BACKGROUND:Body mass index (BMI) is an independent, predictor of adverse outcomes among patients with cardiovascular diseases. Our aim was to evaluate how BMI modifies the association of severe tricuspid regurgitation (TR) with poor survival. METHODS:Consecutive echocardiographic reports linked to clinical data from a tertiary medical center (2007-2021) were reviewed. BMI was stratified to underweight, normal weight, overweight, and obesity with cutoffs of 18.5, 25, and 30 Kg/m2. Multivariable Cox regression models were applied to calculate adjusted hazard ratios (aHR) for all-cause mortality. RESULTS:The study population included 111,830 patients with a median age of 65 (IQR 52-76) years (58% males), 3436 (3.1%) patients had severe TR. There were 2398 (2%), 40,393 (36%), 43,790 (39%), and 25,249 (24%) individuals with underweight, normal weight, overweight, and obesity, respectively. During a median follow-up of 6 (3-10) years, 29,921 (27%) patients died. There was an interaction between BMI and TR with the outcome (p < 0.01). Severe TR was associated with mortality for patients with normal weight, overweight, and obesity, with an HR of 1.29 (95% CI 1.20-1.39), 1.26 (1.16-1.37), and 1.28 (1.15-1.43), respectively. This association was not evident among patients with underweight with an HR of 0.88 (0.64-1.22). Sub-analysis of hospitalized patients, with adjustment of the model to baseline comorbidities, including frailty, yielded similar point estimates to the main analysis. CONCLUSIONS:The association of severe TR with mortality is modified by BMI group. Severe TR is associated with mortality among patients of all BMI groups, except for individuals with underweight.

Chronic kidney disease (CKD) is a common comorbidity among patients with tricuspid regurgitation, yet its impact on tricuspid regurgitation outcomes is underexplored. This study examines how CKD affects the relationship between severe tricuspid regurgitation and overall survival. This is a retrospective cohort study of all adult patients (> 18 years old) evaluated at the Sheba Medical Center, between 2007 and 2022, who underwent transthoracic echocardiographic evaluation. It is based on the SHEBAHEART big data registry. Sheba Medical Center is the largest hospital in Israel with approximately 115,000 admissions per year. The echocardiographic reports together with the electronic medical records of all patients are the source for this study. Patients with missing creatinine data within one month of their echocardiography study, as well as those who underwent tricuspid regurgitation intervention, were excluded from the study. Patients were categorized into four groups, according to the presence and severity of tricuspid regurgitation and stratified by CKD stage. The primary outcome was all-cause mortality. The study included 78,147 patients (median age 67, IQR 55–78), with 2989 (4

BACKGROUND:Chronic kidney disease (CKD) is a common comorbidity among patients with tricuspid regurgitation, yet its impact on tricuspid regurgitation outcomes is underexplored. This study examines how CKD affects the relationship between severe tricuspid regurgitation and overall survival. METHODS:This is a retrospective cohort study of all adult patients (> 18 years old) evaluated at the Sheba Medical Center, between 2007 and 2022, who underwent transthoracic echocardiographic evaluation. It is based on the SHEBAHEART big data registry. Sheba Medical Center is the largest hospital in Israel with approximately 115,000 admissions per year. The echocardiographic reports together with the electronic medical records of all patients are the source for this study. Patients with missing creatinine data within one month of their echocardiography study, as well as those who underwent tricuspid regurgitation intervention, were excluded from the study. Patients were categorized into four groups, according to the presence and severity of tricuspid regurgitation and stratified by CKD stage. The primary outcome was all-cause mortality. RESULTS:The study included 78,147 patients (median age 67, IQR 55-78), with 2989 (4%) having severe tricuspid regurgitation and 19,910 (25%) with an estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2. Over a median 4-year follow-up, 28,112 patients (36%) died. Both tricuspid regurgitation severity and CKD stage were associated with increased mortality risk (log-rank p < 0.001 for both). Adjusted models showed that compared to the none/trivial group, patients with mild, moderate, and severe tricuspid regurgitation had a 6%, 12%, and 35% higher risk of death, respectively (p < 0.001 for all). The association of tricuspid regurgitation with poor survival was CKD-dependent, with increased mortality risk of 56% vs. 23% among patients with eGFR < 60 vs. eGFR ≥ 60 (p for interaction < 0.001). The interaction analysis was no longer significant when right ventricular function was incorporated into the multivariable model. Subanalysis, limited to patients with isolated tricuspid regurgitation, yielded consistent results. CONCLUSIONS:The association between severe tricuspid regurgitation and poor survival is stronger in advanced CKD patients and may be modulated through right ventricular function.

BACKGROUND:The ratio between early mitral flow wave to early diastolic mitral annulus velocity (E/e' ratio) varies according to age and sex and is associated with mortality in heart failure. We sought to describe the association between E/e' and mortality in patients with no apparent structural or functional cardiac abnormality and explore possible modifiers of this association. METHODS:A retrospective study of 104,315 patients who underwent echocardiographic evaluation during 2009-2021 in the largest tertiary center in Israel. Patients with cancer, ventricular dysfunction, significant valvular or structural heart disease, or evidence of pulmonary hypertension were excluded. RESULTS:The final analysis included 32,836 patients with a median age of 56 (43-66) years, and 13,547 (41%) were female. The median E/e' was 8.3 (6.8-10.3), and 9,306 (28%) had an E/e' >10. During a median follow-up of 5.7 (3.3-8.5) years, 2,396 (7.3%) individuals died. E/e' >10 was associated with mortality (adjusted hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.07-1.27, p<0.001). The mortality risk associated with E/e' >10 was significantly higher in those aged ≤70 (HR 1.26, 95% CI 1.12-1.42, p<0.001), males (HR 1.34, 95% CI 1.19-1.49, p<0.001), a normal left ventricular mass (HR 1.13, 95% CI 1.02-1.24, p = 0.017), and pulmonary artery pressure <30 mmHg (HR 1.18, 95% CI 1.06-1.30, p = 0.003). CONCLUSION:An elevated E/e' is associated with mortality, specifically in younger individuals, males, and those with a normal left ventricular mass and lower pulmonary artery pressure. This suggests that an elevated E/e' might be a marker of subclinical risk in these subgroups. Further studies are needed to identify whether an elevated E/e' is useful in shared decision-making regarding the management of cardiovascular risk factors.

Background: The prevalence of significant Tricuspid Regurgitation (TR) in individuals with Atrial Fibrillation (AF) is notably high. This analysis aimed to investigate the association of AF with TR progression after more than 10 years, and to ascertain influencing factors of this association. Methods: Electrocardiographic reports linked to clinical data (N=52,389; 2007-2012) were reviewed. Only patients with apparently normal left heart and with ECG and echocardiographic reports at baseline and at after a minimum of 5 years were included. The primary outcome was the occurrence of new significant TR in a follow-up echocardiogram. Results: The final study included 5,691 patients with a median age of 62 (IQR: 53-70), 845 (14%) of whom had baseline AF. During a median follow-up period of 12 years, 279 (5%) patients developed significant TR. Patients with AF were 6 times more likely to develop significant TR in a univariate model (95% CI 5.3-6.8,p <.001). A multivariate model demonstrated that AF, older age, female sex and pulmonary pressures were all associated with increased risk of TR progression (p<.001 for all). The association of AF with future TR was age-dependent such that among patients older than 60, AF was associated with 3.6-fold increased risk compared with 4.5-fold increased risk among younger adults (p for interaction=0.01). During follow up, 1,197 (21%) patients died. Kaplan-Meier analysis revealed increased mortality risk with significant TR and/or AF (log-rank p<.001 for both). Multiarvariate Cox analysis demonstrated that compared to significant TR patients without AF, the combination of TR and AF was associated with a significant 42% higher risk of death during follow up (p=0.04). Conclusions: The association of AF with TR progression after more than 10 years of follow up is more prominent among younger patients. This emphasize the importance of TR screening in AF patients and implementing interventions to mitigate TR progression and improve outcomes.

Background: The aim of this study was to evaluate left ventricular mechanical activation pattern by speckle tracking echocardiography (STE) as a predictor of response to cardiac resynchronization therapy (CRT) in patients with heart failure. Methods: Echocardiography was performed during no pacing, right ventricular pacing (RVP), biventricular pacing (BVP) and multipolar pacing (MPP) immediately after CRT implantation in 16 patients at a single centre. Seven patients were diagnosed as responders and 9 patients as non-responders after 6 months of standard CRT pacing. All had adequate short axis views, and 1 CRT responder and 2 CRT non-responders had limited longitudinal views. Results: Longitudinal and circumferential global strain (GS) and global strain rate (GSR) or their change analysis, did not yield any CRT response prediction. However, the longitudinal BVP/RVP GS ratio was significantly higher in the responder group (1.32 ± 0.2%, 2.0 ± 0.4% and 1.9 ± 0.4%), compared with the non-responder group (1.06 ± 0.2%, 1.1 ± 0.4% and 1.2 ± 0.4%) in the apical two-chamber, APLAX and four-chamber views, respectively. Similarly, the longitudinal BVP/RVP GSR at active systolic phase (GSRs) was significantly higher in the responder group (1.9 ± 0.9% and 1.7 ± 0.4%) compared with the non-responder group (1.0 ± 0.4% and 1.1 ± 0.2%) in the apical APLAX and four-chamber views, respectively. Measurements of the strain delay index showed predictive power regarding CRT response in non-paced patients. Conclusion: Post implantation, longitudinal BVP/RVP GS and GSRs ratios of 1.4% and above may be useful as a CRT response prediction tool. Furthermore, our findings support the usefulness of strain delay index prior to CRT implantation in non-paced patients.

The Norton score is a well‐known scale to assess frailty. Frailty and a low Norton score are associated with complications and mortality in hospitalized patients. We aimed to evaluate whether a low Norton score is associated with surgical complications and death after aortic valve replacement (AVR).

BACKGROUND AND AIMS:Renal function plays an important role in the management of patients referred for coronary artery bypass grafting (CABG). Current data is insufficient for precise risk stratification using the estimated glomerular filtration rate (eGFR).METHODS:This retrospective study includes 3744 consecutive patients who underwent CABG between 2004 and 2020. We assessed five different eGFR formulas: Cockcroft-Gault (CG), modification of diet in renal disease (MDRD), chronic kidney disease Epidemiology Collaboration (CKD-EPI), Mayo, and inulin clearance-based (IB).RESULTS:The Mayo formula yielded the highest mean eGFR (90 ± 24 ml/min per 1.73 m2 ) and CKD-EPI the lowest (74 ± 21 ml/min per 1.73 m2 ). As a result, more patients were classified as having a normal renal function (57%) with the Mayo formula as compared with the others. Using MDRD as the reference formula, there was a significant and stronger correlation between the values obtained from the CKD-EPI (r = .95, p < .001) and Mayo (Mayo: r = .87, p < .001) compared to the IB (r = .8, p < .001) and CG (r = .79, p < .001) formulas. Multivariable analysis demonstrated that decreased renal function is an independent predictor of 10-year mortality in all five formulas, with risk increasing by 13-17% for each 10-unit decrease in eGFR. Despite the similarities between the formulas, the ability to predict mortality was highest in the Mayo formula and lowest in the CG and IB.CONCLUSIONS:Our data suggest that the Mayo formula may be superior to the other formulas in prognosticating mortality after CABG. We have shown that the Mayo equation classified fewer individuals as having renal dysfunction and more accurately categorized the risk for mortality than did all other formulas.

OBJECTIVES:Significant functional tricuspid regurgitation (TR) should be corrected in patients undergoing surgery for left-sided valvular diseases. We hypothesized that ring type may affect outcomes in tricuspid annuloplasty. Herein, we report our experience with three-dimensional semi-rigid rings compared to open simple-band annuloplasty.METHODS:This is a retrospective study that included all patients who underwent tricuspid annuloplasty concomitant to left-sided valvular surgery. The study's main outcome measure was long-term recurrent TR probability.RESULTS:Of the 781 study patients, 611 (78%) underwent annuloplasty using flexible band and 170 (22%) underwent rigid ring implantation. Early mortality did not differ significantly between the rigid and flexible groups (4.4% vs 4.1%, P = 1.000). Long-term mortality was similar between the groups [hazard ratio (HR) 0.97, 95% confidence interval (CI) 0.69-1.36, P = 0.847]. At a mean follow-up of 62 (50) months, freedom from TR grade 3+/4+ was 96.4% and 96.7% in the rigid and flexible groups, respectively (HR 1.41, 95% CI 0.55-3.61, P = 0.476). Furthermore, 2.4% of the rigid and 1.3% of the flexible groups required reoperation (HR 1.01, 95% CI 0.21-4.82, P = 0.988). Multivariable analysis demonstrated that rheumatic valve aetiology (HR 1.92, CI 1.04-2.98, P = 0.042) and mitral stenosis (HR 1.44, CI 1.01-2.2, P = 0.044) were predictors for recurrent TR (3+/4+). Ring type was not associated with recurrence (HR 0.86, 95% CI 0.3-2.47, P = 0.787).CONCLUSIONS:Open bands performed at least as well as three-dimensional rings. Our results suggest that late clinical results of tricuspid annuloplasty depend on left-sided pathology and patient factors and less on the type of ring used.

Background Several studies have examined hospitalizations among patients with adult congenital heart disease (ACHD). Few investigated other services or utilization patterns. Our aim was to study service utilization patterns and predictors among patients with ACHD. Methods and Results We identified 11 653 patients with ACHD aged ≥18 years (median, 47 years), through electronic records of 2 large Israeli healthcare providers (2007–2011). The association between patient, disease, and sociogeographic characteristics and healthcare resource utilization were modeled as recurrent events accounting for the competing death risk. Patients with ACHD had high healthcare utilization rates compared with the general population. The highest standardized service utilization ratios (SSRs) were found among patients with complex congenital heart disease including primary care visits (SSR, 1.53; 95% CI, 1.47–1.58), cardiology outpatient visits (SSR, 5.17; 95% CI, 4.69–5.64), hospitalizations (SSR, 6.68; 95% CI, 5.82–7.54), and days in hospital (SSR, 15.37; 95% CI, 14.61–16.12). Adjusted resource utilization hazard increased with increasing lesion complexity. Hazard ratios (HRs) for complex versus simple disease were: primary care (HR, 1.14; 95% CI, 1.06–1.23); cardiology outpatient visits (HR, 1.40; 95% CI, 1.24–1.59); emergency department visits (HR, 1.19; 95% CI, 1.02–1.39); and hospitalizations (HR, 1.75; 95% CI, 1.49–2.05). Effects attenuated with age for cardiology outpatient visits and hospitalizations and increased for emergency department visits. Female sex, geographic periphery, and ethnic minority were associated with more primary care visits, and female sex (HR versus men, 0.89 [95% CI, 0.84–0.94]) and periphery (HR, 0.72 [95% CI, 0.58–0.90] for very peripheral versus very central) were associated with fewer cardiology visits. Arab minority patients also had high hospitalization rates compared with the majority group of Jewish or other patients. Conclusions Healthcare utilization rates were high among patients with ACHD. Female sex, geographic periphery, and ethnicity were associated with less optimal service utilization patterns. Further research should examine strategies to optimize service utilization in these groups.

Contemporary guidelines recommend a universal cutoff of 14 for the ratio between early mitral flow wave and early diastolic mitral annulus velocity measured by tissue doppler (E/e' ratio). While age-dependent normal E/e' values have been suggested, outcome data is lacking. We sought to evaluate the modification effect of age and gender on the prognostic value of the E/e' ratio. Consecutive patients who underwent echocardiographic evaluation between 2009 and 2021 (N=104,315) in a single tertiary cardiovascular center. Patients with left or right ventricular dysfunction, any significant valvular disease, structural heart disease or evidence of pulmonary hypertension were excluded. Cancer and mortality data were available for all subjects from national registries. Patients with a metastatic malignancy at baseline or during follow up were excluded. Cox regression models were applied. Overall, 44,541 patients were included in the final analysis. Mean age was 55±17, 59% were male and 63% of the exams were performed in an outpatient setting. An elevated E/e' ratio above 14 was documented in 2,598 (7%) patients. During a median follow-up of 5.7 (IQR 2.8–9.1) years, 5,015 (11.3%) patients died. Kaplan Meier survival analysis demonstrated that the cumulative probability of death at 6 years was 23.4% (21.6–25.3) among patients with elevated E/e' ratio compared with 9.7% (9.3–10.0) among patients with E/e'<14 (p Log rank <0.001). This difference was less significant as age progressed (figure 1). Multivariate cox-regression model yielded consistent results such that an elevated E/e' ratio was associated with 2.66-fold increased risk of death during follow up (95% CI 2.44–2.89, p<0.001), and there was a decline in the increased risk and significant as age advanced in both genders (figure 2). Interaction analysis was significant for both gender and age such the association of elevated E/e' ratio with poor survival was more significant among men compared with women and among young vs. older subjects. Among women, elevated E/e' was associated with 2.4-fold increased risk of death versus 2.7-fold increased risk among men. Similarly, the hazard ratio for death associated with elevated E/e' was 2.29 (95% CI 1.74–3.02), 1.8 (95% CI 1.5–2.1), 1.13 (95% CI 0.97–1.31) and 1.07 (95% CI 0.92–1.25) for the age groups of <60, 60–70, 70–80 and >80, respectively. In a sensitivity analysis, similar findings were seen in when excluding patients with mild hypertrophy (maximal wall thickness >12mm) and without any mitral annulus calcification. In apparently normal hearts, an elevated E/e' ratio is independently associated with increased mortality. This association is more pronounced among men and is attenuated with increased age. This study supports the need for gender-specific and age-specified outcome data with respect to measures of diastolic dysfunction. Type of funding sources: None. Survival by age and gender groups E/e' >14 and mortality by age and gender

Introduction: There is no consensus regarding the natural history of rheumatic mitral stenosis (MS) among adults presenting with nonsevere disease. This study aims to describe the progression of stenosis among adult rheumatic MS patients, to identify predictive factors for progression, and to assess the incidence of complications. Methods: A retrospective cohort analysis was performed among patients with rheumatic MS treated at a single center. Eighty-five patients were included with mild to moderate MS, >= 30 years old on initial echocardiography. Demographics, medical history, echocardiographic reports over at least 10 years, and related complications were obtained from a computerized database. Results: Over a period of 13.1 +/- 2.38 years, 75 patients (88%) had no significant progression in stenosis severity. The final echocardiographic assessment demonstrated 2 groups with a significant difference between them regarding the mitral valve area (1.58 +/- 0.44 vs. 1.1 +/- 0.26 cm(2), p = 0.001) and mean valvular pressure gradient (6.27 +/- 2.52 vs. 8.5 +/- 2.69 mm Hg, p = 0.01). Patients with indolent MS (group A) were compared to patients with progressive disease (group B), and a higher percent of Bedouin patients were found in group B (OR 8.036, p = 0.015). No significant differences were found in other parameters. Complications including atrial fibrillation, cerebral ischemic events, and impaired right ventricle function, although frequent, were not statistically different between the groups. Conclusions: An indolent natural progression of rheumatic MS was observed in our study. Despite this finding, it still has potentially deleterious effects. Bedouin patients have a higher risk for progressive disease.

Since the surgical palliation of a univentricular congenital heart defect was first described in the early 1970s, thousands of lives were saved by this groundbreaking operation. Although initially described for the palliation of tricuspid valve atresia, the Fontan operation is now utilized for many other univentricular heart defects involving either hypoplastic right or left ventricles, and the number of babies who survive the surgery and the postsurgical hospitalization continues to grow. Echocardiography constitutes the mainstay follow-up imaging modality for patients with a Fontan system. In order to obtain all the needed information from the echocardiographic studies, close familiarity with the native congenital heart defects, the build of the Fontan systems, and the potential long-term complications is required. Detailed studies provide valuable information on the various components of the Fontan circulation such as the function of the single ventricle and the valves, flow in the Glenn and Fontan pathways, and possible sources of cyanosis and shunts. Three-dimensional and transesophageal echocardiogram studies can assist in delineating the Fontan anatomy and to evaluate smaller intracardiac structures.

Background: The significance of depression/anxiety among ACHD patients in terms of health care utilization is unknown and data on the association with mortality are scarce. Methods: Analyses comprised 8334 ACHD patients, age >= 18 years, insured by a large healthcare organization (2007-2011). Depression/anxiety were determined by diagnoses and treatments recorded in the organization database. Adjusted utilization relative rates (RRs) were estimated with negative binomial models and mortality hazard ratios (HRs) with the Cox proportional hazard model. Results: ACHD patients with depression/anxiety (N=2950, 35%) were more likely to be older (mean +/- SD: 54 +/- 17 vs. 45 +/- 18 years), women (61% vs. 45%), and have comorbidities than counterparts without depression/anxiety. Following multivariable adjustment, patients with depression/anxiety had more primary care and cardiology clinic visits, more emergency department visits and more hospitalizations. RRs (95% confidence interval) were: 1.31 (1.27-1.35); 1.07 (1.01-1.13); 1.60 (1.46-1.77); and 1.18 (1.08-1.29) respectively, for diagnosis before the study period, and 1.36 (1.31-1.42); 1.22 (1.14-1.30); 1.43 (1.24-1.60) and 1.47 (1.33-1.64), respectively, for diagnosis during the study. Stratifying by age, the highest adjusted primary care and cardiology visit RRs were found among 18-24 years old patients and the lowest among patients >= 65 years. Between 2007 and 2017, 905 patients died. Depression/anxiety were associated with increased mortality risk with adjusted HRs: 1.10 (95% CI: 0.94-1.29) for past diagnosis and 1.40 (1.17-1.67) for study period depression/anxiety diagnosis. Conclusions: Depression/anxiety in ACHD patients is associated with increased health-care utilization and a higher risk of death. The efficacy of addressing patients' psychosocial needs in optimizing health-care utilization and improving prognosis needs further evaluation. (c) 2018 Elsevier B.V. All rights reserved.

Abstract Background Following percutaneous coronary interventions (PCI), both short and long terms ischemic outcomes are worse in patients with Diabetes Mellitus (DM) compared to those without DM. Methods We prospectively enrolled consecutive patients undergoing PCI. Glycated Hemoglobin (HbA1c) levels were assessed during the index hospitalization and newly diagnosed DM was defined as HbA1c≥6.5% in the absence of the previous diagnosis. The primary outcome was Major Adverse Cerebro and Cardiovascular Events (MACCE) defined as death, stroke, PCI or acute myocardial infarction at five years. Results Diabetes was previously diagnosed in 391 (34%) patients (DM group), 221 (19%) had newly diagnosed DM based on the HbA1c level and 539 (47%) did not have diabetes (Non-DM). In DM group HbA1c was 7.80±1.36% as compared with 7.62±1.30% in patients with newly diagnosed DM (p<0.001). These patients were younger (62.0±11.3 years) compared to DM (67.9±10.4 years) and non-DM (63.7±13.0) patients, p<0.001. five years MACCE rates were 37.8%, 65.5% and 42.5% in the non-DM, newly diagnosed DM and DM groups, respectively (p<0.001). Multivariate analysis showed that compared to non-DM, the adjusted two year hazard ratios for MACCE were 1.83 (p<0.001), 1.47 (p=0.01) and 0.52 (p=0.01) respectively in patients with known DM, newly diagnosed DM, and patients with newly diagnosis DM who had DM treatment started after PCI. Conclusion Newly diagnosed DM based on peri-procedural HbA1c is common and associated with increased short and long term risk for adverse outcomes. Our results show that the diagnosis and early treatment of diabetes in patients undergoing PCI should be included into the routine practice.