bluuebunny/crossref_metadata_2025 huggingface dataset:
Duration of resuscitation efforts and long-term prognosis following in-hospital cardiac arrest (IHCA)
Authors: Yonis H , Winkel B , Andersen M P , Wissenberg M , Kober L , Gislason G , Larsen J M , Folke F , Pedersen C T , Sogaard P , Kragholm K
Published: October 2021

Background

The decision to terminate resuscitation efforts can be challenging. Notably, the association between duration of resuscitation and long-term survival and functional outcomes after in-hospital cardiac arrest (IHCA) is unknown.

Purpose

To examine 30-day and 1-year survival stratified by duration of resuscitation efforts. Further, to report long term outcome (1-year survival) without anoxic brain damage or nursing home admission among 30-day IHCA survivors.

Methods

We included all patients with IHCA from 13 Danish hospitals between January 1st, 2013 to December 31st, 2015. Patients were only included if there was clinical indication for a resuscitation attempt. Data on IHCA was obtained from the DANARREST database, which was linked to national registries to retrieve information on patient characteristics, survival, anoxic brain damage and nursing home admission. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation efforts: Group A (<5 minutes), group B (5–11 minutes), group C (12–20 minutes) and group D (≥21 minutes).

Using multivariable regression analysis, outcomes were standardized for patient age, sex, Charlson Comorbidity Index, witnessed arrest, monitored arrest, cardiopulmonary resuscitation (CPR) prior to arrival of the in-hospital cardiac arrest team and defibrillation.

Results

The study population comprised of 1868 patients, median age was 74 (1st-3rd quartile [Q1-Q3] 65–81 years) and 65.0% were men. In total, 52.1% (n=973) of the patients achieved return of spontaneous circulation (ROSC). The overall median duration of resuscitation was 12 min (Q1-Q3 5–21 min).

The standardized absolute chance of 30-day survival was 63.6% (95% CI 58.0%-69.0%) for group A, 34.0% (95% CI 29.7%-38.2%) for group B, 14.1% (95% CI 10.7%-17.5%) for group C and 9.0% (95% CI 6.8%-11.8%) for group D. Similarly, the chance of 1-year survival was highest for group A (51.5%; 95% CI 46.3%-56.7%) gradually decreasing to 7.0% (95% CI 4.5%-9.5%) in group D (Fig. 1).

Among 30-day survivors of an IHCA, the standardized absolute chance of survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for patients resuscitated in group A (83.2%; 95% CI 78.4%-88.1%), decreasing to 72.3% (95% CI 64.5%-80.0%) in group B, 68.3% (95% CI 55.3%-81.2%) in group C and 71.1% (95% CI 54.2%-88.0%) in group D (Fig. 2).

Conclusion

Short time to ROSC after in-hospital cardiac arrest is associated with better long-term prognosis. However, the majority of 30-day survivors are alive 1-year post-arrest without anoxic brain damage and without need for nursing home admission despite prolonged resuscitation.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Epidemiology of infective endocarditis in Portugal, a populational study
Authors: Santos De Sousa C , Nogueira P , Pinto F J
Published: October 2021

Introduction

Infective endocarditis (IE) diagnosis and management continues to be a challenge.

Purpose

Describe temporal trends on the incidence of infective endocarditis, its clinical and outcome results, in Portugal.

Methods

A nationwide retrospective temporal trend study on the incidence and clinical characterization of patients hospitalized with infective endocarditis – 2010 to 2018, in Portugal.

Results

7574 hospitalized patients with infective endocarditis from 2010 to 2018 in Portuguese public hospitals. Predominantly men (56.9%), and 47.1% were between 60 and 79 years old. The most frequent infectious agents involved were Staphylococcus (16.4%) and Streptococcus (13.6%). During hospitalization, 12.4% of patients underwent heart valve surgery and 20% of the total cohort died. The annual incidence of infective endocarditis was 8.31 per 100,000 habitants, being higher in men and increased with age. In-hospital mortality rate significantly increased, the strongest independent predictors being ischemic or hemorrhagic stroke, sepsis, acute renal failure and older age.

Conclusions

In Portugal, between 2010 and 2018, the incidence of infective endocarditis presented a general growth trend with a deceleration in the most recent years. A significant rate of in-hospital complications, a mildly lower than expected stable surgical rate and a still high and growing mortality rate were noted.

Funding Acknowledgement

Type of funding sources: None.
Echocardiographic global longitudinal strain as a marker of myocardial fibrosis predicts outcomes in aortic stenosis
Authors: Chin C , Le T T , Singh G , Yip J , Chai S C , Yong Q W , Lee E , Yeo D , Tay E , Goh P P , Ling L F , Richards A M , Delgado V , Ding Z P , Ling L H
Published: October 2021

Background

Left ventricular global longitudinal strain (LV-GLS) by speckle tracking echocardiography (STE) reflects intrinsic myocardial function, influenced by interstitial abnormalities. Cardiovascular magnetic resonance (CMR) detects myocardial fibrosis non-invasively, but it is limited for widespread use. We aim to establish LV-GLS as a marker of replacement myocardial fibrosis on CMR and validate the prognostic value of LV-GLS thresholds associated with fibrosis.

Methods

LV-GLS thresholds of replacement fibrosis were established in the derivation cohort: 151 patients (57±10 years; 58% males) with hypertension who underwent STE to measure LV-GLS and CMR for replacement myocardial fibrosis. Prognostic value of the thresholds was validated in a separate outcome cohort: 261 patients with moderate-severe aortic stenosis (AS; 71±12 years; 58% males; NYHA functional class I-II) and preserved LVEF ≥50%. Primary outcome was a composite of cardiovascular mortality, heart failure hospitalization, myocardial infarction and cerebrovascular events.

Results

In the derivation cohort, LV-GLS demonstrated good discrimination (c-statistics 0.74; 95% confidence interval: 0.66–0.83; P<0.001) and calibration (Hosmer-Lemeshow X2=6.37; P=0.605) for replacement fibrosis. In the outcome cohort, 52 events occurred over 16 [3.1, 42.0] months of follow-up. Patients with LV-GLS >−15.0% (corresponding to 95% specificity to rule-in myocardial fibrosis) had the worst outcomes compared to patients with LV-GLS <−21.0% (corresponding to 95% sensitivity to rule-out myocardial fibrosis) and those between −21.0 and −15.0% (log-rank P<0.001; Figure 1). Furthermore, LV-GLS offered independent prognostic value over clinical variables, AS severity, echocardiographic LVEF and E/e' (hazard ratio 1.18; 95% confidence interval: 1.07 to 1.30; P=0.001).

Conclusions

LV-GLS thresholds associated with replacement myocardial fibrosis is a novel approach to risk-stratify patients with AS and preserved LVEF (Figure 2).

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Figure 1Figure 2
Staging cardiac damage in aortic valve disease: one size fits all?
Authors: Silva G , Sampaio F , Espada Guerreiro C , Goncalves Teixeira P , Ribeiro Queiros P , Ribeiro Da Silva M , Brandao M , Ferreira D , Fontes-Carvalho R
Published: October 2021

Background

Nowadays, in patients with aortic regurgitation (AR), aortic valve surgery is indicated when severe and symptomatic or those with depressed LVEF. However, clinical outcomes of patients with significant aortic regurgitation are not influenced by these factors only. Recently, a new staging system for severe aortic stenosis has been proposed by Généreux on the basis of the extent of anatomic and functional cardiac damage. If this model could be applicable to an unselected significant AR population has not been tested.

Purpose

The aim of our study was to evaluate the prevalence of the different stages of extra-aortic valvular cardiac damage by the application of Généreux staging and its impact on prognosis in a large, real world cohort of significant AR patients.

Methods

This study retrospectively analysed the clinical, Doppler echocardiographic and outcome data in patients with grade III or greater AR between January 2014 and September 2019. According to the extent of cardiac damage on echocardiography, patients were classified as Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage) or Stage 4 (right ventricular damage). Exclusion criteria were severe aortic stenosis and previous valve repair or replacement. The primary end-point was all-cause mortality.

Results

A total of 572 patients, aged 70.1±13.9 years, 294 (51.3%) men were enrolled. One third of patients were in NYHA I. Based on the proposed classification, 82 patients (14.3%) were classified in stage 0, 130 (22.7%) in stage 1, 276 (48.2%) in stage 2, 68 (11.8%) in stage 3 and 17 (3.0%) in stage 4. Median follow-up time was 3.3±1.9 years. There was a progressive increase in mortality rates according to staging: 8.5% in stage 0, 10.8% in stage 1, 24.9% in stage 2, 42.6% in stage 3 and 52.9% in stage 4 (p<0.001). On multivariable analysis, the extent of cardiac damage was independently associated with excess mortality (HR 1.69, 95% CI 1.29 to 2.21)

Conclusion

Our study demonstrated that this new staging system studied for aortic stenosis also provides increased prognostic value to patients with significant aortic regurgitation. This staging system can be helpful to identify the degree of extra-aortic valvular cardiac damage and to optimize the time of valvular intervention. Further prospective studies are needed to confirm the benefit of the applicability of this model in clinical practice.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho Distribution of stages of cardiac damageSurvival analysis according to stage
Cardiac CT derived 3D reconstruction discriminates for complexity and hemodynamic effect of transcatheter mitral valve repair
Authors: Meijerink F , Wolsink I , Holierook M , Chekanova E V , Planken R N , Van Randen A , De Winter R J , Beijk M A M , Koch K T , Robbers-Visser D , Boekholdt S M , Bouma B J , Baan J
Published: October 2021

Background

Transcatheter mitral valve repair (TMVR) is increasingly used to treat mitral regurgitation (MR) in high risk patients. Optimal transseptal access and guiding catheter position are essential to perform adequate repair. Anatomy of the inter-atrial septum (IAS) and mitral annulus (MA) are often complex and difficult to determine from echocardiography.

Purpose

The aim of the current study was to evaluate whether pre-TMVR cardiac CT and 3D reconstruction of the IAS and MA could discriminate for complexity and hemodynamic effect of TMVR.

Methods

Patients planned for TMVR, underwent cardiac CT scan (if eligible). Post-processing software was used to segment and reconstruct the aortic root, IAS, fossa ovalis (FO) and MA, resulting in a 3D model. The following parameters were measured in each model: (1) IAS angle (°) (2) Posterior-FO angle (°) (3) FO-perpendicularity angle (°) (4) MA area (cm2). Patient specific anatomy was categorized in 4 groups as either (1) Posterior-perpendicular (PP) FO + limited IAS angle, (2) PP FO + wide IAS angle, (3) non-PP FO + limited IAS angle or (4) non-PP FO + wide IAS angle. PP FO was defined as posterior-FO angle >65° and FO-perpendicularity angle >135°. IAS angle was considered limited if <110°. Device implantation time (min) was used to assess complexity of the procedure and was compared between the different groups. MR reduction (grades), number of clips used and mitral valve (MV) gradient (mmHg) were compared for patients with MA area <14 cm2 vs. ≥14 cm2.

Results

46 patients (mean age 75 years, 41% male) were included. Anatomy was classified (1) PP FO + limited IAS angle in 13, (2) PP FO + wide IAS angle in 13, (3) Non-PP FO + limited IAS angle in 8 and (4) Non-PP FO + wide IAS angle in 12. Median device implantation time was 20 min in group 1, compared to 39 min in group 2 (p=0.02), 33 min in group 3 (p=0.03) and 29 min in group 4 (p=0.08). In patients with MA area <14 cm2, MR reduction was greater (2.22 vs. 1.68, p=0.02), number of clips used was lower (1.44 vs. 1.79, p=0.05) and MV gradient was higher, though not significant (3.15 vs. 2.58, p=0.26)

Conclusion

The current study showed that TMVR seemed less complex in patients with an optimal anatomy. In patients with limited mitral annulus area a more favorable hemodynamic effect was achieved. Cardiac CT and 3D reconstruction could therefore be of strong aid for procedural planning of TMVR.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott Vascular Anatomy and device implantation timeHemodynamic effect of annulus area
Impact of atrial fibrillation on the progression and outcomes of isolated mild functional tricuspid regurgitation
Authors: Kwak S , Park J B
Published: October 2021

Background

Atrial fibrillation (AF) is increasingly recognized as a cause of tricuspid regurgitation (TR) in the structurally normal tricuspid valve. However, there are limited data regarding the impact of AF on TR progression and its long-term cardiovascular outcomes.

Purpose

We aimed to investigate the association of AF with the significant TR progression and its impact on clinical outcomes among patients with isolated mild functional TR.

Methods

We studied 834 patients with mild function TR identified on the echocardiography between 2007 and 2019, whose follow-up echocardiography beyond 1-year was available. Major exclusion criteria were the overt causes of primary and secondary TR (i.e., concomitant left-sided heart disease). Primary endpoint was the significant TR progression to more than a moderate degree on the follow-up echocardiography. Composite cardiac event was defined as cardiovascular death, TR surgery, and heart failure admission due to TR.

Results

Of 834 patients with isolated mild functional TR (mean age 65.6 years, 41% men), 292 (35.0%) patients had AF at the baseline. Patients with AF were older and had larger left atrium compared to those without. During the median of 4.55 years follow-up (interquartile interval 2.56–7.24 years), 36 patients developed a significant TR ≥ moderate degree. The cumulative rate of TR progression was significantly higher in patients with AF than those without (11.3% versus 0.6%, P<0.001) (Figure 1). Multivariable Cox analyses showed that AF was associated with a 3-fold higher risk of TR progression (adjusted hazard ratio 3.50, 95% confidence interval 1.42–8.65). Regarding the cardiovascular outcomes, patients who developed significant TR had a higher rate of composite cardiac events compared to those who did not (cardiac events: 38.9% versus 6.3% P<0.001) (Figure 2).

Conclusions

AF is a strong risk factor for TR progression among patients with isolated mild functional TR. In addition, the development of significant TR is associated with worse cardiovascular outcomes. These findings highlight the important pathophysiology of AF on TR development and its clinical consequences.

Funding Acknowledgement

Type of funding sources: None.
Predictors of mortality in patients with left-side infective endocarditis, the ESC-EORP EURO-ENDO registry
Authors: Sambola A , Lozano Torres J , Olmos C , Ternacle J , Calvo-Iglesias F E , Tribouilloy C , Reskovic Luksic V , Separovic-Hanzevacki J , Park S W , Bekkers S , Chan K L , Arregle F , Lung B , Lancellotti P , Habib G ,   EURO-ENDO Investigators
Published: October 2021

Background/Introduction

Infective endocarditis (IE) is associated with high in-hospital mortality, ranging from 16% to 25%, despite improvement in diagnostic and therapeutic strategies, mainly due to complications and heterogeneity of the disease. Baseline risk stratification is essential, in order to focus an aggressive management toward high-risk patients.

Purpose

We sought to assess the association between surgery and 30-day mortality rate as related to vegetation size.

Methods

The ESC-EORP EURO-ENDO registry is a prospective multicentre observational study of patients presenting with definite or possible IE in Europe and ESC-affiliated/non-affiliated countries. Patients were included from January 2016 to 31 March 2018 in 156 centers from 40 countries. Clinical data, blood test analysis and multi-modality imaging tests (echocardiography, computed tomography, PET-CT, magnetic resonance) were collected. Primary endpoint was 30-day mortality. Multivariable logistic regression analysis was performed to assess variables associated with 30-day mortality. Besides, univariable analysis was performed to assess best vegetation size cut-off related to 30-day mortality.

Results

Among 2171 patients with left-side IE, 257 patients (11.8%) died during the first 30 days of IE diagnosis. Patient characteristics and univariable analysis are summarized in TABLE 1. Cut-off value for best vegetation size related to 30-day mortality was vegetation length >14mm, with a HR =2.00 (95% CI 1.59–2.51, p<0.0001) and a Harrell's Concordance of 0.58. After multivariable logistic regression analysis, factors associated with 30-day mortality risk were: vegetation size >14mm (OR =2.68, 95% CI [1.96–3.67], p<0.0001), previous stroke or transient ischemic attack (TIA) (OR =1.60, 95% CI [1.07–2.40], p=0.0235), creatinine >2mg/dL (OR =2.45, 95% CI [1.73–3.47], p<0.0001), presence of embolic events (OR =2.64, 95% CI [1.86–3.74], p<0.0001), hemorrhagic stroke (OR=3.71, 95% CI [1.80–7.64], p=0.0004), presence of heart failure or cardiogenic shock (OR =3.50, 95% CI [2.57–4.77], p<0.0001) and no cardiac surgery during the event (OR =4.07, 95% CI [2.93–5.67], p<0.0001). The C-statistic of the logistic model to predict 30-day mortality was 0.795.

Conclusion

Left-side infective endocarditis had a high 30-day mortality rate (11.8%). Presence of a large vegetation size (>14mm), embolic events, hemorrhagic stroke, renal failure, presence of heart failure or cardiogenic shock were associated with an increase in 30-day mortality. Performing cardiac surgery had a protective effect.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC-EORP EURO-ENDO project from the ESC society
The impact of establishing a regional infective endocarditis (IE) network on pre-operative IE-related complications and on post-operative outcome
Authors: Diab M , Franz M , Hagel S , Guenther A , Struve A , Kuehn H , Ibrahim K , Jahnecke M , Sigusch H , Ebelt H , Faerber G , Lehmann T , Schulze P C , Pletz M W , Doenst T ,   Thuringian endocarditis netowrk
Published: October 2021

Background

Infective endocarditis (IE) requires a high degree of suspicion and advanced level of multidisciplinary management. In 2015, the European guidelines recommended the formation of an endocarditis-team (ET) for optimal treatment of IE. In 2011, we already established an ET within the hospital that was only consulted on demand for certain patients. Since 2015, ET has been increasingly involved in the management of almost all patients with IE. In addition, we established in 2015 a statewide endocarditis- (E) network for the referring hospitals.

Purpose

We investigated the effect of E-network on reducing referral latency and pre-operative IE-related complications. We also investigated the adherence to the ET management recommendations in our hospital and its impact on post-operative stroke and mortality.

Methods

We retrospectively analyzed data from patients operated for IE in our center between 01/2007 and 03/2018. We conducted univariate analysis using Chi-square or Fisher's exact test, Multivariate logistic regression models for in-hospital mortality and post-operative stroke, and Kaplan-Meier estimate of 5-years survival.

Results

Among 630 patients operated for IE in our center, 409 (65%) underwent surgery in the 1st era before 12/2014. S. aureus IE was more frequent in the second era (34% vs 25%, p<0.001). The median time from the onset of symptoms to referral in the 2nd era was halved compared to the first one [7 days (IQR 2–19) vs 15 days (IQR 6–35)]. Patients in the 2nd era were admitted with less IE-related complications, i.e. less preoperative stroke (14% vs 27%, p<0.001), less heart failure (45% vs 69%, p<0.001) less cardiac abscesses (24% vs 34%, p=0.018), less acute renal insufficiency requiring hemodialysis (8% vs 14%, p=0.026). The lack of ET management recommendations was an independent predictor for in-hospital mortality (adjusted OR: 2.13, 95% CI: 1.27–3.53, p=0.004) and post-operative stroke (adjusted OR: 2.23, 95% CI: 1.12–4.39, p=0.02), and was associated with worse 5-years survival (59% compared to 40%, log rank<0.001).

Conclusion

Endocarditis-network led to earlier referral of patients, which resulted in less IE-related complications on admission. Lack of ET management recommendations was an independent predictor for post-operative stroke, in-hospital mortality and was associated with worse 5-years survival.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Comparison of echocardiographic parameters of patients with COVID-19 pneumonia in hospital and three months after discharge
Authors: Yaroslavskaya E , Krinochkin D , Shirokov N , Gultyaeva E , Garanina V , Mamarina A , Osokina N , Gorbatenko E , Musikhina N , Petelina T
Published: October 2021

Background

COVID-19 affects firstly the respiratory system of patients however cardiovascular system is also damaged. To study the impact of a novel coronavirus infection on the cardiovascular system, in particular on echocardiographic parameters after SARS-CoV-2 is very important.

Purpose

To compare echocardiographic parameters in patients with COVID-19 pneumonia in hospital and 3 months after hospital discharge.

Methods

A total of 106 patients with confirmed COVID-19 pneumonia were included in the period from April to July 2020 within “One-year Cardiac Follow-up of COVID-19 Pneumonia”. All patients underwent clinical examination including transthoracic echocardiography in hospital and 3 months ± 2 weeks after discharge. Mean age of patients was 47±16 years (19–84 years), mean body mass index was 28.2±5.7 kg/m2, females were 49%. During hospitalization, chest computed tomography detected mild lesions in 29.2%, moderate lesions in 31.1%, severe lesions in 27.4% and critical lesions in 5.7%. Cardiovascular pathology detected in 52% of patients.

Results

Three months after discharge significant dynamics of mean echocardiographic parameters was observed. Left ventricular end-diastolic, end-systolic and stroke volume decreased (113.8±26.8 vs 93.5±29.4 ml; 37.7±13.0 vs 31.3±14.2 ml; 77.2±17.8 vs 62.2±18.7 ml, respectively; all p<0.001). End-diastolic right ventricular outflow tract diameter, pulmonary artery trunk diameter decreased (26.0 [24.0–9.3] vs 25.0 [23.0–27.0] mm, p=0.004; 21.7±3.6 vs 18.7±2.5 mm, p<0.001), as well as pulmonary artery systolic pressure (28.0 [25.0–32.25] vs 21.5 [17.0–25.0] mmHg) and rate of moderate to severe tricuspid regurgitation (52.4 vs 19.8%, both p<0.001). Right atrium volume (42.0 [37.0–50.0] vs 31.0 [22.0–36.5] ml, p<0.001) and width decreased (36.1±4.6 vs 34.5±6.5 mm, p=0.023), however right atrium length increased (46.7±6.8 vs 48.6±7.1, p=0.021).

Conclusions

In patients after COVID-19 pneumonia echocardiography showed decrease of the load predominantly on the right heart 3 months after discharge. A subgroup analysis is planned depending on the severity of lung damage and presence of cardiovascular pathology.

Funding Acknowledgement

Type of funding sources: None.
Echocardiographic predictors of low risk haemodynamic parameters in patients with pulmonary arterial hypertension
Authors: Rotunno M , Dardi F , Palazzini M , Guarino D , Zuffa E , Magnani I , De Lorenzis A , Ballerini A , Manes A , Galie N
Published: October 2021

Background

A periodic and multiparametric assessment of the risk profile of patients with pulmonary arterial hypertension (PAH) is essential for a low-risk oriented treatment strategy. Haemodynamic parameters anyway cannot be collected at each scheduled outpatients clinic follow-up visit.

Purpose

To evaluate echocardiographic predictors of haemodynamic low-risk parameters in patients with PAH.

Methods

Patients with PAH referred to our centre were included up to 31 December 2019. All patients underwent baseline demographic, clinical, WHO functional class, 6-minute walk test, brain natriuretic peptide (BNP), right cardiac catheterization and echocardiographic evaluation. Through a multivariate logistic regression analysis we evaluate the echocardiographic predictors of low risk for: 1) BNP/right atrial pressure (RAP): NT-proBNP <300 ng/l/BNP <50 ng/l AND RAP <8 mmHg; 2) cardiac index (CI)/mixed venous oxygen saturation (SvO2): CI ≥2.5 l/min/m2 AND SvO2 >65%. Echocardiographic parameters cut-offs were chosen on the basis of the ROC curves or Literature data.

Results

1020 patients were included. The two analysis were performed independently.

1. Independent echocardiographic predictors of low-risk BNP/RAP were: indexed right atrial area, mitral E/A ratio, dimension and inspiratory collapse of inferior vena cava and indexed left ventricular diastolic volume. We elaborated a score utilizing these parameter cut-offs: an indexed right atrial area of 10.4–15 cm2/m2, a mitral E/A ratio of 0.8, dimension and inspiratory collapse of inferior vena cava indicative of 0–5 vs 5–10 vs 10–20 mmHg and an indexed left ventricular diastolic volume of 32 ml/m2. The score has AUC: 0.62, specificity: 92%, sensitivity: 33%, negative predictive value: 70%, positive predictive value: 69%.

2. Independent echocardiographic predictors of low-risk CI/SvO2 were: S wave at TDI, Tei index, tricuspid annular plane systolic excursion (TAPSE), indexed left ventricular diastolic volume and the severity of the tricuspid regurgitation. We elaborated a score utilizing these parameter cut-offs: an S wave at TDI of 9.5 cm/s, a Tei index of 0.4, a TAPSE of 1.7 cm, an indexed left ventricular diastolic volume of 32 ml/m2 and a mild vs more than mild tricuspid regurgitation. The score has AUC: 0.70, specificity: 89%, sensitivity: 50%, negative predictive value: 71%, positive predictive value: 77%.

Conclusion

Echocardiographic parameters can be used to rule out the presence of low-risk BNP/RAP values (indexed right atrial area, mitral E/A ratio, dimension and inspiratory collapse of inferior vena cava and indexed left ventricular diastolic volume) and low-risk CI/SvO2 (S wave at TDI, Tei index, TAPSE, indexed left ventricular diastolic volume and severity of tricuspid regurgitation).

Funding Acknowledgement

Type of funding sources: None.
Circulating CD4+T/methylation signatures of network-oriented SOCS3, ITGAL, NFIC, NCOR2, PGK1 genes associate with hemodynamics in pulmonary arterial hypertension patients
Authors: Benincasa G , Maron B A , Affinito O , D'Alto M , Franzese M , Argiento P , Schiano C , Romeo E , Bontempo P , Golino P , Berrino L , Loscalzo J , Napoli C
Published: October 2021

Background

CD4+ T cells are associated with pulmonary arterial hypertension (PAH) pathogenesis but mechanistic insights are limited.

Purpose

To identify differential CD4+ T methylation signatures in healthy controls vs PAH and evaluate a putative association with the cardiopulmonary hemodynamic profile of affected patients.

Methods

We used RRBS platform to profile CD4+ T DNA methylome in the CLEOPAHTRA clinical trial.

Results

Differentially methylated CpG sites (N=631) annotated to N=408 genes (DMGs). Most of them (65%) were hypermethylated and localized in distal intergenic (36%) and promoter regions (31%). Promoter-related network analysis established the PAH subnetwork highlighting 5 hub DMGs (SOCS3, GNAS, ITGAL, NCOR2, NFIC) and 5 non-hub DMGs (NR4A2, GRM2, PGK1, STMN1, LIMS2) as potential candidate genes (Figure 1). The Infinium Human MethylationEPIC BeadChip on CD4+ T cells from an independent study population confirmed the global RRBS-methylation trends. Both in idiopathic and Associated-PAH, each of these 10 network-oriented DMGs was strongly correlated with at least one hemodynamic parameter such as right atrial pressure (RAP), cardiac index (CI), mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), and pulmonary capillary wedge pressure (PCWP) (Figure 2). In addition, mRNA levels of the ITGAL, NFIC, NCOR2, PGK1 genes and the IL-6-STAT3-SOCS3 signaling axis were significantly upregulated in PBMCs from patients with PAH vs controls suggesting putative drug targets. Furthermore, both SOCS3 methylation and mRNA levels were positively correlated with cardiac index (CI) in idiopathic PAH whereas both PGK1 methylation and mRNA levels were positively correlated with RAP and inversely with CI in Associated PAH suggesting putative non-invasive biomarkers.

Conclusions

This hypothesis-generating study shows for the first time that circulating CD4+ T methylation signatures, inclusive of SOCS3, ITGAL, NFIC, NCOR2, and PGK1 genes may yield insight into pro-inflammatory mechanisms that exacerbate vascular remodeling in PAH and suggest non-invasive biomarkers to optimize patient phenotyping and, possibly, prognostication in PAH.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): PRIN2017F8ZB89 from Italian Ministry of University and Research (MIUR) (PI Prof Napoli) and Ricerca Corrente (RC) 2019 from Italian Ministry of Health (PI Prof. Napoli). Figure 1Figure 2
Impact of COVID-19 pandemic on surgical care of patients with acute aortic conditions
Authors: Yuan X , Rosendahl U , Asimakopoulos G , Quarto C , Rosser B , Gaer J , Petrou M , Bhudia S , Bahrami T , Nienaber C ,   Aortic Centre, Royal Brompton and Harefield Hospital NHS Trust
Published: October 2021

Background

The outbreak of COVID-19 pandemic catastrophically interrupted medical care systems causing substantial decrease in the admission of patients and consecutively a sharp decline in the number of surgeries and interventions. In several European countries, the nationwide lockdown severely restricted movement which may have contributed to this phenomenon on top of anxiety of patients to contract COVID-19 when admitted to hospital.

Purpose

The aim of this analysis was to evaluate the impact of the COVID-19 pandemic onto acute and elective thoracic aortic surgeries and interventions and to compare the data with the same period in 2019 in a single aortic centre.

Methods

Information on admission and surgery/intervention was extracted from hospital electronic record system. Patients who were admitted for treatment of aortic conditions between January 1st to June 30th both in 2019 and 2020 were identified and selected for this analysis. The time from referral to admission and surgery/intervention was noted for service delay analysis. Aortopathies were classified as type A aortic dissection, type B aortic dissection, aortic aneurysm and others. In a daily central hub meeting, urgency was defined as emergent (operation required before the next working day), urgent (operation needed within 48 hours), and elective. Patients' condition and comorbidities were represented by ACEF II score.

Results

Total case volume of 81 in 2019 reference period was reduced to 70 in 2020 (−14%). Elective cases significantly declined from 59 (72.8%) in 2019 to 30 (42.8%) in 2020 (−49%). Urgent and emergent cases were performed more frequently in 2020 with 40 cases versus 22 in 2019 (+45%).

The ACEF II score showed no difference for patients in both periods (2.1±1.9 vs. 2.5±2.1, p=0.221), however, a trend to higher ACEF II score in 2020 consistent with a higher proportion of urgent and emergent cases.

The overall in-hospital delay (from admission to surgery) was not significant affected with 1 (IQR 1–2) versus 1 (IQR 0–2); p=0.991. However, with the official declaration of a pandemic and introduction of restrictions, no in-hospital delay was documented.

In-hospital mortality was observed lower in 2019 as compared in 2020 (6.1% vs 11.4%, P=0.251).

Conclusion

The first wave of COVID-19 pandemic disrupted the aortic service, however, acute care for urgent thoracic aortic conditions and subsequent procedures even increased compared to 2019 as a result of both centralised allocation system and decline of elective cases. Acute aortic syndromes were managed despite COVID-19 according to current guidelines.

Funding Acknowledgement

Type of funding sources: None. Impact of COVID on aortic case load
Prospective application of a risks-adjusted antithrombotic protocol in elderly patients treated with the last generation of everolimus-eluting stents. The SIERRA-75 (EPIC-05) registry
Authors: De La Torre Hernandez J M , Lopez Palop R , Jimenez Mazuecos J M , Carrillo Saez P , Gutierrez Barrios A , Pinar E , Cid B , Fernandez L , Garcia Camarero T , Urbano C , Oteo J F , Jimenez Diaz V A , Gomez Menchero A , Galindo Fernandez E , Perez De Prado A ,   SIERRA-75 (EPIC-05)
Published: October 2021

Background

Elderly patients show a higher incidence of ischemic and bleeding events after PCI.

Purpose

We sought to investigate clinical outcomes in elderly patients revascularized with last generation everolimus-eluting stent (EES) treated with antithrombotic strategies guided by bleeding and ischemic risks.

Methods

Prospective multicenter registry including patients over 75 years revascularized with EES and subsequent antithrombotic therapy guided according to a protocol based on clinical presentation, PCI complexity and the PRECISE DAPT score. The primary safety endpoint was a composite of cardiac death, myocardial infarction and definitive/probable stent thrombosis and the primary efficacy endpoint was TLR. An historical matched group of patients treated with current drug eluting stents other than EES was used as control.

Results

Finally, 1,064 patients were included, 80.8±4.2 years, 36.6% women, 72% ACS and 53.6% complex PCI. Primary safety endpoint was met in 6.2% and primary efficacy endpoint in 1.5%. Bleeding BARC 2–5 was reported in 7.8% and definite or probable stent thrombosis in 1.3%. The multivariable adjusted model showed no significant association of the prescribed short/long therapies with any endpoint. No stent thrombosis were reported in the subgroup with shorter DAPT duration. As compared to control group, bleeding BARC 2–5 was significantly lower in SIERRA-75 group (7.4% vs 10.2%, p=0.04) as well as the composite of MACE and bleeding (14.3% vs 18.5%, p=0.02).

Conclusions

In elderly population the use of last generation EES along with a predefined risks-adjusted antithrombotic regimen seems to be associated with an improved prognosis in terms of ischemic and bleeding outcomes.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott Laboratories
Clinical outcomes following use of sirolimus coated balloon in side-branches during provisional stent technique in true bifurcations
Authors: Athulorala S , Loku Waduge B H , Kalkat H , Saif A , Fawzy A M , Bhatia G , Kumar N , Freestone B H , Ment J , Lee K , Pitt M , Pulikal G , Basavarajaiah S
Published: October 2021

Introduction

Provisional stenting is the preferred strategy even in true bifurcations, however, to minimise the need for repeat revascularization of side-branches, the use of drug coated balloons has been suggested. Most of the data available in the literature are on Paclitaxel coated balloons, a drug which is almost obsolete in stents due to its cytotoxic properties. There is limited data on Limus coated balloons (SCB), a drug which is the default for all the currently available drug eluting stents. In this study, we explore the clinical outcomes following use of SCB in side-branches during provisional stent technique in true bifurcations.

Methods and results

We evaluated all de novo lesions treated with DCB for true bifurcations between March 2018 and October 2020 at our centre. The results are reported as cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularisation (TLR) and MACE (combination of cardiac death, target vessel MI and TLR).

During the study period 110 patients with de novo lesions were treated with SCB for bifurcation lesions. Of them; 66 were in true bifurcations. The mean age of patients were 66.3±10.7 years, 75% (n=50) were male, 40 (61%) were in the setting of acute coronary syndrome, 52% (n=34) had diabetes and 32% (n=21) had CKD. Pre-dilatation was performed in all cases and none of them needed bailout stenting. Small vessels (<3.0 mm) accounted for 72% (n=48) of cases. Non-compliant balloons and scoring balloons to prepare the lesion was used in 51% (n=34) and 13% (n=9) of cases respectively. The mean diameter and length of SCBs were 2.6±0.4 mm and 23.2±7.3 mm respectively.

During a median follow-up of 729 days (2-years); there were no cardiac deaths, TVMI occurred in one case (2%), TLR in 3% (n=2) and the overall MACE rate was 3% (n=2). There were no documented cases of acute vessel closure

Conclusion

The results from long term follow-up with this relatively new technology of DCB in treatment of side-branch in true bifurcation is encouraging. We have demonstrated low rates of hard endpoints, TLR and MACE rates despite complex group of patients (61% ACS, 52% diabetics and 32% CKD). These results are encouraging, but going forward, we need more data from larger patient trials. In the meanwhile our data should instil confidence to adopt this technology in clinical practice.

Funding Acknowledgement

Type of funding sources: None.
Does the use of scoring balloon prior to drug coated balloons improve clinical outcomes in de Novo coronary lesions?
Authors: Fawzy A M , Loku Waduge B H , Kalkat H , Saif A M , Athulorala S , Bhatia G , Kumar N , Freestone B H , Ment J , Lee K , Pitt M , Pulikal G , Basavarajaiah S
Published: October 2021

Aims

The use of scoring balloon prior to drug coated balloon has been proven to be effective in restenotic lesions. However, their effect in de novo lesions has not been tested. Logic tells that the use of scoring balloons should enhance the drug uptake into the vessel wall. In this study, we evaluated this concept of scoring balloon prior to DCB in de novo lesions and compared to those who were treated with a conventional approach (semi-compliant and/or non-compliant balloons).

Methods and results

We evaluated all de novo lesions treated with DCB between March 2018 and October 2020 at our centre. The results are reported as cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularisation (TLR) and MACE (combination of cardiac death, target vessel MI and TLR).

During the study period 348 patients with de novo lesions were treated with DCB. Of those, 49 were predilated with scoring balloon prior to use of DCB and the remaining 299 were predilated with non-scoring balloons (semi-compliant and/or non-compliant). The majority of the baseline characteristics had no statistically significant differences (table 1), with the exception of the mean diameter of the lesions were larger in the scoring balloon group than non-scoring balloon group: 2.7±0.5 vs. 2.49±0.4; p=0.003 and mean length of lesions were longer in the non-scoring balloon group: 26±8.8 vs. 23±7.7; p=0.02. During the median follow-up of 660 days, clinical outcomes between the scoring and non-scoring balloons were; cardiac death: 0 vs. 8 (3%); p=0.5, TVMI: 2 (4%) vs. 8 (3%); p=0.9, TLR: 3 (6%) vs. 25 (8.4%); p=0.8, MACE: 4 (8%) vs. 34 (11%) p=0.7

Conclusion

There were no differences in the clinical outcomes between the two groups indicating that use of scoring balloon prior to DCB may not offer additional benefit, although this needs to be confirmed in a larger patient group.

Funding Acknowledgement

Type of funding sources: None.
Sex differences in transradial access site characteristics and crossover in STEMI
Authors: Zafirovska Taleska B , Petkoska D , Jovkovski A , Vasilev I , Taravari H , Kitanoski D , Kedev S
Published: October 2021

Objective

To assess the differences according to sex in radial artery access site characteristics and crossover and it's influence on the success of ST segment elevation myocardial infarction (STEMI) procedures with primary chosen transradial access site in a large series of patients.

Background

Transradial angiography (TRA) is now the default access site for PPCI, but technically is a more challenging approach mostly due to anatomic challenges connected to the radial artery.

Methods

All 5092 consecutive STEMI patients from our center, in the period from March 2011 until December 2017 were examined. Patient were divided in two groups according to sex. Preprocedural radial artery angiography was performed in all patients. Clinical and procedure characteristics, type of radial anatomy variants, transfer to other access sites, transfer direction and procedure time were analyzed. Access site bleeding complications and in-hospital mortality were also recorded. Primary end-point of the study was the occurrence of TRA failure and need to crossover to another access site to finish the procedure.

Results

From the STEMI population in this period the female group had 1326 PPCI treated patients and the male group 3766 patients. The female group of patients was older 65±11 than the male group 59±11 (p<0,0001). BMI was 27 vs. 30 in the male group (p=0.0003). Most common risk factors in both groups were hypertension, smoking and diabetes, with the latter being more frequent in the female group p<0,0001. Radial artery anomalies were more frequent in the female group 8,8% vs 6,5% (p<0,0001), with complex RA loop and tortuous RA having double percentage than in their male counterparts. Primary chosen TRA access site failure occurred in 4.6% (61) vs. 3.5% (97) of STEMI patients (p<0.0001). Most common access site crossover site was right ulnar access in both groups with 57 and 61% accordingly. Access site bleeding complications, were more common in the female group with 4.4% vs. 3.2%, also this difference persisted in EASY score hematoma 3 to 5. Clinical radial artery spasm was significantly more frequent in female patients 5,7% vs. 2.2% (p<0.0001). In-hospital mortality rate was similar in the two group of patients.

Conclusion

Female sex is a significant risk factor for TRA failure in STEMI usually connected to smaller size of RA and the more common finding of radial artery anomalies and spasm.

Funding Acknowledgement

Type of funding sources: None.
The timing and mechanism of high-grade AV block post-TAVI: knowing your enemy
Authors: Gomes D , Felix Oliveira A , Campante Teles R , Gama F , Carmo P , Brito J , De Araujo Goncalves P , Cavaco D , Sousa Almeida M
Published: October 2021

Background

Complete atrioventricular block (AVB) requiring permanent pacemaker implantation (PPMI) is still a major limitation of transcatheter aortic valve implantation (TAVI) procedures. Although right-bundle branch block (RBBB), membranous septum (MS) length and self-expandable prothesis are recognizable risk factors, their predictability to PPMI is far from satisfactory. While some patients develop persistent intra-procedure high-grade AVB (H-AVB), others present much later with severe bradycardia.

Purpose

This study aims to describe and compare the characteristics of patients who develop AVB during or after TAVI.

Methods

Single centre prospective registry of 506 consecutive patients submitted to TAVI with no previous pacemaker between 2017 and 2020. Post-procedure PPMI (up to 30 days after discharge) was studied and divided into two groups according to the development of persistent intra-procedure H-AVB (Group A) or post procedure H-AVB (Group B). Baseline ECG, computed tomography and TAVI-related characteristics were analyzed.

Results

A total of 88 patients (17,3%), aging 83±6 years, 36.4% male, underwent post-TAVI PPMI (6 after discharge). Previous conduction disturbances were present in 50 (56.8%) patients and 25 (28.4%) had RBBB. 83% were submitted to self-expandable TAVI. Forty-two patients (47.7%) had persistent intra-procedure H-AVB (Group A) whereas 52.3% had post-procedure H-AVB (Group B). In patients with persistent intra procedure H-AVB previous RBBB was significantly more frequent (45.2%, n=19) when compared to patients with post-procedure H-AVB (13%, n=6; p=0.001). Contrarily, AF and previous left-bundle branch block (LBBB) were more likely in Group B. No difference in valvular calcification, MS length, prosthesis type or implantation technique was noted (picture 1). In the group with post-procedure H-AVB, 21.7% had transient AVB during TAVI and all developed de novo LBBB or first-degree AVB post-TAVI. Among these, 33 patients (71.7%) developed delayed H-AVB (>48h post-procedure) while the remaining presented earlier.

Conclusions

In patients with PPMI post-TAVI, those with persistent intra-procedure H-AVB had higher rates of previous RBBB, while those with post-procedure H-AVB frequently had a normal baseline ECG. Anatomical and procedural characteristics did not differ between groups. Further studies are needed to confirm these results.

Funding Acknowledgement

Type of funding sources: None.
Pacemaker implantation rate after TAVI with the latest generation balloon-expandable valve SAPIEN 3 Ultra
Authors: De Torres-Alba F , Kaleschke G , Vormbrock J , Deschka H , Baumgartner H
Published: October 2021

Introduction

The latest generation balloon-expandable transcatheter heart valve SAPIEN 3 Ultra (S3-Ultra) was recently released and has shown promising initial results. So far, the pacemaker (PM) implantation rate after transcatheter aortic valve implantation (TAVI) with the S3-Ultra system compared to the SAPIEN 3 (S3) system has not been widely investigated.

Aims

To compare the PM implantation rate after TAVI with the latest generation S3-Ultra system with the S3 system in an unselected cohort of patients at risk.

Methods

We analyzed the development of conduction abnormalities after TAVI in 1780 consecutive patients treated with S3 and S3-Ultra between January 2014 and February 2021. After excluding valve-in-valve procedures (n=31) and patients with previously implanted PM (n=203) 1546 patients were finally analyzed. All patients at risk (i. e. those without previous PM) were monitored with ECG for at least 7 days after TAVI.

Results

Of 1546 patients, 1382 were treated with S3 (20 mm, 14; 23 mm, 524; 26 mm, 558; 29 mm, 286) and 164 with S3-Ultra (20 mm, 0; 23 mm, 77; 26 mm, 87). There were no significant differences in baseline demographic, ECG and procedural characteristics. There was no significant difference in the rate of new developed conduction abnormalities or PM implantation rate between S3 and S3-Ultra in the overall cohort (37.8% S3 vs 33,7% S3-Ultra, p=0.451 for all new conduction abnormalities, 13.8% S3 vs 14.6% S3-Ultra, p=0.756 for PM implantation). This comparable PM implantation rate between the two systems was consistent when analyzing only the 23 and 26 mm valve sizes of the S3 system (12.1% S3 vs. 14.6% S3-Ultra, p=0.361) and when excluding the first period of S3 implantation at our institution (2014) before a modification of the implantation technique that lead to a drop in the rate of PM implantations (S3 2015–2020 12.9% vs S3-Ultra 14.6%, p=0.534).

Conclusions

In our cohort, the PM implantation rate after TAVI with the S3-Ultra system was comparable to that of its predecessor.

Funding Acknowledgement

Type of funding sources: None.