bluuebunny/crossref_metadata_2025 huggingface dataset:
The impact of right atrium and left atrium reverse remodeling for functional regurgitation of atrioventricular valve among patients who were underwent ablation for atrial fibrillation
Authors: Nemoto N , Samejima Y , Takenaka H , Yaguchi T , Kameda Y , Shimizu T , Sahara N , Takenaka H , Nagashima Y , Anzai H
Published: October 2022

Background

Atrial fibrillation (AF) is a risk factor of Regurgitation of Atrioventricular Valve and Regurgitation of Atrioventricular Valve is improved after ablation for AF. However, Mechanism of improvement of Tricuspid regurgitation (TR) and Mitral regurgitation (MR) after ablation for AF were unclear.

Methods

The one hundred fifty-seven cases consecutive patients who were underwent ablation for persistent AF were examined in this study. These patients were performed Holter ECG and Echocardiography 6 months after ablation for persistent AF. The area of the Right Atrium (RA), Left Atrium (LA), diameter of the tricuspid valve anulus and Mitral valve annulus, were measured by echocardiography at before and 6 months after ablation for AF. The reverse remodeling index (RRI) was defined as divided post area of RA and LA by pre area of RA and LA. The Improved group was defined as one or more than regurgitation grade improvements.

Results

TR improved in 56 cases (35.7%) of 157 cases and MR improved in 25 (16.6%) cases of 157 cases. The ratio of improved TR was significantly higher than ratio of improved MR (p<0.01). The difference in tricuspid annulus diameter before and after ablation for AF was significantly longer in TR improved group than in TR non-improved group. (4.9±5.3 mm vs 1.6±5.4 mm, p<0.01). The RRI of RA in TR improved group was significantly smaller than in TR non-improved group (0.73±0.19 vs 0.89±0.26 p<0.01). The difference in mitral annulus diameter before and after ablation for AF was not significant differences between MR improved group and MR non-improved group. The RRI of LA in MR improved group was significantly smaller than in MR non-improved group (0.79±0.22 vs 0.90±0.25 p<0.01). The RRI of RA was significantly smaller than RRI of LA among patients who were able to maintain sinus rhythm after ablation for persistent AF (0.79±0.23 vs 0.85±0.24 p=0.04).

Conclusion

Reverse remodeling of RA was higher than Reverse remodeling of LA among patients who were able to maintain sinus rhythm after ablation for persistent AF and Reverse remodeling of RA and LA were important factors of improvement of TR and MR after ablation for persistent AF. These results considered to be the cause why the improvement rate of TR was higher than the Improvement rate of MR after persistent AF.

Funding Acknowledgement

Type of funding sources: None.
Long-term outcomes following transcatheter pulmonary valve implantation with the sapien 3 valve: an international multicentre registry
Authors: Hascoet S , Bentham J R , Betrian-Belasco P , Houeijeh A , Jones M , Biernacka E K , Karsenty C , Malekzadeh-Milani S G , Dohlen G , Kantzis M , Valdeolmillos E , Georgiev S , Guerin P , Tengler A , Fraisse A
Published: October 2022

Background

Transcatheter pulmonary valve implantation (TPVI) is indicated to treat right-ventricular outflow tract dysfunction related to congenital heart disease. Long-term outcomes following TPVI with the new-generation SAPIEN 3 valve are not well documented.

Purpose

We investigated mid-term outcomes in a large cohort of patients who underwent TPVI using the SAPIEN 3 valve.

Methods

We retrospectively analysed data from a multicentre observational registry of patients who underwent TPVI with SAPIEN 3 in 30 centres in 12 countries from Europe, the Middle East, and Canada. Patient-related, procedural, and mid-term-outcome data were assessed.

Results

We obtained data for 713 patients treated in 2014–2021. Number of procedures performed among centres varied from 1 to 190 with a median of 15. Median age was 29.4-year-old [19.0–42.8]. The most common underlying diagnosis was cono-truncal defect (68.9%), with a native or patched right-ventricular outflow tract, a bioprosthetic valve, a homograft and a conduit, in 50.8%, 19.6%, 16.5% and 13.2% patients, respectively. Pre-stenting was performed in 74.8% patients. The 20-mm, 23-mm, 26-mm, and 29-mm valves were used in 0.4%, 28.2%, 31.2%, and 40.2% of patients, respectively. Valve implantation was successful in 98.6% patients. Life-threatening peri-procedural adverse events occurred in 3.7% patients, including 0.6% peri-procedural death. Median follow-up was 1.4 years (maximum, 5.9 years; 1160 patient-years), At last follow-up, pulmonary regurgitation grade 2, 3 and 4 was noted in 6.9%, 0.9% and 0.0% patients, respectively. Median maximal gradient at last follow-up was 18 mmHg.

Six patients experienced infective endocarditis (0.5 per 100 patient-years) of whom 1 died and 2 required pulmonary valve replacement. Nine patients (0.8 per 100 patient-years) had secondary pulmonary valve replacement (including 2 by valve-in-valve TPVI; 7 patients had 23-mm and 2 had 26-mm valves). Four patients experienced pulmonary valve thrombosis (0.6 per 100 patient-year) of whom one died and 3 resolved under anticoagulation therapy.

Cumulative incidences of infective endocarditis, secondary pulmonary valve replacement and valve thrombosis were 0.7%, 1.3% and 1.3%; 0.4%, 1.3% and 4.6%; 0.5%, 0.5% and 0.8% at 1, 3 and 5 years after TPVI respectively.

Conclusion

TPVI with the SAPIEN 3 valve was feasible and safe in a wide range of patients with congenital heart defects, most of whom had large native right-ventricular outflow tracts. Mid-term outcomes were favourable.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The study is promoted and financially supported by a Research grant of the Groupe Hospitalier Paris Saint Joseph
Prognostic impact of cerebral embolism in patients with active infective endocarditis and therapeutic strategies. A retrospective real world study in a surgical centre
Authors: Scheggi V , Menale S , Tonietti B , Giovacchini J , Bigiarini C , Del Pace S , Zoppetti N , Alterini B , Stefano P L , Marchionni N
Published: October 2022

Purpose

Infective endocarditis still has high mortality and invalidating complications, such as cerebral embolism. The best strategies to prevent and to manage neurologic complications remain uncertain. This study aimed to identify predictors of septic cerebral embolism and to evaluate the role of surgery in these patients, in a real-world surgical center.

Methods

We retrospectively analyzed 551 consecutive patients admitted to our department with a definite diagnosis of non-device-related infective endocarditis; of these, 126 (23%) presented a neurologic complication.

Results

Cerebral embolism was significantly more frequent in patients with large vegetations (p=0.001), mitral valve infection (p=0.001), and Staphylococcus aureus infection (p=0.025). At multivariable analysis, only vegetation length was an independent predictor of cerebral embolism (HR 1.057, 95% CI 1.025–1.091, p 0.001), with a best predictive threshold of 10 mm at ROC curve analysis (AUC 0.54, p=0.001). Patients with neurologic complications were more often excluded from surgery despite an indication to it (16% vs 8%, p=0.001). If eligible, they were treated within two weeks from diagnosis in similar proportion as patients without cerebral embolism with similar survival rate. Predictors of mortality were hemorrhagic lesions (p=0.018), a GCS<14 (p=0.001) or a severe degree of disability (p=0.001) at presentation. The latter was the only independent predictor of mortality at multivariable analysis (HR 2.3, 95% CI 1.43–3.80, p=0.001).

Conclusions

The present study highlights the prognostic value of clinical functional presentation and the safety of cardiac surgery, when feasible, in patients with septic cerebral embolism.

Funding Acknowledgement

Type of funding sources: None.
Endocarditis-TR: diagnosis, treatment and prognosis of the infective endocarditis patients admitting tertiary centers of Turkey
Authors: Calik A N , Ozluk O A , Karatas M B , Canga Y , Eren S , Ayhan G , Akdeniz A , Palice A , Candemir A , Akyuz S , Zoghi M , Kozan O
Published: October 2022

Background/Aim

Infective endocarditis (IE) is still a significant cause of morbidity and mortality among cardiovascular diseases. ENDOCARDITIS-TR study aims to evaluate the compliance of the diagnostic and therapeutic methods being used in Turkey with current guidelines.

Material and methods

The ENDOCARDITIS-TR trial is a multi-centre, prospective, observational study consisting of patients admitted to tertiary centres with a definite diagnose of IE. In addition to the demographic, clinical, microbiological and echocardiographic findings of the patients, adverse events, indications for surgery, and in-hospital mortality were recorded during a 2-year time interval.

Results

A total of 208 IE patients from 7 tertiary centres in Turkey were enrolled in the study. The study population included 125 (60.1%) native valve IE (NVE), 65 (31.3%) prosthetic IE (PVIE), and 18 (8.7%) intracardiac device-related IE (CDRIE). One hundred thirty-five patients (64.9%) were culture positive, and the most frequent pathogenic agent was methicillin-susceptible Staphylococcus aureus (MSSA) (18.3%). Among 155 (74.5%) patients with an indication for surgery, only 87 (56.1%) patients underwent surgery. The all-cause mortality rate was 29.3% in-hospital follow-up. Multivariable Cox regression analysis revealed that absence of surgery when indicated (HR: 3.29, 95% CI: 0.93–11.64, p=0.05), albumin level at admission (HR: 0.46 95%, CI: 0.29–0.73, p<0.01), abscess formation (HR: 2.11, 95% CI: 1.01–4.38, p=0.04) and systemic embolism (HR: 1.78, 95% CI: 1.05–3.02, p=0.03) were ascertained as independent predictors of in-hospital all-cause mortality.

Conclusion

The short term results of the ENDOCARDITIS-TR trial showed the high frequency of staphylococcal IE, relatively high in-hospital mortality rates, shortage of surgical treatment despite guideline-based surgical indications and low usage of novel imaging techniques. The results of this study will provide a better insight to physicians in respect to their adherence to clinical practice guidelines.

Funding Acknowledgement

Type of funding sources: None.
Outcomes of infective endocarditis in patients with and without pericardial effusion: a National Inpatient Sample study
Authors: Cruz Torres R , Bansal R , Palicherla A , Thandra A , Sharma A , Narmi A , Smer A
Published: October 2022

Introduction

Pericardial effusion (PE) in patients with infective endocarditis (IE) has been shown to be an independent risk factor for severe complications, however no significant association with mortality has been established. Our study aims to study the significance of pericardial effusion in patients with IE.

Methods

We performed a retrospective analysis using the United States National Inpatient Sample (NIS) database to identify all the hospital admissions with IE using ICD 10 codes and divided them into two groups based on the presence of PE. The outcomes of interest were in-hospital mortality, in-hospital complications, need for cardiac surgery, and length of stay (LOS).

Results

A total of 381,300 patients were hospitalized from 2016 to 2019 with IE, of whom 10,370 developed PE. Mean age of patients in the PE group was 51 years and in non-PE group was 61 years with males and Caucasian race being predominant in both groups. PE group had higher rates of in-hospital death (12.7% vs 9%, P≤0.001) and longer in-hospital stay (12 days vs 7 days, P≤0.001) compared to non-PE group. The rates of cardiac surgery were higher in PE group (26.1% vs 8.4%, P≤0.001). The rates of heart failure, heart block, renal failure, cardiogenic shock, and embolic stroke were higher in PE group [Table 1].

Conclusion

Our study shows that presence of PE in patients with IE is a predictor for in-hospital mortality, length of stay, and need for cardiac surgery. Also, these patients are at higher risk for heart failure, heart block, cardiogenic shock and embolic stroke.

Funding Acknowledgement

Type of funding sources: None.
TAVI-prosthetic valve endocarditis can often be cured without surgery
Authors: Ried I , Omran H , Rudolph T K , Scholtz S , Bleiziffer S , Piper C
Published: October 2022

Introduction

Prosthetic valve endocarditis (PVE) is the most unfavourable complication after any aortic valve replacement.

Purpose

The aim of this study was to analyse the impact of antibiotic-only and additional surgical therapy in patients with TAVI-PVE and to compare it with the results of patients with PVE after surgical aortic valve replacement (SAVR) regarding survival.

Methods

All patients who underwent primary isolated aortic valve replacement via SAVR (n=3.447) or TAVI (n=2.269) in our heart center between 01/2012–12/2018 were analysed. The diagnosis of PVE was made using the 2015 modified Duke criteria. Follow-up was performed until 06/2019 (max. 89, mean 34 months) with a follow-up rate of 98% regarding mortality.

Results

PVE incidence did not differ significantly between SAVR with 4.9 cases per 100 patient-years and TAVI with 2.4 cases per 100 patient-years (p=0.49), although TAVI patients were significantly older (mean 80 vs. 67 years) and had more multimorbidities (STS score mean 5.9 vs. 1.6) (p<0.001). TAVI prostheses with polymer showed a 4.3-fold higher risk to develop PVE than TAVI prostheses without polymer (p=0.004). Most common pathogens were staphylococci and enterococci in all PVEs. Antibiotic-only therapy in TAVI-PVE patients resulted in a significantly better 1-year survival compared with additional surgical therapy (90.9% vs. 33.3%; p=0.005) even in 4 patients with an indication for surgery according to ESC guidelines. In SAVR-PVE patients both therapies led to comparable survival (p=0.861). However, SAVR-PVE who were not operated although indication for surgery was given by the guidelines resulted in a significantly worse survival after 1 year (p=0.004).

Conclusion

TAVI patients did not have a significantly higher risk to develop PVE than SAVR patients despite their older age and greater comorbidities. The 1-year survival of TAVI-PVE patients was significantly higher after antibiotic-only therapy than after additional surgery, even if surgery had been indicated according to guidelines. This new finding is presumably due to the fact that TAVI prostheses do not have a polymeric suture ring. Our results show for the first time that indication for surgery in TAVI-PVE patients should be made carefully. SAVR-PVE patients however benefit from guideline-compliant surgery as in this respect antibiotics-only led to a significantly worse prognosis. This is probably related to the ability of gram-positive cocci to migrate into the polymeric ring and to protect themselves from antibiotic therapy by forming a biofilm. Some of the newer TAVI prostheses contain plastic components which can also be cured often with antibiotic-only but are associated with an increased risk to develop PVE.

Funding Acknowledgement

Type of funding sources: None.
Factors associated with outcome five years after infectious endocarditis – the POET trial
Authors: Pries-Heje M
Published: October 2022

Introduction

In stabilized patients with left-sided infectious endocarditis (IE) a shift to oral antibiotic treatment was non-inferior compared to conventional intravenous antibiotic treatment as assessed six months after randomization (1). After 5 years the primary outcome was superior in the orally treated group (2). Factors associated with primary outcome in the POET trial have not previously been reported.

Purpose

To identify factors associated with the occurrence of the primary outcome in the POET trial (Partial Oral Antibiotic Endocarditis Treatment) after 5-years of follow-up.

Method

The POET trial was a Danish national randomized clinical trial with inclusion from 2011–2017. Patients were randomized 1:1 to shift to partial oral versus continued intravenous antibiotic treatment after fulfilling stabilization criteria. Patients were followed from randomization until July 2020. The primary outcome was a composite outcome including the occurrence of 1) all-cause mortality, 2) non-intended heart valve surgery, 3) embolization or 4) relapse of positive blood culture with the primary IE causing bacteria. Associations between baseline characteristics and IE-specific factors and the occurrence of the primary outcome were examined using univariate cox-regression analysis and a multivariate model was constructed using backwards elimination at p>0.05. The proportional hazard assumption was assessed with Schoenfeld residuals.

Results

A total of 400 patients with left-sided endocarditis were randomized. After a median follow-up of 5.4 years (IQR 4.0–6.9), one or more of the components of the primary outcome had occurred in 156 patients (Table 1) (mean age 71.5 years (SD 10.0), 119 males (76.3%)). Patients who reached a primary outcome were older, more comorbid, more often had an existing prosthetic valve at time of IE admission, had IE localized to the aortic valve, had vegetations >9 mm or valvular incompetence at time of admission. In multivariable regression analysis older age (HR 1.03; 95% CI 1.02–1.05, p<0.001), diabetes (HR 1.56; 95% CI 1.06–2.30, p=0.025), renal failure (HR 2.13; 95% CI 1.40–3.24, p<0.001), and prosthetic aortic valve (HR 1.52; 95% CI 1.08–2.14, p=0.016) were associated with a risk of reaching a primary outcome, while heart valve surgery during primary admission for endocarditis (HR 0.41; 95% CI 0.27–0.62, p<0.001) and shift to oral antibiotic treatment (HR 0.69; 95% CI 0.50–0.95, p=0.022) were associated with a lower risk (Table 2).

Conclusion

In the POET-trial older age, diabetes, renal failure and prosthetic aortic valve at baseline were independently associated with a higher risk of reaching a primary outcome, while heart valve surgery and shift to oral antibiotic treatment were associated with a lower risk. These findings may inform future guidelines for treatment of endocarditis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Danish Heart FoundationNovo Nordisk Foundation
Clinical findings of triglyceride deposit cardiomyovasculopathy
Authors: Ono R , Miyauchi H , Iimori T , Hoshi K , Ohyama M , Hirano K , Kobayashi Y
Published: October 2022

Background

Triglyceride (TG) deposit cardiomyovasculopathy (TGCV) is a novel cardiovascular disorder and was recently encoded as an orphan disease in Europe (ORPHA code: 565612). Defective intracellular lipolysis results in TG accumulation in the myocardium and coronary arteries in TGCV. The myocardial washout rate (WR) of iodine-123-β-methyl-p-iodophenylpentadecanoic acid (BMIPP) is an essential indicator to evaluate myocardial lipolysis in vivo, and decreased WR (<10%) of BMIPP is one of the essential items of diagnostic criteria for TGCV.

Purpose

To clarify clinical findings of TGCV including comorbid conditions and laboratory findings.

Methods

We enrolled 234 patients who underwent BMIPP scintigraphy between September 2015 and July 2019. The distributions of TGCV in each comorbidity, cardiac functions and laboratory findings were investigated.

Results

In total, 104 patients were diagnosed with definitive TGCV. The BMIPP WR of TGCV patients was −1.37±10.6%. TGCV patients had various comorbid conditions, including coronary artery disease (75%), diabetes mellitus (56%), and heart failure (21%). Left ventricular ejection fraction (LVEF) of TGCV patients was significantly lower than that of non-TGCV patients (38.1±18.0% vs. 43.6±18.9%, p-value=0.026). Moreover, among those who did not take lipid-lowering drugs, there was no difference in the serum TG level between TGCV and non-TGCV patients (TGCV: n=44, 127±84.6 mg/dL, non-TGCV: n=66, 133±70.7 mg/dL, p-value=0.73).

Conclusions

TGCV patients showed multiple coexistence of coronary artery disease, diabetes mellitus, or heart failure with lower LVEF. Serum TG level was not significantly different between TGCV and non-TGCV patients. Serum TG did not affect the intracellular TG accumulation in TGCV patients directly, and this result was consistent with the pathophysiological hypothesis that the TG accumulation in the myocardial cytoplasm is due to intracellular lipase dysfunction.

Funding Acknowledgement

Type of funding sources: None.
Acute myocarditis associated with desmosomal gene variants
Authors: Ammirati E , Raimondi F , Piriou N , Mohiddin S A , Imazio M , Aquaro G , Olivotto I , Van De Heyning C M , Peretto G , Merlo M , Klaassen S , Poller W , Adler E D , Camici P G , Cooper L T
Published: October 2022

Background

The risk of adverse cardiovascular events in patients with acute myocarditis (AM) and desmosomal gene variants (DGV) remains unknown.

Purpose

To ascertain the risk of death, ventricular arrhythmias, recurrent myocarditis, and heart failure (main endpoint) in patients with AM and pathogenic or likely pathogenetic DGV.

Methods

In a retrospective international study from 23 hospitals, 97 patients were included: 36 with AM and DGV (DGV(+)), 25 with AM and negative gene testing (DGV(−)), and 36 AM patients without genetics (w/o genetics). All patients had troponin elevation plus findings consistent with AM on histology or at cardiac magnetic resonance imaging (CMRI). In 86 patients CMRI changes in function and structure were re-assessed at follow-up.

Results

In the DGV(+) AM group (88.9% DSP variants), median age was 24 years, 91.7% presented with chest pain, and median left ventricular (LV) ejection fraction was 56% on CMRI (p=NS vs. the other 2 groups). Kaplan-Meier curves demonstrated a higher risk of the main endpoint in DGV(+) AM compared to DGV(−) and w/o genetics patients (62.3% vs. 17.5% vs. 5.3% at 5 years respectively; p<0.0001), driven by myocarditis recurrence and ventricular arrhythmias (Figure 1A, B). At follow-up CMRI, a higher number of late-gadolinium enhanced segments was found in DGV(+) AM.

Conclusions

Patients with AM and evidence of DGV have a higher incidence of adverse cardiovascular events compared with AM patients without DGV. Further prospective studies are needed to ascertain if genetic testing might improve risk stratification of patients with AM who are considered at low risk.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Health
Does my TAVR patient have cardiac amyloidosis?
Authors: De Almeida J P L , Martinho S , Rosa J , Campos G , Cunha M , Ferreira M , Costa C , Marinho V , Goncalves L
Published: October 2022

Introduction

Aortic stenosis (AS) is highly age-related, and its prevalence is increasing rapidly in high-income countries. There are 2 major types of amyloid protein responsible for cardiac amyloidosis (CA) - transthyretin (TTR) and immunoglobulin lightchain (AL). Previous cohorts report an incidence ranging from 9 to 16% for the presence of CA in patients with AS referred for TAVR. These patients appear to have a similar prognosis to those with lone AS when undergoing TAVR, but a trend toward worse prognosis if left treated. We aimed to investigate the prevalence of CA in patients with severe AS referred for TAVR in the Portuguese population.

Methods

We prospectively recruited 60 consecutive patients referred for TAVR at our tertiary center between November 2020 and May 2021. 59 patients agreed to participate and signed an informed consent, approved by the local Ethics Commission. All patients performed coronary angiogram, echocardiogram, thoracic abdominal pelvic CT scan, ECG, bone scintigraphy (99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid [DPD]) and blood and urine monoclonal immunoglobulin testing. (Figure 1).

Results

About half (54.2%) of patients were male, average age was 82 years and the prevalence of ischemic heart disease and cardiovascular risk factors was high. About one third of patients had atrial fibrillation and 27.1% were pacemaker carriers. Echocardiographic baseline findings were: maximum aortic valve gradient 72.77±18.18 mmHg; mean aortic valve gradient 43.49±11.60; aortic valve area 0.65±0.15 cm2; interventricular septum thickness 1.30±0.23 cm; left ventricular ejection fraction (LVEF) 52.06±11.35%; E/E' 14.63±7.5; tricuspid annular plane systolic excursion 19.2±4mm; right ventricle/ right atrial gradient 38.1±14.32mmHg.

CA was diagnosed in 6 (10.2%) patients. Perugini grade was 1 (n=3) and 3 (n=3). One patient (Perugini grade = 3) was found to have plasma cell dyscrasia, producing monoclonal IgG Kappa protein. CA patients were all male, older (86.5 vs 81.30 years, p=0.049), more frequently pacemaker carriers (66.7 vs 22.6%, p=0.041) and had a tendency to have a thicker interventricular septum (1.48 vs 1.28 cm, p=0.065).

Conclusions

We show that in the Portuguese population, the prevalence of CA in severe AS patients referred for TAVI is in line with what is observed in other countries. This has important consequences regarding the diagnosis and management of these patients.

Funding Acknowledgement

Type of funding sources: None.
Validation of an electrocardiographic algorithm for the detection of cardiac amyloidosis
Authors: Schrutka L , Seirer B , Dusik F , Rettl R , Duca F , Dalos D , Dachs T M , Binder C , Badr-Eslam R , Kastner J , Hengstenberg C , Stix G , Bonderman D
Published: October 2022

Background

Despite new therapies, diagnosis of cardiac amyloidosis (CA) is often delayed. We recently developed a simple electrocardiographic (ECG) algorithm to suspect CA without the aid of advanced imaging modalities (Figure).

Methods

The aim of this study was to validate the algorithms' usefulness in clinical practice. ECG readings from patients with CA, heart failure with preserved ejection fraction (HFpEF), and hypertrophic cardiomyopathy (HCMP) were analyzed in a blinded fashion.

Results

884 patients were included. Patients with pacemakers were excluded, leaving 827 ECGs (237 CA, 407 HFpEF, 183 HCMP) for final analysis. A characteristic pattern defined by the algorithm was visually perceptible in 165 ECGs (69.6%) of the amyloidosis patients vs. 114 (28%) of HFpEF vs. 22 (12.0%) of HCMP patients (p<0.001). The area under the curve (AUC) for the detection CA was 0.75 with a sensitivity of 69.6% and a specificity of 76.9% (Figure). Binary logistic regression analysis revealed that the presence of a distinctive pattern increased the probability of CA with an odds ratio of 7.66 (CI: 5.47–10.72; p<0.001).

Conclusion

This easy-to-use ECG algorithm has proven helpful to suspect CA. Our tool may significantly improve the treatment of heart failure patients by identifying those with amyloidosis-related disease.

Funding Acknowledgement

Type of funding sources: None.
Prognostic value of left ventricle global constructive work in patients with cardiac amyloidosis
Authors: Geers J , Luchian M L , Motoc A , De Winter J , Roosens B , Cosyns B , Droogmans S
Published: October 2022

Background

Left ventricle (LV) global longitudinal strain (LVGLS) has demonstrated incremental diagnostic and prognostic value in patients with cardiac amyloidosis (CA), however it is sensitive to loading conditions (1). Therefore, myocardial work (MW) analysis emerged as a novel echocardiographic method that incorporates both GLS and afterload for a better assessment of LV performance in several pathologies (2). Nevertheless, data regarding its additional value in patients with CA remains limited.

Purpose

We aimed to evaluate the additional prognostic value of global constructive work (GCW), assessed using MW analysis, in patients with CA.

Method

Seventy-one unselected CA patients were included retrospectively between 2015 and 2021. Patients underwent comprehensive clinical, biochemical and imaging evaluation including two-dimentional (2D) echocardiography with MW analysis. The primary endpoint was defined as all-cause mortality and heart failure requiring hospitalization.

Results

The population (mean age 76,76±11.52 years, 73.2% males) consisted of 53 (74.6%) patients with transthyretin (ATTR), 14 (19.7%) patients with light-chain (AL), and 4 (5.6%) patients with unknown phenotype of CA. The primary endpoint was reached in 37 (52.1%) patients. Patient with the primary endpoint had a significantly lower LV ejection fraction (LVEF) (40.54% vs. 49.31%, p=0.003), LVGLS (−9.26% vs. −11.32%, p=0.017) and GCW (1034.47mmHg% vs. 1424.86 mmHg%, p=0.005) than those without. No significant clinical differences were found between the two groups. Multivariable analysis (Figure 1) showed that LVEF (p=0.003; odds ratio (OR): 0.881; 95% confidence interval (CI): 0.810–0.959), LVGLS (p=0.021; OR: 0.688; 95% CI: 0.502–0.944) and GCW (p=0.016; OR: 0.995; 95% CI: 0.991–0.999) were independent predictors for the primary outcome. The model including GCW had the best discriminative ability to predict the primary endpoint (C-index = 0.900; 95% CI: 0.781–1.000, p=0.001). A GCW less than 1443mmHg% was able to predict the primary endpoint with a sensitivity of 94.1% and a specificity of 64.3% (Figure 2; area under the curve (AUC): 0.771 (95% CI: 0.581–0.961; p=0.005).

Conclusion

In patients with CA, a decrease in GCW as a reflection of an impaired systolic performance of the LV was independently associated with an increase in heart failure hospitalization and all-cause mortality. Further prospective studies are warranted in order to confirm the potential role of GCW to improve the prognosis of CA patients.

Funding Acknowledgement

Type of funding sources: None.
Management of fulminant myocarditis: peripheral venoarterial extracorporeal membranous oxygenation and associated complications
Authors: Costa C , Ferraz A L , Ferreira A R , Roncon-Albuquerque R
Published: October 2022

Background

Fulminant Myocarditis (FM) leads to cardiogenic shock with multi-organic dysfunction, being peripheral venoarterial extracorporeal membranous oxygenation (VA-ECMO) a rescue technique. Despite growing experience, it is still related with several complications. We aim to appraise the management of patients with FM and the adverse events associated to VA-ECMO.

Methods

We conducted a retrospective study in a ECMO centre in Portugal, which included 15 patients diagnosed with FM and managed on VA-ECMO from 2008 to 2018. Hemorrhage or infection on cardiac device site, cardiac tamponade, limb ischemia, ischemic stroke, cerebral hemorrhage, severe hemolysis and accidental decannulation were considered major complications.

Results

For sample characteristics and resumed complications, see Table. Inotropic and mechanical ventilation support were transversal to all, with only one patient extubated before decannulation. Six patients received renal replacement therapy, whom half recovered renal function and the remaining died. VA-ECMO operated on average for 8,5 days (range, 1 to 20 days). 3 patients had concomitant Impella heart pump and one of them had a third assistance device with Intra-Aortic Ballon pump.

Major complications were observed in 9 patients (60%), being ischemic stroke the most common. Limb ischemia, observed in 5 patients, related with longer duration of VA-ECMO support (limb ischemia vs non-limb ischemia; 12,8±4,9 vs. 6,8±6,5 days). Two patients presented hemorrhage on cardiac assistance device site, and 1 patient had a cardiac tamponade, all with fatal outcome. Infection on cardiac site, cerebral hemorrhage, severe hemolysis and accidental decannulation were not observed.

Conclusion

The most common complications were ischemic stroke and limb ischemia, both not apparently related with mortality. Differently, hemorrhage on cardiac site and cardiac tamponade were less frequent but presented ominous outcome. Overall, adverse events can be serious and hinder recovery and discharge.

Funding Acknowledgement

Type of funding sources: None.
SARS-CoV-2 vaccination and myocarditis in a highly vaccinated New Zealand population
Authors: Greer C , Daly M , Troughton R , Adamson P D
Published: October 2022

Background

A higher incidence of myocarditis has been reported in those who have recently received mRNA SARS – CoV-2 vaccination.1 Canterbury District Health Board (CDHB) serves 578,290 people, including 441,852 adults, with one large tertiary referral hospital offering specialist cardiology services. In 2021 97% of eligible adults received at least one dose and 92% two doses of the BNT162b2 mRNA vaccine (Pfizer-BioNTech). During this time only 21 community cases of COVID-19 infection were reported. We investigated the incidence of myocarditis during the BNT162b2 mRNA vaccine rollout in comparison to the preceding 5 years assuming a stable population size.

Methods

All adult patients admitted to our hospital who received a diagnostic code of acute myocarditis (ICD10 codes I40, I41 and I51.4) during admission between 2016 and 2021 were included. Demographics and peak troponin concentration (hsTnI) were recorded. Vaccine-associated myocarditis was defined as that leading to admitted within 28 days of BNT162b2 vaccination. Myocarditis-associated mortality was defined as death occurring within 28 days of hospital admission. Incidence of myocarditis before and during COVID-19 vaccination was tested using ANOVA.

Results

Between 2016 and 2020 there were 178 total hospital admissions (annualised mean 35.6 [SD6.3] range 28–44) with myocarditis. The mean age was 47.8 [SD15.9] years, 38% were women, and median peak hsTnI 641 (IQR 95.25–8526) ng/L. One patient died within 28 days of admission. In 2021 there were 43 myocarditis admissions, mean age 49.7 [SD18] years, 42% women, with a median hsTnI 355 (IQR 106.5–1876.5) ng/L. Nine of these admissions were within 28 days of vaccination. They were 78% female, mean age 52.6 [SD24.8] years, median peak hsTnI 179 (IQR 52–528) ng/L. One patient died during admission. There was no variance in annual incidence of myocarditis during vaccine rollout (p=0.342).

Conclusion

In a highly vaccinated adult population largely free of COVID-19 infection there were few cases of myocarditis within 28 days of vaccination and no increase in incidence overall compared to the preceding 5 years.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Heart Foundation of New Zealand grant to C Greer
HCM-AF South Italy score for prediction of new-onset atrial fibrillation in patients with hypertrophic cardiomyopathy: data from a derivation and validation italian cohorts
Authors: Todde G , Monda E , Canciello G , Lioncino M , Lombardi R , Rubino M , Borrelli F , Caiazza M , Paoletta D , De Simone G , Pacileo G , Esposito G , Limongelli G , Losi M A
Published: October 2022

Background

Only one score for prediction of new-onset atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) has been developed in North America (HCM-AF North America score).

Purpose

To develop a new score (HCM-AF South Italy score) in an Italian derivation cohort and to test the new score with that from North America, in an Italian validation cohort.

Methods

A cohort of 228 patients with HCM and without history of AF, followed at referral center 1 for HCM, was used for model development. A cohort of 226 patients without history of AF, followed at referral center 2, was used for external validation. During follow-up (IQR 3–13 years, median 8 years), 59 (26%) patients developed new-onset AF. Data in the development cohort generated the HCM-AF South Italy score, a point score to predict AF probability: left atrial dimension >49 mm (+5 points), age at clinical evaluation <55 years (+2 points), the use of angiotensin-converting enzyme (ACE) or inhibitor or angiotensin receptor blocker (ARB) at initial evaluation (+2 points), low left ventricular (LV) ejection fraction (<50%) (+2 points), LV outflow tract obstruction (LVOTO) >25 mmHg (+2 points), NYHA class >1 (+1 point).

Results

Patients from the validation cohort were older, had lower prevalence of HCM family history, lower systolic and diastolic blood pressure, taken fewer drugs like beta-blockers, ACE or ARB, calcium-channel blockers, and antiarrhythmic drugs and had lower LVOTO than patients from the derivation cohort, (overall p<0.05). During follow-up (IQR 1–10 years, median 5 years), 25 (11%) patients developed AF. ROC curve analysis demonstrated that HCM-AF South Italy score was superior to HCM-AF North America score (Figure). A HCM- AF South Italy score >4 identified patients at risk of AF with a sensitivity of 48%, specificity of 76%, PPV of 20% and NPV of 92%.

Conclusion

Although derived and tested in little and quite different populations, the performance of the HCM-AF South Italy score was superior to that of the score developed in North America.

Funding Acknowledgement

Type of funding sources: None.
Heterogeneous mechanisms of pulmonary congestion in hypertrophic cardiomyopathy unmasked by comprehensive exercise stress echocardiography
Authors: Palinkas E D , Re F , Peteiro J , Tesic M , Palinkas A , Torres M A R , Djordjevic Dikic A , Beleslin B , Van De Heyning C M , D'Alfonso M G , Mori F , Ciampi Q , Sepp R , Olivotto I , Picano E
Published: October 2022

Background

B-lines detected by lung ultrasound (LUS) during exercise stress echocardiography (ESE), indicating pulmonary congestion, are present in 1 out of 3 patients with hypertrophic cardiomyopathy (HCM).

Aim

To assess the functional and anatomical correlates of exercise B-lines in HCM.

Methods

We enrolled 191 HCM patients (age 53±15 years, 123 males) consecutively referred for ESE (treadmill in 74, bicycle in 117 patients) in 11 quality-controlled centers from 8 countries. ESE assessment at rest and peak stress included: left ventricular (LV) outflow tract gradient, left atrial (LAVi) and LV end-diastolic volume index (EDVi), mitral regurgitation (MR, score from 0 to 3); E/e'; systolic pulmonary arterial pressure (SPAP) and LV force (LV outflow tract gradient+systolic blood pressure/LV end-systolic volume). B-lines at rest and at peak exercise were assessed by LUS with the 4-site simplified scan. B-lines positivity was considered if the sum of detected B-lines was ≥2.

Results

LUS was feasible in all subjects. B-lines were present in 55 (29%) patients during stress. When compared to patients without stress B-lines (n=136), patients with B-lines (n=55) at peak exercise had lower peak EDVi (43±17 vs 52±18 ml/m2, p=0.003) higher peak E/e' (16±6 vs 12±5, p<0.001), increase in MR (34 vs 12%, p=0.001), greater stress LAVi (43±14 vs 37±14 ml/m2, p=0.003) and stress SPAP (56±18 vs 40±12 mm Hg p<0.0001): see Figure. Among baseline parameters, the number of B-lines (OR: 7.53, 95% CI 1.21–46.72 p=0.03), LAVi (OR: 1.05, 95% CI 1.00–1.09 p=0.04), and LV force (OR: 1.36, 95% CI 1.04–1.79 p=0.03) were the independent predictors of exercise pulmonary congestion.

Conclusion

HCM patients with pulmonary congestion on exercise show different, and not mutually exclusive mechanisms of diastolic dysfunction and worsening mitral regurgitation. These different hemodynamic mechanisms may require personalized therapeutic actions beyond a pulmonary decongestion therapy with diuretics.

Funding Acknowledgement

Type of funding sources: None.
Sudden cardiac death during exercise in young individuals with hypertrophic cardiomyopathy
Authors: Bhatia R , Westaby J , Behr E , Papadakis M , Sharma S , Finocchiaro G , Sheppard M
Published: October 2022

Background

Sudden cardiac death (SCD) in young individuals and athletes is generally caused by hereditary cardiac conditions, including cardiomyopathies such as hypertrophic cardiomyopathy (HCM). Although historically HCM has been reported as the predominant cause of SCD in young athletes, it is unclear as to what degree exercise is a trigger for possible fatal arrhythmias.

Aim

We aimed to report on the circumstances of SCD in a cohort of young individuals aged ≥10 and <30 whose autopsy was consistent with HCM.

Methods

We reviewed 6860 consecutive cases of SCD referred to our specialist cardiac pathology centre 1994 and 2020. SCD was defined as death from a cardiovascular cause within 12 hours of apparent well-being. All cases underwent detailed autopsy evaluation of the heart, including histological analysis, by expert cardiac pathologists. A minimum of 10 blocks of tissue were taken for histological analysis. HCM was defined by the presence of increased heart weight or increased wall thickness and significant myocyte disarray at histological examination.

Results

Of the total cases of SCD, 264 (4%) were due to HCM. Our cohort of young decedents comprised of 66 individuals (average age 21±5 years, males 76%). For the majority (n=52, 79%) SCD was the first manifestation of HCM. The average heart weight was 507±152 grams and left ventricular (LV) fibrosis was found in 28 (42%) cases (Figure 1A). Death was more common between 16 and 20 years of age (n=24) (Figure 1B). Death occurred during exertion in 25 (38%) individuals and at rest or during daily activities in the remaining 41 (62%), including 5 individuals who died during sleep. Male sex was more represented among decedents who died during exertion (88% compared with 68% in the group that died at rest, p=0.07); LV fibrosis was more commonly observed in individuals who died during exertion (56% compared with 34% in the group who died at rest, p=0.08). Younger individuals between 10–15 years of age died mostly during exercise (80%), in other age groups death occurred mainly at rest (33% in age group 16–20 years, 30% in age group 21–25 years, 33% in age group 26–30 years) (Figure 1B).

Conclusions

We observed a high age-related variability in terms of circumstances of death. In the context of HCM, our findings suggest that individuals aged 10–15 years are the most vulnerable in terms of exercise-related-SCD. This exemplifies the importance of preventative cardiac screening in young individuals who might be harbouring quiescent cardiac conditions associated with young SCD.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Acknowledgements: We thank the charitable organisation, Cardiac Risk in the Young (CRY) who fund and support the CRY Cardiovascular Pathology Unit and CRY database.
New-onset atrial fibrillation diagnosed by cardiac implantable devices in patients with hypertrophic cardiomyopathy: a systematic review and meta-analysis
Authors: Hurtado V , Fernandes A , Silva M M C A , Fernandes G C , Cardoso R , Davila A
Published: October 2022

Background

Atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM) is associated with high thromboembolic risk, morbidity, and mortality.

Purpose

We aimed to study the role of cardiac implantable devices (CID) for AF diagnosis in patients with HCM without prior AF history.

Methods

A comprehensive systematic review and meta-analysis was conducted using Pubmed, Embase, and ClinicalTrials.gov through November 2021 for studies reporting incidence of new-onset AF detected by CID including implantable cardioverter defibrillators, pacemakers, cardiac resynchronization therapy, and loop recorder devices in HCM patients. We used a Freeman-Tukey transformation to calculate the weighted summary proportion of the incidence of AF and stroke and pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model.

Results

Eight cohort studies were included, totalizing 910 patients with HCM and CID without baseline AF. Mean age was 54 years and 21% were female. Mean left ventricular wall thickness was 22.6 mm. Mean follow-up was 3.1 years. New-onset AF was detected in 27.6% (95% CI 18.7–37.5) of patients (Figure A) and 84% of the episodes were subclinical. Stroke occurred in 4.7% (95% CI 1.8–9.0) of patients without baseline AF (Figure B). There was no significant difference in the unadjusted risk of stroke between patients with newly diagnosed AF vs no AF detected at the end of follow-up (9.4% vs 4.7%, OR 1.93, 95% CI 0.83–4.48, p=0.13).

Conclusion

There is a high incidence of subclinical new-onset AF in patients with HCM, supporting the use of CID for early detection of AF in this population.

Funding Acknowledgement

Type of funding sources: None.
Predictors of left ventricular dysfunction in hypertrophic cardiomyopathy: results from a nationwide registry
Authors: Brandao M , Goncalves Almeida J , Fonseca P , Faria R , Sousa O , Fonseca C , Fontes-Carvalho R
Published: October 2022

Introduction

Progression of hypertrophic cardiomyopathy (HCM) with incident left ventricular (LV) dysfunction (HCM-LVSD) is associated with poor prognosis and advanced heart failure (HF). Prevalence ranges from 5–10% in previous studies. Identification of predictors of adverse remodeling may improve risk stratification and prognostication in HCM.

Purpose

To identify predictors of HCM-LVSD in a nationwide cohort of HCM patients (pts).

Methods

Retrospective study including all HCM pts enrolled in a European country-based nationwide registry. HCM-LVSD group included pts with LV ejection fraction (LVEF) ≤50% at baseline and pts who developed LV dysfunction/dilated phenotype during follow-up. Multivariate logistic regression was performed to identify predictors of HCM-LVSD.

Results

1042 HCM patients (57.8% male, mean age at diagnosis 52 years) were included, of whom 81 (8%) belonged to the HCM-LVSD group. HCM-LVSD pts were mostly male (60.5%) and tended to be older at the time of diagnosis than those without LVSD (55 vs 52 years, p=0.054). HCM-LVSD pts were more often symptomatic at the index visit (84.1% vs 65.2%, p<0.001), with more functional impairment (New York Heart Association class III–IV: 18.5% vs 9.2%, p=0.021). Atrial fibrillation (21.3% vs 8.6%, p<0.001) and intraventricular conduction disturbances (28.6% vs 14.4%, p=0.002) were more prevalent in HCM-LVSD pts. HCM-LVSD pts had higher baseline left atrium (LA) volumes (52 vs 39 ml, p=0.001), lower LVEF (50 vs 67%, p<0.001) and higher rates of mitral regurgitation (79.0% vs 65.1%, p=0.011). Prevalence of obstructive HCM was lower in the HCM-LSVD group (25.3% vs 40.9%, p=0.007). Presence of late gadolinium enhancement (92.6% vs 74.6%, p=0.035) was more common in pts with LVSD. Baseline N-terminal pro–B-type natriuretic peptide was higher in HCM-LVSD (3839 vs 1281 pg/ml, p=0.027). There were no differences in the number and type of genetic variants between groups. In HCM-LVSD pts, implantation of cardioverter-defibrillators for secondary prevention was more frequent (28.6% vs 6.4%, p=0.002), as was the use of pacemaker (16.7% vs 7.0%, p=0.002). During a mean follow-up of 5.3±6.1 years, hospitalization for HF (50.0% vs 11.3%) and all-cause mortality (12.3% vs 2.9%, p<0.001) were more frequent in HCM-LVSD group.

After multivariate analysis, higher LA volume (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05, p=0.003) and nonobstructive HCM (OR 2.74, 95% CI 1.03–7.27, p=0.043) were independent predictors of HCM-LVSD.

Conclusions

In this large nationwide cohort of HCM pts, prevalence of LVSD was 8%, in line with existing literature. In this cohort, larger LA volumes and nonobstructive HCM predicted progression to HCM-LVSD.

Funding Acknowledgement

Type of funding sources: None.