When left ventricular (LV) filling pressure (FP) increases, the mitral valve (MV) opens early and precedes tricuspid valve (TV) opening in early diastole. We hypothesized that a visually-assessed time sequence of atrioventricular valves opening could become a new marker of elevated LVFP. We thus tested the diagnostic ability of a novel echocardiographic scoring system, visually-assessed time-difference between MV and TV opening (VMT) score, in heart failure (HF) patients. We retrospectively analyzed 119 consecutive patients who underwent cardiac catheterization within 24 hours of echocardiography examination as a derivation cohort. In addition, a prospective study was conducted to validate the diagnostic ability of the VMT score in 50 patients. Elevated LVFP was defined as mean pulmonary arterial wedge pressure (PAWP) ≥15 mmHg. Time sequence of atrioventricular valves opening was visually assessed and scored (0, TV first; 1, simultaneous; 2, MV first). When the inferior vena cava was dilated, 1 point was added and VMT score was finally graded as 0-3. Cardiac events were recorded for 1 year after echocardiography. In the derivation cohort, PAWP was elevated in the higher VMT scores (0, 10±5; 1, 12±4; 2, 22±8; 3, 28±4 mmHg; ANOVA P<0.001). VMT≥2 predicted elevated PAWP with an accuracy of 86% and showed an incremental predictive value over clinical variables and guideline-recommended diastolic function grading. These observations were confirmed in the prospective validation cohort. Importantly, VMT≥2 discriminated elevated PAWP with accuracy of 82% in 33 patients with monophasic LV inflow in the derivation cohort. Kaplan-Meier analysis demonstrated that patients with VMT≥2 were at a higher risk of cardiac events than those with VMT≤1 (P<0.001). VMT scoring could be a novel additive marker of elevated LVFP and might also be associated with adverse outcomes in HF patients.

Elevated left ventricular filling pressure (LVFP) is a powerful indicator of worsening clinical outcomes in heart failure with preserved ejection fraction (HFpEF); however, detection of elevated LVFP is often challenging. This study aimed to determine the association between the newly proposed echocardiographic LVFP parameter, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score, and clinical outcomes of HFpEF. We retrospectively investigated 310 well-differentiated HFpEF patients in stable conditions. VMT was scored from 0 to 3 using two-dimensional echocardiographic images, and VMT ≥2 was regarded as a sign of elevated LVFP. The primary endpoint was a composite of cardiac death or heart failure hospitalization during the 2 years after the echocardiographic examination. In all patients, Kaplan–Meier curves showed that VMT ≥2 (n = 54) was associated with worse outcomes than the VMT ≤1 group (n = 256) (P < 0.001). Furthermore, VMT ≥2 was associated with worse outcomes when tested in 100 HFpEF patients with atrial fibrillation (AF) (P = 0.026). In the adjusted model, VMT ≥2 was independently associated with the primary outcome (hazard ratio 2.60, 95% confidence interval 1.46–4.61; P = 0.001). Additionally, VMT scoring provided an incremental prognostic value over clinically relevant variables and diastolic function grading (χ² 10.8–16.3, P = 0.035). In patients with HFpEF, the VMT score was independently and incrementally associated with adverse clinical outcomes. Moreover, it could also predict clinical outcomes in HFpEF patients with AF. Pathophysiology and prognostic impact of VMT scoring in HFpEF patients. Early-diastolic pressure crossover between the left atrial pressure and left ventricular pressure happens earlier with the increase in the LA v wave. In addition, reduced right ventricular (RV) relaxation owing to passive pulmonary hypertension delays early-diastolic pressure crossover between the right atrial pressure and RV pressure. Therefore, early mitral valve opening which precedes tricuspid valve opening pathophysiologically reflects the LAP elevation. HFpEF patients with higher VMT scores were characterized by elevated LAP and subsequent higher RVP, resulting in a higher prevalence of advanced right heart remodelling. As a result, VMT ≥2 was associated with adverse clinical outcomes in HFpEF patients. Notably, VMT ≥2 was also associated with worse outcomes when tested in atrial fibrillation patients. Orange dashed circles indicate the atrioventricular valve which opens earlier in early diastole. Orange vertical lines indicate the timing of pressure crossover between the atrium and ventricle which occurs earlier in early diastole. AF, atrial fibrillation; HF, heart failure; LA, left atrial; LAP, left atrial pressure; LV, left ventricular; LVP, left ventricular pressure; RA, right atrial; RAP, right atrial pressure; RV, right ventricular; RVP, RV pressure; VMT, visually assessed time difference between mitral and tricuspid valves opening.

Background: Heat application before peripheral intravenous catheterization is recommended for venous dilation. Hot pack application enlarges the venous diameter in healthy adults; however, hot towels (moist and dry heat) are used often in some medical cases. However, it is unclear whether hot towel application promotes venous dilation better than hot pack application. This study compared the venous dilation effect of using a hot towel (moist and dry heat) to a hot pack before applying the tourniquet at an access site for peripheral intravenous catheterization. Methods: Eighty-eight healthy females aged 18–29 years were recruited for this quasi-experimental study. They underwent three types of heat applications (hot pack, moist hot towel, and dry hot towel [moist hot towel wrapped in a dry plastic bag], all of which were warmed to 40 ± 2 °C and performed for 7 min) to their forearm and tourniquet application for 30 s after each heating. Venous diameter and depth were measured using ultrasonography, and venous palpability and visibility (venous assessment score) was observed as venous dilatation effects. In addition, the skin temperature, stratum corneum hydration, and subjective evaluation of the warmth were measured. Results: There were no significant differences in venous diameter and assessment scores after intervention between the dry hot towel and the hot pack groups, and the effect size was negligible (Cohen’s d < 0.20). However, these measurements were significantly lower for the moist hot towel than for the other two heat applications (P < .001). Although there was no significant difference in skin temperature and warmth rating score between the dry hot towel and the hot pack, these were significantly lower for the moist hot towel than for the other two heat applications (P < .001). The amount of change in stratum corneum hydration of the dry hot towel was not significantly different from that of the hot pack; however, that of the moist hot towel was significantly larger than that of the other two heat applications (P < . 001.) Conclusions: A method in which a towel warmed in hot water is wrapped in a dry barrier may be an alternative to a hot pack. Trial registration: This study was registered with University Hospital Medical Information Network in Japan (Registration No.: UMIN000048308. Registered on July 7, 2022).

BACKGROUND: Accurate assessment of left ventricular filling pressure in patients with atrial fibrillation or flutter (AF) remains difficult. A novel 2-dimensional scoring system, visually assessing time difference between mitral valve and tricuspid valve opening (VMT) score, based on temporal analysis of early diastolic valve opening, could be applied to these patients. We aimed to determine the usefulness of the VMT score in patients with AF. METHODS: We analyzed 119 consecutive patients with AF who underwent cardiac catheterization as a derivation cohort. The diagnostic performance of the VMT score was further evaluated in an external data set containing 189 patients with AF. Elevated left ventricular filling pressure was defined as a mean pulmonary arterial wedge pressure ≥15 mm Hg. The time sequence of atrioventricular valve opening was visually assessed and scored (0, tricuspid valve first; 1, simultaneous; 2, mitral valve first). When the inferior vena cava was dilated, 1 point was added, and the VMT score was finally graded as 0 to 3. Conventional Doppler parameters to estimate left ventricular filling pressure were also measured. RESULTS: Pulmonary arterial wedge pressure was elevated with an increase in the VMT score (0: 10±3, 1: 13±5, 2: 22±7, 3: 27±6 mm Hg; P <0.001), resulting in a significant rise in pulmonary arterial wedge pressure from VMT score 1 to 2. VMT≥2 predicted elevated pulmonary arterial wedge pressure with an accuracy of 87%, and the diagnostic accuracy of the VMT score was significantly higher than that of conventional Doppler parameters ( C index, 0.88 versus 0.54–0.68; P <0.001). In addition, VMT ≥2 showed an incremental predictive value over plasma brain natriuretic peptide levels ( C index, 0.79–0.93; P <0.001). In the external validation cohort, VMT≥2 demonstrated acceptable accuracy of 72%. CONCLUSIONS: VMT scoring was a useful echocardiographic marker of elevated left ventricular filling pressure and had an incremental benefit over practical biomarkers in patients with AF.