bluuebunny/crossref_metadata_2025 huggingface dataset:
Association between lowering heart rate during IMPELLA support and favorable short-term outcome in patients with cardiogenic shock
Authors: Maemura K , Ikeda Y , Eda Y , Oki T , Yazaki M , Fujita T , Iida Y , Nabeta T , Ishii S , Koriyama K , Maekawa E , Koitabashi T , Ako J
Published: October 2021

Background

Impella has been increasingly used in patients with cardiogenic shock (CGS). Target values for clinical indices for appropriate management of Impella have not yet been established.

Purpose

We aimed to elucidate the association between heat rate (HR) during Impella treatment in patients with CGS and clinical outcomes.

Methods and results

We retrospectively evaluated 62 patients (68±14 years; male 77%) with CGS receiving temporary circulatory support with the Impella between February 1, 2019, and February 31, 2021. The primary end point was 30-day mortality. Clinical characteristics, laboratory and hemodynamic markers at implantation of Impella (baseline), 12, 24 hr after implantation, and removal of Impella were assessed. There were 28 patients with concomitant use of extracorporeal membrane oxygenation (ECMO). Treatment periods using Impella were 8±6 days. After excluding 11 patients who died during Impella support, the relationship between clinical indicators at each time points and 30-day mortality was evaluated. There were 22 patients (43%) with 30-day mortality. Factors associated with 30-day mortality were: female, ECMO, higher 24-hr lactate level, lower 24-hr cardiac power output, and higher HR at removal. Lower HR of ≤81 bpm at removal was found to most accurately predict lower 30-day mortality (Figure 1). Higher increases in dose of beta-blockers during Impella support and lower absolute doses of norepinephrine at removal were correlated with decreases in HR during Impella support.

Conclusions

In patients with CGS treated with Impella, lower HR at removal was associated with lower incidence of 30-day mortality. Lowering HR during Impella treatment was recognized as a simple indicator for favorable clinical outcomes in patients with CGS. It was suggested that chronotropic interventions during Impella treatment may be novel therapeutic options in patients with CGS.

Funding Acknowledgement

Type of funding sources: None. Figure 1
First Asian validation of ORBI score in predicting in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention
Authors: Putra A , Juzar D A , Widyantoro B , Firdaus I
Published: October 2021

Background

Cardiogenic shock (CS) complicating an acute coronary syndrome still worsening the prognosis with 30-day mortality rates approximating 40–45%, despite improvements in the acute management of ST-segment elevation myocardial infarction (STEMI), particularly the widespread use of timely primary percutaneous coronary intervention (pPCI). The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making. This is essential in developing countries with wide variation in health care facilities, scarce resources and increasing burden of cardiovascular diseases.

Purpose

To validate ORBI Score in identifying patients at high-risk of in-hospital STEMI related cardiogenic shock in a multi-ethnic developing country.

Method

The ORBI risk score was evaluated in 1934 patients STEMI without CS on admission and treated by primary percutaneous coronary intervention (pPCI) in our national cardiovascular centre included this study. Model discrimination and calibration was tested in the overall population. Eleven variables from the ORBI score were independently associated with the development of in-hospital CS: age >70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay >90min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycaemia >10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0–7), low- to-intermediate (8–10), intermediate-to-high (11–12), and high (≥13).

Results

Observed in-hospital CS rates were 0.3%, 6.4%, 19.5%, and 32.12%, across the four risk categories, respectively. The score demonstrated high discrimination (c-statistic of 0.91 (CI 95% 0.88–0.93), p<0.001 in the validation cohort)

Conclusion

The ORBI risk score is valid and can be used for predicting the development of cardiogenic shock in STEMI patients for better targeted treatment.

Funding Acknowledgement

Type of funding sources: None. ROC curveObserved in-hospital CS rates
Association between mean arterial pressure and neurological outcome in survivors of a cardiac arrest undergoing targeted temperature management
Authors: Vasserot I , Severo A , Juarez V , Rivero B , Arbas E , Poveda D , Tebar D , Merino C , Marco I , Martin L , Garcia-Arribas D , Caro J , Rosillo S , Armada E , Lopez De Sa E
Published: October 2021

Background

Besides targeted temperature management (TTM), no other therapeutic strategy has shown to improve neurological outcome in cardiac arrest patients. Recently, it has been suggested that higher levels of mean arterial blood pressure (>90 mmHg) may have a protective neurological effect in this population, yet data is scarce.

Objective

To describe the association between neurological outcomes and MAP during TTM.

Methods

Retrospective study of a prospective database including survivors of a cardiac arrest undergoing TTM and admitted to the acute cardiac care of a tertiary university hospital from September 2007 to July 2020. MAP was recorded from arrival and hourly during TTM. Neurological outcome was graded 3 months after initial event using the Pittsburgh Cerebral Performance Category (CPC) scale and patients were divided classified as follows: Group A patients with CPC of 1 to 2 (good neurological outcome), and group B, with CPC 3 to 5 (poor neurological outcome or death). As CPC 5 comprises patients who have died but whose cause of death may not be related to their neurological condition, we sort to control this potential source of bias, by including a variable of “severe neurological injury”, which includes patients with CPC 3–4 and those CPC 5 who died due to WLST due to poor neurological prognosis/brain death.

Results

A total pf 431 patients were analysed. Baseline and cardiac arrest characteristics are depicted in Table 1. Patients in group B had a higher proportion of non-witnessed cardiac arrest, out-of-hospital cardiac arrest, non-shockable rhythm, and longer time before ROSC. The relation between MAP and neurological outcome is shown in Table 2. The were no differences of MAP in day 1 and 3 between groups. MAP was statistically higher in Group A during day 2 or rewarming phase. Mean MAP during day 1 and 2; and during day 1, 2 and 3 was also significantly higher in group A. However, when same analysis was performed under the variable “severe neurological injury” no statistically significant differences were observed.

Conclusion

There is no association between MAP and neurological outcomes, when true “severe neurological injury” is analysed. Therefore, and until further data is obtained, following actual practical guidelines or avoiding hypotension seems to be the goal in this population, as higher MAP may also have deleterious effects.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital La Paz
High-degree atrioventricular block after valve-in-valve transcatheter aortic valve implantation: incidence and predictors
Authors: Jung S , Arnold M , Marwan M , Kondruweit M , Achenbach S
Published: October 2021

Background

High-degree atrioventricular (AV) block and permanent pacemaker (PPM) implantation represent major complications after transcatheter aortic valve implantation (TAVI). Data on the incidence of AV block for patients undergoing valve-in-valve (ViV) TAVI are scarce. We examined the incidence and predictors of periinterventional AV conduction disturbances in a cohort of subjects undergoing ViV TAVI compared to subjects undergoing TAVI of native aortic valves.

Methods

In 50 consecutive patients who underwent ViV TAVI, clinical characteristics, incidence and predictors for AV conduction disturbances as well as intrahospital outcome were assessed. Applying a matched pair approach for age, gender, type and size of transcatheter valve, these subjects were compared to 50 patients undergoing TAVI of native tricuspid aortic valves.

Results

Mean age in both groups was 80±6 years and 50% of subjects were male. In the ViV group, 22 patients (44%) had a stented bioprosthesis, 10 patients (20%) a stentless bioprosthesis and 18 patients (36%) a previous TAVI prosthesis (balloon-expandable: n=15, self-expandable n=3). The majority of subjects (92% in each group) were treated using balloon-expandable valves (ViV group: Sapien XT, n=20 or Sapien 3, n=26, control group: Sapien XT, n=19 or Sapien 3, n=27).

Periinterventional, non-reversible 3rd degree AV-block occurred in 6 patients within each group (12%), and all of the affected patients underwent PPM implantation. Among the 32 patients who underwent ViV-TAVI of a surgically placed bioprosthesis, only 2 (6%) developed a high-degree AV block (1/22 with a stented bioprosthesis and 1/10 with a stentless bioprosthesis). In contrast, high-degree AV block occurred in 4/18 patients (22%) who underwent ViV TAVI of a prior TAVI prosthesis. There was a significant difference in the occurrence of total high-degree AV blocks requiring postinterventional PPM implantation (p=0.033) between subjects who received TAVI of stented bioprostheses and those who received re-TAVI.

In logistic regression analysis, pre-existing RBBB represented a significant predictor for periinterventional 3rd degree AV block across the whole cohort (p=0.001, Exp(B)=10.667), both in ViV subjects (p=0.016, Exp(B)=12.0) and in the control group (p=0.018, Exp(B)=10.0).

Conclusion

Periinterventional AV block occurs infrequently in subjects undergoing ViV TAVI for treatment of degenerated surgical bioprostheses. However, patients undergoing ViV TAVI for degenerated transcatheter prostheses as well as subjects with pre-existing RBBB are at substantial risk for the occurence of AV block and require close peri-interventional monitoring.

Funding Acknowledgement

Type of funding sources: None.
Increased rate of new-onset left bundle branch block in patients with bicuspid aortic stenosis undergoing TAVR; data from a national registry
Authors: Shiyovich A , Kornowski R , Plakht Y , Aviv Y , Vaknin Assa H , Assali A , Lessick J , Kerner A , Segev A , Barabash I , Goitein O , Brodov Y , Finkelstein A , Perlman G , Hamdan A
Published: October 2021

Background

There is a growing interest in transcutaneous aortic valve replacement (TAVR) therapy among patients with bicuspid severe aortic stenosis (BAV). Conduction disturbances remain a frequent complication of TAVR, and new-onset permanent LBBB (NOP-LBBB) post-TAVR may be a marker of worse outcomes.

Purpose

To evaluate primarily the rate of NOP-LBBB following TAVR among patients with BAV as compared to tricuspid severe aortic stenosis (TAV).

Methods

Patients enrolled in the multicenter (5 centers) Bicuspid AS TAVR Registry were reviewed and compared with patients with TAV. Patients with prior aortic valve replacement, other valve morphologies and those with preprocedural LBBB or pacemaker were excluded. NOP-LBBB was defined as LBBB first detected and persisting 30-days following TAVR.

Results

A total of 387 patients (66 with BAV, 321 with TAV), age 80.3±7.3, 47% females were analyzed. The device success rates were 95% in both groups without any conversions to surgery. The rate of NOP-LBBB was significantly higher among patients with BAV vs. TAV (29.2% vs. 16.9%, p=0.02). However, the rate of post procedural pacemaker implantation was similar (14.8% vs. 12.5%; respectively, p=0.62). In BAV and TAV groups, 1-year mortality (6.1% vs. 7.2%; respectively, p=0.75) and stroke rates (6.1% vs. 3.5%; respectively, p=0.3) were not significantly different. Multivariate analysis identified BAV as an independent predictor of NOP-LBBB (OR=2.7, 95% CI 1.3–5.4). Furthermore, BAV subtypes with raphe (type 1) were identified as independent predictors of NOP-LBBB (OR=3.2, 95% CI: 1.5–6.7).

Conclusions

Patients with BAV undergoing TAVR have greater risk for developing NOP-LBBB compared with patients with TAV and the presence of raphe was associated with increased risk of NOP-LBBB. The prognostic significance for this finding warrants further evaluation in future studies.

Funding Acknowledgement

Type of funding sources: None.
Acute myocarditis with preserved ejection fraction: the role of CMR in long term follow up
Authors: Ghionzoli N , Mandoli G E , Gismondi A , Di Florio A , Cavigli L , Sciaccaluga C , Pastore M C , D'Ascenzi F , Cameli M , Focardi M
Published: October 2021

Background

Cardiac Magnetic Resonance (CMR) has an important role in subjects presenting with acute myocarditis and preserved ejection fraction (pEF); it is widely used as a non-invasive imaging test in patients with suspected myocarditis, both for diagnostic and prognostic purpose. Despite this, poor data is available regarding which parameters define a worst prognosis in acute myocarditis with pEF.

Purpose

The aim of this study was to analyze the role of CMR in acute myocarditis with pEF at long term follow up.

Methods

We retrospectively enrolled 61 patients admitted to our Cardiology Department with suspected acute myocarditis and pEF. In the acute phase we analyzed clinical parameters, blood sample tests, echocardiographic and CMR indices. Myocarditis was confirmed using the Lake-Louis criteria on CMR images. The patients were followed up for a median of 4.8 years for the development of two composite endpoints: the first including cardiovascular death, cardiac arrest and/or ICD implantation; the second hospitalization for acute heart failure and/or recurrence of myocarditis.

Results

The clinical presentation was infart-like in the 78% of subjects; they all had a NYHA class I and had a pEF at basal echocardiogram. CMR showed myocardial edema in 50 patients (83%) and late gadolinium enhancement (LGE) in 94% of subjects. LGE involved the inferolateral wall in the 70%, the interventricular septum in 25% and other walls in 5%. During follow up, the first composite endpoint occurred in the 8% of patients, while 7 subjects (11%) had a new hospitalization for cardiac causes (heart failure or recurrence of myocarditis). Those patients with events during follow up had a significantly higher LGE quantity (21±9,8 gr vs 12,8±6 gr; p=0.006 Figure 1) at basal CMR compared to the other group.

Conclusions

LGE quantification by CMR could represent a prognostic added tool at long-term follow up in patients presenting with acute myocarditis and left ventricular pEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Impact of mitral valve regurgitation severity on clinical outcomes in patients with severe aortic stenosis undergoing TAVI
Authors: Jimenez Franco V , Sanchez Vega J D S V , Rajjoub E A R A , Pardo A P S , Garcia C G S , Amores M A L , Salido L S T , Mestre J L M B , Sanchez A S R , Zamorano J L Z G
Published: October 2021

Background

Significant mitral regurgitation (MR) is among the most common cardiac diseases associated with severe aortic stenosis (AS). It is frequently caused or exacerbated by increased left ventricular diastolic pressure and/or diameter, with consequent stretching of the mitral annulus and reduction of leaflet coaptation. Transcatheter aortic valve implantation (TAVI) has been established as an alternative treatment in patients with severe AS, with a prevalence of MR that ranges from 3–37%, but in this setting is typically left untreated. Prognostic clinical impact of concomitant MR in patients undergoing TAVI on outcomes is not clear and conflicting results have been reported.

Purpose

We sought to investigate the clinical impact of significant MR (≥2+) on mortality at 1-year follow-up in a group of patients with severe aortic stenosis that underwent TAVI procedure. Secondary objective was to evaluate the rate of re-hospitalization during that time.

Methods

From July 2010 to December 2019 information was gathered from a total 400 patients with severe aortic stenosis who underwent successful TAVI procedure at a University Hospital. We performed a monocentric, non-randomized, observational and prospective study that evaluated clinical outcomes following TAVI in patients with severe aortic stenosis and significant MR (≥2+; Group A) compared to those with mild or absent MR (<2+; Group B). The primary end point was the percentage of all-cause mortality at 1-year follow-up. Secondary end point was the rate of re-hospitalization following TAVI procedure at 1-year follow-up.

Results

The mean age of the global population (n=400) was 83±7 years and 243 were females (60.7%). Among the total sample, 72 (18%) patients had baseline moderate to severe MR (Group A) and were compared to the remaining 328 patients with mild or absent MR (Group B). At one-year follow-up, we observed a statistically significant higher all-cause mortality in 10 (22.3%) patients from Group A compared to 10 (6.7%) in Group B (p=0.05). The rate of re-hospitalization was significantly higher (p=0.01), occurring in 38.8% (85) of patients in Group A compared to 25.9% (28) in Group B.

Conclusion

Baseline significant MR (≥2+) in patients with severe aortic stenosis that underwent TAVI was associated with higher all-cause mortality and re-hospitalization at 1-year follow-up. To date, it is not clear whether this association is related to MR severity or if is simply a marker of worst prognosis. Further studies are warranted to reproduce these results.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier estimates of survival
Clinical and haemodynamic effects of percutaneous edge-to-edge mitral valve repair in atrial versus ventricular functional mitral regurgitation
Authors: Claeys M J , Debonnaire P , Bracke V , Bilotta G , Shkarpa N , Vanderheyden M , Coussement P , Vanderheyden J , Van De Heyning C , Cosyns B , Pouleur A C , Lancellotti P , Paelinck B , Ferdinande B , Dubois C
Published: October 2021

Background

Atrial functional mitral regurgitation (A-FMR) is a novel entity characterized by a MR due to atrial remodeling but with preserved left ventricular (LV) systolic function.

Purpose

To assess the clinical and haemodynamic impact of percutaneous edge-to-edge mitral valve repair with MitraClip in patients with A-FMR as compared to ventricular (V)-FMR.

Methods

MR grade, functional status (NYHA class), and major adverse cardiac events (MACE= all-cause mortality or hospitalization for heart failure (HF)) were evaluated in 52 A-FMR patients (pts.) and in 307 V-FMR pts. who underwent MitraClip implantation in 7 Belgian centers. In a subgroup of 56 pts (10 A-FMR and 46 V-FMR) haemodynamic assessment during a symptom-limited exercise echocardiography was performed before and 6-month after intervention.

Results

MitraClip implantation resulted in similar MR reductions in A-FMR and V-FMR (MR grade ≤2 at 6-month in 94% versus 82%, respectively (p=0.08)) and was associated with improvement of functional status in both groups (NYHA class ≤2 at 6 months in 90% versus 80%, respectively (p=0.2)). Serial haemodynamic assessment revealed that the cardiac output at 6-month was significantly higher in A-FMR pts. both at rest (5.1±1.5 L/min versus 3.8±1.5 L/min, p=0.002) and during peak exercise (7.9±2.4 L/min versus 6.1±2.1 L/min, p=0.02). Also the reduction in systolic pulmonary artery pressure (sPAP) was more pronounced in A-FMR: Δ sPAP at rest – 13.1±15.1 mmHg versus – 2.2±13.3 mmHg (p=0.03). During a follow-up period of 1.3±1.2 years MACE rate was significantly lower in A-FMR versus V-FMR with an adjusted OR of 0.46 (95% CI 0.24–0.88, see figure), which was mainly driven by a reduction in HF hospitalization.

Conclusion

Percutaneous edge-to-edge mitral valve repair with MitraClip is at least as effective in A-FMR as in V-FMR in reducing MR. But, the haemodynamic and clinical impact is stronger in A-FMR pts.

Funding Acknowledgement

Type of funding sources: None. MACE in A-FMR versus V-FMR pts
Long-Term survival and functional status in patients with elevated mitral valve pressure gradient after transcatheter mitral valve repair
Authors: Koell B , Ludwig S , Weimann J , Waldschmidt L , Schofer N , Seiffert M , Schirmer J , Westermann D , Reichenspurner H , Blankenberg S , Lubos E , Conradi L , Kalbacher D
Published: October 2021

Background

A growing number of patients are currently treated for severe mitral regurgitation (MR) using a transcatheter mitral valve repair (TMVr). In clinical routine, the potential risk of elevated post-procedural mitral valve pressure gradient (MPG) may prohibit optimal MR reduction driven by the avoidance of additional clip implantations. Thus, the unfavorable impact on survival and functional outcome of increased MPG in patients undergoing TMVr is currently debatable.

Methods

In this single-center, prospective study, survival and functional outcome of 780 consecutive patients with severe MR undergoing TMVr between September 2008 and January 2020 were investigated. After exclusion of patients with unsuccessful procedure and those lost to follow-up, data of 676 patients with a median follow-up time of 5.26 (5.11, 5.51) years were analyzed. MPG was determined by transthoracic echocardiography at discharge and considered elevated in excess of 4.5 mmHg. Kaplan-Meier analysis as well as multivariable Cox regression models were performed for the impact on elevated MPG on 5-year outcomes for the subgroups of functional MR (FMR) and degenerative MR (DMR). The primary outcome measure was a combined endpoint of death or rehospitalization for congestive heart failure.

Results

Among 676 patients undergoing TMVr (mean age 74.6±8.5 years, 59.0% male, median STS Score 3.9 [interquartile range 2.5; 6.0]), 179 (26.4%) patients had elevated MPG >4.5 mmHg. FMR was present in 426 (63.0%) patients. In the overall patient cohort, Kaplan-Meier and Cox Regression analyses could not demonstrate significant differences for the combined endpoint (p=0.99). In contrast, subgroup analysis according to MR etiology indicated a significant adverse influence of elevated MPG on the combined endpoint as well as functional outcome in patients with DMR, but not with FMR (Figure 1). After adjustment, multivariate Cox Regression analysis showed an inferior prognosis in patients with DMR and elevated MVPG >4.5 mmHg (hazard ratio 1.79 [1.17, 2.72], p=0.0069, Figure 2).

Conclusions

TMVr-patients with DMR and measurable elevated post-procedural MVPG face an inferior prognosis and reduced functional outcomes compared to patients with FMR.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Artificial intelligence to improve decision making in transcatheter aortic valve implantation
Authors: Hofmann F J , Hofmann S , Doerr O , Blachutzik F , Keranov S , Widmann L , Boeder N F , Hamm C , Nef H M , Kim W
Published: October 2021

Background

The current state of the art in the diagnosis and treatment of cardiovascular diseases has been based on evidence resulting from traditional trials as well as years of clinical experience. Due to interindividual differences and a huge number of possible cofounders, in interventional cardiology a linear algorithm is usually not able to precisely estimate individual risk, therapy, or outcome. With the technological evolution in deep machine learning (ML) and artificial intelligence (AI), clinicians may now address aspects that might not have been investigated previously, as supercomputers may handle the plethora of data that are generated as part of treatment. Ultimately, treatment recommendations and decisions may be made on a personalized level.

Purpose

The aim of this study was to apply AI to routine clinical practice to improve decision making in transcatheter aortic valve implantation (TAVI) to determine the best type and size of prosthesis personalized for each patient with pre-procedural risk stratification.

Methods

All patients included in the study were undergoing TAVI. To predict the clinical outcomes we applied a random forest classification, a ML method with high interpretability. For baseline data 58 features were chosen, including valve type and size used. After removing highly collinear features with a certain variance inflation factor, feature selection was based on impurity-based feature importance as well as permutation importance. The performance of the estimators was evaluated by a five-fold nested stratified cross-validation. To evaluate the model ROC and mean AUC scores were chosen.

Results

A total of 3882 patient datasets were included in this trial. The baseline characteristics were consistent with a high cardiovascular risk typical of this collective. Device success was achieved in 83.3%, pacemaker implantation was necessary in 12.2%, and aortic valvular insufficiency was observed in 2.5%. The 30-day mortality was 3.4% and one-year mortality was 12.7%. The mean AUC for the outcome parameters device success, aortic valvular insufficiency, any pacemaker operation, and 30-day and one-year mortality after five-fold cross validation were 0.61±0.03, 0.71±0.04, 0.66±0.04, 0.67±0.03, and 0.69±0.01, respectively.

Conclusions

We report preliminary data concerning a promising method to improve decision making in the context of TAVI evaluation and planning using ML algorithm. We showed the feasibility with acceptable AUC values for all outcome parameters. Thus, the integration of AI in TAVI strategy planning process offers a valuable tool providing patient focused personalized therapy.

Funding Acknowledgement

Type of funding sources: None.
The management of severe aortic stenosis during the COVID-19 pandemic: an observational study comparing TAVI and SAVR
Authors: Akhtar M , Shafi A , Khanna V , Mukhopadhyay S , Patel K , Ozkor M , Baumbach A , Mathur A , Kennon S , Awad W , Mullen M M
Published: October 2021

Introduction

Outcomes and characteristics of patients with severe aortic stenosis (AS) treated during the COVID-19 pandemic is unknown.

Methods

This was a single-centre observational study of patients undergoing AS treatment with transcatheter (TAVI) or surgical (SAVR) therapy during the first-wave of the UK COVID-19 pandemic compared to a control cohort undergoing treatment in 2019.

Demographics, baseline echocardiogram, CT, procedural characteristics and outcome data were collated. The primary outcome was 30-day all-cause mortality. The secondary endpoint was duration of post-procedural hospitalisation.

Results

319 patients were recruited - 122 underwent intervention during the pandemic [73 TAVI; 49 SAVR] and 197 in 2019 [127 TAVI; 70 SAVR].

In 2020, TAVI patients had a higher Euroscore II (p<0.001) but there were no differences in procedural complications or mortality [p=0.16] compared to TAVI 2019 cases. Duration from TAVI to discharge was shorter in 2020 (p<0.001).

SAVR 2020 patients had similar baseline profile [p=0.48], surgical characteristics, mortality (p=0.68) and duration from SAVR to discharge compared to those in 2019.

During the pandemic, TAVI patients were older (p<0.001) and had a higher Euroscore II (p<0.001) than SAVR counterparts. TAVI patients had reduced 30-day mortality [0 (0%) vs 3 (6%); p=0.06] and were discharged more rapidly post-intervention than SAVR patients [median 1 [1] vs 7 [4] days; p<0.001) translating into shorter hospitalization (p<0.001).

Conclusions

TAVI and SAVR can be safely delivered with predictable resource utilisation during a pandemic. Despite the TAVI cohort incorporating higher risk, older patients, outcomes were at least as good as SAVR with a shorter length of post-procedural hospitalisation.

Funding Acknowledgement

Type of funding sources: None. Procedural Complications TAVI/SAVRDuration to discharge post TAVI/SAVR
Left atrial dynamics in the hemodynamic response during exercise in patients with asymptomatic severe aortic stenosis
Authors: Sugimoto T , Bandera F , Generati G , Alfonzetti E , Guazzi M
Published: October 2021

Background

The hemodynamic impact of left atrial (LA) dynamics in aortic stenosis (AS) in relation to cardiopulmonary response to exercise has never been studied. We aimed at investigating the link between LA function vs hemodynamics and prognosis in asymptomatic severe AS patients.

Methods

A total of 106 patients: 76 asymptomatic severe AS patients (aortic valve area (AVA) <1.0 cm2 or AVA index <0.6 cm2/m2) and 30 gender-matched control subjects underwent cardiopulmonary exercise testing combined with Echo-Doppler with assessment of LA strain. AS patients were divided into 4 groups according to peak aortic jet velocity (PV), mean pressure gradient (MPG), stroke volume index (SVI), and left ventricular ejection fraction (LVEF).

Results

Normal-flow low-gradient AS (NFLG: PV <4 m/s and MPG <40 mmHg, SVI >35ml/m2, LVEF ≥50%, N=23), High-gradient AS (HG: PV ≥4 m/s or MPG ≥40 mmHg, LVEF ≥50%, N=23), Paradoxical low-flow low-gradient AS (PLFLG: PV <4 m/s and MPG <40 mmHg, SVI ≤35ml/m2, LVEF ≥50%, N=18), and Classical low-flow AS (CLF: LVEF <50%, N=12) had a higher LA volume index than Control (Control 22±6, NFLG 38±12*, HG 33±9*, PLFLG 33±11*, and CLF 49±15* ml/m2, *P<0.05 vs Control). In PLFLG and NFLG AS, LA strain at rest (21±9 and 26±13%) and during exercise (26±12 and 31±14%) were decreased compared to Control (37±8% at rest, 43±11% during exercise) but LA strain was increased from rest to exercise (P<0.001). HG and CLF AS had no increase in LA strain (31±15 and 19±10% at rest, 28±15 and 18±9% during exercise) (figure). In Cox proportional hazards analysis, age and gender adjusted hazard ratio for the composite end point (aortic valve replacement, hospitalization for heart failure, and all-cause mortality) of changes in LA-strain from rest to exercise (1% increase) was 1.05 (95% CI 1.00 to 1.09, P=0.044) among AS patients.

Conclusions

In asymptomatic severe AS, the study of LA functional adaptation to exercise plays a key role in the hemodynamic unfavorable cascade signaling major adaptive differences in dynamics during physical challenge. Overall, LA dynamics provides prognostic information also in AS patients.

Funding Acknowledgement

Type of funding sources: None.
Long-term morphological appearance of transcatheter valves left in the ascending aorta after valve dislocation during transcatheter aortic valve implantation
Authors: Frumkin D , Pietron M , Kind A , Leistner D , Krackhardt F , Laule M , Brand A , Knebel F , Lembcke A , Landmesser U , Stangl K , Dreger H
Published: October 2021

Background

Transcatheter valve embolization and migration (TVEM) is a potential complication of transcatheter aortic valve implantation (TAVI) (1). Registries suggest low incidence but clinical relevance due to increased acute and mid-term mortality with the majority embolizing in the aorta. However, there is little data on potential late complications such as leaflet and stent thrombosis or aortic wall alterations by migrated valves.

Purpose

The aim of our study was to analyze the incidence and clinical characteristics of TVEM in a large single center cohort of TAVI patients and to examine dislocated valves by ECG-gated computed tomography (CT).

Methods and results

Between July 2009 and May 2020, 40 TVEM occurred in 3387 TAVI procedures performed in our center (1.18%). TVEM was defined according to Valve Academic Research Consortium-2 (VARC-2) criteria (3). Majority of TVEM were left in the ascending aorta (31 ascending, 3 arch, 1 descending aorta). 90% of TVEM occurred with a self-expanding valve (SEV), with no difference between older and newer valve generations, 10% with a ballon-expandable valve. Analyzing a TAVI sample cohort (n=200), horizontal aorta (p<0.001, OR 11.7, 95% CI: [3.9:34.8]), defined as aortic angulation >48°(4), as well as the use of SEV (p<0.001, OR 12.8, 95% CI: [3.1:53.9]) were identified as a predisposing risk factor for TVEM. OR in SEV was severely increased when isolating the analysis for patients with horizontal aorta only (p=0.003, OR 23.75, 95% CI: [2.8:129]). No other predisposing risk factors were identified in this cohort. Out of 35 patients still alive, 6 patients were willing to participate in our imaging sub-study. CT exams were performed on average 47 months after TAVI (IQR 50 months [25%Q: 16.8, 75%Q: 72.8]). We detected no leaflet or stent thrombosis, yet CT identified pin protrusions in the aorta in 3 out of 6 patients.

Conclusions

TVEM is a rare complication of TAVI. TVEM was significantly associated to the use of self-expanding valves and the presence of horizontal aorta. CT did detect pin protrusions in several cases which could bear the possible risk of perforation but showed no signs of long-term damage.

Funding Acknowledgement

Type of funding sources: None. Representative CT images after TVEM
Effect of concomitant atrioventricular valve regurgitation on the outcome after transcatheter aortic-valve implantation
Authors: Drakopoulou M , Karmpalioti M , Simopoulou C , Oikonomou G , Apostolos A , Toskas P , Soulaidopoulos S , Stathogiannis K , Synetos A , Latsios G , Tsioufis C , Toutouzas K
Published: October 2021

Background

Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or more. The impact of coexistent tricuspid regurgitation (TR) remains to be determined.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA)≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were divided into 4 groups according to MR and TR severity pre-procedurally: no/mild MR and TR, moderate/severe MR, moderate/severe TR, moderate/severe MR and TR. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

A total of 244 consecutive patients were enrolled in the study: 148 (60.7%) patients no/mild MR and TR, 32 (13.1%) moderate/severe MR, 35 (14.3%) moderate/severe TR, 29 (11.9%) moderate/severe MR and TR pre-procedurally. There was significant difference in pre-procedural pulmonary artery systolic pressure (PASP) among groups (no/mild MR and TR: 40.8±10 mmHg, moderate/severe MR: 46.6±11.2 mmHg, moderate/severe TR: 49.9±13mmHg, moderate/severe MR and TR: 59.8±15.2mmHg, p<0.0001). The Kaplan–Meier curves for 2 year mortality showed that the severity of TR was associated with poor survival. Interestingly, patients with moderate/severe MR and TR had the worse survival (no/mild MR and TR (91.2%), moderate/severe MR (78.1%), moderate/severe TR (62.9%), moderate/severe MR and TR (62.1%), p<0.0001).

Conclusion

The presence of concomitant moderate or severe mitral and tricuspid valve regurgitation was associated with the higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.

Funding Acknowledgement

Type of funding sources: None.
Rheumatic myocarditis: a poorly recognized etiology of left ventricular dysfunction in valvular heart disease patients
Authors: Emer Egypto Rosa V , Lopes M P , Spina G S , Soares Jr J , Salazar D , Romero C E , Lottemberg M P , De Santis A , Pires L J N T , Goncalves L F T , Fernandes J R C , Sampaio R O , Tarasoutchi F
Published: October 2021

Background

Heart failure is present in about 10% of patients with acute rheumatic fever (RF), and several studies showed that cardiac decompensation in RF results primary from valvular disease, and not due to primary myocarditis. However, literature is scarce in this topic and a recent case series showed that recurrent RF could cause ventricular dysfunction even in the absence of valvular heart disease.

Purpose

To evaluate clinical, laboratory and echocardiographic profile of rheumatic fever patients with confirmed myocarditis diagnosis using Fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) or Gallium-67 cardiac scintigraphy.

Methods

Clinical, laboratory and imaging characteristics of 25 consecutive patients with diagnosis of myocarditis, using 18F-FDG PET/CT or gallium-67 cardiac scintigraphy (Figure 1A and 1B, respectively), and RF reactivation according to revised Jones Criteria, were evaluated. Patients underwent 3 sequential echocardiograms: (1) baseline, (2) during myocarditis and (3) post- corticosteroid treatment, and were divided according to the presence (Group 1) or absence (Group 2) of reduced left ventricular ejection fraction (LVEF) during myocarditis episode.

Results

Median age was 42 (17–51) years, 64% had more than 40 years and 64% were women. Comparing patients in Group 1 (n=16) with Group 2 (n=9), there was no demographic, echocardiographic or laboratory difference between groups, except for NYHA III/IV heart failure (Group 1: 100.0% versus Group 2: 50.0%; p=0.012) and LVEF (30 [25–37] versus 56 [49–62] %, respectively; p<0.001), as expected. Group 1 patients had significant reduction of LVEF during carditis with further improvement after treatment (Figure 1C). There was no correlation between LVEF and valvular dysfunction during myocarditis. Of all patients, 19 (76%) underwent 18F-FDG PET/CT, with positive scan in 68.4% and 21 (84%) underwent Gallium-67 cardiac scintigraphy, with positive uptake in 95.2%, both with no difference between groups.

Conclusion

Myocarditis due to rheumatic fever reactivation can cause left ventricular dysfunction despite of valvular disease, and is reversible after corticosteroid treatment.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Sutureless bioprosthesis as an alternative to conventional aortic valve replacement surgery
Authors: Rua N , Ferreira R , Sena A , Nobre A
Published: October 2021

Background

Aortic valve stenosis is the most common adult valve disease in industrialized countries. The ageing population and the rising in comorbidities have urged the development of safer alternatives to the current gold standard surgical treatment. Sutureless bioprosthesis have shown promising results, especially in technically difficult procedures and as more and more patients need concomitant surgeries.

Purpose

Assess clinical and haemodynamic performance, safety and durability of the sutureless bioprosthesis implanted in patients with aortic valve disease, over a period of 5 years, both in isolated aortic valve replacement surgeries as well as in concomitant procedures.

Methods

Single centre retrospective longitudinal cohort study collected data of all adult patients with aortic valve disease who underwent valve replacement with a sutureless bioprosthesis between February 2015 and October 2020. Of the 196 patients analysed (mean age 77.20±5.08 years; 45.40% were female; mean logistic EuroSCORE 2.91±2.20%), the majority had aortic stenosis. To assess the comparative risk of adding concomitant procedures, patients were divided into two groups and compared: one comprised patients who underwent isolated valve implantation (n=132) and the other patients who had concomitant coronary artery bypass graftings (n=49). 15 patients had other heterogeneous concomitant procedures and were therefore not considered in this comparison.

Results

Overall mean cross-clamp and cardiopulmonary bypass times were 45.50±19.04 and 36.50±11.40 minutes, respectively. 4 valves were reimplanted due to misplacement. Mean transvalvular gradients were 7.82±3.62 mmHg. Mean ICU and total hospital stay were 3.32±3.20 and 7.70±5.82 days, respectively. Procedural success was 99%, as two explantations occurred. Pacemaker implantation occurred in 12.8% of patients, atrial fibrillation de novo in 21.9% and renal replacement support was necessary in 3.1%. Early mortality was 0.51%. We report no structural valve deterioration, strokes or endocarditis and one successfully treated valve thrombosis. By comparison, patients with concomitant procedures had worse left ventricular function (40.8 vs 79.5%; p=0.030), longer aortic clamping (43.33±11.60 vs 27.30±8.10 minutes; p<0.001) and cardiopulmonary bypass times (59.98±17.60 vs 37.45±11.30 minutes; p<0.001), as expected. ICU stay after surgery was also longer (3.96±3.20 vs 2.80±2.70 days; p=0.016). Apart from this, there were no other significant differences in postoperative complications and survival, even up to 5 years.

Conclusion

Our study confirms the excellent clinical and haemodynamic performance and safety of a truly sutureless aortic valve, even up to the 5-year follow-up. These results were consistent both in isolated and concomitant interventions, solidifying this device as a viable treatment of isolated aortic valve disease, and now also in patients needing concomitant procedures.

Funding Acknowledgement

Type of funding sources: None.
Long-term outcomes in patients with left bundle branch block after transcatheter aortic valve replacement
Authors: Simon Paracuellos T , Perez Guerrero A , Gambo Ruberte E , Peiro Aventin B , Gomez Martin D , Ferrer Gracia M C , Galache Osuna G , Sanchez-Rubio Lezcano J , Fuertes Ferre G , Cortes Villar C , Ortas Nadal R , Diarte De Miguel J A
Published: October 2021

Introduction

New-onset persistent left bundle branch block (NOP-LBBB) is one of the most common complications after transcatheter aortic valve replacement (TAVR). The impact that this conduction disorder may have on the cardiovascular events during the follow-up of these patients remains unclear.

Objective

The main goal was to assess the prognosis of TAVR recipients that develop persistent LBBB after TAVR, evaluating long-term outcomes.

Methods

A cohort study was conducted. Consecutive patients undergoing TAVR from January 2012 to December 2020 were included. NOP-LBBB was defined as a new LBBB occurring during the hospitalization period after the TAVR procedure that persisted at hospital discharge. Patients were divided into 2 groups according to whether they had a NOP-LBBB. Patients carrying a pacemaker before the procedure and those who already presented LBBB were excluded.

MACE (major adverse cardiovascular events including cardiovascular death, myocardial infarction, cerebrovascular accident and heart failure hospitalization) as primary outcome was searched.

Results

A total of 254 patients were included with a median age of 81.07 years (77.73–86.22). 77% TAVR patients received self-expanding prosthesis. 21.57% of our cohort presented NOP-LBBB and 29% of this group required a pacemaker. We reported a single case of prosthesis dysfunction, in a patient of the NO-LBBB group. Global baseline characteristics and long term events at follow-up according to the occurrence of LBBB are summarized at figure 1. Patients in both groups were statistically comparable.

At a median of 21.3 (8.52–38.94) months of follow-up, a higher incidence of syncope was found among the patients with NO-LBBB, reaching the statistical significance. There were no significant differences between groups regarding cardiovascular mortality (OR 1.48 95% CI: 0.36–4.00 p=0.41). NOP-LBBB group showed higher rates of heart failure hospitalization (OR 1.95 95% CI: 0.98–3.9 p=0.057)

NOP-LBBB was associated with an increased risk of MACES at follow-up (27.72% vs 17.54%; adjusted HR: 1.77 95% CI 1.02–3.06, p 0.04).

Survival curves are displayed in figure 2.

Conclusions

Developing LBBB after TAVR seems to lead to more cardiovascular events, with a significant difference in long- term survival. These data suggest an adverse clinical impact of “de novo” LBBB, highlighting the necessity of a close vigilance of these patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Predictors of exercise capacity in patients with asymptomatic primary moderate to severe mitral regurgitation and preserved left ventricle ejection fraction
Authors: Zvirblyte R , Tamulenaite E , Montvilaite A , Bucius P , Berontaite S , Vaskelyte J J
Published: October 2021

Introduction

Patients with primary moderate or severe mitral regurgitation (MR) often remain asymptomatic for a long time due to mechanisms of compensation. Exercise stress could provoke symptoms, unmask subclinical changes of left and right ventricles and reveal decreased functional capacity. Reduced exercise capacity is related to worse outcomes.

Purpose

The aim of this study was to evaluate an exercise capacity and factors influencing it in patients with asymptomatic primary moderate to severe MR and preserved left ventricle (LV) ejection fraction (EF).

Methods

60 patients with asymptomatic moderate or severe MR and LV EF >60% underwent resting and stress (bicycle–ergometry as per protocol 25 + 25W every 3 minutes) echocardiography. Their exercise capacity was evaluated in Watts (W) and metabolic units (MET). The blood sample for NT-proBNP evaluation was collected just before the stress test.

Results

Patients with primary MR achieved 84.74±35.16 W and 4.87±1.51 MET. According to univariate linear regression analysis exercise capacity in MET was significantly related to age (B=−0.066, p<0.001), systolic pulmonary artery pressure (SPAP) at rest (B=−0.048, p=0.034), resting E wave (B=−0.015, p=0.031) and NT-proBNP (B=−0.003, p=0.006). Predictors of exercise capacity in W also were age (B=−1.273, p=0.002), resting E wave (B=−0.318, p=0.041), NT-proBNP (B=−0.057, p=0.018). Higher concentration of NT-proBNP and bigger SPAP at rest correlated with lower exercise capacity (picture 1). In patients who had exercise induced pulmonary hypertension (EIPH; SPAP >60 mmHg during peak stress) ergometry was more frequently terminated prematurely (19 (95%) and 24 (60%), p=0.012). They also had significantly lower exercise capacity than subjects without EIPH ((W: p=0.015 and MET: p<0.001).

Conclusions

Age, NT-proBNP concentration, resting SPAP and E wave were predisposing factors of exercise capacity in patients with asymptomatic primary moderate to severe MR and preserved LV EF. EIPH and elevated NT-proBNP were related to premature exercise termination and lower exercise capacity.

Funding Acknowledgement

Type of funding sources: None. Picture 1