bluuebunny/crossref_metadata_2025 huggingface dataset:
Trends in reperfusion therapy for acute ST-segment elevation myocardial infarction in an academic PCI centre in the metropolitan area of a developing country
Authors: Dharma S , Dakota I , Andriantoro H , Firdaus I , Limadhy I.G , Van De Werf F
Published: November 2020

Background

Long-term reports on reperfusion therapy for acute ST-segment elevation myocardial infarction (STEMI) in developing countries are scarce.

Purpose

We reported changes in acute reperfusion therapy for STEMI that have been observed over time in an academic tertiary care percutaneous coronary intervention (PCI) centre that hosting a STEMI network in the large metropolitan area of Jakarta, Indonesia since 2010 and covering around 11 million inhabitants.

Methods

A retrospective analysis was performed in 6336 patients with STEMI who admitted to the emergency department of a PCI centre in 2008 (before STEMI network introduction), and during 2011 to 2018.

Results

Among STEMI patients admitted during 2011–2018 (mean age: 56±10 years, 86% male), 57.6% had anterior wall myocardial infarction, and 71.3% presented with Killip classification I. Compared with the period 2011–2014 (N=2766), patients who were admitted in the period 2015–2018 (N=3250) were receiving more primary percutaneous coronary intervention (PCI) (61.6% vs. 44.2%, P<0.001) with shorter door-to-device time (median 72 min versus 97 min, P<0.001), and less in-hospital fibrinolytic therapy (2.7% vs. 4.8%, P<0.001). The percentage of STEMI patients who did not receive reperfusion treatment decreased from 51% to 35.5% (P<0.001). In-hospital mortality declined from 10% in 2008 (before the STEMI network was initiated) and 8% in 2011 to 6.4% in 2018 (P for trends = 0.05). Multivariable analysis showed that primary PCI was significantly associated with better in-hospital survival (adjusted odds ratio, 0.52; 95% confidence interval, 0.42 to 0.65, P<0.001).

Conclusion

The data indicate that the introduction of a STEMI network resulted in more patients receiving timely primary PCI and lower early mortality rates in recent years.

Funding Acknowledgement

Type of funding source: None
Prognostic impact of SYNTAX II score in patients with cardiogenic shock complicating ST-elevation myocardial infarction: analysis of an 10-year all-comers registry
Authors: Juskova M , Tasende Rey P , Cid Alvarez B , Alvarez Alvarez B , Garcia Acuna J.M , Rigueiro Veloso P , Agra Bermejo R , Lopez Pais J , Sanmartin Pena J , Lopez Otero D , Fernandez Alvarez M , Trillo Nouche R , Gonzalez Juanatey J.R
Published: November 2020

Background

The SYNTAX II score (SS-II) can predict 4-year outcomes in patients with complex coronary artery disease and ST-segment elevation myocardial infarction (STEMI). Nonetheless, the prognostic value of SS-II for a cardiogenic shock (CS) in the setting of STEMI has not been assessed.

Purpose

This study aimed to investigate the predictive impact of SS-II in patients with CS complicating STEMI undergoing primary percutaneous coronary intervention, and whether SS-II adds prognostic information to predict major adverse cardiac events (MACE) and all-cause death in this population.

Methods

This prospective cohort study included 1965 consecutive patients with STEMI who underwent primary-PCI between January 2008 and December 2017. The cohort of patients with CS (n=153) was identified and divided into three groups based on SS-II tertiles [SS-II low tertile <38 (n=51), ≥38 SS-II intermediate tertile <47 (n=51), and SS-II high tertile ≥48 (n=51)].

Results

Amongst the cohort of patients with CS mean age was 68.4±14.0 years, 69.2% were male and 51.6% presented with anterior STEMI (mean SSII was 45.1±14). In-hospital mortality was significantly higher in the high SS-II tertile (85.7% vs. 38.9% vs 24.4%, p≤0.001) compared with SS-II intermediate and low tertiles. During follow-up (median 2.5 years), SS-II was positively correlated with MACE (89.3% (high SS-II) vs. 52.8% (int SS-II) vs. 42.2% (low SS-II), p≤0.001), and with all-cause mortality (89.3% vs 44.4% vs 26.7%, p≤0.001).

The SS-II was also an independent predictor of MACE (HR=1.042, 95% CI: 1.020–1.063, p=0.000) and all-cause mortality during follow-up (HR=1.056, 95% CI: 1.033–1.079, p=0.000)

Conclusion

In a real-world cohort of patients with STEMI related CS, the SS-II added important prognostic information, being an independent predictor of MACE and all-cause mortality during follow-up.

Image 1

Funding Acknowledgement

Type of funding source: None
Cardiogenic shock and radial access in patients with an acute ST elevation myocardial infarction
Authors: Zahn R , Hochadel M , Schumacher B , Pauschinger M , Stellbrink C , Schaechinger V , Behrens S , Mudra H , Elsaesser A , Zeymer U
Published: November 2020

Background

Cardiogenic shock (CS) in patients (pts) with acute ST elevation myocardial infarction (STEMI) is the strongest predictor of hospital mortality. Radial in contrast to femoral access in STEMI pts might be associated with a lower mortality. However, little is known on radial access in CS pts.

Methods

We retrospectively analysed all STEMI pts between 2009 and 2015 who sufferend from CS and who were included into the ALKK PCI registry. Pts treated via a radial access were compared to those treated via a femoral access.

Results

Between 2009 and 2015 23796 STEMI pts were included in the registry. 1763 (7.4%) of pts were in CS. The proportion of radial access was 6.6%: in 2009 4.0% and in 2015 19.6%, p for trend <0.0001 with a strong variation between the participating centres (0% to 37%).

Conclusions

Radial access was only used in 6.6% of STEMI pts presenting in CS. However, a significant increase in the use of radial access was observed over time (2009: 4%, 2015 19.6%, p<0.001), with a great variance in its use between the participating hospitals. Despite similar pt characteristics the difference in hospital mortality according to access site has to be interpretated with caution.

Funding Acknowledgement

Type of funding source: None
Sick euthyroid syndrome and its association with cardiogenic shock in acute coronary syndromes
Authors: Lobianco M , Costa D , Aladio J.M , Matsudo M , Swieszkowski S , Perez De La Hoz R
Published: November 2020

Introduction

Sick euthyroid syndrome (SES) constitutes an acute response to stress, and patients who develop it usually show more severe illness than those who do not. It could be related to disease severity in acute coronary syndrome (ACS), as assessed with Killip-Kimball class (KK), since cardiomyocytes are specifically sensitive to T3 levels.

Objective

To determine the prevalence of SES and low T3 in patients with ACS, and to assess its association with disease severity.

Methods

Prospective, observational and single center study in consecutive patients admitted to the CCU with a diagnosis of ACS. Clinical variables were collected from medical records; blood samples were obtained at admission to measure TSH, T3 and free T4 levels. SES was defined as low T3 with normal TSH and free T4. Maximum KK was determined by treating physicians. Categorical variables were compared with the chi-squared test, and categorical variables with Kruskal-Wallis and Wilcoxon tests. Statistical significance was set at p<0.05.

Results

There were 149 patients with complete data available for analysis. Their age was 67.8±12.4 years, and 64% were male. A total of 16.3% had SES. There were 7.5% patients with SES and KK-A, 34.8% KK-B, 14.3% KK-C and 70% KK-D (p<0.001). Thus, SES was more frequent in patients with some grade of heart failure, particularly cardiogenic shock. Figure 1 shows the difference in T3 values according to Killip-Kimball class.

Conclusion

Cardiomyocytes lack deiodinase and only possess T3 receptors, which makes them dependent on circulating T3 levels. T3 directly stimulates calcium channel and contractile protein synthesis in cardiomyocytes, and its deficit could affect cardiac contractility. Future studies should determine if thyroid hormone administration in cardiogenic shock can improve contractility and contribute to hemodynamic stability.

T3 values according to Killip-Kimball

Funding Acknowledgement

Type of funding source: None
Peripheral vascular disease and/or need for dialysis predicts mortality in acute myocardial infarction with shock treated with mechanical circulatory support
Authors: Ortiz F , Stouffer G , Rossi J
Published: November 2020

Background

Acute myocardial infarction (AMI) with left ventricular systolic dysfunction remains the largest cause for cardiogenic shock (CS) admissions. Aside for prompt revascularization few therapies have been shown to improve survival in this patient population. In the last decade, the use of mechanical circulatory support devices (MCS) for CS has increased, despite little evidence guiding their use.

Purpose

To explore for different baseline factors which may favor treatment with MCS vs pharmacological circulatory support (PCS) in AMI related CS.

Methods

Baseline clinical and procedural variables were retrospectively collected for all patient presenting to the cardiac cath lab with an AMI and CS at a large health care system. Patients were stratified by whether they received MCS or only PCS. The outcomes of interest were 30 day and one year mortality.

Results

Between 01/2014 andv08/2018, 205 patients presented to the cath lab with an AMI complicated by CS. The vast majority of cases were STEMIs (133/205, 65%). Overall mortality for the cohort at 30 days and one year were 41% and 50% respectively. There was no difference in 30 day or 1 year mortality between the MCS and PCS groups. A STEMI presentation was associated with increase 30 day mortality in the MCS group but the association was not seen at one year. Interestingly having a prior history peripheral vascular disease (PVD) and/or being on dialysis prior to the procedure was predictive of one year mortality in the MCS group (OR 3.8, 1.4–10.6, p=0.006) but not in the PCS.

Conclusion

Patients presenting with AMI complicated by CS have a high mortality despite successful revascularization. In our cohort having PVD and/or needing dialysis was predictive of mortality in patients receiving MCS. Patient selection is an important factor in choosing appropriate circulatory support, further prospective studies are needed.

Figure 1

Funding Acknowledgement

Type of funding source: None
Searching for the final diagnosis using cardiac magnetic resonance in MINOCA patients
Authors: Caldeira Da Rocha R , Picarra B , Santos A.R , Pais J , Carrington M , Bras D , Guerreiro R.A , Fernandes R , Aguiar J
Published: November 2020

Introduction

In patients with clinical evidence of acute myocardial infarction (AMI), absence of obstructive coronary disease does not imply absence of acute thrombotic process. Thereafter, it can be designated as Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). In these cases, performing Cardiac Magnetic Resonance (CMR) can be essential for establishing a final diagnosis, due to evaluation of the presence and pattern of late enhancement.

Purpose

The aim of this study is to evaluate the diagnostic and prognostic impact of cardiac magnetic resonance in patients with a possible diagnosis of MINOCA.

Methods

A 7-years prospective study in our centre, which included all patients proposed to CMR with a presumptive diagnosis of MINOCA due to acute chest pain, troponin raise and absence of angiographically significant coronary disease (luminal stenosis of <50%). All patients performed functional, anatomical evaluation, as so late gadolinium enhancement search. We analysed clinical characteristics, electrocardiographic presentation, echocardiographic and coronariography results. A presumptive diagnosis was elaborated after coronariography and comparison was made with the definitive one after CMR.

Results

A total of 85 patients were included, 53% were male, with a mean age of 49±20 years old. Clinical history of hypertension was observed in 52% patients, 34% had dyslipidaemia, 8% with diabetes, obesity was present in 21% of patients and smoking habits in 33%. At admission, 47% had ST segment elevation, so emergent coronariography was performed. The mean highest troponin I was 7,54±9,39ng/mL. Late gadolinium enhancement was observed in 50 (59%) of patients. After CMR realization a final diagnosis of MINOCA was made in only 13 patients (15%) and in 51 patients (60%) CMR evaluation allowed a diagnosis modification, with impact on patients' management and prognosis. Of these 51 patients, a definitive diagnosis of myocarditis was seen in 65% of cases, of Takotsubo's myocardiopathy in 27%, and hypertrophic cardiomyopathy in 8%. In 21 (25%) of patients, late gadolinium enhancement was not found. However its absence could exclude type 1 AMI as definitive diagnosis.

Conclusion

CMR is a fundamental technique on MINOCA patients' management. In our population, performing CMR allowed initial diagnosis modification in about two thirds of the cases, with important therapeutic and prognostic implications.

Funding Acknowledgement

Type of funding source: None
Shall be takotsubo tear apart from working diagnosis of myocardial infarction with non-obstructive coronary arteries?
Authors: Lopez-Pais J , Izquierdo Coronel B , Raposeiras-Roubin S , Alvarez Rodriguez L , Vedia O , Almendro-Delia M , Uribarri A , Galan Gil D , Espinosa Pascual M.J , Martin De Miguel I , Garcia Acuna J.M , Iniguez Romo A , Alonso Martin J.J , Gonzalez Juanatey J.R , Nunez Gil I
Published: November 2020

Aims

Whether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCA) is still controversial. The aim of this work is to evaluate main differences between TTS and non-TTS MINOCA.

Methods and results

A cohort study based on two prospective registries: TTS from the RETAKO registry (N:1055) and non-TTS MINOCA patients from contemporary records of acute myocardial infarction from 5 national centres (N:1080). Definitions and management recommended by the ESC were used. Survival analysis was based on Cox regression; propensity score matching was created to adjust prognostic variables.

TTS were more often women (85.9% vs. 51.9%; p<0.001) and older (69.4±12.5 vs. 64.5±14.1 years; p<0.001). Atrial fibrillation was more frequent in non-TTS MINOCA (10.4% vs. 14.4%; p 0.007). Psychiatric disorders were more prevalent in TTS (15.5% vs. 10.2%, p<0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs 1.8%, (p 0.015) and 25.8% vs. 11.5%, (p<0.001).

Median follow-up was 32.4 months; TTS had less major adverse cardiovascular events (MACE): Hazard Ratio (HR) 0.59; 95% confidence interval (CI) 0.42 to 0.83. There were no differences in total mortality (HR 0.87; CI: 0.64 to 1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35 to 0.98).

Conclusions

TTS has a different patient's profile and a more aggressive acute phase than the rest of MINOCA. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a distinct entity with unique characteristics and prognosis.

Funding Acknowledgement

Type of funding source: None
The impact of kids save lives program on knowledge, skills and attitude of students, preliminary results from 2 years of implementation
Authors: Parisis C , Bouletis A , Ntaliani M , Palla D , Makri P , Triantafyllou T.H , Chatzidimitriou K , Economou K , Papa E
Published: November 2020

The impact of Kids Save Lives program on Knowledge, skills and attitude of students. Preliminary results from 2 years of implementation

Background

Sudden cardiac death is one of the main issues worldwide, with more than 700.000 deaths annually. It is strongly believed that the implementation of “Kids Save Lives” project in schools can change this situation. The World Health Organization endorsed the “Kids Save Lives” project in 2015 in order to reduce mortality, while in countries, where children were taught cardiopulmonary resuscitation (CPR) in schools, have higher rates of bystander CPR and higher survival rates. In a lot of countries this project is a suggestion from Ministry of Education to schools.

Purpose

To evaluate the level of theoretical knowledge, willingness to perform Cardiopulmonary resuscitation (CPR) and active skills of Greek secondary school students on the subject of Basic life Support before and after a “Kids Save Lives” program.

Material – Method: Data collection took place on the academic periods of 2017–2018 and 2018–2019 and was performed in secondary schools. A total of 3421 students (51,9% female, mean age 14.2 years) participated on the “Kids save Lives” program according to the European Resuscitation Council (ERC) and World Health Organization (WHO) statement. A 12-question questionnaire was answered by the students before and after the “kid saves lives” program, while practical skills were evaluated on manikins by experienced ERC Basic Life Support (BLS) Instructors.

Results

The training improves significantly the theoretical knowledge regarding Cardiopulmonary resuscitation (CPR), with the percentage of correct answers being 49.5% and 82,41%,before and after the course respectively (p<0.001). The participants willingness to perform bystander CPR significantly increased after the completion of the course (93,1% before to 97,3% after, p<0.001). Almost all of the participants (98.9%) could recognize the correct position near the victim and 91% performed chin lift maneuver and recognized cardiac arrest. More than 90% of the students performed chest compressions with the correct rate and placing their hands on the center of the chest (90,1% and 93.4%, respectively), whereas only 76.4% of the participants achieved the desired compression depth of 5 to 6 cm.

Conclusions

The overall results strongly depict the benefits of “Kids Save Lives” program by improving the theoretical knowledge, the practical skills and the attitude of students towards CPR and indicate the necessity of implementation in a greater scale nationwide.

Funding Acknowledgement

Type of funding source: None
Hyperoxia is associated with adverse outcomes in the cardiac intensive care unit: insights from the Medical Information Mart for Intensive Care (MIMI-III) database
Authors: Lui A.Y , Garber L , Vincent M , Celi L , Masip J , Sionis A , Serpa Neto A , Keller N , Morrow D.A , Miller P.E , Van Diepen S , Smilowitz N.R , Alviar Restrepo C
Published: November 2020

Background

Hyperoxia produces reactive oxygen species, apoptosis, and vasoconstriction, and is associated with adverse outcomes in patients with heart failure and cardiac arrest. Our aim was to evaluate the association between hyperoxia and mortality in patients (pts) receiving positive pressure ventilation (PPV) in the cardiac intensive care unit (CICU).

Methods

Patients admitted to our medical center CICU who received any PPV (invasive or non-invasive) from 2001 through 2012 were included. Hyperoxia was defined as time-weighted mean of PaO2 >120mmHg and non-hyperoxia as PaO2 ≤120mmHg during CICU admission. Primary outcome was in-hospital mortality. Multivariable logistic regression was used to assess the association between hyperoxia and in-hospital mortality adjusted for age, female sex, Oxford Acute Severity of Illness Score, creatinine, lactate, pH, PaO2/FiO2 ratio, PCO2, PEEP, and estimated time spent on PEEP.

Results

Among 1493 patients, hyperoxia (median PaO2 147mmHg) during the CICU admission was observed in 702 (47.0%) pts. In-hospital mortality was 29.7% in the non-hyperoxia group and 33.9% in the hyperoxia group ((log rank test, p=0.0282, see figure). Using multivariable logistic regression, hyperoxia was independently associated with in-hospital mortality (OR 1.507, 95% CI 1.311–2.001, p=0.00508). Post-hoc analysis with PaO2 as a continuous variable was consistent with the primary analysis (OR 1.053 per 10mmHg increase in PaO2, 95% CI 1.024–1.082, p=0.0002).

Conclusions

In a large CICU cohort, hyperoxia was associated with increased mortality. Trials of titration of supplemental oxygen across the full spectrum of critically ill cardiac patients are warranted.

Funding Acknowledgement

Type of funding source: None
Validation of the Zwolle score for selection of very low-risk STEMI patients treated with primary angioplasty
Authors: Cordero A , Cid B , Monteiro P , Garcia-Acuna J.M , Rodriguez-Manero M , Trillo Noche R , Lopez Otero D , Sanmartin Pena J.C , Bertomeu-Gonzalez V , Escribano D , Goncalvez F , Goncalves L , Zuazola P , Gonzalez-Juanatey J.R
Published: November 2020

Background

The Zwolle risk score was designed to stratify the actual in-hospital mortality risk of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (p-PCI) but, also, for decision-making related to patients location in an intensive care unit or not. Since the GRACE score continues being the gold-standard for individual risk assessment in STEMI in most institutions we assessed the specificity of both scores for in-hospital mortality.

Methods

We assessed the accuracy of Zwolle risk score for in-hospital mortality estimation as compared to the GRACE score in all patients admitted for STEMI in 3 tertitary hospitals. Patients with Zwolle risk score <3 would qualify as “low risk”, 3–5 as “intermediate risk” and ≥6 as “high risk”. Patients with GRACE score <140 were classified as low-risk. Specificity, sensitivity and classification were assessed by ROC curves and the area under the curve (AUC).

Results

We included 4,446 patients, mean age 64.7 (13.6) years, 24% women and 39% with diabetes. Mean GRACE score was 157.3 (4.9) and Zwolle was 2.8 (3.3). In-hospital mortality was 10.6% (471 patients). Patients who died had higher GRACE score (218.4±4.9 vs. 149.6±37.5; p<0.001) and Zwolle score (7.6±4.3 vs. 2.3±2.18; p<0.001); a statistically significant increase of in-hospital mortality risk, adjusted adjusted by age, gender and revascularization, was observed with both scores (figure). A total of 1,629 patients (40.0%) were classified as low risk by the GRACE score and 2,962 (66.6%) by the Zwolle score; in-hospital mortality was 1.6% and 2.7%, respectively. Moreover, the was a significant increase of in-hospital mortality rate according to Zwolle categories (2.7%; 13.0%; 41.6%)The AUC of both score was the same (p=0.49) but the specificity of GRACE score <140 was 43.1% as compared to 72.6% obtained by Zwolle score <3; patients accurately classified was also lower with the GRACE score threshold (48.8% vs. 73.7%).

Conclusions

Selection of low-risk STEMI patients treated with p-PCI based on the Zwolle risk score has higher specificity than the GRACE score and might be useful for the care organization in clinical practice.

Funding Acknowledgement

Type of funding source: None
Gender disparities in patients with OHCA without ST-segment elevation: a substudy of the COACT trial
Authors: Spoormans E , Lemkes J.S , Janssens G.N , Van Der Hoeven N.W , Jewbali L.S.D , Dubois E.A , Appelman Y.E.A , Van Royen N
Published: November 2020

Background

Gender disparities in a population of OHCA remains rather unclear. The aim of this study is to evaluate coronary angiography treatment strategy and survival after one-year survival.

Methods

Using the randomized-controlled COACT-database, we evaluated gender differences in a population of patients successfully resuscitated after OHCA without STEMI and the effect of immediate coronary angiography on survival at one year.

Results

In total, 522 patients were included in the current analysis, of whom 413 (79%) were men. Among patients who underwent coronary angiography, men had more frequent significant CAD (37.0% vs. 71.3%; p<0.001) and more severe (1-vessel disease 18.5% vs. 29.8%; 2-vessel disease 9.9% vs. 23.1%; 3-vessel disease 8.6% vs. 18.4%; p<0.001) compared to women. Additionally, revascularization was more often performed in men (14.6% vs. 38.0%; p<0.001). Overall, one-year survival rate was 59.6% in women and 63.4% in men (HR 0.85; 95% confidence interval [CI]: 0.55–1.31; p=0.47). In the immediate strategy, survival was 59.2% in women vs. 61.9% in men. In the delayed strategy, survival was 60.0% in women vs. 65.2% in men. In both men and women, immediate coronary angiography did not improve 1-year survival when compared to delayed angiography (OR 0.87; 95% CI 0.58–1.30; p=0.49; vs. OR 0.97; 95% CI 0.45–2.09; p=0.93; p-value for interaction=0.81).

Conclusion

In patients with OHCA without STEMI, men were more likely to have significant CAD and undergo revascularization than their female counterparts, however both males and females did not benefit from a strategy of immediate coronary angiography strategy as compared to delayed angiography.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Biotronik, AstaZeneca
LV replacement fibrosis in aortic stenosis: prevalence and relation to LV remodelling and function
Authors: Sa Mendes G , Abecasis J , Ferreira A , Ribeiras R , Saraiva C , Ferreira S , Gil V , Andrade M.J , Mendes M , Neves J.P , Campante Teles R , Goncalves P
Published: November 2020

Background

Progressive myocardial fibrosis takes part in left ventricular (LV) remodeling in aortic stenosis (AS) and drives the transition from hypertrophy to heart failure. Replacement fibrosis may be characterized by late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

Aim

To assess the prevalence and association between LGE and indexes of LV function in patients with severe aortic stenosis.

Methods

We prospectively studied 53 consecutive patients (age: 71±8 years [min. 51–max. 84], 54.7% men) with severe symptomatic AS, referred for surgical aortic valve replacement with no previous history of ischemic cardiomyopathy. Aortic valve mean gradient was 54.6 mmHg [IQR 46.6–63.2] and aortic valve area 0.74cm2 [IQR 0.61–0.89]; all patients with high gradient, 4 with low-flow. CMR with tissue characterization (T1 mapping, LGE and extracellular volume by ECV quantification – using 5SD from remote myocardium as signal intensity cut-off), was performed before surgery. AS severity indexes, LV mass, systolic and diastolic LV function indexes including global longitudinal strain (GLS) and torsion were compared in both groups of patients, with and without LGE.

Results

Mid-wall LGE was present in 36 patients (67.9%) with a median fraction of 6.0% [IQR 4.9–12.7%] of LV mass. Native T1 value and ECV were within normal ranges (median values: 1047ms [IQR 1028–1084]; 22% [IQR 18–25], respectively). Median CMR LV ejection fraction and mass were 64.5% [IQR 51.3–70.8%] (11 patients with reduced EF) and 76.5g/m2 [IQR 57.4–94.8g/m2], respectively. Median GLS was −13.9% [IQR −11.4 to −17.0%] and torsion was 24.2° [IQR 19.8–32.5°]. Patients with LGE had significantly higher LV mass (87.1g/m2 vs 63.3 g/m2, p=0.001), worse GLS (−14.4% vs −16.9%, p=0.041) and higher NT-proBNP values (1333.7ng/mL vs 559.9ng/mL, p=0.004) (Figure).

Conclusions

Non-ischemic LGE is common in this group of patients with severe symptomatic high gradient aortic stenosis. As it is more prevalent in patients with more pronounced LVH, lower longitudinal deformation and higher NT-proBNP values, it probably represents a more advanced stage of the disease.

Funding Acknowledgement

Type of funding source: None
Long-term analysis of pulmonary hypertension and tricuspid regurgitation after transcatheter aortic valve replacement
Authors: Bignoto T , Le Bihan D , Souza A.C , Oliveira N , Nascimento B.M.O , Sousa P.C.C , Santos M.F.M , Simonato M , Barretto R.B.M , Ramos A.I.O , Siqueira D.A.A , Sousa A.G.M.R , Abizaid A
Published: November 2020

Introduction

Transcatheter aortic valve replacement (TAVR) is increasingly utilized in treatment of aortic stenosis (AS). AS is commonly associated to pulmonary hypertension (PH) and tricuspid regurgitation (TR). We aimed to evaluate the long-term post-TAVR course of PH and TR.

Methods

Patients undergoing TAVR were screened for 24-month echocardiographic data on PH and TR. All echocardiograms were performed by a single team. Patients were divided in groups according to TR and PH (pulmonary systolic pressure ≥ or <45 mmHg) grading at 24 months with follow-up of up to 96 months. Standardized clinical outcomes and survival were compared.

Results

156 and 151 patients were selected for PH and TR follow-up, respectively. Mean follow-up was 42.23±17.53 months and 42.60±17.67 months for PH and TR groups. Maximum follow-up was 96 months. PH was reduced post-TAVR (32.7% pre-TAVR vs. 20.5% post-TAVR, p<0.001), but no significant difference in TR was found (11.9% pre-TAVR vs. 10.6% post-TAVR). Increased left atrial (LA) diameter (p=0.002) was associated to maintenance PH. Moreover, increased LA diameter (p=0.015) and increased EuroSCORE II (p=0.041) were correlated to new onset PH. On a multivariable Cox regression model, new onset PH (HR 6.17, 95% CI 1.71–22.29, p=0.005), diastolic dysfunction type II or III (HR 1.06, 95% CI 1.06–1.11, p=0.036) and LA diameter (HR 1.11, 95% CI 1.02–1.21, p=0.02) were independent predictors of long-term mortality.

Conclusions

TAVR was able to reduce the severity of PH, but not TR, in this cohort. Additionally, long-term survival was affected by PH, diastolic dysfunction and LA sizing.

Kaplan-Meier survival curve

Funding Acknowledgement

Type of funding source: None
Electrocardiographic and echocardiographic abnormalities associated with mitral valve prolapse in patients with Marfan syndrome
Authors: Lasne A , Milleron O , Delorme G , Arnoult F , Hanna N , Arnaud P , Eliahou L , Extramiana F , Iung B , Boileau C , Jondeau G
Published: November 2020

Introduction

Marfan syndrome (MFS) is responsible for cardiovascular disorders such as aortic aneurism and mitral valve prolapse (MVP).

A malignant MVP phenotype combining clinical, electrical and morphological features has been described in symptomatic patients who have experienced sudden cardiac death or complex ventricular arrhythmias.

We have taken advantage of the high prevalence of MVP in MFS patient to study the clinical, electrical and echocardiographic abnormalities associated with MVP.

Purpose

The aim of this study is to describe the clinical, electrical and morphological cardiac abnormalities associated with MVP in a cohort of MFS patients with FBN1 mutations with a high prevalence of MVP and who did not suffer from severe ventricular arrhythmias.

Methods

All consecutive patients coming to the National Reference Center for Marfan syndrome were evaluated prospectively i.e. clinical examination, 12-lead electrocardiogram, standard transthoracic echocardiography study and molecular genetic screening.

Results

352 consecutive patients were included from April 2015 to October 2016 [250 FBN1 mutation carriers (MFS) and 102 healthy relatives (HR)]. None of the patients had a history of sudden cardiac death or complex ventricular arrhythmia.

MFS vs HR: MFS patients were younger (33 vs 41yo p<0.001) and 2/3 were women in both groups. In the MFS group, abnormal T waves repolarization in lateral leads were more common [172 MFS (70.2%) vs. 87 HR (86.14%) p<0,0012], as was MVP [38.37% vs 1.96%; p<0,0001], and diastolic hypertrophy of the basal segment of the inferolateral wall (thickness >11mm) [22.31% vs. 9.18%; p<0.0001].

In MFS, MVP affected either one valve (21.22%), or both (17.14%), and was not associated with electric abnormalities. However, diastolic basal inferolateral wall hypertrophy was associated with mitral valve prolapse (p<0,0001), QTc interval prolongation (p<0.0229), abnormal T waves repolarization in the inferior leads (p=0.004), and higher aortic Z-Score (p=0.274).

Conclusion

In MFS patients, the prevalence of MVP is high and no significant association between MVP and electrical abnormalities was found. In contrast, basal inferolateral wall hypertrophy is associated with MVP and repolarization disorders in inferior leads and QTc interval prolongation, i.e, electrocardiographic abnormalities described in malignant MVP.

QTc and basal inferolateral hypertrophy

Funding Acknowledgement

Type of funding source: None
Three-D measurements of LVOT: impact on quantification of aortic stenosis (AS)
Authors: Anderson N , Thiru S , Chenzbraun A
Published: November 2020

Background

Discrepancies between aortic valve area (AVA) and gradients are recognized in patients with AS and normal LVEF and can impact on surgical referral decisions.

Purpose

Pilot study to determine whether using 3D rather than 2D LVOT dimensions leads to fewer discrepancies and less patients diagnosed with severe AS by continuity equation.

Methods

AS was quantified as per BSE guidelines in 55 consecutive patients (M: 32, age: 73±10) with LVEF>50% and at least moderate AS by AVA. LVOT was imaged with 3D zoom and its two orthogonal diameters were used to calculate the LVOT area for the continuity equation.

Results

Severe AS was diagnosed by AVA in 24/55 (44%) patients (Table 1). By 3D measurements the LVOT eccentricity index (D1/D2) was 0.8±0.1 and the LVOT area and SVi were larger than the ones calculated by 2D measurements:3.74±0.7 cm2 vs. 3.29±0.5 cm2 and 51.4±13 ml/BSA, vs. 45.3±9 ml/BSA, respectively, p<0.05. 3D measurements reduced the number of severe AS cases from 24 to 18 (AVA) and from 33 to 24 (AVAi) (25% and 27% respectively, p<0.05). AS severity agreement for all parameters slightly improved from 34/55 (62%) to 37/55/ (67%), p: ns

Conclusions

1) In this pilot study, the use of 3D-derived LVOT measurements reduced by 25% the frequency of severe AS diagnosis.

2) If these results are confirmed in larger studies, use of 3D LVOT measurements may become standard of practice.

Funding Acknowledgement

Type of funding source: None
Do we need cardiopulmonary exercise to determine the optimal time for intervention in valvular heart disease?
Authors: Cortina C , Sarrion M , Beltran C , Suberviola V , Sanchez A , Mora L , Estevez A , Briongos S , Vaqueriza D , Dominguez M , Munoz Aguilera R
Published: November 2020

Introduction

Cardiopulmonary exercise testing (CPET) is underused in many clinical conditions other than HF. In valvular heart disease (VHD), CEPT can aid in choosing the right timing for surgery. The goals of this study were to compare the assessment of functional capacity (FC) by CEPT and NYHA scale, and to analyze the relationship between ventilatory efficiency (VE) parameters and time to surgery.

Methods

197 CPET were performed in 163 patients with moderate or severe VHD (51% female). Real METS (RM) were calculated as indexed peak VO2/3.5 (1 MET = 3.5 ml O2/kg/min) and compared to estimated METS (EM) derived by the exercise duration. An agreement analysis between RM, EM and NYHA was performed. The association among VE/VCO2 slope, pet CO2 at anaerobic threshold (AT), OUES and time to surgical indication was also studied using Cox logistic regression analysis.

Results

See Table. The RM and EM were 4,7±1,7and 6,2±2,9, respectively (p<0.01), and the correlation was low (ICC=0,7, p<0.001). The agreement between NYHA class and % of peak predicted V02 was very low (kappa index = 0.1, p<0.001). VE parameters were predictive of an earlier surgical indication: petCO2 AT (p=0.02), VE/VCO2 slope (p=0.069), OUES (p=0.014).

Conclusions

In asymptomatic VHD patients, the surgical indication should not rely solely in their FC assessed by either NYHA scale or EM derived by duration of exercise. In our series, these parameters clearly overestimated the FC of the population. Also, the ventilatory inefficiency may be a surrogate marker of advanced disease and lead to a closer surveillance for an earlier intervention.

Real and estimated METS by type of VHD

Funding Acknowledgement

Type of funding source: None
Association between prosthesis geometry and leaflet thrombosis following transcatheter aortic valve replacement
Authors: Rashid H , Michail M , Khav N , Tan S , Nasis A , Cameron J , Nicholls S , Gooley R
Published: November 2020

Introduction

Leaflet thrombosis (LT) following transcatheter aortic valve replacement (TAVR) is a recognised condition. The association between prosthesis geometry [expansion, implant depth and commissural alignment (CA)] and LT is unclear.

Methods

Patients that received intra-annular TAVR prosthesis and post-procedure computed tomography (CT) with a 320-slice scanner were included. LT, defined as at least 50% restricted leaflet motion, was assessed with a dedicated 3Mensio workstation by two experienced CT readers. Prosthesis expansion was defined as actual divided by expected prosthesis area as a percentage of expected area whilst eccentricity was [(maximum diameter − minimum diameter) / maximum diameter) × 100%], both measured at prosthesis inflow, annulus and outflow. Implant depth was the average distance between prosthesis inflow and nadir of each cusp. CA was the average angle between each native and prosthesis leaflet coaptations. Significant commissural misalignment (CMA) was defined as CA greater than 30 degrees. To exclude anticoagulation bias, similar analysis was also performed in the cohort of non-anticoagulated patients.

Results

117 patients were included; the prevalence of LT was 13.7% [13/93 cases (14.0%) of Lotus valves and 3/24 cases (12.5%) of Sapien 3 valves]. Baseline demographics (age, STS score, cardiac risk factors) and procedural characteristics (access site, post-dilation, repositioning) were similar in both groups. None of the patients with LT were discharged on anticoagulation therapy (0.0% vs 22.8%, p<0.01). There were no differences in actual prosthesis area, perimeter or eccentricity at the three prosthesis levels. Patients with LT had reduced annulus expansion (89.3±9.8% vs 94.6±8.3%, p=0.02), lower implant depth (6.9±1.5mm vs 4.9±1.5mm, p<0.01) and more significant CMA (81.3% vs 48.5%, p=0.02). These findings were similar in patients that were not anticoagulated (94/117 patients).

Conclusion

Patients with LT had reduced annulus expansion, lower implant depth and greater CMA. These findings were not affected by presence or absence of anticoagulation. These factors may be important considerations during procedural planning for TAVR.

Graphical abstract

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council (NHMRC). National Heart Foundation (NHF) Australia.
Prognostic value of global myocardial constructive work in patients with secondary mitral regurgitation
Authors: Yedidya I , Lustosa R.P , Fortuni F , Van Der Bijl P , Namazi F , Vo N.M , Ajmone Marsan N , Delgado V , Bax J
Published: November 2020

Background

Left ventricular (LV) myocardial contractility evaluation is of crucial importance in patients with secondary mitral regurgitation (SMR). The most widespread echocardiographic tool, left ventricular ejection fraction (LVEF), might overestimate LV function, since it calculates the volume changes regardless of the flow direction. Global myocardial constructive work (GMCW) might be a more suitable tool, as LV myocardial work derived from pressure-strain loops obtained with speckle tracking echocardiography incorporates non-invasive blood pressure measurements.

Purpose

To evaluate the prognostic value of LV GMCW in patients with SMR.

Methods

378 patients (72% men, median age 68 [range 60 to 74 years]) with various grades of SMR were retrospectively analysed. LV global myocardial constructive work, wasted work and work efficiency were measured with speckle tracking echocardiography.

Results

There were 145 patients with mild SMR, 130 with moderate SMR and 103 with severe SMR. Patients with severe SMR had larger LV volumes, lower LVEF and more impaired LV GLS. GMCW was more impaired in patients with severe SMR, compared with mild MR (678 mmHg% vs. 845 mmHg% p<0.001 respectively). After a mean follow-up of 59±37 months, 162 patients died. When dividing the population according to prognostically relevant cut offs derived by spline curve analysis, patients with a GMCW≤700 mmHg% had a worse prognosis, compared with their counterparts (Figure 1).

Conclusion

Global myocardial constructive work ≤700 mmHg% is associated with worse long-term survival in patients with SMR.

Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None
The importance of comorbidities for long-term outcome after aortic valve intervention in patients with preserved left ventricular ejection fraction, a nation-wide register study
Authors: Thilen M , James S , Lindhagen L , Stahle E , Christersson C
Published: November 2020

Background

In Aortic stenosis (AS) cardiovascular comorbidities as well as left ventricular ejection fraction (LVEF) have an impact on postoperative outcome among patients undergoing aortic valve replacement (AVR). The prevalence of heart failure (HF) based on LVEF in patients with severe AS varies. Lately HF with preserved LVEF has gained more attention. The aim is to describe the prevalence and prognostic impact of cardiovascular comorbidities, including HF, in relation to LVEF before AVR in a national cohort of patients with AS.

Methods

Patients >18 years, undergoing AVR due to AS 2008–2014 were identified in the national register for heart diseases, SWEDEHEART. Preoperative LVEF and comorbidities were collected from the register and enriched with data from national patient registries. The outcome events were all cause mortality and hospitalization for HF as the main diagnosis. The cohort was separated by preoperative LVEF status; preserved (>50%) or reduced (≤50%). Outcome events were analysed by Cox regression.

Results

10406 patients, median age 73 (18–96) years whereof 3817 (36.7%) women, were included with a median follow-up of 35 months. In the cohort 15.9%, 73.9% and 10.2% received a mechanical, surgical biological and trans-catheter biological valve prosthesis, respectively. Preserved LVEF was present in 7512 (72.2%). Comorbidities were more frequent in the group with reduced LVEF (p<0.001). Irrespective of LVEF HF influenced outcome negatively (see table).

Conclusion

In patients planned for AVR a history of HF irrespective of LVEF worsen postoperative prognosis and a history of HF seems at least as important as LVEF when predicting long-term outcome. When stratifying patients for AVR with preserved LVEF, comorbidities such as HF and atrial fibrillation should be highlighted, and further research to identify risk factors for a negative postoperative outcome in this group seems important in optimizing the follow-up after AVR.

Funding Acknowledgement

Type of funding source: None
Favorable course of tricuspid regurgitation after percutaneous mitral valve repair is associated with improved survival and clinical outcome
Authors: Meijerink F , Baan J , Bouma B.J
Published: November 2020

Background

Tricuspid Regurgitation (TR) is often present in patients with mitral regurgitation (MR) and is associated with increased mortality and morbidity after percutaneous mitral valve repair (PMVR) using the MitraClip (Abbott Vascular). It is unclear to what extent TR is reduced after PMVR and whether the reduction of TR is related to survival and functional outcome.

Purpose

The aim of this study was to determine (1) the TR course after PMVR and (2) if this was related to survival and clinical outcome.

Methods

Patients who underwent PMVR and had complete echocardiographic data at baseline and follow-up were included. TR severity was graded as none, mild, moderate or severe (according to current guidelines) and was determined before treatment and at 6-months of follow up. Favorable TR course was defined as improvement of ≥1 grade or ≤ mild TR at 6-months. Clinical endpoints were all-cause mortality during 1-year of follow-up and improvement in New York Heart Association (NYHA) functional class after 6 months.

Results

A total of 67 patients were included (mean age 76 years, 57% male, 81% NYHA class ≥3 and 69% baseline TR ≥ moderate). Favorable TR course was achieved in 31 patients (46%) (figure 1A). All-cause mortality at 1 year was 7.5%, and was lower in the favorable TR course group (0% vs. 13.9%, p=0.057) (figure 1B). Improvement in NYHA class at 6-months was seen in 45% of patients without vs. 81% of patients with favorable TR course (p=0.01) (figure 1C).

Conclusion

A favorable TR course is achieved in 46% of PMVR patients and is associated with improved survival and improvement of NYHA class. The relatively high rate of an unfavorable TR course at 6-months, indicates that interventional treatment of the tricuspid valve might benefit these patients.

TR course (A) and NYHA improvement (B)

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Abbott
Postoperative prognostic impact of replacement fibrosis in patients with aortic valve stenosis
Authors: Igual Munoz B , Blanco Herrera O , Perez Bosca J.L , Forner Giner J , Barber Hueso C , Berenguer Jofresa A , Oscar Gil Albaroya O , Ruiz Sauri A , Montero Argudo A , Paya Serrano R
Published: November 2020

Nowadays, risk assessment in patients undergoing aortic valve replacement (AVR) is mainly performed using Euroscore II risk model. Nevertheless other imaging findings as presence of replacement myocardial fibrosis (RMF) assessed by magnetic resonance imaging (MRI) is reported to be a potent risk marker. Our objective is to assess the prognostic value of RMF in patients undergoing surgical AVR and its value using as reference Euroscore II model.

Methods

121 patients without any coronary or additional valve disease undergoing surgical aortic valve replacement were included. All of them have a preoperative MRI study including b-SSFP short axis sequences to assess left ventricular mass, volume and ejection fraction and IR-FGRE sequences to assess replacement fibrosis and also clinical follow up for a median time of 40 months. The postoperative risk of events was also estimated using Euroscore II model. The impact of fibrosis on survival free of cardiovascular events was estimated using the Kaplan-Meier test and its value against reference parameters was estimated using a multivariate Cox model.

Results

121 consecutive patients, 50% males with a mean age of 72 years (SD 10) with an average Euroscore value of 1.55 (SD 1) undergoing AVR, 100 (78%) with a biological prosthesis. Patients with replacement fibrosis had significantly decreased survival (p<0.05). Furthemore multivariate analysis showed Euroscore II and replacement fibrosis as the most potent predictors (HR: 1.5, p=0.01 and HR: 1.8, p=0.09 respectively) and furthermore to include replacement fibrosis in the model significantly improves prediction of postoperative MACE.

Conclusions

1. Patients with replacement fibrosis had significantly decreased postoperative survival free of MACE.

2. To Include replacement fibrosis in the preoperative risk assessment significantly improves prediction of postoperative MACE.

Survival plots regarding fibrosis

Funding Acknowledgement

Type of funding source: None