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Paradoxical Low-Flow Low-Gradient Aortic Valve Stenosis Presented Similar Severity of Heart Failure to Normal-Flow High-Gradient Aortic Valve Stenosis
The 20th Annual Scientific Meeting
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JHFS
S183
O17-2
O17-5
Leaflet Remodeling in Functional Mitral Regurgitation Nobuyuki Kagiyama1, Misako Toki2, Chihiro Karashima1, Hideta Takushi1, Akihiro Hayashida1, Kiyoshi Yoshida1; 1Department of Cardiology, The Sakakibara Heart Institute of Okayama, Okayama, Japan; 2Department of Clinical Laboratory, The Sakakibara Heart Institute of Okayama, Okayama, Japan
Assessment of Systolic Dysfunction in Patients with Aortic Stenosis and Preserved Ejection Fraction Using Mitral Annular Displacement by Tissue-Tracking Echocardiography Takeshi Hozumi, Hiroki Emori, Kazushi Takemoto, Makoto Orii, Keishi Ohkochi, Yoshiki Matsuo, Yasushi Ino, Takashi Kubo, Atsushi Tanaka, Takashi Akasaka; Department of Cardiology, Wakayama Medical University, Wakayama, Japan
Background: Functional mitral regurgitation (FMR) due to left ventricular dilatation is one of the biggest concerns in heart failure. Recently, mitral leaflet has been reported to adapt to the mitral annular and left ventricular dilatation. We thought to investigate leaflet remodeling in FMR in our institute. Methods: We analyzed threedimensional datasets of mitral valve in 24 patients with FMR and 13 normal subjects. Total leaflet area was measured in end-diastole and closure leaflet area was measured in systole. The ratio of total leaflet area to closure leaflet area (TLA/CLA) was calculated as a factor representing leaflet remodeling. Results: Although total leaflet area was significantly larger in FMR group than normal subjects (992 ± 179 vs. 767 ± 154 mm2/m2, P < .001), the difference in closure area was much larger (FMR 848 ± 175 vs. normal subjects 533 ± 98 mm2/m2, P < .001). As a result, TLA/CLA was significantly smaller in FMR group (1.18 ± 0.1 vs. 1.44 ± 0.21, P < .001), indicating the leaflet size is not sufficient. Conclusions: In patients with FMR, although total leaflet area increased, it was not sufficient. These results provide important insight in the mechanism of FMR and a biological or interventional therapeutic target for leaflet remodeling should be studied in the future.
Backgraound: Previous studies have reported that left ventricular global longitudinal strain (GLS) can be used for detection of longitudinal dysfunction in patients with severe aortic stenosis (AS) and preserved ejection fraction (EF). Tissue-tracking echocardiography provides rapid assessment of mitral annular displacement (MAD). Thus, we examined whether MAD measurements can be used as an alternative index of GLS for longitudinal dysfunction in patients with severe AS and preserved EF. Methods: The study population consists of 48 subjects with preserved EF; 37 with severe AS and 11 without AS. GLS was assessed by tissue-tracking echocardiography. MAD was automatically and quickly evaluated in 4-chamber view. Results: Both GLS and %MAD were successfully assessed in 42 of 48 subjects (88%). There was a good correlation between GLS and %MAD (r = −0.83). In patients with AS (n = 31), a good correlation was shown between GLS and %MAD (r = −0.82). Among the patients with AS, %MAD was significantly lower in patients with LV-GLS > −16% than that in patients with LV-GLS < −16% (8.0 ± 2.0 vs 12.4 ± 2.1%, P < .01). Conclusions: In patients with severe AS and preserved EF, %MAD by echocardiography correlated well with standard GLS. %MAD may be used as an alternative index of LV-GLS for longitudinal LV dysfunction in these patients.
O17-3 Echocardiographic Indices for Predicting Worse Outcomes after Surgical Treatment of Functional Mitral Regurgitation in Patients with Non-Ischemic Cardiomyopathy Kaoruko Sengoku1, Hidetaka Kioka1, Tomohito Ohtani1, Osamu Yamaguchi1, Satoshi Nakatani2, Yoshiki Sawa3, Yasushi Sakata1; 1Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan; 2Department of Functional Diagnostic Science, Osaka University Graduate School of Medicine, Osaka, Japan; 3 Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
O17-6 Paradoxical Low-Flow Low-Gradient Aortic Valve Stenosis Presented Similar Severity of Heart Failure to Normal-Flow High-Gradient Aortic Valve Stenosis Masayoshi Oikawa, Atsushi Kobayashi, Akiomi Yoshihisa, Takayoshi Yamaki, Hiroyuki Kunii, Kazuhiko Nakazato, Hitoshi Suzuki, Shu-Ichi Saitoh, Yasuchika Takeishi; Department of Cardiovascular Medicine
Background: Previous reports demonstrated that the presence of functional mitral regurgitation (fMR) is associated with poor prognosis in non-ischemic cardiomyopathy. Although surgical treatment is one of the options for these patients, the pre-operative indices for identifying high-risk patient after surgery has not been established. Methods: Consecutive 25 patients with non-ischemic cardiomyopathy who underwent surgical treatment of fMR (mitral valve plasty n = 9, mitral valve replacement n = 16) were retrospectively studied. The association between cardiac events (heart failure re-hospitalization, left ventricular (LV) assist device implantation or cardiac death) and pre-operative indices assessed by echocardiography were analyzed. Results: About half of patients (n = 13) had no cardiac events within 1-year after surgery. They had larger LV outflow tract velocity time integral (10.9 ± 2.1 vs 8.7 ± 1.8 cm, P < .05) and greater LV dimension at diastole (77.8 ± 5.6 vs. 72.2 ± 7.3 mm, P < .05) and at systole (70.8 ± 6.1 vs. 65.4 ± 6.8 mm, P < .05) than the patients with cardiac events, while there were no significant differences between two groups in LV ejection fraction, left atrial diameter, tenting height, tissue Doppler index E/e‘ ratio, and tricuspid regurgitation pressure gradient. Conclusion: Pre-operative LV dimensions and stroke volume are likely to be predictive for post-operative outcomes in patients with non-ischemic fMR.
Paradoxical low-flow low-gradient (PLFLG) aortic valve stenosis (AS) is characterized as low stroke volume and low-pressure gradient despite preserved left ventricular ejection fraction (LVEF). The treatment of PLFLG AS is still under discussion because its clinical characteristics remain unclear. We analyzed 63 patients with severe AS, and they were divided into three groups based on findings of echocardiography and cardiac catheterization: normal-flow high-gradient (NFHG) group (aortic peak velocity (A vel) > 4.0 m/s, LVEF >40%, n = 44), low-flow low-gradient (LFLG) group (A vel < 4.0m/ s, LVEF < 40%, n = 11), and PLFLG group (stroke volume index <35 ml/m2, A vel < 4.0 m/s, LVEF > 50%, n = 8). LFLG group showed higher pulmonary capillary wedge pressure (PCWP) (15 [8.8–32.5] mmHg vs. 10 [7.0–12.5] mmHg, P < .05), mean pulmonary artery pressure (mPAP) (25 [16–45] mmHg vs. 16 [14–20] mmHg, P < .05), and B-type natriuretic peptide (BNP) (879 [220–2607] pg/ml vs. 171 [61–419] pg/ ml, P < .01) compared to NFHG group, indicating that LFLG group showed more severe heart failure than NFHG group. In contrast, PLFLG group showed similar PCWP, mPAP, and BNP compared to NFHG group. Although PLFLG group was exposed to lower pressure gradient than NFHG group, the severity of heart failure was similar to NFHG group. We conclude that PLFLG group possessed similar severity of heart failure to NFHG group despite of low-pressure gradient.
O17-4
O18-1
Estimation of Mitral Regurgitation Severity with Left Ventricular Early InflowOutflow Index Aika Matsumoto, Akiko Goda, Masataka Sugahara, Kumiko Masai, Yuko Soyama, Tohru Masuyama, Toshiaki Mano; Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicne
Launch of the Heart Failure Medical Team and Cardiac Rehabilitation in Our Hospital Yoshihiro Masaki1, Tomoya Tsuchida2, Ippei Nakano1, Kenichi Matsutani1, Toshihiro Shimizu1, Takayuki Hirabayashi1; 1Cardiovascular Medicine, Sunagawa City Medical Center, Hokkaido, Japan; 2Nursing Department, Sunagawa City Medical Center, Hokkaido, Japan
Background: There are some difficulties for the quantification of mitral regurgitation (MR) severity. Recently, left ventricular early inflow-outflow index (LVEIO index), which is calculated by dividing the mitral E-wave velocity by the LV outflow velocity time integral has been proposed as a simple method. The aim of this study is to determine the ideal threshold of LVEIO index to diagnose severe MR. Methods and Results: We reviewed 76721 transthoracic echocardiography reports at the hospital of Hyogo College of Medicine from 2008 to 2015. MR severities were evaluated according to the guideline of the American society of echocardiography. We excluded the cases with moderate or severe aortic valve regurgitation, any mitral stenosis. We evaluated 18692 cases and classified them as no, trivial, or mild (Grade 0/1), moderate (Grade 2), moderate to severe (Grade 3), and severe MR (Grade 4). The optimal threshold of LVEIO was 5.4 to distinguish moderate to severe or severe MR from non-severe MR (sensitivity 84%, specificity 91%). There were no differences in the significance of LVEIO index between the cases with reduced LV ejection fraction (<50%) and preserved LV ejection fraction (≥50%). The group of secondary MR has higher LVEIO than those of primary MR.
It is very important for the heart failure patients that team medical approach and cardiac rehabilitation by the various occupations. So we have launched heart failure medical team and cardiac rehabilitation in our hospital. The heart failure team members are ward nursing staff, outpatient nursing staff, ward pharmacists, physical therapists, dietitians and cardiologists. Certified nurse of chronic heart failure nursing is a central personage of the team, and he also manages a nursing outpatient care. Our hospital is in the Sorachi region of Hokkaido, where aging and depopulation is in progress. There is a large number of elderly people living alone, so medical social workers of community cooperative section also have very important role. A physical therapist who has the license of heart rehabilitation guidance person has been adopted, then cumulative total number of outpatient of rehabilitation has increased from about 450 people in 2014 to about 1200 people in 2015, and also cumulative total number of rehabilitation units has increased from about 500 units to 2400 units. There are many patients difficult to visit our hospital regularly, because our medical district is widely distributed. And there are very few hospital who have done cardiac rehabilitation in the rural
•
JHFS
S183
O17-2
O17-5
Leaflet Remodeling in Functional Mitral Regurgitation Nobuyuki Kagiyama1, Misako Toki2, Chihiro Karashima1, Hideta Takushi1, Akihiro Hayashida1, Kiyoshi Yoshida1; 1Department of Cardiology, The Sakakibara Heart Institute of Okayama, Okayama, Japan; 2Department of Clinical Laboratory, The Sakakibara Heart Institute of Okayama, Okayama, Japan
Assessment of Systolic Dysfunction in Patients with Aortic Stenosis and Preserved Ejection Fraction Using Mitral Annular Displacement by Tissue-Tracking Echocardiography Takeshi Hozumi, Hiroki Emori, Kazushi Takemoto, Makoto Orii, Keishi Ohkochi, Yoshiki Matsuo, Yasushi Ino, Takashi Kubo, Atsushi Tanaka, Takashi Akasaka; Department of Cardiology, Wakayama Medical University, Wakayama, Japan
Background: Functional mitral regurgitation (FMR) due to left ventricular dilatation is one of the biggest concerns in heart failure. Recently, mitral leaflet has been reported to adapt to the mitral annular and left ventricular dilatation. We thought to investigate leaflet remodeling in FMR in our institute. Methods: We analyzed threedimensional datasets of mitral valve in 24 patients with FMR and 13 normal subjects. Total leaflet area was measured in end-diastole and closure leaflet area was measured in systole. The ratio of total leaflet area to closure leaflet area (TLA/CLA) was calculated as a factor representing leaflet remodeling. Results: Although total leaflet area was significantly larger in FMR group than normal subjects (992 ± 179 vs. 767 ± 154 mm2/m2, P < .001), the difference in closure area was much larger (FMR 848 ± 175 vs. normal subjects 533 ± 98 mm2/m2, P < .001). As a result, TLA/CLA was significantly smaller in FMR group (1.18 ± 0.1 vs. 1.44 ± 0.21, P < .001), indicating the leaflet size is not sufficient. Conclusions: In patients with FMR, although total leaflet area increased, it was not sufficient. These results provide important insight in the mechanism of FMR and a biological or interventional therapeutic target for leaflet remodeling should be studied in the future.
Backgraound: Previous studies have reported that left ventricular global longitudinal strain (GLS) can be used for detection of longitudinal dysfunction in patients with severe aortic stenosis (AS) and preserved ejection fraction (EF). Tissue-tracking echocardiography provides rapid assessment of mitral annular displacement (MAD). Thus, we examined whether MAD measurements can be used as an alternative index of GLS for longitudinal dysfunction in patients with severe AS and preserved EF. Methods: The study population consists of 48 subjects with preserved EF; 37 with severe AS and 11 without AS. GLS was assessed by tissue-tracking echocardiography. MAD was automatically and quickly evaluated in 4-chamber view. Results: Both GLS and %MAD were successfully assessed in 42 of 48 subjects (88%). There was a good correlation between GLS and %MAD (r = −0.83). In patients with AS (n = 31), a good correlation was shown between GLS and %MAD (r = −0.82). Among the patients with AS, %MAD was significantly lower in patients with LV-GLS > −16% than that in patients with LV-GLS < −16% (8.0 ± 2.0 vs 12.4 ± 2.1%, P < .01). Conclusions: In patients with severe AS and preserved EF, %MAD by echocardiography correlated well with standard GLS. %MAD may be used as an alternative index of LV-GLS for longitudinal LV dysfunction in these patients.
O17-3 Echocardiographic Indices for Predicting Worse Outcomes after Surgical Treatment of Functional Mitral Regurgitation in Patients with Non-Ischemic Cardiomyopathy Kaoruko Sengoku1, Hidetaka Kioka1, Tomohito Ohtani1, Osamu Yamaguchi1, Satoshi Nakatani2, Yoshiki Sawa3, Yasushi Sakata1; 1Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan; 2Department of Functional Diagnostic Science, Osaka University Graduate School of Medicine, Osaka, Japan; 3 Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
O17-6 Paradoxical Low-Flow Low-Gradient Aortic Valve Stenosis Presented Similar Severity of Heart Failure to Normal-Flow High-Gradient Aortic Valve Stenosis Masayoshi Oikawa, Atsushi Kobayashi, Akiomi Yoshihisa, Takayoshi Yamaki, Hiroyuki Kunii, Kazuhiko Nakazato, Hitoshi Suzuki, Shu-Ichi Saitoh, Yasuchika Takeishi; Department of Cardiovascular Medicine
Background: Previous reports demonstrated that the presence of functional mitral regurgitation (fMR) is associated with poor prognosis in non-ischemic cardiomyopathy. Although surgical treatment is one of the options for these patients, the pre-operative indices for identifying high-risk patient after surgery has not been established. Methods: Consecutive 25 patients with non-ischemic cardiomyopathy who underwent surgical treatment of fMR (mitral valve plasty n = 9, mitral valve replacement n = 16) were retrospectively studied. The association between cardiac events (heart failure re-hospitalization, left ventricular (LV) assist device implantation or cardiac death) and pre-operative indices assessed by echocardiography were analyzed. Results: About half of patients (n = 13) had no cardiac events within 1-year after surgery. They had larger LV outflow tract velocity time integral (10.9 ± 2.1 vs 8.7 ± 1.8 cm, P < .05) and greater LV dimension at diastole (77.8 ± 5.6 vs. 72.2 ± 7.3 mm, P < .05) and at systole (70.8 ± 6.1 vs. 65.4 ± 6.8 mm, P < .05) than the patients with cardiac events, while there were no significant differences between two groups in LV ejection fraction, left atrial diameter, tenting height, tissue Doppler index E/e‘ ratio, and tricuspid regurgitation pressure gradient. Conclusion: Pre-operative LV dimensions and stroke volume are likely to be predictive for post-operative outcomes in patients with non-ischemic fMR.
Paradoxical low-flow low-gradient (PLFLG) aortic valve stenosis (AS) is characterized as low stroke volume and low-pressure gradient despite preserved left ventricular ejection fraction (LVEF). The treatment of PLFLG AS is still under discussion because its clinical characteristics remain unclear. We analyzed 63 patients with severe AS, and they were divided into three groups based on findings of echocardiography and cardiac catheterization: normal-flow high-gradient (NFHG) group (aortic peak velocity (A vel) > 4.0 m/s, LVEF >40%, n = 44), low-flow low-gradient (LFLG) group (A vel < 4.0m/ s, LVEF < 40%, n = 11), and PLFLG group (stroke volume index <35 ml/m2, A vel < 4.0 m/s, LVEF > 50%, n = 8). LFLG group showed higher pulmonary capillary wedge pressure (PCWP) (15 [8.8–32.5] mmHg vs. 10 [7.0–12.5] mmHg, P < .05), mean pulmonary artery pressure (mPAP) (25 [16–45] mmHg vs. 16 [14–20] mmHg, P < .05), and B-type natriuretic peptide (BNP) (879 [220–2607] pg/ml vs. 171 [61–419] pg/ ml, P < .01) compared to NFHG group, indicating that LFLG group showed more severe heart failure than NFHG group. In contrast, PLFLG group showed similar PCWP, mPAP, and BNP compared to NFHG group. Although PLFLG group was exposed to lower pressure gradient than NFHG group, the severity of heart failure was similar to NFHG group. We conclude that PLFLG group possessed similar severity of heart failure to NFHG group despite of low-pressure gradient.
O17-4
O18-1
Estimation of Mitral Regurgitation Severity with Left Ventricular Early InflowOutflow Index Aika Matsumoto, Akiko Goda, Masataka Sugahara, Kumiko Masai, Yuko Soyama, Tohru Masuyama, Toshiaki Mano; Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicne
Launch of the Heart Failure Medical Team and Cardiac Rehabilitation in Our Hospital Yoshihiro Masaki1, Tomoya Tsuchida2, Ippei Nakano1, Kenichi Matsutani1, Toshihiro Shimizu1, Takayuki Hirabayashi1; 1Cardiovascular Medicine, Sunagawa City Medical Center, Hokkaido, Japan; 2Nursing Department, Sunagawa City Medical Center, Hokkaido, Japan
Background: There are some difficulties for the quantification of mitral regurgitation (MR) severity. Recently, left ventricular early inflow-outflow index (LVEIO index), which is calculated by dividing the mitral E-wave velocity by the LV outflow velocity time integral has been proposed as a simple method. The aim of this study is to determine the ideal threshold of LVEIO index to diagnose severe MR. Methods and Results: We reviewed 76721 transthoracic echocardiography reports at the hospital of Hyogo College of Medicine from 2008 to 2015. MR severities were evaluated according to the guideline of the American society of echocardiography. We excluded the cases with moderate or severe aortic valve regurgitation, any mitral stenosis. We evaluated 18692 cases and classified them as no, trivial, or mild (Grade 0/1), moderate (Grade 2), moderate to severe (Grade 3), and severe MR (Grade 4). The optimal threshold of LVEIO was 5.4 to distinguish moderate to severe or severe MR from non-severe MR (sensitivity 84%, specificity 91%). There were no differences in the significance of LVEIO index between the cases with reduced LV ejection fraction (<50%) and preserved LV ejection fraction (≥50%). The group of secondary MR has higher LVEIO than those of primary MR.
It is very important for the heart failure patients that team medical approach and cardiac rehabilitation by the various occupations. So we have launched heart failure medical team and cardiac rehabilitation in our hospital. The heart failure team members are ward nursing staff, outpatient nursing staff, ward pharmacists, physical therapists, dietitians and cardiologists. Certified nurse of chronic heart failure nursing is a central personage of the team, and he also manages a nursing outpatient care. Our hospital is in the Sorachi region of Hokkaido, where aging and depopulation is in progress. There is a large number of elderly people living alone, so medical social workers of community cooperative section also have very important role. A physical therapist who has the license of heart rehabilitation guidance person has been adopted, then cumulative total number of outpatient of rehabilitation has increased from about 450 people in 2014 to about 1200 people in 2015, and also cumulative total number of rehabilitation units has increased from about 500 units to 2400 units. There are many patients difficult to visit our hospital regularly, because our medical district is widely distributed. And there are very few hospital who have done cardiac rehabilitation in the rural