bluuebunny/crossref_metadata_2025 huggingface dataset:
108 Atrial fibrillation effects on coronary perfusion across the different myocardial layers: a computational analysis
Authors: Saglietto Andrea , Scarsoglio Stefania , Fois Matteo , Ridolfi Luca , De Ferrari Gaetano Maria , Anselmino Matteo
Published: December 2021

Aims

Atrial fibrillation (AF) patients may present ischaemic chest pain in the absence of classical obstructive coronary disease. Among the possible causes, the direct haemodynamic effect exerted by the irregular arrhythmia has not been studied in detail.

Methods and results

A computational fluid dynamics analysis was performed by means of a 1D-0D multiscale model of the entire human cardiovascular system, characterized by a detailed mathematical modelling of the coronary arteries and their downstream distal microcirculatory districts (subepicardial, midwall, and subendocardial layers). Three mean ventricular rates were simulated in both sinus rhythm (SR) and AF: 75, 100, 125 b.p.m. We conducted inter-layer and inter-frequency analysis of the ratio between mean beat-to-beat blood flow in AF compared to SR (Q¯AP/Q¯SR Inter-layer analysis showed that, for each simulated ventricular rate, Q¯AP/Q¯SR progressively decreased from the epicardial to the endocardial layer in the distal left coronary artery districts (P-values < 0.001 for both left anterior descending artery—LAD, and left circumflex artery—LCx), while this was not the case for the distal right coronary artery (RCA) district. Inter-frequency analysis showed that, focusing on each myocardial layer, Q¯AP/Q¯SR progressively worsened as the ventricular rates increased in all investigated microcirculatory districts (LAD, LCx, and RCA) (P-values < 0.001 for all layer-specific comparisons).

Conclusions

AF exerts direct haemodynamic consequences on the coronary microcirculation, causing a reduction in microvascular coronary flow particularly at higher ventricular rates; the most prominent reduction was seen in the subendocardial layers perfused by left coronary arteries (LAD and LCx).
178 Catheter inversion during cavotricuspid isthmus catheter ablation: the new shaft visualization catheter reduces fluoroscopy use
Authors: Sisti Nicolò , Santoro Amato , Baiocchi Claudia
Published: December 2021

Aims

Catheter ablation (CA) is the choice therapy of cavotricuspid isthmus (CTI) atrial flutter. The aim of this study was to describe our approach to improve the CTI ablation using a zero-fluoroscopy (ZF). The procedural difficulties could be related to anatomical characteristics of the CTI.

Methods and results

One hundred eighty-eight patients that performed CA of CTI were retrospectively and consecutively evaluated between 2017 and 2019. The studied population was divided into two groups. Eighty-eight patients who were undergone CA using ablation catheter without shaft visualization catheter (NSV) were Group 1. One hundred patients were undergone CA using ablation catheter with a shaft visualization (SV); they were Group 2. The catheter was looped at the Eustachian ridge after 200 s of radiofrequencies (RF) without elimination of local electrogram. A conduction line block of CTI was obtained in all patients of Group 2 using a ZF approach. In 16 patients of Group 1, the catheter inversion was obtained using fluoroscopy to avoid damages during its loop. In Group 2, a complete CTI block was obtained with a catheter inversion approach in 10 patients without fluoroscopy, visualizing the shaft and the tip of the ablation catheter on the electroanatomic (EAM) map. In the overall population studied the use of SV had a linear correlation with the ZF approach (r = 0.629; P < 0.001). The duration of RF was lower in Group 2 than in Group 1 (Group 1: 27.8 ± 6.3 vs. Group 2: 15.6 ± 7.2 min; P < 0.01). The procedure time between two groups was lower in Group 2 than in Group 1 (Group 1: 58.4 ± 22.4 vs. Group 2: 42.2 ± 15.7 min; P < 0.01). No differences between two groups were documented regarding success and complications.

Conclusions

The visualization of the shaft’s catheter on the EAM permitted the catheter inversion safely in order to overcome some complex CTI anatomy and obtain bidirectional block. The SV reduced procedure time, RF applications, and fluoroscopy exposition during CTI ablation.
286 Incidence of pocket haematoma with different anticoagulation strategies in patients undergoing cardiac implantable device implant or revision
Authors: Spinoni Enrico Guido , Santagostino Matteo , Costantino Simona , Battistini Eleonora , Dell’Era Gabriele , Porcellini Stefano , De Vecchi Federica , Mennuni Marco , Patti Giuseppe
Published: December 2021

Aims

Direct oral anticoagulants (DOACs) are known for lower bleeding risk than vitamin K antagonist (VKA) in patients with atrial fibrillation (AF). To date, it has not been established whether in such population DOAC may offer reduction of bleeding complication in patients undergoing cardiac implantable electronic device (CIED) implant or revision (substitution, upgrade, or downgrade). We evaluated whether DOACs compared to VKAs, decrease bleeding complications at the time of CIED implant in patients with AF, requiring oral anticoagulant therapy.

Methods and results

We present a monocentric observational retrospective study. Patients undergoing implant, generator replacement, or upgrading/downgrading of an intracardiac device (PM, ICD, or CRT) between January 2015 and March 2021 with AF undergoing DOAC or VKA were included. The comparison of risk of clinically significant pocket hematoma at 30-days follow-up in the two-treatment group [DOAC vs. VKA and DOAC vs. VKA without low molecular weight eparin (LMWH) bridge] was performed. Cox proportional hazards regression analysis including main clinical findings was performed to test the primary endpoint. Propensity score matching analysis was performed, with inversed proportional weighted (IPW) propensity score included in the multivariate analysis. 311 patients were included, 146 (46.9%) treated with DOAC and 165 (53.1%) treated with VKA. The incidence pocket haematoma was significantly reduced in patients treated with DOAC compared with VKA (3.4% vs. 13.3%, respectively, P = 0.002), a finding confirmed on multivariate analysis (HR: 3.02, CI: 1.10–8.29, P = 0.032). The incidence of pocket haematoma in patients on DOAC vs. VKA without LMWH bridge therapy was found to be significantly higher in the latter group of patients (P = 0.033, HR: 2.93, CI: 1.01–8.49, P = 0.48). After adjusting at propensity score with IPW, DOAC use showed decreased risk of pocket haematoma (HR: 0.29, CI: 0.09–0.95, P = 0.42).

Conclusions

In patients with atrial fibrillation undergoing CIED implant or revision, DOAC therapy appears to be associated with lower risk of event-related pocket haematoma at 30-day follow-up, even in the absence of bridging with LWMH. Such findings are hypothesis-generating.
473 Propensity-matched comparison of left atrial appendage occlusion and direct oral anticoagulation for thromboembolic prevention in octogenarians
Authors: Magnocavallo Michele , Della Rocca Domenico Giovanni , Lavalle Carlo , Chimenti Cristina , Carola Gianni , Mohanty Sanghamitra , Trivedi Chintan , Bassiouny Mohamed , Al-Ahmad Amin , Burkhardt David J , Gallinghouse Joseph G , Sanchez Javier E , Horton Rodney P , Natale Andrea
Published: December 2021

Aims

A significant amount of atrial fibrillation patients does not receive appropriate anticoagulation, owing to contraindications and side effects. Octogenarians have higher competing comorbidities with a remarkable bleeding/thromboembolic (TE) risk. We aimed at analysing the clinical outcomes of LAAO compared with direct oral anticoagulation (DOAC) in octogenarians.

Methods and results

Data were extracted from two prospective databases including 488 LAAO and 825 DOAC patients. Patients aged 80 years or older accounted for 37.1% (n = 181) and 39.5% (n = 326). In order to attenuate the imbalance in covariates between the groups, a propensity score matching technique was used (covariates: age, sex, CHA2DS2-VASc, and HAS-BLED scores, follow-up duration; tolerance 0.02). This method resulted in matched populations with 108 octogenarian patients per group. The annual stroke/transient ischaemic attack (TIA) risk was estimated based on the CHA2DS2-VASc, and compared to the annualized observed risk, owing to calculate the % risk reduction associated with the two treatment strategies. A total of 216 octogenarians were included in the analysis (84 ± 3 years; CHA2DS2-VASc: 4.9 ± 1.4, HAS-BLED: 3.1 ± 0.9). A Watchman device was successfully deployed in all LAAO ≥ 80 patients; periprocedural adverse events were observed in 2.8% (n = 3) of LAAO patients. During a follow-up of 13 ± 4 months, 3 (2.8%) TE complications (1 stroke, 2 TIA) occurred in LAAO ≥ 80 pts and 4 (3.7%; 1 stroke, 3 TIA) in DOAC ≥ 80 pts (P = 0.99). The annualized risk of stroke/TIA was 2.5% in the first and 3.5% in the second group. Based on the estimated annual TE risk according to the CHA2DS2-VASc score, the % risk reduction after LAAO and DOAC was 54.5% and 36.4%, respectively. Major bleeding events were 3 [1 intracranial, 2 gastrointestinal (GI)] LAAO ≥ 80 pts, and 3 (2 intracranial, 1GI) in DOAC ≥ 80 pts (2.8% in both groups). Minor bleeding events were significantly higher in DOAC ≥ 80 pts [13.0% (n = 14) vs. 2.7% (n = 3); RR: 4.7, 95% CI: 1.4–15.7; P = 0.009].

Conclusions

LAAO was safe and similar to DOAC at preventing ischaemic/major bleeding events in a matched population of patients aged ≥80 years. A significantly higher incidence of minor bleeding events was observed in the DOAC group.
51 Palmitoylethanolamide associated to polydatin reduces inflammation in human endothelial vascular cells exposed to doxorubicin and trastuzumab through PPAR-a and NLRP3-related pathways
Authors: Quagliariello Vincenzo , Iovine Martina , Maurea Carlo , Buccolo Simona , Paccone Andrea , Maurea Nicola
Published: December 2021

Aims

Palmitoylethanolamide is an endogenous fatty acid mediator that is synthetized from membrane phospholipids by N-acyl phosphatidylethanolamine phospholipase D. Polydatin is a nutraceutical agent derived from trans-resveratrol with established anti-inflammatory and anti-atherogenic properties. We aimed to assess whether palmitoylethanolamide combined to polydatin, co-incubated during doxorubicin and trastuzumab, reduces anticancer drugs-related cardiotoxicity in cellular models.

Methods

Human vascular endothelial cells were exposed to subclinical concentration of doxorubicin (at 100 and 200 nM) combined to trastuzumab (at 100 and 200 nM) alone or in combination with a formulation composed by palmitoylethanolamide and polydatin (500 nM and 50 µM, respectively) for 48 h. After the incubation period, we performed the following tests: determination of cell viability, through analysis of mitochondrial dehydrogenase activity, study of lipid peroxidation (quantifying cellular Malondialdehyde and 4-hydroxynonenal), intracellular Ca2+ homeostasis. Moreover, pro-inflammatory studied were also performed (activation of NLRP3 inflammasome; expression of peroxisome proliferator-activated receptor-α; mTORC1 Fox01/3a; transcriptional activation of p65/NF-κB and secretion of cytokines involved in cardiotoxicity (Interleukins 1β, 8, 6).

Results

Palmitoylethanolamide combined to polydatin co-incubated with doxorubicin exerts vasculoprotective effects, enhancing cell viability of 54.7–68.3% compared to untreated cells (P < 0.001 for all). The formulation reduced significantly the cardiotoxicity through peroxisome proliferator-activated receptor-α–related pathways and NLRP3 inflammasome but without the involvement of calcium homeostasis.

Conclusion

The present study demonstrates that palmitoylethanolamide and polydatin protects against vasculotoxicity of doxorubicin and trastuzumab by promoting an anti-inflammatory phenotype, representing a new therapeutic approach to resolve doxorubicin-induced vasculotoxicity and inflammation.
61 Right ventricular function in patient with heart failure with reduced ejection fraction and sacubitril/valsartan treatment
Authors: Mazzeo Pietro , Fortunato Martino , Croella Francesca , Alfieri Simona , Fanizzi Angela Ilaria , Furore Andrea , Ferrara Salvatore , Tricarico Lucia , Correale Michele , Iacoviello Massimo , Di Biase Matteo , Brunetti Natale D
Published: December 2021

Aims

Observational studies have demonstrated that treatment with sacubitril/valsartan may improve left ventricular (LV) systolic and diastolic function in subjects with reduced LV ejection fraction (LVEF) in real-world studies. Subjects with heart failure and reduced EF (HFrEF), however, are also characterized by an impaired right ventricular (RV) function. We therefore aimed to evaluate whether also RV function may improve after S/V therapy and possible predictors of RV improvement could be identified at echocardiography and tissue Doppler imaging.

Methods

Fifty consecutive patients (67 ± 8 years, LVEF 28 ± 6%, male 86%) with chronic HFrEF and NYHA Classes II–III were followed up for 6 months after therapy with S/V. LV&RV function was assessed at baseline and after 6 months of therapy.

Results

After 6-month therapy with S/V a significant improvement was shown in the following echocardiography parameters assessing RV function: PAsP (31 ± 11 vs. 35 ± 10 mmHg, P < 0.001), TAPSE (19 ± 3 vs. 18 ± 3 mm, P < 0.001), RV FAC (38 ± 7 vs. 34 ± 6 mm, P < 0.001), RV S’ (12 ± 2 vs. 10 ± 2 cm/sec, P < 0.001), RV-FW-LS (−20 ± 5 vs. −18 ± 5%, P < 0.001), RV-4Ch-LS (−16 ± 5 vs. −14 ± 5%, P < 0.001). At multivariable analysis improvement in RV-FW-LS was associated to baseline levels of RV S’ (r 0.75, P < 0.01) and RAV (r –0.32, P < 0.05).

Conclusions

In a real-world scenario, 6-month therapy with S/V was associated with an improved RV function in HFrEF. RV function improvement may be predicted by assessing baseline RV S’ and right atrial volume values.
411 Reproducibility and applicability of automated speckle tracking echocardiography in patients with aortic valve stenosis
Authors: Butturini Caterina , Fanti Diego , Springhetti Paolo , Tadiello Enrico , Bergamini Corinna , Rossi Andrea , Ribchini Flavio Luciano , Benfari Giovanni
Published: December 2021

Aims

New speckle tracking echocardiography (STE) tools allow an automated detection of strain measurements, but in case of suboptimal image quality or electrocardiogram signal, both regions-of-interest (ROIs) tracking and cardiac cycle’s landmarks need to be edited. In this study, we aimed to assess the variability of STE measurement performed with Tomtec’s Autostrain LV/RV/LA® application across different operators’ expertise in patients with significant aortic valve stenosis, known to have often suboptimal acoustic windows.

Methods and results

Automated strain analysis was performed by two observers with different levels of expertise in STE (a student sonographer and a trained cardiologist) on scans from 30 consecutive patients with moderate to severe aortic stenosis. Interobserver variability was tested. Intra-observer variability was also assessed repeating measurements about one month after the first set. Manual editing of the automated ROIs or cardiac cycle landmarks tracing results was manually made from both users on the majority (>80%) of examinations; notably RV strain analysis required the least editing. At repeated measurement test (Figure), the average strain values were not found to be significantly different for measurements of apical-four-chamber-global-longitudinal-strain (A4C-GLS) (mean difference 0.96%, P = 0.08), left-atrium-longitudinal strain (LALS) (peak-atrial-longitudinal-strain, PALS, mean difference −0.89% P = 0.37; peak-atrial-contraction-strain, PACS, mean difference −0.76%, P = 0.13) and right-ventricle-free-wall-strain (RV-FWS) (mean difference 0.44%, P = 0.59). A stronger agreement between testers was observed for patients with markedly reduced left-ventricle-global-longitudinal-strain (LV-GLS) and was not affected by the quality of acoustic windows. Similar trend was evident for the left atrial and right ventricular parameters.

Conclusions

New tool AutoStrain LV/RV/LA® for automated strain analysis showed a good agreement between operators with different levels of expertise in the challenging setting of patients with aortic valve stenosis. The reproducibility was particularly accurate for A4C view and in patients with worse LV-GLS values, independently from image quality.
704 Stress echocardiography: myocardial work ‘works’
Authors: Cusma Maurizio , Caminiti Rodolfo , Parlavecchio Antonio , Vizzari Giampiero , Fichera Nunzio , Mancini Nastasia , De Sarro Rosalba , Trio Olimpia , Manganaro Roberta , Carerj Scipione , Di Bella Gianluca , Micari Antonio , Zito Concetta
Published: December 2021

Stress echocardiography is a widely employed diagnostic technique relying on subjective assessment of left ventricular wall motion and particular expertise. We report a case of a male patient with chronic coronary syndrome, who underwent dipyridamole echocardiography before planned non cardiac surgery. Despite the absence of symptoms and relevant electrocardiographic and wall motion changes, only 2D strain and, especially, Myocardial Work analysis was able to detect abnormalities suggestive of myocardial ischaemia. Thus, coronary angiography was performed, showing critical stenosis of the proximal Circumflex artery, that was treated with angioplasty and drug-eluting stent implantation. Interestingly, the location of strain and myocardial work abnormalities was consistent with the culprit vessel territory. This case highlights the particular usefulness of advanced echocardiographic techniques, especially for the detection of one-vessel coronary artery disease, during stress echocardiography.
491 Short-term prognostic implications of left ventricular myocardial work indices in advanced heart failure patients treated with repetitive Levosimendan infusions
Authors: Fazzari Fabio , Cannata Francesco , Banfi Daniele , Pellegrino Marta , Pagliaro Beniamino , Loiacono Ferdinando , Mantovani Riccardo , Donghi Valeria , Curzi Mirko , Maurina Matteo , Condello Francesco , Liccardo Gaetano , Francone Marco , Condorelli Gianluigi , Stefanini Giulio Giuseppe , Pini Daniela , Bragato Renato Maria
Published: December 2021

Aims

Repetitive Levosimendan treatment in advanced heart failure patients has not been investigated yet via myocardial work indices (MWI), which could more accurately detect the effects of this both inotropic and vasodilatory drug. The aims of this study were (1) to describe variations of myocardial work indices, as a consequence of repetitive Levosimendan infusions and (2) to assess the prognostic value of myocardial work parameters in these patients.

Methods and results

Fourteen patients with advanced heart failure treated with intermittent in-hospital levosimendan infusions were prospectively included. Clinical, laboratory, and echocardiographic assessment were performed before and after every Levosimendan infusion. The primary endpoint was a composite of any episode of decompensated HF, urgent HF rehospitalization, cardiogenic shock, cardiac arrest and cardiovascular death at 4–6 weeks follow-up after each planned infusion. During follow-up (mean: 150 ± 99 days) a total of 37 infusions were performed and a total of 11 cardiovascular events occurred. Global constructive work (GCW), global work efficiency (GWE), and global work index (GWI) increased after Levosimendan infusion in 62.2%, 73.0%, and 70.3% of cases, with significant differences between patients with and without outcomes [delta GCW: −7.36 mmHg% (134.12) vs. 113.81 mmHg% (204.41), P = 0.007; delta GWE: −3.27% (8.38) vs. 4.30% (5.58), P = 0.002]. Delta value of GWE showed the largest area under curve (AUC: 0.82, 95% CI: 0.64–1.00, P = 0.002) for outcome prediction with a cut-off point of 0.5%. Independent prognostic value of GWE variation was confirmed in multivariable regression models (OR: 0.825, 95% CI: 0.702–0.970, P = 0.02).

Conclusions

GWE and GCW provided incremental and independent prognostic value at short-term follow-up over traditional echocardiographic parameters. The differentiation of patients into ‘workers’, whose GWE improved after Levosimendan infusion, and ‘non-workers’, who failed to improve their GWE, permitted to identify patients at higher risk of forthcoming cardiovascular events. Monitoring these patients with MWI may have relevant clinical implications.
750 Mitral annulus disjunction in consecutive patients undergoing cardiovascular magnetic resonance: arrhythmogenic substrate or anatomical variant?
Authors: Figliozzi Stefano , Bombace Sara , Stankowski Kamil , Olivieri Marzia , Lofino Ludovica , Di Dedda Emanuele , Donghi Valeria , Cannata Francesco , Mantovani Riccardo , Fazzari Fabio , Curzi Mirko , Bragato Renato M , Stefanini Giulio G , Francone Marco , Condorelli Gianluigi , Monti Lorenzo
Published: December 2021

Aims

Mitral annulus disjunction (MAD) has been associated with sudden cardiac death in selected patients with arrhythmic presentation, while its clinical significance in unselected cohorts remains unknown. Our purpose was to assess the prevalence and clinical significance of MAD in consecutive patients referred to cardiovascular-magnetic-resonance (CMR).

Methods and results

Our population included 103 consecutive patients undergoing CMR at our Institution, between August and September 2021. MAD was defined as a  ≥ 1 mm atrial displacement of the mitral leaflet hinge point in standard long-axis cine images during end-systole. MAD analysis was performed in 97 patients (feasibility = 94%) and resulted positive in 49 (51%). MAD—patients were more often males (75% vs. 57%; P = 0.045) and affected by ischaemic (35% vs. 12%, P = 0.01) and non-ischaemic cardiomyopathy (38% vs. 16%, P = 0.026) compared to MAD+ patients. No significant differences were found in terms of age, history of ventricular arrhythmias, bi-ventricular and bi-atrial volumes, bi-ventricular ejection fraction, native T1 and T2 mapping values, extracellular volume, and prevalence of late gadolinium enhancement (P > 0.05 for all) between MAD + vs. MAD—patients. MAD extent was higher in patients with mitral valve prolapse (MVP; n = 7), (3.5 ± 1.5 mm in MVP+ vs. 2.0 ± 1.0 mm in MVP– patients; P = 0.004). No significant differences were conversely found in MAD extent between patients with and without ventricular arrhythmias (2.5 ± 1.1 mm vs. 2.3 ± 1.1 mm; P = 0.815).

Conclusions

Our findings suggest a high prevalence of MAD in unselected cohorts of patients, with no clinical significance. Prospective studies are needed to further elucidate the interplay between MAD and malignant ventricular arrhythmias in unselected cohorts of patients.
70 Estimation of pulmonary arterial pressures by tricuspid regurgitation: a comparison with invasive data
Authors: Landra Federico , Mandoli Giulia Elena , Chiantini Benedetta , Barilli Maria , Merello Giacomo , De Carli Giuseppe , Sciaccaluga Carlotta , Lisi Matteo , Focardi Marta , D’Ascenzi Flavio , Fineschi Massimo , Iadanza Alessandro , Bernazzali Sonia , Valente Serafina , Cameli Matteo
Published: December 2021

Aims

The evaluation of the haemodynamic of pulmonary circulation is essential in various pathological conditions. Right heart catheterization (RHC) is the gold standard for the measurement of pressures and resistances in this context. However, since indications for RHC are limited, a more accessible estimation method would be helpful. This study aimed to explore the reliability of an echocardiographic method based on tricuspid regurgitation (TR) to estimate mean, systolic and diastolic pulmonary arterial (PA) pressures in a cohort of patients with advanced heart failure considered for heart transplantation.

Methods and results

All consecutive patients with advanced heart failure considered for heart transplantation from 2016 to 2021 that had already performed right heart catheterization (RHC) as part of the workup and with an available echocardiographic exam were included (n = 91). Mean PA pressure was obtained adding mean right ventricular-right atrial (RV-RA) gradient to mean RA pressure. Systolic PA pressure was obtained adding maximum RV-RA gradient to mean RA pressure. Diastolic PA pressure was derived from mean and systolic PA pressures. Results were compared with PA pressures by RHC. Median time between RHC and echocardiography was 0 months [interquartile range (IQR): 0–3.5]. Median age was 58 years (IQR: 52–61.5), most of the patients were men (83.5%). The absolute mean difference between mean, systolic and diastolic PA pressures by RHC and echocardiography was 0.46 ±9.78 mmHg, 2.18 ±12.92 mmHg and −2.30 ±8.61 mmHg, respectively. PA pressures by echocardiography significantly correlated with PA pressures by RHC (mean PA pressure: r = 0.460, P < 0.001; systolic PA pressure: r = 0.520, P < 0.001; diastolic PA pressure: r = 0.372, P < 0.001). AUC for prediction of pulmonary hypertension, defined as mean PA > 25 mmHg, by mean PA pressure by echocardiography was 0.828 and a cut-off of 25.5 mmHg demonstrated a high specificity (sensibility 66.7%, specificity 93.2%).

Conclusions

Estimation of pulmonary arterial pressures through an echocardiographic method mainly based on tricuspid regurgitation gradients is reliable and an estimated mean pulmonary arterial pressure >25.5 mmHg has a high specificity for predicting pulmonary hypertension.
47 Quantified mitral regurgitation and left atrial function in HFrEF: intraplay and outcome implications
Authors: Malagoli Alessandro , Rossi Luca , Zanni Alessia , Sticozzi Concetta , Piepoli Massimo Francesco , Benfari Giovanni
Published: December 2021

Aims

The debate about the independent prognostic responsibility of functional mitral regurgitation (FMR) is still in turmoil. Growing findings about the predictive role of left atrial (LA) function are emerging in several scenarios. This study aims to define FMR linkage to cardiovascular (CV) outcomes and the interplay with LA function in a prospective cohort of consecutive heart failure patients with reduced ejection fraction (HFrEF).

Methods and results

286 consecutive outpatients with chronic HFrEF were enrolled. FMR was quantified by effective regurgitant orifice area (EROA). Global peak atrial longitudinal strain (PALS) was measured by speckle tracking echocardiography (STE). The primary endpoint was defined as a composite of congestive HF hospitalization and CV death. The majority (81%) of patients were men (mean age: 67 ± 11 years, mean LVEF: 32 ± 6%). The median global PALS was 17.7% ranging from 2.7% to 49.2%. FMR was quantifiable in 240 (84%) patients. During a median follow-up period of 6.4 (IQR: 3.9–7.7) years, the primary endpoint occurred in 88 (31%) patients (35 HF admissions, and 53 deaths). EROA showed independent prediction for the primary endpoint [HR: 1.30 (1.05–1.57), P = 0.01]. The spline modelling of the risk by EROA values showed an excess event risk starting at about the EROA value of 0.1 cm2 (Figure 1). There was a remarkable graded association between the EROA strata, even if tested per 0.1 cm2 increase, and the risk of congestive HF hospitalization and CV death (P = 0.0004). Any FMR grade presenting with reduced LA function (PALS < 14%) was associated with dismal outcome (event rate of 63 ± 10% for EROA exceeding 0.3 cm2 and 49 ± 6% for EROA ≥0.1 cm2 at 5 years). Conversely, the presence of EROA ≥0.1 in the context of preserved global PALS showed a better outcome (Figure 2). 47 Figure 1 47 Figure 2 

Conclusions

Our results refine the independent association between FMR and CV outcome among HFrEF outpatients. The risk of CV events starts at a low EROA value, reaching a severe level above the threshold of 0.3 cm2. Within a moderate EROA range, the LA function mitigates the clinical consequences of the mitral regurgitation, providing measurable proof of the interplay between the regurgitation and the LA compliance.
100 Global longitudinal strain by CMR improves prognostic stratification in acute myocarditis presenting with normal LVEF
Authors: Porcari Aldostefano , Merlo Marco , Baggio Chiara , Gagno Giulia , Cittar Marco , Barbati Giulia , Paldino Alessia , Castrichini Matteo , Vitrella Giancarlo , Pagnan Lorenzo , Cannata Antonio , Andreis Alessandro , Cecere Annagrazia , Cipriani Alberto , Raafs Anne , Bromage Daniel I , Rosmini Stefania , Scott Paul , Sado Daniel , Di Bella Gianluca , Nucifora Gaetano , Marra Martina Perazzolo , Heymans Stephane , Imazio Massimo , Sinagra Gianfranco
Published: December 2021

Aims

Prognostic stratification of acute myocarditis (AM) presenting with normal left ventricular (LV) ejection fraction (EF) relies mostly on late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) imaging. In this specific AM population, LV peak global longitudinal strain (LV-GLS) measured by feature tracking (FT) analysis might provide further prognostic information.

Methods and results

Data of patients undergoing CMR for clinically suspected AM in seven European Centres, between January 2013 and August 2020, were retrospectively analysed. Those patients fulfilling CMR Lake Louise Criteria (LLC) for the diagnosis of AM and presenting with normal LVEF (≥50%) were included. Patients presenting with heart failure (HF) or significant arrhythmic events, LVEF <50% or haemodynamic instability were excluded. CMR-LGE extent (localized vs. diffuse), localization (subepicardial vs. mid-wall), and distribution (anteroseptal vs. inferolateral) were visually assessed. LV-GLS was measured by dedicated software. The primary outcome was the first occurrence of an adverse cardiovascular event (ACE) including a composite of cardiac death, development of heart failure, life-threatening arrhythmias, or development of LVEF <50%. In patients experiencing more than one event, the first one was considered for the outcome analysis. Of 389 patients with clinically suspected AM, 256 (66%) had confirmed AM with LVEF ≥50% and were included. Median age was 36 years, 71% were males, median LVEF was 60%, and median LV-GLS −17.3%. CMR was performed at a median time of 4 (IQR: 2–12) days from hospital admission. At a median follow-up of 27 months, 24 (9%) patients experienced at least one ACE with development of LVEF <50% accounting for 17 [71%]. Compared to the others, patients experiencing ACEs had lower median LV-GLS values at baseline (−13.9% vs. −17.5%, P = 0.001). At Kaplan–Meier analysis, impaired LV-GLS (both considered as >-20% or quartiles), diffuse and mid-wall LGE were associated with a significantly higher rate of ACEs. LV-GLS remained independently associated with ACEs after adjustment for diffuse or mid-wall LGE as covariate at bivariable analysis.

Conclusions

In AM with LVEF ≥50%, LV-GLS provides independent prognostic value over LGE, improving risk stratification and providing a rationale for further studies of therapy in this cohort.

100 Figure
106 The effective study: development and application of a question-driven, time-effective cardiac magnetic resonance scanning protocol
Authors: Torlasco Camilla , Castelletti Silvia , Soranna Davide , Volpato Valentina , Figliozzi Stefano , Menacho Katia , Cernigliaro Franco , Zambon Antonella , Kellman Peter , Moon James C , Badano Luigi Paolo , Parati Gianfranco
Published: December 2021

Aims

Long scanning times impede cardiac magnetic resonance (CMR) clinical uptake. A ‘one-size-fits-all’ shortened, focused protocol [e.g. only function and late-gadolinium enhancement (LGE)] reduces scanning time and costs, but provide less information. We developed two question-driven CMR and stress-CMR protocols, including tailored advanced tissue characterization, and tested their effectiveness in reducing scanning time while retaining the diagnostic performances of standard protocols.

Methods and results

Eighty-three consecutive patients with cardiomyopathy or ischaemic heart disease underwent the tailored CMR. Each scan consisted of standard cines, LGE imaging, native T1-mapping, and extracellular volume. Fat/oedema modules, right ventricle cine, and in-line quantitative perfusion mapping were performed as clinically required. Workflow was optimized to avoid gaps. See Figure 1 for protocol details. Time target was <30 min for a CMR and <35 min for a stress-CMR. CMR was considered impactful when its results drove changes in diagnosis or management. Advanced tissue characterization was considered impactful when it changed the confidence level in the diagnosis. Images’ quality was assessed. A ‘control group’ of 137 patients was identified among scans performed before February 2020. Compared to standard protocols, the average scan duration dropped by > 30% (CMR: from 42 ± 8 to 28 ± 6min; stress-CMR: from 50 ± 10 to 34 ± 6min, both P < 0.0001). Independent on the protocol, CMR was impactful in ∼60% cases, and advanced tissue characterization was impactful in > 45% of cases. Quality grading was similar between the two protocols. Tailored protocols did not require additional staff.

Conclusions

Tailored CMR and stress-CMR protocols including advanced tissue characterization are accurate and time-effective for cardiomyopathies and ischaemic heart disease.
654 Fragility of functional/symptomatic endpoints to assess the efficacy of drugs for pulmonary arterial hypertension
Authors: Barca Luca , De Marzo Vincenzo , Toma Matteo , Guglielmi Giulia , Crimi Gabriele , Porto Italo , Ameri Pietro
Published: December 2021

Aims

Drugs for pulmonary arterial hypertension (PAH) have historically been evaluated for their efficacy in improving functional capacity and decreasing symptoms. However, these measures of treatment effect are approximate and subject to substantial variability, and therapeutic choices based on them may be aleatory.

Methods and results

We reviewed the articles reporting the results of phase 3 PAH randomized controlled trials (RCTs) and calculated the fragility index (FI) for the outcomes exploring functional capacity and symptoms. The FI corresponds to the number of events that need to be added to the arm with the smallest number of events to make a significant result non-significant: the lower the FI, the fragile the trial with respect to the endpoint examined. For RCTs with non-significant results, we calculated the FI as the number of events that need to be removed from the investigational drug (ID) group to reach a P-value <0.05. When possible, we also computed the FI for PAH hospitalization. Data about the rate of functional/symptomatic improvement were available for 22 (63%) of 35 RCTs (Table). The ID was superior to placebo or comparator with P < 0.05 in 10 (45%) of these 22 studies. The median FI was 2 [interquartile range (IQR): 6.5], with 4 RCTs having a FI = 1 and only 2 > 10 (Table). For the 12 RCTs in which the effect of the ID was neutral (P > 0.05), the median FI was 6 (IQR 4.25) (Table). The hospitalization FI was determined for 17 (77%) of the 22 RCTs and was overall higher than the one for the functional/symptomatic outcome (median 6, IQR 8).

Conclusions

Accessible information about the effects of PAH drugs on functional capacity and/or symptoms is published for 6 in 10 RCTs, in which very few events in one arm could have flipped the results from non-significant to significant or, more remarkably, from significant to non-significant. The evidence supporting the reduction of PAH hospitalizations as a treatment goal appears to be more robust.
253 Imaging of congenital AV block caused by maternal autoantibodies: a single-centre experience
Authors: Basso Alessia , Maluta Nicole , Biffanti Roberta , Reffo Elena , Leoni Loira , Tonello Marta , Sabatino Jolanda , Vida Vladimiro , Cerutti Alessia , Di Salvo Giovanni
Published: December 2021

Aims

Autoimmune congenital heart block (CHB) is a severe manifestation of neonatal lupus syndrome. There is lack of consensus regarding treatment of pregnant women with anti-SSA/SSB autoantibodies. To evaluate the effectiveness of the combined protocol therapy (oral steroid, plasmapheresis, and IVIG) for the CHB treatment.

Methods and results

All cases of CHB from 2000 to 2020 were retrospectively enrolled. All the patients underwent foetal echocardiography for the evaluation of CHB, ventricular rate and main related foetal complications: cardiomegaly, pericardial and pleural effusion, foetal hydrops, dilated cardiomyopathy, and heart failure. Moreover, postnatal major adverse cardiovascular, such as death and pacemaker implantation, were recorded. For statistical analysis, the population was divided into two cohorts: a protocol group receiving in utero combined therapy and a control group receiving other therapies or not treated. Among 252 pregnancies with anti-SSA/SSB antibodies, 36 developed CHB. At birth, complete CHB treated with protocol therapies showed a significantly higher ventricular rate (P = 0.042), a significant reduction in intrauterine or postnatal mortality (P = 0.018), and a lower rate of pacemaker implantation (P = 0.049).

Conclusions

The combined treatment protocol has proven effective in improving foetal and neonatal short- and long-term survival.
83 The predictive role of neutrophil-to-lymphocyte ratio in post-operative cardiopulmonary bypass surgery
Authors: Bucciarelli Valentina , Bianco Francesco , Blasi Annaclara , Primavera Martina , Alessandra Baldinelli , Colaneri Massimo , Gallina Sabina , Pozzi Marco
Published: December 2021

Aims

Postoperative arrhythmias (POA) are a common complication after cardiac surgical repairs for congenital heart disease (CHD), representing a substantial source of morbidity, mortality, and prolonged total in-hospital stay, with an incidence of 7.5–48% in postoperative pediatric cardiac patients. The etiology is multifactorial, and it has been related to the direct surgical manipulation of the cardiac conduction system, to the local tissue inflammation in the myocardium adjacent to the conduction system and to the arrhythmogenic effects of cardiopulmonary bypass (CPB), inotropes, and electrolyte disturbances. Recently, the prognostic role of neutrophil-to-lymphocyte ratio (NLR), a novel inflammation marker, has been evaluated in pediatric patients after CPB surgery. To evaluate the predictive role of NLR in POA in a population of pediatric CHD patients after CPB.

Methods and results

We retrospectively collected perioperative clinical and laboratory data of 146 patients (age 8.27 ± 10.79 years; male gender: 60.8%) consecutively admitted to the cardiac surgery intensive care unit (ICU) of our institute after elective cardiac surgery with CPB in 2018. We grouped and analyzed our population over NLR tertiles evaluated at 24 h from CPB and types of POA: supraventricular (SVT) and junctional (JET). The prognostic value of NLR and its association with POA was analyzed. Diagnoses of 146 patients included atrial septal defect (n = 36), ventricular septal defect (n = 20), pulmonary atresia/stenosis (n = 10), tetralogy of Fallot (n = 20), endocardial cushion defect (n = 8), left ventricular outflow tract obstruction (n = 14), anomalous origin of coronary artery (n = 6), complex CHD (n = 13), interrupted/hypoplastic aortic arch (n = 12), anomalous pulmonary venous return (n = 3). The mean CPB time was 121.6 ± 84.6 min. The median ICU hospitalization was 48 h [Q1, Q3: 24, 96]. Twelve patients experienced POA: 6 SVT and 6 JET. The frequency of POA incremented over NLR-tertiles (P-Trend 0.017), while SVT onset was associated with higher values of NLR and C-reactive protein (P = 0.034 and P = 0.011, respectively). Patients in the second and third tertiles of NLR had a prolonged hospitalization (log-rank, P = 0.029), especially when associated with POA (log-rank, P = 0.012). At the multivariable analysis, higher age and NLR values were independently associated with SVT [OR per year 1.22; 95% CI (1.02, 1.25), P = 0.043 and OR per point 1.91; 95% CI (1.29, 2.82), P = 0.012, respectively], but not with JET.

Conclusions

24-h post-CPB NLR can predict postoperative SVT in a population of pediatric CHD patients. Our data suggest that the NLR could be a useful, easy-to-obtain marker for postoperative outcome in pediatric patients who had undergone elective CPB.
111 Extravalvular cardiac damage and renal function following TAVI for severe aortic stenosis
Authors: Fezzi Simone , Pesarini Gabriele , Mammone Concetta , Flaim Massimo , Castaldi Gianluca , Tavella Domenico , Scarsini Roberto , Ribichini Flavio , Pighi Michele
Published: December 2021

Aims

Acute kidney injury (AKI) represents a common complication following TAVI, that correlates strictly with in-hospital, short, and long-term mortality. Extra-valvular cardiac damage (EVCD) showed to affect long-term outcomes in patients with severe aortic stenosis (AS). We sought to determine the differences in the incidence of AKI and acute kidney recovery (AKR) among patients undergoing TAVI and their impact on clinical outcomes according to EVCD.

Methods and results

706 symptomatic severe AS patients were selected and retrospectively analysed. Based on echocardiography findings, patients were classified based on the degree of EVCD. AKI was defined as a relative increase at 24–72H in sCr concentration of at least 0.3 mg/dl, and was classified according to AKIN stages. AKR was defined either as an increase of GFR of 25% or a decrease in sCr of at least 0.3 mg/dl, both measured at 24–72H after the procedure. After dichotomized analysis, patients in EVCD stage 3–4 reported a significantly higher rate of AKI (27.4% vs. 11.3%; P < 0.001), significant AKI (5.3% vs. 1.5%; P < 0.010) and the need for continuous renal replacement therapy (CRRT) after TAVI (2.7% vs. 0.7%; P = 0.052), whereas a lower incidence of AKR was reported (11.6% vs. 6.2%; P = 0.087). At the multivariate model higher EVCD stage, lower GFR and the amount of contrast used were found to be independent predictors of AKI, while early stages of cardiac damage (HR: 0.420; 95% CI: 0.224–0.785; P = 0.007) and lower GFR were found to be independent predictors of AKR. In the overall population, at a median 24-months follow-up, after multivariate analysis AKI was associated with a higher incidence of all-cause mortality [HR: 2.636; 95% CI: (1.360–5.108); P = 0.004] and MACEs [HR: 2.122; 95% CI: (1.170–3.849); P = 0.013]. Notably, at the multivariate analysis, AKI significantly impacted on survival in patients in stages 3–4 [HR: 2.461; 95% CI: (1.017–6.067); P = 0.046], but not in patients in stages 0–2 [HR: 1.301; 95% CI: (0.380–4.457); P = 0.675], with an interaction that achieved statistical significance (p for interaction 0.006). AKR did not reduce adverse clinical outcomes [HR: 0.742; 95% CI: (0.339–1.623); P = 0.455 for all-cause mortality; HR: 0.701; 95% CI: (0.351–1.397); P = 0.312 for MACEs] but was associated with an improvement of renal function at 12 months.

Conclusions

AKI demonstrated to negatively impact on 24-month all-cause mortality only when occurring in advanced stages of EVCD, but not in early stages. Conversely, early EVCD was associated with a higher incidence of AKR, which not significantly improved clinical outcomes but was associated with an improvement of renal function at 12-months. The application of this staging system may provide an additional tool for the decision-making process in patients with severe AS. 111 Figure
600 Validation of the academic research consortium high bleeding risk criteria in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis of 10 studies and 67 862 patients
Authors: Silverio Angelo , Maio Marco Di , Buccheri Sergio , Luca Giuseppe De , Esposito Luca , Sarno Giovanna , Bellino Michele , Cancro Francesco Paolo , Centore Mario , Verdoia Monica , Vecchione Carmine , Galasso Gennaro
Published: December 2021

Aims

The Academic Research Consortium for High Bleeding Risk (ARC-HBR) has recently proposed, by consensus, 20 clinical criteria for the assessment of the bleeding risk after percutaneous coronary intervention (PCI). A major criterion was defined as any individual clinical condition conferring in isolation a risk for major bleeding ≥4% up to 1 year after PCI; instead, a minor criterion was considered to confer a bleeding risk of < 4%. The aim of this meta-analysis was to assess the performance of the ARC-HBR criteria in stratifying the risk of bleeding and ischaemic events after PCI.

Methods and results

MEDLINE, COCHRANE, Web of Sciences, and SCOPUS were searched for studies aimed at validating the ARC-HBR criteria in patients treated with PCI. The primary outcome measure of this meta-analysis was major bleeding. The analysis included 10 studies encompassing 67 862 patients undergoing PCI; the HBR definition was fulfilled in 44.7% of the cases. The risk of major bleeding was significantly higher in HBR vs. Non-HBR group (RR: 2.56, 95% CI: 2.28–2.89). The average C-statistic was 0.64 (95% CI: 0.60–0.68), indicating modest discrimination. The risk of intracranial haemorrhage, gastrointestinal bleeding, fatal bleeding, ischaemic stroke, cardiac death and all-cause death was higher in HBR vs. Non-HBR group. Despite a higher incidence of myocardial infarction and stent thrombosis in patients deemed at HBR, the rate of target lesion revascularization was comparable between groups (RR, 1.01, 95% CI: 0.88–1.16). When assessed in isolation, the mean cumulative incidence of major bleeding at 1 year exceeded the cut-off value of 4% for all the major criteria and for two out of six minor criteria, including age ≥75 years and moderate chronic kidney disease (CKD) (Figure).

Conclusions

The ARC-HBR definition identifies patients at higher risk of major bleeding and other adverse cardiovascular events after PCI. Almost all major criteria, but also two of the minor criteria, were individually associated with rates of major bleeding above 4% thus fulfilling the definition of major HBR criteria. These findings corroborate the ability of ARC-HBR major criteria in identifying PCI patients who are more likely to develop adverse events, but also suggest caution in the decision making of patients with isolated minor criteria, including age ≥ 75 years and moderate CKD.