bluuebunny/crossref_metadata_2025 huggingface dataset:
Utility and futility of MitraClip implantation in secondary mitral regurgitation in a real-world population: the role of 3D transthoracic echocardiography
Authors: Mantegazza V , Muratori M , Ghulam Ali S , Garlasche' A , Gripari P , Fusini L , Vignati C , De Martino F , Agostoni P , Ferrari C , Bartorelli A L , Pontone G , Pepi M , Tamborini G
Published: October 2022

Introduction

Two recent prospective trials have been published, reporting opposite results on the efficacy and utility of the MitraClip (MC) procedure in patients with secondary mitral regurgitation (SMR). A ratio between the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV) ≥0.150 by two-dimensional (2D) transthoracic echocardiography (TTE) has been proposed to identify patients with disproportionate SMR, who would benefit from MC.

Purpose

To assess the prognostic role of clinical and echocardiographic parameters in a real-world population of SMR patients undergoing the MC procedure at our Institute.

Methods

Ninety-two patients underwent MC implantation. We retrospectively reviewed their clinical, and laboratory data, as well as 2D and three-dimensional (3D) TTE, and intraoperative transoesophageal echocardiography (Figure 1). The primary endpoint was a composite of cardiovascular death and/or hospitalisation for heart failure within 12-months follow-up.

Results

Thirty-one patients reached the endpoint (EP+), 61 did not (EP−). Demographics and anti-remodelling drugs were similar in EP+ and EP. Among comorbidities and laboratory data, EP+ significantly differed from EP− in smoking history, and extracardiac artery disease prevalence (65% vs. 39%, and 39% vs. 16%, respectively); EuroScoreII (12.2% vs. 5.2%); NYHA class ≥3 (94% vs. 69%); haemoglobin (12±2 vs. 13±2 g/dL), and brain natriuretic peptide levels (855 [426–1500] vs. 357 [170–902] pg/mL). At 2D TTE no significant difference emerged, including the SMR grade, except for the tricuspid annular plane systolic excursion (Figure 2). Biventricular 3D ejection fraction was significantly lower in EP+ vs. EP− (Figure 2). Residual intraoperative SMR grade after MC deployment was 1.9±0.6 in EP+ vs. 1.3±0.5 in EP− (p<0.001).

Conclusion

The proposed cut-off for EROA/LVEDV ratio may be suboptimal for predicting the MC utility in real-world populations. Rather, prognosis may be more influenced by the patient's pre-operative clinical status, right ventricular systolic function, 3D left ventricular ejection fraction, and by the success of the procedure.

Funding Acknowledgement

Type of funding sources: None.
Supine ergometry for aged population with degenerative mitral regurgitation: evidence for prognostic yield
Authors: Armenis I , Demerouti E , Motsi A , Kyrzopoulos S , Tsiapras D , Athanassopoulos G
Published: October 2022

Introduction

Degenerative mitral regurgitation (MR) has an increased prevalence with aging with risk stratification evolving as a complex scenario. Semisupine bicycle ergometry (SBE) is a currently applied means to interrogate noninvasive hemodynamics.

Aim

Aim of the study was to interrogate prognostic parameters by SBE in asymptomatic moderate to severe degenerative MR for patients older than 65 years.

Patients and methods

One hundred seventy-four asymptomatic MR patients (pts), followed up on valve clinic in a tertiary center (age 56/14 female 71), were referred for SBE. MR related cardiac events (surgery, NYHA worsening) during follow up of 34/25 months occurred in 24 pts. Age group >65 had 53 pts (age 71/4 vs 50/13 <0.001, females 36% vs 43%). The following parameters (mean/SD) were estimated at rest (R) and SBE (Ex): Biplane left ventricular (LV) ejection fraction (EF), stroke volume (SV), 2D LV strain (SR), tricuspid peak gradient (TRpg), transmitral E/e, HR, systolic blood pressure (SBP), HR*SBP product and their respective % changes (%d).

Results

Group >65 during SBE had a decreased workload (Watts: 74/22 vs 89/18, p<0.001), similar % achieved target heart rate (73/11 vs 69/10), with more symptoms (30% vs 16%, p<0.01). Event rate was greater (30% vs 7%, p<0.001). Group aged>65 had differences in SBPR (145/20 vs 132/19, p<0.002), SREx (20/4 vs 21/5, p<0.04), EFEx (64/9 vs 68/6, p<0.01), TRpgR (34/11 vs 27/6, p<0.001), TRPG Ex (55/13 vs 50/10, p<0.02), E/eEx (14/6 vs 11/3, p<0.006), %dSV (0.01/0.23 vs 0.14/0.25, p<0.001) and %dEF (0.12/0.08 vs 0.15/0.11, p<0.03). In stepwise logistic regression analysis for events, E/eEx was the only selected (log exp 0.89, p<0.05). Classification for events by ROC analysis gave a E/eEx cut off 13 (area 0.67, p=0.01) with sensitivity/specificity 50/80%. Kaplan Meier analysis revealed prognostic contribution for E/eEx >13 only in the age >65 (log rank p<0.04, Figure 1). Moreover, symptomatic SBE had a decisive prognostic contribution in the aged cohort (Kaplan-Meier log rank = 0.004, Figure 2).

Conclusion

SBE may be applied with an efficient performance in the older then 65 years age spectrum, within the context of asymptomatic moderate to severe degenerative MR, providing critical information for risk stratification

Funding Acknowledgement

Type of funding sources: None.
Correlation between NT-proBNP and pulmonary hypertension in patients with asymptomatic pirmary mitral regurgitation and preserved left ventricular ejection fraction
Authors: Dirsiene R , Tamulenaite E , Montvilaite A , Ereminiene E , Vaskelyte J J
Published: October 2022

Background

Pulmonary hypertension (PH) is a significant complication of mitral regurgitation (MR), leading to worse outcomes [1]. PH is not prominent at rest during an early stage of MR, but could be induced during stress. Elevated levels of natriuretic peptides are related to subclinical myocardial injury [2,3] including elevated systolic pulmonary artery pressure (SPAP) and it has a prognostic impact in patients with primary MR [4,5].

Aim

The aim of this study was to evaluate correlation between NT-proBNP and SPAP at rest and during stress in asymptomatic patients with primary MR and preserved left ventricular ejection fraction.

Methods

Resting and stress (veloergometry as per protocol 25+25 W every 3 minutes) 2D transthoracic echocardiography was performed for 60 asymptomatic patients (age 61.45±11.99 years) with moderate–severe MR and preserved left ventricular ejection fraction (>60%) at rest. According to the presence of exercise induced pulmonary hypertension ((EIPH) SPAP >60 mmHg during stress) patients were divided into PH (n=20, 33.33%) and non-PH (n=40, 66.67%) groups. Statistical analysis was performed using the SPSS 27.0 software. The value of p<0.05 was considered as statistically significant.

Results

Age, gender ratio, clinical characteristics, LV volume and diameter indexes, RV size and conventional functional parameters were similar in both groups. NT-proBNP concentration was significantly higher in PH group than in patients without EIPH (261.50 [138–543] pg/ml vs. 92 [58.95–149.50] pg/ml, p=0.002). Also, NT-proBNP concentration has significant moderate correlation with SPAP at rest (r=0.599, p<0.001) and during peak stress (r=0.652, p<0.001). NT-proBNP >122 pg/ml could predict the presence of EIPH with 91.7% sensitivity and 66.7% specificity in patients with primary moderate–severe MR with preserved left ventricular ejection fraction (Picture 2).

Conclusions

In patients with primary moderate-severe MR and preserved left ventricular ejection fraction, higher levels of NT-proBNP correlated with higher SPAP at rest and during stress and was related to EIPH. NT-proBNP >122 pg/ml is a sensitive predictive value of EIPH in cases of primary MR and preserved left ventricular ejection fraction.

Funding Acknowledgement

Type of funding sources: None.
Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve intervention
Authors: Tanaka T , Sugiura A , Kavsur R , Oeztuerk C , Vogelhuber J , Kuetting D , Meyer C , Zimmer S , Grube E , Bakhtiary F , Nickenig G , Weber M
Published: October 2022

Background

The role of right-ventricular (RV) function in patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI) is poorly understood. Although cardiac computed tomography (CCT) provides elaborate three-dimensional (3D) visualization of the entire anatomy of the RV and theoretically allows to assess the global RV systolic function. Nevertheless, the utility of the functional assessments of the RV using CCT remains unclear in patients undergoing TTVI.

Purpose

This study investigated the association of right-ventricular ejection fraction (RVEF) assessed by CCT with clinical outcome in patients undergoing TTVI.

Methods

We retrospectively assessed 3D-RVEF by using pre-procedural CCT images in patients undergoing TTVI with either edge-to-edge repair or annuloplasty device. RV dysfunction (RVD) was defined as a CT-RVEF <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within one year after TTVI.

Results

Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Patients with CT-RVEF <45% were more likely to be male, to have a previous history of coronary artery disease, and had higher EuroSCORE II and a lower LVEF compared to those with CT-RVEF ≥45%, while the severity of TR was comparable between the groups.

Among the patients with CT-RVEF <45%, acute procedural success was achieved in 93.1%, and in-hospital mortality was 1.7%, which were comparable to those with CT-RVEF ≥45%.

Patients with CT-RVEF <45% had an improvement in New York Heart Association functional class at follow-up compared to baseline; however, CT-RVEF <45% was associated with a higher risk of the composite outcome (adjusted hazard ratio: 3.23; 95% confidence interval: 1.52–6.88; p=0.002) (Figure 1). Furthermore, CT-RVEF had an additional value to stratify the risk of the composite outcome beyond two-dimensional transthoracic echocardiographic (TTE) assessments (Figure 2).

In addition, patients with CT-RVEF <45% exhibited an attenuated association between a reduction in TR to <3+ and a lower incidence of the composite outcome after TTVI compared to those with CT-RVEF ≥45%.

Conclusions

TTVI is safe and feasible regardless of baseline RV function, while RVD, defined as 3D-RVEF <45%, is associated with a higher risk of the composite outcomes within one year after TTVI. Furthermore, our findings suggest that the prognostic benefits of TR reduction might be attenuated in patients with RVD. Given the additional prognostic value of CT-RVEF to the conventional echocardiographic assessments, the assessments of 3D-RVEF with CCT may refine the patient selection for TTVI.

Funding Acknowledgement

Type of funding sources: None.
A streamlined, machine learning-derived approach to risk-stratification in heart failure patients with secondary tricuspid regurgitation
Authors: Heitzinger G , Spinka G , Koschatko S , Dannenberg V , Halavina K , Mascherbauer K , Winter M P , Strunk G , Pavo N , Kastl S , Huelsmann M , Rosenhek R , Hengstenberg C , Bartko P E , Goliasch G
Published: October 2022

Background

Secondary tricuspid regurgitation (sTR) is the most frequent valvular heart disease and has significant impact on mortality. A high burden of comorbidities often worsens the already dismal prognosis of sTR, while tricuspid interventions remain underused and initiated too late.

Objectives

To examine the most powerful predictors of all-cause mortality in moderate and severe sTR using machine learning techniques and to provide a streamlined approach to risk-stratification using readily available clinical, echocardiographic and laboratory parameters.

Methods

This large-scale, long-term observational study included 3359 moderate and 1509 severe sTR patients encompassing the entire heart failure spectrum (preserved, mid-range and reduced ejection fraction). A random survival forest was applied to investigate the most important predictors and group patients according to their number of adverse features (Figure 1).

Results

The identified predictors and thresholds, that were associated with significantly worse mortality were higher age (≥75 in moderate and ≥70 years in moderate and severe sTR respectively), higher NT-proBNP (≥4000 pg/ml), increased high sensitivity C-reactive protein (≥1.0 mg/dl), serum albumin <40 g/L and hemoglobin <13 g/dL. Additionally, grouping patients according to the number of adverse features yielded important prognostic information, as patients with 4 or 5 adverse features had a sevenfold risk increase in moderate sTR (7.11 [2.27–4.30] HR 95% CI, P<0.001) and fivefold risk increase in severe sTR (5.08 [3.13–8.24] HR 95% CI, P<0.001) (Figure 2: A moderate sTR derivation, B moderate sTR validation, C severe sTR derivation, D severe sTR validation).

Conclusion

This study presents a streamlined, machine learning-derived and internally validated approach to risk-stratification in patients with moderate and severe sTR, that adds important prognostic information to aid clinical decision-making.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund
The 4A classification for patients with tricuspid regurgitation
Authors: Gonzalez Gomez A , Hinojar R , Fernandez-Golfin C , Monteagudo J M , Garcia-Martin A , Gacia-Sebastian C , Garcia-Lunar I , Sanchez-Recalde A , Salido L , Pardo A , Zamorano J L
Published: October 2022

Background

Significant Tricuspid Regurgitation (TR) is associated with increased morbi-mortality. Clinical evaluation of TR patients is challenging.

Purpose

To establish a new clinical classification specific for patients with TR, the 4A classification, and evaluate its performance on prognosis.

Methods

Consecutive patients with isolated at least severe TR and absence of episodes of heart failure (HF) evaluated in the Heart Valve Clinic were included. Signs and symptoms of Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia where registered, follow up was performed every 6 months. 4A classification ranged from A0 (no A) to A4 (three or four A's present). A combined endpoint of hospital admission due to right HF and cardiovascular mortality was defined.

Results

135 patients with significant TR between 2016 and 2021 were included (69% females, mean age was 78±7 years). During a median follow-up of 26 months (IQR: 10–41 months), n=53 patients (39%) reached the combined endpoint. 52 (38%) admitted for heart failure and 11% (n=15) died. At baseline 94% of patients were in NYHA I or II whereas 24% presented A2 or A3. The presence of A2 or A3 showed a high incidence of events (figure). The change in 4A class and GGT remained independent predictor of HF and cardiovascular mortality (adjusted HR per unit of change of 4A class 1.95 [1.37–2.77], p<0.001)

Conclusions

For the first time, we show the use of a new clinical classification, specific for patients with TR based on signs and symptoms of right HF that is prognostic of events.

Funding Acknowledgement

Type of funding sources: None.
Influence of pacemaker leads on the severity of tricuspid regurgitation after successful mitral valve edge to edge repair
Authors: Alsaad M , Lawrenz T , Marx K , Stellbrink C
Published: October 2022

Background

After percutaneous mitral-valve edge-to-edge repair (MVER) for mitral regurgitation (MR) in patients with baseline tricuspid regurgitation (TR), about one third of patients shows improvement in TR severity. It is unknown whether this improvement may depend on the presence of a right ventricular (RV) pacemaker (PM) lead.

Aim

We investigated whether the presence of an existing RV PM lead influences TR severity after successful MVER due to symptomatic secondary MR.

Methods and results

We retrospectively analyzed 115 consecutive patients with symptomatic secondary high-grade MR (age 78.1±9.4 years, 50 women (43%) and baseline TR grade > or =1 (semiquantitative grading from 0 to 5) treated with MVER using the MitraClipTM device (Abbott, Cardiovascular, USA) and separated them in 2 groups, 43 patients with a PM lead compared to 72 pts without (see Table). TR grading by echocardiography was performed before and 3 months after MVER. (median follow up duration was 3 months). Procedural success with reduction of MR to < or =2/4 grades was 100% in both groups (p<0,001 vs. baseline). There was an overall significant change in TR grade after MVER in 46 pts (p 0,032): but both increase in TR in 17 pts (16.7%, p=0.58), in 10 pts with and in 7 pts without PM lead (58.8% vs. 41.2%, respectively; p=0.84) was not significant; the decrease in TR in 29 patients (28.4%, p=0.57), in 20 pts with and in 9 pts without PM lead (69% and 31%, respectively; p=0.47) also failed to reach statistical significance. TR reduction was associated with RV dilatation at baseline (p=0.006) but not the presence of pulmonary hypertension (p=0.83).

Conclusion

There was an overall significant change in TR after successful MVER. Although there was a trend towards an increase in TR after MVER in pts with PM lead there was no overall significant correlation between changes in TR severity and the presence of an RV PM lead but rather with baseline RV dilatation.

Funding Acknowledgement

Type of funding sources: None.
Infective endocarditis in diabetic patients: a different profile with prognostic
Authors: Biezma Lopez M , Munoz Garcia P , De La Villa Martinez S , Farinas Alvarez M C , Arnaiz De Las Revillas F , Gutierrez Carretero E , De Alarcon Gonzalez A , Rodriguez Garcia R , Llopis J , Goenaga Sanchez M A , Gutierrez Villanueva A , Plata Ciezar A , Vidal Bonet L , Martinez-Selles M
Published: October 2022

Background

Infective Endocarditis (IE) is a severe condition. Diabetes mellitus (DM) has been associated with a poor prognosis in other settings. Our aim was to describe the profile and prognosis of IE with and without DM and to analyse the prognostic relevance of DM-related organ damage.

Methods

Retrospective analysis of the Spanish IE Registry (2008–2020).

Results

The cohort comprises 5.590 IE patients with a mean age of 65.0±15.5 years, 3.764 (67.3%) were male. DM was found in 1.625 patients (29.1%) and 515 presented DM-related organ damage. DM prevalence during the first half of the study period was 27.6% vs. 30.6% in the last half, p=0.015. Patients with DM presented higher in-hospital mortality than those without DM (521 [32.1%] vs 924 [23.3%] p<0.001) and higher one-year mortality (640 [39.4%] vs 1.131 [28.5%] p<0.001). Among DM patients, organ damage was associated with higher in-hospital (200 [38.8%] vs 321 [28.9%], p<0.001) and one-year mortality (247 [48.0%] vs 393 [35.4%], p<0.001). Multivariate analyses showed an independent association of DM with in-hospital (odds ratio [OR] = 1.34, 95% confidence interval [CI]: 1.16–1.55, p<0.001) and one-year mortality (OR = 1.38, 95% CI: 1.21–1.59, p<0.001). Among DM patients, organ damage was independently associated with higher in-hospital (OR = 1.37, 95% CI: 1.06–1.76, p=0.015) and one-year mortality (OR=1.59, 95% CI: 1.26–2.01, p<0.001)

Conclusions

The prevalence of DM among patients with IE is increasing and is already above 30%. DM is independently associated with a poor prognosis, particularly in the case of DM with organ damage.

Funding Acknowledgement

Type of funding sources: None.
Risk calculator to predict 30-day mortality in left-sided infective endocarditis. The EURO-ENDO score
Authors: Lozano Torres J , Sambola A , Magne J , Olmos C , Ternacle J , Calvo F , Tribouilloy C , Reskovic Luksic V , Separovic-Hanzevacki J , Park S W , Cam Bekkers S , Chan K L , Iung B , Lancellotti P , Habib G
Published: October 2022

Background/Introduction

Infective endocarditis (IE) is associated with high in-hospital mortality, despite improvements in therapeutic strategies. Nonetheless, there is no prospective risk model to estimate IE mortality.

Purpose

We sought to develop and validate a calculator to predict 30-day mortality risk regarding to perform surgery or medical treatment alone in left-sided IE.

Methods

This is a prospective, multicenter registry that included patients between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Patients with possible or definite left-sided IE were included in the analyses. Clinical, biological, microbiological and imaging data were collected. The primary end point was 30-day mortality in patients with left-sided IE. The risk calculator was based on multivariable Cox regression models. The accuracy of the logistic regression models was assessed by discrimination and calibration using C-statistic and Hosmer-Lemeshow test.

Results

Among 3116 patients included, 2171 patients presented left-sided IE and 257 patients (11.8%) died during the first 30 days of IE diagnosis. After multivariable Logistic regression analysis, eleven variables were associated with 30-days mortality and were included in the calculator: previous cardiac surgery, previous stroke/TIA, creatinine >2 mg/dL, S. aureus infection, embolic events on admission, heart failure or cardiogenic shock, vegetation size >14 mm, presence of abscess, severe regurgitation, double left-sided IE and no left valve surgery. There was an excellent correlation between the predicted 30-days mortality in both models with or without performing left valve surgery (area under the receiver operator curve: 0.798 and 0.758, respectively). Moreover, calibration by Hosmer-Lemeshow were 0.085 and 0.09, respectively).

Conclusion(s)

Our risk score in patients with left-sided IE provides an accurate individualized estimation of 30-day mortality according to perform or not perform left-valve surgery. It allows medical professionals to determine whether submitting patients to surgery or not, and thus improve their prognosis.

Funding Acknowledgement

Type of funding sources: None.
Characteristics, management, and outcomes of patients with left-sided infective endocarditis complicated by heart failure: a substudy of the ESC-EORP EURO-ENDO (European infective endocarditis) regist
Authors: Bohbot Y , Habib G , Stohr E , Chirouze C , Hernandez-Meneses M , Melissopoulou M , Scheggi V , Branco L , Olmos C , Reye G , Pazdernik M , Iung B , Sow R , Lancellotti P , Tribouilloy C
Published: October 2022

Background/Introduction

Congestive heart failure (CHF) is a strong prognostic factor in infective endocarditis (IE), but data are lacking regarding its current management and outcome in Europe.

Purpose

To evaluate the current management and survival of patients with left-sided IE complicated by CHF.

Methods

We used data of the ESC-EORP EURO-ENDO registry, which is a prospective multicentre observational study conducted between January 1, 2016 and March 31, 2018 in 156 centres in 40 countries. The primary endpoints were 30-day and one-year mortality.

Results

Among the 3116 patients enrolled in this prospective registry, 2449 (mean age: 60 years, 69% male) with left-sided (native or prosthetic) IE were included in this study. Patients with CHF (n=698, 28.5%) were older, with more comorbidity and more severe valvular damage (mitro-aortic involvement, vegetations >10mm and severe regurgitation/new prosthesis dehiscence) than those without CHF (all p≤0.019). Patients with CHF experienced higher 30-day and one-year mortality than those without (20.5% vs. 9.0% and 36.1% vs. 19.3%, respectively) and CHF remained strongly associated with 30-day (OR [95% CI]: 2.37 [1.73–3.24]; p<0.001) and one-year mortality (HR [95% CI]: 1.69 [1.40–2.05]; p<0.001) after adjustment for established outcome predictors, including early surgery, or after propensity matching for age, sex, and comorbidity (n=618 [88.5%] for each group, both p<0.001). Early surgery, performed on 49% of these patients with IE complicated by CHF, remained associated with a substantial reduction in 30-day mortality following multivariable analysis, after adjustment for age, sex, Charlson index, cerebrovascular accident, staphylococcus aureus IE, Streptococcal IE, uncontrolled infection, vegetation size >10mm, severe valvular regurgitation and/or new prosthetic dehiscence, perivalvular complication, and prosthetic IE (OR [95% CI]: 0.22 [0.12–0.38]; p<0.001) and in one-year mortality (HR [95% CI]: 0.29 [0.20–0.41]; p<0.001).

Conclusion

CHF is common in left-sided IE and is associated with older age, greater comorbidity, more advanced lesions, and markedly higher 30-day and one-year mortality. Early surgery is strongly associated with lower mortality but is performed on only approximately half of patients with CHF, mainly because of a surgical risk considered prohibitive.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott Vascular Int. (2011–2014) Amgen Cardiovascular (2009–2018),
Temporal trends in the incidence of endocarditis among patients with a prosthetic heart valve: a nationwide study
Authors: Hadji-Turdeghal K , Jensen A D , Bruun N E , Iversen K , Bundgaard H , Smerup M H , Koeber L , Oestergaard L , Fosboel E L
Published: October 2022

Background

The incidence of infective endocarditis (IE) is increasing in the adult population, as is the insertion of prosthetic heart valves. Patients with prosthetic heart valves are considered at high risk of IE – a complication with a high mortality. However, data on temporal changes in the incidence of IE among patients with prosthetic heart valves from unselected cohorts are sparse

Purpose

We aimed to examine nationwide temporal trends in the incidence of IE in patients with an implanted prosthetic heart valve in Denmark from 1999 to 2018.

Methods

Using Danish nationwide health-care registries we identified all patients, who underwent heart valve implantation between 1996–2018. Crude annual incidence rates per 1,000 person years (PY) of IE were computed and presented in two year intervals. Analyses were stratified by sex and age groups (<50, 50–59, 60–69, 70–79, >80 years).

Results

We identified 26,604 patients with first time prosthetic valve implantation with a median age of 72.7 years at the time of implantation, 63.1% were men with a median follow-up of 6.5 years. We found 1,442 cases of first time IE. The IE incidence rate ranged from 5.4 /1,000 PY (95% CI 3.9–7.4) in calendar period 2001–2002 to 10.0/1,000 PY (95% 8.84–11.11) in calendar period 2017–2018 with an unadjusted increasing trend during the study period (ptrend<0.0001), (Figure 1). Overall, men had a higher crude incidence rate compared with women, however no significant temporal changes were seen in the incidence rate during the study period. For age groups, a trend of stepwise increase in the incidence rate of IE was observed for increasing age groups, however no temporal changes were observed (Figure 2).

Conclusion

The incidence of IE following prosthetic heart valve implantation has increased slightly over the last 20 years in Denmark.

Funding Acknowledgement

Type of funding sources: None.
Infective endocarditis in adults with congenital heart disease – 11 years data from Hungary
Authors: Bence A , Balint H , Borbas S , Denes M , Andreka P
Published: October 2022

Background

Despite recent preventive strategies and advances in antimicrobial and surgical treatment the incidence and mortality rate of infective endocarditis (IE) remains high in adult Congenital Heart Disease (ACHD) patients.

Purpose

The aim of our retrospective study was to assess the clinical and microbiological characteristics, inhospital and one year mortality rates of ACHD patients admitted with IE in our tertiary referral hospital between 2010 and 2020.

Methods

Definitive diagnosis of IE were in agreement with modified Duke's criteria. Inhospital baseline data and up to one year follow-up data were collected from the hospital records. ACHD patients were classified based on their lesion severity (ESC guideline classification). Survival data and mortality predictors were analysed by Kaplan-Meier estimator and by uni- and multivariate model.

Results

60 cases had been treated with IE. Mean age was 37±11.3 years (18–69), and most of them (76.6%, n=46) were men. ACHD complexity was as following: simple 66.7% (n=40), moderate 20% (n=12) and severe 13.3% (n=8). The most common pre-existing congenital cardiac abnormality was bicuspidal aortic valve seen in 52% (n=31) of cases. Sixty four percent (n=37) of patients had previous heart surgery (n=16, artificial heart valve surgery). Majority of patients had a left sided valve endocarditis (85%, n=51). IE related hospital stay was mean 28±9 days. Infection route was presumed in 30% of patients (n=18), they had an invasive procedure within 6 months preceding the IE diagnosis. Besides common bacterinemia caused by Staphylococcus (33%, n=20) and Streptococcus (25%, n=15), 18% (n=11) of patients had a negative blood culture. IE affected 36 patients with a native valve, and all 16 with an artificial valve. Seventy seven percent of patients required surgical intervention, immediate or urgent surgery in 22 and elective in 24 patients. Overall inhospital mortality was 13%, the majority 5 out of 8 patients having an immediate/emergent surgical intervention. IE was complicated by acute heart failure in 17 (28%) and by stroke in 4 (6.7%) patients. During one year follow-up 21 patients (38%) remained with chronic heart failure, and 3 more died. There was no significant difference in mortality between ACHD complexity groups, and no significant predictors of mortality were found.

Conclusion

The most common ACHD lesion affected by IE was bicuspid aortic valve. Two-third of patients required surgical intervention, those with immediate/emergent surgery having a 22% early mortality rate. ACHD complexity was not related to early or late outcome in this population.

Funding Acknowledgement

Type of funding sources: None.
Renin-angiotensin and endothelin systems in patients post takotsubo syndrome
Authors: Khan H , Rudd A , Gamble D , Mezincescu A M , Cheyne L , Horgan G , Dhaun N , Newby D E , Dawson D K
Published: October 2022

Background

We investigate if renin-angiotensin and endothelin-1 response pathways follow the same pattern of recovery as left ventricular ejection fraction in patients with takotsubo syndrome.

Purpose

To provide better insight into the pathophysiology underlying this condition.

Methods

Ninety takotsubo syndrome patients [n=30 in each of “acute”, “convalescent” (3–5 months) and “recovered” (>1 year) groups] who were on minimal or no medication and were free of any significant cardiac/metabolic co-morbidities, and 30 healthy controls were studied. Serum concentrations of renin, angiotensin converting enzyme, angiotensin II, big endothelin-1, endothelin-1 were measured using commercially available ELISA, and BNP was measured using an immunoassay.

Results

Left ventricular ejection fraction was 38±1.6% in acute, 63±2.0% in convalescent and 64±2.6% in recovered takotsubo syndrome patients. As shown in Figure 1, serum renin concentrations are persistently elevated after a takotsubo episode (p=0.03 vs controls). Angiotensin converting enzyme levels are significantly depressed during the acute phase compared to convalescent (p=0.004), recovered takotsubo (p=0.02) or controls (p=0.03). Angiotensin II is increased in takotsubo patients (p<0.001 vs controls) remaining persistently elevated long-term in the recovered group (p=0.03 vs controls). B-type natriuretic peptide concentrations remain elevated after a Takotsubo episode compared to controls (p=0.003). Big endothelin-1 levels are unchanged, but endothelin-1 is significantly lower after takotsubo syndrome compared to controls (p=0.03).

Conclusions

Despite “normalisation” of the left ventricular ejection fraction, there is long-term maladaptive activation of renin-angiotensin system in takotsubo syndrome patients. This suggests therapy aimed at modulating this pathway may be beneficial in the long-term.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation
Changes in myocardial tissue velocities over a decade: the Copenhagen City Heart study
Authors: Sengelov M , Noergaard J L , Lassen M C H , Skaarup K G , Schoeps L B , Marott J L , Johansen N D , Joergensen P G , Jensen G B , Schnohr P , Prescott E , Soegaard P , Moegelvang R , Biering-Soerensen T
Published: October 2022

Background

The aim of the present study was to investigate the impact of cardiovascular risk factors – age, sex, hypertension, hypercholesterolemia, diabetes, smoking and obesity on Tissue Doppler imaging (TDI) measures of systolic and diastolic tissue velocities in the general population over a 10-year period. Identifying risk factors that are associated with changes in TDI velocities could lead to an improved understanding of the pathophysiology of the deteriorating heart and enable early preventive actions and strategies.

Methods

The study included 1128 members from the general population who participated in both the 4th and 5th Copenhagen City Heart Study. At both examination rounds, the participants underwent echocardiography. The examinations were 10 years apart. Conventional echocardiographic measures of cardiac structure and function and measures of TDI myocardial tissue velocities were obtained.

Results

Average change in s', e' and a' were −0.4±1.1 cm/s, −0.9±1.7 cm/s and 0.5±1.7 cm/s, respectively. After multivariable adjustments, older age (P<0.001) and higher systolic blood pressure (BP) (P=0.029) were found to be associated with a decrease in s' at follow-up. Male sex (P<0.001) was found to be associated with an increase in s'. Older age (P<0.001) and greater number of smoking pack-years (P=0.004) were associated with a decrease in e' at follow-up after multivariable adjustments. In addition, greater BMI (P=0.004) was significantly associated with a decrease in a'. Higher diastolic BP (P=0.004) and male sex (P=0.004) were associated with an increase in a'.

Conclusion

In the general population, overall systolic and diastolic function declined over a 10-year period. Both systolic and diastolic function as assessed by myocardial TDI velocities were affected by multiple conventional cardiovascular risk factors.

Funding Acknowledgement

Type of funding sources: None.
Mechano-energetic efficiency in patients with hypertrophic cardiomyopathy with and without sarcomeric mutations
Authors: Borrelli F , Lombardi R , Canciello G , Frisso G , Todde G , Paoletta D , Esposito G , Losi M A
Published: October 2022

Background

Hypertrophic Cardiomyopathy (HCM) is mainly caused by sarcomeric mutations. In about 40% of cases the causal mutation is unknown. Myocardial mechano-energetic efficiency per unit of left ventricular (LV) mass (MEEi) is an echocardiographic parameter of LV pump performance. Sarcomeric mutations may affect energy efficiency.

Purpose

We investigated the effects of the presence of sarcomeric mutations on MEEi in patients with HCM.

Methods

We included 49 genetically screened HCM patients (50±10 years, 27% women) with LV ejection fraction >50%, LV maximal wall thickness >14 mm and no moderate to severe mitral regurgitation. MEEi was calculated as the ratio between stroke volume and heart rate, normalized by LV mass. Echo-LV mass was calculated as LV epicardial minus LV endocardial volumes in 4 and 2 chamber views multiplied by 1.05, a method validated with nuclear magnetic resonance.

Results

27 HCM patients carried a sarcomeric mutation (HCM-Sarc; 55%). As shown in the table, patients with and without sarcomeric mutations (HCM-Sarc vs HCM-NoSarc) had similar LV ejection fraction, heart rate, LV mass and LV outflow tract gradient. HCM-Sarc showed early age at diagnosis, higher frequency of HCM family history and significantly reduced MEEi as compared with HCM-NoSarc. Presence of sarcomeric mutation could be predicted by younger age, lower MEEi and by family history of HCM (overall p<0.05).

Conclusions

In a population of HCM patients, the presence of a sarcomeric mutation is the only determinant of reduced the LV pump performance as estimated by MEEi. MEEi may be used as an imaging biomarker in sarcomeric mutation carriers.

Funding Acknowledgement

Type of funding sources: None.
Family screening in dilated cardiomyopathy-qualifying screening and need for follow-up
Authors: Vissing C R , Espersen K , Mills H L , Bartels E D , Jurlander R , Skriver S V , Ghouse J , Thune J J , Axelsson Raja A , Christensen A H , Bundgaard H
Published: October 2022

Background

Guidelines recommend family screening in dilated cardiomyopathy to uncover pre-symptomatic disease to improve morbidity and mortality through early treatment. According to patterns of inheritance and incomplete penetrance, less than half of relatives to dilated cardiomyopathy probands will develop disease, but so far, no guidelines provide recommendations on the frequency and intensity of follow-up screening.

Purpose

To investigate the prevalence and incidence and identify predictors of developing familial dilated cardiomyopathy (FDC) in relatives participating in family screening.

Methods

The study was an observational, longitudinal cohort study of families screened and followed from 2006 to 2020, at a regional assembly of clinics for inherited cardiomyopathies in Denmark.

Results

We included 211 families totaling 774 subjects (n=563 relatives, 47% women). At baseline, 124 relatives (22%) were diagnosed with dilated cardiomyopathy, while 43 relatives (8%) not fulfilling FDC criteria were found to carry class IV to V genetic variants. Thus, the combined clinical and genetic yield of screening was 30% at baseline. Relatives not fulfilling diagnostic criteria for FDC at baseline (n=439), were stratified into four groups based on results from genetic screening and clinical work-up at baseline (Figure 1). The risk of developing FDC during follow-up was strongly associated with this classification (see figure 1 and 2). The highest risk of developing FDC was observed in relatives carrying class IV to V genetic variants (n=43, age-adjusted incidence rate of 10% per person-year), while none of the subjects identified as non-carriers of family variants developed disease (n=58). In subjects sub-grouped according to baseline-findings on ECG and echocardiography, relatives with abnormal (n=70) vs normal (n=268) findings had markedly higher incidence rates of FDC (overall 4.7% vs 0.4% per person-year), regardless of age-group (Figures 1 and 2). The relatives with abnormal ECG and/or echocardiographic findings at baseline had a (age-group-adjusted) hazard ratio of 12.9 (CI: 4.8 to 35.1, p<0.001), when compared to relatives with normal findings.

Conclusion

Family screening identified a genetic predisposition to or overt FDC in 30% of screened relatives at baseline. In relatives not fulfilling criteria for FDC at baseline, findings from genetic testing and/or non-diagnostic findings on echocardiography and/or ECG were strongly associated with progression to disease. Importantly, relatives with normal genetic or objective findings had a low incidence rate and overall risk of developing FDC. Thus, baseline-screening identified a large proportion of relatives, in whom follow-up can be considered to be reduced allowing focused follow-up of relatives at higher risk of progression.

Funding Acknowledgement

Type of funding sources: None.
PTX3 as a novel inflammatory biomarker in patients with myocarditis
Authors: Villatore A , Sciorati C , Monno A , Sala S , Della Bella P , Manfredi A A , Peretto G
Published: October 2022

Background

Pentraxin-3 (PTX3) is an acute phase protein, which plays pivotal roles in innate immunity and inflammation. Among cardiovascular diseases, PTX3 was found to be elevated in acute myocardial infarction, chronic heart failure, and cardiac arrest. So far, however, PTX3 has never been investigated in the context of myocarditis.

Purpose

To evaluate PTX3 as a circulating marker of inflammation in patients with suspected myocarditis.

Methods

We enrolled 30 consecutive inpatients with new diagnosis of myocarditis, proven both by the updated Lake Louise criteria on cardiac magnetic resonance (CMR), and by the Dallas criteria on endomyocardial biopsy (EMB) (100%). Circulating serum PTX3 was assessed at the time of EMB, by ELISA technique using a commercial kit. Normal values for PTX3 were considered as <2 ng/mL, as in previous studies. A normal control group (n=10) was used for results validation of PTX3.

Results

In our cohort (77% males, age 50±18 y; median left ventricle ejection fraction [LVEF] 50%, IQR 30–59%), PTX3 levels were assessed in 30 patients. PTX3 levels were elevated in 26/30 (87%) patients with myocarditis (median 4,36 ng/mL, IQR 2,44–6,72, range 1,20–40,0), and in none (0/10) among healthy controls (median 1,28 ng/mL, IQR 1,04–1,36, range 0,77–1,94) (p=0,001). In the study group, the yield of other cardiac biomarkers was lower: 12/30 (40%) for C-reactive protein, 23/30 (77%) for T-troponin, and 20/30 (67%) for NTproBNP. PTX3 was constantly elevated in patients presenting with heart failure (HF) (16/16, 100%), compared with those presenting with acute coronary syndrome-like (8/10, 80%), or arrhythmias (2/4, 50%) (p=0,024). In particular, elevated PTX3 was associated with systolic dysfunction (LVEF <50%) at discharge (16/16 vs. 10/14, p=0,022).

Conclusion

Our preliminary data suggest PTX3 as a novel biomarker with potential diagnostic and prognostic value for myocarditis and inflammatory cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.
Relevance of subclinical right ventricular dysfunction measured by feature-tracking cardiac magnetic resonance in non-ischemic dilated cardiomyopathy
Authors: Pozo Osinalde E , Urmeneta Ulloa J , Cabrera J A , Martinez De Vega V , Thuissard I J , Andreu-Vazquez C , Perez De Isla L , Marcos-Alberca P , Cabeza B , Rodriguez-Hernandez J L , Luaces Mendez M , Gomez De Diego J J , Bustos A , Perez-Villacastin J , De Agustin J A
Published: October 2022

Background

Right ventricular (RV) dysfunction is associated with worse prognosis in non-ischemic dilated cardiomyopathy (NIDCM). Cardiac magnetic resonance (CMR) is considered the gold standard for RV evaluation. However, scarce data is available with the new feature tracking (FT) technique, which allows strain evaluation from conventional cine sequences.

Purpose

Our aim is to analyze the prognostic relevance of RV myocardial deformation measured by FT-CMR in NIDCM.

Methods

Consecutive patients with NIDCM diagnosis and CMR at diagnosis were retrospectively included. Global longitudinal strain of RV free wall (GLS-RVFW) and fractional area change (FAC) were obtained from standard CMR cine sequences with a dedicated FT software. Their association with a composite endpoint (heart failure admission, implantable cardioverter defibrillator in secondary prevention, and death) was evaluated using a logistic regression model.

Results

FT derived strain was obtained in 98 patients (68±13 years, 71.4% males) with NIDCM, mostly idiopathic (75.5%). Although our cohort showed a severely impaired left ventricular systolic function (LVEF = 29.5±9.6%, 47% with LVEF ≥30%) the RV function was relatively preserved on average (RVEF 52.2±14.6%, 72% with RVEF ≥45%). During a 3.2 [2.2–4] years follow-up 26.5% presented at least one admission for heart failure (HF), 5.1% received an implantable cardioverter defibrillator in secondary prevention, and 8% died. There was no association of RV-FT parameters with prognosis considering the entire study population. However, in patients with LVEF ≥30%, admissions for HF were associated with worse values of GLS-RVFW (−21.6±6.6% vs −31.3±10%; p=0.006) and FAC (32.8±15.8% vs 47.5±13.9%; p<0.001). Similar differences were observed when only patients with RVEF >45% were considered. An GLS-RVFW cut-off point of −19.5% and FAC of 36.5% showed good prognostic performance. Decreased GLS-RVFW or FAC represented an independent predictor for the composite endpoint in patients with LVEF ≥30%.

Conclusions

In our series of NIDCM decreased values of GLS-RVFW or FAC were able to predict major events independently of RVEF in the subgroup of patients without severe LV dysfunction. Therefore, RV deformation parameters by FT may be early markers of poor prognosis in NIDCM.

Funding Acknowledgement

Type of funding sources: None.
Echocardiographic evolution of patients undergoing 99mTc-DPD scintigraphy for suspected cardiac amyloidosis
Authors: Ramos Lopez N , Ferrandez Escarabajal M , Enriquez Vazquez D , Cn Perez Garcia C N , Wakfie-Corieh C , Islas Ramirez F , Mahia Casado P , Gomez De Diego J J , Vivas D , Vilacosta I , De Agustin Loeches J A
Published: October 2022

Introduction

Cardiac transthyretin amyloidosis (ATTR) is usually associated with thickening of the interventricular septum (IVS), although this finding is not specific and can be attributed to other diseases such as high blood pressure (HBP) or hypertrophic cardiomyopathy. The objective was to evaluate echocardiographic changes over time in patients with ventricular hypertrophy, undergoing 99mTc-DPD scintigraphy (DPD), in order to compare findings between patients with cardiac amyloidosis and other etiologies.

Methods

Retrospective registry of 63 patients who underwent DPD due to suspected cardiac amyloidosis in our center between 2018 and 2021. Clinical and echocardiographic characteristics were collected, including 2 echocardiograms per patient, with a minimum separation of one year (echo1, echo2). We compared patients diagnosed with ATTR, with positive scintigraphy grade 2–3 (ATTR group), with patients with negative scintigraphy (grade 0, nATTR group).

Results

The mean age of the patients was 81.3±8.6 years, 67.7% males. 83.9% of patients had HBP, without differences between groups (table1). DPD was positive in 32 (51.6%) patients. Patients with a negative DPD were diagnosed with hypertensive heart disease. The median time between echo1 and echo2 was 3.5 years (IQR 1.2–7), with no differences between groups (4.9 years in nATTR group vs 3.8 years in ATTR group, p=0.2). Results are shown in table1. In echo1, no significant differences were observed in the IVS and biventricular function between both groups. However, in echo3, patients in the ATTR group had significantly greater interventricular septum (IVS) thickness and a worse biventricular function compared to the nATTR group.

A significantly greater growth of the IVS and deterioration of left ventricular ejection fraction (LVEF) between echo1 and echo2 was observed in the ATTR group (table1). The percentage of IVS increase respect to the basal value was also significantly higher in ATTR group. There were no significant differences in the IVS growth per year. In the multivariable analysis LVEF and IVS thickness were independent predictors of a positive DPD.

Conclusions

The increase in thickness of the IVS and deterioration of left ventricular ejection fraction during follow-up of patients with ventricular hypertrophy could be a differential characteristic of ATTR, compared to patients with ventricular hypertrophy of other etiologies. This echocardiographic findings could help to suspect the presence of ATTR.

Funding Acknowledgement

Type of funding sources: None.