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Background This single-center retrospective study assessed the variation of left ventricular ejection fraction (LVEF) after transapical transcatheter aortic valve implantation and its effect on survival. We also evaluated the effect of sheath diameter on LVEF. Methods We analyzed data of all consecutive patients who underwent transapical transcatheter aortic valve implantation with the Sapien (Edwards Lifesciences, Irvine, CA) device (and its evolutions) between 2009 and 2015. We analyzed the difference between preoperative LVEF and LVEF at discharge (ΔEF = LVEFpost-op – LVEFpre-op) and considered its interquartile range (±5%) as the cutoff. Patients were divided in three groups: (1) improved LVEF (ΔEF ≥ +5%); (2) unchanged LVEF (ΔEF –5% to +5%), and (3) worsened LVEF (ΔEF ≤ –5%). Survival was evaluated with Kaplan-Meier analysis, and logistic regression multivariable analysis was used to determine independent predictors of LVEF improvement. Results Data of 122 patients were analyzed. Patients in the three groups were distributed as follows: (group 1) 27 patients (22.1%), (group 2) 69 (56.6%), and (group 3) 26 (21.3%). The mean ΔEF was 12.7% ± 4.7% in group 1 and –10.8% ± 3.9% in group 3. The ΔEF was more likely to improve in patients with preoperative LVEF of less than 0.35 ( p = 0.014). There were no significant differences in survival ( p = 0.41), rehospitalization ( p = 0.472), and New York Heart Association Functional Classification ( p = 0.307) among the groups. The use of the smallest available sheath (18F) was not associated with a significant change of ΔEF. Conclusions LVEF worsened in a small number of patients after transapical transcatheter aortic valve implantation, but this change was not associated with worse postoperative outcomes. Patients with a low LVEF showed better improvement. The progressive reduction of sheath diameter does not have a significant effect on LVEF changes.

Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to various stimuli such as exercise and ischaemia, which can precipitate the development of symptoms and subsequent cardiac events. In both chronic primary and secondary MR, the dynamic behaviour of MR can be reliably examined during stress echocardiography. Dynamic fluctuation of MR can also have prognostic value; patients with a marked increase in regurgitant volume or who exhibit increased systolic pulmonary artery pressure during exercise have lower symptom-free survival than those who do not experience significant changes in MR and systolic pulmonary artery pressure during exercise. Identifying patients who have dynamic MR, and understanding the mechanisms underlying the condition, can potentially influence revascularization strategies (such as the surgical restoration of coronary blood flow) and interventional treatment (including cardiac resynchronization therapy and new approaches targeted to the mitral valve).

Cardiac Calcification at Transthoracic EchocardiographyPredicts Stress EchoResults: a Multicentre StudyNicola Gaibazzi, Rosa Sicari, Eustachio Agricola, Giovanni Cioffi, CarmineMazzone, Lisa Albertini, Giacomo Faden, Sabrina Molinaro, DamianoRegazzoli, Andrea Di Lenarda,Pompilio FaggianoPII: S0167-5273(14)00666-4DOI: doi: 10.1016/j.ijcard.2014.04.007Reference: IJCA 17908To appear in

Coronary flow-reserve (CFR) can be impaired in non-ischaemic dilated cardiomyopathy (DCM), unmasking a coronary microcirculatory dysfunction of potential prognostic impact. The aim of the present study is to evaluate the prognostic value of Doppler echocardiographic-derived CFR in patients with DCM.We evaluated 129 DCM patients (85 male; age 62+/-11) by transthoracic dipyridamole (0.84 mg/kg in 10 min) stress echocardiography. All patients had an ejection fraction40% (mean 32+/-7) and angiographically normal coronary arteries with NYHA classor=3. CFR was assessed on left anterior descending artery using pulsed Doppler as the ratio of maximal peak vasodilation (dipyridamole) to rest diastolic flow velocity. All patients were followed-up for a median of 22 months. Mean CFR was 2.0+/-0.5. At individual patient analysis 46 patients had normal (CFR2.0) and 83 had abnormal CFR. During follow-up, 18 patients died and 33 showed worsening of NYHA class. The worse event-free survival was observed in those patients with an abnormal CFR when compared with those having a normal CFR at high dose of dipyridamole (70 vs. 22%, at 75 months of follow-up, P0.0001). In the multivariable analysis, severity of mitral insufficiency (HR=1.9, 95% CI=1.06-2.87), abnormal CFR (HR=4.0, 95% CI=1.1-15.6), resting wall motion score index (HR=6.9, 95% CI=1.5-30.7) were independent predictors of survival.In DCM patients, CFR is often impaired. A reduced CFR during vasodilator stress is an independent prognostic marker of bad prognosis.

Aims: Cardiac resynchronization therapy (CRT) has become an attractive therapeutic option for patients with end-stage heart failure (HF). Currently, patients are selected for CRT on ECG and on echocardiographic criteria analysed at rest. Whether the physical effort may further increase myocardial dyssynchrony is not fully established. The aim of the study was to test by the use of Doppler myocardial imaging (DMI) if dynamic left ventricular (LV) dyssynchrony during physical effort may be a determinant of dynamic mitral regurgitation in patients with dilated cardiomyopathy and 'narrow' QRS. Methods and results: Sixty patients (62.3 ± 8.3 years) with idiopathic dilated cardiomyopathy and narrow QRS duration (< 120 ms) were selected. All the patients underwent standard Doppler echo, colour DMI, supine bicycle exercise stress echocardiography, and cardiopulmonary exercise testing. Cardiac synchronicity was assessed, at rest and at peak exercise, from measurements of time intervals (Ts) between the onset of the QRS complex and the peak myocardial systolic velocity, in a six-basal-six-mid-segmental model. Standard deviation of Ts of the 12 LV segments (Ts-SD-12) was also calculated. In baseline conditions, HF patients showed an LV ejection fraction of 30.1 ± 4%, and a significant electromechanical delay (Ts-SD-12 ≥ 34.4 ms) in 20 patients (33.3%). At peak of physical exercise, a significant electromechanical delay was detected in 35 patients (58.3%), whereas in 47 patients (78.3%) exercise-induced increase in mitral valve effective regurgitant orifice (ERO) was observed. By multivariable analysis, an independent positive association between changes in Ts-SD-12 and in mitral valve ERO (P < 0.0001), as well as an independent inverse correlation of the same changes in Ts-SD-12 with LV stroke volume (P < 0.0001) were detected. In addition, changes in Ts-SD-12 were also independent determinants of peak VO2 (P < 0.0001) during cardiopulmonary exercise testing. Conclusion: Colour DMI is an effective technique for assessing the severity of regional delay in activation of LV walls in HF patients with narrow QRS both at rest and during stress test. The increase in LV dyssynchrony during exercise strongly correlates with the increase in mitral regurgitation severity and with the impairment of LV stroke volume. © The European Society of Cardiology 2007. All rights reserved.

Objective Mitral valve annuloplasty and mitral valve replacement are common strategies for the management of functional ischemic mitral regurgitation with ischemic cardiomyopathy. However, mitral valve annuloplasty may create some degree of functional mitral stenosis. The purpose of this study was to compare the mitral valve hemodynamics in patients with functional ischemic mitral regurgitation undergoing mitral valve annuloplasty or mitral valve replacement, using exercise echocardiography. Methods We performed resting and exercise echocardiography in 70 patients matched for indexed effective orifice area, systolic pulmonary arterial pressure, and left ventricular ejection fraction after mitral valve annuloplasty or mitral valve replacement with coronary artery bypass grafting. Results There was no significant difference between the 2 groups regarding baseline demographic and clinical data. Exercise systolic pulmonary arterial pressure was higher in the mitral valve annuloplasty group compared with the mitral valve replacement group (from 36.3 ± 8.1 mm Hg to 55 ± 12 mm Hg, vs mitral valve replacement: 33 ± 6 mm Hg to 42 ± 6.2 mm Hg, P = .0001). Exercise-induced improvement in effective orifice area and indexed effective orifice area was better in the mitral valve replacement group (mitral valve replacement: +0.23 ± 0.04 vs mitral valve annuloplasty: −0.1 ± 0.09 cm², P = .001, for effective orifice area; mitral valve replacement: +0.14 ± 0.03 vs mitral valve annuloplasty: −0.04 ± 0.07 cm²/m², P = .03, for indexed effective orifice area). Exercise indexed effective orifice area was correlated with exercise systolic pulmonary arterial pressure ( r = −0.45; P = .01). In a multivariable analysis mitral valve annuloplasty, postoperative indexed effective orifice area and resting mitral peak gradients were independent predictors of elevated systolic pulmonary arterial pressure during exercise. Conclusions In patients with functional ischemic mitral regurgitation, mitral valve annuloplasty may cause functional mitral stenosis, especially during exercise. Mitral valve annuloplasty was associated with poor exercise mitral hemodynamic performance, lack of mitral valve opening reserve, and markedly elevated postoperative exercise systolic pulmonary arterial pressure compared with mitral valve replacement.