bluuebunny/crossref_metadata_2025 huggingface dataset:
Multi-dimensional assessment of long-term outcomes in patients treated with extracorporeal cardiopulmonary resuscitation during refractory cardiac arrest
Authors: Thevathasan T , Voss F , Wahl V , Kenny M A , Selzer S , Al Harbi A S , Boettel J , Paul J , Dorsch E M , Audebert H , Landmesser U , Westenfeld R , Skurk C
Published: October 2024

Background

Recent randomised controlled trials showed short-term survival benefits with extracorporeal cardiopulmonary resuscitation (ECPR) compared to standard cardiac arrest treatment in selected patients with refractory cardiac arrest. Only limited data exist on multi-dimensional long-term outcomes after ECPR.

Purpose

To investigate multi-dimensional long-term outcomes of ECPR survivors, that is general health status, as well as cardiac, cognitive and psychological functions.

Methods

This is a multicenter, mixed-method clinical study conducted by cardiologists, neurologists and psychologists between May 2021 and December 2023. Adult patients who survived ECPR with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or "ECMELLA" (i.e., VA-ECMO plus percutaneous left-ventricular assist device) in two German tertiary care centers were included. A comprehensive set of functional outcomes across multiple dimensions were assessed at approximately 18 months after the index cardiac arrest event (see Figure for stations A to E and explanation of abbreviations).

Results

Long-term outcomes were assessed in 32 ECPR survivors, out of whom 15 patients (46%) had received VA-ECMO and 18 (54%) ECMELLA treatment. 23 patients (70%) were male and the average age was 55 years (±13). Vital signs and laboratory markers were unremarkable. Most patients denied heart failure symptoms although the average EQ-5D-5L score was 52 (±8). The left-ventricular ejection fraction was 51% (±9), which improved by 14% (±11) in the ECMO group and 31% (±15) in the ECMELLA group since the index cardiac arrest event. Bicycle exercise (on average 6 minutes duration with a power of up to 100 Watts) and 6-minute walk test (average distance of 394 meters ±145) revealed physical impairments. 29 patients (88%) had a good cerebral performance (i.e., Cerebral Performance Category scale of 1) and the average mental status was good (mini–mental state examination score 29 ±1). 22 patients (56%) perceived (partial) impairments in activities of daily living although the average Barthel index was 100 (±5) and modified Rankin scale was 1 (±1). 12 patients (36%) were unable to return to their jobs. Remarkably, 17 (51%) and 4 (12%) patients reported depressive symptoms and suicidal thoughts, respectively.

Conclusion

Although ECPR remains a highly complex procedure, cardiac and neurologic functions in survivors have almost recovered, while physical and psychological impairments still persisted at 18 months after cardiac arrest. Physical rehabilitation and psychological care appear to be important measures for ECPR survivors.
Increased miRNA-related inflammation markers and pro-inflammatory circulating cell profile in patients with poor neurological outcome after out-of-hospital cardiac arrest
Authors: Jimenez Trinidad F , Moreno E , Roca C , De Diego O , Lopez T , Izquierdo M , Tecero A , Gaig C , Sabater L , Freixa X , Dantas A P , Andrea R
Published: October 2024

Background

Out-of-Hospital Cardiac Arrest (OHCA) supposes a main cause of disability and mortality worldwide. Between patients suffering OHCA, only a 10-20% can be successfully resuscitated and, between them, a 50% suffers of neurological sequelae. Mechanisms underlying brain damage seems to be strongly related with neuroinflammation, mediated by classical (PCR, NLR) and novel (miRNAs) agents at play. Even there are studies suggesting the relevance of miRNA-mediated inflammatory response in ECA, no consistent conclusions about its role in ECA outcomes have been obtained.

Purpose

The aim of the present investigation is to study the temporal patterns of classical (PCR, NLR) and novel (miRNAs) inflammation markers during hospitalization of ECA patients and to correlate them with neurological outcome.

Methods

Consecutive OHCA patients were prospectively recruited at the Acute Cardiac Care Unit (ACCU) of the hospital Clinic of Barcelona from March 2019 to December 2023. Serum samples were obtained at 0, 24 and 72 hours after hospital admission. Patients were grouped according to their neurological outcome, measured by Cerebral Performance Category (CPC), at hospital discharge. Classical inflammation markers (PCR and NLR) were measured and in silico pre-targeted serum circulating-miRNAs were analysed by qPCR.

Results

A total of 120 patients (60 ± 13 years, 20% female) were included for the analysis. At hospital discharge, 55 (45%) patients survived with good NO (GNO; CPC 1-2) and 65 (55%) patients presented a poor NO (PNO; CPC 3-5). Classical inflammation markers such as PCR and NLR were significant higher in PNO than in GNO Group (P-value = 0.0042 and p-ANOVA = 0.0444, respectively) (Figure 1A). 11 inflammation-related miRNAs with strong correlation with OHCA-related conditions such as cardiovascular and coronary artery disease, hypoxic encephalopathy and neuro-inflammation were pre-targeted by in silico analysis. Five of the pre-targetedmiRNAs (miR-21-5p, miR-23a-3p, miR-146-5p, miR-155-5p and miR-181a-5p) presented significant differences between GNO and PNO groups (p-ANOVA = 0.0001, 0.0027, 0.0001, 0.0023 and 0.0002 respectively) in at least one time point, with an reduced expression in all cases in the PNO respect the GNO group (Figure 1B).

Conclusions

Patients with PNO after OHCA presents a downregulation of inflammation-regulatory miRNAs that leads an increase of clinical inflammation-related mediators such as PCR and NLR, with potential neuro-inflammatory consequences.
CT-perfusion quantitation of cardiac infarct size - a novel technique
Authors: Ho K T , Loh W T , Zainuddin N , Lai C
Published: October 2024

Introduction

Cardiac infarct size is associated with cardiac prognosis after AMI. Cardiac CT is able to delineate both coronary anatomy and myocardial pefusion. Thus far, CT identification of infarction has been qualitative. We describe a novel technique for quantitation of myocardial infarct size in CT-perfusion imaging.

Methods

Patient Population comprised 51 patients that were previously clinically diagnosed with myocardial infarction on the basis of clinical presentation, ECG findings and elevated cardiac enzymes.

CTP Imaging

All patients had undergone dynamic rest, vasodilator-stress, rest, delayed enhancement CT perfusion imaging performed on a dual-source, third generation scanner (FORCE, Siemens Healthcare).

Image Analysis

2 trained investigators independently quantified the infarct volume in 51 patient studies using Siemens SmartSimulator software.

Mean ± SD HU were taken from a 1cm² circular ROI of normal myocardium used in a thresholding method. The epicardium and endocardium of infarcted areas were manually contoured from apex to base. Volumetric measurements were obtained of the infarct and total myocardium. Interpolation of contours for segmentation objects was performed. Subtraction of left ventricle cavity from total left ventricle allowed volumetric measurements of total left ventricular myocardium.

ROIs of the infarct were estimated using SDs above mean HU of normal myocardium (0.5, 1, 1.5 and 2 SDs) in delayed imaging. Selection of optimal threshold HU was based on visual assessment that best mapped the hyperenhanced infarct area. This allowed volumetric asessment of infarct and total myocardium.

Inter-investigator variability was evaluated with Bland-Altman and Intra-Class Correlation Coefficient (ICC).

Results

Patient characteristics are follow: Age 60.20±11.35 years, 41(89%)male, BMI 25.41±4.17kg/m², Hypertension 23(50%), diabetes 10(22%), hyperlipidemia 40(87%), smoking 7(15%), family history of premature CAD 4(8.7%), previous PCI 45(97.8%).

In 51 patients, 23(41%), 24 (46%) & 5(10%) of the infarctions were quantitated as being medium-sized (10%-20%), large (20% -30%) and very large (>30%). Thirty-seven (70%), 6 (11%) & 10(19%) involved the LAD, LCx and RCA territories respectively. 49 (94%) of infarctions were transmural.

Identical thresholding was selected by both investigators for each SD above mean (mean 1.42; SD 0.46). 93% of the total cases were within a set threshold of 1 to 2 SDs above the mean HU for both. Interclass correlation coefficient was 0.95, CI range 0.90 – 0.97. Bland-Altman analysis did not demonstrate systemic variations or proportional bias from the plot.

Conclusion

The study suggests that a method of quantifying cardiac infarct size using a threshold technique and delayed hyperenhancement images with dynamic perfusion imaging is clinically feasible and consistent.Rest-Stress-Delayed Enhancement infarct
Epicardial adipose tissue volumes for long-term risk stratification in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement
Authors: Schulz A , Beuthner B E , Boettinger Z M , Gersch S S , Lange T , Gronwald J , Evertz R , Backhaus S J , Kowallick J T , Hasenfuss G , Schuster A
Published: October 2024

Background

Accurate risk stratification is important to improve patient selection and outcome of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). As epicardial adipose tissue (EAT) is discussed to be involved in cardiovascular disease, it could be useful as a marker of poor prognosis in patients with severe AS undergoing TAVR.

Purpose

We hypothesized that EAT impacts long-term outcome of patients with severe AS undergoing TAVR independently from subtype and other risk factors.

Methods

A total of 416 patients diagnosed with severe AS by transthoracic echocardiography were assigned for TAVR and enrolled for systematic assessment. Patients underwent clinical surveys and 5-year long-term follow-up, with all-cause mortality as the primary endpoint. EAT volume was quantified on pre-TAVR planning CTs. Patients were retrospectively dichotomized at the median of 74cm3 of EAT into groups with low-EAT and high-EAT volumes. Mortality rates were compared using Kaplan-Meyer plots and uni- and multivariable cox regression analyses.

Results

A total number of 341 of 416 patients (median age 80.9years, 45% female) was included in the final analysis. Patients with high-EAT volumes had similar short-term outcome (p=0.794) but significantly worse long-term prognosis (p=0.023) compared to patients with low-EAT volumes. Increased EAT volumes were associated with worse long-term outcome (HR1.59;p=0.031) independently from concomitant cardiovascular risk factors, general type of AS and functional echocardiography parameters of AS severity (HR1.69;p=0.013).

Conclusion

Increased EAT volume is an independent predictor of all-cause mortality in patients with severe AS undergoing TAVR. It can be easily obtained from pre-TAVR planning CTs and may thus qualify as a novel marker to improve prognostication and management of patient with severe AS.Graphical Abstract
Artificial intelligence to assist the echocardiographic identification of transthyretin cardiac amyloidosis
Authors: Algalarrondo V , Perault A , Mihoubi K , Eliahou L , Elbez Y , Ducrocq G , Steg P G
Published: October 2024

Introduction

Transthyretin cardiac amyloidosis (ATTR-CM) is a severe disease, and treatments are most effective when initiated at early stage. Echocardiography is the main tool for screening patients with suspected ATTR-CM or populations at high risk of ATTR-CM. Suspicion of ATTR-CM triggers a dedicated confirmatory evaluation. Echocardiographic diagnosis is however difficult to implement in a non-expert cardiologist workflow. An algorithm to assist the identification of potential cases would be helpful to assist clinicians.

Objective

To develop an algorithm using artificial intelligence (AI) to assist the identification of potential ATTR-CM cases using routine transthoracic echocardiography.

Methods

In this non-interventional, monocentric case-control study, a dedicated database, comprising confirmed ATTR-CM patients and a control group, was built. We trained and validated a deep learning model based on Convolutional Neural Network from transthoracic echocardiography video loops.

Results

A total of 4394 patients were included in the database: 208 in the ATTR-CM group (76% males, mean age 69±10 years old, 90% hereditary ATTR-CM with NAC I score in 77%) and 4186 in the control group (59% male, mean age 62±16 years). After training the model to identify potential ATTR-CM, the ROC curve AUC was 0.97, accuracy was 94.7%, precision was 87.3%, and recall 84.4%. After selecting a subgroup of 130 pairs of matched ATTR-CM/controls based on age, sex, and wall thickness, the algorithm performance remained robust (AUC 0.99, accuracy 99.4%, precision 100%, recall 98.3%).

Conclusion and Perspectives: Diagnosis of ATTR-CM by echocardiography can be assisted by an algorithm using AI. The algorithm remains effective in distinguishing ATTR-CM from other causes of left ventricular hypertrophy. External validation of this tool is underway.ROC curveAssisted classification
Role of CT-derived global longitudinal strain in identifying left ventricular dysfunction in patients with severe aortic stenosis and preserved left ventricular ejection fraction
Authors: Hopfgarten J , Baron T , James S , Christersson C
Published: October 2024

Introduction

In patients with severe aortic stenosis, LVEF <50% is a current class 1 indication for aortic valve replacement. There are however studies showing increased mortality in patients with asymptomatic severe aortic stenosis and LVEF between 50-59% [1, 2]. Global longitudinal strain (GLS) has emerged as a more sensitive predictor of systolic dysfunction than ejection fraction in a wide number of cardiac diseases [3].

Purpose

The aim of our study was to analyze left ventricular global longitudinal strain (GLS) by cardiac computed tomography (CT) in patients with severe aortic stenosis. We hypothesized that a larger portion of patients with LVEF 50-59% have signs of systolic dysfunction by GLS as compared to patients with LVEF ≥60%.

Methods

We identified 238 patients (median age 81, 51.3% females) with severe aortic stenosis, assessed by cardiac CT before undergoing transcatheter aortic valve replacement at Uppsala University hospital between 2016-2019. Patients in atrial fibrillation was excluded due to suboptimal image quality. Left ventricular mass index (LVMi), EF and peak GLS were calculated. The patients were divided into three groups based on LVEF (Reduced LVEF <50%, Low-Normal LVEF 50-59% and Normal LVEF ≥60%) and compared with each other regarding GLS, biomarkers and background variables. The cut off for significantly reduced GLS was set at <16%, in accordance with recently proposed criteria [4].

Results

As expected GLS was significantly reduced in all patients with LVEF <50%. Among patients with Low-Normal LVEF, 62.3% had significantly reduced GLS as compared to only 3.8% patients with Normal LVEF >60% (p < 0.001). Median GLS in Low-Normal LVEF was 15.5% (IQR 14.1 - 17.4) as compared to 20.2% (IQR 18.4 - 21.9) in Normal LVEF (p < 0.001). Patients with Low-Normal LVEF had a significantly higher LV mass as compared to patients with Normal LVEF (median LVMi 85.8 g/m² vs. 75.8 g/m², p < 0.001). NT-pro-BNP was significantly higher in patients with Low-Normal LVEF compared to Normal LVEF (median 1130 vs. 664 ng/l, p = 0.003).

Conclusions

Almost two third of patients with severe aortic stenosis and lower range of normal LVEF (50-59%) had abnormally reduced GLS, reflecting systolic LV dysfunction, which was uncommon among those with LVEF >60%. Patients with LVEF 50-59% also presented with higher LV mass index and higher levels of NT-pro-BNP than patients with normal LVEF >60%, reflecting hypertrophic response of the myocardium to pressure overload which over time may lead to progressive myocardial decompensation. LVEF in the range of 50-59% might be an early sign of LV decompensation in severe aortic stenosis.
Computed tomography-derived myocardial extracellular volume as a prognosis predictor in patients with severe aortic stenosis
Authors: Reis Santos R , Carvalho R , Lopes P M , Gama F , Freitas P , Guerreiro S , Abecasis J , Saraiva C , Teles R C , Almeida M S , Adragao P , Ferreira A M
Published: October 2024

Background

Patients with severe aortic stenosis (AS) face a higher risk of mortality, but prognosis is still heterogeneous and tools for prioritizing intervention are needed. Myocardial extracellular volume (ECV), measured non-invasively in pre-TAVR computed tomography (CT), is a marker of fibrosis that may reflect the degree of irreversible damage. The aim of this study was to assess the prognostic value of CT- derived ECV (ECVCT) in patients with severe AS referred for TAVR-planning CT.

Methods

Consecutive patients with severe symptomatic AS undergoing TAVR-planning CT between April and December 2022 at single centre were prospectively included. CT was performed on a 192-slice dual-source 3rdgeneration scanner. ECVCT was acquired during TAVR-planning using an additional post-contrast low-radiation-dose prospective acquisition. ECVCT was calculated as the ratio of change in CT attenuation (Hounsfield units [HU]) of the septal myocardium and the left ventricle (LV) blood pool before and after contrast administration, according to the equation: ECVCT = (1 – hematocrit) x (DHUmyo/DHUblood) – Figure 1A. The primary endpoint was all-cause mortality. The secondary endpoint was a composite endpoint including all-cause mortality and heart failure hospitalization.

Results

A total of 138 patients were included (mean age 81 ± 7 years; 46% male; mean transaortic gradient 51 ± 15 mmHg; mean aortic valvearea 0.75 ± 0.19 cm2; mean LV ejection fraction (EF) by 2D echocardiogram 57 ± 11%). No patient had a clinical diagnosis of cardiac amyloidosis. Mean ECVCT was 33.9 ± 8.0%. During a median follow-up period of 386 days (IQR 332 – 464), there were 18 deaths (13%), 13 before intervention and 5 after intervention; the secondary endpoint occurred in 26 patients (19%), 17 of which before intervention and 9 after. Patients who attained the primary endpoint were significantly older [81 ± 7 vs. 85 ± 7 years, P = 0.011], had lower left ventricular ejection fraction [51 ± 11 vs. 58 ± 11%, P = 0.015], higher NTproBNP levels [4739 (IQR 2003 – 9970) vs. 751 (IQR 314 – 2541), P <0.001] and higher ECV values (39.9 ± 7.4% vs. 33.0 ± 7.7%, P <0.001). After adjustment for age, LVEF and NTproBNP levels, ECVCT remained an independent predictor of all-cause mortality (adjusted HR 1.09 per 1% ECV increase, 95%CI 1.02 – 1.17, p=0.005 – Figure 1B) and also the secondary endpoint (adjusted HR 1.07 per 1% ECV increase, 95%CI 1.01 – 1.13, p=0.002).

Conclusions

In this prospective observational cohort study, interstitial fibrosis assessed by CT-derived ECV was associated with poor outcomes in patients with severe AS. ECVCT values may be useful to identify a subgroup of patients with higher risk who may benefit from earlier intervention.
Surgery versus thrombolytic therapy for the management of left-sided prosthetic valve thrombosis without hemodynamic compromise: a systematic review and meta-analysis
Authors: Chopard R , Vidoni C , Besutti M , Ismail M , Ecarnot F , Favoulet B , Badoz M , Schiele F , Perrotti A , Meneveau N
Published: October 2024

Background

The optimal strategy in prosthetic heart valve thrombosis (PVT) remains controversial, with no randomized trials and conflicting observational data.

Objectives

To perform a systematic review and meta-analysis of evidence comparing systemic thrombolysis and cardiac surgery in PVT.

Methods

We searched for studies on treatment strategies in patients with left-sided PVT since 2000 in PubMed, Cochrane and Embase. Primary outcome was mortality, secondary outcomes were major bleeding, and thrombo-embolism during follow-up.

Results

We identified 2,298 studies, of which 16 were included, comprising 1,389 patients with PVT (mean age, 50.4±9.3 years, 60.0% were women). Among them, 67.2% were New York Heart Association Stage III/IV at admission. Overall, 48.1% were treated with systemic thrombolysis, and 51.9% with cardiac surgery. Mortality was 10.8% in the thrombolysis group, and 15.3% in the surgery group (Figure 1). The pooled OR for mortality with systemic thrombolysis was 0.66 (95% CI, 0.46-0.96; I2 = 36.6%; τ2, 0.428; p = 0.03) versus cardiac surgery. Rates of both transient ischemic attack and non-central nervous system embolism were higher in the thrombolysis group (p=0.002 and p=0.02, respectively). Treatment success, major bleeding and stroke were similar between groups. Sensitivity analysis including studies that used low dose and/or slow infusion thrombolysis showed that mortality was lower, and treatment success was higher in patients referred to systemic thrombolysis, with similar rates of other secondary outcomes.

Conclusions

Thrombolysis seems to be the preferred option for the management of PVT without cardiogenic shock, pending future RCTs or larger observational studies.
Cusp-overlap technique to reduce permanent pacemaker implantation rate after transcatheter aortic valve implantation
Authors: Abrantes De Figueiredo M , Rodrigues I , Teixeira B , Grazina A , Albuquerque F , Carvalheiro R , Cacela D , Ramos R , Fiarresga A , Mendonca T , Cruz Ferreira R
Published: October 2024

Background

Persistent conduction disturbances requiring permanent pacemaker (PPM) implantation are one of the most common complications after Transcatheter Aortic Valve Implantation (TAVI). Cusp-Overlap Technique (COT) is a novel approach for self-expandable valve implantation to minimize the rate of procedural complications, mainly PPM implantation.

Purpose

To determine if the COT during TAVI with self-expandable valves leads to a reduction of PPM implantation rate in the real-world setting.

Methods

A retrospective analysis of consecutive patients undergoing TAVI between January 2020 and November 2023 in one high-volume tertiary care center in Portugal was conducted. Two groups were defined, the COT group and the control group based on the fluoroscopic approach. A baseline comparison between the 2 groups was made using independent-samples t-test and chi-square analysis to determine if there was a difference between the prevalence of known risk factors for PPM implantation after TAVI. Afterwards, chi-square analysis was used to determine if COT led to a reduction in the PPM implantation rate.

Results

Of the 539 completed procedures in this timeframe, 289 were excluded due to previous pacemaker implantation, use of a valve not amenable to COT or valve-in-valve implantation. COT was used in 57.6% of eligible cases. Baseline comparison did not show a significant difference in the prevalence of several known risk factors for PPM implantation, including complete right bundle branch block, atrio-ventricular block, calcium score, aortic ring dimensions and pre/post-dilation. PPM implantation after TAVI was required in 31.6% of cases. In the COT group the PPM implantation rate was 22.9% and in the control group 43.4%. Chi-square analysis showed a very statistically significant difference between the 2 analyzed groups (p-value = 0.001).

Conclusion

PPM implantation remains a frequent complication of TAVI. However, this study showed that the utilization of COT leads to a reduction of the PPM implantation rate.
Identifying missing tools in aortic systolic upstroke parameter for valvular aortic stenosis diagnosis
Authors: Wangpermpoon W , Sasiprapha T , Ngernsritrakul T , Chandavimol M
Published: October 2024

Background

Echocardiography is a widely accepted method for diagnosing severe aortic stenosis (AS), but it has certain limitations. Alternative methods, such as the direct catheter-based crossing of the valves, carry a risk of stroke. Delayed aortic upstroke parameters might predict the severity of aortic stenosis.

Objective

This study aimed to investigate the diagnostic utility of measuring catheter-based aortic acceleration time with ejection (AT/ET) for the diagnosis of severe aortic stenosis, including low-gradient (LG) AS.

Methods

We included 139 patients who underwent cardiac catheterization at our hospital, including patients with varying degrees of AS. Patients with LGAS were classified byan algorithm according to ESC guideline. All patients received echocardiographicassessments and direct hemodynamic measurements of AT/ET. The association between AT/ET and AS severity and other conventional utilities was analyzed using logistic regression and ROC analysis.

Results

Among the 139 patients, 73 had severe AS (52.5%), and 20 also had low gradient (27.3%). The mean AT/ET was 0.33 in the severe AS group and 0.28, 0.24 in moderate, and mild-no AS patients, respectively. AT/ET was significantly correlated with conventional echocardiographic and hemodynamic parameters. Furthermore, AT/ET is the strongest predictor of severe aortic stenosis using the multivariable test with relevant variables (OR; 2.01, 95% CI 1.17-3.45). Using a cut-off value of 0.30, catheter-based AT/ET had a sensitivity of 80% and specificity of 92% for diagnosing severe AS (AUC 0.94, 95% CI 0.90-0.97), withconsistent results from subgroup LGAS (AUC 0.94, 95% CI 0.93-0.99).

Conclusion

This study supports the use of catheter-based AT/ET of greater than 0.30 as a complementary diagnostic tool for severe aortic stenosis across the spectrum of low-gradient AS. Further studies are needed to validate these findings in larger, multicenter studies with more diverse patient populations.
Evaluation of renal tubulointerstitial damage as a residual renal risk factor for adverse cardiac events in patients with aortic valve stenosis
Authors: Kobayashi T , Nakamura T , Yoshizaki T , Yamaguchi K , Horikoshi T , Nakamura K , Ando R , Eguchi M , Sato A
Published: October 2024

Background

Renal dysfunction, defined as a lower eGFR, has been shown to be related to cardiovascular events in patients with aortic stenosis treated with transcatheter aortic valve implantation (TAVI). However, the contribution of renal tubulointerstitial damage to the predictive value for cardiovascular events remains unclear. The aim of this study was to elucidate whether renal tubulointerstitial damage is associated with the occurrence of all death and heart failure patients who have had TAVI.

Methods and results

In a cohort of 155 patients, urinary beta2-microglobulin (beta2MG) levels were measured. Patients were monitored for less than three years or until experiencing all-cause mortality or hospitalization due to heart failure. The cumulative all-cause mortality was 11.5%, and heart failure admission rate stood at 5.4%. Stratifying outcomes by beta2MG levels revealed significantly lower rates of all-cause mortality and heart failure in patients with beta2MG <0.20 mg/gCre compared to those with beta2MG ≥0.20 mg/gCre (10.2% versus 24.2%, p=0.01). When outcomes were stratified according to the beta2MG levels in combination with eGFR levels, Kaplan-Meier analyses showed that all-cause mortality and heart failure rates increased depending on an increase in the beta2MG levels (p<0.05) even if eGFR is above 60 ml/min. Moreover, multivariate Cox analyses revealed that high levels of beta2MG were an independent predictor of adverse events.

Conclusion

Renal tubulointerstitial damage is associated with the occurrence of all death and hospitalization for heart failure independent of renal glomerular function.
Bacteremia after transcatheter aortic valve implantation: a nationwide cohort study
Authors: Hadji-Turdeghal K , Petersen J K , Butt J H , Graversen P L , Strange J E , Ihlemann N , Dahl J S , Povlsen J A , Terkelsen C J , Freeman P , Nissen H , Backer O D , Koeber L , Oestergaard L , Fosboel E
Published: October 2024

Background

Bacteremia and infective endocarditis (IE) are rare but severe complications to transcatheter aortic valve implantation (TAVI). However, data on early bacteremia and microbiological etiological profile are scarce.

Purpose

The study aimed to investigate the incidence of bacteremia and IE within six months after TAVI.

Methods

Using Danish nationwide registries, we identified all patients who underwent TAVI from 2012 to 2021. These patients were matched 1:1 by age, sex, and index-year with individuals who underwent elective coronary angiography (CAG). The primary outcomes were bacteremia and IE within six months. Outcomes were compared with cumulative incidence functions and adjusted hazard ratios (HR). All patients were followed six months from the index date until the outcome of interest, death, emigration, or end of study (December 31st, 2021), whichever came first.

Results

We identified 5,990 patients undergoing first-time TAVI, of whom 56 % were men, and the median age was 81 years [IQR 77–85]. All patients were matched with controls undergoing CAG (56% men, median age 81 [IQR 77-85]). Patients undergoing TAVI had more comorbidities than controls. The six-month cumulative incidence of bacteremia was 4.2% [95% CI 3.7-4.7] and 2.6% [95% CI 2.2-3.0] after TAVI and CAG, respectively, corresponding to an adjusted HR of 1.57 (95% CI 1.27-1.96) (Figure 1). The common bacterial etiologies for bacteremia after TAVI were Streptococci (20%), Coagulase-negative staphylococci (CoNS) (19%), and Enterococci (18%). After CAG, CoNS (22%) and Staphylococcus aureus (16%) were the most frequent. By six months, 1.1% [95% CI 0.9-1.4] and 0.2% [95% CI 0.1-0.3] developed IE after TAVI and CAG, respectively, with an adjusted HR of 20.01 (95% CI 5.97-67.48).

Conclusion

In this nationwide cohort study, the risks of bacteremia and infective endocarditis within six months post-TAVI were significantly higher than in the matched coronary angiography population. Bacteremia post-TAVI was characterized by significantly more Enterococci spp. These results could have implications in the selection of peri-procedural antibiotics, as commonly used antibiotic regimens do not cover Enterococci spp.Cumulative incidence of bacteremia
Aortic valve calcium score to mean gradient ratio: a new frontier in aortic stenosis prognostication
Authors: Tsai C M , Foley T A , Scott C G , Thaden J J , Alsidawi S , Pislaru S V , Nkomo V T
Published: October 2024

Introduction

Aortic stenosis (AS) presents diagnostic challenges, especially in patients with discordant low gradient AS (LGAS), i.e., small aortic valve area (AVA) and low Doppler mean gradient (MG). LGAS is associated with worse outcomes compared to concordant AS. Aortic valve calcium score (AVCS) is a measure of AS severity independent of flow and helps diagnose severe AS. It is unknown if the degree of discordance in AVCS and MG is of any clinical significance. A high AVCS/MG ratio may indicate impaired ventricular function and response to pressure overload despite preserved LVEF, potentially contributing to worse outcomes.

Purpose

This study aims to elucidate the prognostic significance of the AVCS/MG ratio in patients with severe AS and preserved left ventricular ejection fraction (LVEF) undergoing TAVR. We hypothesized a higher AVCS/MG ratio correlates with increased mortality.

Methods

Patients who underwent transcatheter aortic valve replacement (TAVR) from 2010 to 2020 for native valve severe AS with LVEF≥50% were identiﬁed from an institutional database. AVCS were obtained within 90 days of pre-TAVR echocardiography. Patients were divided into tertiles based on their AVCS/MG ratio. Primary outcome was overall mortality.

Results

The analysis included 1067 patients (mean age 79±9 years, 43% female); overall AVA was 0.80±0.14 cm², LVEF 63±6%, MG 46±12 mmHg, AVCS 2630±1528 AU, and AVCS/MG ratio 58±31. Patients stratified by AVCS/MG tertiles showed no difference in overall comorbidity index across tertiles (Figure 1). However, the group in the highest tertile was the oldest (80±8 vs 79±8 vs 77±9 years), predominantly male (87% vs 61% vs 24%), with the highest prevalent atrial fibrillation (44% vs 28% vs 25%) and stroke volume index <35 mL/m² (16% vs 11% vs 5%). 9-year survival was 15% vs 25% vs 36% (p<0.001, Figure 2). In multivariate analysis adjusted for age, sex, comorbidities, LVEF and AVA, AVCS/MG ratio was independently associated with increased risk of mortality (HR 1.005; 95% CI [1.001-1.008], p=0.005).

Conclusion

Higher AVCS/MG discordance is associated with increased risk of mortality following TAVR. Serial AVCS measurements during progressive AS may help identify patients at higher risk who may potentially benefit from earlier aortic valve intervention.
Invasive hemodynamic response to exercise in hemodynamically significant aortic stenosis with preserved left ventricular ejection fraction
Authors: Ali M , Frederiksen P , Moeller J E , Mogensen N S B , Chemnitz A , Haujir A , Poulsen M K , Oevrehus K A , Pibarot P , Pellikka P A , Clavel M A , Dahl J S
Published: October 2024

Background

Guidelines acknowledge that discordant low-gradient (LG) aortic stenosis (AS) may be severe, but verifying this can be challenging. Right heart catheterization during exercise is considered the gold standard evaluating ventricular hemodynamics. No invasive studies have compared the hemodynamic response of discordant LG and severe AS during exercise.

Purpose

To describe exercise hemodynamics in patients with asymptomatic discordant AS and left ventricular ejection fraction ≥50%, and to identify the variables associated with the steepness of the pulmonary capillary wedge pressure (PCWP)/cardiac output (CO) slope defined as (peak exercise PCWP-rest PCWP)/(peak exercise CO-rest CO).

Methods

Patients with aortic valve area (AVA) ≤1.5 cm² underwent right heart catheterization at rest and during maximal exercise measuring pulmonary artery pressures, PCWP, CO and PCWP/CO slope. Patients were stratified in three groups: 1) discordant LG AS (AVA ≤1.0 cm² and mean gradient <40 mmHg); 2) moderate AS (AVA >1.0 cm²) and 3) high-gradient severe AS (AVA ≤1.0 cm² and mean gradient ≥40 mmHg).

Results

Among 86 patients, 17 (20%) had discordant LG, 49 (57%) moderate, and 20 (23%) high-gradient severe AS. The PCWP/CO slope was significantly steeper in discordant LG: median 3.3 mmHg/L/min (interquartile range: 2.2 mmHg/L/min) and high-gradient severe AS: 2.7 mmHg/L/min (1.5 mmHg/L/min) compared to moderate AS: 1.9 mmHg/L/min (2.0 mmHg/L/min), p=0.004. In a linear regression model adjusted for age, sex and rest PCWP, systemic arterial compliance and AS severity were significantly associated with the PCWP/CO slope. Furthermore, patients with discordant LG AS had a leftward and upward shift in the PCWP/CO slope.

Conclusions

Discordant LG and high-gradient severe AS had similar hemodynamic response to exercise with steeper PCWP/CO slope than in moderate AS, suggesting that discordant LG AS is a severe form of AS. In addition, the left-upward shift in PCWP/CO slope for discordant LG compared to high-gradient severe AS indicates that, this group also has latent heart failure with preserved ejection fraction physiology.
Prognostic implications of right ventricular dysfunction in degenerative mitral regurgitation
Authors: Bohbot Y , Essayagh B , Benfari G , Bax J J , Le Tourneau T , Topilsky Y , Rusinaru D , Ajmone Marsan N , Van Wijngaarden A , Hochstadt A , Roussel J C , Thapa P , Michelena H , Enriquez Sarano M , Tribouilloy C
Published: October 2024

Background

The prevalence and impact of right ventricular dysfunction (RVD) in degenerative mitral regurgitation (DMR) is unknown. We aimed to determine whether RVD assessed by echocardiography in routine clinical practice is independently associated with survival in patients with DMR.

Methods

We used data from the Mitral Regurgitation International DAtabase-Quantitative (MIDA-Q) which included patients with isolated DMR due to mitral valve prolapse from January 2003 to January 2020 from 5 tertiary centers across North America, Europe, and the Middle East. A cohort of 4,379 (mean age: 67 years, 64.6% males, follow-up:5.3[3.3-8.2]years) consecutive patients with significant (≥moderate) DMR was included and long-term survival was analyzed.

Results

RVD, identified in 584(13.3%) patients, was associated with reduced 10-year survival (49±3% vs. 67±1%; p<0.001), overall and in all subgroups of patients, even after comprehensive adjustment including left ventricular dilatation and dysfunction, DMR severity, pulmonary pressures and surgery (adjusted HR[95%CI]=1.55[1.31-1.84]; p<0.001). This excess mortality was observed under medical management (adjusted HR[95%CI]=1.39[1.12-1.72]; p=0.003) and after surgical correction of mitral regurgitation (adjusted HR[95%CI]=1.56[1.08-2.27]; p=0.019). Patients with RVD undergoing surgery within 3 months of diagnosis experienced a better 10-year survival (73±4% vs. 38±4%; p<0.001), even after adjustment (adjusted HR[95%CI]=0.53[0.35-0.81]; p=0.003) despite an increase of 1-month post-operative mortality (5% vs 2.2% for patients without RVD; p<0.001).

Conclusions

RVD is observed in 13.3% of significant DMR and exhibits a powerful and independent association with excess mortality partially attenuated by mitral surgery. Therefore, assessment of right ventricular systolic function should be included in routine DMR evaluation and in the clinical decision-making process.determinant ans prognosis of RVD in MR
Extra-cellular volume fraction analysis on cardiac CT is useful for predicting the prognosis of hypertrophic cardiomyopathy
Authors: Aoki S , Takaoka H , Kanaeda T , Asada K , Kinoshita M , Yashima S , Suzuki K , Yoshida K , Nishikawa Y , Matshumoto M , Noguchi Y , Sasaki H , Suzuki-Eguchi E , Kobayashi Y
Published: October 2024

Introduction

Extra-cellular volume (ECV) fraction on magnetic resonance imaging (MRI) can evaluate the degree of myocardial fibrosis and has been reported to help diagnose and evaluate the prognosis of cardiomyopathy. In hypertrophic cardiomyopathy (HCM), ECV analysis on MRI is reported to help predict ventricular arrhythmias. However, the performance of cardiac MRI takes time, and there are also several contraindications. Cardiac computed tomography (CT) is more versatile than cardiac MRI and is also useful in screening coronary artery disease. ECV analysis on CT is now available, and a good correlation with ECV on MRI has been reported. We hypothesized that ECV on CT, a new fibrosis indicator, would be useful in predicting prognosis in HCM patients.

Purpose

To determine the utility of ECV analysis on CT to predict the prognosis in patients with HCM.

Methods

One hundred and three HCM patients (68 males, 66 ± 11 years old) who underwent cardiac CT using 320-row detector CT or 256-row detector CT, from 2008 to 2021 at our two hospitals were analyzed. We measured left ventricular (LV) ECV (LV-ECV) on CT and collected patient characteristics, transthoracic echocardiographic, and other CT findings. We investigated the relationship between these findings and the major adverse cardiac events (MACEs) (cardiac death, fatal arrhythmia, and heart failure hospitalization) after CT.

Results

All patients were followed for 64 ± 54 months after cardiac CT, and 15 patients (14.6%) had MACEs (ten heart failure hospitalization cases, two ventricular fibrillation cases, two sustained ventricular tachycardia cases, and one sudden cardiac death case). The patients with MACEs had a significantly higher LV-ECV, sudden cardiac death (SCD) risk score and lower LV ejection fraction (LVEF) than those without MACEs（42.0 ± 8.3% vs. 33.7 ± 6.1%, P < 0.001, 2.4 ± 0.39 vs 1.95 ± 0.16, P= 0.047, and 57.7 ± 11.9% vs. 66.7 ± 6.9%, P = 0.004). The percentage of dilated phase HCM was significantly higher in the patients with MACEs than those without MACEs (21% vs 0%, p=0.002). LV-ECV was the only significant predictor of MACEs based on the multivariate analysis by Cox proportional hazard model (hazard ratio 1.23, 95% confidence interval 1.09-1.41, P<0.001). The optimal threshold of LV-ECV to predict MACEs was 37.6% based on the receiver operating characteristic analysis. The sensitivity and specificity of LV-ECV to predict MACEs were 73% and 78% at the best cut-off, and the area under the curve was 0.79 (Figure A). The patients with LV-ECV ≥ 37.6% (30 patients) had significantly higher MACEs than those with LV-ECV < 37.6% during the follow-up periods (P < 0.001) (Figure B).

Conclusion

LV-ECV on CT of 37.6% is a good prognostic indicator in HCM cases. ECV analysis on CT helped predict MACEs in HCM cases.
Tricuspid regurgitation in the context of severe concomitant left-sided valvular heart disease: patients characteristics and long-term clinical and interventional outcomes
Authors: Margonato D , Ingallina G , Belli M , Tavernese A M , Ricchetti G , Ancona F , Stella S , Biondi F , Fiore G , De Bonis M , Maisano F , Topilsky Y , Agricola E
Published: October 2024

Background

The clinical features, therapeutical management and outcome of patients with significant tricuspid regurgitation (TR) in the context of multiple valvular disease (VD) are poorly defined.

Purpose

To assess the characteristics, management and long-term prognosis of a large cohort of patients with multiple VD, focusing on the context of significant TR and concomitant severe mitral or aortic disease.

Methods

Clinical and echocardiographic data were collected in 1183 patients with ≥moderate TR diagnosed at our centers from January 2012 to June 2020: after propensity score matching for age to create matched cohort with < 10% of absolute difference, 975 patients were included in this study and divided in 4 groups as shown in Figure 1. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization+any valvular intervention.

Results

Patients with isolated TR (356, 37%) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). TR+ severe MR patients (466, 48%) showed higher rates of concomitant coronary artery disease, NYHA class III/IV symptoms and larger left atrial volumes. The group of TR+ severe AS (131 patients, 13%) was characterized by older age, more comorbidities and lower LVEF. Patients with TR and severe AR (22, 2%) were younger, with larger LV dimensions and higher pulmonary pressures.

Overall, in 37(4%) patients tricuspid intervention was performed: no differences were found between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment (p=0.444 and p= 0.624, respectively), while left-valve only surgical treatment was more common among patients with TR and severe MR and left-valve transcatheter treatment among patients with TR and severe AS (both p<0.001).

After a median follow-up of 2.8 years, the primary endpoint occured in 374 (38%) of patients, and was significantly more frequent in the group of patients with TR and severe AS (p<0.001, Figure 2). In this group, after multivariate analysis, indexed stroke volume remained independenty associated with ACD (OR 0.96, CI 0.93-0.98, p =0.040). Eventually, the secondary endpoint too was more common in patients with TR and severe AS (p<0.001, Figure 2).

Conclusions

In the context of significant TR, concomitant severe left-sided VD is common, and each subtype presents with different clinical features and echocardiographic phenotypes; in this scenario, TR was profoundly underteated. Long-term, patients with significant TR+ severe AS have considerable worse prognosis.Figure 1Figure 2
A decade of follow-up: atrial fibrillation, pulmonary pressure, and the progression of tricuspid regurgitation
Authors: Loutati R , Katz A , Kuperstein R , Sabbag A , Maor E
Published: October 2024

Background

While Atrial fibrillation is considered a risk factor for tricuspid regurgitation (TR), prospective long term data in the field is lacking. This analysis aimed to identify risk factors of TR progression during a decade of follow up among patients with and without AF.

Methods

Patients with full echocardiographic and clinical follow of at least 5 years were included. Individuals presenting with significant TR at baseline were excluded. Patients were divided into two groups based on baseline diagnosis of AF, followed by stratification according to systolic pulmonary artery pressure (sPAP). The primary outcome was the occurrence of new significant TR (≥ Moderate).

Results

Study population included 15,957 patients with a median age of 63 (IQR: 54-72) of whom 6,068 (38%) were women and 1,837 (11.5%) had baseline AF. During a median follow-up period of 11 years (8.5 – 13.5), 1,191 (7.5%) patients developed significant TR. Compared with sinus rhythm, patients with AF were 4 and 2 times more likely to develop significant TR during follow up in a univariate and multivariate models, respectively (95% CI 3.66 - 4.68 and 1.98 – 2.56, p < 0.001 for both). Older age, female sex, chronic kidney disease (CKD), left heart disease (LHD) and impaired right ventricular (RV) function, rate control and permanent AF were all risk factors for TR progression. The association of baseline AF with TR during follow up was sPAP – dependent, such that among patients with normal sPAP AF associated risk was high while among patients with high baseline sPAP AF-associated risk was significantly lower (HR 2.87 vs. 1.77; p for interaction < 0.001). Competing risk analysis with death as competing event yielded consisted results.

Conclusions

Baseline AF is a strong and independent risk factor for TR development. This association is more pronounced among patients with normal pulmonary arterial pressures, emphasizing the need for focused research on preventing TR development in this population.
Is etiology of severe tricuspid regurgitation related to prognosis?
Authors: Gomez Polo J G P , Miguel Angel Marquez Rivera M A M R , Patricia Mahia P M , Itziar Gomez Salvador I G S , Esther Perez David E P D , Pere Pericas P P , Manuel Barreiro M B , Carlos Izurieta C I , Ana Revilla Orodea A R O , Vanessa Monivas V M , Ana Testa A T , Lara Miguel L M , Laura Gutierrez L G , Jose Alberto San Roman J A S R , Isidre Vilacosta I V
Published: October 2024

Objective

Our aim was to assess the prognostic role of the etiology tricuspid valve disease in patients with severe tricuspid regurgitation (TR).

Methods

Multicenter, observational, and prospective registry in which all patients with severe TR have been consecutively collected within a 6-month period and followed up for one year.

Results

A total of 1247 patients with severe TR [mean age: 76.7±10.5 years, 876 women (70.2%)] were included: 810 (64.9%) met criteria for severe TR, 301 (24.1%) massive TR, and 136 (11%) torrential TR. The most frequent etiology was functional TR secondary to left-heart disease in 621 patients (49.9%) followed by "atriogenic" TR in 247 (19.8%). TR etiology distribution is described in Figure 1. Death due to refractory HF occurred in 9,2% of patients, hospitalization for HF in 20,8%, and 12,3% underwent TR interventions. In the univariate and multivariate analysis, age, impaired renal function, previous HF admission, and massive and torrential TR were associated with an increased risk of HF hospitalization and cardiovascular mortality. Global (p=0,476) and cardiovascular mortality (p=0,138) rates were similar when comparing different TR etiologies (Figure 2).

Conclusion

Severe TR is associated with high rates of CV mortality and new HF admission. These findings are and independent from TR etiology.