bluuebunny/crossref_metadata_2025 huggingface dataset:
Dobutamine stress echocardiography in low-gradient aortic stenosis
Authors: Borg Mogensen N , Ali M , Carter-Storch R , Annabi M S , Grenier-Delaney J , Moeller J E , Oevrehus K A , Pellikka P A , Pibarot P , Clavel M A , Dahl J S
Published: November 2023

Background

Dobutamine stress echocardiography (DSE) is recommended to distinguish between true-severe and pseudo-severe aortic stenosis (AS) in patients with low flow low-gradients and left ventricular ejection fraction (LVEF) <50%. However, DSE has mostly been tested in the setting of LVEF<35%.

Purpose

The purpose of this study was to examine the diagnostic accuracy of DSE according to aortic valve calcification (AVC) score, in patents with low-flow, low-gradient AS across a wide range of LVEF.

Methods

Patients with aortic mean gradient <40 mmHg, aortic valve area (AVA) <1.0 cm2, and stroke volume index (SVi) ≤35 mL/m2 undergoing DSE were identified from three prospectively collected patient cohorts, and stratified according to LVEF; <35%, 35-50% and >50%.

Severe AS was defined as AVC score ≥2000 AU among men, and ≥1200 AU for women. Recommendation for severe AS according to DSE, are an AVA <1.0 cm2 combined with an aortic mean gradient ≥40 mmHg or peak velocity ≥4 m/s.

Receiver operating characteristic curves for DSE-derived AVA, mean gradient and Vmax were used to identify optimal cut-off points for each LVEF subgroup.

Results

Of the 221 patients included in the study, 78 (35%) presented with LVEF <35%, 67 (30%) with LVEF 35-50%, and 76 (34%) with LVEF >50%. Baseline characteristics are presented in the table. Based on AVC, severe AS was present in 102 (46%) of patients.

Using recommended thresholds for severe AS for AVC and DSE, led to a sensitivity of 49%, a specificity of 84% and an accuracy of 67% for DSE for all patients with LVEF <50%, but with significant heterogeneity between groups figure.

AVA performed rather uniformly across LVEF subgroups; (AUC =0.68 vs 0.62 vs 0.54, p=0.36) LVEF<35%, LVEF 35-50%, LVEF>50% respectively and displayed a rather uniform optimal cut-off (1.0 cm2 vs 0.9 cm2 vs 0.8 cm2).

However, mean gradient and Vmax during DSE, both showed significantly diagnostic heterogeneity across LVEF groups (AUC= 0.90 vs 0.67 vs 0.65, p=<0.001 and AUC= 0.90 vs 0.66 vs 0.60, p=<0.001) with different optimal thresholds (30 mmHg & 3.8 m/s, 45 mmHg & 4.3 m/s and 37mmHg & 4 m/s, LVEF<35%, LVEF 35-50%, LVEF>50%, respectively).

Conclusion

Our study shows, that the association between DSE gradients and AS severity assessed by AVC demonstrates important heterogeneity depending on LVEF. While DSE had the highest accuracy in patients with LVEF<35% both patients with LVEF 35-50%, and patients with LVEF>50% showed significantly less concordance between DSE and AVC.
Left ventricular early diastolic strain rate predicts mortality after transcatheter aortic valve implantation
Authors: Anwer S , Zuercher D , Benz D C , Winkler N E , Donati T G , Tsiourantani G , Wilzeck V , Michel J , Kasel A M , Tanner F C
Published: November 2023

Introduction

Speckle-tracking echocardiography is an increasingly important tool for assessing degenerative aortic valve stenosis (AS). This study aims to analyse left ventricular early diastolic strain rate (eSR) in patients with severe AS undergoing transcatheter aortic valve implantation (TAVI) and explore its association with mortality during long-term follow-up.

Methods

From our prospective AS cohort study, 100 patients with severe AS and a comprehensive echocardiographic examination prior to TAVI were identified and eSR was determined using TomTec ImageArena v.4.6 (Figure A). All-cause five-year mortality was defined as the endpoint.±

Results

Baseline characteristics were comparablebetween non-survivors (14%) and survivors (86%) except for a higher STS-Score among the former (non-survivors: 3.6 [2.7–7.4]%; survivors: 2.6 [1.8–3.7]%; P=0.024). There was no significant difference between non-survivors and survivors with regard to LVEF (54 [50–58]% vs 58 [52–63]%; P=0.069) and LVGLS (-14.8 [-15.8 to -12.7]% vs -15.4 [-15.8 to -14.7]%; P=0.339). In contrast, eSR was significantly lower in non-survivors (0.72 [0.67–0.87]s-1) than survivors (0.88 [0.73–1.22]s-1); P=0.013; Figure B). Patients with an eSR ≤ 0.72 s-1 (ROC AUC 71%; P=0.008) exhibited a lower survival probability as revealed by Kaplan-Meier survival analysis (P=0.001; Figure C). Inclusion of eSR improved the fitness (2) of a multivariable logistic regression model for LV systolic function (LVEF and LVGLS; Figure D). A similar effect was observed when eSR was included in a model for LV diastolic function (E/A and E/e’; Figure D). These improvements in 2 were significant for both models (ANOVA P=0.026, and P=0.037, respectively).

Conclusions

eSR differentiated non-survivors from survivors and was associated with long-term mortality after TAVI. This association was independent of and improved outcome prediction by LV systolic or diastolic function parameters. These findings highlight the potential value of eSR for assessing long-term mortality after TAVI.Figures
Predictors of futility outcomes after TAVI: insights from the France TAVI Registry
Authors: Suc G , Boureau A , Gouysse M , Gilard M , Iung B , Eltchaninoff H
Published: November 2023

Background

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of aortic stenosis and provides a significant symptom relief and mortality reduction. However, a substantial group of patients fail to derive a benefit from TAVI, whether in terms of mortality, quality of life (QoL) or functional benefit.

Objectives

The aim of the present analysis was to report factors associated with a futility outcome one year after TAVI, in a national real-life registry.

Methods

This prospectively designed France TAVI-QoL substudy included patients from the national France TAVI registry between February the 12th 2018 and February the 12th 2019. Patient’s QoL was assessed at baseline and one year after TAVI using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaire. Vital status was collected from the SNDS ("Systeme Natiobal des donnees de sante"). Factors associated with a futility outcome, defined by death or significant degradation of QoL one-year after a TAVI, were analyzed through a multivariable logistic regression.

Results

The mean age of the 3159 included patients was of 83 years old, and 51,1% were male.

At follow-up, a total of 1055 patients (33.4%) met the primary outcome of procedure futility: 596 (18.9%) died and 459 (14.5%) had a significant decrease in QoL. The independent factors associated with procedure futility were general conditions (diabetes under insulin (RR 1.7, 95CI[1.2-2.3]; p=0.001), estimated glomerular filtration rate (odds-ratio [OR] 0.9 per 1 ml/min increase, 95CI[0.9-1.0]; p<0.001), chronic pulmonary disease (OR 1.6, 95CI[1.2-1.9]; p<0.001)), geriatric values (severe reduction in mobility (OR 1.5, 95CI[1.1-2.1]; p=0.003)), cardiologic values (supraventricular arrhythmia (OR 1.5, 95CI[1.2-1.8]; p<0.001), anticoagulation therapy at discharge (OR 1.3, 95CI[1.1-1.6]; p=0.01)), and procedural features (immediate complications (OR 1.5, 95CI[1.2-1.7]; p<0.001), and time to discharge (OR 1.1, 95CI[1.1-1.1]; p<0.001)).

Conclusion

One third of patients treated in the TAVI Qol Substudy presented with a futility outcome. Certain risk factors are potentially reversible (e.g. severe reduction in mobility or supraventricular arrhythmia), and their management might attenuate the risk of treatment futility and improve TAVI outcomes. Futility outcomes should be assessed with the growing number of patients with aortic stenosis and increasing concerns in the allocation of resources.
Survival in moderate and severe aortic stenosis patients with and without symptoms: a multicenter clinical cohort study
Authors: Playford D , Schwarz N , Chowdhury E , Williamson A E , Duong M , Kearney L , Stewart S , Strange G
Published: November 2023

Background

Untreated moderate and severe aortic stenosis (AS) is associated with poor long-term survival, however the association of symptom status with mortality risk remains unknown.

Methods

Echocardiography report data from an 80-site national cardiology service was extracted and classified into: No AS (mean AV gradient<10.0mmHg or peak AV velocity<2.0m/s, and AVA>1.5cm²), moderate AS (20.0-39.9mmHg/3.0-3.9m/s and AVA>1.0cm2) or severe AS (≥40.0mmHg/≥4.0m/s and/or ≤1.0cm2). Symptom status was extracted using Natural Language Processing of cardiologist reviews and mortality extracted from the National Deaths Index. Native valve AS severity, symptoms and survival were examined during a fixed 2-year follow-up.

Results

29,368 individuals (mean age 60.9±17.4 years, 50.3% male) experienced 1,140 fatal events, more likely in severe than moderate AS, but not increased by the presence of symptoms: 16.8 deaths per 1000 person-years in no AS, 35.4 per 1000 person-years in asymptomatic moderate AS, 32.5 per 1000 person-years in symptomatic moderate AS, 68.7 per 1000 person-years in asymptomatic severe AS and 56.1 per 1000 person-year in symptomatic severe AS (p<0.001 compared with no AS). In adjusted models (including age, sex and cardiac damage score), symptomatic moderate and severe AS had similar mortality to asymptomatic moderate AS, with only asymptomatic severe AS showing increased mortality (HR 1.67, 95% CI 1.17-2.38, p=0.005).

Conclusions

Mortality is increased in both moderate and severe AS, with and without symptoms. The high rates of mortality in asymptomatic severe AS warrants re-examination of the role of symptoms in management decisions, including clinical trials to address whether earlier AVR in asymptomatic moderate and severe AS improves mortality.
Aortic stenosis drives the differential in survival in patients with concomitant moderate aortic and mitral valves diseases
Authors: Hajj Ali A , Gaballa A , El Dahdah J , Popovic Z , Wang T K M , Reed G , Rodriguez L , Griffin B , Roselli E , Gillinov A M , Kapadia S , Svensson L G , Desai M
Published: November 2023

Background

Valvular heart diseases are common causes of morbidity and mortality worldwide. In this study we sought to assess the long-term outcomes of patients diagnosed with concomitant moderate aortic and mitral valves diseases at a tertiary center.

Methods

All 3257 patients (aged 71.7 ± 12.9 years old, 55.2% male, 83.1% white) who presented to the Cleveland Clinic between 1/2010 and 1/2018 and were diagnosed with concomitant moderate aortic and mitral valves diseases were included in this study. The patients were categorized into groups on the basis of aortic and mitral stenosis/regurgitation (AS/AR and MS/MR). The primary endpoint of the study was the composite event defined as heart failure hospitalization or all-cause mortality. The data was analyzed via Kaplan Meier and Cox proportional hazards regression analysis on SPSS.

Results

The median follow-up period was 21.8 months (range 1-155.8). All-causes mortality occurred in 1611 patients (49.5%), heart failure hospitalization in 1119 (34.4%) and the composite event in 1926 patients (59.1%). AR/MR was the most frequent group with 2090 patients (64.2%) followed by AS/MR with 866 (26.6%), AS/MS with 179 (5.5%) and AR/MS with 122 (3.7%). As presented in figure 1, patients with AS/MR had the worst outcome followed by AS/MS, AR/MR and finally AR/MS (p-value <0.001). However, when dividing the comparison on the basis of one valve only, and even after adjusting for aortic and mitral valve interventions, no significance difference in outcomes is noted between MR and MS (p=0.755) while AS had significantly poorer outcome than AR with p<0.001.

Conclusion

In our cohort, patients with concomitant moderate aortic and mitral valves diseases had an overall high rate of death and heart failure hospitalization. Patients with AS had significantly poorer outcomes than patients with AR but no difference was noted when comparing MS to MR.Figure 1Figure 2
A high-risk late gadolinium enhancement pattern is associated with arrhythmic events in patients with dilated cardiomyopathy
Authors: Zulet Fraile P , Ferrandez Escarabajal M , Islas F , Travieso Gonzalez A , Restrepo A , Goirigolzarri J A , De Agustin Loeches A , Vilacosta I , Olmos Blanco C
Published: November 2023

Introduction

Myocardial fibrosis constitutes a substrate for the development of ventricular arrhythmias in patients with non-ischaemic dilated cardiomyopathy (DCM). Late gadolinium enhancement (LGE)-cardiac magnetic resonance (CMR) imaging represents a powerful tool for arrhythmic risk stratification. Moreover, arrhythmic risk is determined by the extent and localization of LGE.

A high-risk LGE pattern, defined as the presence of epicardial, transmural or septal plus free-wall LGE, has been recently associated with a higher incidence of arrhythmic events comparing with other LGE patterns.

Purpose

To evaluate the prevalence of a high-risk LGE pattern in patients with DCM and its association with arrhythmic events.

Methods

From 2014 to 2021, all patients (N = 229) with DCM were prospectively evaluated in our tertiary care hospital. 174 patients underwent a 1.5 Tesla scanner CMR as part of the diagnostic workup and were included in the present study.

The primary endpoint was a composite of sudden cardiac death or sustained monomorphic ventricular tachycardia.

Results

Mean age of our cohort was 61 years (standard deviation 14.5), and 64.2% were male. Median follow-up was 41 (interquartile range 26-62) months.

LGE was present in 96 (55.2%) patients of our cohort (LGE+), and a high risk LGE pattern was found in 41 (42.7% of all LGE+ patients). LGE was more frequently located in the basal segments (78.6%). Mid-wall septal LGE was found in 46.9% of LGE+ patients, and it was the most common pattern. 21.4% of LGE+ patients had combined septal and free-wall LGE, 23.5% had epicardial LGE and 13.3% had transmural LGE.

Baseline characteristics of LGE+ patients with and without a high-risk LGE pattern are shown at the Table.

The incidence of ventricular arrhythmic events during follow-up was 31.7% in patients with a high-risk LGE pattern, and 9.1% in LGE+ patients but without a high-risk pattern (p=0.005). In patients without a high-risk LGE, including LGE- patients and LGE+ patients with other LGE patterns, incidence of ventricular arrhythmic events was 8.3% (p<0.001). The survival free curves for the combined arrhythmic endpoint comparing LGE+ patients with and without a high-risk pattern are shown in the Figure.

Conclusion

The presence of a high-risk LGE pattern in patients with DCM its associated with a higher incidence of ventricular arrhythmic events, comparing with LGE+ patients without a high-risk pattern. We suggest that this high-risk pattern should be taken into account when performing arrhythmic risk stratification in patients with DCM.TableFigure
Impact of cardiac staging classification in transcatheter aortic valve implantation for major subtypes of severe aortic stenosis
Authors: Nakase M , Okuno T , Tomii D , Lanz J , Praz F , Stortecky S , Windecker S , Pilgrim T
Published: November 2023

Background

Staging classification to quantify the extent of extra-aortic valve cardiac damage is recognized as a useful prognostic tool in patients undergoing transcatheter aortic implantation (TAVI) for aortic stenosis (AS). However, this classification has not been validated in each AS subtype.

Objectives

The present study aimed to investigate the prognostic impact of staging classification in patients with four major AS subtypes.

Methods

In a prospective TAVI registry, patients were classified into high gradient AS (HG-AS), classical low flow low gradient AS (LFLG-AS), paradoxical LFLG-AS, and normal flow low gradient AS (NFLG-AS). Five-year mortality was compared between early stage (stage 0, 1, or 2) and advanced stage (stage 3 or 4).

Results

Among 1,507 patients undergoing TAVI, 812 patients had HG-AS, 186 patients had classical LFLG-AS, 277 patients had paradoxical LFLG-AS, and 232 patients had NFLG-AS. There were much difference in the distribution of cardiac stage among AS subtypes; advanced stage accounting for 54.3% in HG-AS, 58.6% in NFLG-AS, 62.5% in paradoxical LFLG-AS, and 80.6% in classical LFLG-AS. Patients with advanced stage had higher all-cause mortality compared with early stage in HG-AS and paradoxical LFLG-AS (HRadjusted 2.00; 95% CI 1.44-2.78 and HRadjusted 2.15; 95% CI 1.43-3.21), but not in classical LFLG-AS and NFLG-AS (HRadjusted 1.17; 95% CI 0.70-1.95 and HRadjusted 1.43; 95% CI 0.90-2.27).

Conclusions

Early stage was associated with a reduced risk for five-year mortality in patients with HG-AS and paradoxical LFLG-AS, while there was comparable mortality between early and advanced stages in patients with classical LFLG-AS and NFLG-AS.
The efficacy and safety of novel oral anticoagulants versus vitamin k antagonist in transcatheter aortic valve replacement patients with indications for anticoagulation
Authors: Abella J , Vestal M
Published: November 2023

Introduction

Thrombotic events from atrial fibrillation, clinical and subclinical leaflet thromboses continue to be a major concern in Transcatheter Aortic Valve Replacement (TAVR) patients despite technological advancement and operator expertise. The proportion of TAVR patients who have or eventually develop indications for anticoagulation is not negligible and thus may warrant oral anticoagulants. However, the choice of anticoagulation is this select patients remained debatable. Thus, this study was conducted to determine whether current collective data support the efficacy and safety of novel oral anticoagulants (NOACS) versus vitamin K antagonists (VKAs).

Purpose

Oral anticoagulation (OAC) is necessary but the patients who needed it the most have baseline high bleeding risks. Anticoagulation carries a high bleeding risk especially among majority of a typical post TAVR patients with indications for anticoagulation. The paucity of data among asian TAVR patients were propensity to bleed are prevailing issues with anticoagulation owing perhaps to genetic or race predisposition and lower body weights or BMI compared to non-Asian counterparts. Currently the high court is still out to settle the optimum choice of anti-thrombotic therapy after TAVR. With TAVR now being performed in our local setting, we find this a relevant issue, hence we conducted a meta-analysis.

Methods

A literature search from Pubmed, Embase, and Cochrane databases for relevant RCTs and observational studies published until February 2022 were conducted. The pooled estimates of all-cause mortality, stroke and major bleeding events were measured using RevMan version 5.4.1 software.

Results

Eleven eligible studies (9 observational studies and 2 RCTs) allocated 29,156 TAVR patients with indications for anticoagulation either to receive NOACS (n = 11,718) or VKAs (n = 17,468). The effect estimate using random effects model showed no significant differences in all-cause mortality (RR 0.79, 95% CI 0.42–2.25, p = 0.07), stroke (RR 0.96, 95% CI 0.54–2.79, p = 0.70), and major bleeding events (RR 0.82, 95% CI 0.48–1.44, p = 0.08) between the NOACs and VKAs treatment arms.

Conclusion

NOACs demonstrated non-inferiority over VKA in reducing all-cause mortality, stroke and major or life-threatening bleeding events in TAVR patients with indications for anticoagulation.
Three-year outcomes following transcatheter versus surgical aortic valve replacement in younger, low surgical risk patients with severe aortic stenosis
Authors: Modine T , Tchetche D , Van Mieghem N , Huang J , Forrest J , Reardon M
Published: November 2023

Background/Introduction

Prior randomized studies in patients with severe aortic stenosis at low risk for surgery have shown comparable 3-year outcomes with transcatheter aortic valve implantation (TAVI) and surgery. Less is known about the intermediate term outcomes in younger (<75 years) patients at low risk for surgery treated with TAVI or surgery.

Purpose

To compare 3-year clinical outcomes in younger (<75 years) patients with severe aortic stenosis and low risk for surgery randomly assigned to TAVI or surgery.

Methods

The Evolut Low Risk randomized trial treated 1414 patients at low surgical risk with a supra-annular, self-expanding TAVI or surgery. Patients less than 75 years of age were selected for this analysis. The primary endpoint was the 3-year occurrence of all-cause mortality or disabling stroke (Kaplan-Meier estimates). Serial echocardiographic outcomes were also compared through 3-year follow-up.

Results

703 younger (mean age, 69 years) low-surgical risk (STS PROM, 1.6%) aortic stenosis patients were treated with TAVI (N=352) and SAVR (N=351). At 3 years, the primary endpoint of all-cause mortality or disabling stroke was not different between TAVI (5.7%) or surgery (8.0%, p=0.241). TAVI was associated with lower incidence (0.6%) of disabling stroke compared with surgery (2.9%, p=0.019) and atrial fibrillation (13.3%) compared with surgery (36.4%, p<0.001) while surgery was associated with lower incidence of pacemaker implantation (7.1%) compared with TAVI (21.0%, p<0.001). Valve reintervention rates were low in both groups (1.5% with TAVI; 1.5% with surgery, p=0.962). Mean aortic gradients were significantly lower with TAVI (9.7 mmHg) compared with surgery (12.9 mmHg, p<0.001) and effective orifice areas were significantly larger with TAVI (2.2 cm²) compared with surgery (1.9 cm², p<0.001). There were no differences in the rates of residual moderate or greater paravalvular regurgitation (TAVI: 1.1% and surgery: 0.4%, p=0.626).

Conclusion(s)

Low risk patients less than 75 years age who underwent TAVI with a supra-annular, self-expanding TAVI had comparable clinical and haemodynamic outcomes with surgery through the 3-year follow-up; additional study through 10 years in these low risk patients is ongoing.
Insulin resistance in patients suffering from severe AS
Authors: Freitag L , Leuders P , Kelm M , Zeus T , Quast C
Published: November 2023

Background

There are several cardiovascular risk factors known to promote the development of AS, one of them being type 2 diabetes (T2D). T2D is increasingly recognized as a heterogenous disease, leading to the latest concept of five diabetes clusters based on clinical parameters. Until now, the impact of the respective clusters, especially insulin resistance in prediabetes, on valvular cells and therefore the development of AS is not clear.

Purpose

We hypothesize that insulin resistance, which is frequently underrated, features a specific pattern of aortic valve calcification characterized by an elevated degree of calcification.

Methods

In order to analyze the impact of diabetes on AS we examined 200 patients with severe AS, scheduled for a transcatheter aortic valve implantation (TAVI). With the exemption of previously diagnosed diabetics, we performed an oral glucose tolerance test (OGTT), identifying patients with prediabetes and T2D. Additionally, blood was drawn from all included patients 2-5 days after TAVI, depicting their metabolic condition and thereby assigning them to a diabetes cluster. These findings were subsequently correlated with data from computertomography in all patients pertaining the severity of the stenosis, including the Agatston score, which illustrates the aortic valve calcium burden.

Results

Following the hypothesis that the extent of insulin resistance impacts the aortic valve calcification, we correlated the HOMA-IR with the Agatston score, resulting in a weak non-significant linear correlation (r=-0.129, p = 0.097, n = 166). Therefore, increased insulin resistance has not been shown to be associated with increased aortic valve calcification. Moreover, no differences in the extent of calcification between diabetic, prediabetic and non-diabetic patients could be demonstrated (F (2, 147) = 0.410, p = 0.665). However, it was clearly striking that the majority of the patients examined had already developed prediabetes or diabetes (Non-Diabetic = 7.1%, Prediabetic = 34.6%, Diabetic = 58.2%, n= 182).

Conclusion

Although we were able to observe an increased rate in prediabetic and diabetic patients in our AS cohort, there was no significantly elevated aortic valve calcification in patients with pronounced insulin resistance. This suggests that insulin resistance might not directly impact valvular calcification but upstream processes in valvular cells predisposing for AS since the majority of AS patients in our cohort is (pre)diabetic.
Patient-reported functional and symptomatic outcomes in patients with mild cognitive disorder undergoing transcatheter aortic valve implantation - A secondary analysis of a randomized controlled trial
Authors: Thevathasan T , Hornig C , Leistner D M , Suendermann S , Unbehaun A , Sherif M , Haghikia A , Stangl K , Falk V , Landmesser U , Dreger H , Stangl V , Brand A
Published: November 2023

Background

The impact of pre-existing mild cognitive disorder (MCD) on patient-reported outcome measures (PROMs) after transcatheter aortic valve implantation (TAVI) remains unclear.

Purpose

To investigate functional and symptomatic outcomes after TAVI in patients with or without MCD at two German tertiary care centers as part of a randomised controlled trial (TAVI-COMIC study).

Methods

Adult patients undergoing elective TAVI were enrolled. MCD was defined by the Montreal Cognitive Assessment (MoCA) <26 points. PROMs were assessed at 90 days after TAVI.

Results

Of 199 patients, 109 (54.8%) showed MCD. Female patients had significantly more often MCD (49.5% vs. 34.4%, p=0.046). Prior to TAVI, 21.6% reported dyspnea (NYHA class III-IV), 35.1% angina (CCS class II-IV), 41.2% dizziness and 12.6% syncope. Both patient groups reported similar improvements in general health status after TAVI: "marginally or significantly better" health status in 73.5% with MCD vs. 68.9% without MCD (p=n.s.). In multivariable logistic regression models, the number of patients reporting a "good, very good or excellent" general health status after TAVI was similar in both patient groups (p=n.s.) (Table). Similarly, post-TAVI symptoms of dyspnea, angina, dizziness or syncope were similar between both groups (each p=n.s.). Procuration and walking ability without difficulties as well as functional independence were 54% [95% Confidence Interval (CI) 0.23-0.92] (p=0.028), 55% [95% CI 0.22-0.89] (p=0.023) and 52% [95% CI 0.24-0.94] (p=0.035) less frequently reported by patients with MCD compared to patients without MCD, respectively. Of note, delirium was more frequently observed in patients with MCD within 3 days after TAVI (8.3% vs. 1.1%, p=0.049).

Conclusions

TAVI appeared to result in similar improvements in general health status and symptomatic PROMs in patients with and without MCD. Though, patients with MCD reported impaired functional PROMs after TAVI. More careful post-procedural care should be taken for patients with MCD to enhance functional independence in this vulnerable patient group.
Prevalence and predictors of pacemaker implantation in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: TAVI-NOR study
Authors: Wasim D , Ali A M , Bleie Ø , Packer E J S , Eriksen E , Rotevatn S , Saeed S
Published: November 2023

Background

The transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis (AS) asserts mechanical forces during valve expansion both on the aortic root and conduction system. TAVI is therefore frequently associated with the development of conduction abnormalities requiring a permanent pacemaker implantation (PMI).

Purpose

To identify predictors of new PMI in unselected patients with severe AS undergoing TAVI.

Methods

Among the 600 patients consecutively enrolled in TAVI-NOR study, 52 had PMI prior to TAVI and were excluded, remaining 548 patients eligible for this analysis. Predictors of PMI were identified in binary logistic regression analyses.

Results

A total of 189 patients (31.5%) required a new PMI post TAVI, evenly distributed between females and males (30.1% vs 32.9%, p=0.456). Higher age, comorbidities such as hypertension, chronic kidney disease, coronary artery disease, diabetes, and left ventricular hypertrophy on ECG or echocardiography, and the severity of AS had no association with the risk of PMI after TAVI (Table 1). In univariate logistic regression analyses, larger aortic root diameter was associated with a higher risk of new PMI (OR 1.66; 95% 1.07-2.58, p=0.024), but was no longer significant in multivariate model, and bioprosthesis size had no association with the need for a PMI following TAVI. Bundle branch block (BBB) (OR 1.52; 95% 1.00-2.31, p= 0.051), and especially right BBB (RBBB) (OR 2.05; 95% 1.14-3.70, p= 0.017) showed increased risk of a new PMI, also in a multivariable-adjusted analysis (OR 2.67; 95% 1.39-5.11, p=0.003). Lotus bioprosthesis with mechanical expansion was associated with an increased risk of PMI (OR 2.92; 95% CI 1.92-4.45, p<0.001), while balloon expandable Sapiens had a lower risk for PMI (OR 0.15; 95% CI 0.06-0.37, p<0.001). In a multivariable-adjusted analysis, the use of Lotus valve (OR 2.23; 95% CI 1.44-3.46, p<0.001) was still associated with a higher risk, and use of Sapien with a lower risk of PMI (OR 0.15; 95% CI 0.06-0.40, p<0.001) independent of non-significant association with atrial fibrillation (p=0.067), lower heart rate (0.077), aortic root (p=0.225) and stroke volume index (p=0.097). Adding age and gender to the same primary multivariable-adjusted model did not change our conclusions: Lotus (OR 2.28; 95% CI 1.46-3.57, p<0.001) and RBBB (OR 2.63; 95% CI 1.37-5.04, p=0.004) and Edward Sapien (OR 0.15; 95% 0.06-0.39, p<0.001) of post-procedural PMI.

Conclusion

Our data from less selected patients with severe AS patients show that pre-intervention RBBB and the use of bioprosthesis with mechanic expansion (Lotus) were associated with a higher risk, and the use of balloon expandable bioprothesis (Sapiens) with a lower risk of PMI after TAVI. We found no gender differences in risk of PMI.
Improving risk stratification of moderate aortic stenosis
Authors: Teixeira R , Neves I , Sousa-Nunes F , Almeida M , Leite M , Lobo A , Sampaio F , Fontes-Carvalho R
Published: November 2023

Background

The clinical course of patients with moderate aortic stenosis (AS) remains ill-defined. While a watchful waiting approach is advocated by international guidelines, several studies suggest that the long-term prognosis of these patients is worse than previously considered and may even be similar to patients with severe AS. Whether these findings reflect a subgroup of moderate AS with a high comorbid burden or rapid progression to severe AS is not known.

Purpose

This study sought to 1) analyze the clinical course of AS throughout all stages of the disease, 2) unveil different trajectories of progression through clustering analysis, 3) explore their impact in all-cause death.

Methods

Patients with mild to severe AS in seriated echocardiograms (TTE) were retrospectively identified after excluding for abnormal flow conditions. Aortic peak velocity (APV) was used to monitor disease progression. A sigmoid function was used to model APV throughout time. Individual acceleration rates coefficients were calculated using random-effects models and patients were then clustered into rapid (RP) and slow progressors (SP).

Results

This study included 914 patients (age 76 ± 8 years, 52% female, median follow-up time 6.8 years). 483 patients were clustered as RP (53%) and 431 as SP (47%) based on their individual acceleration rate coefficients (core parameter of sigmoid model). Since the core parameter is constant throughout time and evaluations, only two consecutive TTEs per patient are needed to calculate the acceleration rate coefficient. The time interval required between these seriated TTEs varies between 9 and 14 months. No clinical variables were consistently associated with each cluster. When comparing mortality hazard rates for SP with RP across the range of APV, we found that rapid progression was persistently associated with excess mortality (HR 1.35, CI [1.07-1.69]; p=0.01; after adjusting for demographics, comorbidities, baseline AS severity, and time-dependent aortic valve replacement [AVR]). Using the upper limit of the mortality rate of a SP with an APV of 4 m/s as a reference, we found that a RP significantly exceeded this threshold with an APV velocity of only 3.2 m/s. We built a predictive model which incorporated the AS progression on top of guideline-derived AVR triggers to assign patients with a predicted probability of death ≥ 50% at 5 years to AVR. Using this model, we estimated that an extra death can be prevented for every 100 patients treated without exposing more patients to unnecessary AVR.

Conclusion

We identified two clusters of AS progressors, based on APV from two consecutive TTEs. RP displayed higher mortality rates across all the range of APV which can explain why same patients with moderate AS have a dismal prognosis. Since RP patients have excess adverse outcomes in early stages of AS (moderate AS), a lower APV threshold may be required to better reflect the prognosis of AS and trigger treatment.
Prognostic value of left atrial volume index in patients with rheumatic giant left atrium
Authors: Adrian L H , Sanjaya C R , Hutomo S A , Negari A D S
Published: November 2023

Background

Giant left atrium (GLA), conventionally defined as an anteroposterior diameter of more than 65 mm, is a rare condition mostly resulted from rheumatic mitral valve disease. Assessment of left atrial volume index (LAVI), in place of LA diameter, may have important prognostic implications in rheumatic GLA patients, incremental to clinical and additional imaging parameters.

Purpose

This study investigated whether initial assessment of LAVI is associated with short-term outcomes in rheumatic GLA patients who did not undergo surgery.

Methods

This was a single-center, prospective cohort study in 58 patients with definite rheumatic heart disease and echocardiographic-confirmed GLA who refused valve surgery and/or LA reduction procedure. Assessment of clinical, laboratory, echocardiography, and CT angiography thorax with contrast were performed on their first hospital admission. The study population was subdivided based on a LAVI value of 254 mL/m², following the prior ROC curve analysis. Both groups were followed for up to 17 months. The primary endpoint was all-cause mortality. The association between variables and all-cause mortality was analyzed using the Kaplan-Meier curve and Cox proportional hazard regression models.

Results

A total of 54 out of 58 patients (age 46 ± 11 years; 90.7% women) were included. At baseline, patients with LAVI ≥ 254 mL/m² exhibited significantly higher NT-proBNP level, reduced estimated glomerular filtration rate (eGFR), lower TAPSE, higher systolic pulmonary arterial pressure (sPAP), larger LA diameter, and more prone to atrial fibrillation and LA appendage aneurysm, rather than patients with LAVI < 254 mL/m² (all p<0.05). During a median follow-up of 12 (8–17) months, 11 (20.4%) patients died. Patients with LAVI ≥ 254 mL/m² demonstrated significantly higher mortality rates at 3-, 6-, and 12-months follow up (4%, 6%, and 16%, respectively) when compared with patients with LAVI < 254 mL/m² (2%, 2% and 4%, respectively, log-rank p=0.03). LA appendage aneurysm [hazard ratio (HR): 4.17; 95% confidence interval (CI): 1.15–6.52; p=0.035] and LAVI (HR: 1.07; 95% CI: 1.05–1.1; p=0.042) were independently associated with all-cause mortality. The addition of LAVI to a clinical model (including eGFR, NT-proBNP, LA diameter, cardiogenic shock, echo signs of chambers compression, and LA appendage aneurysm by CT) was associated with significant increase in the X² value (X² difference = 7.19; p<0.001), suggesting the incremental prognostic value of LAVI in patients with rheumatic GLA.

Conclusions

LAVI is independently associated with all-cause mortality in rheumatic GLA patients not undergoing surgery and provides incremental prognostic value over clinical and imaging variables for short-term survival. LAVI may therefore be useful in the risk stratification of patients with rheumatic GLA and optimize timing of surgical intervention.Baseline characteristics of the studyPrognostic value of LAVI on mortality
Risk of thromboembolic and bleeding events in patients with atrial fibrillation after valvular intervention in either aortic or mitral position
Authors: Skogseid E L , Batra G , Westerbergh J , Held C , Christersson C
Published: November 2023

Background

The optimal oral anticoagulant treatment (OAC) for patients with atrial fibrillation (AF) undergoing valvular intervention is uncertain. Mitral valve prostheses are believed to be more thrombogenic than the aortic due to lower flow velocity across the valves. The only randomized controlled trial of AF patients with biological valve prostheses included only patients receiving mitral valve prostheses (1). It is unclear if these findings could be extrapolated to patients receiving aortic valve prostheses.

Purpose

To describe baseline characteristics and comorbidities of patients receiving biological valve prostheses in aortic or mitral valve position and to investigate possible associations between valve position and the incidence of cardiovascular (CV) death, ischemic stroke or systemic embolism and major bleeding.

Methods

All patients in Sweden undergoing open heart surgery with aortic or mitral valve replacement with biological prostheses between 2010-2016 with known AF were included. The study cohort was identified in the SWEDEHEART registry. Information on comorbidities, drug exposure and occurrence of outcome events was collected from SWEDEHEART and other national registries. Association between the position of valve prosthesis (mitral and aortic) and incidence of outcome events was investigated using Cox regression analysis. Multivariable adjustments were made for comorbidities.

Results

In total, 2359 patients with AF underwent aortic (n=2103) or mitral (n=256) valve replacement. The median age was 75 and 73 years, respectively. Hypertension, diabetes mellitus and previous TIA were more common in the aortic valve group, whereas heart failure and previous major bleeding was more frequently observed in the mitral group. In both groups, about 50% of the patients were not on OAC treatment at time of discharge from valve intervention, despite that the mean CHA2DS-VASc score was 3.3 and 3.2, respectively. Mitral valve prostheses were associated with similar risk of CV death (hazard ratio (HR) 1.09; 95% confidence interval (CI), 0.77 – 1.56), ischemic stroke and systemic embolism (HR 1.27; 95% CI, 0.85-1.92) compared to aortic valve prostheses. In contrast, receiving mitral valve prosthesis was associated with lower risk of major bleeding compared to aortic prosthesis (HR 0.58; 95% CI 0.38 – 0.88).

Conclusion(s)

The study indicated similar risk of CV death, ischemic stroke and systemic embolism among patients with AF undergoing valve replacement with biological prostheses in either aortic or mitral position. Mitral valve replacement was associated with lower risk of major bleeding.
Left ventricular remodeling in chronic aortic regurgitation: both age and sex matter
Authors: Hanet V , Altes A , De Azevedo D , Vanoverschelde J L , Pasquet A , Vancraeynest D , Gerber B
Published: November 2023

Background

For chronic and severe aortic regurgitation (AR), both European and American guidelines recommend surgery in the setting of dilated left ventricle (LV). However, normal LV volumes are described according to age and gender (1) and differences in remodeling according to gender have been described in AR (2) and late referral bias has been suggested as a cause for outcome penalty in female patients with AR (3).

Objective and methods

To clarify the interactions of age and gender on LV volumes in the setting of AR with cardiac magnetic resonance (CMR). This is a single-center study performed in a referral center for cardiac surgery and aortic valve repair. Patients were adults identified or referred for an at least moderate AR (grade II) by transthoracic echocardiogram (TTE) and were invited to perform a CMR. Exclusion criteria were acute AR caused by bacterial infection or dissection, dilated cardiomyopathy from another identified cause, concomitant more than moderate left heart valve disease or intra-cardiac devices.

Results

Among 296 patients included (51+/-16 years, 56 (19%) females and 129 (44%) bicuspid), mean regurgitant fraction (RF) was 33%. Age was similar among men and women (50+/-16 vs 54+/-16; p=0.142) but RF was higher among men (35+/-18 vs 25+/-15%, p<0.001). Both LV end-diastolic (iLVEDV) and end-systolic (iLVESV) were moderately correlated to regurgitant fraction (Pearson R of respectively 0.605 and 0.569). Women had lower iLVEDV and iLVESV than men after correction for AR severity (respectively 105+/-24 vs 136+/-43ml/m²; p<0.001 and 48+/-17 vs 66+/-30ml/m²; p=0.007). Female gender was associated with a significantly lower susceptibility to dilate both iEDV and iESV in the setting of an increasing AR severity (p for interaction of respectively 0.048 and 0.041). Similarly, advancing age was associated with a continuous decrease in iEDV and iESV dilatation ability (p for interaction of respectively 0.006 and 0.048).

Conclusion

Sex and age are significant determinants for LV volumes in AR. Furthermore, both female sex and aging independantly lead to a decreased capability of LV dilatation, suggesting sex and aged-based CMR thresholds for LV dilatation should be further developed to avoid possible late referral bias for surgery in female or elderly population.Gender interaction on LV dilatationLV volumes prediction models
Moderate mixed aortic valve disease -evaluation, treatment and prognosis of patients referred to heart valve center
Authors: Lupinek P , Kotrc M , Marek T , Kockova R , Pecenkova V , Dorazilova Z , Blaha M , Benes J , Praveckova A , Kroupova K , Capkova V , Podzimkova M , Kettner J , Kautzner J
Published: November 2023

Background

Indications for valve intervention in mixed aortic valve disease (MAVD) are not clearly defined. Decision is usually based on predominant lesion, extrapolated from guidelines for isolated aortic stenosis (AS) or aortic regurgitation (AR). However, data have been published suggesting that the prognosis of patients who have both moderate AS and moderate AR is not benign and may be similar to the prognosis of isolated severe AS.

Goal: To assess diagnostic process, decision making and prognosis in patients with MAVD and moderate stenosis and regurgitation examined in a tertiary referral centre.

Methods

Patients with MAVD and EF ≥50% examined at tertiary referral center in years 2010-2021 were retrospectively identified. MAVD was defined as moderate AS by aortic valve area >1,0 cm2 and ≤1,5 cm2 and moderate AR by integrative assessment. Patients with more than mild to moderate disease of other valves were excluded.

Results

A total of 85 patients were eligible, mean age 66,4±7,9 years, males/females 58/27, 40 (47.1%) with bicuspid or monocuspid aortic valve, 50 asymptomatic. During a mean follow-up (F-U) of 5.9±3.6 years, 20 patients died and 46 underwent aortic valve replacement (AVR). At 1, 2, and 5 years of F-U, the mortality rate was 3.5%, 7.1% and 15.3% and the rate of AVR reached 23.5%, 30.6% and 43.5%, respectively. At 1, 2 and 5 years 61 (71.7%), 54 (63.5.%) and 40 (47.1%) patients were alive and free of AVR.

In 10/13 patients who died within 5 years, MAVD was classified as nonsevere. Therefore, these patients were treated conservatively and eight of them died without AVR. Except one, all had peak velocity at aortic orifice <4 m/s. In all 6 patients who died within 2 years, MAVD was classified as nonsevere on index examination, AVR was indicated and performed only in 1 due to associated aortic aneurysm.

Conclusions

MAVD where both AS and AR are moderate is not a benign condition. Its overall severity is often underestimated, indication criteria for AVR are not clear and substantial proportion of patients die while being treated conservatively. These patients should be followed closely and lower threshold for aortic valve replacement/repair may be appropriate.
Left atrial strain and risk of systemic embolic event in rheumatic mitral stenosis with sinus rhythm
Authors: Lee S , Cho I S , Kim D Y , Kim I C , Hong G R , Kim H S
Published: November 2023

Backgrounds

Stroke and systemic embolism might be an important complication of rheumatic mitral stenosis (MS) even though patients are in sinus rhythm (SR), but the risk of embolic events in this population are not well studied.

Purpose

We aimed to evaluate the risk factors of embolic events in patients with rheumatic MS and SR.

Methods

From the multi-center retrospective registry of 2426 patients with rheumatic MS, we included patients with rheumatic MS and SR (n=583) between January 2000 and December 2021. After exclusion of patients who had history of systemic embolic events, taking the anticoagulants, combined significant aortic valve dysfunction, and a history of valve surgery. We finally analyzed 443 patients. The primary outcome was defined as composite of stroke, transient ischemic attack, noncentral nervous system embolism.

Results

Among 448 patients (77.1% female; mean age, 52.3 ± 10.1 years), systemic embolic events developed in 38 (8.4 %) patients with annual incidence rate of 4.6/100 person-year during mean follow-up period of 96.4 ± 61.1 months (median 94.2 months). Patients who had systemic embolic events were significantly older and had higher the prevalence of hypertension and diabetes than those who did not, without significant differences in left atrial (LA) dimensions, volumes, pulmonary artery systolic pressure. Instead, LA strain was significantly impaired in patients with systemic embolic events (19.1 ± 9.3 vs. 15.5 ± 8.07, p= 0.034). In the multivariate analysis, LA strain was independent predictors of systemic embolic events [HR 0.96, 95 % CI: 0.93-0.99; P = 0.021], after adjustment for confounding factors. The impaired LA strain (LA reservoir strain < 16.6 %) also had incremental prognostic value for development of systemic embolic events over clinical factors and traditional echocardiographic parameters (Figure).

Conclusions

Impaired LA strain is a predictor of stroke and systemic embolism in patients with rheumatic MS in SR. Considering the risk for embolism, oral anticoagulation might be considered in patients with rheumatic MS in SR and impaired LA strain.Figure