bluuebunny/crossref_metadata_2025 huggingface dataset:
Tricuspid regurgitation severity and transcatheter tricuspid annuloplasty
Authors: Ortega Perez R , Martinez Moya R , Pardo Sanz A , Salido Tahoces L , Sanchez Recalde A , Rivas Garcia S , Abellas Sequeiros M , Sanchez Vega D , Arteagoitia Bulumburu A , Fernandez Golfin C , Garcia Martin A , Hinojar Baydes R , Zamorano Gomez J L
Published: October 2022

Introduction

Transcatheter tricuspid annuloplasty is a promising therapeutic alternative for the treatment of tricuspid regurgitation (TR) in patients with a high surgical risk. To date, the published experience with percutaneous tricuspid devices is quite limited. The objective of this study is to present the impact of the transcatheter tricuspid annuloplasty with band implantation on the degree of TR and on several echocardiographic parameters in a series of 27 patients.

Methods

A single-center cohort of 27 patients was followed up prospectively after the transcatheter tricuspid annuloplasty with band implantation (mean follow-up: 10,39 months) (Figure 1). The degree of tricuspid regurgitation (mild, moderate, severe, massive, torrential) was measured before and after the procedure, as well as at 6 months and one year of follow-up. Other parameters have also been considered, such as the septal-lateral end-diastolic diameter of the tricuspid annulus, the vena contracta (VC), regurgitant orifice area (ROA) 2D, tricuspid annular plane systolic excursion (TAPSE), right ventricular ejection fraction (RVEF) and fractional area change (FAC).

Results

Initially, there were 22.3% of patients with torrential TR, 29.6% massive and 48% severe. After the procedure, these percentages were reduced to 3.8%, 7.7% and 23.1% respectively, leading to an amount of 65% of patients with mild or moderate TR.

With respect to the the diameter of the lateral septum ring, the mean was initially 44.74 mm. After the procedure, it decreased to 34.5 mm (22% of reduction) and, as can be seen during follow-up, it remains stable over time.

The ROA and VC were also significantly reduced while TAPSE, CAF and RVEF do not show significant changes (Figure 2).

Percutaneous tricuspid annuloplasty demonstrated a notable impact on the degree of tricuspid regurgitation reduction in the patients in our study. The differences are already noticeable from the moment of the procedure and are maintained throughout the follow-up, where the stability of the diameter of the septolateral ring, the ERO and the vena contracta is observed.

Funding Acknowledgement

Type of funding sources: None.
Three-year outcomes following transcatheter tricuspid valve edge-to-edge repair
Authors: Hausleiter J , Stolz L , Weckbach L , Wild M , Doldi P , Braun D , Stocker T , Higuchi S , Naebauer M , Massberg S
Published: October 2022

Background

Tricuspid regurgitation (TR) has long been neglected due to limited therapeutic options. Within the past five years, transcatheter tricuspid valve edge-to-edge repair (T-TEER) has become a valuable tool in the treatment of TR besides diuretic medical therapy and valve surgery. Owing its novelty, data on long-term survival after T-TEER for relevant TR are sparse. Beyond that, there is uncertainty on the impact of TR reduction on outcomes after successful T-TEER.

Purpose

This study sought to investigate long-term survival outcome after T-TEER for relevant symptomatic TR. We evaluated the impact of TR reduction on outcome in patients with successful T-TEER.

Methods

Consecutive patients who underwent successful isolated T-TEER for relevant TR from 2016 until 2022 at a high-volume university center were included in the study. Procedural success was defined as at least one degree TR reduction. Long-term survival endpoint was three-year all-cause mortality. Survival follow-up was completed via phone calls with the patients themselves, the next of kin, local practitioners and using the German national population registry. Post-procedural TR was assessed by interventionalist and echocardiographer at the end of the T-TEER procedure.

Results

A total of 244 patients who underwent successful T-TEER in the study period were included in the present analysis (mean age 77.7±8.7 years; 50.8% female). Patients were highly symptomatic as represented by New York Heart Association functional class ≥ III in 95.9% of cases. TR was 4+ in 128 patients (52.2%), 3+ in 106 patients (43.4%) and 2+ in 10 patients (6.1%). The etiology of TR was predominately functional (88.5%), while 5.4% presented with degenerative TR and 6.1% with TR of mixed etiology. Median time to last contact or death was 365 days (interquartile range 166–809 days). Three-year follow-up was available in 98% of eligible patients. T-TEER was performed using a mean number of 2.0±0.6 devices (Mitra-/TriClip 53%; PASCAL 47%). Post-procedural TR was 1+ in 126 patients (51.6%), 2+ in 101 patients (41.4%) and 3+ in 17 patients (7.0%). Survival rates at one, two and three years were 76%, 68% and 56%. Among patients with procedural success (at least 1° TR reduction), a higher degree in post-procedural TR was associated with a trend towards reduced postinterventional survival (Figure 1). The absolute degree of TR reduction did not impact survival rates in patients with procedural success (Figure 2).

Conclusion

T-TEER effectively reduces TR severity and shows high rates of procedural success. While the extent of TR reduction did not yield prognostic value in terms of long-term survival, the degree of post-procedural TR showed a trend regarding survival outcome. These results indicate that procedural techniques and strategies should be refined to achieve TR1+ at the end of the procedure.

Funding Acknowledgement

Type of funding sources: None.
Feasibility and mid-term results of transcatheter pulmonary valve replacement using Edwards-Sapien valves
Authors: Calvo-Barcelo M , Belahnech-Pujol Y , Betrian-Blasco P , Dos-Subira L , Pijuan-Domenech A , Giralt-Garcia G , Miranda-Barrio B , Gordon-Ramirez B , Gonzalez-Fernandez V , Rodenas-Alesina E , Roses-Noguer F , Garcia-Del Blanco B , Ferreira-Gonzalez I , Marti-Aguasca G
Published: October 2022

Background

Transcatheter pulmonary valve replacement (TPVR) is an alternative to surgery in certain patients with pulmonary valve dysfunction. When feasible, a percutaneous approach is increasingly common in congenital heart disease (CHD). There is paucity of data to support the use of the Edwards Sapien (ES) 3 or XT valves for TPVR.

Purpose

To describe the feasibility and outcomes of TPVR with the ES valve.

Methods

Consecutive patients who underwent TPVR between 2014 and 2021 in a tertiary referral center for CHD were retrospectively included. Outcomes assessed included complications during admission, echocardiographic parameters of ventricular remodeling after TPVR as well as mortality and valve-related complications during follow-up.

Results

During the study period, 70 patients underwent TPVR with the ES valve. Of them, 70% were men with a median age of 28.3 years. The underlying cardiac conditions were tetralogy of Fallot (N=35, 45.7%), pulmonary atresia or stenosis with ventricular septal defect (N=10, 14.3%), pulmonary stenosis (N=10, 14.3%) and Ross procedure (N=5, 7.1%). The main reason for TPVR was pulmonary regurgitation (N=23, 33.3%), pulmonary stenosis (N=10, 24.6%) or a combination of both (N=29, 42.0%). Transfemoral access (N=68, 97.1%) was more common than transjugular (N=2, 2.9%). TPVR was performed in a native or patch-extended right ventricular outflow tract (N=26, 37.1%), as a valve-in-valve procedure in a previous bioprosthetic valve (N=23, 32.9%) or within a conduit (N=21, 30.0%: 11 homografts, 9 heterografts and 1 Dacron conduit), and stenting before deploying the valve was performed in 48 (68.5%) cases.

TPVR was successful in 69 (98.6%) patients with iatrogenic tricuspid damage in 2 cases, with a median hospital length of stay of 1 day, no deaths and 4 serious complications during admission (2 pulmonary edema, 1 femoral vein rupture and 1 pulmonary bleeding). Urgent surgery was not required in any case. No cardiovascular deaths, pulmonary thromboembolisms or strokes were observed during a median follow-up 25.9 months. During this period, there was 1 non-cardiac death, 1 heart transplant, 3 endocarditis (without valve dysfunction), 1 prosthetic valve degeneration and 1 subclinical prosthetic thrombosis. After 1 year, the mean echocardiographic transprosthetic peak gradient was 23 mmHg and there was a reduction in the number of patients presenting moderate-to-severe tricuspid regurgitation (22.9 to 14.8%).

Conclusions

TPVR with ES valves is feasible and safe in a variety of substrates and ACHD population, with a short length of stay and a low rate of adverse events both in the medium-term follow-up.

Funding Acknowledgement

Type of funding sources: None.
Supraventricular arrhythmia following patent foramen ovale percutaneous closure
Authors: Guedeney P , Laredo M , Zeitouni M , Hauguel-Moreau M , Wallet T , Alamowitch S , Sabben C , Deltour S , Benyounes N , Obadia M , Collet J P , Rouanet S , Hammoudi N , Silvain J , Montalescot G
Published: October 2022

Background

Randomized studies have reported low rates of atrial fibrillation (AF) after patent foramen ovale (PFO) closure (<6%) but have relied on patients-reported symptomatic episodes, thus true incidence and timing of AF after PFO closure remain unknown.

Objective

To prospectively determine the incidence, timing, and determinants of supraventricular arrhythmia following PFO closure based on loop recorder monitoring.

Methods

Cardiac monitoring was proposed to all patients after PFO closure from June 2018 to October 2021 in our center by mean of implantable loop recorder (ILR) monitoring in patients considered at higher risk of AF (age ≥55 years, associated cardiovascular risk factors, prior palpitations, or documented supraventricular ectopic activity) or 4-week external loop recorder (ELR) monitoring in other patients. The primary endpoint was the incidence of AF, flutter, or atrial tachycardia lasting >30 seconds within 28 days of the procedure. Determinants of the primary endpoint were assessed with stepwise logistic regression model.

Results

A total of 225 patients were included. The primary endpoint occurred in 47/225 (20.9%) patients, including n=13 (9.9%) and n=24 (28.9%) among ELR- and ILR-monitored patients, respectively. Among ILR-monitored patients, median follow-up was 428 (211–752) days, and four more cases of supraventricular arrhythmia were diagnosed beyond 28 days (Figure 1). Overall, median delay from procedure to arrhythmia was 14.0 (6.5–19.0) days and half of these patients reported symptomatic episodes. Determinants of the primary endpoint were older age (adjusted odds ratio [aOR]: 1.67, 95% confidence interval [CI]: 1.18–2.36, per 10-year increase), device left disc diameter ≥25mm (aOR: 2.67, 95% CI: 1.19–5.98) and male sex (aOR: 4.78, 95% CI: 1.96–11.66) (Figure 2).

Conclusion

Using prolonged loop recorder monitoring, supraventricular arrhythmia was diagnosed in one patient out of five with a median delay of 14 days suggesting that this post-procedural event has been so far, underestimated.

Funding Acknowledgement

Type of funding sources: None.
Atrial function analysis after percutaneous umbrella device and suture-mediated patent fossa ovalis closure: a prospective study
Authors: Tarsia C , Gaspardone C , De Santis A , D'Ascoli E , Piccioni F , Sgueglia G A , Iamele M , Leonetti S , Posteraro G A , Gaspardone A
Published: October 2022

Background

Suture-mediated patent fossa ovalis (PFO) closure is a new technique, achieving closure of the PFO by means of a simple suture. The difference between traditional occluders and a simple suture might have different impact on atrial structure, geometry and function.

Purpose

Aim of this study was to evaluate bi-atrial function after closure of PFO by direct suture and traditional occluders.

Methods

We studied 40 age and sex matched patients, 20 undergoing PFO closure by device and 20 by suturing. Only patients with no residual right-to-left shunt, assessed by contrast-enhanced echocardiography, were included. Left and right atrial function was evaluated by using speckle-tracking analysis assessing the following parameters: strain values of the reservoir (r-ED), conduit (cd-ED) and contraction phase (ct-ED). All patients underwent transthoracic echocardiographic examination the day before and 1 year after the procedure. All exams and measurements were conducted by two echocardiographers and validated with common consent by two other expert operators.

Results

Compared with values baseline PFO closure, at one year follow-up, patients underwent occluder implantation had significantly worst indices of left (LA) and right (RA) atrial reservoir function (LA r-ED p<0.001; RA r-ED p<0.001), conduit function (LA cd-ED p<0.001; RA cd-ED p<0.001) and contraction function (LA ct-ED p<0.05; RA ct-ED p<0.05).

In patients underwent suture-mediated PFO closure, no significant differences were observed in the same indices of reservoir (LA r-ED p=0.848; RA r-ED p=0.183), conduit (LA cd-ED p=0.156; RA cd-ED p=0.419) and contraction function (LA ct-ED p=0.193; RA ct-ED p=0.375).

Conclusions

Suture-mediated PFO closure does not alter atrial function. Conversely, PFO closure by metallic occluders is associated with worse atrial function. This detrimental effect on atrial function could favor the development of atrial arrhythmias.

Funding Acknowledgement

Type of funding sources: None.
Reduction of major adverse and major cardiovascular events in patients with atrial fibrillation and stent implantation treated with left atrial occlusion device vs oral anticoagulants strategy
Authors: Lopez-Minguez J R , Suarez-Corchuelo E , Lopez-Tejero S , Nombela-Franco L , Freixa-Rofastes X , Bastos-Fernandez G , Millan-Alvarez X , Moreno-Gomez R , Fernandez-Diaz J A , Amat-Santos I , Benito-Gonzalez T , Alfonso-Manterola F , Navarro-Romero R , Cruz-Gonzalez I , Nogales-Asensio J M
Published: October 2022

Background

Treatment of patients with Nonvalvular Atrial Fibrillation (NVAF) who need coronary stent implantation is a challenge. Although trials have shown “direct anticoagulants (DOAC) indefinitely plus clopidogrel for one year” strategy reduces bleeding events in comparison to triple therapy, especially with warfarin, many questions remain about the safety and efficacy of this strategy.

Purpose

This study compared the events in patients who received left atrial appendage occlusion (LAAO) and antiplatelet therapy (APT) with those who were treated with oral anticoagulants (OAC) (including DOAC) and APT.

Methods

207 consecutive patients with NVAF who underwent coronary stent implantation (most of them for NSTEACS), were analysed. 146 were treated with OAC (75 with acenocoumarol, 71 with DOAC) and 61 with LAAO during a mean follow-up of 35 months. Furthermore, they received APT according to the clinical cardiologist criteria (Figure 1).

Results

There were no significant differences in variables like age (average 75.7 years-old) hypertension, diabetes, gender, permanent or paroximal AF or a history of stroke or thromboembolisms between groups. But there were more unfavourable characteristics in LAAO group with significant differences in the percentage of history of coronary artery disease (43.2% vs 75,4% p= <0.001), CHA2DS2-VASc (4.07±1.70 vs 4.56±1.53 p=0.033), history of relevant bleedings (BARC ≥2) (8.9% vs 49.2% p<0.001), history of high bleeding risks defined as previous bleedings or HASBLED ≥3 (19.9% vs 62.3% p<0.001) and HAS-BLED (1.63±1.09 vs 2.49±1.18, p<0.001), between OAC and LAAO groups respectively.

Observed total death, stroke/TIA and relevant bleedings incidence rates (expressed per 100 patient-years) were higher in OAC- than in LAAO-group: 10.86 vs. 6.96% (HR: 1.56; p=0.183), 4.59 vs. 1.27% (HR: 3.61; p=0.084), 12.43 vs. 4.57% (HR: 2.72; p=0.014), respectively. The composite events of MAE and MCVE (defined as in Figure 1 and 2) were also significantly higher: 23.40 vs. 9.8% (HR: 2.40; p=0.002) (Figure 2, left) and 7.41 vs. 1.9% (HR: 3.90; p=0.025) (Figure 2, right), respectively.

Conclusions

In patients with NVAF receiving coronary stents, a LAAO strategy with APT, shows better results in MAE and MCVE than treatment with OAC (DOAC included) plus APT strategy in a long term-follow-up, despite more unfavourable variables in LAAO group.

Funding Acknowledgement

Type of funding sources: None.
Trends in percutaneous left atrial appendage occlusion and 1-year mortality: a nationwide cohort study
Authors: Juhl Madsen O , Lamberts M K , Fosboel E L , Gislason G , Olesen J B , Strange J E
Published: October 2022

Background

Percutaneous left atrial appendage occlusion (LAAO) is increasingly used for stroke prevention in high-risk patients with atrial fibrillation and contraindication for oral anticoagulation. However, studies evaluating comorbidities and mortality remain scarce.

Objectives

The aim of this study was to evaluate changes in patient characteristic over time and 1-year risk of death.

Methods

Using Danish nationwide registers, we included all patients undergoing first-time LAAO between 2013 and 2021. To evaluate changes in patient characteristics, the study population was stratified according to calendar year of LAAO procedure: 2013–2015, 2016–2018, and 2019–2021. Baseline patient characteristics were defined from 10 years prior to date of LAAO procedure. Antithrombotic therapy was defined as claimed prescriptions within 180 days prior to LAAO procedure. Patients were then followed until either emigration, death, one year of full follow-up, or end of study period. Baseline frailty risk was estimated with The Hospital Frailty Risk Score, a validated frailty risk assessment tool based on ICD-10 codes. The 1-year unadjusted risk of death was estimated with the Aalen-Johansen method.

Results

In total, 1,306 patients underwent LAAO. The number of LAAO increased from 201 procedures in 2013–2015 to 586 in 2019–2021. During follow-up, the age of the patients remained stable (2013–2015: median age: 70 years; 2016–2018: median age 69 years; 2019–2021: median age 69 years). Fewer patients had a history of ischemic stroke (2013–2015: 44.3% vs 2019–2021: 27.6%), hemorrhagic stroke (2013–2015: 32.8% vs 2019–2021: 21.0%), and previous bleeding (2013–2015: 71.1% vs 2019–2021: 59.2%). Median CHA2DS2-VASs score decreased over time (2013–2015: 4 vs 2019–2021: 3) and same trend was found in median HAS-BLED score (2013–2015: 3 vs 2019–2021: 2).

In addition, fewer patients were categorized as high frailty risk (2013–2015: 16.9% vs 2019–2021: 8.9%). However, there was an increase in patients with a history of cancer (2013–2015: 11.9% vs 2019–2021: 18.9%). The use of antiplatelet therapy prior to LAAO decreased while the use of oral anticoagulation increased (2013–2015: 50.2% vs 2019–2021: 68.9%) due to a marked increase in non-vitamin K antagonist oral anticoagulants and a decrease in vitamin K antagonists (Figure 1).

In total, 88 (7.22%) patients died within one year of LAAO procedure. The 1-year all-cause mortality risk in each period were similar (2013–2015: 7.0%; 2016–2018: 7.1%; 2019–2021: 6.9%). [Figure 2]

Conclusion

In the years 2013–2021, the annual number of LAAO procedures increased. The age of patients remained stable. Comorbidity burden decreased and fewer patients were at high frailty risk, but the 1-year mortality risks were similar. Our real-life data suggest that profiles of patients undergoing LAAO has changed considerably over time.

Funding Acknowledgement

Type of funding sources: None.
Impact of bifurcation lesion on 10-year mortality in the SYNTAX trial
Authors: Ninomiya K , Serruys P W , Garg S , Gao C , Masuda S , Lunardi M , Burzotta F , Morice M C , Colombo A , Mack M J , Holmes D R , Davierwala P M , Thuijs D , Onuma Y
Published: October 2022

Background

Percutaneous coronary intervention (PCI) of bifurcation lesions is associated with higher rates of adverse events, and currently it is unclear whether PCI or coronary artery bypass grafting (CABG) is the safer treatment for these patients at very long-term follow up.

Objectives

To investigate the impact of bifurcation lesions on observed all-cause 10-year mortality in the SYNTAX trial.

Methods

In the SYNTAX Extended Survival study, 10-year observed mortality was compared among four groups: (a) presence of ≥1 bifurcation lesion and treatment with PCI (n=649), (b) no bifurcation lesion and treatment with PCI (n=248), (c) presence of ≥1 bifurcation lesion and treatment with CABG (n=651), and (d) no bifurcation lesion and treatment with CABG (n=239).

Results

Compared to patients without bifurcations, those with bifurcation lesion(s) treated with PCI had a significantly higher risk of all-cause death (19.8% vs 30.1%; HR: 1.55, 95% CI: 1.12 to 2.14; p=0.007), whereas following CABG, mortality was similar in patients with or without bifurcation lesion(s) (23.3% vs 23.0%; HR: 0.81, 95% CI: 0.59 to 1.12; p=0.207). (Figure1) There was a significant interaction between bifurcation lesion(s) and treatment arm (p for interaction=0.006).

In PCI patients, at 5-years there was no significant difference in mortality between 1- vs 2-stent techniques, whereas at 10-years, a 2-stent technique was associated with higher mortality (33.3% vs 25.9%; HR: 1.51, 95% CI: 1.06 to 2.14; p=0.021, Figure2).

Conclusions

Bifurcation lesion(s) require special attention from the heart team discussion, considering the higher 10-year all-cause mortality associated with PCI. Careful evaluation of bifurcation lesion complexity may be helpful in decision-making.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The SYNTAX Extended Survival study was supported by the German Foundation of Heart Research (Frankfurt am Main, Germany). The SYNTAX trial, during 0-5 years follow-up, was funded by Boston Scientific Corporation (Marlborough, MA, USA). Both sponsors had no role in the study design, data collection, data analyses, and interpretation of the study data, nor were involved in the decision to publish the final manuscript. The principal investigators and authors had complete scientific freedom.
Appropriateness of the modality of revascularization according to the SYNTAX 2020 in the FASTTRACK CABG study
Authors: Ninomiya K , Serruys P W , Masuda S , Kageyama S , Kotoku N , Onuma Y
Published: October 2022

Objectives

To compare the modality of revascularization selected by the local heart team to the one recommended by the core laboratory according to the SYNTAX score 2020 amongst patients with three-vessel disease (3VD) with or without left main disease (LMCAD), who were allocated to CABG planned and solely guided by coronary computerized tomographic angiography in the FASTTRACK CABG trial.

Background

Personalized long term vital prognosis plays a key role in deciding between PCI and coronary artery bypass grafting (CABG) in patients with complex coronary artery disease.

Methods

In an interim analysis requested by the Data Safety Monitoring Board the treatment recommendations according to the SYNTAX 2020 were prospectively assessed in 57 consecutive patients (half of the planned population in this First in Man) by a core laboratory and compared to the decision of the “on site” heart team.

Results

According to SS-2020, the predicted absolute risk difference (ARD) in mortality between the virtual PCI treatment population and the CABG treatment group, which can be considered a virtual surrogate for the average treatment effect, increased with the duration of follow up, from 4.8±3.5% at 5 years to 8.8±5.1% at 10 years (Table 1). The ARD of less than 0% in mortality at 5-year in favour of PCI was only documented in two patients while the 55 remaining patients had a predicted survival benefit over PCI if receiving CABG. However, based on a novel threshold of equipoise (ARD <4.5%) recently validated in a contemporary registry of 3VD and LMCAD, CABG was mandatory in 26 (45.6%) patients, whereas PCI or CABG could have been equally selected in 31 (54.4%) patients (Figure 1).

Conclusions

According to the SYNTAX Score 2020 there was a strict observance of the CABG treatment recommendation in the first 57 consecutive patients with 3VD or LMCAD, screened on site in the FAST TRACK CABG trial. The more lenient selection criteria derived from the contemporary regitry will have to be tested propectively. Application of artificial intelligence with expanded collection of baseline characteristics, scientific endorsement and regulatory enforcement as well as further prospective evaluation are the challenges of future decision-making scores, that should be ultimately shared with the patients.

Funding Acknowledgement

Type of funding sources: None.
Redo cardiac surgery in the era of percutaneous solutions: pattern of presentation and outcomes in a single tertiary care center
Authors: Montella A P , Golini Petrarcone C , Palmieri L , Galbiati D , Amarelli C , De Feo M , De Santo L S
Published: October 2022

Introduction

The advent of new medical and interventional approaches has recently impacted on the referral for redo surgical operations. Little is known on current practice pattern and outcomes.

Purpose

We reviewed our institutional experience of 10 years (January 2011–December 2020) in a single university affiliated center to document frequency, outcome, and complications of the various types of redo procedures.

Methods

Retrospective analysis of a prospectively collected computed institutional database developed according to STS/EACTS recommendations.

Results

During study period 616 patients were referred for redo cardiac procedures, of which 129 patients underwent either medical or interventional procedures (75 thrombolysis, 22 valve-in-valve, 19 native mitral and or tricuspid percutaneous treatment, 13 paravalvular leakage devices), 459 patients were operated on, and 28 patients were denied any invasive treatment because of futility. Study group included these 459 surgical patients with a mean age of 62±12.7 years (octogenarians 5.6%, female sex 52.8%, diabetes 19.5%, chronic kidney disease 30%, urgent/emergent status 34.8%, third-time sternotomy 9.8%). The EuroSCORE II averaged 25.7±15.4%. Study group patients represented a nearly constant subgroup over the 6890 patients operated over this decade. Most frequent surgical procedures were valve operations, which were accomplished in 48.6% (223 pts), whereas isolated coronary bypass surgery was performed in 1.9% (9 pts) only. Valve thrombosis, mechanical prosthesis malfunction, paravalvular leakage, bioprosthetic failure and endocarditis (87% on prosthetic valve) were the most frequent indications. Combined procedures were performed in 15.2% (70 pts). Aortic root, ascending and arch replacement procedures were performed in 10.9% (50 pts, aortic dissection 7.8%). Cardiac transplantation in the setting of previous cardiac surgery was performed in 13.1% (60 pts including: previous conventional procedures [29 pts], mechanical circulatory devices [28 pts, 25 left ventricular assist device and 3 total artificial heart] and re-transplantation [3 pts]). Other procedures were performed in 10.2% (47 pts). Overall hospital mortality was 23,9%, rates of major complications were: surgical revision for bleeding 2,9%, Acute Kidney Injury (I/F) 17,4%, prolonged mechanical ventilation 12,9%, stroke 2,7%. Age, surgical priority, endocarditis, and heart failure represented the major independent predictors of morbidity and mortality.

Conclusions

Although percutaneous solutions are increasing their consensus, the rate of redo cardiac surgical procedures remained stable during the last 10 years. Outcomes are satisfactory despite increasingly complex patients features. Careful Heart Team evaluation is mandatory.

Funding Acknowledgement

Type of funding sources: None.
Are severe mitral annular calcification still a contraindication to open surgery?
Authors: Cerillo A , Petrini F , Bugetti M , Iannone L , De Cillis P , Paduvakis J , Marchionni N , Stefano P
Published: October 2022

Background

Mitral annular calcifications are considered a contraindication to open mitral valve repair/replacement, being associated with a significant risk of rupture of the atrioventricular groove or prosthesis detachment/paraprosthetic leak. Recently a scoring system has been proposed, to quantify the severity of MAC and predict the success of transcatheter valve in MAC implantation.

Objective

We present a series of consecutive patients with MAC undergoing sugical mitral valve replacement in recent years.

Patients and methods

82 consecutive patients with MAC underwent open surgical correction from January 2019 at our centre. This was a complex cohort of patients with a high surgical risk profile (STS 5.3±3.2). The degree of MAC was moderate in 60 and severe in 22. Annular decalcification was required in 16 patients, and patch reconstruction of the AV groove in 4. The main predictor of the need for annular decalcification and reconstruction was the depth of calcium infiltration in the ventricular wall at CT. At intraoperative TEE only one patient had a significant paraprosthetic leak, that was repaired during a second short period of aortic cross-clamping. 30 days mortality was 1.2% (one patient), and 87% of patients were alive and well at one year.

Comment

The presence of significant mitral annular calcificaion per se should not be considered a contraindication to open mitral valve surgery. The depth of the calcifications in the ventricular wall, as measured at CT 3D multiplanar reconstructions is the best predictor of the need to decalcify/reconstruct the AV groove. Detailed imaging analysis is crucial for the success of the procedure.

Funding Acknowledgement

Type of funding sources: None.
The Pitfall of VA ECMO management in the Impella era
Authors: Shibao K , Kitamura C , Matushima Y , Yanai T , Shibata T , Honma T , Otsuka M , Fukumoto Y
Published: October 2022

Introduction

VA ECMO is effective in cardiogenic shock, but complications of cardiogenic pulmonary edema due to increased afterload are problematic. The advent of percutaneous left ventricular assist devices (Impella) has enabled effective reduction of left ventricular intraventricular pressure and has avoided these complications, but differential hypoxia can still occur during VA ECMO + Impella (Ecpella) management, requiring conversion to V-AV ECMO. Cases may be experienced.

Purpose

Elucidate the frequency of differential hypoxia and its pathogenesis, which requires the transition from VA ECMO to V-AV ECMO.

Methods

We retrospectively reviewed 52 consecutive patients who underwent E-CPR from January 2017 through November 2021 in our institute. 8 patients who received ECMO alone were excluded, and 44 patients were recruited. 22 patients underwent VA ECMO with IABP (VA ECMO + IABP group) and 22 patients underwent VA ECMO with Impella (VA ECMO + Impella group). The 30-day survival rate and the rate of transition VA ECMO to VA-V ECMO, The date just before VA ECMO to V-AV ECMO were assessed.

Results

The 30-day all-cause mortality was no significant difference between the two groups. 2 patients (9%) in the VA ECMO + IABP group and 8 patients (36%) in the VA ECMO + Impella group were transferred to V-AV ECMO (P=0.025). At the time of addition of V-AV ECMO, SaO2 (right radial artery) was 87±7.1% and 91.3±1.9% (p=0.112) in the VA ECMO + IABP and VA ECMO + Impella groups, respectively, and the P/F ratio was 86±37.1 and 95±24.6 (p=0.685). Mean pulmonary artery wedge pressure was 23±1.4 mmHg in the VA ECMO + IABP group and 16.3±3 mmHg in the VA ECMO + Impella group (p=0.0193), significantly lower in the Impella group.

Conclusion

The Impella group was more likely to have hypoxia due to factors other than cardiogenic pulmonary edema. In cases of cardiopulmonary arrest requiring V-AV ECMO management, differential hypoxia due to causes other than cardiogenic pulmonary edema may become apparent earlier in the Impella group, suggesting that careful management, including the addition of V-AV ECMO, is required.

Funding Acknowledgement

Type of funding sources: None.
Combining serum miR-144-3p and miR-652-3p as potential biomarkers for the early diagnosis and stratification of acute cellular rejection in heart transplantation patients
Authors: Perez-Carrillo L , Gimenez-Escamilla I , Snachez-Lazaro I , Trivino J C , Martinez-Dolz L , Portoles M , Tarazon E , Rosello-Lleti E
Published: October 2022

Background

There is a dire need for specific, noninvasive biomarkers that can accurately and early detect cardiac acute cellular rejection (ACR). Previously, we described miR-144-3p as an excellent candidate to detect Grade ≥2R ACR.

Purpose

Now, we investigated the combination of miR-144-3p with other differentially expressed serum miRNA that we previously described to improve diagnostic accuracy, mainly in mild rejection to avoid reaching severe stages.

Methods

We selected miR-652-3p, miR-6747-3p and miR-221-3p from a preliminary RNA-seq study to be validated by RT-qPCR on 212 consecutive serum samples from transplantation recipients undergoing routine endomyocardial biopsies to subsequently combine them with miR-144-3p results and investigate their diagnostic capability.

Results

We confirmed the miR-652-3p overexpression (p<0.0001) and its capability to discriminate between patients with and without ACR of any grade (p<0.0001), but not miR-6747-3p or miR-221-3p. The combined serum levels of miR-144-3p and miR-652-3p were significantly higher in patients with rejection regardless of posttransplantation time (p<0.0001). This combination resulted in a diagnostic efficacy for 1R (AUC=0.794) and ≥2R (AUC=0.892) (p<0.0001) that was superior to each biomarker alone. Furthermore, it was a strong independent predictor of ACR for 1R (odds ratio of 10.950, p<0.0001) and ≥2R (odds ratio of 14.289, p<0.01).

Conclusions

We demonstrated that an appropriate combination of blood-based biomarkers can exhibit greater efficiency for cardiac rejection diagnosis. The combined detection of abnormal expression of miR-144-3p and miR-652-3p in the serum of ACR patients can improve the diagnostic sensitivity of rejection at the early stage and contribute to increasing the diagnostic accuracy, mainly in the lower rejection grades.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Carlos III European Regional Development Fund (ERDF)
Non-invasive diagnosis of cardiac rejection using small non-coding RNAs
Authors: Gimenez-Escamilla I , Perez-Carrillo L , Sanchez-Lazaro I , Martinez-Dolz L , Portoles M , Tarazon E , Rosello-Lleti E
Published: October 2022

Background

Endomyocardial biopsy is the standard technique for rejection surveillance in heart transplantation recipients and is an invasive method with important limitations and clearly associated with both a risk of procedural complications and serious long-term sequelae when performed repeatedly. All of these considerations highlight the need to identify non-invasive alternative methods capable of discriminating between the different grades of rejection and reducing the need for endomyocardial biopsy.

Purpose

We conducted a non-targeted transcriptomic study focused on identifying serum small non-coding RNAs, mainly aimed on the less studied types, to evaluate their diagnostic accuracy for detecting rejection episodes.

Methods

We included consecutive serum samples from transplant recipients undergoing routine endomyocardial biopsies. Non-coding RNA sequencing analysis (Illumina HiSeq 2500) was performed on 40 samples, 28 diagnosed with RCA (RCA Grade 1R, n=16; and RCA Grade ≥2R, n=12) and 12 samples without cardiac rejection.

Results

636 non-coding RNAs were detected among the scaRNAs, snoRNAs, snRNAs and miscRNAs biotypes. But, neither piRNA nor siRNA biotypes were detected. Of all of them, 41 were altered in patients with rejection Grade ≥2R, finding no alteration in the scaRNAs biotype. Three molecules of miscRNA biotype showed the best results with excellent diagnostic capacity in moderate/severe rejection: RN7SL840P (AUC=0.938, p<0.01), Y_RNA [ENSG00000223302] (AUC=0.931, p<0.0001) and Y_RNA [ENSG00000202273] (AUC=0.903, p<0.001). In addition, RN7SKP5 showed a good capacity for the diagnosis of Grade ≥2R (AUC=0.806, p<0.05) and preserving the accuracy at Grade 1R (AUC=0.781, p<0.05).

Conclusions

The 6.5% of the small non-coding RNAs detected have differential expression in patients with acute cellular rejection. The non-detection of the piRNAs and siRNAs biotypes stands out, as well as the absence of alteration in the scaRNAs biotype. We propose serum miscRNA levels as potential biomarkers of cardiac rejection. We highlight the role of RN7SL840P due to its excellent diagnostic capacity for RCA, and RN7SKP5 since it also allows the detection of mild rejection.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Carlos III European Regional Development Fund (ERDF)
Outcomes comparison between robotic and conventional mitral valve surgery: a systematic review and meta-analysis
Authors: Pratita J , Ardaya R , Pritazahra A , Rahman F H F
Published: October 2022

Background

Robotic-assisted cardiac surgery has emerged as a popular minimal invasive cardiac surgery approach, as it provides several advantages compared to conventional and other minimally invasive approaches. Mitral valve surgeries, including repair and replacement, are currently the most common cardiac surgeries performed with a robotic approach. However, there are concerns that surgeon's learning curve and prolonged operation time associated with this approach could compromise the surgical outcomes, hence the low acceptance of the technique in the clinical setting. In addition, despite various studies comparing robotic and conventional mitral surgery, it remains unclear whether the former would give comparable, if not better, outcomes.

Purpose

This study aims to compare the outcomes of robotic and conventional sternotomy mitral valve surgeries.

Methods

A comprehensive literature search was performed through Pubmed, CENTRAL, and ScienceDirect for studies comparing robotic and sternotomy approach for mitral valve repair and replacement. Studies were screened with our eligibility criteria, and their quality was examined using the Newcastle-Ottawa scale. The primary outcome analysed in this study was the perioperative mortality.

Results

Twelve studies involving 4300 patients (2223 experienced robotic surgery) were included. Pooled analysis showed that patients who underwent robotic surgery had a significant decrease in perioperative mortality compared to those who underwent sternotomy surgery (RR 0.33, 95% CI 0.18, 0.60, p=0.0003, I2=0%). Moreover, ICU length of stay was also shorter in the robotic group (MD −13.67, 95% CI −20.04, −7.29, p<0.0001, I2=93%). Re-operation risk due to bleeding was not significantly different between both groups (RR 1.13, 95% CI 0.79, 1.62, p=0.51, I2=0%). Egger's test result showed no evidence of small-study effects (p=0.83), and the funnel plot appeared symmetrical, meaning there was no publication bias.

Conclusion

Results from our meta-analysis refute the current concerns limiting the acceptance of robotic approach in mitral valve surgeries, showing significantly lower perioperative mortality and ICU length of stay, as well as a comparable re-operation risk due to bleeding with the conventional approach.

Funding Acknowledgement

Type of funding sources: None.
20 years outcomes after hybrid coronary revascularization
Authors: Gadelkarim I , Verevkin A , Von Aspern K , Deshmukh N , Holzhey D , Saeed D , Davierwala P , Misfeld M , Borger M A
Published: October 2022

Background

Hybrid coronary revascularization (HCR) is a Heart Team directed strategy for selected patients with mutlivessel coronary artery disease. However, data on long-term results are lacking.

Purpose

To analyse long-term outcomes after HCR over a 20-year period.

Methods

Between 1996 and 2020, a total of 2667 consecutive patients underwent minimally invasive direct coronary artery bypass grafting (MIDCAB) at our institution, and 177 of these were planned HCR cases. Planned HCR consisted of a MIDCAB procedure to the left anterior descending (LAD) artery preceded or followed by percutaneous intervention (PCI) of non-LAD lesions. We excluded patients who underwent prior cardiac surgery and patients with emergency indications for revascularization (either surgical or transcatheter). Short- and long-term results for the entire cohort were analysed and a propensity score-matched comparison was performed between MIDCAB-first and PCI-first revascularization strategies.

Results

The mean age of all patients was 67 (±12) years with 37% suffering from diabetes (n=67). The median time-interval between MIDCAB and PCI was 22 days (IQR 5–53). Thirty-day mortality was 3.9% for the entire cohort. A total of 9 patients (5.0%) underwent early target vessel revascularization; 4 patients (2.2%) involving the LAD following the MIDCAB procedure and 5 patients (2.8%) involving non-LAD vessels following PCI. The rate of incomplete revascularization following completion of HCR was 25.4% (n=45). Long-term survival was 53.5% at 15 years and 30.4% at 20 years and the rate of repeat revascularization with PCI or surgery was 15.8% (n=28). The propensity matched sub-analysis of MIDCAB- versus PCI-first strategy showed no significant differences with regard to short- and long-term outcomes. Age (HR: 1.01, 95% CI 0.98–1.04, p=0.042) and incomplete revascularization (HR: 2.60, 95% CI 1.26–5.34; p=0.01) were independent risk factors for follow-up mortality.

Conclusions

Hybrid coronary revascularization as a less invasive strategy for selected patients is associated with acceptable 20-year survival. However, repeat revascularization rates are substantial.

Funding Acknowledgement

Type of funding sources: None.
The importance of frontal QRS-T angle for predicting reverse dipper status in newly diagnosed hypertensive patients
Authors: Karakayali M , Artac I , Omar T , Rencuzogullari I , Karabag Y , Hamideyin S
Published: October 2022

Background

The frontal QRS-T angle (fQRS-T angle) in electrocardiography is a new measure of myocardial repolarization, in which a higher fQRS-T angle is linked with worse cardiac outcomes. Reverse dipper hypertension is also linked to poor cardiac outcomes. The purpose of this study was to investigate the association between the fQRS-T angle and reverse dipper status in individuals newly diagnosed with hypertension who did not have left ventricular hypertrophy (LVH).

Methods

The investigation recruited 171 hypertensive individuals without LVH who underwent 24h ambulatory blood pressure monitoring (ABPM). Based on the findings of 24h ABPM, the study population was categorized into the following three groups: patients with dipper hypertension, with non-dipper hypertension, and with reverse dipper hypertension. The frontal QRS-T angle was measured using 12-lead electrocardiography (ECG).

Results

The fQRS-T angle in individuals with reverse dipper hypertension was substantially greater than in patients with and without dipper hypertension (510±280 vs. 280±220 vs. 390±250 respectively, p<0.001). The fQRS-T angle (OR: 1.040, 95% CI: 1.016–1.066; p=0.001) was independently associated with reverse dipper hypertension according to multivariate analysis. In receiver operating characteristic curve analysis, the fQRS-T angle to predict reverse dipper hypertension was 33.5° with 76% sensitivity and 71% specificity.

Conclusion

This study showed that an increased fQRS-T angle was a predictor of reverse hypertension in newly diagnosed hypertensive patients without LVH.

Funding Acknowledgement

Type of funding sources: None.
Elevated platelet reactivity in patients with uncontrolled hypertension: the effect of CHA2DS2-VASc score
Authors: Marketou M , Spatharaki P , Nioti E , Kalomoirakis P , Karagounis T , Alifrangie A , Zervakis S , Fragkiadakis K , Plevritaki A , Anastasiou I , Androulakis N , Kalpadaki C , Kochiadakis G
Published: October 2022

Background

Hypertension is associated with vascular and endothelial dysfunction that may result in a greater propensity for reactive platelets to cause thrombosis.

Purpose

The aim of this study was to evaluate multiple platelet activation pathways in hypertensive patients with different level of blood pressure control and cardiovascular risk factors.

Methods

Thirty nine uncontrolled (office BP >140/90 mmHg and ambulatory daytime BP >135/85 mmHg, 27 males, aged 58±9 years) and 32 well controlled (office BP <140/80 mmHg and ambulatory daytime BP <135/85 mmHg, 21 males, aged 58±8 years) essential hypertensive patients were included in the study. Twenty four healthy individuals (12 males, aged 53±10 years) were served as control group. Blood samples were obtained before and 48 hours after the procedure and platelet aggregation was tested in platelet rich plasma after activation with arachidonic acid (AA), adenosine diphosphate ADP), collagen (Col), epinephrine (Epi) and ristocetin (Risto), by using AggRAM Platelet Aggregation Analyzer.

Results

Hypertensive patients showed elevated platelet reactivity in all platelet activation pathways compared to normotensive group (AA: 88.8±6.8% versus 79.5±7.3%, ADP: 86.8±9.1% versus 71.5±7.7%, Col: 86.5±5.7% versus 73.9±6.7%, Epi: 92.6±5.4% versus 80.5±5.7%, Risto: 93.8±6.8% versus 79.9±6.3%, p<0.05 for all). Col, Epi and Risto platelet activation pathway showed a statistically significant increase in patients with uncontrolled hypertension compared to the group with well controlled hypertension (AA: 88.8±6.1% versus 89.1±4.1%, ADP: 89.8±4.1% versus 87.5±4.7%, Col: 87.5±4.7% versus 81.9±6.7%, Epi: 93.6±4.4% versus 80.1±5.7%, Risto: 94.8±3.8% versus 80.9±4.3%,). Notably, strong correlations were found between the Col platelet pathway activation and Risto platelet pathway activation and CHA2DS2-VASc score (r=0.57, p<0.001 and r=0.61, p<0.001, respectively) in hypertensive patients.

Conclusions

Patients with uncontrolled hypertension showed elevated platelet reactivity. Patients with high CHA2DS2-VASc even without atrial fibrillation carry also a higher risk of thrombosis as indicated by the increased platelet aggregation under certain pathways of activation.

Funding Acknowledgement

Type of funding sources: None.
Longitudinal constancy of vascular ageing phenotypes in middle-aged Japanese employees
Authors: Tomiyama H , Shiina K , Nakano H , Fujiii S , Takahasi T , Matsumoto C , Yamashina A , Chikamori T
Published: October 2022

Background

Recently, the concept of healthy vascular aging (HVA) and early vascular aging (EVA) phenotypes was proposed.

Purpose

We examined following issues; constancy of the vascular phenotypes over time; validity of assuming that constancy of the vascular phenotypes reflects the progression rate of structural arterial stiffening; and associations of vascular phenotype constancy with cardiovascular risk factors/their treatment, and the heart rate (HR).

Methods

Data on the brachial-ankle pulse wave velocity (baPWV) measured annually over a 16-year period in 4682 middle-aged Japanese employees were analyzed.

Results

Of all subjects, 30% showed constancy of the vascular phenotype during the study period. The estimated marginal mean of baPWV values and the slope of the annual increase of the baPWV were higher in the constant EVA group (EVA-EVA) than in the constant HVA group (HVA-HVA) (Figure 1). Elevated serum HbA1c levels, medication for hypertension, and high HR were significantly associated with constancy of the EVA phenotype, whereas a low HR was significantly associated with constancy of the HVA phenotype.

Conclusions

In middle-aged Japanese employees with the HVA/EVA phenotype at the study baseline, while the phenotype changed over time in most subjects, HVA/EVA phenotype constancy in the remaining subjects reliably reflected a low/high rate of progression of structural arterial stiffening. Hypertension and abnormal glucose metabolism were associated with constancy of the EVA phenotype, but treatment for these conditions failed to improve the phenotype. Low/high HR was a robust marker of the presence/constancy of the HVA/EVA phenotype.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Omron Health CareTeijin Pharma