bluuebunny/crossref_metadata_2025 huggingface dataset:
Influence of coronary plaque characteristics on lesion-specific ischemia assessed by coronary computed tomography angiography and fractional flow reserve - a systematic review and meta-analysis
Authors: Iraqi N , Noergaard B L , Dey D , Abdulla J
Published: October 2024

Background

Characterization of atherosclerotic plaque features by coronary computed tomography angiography (CCTA) carries profound prognostic value. Previous studies indicate that coronary plaque burden and certain plaque features are associated to lesion-specific ischemia by invasive fractional flow reserve (FFR). However, the existing literature is limited by small sample sizes, and provide inconsistent results.

Purpose

We performed a meta-analysis in order to delineate further the potential association between coronary plaque phenotype by CCTA and FFR.

Methods

A comprehensive systematic literature review and meta-analysis was conducted. PubMed and Embase databases were searched for studies that investigated the association between coronary plaque characteristics and FFR between January 2010 and August 2023. Study search, evaluation, and data extraction were performed independently by two researchers. Weighted mean difference (WMD) method for WMD was used for comparison of pooled per-lesion plaque parameters and presence of specific plaque features against presence of lesion-specific ischemia (FFR ≤0.80). Lesions with stenosis severity of 25-90% were included. Extracted data from eligible studies were analysed using random effects model for WMD and to estimate odds ratios (OR) with 95% confidence intervals (CI).

Results

A total of 12 studies were deemed eligible with 1,318 patients and available data on 1,915 coronary lesions. Of these, 626 lesions caused ischemia. Significantly greater total plaque volume (TPV) and non-calcified plaque volume (NCPV) occurred in lesions with abnormal FFR compared to normal FFR (WMD 83.0 mm3, 95% CI: 44.27; 121.81, p<0.001; WMD 83.63 mm3, 95% CI: 55.0; 112.24, p <0.001, respectively). Similar findings were observed for aggregate plaque volume (%APV) and plaque burden (%PB) with WMD 9.18, 95% CI: 6.08; 12.28, p<0.001; WMD 8.83, 95% CI: 4.32; 14.24, p=0.001, respectively. Napkin ring-sign and spotty calcification appeared more frequent in ischemia-causing lesions compared to those with FFR >0.80 (OR 4.25, 95% CI: 1.39; 13.00, p=0.011; OR 1.92, 95% CI: 1.33; 2.75, p=0.001, respectively). A summary of the meta-analysis findings regarding the association between plaque burden and plaque characteristics and FFR is provided in Figure 1 and 2.

Conclusion

CCTA-derived TPV and NCPV as well as %APV, %PB and the presence of napkin-ring sign and spotty calcification are associated with presence of lesion-specific ischemia. Coronary plaque assessment from CCTA images provide improved discrimination of lesion-specific ischaemia.
Early risk stratification of patients after successfully resuscitated out-of-hospital cardiac arrest without ST-segment elevation - the TOMAHAWK risk score
Authors: Thevathasan T , Spoormans E , Freund A , Akin I , Fuernau G , Hassager C , Zeymer U , Poess J , Abdel-Wahab M , Jobs A , De Waha S , Lemkes J , Thiele H , Skurk C , Desch S
Published: October 2024

Background

Mortality after out-of-hospital cardiac arrest (OHCA) remains high. Early risk stratification is crucial to make adequate treatment decisions. Existing OHCA risk scores are either medically outdated, limited to registry data, small cohorts, certain healthcare systems only or include complex calculations.

Purpose

The aim of this study was to develop an easy-to-use, readily available risk prediction score for short-term mortality in patients with successfully resuscitated OHCA without ST-segment elevation, derived from the TOMAHAWK (Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation) trial.

Methods

The risk score was developed using a backward stepwise regression analysis. The risk score was externally validated in the COACT (Coronary Angiography after Cardiac Arrest Trial) cohort, which included patients with shockable rhythms only.

Results

Development and validation of the risk score was performed across 50 centres in three countries. Five variables emerged as independent predictors for 30-day mortality and were used as risk score parameters: age ≥72 years, known diabetes, unshockable initial electrocardiogram rhythm, time until return of spontaneous circulation ≥23 minutes and admission serum lactate level above 7.9 mmol/L. Between 1 and 4 points were attributed to each variable, leading to a score with three risk categories: low (0 to 2), intermediate (3 to 6) and high (7 to 10). The observed 30-day mortality rates were 23.6%, 68.8% and 86.2%, respectively (p<0.001) with a very good discrimination at an area under the curve of 0.82. Kaplan-Meier analysis revealed a stepwise increase in mortality between the different risk score categories (p<0.001 for low vs. intermediate, intermediate vs. high and low vs. high; see Figure). External validation in the COACT cohort showed short-term mortality rates of 23.1% (score 0 to 2), 44.8% (score 3 to 6) and 78.9% (score 7 to 10), respectively (each p<0.001).

Conclusion

The TOMAHAWK risk score can be easily calculated in daily clinical practice and is strongly correlated with mortality in patients with successfully resuscitated OHCA without ST-segment elevation. It may help stratify patient risk for short-term mortality and facilitate clinical decision making.
Drug-use-associated infective endocarditis in Denmark
Authors: Petersen J , Bager L G V , Oesgergaard L , Graversen P L , Iversen K , Bundgaard H , Koeber L , Fosbol E L
Published: October 2024

Introduction

Infective endocarditis (IE) has high mortality and the incidence is rising. Intravenous drug use is a risk factor for IE and poses challenges in clinical care. Amid the opioid crisis in many countries, rates of drug-use-associated IE (DU-IE) are increasing. While drug use in Denmark has remained stable the last decade, little is understood about the features and prognostic impact of DU-IE in developed nations not facing a current opioid crisis. Further, with multiple preventive measures deployed in local Danish regions, data on the evolution of DU-IE are warranted.

Purpose

To examine the temporal evolution, baseline characteristics, and long-term rates of all-cause mortality and IE recurrence in patients with DU-IE compared with patients with non-DU-IE.

Methods

This nationwide cohort study identified all first-time IE-patients (1999-2018) and categorized them in 1) patients with DU-IE, and 2) patients with non-DU-IE. Drug use was defined using ICD-8/10 codes or treatment for opioid use disorder. Patients were followed from the date of discharge, and absolute one-year rates of mortality and IE recurrence were examined with Kaplan-Meier estimates and the cumulative incidence function, respectively. Outcomes were compared with a multivariable adjusted Cox model.

Results

We identified 8,843 patients with IE: 407 (4.6%) with DU-IE (61% male, median age 44 years) and 8,436 (95.4%) with non-DU-IE (66% male, median age 72 years). While the absolute number of DU-IE increased, the proportion of DU-IE decreased from 5.9% in 1999-2003 (n=87) to 3.8% in 2014-2018 (n=114). Patients with DU-IE had a higher proportion of bloodstream infection with Staphylococcus aureus (49.4% vs 26.7%, p<0.001); conversely, they had a lower proportion of bloodstream infections with Streptococcusspecies (14.4% vs. 26.2%, p<0.011). Patient with DU-IE had lower in-hospital mortality compared with non-DU-IE (15.5% vs. 20.9%, p<0.001). Among those surviving admission, the one-year cumulative incidence of all-cause mortality was 16.9% in DU-IE and 17.3% in non-DU-IE (p=0.82), yet in adjusted analysis, DU-IE was associated with a higher one-year mortality rate (HR 1.64 [95% CI:1.23-2.21]) (Figure). The one-year cumulative incidence of IE recurrence was 12.8% in DU-IE and 4.3% in non-DU-IE, which corresponded to an adjusted HR of 3.39 (95% CI:2.35-4.88) in DU-IE.

Conclusion

While an increase in the absolute number of patients with DU-IE was observed, the proportion among all IE-patients was on the decline in Denmark until 2018—which contrasts with other countries where physicians currently battle collateral damage of the opioid crisis. Although drug use was associated with lower in-hospital mortality, it was striking that even though patient with DU-IE was almost 30 years younger, they still had higher rates of all-cause mortality and a more than three-fold increase in IE recurrence one year following discharge.
Implementing a novel selection criteria and pathway for same-day discharge after TAVI
Authors: Sethi R , Khokhar A A , Gonnah A , Hartley A , Seligman H , Lucarelli C , Pih O , Xu H , Martin M , Khawaja S , Ruparelia N , Sen S , Hadjiloizou N , Mikhail G , Malik I
Published: October 2024

Background

The expansion in indications for transcatheter aortic valve implantation (TAVI) has fuelled an increase in demand worldwide. Prolonged waiting lists and waiting list mortalities are not infrequent and often arise from limited hospital capacity and infrastructure. Approaches to address this have included procedural modifications – ‘minimalist TAVI’ and more recently the development of pathways to facilitate early discharge post-TAVI, such as same-day discharge (SDD) post-procedure.

Purpose

This study aims to evaluate the safety and effectiveness of a novel SDD pathway a large volume tertiary referral cardiac centre.

Methods

A new SDD pathway was established between March 2023 and February 2024 at a large-volume tertiary cardiac centre in UK. All patients accepted for TAVI were screened for SDD suitability based on three factors: 1) availability of adequate social support, (defined as presence of able-bodies adult individual to assist in home recovery), 2) technically suitable for transfemoral approach and 3) presence of previous pacemaker or low risk for conduction abnormalities (defined as no baseline conduction disturbances). Following TAVI, patients were deemed suitable for SDD if they were clinically stable, the procedure was technically successful and there were no procedural complications. Demographic, clinical, procedural and outcome data were collected for all patients enrolled onto the SDD pathway and reasons for non-SDD were identified. Ethical approval was obtained in accordance with local institutional policies.

Results

From March 2023 to February 2024, 81 out of 305 patients (26.6%) were enrolled onto the SDD pathway (median age 82 years old, 66.7% male, median STS risk score 2.34%). Indications for TAVI were severe native aortic stenosis (74/81, 91.4%), severe native aortic regurgitation (2/81, 2.5%) and severe surgical valve degeneration (5/81, 6.2%). SDD was feasible for 58/81 (71.6%) of patients, with 10/81 (12.3%) discharged the following day and 13/81 (16.0%%) requiring >24 hours hospital admission (Figure 1). Reasons for non-SDD included new conduction abnormality (10/81, 12.3%), vascular complication (6/81, 7.4%), acute stroke (3/81, 3.7%), patient preference (2/81, 2.5%) and haemodynamic instability (2/81, 2.5%). Out of the 58 SDD patients, 25/58 (43.1%) had no previous permanent pacemaker system and in these patients a balloon-expandable valve was selected for 24/25 (96.0%) of patients (Figure 2).

Conclusions

Patient selection based on the presence of social support at home, low risk of conduction abnormalities or previous pacemaker combined with appropriate valve selection can facilitate a safe and effective SDD post-TAVI programme.
Prevalence and outcomes of patients with discordant high gradient aortic stenosis
Authors: Unger P , Powers A , Le Nezet E , Lacasse-Rioux E , Galloo X , Clavel M A
Published: October 2024

Background

Conflicting prognostic results have been reported in patients with discordant high gradient aortic stenosis (DHG-AS, the combination of a mean pressure gradient ≥40 mmHg and an aortic valve area (AVA) >1cm² ). Moreover, existing studies only included selected patients without concomitant aortic regurgitation.

Purpose

We assessed the prevalence and survival of patients presenting with DHG-AS in an unselected group of consecutive patients presenting to the echocardiography laboratory of a tertiary referral center.

Methods

3,547 adult patients with AVA ≤1.5cm² and peak aortic jet velocity ≥2.5m/s or mean gradient ≥25mmHg who presented between 2005 and 2015 were included. Baseline clinical and echocardiographic data, and, when available, aortic valve calcium score (AVC) were collected in an institutional database, with subsequent retrospective analysis. The primary endpoint was all cause mortality during follow-up.

Results

DHG-AS was observed in 163 patients (11.6% of all patients with a gradient ≥ 40mmHg). After adjustment for potential confounders, overall mortality rate of patients with DHG-AS was similar to that of concordant severe AS (AVA ≤1cm², mean gradient ≥40mmHg; CSev-AS) patients (N=1,243; HR: 0.98[0.68;-1.44]; p=0.91), and discordant low gradient-AS (AVA ≤1cm²; gradient <40 mmHg; HGDLG-AS) patients (N=1,131, HR: 0.85[0.58-1.26]; p=0.42), and was worse than that of concordant moderate AS (AVA >1.0cm², gradient <40mmHg; CMod-AS) patients (N=1,010; HR: 0.54[0.36-0.81]; p=0.003, Fig 1). After adjustment for aortic velocities, aortic regurgitation had no significant impact on survival. Calcium scoring was performed in 716 patients, including 40 patients with DHG-AS. AVC in DHG-AS was higher than in patients with CMod-AS and DLG-AS, and not significantly different from that of CSev-AS. The AVC ratio (AVC divided by the sex-specific thresholds) was higher in patients with DHG-AS as compared to both CMod-AS and DLG-AS patients (Fig 2).

Conclusions

DHG-AS is not uncommon. Although an AVA ≥1.0 cm² is often seen as reassuring and mistaken as moderate AS, a high-pressure gradient conveys a poor prognosis, whatever the AVA and independently of the presence of concomitant aortic regurgitation.
Nitisinone attenuates progression of aortic stenosis in patients with alkaptonuria: an analysis of the SONIA 2 study
Authors: Bruce C , Hariharan P , Hussain S , Eleuteri A , Ranganath L , Fisher M
Published: October 2024

Background/introduction

Alkaptonuria (AKU) is a rare metabolic disorder caused by a defective enzyme, resulting in deposition of unmetabolised homogentisic acid in various connective tissues throughout the body (also termed "ochronosis"). Ochronosis of the aortic valve leading to progressive aortic stenosis is a rare but serious complication. Nitisinone decreases urinary and serum homogentisic acid levels and has been shown to improve morbidity and slow disease progression in AKU but the effects of this treatment on the progression of aortic stenosis have not yet been described. This review extrapolated from the data set of the SONIA 2 study, a 4-year multi-centre, randomised controlled trial investigating the effect of nitisinone on a composite clinical measure of AKU disease activity, but looked more specifically at measures of aortic stenosis disease progression.

Methods

Data was obtained from echocardiograms performed on 138 patients at baseline, 12, 24, 36 and 48 months of follow-up. In measuring the degree of aortic stenosis, the peak trans-aortic velocity (Vmax) was examined. A linear mixed effects regression model was used to assess the association between treatment and Vmax and to ascertain the difference in this measure at baseline and 48 months between the treatment and control groups. The mixed effects model incorporated both fixed effects for population parameters (age, sex, baseline Vmax, follow-up time) and treatment; and random effects, to account for intra-subject correlation of longitudinal observations of Vmax, inter-subject variability of baseline measurements of Vmax, and centre.

Results

At baseline, 19/138 patients (13.8%) had aortic stenosis, as classified by echocardiogram findings in accordance with the European Society of Cardiology (ESC) guidance on valvular heart disease, with 9/19 having mild aortic stenosis, 6/19 having moderate aortic stenosis and 4/19 having severe aortic stenosis. 25/138 had aortic sclerosis (see figure 1). The prevalence of aortic valve disease increased with age. From the 4-year follow-up period, 613 longitudinal observations of 138 subjects across all sites were obtained. At baseline, the difference in Vmax between the control and treatment groups was 0.063 m/s [95% CI: -0.054 m/s to 0.18 m/s] and did not reach statistical significance (p=0.23). At the end of the 4-year treatment period, the difference in Vmax was 0.10 m/s [95% CI: -0.0007 m/s to 0.20 m/s] and was statistically significant (p=0.05) (see figure 2).

Conclusion

Nitisinone slowed progression of aortic stenosis in patients with AKU. This may be grounds for timely initiation of nitisinone in those deemed to be at high risk, as identified by echocardiography. Of note, this is the first time that any medical therapy has ever been shown to affect the natural history of aortic stenosis.
Symptoms of Anxiety and Depression (SAD) in patients undergoing transcatheter aortic valve implantation. A multicentre Australian experience: The SAD-TAVI Study
Authors: Butala A , Sehgal K , Stub D , Palmer S , Noaman S , Htun N , Gardner E , Johnston R , Lynch K , Walton A , Nanayakkara S
Published: October 2024

Background

Symptoms of anxiety and/or depression (SAD) commonly co-exist in severe aortic stenosis, associated with increased morbidity and mortality following transcatheter aortic valve implantation (TAVI). Despite this, mental health remains under-researched in the TAVI literature.

Purpose

To characterise the prevalence of SAD in those undergoing TAVI and identify patient phenotypes at highest risk of these symptoms. We also aimed to examine how SAD evolve following TAVI and establish factors predictive of improvement and regression in mental health.

Methods

Retrospective review of prospectively collected data from patients undergoing TAVI between 2018 and 2023 included in an Australian TAVI registry.

Results

Of 1279 patients, median age was 82 (IQR 77, 87), 41% were female and median STS score was 3.9 (2.3, 5.9). 353 (28%) patients reported moderate or worse SAD at baseline. Of this group, 260 (74%) had complete resolution in symptoms within 30-days. Body Mass Index<25 (adjusted odds ratio [aOR] 3.4, p<0.001), vascular site complications (aOR 3.4, p=0.029) and non-home discharge (aOR 2.4, p=0.036) independently predicted failed improvement in SAD. Onset of new SAD was uncommon, present in only 72 (8%) patients. Non-home discharge (19% vs 8%, p=0.006) and a composite endpoint of stroke, acute myocardial infarction, and heart-failure readmission (11% vs 4%, p=0.012) were more prevalent in this cohort.

Conclusion

Symptoms of anxiety and depression are common but under recognised in severe aortic stenosis. TAVI is highly effective at improving these symptoms. Regular screening for mental health should be adopted as a standard of care in TAVI.Evolution of SAD Following TAVI
Emergency interventional treatment of cardiogenic shock due to decompensated aortic stenosis: a systematic review and meta-analysis
Authors: Kuehne S G , Raake P W J , Chiarito M , Bongiovanni D
Published: October 2024

Introduction

Cardiogenic shock (CS) induced by severe aortic stenosis (AS) represents a critical condition with a high mortality rate. Its optimal treatment is still unclear due to the recent advances in interventions and supportive therapies. Emergency transcatheter aortic valve implantation (eTAVI) as definitive therapy and emergency balloon aortic valvuloplasty (eBAV) as bridge to intervention are viable therapeutic options, but it is still unclear which strategy provides the best outcomes.

Purpose/Objective

This meta-analysis aimed to investigate the effectiveness and safety of eTAVI versus eBAV in patients with cardiogenic shock due to severe aortic stenosis. The primary endpoint was mortality at 30-day. Secondary outcomes were 1-year mortality and vascular and bleeding complications as well as incidence of pacemaker implantation.

Methods

We performed a systematic literature review to identify relevant studies reporting outcomes of patients undergoing eBAV or eTAVI due to CS. Studies conducting eTAVI or eBAV in patients with cardiogenic shock due to severe aortic stenosis were included. Data extraction and analysis were performed to evaluate mortality rates at 30 days and 1 year, as well as secondary endpoints including procedural complications.

Results

15 studies were included in the meta-analysis (6 for eTAVI, 10 for eBAV, one study comparing the two strategies) with a total of 2702 patients.

The pooled estimated rate for mortality at 30 days was 19% (I²= 11.4%; CI 0.16, 0.22) for eTAVI and 40% (I²= 56%; CI 0.31, 0.49) for eBAV while the pooled estimated rate for mortality at one year were 66% (I²= 27.1%; CI 0.57, 0.75) and 45% (I²= 82.8%; CI 0.21, 0.69) for eBAV and eTAVI respectively. Pooled estimated rate for any bleeding was 11% (I²= 54.3%; CI 0.02, 0.21) for eBAV and 11% (I²= 88.3%; CI 0.02, 0.20) for eTAVI, while for major vascular complications were 6% (I²= 72.7%; CI 0.00, 0.13) and 7% (I²= 52.1%; CI 0.03, 0.11) for eBAV and eTAVI respectively. As expected, pooled estimates for pacemaker implantation was high for eTAVI 9 %(I²= 0%; CI 0.08, 0.10) while 1% (I²= 9.5%;CI 0.0, 0.05) for eBAV.

Conclusion

Using the totality of existing evidence, this study synthesizes the current evidence to elucidate the benefits and risks associated with eTAVI and eBAV in patients with CS due to AS. eTAVI procedure has beneficial survival rates, while it is associated with higher pacemaker implantations. While these findings are hypothesis generating only, as selection bias and other confounders cannot be excluded, they provide valuable insights to guide clinical decision-making in CS patients.30-day mortality
Multi-modal artificial intelligence-based prediction for cardiovascular mortality after transcatheter aortic valve implantation: a time-to-event survival prediction
Authors: Shiri I , Tomii D , Nakase M , Balzer S , Windecker S , Pilgrim T , Grani C
Published: October 2024

Background

Predicting long-term outcomes following Transcatheter Aortic Valve Implantation (TAVI) presents a significant challenge.

Objective

We aimed to predict post-TAVI long-term cardiovascular mortality using multimodal data and employing time-to-event artificial intelligence (AI) algorithms.

Methods

This study enrolled 3,973 consecutive patients from the prospective TAVI registry (between August 2007 and June 2023). Multimodal information was collected and extracted as numerical data for each patient, encompassing clinical history, medication, laboratory, procedural characteristics, ECG, angiography, echocardiography (TTE and TEE), and CT. Clinical outcomes were adjudicated by an independent clinical event committee. From the multimodal information, 147 features were extracted at baseline before the TAVI procedure. The datasets were divided into a training/validation set (80%) and a hold-out test set (20%) for model development and evaluation, respectively. Cox-LASSO feature selection was employed to identify the most relevant features, followed by the implementation of Random Survival Forest (RSF), Gradient Boosting Survival Analysis (GBSA), and Survival Support Vector Machine (SSVM) to predict the timing and occurrence of cardiac death events in patients. Feature selection, model parameters, and hyperparameters selection were performed using 10-fold cross-validation on the training set. Model performance was evaluated using different metrics, such as the concordance index (c-index) and cumulative Area Under the Curve (C-AUC) on a 20% untouched test set.

Results

In the patient cohort, 28.4% experienced cardiovascular death. Features were selected from various modalities, including 22 from clinical history, two from medication, eight from laboratory tests, one from ECG, eight from CT scans, and five from echocardiography and angiography. In the univariate Cox-PH model, all features exhibited a C-index ranging from 0.50 to 0.57. In the test set, the conventional Multivariate Cox-PH model achieves a c-index of 0.59 (C-AUC: 0.56). RSF, GBSA, and SSVM achieve a C-index of 0.70 (C-AUC: 0.69), 0.66 (C-AUC: 0.64), and 0.69 (C-AUC: 0.68), respectively, in the holdout test set.

Conclusion

Integrating multimodal information, encompassing imaging, signal, laboratory data, and clinical history, with AI algorithms has markedly enhanced the prediction of long-term cardiac outcomes following the TAVI procedure. The initially developed model can predict the probability of cardiac death up to 10 years. Furthermore, the RFS model significantly outperformed the conventional Cox model in predicting time-to-event outcomes.
Incremental value of biventricular strain in patients with severe aortic stenosis
Authors: Sarrazyn C , Galloo X , Meucci M C , Butcher S , Myagmardorj R , Van Der Kley F , De Backer T , Bax J J , Ajmone Marsan N
Published: October 2024

Background

Left ventricular global longitudinal (LVGLS) and right ventricular free wall strain (RVFWS) demonstrated separately prognostic value in patients with severe aortic stenosis (AS). However, studies evaluating combined assessment of LVGLS and RVFWS have shown contradictory results.

Aim

To explore the prognostic value of combining LVGLS and RVFWS in a large group of severe AS patients referred for transcatheter aortic valve implantation.

Methods

Patients were classified into three groups: preserved (LVGLS ≥15% AND RVFWS >20%), single-ventricle impaired (LVGLS <15% OR RVFWS ≤20%), or biventricular impaired strain group (LVGLS <15% AND RVFWS ≤20%). Cut-off values were based on previously published data and spline analyses. Endpoint was all-cause mortality.

Results

Of the 712 patients included (age 80±7 years, 53% men), 248 (35%) died. The single-ventricle impaired and biventricular impaired (vs. preserved) strain groups showed significantly lower 5-year survival rates (68%and 55%vs.77%, respectively, p<0.001; Figure 1). On multivariable analysis, single-ventricle impaired (HR 1.762; 95%CI:1.114-2.788; p=0.015) and biventricular impaired strain groups (HR1.920; 95%CI:1.134-3.250; p=0.015) were independently associated with all-cause mortality. These findings were confirmed by sensitivity analysis in patients with preserved LV ejection fraction (Figure 2).

Conclusions

In patients with severe AS, biventricular strain allows better risk stratification, even if LV ejection fraction is preserved.
Comic-based consenting on patient-reported experience and outcome measures for transfemoral aortic valve implantation
Authors: Thevathasan T , Reitz F , Hornig C , Leistner D , Dreger H , Suendermann S , Unbehaun A , Haghikia A , Stangl K , Falk V , Landmesser U , Hindricks G , Skurk C , Stangl V , Brand A
Published: October 2024

Background

The impact of an improved patient informed consent (IC) before transcatheter aortic valve implantation (TAVI) on patient-reported experience and outcome measures (PREMs and PROMs) as well as on clinical outcomes remains unclear.

Purpose

To investigate patient satisfaction, PREMs, PROMs and clinical outcomes in patients receiving additional illustrative graphic-based IC (comic group) compared to conventional IC (control group) for TAVI at two tertiary care centers as part of a randomised controlled trial ("TAVI-COMIC study").

Methods

Adult patients undergoing elective TAVI were enrolled. Patient satisfaction and PREMs were assessed after providing IC, PROMs at 90 days after TAVI and clinical safety outcomes within 7 days after TAVI (Figure).

Results

Only 48 (32%) of all patients read the official usual patient information sheet. Of 299 patients undergoing TAVI, comic-based IC was performed in 152 (51%) patients. Patient satisfaction was significantly higher (29 [23-32] vs 25 [22-30] of a maximum of 32 points in the validated Client Satisfaction Questionnaire [CSQ], p<0.001) and anxiety was lower (34 [25-51] vs 39 [29-55], p<0.001 in the validated Spielberger State-Trait-Anxiety Inventory [STAI]) in the comic group. 92 (61%) patients in the comic group felt "relaxed" prior to the procedure compared to only 44 (30%) patients receiving conventional IC (p<0.001). 91 (60%) were "very satisfied" with the delivered patient IC compared to 28 (19%) patients in the control group (p<0.001). PROMs at 90 days were assessed in a subgroup of 198 (66% of total cohort) patients: The comic group had similar PROMs as the control group (e.g. general health condition, walking ability and rate of dizziness, syncope, helplessness, depression, dyspnea or angina). Clinical outcomes, such as bleeding, pneumonia, stroke, delirium, or TAVI unit and hospital length of stay, were similar in both groups.

Conclusion

Use of an alternative IC approach, such as medical graphic narratives, might significantly improve patient satisfaction and PREMs, while facilitating similar PROMs and procedural safety as conventional treatment strategies.
Impact of left atrial size on outcomes in patients with atrial functional mitral regurgitation
Authors: Kato N , Kaneko T , Amano M , Sato Y , Ohno Y , Obokata M , Sato K , Okada T , Watanabe H , Machino-Ohtsuka T , Abe Y , Kagiyama N
Published: October 2024

Background

Atrial functional mitral regurgitation (AFMR) is caused by mitral annular enlargement following left atrium (LA) enlargement because of atrial fibrillation and/or heart failure with preserved ejection fraction. However, the distribution and clinical impact of LA size are unknown.

Purpose

To assess the impact of LA volume index (LAVI) on clinical outcomes in patients with AFMR.

Methods

We investigated patients with ≥moderate AFMR from the REVEAL-AFMR registry. Patients with ≥moderate aortic valve diseases and/or missing LAVI were excluded. The primary endpoint was a composite of cardiovascular death and heart failure hospitalization.

Results

Of total 871 patients with AFMR (age 78 ± 9 years, men 45%, atrial fibrillation 80%, severe MR 28%), median LAVI was 75 [58-110] mL/m². LAVI <50, 50-99, 100-149, 150-199 and ≥200 mL/m² were present in 117 (13%), 48 (55%), 162 (19%), 61 (7%) and 48 (6%), respectively. In these subgroups, severe MR was present in 10%, 20%, 38%, 61%, and 69% (Figure A), and NYHA III or IV in 8%, 8%, 13%, 13% and 23%, respectively. During the median follow up of 2.9 [2.0-3.2] years, LAVI ≥200 and 150-199 mL/m² were associated with lower event-free survival compared with <50 mL/m² (Figure B) . In the multivariable analysis, LAVI ≥150 mL/m² was an independent risk factor of adverse events (adjusted hazard ratio [HR] 1.69; 95% CI 1.05-2.73, p=0.030), adjusted for age, sex, body mass index, severe symptoms, chronic kidney disease, anemia, severe MR and tricuspid regurgitation (TR). Variables associated with LAVI ≥150 mL/m² were atrial fibrillation (adjusted OR 5.95; 95% CI 1.79-19.8, p<0.01), severe MR (OR 3.99; 95% 2.49-6.39, p<0.01) , elevated PASP (OR 3.10; 95% 1.80-5.33, p<0.01) and TR (OR; 2.46 95% 1.43-4.21, p<0.01), left ventricular end-diastolic volume (adjusted OR 1.26 per 10mL; 95% 1.17-1.36, p<0.01).

Conclusion

LAVI was 50-99 mL/m² in nearly a half of patients with AFMR, but enlarged to ≥150 mL/m² in 13%. Patients with larger LAVI more frequently had severe symptoms. LAVI ≥150 mL/m² was associated with worse outcomes, independent of MR severity. Severe MR and left ventricular size were strongly associated with LA enlargement other than atrial fibrillation.Figure AFigure B
Impact of the lower extremity arterial calcification score on clinical outcomes after drug-coated balloon angioplasty for de novo femoropopliteal artery disease
Authors: Kawamura K , Tokioka K , Yoshida H , Miyagi R , Saito E , Matsuo N , Mori A , Namba Y , Ohe T , Kawai Y
Published: October 2024

Background

Severe calcification, assessed using the peripheral artery calcification scoring system (PACCS), is associated with poor clinical outcomes after endovascular treatment (EVT) for de novo femoropopliteal lesions. However, the PACCS classification is a qualitative assessment performed in the angiographic room, and there are no established indicators for the quantitative assessment of calcification prior to treatment.

Purpose

We aimed to investigate the impact of the lower extremity arterial calcification score (LEACS) calculated using non-contrast lower limb computed tomography on clinical outcomes after drug-coated balloon angioplasty for de novo femoropopliteal artery disease.

Methods

We retrospectively analyzed the clinical outcomes of 141 consecutive patients treated at our center for de novo femoropopliteal artery disease using a drug-coated balloon between April 2018 and December 2022. Patients who did not undergo lower limb computed tomography before EVT were excluded from the analyses. LEACS was determined based on the method used to calculate the Agatston score for the coronary arteries. Each patient’s score consisted of a sum of calcification scores from ostium of superficial artery to the popliteal artery at the knee joint of treated limb. The primary and secondary outcomes measured were primary patency and clinically-driven target vessel revascularization (CD-TVR) at 1 year. Cox proportional hazards analysis was used to explore independent predictors of clinical outcomes. The study population was divided into higher and lower LEACS groups based on the cut-off value (1750), which best discriminated patency, and the outcomes were compared between the two groups.

Results

In the higher and lower LEACS groups, the mean age was 75.1 ± 9.1 years and 75.5 ± 11.0 years (p = 0.87) and the mean lesion length was 170.3±102.8 mm and 157.7±112.1 mm (p = 0.64), respectively. The higher LEACS group showed significantly lower 1-year patency than the lower LEACS group (53.5% vs. 84.3%, log-rank, p = 0.041). In addition, freedom from 1-year CD-TVR was significantly lower in the higher LEACS group than in the lower LEACS group (66.8% vs. 93.7%, p = 0.047). The Cox proportional hazard analysis showed that the higher LEACS group was an independent predictor of 1-year restenosis (odds ratio: 2.80, 95% confidence interval: 1.24–8.84, p=0.037), along with a small (< 5 mm) reference vessel diameter (odds ratio: 3.55, 95% confidence interval: 1.44–9.53, p=0.028).

Conclusion

Higher LEACS scores were independently associated with clinical outcomes after drug-coated balloon angioplasty for de novo femoropopliteal artery disease. Non-contrast lower limb computed tomography is an acceptable and feasible option for predicting the outcomes in patients with de novo femoropopliteal artery disease prior to treatment.
Deep learning and Diagnostic value of cardiac cine MRI for assessing patent foramen ovale in patients with cerebral disorders compared with cTCD
Authors: Liu G
Published: October 2024

Purpose

To investigate the clinical feasibility of cardiac MRI (CMRI) cine technology using deeplearning without contrast for diagnosis and classification of patent foramen ovales (PFOs) in patients with cerebral disorders.

Materials and Methods

Fourty-four patients (24 males and 20 females; mean age, 41.3 years; range, 21-64 years) with cerebral disorders underwent both contrast transcranial doppler sonography (cTCD) and non-enhanced CMRI examinations between October 2019 and March 2020. and datas from 335 patients were collected by 2023.CMRI was performed with a 3.0T MR scanner by using OBL FIESTA CINE 4CH sequence. The scanning direction was perpendicular to the interatrial septum (IAS) slice. The obtained MR images were analyzed by AW station 4.7 and the pseudo-color coding was also performed according to the different phases. The condition of the blood shunt was observed and recorded by using deep learning, including measuring the length and width of the PFO and observing whether it was complicated with IAS aneurysm or secondary septum thickening.

Results

Thirty-nine of 44 patients with cerebral disorders were confirmed with positive RLS by cTCD test, and 37 of the 39 patients were diagnosed with a PFO at CMRI. Two of 5 patients with negative cTCD test were also diagnosed with a PFO at CMRI. Compared with cTCD as a standard, CMRI had a sensitivity of 94.9%, specificity of 60.0%, accuracy of 90.9%, positive predictive value of 94.9%, negative predictive value of 60.0%, and AUC of 0.774. Based on the pseudo-color coding, the right-to-left color jet was observed in 34 patients, and the two-way shunting was found in 5 patients. The IAS aneurysm and secondary septum thickening were found in 5 and 3 patients (11.4% and 6.8%). The maximum diameters of PFOs ranged from 1.7 mm to 16.8 mm and the mean diameter was 5.4±3.4 mm.

Conclusion

By using deep learning,CMRI cine technology without contrast provided a noninvasive and excellent method for PFO identification, evaluation and classification, with both high sensibility (92.85%) and concordance (90.9%) when compared to cTCD.PFO types
Different treatments in chronic thromboembolic pulmonary hypertension: comparison of strategies in the Italian centre real-world experience
Authors: Ballerini A , Salvi M , Guarino D , Magnani I , Dardi F , Bertozzi R , Donato F , Cennerazzo F , Palazzini M , Manes A , Galie' N
Published: October 2024

Rationale

Pulmonary endarterectomy (PEA) has been the most effective therapy for chronic thromboembolic pulmonary hypertension (CTEPH). However, there is a substantial proportion of patients declared not operable in whom other treatment strategies are available: medical therapy and balloon pulmonary angioplasty (BPA). We aimed to compare different CTEPH treatment strategies effect in real-world setting.

Methods

All CTEPH referred to our Centre were included. We compare the short-term clinical, functional, exercise and haemodynamic effect of medical therapy (irrespective of subsequent treatment strategies), PEA and BPA (irrespective of previous/subsequent treatment strategies); we also describe the long-term outcome of the different patient groups.

Results

We included 467 patients (39% were treated only with medical therapy, 43% underwent PEA, 13% underwent BPA and 5% were not treated with any therapy). Patients treated only with medical therapy were the oldest; compared to patients undergoing PEA, they had a lower exercise capacity, a higher risk profile and gained a lower haemodynamic, functional and survival benefit from the treatment. Patients undergoing BPA had a lower haemodynamic improvement but a comparable functional, exercise and risk improvement and a similar survival compared to patients undergoing PEA; their survival is anyway better than patients undergoing only medical treatment. Untreated historical control patients had the worst survival.

Conclusions

We confirm the superiority of PEA compared to any alternative treatment in CTEPH and we observe that BPA, in patients declared not operable or with persistent/recurrent PH after PEA, leads to a better outcome than medical therapy alone.
Intravascular imaging-guided percutaneous coronary intervention according to lesion complexity
Authors: Lee S Y , Lee S J , Kwon W C , Lee S H , Shin D S , Lee J Y , Lee J M
Published: October 2024

Background

Recent trials have shown intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) has prognostic benefit compared with angiograph-guided PCI in complex coronary artery lesions. However, it is unclear whether this benefit is affected by overall complexity of target lesions in each patient.

Objectives

To investigate an impact of the number of complex lesion features on the benefit of IVI-guided PCI.

Methods

A total of 4,611 patients with complex coronary artery lesions from the RENOVATE-COMPLEX-PCI trial (n=1,639) and the institutional registry of a medical center (n=2,972) were classified according to the number of complex lesion features found in each patient. The primary outcome was a target vessel failure (TVF) at 3 years, a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization.

Results

The best cut-off number of complex lesion features for the risk of TVF was 3 and patients with ≥3 complex lesion features had higher risk of TVF than those with <3 complex lesion features (11.0% vs. 7.2%; HR 1.59, 95% CI 1.28-1.96, P<0.001). IVI-guided PCI significantly reduced the risk of TVF compared to angiography-guided PCI in both groups (≥3 complex lesion features: 7.4% vs. 14.4%, HR 0.49; 95% CI 0.35-0.69, P<0.001; <3 complex lesion features: 5.7% vs. 8.1%; HR 0.72, 95% CI 0.53-0.98, P=0.039). The benefit of IVI-guided PCI tended to increase as the number of complex lesion features increased (absolute risk reduction for TVF: -0.012 vs. -0.027 vs. -0.055 vs. -0.077, respectively, for the number of complex lesion features 1 vs. 2 vs. 3 vs. ≥4, interaction P=0.048).

Conclusion

In patients with complex coronary artery lesions, IVI-guided PCI reduced the risk of TVF regardless of overall complexity of the target lesions in each patient. The prognostic benefit of IVI-guided PCI tended to increase as patients had more complex lesion features.Clinical Outcomes
Diagnostic accuracy of automatic quantitative flow ratio for hemodynamic assessment of coronary artery stenosis: prospective observational study
Authors: Ki Y J , Hwang D , Yang S , Koo B K
Published: October 2024

Background

Quantitative flow ratio (QFR) is a method for evaluating fractional flow reserve (FFR) without the use of an invasive coronary pressure wire or pharmacological hyperemic agent. Automatic QFR (auto QFR) is a recently developed, simpler method of calculating QFR that uses a patient-specific TIMI (Thrombolysis in Myocardial Infarction) frame count, but with automatically specified start and end frames. Although the previous studies demonstrated that contrast QFR is more accurate than fixed QFR, there is no evidence for auto QFR.

Purpose

The aim of this study was to evaluate the diagnostic performance of auto QFR, fixed QFR, and contrast QFR for the diagnosis of hemodynamically significant coronary stenosis defined by FFR ≤0.80.

Methods

This prospective, multicentre trial enrolled patients suspected with coronary artery disease undergoing diagnostic coronary angiography with an indication for to perform invasive FFR. QFR was calculated at a blinded core laboratory. The primary endpoint was the diagnostic accuracy of auto QFR, fixed QFR, and contrast QFR to determine hemodynamically significant coronary stenosis using invasive FFR (≤0.80) as a reference standard.

Results

A total of 325 vessels from 274 patients were analysed. Mean FFR was 0.82±0.09, mean auto QFR was 0.80±0.12, and mean contrast QFR was 0.82±0.11, respectively. The overall diagnostic accuracy for identifying an FFR of ≤0.80 was highest by contrast QFR (81.5%), followed by fixed QFR (79.1%), and auto QFR (77.5%). The AUC was higher for contrast QFR (AUC 0.885; 95% CI: 0.845-0.925) than fixed QFR (AUC 0.856; 95% CI: 0.812-0.900) or auto QFR (AUC 0.854; 95% CI: 0.806-0.901), but did not differ significantly between fixed QFR and auto QFR (Figure).

Conclusions

There was no significant difference in AUC between fixed and auto QFR, but the accuracy of contrast QFR was significantly higher compared to both QFRs. Auto QFR has the advantage of faster computation time while using patient-specific coronary flow, but accuracy still needs to be improved.
The effect of transcatheter aortic valve implantation on fractional flow reserve and non-hyperemic pressure ratios
Authors: Minten L , Bennett J , Otsuki H , Takahashi K , Dubois C , Fearon W F
Published: October 2024

Background

Coronary artery disease in patients undergoing transcatheter aortic valve implantation (TAVI) is a very frequent clinical issue. Complex coronary artery disease can negatively influence outcomes after TAVI, however, angiography-guided percutaneous coronary intervention (PCI) has not been shown to offer any prognostic benefit. Coronary pressure indices, to select which lesions need treatment, are promising but are currently underused in aortic stenosis (AS) patients due to many physiological pitfalls. Available studies are small and show conflicting results on the effect of transcatheter aortic valve implantation (TAVI) on these indices.

Purpose

The aims is to compare the effects of TAVI on fractional flow reserve (FFR) and Non-hyperemic pressure ratio’s (NHPRs). Both immediate and long-term effects were studied.

Methods

Lesion specific coronary pressure data was extracted from 6 studies resulting in 147 lesions for immediate change in FFR analysis and 105 for NHPR analysis. To investigate the long-term changes, 93 lesions for FFR analysis and 68 for NHPR analysis were found.

Results

Immediately after TAVI, FFR decreased significantly (-0.0130 ± 0.0406 standard deviation, p-value: 0.0002) while NHPR remained stable (0.0003 ± 0.0675, p-value: 0.9675). Long-term after TAVR, FFR decreased significantly (-0.0230 ± 0.0747, p-value:0.0038) while NHPR increased non-significantly (0.0166 ± 0.0699, p-value: 0.0543). This increase in NHPRs became significant when only borderline NHPR lesions were considered (0.0249 ± 0.0441, p-value: 0.0015). All other results were confirmed in borderline-only lesions.

Conclusions

TAVI caused small significant, but opposite, changes in FFR and NHPR. In AS, FFR might underestimate lesion significance while NHPRs might overestimate its significance. This is only clinically relevant in borderline lesions, clear positive or negative physiological assessments can be trusted.Figure 1Figure 2
Rotational atherectomy versus orbital atherectomy for the treatment of calcified coronary lesions: a systematic review and meta-analysis of 81,873 patients
Authors: Altobaishat O , Abuelazm M , Amin A M , Tanashat M , Turkmani M , Manasrah A , Sharaf I , Abouzid M
Published: October 2024

Background

Previous studies have suggested that pre-treatment of coronary artery calcification with rotational atherectomy (RA) prior to stent deployment can enhance procedural success, but this does not necessarily translate into improved clinical outcomes. Recently, the Orbital Atherectomy (OA) system has been introduced into clinical practice to enhance lesion preparation.

Purpose

Our study aims to evaluate the safety and efficacy of both RA and OA as pre-treatment strategies before stent deployment in patients with coronary artery calcification.

Methods

We conducted a comprehensive systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. These were identified through systematic PubMed, Web of Science, Scopus, Embase, and Cochrane searches until January 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using Stata version 17.

Results

Our analysis included eleven studies encompassing 81,873 patients. No significant difference was observed between RA and OA in terms of major adverse cardiovascular events (MACE) (RR: 0.81 with 95% CI [0.64, 1.02], P= 0.07). However, OA was significantly associated with a decreased incidence of all-cause mortality (RR: 0.60 with 95% CI [0.52, 0.70], P< 0.01), target vessel revascularization (TVR) (RR: 0.43 with 95% CI [0.22, 0.82], P= 0.01), coronary artery bypass grafting (CABG) (RR: 0.78 with 95% CI [0.62, 0.97], P= 0.03), and fluoroscopy time (MD: -3.93 with 95% CI [-7.39, -0.48], P= 0.03).

There was no significant difference between RA and OA in cardiac death (RR: 2.65 with 95% CI [0.94, 7.51], P= 0.07), target lesion revascularization (TLR) (RR: 0.57 with 95% CI [0.23, 1.41], P= 0.22), myocardial infarction (RR: 0.79 with 95% CI [0.62, 1.01], P= 0.06), stent thrombosis (RR: 0.33 with 95% CI [0.09, 1.23], P= 0.10), stroke (RR: 0.76 with 95% CI [0.57, 1.01], P= 0.06), re-admission (RR: 0.76 with 95% CI [0.48, 1.19], P= 0.23), vessel closure (RR: 0.78 with 95% CI [0.18, 3.33], P= 0.74), procedural duration (MD: -5.43 with 95% CI [-21.71, 10.84], P= 0.51), length of hospital stay (MD: 0.21 with 95% CI [-0.47, 0.90], P= 0.54), and contrast amount (MD: -3.68 with 95% CI [-9.37, 2.01], P= 0.21).

Conclusion

Both RA and OA as pre-treatment strategies before stent deployment demonstrate similar outcomes for numerous cardiovascular events. However, OA is associated with lower rates of all-cause mortality, TVR, CABG, and fluoroscopy time.