bluuebunny/crossref_metadata_2025 huggingface dataset:
Improved diagnostic accuracy for apical hypertrophic cardiomyopathy
Authors: Hughes R K , Shiwani H , Rosmini S , Burke L , Pierce I , Castelletti S , Xue H , Kellman P , Lopes L R , Treibel T , Manisty C , Captur G , Davies R , Moon J
Published: October 2022

Introduction

The diagnosis of apical hypertrophic cardiomyopathy (ApHCM) is contingent on demonstrating apical maximum wall thickness (MWT) of ≥15mm; the same threshold as other HCM subtypes. However, the myocardium naturally tapers towards the apex in healthy individuals, so ≥15mm MWT is proportionately higher in the apex than in naturally thicker basal segments. Using cardiac magnetic resonance (CMR), relative ApHCM has been described (typical ECG features, loss of apical tapering, cavity obliteration but hypertrophy <15mm). Wall thickness measurement using machine learning now exceeds human performance.

Purpose

We aimed to redefine the optimal diagnostic threshold for ApHCM using segment-specific criteria based on a large cohort of healthy control subjects.

Methods

Segmental wall thickness was measured using healthy subjects from the UK Biobank using a clinically validated machine learning algorithm1,2. A normative reference range was established for all 16 segments, conditioned to body surface area (BSA), sex and age. Derived segment-specific wall thickness thresholds were used to define optimal disease thresholds for patients clinically managed with overt (MWT ≥15mm) and relative ApHCM (MWT <15mm, but typical ECG and imaging findings).

Results

4118 UK biobank subjects were used to define normal segmental thicknesses and reference ranges. These were applied to ApHCM (73 overt, 31 relative). There were no apical wall thickness age related differences. The upper limit of the 95% confidence interval corresponded to a combined maximum apical MWT for both males and females of 10.4mm using non-indexed measurement, or 5.6mm/m2 when indexed to BSA. Non-indexed segmental threshold identified 100% of ApHCM patients (true positives), 81% (25 of 31) relative ApHCM and 3% (115 of 4118) of healthy UK biobank subjects (false positives). Indexed segmental thresholds improved the diagnostic potential in relative ApHCM without an increase in false positives (100% of ApHCM patients, 84% (26 of 31) of relative ApHCM patients, and 3% healthy UK biobank (127 of 4118).

Conclusion

We propose new diagnostic criteria for ApHCM using segmental indexed apical wall thickness of >5.6 mm/m2 to better identify inappropriate apical hypertrophy in those whose wall thickness does not meet current criteria for diagnosis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation
Modeling aortic stenosis progression: impact on follow-up, treatment and survival
Authors: Teixeira R , Ribeiro D , Sousa Nunes F , Leite M , Neves A , Santos D , Silva M , Silva G , Diaz S , Saraiva F , Sampaio F , Fontes-Carvalho R
Published: October 2022

Background

Aortic stenosis (AS) is one of the main valvular heart diseases in developed countries. Degenerative fibrocalcific aortic stenosis is a progressive disease of the valve and ultimately of the myocardium, which can be fatal when symptomatic. There is no medical treatment that can halt or delay its progression. AS does not evolve linearly over time, and not every patient has the same progression rate.

Aims

The aim of this study is to 1) compare different mathematical models of aortic stenosis progression, 2) cluster patients into rapid and slow progressors and explore possible predictors, 4) evaluate the impact of different progression rates on cardiac structure and function, and 5) evaluate survival and optimal timing for follow-up and treatment.

Methods

We retrospectively studied consecutive patients with aortic peak velocities from 2012 to 2020. Follow-up echocardiograms, seriated biomarker assessment, and clinical records were consulted, providing a multiparametric data frame for longitudinal and dynamic modeling of aortic stenosis progression and its consequences.

Results

This study included 9583 studies from 752 patients with a median total follow-up of 4.26 years (interquartile range: 1.28 to 7.24 years). A logistic model was selected with the best accuracy to predict the rate of AS progression. Patients were categorized into slow and rapid progressors in a ratio of 5:1. Multiparametric analysis showed no association between these profiles and clinical variables. However, anti-hypertensive drugs before and after adjustment for blood pressure control (Calcium Channel Blockers, p=0.013, OR 0.50) were associated with slower progression. Meanwhile, elevated inflammatory markers (erythrocyte sedimentation rate, p=0.01) were associated with faster AS progression. Despite no survival difference between these groups, higher rates of valvular intervention were registered in rapid progressors (p<0.001). Moreover, faster progressors were associated with earlier cardiac damage (as demonstrated by early onset of moderate mitral and tricuspid valve regurgitation, left auricle dilation, and left ventricle hypertrophy, p<0.05).

Conclusions

These results can potentially modify follow-up times and deliver more personalized and individualized health care to different AS patients, thereby optimizing resources.

Funding Acknowledgement

Type of funding sources: None.
Effect of the cold pressor test on coronary flow reserve by cardiac magnetic resonance in patients with hereditary TTR+ amyloidosis
Authors: Chango D X , Hurtado A M , Sanchez M I , Vasquez Z Y , Gonzalez-Duarte A , Rosales S
Published: October 2022

Background

Cold pressor test (CPT) is a potent alpha-adrenergic vasoconstrictor stimulus and evaluates the sympathetic reactivity of the cardiovascular system during the immersion of a hand in cold water, its effect on coronary flow reserve (CFR) in patients with hereditary TTR+ amyloidosis is unknown.

Purpose

To evaluate CFR by CPT in hereditary TTR+ amyloidosis patients with different cardiac involvement regarding the distribution of late gadolinium enhancement (LGE) by cardiac magnetic resonance imaging (CMRI) and compare with healthy volunteers

Methods

It was a cross-sectional study of 22 hereditary TTR+ amyloidosis patients with different patterns of LGE (absence/minimum or extensive involvement), and 4 healthy controls without LGE. CPT was performed with immersion of one hand in four Celsius degrees temperated water. Phase-contrast images were acquired on rest and during stress (after four minutes of a hand immersion). Volume quantification was made in posterior analysis to determine flow differences.

Results

No statistically significant differences were found regarding left ventricular (LV) volumes, LV mass, LV ejection fraction, and atrial volumes comparing the three groups of patients. CFR was abnormal in both groups of TTR+ amyloidosis patients compared with higher values in healthy subjects. Nevertheless, no statistically significant differences were determined.

Conclusions

Hereditary TTR+ amyloidosis subjects presented with abnormal values of CFR even with minimal or non-LGE by CMRI in the setting of infiltration. This response hypothesized small vessel involvement due to early infiltration by amyloid deposits before LGE development.

Funding Acknowledgement

Type of funding sources: None.
Oral anticoagulant treatment in patients with atrial fibrillation early after valvular intervention: a nationwide cohort study
Authors: Christersson C , Skogseid E L , Westerbergh J , Held C , Batra G
Published: October 2022

Background

Treatment with non-vitamin K oral anticoagulants (NOAC) is the first option for primary prevention of ischaemic stroke in patients with atrial fibrillation (AF). However, there is still an evidence gap regarding efficacy and safety of NOAC in patients with AF and severe valvular heart disease undergoing valvular intervention.

Purpose

The aim was to evaluate the efficacy and safety of NOAC or no oral anticoagulant (OAC) treatment versus warfarin during the first 3 months after valvular intervention.

Methods

We used data from the National Quality Register SWEDEHEART and included all patients with AF discharged after surgical valvular intervention with bioprosthesis or valvuloplasty, or transcatheter aortic valve implantation (TAVI) between 2010 and 2016. Outcomes, including the composite of cardiovascular (CV) events (CV death, ischaemic stroke or systemic embolism), major bleeding, and relevant comorbidities and OAC treatment at discharge were collected from the National Patient Register, the Swedish Prescribed Drug Register, and the National Cause of Death Register. The association between exposure (warfarin, NOAC or no OAC) and occurrence of composite CV events and major bleeding was explored using a time-dependent adjusted Cox regression analysis.

Results

In total, 4730 patients with AF and valvular intervention were included. The cohort had a mean age of 75 years, 35.9% were women and mean CHA2DS2-VASc score was 3.3 (Table 1). The proportion of patients treated with warfarin was higher in patients undergoing surgical valve intervention whereas NOAC was more commonly prescribed to patients treated with TAVI. Rates of composite CV events and major bleeding was similar between patients treated with NOAC versus warfarin. No OAC treatment versus warfarin was associated with higher rate of composite CV event, but with no difference with regard to major bleeding (Table 1).

Conclusion

A large proportion of patients with AF undergoing valvular intervention was not treated with OAC despite having a high CHA2DS2-VASc score. Also, patients on no OAC versus warfarin had a higher risk of i CV events in the early phase after valvular intervention. The efficacy and safety of NOAC was similar compared to warfarin during the first 3 months after intervention. Treatment with OAC in patients with AF, irrespective of NOAC or warfarin, was associated with improved clinical outcome early after valve intervention.

Funding Acknowledgement

Type of funding sources: None.
Risk factors and clinical effects of late leaflet thrombosis after transcatheter aortic valve replacement
Authors: Bak M , Choi K H , Kim J H , Park T K , Kim E K , Kim S M , Choi S H , Park S J
Published: October 2022

Background

As the indications for trans-catheter aortic valve replacement (TAVR) expand, it is expected that the number of TAVR patients would increase and the follow-up duration would be longer. It is known that the incidence of leaflet thrombosis is higher in TAVR than in surgical aortic valve replacement (SAVR), but not much is known about the risk factors of late leaflet thrombosis in TAVR.

Aim

Therefore, in this study, the incidence and risk factors of late leaflet thrombosis at late term after TAVR and the effect on clinical course of late leaflet thrombosis would be investigated.

Method

There were 176 patients undergone TAVR from January 2015 to October 2020 in one tertiary hospital of south korea. 94 patients had follow-up cardiovascular computed tomography (CT) between 3 months and 2 years after TAVR. Among 94 patients, late leaflet thrombosis was discovered at 20 patients, and risk factors were analyzed by comparing clinical factors, echocardiographic and cardiovascular CT information, and angiographic data between the group with and without late leaflet thrombosis. And the difference in aortic valve hemodynamics between the group with and without leaflet thrombosis was examined and clinical outcomes were compared. Clinical outcome was defined as the composite of all-cause death, stroke, heart failure (HF) admission, redo-aortic valve (AV) replacement and major bleeding after detection of late leaflet thrombosis.

Results

Indexed mean sinus of Valsalva diameter, AV calcium score and post procedure estimated orifice area (EOA) had predictability of late leaflet thrombosis with AUC value of 0.670 (95% CI [0.546–0.795], p value = 0.020), AUC value of 0.698 (95% CI [0.544–0.851], p value = 0.012) and AUC value of 0.665 (95 percent CI [0.548–0.782], p value = 0.031), respectively (Figure 1).

In echocardiography performed at the time of follow-up CT, AV max velocity and AV mean pressure gradient were higher in thrombosis group and EOA and Doppler velocity index were lower in thrombosis group than in no thrombosis group within normal range (Figure 2). Clinical outcome was not significant different between the two groups (log rank p value = 0.560).

Conclusion

Larger indexed sinus of Valsalva diameter, higher AV calcium score and smaller post procedure AV EOA were risk factors for late leaflet thrombosis after TAVR. Subclinical late leaflet thrombosis have a benign course when properly managed.

Funding Acknowledgement

Type of funding sources: None.
Long-term success in percutaneous valve commissurotomy – is Wilkins score over 9 a definitive limit?
Authors: Martins De Carvalho M , Alves Pinto R , Proenca T , Calvao J , Martins Da Costa C , Amador A F , Amaral Marques C , Cabrita A , Santos L , Oliveira C , Pinho A , Sousa C , Paiva M , Silva J C , Macedo F
Published: October 2022

Background

Percutaneous valve commissurotomy (PMC) is an established treatment in patients with significative mitral stenosis (MS). Although rheumatic MS incidence has decreased in the last century, it remains a prevalent pathology worldwide. The Wilkins score (WS) is a reference in echocardiographic assessment of MS; a score ≤8 is considered a predictor of treatment success and score between 9 and 11 is a “grey zone” (WGZ) in which doubts persists regarding PMC success.

Purpose

To evaluate the early and long-term results of PMC in patients with rheumatic MS and to compare long-term events between patients with WS ≤8 and patients in WGZ.

Methods

We retrospectively analysed all patients between 1991 and 2008 with significative rheumatic MS undergoing PMC. Data were collected at baseline and during long-term follow-up. M ACE was defined as a composite of all-cause mortality, mitral valve re-intervention or cardiovascular hospitalization.

Results

In our cohort, 124 patients were included. Most were female (87%), mean age at the time of repair was 46±11 year-old and mean follow-up was 20±6 years. Before the procedure, 81% had WS ≤8 and 19% were in WGZ. Both groups had similar baseline characteristics, namely age at first intervention, NYHA class and follow-up time. All patients had preserved biventricular systolic function, 83% presented PH, mean transvalvular gradient (TVG) and mitral valve area (MVA) were 12.8 mmHg and 1.0 cm2, respectively. Most of the procedures were successful (91%) and without complications (94%). Mean MVA improvement was similar in both groups [0.9 cm2 in WS ≤8 and 0.8 cm2 in WGZ, t(102)=0.173, p=0.863]; there was also no significative difference in TVG and PASP reduction after PMC. During long-term follow-up, re-intervention and mortality occurred in 40% and 23% in WS ≤8 and in 50% and 29% in WGZ, respectively, and none of these differences was statistically significant (p=0.389 and p=0.544, respectively). Concerning time-to-event analysis, approximately 80% of patients kept uneventful and >90% alive after 10 years in both groups and no significant difference in M ACE events and all-cause mortality between WS ≤8 and WGZ was observed (Log Rank, p=0,419 and p=0.950, respectively).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS in both WS ≤8 and WS 9–11, with similar MVA improvement. After 10 years, approximately 80% of patients were MACE-free and >90% alive in both groups. There was no difference in all-cause mortality and in a composite of all-cause death, mitral valve re-intervention or cardiovascular hospitalization concerning WS groups.

Funding Acknowledgement

Type of funding sources: None.
Predictive Role of Aortic Valve Calcium score on post-procedural outcomes and mortality after Transcatheter aortic valve replacement
Authors: Taskesen T , Ahsan M , Putz J , Park A , De Santis T , Latif A , Ugwu J , Ellerman M , Shivapour D , Chawla A , McAllister D , Sigurdsson G , Martin E
Published: October 2022

Introduction

Extent of aortic valve (AV) calcium increases as degenerative aortic valve stenosis progresses. Initial studies postulated AV calcium (AVC) score to be a predictor of complications such as need for pacemaker implantation, paravalvular regurgitation and mortality after Trans-catheter Aortic valve Replacement (TAVR). However, evidence regarding the impact of AVC score as a predictor of post-procedural complications and mortality has been conflicting.

Objective

This study aimed to determine the prognostic impact of AVC as predictor of post-procedural outcomes and mortality in patients with severe aortic stenosis (AS) who underwent TAVR.

Methods

We retrospectively abstracted the records of 497 patients with severe AS who underwent TAVR between January 2016 and July 2019 at our institution. All patients underwent a non-contrast cardiac CT scan on a Siemens Somatom Definition Flash 128 slice scanner. AVC score using the Agatston method was obtained retrospectively. Patients were divided into two groups: 1) Non-severe AVC score group [women <1200 Agatston unit (AU) and men <2000 AU]; 2) Severe AV Calcium Score group [women >1200 AU and men >2000 AU]. Primary outcome was 1-year mortality.

Results

Among 466 patients included in the analysis, 352 patients were included severe AVC group while 114 patients were in the non-severe AVC group. Patients in the severe AVC group were older (81±8 vs 79±8 years), were predominantly males (79% vs 71%), and had less diabetes mellitus (31% vs 42%, p=0.02). Post-TAVR AV dimensionless index (0.58±0.13 vs 0.58±0.12, p=0.8) and AV mean gradient (9.5±4.9 vs 9.2±5.4 mmHg) were not statistically different between both groups. There was no statistical difference in the need for PPM (12% vs 7%, p=0.16), post-TAVR stroke (1.5% vs 0%), post-TAVR major complications (17.4% vs 10%, p=0.07), 30 day (3.7% vs 4.4%), and 1-year mortality (13.6 vs 11.4, p=0.6) between both groups.

Conclusion

Our study report that the severity of AVC score does not have a prognostic impact on major post-procedural outcomes and mortality after TAVR.

Funding Acknowledgement

Type of funding sources: None.
Same-day discharge following transcatheter aortic valve replacement: a propensity-matched analysis from national readmission database
Authors: Goel A , Malik A , Bandyopadhyay D , Chakraborty S , Gupta R , Hajra A , Abbott J D , Ahmad H
Published: October 2022

Background

The length of hospital stay following transcatheter aortic valve replacement (TAVR) has decreased in recent years, and next-day discharge strategy is being increasingly adopted in some centers. Whether it is safe to further expedite discharge post-TAVR in selected patients by allowing discharge on the same day as the procedure remains unknown. In addition to potentially decreasing hospitalization costs, it could also limit the inpatient footprint and strain on healthcare resources.

Purpose

The purpose of our study was to compare the 30-day readmission rate in patients receiving TAVR who were discharged the same day (same-day discharge or SDD group) with those who were discharged on a different day (different-day discharge or DDD group). Additionally, we aimed to identify risk factors for readmission after TAVR.

Methods

We used the United States Nationwide Readmission Database to identify all adults who underwent elective TAVR in the years 2015–2019. The primary outcome of this study was all-cause 30-day readmission rate. The secondary outcomes were total hospital costs for the index admission, and risk factors for 30-day readmission. Propensity score matching was conducted to compare the SDD and DDD groups. Independent risk factors of 30-day readmission were identified using multivariate Cox proportional hazards regression analysis of the unmatched cohort.

Results

Of the 196,618 patients who received TAVR (mean age 79.5±8.4 years, 45.0% females), 245 (0.12%) patients were discharged on the same day they received TAVR (SDD group), and the remaining 196,373 were discharged on a different day (DDD group). In the DDD group, the median length of hospital stay was 2 days (interquartile range 1–4 days). A 1:3 propensity score analysis generated a matched cohort including 245 and 889 patients in the SDD and DDD groups, respectively. The 30-day readmission rate was similar between the SDD and DDD groups (11.0% versus 10.8%, hazard ratio [HR] 1.01, 95% confidence interval [CI] 0.59–1.71, p=0.989). Hospitalization costs were significantly lower in the SDD group than the DDD group ($37,811±18,029 versus $49,130±27,007, p<0.001) (see Picture 1). Age, female gender, history of diabetes, chronic kidney disease, chronic pulmonary disease, oxygen use, prior stroke, peripheral vascular disease, anemia, liver disease, and cancer were found to be independent risk factors for 30-day readmission after TAVR (see Picture 2).

Conclusion

In this large nationwide database analysis, patients receiving uncomplicated TAVR who were discharged on the same day as the procedure had a similar all-cause 30-day readmission rate and significantly lower hospital costs compared to those discharged on a different day. These results indicate that same-day discharge after TAVR may be a safe and feasible option in carefully selected patients.

Funding Acknowledgement

Type of funding sources: None.
Severe rheumatic mitral stenosis – analysis of clinical and echocardiographic very long-term outcomes after percutaneous mitral balloon valvuloplasty
Authors: Presume J , Paiva M , Gomes D , Albuquerque F , Guerreiro S , Marta L , Freitas P , Trabulo M , Abecasis J , Andrade M J , Ribeiras R
Published: October 2022

Introduction

Mitral balloon valvuloplasty (MBV) is the guideline recommended treatment for symptomatic severe mitral stenosis (MS) with suitable anatomy, but is often deemed transitory. However, data on very-long term echocardiographic follow-up is scarce. The aim of our study was to describe clinical and echocardiographic outcomes in patients previously submitted to MBV for rheumatic MS.

Methods

We conducted a single-centre retrospective study enrolling patients previously submitted to MBV for rheumatic MS from 1990 until 2021. Follow-up was considered until last registered echocardiographic re-evaluation. Patients without electronic health records available were excluded. The primary endpoint was a composite of all-cause death or need of surgery.

Results

A total of 193 patients were included (15.5% male, with a mean age of 52±15 years at the time of MBV, 60.6% with permanent atrial fibrillation). During a mean follow-up of 11±8 years, 87 (45.1%) patients implanted a mitral valve prosthesis, 4 (2.1%) were submitted to surgical mitral valvuloplasty and 30 (15.5%) died without being reinterventioned. Moreover, a total of 23 (11.9%) embolic events were registered – 21 strokes, 1 pulmonary embolism and 1 acute lower limb embolism.

Overall, 133 patients (68.9%) survived more than 5 years, 95 (49.2%) more than 10 years and 56 (26.9%) more than 15 years since MBV without meeting the primary endpoint. The maximum follow-up without intervention was 32 years. Concerning patients submitted to surgery, the mean time from MBV until operation was 9.4±7.3 years (minimum 8 days; maximum 29.3 years).

In regard to echocardiographic long-term outcomes on alive non-operated patients (mean follow-up of 12±9 years), 52.8% remain with mild MS, 91.6% with mild or no mitral regurgitation and 77.6% with mild or no tricuspid regurgitation. Furthermore, only 20.4% have right ventricle dysfunction (defined as a TAPSE <17 mm), 18.3% have pulmonary hypertension (pulmonary artery systolic pressure >45 mmHg), and 6.8% have residual interatrial communication.

Conclusion

MBV is a minimally invasive procedure that has an important benefit in a very significant proportion of patients with rheumatic mitral stenosis, with potential benefit that may last more than three decades without need for another invasive intervention.

Funding Acknowledgement

Type of funding sources: None.
Assessment of paravalvular regurgitation after transcatheter aortic valve replacement by hemodynamic measurements and cardiac magnetic resonance (APPOSE trial)
Authors: Rooijakkers M J P , Stens N A , Van Wely M H , Van Der Wulp K , Rodwell L , Gehlmann H , Van Garsse L A F M , Geuzebroek G S C , Verkroost M W A , Habets J , El Messaoudi S , Thijssen D H J , Nijveldt R , Van Royen N
Published: October 2022

Background

Paravalvular regurgitation (PVR) is a common complication after transcatheter aortic valve replacement (TAVR) which poses an increased risk of rehospitalization for heart failure and mortality.

Purpose

To assess the accuracy of hemodynamic indices to detect relevant PVR as compared to gold-standard cardiac magnetic resonance (CMR) quantitative flow assessment.

Methods

In this prospective single-centre clinical trial, four hemodynamic indices of PVR measured directly after TAVR were assessed for their correlation with CMR regurgitant fraction (CMR-RF) at one month follow-up: diastolic delta (DD), heart rate adjusted diastolic delta (HR-DD), aortic regurgitation index (ARI) and aortic regurgitation index ratio (ARI ratio). The hemodynamic indices were analyzed for their ability to detect relevant PVR (defined as more than mild PVR, CMR-RF >20%) using receiver operating characteristic (ROC) curves.

Results

We examined 77 patients in whom CMR was performed one month after TAVR. Mean age was 80.4±5.1 years and 46.8% of patients were men. Mean CMR-RF was 12.4±9.3%. Sixty-two (80.5%) patients had ≤ mild PVR (CMR-RF ≤20%), 14 (18.2%) patients had moderate PVR (CMR-RF 21–39%) and one (1.3%) patient had severe PVR (CMR-RF ≥40%). DD was the best hemodynamic index to discriminate between relevant and non-relevant PVR (area under the curve (AUC) 0.82; 95% CI, 0.72–0.92), followed by HR-DD (AUC 0.78; 95% CI 0.67–0.89), ARI (AUC 0.78, 95% CI 0.66–0.89) and ARI ratio (AUC 0.65; 95% CI 0.49–0.81).

Conclusions

Diastolic delta measured directly after TAVR has a high accuracy to predict relevant PVR at one month follow-up as assessed by CMR. Correction for heart rate (HR-DD) or systolic blood pressure (ARI, ARI ratio) does not improve this accuracy.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott Medical
Revascularization of significant coronary artery disease in patients undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis
Authors: Aarts H , Van Hemert N D , Meijs T A , Van Nieuwkerk A C , Voskuil M , Delewi R
Published: October 2022

Background

The prevalence of coronary artery disease (CAD) in patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation (TAVI) is high. However, the importance of a percutaneous coronary intervention (PCI) prior to TAVI has been matter of debate. Importantly, patients undergoing TAVI are characterized by high age often accompanied by highly calcified coronary arteries, increasing the risk of severe periprocedural complications. Moreover, patients with a severe aortic valve stenosis are limited in their ability to compensate for these life-threatening complications. Together with the necessity of dual antiplatelet therapy after PCI, this may explain a possible negative effect of PCI in this patient population. However, there is still insufficient evidence regarding the importance of PCI in patients undergoing TAVI.

Purpose

The aim of this systematic review and meta-analysis was to assess the need for PCI in patients with significant CAD undergoing TAVI.

Methods

A systematic search was conducted to identify studies comparing optimal medical treatment only versus PCI in patients with significant CAD undergoing TAVI. Endpoints were all-cause mortality, cardiac death, stroke, myocardial infarction, and major bleeding which were assessed at 30 days, one year, and beyond one year following TAVI.

Results

A total of 14 studies was included in this meta-analysis, including 3838 patients of which 1806 patients (47.1%) underwent PCI before TAVI. All-cause mortality was not significantly different between optimal medical treatment only and PCI at 30 days (OR: 1.27; 95% CI, 0.91–1.77; p=0.17; I2=0%), at one year (OR: 0.91; 95% CI, 0.64–1.29; p=0.59; I2=45%), and beyond one year (OR 0.68; 95% CI, 0.42–1.08; p=0.10; I2=49%). Cardiac death and myocardial infarction was similar across the groups at 30 days (OR cardiac death: 1.94; 95% CI, 0.36–10.56; p=0.45; I2=28%; OR myocardial infarction: 0.50; 95% CI, 0.13–1.91; p=0.31; I2=0%), and at one year (OR cardiac death: 0.77; 95% CI, 0.19–3.13; p=0.72; I2=84%; OR myocardial infarction: 0.74; 95% CI, 0.21–2.66; p=0.64; I2=18%). Stroke did not significantly differ between PCI and optimal medical treatment groups at 30 days (OR: 0.77; 95% CI, 0.31–1.92; p=0.57; I2=0%). However, patients that underwent TAVI without preceding PCI had significantly lower risk of major bleeding at 30 days (OR: 0.66; 95% CI, 0.46–0.94; p=0.022; I2=0%).

Conclusion

This systematic review and meta-analysis showed no significant differences in clinical outcomes between patients with and without PCI prior to TAVI at both short- and long-term follow-up, apart from a higher risk of major bleeding within 30 days in patients undergoing PCI before TAVI.

Funding Acknowledgement

Type of funding sources: None.
Early results of rapid-deployment aortic prosthesis in multivalvular surgery – a propensity score matching
Authors: Carvalho Guerra N , Velho T , Pereira R M , Reis I , Nobre A
Published: October 2022

Background

Multivalvular surgery (MV) requires prolonged extracorporeal circulation (ECC) and aortic cross-clamp times (X-Ao). Rapid-deployment aortic prosthesis (RD-AV) allow lower ECC and X-Ao times in isolated aortic valve surgery (AVR), but have not been studied in MV surgery.

Purpose

To determine if RD-AV use influences early outcomes when compared to biological stented or mechanical aortic valves in MV surgery.

Methods

Retrospectively collected pre, intra and immediate post-operatory data on all MV adult patients with AVR operated on our Department from January 2016 to February 2022. Bentall surgery and aortic dissection patients were excluded. A propensity score matching (PSM) of patients receiving RD-AV (Group A) compared to patients with non-RD-AV (Group B) was performed using sex, age, Euroscore II, type of surgery (involved valves, CABG, ascending aortic replacement), active endocarditis, ventricular function and redo surgery. After PSM, we compared outcomes until death or discharge. Normal distribution of samples was tested using the Kolmogorov-Smirnov test. Normal data was analysed with unpaired t-testing and non-normal data with non-parametric Mann Whitney U test. Categorical data were analysed with Fisher test. A significance level of p<0.05 was accepted.

Results

205 patients received non-RD-AV and 58 patients RD-AV. After PSM, 57 pairs of patients were obtained. Sex, BMI, Euroscore II, age, redo surgery, insulin dependent DM, baseline creatinine, left ventricle ejection fraction, right ventricle dysfunction, pulmonary artery systolic pressure, and active endocarditis were similar in both groups. Intra-operatory, RD-AV valves (Group A) were associated with shorter surgery duration (167.3±52 vs 206.6±91 min, p=0.005), shorter ECC duration (89.5±36.5 vs. 118.9±56.5 min, p=0.002), and aortic X-clamp time (71.6±28 vs. 98.9±38.2 min, p<0.001). No differences were found between both groups A vs. B in ventilation time (1270±1911 vs. 2428±5627 min, p=0.59), inotropic support (113±178 h vs. 85±101 h, p=0.38), transfusion of red cells units (1.1±1.6, vs. 1.2±1.7, p=0.73), Fresh frozen plasma units (0.86±1.9, vs. 0.77±1.8, p=0.77), platelet pools (0.79±1.0 vs. 0.7±0,9, p=0.67), fibrinogen (0.77±1.5 vs. 0.75±1.4 g, p=0.98), intra-aortic balloon pump use (5 vs. 12 patients, p=0.11), chest drain output (804±656 vs. 825±992 ml, p=0.69), new-onset dialysis (10 vs. 10 patients, p=1.0), new-onset atrial fibrillattion (10 vs 13 patients, p=0.6) and permanent pacemaker implantation (8 vs. 3 patients, p=0.20). Total ICU stay (9.25±21 vs. 4.5±4 days, p=0.3), hospital stay (14.4±26 vs. 10.1±13 days, p=0.52) and intra-hospital mortality (7 vs 9 patients, p=0.79) were also similar.

Conclusion

Despite shorter surgery duration, ECC duration and aortic X-clamp duration, RD-AV have similar early outcomes when compared with non-RD-AV in multivalvular surgery.

Funding Acknowledgement

Type of funding sources: None.
The long-term effect of surgical aortic valve replacement on arterial stiffness and wave reflections
Authors: Sigala E , Terentes-Printzios D , Baikoussis G N , Katsaros A , Koumallos N , Lozos V , Giakis N , Filis K , Tsioufis K , Vlachopoulos C
Published: October 2022

Background

Assessing arterial properties in patients with aortic valve stenosis undergoing surgical aortic valve replacement (SAVR) is difficult, and the results to date have been inconclusive.

Purpose

We sought to investigate how SAVR affects vascular stiffness in the short and long term.

Methods

We included 69 patients (mean age 70.8±8.4 years, 62% men) with severe symptomatic aortic stenosis who underwent SAVR. Arterial stiffness was assessed using the carotid femoral pulse wave velocity (cfPWV) and brachial-ankle pulse wave velocity (baPWV). Measurements in patients with an ankle-brachial index (ABI) <0.9 were excluded from the analysis for baPWV measurments because a low ABI can affect the accuracy of baPWV. Augmentation index corrected for heart rate (Alx@75), central pressures and subendocardial viability ratio (SEVR) were assessed with arterial tonometry. Measurements were conducted at baseline, in the acute phase and 1 year after the operation.

Results

Immediately after SAVR there was an increase in cfPWV (8.04±1.3 m/s vs 8.54±1.6 m/s, p=0.02) that was sustained at 1 year (8.04±1.3 m/s vs 9.42±2.4 m/s, p≤0.001). Similarly, baPWV (n=55) increased in the acute phase (1633±429 cm/s vs 2014±606 cm/s, p<0.001) and persisted 1 year postoperatively (1633±429 cm/s vs 1867±408 cm/s, p<0.001). Post-SAVR we also observed a decrease in Alx@75 (31.02±10% vs 22.73±12%, p≤0.001) that was attenuated 1 year later (31.02±10% vs 26.65±8%, p≤0.001), and an increase in SEVR (136.1±30.4% vs 149.2±37.7%, p=0.01) which remained improved at 1 year (136.1±30.4% vs 147.5±30.4%, p=0.01).

Conclusions

After SAVR the arterial system shows an increase of stiffness in response to the acute relief of the obstruction, which is retained in the long term.

Funding Acknowledgement

Type of funding sources: None.
Predictors of short and long-term mortality after surgical aortic valve replacement in 681 octogenarians: a monocentric experience
Authors: Mistiaen W P , Deblier I , Dossche K , Vanermen A
Published: October 2022

Introduction

In spite of potential frailty, very elderly patients are increasingly referred for surgical aortic valve replacement (SAVR), even after the introduction of transcatheter aortic valve implantation.

Purpose

What are the predictors for short and long-term mortality after surgical aortic valve replacement in octogenarians and are these avoidable?

Patients and methods

This is a retrospective file study of 861 octogenarians, who underwent SAVR with or without associated procedures between 1987 to 2017. Mechanical valves and valves in another position were excluded. Age, gender, cardiac and non-cardiac comorbid conditions (renal, pulmonary, diabetes, malignancy), operative data (cross-clamp and bypass time, associated procedures) and postoperative adverse events were investigated for their effect on 30-day and on long-time mortality. Significant factors in an univariate analysis (chi-square and Kaplan-Meier) were entered in a multivariate model (logistic regression, Cox' proportional hazard analysis).

Results

Hospital mortality was 68/681 (10%). The follow-up was 3817 years, with a mean of 6.2 years for the remaining 613 patients. Predictors (Odds Ratio, p-value) for hospital mortality are:

– Need for SAVR <24h, 3.87 (p=0.001)

– Pulmonary disease, 2.44 (p=0.002)

– Atrial fibrillation, 2.30 (p=0.004)

– Age >85 years, 2.02 (p=0.021)

– Renal disease, 1.94 (p=0.025)

– Coronary artery disease, 1.99 (p=0.046)

Five-year survival is 66.4±1.9% (392 patients at risk); ten-year survival is 25.3±2.0 (89 patients at risk), 15-year survival is 4.0±1.3% (6 patients at risk). Its predictors (Odds Ratio, p-value) are:

– Renal disease, 1.40 (p=0.005)

– Congestive heart failure, 1.37 (p=0.006)

– Postoperative Low Cardiac Output Syndrome, 1.82 (p=0.007)

– Postoperative delirium, 1.45 (p=0.010)

– Postoperative ventricular arrhythmia 1.84, (p=0.014)

– Need for SAVR <24 h, 1.69 (p=0.021)

– Diabetes mellitus, 1.30 (p=0.032)

– Malignancy, 1.30 (p=0.046)

– Pulmonary disease, 1.26 (p=0.047)

– Preoperative carotid artery endarterectomy, 1.49 (p=0.052)

Conclusions

In this elderly population, short and long-term mortality are acceptable. The need for urgent SAVR (<24h) is the dominant predictor for 30-day mortality. Of the ten predictors for long-term survival, seven are of preoperative nature. Two postoperative cardiac events as well as need for urgent SAVR have an important effect on long-term outcome. No operative variables were identified as predictor. Need for urgent SAVR should be avoided by early referral.

Funding Acknowledgement

Type of funding sources: None.
Temporal changes in aortic valve replacement according to age in Denmark: nationwide data from 2008 to 2020
Authors: Graversen P L , Butt J H , Oestergaard L , Jensen A D , Warming P E , Strange J E , Moeller C H , Schou M , Backer O D , Koeber L , Fosboel E L
Published: October 2022

Background

Since the introduction of transcatheter aortic valve implantation (TAVI), the management of symptomatic severe aortic stenosis has changed. Recent published European guidelines (2021) favours TAVI over surgical aortic valve replacements (SAVR) in patients with older age (≥75 years of age) or patients with high surgical risk. The study of nationwide practice patterns for AVR is important and renders the possibility to evaluate whether clinical practice differs from current guidelines.

Purpose

To evaluate temporal changes in use of isolated aortic valve replacement (AVR) procedures according to age in the era of TAVI in Denmark.

Methods

We identified all first-time aortic valve replacement procedures (TAVI or SAVR) from 2008 until the end of 2020 through administrative registries in Denmark. Patients with no prior diagnosis of aortic stenosis at time of AVR were excluded. Patients with prior AVR or valve repair were excluded. SAVR was divided according to type of prostheses: surgical bioprostheses and mechanical prostheses. To evaluate changes according to age the study cohort was divided into two age groups: <75 and ≥75 years of age.

Results

Between 2008 and 2020, 12,313 first-time isolated AVR procedures were performed in Denmark. Volume of isolated AVR increased from 621 to 1256 procedures per year (ptrend <0.001). Isolated SAVR was performed in 6,548 patients (53.2%) and TAVI in 5,765 patients (46.8%). Median age of TAVI patients was 81.4 [76.9–85.2] years of age compared to 73.1 [68.0-≥77.7] in patients receiving surgical bioprostheses and TAVI patients had a higher degree of comorbidity (TAVI: 70% of patients with Charlson comorbidity score ≥1, surgical bioprostheses: 50% of patients with Charlson comorbidty score ≥1). TAVI increased during study period compared to isolated SAVR, where a decreasing trend was observed from 2014 and onwards. In <75-year-old patients, volume of TAVI significantly increased during study period (ptrend<0.001), whereas volume of surgical bioprostheses remained stable. Volume of mechanical prostheses decreased over time (ptrend <0.001) TAVI increased in ≥75-year-old patients (ptrend <0.001) and TAVI accounted for 91.5% of all isolated AVR procedures in 2020. In contrast, volume of isolated SAVR declined driven by a decreasing use of surgical bioprostheses (ptrend=0.001). (Figure 1).

Conclusions

Volume of isolated aortic valve replacement (AVR) doubled from 2008 and 2020. The increase in isolated AVR was driven by transcatheter aortic valve implantation (TAVI). TAVI has become the predominant choice of isolated AVR in management of aortic stenosis and our results suggest that real-world practise patterns are in line with current guideline recommendations.

Funding Acknowledgement

Type of funding sources: None.
Dynamics of sympathetic nerve activity in patients with functional tricuspid regurgitation and its postinterventional progression
Authors: Ozturk C , Ozkan N , Vogelhuber J , Nickenig G , Weber M U , Hammerstingl C
Published: October 2022

Background

Increased muscle sympathetic nerve activity (MSNA) is associated with poor prognosis in patients with chronic heart failure (CHF). The improving effect of interventional therapy of mitral regurgitation (MR) and aortic stenosis on MSNA in patients with CHF has been previously shown.

Purpose

MSNA in patients with functional tricuspid regurgitation (FTR) has not been evaluated yet, and the effect of transcatheter tricuspid valve repair (TTTVR) on MSNA is unknown.

Methods

We prospectively included 28 patients with ≥ severe FTR who underwent TTVR. All patients were followed up at the earliest 12 months after the procedure. Microneurography was performed to determine MSNA, as described previously. Tungsten needles (200 μm) were used to record multiunit postganglionic sympathetic activity from the nervus peroneus longus close to the caput fibuli. There are two MSNA-defining parameters – burst frequency (burst/min) and burst incidence (burst/beats). In 9 patients, it was possible to perform microneurography at follow-up.

Results

28 patients (80.7±5.2 years, 53.6% female) with symptomatic (100% NYHA≥ II) high-grade FTR (severe TR: 78.6%, massive TR: 14.3%, torrential TR 7.1%) were prospectively included. At baseline, we documented preserved left ventricular function with a LVEF of 57.7±10.9%, however impaired right ventricular function (TAPSE: 15.8±5.2 mm) with biatrial dilation (left atrial volume: 95.4±40.7 ml, right atrial area: 31.8±10.8 cm2. Baseline NT pro-BNP was 2659.3±2214.3pg/dl. There was no relevant MR at baseline (MR ≤ moderate). According to baseline microneurography, we found a significantly increased MSNA (incidence: 146.16±65.85 bursts/beats, frequency: 182.21±140.6 bursts/min). Furthermore, MSNA was significantly and negatively correlated with renal function at baseline (MSNA incidence r=−0.67, p=0.0001; MSNA frequency r=−0.40, p=0.034). On the other hand, the serum level of NT pro-BNP showed a positive and significant correlation with MSNA incidence (r=0.64, p=0.0004), however no relevant association with MSNA frequency (r=0.23, p=0.24). The procedural success was 96.4%. One procedure was interrupted due to irreducible TR. At FU, we found sustained TR reduction (81.4% TR

Conclusion

We documented increased sympathetic nerve activity in patients with FTR. Renal function inversely correlates with all MSNA-defining parameters, and MSNA incidence shows a positive correlation with levels of NT-pro BNP. TTVR decreases MSNA, which might be regarded as an additional neurological pathway of postinterventional clinical improvements apart from intracardiac volume and pressure changes.

Funding Acknowledgement

Type of funding sources: None.
CT-determined tricuspid annular dilatation is associated with persistence of tricuspid regurgitation after transcatheter aortic valve replacement
Authors: Loew K , Steffen J , Theiss H , Orban M , Rizas K , Hagl C , Massberg S , Hausleiter J , Braun D , Deseive S
Published: October 2022

Introduction

Moderate or severe tricuspid regurgitation (TR) can be observed in 11% to 27% of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Even though in most patients an improvement of TR can be achieved after TAVR, the persistence of severe or massive TR after the procedure is associated with increased all-cause mortality.

Purpose

The aim of this study was to investigate if tricuspid annular dilatation (TAD) measured in pre-procedural CT among TAVR patients who had at least moderate TR at baseline could serve as a predictor for the persistence of TR. Moreover, the predictive value of TR persistence on the composite of 2-year mortality or tricuspid valve intervention was analysed.

Methods

We examined 151 patients with severe AS and at least moderate concomitant TR at baseline, who were treated with TAVR from April 2013 to December 2019. TR persistence was defined as the same or a higher grade of TR in the follow-up echocardiography at least 30 days after the procedure compared to preprocedural TR grade. To identify patients with TAD, the maximum septolateral diameter of the tricuspid annulus was measured in pre-procedural cardiac computed tomography images and normalized to the body surface area.

Results

The median value of 25.5 mm/m2 was determined as cut-off value for TAD. Out of 151 patients with moderate or more TR before TAVR, 75 patients (49.7%) were above the threshold of 25.5 mm/m2. Improvement of TR after TAVR of at least one grade was significantly more frequent in patients without TAD than with TAD (59% vs. 32%, corresponding odds ratio for persistence of TR: 3.06, 95% confidence interval: 1.50–6.35, p=0.001) (Figure 1A). Multivariable logistic regression analysis with adjustment for baseline TR severity confirmed that the predictive value of TAD for TR persistence after TAVR was irrespective of baseline TR (adjusted odds ratio: 2.79, 95% confidence interval: 1.42–5.59, p=0.003). Tricuspid valve intervention was conducted in 11 patients with TAD after TAVR (14.6%) and in no patients without TAD. Accordingly, at 2-years, tricuspid valve intervention-free survival was lowest among patients with TAD and persistent TR (Figure 1B).

Conclusion

Our analysis demonstrates for the first time that in patients undergoing TAVR for severe AS and at least moderate concomitant TR, CT-derived TAD is associated with persistence of TR after the procedure. Furthermore, TR persistence is associated with an adverse outcome.

Funding Acknowledgement

Type of funding sources: None.