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Aims This study aimed to evaluate the prevalence and distribution of pulmonary venous systolic flow reversal (PVSFR) in patients with severe mitral regurgitation (MR), and to examine the relationship between PVSFR profile and cardiac parameters. Methods and results A total of 125 patients with severe MR who had transoesophageal echocardiography (TOE) performed were reviewed. Of these, 121 (96.8%) patients showed all four pulmonary venous (PV) flows by TOE. They were categorized into three groups by the MR aetiology: degenerative MR (DMR) (n  = 72), ventricular functional MR (V-FMR) (n  = 20), and atrial functional MR (A-FMR) (n  = 16). Eighteen (16.7%) patients had PVSFR in all four PVs. Twenty-nine (26.9%) had PVSFR in three PVs, 23 (21.3%) in two PVs, and 23 (21.3%) in one PV. PVSFR appeared at right PVs more frequently compared with left PVs. A high number of PVSFR was significantly correlated with higher pulmonary capillary wedge pressure (PCWP) and 3D vena contracta area (3D-VCA). With regard to MR aetiology, the number of PVSFRs was correlated with high 3D-VCA in patients with DMR and A-FMR, while it was correlated with high PCWP in patients with V-FMR. Laminar-type PVSFR appeared more frequently in FMR compared with DMR, and it had a relationship with higher PCWP and lower right ventricular fractional area change (RVFAC). Conclusion All four PV were detected in 96.8%, and 16.8% patients had PVSFR in all four PVs. PCWP and 3D-VCA were correlated with the number of PVSFRs in severe MR patients. Laminar-type PVSFR was related to higher PCWP and lower RVFAC. [ABSTRACT FROM AUTHOR]

Aims  We sought to investigate tricuspid valve (TV) geometry and right heart remodelling in atrial functional tricuspid regurgitation (AF-TR) as compared with ventricular functional TR with sinus rhythm (VF-TR). Methods and results  Transoesophageal 3D echocardiography datasets of the TV and right ventricle were acquired in 51 symptomatic patients with severe TR (AF-TR, n  = 23; VF-TR, n  = 28). Three-dimensional right ventricular (RV) endocardial surfaces were reconstructed throughout the cardiac cycle and then postprocessed using semiautomated integration and segmentation software to calculate position of papillary muscle (PM) tips. Compared with VF-TR, AF-TR had more dilated and posteriorly displaced annulus and less leaflet tethering angles with more prominent right atrium and smaller RV end-systolic volume. On the XY (annular) plane, the centre of annulus was getting closer towards the anterior and posterior PM tips and was going away from the medial PM tip caused by prominent annular dilatation in AF-TR. On the Z -axis, the position of each PM tip in AF-TR was not so much displaced apically as that in VF-TR. Multiple linear regression analyses revealed that right atrial volume and right atrial/RV end-systolic volume ratio were determinants of annular area and orientation in AF-TR, respectively (both P  <   0.001). Additionally, the posteromedial-directed component of posterior PM tip position and the apically directed component of the position of all three PM tips were independently associated with TV tethering angles of each leaflet in AF-TR (all P  <   0.02). Conclusion  Right heart remodelling and its association with 3D TV geometry differ entirely between AF-TR and VF-TR, which may offer distinctive therapeutic implication. [ABSTRACT FROM AUTHOR]

Background The CHADS 2 scoring system is simple and widely accepted for predicting thromboembolism in patients with nonvalvular atrial fibrillation (NVAF). Although congestive heart failure (CHF) is a component of the CHADS 2 score, the definition of CHF remains unclear. We previously reported that the presence of CHF was a strong predictor of left atrial appendage (LAA) thrombus. Therefore, the present study aimed to elucidate the relationship between LAA thrombus and the brain natriuretic peptide (BNP) level in patients with unanticoagulated NVAF. Methods The study included 524 consecutive patients with NVAF who had undergone transesophageal echocardiography to detect intracardiac thrombus before cardioversion between January 2006 and December 2008, at Hiroshima City Asa Hospital. The exclusion criteria were as follows: paroxysmal atrial fibrillation, unknown BNP levels, prothrombin time international normalized ratio ≥2.0, and hospitalization for systemic thromboembolism. Results Receiver operating characteristic analysis yielded optimal plasma BNP cut-off levels of 157.1 pg/mL (area under the curve, 0.91; p <0.01) and 251.2 pg/mL (area under the curve, 0.70; p <0.01) for identifying CHF and detecting LAA thrombus, respectively. Multivariate analyses demonstrated that a BNP level >251.2 pg/mL was an independent predictor of LAA thrombus (odds ratio, 3.51; 95% confidence interval, 1.08–10.7; p =0.046). Conclusions In patients with unanticoagulated NVAF, a BNP level >251.2 pg/mL may be helpful for predicting the incidence of LAA thrombus and may be used as a surrogate marker of CHF. The BNP level is clinically useful for the risk stratification of systemic thromboembolism in patients with unanticoagulated NVAF. [ABSTRACT FROM AUTHOR]

Tricuspid valve (TV) remodeling occurs in patients with atrial fibrillation (AF); however, the affecting factor related to TV remodeling in AF remains to be elucidated. We sought to explore whether the AF persistence itself affects right heart remodeling. A total of 372 lone AF patients (234 paroxysmal AF [paroxAF] and 138 persistent AF [persAF]) who underwent 3-dimensional transesophageal echocardiography (3D-TEE) was retrospectively reviewed. The duration from first-detected episode of AF to the TEE exam date was defined as AF duration. PersAF patients had a larger TV area index (625.4 vs 719.0 mm2/m2; P < 0.001) and a higher right atrium area-to-right ventricle end-systolic area ratio (RA/RVESA ratio, 1.7 vs 1.9; P = 0.005) than paroxAF patients. The prevalence of AF-tricuspid regurgitation was higher in persAF than in paroxAF patients (1.3% vs 12.3%; P < 0.001). In persAF patients, AF duration was moderately correlated with TV diameter and 3D-TEE-derived TV annular area but not in paroxAF. On multivariable analysis, AF duration was independently associated with TV annular dilatation even after adjustment for RA/RVESA ratio and tricuspid regurgitation severity (β 0.37 [95% CI: 0.77–1.81]; P < 0.001). Additionally, AF duration with cutoff values of 20 months for predicting TV annular dilatation and 37 months for predicting RA/RVESA ratio > 2.1 had both high diagnostic accuracies among persAF patients (both P < 0.01). AF duration itself is independently associated with right heart remodeling in persAF but not in paroxAF, such as TV annular dilatation and predominant RA remodeling which may lead to subsequent TR progression and adverse outcomes. • Previous studies have suggested that increasing tricuspid regurgitation (TR) severity is associated with worse survival and atrial fibrillation (AF) persisting itself is associated with adverse cardiovascular outcomes; hence it is important to prevent tricuspid valve (TV) remodeling and progression of atrial functional TR (AF-TR) to improve prognosis. • In this study, AF duration itself is one of independent determinants of TV annular dilatation only in patients with persistent AF, not in paroxysmal AF. • Significant TV annular dilatation (TV annular area index ≥840 mm2/m2) and predominant right atrial remodeling (right atrium area-to-right ventricle end-systolic area ratio > 2.1) has already initiated at AF duration of 20 months and 37 months, respectively. • Based on the relationship between AF duration and right heart remodeling to progress along the time sequence in this study, early rhythm control may be important in the management of AF patients to prevent right heart structure remodeling leading to the incidence of AF-TR. [ABSTRACT FROM AUTHOR]

Background: Currently the surgical decision-making of tricuspid annuloplasty for tricuspid regurgitation (TR) depends on the measurements of tricuspid annular diameter (TAD) obtained in the apical 4-chamber view on 2-dimensional transthoracic echocardiography (2DTTE). However, whether shape and orientation of the dilated annulus would affect the accuracy of 2DTTE-TAD is unknown. Methods: A total of 185 patients with moderate to severe TR with various underlying causes and 22 controls underwent 2DTTE and 3DTEE assessment of the tricuspid valve (TV). The 3DTEE-TAD defined as the maximum diameter and tricuspid annular (TA) eccentricity index defined as the minimum diameter/maximum diameter ratio, were obtained on mid-diastole frame. As an index of TA orientation, the angle between the 3D TEE-TAD and the interatrial septum parallel to the vertical axis (α°) was measured (Figure 1). Results: Compared with normal TV, TR subgroups had a larger α° irrespective of its etiology (all P <0.05 after multiple comparison) with most frequency of patients with posteriorly orientated TA in atrial fibrillation-TR (normal control, 49±10°; primary TR, 81±36°; left-sided heart disease-TR, 66±28°; atrial fibrillation-TR, 103±35°; Figure 2). An excellent correlation was found between 3DTEE-TAD and 2DTTE-TAD (r=0.88, P <0.001); but 2DTTE-TAD was significantly smaller than 3DTEE-TAD (36.6±5.3 vs 40.6±5.6 mm; P <0.001; bias, 4.0±2.7 mm; limits of agreement, –1.3 to 9.3 mm). After multivariate adjustment, a larger 3DTEE-TAD (P <0.001) and larger absolute value of 90–α° (P <0.001) were independent determinants of the bias between 3DTEE-TAD and 2DTTE-TAD. Notably, a strong curved correlation between TA orientation and the bias was observed (r=0.57, P <0.001; Figure 2). Conclusion: This 3DTEE study demonstrates various TA orientation and its impact on the measurement of 2DTTE-TAD in patients with TR, highlighting the need for reappraising methodology for the measurement of TAD. [ABSTRACT FROM AUTHOR]

Background: Exercise-induced mitral regurgitation (MR) is an important prognosticator regardless of MR etiology. However, different mechanisms of exercise-induced MR according to MR subgroups remain unknown. Measured using three-dimensional (3D) transesophageal echocardiography (TEE), 3D vena contracta area (3D-VCA) has shown to be an accurate parameter to quantify MR. The aims of this study were (1) to investigate the increase between resting 3D-VCA and 3D-VCA after hand-grip exercise (Δ3D-VCA), (2) to compare the Δ3D-VCA between degenerative and functional MR. Methods: Fifty-seven symptomatic patients with moderate to severe MR (degenerative MR, n=30; functional MR, n=27) were prospectively enrolled between May 2017 and May 2018. Using 3D TEE, MV geometry (annular diameters, annular height, averaged tenting height, 3D-VCA) and hemodynamic status were measured immediately before and after 5-minute hand-grip exercise (Figure 1). Results: There was no significant difference in 3D-VCA at rest (38.7±17.2 mm2 in degenerative MR vs. 34.4±14.3 mm2 in functional MR, P =0.32). After hand-grip exercise, the 3D-VCA increased significantly in both MR subgroups, but a larger Δ3D-VCA was observed in functional MR (16.0±9.8 mm2 vs. 5.9±4.7 mm2, P <0.001; Figure 2). In functional MR, a significant augmentation in averaged tenting height was observed after hand-grip exercise (P <0.001). Univariable linear regression analysis revealed the association of Δ3D-VCA with averaged tenting height in functional MR and with blood pressure in degenerative MR (both P <0.01). Conclusions: Hand-grip exercise alters MV geometry and causes an exacerbation of MR. The effects of changes in MV geometry and their association with increased MR severity differs between degenerative and functional MR. [ABSTRACT FROM AUTHOR]