bluuebunny/crossref_metadata_2025 huggingface dataset:
Characteristics and prognostic implications of pre-shock and normotensive cardiogenic shock in the Critical Care Cardiology Trials Network Registry
Authors: Patel S , Berg D D , Bohula E A , Park J G , Van Diepen S , Katz J , Morrow D A
Published: November 2023

Background

Limited data exist regarding the epidemiology and prognostic implications of pre-shock and normotensive cardiogenic shock (CS) states. Moreover, optimal staging of risk for pts with isolated hypotension versus isolated hypoperfusion remains unclear.

Purpose

We sought to compare characteristics and outcomes of pre-shock states and normotensive CS as compared with conventional CS.

Methods

The Critical Care Cardiology Trials Network (CCCTN) is an investigator-initiated multicenter registry of CICUs coordinated by the TIMI Study Group. Consecutive admissions (n=22,869) from 42 centers (2017-2022) were stratified into groups of isolated low CO, isolated hypotension, normotensive CS, and SCAI Stage C CS using criteria in Fig A.

Results

A total of 1,754 were stratified into one of the four groups: 5% isolated low CO, 9% isolated hypotension, 13% normotensive CS, and 74% SCAI stage C CS. Prior HF was more common in pts w/ isolated low CO (73%) and normotensive CS (60%), compared to pts w/ isolated hypotension (44%) or SCAI stage C CS (55%) (global p<0.001). Overall, in-hospital mortality was 18.4% with marked differences among groups (global p < 0.001; Fig B). Specifically, mortality was significantly lower in those with an isolated low CO or isolated hypotension than among the normotensive CS group (pairwise p [isolated hypotension vs. normotensive CS] = 0.03; Fig B). In contrast, mortality rates among admissions with normotensive CS vs. SCAI stage C CS did not significantly differ (pairwise p=0.08; Fig B).

Conclusions

Normotensive CS is associated with a >2-fold higher in-hospital mortality compared with isolated hypotension or an isolated low CO state. These findings indicate that the presence of malperfusion, irrespective of hypotension, is associated with worse outcomes in CS. These data may inform refinement of CS staging with respect to pre-shock states.Figure
A machine learning algorithm to predict a culprit lesion after out of hospital cardiac arrest
Authors: Roy R , Abdrazak M , Smith M , Frohmaier C , Kordis P , Sunderland N , Webb I , Dworakowski R , Melikian N , Johnson T W , Noc M , Byrne J , Maccarthy P , Shah A M , Pareek N
Published: November 2023

Background

Between 50-90% of patients suffering from out-of-hospital cardiac arrest (OHCA) have a primary cardiac aetiology of arrest with the presence of a culprit coronary lesion. However, recent trials have failed to show a benefit from an early invasive angiographic approach following OHCA. Identification of patients with high likelihood of a culprit lesion may enable selection of patients likely to benefit from direct conveyance to cardiac arrest centres and for an early invasive approach. However, electrocardiogram (ECG) following return of spontaneous circulation, the current gold-standard, is a poor predictor of presence of a culprit lesion.

Purpose

We aimed to develop a machine learning algorithm to predict the presence of a culprit lesion in patients with OHCA.

Methods

We used a retrospective cohort of 398 patients admitted with primary cardiac aetiology OHCA to a tertiary cardiology centre in the United Kingdom, between May 2012 and December 2017. The primary outcome was the presence of a culprit coronary artery lesion, for which a Gradient Boosting model was optimised to predict. The algorithm was then validated in two independent European cohorts comprising 568 patients (346 and 222 patients respectively).

Results

The development cohort consisted of 398 patients (median age 64.3 years [IQR 53.3-75.4], 74.6% male), and the two validation cohorts consisted of 346 patients (median age 63.0 years [IQR 55.0-73.0], 81.5% male) and 222 patients (median age 63.0 years [IQR 52.0-74.0], 77.0% male). Of all patients, 85.6% had a witnessed arrest, 69.6% received bystander cardiopulmonary resuscitation, and 77.3% had an initial shockable rhythm. A culprit lesion was observed in 67.4% patients receiving early coronary angiography in the development cohort, and 67.9% and 61.1% in the two validation cohorts respectively. A Gradient Boosting model yielded an algorithm, named KOCAR Culprit Predictor, incorporating nine variables including age, a localising feature on ECG (≥2mm of ST change in contiguous leads), regional wall motion abnormality, history of vascular disease and initial shockable rhythm. This model had an AUC of 0.89 in the development and 0.83/0.81 in the validation cohorts with good calibration (Figure 1), and outperformed the current gold-standard ECG alone (AUC 0.69/0.67/0/67).

Conclusions

A novel simple machine learning derived algorithm (Figure 2) combining nine variables which are readily available to clinicians can be applied to patients with OHCA to predict a culprit coronary artery lesion with high accuracy. The algorithm, KOCAR Culprit Predictor, outperforms the current gold-standard ECG alone.Figure 1Figure 2
Comparison of MIRACLE2 and downtime as predictors of outcome following out-of-hospital cardiac arrest and evidence for the potential of MIRACLE2 as a selection tool for mechanical circulatory support
Authors: Aldous R , Roy R , Abdrazak M , Mohanan S , Stahl D , Kordis P , Parczewska A , Kalra S , Johnson T W , Rakar S , Noc M , Patel S , Byrne J , Maccarthy P , Pareek N
Published: November 2023

Background

Out-of-hospital cardiac arrest (OOHCA) is associated with high morbidity and mortality, driven primarily by poor neurological outcome. Appropriate application of invasive therapies, such as mechanical circulatory support (MCS), currently poses significant challenges. To guide patient selection, effective estimation of patients at high risk of neurological injury, particularly early on arrival to a heart attack centre, is essential.

Purpose

We compared the discrimination performance of MIRACLE2 score with downtime, and its components, low-flow and zero flow, as predictors of poor neurological outcome following OOHCA. Furthermore, we modelled the use of MIRACLE2 score as a selection criterion for MCS.

Methods

The European Cardiac Arrest Registry (EUCAR), a retrospective cohort of patients with OOHCA with likely cardiac aetiology, from 6 European centres (May 2012-September 2022), was utilised. The primary end point was poor neurological outcome on hospital discharge (Cerebral Performance Category 3-5).

Results

1259 patient were included at the point of analysis. The median downtime was 25 minutes (IQR 15-36), with an average age of 62.9 ± 14.5 years. Baseline demographics (age, gender, co-morbidities) were similar across groups. In patients with a total downtime of <10 minutes and MIRACLE2 score >4, poor outcome occurred in 76.5%, whilst those with a downtime >30 minutes and MIRACLE2 score 0-2 had poor outcome in 24.0%.

In a multivariable logistic regression analysis, MIRACLE2 had a stronger association with poor neurological outcome (OR 2.06 [CI 1.83–2.33], p<0.0001) than zero-flow (OR 1.08 [CI 1.03–1.14], p=0.005), low-flow (OR 1.04 [CI 1.00–1.00], p=0.004) and total downtime (OR 0.99 [CI 0.95–1.03]. MIRACLE2 had superior discrimination for poor neurological outcome with AUC of 0.870 (95% CI 0.846 to 0.891) than zero-flow [AUC of 0.616 (95% CI 0.583-0.648)], low-flow [AUC of 0.716 (95% CI 0.685-0.745)] and downtime [AUC of 0.726 (95% CI 0.695-0.754)].

When modelled for inclusion into landmark cardiogenic shock RCTs, based on study criteria (which all incorporate downtime, zero-flow or low-flow times), those modelled for exclusion from study recruitment, the positive predictive value of MIRACLE2 ≥5 for poor outcome was significantly higher (0.91) than CULPRIT-SHOCK (0.62), EUROSHOCK (0.53) and ECLS-SHOCK criteria (0.80) (p<0.001).

Discussion: MIRACLE2 demonstrates superiority over downtime in predicting neurological outcome following out-of-hospital cardiac arrest in this large, multicentre, retrospective cohort study and has potential to improve patient selection for mechanical circulatory support in future cardiogenic shock trials.MIRACLE2 vs Downtime
The MIRACLE2 risk score is associated with cognitive function, referral burden and discharge outcome
Authors: Singh M , Aboushagor L , Yarham K , Abdrazak M , Breeze J , Steadman A , Sadler E , Shaw K , Bastiaenen R , Wilson E , Kanyal R , Shah A , Byrne J , Maccarthy P , Pareek N
Published: November 2023

Background

Out-of-hospital cardiac arrest (OOHCA) can lead to poor neurological outcome. The MIRACLE2 score was devised to predict that risk, whilst supplementing clinical assessment and decision-making processes. However, the score has not previously been shown to correlate with cognitive and functional scoring assessment.

Purpose

To investigate the relationship between the MIRACLE2 risk score and cognitive and functional scoring assessments 1-3 months after hospital discharge.

Methods

We carried out a 1-year pilot evaluation of the cardiac arrest survivors’ clinic in a cardiac tertiary centre in London. From 46 patients, 12 had died, 6 did not attend, 7 were referred to their local hospital or rehabilitation facility, and 21 patients attended. The attending patients were tasked to complete the following questionnaires: Montreal Cognitive Assessment (MOCA), Hospital Anxiety and Depression Scale (HADS), Post-traumatic stress disorder (PTSD) checklist (PCL-5) and EQ-5D-5L score.

Results

Of the 21 patients (median age was 62; 90% were male), 3 had a MIRACLE2 score ≥ 5 (high risk), 6 had scored 3-4 (intermediate risk), whilst 12 had scored 0-2 (low risk). The median MOCA score was 85% (median self-assessed EQ-5D-5L: 65%; median HADS: anxiety 31%, depression 29%; median PCL-5: 14%). We found that patients with a low risk of poor neurological outcome (MIRACLE2 ≤ 2), had scored higher for MOCA (median: 92%) and self-assessed EQ-5D-5L (75%), and lower for HADS (anxiety: 29%, depression: 14%) and PCL-5 (7%). In comparison, patients with a high risk of poor neurological outcome (MIRACLE2 ≥ 5) had scored much lower for MOCA (58%) and self-assessed EQ-5D-5L (50%), and higher for HADS (anxiety: 67%, depression: 38%) and PCL-5 (40%). On average, patients with an intermediate risk of poor neurological outcome (MIRACLE2 3-4) had scored between both extremes. Of all 21 patients, 6 were referred to neurorehabilitation and/or neuropsychology (67% of those who scored ≥5, 33% who scored 3-4, and 17% who scored 0-2 were referred).

Conclusion

After hospital discharge, the MIRACLE2 score can predict the risk of cognitive impairment, anxiety, depression, PTSD and overall health in OOHCA patients. As such, the MIRACLE2 score can support the role for expedited access to neurorehabilitation and neuropsychology for affected patients – especially as recovery is time-sensitive.Assessment results in risk categories
Systemic inflammation 72 hours after cardiac arrest is associated with poor neurological outcome and long term all-cause mortality - the prospective Norwegian Cardio-Respiratory Arrest Study (NORCAST)
Authors: Shetelig C , Tollefsen I M , Nakstad E , Seljeflot I , Bratseth V , Sunde K , Andersen G O
Published: November 2023

Background

Post-cardiac arrest (CA) anoxic brain injury seems to involve local and systemic inflammation. The interleukin (IL)-1/IL-6 pathway has gained increased interest both as prognostic markers and as possible targets for intervention.

Purpose

To evaluate the associations of the IL-1 receptor family, IL-6 and procalcitonin as a marker of systemic inflammation, with neurological outcome and long-term all-cause mortality in patients with out-of-hospital cardiac arrest (OHCA).

Methods

In this prospective observational study, we included 259 adult patients (> 18 years) hospitalized after OHCA. Blood sampling were performed on admission and 72 hours after cardiac arrest. IL-1 receptor antagonist (IL-1ra), ST2 (soluble interleukin 1 receptor-like 1), IL-6 and procalcitonin were analysed on admission and 72 hours after cardiac arrest. Neurological outcome was measured as cerebral performance category score (CPC score) assessed by two experienced neurologists six months after OHCA. CPC score was dichotomized into good (CPC score 1-2) or poor (CPC score 3-5) neurological outcome. All-cause mortality was registered after median 10.7-year follow-up.

Results

Patients with poor neurological outcome six months after CA (red bars) had significant higher levels of IL-6 (p = 0.002), IL-1Ra (p < 0.001), ST2 (p < 0.001) and procalcitonin (p < 0.001) 72 hours after CA (Fig. 1). High levels of IL-6, IL-1Ra, ST2 and procalcitonin measured 72 hours after cardiac arrest were significantly associated with long-term all-cause mortality (Fig. 2).

Conclusions

High levels of inflammatory biomarkers 72 hours after CA were significantly associated with poor neurological outcome and long-term all-cause mortality.Figure 1Figure 2
Myocardial inflammation in Fabry disease: correlations between myocardial histology, T2 mapping, and troponin
Authors: Ditaranto R , Leone O , Lovato L , Baldovini C , Niro F , Kurdi H , Parisi V , Schiavo M A , Di Nicola F , Baldassarre R , Potena L , Martin Suarez S , Galie' N , Moon J A M E S , Biagini E L E N A
Published: November 2023

Background

Myocardial inflammation likely plays a key role in cardiac Fabry disease (FD), supported by the frequent observation using cardiac MRI (CMR) of high T2 mapping values, mainly in areas of late gadolinium enhancement, LGE), typically representing oedema, and increased troponin (myocardial injury).

Purpose

To characterize inflammation in FD cardiomyopathy by comparing myocardial histology, T2 mapping and troponin.

Methods

Fifteen FD patients (67% females; 51 years old, range 39-62), undergoing 3 tests: biopsy (either RV endomyocardial biopsy, n=10, or myectomy, n=5); CMR (1.5T: cines, LGE, native T1/T2 mapping quantified in the sampling area); and troponin assessment (high sensitivity TnI). Mapping values were compared to local healthy volunteers. Left ventricle hypertrophy (LVH) was defined as either MWT ≥12mm or indexed LV mass above sex specific reference ranges. Tissue was stained using Haematoxylin-Eosin and Azan Mallory trichrome. Inflammatory cell staining used CD68 and CD3 antibodies. An abnormal inflammatory infiltrate was defined according to ESC criteria as ≥14 leukocytes/mm2 (up to 4monocytes/mm2, CD3+T-lymphocytes>7cells/mm2) and its distribution classified as focal (<30% of the specimen), multifocal (30-60%), diffuse (>60%).

Results

Median LV ejection fraction was 63% (58-67); indexed end diastolic volume 83ml/m2 (68-91). Seven patients had LVH. 8 patients had low native T1 and 6 had infero-lateral LGE. Median septal T2 value was 50ms (47-52) with 3 (all females) above local upper limit value (ULV). TnI was increased in 6 pts (40%; median value 54ng/L [38-128]). Histology showed mild inflammatory infiltrates in 8 pts (46%), none diffuse (focal 4, multifocal 4). Seven were mixed - T lymphocytes and macrophages, one was exclusively macrophages. Inflammatory foci were quiescent (n=5), or associated to myocytes injury not typical of ischemic damage and fibrosis (n=3). None had histologically visible myocardial oedema.

Patients with inflammatory infiltrates had higher T2 values (52ms [50-54] vs 47ms [46-51]; p=0.043) but the same troponin (18ng/L [3-82] vs 14ms [3-24], p=0.215) (figure 1). The 3 patients with high T2 all had inflammatory cells associated to histologic myocyte injury (figure 2).

Conclusion

For the first time we correlate histology with T2 and myocardial injury in FD. In this small study, mild myocardial macrophage/lymphocyte infiltrates are common in FD and are associated to higher T2 values. Abnormal T2 septal elevation is less common (it is known common in the basal inferolateral wall however) and when present, infiltration with histological myocyte damage is found.
Differential microRNA expression in atrial vs. ventricular functional tricuspid regurgitation. New insights into TR pathophysiology
Authors: Hinojar Baydes R , Moreno-Gomez-Toledano R , Garcia-Martin A , Gonzalez-Gomez A , Monteagudo J M , Rivas S , Sanroman M , Fernandez-Golfin C , Zaragoza R , Zamorano J L
Published: November 2023

Background

Functional tricuspid regurgitation (FTR) is associated with poor cardiovascular outcomes. Different pathophysiologic process can lead to the onset and progression of tricuspid valve disease. While atrial FTR (A-FTR) is a recently defined phenotype associated with permanent atrial fibrillation, ventricular FTR (V-FTR) has classically been related to leaflet tethering in the context of RV remodelling due to pulmonary hypertension. Although the correct identification of both phenotypes carry important therapeutic and prognostic implications, A-FTR and V-FTR overlap in a significant number of patients.

Purpose

The present work study aims to study the differential expression of serum miRNAs in A-FTR vs V-FTR

Methods

Consecutive patients with severe A-FTR and V-FTR evaluated in the Heart Valve Clinic were prospectively recruited. Patients with non-valvular permanent atrial fibrillation without TR undergoing anticoagulant therapy unit were prospectively recruited as a control group. The experimental design included a first screening phase in 16 subjects ((8 A-FTR and 8 AF controls) to identify candidate miRNAs differentially expressed in a miRNA qPCR panel containing 192 specific miRNAs, and a second validation phase in which selected miRNAs were screened for further validation by qRT-PCR in 118 additional patients (40 A-FTR, 37 V-FTR and 41 controls).

Results

The initial screening revealed 16 differentially expressed miRNAs in atrial FTR vs. AF subjets matched by age, gender and atrial dimensions (figure 1). Table 1 demonstrates differential miRNA expression in atrial and ventricular TR compared to controls in the validation phase (n=118). Among all the miRNAs, miR-152-3p, miR 22-3p, miR-324-3p and miR-29c-3p were differentially expressed in the A-FTR compared to V-FTR (p<0.05 for both). A-FTR exhibited significantly different levels of expression of miR-29b-3p, miR-152-3p, miR-30e-5p, miR-186-5p and miR-126-5p (p<0.05), whereas V-FTR expressed differentially miR-15a-5p, miR-152-3p, miR-30e-5p and miR-186-5p, miR-22-3p respectively (p<0.05).

Conclusions

The current study shows for the first time differential miRNA expression in patients with FTR. It further shows a different expression of several miRNA in atrial compared to ventricular FTR. These findings provide needed insights on the pathophysiological pathway of the atrial vs. the ventricular phenotype of FTR, and important implications towards specific therapeutic options.miRNA in A-FTR and V-FTR
Clinical factors affecting survival in patients with congenitally corrected transposition of the great arteries: systemic review and meta-analysis
Authors: Nartowicz S , Jakielska E , Ratajczak P , Lesiak M , Mitkowski P , Trojnarska O
Published: November 2023

Introduction

Congenitally corrected transposition of the great arteries (cc-TGA) is a rare congenital heart defect with diverse anatomy. Most patients have co-existing cardiac abnormalities that warrant further treatment. Some patients do not require surgical intervention, but most undergo physiological repair, anatomical surgery, or univentricular palliation, which enables them to reach adulthood.

Purpose

We aimed to evaluate mortality risk factors in patients with cc-TGA.

Method

We searched the PubMed database and included 10 retrospective cohort studies with at least 5-year follow-up time with an end-point of cardiovascular death minimum 30 days after surgery.

Results

550 patients were enrolled, and 80 met the end-point of cardiovascular death or equivalent event. As a risk factor for long-term mortality, we identified New York Heart Association (NYHA) class ≥III /heart failure hospitalization (OR=12.2; 95% CI, 2.77-53.74) and systemic ventricle dysfunction (SVD; OR=5.55; 95% CI, 2.05–15.0). We did not show history of supraventricular arrhythmia (OR = 2.92; 95% CI, 0.95–8.94), systemic valve regurgitation ≥moderate (SVR; OR=4.01; 95% Cl, 0.84-19.11) and pacemaker implantation (OR=1.7; 95% Cl, 0.22-12.84) to affect the long-term survival. In operated patients only, SVD (OR = 5.25; 95% CI, 2.26–12.17) and SVR (OR = 3.95; 95% CI, 1.41–11.07) showed a statistically significant impact on survival.

Conclusions

The risk factors for long-term mortality for the entire cc-TGA population are NYHA Class ≥III/heart failure hospitalization/death and systemic ventricle dysfunction. In operated patients, systemic ventricle dysfunction and at least moderate systemic valve regurgitation were found to affect survival.Forest plots of pooled OR - all pts.Forest plots of pooled OR: operated pts.
Relative longitudinal strain apical sparing pattern and low albumin as detrimental factors of cardiovascular outcome after transcatheter aortic valve replacement
Authors: Liu D , Hu K , Schimpf V , Sokalski V , Hermann F , Lau K , Lengenfelder B , Ertl G , Frantz S , Nordbeck P
Published: November 2023

Background

Relative apical sparing pattern (RASP) of longitudinal strain (LS), a typical echocardiographic feature of cardiac amyloidosis, is associated with cardiac death or heart failure admission in severe aortic stenosis (AS) patients, and associated with all-cause death among elderly patients with severe AS undergoing transcatheter aortic valve replacement (TAVR).

Purpose

Present study aimed to explore clinical and echocardiographic determinants of short-term and long-term CV outcome (including CV death and CV hospitalization) in symptomatic severe AS patients after TAVR, and to assess the independent and incremental prognostic value of RASP on CV outcome in TAVR patients.

Methods

This retrospective study comprised 598 consecutive AS patients underwent TAVR (mean age 81.7±5.7 years, 48.7% male). Pre-operative clinical and echocardiography data, including 2D speckle tracking imaging indexes, were analyzed. Clinical outcomes included CV death and procedure related complications at 30 days, 1 year, and at 2 years after TAVR.

Results

Relative apical sparing pattern (RASP) of longitudinal strain (LS) was defined as ≥3 LV wall segments with the apical-basal LS ratio >3.0. The prevalence of RASP was 19.2%. Compared with patients without RASP, patients with RASP were associated with higher risk of acute kidney injury (AKI, 10.4% vs. 3.3%, P=0.001) and new-onset left bundle branch block (LBBB) after TAVR (17.4% vs. 6.8%, P<0.001) and higher 2-year CV mortality (22.6% vs. 9.9%, P<0.001, Figure 1) after TAVR. Lower pre-procedural albumin level and RASP were identified as independent determinants of increased 2-year CV mortality (RASP: HR=2.178, P=0.002; albumin<4.0g/dl: HR= 2.548, P<0.001), regardless of TAVR approach and EuroSCORE II. After adjustment, the addition of RASP significantly improved prognostic power of a model including clinical variables and low albumin level for predicting 2-year CV death (χ2 from 28.179 to 40.699, P=0.001, Figure 2).

Conclusion

RASP is a significant determinant of AKI and new-onset LBBB after TAVR. RASP together with low pre-procedural albumin level serve as the strongest determinants of increased risk of 2-year CV mortality after TAVR.Figure 1Figure 2
Serial global and longitudinal RV functional assessment in symptomatic, severe aortic stenosis undergoing AVR
Authors: Maltes S , Abecasis J , Santos R R , Oliveira L , Guerreiro S , Freitas P , Ferreira A M , Ribeiras R , Andrade M J , Cardim N , Nevez J P , Mendes M
Published: November 2023

Background

Right ventricular (RV) dysfunction is currently regarded as an end-stage marker of of cardiac damage in patients with severe aortic stenosis (AS). However, global RV assessment prior to and after aortic valve replacement (AVR) has largely been neglected and little is known about RV response after AVR.

Aims

to describe the prevalence of RV dysfunction in a group of patients with severe AS referred to surgical AVR, and to evaluate post-operative evolution, as assessed by both CMR and echocardiography.

Methodology

Single-center prospective cohort study of patients with isolated severe symptomatic high-gradient AS submitted to surgical AVR. Those with previous known cardiomyopathy were excluded. All patients performed same day transthoracic echocardiogram (TTE) and CMR both before surgery and at the 3rd to 6th post-operative month. Global RV dysfunction was defined by an RVEF <45% at CMR. Echocardiographic evidence of RV dysfunction was defined by: tricuspid annular plane excursion (TAPSE) <17mm, free wall longitudinal strain (FWLS) >- 21% or RV S’ wave by tissue Doppler imaging <12 cm/s.

Results

A total of 112 patients were included (mean age 71 ± 8 years; mean valvular transaortic gradient 61 ± 18 mmHg; mean indexed aortic valve area 0.4 ± 0.1 cm2/m2; mean indexed systolic volume 48 ± 11mL/m2,mean LV ejection fraction by CMR pre and post-AVR: 60 ± 10% and 59 ± 8%; mean pulmonary artery systolic pressure pre-AVR: 35 ± 10mmHg). Only four of the patients (3.4%) had pre-operative stage 4 cardiac damage (RV dysfunction) as assessed by CMR. Moreover, only FWLS at TTE was significantly related to CMR RVEF at both pre-operative (Spearmen R= -0.337, p<0.001) and post-operative evaluation (Spearmen R = -0.217, p=0.026). Contrary to CMR RVEF (58 ± 15% vs. 57 ± 8%, p=0.461), there was a significant worsening of all TTE parameters at post-operative evaluation – overall, 32%, 20% and 25% of patients met one, two or three echocardiographic parameters of RV dysfunction - Figure 1.

Conclusion

RV dysfunction is common after AVR is patients with severe AS as assessed by common TTE parameters, but this is not accompanied by significant impairment of RVEF. Overall, only FWLS showed a consistent, albeit only moderate, correlation with RVEF at pre and post-AVR. These results highlight the limitations of longitudinal function indexes in evaluating post-surgical global RV function.
Progression of non-significant mitral and tricuspid regurgitation after surgical aortic valve replacement for aortic regurgitation
Authors: Kazum S , Vaturi M , Yedidia I , Shapira Y , Morelli O , Skalsky K , Ofek H , Schwartzenberg S , Sharoni R , Kornowski R , Shechter A
Published: November 2023

Background

There is limited evidence to guide the management of below moderate mitral and tricuspid regurgitation (MR and TR) during surgical aortic valve replacement (SAVR) for aortic regurgitation (AR). We assessed the long-term progression of these valvulopathies.

Methods

This is a single-center, retrospective analysis encompassing 7.0 (IQR, 3.4-12.1) years of follow-up after consecutive patients undergoing SAVR between 1995 and 2022. Cases with ≥moderate non-aortic valve disorders or congenital heart disease at baseline and those who had undergone prior or concomitant valvular interventions were excluded. The primary outcome was the incidence of ≥moderate MR or TR on the last documented echocardiogram.

Results

A total of 184 patients (141 (76.6%) males, median age 64 (IQR, 55-74) years, 134 (72.8%) with pure AR) were included. Of them, 46 (25.0%) underwent both SAVR and ascending aortic replacement. On the last echo study, performed at a median of 5.8 (IQR, 2.7-11.0) years after surgery, ≥moderate MR, ≥moderate TR, and either were evident in 20 (10.9%), 25 (13.5%), and 36 (19.6%) individuals, respectively. Of the latter, above moderate MR or TR occurred in 26 (72.2%). Survival rate was lower among patients with ≥moderate MR or TR on the last echocardiogram (47.2% vs 79.7%, p<0.001). After multivariable analysis, a higher risk for the primary outcome was associated with 4 baseline variables: mild to moderate (vs up to mild) MR or TR (OR 4.17, 95% CI 1.35-12.91, p=0.013), clinical heart failure (OR 7.42, 95% CI 3.47-14.82, p=0.004), atrial fibrillation (OR 3.30, 95% CI 1.10-9.85, p=0.033), and use of composite graft (OR 4.20, 95% CI 1.29-13.61, p=0.017). Conversely, echocardiographic measures of biventricular function and dimensions, aortic valve morphology, and surgical urgency were not predictive of the combined endpoint.

Conclusion

Among patients undergoing SAVR for AR, new significant MR or TR develop in one-fifth by 6 years and may be predicted by baseline clinical and echocardiographic observations.Risk Factors for the Primary Outcome
T1rho and T2rho based myocardial tissue characterisation in small animals at high-field MRI
Authors: Gram M , Williams T , Albertova P , Jakob P M , Gerull B , Bauer W R , Nordbeck P , Christa M
Published: November 2023

Introduction

Cardiac tissue characterisation using T2-based MRI promises non-invasive diagnosis or monitoring of inflammatory heart disease, toxic heart damage after chemotherapy and myocardial infarction or post-infarction patients. T2 relaxation is also an indicator for the detection of myocardial oedema or intramyocardial haemorrhage [1]. However, accurate T2 quantification is challenging due to motion, blood flow and field inhomogeneities, especially in high-field MRI [2].

In this work, we present an alternative to T2 imaging that uses spin-locking (SL) to provide a robust measurement of T2ρ relaxation. It is known from relaxation theory that T2ρ has a sensitivity almost identical to T2 [3]. In the small animal study presented here, cardiac T2ρ quantification is tested for the first time using a newly developed pulse sequence and compared with established methods.

Methods

All measurements were performed on a preclinical 7T MRI. T2 contrast was prepared using a CPMG (Carr-Purcell-Meiboom-Gill) sequence. T2ρ contrast was conventionally generated by a balanced-SL (BSL) preparation [4]. Furthermore, a new approach for T2ρ was developed based on a MLEV sequence (Malcolm-Levitt, [2]). In contrast to [2], all pulse delays were minimised here, producing pure T2ρ contrast (Fig. 1). The new method was first validated in phantom experiments and then tested in three mice with radial image acquisition accelerated for cardio-MRI.

Results

The results of the phantom study are shown in figure 2. No significant differences were found between BSL and MLEV for T2ρ quantification (mean deviation 0.74%). In vivo, significant artefacts were observed for T2 (Fig. 3), while both T2ρ methods showed improved image quality. For the evaluation of relaxation times in the left ventricle, the mean across all animals was: T2=22.9±2.6ms (R2=0.979), BSL-T2ρ=51.4±5.4ms (R2=0.983) and MLEV-T2ρ=60.0±3.4ms (R2>0.99). Thus, the MLEV-T2ρ method achieves the most robust quantification with a mean R2>0.99 and provides relaxation time maps with diagnostic image quality.

Discussion: In the present study, myocardial T2ρ mapping was tested at 7T. While no significant differences between BSL and MLEV appeared in phantom experiments, significant difference was found in vivo. Here, only the MLEV technique could achieve robust quantification. One reason for the improved performance is the continuous refocusing and minimisation of free dephasing of the transverse magnetisation. The results also show that MLEV-T2ρ has improved image quality and more robust quantification compared to CPMG-T2.

Conclusion

Cardiac T2ρ quantification is a robust alternative to established T2 imaging and can be applied under high-field conditions. A combined measurement of T1ρ and T2ρ relaxation time could be used for native detection of myocardial fibrosis and oedema.Figure 1)Comparison of image qualityFigure 2)Results in a knockout model
Trends and burden of decompensated valvular heart disease
Authors: Patel K , Sawatari H , Chahal A , Ricci F , Khanji M
Published: November 2023

Background

The prevalence of valvular heart disease (VHD) is increasing. However, the incidence and burden of valve-related decompensation are unknown. This will have significant implications for the management of patients with VHD and healthcare provision.

Purpose

To evaluate the incidence and clinical and healthcare burden of valve-related decompensated.

Methods

Between 2016-2019, data on patients with decompensated heart failure was extracted from the US National Readmission Database. Patients were divided into valve-related and non-valve related decompensation based on the predominant pathology resulting in decompensation. ICD-10 codes were used to categorise and select patients. Comparisons between both cohorts was made regarding frequencies and clinical and healthcare burden. Fine-Gray hazards models were used to assess the incidence of outcomes.

Results

Of 5,369,433 patients with decompensated heart failure, 691,581 (12.9%) were due to valve-related decompensation. The incidence of valve-related decompensation increased from 154,572 patients in 2016 to 185,510 patients in 2019 (p<0.001). Patients with valve-related decompensation had a marginally longer hospital length of stay [4 (3-7) vs 4 (2-7)days; p<0.0001] and greater adjusted cost [$12,475 (6,923-27,189) vs 10,194 (6,121-19,569); p<0.0001] compared to non-valve related decompensation. Aortic valve disease was the most common cause of valve-related decompensation (47.6%), followed by mitral (39.4%), mixed valvular (10.0%) and tricuspid (3.0%) valve disease. Valve repair/replacement was performed during the index admission in 19%, 7%, 17% and 3% of patients respectively. Compared to non-valve related decompensation, 30-day heart failure readmission for aortic (HR: 1.03, 95% CI: 1.01-1.04; p<0.0001), mitral (HR: 1.61, 95% CI: 1.59-1.64; p<0.0001), mixed valvular (HR 1.77, 95% CI: 1.72-1.81; p<0.0001) and tricuspid valve disease (HR: 1.61, 95% CI: 1.53-1.69; p=0.004) was higher.

Conclusions

Valve-related decompensated heart failure is common, and its incidence is increasing. It places a significant burden on healthcare resources. In-patient valve repair/replacement is rarely performed for all valve types, especially tricuspid valve-related decompensation. Subsequently, heart failure readmission rates are higher. Strategies to reduce decompensation from valve disease are required in order to alleviate the clinical and healthcare burden associated with it.Table 1
Pulmonary hypertension and atrial arrhythmias: incidence, risk factors, and clinical impact
Authors: Godinez Cordova L B , Sanchez-Amaya D J , Zebadua-Torres R , Lopez-Lizarraga M A , Cabrera-Jara A , Patino-Gomez T A , Lopez-Reyes J C , Zayas-Hernandez N G
Published: November 2023

Background

Atrial arrhythmias (AA) occurrence in pulmonary hypertension (PH) may determine clinical deterioration but also a herald of disease progression limiting survival and quality of life. The incidence of AA in patients with PH has not been well established in the Mexican population and scant data exist concerning the correlation of AA with clinical parameters, hemodynamic, and echocardiography variables.

Purpose

To describe risk factors, comorbidities, haemodynamic and echocardiographic variables in patients with AA in the whole spectrum of PH disease.

Methods

In this prospective cohort study from January 2021 to August 2022 we collected clinical, haemodynamic, and echocardiographic variables from 160 patients admitted to Cardiopulmonary Department. Results – Among the 160 patients, 106 (66.3%) were women, with a mean age of 46.6 years old and 78 (48.8%) belonged to World Health Organization (WHO) Group 1 of PH. AA were documented in a total of 38 patients (32.8%), being the most frequent Atrial fibrillation in 20 patients (12.5%) followed by atrial flutter in 14 patients (8.8%). Patients with AA were older and with a longer term of PH diagnosis (p < 0.001) and a greater proportion had coronary artery disease prevalence (p <0.001). AA were more common in patients with WHO functional class (FC) IV, 11/38 vs 11/122 (p 0.005) and they achieved lower distance in the 6-minute walk test 144 vs 264 (p 0.001). In the haemodynamic parameters we found higher right atrial pressure (p 0.029) and pulmonary wedge pressure (p 0.016) in patients with AA. Serum NT-proBNP was higher among AA patients (p 0.030). Echocardiographic data analysis revealed that patients with AA had increased right atrial volume (p 0.002) and lower tricuspid annular plane systolic excursion (TAPSE) (p 0.016).

Conclusions

Age and WHO FC IV were risk factors for the development of AA, patients with coronary artery disease had more prevalence of AA. Right atrial volume was a predictor for AA while TAPSE had a negative association with AA. In our study we did not find haemodynamic variables that predicted AA.
Quality of anticoagulation and outcomes after mechanical aortic valve replacement in patients with atrial fibrillation: a nationwide cohort study
Authors: Lehto J , Bjorn R , Halminen O , Linna M , Haukka J , Putaala J , Mustonen P , Kinnunen J , Hartikainen J , Airaksinen K E J , Kiviniemi T O , Lehto M
Published: November 2023

Background

Mechanical aortic valve replacement (AVR) remains predominant treatment approach for younger patients in need of aortic valve operation. However, little is known about the success of the required Vitamin K Antagonist (VKA) treatment and its relation to adverse events.

Purpose

We assessed the quality of VKA treatment prior to ischemic events and major bleeding episodes after mechanical AVR in AF patients.

Methods

The registry-based FinACAF study combining data from several Finnish health care registers covers all patients diagnosed with atrial fibrillation (AF) during 2007–2018 in Finland. In the present study, we included patients undergoing mechanical AVR before or after the AF diagnosis. Hazard ratios (HR) of first-ever ischemic stroke, any bleeding, intracranial bleeding, and myocardial infarction (MI) after AVR were estimated with Fine-Gray model adjusted for known bleeding and stroke risk factors.

Results

We identified 1086 patients (27.1% female, median age 62.8 (IQR 56.2–68.3) years) with mechanical AVR and AF diagnosis, either before (58.8%) or after (41.2%) the operation, and without prior bleeding episode, ischemic stroke, or MI. Cumulative incidence estimates at 10 years after AVR were 12.8% for ischemic stroke, 27.9% for significant bleeding, 5.8% for intracranial hemorrhage (ICH), and 7.2% for MI. International Normalized Ratio (INR) was <2.0 during 27.9–33.9% of ischemic events and lower mean Time in Therapeutic Range (TTR) with INR target ≥2.0 was associated with subsequent higher stroke occurrence (standardized adjusted HR 1.23 (1.03–1.49) for lower TTR, p=0.030, Figure 1). INR was >3.5 during 23.4–24.3% of major bleeding events and lower mean TTR (INR target 2.0–3.5) was associated with subsequent bleeding episode (adjusted HR 1.20 (1.03–1.41), p=0.021, Figure 2). Mortality was high (10-year estimated survival 71.1%), and lower mean TTR (INR target 2.0–3.5) was associated with higher mortality (adjusted HR 1.56 (1.39–1.72), p<0.001).

Conclusions

Adverse events after mechanical AVR are frequent in AF patients and mortality is high. Suboptimal mean TTR appears to identify the patients at high risk for both bleeding episodes and ischemic stroke.Figure 1.Figure 2.
Aortic stenosis progression among patients with bicuspid aortic valve
Authors: Teixeira R , Almeida M , Neves I , Sousa-Nunes F , Leite M , Lobo A , Ferreira D , Brandao M , Sampaio F , Fontes-Carvalho R
Published: November 2023

Background

Bicuspid aortic valve (BAV) is associated with an increased risk of aortic stenosis (AS). The role of AS progression rate, its determinants, and prognostic implications need to be better understood in patients with BAV-AS.

Aim

This study aims to compare AS progression rate between patients with BAV and tricuspid aortic valve (TAV), its determinants, and its impact on clinical outcomes.

Methods

We retrospectively included patients who had undergone > 1 transthoracic echocardiogram (TTE) documenting AS and preserved left ventricular ejection fraction (LVEF). Moderate to severe aortic valve regurgitation and aortic prosthetic valves were excluded. Patients with suspected BAV in TTE and a confirmatory CT scan were identified. A greedy matching was used to match patients with BAV and patients with TAV on age and sex in a ratio 1:1. Aortic peak velocity (APV) was modeled as a function of time using a mixed-effects nonlinear model to capture possible biphasic progression. A core model parameter reflecting AS rate of progression was calculated and compared between patients with BAV-AS and TAV-AS. Multivariate linear regression was used to explore possible predictors of AS progression. All-cause death was compared between patients with BAV and TAV.

Results

We matched 80 patient-pairs from within our study cohort by age and sex (age 54 ± 11 years, 40 % female). Follow-up time was higher for patients with tricuspid aortic valves (TAV) (5.9±2.6 years vs. 4.6±2.8 years, p<0.01). Patients with TAV-AS had a higher prevalence of cardiovascular risk factors (arterial hypertension [81 % vs. 41 %, p<0.001], diabetes mellitus [39% vs. 8%, p<0.001], and dyslipidemia [71 % vs. 26 %, p<0.001]). Baseline APV was similar between patients with TAV-AS and BAV-AS (2.9±0.9 m/s vs. 2.7±1.0 m/s, p=0.05), but AS progression rate was higher among patients with TAV-AS (logistic growth rate: 0.11±0.04/year vs. 0.02±0.04/year, p<0.001). No interaction was seen between aortic valve morphology and comorbidities with respect to AS progression rate. TAV-AS was associated with increased rate of all-cause death (p=0.02) but failed to remain a significant predictor of mortality after multivariate adjustment for baseline comorbidities and AS rate of progression.

Conclusion

In our matched cohort, the BAV-AS progression rate was lower than TAV-AS. BAV-AS was associated with lower mortality despite similar baseline AS severity, possibly reflecting a slower AS progression and a decreased burden of cardiovascular risk factors in this population.
Right heart function in isolated severe tricuspid regurgitation. a new stratification approach by Speckle tracking echocardiography
Authors: Hinojar Baydes R , Gonzalez-Gomez A , Garcia-Martin A , Monteagudo J M , Rivas S , Ramos P , Garcia-Sebastian C , Pardo A , Sanchez-Recalde A , Fernandez-Golfin C , Zamorano J L
Published: November 2023

Background

Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular (RV) systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown.

Purpose

to evaluate the clinical utility of combining RV and RA strain by Speckle-tracking echocardiography to assess RV and RA function for prediction of cardiovascular outcomes.

Methods

Consecutive patients with at least severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic were prospectively included following a comprehensive clinical protocol. Consecutive control subjects and patients with permanent atrial fibrillation were included for comparison. An independent cohort of patients was included for external validation. RA and RV mechanics analysis was performed using a novel, automated 2D strain analytical software. A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined.

Results

176 patients with at least severe TR, 20 AF patients and 20 control subjects were included in this study. Patients with TR showed lower RA reservoir strain (RASr) and RV-free wall longitudinal strain (RV-FWLS) compared to controls and to AF patients (p<0,001). After a median follow-up of 2,2 years (IQR: 12-41 months), 38% reached the combined endpoint. Reservoir RA strain (RASr) and RV-FWLS were predictors of outcomes independently of TR severity and RV dimensions in a multivariate Cox analysis (table, model 1). RA strain showed incremental value to RV strain. Conventional parameters of RV function were not predictive of events. RV-FWLS>-20% and RASr <10% identified patients with a higher event rate (p<0,001). The combination of abnormal values of RA and RV strain (STREI stratification) stratified 4 different groups of risk independently of TR severity, RV dimensions and clinical status (adj HR per stratum 1,89 (1,4-2,34), p<0,001) (table-model 2 and figure). Pre-defined cut-off values achieved similar prognostic performance in the validation cohort (n=50).

Conclusion

Clinical outcomes demonstrate that strain parameters are superior to conventional indices of RV function in patients with at least severe TR. The combination of RA and RV strain stratify better patients’ risk, reflecting a broader effect of TR on right heart chambers.STREI STRATIFICATION.Cox regression analysis
Clinical utility and prognostic value of right atrial function in severe tricuspid regurgitation. One more piece of the puzzle
Authors: Hinojar Baydes R , Garcia-Martin A , Gonzalez-Gomez A , Monteagudo J M , Sanroman M , Salido L , Sanchez-Recalde A , Zamorano J L , Fernandez-Golfin C
Published: November 2023

Background

Optimal management of severe tricuspid regurgitation (TR) remains controversial. While right ventricular systolic function is an established prognostic marker of outcomes, the potential role of right atrial (RA) function is unknown.

Purpose

This study aimed to describe RA function by 2D speckle tracking echocardiography (STE) in at least severe TR and to evaluate its potential association with cardiovascular outcomes.

Methods

Consecutive patients with at least (≥) severe TR (severe, massive or torrential TR) evaluated in the Heart Valve Clinic following a comprehensive clinical protocol were included. Consecutive control subjects and patients with permanent isolated AF were included for comparison (control and AF group respectively). RA function was measured with 2D-STE and RA reservoir strain (RASr) was calculated in all subjects (figure 1, AutoStrain, Philips Medical Systems the EPIQ system). The interobserver variability of RA strain was assessed in 30 randomly selected subjects (20 TR+5 AF+5 controls). A combined endpoint of hospital admission due to heart failure (HF) or all cause mortality was defined.

Results

A total of 227 patients with severe TR, 20 AF patients and 20 controls subjects were included in this study. Patients with at least severe TR showed lower RASr compared to controls and to AF patients (p<0,05). After a median follow-up of 26 months (IQR: 15-48 months), n=83 patients with severe TR (37%) reached the combined endpoint. Patients with events showed lower values of RASr (p<0,01 for both). RASr was an independent predictor of heart failure and all cause mortality adjusted by additional imaging prognostic parameters in a multivariable analysis (biplane vena contracta, RV end-diastolic area, and RV- free wall longitudinal strain [LR Chi2 : 49,7, p<0,001]). RA area or volume was not associated with outcomes. A cut-off value of RASr of <10% held the best accuracy to predict outcomes (adjusted HR 3,8 (2,4-6,1), p<0,001, figure 2). Inter-observer agreements for RA strain values across the whole cohort were high (intraclass correlation coefficient for RASr, RAScd and RASct, r= 0,95, r=0,86, r=0,92 respectively).

Conclusions

Evaluation of RA function by 2D-STE is feasible, reproducible and is an independent predictor of heart failure and all-cause mortality in patients with at least severe TR.LA STRAINKaplan Meier Curves