bluuebunny/crossref_metadata_2025 huggingface dataset:
Neutrophil counts and cardiovascular disease
Authors: Luo Jiao , Thomassen Jesper Qvist , Nordestgaard Børge G , Tybjærg-Hansen Anne , Frikke-Schmidt Ruth
Published: November 2023

Background and Aims

Anti-inflammatory trials have shown considerable benefits for cardiovascular disease. High neutrophil counts, an easily accessible inflammation biomarker, are associated with atherosclerosis in experimental studies. This study aimed to investigate the associations between neutrophil counts and risk of nine cardiovascular endpoints using observational and genetic approaches.

Methods

Observational studies were conducted in the Copenhagen General Population Study (n = 101 730). Genetic studies were firstly performed using one-sample Mendelian randomization (MR) with individual-level data from the UK Biobank (n = 365 913); secondly, two-sample MR analyses were performed using summary-level data from the Blood Cell Consortium (n = 563 085). Outcomes included ischaemic heart disease, myocardial infarction, peripheral arterial disease, ischaemic cerebrovascular disease, ischaemic stroke, vascular-related dementia, vascular dementia, heart failure, and atrial fibrillation.

Results

Observational analyses showed associations between high neutrophil counts with high risks of all outcomes. In the UK Biobank, odds ratios (95% confidence intervals) per 1-SD higher genetically predicted neutrophil counts were 1.15 (1.08, 1.21) for ischaemic heart disease, 1.22 (1.12, 1.34) for myocardial infarction, and 1.19 (1.04, 1.36) for peripheral arterial disease; similar results were observed in men and women separately. In two-sample MR, corresponding estimates were 1.14 (1.05, 1.23) for ischaemic heart disease and 1.11 (1.02, 1.20) for myocardial infarction; multiple sensitivity analyses showed consistent results. No robust associations in two-sample MR analyses were found for other types of leucocytes.

Conclusions

Observational and genetically determined high neutrophil counts were associated with atherosclerotic cardiovascular disease, supporting that high blood neutrophil counts is a causal risk factor for atherosclerotic cardiovascular disease.
Cardiovascular magnetic resonance rest and exercise-stress left atrioventricular coupling index to detect diastolic dysfunction
Authors: Backhaus S J , Lange T , Schulz A , Evertz R , Frey S M , Hasenfus G , Schuster A
Published: November 2023

Background

Left atrial and ventricular (LA/LV) dysfunction are inter-linked in heart failure with preserved ejection fraction (HFpEF), however little is known about their inter-play and relation to cardiac decompensation. We hypothesized that cardiovascular magnetic resonance (CMR) left atrioventricular coupling index (LACI) would identify pathophysiological alterations in HFpEF and be amenable to rest and ergometer-stress CMR.

Methods

Patient with exertional dyspnoea, signs of diastolic dysfunction (E/e’ ≥8) and preserved EF (≥50%) on echocardiography were prospectively recruited and classified as HFpEF (n=34) or non-cardiac dyspnoea (NCD, n=34) according to pulmonary capillary wedge pressure (PCWP) on right heart catheterisation (rest/stress: ≥15/25 mmHg). LA and LV volumes were assessed on short-axis real-time cine sequences at rest and during exercise-stress. LACI was defined as the ratio of the LA/LV end-diastolic volume. Cardiovascular hospitalisation (CVH) was assessed after 24 months.

Results

Volume-derived LA (p≥0.008) but not LV (p≥0.347) morphology and function at rest and during exercise-stress detected significant differences comparing HFpEF and NCD. There was impaired atrio-ventricular coupling in HFpEF at rest (LACI 45.7 vs 31.6 %, p<0.001) and during exercise-stress (45.7 vs 27.9 %, p<0.001). LACI correlated with PCWP at rest (r=0.48, p<0.001) and during exercise-stress (r=0.55, p<0.001). At rest, LACI was the only volumetry derived parameter to differentiate NCD and HFpEF patients which were identified using exercise-stress thresholds (p=0.001). Resting and exercise-stress LACI dichotomised at their medians were associated CVH (p≤0.005).

Conclusions

Assessment of LACI is a simple approach for LA/LV coupling quantification and allows easy and fast identification of heart failure with preserved ejection fraction (HFpEF).
Quantification of aortic valve fibrosis and calcification by computed tomography angiography: a prospective head-to-head comparison with histology
Authors: Grodecki K , Olasinska-Wisniewska A , Cyran A , Urbanowicz T , Kwiecinski J , Gocol R , Nawara-Skipirzepa J , Wilimski R , Perek B , Jemielity M , Wojakowski W , Gornicka B , Huczek Z , Dey D
Published: November 2023

Background

Calcific aortic stenosis (AS) is characterized by leaflet degeneration involving fibrocalcific alterations which limit leaflet mobility and eventually lead to obstruction of flow across the aortic valve. While cardiac computed tomography (CT) has been routinely used for quantification of aortic valve calcium in individuals in whom echocardiography is inconclusive, recent studies on quantification of aortic valve fibrosis are lacking histological validation. [1,2]

Purpose

We, thus, aimed to validate a non-invasive CTA-derived quantitative characterization of aortic valve tissue against histologic examination of excised aortic valve leaflets.

Methods

In this prospective study, patients underwent CTA within a month before surgical aortic valve replacement for aortic stenosis. Tomographic valve tissue components were identified by Gaussian mixture modeling applied to CTA, by automatically fitting Gaussian functions to the Hounsfield Unit (HU) histograms for blood pool, non-calcific, and calcific aortic valve tissue. Tissue composition, expressed as % [(tissue component volume / total tissue volume) × 100%], was automatically calculated. For histologic evaluation, explanted valve leaflets were stained with Movat's Pentachrome. For every leaflet, three non-consecutive 5-µm sections were obtained. Further, an automatic algorithm detecting pixel intensities was applied for color differentiation and quantification of tissue components (Figure 1). Separate measurements from all the sections of the single valve were finally averaged and compared with CTA-derived calculations.

Results

A total of nineteen patients (63% men, 67±8 years old) undergoing isolated surgical aortic valve replacement for severe aortic stenosis with preoperative CTA were evaluated. The mean proportion of non-calcific aortic valve tissue was 68±16% in CTA and 75±3% on Movat’s Pentachrome staining (p=0.004, paired samples comparison). There was a strong correlation between the two modalities (r=0.856, p<0.001; Figure 2A). Intermodal repeatability between CTA and histology for non-calcific tissue quantification was excellent with an interclass correlation coefficient of 0.855 (95% CI 0.663 – 0.942, p<0.001), coefficient of repeatability of 16.8% and bias of -6.7% (p=0.234, Figure 2B).

Conclusions

CTA-derived characterization of aortic valve tissue provides an accurate quantification of non-calcific tissue as compared with gold-standard histologic examinations of explanted stenotic valves.Figure 1Figure 2
Structural and functional abnormalities of cardiac chambers in Barlow disease without significant mitral regurgitation
Authors: Meucci M C , Mantegazza V , Wu H , Garlasche A , Tamborini G , Pepi M , Bax J J , Ajmone Marsan N
Published: November 2023

Background

Limited and conflicting data have been reported on the existence of an early chamber remodelling in patients with Barlow disease (BD) without significant mitral regurgitation (MR).

Purpose

To explore the presence of left ventricular (LV) and left atrial (LA) morphological and functional abnormalities, evaluated by conventional and speckle-tracking echocardiography, in patients with BD and without significant MR; in addition, potential determinants of MR progression in these patients have been investigated.

Methods

We retrospectively identified consecutive patients with BD evaluated in two tertiary centers between 2010 and 2021. Only patients with MR graded from trivial to mild-to-moderate, as defined by an integrated multiparametric echocardiographic assessment, were selected. BD patients were matched with healthy controls with similar demographic characteristics and prevalence of cardiovascular risk factors, in a 1:1 ratio. A comprehensive echocardiographic evaluation, including LV and LA strain assessment by speckle-tracking analysis, was performed in all patients. Follow-up echocardiograms, when available, were reviewed in BD patients to evaluate the MR progression.

Results

A total of 231 patients with BD were included, of which 109 (56%) had trivial or mild MR and the remaining 122 (44%) had mild-to-moderate MR. As showed in Figure 1, patients with BD showed increased LV dimensions and indexed LV mass (LVMi), as compared with controls (all p<0.001); LV remodelling worsened with higher degree of MR (trivial-mild vs mild-to-moderate) and was accompanied by an increased prevalence of eccentric LV hypertrophy (eLVH). Conversely, parameters of LV systolic performance, including LV strain, were similar to controls and between the two groups. In addition, BD patients had larger LA volumes and more impaired LA reservoir strain than controls (p<0.001), without differences in the latter according to MR severity. Multivariable linear regression analyses in the overall population identified BD and MR grade as independent predictors of remodelling markers (LV dimensions, LVMi and LA volumes), and BD as independent correlate of LA reservoir strain.

Progression to moderate-to-severe or greater MR was observed in 51 subjects (on 172 with available follow-up) after a median time of 38 (range: 24-68) months. On multivariable Cox regression analysis, LVMi (or alternatively eLVH), together with age, MR grade and the presence of mitral annular disjunction emerged as independent predictors of MR progression (Figure 2).

Conclusions

Patients with BD and no significant MR show an early LV and LA remodeling, together with a mild impairment of LA reservoir strain, but not of LV function. LV remodelling, and the presence of eLVH in particular, portends a higher risk of MR progression.Comparative echocardiographic analysisMultivariable Cox regression analyses
Progression of different echocardiographic parameters of aortic stenosis have different clinical associations
Authors: Sen J , Wahi S , Marwick T
Published: November 2023

Background

Previous reports have described the risk factors for progression of aortic stenosis (AS). However, AS is recognized as a condition of the aortic valve and ventricle, and the AS marker chosen for the assessment of progression may influence the determinants of progression.

Purpose

To assess whether different clinical and demographic characteristics have a different impact on the progression of echocardiographic parameters on which stroke volume has a lesser (aortic valvular area [AVA], dimensionless severity index [DSI]) or greater influence (mean pressure gradient [MPG], or peak velocity [Vmax]).

Methods

Patients diagnosed with at least mild AS without an aortic valvular intervention identified from an echocardiographic database from January 1, 2009, to July 26, 2022, from a tertiary level hospital were included. AS progression models were evaluated using univariable and multivariable linear regression or mixed effects. AS severity was defined based on international guidelines.

Results

A total of 8,720 patients with at least mild AS were included and followed for up to 13.7 years. Multivariable mixed effects models identified important clinical predictors in understanding AS progression. After adjustment for relevant covariates, AVA decreased by 0.02 cm per year (95% CI: -0.025, -0.016, p<0.001), DSI decreased by 0.006 per year (95% CI: -0.008, -0.005), MPG increased by 0.962 mmHg per year (95% CI: 0.818, 1.107, p<0.001), Vmax increased by 6.742 cm/s per year (95% CI: 5.934, 7.549, p<0.001). Age, calcification, revascularisation, ejection fraction below 50%, and rheumatic heart disease, were the most consistent associations of progression of all echocardiographic parameters (Figure 1). Sex was associated with progression of AVA and DSI but not gradients. Changes in gradients (but not AVA and DSI) were associated with ischemic heart disease, chronic kidney disease, and atrial fibrillation or atrial flutter.

Conclusion

This longitudinal data analysis demonstrates differences in impact of baseline risk factors on AS progression on different echocardiographic parameters.Figure 1.Colour map of clinical predictors
Myocardial edema measured by T2 mapping is an independent predictor of ventricular arrhythmias in hypertrophic cardiomyopathy
Authors: Kirshenboim Z K , Fardman A F , Shagraui R S , Sabbag A S , Konen E K , Beytelman A B , Arad M A , Wassershtrum Y W , Goitein O G , Brodov Y , Kirshenbaum Z K
Published: November 2023

Introduction

Clinical outcome of patients with hypertrophic cardiomyopathy (HCM) largely depends on ventricular arrhythmias. Parametric T2 mapping from Cardiac MRI (CMR) was found to be a measure of myocardial edema. We sought to study whether elevated T2 values on CMR in patients with hypertrophic cardiomyopathy (HCM) might predict ventricular arrhythmias (VA) and adverse clinical outcome.

Methods

Consecutive patients with HCM (n = 59) and healthy volunteers (n = 21) underwent 3 Tesla CMR. T2 mapping values were independently analyzed by 2 independent readers and presented using a 16-segment AHA model. VA was recorded by 24-hour Holter monitoring and/or during exercise stress test. Composite outcome was defined as ventricular tachycardia (VT) per Holter and/or ergometry, admission due to arrhythmias, ICD insertion and all-cause mortality. Statistical analysis was a t-test for VA and multi-variant logistic regression model adjusted for age and gender.

Results

Septal and apical variants of HCM were found in 42 and 17 patients, respectively. We found good interobserver agreement in T2 values (ICC=0.92, 95% CI 0.86 - 0.96, p value <0.001). The 3rd tertile of T2 values (48 ± 8 msec) was significantly associated with VA 92% vs. 57 and 40% in lower tertiles, p = 0.02. Logistic regression analysis showed the 3rd tertile was an independent predictor of composite outcome (VT per Holter and/or ergometry, admission due to arrhythmias, ICD and all-cause mortality) OR 95% CI = 22.8 (1.4 - 361.6), p = 0.026. ROC analysis to find best cut-off of T2 for prediction of outcome showed AUC 0.7 (Figure 1).

Conclusion

Elevated T2 is an independent predictor of VA and adverse outcome in HMC patients. These results suggest the impact of myocardial edema in myocardial disease activity in HCM.ROC analysis to find best cut-off of T2
Effects of treatment response on echocardiographic features among patients with light-chain cardiac amyloidosis
Authors: Briasoulis A , Rempakos A , Petropoulos I , Bampatsias D , Theodorakakou F , Dimopoulos M A , Stamatelopoulos K , Kastritis E
Published: November 2023

Background

Complete response to treatment for light chain cardiac amyloidosis (AL-CA) may lead to improvement of myocardial function. The aim of this study was to evaluate the effect of treatment for AL-CA on echocardiographic characteristics of patients, and the prognostic impact of changes in longitudinal strain and myocardial work.

Methods

The study population comprised of sixty-one patients treated for AL between 2020 and 2022. All patients underwent comprehensive echocardiographic assessment including longitudinal strain and myocardial work imaging at baseline and at 1-year follow-up. Patients were stratified according to the depth of hematologic response to treatment for AL-CA as complete or not complete responders. The relationship between echocardiographic parameters and all-cause mortality was assessed by Kaplan Meir curves and cut-off points were selected using ROC analysis.

Results

A significant reduction in median NT-proBNP (from 2,771 to 1,486 pg/mL; p<0.001), posterior wall thickness (PWT) (from 13 to 12mm; p=0.002), and an increase in global work index (GWI) (from 1,115 to 1,356 mmHg%; p=0.018) was observed in all patients at 1-year follow up. After stratifying patients based on hematologic response to treatment, patients with complete response (CR) had a more pronounced decrease in intraventricular septum thickness (14.2 to 12.0mm; p=0.006), a trend towards improved global longitudinal strain (GLS) (-11.6 to -13.1%; p=0.064) and increased global constructive work (1,245 to 1,436 mmHg%; p=0.008), in addition to significant improvements in NT-proBNP, posterior wall thickness and global work index. Furthermore, the delta GLS (ρspearman=0.35; p<0.001) and delta GWI (ρspearman=-0.32; p=0.02) significantly correlated with delta NT-proBNP. Patients with GWI response, either any response or ROC-curve derived cut-off, had a better prognosis compared with patients without GWI response (log-rank p=0.043 and log-rank p=0.035, respectively).

Conclusions

Among patients treated for AL-CA, those with hematologic CR exhibited significant improvement in GWI and GWW. Additionally, our results indicate that GLS and GWI may have prognostic value in predicting survival among AL-CA patients and their changes correlate to NTproBNP decrease.
Anatomical, functional and prognostic correlates of resting coronary flow velocity in patients with hypertrophic cardiomyopathy
Authors: Palinkas E D , Tesic M , Djordjevic Dikic A , Aguiar S R , Cortigiani L , Rigo F , Palinkas A , Del Franco A , Wierzbowska-Drabik K , Ciampi Q , Dekleva M , Beleslin B , Viegas J , Olivotto I , Picano E
Published: November 2023

Background

The clinical significance of baseline peak diastolic coronary flow velocity (CFV) in the left anterior descending coronary artery (LAD) has not been investigated yet in patients with hypertrophic cardiomyopathy (HCM).

Aim

To assess the anatomical, functional and prognostic correlates of baseline LAD CFV in HCM.

Methods

384 consecutive adult HCM patients (age=52+15 years, 164 [43%] females) with no known coronary artery disease from 8 centers in 5 countries were prospectively analyzed. All patients underwent comprehensive transthoracic echocardiography including CFV measurement with pulse wave Doppler in the mid-distal LAD. All patients had preserved left ventricular (LV) function. LV force was calculated as (peak instantaneous LV outflow tract gradient+systolic blood pressure)/LV end-systolic volume. Patients were followed for a median of 50 months (IQ range 18-97 months), the outcome measure was a composite endpoint of all-cause death and acute heart failure.

Results

The mean CFV was 36±11 cm/s. CFV was positively correlated with LV maximal wall thickness (r=0.375, p<0.001), LV maximal septal thickness (r=0.320, p<0.001), resting LV outflow tract gradient (r=0.274, p<0.001), LV force (r=0.227, p<0.001), mean E/e’ (r=0.479, p<0.001) and heart rate (r=0.221, p<0.001). During follow-up, 54 events occurred (33 all-cause deaths and 21 acute heart failures). Receiver operating characteristic analysis was used to determine the best cut-off value of CFV (>31 cm/s) to predict the composite endpoint. Patients with CFV >31 cm/s had a significantly worse 10-year event-free survival compared to those with CFV ≤31 cm/s, see Figure.

Conclusion

Higher resting LAD CFV is associated with greater LV wall thickness, higher LV outflow tract gradient, faster heart rate and more elevated left ventricular filling pressures in HCM. Elevated resting CFV may indicate a coronary microcirculation dysfunction either primary or secondary to anatomical (septal hypertrophy), functional (increased myocardial oxygen demand), or autonomic (increased sympathetic drive) determinants. Whatever the underlying endotype, high resting CFV is related to worse prognosis in the long term.Figure.
Echocardiographic wall motion abnormalities and mortality reported in 492,338 individuals
Authors: Strange G , Stewart S , Playford D
Published: November 2023

Background

The prevalence of abnormal regional left ventricular function in the setting of myocardial ischaemia is incompletely studied, along with the relative frequency of individual wall motion abnormalities (WMA). We examined the prevalence and distribution of regional WMA in adults being investigated with echocardiography, and the association with mortality.

Methods

Routinely acquired echocardiographic reporting data and individually linked survival profiles were extracted from the Australia-wide, multicentre National Echocardiography Database of Australia. By applying natural language processing (NLP) to the cardiologist’s report of left ventricular (LV) function, we examined global and regional LV dysfunction.

Results

492,338 (age 61.9± 17.9) individuals (255,697 men aged 60.5±17.1 and 236,341 women aged 60.9±18.3 years) could be evaluated. 57,180 (17.6%) individuals were reported to have abnormal wall motion (39,346 men aged 69.0+/-13.4 yrs and 17,834 women, 71.3+/-14.3 yrs). The presence of a WMA was associated with increased left atrial volumes (LAVi: 55.5±36.4 vs 40.9±27.5 ml/m2 for women) , impaired LVEF (50.8±15.1% vs 61.1±12.2% for women), impaired diastolic function (E` 6.64±2.21 vs 8.25±2.86 cm/s for women), and higher pulmonary artery pressure (eRVSP 36.2±11.5 vs 32.5±10.7 mmHg) . Most, but not all individuals had a history of myocardial infarction with or without revascularisation. An inferior WMA was the commonest, with 18,638 WMA reported (4.7%), followed by apical WMA (19,682; 3.4%), lateral WMA (16,976; 2.9%), septal WMA (15,722; 1.7%) and anterior WMA in 9,432 (1.6%). In men, long-term all-cause mortality for WMA was 40.5% (compared to 23.3% without), and in women 42.7% (vs 20.5%). These WMA observations were magnified in those >65 years and with impaired systolic function. The presence of akinesis/dyskinesis/aneurysm of any wall fared worse than hypokinesis (OR 1.34 CI:1.22-1.44 P< 0.001 for Inferior WMA). Females with a WMA had less mortality (OR 0.80 CI: 0.74 – 0.85; P, 0.001), and any revascularisation was protective (OR 0.76 CI 0.46 – 0.69 P<0.001).

Conclusion

WMA are reported in men at greater than twice more frequently than women, and overall contribute almost a fifth of echocardiographic reports. The presence of a WMA is associated with impaired LV systolic and diastolic function, signs of increased LV filling pressure and pulmonary pressure, and high long-term mortality that is partially ameliorated by revascularisation. Prognosis is affected by the presence, extent and severity of WMA.
Plasma exosomes reflect myocardial injury detected by cardiac magnetic resonance in STEMI patients
Authors: Baggiano A , Zara' M , Banfi C , Campodonico J , Tedesco C , Amadio P , Gili S , De Dona G , Sandrini L , Maragna R , Junod D , Fusini L , Marenzi G , Pontone G , Barbieri S
Published: November 2023

Background

Cardiac magnetic resonance (CMR) is the gold standard technique to detect microvascular obstruction (MVO) and myocardial salvage index (MSI) in patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (pPCI). Exosomes are lipid vesicles released by all cells that reflect the metabolic status of the releasing cells, thus representing potential biomarkers of disease. The aim of this study is to evaluate the correlation between exosome profile and myocardial infarction characteristics as detected by CMR in patients after STEMI.

Methods

Exosomes were isolated from plasma of 42 patients by different commercial kits, their concentration and size distribution determined by Nanoparticle Tracking Analysis, exosomal surface epitopes by the MACSPlex Exosome Kit and GPIIb-IIIa expression by ELISA kit. Data obtained were correlated with parameters of myocardial damage (STEMI location, culprit lesion, time to revascularization, MVO and MSI).

Results

Levels of circulating plasma exosomes were higher in patients with anterior STEMI (p = 0.0002) and when the culprit lesion was located in LAD (p = 0.045). In addition, a high number of exosomes was measured in the subset of patients who underwent a late revascularization (> 3 h from onset of symptoms; p = 0.038). Patients with MVO and low MSI (< 0.5) have smaller exosome (p = 0.0015 and p = 0.014, respectively). By analysing the expression of 37 surface protein markers, the strongest signals are platelet specific markers (CD41b and CD42a) followed by endothelial and immune cells markers. Interestingly, a lower expression of platelet marker GPIIb-IIIa was detected in both patients with MVO and anterior STEMI (p = 0.039 and p = 0.0038, respectively). Univariate analysis demonstrated that exosome size and GPIIb-IIIa were independent predictors of MVO/MSI and ROC analysis demonstrated that dimension and GPIIb-IIIa can identify patients with MVO/MSI (AUC 0.75 and 0.71, respectively).

Conclusion

The plasma exosome profile well reflects CMR-assessed myocardial injury after STEMI. In particular, the exosome dimension and the expression of platelet marker GPIIb-IIIa are independently associated with MVO. Future studies with larger populations are required to confirm the role of platelet-derived exosomesin risk stratification after STEMI.Unfavourable CMR and sEV profi leFavourable CMR and sEV profi le
Pericardiocentesis versus pericardial window surgery in malignant pericardial effusion: trends and clinical outcomes
Authors: Lee J , Kim K , Cho I S , Ha J W , Shim C Y
Published: November 2023

Backgrounds

Pericardial effusion (PE) is often an obstacle to cancer treatment and a life-threatening factor. Although cancer survival has improved over the past two decades, an appropriate treatment method for PE in cancer patients has not yet been established. The purpose of this study was to investigate the temporal trends and clinical results in the method of drainage of PE.

Methods

Between 2003 and 2022, 744 consecutive patients with malignant PE who underwent pericardial drainage were retrospectively analyzed. The patients were divided according to the time of pericardial drainage (Period 1: 2003-2012, Period 2: 2013-2022) and initial drainage method (pericardiocentesis vs. window surgery). The rates of all-cause death and redo pericardial drainage for recurrent PE were compared according to the drainage methods.

Results

In comparison with Period 1, there was an increasing number of patients who underwent pericardial drainage in Period 2 (235 vs. 509). However, the proportion of window surgery decreased (21.7 vs. 14.9%, P=0.029). The median survival time of patients was improved (4.4 vs. 6.3 months, log-rank P<0.001). There was no significant difference in all-cause death and 30-day mortality (24.4 vs. 18.6%, P=0.171) after drainage between surgery and pericardiocentesis groups. The window surgery group had a significantly lower incidence of redo pericardial drainage than the pericardiocentesis group (hazard ratio [HR]: 0.49, 95% confidence interval [CI]: 0.26–0.91, P=0.022). In Period 1, there was no significant difference in redo pericardial drainage between window surgery and pericardiocentesis (HR: 0.78, 95% CI: 0.35–1.74, P=0.540). However, the window surgery group had significantly lower redo pericardial drainage than the pericardiocentesis group in Period 2(HR: 0.33, 95% CI: 0.12–0.91, P=0.024).

Conclusions

The window surgery was safe in cancer patients. As cancer survival rates improve, surgery showed benefits in reducing redo pericardial drainage. Pericardial window surgery could be preferred over pericardiocentesis in patients who expected longer life expectancy.
Effect of sodium-glucose type 2 cotransporter inhibitors on cardiac structure and function in patients with normal ejection fraction
Authors: Cortes Garcia M , Lorenzo O , Lumpuy-Castillo J , Taibo M , Pello A M , Orejas M , Navas M A , Martinez M E , Macia E , Rueda A , Hang T , Tunon J
Published: November 2023

Introduction

Sodium-glucose cotransporter inhibitors (SGLT2i) have proven a reduction in cardiovascular events in diabetic patients with and without heart failure (HF), as well as in non-diabetic patients with heart failure with reduced and preserved ejection fraction (EF). The mechanisms underlying this benefit are not well known, with contradicting data on the changes that SGLT2i produce on cardiac function and structure.

Methods

Between October 2020 and October 2021, 31 diabetic patients without prior history of SGLT2i use with normal EF (>50%), glycated hemoglobin <6.5%, renal clearance rate of >60 ml/min/1.73 m2 and sinus rhythm were prospectively included. In all of them, SGLT2i were started. At inclusion and 6-months follow-up, different clinical, ECG, analytical and echocardiographic (standard, 3D and speckle tracking) variables were recorded.

Results

The average age of our population was 66.4 years (±8.4). 90% were male, 71% were hypertensive, 77.4% were dyslipidemic, 22.6% were obese and 87.1% were current or former smokers. 77.4% of patients had a history of ischemic heart disease, and 10% had vascular disease in other territories. At the time of inclusion, 80.6% of the population was treated with ACEI or ARB, 54.8% with beta-blockers, 29% with diuretics, and 93.5% with statins. After an average follow-up period of 6.6 months (±0.8), medication had to be withdrawn in 5 patients (in 3 of them due to repeated genital or urinary infections, and in 2 of them because of patient choice). An average reduction of 0.89 mm (±0.24, p = 0.001) in myocardial thickness was observed, as well as a reduction in the 3D-estimated left ventricle mass of 9.9 g/m2 (±4.5, p = 0.03), and in the E/é ratio of 1.4 (±4.5, p = 0.02). An increase in absolute left ventricle global longitudinal strain (LVGLS) of 0.74 (±0.35, p = 0.05) was observed, as well as an increase in isovolumetric relaxation time (IVRT) of 9.8 ms (±4.8, p = 0.05). An increase in LA strain and indexed volume was noted, although differences did not achieve statistical significance. No relevant differences in LV dimensions and volumes were observed, as well as in the evaluated RV parameters (picture 1).

Conclusions

It is necessary to understand the mechanism underlying the clinical benefit of these drugs. This will allow us to better understand its effect in patients with HF. Our data shows that the use of SGLT2i is associated with cardiac improvements, both structural (myocardial mass) and functional (IVRT, LVGLS, E/e'), in a population of patients with normal EF.
Echocardiographic reference ranges for non-invasive myocardial work indices in heart transplant patients
Authors: Landra F , Martini L , Tanzi L , Fusi C , Barilli M , Sciaccaluga C , Diviggiano E , Focardi M , D'ascenzi F , Bernazzali S , Maccherini M , Valente S , Cameli M , Mandoli G E
Published: November 2023

Background

Non-invasive myocardial work (MW) is a relatively novel echocardiographic method with increasing fields of application. Normal reference ranges of MW indices in a healthy population have already been determined but these may differ in patients who have undergone a heart transplant (HTX).

Purpose

To obtain the reference ranges for 2D echocardiographic indices of MW for HTX patients and to compare them with the results of the EACVI NORRE study regarding healthy volunteers.

Methods

All consecutive HTX patients admitted at our Institution under Day Hospital regimen from September 2019 to May 2022 who performed endomyocardial biopsy (EMB) were considered. Patients with echocardiographic exam or brachial artery cuff pressure unavailability, history of rejection, history of coronary artery vasculopathy (CAV) and either acute cellular rejection (ACR) or acute antibody-mediated rejection (AMR) at EMB were excluded. Non-invasive MW calculation through Speckle-tracking Echocardiography (STE) was retrospectively performed for included patients. Further, MW analysis results were compared to those from the EACVI NORRE study.

Results

Out of 176 HTX patients who had performed EMB and had available echocardiographic and blood pressure data, 35 patients were excluded because of history of rejection, 4 patients because of history of CAV and 55 patients because of either ACR or AMR at EMB. Therefore, study population consisted of 82 HTX patients (68.3% male, median age 53 (46 – 62) years). Median age from HTX was 5 (2 – 22) months. Mean global work efficiency (GWE, 84 ± 8 %), global work index (GWI, 1447 ± 409 mmHg%), global constructive work (GCW, 2067 ± 423 mmHg%) and median global wasted work (GWW, 310 (217 – 499) mmHg%) did not differ between sex categories (p-value > 0.05). Each of these indices significantly differed from those reported in the EACVI NORRE study (p-value < 0.001), with lower GWI, GCW, GWE and higher GWW in the HTX population.

Conclusion

This study provides reference ranges for non-invasive MW indices in a HTX population free from transplant-related complications which are different from those regarding a population of healthy volunteers.Table 1
Right ventricular pulmonary arterial coupling in patients with implanted left ventricular assist devices
Authors: Stapor M , Sobczyk D , Wasilewski G , Wierzbicki K , Gackowski A , Kleczynski P , Zmudka K , Kapelak B , Legutko J
Published: November 2023

Background

Both the right ventricular (RV) contractile function and pulmonary arterial (PA) pressure influence clinical outcomes in patients supported with left ventricular assist devices (LVADs), but the impact of RV-PA coupling is unknown.

Purpose

This study aimed to determine the prognostic impact of RV-PA coupling in patients with implanted LVADs.

Methods

Patients with implanted third-generation LVADs were retrospectively enrolled. The RV-PA coupling was assessed preoperatively by the ratio of RV free wall strain (RVFWS) and noninvasively measured peak RV systolic pressure (RVSP). The primary endpoint was a composite of all-cause mortality or right heart failure (RHF) hospitalization. Secondary endpoints consisted of all-cause mortality at a 12-month follow-up and RHF hospitalization.

Results

A total of 72 patients with good RV myocardial imaging were included. The median age was 57 years, 67 patients (93.1%) were men and 41 (56,9%) had dilated cardiomyopathy. A receiver-operating characteristic analysis (AUC 0.703, 51.5% sensitivity, 94.9% specificity) was used to identify the optimal cutoff point (0.28%/mmHg) for the RVFWS/TAPSE threshold. Event rates were estimated using the Kaplan-Meier method showing an association with an increased risk for the primary endpoint of death or RHF hospitalization (89.47% vs. 30.19%, p<0.001). A similar observation applied to all-cause mortality (47.37% vs. 13.21%, p=0.003) and RHF hospitalization (80.43% vs. 20%, p<0.001).

Conclusion

An advanced RV dysfunction assessed by RV-PA coupling may serve as a predictor of adverse outcomes in patients with implanted LVADs.
A preliminary study on the standard value of left ventricular mechanic dyssynchrony by speckle tracking
Authors: Tan J , Zhang Q , Luo Y R , Tan X , Feng K
Published: November 2023

Background

Speckle tracking imaging automatic functional imaging (AFI) is a new method to measure left ventricular mechanical dyssynchrony. Parameter peak strain dispersion (PSD) is the standard deviation when the long axial strain of 17 segments of the left ventricle (LV) reach there’s peak. There is no unified standard value at present. Li C[1] included 59 healthy women aged 43.08 ± 8.22 years old, whose PSD was 31.44±3.83ms. Ji X[2] included 57 healthy volunteers aged 43.30 ±6.03 years old whose PSD value was 23.8±2.2ms. Some studies referred to the standard range of Yu index and used PSD>32.6ms as an indicator of left ventricular mechanic dyssynchrony.

Purpose

To investigate the standard value range of PSD and PSD/R-R interval.

Methods

Healthy volunteers who came to our hospital for physical examination from March 2020 to September 2021 were included, excluding hypertension, diabetes, hyperlipidemia, coronary heart disease and other diseases. According to the 20∼29 years old, 30∼39 years old, 40∼49 years old, 50∼59 years old, 60∼69 years old and 70∼79 years old, 10 males and 10 females were included, respectively. GE Vivid E95 was used to collect echocardiographic images, and the following parameters were measured: ①The general parameters of the heart, such as the diameter of the atrium(LA) and the left ventricle (LV) and the thickness of the left ventricular wall .; ②the values of PSD and PSD/ R-R interval. The normal distribution parameters were represented by mean plus or minus the standard deviation. Analysis of variance and post hoc test (LSDt-test) were used to analyse measured values statistically.

Results

Values of general echocardiographic data such as BSA, atrial and ventricular diameter, interventricular septal thickness, left ventricular posterior wall thickness, and LV ejection fraction were consistent with the guideline of Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging published in 2015. The range of PSD values for subjects in this study was 43±9ms, and the maximum was 65ms. The range of PSD/R-R was 5±1%, and the maximum was 7%. The values of PSD and PSD/R-R were 36±5ms(27∼45ms) and 4.4±0.76%(3∼6.4%) for 20∼39 years old, 42±5ms(34.9-54ms), 5.0±0.8%(3.5-6.7%) in 40∼59 years; 51±8ms(34∼65ms), 5.8±0.9%(3.9∼7%) in age 60∼79.

Conclusions

The preliminary study has shown that left ventricular mechanical dyssynchrony is associated with age. The standard value range of PSD is inconsistent in different age groups, and PSD and PSD/R-R values increase with age.PSD values at different agesBar chart of PSD values at different age
Resting strain analysis to identify myocardial ischemia in patients with advanced chronic kidney disease
Authors: Tsartsalis D , Kakiouzi V , Dimitroglou Y , Koukos M , Patsourakos D , Tolis E , Liakos C , Zisimos K , Tzoras S , Petras D , Tsioufis C , Aggeli C
Published: November 2023

Background

Chronic kidney disease (CKD) is associated with a higher incidence of cardiovascular death, particularly as the disease progresses and patients are on long term dialysis treatment. Screening for coronary artery disease in asymptomatic or mildly symptomatic patients is challenging and controversial.

Objective

The aim of this study was to investigate the incremental value of resting deformation analysis with speckle tracking echocardiography in predicting positive results on stress transthoracic echocardiography in patients with end-stage renal disease on dialysis (stage 5 CKD).

Methods

Our cohort consisted of 61 consecutive patients (mean age 62.3±11.8, 65.7% men) with stage 5 CKD. Patients with a confirmed diagnosis of pre-existing cardiac diseases, such as obstructive coronary artery disease, heart failure, severe arrhythmias or severe valvular disease were excluded. Patients underwent a resting transthoracic echocardiogram and a dobutamine stress contrast echo (DSCE) protocol. Positive results of DSCE were defined as stress-induced LV wall motion abnormalities (new or worsening preexisting abnormalities).

Results

The study cohort had normal or mildly impaired systolic function with mean LV ejection fraction (EF) of 49.17% (±10.41) and a mean LV GLS of 14.35% (±4.49) (Figure 1). In addition, half of our population had impaired LA strain: mean LA reservoir, LA conduit, and LA contractile reserve were 24.11% (±12.61), 10.56% (±5.88), and 13.60% (±9.15), respectively. DSCE was positive for ischemia in 55.7%. Age, gender, and history of diabetes were significantly correlated with positive result in DSCE (p=0.027, p=0.022 and p=0.039, respectively). Additionally, a significant negative association with DSCE results was found for the echocardiographic parameters LV EF, LV GLS, the conduit phase of LA strain, LV end diastolic volume as well as LA dimensions (p=0.002, p=0.002, p=0.004, p= 0.002 and p=0.048, respectively). Logistic regression analysis showed that LV global longitudinal strain was independently associated with DSCE outcome (p=0.007), after controlling for covariates. The area under the curve (AUC) to predict positive results for LV GLS was 0.92 with with a sensitivity of 96%, a specificity of 56% and an overall diagnostic accuracy of 84% (Fig 2).

Conclusion

The present findings demonstrate that resting LV deformation is associated with the presence of coronary ischemia and may be useful to better identify patients with advanced CKD who might benefit from coronary artery screening.LV GLSAUC
Home- versus clinic-based exercise intervention in patients with heart failure (EXIT-HF trial): a pragmatic randomized controlled trial
Authors: Santos M , Schimdt C , Magalhaes S , Teixeira M , Oliveira M I , Ferreira J P , Ribeiro F
Published: November 2023

Background

The limited accessibility partially explains the low uptake of cardiac rehabilitation (ExCR) for heart failure (HF). Home-based programs might address those obstacles but few data from randomized trials are available.

Purpose

To compare the effectiveness of a home-based versus clinic-based ExCR intervention in HF patients.

Methods

Single-center, single-blind, parallel groups, non-inferiority pragmatic randomized control trial (1:1 and after COVID-19 2:1 home- vs clinic-based). Adult HF patients referred to our cardiac rehabilitation (CR) unit were randomized to either a clinic-based (24 supervised sessions at a CR unit of a tertiary hospital over 12 weeks) or home-based (4 supervised ExT sessions to familiarize with the training protocol and the remaining sessions continued at home) over 12 weeks. Exercise training protocol consisted of a combination of endurance (at 60%-80% of peak oxygen uptake [VO2peak] and resistance training (elastic bands). The primary endpoint was the change in VO2peak at the end of the 12-week program. Secondary outcomes included adherence (>80% of sessions attendance) and change of Minnesota Living with HF Questionnaire (MLHFQ) scores.

Results

120 patients (mean age 64±11 years; 64% men) were randomized: 44 to clinic- and to 76 home-based intervention. 41% had an ischemic cardiomyopathy, 27% had an ICD/CRT, the mean LVEF was 36±11% (62% had LVEF <40%), 73% were on NYHA class II, and the median NT-proBNP was 361 [IQR 170-1008] ng/mL. Intervention groups were well balanced, including basal VO2peak that was similar between groups (17.8±4.8 vs 18.1±5.2 mL/min/Kg; p=0.75). Adherence was similar between groups (87.5% vs 82.5%; p=0.50). At week 12, on average, patients increased VO2 peak by 0.9±2.5 mL/min/Kg compared to baseline (p<0.001). No significant differences were found between clinic- and home-based interventions (p=0.25). Consistently, the MLHFQ total score decreased significantly overall (-10.3±1.7 points; p<0.001), with no significant differences between groups (p=0.91). The drop-out rate was 14% and 17% in clinic- and home-based groups, respectively.

Conclusions

The clinical impact of home-based CR program on peakVO2 and health-related quality of life of HF patients was similar to a standard supervised clinic-based one. Our data support the home-based program as an effective alternative way of delivering CR in HF.
A systematic review of Australian hospitals' policies on the deactivation of implantable cardioverter defibrillators
Authors: Grose D , Smallwood N , Corbett C , Walker A , Lim W K , Zentner D
Published: November 2023

Introduction

Increasing numbers of older adults are living with implantable cardioverter defibrillators (ICD), reflecting expanded indications and increased insertion rates (1). Deactivation rates for those approaching end of life are low, risking undue distress and an undignified death (2). International guidelines recommend discussions regarding deactivation be part of pre-implantation consent (3). Local health service policies, procedures and guidelines regarding deactivation are crucial for best-practice end-of-life care.

Objective

This systematic review aimed to determine the availability and content of hospital policies, procedures and guidelines regarding ICD deactivation towards end of life.

Methods

Victorian (PROMPT) and South Australian hospital guidelines databases were systematically searched (September 2022 - February 2023) to identify all documents regarding ICD deactivation at end-of-life. Eligible documents were analysed using a data extraction tool.

Results

Of 4001 documents identified from 93 health services (population 8.45 million Australians), 11 were included, with 10 (91%) from public, and 8 (73%) from metropolitan, health services. Two (18%) documents provided recommendations for subacute healthcare settings and 1 (9%) for community-based patients.

Guidance for prompting ICD deactivation discussions was limited. Only 2 (18%) documents advised at time of insertion, 1 (9%) at generator change and 6 (55%) during advance care planning discussions (Figure 1).

Recommended indications for ICD deactivation varied and included: patients with a palliative condition (2, 18%) or receiving end-of-life care (11, 100%), patient’s request (7, 64%) and with an active do not resuscitate order (5, 45%). Nine (82%) documents provided key points for informed consent discussions including that deactivation does not cause/hasten death (8, 73%), does not deactivate pacing (8, 73%), aims to promote a peaceful death (8, 73%) and that reactivation is possible (8, 73%).

Instructions for temporary deactivation using a magnet were provided in 10 (91%) documents (8 (73%) included manufacturer-specific instructions, 2 (18%) including correct magnet placement diagram). Most (10, 91%) gave non-urgent deactivation instructions. Advice for managing ICDs after death was detailed in 4 (36%) documents.

Conclusion

There is a paucity of local health service guidance to support Australian clinicians navigate the challenges of ICD deactivation at end of life. Consistent, detailed, high-quality local health service guidance is required to facilitate active recognition of people with whom timely discussion and action regarding ICD deactivation is appropriate. This may contribute to improved end of life care. Additionally, given the geographical size and population spread of Australia and implications for cardiologist access, logistical caveats that allow adaptation for local health service should be highlighted.Figure 1
Warranty period for low risk positron emission tomography for detection of cardiac allograft vasculopathy
Authors: Abadie B , Albert C , Bhat P , Harb S , Jacob M , Starling R , Cremer P , Tang W H , Jaber W
Published: November 2023

Background

Positron emission tomography/computed tomography (PET/CT) is increasingly being used as an alternative to invasive coronary angiography for the detection of cardiac allograft vasculopathy (CAV) in heart transplant patients. The appropriate screening interval for patients with low-risk testing is unknown.

Purpose

The purpose of the study was to determine the number of patients with an initial-low risk PET/CT who progressed to a high-risk result with annual screening and what patient characteristics were associated with this progression.

Methods

Patients with heart transplant with no history of CAV 2/3 by angiography, whose initial PET/CT scan was low-risk, and who had a repeat PET/CT as part of an annual screening program were included in the study. A low-risk PET/CT was PET CAV score 0/1, and a high-risk PET/CT was PET CAV score 2/3, as defined by a previously published and validated diagnostic algorithm. The primary outcome was the percentage of patients who progressed to a high-risk result.

Results

The median time between PET/CT scans was 382 days (IQ 365 – 443). Only 2/163 (1.2%) patients with initial PET/CAV 0 progressed to PET CAV 2/3 on their repeat study compared to 7/37 (19%) for those with PET CAV 1 (RR 9.16, 95CI 2.97 – 28.29). During the study period, there were 0 episodes of urgent revascularization and 1 elective revascularization.

Conclusions

The risk of developing PET CAV 2/3 in patients with an initial result of PET CAV 0 is low at one year and annual screening may be unnecessary. Conversely, in patients initially classified as PET CAV 1, the risk of progression to PET CAV 2/3 is high and more frequent screening may be indicated.