bluuebunny/crossref_metadata_2025 huggingface dataset:
Patient characteristics and clinical outcome in acute myocardial infarction related cardiogenic shock according to vascular access site for PCI
Authors: Peters E , Bogerd M , Ten Berg S , Timmermans M J C , Engstrom A E , Thiele H , Jung C , Schrage B , Sjauw K D , Verouden C J W , Teeuwen K , Dedic A , Danse P W , Claessen B E P M , Henriques J P S
Published: October 2024

Background / Introduction

The optimal vascular access site for percutaneous coronary interventions (PCI) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) remains uncertain. While observational data favor trans-radial access (TRA) due to lower complication rates and mortality, trans-femoral (TFA) PCI offers advantages such as shorter access and procedure times, along with quicker escalation to mechanical circulatory support (MCS).

Purpose

In this study, we aimed to investigate factors associated with a transfemoral approach and compare mortality rates between TRA and TFA in AMI-CS patients undergoing PCI.

Methods

Data from a nationwide registry of AMI-CS patients undergoing PCI (2017-2021) were analyzed. We compared patient demographics, procedural details, and outcomes between TRA and TFA groups. Logistic regression identified access site factors and radial-to-femoral cross-over predictors. Propensity score matched (PSM) analysis examined the impact of access site on mortality.

Results

Of 1562 patients, 45% underwent TRA PCI, with an increasing trend over time. TFA patients were more often female, had a history of coronary artery bypass grafting (CABG), lower blood pressure, higher resuscitation and intubation rates, and elevated lactate levels. After PSM, 30-day mortality was lower in TRA (33% vs. 46%, p <0.001). Predictors for cross-over included left coronary artery interventions, multivessel PCI, and MCS initiation.

Conclusion

Significant differences exist between TRA and TFA PCI in AMI-CS. TFA was more common in patients with worse hemodynamics and was associated with higher 30-day mortality compared to TRA. TRA should be the default access, given its feasibility and favorable outcomes in many patients.Baseline characteristicsPredictors for femoral access
Serum potassium levels and in-hospital mortality in distinct phenotypes of myocardial infarction patients by machine learning clustering
Authors: Park S W , Park G M
Published: October 2024

Background

Abnormal serum potassium levels are associated with an increased risk of mortality in patients with myocardial infarction (MI); however, it is unclear whether the impact of potassium levels on mortality risk varies depending on the characteristics of MI patients.

Purpose

We aimed to classify MI patients according to their clinical characteristics and explore the relationship between potassium levels and in-hospital mortality in distinct clusters of MI.

Methods

Using Medical Information Mart for Intensive Care (MIMIC) IV database, we identified 3,159 patients who admitted for the first time to the intensive care unit with a primary diagnosis of acute MI. Machine learning clustering was performed on this population based on available clinical and laboratory data.

Results

Three distinct clusters of MI patients were identified using clustering analysis: 1,455 (46%) in cluster 1, 587 (19%) in cluster 2, and 1,117 (35%) in cluster 3. Patients in cluster 2 were older, had the highest comorbidity burden, Sequential Organ Failure Assessment (SOFA) score, peak lactate, creatinine, peak troponin, N-terminal B-type natriuretic peptide (NT-proBNP) levels and the lowest hemoglobin levels among the 3 clusters. Patients in cluster 3 were younger, had the lowest comorbidity burden, SOFA score, peak lactate, creatinine, NT-proBNP levels. Patients belonging to cluster 1 had clinical characteristics intermediate to those of cluster 2 and 3, except for the lowest troponin level. In-hospital mortality was highest in cluster 2, followed by cluster 1 and then cluster 3. Patients in cluster 2 had the highest in-hospital mortality risk with hypokalemia (OR 3.71, 95% 1.81­­-7.63) and patients in cluster 3 had highest in-hospital mortality risk with hyperkalemia (OR 2.77, 95% CI 0.84-9.06). Patients in cluster 1 did not exhibit a linearly increasing mortality with hyperkalemia.

Conclusions

The use of clustering analysis in patients with acute MI could characterize baseline clinical data into clinically distinct clusters with different in-hospital mortality across the dyskalemia continuum. The results suggest that the optimal range of potassium levels in patients with MI may vary depending on patient characteristics.Figure - clusteringTable - K and In-hospital mortality
Classification of 90-day mortality risk among patients with cardiogenic shock requiring advanced mechanical circulatory support
Authors: Nakayama T , Unoki T , Anai M , Inamori T , Sato T , Oimatsu Y , Konami Y , Inoue M , Horio E , Kodama K , Taguchi E , Sakamoto T , Nakao K , Koyama J
Published: October 2024

Background

The SCAI shock classification aims to provide a simple and practical stratification of the severity of patients with cardiogenic shock (CS) and to immediately offer them crucial treatments such as mechanical circulatory support (MCS). Additionally, the IABP shock II risk score is designed to predict 30-day mortality in patients with CS following acute coronary syndrome (ACS), and the SAVE score can also predict in-hospital mortality for patients after veno-arterial extracorporeal membrane oxygenation (V-A ECMO) insertion due to refractory CS. However, previous studies on SCAI staging in patients with MCS have been inconsistent, and the association with prognosis remains unclear.

Purpose

The aim of this study is to investigate the correlation between the SCAI shock stage and prognosis in ACS patients requiring advanced MCS, and to compare it with other prognostic scores.

Methods

From January 2012 to July 2023, 137 ACS patients with advanced MCS (excluding IABP) were evaluated. Upon ICU admission, patients were categorized into SCAI stages B to E. The IABP shock II score and the SAVE score were also calculated to serve as prognostic tools. The type of MCS was categorized as Impella, VA-ECMO with IABP, and ECPELLA (VA-ECMO with Impella). We compared the 90-day survival rates with the SCAI shock stage and other prognostic tools.

Result

The distribution for SCAI classifications stage B to E was 13 (10%), 38 (28%), 21 (15%), and 65 (47%), respectively. There were no significant differences among the groups regarding age, gender, comorbidities, the ratio of ST-elevation myocardial infarction, door-to-balloon time, and onset-to-reperfusion time. In SCAI Stage E, a significantly higher proportion of patients (86%) underwent extracorporeal cardiopulmonary resuscitation, exhibiting elevated lactate and peak CK-MB levels, along with higher IABP Shock II and lower SAVE scores, compared to other stages. A Kaplan-Meier analysis of 90-day mortality, based on the SCAI, the IABP Shock II, the SAVE categories, and the type of MCS, demonstrated that outcomes deteriorated as the stage advanced across all classifications. In the univariate Cox regression analysis for 90-day mortality, significant differences in outcomes were observed across the four classifications. However, in the multivariate Cox regression analysis that incorporated all four classifications, only the type of MCS (Impella vs. ECMO with IABP; hazard ratio [HR] 0.36; 95% confidence interval [CI], 0.16 - 0.78, p = 0.012) and the SCAI classification (stage E vs. stage C; HR 3.03; 95% CI, 1.51 - 6.08, p = 0.002) demonstrated a significant association with 90-day mortality.

Conclusion

The SCAI shock stage upon ICU admission suggests the potential for convenient prediction of mid-term outcomes in ACS patients who received advanced MCS.
Direct comparison of mechanical circulatory support devices in porcine model of acute myocardial infarction complicated by ventricular septal defect and cardiogenic shock
Authors: Ostadal P , Grus T , Burkert J , Valerianova A , Vondrakova D , Neuzil P , Kittnar O , Mlcek M
Published: October 2024

Introduction

Despite urgent clinical need, until now optimal strategy for mechanical circulatory support in acute myocardial infarction (AMI) complicated by ventricular septal defect (VSD) and cardiogenic shock has not been determined.

Purpose

The aim of our study was to compare hemodynamic effects of intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO) and Impella CP in the animal model of AMI complicated by VSD and cardiogenic shock.

Methods

Under general anesthesia and mechanical ventilation in pigs (sus scrofa domestica), using partial sternotomy, AMI was induced by ligation of left anterior descending. VSD was simulated by insertion of 25F cannulas into the left and right ventricles and their extracorporeal connection by 3/8 tubes generating left-to-right shunt. The hemodynamic effect of ECMO (2 L/min), IABP, and Impella CP (2 L/min) was evaluated by the measurement of the left ventricular end-diastolic pressure (LVEDP), mean arterial pressure (MAP), carotid flow (CAR) as a surrogate of total circulatory output, and VSD flow. Data are presented as mean (SD), P < 0.05 was considered statistically significant.

Results

Eleven animals were used, one died after induction of AMI, ten pigs completed all study procedures. Baseline (no mechanical support) LVEDP was 13.8 (3.0) mmHg, MAP 54.5 (11.0) mmHg, CAR 290.9 (37.3) mL/min, and VSD 1174.0 (499.3) mL/min (Table 1). IABP significantly improved all parameters in comparison to Baseline (Table 1). ECMO significantly improved MAP and CAR not only in comparison to Baseline but also in comparison to IABP and Impella; on the other hand, ECMO increased VSD flow (Table 1). Impella significantly improved all parameters with the largest effect on LVEDP and VSD flow (Table 1).

Conclusions

All tested devices improved the key hemodynamic parameters of MAP and CAR, however each to different extent. Individual devices influenced differently LVEDP and VSD flow. The results of this study may help in selection of optimal therapeutic strategy in AMI complicated by VSD and cardiogenic shock.Table 1.Hemodynamic outcomes.
Paired single-cell RNA sequencing and T cell receptor sequencing reveals both pro- and anti-inflammatory roles of T cells in patients with calcific aortic valve disease
Authors: Zhang X , Chu C , Xu L , Li F , Dong N
Published: October 2024

Background

Calcified aortic valve disease (CAVD) is a chronic unresolvable inflammatory disorder that affects 25% of adults over 65 years old, leading to aortic stenosis, heart failure, and death [1]. Since the molecular mechanisms of its pathogenesis are not well understood, therapies to treat root causes of the disease remain to be developed, with valve replacement as the major intervention strategy currently. Increasing evidence indicates that substantial T cells infiltrate in the aortic valve during calcification, and clonal expanded CD8+ T cells have been identified in the calcificed aortic valve by bulk T cell receptor (TCR) repertoire sequencing [2].

Purpose

To decipher T cell heterogenity and understand the precise mechanisms of T cell subsets involving CAVD progression as a basis for novel therapeutic targets.

Methods

In Cohort 1, we collected aortic valves from CAVD (n=3) and healthy (n=2) patients for single-cell RNA sequencing (scRNA-seq). In Cohort 2, we performed paired scRNA-seq and TCR sequencing (scTCR-seq) on aortic valves obtained from CAVD (n=3) and healthy (n=3) patients to evaluate both gene expression and clonality. Pathway enrichment analysis and cell-cell interaction analysis elucidated the function of T cells in the calcificied valves. Immunohistochemistry and fluorescence-activated cell sorting were recruited to verify the key findings.

Results

scRNA-seq demonstrated a conversion from anti-inflammatory regulatory T (Treg) cells towards pro-inflammatory T helper 17 (Th17) cells in the calcificied aortic valve. Paired scRNA-seq and scTCR-seq revealed CAVD-related signaling pathways (osteoclast differentiation, NOD-like receptor signaling pathways, IL-17 signaling pathways) significantly upregulated in highly expanded CD8+ T cells in the calcified valve, with upregulation of pro-inflammatory mediators such as IFNG, CCL4 and CCL5, suggesting pro-inflammation functions in clonally expanded T cells. Moreover, we characterized tissue-resident memory T cells, which resembled similar transcriptome and TCR clonality as exhausted T cells in calcified valves. These cells up-regulated anti-inflammation-related transcriptomes but their cellular fraction decreased in calcified valves, implying anti-inflammatory functions of these tissue-resident memory and exhausted T cells.

Conclusion

This study elucidates transcriptomic and immune profiling of T cells in the calcified aortic valve, therefore shedding light on the pathophysiological mechanisms underlying aortic valve calcification from the novel perspective of tissue-specific T lymphocytes, providing promising targets for immune checkpoint-based therapeutic interventions.
Sex-based differences in anatomical and hemodynamic parameters and outcomes in patients with hypertrophic cardiomyopathy undergoing alcohol septal ablation
Authors: Damlin A , Mustafic M , Jander R , Eriksson M J , Rickenlund A , Ruck A , Saleh N , Marlevi D
Published: October 2024

Background

This study aimed to assess sex differences in anatomical and hemodynamic parameters, and in procedure related outcomes, in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA).

Methods

154 patients that underwent ASA in at our university hospital, between 2009 and 2021, were retrospectively included. Anatomical and hemodynamic parameters were collected from invasive catheterization before and during ASA, and from echocardiography (ECHO) examinations at maximum one week before ASA. Follow-up was conducted one year after ASA. The parameters analyzed were left ventricular (LV) volume, basal septal wall thickness (BSWT), anterior (AML) and posterior mitral leaflet (PML) length, minimal left ventricle outflow tract (LVOT) diameter, and LVOT pressure gradient at rest, prior to ASA, and prevalence of atrioventricular block after ASA. Linear and logistic regression models were used to assess the sex differences between the parameters.

Results

50% of the patients were women. At the time of ASA, women were significantly older, had lower LV volume indexed for BSA in end-diastole (44 vs. 54 ml, p<0.001) and end-systole (18 vs. 23 ml, p=0.021), longer AML length indexed for BSA (13.7 vs. 11.6 mm, p<0.001) and PML length indexed for BSA (8.8 vs. 8.1 mm, p=0.018), smaller minimal LVOT diameter (4.6 vs. 4.9 mm, p=0.042), and higher LVOT pressure gradient at rest (49.3 vs. 32.5 mmHg, p=0.014), compared with men. The median follow-up was 364 days. Atrioventricular block (II or III) was more common among women (n=20, 26%) compared with men (n=10, 13%, p=0.045).

Conclusions

ECHO and invasive catheterization prior to ASA showed that women with HOCM presented with less favorable anatomical and hemodynamic pre-conditions, compared with men. At follow-up, women had a greater incidence of atrioventricular block after ASA. This strongly emphasizes the need for a sex-specific approach to optimize care and improve outcomes in patients with HOCM.
Residual tricuspid regurgitation after transcatheter tricuspid valve edge-to-edge repair: the EuroTR Registry
Authors: Stolz L , Lurz P , Iliadis C , Rudolph V , Kalbacher D , Kessler M , Praz F , Lauten P , Maisano F , Karam N , Luedike P , Estevez-Loureiro R , Metra M , Thiele H , Hausleiter J
Published: October 2024

Background

Data on the prognostic impact of residual tricuspid regurgitation (TR) after transcatheter tricuspid valve edge-to-edge repair (T-TEER) are scarce.

Purpose

The aim of this analysis was to evaluate two-year survival and symptomatic outcomes of patients in relation to residual TR after T-TEER.

Methods

Using the large European Registry of Transcatheter Repair for Tricuspid Regurgitation (EuroTR Registry) we investigated the impact of residual TR on two-year all-cause mortality and New York Heart Association (NYHA) functional class at follow-up. The study further identified predictors for residual TR ≥3+ using a logistic regression model.

Results

The study included a total of 1286 T-TEER patients (53.6% females, mean age 78.0 ± 8.9 years). TR was successfully reduced to ≤1+ in 42.4%, 2+ in 40.0% and 3+ in 14.9% of patients at discharge, while 2.8% remained with TR ≥4+ after the procedure. Residual TR ≥3+ was an independent multivariable predictor of two-year all-cause mortality (hazard ratio 2.06, confidence interval 1.30-3.26, p=0.002, Figure 1). The prevalence of residual TR ≥3+ was 4-times higher in patients with higher baseline TR (vena contracta > 11.1 mm) and more severe TV tenting (tenting area >1.92 cm2) (Figure 2). Of note, no survival difference was observed in patients with residual TR ≤1+ vs. 2+ (76.2% vs. 73.1%, p=0.461). The rate of NYHA functional class ≥ III at follow-up was significantly higher in patients with residual TR ≥3+ (52.4% vs. 40.5%, p<0.001). Of note, the degree of TR reduction significantly correlated with the extend of symptomatic improvement (p=0.012).

Conclusions

T-TEER effectively reduced TR severity in the majority of patients. While residual TR ≥3+ was associated with worse outcomes, no differences were observed for residual TR 1+ vs. 2+. Symptomatic improvement correlated with the degree of TR reduction.Figure 1- Residual TR after T-TEERFigure 2 - Predicting residual TR
Effective RV ejection fraction by CMR: a new index of RV function in patients with severe TR
Authors: Hinojar Baydes R , Ramos N , Rodriguez Palomares J , Eiros R , Barreiro M , Calero M J , Rodriguez Diego S , Gutierrez S , Galian L , Carrion I , Monteagudo J M , Gonzalez-Gomez A , Garcia Martin A , Fernandez-Golfin C , Zamorano J L
Published: October 2024

Background

Right ventricle (RV) dysfunction represent an formal indication for intervention in patients with significant tricuspid regurgitation (TR). RV ejection fraction (RVEF) by Cardiac Magnetic Resonance (CMR) is considered the gold standard of RV function; however it is influenced by changes of preload conditions and may remain unaffected until late stages in severe TR. Effective RV ejection fraction (eRVEF) is corrected by the amount of TR and may reflect an earlier parameter of RV dysfunction.

Purpose

To compare the prognostic impact of both indices of RV function: RVEF and eRVEF in a multicentre cohort of patients with severe TR.

Methods

Patients with at least severe TR assessed by 2D echocardiography with a contemporary cardiac magnetic resonance (CMR) study were included in this study. In addition to conventional parameters of biventricular volume and function, eRVEF was assessed in all patients. eRVEF was calculated according to the formula: eRVEF=net pulmonary forwardflow/RV− EDV (figure). A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined.

Results

271 patients with severe TR recruited from 5 tertiary care hospitals were included in this study (age 71 ± 11 years, 67% female, 83% NYHA I or II). Regarding the etiology, 10% were primary TR, 1% CIED-related TR, 46 % atrial secondary TR and 43% ventricular secondary TR. After a median follow-up of 27 months (IQR: 10-53 months), 41% of the patients (n=112) experienced the combined endpoint (n=97 were admitted due to HF, n=49 died). After adjusting for age, NYHA class, comorbidities, type of TR and LVEF in multivariate Cox proportional models, both RVEF and eRVEF were independently associated with all-cause mortality and heart failure (adj HR for RVEF HR per 1%=0.96 [0.94-0.98], p<0.001 and for eRVEF per 1%=0.98 [0.96-0.99], p<0.001). A value of eRVEF of ≤37% were associated with impaired prognosis (figure). eRVEF identified higher rates of RV dysfunction compared to RVEF (49% vs 38%, p<0.001). eRVEF was superior to RVEF to predict outcomes (higher AUC 0.70 [0.63-0.76] vs 0.66 [0.59-0.73, p<0.001; Δ C-statistic 0.139 [0.040-0.237], p=0.05).

Conclusion

RV function is crucial for determining optimal timing for TR intervention. eRVEF is corrected by the amount of TR and identify higher rates of RV dysfunction in severe TR. eRVEF held stronger association with outcome compared to RVEF.eRVEF calculationKaplan Meier Curves
AI-based algorithm for assessing coronary artery calcium score on contrast-enhanced cardiac computed tomography scans
Authors: Miszalski-Jamka K , Malawski F , Goslinski J , Witkowska M , Purgol P , Bujny M , Bartczak T , Malara W , Banach M , Kostur M
Published: October 2024

Introduction

In cardiac computed tomography (CT) examinations, non-contrast scans are often performed in addition to contrast-enhanced scans to quantify the coronary artery calcification (CAC) score. These calcium score scans are associated with additional exposure to ionizing radiation.

Purpose

We sought to develop a fully automated artificial intelligence (AI)-based algorithm capable of determining CAC score based solely on contrast-enhanced CT scans, eliminating the need for additional non-contrast scans.

Methods

An automated CAC scoring algorithm on contrast-enhanced CT scans was developed and trained using a dataset of 297 cardiac CT studies. Coronary artery calcifications were manually segmented in contrast-enhanced scans using a threshold of 2 standard deviations above the mean attenuation value of the ascending aorta. On non-contrast scans, CAC was manually assessed using a standard threshold of ≥130 Hounsfield Units. A correction factor for calcium score results assessed on contrast-enhanced scans was determined using linear regression. The algorithm was tested on an independent set of 90 contrast-enhanced CT scans (four manufacturers, eight scanner models). We compared automated CAC scores to manual expert reader reference assessments on non-contrast CT scans. CAC scores were categorized into four risk categories following the Society of Cardiovascular Computed Tomography recommendations: 0, 1-100, 101-300, and >300 Agatston Units.

Results

In the assessment of 90 CT studies (mean age 61.0±11.4 years, 46.7% males), the AI-model detected CAC in 69 contrast-enhanced scans (76.7%), comparable to the human reader's detection rate of CAC in 71 non-contrast scans (78.9%) (p = 0.63). The CAC score was initially calculated using AI-based segmentation of coronary calcification on contrast-enhanced scans and then the result was multiplied by established linear correction factor of 1.97. There was an excellent correlation between AI-model and manual reference total CAC scores (Pearson’s r = 0.96, 95% CI 0.94–0.97, p < 0.001). The model correctly classified 77 patients (85.6%) into the same CAC risk category as the human reader (Figure 1). Among 19 patients (21.1%) with a CAC score of zero, only 1 patient (5.3%) was reclassified with a non-zero CAC score by the AI-model. Cohen’s kappa value for CAC score risk categorization was 0.80 (p < 0.001), indicating very good agreement (Figure 2). Bland–Altman analysis revealed minimal bias of -9.7 Agatston Unit with 95% limits of agreement ranging from -184.8 to 165.5 Agatston Unit.

Conclusions

CAC score can be accurately quantified on contrast-enhanced cardiac CT scans using an automated AI-based algorithm. This approach has the potential to eliminate the necessity for an additional non-contrast CT scan, thereby reducing the patient's exposure to ionizing radiation.
Prevalence and prognostic significance of restriction versus systolic dysfunction in patients with transthyretin and light chain cardiac amyloidosis
Authors: Zampieri M , Biagioni G , Del Franco A , Canepa M , Porcari A , Merlo M , Tini G , Musumeci B , Longhi S , Biagini E , Argiro' A , Fumagalli C , Olivotto I , Perfetto F , Cappelli F
Published: October 2024

The tenet of cardiac amyloidosis (CA) as a paradigm of heart failure with restrictive ventricular physiology and preserved systolic function has come under scrutiny. Thus, we aimed to evaluate the prevalence and clinical significance of left ventricular (LV) systolic dysfunction versus restriction in a large real-world cohort with CA, assessed at the time of diagnosis.

Methods

This is a multicenter retrospective analysis including 540 transthyretin (ATTR)-CA and 280 light chain (AL)-CA.

Patients were divided into 3 phenotypes:

1) preserved LV function: LV ejection fraction (EF) ≥50% associated with grade 0/I diastolic dysfunction; 2) restriction: LV-EF≥50% associated with grade II/III diastolic dysfunction; 3) systolic dysfunction: LV-EF<50% irrespective of diastolic function.

We analysed progression from preserved LV function towards the other two phenotypes and their survival.

Results

In ATTR-CA, prevalence of preserved LV function was 27%, restriction was 44% and systolic dysfunction was 28%. Among patients with preserved LV function, annual conversion rate to restriction was 24% and to systolic dysfunction was 17%. At 3 years, survival free from all-cause mortality was 88%, 76% and 63% respectively (figure A).

In AL-CA, prevalence of preserved LV function was 30%, restriction was 49% and systolic dysfunction was 20%. Among patients with preserved LV function, annual conversion rate to restriction was 28% and to systolic dysfunction was 8%. At 3 years, survival free from all-cause mortality was 56%, 39% and 29% respectively (figure B).

Conclusions

Restriction was the presenting phenotype in less than half of patients, while systolic dysfunction in approximately one quarter. The annual rate of progression form preserved LV function towards restriction or systolic dysfunction was high. In ATTR systolic dysfunction was associated with worse outcome, compared to restriction; in AL both restriction and systolic dysfunction were associated with equally ominous outcome.
Comparative evaluation of approach sites in right ventricular biopsy: influence on complication rates, particularly conduction defects
Authors: Yoshida S , Takeji Y , Tada H , Nomura A , Takashime S , Usui S , Sakata S , Hayashi K , Fujino N , Takamura M
Published: October 2024

Background

Myocardial biopsy is an essential procedure for the diagnosis of myocarditis and cardiomyopathy. As specific treatment for secondary cardiomyopathies becomes available, EMB becoming increasingly important. Although the procedure can be performed safely at institutions familiar with the procedure, some institutions tend to hesitate to perform EMB because of procedural complications. In addition, complete right bundle branch block (CRBBB) is a complication of right ventricular biopsy (RV-EMB) that occurs at a certain rate. Therefore, Patient with complete left bundle branch block (CLBBB) often exibit reluctance to undergo RV-EMB due to the risk of complete atrioventricular block.

Although there are two approaches to RV-EMB, transfemoral vein and trans-intracavitary vein, and each institution is familiar with its approach, no study has ever looked at the difference in complication rates, mainly complete right bundle branch block, due to the different approach sites for right ventricular biopsy.

Aims

This study aims to examine the differences in complication rates, mainly CRBBB, due to differences in the approach site of the RV-EMB procedure.

Methods/Results

The subjects were 338 consecutive patients who underwent RV-EMB at our hospital between January 2017 and December 2022. We performed a retrospective analysis of 274 cases, excluding 43 cases that were originally CRBBB and 21 cases with ventricular pacing, ventricular fibrillation (VF), complete atrioventricular block from beginning to end, and no pre- and post-ECGs. The transfemoral venous approach group (Group TF) included 96 cases and the transjugular venous approach (Group TJ) included 178 cases, with Group TF using more warfarin (13.5% vs. 3.4%, p=0.004) and obtaining fewer specimens compared to Group TJ (3.0±1.0 vs. 3.8±0.6 pieces, p<0.001).

Transient CRBBB was present in 28 (29.2%) patients in Group TF and 12 (6.7%) patients in Group TJ (p<0.001); CRBBB persisted beyond 24 hours in 8 (8.3%) and 2 (1.1%) patients, respectively. There was one case of cardiac tamponade in Group TF and two cases of VF in Group TJ, but no cases of stroke, permanent pacemaker implantation, or death.

Multivariate logistic regression analysis showed that the transfemoral approach and corticosteroid administration emerged as independent predictor in the occurrence of CRBBB (p<0.001, odds ratio 0.17 and p=0.021, odds ratio 3.76, respectively.), whereas in cases of sustained CRBBB, solely the transfemoral approach stood as an independent predictor (p=0.002, odds ratio 0.07).

Conclusions

In RV-EMB, the transjugular venous approach has the potential to decrease CRBBB as a complication. The transjugular vein approach may be preferable in cases where complete AV block is a concern, such as patients who originally have CLBBB.
High-intensity exercise-related sudden cardiac death in hypertrophy cardiomyopathy
Authors: Lee H J , Gwak S Y , Kim K , Cho I , Shim C Y , Ha J W , Hong G R
Published: October 2024

Background

Whether exercise provokes sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM) is uncertain. Current European guidelines recommend against high-intensity exercise in individuals with high SCD risk or obstructive physiology.

Purpose

We investigated the factors associated with exercise-related SCD in HCM.

Methods

We retrospectively analyzed of 2,844 consecutive patients with HCM who underwent evaluation between 2005 and 2023 at a high-volume tertiary center. SCD events were defined as a composite of aborted SCD, appropriate implantable cardioverter-defibrillator (ICD) shock, and SCD. Among 80 first SCD events (2.8%), 75 events had a description of the physical activity at the time of the event. Patients were classified into two groups according to physical activity level at the time of the SCD event. Group 1 included patients with high-intensity exercise-related SCD events, defined as happening during or immediately after high-intensity exercise or physical activity, while Group 2 included patients with SCD events happening at rest or during light or moderate physical activity.

Results

The 75 first SCD events included 44 aborted SCD, 22 appropriate ICD shocks, and 9 SCD. Median age at SCD event was 54 (IQR 39.5–62.5) years and 60 (80%) were men. Patients in Group 1 (n=14) were younger than patients in Group 2 (n=61) (23.5 [IQR 16–48] vs. 55 [IQR 44–64] years, p<0.001), and most patients in group 1 (92.9%) were under the age of 60 years. Patients in Group 1 had slightly smaller left ventricular (LV) end-diastolic dimension and had higher ESC SCD risk scores (3.6 [IQR 2.5–6.7] vs. 2.4 [IQR 1.7–4.8], p=0.044) than patients in Group 2; however, there were no significant differences in the proportion of high-risk patients (28.6% vs. 14.8%, p=0.396) or patients with AHA major SCD risk factors (57.1% vs. 55.7%, p=0.999). Otherwise, there were no significant differences in the presence of obstructive physiology, apical HCM, and apical aneurysm, LV systolic and diastolic function, and comorbidities between the two groups. Furthermore, of the 29 patients who underwent genetic testing, there was no difference in the proportion of patients with pathogenic sarcomeric variants according to exercise-related SCD (50.0% vs. 65.2%, p=0.683). To note, there was a non-significant tendency towards higher proportion of thin filament variants in Group 1 than Group 2 among those with pathogenic sarcomeric variants (100% [3/3] vs 26.7% [4/15], p=0.084).

Conclusions

Most high-intensity exercise-related SCD events happened under the age of 60. The ESC SCD risk score was higher in patients with high-intensity exercise-related SCD events, although the SCD risk categories or AHA risk factors could not discriminate patients at higher risk of events. These results suggest that exercise recommendations should not be based on SCD risk category, presence of obstruction, or degree of LV hypertrophy.
Frailty, cognition and patient-reported outcomes in middle-aged and older adults with congenital heart disease: insights from an international multicentric study
Authors: Daelman B , Van Bulck L , Goossens E , Luyckx K , Kovacs A H , Moons P
Published: October 2024

Background

Prior research has demonstrated that a significant proportion of older patients with congenital heart disease (CHD) are frail or pre-frail and experience cognitive impairment. However, it remains unclear whether frailty and cognition are related to patient-reported outcomes (PROs) such as perceived health, anxiety and depression symptoms or quality of life in CHD.

Purpose

The objective of this study was to explore the relationships between frailty, cognitive function, and PROs in middle-aged and older adults with CHD ranging from mild to severe complexity.

Methods

As part of the cross-sectional ‘Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease – International Study II’ (APPROACH-IS II), we enrolled 814 individuals aged 40 years and older (median age: 52.0 years [45.0-61.0]; 51.4% female; 12.7% mild, 70.1% moderate, 17.2% complex CHD; 41.9% pre-frail, 5.8% frail; 38.7% cognitively impaired) across 17 centers in 11 countries. Frailty status was assessed using the Fried criteria, which categorize individuals into robust, pre-frail, and frail based on five factors: weakness, slow gait, unintentional weight loss, exhaustion, and low physical activity levels. Cognitive function was determined using the Montréal Cognitive Assessment. Participants completed questionnaires to evaluate perceived health (RAND-12 Health Survey, yielding both Physical and Mental Component Summaries, and EuroQOL-5D Visual Analog Scale), depressive symptoms (Patient Health Questionnaire-8), anxiety symptoms (General Anxiety Disorder scale-7), and quality of life (QoL Linear Analog Scale).

Results

Frailty was significantly associated with all PROs, with frail and pre-frail individuals reporting less favorable outcomes (see Figure). Cognitive function was linked to perceived health and anxiety, with patients exhibiting cognitive impairments reporting poorer perceived health and more anxiety symptoms.

Conclusion

This study indicates that concepts of frailty, cognitive functioning and PROs are closely related in adults with CHD. Frailty and cognition thus represent important domains when developing strategies to optimize PROs in adults with CHD. Moreover, when working with patients who are frail or cognitively impaired, healthcare workers are encouraged to consider and inquire about potential impact on PROs. Longitudinal research is needed to explore the direction of the association.
White Smoke in the Intermediate risk PE debate, could POPE be the solution?
Authors: Martins A , Garcia A B , Oliveira C , Abrantes A , Azaredo Raposo M , Gregorio C , Esteves S , Silva B V , Nobre De Menezes M , Jorge C , Pinto F J
Published: October 2024

Introduction

In spite of a multitude of innovative therapeutic strategies emerging in the past decade, acute pulmonary embolism (PE) remains a potentially fatal disease. However, mortality varies significantly according to risk stratification, substantiating current recommendations to use reperfusion therapy only in hemodynamically unstable patients. There is an ongoing debate around whether hemodynamically stable patients showing signs of right ventricle dysfunction and myocardial injury (intermediate-high risk acute PE) may also benefit from reperfusion therapy. While the majority of patients in this category typically improve with anticoagulation alone, up to 10% may experience clinical deterioration.

Aim

We aimed to characterize the clinical in-hospital progression of patients with intermediate-risk PE and to evaluate the discriminative efficacy of PE scores in anticipating unfavorable clinical outcomes.

Methods

We conducted a retrospective observational study in patients admitted with the diagnosis of PE classified as intermediate risk in a tertiary center. Clinical, laboratory and ECG data were obtained. The BOVA score, the News score and the Pope score were evaluated. A composite endpoint of in-hospital mortality and use of reperfusion therapy due to hemodynamic deterioration was defined. Predictive abilities of these three scores were compared using area under the receiver operating characteristics (AUC-ROC) curve.

Results

From January 2019 to December 2020, a total of 166 patients were admitted with acute PE, classified as intermediate-risk, in our center. The mean age 71.9 ± 16.2 years and 57.2% were female. 71.1% of the pts showed bilateral PE in chest CT. The composite endpoint of in-hospital mortality and reperfusion therapy due to hemodynamic deterioration occurred in 9.8% of the pts.

The median BOVA score was 3 (2-4), the median POPE score was 1 (0-2) and the median News score was 4 (2-6). The ROC curve analysis showed a significant higher discriminative power of POPE score compared to the other scores (AUC 0.856 95%CI 0.79–.92, p<0.001) (Fig1). Compared to patients with a POPE score 1, the composite endpoint was 4,6 times higher in patients with higher scores (OR 4.6 95%CI 1.63- 6914, p=0.029) (Fig2).

Conclusion

Despite classification as intermediate risk, these patients displayed a non-negligible in-hospital mortality rate. Close clinical monitoring is warranted in this group of pts and there is pressing need for an early identification of those who might benefit from more than just anticoagulation. In our population POPE score showed to be a simple and accurate tool in predicting those with an unfavorable evolution that could have benefitted from more advanced intervention.
Deep learning approaches for image restoration in invasive coronary angiography
Authors: Oh S U , Park H B , Jeong H S , Lee J N , Heo R , Hong Y T , Chang H J
Published: October 2024

Background

Despite being the gold standard for diagnosing coronary artery disease and guiding percutaneous coronary interventions (PCI), image restoration during invasive coronary angiography (ICA) has rarely been explored. Generative adversarial network (GAN), a deep learning model, has demonstrated its effectiveness in image restoration. Our hypothesis was that we could restore ICA images, damaged or deleted to varying degrees, using the inpainting GAN method, and we undertook efforts to test this hypothesis.

Methods

We extracted 22,659 ICA patch images (128 × 128 size) from 60 patients, focusing on sparse vessels for model training. To assess our inpainting GAN model, we degraded the extracted images to varying degrees: minimal, mild, moderate, severe, and completely blocked. The performance was quantitatively analyzed using metrics such as the peak signal-to-noise ratio (PSNR), structured similarity indexing methods (SSIM), and mean squared error (MSE).

Results

The inpainting GAN method significantly improved the image quality in all degraded images. For the blocked images, PSNR and SSIM were enhanced by 161.9% and 14.3%, respectively, with a 98% MSE reduction. In severely, moderately, mildly, and minimally damaged images, PSNR and SSIM increased by 14.9% and 14.8%, 15.7% and 14.7%, 19.3% and 15.6%, and 12.7% and 5.3%, respectively, with MSE reductions of 61.5%, 64.1%, 72.7%, and 33.9%, respectively.

Conclusions

Inpainting GAN can restore ICA images with varying damage levels, including deletions. Our deep-learning model can instantaneously improve ICA image quality, potentially aiding in emergency or chronic total occlusion PCI.Table 2.Quantitative Analysis of ImageFigure 1.Sample Cases Pre and Post-Rest
Impact of intravascular imaging on mortality in patients undergoing left main coronary artery PCI. Propensity score matching analysis of the high-volume single centre registry
Authors: Dabrowski E J , Dobrzycki S , Kralisz P , Nowak K , Gugala K , Prokopczuk P , Kuzma L , Swieczkowski M , Kozuch M
Published: October 2024

Background

Recent guidelines endorsed use of intravascular imaging in left main coronary artery (LMCA) percutaneous coronary intervention (PCI). However, impact of adjunctive percutaneous imaging tools on mortality is ambiguous.

Purpose

The purpose was to investigate impact of intravascular imaging (IVI) on all-cause mortality in patients with LMCA disease.

Methods

Group of 998 individuals undergoing LMCA PCI was selected from medical records of patients hospitalized in years 2008-2022. Data on mortality were obtained from the Ministry of Digital Affairs. Overall observation time was 14 years (mean 4.3 years). Survival analysis was performed using Cox proportional hazard regression in the overall and propensity-score matched (PSM) population.

Results

The median age was 71 y.o. (IQR 16), 265 (41.0%) of patients presented with acute myocardial infarction and 183 (20.7%) had history of previous coronary artery bypass grafting (CABG). IVI-guided PCI was performed in 353 (35.4%) patients.

In the overall unmatched population, IVI reduced one-year and long-term mortality by 70% (HR 0.3, 95% 0.19-0.47, P<0.001) and 57% (HR 0.43, 95% CI 0.34-0.55, P<0.001). In the subgroup analysis stratified on the history of previous CABG, in patients with unprotected LMCA, IVI resulted in 74% and 63% mortality reduction in the one-year and long-term follow-up (HR 0.26, 95% CI 0.16-0.42, P<0.001; HR 0.37, 95% CI 0.28-0.47, P<0.001; respectively). No influence of IVI on patients with previous CABG was observed.

After PSM adjustment for baseline and angiographical characteristics, in the overall population IVI was still associated with significant one-year (HR 0.49, 95% CI 0.25-0.99, P=0.045) and long-term mortality reduction (HR 0.65, 95% CI 0.44-0.97, P=0.03). In patients with unprotected LMCA disease, IVI reduced mortality in two-year observation (HR 0.49, 95% CI 0.26-0.91, P=0.02) and long-term follow-up (HR 0.62, 95% CI 0.41-0.93, P=0.02), with no significant effect in one-year observation. No effect of IVI was observed in the PS-matched cohort of patients with previous CABG.

Conclusions

Intravascular imaging is associated with significantly better survival in patients undergoing LMCA PCI. The greatest benefit may be obtained in patients with no previous history of CABG. Further studies should investigate subgroups that benefit the most from adjunctive percutaneous tools.PS-matching detailsKaplan-Meier curves in subgroups
Comparison of adenosine, dobutamine and bicycle exercise on intracoronary physiological indices in patients with myocardial bridges
Authors: Sinha A , Rahman H , Rajani R , Demir O , Morgan H , De Silva K , Ryan M , Likamwa M , Ezad S , Ellis H , Hogan D , Shah A , Webb A , Marber M , Perera D
Published: October 2024

Background

We have recently demonstrated that patients with angina and nonobstructive coronary arteries (ANOCA) with myocardial bridges (MBs) exhibit maladaptive exercise physiology, due to abnormal wave energies arising at the tunnelled segment (1). Intracoronary pressure-derived indices in response to dobutamine and adenosine are used to identify an ischaemic substrate in these patients in clinical practice (2). However, it remains unknown if the changes induced by dobutamine and adenosine are comparable with physical exercise.

Methods

Patients with ANOCA and a MB in the left anterior descending artery underwent simultaneous acquisition of intracoronary pressure and flow sequentially during rest, supine bicycle exercise and intravenous adenosine and dobutamine infusion. We compared coronary perfusion efficiency (accelerating energy/total energy flux) and changes in specific wave energies in response to these three stressors.

Results

Twenty-five patients were enrolled (36% females, 59±9 years old). Patients had a high symptom burden (88% CCS II-IV) and myocardial bridge muscle index (79±30). Fractional flow reserve and coronary flow reserve were 0.86±0.05 and 2.5±0.5. Microvascular resistances during adenosine, dobutamine and exercise were 2.0±0.7, 3.4±1.4 and 4.3±1.3 mmHg.cm-1.s-1 respectively (p<0.001). There was a reduction in coronary perfusion efficiency in response to adenosine (64±8% to 51±12%), dobutamine (65±9% to 53±13%) and exercise (66±10% to 56±9%) (all p<0.001), with no between stressor differences in delta perfusion efficiency (ANOVA p=0.641). However, the impact of each stressor on the wave energy arising from the tunnelled segment was different whereas no such difference (between stressors) was observed in the wave energies arising from the microcirculation. There was no difference in tunnelled-segment derived delta wave energies between dobutamine and exercise (Figure 1).

Conclusions

Adenosine, dobutamine and exercise have different effects on coronary microvascular resistance and cardiac coronary coupling in patients with myocardial bridges. Our findings provide novel mechanistic insights into the pathophysiology of ANOCA in combination with MB, and suggest that dobutamine (but not adenosine) could be used as a surrogate for physical exercise during intracoronary physiological assessment.Figure 1.
Trends in intracardiac thrombus formation in myocardial infarction patients after PCI: a nationwide analysis
Authors: Perry J , Adarsh Balaji A B , Allen Mcnamara A M , Kibwey Peterkin K P , Akinti O A , Sinclair S , Khan A
Published: October 2024

Background

Percutaneous coronary interventions (PCI) have become a crucial therapeutic option for myocardial infarction (MI) patients. However, the clinical outcomes and complications associated with PCI, especially in relation to intracardiac thrombus, remain a subject of concern.

Purpose

We aimed to examine the real-world clinical outcomes and temporal trends of in-hospital mortality and intracardiac thrombus among myocardial infarction patients treated with PCI between 2017 and 2020.

Methods

The National Inpatient Sample was queried from 2017 to 2020 to identify all adults with myocardial infarction (ST elevation and Non-ST elevation MI) who underwent PCI using the International Classification of Diseases, 10th Revision codes. The Cochran-Armitage test assessed the linear trend of in-hospital intracardiac thrombus and mortality. Multivariable regression analysis was conducted to assess the association of PCI with in-hospital mortality and intracardiac thrombus. The Charlson comorbidity index was used to adjust for confounders. Results are represented as adjusted odds ratios (ORs) with their respective 95% confidence intervals (CIs).

Results

Of the 1,394,650 patients who underwent PCI, 8,080 (0.58%) experienced intracardiac thrombus, with a mean age of 62, predominantly male (76%). Despite decreasing rates of PCI noted over this 4-year period (Figure 1). There was an upward trend in in-hospital intracardiac thrombus revealed over a 4-year period (trend: 0.54%, p < 0.001). PCI was associated with a yearly increase in intracardiac thrombus in 2018 in 0.54% of patients (OR = 1.36, 95% CI 1.2 to 1.6, p < 0.001). In 2019, 0.56% of patients experienced intracardiac thrombus (OR = 1.4, 95% CI 1.2 to 1.6, p = 0.001); in 2020, 0.72% of patients (OR = 1.8, 95% CI 1.6 to 2.1, p = 0.008), compared to 2017 (0.4%). Mortality rates for PCI and ICT patients were 6% in 2017 (OR 2.2, p < 0.001, 95% CI 1.4-3.2), decreased to 5% in 2018 (OR 1.8, p < 0.004, 95% CI 1.2-2.6) and 4.7% in 2019 (OR 1.6, p < 0.01, 95% CI 1.1-2.4), then rose to 6.6% in 2020 (OR 2, 95% CI 1.4-2.8) (Table 1). Overall, in-hospital mortality was 5.6% (OR = 1.6, 95% CI 1.3 to 1.9, p < 0.001) among patients who had intracardiac thrombus related to PCI.

Conclusions

Our findings indicate a significant increase in intracardiac thrombus rates among MI patients treated with PCI from 2017 to 2020, accompanied by a considerable risk of in-hospital mortality. These outcomes underscore the critical need for vigilant monitoring and enhanced management approaches in this patient demographic.Figure 1Table 1