bluuebunny/crossref_metadata_2025 huggingface dataset:
The truly forgotten chamber: prognostic value of right atrial dilation in patients with sinus rhythm and significant functional tricuspid regurgitation
Authors: Fortuni F , Dietz M.F , Prihadi E.A , Priori S.G , Bax J.J , Delgado V , Ajmone Marsan N
Published: November 2020

Background

Functional tricuspid regurgitation (FTR) can be caused by right ventricular (RV) and/or right atrial (RA) dilation, and it leads in turn to further RV and RA remodeling. While it is known that in these patients RV dilation is associated with worse prognosis, there are no data on the prognostic value of RA enlargement.

Purpose

To assess the prognostic impact of RA dilation in patients with significant (≥ moderate) FTR taking into account the presence of atrial fibrillation (AF).

Methods

1382 patients (mean age: 69±13 year; 50% male) with moderate or severe FTR were included. Patients with congenital heart disease were excluded. Significant RA enlargement was identified by the value of RA area associated with excess of mortality according to spline curve analysis in the overall population (30 cm2 – Figure: Left Panel). The prognostic value of RA enlargement was investigated separately in patients with sinus rhythm (SR) and AF. The primary endpoint was all-cause mortality.

Results

A total of 987 (71%) patients were in SR while the remaining 395 (29%) had AF at the time of significant FTR diagnosis. Patients in SR with RA enlargement were more likely to present with RV failure symptoms and to receive diuretics compared with patients in SR with non-enlarged RA, whereas these differences were not detected in patients with AF. During a median follow-up of 53 (interquartile range, 20–89) months, 698 (51%) patients died. The survival rates of patients in SR with RA enlargement were significantly worse compared to the ones of patients in SR with normal RA size (Figure: Right Panel). In contrast, RA enlargement did not affect the prognosis of patients in AF (Log-rank χ2: 0.41; P=0.522). RA enlargement was associated with 33% increase risk of all-cause mortality in patients with SR and this association was retained on a multivariable Cox regression analysis (HR 1.27; 95% CI 1.04–1.56; P=0.022) together with older age, coronary artery disease, diabetes, severe renal impairment, reduced left ventricular or RV systolic function, and increased pulmonary artery pressures.

Conclusion

RA enlargement has an independent prognostic value for all-cause mortality in patients with FTR and SR, and therefore its evaluation might be useful to further improve their risk stratification.

Funding Acknowledgement

Type of funding source: None
Left atrial emptying fraction: a powerful predictor of events in severe aortic stenosis
Authors: Goncalves V , Ferreira J , Almeida J , Freitas A , Martins R , Vieira H , Goncalves L
Published: November 2020

Background

Increasing evidence suggests that left atrial (LA) structural and functional changes have an important role in risk stratification and prediction of clinical outcomes. We know from multiple data that left atrial maximum volume (LAVI), measured at end-systole, is a powerful prognostic marker in multiple patient groups. However, recent studies have suggested that this marker may not be the best representative of diastolic function as it does not image the full spectrum of atrial mechanics. Another measure of LA function is the left atrial emptying fraction (LAEF), which has proved to be a significant prognostic marker in many patient groups. Less known is its role in event prediction in severe aortic stenosis patients, a disease with a very important burden in modern societies.

Purpose

The authors hypothesised that LAEF is a powerful predictor of clinical outcomes at 1 year in patients with severe aortic stenosis.

Methods

We retrospectively evaluated 151 patients referred to our echocardiography laboratory with the diagnosis of severe aortic stenosis. All patients underwent transthoracic echocardiography. LA maximum volume was indexed to body surface area. LAEF was calculated as LAVI-LA minimum volume divided by LAVI. Patients were followed for 1 year regarding clinical outcomes. Clinical outcome was defined as a composite of hospital admission for a cardiovascular (CV) cause, emergency department recurrence for a CV cause or CV death. Logistic binary regression was used to evaluate associations of LAEF with the outcome.

Results

A total of 51.7% of patients (n=78) were males. Mean patient age was 76.6±8.0 years. A total of 38.4% of patients were diabetics (n=56), 96% had dyslipidaemia (n=145) and 25% (n=37) had atrial fibrillation. Mean left ventricular ejection fraction (LVEF) was 60.6±7.3, and mean LAVI was 41.4±12.1. In a multivariable regression model including clinical and echocardiographic markers, higher LAVI and pulmonary artery systolic pressure (PASP) were associated with lower LAEF. Receiver operating characteristic curve analysis showed that the predictive value of LAEF for outcomes at 1 year was 0.693 (AUC=0.693, CI 95% 0.578–0.809, p=0.002), performing better than other echocardiographic markers such as LAVI (AUC=0.567, CI 95% 0.440–0.694, p=0.286), PASP (AUC=0.582, CI 95% 0.451–0.714, p=0.191) and LVEF (AUC=0.590, CI 95% 0.464–0.716, p=0.153). After adjustment of baseline characteristics, a LAEF less than 41.3% remained a good predictor of clinical outcomes at 1 year (OR 2.615, CI 95% 1.085–6.305, p=0.32).

Conclusions

In this cohort of severe aortic stenosis patients, a reduced LAEF was associated with greater incidence of cardiovascular events, being a stronger predictor than LAVI, PASP or LVEF. This study suggests that LA dysfunction over LA volumes correlates better with clinical outcomes.

Funding Acknowledgement

Type of funding source: None
Spondylodiscitis and endocarditis, the strange couple
Authors: Scheggi V , Del Pace S , Virgili G , Stefano P.L
Published: November 2020

Background

The association between spondylodiscitis and infective endocarditis (IE) was first reported in 1965 but only a few data are available in the literature about this clinical picture. Early diagnosis of infective endocarditis as the source of spondylodiscitis is often difficult. The aim of this study was to evaluate the proportion of spondylodiscitis in patients with IE and to determine its clinical features.

Methods

We retrospectively analyzed 355 consecutive patients (127 women) admitted to our department with definite diagnosis of IE. Mean age was 65 years (SD 15.3). IE occurred on native valves in 223 patients (63%) and it involved the aortic valve in 191 cases (54%), mitral valve in 138 cases (39%) and tricuspid valve in 26 (7%). Spondylodiscitis occurred in 24 patients (7%). The diagnosis of spondylodiscitis was made on the basis of typical clinical and radiologic signs. Long-term follow-up was obtained by structured telephone interviews. Average duration of follow-up was three years. Primary endpoint was to establish clinical features of patients with IE complicated by spondylodiscitis.

Results

At univariable analysis spondylodiscitis was associated with male sex (p=0.043), diabetes (p=0.049), drug abuse (p=0.017) and enterococcus infection (p=0.043). At multivariable analysis diabetes (p=0.014) and drug abuse (p=0.006) were independently correlated with the presence of spondylodiscitis. Other clinical features were not associated with the presence of spondylodiscitis (age, BMI, chronic renal failure, paravalvular extension of infection, vegetation length, EuroScore 2, PCR and procalcitonin levels, type of valve infected). Mortality was similar between patients with and without spondylodiscitis.

Conclusions

The association of spondylodiscitis and infectious endocarditis should always be suspected, expecially in patients with a high risk profile. Hence, patients with spondylodiscitis should be submitted to echocardiography, mainly when the infective organism is an Enterococcus. Conversely, patients with IE should undergo screening for methasthatic infection.

Funding Acknowledgement

Type of funding source: None
Prognostic value and reversibility of liver stiffness in patients undergoing tricuspid annuloplasty
Authors: Chen Y , Chan Y.H , Wu M.Z , Yu Y.J , Ren Q.W , Lam Y.M , Seto W.K , Yuen M.F , Lau C.P , Tse H.F , Yiu K.H
Published: November 2020

Background

Hepatic dysfunction was previously suggested to be related to poor outcome in patients undergoing tricuspid annuloplasty (TA), the predictive value of liver stiffness (LS) for adverse events is nonetheless uncertain.

Purpose

The aim of this study was to evaluate the prognostic value and reversibility of LS in patients undergoing TA.

Methods

A total of 158 patients (age 63, male 35%) who underwent TA during left-sided valve surgery were prospectively evaluated. Transient elastography was used to assess LS. Patients were divided into three groups according to tertiles of LS. Adverse outcome was defined as heart failure requiring hospital admission or mortality.

Results

The median LS was 13.9 (8.1–22.3) kPa which independently correlates with tricuspid regurgitation severity (assessed by effective regurgitant orifice area), inferior vena cava diameter and tricuspid annular plane systolic excursion. During a median follow-up of 31 months, 49 adverse events occurred. Multivariable Cox regression analysis demonstrated that LS was an independent predictor of adverse events. Furthermore, a higher LS tertile was predictive for adverse events (Hazard Ratio 4.19, P<0.01) even after adjusting for the other prognosticators. Kaplan-Meier curve showed that patients in the third tertile LS group had the highest percentage of adverse events followed by patients in the second tertile. Significant improvement of LS at 1-year post-TA was noted only in patients who had no adverse events but not in those who experienced heart failure.

Conclusions

The present study demonstrates that LS is predictive of adverse outcome in patients undergoing TA. These findings suggested that assessing LS, an integrative assessment of right heart condition, may aid the management of patients undergoing TA.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Health and Medical Research Fund from the Food and Health Bureau, the Government of Hong Kong Special Administrative Region.
Gender specific differences in functional capacity in asymptomatic patients with isolated severe aortic stenosis
Authors: Banovic M , Iung B , Brkovic V , Aleksandric S , Mitrovic P , Nedeljkovic I , Popovic D , Jaukovic M , Asanin M , Penicka M , Bartunek J
Published: November 2020

Risk stratification as well as treatment decision in asymptomatic patients with isolated severe aortic stenosis (AS) is matter of ongoing debate. It has been known that gender-specific difference in left ventricular reaction to AS exists. Female gender has also been linked to increased risk of adverse events after surgical AVR but with better outcome after TAVI. We investigated whether there is a gender difference in functional capacity in asymptomatic patients with isolated severe AS.

Asymptomatic patients with severe AS were prospectively enrolled and underwent cardiopulmonary stress-echocardiography exercise testing (ESE-CPET) on supine ergobicycle, ramp protocol, 15 W/min. Patients with ischemia positive test were excluded (ECG and/or echo)

There were 139 patients, 61 women. There were no gender differences in age (66.36 vs 67.37, p=ns), echo parameters (Vmax 4.54 vs 4.48m/s, AVA 0.62 vs 0.68cm2, and Pmean 52.6 vs 53.8mmHg, all p=ns), LVEF (68.56 vs 70.90%, p=ns), e/E' (12.74 vs 14.45, p=ns), BNP (112.51 vs 110.55 pg/ml, p=ns) and valvulo-arterial impedance (4.65 vs 5.14mm Hg·ml–1·m2, p=0.07). Women had higher body mass index (29.05 vs 26.95, p=0.022), lower VO2max (12.96 vs 17.93 ml/kg/m2, p=0.001) and higher VE/VCO2 slope (33.69 vs 29.01, p=0.003). Univariable and multivariable linear regression analysis were used to test the relation between various clinical and echocardiographic parameters and VO2max. The variables independently associated with the VO2max are shown in table 1, with female gender being the strongest independent predictor of VO2max

Conclusion

Female gender is independent predictor of decreased functional capacity, even when adjusting for other variables, including BMI and echo markers of AS severity. Further studies are needed to determine whether this finding affects the course and outcome of the disease

Funding Acknowledgement

Type of funding source: None
Pace of progression of aortic stenosis severity in patients with tricuspid and bicuspid valve
Authors: Hamala P.H , Kasprzak J.D.K , Wierzbowska-Drabik K.W.D
Published: November 2020

Background

Knowledge about determinants and pace of aortic stenosis (AS) progression may improve classification to aortic valve replacement. We quantified and compared pace of AS progression in patients with tricuspid and bicuspid aortic valve (TAV and BAV) examined by transthoracic echocardiography (TTE) in years 2004–2019.

Methods

We analysed retrospectively 322 TTE performed in two time points (median time between examinations 31±31 months) in 161 AS patients (mean age 69±11 years, 101 male, 40 BAV), evaluating the changes of parameters reflecting AS severity: peak pressure gradient (PG), aortic valve area by planimetry (AVApl) and continuity equation (AVAce). Then we compared pace of AS progression (defined as change of parameters per year) between patients with BAV and TAV and searched for correlates of AS progression.

Results

Although patients with BAV were younger, cardiovascular risk factors profile and baseline AS advancement were similar in both groups, see Table. Severe AS was present in 20% in BAV and 21% in TAV, p=ns. Patients with BAV showed circa 3 times more rapid AS progression expressed as the increase of PG per year (18.5±41.3 mmHg vs 4.1±34.4 mmHg in TAV, p=0.03) and yearly AVAce decrease (−0.23±0.27 vs −0.03±0.32, p=0.028). Smaller AVA value at baseline predicted faster pace of AS progression (with correlation coefficient r=−0.34, p=0.002 for AVApl).

Conclusion

Progression rate of AS depends on valve morphology being more rapid in BAV with similar to TAV baseline AS severity. In the whole group pace of progression correlated negatively with baseline AVA.

Funding Acknowledgement

Type of funding source: None
Outcomes in severe tricuspid regurgitation by CMR: when severe is too severe
Authors: Hinojar Baydes R , Vieitez J.M , Gonzalez-Gomez A , Garcia-Martin A , Hernandez-Jimenez S , Pascual M , Monteagudo J.M , Garcia De Vicente A , Zamorano J.L , Fernandez-Golfin C
Published: November 2020

Introduction

Tricuspid regurgitation (TR) is related to poor prognosis independently of the etiology. Recently a new scale classification has been proposed to better characterize the grading of more than severe TR. Massive and torrential TR seem to have worse prognosis based on recent echocardiographic studies. There is no information on how that classification would apply when TR is quantified by cardiac magnetic resonance (CMR).

Purpose

To define the cut-off value of massive and torrential TR by CMR and to investigate its potential prognostic implications.

Methods

Consecutive patients in stable clinical status with significant TR evaluated in the Heart Valve Clinic with a contemporaneous echo and CMR were included. TR severity was evaluated by biplane vena contracta and effective regurgitant orifice method, using EPIQ system and by TR regurgitant fraction using a 1.5 Tesla CMR Philips scanner. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure.

Results

A total of 56 patients were included (mean age was 72±9 years, 74% females). According to echocardiography n=43 (76%) were severe TR, n=8 (14%) were massive IT and n=5 (9%) were torrential TR. Patients with massive and torrential TR showed higher RV end-diastolic volume and lower RVEF. A TR regurgitant fraction (TRF) >50% held the best accuracy to define massive / torrential TR. During a median follow up of 2.4 years (IQR: 1.1–3.3 years) 31% of the patients reached the combined endpoint. TR regugitant fraction was predictive of worse prognosis (hazard ratio per 1%TRF=1.085 [1.024–1.150] p=0.003). Patients with a massive and torrential TR showed a significantly higher rate of events (figure). Figure shows on the left (A) spline curves displaying survival free of events for each value of TR regurgitant fraction. y-axis represents the hazard ratio regurgitation fraction (green line) and 95% confidence interval (shadow). On the right (B) Kaplan Meier curves show a significantly higher rate of events in patients with RF>50%.

Conclusions

Our results confirm that patients with massive/torrential TR are populations at higher risk of cardiovascular events. New classification scheme may be included in CMR grading scales. Further research will establish who may benefit the most of intensive therapeutic treatments and intervention on the tricuspid valve.

Funding Acknowledgement

Type of funding source: None
Early haemodynamic and structural impact of transcatheter aortic valve replacement in pure aortic regurgitation
Authors: Graziani F , Mencarelli E , Burzotta F , Paraggio L , Aurigemma C , Romagnoli E , Pedicino D , Locorotondo G , Lombardo A , Leone A.M , Laezza D , Crea F , Trani C
Published: November 2020

Background

Patients with severe aortic regurgitation (AR) are treated by surgery and have variable left-ventricular (LV) “reverse remodelling” after intervention. Transcatheter-aortic-valve replacement (TAVR) might be considered in selected AR patients.

Purpose

To evaluate the hemodynamic and structural impact of TAVR in patients with pure AR.

Methods

Consecutive AR patients underwent TAVR in our Institution were identified. Left heart catheterization before and after TAVR and complete echocardiographic assessment before TAVR, after (24–72 hours) TAVR and at follow-up (3–12 months) were systematically performed.

Hemodynamic and echocardiographic parameters were compared before and after TAVR.

Results

Twenty-two patients with severe AR, high surgical risk and advanced heart damage were treated by TAVR using mainly self-expandable prostheses. The procedure was successful in 21 patients (95.5%). An immediate hemodynamic impact of the TAVR procedure was documented by different parameters and included significant decrease in LV end-diastolic pressure (from 26.2 to 20.1 mmHg, P=0.012). Significant reduction in LV size (left ventricular end diastolic diameter (LVEDD): 60.0±8.0 mm vs 54.6±8.1 mm, p=0.002) and mass (left ventricular mass indexed (LVMi): 163.2±58.8 g/m2 vs 140.2±45.6 g/m2, p 0.004) as well as a sharp reduction in systolic-pulmonary-arterial-pressure (48.3±17.6 vs 32.9±7.8 mmHg, p<0.0001) was documented at 24–72 hours. Furthermore, patients with baseline moderate-to-severe mitral and tricuspid regurgitation showed a significant, early, valvular regurgitation reduction. All favourable changes persisted at follow-up. More pronounced LVEDD reduction was predicted by baseline LVEDD (p=0.019).

Conclusions

In patients with severe AR, TAVR determines a profound impact on heart remodelling, which is early detectable and durable.

Impact of TAVR in pure AR

Funding Acknowledgement

Type of funding source: None
Temporal trends in readmissions after transcatheter aortic valve replacement
Authors: Arora S , Strassle P.D , Hendrickson M.J , Sitammagari K , Qamar A , McRee C.W , Yeung M , Vavalle J.P
Published: November 2020

Background

Although readmissions after transcatheter aortic valve replacement (TAVR) were frequent in initial experiences, it is unknown if the incidence of readmission has changed with technological advances and other factors.

Purpose

Assess temporal trends in 30-day readmission after TAVR

Methods

Hospitalizations of adults aged ≥50, with aortic stenosis and undergoing elective TAVR or SAVR between 2012 and 2016 in the National Readmission Database were analyzed. Causes of 30-day readmission were classified as cardiovascular (CV) and non-cardiovascular (non-CV). Poisson regression was used to assess quarterly trends in TAVR and SAVR readmissions.

Results

Overall, 29,031 TAVR and 72,412 SAVR hospitalizations were included (weighted N 56,858 TAVR and 151,899 SAVR), and 14% were readmitted within 30-days (TAVR: 15%; SAVR: 13%). Of all the readmissions, 38% were cardiovascular (TAVR: 35%; SAVR: 40%). Between January 2012 and November 2016, the incidence of overall 30-day readmission significantly declined from 20% to 13% (CIE −0.13, 95% CI: −0.13, −0.13, p<0.0001) after TAVR and from 15% to 12% (CIE −0.05, 95% CI: −0.05, −0.05, p<0.0001) after SAVR. When stratified by readmission cause, the incidence of both CV (7.2% to 4.2%; CIE −0.18, 95% CI: −0.18, −0.18, p<0.0001) and non-CV readmissions declined after TAVR (14% to 9.0%; CIE −0.24, 95% CI: −0.24, −0.24, p<0.0001), Figure 1. CV readmissions (5.6% to 4.7%; CIE −0.05, 95% CI: −0.05, −0.05, p<0.0001) and non-CV readmissions (9.7% to 7.7%; CIE −0.12, 95% CI: −0.12, −0.12, p<0.0001) also declined after SAVR. Finally, the cost of TAVR admissions decreased for both patients who were not readmitted within 30-days (CIE −2.3, 95% CI: −2.5, −2.0, p<0.0001) and patients who were readmitted (CIE −1.9, 95% CI: −2.6, −1.2, p<0.0001) from 2012 to 2016. Costs of readmission have not changed (CIE −0.23, 95% CI: −0.80, 0.35, p=0.44).

Conclusion

Readmissions after TAVR have declined over the last several years, likely due to improvements in technology and operator experience, greater attention to comorbidities, and reductions in inpatient complications. More work is needed to reduce further inpatient complications and the incidence of readmission.

Figure 1

Funding Acknowledgement

Type of funding source: None
High post-procedural transvalvular gradient or delayed gradient increase after transcatheter aortic valve implantation: the FRANCE-2 registry
Authors: Didier R , Le Ven F , Eltchaninoff H , Nasr B , Lefevre T , Fajadet J , Teiger E , Carrie D , Meneveau N , Ghostine S , Souteyrand G , Cuisset T , Le Breton H , Inug B , Gilard M
Published: November 2020

Background

Mean gradient (MG) elevation can be detected immediately post-procedure or secondarily during follow-up. Comparison between these two parameters and impact on outcomes has not previously been investigated.

Objectives

The study aimed to identify incidence, influence on prognosis and parameters associated with immediate high post-procedural mean transvalvular gradient (PPMG) and delayed mean gradient increase (DMGI), in the FRANCE 2 (French Aortic National CoreValve and Edwards 2) registry.

Methods

The registry includes all consecutive symptomatic patients with severe aortic stenosis. Three groups were analyzed: 1) PPMG <20mmHg without DMGI >10 mmHg (control); 2) PPMG <20mmHg with DMGI >10 mmHg (group 1); 3) PPMG ≥20 mmHg (group 2).

Results

From January 2010 to January 2012, 4201 consecutive patients were prospectively enrolled in the registry. The control group comprised 2078 patients; the group 1, 131 patients; and the group 2, 144 patients. DMGI exceeded 10 mmHg in 5.6%, and was not associated with greater 4-year mortality than in control group (32.6% vs. 40.1%, p=0.27, respectively). PPMG was at least 20 mmHg in 6.1%, and was associated with higher 4-year mortality than in control group (48.7% versus 40.1%, p=0.005, respectively) (Figure 1). Two-thirds of patients with initial PPMG ≥20 mmHg had finally a MG <20 mmHg at 1 year, with mortality similar to controls (39.2% vs. 40.1%, p=0.73).

Conclusions

Patients with PPMG >20 mmHg 1 year post-TAVI had higher 4-year mortality than the general population of the registry, unlike patients with MG normalization at 1 year.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): French National Society of Cardiology
Real world use of cerebral protection in patients undergoing transfemoral transcatheter aortic valve replacement
Authors: Stachon P.S , Kaier K.K , Zehender M.Z , Bode C.B , Von Zur Muehlen C.M
Published: November 2020

Aims

Preventing strokes is an important aim in TAVR (transcatheter aortic valve replacement) procedures. Embolic protection devices may protect from cardiac embolisms during TAVR, but use and outcomes in clinical practice remain controversial.

Methods and result

Isolated transfemoral TAVR procedures performed in Germany with or without cerebral protection devices were extracted from a comprehensive nationwide billing dataset. In the most recent years available, 2015 and 2017, 41,654 TAVR procedures were analyzed. The overall share of procedures employing cerebral protection devices was 3.7%. In order to compare outcomes, which may be related to the use of a cerebral protection device, a risk-adjusted comparison was performed. The risk of in-hospital mortality did not differ (OR 0.71, 95% CI 0.47–1.17, p=0.103). Moreover, there were no differences in in-hospital cerebral events: the risk for stroke did not differ in patients receiving a cerebral protection device (OR 1.07, 95% CI 0.75–1.12, p=0.714). Risk for delirium was similar in both groups (OR 0.95, 95% CI 0.71–1.16, p=0.621).

Conclusions

Based on our findings and previous studies the routine use of cerebral protection devices should be performed with caution until further data from randomized controlled trials show a reliable reduction of strokes or cerebral failure such as delirium or long-term cognitive decline.

Funding Acknowledgement

Type of funding source: None
Echocardiographic assessment of functional changes of prosthetic valve after transcatheter aortic valve implantation in one year follow up: insights from the multicenter, randomized DIRECT trial
Authors: Toutouzas K , Karmpalioti M , Benetos G , Drakopoulou M , Xanthopoulou M , Stathogiannis K , Latsios G , Synetos A , Bei E , Voudris V , Kosmas E , Mastrokostopoulos A , Katsimagklis G , Danenberg H , Tousoulis D
Published: November 2020

Introduction

The DIRECT trial (Predilatation in Transcatheter Aortic Valve Implantation (TAVI) Trial) was a multicenter, randomized, clinical trial designed to evaluate the safety and efficacy of TAVI with or without balloon aortic valvuloplasty (BAV) in patients with symptomatic, severe aortic valve stenosis.

Purpose

To investigate by echocardiography the functional changes of self-expanding prosthetic valves during the first year after TAVI with or without BAV.

Methods

One hundred seventy one consecutive patients with severe aortic stenosis were enrolled at 4 centers and randomized to TAVI using self-expanding prostheses with (pre-BAV) or without pre-dilatation (no-BAV). Transthoracic echocardiography was obtained at baseline, 30 days and 1 year after TAVI.

Results

Of 171 patients, 86 patients were randomized to pre-BAV group and 85 to no-BAV group. Over the one year, 7 (4%) patients died and in 18 (10%) there was no available paired 30 day/1 year echo. At baseline echocardiography the peak and mean aortic valve gradient and the aortic valve area (AVA) in no-BAV group were 77.31±22.56 mmHg, 47.23±14.98 mmHg and 0.69±0.16cm2 and in pre-BAV group 81.97±23.17 mmHg, 49.39±14.78 mmHg and 0.65±0.15cm2 respectively. One year after TAVI, patients in no-BAV and pre-BAV group showed stable peak and mean aortic valve gradients similar to those at 30 days (from 16.36±7.88 to 14.51±6.6 mmHg vs. 17.17±8.88 to 15.95±9.97 mmHg and from 8.87±4.23 to 7.99±4.04 mmHg vs. 9.39±4.79 to 8.38±5.02 mmHg respectively, P<0.001 vs. baseline). The AVA was similarly stable in one year follow up in no-BAV group (from 1.85±0.43cm2 to 1.85±0.44cm2, P<0.001 vs. baseline) and in pre-BAV group (from 1.86±0.49cm2 to 1.84±0.39cm2, P<0.001 vs. baseline). The incidence of moderate or severe paravalvular regurgitation remained unchanged in both groups (from 4.7% to 5.7% in no-BAV group and from 5.8% to 6.6% in pre-BAV group).

Conclusions

In both pre-BAV and no-BAV groups the improvement in hemodynamics of self-expanding prosthetic valves remained durable during the one year echocardiographic follow up assessment.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): MEDTRONIC
Calcified mitro-aortic continuity and mitral regurgitation in patients undergoing transcatheter aortic valve replacement
Authors: Rys M , Szymanski P , Zatorska K , Michalowska I , Witkowski A , Hryniewiecki T
Published: November 2020

Introduction

Calcified aortic stenosis (AS) and mitral annular calcification (MAC) have similar etiology and pathophysiological mechanisms. Half of all patients undergoing transcatheter aortic valve implantation (TAVI) have MAC. Several studies assessed the role of mitral regurgitation (MR) following TAVI but only few examined influence of MAC on its changes after TAVI. MAC frequently coexists with the calcification of mitro-aortic continuity (CMAC).

Purpose

Presence of CMAC may influence the results of TAVI, especially in the case of deeper implantation, protruding to let ventricular outflow tract (LVOT). In the present study we aimed at qualitative and semi-quantitative analysis of calcifications of the mitral complex – MAC and CMAC in multi-slice computed tomography (MSCT) in patients qualified to TAVI, in order to assess their impact on the occurrence and dynamics of MR following aortic valve implantation.

Methods

MAC was assessed quantitatively (Calcium Score) and semi-quantitative scale in depending on the degree of annular involvement. CMAC was evaluated in semi-quantitatively scale in depending on length of calcifications in the largest dimension. Subsequently patients were classified in a dichotomous manner as having non-severe or severe MAC and CMAC. All patients underwent transthoracic echocardiographic examinations prior to the procedure and after TAVI. Changes of MR severity following TAVI were defined as no change, improvement or worsening by at least one degree.

Results

The study group consisted of 94 patients. Fifty six (59.6%) out of 94 patients had MAC and 21 patients (22.3%) had severe MAC. Patients with MAC had higher mean aortic gradients (54.07±13,62 mmHg vs 46.79±14.42 mmHg, p=0.02) and smaller left ventricular diastolic diameter (46.09±6.86 mm vs 51.19±8.42 mm, p=0.002). Almost half of the patients - 46 (48.9%) had CMAC and 12 patients (12.8%) had severe CMAC. Patients with CMAC had higher Calcium Score Aortic Valve (3773.67±1734.02 Hounsfield Units (HU) vs 2875.1±1352.76 HU, p=0.006) and smaller AVA (0.59±0.16 cm2 vs 0.66±0.20 cm2, p=0.052). Before TAVI 35.1% of patients had more than mild MR. MR improved by at least one grade following TAVI in 17 (18.1%) patients and worsened by at least one grade in 7 (7.5%) patients. In multivariable logistic regression analysis MR worsening was associated with higher CMAC [OR 1.092, 95% CI: 1.006–1.185, p=0.035].

Conclusions

The study demonstrated CMAC is prevalent in patients undergoing TAVI. CMAC was associated with MR worsening. This is a novel finding, which may be particular importance in patients with severe AS and coexisting MR in whom arguments for and against surgical repair of concomitant mitral insufficiency are considered, as opposed to isolated aortic valve procedure.

Funding Acknowledgement

Type of funding source: None
Rivaroxaban in patients undergoing surgical mitral valve repair
Authors: Sadeghipour P , Noohi F , Hosseini S , Kordrostami S , Shafe O , Moosavi J , Rokni M , Tashakori Beheshti A , Rezaei Y
Published: November 2020

Background

The role of the non-vitamin K antagonist oral anticoagulants has here been scarcely studied In patients undergoing mitral valve repair (MVre).

Methods

In the present mixed cohort study, the safety and efficacy of rivaroxaban (prospective analysis) were compared with those of warfarin (retrospective analysis) in patients undergoing MVre.

Results

Study flow chart were presented In Figure. Dissimilarities in baseline characteristics necessitated propensity score matching, in which 104 patients in each group were compared. No major bleeding or cerebrovascular accident occurred during the 1-year follow-up. Clinically relevant non-major bleeding was reported in 2 patients in the rivaroxaban group and 4 patients in the warfarin group, a difference non-statistically significant before and after propensity score matching (P=0.371 and P=0.407, respectively). The type of anticoagulation did not predict the 1-year outcome (HR: 2.165, 95% CI: 0.376 to 12.460; P=0.387).

Conclusion

In this mixed cohort study, rivaroxaban was both safe and efficient in patients with MVre. Such preliminary results should prompt larger randomized controlled trials.

Cohort flow chart

Funding Acknowledgement

Type of funding source: None
Myocardial tissue characterization and mortality in transcatheter aortic valve replacement
Authors: Nitsche C , Kammerlander A.K , Koschutnik M.K , Dona C.D , Sinnhuber L.S , Eidenberger A.E , Forutan N.F , Andreas M.A , Hengstenberg C.H , Mascherbauer J.M
Published: November 2020

Background

Cardiac decompensation in severe aortic stenosis involves accumulation of myocardial extracellular matrix and congestion, which can be objectively quantified by cardiac magnetic resonance (CMR) and bioelectrical impedance spectroscopy (BIS). The aim of this study was to determine whether the extent of extracellular matrix pre-intervention correlates with congestion and is associated with adverse outcomes.

Methods

Consecutive patients scheduled for transcatheter aortic valve replacement (TAVR) underwent assessment of volume status using BIS, and CMR, and were prospectively followed. CMR included T1 mapping and extracellular volume (ECV) quantification for the assessement of diffuse myocardial tissue alterations and T2 mapping (n=100) for the assessment of myocardial edema. The combination of all-cause death and heart failure (HF) hospitalization was selected as primary study endpoint.

Results

180 patients (80.6±7.2 y/o, 48.9% female) with valid BIS and CMR data were included. ECV levels≥median was linked to worse ventricular function, more severe pulmonary hypertension and mitral/tricuspid regurgitation (p for all<0.05). Fluid levels significantly correlated with ECV (r=0.403, p<0.001) and T2 (r=0.378, p=0.015), but not T1 relaxation times (p>0.05). Moreover, fluid levels were independently associated with CMR-ECV by multivariate linear regression analysis (p<0.001), alongside with body mass index, left ventricular ejection fraction and hematocrit (p for all<0.05).

In total, 22.9% (39/170) had experienced an event (22 deaths, 17 heart failure) 13.4±7.5 months following TAVR. ECV levels≥median of 27.0% were significantly associated with the combined endpoint by Kaplan Meier estimates (log rank, p<0.001, Figure 1), but also with HF hospitalization (p<0.001) and death (p=0.020), when analyzed separately. Quantitively, every 1% increase in ECV increased event hazard by 11% [hazard ratio 1.111, 95% confidence interval 1.030–1.198, p=0.007]. After multivariate adjustment for important clinical, laboratory and CMR parameters, ECV≥median remained independently associated with outcome (p=0.045), alongside with serum albumin (p<0.001) and body fluid levels (p=0.015) by Cox regression analysis.

Conclusions

Cardiac decompensation in AS involves myocardial ECV expansion and body fluid accumulation. Fluid accumulation seems to impact the amount of ECV, and both parameters are independently associated with adverse outcomes following TAVR.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Österreichische Kardiologische Gesellschaft
Blood coagulation status after transcatheter aortic valve implantation between the patients with vitamin k antagonist and direct oral anticoagulants
Authors: Katayama T , Yokoyama N , Hirofumi H , Kataoka A , Watanabe Y , Kozuma K
Published: November 2020

Background

Ischemic stroke after transchatheter aortic valve implantation (TAVI) was recognized. Previous study showed that the median time of a stroke was 2.0 days (IQR, 1.0–5.0) after TAVI. One of the main mechanisms for ischemic stroke after TAVI was hyper-coagulation activity associated with TAVI procedure. However, the change of coagulation status in patients with oral anticoagulant (OAC) therapy was not investigated fully.

Purpose

We investigated the difference of blood coagulation parameters between the patients with vitamin K antagonist (VKA) and those with direct oral anticoagulants (DOAC).

Methods

We enrolled 253 patients underwent transfemoral TAVI between February 2017 and March 2019 in our hospital. Of 253 patients, 71 patients (age: 85, male: 20%) took OAC therapy (VKA: 21 patients, DOAC: 50 patients). Patients who took apixaban was 32 patients, rivaroxaban was 7, edoxaban was 11. Prothrombin activation fragment 1+2 (F1+2) as a molecular marker of thrombin generation, thrombin-anti-thrombin complex (TAT) as a marker of thrombin neutralization, soluble fibrin monomer complex (SFMC) as a marker of thrombophilia and fibrin/fibrinogen degradation product (FDP) as a marker of fibrinolysis were measured before and immediately after TAVI, and on 1 and 2 day postoperatively. We also assessed ischemic stroke after TAVI between 2 groups according to BARC-2 criteria.

Results

In patients with VKA, the value of PT-INR the day before TVAI was 1.2 (1.1–1.4). The level of F1+2 in patients with VKA was significantly greater on day 0 postoperatively than those with DOAC [855 pmol/l (595–1135) vs 614 pmol/l (452–774) P=0.003]. The level of SFMC in patients with VKA was significantly greater on day 0 postoperatively than those with DOAC [37.4 μg/ml (17.3–64.5) vs. 15.7 μg/ml (8.8–27.3) P=0.002]. The level of FDP in patients with VKA was significantly greater on day 0 postoperatively than those with DOAC [VKA: 5.8 μg/ml (3.8–7.9), DOAC: 4.0 μg/ml (3.1–5.3) P=0.023]. There were no patients with ischemic stroke among 2 groups.

Conclusion

This study revealed that coagulation activity was increased after TAVI. Furthermore, the coagulation activity in patients with VKA was significantly higher than that with DOAC at especially immediately after TAVI. Careful attention should be paid to hyper-coagulation status after TAVI in patients with VKA.

Funding Acknowledgement

Type of funding source: None
Meta-analysis confirms improvement of hospitalizations and all-cause mortality of transcatheter mitral valve repair in functional mitral regurgitation
Authors: Noutsias M , Matiakis M , Bigalke B , Sedding D , Rigopoulos A
Published: November 2020

Background

Moderate-to-severe or severe functional mitral regurgitation (FMR) is associated with higher rates of hospitalizations and with increased mortality in heart failure (HF). Transcatheter mitral valve repair by MitraClip® implantation (TMVrMC) may effectively reduce severe MR, and is associated with symptomatic improvement. However, the long-term clinical effects of this procedure are not well defined.

Aims

We analyzed outcomes for rehospitalization and survival in HF patients with moderate-to-severe or severe FMR treated by either medical treatment (MT) only versus TMVrMC+MT by meta-analysis.

Methods and results

By systematic search of bibliographic databases, we evaluated publications comparing HF patients with FMR treated by MT only versus treatment by MT combined with TMVrMC. Studies with a minimum of 25 enrolled patients and a follow/up period of at least 12 months were deemed eligible for this meta-analysis. We identified n=7 studies enrolling 2,884 HFrEF patients, divided into two study arms: TMVrMC+MT (n=1,618), versus FMR patients receiving MT only (n=1,266). At 12 months, there was a significant reduction in all-cause mortality favoring TMVrMC+MT (OR: 0.65; CI 95% 0.53–0.79), compared with the MT only patients. At 24 months, a significant reduction of all-cause mortality in the TMVrMC+MT patient group (OR: 0.54; CI: 95%: 0.43–0.67; p<0.001) was calculated. TMVrMC+MT was associated with significantly lower rates of unplanned re-admissions for heart failure compared with MT only at 12 months (OR: 0.69; 95%; CI 0.53–0.89; p<0.001) and at 24 months (OR: 0.53; 95% CI: 0.39–0.71; p<0.001). In one publication, a survival benefit of TMVrMC+MT over MT alone was shown at 5 years post intervention (HR: 0.75; 95% CI: 0.69–0.94; p=0.012) after weighting for propensity score and controlling for age.

Conclusions

This meta-analysis on n=2,884 patients with moderate-to-severe or severe FMR reveals that TMVrMC+MT, as compared with MT alone, is associated with a significant reduction of rehospitalizations and improvement of survival up to 24 months after MitraClip implantation. However, the discordant results of 2 randomized controlled trials (MITRA-FR and COAPT) warrant further clarification, i.e. of the eligible FMR patient profiles who might benefit from TMVrMC+MT in terms of improvement of prognosis. These data imply additional evidence for TMVrMC in eligible HF patients with relevant FMR, which might be important for an update of the corresponding guidelines.

Funding Acknowledgement

Type of funding source: None
Predictors of outcomes in patients with mitral regurgitation undergoing percutaneous valve repair
Authors: Polimeni A
Published: November 2020

Background

Percutaneous mitral valve repairs has been increasingly performed worldwide. The MITRA-UMG registry provides a snapshot of a real-world clinical data and outcomes.

Purpose

We sought to investigate predictors of clinical outcomes in patients with mitral regurgitation undergoing percutaneous valve repair.

Methods

The MITRA-UMG registry retrospectively collected data from consecutive patients with symptomatic moderate-to-severe or severe MR underwent MitraClip implantation. The primary endpoint of interest was the composite of cardiovascular death or rehospitalization for HF.

Results

Between March 2012 and July 2018, a total of 133 consecutive patients admitted to our institution were included. Acute procedural success was obtained in 95.4% of patients, with no intraprocedural death. The composite primary endpoint of cardiovascular death or rehospitalization for heart failure was met in 50 patients (38%) with cumulative incidences of 7%, 25%, at 30 days and 1 year, respectively. In the Cox multivariate model, NYHA functional class IV, left ventricular end-diastolic volume index (LVEDVi), Euroscore II, independently increased the risk of the primary endpoint at long-term follow-up. At Kaplan-Meier analysis, a LVEDVi >92 ml/m2 was associated with an increased incidence of the primary endpoint.

Conclusions

In searching the ideal phenotype of patients who benefit most of percutaneous mitral valve repair, those presenting with severely dilated ventricles (LVEDVi >92 ml/m2), high operative risk (EUROSCORE II >7%) or advanced heart failure symptoms (NYHA IV) at baseline carried the worst prognosis at long-term.

Funding Acknowledgement

Type of funding source: None
Prevalence and prognosis of mitral disease due to mitral annular calcification
Authors: Ahmed A , Cavalcante J.L , Goessl M , Ukaigwe A.C , Schmidt C.W , Du Y , Lopes B.C , Bae R , Sorajja P
Published: November 2020

Background

While mitral annular calcification (MAC) is associated with valvular regurgitation or stenosis, this disease entity remains poorly understood.

Purpose

We sought to evaluate the prevalence and outcomes of patients with MAC.

Methods

Between January 2014 and December 2015, we reviewed all patients who underwent transthoracic echocardiography (TTE), and were identified as having MAC with either mitral regurgitation (MR) or stenosis (MS). Medical records were manually examined for demographics, morbidities, type and severity of mitral disease, and clinical outcomes for this cohort.

Results

Of 41,136 patients who had undergone TTE, MAC was identified in 2,855 (6.9%) patients, including 434 (1.0%) patients who had significant concomitant MR or MS (mean age, 78.9±10.4 years; 63% women). Severe heart failure (NYHA III or IV, 37%), renal failure (mean GFR, 47.3±15.7 ml/min), aortic stenosis (26% with severe stenosis or prior aortic intervention), diabetes (35%), and atrial fibrillation (50%) were common. The mean mitral gradient was 6.2±3.0 mmHg. Fifty-eight patients (13%) underwent surgical or transcatheter mitral valve intervention, with two procedural deaths (3.4%). Overall, the 3-year survival free of all-cause mortality was 53.9%, while freedom from all-cause mortality, hospitalization for heart failure, myocardial infarction and cerebrovascular accident was only 26.5% (Figure 1). Three-year survival free of all-cause mortality for those who had surgery or transcatheter therapy was better in comparison to those treated medically (77.6% vs. 50.3%; p<0.001).

Conclusions

Patients with MAC with MR or MS are common, have severe co-morbidities, and have poor long-term survival. Further study is needed to improve the clinical outcomes of these patients.

KM curves for MAC and MR/MS patients

Funding Acknowledgement

Type of funding source: None
Prevalence of infective endocarditis in streptococcal bloodstream infections is dependent on streptococcal species
Authors: Chamat S , Dahl A , Oestergaard L , Arpi M , Fosboel E , Boel J , Oestergaard L.B , Lauridsen T.K , Gislason G , Torp-Pedersen C , Bruun N.E
Published: November 2020

Background

Streptococci frequently cause infective endocarditis (IE), yet the prevalence of IE in patients with bloodstream infections (BSIs) caused by different streptococcal species is unknown.

Purpose

To investigate the prevalence of IE in BSIs with different streptococcal species.

Methods

We included all patients with streptococcal BSIs, from 2008 to 2017, in a population-based setup. Based on microbiological identification of phylogenetic relationship, streptococcal species were classified into eight main groups: Anginosus, Bovis, Mitis, Mutans, Salivarius, Pyogenic, S. pneumoniae, and “other streptococci”. Using nationwide registries, we determined the prevalence of IE at streptococcal group level and at species level. In a multivariable logistic regression analysis, we investigated the risk of IE according to streptococcal species with S. pneumoniae as reference and adjusted for age, sex, ≥3 positive blood culture (BC) bottles, native valve disease, prosthetic valve, previous IE, and cardiac device.

Results

In 6,506 cases with streptococcal BSIs (mean age 68.1 years (SD 16.2), 52.8% men), the IE prevalence was 7.1% (95% CI: 6.5–7.8%). For the most common streptococcal species (>5% of BSIs), the IE prevalence was: S. pneumoniae 1.2% (95% CI: 0.8–1.6%), S. dysgalactiae 6.4% (95% CI: 4.9–8.2%), S. pyogenes 1.9% (95% CI: 0.9–3.3%), S. agalactiae 9.1% (95% CI: 6.6–12.1%), S. anginosus 4.8% (95% CI: 3.0–7.3%), and S. mitis/oralis 19.4% (95% CI: 15.6–23.5%) (Figure 1). For moderately common streptococcal species (1–5% of BSIs), the IE prevalence was: S. gallolyticus 30.2% (95% CI: 24.3–36.7%), S. salivarius 5.8% (95% CI: 2.9–10.1%), S. sanguinis 34.6% (95% CI: 26.6–43.3%), S. parasanguinis 10.3% (95% CI: 5.2–17.7), and S. gordonii 44.2% (95% CI: 34.0–54.8%). For uncommon streptococcal species (0.1–1% of BSIs), the highest IE prevalence was in S. mutans with 47.9% (95% CI: 33.3–62.8%). In a multivariable adjusted analysis using S. pneumoniae as a reference, we identified that all species except S. pyogenes were associated with a significantly higher IE risk (Figure 1). The highest associated IE risk was found in S. mutans (OR 81.3, 95% CI: 37.6–176), S. gordonii (OR 80.8, 95% CI: 43.9–149), S. sanguinis (OR 59.1, 95% CI: 32.6–107), S. gallolyticus (OR 31.0, 95% CI: 18.8–51.1), and S. mitis/oralis (OR 31.6, 95% CI: 19.8–50.5) (Figure 1).

Conclusion

The prevalence of IE in streptococcal BSIs is highly species dependent with the lowest IE prevalence observed in S. pneumoniae and S. pyogenes BSIs, whereas S. mutans, S. gordonii, S. sanguinis, S. gallolyticus and S. mitis/oralis had the highest IE prevalence and the highest associated IE risk after adjusting for IE risk factors.

Figure 1. Risk of IE in streptococcal BSIs

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Herlev-Gentofte University Hospital