bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors of residual lipid content detected by near-infrared spectroscopy after elective stenting in patients with chronic coronary syndrome
Authors: Usui E , Sakamoto T , Matsuda K , Nogami K , Ueno H , Hanyu Y , Nagamine T , Hada M , Hoshino M , Kakuta T
Published: November 2023

Backgrounds

Residual lipid-rich plaque (LRP) in stented segments assessed by near-infrared spectroscopy (NIRS) immediately after percutaneous coronary intervention (PCI) is reportedly associated with target lesion failure. However, morphological determinants of residual LRP after elective PCI remains unknown.

Purpose

This single-center observational study aimed to explore morphological and procedural predictors of residual LRP after electing PCI.

Methods

We investigated 340 consecutive patients who underwent elective NIRS-intravascular ultrasound-guided PCI for de novo coronary lesions. Lesions requiring balloon dilatation or debulking before NIRS imaging, requiring ≥2 remote stent deployment in the vessel, being treated with drug-coated balloon, and having insufficient NIRS imaging were excluded. Maximum lipid core burden index in 4mm (maxLCBI4mm) in culprit segment both before and after PCI was assessed by NIRS. Residual LRP was defined as post-PCI maxLCBI4mm in stented lesions >200. Baseline clinical and morphological findings were compared between lesions with versus without residual LRP. Multivariable logistic regression analysis was performed to determine predictors of residual LRP.

Results

A total of 236 de novo lesions in 223 patients were included in the final dataset. After PCI, residual LRP was observed in 69 (29%) lesions. Patients with residual LRP tended to be older than those without residual LRP. Pre-PCI maxLCBI4mm in culprit lesions, plaque burden, and remodeling index were greater in lesions with residual LRP. Post-PCI minimum stent area and expansion index tended to be smaller in lesions with residual LRP. In a multivariable analysis, pre-PCI maxLCBI4mm (per 10, adjusted odds ratio [OR]:1.04; 95% confidence interval [CI]: 1.02 to 1.05; p<0.01) and stent expansion index (per 10%, adjusted OR: 0.80; 95%CI: 0.64 to 0.99; p=0.047) were independently predictive of residual LRP.

Conclusions

In patients undergoing elective PCI, greater pre-PCI maxLCBI4mm and smaller stent expansion were associated with post-PCI residual LRP.
Association between myocardial bridge with transthoracic doppler echocardiography-defined physiological indices and fractional flow reserve before and after elective percutaneous coronary intervention
Authors: Sakamoto T , Usui E , Hoshino M , Hada M , Hanyu Y , Nagamine T , Ueno H , Nogami K , Matsuda K , Yonetsu T , Sasano T , Kakuta T
Published: November 2023

Background

A myocardial bridge (MB) is a coronary variant in which an epicardial coronary artery courses through myocardium. MB can be identified by computed tomographic coronary angiography (CTCA) or invasive coronary angiography (ICA), which is known to be common in left anterior descending artery (LAD). Transthoracic Doppler echocardiography (TDE) noninvasively provides coronary flow information.

Purpose

We aimed to investigate the physiological impact of myocardial bridge on coronary flow dynamics assessed by adenosine-induced stress-TDE before and after elective percutaneous coronary intervention (PCI).

Methods

We examined 93 consecutive patients treated with fractional flow reserve (FFR)-guided elective PCI who underwent pre-PCI CTCA and pre- and post-PCI stress-TDE. We compared patient characteristics, angiographic, physiological data, and stress-TDE-defined coronary flow parameters in patients with versus without MB.

Results

We identified MB in 40 (43.0%) and 15 (16.1%) patients by CTCA and ICA, respectively. All MBs diagnosed by ICA were identified by CTCA. Longer MB was associated with the detectability by ICA. Older age and higher frequency of diabetes mellitus were observed in patients with CTCA-defined MB compared with those without. Pre-PCI FFR was similar in patients with versus without CTCA-defined MB (0.69 [0.61-0.73] vs. 0.69 [0.61-0.75], P=0.92), while post-PCI FFR was significantly lower in patients with versus without CTCA-defined MB (0.82 [0.78-0.86] vs. 0.84 [0.82-0.88], P=0.01). Pre- and Post- PCI hyperemic systolic peak flow velocity (SPV) by stress-TDE was higher in patients with versus without MB by CTCA (36 [26-43] m/s vs. 30 [23-34] m/s, P=0.03 and 38 [32-52] m/s vs. 33 [20-39] m/s, P=0.02, respectively). Pre-PCI hyperemic diastolic peak flow velocity (DPV) by stress-TDE was not significantly different between the 2 groups (49 [39-64] m/s vs. 45 [34-55] m/s, P=0.12), while post-PCI hyperemic DPV was higher in patients with versus without CTCA-defined MB (73 [60-85] m/s vs. 63 [50-81] m/s, P=0.03).

Conclusion

In patients undergoing elective PCI for LAD, a presence of CTCA-defined MB was associated with higher pre- and post-PCI hyperemic SPV and an acceleration of hyperemic DPV after the PCI. Impact of systolic compression by MB on hyperemic DPV at the distal segment accelerated by the treatment of upstream stenosis may lead to lower post-PCI FFR compared with patients without MB.
A novel scoring system devised by an international large-scale coronary bifurcation registry to guide the optimal choice between the 1- and 2-stent strategy: the BIFURCAT Two-Stent (BTS) score
Authors: Jang A Y , Oh P C , Kim M S , Lee K H , Lee J P , Won Y S , Koo B K , Han S H
Published: November 2023

Background and Aims

Previous studies used predefined criteria to evaluate the outcomes of two stents over one stent. We sought to devise a scoring system based on data-driven criteria for the guiding the optimal choice between two approaches.

Methods

We analyzed an international coronary bifurcation cohort with 2nd-generation drug-eluting stents, the combined insights from the unified RAIN and COBIS bifurcation registries (BIFURCAT) registry. The primary endpoint was major adverse cardiac events (MACE), a composite of death, myocardial infarction, and target lesion failure.

Results

We analyzed 5333 patients (mean age: 66.2 years; male: 76%; 1-stent: 82%). We found one clinical and five angiographic factors associated with lower MACE risk when two stents were implanted compared with one. We assigned one point per each component the patient was positive for and defined this as the BIFURCAT Two-Stent (BTS) score. The 2-stent strategy was associated with significantly higher MACE rate in the total patient cohort (HR: 1.49; 95% CI: 1.19-1.87; P<0.001) and BTS score<4 (HR: 2.04; 95% CI: 1.64-2.56; P<0.001). However, the two stents had a lower chance of MACE in BTS score≥4 (HR: 0.56; 95% CI: 0.35-0.89; P=0.014) with or without adjustment for baseline and procedural characteristics and antiplatelet therapy.

Conclusions

Approximately 80% of the patients had low (<4) BTS score that showed favorable outcomes with the 1-stent strategy. However, those with high BTS scores (≥4) proved favorable outcomes with the 2-stent strategy. The BTS score may be able to guide interventionists to select an optimal stenting strategy in bifurcation lesions.
Optical coherence tomography assessment of dissection following Drug-Coated Balloon treatment in de-novo small vessel disease
Authors: Ninomiya K , Huang J , Masuda S , Ding D , Tu S , Dijkstra J , Reimers B , Colombo A , Onuma Y
Published: November 2023

Background/Introduction

Several studies have shown either favorable or unfavorable effects of dissection following drug-coated balloon (DCB) angioplasty. However, there is no established method to precisely assess the extent of dissection during DCB treatment and the relationship between dissection and late lumen gain (LLG) remains unclear.

Purpose

The aim of this study is to develop a new method to quantify the dissection and investigate the impact of dissection volume on angiographic outcomes.

Methods

The present study consisted of patients enrolled in the randomized TRANSFORM-I trial, comparing novel Magic TouchTM sirolimus coated-balloon with SeQuent Please NeoTM paclitaxel coated balloon (PCB) in patients with de-novo small vessel coronary artery disease.

One-hundred lesions in 98 patients were investigated with OCT after pre-dilatation to assess the dissection. A customized software (QCU-CMS, Leiden) precisely quantifies the dissection and lumen volumes separated by a common boundary connecting the two edges of the intimal fracture. Quantitative OCT analysis of dissection volume is derived from cross-sectional slices with a thickness of 200 microns. Tissue composition analysis, using OCT-Deep Learning (DL) (Pulse, Shanghai), at the starting site of the dissection was performed to elucidate the mechanisms triggering the dissection.

Results

The dissection was found in 96% (96/100) of the treated lesions. The median dissection volume was 1.98 (0.57 – 3.89)mm3. The median maximal dissection arc was 113 degree.

The tissue composition analysis showed that the dissection occurs at the thinnest site (320 μm) of fibrous intima (83%) (Figure). The 6-month angiographic outcomes of TRANSFORM-I will be presented at the late breaking session by then the mechanistic determinant of late loss and gain will have been examined in details.

Conclusions

Quantitative OCT analysis of dissection demonstrated that dissection occurs during DCB treatment. Final results with 6-month outcome, relationship between the dissection volume and late lumen loss (LLL) or LLG will be presented at the time of congress.Figure
Increased in-hospital complication risk in women undergoing chronic total occlusion recanalization
Authors: Hamzaraj K , Holzgruber M , Kastrati L , Graf S , Gyoengyoesi M , Lang I , Hengstenberg C , Aschauer S , Distelmaier K , Frey B , Toma A
Published: November 2023

Introduction

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is a complex procedure that requires advanced operator skills and dedicated devices. Despite increasing success rates of up to 95% in experienced centers, in-hospital complications associated with CTO PCI remain high, and predictors of short-term outcomes and complications are yet scarce. Female sex is often observed to be correlated with in-hospital complications in complex interventions, but current evidence related to CTO PCI is ambiguous and inconclusive. Our aim was to investigate the potential impact of sex on individual and composite in-hospital complications associated with CTO PCI.

Methods

We prospectively included patients undergoing CTO PCI at our university-affiliated tertiary care center over four years (2018-2021). In this analysis, we compared comprehensive baseline characteristics and angiographic parameters between men and women and estimated their correlation with a composite endpoint of in-hospital complications using adjusted logistic regression analysis. We presented group differences related to individual component in-hospital complications.

Results

Out of 271 patients undergoing antegrade or retrograde CTO PCI, 222 (81.9%) were men, and 49 (18.9%) were women. Compared with men, women were older (67 ±11 vs. 72±12 years, P=.005) and had less prior PCI (65.8% vs. 44.9%, P=.006). Both groups had comparable angiographic complexity. Overall MACCE was 2.6%, and any in-hospital complication occurred in 8 women (16.3%) and 15 men (6.8%). Univariate analysis showed that sex, J-CTO score, and proximal cap ambiguity were correlated with the primary composite endpoint. By adjusted multivariate analysis, sex was independently associated with any in-hospital complication (OR=.334; CI .129 to .864; P=.024). The results were numerically driven by major bleeding, acute kidney injury, and MACCE.

Conclusion

Our findings suggest that women undergoing CTO PCI are at an increased risk of any in-hospital complication, regardless of clinical severity. Further studies are needed to confirm this finding and explain potential gender disparities in patients undergoing CTO PCI.Clinical and angiography characteristicsIn-hospital complications
Percutaneous coronary intervention versus optimal medical therapy for chronic total occlusion: an updated meta-analysis of randomized controlled trials comparing clinical and health status outcomes
Authors: Gandhi K , Moras E , Isath A , Correa A , Mahmood K , Casso Dominguez A , Tamis-Holland J
Published: November 2023

Background

The prevalence of coronary chronic total occlusion (CTO) varies widely from 18-52% in patients with stable ischemic heart disease. Despite recent advances in operator techniques and improving operator experience, percutaneous coronary intervention (PCI) for CTO still poses a major challenge. While several observational studies have demonstrated superior outcomes for CTO-PCI, the overall benefit of CTO intervention remains controversial.

Purpose

We aimed to compare the clinical endpoints and health status outcomes in all randomized controlled trials (RCT's) to evaluate safety and efficacy of PCI as compared to optimal medical therapy (OMT).

Methods

We queried PubMed/MEDLINE, Cochrane Library and EMBASE for RCT’s that compared CTO-PCI with OMT. The primary endpoint was all-cause mortality. Secondary outcomes included cardiac mortality, major adverse cardiac and cerebrovascular events (MACCE), myocardial infarction (MI), target vessel revascularization (TLR), stent thrombosis, left ventricle ejection fraction (LVEF) changes and health status outcomes. Risk ratios (RR’s) and their corresponding 95% confidence intervals (CIs) were calculated using the random-effects model.

Results

We included a total of 6 RCT’s (1890 total patients, mean age 61.8±3.6, and 84.6 % male) Follow-up ranged from 4 to 48 months. All-cause mortality and cardiac mortality were comparable between CTO-PCI and OMT groups (RR 0.83; 95% CI 0.47 – 1.48; p = 0.53 and RR 0.98; 95% CI 0.24 – 4.07; p = 0.98, respectively). There was no significant difference between PCI or medical therapy with regards to MACCE (RR 0.85; 95% CI 0.50 – 1.45; p = 0.55) and TLR at follow-up (RR 0.50, 95% CI 0.24 – 1.06; p = 0.07). Moreover, the risk for MI (RR 1.36; 95% CI 0.91 – 2.-2; p = 0.13), stent thrombosis (RR 1.74; 95% CI 0.36 – 8.40; p = 0.49), and stroke at follow-up (RR 0.57; 95% CI 0.24 – 1.38; p = 0.21) was comparable between the two groups. Health status outcomes such as angina frequency (RR 4.05; 95% CI –1.95 – 10.05; p = 0.19), physical limitations (RR 3.83; 95% CI –0.75 – 8.41; p = 0.10), quality of life (RR 6.25; 95% CI –1.54 – 14.03; p = 0.12), and treatment satisfaction (RR 2.60; 95% CI –1.15 – 6.35; p = 0.17), were comparable between the two groups.

Conclusion

Pooled data from RCT does not support an advantage to CTO PCI in terms of a reduction in cardiovascular events or improved quality of life. Further adequately powered and long-term trials are required to identify the best management strategy for patients with coronary CTO.Figure 1Figure 2
Prognostic implications of iron deficiency and supplementation in patients undergoing valvular heart surgery
Authors: Tse Y K , Ren Q W , Wu M Z , Huang J Y , Leung C K L , Li H L , Tse H F , Yiu K H
Published: November 2023

Background

Iron deficiency is common in patients with cardiovascular diseases, present in up to 60% of patients with coronary artery disease, heart failure, or pulmonary hypertension. Its role in valvular heart disease, including its prevalence, determinants, and prognostic implications, remains unclear.

Purpose

The present study aimed to evaluate the prognostic significance of iron deficiency in patients undergoing valvular heart surgery.

Methods

Pre-operative haematology and iron profiles were retrospectively collected in all patients undergoing valvular heart surgery in Hong Kong between 2010 and 2021. Iron deficiency was defined referencing the ESC 2021 guidelines as a ferritin level <100 ng/mL or a transferrin saturation <20% with a ferritin level of 100 to 299 ng/mL. Logistic regression analyses were conducted to determine variables associated with guideline-defined iron deficiency. Stepwise Cox proportional hazards regression was applied to identify predictors of 5-year mortality. The impact of iron supplementation on outcomes was estimated in iron-deficient patients, modelled by inverse probability of treatment-weighted logistic regression.

Results

Our study included 578 patients; the median age was 62 (interquartile range 54-70) years, and 47.4% were males. Iron deficiency was present in 324 (56.1%) patients. Independent correlates of iron deficiency were age, male sex, diabetes mellitus, atrial fibrillation, heart failure, diuretics and warfarin use, aortic stenosis, and tricuspid regurgitation (Table 1).

Death from any cause occurred in 99 patients over five years of follow-up, of which 45 were due to cardiovascular events. Iron deficiency was associated with a two- to three-fold excess risk of all-cause (hazard ratio [HR] 1.89, 95% CI 1.23-2.90; P = 0.004) and cardiovascular mortality (HR 2.84, 95% CI 1.23-2.90; P = 0.004). Results were consistent in multivariable models incorporating comorbidities, medications, type of valvular intervention, and cardiac surgery risk-scoring systems, even after adjustment for haemoglobin levels (Table 2). For individual components of the guideline criteria, transferrin saturation <20% and ferritin <300 ng/mL were associated with worse all-cause and cardiovascular mortality.

Among 324 patients with iron deficiency, 61 (18.8%) received iron supplementation before valvular surgery. Iron supplementation was associated with a 58% lower risk of death in multivariable models with IPTW (HR 0.42; 95% CI, 0.19–0.99; P = 0.047).

Conclusions

In patients undergoing valvular surgery, iron deficiency is associated with worse survival. This elevated risk may be mitigated by iron supplementation before valvular surgery.Table 1Table 2
Impact of implantation depth and cusp-specific calcium score on the incidence of left bundle branch block and infranodal conduction delay after transcatheter aortic valve replacement
Authors: Serban T , Papa A , Isenegger C , Knecht S , Nestelberger T , Kaiser C , Leibundgut G , Sticherling C , Kuehne M , Badertscher P
Published: November 2023

Background

Conduction disorders and left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) are common. Risk factors, however, remain incompletely understood.

Purpose

To assess the impact of valve implantation depth and overall and cusp-specific aortic valve calcification on the incidence of LBBB and infranodal conduction delay post-TAVR.

Methods

In all patients undergoing TAVR between June 2020 and June 2021 the His-Ventricle (HV) interval was measured at least twice (pre-and post-valve deployment) and in the case of LBBB additionally one day after TAVR. Infranodal conduction delay was defined as HV > 55ms. The implantation depth of the valve was defined as the distance between the lower edge of the valve frame and the aortic annulus level and examined by two independent raters. Aortic valve calcification was assessed using the Agatston calcium score: overall and for each aortic cusp separately. Patients with valve-in-valve procedures were excluded.

Results

A total of 101 patients (mean age 81±5.7 years, 47% women) were included. The mean implantation depth was 5±3.1 mm. The median calcium score was 1840 AU [IQR 632-2400]. The baseline median HV interval was 46ms [IQR 39-50] and 8 patients demonstrated LBBB at baseline. Post-valve deployment LBBB was observed in 52 patients (52%), in whom the median HV interval was 52 ms [IQR 44-57]. Infranodal conduction delay was noted in 27 of 101 patients (27%). There was no correlation of delta HV (pre- vs. post-TAVR) and implantation depth or calcium score (r=0.08 and r=0.01, respectively). Patients with LBBB and infranodal conduction delay had comparable valve implantation depths (p=0.5) and total calcium scores (p=0.19) compared to patients with no LBBB and no infranodal conduction delay. Left ventricular outflow tract calcification measured at non-coronary cusp (NCC) level was a significant predictor for infranodal conduction delay post-valve deployment in a multivariable logistic regression model (OR 1.62, 95% CI 1.06-2.69 per 100 AU increase, p=0.04) and in a quantile regression model (p=0.002, Figure). In all models, the implantation depth was unable to predict new conduction disorders.

Conclusion

While the implantation depth had no impact on the incidence of LBBB or infranodal conduction delay, preprocedural assessment of aortic valve calcification for the NCC may help identify patients at risk for conduction disorders after TAVR. Further studies are needed to confirm these findings.
Impact of platelet reactivity on subclinical valve thrombosis in patients treated with TAVR
Authors: Jimenez-Quevedo P , Espejo-Paeres C , Mcinerney A , Tirado-Conte G , Marroquin L , Spione F , Hennessey B , Gonzalo N , Fernandez-Ortiz A , Escaned J , Nunez-Gil I , Regueiro A , Gomez De Diego J J , Nombela-Franco L , Pozo E
Published: November 2023

Background and introduction

High residual platelet reactivity (HPR) in patients undergoing percutaneous coronary intervention with dual antiplatelet therapy (DAPT) is associated with an increased risk of thrombotic events. The relationship between HPR and the presence of subclinical valve thrombosis (SVT) following transcatheter aortic valve replacement (TAVR) is unknown.

Purpose

The aim of this study was to determine whether HPR is associated with the occurrence of SVT in patients undergoing TAVR treated with DAPT and to determine independent predictors of SVT.

Methods

This is a prospective, multicentre study. Patients with symptomatic aortic stenosis successfully treated with TAVR followed by DAPT (aspirin + clopidogrel) for 3 months were included. Patients with monotherapy, oral anticoagulation, or severe renal impairment were excluded. For the purpose of the study, platelet reactivity was measured either with Multiplate analyzer or VerifyNow point-of-care assay at baseline, at 1-2 days post, and 1-3 months post-TAVR. HPR was defined as ≥ 468AU, or ≥208PRU, respectively. The primary endpoint was the incidence of SVT measured by multi-slice CT at 3-months post TAVR in relation to HPR. Secondary objectives included the relationship between HPR following TAVR and the incidence of major adverse cardiac and cerebral clinical events (MACCE), to determine whether a pro-thrombotic inflammatory response is associated with the appearance of SVT and to evaluate factors associated with the occurrence of SVT.

Results

A total of 169 patients were included, the mean age was 81.5±5 and 51% were female. The overall rate of SVT was 22%. Patients with HPR demonstrated a similar incidence of SVT to those without (23,7% vs 33,6%: p=0,29). The overall bleeding rate was 4,9%. No differences in the rate of stroke at 1-year follow-up were observed (no SVT group 1.5% vs SVT group 2.6%: p=0.6). Independent predictors of SVT, were: dyslipemia OR 0,38 (0,15-0,96) p=0,039, creatinine clearance 0.98 (0.96.1.0, p=0.04), self-expandable valve OR 3,57 (1,40-9,06); p=0,006 and prosthesis size 0,78 (0,64-0,96): p=0,009. Patients with SVT expressed increased inflammatory parameters at 6 months compared to those without SVT CD14+ CD16-: 76,6±9,9 vs 70,7±13,9: p=0.02.

Conclusion

In contrast to coronary interventions, for the first time we have demonstrated that HPR does not appear to be associated with the development of SVT in TAVR patients treated with DAPT.
A novel hemodynamic index characterizing mitral regurgitation undergoing transcatheter edge to edge repair: the mitral pulse pressure fraction
Authors: Leone A M , Di Giusto F , Lucarelli K , Vicere A , Anastasia G , Galante D , Petrolati E , Burzotta F , Aurigemma C , Lombardo A , Locorotondo G , Graziani F , Casamassima V , Grimaldi M , Trani C
Published: November 2023

Objectives

Our study sought to investigate the role of invasive hemodynamic monitoring during Transcatheter Edge to Edge Repair (TEER) procedure on top of transesophageal echocardiographic (TEE) guidance.

Background

Direct hemodynamic impact of residual MR after TEER is not always univocally measured by TEE assessment alone. When analyzing TEER procedure result operators often encounter discrepancy between TEE guidance and invasive hemodynamic monitoring.

Methods

We analyzed 78 patients with moderate-to-severe or severe mitral regurgitation (MR) who underwent TEER. Mitral pulse Pressure Fraction (MPF) was extracted from intraprocedural continuous left atrial pressure monitoring. 23 patients with the same grade of MR not undergoing TEER were included as a control group.

Results

TEER had a significant impact reducing MR burden on both TEE guidance and invasive hemodynamic monitoring. Post-TEER MPF was significantly reduced compared to both pre-TEER setting (p < 0.001) and control group (p = 0.004). MR reduction assessed by TEE guidance was not found to be correlated with improved clinical and functional status at follow-up as assessed by New York Heart Association (NYHA) classification (p = 0.424) and 12-items Kansas City Cardiomyopathy Questionnaire (KCCQ) (p = 0.1). On the contrary, a greater reduction in MPF was associated with a significant amelioration of both NYHA classification (p = 0.003) and 12-items KCCQ (p<0.001) during the follow-up period.

Conclusions

MPF provides an immediate estimate of the real hemodynamic impact of MR and can offer a prompt prediction of the functional improvement after TEER.
Investigating the impact of chronic heart failure on in-hospital outcomes following transcatheter mitral valve repair or replacement: a national inpatient sample study (2016-2020)
Authors: Nomigolzar S , Nomigolzar R , Vallabhaneni M , Hammammi A
Published: November 2023

Background

Chronic heart failure (CHF) is a global health problem and one of the primary causes of morbidity and mortality worldwide. Transcatheter mitral valve repair or replacement (TMVr or TMVR) is a procedure that has demonstrated improved outcomes in patients with severe mitral valve disease. However, the impact of CHF on in-hospital outcomes following TMVR or TMVr remains unclear.

Methods

In this retrospective cohort study, we utilized the United States National Inpatient Sample database from 2016 to 2020. We identified patients who underwent TMVR or TMVr using ICD-10 codes and stratified them based on the presence or absence of CHF diagnosis. We assessed in-hospital complications, length of stay, and cost of care as primary and secondary outcomes. We performed multivariate logistic regression analysis to control for potential confounders.

Results

Our study included 48,885 patients who underwent TMVR or TMVr, of which 16,132 (33%) had a diagnosis of CHF. The cohort was predominantly male (54%) with a mean age of 76 years. Compared to patients without CHF who underwent TMVR/TMVr, those with CHF had lower rates of in-hospital mortality, valvular complications, cardiogenic shock, vascular complications, bleeding, blood transfusions, respiratory failure, acute kidney injury, and acute myocardial infarction (see Figure 1). Additionally, patients with CHF had a reduced length of stay (coefficient -3.48; p <0.001) and cost of care (coefficient -$58749.37; p <0.001). However, there were no significant differences in rates of pericardial tamponade, intracranial hemorrhage, or ischemic strokes.

Conclusions

Our findings suggest that patients with chronic heart failure (CHF) who underwent transcatheter mitral valve repair or replacement (TMVr or TMVR) had better in-hospital outcomes compared to those without CHF. This may be due to a protective effect of the chronic disease, where compensatory mechanisms developed by the body may help patients with CHF better tolerate the procedure and have decreased in-hospital complications. These results highlight the importance of further investigating the role of CHF in TMVr/TMVR outcomes and tailoring patient selection for these procedures.
Preprocedural simulation of a mitral transcatheter edge-to-edge repair using computed tomography imaging
Authors: Miyata A , Miyamoto T , Imai M , Sato Y
Published: November 2023

Mitral transcatheter edge-to-edge repairs (TEERs) are a widespread treatment option for heart failure complicated with mitral regurgitation. Although we generally use trans-oesophageal echocardiography (TOE) to understand structural heart disease conditions, TOE does not provide a complete view of the heart and surrounding structures. As the TEER device moves in complex ways during the procedure, it is difficult to imagine the actual behavior of the device only from the images obtained from TOE because of its restricted angle of view. Contrast-enhanced CT, on the other hand, is a modality that can capture the image of the heart as a whole, as if looking at a bird’s eye view.

The purpose of our study was to create a TEER device simulator using ECG-gated computed tomography imaging.

As the first step, we created a virtual inferior vena cava and fossa ovalis model. We obtained 192 possible CT image patterns of the TEER device with this model, and they all were extracted into an STL file format. As the second step, the ECG-gated cardiac CT images of the patients were segmented into each cardiac structure and also extracted into STL files. Finally, both STL file images were fused by some 3D software, and we made a simulation of the TEER procedure preoperatively. By piling up each knob operation and rotation, we could reproduce the serial movement of the TEER device.

We could successfully reproduce the TEER device with each knob operation and rotation on a patient-specific cardiac CT image. The positional relationship between the heart and device were visualized, showing the entire trajectory of the device. It could also allow preoperative simulations to be tailored to each patient. Compared to some previous reports about TEER simulations using 3D printing models, our method could save time and cost 1)2). Another report demonstrated a simulator using a cardiac CT image, but that report did not mention how to obtain the device image 3). Our method would be more precise because our simulator was based on real TEER device images. We will apply this method for upcoming real cases and will then confirm whether a preoperative simulation of the ideal manipulation would enable optimal clipping.

We successfully created a prototype of a TEER simulator using ECG-gated computed tomography imaging.en face view of the mitral valve (TOE)en face view (simulator)
Impact of the antiplatelet strategy following patent foramen ovale percutaneous closure
Authors: Guedeney P , Farjat-Pasos J I , Asslo G , Roule V , Hermida A , Huang F , Lattuca B , Leclercq F , Mesnier J , Abtan J , Rouanet S , Zeitouni M , Silvain J , Montalescot G , Rodes-Cabau J
Published: November 2023

Background

Temporary dual antiplatelet therapy (DAPT) is recommended following patent foramen ovale (PFO) percutaneous closure although its benefit, compared to single antiplatelet therapy (SAPT), has not been demonstrated in this setting.

Objective

We aimed at assessing outcomes following PFO closure according to the antiplatelet strategy at discharge.

Methods

The ambispective AIR-FORCE cohort included consecutive patients from 7 centers in France and Canada undergoing PFO closure and discharged without anticoagulation. Patients treated in French and Canadian centers were mostly discharged with DAPT and SAPT, respectively. The primary endpoint was the composite of death, stroke, transient ischemic attack, peripheral embolism, myocardial infarction, or BARC type ≥2 bleeding with up to 5 years of follow-up. The impact of the antiplatelet strategy on outcomes was evaluated with a marginal Cox model (cluster analyses per country) with inverse probability weighting according to propensity score.

Results

A total of 1,532 patients were included from 2001 to 2022, of whom 599 (39.1%) were discharged with SAPT and 933 (60.9%) with DAPT, for ≤3 months in 894/923 (96.9%) cases (Table 1). After a median follow-up of 2.4[1.1-4.4] years, a total of 58 events were observed. In the weighted analysis the rate of the primary endpoint up to 5 years was 7.8% in the SAPT strategy and 7.3% in the DAPT strategy (weighted hazard ratio 1.04, 95% confidence interval 0.59-1.83) (Figure 1). Results were consistent in a sensitivity analysis.

Conclusion

The strategy of antiplatelet strategy following PFO closure did not seem to impact clinical outcomes, thus challenging the current recommendations of temporary DAPT.Table 1.Baseline characteristicsFigure 1.Central illustration
Interventional left atrial appendage occlusion is effective and safe in high-risk patients with prior stroke: comprehensive insights from the multicenter German LAARGE registry
Authors: Fastner C , Brachmann J , Lewalter T , Zeymer U , Sievert H , Ledwoch J , Geist V , Hochadel M , Schneider S , Senges J , Akin I , Ansari U
Published: November 2023

Background

Interventional left atrial appendage occlusion (LAAO) is an alternative therapeutic strategy equivalent to non-vitamin K antagonist oral anticoagulation (OAC) in preventing thromboembolism (TE) for non-valvular atrial fibrillation (AF) patients with contraindications to OAC. However, patients with prior stroke are at relevant higher risk for TE than general patient populations. These patients are often prone to multimorbidity, are at high risk for bleeding, and may well benefit from LAAO.

Purpose

To investigate the performance of LAAO in secondary prevention after prior stroke versus patients without history of stroke and to reveal any potential differences in effectiveness and safety.

Methods

Data from multicenter German LAARGE was used, which is a prospective, non-randomized registry on clinical reality of LAAO with different standard commercial devices. Effectiveness was primarily assessed by the combined absence of all-cause death or non-fatal stroke within 365 days after the procedure, and secondarily by the absence of transient ischemic attack (TIA) or systemic embolism. Safety was assessed with data documenting adverse events during index hospitalization or follow-up.

Results

638 patients from 38 centers were consecutively included. 137 patients had a history of stroke (21.5%) and 501 patients had none. Stroke patients had a significantly pronounced cardiovascular comorbidity: CHA2DS2-VASc score 5.9+1.3 vs. 4.1+1.4 and HAS-BLED score 4.6+1.0 vs. 3.7+1.1, respectively (each p<0.001). A high procedural success (98.5 vs. 97.4%, p=NS) was accompanied by low periprocedural MACCE or major complication rates (0% vs. 0.6 and 4.4 vs. 4.0%, respectively; each p=NS). Primary effectiveness outcome measure was not statistically different between both groups on follow-up (freedom from all-cause death or non-fatal stroke: 87.8 vs. 87.7%), while TIA (0 vs. 0.5%), systemic embolism (0.9 vs. 0%) as well as severe bleeding events (0 vs. 0.7%; each p=NS) were extremely rare.

Conclusions

Patients with history of stroke, though showing significantly pronounced multimorbidity, demonstrated a similar effectiveness and safety profile for LAAO as compared to patients without prior stroke. LAAO could serve as a feasible alternative to OAC in this selected group of high-risk AF patients with contraindications to standard care.All-cause death or non-fatal stroke (KM)
Left appendage closure after intracranial hemorrhage: safety, efficacy and timing
Authors: Laffond A , Gonzalez Calle D , Nunez Garcia J C , Blanco Fernandez F , Lopez Tejero S , Antunez Muinos P , Barreira De Sousa G , Rodriguez Collado J , Herrero Garibi J , Diego Nieto A , Martin Moreiras J , Sanchez Ledesma M , Sanchez Fernandez P L , Cruz Gonzalez I
Published: November 2023

Background

Oral anticoagulation (OAC) use increases the risk of intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF). Left atrial appendage occlusion (LAAO) is an alternative to OAC, however data about its use in patients with prior ICH is scare and the timing of its performance is controversial. Furthermore, the long-term outcomes in this group of patients have not been described.

Objective

To evaluate the safety and efficacy of LAAO in patients with non-valvular AF and prior ICH (CHA2SVASc >2) and to determine adequate timing of its performance.

Methods

The sample was obtained from a cohort of 397 patients with AF in which LAAO was performed between 2009 and 2020. In 115 of these patients, the indication for this procedure was ICH (29.8 %). Patients were divided into two groups: early occlusion (n=68; 59%), in which the procedure was performed before 90 days had elapsed after the bleeding, and late occlusion (n=47; 41%), after 90 days.

Results

Procedure success was 97% globally. Annual incidence of ischemic events was of 0,6%, with an absolute risk reduction of 5,9% and relative risk reduction of 90,3% compared to the predicted risk by CHA2DS2-VASC score. Regarding major hemorrhagic events, annual incidence was of 4%, with an absolute risk reduction of 3,4% and relative risk reduction of 45% compared to the predicted risk by HASBLED score.

There were no significant differences between the procedures performed in patients with history of intracranial bleeding and other indications for the procedure.

Early closure (first 90 days after the intracranial hemorrhage) was as safe as late closure, without an increase in in-hospital bleedings or complications. Furthermore, long-term follow-up demonstrated a significant reduction in all-cause mortality (11.76% versus 46.8%; HR 0.2, IC95% 0.07-0.55; p<0.001). compared with late occlusion.

Conclusions

Left atrial appendage occlusion is an effective and safe treatment option to reduce the risk of ischemic stroke in selected patients with AF patients and history of ICH over mean follow-up of 3 years. Early occlusion seems to be at least as safe and effective as late occlusion and therefore could potentially reduce the rate of complications after ICH in selected patients.Survival and closure timingIschemic and bleeding risk reduction
The COVID-19 pandemic and reduced surgical site infection following cardiac surgery: time to take up the baton
Authors: Jameie M , Ilkhani S , Pashang M , Bagheri A , Jalali A , Barkhordari K H , Nosrati M , Boroumand M , Hosseini K , Masoudkabir F , Bagheri J
Published: November 2023

Background

Various hygienic measures have been reinforced or newly-adopted since the start of the COVID-19 pandemic. At the same time, studies have indicated a reduction in various types of hospital-acquired infections, including surgical site infections (SSI).

Purpose

This study investigated the association of the pandemic with SSI following cardiac surgeries.

Method

From 2014 to 2022, 26143 patients undergoing cardiac surgery were included and categorized into "pre-pandemic" (n= 22015) and "during-pandemic" (n=4128) groups. SSIs were classified into harvest-site, superficial sternal, and complex sternal infection. Logistic regression (univariate and multivariable) and inverse probability weighting (IPW) assessed the association of the pandemic with SSIs. For both analyses, various known SSI-related risk factors were taken into account as covariates.

Results

Among the study population, 793 SSIs occurred. The "during-pandemic" patients were significantly younger (61.87±10.58 vs. 65.64 ±11.82) with a higher male proportion (70.1% vs. 67.4%) and a higher prevalence of comorbidities/risk factors (expect for cigarette smoking). Total SSI rate significantly plummeted from 3.3% before COVID-19 to 1.8% afterward (P<0.001) (Figure 1 and 2). IPW analyses evinced an independent association of the pandemic with a reduced risk of total (adjusted-OR: 0.59, 95% confidence interval (CI):0.45-0.78), harvest-site (adjusted-OR: 0.36, 95%CI: 0.19-0.70), and superficial sternal infection (adjusted-OR: 0.60, 95%CI: 0.43-0.81). No significant association was observed with complex sternal site infection (adjusted-OR: 1.05, 95% CI: 0.55-2.01). Multivariable regression recapitulated these findings (Figure 2).

Conclusions

The COVID-19 pandemic pertained to more than a 40% reduction in SSI occurrence, particularly affecting harvest-site and superficial sternal infections. To some extent, the drop in SSIs following the pandemic can be justified by reinforced hygienic precautions, emphasizing the necessity of extending reinforcement of and adherence to these measurements into the post-COVID-19 era to maintain the status quo.
Veno-arterial extracorporeal membrane oxygenation as direct bridge to heart transplantation in a low and middle income country
Authors: Burgos L , Chicote F , Vrancic M , Seoane L , Costabel J , Furmento J , Ballari F , Baro Vila R , Piccinini F , Espinoza J , Navia D , Diez M
Published: November 2023

Introduction

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) as a direct bridge to heart transplantation (BTT) is not common in adults worldwide. BTT with ECMO is associated with increased early/mid-term mortality compared with other interventions. In low- and middle-income countries (LMIC), where no other type of short-term mechanical circulatory support is available, its use is widespread and increasingly used as rescue therapy in patients with cardiogenic shock (CS) as a direct bridge to heart transplantation (HT).

Objective

To assess the outcomes of adult patients using VA ECMO as a direct bridge to heart transplantation in a LMIC and compare them with international registries.

Methods

We conducted a single-center study analyzing consecutive adult patients requiring VA-ECMO as BTT due to refractory CS or cardiac arrest (CA) in a cardiovascular center in Argentina between January 2014 and December 2022. Survival and adverse clinical events after VA-ECMO implantation were evaluated.

Results

Of 86 VA-ECMO, 22 (25.5%) were implanted as initial BTT strategy and 52.1% finally underwent HT. Mean age was 46 years (SD 12); 59% were male. ECMO was indicated in all cases for CS and the most common underlying condition was coronary artery disease (30%), followed by idiopathic dilated cardiomyopathy (15%). Patient outcomes are described in Figure 1. Overall in-hospital mortality for VA ECMO as BTT was 50%. Survival to discharge was 83% in those who achieved HT and 10% in those who did not, p<0.001. In those who did not achieve HT, the main cause of death was haemorrhagic complications (44%), followed by thrombotic complications (33%). The median duration of VA ECMO was 6 days (IQR 3-16). There were no differences in the number of days on ECMO between those who received a transplant and those who did not. In the Spanish registry (Barge Caballero et al 2018), in-hospital survival after HT was 66.7%, the United Network of Organ Sharing registry (Fukuhara et al 2018) estimated post-transplant survival at 73.1% ± 4.4%, and in the French national registry (Jasserson et al 2016), 1-year post-transplant survival was 70% in the VA ECMO group.

Conclusions

In adult patients with cardiogenic shock, VA-ECMO as a direct BTT allowed successful HT in half of the patients. HT provided a survival benefit in listed patients on VA-ECMO. VA-ECMO can be used to bridge critically ill candidates directly to HT in a setting where no other circulatory support is available, as a salvage strategy with acceptable mortality in a high-volume specialized center. We present a single center experience with results comparable to registries in Spain, France and the United States.
Arterial stiffness assessment in patients with resistant hypertension using pulse wave analysis
Authors: Akhmimi A , Sprung V S , Lip G Y H , Oxborough D , Shantsila A
Published: November 2023

Introduction

People living with resistant hypertension (RH) have a higher prevalence of target organ damage, and demonstrate increased risk of cardiovascular (CV) morbidity and mortality. There are distinctive vascular structural and functional changes associated with hypertension. Among these, endothelial dysfunction and increased arterial stiffness are prevalent. Increased aortic augmentation index (AIx) is a non-invasive hemodynamic indicator of systemic arterial stiffness, which has been associated with hypertension; however, there are less data in RH patients.

Purpose

To test the hypothesis that people living with RH have increased AIx compared to those with controlled essential hypertension (CH) and normotensive controls (NC); and to explore demographic and clinical variables related to AIx.

Methods

In our observational study, 54 participants: 17 with RH (mean age 60.5±12.4 years), 18 with CH (57.7±12.2 years), and 19 NC (54.7±11.9 years) were recruited. Anthropometric and resting office blood pressure (BP) measurements were obtained. Pulse wave analysis was performed using a commercially available device (Vicorder) to measure central BP, aortic pulse pressure, mean arterial pressure (MAP), aortic augmentation pressure and AIx.

Results

The study groups were matched for age, sex, ethnicity, height, body surface area and heart rate (P>0.05) (Table 1). Both office and central BP readings were elevated in RH group compared to CH and NC (162/102mmHg vs 126/86mmHg and 118/80mmHg, P<0.001) and (163/83mmHg vs 131/73mmHg and 120/67mmHg, P<0.05). Aortic pulse pressure, MAP and aortic augmentation pressure were significantly increased in patients with RH compared to other groups (P<0.001). AIx was markedly increased in RH compared to CH and NC (31±7% vs 23±8% and 21±9%, P=0.001, respectively). Antihypertensive medications were similar between both hypertensive groups, except for diuretics and beta-blockers which were more prevalent in the RH group (100% vs 28% and 47% vs 6%, P<0.05, respectively). In stepwise regression analysis, elevated AIx was significantly and independently associated with the presence of RH (β=6.4, P=0.005), age (β=.23, P=0.005), female sex (β=6.3, P=0.003) and body mass index (β=.71, P=0.038).

Conclusion

AIx is increased in RH patients and independently related to the presence of RH, age, female sex and body mass index. Increased arterial stiffness and reduced arterial compliance in patients with RH may play an important role in the progression of serious CV complications seen in these patients. The non-invasive assessment of arterial stiffness indices such as AIx in RH patients may be valuable to provide prognostic and therapeutic insights.Table 1