This thesis describes the additional value of advanced echocardiographic techniques in patients with primary cardiac disease, resulting in mitral regurgitation, and secondary cardiac disease caused... Show moreThis thesis describes the additional value of advanced echocardiographic techniques in patients with primary cardiac disease, resulting in mitral regurgitation, and secondary cardiac disease caused by a systemic disease. In this thesis we focussed on patients with mitral regurgitation, specifically primary MR and functional MR (FMR), and patients with Systemic Sclerosis (SSc). The general introduction provides a background of MR and cardiac involvement in SSc and how conventional 2-dimensional (2D) echocardiography is currently used. The potential role of 2D speckle tracking echocardiography and 3-dimensional (3D) echocardiography together with customized software to create 4-dimensional (4D) mitral valve models is introduced. This thesis aims to provide new insights in diagnosis, disease progression and risk stratification in patients with MR and patients with SSc with the implementation of advanced echocardiographic techniques. Show less
Stassen, J.; Namazi, F.; Bijl, P. van der; Wijngaarden, S.E. van; Kamperidis, V.; Marsan, N.A.; ... ; Bax, J.J. 2022
Background: Left atrial (LA) size is a marker of disease severity and is related to worse outcomes in secondary mitral regurgitation (MR). The prognostic value of LA function assessed by LA... Show moreBackground: Left atrial (LA) size is a marker of disease severity and is related to worse outcomes in secondary mitral regurgitation (MR). The prognostic value of LA function assessed by LA reservoir strain (LARS), however, remains unknown. The aim of this study was to investigate the prognostic implications of LARS in patients with significant secondary MR. Methods: LARS was evaluated using speckle-tracking echocardiography in patients with more than mild (grade >= 2) secondary MR. The population was divided into two groups according to the median LARS value (9.8%). The primary end point was all-cause mortality. Results: A total of 666 patients (mean age, 66 +/- 11 years; 68% men) were included. On multivariable analysis, more severe MR was independently associated with more impaired LARS (LARS < 9.8%; odds ratio, 0.419; 95% CI, 0.249-0.704; P = .001). During a median follow-up period of 5 years (interquartile range, 2-10), 383 patients (58%) died. Patients with LARS < 9.8% had significantly lower survival rates at 1-, 2-, and 5-year follow-up (85%, 70%, and 45%, respectively) compared with patients with LARS >= 9.8% (96%, 93%, and 78%, respectively; P<.001). After multivariable adjustment (including LA volume and left ventricular global longitudinal strain), more preserved LARS (>= 9.8%; hazard ratio, 0.499; 95% CI, 0.386-0.645; P<.001) was independently associated with lower all-cause mortality. LARS provided incremental prognostic value over LA volume and left ventricular global longitudinal strain. Conclusions: LARS is independently associated with all-cause mortality in patients with significant secondary MR and has incremental prognostic value over LA volume and left ventricular global longitudinal strain. LARS may improve risk stratification of patients with secondary MR. Show less
Namazi, F.; Bijl, P. van der; Vo, N.M.; Wijngaarden, S.E. van; Marsan, N.A.; Delgado, V.; Bax, J.J. 2021
Aims Secondary mitral regurgitation (MR) is more frequent in men than in women. However, little is known about differences in prognosis between men and women with secondary MR. The objective of... Show moreAims Secondary mitral regurgitation (MR) is more frequent in men than in women. However, little is known about differences in prognosis between men and women with secondary MR. The objective of this study is to investigate the sex distribution of secondary MR and the prognostic differences between sexes.Methods Patients with significant secondary MR, of both ischaemic and non-ischaemic aetiologies, were identified through the departmental electronic patient files and retrospectively analysed. The primary endpoint was all-cause mortality.Results A total of 698 patients (mean age 66 +/- 11 years) with significant secondary MR were included: 471 (67%) men and 227 (33%) women. Ischaemic heart failure was significantly more common in men (61%), whereas non-ischaemic heart failure was more prevalent in women (63%). Women had significantly smaller left ventricular (LV) volumes when compared with men and more preserved LV systolic function when assessed with LV global longitudinal strain (GLS; 8.5 +/- 4.1% vs. 7.5 +/- 3.6%; P = 0.004). Women more often underwent surgical mitral valve repair (34%) when compared with men (26%), although no differences were observed for transcatheter mitral valve repair. During a median follow-up of 57 [interquartile range 29-110] months, 373 (53%) patients died. Women showed significantly lower mortality rates at 1-, 2- and 5-year follow-up (9%, 16% and 33% vs. 10%, 20% and 42%) when compared with men (P = 0.001).Conclusions Significant secondary MR is more frequently observed in men as compared with women and is associated with worse prognosis. Show less
The aim of this study is to evaluate the agreement between three-dimensional (3D) transesophageal echocardiography (TEE) and multidetector computed tomography (MDCT) for assessing mitral annular ... Show moreThe aim of this study is to evaluate the agreement between three-dimensional (3D) transesophageal echocardiography (TEE) and multidetector computed tomography (MDCT) for assessing mitral annular (MA) dimensions. A total of 105 patients (79 +/- 9 years old, 52% male) who underwent clinically indicated 3D TEE and MDCT feasible for MA geometrical assessment were included. Using dedicated semi-automated postprocessing software, MA geometry, including mitral annular area (MAA), perimeter, septal-lateral (SL) diameter, and inter-trigonal (TT) diameter, was evaluated using 3D TEE and MDCT. Compared to 3D TEE, MAA, perimeter, and SL distance measured on MDCT data were larger (9.9 +/- 3.0 vs. 9.3 +/- 3.1 cm(2) for MAA; 115 +/- 18 vs. 108 +/- 18 mm for perimeter; and 35 +/- 5 vs. 32 +/- 5 cm for SL distance, all p < 0.001). By contrast, the TT distance was comparable between MDCT and 3D TEE (26 +/- 4 vs. 26 +/- 4 cm, p = 0.258). The correlations of all the MA dimensions were good to excellent between the two modalities (R = 0.911 for MAA, 0.890 for perimeter, 0.739 for TT distance, and 0.857 for SL distance, respectively, all p < 0.001). This study showed good agreement between 3D TEE- and MDCT-derived MA measurements although MDCT systematically provided larger MAA, perimeter, and SL distance compared with 3D TEE. Show less
The development of transcatheter mitral valve replacement therapies requires accurate post-processing analysis tools to provide D-shaped mitral annulus dimensions from 3-dimensional (3D) data. The... Show moreThe development of transcatheter mitral valve replacement therapies requires accurate post-processing analysis tools to provide D-shaped mitral annulus dimensions from 3-dimensional (3D) data. The agreement between two semi-automated, software packages to process 3D transesophageal echocardiography (TEE) data for the measurement of the mitral valve annulus dimensions was evaluated. 3DTEE data of patients with moderate-severe mitral regurgitation (MR) were postprocessed with semi-automated, vendor-independent (VI) software and vendor-specific (VS) software. Both post-processing software provided key measurements for the selection of transcatheter valve prosthesis size: annulus area, annulus circumference and the septal-to-lateral distance of the annulus. The intertrigonal distance was provided only by the VS software. The inter- and intra-observer agreements were assessed with Bland-Altman analysis. Of 105 patients (63.8 +/- 11 years, 66% male) with MR, 28 had secondary MR, 45 fibroelastic deficiency, and 32 Barlow's disease. Using VS software, the dimensions for the overall population were 16.1 +/- 4.6 cm(2) for annulus area, for circumference 14.4 +/- 1.9 cm, intertrigonal distance 3.4 +/- 0.5 cm and septal-to-lateral distance 3.8 +/- 0.6 cm. Similar dimensions were obtained using VI software: 15.7 +/- 4.6 cm(2) for annulus area, 14.5 +/- 2.0 cm for circumference, and 4.1 +/- 0.6 cm for septal-to-lateral distance. The inter- and intra-observer agreement for both software programs was excellent. In conclusion, current post-processing software programs for 3DTEE data of the mitral valve annulus provide good reproducibility of key measurements to select the transcatheter prosthesis size. Show less
Valvular atrial fibrillation (AF) is defined as AF in the presence of mitral stenosis or mechanical valve prosthesis. However, there are patients with AF who have significant native valvular heart... Show moreValvular atrial fibrillation (AF) is defined as AF in the presence of mitral stenosis or mechanical valve prosthesis. However, there are patients with AF who have significant native valvular heart disease (VHD) others than mitral stenosis that are classified as nonvalvular AF. The characteristics and prognostic implications of these entities have not been extensively studied. Of 1,885 AF patients referred for electrical cardioversion (64 +/- 13years, 71% male), 171 (9.1%) had valvular AF (any grade of mitral stenosis or mechanical/biological valve prostheses) and 1,714 patients were identified as nonvalvular AF, of whom 329 (17.5%) had significant left-sided VHD. Patients with nonvalvular AF but with significant left-sided VHD were older, more frequently women and had more co-morbidities compared with the other groups. Furthermore, nonvalvular AF patients with significant left-sided VHD showed the worst left ventricular systolic function and largest left atrial volumes. During a median follow-up of 64 months (interquartile range: 33 to 96 months), 488 patients presented with the combined endpoint of all-cause mortality, heart failure hospitalization, and ischemic stroke. Patients with nonvalvular AF and with significant left-sided VHD had more events of heart failure whereas patients with valvular AF had higher all-cause mortality events. There were no differences in ischemic stroke events. Type of AF was not associated with outcomes after correcting for echocardiographic variables. In conclusion, the frequency of AF patients with significant VHD is relatively high. The consequences of VHD and AF on cardiac structure and function are more important determinants of adverse outcome than the type of AF. (C) 2020 Elsevier Inc. All rights reserved. Show less
Namazi, F.; Bijl, P. van der; Hirasawa, K.; Kamperidis, V.; Wijngaarden, S.E. van; Mertens, B.; ... ; Bax, J.J. 2020
BACKGROUND Left ventricular (LV) systolic function may be overestimated in patients with secondary mitral regurgitation (MR) when using LV ejection fraction (EF). LV global longitudinal strain (GLS... Show moreBACKGROUND Left ventricular (LV) systolic function may be overestimated in patients with secondary mitral regurgitation (MR) when using LV ejection fraction (EF). LV global longitudinal strain (GLS) is a less load-dependent measure of LV function. However, the prognostic value of LV GLS in secondary MR has not been evaluated. OBJECTIVES This study sought to demonstrate the prognostic value of LV GLS over LVEF in patients with secondary MR. METHODS A total of 650 patients (mean 66 +/- 11 years of age, 68% men) with significant secondary MR were included. The study population was subdivided based on the LV GLS value at which the hazard ratio (HR) for all-cause mortality was >1 using a spline curve analysis (LV GLS <7.0%, impaired LV systolic function vs. LV GLS $7.0%, preserved LV systolic function). The primary endpoint was all-cause mortality. RESULTS During a median follow-up of 56 (interquartile range: 28 to 106 months) months, 334 (51%) patients died. Patients with a more impaired LV GLS showed significantly higher mortality rates at 1-, 2-, and 5-year follow-up (13%, 23%, and 44%, respectively) when compared with patients with more preserved LV systolic function (5%, 14%, and 31%, respectively). On multivariable analysis, LV GLS <7.0% was associated with increased mortality (HR: 1.337; 95% confidence interval: 1.038 to 1.722; p = 0.024), whereas LVEF #30% was not (HR: 1.055; 95% confidence interval: 0.794 to 1.403; p = 0.711). CONCLUSIONS In patients with secondary MR, impaired LV GLS was independently associated with an increased risk for all-cause mortality, whereas LVEF was not. LV GLS may therefore be useful in the risk stratification of patients with secondary MR. (c) 2020 by the American College of Cardiology Foundation. Show less
OBJECTIVES This study sought to investigate whether left ventricular (LV) global longitudinal strain (GLS) is associated with long-term outcome after mitral valve (MV) surgery for primary mitral... Show moreOBJECTIVES This study sought to investigate whether left ventricular (LV) global longitudinal strain (GLS) is associated with long-term outcome after mitral valve (MV) surgery for primary mitral regurgitation (MR) and assess the differences in outcome according to MR etiology: Barlow's disease (BD), fibroelastic deficiency (FED), and forme fruste (FF).BACKGROUND Appropriate timing of MV surgery for primary MR is still challenging and may differ according to the etiology. In these patients, LV-GLS has been proposed as more sensitive measure to detect subtle LV dysfunction as compared with LV ejection fraction.METHODS Echocardiography was performed in 593 patients (64% men, age 65 +/- 12 years) with severe primary MR who underwent MV surgery, including assessment of LV-GLS. The etiology (BD, FED, or FF) was defined based on surgical observation. During follow-up, primary endpoint was all-cause mortality and a secondary endpoint included cardiovascular death, heart failure hospitalizations, and cerebrovascutar accidents.RESULTS During a median follow-up of 6.4 (interquartile range: 3.6 to 10.4) years, 146 patients died (16 within 30 days after surgery), 46 patients were hospitalized for heart failure, and 13 patients had a cerebrovascutar accident. Age (hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 1.05 to 1.11; p < 0.001) and LV-GLS (HR: 1.13; 95% CI: 1.06 to 1.21; p < 0.001) were independently associated with all-cause mortality. Patients with LV-GLS >-20.6% (more impaired) showed significant worse survival than did patients with LV-GLS <=-20.6%; of interest, patients with BD showed similar prognosis compared with FED and FF. In addition, previous atrial fibrillation (HR: 1.70; 95% CI: 1.01 to 2.86; p = 0.045) and LV-GLS (HR: 1.01; 95% CI: 1.01 to 1.15; p = 0.019) were independently associated with the secondary endpoint.CONCLUSIONS LV-GLS is independently associated with all-cause mortality and cardiovascular events after MV surgery for primary MR and might be helpful to guide surgical timing. Importantly, patients with BD showed similar prognosis when corrected for age, compared with patients with FED or FF. (C) 2020 by the American College of Cardiology Foundation. Show less
Objective. Cardiac involvement is a main cause of mortality in systemic sclerosis (SSc). Its detection remains challenging using conventional echocardiography and little is known about its... Show moreObjective. Cardiac involvement is a main cause of mortality in systemic sclerosis (SSc). Its detection remains challenging using conventional echocardiography and little is known about its potential progression. This study assessed changes in cardiac performance over time in a prospective cohort of patients with SSc, including echocardiographic speckle-tracking strain analysis.Methods. The study included 234 patients with SSc [196 women, age 52 +/- 14 yrs, 165 limited SSc, time since diagnosis 5.2 yrs, interquartile range (IQR) 2.9-11.3]. Clinical variables, laboratory tests, pulmonary function tests, and echocardiographic measures were recorded at baseline and followup (median 2.3 yrs, IQR 1.3-3.9). Additionally, left ventricular (LV) systolic function was assessed with global longitudinal strain (GLS) by echocardiographic speckle-tracking analysis.Results. At followup, GLS had significantly worsened (-21% +/- 2 vs -19% +/- 2, p < 0.001) while LV ejection fraction had not changed (62% +/- 7 vs 61% +/- 8, p = 0.124). In particular, 39 patients showed a significant deterioration of GLS as defined by a >= 15% decrease, which was accompanied by a concomitant worsening of proximal muscle weakness, lung fibrosis, renal function, LV diastolic function, and right ventricular systolic function. Baseline variables associated with >= 15% deterioration in GLS were proximal muscle weakness (OR 3.437, 95% CI 1.13-10.43, p = 0.020), decreased DLCO (OR 3.621, 95% CI 1.25-10.51, p = 0.049), and LV diastolic dysfunction (OR 2.378, 95% CI 1.07-5.27, p = 0.033).Conclusion. In patients with SSc, progression of LV systolic dysfunction was demonstrated by GLS but not by LV ejection fraction. Proximal muscle weakness, DLCO, and LV diastolic dysfunction may identify patients at risk for progressive LV systolic dysfunction and in need of closer cardiac monitoring. Show less
