bluuebunny/crossref_metadata_2025 huggingface dataset:
Transposition of great arteries with left outflow tract obstruction and non-committed VSD: surgical management and late results
Authors: Kari Fabian A , Uzdenov Murat , Kroll Johannes , Bohnens Holger , Stiller Brigitte , Bauer Ulrike , Kubicki Rouven
Published: October 2021

OBJECTIVES

Transposition of the great arteries with ventricular septal defect (VSD) and left ventricular outflow tract obstruction (LVOTO) is a rare malformation. Our objective was to report on management and results of the cohort with non-committed VSD from a national registry for congenital heart disease.

METHODS

Multicentre data were screened in the German National Registry for Congenital Heart Defects (Berlin, Germany) for repairs of transposition of the great arteries–VSD–LVOTO. A subgroup of patients with a remote/non-committed VSD was identified. End points included survival, reoperation and a composite of reoperations for LVOTO-/VSD- or baffle-related problem.

RESULTS

N = 47 patients were identified treated in 14 different national centres between 1984 and 2020. The mean age was 14 (standard deviation 9) months, ranging from 7 days to 9.5 years. Nine patients (19%) were treated as neonates, 21 (45%) as infants and 17 children (36%) beyond the age of 1 year. Survival was >90% (80–100%) at 20 years. Freedom from any reoperation was 30% (10–50%) at 20 years. Freedom from the composite end point was 72% (50–90%) at 20 years. Patients after Rastelli underwent more reoperations compared to those without intraventricular baffle (freedom from reoperation 14% vs 50%, P = 0.1). The rates of the composite end point were similar when comparing Rastelli to other techniques (63% vs 83%, P = 0.32).

CONCLUSIONS

The Rastelli operation yields robust results in the setting of non-committed VSD. Late results after neonatal arterial switch operation are outstanding. If LVOTO is not resectable and neonatal arterial switch operation suboptimal, interim palliation does not negatively impact outcome, patients can be safely delayed to beyond 1 year of age.
Twinning during the pandemic
Authors: Catalano Ralph , Bruckner Tim , Casey Joan A , Gemmill Alison , Margerison Claire , Hartig Terry
Published: October 2021

Background and objectives

The suspicion that a population stressor as profound as the COVID-19 pandemic would increase preterm birth among cohorts in gestation at its outset has not been supported by data collected in 2020. An evolutionary perspective on this circumstance suggests that natural selection in utero, induced by the onset of the pandemic, caused pregnancies that would otherwise have produced a preterm birth to end early in gestation as spontaneous abortions. We test this possibility using the odds of a live-born twin among male births in Norway as an indicator of the depth of selection in birth cohorts.

Methodology

We apply Box–Jenkins methods to 50 pre-pandemic months to estimate counterfactuals for the nine birth cohorts in gestation in March 2020 when the first deaths attributable to SARS-CoV-2 infection occurred in Norway. We use Alwan and Roberts outlier detection methods to discover any sequence of outlying values in the odds of a live-born twin among male births in exposed birth cohorts.

Results

We find a downward level shift of 27% in the monthly odds of a twin among male births beginning in May and persisting through the remainder of 2020.

Conclusions and implications

Consistent with evolutionary theory and selection in utero, birth cohorts exposed in utero to the onset of the COVID-19 pandemic yielded fewer male twins than expected.

Lay Summary

Our finding of fewer than expected male twin births during the onset of the COVID-19 pandemic provides more evidence that evolution continues to affect the characteristics and health of contemporary populations.
Monte Carlo Simulation Approaches for Quantitative Bias Analysis: A Tutorial
Authors: Banack Hailey R , Hayes-Larson Eleanor , Mayeda Elizabeth Rose
Published: October 2021

Quantitative bias analysis can be used to empirically assess how far study estimates are from the truth (i.e., an estimate that is free of bias). These methods can be used to explore the potential impact of confounding bias, selection bias (collider stratification bias), and information bias. Quantitative bias analysis includes methods that can be used to check the robustness of study findings to multiple types of bias and methods that use simulation studies to generate data and understand the hypothetical impact of specific types of bias in a simulated data set. In this article, we review 2 strategies for quantitative bias analysis: 1) traditional probabilistic quantitative bias analysis and 2) quantitative bias analysis with generated data. An important difference between the 2 strategies relates to the type of data (real vs. generated data) used in the analysis. Monte Carlo simulations are used in both approaches, but the simulation process is used for different purposes in each. For both approaches, we outline and describe the steps required to carry out the quantitative bias analysis and also present a bias-analysis tutorial demonstrating how both approaches can be applied in the context of an analysis for selection bias. Our goal is to highlight the utility of quantitative bias analysis for practicing epidemiologists and increase the use of these methods in the epidemiologic literature.
(Mis)Matched College Aspirations and Expectations: The Role of Social Background and Admission Barriers
Authors: Finger Claudia
Published: October 2021

Not all high school students who wish to study think that they will be able to realize this wish. This article examines whether admission barriers to higher education (HE) are a potential reason for this mismatch between educational aspirations and expectations and whether they are more constraining for students from socially less advantaged backgrounds. It does so for the German context in which the role of admission barriers for social inequality in HE has long been neglected. Empirically, the paper uses a unique combination of individual data on high school students’ educational aspirations and expectations and institutional data on admission barriers that vary by field of study. Findings indicate that the socially most privileged students stick to their college aspiration regardless of admission barriers to their aspired field of study. However, they seem to be willing to compromise their preferred field of study if this comes along with high admission barriers. Contrastingly, socially less privileged students seem willing to compromise both their general college aspiration and their aspired field of study if admission appears difficult. The concluding section discusses the implications of these findings for social inequality in education.
Predicting silent atrial fibrillation in the elderly – NOMED-AF study
Authors: Mitrega K , Lip G Y H , Sredniawa B , Sokal A , Streb W , Przyludzki K , Zdrojewski T , Wierucki L , Rutkowski M , Bandosz P , Kazmierczak J , Grodzicki T , Opolski G , Kalarus Z
Published: October 2021

Background

Asymptomatic (“silent”) atrial fibrillation is common and associated with poor outcomes. It is important to determine the risk factors that predispose elderly individuals from the general population to atrial fibrillation (AF). However, population-based data for silent AF (SAF) are limited.

Design

First, to study the risk factors for symptomatic AF and SAF in an elderly (≥65 years) general population. Second, to develop a risk stratification model for predicting SAF.

Methods

Continuous ECG monitoring was performed for up to 30 days using a vest-based system in a cohort from NOMED-AF, a cross-sectional study based on a nationwide population sample. The independent risk factors for AF and SAF were determined using multiple logistic regression. ROC analysis was applied to validate developed risk stratification score.

Results

From the total cohort of 3014 subjects, AF was diagnosed in 680 individuals (mean age, 77.5±7.9; 50.1% men) with AF, and of these, 279 (41%) had SAF. Independent associations with an increased risk of AF were age, male gender, coronary heart disease, thyroid diseases, prior ischemic stroke or transient ischemic attack (ICS/TIA), diabetes, heart failure, chronic kidney disease (CKD), obesity (BMI>30) and NT-proBNP >125 ng/ml. Prior revascularization was negatively associated with risk of AF.

The main risk factors for SAF were age, male gender, prior ICS/TIA, diabetes, heart failure, CKD and NT-proBNP >125 ng/ml.

We developed a simple clinical risk scale (MR-DASH score) which had good prediction in the derivation cohort (AUC 0.726) and the validation cohort (AUC 0.730).

Conclusions

SAF is associated with various clinical risk factors in a population sample of individuals ≥65 years. Stratifying individuals from the general population according to their risk for SAF may be possible using the MR-DASH score, facilitating targeted screening programs of individuals with high risk of SAF

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Centre for Research and Development
Are the results of the RATE-AF trial reproducible in daily practice? Clinical outcomes with digoxin vs beta-blocker for heart rate control in permanent atrial fibrillation
Authors: Fauchier L , Bisson A , Bodin A , Spiesser P.H , Clementy N , Pierre B , Babuty D , Lip G.Y.H
Published: October 2021

Background

There is little evidence to support selection of heart rate control therapy in patients with permanent atrial fibrillation (AF), in particular those with coexisting heart failure. In the recent RATE-AF trial that included patients with permanent AF and symptoms of heart failure, treatment with low-dose digoxin or bisoprolol did not result in statistically significant difference in quality of life at 6 months. The purpose of the study was to analyse whether the clinical outcomes may differ among unselected patients with permanent AF treated with digoxin or beta-blocker seen in daily practice.

Methods

All patients with atrial fibrillation (AF) seen in an academic institution were identified in a database. We examined the clinical course of 8962 consecutive patients with AF seen over a 10-year period. The adverse outcomes were investigated during follow-up and we identified the causes of death. Among them 1,787 patients had the RATE-AF criteria of inclusion (permanent AF, age ≥60 and NYHA ≥2), of whom 512 patients (29%) were treated with beta-blocker alone, 425 (24%) were treated with digoxin alone and 237 (13%) were treated with both a beta-blocker and digoxin. Outcomes in patients treated with beta-blocker alone or digoxin alone were compared after 1:1 propensity-score matching.

Results

After propensity score matching, 270 patients treated with beta-blocker were matched 1:1 with 270 patients treated with digoxin. In these patients (age 79±8 years, CHA2DS2VASc score 4.0±1.3), 125 deaths were recorded during a follow-up of 2.2±2.7 years (median 1.1, interquartile 0.1–3.5 years, yearly rate of death 10.4%) including 72 cardiovascular deaths (yearly rate 6.0%). Major clinical events (all-cause death, myocardial infarction, ischemic stroke or major bleeding) were recorded in 192 patients (yearly rate 19.1%). In this matched analysis, risk was not statistically significant in the 2 groups for all-cause death (HR 0.95, 95% CI 0.67–1.35 for beta-blocker use vs digoxin use), cardiovascular death (HR 1.23, 95% CI 0.77–1.96 for beta-blocker use vs digoxin use) or major clinical events (HR 0.98, 95% CI 0.74–1.31 for beta-blocker use vs digoxin use).

Conclusion

Our analysis included more patients and had a longer follow-up than in the RATE-AF trial, resulting in a 10-fold higher number of clinical events. We found that among patients with permanent AF and symptoms of HF, there was no statistically significant difference in the risk of all-cause death, cardiovascular mortality and major clinical events between those treated with digoxin or beta-blocker. Concerns regarding the use of digoxin, such as the narrow therapeutic window and drug interactions, were not issues resulting in worse clinically relevant cardiovascular outcomes with the approach used in the current study.

Funding Acknowledgement

Type of funding sources: None.
Age and impaired left atrial performance are associated with increased atrial fibrosis in patients with paroxysmal and persistent atrial fibrillation
Authors: Traykov V , Radoslavova R , Boychev D , Konstantinova V , Marchov D , Marinov M , Gelev V
Published: October 2021

Background

Atrial performance assessed by strain imaging is used as a surrogate for left atrial (LA) structural remodelling. Presence of low voltage zones (LVZs) detected by three-dimensional electroanatomical mapping in patients with atrial fibrillation (AF) denotes more expressed extrapulmonary substrate potentially leading to worse outcomes following pulmonary vein isolation (PVI) for the treatment of AF.

Purpose

The current study aims to investigate the association between strain imaging parameters from echocardiography and the presence and extent of LVZs derived from LA electroanatomical mapping in patients undergoing AF ablation.

Methods

Seventy-eight patients (58 males, 74%) aged 59±9.48 years undergoing PVI for paroxysmal (35 patients, 49%) or persistent AF were prospectively studied. Preprocedural echocardiography included LA strain imaging assessing global LA strain (LAS) and regional strain of the basolateral region (RSLB). During the procedure, LA electroanatomical mapping during paced atrial rhythm was performed in all patients obtaining a LA voltage map. All LA maps were analysed offline using a custom-made software calculating the zone of low bipolar voltage <0.5 mV (LVZ<0.5mV) and the total LA endocardial area excluding pulmonary veins antra. LVZ<0.5mv was expressed as an absolute value and as percentage of the whole LA area.

Results

Patients aged more than 65 years (N=21, 27%) demonstrated a larger area of LVZ<0.5mV: 25.5±17.8 cm2 vs. 9.4±10.6 cm2 in those younger than 65 years, P=0.001. This corresponded to a higher proportion of the LA area demonstrating LVZ<0.5mV in patients older than 65 years: 22.6±14.6% vs. 8.9±11.8% in those younger than 65 years, P<0.0001. Twenty-nine of 78 patients (37.1%) had preprocedural LAS<20% and 23 (29.5%) demonstrated RSLB of <21%. Patients with LAS <20% had a higher total LVZ<0.5mV: 20.3±16.6 cm2 vs. 9.8±12.1 cm2 in patients with LAS≥20% at baseline, P=0.004. This equaled to 17.7±15.6% vs. 9.5±11.9% of total LA area, respectively (P=0.011). Patients with RSLB<21% also demonstrated larger areas of LVZ<0.5mV in the LA: 21.6±17.9 cm2 vs. 10.39±11.83 cm2 in the patients with RSLB ≥21%, P=0.012. Expressed as a proportion of the whole LA area the difference remained significant: 18.8±17.1% vs. 9.9±11.6%, respectively P=0.01.

Conclusion

Older age and impaired LA performance assessed by LA strain imaging are associated with larger areas of LVZ<0.5mV possibly reflecting more expressed LA fibrotic changes in patients with paroxysmal and persistent AF. These findings might serve in the preprocedural selection of the patients undergoing catheter ablation of AF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Bulgarian Society of Cardiology
DOAC versus warfarin in patients with atrial fibrillation and stage IV-V chronic kideny disease including patients on dialysis
Authors: Wartanian A , Lewinter C , Edfors R
Published: October 2021

Introduction

Patients with atrial fibrillation (AF) and severe chronic kidney disease (CKD) were excluded from most phase III randomized controlled trials (RCTs) of direct oral anticoagulants (DOACs). Evidence of warfarin versus DOAC in the AF population with stage IV-V CKD is therefore limited.

Aim

To evaluate the effectiveness and safety of DOAC compared with warfarin on this population including dialysis patients.

Methods

A systematic review and meta-analysis of RCTs and observational studies involving AF patients with stage IV-V CKD treated with warfarin versus DOACs were conducted to evaluate the following outcomes: stroke (ischemic and hemorrhagic) or systemic embolism (SE), all-cause mortality, major bleeding, gastrointestinal (GI) bleeding, and intracranial bleeding. If the heterogeneity between studies was moderate to high calculated as the I2 ≥50%, a meta regression was undertaken between baseline characteristics and the study outcomes. We conducted a literature search using key words related to AF, severe CKD, DOAC and warfarin in PubMed, Embase and Cochrane Library.

Results

Nine studies were included in the meta-analysis. Compared to warfarin, DOAC was significantly associated with a reduced risk of stroke or systemic embolism (SE) (risk ratio [RR] = 0.69; 95% confidence interval [CI] 0.50–0.95) (Figure 1), intracranial bleeding (RR=0.54; 95% CI 0.35–0.84) and hemorrhagic stroke (RR=0.39; 95% CI 0.16–0.95). There was no significant difference between DOACs and warfarin in the risk of all-cause mortality (RR=0.80; 95% CI 0.57–1.13), major bleeding (RR = 0.70; 95% CI 0.44–1.11) (Figure 2) and GI bleeding (RR=0.76; 95% CI 0.56–1.02). For the outcome stroke or SE, dabigatran (compared with apixaban) significantly eliminated the net effect of DOAC as compared with warfarin (coefficient, 0.8; P=0.003). Regarding major bleeding, rivaroxaban and dabigatran both eliminated the DOAC effect from the meta-analysis as compared to apixaban (P=0.01 & P<0.0001). Dabigatran significantly increased the risk of GI bleeding in comparison to apixaban (coefficient, 0.48; P=0.002) in comparison with the overall similar effect of warfarin in the meta-analysis.

Conclusion

Among patients with AF and stage IV or V CKD including dialysis patients, DOAC appears to have similar or better effectiveness and safety compared to warfarin.

Funding Acknowledgement

Type of funding sources: None. Stroke or systemic embolism
The individual approach to management of patients with atrial fibrillation and its influence on patient adherence to anticoagulant therapy
Authors: Novikova T , Ashurov A , Babova T , Bitakova F , Hagush A , Liksyutina N , Podoprigora E , Sayganov S
Published: October 2021

Background

The key points in the treatment of patients with atrial fibrillation (AF) with the ABC (Atrial Fibrillation Better Care) pathway are the prevention of stroke and increasing patient adherence to therapy. The basis for increasing adherence to therapy is regular communication between medical staff and the patients.

Purpose

To assess the effect of telephone contact (TC) frequency on patient adherence to anticoagulant therapy (ACT).

Methods

A prospective, non-interventional observational study was carried out, during which 84 patients with non-valvular AF were observed remotely after being discharged from the hospital. Patient education was provided in the hospital, which included an explanation of the importance of ACT. The observation period was 12 months. All enrolled patients were 18 years of age or older; AF was documented before enrolment on the basis of objective electrocardiographic evaluation; all patients had indications for taking anticoagulants (AC) for stroke prevention. Adherence to therapy was assessed using the Morisky-Green test.

Results

The patients were randomized into 2 groups: group 1 – TC monthly, group 2 – TC every 6 months. In the first group, 85.7% of patients received the non–vitamin K antagonist oral anticoagulants (NOAC), and 14.3% received warfarin; in the 2nd group, 92.9% of patients received NOAC, and 7.1% received warfarin. The mean score of the adherence to therapy according to the Morisky-Green test was initially 3.3±0.8 in group 1, and 3.3±0.7 in group 2, p=0.78. After 12 months: in group 1, 14.6% of patients refused to take AC; and in group 2, 25.0% did the same. The mean value score of the adherence to therapy in group 1 underwent a statistically insignificant change over time (from 3.3±0.8 to 3.1±1.5, p=0.48). In group 2, after 12 months, the mean score of adherence to therapy saw a significant decrease from 3.3±0.7 to 2.7±1.6, p=0.03. Both in group 1 and in group 2, the decrease in the mean score of adherence to therapy occurred mainly due to patients with an initially insufficient level of adherence.

Conclusions

The results of our study confirm the need for individual strategy for managing patients through the ABC pathway. In most cases, face-to-face or telephone contact with medical staff once every six months is sufficient for patients who are initially adherent to therapy, after receiving an introductory briefing. Patients with insufficient level of adherence require more frequent contact.

Funding Acknowledgement

Type of funding sources: None.
Cancer and atrial fibrillation/flutter: an analysis of patients referred to electrical cardioversion
Authors: Menezes Fernandes R , Mota T.F , Costa H.A , Espirito Santo M , Bento D , Candeias R , Mimoso J , Jesus I
Published: October 2021

Introduction

Cancer is associated with an increased risk of atrial fibrillation (AF) development. Both an active tumour and AF are related to increased thromboembolic risk.

Purpose

To determine the clinical characteristics, management and prognosis of cancer patients with AF or atrial flutter (AFL) referred to electrical cardioversion (EC).

Methods

We conducted a retrospective study encompassing patients referred to EC due to AF/ AFL in our Cardiology Department, from September 2011 to September 2020. Clinical characteristics, echocardiographic studies and follow-up data were analysed. We considered patients with a recent (up to 5 years) diagnosis of cancer. Primary endpoints were the occurrence of stroke, bleeding complications and all-cause mortality.

Results

A total of 691 patients were included, with a median age of 67 years-old and 70,8% male predominance. AFL was identified in 21,1% of patients and 57,4% had arterial hypertension. Persistent AF/AFL was diagnosed in 60,7%, 20,4% presented with first diagnosed AF/AFL and 17,9% had paroxysmal episodes. 89,5% of patients had indication for anticoagulation therapy and, of these, 75,4% were medicated with non-vitamin K antagonist oral anticoagulants (NOAC). 58 patients (8,4%) had a recent diagnosis of cancer, who were older (69,7 vs 67,9 years-old; p<0,001) and more frequently cardioverted in an outpatient setting (63,8%). They had a lower rate of heart failure (1,9% vs 16,7%; p=0,004), but a higher prevalence of sleep apnea (13% vs 5,4%; p=0,025) and chronic kidney disease (10,9% vs 4,2%; p=0,027). HAS-BLED score was applied, and higher values were obtained in cancer patients (1,0 vs 0,7; p=0,002). CHA2DS2-VASc score was not significantly different between both groups. NOAC were preferred in cancer patients (86,8% vs 74,2%; p=0,043), instead of vitamin K antagonists. These patients were less referred to AF/AFL ablation procedures (1,9% vs 11,6%; p=0,027). During a median follow-up of 1342 days, no significant differences were found regarding the occurrence of ischemic stroke and bleeding complications. All-cause mortality was significantly higher in cancer patients (31,5% vs 15,5%; p=0,003), but none died from cardiovascular causes.

Conclusion

Cancer is frequent in patients with AF/AFL referred to EC, who are older and had a higher bleeding risk. Stroke rate was not significantly different than other patients, and NOAC seem to be a safe medication in this population. All-cause mortality is high in cancer patients, but we did not find any association with cardiovascular causes.

Funding Acknowledgement

Type of funding sources: None.
Sex differences in incidence of out-of-hospital cardiac arrest across ethnic and socioeconomic groups: a population-based cohort study in the Netherlands
Authors: Bolijn R , Sieben C.H.A.M , Kunst A.E , Blom M , Tan H.L , Van Valkengoed I.G.M
Published: October 2021

Background

Current out-of-hospital cardiac arrest (OHCA) prevention strategies are suboptimal due to the inability to identify subgroups at high risk. Insight into the occurrence of OHCA within general populations may help to target prevention strategies. Case registries suggest that there may be substantial differences in emergency medical service (EMS)-attended OHCA incidence between men and women. However, due to a lack of individual-level prospective data, relative sex differences across ethnic groups and socioeconomic (SES) groups have not been studied.

Purpose

We investigated sex differences in OHCA incidence, overall and across ethnic groups and SES groups.

Methods

We performed a retrospective population-based cohort study, combining individual-level data on ethnicity and income (as SES measure) from Statistics Netherlands of all men and women aged ≥25 years living in one study region in the Netherlands on 01–01–2009 (n=1,688,285) with prospectively collected EMS-attended OHCA cases (n=5,676) from the ARREST registry until 31-12-2015. We calculated age-standardised incidence rates of OHCA. Sex differences were assessed with Cox proportional hazards regression analyses, adjusted for age, ethnicity and income, in the overall population, and across ethnic and SES groups.

Results

Overall, the age-standardised incidence rate of OHCA was lower in women than in men (30.9 versus 87.3 per 100,000 person-years), corresponding with a hazard ratio (HR) of 0.33 (95% confidence interval [CI] 0.31–0.35). While incidence rates varied across subgroups (range: 22.6–104.6 per 100,000 person-years), the sex differences in hazard for OHCA existed in all income quintiles (HR range: 0.30–0.35) and ethnic groups (HR range: 0.19–0.40), except among Moroccans (HR 0.89, 95% CI 0.51–1.57).

Conclusion

In most ethnic groups and all SES groups, women have a substantial, yet lower OHCA incidence rate than men. This confirms that men are an important target group for OHCA prevention strategies across social strata. Nevertheless, considering potentially differential aetiology as well as the lower survival rates among women, women will also benefit from targeted prevention strategies.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 research and innovation programme under acronym ESCAPE-NET (grant number 733381) and the COST Action PARQ (grant agreement number CA19137).ZonMw Gender and Health (grant number 8492ehab724.06458) and Gender and Prevention (grant number 555003016) programmes.
Single-chamber transvenous and subcutaneous defibrillators: clinical outcomes
Authors: Bodin A , Clementy N , Bisson A , Pierre B , Herbert J , Babuty D , Fauchier L
Published: October 2021

Introduction/Background

By using an entirely extra-thoracic lead placement, subcutaneous implantable cardioverter–defibrillators (S-ICD) were designed to avoid lead-related complications of single-chamber transvenous implantable cardioverter-defibrillators (VVI ICD).

Purpose

Our objective was to assess and compare outcomes following first VVI ICD or S-ICD implantation in an exhaustive nationwide matched cohort.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals From January 1, 2010 to September 1, 2020, who underwent a VVI ICD or S-ICD implantation were included. Patients with a previous pacemaker or ICD or with a history of infective endocarditis were excluded.

Results

21,667 patients were included in the cohort, 19,493 patients had a transvenous VVI ICD and 2,174 had a subcutaneous ICD.

Mean follow-up was 28.8±31.8 months. S-ICD patients was associated with higher rate of all-cause death (HR: 1.684, 95% CI: 1.309–2.165, p<0.001). There were no significant differences in cardiovascular death (HR: 1.092, 95% CI: 0.697–1.711, p=0.70) and infective endocarditis (HR: 0.354, 95% CI: 0.067–1.433, p=0.15) between the two groups

Using propensity score, 1,582 patients with VVI ICD were matched 1:1 with S-ICD patients. Mean follow-up was 4.5±7.2 months. In the matched analysis, there were no significant differences in all-cause death (HR: 1.090, 95% CI: 0.728–1.633, p=0.68) and cardiovascular death (HR: 1.167, 95% CI: 0.603–2.260, p=0.65) between the two groups. A trend toward a lower risk of infective endocarditis in the S-ICD group was also observed without reaching significance (HR: 0.219, 95% CI: 0.047–1.017, p=0.053).

A sensitivty analysis in patients with coronary artery disease in the matched cohort was performed. 1,024 patients had a VVI ICD and 977 had a S-ICD. Same trends were observed without significant differences in all-cause death (HR: 0.966, 95% CI: 0.605–1.543, p=0.88) and cardiovascular death (HR: 1.307, 95% CI: 0.610–2.799, p=0.49).

Conclusion

Our nationwide study highlighted a higher risk of all-cause death in patients treated with subcutaneous which however was not statistically significant after propensity score matching. No differences regarding cardiovascular mortality was found. An interesting trend toward diminution of infective endocarditis was also observed without reaching significancy.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristicsCardiovascular death
Hemodynamic arterial changes in heart failure. a proposed new paradigm of heart and vessels failure. The Copernican revolution?
Authors: Galati G , Germanova O , Iozzo R.V , Buraschi S , Shchukin Y.V , Germanov A , Germanov V , Tereshina O , Senni M , Margonato A
Published: October 2021

Background

Although heart failure (HF) is one of the most common conditions affecting the heart, little attention has been placed on the role of arteries in contributing to the progression of this disease.

Purpose

We sought to determine the hemodynamic change of arteries in HF patients subdivided according to left ventricular ejection fraction. The major goal was to establish the active compensatory role of arteries in HF

Methods

Using sphygmography, we systematically studied a cohort of 228 HF patients and 52 healthy controls. We focused on the common carotid as the main elastic artery and the posterior tibial as the main muscular artery (Figure 1). Moreover, we categorized the three HF groups, HFrEF, HFmrEF, HFpEF, into two subgroups (A and B) according to the presence or absence of HF signs at baseline.

Results

We discovered that all the parameters of measured arterial kinetics, i.e., work, power, acceleration, and speed, were significantly increased (p<0.001 by one-way ANOVA) in the groups without HF signs. In contrast, all the arterial kinetics parameters were significantly reduced (p<0.001) in the groups exhibiting HF signs. Similar results were obtained in both types of arteries and were consistently observed across all the three different types of HF, although with some differences in magnitude. Finally, we discovered that HFpEF patients exhibited more compromised arterial function vis-à-vis HFrEF patients (Figure 2: Patients Disposition (Top) and Quantification of arterial kinetics and hemodynamic parameters (Down) from the common carotid artery [A] and the posterior tibial artery [B]).

Conclusions

We provide the first documentation of an active compensatory role of arteries during HF. Mechanistically, we explain these findings by a dual activity of large arteries accomplished via an active propulsive work and a concurrent hemodynamic suction. These underestimated arterial functions partially compensate for the heart dysfunction in HF, underlining a key interplay between the heart and the vessels. We propose a new paradigm that we define as “heart and vessels failure” that explicitly focuses on both heart and vessels' interaction during the progression of HF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Sphygmograms of CCA and PTAFigure 2. Patients disposition & Results
Low-carbohydrate diets and right ventricular structure and function: the MESA-Right Ventricle study
Authors: Zhuang Z.X.D , Lai Y.H , Zhang S.Z , Liao X.X
Published: October 2021

Background

The association between daily carbohydrate intake and right ventricular (RV) morphology has not been well studied. We aimed to figure out the relationship between daily carbohydrate intake and right ventricular structure and function in a large multiethnic population-based cohort.

Methods

The Multi-ethnic Study of Atherosclerosis (MESA) -Right Ventricle Study measured RV mass and volumes by cardiac MRI in participants aged 45 to 84 years without clinical cardiovascular disease (CVD) in the MESA study. Participants were divided into three groups based on average daily carbohydrate intake: low (≤45%), medium (45–55%), and high (≥55%).

Results

The study sample included 3,776 participants which were aged 61.5±10.1 years, 47.5% male, 40.0% white, 24.9% African American, 21.8% Hispanic, and 13.3% Chinese. Higher levels of daily carbohydrate intake were linearly associated with greater RV stroke volume (RVSV), and RV ejection fraction (RVEF) (P<0.001) with larger carbohydrate-intake-related increasements in men than in women (P=0.006 for interaction) after adjusting for demographics, anthropometrics, smoking, drinking, daily protein intake, daily total energy intake, cholesterol, diabetes mellitus, hypertension, education, utilization of medicine and other covariates. The results remained significant after adjustment for LV parameters.

Conclusions

Carbohydrate intake was independently associated with differences in RV morphology after adjustment for all covariates. This association may be explained by the decreased intake of specific nutrients from carbohydrates. Given the nature of the study, causality cannot be proven. Therefore, further studies are needed to extend these findings, which if confirmed, may suggest a need to rethink recommendations for carbohydrate intake in clinical practice, for optimal nutrient achievement, meals need to be well formulated.

Funding Acknowledgement

Type of funding sources: None.
Pill burden and out-of-pocket medication costs of a contemporary heart failure with reduced ejection fraction cohort
Authors: Oliveira Campinas A , Costa R.C , Dias De Frias A.D.F , Alexandre A.A , Gomes C.G , Santos M.S , Torres S.T
Published: October 2021

Introduction

Modern pharmacological treatment of heart failure with reduced ejection fraction (HFrEF) dramatically improves its prognosis. However, the increasingly complexity and associated costs might threat their effective uptake in clinical practice. We aimed to study the pill burden and out-of-pocket costs of cardiovascular drug therapy of a contemporary cohort of HFrEF patients.

Methods

We performed a retrospective, cross-sectional, single-center study on a convenience sample of 100 consecutive HFrEF patients assessed at our HF outpatient clinic (January-June 2020). The pill burden was assessed by the number of prescribed different cardiovascular drugs and pills per day. The out-of-pocket (OOP) costs were defined using the total patients co-payment of cardiovascular medications per month of treatment, taken in account the exemptions provided by the Portuguese National Health System (NHS). The included drug classes were antiplatelets, anticoagulants, statins, HF drugs (Beta-blockers [BB], angiotensin-converting enzyme inhibitors [ACEi]/ angiotensin receptor blockers [ARBs]/ angiotensin receptor-neprilysin inhibition [ARNI], mineralocorticoid antagonists [MRA], sodium glucose cotransport inhibitors [iSGLT2], digoxin, loop diuretic) and antiarrhythmics.

Results

The mean age was 62±12 years and only 24% were female. The etiology of HF was ischemic in 42% of the patients, 86% were in NYHA II class and 5% in NYHA III-IV. The mean LVEF was 34±5% and the median NT-proBNP was 482 pg/mL [172–1120]. 92% of patients were on BB, 67% on ACEI/ARBs, 25% on ARNI, 81% on MRA and 30% on iSGLT2. The use of implantable cardioverter-defibrillators was 38% and 20% of patients were resynchronized. The number of cardiovascular (CV) drugs per day was 5.4±1.6 per patient and the number of CV pills per day was 6.6±2. Most patients (65%) had low income and had the maximal exemption on medication costs provided by NHS. Overall, the mean OOP costs was €16.1 per month of treatment and the mean OOP costs for patients exempted and not exempted was €12.9 and €22.3, respectively. The mean OOP costs of evidence-based HF-modifying drugs (BB, ACEI/ARBs, ARNI, MRA, iSGLT2) was €10.1 and the mean OOP costs of evidence-based HF-modifying drugs for patients exempted and not exempted were €7.9 and €14.2, respectively. However, for patients on ARNI the mean OOP costs was almost 3 times higher (€33.6).

Conclusions

In this optimally treated contemporary cohort of HFrEF, the pill burden due to cardiovascular therapy only is high (7 pills/day). With the exception of patients on ARNI, the overall OOP costs of HF-modifying prognostic drugs are low.

Funding Acknowledgement

Type of funding sources: None.
Peripheral artery disease is associated with adverse outcome among hospitalized patients with decompensated heart failure
Authors: Itelman E , Maor E.M , Kuperstein R.K , Freimark D.F , Matetzky S.M , Mazin I.M
Published: October 2021

Patients with heart failure (HF) and peripheral artery disease (PAD) share common high co-morbidities and outcomes. Management of HF patients has changed dramatically in the last decade. Our purpose in this analysis was to describe the prognostic significance of PAD in a large contemporary cohort of HF patients.

Methods

Analysis included consecutive patients who were hospitalized with decompensated HF between 2008–2020 at our Center. All patients' records were reviewed for the presence of PAD. Patients with cancer or chronic obstructive pulmonary disease were excluded from the analysis. Study outcomes were all-cause mortality and HF hospitalizations. Cox regression and propensity score matching models were applied.

Results

Final study population included 8,216 patients of whom 548 (7%) had PAD. Patients with PAD had higher rates of co-morbidities. Median follow-up was 3 (IQR 1–7) years. PAD was associated with a significant 35% increased risk of re-admission and mortality in univariate analysis (p<.001 for both). Propensity score matching analysis has demonstrated that PAD patients had similar mortality rates, but higher re-hospitalization rates during follow up. Finally, sensitivity analysis of the matching model (n=474), after excluding patients with RV dysfunction or severe pulmonary hypertension, successfully showed that HF patients with PAD were 50% more likely to be re-admitted and 30% more likely to die during follow-up (p=0.02 and 0.006 respectively; Figure 1)

Funding Acknowledgement

Type of funding sources: None. Figure 1
Predictive ability of cardiopulmonary exercise test parameters in heart failure patients with cardiac resynchronization therapy
Authors: Dias Ferreira Reis J.P , Goncalves A , Bras P , Moreira R , Rio P , Pereira Silva T , Timoteo A , Soares R , Cruz Ferreira R
Published: October 2021

Introduction

There is evidence suggesting that a peak oxygen uptake (pVO2) cut-off of 10ml/kg/min provides a more precise risk stratification in Cardiac Resynchronization Therapy (CRT) patients. Our aim was to compare the prognostic power of several cardiopulmonary exercise testing (CPET) parameters in patients with CRT and assess the discriminative ability of the guideline-recommended pVO2 cut-off values.

Methods

Prospective evaluation of consecutive heart failure (HF) patients with left ventricular ejection fraction ≤40%. The primary endpoint was a composite of cardiac death and urgent heart transplantation (HT) in the first 24 follow-up months and was analyzed by several CPET parameters for the highest area under thecurve (AUC) in the CRT group. A survival analysis was performed to evaluate the risk stratification provided by several different cut-offs.

Results

A total of 450 HF patients, of which 114 had a CRT device. These patients had a higher baseline risk profile, but there was no difference regarding the primary outcome (13.2% vs 11.6%, p=0.660). End-tidal carbon dioxide pressure at the anaerobic threshold (PETCO2AT) had the highest AUC value, which was significantly higher than that of pVO2 in the CRT group (0.951 vs 0.778, p=0.046). The currently recommended pVO2 cut-off provided accurate risk stratification in this setting (p<0.001),and the suggested cut-off value of 10 ml/min/kg did not improve risk discrimination in device patients (p=0.772).

Conclusion

PETCO2AT outperforms pVO2's prognostic power for adverse events in CRT patients. The current guideline-recommended pVO2 cut-off can precisely risk-stratify this population.

Funding Acknowledgement

Type of funding sources: None.
Discongruence Index: predictor of prosthesis size loss after transcatheter aortic valve replacement
Authors: De Agustin Loeches J.A , Pozo E , Nombela- Franco L , Jimenez-Quevedo P , Tirado G , Mahia P , Marcos-Alberca P , Luaces M , Perez De Isla L , Gomez De Diego J.J , Cobos M.A , Islas F , Fernandez-Ortiz A , Villacastin J , Macaya C
Published: October 2021

Introduction

Prosthesis under-expansion has been associated with higher rates of complications and worse long term outcome after transcatheter aortic valve replacement (TAVR). The objective of the current study was to assess the value of a new “Discongruence index”, to predict the percentage of prosthesis size loss (compared to its nominal size). The “discongruence index” is obtained from the relation between transcatheter valve size and the patient body surface area.

Methods

A total of 247 consecutive patients with severe aortic stenosis that underwent TAVR with balloon expandable Edwards-Sapiens prosthesis or CoreValve Revalving system at our institution were included. The “Discongruence index” was calculated pre-procedurally as the ratio: selected transcatheter valve size (mm) / body surface area (cm2). Two-dimensional transesophageal echocardiography images were studied in the 120–135° plane after the prosthesis deployment, and the maximum anteroposterior diameter was measured (in millimeters). From this measurement was obtained the percentage of prosthesis size loss (compared to the prosthesis nominal size).

Results

Mean age was 82±6 years and 102 patients (41.3%) were men. Mean aortic valvular area before TAVR was 0,87±3,8 cm2, (indexed 0,36±0,1 cm2) and the mean aortic gradient 49,1±16,9 mmHg. Mean prosthesis maximum deployment was 18,9±2,7 mm; absolute loss of prosthesis size compared to nominal 6,5±2,8 mm and the percentage loss of prosthesis size 25.1±9,5%. The “Discongruence index” was predictor of the percentage of prosthesis size loss (y = 5,7650 + 1,3010x, p<0,001), see figure.

Conclusions

The “Discongruence index” is a useful tool to predict the percentage of prosthesis size loss after TAVR. This new index should be taken into consideration in the selection of transcatheter valve sizes to avoid prosthesis under-expansion.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Area strain predicts clinical course in patients with heart failure with midrange ejection fraction
Authors: Tunyan L.G , Chilingaryan A , Sisakyan J.G , Tumasyan L.R , Kzhdryan H.K , Zelveyan P.H
Published: October 2021

Heart failure with midrange ejection fraction (HFmrEF) as a relatively new category remains understudied. Some studies have shown that patients with HFmrEF more resemble to those with heart failure with reduced ejection fraction (HFrEF), but many patients with HFmrEF are able to improve their EF to preserved one. The transformation course is hard to predict. We assumed that novel strain parameters might predict this transformation.

Methods

73 patients with HFmrEF NYHA II-III, 62±5 years (32 female) on optimal medical therapy and 43 age and sex matched healthy controls were involved in the study. Global values of longitudinal (GLS), circumferential (GCS) and radial strain (GRS), left ventricular torsion (LVT), peak LV twist (LVTR) and untwist rates (LVUTR), and area strain (AS) were measured by 2D/3D echocardiography and analyzed offline by one experienced specialist. All measurements were done at the study onset and in 1 year follow up.

Results

Patients with HFmrEF had significantly lower absolute values of GLS, GCS, GRS, LVT, LVTR, LVUTR and AS compared with controls. In one year follow up 24 (37%) patients with HFmrEF moved into HFrEF category and 14 (19%) moved up to HFpEF and the rest of the patients remained in HFmrEF group. Patients with HFrEF had significantly lower absolute values of AS, LVT, LVTR and LVUTR compared with patients who remained in HFmrEF group and patients that moved to HFpEF category, whereas patients with HFpEF had greated absolute values of GRS, AS and LVT, and without differences in LVTR and LVUTR compared with patients with HFmrEF. (HFrEF AS: −16.31±3.21% vs −22.34±6.31%, p<0.01; LVT: 0.72±0.13°/cm vs 1.12±0.42°/cm, p<0.03; LVTR 29.31±11.23°/s vs 48.32±19.71°/s, p<0.03; LVUTR 25.33±12.41°/s vs 49.23±18.34°/s, p<0.03; HFpEF AS: −31.23±4.35% vs −23.34±6.31%, p<0.01; LVT: 1.93±0.13°/cm vs 1.12±0.42°/cm, p<0.03; LVTR 41.62±15.81°/s vs 48.32±19.72°/s, p=0.08; LVUTR 41.41±16.72°/s vs 49.22±18.31°/s, p=0.12, GRS 45.34±7.41% vs 29.42±5.81%, p<0.002). Patients with subsequent HFrEF transformation also had lower AS values at beseline (−17.31±4.21% vs −24.21±6.83%, p<0.002). AS was the only predictor of HFmEF transformation into HFrEF or HFpEF with cut off values −17.1% and −32.7% respectively, (area under the curve 0.834)

Conclusion

Patients with HFrEF move into HFrEF category more frequently than into HFpEF. AS predicts transformation of HFmEF into HFrEF or HFpEF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): City Hall resources
Trends, predictors and outcomes of need for hemodialysis after heart transplantation
Authors: Briasoulis A , Doulamis I , Kampaktsis P , Kuno T , Alvarez P
Published: October 2021

Introduction

Acute renal failure is not uncommon immediately after heart transplantation (HT) and it is related to pre-existing cardiorenal syndrome, perioperative parameters, early post-operative course and initiation of calcineurin inhibitor therapy. We sought to investigate the trends, predictors and outcomes of renal failure requiring hemodialysis after HT.

Methods

Adult HT recipients were identified in the United Network for Organ Sharing (UNOS) registry between 2009 and 2020. Patients were grouped according to the requirement for hemodialysis in the post-operative period after HT. Accounting for re-transplantation, Fine and Gray's test compared cumulative incidences of all-cause mortality between groups. Univariate and multivariate analysis were performed using the competing risk model.

Results

A total of 26,634 patients were included in the study including 3,148 HT that required hemodialysis. Overall, the incidence of post HT dialysis increased during the study period (p<0.001, Figure 1). Patients on hemodialysis had significantly higher serum creatinine at the time of HT (1.51 vs. 1.21 mg/dl, p<0.001). Multivariable logistic regression analysis identified longer ischemic time (p<0.001), serum creatinine at HT higher than 1.2 mg/dl, higher calculated panel reactive antibody (%) (p=0.003), prior cardiac surgery (p<0.001), older donor age (p<0.001), higher recipient body mass index (p<0.001), mechanical ventilation at HT (p<0.001), support with extracorporeal membrane oxygenation (p<0.001) as independent predictors of hemodialysis need after HT. After adjusting for described confounders patients on hemodialysis had higher risk of 30-day (odds ratio 1.44, 95% CI 1.33–1.56, p<0.001) and all-cause mortality (sub-hazard ratio = 5.4, 95% CI 4.81–6.03, p<0.001)

Conclusion

Over 1 in 10 HT recipients require hemodialysis after HT. Need for hemodialysis is associated with worse 30-day and long-term mortality after HT.

Funding Acknowledgement

Type of funding sources: None. Figure 1