bluuebunny/crossref_metadata_2025 huggingface dataset:
Propofol versus midazolam sedation in patients with cardiogenic shock – an observational propensity-matched study
Authors: Scherer C , Kleeberger J , Kellnar A , Binzenhoefer L , Luesebrink E , Stocker T J , Thienel M , Deseive S , Braun D , Petzold T , Brunner S , Hagl C , Hausleiter J , Massberg S , Orban M
Published: October 2022

Introduction

Benzodiazepines are recommended as first line sedative agent in ventilated cardiogenic shock patients, although data regarding the optimal sedation strategy are sparse. On our cardiac ICU, midazolam was used as first line sedation until 2016, whereas soybean oil formulated propofol was used preferentially since 2017.

Purpose

The aim of this study was to investigate the hemodynamic effects of propofol versus midazolam sedation in our cardiogenic shock registry.

Methods

Mechanically ventilated patients suffering from cardiogenic shock were retrospectively enrolled from a cardiogenic shock registry. 174 patients treated predominantly with propofol were matched by propensity-score to 174 patients treated predominantly with midazolam.

Results

Catecholamine doses were similar on admission but significantly lower in the propofol group on days 1–4 of ICU stay (Figure 1). Mortality rate was 38% in the propofol and 52% in the midazolam group after 30 days (p=0.002, Figure 2). Rate of ≥BARC3 bleeding was significantly lower in the propofol group compared to the midazolam group (p=0.008). Age, gender, first lactate measured on ICU, first GFR measured on ICU, cardiac arrest, coaxial left ventricular assist device and sedation with midazolam were significantly associated with ICU mortality.

Conclusion

In this observational cohort study, sedation with propofol in comparison to midazolam was linked to a reduced dose of catecholamines, decreased mortality and bleeding rates for patients with cardiogenic shock. Based on this study and in contrast to current recommendations, propofol should be given consideration for sedation in cardiogenic shock patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft
24h SCAI stage reclassification to predict outcome. Insights from the prospective Altshock-2 registry
Authors: Morici N , Frea S , Ditali V , Briani M , Bertaina M , Ravera A , Sorini Dini C , Moltrasio M , Saia F , Corrada E , De Ferrari G M , Garatti L , Colombo C , Tavazzi G , Pappalardo F
Published: October 2022

Background

Cardiogenic shock (CS) includes several phenotypes of congestion or hypoperfusion with heterogenous hemodynamic features. Timely prognostication with scoring tools is warranted to identify patients requiring escalation to mechanical circulatory support (MCS) and to avoid futility.

Purpose

Accordingly, we explored the role of the updated Society for Cardiovascular Angiography and Interventions (SCAI) stages classification on in-hospital mortality using a prospective national registry.

Methods

The Altshock-2 Registry includes 237 patients with CS of all etiologies enrolled between March 2020 and February 2022 in 11 Italian Centers. Patients were classified according to the admission SCAI stages (assigned prospectively and independently updated according to the most recently released version); 24-hour re-assessment was prospectively performed in 201 patients. In-hospital mortality was evaluated for association with admission and 24 hours SCAI stages adjusted for the most relevant clinical covariates.

Results

Of the 237 patients included, 20 (8.4%) had SCAI shock stage B, 132 (55.8%) SCAI stage C, 60 (25.3) SCAI stage D and 25 (10.5%) SCAI stage E. Patients in stage B had the worst reclassification at 24-hours, with 42% of them showing worsened status and only 8% improving. In-hospital mortality was 38%. The revised SCAI stages at baseline were not independently associated with in-hospital mortality, whereas the SCAI classification at 24-h correctly and independently predicted mortality (the rate of in-hospital death was 18% for patients in SCAI shock stage B, 27% for SCAI shock stage C, 64% for SCAI shock stage D, 100% for SCAI shock stage E). At the multivariate analysis (adjusted for age, gender, eGFR, inotropic score and MCS) only SCAI classification at 24-hour evaluation was an independent predictor of in-hospital mortality (OR and 95% CI were, respectively, 3.32, 0.36–30.63, p=0.290 for SCAI stage C and 13.07, 1.69–146.3 for SCAI stage D, with E perfectly predicting because all patients died).

Conclusions

The revised SCAI stage classification may improve prognostication only at 24-hour evaluation. Aggressive treatment (either pharmacological or with MCS escalation) should be tailored in order to achieve prompt clinical improvement within the first 24-hours; refractory SCAI stage E at 24 hours portends dismal prognosis.

Funding Acknowledgement

Type of funding sources: None.
Long-term neurological intact survival and quality of life after refractory out-of-hospital cardiac arrest treated with rescue mechanical circulatory support
Authors: Rasalingam Moerk S , Kristensen L Q , Osterlund L G , Christensen S , Tang M , Terkelsen C J , Eiskjaer H
Published: October 2022

Background

Mechanical circulatory support (MCS) with either veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella has emerged as a rescue therapy for refractory out-of-hospital cardiac arrest (OHCA). However, only short-term outcome is specified and most studies do not report follow-up beyond six months. Long-term survival and quality of life in this high-risk population remains unknown.

Purpose

To determine long-term neurological intact survival and quality of life in patients with refractory OHCA treated with MCS.

Methods

This was an observational, single-centre study of OHCA-patients from January 2015 to December 2019. Patients treated with MCS for OHCA were compared with patients receiving conventional cardiopulmonary resuscitation (CPR). A follow-up of long-term survivors in the MCS group was conducted (>1 year after arrest). This included health related quality of life questionaries (Short Form-36 [SF-36]) and assessment of neurological function with Cerebral Performance Category (CPC). Good neurological outcome was defined as CPC 1 and CPC 2.

Results

A total of 1015 with OHCA were included; 101 received MCS for refractory cardiac arrest. Among these V-A ECMO was deployed in 97 patients and Impella in 4 patients. The MCS group had significantly longer low-flow times compared to the conventional group (105 [IQR, 94–123] minutes versus 18 [IQR 10–39] minutes) and were more metabolically deranged upon arrival at hospital (Table 1). In patients receiving MCS, the hospital discharge rate was 27% and good neurological outcome was seen in 93% among patients discharged. At follow-up, 15 out of 21 long-term survivors participated. Median follow-up time was 4.8±1.6 (range 2.8–6.1 years). Mean age at follow-up was 61±7.3 years, 11 (73%) were men. Neurological outcome with CPC 1 was found in 12 patients (80%), with CPC 2 in 2 patients (13%), and with CPC 3 in 1 patient (7%). Two had improved neurological status from CPC 2 to CPC 1 since discharge. Mean scores of the SF-36 revealed an overall high level of psychical and mental health in long-term survivors (Figure 1).

Conclusion

Long-term survival with good neurological outcome was high in patients with refractory OHCA treated with MCS despite prolonged resuscitation and severe metabolic derangement. These patients may expect a reasonable quality of life after discharge.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University HospitalSnedkermester Sophus Jacobsen og hustru Astrid Jacobsens Fond
Neurological evolution of patients in coma at 72 hours after out-of-hospital cardiac arrest
Authors: Badosa Gali E , Nunez Torras M , Aboal Vinas J , Pascual Mayans J , Kassem Perez H , Singh M , Brugada Terradellas R , Loma-Osorio Ricon P
Published: October 2022

Introduction

Establishing neurological prognosis after out-of-hospital cardiac arrest (OHCA) safely and early in those patients who remain in a coma at 72 hours of admission.

Purpose

To analyze the prognostic performance of neuron-specific enolase (NSE), Somatosensory evoked potentials (SSEPs) and electroencephalogram (EEG) in these patients.

Methods

Prospective and observational study, including all OHCAs admitted to a Cardiovascular Intensive Care Unit (CICU) of a tertiary hospital. Neurological stratification was performed at 72 hours with NSE (poor prognosis >60 ng/mL), SSEP (poor prognosis in the absence of N20) and EEG (poor prognosis). The sensitivity and specificity of each test for poor prognosis were calculated, as well as the three tests together.

Results

Between 03/17/2013 and 02/24/2022, 422 OHCAs were registered, of which 170 patients remained in a coma at 72 hours. The EEG had a sensitivity of 84% and a specificity of 89% due to poor prognosis. SSEPs had a sensitivity of 68% and a specificity of 98% due to poor prognosis. The NSE had a sensitivity of 67% and a specificity of 100% due to poor prognosis. The three tests were able to be performed on 110 patients, the sensitivity for poor prognosis of the three combined tests was 49% and the specificity was 100%.

Conclusions

In patients in a coma at 72 hours of OHCA, the most specific test to establish a poor prognosis was SSEP and the most sensitive was EEG. The combination of the three had a specificity of 100%.

Funding Acknowledgement

Type of funding sources: None.
Prevalence of atrial myopathy among hypertrophic cardiomyopathy patients without atrial fibrillation
Authors: Pagourelias E , Boulmpou A , Evangeliou A , Zormpas G , Alexandridis G , Kotzadamis D , Vergopoulos S , Tsavousoglou C , Antoniadis A , Mavroudi M , Papadopoulos C E , Tzikas S , Fragakis N , Vassilikos V P
Published: October 2022

Background

Atrial myopathy (AM) is an entity reflecting left atrial (LA) structural and electrical remodeling, connected to atrial fibrillation (AF) development and heart failure progression in various substrates. In hypertrophic cardiomyopathy (HCM), prevalence of AM beyond AF and its correlations are not fully investigated.

Purpose

Aim of this study was to estimate the prevalence of AM in a cohort of HCM patients without AF history through assessment of LA volume index (LAVI), LA reservoir strain (LARS) and total atrial conduction time (TACT) (estimated by tissue Doppler imaging). Additionally, to investigate AM indices' correlation with other phenotypic and functional characteristics of HCM.

Methods

We included 50 HCM patients (60±16 years, 80% male, maximum wall thickness 18.6±4.1mm) without history of AF who have consecutively undergone 2D-speckle tracking echocardiography and cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). TACT and LARS measurement is shown on left panel. Burden of fibrosis (percentage of LV mass) was defined by LGE extent (>5 standard deviations compared to nulled myocardium) in CMR slices. Cut-off points for TACT, LAVI and LARS were adopted by literature (≥115 msec, ≥34 mL/m2 and <21.3% respectively).

Results

All HCM patients had preserved EF (61.8±8%), while 13 (26%) presented outflow tract obstruction and 4 (8%) diastolic dysfunction stage≥2. LGE was observed in 32 patients (64%) occupying 7.2±5% of left ventricular (LV) mass. Mean TACT was 139.9±22 msec, with LAVI being 30.8±16.1 mL/m2 and LARS 27.6±13.9%. After assessing prevalence of AM parameters, 41 patients (82%) presented a prolonged (≥115 msec) TACT with only 13 of them having also a significantly dilated LA (≥34 mL/m2) and 16 an impaired LARS. Among HCM demographic, phenotypic and functional characteristics tested, age and LV mass index were found to be the only independent regressors of TACT (r=0.54, p<0.0005 and r=0.44, p=0.002 respectively, right panels), while E/E' (r=−0.44, p=0.003) and fibrosis extent (r=0.36, p=0.02) were the strongest predictors of LARS and LAVI values respectively.

Conclusions

Atrial electro-mechanical delay assessed through TDI based TACT, is the most frequent AM parameter among HCM patients irrespective of AF and even before LA dilatation and LA strain impairment. AM parameters seem to correlate with various morphological and functional characteristics of HCM, their significance, however, in predicting progression towards AF development or HF presentation remains to be elucidated.

Funding Acknowledgement

Type of funding sources: None.
Amyloidosis of the aortic valve in patients with degenerative and bicuspid aortic stenosis
Authors: Perez E , Abedat S , Meir K , Pollak A , Shapira O , Erez E , Leibowitz D , Asleh R , Amir O , Beeri R
Published: October 2022

Introduction

Aortic stenosis (AS) is a common valvular disease, resulting in substantial morbidity and mortality. In younger patients, AS may occur as part of the bicuspid aortic valve (BAV) syndrome. Transthyretin cardiac amyloidosis (ATTR-CA) is an infiltrative disorder caused by the extracellular deposition of insoluble amyloid-derived fibrils. Recent studies have shown the presence of ATTR-CA in 4%-29% of degenerative AS patients. We hypothesized that amyloidosis may be involved in valve injury leading to AS.

Material and methods

We studied the aortic valves of 124 patients who underwent surgical aortic valve replacement at our institution over the last decade, included in our cardiosurgical database. Valves from 86 degenerative AS patients were compared to a control group of 38 patients with BAV stenosis. Patients with pure aortic regurgitation, history of rheumatic disease, or severe renal disease were excluded. The slides were stained with Congo red, and Thioflavin S then examined with regular, fluorescence and polarized light microscopy.

Results

In the degenerative AS group, Congo red and Thioflavin S staining was positive in 63% of the valves and 37% negative. The bicuspid AS group showed 68% positive and 32% negative for the Congo Red and Thioflavin S stains.

Discussion and conclusion

Our results indicate the presence of valvular amyloidosis in patients with AS, whether due to degenerative or congenital etiologies. This corroborates several recent studies. Intriguingly, there was an equally positive Congo red and Thioflavin S signal in bicuspid aortic valves. We speculate that the positive staining in the BAV group may indicate an inflammatory process associated with valve pathology inducing the accumulation of amyloid, and thus may not be transthyretin, as we expect in the experimental group. Another explanation may be that amyloidosis may be an epiphenomenon of valve “wear and tear” and not related to the pathogenesis in either etiology. Specific TTR immunofluorescence is underway to elucidate this question.

Funding Acknowledgement

Type of funding sources: None.
Impact of left ventricular contractility on mitral annular motion in an acute animal model
Authors: Persson R M , Dahl Aguilera H M , Kvitting J P , Grong K , Salminen P R , Svenheim B , Leiknes A , Stangeland L , Haaverstad R , Urheim S
Published: October 2022

Background

We know that the ventricular function has a profound effect on the mitral valve in chronic disease with ventricular remodeling. However, acute effects of ventricular function on the mitral valve apparatus are not well understood.

Purpose

To investigate the effect of left ventricular (LV) contractility on all aspects of mitral annular motion.

Methods

Eight piezoelectric transducers were implanted equidistantly around the mitral annulus in ten pigs. Sonomicrometer array localization recorded transducer position after weaning from bypass. LV contractility was evaluated by the slope of the end-systolic pressure-volume relationship. Mitral annular area was calculated from cubic spline interpolation through the annular points. Circularity and non-planarity angle were calculated from principal component analysis. Mitral annular excursion was calculated as the projected distance from the annular geometric mean point to the least square plane of the mitral annulus in end diastolic configuration.

Results

LV contractility was strongly associated to change in mitral annular area and mitral annular excursion (r=0.88, p<0.001 and r=0.90, p<0.001, respectively). Change in non-planarity angle was only moderately associated with LV contractility (r=0.68, p<0.03), whereas circularity was not (r=0.05, p<0.089).

Conclusions

LV contractility was closely related to mitral annular size reduction and apicobasal annular excursion, and only moderately associated to folding of the mitral annular saddle shape. No associations were found with change in mitral annular circularity. This is to our knowledge the first detailed description of the acute relationship between LV contractility and mitral annular dynamics.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority Research Grant
Atrial extrasystoles unmask early electropathology in pediatric congenital heart disease
Authors: Ramdat Misier N , Taverne Y J H J , Van Schie M S , Kharbanda R K , Van De Woestijne P C , Van Leeuwen W J , Bartels B , Bogers A J J C , De Groot N M S
Published: October 2022

Background

Despite improvement in (timing of) of intervention or surgery, atrial fibrillation (AF) still occurs more often and at a younger age in patients with congenital heart disease (CHD) than in the general population. This suggests that in this population atrial conduction is already affected in an early stage.

Purpose

To unmask early, enhanced non-uniform anisotropic atrial conduction in pediatric patients with CHD by examining the impact of spontaneous aberrant atrial extrasystoles (AES) on atrial conduction.

Methods

Twenty-one pediatric patients with various CHD (mild 43%, moderate 24% and severe 33%) (median age=1.8 years [0.2–7.3]) undergoing primary cardiac surgery were included for an intra-operative epicardial mapping of both atria, including Bachmann's bundle. Conduction velocity (CV), localized areas of conduction delay and/or block (CD, CB and continuousCDCB) and unipolar electrogram (EGM) characteristics (voltages and amount of fractionated potentials) were quantified during sinus rhythm (SR) and compared with corresponding AES beats.

Results

During 41 AES median unipolar voltage and CV decreased compared to corresponding SR beats (7.08 [5.50–9.10] mV vs. 5.71 [3.95–7.48] mV, p<0.001); 87.9 [76.7–101.6] cm/s vs. 84.5 [73.0–93.6] cm/s, p=0.013; respectively), whereas the amount of fractionated potentials increased (12.7 [3.5–18.2] % vs. 19.5 [10.5–30.0] %, p<0.001). Conduction disorders, consisting of CD, CB and cCDCB, were more prominent during AES (4.5 [2.3–6.3] %; 1.5 [0.0–4.3] %; 6.3 [2.6–11.2] %, respectively) (all p≤0.006). Differences in EGM morphology and conduction heterogeneity were not influenced by the degree of the prematurity of AES (p>0.05).

Conclusions

AES in pediatric patients with CHD cause localized areas of conduction slowing and block, potentials with lower unipolar voltages and a higher degree of fractionation compared to SR potentials, independent of its prematurity. Our findings indicate that in pediatric patients with CHD, early, enhanced non-uniform anisotropic atrial conduction is already present and can be unmasked by AES. These insights are the first step in further understanding the time course of AF in CHD patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CVON-AFFIPNWO-Vidi
The long-term clinical course of moderate tricuspid regurgitation
Authors: Margonato D , Ancona F , Melillo F , Ingallina G , Stella S , Biondi F , Manini C , Montorfano M , Maisano F , Topilsky Y , Agricola E
Published: October 2022

Background

Moderate TR is a frequent condition, worsening mid and long-term survival, particularly in patients >75 years old, and in those suffering from left ventricular systolic dysfunction. As TR is often clinically unsuspected until an advanced stage of congestive heart failure (HF), there is a great need of early diagnosis and long-term appropriate follow-up. However, data focusing on the clinical and echocardiographic course of a cohort of patients with moderate TR is lacking, and the most appropriate type and time of management of these patients is still heavily debated.

Purpose

To evaluate the evolution and the long-term clinical outcome of a cohort of patients suffering from moderate and moderate to severe TR, regardless of its etiology.

Methods

Clinical outcome and echocardiographic follow-up were assessed in 212 patients diagnosed with moderate and moderate to severe TR in our centre between January 2014 and December 2019. TR progression at follow-up was defined as TR grade increase to at least severe. The primary endpoint was all-cause death; secondary endpoints were cardiovascular (CV) death and HF hospitalization.

Results

After a median follow-up of 4.2 years, TR progression occurred in 76 patients (36%): patients with TR progression presented with more history of coronary artery disease (p=0.042), atrial fibrillation (AF, p=0.007) and chronic kidney disease (CKD, p=0.007) and with baseline larger right ventricle end-diastolic diameter (RVEDD, p<0.001) and worse left ventricular ejection fraction (LVEF, p=0.048). After univariate and multivariate analyses, a history of AF (HR 2.3, CI 1.2–4.5, p=0.011) and RVEDD (HR 2.4, CI 1.3–4.4, p=0.003) were independent predictors of TR progression. The primary endpoint occurred in 57 patients (27%) and was significantly more frequent (p=0.015) in the group of patients with TR progression compared to those without TR progression; multivariate analyses showed TR grade progression (HR 4.3, CI 2.1–9.1, p<0.001), CKD (HR 3.2, CI 1.5–7.1, p=0.002) and LVEF (HR 0.9, CI 0.93–0.99, p=0.007) as being independently associated with the primary outcome. Moreover, both CV death (p=0.003) and HF hospitalization (p=0.0139) were significantly more frequent in patients with TR progression.

Conclusions

Our results showed that moderate TR, by progressing in a relevant proportion of patients over a long-term follow-up, significantly increases the risk of mortality and HF hospitalization. We identified specific risk factors associated with TR progression, which could help to identify patients at risk before an advanced stage of this disease. We believe that this cohort of patients should be appropriately managed and closely followed-up to avoid adverse clinical events related to the natural course of this valvulopathy.

Funding Acknowledgement

Type of funding sources: None.
Diabetes mellitus and cardiovascular mortality across the spectrum of aortic stenosis
Authors: Coisne A , Montaigne D , Ninni S , Lamblin N , Lemesle G , Delsart P , Butruille L , Decoin R , Woitrain E , Granada J , Staels B , Bauters C
Published: October 2022

Background

Current data regarding the impact of diabetes mellitus (DM) on cardiovascular mortality in patients with aortic stenosis (AS) are restricted to severe AS or aortic valve replacement (AVR) trials.

Purpose

To investigate cardiovascular mortality according to DM across the entire spectrum of AS outpatients.

Methods

Between May 2016 and December 2017, patients with mild (peak aortic velocity=2.5–2.9m/s), moderate (3–3.9m/s) and severe (≥4m/s) AS graded by echocardiography were included during outpatient cardiology visits in the Nord-Pas-de-Calais region in France and followed-up for modes of death.

Results

Among 2,703 patients, 820 (30.3%) had DM, mean age was 76±10.8 years with 46.6% of women and a relatively high prevalence of underlying cardiovascular diseases. There were 200 cardiovascular deaths prior to AVR during the 2.1 years (IQR 1.4–2.7) follow-up period. In adjusted analyses, DM was significantly associated with cardiovascular mortality (HR=1.40, 95% CI 1.04–1.89; P=0.029). In mild or moderate AS, the cardiovascular mortality of diabetic patients was similar to that of nondiabetic patients (Figuer 1). In severe AS, DM was associated with higher cardiovascular mortality (HR=2.65, 95% CI 1.50–4.68; P=0.001). This was almost exclusively related to a higher risk of death from heart failure (HR=2.61, 95% CI 1.15–5.92; P=0.022) and sudden death (HR=3.33, 95% CI 1.28–8.67; P=0.014) (Figure 2).

Conclusion

The effect of DM on cardiovascular mortality varied across AS severity. Despite no association between DM and outcomes in mild/moderate AS patients, DM was strongly associated with death from heart failure and sudden death in severe AS patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Fédération Française de Cardiologie
Diagnostic performance of coronary CTA and CT-FFR for the detection of coronary artery disease in routine TAVI work-up
Authors: Peper J , Becker L M , Van Den Berg H , Bor W L , Brouwer J , Nijenhuis V J , Van Ginkel D J , Rensing B M J W , Timmer L , Ten Berg J M , Leiner T , Swaans M J
Published: October 2022

Objectives

To assess the diagnostic performance of CT-FFR for the diagnosis of CAD in the work-up for TAVI.

Background

Work-up for transcatheter aortic valve implantation (TAVI) currently utilizes computed tomography (CT) to evaluate annulus diameter and peripheral vascular access, plus invasive coronary angiography (ICA) to assess significant coronary artery disease (CAD). ICA might partially be redundant with the use of Coronary CT Angiography (CCTA). Prior studies found improvement of the diagnostic accuracy of CCTA by use of CT derived fractional flow reserve (CT-FFR).

Methods

Consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVI work-up between 2015–2019 were included in this cross-sectional study. All patients underwent CCTA and ICA within 3 months and diagnostic performance of both CCTA and CT-FFR were assessed using ICA as reference.

Results

Seventy-six of the 338 patients included in the analysis had ≥1 significant coronary stenosis at ICA. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy per-patient were 76.9%, 64.5%, 34.0%, 92.1% and 66.9% for CCTA and 84.6%, 88.3%, 63.2%, 96.0% and 87.6% for CT-FFR. The area under the receiver-operating characteristic-curve significantly differ between CCTA and CT-FFR (0.84 versus 0.90 p=0.02). A CT-FFR guided approach could avoid ICA in 57.1% versus 43.6% using CCTA.

Conclusions

CT-FFR significantly improves the diagnostic accuracy of CCTA without additional testing and increases the proportion of patients in whom ICA could have been safely avoided It has the potential to be integrated in the current clinical work-up for TAVI for diagnosing stable CAD requiring treatment.

Funding Acknowledgement

Type of funding sources: None.
Left ventricular reverse remodeling in post operative aortic stenosis patients: prevalence and predictor(s)
Authors: R Santos R , Abecasis J , Maltes S , Mendes G S , Oliveira L , Horta E , Guerreiro S , Freitas P , Ferreira A , Ribeiras R , Andrade M J , Cardim N , Gil V , Mendes M , Neves J P
Published: October 2022

Background

In patients with severe aortic stenosis (AS), left ventricular (LV) remodeling is believed to be a compensatory adaptive process which should reverse after aortic valve intervention. However, this is not always the rule and remodeling persistence may negatively impact post-procedural outcomes and survival.

Aim

To assess the prevalence and predictors of morphological LV reverse remodeling in severe symptomatic AS patients after surgical aortic valve replacement (AVR).

Methods

We prospectively studied 75 patients (72y [68–77y], 45% male) with severe symptomatic AS - mean gradient (AVM): 61±17mmHg; mean indexed aortic valve area (AVAi) 0.41±0.10 cm2/m2 with no previous history of ischemic cardiomyopathy, all with high gradient, 4 with low-flow, 81% with hypertension, 27% with type 2 diabetes mellitus and 35% patients with stage 3 chronic kidney disease: median MDR creat clearance: 70.4mL/min [40–102]. All patients performed pre-operative cardiac magnetic resonance (CMR) at a mean period of 3.4 months (0–17 months) before AVR and at the 3–6th months after AVR, for LV reverse remodeling assessment. It was defined as at least the occurrence of one of the following: >15% reduction in LVEDVi; >15% reduction in LVMi by CMR; >10% reduction in geometric remodeling ratio. Clinical, AV severity data, preoperative functional LV and tissue characterization data were analyzed at multivariate regression to predict the occurrence of LV reverse remodeling.

Results

Overall, at pre-operative CMR: mean LV indexed mass (LVMi): 82±28.9 g/m2; mean end-diastolic LV indexed volume (LVEDVi): 87.4±26.6 mL/m2; mean geometric remodeling (LV mass/end-diastolic volume): 0.92±0.2 g/mL. After AVR, at echocardiographic evaluation, no patient had prosthetic obstruction or prosthetic patient mismatch: median LV-Ao gradient 12mmHg [9.1–14 mmHg]; 5 of them had mild paravalvular regurgitation. LV reverse remodeling occurred in 65 patients (88%) (Figure 1A) and these were younger, had significantly smaller preoperative AVAi and higher valvular gradients (Figure 1B). At multivariate analysis, only preoperative AVAi remained an independent predictor (odds ratio 0.85, 95% CI 0.735–0.984, p=0.029).

Conclusions

In this prospective cohort of patients LV reverse remodeling after surgical AVR was highly frequent, occurring in almost nine out of every ten patients.

Funding Acknowledgement

Type of funding sources: None.
Cardiac magnetic resonance patterns of left ventricular hypertrophy in aortic stenosis patients
Authors: R Santos R , Abecasis J , Maltes S , Mendes G S , Oliveira L , Horta E , Guerreiro S , Freitas P , Ferreira A , Ribeiras R , Andrade M J , Cardim N , Gil V , Mendes M , Neves J P
Published: October 2022

Background

Left ventricular (LV) hypertrophy is a known compensatory mechanism to pressure overload in aortic stenosis (AS) patients. However, by cardiac magnetic resonance (CMR) different patterns of LV adaptation are seen in this group of patients.

Aim

To describe the patterns of LV adaptation (by CMR) and to analyze its structure and function indexes in AS patients referred for surgical aortic valve replacement (AVR).

Methods

We prospectively studied 134 consecutive patients (age: 73y [IQR 68–77y], 49% men) with severe symptomatic AS - mean transaortic pressure gradient (AVmean): 61±1.5 mmHg; mean aortic valve area: AVA): 0.7±0.1 cm2, referred for surgical AVR with no previous history of ischemic cardiomyopathy or other. All patients underwent electrocardiogram, 2D transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) before surgery for LV assessment and tissue characterization. Five patterns of LV structure were considered: normal ventricular structure (normal LV mass/volume ratio [M/V], normal LVMi and normal indexed LV end-diastolic volume (LVEDVi); concentric remodeling: increased M/V, normal LVMi; concentric hypertrophy: increased M/V and LVMi; eccentric hypertrophy: increased LVMi and LVEDVi, normal M/V and ejection fraction; and adverse remodeling: dilated left ventricle, increased LVMi and normal M/V in the context of an impaired ejection fraction. Echocardiogram and CMR structural and functional indexes were compared between these groups.

Results

At baseline study, at CMR: mean LV indexed mass [LVMi]: 80.3±26.5 g/m2; mean end-diastolic LV indexed volume [LVEDVi]: 84.4±24.5 mL/m2 and median geometric remodeling ratio [M/V]: 0.95 g/mL [IQR 0. 81–1.08 g/mL]. Overall, 22% patients had normal LV structure, 30% concentric remodeling ventricular geometry, and two patients had an adverse remodeling pattern. LV hypertrophy was the most prevalent pattern and occurred in 48% of subjects (concentric 43%; eccentric 4%). In our cohort, the severity of AS (AVmean (p<0.001), LV function (LV ejection fraction [p<0.001] and Global longitudinal strain [p<0.001]), LV loading conditions (indexed left atrial volume [p<0.001] and E/e' ratio [p<0.001]) and NT-proBNP (p<0.001) were related to the pattern of LV structure (Table 1).

Conclusions

In our cohort, AS patients presented several distinct patterns of LV remodeling. Disease severity, functional repercussion and loading conditions are distinct between them.

Funding Acknowledgement

Type of funding sources: None.
Effects of guideline directed medical therapy on secondary mitral regurgitation
Authors: Spinka G , Bartko P E , Heitzinger G , Prausmueller S , Winter M P , Arfsten H , Strunk G , Rosenhek R , Kastl S , Hengstenberg C , Pavo N , Huelsmann M , Goliasch G
Published: October 2022

Background

Guideline directed medical therapy (GDMT) is the recommended initial treatment for secondary mitral regurgitation (SMR), however supported by only little comprehensive evidence. This study therefore sought to assess the effect of GDMT titration on SMR and to identify specific substance combinations able to reduce SMR severity.

Methods

We included 261 patients who completed two visits with an echocardiographic exam available within one month at each visit. After comprehensively defining GDMT titration as well as SMR reduction, logistic regression analysis was applied in order to assess the effects of overall GDMT titration and specific substance combinations on SMR severity.

Results

SMR severity improved by at least one degree in 39.3% of patients with subsequent titration of GDMT and was accompanied by reverse remodelling and clinical improvement. The effects of GDMT titration were significantly associated with SMR reduction (adj. OR 0.31, 95% CI 0.13–0.71, P=0.006). Moreover, ARNI as well as the combined dosage effects of (i) renin angiotensin system inhibitors (RASi) and mineralocorticoid-receptor antagonists (MRA), (ii) betablockers (BB) and MRA, as well as (iii) RASi, BB, and MRA were all significantly associated with SMR improvement (P<0.001 for all).

Conclusions

The present study provides comprehensive evidence for the effectiveness of contemporary GDMT to specifically improve SMR. Our data indicates that GDMT titration conveys a threefold increased chance of reducing SMR severity. Moreover, the dosage effects of ARNI, as well as the combination of RASi and MRA, BB and MRA, and all three substances in aggregate are able to significantly improve SMR.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): FWF - Austrian Science Fund
Prognosis after aortic valve replacement in dialysis patients: results from the Swedish Renal Registry
Authors: Vavilis G , Back M , Barany P , Ruck A , Szummer K
Published: October 2022

Background

The choice of aortic valve prosthesis in aortic stenosis patients is based on patient preference, preoperative age, life expectancy, need for anticoagulant therapy and valve durability. Major uncertainties remain regarding optimal prosthetic valve choice in dialysis patients.

Objectives

The aim of the study was to compare the clinical outcomes after aortic valve replacement with mechanical (MAV) or bioprosthetic valves (BAV) in dialysis patients.

Methods

We used the observational, prospective, multicenter cohort from the Swedish Renal Registry, which includes all dialysis patients in Sweden. The study included 294 dialysis patients with aortic stenosis who underwent aortic valve replacement with MAV or BAV (obtained from surgical procedure codes) between 2005 and 2018, either before (n=155) or after dialysis start (n=139). Comorbidities and net adverse clinical events (bleeding events, stroke and reoperation) were obtained from national registries and defined by International Classification of Diseases codes (ICD-10). The incidence rate (IR) of primary endpoint comprised of all-cause death, bleeding events, stroke and aortic valve reoperation, as well as only all-cause death rates between recipients of MAV or BAV were estimated with Kaplan – Meier curves.

Results

The median age was 72 years (interquartile range [IQR]: 63.9, 77.3), 77% were males and 60% received mechanical valves. During a median follow-up of 1.49 years (IQR: 0.66–2.83), the primary endpoint occurred in 202 patients. Compared to BAV-recipients, those who received MAV had comparable IR of the primary end-point (40.1/100 person-years; [95% Confidence Interval (CI): 33.7–47.7], vs 36.2/100 person-years; [95% CI: 28.9–45.4], P=0.322) (Figure 1).

Mortality rate at 1-year of follow-up was 28.9% without difference between recipients of MAV or BAV (68.8% in MAV-group and 57.6% with BAV; mortality rate MAV 33.3/100 person-year; (95% CI: 27.9–39.8) vs BAV 27.3/100 person-year; (95% CI: 21.5–34.6), P=0. 183)), (Figure 2). Additional statistical analysis of the secondary endpoint based on the occurrence of aortic valve intervention before or after dialysis start, was consistent with the main results.

Conclusion

There is no difference in mortality and complication rates in dialysis patients who underwent aortic valve replacement with MAV or BAV.

Funding Acknowledgement

Type of funding sources: None.
Percutaneous valve commissurotomy in mitral stenosis patients: a 20 years follow-up
Authors: Alves Pinto R , Martins Carvalho M , Proenca T , Costa C , Amador A F , Calvao J , Marques C , Cabrita A , Santos L , Pinho A , Oliveira C , Paiva M , Silva J C , Macedo F
Published: October 2022

Background

Percutaneous valve commissurotomy (PMC) is a viable alternative to mitral valve surgery in the treatment of patients with clinically significant mitral stenosis (MS). Although rheumatic MS incidence has decreased in developed countries, it remains a prevalent healthcare problem in Cardiology clinics

Purpose

To evaluate the early and long-term results of PMC in patients with rheumatic MS and to compare long-term events between patients with and without pulmonary hypertension (PH).

Methods

We retrospectively analysed all consecutive patients between 1991 and 2008 with clinically significant rheumatic MS undergoing PMC. Clinical and echocardiographic data were collected at baseline and during long-term follow-up. MACE was a composite of adverse events defined as all-cause mortality, mitral valve re-intervention or hospitalization for a cardiovascular cause.

Results

A total of 124 patients were enrolled: 87% were female, with a mean age at the time of repair of 46±11 year-old and a mean follow-up of 20±6 years. Before the procedure, 34% were in NYHA class ≥ III and 81% had a Wilkins score ≤8; all patients had preserved biventricular systolic function, 83% presented PH, mean transvalvular gradient (TVG) and mitral valve area (MVA) were 12.8 mmHg and 1.0 cm2, respectively. Most of the procedures were successful (91%) and without complications (94%), with a mean MVA improvement of 0.9 cm2 and reduction of 8.5 mmHg in TVG and 9.7 mmHg in pulmonary artery systolic pressure (PASP) after PMC.

During long-term follow-up, 42% of patients were submitted to re-intervention (most of them surgically) and 24% died. In patients non-submitted to re-intervention, TVG and PASP remained similar with early post-procedure evaluation (p=0.109 and p=0.777, respectively), while MVA reduced over time, yet still statistically superior to baseline MVA (1.6 cm2 vs 1.0 cm2, p<0.001). Concerning time-to-event analysis, approximately 80% of patients kept uneventful after 10 years; after 30 years, more than 20% continued MACE-free and approximately 50% were alive. Regarding PH presence at time of PMC, there was no significant difference in MACE events and all-cause mortality between the two groups (Log Rank, p=0,846 and p=0.661, respectively).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS. After a long-term follow-up patients maintained the reduction in TVG and PASP and a smaller but significative improvement in MVA. Most of the patients were free from adverse events after 10 years and half were alive after 30 years. There was no difference in all-cause mortality and in a composite of all-cause death, mitral valve re-intervention or cardiovascular hospitalization concerning PH presence.

Funding Acknowledgement

Type of funding sources: None.
Prognostic impact of acute kidney injury following tricuspid transcatheter edge-to-edge repair
Authors: Tanaka T , Kavsur R , Sugiura A , Galka N , Oeztuerk C , Vogelhuber J , Becher M U , Weber M , Zimmer S , Nickenig G , Zachoval C
Published: October 2022

Background

A considerable risk of acute kidney injury (AKI) following transcatheter interventions without iodinated contrast agents has also been recognized; however, little is known about the incidence and clinical relevance of post-procedural AKI in patients undergoing transcatheter edge-to-edge repair (TEER) for tricuspid regurgitation (TR).

Purpose

This study aimed to investigate the prognostic impact and predictors of post-procedural AKI following TEER for TR.

Methods

We retrospectively analyzed 218 consecutive patients who underwent TEER for TR. Post-procedural AKI was defined as an increase in serum creatinine of ≥0.3 mg/dl within 48 hours or of ≥50% within seven days after the procedure, compared to baseline. Procedural success was defined as at least one grade reduction in TR severity upon discharge. We determined the association between post-procedural AKI and the composite outcome consisting of all-cause mortality and re-hospitalization due to heart failure within one year after the procedure.

Results

Overall, the mean age of the patients was 79±7 years, and 46.3% of the patients were male. Post-procedural AKI occurred in 32 patients (14.7%) (Figure 1). Among baseline characteristics, male sex and an estimated glomerular filtration rate of <60 ml/min/m2 were associated with the occurrence of AKI. In addition, patients without procedural success had a higher incidence of post-procedural AKI (30.4% vs. 1.8%; p=0.024).

Patients with AKI had a higher incidence of in-hospital mortality compared to those without AKI (12.5% vs. 1.1%; p=0.005). Moreover, AKI was associated with the incidence of the composite outcome within one year after TEER for TR (adjusted hazard ratio: 2.06; 95% confidence interval: 1.11–3.84; p=0.023). In addition, our restricted cubic spline curve showed that a post-procedural increase in the creatinine level within seven days after the procedure was associated with a linear trend of the risk of the composite outcome after TEER (Figure 2).

Conclusions

Post-procedural AKI occurred in 14.7% of patients undergoing TEER for TR, despite the absence of iodinated contrast agents, which was associated with worse clinical outcomes. Male sex and CKD at baseline were related to the occurrence of AKI, and the procedural success of TEER was associated with a lower incidence of AKI. Our findings highlight the clinical impact of AKI following TEER for TR and should help with identifying patients at high risk of AKI.

Funding Acknowledgement

Type of funding sources: None.
Effectiveness of transcatheter edge-to-edge repair for atrial secondary mitral regurgitation
Authors: Tanaka T , Sugiura A , Oeztuerk C , Vogelhuber J , Tabata N , Wilde N , Zimmer S , Nickenig G , Weber M
Published: October 2022

Background

Atrial secondary mitral regurgitation (ASMR) is a subtype of SMR that is characterized by normal left ventricular (LV) function, an enlarged left atrium and mitral annulus, and flattened leaflets. This anatomical feature is different from ventricular SMR (VSMR) and might therefore impact the procedural results of transcatheter edge-to-edge repair (TEER). The effectiveness and durability of TEER in patients with ASMR has not yet been well-studied.

Purpose

This study aimed to investigate the effectiveness of TEER and anatomical characteristics related to optimal MR reduction in patients with ASMR.

Methods

We retrospectively analyzed consecutive patients who underwent MitraClip at our institution. ASMR was defined as cases that met all of the following criteria: 1) normal mitral leaflets without organic disorder, 2) LV ejection fraction >50%, and 3) absence of LV enlargement and segmental abnormality. The primary outcome measure was MR reduction to ≤1+, and its predictors were explored in a logistic regression analysis. Leaflet-to-annulus index (LAI) was measured using the mid-esophageal long-axis view in the A2-P2 segment as follows: (anterior leaflet length + posterior leaflet length) / anteroposterior length of the mitral annulus.

Results

Among 415 patients with SMR, 118 patients met the criteria for ASMR (mean age: 80±8 years; male: 39.8%) (Figure 1). Patients with ASMR had a larger mitral annulus diameter, shorter mobile posterior leaflet length, and smaller coaptation depth compared to those with VSMR.

The technical success rate was 90.7%, and the MR reduction to ≤1+ after TEER was achieved in 94 (79.7%) patients with ASMR, which was comparable with VSMR. The in-hospital mortality rate was 2.5%. In multivariable logistic analysis, a large left-atrial (LA) volume index and a low LAI were associated with a lower rate of MR reduction to ≤1+ after TEER for ASMR (odds ratio [OR]: 0.98; 95% confidence interval [CI]: 0.97–0.99, and OR per 0.1 increase: 1.98; 95% CI: 1.13–3.45, respectively). The combined assessment of the LA volume index and LAI stratified the risk of residual MR ≥2+ after TEER (Figure 2).

In addition, the use of a newer generation of the MitraClip systems (NTR/XTR or G4 systems) was associated with a higher rate of MR reduction to ≤1+ compared to older generations (OR: 4.65; 95% CI: 1.67–13.00).

Conclusions

TEER with the MitraClip system achieved a high rate of MR reduction to ≤1+ in patients with ASMR. Furthermore, the new generations of the MitraClip system may provide a more effective reduction in ASMR. Although our findings suggest that TEER with the MitraClip system is a safe and feasible approach in patients with ASMR, the combined assessment of the LA volume index and LAI might be useful to refine the device selection for transcatheter mitral valve treatment in this subgroup of SMR patients.

Funding Acknowledgement

Type of funding sources: None.
Speckle tracking echocardiography in plasma cell disorders: the role of advanced imaging in the early diagnosis of AL (Light Chain) cardiac amyloidosis
Authors: De Carli G , Mandoli G E , Sciaccaluga C , Biagioni G , Marallo C , Turchini F , Ghionzoli N , Melani A , Barilli M , Pastore M C , Gozzetti A , Giacomin E , Focardi M , Valente S , Cameli M
Published: October 2022

Introduction

Cardiac involvement is described as the most important prognostic factor in light chain amyloidosis. An early diagnosis is mandatory to customize the follow-up timing and the best treatment. The aim of the study was to identify the role of advanced echocardiography in the diagnosis of amyloid light chain cardiac amyloidosis (ALCA).

Material and methods

Seventy-seven patients were prospectively included in the study: 22 patients with biopsy proven ALCA, 28 patients with multiple mieloma, and 27 with monoclonal gammopathy of undetermined significance. All patients underwent first and second level imaging including Speckle Tracking and complete biochemical profile. Univariate and Multivariate analysis was applied to the best multi-chamber predictor assessed with Receiver Operating Curve analysis. Continuous variables were discretized and compared with different subgroups based on multiparametric imaging assessment using available AL score.

Results

Biochemical indices have been confirmed as the best predictors of ALCA. More specifically, high sensitivity troponin (hsTn) and N-terminal pro brain natriuretic peptide (NT-pro-BNP) showed an AUC of 0.88 and 0.91 respectively. Among left ventricular systolic function parameters, left ventricular longitudinal strain (AUC: 0.92); apical sparing pattern (AUC: 0.75) and relative wall thickness (RWT) (AUC: 0.88) showed the best diagnostic accuracy. Atrial parameters such as left atrial volume index (LAVI) (AUC: 0.74), left atrial stiffness (LAS) (AUC: 0.82) and inter-atrial septum diameter (AUC: 0.75) showed a good diagnostic accuracy in ALCA (Figure 1). LAS and AL score maintained their diagnostic value in the multivariate model analysis (B=2,16; p=0,01 and B= 0,72; p<0.01 respectively). However, only LAS, with a cut off value of 0.65, was able to discriminate ALCA when AL score was not detrimental (P<0.001).

Conclusion

ALCA diagnosis often relies only on the biochemical profile. A comprehensive cardiac evaluation by a multiparametric imaging approach with LAS estimation is mandatory to ensure early diagnosis and a prompt treatment through a multidisciplinary team assessment.

Funding Acknowledgement

Type of funding sources: None.