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Background--Ischemic mitral regurgitation (IMR) is associated with poor outcomes. It is unknown what factors contribute to progression of IMR and how progressive IMR affects outcomes. We sought to determine imaging predictors of IMR progression and to determine if progressive IMR is an independent predictor of survival in patients with advanced ischemic cardiomyopathy. Methods and Results--Consecutive advanced ischemic cardiomyopathy patients who underwent cardiac magnetic resonance and echocardiograms at baseline with echocardiographic follow-up were studied. Cardiac magnetic resonance was used to assess left ventricular volumes, infarct size, and mitral valve geometry. The effective regurgitant orifice area (EROA) was calculated from the proximal isovelocity surface area by echocardiography. Repeated measures mixed effects and Cox proportional hazards regression models were built to identify predictors of IMR progression and survival. We evaluated 336 patients (age, 62±11 years) over a median follow-up time of 54 months: 154 patients were subsequently revascularized, and 182 patients were medically treated. Ninety-eight patients (29%) demonstrated an increase in EROA values of ≥0.1 cm². There were 87 adverse events (death or transplant). On multivariable analysis, infarct size (P<0.001), progression in IMR (P=0.008), age (P=0.003), and baseline EROA (P=0.010) were independently associated with adverse events. Independent predictors of IMR progression were as follows: baseline EROA (P<0.001), left ventricular end--systolic volume index (P=0.014), and total scar (P=0.036). Conclusions--IMR frequently increases in severity, and progression is independently associated with adverse left ventricular remodeling and infarct size, as assessed by cardiac magnetic resonance. Furthermore, IMR progression is a powerful independent predictor of adverse events, even after controlling for the severity of IMR at baseline. [ABSTRACT FROM AUTHOR]

The performance of prediction models can be assessed using a variety of methods and metrics. Traditional measures for binary and survival outcomes include the Brier score to indicate overall model performance, the concordance (or c) statistic for discriminative ability (or area under the receiver operating characteristic [ROC] curve), and goodness-of-fit statistics for calibration.Several new measures have recently been proposed that can be seen as refinements of discrimination measures, including variants of the c statistic for survival, reclassification tables, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Moreover, decision-analytic measures have been proposed, including decision curves to plot the net benefit achieved by making decisions based on model predictions.We aimed to define the role of these relatively novel approaches in the evaluation of the performance of prediction models. For illustration, we present a case study of predicting the presence of residual tumor versus benign tissue in patients with testicular cancer (n = 544 for model development, n = 273 for external validation).We suggest that reporting discrimination and calibration will always be important for a prediction model. Decision-analytic measures should be reported if the predictive model is to be used for clinical decisions. Other measures of performance may be warranted in specific applications, such as reclassification metrics to gain insight into the value of adding a novel predictor to an established model. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text. Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery. Methods: Of 833 consecutive patients with surgically proven IE during May 1, 2014 to May 1, 2019, at Cleveland Clinic, 155 underwent both preoperative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II (European System for Cardiac operative Risk Evaluation II). Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients, respectively. Thirty-day mortality occurred in 3 (1.9%) patients and composite mortality or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality or morbidities in-hospital, with odds ratio (95% CI) of 3.66 (1.76–7.59), P =0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95% CI) of 3.82 (1.25–11.7), P <0.001 and 9.84 (1.89–51.0), P =0.007, respectively. Conclusions: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery. [ABSTRACT FROM AUTHOR]

Introduction: Little is known about gender differences in ischemic mitral regurgitation (MR). Hypothesis: We hypothesized that women with ischemic cardiomyopathy (ICM) have greater degrees of MR leading to worse outcomes. Methods: We retrospectively evaluated ICM patients with cardiac magnetic resonance imaging (cMRI) and ECHO between 2002-06 and recorded treatment and survival outcomes. Generalized linear models were constructed to assess gender effects on LV and RV size, left atrial strain, and total scar burden and peri-infarct zone (PIZ) area (defined as signal intensity > 2 standard deviations and between 2 and 3 standard deviations of non-infarcted myocardium on delayed enhancement imaging, respectively). The effect of gender on MR severity by ECHO was assessed by a chi-square test. A Cox proportional hazards model was used to assess the interaction of gender and MR severity as a predictor of all-cause mortality adjusting for comorbidities, treatment (medical therapy vs revascularization), total scar and device therapy. Results: We studied 483 patients (25% women). Table 1 summarizes baseline characteristics and effect of gender on cMRI and ECHO data. Women had worse MR despite smaller indexed LV and RV volumes, and similar total scar burden and PIZ area. Estimated hazard ratios of worse outcomes in women with moderate or worse MR were higher than in men (HR >1) (Figure 1). Conclusions: Women with ICM have more severe MR despite smaller indexed LV and RV size and similar scar burden, and are at higher risk of worse outcomes than men with moderate or greater MR. Further research on how women with ICM remodel differently than men is needed to clarify these differences. [ABSTRACT FROM AUTHOR]