bluuebunny/crossref_metadata_2025 huggingface dataset:
Prediction of scar and microvascular obstruction after myocardial infarction
Authors: Breitbart P , Schmitt R , Brado J , Westermann D , Ruile P
Published: October 2024

Background

Myocardial scar, demonstrated by late gadolinium enhancement (LGE), and microvascular obstruction (MVO) at cardiac magnetic resonance imaging (CMR) are well described risk factors for cardiac events after myocardial infarction (MI).

Purpose

This study aimed to evaluate the prediction of myocardial scar and MVO based on cardiac biomarker levels.

Methods

We evaluated 631 patients with CMR 3 days [interquartile range 2-4 days] after myocardial infarction (420 with ST-segment elevation and 211 with non-ST-segment elevation myocardial infarction). Cardiac biomarker levels were measured at admission as well as 8, 16, 24 and 48 hours after percutaneous coronary intervention (PCI).

Results

A myocardial scar was detectable in 586 patients (92.9%), microvascular obstruction in 170 patients (29.3%). Patients with LGE showed significantly higher peak hs-cTnT levels than those without (3908.2±4374.0 ng/l vs 416.8±426.8 ng/l, p<0.001). A cut-off value of hs-cTnT >688.5 ng/l was a predictor for scar with a sensitivity of 81.7% and a specificity of 84.4%. Patients with MVO showed significantly higher peak hs-cTnT levels than those without (6909.8±5525.1 ng/l vs 2467.1±2993.0 ng/l, p<0.001). A cut-off value of hs-cTnT >1500.0 ng/l was a predictor for MVO with a sensitivity of 92.9% and a specificity of 43.4%.

Conclusions

Higher peak hs-cTnT levels are strong predictors for the occurrence of myocardial scar and MVO at CMR after MI as risk factors for future myocardial events. We propose the new cut-off value of hs-cTnT of >688.5 ng/l within 48 hours after PCI for prediction of myocardial scar and hs-cTnT of >1500.0 ng/l for prediction of MVO. This could be used as a screening tool for post-myocardial infarction patients, who may benefit from further evaluation using CMR.
Safety and efficiency of modified HEART scores without troponin or electrocardiography: an analysis based on two European out-of-hours primary care cohorts
Authors: Melessen I , Vallersnes O M , Harskamp R E , Atar D , Manten A , Halvorsen S , Johannessen T R
Published: October 2024

Background

Differentiating between acute chest pain of cardiac versus non-cardiac origin poses a diagnostic challenge. Risk stratification tools, such as the HEART (History, ECG, Age, Risk and Troponin) score, have been developed to aid in decision-making. These scores typically rely on troponin or electrocardiography (ECG), often unavailable in (low-resource) community-based healthcare settings.

Purpose

We evaluated the diagnostic performance of the HEART score in a low-risk setting when one of its five metrics is missing

Methods

We relied on data from two cohorts, OUT-ACS (n=1,711; for analyses with and without troponin) and TRACE (n=664; for analyses without troponin) of consecutive patients evaluated at primary care emergency clinics in respectively Norway (2016-2018; 47.7% female, median age: 56, 25th-75th percentiles:45-68) and the Netherlands (2017, 56.9% female, median age: 48, 25th-75th percentiles:32-67). We evaluated the HEAR score (all elements except troponin) and the HART score (all elements except ECG). The primary outcome was the diagnostic performance for ruling out myocardial infarction (MI) at index presentation, with a secondary outcome consisting of the composite of all-cause death or MI at 90-day follow-up.

Results

Among study participants, 61 (3.6%) were diagnosed with an MI in the OUT-ACS and 20 (3.0%) in the TRACE cohort. The percentages of patients deemed at low risk by HEAR (<=3) were 925 (54.1%) and 527 (79.4%) in OUT-ACS and TRACE, respectively. Sensitivity and specificity were 70.5% (95 % confidence interval 57.4-81.5) and 55.0% (52.5-57.4), and 75.0% (50.9-91.3) and 81.1% (77.8-84.0) for HEAR in the two respective cohorts. For the HART score, low risk was found in 696 (40.7%) OUT-ACS participants, with a respective sensitivity and specificity of 96.7% (88.7-99.6) and 42.1% (39.7-44.5), Positive predictive values ranged from 5.5-15.3%, whilst negative predictive values were 98.1-99.1% for HEAR and 99.7% for HART. By comparison, the HEART score determined 639 (37.3%) patients as low risk, had a sensitivity and specificity of 98.4% (91.2-100) and 38.7% (36.3-41.1), and positive and negative predictive values of 5.6% (5.3-5.9) and 99.8% (98.9-100). Similar findings were found for analyses using the secondary outcome.

Conclusion

HEART score variants in which troponin or ECG are omitted have higher efficiency but at the cost of decreased safety, particularly when leaving out troponin. Therefore, these biomarkers are paramount for adequate safety, despite the overall high negative predictive values in this low-prevalence primary care setting.
Assessment of a new index of myocardial strain for the diagnosis of cardiac sarcoidosis
Authors: Conci Santorio N , Santorio P T , Conci N B , Krieger J E , Rochitte C E , Soares Junior J , Kairalla R A , Arimura F E , Fernandes F , Hotta V T
Published: October 2024

Background

The diagnosis of cardiac involvement in sarcoidosis is challenging and often expensive.

Purpose

The aim of this study is to assess whether a new strain index proposed by the authors has incremental value in the evaluation of cardiac involvement, compared to the use of left ventricular (LV) global longitudinal strain (GLS).

Methods

This is a single-center, non-blinded, pilot cross-sectional study. Patients of both genders, >18 years old, with confirmed diagnosis of cardiac sarcoidosis according to the Heart Rhythm Society criteria, and controls consisting of individuals diagnosed with systemic sarcoidosis without cardiac involvement, were included. Patients with obesity grade 2 or higher , moderate or severe primary heart valve disease, myocardial diseases of other etiologies, established coronary artery disease, and inadequate acoustic window were excluded. All patients underwent transthoracic echocardiography, with subsequent measurements performed on a workstation. The following LV indexes were evaluated: GLS and the new proposed index, calculated by the ratio between LVEF and the sum of the two segments with the lowest absolute strain values. ROC curves were calculated for both parameters using an online dedicated software, with determination of the optimal cutoff point for both variables, corresponding to the point of highest sensitivity and specificity. Confidence intervals were established by the DeLong method, and curves were compared using the Bonferroni method. A two-tailed p value of 0.05 was considered significant.

Results

Twenty patients with cardiac involvement and twenty patients without cardiac involvement were evaluated. The results of the variables are presented in table 1.

Conclusions

The new index showed a larger area under the curve compared to isolated GLS, as well as higher sensitivity and specificity for the identified cutoff point, although without statistical significance, possibly due to the small sample size. Further studies are needed for subsequent validation of this innovative index.
Serial troponin sampling over 60-minutes allows early distinction between myocardial infarction and chronic myocardial injury in patients presenting to emergency departments
Authors: Vimalaratnam G , Middleton P M , Ferguson I M C , Juergens C P , Idris H I , Alazrag W A , French J
Published: October 2024

Background

High-sensitivity cardiac troponins (hs-cTn) are key clinical biomarkers in the assessment and diagnosis of patients with suspected acute coronary syndromes presenting to Emergency Departments (ED). These tests facilitate rapid triage through 0h/1h blood sampling regimens. Most patients will not have myocardial infarction (MI) diagnosed, having either hs-cTn levels below the upper reference limit (URL) or stable elevations. The latter group of complex, often multimorbid, patients is termed chronic myocardial injury (CMI) according to the 4th Universal Definition of MI (4thUDMI). These patients have long-term morbidity and mortality rates higher than those with type 1 MI. Early distinction of CMI from MI remains challenging with debate regarding optimal hs-cTnT delta cut-offs; both 3ng/L and 5ng/L over one-hour have been proposed.

Methods and Results

We prospectively collected 0-, 30- and 60-minutes (+/- 5 min) hs-cTnT samples from 185 patients presenting to Liverpool Hospital ED (Sydney, Australia) between March and August 2023. Diagnoses were adjudicated according to the 4thUDMI as follows: 16 (8.6%) MI ruled-in, 66 (35.7%) CMI and 103 (55.7%) MI ruled-out. Linear regression was used to calculate individual hs-cTnT slopes for each patient. Between CMI and MI, each 1 ng/L/hour increase in the slope of hs-cTnT resulted in a two-fold (95% CI: 1.5 to 2.9) greater likelihood of MI being diagnosed (P < 0.001). A stable hs-cTnT trajectory was observed in CMI, which ranged between 0 and 3 ng/L/hour in all patients with an initial hs-cTnT level ≤ 50 ng/L. Chronic myocardial injury patients with an initial hs-cTnT level > 50ng/L (n=12), exhibited more kinetic slopes ranging up to 8ng/L/hour (P <0.001). Unexpectedly, three MI patients had a non-linear slope, of whom two patients would not have displayed a significant rise had the additional 30-minute sample not been collected. These outlying patients presented at 9-12 hours and over 12 hours from symptom onset.

Conclusion

This study offers a novel characterisation of CMI, which has not previously been investigated in an unselected ED cohort using three serial samples over one hour. It validates a hs-cTnT delta of 3ng/L/hour in the recent ESC guidelines. However, there is a need for greater characterisation of short-term hs-cTn variability for more personalised MI risk stratification and to guide more targeted observation and further investigation of CMI patients.
Frequency of periprocedural myocardial injury and infarction stratified by cardiac troponin I and T
Authors: Chenniganahosahalli Revaiah P , Tsung-Ying T , Wlodarczak A , Lemoine J , Mollmann H , Sabate M , Wykrzykowska J , Muramatsu T , Onuma Y , Serruys P W
Published: October 2024

Background

There are different definitions of periprocedural myocardial infarction (PPMI) both in terms of thresholds for cardiac biomarkers and the ancillary criteria for myocardial ischemia. Cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) are used interchangeably to diagnose PPMI.

Objectives

This study evaluated the frequency of periprocedural myocardial injury and infarction as defined by the Society of Cardiovascular Angiography & Interventions (SCAI), the Academic Research Consortium-2 (ARC-2), and the 4th Universal definition of MI (4UDMI) stratified using cTnT versus cTnI, among patients with chronic coronary syndrome (CCS) and unstable angina.

Results

Among 830 patients, PPMI rates according to the SCAI, ARC2 and 4UDMI criteria were 4.34%, 2.05%, and 4.94% respectively, with higher rates seen for all definitions when using cTnI versus cTnT (SCAI: 9.84% vs. 1.91%, p<0.001; ARC 2: 3.15% vs. 1.56%, p=0.136; and 4UDMI 5.91% vs. 4.51%, p=0.391). Minor and major periprocedural myocardial injury was respectively observed in 58.31% and 27.10% of patients, with rates of both significantly higher when using cTnI versus cTnT (Minor: 69.29% vs. 53.47%, p<0.001, Major: 49.21% vs. 17.36%, p<0.001).

Conclusions

Among patients with CCS and unstable angina, PPMIs defined by SCAI occurred more frequently when using cTnI as opposed to cTnT, whereas the type of troponin had no impact on the incidence of PPMIs according to the ARC-2 and 4UDMI
The gut-microbiome derived phenylacetylglutamine predicts adverse events in patients with acute coronary syndromes
Authors: Allemann M , Saeedi S S , Lee P , Thomas A , Kraler S , Wenzl F , Balbi C , Camici G , Beer J H
Published: October 2024

Background and Introduction

The gut microbiota-derived metabolite phenylacetylglutamine (PAG) is associated with incident cardiovascular events(1). Acute coronary syndromes (ACS) present a major health challenge, especially as population ages(2). Data from our group show increased PAG levels during aging in humans. However, the predictive potential of PAG for mortality and major adverse cardiovascular events (MACE) in patients (pts) with ACS is unknown.

Purpose

Here, we investigated the potential of PAG to predict ischemic and fatal events in pts with acute coronary syndromes (ACS). We also compared the predictive potential of PAG to another relevant gut-microbiota derived metabolite involved in CVD, namely Trimethylaminoxyde, (TMAO), and we evaluated their cumulative risk potential.

Methods

A total of 1’848 patients were enrolled in Cohort I of the SPUM-ACS study – a multi-center prospective ACS cohort study from Switzerland. Overall survival and incident MACE after 1 year follow-up were analyzed using Kaplan-Meier (KM) estimates and compared by log-rank test after patient stratification into PAG tertiles. Uni- and multivariable Cox-regression models were fit to calculate the hazard ratios for 1-year MACE in a crude model and adjusted model (adjusted for established confounders). Healthy controls served as additional controls. PAG plasma levels were quantified using LC-HRMS.

Results

The median PAG plasma level in the healthy control group was 1.76µM, whereas for the whole ACS patient population it was 1.92µM (Table 1). Pts in the third PAG tertile had a two times higher MACE rate and a four times higher mortality rate compared to pts in the first PAG tertile (p<0.001). (Table 2). PAG levels were significantly higher in pts who presented with MACE (2.63µM) or died (3.1µM) within the 1-year follow-up compared to the healthy control subjects (p<0.0001) (Figure 1A). Spearman correlation analysis revealed that plasma PAG levels were positively associated with age (r=0.43, p<0.0001), while a negative association with eGFR was observed (r=-0.51, p<0.0001) (Figure 1B). KM estimates indicated that pts in the highest PAG tertile had significantly higher 1-year MACE risk relative to those with low levels (Figure 1C; p<0.001 log rank). Following multivariable adjustment, PAG remained an independent predictor for MACE at 1-year follow-up with a hazard ratio (HR) of 1.8 (95% CI, 1.1–3.2, p=0.048) (Figure 1D). KM estimates of both, high levels of PAG and high levels of TMAO together, indicate that the combination of these two detrimental metabolites leads to an even higher risk of 1-year MACE relative to lower levels (Figure 1E).

Conclusion

PAG is a novel and independent predictor of adverse outcomes in patients with ACS. This study indicates the role of the gut-microbiome and its metabolites in predicting ischemic and fatal outcomes of pts with established CVD.
Novel scoring system specific for patients treated with micro-axial percutaneous left ventricular assist device
Authors: Mierke J , Baron D , Nowack T , Schuster M C , Sveric K , Hoellriegel R , Winzer E , Jellinghaus S , Woitek F , Haussig S , Linke A , Mangner N
Published: October 2024

Background

Cardiogenic shock (CS) is characterized by high mortality. The impact of micro-axial percutaneous left ventricular assist devices (ma-pLVAD) remains unclear. Nevertheless, the utilization of these devices increased lately which binds considerable resources. Accurate prognosis assessment is crucial for physicians to identify patients who may benefit from the device upfront.

Purpose

We developed a novel scoring system predicting 30-day all-cause mortality specifically for CS patients treated with ma-pLVAD.

Methods

Data were collected from an ongoing Impella registry including more than 830 patients since 2014. Among them, 460 patients received a ma-pLVAD in CS. Based on 53 clinically relevant parameters univariate logistic regressions on 30-day-mortality were performed. Subsequently, parameters with a p-value < 0.1 were included in a multivariate logistic regression analysis (MLRA) using backwards selection by likelihood ratio. The remaining continuous parameters underwent a correlation and regression tree analysis (CART) to define the optimal thresholds and MLRA was performed on all the selected parameters for calculation of odds ratios. These were used for score building. All-cause mortality was assessed by Kaplan-Meier method. Area under the curve (AUC) based on receiver operating characteristic (ROC) was estimated to determine the predictive value of the novel score for 30-day-mortality. Validation was performed on a timely independent cohort of CS patients treated with ma-pLVAD.

Results

Patients were 68±1 years old with predominance of male gender (74.4% [n=342]). CS was mainly caused by acute myocardial infarction (AMI) (60% [n=276]). A cardio-pulmonary resuscitation before ma-pLVAD was performed in 49.0% [n=215]. Initial serum lactate was 8.6±0.3 mmol/l. All-cause mortality at 30 days was 65.1±2.2% (Fig. 1A). A model of 6 parameters resulted after first MLRA with following odds ratios provided in Tab. 1A. CART analysis revealed optimal thresholds for age with 68 a [Gini-coefficient (G)=0.1], for initial serum lactate with 6.5 mmol/l [G=0.042], thrombocytes with 210 Gpt/l [G=0.021], and mean arterial pressure (MAP) with 70 and 90 mmHg [G1=0.027; G2=0.008]. Results of MLRA on the 6 parameters including the determined thresholds are given in Tab. 1B. A 0 to 17 point risk score resulted by using the odds ratios (Tab. 1C). ROC analysis indicated strong predictive capability for 30-day mortality (ROC AUC [95% CI] 0.767 [0.722-0.811]; p<0.001, Fig. 1B), with discrimination details provided in Tab. 1D. In the validation cohort, the score demonstrated favorable performance (ROC AUC [95% CI] 0.793 [0.607-0.979]; p=0.016; n=24).

Conclusion

We developed an internally validated, clinically feasible scoring system to estimate 30-day-mortality of CS patients treated with ma-pLVAD. Further studies are mandatory for external validation.
Sex differences in the long-term outcomes of moderate rheumatic mitral stenosis
Authors: Kim D , Cho I , Kim I , Lim H , Son J , Shim C , Ha J , Hong G
Published: October 2024

Background

There are limited data on the sex differences in the long-term outcomes of moderate mitral stenosis (MS).

Purpose

This study aimed to investigate sex differences in long-term outcomes of moderate AS.

Methods

From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry of 3,140 patients, we included patients with moderate MS (1.5 < mitral valve area ≤ 2.0 cm2) between January 2000 and December 2021 who had not undergone previous percutaneous of surgical treatment of MS. Primary outcomes were a composite of all-cause death, heart failure (HF) hospitalization, ischemic stroke, and mitral valve intervention. We analyzed clinical and echocardiographic variables based on sex.

Results

A total of 788 patients (mean 62.2 ± 12.9 years, women 74.5%) were followed over a mean duration of 7.0 ± 6.0 years. During follow-up, 287 patients (36.4%) experienced primary outcomes. Women (n=587) had more atrial fibrillation (AF) (p=0.022), higher left ventricular (LV) ejection fraction (EF) (p<0.001), and smaller LV chamber (LV mass index; p<0.001) compared to men. Primary outcomes did not differ for both sexes (p=0.285). However, on the analysis of both sexes according to right ventricular systolic pressure (RVSP), men with elevated RVSP had poorer outcomes (p<0.001) but women did not differ (p=0.238) (Figure 1). On the multivariate Cox regression analysis, elevated RVSP was the only factor that was independently associated with poorer outcomes (hazard ratio [HR], 1.30 [95% CI, 1.10-1.05], p=0.005) in men. However, in women, several factors including older age (HR 1.02, 95% CI 1.00-1.03, p=0.012), presence of AF (HR 2.40, 95% CI 1.66-3.48, p<0.001), decreased LV EF (HR 0.98, 95% CI 0.97-1.00, p=0.007), and higher mean diastolic pressure gradient (HR 1.09, 95% CI 1.01-1.17, p=0.027) showed the independent association with poorer outcome, but not in RVSP (Figure 2).

Conclusions

In moderate MS, RVSP showed a significant prognostic role in men, but in women, various comorbidities other than that were associated with prognosis. Therefore, different follow-up strategy using specific parameters for each gender would be needed.
Temporal trends in antithrombotic therapy following transcatheter aortic valve implantation in denmark
Authors: Vistisen H , Graversen P L , Havers-Borgersen E , Strange J E , Oestergaard L , Butt J H , Dahl J S , Povlsen J A , Terkelsen C J , Freeman P , Nissen H , Koeber L , De Backer O , Fosboel E L
Published: October 2024

Background

A number of randomized clinical trials have examined the use of antithrombotic therapy after transcatheter aortic valve implantation (TAVI), and guidelines have changed over time. Yet, data from clinical practise patterns are lacking and it is important to evaluate adherence to guideline recommendations over time.

Purpose

This study aims to evaluate the temporal use of antithrombotic therapy after TAVI in Denmark.

Methods

A nationwide Danish cohort of patients undergoing first-time TAVI from 2008 to 2017 were identified from Danish nationwide registries. Patients were categorized into four groups according to data on prescription filling of antithrombotic therapy within a three-months period post-TAVI: i) No antithrombotic therapy, ii) single antiplatelet therapy (SAPT), iii) dual antiplatelet therapy (DAPT), or iv) anticoagulant therapy. The use of antithrombotic therapy post-TAVI was examined for each year from 2008 to 2017.

Results

We identified 3187 patients undergoing first-time TAVI, among whom 120 (3.8%) did not receive any antithrombotic therapy, 715 (22.4%) were prescribed SAPT, 1244 (39.0%) were on DAPT, and 1108 (34.8%) were treated with anticoagulant therapy at three months post-TAVI. Patients without antithrombotic therapy were more often men (64.2%) and were more likely to have a history of malignancy (23.3%) compared with the other treatment groups. Patients who received oral anticoagulation had a higher burden of atrial fibrillation (75.7%). The proportion of patients with atrial fibrillation remained stable over time. During the first decade of TAVI, there was a shift in the antithrombotic treatment pattern: no therapy was ranging from 1.1% to 6.6%, SAPT from 19.1% to 29.4%, while DAPT decreased from 51.0% to 31.2% and anticoagulant therapy increased from 21.6% to 39.8% (Figure 1).

Conclusion

During the first decade of TAVI, antithrombotic therapy patterns post-TAVI changed substantially, such that the use of dual antiplatelet therapy decreased over time, while the use of anticoagulant therapy increased. Since atrial fibrillation remained stable over time, the increase in anticoagulant therapy is most likely due to changes in guidelines for management of atrial fibrillation in 2010. These findings show the evolving treatment patterns in the first decade of TAVI, which reflects the recommendations from clinical trials and guidelines for the management of antithrombotic therapy for patients with TAVI.
Magnetocardiographic imaging of Tpeak-Tend magnetic field dynamics discriminates between ventricular repolarization disorders due to mitral valve prolapse and to ischemic heart disease
Authors: Brisinda D , Fenici P , Fenici R
Published: October 2024

Background

Several etiopathogenetic mechanisms, including ischemia of the papillary muscles, abnormal catecholamine regulation, baroreflex modulation, and activation of atrial natriuretic peptide induced by abnormal stretch of the prolapsing mitral leaflets, have been suggested as possible causes of ventricular repolarization abnormalities (VRab) in patients (pts) with mitral valve prolapse (MVP) [1-3], especially in those with chest pain (CP).

Purpose

Since magnetocardiography (MCG) is a sensitive alternative to improve the detection of VRab, this study aimed to evaluate its discrimination accuracy to differentiate VRab due to MVP from those due to ischemic heart disease (IHD).

Methods

MCG recordings of 32 female patients (age 40.3±13.3 years) with MVP (at echocardiography), 20 of them with CP and/or palpitations, were retrospectively compared with those of 35 pts with IHD (at least one vessel stenosis >70%) (age 66.2±10.6 years), and with those of 32 age-matched (age 40.8±11.5 years) healthy females (HF) without MVP. The cardiac magnetic field (MF) component perpendicular to the anterior chest wall (Bz) was recorded with a 36-channel DC-SQUID MCG system (sensitivity ~30 fT/VHz). Thirteen MCG parameters, five derived from the analysis of the T-wave MF extrema dynamics, and eight from the effective magnetic vector (EMV) dynamics, were automatically calculated with proprietary software during the Tpeak-Tend interval (T3-T4 in Figure 1). Discriminant analysis (DA) was applied to separate groups.

Results

At univariate analysis, 11 MCG parameters were significantly different (p< 0.05) between MVP and IHD pts (Table 1). After multivariate analysis, 9 parameters (AzimuthMeanA, TrajectoryLengthRangeD, AngleDerivativeRangeD, AzimuthdiffAD, Q2AnalysisScore, AngleMinimum, AngleDynamics, DistanceDynamics, RatioDynamics) differentiated MVP and IHD pts’ VRab with 80% accuracy (cross-correlated), at DA. Moreover, in IHD pts abnormality of EMV dynamics extended also along the whole T-wave [4]. Three EMV parameters of the Tpeak-Tend interval (TrajectoryLengthRangeD, AzimuthdiffAD, Q2AnalysisScore), and three T-wave MF extrema parameters (AngleMinimum, Distance Dynamics, and Ratio Dynamics) were abnormal in 11 MVP pts, 10 of them with CP but normal ECG, and only one asymptomatic.

Discussion: MCG EMV and MF dynamics calculated from rest-MCG data are reliable to identify VRab in pts with MVP and with IHD, differentiating them with a good discrimination accuracy. MCG VRa abnormality was mostly confined in the Tpeak-Tend interval in pts with MVP (in agreement with previous ECG findings [5]), while extended to the whole ST interval in IHD pts. Rest MCG is more sensitive than ECG in detecting VRab in pts with MVP and CP. Due to the limited number of investigated cases, the potential arrhythmogenicity of MVP-related VRab detected with MCG was not evaluated.Figure 1.MCG imaging of Tpeak-Tend MFTable 1
First in-human study of 64Cu-DOTATATE positron emission tomography/computed tomography(PET/CT) in infective endocarditis: a prospective head-to-head comparison with 18-FDG PET/CT
Authors: Hadji-Turdeghal K , Fosboel M Ø , Hasbak P , Lofgren J , Rasmussen I B , Bundgaard H , Iversen K , Bruun N E , Moeller C H , Tuxen C , Johannesen H H , Koeber L , Kjaer A , Ripa R S , Fosboel E
Published: October 2024

Background

Infective endocarditis (IE) is a severe and potentially fatal condition, which can be challenging to diagnose. Positron emission tomography/computed tomography (PET/CT) with [18F]fluorodeoxyglucose ([18F]FDG) is proposed as a diagnostic tool in the ESC endocarditis guidelines, but holds limitations.

Purpose

To compare the tracer uptake between [64Cu]Cu-DOTATATE and [18F]FDG in patients with IE, and to examine sensitivity and specificity in patients with prosthetic valve endocarditis (PVE) or native valve endocarditis (NVE).

Methods

The CuDOS-study was a prospective study including 20 cases with IE (10 with PVE and 10 with NVE) and 20 controls. [64Cu]Cu-DOTATATE and [18F]FDG PET/CT were performed in all participants. Scans were read blinded to clinical data. Tracer uptakes were measured as maximum standardized uptake values (SUVmax) in each heart valve. A visual interpretation of the presence or absence of IE was recorded for [64Cu]Cu-DOTATATE and [18F]FDG, respectively.

Results

The median age of the cases and controls was 68 years [IQR 53-71] and 61 years [IQR 56-67], respectively. In cases and controls, 85% and 70% were men, respectively. [64Cu]Cu-DOTATATE uptake (median SUVmax [IQR]) in patients with IE was higher than in controls (2.38 [1.87-2.90] vs. 1.43 [1.30-1.56], p<0.001), although this difference was mainly driven by PVE-cases (2.99 [2.22-3.75] vs. 1.43 [1.30-1.56 (controls), p<0.001) and to a lesser extent the NVE-cases (1.78 [1.22-2.33] vs. 1.43 [1.30-1.56 (controls), p=0.079), Figure 1. The sensitivity of [64Cu]Cu-DOTATATE and [18F]FDG PET/CT in 20 cases and the 20 controls were comparable, and the specificity was 90% and 75%, respectively. The analysis of PVE versus the 20 controls showed equal sensitivity (80%) for [64Cu]Cu-DOTATATE and [18F]FDG PET/CT and a specificity of 90% and 75%, respectively. The difference in the specificity between [64Cu]Cu-DOTATATE and [18F]FDG was 15% [IQR -5.9-36%], p=0.38.

Conclusion

[64Cu]Cu-DOTATATE PET/CT showed relevant uptake in the infected valve in patients with infective endocarditis. [64Cu]Cu-DOTATATE had a numerically higher specificity than [18F]FDG in prosthetic valve endocarditis, although the difference was not statistically significant. Both tracers were limited in the detection of native valve endocarditis.Figure 1 [64Cu]Cu-DOTATATE and [18F]FDG
Coronary CTA and CT-FFR in trans-catheter aortic valve implantation candidates: a systematic review and meta-analysis
Authors: Becker L , Peper J , Van Ginkel D J , Overduin D C , Van Es H W , Rensing B J M W , Timmers L , Ten Berg J M , Mohamed Hoesein F A A , Leiner T , Swaans M J
Published: October 2024

Objectives

To perform a systematic review and meta-analysis on diagnostic accuracy and other outcomes of coronary computed tomography angiography (CCTA) and CT-derived fractional flow reserve (CT-FFR) in candidates for trans-catheter aortic valve implantation (TAVI).

Background

Screening for obstructive coronary artery disease (CAD) with CCTA during TAVI work-up could prevent unnecessary invasive coronary angiography (ICA). This becomes increasingly relevant as the TAVI-population grows. CT-FFR improves CCTA accuracy in chest pain patients, but its reliability is unknown in the TAVI-population.

Methods

Pubmed, Embase and Web of Science were searched for studies regarding CCTA and/or CT-FFR in TAVI-candidates. Primary endpoint was correct identification and rule-out of obstructive CAD. Results were pooled in a meta-analysis.

Results

Twenty-four of the 29 included articles were part of the meta-analysis, reporting results for CCTA and CT-FFR in 3.494 and 797 patients respectively. Reference standard was anatomical severity of CAD in most studies. At patient-level, pooled CCTA sensitivity was 94.3% and specificity 74.8%. CT-FFR sensitivity was 91.5% and specificity 60.3% with strong variation between studies. CCTA correctly ruled out CAD in 52% of all patients, but 42% of positive CCTAs were false positives. CT-FFR correctly ruled out CAD in 47% of all patients included in this meta-analysis, but showed better accuracy than CCTA in studies that compared both. In these studies, sensitivity of CCTA versus CT-FFR was 70.7% versus 79.0% and specificity was 64.4% versus 92.9%.

Conclusions

Negative CCTA effectively rules-out CAD in the TAVI-population. Adding CCTA to TAVI work-up could lead to significant reduction in pre-TAVI ICA procedures, but the proportion of false-positives remains high. In studies performing a direct comparison, CT-FFR performed better than CCTA. This is not reflected in the CT-FFR meta-analysis. Therefore, diagnostic accuracy of CT-FFR and added value over CCTA in the TAVI-population remains unclear. Further research regarding validation and reliability is warranted.Meta-analysis of CCTA and CT-FFR
Increased index of microcirculatory resistance, capillary rarefaction, elevated troponin levels, and their association with transthyretin amyloidosis cardiomyopathy
Authors: Suiko Y , Matsuura Y , Gi T , Tanaka H , Komaki S , Moribayashi K , Yamamura Y , Ideguchi T , Yamashita A , Tsuruda T , Kaikita K
Published: October 2024

Background

The pathophysiology of coronary microvascular disease (CMD) in patients with transthyretin amyloidosis cardiomyopathy (ATTR-CM) remains unclear.

Objective

This study aims to functionally and pathologically assess coronary microvasculature to elucidate the underlying mechanisms of myocardial injury in patients with ATTR-CM.

Methods

Fifty patients (median age, 74 years; men, n=46, 92%) with echocardiographic evidence of left ventricular hypertrophy (≥12 mm) who underwent endomyocardial biopsy (EMB) and invasive coronary physiological assessments following coronary angiography were enrolled between October 2021 and September 2023 and divided into ATTR-CM (n=30) and non-cardiac amyloidosis (CA) (n=20) groups according to EMB results. All patients with ATTR-CM exhibited positive heart-to-contralateral (H/CL) ratios (>1.5) on technetium 99m pyrophosphate scintigraphy. Fractional flow reserve (FFR), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR) were measured using the PressureWire X guidewire in the left anterior descending artery. Capillary density (/mm2) was determined with EMB tissues by counting the number of CD31 immunopositive luminal structures, whereas the amyloid deposition burden was assessed by measuring the transthyretin immunopositive areas. Circulating cardiac troponin T (hs-cTnT) and brain natriuretic peptide (BNP) were measured.

Results

Compared to the non-CA group, the ATTR-CM group exhibited lower CFR (2.4±0.3 vs. 3.6±0.4, p=0.01), higher IMR (35.4±3.0 vs. 18.7±3.7, p=0.0009), lower capillary density (255.3±24.9 /mm2 vs. 408.6±29.5 /mm2 , p=0.0002), and elevated hs-cTnT levels (0.056±0.006 ng/mL vs. 0.036±0.004 ng/mL, p=0.01), with similar FFR (0.87±0.015 vs. 0.84±0.013, p=0.1) and BNP levels (229.6±38.1 pg/mL vs. 210.2±46.7 pg/mL, p=0.75). In the overall and ATTR-CM groups, capillary density had no significant correlation with IMR (r=0.16, p=0.41 and r=0.04, p=0.84, respectively) and a significant inverse correlation with hs-cTnT (r=-0.47, p=0.001, and r=-0.48, p=0.009, respectively). In the ATTR-CM group, capillary density was not significantly correlated with the H/CL ratio (r=-0.23, p=0.09); nevertheless, transthyretin immunopositive areas were positively correlated with the H/CL ratio (r=0.47, p=0.01).

Conclusion

Capillary rarefaction correlates with elevated hs-cTnT levels but not with elevated IMR, and H/CL ratios, suggesting that CMD is involved at the capillary level in ATTR-CM-related myocardial injury independent of the amyloid deposition burden.
Left ventricular ejection fraction and clinical outcomes after transcatheter aortic valve implantation
Authors: Wang Gottlieb A , Nilsson K , Settergren M , James S , Shahim B
Published: October 2024

Background

Reduced left ventricular ejection fraction (LVEF ≤50%) has been associated with poor prognosis in patients with severe aortic stenosis treated medically or with aortic valve replacement. However, less is known regarding the impact of different degrees of LVEF including moderately to severely reduced LVEF after transcatheter aortic valve replacement (TAVR).

Purpose

To examine the association between baseline LVEF and clinical outcomes after TAVR.

Methods

Patients undergoing TAVR between 2008-2021 from the Swedish Transcatheter Cardiac Intervention Registry (SWENTRY) were included. LVEF was estimated from echocardiography before TAVR and categorized as ≥50%, 40-49%, 30-39% and <30%. SWENTRY was linked to the National Patient Registry and Cause of Death Registry for outcome variables. Patients were followed for a median of 3.2 years for the primary outcome heart failure hospitalizations and the secondary outcome all-cause mortality. Cox regression analyses adjusted for age, sex, BMI, atrial fibrillation, eGFR class, diabetes, hypertension, frailty, chronic pulmonary disease and coronary artery disease were performed for the association between LVEF groups and outcome.

Results

In total, 8686 patients were included (mean age 81 years, 47% female) of whom 5904 (68%) patients had LVEF ≥50%, 1342 (15%) had LVEF 40-49%, 906 (10%) had LVEF 30-39% and 534 (6%) had LVEF <30%. Significant differences were observed across the LVEF groups in the cumulative incidence rates of heart failure hospitalizations (19, 30, 37 and 43%; p<0.001) and all-cause mortality (41, 54, 55, 57%; p<0.001) at five years. In adjusted analyses there was a stepwise increase in the risks of heart failure hospitalizations (Figure 1A) and all-cause mortality (Figure 1B) for each respective LVEF category.

Conclusion

Reduced LVEF, especially LVEF <30%, was associated with a dramatically increased long-term risk of heart failure hospitalizations and all-cause mortality in patients undergoing TAVR. LVEF should be considered in risk stratification and patient selection for TAVR.
Bioprosthetic versus mechanical prostheses in patients aged 50 to 70 years undergoing aortic valve replacement surgery: outcomes analysis from propensity score matching
Authors: Courtney W A , Ng P , Budgeon C , Gilbert T , Waller L , Graham G , Butcher S , Lewin S , Walker J , Playford D , Schultz C , Ihdayhid A , Sanfilippo F , Briffa T , Hillis G
Published: October 2024

Introduction

Despite increasing use of bioprosthetic surgical aortic valve replacement (bAVR) in patients ≤70 years [1, 2], the relative benefits compared to mechanical valve replacement (mAVR) remain uncertain [3, 4].

Purpose

The current study aims to compare mortality and other important clinical endpoints by prosthesis type for patients aged 50-70 years who received an AVR in a well-characterised Australian cohort.

Methods

A retrospective cohort study was designed utilising the WAVES Patient Registry and incorporating linked administrative outcome data including all patients who had an AVR in Western Australian public hospitals between 2010-2020. The primary endpoint was all-cause mortality. Secondary endpoints included cardiovascular (CV) mortality, separately and combined with non-fatal myocardial infarction and non-fatal stroke (MACE), major bleeding, and days alive and out of hospital (DAOH). Outcomes were compared based on a propensity-matched analysis (including demographics, biometrics, and clinical characteristics).

Results

Within the initial cohort of 727 patients undergoing surgical AVR (mean age = 63 ± SD 6), a propensity-matched cohort identified 151 patients each with bAVR (mean age = 61 ± 4) and mAVR (mean age = 60 ± 5). Patients who received mAVR versus bAVR had improved all-cause survival (Hazard Ratio [HR] 0.50; 95% CI 0.25-0.99) but increased risk of major bleeding (HR 4.85; 95% CI 1.57-14.98). There were no significant differences in CV mortality (HR 0.58; 95% CI 0.19-1.74), MACE (HR 0.59; 95 % CI 0.32-1.07), or DAOH by prosthesis type (P = 0.452).

Conclusions

Patients aged 50-70 years who underwent mAVR had lower risk of all-cause mortality compared with bAVR, despite higher bleeding risk. Although risks of CV mortality and MACE were lower in mAVR, statistical significance was not reached, likely due to the small sample size. Larger studies are necessary to confirm these findings, which have important clinical implications.
Differentiation of severe from non-severe mitral stenosis with dimensionless index and its prognostic implications in patients with rheumatic mitral stenosis
Authors: Leow R , Li T Y , Chan M W , Kong W K , Poh K K , Kuntjoro I , Sia C H , Yeo T C
Published: October 2024

Introduction

Accurate identification of the severity of rheumatic mitral stenosis (MS) commonly relies on measurement of mitral valve area (MVA) by transthoracic echocardiography (TTE). The dimensionless index (DI) of mitral valve (MV) was recently shown to be useful in identifying severity of degenerative MS. It is uncertain if DI MV is useful in rheumatic MS.

Purpose

We aimed to validate the DI MV in rheumatic mitral stenosis, identify threshold values of the DI MV for the accurate identification of severe and non-severe rheumatic MS, and study its association with clinically significant outcomes.

Methods

We studied DI MV in 406 cases of rheumatic MS, with 174 cases in a derivation cohort , 121 cases in a TTE validation cohort, and 111 cases in a transoesophageal echocardiography (TEE) validation cohort. Outcome data were collected in the derivation and TTE validation cohorts. DI MV was calculated by dividing the left ventricular outflow tract pulsed-wave Doppler time-velocity integral (TVI) by the MV continuous-wave Doppler TVI.

Results

In the derivation cohort, ROC analysis showed that MV DI was significantly associated with MS severity (AUC = 0.838, 95% CI, 0.780-0.897, p<0.001) but no threshold value was able to identify severe MS (MVA ≤ 1.5 cm2) with both sensitivity and specificity greater than 80%. DI MV ≤ 0.34 had the best combination of sensitivity and specificity (78.5% and 75.8% respectively). However, with an approach using two threshold values, namely DI MV ≤ 0.25 to identify severe MS and DI MV ≥ 0.40 to identify non-severe MS, both values showed a high specificity of 93.7%. When tested in the validation cohorts, these values have similar high specificity for identifying severe (93.8%) and non severe MS (91.4%). DI MV was univariately significant (HR = 0.075, 95% CI 0.0215-0.378, p=0.002) in Cox regression analysis for a composite outcome of death and MV intervention. Multivariate analysis incorporating age, sex, DI MV, pulmonary artery systolic pressure (PASP) and left ventricular ejection fraction (LVEF) showed that age, DI MV and PASP were independently associated with the composite outcome.

Conclusion

While not a replacement for MVA in the assessment of MS severity, the DI MV can rule-in or rule-out severe MS with a high specificity and is useful as a complementary tool in the integrative assessment of MS severity. DI MV is independently associated with composite outcomes of death and MV intervention.Receiver operating characteristic curveSensitivity and Specificity of DI MV
Prognostic stratification of patients with mitral regurgitation using artificial intelligence-enhanced electrocardiogram for left ventricular diastolic function assessment
Authors: Tsaban G , Lee E , Wopperer S , Abbasi M , Yu H T , Kane G C , Lopez-Jimenez F , Pislaru S , Nkomo V T , Deshmukh A , Asirvatham S J , Noseworthy P A , Friedman P , Attia Z I , Oh J K
Published: October 2024

Background

The determination of left ventricular diastolic dysfunction (LVDD) and filling pressure in patients with significant (>moderate) mitral regurgitation (MR) poses a complex challenge. We recently validated an artificial intelligence-enabled electrocardiogram (AI-ECG) algorithm to detect LVDD and estimate LV filling pressures.

Methods

This retrospective study sought to examine the risk of all-cause mortality across AI-ECG LVDD grades. Patients from the AI-ECG LVDD study test cohort who underwent transthoracic echocardiography confirming significant MR and an ECG within fourteen days of each other at Mayo Clinic between 09/2001 and 06/2022 were included. LVDD status was determined based on the index ECG, and patients were categorized into groups representing normal diastolic function (NDF) or LVDD grades 1 (G1), 2 (G2), or 3 (G3).

Results

Of 4,019 patients with significant MR (mean age 69.8, 49.0% women), 1,175 (29.2%), 1,881 (46.8%), and 963 (24.0%) were classified by AI-ECG as NDF/G1-LVDD, G2-LVDD, and G3-LVDD, respectively. The median mitral effective regurgitant orifice area was 26 mm² (interquartile range 20-36 mm²). Over a median follow-up of 3.5 years, 1,636 (40.7%) patients died. In multivariable survival analysis adjusted for multiple risk factors, a worse AI-ECG LVDD grade was independently associated with an increased death risk [G2DD: adjusted hazard ratio (aHR) 1.98 (95% confidence interval (95% CI) 1.63-2.40), G3DD: aHR 2.59 (95% CI 2.09-3.20)]. These findings were consistent when accounting for mitral valve intervention and among patients with >moderate MR or after mitral valve intervention.

Conclusion

In patients with significant MR, the grading of LVDD by AI-ECG is independently associated with all-cause mortality.
Efficacy of native T1 mapping for patients with non-ischemic cardiomyopathy and ventricular functional mitral regurgitation undergoing transcatheter edge-to-edge repair
Authors: Tsunamoto H , Yamamoto H Y , Takahashi N T , Masumoto A M , Onishi T O , Tanigichi Y A , Takaya T T , Kawai H K , Hirata K H , Tanaka H T
Published: October 2024

Background

The objectives of this study were to investigate the efficacy of LV myocardial damage assessment by native T1 mapping obtained with cardiac magnetic resonance (CMR) for symptomatic heart failure (HF) patients with non-ischemic cardiomyopathy (NICM) and ventricular functional mitral regurgitation (VFMR) undergoing transcatheter edge-to-edge repair (TEER).

Methods

We studied 40 symptomatic HF patients with NICM and VFMR undergoing TEER. LV myocardial damage was defined as the native T1 Z-score which was converted from native T1 value obtained with CMR before TEER. The primary endpoint was defined as first re-hospitalization for HF or cardiovascular death over a median follow-up period of 12 months after TEER.

Results

Multivariable Cox-proportional hazards analysis showed that a native T1 Z-score was the only independent parameter associated with cardiovascular events (hazard ratio: 3.40, 95% confidential interval: 1.51-7.67), and patients with native T1 Z-score < 2.41 experienced significantly fewer cardiovascular events than those with a native T1 Z-score ≥ 2.41 (log-rank P = 0.001). Moreover, such a low native T1 Z-score and more severe VFMR in an effective regurgitant orifice area (EROA) ≥ 0.30 cm2 was associated with fewer cardiovascular events than for a high native T1 Z-score of ≥ 2.41 and less severe VFMR of EROA < 0.30 cm2 (log-rank P = 0.002).

Conclusion

Assessment of baseline LV myocardial damage by means of native T1 Z-score obtained with CMR without the use of gadolinium-based contrast media is a valuable additional parameter for better management of symptomatic NICM patients with reduced LVEF and VFMR following TEER.
Gender-specific differences in severe tricuspid regurgitation. Finding from a TR multicentre CMR registry
Authors: Hinojar Baydes R , Ramos N , Rodriguez Palomares J , Eiros R , Barreiro M , Calero M J , Rodriguez Diego S , Gutierrez S , Galian L , Martinez Vives P , Monteagudo J M , Garcia Martin A , Gonzalez-Gomez A , Fernandez-Golfin C , Zamorano J L
Published: October 2024

Background

Observational studies have suggested that severe tricuspid regurgitation (TR) is more prevalent in women than in men, although the pathophysiological causes that justify this difference are unknown.

Purpose

1) to assess clinical and imaging differences by Cardiac Magnetic Resonance (CMR) between men and women and 2) to examine the relationship between gender and all-cause mortality in a multicentre cohort of patients with at least severe TR.

Methods

The study-enrolled patients with at least severe TR assessed by 2D echocardiography who underwent a contemporary cardiac magnetic resonance (CMR) study. The primary outcome was all-cause mortality.

Results

318 patients with severe TR recruited from 5 tertiary care hospitals were included in this study (70 ± 11 years, 67% female, 73% NYHA I or II). Regarding the etiology, 10% were primary TR, 1% CIED-related TR, 46 % atrial secondary TR and 43% ventricular secondary TR. Women showed a non-significant tend to lower prevalence of comorbidities, lower BNP and significantly lower creatinine values (table). Regarding CMR variables, women showed smaller indexed right ventricle (RV) volumes higher RVEF and lower TR regurgitant volume (table, p<0.05 for all). Left ventricle (LV) volumes were smaller and LVEF higher in women compared to men (p<0.001).

During a median follow-up of 28 months (IQR: 10-54 months), there were 61 deaths (19%) with an estimated 5-year survival of 74%. Cumulative all-cause mortality was significantly worse in men compared to women (27% vs. 15%, p<0.001, figure). Male gender was significantly associated with all-cause mortality independently of age, RV volumes, RVEF and LVEF (HR 2,2 [1.34-3,68], p =0.002). Different cut-off values of index RV volumes and EF were predictive of mortality in men and women. In men a RV-EDV >110 ml/m2 and RVEF<57%; in women a RV-EDV >90 ml/m2 and RVEF< 60% were predictive of all-cause mortality (p<0.01).

Conclusion

Severe TR is more prevalent in women; however, it shows lower RV remodeling, better RV function and lower rate of events compared to men. Different prognostic RV cut-off values are provided based on CMR data.Gender differencesKaplan Meier Curves