bluuebunny/crossref_metadata_2025 huggingface dataset:
Pulmonary artery catheterization in cardiogenic shock: a systematic review and meta-analysis
Authors: Chow J , Vadakken M.E , Whitlock R.P , Koziarz A , Ainsworth C , Amin F , Demers C , Belley-Cote E.P
Published: November 2020

Background

Cardiogenic shock carries high morbidity and mortality. Pulmonary artery catheterization (PAC) allows invasive hemodynamic assessment and tailored therapy; however, evidence supporting this practice is sparse.

Methods

We performed a systematic review and meta-analysis of observational studies and randomized controlled trials comparing PAC versus no PAC in cardiogenic shock. We searched MEDLINE, EMBASE, Cochrane CENTRAL, and grey literature. We screened references, abstracted data and evaluated risk of bias in duplicate. We pooled data using a random-effects model and evaluated the quality of evidence using GRADE. Outcomes of interest were mortality and length of stay (LOS).

Results

We identified 13 observational studies (1,982,047 patients) and no randomized controlled trials; 12 studies were at high risk of bias. When pooling adjusted results, PAC was associated with reduced mortality at hospital discharge (RR 0.64; 95% CI 0.50–0.82) and at longest available follow-up (RR 0.65; 95% CI 0.49–0.87). Unadjusted LOS was 5.0 days longer (95% CI 4.93–5.07) with PAC. Quality of evidence was very low for all outcomes.

Conclusion

Based on very low quality evidence, PAC use in patients with cardiogenic shock may be associated with lower mortality. The observed increase in hospital LOS may represent survivor bias or relate to more aggressive management with PAC. Overall, these results support consideration of PAC for hemodynamic assessment and tailored therapy in cardiogenic shock.

Funding Acknowledgement

Type of funding source: None
GLP-1 is an independent predictor of long-term mortality in patients with myocardial infarction complicated by cardiogenic shock – a substudy of the IABP-SHOCK II trial
Authors: Fuernau G , Lehrke M , Jung C , Kahles F , Lebherz C , Eitel I , Thelemann N , Desch S , Werdan K , Zeymer U , Adams V , Marx N , Thiele H
Published: November 2020

Background

The incretin hormone Glucagon-like-peptide 1 (GLP-1) is a major stimulus for glucose dependent insulin secretion and holds cardioprotective efficacy. This has made the GLP-1 system a preferred target for diabetes therapy. Secretion of GLP-1 happens in response to nutritional but also inflammatory stimuli. Consequently, marked elevation of circulating GLP-1 levels were found in critically ill patients featuring marked association to markers of inflammation.

Purpose

Our study sought to investigate GLP-1 levels in patients with cardiogenic shock (CS) complicating myocardial infarction and a possible prognostic correlation to short- and long-term outcome.

Methods

We serially assessed circulating GLP-1 levels in a prospectively planned biomarker substudy in the IABP-SHOCK II trial. Blood samples were drawn during index PCI and at day 2. The blood was centrifuged immediately, and serum was frozen at −87°C. GLP-1 was measured with a standard ELISA-kit. All-cause mortality at short- (30 days), intermediate- (1 year) and long-term (6 years) follow-up was used for outcome assessment.

Results

In this study we found circulating GLP-1 to be markedly elevated in patients with myocardial infarction complicated by CS (n=172) at time of index PCI. Patients with fatal short-term outcome (n=70) exhibited higher GLP-1 levels (86 [45–130] pM) at ICU admission in comparison to patients with 30-day survival (48 [33–78] pM; p<0.001) (n=102). In repeated measures ANOVA the course of GLP-1 levels between baseline and day 2 showed a significant interaction between survivors and non-survivors (p=0.04). By univariate Cox-regression analysis GLP-1 levels >median were predictive of short- (hazard ratio [HR] 2.43; 95% confidence interval [CI] 1.50–3.94; p<0.001), intermediate- (HR 2.46; 95% CI 1.62–3.76; p<0.001) and long-term (HR 2.12; 95% CI 1.44–3.11; p<0.001) outcome. This association remained after multivariable correction (HR 2.01; 95% CI 1.37–3.07; p<0.001). In a landmark analysis we found a significant higher mortality in patients with GLP-1 levels >median from day 30 to 1 year (HR 2.56; 95% CI 1.08–6.09; p=0.03). In contrast, beyond 1 year up to 6 years no difference has been observed anymore (HR 1.02; 95% CI 0.41–2.58; p=0.96).

Conclusions

Elevated plasma levels of GLP-1 are an independent predictor for impaired prognosis in patients with myocardial infarction complicated by CS at short-, intermediate and long-term follow-up. In a landmark analysis this prognostic effect is sustained up to 1 year. The functional relevance of GLP-1 in this context is currently unknown and needs further investigations.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Research Foundation (DFG), German Heart Research Foundation
The in-hospital outcomes of the use of microaxial left ventricular assist device vs intra-aortic ballon pump in acute myocardial infarction complicated by cardiogenic shock
Authors: Jin C , Yang Y , Liu B
Published: November 2020

Purpose

To compare the outcomes of patients with AMI underwent percutaneous coronary intervention (PCI) complicated by cardiogenic shock treated with IABP vs MLVAD.

Methods

The Nationwide Inpatient Sample (NIS) database is the largest inpatient registry in the U.S. We used NIS year 2009–2014 to identify adult patients admitted for AMI, who received PCI and complicated by cardiogenic shock. Based on the use of IABP or MLVAD, the study population was divided into 2 groups. To reduce selection bias, we performed propensity score matching using Kernell method. Patient characteristics, hospital characteristics, and comorbidities were matched. Logistic regression was used for categorical variables including in-hospital mortality, requirement of blood transfusion, sepsis, cardiac arrest and cardiac complications (including iatrogenic complications, hemopericardium, and cardiac tamponade). Poisson regression was used for continuous variables including length of stay and total cost.

Results

A total of 49837 patients were identified. With propensity score match, 34132 patients in IABP group were matched to 1430 patients in MLVAD group. Compared with MLVAD group, the IABP group had lower in-hospital mortality rates (28.29% vs 40.36%, OR 0.58 (0.42–0.81), p=0.002), lower rate of blood transfusion (9.63% vs 11.50%, OR 0.49 (0.27–0.88), p=0.017), and lower cost (47167 vs 70429 USD, p<0.001). IABP and MLVAD group had similar length of stay (8.9 versus 9.3 days, p=0.882), rates of cardiac complication (6.50% vs 7.24%, OR 0.56 (0.26–1.19), p=0.134), rates of sepsis (9.30% vs 14.98%, OR 0.66 (0.38–1.14), p=0.133), and rates of cardiac arrest (37.84% vs 41.05%, OR 0.70 (0.45–1.10), p=0.123).

Conclusion

In patients with AMI underwent PCI and complicated by cardiogenic shock, MLAVD compared with IABP was associated with higher risk of in-hospital mortality, requirement of blood transfusion indicating presence of major bleeding complications, and cost, although study interpretation is limited by retrospective observational design. Further research is warranted to elucidate the optimal MCSD in these patients.

Funding Acknowledgement

Type of funding source: None
All cause 30 readmission in patients with history of sudden cardiac arrest
Authors: Mastoris I , Acharya P , Haglund N , Sauer A , Shah Z
Published: November 2020

Background

Sudden cardiac arrest (SCA) remains a significant cause of morbidity and mortality. Current evidence on readmission rates and causes after SCA are scarce.

Purpose

To describe patient characteristics, predictors of readmission and outcomes patients with history of sudden cardiac arrest and 30-day readmission

Methods

We analyzed the National Readmission Database for years 2016 and 2017 to identify all patients with initial diagnosis of SCA and 30 days readmission after the initial event. We analyzed baseline characteristics and looked into predictors, outcomes and diagnoses of re-admission.

Results

We identified 79,844 patients with an initial diagnosis of SCA that were discharged alive after index admission. Of those 14,387 (18.01%) had one readmission and 3,978 (4.99%) had more than one readmission. The mean age was 64 years and 41.3% were females. Hypertension, dyslipidemia, diabetes, CAD, CHF and CKD were present in 76.5%, 42.4%, 46.3%, 50.4%, 62.3% and 43.5% respectively. Overall mortality was 9.1% and length of stay 7.8 days. (Table 1). Congestive heart failure was the predominant diagnosis for readmission (Figure). Female sex (HR=0.93; p=0.004) was the only independent risk factor for all cause readmission.

Conclusions

Patients with history of SCA that have a 30-day readmission have significantly more comorbidities and length of day. Congestive heart failure is the predominant diagnosis for readmission

Funding Acknowledgement

Type of funding source: None
Heart failure in survivors of out-of-hospital cardiac arrest – factors associated with reduced systolic ventricular function at follow-up
Authors: Bahrami H.S.Z , Kjaergaard J , Thomsen J.H , Lippert F , Koeber L , Hassager C , Soeholm H
Published: November 2020

Background

Survival after out-of-hospital cardiac arrest (OHCA) has increased in recent years but is still only 10%. Little is known about the association between post-resuscitation comorbidity and heart failure after discharge from the initial OHCA-admission.

Purpose

In OHCA-survivors we aimed to describe predictors of left ventricular (LV) dysfunction, defined as LV ejection fraction (LVEF) <40%, at follow-up.

Methods

A consecutive cohort of OHCA-patients with cardiac cause from 2007 to 2011 without a pre-OHCA congestive heart failure diagnosis (according to the Danish National Patient Registry, which holds data on all Danish citizens) were retrospectively examined. Logistic regression analyses were used to assess factors associated with LV dysfunction (LVEF <40%) at follow-up after a median of 6 months. Follow-up was not performed systematically in the OHCA-survivors and data from follow-up was assessed by reading of patient charts.

Results

A total of 365 OHCA-survivors with a mean age of 61 years were discharged alive from hospital. LVEF <40% at hospital discharge was seen in 54% (n=184, 7% missing), and at follow-up after a median of 6 months 19% (n=69) of the total OHCA-cohort of survivors still had LV dysfunction. Factors associated with LV dysfunction at follow-up were chronic ischemic heart disease (IHD) prior to OHCA (odds ratio (OR) = 2.9 (95% CI: 1.2 – 7.1)) and ST-elevation myocardial infarction (STEMI) as cause of OHCA (OR = 2.9 (1.4–6.0)), whereas age, gender, high comorbidity burden prior to OHCA or pre-hospital circumstances (including shockable cardiac arrest rhythm) were not.

Conclusion

More than half of OHCA-survivors with LVEF <40% at hospital discharge improved LV function and LV dysfunction at follow-up after a median of 6 months after discharge was present in 1 in 5 (19%) of the cohort. Chronic IHD and STEMI were the only factors significantly associated with LV dysfunction at follow-up. A systematic follow-up including echocardiography in the outpatient clinic for OHCA-survivors is recommended especially in patients with reduced LV function at discharge and in STEMI-patients in order to assess the appropriateness of heart failure medication and an implantable cardiac defibrillator.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Danish Foundation Trygfonden
Long telomere length in circulating leukocytes is associated with monocytosis and poorer survival in patients with transcatheter aortic valve replacement
Authors: Hoffmann J , Tabata N , Mas-Peiro S , Spyridopoulos I , Sinning J.M , Nickenig G , Dimmeler S , Zeiher A.M , Vasa-Nicotera M
Published: November 2020

Background

Whiletranscatheter aortic valve replacement (TAVR) has become a standard treatment option in the management of patients with severe aortic stenosis and higher risk for cardiac surgery, occurrence of a systemic inflammatory response after TAVR limits patients' prognosis. Leukocyte telomere length (LTL) is an established marker of cellular senescence and longer telomeres are hallmarks of immune competence and inflammatory responsiveness of leukocyte subsets. In the present study, we assessed LTL and its impact on 2-year survival in patients (pts) following TAVR.

Methods and results

LTL was analyzed using quantitative real-time PCR in 285 consecutive pts (mean age 80.9 years, 49% male) undergoing TAVR and correlated with 2-year all-cause mortality (46 deaths, 16%). Kaplan-Meier survival curves showed that the highest compared to lowest tertile of LTL was associated with an increased rate of all-cause mortality (log rank p=0.03). Multivariate regression model revealed higher EuroSCORE 2 (HR: 1.03, 95% CI: 1.01–1.05; p=0.021) and long LTL (HR: 1.001, 95% CI: 1.001–1.001; p=0.023) to be independent predictors for 2-year mortality, after adjustment for clinical variables such as age, sex, cardiovascular risk factors, LVEF and renal function. When analyzing blood leukocyte subset composition, pts in the highest LTL tertile showed significantly higher levels of circulating neutrophils (p=0.011) and monocytes (p=0.011), whereas there was no significant correlation between LTL and lymphocyte counts (p=0.12).

Conclusion

In elderly patients with severe aortic valve stenosis, long leukocyte telomere length is associated with increased mortality after TAVR. This might be explained by enhanced immune competence and increased pro-inflammatory leukocyte function in these patients as indicated by significant monocytosis, which might drive systemic inflammatory response syndrome or chronic inflammation and limit the prognosis in TAVR patients.

Funding Acknowledgement

Type of funding source: None
Effects of bisphosphonate and calcium carbonate on normal aortic valve and cholecalciferol induced in vivo rabbit aortic stenosis model
Authors: Okutucu S , Sabanoglu C , Saglam Ayhan A , Tulumen E , Aksoy H , Oto A
Published: November 2020

Background

Calcific aortic valve disease (CAVD) is the most common valvular heart disease. Bisphosphonates are stable analogs of pyrophosphates and commonly prescribed in the treatment of osteoporosis. The effects of bisphosphonate treatment on CAVD are not clearly known and there are inconsistent results. Similarly, the effect of calcium supplementation on CAVD remains controversial.

Purpose

The aim of this study was to assess the effects of bisphosphonate therapy on the normal aortic valve and vitamin D induced in vivo rabbit aortic stenosis (AS) model.

Methods

The impact of calcium supplementation on the rabbit AS model was also evaluated. A total of 30 New Zealand white rabbits were divided into five equal groups: no treatment (Group I); 25,000 IU/day vitamin D3 (cholecalciferol) (Group II, rabbit AS model); 25,000 IU/day cholecalciferol plus 2500 mg/day calcium carbonate (Group III); 20 μg/kg/week intravenous alendronate (Group IV) and 25,000 IU/day cholecalciferol plus 2500 mg/day calcium carbonate plus 20μg/kg/week alendronate (Group V). Echocardiography was performed at baseline and after 12 weeks of treatment. The left ventricular mass index (LVMI), aortic valve area (AVA), transvalvular velocities and gradients were recorded. Radiologic and histopathologic examination was performed at the end of the 12th week. Control animals displayed no abnormalities of the aortic valve.

Results

There was no echocardiographic change in Group IV. In Groups II, III and V, there was a significant decrease in AVA and increases in transvalvular velocities and gradients. However, these stenotic changes were significantly prominent in Group V (p=0.001 for all, via repeated measures ANOVA). Moreover, LVMI was only increased in Group V (p<0.05). Calcification of aortic valvar complex was detected in 14 (46.7%) cases by radiologic imaging and 10 (33.3%) cases by histopathologic examination. Most frequent calcification was found in Group V (5 for each method, 83.3%). Agatston, volume and equivalent mass scores of calcific foci in Group V were significantly higher than other groups (p<0.05 for all). There was no significant difference between groups regarding with presence of osteoclasts in calcific foci.

Conclusion

Calcium supplementation has no effect on the in vivo rabbit AS model. Alendronate treatment aggravates the stenosis and increases the calcification in the rabbit AS model. Alendronate treatment has no effect on the normal valve in which there was no osteogenesis and osteoclastogenesis. Based on these findings, in patients with CAVD, alendronate treatment should be given with regular echocardiographic follow-up or may not be preferred.

Central figure

Funding Acknowledgement

Type of funding source: None
Predictors of adverse prognosis in patients with infective endocarditis in a surgical referral center
Authors: Scheggi V , Olivotto I , Ceschia N , Merilli I , Andrei V , Alterini B , Stefano P.L
Published: November 2020

Background

Despite optimal medical and surgical treatment, mortality in infective endocarditis (IE) remains high. Aim of this study was to identify predictors of long term mortality for any cause, adverse event rate, relapse rate and valvular dysfunction at follow-up, in a high-volume surgical center.

Methods

We retrospectively analyzed 358 consecutive patients (127 women) admitted to our department with definite diagnosis of IE not device-related. IE occurred on native valves in 224 patients (63%); the infection involved the aortic valve in 192 (54%), mitral valve in 139 (39%) and tricuspid valve in 26 (7%). Overall 285 (80%) patients underwent surgery and 73 (20%) were treated conservatively, 38 due to absence of surgical indication and 35 due to refusal or prohibitive surgical risk. Long-term follow-up was obtained by structured telephone interviews. Primary endpoints were all-cause mortality, freedom from recurrent endocarditis, postoperative incidence of major adverse events (hospitalization for any cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence), worsening of left ventricular ejection fraction (LVEF) and valvular dysfunction.

Results

Mean age was 65 years (SD 15.2). Mean vegetation length was 8.9 mm (SD 7.6). Endocarditis was left-sided in 332 (93%). Average follow-up was 6 months. At univariable analysis, mortality was associated with female gender (p=0.031), age (p<0.001), higher EuroSCORE 2 (p<0.001), chronic renal failure (p<0.001), diabetes (p=0.002), brain embolism on presentation (p=0.05), double valve infection (p=0.008), low ejection fraction (p<0.001), paravalvular extension (p=0.031), prosthetic infection (p=0.018), exclusion from surgery if indicated (p<0.001), high procalcitonin levels (p=0.035); factors associated with a significantly lower mortality were streptococcal infection (p=0.04; OR 0.34) and early surgery (p=0.009, OR 0.55). At multivariable analysis independent predictors of all-cause mortality were lower EF, EuroSCORE2, procalcitonin levels and diabetes. Non-fatal adverse events were associated with renal failure (p 0.035, OR 2.8). Relapse rate was associated with S aureus infection (p=0.005, OR 3.8), right-sided endocarditis (p<0.001, OR 6.7) and drug abuse (p<0.001, OR 9.4).

Conclusions

The present study shows that low EF, EuroSCORE2, procalcitonin levels and diabetes are independent predictors of death in patients with IE. Non-fatal adverse events are more frequent in patients with renal failure. Relapse rate is higher in drug abusers. These informations may help personalize follow-up strategies after acute admission for IE.

Funding Acknowledgement

Type of funding source: None
Proof of concept study on the utility of integrated transthoracic and transesophageal echocardiography aortic stenosis assessment
Authors: Schwartzenberg S , Sagie A , Kazum S , Yedidya I , Monakier D , Ofek H , Vaturi M , Kornowski R , Shapira Y
Published: November 2020

Background

Integrated echo method (IEM) combining transthoracic and transesophageal echocardiography (TTE/TEE) data can provide accurate aortic stenosis (AS) assessment. Our objectives were to evaluate the impact of IEM classification on mortality in AS patients.

Methods

Between 2016–2017, 63 out of 81 consecutive patients with at least moderate AS underwent comprehensive sequential TTE and TEE. AS types were determined by TTE and IEM (utilizing TEE planimetry of left ventricular outflow tract and highest Doppler spectral signals from both TTE and TEE). Based on conservative vs actionable implication, AS types were dichotomized into Group A, comprising moderate and Normal-Flow Low-Gradient (NFLG), and Group B, comprising High-Gradient (HG), Low ejection fraction Low-Flow Low-Gradient (Low EF LFLG), and Paradoxical Low-Flow Low-Gradient (PLFLG) AS. Survival under medical therapy was determined.

Results

Dichotomous classification was discordant in 15.9% of the patients with the two methods, with a relative risk of 1.55 of A to B Group re-classification with IEM (p<0.001). The optimal cut-off value of TTE-determined AVA for AS classification was 0.82 cm2 (75% sensitivity and 87% specificity) vs an IEM-determined optimal AVA cut-off value of 0.92 cm2 (84.4% sensitivity and 76% specificity). During a median time of 9 months (quartiles 2.4–22 months) of follow-up under medical treatment, Group B patients had a worse survival under medical therapy than Group A patients, with additional independent prognostic value for Group A/B dichotomization by IEM in Group A (non-actionable) TTE-defined patients after multivariable adjustment (hazard ratio 5.3, confidence interval 1.39–20.3, p value=0.015).

Conclusions

IEM in patients with ambiguous AS severity can improve detection of patients who may benefit from early invasive therapy.

Graphical Abstract

Funding Acknowledgement

Type of funding source: None
Impact of pericoronary inflammation assessed by coronary computed tomography angiography on the progression of aortic valve calcification
Authors: Misawa T , Sugiyama T , Kanaji Y , Hoshino M , Yamaguchi M , Hada M , Sumino Y , Ueno H , Nogami K , Kakuta T
Published: November 2020

Background

Aortic valve calcification (AVC) has been known as an independent predictor for adverse cardiovascular events and all-cause mortality. Previous studies demonstrated that AVC was associated with aortic valve inflammation and atherosclerosis. However, the relationship between the progression of AVC and pericoronary inflammation remains undetermined.

Purpose

The purpose of this study was to evaluate the impact of the pericoronary inflammation on the progression of AVC.

Methods

A total of 107 patients with suspected or known chronic coronary syndromes who underwent clinically indicated serial 320-slice coronary computed tomography angiography (CTA) at Tsuchiura Kyodo General Hospital from January 2011 to June 2019 were retrospectively studied. Pericoronary inflammation was assessed by pericoronary adipose tissue attenuation (PCATA) defined as the mean CT attenuation value of PCATA (−190 to −30 Hounsfield units [HU]) on proximal 40 mm segments of coronary arteries. AVC was quantified by Agatston score on CTA. The mean aortic attenuation (HU Aorta) and the standard deviation (SD) in the region of interest at the level of the sinotubular junction was measured. AVC was defined as the threshold for calcium detection (mean HU Aorta + 2SD). AVC index was calculated as follows: (follow-up/baseline) AVC divided by follow-up period. AVC progression was defined as newly-developed AVC at follow-up or an increased AVC index during follow-up. All patients were divided into two groups according to the presence or absence of AVC progression, and clinical characteristics and CT findings were compared between these two groups.

Results

AVC progression was observed in 26 patients (24.3%) between 2 serial CT examinations (median, 34 months). There was no significant difference in age, gender and the prevalence of other cardiovascular risk factors between the 2 groups. Patients in AVC progression group were associated with higher prevalence of elevated PCATA-LAD, higher LV mass index at baseline and the initial AVC presence. Receiver-operating characteristic curve analysis revealed that the optimal cut off value of PCATA-LAD for predicting AVC progression was −68.26 HU (area under the curve 0.605; 95% confidence interval [CI], 0.465–0.745). Multivariable logistic regression analysis revealed that baseline PCATA-LAD ≥−68.26 HU (odds ratio [OR], 3.12; 95% CI, 1.04–9.35, p=0.042) and the presence of baseline positive AVC (OR, 6.84; 95% CI, 2.34–20.0, p=0.0004) were independent predictors of AVC progression.

Conclusions

The increased pericoronary inflammation and the presence of AVC may help identify patients with high risk for future AVC progression.

Funding Acknowledgement

Type of funding source: None
Mechanism of transcatheter heart valve deployment for right ventricular outflow tract insufficiency after surgical reconstruction in childhood as assessed with intravascular ultrasound
Authors: Kalinczuk L , Rynkiewicz K , Skotarczak W , Mintz G.S , Zielinski K , Swierczewski M , Michalowska I , Biernacka K , Ruzyllo W , Demkow M
Published: November 2020

Introduction

Transcatheter heart valve (THV) deployment can be used to treat right ventricular outflow tract (RVOT) insufficiency.

Purpose

To study deployment mechanism of a balloon expandable THV (Melody or Edwards SAPIEN [ES] 3) implanted for pulmonary homograft insufficiency using intravascular ultrasound (IVUS) with Visions PV.035 Digital Catheter (Philips) offering an imaging field of 60mm.

Methods

Sequential (baseline and post-THV) IVUS was performed in 6 pts (median age 33 [20–44] yrs, 3 ♀, all with Tetralogy of Fallot) who had undergone prior corrective surgery (4 transannular patch, 1 bioprosthetic valve or 1 pulmonary homograft), but who presented with significant RVOT insufficiency. IVUS-visualized homograft cross-sections were perpendicular to its long axis and were obtained along the entire homograft length (Fig. 1). Volumetric measurements included the native pulmonary homograft (inner lumen and outer dimension) and the corresponding inner-stent/inner-THV cross-sections post-THV for a total of 16 evenly spaced cross-sections per analyzed region. Each THV (1 Melody [Ø 22mm, 28mm nominal length] and 5 ES3 [Ø 23mm, 18mm height; 4 Ø 29mm, 22.5mm height]) was implanted after pre-stenting using stents of 36, 39, or 48mm length, deployed on a 24mm (n=1) or 30mm (n=4) balloon-in-balloon catheter.

Results

Overall, there were 96 paired cross-sections. There was significant increase in average lumen dimension after THV deployment (Δ of 97.5mm2) accompanied by the similar increase in outer pulmonary homograft dimensions (Δ of 84.0mm2) (Table 1). Whereas the maximal lumen diameter was unchanged, the minimal lumen diameter increased significantly resulting in substantial decrease in the ratio of max/min lumen diameter of 1.41±0.20 vs 1.16±0.13 (p<0.001) representing a reduction in lumen eccentricity.

Conclusions

During balloon-expandable THV implantation to treat RVOT insufficiency, there is a significant increase in baseline lumen dimensions accompanied by a substantial outer RVOT dimension increase to normalize lumen eccentricity.

Figure 1. IVUS intraprocedural visualisation

Funding Acknowledgement

Type of funding source: None
Pressure constrained mitral annular dysfunction determines severity of regurgitation in Barlow's disease – a 3D echocardiographic study
Authors: Dumont K.A , Persson R , Kvitting J.P , Lundblad R , Haaverstad R , Fiane A , Urheim S
Published: November 2020

Background

Barlow's disease provides both diagnostic and therapeutic challenges. The impact of systemic blood-pressure on severity of regurgitation is still unclear.

Purpose

We hypothesized that mitral annulus behaves passively with enlargement during ventricular systole, and secondly, we tested the hypothesis that severity of regurgitation correlates to systemic blood-pressure (BP) of the patient.

Methods

Ten patients with Barlow's disease were compared with 10 healthy controls. Brachial blood-pressure was measured according to guidelines. Transthoracic 3D echo was obtained from an apical view (38.6±8.2 frames per second). Data was analyzed using a holographic display. We measured commissure width (CW), septallateral length (SL) and mitral annular surface area throughout the cardiac cycle. Aortic flow ejection time was derived from continuous Doppler across the aortic valve. Timing of aortic valve closure was visually assessed by 3D echo. Onset and end of mitral regurgitation was derived from continuous wave Doppler of transmitral flow.

Results

Systolic BP in controls and patients were 122±5 and 133±12 mmHg, respectively (p<0.05). Enddiastolic volume was 87±7 ml/m2 (controls) and 100±14 ml/m2 (Barlow), p<0.02. Left ventricular EF in controls and patients were 59±5 and 62±5%, respectively, p=NS. Barlow patients had moderate or severe late systolic regurgitation with mean regurgitation volume of 51±18 ml. Annular surface area, CW and SL behaved passively with enlargement during ventricular systole (Figure 1). Peak systolic surface area, CW and SL in healthy controls and Barlow patients were 8.7±0.5 vs 20.7±3.2 cm2 (p<0.001), 30.1±1.5 vs 49.5±4.9 mm (p<0.001) and 30.9±1.5 vs 44.9±3.3 mm (p<0.001). Peak annular surface area and regurgitation volume in patients showed a positive correlation with systolic BP (y = 0.156x − 0.077, r=0.60 and y = 1.136x − 99.7, r=0.80, respectively).

Conclusions

We have demonstrated pressure constrained mitral annular dysfunction in Barlow's disease, indicating that systemic blood pressure may modify the severity of regurgitation. The study provides novel insights into mechanisms of mitral regurgitation and potential therapeutic actions in the future.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Grieg Foundation
Transcatheter echo guided mitral valve repair with neochord implantation for posterior leaflet disease
Authors: Mahia P , Cobiella J , Enriquez D , Carnero M , Maroto L , Perez De Isla L , Macaya C
Published: November 2020

Background/Introduction

Transapical off-pump mitral valve repair with NeoChord implantation (TOP-MINI) has become applied for patients presenting with severe mitral regurgitation (MR) due to posterior leaflet (PML) prolapse or flail. The procedure is performed under real-time 2D- and 3D-transesophageal echocardiography for both implantation and neochordae tension adjustment allowing real-time monitoring of hemodynamic recovery.

Purpose

This prospective study sought to evaluate acute safety and efficacy of this innovative, minimally invasive, transcatheter mitral valve repair approach.

Methods

33 symptomatic patients patients with severe MR secondary to PML flail/prolapse (March 2017-Dec 2019) were included. Patients were stratified on the basis of the preoperative 3D transesophageal echocardiography assessment of MV morphology: type A, isolated central PML prolapse/flail (25 patients); type B, posterior multisegment prolapse/flail (3 patients); type C and D, anterior or bileaflet prolapse/flail or paracommissural prolapse/flail or any type of disease with the presence of significant leaflet/annular calcifications (5 patients). Type A was considered the more favorable morphology.

Results

Median age was 67.7±13.4 y. Median EuroSCORE-II 2.7%±1.91. Procedural success was achieved in 28 patients (84,9%). 5 patients, 2 type A and 3 type D, underwent conversion to open surgery for immediate failure. The median number of chords implanted was 3.1±0.6. 1 high-risk patient considered inoperable because of severe comorbidities and extensive annular calcifications died before discharge. Postoperative length of stay was 4.25±1 days. At 12.3±4.9 months median follow-up, MR≤moderate was present in 25 (90%). Overall 1-year survival was 100%. Freedom from reintervention was 97% for overall population. Transthoracic echocardiography at 1 year revealed ventricular reverse remodeling, with a significant decrease in indexed left ventricular end- end-systolic volumes (25.3±6.4 to 21.6±8.2 mL/m2, P<0.001). 92.9% were in New York Heart Association class I.

Conclusions

TOP-MINI procedure is a feasible, low-risk technique that allows safely repair degenerative mitral valve failure secondary to prolapse/flail valvular and its efficacy is maintained up to 1-year.

Funding Acknowledgement

Type of funding source: None
Transcatheter versus surgical aortic valve replacement: an updated systematic review and meta-analysis with a focus on outcomes by sex
Authors: Dagan M , Yeung T , Stehli J , Stub D , Walton A.S , Duffy S.J
Published: November 2020

Background and purpose

Women at increased surgical risk have been shown to have better outcomes with transcatheter aortic valve implantation (TAVI) as compared to surgical valve replacement (SAVR). With the scope of TAVI moving into low-surgical risk patients we aimed to update the current literature to include the new low-risk randomized controlled trial data in investigating outcomes by sex.

Methods

We systematically searched MedlineOVID, PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and reference lists for relevant randomised controlled trials (RCTs) comparing TAVI to SAVR published prior to October 7th 2019. Data extraction was performed by two independent authors and included trial design details, baseline characteristics and outcome data stratified by sex. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Quantitative synthesis of pooled data was performed using Mantel-Haenszel fixed or random effects model. Q-statistic and the I2 test were used for assessment of heterogeneity.

Results

Our search yielded eight RCTs included in the final quantitative synthesis. The overall pooled cohort was 8,040, of whom 41.4% were female. Women had significantly lower rates of one-year all-cause mortality and one-year composite endpoint with TAVI as compared to SAVR. The selective mortality benefit with TAVI over SAVR in women did not persist to five-years. At 30-days, women demonstrated lower rates of major bleeding and acute kidney injury following TAVI compared to SAVR. For men, these outcomes were similar regardless of type of intervention. Both sexes were at increased risk of major vascular complications with TAVI as compared to SAVR, however women demonstrated nearly double the odds of major vascular complication with TAVI compared to men.

Conclusion

Our updated meta-analysis demonstrates that at one-year women undergoing TAVI have significantly lower mortality and better safety outcomes compared to those undergoing SAVR. These benefits are not seen in men. In the new low-risk era, these results are ever more important for guiding appropriate patient selection.

Composite endpoint at one-year

Funding Acknowledgement

Type of funding source: None
Doppler echocardiographic predictors of low mitral valve area after implantation of one MitraClip: time for a paradigm shift?
Authors: Kassar M , Brugger N , Seiler C , Windecker S , Praz F
Published: November 2020

Introduction

During edge-to-edge therapy using MitraClip (MC) for severe mitral regurgitation (MR) the interventional cardiologists usually rely on the mean transmitral gradient to decide if they “go for” a second clip in case of suboptimal MR reduction or to stabilise the first MC in the context of prolapse or flail leaflet. The value of this parameter to detect low mitral valve area (MVA) is unknown.

Method

During each intervention of the last two years, high quality volumes focused on the MV were acquired. Using a dedicated 3-D analysis software and a new planimetry method, we measured the MVA before and after the implantation of one MC (each orifice was evaluate independently on the most optimal plane). The usual transmitral CW-Doppler parameters (mean gradient (MG), VTI, PHT) were evaluated.

Results

We included 120 patients, 69 primary (PMR) and 51 secondary (SMR) mitral regurgitation. For all the parameters, the best model for the curve fitting was y = a + b / x and the two parameters who best correlated with the MVA after MC were PHT (R2 0.67, p=0.0001) and MG (R2 0.28, p. 0001). Looking at SMR, the correlation with PHT was even better but there was no correlation with MG. In PMR, the correlation with MG was good but still lower than with PHT (Figure 1). The ROC analysis for PHT showed an AUC of 0.948 and defined an optimal cut-off of 127ms with sensibility and specificity 91% to detect a MVA <2 cm2 after one MC.

Conclusion

The transmitral MG appears as a poor parameter to predict low MVA after the implantation of one MC, especially in SMR probably because in this population the MG depends more on the flow than on the MVA. In the contrary PHT appears as a robust parameter.

Figure 1

Funding Acknowledgement

Type of funding source: None
Relative apical sparing in patients with severe aortic stenosis: prevalence and significance
Authors: Abecasis J , Mendes G , Ferreira A , Andrade M.J , Ribeiras R , Ramos S , Masci P.G , Gil V
Published: November 2020

Relative apical sparing (RAS) of LV longitudinal strain (LS) is a red flag for diagnostic suspicion of amyloid cardiomyopathy (AC). However, it may present in pts with aortic stenosis (AS), where the prevalence of transthyretin AC is being increasingly reported.

Aim

To describe the prevalence of RAS deformation pattern in patients with AS and its clinical significance.

Methods

We prospectively studied 53 pts (71±8y, 54.7% men) with severe symptomatic AS - mean gradient (AVM): 54.6 mmHg; aortic valve area 0.74cm2, referred for surgical replacement with no previous history of ischemic cardiomyopathy. Beyond ECG and transthoracic echo (TTE), all pts underwent CMR, with tissue characterization before surgery. RAS was defined as average apical LS / average basal LS + average mid LS >1 at 2D LV LS analysis. Aortic valve replacement and septal myocardial biopsy were already performed in 26 pts. AS severity indexes, LV remodelling and tissue characterization were compared in both groups, with and without RAS.

Results

RAS was present in 16 pts (30.8%). There were neither pseudoinfarct pattern or low voltage at ECG, nor infiltration suspicion from CMR study (native T1 value 1047ms [IQR 1028–1084]; ECV 22% [IQR 18–25]). Furthermore, none of the pts had suspicion of amyloid deposition at histopathology. Median CMR LVEF was 64.5% [IQR 51.3–70.8%] and 36 pts (67.9%) had non-ischemic DE, with a median fraction of 6.0% [IQR 4.9–12.7%] of LV mass. Comparing both groups, RAS cohort showed a significantly higher AVM, relative wall thickness, maximum septal thickness, peak systolic dispersion and higher LV indexed mass, DE and lower LVEF at CMR. RAS group has also higher NT pro BNP (Table).

Conclusions

RAS is common in this group of pts despite the absence of clinical and histological signs of myocardial infiltration. RAS occurs with worse indexes of LV remodeling and fibrosis consistent with a more advanced stage of the disease.

Funding Acknowledgement

Type of funding source: None
Recommendations on echocardiography following surgical aortic valve replacement (SAVR): time for revision?
Authors: Schmiegelow M , Bruun N.E , Carranza C.L , Dahl J , Elming H , Kober L , Sibilitz K , Torp-Pedersen C.L , Schmiegelow S.S
Published: November 2020

Background

ESC guidelines recommend annual echocardiographic evaluation following biological surgical aortic valve replacement (SAVR), and 5 years following mechanical SAVR. Conversely, increased life expectancy result in increasing demand on health care resources.

Purpose

To assess aortic reintervention rates at 1-year, 3-year and 5-year following biological and mechanical SAVR in relation to estimated echocardiographic controls.

Methods

From the nationwide Danish Register of Surgical Procedures, we identified all patients ≥40 years with isolated biological or mechanical SAVR +/− concomitant coronary artery bypass graft surgery (CABG) during 2000–2016. In 90-day reintervention-free survivors we assessed aortic valve reintervention rates at 1-year, 3-years and 5-years until December 31st, 2017. We further assessed cumulative risk of reintervention by age (<60, 60–69, 70–79, ≥80 years at SAVR) accounting for the competing risk of death during the study period.

Results

The population of 90-day reintervention-free survivors included 10,526 patients with biological SAVR (CABG 39.7%) and 3,677 patients with mechanical SAVR (CABG 23.8%). Reintervention rates at 1-year, 3-years and 5-years were comparable across type of SAVR, and generally low (Figure). Accounting for the competing risk of death, reintervention rates at 5-years were 1.4% (95% CI 1.1–1.6) for biological SAVR and 1.5% (95% CI 1.1–1.9) for mechanical SAVR, respectively. In age-stratified competing risk analyses, we observed the highest rates in patients aged 40–59 years (4% [95% CI 1.8–6] at 5 years for biological SAVR, and 2% [95% CI 1.3–3] for mechanical SAVR). Following biological SAVR, annual echocardiographic controls would yield a total of 34,516 scans in our population in the first 5 years following surgery. This contrasts to a total of 66 reinterventions following biological SAVR in our population between years 1–5 of which the majority was preceded by a hospital admission with a primary diagnosis of endocarditis within the last 90 days prior to the reintervention; which are unlikely to have been diagnosed at the annual assessment scan.

Conclusion(s)

In this nationwide study, reintervention rates following biological or mechanical SAVR were very low within the first five years after surgery suggesting a discrepancy between ESC recommendations on echocardiographic controls following SAVR, the benefit for patients, and the associated resource burden on the health care system.

Figure 1

Funding Acknowledgement

Type of funding source: None
Novel staging classification of primary mitral regurgitation based on the presence of cardiac damage
Authors: Van Wijngaarden A.L , Hiemstra Y.L , Van Der Bijl P , Delgado V , Ajmone Marsan N , Bax J.J
Published: November 2020

Background

The indication for surgery in patients with severe primary mitral regurgitation (MR) is currently based on the presence of symptoms, left ventricular (LV) dilatation and dysfunction, atrial fibrillation and pulmonary hypertension. The aim of this study was to evaluate the prognostic impact of a new staging classification based on cardiac damage including the known risk factors but also including global longitudinal strain (GLS), severe left atrial (LA) dilatation and right ventricular (RV) dysfunction.

Methods

In total 614 patients who underwent surgery for severe primary MR with available baseline transthoracic echocardiograms were included. Patients were classified according to the extent of cardiac damage (Figure): Stage 0-no cardiac damage, Stage 1-LV damage, Stage 2-LA damage, Stage 3-pulmonary vasculature or tricuspid valve damage and Stage 4-RV damage. Patients were followed for all-cause mortality.

Results

Based on the proposed classification, 172 (28%) patients were classified as Stage 0, 102 (17%) as Stage 1, 134 (21%) as Stage 2, 135 (22%) as Stage 3 and 71 (11%) as Stage 4. The more advanced the stage, the older the patients were with worse kidney function, more symptoms and higher EuroScore. Kaplan-Meier curve analysis revealed that patients with more advanced stages of cardiac damage had a significantly worse survival (log-rank chi-square 35.2; p<0.001) (Figure). On multivariable analysis, age, male, chronic obstructive pulmonary disease, kidney function, and stage of cardiac damage were independently associated with all-cause mortality. For each stage increase, a 22% higher risk for all-cause mortality was observed (95% CI: 1.064–1.395; p=0.004).

Conclusion

In patients with severe primary MR, a novel staging classification based on the extent of cardiac damage, may help refining risk stratification, particularly including also GLS, LA dilatation and RV dysfunction in the assessment.

Funding Acknowledgement

Type of funding source: None
Advanced pathologic study for definite diagnosis of mitochondrial cardiomyopathy
Authors: Takeda A , Murayama K , Okazaki Y , Imai-Okazaki A , Ohtake A , Takakuwa E , Yamazawa H , Izumi G , Abe J , Nagai A , Taniguchi K , Sasaki D , Tsujioka T , Basgen J
Published: November 2020

Mitochondrial cardiomyopathy (MCM) is usually recognized as one of the phenotypes of systemic mitochondrial disease. However if there are no cardiac symptoms, it is difficult to make a definite diagnosis because of various cardiovascular phenotypes and no diagnostic criteria in pathological examination. To add myocardial pathology to the diagnostic criteria for mitochondrial respiratory chain disorders, which is the gold standard in the diagnosis of mitochondrial diseases, we performed quantitative analysis of mitochondria using electron microscopy and immunohistopathologic analysis with respiratory chain enzyme antibodies. Ten patients with hypertrophic or restrictive cardiomyopathy who had undergone endomyocardial biopsy were studied. Respiratory chain enzymatic assay and genetic study were performed and four patients were diagnosed with MCM. Using electron microscopy with quantitative analysis, volume density of mitochondria within cardiac muscle cells was significantly increased in the MCM group compared to the non-MCM group (p=0.013). Immunohistopathologic results were compatible with the result of the respiratory chain enzymatic assay. These advanced pathological tests can distinguish MCM from other cardiomyopathies.

Results of immunopathologic study

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Practical Research Project for Rare/Intractable Diseases from the Japan Agency for Medical Research and Development, AMED.
Exploring the phenotypic spectrum of desmoplakin cardiomyopathy
Authors: Protonotarios A , Cannie D , Akhtar M , Savvatis K , Sekhri N , Mohiddin S , Lopes L , Syrris P , Elliott P.M
Published: November 2020

Introduction

Desmoplakin (DSP) gene mutations are reported to cause arrhythmogenic right ventricular cardiomyopathy (ARVC), but recent evidence suggests that they manifest as a much broader range of phenotypes.

Purpose

To describe the phenotypic characteristics of DSP mutation carriers in a consecutive cohort of patients with heart muscle disease.

Methods

A retrospective analysis of consecutive patients with heart muscle disease and their relatives that underwent diagnostic or research genetic testing. Only DSP variants classified as pathogenic by the American College of Medical Genetics and Genomics criteria were considered. Dilated cardiomyopathy (DCM), hypokinetic non-dilated cardiomyopathy (HNDC) and ARVC were diagnosed in accordance with current criteria.

Results

109 mutation carriers were identified: 34 (31%) had DCM and 23 (21%) HNDC. ARVC diagnosis was borderline and definite in 39 (36%) and 39 (36%) individuals, respectively. Sixteen (15%) presented with clinically suspected myocarditis. 23 patients met both definite AC and DCM criteria and 13 patients met definite AC and HNDC criteria. In 87 patients with cardiac magnetic resonance imaging, a spectrum of disease was observed (Table) including an intermediate phenotype characterised by subepicardial LV fibrosis in the absence of ventricular dilatation or dysfunction. Ventricular dysfunction was manifest as left dominant disease (n=22, 48%) and biventricular disease (n=24, 52%); none had right dominant disease.

Conclusions

DSP mutations are associated with left and biventricular phenotypes and can present as myocarditis. Current ARVC and DCM diagnostic criteria inadequately describe the clinical subtypes of DSP related disease. A novel approach to disease classification is proposed.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation