bluuebunny/crossref_metadata_2025 huggingface dataset:
5-year outcome comparison among aortic stenosis patients underwent transcatheter aortic valve implantation with or without permanent pacemaker
Authors: Liu D , Hu K , Sokalski V , Lau K , Lengenfelder B , Ertl G , Frantz S , Nordbeck P
Published: November 2023

Background

The occurrence of atrioventricular block due to local damage to the atrioventricular and infranodul tissues, requiring permanent pacemaker (PMI), is one of major complications of transcatheter aortic valve implantation (TAVI). Previous studies show conflicting results regarding impact of PMI on outcomes in TAVI patients.

Purpose

The purpose of this study was to compare the 5-year survival rate and CV mortality of TAVI patients without PM, patients with PMI before TAVI, and patients underwent PMI after TAVI. In addition, we also assessed the influence of early- and new-generation prostheses on the prevalence of PMI after TAVI and related outcomes.

Methods

A total of 778 patients who underwent TAVI in our hospital between 2009 and 2021 were included in this study (mean age 81.4±5.7 years, 50.9% male). Patients were divided into 3 groups: no PMI (n=614), PMI before TAVI (n=76), and PMI after TAVI (n=88). Primary endpoints were defined as all-cause death and cardiovascular (CV) death up to 5 years after TAVI.

Results

The prevalence of PMI after and before TAVI were 11.3% (88/778) and 9.8% (76/778), respectively. During a median follow-up time of 30 (18-49) months, the survival rate at 1, 2, and 5 years was 90.7%, 83.1%, and 69.2% in the no PMI group, 92.0%, 86.4%, and 76.1% in the PMI after TAVI group, and 89.5%, 86.8%, and 75.0% in the PMI before TAVI group. There was no significant difference in survival rate and CV mortality among the 3 groups (P>0.05, Figure 1).

Of 778 patients, 251 (32.3%) patients received early-generation prostheses (Edwards SAPIEN or SAPIEN XT), 527 (67.7%) patients received new-generation prostheses (Edwards SAPIEN 3, SAPIEN 3 Ultra, or ACURATE neo). As compared with TAVI patients who received early-generation prostheses, the prevalence of PMI after TAVI was significantly higher (13.3% vs. 7.2%, P=0.012), while the 5-year all-cause mortality (20.7% vs. 47.8%, P<0.001) or CV mortality (14.8% vs. 31.1%, P<0.001) was significantly lower in those who received new-generation prostheses. TAVI patients with new-generation prostheses was associated with a better 5-year survival rate as compared with early-generation prostheses, irrespective of age, sex, and PMI (hazard ratio=0.654, 95% CI 0.500-0.855, P=0.002, Figure 2).

New-generation prostheses (relative risk=1.784, 95% CI=1.089-2.922, P=0.022) and greater prostheses diameter (per 1 mm increase, relative risk=1.144, 95% CI=1.017-1.287, P=0.025) were independently associated with increased risk of PMI after TAVI.

Conclusion

There is no significant difference in survival rate and CV mortality between patients who underwent PMI after or before TAVI and those who did not. New-generation prostheses is related to higher risk of PMI and better 5-year survival in TAVI patients.Figure 1Figure 2
Sex influence in the etiology and long-term prognosis of significant tricuspid regurgitation
Authors: Alegre Garcia G , Rodriguez Capitan J , Segovia Reyes J , Soler Gonzalez M , Marquez Camas P , Carmona Carmona J , Garcia Rodriguez L , Rodriguez Cordoba A , Gonzalez Aguado N , Diaz Exposito A , Angullo Gomez M , Luna Morales M , Palma Marti L , Gomez Doblas J J , Jimenez Navarro M
Published: November 2023

Introduction

It is widely recognized that significant tricuspid regurgitation is more frequent in women, but there is practically no information on the prognostic differences according to sex in the different etiological groups. Our objective was to analyze the impact of sex on the frequency and prognosis according to the etiological group.

Methods

Retrospective multicenter study that included consecutive patients with significant tricuspid regurgitation (moderate-severe degree or greater) diagnosed between 2002 and 2017 in 3 referral hospitals. We retrospectively classified the patients according to sex and type of tricuspid regurgitation based on clinical and echocardiographic data. The type of tricuspid regurgitation was defined in the first step that met the established criteria, differentiating between congenital and organic etiology (structural tricuspid disease), left valve disease (mild mitral stenosis or another at least moderate valve disease), ventricular dysfunction, associated with pulmonary hypertension, or atrial (by not fulfilling any of the above and presenting atrial dilatation). Subsequently, we compared prevalence and mortality from all causes according to sex for each etiology.

Results

A total of 778 patients were included, 71% women. The median follow-up was 40.2 months (interquartile range 11.2-80.9). When comparing the frequency of each etiological group according to sex, we only found significant differences in tricuspid regurgitation associated with ventricular dysfunction (9.7% men vs 3.1% women, p <0.001). In terms of survival, we found significant differences with higher survival in women with organic etiologies (92.4 months in women vs 54.1 in men, p=0.021), secondary to valve disease (79.6 months in women vs 54.1 in men, p<0.001) or pulmonary hypertension (58.9 months in women vs 28.7 in men, p=0.01). In the rest of the etiological groups, differences were not statistically significant. Figure shows Kaplan-Meier survival curves based on each etiology for each gender.

Conclusions

Significant tricuspid regurgitation was observed in a higher percentage of women (71%). Regarding the frequency for each type of tricuspid regurgitation, only significant differences were found in the etiology secondary to ventricular dysfunction, being more frequent in men. Regarding the survival curves, significant differences were found with greater survival in the group of women in organic tricuspid regurgitation, secondary to valve disease and secondary to pulmonary hypertension.Kaplan Meier survival curves
Predictors of major adverse cardiovascular events in patients with severe aortic stenosis awaiting aortic valve replacement
Authors: Fialho I , Mateus C , Passos M , Lima-Lopes J , Gerardo F , Miranda I , Madeira M , Marques M , Augusto J , Santos M , Baptista S , Farto-E-Abreu P , Morais C , Neves J
Published: November 2023

Background

Severe aortic stenosis (AS) is a progressive disease associated with an increased risk of heart failure (HF) and mortality if left untreated. Aortic valve replacement (AVR) is the treatment of choice. However, it is not always immediately available, and some patients have experienced major cardiovascular events (MACE) while waiting for AVR. The identification of reliable predictors of MACE can help clinicians risk-stratify severe AS patients and tailor their management to prevent adverse outcomes.

Purpose

We aimed to evaluate predictors of MACE in real-world patients with severe AS who are waiting for AVR.

Methods

We conducted a prospective registry of consecutive patients discussed in the Heart Team meeting of a single centre, between January 2018 and June 2021. All patients with severe AS were included. For each patient we recorded demographic data, blood test results, echocardiogram parameters, and MACEs (a composite of death, HF hospitalization, non-fatal acute myocardial infarction, and non-fatal stroke). MACEs were recorded until the patient underwent AVR. The median follow-up time was 187 days (IQR 59-352).

Results

Overall, 235 patients were included (mean age 76.7±10.7 years, 48.1% male). Previous HF hospitalization (HR 2.77, 95% CI 1.66 – 4.62), HF symptoms with New York Heart Association (NHYA) class ≥3 (HR 2.64, 95% CI 1.58–4.39), and the presence of left ventricular dysfunction (HR 2.86, 95% CI 1.71–4.78) were independent predictors of MACE (Figure 1). The presence of pulmonary hypertension (HR 2.16, 95CI 1.27–3.66), but not right ventricular dysfunction (HR 2.34, 95CI 0.45–12.08, p=0.31), was associated with MACE until AVR. Concomitant moderate to severe tricuspid regurgitation (HR 10.88, 95CI 1.41–83.94) and moderate to severe mitral regurgitation (HR 5.91, 95CI 1.50–23.34) were associated with a worse prognosis, even when adjusted for other relevant MACE predictors. Laboratory data such as serum creatinine, haemoglobin, and NT-proBNP levels were not associated with the occurrence of MACE in this population (HR 1.00). Past medical history of hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease were not associated with MACE. Age was a limited predictor of MACE (HR 1.03, 95CI 1.00 – 1.06, p=0.04).

Conclusion

Previous HF hospitalization, NYHA class ≥3 symptoms, left ventricular dysfunction, and pulmonary hypertension were independent predictors of MACE in patients with severe AS awaiting AVR. Additionally, concomitant moderate to severe tricuspid and mitral regurgitation were also associated with worse prognosis. These findings may help identify those at high risk of MACE who would benefit most from early intervention and close monitoring.
Degenerative or rheumatic: after all, what is the most prevalent etiology of mitral regurgitation in developing countries?
Authors: Vicente Pereira Lipari L F , Fernandes J R C , Ziotti S V , Nazzetta D C , Tessari F C , Pessoa R S , Haussauer Jr H V , Rosa V E E , Pires L J N T , Accorsi T A D , Lopes M P , De Santis A S , Spina G S , Sampaio R O , Tarasoutchi F
Published: November 2023

Introduction

Mitral regurgitation (MR) is the most prevalent valve disease in Europe, mostly degenerative. In Brazil, on the other hand, there are few recent epidemiological data and previous studies show a higher prevalence of rheumatic disease.

However, a change in the epidemiological profile of valve disease has recently been observed, largely due to the increase in life expectancy and decrease in the incidence of rheumatic fever.

This study aims to evaluate patients with MR in a tertiary hospital in Brazil, emphasizing the etiological analysis.

Methods

Patients with moderate or severe MR on echocardiogram performed between 07/01/2018 and 06/30/2020 in a Brazilian Cardiology hospital were retrospectively evaluated, including 2,017 cases. Clinical data (age, sex, symptoms and comorbidities) were analyzed, in addition to complementary tests, such as electrocardiogram and echocardiogram.

Results

A total of 2,017 cases were included, of which 1,966 (97.5%) had severe MR. The mean age was 65 years and 52% were female.

In this cohort, 924 patients (45.8%) had primary MR, while 1093 (54.2%) had secondary causes. Among the primary etiologies (N=1093), degenerative was the most prevalent, responding to 51.3% (n=474), followed by rheumatic disease, present in 34.5% of the patients (n=319). The other primary etiologies observed were calcific (94 patients = 4.7%), infective endocarditis (15 patients = 0.7%) and congenital (10 patients = 0.5%).

In the comparative analysis between degenerative and rheumatic MR, a statistically significant difference was observed in age and gender. Patients diagnosed with rheumatic MR were younger - mean age: 58 years (standard deviation 49-68) compared to 67 years in patients with degenerative mitral disease (standard deviation 58-76 years). Most patients with rheumatic disease were female (N=255, 79.9%), with percentages almost twice as high as those observed in degenerative MR (N=192 - 40.5%).

Secondary causes (N=1,093) were composed of dilated etiology in 859 patients (78.6%), ischemic (140 patients - 12.8%) and atrial functional (55 patients - 5%).

Conclusion

In agreement with the current epidemiological change in valvular heart disease, we could also observe an important change in the etiology of MR in Brazil, with a reduction in the burden of rheumatic disease and greater expressiveness of mitral prolapse.
Derivation and validation of risk score to predict mortality or heart failure-related hospitalisation based on clinical and echocardiographic factors in moderate or severe aortic stenosis
Authors: Sen J , Wahi S , Marwick T
Published: November 2023

Background

Multiple studies from echocardiographic databases have investigated association between moderate or severe aortic stenosis (AS) and poor cardiovascular outcomes. However, outcomes and treatment response are also dependent on the clinical picture.

Purpose

To improve prognostication and management response of patients with moderate or severe AS by development and validation of a new risk score algorithm that combines clinical and echocardiographic parameters to predict 5-year all-cause mortality or heart failure (HF)-related hospitalisation.

Methods

3,452 consecutive patients diagnosed with moderate or severe AS [aortic valvular area <1.5 cm2, peak velocity > 3 m/s or dimensionless severity index < 1.5] were included in this observational cohort study. The least absolute shrinkage and selection operator (LASSO) and logistic regression was used to develop a risk score. This score provided an estimated probability of 5-year composite outcomes of all-cause mortality or HF-related hospitalisation in moderate or severe AS patients. The risk score was then validated with a geographically separate independent test cohort (n=1,788).

Results

Among 3,452 patients with at least moderate AS with median follow up of 7.3 years, 41 variables were important predictive parameters to be included in risk score (Figure 1). The most significant independent predictors were non-cardiac (Table 1). Areas under the receiver operating characteristic curves for the score were 0.80 (95% CI: 0.79-0.82) in the training set and 0.76 (95% CI: 0.73-0.80) in the test dataset, demonstrating good discrimination.

Conclusions

A risk score algorithm based on demographics, echocardiography, and clinical features was developed and validated with over 1000 patients. This risk score can be useful to predict outcomes beyond conventional echocardiographic parameters in patients with moderate or severe AS.Fig 1.Score vs 5-yr composite outcomesTable 1.OR for predictors in risk score
Maternal pre-existing and gestational diabetes and the risk of bicuspid aortic valve in the offspring
Authors: Hansson M , Sillesen A S , Dannesbo S , Voegg R O B , Axelsson Raja A , Vejlstrup N , Iversen K , Bundgaard H
Published: November 2023

Background

Approximately 6% of all pregnancies in Denmark are affected by maternal pre-existing or gestational diabetes. Maternal diabetes is a well-known risk factor for congenital heart defects. Among the most common congenital heart defects is bicuspid aortic valve (BAV), which is present in 0.8% of newborns. Familial clustering of BAV is seen in 30-40%, but the heritability is not completely understood and since most cases are sporadic, a multifactorial aetiology has been proposed. The association between maternal diabetes and BAV in the offspring has been sparsely investigated previously.

Purpose

The purpose was to assess the prevalence of BAV in newborns born to mothers with pre-existing or gestational diabetes compared with children born to mothers without diabetes.

Method

Systematic, standardized transthoracic echocardiography was performed within 60 days of birth in over 25,000 newborns included in a population-based, multicentre, cohort study between 2016 and 2018. Maternal diabetes-status was collected from obstetrical records maintained by the obstetrical departments of the participating hospitals, supplemented by records from a nationwide registry covering patients contacts with private and public hospitals since 1976. Maternal diabetes was categorized as type 1, type 2, or gestational diabetes (GDM) using the ICD-10 codes DO240, DO241, and DO244, respectively.

The exposed newborns were compared with newborns not exposed to maternal diabetes.

Results

In total, the cohort consisted of 25,553 new-borns of whom 24,707 (96.7%) were not exposed to diabetes, 648 (2.5%) were exposed to GDM, and 198 were exposed to pre-existing diabetes; 136 (0.5%) to type 1 and 62 (0.2%) to type 2 diabetes. Median gestational age was 281 days (interquartile range (IQR) 273;287), median age at examination was 11 days (IQR 7;15), and 48% were female. None of the newborns exposed to pre-existing diabetes had a BAV. Nine (1.4%) new-borns exposed to GDM, and 179 (0.7%) newborns not exposed to diabetes were found to have a BAV, corresponding to a relative risk of 1.92 (95%CI 0.99-3.73), p= 0.056.

Conclusion

Exposure to maternal diabetes is associated with an increased risk of congenital heart disease. In our large cohort of unselected newborns, the association between diabetes and BAV did not reach statistical significance, but the numerically observed twice higher risk of BAV in children born to women with gestational diabetes is nevertheless intriguing and deserves future attention.
Predictors of clinical outcome in adults with repaired tetralogy of Fallot and the prognostic value of surrogate markers of right ventricular dyssynchrony
Authors: Papa A , Nussbaumer C , Schwitz F , Wustmann K , Greutmann M , Schwerzmann M
Published: November 2023

Introduction

Sequelae or residual lesions after surgical repair of tetralogy of Fallot (rTOF) are inevitable and have an impact on long-term outcome. So far, most of our attention was directed to negative consequences of residual pulmonary regurgitation. Less attention has been paid to the impact of right bundle branch block and intraventricular dyssynchrony on biventricular function, exercise capacity and clinical outcome.

Purpose

Using the Swiss Adult Congenital HEart disease Registry we aimed to investigate the 5-year clinical course of adults with rTOF late after surgical repair. We used echocardiography strain analysis as surrogate to quantify right and left ventricular dyssynchrony and correlated our findings with routine clinical measures from cardiopulmonary exercise testing, neurohumoral blood work and cardiac magnetic resonance imaging with the aim to identify patients at increased risk for an adverse clinical event.

Methods

2D speckle-tracking strain analysis of the right and left ventricle was performed with dedicated software (Tomtec, Germany). RV dyssynchrony index was measured as the standard deviation of time to peak shortening (TTP) in six RV segments. Interventricular shortening delay (IVSD) was defined as the maximal delay of TTP between ventricular segments. We constructed a multivariate model with NT-proBNP, ECG, clinical, imaging and exercise testing variables to predict the composite outcome of all-cause mortality, relevant arrhythmias and hospital admission for decompensated heart failure.

Results

A total of 285 patients were included. During a mean follow-up of 48±21 months, 33 patient (12 %) suffered an adverse event with a mean time to event of 30 ± 21 months after the baseline visit. RV dyssynchrony index and IVSD did not differ statistically between the groups with and without events (49±31ms vs 41±18ms, p-value 0.21, 130±65ms vs. 103±50ms, p-value 0.9). In the multivariate Cox-regression model, NT-proBNP, right atrial area and peak heart rate at exercise testing were independent predictors of outcome. An integrated risk score with the median values of these 3 variables as cut-off was highly accurate in separating patients at low risk (score 0; n=39) and high risk (score 3; n=38) for an adverse event. After 6 years of follow-up, no patient at low risk (score 0) had an adverse event, while in 62% of patients at high risk (score 3) an adverse event occurred (p<0.001).

Conclusion

In our cohort of rTOF patients, echocardiographic surrogates of RV dyssynchrony did not correlate with clinical events. An integrated multimodality approach proved to be effective in predicting outcomes.
Sex differences in aortic stenosis progression and myocardial response
Authors: Teixeira R , Duarte F , Sousa-Nunes F , Almeida M , Neves I , Lobo A , Leite M , Ferreira D , Brandao M , Diaz S , Saraiva F , Barros A , Sampaio F , Fontes-Carvalho R
Published: November 2023

Background

Aortic stenosis (AS) produces an increased afterload and consequently left ventricular (LV) remodeling. While current guidelines recommend the same echo-doppler criteria for diagnosis and grading of AS for men and women, different sex-specific patterns of cardiac remodeling, and eventually damage, have been reported. Whether these different patterns are caused by sex-related AS progression rate or myocardial response is less well known.

Aim

We aim to compare longitudinal changes in aortic valve and cardiac function between women and men with AS to investigate sex-related differences in AS progression and cardiac remodeling.

Methods

Patients with mild-to-severe AS and LV ejection fraction (LVEF) ≥ 50 % at least in 2 transthoracic echocardiograms (TTE) were retrospectively identified. Prosthetic and bicuspid valves were excluded. Serial TTEs provided a multiparametric framework to compare AS severity, progression rate and induced cardiac changes between sexes.

Results

914 patients were included (median follow-up time of 6.8 years) and 52 % (473) were female. Both sexes had similar baseline aortic peak velocities (APV) (2.9±0.9 m/s), mean pressure gradient (MPG) (27±13 mmHg) and LVEF (60±5 %). Women were older (75±9 vs 73±8 years; p<0.001), had smaller body surface area (BSA) (1.70±0.15 vs 1.88±0.16 m2, p<0.001), proportionally lower stroke volume (SV) (82±19 mL vs 91±22 mL, p<0.001), lower indexed LV mass (iLVM) (118±33 g/m2 vs 125±28 g/m2, p<0.001) and higher indexed left atrial (LA) volume (39±13 vs 49±20 mL/m2, p<0.001). The average annual progression rate of APV and MPG was similar for both groups (2 mmHg/year and 0.14 m s-1 year-1). After multivariate adjustment including time-dependent aortic valve replacement, women had a higher incidence of severe LV hypertrophy as measured by iLVM (HR=1.16, CI=1.08-1.91, p<0.01), moderate-to-severe tricuspid valve regurgitation (HR=2.03, CI=1.01-4.07, p<0.05) and pulmonary hypertension (PHT) (HR=1.49, CI=1.02-2.18, p=0.04) at 5 years. Similar incidence rates were seen for LV dilation, LVEF reduction and mitral valve regurgitation. All-cause mortality rates were similar between groups (p=0.30).

Conclusion

This study suggests that under similar static and dynamic loading conditions, women will develop severe LV hypertrophy and PHT earlier than men, possibly reflecting sex-specific response differences intrinsic to the myocardium. This suggests that the definition of AS severity may benefit from a shift from a valve-focused to a myocardial-integrative approach taking gender into account.
Coronary vascular function in females with history of hypertensive disorders of pregnancy an oxygenation-sensitive cardiovascular magnetic resonance imaging study
Authors: Hillier E , Luu J , Plasa G , Palmer C , Moukarzel M , Lindsay K , Friedrich M G , Quesada O
Published: November 2023

Background

Hypertensive disorders of pregnancy (HDP), including gestational hypertension and preeclampsia, have been associated with increased risk for cardiovascular disease decades after HDP pregnancy. HDP is thought to unmask pre-existing cardiovascular risk in the mother; and in addition HDP triggers a cascade of inflammatory and oxidative stress which leads to vascular endothelial dysfunction and abnormalities in cardiac structure and function evident early post-partum that may persist sub-clinically. Oxygenation-sensitive cardiovascular magnetic resonance (OS-CMR) is an emerging approach that can identify dynamic changes of myocardial oxygenation as a marker for coronary vascular function. The objective of this study was to assess coronary vascular function in females with history of HDP using OS-CMR.

Methods

We analyzed data from two short axis OS-CMR slices in 20 females with history of HDP, including gestational hypertension, preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) and 20 healthy controls with history of normal pregnancy acquired on a 1.5T MRI scanner. Images were analyzed using a prototype tissue oxygenation module. The images were normalized for signal intensity to both ventricular blood pools. We used both traditional statistics and feature selection machine learning algorithms to select for predictive biomarkers in the dataset. Finally, we used a random forest classifier model for disease classification. We report area under the receiver operating curve (AUROC) as a metric for diagnostic accuracy.

Results

Global breathing-induced myocardial oxygenation reserve (B-MORE) of the mid left ventricular slice was significantly reduced in HDP females (-1.6 ± 14.8) when compared to healthy controls (11.3 ± 17.2, p=0.03), when normalized to ventricular blood pools (Figure 1A). Our feature selection algorithm selected the signal intensity during end-systole normalized to the series as the most predictive biomarker. Our model, which integrated data from >3,300 discrete data points per participant, correctly differentiated healthy controls from women with HDP history with a 90% ± 3% AUROC accuracy, indicating high sensitivity and specificity (Figure 1B).

Conclusion

Compared to healthy controls, females with history of HDP have abnormal coronary vascular function, as shown by reduced myocardial oxygenation on OS-CMR. Combining advanced machine learning approaches can further enhance the potential application of OS-CMR to risk stratify females with adverse pregnancy outcomes susceptible to future cardiovascular disease.
Dobutamine stress echocardiography remains indispensable for the diagnosis of low-flow low-gradient severe aortic stenosis
Authors: Adrichem R , Bouwmeester S , Abdelkarim O , Vogel B , Blusztein D I , Veulemans V , Kuneman J H , Geleijnse M , Bax J J , Bertrand P B , Kodali S K , Mehran R , Little S H , Houthuizen P , Van Mieghem N M
Published: November 2023

Background

In patients with low-gradient aortic stenosis (AS) and low transvalvular flow, current guidelines recommend dobutamine stress echocardiography (DSE) to determine valve stenosis severity. Additionally, aortic valve calcification (AVC) scores are also used with this intent. Previous studies have determined cut-off values of ≥2000AU for men and ≥1200AU for women to distinguish between true severe AS and pseudosevere AS.

Purpose

To assess the relationship between AVC and DSE in low-flow low-gradient aortic stenosis.

Methods

We performed a multicenter international registry study including patients that underwent DSE to determine AS severity and multi-slice computed tomography (MSCT) of sufficient quality to determine AVC scores. Severe AS was diagnosed when resting peak aortic valve velocity was ≥4.0 m/s, or stress aortic valve area (AVA) remained <1.0cm2 at peak dobutamine stress levels; moderate AS was diagnosed when resting AVA was ≥1.0cm2 and peak velocity was < 4.0m/s or stress AVA exceeded 1.0cm² at peak stress.

Using the previous cut-off values, MSCT-AVC scores were compared to DSE-derived AS diagnoses to determine sensitivity and specificity of AVC, and the positive and negative predictive values of high and low scores. Subsequently, we performed a receiver-operating characteristics (ROC)-curve analysis for men and women separately.

Results

We included 271 patients from 8 centers, of which 231 patients had sufficiently interpretable DSE and MSCT. Median age was 79 years (Interquartile range (IQR): 71-84), median BMI was 26.4 kg/m2 (IQR: 24.1-30.0) and median BSA was 1.9 m2(IQR: 1.8-2.1). Left ventricular ejection fraction was reduced (<50%) in 209 (90.5%) patients. Bicuspid valve morphology was present in 20 patients (8.7%).

DSE confirmed severe AS in 103 patients, 4 of whom already had resting peak aortic valve velocity ≥4.0m/s. Moderate AS was diagnosed in 128 patients, of which 76 had a resting AVA ≥ 1.0cm2. Characteristics of these patients are summarized the table.

Of the patients with severe AS, 49 (47.6%) had a high AVC score (≥2000 for men or ≥1200 for women) and of patients with moderate AS, 75 (58.6%) had an AVC score below those cut-off values. This corresponds to a sensitivity of 47.6%, a specificity of 58.4% and positive and negative predictive values of 53.5% and 51.6%, respectively. The ROC-curves are shown in the figure; the area under the curve was 0.55 for men and 0.52 for women, signifying poor discriminative performance.

Conclusion

In this multicenter international registry we found that aortic valve calcification scores correlated poorly with AS severity and therefore DSE remains the preferred technique to assess borderline AS severity.Table.Patient characteristicsFigure.ROC curve
Myocardial work and left heart deformation parameters across mitral regurgitation severity
Authors: Pastore M C , Mandoli G E , Vannuccini F , Lisi M , Iuliano M A , Santoro A , Niglio F P , Lorenz V , Montesi G E , Cavigli L , Focardi M , D'ascenzi F , Valente S , Cameli M
Published: November 2023

Background

Myocardial work (MW) is estimated by pressure-strain loops using an implemented speckle tracking software. It has emerged as an index of LV contractile properties overcoming the load-dependency limit of left ventricular (LV) global longitudinal strain (GLS). This is particularly useful in clinical setting characterized by frequent hemodynamic variations, such as heart failure and valvular heart disease. However, the variation of MW parameters across different stages of primary mitral regurgitation (MR) and its impact on symptoms has never been investigated.

Objective

The aim of this observational study was to assess the variations of MW and deformation parameters of left heart chambers in mild, moderate and severe MR.

Methods

Consecutive patients with mild, moderate and severe MR were prospectively enrolled. Exclusion criteria were: chronic atrial fibrillation, valvular heart prosthesis, previous cardiac surgery.

Patients underwent clinical evaluation, blood sample tests, ECG and echocardiography. Speckle tracking analysis, completed by MW after inclusion of blood pressure values at the time of echocardiographic exam (Fig.1), ,was performed offline. Patients were then divided into groups first according to MR severity. Differences among the groups were analyzed by student T-test (or non-parametric tests for non-normally distributed variables) and predictors of symptoms (as NYHA class ≥ 2) were explored by logistic regression analysis and receiver operating characteristic (ROC) curves.

Results

Overall, 180 patients were enrolled (60 mild, 60 moderate, 60 severe MR). LV GLS and global PALS reduced according to MR severity. Global constructive work (GCW) and global wasted work (GWW) significantly improved in patients with moderate and severe MR, while global work efficiency (GWE) showed a trend towards reduction in patients with higher grades of MR. Global work index did not change significantly in the three groups (Fig.1). Among strain parameters, global PALS emerged as the best predictor of NYHA class (p<0.001; area under curve, AUC=0.75, Fig.2) These results are explained by the pathophysiology of MR, characterized by a mechanism of attempted LV compensation to volume overload with increased contractility parallel to the disease progress, although with low efficacy on increasing LV stroke volume and increased wasted work; while LA and diastolic function have an early reduction which is associated with the occurrence of symptoms.

Conclusions

myocardial deformation parameters of the left heart chambers vary accordingly to the pathophysiologic mechanisms of MR through increasing severity stages and are associate with the burden of symptoms.Fig.1Fig.2
18F-FDG PET/CT as a diagnostic tool for cardiac implantable electronic device infections
Authors: Costa G , Batista G , Guimaraes J , Monteiro E , Fernandes D , Santos T , Simoes M , Silva A L , Marinho A V , Costa G , Goncalves L , Ferreira M J
Published: November 2023

Background

The diagnosis of infective endocarditis (IE) in patients with cardiac implantable electronic devices (CIED) remains a clinical challenge. The modified Duke criteria have suboptimal diagnostic accuracy in this population, highlighting the need for alternative diagnostic tools.

Purpose

This retrospective study aimed to evaluate the diagnostic value of 18F-FDG PET/CT in suspected CIED infection.

Methods

From May 2016 to January 2022, 87 patients referred for 18F-FDG PET/CT for suspected IE were included in the study. The final diagnosis of IE was established by consulting the endocarditis team's diagnosis at the time of hospital discharge or death, based on clinical, microbiological, and imaging information as well as clinical response. Sensitivity, specificity, and positive and negative predictive values of 18F-FDG PET/CT in the evaluation of CIED infection were estimated.

Results

Of the 87 patients, 10 had suspected CIED infection, with a median age of 75 years. Pacemaker was the most common device found (65%). Fever was present in 80% of patients, and laboratory results showed a mean C-reactive protein of 15.9 mg/dL and mean leucocyte count of 10.5 G/L. According to the Duke Criteria, 60% were classified as "possible diagnosis," 20% with "definitive diagnosis," and 20% as "rejected diagnosis." Of the suspected CIED infection patients, compatible findings in 18F-FDG PET/CT were observed in 7 patients. The calculated sensitivity of 18F-FDG PET/CT was 78%, and specificity was 100%.

Conclusion

Our study suggests that 18F-FDG PET/CT is a valuable imaging tool for patients with suspected CIED infections, providing high sensitivity and specificity. The use of this technique could aid in the diagnosis of infective endocarditis and guide treatment decisions, particularly in cases where the modified Duke criteria have limited diagnostic accuracy.
Clinical and neurocognitive outcomes in patients with supra-arch vascular disease following transcatheter aortic valve replacement
Authors: Ko T , Tsai C H T , Kao H L K , Lin M S L
Published: November 2023

Background

Symptomatic carotid, vertebral and subclavian artery stenosis are associated with the risk of stroke, but the impact of these supra-arch vascular diseases (SAVD) on clinical and neurocognitive outcomes following transcatheter aortic valve replacement (TAVR) is unclear.

Methods

Preoperative carotid/vertebral duplex ultrasonography and computed tomography were performed to identify the presence of SAVD. Prospective neurological assessments (Barthel Index), global cognitive tests (Mini-Mental State Examination, MMSE) and executive performances (Color Trail Test A and B and verbal fluency), were applied at baseline, 3 months and 1 year post-TAVR.

Results

Overall, a total of 210 patients were evaluated, and 59 patients (28.1%) had SAVD (carotid stenosis: 37, vertebral stenosis: 23, subclavian stenosis: 6). The patients with SAVD were older (84.0±5.7 vs 79.4±8.2, P=0.0001) and had higher incidence of prior stroke or transient ischemic accident (15.3% vs 5.9%, P=0.031). There was no association between the presence of SAVD and stroke (adjusted hazard ratio (aHR): 1.26; 95% confidence interval (95% CI): 0.217-7.341) or mortality (aHR, 1.38; 95% CI:0.834-2.813). After propensity score matching in patients complete neurocognitive assessment after TAVR, the baseline neurocognitive performance were similar between the patients with (N=44) and without SAVD (N=74). Persistent improvement up to 1 year in Barthel Index, MMSE, Color Trail Test A and B could be observed only in the patients without SAVD, but not in patients with SAVD.

Conclusions

The presence of SAVD was not associated with an increased risk of post-TAVR stroke or mortality. However, the persistent improvement in neurocognitive assessments after TAVR could only be seen in patients without SAVD.
Predictors of permanent pacemaker implantation after transcatheter aortic valve implantation - Results from the SOLVE-TAVI trial
Authors: Feistritzer H , Stachel G , Kurz T , Eitel I , Marquetand C H , Abdel-Wahab M , Desch S , Thiele H
Published: November 2023

Background

Permanent pacemaker implantation (PPI) is frequently required following transcatheter aortic valve implantation (TAVI). However, the predisposing parameters increasing the likelihood of severe conduction abnormalities are still not fully understood.

Purpose

To analyze predictors of PPI 30 days after TAVI.

Methods

The SOLVE-TAVI trial randomized 447 patients to TAVI using either the balloon-expandable Edwards Sapien 3 valve or the self-expanding Medtronic Evolut R valve. Pacemaker rates at 30 days were relatively high, but comparable between both transcatheter heart valve (THV) types (19% vs. 23%). Computed tomography (CT) scans were analyzed semi-automatically to determine aortic annulus size and subannular calcification. The percentage of THV oversizing was calculated using the formula (nominal THV circumference/annular circumference – 1) x 100).

Results

From all patients treated with either the Sapien 3 or Evolut R valve, 47 patients were excluded because of prior pacemaker implantation. Rates of new PPI at 30 days were similar in patients with and without pre-existing left bundle branch block (7/36 patients vs. 53/342 patients, p=0.48) and right bundle branch block (11/51 patients vs. 48/327 patients, p=0.22), without significant differences according to valve type. Patients with new PPI showed a significantly higher degree of THV oversizing compared to patients without PPI (median 15%, interquartile range [IQR] 9-20% vs. median 12%, IQR 7-17%; p=0.03). Moderate/severe compared to no/mild subannular calcification did not result in higher PPI rates (17/121 patients vs. 40/245 patients; p=65).

Conclusion

THV oversizing but not pre-existing left and right bundle branch block and subannular calcification is associated with PPI after TAVI.
Up to 6-year performance and clinical outcomes of balloon expandable transcatheter aortic valve according to the implantation strategy: insight from the DIRECTAVI trial
Authors: Leclercq F , Jammoul N , Dupasquier V , Akodad M , Meunier P A , Soltani S , Moulis L , Macia J C , Robert P , Schmutz L , Piot C , Targosz F , Benkemoun H , Roubille F , Cayla G
Published: November 2023

Background

The randomized DIRECTAVI trial demonstrated safety and feasibility of transcatheter aortic valve implantation (TAVI) without balloon aortic valvuloplasty (BAV) using SAPIEN 3 balloon-expandable devices.

Purpose

To evaluate long-term clinical and hemodynamic results according to the implant strategy (direct TAVI versus BAV) with the SAPIEN 3 balloon-expandable device in patients included in the DIRECTAVI trial.

Methods

All patients included in the DIRECTAVI trial since 2016 were offered a clinical and echocardiographic follow-up until January 2023. We applied Valve Academic Research Consortium (VARC-3) criteria to define moderate/severe hemodynamic valve deterioration (HVD) as an increase in mean gradient ≥10 mm Hg resulting with a final mean gradient ≥20 mm Hg, or new/worsening aortic regurgitation (AR) of 1 grade resulting in ≥moderate AR. Survival until moderate/severe HVD between the 2 groups was the primary end-point and overall survival between direct TAVI and BAV were compared using logrank tests. Major clinical outcomes at latest follow-up were also assessed using Chi² or Fisher’s tests.

Results

Among 250 patients included in DIRECTAVI, 228 patients were followed-up during 4.5 ± 1.1 years. Mean age at follow-up was 87 ± 6.7 years. Incidence rates of moderate/severe HVD were similar in the 2 groups (1.45 versus 1.97 per 100 person-years, p=0.6) (Figure). Incidence rates for death were similar between groups (9.19 and 7.34 events per 100 persons-years for BAV and direct TAVI, respectively, p=0.4). No clinically significant differences in outcomes were observed at the latest follow-up, including major stroke (4.4% for BAV versus 2.6% for direct TAVI, p=0.7), hospitalizations for heart failure (15.8% for BAV group and 11.4% for direct TAVI group, p=0.3), permanent pacemaker implantation (37.7% for BAV and 31.6% for direct TAVI, p=0.3). Moderate/severe patient-prosthesis mismatch was also similar between groups (p=0.6).

Conclusion

Compared to systematic BAV, direct implantation of the SAPIEN 3 device was not associated with an increased risk of moderate/severe valve deterioration or adverse clinical events up to 6-year follow-up. These results encourage wide use of this simplified strategy with balloon-expandable devices, when possible.Survival without valve deterioration
Prognostic significance and outcomes of patient-reported symptoms after valve intervention in severe aortic stenosis
Authors: Ybarra-Falcon C , Garcia-Gomez M , Carnicero D , Ona A , Ruiz J , Ramos N , Vilacosta I , Nombela L , Carnero M , Carrasco M , Sevilla T , Revilla Orodea A , Amat-Santos J I , Lopez-Diaz J , San Roman J A
Published: November 2023

Background

Symptoms in patients with severe aortic stenosis (AS) are the main indication for intervention. The evolution of symptoms after intervention is unknown.

Objective

To describe the evolution of symptoms in patients with symptomatic AS undergoing valve replacement, the predictors of their persistence and their prognostic significance.

Methods

Retrospective analysis of 451 patients with symptoms attributed to severe isolated aortic stenosis (without other valvular heart disease or coronary disease), from two tertiary Spanish hospitals, who underwent aortic valve replacement. The presence of symptoms prior to intervention and the evolution of these after it, were evaluated. Clinical history, laboratory parameters, EKG, echocardiographic findings, total death, and cardiovascular death were also analyzed.

Results

Surgical aortic valve replacement was performed in 216 patients (57.8%) and percutaneous in 190 (42.1%). 133 patients had heart failure (29.5%), 287 dyspnea on effort (90.2%), 129 angina (40.5%) and 29 syncope (n=59). Symptoms disappeared after intervention in 192 patients (42.6%) and remained in 259 (57.4%): 193 dyspnea, 9 angina, 17 syncope and 60 heart failure (Picture 1). Age [OR 1.06 (1.04–1.09)], BMI [OR 1.09 (1.04-1.14)], previous heart failure [OR 1.67 (1.07-2.63)] and chronic obstructive pulmonary disease [OR 2.62 (1.27-5.40)] were independently related to persistence of symptoms. Over a median follow-up of 56 months (IQR: 40-73), 129 deaths were registered (28.6%), 48 cardiovascular (10.6%). Age [HR 1.04 (1.02-1.07), p=0.001], chronic obstructive pulmonary disease [HR 1.74 (1.11-2.71)], chronic kidney disease [HR 1.48 (1.01-2.19)], atrial fibrillation [HR 1.62 (1.13-2.32)], heart failure [HR 1.81(1.27-2.58)] and persistence of symptoms [HR 2.08 (1.35-3.21)] were independently associated to total death. However, persistence of symptoms was not associated to cardiovascular mortality (Picture 2).

Conclusions

Our work shows that symptoms putatively attributed to severe aortic stenosis may remain after valve intervention, particularly dyspnea on effort and syncope at rest. Therefore, before indicating intervention, the cause of dyspnea on effort and syncope at rest must be searched for. The persistence of symptoms was independently related to total death but not to cardiovascular death. According to these results, the recommendation of intervention based on certain symptoms, if confirmed in larger studies, should be called into question.Symptoms before and after interventionKaplan-Meier survival curve
Prognostic impact of atrial fibrillation in patients with paradoxical low-flow low-gradient aortic stenosis undergoing TAVI
Authors: Nakase M , Tomii D , Heg D , Praz F , Stortecky S , Windecker S , Pilgrim T
Published: November 2023

Background

Atrial fibrillation (AF) has been associated with adverse clinical outcomes after transcatheter aortic valve implantation (TAVI). However, the impact of AF on post-TAVI flow status and clinical outcomes in patients with paradoxical low-flow low-gradient aortic stenosis (PLFLG-AS) is still unclear.

Objectives

The present study aimed to investigate the effect of AF on post-TAVI flow status and clinical outcomes in patients with PLFLG-AS undergoing TAVI.

Methods

In a prospective TAVI registry, patients with preserved left ventricular ejection fraction (LVEF ≥50%) were stratified according to the flow-gradient status and presence of AF.

Results

Among 2,259 TAVI patients with preserved LVEF between August 2007 and June 2021, 765 had high-gradient AS (HG-AS) (mean gradient ≥40 mmHg) and 444 had PLFLG-AS (mean gradient <40 mmHg and stroke volume index [SVi] <35 ml/m2). AF was observed in 199 patients with HG-AS (26.0%) and 190 patients with PLFLG-AS (42.8%). At 1 year after TAVI, SVi was significantly improved in PLFLG-AS patients with no AF, whereas those with AF remained low-flow status (from 25.9 ± 8.5 mL/m2 to 37.2 ± 9.9 mL/m2 and from 26.8 ± 5.1 mL/m2 to 26.1 ± 9.1 mL/m2, respectively). PLFLG-AS patients had an increased risk of all-cause mortality at 1 year after TAVI compared with those without AF (HRadjust 2.79; 95% CI 1.58-4.93). Whereas PLFLG-AS patients with no AF had a similar mortality compared with HG-AS patients with no AF (HRadjust 0.84; 95% CI 0.49-1.44).

Conclusions

AF was associated with worse flow status and impaired prognosis after TAVI in patients with PLFLG-AS.
Prevalence of pulmonary hypertension in aortic stenosis and its influence on outcomes
Authors: Ratwatte S , Stewart S , Strange G , Playford D , Celermajer D
Published: November 2023

Background

Aortic stenosis (AS) is the commonest valve abnormality in developed countries with increasing prevalence and a long pre-symptomatic phase. Measurable variables are likely important in stratifying risk and potentially guiding management decisions. The significance of Pulmonary Hypertension (PHT) complicating AS is poorly characterised.

Purpose

We aimed to describe the prevalence and prognostic importance of PHT in a large cohort of adults with at least moderate AS.

Methods

In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000-2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50% and with moderate or greater AS were included (n= 14980). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 2.6 years, interquartile range 1.0-4.6 years).

Results

Subjects were aged 77±13years and 57.4% were female. Overall, 2049 (13.7%), 5085 (33.9%), 4380 (29.3%), 1956 (13.1%) and 1510 (10.1%) patients had no (eRVSP<30.00mmHg), borderline (30.00-39.99mmHg), mild (40.00-49.99mmHg), moderate (50.00-59.99mmHg) and severe PHT (>60.00mmHg), respectively. A echocardiographic phenotype was evident with worsening PHT, showing rising E:e’ ratio and right and left atrial sizes (p<0.0001, for all). After adjustment for age and sex, the risk of long-term mortality increased as eRVSP increased (adjusted hazard ratio (aHR) 1.15, 95% confidence interval 1.05-1.26 in borderline PHT, to aHR3.04, 95%CI 2.74-3.36 in severe PHT) (Figure 1). These trends were maintained on a sensitivity analysis excluding patients with ≥moderate mitral and/or aortic regurgitation (n=12005), (aHR 1.12, 95% CI 1.002-1.24 in borderline PHT, to aHR3.00, 95%CI 2.66-3.39 in severe PHT). A mortality threshold was identified in the 4th decile of eRVSP categories (35.01–38.00mmHg; HR1.20, P=0.005), with risk progressively increasing through to the 10th decile (HR2.95 p <0.0001).

Conclusions

Both AS and PHT confer an increased risk of mortality as they progress. In this large cohort study, we find that PHT is common in ≥moderate AS and mortality increases as PHT becomes more severe. A threshold for higher mortality lies within the range of "borderline-mild" PHT.Adjusted Risk for All-Cause MortalityThreshold for Mortality