bluuebunny/crossref_metadata_2025 huggingface dataset:
Precapillary pulmonary hypertension: RVOT systolic flow profile as a usuful tool
Authors: Oliveira C , Silva P , Brito J , Valente Silva B , Garcia B , Martins A M , Raposo M , Abrantes A , Gregorio C , Rigueira J , Guimaraes T , Placido R , J Pinto F , Almeida A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

In patients (pts) with pulmonary hypertension (PH), right ventricular outflow tract (RVOT) systolic Doppler flow envelope is frequently abnormal, showing a mid-systolic notch that suggests elevation of pulmonary vascular resistance (PVR). Recent studies have demonstrated that other parameters, such as time-to-notch, may be indicators of elevated pulmonary artery pressures (PAP) and disease severity, conveying an important prognostic value.

Purpose

To evaluate the correlation between RVOT systolic flow morphology and hemodynamic parameters in pts with PH.

Methods

Retrospective, single-center study of consecutive pts diagnosed with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). We included pts who performed right heart catheterization (RHC) and transthoracic echocardiogram (TTE) within a six month period. RVOT systolic Doppler flow envelope was analyzed by measuring the ejection time (ET), time-to-notch (TN), pulmonary acceleration time (PAT), deceleration slope, pre- and post-notching velocity peak. Clinical, epidemiological, TTE and RHC data were recorded. For statistical analysis, Student's T tests, Chi-square and non-parametric tests were performed when appropriate.

Results

We included 79 pts, 42 with PAH (53%) and 37 with CTEPH (47%). 52 pts were women (66%) with a mean age of 58.06 ± 15.3 years. The mean follow-up (FUP) was 3.6±2.8 years. Most pts (92.3%) were symptomatic with a WHO functional status of II or III, despite specific PH treatment (69.4% PDE5 inhibitors, 63% endothelin receptor antagonists). In our analysis a higher TN correlated negatively with hemodynamic parameters such as mPAP (p = 0.02), PVR (p = 0.015), and mean right atrial pressure (mRAP), (p = 0.02). Similarly, pts with higher ET showed lower mPAP and sPAP in right ventricular catheterization (p = 0.044, p = 0.05 respectively). As previously reported, lower PAT showed a positive association with sPAP (p = 0.008), pulse pressure in pulmonary artery (p = 0.028), mRAP (p = 0.022), cardiac index (p = 0.01) and pulmonary vascular resistance (p = 0.04). When attempting to stratify TN and ET we noted a positive correlation with higher COMPERA score during FUP and lower clinical events, despite lack of clear statistical significance (p = 0.1). Regarding the remaining RVOT flow variables no statistically significant correlations were found.

Conclusion

This study shows that TN and ET accurately correlate with PAP and PVR, mirroring disease severity. Therefore, RVOT systolic flow profile is a non-invasive parameter that can be used as a valid tool when evaluating patients with PH.
CMR access for patients with chest pain, raised troponins and unobstructed coronary arteries. A retrospective real world analysis from a large UK district general hospital
Authors: Christodoulis N , Azeez S A , Henry F H , Korchi F K , Elkington A E , Bull S B
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

The differential diagnosis in patients with chest pain, a dynamic troponin rise and unobstructed coronary arteries is broad. Cardiac magnetic resonance (CMR) imaging can differentiate between the aetiologies of myocardial injury The UK has a low number of MR scanners/million people compared to Germany (8.6 v 34.4) resulting in poor equity in access to CMR (1). Our hospital relies on an off-site private health care provider for the CMR service.

Background

The 2020 ESC Taskforce guidelines recommend the use CMR in all myocardial infarction with normal coronary artery (MINOCA ) patients ideally within 2 weeks.

Purpose

There were three objectives: 1. To identify what proportion of these patients had a CMR scan 2. To determine the mean CMR waiting time 3. To establish in how many cases CMR changed the diagnosis and patient management.

Methods

We retrospectively collected the data from January - December 2021 of all patients admitted to our hospital with chest pain, a dynamic troponin rise and unobstructed coronary arteries on coronary angiography. Patient demographics, troponin levels, the discharge diagnosis, timing and details of CMR study and changes in diagnosis and management post CMR scan were recorded.

Results

81 patients fit inclusion criteria (49% male, mean 61.2±14.8 years). Mean troponin rise 271±403 ng/L. 45% underwent CMR imaging. Mean waiting time for CMR 35 ± 26.9 days. 21% had CMR in < 14 days. CMR scan led to a change in diagnosis in 40% and changed management in 29.7%. In 37.5 % of patients with a pre-scan diagnosis of myocarditis were found to have myocardial infarction post CMR scan.

Conclusion

The majority (55%) of our MINOCA patients did not have CMR imaging and the minority had it in < 2 weeks. As CMR led to a management change in almost one third of patients there is no doubt that our patients are getting suboptimal care due to lack of timely access to CMR. This study shows the difficulties of implementing guidelines in the real world particularly in a UK hospital where resources are strained and rapid expansion of urgent CMR slots is not possible.
Left atrial function assessed by speckle tracking echocardiography as a marker of atrial reverse remodeling in patients with mitral regurgitation treated with transcatheter edge-to-edge repair
Authors: Avondo S A , Arzuffi L A , Zannoni J Z , Vairo A V , D'ascenzo F D A , Alunni G A , De Ferrari G M D F , Tusa M T , Bedogni F B
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial reverse remodeling has been defined relying on changes in left atrial volume following specific procedures. Little is known about functional assessment of the left atrium by left atrial strain and left atrial emptying fraction (LAEF) following edge-to-edge mitral repair.

Purpose

The aim of this study is to assess left atrial function by speckle tracking echocardiography and changes in LAEF, as markers of atrial reverse remodeling, in patient with mitral regurgitation treated with edge-to-edge repair technique.

Methods

A total of 35 patients diagnosed with severe functional or organic mitral regurgitation who underwent trans-catheter edge-to-edge mitral valve repair were selected. Demographic, clinical and echocardiographic data were collected at the time of enrollment and after a minimum follow-up of six months. The primary endpoint was to assess if left atrial speckle tracking echocardiographic parameters (LASr, LAScd, LASct) and changes in LAEF were reliable indicators of left atrial reverse remodeling, defined as a reduction in indexed left atrial volume ≥ 15% with respect to basal assessment. Collaterally, we tried to identify clinical and standard echocardiographic parameters significantly related to atrial reverse remodeling. Changes between baseline and follow-up parameters were assessed using paired t-test.

Results

LASr, LASct and LAEF improved significantly in patients with left atrial remodeling during follow-up (LASr: 15,8%±8,43 vs 19,7%±12,22 - P 0,047; LASct: −6,4%±6,21 vs − 9,9%±8,52 - P 0,036; LAEF: 35,5%±14,17 vs 44,1%±15,17 - P 0,003). Collaterally, among all demographics, clinical and echocardiographic data, the absence of coronary artery disease, a systolic dominant pulmonary vein flow, as assessed with pulse-wave-Doppler after the repair, therapy with ACEi/ARB, lower increases in mitral valve pressure gradient after the procedure and lower pulmonary artery systolic pressure at discharge significantly correlated with reverse atrial remodeling.

Conclusions

In patients with mitral regurgitation treated with edge-to-edge repair, the assessment of left atrial function by speckle tracking echocardiography and left atrial emptying fraction correlates with atrial reverse remodeling, after a minimum follow-up of six months from the procedure. Further studies are needed to better clarify the impact of left atrial remodeling on strong clinical outcomes in patient with mitral regurgitation treated with edge-to-edge repair technique and the role of functional parameters in the definition of the optimal candidate and timing for the repair.
Time course of myocardial fibrosis activity following ST elevation myocardial infarction using 68Ga-FAPI PET/MR
Authors: Barton A , Tzolos E , Waight C , Loganath K , Joshi S , Singh T , Williams M , Van Beek E , Brian D , Fletcher A , Clark T , P S L O M K A , Dey D , Newby D , Dweck M
Published: June 2023

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): British Heart Foundation - Prof Marc Dweck Senior Fellowship, and BHF Research Excellence Award 3 for Dr Anna K Barton.

Background

Myocardial fibrosis is a key healing response following myocardial infarction (MI). Although scar formation following MI is considered complete by 12 weeks, its exact time course is unknown. Fibroblast activation protein is a key factor in fibrogenesis that is expressed by activated fibroblasts in the myocardium following MI. Hybrid positron emission tomography and cardiovascular magnetic resonance (PET/MR) with radiolabelled fibroblast activation protein inhibitor (68Ga-FAPI) is an emerging method to measure in vivo fibrosis activity.

Purpose

To investigate the timing of myocardial fibrosis activity following ST-elevation MI using 68Ga-FAPI PET/MR

Methods

Twenty patients underwent multi-timepoint hybrid 68Ga-FAPI PET/MR <1, 2, 4, and 12 weeks following acute ST-elevation MI. They were compared to patients with prior established ST-elevation MI (>12 months) and healthy controls who underwent single-timepoint 68Ga-FAPI PET/MR to determine fibrosis activity in chronic infarcts and healthy myocardium respectively. All participants were imaged 30 min following administration of 100–200 MBq 68Ga-FAPI-04. Infarct zone 68Ga-FAPI uptake was quantified using tissue-to-background ratio (TBRmax) after correction for blood-pool activity in the left ventricle. Comparisons between timepoints for the acute MI group were assessed by ANOVA with repeated measures and post hoc Bonferroni correction, and between groups by two-tailed t-test.

Results

Participants were predominantly middle-aged men (Table). Focal 68Ga-FAPI uptake localised to areas of infarction within the infarct and peri-infarct zones on late gadolinium enhancement on magnetic resonance imaging (Figure). In acute MI, there was substantial uptake with consistent TBRmax values at weeks 1, 2 and 4 (Table and Figure). Though TBRmax values started to decline by week 12 they remained persistently elevated compared to prior established MI and healthy myocardium (Table). Participants with prior established MI had modestly increased 68Ga-FAPI uptake compared with the healthy myocardium of control participants (Table and Figure).

Conclusions

Intense myocardial fibrosis activity is observed in the infarct and peri-infarct zones throughout the first month following ST-elevation MI. Although this starts to decline by 12 weeks, it remains markedly elevated even several years after myocardial infarction, indicating that low-level chronic fibroblast activity is a feature of established MI.
Late gadolinium enhancement persistence in early cardiac magnetic resonance follow-up after acute myocarditis
Authors: Parada Barcia J , Rodriguez Perez A , Barreiro Perez M , Pazos Lopez P , Matajira Chia T , Calvo Iglesias F , Iniguez Romo A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Multiparametric cardiac magnetic resonance (CMR) evaluation with modified Lake Louise criteria (mLLC) is the gold standard non-invasive test for the diagnosis of acute myocarditis. Although CMR in the follow-up may inform of edema resolution and myocardial fibrosis there is a lack of consensus on the optimal time interval to perform it and the clinical and prognostic differences between patients with complete resolution and those who present late gadolinium enhancement (LGE) persistence.

Purpose

To describe the clinical profile, CMR findings, early CMR follow-up and clinical events in patients with acute myocarditis focusing on the differences between patients who present complete LGE resolution versus patients with LGE persistence.

Methods

All patients who underwent a CMR for a suspected myocarditis during a period of 1 year from June 2021 to June 2022 were retrospectively evaluated. Those with a confirmed myocarditis by mLLC and a follow-up CMR were included. Electronic medical records were analyzed to collect data on baseline clinical variables, CMR features and follow-up events. Follow-up CMR was performed on follow-up based on clinician’s criteria.

Results

A total of 27 patients fulfilled mLLC for myocarditis during the period of study and had a follow-up CMR. The mean time to first CMR control was 186 +/- 95 days (6,2 months). Of those 23 (85.2%) presented persistent LGE enhancement and 4 of them presented a complete resolution of LGE. There were no statistically significant differences between groups although patients with complete LGE resolution tend to be younger. There were no differences between groups in terms of LVEF and RVEF. Patients with persistent LGE in the follow-up tend to have higher edema and LGE extension during the acute myocarditis episode, being the LGE difference statistically significant. In the follow up CMR almost all patients presented edema resolution and although the majority of patients (85.2%) presented LGE persistence they presented a trend to a decrease of affected segments (4.4 to 3.1 after mean time of 6 months). There were no differences in clinical events between groups in terms of death, admissions, ventricular arrhythmias and new episodes of myocarditis, patients with persistent LGE tend to have more visits for unresolved chest pain.

Conclusions

The majority of patients with a confirmed acute myocarditis had edema resolution and LGE persistence after 6 months. There were no differences in clinical events during follow-up. Follow up CMR before 6 months can prove resolving edema but LGE persistance is common. Further studies are needed to define the optimal interval to perform CMR after the index event.
Left ventricular torsion as a prognostic marker in patients with dilated cardiomyopathy
Authors: Kunal S , Kumar A M I T
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular (LV) torsion is the wringing motion of the ventricle around its long axis induced by contracting obliquely oriented myofibers in the LV wall and it predicts functional capacity more appropriately than LV ejection fraction (EF).

Purpose

This study was intended to evaluate reduced LV torsion as a potential marker of disease severity and a predictor of hospitalization for worsening heart failure in patients with non-ischemic dilated cardiomyopathy (DCM).

Methods

This was a single center prospective observational study wherein 127 patients with a diagnosis of non-ischemic DCM with a LVEF <50% were enrolled. In addition, 48 age and sex matched healthy individuals without any prior history of cardiovascular diseases and normal LVEF were enrolled as controls. All these patients underwent detailed clinical assessment including symptomatology, NYHA function class evaluation and routine blood investigations including CPK-MB levels. In addition, all enrolled subjects underwent 2D transthoracic echocardiography along with speckle tracking imaging to determine the LV global longitudinal strain (LV-GLS), LV twist and LV torsion. Based on the measurement of LV torsion, patients were stratified into two groups: preserved LV torsion (>0.59 degrees/cm) and reduced LV torsion (<0.59 degrees/cm). These patients were followed up for six months in terms of MACE events.

Results

Reduced LV torsion was reported in 52/127 (40.9%) patients with DCM. These patients had significantly lower LVEF, altered LV geometry (base-apical distance) and higher levels of CPK-MB. Additionally, patients with reduced LV torsion had a worsened functional class and a greater frequency of hospital admissions (34 vs 6; P<0.001) over 6 months of follow-up as compared to those with preserved LV torsion. Multivariate logistic regression reported reduced LV torsion to be an independent predictor of MACE events over six months of follow-up (OR:4.20; P=0.001).

Conclusion

Findings from our study suggested that LV torsion can serve as an additional prognostic marker in patients with non-ischemic DCM.
Transcatheter tricuspid valve repair: results according to TV morphology
Authors: Barreiro Perez M , Sanchis Ruiz L , Chi Hion L , Monivas Palomero V , Garrote C , Diaz Pelaez E , Mesa Rubio D , Arzamendi D , Freixa X , Estevez Loureiro R
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Tricuspid regurgitation is a prevalent and undertreated condition. Transcatheter edge-to-edge tricuspid valve repair (TTVR E2E) is an emergent option with promising procedural results in clinical trial and selected high-experienced centres. Tricuspid valve (TV) anatomy is highly variable. Whether different morphologies have a clinical or procedural impact over TTVR results are unclear.

Purpose

Our aim is to define the procedural, clinical and echocardiographic results of TTVR E2E technique in a "real-world" population according to TV anatomy.

Methods

We collected all TTVR E2E cases from 8 University Hospitals with large experience in SHDI from 2017 to 2022. It was a prospective inclusion, not randomized (real-world clinical practice). The TV morphology according to Hahn R. et al classification. Different devices (Mitraclip, Triclip & PASCAL) were employed. Clinical and echocardiographic follow-up were collected at 3 & 12 months after index procedure. We defined a combined clinical endpoint of all-cause death, HF admission and TV reintervention

Results

147 consecutive patients were recruited (74 years old, 74% female). The baseline profile was HTN 68%, DM-2 21%, DLP 44%, atrial fibrillation 91%, previous CAD 19% and previous cardiac surgery 42%, COPD 19% and CKD 42%, STS mean 5,8 pts. The TR was ≥severe in all patients (vena contracta mean 12mm, gap size 7mm). According to the procedure, the most employed device was Triclip XT (70%, 1,7 devices/patient, 89% in anteroseptal commissure), with a procedural success of 99% and 93% without clinical complications.

In our cohort, TV anatomy was conformed by 3 leaflets in 56% and 4 leaflets in 37% of cases. The morphology distribution was type I (50%), IIIB (31%), and a much lower frequent distribution of the other types (Figure 1). A significant TR reduction was accomplished in all TV morphologies without significant differences between them (Figure 2). The most frequent morphology (type I) versus the rest of morphologies, not revealed differences in terms of TR reduction or combined clinical endpoint. Restrictive septal leaflet presence (39%) is related with higher partial detachment prevalence (87 vs 17%, p 0,03). No other morphology parameters were related with procedural or clinical endpoint.

Conclusions

TV morphology was highly variable (50% of patients are non-Type I) being type I and IIIB the most prevalent. Posterior leaflet anatomy was the highest variable. Not differences were noted in TR reduction or clinical outcomes according to TV morphology. A restrictive septal leaflet were related with higher prevalence of partial detachment.
The importance of the imaging methods in patients with COVID-19 infection
Authors: Krljanac G , Asanin M , Maksimovic R , Nedeljkovic-Arsenovic O , Djordjevic N , Tomic M , Stankovic S
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Echocardiography, pulmonary CT and cardiac magnetic resonance (CMR) were have been used in detecting organ damage in COVID-19 patients. The aim of this study is to compare imaging findings and clinical symptoms patients with COVID-19.

Methods

The study was conducted in our university clinical center. All pts underwent clinical examination, laboratory analysis, echocardiography, pulmonary CT and CMR.

Results

126 pts with COVID-19 infection, 61 (48%) male, mean age 45±15years with symptoms of palpitation, fatigue, dyspnea and chest pain. Meantime from the onset of infection to observation was 107 days. In pts with palpitation, brain natriuretic peptide (NTproBNP) was not higher (39.4±9.1 vs. 19.2±9.4 pg/ml, p = 0.075). In case of pts with dyspnea ejection fraction of the left ventricle (LVEF) as founded by echocardiography, was significantly lower (62±6 vs. 67±6%, p = 0.025). The CT severity score index was not significantly higher in patients with fatigue after acute infection (21.0±8.1 vs. 10.1±5.1, p = 0.060). Late gadolinium enhancement (LGE) was seen in 61/126 (48%) pts, distribution was predominantly in mid and epicardial layers 41/61 pts (67%), >3 segments were identified in 37/61 pts (61%), myocardial edema was seen in 50/126 pts (40%). The extracellular volume (ECV) quantification by CMR were significantly higher in patients with fatigue (22.6±3.8 vs. 19.7±5.2%, p = 0.010). There is no significant correlation between clinical symptoms and myocardial oedema by using T2FS.

Conclusions

Echocardiography and CMR are the most important imaging methods in risk stratification and optimal therapeutic strategies in pts with myocardial injury caused by COVID-19 infection.
A unique perfusion pattern with 15O-water PET as a risk marker for arrhythmias in hypertrophic cardiomyopathy
Authors: Svanstroem P , Nordstrom J , Lubberink M , Harms H J , Magnusson P , Sigfridsson J , Sorensen J
Published: June 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Swedish Heart Lung Foundation.

Background

Myocardial ischemia in hypertrophic cardiomyopathy (HCM) is associated with an elevated risk of ventricular arrhythmia and sudden cardiac death. Fibrosis often occurs in subendocardial regions of the LV and the RV insertion in the interventricular septum. Globally lowered hyperemic myocardial blood flow (MBF) by 15O-water PET is known to indicate poor prognosis, but is mainly linked to late-stage "burn-out". Recent scanner and image analysis developments allow detailed 3D visualisation of quantitative biventricular 15O-water MBF.

Purpose

To investigate whether there is a visual myocardial perfusion pattern with 15O-water PET in patients with HCM which could indicate an increased risk of arrhythmias.

Methods

We reanalysed rest/adenosine stress 15O-water PET in 24 patients with high-risk HCM treated with implantable cardioverter-defibrillator from a previous study. Non-sustained ventricular tachycardia (NSVT) was noted in 10 patients during 1 year preceding PET. PET was used to determine the LV MBF subendocardial-subepicardial gradient (ml/g/min per mm). Parametric MBF images from 15O-water PET at rest and stress were visually analysed at a segmental level. The myocardial segment which visually had both the highest endocardial MBF at rest and the lowest endocardial MBF at stress was selected as the most affected segment for each patient.

Results

Reduced resting MBF with partial normalisation at stress was seen in the RV insertion in 15 patients, including all NSVT subjects. Sixteen patients, including all NSVT subjects, had a visual perfusion pattern in the septal wall or apex with enhanced subendocardial MBF at rest and reduced MBF at stress in the same segment. The MBF gradient at stress was 0.04±0.01 ml/g/min per mm for the patients with NSVT and 0.07±0.03 ml/g/min per mm for the patients without NSVT in the visually most affected segments (p = 0.01).

Conclusions

Using 3D visualisation of quantitative MBF we noted a distinct pattern with intramural redistribution of perfusion between rest and stress in HCM, significantly associated with NSVT. Reduced resting perfusion at RV insertion points has not been reported in other cardiomyopathies. Enhanced subendocardial resting perfusion in ischemic segments might indicate reactive postischemic hyperemia. Clinical use of 15O-water PET to predict ventricular arrhythmia requires prospective trials.
Inflammation and coronary flow reserve in chronic stable coronary artery disease: Evidence for a long standing interplay
Authors: Armenis I , Zymatoura M , Kontonika M , Tsiapras D , Kyrzopoulos S , Athanassopoulos G D
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Low grade inflammation is involved in pathogenesis of ischemia and outcome in coronary artery disease (CAD). Dobutamine stress echo (DSE) and coronary flow reserve (CFR) are both related with incident CAD and respective outcome as well.

Purpose

To evaluate the potential relationship between inflammation, evaluated by high-sensitivity C-reactive protein as surrogate, and DSE outcome/left anterior descending artery (LAD) CFR in stable chronic CAD.

Methods

We studied 132 consecutive pts (age 58±12years, 18 females, 33 diabetics) with stable CAD, by DSE with concomitant evaluation of LAD CFR. A cut off 3 mg/dL was used to define high and low CRP groups (CRPH/30pts, CRPL/92pts). CRP distribution was positive skewed (median 1.7mg/l) and CRP was then normalized by log transformation (CRP 0.72±0.9, logCRP 3.2±3.3). Sixty-three out of 132 pts had a follow up DSE with a concomitant reevaluation of CFR at 98±74 months. Absolute and % changes of CFR were estimated.

Results

CRPH and CRPL groups had similar baseline: CFR (CRPH: 2.3±0.6, CRPL: 2.4±0.6mg/dl), creatinine (1.0±0.2 vs 1.1±0.4mg/dl), HbA1c (5.4±1.0 vs 5.6±1.3%) and LDL (109±46 vs 102±35mg/dl). CRPH and CRPL groups had also similar hemodynamic burden at DSE and incidence of positive DSE. dCFR and %dCFR were lower in CRPL (0.20±0.70 vs 0.69±0.92, p = 0.02 and 0.13±0.33 vs 0.46±0.67 p = 0.01). Further clustering based on optimal CAD treatment achieved at baseline (guidelines defined optimal resting heart rate and LDL) did not change the findings. CFR was inversely related with logCRP (figure 1: r=-0.21, p = 0.04) and creatinine (r=-0.18 p = 0.05). Moreover, during follow up the improvement in CFR (%dCFR) was related with baseline logCRP (figure 2: r=0.30 p = 0.03). In stepwise logistic regression analysis for prediction of a CFR>2, including categorical classification of CRP (>3), diabetes, LDL (>80), Lpa(>50) and resting heart rate, then only CRP>3 classification was finally selected (exp(B)=0.38, p = 0.01).

Conclusion

Inflammation activity evaluated by CRP in stable CAD is related with the estimated LAD CFR irrespectively from the DSE outcome, both at baseline evaluation as well as dynamically during a long term follow up. The relationship is independent from LDL, Lpa levels and diabetic substrate, thus implying a strong pathophysiological interplay.
Lp(a) and evolution of left anterior descending velocity reserve in stable coronary artery disease: Is there anything beyond dobutamine stress echo outcome?
Authors: Armenis I , Zymatoura M , Kontonika M , Tsiapras D , Kyrzopoulos S , Athanassopoulos G D
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Elevated Lp(a) is related with premature and accelerated atherosclerosis, thus confering increased risk for incident chronic coronary disease (CAD) and adverse outcome. Dobutamine stress echo (DSE) and coronary flow reserve (CFR) are both related with incident CAD and outcome as well.

Purpose

Aim of the study was to evaluate the potential relationship between Lp(a) and DSE outcome/left anterior descending (LAD) based CFR in chronic CAD.

Methods

132 consecutive pts (age 59±11years, 18 females, 33 diabetics) with stable CAD were studied by DSE with a concomitant evaluation of LAD CFR. Lp(a) distribution was positive skewed (median 18.6 mg/dL) and it was then normalized by log transformation (logLpa: 2.9±1.1). High and low Lpa groups (LpaH/LpaL: 30/92) were defined using the conventional cut off 50 mg/dL. Sixty-eight/132 pts had a follow up DSE with concomitant revaluation of CFR at 98±74 months. Absolute and % changes (%d) of LAD CFR were estimated.

Results

LpaH and LpaL groups had similar baseline: CFR (2.4±0.5 vs 2.4±0.6), %dCFR (0.33±0.7 vs 0.35±0.8), creatinine (0.98±0.18 vs 1.0±0.26), HbA1c (5.3±0.9 vs 5.3±1.0) and high sensitivity C reactive protein (2.8±2.7 vs 2.6±2.8mg/L).

LpaH had lower baseline LDL (93±31 vs 111±50 p = 0.04).

LpaH and LpaL groups had also similar hemodynamic burden at DSE and incidence of positive DSE.

LpaH nondiabetics had a trend for more nonLAD distribution of ischemia (odds ratio=1.8, p = 0.07) with a greater incidence of previous revascularization (odds ratio=2.3, p = 0.03).

Further clustering based on optimal CAD treatment achieved at baseline (guidelines achieved optimal resting heart rate and LDL) did not change the findings.

However, improvement in %d LAD CFR during follow up was inversely related with logLpa (figure: R2=0.09 p = 0.05). A similar trend for %d LAD CFR and logLpa was evident for a follow up period shorter than 100 months.

Conclusion

In chronic CAD, high Lpa levels in the absence of diabetes are related with greater incidence of DSE ischemia. Despite similar CFR baseline values between conventionally defined high and low Lpa groups, the evolution of LADCFR during long term follow up is affected consistently on time by the baseline logLpa. These findings support a potential role of Lpa on ischemic burden and microvascular function in the time domain of CAD.
Chronic kidney disease and outcome of patients with tricuspid regurgitation
Authors: Loutati R , Copeland V , Fefer P , Barbash I M , Segev A , Guetta V , Mazor E , Ben-Zekry S , Hay I , Klempfner R , Kuperstein R , Maor E
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Although chronic kidney disease (CKD) is common among patients with tricuspid regurgitation (TR), these patients are under-represented in clinical trials examining tricuspid transcatheter interventions, and data regarding their outcome are limited.

Methods

Consecutive echocardiographic reports linked to clinical data from the largest medical center in Israel (2007–2022) were reviewed. Patients were dichotomized into three groups TR groups (mild, moderate and severe), following by stratification according to renal function. The primary outcome was all-cause mortality. Kaplan Meier, Multivariate Cox regression and interaction analysis models were applied.

Results

The final study population included 78,461 patients with a mean age of 65 (IQR: 55–78 years), 2,998 (4%) of whom had severe TR. There were 11,443 (15%) patients with at least moderate CKD (estimated glomerular filtration rate [eGFR] < 45 mL/min/1.73 m2), 5573 (7%) with eGFR<30 and 1853 (2%) with eGFR<=15. During a median follow-up period of 4 years (IQR: 1–7 years), 28,228 patients (36%) died. Kaplan-Meier survival analysis demonstrated an increased risk for death with both increasing severity of TR and/or CKD grade (log-rank p<.001 for both;). The association of severe TR with poor survival was consistent among all CKD subgroups (FIGURE). Multivariate Cox analysis with adjustment for age, sex, ejection fraction, estimated pulmonary pressure and eGFR demonstrated that compared to mild TR, patients with severe TR were 56% more likely to die during follow up (95% CI 1.47–1.66, p<.001). Interaction analysis demonstrated that the association of severe TR degree with survival was consistent in all subgroups but dependent on renal function, such that it was more pronounced as renal function declined, with adjusted HR of 1.6 among patients with eGFR<=15 (P for intercation <.001).

Conclusions

While the association of TR with poor survival is consistent across all CKD groups, it is more pronounced among patients with advanced CKD. When examining data and outcome of tricuspid clinical trials, special emphasis should be given to CKD status.
Comprehensive CMR to differentiate between fitness levels amongst veteran endurance athletes
Authors: Javed W , Goh Z M , Shabi M , Poh J , Chambers B , Sharrack N , Levelt E , Dall Armellina E , Greenwood J P , Plein S , Swoboda P
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): British Heart Foundation.

Background

Myocardial fibrosis has been demonstrated to be highly prevalent amongst endurance athletes. However, it is unknown whether endurance athletes with a greater exercise capacity have an increased prevalence of fibrosis.

Purpose

To determine whether greater maximal exercise threshold is associated with increased myocardial fibrosis on cardiac magnetic resonance (CMR) in veteran endurance athletes.

Methods

50 healthy veteran (aged > 50 years old) endurance athletes (cyclists/triathletes) who train >10 hours/week for >15 years underwent comprehensive CMR assessment and functional threshold power (FTP) cycling testing.

Focal myocardial fibrosis was measured quantitively from late gadolinium enhancement (LGE) imaging. Diffuse myocardial fibrosis was identified using global native T1 mapping of mid-left ventricular (LV) slices whilst extracellular volume (ECV) was calculated using haematocrit on the same day as CMR.

Statistical analysis between groups was performed using independent t-test for nominal values and chi-squared for ordinal values.

Results

Athletes were divided into high and low performance groups based on FTP assessment (median 240.8 Watts). High performance athletes were significantly younger with increased bi-ventricular size and reduced right ventricular ejection fraction (RVEF) at rest (Table 1). However, there was no statistical difference in focal fibrosis, ECV or native T1 between the groups.

Conclusion

Maximal effort capacity did not appear to influence the prevalence of cardiac fibrosis which may be related to alternative factors such as cumulative exercise exposure. However, higher performing athletes had increased bi-ventricular size, particularly affecting the more compliant right ventricle (RV). Further larger studies are needed to confirm these findings.
Joining efforts for the non-invasive evaluation in pulmonary hypertension: TAPSE/sPAP ratio
Authors: Alves Da Silva P , Brito J , Silva B , Garcia B , Martins A M , Oliveira C , Abrantes A , Raposo M , Gregorio C , Fonseca J , Rigueira J , Placido R , Pinto F J , Almeida A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulmonary hypertension remains an important challenge given its still elevated mortality rate and its complex clinical management, especially when it comes to risk stratification and imaging evaluation. In this respect, TAPSE/sPAP ratio obtained by echo is a surrogate of PA-RV coupling and has been suggested as a complementary approach to PH diagnosis and risk stratification. However, cut-offs for this ratio are yet to be clarified as recent guidelines refer a cut-off of 0,55, whilst other papers point that a lower cut-off of 0,35 could better estimate risk and prognosis.

Purpose

To analyse TAPSE/sPAP ratio impact in our population and to define an ideal cut-off to best correlate it with invasive hemodynamics and prognosis.

Methods

Single center retrospective study of patients with precapillary pulmonary hypertension who underwent right heart catheterization (RHC) and echocardiography within a time frame of 2 months. Clinical, laboratorial, echo and cath data were collected and statistical analysis was performed using Chi-square test, Mann-Whitney test, as well as ROC curve analysis and Kaplan-Meier analysis of survival.

Results

We analysed 79 patients (66% female, mean age 58,06 +- 15,3) with pre-capillary pulmonary hypertension – 53% had group 1 PH and 47% group 4 PH – followed during a mean period of 3,6 ±2,8years.

Most patients were under specific therapy (93%), mostly with PDE5 inhibitors and endothelin receptor antagonists. According to guidelines, echo derived TAPSE/sPAP ratio of 0,55 was used and it correlated with hemodynamic parameters, namely mPAP (p = 0,005), RAP (p = 0,007), cardiac output (p = 0,007) and cardiac index (p = 0,045) and pulmonary vascular resistance (p = 0,01). However, a ratio<0,55 was not ideal to predict prognosis as it failed to show correlation with COMPERA score in follow-up (p = 0,69), clinical events (p = 0,31), progression to triple therapy or death (p = 0,45).

Pts were alternatively divided into tertiles with ratios of <0,29, 0,30–0,58 and >0,59. These cut-offs showed a better positive correlation with COMPERA on follow-up (p = 0,05) and death. Kaplan-Meier curve analysis showed a clear separation of the three groups with these values. ROC curve analysis revealed that a cut-off of 0,39 had the best sensitivity and specificity to estimate clinical events (figure 1 and 2).

Conclusion

TAPSE/sPAP ratio showed a good correlation with hemodynamic parameters in pts with precapillary pulmonary hypertension. Notwithstanding, a cut-off of 0,39 showed positive correlation with survival and prognosis.
The relationship between RV strain and haemodynamic parameters in patients with pulmonary arterial hypertension
Authors: Csadi R , Morvai Illes B , Jdid Mahmoud S , Monoki M , Varga A , Agoston G
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary arterial hypertension (PAH) is a progressive disease leading to right ventricular (RV) failure and death. Risk stratification is crucial for patient management. Guideline recommends several imaging parameters for screening and risk stratification. Right ventricular 2-dimensional speckle tracking strain (RVS) is a promising parameter, as it is angle-independent, less load-dependent, and highly reproducible.

We aimed to determine the relationship between invasive haemodynamic parameters and simultaneously measured RV global (RVGLS) and RV free wall strain (RVFWS).

Methods

A single-centre prospective cohort of 17 patients with idiopathic and systemic sclerosis-related PAH (54±15 years, 89% female) were consecutively enrolled. Right heart catheterisation was performed in all patients according to the recommendation of the recent guideline. The patients underwent simultaneous transthoracic echocardiography, complying with the rules of asepsis, and also, particular attention was paid to the standard zero reference level during the recordings.

Results

The RVGLS showed a strong correlation with systolic and mean pressure measured invasively in the RV (p<0.005, r−0.8 and p<0.05, r−0.73). Also observed was a strong correlation between RVGLS and mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR) (p<0.005, r−0.749, and p<0.005, r−0.005- Figure 1.). RVGLS correlated with NT-proBNP level (p<0.05, r−0.58), but, we did not find a relationship between RVFWS and invasively measured parameters.

Conclusion

In our cohort of patients with PAH, RVGLS correlated well with simultaneously measured haemodynamic parameters. RVFWS was not shown to have a relationship with RHC parameters. The observation highlights the importance of global RV dysfunction caused by elevated PVR and mPAP.
Moderate aortic stenosis: not as benign as it seems
Authors: Martins A , Alves Da Silva P , Brito J , Valente-Silva B , Oliveira C , Garcia B , Raposo M , Gregorio C , Abrantes A , Fonseca J , Cazeiro D , Rigueira J , Placido R , Pinto F J , Almeida A G
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Severe aortic stenosis (AS) represents an important cause of morbidity and mortality, being aortic valve replacement the cornerstone for prognostic shift. Although mild and moderate AS are regarded as low risk, its benign course has recently been challenged.

Purpose

to evaluate cardiovascular (CV) events and identify prognostic factors in patients (pts) with moderate AS.

Methods

Single center observational study of pts with moderate AS in consecutive echocardiographic evaluations, during a minimum followup (FUP) of 3 years. Clinical characteristics and laboratory and echocardiographic data were collected at baseline and during follow-up (FUP).

Analyzed events at FUP included pre-syncope/syncope, chest pain, dysrhythmic episodes, hospital admission due to heart failure (HF), death and CV death. Statistical analysis was performed using Chi-square and Mann-Whitney tests.

Results

a total of 78 pts (74±10 years; 52.6% males), were monitored during a mean FUP of 47±16 months. The main CV risk factors were systemic arterial hypertension (83.3%), hypercholesterolemia (66.7%) and diabetes (41%). Atrial fibrillation was present in 39.8% of pts.

At baseline, the mean left ventricular ejection fraction (LVEF) was 62±8,6% and LV mass index (LV MI) was 118±30 g/m2. At FUP, NTproBNP was 7879 pg/ml and echocardiographic evaluation depicted a LVEF of 59±9.6% and a LVMI of 131±36 g/m2 (table 1).

At FUP, 6% of pts had pre-syncope/syncope, 13% chest pain and about 5% presented with a dysrhythmic episodes, namely complete atrioventricular block and ventricular ectopic beats. All patients with dysrhythmias had a mean aortic gradient greater than 30 mmHg (p = 0.030).

Lower LV EF at baseline (p = 0.005), greater index LV MI at baseline (p = 0.021) and at FUP (p = 0.016) and right ventricular dysfunction at FUP (p = 0.048) correlated with hospital admission due to HF (28% of pts).

During FUP, 29% of pts died, 14% from CV cause. Greater LV MI at baseline (p = 0.046) and at FUP (p = 0.032) and worse LV EF at baseline (p = 0.016) were associated with death, while a higher LVMI at baseline (p = 0.034) showed correlation with CV death.

Conclusion

Contemporary risk stratification of moderate AS is still incipient. However, less than severe AS is associated with CV events and death. In our population, about 1/3 of pts died at mean 4 years FUP, half of them from CDV death, although they didn’t progress to severe AS.

Further investigation is warranted to assess whether earlier intervention could improve outcomes in this subset of pts.
Body mass index, frailty and outcome of patients with significant tricuspid regurgitation
Authors: Fishman B , Maor E , Ashri S , Mazor E , Ben-Zikri S , Hai I , Klempfner R , Segev A , Fefer P , Barbash I M , Guetta V , Kuperstein R
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Body weight is associated with frailty and is an independent strong predictor of adverse outcomes among patients with cardiovascular diseases.

Purpose

To evaluate how body mass index (BMI) and frailty modify the association of significant tricuspid regurgitation (TR) with poor survival.

Methods

Consecutive echocardiographic reports linked to clinical data from a tertiary medical center (2007–2021) were reviewed. Patients with BMI between 14 and 45 Kg/m2 were included, with the first echocardiography as the index case. Significant TR was defined as moderate-to-severe or severe. BMI categories included underweight, normal weight, overweight and obesity with cutoffs of 18.5, 25 and 30, respectively. Frailty was stratified into 3 groups. The primary outcome was all-cause mortality and was available for all patients. Multivariable Cox regression and interaction analysis models were applied.

Results

Final study population included 109,927 patients with a median age of 65 (IQR 52–76) years of whom 63,368 (58%) were males. 3,352 (3.1%) patients had significant TR. There were 2,384 (2%), 39,638 (36%), 43,086 (39%), and 24,700 (24%) individuals with underweight, normal weight, overweight, and obesity, respectively, with 3% of significant TR in each weight group. During a median follow-up of 4.7 (1.8–8.5) years 28,917 (26%) patients died. Interaction analysis of the multivariable model demonstrated that the association of significant TR with poor survival was significantly modified by BMI such that the association of significant TR with mortality differed across BMI groups (not significant for underweight groups, HR of 1.27 1.32 and 1.34 for normal weight, overweight and obesity, p<.0001 for all three groups: Figure 1A). Interaction analysis between TR and frailty was not significant, as in all frailty groups the TR was similarly associated with mortality. Sub-analysis of 67,188 (61%) patients who were hospitalized, with adjustment of the model to baseline comorbidities (heart failure, ischemic heart disease, diabetes etc.) yielded similar point estimates to the main analysis (Figure 1B).

Conclusions

The association of significant TR with poor survival is not modified frailty, whereas it is modified by body weight. Among underweight patients, significant TR is not an independent predictor of mortality.
Acute anatomic and hemodynamic impact of mitral TEER: G4 MitraClip vs. PASCAL
Authors: Ovsenik A , Kassar M , Madhkour R , Tuyet Vi Chong-Nguyen C , Windecker S , Praz F , Hunziker Munsch L , Brugger N
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter mitral edge-to-edge repair (TEER) represents a safe and effective alternative to surgery for high-risk patients suffering from symptomatic severe mitral regurgitation (MR). New devices and new device iterations are constantly developed and their impact on the mitral valve (MV) anatomy should be regularly evaluated to provide the best patient-tailored approach in the future.

Purpose

The purpose of this study was to compare the acute anatomic and hemodynamic effects of the worldwide most implanted commercially available TEER devices: the Abbott G4 MitraClip (MC) vs. the Edwards PASCAL.

Methods

Consecutive patients from our mitral registry treated by TEER were included. High quality volume datasets focused on the MV were acquired during each intervention. Mean transvalvular gradient (Gd) corrected for the heart rate (HR), 3D mitral valve area (MVA) and anteroposterior diameter (AP) of MV annulus were evaluated before and after the implantation of each device; remaining orifices created after implantation were measured independently and summed.

Results

Eighty patients were included in this analysis; the majority were treated with "bulky" first devices: PASCAL P10 (10mm wide) or MC NTW/XTW (6mm wide). Individuals treated with MC exhibited higher MVA before clipping, however there were no differences in the AP diameter of the annulus between both groups. The first device produced a significantly higher reduction of MVA in the MC group, while no difference in MVA reduction was seen after the second implant. The impact on the AP-diameter (i.e., the indirect annuloplasty) and on the transvalvular corrected Gd after one or two devices was not significantly different between groups despite the smaller native MVA in the PASCAL population.

Conclusion

The design differences between both devices with an active closure for MC and a passive one for PASCAL (possibly leading to a lower tension on the leaflets) could explain the lower impact of the latter on the MVA, despite the wider arms of the P10. A study including a higher number of patients is needed to confirm these findings, which may affect patient selection according to the native MVA and the treatment strategy.