bluuebunny/crossref_metadata_2025 huggingface dataset:
Association between serum osteoprotegerin levels and severity of coronary artery disease in patients with acute myocardial infarction
Authors: Cottin Y , Issa R , Benalia M , Mouhat B , Meloux A , Tribouillard L , Bichat F , Vergely C , Zeller M
Published: October 2021

Background

Osteoprotegerin (OPG), a glycoprotein of the tumor necrosis factor (TNF) superfamily is a main biomarker for vascular calcification.

Aim

We aimed to evaluate the association between serum OPG levels and extent of coronary lesions in patients with acute myocardial infarction (MI).

Methods

Consecutive patients hospitalized for an acute MI who underwent coronary angiography were included. SYNTAX score was calculated to assess the severity of coronary artery disease. The population was analysed in low (5 (3–6)), medium (11 (9–13)) and high (20 (18–23)) tertiles of SYNTAX score.

Results

Among the 378 patients included, there was a gradual increase in age, rate of diabetes, anterior wall location, and a reduction in left ventricular ejection fraction across the SYNTAX tertiles. OPG levels significantly increased across the tertiles (962 (782–1,497), 1,240 (870–1,707), and 1464 (1,011–2,129) pg/ml, respectively (p<0.001)). In multivariate analysis, OPG [OR (CI95%): 2.09 (1.31–3.32) p=0. 002], were associated with the high SYNTAX group, beyond hypercholesterolemia, CV history and creatinine.

Conclusion

We found an association between OPG levels and coronary lesions complexity patients with acute MI. Determining OPG levels in combination with an ischemia test could be used in the clinical setting for the early diagnosis of subclinical atherosclerosis.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): CHU Dijon BourgogneConseil Régional Bourgogne Franche Comté
Prognostic value of PCSK9 Levels in Non-ST elevation myocardial infarction patients undergoing percutaneous coronary intervention
Authors: Wang J.-X , Han P , Gao M.-D , Xiao J.-Y , Li X.-W , Zhang N , Ma J , Cui Z , Yao T.-T , Chen Y , Gao J , Liu Y
Published: October 2021

Background

The role of proprotein convertase subtilisin/kexin type 9 (PCSK9) in predicting major adverse cardiovascular events (MACEs) in Non-ST elevation myocardial infarction (NSTEMI) patients is still an open question and the PCSK9 concentration of clinical usefulness remains unknown in guiding treatment.

Purpose

To explore the role of PCSK9 in predicting major adverse cardiovascular events (MACEs) in Non-ST elevation myocardial infarction patients.

Methods

272 patients with NSTEMI were included in our study, all patients received PCI therapy after admission. Patients were followed up for 1 year and MACEs were recored. Their baseline plasma PCSK9 levels were determined by ELISA. Patients were divided into high, medium and low PCSK9 groups and the associations of PCSK9 with other biomarkers and MACEs were evaluated.

Results

The results showed that PCSK9 levels was related to levels of lipoproteins, high-sensitivity C-reactive protein (r=0.162, P=0.008), platelet volume distribution width (r=0.299, P<0.001) and D-dimer (r=0.285, P<0.001). And the concentrations of PCSK9 was greater higher in people with MACEs (137.2ng/ml vs 243.6ng/ml) (Fig. 1A). The Kaplan-Meier curves showed patients with high PCSK9 level had lower event-free survival rate (Fig. 1B). Survival analysis indicated high level of PCSK9 predicted MACEs independently after adjusted for traditional cardiovascular risk factors and GRACE score (HR=2.646, 95CI%: 1.047–6.686, P=0.027) (Fig. 1C, Fig. 2). Subgroup analysis demonstrated the prognostic value of high PCSK9 level was greater for patients classified by the GRACE score as high risk (Fig. 1D).

Conclusions

In a NSTEMI setting, the concentration of PCSK9 is associated with hypercoagulability and hyper-inflammation. High levels of PCSK9 independently predict future MACEs in NSTEMI patients, particularly those classified by the GRACE score as high risk.

Funding Acknowledgement

Type of funding sources: None.
Outcomes of patients admitted with high-sensitive cardiac troponin T levels meeting the new rule out criteria for myocardial infarction
Authors: Cohen B C , Cohen S C , Tor R T , Fuchs S F , Kornowski R K , Grossman A G , Hasdai D H
Published: October 2021

Background

The 2020 ESC non-ST-elevation (NSTE) acute coronary syndromes (ACS) guidelines have adopted the paradigm that patients presenting with suspected NSTE-ACS and high-sensitive cardiac troponin T (hs-cTnT) values <99th percentile in a single test or small increment within 1/2 hours have a high negative predictive value for myocardial infarction (MI). Their management remains controversial.

Purpose

We examined the clinical outcomes and resource utilization of suspected NSTE-ACS patients who presented with hs-cTnT values meeting the early rule out criteria, but were nevertheless admitted.

Methods

Our single center retrospective cohort study included 4,263 visits for suspected NSTE-ACS triaged in the Emergency Room (ER), had hs-cTnT values that met the early rule-out criteria, and were admitted (Figure 1).

Routine quality control and dedicated tests proved a coefficient of variance of <10% for hs-cTnT values <99th percentile (14 ng/L).

Results

There were no deaths in-hospital and at 30 days. Discharge diagnosis of MI was documented in 10 patients (∼0.2%). Median ER stay and hospital stay were 6 hours and 3 days, respectively. In hospital evaluation included 844 gated cardiac CT angiography (CTA), 580 SPECT heart scans, 101 ECG-exercise tests, and 178 coronary angiography, of which 70 (∼1.6% of cohort) culminated in percutaneous/surgical intervention.

Conclusion

Our findings highlight the high negative predictive value for MI applying the early rule out algorithm and supports a policy of ER discharge for further evaluation, sparing unnecessary and resource-consuming hospital admissions.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Outcomes of patients admitted with limit of blank high-sensitive cardiac troponin T levels versus those with levels under the limit of detection
Authors: Cohen B C , Cohen S C , Tor R T , Fuchs S F , Kornowski R K , Grossman A G , Hasdai D H
Published: October 2021

Background

Patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) and high-sensitive cardiac troponin T (hs-cTnT) values below the level of detection (5 ng/L) in a single test have a high negative predictive value for myocardial infarction (MI).

Purpose

We compared the clinical outcomes and resource utilization of suspected NSTE-ACS patients who were admitted despite hs-cTnT values below the limit of detection (5 ng/L) versus those with values ≤ the limit of blank (3 ng/L).

Methods

This single center retrospective cohort analysis included 2,081 emergency room (ER) visits for suspected NSTE-ACS that manifested single hs-cTnT value <5 ng/L (limit of detection) - 624 with single hs-cTnT ≤3 ng/L (limit of blank) and 1,457 with single hs-cTnT values >3 ng/L and <5 ng/L, and yet were admitted (Figure 1).

Routine quality control and dedicated tests proved a coefficient of variance of <10% for hs-cTnT values <99th percentile (14 ng/L).

Results

There were no in-hospital or 30-day deaths in both groups. Discharge diagnosis of MI was documented only in the 3–5 ng/L hs-cTnT group – 3 cases (∼0.2%). Median ER stay were 5 and 6 hours for ≤3 ng/L and 3–5 ng/L groups, respectively. Median hospital stay was 3 days for both groups. Coronary angiographies culminating in interventions were documented in 1 case (∼0.2%) and 24 cases (∼1.6%) for ≤3 ng/L and 3–5 ng/L groups, respectively.

Conclusion

Suspected NSTE-ACS patients with hs-cTnT values ≤ the limit of blank are at very low risk and may not need any further evaluation.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Determination of physiological cardiac myosin-binging protein levels (cMyc) in healthy populations
Authors: Inoue K , Shiozaki M , Sasaki S , Sasaki Y , Tamura H , Fukuda K , Kubota N , Hiki M , Funamizu T , Sumiyoshi M , Minamino T
Published: October 2021

Background

Cardiac myosin–binding protein C (cMyC) is a cardiac-restricted protein that has more abundant, rapid release and clearance kinetics than cardiac troponin. The current ESC guideline suggests the cMyC may provide value as an alternative to cardiac troponin. The 99th percentile value is universally endorsed as the reference cut off to aid in the diagnosis of acute myocardial infarction (AMI), however, none of the report of healthy population of cMyC.

Purpose

The aim of this study was to evaluate the distribution of cMyC values in healthy subjects.

Methods

We used two cohorts in this retrospective study. 1) Healthy subjects; a total of 500 subjects (250 men and 250 women) who had annual health examinations in 2012 in the area of Kamigoto, a suburb of Nagasaki city in Southern Japan were enrolled. All participants showed none of abnormal findings including cell blood counts, chemical analysis, liver function tests, general urine tests, occult blood tests of stool, barium swallow, mammography for women, abdominal ultrasound sonography, and electrocardiogram. All blood samples were obtained in a fasting state in the morning. 2) Chest pain subjects; we collected samples from 250 subjects including 50 with non-ST elevation myocardial infarction visited admitted to a university hospital for measurement of high-sensitivity troponin T and coronary artery assessment by coronary angiography. We measured cMyC level in both cohorts by HISCL™-800 system (Sysmex corporation, Japan). The assay has a limit of detection of 0.5 ng/L and a lower limit of quantification of 1.3 ng/L.

Result

In healthy subjects, median age (IQR) was 44 (20, 82) in men and 50 (23, 91) in women. The 99th percentile of cMyC was 27.3 ng/L, which was around one-third lower than that in previous report (87 ng/L). In chest pain subjects, the concentrations of cMyC at presentation were significantly higher in those with versus without AMI (median, 66 ng/L versus 10 ng/L, P<0.001). Discriminatory power for AMI, as quantified by the area under the receiver-operating characteristic curve (AUC), was comparable for cMyC (AUC, 0.85 (95% CI 0.79–0.91) and hs-cTnT (AUC, 0.81 (95% CI 0.76–0.88)).

Conclusion

We defined the normal range of cMyC in healthy Japanese subjects. The level of cMyC at presentation provides discriminatory power comparable to hs-cTnT in the diagnosis of AMI. To determine the physiological value of a biomarker may be necessary to evaluate enough information about their health status.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research
Regional wall motion abnormalities predict culprit lesions in patients presenting with acute chest pain
Authors: Roggel A , Hendricks S , Dykun I , Balcer B , Al-Rashid F , Risse J , Kill C , Totzeck M , Rassaf T , Mahabadi A A
Published: October 2021

Background

Current ESC guidelines for non-ST-segment elevation myocardial infarction suggest the utilization of echocardiography in patients with inconclusive initial electrocardiography and cardiac enzymes. Besides detection of alternative pathologies associated with chest pain, echocardiography can screen for wall motion abnormalities (WMA) as sign of myocardial necrosis.

Purpose

We evaluated the ability of the assessment of regional WMA, detected via transthoracic echocardiography, to predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department.

Methods

In this prospective single-centre observational cohort study, we included consecutive patients presenting to the emergency department of our University Hospital with acute chest pain, suggestive of an acute coronary syndrome, between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, hemodynamic instability, or known coronary artery disease were excluded. As part of initial workup, patients received bedside echocardiography for the assessment of regional WMA by a dedicated study physician, blinded to all patients' characteristics. The primary endpoint was defined as the presence of culprit lesions as detected in subsequent invasive coronary angiography, requiring coronary revascularization therapy. Logistic regression analysis was performed in different models adjusted for traditional cardiovascular risk factors, cardiac biomarkers as well as established risk scores. Area under the receiver operating characteristics curve (AUC) was calculated to assess a potential improvement in the prediction of culprit lesions.

Results

Overall, 657 patients (age 58.06±18.04 years, 53% male) were included in our study. WMA were detected in 76 patients (11.6%). Patients with WMA were older (66.92±13.85 vs. 56.90±18.21 years, p<0.001), had significantly higher Troponin-levels (18.5 [6.0; 91.5] vs. 6.0 [6.0; 15.0], p<0.001) and higher blood pressure (139.0±19.29 vs. 135.1±19.21, p=0.04). WMA were significantly more frequent in patients reaching the primary endpoint (26.2% vs. 7.6%, p<0.001). In multivariable regression analysis, the presence of WMA was associated with 3-fold increased odds of the presence of culprit lesions (3.41 [1.99–5.86], p<0.001). Adding WMA to a multivariable model containing the TIMI risk score, cardiac biomarkers and traditional risk factors significantly improved the AUC for prediction of obstructive coronary artery disease (0.777 to 0.804, p=0.009).

Conclusion

WMA strongly and independently predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Our results suggest that routine bedside echocardiography for assessment of WMA in emergency department may improve diagnostic algorithms in suspected acute coronary syndrome.

Funding Acknowledgement

Type of funding sources: None.
Differential impact of renal function on the diagnostic performance of resting full-cycle ratio as non-hyperemic physiological assessment
Authors: Ohashi H , Takashima H , Nawano T , Ando H , Nakano Y , Sakurai S , Suzuki A , Suzuki W , Amano T
Published: October 2021

Background

Fractional flow reserve (FFR) is a gold standard method to evaluate functional lesion severity in daily clinical practice. Recently, the resting full-cycle ratio (RFR) was Previous studies showed the better diagnostic performance of RFR comparing with FFR. It is well known that patients with chronic kidney disease (CKD) have poor prognosis. Therefore, we should carefully assess the functional lesion severity in CKD patients. However, it is unclear whether the diagnostic performance of RFR for detecting functional ischemia is similar regardless of the degree of renal function. The aim of this study is to compare the diagnostic performance of RFR based on renal function.

Method

This study was a prospectively enrolled observational study. A total of 265 consecutive patients with 373 intermediate lesions were enrolled in this study. There were classified into three groups according to renal function (Group 1: eGFR ≥60 mL/min/1.73m2; Group 2: 30 mL/min/1.73m2 ≤eGFR <60 mL/min/1.73m2; Group 3: eGFR <30mL/min/1.73m2). The RFR was measured after adequately waiting for stable condition, while FFR was measured after intravenous administration of ATP (180mcg/kg/min). The discordance between FFR and RFR were assessed the data using known cutoffs for FFR (≤0.80) and RFR (≤0.89).

Results

Of 373 lesions, the median age was 70.1±11.0 years. Functional significance was observed in 153 lesions (41.0%) of all lesions. RFR showed a significant correlation with FFR in each group (Group 1; r2=0.63 [p<0.001], Group 2: r2=0.67 [p<0.001], Group 3: r2=0.51 [p<0.001], respectively). The ROC curve analysis of RFR showed differential results for predicting functional significance (Group 1: AUC 0.88, cut-off value 0.91; Group 2: AUC 0.88, cut-off value 0.89; Group 3: AUC 0.81, cut-off value 0.83; respectively) in each group. The prevalence of discordant between RFR and FFR was significantly different among 3 groups (Group 1: 16.5%, Group 2: 19.4%, Group 3: 25.0%, respectively, p<0.05 for among 3 groups).

Conclusion

The diagnostic performance of RFR was different based on renal function. During RFR acquisition, the degree of renal function could influence concordance with FFR, and should be taken into account when interpreting RFR.

Funding Acknowledgement

Type of funding sources: None.
Evaluation of management strategies in patients with coronary ectasia: a retrospective cohort study
Authors: Sierra Gonzalez De Cossio A , Solis-Jimenez F , Viana Rojas J A , Villalobos Pedroza M , Terrazas Cervantes E , Jimenez Ruan L A , Reyes Tovilla J E , Ornelas Casillas M A , Cornejo Guerra J A , Araiza Garaygordobil D , Gonzalez Pacheco H , Pina Reyna Y , Eid Lidt G
Published: October 2021

Background/Introduction

Since patients with coronary ectasia have an increased risk of developing myocardial infarction and cardiovascular death, these patients could benefit from a more intensive treatment. Unfortunately, the evidence regarding outcomes with different management strategies is limited, especially with direct oral anticoagulants (DOAC).

Purpose

To compare clinical outcomes in patients with coronary ectasia based on the selected/chosen treatment strategy.

Methods

We conducted a retrospective cohort study in patients diagnosed with coronary artery ectasia. They were divided into 3 different groups based on the treatment they received at discharge and we evaluated the main cardiovascular outcomes at one-year follow-up.

Results

Between 2016 and 2019, 7,579 angiographies were performed, in which 510 patients with coronary ectasia were found (prevalence of 6.72%). Of these patients, 43.9% (n=224) had the diagnosis of STEMI, 21% NSTEMI (n=107), 5.1% unstable angina (n=26), 18.6% chronic stable angina (n=95) and other 11.4% (n=58). The angiographic distribution of the lesions was as follows: left main coronary artery 25.1%, Left descending coronary artery 62.7%, circumflex artery 52.1%, right coronary artery 79.2%.

It was possible to obtain the follow-up of 363 patients (71.2%) because 25 died during their hospitalization and data of 122 were not available at the time of analysis. Three groups were formed based on the treatment: (1) Dual Antiplatelet Therapy (DAPT) in 47% (n=174); (2) DAPT + Vitamin K Antagonist (VKA) in 8.5% (n=31); (3) DAPT + DOAC in 6.6% (n=24).

The overall MACE rate at 1-year of follow-up was 6.6% (n=15): 11 patients in the DAPT group (6.3%), 1 patient in the DAPT + VKA group (3.2%), and 3 patients in the DAPT + DOAC group (12.5%). During this period, 3 patients died from cardiovascular causes, all of them in the DAPT group. Myocardial infarction occurred in 12 patients, 8 in the DAPT group (4.2%), 1 in the DAPT + VKA group (3.2%) and 3 in the DAPT + DOAC group (12.5%). Stroke occurred in 2 patients: 1 patient in the DAPT group (0.5%) and 1 patient in the DAPT + DOAC group, 4.1% None of these findings were statistically significant.

One-year occurrence of bleeding events was also evaluated: 23 patients presented a bleeding event, 14 in the DAPT group (8%), 7 in the DAPT + VKA group (22.5%) and 2 in the DAPT + DOAC group (8.3%); p=0.010.

Conclusion(s)

Our findings suggest that there is no statistically significant difference in the incidence of thrombotic complications, when comparing the treatment options. Patients using the combination of DAPT+VKA have a higher incidence of bleeding.

Funding Acknowledgement

Type of funding sources: None.
Acute circumflex coronary artery occlusion; dilemma in diagnosis and management
Authors: Komatsu J , Nishimura Y , Sugane H , Hosoda H , Imai R , Nakaoka Y , Nishida K , Seki S , Kubokawa S , Kawai K , Hamashige N , Doi Y
Published: October 2021

Background

Acute coronary syndrome (ACS) with occlusion of the circumflex coronary artery (LCX) poses diagnostic dilemma that may lead to a delay in reperfusion.

Purpose

We sought to assess the diagnostic significance of initial electrocardiography (ECG) changes in patients with acute LCX occlusion in relation to its clinical characteristics and the management.

Methods

From consecutive 1269 patients with ACS who were admitted to our institution during a 5-year period (2015–2019), 138 patients with ACS due to LCX occlusion were analyzed for clinical, ECG and angiographic presentation, and the door-to-balloon (DTB) time. ECG changes were classified into 4 different patterns: 1) ST-elevation in inferior/lateral leads (ST-E); 2) ST-depression in V1-V4 (ST-D); 3) no significant ST changes (No-ST); and 4) others.

Results

(1) No-ST pattern was found in 47 patients (34%), ST-E in 47 patients (34%), ST-D in 25 patients (18%) and others in 19 patients (14%). (2) Occlusion site: Proximal LCX; 16 patients with No-ST (34%), 6 patients with ST-E (13%), 13 patients with ST-D (52%). Distal LCX; 28 patients with No-ST (60%), 35 patients with ST-E (74%), 11 patients with ST-D (44%) (p=0.007). (Table) (3) Echocardiographic identification of left ventricular asynergy; 31 patients with No-ST (66%), 38 patients with ST-E (81%), 22 patients with ST-D (88%). (4) No-ST group was associated with longer DTB time; 245 min (170–562 min), compared to 93 min (83–121 min) in ST-E group and 97 min (70–129 min) in ST-D group (p<0.0001). DTB time ≤90 min was significantly uncommon in No-ST group (11%), compared to ST-E group (46%) and ST-D group (43%) (p=0.0004). (Figure)

Conclusion

One-third of the patients with LCX-ACS showed no ST changes, resulting in significantly longer DTB time. Improving diagnostic accuracy with anticipation for LCX-ACS and the use of echocardiographic examination and also the possible application of posterior leads (V7-V9) recording is challenging but critical to avoid delayed reperfusion and to improve outcomes in these patients without ECG changes.

Funding Acknowledgement

Type of funding sources: None.
Clinical and electrocardiographic differences between apical and midventricular stress cardiomyopathy
Authors: Esteban-Lucia L , Martinez-Milla J , Franco-Pelaez J A , Lopez-Castillo M , Martin-Reyes R , Palfy J , Romero-Daza A , Pinero Lozano A , Avila Barahona P , Kallmeyer Mayor A M , Gonzalez Lorenzo O , Tunon J
Published: October 2021

Background

Stress cardiomyopathy (SCM) is a transient ventricular dysfunction frequently precipitated by acute emotional or physical stress. According to ventricular contractile pattern there are four SCM variants, being apical (80%) and midventricular (15%) the most frequents. Our aim is to describe the differences between these two SCM variants.

Methods

We performed an observational study of patients who were diagnosed with SCM in our centre from February 2010 to January 2020. We registered demographic information, medical history, clinical, echocardiographic and analytical data of our patients and we performed a digital analysis of the 12-lead electrocardiogram (ECG) recorded in the first 48 hours after the onset of symptoms. Patients were divided into two groups, those with apical LV ballooning and patients with midventricular SCM.

Results

We included 86 patients; baseline characteristics of the population are described in the table. The median age was 77 (IQR: 67.7–82.9), and 91.9% were female. Fifty-six patients (65.1%) had apical variant whereas thirty patients (34.9%) showed midventricular one. The most frequent antecedent trigger was an emotional stressor (36.3%) follow by physical stressor (identified in 23.8%). Chest pain was the most frequent clinical presentation (54.7%). Median LVEF was 35% (IQR 30.0–45.0) and mean basal septal thickness was 9.50 (IQR 9.0–11.0). Median peak of troponin level was 1.71 (IQR 0.6–3.4).

Comparing apical and midventricular variants of SCM median age was 80.2 (IQR 68.9–84.5) in apical group and 71.6 (IQR 59.64–78.0) in midventricular variant (P=0.001). There were no other differences in the medical history, clinical, echocardiographic and analytical data between both groups (table). After comparative analysis of ECG we found differences in negatives T wave location and QT duration. Apical variant present more negative-T waves in leads II, III, AVF, V4, V5, V6, while in midventricular variant they are more present in AVR and AVL (figure 1). Mean QT duration was 508.0ms (IQR 470.0–552.0) in apical variant and 470.5ms (IQR 423.7–524.2) in midventricular group (p=0.026). There were no differences in Q waves between both groups.

Conclusions

In our group of patients, apical and midventricular stress cardiomyopathy variants exhibit clinical and electrocardiographic differences. Patient with apical stress cardiomyopathy are older. They present more negative T waves in inferior and precordial leads, and longer QT interval. These results suggest that the pathophysiology of both entities could be different.

Funding Acknowledgement

Type of funding sources: None. Negative T-Waves comparationPopulation characteristics.
Right ventricular dysfunction before transcatheter aortic valve implantation: incidence, predictive factors and prognostic impact
Authors: Sacri C , Durand E , Tron C , Barbe T , Hemery T , Burdeau J , Dacher J N , Eltchaninoff H
Published: October 2021

Background

Right ventricular dysfunction (RVD) is considered to be a late marker of advanced aortic stenosis (AS) and is associated with poor prognosis. Currently. there are conflicting data on the impact of RVD on clinical outcomes in patients with severe AS treated with TAVI. Moreover, few studies have studied the evolution (recovery or persistence) of RVD and its prognostic impact.

Objectives

To assess the incidence and predictive factors of RVD before TAVI, its prognostic impact and its evolution after TAVI.

Methods

All patients treated with TAVI for severe AS were included in a prospective single center database. Only patients who had a quantitative assessment of RV including Tricuspid Annular Plane Systolic Excursion (TAPSE) and/or doppler tissue imaging-derived tricuspid lateral annular systolic velocity (S') measurements, were eligible to this study. RVD was defined by a TAPSE <17 mm or S' <9.5 cm/s if TAPSE was not available.

Results

Between May 2014 and April 2019, 503 patients with RV function evaluation were included. Incidence of RVD before TAVI was 18.7%. Predictors of RVD were diabetes (P=0.03), atrial fibrillation (P=0.001), altered left ventricular ejection fraction (P<0.0001), left ventricular dilatation (P=0.007), and previous cardiac surgery (P=0.002). Long-term survival was altered in patients with RVD before TAVI as compared to those without RVD (HR 1.97, 95% CI: 1.1–3.4, P=0.01). One year after TAVI, 58.7% of patients with baseline RVD had a normal RV function and had similar outcome as compared to those without RVD at baseline. In contrast, patients with persistent RVD had the worst prognosis.

Conclusions

RVD is not rare and has a deleterious prognostic impact in patients treated by TAVI. Recovery of normal RV function is frequent after TAVI whereas persistence of RVD is associated with poor outcomes.

Funding Acknowledgement

Type of funding sources: None.
TAVR in patients with low-flow low-gradient aortic stenosis – outcome data after three years from one large centre
Authors: Steffen J , Reissig N , Zadrozny M , Fischer J , Andreae D , Braun D , Orban M , Theiss H , Peterss S , Hausleiter J , Massberg S , Deseive S
Published: October 2021

Background

The outcome of patients with low-flow low-gradient (LFLG) aortic stenosis after transcatheter aortic valve replacement (TAVR) is not well evaluated. Long-term clinical success is thought to be less pronounced in LFLG patients compared to patients with high gradient (HG) aortic stenosis.

Purpose

The purpose of this study was to characterise different LFLG groups and determine their outcome after TAVR. We hypothesised that there would be relevant differences in baseline characteristics and patient survival after TAVR.

Methods

All patients undergoing TAVR for severe aortic stenosis at our centre between 2013 and 2019 were included in the study. Patients have been split into groups according preinterventional echocardiography data according to mean pressure gradient (dPmean), ejection fraction (EF), and stroke volume index (SVi). Patients with a dPmean <40 mmHg and SVi ≤35 ml/m2 were subdivided into classical low-flow low-gradient (cLFLG, EF <50%) and paradoxical low-flow (pLFLG, EF ≥50%). Patients with previous aortic valve replacement or severe aortic regurgitation were excluded from the analysis.

Results

1,772 patients were analysed (mean follow-up 2.2 years, median age 81.7 [77.5–85.7] years) and split into groups: HG, 953 patients (54.3%), cLFLG, 446 patients (25.2%), and pLFLG 373 patients (21.1%). Baseline characteristics showed significant differences (p<0.01), among others, in sex (male sex, HG 46.1% vs. cLFLG 69.5% vs. pLFLG 44.5%), rate of atrial fibrillation (HG 20.3% vs. cLFLG 36.3% vs. pLFLG 41.6%), coronary artery disease (HG 56.2% vs. cLFLG 73.5% vs. pLFLG 63.4%), and grade 3 or 4 mitral regurgitation (HG 2.2% vs. cLFLG 5.5% vs. pLFLG 6.8%). Accordingly, Society of Thoracic Surgeons (STS) Scores differed significantly: HG, 3.0 [2.0–5.0], cLFLG, 5.0 [3.0–7.3] pLFLG, 3.9 [2.2–6.0] (p<0.01).

Rates of periprocedural complications including death, device failure, pericardial effusion, stroke or myocardial infarction were comparable between groups. Mortality rate (figure 1) was highest for cLFLG patients (43.4% [95% confidence interval, 37.3–48.6%]) compared to HG (25.1% [21.6–28.5%]) or pLFLG (32.9% [26.9–38.4%]), Log-rank test, <0.001. Corresponding hazard ratios were 2.1 [1.7–2.6] (p<0.001) for cLFLG and 1.5 [1.2–2.0] (p<0.001) for pLFLG. Similar results were obtained when adjusting to STS score (figure 2).

Conclusion

In this all-comer analysis, almost half of the patients belong toLFLG groups with considerable differences in patient characteristics. While equally safe during the procedure, patients with LFLG aortic stenosis show increased 3-year mortality rates compared to patients with HG aortic stenosis. Further studies evaluating this are needed.

Funding Acknowledgement

Type of funding sources: None. Figure 1. 3-year mortalityFigure 2. STS score-adjusted mortality
Invasive and Doppler Transvalvular gradients after transcatheter aortic valve replacement
Authors: Fugar S , Deka K , Anderson C , Lama Von Buchwald C , Geroux R , Al-Amoodi M , White J , Kavinsky C
Published: October 2021

Background

Differences in mean gradients after Transcatheter valve replacement (TAVR) vary depending on the valve type and the modality used to measure the gradients. Currently there is a paucity of data on the relationship between invasive and doppler derived gradients after TAVR.

Purpose

We sort to assess the difference in doppler, and catheter derived aortic valve gradients after TAVR

Methods

This is a single center retrospective study using consecutive patients who presented for TAVR on account of native aortic valve stenosis at our institution from May 2012 till December 2020. Patients with both intraoperative invasive and postoperative doppler derived pressure gradients were included in the analysis. Student T-test were used to compare mean gradients. Pearson's correlation test was used to examine the correlation between measured gradients.

Results

A total of 587 patients were included in our study. Fifty one percent were male and 462 (78.7%) underwent TAVR with a balloon expandable valve. In the entire cohort the mean gradient measured invasively was significantly lower than those measured by echo doppler (4.48±3.25 vs. 5.57±3.11, P<0.001). There, however, was a positive correlation between invasive and doppler measured gradients (figure 1). In those who received balloon expandable valves, the invasive gradient was 4.39±3.30 and the doppler derived gradient was 5.47±3.04 (P<0.001), while in those self-expanding valves, the invasive gradient was 4.81±3.04 and doppler derived gradient was 5.94±3.36 (P<0.001).

Conclusion

Post TAVR gradients were all significantly lower when measured invasively as compared to those measured using doppler. Self-expanding valves overall had higher residual gradients. Further studies are needed to assess the correlations between invasively measured gradients and clinical outcomes post TAVR.

Funding Acknowledgement

Type of funding sources: None.
Left ventricular hypertrophy secondary to Fabry disease: mechanical dispersion and arrhythmic burden
Authors: Menezes Fernandes R , Azevedo O , Cordeiro F , Lourenco A
Published: October 2021

Introduction

Fabry disease (FD) is an X-linked progressive and multisystemic disease, that could lead to left ventricular hypertrophy (LVH). Mechanical dispersion (MD) has been associated to risk of ventricular dysrhythmias and sudden death in several cardiomyopathies.

Purpose

To evaluate MD and arrhythmic burden in FD patients with and without LVH.

Methods

We conducted a prospective study encompassing FD patients followed in a Reference Center of Lysosomal Storage Disorders. All patients performed a complete echocardiographic evaluation, including left ventricular (LV) strain analysis by two-dimensional speckle tracking imaging. Clinical characteristics, echocardiographic parameters and 24h-holters results were analysed. FD patients were divided in two groups according to the presence or absence of LVH. Both groups were compared by Chi-square test for categorical variables and Student's T-test for continuous variables. The significance level was 0,05.

Results

A total of 91 FD patients were included, with 62,6% of female predominance and 36,3% of patients with LVH. Patients with LVH were older (63,6 vs 44,2 years-old; p<0,001), were predominantly male (60,6% vs 24,1%; p=0,001), had a larger prevalence of arterial hypertension (63,6% vs 10,3%; p<0,001), coronary heart disease and stroke (both 9,1% vs 0%; p=0,02). In FD patients with LVH, mean interventricular septum thickness was 16,4 mm, mean LV mass index was 157,7 g/m2, mean left atrial volume index was 34,4 ml/m2 and mean E/e' was 12,6, with 63,6% of these patients having diastolic dysfunction. Global longitudinal strain (GLS) was lower in patients with LVH (−15,6% vs −19,6%; p<0,001), with a higher base-to-apex longitudinal strain gradient (9,3% vs 6,5%; p=0,013). Global radial and circumferential strains were not statistically different between both groups. Interestingly, twist was higher in patients with LVH (17,5° vs 13,8°), despite the lower GLS, but it did not reach statistical significance (p=0,077). MD was higher in patients with LVH (72,4 vs 38,3 ms; p<0,001), as well as the prevalence of premature ventricular contractions (PVC) (93,8% vs 61,8%; p=0,001). Non-sustained ventricular tachycardia (NSVT) was also more prevalent in patients with LVH (18,8% vs 9,1%), although not reaching statistical significance (p=0,191).

Conclusion

FD patients with LVH present lower GLS, with a higher base-to-apex longitudinal strain gradient and higher MD, compared to FD patients without LVH. Although PVC were significantly more frequent in FD patients with LVH, NSVT were not statistically different between both groups.

Funding Acknowledgement

Type of funding sources: None.
Mortality in patients with isolated congenital complete atrioventricular block in Sweden: a register-based, nationwide cohort study
Authors: Shao Y , Kok W , Eriksson P , Johansson B , Dellborg M , Mandalenakis Z
Published: October 2021

Purpose

The congenital heart block is a rare but potentially serious heart conduction disease and associated with high mortality during the fetal or neonatal periods. Earlier reports are based on relatively small number of patients and there are limited data about long-term outcomes.

Methods

Data were collected from the Swedish Patient and Cause of Death register to identify all patients who were born and diagnosed with isolated congenital complete atrioventricular block (CCAVB) between 1970 and 2017. Each patient with isolated CCAVB was matched with 10 control individuals, by birth year and sex from the Total Population Register.

Results

Totally 506 patients with CCAVB and 5,050 controls included in the study (55.3% males). The incidence rate of mortality in patients with isolated CCAVB was 166 per 10.000 person-years. The overall risk of mortality in patients with isolated CCAVB was 45.4 times (95% confidence interval (CI) 32.7–62.9) higher compared to matched controls. In a subgroup investigation, the highest risk of mortality was found in patients with isolated CCAVB from birth until the age of 17 (hazard ratio 80.8, 95% CI 51.6–126.4), compared to matched controls without CCAVB.

Conclusion

In this nationwide cohort study, patients with isolated CCAVB was associated with more than 40-fold risk for overall mortality compared to age and sex matched controls. The greatest risk was found during childhood. Regularly follow-up in tertiary centers and the aware of high risk of complications may be the key to prevention.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swedish Government, the Swedish Research Council
Anomalous origin of the right coronary artery with interarterial course: red flag or innocent bystander?
Authors: Albuquerque F , De Araujo Goncalves P , Ferreira A , Lopes P , Dores H , Marques H , Freitas P , Goncalves M , Cardim N
Published: October 2021

Aims

Anomalous origin of the right coronary artery from the opposite sinus (right-ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomography angiography (CCTA) has led to increasing recognition of this condition, even among healthy individuals. Our study sought to examine the prevalence, anatomical characteristics and outcomes of right-ACAOS with IAC in patients undergoing CCTA for suspected coronary artery disease (CAD).

Methods and results

We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital from January 2012 to December 2020. Right-ACAOS with IAC patients were analyzed for cardiac symptoms and long-term occurrence of first MACE (SCD, non-fatal myocardial infarction (MI) or revascularization of the anomalous vessel). CCTAs were reviewed for anatomical high-risk features and concomitant CAD. Among 10928 patients referred for CCTA, 28 patients with right-ACAOS with IAC were identified. Mean age was 55±17 years, 64% were male and 11 (39.3%) presented with stable cardiac symptoms. Most patients had at least one high risk anatomical feature. During follow-up, there were no CV deaths or aborted SCD episodes and only 1 patient underwent surgical revascularization of the anomalous vessel.

Conclusion

Right-ACAOS with IAC is an uncommon finding (prevalence of 0.26%). In a contemporary population of predominantly asymptomatic patients who survived this condition well into adulthood, most patients were managed conservatively with a low event rate. Additional studies are needed to support medical follow-up as the preferred option in this setting.

Funding Acknowledgement

Type of funding sources: None.
Screening for Fontan-associated liver disease: are we doing enough?
Authors: Tsoi V , Mitropoulou P , Chatterjee K , Lwin M , Salmon A , Smith L , Fitzsimmons S , Kyi N , Carroll A
Published: October 2021

Introduction

Fontan-associated Liver Disease (FALD) is an extracardiac complication with a substantial disease burden that can reduce quality of life, increase healthcare demand and result in premature mortality. Effective FALD screening is paramount in preventing late-stage complications.

Purpose

To assess the adherence of a tertiary adult congenital heart disease referral centre to FALD screening.

Methods

1. A total of 256 Fontan patients reviewed at our centre between 1st January 1977 and 31st December 2020 were identified from the congenital cardiac surgical database and the adult congenital heart disease clinical nurse specialist database.

2. The following patients were excluded: aged under 18 years on 31st December 2020 (103 cases), out of region or loss to follow-up (35 cases), death (30 cases), cardiac or liver transplantation (4 cases) and Fontan takedown (3 cases.) The mean endpoint (death, transplant or Fontan takedown) was 30 years.

3. The final study population included 81 patients.

4. Data was collected by review of clinic letters, blood test and imaging results from electronic records between 1st January 2018 and 31st December 2020.

5. The data were analysed to determine whether the screening recommendations from “Fontan-Associated Liver Disease: Proceedings from the American College of Cardiology Stakeholders Meeting, October 1 to 2, 2015, Washington DC” (ACC Stakeholders Meeting) were performed.

Results

The ACC Stakeholders Meeting recommended history taking and physical examination at least once a year with Fontan blood tests (full blood count, urea and electrolytes, liver function tests, alpha-fetoprotein and international normalized ratio) and imaging (abdominal ultrasound, computerised tomography or magnetic resonance imaging) at least once every three years.

Of the 81 patients (47 male, mean age 27±8.3 years), the mean age of Fontan completion was 6.6±5.3 years. The mean follow-up period since Fontan completion was 20±8.1 years. History taking and physical examination were documented in 84% (68/81) and 79% (64/81) of patients respectively. 60% (59/81) had a full set of Fontan blood tests taken which increased to 73% (49/81) if alpha-fetoprotein was excluded while imaging was performed in 80% (65/81) of cases.

Overall, 46% (37/81) cases had abnormal Fontan blood test or imaging. Hepatology referral was made in only 21% (17/81) of cases and MELD-XI score was not documented.

Conclusions

FALD screening tests were frequently underperformed compared to international guidance. Adherence may be improved by 1) promoting a Fontan blood test bundle; 2) implementing a standardised letter template which includes an investigation date list; 3) advocating MELD-XI score; and 4) exploring a joint cardiac and hepatology Fontan clinic.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Effects of varying shear stress profiles on the regulation of pulmonary artery endothelial cell gene expression: a focus on selected mediators of vascular tone, inflammation and angiogenesis
Authors: Mahomed A S , Burke-Gaffney A , Toe Q , Naser J , Quinlan G J , Wort S J
Published: October 2021

Background

Pulmonary arterial hypertension (PAH) is a complex pathology characterized by obliterative vascular remodeling that leads to right heart failure and death. Predisposition to PAH is associated with mutations in the BMPR2 gene in approximately 70–80% of familial cases and around 30% for that of sporadic PAH. The study of the pathogenetic basis of PAH is often performed in static endothelial cultures. Such two-dimensional, isolated cell microenvironments fail to consider the heterogeneity in mechanical stress acting on endothelial cells in various regions of the pulmonary vascular tree. In the remodeled pulmonary vasculature, low and oscillatory shear stress is observed in the proximal pulmonary artery with high shear stress in distal pre-capillary pulmonary arterioles. Therefore, the impact of varied shear profiles (including both laminar and oscillatory flow) on pulmonary artery endothelial cell (and that of BMPR2-deplete) gene expression of common vasoactive (EDN1, ENOS), proinflammatory (IL6, IL8) and angiogenic mediators (ANG2, VEGFA), are poorly described.

Purpose

To evaluate the effects of shear stress magnitude, including unidirectional and oscillatory flow on BMPR2-knockdown human pulmonary artery endothelial cell (HPAEC) gene expression of EDN1, ENOS, IL6, IL8, ANG2 and VEGFA.

Methods

HPAECs were transfected with siRNA directed against BMPR2 (siB2) or with a non-targeting control (siCon). Cells were exposed to 10 hours of laminar or oscillatory flow (1Hz; 1.5 dyn/cm2, 15 dyn/cm2 or 90 dyn/cm2) using a parallel-plate fluid flow chamber system. Measurement of mRNA expression was performed using qPCR.

Results

Shear stress intensity and flow type (unidirectional and oscillatory) mediated diverse effects on HPAEC gene expression across the markers studied. Changes in gene expression were calculated relative to that of static siCon-transfected HPAECs and in such a manner are summarized as fold changes in the table below. Asterisks are shown where significant fold differences are reported. *P≤0.05, **P≤0.01, ***P≤0.001, ****P≤0.0001. aP≤0.05, bP≤0.05, cP≤0.05, denote comparisons between groups. Of note, no significant differences in gene expression were observed between static siCon and static siB2.

Conclusions

For the markers studied, different magnitudes of shear stress and flow profiles (together with BMPR2 loss) exhibit varied patterns of gene expression in the pulmonary vascular endothelium. As such, this illustrates the need for wider study of in vitro endothelial-shear stress interactions in understanding mechanisms of remodeling in PAH.

Funding Acknowledgement

Type of funding sources: None. Table 1
Pulmonary artery capacitance a simple and novel prognostic variable in acute pulmonary embolism
Authors: Quintero-Martinez J A , Cordova S N , Alam M M , Jain V , Vlazny D T , Houghton D E , Casanegra A I , Wysokinski W E , Villarraga H R
Published: October 2021

Background

The non-invasive calculation of right ventricular hemodynamics such as the pulmonary artery capacitance (PAC) has proven to be feasible and easy to perform. The simplified pulmonary embolism severity index (sPESI) and pulmonary vascular resistance (PVR) are other prognostic tools that have been used in the past.

Purpose

To evaluate if baseline PAC can outperform PVR and sPESI to predict all-cause short-term mortality in patients with acute pulmonary embolism (PE).

Methods

373 patients with acute PE and a transthoracic echocardiogram performed within one day of diagnosis from March 2013 through June 2020 were followed prospectively. PAC was calculated as: Left ventricular stroke volume/ (Pulmonary artery systolic pressure – Pulmonary artery diastolic pressure). PVR was calculated as: Tricuspid regurgitant velocity / Right ventricular outflow tract velocity time integral x 10 + 0.16. The sPESI was used to evaluate prognosis by categorizing patients into low and high-risk categories. Multiple logistic regression analyses and receiver-operating characteristic curves were used to evaluate the ability of PAC, PVR, and sPESI to predict all-cause mortality up to six months. The Youden index was used to determine the cut-off value with the highest sensitivity and specificity. Kaplan–Meier curves were performed to determine event-free survival rate, differences between groups were assessed using the Wilcoxon Test.

Results

Mean age was 64±15 years (58% male, 28% cancer). PAC was associated with mortality at thirty days (p 0.0003), three months (p 0.003), and six months (p 0.011) (Table). PVR was associated with mortality at thirty days, three months, and six months (p 0.045, 0.012, and 0.031 respectively). The sPESI score ≥1 (high risk) was associated with all-cause mortality at three months and six months (p 0.0136 and <0.0001 respectively). PAC was the strongest predictor of all-cause mortality with an AUC of 0.95 (CI 0.82- 0.99) at thirty days, 0.84 (CI 0.65–0.99) at three months, and 0.77 (CI 0.57–0.96) for six months. Corresponding Kaplan-Meier survival curve of PAC and thirty days all-cause mortality is presented in the Figure. PVR had an AUC of 0.75 (CI 0.48–0.95) at thirty days, 0.79 (CI 0.58–0.94) at three months, and 0.72 (CI 0.50–0.90) at six months. The sPESI had an AUC of 0.62 (CI 0.54–0.66) at three months and 0.64 (CI 0.59–0.67) at six months.

Conclusion

In patients with acute PE, PAC outperforms sPESI and PVR as a predictor of short-term all-cause mortality at thirty days, three months, and six months. These three variables should be explored head to head prospectively for their utility to predict short term all-cause mortality.

Funding Acknowledgement

Type of funding sources: None.