bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of severe tricuspid regurgitation on the prognosis of patients with atrial functional mitral regurgitation: the REVEAL-AFMR registry
Authors: Kaneko T , Kagiyama N , Amano M , Sato Y , Ohno Y , Obokata M , Sato K , Okada T , Machino-Ohtsuka T , Abe Y , Minamino T
Published: October 2024

Background

Tricuspid regurgitation (TR) often coexists with atrial functional mitral regurgitation (AFMR), resulting from tricuspid annular dilatation by right atrial enlargement/dysfunction without balanced leaflet area enlargement. The clinical impact of TR coexisting with AFMR have not been well understood.

Purpose

We aimed to investigate the prevalence and prognostic value of TR coexisting with AFMR.

Methods

In 26 facilities in Japan, patients with AFMR defined with significant functional MR with dilated left atrium and preserved left ventricular ejection fraction were enrolled. The primary endpoint was all-cause death, and the secondary endpoints were the composite of all-cause death and re-hospitalization for HF readmission.

Results

We analyzed 829 cases (age 77±9 years, 55% male) with moderate or severe AFMR excluding moderate or greater valvular stenosis and severe valvular regurgitation. Of these, 14.5% (n=120) had severe TR. The prevalence of severe TR increased as the severity of AFMR worsened (Figure A). Patients with severe TR had a longer history of atrial fibrillation, elevated NT-proBNP levels, a higher rate of prior heart failure hospitalizations, and a higher rate of prescription of loop diuretics than those with non-severe TR. There were no significant differences in tricuspid annular plane systolic excursion (TAPSE) and right ventricular S′ between the groups. In a multivariate logistic regression analysis, existence of atrial fibrillation and its duration, and higher right atrial pressure were independent determinants of severe TR. Kaplan-Meier curves showed prognostic stratification by severe or non-severe TR for both all-cause mortality and the composite endpoints (p<0.001). Severe TR was significantly associated with both all-cause deaths and the composite endpoints after adjusted for covariates regardless of the severity of MR (adjusted hazard ratio (HR) 1.74 [95% confidence interval 1.05-2.87], p=0.031 for all-cause deaths and adjusted HR 1.54 [1.03-2.30], p=0.033 for the composite endpoints) (Figure B).

Conclusion

Severe TR was associated with increased adverse events in patients with AFMR, independently of the severity of MR.
Higher product of right ventricle to left ventricle diameter ratio and septal wall thickness is associated with increased risk of cardiovascular death in patients post TAVI
Authors: Hu K , Liu D , Dormann A , Nass J , Buravezky L , Sokalski V , Lau K , Lengenfelder B , Morbach C , Ertl G , Frantz S , Nordbeck P
Published: October 2024

Background

Right ventricular (RV) dilatation is a significant predictor for mortality in various cardiovascular diseases. Hypertrophy is common in patients undergoing transcatheter aortic valve implantation (TAVI). We tested the hypothesis that the product of right ventricle to left ventricle diameter (RV/LV) ratio and septal wall thickness (SWT) might be a determinant of cardiovascular death in TAVI patients.

Methods

This retrospective study enrolled 1123 patients undergoing TAVI in our department between 2009 and 2021 (mean age 81.4±5.6 year, male 51.2%). We assessed standard echocardiographic measures prior to the TAVI procedure. End-diastolic basal biventricular dimensions were measured from a standard apical 4-chamber view, and the ratio of RV dimension (RVD) to LV dimension (LVD) was calculated as the RV/LV ratio. We tested the prognostic performance of the product of RV/LV ratio and septal wall thickness (RV/LV ratio*SWT). The primary endpoint was cardiovascular (CV) death up to 2 years after TAVI.

Results

CV mortality was 11.8% (132/1123) at 2 years after TAVI. SWT was similar between the groups with and without CV death (11.9±1.9 vs. 11.6±1.8 mm, P=0.188). However, the RV/LV ratio (0.84±0.15 vs. 0.80±0.13, P=0.002) and RV/LV ratio*SWT (10.0±2.7 vs. 9.3±3.1 mm, P=0.005) were notably higher in the CV-death group compared to the no CV-death group. Higher RV/LV ratio*SWT remained independently associated with elevated 2-year CV mortality after TAVI (HR=1.09, 95% CI 1.01-1.17, P=0.024), while the RV/LV ratio was no longer significantly linked with CV mortality (HR=2.83, 95% CI 0.87-9.19, P=0.082) after adjusting for potential confounding factors including age, sex, and atrial fibrillation. RV/LV ratio*SWT >12.7 mm was associated with a twofold increased risk of 2-year CV mortality compared to patients with RV/LV ratio*SWT ≤12.7 mm (2-year mortality 14.4% vs. 6.0%, P<0.001; HR=2.04, 95% CI 1.25-3.32, P=0.004), regardless of age, sex, and atrial fibrillation.

Conclusions

Combined assessment of biventricular remodelling and left ventricular hypertrophy by calculating RV/LV ratio*SWT is of clinical importance for risk stratification of cardiovascular death among TAVI patients.
Prognostic impact of lean diabetes mellitus on aortic stenosis
Authors: Ong J , Leow A , Ching K , Kong W , Yeo T C , Sia C H , Poh K K
Published: October 2024

Background

Obesity and type 2 diabetes mellitus (DM) has traditionally been thought to coexist. Lean DM is a distinct condition defined by body mass index (BMI) < 25, associated with elevated insulin resistance, rapid beta-cell failure, absence of ketosis and malnutrition. Lean DM has been linked to poor cardiovascular outcomes, but remains an understudied entity in valvular heart disease.

Purpose

This study aims to demonstrate the prognostic implications of lean DM on aortic stenosis (AS).

Methods

Between 2011 to 2021, 700 consecutive patients with index echocardiographic diagnoses of aortic stenosis were stratified into 4 groups, namely lean (BMI < 25) DM, lean non-DM, obese (BMI > 25) DM, and obese non-DM. Demographics, co-morbidities, echocardiographic findings and clinical outcomes were collected. Clinical outcomes were compared using Kaplan-Meier curves and a multivariate Cox regression model was constructed.

Results

396 (56.6%) patients were female, and 435 (62.1%) patients were of Chinese ethnicity. 279 (39.9%) patients had DM, of whom 155 (55.6%) patients had lean DM. The mean BMI in the lean group was 21.4 ± 2.4 kg/m² compared to 29.5 ± 4.9 kg/m² in the obese group. Irregardless of BMI, higher proportions of DM patients were on baseline antiplatelets and statins compared to non-DM patients. Echocardiographically, obese DM had smaller indexed left ventricular volumes and mass - left ventricular end diastolic volume index (LVEDVi) (65.7 ± 21.7 ml/m² vs. 70.8 ± 23.6 ml/m², p = 0.002) and left ventricular mass index (LVMi) (115.7 ± 31.9 g/m² vs. 116.3 ± 36.5 g/m², p = 0.401) compared to lean DM respectively. Obese DM was associated with more cardiovascular risk factors compared to lean DM in terms of hypertension (91.9%, n = 114 vs. 89.0%, n = 138, p < 0.001), hyperlipidaemia (82.3%, n = 102 vs. 73.5%, n = 114, p < 0.001) and chronic kidney disease (50.8%, n = 62 vs. 45.5%, n = 70, p < 0.001). On the contrary, lean DM was associated with more cardiovascular sequelae of acute myocardial infarction (36.8%, n = 57 vs. 24.2%, n = 30, p < 0.001) compared to obese DM. AS patients with lean DM experienced the highest significant all-cause mortality (71%, n = 110 in lean DM vs. 58.9%, n = 73 in obese DM vs. 49.1%, n = 86 in obese non-DM vs. 65%, n = 160 in lean non-DM, p < 0.001) compared to all other groups. On the contrary, AS patients with lean DM had the lowest heart failure incidence (17.4%, n = 27 in lean DM vs. 23.4%, n = 29 in obese DM vs. 33.1%, n = 58 in obese non-DM vs. 23.2%, n = 57 in lean non-DM, p = 0.009). On multivariate analyses adjusted for age, comorbidities, and echocardiographic parameters, lean DM was an independent predictor of worse all-cause mortality in AS patients (HR 1.60, CI: 1.19 - 2.16, p = 0.010).

Conclusion

Lean DM in AS patients was associated with worse all-cause mortality. Lean DM was a prognostic marker of all-cause mortality in patients with AS.Figure 1
Late iodine enhancement quantification by computed tomography: a comparison study against cardiac magnetic resonance imaging
Authors: Garcia Sebastian C , Monteagudo Ruiz J M , Antonana Ugalde S , Carrion Sanchez I , Hinojar Baydes R , Garcia Martin A , Martinez Vives P , Casas Rojo E , Jimenez Nacher J J , Moreno Planas J , Zamorano Gomez J L , Fernandez-Golfin Loban C
Published: October 2024

Introduction

Cardiac computed tomography (CT) has emerged as a promising alternative to cardiac magnetic resonance (CMR) for myocardial characterization. However, the quantification of late iodine enhancement (LIE) and its threshold values have not been previously reported. The Full Width Half Maximum (FWHM) technique established a cut-off value of 50% of the maximum intensity signal to quantify late gadolinium enhancement (LGE) in CMR. Nevertheless, the distinction between healthy and fibrotic myocardium in CT is less pronounced, prompting the need for specific threshold values for accurate quantification of LIE with this technique.

Purpose

Our primary aim was to validate and determine the optimal cut-off values for quantifying LIE using cardiac CT.

Methods

We included consecutive patients who underwent both LIE and LGE within a period of less than 2 months. Late enhancement quantification was performed using a commercially available software (figure 1). The FWHM technique was applied for LGE quantification. Various signal density cut-off values (70%, 75%, 80%, 85%, and 90%) were explored for LIE quantification. The total myocardial mass, total scar mass and scar proportion were calculated. The Intraclass Correlation Coefficient (ICC) was computed for each of the specified cut-off values.

Results

From November 2022 to February 2024, 58 patients underwent cardiac CT with LIE. Among them, 17 patients (48 (33;59) years; 13 (68,4%) male) had concomitant LGE and were included in the final analysis. The most common indication for CT was myocardial infarction with non-obstructive coronary arteries (52,9%).

The total myocardial mass by CT was 108.83 ± 21.69 g, while the total myocardial mass by CMR was 100.33 ± 25.19 g. The ICC between both techniques was good (0.78, p=0.001).

A cut-off value of 75% for the CT showed the strongest correlation with the CMR, both for total scar mass and scar proportion. Total scar mass was 9.43 ± 8.29 g for CT and 10.7 ± 8.46 g for CMR, with an ICC of 0.68 (p=0.01). Scar proportion was 9.97 ± 8.26% for CT and 11.09 ± 9% for CMR, showing a good correlation (ICC 0.73, p=0.006).

Conclusion

Late iodine enhancement quantification by cardiac computed tomography is feasible. A signal density threshold of 75% showed the strongest correlation with the cardiac magnetic resonance.Example of late iodine enhancement
Symptoms trend in patients with obstructive hypertrophic cardiomyopathy treated with disopyramide
Authors: Todde G , Lupo Dei L , Polizzi R , Gabrielli D , Canciello G , Romano S , Borrelli F , Halasz G , Ordine L , Pacella D , Bossone E , Lombardi R , Esposito G , Re F , Losi M A
Published: October 2024

Background

In obstructive hypertrophic cardiomyopathy (HOCM) medical intervention becomes necessary when symptoms coexist, whereas invasive septal reduction therapy (SRT) is indicated in presence of NYHA class >II, although optimized medical therapy. Thus, if SRT is avoided by medical therapy patient should be considered responder. However, due to inconsistency on definition of responders, effectiveness of medical therapy among data are conflicting. In addition, only short follow-up (FU) is available for analyses.

Purpose

To address this, we conducted a retrospective analysis in two HCM centers, both defining responders based on guidelines recommendations.

Methods

62 symptomatic HOCM patients (43% women, age 52±14 years) with LVOTG ≥50 mmHg at rest or during provocation, were recruited from two HCM Italian centers. Disopyramide was added as second-line therapy. Responders were those reaching at least NYHA class II, if >II at baseline and those reaching NYHA class I or with stabilization of symptoms if in NYHA II class at baseline.

Results

At FU, (mean 4.4 years, IQR 1.1-6.6 years), 47 patients (76%) were responders, whereas 15(24%) patients were no-responders. Changes in NYHA class from baseline to follow-up are reported in the Figure. There were no differences at baseline of clinical and echocardiographic data between responders and no-responders, whereas at FU responders showed a significant lower LVOTG than no-responders (43 ±32 vs 66 ±28 mmHg, respectively, p=0.013), with LVOTG <50 mmHg more represented in responders than in no-responders (75% vs 25%, respectively; p=0.004) (Figure). No side effects indicating discontinuation of the therapy were recorded.

Conclusion

Patients treated with disopyramide as second-line therapy showed a reduction in symptoms in a quite long-follow-up, avoiding SRT in up to 70% of them. Patients who might benefit the most from the therapy are those who reached LVOTG <50 mmHg during treatment.
The comparison of echocardiographic and serum parameters between Sapien 3 Ultra Resilia and Sapien 3 at one month
Authors: Kanehama N , Ninomiya R , Tosaka K , Yoshizawa M , Hashimoto N , Kumagai A , Fusazaki T , Morino Y
Published: October 2024

Background

Sapien 3 Ultra Resilia (S3UR) is the latest balloon-expandable valve for transcatheter aortic valve replacement (TAVR). Compared to Sapien 3 (S3), previous model of balloon-expandable valve, the leaflets are modified to anti-calcification tissue and the outer skirt becomes 40% higher with textured polyethylene terephthalate. However, it is unknown how these structural changes affect echocardiographic and serum parameters after TAVR.

Purpose

To compare impacts of these design changes on relevant echocardiographic and serum parameters between S3UR and S3 in the short term.

Methods

Patients with severe aortic valve stenosis who underwent TAVR with S3 or S3UR were included in this study. Echocardiographic parameters and blood samples were retrospectively collected at discharge and at 1 month post-procedure. Echocardiographic outcomes included mean pressure gradient (PG), effective orifice area index (EOAi), and paravalvular leak (PVL) grade. Hemolytic anemia indicators, specifically lactate dehydrogenase (LDH) and hemoglobin (Hb), were also assessed. Findings suggestive of hemolytic anemia at 1 month were defined as "an increase in LDH level of ≧200 IU/L as well as a decrease in Hb level of ≧1.0 g/dL from pre-procedure."

Results

Among 443 patients (S3: April 2020-March 2023, S3UR: April 2023-December 2023), 339 patients (S3: n=270, S3UR: n=69) were available for this study. The mean PG was significantly lower in the S3UR group compared to the S3 group at discharge and at 1 month (Figure 1A). On the other hand, the EOAi was similar between the two groups at discharge and at 1 month (Figure 1B). Although the prevalence of none/trace PVL was significantly higher in the S3UR group at discharge, this difference disappeared at 1 month (Figure 1C). LDH levels were significantly increased from pre-procedure to 1 month in both groups (Figure 2A). The median of ΔLDH (1 month – pre-procedure) and %change of LDH (ΔLDH/ pre-procedure) were significantly higher in the S3UR group. The prevalence of hemolytic anemia at 1 month was also significantly higher in this group (Figure 2B).

Conclusion

At 1 month, S3UR demonstrated superiority in mean PG but equivalence in EOAi and PVL grade compared with S3. Although both S3UR and S3 showed significant increase in LDH from pre-procedure to 1 month, hemolytic anemia was experienced more frequently in S3UR cases. Further evaluation will be needed to assess the potential clinical impacts of these differences.
Association between silent cerebral embolism and cognitive alterations following transcatheter aortic valve replacement in bicuspid versus tricuspid aortic valve patients
Authors: Huang Y , Fang Z , Zhou S
Published: October 2024

Background

Silent cerebral ischemic lesions (SCILs) is a common magnetic resonance imaging (MRI) finding in severe aortic stenosis patients post - transcatheter aortic valve replacement (TAVR). We evaluated the association between SCILs and cognitive alterations in patients with bicuspid aortic valve (BAV) versus tricuspid aortic valve (TAV) post-TAVR.

Methods

This study enrolled 100 consecutive TAVR (45 with BAV and 55 TAV). DW-MRI and neurocognitive evaluation (MoCA score) were performed at baseline, discharge, and 1- and 12-month post-discharge.

Results

Ninety-two out of the 100 patients (92%) exhibited cognitive dysfunction at baseline. Post-TAVR, overall cognitive function significantly improved, the average MOCA score increased from 18.69±6.74 to 22.18±6.30. During the 1-year follow-up, 54 patients demonstrated improved cognitive function, and the number of patients with moderate-to-severe cognitive dysfunction (MoCA score < 18) significantly decreased from 32 to 16. Prevalence of SCILs was 14% and 72% at baseline and discharge, respectively. New SCILs were observed in 60 patients at discharge, distributed across all vascular territories, averaging 4 lesions with a total volume of 215.4±195.4mm3. Although no significant correlation existed between total volume of new SCILs and cognitive changes post-TAVR (R=-0.133, p=0.206), patients with SCILs still displayed significant cognitive improvement (MoCA score from 18.4±6.6 to 22.0±7.1), whereas patients who developed large SCILs (lesion diameter >9) showed less improvement compared to those with small or median SCILs (number of patients who had cognitive improvement: 32 vs. 52, p<0.05). Cognitive function improvement post-TAVR did not significantly differ between BAV and TAV patients, MoCA scores were comparable (BAV group, n=45, from 18.63±6.68 to 21.88±6.80 vs. TAV group, n=55, from 18.73±6.81 to 22.42±5.80; p>0.05). DW-MRI revealed more new SCILs in BAV patients post-TAVR compare to TAV patients (235 lesions vs. 150 lesions, respectively). In BAV patients, SCILs primarily manifested in small and medium sizes (224 lesions), despite more severe calcification (valvular calcium volume 956.5±644.0 mm vs. 634.4±508.0 mm3; p=0.028). The number of large lesions was similar in the two groups (11 in BAV group and 10 in TAV group).

Conclusion

TAVR demonstrates positive effects on improving cognitive function in aortic stenosis patients, despite common occurrence of SCILs in both BAV and TAV patients. Cognitive function post-TAVR was comparable between BAV and TAV patients. The cognitive improvement from TAVR may be less impacted by small- and medium-sized SCILs, while severe SCILs might impede or diminish the cognitive benefits of TAVR.table
Mortality rates in patients undergoing urgent versus elective transcatheter aortic valve replacement: a systematic review and meta-analysis
Authors: Apostolos A , Ktenopoulos N , Chlorogiannis D D , Konstantinou K , Katsaros O , Drakopoulou M , Tsalamandris S , Karanasos A , Latsios G , Synetos A , Aggeli C , Panoulas V , Tsioufis C , Toutouzas K
Published: October 2024

Background

Patients with severe aortic stenosis (AoS) often present with acute heart failure and compensation, leading frequently to cardiogenic shock. Transcatheter Aortic Valve Replacement (TAVR) has been recently performed as a bailout treatment in such patients. The aim of our meta-analysis is to compare urgent TAVR to elective procedures.

Methods

We systematically screened three databases searching for studies comparing urgent versus elective TAVR. Primary endpoint is the 30-days mortality. Secondary endpoints included in-hospital mortality, device success, periprocedural vascular complications, 30-day stroke, 30-day acute kidney injury (AKI), permanent pacemaker implantation (PPM), moderate or severe paravalvular leakage and 30-day bleedings.

Results

Seventeen studies were included, with a total of 84,495 patients. Urgent TAVR was associated with an increased risk for 30-days mortality (RR: 2.53, 95% CI: 1.81 – 3.54), in-hospital mortality (RR: 2.67, 95% CI: 1.94 – 3.68), periprocedural vascular complications (RR: 1.91, 95% CI: 1.28 – 2.85) and AKI (RR: 2.83, 95% CI: 1.93 – 4.14), compared to elective procedure. No differences were observed in the rest secondary endpoints.

Conclusions

Urgent TAVR was associated with higher in-hospital and 30-day mortality, possibly driven by the increased incidence of AKI and vascular complications in urgent TAVR. The results highlight the importance of early TAVR in stable AoS patients.
Morphologic differences in atrial and ventricular secondary tricuspid regurgitation by computed tomography
Authors: Chua A P A , Lopez Santi P , Sarrazyn C , Wu H W , Bax J J , Ajmone Marsan N
Published: October 2024

Background

Differences in the mechanism behind atrial (ASTR) and ventricular (VSTR) secondary tricuspid regurgitation cause distinct remodeling in the tricuspid valve annulus (TA), right atrium (RA) and right ventricle (RV). Although these morphological changes have been described by echocardiography, computed tomography (CT) can provide better spatial resolution and detailed anatomical information particularly when planning valvular interventions.

Purpose

To compare the morphologic characteristics of the TA, RA and RV between ASTR and VSTR as measured by CT.

Methods

Patients with at least moderate secondary TR and who underwent CT were selected as follows: for the ASTR group (n=32), patients referred for atrial fibrillation (AF) ablation; for the VSTR group, patients referred for transcatheter aortic valve implantation, and which were further subdivided according to the presence of AF (with AF [n=51] and without AF [n=68]). Multiparametric echocardiographic approach was used to define TR severity. CT dataset were analyzed in diastole using a dedicated software for the following parameters: TA area, perimeter, antero-posterior (AP) and septal-lateral (SL) diameters, eccentricity index, annulus depth (to assess TA saddle shape), and RA and RV dimensions and volumes (Fig. 1).

Results

TR was more severe in VSTR, as 55% and 43% of patients had severe to massive TR in the VSTR group with and without AF, respectively, as compared to 12% in the ASTR group (p<0.001). The TA area was significantly larger in the ASTR and VSTR with AF patients (Fig.2), with a trend towards a more circular annulus by eccentricity index. Annulus depth was lower (flatter) in ASTR compared to both VSTR groups. For the RA, annulus to roof distance was larger in VSTR patients with AF, but the diameter width was wider for both ASTR and VSTR with AF. Indexed RA volume was larger in the VSTR with AF compared to both ASTR and VFTR without AF. The RV, on the other hand, showed a wide base and narrow mid in the ASTR group, both a wide base and mid in the VSTR group with AF, and slightly narrower base and wider mid in the VSTR without AF. RV base-to-mid ratio was lower for both VSTR groups compared to ASTR, but volumes did not significantly differ. RA-to-RV-volume ratio, however, was higher for the ASTR and VSTR with AF.

Conclusion

Remodeling of the TA and right chambers differ significantly between TR etiologies. ASTR is characterized by a larger and flatter TA, a widened RA and RV base, narrow RV mid, and almost proportional RA-to-RV volumes. VSTR remodeling differs with the presence of AF, as those without AF have a smaller and deep TA, smaller RA, a proportional dilatation of RV diameters, and a larger RV compared to RA. Differentiating these patterns may be useful to guide future interventions.
Effect of patient prosthesis mismatch on clinical outcomes following surgical aortic valve replacement
Authors: Lewin S , Budgeon C , Courtney W , Ng P , Graham G , Waller L , Butcher S , Gilbert T , Briffa T , Sanfilippo F , Hillis G , Ihdayhid A
Published: October 2024

Introduction

Patient prosthesis mismatch (PPM) after surgical aortic valve replacement (SAVR) occurs when the valve’s effective orifice area (EOA) does not allow appropriate cardiac output to meet demand, causing increased transvalvular gradients. The literature is conflicting regarding the effect of PPM on long-term mortality and other adverse outcomes.

Purpose

To characterise the effect of PPM on all-cause mortality, cardiovascular death, heart failure hospitalisation and major adverse cardiac events (MACE; a composite of cardiovascular death, myocardial infarction, and stroke) following SAVR, stratified by sex.

Methods

This retrospective cohort study uses data from the Western Australia Heart Valves Study linked to administrative health data and includes all patients who underwent SAVR in Western Australian public hospitals between 2010-2020. PPM was defined according to the Valve Academic Research Consortium 3 criteria. The indexed EOA was derived from body surface area and published in-vivo EOA’s calculated for each prosthesis model and size.

Results

During the study period 1837 patients underwent SAVR (mean age 65 ± SD 14 years, 31% female). Median follow-up was 3.76 years (IQR 1.73-6.62). A mechanical prosthesis was implanted in 579 (32%) patients. Moderate or severe PPM was present in 250 (14%) patients, whilst no significant PPM was present in 1587 (86%) patients. Compared to those without significant PPM, patients with PPM were older (69 ± 14 vs 64 ± 11 years; p<0.001); included more women (101/250; 40% vs 459/1587; 29%; p<0.001) and were more likely to have bioprosthetic SAVR (213/250; 85% vs 1045/1587; 66%; p<0.001). The presence of PPM (moderate or severe vs no significant PPM) was associated with increased all-cause death (Hazard Ratio (HR) 1.74, 95% CI 1.09-2.75), cardiovascular death (HR 2.44, 95% CI 1.33-4.48) and MACE (HR 1.89, 95 CI 1.17-3.04) in females in adjusted analyses, but not males (table). The presence of PPM was not associated with heart failure hospitalisation, overall or in either sex.

Conclusion

The presence of moderate or severe PPM is associated with increased all-cause death, cardiovascular death, and MACE in females only. These results highlight the importance of patient selection, valve choice and operative technique to minimise PPM, particularly in female patients.Table 1
Outcomes of CT- or CMR-guided TAVR according to sex: a secondary analysis of the randomized TAVR-CMR trial
Authors: Oberhollenzer F , Lechner I , Reindl M , Tiller C , Holzknecht M , Von Der Emde S , Binder R K , Klug G , Bauer A , Mayr A , Reinstadler S J , Metzler B
Published: October 2024

Background

Previous studies have reported sex differences in pre-procedural imaging characteristics of patients undergoing transcatheter aortic valve replacement (TAVR) evaluation. Whether these differences affect the outcome of computed tomography (CT)-guided or cardiac magnetic resonance (CMR)-guided TAVR has not been studied.

Objectives

This analysis aimed to evaluate sex-based differences in imaging findings and outcomes in patients undergoing TAVR for severe aortic valve stenosis.

Methods

This was a secondary analysis of the TAVR-CMR trial, a randomized clinical trial comparing TAVR planning by CT or CMR. Outcomes (based on the Valve Academic Research Consortium (VARC)–2 definition) with each imaging strategy were compared according to sex.

Results

Of 380 patient randomized into the TAVR-CMR trial, 194 (51.1%) were female and 186 (48.9%) were male. Of these, 267 patients eventually underwent TAVR (133 women (49.8%) and 134 men (50.2%), p=0.457). Imaging findings differed between the sexes for both imaging modalities. The comparison between CT and CMR to assess the access route and landing zone showed no difference in both women and men (all p>0.05). Implantation success was not significantly different between imaging strategies for both women (84.7% (CT group) vs. 93.2% (CMR group), p=0.11) and men (95.7% (CT group) vs. 93.8% (CMR group), p=0.61). All-cause mortality at 6 months was not significantly different between imaging strategies for both women (10.2% (CT group) vs. 8.1% (CMR group), p=0.68) and men (4.3% (CT group) vs. 9.4% (CMR group), p=0.24).

Conclusions

This secondary analysis has confirmed sex-related differences in pre-procedural imaging characteristics, with no influence of the imaging modality used. Similar outcomes were observed in both female and male patients when the TAVR was guided by either a CMR or a CT scan.
Impact of atrial fibrillation on progression of tricuspid regurgitation in patients undergoing transcatheter aortic valve replacement
Authors: Yoshida T , Okuno T , Kuwata S , Miyahara D , Kai T , Sato Y , Koga M , Kida K , Ishibashi Y , Tanabe Y , Izumo M , Akashi Y J
Published: October 2024

Background

Recent advancements in interventional cardiology have spurred growing interest in atrial tricuspid regurgitation (TR) as a potential therapeutic target. Atrial TR, a form of secondary TR, arises from the dilatation and dysfunction of the right atrium, frequently seen in the context of atrial fibrillation (AF). While the concept is increasingly recognized, the natural history of TR in relation to AF remains incompletely understood.

Purpose

This study aims to elucidate the impact of AF on the progression of TR in patients undergoing transcatheter aortic valve replacement (TAVR).

Methods

Utilizing data from a comprehensive single-center TAVR registry, this study included patients who underwent TAVR between 2016 and 2023, excluding those with severe TR post-TAVR. Subjects were categorized based on the presence or absence of paroxysmal or persistent/permanent AF/atrial flutter (AFL). The study employed the cumulative incidence function to depict the progression to severe TR, considering all-cause mortality as a competing risk.

Results

Among 981 eligible patients, 169 (17.2%) presented with AF/AFL, with 57 (5.8%) having persistent/permanent and 112 (11.4%) paroxysmal forms. Patients with AF/AFL had a higher surgical risk, a higher prevalence of significant mitral regurgitation and TR, and a lower left ventricular ejection fraction. The median follow-up period was 366 days, with an interquartile range from 36 to 1079 days. Over a 5-year period, 11.7% of patients with AF/AFL experienced progression to severe TR, with 14.2% in those with persistent/permanent AF/AFL and 10.6% in those with paroxysmal AF/AFL, compared to merely 0.8% in patients without AF/AFL (sub-distribution HR: 7.60, 95%CI: 2.86-20.0; P<0.001) (Figure 1). Multivariable Fine-Gray regression analysis showed that AF/AFL was associated with the progression of TR by at least one grade, independently of the TR grade post-TAVR and other echocardiographic parameters (sub-distribution HR: 1.38, 95% CI: 1.06-1.78; p=0.015). Other factors associated with progression included the TR grade post-TAVR (sub-distribution HR: 1.20, 95% CI: 1.05-1.38; p=0.009) and the presence of a permanent pacemaker (sub-distribution HR: 1.53, 95% CI: 1.18-1.71; p=0.001) (Figure 2).

Conclusions

The presence of AF/AFL significantly increases the risk of developing severe TR in the long-term following TAVR, underscoring the need for vigilant monitoring and potentially preemptive management strategies in this patient cohort.
Beyond 2D echocardiography: A novel multiparametric assessment of right ventricular dysfunction in transcatheter tricuspid valve repair
Authors: Doldi P , Stolz L , Weckbach L , Hausleiter J
Published: October 2024

Background

Patients with severe tricuspid regurgitation (TR) are heterogenous and complex in terms of etiology, comorbidities and state of disease. Right ventricular (RV) function measured by RV to pulmonary artery coupling (RVPAc) is prognostic in transcatheter tricuspid valve repair (T-TEER). However, traditional 2D echocardiographic measures have critical limitations and RVPAc fails to respect the degree of volume overload/dilation of the RV, which is a key clinical tracer for right ventricular dysfunction (RVD).

Purpose

We aimed to refine RVPAc by incorporating RV dilation, assessed by 3D echocardiography, to improve the assessment of RV dysfunction for an enhanced outcomeprediction in T-TEER patients.

Methods

We analyzed 262 patients undergoing T-TEER with complete 3D echocardiography.

Results

Despite similar RV function across groups, RV dilation (HR 1.85; 1.10, 3.12; p=0.020) and impaired RV free wall longitudinal strain (RVFWLS, HR 1.73, 1.02, 2.92, p=0.042) predicted increased 1-year mortality. A novel RVPAc parameter [RVFWLS/(3D-RVEDV*sPAPinvasive)] was developed, associating RVPA-Uncoupling with a tripled risk of death (HR 3.19, 1.7-6.0, p<0.001). NYHA Class IV and the new RVPAc were independent mortality predictors after T-TEER, with the modified RVPAc showing superior predictive value over traditional RVPAc (c-index 0.68 vs. 0.57, p=0.027).

Conclusion

The novel RVPAc parameter, integrating RV dilation and function, is a powerful predictor of survival post-T-TEER, underscoring the importance of timely intervention in severe TR and RVD. 3D echocardiography plays a critical role in assessing RV dimension and function, with implications for the management and prognosis of TR patients.Central Figure
Infective endocarditis on percutaneous aortic valve prosthesis: incidence, characteristics and comparison with endocarditis on surgically implanted aortic bioprostheses
Authors: Barreiro Mesa L , Anguita Sanchez M P , Castillo Dominguez J C , Lopez Aguilera J , Gonzalez Manzanares R , Crespin Crespin M , Ojeda Pineda S , Urbano Sanchez C , Roldan Roldan A , Aguayo Cano N , Pan Alvarez Ossorio M P
Published: October 2024

Background

Transcatheter aortic valve replacement (TAVR) has become a first-line therapeutic measure in patients with severe aortic stenosis, especially in selected patients who present a very high surgical risk; nevertheless, this technique is becoming increasingly widespread even among patients with a lower surgical risk. Infective endocarditis (IE) is an infrequent but very serious complication in patients undergoing TAVR implantation. The aforementioned generalization of this technique means that more and more patients are at risk of developing this complication which, in addition, seems to have some particularities with respect to endocarditis in other patients.

Purpose

The aim of our study was to analyze the incidence, clinical characteristics and mortality of IE in patients with TAVR, comparing them with IE in patients with surgically implanted prostheses (SAVR).

Methods

Observational, single-center, prospective cohort study including all cases of IE diagnosed and prospectively followed up in our center from 2008 to 2022, according to Duke or ESC diagnostic criteria, depending on the era. We identified cases of IE in patients with TAVR in this period and compared their characteristics with endocarditis in patients with surgical aortic prostheses.

Results

In our center 10 cases of IE have been diagnosed in patients with TAVR. Since 2008 this procedure has been successfully performed in 778 patients, which gives an incidence of 1.29% compared to 1.68% of its surgical counterpart with a total of 24 cases of IE. The clinical characteristics of these patients are shown in the table. With the exception of mean age (p= 0.006), there were no significant differences between the two groups. In approximately half of the cases the diagnosis was made early after valve replacement (<1 year after replacement). With respect to the causative microorganisms, the most prevalent agent was enterococci, followed by coagulase-negative staphylococci and staphylococcus aureus; in 17% of patients with SAVR the causative agent was not identified. The clinical evolution was similar in both groups, with a high proportion of severe complications and 50% of cardiac complications in the TAVR group. Half of the patients had a surgical indication at diagnosis, but only 50% underwent surgery. There were also no differences in mortality, which, nevertheless, was high, around 30%.

Conclusions

Despite the differences in mean age, no significant differences were found between the two groups. IE is an infrequent but serious complication in patients with prosthetic valves, with a high rate of serious complications and mortality regardless of its management.Baseline characteristics of patients
Infective endocarditis - characteristics and long-term outcomes in patients with congenital heart disease are distinct from those without congenital heart disease
Authors: Havers-Borgersen E , Oestergaard L , Holgersson C K , Stahl A , Schmidt M R , Smerup M , Koeber L V , Fosboel E L
Published: October 2024

Background

Patients with congenital heart disease (CHD) form a high-risk niche among patients considered at high-risk of infective endocarditis (IE). Their life-long exposure to the risk of IE, starting from birth, necessitates a nuanced approach to both prevention and treatment strategies. However, comprehensive data from an unselected nationwide cohort, including children, are lacking.

Purpose

This study sets out to compare characteristics and associated outcomes among patients with IE with and without CHD.

Methods

Using nationwide registries, all Danish patients diagnosed with IE from 1977-2021 were identified and stratified on whether they had a diagnosis of CHD, regardless of its complexity. Characteristics prior to and during admission as well as associated outcomes (i.e., in-hospital mortality, 1-year mortality, and 10-year mortality, and IE recurrence) were compared between groups.

Results

In total, 14,040 patients were diagnosed with IE from 1977-2021 including 895 (6.4%) with a diagnosis of CHD. Patients with versus without CHD were significantly younger at time of IE diagnosis (median age 38.8 years [IQR 21.2-56.4 years] versus 70.7 years [IQR 58.8-78.9 years], Figure 1) and less comorbid. Patients with versus without CHD were hospitalized due to IE for a similar period of time but more often underwent cardiac surgery during admission (44.9% versus 21.3%). The IE-related bacteremia was significantly different between groups: the most common bacteriemia in relation to IE was Streptococci (29.9%) in patients with CHD and Staphylococcus Aureus (29.9%) in patients without CHD. Patients with CHD were associated with a significantly lower risk of in-hospital mortality (6.4% versus 19.8%), 1-year mortality (10.5% versus 32.4%) and 10-year mortality (21.3% versus 58.7%) compared with those without CHD. The 10-year incidence of IE recurrence was similar among groups (p-value 0.5).

Conclusions

Patients with CHD who develop IE are distinctive from patients with IE without CHD in terms of characteristics as well as long-term outcomes. Notably, our findings stress a key point: the majority of children and adolescents with IE have a CHD. These unselected findings should help guide future preventive strategies, diagnosis, and management.
Pnn deficiency alters expressions of calcium handling proteins and impairs nuclear envelope structure in cardiomyocytes
Authors: Leu S , Ouyang P
Published: October 2024

Pnn is a multi-functional protein playing roles in the regulation of gene transcription, mRNA alternative splicing, as well as cell-cell connection. Previous studies suggested an association between Pnn genetic defects and arrhythmogenic right ventricular cardiomyopathy (ARVC) in human. In this study, we applied an inducible cardiomyocyte-specific Pnn depletion mouse model (Myh6-CreERT2, Pnnflox/flox) to determine the impact of loss of Pnn on cardiac structure and function in mice. Six weeks after inducing Pnn gene disruption, electrocardiographic abnormalities, ventricular dilatation, and reduced left ventricular ejection fraction (LVEF) were observed in mice with loss of Pnn in cardiomyocytes. Histopathological examinations showed that the proliferation of cardiac fibroblasts and expression of α-smooth muscle actin were increased with Pnn depletion, while the cell-cell connection between cardiomyocytes were impaired. In addition to impaired intercalated discs, loss of Pnn also altered the distribution and expression of nuclear envelope proteins and the linker of nucleoskeleton and cytoskeleton (LINC) complex proteins, such as nuclear lamins, Emerin, and SUNs, in cardiomyocytes. Microarray analysis as well as subsequent RT-PCR and Western blots also indicated that loss of Pnn regulated myocardial expressions of genes responsible for calcium handling, such as RYR2, Atp2a2, Slc8a1, and Kcnj3. Furthermore, infiltrations of macrophages and neutrophiles were observed in the myocardium with Pnn depletion, while expression levels of oxidative stress-associated proteins were also significantly regulated by Pnn depletion. In conclusion, Pnn plays an essential role in the maintenance of intercalated disc integrity and nuclear envelope structure of cardiomyocytes, while cardiomyocyte-specific loss of Pnn impairs the calcium handling and leads to arrhythmogenic dilated cardiomyopathy in mice.Cardiac MRI of mice with Pnn depletionMyocardial expression of SUN2 and Emerin
Gender-related differences in clinical characteristics of patients with hypertrophic cardiomyopathy in our city
Authors: Tosun R , Mann C , Hengstenberg C , Dalos D
Published: October 2024

Background

Female patients with hypertrophic cardiomyopathy (HCM) tend to display a higher rate of heart failure as well as lower survival compared to male patients. Despite this, gender-related differences in the clinical characteristics of HCM patients remain unclear.

Methods and Aim

Consecutive HCM patients were prospectively enrolled at a tertiary referral center. The primary objective of this study was to investigate and emphasize gender differences in clinical characteristics including imaging and laboratory parameters.

Results

Between May 2018 and January 2024, a total of 301 HCM patients were included, of which 41.9% were female (n=125). Female patients were significantly older and more symptomatic than male counterparts (59 years [IQR 47-67] vs. 53 years [IQR 39-61], p=0.001; New York Heart Association functional class ³III: 28.8% vs. 17.6%, p=0.002, respectively). No significant differences in body mass index were found (28.4 kg/m² [IQR 24.9-31.6] vs. 28.4 kg/m² [IQR 25.9-31.8], p=0.8).

With respect to echocardiographic parameters, although interventricular septal thickness was comparable (19.0 mm [IQR 16.0-22.0] vs. 19.5 mm [IQR 17.0-22.0], p=0.4) left atrial as well as right atrial volume index were higher in women (30.0 cm³/m² [IQR 27.0-35.0] vs. 27.0 cm³/m² [IQR 24.0-30.0], p<0.001; 27.1 cm³/m² [IQR 25.4-29.3] vs. 24.7 cm³/m² [IQR 22.5-28.2], p<0.001). These findings were further supported by elevated filling pressures in female patients reflected by E/e’ ratio (16 [IQR 14-22] vs. 10 [IQR 9-12], p<0.001). Moreover, these patients showed more frequent left ventricular (LV) outflow tract obstruction (50% vs. 33%, p=0.029) which is accompanied by a slightly higher LV ejection fraction compared to men (69% [IQR 62-74] vs. 62% [IQR 55-67], p=0.004).

In terms of cardiac biomarkers, female HCM patients presented with higher levels of serum N-terminal pro brain natriuretic peptide (671 pg/ml [IQR 333-1613] vs. 357 pg/ml [IQR 115-959], p<0,001) as well as lower concentrations of serum creatinine (0.84 mg/dl [IQR 0.75-0.95] vs. 0.98 mg/dl [IQR 0.87-1.15], p<0.001) whereas no differences regarding high-sensitive troponin-T levels were observed.

Conclusion

This single-center analysis illustrates profound gender-related differences among HCM patients in Vienna. Female patients tend to present in a more advanced clinical status, rather reflecting the phenotype of heart failure with preserved ejection fraction. Whether these findings should prompt an early HCM diagnosis in female patients with unspecific symptoms, or may result in early treatment initiation of e.g. sodium-glucose-transporter 2 inhibitors, should be part of future research.
Effect of tafamidis on left atrial function in patients with transthyretin amyloid cardiomyopathy
Authors: Uemura K , Ichikawa Y , Nagai S , Takeuchi M , Nishihara Y , Takeuchi K , Oota E , Odajima S , Kintsu M , Todo S , Fukuda T , Hisamatsu E , Hirata K , Tanaka H
Published: October 2024

Background

Transthyretin amyloid cardiomyopathy (ATTR-CM) is characterized by the functional and structural consequences of amyloid infiltration predominantly within the ventricles, causing biventricular wall thickening. Amyloid infiltration can be observed in left atrium in ATTR-CM, however, the association of left atrial (LA) myocardial function with cardiovascular events and changes in LA myocardial function with tafamidis administration have not been elucidated.

Purpose

The aim of this study was to identify the association between baseline LA reservoir function evaluated by left atrial reservoir strain and cardiovascular events. Furthermore, monitoring the LA reservoir function before and after tafamidis administration, we also investigated the baseline factors associated with changes in LA reservoir function in patients with ATTR-CM.

Methods

We studied 55 patients with biopsy-proven ATTR-CM who were started on tafamidis in our institution between July 2019 and December 2022 (age: 76 ± 2 years, male: 93%). The primary endpoint was defined as hospitalization for heart failure or cardiovascular death during a median follow-up period of 28 ± 4 months after tafamidis administration. Furthermore, we assessed the factors associated with changes in LA function before and 25 ± 3 months after tafamidis administration for 49 patients who underwent sufficient follow-up echocardiography.

Results

During the follow-up period, 8 patients had cardiovascular death or cardiovascular hospitalization. The Kaplan-Meier curve indicated that the occurrence of cardiovascular events for patients with LA strain ≥ the median 8.6% was significantly lower than for those with LA strain < 8.6% (log-rank P =0.002; Figure A). Furthermore, comparing LA strain before and after tafamidis administration, the group with worsening LA strain tended to be older (79.0 ± 2.0 years vs. 73.6 ± 3.3 years, P=0.004), have higher brain natriuretic peptide (350 ± 83 pg/mL vs. 199 ± 47 pg/mL, P=0.003), have lower global longitudinal strain (GLS) (9.8 ± 1.4 % vs. 12.6 ± 1.6 pg/mL, P=0.008), and higher relative apical longitudinal strain index (1.63 ± 0.4 % vs. 1.14 ± 0.2 %, P=0.021). The multivariate logistic regression analysis was that age, GLS and relative apical longitudinal strain index were the independent determinants for deterioration of LA strain after tafamidis administration (Figure B).

Conclusion

In our study, baseline LA reservoir function was found to be closely associated with cardiovascular events after tafamidis administration, while age, GLS and relative apical longitudinal strain index were associated with worsening LA strain after tafamidis administration. Our findings could represent an additional parameter for the effective management of patients with ATTR-CM.Figure AFigure B