bluuebunny/crossref_metadata_2025 huggingface dataset:
The global effect of Covid-19 on acute coronary syndromes management
Authors: Lunardi M , Mylotte D , Serruys P , Wijns W
Published: October 2021

Aim

Covid-19 has had a dramatic impact on the healthcare systems globally. Despite efforts to maintain systems of cardiovascular care during the pandemic, public health responses to the virus have contributed to adverse cardiovascular outcomes. Herein, we summarize current evidence detailing the impact of Covid-19 on interventional cardiology.

Methods

According to PRISMA criteria, a systematic review was performed through Medline, Embase, and Cochrane databases, to identify reports on the impact of Covid-19 on interventional cardiovascular procedures. We identified 50 published studies that met the prespecified inclusion and exclusion criteria.

Results

In the acute setting, several datasets report a reduction of acute coronary syndrome (ACS) admission by 40% globally (−40%, 95% CI 37–43 from the National Health Service hospital trusts in England). Most surveys and registries reported a numerically higher impact on NSTEMI/unstable angina cases compared to STEMI (−42%, 95% CI 38–46 and −23%, 95% CI 16–30 respectively, from the National Health Service hospital trusts in England).

In STEMI care pathways, several studies report increased delays between symptom onset and first medical contact (105 min, 95% CI 45–222 during the pandemic vs 71 min, 95% CI 30–180 before it, p<0.001, from the National STEMI registry in Spain), with a subsequent increased duration of the ischaemic period (200 min, 95% CI 140–332 during the pandemic vs 233 min, 95% CI 150–375 before it, p<0.001, from the National STEMI registry in Spain). Importantly, hospital “door-to-balloon” times were unchanged.

Most studies suggest similar in-hospital mortality for STEMI during the pandemic compared to historic controls (1.7% vs 1.8%, p=0.67 from British National Institute of Cardiovascular Outcomes Research database). An increased incidence of mechanical complications were observed (41.2% vs 19.6%, p=0.030, from an Italian monocentric experience).

In the United States (New York city), overall mortality from ischemic heart diseases depicted a 2-fold increase during the pandemic (relative change 2.39, 95% CI 1.39–4.09). Of note, in the same city home deaths increased from 35/day in 2013–2017 to 200/day during the pandemic. These data suggest that ACS incidence has not decreased, but more likely patients presenting ischemic symptoms may have not contacted health care services, and have died at home.

Conclusions

The Covid-19 pandemic has adversely impacted outcomes in patients with ischemic heart disease (IHD). The diagnosis and treatment of IHD should be designated a health system priority that remains intact during pandemic events as the magnitude of harm induced by its interruption is substantial.

Funding Acknowledgement

Type of funding sources: None.
ABCA1, TCF7, NFATC1, PRKCZ and PDGFA DNA methylation as potential epigenetic-sensitive targets in acute coronary syndrome via network analysis
Authors: Infante T , Franzese M , Ruocco A , Schiano C , Affinito O , Pane K , Memoli D , Rizzo F , Weisz A , Bontempo P , Grimaldi V , Berrino L , Soricelli A , Mauro C , Napoli C
Published: October 2021

Background

Acute coronary syndrome (ACS) is the most severe clinical manifestation of coronary heart disease and the leading cause of death worldwide.

Purpose

To perform an epigenome-wide analysis in circulating CD4+ and CD8+ T cells of ACS patients and healthy subjects (HS) enrolled in the DIANA clinical trial (NCT04371809) in order to identify differentially methylated genes (DMGs).

Methods

Genomic DNA was extracted from CD4+ and CD8+ T cells of all subjects and sequenced by the reduced representation bisulfite sequencing (RRBS) platform. Functional pathway analysis was performed and significant DMGs were selected for gene expression validation by qRT-PCR in ACS patients and HS. GeneMANIA was used to built a prediction gene network. Correlation analyses between molecular data and clinical variables were performed.

Results

In CD4+ T cells we identified 61 differentially methylated regions (DMRs) associated to 57 annotated genes of which 53% (n=32) were hyper- and 47% (n=29) were hypo-methylated in ACS patients vs HS. In CD8+ T cells we identified 613 DMRs associated to 569 annotated genes of which 28% (n=173) were hyper- and 72% (n=440) were hypo-methylated between two groups. In both cell type of ACS patients, 175 DMRs were associated to 157 annotated genes of which 41% (n=72) were hyper- and 59% (n=103) were hypo-methylated. From functional analysis, we selected the top 5 DMGs in the prevalent pathways with the highest differential of methylation values. Specifically, we considered 6 hub genes: NFATC1, TCF7, PDGFA, PRKCB, PRKCZ and ABCA1 and determined their respective expression levels by q-RT-PCR. We found a significant up-regulation of the selected genes in ACS patients vs HS (P<0.001 for all comparisons). Correlation analysis showed both common and cell specific correlation patterns. In CD4+ T cells, PDGFA promoter methylation was negatively correlated with CK-MB concentrations (r=−0.79, P=0.018). ABCA1, TCF7, PDGFA and PRKCZ gene expression was positively associated to CK-MB concentrations (r=0.75, P=0.03; r=0.760, P=0.029; r=0.72, P=0.044; r=0.74, P=0.035, respectively).

Conlusions

This study is the first single-base resolution map of DNA methylome by RRBS in CD4+ and CD8+ T cells, providing specific methylation signatures that could help to clarify the role of aberrant methylation in ACS pathogenesis, and provide the basis for the search of novel epigenetic-sensitive biomarkers in the prevention and early diagnosis of this pathology.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Health;Italian Ministry of Research and University
Impact of impaired renal function on kinetics of high-sensitive troponin I (hs-cTnI) following cardiac surgery
Authors: Omran H , Deutsch M A , Scholtz S , Renner A , Scholtz W , Hakim Meibodi K , Rudolph T K , Gummert J , Rudolph V
Published: October 2021

Background

Renal insufficiency might result in increased levels of cardiac troponin due to decreased elimination. Hence, the diagnostic utility of hs-cTnI might be lower in patients with impaired renal function. There is only scarce data on kinetics of high-sensitivity cardiac troponin I (hs-cTnI) following cardiac surgery with regard to renal function.

Purpose

The aim of this study was to assess the impact of impaired renal function on the kinetics of hs-cTnI following cardiac surgery differentiating between patients with and without postoperative myocardial infarction (PMI) and to analyze the prognostic value of hs-cTnI elevations in patients with impaired renal function.

Methods

We performed a retrospective analysis of all adult patients (>18 years) who underwent cardiac surgery at our hospital between Jan, 1st 2013 and May, 1st 2019.

Serial measurements of high-sensitive cardiac troponin I (hs-cTnI) were assessed from baseline up to 48 hours after surgery. Renal function was assessed based on estimated glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) formula with impaired renal function defined by GFR <60 ml/min. Postoperative myocardial infarction was defined by new vessel occlusion on angiography. Predictors of long-term all-cause mortality were assessed by cox regression analysis.

Results

A total of 14,465 patients were included (51.4% underwent coronary artery bypass grafting (CABG), 39.4% had valvular procedures and 9.2% thoracic aortic procedures).

Levels of hs-cTnI were higher in patients with impaired renal function in the overall collective (figure 1). However, in patients with postoperative myocardial infarction levels of hs-cTnI did not differ with regard to renal function (figure 2).

Cox regression analysis showed postoperative elevation of hs-cTnI to be a significant predictor of long-term all-cause mortality over a median follow-up of 3.0 years regardless of baseline kidney function (Hazards ratio 1.67, 95% Confidence interval [1.46–1.91], p<0.001).

Conclusion

Renal function had an impact on postoperative hs-cTnI kinetics only in patients with an uneventful postoperative course. In patients with postoperative myocardial infarction kinetics of hs-cTnI were not affected by baseline renal function. Moreover, elevated hs-cTnI levels were a significant predictor of all-cause mortality regardless of baseline renal function.

Funding Acknowledgement

Type of funding sources: None.
Increased symmetric dimethyl-arginine is a predictor factor of decreased platelet reactivity and increased bleeding risk in patients with acute coronary syndrome
Authors: Eyileten C , Jarosz-Popek J , Jakubik D , Gasecka A , Wolska M , Czajka P , Nowak A , Ufnal M , Dizdarevic A , Toma A , Lang I , Postula M , Siller-Matula J M ,   I-COMET
Published: October 2021

Background

One of the promising biomarkers in CVD are asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA), which are products of L-arginine methylation and are both involved in endothelial dysfunction. ADMA, SDMA and L-homoarginine, have emerged as biomarkers linked to cardiovascular outcomes [1].

Purpose

To investigate the association of SDMA with platelet reactivity and bleeding risk in patients with acute coronary syndrome (ACS) treated with potent P2Y12 inhibitors prasugrel and ticagrelor.

Methods

Our prospective observational study enrolled 292 patients with ACS undergoing percuteneus coronary intervention [2]. Plasma concentrations of SDMA were measured during the hospitalization for ACS. Impedance aggregometry was used. The primary study endpoint was the concentration of metabolites and platelet reactivity. The primary clinical outcome endpoint was the incidence of Thrombolysis in Myocardial Infarction (TIMI) bleeding events (major, minor and minimal). The efficacy endpoint was the composite of major adverse cardiac events (MACE: stent thrombosis, myocardial infarction, stroke and cardiac death).

Results

There was an inverse correlation between SDMA serum levels and platelet reactivity (r=−0.25; p<0.000). The ADP+PGE1-induced platelet reactivity was 33% lower among patients with the highest SDMA quartile (4th) as compared to those with the 1–3rd SDMA quartile (8 [0–29] vs 12 [0–126] U; p<0.001). The AA-induced platelet reactivity was 56% lower among patients with the highest SDMA quartile (4th) as compared to those with the 1–3rd SDMA quartile (4 [0–48] vs 9 [0–133]; p<0.001). In a multivariate model, the highest SDMA (4th) quartile was found to be an independent predictor of the lowest ADP+PGE1 and AA induced platelet aggregation (OR: 2.666, 95% CI [1.184–5.999], p=0.018).

Conclusions

Our study shows that high plasma concentration of SDMA, but not ADMA, is independently associated with low platelet reactivity to ADP and AA and is associated with major and minor bleeding events in patients with ACS on potent antiplatelet therapies. Therefore, SDMA might have a potential to be further evaluated as a blood biomarker for individualization of duration and potency of antiplatelet therapies in an ACS population at high risk of bleeding complications.

Acknowledgment

I-COMET research team

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1
Instantaneous wave-free ratio for the assessment of nonculprit lesions in patients with acute coronary syndrome
Authors: Gonzalez-Manzanares R , Hidalgo F J , Ojeda S , Piserra A , Perea-Armijo J , Rodriguez-Nieto J , Flores G , Suarez De Lezo J , Benito-Gonzalez T , Gutierrez-Barrios A , De La Torre J M , Mazuelos F , Segura J M , Romero M , Pan M
Published: October 2021

Background

A physiological assessment with the fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) is strongly recommended by the European Guidelines of Revascularization to guide percutaneous coronary intervention (PCI) decision making in intermediate coronary stenosis. However, data supporting its use in the pro-inflammatory setting of ACS is weak.

Purpose

To analyze the usefulness of a physiological coronary evaluation with iFR of nonculprit lesions in patients with ACS.

Methods

Retrospective multicenter study including patients with ACS and underwent successful revascularization of the culprit vessel and had other nonculpritlesions physiologically evaluated with the iFR between January 2017 and December 2019. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, stent thrombosis and new revascularization (MACEs).

Results

A total of 356 patients with 472 nonculprit lesions were included. The mean age was 66±11 years. The clinical presentation was non-ST-segment elevation myocardial infarction (NSTEMI) in 235 patients and ST-segment elevation myocardial infarction (STEMI) in 121 patients. After a mean follow-up period of 22±10 months, the primary endpoint occurred in 32 patients (9%). There were no differences in outcomes regarding iFR induced treatment strategy (patients with all lesions revascularized vs. patients with at least one lesion deferred for revascularization, 10.5 vs 8.4%, p=0.476).

Conclusion

The use of the iFR to guide percutaneous coronary intervention decision making in nonculprit lesions seems to be safe, with an acceptable percentage of MACEs at the mid-term follow-up.

Funding Acknowledgement

Type of funding sources: None. FlowchartSurvival curves by iFR and ACS group
The incidence of muscle tissue damage during therapy with atorvastatin in patients after STEMI
Authors: Salyamova A , Khromova A , Kvasova O , Burko N , Oleinikov V
Published: October 2021

Objective

To study the incidence of side effects from muscle tissue during therapy with atorvastatin at various doses in patients with acute ST-segment elevation myocardial infarction (STEMI) during 48 weeks of follow-up.

Methods

The study included 115 STEMI patients aged 30 to 65 years (mean age 51.7±9.5 years). Patients were randomized to atorvastatin treatment groups. Group 1 included 59 people who took atorvastatin 80 mg / day; group 2 - 56 patients who received moderate doses of atorvastatin. The compared persons were matched by age, sex, and anthropometric data. Initially on the 7–9th days, after 24 and 48 weeks of follow-up, the CPK-MB serum level was analyzed. Muscle damage was assessed after 5–6, 24, 48 weeks of follow-up according to the development of the following symptoms: pain, fatigue, muscle weakness, decreased physical activity - on a 10-point scale.

Results

The CPK-MB level in the 1st group initialy was 701.5 [95% CI 391; 1012] U / L, after 24 weeks - 162.8 [95% CI 130.2; 195.4] U / L (p<0.001), after 48 weeks - 205.6 [95% CI 134.8; 276.4] U / L (p<0.001). In group 2, the dynamics of CPK-MB: on days 7–9 - 522.7 [95% CI 115.8; 755.1 U / L, after 24 weeks - 141.4 [95% CI 122.6; 160.3] U / L (p=0.0004), after 48 weeks - 150.5 [95% CI 123.9; 177.1] U / L (p=0.0003).

A detailed analysis in four patients of the 1st group revealed an increase in CPK-MB >4 upper limit of normal (ULN) after 48 weeks of follow-up (6.8%). Moreover, symptoms of muscle damage against the background of pathological CPK-MB values were observed only in two people (3.4%). In patients of the 2nd group after 24–48 weeks of therapy with atorvastatin, there was no increase in CPK-MB >4 ULN. In addition, there were no cases of drug withdrawal in any of the groups due to an increase in CPK-MB>10 ULN. Clinical symptoms of muscle damage after 5–6th, 24th and/or 48th weeks of follow-up were diagnosed in the 1st group in 41 patients (69.5%), in the 2nd group - in 31 people (55%) (p=0.11).

Conclusion

In STEMI patients on the background of 48-week therapy with atorvastatin, no serious adverse effects on the muscle tissue were revealed, which testifies in favor of the safety of high-dose statin therapy. The incidence of myalgia did not depend on the dose of the drug.

Funding Acknowledgement

Type of funding sources: None.
Mortality risk in cardiogenic shock: head to head comparision CardShock vs IABP score in a Mediterranean cohort: the Shock CAT study
Authors: Garcia-Garcia C , Lopez T , Sanz E , Sanchez-Salado J C , Aboal J , Tomas C , Baneras J , Sionis A , Andrea R , Perez-Rodriguez M , Ariza A , Pastor P , Buera I , Cediel G , Rueda F ,   Grup de Treball Cures Agudes Cardiològiques Societat Catalana Cardiologia
Published: October 2021

Background

Mortality in cardiogenic shock (CS) remains very high. Several risk scores have been purposed to early stratification.

Purpose

The aim is to investigate in-hospital prognosis and mortality risk in CS patients comparing the prognostic accuracy of CardShock and IABP scores in a Mediterranean cohort.

Method

Shock CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Catalonia (Spain), including CS patients due to acute coronary syndrome (ACS) and other aetiologies. Data on clinical presentation, biomarkers, management, including mechanical assistance support were analyzed. Cardshock and IABP score have been compared to assess 90-days mortality risk in a Mediterranean cohort.

Results

A total of 382 CS patients were included, mean age was 65.3 (SD 13.9) years and 75.1% were men. The most common cause of CS was ACS (61%, n=233); of them, 77.6% were STEMI, 9% developed mechanical complications and 19.4% primary ventricular fibrillation. STEMI patients were reperfused in 84.7% of cases, all with primary angioplasty. Main non-ACS aetiologies were severe acute heart failure, malignant arrhythmias and myocarditis. Mechanical assistance device was implanted in one third of patients (n=119), mainly intraaortic balloon pump (26.1%), ECMO in 7.8% and Impella in 4.5%. Average Cardshock score was 4.3 (SD 1.74) and mean IABP score was 2.2 (SD 1.61). In-hospital mortality was 33% (126 patients) and 90-days mortality was 37.3% (141 patients). Receiver-operating characteristic curves demonstrated that IABP shock score had superior prognostic power for predicting 90-days mortality when compared with Cardshock score (area under the curve 0.72 vs 0.66) respectively, p=0.042; Figure 1.

Conclusions

Even though invasive management with STEMI reperfusion and mechanical assistance devices, cardiogenic shock in-hospital mortality remains 33% in a contemporary Mediterranean cohort. In this population, IABP shock score provided better 90-days mortality risk prediction than CardShock score

Funding Acknowledgement

Type of funding sources: None.
Coronary slow-flow phenomenon in takotsubo syndrome: the prevalence, clinical determinants and long-term prognostic impact
Authors: Stepien K , Nowak K , Stepien A , Nessler J , Zalewski J
Published: October 2021

Background

Previous studies demonstrated that patients with takotsubo syndrome (TTS) may present with coronary slow-flow (CSF) at coronary angiography performed in the acute phase [1]. However, the exact clinical relevance and its long-term prognostic impact have not been established yet. In the only recently published study Montone et al. proved that TTS patients with CSF were characterized by a worse clinical presentation with higher rate of intrahospital complications and poor long-term clinical outcome [2].

Purpose

We sought to investigate the prevalence of CSF in TTS patients, its determinants and long-term prognostic impact.

Methods

Among 7771 myocardial infarction patients hospitalized in our center in 2012–2019 years, we identified 82 (1.1%) TTS patients with performed coronary angiography (Figure 1A). The coronary flow was assessed quantitatively with TIMI Frame Count (TFC), whereas myocardial perfusion with TIMI myocardial perfusion grade (TMPG). The clinical and angiographic characterstics of 67 TTS patients complying with MINOCA definition were compared with representative 50 non-TTS MINOCA (Figure 1A).

Results

CSF (TIMI 2) was identified in 33 (40.2%) TTS patients. CSF-TTS patients were characterized with higher TFC and worse TMPG in each analyzed coronary vessel (Figure 1B). CSF was observed in LAD artery in each patient, in 78.8% in LCx and in 33.3% in RCA, respectively. In CSF-TTS lower values of LVEF on admission (33.5 (25–40) vs 40 (35–45)%, P=0.019) as well as more frequent midventricular TTS (27.3 vs 8.2%, P=0.020), nearly normal coronary arteries (<30% stenosis) (75.8 vs 49.0%, P=0.015) and coexistence of both physical and emotional triggers (9.1 vs 0%, P=0.032) were noted. Moreover, CSF was observed significantly more frequent than in non-TTS MINOCA (44.8 vs 10.0%, P<0.001) with different distribution in particular vessels (P<0.001). In median 55 months of long-term observation higher all-cause mortality was stated in CSF-TTS (30.3 vs 10.2%, P=0.024) (Figure 1C) without difference between TTS and non-TTS MINOCA (P=0.42) (Figure 1D). By Cox proportional hazards model the CSF was identified as an independent predictor of long-term mortality (P<0.001).

Conclusions

As has been shown high proportion of TTS patients were characterized with remarkably marked myocardial perfusion abnormalities, especially in the left coronary vessels, which were associated with unfavorable long-term prognosis. Our study is the first presenting the direct angiographic, clinical and prognostic comparison of TTS MINOCA and non-TTS MINOCA patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1
How did the first pandemic COVID wave affect acute myocardial infarction hospital assistance?
Authors: Pacheco A , Carvalho D , Carvalho P , Ferraz L , Briosa A , Bem Haja P , Bastos M
Published: October 2021

There is a general notion that the COVID pandemic has made access to adequate health care difficult. A retrospective study looked at patients with acute myocardial infarction (AMI) admitted to a hospital, including the time between admission and diagnosis, the time until treatment, and the delay in transferring to a hospital with a catheterization laboratory in the case of ST-Elevation Myocardial Infarction (STEMI).The period analysed was March to July 2019 and March to July 2020 (first Covid pandemic wave). 197 patients, 101 in 2019 (SCA19) and 96 in 2020 (SCAcov), 142 males (72%) mean age 67.3±12.6. It was observed in 2019 29 STEMI and 72 acute myocardial infarct without ST elevation (NSTEMI) na 2020 36 STEMI and 60 NSTEMI, this proportions didn't achieve statistical meaning χ2(1)=1.719, p=0.226. When compared SCA19 versus SCAcov there were no differences between groups in relation to demographic data. The clinical presentation (none, hemodynamic instability, refractory pain, arrhythmia, mechanic complication, acute heart failure) not varied between groups χ2(6)=3.42, p=0.755. When analysed, between SCA19 and SCAcov, there were no significant time difference between the admission and the electrocardiogram execution (MSCA19 = 44.78; MSCAcov = 56.84; Tweich (132.66) = −0.73, p=0.476 g Hedge = 0.71, between time of admission and time of diagnosis MSCA19 = 264.84; MSCAcov = 254.2; Tweich (188.81) = −0.34, p=0.731 g Hedge = 0.05, and the duration of hospitalization MSCA19 = 5.90; MSCAcov = 5.78 U=9400, Z=−0.263, p<0.792.

Conclusion

In COVID times even with the all restrictions and contingencies lived in hospitals our results pointed to no significant changes in the variables analysed. Interestingly, in spite of no significant difference, a slightly more delay in ECG execution, higher prevalence of STEMI but a short time of diagnosis were observed.

Funding Acknowledgement

Type of funding sources: None.
High sensitivity troponin as a 60-day mortality marker in patients with COVID-19 in intensive care at a Latin American hospital
Authors: Sprockel J , Murcia A L , Rincon J M , Santofimio Z , Cardenas H M , Hernandez D , Parra J E
Published: October 2021

Introduction

Coronavirus disease (COVID) - 19 presents with periodic outbreaks with a large number of critical cases that overwhelm the health system. One of the objectives of screening and management is to have markers that can efficiently stratify the individual risk of experiencing adverse results. High-sensitivity troponin has been proposed as one of the possible prognostic markers.

Purpose

To evaluate the prevalence of troponin elevation and its performance for predicting 60-days mortality in patients in ICU due to COVID - 19 in a Latin American population.

Methodology

A single-center retrospective cohort study was carried out in which patients in ICU for COVID-19 confirmed by RT-PC between May and December 2020 were included. Patients with previous conditions that determined a limitation of therapeutic effort and pregnant women were excluded. The outcome was 60-days mortality. Kaplan Meier survival curves were constructed, a ROC curve was generated for the prediction of death according to troponin levels by calculating the area under the curve. Finally, a Cox proportional hazards model was generated.

Results

296 patients were included, 110 (37.2%) female, the mean age was 60 (SD 14) years and the duration of symptoms before admission to the ICU was 8.4 (SD 4.2) days. 81.4% of the patients had at least one comorbidity, 117 (39.5%) had hypertension, 65 (21.9%) had diabetes, and 63 (21.3%) had chronic lung disease. Mortality occurred in 151 cases (51%), 225 (76%) presented shock, 242 (81.8%) severe ARDS (PaO2 / FiO2 <100 mmHg), 232 (78.4%) required invasive ventilatory support, and 153 (5.7%) developed acute kidney injury. The APACHE II average was 13.1 and SOFA 4.8. Troponin was positive in 118 (39.9%) patients, 29.6% of the survivors and 49.7% in non survivors. The AUC was 0.65 (95% CI 0.59–0.71) for predicting mortality (Figure 1). The Kaplan Meier curves are shown in Figure 2 with a p less than 0.001 by achieving the test. In the bivariate analysis, troponin obtained a HR of 1.94 and p<0.001, but in the multivariate model it was 1.39 (95% CI of 0.21–1.56) and p of 0.12.

Conclusions

High sensitivity troponin was found to be elevated in patients hospitalized for COVID-19 in the intensive care unit who died, with regular discrimination (AUC: 0.65), even though the univariate analysis by the Cox and Kaplan Meier methods showed association with 60-days mortality, this was not maintained in the multivariate model.

Funding Acknowledgement

Type of funding sources: None. Figure 1. ROC curveFigure 2. Kaplan Meier survival curves
Does the availability of transcatheter aortic valve replacement impact inpatient outcomes after surgical aortic valve replacement? Analysis of the national inpatient sample
Authors: Hiltner E , Russo M , Chen C , Singh A , Kassotis J , Sethi A
Published: October 2021

Background

With the introduction of transcatheter aortic valve replacement (TAVR), the treatment of aortic stenosis (AS) has experienced a paradigm shift, altering patient selection for surgical aortic valve replacement (SAVR) over the past decade. What remains to be determined is the impact of a hospital's ability to offer TAVR, in the contemporary era, on inpatient outcomes following SAVR.

Purpose

The goal of this study was to assess inpatient mortality and the use of mechanical aortic valve replacement (mAVR) in patients undergoing SAVR at TAVR versus non-TAVR centers in the United States.

Methods

The National Inpatient Sample (2011–18), a probability sample of inpatient visits in the United States, was used to study trends in admissions for SAVR at TAVR and non-TAVR centers; in-hospital mortality was trended over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 559,365 inpatient visits for SAVR with 75.2% (95% CI 74.2%-76.2%) and 24.7% (95% CI 23.8%-25.8%) receiving bioprosthetic SAVR (bAVR) and mAVR, respectively at TAVR centers and 64.5% (95% CI 63.3%-65.6%) and 35.5% (95% CI 34.4%-36.7%) receiving bAVR and mAVR, respectively at non-TAVR centers. SAVR recipients at non-TAVR centers were older when compared to recipients at TAVR centers (68.3±0.09 vs 66.9±0.11 years p<0.001). Heart failure, cardiac arrhythmias, peripheral vascular disorders, complicated hypertension and diabetes, renal failure and liver disease were more common in patients undergoing SAVR at TAVR-centers. During the study period, both crude (OR = 0.78 95% CI 0.73–0.83) and adjusted (OR = 0.79 95% CI 0.73–0.86) inpatient mortality was lower amongst SAVR recipients at TAVR centers. The utilization rates of mAVR at both TAVR and non-TAVR centers decreased over time amongst all age groups (p trend <0.001).

Conclusions

Patients undergoing SAVR at TAVR centers were younger and had more co-morbidities compared to patients undergoing SAVR at non-TAVR centers. Although patients undergoing SAVR at TAVR centers had significantly more co-morbidities, inpatient mortality was lower at TAVR centers compared to non-TAVR centers. Further research is needed to determine whether the impact of a multidisciplinary cardiac approach resulted in significant differences in patient selection for SAVR, due to the availability of TAVR, influencing patient outcomes.

Funding Acknowledgement

Type of funding sources: None.
Trends in the use of mechanical and bioprosthetic aortic valve replacement in the era of transcatheter aortic valve replacement
Authors: Hiltner E , Erinne I , Singh A , Russo M , Chen C , Kassotis J , Sethi A
Published: October 2021

Background

The choice between a mechanical versus a bioprosthetic valve in aortic valve replacement (AVR) is based on life expectancy, bleeding risk and co-morbidities, since bioprosthetic AVR (bAVR) as compared to mechanical AVR (mAVR), are associated with a more rapid structural deterioration. However, refinements in bioprosthetic valves and the introduction of transcatheter aortic valve replacement (TAVR) (potential for valve-in-valve procedures), will most likely influence valve selection in the future. The impact of widespread transcatheter valve replacements, on the decision to use bAVR versus mAVR, in the contemporary era and subsequent outcomes remain to be determined.

Purpose

The goal of our study was to assess trends in utilization of bAVR and mAVR in the United States while, assessing in-hospital mortality over time.

Methods

The National Inpatient database (2009–18) was used to study trends in admissions for bAVR and mAVR and in-hospital mortality over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 700,896 inpatient visits for AVR with 70.1% (95% CI 69.2%-71.1%) and 29.9% (95% CI 28.9%-30.8%) visits for bAVR and mAVR, respectively. Those undergoing bAVR were significantly older, [bAVR (69.8 years) vs mAVR (62.7 years) p<0.001]. Heart failure, cardiac arrhythmias, hypertension, diabetes with complications and renal failure were more common in those undergoing a bAVR. Through the course of the study period, the rates of mAVR decreased across all age groups (p trend <0.001), including patients younger than 50 years (p trend <0.001). Both crude (OR = 1.20 95% CI 1.13–1.27) and adjusted (OR = 1.34 95% CI 1.25–1.44) inpatient mortality was higher amongst mAVR recipients.

Conclusions

In the contemporary TAVR era, the utilization of mAVR has decreased across all age groups, including those younger than 50 years old. Although mAVR recipients were healthier with significantly less co-morbidities, inpatient mortality was higher after mAVR compared to bAVR. In addition to understanding the causes accounting for the higher mortality after mAVR, future research should focus on developing TAVR friendly bAVR; possibly enhancing our ability to perform percutaneous valve-in-valve procedures in the future.

Funding Acknowledgement

Type of funding sources: None.
Prevalence of cardiac amyloidosis in patients undergoing transcatheter edge-to edge mitral valve repair
Authors: Dona C , Nitsche C , Koschutnik M , Koschatko S , Dannenberg V , Kammerlander A , Goliasch G , Bartko P , Schneider M , Traub-Weidinger T , Hacker M , Hengstenberg C , Mascherbauer J
Published: October 2021

Introduction

Cardiac amyloidosis (CA) is associated with severe aortic stenosis, however, its prevalence in patients with severe mitral regurgitation in elderly patients is unknown.

Methods

Patients scheduled for transcatheter edge-to edge mitral valve repair (TMVR) were prospectively screened for CA using 99m technetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy and subsequent serum as well as urine free light-chain quantification in case of a positive DPD scan, defined as visual cardiac update based on the Perugini grading scale.

Results

Out of 100 patients undergoing TMVR, 28 patients (28.0%) had a positive DPD-scan (DPD+). 14 patients (14.0%) showed Perugini grade I enhancement, 9 patients (9.0%) grade II enhancement, and in 5 patients (5.0%), grade III enhancement was present. 28 patients suffered from TTR and two from AL- amyloidosis (one patient had a combination of TTR and AL-amyloidosis). When compared to patients with a negative scan (DPD-), DPD+ patients presented with similar baseline characteristics such as age (DPD- vs DPD+ 76y/o vs 77y/o, p=0.44), gender (female; 62.7% vs 50.0%, p=0.25), coronary artery disease (59.7% vs 42.9%, p=0.13), previous valve surgery (25.4% vs 14.3%, p=0.24) and atrial fibrillation (68.7% vs 78.6%, p=0.33). Also, NYHA functional class and EuroScore II were similar (NYHA ≥ III; 85.1% vs 82.1%, p=0.72, and EuroScore II 9.9±9.8% vs 7.0±4.8%, p=0.21, respectively). On echocardiography, DPD+ patients presented with more pronounced left and right ventricular hypertrophy (interventricular septum: 15mm vs 13mm, p<0.01) but similar left ventricular ejection fraction (44.9% vs 42.3%, p=0.34). At 3-months after TMVR, DPD+ patients showed significant improvement in BNP serum levels when compared to DPD- patients (DPD+ vs DPD-: +315±2569pg/ml vs −2404±8696pg/ml, p=0.03), while NYHA functional class remained unchanged (NYHA improvement ≥1 class: 57.6% vs 50.0%, p=0.52)

Conclusions

In this single centre experience, CA was highly prevalent among elderly patients with severe mitral regurgitation scheduled for TMVR. TMVR in CA patients resulted in significant improvement of NT-pro BNP levels. Future studies need to clarify the prognostic relevance of CA in this specific patient population.

Funding Acknowledgement

Type of funding sources: None.
Mortality and heart failure in patients with severe tricuspid regurgitation. Risk stratification based on TR severity by CMR
Authors: Hinojar Baydes R , Gonzalez-Gomez A , Garcia-Martin A , Monteagudo J M , Alonso-Salinas G , Hernandez-Jimenez S , Fernandez-Mendez M A , Garcia De Vicente A , Jimenez-Nacher J J , Zamorano J L , Fernandez-Golfin C
Published: October 2021

Background

Tricuspid regurgitation (TR) is related to poor prognosis independently of the etiology. A new scale classification has been proposed to better characterize the grading of more than severe TR. Massive and torrential TR seem to have worse prognosis based on echocardiographic studies.

Purpose

To stratify patients' risk based on TR severity by CMR

Methods

Consecutive patients in stable clinical condition evaluated in the Heart Valve Clinic with significant TR (severe, massive or torrential TR) with a contemporaneous echo and CMR were included. TR severity was evaluated by vena contracta (VC) and ERO method, using EPIQ system (Phillip Medical system Andover, Massachusets) and by TR regurgitant fraction (TRF) using a 1.5 Tesla CMR Philips scanner. A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined.

Results

75 patients were included in this study (age 75±8 years, 75% female, 91% functional TR). According to echocardiography 75% were severe, 15% were massive and 10% were torrential TR. Patients with massive and torrential TR showed higher RV end-diastolic volume and lower RVEF. A TRF >50% held the best accuracy to define massive / torrential TR. During a median follow-up of 3 years (IQR: 1.4 – 3.9 years), 39% of the patients (n=29) experienced the combined endpoint. After adjusting for age and LVEF in a multivariate Cox proportional model, TRF was independently associated with cardiovascular mortality and heart failure (hazard ratio per 1%=1.05, [1.02–1.08], p<0.001). Patients were stratified in 3 groups according to TR severity. Patients with TRF ≤40% showed the lowest incidence of events and those with TRF ≥50% experienced the worse prognosis (log rank=0.001, figure)

Conclusion

Patients with massive/torrential TR are populations at higher risk of heart failure and mortality. Risk stratification strategies may identify the patients who benefit the most of intensive therapeutic treatments and intervention on the tricuspid valve. New classification scheme should be included in CMR grading scales.

Funding Acknowledgement

Type of funding sources: None. Kaplan Meier curve. Risk stratification
Prevalence and determinants of right ventricular dysfunction in patients with severe symptomatic high gradient aortic stenosis
Authors: Maltes S , Abecasis J , Mendes G S M , Padrao C , Reis C , Guerreiro S , Freitas P , Ribeiras R , Andrade M J , Cardim N , Gil V , Mendes M
Published: October 2021

Background

Right ventricular (RV) function in aortic stenosis (AS) has been largely neglected. Recently it was demonstrated that right ventricular impairment may be influenced by left ventricular (LV) function and afterload, well before overt pulmonary hypertension development.

Aim

To describe the prevalence of RV dysfunction in a group of patients with severe symptomatic aortic stenosis (AS) and its relation to LV function parameters and afterload.

Methods

We prospectively studied 93 consecutive patients (age: 73 years [IQR 68–77] years, 55% women) with pure severe symptomatic high gradient aortic stenosis: mean transaortic pressure gradient: 57.0mmHg [IQR 46.9–71.1]; aortic valve area: 0.72cm2 [IQR 0.61–0.88]; indexed stroke volume: 48.8±1.5 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance (CMR) for LV myocardium tissue characterization (late gadolinium enhancement and extracellular volume). Normal RV function was defined according to TAPSE ≥17mm, tricuspid annular systolic velocity ≥12cm/s, mean free wall longitudinal strain ≤−20%. Patients were divided into four groups: (0) – all three RV parameters below normal (1.1%), (1) – 1 normal parameter (12.9%), (2) – 2 normal parameters (44.1%), (3) – 3 normal parameters (41.9%). Indexes of LV systolic and diastolic function, CMR derived LV geometric remodeling, hypertrophy and tissue characterization, aortic valve disease severity and afterload were compared across the 4 groups of patients. We tried to identify predictors of RV dysfunction (group 0, 1, 2 vs. group 3) at multivariate regression analysis.

Results

Left ventricular performance parameters, diastolic and myocardial work indexes were significantly different across the groups (Figure). Neither AV severity indexes nor LV tissue characterization were distinct. At multivariate analysis only global constructive work was an independent predictor of RV dysfunction.

Conclusion

RV dysfunction is common in this group of patients with severe high gradient aortic stenosis and preserved ejection fraction. RV impairment is significantly related to several LV systolic and diastolic parameters and also to LV afterload, probably accounting for RV-LV interdependence.

Funding Acknowledgement

Type of funding sources: None.
Interventional treatment of para-valvular leaks after prosthetic valve replacement with plug devices -first results from a prospective registry
Authors: Zahn R , Kment H , Schofer J , Lubos E , Geist V , Eggebrecht H , Butter C , Wolf A , Schaefer U , Schumacher B , Schneider S
Published: October 2021

Background

Interventional closure of symptomatic paravalvular leaks (PVL) after surgical or interventional valve replacement by plug implantation has emerged as an alternative to surgical correction, which is associated with high morbitity and mortality rates. To date, data on procedural efficacy and clinical outcome after transcatheter closure with plugs is sparse, especially prospective data are missing.

Methods

We analysed data from a multi-center prospective registry on interventional PVL closure with plug devices.

Results

Between 06/2012 and 04/2020 55 interventions were performed with different numbers of plugs (maximal 4) in 51 patients at 9 hospitals. Interventions were performed in 15 women and 36 men at high surgical risk for repeat surgery. 48% of procedures were performed for mitral PVLs and 52% procedures were performed for aortic PVLs. Mean age of the population treated was 69±13 years and mean log. Euro-Score I was 22.5±14.2%. Patients were treated by implantation of Amplatzer Vascular Plug III (80%) and Occlutec occluders (9%). Aortic PVLs were treated using a retrograde transfemoral access, mitral PVLs were treated using either a transseptal (25/26) or transapical access (1/26) with 3-dimensional transesophageal echocardiographic and fluoroscopic guidance. Indication for PVL closure was previous surgery (n=39), high-risk patients (n=24), heart failure (n=22), age (n=20) and hemolysis (n=12). 40 patients had NYHA class III/IV at admission. Interventional closure of PVL was completely successful in 40 procedures (73%), partially successful in 7 procedures (13%) and failed in 7 procedures (13%). NYHA class I/II after PVL closure was achieved in 75% patients. However, 8 out of 12 patients with hemolysis as indication still hemolyzed at discharge. Complications occurred in 16% of patients. In-hospital mortality rate was 4% of procedures (2/51). After hospital discharge no death occurred during 30-day follow-up.

Conclusions

In this prospective interventional PVL registry inclusion rate was lower than expected. There was an equal distribution of aortal and mitral PVLs. At least partial success could be achieved in 86% of patients, with significant functional improvement in most patients. In this high risk population hospital mortaliy was low (4%), indicating that interventional PVL treatment should be the treatment of choice, when discussed by a heart team.

Funding Acknowledgement

Type of funding sources: None.
Valve-in-valve procedure for bioprosthesis dysfunction in rheumatic patients: a new procedure for an old disease
Authors: Lopes M P , Emer Egypto Rosa V , Palma J H , Fernandes J R C , De Santis A S A L , Spina G S , Abizaid A C , De Brito Jr F S , Tarasoutchi F , Sampaio R O , Ribeiro H B
Published: October 2021

Background

Bioprosthetic heart valve has a limited durability and lower long-term performance especially in rheumatic patients. The standard treatment for degenerated bioprosthesis involves redo open-heart surgery, which is associated with significant morbidity and mortality, particularly in high-risk patients. Minimally invasive procedures, as valve-in-valve (ViV) implantation, may offer an attractive therapy alternative.

Methods

The aim of this study was to evaluate the characteristics and short-term post-procedure data of rheumatic and non-rheumatic patients undergoing aortic, mitral or tricuspid ViV procedure.

Results

Single centre data-base analysis study, with prospective data collection, during the period of May 2015 to September 2020. Among 106 patients included, 69 had rheumatic etiology and 37 were non-rheumatic. Rheumatic patients had higher incidence of female sex (73.9% vs 43.2%, respectively; p=0.004) and atrial fibrillation (82.6% vs 45.9%, respectively; p<0.001). There were no statistical difference regarding number of previous surgeries (2 [3–1] vs 1 [2–1], respectively; p=0.103). There was a tendency towards higher 30-day mortality in rheumatic patients (21.7% vs 5.4%, respectively; p=0.057) and device success rate was low, but similar between groups (78.3% vs 72.0%, respectively; p=0.710). Transapical access rate was also higher in rheumatic group (92.6% vs 70.3%, respectively; p=0.008);

Conclusion

Rheumatic patients tend to have a higher mortality when undergoing ViV procedures, although not statistically significant. Rheumatic patients underwent a greater number of previous valve surgeries than reported in literature, and also had high rate of transapical ViV procedure, which may have contributed to higher 30-day mortality and a lower device success rate.

Funding Acknowledgement

Type of funding sources: None.
Cardiac damage staging classification and prognosis in low flow low gradient severe aortic stenosis
Authors: Snir A , Ng M K , Strange G , Playford D , Stewart S , Celermajer D S
Published: October 2021

Introduction

There are currently no established prognostic models for low-flow, low-Gradient (LFLG) severe aortic stenosis (AS). The Cardiac Damage Staging Classification, has been validated as a clinically useful prognostic tool in high-gradient severe AS, but not specifically in LFLG severe AS.

Objective

To assess and confirm the prognostic utility of the Cardiac Damage Staging Classification, in LFLG severe AS patients.

Methods

We analysed data from the National Echocardiography Database of Australia (NEDA), a national multicentre registry with individual data linkage to mortality. Of 192,060 adults (aged 62.8±17.8 years) with comprehensive ultrasound profiling of the native aortic valve studied between 2000–2019, 12,013 (6.3%) had severe AS. Based on standard echocardiographic parameters, 611 classical and 959 paradoxical LFLG patients were identified. Mean follow-up was 70±41 months. All-cause and cardiovascular-related mortality were assessed for each LFLG group on an adjusted basis (age and sex), according to cardiac damage classification staging.

Results

Paradoxical LFLG patients were younger (mean age 74.3 vs 76.2, p=0.006) and more often female (62.8% vs 36.3%, p<0.001). Classical LFLG patients had greater associated cardiac damage at diagnosis (76% vs. 49%, for Stage ≥2, p<0.001). Compared to Stage 0 paradoxical LFLG patients, adjusted 1- and 5-year cardiovascular-related mortality was 200% (HR 2.82, 95% CI 1.12–7.11) and 120% (HR 2.42, 95% CI 1.46–4.02) higher in Stage 2 patients and 350% (HR 4.23, 95% CI 1.68–10.63) and 175% (HR 3.18, 95% CI 1.90–5.34) higher in Stage 3/4 patients, respectively. Compared to Stage 1 classical LFLG patients, adjusted 1- and 5-year cardiovascular-related mortality was 58% (HR 1.66, 95% CI 0.95–2.90) and 24% (HR 1.35, 95% CI 0.91–1.99) higher in Stage 2 patients and 125% (HR 2.48, 95% CI 1.43–4.28) and 52% (HR 1.87, 95% CI 1.26–2.78) higher in Stage 3/4 patients, respectively.

Conclusion

In patients with LFLG severe AS identified by echocardiography, increasing severity denoted by the cardiac damage staging classification is strongly associated with increasing medium- to long-term mortality.

Funding Acknowledgement

Type of funding sources: None. Stages + Classical LFLG 5 year mortalityParadoxical LFLG 5 year mortality curves