bluuebunny/crossref_metadata_2025 huggingface dataset:
A new wearable cardiac acoustic monitoring technology for the evaluation of subclinical leaflet thrombosis after transcatheter aortic valve replacement: a pilot study
Authors: Liu R , Yan X W , Song G Y
Published: October 2024

Background

Subclinical leaflet thrombosis characterized by hypoattenuated leaflet thickening (HALT) and reduced leaflet motion (RLM) is a common complication after transcatheter aortic valve replacement (TAVR), whether it affects hemodynamic change is still debated.

Purpose

We attempted to use a novel wearable heart acoustic monitoring device, and combined multi-dimensional computed tomography (MDCT) and echocardiography to diagnose SLT and analyze the changes of transvalvular hemodynamics after TAVR.

Methods

Patients with severe symptomatic aortic stenosis and underwent successful TAVR were consecutively enrolled. Clinical data, acoustic cardiographic parameters including the frequency, amplitude, and energy of heart sounds , and imaging results were collected and analyzed by Core laboratory at pre- and post TAVR, and follow-up at one month and six month. According to severity of SLT at one month follow-up, we divided the patients into three groups: Group1: no SLT, Group2: mild SLT, defined as existed HALT did not qualify for Group 3, and Group 3: moderate to severe SLT, defined as at least 1 leaflet with HALT of grade 3 or 4 or RLM of ≥50%, or 2 leaflets with HALT of grade 2 or RLM of ≥50%. A consistency analysis of SLT presence between MDCT findings and acoustic cardiographic variables was performed using Kappa statistics.

Results

The study included 116 TAVR patients. The prevalence of SLT as detected by MDCT at one-month follow-up was 25%, with moderate to severe SLT representing 11.2% of cases. A significant decrease in aortic valve orifice area (AVA) (-0.2±0.48cm2 vs. -0.1±0.33cm2, p=0.009) and an increase in mean gradient (MG) (3.5±5.85 mmHg vs. 0.1±11.34mmHg, p=0.028) were observed in moderate to severe SLT group at one-month follow-up versus post-TAVR via echocardiography. However, no significant differences were found in the mild SLT or no SLT group. Acoustic cardiographic characteristics exhibited a distinct pattern with early systolic, baseless, and high-energy murmurs in patients with moderate to severe SLT, but not in the mild SLT or no SLT group. The sensitivity, specificity, and Kappa values for acoustic cardiography in diagnosing moderate to severe SLT were 81.82%, 83.33%, and 0.41, respectively. At the 6-month follow-up, MDCT showed that 11 (85%) patients with moderate to severe SLT who received anticoagulant therapy reached complete dissolution of SLT.

Conclusion

Moderate to severe SLT presented notably transvalvular hemodynamic influences following TAVR. Acoustic cardiography demonstrated specific characteristics of moderate to severe SLT, providing a valuable tool for SLT diagnosis and evaluation in clinical follow-up.Figure 1.Baseline characteristicsFigure 2.SLT and acoustic cardiography
Major bleeding complications and antithrombotic treatment after isolated surgical bioprosthetic aortic valve replacement
Authors: Bjorn R , Lehto J , Malmberg M , Anttila V , Gunn J , Nieminen T , Hartikainen J E K , Biancari F , Airaksinen J K E , Kiviniemi T
Published: October 2024

Background

Despite advancements in surgical techniques and perioperative care, post-operative bleeds and stroke remain significant concerns after bioprosthetic surgical aortic valve replacement (SAVR).

Purpose

We assessed the incidence of short-term (30d) and long-term major bleeds and strokes and their relations to antithrombotic treatment after isolated bioprosthetic SAVR.

Methods

The CAREAVR study included 721 patients who underwent isolated SAVR at four Finnish university hospitals between 2002 and 2014. The day-to-day information on short-term antithrombotic treatment was available from a subgroup including 227 patients, of whom 138 (60.7%) had preoperative aspirin. Preoperative aspirin was usually discontinued the day before the index surgery. Enoxaparin 1mg/kg twice daily and vitamin K antagonist (VKA) were routinely initiated on the first postoperative day, and enoxaparin continued until the INR remained at a therapeutic level ≥ 2.0 for two days. The routine duration of VKA treatment after surgery was 3 months.

Results

The median follow-up time was 4.9 (interquartile range 3.0–7.0) years. During the short-term 30-day period, 31 (4.3%) patients had a major bleed, and 13 (1.8%) patients experienced a major stroke. A vast majority of the bleeding (80.6%) occurred within two days after the surgery, and the tail effect of preoperative aspirin (5-7d) was present in 51.6% of episodes, indicating unintentional triple antithrombotic therapy. During the long-term follow-up (>30d after the index surgery), 40 (5.5%) major bleeding episodes occurred, and 47 (6.5%) patients experienced a major stroke. Overall, 23 (57.5%) of the patients with major bleeding were on OAC during the event. In addition, 13 (27.7%) of the patients experiencing major stroke during the long-term follow-up were on OAC during the event.

Conclusions

Compared to major strokes, the incidence of perioperative major bleeds was over twofold, the majority occurring during the tail effect of preoperative aspirin. During the long-term follow-up, the risks of stroke and bleeding were equal, and the majority of bleeding episodes appeared during anticoagulation treatment.
Adverse events following transcatheter aortic valve implantation (TAVI) in patients with amyloidosis: observations from a global federated network
Authors: Gerra L , Bucci T , Lam S H M , Argyris A A , Alobaida M , Sandhu K , Mills J , Boriani G , Lip G Y H
Published: October 2024

Background

A high proportion of patients with aortic stenosis are affected by cardiac amyloidosis, but there is a paucity of data describing the effect of amyloidosis on the clinical course of patients who underwent transcatheter aortic valve implantation (TAVI).

Purpose

To assess the one-year risk of adverse events following TAVI in patients with amyloidosis.

Methods

Retrospective study using data from a large multinational electronic health record network (TriNetX). Patients aged 18 years or older who underwent TAVI between 2005 and 2022 were included in the analysis. The patients were categorised in two groups based on the presence of amyloidosis (ICD-10-cm code E85). Primary outcome was the one-year risk of the composite of emergency department (ED) admission, acute heart failure (HF), stroke, conduction system disease, pacemaker (PM) implantation, acute kidney injury, and all-cause death. Secondary outcomes were the risks for each component of the composite outcome. We used Cox regression analysis to calculate hazard ratio (HR) and 95% confidence interval (CI) after propensity score matching (PSM) 1:1.

Results

We identified 477 TAVI recipients with a diagnosis of amyloidosis (age 78.6±8.1 years, 31.4% females) and 43,379 TAVI patients without a diagnosis of amyloidosis (78.1±8.8, 40.2% females). Before PSM, patients affected by amyloidosis were more likely to be Black or African American and had a higher prevalence of cardiovascular risk factors compared to TAVI patients without amyloidosis. After PSM, patients with a diagnosis of amyloidosis showed a higher one-year risk of composite outcome (HR 1.28, 95%CI 1.10-1.49) compared to those who underwent TAVI without amyloidosis. Regarding secondary outcomes, amyloidosis patients had a higher risk of ED admission (HR 1.41, 95%CI 1.13-1.75), acute HF (HR 1.56, 1.23-1.99), stroke (HR 1.55, 1.04-2.32), conduction system disease (HR 1.27, 1.04-1.55), PM implantation (HR 1.55, 1.06-2.28), but not acute kidney injury (HR 1.11, 0.84-1.48) and all-cause death (HR 0.98, 0.66-1.45).

Conclusion

Among patients undergoing TAVI, those affected by amyloidosis are at higher risk of adverse events in the first year after TAVI. More studies are needed to define the exact role of amyloid fibrils in structural valve deterioration and to elucidate whether subtypes of amyloidosis have a different impact on patients’ outcomes following TAVI.Risk of composite outcome following TAVI
Polymorphic size of Lipoprotein (a) and structural bioprosthetic valve degeneration
Authors: Capoulade R , Croyal M , Senage T , Guimbretiere G , Le May C , Piriou N , Costa C , Galinanes M , Manez R , Soulilou J P , Cozzi E , Padler-Karavani V , Roussel J C , Cariou B , Le Tourneau T
Published: October 2024

Background

The use of biological heart valves (BHV) is constantly growing for the treatment of patients with aortic stenosis and their durability arises as a main concern in the field. Structural valve deterioration (SVD) of the BHV occurs gradually post-implantation and seems to reiterate, at least in part, the pathophysiological processes described in native valve stenosis. Lipoprotein (a) [Lp(a)] is an important genetically determine cardiovascular risk factors, associated with native valve calcification. The shorter polymorphic sizes of Lp(a), defined as low of apolipoprotein (a) [apo(a)] Kringle-IV copy number, have been associated with more deleterious cardiovascular phenotype. However, the association of Lp(a) plasma levels and/or its polymorphic sizes with SVD remains unclear.

Purpose

To determine whether Lp(a) plasma levels and/or the Lp(a) polymorphic size were associated with SVD.

Methods

332 patients who underwent aortic valve replacement (AVR) with BHV from the Translink trial were included in this study. Clinically significant SVD has been defined as Stage 3 SVD based on the VARC-3 definition. Lp(a) concentration was determine by immunoturbidimetry method and the apo(a) Kringle-IV copy number by liquid chromatography-tandem mass spectrometry. Univariable and multivariable models, adjusted for clinically relevant and statistically significant variables, were used to determine the independent association between Lp(a) concentrations or apo(a) Kringle-IV copy numbers with SVD.

Results

Among the 332 patients included in this study, the mean age was 78 ±8 years and 71% were males. 76 patients (23%) presented clinically significant SVD. Low apo(a) Kringle-IV copy number was associated with an increased risk of SVD (per log decrease: OR=2.71 [1.34-5.50], p=0.006), but not Lp(a) plasma concentration (OR=0.99 [0.84-1.15], p=0.85). This association remained significant after comprehensive multivariable adjustments, including Lp(a) concentration (OR=3.21 [1.31-7.84], p=0.01). The analysis of the transprosthetic mean gradient, as a surrogate marker of SVD, provided consistent results (all p≤0.03).

Conclusion

This cross-sectional study from the Translink trial demonstrates the association between Lp(a) polymorphic size and SVD, highlighting a potential therapeutic option to limit the occurrence of SVD in selected patients who underwent AVR with surgical or transcatheter BHV.
Left ventricular dilatation in patients with significant aortic regurgitation: association with mortality
Authors: Lopez Santi M P , Bernard J , Fortuni F , Butcher S , Sarrazyn C , Ching-Yan Z H U , Chua A P , Meucci M C , Popescu B A , Tay E , Yiu K H , Clavel M A , Pibarot P , Bax J J , Ajmone Marsan N
Published: October 2024

Background

In aortic regurgitation (AR), left ventricular (LV) dilatation occurs as a response to volume and pressure overload. Current guidelines recommend the use of LV end-systolic diameter index (LVESDi) to give indication for intervention, but recent studies suggested that volumetric measures may be more accurate in identifying LV remodeling in AR as compared to linear dimensions.

Purpose

To characterize LV dilatation in patients with significant AR (≥moderate), based on linear and volumetric dimensions, and to determine their prognostic value.

Methods

A total of 1070 patients (56 ± 18 years,65% male) were included. Cut-off values of 20 mm/m2 for LVESDi and 45 ml/m2 for end-systolic volume index (LVESVi) were used to identify the following LV remodeling patterns: No-significant LV dilatation (N=485), when both LVESDi and LVESVi were below the cut-off values; Discordant LV dilatation (N=279) if only one positive criterion was present; and Concordant LV dilatation (N=306) when both LVESDi and LVESVi were enlarged (Figure 1). The primary endpoint was all-cause mortality.

Results

Baseline characteristics differed across the 3 LV dilatation groups. Compared to patients with no-significant or discordant LV dilatation, those with concordant LV dilatation were more likely to be men, had a lower prevalence of systemic arterial hypertension and were more symptomatic. Concerning the echocardiographic characteristics, patients with concordant LV dilatation showed more severe AR, worse LV systolic function and larger left atrial volumes compared to the other two LV dilatation groups.

During a median follow-up of 89 (IQR,54-132) months, 168 (16%) patients died and 484 (45%) underwent aortic valve surgery (AVS). Patients with concordant LV dilatation had worse 10-year survival (72%) compared to the groups (Figure 2), but benefited more from AVS based on a landmark analysis (p=0.001). In multivariable analysis, a significant association with the risk of all-cause mortality was observed for the presence of discordant (HR 1.645, 95%CI 1.077-2.513;p=0.021) or concordant LV dilatation (HR 2.695, 95% CI 1.710 to 4.249;p<0.001) after adjusting for the variables significant in the univariate analysis such as, age, male gender, NYHA class III-IV, AVS as a time-dependent covariate and LV ejection fraction (LVEF) ≤55%. Moreover, the addition of LV dilatation groups to a basal model including the above mentioned clinical and echocardiographic variables led to a significant increase in the predictivity of the model (Chi-square difference=21.1,p<0.001).

Conclusion

In patients with significant AR, LV dilatation detected by linear and/or volumetric measures was independently associated with increased mortality. Combining both methods for assessment of LV remodeling may improve risk stratification of these patients.
Natural progression of rheumatic aortic valve disease following rheumatic mitral valve intervention: 16-year single center experience
Authors: Kim S H , Park Y H , Lee S H , Lim J H , Je H G , Lim M H , Ju M H , Lee C H
Published: October 2024

Backgrounds and Objectives

Recognizing the natural progression of the aortic valve (AV) disease is helpful in planning the intervention of significant rheumatic mitral valve (MV) disease accompanying rheumatic AV disease. We aimed to investigate the long-term course of AV disease and the need for AV surgery in patients with rheumatic mitral valve disease who underwent MV intervention.

Methods

We retrospectively investigated the progression of AV disease with rheumatic changes following MV intervention in a single tertiary center. A total of 890 patients who underwent MV intervention for rheumatic MS or mitral regurgitation (MR) without concurrent AV intervention were initially screened for eligibility. Among them, 76 patients met the criteria for rheumatic etiology and had over a year of echocardiographic follow-up after MV intervention (64 surgery, 12 balloon valvuloplasty).

Results

The median follow-up period was 4 years (mean 5.8 years, ranging from 1 to 31 years). MS was the most common indication for mitral intervention. Overall, trans-aortic peak velocity (AV Vmax) changed from 2.2 ± 0.6 m/s to 2.4 ± 0.8 m/s, and mean pressure gradient (mean PG) changed from 11.1 ± 6.0 mmHg to 13.2 ± 8.2 mmHg. Six patients fell under severe aortic stenosis (AS) definition-wisely (Figure 1) and three of them were classified as low flow low gradient severe AS despite normal ejection fraction. Eventually, four patients were found to have true-severe AS and only one of them underwent AV surgery for severe AS per se. None of the patients with aortic regurgitation deteriorated to severe (Figure 2).

Conclusions

Only a small portion of rheumatic AV involvement progresses to severe AS after MV intervention, and performing MV intervention for severe mitral stenosis or mitral regurgitation in patients with concurrent mild or moderate AS or aortic regurgitation due to rheumatic changes might be reasonable.The changes in the grading of ASThe changes in the grading of AR
Clinical outcomes and impact of mitral valve surgery in atrial functional mitral regurgitation: the REVEAL-AFMR registry
Authors: Kagiyama N , Kaneko T , Amano M , Sato Y , Ohno Y , Obokata M , Sato K , Okada T , Tabata M , Minamino T , Hirose N , Morita K , Machino-Ohtsuka T , Delgado V , Abe Y
Published: October 2024

Background

The real-world impact and effective treatment strategies of atrial functional mitral regurgitation (AFMR) are poorly understood. The aim of this study was to investigate the prevalence, clinical characteristics, and the effectiveness of mitral valve surgery in AFMR.

Methods

The REal-world obserVational study for invEstigAting the prevaLence and therapeutic options for Atrial Functional Mitral Regurgitation (REVEAL-AFMR) was a retrospective cohort study conducted across 26 Japanese centers. All transthoracic echocardiography performed in 2019 were reviewed and patients with moderate or severe AFMR defined by preserved left ventricular function, dilated left atrium, and absence of degenerative valvular changes. The primary composite outcomes were heart failure hospitalization and all-cause mortality. Besides traditional multivariable regression analysis, propensity score-based time-zero matching was performed to account for immortal time bias.

Results

In 177,235 patients who underwent echocardiography, 8,867 had moderate or severe MR. Within this group, 1,007 were diagnosed with AFMR (mean age 78±10, 56% female, 80% atrial fibrillation). Of these, 113 underwent MV surgery, with 81% receiving concurrent tricuspid valve surgery. Patients who underwent surgery were younger but had more severe MR, larger left heart chambers, and a higher prevalence of heart failure than those who remained under medical therapy. During a median follow-up of 1050 days, 28% experienced the primary outcome, and 18% died. Despite a more severe disease status, only the surgical group showed a decrease in natriuretic peptide levels at follow-up and had significantly lower rate of the primary outcome (hazard ratio 0.43 [0.29-0.64], p<0.001 after adjustment for 25 covariates). Propensity score-based time-zero matching also indicated a lower risk of the primary outcome in the surgical group (hazard ratio 0.39 [0.20–0.78], p=0.007). Multiple sensitivity analyses yielded consistent results. Subgroup analysis suggested a significantly greater benefit of surgery for patients with severe MR than those with non-severe MR (p for interaction=0.044).

Conclusions

Our registry revealed that patients with AFMR are typically old with predominantly with atrial fibrillation, facing poor outcomes. MV surgery was associated with fewer adverse events, a finding that should be validated in future clinical trials.
Atrial functional and ventricular functional mitral regurgitation: definitions, epidemiology, and prognostic implications
Authors: Koschatko S , Heitzinger G , Spinka G , Dannenberg V , Koschutnik M , Dona C , Jantsch C , Halavina K , Hemetsberger R , Nitsche C , Demirel C , Hengstenberg C , Goliasch G , Bartko P E
Published: October 2024

Background

Severe functional mitral regurgitation (fMR) can be divided into two subgroups: fMR of atrial (AfMR) and fMR of ventricular origin (VfMR). Studies on AfMR are scarce and inconsistent, lacking a uniform definition of AfMR. Hence, little is known about its epidemiology, morphological features, associated risk profiles, and prognostic implications.

Purpose

The objective of this study was to develop and test a uniform definition of fMR based on the morphological correlate and to describe demographic characteristics, detail entity-specific morphological features and to investigate the associated prognostic impact.

Methods

13052 patients with severe fMR and those at risk of severe fMR (comprising mild and moderate fMR)were included. Based on the ratio of left atrial volume (LA) to left ventricular end-diastolic volume (LVEDV), those with severe fMR (n=1163) were divided into AfMR and VfMR. The median of this ratio was used for allocation. Therefore, a LA/LVEDV ratio ≤ 0.56 indicated predominantly ventricular eccentric remodelling, whereas a ratio > 0.56 indicated predominantly atrial remodelling.

Results

AfMR was more frequently observed in female patients and peak age was a decade later, compared to VfMR. AfMR was the predominant fMR subtype in patients with heart failure with preserved (76%) and mildly reduced ejection fraction (61%), but a significant proportion could be observed even in patients with heart failure with reduced ejection fraction (32%). Severe fMR was associated with excess mortality for both entities: VfMR HR 1.31 [95% CI: 1.14-1.50], p<0.001, with a more pronounced impact in patients with AfMR HR 1.68 [95% CI: 1.47-1.91], p<0.001; AfMR vs. VfMR: HR 1.27 [95% CI: 1.06-1.54], p=0.011. The association between fMR and excess mortality persisted even after multivariate adjustment. In both entities, ischaemic heart disease was common and resulted in a significant increase of mortality (VfMR: HR 1.67 [95% CI: 1.40-1.98], p for interaction<0.001; AfMR: HR 2.10 [95% CI: 1.75-2.52], p for interaction=0.006).

Conclusion

Based on the entity-specific morphological correlate, severe fMR can be classified into AfMR and VfMR. AfMR occurs across the entire HF spectrum, is more frequently observed in elderly and female patients, and exhibits a worse prognosis than VfMR. The presence of ischaemic heart disease is associated with a near doubling of mortality in both subgroups of severe fMR.Prevalence of fMRKaplan-Meier analysis
Prevalence, characteristics, and long-term outcomes of patients with mitral annular disjunction undergoing surgery for degenerative mitral regurgitation
Authors: Lodin K , Wang A , Haby I , Ruck A , George I , Cohen D J , Braunschweig F , Haugaa K H , Svenarud P , Dalen M , Shahim B
Published: October 2024

Background

Mitral valve prolapse (MVP) is associated with progressive mitral regurgitation (MR) requiring surgical repair. A subset of patients with MVP may also suffer from malignant ventricular arrhythmias (VAs), especially in the presence of mitral annular disjunction (MAD).

Purpose

To assess the prevalence, associated characteristics, and long-term outcomes of patients with MVP with and without MAD undergoing mitral valve surgery for degenerative MR.

Methods

Patients with MVP and moderate-to-severe or severe degenerative MR undergoing mitral valve surgery between 2010-2022 at a university hospital in Sweden were included. MAD length was measured on echocardiograms at end-systole from the insertion of the posterior leaflet on the detached mitral annulus to the border of the bulging left ventricle. Patient demographics and clinical outcomes were collected from medical records. The primary endpoint consisted of VAs, defined as sustained- or non-sustained ventricular tachycardia or high burden of premature ventricular complexes causing hospitalizations or ablation or identified at Holter monitoring. Other endpoints included sudden cardiac death, all-cause mortality, new onset postoperative atrial fibrillation, stroke, mitral valve reoperation, endocarditis, new or worsened heart failure, myocardial infarction and implantation of permanent pacemaker or cardiac defibrillator.

Results

Of 599 patients undergoing mitral valve surgery, 96 (16%) had preoperative MAD, with a median (Q1, Q3) MAD length of 8.0 (5.0-10.0) mm. Compared with patients without MAD, patients with MAD were younger (55 vs 63 years), more likely to be female (31% vs 17%), to have diffuse myxomatous valve disease (66% vs 25%) and bileaflet prolapse (57% vs 17%). Most patients underwent mitral valve repair (84% vs 80%). No patient had residual MAD after surgical repair. At a mean follow up time of 5.8 ± 3.5 years after mitral valve repair, VAs were more common in patients with pre-operative MAD (10% vs 2% (adjusted HR 4.52, 95% CI 1.57-13.0)) (Figure 1). There were no significant differences in the risks of other clinical outcomes.

Conclusions

MAD was associated with almost a 5-fold increased long-term risk of VAs after mitral valve repair despite successful anatomical correction of MAD. These findings highlight the importance of increased awareness of VAs in patients with MAD also after mitral valve surgery.
Echocardiographic pulmonary vascular resistance in patients undergoing tricuspid annuloplasty: prognostic implications and reversibility
Authors: Zhang J , Zhu C Y , Yiu K H
Published: October 2024

Background

Pulmonary vascular resistance (PVR) intimately connects with right ventricular afterload and the development of secondary tricuspid regurgitation (sTR).

Objectives

We sought to investigate the prognostic roles of PVR derived from echocardiography in patients who underwent tricuspid annuloplasty (TA) for sTR.

Methods

Data from 322 patients who underwent TA [median age (interquartile range): 65.0 (59.0-70.0) years; 35.7% males] were obtained from a prospective registry to determine the impact of PVR on the composite outcome (including all-cause mortality and heart failure hospitalization). PVR was calculated by dividing the peak TR velocity by time-velocity integral of the right ventricular outflow tract and then adding 0.16.

Results

During a median follow-up of 5.2 (interquartile range: 2.2-8.2) years, 108 adverse events occurred including 48 deaths and 60 heart failure readmissions. Baseline PVR ≥ 2.0WU was independently associated with a higher risk of composite outcome (adjusted HR[KY1] [u2] :1.674, 95% CI: 1.028-2.726, P=0.038). Baseline PVR outperforms pulmonary artery systolic pressure (PASP) and the ratio of tricuspid annulus plane systolic excursion to PASP in terms of outcome prediction, with pronounced improvement of global model fit, reclassification, and discrimination. In 150 patients who received echocardiograms after surgery, the presence of post-operative PVR ≥ 2.0WU (n=20, 13.3%) was independently associated with the composite outcome (adjusted HR: 2.621, 95% CI: 1.292-5.319, P=0.008).

Conclusion

PVR measured on echocardiography is an independent determinant of clinical outcomes in patients undergoing TA. The inclusion of echocardiographic PVR assessment may provide valuable additional information for patient selection and risk stratification in this population.Kaplan-Meier CurveChange of PVR after Surgery
Mortality and heart failure in patients with severe tricuspid regurgitation. Impact of RV volumes and function by CMR.
Authors: Hinojar Baydes R , Ramos N , Rodriguez Palomares J , Eiros R , Barreiro M , Calero M J , Rodriguez S , Gutierrez L , Galian L , Garcia-Sebastian C , Monteagudo J M , Garcia-Martin A , Gonzalez-Gomez A , Fernandez-Golfin C , Zamorano J L
Published: October 2024

Background

Beyond symptoms, right ventricle (RV) dilatation and dysfunction are established criteria for intervention in patients with significant tricuspid regurgitation (TR); however defined thresholds to support intervention are lacking. As a result, the optimal timing for intervention remains controversial and it is commonly undertaken at a late stage.

Purpose

To describe prognostic cut-off values of RV size and function by Cardiac Magnetic Resonance in a multicentre cohort of patients with at least severe TR.

Methods

The study enrolled patients with at least severe TR assessed by 2D echocardiography who underwent a contemporary cardiac magnetic resonance (CMR) study. Conventional parameters of biventricular volume and function were assessed in all patients. A combined endpoint of hospital admission due to heart failure (HF) and all-cause mortality was defined.

Results

318 patients with severe TR recruited from 5 tertiary care hospitals were included in this study (70 ± 11 years, 67% female, 73% 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 28 months (IQR: 10-54 months), 42% of the patients (n=134) experienced the combined endpoint (n=113 were admitted due to HF, n=61 died). After adjusting for age, NYHA class, comorbidities, type of TR and LVEF in a multivariate Cox proportional model (LR Chi-Square: 88.01, p<0.001), RV-EDV and RVEF were independently associated with all-cause mortality and heart failure (adjusted HR for RV-EDV per ml/m2 =1.008 [1.005-1.012], p<0.001 and RVEF HR per 1%=0.961 [0.942-0.981], p<0.001). Thresholds of RV-EDV ≥ 93 ml/m2, RV-ESV ≥ 39 ml/m2 and RVEF ≤ 58% held the best accuracy to predict outcomes (figure). In multivariable analysis, prognostic cut-off values of RV-EDV, RV-ESV and RVEF was associated with 1.91, 2.03, and 1.76-fold increased risk of HF or all-cause mortality respectively (RV-EDV HR: 1.91 [1.34-2.71], p<0.001, RV-ESV HR 2.03 [1.42-2.89], p<0.001 and RVEF HR1.76 [1.25-2.49], p=0.001).

Conclusion

RV size and function are crucial for determining optimal timing for TR intervention. CMR remains the gold standard to assess RV remodeling. Cut-off values of RV volume and function by CMR are defined in a multicentre cohort of patients based on outcome data; proposed thresholds differ from those previously established by echocardiography.Kaplan Meier curves
Predictors of progression to significant atrial functional tricuspid regurgitation in patients with paroxysmal or persistent atrial fibrillation
Authors: Song S S , Kang J M
Published: October 2024

Background

Atrial functional tricuspid regurgitation (atrial TR) has received growing recognition as a TR entity with a distinct cause owing to its independence from valvular tethering as the predominant mechanism underlying TR. Atrial fibrillation (AF) is highly prevalent in patients with AFTR and is considered a major contributor to its development. However, evidence on predictors of progression to significant atrial function TR in patients with diagnosed AF is lacking.

Methods

At a single tertiary university hospital, we studied 11445 patients who underwent echocardiograms at least 1 year apart between 2010 and 2023. Patients with moderate or greater TR at the initial examination (n=432) were excluded to ensure that only subjects with confirmed progression to atrial functional TR were included. Only those with EF > 50%, no other moderate or severe valve stenosis or regurgitation, no valve surgery, and RVSP < 40mmHg were subsequently identified (n= 8159). Patients diagnosed with AF 3 months before or after the echocardiogram were included. The final analysis included 629 patients, 44 progressed to moderate or worse TR during follow-up.

Results

The mean age of the patients was 68 (62-74) years and 57% were male. The mean time to progression to severe TR was 5.7 years. There was no difference in left ventricle size, ejection fraction of LV, right atrium, and right ventricle size on the initial echocardiogram between the group that progressed to significant TR (group 1) and the group that did not progress (group 2). LA diameter (LAAP), LAV(LA volume), and LAVi were significantly larger in group 1. In particular, the Kaplan-Meier graph of TR progression divided into two groups based on LAV 75ml and LAVi 45ml/m2 showed a significant difference, and in particular, LAVi was a significant predictor compared to other factors.

Conclusion

In patients with AF, the most common cause of atrial functional TR, an initial LAVi >45ml/m2 was shown to be a predictor of progression to significant TR.cumulative survival rate
Predictors of debulking devices use by coronary artery calcification classification using cardiac CT
Authors: Nakano Y , Okutsu M , Sadamatsu K , Nagata T , Serikawa T , Hasegawa K , Fujimoto Y , Yamada S , Takahashi Y , Kurogi K , Masuda N , Nakano M , Torii S , Tanabe M , Matoba T
Published: October 2024

Background

Multi-slice computed tomography (CT) is useful for the non-invasive detection and quantiﬁcation of coronary calcium burden. However, a definitive parameter based on CT imaging for predicting the need for debulking devices, such as rotational atherectomy (RA) and orbital atherectomy (OAS), has yet to be established.

Purpose

We aimed to develop a calcification risk score using cardiac CT to predict the use of debulking devices during coronary intervention.

Methods

In this retrospective, multi-center, observational study in Japan, patients who underwent percutaneous coronary intervention (PCI) were screened. Inclusion criteria were (1) cardiac CT within 6 months prior to PCI, (2) moderate or severe coronary calcification detected on CT, and (3) de novo lesions in a native coronary artery. A total of 349 lesions in 343 patients from 13 hospitals, there were 124 lesions that were treated with debulking devices and 225 lesions without debulking devices. Cardiac CT images were analyzed for circumferential degree, longitudinal length, intracoronary distribution of calcification, peak density, mean density, vessel bend and presence of bifurcation lesions. Data from a random two-thirds (the derivation cohort, n=247) were used to develop a new risk prediction model, which was then tested in the remaining one-third (the validation cohort, n=102). Odds ratios and the risk prediction model were developed using a logistic regression model. The predicted risk was translated into a simplified scoring system (Figure 1A).

Results

RA was used in 111 lesions and OAS in 23 lesions. Factors selected in the model included circumferential degree (≥270°: 3 points), bifurcation (2 points), longitudinal length (≥8mm: 1 point), and mean density (≥600 HU: 1 point) (Figure 1B). This model demonstrated good discrimination (c-statistic=0.772) and calibration (Hosmer–Lemeshow χ²-statistic=0.885; P=0.64) in the validation cohort (Figure 2).

Conclusions

The new prediction model based on cardiac CT performed well in predicting the need for debulking devices. This could serve as an objective tool to support a clinical decision to use debulking devices even in cases where intravascular imaging is not applicable.Study flow and Cardiac CT calcium scoreDiscrimination and Calibration
HFpEF is associated with a higher risk of hospitalization or death in men undergoing transcatheter edge-to-edge tricuspid valve repair
Authors: Walther E , Groeger M , Schneider L , Rottbauer W , Kessler M
Published: October 2024

Aims

There are fundamental differences between women and men regarding the pathophysiology and etiology of tricuspid regurgitation (TR) as well as underlying comorbidities. The aim of this study was to analyze differences between female and male patients undergoing transcatheter edge-to-edge tricuspid valve repair for TR (T-TEER) and to identify gender-specific predictors of adverse outcome.

Methods and Results

In this monocentric study 197 consecutive patients (96 women and 101 men) undergoing T-TEER at our university heart center were included. Prevalence of heart failure with preserved ejection (HFpEF) was higher in women than in men (63% vs. 37.3%; p=0.001) whereas men more often had heart failure with reduced ejection fraction (HFrEF; 62.7% vs. 37%; p=0.001). Women had more severe symptoms (86.2% in New York Heart Association (NYHA) class III-IV vs. 72.3% in men; p=0.022). Device success rates (p=0.64), procedural characteristics (e.g. number of clips, p=0.17) and postprocedural results (TR grade post clip, p=0.1) were comparable. One-year mortality did not differ between genders (5.9% in women, 8.6% in men; p=0.53). Likewise, no significant difference could be found with regard to heart failure hospitalizations within one year after T-TEER (20.3% in women, 18.8% in men, p=0.82). Strikingly, prevalence of HFpEF was substantially higher than of HFrEF in men that reached the combined endpoint of one-year mortality or rehospitalization for heart failure (61.5% vs. 38.5%; p = 0.08). In women, no relevant difference could be found (27.0% vs. 32.4%; p=0,623).

To identify gender-specific predictors of the combined endpoint, a cox regression analysis was performed. In men, HFpEF emerged as an independent predictor (HR 2.703; 95% CI 1.069 – 6.837; p = 0.036). In women, NYHA functional class proved to be an independent risk factor (Hazard Ratio (HR) 3.362; 95% confidence interval (CI) 1.085 – 10.415; p=0.036) for the combined endpoint whereas HFpEF was not associated with adverse outcome (HR 0.865, 95% CI 0.259 – 2.885, p=0.81).

Conclusions

Women undergoing T-TEER were more symptomatic and had higher prevalence of HFpEF compared to men. Nevertheless, HFpEF emerged as an independent predictor of the combined endpoint of one-year mortality or rehospitalization for heart failure only in men. NYHA functional class independently predicted adverse outcome in women.
Epidemiology and temporal trends of infective endocarditis between 2006 and 2018 at a tertiary referral center
Authors: Bence A , Denes M , Borbas S , Ferenci T , Andreka P
Published: October 2024

Introduction

Despite modern diagnostics, targeted antibiotic therapy and surgical treatment the mortality rate of infective endocarditis (IE) remains high. In developed countries both the risk factors and pathogens have changed.

Objective and methods

In our retrospective study we analyzed the clinical and microbiological characteristics, short- and long-term all-cause mortality, and temporal trends of consecutive patients admitted with IE between 2006 and 2018.

Results

We included 537 cases in our study, the mean age was 55.9 ± 16.5 years (72.2% male). 325 (60.5%) cases were native left-sided IE, 14 (3%) cases were right-sided IE, 130 (24%) cases were prosthetic valve IE, 62 (11.5%) cases were intracardiac device-related IE and 6 (1%) other cases. The most common microorganisms were Staphylococci (n=175; 33%), including 104 cases of methicillin-sensitive Staphylococcus aureus (MSSA), 27 cases of methicillin-resistant Staphylococcus aureus (MRSA) and 44 cases of coagulase-negative Staphylococci. Streptococcus species were identified in 141 cases (26%), Enterococcus species in 88 cases (16%) and 72 cases (13%) were classified as blood culture-negative IE. In-hospital all-cause mortality was 14%, mortality at six months was 27%, at one-year was 31%, and at five-year was 45%. The incidence of MSSA infections increased over time (p=0.024), while coagulase-negative Staphylococci (p<0.001), and Streptococci (p=0.047) infections decreased. None of the observed mortality rates showed significant change over the study period. Predictors of mortality were advanced age (HR 1.37; p<0.001), impaired renal function (HR: 1.03; p<0.001), reduced ejection fraction on admission (HR 1.38; p<0.001), stroke (HR 1.74; p=0.001), and MRSA infection compared to Streptococci (HR 2.56; p=0.002).

Conclusion

During the observed 13-year period Staphylococci were the most common pathogens, with an increasing incidence of MSSA infection in our tertiary center. The mortality rate of IE remained high and showed no improvement over time.
Changes in length of hospital stay for infective endocarditis - data from before and after the POET trial
Authors: Ostergaard L , Pries-Heje M P H , Voldstedlund M A V , Bruun N E B , Povlsen J A P , Valeur Kober N V K , Ihlemann N I , Tuxen C T , Hasselbalch R H , Stahl A S , Moser C M , Kober L K , Bundgaard H B U , Iversen K I , Fosbol E L F
Published: October 2024

Background

The results from the Partial Oral Treatment of left-sided Endocarditis (POET) trial was published in August 2018 and established non-inferiority of a switch to oral step-down antibiotic treatment in stabilized patients with infective endocarditis (IE). However, data on length of hospital stay and safety following the POET trial are warranted.

Purpose

To examine the changes in length of hospital stay before and after POET publication. Further, to assess safety (relapse of bacteremia and 180 days of mortality) before and after POET publication.

Methods

By cross-linkage of Danish nationwide registries, patients with first-time IE caused by Streptococcus spp., Enterococcus faecalis, Staphylococcus aureus, or coagulase negative staphylococci from 2012-2021 were identified. Immediately following the publication of the POET trial, the POET criteria was implemented and used in Denmark. The study period was categorized according to publication date (before and after September 2018). Median length of hospital stay was examined according to calendar period. Mortality (from admission date) and relapse of bacteremia (after discharge) at 180 days of follow-up were examined with the Kaplan-Meier estimator and the Cumulative Incidence Function, respectively.

Results

We identified 3,008 patients before publication of the POET trial (median age 72.8 years) and 1,740 after the publication (median age 75.2 years) (p<0.0001). The burden of comorbidities was comparable between groups. The median length of hospital stay decreased by 8 days: 41 days (IQR: 29-49) before POET publication and 33 days (IQR: 21-44) after POET publication (p<0.0001 for difference), Figure 1. Similar reductions in length of hospital stay were seen across different microbiological etiologies and age groups. The reduction in length of hospital stay was most pronounced in non-surgically treated patients. The mortality from IE admission with a maximum of 180 days follow-up was 27.5% before POET publication and 28.3% after POET publication (p-value=0.41 for difference). The bacteremia relapse rate within 180 days was 3.5% before POET publication and 1.6% after POET publication (p-value=0.0002 for difference), Figure 2.

Conclusion

Following the POET trial, we found an 8 days reduction in median length of hospital stay with no change in mortality and an associated lower rate of relapse of bacteremia.
Characteristics and outcomes of patients with moderate multivalvular disease in the context of tricuspid regurgitation
Authors: Morosato M , Margonato D , Ingallina G , Ancona F , Stella S , Biondi F , Tavernese A , Belli M , Fiore G , Maisano F , Topilsky Y , Agricola E
Published: October 2024

Background

The clinical features and the long-term prognosis of patients with moderate tricuspid regurgitation (TR) in the context of concomitant moderate left-sided valvular disease (VD) are poorly characterized.

Purpose

This study sought to describe the characteristics and the outcomes of patients with combined moderate TR and moderate mitral or aortic VD.

Methods

Baseline clinical and follow-up data were collected from 2110 patients with moderate TR in combination with a moderate left-sided VD diagnosed at our centers from January 2012 to July 2020; the final cohort was divided in 4 groups as shown in Figure 1. The primary endpoint was all-cause death; secondary EP was the first occurrence of heart failure (HF) hospitalization.

Results

Group 1 patients (1529, 72.5%) had the highest prevalence of chronic kidney disease (897, 66%) and lowest left ventricular systolic function (LVEF <50%, 298, 21%), as detailed in Table 1. Coronary artery disease was most prevalent in Group 2 patients (43, 41%), which also presented with the lowest average Charlson Index scores (3.95±1.87) and most prevalent dyspnea symptoms (44, 41%). Group 3 patients (41, 1.9%) were the oldest (82±7 years), had the highest rate of comorbidities (mean Charlson score 5.2±1.6), atrial fibrillation (20, 54%) and pulmonary hypertension (17, 46%). Eventually, Group 4 patients (422, 20%) were the youngest (74±13 years), more commonly female (279, 66%) and with the highest right ventricular dysfunction rate (TAPSE < 17 mm, 114, 40%).

After a median follow-up of 2.1 years, the primary endpoint occurred in 895 (42.4%) patients, with a significantly higher incidence in Group 3 patients (p<0.001) (Figure 1). The secondary endpoint occurred in 316 (15.0%) patients and, similarly, significantly more frequently in Group 3 patients (p=0.01). Subgroup analysis for the primary and secondary endpoint in patients with preserved ejection fraction (LVEF > 50%) confirmed the results of the primary analysis, with Group 3 as the cohort with the most adverse outcomes.

Conclusions

Patients with significant TR frequently exhibit concurrent left-sided VD, identifying distinct patient subgroups with varying clinical profiles. Notably, TR combined with moderate AS is associated with the most severe clinical presentation and the poorest long-term prognosis, even in patients with preserved LVEF.Figure 1.
Role of negative transthoracic echocardiography in excluding infective endocarditis
Authors: Cambise N , Tremamunno S , Marino A , Lenci L , De Benedetto F , Belmusto A , Tinti L , Di Renzo A , Di Perna F , Buonamassa G , Pontecorvo S , Lombardo A , Lanza G A
Published: October 2024

Background

Recent guidelines suggest an extensive role of transesophageal echocardiography (TOE) in the diagnostic work-up for suspected infective endocarditis (IE).

However, the negative predictive value of transthoracic echocardiography (TTE) remains poorly investigated.

Purpose

The purpose of our study was to evaluate the accuracy of TTE in ruling out IE in order to avoid unnecessary TOE, a more invasive and expensive diagnostic exam.

Methods

We reviewed data of 637 consecutive patients referred to our laboratory of echocardiography with a suspected diagnosis of IE who underwent TOE within 14 days of TTE (median 4.4 days; interquartile range 2.4-7.4). For each patient we obtained age, sex, blood culture results, complete blood count, blood chemistry, evidence of systemic embolism or pulmonary embolism, and presence of moderate/severe heart valve disease, congenital heart disease, valve prostheses and intracardiac devices.

Patients with initial doubtful findings at TOE were referred for a follow-up TOE after one week and/or 18F fluorodeoxyglucose positron emission tomography computed tomography to achieve a definitive clinical diagnosis. Patients in whom a clear diagnosis of IE could not be achieved (n=7) were considered to have the disease.

Results

Of the 637 patients enrolled, 375 had negative TTE for IE (59%). TOE was positive and doubtful for IE in 44 (12%) and 29 (8%) of these patients, respectively.

After further assessment, a final diagnosis of IE was achieved in 56 patients (15%).

Variables associated with IE at univariable analysis included presence of valve prostheses (p<0.001), systemic or pulmonary embolism (p<0.001), lower platelet count (p=0.003), positive blood culture (p=0.005), aortic valve regurgitation (p=0.02), aortic valve stenosis (p=0.03) and mitral regurgitation (p=0.03).

At multivariable logistic regression, independent predictors of IE (OR=odds ratio; CI=confidence interval) included evidence of systemic or pulmonary embolism (OR 17.75, 95% CI 6.66-47.3, p<0.001), bioprosthetic heart valves (OR 2.93, 95% CI 1.31-6.53 p=0.023) and lower platelet count (OR 0.995, 95% CI 0.991-0.998, p=0.003).

Among the subgroup of patients (n=183, 49%) with no evidence of embolism, no bioprosthetic valve and platelet count >190,000/mL (median value), IE was diagnosed in 11 patients only (6%).

Conclusions

In our study, a negative TTE in the subgroup of patients with suspected IE showing platelet count >190,000/mL and absence of embolism and valvular bio-prosthesis, had a negative predictive value for IE of 94%, suggesting that, in this subset of patients, TOE can initially be delayed and performed only if clinical suspicion continues to remain high.