bluuebunny/crossref_metadata_2025 huggingface dataset:
Prognostic relevance of mitral regurgitation at different follow-up timepoints after transcatheter aortic valve implantation (TAVI): implications for therapeutic decision making?
Authors: Franz M , Baez L , Moebius-Winkler S , Diab M , Ibrahim K , Kraeplin T , Schulze P C
Published: October 2022

Background

Transcatheter aortic valve implantation (TAVI) has developed rapidly in the last decade and is now recommended as state-of-the-art treatment for elderly patients suffering from severe symptomatic degenerative aortic stenosis (AS). The extent of mitral regurgitation (MR) following TAVI is likely to be of prognostic relevance. This raises the question whether treating MR following TAVI improves outcome of patients with significant MR.

Purpose

The current study was aimed to elucidate the prognostic value of MR at different follow-up (FU) timepoints after TAVI in a prospective real-world single-center registry study.

Methods

A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included and a wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed. Mortality was recorded at 30 days, 1 year and 2 years after TAVI. Complete FU data including echocardiography were available at 6 to 8 weeks (n=334) as well as 6 months (n=235) after TAVI.

Results

All patients (mean age: 78.7±7.3 years, 52% female, mean STS score: 5±3.9%) were successfully treated by transfemoral TAVI using balloon- or self-expanding prostheses and showed mortality rates of 3.6% after 30 days, 16.4% after 1 year and 22.6% after 2 years. Moderate or severe (relevant) MR was detectable in 39% of the patients at baseline, in 27% of patients after 6 weeks (p=0.001) and in 28% of patients after 6 months (p=0.036, compared to baseline). Multivariate analysis identified independent predictors of 2-year mortality: clinical frailty scale and PAPsys at 6 to 8 weeks post-TAVI as well as BNP and relevant MR 6 months post TAVI. Among those parameters, MR after 6 months was the strongest predictor of long-term mortality (OR 3.192, CI 0.971–10.487, p=0.056). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant MR at 6 months (12.1% versus 4.8%, p=0.042).

Conclusions

Taken together, this real-life single-center experience underlines the prognostic value of relevant MR 6 months after TAVI with respect to long-term survival. Interestingly, MR was not predictive at the 6 to 8 weeks FU suggesting that early remodeling includes MR with prognostic relevance in those patients. Whether MR treatment, e.g., by transcatheter edge-to-edge repair, will improve patient outcomes post-TAVI has to be tested in prospective trials.

Funding Acknowledgement

Type of funding sources: None.
Rapid deployment bioprostesis for aortic valve stenosis: single center short and long-term outcomes
Authors: Ferreira R , Velho T , Sena A , Goncalves J , Junqueira N , Pereira R , Almeida A , Pinto F , Nobre A
Published: October 2022

Background

Despite recent advances, surgical aortic valve replacement (SAVR) remains the gold standard for most of the patients with aortic valve stenosis. The ageing population, with increased comorbidities and the rising of minimally invasive techniques, led to the development of new prosthetic devices of easier and faster implantation.

Purpose

This study aimed to analyse short and long-term outcomes of SAVR with rapid-deployment (RD) aortic bioprosthesis for isolated aortic valve stenosis

Method

Singe center, retrospective longitudinal cohort study of patients with isolated aortic valve stenosis who underwent elective aortic valve replacement using RD devices between 2014 and December 2021.

Continuous variables are presented with median (IQR) and were analyzed using Mann-Whitney test. Categorical variables are presented in percentage or frequency and were analyzed using chi-square test. Kaplan-Meyer survival curve was constructed base on collected data from national registry.

Results

A RD device was implanted in 358 patients with a median age of 75,8 years and Euroscore II of 2,3. Median cross clamp and extracorporeal circulation time were 27,4 and 36,7 min, respectively. No significant paravalvular leaks.

Intensive care unit (ICU) length of stay was 3 days with acute renal lesion (any stage-53,2%; Dialysis-2,5%), need for hemodynamic support (63,1%) and new onset atrial fibrillation (33,6%) being the most frequent post-operative complications. Stroke occurred in 0,6% of cases and mortality was 1,1%. Pacemaker implementation rate of 11%.

The mean follow-up time was 6,7 years with 90% 5-years survival rate. Mean gradients of 11,2±4,8 mmHg at 6 months

Conclusion

Surgical treatment of aortic valve stenosis using RD devices is safe, with a low mortality rate. ICU length of stay and hospital length of stay are reduced. Follow-up shows an excellent long-term survival and hemodynamic performance.

Funding Acknowledgement

Type of funding sources: None.
Edge-to-edge mitral valve repair improves concomitant high-grade tricuspid regurgitation
Authors: Groeger M , Zeiml K , Scheffler J K , Schoesser F , Schneider L M , Rottbauer W , Markovic S , Kessler M
Published: October 2022

Background

Mitral regurgitation (MR) and tricuspid regurgitation (TR) often occur simultaneously and symptoms of biventricular heart failure can overlap. There is currently no consensus on the management of combined MR and TR.

Purpose

To evaluate the impact of TR on echocardiographic and functional outcome after M-TEER.

Methods

740 patients underwent M-TEER for moderate-to-severe MR at our center from 2010 to 2021. Patients were analyzed according to severity of concomitant TR: low-grade TR (grade ≤ I (trace - mild)), moderate TR (grade II) and high-grade TR (grade III - V (severe - torrential)). After M-TEER, patients were followed up for 12 months and their echocardiographic and functional outcome was evaluated.

Results

Low-grade TR was present in 279 patients (37.7%), moderate TR in 170 patients (23.0%) and high-grade TR in 291 patients (39.3%) at the time of M-TEER procedure. Patients with moderate to high-grade TR had higher morbidity resulting in higher EuroSCORE II and STS-Score. At baseline more patients had MR grade ≥III in the high-grade TR group (92.8% vs. 87.1% in the low-grade TR group; p=0.023).

Procedural success of M-TEER was achieved similarly in all groups (98.2% vs. 97.6% vs. 95.9%, p=0.22). At discharge 87.6% of patients with low-grade TR and 80.9% of patients with high-grade TR had residual MR grade ≤I (p=0.036). Residual MR grade ≥III was present in 6.0% of low-grade TR patients and 10.5% of high-grade TR patients at discharge (p=0.062). 3 months after M-TEER residual MR ≥III increased to 9.4% vs. 13.4% (p=0.23) and after 12 months further increased to 12.3% vs. 15.3%, respectively (p=0.52).

TR grade decreased rapidly and consistently after M-TEER. 3 months after the procedure only 48.0% of high-grade TR patients still had TR grade ≥III (p<0.001). After 12 months this proportion declined to 46.8% (p=0.99).

High-grade TR patients had significantly higher mortality (21.5% vs. 18.2% vs. 11.1%, p=0.003) up to 12 months after M-TEER. However, TR-grade ≥III did not independently predict mortality (HR 1.326, 95% CI 0.623–2.824, p=0.46).

Conclusion

M-TEER patients with concomitant moderate to high-grade TR had higher morbidity at baseline compared to low-grade TR patients. M-TEER was safe and effective in MR reduction independent of concomitant TR severity. However, high-grade TR patients had an increased risk for mortality after M-TEER, but high-grade TR did not independently predict adverse outcome. After M-TEER TR grade decreased rapidly and significantly in the high-grade TR group.

Funding Acknowledgement

Type of funding sources: None.
Topological data analysis identified prognostically-distinct phenotypes in MitraClip patients
Authors: Chao C , Seri A , Fortuin F D , Sweeney J P , Thaden J J , Eleid M , Alkhouli M , Rihal C R , Holmes D R , Pollak P M , Elsabbagh A , Lester S J , Oh J K , Banerjee I , Arsanjani R
Published: October 2022

Background

Topological data analysis (TDA) is the state-of-the-art unsupervised machine learning framework that can provide insight into the dataset and visualize condensed information via the topological network graph. This robust approach was never used to assess the heterogeneous MitraClip population.

Purpose

We aim to develop a TDA model that will identify prognostically-distinct phenogroups in MitraClip patients without a priori knowledge of the population and their outcomes.

Method

Patients who underwent MitraClip (June 2014-September 2020) at Mayo Clinic sites were identified from the institutional database for baseline and follow-up data. Thirteen variables were used for TDA. The topological network graph was created using the Python Scikit-TDA Kepler-Mapper package (v. 2.0.1), and clustering was performed at the graph level with Louvain's modularity method. Kaplan-Meier survival analysis was used to assess the all-cause mortality endpoint of each cluster identified in an unsupervised manner. The dataset with cluster labels was also used to train a Light Gradient Boosted Machine model, and SHapley Additive exPlanations (SHAP) analysis was applied to determine the feature importance.

Results

A total of 389 consecutive patients were included in the final analysis and two major clusters consisting of 384 patients were identified. The mean age was 80.3±8.7 years; 256 (65.8%) were male. The mean Society of Thoracic Surgeons Mitral Valve Replacement risk score was 9.6±6.9%. Fifty-five (14.5%) patients died during the mean follow duration (185 days). Kaplan-Meier analysis showed significant survival differences among the two clusters (HR: 2.38; 95% CI: 1.39–4.06, p=0.001; Figure 1). Clusters 1 (n=195) was associated with > mild residual mitral regurgitation and worse survival performance and was characterized with worse tricuspid regurgitation severity, a higher proportion of patients with atrial fibrillation/flutter, anterior leaflet prolapse, and mitral annular/leaflet calcification, as summarized in Table 1.

Conclusion

TDA can identify distinct phenotype clusters with prognostic significance in MitraClip patients based on mitral valve morphology and clinical risk factors. This simple model can facilitate clinical risk stratification for MitraClip patients regarding procedural success and survival performance.

Funding Acknowledgement

Type of funding sources: None.
Aortic valve replacement for aortic stenosis in France – influence of centers' volumes on TAVR adoption rate and outcomes
Authors: Willner N A , Nguyen V , Eltchaninoff H , Burwash I G , Michel M , Durand E , Gilard M , Dindorf C , Iung B , Cribier A , Vahanian A , Chevreul K , Messika-Zeitoun D
Published: October 2022

Aims

Over the last decade, transcatheter aortic valve replacement (TAVR) became extensively used, now being the recommended as first line procedure for aortic valve replacement (AVR) in selected patients' populations. It is unknown whether TAVR adoption rate and variability in outcomes is influenced by centers' volume.

Methods

From a French administrative hospital-discharge database, we collected all AVR performed in France between 2007 and 2019. Centers were stratified to terciles based on their annual SAVR per year per center during 2007–2009 (“pre TAVR era”).

Results

There was 218,489 AVRs (153,747 SAVR and 74,732 TAVR) performed in 46 centers between 2007–2019. Number of total AVR and even more so number of number of TAVR significantly and linearly increased from 2007 to 2019 in all terciles but faster in the high volume tercile (+17, +17 and +31 AVR/center/year in the low, middle and high terciles respectively, P [ANCOVA]<0.001; +11, + 19 and +33 TAVR/center/year in the low, medium and high tercile respectively, P [ANCOVA] <0.00, Figure 1). The age of patients underwent TAVR remained grossly unchanged in all three terciles, however, the Charlson index declined from 2010 to 2019 (from 1.35±1.42 to 0.65±1.04, from 1.21±1.40 to 0.65±1.05 and from 1.53±1.58 to 0.81±1.21, in the low, middle and high terciles, P for trend <0.001, 0.021, and <0.001, respectively). Charlson score in the years 2017–2019, was higher in the high than middle and low terciles (0.87±1.22, 0.76±1.11 and 0.65±1.04, respectively, P<0.0001). The in-hospital mortality rate for TAVR significantly declined from 2010 to 2019 for TAVR in all terciles (from 8.3% to 2.1%, from 7.5% to 2.5% and from 8.2% to 2.1% for low, middle and high TAVR terciles, respectively; p for trend = 0.002, 0.001 and <0.001, respectively, Figure 2). Average mortality in 2017–2019 was similar in all terciles (2.3%, 2.5% and 2.2% for low, middle and high terciles, respectively, P=0.47). After adjusting for age, sex and Charlson score, mortality was higher in the low tercile compared with middle and high terciles (OR 1.15, P<0.001, confidence interval [CI] 1.0–1.2, and OR 1.18, P<0.001, CI 1.1–1.2, respectively).

Conclusions

From 2007 to 2019 total AVR linearly increased, mostly due to increase in TAVR, irrespective of centers' volume, but increase rate was higher in high volume centers. A constant decline in patients risk profile, with a striking decrease in mortality rate, was observed in all volume terciles. High-volume centers patients' have higher risk profile, with adjusted mortality slightly lower than medium and low volume centers.

Funding Acknowledgement

Type of funding sources: None.
Quantification of systolic anterior motion of the mitral valve to predict left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy
Authors: Verheyen N , Batzner A , Zach D , Zirlik A , Gerull B , Stoerk S , Maack C , Seggewiss H , Morbach C
Published: October 2022

Background

In patients with hypertrophic cardiomyopathy (HCM), left ventricular outflow tract obstruction (LVOTO) is associated with an increased risk of heart failure and death (1). It is typically caused by dynamic systolic anterior motion (SAM) of the mitral valve leaflet. SAM can be categorized by echocardiography but diagnostic accuracy is limited by high inter-observer variability.

Purpose

To investigate the accuracy of echocardiographic parameters quantifying systolic motion of the mitral valve leaflets to identify LVOTO in patients with HCM.

Methods

We present a cross-sectional analysis of the HyperCard Registry, a prospective single-center cohort study enrolling consecutive patients with suspected or confirmed HCM. For the present analysis, patients with confirmed HCM and a valid standardized transthoracic echocardiographic were included. LVOT gradients were measured at rest and during Valsalva maneuver using continuous wave Doppler. In patients with clinical suspicion of dynamic LVOTO, further provocation maneuvers were conducted. LVOTO was defined as a maximal peak LVOT gradient ≥30 mmHg. Parameters quantifying systolic motion of the mitral valve were measured in parasternal and apical views, both at early and late systole, by an investigator blinded to individual patient characteristics. SAM was visually assessed and categorized into grade 0 (no SAM), I (leaflet motion towards LVOT), II (late systolic septal contact), and III (early systolic septal contact).

Results

We analyzed 142 patients (59±13 years, 42% women). LVOTO was present in 68 (48%) patients of whom 30 (21% of all) exhibited LVOTO at rest, and 38 (27% of all) had LVOTO only during provocation maneuvers (ie. dynamic LVOTO). SAM was present in 86 patients (60%) and had a sensivitiy, specificity and PPV of LVOTO of 91%, 69% and 73%, respectively (table). The late-systolic distance between mitral leaflet tip and anterior septum (TISls) measured in apical 3-chamber view was best associated with the degree of SAM (F=123, P<0.001), and with peak LVOT gradient (at rest: Pearson r=−0.817; during Valsalva maneuver: r=−0.816, both P<0.001). In ROC analyses (figure), the AUC of TISls for identification of LVOTO and dynamic LVOTO were 0.914 (95% CI 0.868–0.959) and 0.857 (0.786–0.927), respectively. TISls ≤14 mm had a 97% sensitivity for LVOTO and of 94% for dynamic LVOTO. TISls ≤9 mm showed specificity and PPV of 95% and 92% for LVOTO, and 94% and 83% for dynamic LVOTO, respectively.

Conclusions

Quantification of SAM by TISls showed high diagnostic accuracy in identifying HCM patients with LVOTO. Prospective studies are needed to assess the incremental benefit of this novel parameter in the diagnostic work-up of HCM patients.

Funding Acknowledgement

Type of funding sources: None.
Transcatheter aortic-valve replacement with the self-expanding valve Portico in low-risk patients
Authors: Tamargo M , Gutierrez E , Vazquez M E , Sanz-Ruiz R , Diez-Delhoyo F , Soriano J , Elizaga J , Fernandez-Aviles F
Published: October 2022

Background

In the past years, transcatheter aortic-valve replacement (TAVR) has risen as a feasible and safe option for patients with aortic stenosis, been now an option of treatment in low-risk (Euroscore II <4%) patients over 75 years.1

Evidence of this treatment with self-expandable supraanular bioprothesis Evolut have widely proven to be no inferior to surgical valve replacement.2 Nevertheless, experience of the annular self-expandable prothesis Portico available in this population is scarce.

Purpose

We present our early experience with the annular self-expandable prothesis Portico in our low-risk population.

Methods

We retrospectively studied 219 symptomatic low-risk patients with who underwent TAVR procedure with self-expandable valves between 2018 and 2021. Assessment included echocardiogram, immediate and 30-day follow-up, as well as last clinical visit follow-up. 92 subjects received an annular Portico prothesis. Our reference group was the suprannular prothesis Evolut (n=127), already validated for low-risk patients in clinical trials.2

Results

The mean age of the patients was 79 years, 43.4% were women, and all the patients were at low surgical risk (2.2 [1.6; 3.0]). No significant differences could be appreciated in baseline demographics and echocardiographic characteristics except for body mass index (BMI), which was higher in the Portico group (p<0.001) (Table).

Procedure length was similar, with the particular need of higher predilation in the Portico group according to recommendations. Both self-expandable prothesis had similar rates of intraprocedural atrioventricular block, bleeding, vascular complications, stroke, and new onset atrial fibrillation.

Mean aortic-valve gradients before discharge were lower at the suprannular Evolut group than in the annular Portico group, and immediate residual aortic regurgitation was almost inexistent in both groups (Table 1).

At a 30-day follow up, the incidence of major adverse cardiac events was low and similar among groups (p=0.6) (Figure 1), with no significant differences in the incidence of permanent pacemaker implantation, heart failure admission, stroke, bleeding o vascular complication (Figure 1).

Conclusion

Annular aortic self-expandable prothesis Portico is a feasible alternative for patients with AS and low surgical risk who undergo TAVR procedure.

Funding Acknowledgement

Type of funding sources: None.
Impact of proportionate versus disproportionate mitral regurgitation on acute procedural changes and clinical outcomes following transcatheter mitral valve repair
Authors: Kronzer E , Pislaru S , Padang R , Oguz D , Nkomo V , Oh J , Alkhouli M , Guerrero M , Reeder G , Eleid M , Rihal C , Thaden J
Published: October 2022

Background

Transcatheter mitral edge-to-edge repair (TEER) with MitraClip offers a less invasive alternative for patients with severe, symptomatic mitral regurgitation (MR) who are considered high risk for surgery. However, patient selection for TEER remains challenging given the variability in underlying MR pathology and current discordance among studies regarding predictors of procedural efficacy and clinical outcomes.

Purpose

This study aimed to assess acute procedural changes and long-term outcomes in patients who underwent TEER according to the proportionality of MR, defined as the ratio of the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV).

Methods

We analyzed patients who underwent TEER at our institution between 2014 and 2020 with available biplane left ventricular volume measurement. Relevant clinical comorbidities, demographics, and anthropometrics, along with pertinent pre- and post-procedural echocardiogram measurements, were obtained by review of the electronic medical record. The EROA to LVEDV index was calculated for all patients who were then stratified by quartiles. Patients with an EROA/LVEDV index in the lowest quartile were defined as having the most proportionate MR and those with an index in the highest quartile were defined as the most disproportionate MR. Baseline and post-TEER parameters were used to assess acute procedural and longitudinal outcomes.

Results

Baseline clinical and echocardiographic parameters of the 230 subjects according to quartile are shown in the table. Following TEER, there was a larger reduction in the left ventricular end-diastolic diameter and increased MR reduction with increasingly disproportionate MR (p=0.03 and p=0.05, respectively). The change in ejection fraction pre- versus post-TEER did not significantly differ across groups (p=0.64). Median follow up time was 1.7 (0.7–3.5) years; mortality occurred in 77 patients (33.5%) and heart failure hospitalizations occurred in 20 patients (8.7%) during follow up. No significant difference in all-cause mortality or post-procedural heart failure hospitalizations was identified across groups.

Conclusions

In our series, patients with proportionate MR were similarly symptomatic to those with disproportionate MR but had less severe MR with increased comorbidities. Post-TEER MR grade was similar between groups. Longer-term follow up in larger groups of patients is needed to determine the clinical implications.

Funding Acknowledgement

Type of funding sources: None.
Experience of the combined use of the cusp-overlap projection and auricular pacing in transcatheter aortic-valve replacement with the self-expanding valves
Authors: Tamargo M , Gutierrez E , Vazquez M E , Sanz-Ruiz R , Diez-Delhoyo F , Soriano J , Elizaga J , Fernandez-Aviles F
Published: October 2022

Introduction

Need of permanent pacemaker implantation (PPI) continues to be an undesirable side-effect after transcatheter aortic-valve replacement (TAVR), mostly in self-expandable (SE) valves. Recently, different techniques have arisen, as the cusp-overlap projection (COP) to better control TAVR implantation depth, and the sequential atrial pacing (AP) after deployment to test atrioventricular (AV) conduction. However, the combination of both techniques has not been tested yet. We sought to determine if the combination of COP and AP can decrease the need of PPI after SE aortic prothesis.

Methods

We retrospectively studied 253 patients in sinus rhythm who underwent TAVR procedure with SE valves between 2018 and 2021, and compared standard implantation (n=143) with the combined use of COP and AP (n=110). Patients with permanent atrial fibrillation or previous pacemaker were excluded. Assessment included EKG, imaging, immediate and 30-day follow-up. AP was performed after TAVR in the absence of complete AV block at rates of 70 to 120 beats/min (or until AV Block was observed).

Results

Median patient age was 80 [75–85] years old and 52.2% were female. No significant differences could be appreciated in baseline demographics or treatment. Both cohorts had similar EKG intervals and similar rates of conduction disturbances (Table 1). Patients with CO+AP displayed bigger outflow tract perimeters (p=0.003). Also, the CO+AP cohort underwent more frequent predilation prior to valve deployment (p<0.001).

During TAVR complete AV block occurred in 4.6% of the CO+AP cohort vs 14.8% in the standard group (p=0.002). Among patients with transient or no conduction disturbances immediately after deployment, AP showed Wenckebach phenomenon in 22 subjects at a median heart rate of 110 bpm. PPI was considered within 24 hours when Wenckebach phenomenon developed below 90 bpm. Testing atrio-his conduction led to a significant decrease in the next 24-hour surveillance with a temporary pacemaker in the COP+AP cohort (23.1% vs 90.2% in the standard cohort, p<0.0001). Time of hospitalization was significantly reduce in the COP + AP cohort (mean stay 2 [1; 3] days vs 5 [4; 8] days in the standard cohort, p<0.0001), and the total amount of total PPI at that time was still lower CO+AP group (12.7% in CO+AP group vs 21.0% in the standard, p=0.121) (Figure 1).

On a 30-day follow-up, the rate of PPI after TAVR remained significantly decreased in the COP+AP cohort (p=0.039, Figure 1).

Conclusion

Combining COP with AP reduces the need of immediate and short-term PPI and reducing on-admission conduction surveillance and hospitalization stay after self-expandable TAVR.

Funding Acknowledgement

Type of funding sources: None.
Refining the accuracy of right ventricular-pulmonary arterial coupling in patients undergoing transcatheter tricuspid valve treatment
Authors: Sugiura A , Tanaka T , Zimmer S , Nickenig G , Weber M
Published: October 2022

Background

Assessing right-ventricular (RV) function is paramount for risk stratification but remains challenging in patients with TR. RV-pulmonary artery (PA) coupling seems more feasible for the assessment of RV function.

Methods

We assessed RV-PA coupling by the ratio of TAPSE and PASP at baseline, in which PASP was measured both by echocardiography (ePASP) and invasively using a right-heart catheter (iPASP). We also assessed the RV fractional-area change (RVFAC) as measured by transthoracic echocardiography. Participants for the present study comprised patients undergoing TTVR from June 2015 to July 2021 at the University Hospital of Bonn. Patients lacking either echocardiographic or invasive measurements for the assessment of RV-PA coupling were excluded from the analysis. The outcome was defined as a composite of mortality and rehospitalization due to heart failure within one year after the procedure.

Results

A total of 206 patients were included in the present analysis. The participants were at an advanced age (78.5±7.1 years), predominantly female (58.3%), and at a high risk for surgery (EuroSCORE II: 7.4±4.8%). Massive/torrential TR was observed in 100 of these patients. With the median follow-up duration of 201 days (interquartile range 98–424 days), the outcome occurred in 57 patients. Compared to TAPSE/ePASP, TAPSE/iPASP showed better predictability for the outcome: the AUCs were 0.582 for TAPSE/ePASP and increased to 0.714 when iPASP was applied to the formula (i.e. TAPSE/iPASP). The trend was also true for RV-PA coupling using RVFAC (AUCs: 0.561 for RVFAC/ePASP, 0.693 for RVFAC/iPASP). There was a significant correlation between ePASP and iPASP, whereas the correlation was attenuated in patients with TR beyond severe (i.e. massive/torrential TR) (interaction p = 0.01). In addition, a semiquantitative echocardiographic estimation of right atrial (RA) pressure was not correlated with the invasive measurement.

Conclusion

The present analysis confirms that RV-PA coupling, measured as TAPSE/PASP, is a powerful predictor of mortality and rehospitalization due to heart failure in patients undergoing TTVR. The predictability is even more improved if PA pressure is measured invasively and applied to the formulas.

Funding Acknowledgement

Type of funding sources: None.
Detection of lymphatic circulation abnormalities in adult Fontan Kreutzer patients using magnetic resonance imaging
Authors: Nicolosi L N N , Choe H J , Moros C G , Pacheco Otero M , Grippo M
Published: October 2022

Background

Altered lymphatic circulation could be an indicator of risk of complications after Fontan-Kreutzer surgery.

Purpose

To determine the degree of lymphatic circulation abnormality in adult patients who underwent the Fontan-Kreutzer procedure (FKP) and explore association between type of abnormality and complications during follow-up.

Methods

A retrospective observational study was conducted in patients (p) with grown-up congenital heart disease included on the GUTI-GUCH database. Lymphatic circulation of patients who had undergone FK procedure (FKP) was assessed using Cardiac Magnetic Resonance (CMRI). Lymphatic abnormalities were divided into four types according to the classification by Dori; type III and IV abnormalities were considered complex. Association between complex abnormalities and complications during follow-up was explored. Statistical analysis was performed using SPSS 22 software.

Results

One-hundred and thirty-eight (4.7%) of the 2920 p on the database had undergone FKP; the 47 patients (34%) who had had a CMRI for lymphatic assessment were included. Fifty-three percent (25p) were women; mean age was 26.5 years ± 7.8 years.

Analysis of patient data showed the following prevalence of lymphatic abnormalities according to Dori's classification: Type I: 14p (29.8%); Type II: 17p (36.2%); Type III: 13p (27.7%); Type IV: 3p (6.4%); severe/complex Types III+IV: 16p (34%). Prevalence of the studied complications was as follows: presence of ascites: 6p (12.8%); aortopulmonary collaterals: 7p (14.9%); NYHA functional classification more than II: 19p (40.4%); ventricular dysfunction: 14p (29.8%); tube mismatch: 11p (23.4%); moderate or severe AV valve dysfunction: 11p (23.4%); left-type ventricle: 30p (63.8); congestive heart failure (CHF): 4p (8.5%); arrhythmias: 16p (34%) hospitalization: 7p (14.9%); use of furosemide: 11p (23.9%); use of spironolactone: 25p (53.2%); use of IECA 38p (80.9%); and use of beta blockers: 28p (59.6%).

The presence of type III+IV abnormalities (Dori) observed in 16p (34%) was associated with ascites p=0.006 R: 13 (1.4–130). No significant correlation was observed between type of lymphatic abnormality and the remaining studied complications.

Conclusions

One third of patients had complex lymphatic circulation abnormalities. The presence of severe complications was significantly associated with the presence of ascites, a late sign of dysfunction of the Fontan-Kreutzer system.

Lymphatic circulation abnormalities are very frequent in patients who have undergone a Fontan-Kreutzer procedure. Further studies are necessary to determine their prognostic value.

Funding Acknowledgement

Type of funding sources: None.
Concomitant tricuspid repair in mitral regurgitation surgery: a systematic review and meta-analysis
Authors: Costa G , Cardoso J , Donato H , Goncalves L , Teixeira R
Published: October 2022

Background

Tricuspid Regurgitation (TR) is common in patients with severe mitral disease. However, the evidence is insufficient to inform a decision about whether to perform prophylactic tricuspid-valve repair during mitral-valve surgery in patients who have moderate TR or less-than-moderate regurgitation.

Purpose

To compare the outcomes of concomitant tricuspid repair in mitral valve surgery versus no concomitant tricuspid repair in less-than-severe TR patients.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for interventional studies comparing concomitant tricuspid repair in mitral valve surgery versus no tricuspid intervention. Random-effects meta-analysis was performed.

Results

Four randomised trials were included, providing a total of 651 patients (323 in prophylactic tricuspid intervention group and 328 patients in conservative group). Our meta-analysis showed a similar all-cause mortality for concomitant prophylactic tricuspid repair compared with no tricuspid intervention (pooled OR, 0.54; 95% CI [0.25, 1.15], P=0.11; I2=0%). Additionally, there is a similar New York Heart Association (NYHA) III–IV classes in both groups, despite a lower trend in the tricuspid intervention group (pooled OR, 0.63; 95% CI [0.38, 1.06], P=0.08; I2=0%) (Figure 3). However, there was a significant lower progression of TR (pooled OR, 0.06; 95% CI [0.02, 0.24], P<0.01; I2=0%) and moderate-severe TR (pooled OR, 0.23; 95% CI [0.11, 0.46], P<0.01; I2=27%).

Conclusions

Our pooled analysis suggests that a tricuspid-valve repair at the time of mitral-valve surgery in patients with moderate or less-than-moderate TR does not impact perioperative or postoperative all-cause mortality, despite reducing TR severity and progression of TR following intervention.

Funding Acknowledgement

Type of funding sources: None.
Early aortic valve replacement in asymptomatic severe aortic stenosis with preserved ejection fraction
Authors: Costa G , Cardoso J , Goncalves L , Teixeira R
Published: October 2022

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. Specific timing of intervention for asymptomatic patients with severe aortic stenosis and preserved ejection fraction remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic AS patients with preserved ejection.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both interventional or observational studies comparing early-AVR with WW in the treatment of asymptomatic severeAS with preserved ejection fraction criteria. Random-effects meta-analysis was performed.

Results

Eight studies were included in which two were randomized clinical trials. A total of 2672 patients were included, providing a 642 pooled death events (327 in early-AVR and 941 in watchful waiting). In our meta-analysis, early-AVR revealed a significant lower all-cause mortality (pooled OR, 0.39; 95% CI [0.30, 0.51], P<0.01; I2=47%). Additionally, the early-AVR group presented a lower rate of cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P<0.01; I2=64%). Both strategies had similar rate of stroke (pooled OR, 1.30; 95% CI [0.39, 4.27], P=0.67; I2=0%) and myocardial infarction (pooled OR, 0.49; 95% CI [0.14, 1.78], P=0.28; I2=0%). Heart Failure hospitalizations presented a lower trend early-AVR group (pooled OR, 0.22; 95% CI [0.05, 1.08], P=0.36; I2=36%).

Conclusion

Our pooled data suggests that early-AVR strategy is preferable for asymptomatic severe AS patients with preserved ejection fraction.

Funding Acknowledgement

Type of funding sources: None.
A decade of the twenty-first century of percutaneous balloon mitral valvuloplasty in rheumatic mitral stenosis: long-term outcomes and clinical risk score among the AF and non-AF patients
Authors: Kosallavat S , Meemook K
Published: October 2022

Backgrounds

Percutaneous balloon mitral valvuloplasty (PBMV) is the treatment of choice for anatomically suitable severe rheumatic mitral stenosis (MS). Atrial fibrillation (AF) is one of the most common arrhythmic conditions in rheumatic MS and may decrease successful or alter the long-term outcomes of rheumatic MS patients who are undergoing PBMV.

Purpose

The purpose of this study is to investigate the long-term outcomes of treatment in patients with AF compared to sinus rhythm (SR).

Results

Post-PBMV median follow-up time was 10.83±5.69 years. The incidence of the primary endpoint was 57.8% (95% confidence interval [CI]: 48.6% to 66.9%) and 20.0% (95% CI: 10.3% to 29.6%), p-valve <0.001 in AF and SR patients respectively. The adjusted hazard ratio (HR) of the primary endpoint in the AF compare with SR group was 2.377 (95% CI: 1.250 to 4.520, p-valve = 0.008). Not only the rate of death that was greater in AF than SR group with 30% (95% CI: 22% to 39%) and 11% (95% CI: 4% to 19%), p-valve <0.001 respectively but also as in MV surgery, the incidence rate was 30% (95% CI: 22% to 39%) and 10% (95% CI: 2% to 18%). Independence predictors of the primary endpoint were age >55 years (hazard ratio [HR]: 1.765; 95% CI: 1.05 to 2.95, p=0.031) and echocardiographic score >8 (HR: 2.94; 95% CI: 1.22 to 7.09, p=0.017). The MiTrAL-55 score has a C-statistic of 0.71±0.036 reflecting the good ability to predict long-term outcomes.

Conclusion

Severe rheumatic MS patients with AF had a worse long-term prognosis than SR after PBMV. An early decision to PBMV in patients with MS supporting with the predictive scoring system to minimize morbidity and mortality is necessary.

Funding Acknowledgement

Type of funding sources: None.
Perioperative cerebral microinfarction and quality of life following mitral valve surgery
Authors: Gorecka M , Nejadhamzeeigilani H , Craven T P , Chew P G , Dobson L E , Brown L A E , Chowdhary A , Jex N , Thirunavukarasu S , Sharrack N , Javed W , Kotha S , Levelt E , Goddard A J P , Greenwood J P
Published: October 2022

Introduction

Mitral regurgitation (MR) is the second most common valvular pathology worldwide. When untreated, severe MR is associated with significant morbidity and mortality. Mitral valve surgery is recommended in symptomatic patients and those with evidence of adverse left atrial or left ventricular remodelling. Although uncommon, stroke is a recognised complication of mitral valve surgery and is associated with unfavourable outcomes. While silent cerebral microinfarction has been described following cardiac surgery, its incidence in mitral valve surgery and its impact on quality of life is presently unknown. The main aim of this study was to assess the incidence of perioperative cerebral microinfarction following mitral valve surgery and its impact on medium-term health-related quality of life (HRQoL).

Methods

Cerebral diffusion-weighted magnetic resonance imaging (DWI-MRI) was conducted pre-operatively and prior to discharge in 31 patients undergoing mitral valve surgery for mitral regurgitation. Blinded analysis was conducted by a neuro-radiologist. HRQoL assessment was undertaken at baseline and at a 6-month follow up with EuroQoL-5 dimensions (EQ-5D-5L) and Hospital Anxiety and Depression Scale (HADS) questionnaires.

Results

Thirty-one patients underwent paired cerebral DWI-MRI (mitral valve replacement (MVR) n=16 [52%] and mitral valve repair (MVr) n=15 [48%]). Prevalence of atrial fibrillation was similar in both groups (MVR n=9 [56%] vs. MVr n=7 [47%], p=0.59). Peri-operative cerebral microinfarction occurred in 9 patients (29%). Embolic events were numerically higher in the MVR group versus MVr group, but not statistically significant (n=7 [44%] vs. n=2 [13%], p=0.06). Presence of multiple lesions, large lesions >5mm, small lesions <5mm and the total number of lesions did not differ significantly between the two groups. Median volume of lesions was higher in the MVR group versus MVr (0 [0–0.4] vs 0 [0–0], p=0.04) (Table 1).

There was no difference in the mean change in HRQoL during 6m follow up between patients with peri-operative cerebral microinfarction and those with no detectable embolic events (Table 2). Within group comparison (MVR group and MVr group) also did not demonstrate any significant difference.

Conclusions

Peri-operative cerebral microinfarction occurred in almost a third of patients undergoing mitral valve surgery, with higher volume of lesions following MVR. These lesions however, did not exhibit significant impact on medium term health-related quality of life.

Funding Acknowledgement

Type of funding sources: None.
Clinical and prognosis assessment of Atrial Fibrillation patients with significant valvular disease. Validation of the EHRA valve classification (Evaluated Heartvalves. Rheumatic or Artificial)
Authors: Escolar Conesa A , Esteve Pastor M A , Roldan Schilling V , Rivera Caravaca J M , Gil Perez P , Gonzalez Lozano E , Taboada Martin R , Arribas Leal J M , De La Morena Valenzuela G , Saura Espin D , Oliva Sandoval M J , Pinar Bermudez E , Garcia De Lara J , Marin F
Published: October 2022

Introduction

Historically, the definition of valvular heart disease in atrial fibrillation (AF) patients has been inconsistent. For this reason, in 2017 the EHRA proposed a more accurate classification, classifing AF patients in EHRA I (AF patients with mechanical prostheses or moderate/severe rheumatic mitral stenosis), EHRA II (includes the presence of significant valve disease, bioprosthetic valve replacement, TAVR – Transcatheter Aortic Valve Replacement – or mitraclip) and EHRA III (absence of valve involvement).

Purpose

The objective was to evaluate the prevalence of valve involvement in AF patients, clinical characteristics and adverse outcomes according to new EHRA classification, focusing in the EHRA II vs EHRA III comparison.

Methods

Observational, multicenter, retrospective study of stable anticoagulated AF patients was performed. Clinical, echocardiographic, demographic characteristics and adverse events after 2 years of follow-up were collected according to EHRA II vs EHRA III groups.

Results

981 patients were analyzed: 755 (76.9%) classified as EHRA II [440 (56.8%) with native valve involvement, 134 (17.8%) with surgical biological prostheses and 181 (23.4%) with TAVR] and 226 (23.1%) as EHRAIII. Higher comorbidity profile was observed in the different EHRA II subgroups compared to patients with EHRA III (Table 1). After 2 years of follow-up, the occurrence of adverse events was higher in EHRA-II than EHRA III patients (Figure 1). In the Cox analysis, weo bserved that patients with native valve involvement and TAVR had up to 3 times higher risk of mortality [HR 3.32, (95% CI 1.88–5.85; p<0.001)], 2 times higher risk of Heart Failure [HR 2.14, (95 CI 1.30–3.5; p<0.001)] and MACE [HR 2.01, (95% CI 1.14–3.52; p<0.015)] than EHRA III patients.

Conclusion

The prevalence of valve involvement in patients with AF is high. Only 23% of AF patients did not present any valve disease. Patients with native valve involvement or TAVR had a high burden of comorbidities and cardiovascular risk factors. Patients with native involvement and TAVR also showed an 2.5-fold increased risk of adverse events during the follow-up. These findings highlight the increased risk related with the presence of valve disease in patients with AF.

Funding Acknowledgement

Type of funding sources: None.
Is it worthwhile to perform surgical aortic valve replacement in elderly patients with symptomatic aortic valve disease and malignancy: a short and long-term study in 2,500 patients
Authors: Mistiaen W P , Deblier I , Dossche K , Vanermen A
Published: October 2022

Introduction

Malignancy (all types) can be considered as limiting factor for the outcome of surgical aortic valve replacement (SAVR).

Purpose

How does the referral pattern evolve over time for patients with previously malignancy, referred for SAVR

What is their early and long-term outcome after SAVR?

Patients and methods

This is a retrospective file study of 2,500 patients referred for SAVR with a biological prosthesis between 1987 and 2017. Mechanical valves and valve prosthesis in another position were excluded. A chi-square analysis was used to compare patients with and without cancer with respect to age, gender, era of referral (2008, the year of introduction of transcatheter aortic valve implantation, TAVI), preoperative cardiovascular (parameters for ventricular function, severity of valve disease, coronary disease, arrhythmias and conduction defects) and non-cardiac (pulmonary, renal, diabetes, cerebral) comorbid conditions, operative variables (bypass time, associated CABG and mitral valve repair), need for resources (blood products, stay on ICU) and early postoperative mortality, cardiac and non-cardiac events. A Kaplan-Meier (log-rank) analysis was used to evaluate the effect of malignancy on long-term outcome.

Results

Of the 2,500 patients, 388 (15.5%) patients had a documented prior malignancy There was a total of 18.917 patient-years for follow-up. For cancer patients, this was 2,489 patient-years.

The referral of patients increased after 2008 (from 9.1% to 17.7%, p=0.006). Cancer patients had more chronic pulmonary (14.6% vs. 17.9%, p=0.044) and kidney (15.5% vs. 21.5%, p=0.009) disease, more prior CVA (14.8% vs. 19.8%, p=0.038) and permanent pacemaker implant (14.9% vs. 24/19%, p=0.044). Obesity was less present (18.4% vs. 14.2%). Cardiovascular and operative parameters were comparable for both groups.

Postoperative cardiac and non-cardiac adverse events, need for resources and especially mortality (5.0% vs. 6.9%, p=0.105) were comparable.

Long-term survival was significantly reduced in patients with malignancy (p<0.001), but this was acceptable: a mean survival time of 105 (98–113) months vs. 121 (118–125) months.

Five-year survival was 70.0±2.4% vs. 76.6±0.9%

Ten-year survival was 38.6%±1.3% vs. 48.9±2.9%

Fifteen-year survival was 14.1±2.7% vs. 20±1.3%

In a Cox' proportional hazard analysis, malignancy ranks 8th of 10 independent predictors for mortality (odds ratio 1.26).

Conclusion

Even after the introduction of TAVI, the number of valve patients with prior malignancy referred for SAVR increased significantly. Nevertheless, only non-cardiac preoperative factors differed significantly. Operative variables, use of resources and early outcome did not differ significantly. Malignancy reduces long-term survival in a significant but acceptable degree.

Funding Acknowledgement

Type of funding sources: None.
Prognostic implications of paradoxical low gradient severe aortic stenosis: a comprehensive analysis from a large multicentric registry
Authors: De Azevedo D , De Meester C , Hanet V , Altes A , Pouleur A C , Pasquet A , Gerber B , Marechaux S , Tribouilloy C , Vanoverschelde J L , Vancraeynest D
Published: October 2022

Background

Up to 40% of patients with severe aortic stenosis (SAS; indexed aortic valve area (AVAi) <0.6 cm2/m2) present with low transvalvular mean gradient (MG) despite a normal left ventricular ejection fraction (EF). There is intense debate about the prognostic significance of such entity, with some referring to it as an advanced form of the disease, others as an intermediate form between a moderate and a severe form.

Objectives

To compare outcome of patients with paradoxical low gradient SAS (PLG-SAS; i.e., mean gradient <40 mmHg and AVAi <0.6 cm2/m2) vs. moderate aortic stenosis (MAS; i.e. mean gradient <40 mmHg and AVAi >0.6 cm2/m2) and high gradient SAS (HG-SAS; i.e. mean gradient >40 mmHg and AVAi <0.6 cm2/m2).

Methods

2582 consecutive patients with aortic stenosis (PLG-SAS, n=933; MAS, n=876 and HG-SAS, n=773) and a preserved EF (>50%) from an international multicentric registry were studied. Five years mortality between groups was compared using Kaplan Meier analysis. Inverse probability weighting was used to adjust for clinical and imaging baseline characteristics. Additionally, to explore the impact of MG (<40 mmHg vs. >40 mmHg) in patients with AVAi <0.6 cm2/m2 (PLG-SAS vs. HG-SAS) and to explore the impact of AVAi (<0.6 cm2/m2 vs. >0.6 cm2/m2) in patients with MG <40 mmHg (PLG-SAS vs MAS) we performed 2 different propensity score analyses. Patients were censored at the time of surgery.

Results

Overall, during 23 [IQR,10–47] months of follow-up 1003 patients died and 770 patients underwent aortic valve replacement. IPW-adjusted natural history was significantly better in patients with MAS, intermediate for patients with PLG-SAS and worst in patients with HG-SAS (59 vs. 47 vs. 41%, p<0.001, see Figure 1A). Furthermore, at equal MG (448 pairs), survival was significantly better in patients with MAS compared with PLG-SAS (54% vs. 39% p<0.001, see Figure 1B) and at equal AVAi (377 pairs), survival was significantly better in patients with PLG-SAS compared with HG-SAS (43% vs. 32% p<0.001, see Figure 1C).

Conclusions

In this large multicentric cohort, survival of PLG-SAS patients was better than that of HG-SAS patients and worse than that of MAS patients. Furthermore, with a comparable mean gradient, the smaller the calculated AVAi, the worse the prognosis whereas with a comparable AVAi, the higher the mean gradient, the worse the prognosis. Taking together, these data demonstrate that PLG-SAS is an intermediate form in the disease continuum, HG-SAS being the most malignant form of AS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds National de la Recherche Scientifique (F.R.S.–FNRS)