bluuebunny/crossref_metadata_2025 huggingface dataset:
Characteristics of aortic root and vascular anatomy in bicuspid versus tricuspid aortic valve stenosis in patients undergoing transcatheter aortic valve implantation
Authors: Arow Z , Yaron A , Nassar M , Perlman G , Lessick J , Brodov Y , Vaknin-Assa H , Steinvil A , Kornowski R , Hamdan A
Published: November 2020

Background

Transcatheter aortic valve implantation (TAVI) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS).

Objectives

This study sought to compare aortic root and ilio-femoral artery characteristics and clinical outcomes in patients with bicuspid versus tricuspid AS from the Bicuspid AS TAVI multicenter registry.

Methods

88 patients with bicuspid AS and 213 matched patients with tricuspid AS were referred for pre-procedural computed tomography (CT) evaluation before TAVI. We performed a detailed assessment of aortic root anatomy: size of the annulus, sinus of Valsalva (SoV), sino-tubular junction (STJ); we also determined the dimensions of aorta, left subclavian, and ilio-femoral arteries.

Results

Patients with bicuspid AS had significantly larger aortic root dimensions, (annulus mean diameter: 25.5±2.9 mm vs. 23.7±2.4 mm, SoV mean diameter: 35.3±4.7 mm vs. 32±4.4mm, STJ mean diameter: 31.5±4.9 mm vs. 27.6±3.5 mm; respectively) than patients with tricuspid AS (P value for all <0.001), even after adjustment for their larger BSA and height. Dimensions of ascending aorta, left subclavian artery, and ilio-femoral arteries were also consistently larger in bicuspid than in tricuspid AS morphology.

Conclusions

Patients with bicuspid AS had significantly larger aortic root dimensions, larger ascending aorta, subclavian artery and ilio-femoral arteries even after adjustment for their BSA and height.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Rabin Medical Center
Predicting pacemaker implantation after TAVR with procedural CT
Authors: Gama F , Teles R.C , Oliveira A , Brizido C , Goncalves P , Brito J , Ferreira A , Abecasis J , Almeida M , Mendes M
Published: November 2020

Background and aim

The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve replacement (TAVR). Calcium distribution in the aortic-valvular complex (AVC) and, more recently, membranous septum (MS) length seem to be surrogate markers for conduction abnormalities after specific last generation balloon and self-expandable expandable valves. We sough to evaluate whether such pre-procedural association remains across the entire device spectrum.

Methods

Single-centre prospective study of 239 consecutive patients (140 women, median age of 84) with severe symptomatic aortic stenosis patients who underwent ECG-gated contrast-enhanced multi-detector computed tomography (MSCT) before TAVR since Jun/2017. Exclusion criteria were those with previous PPMI, previous bioprothesis, congenital bicuspid valve, and poor imaging quality. The J-score with an 850-Hounsfield unit threshold was used to detect areas of calcium in the region of interest. AVC was characterized by leaflet sector and region, using 3mensio Valves software 7.0 TM. An independent team retrospectively measured MS length blindly by determining the thinnest part of the interventricular septum in the coronal view in the better-defined systolic phase (usually at 40% of the R-R interval, Figure). Device selection (75.8% self-expandable devices, 20.1% balloon expandable, 3.1% other) and positioning were performed according to the operator criteria. Final implant depth was assessed based on the pre-release angiogram or final aortography.

Results

Mortality at 30-days was 1.3% and PPMI occurred in 43 patients (18%). Median MS length was 9.59mm (IQR: 3.11mm). After multivariable logistic regression analysis, MS length emerged as the single significant protective predictor for PPMI (OR: 0.14; 95% 95% CI: 0.05–0.42; p<0.001), independently of the device used (p<0.001). MS length showed strong discriminatory ability for PPMI (c-statistic 0.93; 95% CI 0.88–0.99). Sensitivity/specificity decision plots yielded an MS length of 6.9 mm as the optimal cut-off point for predicting the need for PPMI with a positive and negative predictive value of 91% and 93%, respectively (Figure). There wasn't any calcium accumulation within a specific region of AVC that independently predicted the outcome.

Conclusion

In our experience, a short membranous septum was strongly and independently associated with new permanent pacemaker implantation, regardless of the device type.

Our findings suggest that this simple measure should be routinely made to help device selection and implantation technique.

Funding Acknowledgement

Type of funding source: None
Extracting hypertrophic cardiomyopathy features from cardiac magnetic resonance reports by natural language processing
Authors: Dewaswala-Bhopalwala N , Chen D , Bhopalwala H , Hossein Pour S , Moon S , Bos D , Scott C , Geske J , Noseworthy P , Ommen S.R , Erickson B.J , Araoz P.A , Nishimura R.A , Ackerman M.J , Arruda-Olson A.M
Published: November 2020

Objective

Determine if information regarding hypertrophic cardiomyopathy (HCM) can be accurately retrieved from cardiac magnetic resonance (CMR) reports using natural language processing (NLP).

Background

CMR imaging is used for diagnosis and risk stratification of HCM. Manual annotation of information from CMR is time-consuming. NLP is an artificial intelligence method for automating extraction of information from narrative text.

Methods

We identified 200 HCM patients who had CMR reports from 1998 to 2018. These patients were randomly allocated into training (100 patients with 185 CMR reports) and testing sets (100 patients with 206 reports). An NLP system with 2 tiers was developed; the first extracted information regarding HCM diagnosis while second extracted categorical or numeric concepts for HCM classification. NLP performance was compared with gold-standard manual annotation.

Results

NLP algorithms achieved very high performance across all concepts with mean positive predictive value (PPV) = 0.96. An outlier was the performance for abstracting the presence of an apical pouch from CMR reports, which had noticeably lower PPV= 0.78 which be attributed to the low number of cases with this finding.

Conclusions

The algorithms developed can be translated to clinical decision support systems to increase efficiency and contribute to improved quality of care.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Study supported by the National Heart, Lung and Blood Institute of National Institutes of Health (K01HL124045), the Mayo Clinic Center for Clinical and Translational Science (CCaTS), and the Mayo Clinic K2R award. Content is solely the responsibility of authors and does not necessarily represent official views of the National Institutes of Health.
UK national and regional trends in cardiovascular magnetic resonance usage – the British Society of CMR survey results
Authors: Keenan N , Captur G , McCann G , Berry C , Myerson S , Fairbairn T , Hudsmith L , O'Regan D , Westwood M , Greenwood J
Published: November 2020

Background

CMR is an imaging modality recommended for multiple indications. Access to CMR is a key issue for its clinical use. We surveyed all CMR units in the UK.

Methods

An online survey of CMR units in the UK, with responses analysed by region and compared with population data.

Results

Response rate was 100% (Table). The UK performed a total of 102,886 scans in 2017, and 117,967 in 2018 representing a 1-year 14.7% increase and a 10-year increase of 573% compared to 2008 data (20,597).By head of population in 2018 there were 1,776 CMR scans per million people, with significant variation nationally and regionally, e.g. 4,256 per million in London vs. 396 per million in Wales (Figure). Mean number of scans per unit was 1,404, (range 98–10,000) with wide variation in referral to diagnostic times (mean 45.7 days, range 5–180) (Figure).

Clinical indications for CMR were: heart failure 21%, cardiomyopathy 27%, function and viability 22%, stress 24%, vascular disease 5%, valvular 5%, myocarditis/pericardial 10%, paediatric /congenital 10%, others e.g. transplant/masses 4%, with overlap. There were 358 consultants reporting CMR in 2018 (234 (65%) cardiologists and 124 (35%) radiologists). 81% of units had a CMR service for patients with pacemakers and defibrillators.

Conclusion

The survey shows the state of CMR in the UK. The 10-year growth has been remarkable, but there are wide disparities in terms of use, access and wait times with potential implications for clinical care. Action is needed to make access equitable across the UK.

Figure 1

Funding Acknowledgement

Type of funding source: None
Safety and hemodynamic response of regadenoson stress cardiovascular magnetic resonance imaging in heart transplant recipients
Authors: Muniz Saenz Diez J , Luque Gonzalez M , Martinez Leon A , Ibero Valencia J , Iglesias Colino E , Riesgo Garcia A , Shangutov Kulichok O , De La Torre Carazo F , Rodriguez Junquera M , Irazusta Olloquiegui X , Soriano Aguadero I , Caballeros M , Salterain Gonzalez N , Rabago Juan Aracil G , Bastarrika G
Published: November 2020

Background

The non-invasive detection of coronary allograft vasculopathy remains a challenge, and there is no consensus about which technique should be used. The hypersensitivity to vasodilator drugs (such as adenosine) of heart transplant recipients may have limited the use of stress cardiovascular magnetic resonance imaging (stress-CMR) in this group of patients. Regadenoson is a more specific agonist of adenosine receptors. There is still little data on its safety profile and the hemodynamic response it causes in these patients.

Purpose

We aimed to observe safety and hemodynamic response to regadenoson in heart transplant recipients.

Methods

We studied 505 consecutive patients (22 transplanted and 483 non-transplanted) who underwent stress-CMR between 06/06/2017 and 10/10/2019. We compared the hemodynamic response (blood pressure and heart rate) and the adverse effects and symptoms caused by regadenoson in both groups. Student t test and χ2 were used to compare the continuous and the qualitative variables between both groups, respectively.

Results

In transplant patients there were no events requiring finalization of the test (e.g. atrioventricular block, symptomatic arterial hypotension or poor tolerance to the symptomatic response to regadenoson). There were no differences in the incidence of symptoms after drug administration in transplanted versus non-transplanted patients (50% vs. 50.4%, p=0.97), and all of those symptoms were transient and well tolerated. Transplant recipients presented an attenuated hemodynamic response compared to non-transplanted patients (Table 1).

Conclusions

Stress-CMR with regadenoson is a safe and well tolerated technique in heart transplant recipients. In this group of patients, the hemodynamic response is blunted compared to non-transplanted patients. This lower response has been previously described in obese and diabetic patients, and it does not appear to affect the performance of the test. Further studies should confirm these findings.

Funding Acknowledgement

Type of funding source: None
Feasibility and prognostic value of vasodilator stress perfusion CMR in patients with atrial fibrillation
Authors: Pezel T , Sanguineti F , Kinnel M , Bonnet G , Landon V , Hovasse T , Garot P , Unterseeh T , Champagne S , Louvard Y , Morice M.C , Garot J
Published: November 2020

Background

Several studies have demonstrated the consistently high diagnostic and prognostic value of stress perfusion imaging with cardiovascular magnetic resonance (CMR). The feasibility and the prognostic value of vasodilator stress perfusion CMR in patients with atrial fibrillation (AF) is unknown, because most studies have excluded arrhythmic patients from analysis.

Purpose

The aim of our study was to assess the technical feasibility and the prognostic value of vasodilator stress perfusion CMR in patients with AF.

Material

Between 2008 and 2018, we prospectively included consecutive patients with AF referred for vasodilator stress perfusion CMR with dipyridamole. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or non-fatal myocardial infarction (MI). The secondary outcome was all-cause mortality. The diagnosis of AF was confirmed on 12-lead ECG before and after CMR, and patients with sinus rhythm during CMR were excluded. In the CMR protocol, to limit AF-related artifacts on cine images, an arrhythmia rejection algorithm, or real-time sequences were used. Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR.

Results

Of 639 patients with AF and suspected or stable chronic CAD (72±9 years, 77% men), 602 (94%) completed the CMR protocol, and among those 538 (89%) completed the follow-up (median follow-up 5.1 (3.3–7.1) years). Reasons for failure to complete CMR included AF-related ECG-gating problems (n=17), intolerance to stress agent (n=7), renal failure (n=6), declining participation (n=4) and claustrophobia (n=3).

Stress CMR was well tolerated without occurrence of death or severe disabling adverse event. Patients without inducible ischemia or LGE experienced a substantially lower annual event rate of MACE (1.2%) than those with ischemia and without LGE (8.9%), or those with both ischemia and LGE (9.8%; p<0.001 for all). Using Kaplan-Meier analysis, the presence of myocardial ischemia identified the occurrence of MACE (hazard ratio HR 7.56; 95% confidence interval CI: 4.86–11.80; p<0.001) (Figure).

In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischemia was an independent predictor of a higher incidence of MACE (HR 5.88; 95% CI: 3.70–10.07; p<0.001) and all-cause mortality (HR 2.51; 95% CI: 1.47–4.17; p<0.001).

Conclusion

Stress CMR is technically feasible and has a good discriminative prognostic value to predict the occurrence of MACE and all-cause mortality in patients with AF.

Kaplan-Meier curves for MACE

Funding Acknowledgement

Type of funding source: None
Prevalence of microvascular dysfunction and association with clinical outcomes in heart failure with preserved ejection fraction
Authors: Arnold J , Kanagala P , Budgeon C.A , Jerosch-Herold M.J , Singh A.S , Khan J.N , Gulsin G.S , Squire I.B , Ng L.L , McCann G.P
Published: November 2020

Introduction

Heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of symptomatic heart failure. A recently proposed paradigm for the pathophysiology of HFpEF postulates a central inflammatory aetiology with coronary microvascular function at its core. However, the pathophysiological and clinical significance of microvascular dysfunction in HFpEF remains uncertain.

Purpose

Utilising cardiovascular magnetic resonance (CMR), we sought to (1) quantify coronary microvascular function, (2) evaluate the impact of microvascular dysfunction and fibrosis on long-term clinical outcomes and (3) examine the relationship between myocardial perfusion and fibrosis.

Methods

In a prospective, observational study, 147 subjects (104 HFpEF without a prior history or CMR evidence of coronary artery disease, and 43 asymptomatic controls) underwent multiparametric CMR, comprising left ventricular volumetric assessment, absolute quantitation of myocardial blood flow [MBF] during adenosine stress (140mcg/kg/min) and at rest, and evaluation of diffuse myocardial fibrosis (extracellular volume [ECV]). The primary endpoint was the composite of death or hospitalisation with heart failure.

Results

104 HFpEF patients (mean age 73±9 years, mean ejection fraction 56%) and 43 controls (mean age 73±5 years, mean ejection fraction 58%) were studied. There was no significant difference in resting MBF (1.10±0.42ml/min/g in HFpEF subjects vs 1.00±0.38 ml/min/g in controls, p=0.23), though hyperaemic MBF was lower in HFpEF subjects (1.66±0.68 ml/min/g vs 1.97±0.59 ml/min/g, p=0.01). Myocardial perfusion reserve [MPR] was also lower in HFpEF subjects (1.73±0.75 vs 2.22±0.76; p<0.01). Microvascular dysfunction (defined as MPR<2.0) was present in 70% of HFpEF patients (versus 33% of controls, p<0.01). During median follow-up of 3.4 years, there were 46 composite events. MPR was predictive of clinical outcome (one unit increase – hazard ratio [HR] 0.57; 95% CI 0.35–0.92; p=0.02), as was ECV (one standard deviation [SD] increase – HR 1.65; 95% CI 1.14–2.39; p=0.01). However, there was no significant linear correlation between MPR and diffuse fibrosis (r<0.01, p=0.99).

Conclusion

Microvascular dysfunction is highly prevalent in HFpEF and is associated with adverse clinical outcomes. The lack of correlation between abnormal myocardial perfusion and fibrosis challenges the assertion of a direct causal link between these entities.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): NIHR, BHF
Prevalence, correlates and prognostic relevance of mid-wall late gadolinium enhancement in patients with ischaemic cardiomyopathy
Authors: Nucifora G , Tsoumani Z , De Angelis G , Caiffa T , Bradley J , Sinagra G , Miller C , Schmitt M
Published: November 2020

Background

LGE imaging is an established CMR imaging technique for the assessment of myocardial replacement fibrosis. The presence of mid-wall LGE has been described in ∼30% of patients with non-ischemic dilated cardiomyopathy and is known to be associated with poor outcome. Conversely, little is known regarding the clinical significance of mid-wall LGE in patients with ischemic cardiomyopathy (ICM). Aim of the present study was to investigate the prevalence, correlates and prognostic role of mid-wall late gadolinium enhancement (LGE) in a consecutive cohort of patients with ICM.

Methods

A total of 319 consecutive outpatients with ICM (mean age 64±11 years, 87% males) were included. All patients had CMR with LGE imaging and were followed for a median of 13 months. The outcome end-point was a composite of cardiovascular death, aborted sudden cardiac death, appropriate implantable cardioverter-defibrillator therapy, heart failure hospitalisations, implantation of left ventricular (LV) assist device or occurrence of heart transplant.

Results

Mean LV ejection was 37±9%, mean ischemic-type LGE expressed as % of LV mass was 16±9%, while mid-wall LGE was observed in 32 (10%) patients. LVEDV index (OR 1.02, 95% CI 1.01–1.03, p=0.001) and LV sphericity index (OR 1.04, 95% CI 1.01–1.07, p=0.024) were the only variables significantly and independently related to the presence of mid-wall LGE. The outcome end-point was documented in 37 (12%) patients. Ischemic-type LGE expressed as % of LV mass (HR 1.04, 95% CI 1.01–1.08; p=0.015) and the presence of mid-wall LGE (HR 4.5, 95% CI 2.2–9.2; p<0.001) were the only independent predictors of the composite outcome. Mid-wall LGE had significant incremental predictive value compared to the extent of ischemic-type LGE (Δχ2=16.5, p<0.001). The Kaplan-Meier survival curves showing survival from the composite end-point according to the presence/absence of mid-wall LGE in patients with ischemic-type LGE expressed as % of LV mass < the median value 14.6% and. ≥14.6% are shown in the Figure.

Conclusions

Mid-wall LGE is observed in a substantial minority of patients with ICM. In this population, the presence of mid-wall LGE is associated with adverse LV remodeling and worse prognosis.

Figure 1

Funding Acknowledgement

Type of funding source: None
Elevated native T1 values is in myocardial regions supplied by stenotic coronary arteries
Authors: Brodov Y , Matetzky S.M , Konen E.K , Di Segni M.D.S , Younes A.Y , Massalha E.M , Berkovitch A.B , Chernomordik F.C , Goitein O.G
Published: November 2020

Background

T1 mapping is a novel tool allowing robust quantification of myocardial damage.

Purpose

To quantify and compare the native T1 values in myocardial segments supplied by an infarct related artery (IRA) and stenotic and non-stenotic artery (non IRA).

Methods

Consecutive patients with first STEMI underwent primary PCI for IRA and some non IRA's a followed by cardiac MRI scan within 5±2 days. Obstructive coronary disease was defined as ≥50% stenosis. MRI studies (3T) included steady state free precession, late gadolinium enhancement and MOLLI T1 mapping. T1 mapping values were presented using a 16th segment AHA model. T1 segmental values were compared between the IRA and non IRA (stenotic and non-stenotic).

Results

The study cohort included 61 patients (mean age 59 y, male 90%). A total of 891 segments were analyzed (excluded segments (artifacts) N=85). Mean native T1 values for LAD IRA (stented), LAD non-IRA (≥50% stenosis) (not stented), LAD non IRA (≥50% stenosis) (stented) and LAD non IRA (<50% stenosis) were 1455±72; 1321±44; 1322±22 and 1283±32, respectively, overall P<0.001. For LCX IRA (stented), LCX non-IRA (≥50% stenosis) (not stented), LCX-non IRA (≥50% stenosis) (stented) and LCX non IRA (<50% stenosis) were 1362±75; 1277±50; 1277±72 and 1289±77, respectively, overall P<0.001. For RCA IRA (stented), RCA non-IRA (≥50% stenosis) (not stented), RCA-non IRA (≥50% stenosis) (stented) and RCA non IRA (<50% stenosis) were 1438±92; 1334±43; 1374±101 and 1311±34, respectively, overall P<0.001. Native T1 values in non-IRA LAD ≥50% stenosis vs LAD <50% stenosis were 1321±40 and 1283±32, respectively P=0.02, whereas non-IRA RCA ≥50% stenosis vs RCA <50% stenosis were 1345±61 and 1312±34 respectively, P=0.05.

Conclusion

As expected, the highest native T1 values were documented in the stented IRA's. However, native T1 values were also elevated in non IRA's (both stented and non-stented) with obstructive coronary disease (≥50% stenosis) in comparison with non-obstructive disease (<50% stenosis, documenting the presence of myocardial damage in remote segments. This finding sheds new light on the issue of complete revascularization in STEMI patients.

Funding Acknowledgement

Type of funding source: None
Infectious endocarditis: improving diagnostic performance in native and prosthetic valve infectious with 18F-FDG PET/CT
Authors: De Almeida J.P.L , Marinho V , Silva R , Goncalves F , Costa G , Goncalves L , Ferreira M.J
Published: November 2020

Background

The diagnosis of infective endocarditis (IE) remains a clinical challenge. Diagnostic accuracy of the modified Duke criteria is suboptimal for native valve endocarditis (NVE) and even worse in the presence of prosthetic material-related infection (PVE). We aim to evaluate the diagnostic performance of 18F-FDG PET in patients with suspected IE referred to perform PET/CT.

Methods

Consecutive patients with suspected IE, referred to perform PET/CT between May 2016 and June 2019 were included. Diagnostic performance of modified Duke criteria (mDC) and PET/ CT for IE for NVE and PVE was determined.

Results

In total, 82 patients (mean age of 61±19 years, 62% of male gender) were enrolled. There were 67 18F-FDG PET/CT concordant results with final diagnosis, corresponding to a 96% of agreement, k=0.91 (p=0.04). A SUVmax cutoff value of ≥3.1 identified positive cases with 88.9% sensitivity and 70.0% specificity. In patients with NVE, the addition of PET/CT to the mDC resulted in a reduction of the number of possible IE cases (from 58% to 4.3%). In patients with PVE/intracardiac devices, PET/CT allowed reclassification of 67.4% of possible cases to 4.2%. An alternative diagnosis was provided in 55.6% of the negative IE cases.

Conclusions

18F-FDG PET/CT proved to be a useful diagnostic tool in patients with both suspected NVE and PVE with good sensitivity and specificity, resulting in a significant decrease of the number of possible endocarditis. Furthermore, it allowed the identification of the cause of clinical scenario in more than 50% of patients in which the diagnosis was excluded.

18F-FDG PET SUV max ROC for IE diagnosis

Funding Acknowledgement

Type of funding source: None
Long-term follow-up of cardiac resynchronization therapy patients with non-ischemic dilated cardiomyopathy assessed by radionuclide angiography
Authors: Valzania C , Bonfiglioli R , Fallani F , Frisoni J , Biffi M , Boriani G , Galie' N
Published: November 2020

Background

While the beneficial effects of cardiac resynchronization therapy (CRT) have been widely investigated soon after CRT implantation, relatively few data are available on long-term clinical outcomes of CRT recipients.

Aim

To investigate long-term outcomes of CRT patients with non-ischemic dilated cardiomyopathy stratified as responders and non-responders according to radionuclide angiography.

Methods

Consecutive heart failure patients with non-ischemic dilated cardiomyopathy undergoing CRT implantation at our University Hospital between 2007 and 2013 were enrolled. All patients were assessed with equilibrium Tc99 radionuclide angiography at baseline and after 3 months of CRT. Left ventricular (LV) ejection fraction was computed on the basis of relative end-diastolic and end-systolic counts, and intraventricular dyssynchrony was derived by Fourier phase analysis. Response to CRT was defined by an absolute increase in LV ejection fraction (LVEF) ≥5% at 3-month follow-up. Clinical outcome was assessed after 10 years through hospital records review.

Results

Forty-seven patients (83% men, 63±11 years) were included in the study. At 3 months, 25 (53%) patients were identified as CRT responders according to LVEF increase (from 26±8 to 38±12%, p<0.001). In these patients, LV dyssynchrony decreased from 59±30° to 29±18° (p<0.001). Twenty-two (47%) patients were defined as non-responders. No significant changes in LVEF and LV dyssynchrony (50±30° vs. 38±19°, p=0.07) were observed in non-responders. At long-term follow-up (11±2 years), all-cause and cardiac mortality rates were 24% and 12% in responders vs. 32% and 27% in non-responders, respectively (p=ns). Heart transplantation was performed in 3 patients. One (4%) patient among CRT responders compared with 6 (27%) patients among non-responders died of worsening heart failure (p=0.03).

Conclusions

Although late overall mortality of non-ischemic CRT recipients was not significantly different between mid-term responders and non-responders, CRT responders were at lower risk of worsening heart failure death.

Funding Acknowledgement

Type of funding source: None
Molecular mechanism of a new cardiac syndrome associated with a regulatory element deletion of chromosome 4q25
Authors: Baudic M , Murata H , Le Scouarnec S , Foucal A , Lindenbaum P , Ishikawa T , Si-Tayeb K , Gaborit N , Makita N , Makiyama T , Shimizu W , Vieyres C , Probst V , Schott J.J , Barc J
Published: November 2020

Introduction

We identified a large family of 53 members of whom 22 present a new cardiac syndrome characterized by electrical disorders and developmental defects following an autosomal dominant model. Among the affected family members 6 are implanted with a pacemaker, 2 experienced syncope and one a sudden death at 43yo. Linkage analysis points, with high confidence, to the chromosome 4q25 region. This region is associated with the Ankyrin syndrome (mutation in ANK2) sharing partly the electrical defects observed in the affected family members. No mutation was found in the coding region of the 4q25 region as well as in the coding and non-coding part of the ANK2.

Objective

Our aims are first to identity the responsible mutation present in this family and understand the molecular mechanisms leading to this new syndrome.

Method

Whole genome sequencing (WGS) has been employed to identify genetic variants responsible for this syndrome. ChIP-seq and ATAC-seq were used for functional annotation and genome editing (CRISPR-Cas9) to generate iPS cellular models.

Results

By WGS we uncovered a deleted region of 15kb in a gene desert area on 4q25, segregating in all affected relatives. Five other families (3 French and 2 Japanese) presenting the same phenotype show overlapping deletions. We generated human cardiac epigenetic data and identified among the 15kb deleted region a unique active enhancer region within the presence of a transcript factor CTCF binding site. Isogenic cell lines where the 15kb and the CTCF binding have been deleted are under investigation.

Conclusion

We identified a new cardiac syndrome and for the first time a mutation located within a gene desert area leading to severe and complex cardiac disorders. We demonstrated the presence of a likely gene regulatory element. Experiments are ongoing to characterize the molecular mechanisms and consequence of the deletion on gene expression.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Pays de la loire - Etoiles montantes
MOG1 restores the expression and function of SCN5A-p.R104W through sec23a-mediated forward trafficking
Authors: Luo L , Wang Y , Du Y , Dong C , Ma A , Wang T
Published: November 2020

Background

Brugada syndrome (BrS) is an inherited disease which causes fatal arrhythmias and sudden cardiac death. Mutations in SCN5A gene, which encoding cardiac sodium channel (NaV1.5), are the most common genotype of BrS patients. Some SCN5A-related variants were reported to retain NaV1.5 in endoplasmic reticulum (ER) due to trafficking deficiency. MOG1 was previously reported to interact with NaV1.5 and increased sodium current (INa) through enhancing the trafficking. However, its molecular mechanisms are still unclear. Coat protein complex II (COPII) is responsible for the ER to Golgi transport. Sec23 forms the inner coat of COPII and participates in cargo proteins selection.

Purpose

To demonstrate that MOG1 rescues SCN5A-related variants by enhancing the forward trafficking through Sec23a-NaV1.5 interaction.

Methods

Site directed mutagenesis, immunofluorescence staining, biotinylation assay, Western blot analysis and whole-cell patch clamp recording were used. CRISPR/Cas9 was used to knock out Sec23a expression in HEK293 cells.

Results

We found that SCN5A-p.R104W was characterized as reduced NaV1.5 level and lack of INa. The variant SCN5A-p.R104W was mainly distributed in ER. MOG1 could rescue the total and surface expression of SCN5A-p.R104W but could not restore INa (Figure 1a). Considering that most patients are heterozygous, co-transfection of SCN5A-WT and SCN5A-p.R104W were obtained. We found MOG1 could increase both NaV1.5 level and INa of heterozygous expressed SCN5A-p.R104W. We further revealed an interaction between NaV1.5 and Sec23a by co-immunoprecipitation (Co-IP) assay. The interaction between NaV1.5 and Sec23a was increased by MOG1, which indicates that Sec23a participates in MOG1-mediated increase in NaV1.5 level (Figure 1b). Knockout of Sec23a reduced cell surface, but not total, NaV1.5 level (Figure 1c and 1d). Next, the Sec23a knockout HEK293 cells were co-transfected with SCN5A-p.R104W and pcDNA3 or MOG1. MOG1 could not increase SCN5A-p.R104W protein level in Sec23a knockout cells.

Conclusion

Our data demonstrated a novel mechanism that MOG1 restores the expression and function of SCN5A-p.R104W by enhancing its forward trafficking through Sec23a-NaV1.5 interaction.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Natural Science Foundation of China
Trend in the prevalence of atrial fibrillation 7 years after the Great East Japan Earthquake
Authors: Tamaki K , Koshiyama M , Ohsawa M
Published: November 2020

Background

The age-adjusted prevalence rate of atrial fibrillation (AF) had kept increasing until 2-year after the Great East Japan Earthquake (reported in ESC2017). Whether the elevated prevalence was tentative or not has not been sufficiently elucidated yet.

Methods

Community dwellers aged 40 to 74 years living in Iwate Prefecture who underwent annual health checkups (2010 (n=17490), 2011 (n=174236), 2012 (n=183612), 2013 (n=188429), 2014 (n=188424), 2015 (n=193610), 2016 (n=194882), 2017 (n=195428) account for approximately 30% of total population) were enrolled. Participants were divided into two age categories (40–64, 65–74 years). Direct age-adjusted prevalence rate of AF in each year was estimated using the 2010 population as the reference.

Result

Data are shown in the figure.

Conclusion

Prevalence rates of AF increased only in elderly people for up to 3 years after the disaster. This indicated that accelerated development of AF in elderly people due to stressful life after the disaster would not end within a short term and lasted at least 3 years after the disaster.

Figure 1

Funding Acknowledgement

Type of funding source: None
Pause-triggered episode classification algorithms and high-priority review queue concept for cardiac monitoring devices
Authors: Rajagopal G , Landman S.R
Published: November 2020

Background

Cardiac monitoring technologies often utilize monitoring centers or services in which technicians adjudicate arrhythmia episodes. Arrhythmias with a high prevalence of false detections (such as pauses) can slow down the review process while also delaying review of time-sensitive true episodes.

Objective

To develop algorithms that can stratify device-detected pause episodes into low- and high-priority queues to facilitate monitoring center review.

Methods

The high priority queue algorithm identifies episodes which are likely to be true pause episodes. The algorithm consists of four conditions, which identify features that were found to be predictive of true pauses, including the number of beats in the episode, the noise status of the last pre-pause beat, and the relative flatness of the ECG signal. Using a similar set of features, a set of criteria was determined that would identify pause-triggered episodes that were highly unlikely to be true pauses. 11,567 pause episodes were used for development with 19,520 separate episodes used for validation. All episodes were adjudicated by a cardiac monitoring center. The validation dataset consisted of 18,280 (93.6%) false pauses and 1240 (6.4%) true pauses.

Results

The high-priority queue algorithm identified true pause episodes with a sensitivity of 82.3% and specificity of 96.8% in the validation dataset (see table). The low-priority queue algorithm flagged 78.4% of all pause episodes as low-priority in the validation dataset, with only 4 true pause episodes (<0.1%) flagged as low priority.

Conclusion

The high-priority queue algorithm for device detected pause episodes could potentially identify ∼82% of all true pause notifiable episodes, expediting their review process. The low-priority queue successfully identifies a large percentage (∼80%) of false pause-triggered episodes, which would help to improve monitoring center efficiency as false pause-triggered episodes are a large driver of artifact / normal sinus rhythm episodes.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic
Hardware challenges with an anticoagulation strategy guided by detection of atrial fibrillation by an implantable loop recorder
Authors: Mittal S , Brenner D , Oliveros S , Bhatt A , Preminger M , Sichrovsky T , Musat D
Published: November 2020

Background

A “pill-in-the-pocket” anticoagulation strategy, guided by ECG data from an implantable loop recorder (ILR), has been advocated as a clinical strategy. However, a fundamental requirement is the ability to reliably obtain daily ECG data from patients.

Objective

To determine the reliability of daily ECG data transfer from ILRs.

Methods

We evaluated patients implanted with an ILR in whom we sought to withhold oral anticoagulation (OAC) unless atrial fibrillation (AF) was detected. The ILR transmits data nightly to a bedside monitor. Once received, the data are sent to a central server. Over the course of a month, we tracked for each patient whether ECG data were received by the server.

Results

The study included 170 AF patients with an ILR where we planned to withhold OAC unless AF was documented. Daily ECG data were automatically transmitted and retrievable in only 36 (21%) patients. Two (1%) pts had not a single day of connectivity, 6 (4%) pts were connected <7 days, and 16 (9%) pts were connected <14 days. Wireless connectivity was lost for >48 hours in 89 (52%) patients (Figure). Most patients experienced multiple reasons for data transmission failure within the month.

Conclusions

To determine whether an ILR guided OAC strategy is feasible, reliable daily transmission of ECG data is a fundamental prerequisite. Current technology facilitated daily ECG data transfer in only 1/5 of patients. In the remaining, there was either extended loss of connectivity or no connectivity at all. A “pill-in-the-pocket” anticoagulation approach is currently difficult given existing hardware limitations.

Funding Acknowledgement

Type of funding source: None
Impact of smoking cessation after the new diagnosis of atrial fibrillation on the risk of stroke: a nationwide cohort study
Authors: Lee S.R , Choi E.K , Jung J.H , Han K.D , Oh S , Lip G
Published: November 2020

Background

There are limited data about the impact of modifying behavior such as smoking cessation after atrial fibrillation (AF) diagnosis on the clinical outcome.

Purpose

To evaluate the association between smoking cessation after newly diagnosed AF and the risk of stroke.

Methods

Among subjects with new-onset AF between 2010 and 2016, those who received a national health checkup exam within 2 years before and after the AF diagnosis were included. Subjects were categorized into 4 groups according to the status of smoking before and after AF diagnosis: (i) never smoker; (ii) new smoker after AF diagnosis; (iii) quit-smoker after AF diagnosis; and (iv) persistent smoker. The primary outcome was incident stroke during follow-up.

Results

A total of 97,869 patients were included (mean age 61±12, men 62%, and mean CHA2DS2-VASc 2.3±1.5). During a median of 3 years of follow-up, stroke occurred in 3,121 patients (1.0 per 100 person-years). Never smoker, new smoker, quit-smoker, and persistent smoker was 79%, 2%, 7%, and 12% of the total study population, respectively. After multivariable adjustment, new smoker and persistent smoker were associated with an increased risk of stroke compared to never smoker (hazard ratio [HR] 1.84, 95% confidence interval [CI] 1.48–2.28 for new smoker; HR 1.66, 95% CI 1.48–1.86 for persistent smoker) (Figure). Quit-smoker who stopped smoking after AF diagnosis also showed a higher risk of stroke than never smoker (HR 1.19, 95% CI 1.03–1.38). The quit-smoker group showed a lower compared to those who continued smoking after AF diagnosis (HR 0.720, 95% CI 0.608–0.851).

Conclusion

Smoking cessation after AF diagnosis showed a lower risk of stroke compared to patients smoking persistently. Lifestyle change as smoking cessation after diagnosis of AF could modify the risk of stroke in patients with new-onset AF.

Hazard ratio of smoking status for AF

Funding Acknowledgement

Type of funding source: None
Late gadolinium enhancement location and transcatheter ablation efficacy in a large cohort of patients affected by myocarditis with arrhythmic manifestation
Authors: Persampieri S , Bergonti M , Gasperetti A , Narducci M.L , Perna F , Catto V , Carbucicchio C , Di Biase L , Basso C , Andreini D , Natale A , Dello Russo A , Pelargonio G , Tondo C , Casella M
Published: November 2020

Introduction

Myocarditis is a complex inflammatory disease, usually secondary to viral infections or immune system dysregulation, with extremely heterogeneous clinical manifestations. Among them, potentially life-threatening ventricular arrhythmias (VA) may present at any stage of the disease as an expression of myocardial electrical instability.

Purpose

Our aim was to evaluate the efficacy of radiofrequency catheter ablation (RFCA) of VA in our large cohort of myocarditis, trying to understand the predictors of RFCA success.

Methods and results

144 patients (61 men; age 43 [29–54] years) with history of myocarditis with arrhythmic presentation (118 biopsy-proven, 82%) composed our population. At presentation, 26% of patients suffered of ventricular tachycardia (VT) while in 17% cardiac arrest occurred: overall 49 patients (35%) were implanted with an ICD. The median left ventricular ejection fraction (LVEF) was 58% (48–61%). An intensive non-invasive and invasive work-up was performed: 104 patients underwent cardiac magnetic resonance (CMR) that showed late gadolinium enhancement (LGE) in 67 of them (63%). In 37 patients LGE was found in the anteroseptal portion of the left ventricle: this pattern showed association with major arrhythmic relapse (VT and ventricular fibrillation) during follow up (Fig. 1; OR 4.0, CI 95% 1.14–14.1, p=0.03). 95 patients underwent endocardial RFCA, using contact electroanatomic mapping. Interestingly, in patients with anteroseptal LGE RCFA didn't affect significantly the arrhythmic relapse (OR 5, CI 95% 0.9–33, p=0.06). Otherwise RFCA prevent arrhythmic relapse in patients that showed LGE in ventricular portion other than the anteroseptal one (OR 0.027, IC 95% 0.002–0.40, p<0.01). During a median follow-up of 735 days (418–2168) 6 deaths occurred: logistic regression on all-cause death showed LVEF and VT at presentation as the only independent predictors for mortality (p=0.01).

Conclusions

In myocarditis patients with VA, LGE pattern predicts arrhythmic relapse during follow-up. RFCA success rate is strictly linked to scar location, being significantly higher in patients with non-anteroseptal LGE.

Figure 1

Funding Acknowledgement

Type of funding source: None
Outcome after practical isthmus ablation of scar-related atrial tachycardia guided by high-density mapping
Authors: Jungen C , Akbulak R , Kahle A , Eickholt C , Schaeffer B , Dinshaw L , Schleberger R , Nies M , Gunawardene M , Muenkler P , Klatt N , Hartmann J , Jularic M , Willems S , Meyer C
Published: November 2020

Background

High-density mapping (HDM) has been found to precisely identify the practical isthmus of scar-related atrial tachycardia (AT) circuits. Since practical isthmuses have been found to be shorter than the usual anatomical isthmuses targeted ablation has been proposed. However, outcome data are sparse. Here we describe HDM-guided catheter ablation by targeting the practical isthmus in patients with scar-related ATs.

Methods and results

In 250 consecutive patients with scar-related ATs HDM-guided catheter ablation with the support of a 64-electrode mini-basket catheter has been performed. Most patients underwent a prior catheter ablation (98%) while 13% had a prior cardiac valve surgery and 6% an underlying congenital heart disease. A total of 355 ATs occurred in the index procedure, of which 64% had a macro-, 26% a micro-reentry and 10% a focal mechanism. The ATs had a mean cycle length of 304±4.3 ms and in 237 patients (95%) an acute termination into sinus rhythm was achieved. They were mainly located in the left atrium (72%) but also in the right atrium (25%), bi-atrially (5%) or in the CS (3%) (see figure). Targeting the practical isthmus revealed arrhythmia freedom in 53% of patients after a single procedure during a mid-term follow-up (median 489 days, range 95–1407 days). Freedom from any arrhythmia could be achieved in 74% of patients after multiple procedures and in 93% of patients after multiple procedures and optimal clinical therapy, including pharmaceutical or electrical cardioversion.

Conclusions

HDM-guided catheter ablation of the practical isthmus in patients with scar-related ATs leads to a high acute success rate. Nevertheless, multiple procedures are necessary in a relevant number of patients resulting in a low recurrence rate.

Funding Acknowledgement

Type of funding source: None
Predictors of silent cerebral infarction associated with catheter ablation for atrial fibrillation
Authors: Furukawa Y , Watanabe T , Yamada T , Morita T , Tamaki S , Kawasaki M , Kikuchi A , Kawai T , Seo M , Nakamura J , Kayama K , Kawahira M , Fukunami M
Published: November 2020

Introduction

Cather ablation (CA) has been identified as an effective and safe treatment option for patients with atrial fibrillation (AF). One of the serious complications associated AF is cerebral infarction (CI). Recent studies reported that CA was associated with lower incidence of ischemic stroke in patients with AF. However, CA for AF itself has a potential risk of CI. Several previous studies showed that the incidence of silent CI (SCI) assessed by magnetic resonance imaging (MRI) of the brain occurred 5 to 18% during CA for AF. Recently, CA for AF made a remarkable progress in technology. However, there are few information available that the impact of 3-dimensional electroanatomical mapping system on the incidence of SCI. This study aimed to clarify the prevalence and predictors of SCI during CA for AF.

Methods

We enrolled 893 consecutive patients (male 534, age 71±10 years), who underwent CA for AF and MRI of brain 1 day after the procedure. We collected patients data such as physical examinations, blood sampling, echo cardiography, and CA data. A brain MRI was performed the next day following the procedure to identify any CIs. One-hundred and forty-six of patients used the Rhythmia® mapping system catheter, and the other mapping system such as CARTO or EnSite system used in the remaining 747 patients.

Results

The MRI depicted acute micro-CIs in 144 (16%) patients, but neither symptoms nor abnormal neurological findings were present in these patients. Patients with SCI had significantly higher prevalence of persistent AF (60 vs 43%, p=0.0002), CHADS2 Score (2 (1–3) vs 1 (1–2), p=0.0001), higher prevalence of previous stroke (19 vs 12%, p=0.02), larger left atrial (LA) diameter (43.2±6.4 vs 41.7±6.5mm, p=0.01), lower left ventricular ejection fraction (LVEF) (59.0±13.2 vs 64.2±11.3%, p≤0.0001), higher B-type natriuretic peptide level (221±236 vs 163±225 pg/dl, p≤0.0001), more Rhythmia® mapping system use (30 vs 8%, p<0.0001), and longer procedure time (129±46 vs 108±39 min, p≤0.0001) than those without SCI, while there were no significant differences in age, LA appendage flow velocity, kind of anti-coagulant agent between the two groups. Multivariate regression analysis identified Rhythmia® use [odds ratio (OR) 4.26, (95% CI 2.32–7.84), p=0.0001], LVEF (OR 1.02, p=0.0059), CHADS2 score (OR 1.27, p=0.009), and procedure time (OR 1.005, p=0.04) as independent risk factors of acute SCI during CA for AF.

Conclusion

Acute SCI occurred about 16% after CA for AF. Rhythmia® mapping system use exhibited a higher incidence of acute SCI after catheter ablation for AF than the other mapping system use. Rhythmia® mapping system use, LVEF, CHADS2 score, and procedure time are associated with SCI relating CA for AF.

Funding Acknowledgement

Type of funding source: None