bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors and a novel risk score of statin non-adherence after hospitalisation for an acute coronary syndrome
Authors: Liao Y W L , Lee M L , Poppe K P , Kerr A K , Stewart R S
Published: October 2021

Background

Statin non-adherence after acute coronary syndrome (ACS) hospitalisation is associated with adverse prognosis. Identifying its risk factors can help to develop strategies and target high risk groups to improve outcomes. We evaluated the predictors and devised a risk score for statin non-adherence following ACS.

Methods

Consecutive ACS hospitalisations enrolled in the ANZACS-QI registry during December 2013 to October 2017 were linked to the National Pharmaceutical database for statin dispensing records. The primary endpoint was mean statin possession ratio (MPR) of <0.8 at 6–12 months after discharge. Multivariable Poisson regression was performed to identify predictors and formulate a risk model for statin non-adherence.

Results

Primary endpoint occurred in 4736/19942 (24%) of ACS patients studied. Patients taking statin on admission with LDL-cholesterol<2mmol/L had the lowest risk and were chosen as the reference group. Adjusted relative risks (RR) and 95% confidence intervals (95% CI) were highest in patients with prior cardiovascular disease (CVD) but not on statins 3.79 (3.42–4.20), followed but no prior CVD and not on statins 2.25 (2.04–2.48). RRs (95% CI) for patients on statin with LDL2.0–2.9 and LDL >3.0mmol/L were 1.33 (1.17–1.50) and 1.96 (1.72–2.24) respectively. Other independent predictors were age<45 years, Māori, Pacific and no revascularisation. Together, a risk score out of 25 for statin non adherence was created.

Conclusion

Statin non-adherence remains prevalent after ACS, with history of CVD, statin use and LDL levels being key predictors. A risk model was developed to help identify at risk patients that may benefit the most from delivery of adherence improving interventions and warrants external validation.

Funding Acknowledgement

Type of funding sources: None.
On- vs off-hours primary percutaneous coronary intervention: a single-centre experience
Authors: Mane F G , Flores R , Silva R , Conde I , Rodrigues C , Medeiros P , Oliveira C , Campos I , Ferreira A S , Costa J , Quina C , Braga C , Marques J
Published: October 2021

Introduction

In ST-segment elevation myocardial infarction (STEMI) patients, emergency medical system delays importantly affect outcomes. The effect of admission time in STEMI patients is dubious when percutaneous coronary intervention (PCI) is the preferred reperfusion strategy.

Aims

The authors aimed to retrospectively describe the association between admission time and STEMI patient's care standards and outcomes.

Methods

Characteristics and outcomes of 1222 consecutive STEMI patients treated in a PCI-centre were collected. On-hours were defined as admission on non-national-holidays from Monday to Friday from 8 AM to 6 PM. Time delays, in-hospital and one-year all-cause mortality were assessed.

Results

A total of 439 patients (36%) were admitted on-hours and 783 patients (64%) were admitted off-hours. Baseline characteristics were well-balanced between groups, including the percentage of patients admitted in cardiogenic shock (on-hours: 4.6% vs off-hours 4%; p=0.62).

Median emergency system dependent time to reperfusion (i.e. first-medical contact to reperfusion) did not differ between the two groups (on-hours: 120 min vs. off-hours 123 min, p=0.54). The authors observed no association between admission time and in-hospital mortality (on-hours: 5% vs. off-hours 4.9%, p=0.90) or 1-year mortality (on-hours: 10% vs. off-hours 10%, p=0.97).

In patients admitted directly in the PCI-centre, median time from first-medical contact to reperfusion (on-hours: 87 min vs off-hours: 88 min, p=0.54), in-hospital mortality (on-hours: 4% vs off-hours: 7%, p=0.30) and 1 year mortality (on-hours: 9% vs off-hours: 13%, p=0.27) did not differ between the two groups.

Survival analysis showed no survival benefit of on-hours PCI over off-hours PCI (HR 1.01; 95% CI [0.77–1.46], p=0.95).

Conclusion

In a contemporary well-organized emergency network, STEMI patients admission time in the PCI-centre was not associated with reperfusion delays or increased mortality.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier curve
STEMI around-the-clock: how off-hours admissions impact door-to-balloon time and the long-term prognosis of ST-segment Elevation Myocardial Infarction
Authors: Martinho M , Briosa A , Cale R , Pereira E , Pereira A R , Santos J , Ferreira B , Santos P , Vitorino S , Eusebio C , Morgado G , Martins C , Pereira H
Published: October 2021

Introduction

The outcomes of reperfusion in ST-segment Elevation Myocardial Infarction (STEMI) are time-dependent, and percutaneous coronary intervention (PCI) should be performed within 60 minutes from hospital admission in PCI centers – door-to-balloon time (D2B). The association between Off-Hours Admission (OHA) and long-term outcomes is controversial when considering contemporary organized STEMI networks.

Purpose

This study aims to analyze how OHA influences D2B and long-term mortality.

Methods

Retrospective study of consecutive STEMI patients (pts), admitted in a PCI-centre with a local Emergency Department, between 2010 and 2015. Pts submitted to rescue-PCI were excluded. OHA was defined as admission at night (8p.m. to 8a.m), weekends and nonworking holidays. Predictors of OHA and D2B were studied by logistic regression analysis. Demographic, clinical, angiographic and procedural variables were evaluated using stepwise Cox regression analysis to determine independent predictors of 5-year all-cause mortality (5yM). The cumulative incidence of 5yM stratified by hours of admission was calculated according to the Kaplan-Meier method.

Results

Of 901 pts, 472pts (52.4%) were admitted during off-hours. These pts were younger (61±13 vs 64±12, p=0.002) and had a lower median patient-delay time (128min vs 157min, p=0.014). Clinical severity at presentation, defined by systolic arterial pressure and Killip-Kimball (KK) class, did not differ between groups. OHA did not impact D2B (89 min vs 88 min, p=0.550), which was in turn influenced by age ≥75y (OR 1.85, 95% CI 1.31–2.61, p<0.001). Mean clinical follow-up (FUP) was 68±37 months, with 75.1% of pts achieving a FUP >5 years. 5yM rate was 9.7%. After multivariate cox regression analysis, independent determinants of long-term mortality were age (HR 1.05, 95% CI 1.02–1.08, p<0.001), previous history of heart failure (HR 6.76, 95% CI 1.32–34.72, p=0.022) and pulmonary disease (HR 3.79, 95% CI 1.16–12.33, p=0.027), presentation with KK ≥2 (HR 2.82, 95% CI 1.32–6.01, p=0.007) and radial artery access in catheterization (HR 0.39, 95% CI 0.18–0.83, p=0.014) – figure 1. Although there was an association between a higher D2B time and 5yM (87min vs 101min, p=0.024), neither OHA nor D2B were independent predictors of long-term mortality – figure 2.

Conclusion

OHA did not seem to influence D2B and long-term STEMI outcomes in our PCI-centre. 5yM was mostly influenced by patient characteristics and clinical severity at presentation.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Predictors of long-term mortalityFigure 2. 5-year survival stratified by OHA
Relative impact of acute heart failure and acute kidney injury on short- and long-term prognosis of patients with STEMI treated with primary PCI
Authors: Milasinovic D , Mladenovic D J , Jelic D , Zobenica V , Zaharijev S , Vratonjic J , Isailovic N , Radomirovic M , Pavlovic A , Vukcevic V , Asanin M , Stankovic G
Published: October 2021

Background

Although both acute heart failure (AHF) and acute kidney injury (AKI) have been separately recognized as contributors to an increased mortality risk in patients with ST-segment elevation myocardial infarction (STEMI), their relative importance has not been extensively studied.

Purpose

Our aim was to investigate the relative impact of AHF and AKI on 30-day and 5-year mortality following primary PCI for STEMI.

Methods

8 054 patients referred to primary PCI during the years 2009–2019, and with the available repeated creatinine measurements, were analyzed. AKI was defined as ≥25% relative or ≥0.5 mg/dl absolute rise in creatinine from baseline, within 72 hours of intervention. Acute heart failure was defined as Killip class ≥2 on admission to hospital. Cox regression model was used to assess the effect of the interaction of AHF and AKI on mortality. Median follow-up was 5 years.

Results

The incidence of AKI was 9.9% (n=805) and of AHF 12.3% (n=1050). Concurrence of AHF and AKI was noted in 1.7% of the included patients (n=315). The combined presence of AHF and AKI significantly increased mortality both at 30 days (30.7%) and at 5 years (73.3%), as compared with AKI alone (8.2% at 30 days and 32.3% at 5 years) and AHF alone (13.0% and 53.0%). When adjusted for other significant predictors, such as age, prior stroke, hyperlipidemia, atrial fibrillation, ejection fraction, final TIMI flow in the culprit artery, the use of intra-aortic balloon pump and multivessel disease, both AKI and AHF were independently associated with mortality. The adjusted relative impact of AKI on mortality was stronger than that of AHF at 30 days (adjusted HR 3.5 and 2.2, respectively), whereas it was comparable at 5 years (adjusted HR 1.3 and 1.4, respectively). Furthermore, the combined presence of AHF on admission and the post-primary PCI development of AKI was associated with the highest magnitude of risk at both 30 days (HR 5.0, CI95% 3.0–8.3, p<0.001) and 5 years (HR 2.4, CI95% 1.83–3.16, p<0.001).

Conclusion

Acute kidney injury following primary PCI for STEMI was associated with a higher adjusted risk of short-term mortality when compared with acute heart failure, whereas their relative impact was comparable in the long-term.

Funding Acknowledgement

Type of funding sources: None.
Residual SYNTAX score in relation to culprit-plaque characteristics and cardiovascular risk in acute myocardial infarction:an optical coherence tomography study
Authors: Wang Y , Zhao X X , Zhou P , Liu C , Li J N , Zhou J Y , Chen R Z , Chen Y , Song L , Zhao H J , Yan H B
Published: October 2021

Introduction

The residual SYNTAX score (rSS) as the SYNTAX remaining after completion of percutaneous coronary intervention (PCI) was proved to be related to poor outcomes.

Purpose

This study aimed to investigate the association of culprit-plaque morphology with rSS and the predictive value of rSS for major adverse cardiac events (MACE) in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

A total of 274 STEMI patients undergoing preintervention optical coherence tomography examination were included and divided into 3 groups – rSS=0 (n=72), 08 (n=68). Baseline clinical data and culprit-plaque characteristics were compared. MACE was defined as the composite of all-cause death, recurrence of myocardial infarction (MI), stroke and unplanned revascularization of any coronary artery.

Results

There was a significant difference in the prevalence of plaque ruptures, lipid-rich plaques, and calcification among the three groups (plaque rupture: 44.4% versus 59.0% versus 64.7%, lowest to highest rSS, p=0.04; lipid-rich plaque: 40.3% versus 54.5% versus 69.1%, lowest to highest rSS, p=0.003; calcification: 38.9% versus 52.5% versus 61.8%, lowest to highest rSS, p=0.024). Multivariate logistic regression analysis indicated that rSS>8 was an independent predictor for plaque rupture (OR: 2.21, 95% CI: 1.19–4.19, P=0.013). During a mean follow-up of 2.2 years, MACE occurred in 47 (17.2%) patients. In fully adjusted analyses, rSS was independently associated with MACE (HR: 1.06, 95% CI: 1.02–1.10, P=0.005); patients with rSS >8 had higher MACE risk compared to rSS=0 (HR: 2.68, 95% CI: 1.11–6.5, P=0.029).

Conclusion

In STEMI patients, culprit-plaque morphology was significantly correlated with rSS, and elevated rSS was independently associated with cardiovascular risk.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences OCT findingsSurvival curves according to rSS
Prehospital ECG in patients with acute myocardial infarction during the COVID-19 pandemic
Authors: Avvedimento M , Leone A , Spinelli A , Franzone A , Esposito G , Piccolo R
Published: October 2021

Background

A delayed presentation of patients with ST-segment elevation myocardial infarction (STEMI) has been reported globally after the outbreak of coronavirus disease-19 (COVID-19). However, it remains unknown whether differences already exist at the time of pre-hospital electrocardiograms (ECGs).

Purpose

We therefore compared pre-hospital ECGs of STEMI patients hospitalized in Italy after the first reported case of COVID-19 on February 21, 2020 with data from the same period in 2019 to identifying potential changes between the two periods.

Methods

We analyzed prehospital ECGs of patients with a final diagnosis of STEMI from February 21, 2020, to April 16, 2020. Data were divided in two periods, before and after the first confirmed case of COVID-19 in Italy. Pathological Q-waves and the Anderson-Wilkins acuteness score, which estimates the acuteness of ischemia, were independently assessed by two reviewers.

Results

167 (5.15%) of out 3,239 ECGs qualified for STEMI and were included in the analysis. ECGs recorded during the COVID-19 pandemic showed more frequently pathological Q-wave complexes compared with the control period (54.5% vs. 22.1%, risk difference 32.3%, 95% confidence intervals [CI], 21.2 to 43.5 percentage points) and presented a higher number of pathological Q-waves (1.4±1.6 vs. 0.5±1.2; p<0.001). The Anderson-Wilkins acuteness score was significantly lower during the COVID-19 period (2.4±0.9 vs. 2.8±0.7; p<0.001), suggesting a lower probability of acute ischemia.

Conclusions

Pre-hospital ECGs of patients with a final diagnosis of STEMI presented more frequently the signs of late ischemia during the COVID-19 pandemic.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Comparison between pre-hospital and in-hospital ST-Elevation Myocardial Infarction (STEMI) from 2003 to 2016 in New South Wales, Australia: a population-linkage data analysis
Authors: Ratwatte S , Ng A , Hyun K , Weber C , Boroumand F , Kritharides L , Brieger D
Published: October 2021

Background

Outcomes among patients presenting to hospital with STEMI (PH-STEMI) are favourably impacted by access to reperfusion, which has improved in Australia in recent years. Reperfusion rates and outcomes among patients with in-hospital STEMI (IH-STEMI) in Australia are not well described.

Purpose

We compared frequency of percutaneous coronary intervention (PCI) and all-cause mortality trends between patients with PH-STEMI and IH-STEMI over 13-years in a statewide cohort.

Methods

Patients diagnosed with STEMI (both PH and IH) were identified from the NSW Admitted-Patient-Data-Collection registry from 2003 to 2016 and linked to the death registry until 31-December-2018. We calculated the proportion with PCI over time, and rate of long-term mortality was determined with adjustment for age, sex, year of presentation and PCI.

Results

66,794 STEMI patients were identified; 57,721 (86%) had PH-STEMI. Patients with IH-STEMI were older (mean±SD: 75±13 vs 66±14 years), and more likely to be female (46.2% vs 29.8%) than PH-STEMIs. Patients with IH-STEMI were less likely to undergo PCI (17.1% vs 55.8%). From 2003-4 to 2015-6, overall rate of PCI increased for STEMI, but remained lower for IH-STEMI compared to PH-STEMI (9.5% to 23.9% vs 40.4% to 65.5% respectively).

All-cause mortality from STEMI fell over time in both groups. Predictors of mortality improvement in the PH and IH-STEMI populations respectively included PCI: (adjusted hazard ratio [aHR]=0.48, 95% confidence interval [CI]: 0.46–0.49 and (aHR=0.48 [95% CI: 0.44–0.53) and year of event: (aHR=0.74 [95% CI: 0.69–0.8] and aHR=0.79 [95% CI: 0.70–0.88]). Adding the interaction term PCI by year group to the mortality models showed that this progressive reduction in mortality by year grouping was accounted for by the performance of PCI in the PH-STEMI group (p<0.0001) but not in the IH-STEMI group (p=0.65).

Conclusion

A fall in mortality in patients with PH-STEMI in NSW was observed from 2003 to 2016 and was accounted for by increasing use of PCI. A more modest fall in mortality was seen in patients with IH-STEMI and this was independent of PCI which was under utilised in this population. Efforts to further improve outcomes in STEMI should include a greater focus on patients with in-hospital events.

Funding Acknowledgement

Type of funding sources: None.
Prognostic benefit from an early invasive strategy in patients with non ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines
Authors: Martinon-Martinez J , Alvarez Alvarez B , Gonzalez Ferrero T , Garcia-Rodeja Arias F , Otero Garcia O , Cacho Antonio C , Abou Jokh Casas C , Cordero A , Cid Alvarez B , Iglesias Alvarez D , Agra Bermejo R , Rigueiro Veloso P , Garcia Acuna J M , Gude Sampedro F , Gonzalez Juanatey J R
Published: October 2021

Objectives

The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up.

Methods

This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (<24 h) in patients with: (a) GRACE risk score >140 and (b) patients with “established NSTEMI” (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score <140.

Results

From 2003 to 2017, 6454 patients with “new high-risk NSTEACS” were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary interven- tion in patients with NSTEACS and GRACE >140 [HR 0.62 (IC 95% 0.57–0.67), HR 0.62 (IC 95% 0.56–0.68), HR 0.57 (IC 95% 0.53–0.61), respectively]. In patients with NSTEACS and GRACE <140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56–0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78–1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75–1.24)].

Conclusions

An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score <140 with established NSTEMI or ST/T-segment changes.

Funding Acknowledgement

Type of funding sources: None.
Specific actin (ACTC1) missense variants are associated with different overlapping clinical phenotypes and outcomes
Authors: Valverde M , Garcia Hernandez S , Brogger M N , Fernandez G , Cardenas I , Garcia-Gustiniani D , Fernandez X , Lamounier A , Ochoa J P , Ortiz-Genga M , Monserrat L , McKenna W
Published: October 2021

Introduction

Pathogenic variants in ACTC1 have been associated with hypertrophic (HCM), dilated (DCM), and left ventricular non-compaction (LVNC) cardiomyopathies. Phenotypes often overlap and atrial septal defects have also been reported. Prognostic data on carriers of these variants are scarce.

Methods and results

The proprietary database of a cardiovascular genetic laboratory was examined to assess penetrance and survival in the 438 carriers (191 families) of 75 missense variants in ACTC1 associated with disease. Their mean age at diagnosis was 32.4 (±18.7) years; 52% were male. The diagnosis was isolated HCM in 47%, LVNC in 17%, and DCM in 9%. LVNC with either HCM or DCM was present in an additional 8%; 13% had an atrial septal defect. Among carriers with echocardiographic information, left ventricular dilatation and dysfunction were described in 13% and 16%, respectively. Ventricular arrhythmias and conduction defects were reported in 94 and 93 carriers. Percentages have not been calculated for the latter, as we cannot ensure a denominator in whom cardiac conduction defects and arrhythmias were certainly discarded.

Overall, 50% of carriers were diagnosed by age 45, and 10% had experienced a major cardiac event. The p.Leu10Met and p.His90Tyr variants (23% of all carriers) demonstrated lower penetrance and a better prognosis than the p.Glu101Lys variant and the other missense variants.

Conclusions

Missense variants in ACTC1 are associated with a range of phenotypes that often overlap. Overall, penetrance and outcomes are age-dependent with a moderate rate of major cardiac events, which are highly dependent on the specific disease-causing variant

Funding Acknowledgement

Type of funding sources: None. Figure 1. The graph shows the percentage of carriers of pathogenic or likely pathogenic missense variants in the ACTC1 gene diagnosed at different ages. Considering all the missense variants in ACTC (in red), 50% of carriers had been diagnosed by age 45. It is worth highlighting the percentage of diagnosis (>15%) in the first 15 years of life, which is higher than the figure usually observed in sarcomeric hypertrophic cardiomyopathy.Figure 2. The graph shows the survival free of major cardiovascular events (sudden, heart failure, stroke-related death, appropriate ICD therapy and heart transplant) in individuals with missense variants in ACTC1. Carriers and affected relatives without genetic study were included. Events were infrequent in two of the most informative variants (p.Leu10Met and p.His90Tyr), and significantly different compared with carriers of the other missense variants (p=0.036 for p.Leu10Met and p=0.015 for p.His90Tyr).
Hypo-attenuated leaflet thickening is associated with structural valve deterioration following transcatheter aortic valve replacement
Authors: Rashid H , Ramnarain J , Nasis A , Nicholls S J , Cameron J D , Gooley R P
Published: October 2021

Background

While hypo-attenuated leaflet thickening (HALT) has been extensively described following transcatheter aortic valve replacement (TAVR), it remains unclear if HALT impacts long-term prosthetic haemodynamics or predicts structural valve deterioration (SVD).

Purpose

To determine the role of HALT and its characteristics of depth and thickness in predicting SVD.

Methods

We prospectively evaluated 186 patients who had undergone TAVR with 320-slice CT imaging for the presence of HALT, defined as hypo-attenuation of bioprosthetic leaflets in diastole. All assessments were performed by two blinded operators on the 3Mensio workstation. HALT depth (thickness) was the greatest depth in the sagittal view and HALT area was the greatest area in the axial view. SVD was defined as at least one of mean gradient ≥20 mmHg, increase in gradient ≥10 mmHg from baseline and at least moderate valvular regurgitation. Echocardiograms at discharge, one month and annually were assessed by cardiologists blinded to HALT status.

Results

LT prevalence was 17.7% at a median CT scan of 6 weeks. SVD occurred in 8.6% at a median follow-up of 2 years (IQR 1–3); two required valve re-intervention, five required anticoagulation that reversed moderate-severe gradient and nine had mild-moderate gradients that were closely monitored. Patients with HALT were more likely to develop SVD (39.3% vs 1.9%, p<0.01) and higher trans-valvular gradients throughout follow-up at up to 3-year follow-up. HALT affected one leaflet in 17 cases, two leaflets in 13 cases and three leaflets in 3 cases. Patients with HALT had a median cumulative thickness of 2.9 mm (IQR 1.9–4.7) and a median area of 64.2 mm2 (IQR 40.9–91.6). Threshold for the occurrence of SVD with HALT characteristics were cumulative depth of 2.4 mm (Specificity 94.1%, Sensitivity 75.0%, AUC=0.87) and cumulative area of 28 mm2 (Specificity 92.2%, Sensitivity 81.3%, AUC=0.86).

Conclusion

HALT was associated with SVD and higher trans-valvular gradients following TAVR. HALT depth and area were strong predictors of SVD. CT following TAVR may determine patients at-risk of SVD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Heart Foundation AustraliaNational Health and Medical Research Council Australia
Global constructive myocardial work predicts left ventricular disfunction onset beyond longitudinal strain in patients with significant primary mitral regurgitation
Authors: Tunyan L G , Chilingaryan A , Tumasyan L R , Kzhdryan H K , Zelveyan P H
Published: October 2021

Accurate surgical timing for significant primary mitral regurgitation (PMR) still remains an issue despite of several ways of left ventricular (LV) hidden disfunction detection, including LV global longitudinal strain (GLS). Since novel modalities such as myocardial work (MW) or area strain (AS) are currently available we assumed that they might predict surgical timing beyond known parameters.

Methods

58 patients (31 female) 63±8 years, asymptomatic and with pulmonary systolic pressure (PSP) ≤45 mmHg on exercise echo test (ET), with PMR, in sinus rhythm, with ejection fraction (EF) ≥65% and GLS <−19.5% were enrolled into the study along with 23 healthy subjects matched by age and sex and followed up for 1 year. Comprehensive echocardiography (EchoCG) was performed with offline analysis including MW and AS by one experienced specialist. GW index (GWI) was obtained from pressure-strain loops derived from speckle tracking analysis multiplied by brachial systolic blood pressure.Global constructive work (GCW) as the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation, global wasted work (GWW) aa energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation, and GW efficiency (GWE) as the percentage ratio of constructive work to the sum of constructive work and wasted work were obtained by the dedicated software.

Results

13 (22%) patients with PMR became symptomatic or increase PSP >50 mmHg on ET in 1 year follow up. EF, GLS, AS and GWI did not differ between symptomatic patients and those who remained asymptomatic during follow up, however these patients had significantly lower values of GCW, and higher values of GWW (EF 68.3±6.1% vs 69.2±6.5%, p=NS; GLS –22.4±2.3% vs 23.1±3.2%, p=NS, GWI 2452±161 mmHg% vs 2479±147 mmHg%, p=NS; GCW 1875±119 mmHg% vs 2321±124 mmHg%, p<0.01; GWW 118±9 mmHg% vs 88±7 mmHg%, p<0.03; GWE 93±8% vs 96±9%, p=NS; AS −32.5±5.4% vs −34.3±6.1%, p=NS;). Patients with subsequent symptoms development had significantly lower values of GCW and higher values of GWW. Among all parameters GCW was the predictor of MR clinical course worsening (AUC 0.769).

Conclusion

MR GCW is able to predict clinical course of patients with PMR beyond known conventional parameters.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): City Hall resources
TAVI for low-flow, low-gradient severe aortic stenosis: impact on outcome
Authors: Oikonomou G , Simopoulou C , Drakopoulou M , Synetos A , Latsios G , Stathogiannis K , Toskas P , Karmpalioti M , Apostolos A , Soulaidopoulos S , Toutouzas K , Tsioufis K
Published: October 2021

Background

Several factors have been identified as predictors of events after transcatheter aortic valve implantation (TAVI) but the impact of transaortic flow (F) and mean transaortic gradient (MG) upon outcomes is controversial. This study aimed to clarify the prognostic role of low FL and low MG after TAVI.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2], referred for TAVR at our institution were consecutively enrolled. Given the aim of this analysis, patients were divided according to F and MG into four groups: 1) LF-LG Patients with low flow (SVi <35ml/m2) and low mean gradient (MG <40mmHg), 2) NF-LG Patients with normal flow (SVi ≥35ml/m2) and low mean gradient (MG <40mmHg), 3) LF-HG Patients with low flow (SVi <35ml/m2) and high mean gradient (MG ≥40mmHg) and 4) NF-HG patients with normal flow (SVi ≥35ml/m2) and high mean gradient (MG ≥40mmHg). Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analyzed. One-year outcomes were compared between the 4 groups of patients. Primary clinical endpoint was all-cause mortality at long term follow up, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

In total 255 patients undergoing TAVI at our institution were included in our study: 35 (13.7%) patients with LF-LG, 17 (6.7%) with NF-LG, 108 (42.4%) with LF-HG and 95 (37.3%) with NF-HG. There was a statistically significant difference in gender distribution between the groups with most females being represented in the NF-HG group (64.2%) vs the LF-LG (31.4%), the NF-LG (47.1%) or the LF-HG group (50.9%) (p=0.008). Moreover, LF-LG patients were younger than NF-LG, LF-HG or NF-HG patients (ANOVA, p=0.037). There was a greater prevalence of prior myocardial infarction (MI) in the LF-LG group (34.5%) vs 20% in the NF-LG, 16.1% in the LF-HG and 20.2% in the NF-HG group (p=0.005). At 1 year follow up there were no statistically significant differences in major vascular complication, major bleeding complication or permanent pacemaker implantation rates between the groups, (all p>0.05). At a median follow up of 36 months IQR (17, 56) all-cause mortality was significantly higher in the LF-LG group as opposed to the NF-LG, LF-HG and NF-HG groups (77.41% vs 60% vs 55.67% vs 46.15% respectively, p=0.005). These results were confirmed by multivariate logistic regression analysis, as the combination of low flow and low mean gradient emerged as the strongest long term all cause mortality predictor (HR: 5.39, 95% confidence intervals: 1.72–16.83; p=0.004)

Conclusion

Combination of low flow and low mean transaortic gradient portends a worse prognosis after TAVI.

Funding Acknowledgement

Type of funding sources: None.
Clinical and health status outcomes in nonagenarians undergoing transcatheter mitral valve repair
Authors: Chen K C , Patil R P , Arora Y A , Kapila A K , Rothenberg M R , Nores M N , Chait R C
Published: October 2021

Background

Transcatheter mitral valve repair (TMVR) has emerged as an effective treatment in patients with mitral regurgitation due to degenerative valve disease and increased surgical risk. However, nonagenarians were excluded from the original TMVR trials and there is paucity of data.

Purpose

The aim of this study was to investigate the clinical and health status outcomes in nonagenarians undergoing TMVR.

Methods

This is a retrospective observational study of patients who underwent TMVR at a community hospital between June 2012 and December 2019. Baseline clinical characteristics and post-operative outcomes were collected and compared. This cohort of patients was stratified into three groups, age <80 (n=57), 80–89 (n=150) and ≥90 (n=40). Clinical outcomes assessed were procedural complications and 30-day and 1-year mortality. Health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) at baseline and at 1-month and 12-month follow-up.

Results

Overall there was no significant difference in procedural complications between the three groups (Table 1). Although not statistically significant, nonagenarians had higher rates of stroke (0% vs 0.6% vs 5%, p=0.053). 30-day and 1-year mortality were similar (p=0.796 and p=0.599). At baseline, there was significance difference in KCCQ-OS between three groups (27.0±20.8 vs 45.3±26.4 vs 41.1±26.2, p=0.ehab724.16483). However, there were no difference in KCCQ-OS at 1-month or 12-months (p=0.731 and p=0.561).

Conclusion

In our single center retrospective study, nonagenarians who underwent TMVR had similar clinical and health status outcomes compared to other age groups. TMVR appeared to be a safe and effective procedure in this patient population.

Funding Acknowledgement

Type of funding sources: None.
Transcatheter aortic valve replacement in severe aortic stenosis and cardiac amyloidosis: a systematic review and meta-analysis
Authors: Pinto G , Villaschi A , Sanz-Sanchez J , Fazzari F , Regazzoli D , Mangieri A , Pini D , Bragato R M , Colombo A , Reimers B , Condorelli G , Stefanini G G , Chiarito M , Cannata F
Published: October 2021

Background

Aortic stenosis (AS) and cardiac amyloidosis (CA) are typical degenerative diseases of the elderly. According to recent studies, up to 16% of patients referred to transcatheter aortic valve replacement (TAVR) have a concomitant diagnosis of CA. Until recently, TAVR in patients with CA and AS has been considered futile, following the results of small observational studies. However, few studies recently suggested a beneficial impact of TAVR in patients with AS and CA as compared with medical therapy alone.

Purpose

To clarify the efficacy and safety profile of TAVR in CA-AS patients.

Methods

We performed a systematic review and meta-analysis of studies evaluating the risk of mortality after TAVR in CA-AS patients as compared with medical therapy. Moreover, we performed a systematic review and descriptive meta-analysis of studies reporting outcomes and complication rates of TAVR in CA-AS patients as compared with patients with AS alone.

Results

We identified 4 observational studies reporting data on mortality in CA-AS patients treated with either TAVR or medical therapy. Mortality was significantly lower in patients undergoing TAVR (OR 0.23, 95% CI 0.07–0.73, I2=0%, NNT=2.6) as compared with medical therapy. A sensitivity analysis with hazard ratio as effect estimate showed consistent results. Then, we identified 4 observational studies reporting data on mortality, re-hospitalizations and periprocedural complications of TAVR in CA-AS patients as compared with patients with AS alone. We found higher rates of mortality, cardiovascular hospitalization and need for permanent pacemaker implantation in CA-AS patients as compared to lone AS patients undergoing TAVR. Conversely, no differences were found in terms of stroke, acute kidney injury and vascular complications.

Conclusions

Our analysis rejects the idea of futility of TAVR in CA-AS patients showing a clear survival benefit of CA-AS patients undergoing TAVR as compared with medical therapy. Moreover, these patients may undergo TAVR with an acceptable procedural risk, that is substantially comparable to lone AS patients, except for a higher incidence of permanent pacemaker implantation.

Funding Acknowledgement

Type of funding sources: None.
Relative prevalence and outcomes of low gradient severe aortic stenosis in routine clinical practice
Authors: Snir A , Ng M K , Playford D , Strange G , Stewart S , Celermajer D S
Published: October 2021

Background

The prevalence and outcomes of low-gradient severe aortic stenosis (AS), in particular low-flow low-gradient (LFLG) severe AS, have not been well characterized.

Objectives

We sought to delineate the relative prevalence and outcomes of patients with low-gradient severe AS in routine clinical cardiology practice.

Methods

Data were derived from the National Echocardiography Database of Australia (NEDA), a national multicentre clinical registry with data linkage to mortality. A total of 192,060 adults with native aortic valve profiling from 2000–2019 were identified, of whom 12,013 (6.3%) had severe AS (aged 75.3±13.1 years, 53.5% men). Severe AS subtypes were determined using standard echocardiographic criteria. All-cause and cardiovascular-related mortality were assessed on an adjusted basis (age and sex) in 8,162 patients with classifiable severe AS subtypes, during mean follow-up of 88±45 months. Additionally, rates of recorded Aortic Valve Replacement (AVR) during follow-up were compared between AS groups.

Results

5,601 patients (47%) had high-gradient and 6,412 patients (53%) had low-gradient severe AS. In the low-gradient group, Stroke Volume Index data was recorded in 2,741 patients; 1,750 (64%) had LFLG and 991 (36%) had normal-flow low-gradient (NFLG). For LFLG patients, 1,570 had LV ejection fraction recorded; 959 (61%) had paradoxical LFLG and 651 (39%) had classical LFLG. Adjusted 5-year cardiovascular mortality rates were 28% in high-gradient, 24% in NFLG, 27% in paradoxical LFLG and 50% in classical LFLG patients (p<0.001). Rates of recorded AVR per mean follow-up years were 5.2% for high-gradient, 4.0% for NFLG, 3.1% for classical LFLG and 2.4% for paradoxical LFLG severe AS (p<0.001).

Conclusions

Approximately half the subjects with echocardiographic features of severe AS in routine clinical practice have low-gradient haemodynamics, associated with long-term mortality comparable to or worse than high-gradient severe AS. The poorest survival was associated with classical LFLG severe AS.

Funding Acknowledgement

Type of funding sources: None. Summary illustration5 year mortality curves
Prevalence, echocardiographic profile and clinical outcomes of patients with paradoxical low-gradient rheumatic mitral stenosis
Authors: Ngiam N , Chew N W S , Sia C H , Stassen J , Marsan N A , Poh K K , Kong W K F , Bax J J , Delgado V
Published: October 2021

Introduction

Rheumatic mitral stenosis (MS) has been conventionally defined by the mitral valve area (MVA), and associated with an elevated mean pressure gradient (PG) across the valve. However, there may be discrepancies between MVA and PG. We compared the clinical and echocardiographic parameters, as well asoutcomes of those with consistent (normal-gradient, NG) versus discrepant (Low-gradient, LG) grading between MVA and PG.

Methods

Consecutive patients (n=452) with index echocardiographic diagnosis of rheumatic MS (MVA <1.5cm2) were examined. Patients were matched by MVA and divided based on mean PG (LG <10mmHg or HG ≥10mmHg). The groups were compared using appropriate univariable, multivariable and survival analyses. Patients were followed up prospectively for clinical outcomes (admission for congestive heart failure, stroke or death).

Results

There were 226 patients (50.0%) with LGMS despite MVA<1.5cm2. They had similar age and body mass index. The LG group had higher prevalence of atrial fibrillation (62.4% vs 45.1%, p<0.001), hypertension (31.4% vs 18.8%, p<0.001) and lower heart rate during echocardiography (74.3±16.6 vs 82.5±20.2 beats per minute, p<0.001). LG MS patients had lower incidence of adverse events (log-rank 4.62, p=0.032). On multivariable Cox regression adjusting for age, left ventricular ejection fraction, MVA, pulmonary artery systolic pressure and mitral valve procedure, LG MS remained protective for adverse events (adjusted HR 0.58, 95% CI 0.38–0.89, p=0.013).

Conclusions

There was significant prevalence of paradoxical LG MS. Despite similar MVA, these patients had lower PASP and had fewer adverse outcomes on follow-up.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Dr Jan Stassen is supported by an ESC Training Grant (Appehab724.169164741)
Novel risk model for one-year mortality and guidance of management strategy in isolated severe secondary tricuspid regurgitation
Authors: Wang T K M , Mentias A , Akyuz K , Kirincich J , Duran Crane A , Pettersson G B , Gillinov A M , Popovic Z B , Xu B , Griffin B P , Desai M Y
Published: October 2021

Background

Isolated severe tricuspid regurgitation (TR) is a challenging valve lesion to manage because of adverse prognosis, and surgery remains controversial especially in secondary etiologies. We aimed to devise a risk model to predict one-year mortality in isolated secondary TR patients, and evaluated whether risk category influenced the association between tricuspid valve surgery and survival.

Methods

Consecutive patients with isolated severe secondary TR by echocardiography during 2004–2018 were retrospectively studied. A multivariable model was developed for one-year all-cause mortality from two thirds of study patients (randomly-selected derivation cohort), and then assessed in the remaining patients (validation cohort). Associations between tricuspid valve surgery and survival were analyzed overall and in risk categories in multivariable analyses.

Results

Amongst 8575 isolated TR patients with secondary etiologies, mean age was 71.3±14.5 years and 5153 (60.1%) were female. Tricuspid valve surgery was performed in 487 (5.7%) patients, and was independently associated with improved survival during follow-up with hazards ratio 0.57 (95% confidence interval 0.41–0.81) in multivariable analysis. One-year mortality occurred in 2108 (24.6%) patients, and an additive risk score out of 14 based on independent predictors of one-year mortality is shown in the Table 1. The c-statistic for the derivation cohort was 0.712, and for the validation cohort 0.729. By risk score category, one-year mortality was 5.7% for 0–1 (low), 10.1% for 2–3 (mildly elevated), 24.3% for 4–7 (moderately elevated) and 50.9% for >7 (severely elevated), as shown in Figure 1. Surgery was associated with improved survival in the three higher score categories of isolated TR patients (P<0.001 to P=0.037), but did not improve survival in lower risk patients with scores of 0–1 (P=0.140).

Conclusion

We devised and validated a novel risk model which moderately discriminated one-year mortality for isolated severe secondary TR. The score may help guide decision-making for management strategy in those with elevated scores, when the under-utilized tricuspid valve surgery is associated with improved survival, and further research is necessary to apply this score for those considering for transcatheter therapies.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of New Zealand Table 1Figure 1
Contemporary comparison of infective endocarditis caused by Candida albicans and Candida parapsilosis: a cohort study
Authors: Jeronimo A , Olmos C , Perez-Garcia C N , Ferrera Duran C , Garcia-Granja P E , Lopez Diaz J , Saez Bejar C , Sarria Cepeda C , Alcazar M C , San Roman A , Vilacosta I
Published: October 2021

Background

Although Candida albicans is the most frequent microorganism causing fungal endocarditis, its incidence has decreased during the last two decades, and that of non-albicans Candida species has risen. Among the last, Candida parapsilosis is of particular interest, representing the second most frequent Candida species causing IE1, 2.

Purpose

To compare the clinical course, imaging findings and outcomes among patients with IE caused by C. albicans (CAIE) and C. parapsilosis (CPIE) in order to identify organism-specific peculiarities.

Methods

From January 1998 to June 2020, all consecutive cases of CAIE and CPIE (n=16), admitted to a hospital network composed of 3 tertiary hospitals and prospectively recruited on a multipurpose database, were retrospectively analysed. All cases were evaluated by the Endocarditis Team (ET) and underwent a thorough diagnostic work-up, including blood cultures at admission, transoesophageal echocardiography (TEE) and culture of the valves extracted at surgery. Other imaging tests, such as PET/CT, were performed at the ET's discretion. Diagnosis of IE was made according to the modified Duke criteria until 20153, and the European Society of Cardiology (ESC) 2015 modified diagnostic criteria thereafter4.

Results

Eight patients were diagnosed with CAIE and 8 with CPIE. Regarding predisposing conditions, a higher prevalence of prosthetic valves was found among CPIE. Other population's baseline information is shown in Table 1. Compared to CAIE, CPIE presented a longer time from the beginning of symptoms to hospital admission (40 vs 7 days; p=0.062), but no differences regarding signs and symptoms were observed. Aortic location was the most frequent infection side in both groups, but prosthetic valve involvement was remarkably more frequent among patients with CPIE (75% vs 37.5%; p=0.315. Figure 1). CPIE also presented a higher rate of positive blood cultures at admission (100% vs 62.5%; p=0.200), persistently blood cultures 48–72 hours after antifungals initiation (100% vs 0%; p=0.021) and positive valve cultures (83.3% vs 57.1%; p=0.569). No differences regarding TEE and other imaging tests findings were observed. All patients but 4 underwent valve replacement surgery. No differences in in-hospital complications or in mortality were observed between CAIE and CPIE, even after adjusting for therapeutic management.

Conclusions

Compared to CAIE, CPIE presented a more frequent involvement of prosthetic valves, a longer course of symptoms before admission and a bigger proportion of persistently positive blood cultures. In-hospital complications and mortality were similar between the two groups.

Funding Acknowledgement

Type of funding sources: None. Table 1. Population characteristicsFigure 1. Valve involvement distribution
Clinical relevance of cardiac magnetic resonance feature tracking derived left ventricular strain in nonischemic dilated cardiomyopathy
Authors: Pozo Osinalde E , Urmeneta Ulloa J , Rodriguez Hernandez J L , Perez De Isla L , Martinez Fernandez H , Islas F , Marcos-Alberca P , Mahia P , Cobos M A , Martin Lores I , Luaces M , Gomez De Diego J J , Cabeza B , Macaya C , De Agustin J A
Published: October 2021

Background

Left ventricular (LV) myocardial deformation analysis with echocardiography has shown an additive value for risk stratification in nonischemic dilated cardiomyopathy (NIDCM). However, scarce data is available with the new cardiac magnetic resonance (CMR) technique feature tracking, which allows strain evaluation from conventional cine sequences.

Purpose

Our aim is to analyze prognostic relevance of FT in NIDCM

Methods

Consecutive patients with NIDCM diagnosis and CMR at diagnosis were retrospectively included. LV global longitudinal, circumferential and radial strain (GLS, GCS and GRS, respectively) were obtained from standard CMR cine sequences with a dedicated FT software. Their association with a composite endpoint (heart failure admission, implantable cardioverter defibrillator in secondary prevention, and death) was evaluated.

Results

FT derived strain was obtained in 98 patients (68±13 years, 72% males) with NIDCM, mostly idiopathic (75.5%). The vast majority showed a severely dilated LV (LVEDVi= 133.6±33.4 mL/m2) with severely impaired systolic function (LVEF= 29.5±9.6%), and in 38.8% of the cases fibrosis was demonstrated in late gadolium enhancement (LGE). During a 3.2 [2.2–4] years follow-up 25.5% had an admission due to heart failure, 5.1% received an implantable cardioverter defibrillator in secondary prevention, and 10.2% died. Only a trend towards worse GCS values (−7.1 vs −8.5%; p=0.10) was noted among patients with heart failure hospitalization. Mortality was associated with poorer GCS (−5.9 vs −7.9%; p=0.012) and GLS (−6.9 vs −9.6%; p=0.051) values, whereas GRS was not related with any prognostic variable. Exclusively GCS was associated with the composite endpoint (−6.7 vs −8.2%; p=0.035). Considering other morphological parameters with prognostic relevance (LVEF and LVEDVi), GCS was the only independent predictor (OR 1.15; p=0.038). A cut-off point <−8.2% was able to identify those patients with a worse clinical evolution (Figure, Log Rank 4.6; p=0.032)

Conclusions

In our series LV myocardial deformation analysis with FT has shown prognostic relevance in NIDCM, especially GCS determination.

Funding Acknowledgement

Type of funding sources: None. Figure 1