0.7 cm2 (range 0.3–1.7 cm2) in SR, P &lt; 0.001. Maximal TA area was observed within 60–100% of the R-R interval in 81% of cardiac cycles in SR, but only in 49% of cycles in Afib. Conclusion MA and TA reach maximal size within a broad time interval centred around end-systole and end-diastole, respectively, with significant beat-to-beat variability. Afib leads to a larger beat-to-beat variability in both timing of occurrence and values of annulus size than in SR.

Abstract Background The left ventricle (LV) in obese patients undergoes different patterns of remodeling in order to normalize wall stress. However, little is known about how LV volume indices, LV global longitudinal strain and right ventricular free wall strain (GLS) vary according to the pattern of LV remodeling. Aim To define the echocardiographic reference values of LV volumes and biventricular GLS across the different LV remodeling patterns in obese patients with a preserved ejection fraction. Methods 2393 adult obese patients (1428 females, 965 males) with a normal ejection fraction who underwent echocardiography from January 2008 to December 2018 were selected. They were categorized according to 4 cardiac remodeling groups defined by LV mass index (102g/m2 in males, 88g/m2 in females) and relative ventricular wall thickness (0.42): normal geometry (NG), eccentric hypertrophy (EH), concentric remodeling (CR) and concentric hypertrophy (CH). Obese subjects were further categorized by BMI class (30–35, 35–40, &gt;40 kg/m2). Obese subjects were gender matched to controls with a normal BMI (18.5–25 kg/m2) and normal cardiac geometry. Mean ± SD, One-way Anova and Tukey- Kramer HSD were applied. P&lt;0.05 is considered significant. Results The mean age of controls and obese patients' were 50±16 and 57±13.6 years respectively (P&lt;0.0001). LV GLS for controls compared to obese subjects with NG, EH, CR and CH was −21.1±2 vs. −20.2±1.9, −19.6±2.8, −18.5±2.9, −17.5±3.4 respectively (p&lt;0.0001 for all), and for RV GLS it was −27.9±4 vs −26.7±3.9, −25.1±5, −23.5±5.5, −24.1±5.2 respectively (p&lt;0.01 for all, except for NG where p=0.2). The distribution of LV indices according to cardiac remodeling subtypes is shown in the figure. Indexed end diastolic and end systolic volumes were smaller in NG, CH and CR compared to controls (p&lt;0.001 for each respectively). LV GLS and ejection fraction were higher in females, while indexed LV volumes were higher in males within each remodeling category (P&lt;0.0001). No significant difference in LV GLS or indexed LV volume was seen across BMI categories within each remodeling pattern (P&gt;0.05). Obese subjects with CH had the highest incidence of the cardiovascular risk factors hyperlipidemia, hypertension and history of myocardial infarction or stroke, compared to those with other remodeling patterns (p&lt;0.0001 for each, vs. NG, EH and CR). Conclusion To our knowledge, this is the largest study to define LV volumes and left and right ventricular GLS according to LV remodeling pattern and BMI category. The Lowest GLS was noted in CH. Ejection fraction was similar across the LV remodeling patterns. There were no differences in GLS and LV indexed volumes across BMI categories within each remodeling group. These results can be applied as a reference values for the obese population with a normal LV ejection fraction. Funding Acknowledgement Type of funding source: None