bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of stenotic lesion morphology on trans-lesional computed tomography derived fractional flow reserve (FFRCT) changes
Authors: Tsugu T , Tanaka K , Nagatomo Y , Belsack D , Argacha J F , Cosyns B , De Maeseneer M , De Mey J
Published: November 2023

Background

To assess the indication for revascularization CT-derived fractional flow reserve (FFRCT) has been measured at only a portion distal to the lesion. This conventional method is controversial in terms of its ability to accurately evaluate the coronary flow disturbance. Changes in FFRCT between the portions proximal and distal to the lesion (ΔFFRCT) are implemented as a novel method for the assessment of the coronary flow disturbance. The effect of different morphologies of stenotic lesions on ΔFFRCT remains unclear.

Purpose

To investigate the effect of lesion morphology on ΔFFRCT and the ability of ΔFFRCT to detect lesions with the coronary flow disturbance.

Methods

A total of 1502 outpatients with suspected stable coronary artery disease who underwent FFRCT between January 2017 and May 2022 were evaluated. Among them, 76 patients who underwent both FFRCT and invasive coronary angiography with ≥ 50% stenosis were evaluated and divided into four groups according to the degree of stenosis and lesion length (moderate, 50–69%; severe: 70–99%) and lesion length (focal, < 40 mm; diffuse, ≥ 40 mm) as follows: moderate/focal (n = 23), moderate/diffuse (n = 9), severe/focal (n = 34), and severe/diffuse (n = 10) (Figure 1). Vessel and lesion morphology (length, luminal volume, and plaque characteristics) and left ventricular mass were assessed. Indication for revascularization (percutaneous coronary intervention and coronary artery bypass graft) was assessed by invasive coronary angiography and additional invasive FFR measurement was performed when necessary.

Results

ΔFFRCT was greater in diffuse than in focal stenosis in both moderate and severe stenosis: moderate/focal (0.11 ± 0.12), moderate/diffuse (0.18 ± 0.10), severe/focal (0.26 ± 0.15), and severe/diffuse (0.38 ± 0.12) (Figure 2A). Lesion length correlated with ΔFFRCT (r = 0.31, p = 0.006) (Figure 2B). As for focal lesion, lesion length did not correlate with ΔFFRCT (r = 0.13, p = 0.34), whereas, as for diffuse lesion it did (r = 0.72, p = 0.0007) (Figure 2C). Multivariable analysis showed that lesion length was the strongest predictor of ΔFFRCT (β-coefficient = 0.41, p = 0.003), followed by lesion positive remodelling (β-coefficient = 0.27, p = 0.01), lesion calcified plaque volume (β-coefficient = －0.39, p = 0.02), and lesion spotty calcification (β-coefficient = 0.23, p = 0.04). ΔFFRCT predicted for lesion requiring revascularization (cut-off 0.21, AUC 0.80, sensitivity 64.4%, specificity 85.7%, 95% CI 0.69–0.91) (Figure 2D).

Conclusions

ΔFFRCT was affected by lesion length, followed by lesion calcium components. ΔFFRCT predicted lesions requiring revascularization.Figure 1Figure 2
Prognostic factors and mortality predictive scale in patients treated with in-hospital extracorporeal cardiopulmonary resuscitation
Authors: Alonso Fernandez De Gatta M , Hernandez Martos A V , Diego Nieto A , Merchan Gomez S , Martin Herrero F , Gonzalez Cebrian M , Toranzo Nieto I , Barrio Rodriguez A , Cid Menendez A , Gonzalez Calle D , Sanchez P L
Published: November 2023

Background

Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue option in cardiac arrest (CA) refractory to advanced life support. Patient selection is challenging, evidence is limited and randomized studies are lacking regarding in-hospital CA.

Purpose

Our objective was the identification of factors associated with survival in in-hospital ECPR.

Methods

Retrospective analysis of consecutive cases of venoarterial extracorporeal membrane oxygenator (VA-ECMO) for ECPR indication in a referral center. The ECPR alert includes in-hospital cardiologist/intensivist, on-call interventional cardiologist/cardiac surgeon for cannulation, and on-call perfusionist. We analyzed baseline variables related to CA and ECPR technique and studied their relationship with in-hospital survival.

Results

Out of 207 VA-ECMO implants between 2014-feb 2023, we selected the ECPR cases: N=59 (28.5%). Baseline, admission and ECPR characteristics are collected in the table.

ECMO-VA support intention was bridge to recovery in 68% of cases, transplant 5%, ventricular assist device 5% and decision 22%. The most frequent access was percutaneous femoro-femoral, and ECPR was unsuccessful (no flow, no rhythm, or impossibility of cannulation in 11.8% of cases). All patients underwent temperature control at 36ºC with ECMO.

Overall in-hospital survival was 18.6% (n=11) (cerebral performance cathegory 1-2), and the most frequent causes of death were refractory shock/multiple organ failure (49%) and anoxic encephalopathy (25%).

The patients who died were significantly younger, had peripheral vascular disease (PAD), higher creatinine, LDH and lactate levels, longer CA duration, and its ECMO implantation was more frequent during on-call hours (table). Lactate >10.05 predicted mortality (AUC 0.693, Sens 67,3%, Esp 80%). The time under VA-ECMO support and mechanical ventilation, and the use of adrenaline infusion were more frequent in the survivors (table).

At multivariate analysis, a longer CA duration (HR 0.947, CI95% 0.900-0.977, p0,040) was the only factor independently associated with in-hospital mortality.

We developed a predictive scale including factors related to survival (lactate >10.05, >60 minutes CA, PAD, on-call time) which predicted 100% with 3 or more factors (p<0.001) (figure 2).

Conclusions

In-hospital ECPR is an option for refractory cardiac arrest, with high mortality. CA duration was the only factor independently associated with in-hospital mortality. Three or more adverse factors (lactate >10.05, >60 minutes CA, PAD, on-call time) predicted 100% mortality. Randomized studies are needed to determine a better selection of patientsBaseline, admission and ECPRMortality predictive scale after ECPR
Initial rhythm and survival in refractory out-of-hospital cardiac arrest. Post-hoc analysis of the Prague OHCA randomized trial
Authors: Fingrova Z , Havranek S , Rob D , Smalcova J , Kavalkova P , Smid O , Dusik M , Linhart A , Belohlavek J
Published: November 2023

Background

The prognosis of refractory out-of-hospital cardiac arrest (OHCA) is generally poor. A recent Prague OHCA study has demonstrated that an invasive approach (including extracorporeal cardiopulmonary resuscitation, ECPR) is a feasible and effective treatment strategy in refractory OHCA. Here we present a post-hoc analysis of the role of initial rhythm on patient outcomes.

Methods

The study enrolled patients who had a witnessed OHCA of presumed cardiac cause without early recovery of spontaneous circulation. The initial rhythm was classified as either a shockable or a non-shockable rhythm. The primary outcome was a composite of 180 day-survival with Cerebral Performance in Category 1 or 2.

Results

256 (median age 58y, 17% females) patients were enrolled. The median (IQR) duration of resuscitation was 52 (33-68) minutes. 156 (61%) and 100 (39%) of patients manifested a shockable and non-shockable rhythm, respectively. The primary outcome was achieved in 63 (40%) patients with a shockable rhythm and in 5 (5%) patients with a non-shockable rhythm (p < 0.001). When patients were analyzed separately based on whether the treatment was invasive (n = 124) or standard (n = 132), the difference in the primary endpoint between shockable and non-shockable initial rhythms remained significant (35/72 (49%) vs 4/52 (8%) in the invasive arm and 28/84 (33%) vs 1/48 (2%) in the standard arm; p < 0.001).

Conclusion

An initial shockable rhythm and treatment with an invasive approach is associated with a reasonable neurologically favorable survival for 180 days despite refractory OHCA. Non-shockable initial rhythms bear a poor prognosis in refractory OHCA even when ECPR is readily available.
Long-term prognosis associated with undetectable high-sensitivity cardiac troponin T concentrations in the emergency department
Authors: Strandberg L , Kadesjo E , Edgren G , Roos A
Published: November 2023

Background

The long-term prognostic implications of low or undetectable high-sensitivity cardiac troponin T (hs-cTnT) levels in patients presenting with chest pain in the emergency department (ED) have not been thoroughly studied. Furthermore, the prognosis has not been compared to the general population.

Purpose

This study aimed to investigate the long-term risk of all-cause mortality and cardiovascular outcomes in patients with chest pain but no myocardial injury, compared with the general population in Sweden.

Methods

Among all visits to 7 major EDs in Sweden from December 9, 2010 to August 31, 2017, we included the first visit by patients ≥18 years of age with chest pain and ≥1 hs-cTnT measurement. Visits in patients with myocardial injury (any hs-cTnT >14 ng/l), including those associated with a diagnosis of myocardial infarction (MI) were excluded. Standardized mortality ratios (SMRs) and incidence ratios (SIRs) were estimated to compare risks of death and future MI with the general population. Hazard ratios (HRs) with 95% CIs were calculated for comparisons of mortality and major adverse cardiovascular events (MACE) between visits with undetectable (<5 ng/l) and low (5-14 ng/l) hs-cTnT concentrations.

Results

A total of 112,694 visits were included, of which 69,571 (62%) and 43,123 (38%) occurred in patients with hs-cTnT <5 ng/l and 5-14 ng/l, respectively. All-cause mortality was overall lower compared to the standardized Swedish population (SMR 0.51, 95% CI: 0.49-0.54, and 0.88, 95% CI: 0.85-0.90), while risks of a future MI were higher (SIR 1.33, 95% CI: 1.25-1.42, and 1.53, 95% CI: 1.46-1.59). Hs-cTnT concentrations <5 ng/l were associated with a lower all-cause mortality in men ≥55 years and in women ≥65 years of age, respectively (figures 1 and 2). During a median follow-up of 6.4 years (IQR 4.8-8.0), 1769 (2.5%) and 5535 (13%) deaths occurred in patients with hs-cTnT <5 and 5-14 ng/l, respectively.

The adjusted risks of death and MACE were 1.7- (HR 1.70, 95% CI: 1.60-1.80) and 1.6-fold (HR 1.63, 95% CI: 1.54-1.73) higher in patients with hs-cTnT 5-14 ng/l compared to patients with hs-cTnT <5 ng/l.

Conclusions

Patients with chest pain and low or undetectable hs-cTnT concentrations have an overall lower risk of death, but a higher risk of future MIs, compared with the age-standardized general population. In addition, detectable Hs-cTnT concentrations below the 99th percentile cutoff value are associated with long-term risks of death and MACE.Crude mortality rateStandardized mortality ratio
Comparisons of APACHE II, CURB-65, Pneumonia severity index, and CHA2DS2-VAS score on new onset cardiovascular events, including atrial fibrillation, for critical illness with pneumonia
Authors: Wang T , Lin Y L
Published: November 2023

Background

pneumonia patients afflicted with cardiac disease were frequented with higher rates of short-term mortality. Furthermore, the most common arrhythmia (25%) in critically ill patients is atrial fibrillation and its increased incidences in hospital mortality and extended length of hospital stays. The early detection of the occurrence of atrial fibrillation and other CV events is important among these severely pneumonia patients.

Purpose

The purpose of this article is to determine the appropriate risk assessments and to make a comparison of predictive performance among four common practice risk scores: APACHE II, CURB-65, pneumonia severity index and CHA2DS2-VASc.

Methods

This was a retrospective, observational study from consecutive critical pneumonia patients admitted to medical intensive care unit. Heart failure, acute coronary syndrome, atrial fibrillation, ventricular tachycardia or stroke are defined as a cardiovascular event. Those who had the missing data about APACHE II, CURB-65, PSI and CHA2DS2-VASc scores had already been excluded from this study. The baseline characteristics of patients between the disease groups (CV vs. non-CV; AF vs. non-AF) were compared by using the independent sample t-test for continuous variables and the chi-square test for categorical variables, respectively. The performance of discriminating in-hospital CV and AF events for the four risk scores was evaluated using the ROC curve analysis. The areas under the ROC curve (AUC) of the four risk scores were compared using the Delong’s non-parametric method.

Results

252 (22.6%) of the 1,117 patients suffered from CV events during the hospitalization. Compared to patients averting CV events, those who experienced CV events during hospitalization were older, more likely to smoke, experiencing more altered mental states, of poor renal function, of higher prevalence of all comorbidities except liver disease, of a long duration of ICU and yielded higher values of the four risk scores. There were 99 patients who suffered from CV events other than an AF episode. After excluding the 99 patients, 153 (15%) of the remaining 1,018 patients had an AF event during hospitalization. The values of the four risk scores were also significantly greater in the AF group. The performance of discriminating CV events for the four risk scores was fair with the values of AUC ranging from 61.8% of APACHE II to 64.8% of CURB 65 (Fig 1). However, no significant difference of the AUC values between any two risk scores. In terms of discriminating AF episode (Fig 2) for the four risk scores, the performance was obviously poorer with the values of AUC less than 60%, except for the CURB 65.

Conclusion

CURB 65 is simple and effective tool for predicting new onset cardiovascular events, including atrial fibrillation, in ICU patients with pneumonia.new onset CV eventonw onset AF event
An automated reduced order CT-FFR model for diagnosis of hemodynamically significant coronary artery disease- a prospective validation study
Authors: Tjellaug Braaten A , Fossan F E , Muller L , Joergensen A , Stensaeth K H , Hellevik L R , Wiseth R
Published: November 2023

Background/Introduction

CT derived fractional flow reserve (CT-FFR) is introduced in current guidelines as a gatekeeper for invasive coronary angiography (ICA) in symptomatic patients with intermediate stenoses on coronary CT angiography (CCTA). Traditionally, CT-FFR is validated with knowledge of the precise location of invasive FFR measurements to ensure a direct comparison. However, in a clinical setting, this information will not be available and may affect the diagnostic performance of CT-FFR.

Purpose

To validate the diagnostic performance of a novel physics augmented machine learning algorithm based on reduced order modelling for CT-FFR calculations, with an automated method for defining the site of CT-FFR evaluations.

Methods

In this prospective validation study, 108 consecutive patients with stable coronary artery disease (CAD) and at least one suspected obstructive stenosis of questionable hemodynamic significance on CCTA were included. All patients underwent a clinically indicated invasive coronary angiography. The diagnostic performance of the CT-FFR algorithm was assessed with invasive FFR at a threshold of ≤ 0,80 as reference standard. CT-FFR at the location of invasive FFR measurements (CT-FFRatloc) was compared with CCTA, CT-FFR at automatically selected locations (CT-FFRauto) and CT-FFR predictions at the distal end of the vessel (CT-FFRdistal).

Results

CT-FFRatloc showed good correlation with invasive FFR measurements (r=0,67) and demonstrated improved diagnostic performance compared to CCTA diameter stenosis ≥50%. alone both at lesion level (AUC= 0,85 vs 0,63, p<0,01) and at patient level (AUC=0,87 vs 0,74, p<0,01). Both specificity (84% vs 40%, p=0,01) and accuracy (81% vs 63%, p<0,01) of CT-FFRatloc was significantly increased compared to CCTA. CT-FFRauto performed equally well as CT-FFRatloc, both at lesion level (AUC= 0,82 vs AUC= 0,85, p=0,27) and patient level (AUC= 0,86 vs AUC= 0,87(p=0,67). When comparing CT-FFRdistal to CT-FFRatloc the overall diagnostic performance was poorer (AUC=0,79 vs 0,85, p<0,01).

Conclusions

Compared to CCTA, CT-FFRatloc showed improved diagnostic performance, including accuracy and specificity for the detection of hemodynamically significant coronary artery disease in a symptomatic population. Predictions using an automated location algorithm, CT-FFRauto, was comparable to evaluations at the location of invasive FFR measurements, CT-FFRatloc.Figure 1Figure 2
Decreased levels of plasmacytoid dendritic cells predict survival in critically ill patients
Authors: Steinacher E , Lenz M , Krychtiuk K A , Hengstenberg C , Huber K , Wojta J , Heinz G , Niessner A , Speidl W S , Koller L
Published: November 2023

Background

Critically ill patients admitted to intensive care units (ICUs) exhibit high mortality rates and suffer from a broad variety of life-threatening conditions. Irrespective of the initial cause of hospitalization, many of them experience systemic immune dysregulation accompanied by strong inflammatory activation and subsequent anti-inflammatory response resulting in immune paralysis. Dendritic cells (DCs) are the most potent antigen-presenting cells and play a pivotal role in regulating the immune response by linking the innate to the adaptive immune system. Previous studies already highlighted their prognostic value in sepsis and infectious diseases.

Purpose

DCs may be useful as a biomarker in intensive care medicine. Thus, the aim of this study was to analyse whether DCs or their respective subsets are associated with 30-day mortality in a cohort of unselected patients admitted to a medical ICU with cardiovascular focus.

Methods

231 patients admitted to a tertiary care medical ICU were consecutively included in this single-centre prospective observational study. Patient characteristics and vital parameters were assessed within 24 hours following ICU admission and 72 hours thereafter. Additionally, blood was drawn at both time points. Subsequently, flow cytometry was utilized for the analysis of DCs and their respective subsets. Patients were prospectively followed up for 30 days or until the primary study endpoint, defined as mortality, was reached.

Results

In the study cohort, low percentages of total DCs were significantly associated with sepsis, respiratory failure, and the presence of shock. Percentages of plasmacytoid dendritic cells (pDCs) were inversely correlated with routinely assessed markers of inflammation, organ dysfunction and hemodynamic derangement.

In particular, pDCs at admission showed the most robust association with survival in univariate analysis with a hazard ratio (HR) of 6.5 (95% confidence interval [CI]: 2.5 – 17.2, p < 0.001) comparing the first to the third tertile. In multivariate analysis, pDCs remained a strong and independent predictor of 30-day mortality after adjustment for demographic and clinical variables with an adjusted HR of 4.20 (1.3 - 13.3, p = 0.015). Corresponding Kaplan-Meier curves showing survival according to tertiles of pDCs at day 0 are displayed in figure 2 (log-rank test: p < 0.001).

Conclusion

We observed low percentages of DCs in patients admitted to an ICU suffering from sepsis, respiratory failure, and cardiogenic shock, which potentially contributes to the excessive immune response in critically ill patients. In our cohort, pDCs were identified as the most robust subset to predict 30-day mortality.Figure 1Figure 2
Impact on mortality of a cardiogenic shock programme in a non-transplant hospital
Authors: Pascual J , Aboal J , Loma-Osorio P , Nunez M , Badosa E , Martin C , Ferrero M , Moral S , Ballesteros E , Pedraza J , Brugada R
Published: November 2023

Introduction

Cardiogenic shock is associated with high in-hospital morbidity and mortality. Every hospital should take all possible measures to reduce it.

Methods

Quasi-experimental study in patients with cardiogenic shock comparing two periods: A period of a cardiogenic shock programme including the establishment of a multidisciplinary team (shock team), early alert to the transplant hospital, initiation of a VA ECMO programme and extension of continuous care by acute cardiovascular care specialist, and a previous period without the mentioned measures. The primary objective was whether there were differences in in-hospital mortality and mortality at follow-up. Predictors of in-hospital mortality were examined as a secondary objective.

Results

A total of 139 patients were enrolled, including 69 in the previous period and 70 in the cardiogenic shock programme period. There was a significant reduction in-hospital mortality (55.1% vs. 37.1%, p=0-03) and in the follow-up (62.7% vs. 44.6%, p=0.03) in the second period. Diabetes mellitus, ejection fraction, out-of-hospital cardiac arrest and implementation of the cardiogenic shock programme were independent predictors of in-hospital mortality.

Conclusions

Implementing a comprehensive cardiogenic shock programme in a non-transplanting hospital improved in-hospital and follow-up mortality of patients in cardiogenic shock.
Full percutaneous angio-guided ECLS implantation reduces major vascular complications as compared to surgical implantation
Authors: Asslo G , Truong T , Gall E , Boukantar M , Folliguet T , Teiger E , Gallet R
Published: November 2023

Background

Veno-arterial extracardiac life support (VA-ECLS) has become the current practice for managing severe refractory cardiogenic shock and cardiac arrest. Both surgical and percutaneous approaches can be used for VA-ECLS implantation, with the latter seeming to be associated with fewer complications. A full percutaneous approach using pre-closing enables percutaneous implantation but also explantation and may further decrease vascular complication. We aimed to address the incidence of vascular complications and 30-day mortality using full percutaneous ECLS implantation as compared to surgical implantation.

Methods

We included all patients who received VA-ECLS in a single center between January 2017 and December 2022. All patients had VA-ECLS implantation for severe cardiogenic shock or cardiac arrest, and post-operative patients were excluded. We compared 30-day survival and major vascular complications incidence (major bleeding, groin infection, limb ischemia) between the percutaneous and surgical groups.

Results

A total of 221 patients (mean of 53 years old, 71% men) received VA-ECLS, 115 using full percutaneous approach and 106 using surgical approach. ECLS was implanted in the setting of eCPR in 83 patients (37.7%). Baseline characteristics and clinical severity were comparable between the two groups. In the angio-guided group, there were significantly fewer major bleeding events (7% versus 27%, p<0.01) and groin infection (3.5% versus 12%, p=0.018) compared with the surgical group, but no difference in the incidence of limb ischemia (8.8% versus 10.1%, p=0.74) was observed. Thirty day mortality tended to be lower in the percutaneous group (69.6%) than in the surgical group (79.2%), but this difference did not reach statistical significance (p=0.076). Predictive factors of mortality at 30 days were BMI, SOFA score at implantation, age, and refractory arrest.

Conclusion

Full percutaneous ECLS implantation dramatically reduces major vascular complications as compared to surgical implantation. Larger studies are needed to determine if this benefit may increase survival.
Real world impact of added FFR-CT to coronary CT angiography on clinical decision-making and patient prognosis
Authors: Becker L , Peper J , Verhappen B , Swart L A , Dedic A , Van Dockum W G , Van Der Ent M , Royaards C J , Niezen A , Hensen J H , Van Kuijk J P , Mohamed Hoesein F A A , Leiner T , Bruning T A , Swaans M J
Published: November 2023

Objectives

The addition of CT-derived fractional flow reserve (FFR-CT) increases the diagnostic accuracy of Coronary CT Angiography (CCTA). We assessed the impact of FFR-CT in routine clinical practice on clinical decision-making and patient prognosis in patients suspected of stable coronary artery disease (CAD).

Methods

This retrospective, single-center study compared a cohort that received CCTA with FFR-CT to a historical cohort that received CCTA before FFR-CT was available. We assessed the clinical management decisions after FFR-CT and CCTA and the rate of major adverse cardiac events (MACE) during the one-year follow-up using chi-square tests for independence. Kaplan-Meier curves were used to visualize the occurrence of safety outcomes over time.

Results

360 patients at low to intermediate risk of CAD were included, 224 in the CCTA only group and 136 in the FFR-CT group. During follow-up, 13 MACE occurred in 12 patients, 9 (4.0%) in the CCTA-group and three (2.2%) in the FFR-CT group. Clinical management decisions differed significantly between both groups. After CCTA, 60 patients (26.5%) received optimal medical therapy (OMT) only, 115 (51.3%) invasive coronary angiography (ICA) and 49 (21.9%) single positron emission CT (SPECT). After FFR-CT, 106 patients (77.9%) received OMT only, 27 (19.9%) ICA and three (2.2%) SPECT (p<0.001 for all three options). The revascularization rate after ICA was similar between groups (p=0.15). However, patients in the CCTA-group more often underwent revascularization (p=0.007).

Conclusion

Addition of FFR-CT to CCTA led to a reduction in (invasive) diagnostic testing and less revascularizations without observed difference in outcomes after one year.Clinical decisions and follow upSignificant LAD lesion, negative FFRCT
Survival disparities for in-hospital cardiac arrests occurring during nights and weekends
Authors: Yonis H , Dillon J W , Qvortrup M , Svenstrup Moeller D , Meaidi A , Torp-Pedersen C , Kragholm K
Published: November 2023

Background

In-hospital cardiac arrest is a life-threatening event, often leading to poor outcomes and high mortality rates. There is limited research investigating how the time and day of arrest might impact long-term outcomes, such as mortality and functional status.

Purpose

To investigate the relationship between time and day of arrest and long-term outcomes in patients who experience in-hospital cardiac arrest.

Methods

This study included all patients who experienced an in-hospital cardiac arrest between January 1st, 2013 and December 31st, 2019, and who had a clinical indication for resuscitation. Data was obtained from the Danish in-hospital cardiac arrest registry, which was linked to other national registries to gather information on patient characteristics, such as survival, anoxic brain damage, and nursing home admission.

The patients were stratified into three groups (A-C) based on time and day of the week: Group A included patients who were resuscitated during regular working hours (Monday to Friday from 08:00 to 15:59), Group B included patients who were resuscitated during off-hours (Monday to Sunday from 16:00 to 23:59 and Saturday to Sunday from 08:00 to 15:59), and Group C included patients who were resuscitated during off-hours at night (Monday to Sunday from 00:00 to 07:59).

Standardized average probability of outcomes was estimated using logistic regression.

Results

The study population consisted of 9,225 patients, median age was 74 (1st-3rd quartile [Q1-Q3] 65-81 years) and 63.3% were men. In total, 53.6% (n = 4,909) of the patients achieved return of spontaneous circulation (ROSC). The standardized absolute chance of 30-day survival was 32.7% (95% CI 30.9%-34.5%) for group A, 27.2% (95% CI 25.7%-28.7%) for group B, and 23.6% (95% CI 22.0%-25.3%) for group C. Similarly, the chance of 1-year survival was highest for group A (27.6%; 95% CI 25.9%-29.3%) gradually decreasing to 18.9% (95% CI 17.4%-20.4%) in group C (Fig. 1).

For patients who survived at least 30 days following an in-hospital cardiac arrest, the standardized absolute chance of surviving without anoxic brain damage or admission to a nursing home within one year was greatest among those in group A (81.1%; 95% CI 78.3%-83.8%), but decreased to 75.1% (95% CI 72.2%-78.1%) for those in group B, and 72.2% (95% CI 68.3%-76.1%) for those in group C (Fig. 1D).

Conclusion

In conclusion, this study found that patients who experience in-hospital cardiac arrest during off-hours at night have significantly lower chances of survival at both 30 days and 1 year compared to those experiencing an arrest during on-hours or off-hours. Additionally, among patients who survive the initial 30 days, those resuscitated during off-hours at night have the poorest outcomes, with lower chances of 1-year survival without anoxic brain damage or nursing home admission.Figure 1
Meta-analysis depicting the outcomes of hypothermia versus normothermia post cardiac arrest
Authors: Duhan S , Keisham B , Singh S , Taha A , Sandhyavenu H , Rout A
Published: November 2023

Background

The current American Heart Association (AHA) 2020 guidelines recommend targeted temperature monitoring (TTM) for cardiac arrest patients. However, more recently published trials intrigued us to review the therapeutic benefit of TTM.

Objective

To assess the usefulness of recommended TTM temperature (< 36° C), we performed this updated meta-analysis of randomized controlled trials (RCTs), including the latest Targeted Hypothermia Versus Targeted Normothermia After Out-of-hospital Cardiac Arrest-2 (TTM2) trial and trial conducted by Wolfrum S., comparing neurological and mortality outcomes in targeted hypothermia (TH) (< 36° C) with normothermia group (> 36° C).

Methods

We searched Cochrane, MEDLINE, and EMBASE from inception to December 2022. Only trials with patients randomized for TTM and reported neurological and mortality outcomes were included. Non-randomized design, retrospective cohorts, and non-English abstracts were excluded. The data was extracted using full text for all RCTs except two where abstract and previous meta-analysis was used. Statistical analysis was performed using Cochrane Review Manager using the random effects model and calculated pooled risk ratios of outcomes using the Mantel-Haenszel method.

Results

A total of 12 RCTs and 4,262 patients were included in the review (Table 1). Almost 80% weight was carried by four trials (Lascarrou JB, Dankiewicz J, Nielsen N, and Wolfrum S). The neurological outcomes were mainly measured using the cerebral performance category (CPC) scoring in the RCTs. Patients had significantly improved neurological outcomes [Risk Ratio (RR) 0.90, 95% Confidence Interval (CI): 0.83, 0.98, p = 0.02, I² = 61%] in the TH group (Figure 1). However, no significant difference in mortality was observed [RR 0.97, 95% CI: 0.90, 1.06, p = 0.55, I² = 38%]. In patients with an initial shockable rhythm, no significant difference in the neurological [RR 0.82 (95% CI: 0.67, 1.00), p = 0.05, I² = 82] and mortality outcomes [RR 0.82, 95% CI: 0.57,1.18, p=0.29, I²=94%] was seen between the two groups.

Conclusion

Our meta-analysis indicates a therapeutic benefit in neurological outcomes of patients undergoing TH post-cardiac arrest. Our findings align with the current AHA guidelines and demonstrate the utility of TH irrespective of the initial rhythm.Table 1Figure 1
CT FFR in stable heart disease and Coronary Computed Tomographic Angiography helps improve patient care and societal costs
Authors: Fairbairn T
Published: November 2023

Background

NHS England (NHSE) has advocated Coronary Computed Tomographic Angiography (CCTA) as the first line diagnostic test for suspected symptomatic coronary artery disease (CAD) since NICE Guidance in 2016 and CT Fractional Flow Reserve (CT FFR) as a second line test since 2017. In 2018 a national health technology programme funded CT FFR utilisation with the aim of improving patient pathways and reducing costs.

Purpose

To determine whether the introduction of a new technology (CT FFR) into the national health system improved patient care.

Methods

A multi-centre, observational analytic cohort study of all patients that underwent CCTA at 25 NHSE sites for the assessment of CAD over a 3-year period (April 2017- March 2020). Sites and patients were categorised as pre or post CT FFR health technology introduction. Clinical outcomes (all-cause death, myocardial infarction, cardiovascular death, revascularization) and resource utilization (downstream cardiac tests) were assessed at 2 years from NHS digital health records.

Results

90,573 patients (Age 58.1±13.2, 51.9% male, 48.1% female), received 96,353 CCTA and 8,831 CT FFR as a second line test. Clinical characteristics were well matched between the 2 study groups (Figure 1).

Results are presented as pre-CT FFR vs post-CT FFR with Odds Ratio (95% CI) for Post-CT FFR.

No difference was observed for all-cause mortality (n=1135 (3.2%) vs 1627 (3.0%); OR 0.93 (0.86, 1.01), p=0.07) or Myocardial infarction events (n=348 (1.0%) vs 597 (1.1%); OR 1.12 (0.98, 1.28), p=0.10). Cardiovascular mortality was lower in the post CT FFR population (n=466 (1.3%) vs 628 (1.1%); OR 0.88 (0.78, 0.99), p=0.03) with higher rates of percutaneous intervention (PCI) (n=1866 (5.2%) vs 3069 (5.6%); OR 1.07 (1.01, 1.14), p=0.02 but not CABG (n=669 (1.9%) vs 993 (1.8%); OR 0.97 (0.87, 1.07), p=0.48). Figure 2. Fewer cardiac downstream tests were performed post CT-FFR (n=6356 (17.8%) vs 8073 (14.7%), p<0.001) including fewer invasive coronary angiograms (ICA) (n=4128 (11.6%) vs 5437 (9.9%); OR 0.84 (0.81, 0.88), p<0.001).

Conclusion

The introduction of CT FFR as a new technology on a national scale as part of a health intervention programme resulted in fewer cardiac downstream tests including fewer ICA. There was an associated increase in PCI but not CABG rates. All-cause mortality rates did not differ over time but CV mortality was significantly lower in the post-CT FFR population at 2 years.
Neurofilament Light Chain levels during admission after out-of-hospital cardiac arrest is associated with cognitive performance at 3-months follow-up
Authors: Abdi Isse Y , Wiberg S , Grand J , Obling L , Frikke-Schmidt R , Kjaergaard J , Hassager C , Meyer M A S
Published: November 2023

Background

Patients who are resuscitated from out-of-hospital cardiac arrest (OHCA) and hospitalized in coma are at high risk of mortality or brain injury with consequent cognitive impairment, and new therapy are wanted. Biomarkers of brain injury, including Neuron-specific enolase (NSE) and Neurofilament light chain (NfL), predict mortality from cerebral injury. However, prognostication of cognitive dysfunction after discharge in OHCA survivors is challenging. Montreal Cognitive Assessment (MoCA) is a recommended standardized cognitive function testing which is used in the months following OHCA. Nevertheless, prognostic methods assessed in the initial phase of admittance which identify patients at risk of developing cognitive impairment are needed.

Purpose

To investigate the effect of tocilizumab administered at admission after OHCA on cognitive performance assessed by MoCA at 3-month follow-up, and to investigate the association to time-to-ROSC, and NSE as well as NfL levels during index admission with MoCA at follow-up.

Methods

The IMICA trial evaluated tocilizumab for reducing systemic inflammation after OHCA and randomized 80 comatose adult patients at admission to an infusion of either tocilizumab (8mg/kg, maximum 800mg) or placebo. NSE at 48 hours was measured as part of routine biochemistry based on serum samples, and NFL at 48 hours was measured in serum samples from the biobank. Time-to-ROSC was reported from pre-hospital data and cognitive performance at 3 months follow-up were assessed by the MoCA test. The association between MoCA and time-to-ROSC, NSE and NfL was assessed by Spearman’s correlation analyses.

Results

At follow-up, 35 patients had a MoCA test performed, while 28 patients were deceased, and 17 were alive without having an available MoCA score. There was no difference in MoCA scores at follow-up in the tocilizumab group compared to placebo group (p=0.72), and therefore results for both groups were pooled for analyses. NfL was found to be inversely correlated with MoCA score, r = -0.49, p = 0.003 (Figure), while there were no correlations with MoCA for time-to-ROSC or NSE (p = 0.46 and p = 0.34).

Conclusions

NfL measured at 48 hours after admission was inversely correlated with cognitive performance at 3 months for survivors of OHCA.
Extracorporeal CPR versus conventional CPR for refractory out-of-hospital cardiac arrest: a meta-analysis of randomised clinical trials
Authors: Goel S , Greenstein S G , Park W J P , Hooda A H , Krishnamoorthy P M K , Kini A K , Sharma S S
Published: November 2023

Background

Refractory out of hospital cardiac arrest carry poor outcomes. Extracorporeal cardiopulmonary resuscitation (CPR) help restore perfusion and oxygenation in a patient who does not have spontaneous circulation. Recently published randomized clinical trials (RCT) have conflicting evidence supporting use of early extracorporeal CPR and have small sample size.

Purpose

To compare Extracorporeal CPR versus conventional CPR in improving neurologically favorable survival.

Methods

We conducted an electronic database search of all published data for all RCT that compared Extracorporeal CPR versus conventional CPR for refractory out of hospital cardiac arrest and reported on neurologically favorable survival rates. Event rates were compared using a forest plot of odds ratios using a fixed-effects model assuming interstudy heterogeneity.

Results

Three RCT (n= 428; Extracorporeal CPR = 208, conventional CPR = 210) were included in the final analysis. Mean follow-up period 6 months. In our analysis, extracorporeal CPR compared with conventional CPR had favorable effect on survival with a favorable neurologic outcome (OR = 1.71, 95% CI = 1.08-2.71, P = 0.02, I2= 28).

Conclusions

In patients with refractory out-of-hospital cardiac arrest, extracorporeal CPR compared with conventional CPR had favorable effect on survival with a favorable neurologic outcome
The role of serum lipoprotein(a) levels in bioprosthetic aortic valve degeneration
Authors: Farina J , Chao C J , Pereyra M , Roarke M , Said E , Barry T , Alsidawi S , Sell-Dottin K , Sweeney J P , Fortuin D , Ayoub C , Lester S , Oh J K , Arsanjani R , Marcotte F
Published: November 2023

Introduction

Lipoprotein(a) [Lp(a)] is associated with an increased incidence of aortic stenosis. Bioprosthetic aortic valve degeneration and native aortic stenosis share similar pathological mechanisms. Evidence regarding the role of serum Lp(a) concentrations in bioprosthetic aortic valve degeneration is lacking.

Purpose

To evaluate the association between serum Lp(a) concentrations and bioprosthetic aortic valve degeneration.

Methods

In this retrospective multicenter study, consecutive patients who underwent a bioprosthetic aortic valve replacement between Jan-2010 and Dec-2020 and had a preoperatory serum Lp(a) measurement were included. A baseline transthoracic echocardiography (TTE) was performed following the aortic valve replacement and a follow-up TTE was performed at least 24 months after the baseline study to determine the presence of bioprosthetic valve degeneration. Significant degeneration was defined as: (a) an increase >10 mmHg in mean bioprosthetic aortic valve gradient from baseline status + a decrease in effective orifice area + a decrease in Doppler velocity index + exclusion of clinically thrombotic leaflet thickening, OR (b) new moderate or severe prosthetic aortic regurgitation (if the main component was periprosthetic, then it was not considered). Lp(a) concentrations were compared between patients with and without degeneration and regression analysis was conducted to investigate the association between bioprosthetic valve degeneration and Lp(a) levels.

Results

In total, 211 cases were included (mean age 74.1 ±9.4 years, 72.0% males, 29.9% transcatheter aortic valve replacements) (Figure 1). Median time between baseline and follow-up TTE was 5.0 (IQR 3.7) years. Bioprostheses degeneration was observed in 33 (15.6%) patients at follow-up. Median serum levels of Lp(a) were significantly higher in the patients affected by degeneration versus non-affected cases (50.0 vs 15.7 mg/dl, p=0.003). In the regression analysis, high Lp(a) levels (≥30 mg/dl) were associated with degeneration both in a univariate analysis (OR 4.8, 95%CI 2.2-10.9, p<0.001) and multivariate analysis adjusted by other risk factors for bioprostheses degeneration (age, sex, hypertension, smoking, patient prosthesis mismatch, creatinine levels, and body surface area) (OR 5.2, 95%CI 2.1-12.8, p<0.001).

Conclusion

Serum Lp(a) concentrations seem to be a risk factor for bioprosthetic aortic valve degeneration (Figure 2). There is an increasing need to accurately predict bioprosthetic aortic valve degeneration and to develop novel methods and treatments to increase their durability. Prospective studies are needed to confirm these findings and to investigate whether lowering Lp(a) could slow bioprostheses degradation.Population characteristicsLp(a) and bioprostheses degeneration
The expression of selected microRNAs enables identification of patients with functional atrial tricuspid regurgitation. New insights into TR pathophysiology
Authors: Hinojar Baydes R , Moreno-Gomez-Toledano R , Gonzalez-Gomez A , Garcia-Martin A , Rivas S , Sanroman M , Fernandez-Golfin C , Zaragoza C , Zamorano J L
Published: November 2023

Background

Functional tricuspid regurgitation (FTR) is a powerful and independent predictor of patients’ morbidity and mortality. Atrial FTR (A-FTR) is a recently defined phenotype associated with permanent atrial fibrillation. In A-FTR, the underlying pathophysiological factors behind tricuspid annulus (TA) enlargement and the subsequent development of atrial TRF are still unclear, given that despite RA enlargement, a significant fraction of patients presenting long-term persistent atrial fibrillation (AF) will fail to develop significant TR during follow-up. Different microRNAs (miRNAs) have been studied as regulators and diagnostic biomarkers in mitral and aortic valve disease, but no study has been focus on FTR so far.

Purpose

Our current study aims to identify and validate a selection of circulating miRNAs as potential regulators of A-FTR

Methods

Consecutive patients with severe A-FTR and patients with non-valvular permanent atrial fibrillation (AF without TR) undergoing anticoagulant therapy were prospectively recruited. The experimental design included a first screening phase in 16 subjects ((8 A-FTR and 8 AF controls) to identify candidate miRNAs differentially expressed in a miRNA qPCR panel containing 192 specific miRNAs, and a second validation phase in which selected miRNAs were screened for further validation by qRT-PCR in 80 additional patients (40 TR and 40 AF).

Results

The initial screening revealed 16 differentially expressed miRNAs in atrial FTR vs. AF subjects matched by age, gender and atrial dimensions (figure 1). In the validation phase, the expression of miR-29b-3p, miR-152-3p, miR-30e-5p, miR-186-5p, miR-126-5p and miR-148a-3p (p<0.05) were significantly different in A-FTR compared to AF.

Among all, miR-186-5p, miR-152-3p and miR-30e-5p yielded the highest predictive values for the detection of A-FTR with areas under the curve of 0.96 (0.92-0.99), 0.90 (0.83-0.97) and 0.87 (0.79-0.95) respectively (p<0,001 for all, figure 2).

Conclusions

Patients with atrial FTR exhibited different miRNA fingerprint compared to patients with permanent AF without TR but similar degree of atrial enlargement. Additionally, our study identified 3 novel miRNAs as potential diagnostic biomarkers of A-FTR: miR-186-5p, miR-152-3p and miR-30e-5p which excellent accuracy. Whether the differential expression of such miRNAs precedes or follows the development of FTR or the subsequent leaflet adaptation or growth, will be further explored in future studies.Table and volcano plot of miRNAmiRNA ROC curves in A-FTR
Introducing a novel ex-vivo calcification model for human aortic valves
Authors: El Ouraoui M , Wu H W , Palmen M , Hjortnaes J , Jukema J W , Ajmone Marsan N , Kruithof B P T
Published: November 2023

Background

Aortic stenosis (AS) is a narrowing of the aortic valve opening due to calcification and thickening of the leaflets. There are currently no effective pharmacological treatments for AS, and surgery or percutaneous interventions are the only therapeutic options. The cellular and molecular mechanisms underlying AS are complex and not fully understood due to the complexity and multi-factorial nature of AS and the absence of suitable test systems. In the current in-vitro models to study valvular calcification, isolated valvular interstitial cells (VICs) are cultured in 2D and in the absence of its native extracellular matrix. In addition, other cell types like valvular endothelial cells (VECs) and macrophages, which have been shown to impact the behavior of VICs, are absent.

Purpose

Our goal is to establish an ex-vivo calcification model for human aortic valves which maintains the original valve structure and cellular components.

Methods

Diseased aortic valves were harvested from patients undergoing aortic valve replacement. A 5mm x 7mm piece of this aortic valve tissue was dissected and embedded in agarose, then cut into 300 mm slices using a vibratome (Figure 1). In this way VICs remained in their valvular environment allowing the most native response of VICs to stimuli. The use of multiple slices from a single patient ensured proper internal controls. The slices were placed on a cell culture insert and cultured for 14 days. To induce calcification, the slices were cultured in the presence of 3 mM phosphate (n=23). As a control, valvular slices were cultured in the absence of 3mM phosphate (n=12). To validate if the calcification induced in the ex vivo culture system can be molecularly modulated the glucocorticoid dexamethasone was added to cultures containing 3mM phosphate (n=8). The slices were assessed for the presence of calcification using Alizarin Red staining and for the presence of osteogenic and inflammatory markers using (Immuno) histochemistry.

Results

In the presence of 3mM Phosphate, 74% of the slices demonstrated calcification, whereas no calcification was observed in all slices cultured without 3mM Phosphate (p<0.0001; Figure 2a). Furthermore, osteogenic genes such as Runx and alkaline phosphatase-1, as well as the inflammation marker NFkb were expressed in the calcified slices (Figure 2a). Dexamethason inhibited the calcification in the slices treated with 3 mM phosphate (Figure 2b).

Conclusions

We developed a novel ex-vivo calcification model for human aortic valves in which the initiation and progression of aortic valve calcification can be studied. In addition, the calcification can be modulated at a molecular level providing a unique opportunity to uncover the molecular signaling pathways involved in valvular calcification and to test compounds facilitating pre-clinical translational studies.Figure 1Figure 2