bluuebunny/crossref_metadata_2025 huggingface dataset:
Aortic stenosis reexpanded – a novel approach to determine aortic valve area with phase contrast cardiovascular magnetic resonance imaging
Authors: Troger F , Lechner I , Reindl M , Tiller C , Holzknecht M , Pamminger M , Kremser C , Reinstadler S J , Bauer A , Metzler B , Mayr A , Klug G
Published: October 2021

Background

Transthoracic echocardiography (TTE) has become the diagnostic standard for evaluating aortic stenosis (AS) severity, mainly because of its advantages in comparison to the gold standard of cardiac catheterization. However, its inaccuracies in determining stroke volume (SV) and consequentially computing aortic valve area (AVA) call for a more precise and dependable method. Phase contrast cardiovascular magnetic resonance imaging (PC-CMR) is an aspiring tool to push these boundaries.

Purpose

The aim of this study was to validate a novel and simple approach based on PC-CMR against the invasive and echocardiographic determination of SV and AVA in patients with moderate and severe AS.

Methods

A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR; AVA by PC-CMR was determined via plotting momentary flow across the valve against momentary flow velocity. SV via CMR was measured directly via PC-CMR and volumetrically using cine images. Invasive SV and AVA were determined via Fick principle and Gorlin formula, respectively. TTE yielded SV and AVA using the continuity equation. Finally, gradients were calculated via the modified Bernoulli equation.

Results

SV by PC-CMR showed a strong correlation with cine-CMR with no significant bias (r: 0.730, p<0.001; SV by PC-CMR: 85±31ml; SV by cine-CMR: 85±19ml, p=0.829). Peak gradients determined by PC-CMR were 65±29mmHg and correlated inversely with AVA by PC-CMR (r: −0.371; p=0.008). Mean AVA during the whole systolic phase showed a moderate correlation (r: 0.544, p<0.001) to invasive AVA with a small bias (AVA by CMR: 0.78±0.25cm2 versus invasive AVA: 0.70±0.23cm2, bias: 0.08cm2, p=0.017). Inter-methodical correlation and bias of AVA as measured by TTE and invasive AVA (AVA by TTE: 0.81±0.23cm2, r: 0.580, p<0.001, bias 0.11cm2, p<0.001) were similar to AVA by PC-CMR and invasive AVA.

Conclusion

PC-CMR provides a great option to yield reliable and solid SV values in patients with moderate and severe AS. Furthermore, continuous determination of flow volumes and flow velocities is able to determine AVA in these patients in an easy and reproducible manner. Our novel approach shines a light on the diagnostic potential of PC-CMR for non-invasive AS grading, especially in cases where echocardiography reaches its limits and where clinical findings appear inconclusive.

Funding Acknowledgement

Type of funding sources: None. Central IllustrationCine (l,r) and PC-CMR (m) images in AS
Normal values for paediatric atrial volumes assessed by steady-state free-precession cardiovascular magnetic resonance
Authors: Voges I , Hinz S , Caliebe A , Boroni Gracioli S , Wage R , Gabbert D , Uebing A , Krupickova S
Published: October 2021

Background

Measurement of atrial volumes by steady-state free precession (SSFP)cardiovascular magnetic resonance (CMR) is becoming increasingly important in the treatment and follow-up of paediatric congenital heart disease. It has prognostic value in terms of heart failure and cardiovascular death. However, CMR normal values for the clinically often used mono- and biplane area-length method in children are lacking.

Aims

We sought to create paediatric normal values for atrial volumes using the mono- and biplane area-length method.

Methods

In a retrospective study design, CMR data sets of 157 healthy children with an age range between 4 and 18 years from two centers in the UK and Germany were evaluated. In a four-chamber (4ch-) view, left and right atrial (LA, RA) endocardial borders were segmented during end-diastole and end-systole to calculate minimal and maximal atrial volumes (LAmin, LAmax, RAmin, RAmax) using the monoplane area-length method. Additionally, end-diastolic and end-systolic LA endocardial borders were segmented in a two-chamber (2ch-) view. Using the measurements from the 2ch- and 4ch-views, minimal and maximal LA volumes were calculated using the biplane area-length method. Atrial volumes were normalized for body surface area (BSA in m2). Sex-specific reference curves were created using the lambda mu sigma method.

Results

The median age was 13.8±2.81 years (53 girls).

In children from 4–10 years average atrial volumes measured: monoplane 4ch: LAmin 10.2±3.5 ml/m2, LAmax 28.8±7.4 ml/m2, RAmin 14.1±6.3 ml/m2, RAmax 27.0±11.4 ml/m2; monoplane 2ch: LAmin 10.9±4.1 ml/m2, LAmax 27.0±6.1 ml/m2; biplane: LAmin 10.2±3.3 ml/m2, LAmax 27.4±5.7 ml/m2.

In children from 11–18 years average atrial volumes measured: monoplane 4ch: LAmin 13.6±4.9 ml/m2, LAmax 34.1±9.1 ml/m2, RAmin 19.2±6.8 ml/m2, RAmax 34.2±9.6 ml/m2; monoplane 2ch: LAmin 13.2±4.9 ml/m2, LAmax 31.4±9.7 ml/m2; biplane: LAmin 12.9±4.4 ml/m2, LAmax 31.8±8.8 ml/m2.

Separate centile charts and centile tables for boys and girls for all volumetric parameters were created.

Conclusion

We provide paediatric CMR reference values for atrial volumes. They can be used in the diagnosis and follow-up of congenital or acquired heart disease in children and for research purposes.

Funding Acknowledgement

Type of funding sources: None.
Comparison of direct oral anticoagulants to vitamin-K antagonists as treatment for leaflet thrombosis after Transcatheter Aortic Valve Implantation (TAVI)
Authors: Ferstl P , Marwan M , Achenbach S , Bittner D O
Published: October 2021

Introduction

Leaflet thrombosis can occur following transcatheter aortic valve implantation (TAVI). While a frequent finding in post-TAVI CT scans, leaflet thrombosis is usually clinically silent and the decision to initiate anticoagulation depends on clinical considerations. Best treatment is unknown. We compared the effectiveness of direct oral anticoagulants (DOAC) and vitamin K antagonists (VKA) to resolve leaflet thrombosis in patients with serial CT imaging following TAVI.

Methods

Consecutive TAVI patients who had undergone routine follow-up cardiac CT after TAVI procedures were screened for inclusion in this analysis. A total of 44 patients diagnosed with leaflet thrombosis and available follow-up CT after anticoagulation therapy were identified. Leaflet thrombosis on cardiac CT was defined as presence of hypoattenuated leaflet thickening with or without leaflet motion restriction, as previously described. The indication and type of anticoagulation was according to physician discretion. We compared patients on DOAC with patients on VKA therapy for the resolution of leaflet thrombosis.

Results

Mean age of the 44 patients was 80±6 years (59% men), and the median time interval from TAVI to index CT was 107 days (IQR: 91–189 days). Overall, 39 patients (90%) showed resolution of leaflet thrombosis with anticoagulation therapy, whereas leaflet thrombosis persisted in 5 patients (10%). Resolution of leaflet thrombosis was seen in 26 out of 30 (87%) patients receiving VKA and in 13 out of 14 (93%) patients receiving DOAC, respectively. Groups did not differ regarding age (p=0.97), cardiovascular risk factors (all p>0.1), creatinine levels (p=0.19) TAVI prosthesis type (p=0.54) and size (p=0.66). Also, no difference existed for duration of anticoagulation (median 103 vs. 110 days; p=0.76). The relative risk reduction for persisting leaflet thrombosis using DOACs was 46% in comparison to VKA, however with no statistical significance due to the limited number of patients (p=0.55).

Conclusion

Anticoagulation therapy resolves leaflet thrombosis after TAVI in the majority of patients. In our exploratory analysis, direct oral anticoagulants seem to be an effective alternative to vitamin-K antagonists. This result is hypothesis generating and needs to be confirmed in larger prospective trials.

Funding Acknowledgement

Type of funding sources: None.
Atrial longitudinal strain and new onset of atrial fibrillation in a cohort of hypertrophic cardiomyopathy patients
Authors: Llamas-Gomez H , Esteve Ruiz I , Romero Reyes M J , Navarro Valverde C , Molano Casimiro F J
Published: October 2021

Introduction

Several studies associate atrial fibrillation (AF) presence with a poor prognosis and quality of life in hypertrophic cardiomyopathy (HCM) patients. Detecting and treating AF in time prevents important comorbidities and fatal events as it is cardioembolic stroke.

Several clinical factors have been associated with AF onset, but, is there any echocardiographic parameter that helps to predict it?

Some studies associate low longitudinal auricular strain (ALS) with AF onset in other cardiopathies, like aortic valve replacement.

Purpose

The aim of this study is to analyze auricular longitudinal strain in a HCM cohort and its relation with AF onset.

Methods

Prospective study of a cohort of 146 HCM patients. We obtained the mean value of auricular longitudinal strain (ALS) in AF patients and, afterwards, we separated non-AF patients in two groups depending on this ALS mean value. We analyzed the development of AF and clinical outcomes during the follow-up from 2017 to 2020.

Results

At the beginning of the follow-up, 42 patients had AF, 50% were males, 57% had high blood pressure, 26% diabetes, 50% dyslipidemia 14% chronic renal disease, and 2% COPD. HCM risk-score SCD mean value was 2.53 (1.56–4.71).

Echocardiographic values are represented in table 1.

When comparing AF and non-AF patients, we found statistically significant differences in LA diameter and ALS. Mean ALS value in AF patients was 13%.

We followed-up the remaining 104 patients without AF during a mean time of 36±5 months. 10.6% of them developed AF during follow-up, mean time until apparition of AF 26 months (8–29).

We evaluated clinical characteristics in both groups (new AF onset or not), without significant differences between them, including LA diameter and volume. The only variable statistically associated with AF onset was ALS <13% (p=0.009, OR 10).

Patients with new onset of AF had more hospitalizations due to heart failure (p=0.025, OR 8).

Conclusions

We suggest that in our cohort of HCM patients, ALS<13% can predict AF onset during follow-up, regardless left atrial enlargement. This can help to detect quickly the arrhythmia so we can treat it and prevent important comorbidities and fatal events.

Funding Acknowledgement

Type of funding sources: None. Table 1Graphic 1
Sex difference in aortic valve fibrosis assessed by contrast-enhanced computed tomography in severe aortic stenosis
Authors: Myasoedova V , Fraschini E , Mostardini G , Bonfanti L , Chiesa M , De Pasquale C , Olivares P , Trabattoni D , Bartorelli A L , Andreini D , Poggio P
Published: October 2021

Background

Aortic stenosis (AS) is characterized by fibro-calcific remodeling of aortic valve leaflets. Progressive aortic valve calcification (AVC) occurs in both sexes and cardiac computed tomography (CT) is recognized as a high-quality technique for AVC evaluation. To date, sex-specific CT thresholds of AVC have been implemented in clinical practice since it is now recognized that women have less AVC burden than men. In addition, recent evidences indicate that women have more fibrotic remodeling of aortic valve leaflet compared to men.

Purpose

Aortic valve fibrosis (AVF) being a significant contributor to valve gradient, we sought to evaluate the difference in AVF burden between men and women with severe AS using contrast-enhanced CT.

Methods

We included 56 patients matched for age and sex with severe AS. All patients underwent Doppler echocardiography and cardiac CT before intervention. Contrast attenuation values (Hounsfield Units, HU) and contrast-to-noise ratio were measured at the level of the ascending aorta. Total AVF was assessed based on HU ranging between 30 and 350, adjusting the upper threshold by increments of 25 HU in either direction until blood pool was not highlighted. Indexed contrast-enhanced CT calcium volume (iAVC) and fibrosis volume (iAVF) were calculated dividing the volumes by the aortic annular area. Fibro-calcific ratio was calculate dividing iAVF by iAVC volumes.

Results

There was no difference between men and women in major cardiovascular risk factors, valve phenotype (bicuspid vs. tricuspid), nor pharmacological treatment. Men had higher body surface area than women (1.89±0.14 vs. 1.67±0.17 m2, respectively; p<0.001), while women had lower aortic valve area than men (AVA; 0.74±0.2 vs. 0.91±0.2 cm2, respectively; p=0.007) but similar indexed AVA (0.44±0.15 vs. 0.48±0.12 cm2/m2, respectively; p=0.262). Women had significantly lower iAVC compared to men (36 [36–72] vs. 72 [67–123] mm3/cm2, respectively; p=0.03). However, iAVF was significantly higher in women compared to men (83 [78–123] vs. 63 [58–83] mm3/cm2, respectively; p=0.006). Finally, the fibro-calcific ratio, which indicates the predominance of valve fibrosis if >1.0, was significantly higher in women compared to men (2.57 [2.14–7.02] vs. 0.78 [0.84–2.02], respectively; p=0.003).

Conclusions

Our study highlights for the first time a sex difference in the fibrotic content of severe AS evaluated by contrast-enhanced CT. These findings might be valuable to promote further studies on the role of sex-specific tissue composition in AS progression and outcomes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fondazione Gigi e Pupa Ferrari ONLUS
Outcomes of transctheter mitral valve repair in a large urban US health system
Authors: Hahn J , Hassan Virk H , Greason K , Al-Azza F , Krittanawong C
Published: October 2021

Background

Transcatheter mitral valve repair (TMVR) has become an important minimally invasive alternative to open surgical repair in patients with severe mitral regurgitation. As TMVR develops as an established practice, real-world outcome data is needed to guide clinical decision making as the body of literature on this topic is limited. In our study, we investigate TMVR outcomes in a large urban health system.

Methods

We retrospectively analyzed clinical data from the electronic health records of the extensive urban health system Mount Sinai Data Warehouse and analyzed all individuals who underwent TMVR. Baseline demographics were obtained as well as significant morbidity and mortality outcomes. Finally, multivariable analysis was used to determine associated characteristics with mortality.

Results

We identified 3533 patients who underwent TMVR from 2008 to 2018. The overall mortality was 3.7%. The most common comorbidities observed were heart failure (56%), pulmonary hypertension (26%), atrial fibrillation (26%) and CKD or ESRD (16%). After multivariable analyses, ischemic stroke (adjusted OR 3.46; 95% CI 1.93–5.97, p = <0.001), CKD or ESRD (3.95; 2.72–5.75, p 0.01), aortic stenosis (2.23; 1.12–4.15, p<0.001), and heart failure (8.18; 4.16–18.5, p<0.001) were independently associated with mortality.

Conclusion

In all patients who underwent TMVR at a large urban health system, ischemic stroke, aortic stenosis, heart failure, CKD and ESRD were independently associated with mortality. Future prospective studies will be needed to further define these observed associations.

Funding Acknowledgement

Type of funding sources: None.
Trends in mortality from aortic stenosis in Europe: 2000–2017
Authors: Hartley A , Hammond-Haley M , Marshall D C , Salciccioli J D , Malik I , Khamis R Y , Shalhoub J
Published: October 2021

Background

Trends in mortality from aortic stenosis across Europe are not well understood, especially given the significant growth in transcatheter aortic valve replacement (TAVR) in the last 10 years.

Purpose

To describe trends in mortality from aortic stenosis in European countries from 2000 to 2017.

Methods

Age-standardised death rates were extracted from the World Health Organisation Mortality Database, using the International Classification of Diseases 10th edition code for non-rheumatic aortic stenosis for those aged >45 years between 2000 and 2017. The UK and countries from the European Union with at least 1,000,000 inhabitants and at least 50% available datapoints over the study period were included: a total of 23 countries. Trends were described using Joinpoint regression analysis.

Results

No reductions in mortality were demonstrated across all countries 2000–2017 (Figure 1). Large increases in mortality were found for Croatia, Poland and Slovakia for both sexes (>300% change). Mortality plateaued in Germany from 2008 in females and 2012 in males, whilst mortality in the Netherlands declined for both sexes from 2007. Mortality differences between the sexes were observed, with greater mortality for males than females across most countries.

Conclusions

Mortality from aortic stenosis has increased across Europe from 2000 to 2017. There are, however, sizable differences in mortality trends between Eastern and Western European countries. Significant plateauing or declining mortality was observed for recent years in countries with greater access to TAVR, whilst increasing trends were observed in countries with the least TAVR use. The need for health resource planning strategies to specifically target AS, particularly given the expected increase with aging populations, is highlighted.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Joinpoint regression analysis for trends in age-standardised death rates from non-rheumatic aortic stenosis for those aged >45 years in Europe from 2000 to 2017. Clear squares indicate males; filled circles indicate females. The lines (dotted for males, solid for females) represent modelled trends based on joinpoint data.
Comparison of suture-based and collagen-based vascular closure devices for large bore arteriotomies- an updated meta-analysis of bleeding and vascular complications
Authors: Sohal S S , Kurpad K K , Kaur K K , Wasty N W , Tayal R T
Published: October 2021

Background

Large bore access procedures such as transcatheter aortic valve replacement or mechanical circulatory support devices rely on percutaneous vascular closure devices to minimize access site complications. Suture-based vascular closure devices (S-VCD) have been readily used but recently newer generation collagen-based vascular closure devices (C-VCD) have been introduced to ensure minimally invasive nature of large bore devices and prevent vascular and bleeding complications at the access site. However, large population data on outcomes of these devices is lacking.

Purpose

To compare the bleeding and vascular complications of suture-based and collagen- based vascular closure devices for large bore access.

Methods

PubMed was searched for articles on vascular closure devices using keywords, (“Vascular closure devices”) AND (“bleeding OR vascular complications”) that resulted in a total of 456 studies. Studies were included if bleeding or vascular complications as defined by Valve Academic Research Consortium-2 (VARC-2) were compared between the two types of VCDs. 6 (5 observational and 1 Randomized controlled trial) studies met the inclusion criteria. The event level data was pooled across trials to calculate Odds Ratio (OR) with 95% CI and analysis was done using Review Manager 5.4 (RevMan 5.4). Random effect model was used in RevMan 5.4 for the analysis and p value of <0.05 was deemed significant.

Results

Pooled analyses from these 6 trials resulted in a total of 1,307 patients, out of which 550 received C-VCD and 757 received S- VCD. Among the patients who received C-VCD, the bleeding complications (major and minor) were non significantly lower than in patients who received S-VCD ((OR: 0.71 (0.33–1.53), p=0.38, I2=47%), (OR: 0.78 (0.40–1.50), p=0.45, I2=52%)). The vascular complications (major and minor) in patients who received C-VCD were similar to patients who received S-VCD ((OR: 0.85 (0.47–1.54), p=0.59, I2=0%), (OR: 0.92 (0.38–2.22), p=0.86, I2=37%)) (Picture 1 and Picture 2).

Conclusions

Bleeding and vascular complications after large bore arteriotomy closure with collagen based vascular closure devices are similar to suture based vascular closure devices. Therefore, collagen-based devices seem to be a feasible option to obtain hemostasis in large bore arteriotomies without increasing risk for vascular complications.

Funding Acknowledgement

Type of funding sources: None.
Impact of mitral valve anatomy suitability in echocardiographic and clinical evolution in patients referred for percutaneous edge-to-edge repair
Authors: Salinas Gallegos A , Pozo Osinalde E , Gordillo X , Jimenez Quevedo P , Mahia P , Marcos-Alberca P , Tirado G , Islas F , Macaya C , Perez-Villacastin J , Fernandez-Ortiz A , Nombela-Franco L , De Agustin J A
Published: October 2021

Background

Percutaneous edge-to-edge mitral repair has become an effective therapeutic alternative to surgery in high-risk patients with moderate-to-severe mitral regurgitation (MR). A traffic light system has been proposed to evaluate echocardiographic suitability for this therapy. However, few data is available regarding prognostic impact of these criteria.

Purpose

To study the impact of imaging eligibility classification in echocardiographic and clinical evolution.

Methods

We evaluated all the consecutive patients who underwent percutaneous mitral repair with the MitraClip system between 2010 and 2020 in our tertiary university hospital, excluding the redo procedures (n=1). Imaging eligibility classification was blindly made by two experts in structural heart disease. Pre and posprocedural echocardiographic measurements were reassessed and clinical events were collected from medical records.

Results

87 patients (65.5% males) with a mean age of 76±10 years were finally included. Regarding mitral valve disease, 13 (14.9%) was graded as moderate-to-severe whereas 74 (85.1%) was considered severe. MR etiology was: functional 44.8%, organic 34.5% and mixed 20.7%. Prior to the procedure the NYHA class was III or higher in 88.5% and LVEF was 44.4±15.4%. Eligibility criteria was: green (44, 50.6%), yellow (39, 44.8%) and red (4, 4.6%). The later patients, with theorical contraindication for the procedure, were excluded from analysis. Although less number of clips were needed in green morphology (1.14 vs 1.46; p=0.01), pulmonary vein flow improved more markedly (Table) in these patients. This resulted only in a slightly greater reduction in MR grade at 6 months (−2.5 vs −1.9; p=0.008). No differences were noted in follow up absolute MR grade or changes in ventricular volumes, LVEF or pulmonary artery systolic pressure. Moreover, there was no impact in MACE during the evolution.

Conclusion

Excluding contraindicated group, no relevant echocardiographic or clinical impact was noted regarding eligibility criteria for percutaneous edge-to-edge mitral repair. Thus, suboptimal patients may equally benefit from this therapy even in moderate-volume centers.

Funding Acknowledgement

Type of funding sources: None. Table 1. Postprocedural pulmonary vein flow pattern in relation with eligibility criteria
Severity of tricuspid regurgitation (TR) only based in echo parameters? The failure of guidelines. The 4A in patients with significant TR as a new clinical score to evaluate patients with TR
Authors: Gonzalez Gomez A , Hinojar R , Garcia Sebastian C , Garcia Martin A , Monteagudo J M , Fernandez-Golfin C , Zamorano J L
Published: October 2021

Background

Significant Tricuspid Regurgitation (TR) is associated with increased morbi-mortality. Symptoms due to TR are often insidious and not always characterized by dyspnea. Identification of symptoms and optimal timing for intervention is challenging and intervention is often preformed late. A more specific clinical classification focused on the detection of systemic congestion may help identify those who may benefit from an earlier intervention.

Purpose

To evaluate the prognostic impact of a new proposed “4A” clinical score: Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia, in patients with significant TR.

Methods

Consecutive patients in stable clinical condition evaluated in the Heart Valve Clinic with significant TR (moderate to severe, severe, massive or torrential TR) were included. Signs and symptoms of Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia (“4A score”) where registered, follow up was performed every 6 months. The 4A clinical score ranged from 0 (no A) to 4 (all four A's present). The difference in the 4A score between the first and last visit was determined. A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined.

Results

86 patients were included in this study (age 76±11 years, 70% female, 87% functional TR). At first visit, 92% were in NYHA class I or II and 77% had a 0 or 1 “4A score”. After a median follow-up of 24 months (IQR: 11–35 months), “4A score” was significantly impaired (score mean difference: 0.42±0.8) and only 59% remained with a 0 or 1 “4A score”. 32.6% of the patients (n=28) experienced the combined endpoint. The change in 4A score was a significant predictor of events (hazard ratio per unit 1.88 [1.22–2.88], p=0.004)

Conclusion

We demonstrate for the first time a new clinical score predictive of right heart failure and death in patients with significant TR.

Funding Acknowledgement

Type of funding sources: None.
SHARPEN score: an independent predictor of survival after infective endocarditis discharge
Authors: Pivatto Junior F , Sganzerla D , Terra D H , Filippini F B , Seroiska G , Dannenhauer G P , Bischoff H M , Birk L F S , Alves S G , Miglioranza M H
Published: October 2021

Background

Infective endocarditis (IE) presents high mortality even in patients that were adequately treated. Proper identification of these patients is imperative for better care delivery. SHARPEN score (Systolic BP, Heart failure, Age, Renal function, Pneumonia, Elevated peak CRP, and Non-intravenous drug abusers) was validated to predict in-hospital mortality due to IE; its performance in predicting survival after hospital discharge, however, has not yet been evaluated.

Purpose

To assess the SHARPEN score in predicting survival after hospital discharge due to IE.

Methods

Retrospective cohort study including all patients ≥18 years discharged after definitive IE (modified Duke criteria) admission at a public tertiary teaching hospital in southern Brazil, between 2000–16. Only the first hospitalization for IE was considered in those patients with >1 admission for that reason in the studied period. The SHARPEN score was calculated at admission, and each patient was classified as low-moderate (2–10 points) or high (11–20 points) risk. Follow-up was carried out through the review of medical records, and the assessed outcome was death by any cause. Survival analysis was performed using the Kaplan-Meier curves, which were compared using the Log-rank test.

Results

A total of 135 patients (mean age: 53±17 years, 97 [72%] male) were discharged after IE episode. Staphylococcus aureus was the main etiologic agent (29 [21.5%]), and cardiac surgery was performed in 54 (40%) patients. The median SHARPEN score was 9 (IQR: 7–11 points), being classified as low-moderate risk (96 [71%]) and high risk (39 [29%]) patients, respectively. Median post-discharge follow-up was 3.4 (IQR: 0.19–9) years (682 patient-years), with 37 deaths during the period. Mean post-discharge survival was 12.4 years (95% CI: 10.7–14), significantly higher in patients classified as low-moderate risk (13.7 years) in comparison to high risk (8.4 years) (Log-rank P=0.006; Figure).

Conclusion

Patients classified as high-risk by SHARPEN score during IE admission present significantly higher mortality after discharge, despite being effectively treated for the IE episode. SHARPEN score could also be used to assess morbimortality after discharge, helping to implement special care programs for high-risk patients.

Funding Acknowledgement

Type of funding sources: None.
Epidemiology of infective endocarditis in Hong Kong, 2000–2019
Authors: Li H L , Yu S Y , Tse Y K , Wu M Z , Ren Q W , Tse H F , Yiu K H
Published: October 2021

Background/Introduction

Despite improvements in diagnostic and therapeutic strategies, the mortality and morbidity of infective endocarditis (IE) remain high. The incidence, outcomes, and surgical intervention of IE, particularly in an Asian population, are poorly understood and characterised, and the effect of antibiotic prophylaxis guidelines revision on the incidence of IE remains unexplored.

Purpose

We aim to describe temporal changes in the epidemiology and surgical intervention for IE in Hong Kong in the past 2 decades.

Methods

From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. The temporal trends in the incidence of IE, rate of surgical intervention, and mean Charlson Comorbidity Index (CCI) were characterised using Poisson regression analysis and expressed in annual percentage change (APC [95% CI]). Interrupted time series analysis was used to evaluate the change in incidence after the revision of antibiotic prophylaxis guidelines. The association between surgical intervention and mortality was evaluated using propensity score analytics. Temporal trends in 1-year all-cause mortality were evaluated using multivariable Cox regression.

Results

A total of 5,657 patients (59.9±18.3 years, 37.2% females) were included. The crude incidence remained was stable from 2000 to 2019 (APC 0.1% [−0.5 to 0.7], P=0.675), and remained unchanged following the revision of antibiotic prophylaxis guidelines in 2008 (relative risk of change 0.90 [0.64 to 1.00], P=0.065) (Figure 1). Concordant with an increase in the mean age of IE patients (APC 0.9% [0.8 to 1.1], P<0.001), the comorbidity burden grew substantially from 2000 (CCI 0.55±1.27) to 2019 (CCI 1.09±1.66).

The rate of surgical intervention significantly increased from 5.3% in 2000 to 17.8% in 2019 (APC 2.7% [1.1 to 4.3], P=0.004), and surgical intervention at 1 year was associated with a 45% risk reduction in 1-year all-cause mortality (Hazard Ratio 0.55 [0.46 to 0.65], P<0.001). Nevertheless, the crude all-cause mortality rate at 1 year increased from 27.4% in 2000 to 31.5% in 2019, with no significant trend after adjustment for demographics and comorbidities (APC −0.7% [−1.6 to 0.1], P=0.087).

Conclusions

In this large cohort of Asian patients, the incidence of IE remained static and did not change following the revision of antibiotic prophylaxis guidelines. Over time, patients with IE have evolved to be older and more comorbid. Despite an increasing rate of surgical intervention that conferred improved survival, the mortality of IE remained irresistibly high.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology
Plasminogen activator inhibitor-1 (PAI-1) is anti-fibrogenic in human inflammatory cardiomyopathy
Authors: Baumeier C , Escher F , Pietsch H , Aleshcheva G , Schultheiss H P
Published: October 2021

Background/Introduction

Preclinical data indicate that plasminogen activator inhibitor-1 (PAI-1) is cardioprotective by repressing cardiac fibrosis through TGF-β and plasminogen mediated pathways. In addition it is linked to the recruitment and polarization of non-classical M2 macrophages in cancer.

Purpose

The role of cardiac PAI-1 in fibrogenesis and macrophage polarization is investigated in patients with dilated cardiomyopathy (DCM) and inflammatory dilated cardiomyopathy (DCMi).

Methods

We retrospectively analyzed endomyocardial biopsies (EMBs) of patients with DCM (n=27) and DCMi (n=149) for PAI-1 expression, number of activated myofibroblasts and M1/M2 macrophage polarization.

Results

Patients with high-grade DCMi (DCMi-high, CD3+ lymphocytes >30 cells/mm2) had significantly increased PAI-1 levels compared to DCM and low grade DCMi patients (DCMi-low, CD3+ lymphocytes = 14 - 30 cells/mm2) (15.5±0.4% vs. 1.0±0.1% and 4.0±0.1%, p≤0.001). Elevated PAI-1 expression in DCMi-high subjects was accompanied by a reduced number of alpha smooth muscle actin (α-SMA) positive myofibroblasts and an increased number of CD16+ CD68+ M2 macrophages, indicating anti-fibrogenic and M2 macrophage-favoring properties of PAI-1 in DCMi.

Conclusion

Our findings give evidence that elevated expression of PAI-1 suppresses cardiac fibrosis and promotes M2 macrophage polarization. Thus, PAI-1 could serve as a potential prognostic biomarker of cardiac fibrosis and inflammation, as well as possible therapeutic target in inflammatory cardiomyopathies.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ERA-Net on Cardiovascular Diseases (ERA-CVD) of the German Research Foundation (DFG)Transregional Collaborative Research Center “Inflammatory Cardiomyopathy-Molecular Pathogenesis and Therapy”
Serum autotaxin level predicts future cardiac events in patients with dilated cardiomyopathy
Authors: Araki T , Okumura T , Mizutani T , Kimura Y , Kazama S , Shibata N , Oishi H , Kuwayama T , Hiraiwa H , Kondo T , Morimoto R , Takefuji M , Murohara T
Published: October 2021

Background

Autotaxin (ATX) has been reported to promote myocardial inflammation and subsequent cardiac remodeling through lysophosphatidic acid (LPA) production. However, the prognostic impact of ATX has not been clarified in dilated cardiomyopathy (DCM).

Purpose

We aimed to investigate the prognostic impact of ATX in patients with DCM.

Methods

We enrolled 104 DCM patients (49.8 years, 76 males). The subjects underwent blood sampling, echocardiography, cardiac catheterization, and endomyocardial biopsy. Gender differences in serum ATX levels have been reported, thus we divided the subjects into two groups using median serum ATX levels for men and women: High-ATX group and Low-ATX group. All patients were followed up by expert cardiologists. The cardiac event was defined as a composite of cardiac death and hospitalization for worsening heart failure.

Results

Eighty-nine percent of the subjects were classified as New York Heart Association functional class I or II. Female patients had higher serum ATX levels than male patients, with median values of 257.0 ng/mL and 203.5 ng/mL, respectively (Figure A). The average left ventricular ejection fraction and brain natriuretic peptide levels were 30.6% and 122.5 pg/mL. In survival analysis, cumulative event-free probability was significantly lower in High ATX group (p=0.007, Figure B). In Cox proportional hazards analysis, High-ATX was one of the independent predictors of composite cardiac events (Hazards Ratio, 2.575; p=0.043). On the other hand, high sensitive C-reactive protein and collagen volume fraction in myocardial samples were not significant predictors.

Conclusion

High serum ATX level was associated with poor prognosis in patients with DCM.

Funding Acknowledgement

Type of funding sources: None. Gender difference in autotaxin levelsSurvival analysis of cardiac events
Neutrophil-to-lymphocyte ratio and monocyte-to-lymphocyte ratio predict length of hospital stay in acute myocarditis
Authors: Schmutzler L , Mirna M , Topf A , Hoppe U C , Lichtenauer M
Published: October 2021

Background

Neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) are associated with the severity of various diseases, for example sepsis and coronary artery disease. So far, these ratios have not been described in patients diagnosed with myocarditis. The aim of this study was to demonstrate the relationship of NLR and MLR with the severity of acute myocarditis.

Materials and methods

224 consecutive patients with myocarditis were retrospectively enrolled in this study. Laboratory parameters and clinical data were extracted from hospital records and discharge letters.

Results

Median NLR was 2.48 (IQR 1.51–4.71) and median MLR was 0.42 (IQR 0.29–0.58). NLR and MLR correlated with HF, CRP and leukocyte count. NLR further correlated with pBNP (rs= 0.390, p=0.037) and inversely with oxygen saturation (rs=−0.620, p=0.042), whereas MLR correlated inversely with LV systolic function (rs=−0.386, p=0.018). Both ratios correlated better with length of hospital stay (NLR: rs= 0.450, p=0.001, MLR: rs= 0.547, p<0.0001) than CRP, leukocyte count, troponin, CK or pBNP. In multiple linear regression analysis, a model with eGFR and MLR achieved the best predictive ability for length of stay (adj. R2= 0.61, p<0.0001). AUCs for the prediction of prolonged hospital stay (NLR= 0.79, MLR= 0.82), and optimal cut-offs therefor were calculated (NLR= 4.00 (sens.: 68%, spec.: 84%), MLR= 0.48 (sens.: 79%, spec.: 78%)). Patients who met the combined endpoint of in-hospital complications showed a higher NLR, however, this remained statistically insignificant (NLR: median 3.59 (IQR 1.60–10.13) vs. 2.49 (IQR 1.51–4.60), p=0.288).

Conclusion

NLR and MLR correlated with the length of stay, as well as with several clinical and laboratory parameters in patients with myocarditis. Since white blood cell differentials are relatively easy and fast to perform, both ratios could facilitate further risk stratification in patients with acute myocarditis.

Funding Acknowledgement

Type of funding sources: None.
Does age influence follow-up after alcohol septal ablation in hypertrophic obstructive cardiomyopathy?
Authors: Batzner A , Aicha D , Pfeiffer B , Neugebauer A , Seggewiss H
Published: October 2021

Introduction

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiac disease. Since its introduction in 1995 alcohol septal ablation (PTSMA) was discussed as treatment option only in elderly patients with symptomatic obstructive HCM (HOCM). We report on long-term follow-up after PTSMA with respect to patient's age.

Methods and results

Between 5/2000 and 6/2017 we treated 952 consecutive symptomatic HOCM patients (pts) with first PTSMA in our center. 132 (13.9%) pts were <40 years of age (Group A; mean age 30.3±7.7), 421 (44.2%) pts between ≥40 to <60 years of age (Group B; mean age 50.5±5.9) and 399 (41.9%) pts ≥60 years of age (Group C; 69.6±6.3). Family history (FH) of HCM was more often seen in Group A (50% vs. 25.7% (B) and 13.3% (C); p<0.ehab724.17611) as FH of sudden cardiac death (SCD) (17.4% vs. 11.2% (B) and 7.0% (C); p<0.01). Pts in Group C were more often in NYHA class III/IV (80.7%; p<0.001 each) compared to Group A (68.2%) and B (67.9%). At the time of PTSMA an ICD for primary SCD prevention had been more often implanted in Group A (19.8%; p<0.0001) compared to Group B (10.1%) and C (5.9%).

Echocardiographic measurements showed higher maximal septal thickness in Group A (23.9±5.7 mm; p<0.ehab724.17611 each) compared to Group B (20.9±4.0 mm) and C (20.1±3.5 mm). Pts of Group B had lower resting gradients (60.0±35.3 mmHg; p<0.01 each) compared to Group A (69.5±34.8 mmHg) and C (66.4±41.6 mmHg). Total heart block at PTSMA was less often seen in Group A (28.8%; p<0.05 each) compared to Group B (39.4%) and C (43.4%). Due to persistent total heart block need of permanent pacemaker implantation was lowest in Group A (3.8%, p<0.01 each) compared to Group B (9.3%) and C (14.0%) during hospital stay. One patient in Group A and C died during hospital stay, each.

Follow-up was longer in Group A (6.7±5.2 years) compared to Group C (5.5±4.8 years; p<0.05) and was comparable to Group B (6.2±5.1 years). Re-PTSMA was more often performed in Group A (22.7%; p<0.01 each) compared to Group B (12.8%) and Group C (10.5%). Reported clinical improvement at latest follow-up was comparable (93.3% Group A, 93.8% Group B, and 95.5% Group C). Mortality was highest in Group C (12.5%; p<0.0001 each) compared to Group A (1.5%) and B (4.0%). In Group A no pt died from cardiac reason, whereas 5 pts died from cardiac reasons in Group B and C, each. SCD was not observed in Group A, whereas 2 pts in Group B and 1 pt in Group C suffered SCD.

Conclusion

PTSMA is feasible even in young pts with symptomatic HOCM. Mortality after PTSMA is mainly due to non-cardiac reasons and more often seen in elderly pts. Especially, SCD could be observed in younger pts <40 years of age.

Funding Acknowledgement

Type of funding sources: None.
Clinical effects of metoprolol in obstructive hypertrophic cardiomyopathy (TEMPO). A randomized, double-blinded, placebo-controlled crossover trial
Authors: Dybro A M , Rasmussen T B , Nielsen R R , Andersen M J , Jensen M K , Poulsen S H
Published: October 2021

Background

Treatment with beta blockers (BB) has been used for symptomatic relief in patients with obstructive hypertrophic cardiomyopathy (HCM) for decades. Even so, the guideline recommendation for the use of BB rests on expert opinions and observational cohort studies. Providing comprehensive high-quality data on the effects of BB in obstructive HCM is essential, especially in the context of newly developed pharmacological treatment strategies specifically targeting this disease (1).

Purpose

The study aimed to investigate the effects of metoprolol on left ventricular outflow tract (LVOT) obstruction, symptoms, and exercise capacity in patients with obstructive HCM.

Methods

This double-blinded, placebo-controlled, randomized crossover trial enrolled 30 patients with obstructive HCM and New York Heart Association (NYHA) class ≥ II symptoms from 1 May 2018 to 1 September 2020. Patients received metoprolol or placebo for two consecutive two-week periods in random order. The effect parameters were LVOT gradients, NYHA class, Canadian Cardiovascular Society (CCS) grading angina class, Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS), and cardiopulmonary exercise testing.

Results

Compared with placebo, the LVOT gradient during metoprolol was lower at rest (25 [15–58] mmHg versus 72 [28–87] mmHg; p=0.007), at peak exercise (28 [18–40] mmHg versus 62 [31–113] mmHg; p<0.001), and post-exercise (45 [24–100] mmHg versus 115 [55–171] mmHg; p<0.0001) (figure 1). During metoprolol treatment, 14% of patients were in NYHA class III compared with 38% on placebo (p<0.01). Likewise, no patients were in CCS class ≥ III during metoprolol compared with 10% during placebo (p<0.01). These findings were confirmed by a higher KCCQ-OSS score during metoprolol (76.2 (16.2) versus 73.8 (19.5), p=0.039) (figure 2). Peak oxygen consumption did not differ between study arms.

Conclusion

Compared with placebo, metoprolol reduced LVOT obstruction at rest and during exercise, provided symptom relief, and improved quality of life in patients with obstructive HCM. However, exercise capacity remained unchanged. Findings from the present study support the guideline recommendations that BB should be the first drug of choice in patients with obstructive HCM who develop symptoms.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Novo nordic foundation, Skibsreder Per Henriksen, R. og hustrus Foundation
Prevalence of cardiac amyloidosis in patients with unexplained left ventricle hypertrophy
Authors: Holcman K , Kostkiewicz M , Szot W , Lesniak-Sobelga A , Hlawaty M , Wisniowska-Smialek S , Dziewiecka E , Karabinowska A , Stepien A , Graczyk K , Mroz K , Podolec P , Rubis P
Published: October 2021

Background

Amyloid cardiomyopathy (CA) it is more frequently diagnosed due to rapidly developing imaging modalities. Misfolding of transthyretin (TTR) is the source of two distinct forms of amyloidosis (ATTR): acquired wild-type (ATTRwt) and hereditary (ATTRm). Types of TTR gene variants display genetic and ethnic variability. The aim of this prospective study was to assess the prevalence and types of pathogenic genetic variants associated with ATTRm amyloidosis in patients with unexplained left ventricle (LV) hypertrophy.

Methods

We evaluated prospectively 101 consecutive patients (37 (37%) females, age: 69.7±13.6 y.o.) in years 2016–2021. Analysis included clinical data, free light chain blood immunoglobulins and urine immunofixation, transthoracic echocardiography (TTE), single-photon emission computed tomography (SPECT) with 3,3-disphono-1,2-propanodicarboxylic acid (DPD), and in selected cases cardiac or soft tissue biopsy. Patients with DPD cardiac uptake in SPECT or positive histopathology or family history of ATTR were subjected to genetic testing by an amplicon-based next-generation TTR sequencing approach.

Results

Enrolled patients presented with marked LV hypertrophy with maximum wall thickness of 18.9±4 mm. Based on performed tests 34 patients (33.7%) were diagnosed with amyloidosis, including 17 cases of light-chain amyloidosis (AL), 16 of ATTR, and 1 case of other type of amyloidosis. Overall, patients with CA presented with mean 2.6±0.9 NYHA class. In TTE there was LV maximum wall thickness of 19.5±4 mm and LV mass value index value of 182±48 g/m2, decreased global longitudinal strain value (GLS, −14.1±5%) and advanced diastolic dysfunction (EA 2.2±1.1, E/E' 22±9). Overall, there were 8 cases of ATTRwt and eight patients were diagnosed ATTRm. There were detected following types of TTR variants - c.302C>T p.(Ala101Val) in a single male patient, c.325G>A p.(Glu109Lys) in a single male patient and c.157T>C p.(Phe53Leu) in six patients. Overall, 10 patients with ATTR presented with polyneuropathy, additionally six had diagnosed carpal tunnel syndrome. All patients with ATTRm had positive family history for CA.

Conclusions

In patients with unexpected LV hypertrophy evaluated in a cardiology referral center a high number of patients may suffer from underlying CA. Types of detected TTR gene variants associated with CA included most often Phe53Leu, and rare variants Ala101Val, Glu109Lys.

Funding Acknowledgement

Type of funding sources: None.