bluuebunny/crossref_metadata_2025 huggingface dataset:
Histological and molecular characterization of human aortic stenosis: a matter of sex
Authors: Matilla L , Jover E , Arrieta V , Garcia-Pena A , Fernandez-Celis A , Navarro A , Gainza A , Alvarez V , Sadaba R , Lopez-Andres N
Published: October 2021

Introduction

Aortic stenosis (AS) is the most common heart valve disease and it is strongly prevalent with elderly. AS is a progressive, degenerative disease associated with fibrosis and calcification of the valve leaflets. Surgical valve replacement is the only treatment available. Molecular, cellular and interstitial events activate multifactorial and complex cues with a significant contribution by valve interstitial cells (VICs). Despite male sex is a risk factor for developing AS, there is scant information on sex-specific differences in aortic valve (AV) biology or pathology.

Purpose

The aim of our study was to analyse sex-specific differences in aortic valves from AS patients.

Methods

185 patients with severe AS undergoing surgical valve replacement were recruited. 149 AVs (66 women; 83 men) were used for ex vivo analyses. Human VICs were isolated from 36 AVs (12 women; 24 men) for in vitro experiments. AVs structure were evaluated by haematoxylin-eosin, Movat, Alizarin Red, Congo red and Alcian blue/Sirius Red staining and immunohistochemistry. Western blot, ELISA and zymography were used for molecular biology studies.

Results

AVs from men presented increased inflammatory infiltrates (CD68 and CD45 positive cells) as compared to women. Complementarily, AVs from men exhibited higher levels of the inflammatory molecules interleukin (IL)-6 and IL-1b and RANTES. In line with these results, oxidative stress markers (eNOS, myeloperoxidase, malondialdehyde and nitrotyrosine) were upregulated in male AVs. Concerning, fibrosis, increased levels of collagen type I, fibronectin and syndecan-1 were found in AVs from men. Extracellular matrix (ECM) remodelling was characterized by reduced metalloproteinase-1 expression and increased tissue inhibitor of metalloproteinase-2 expression in male AVs. Importantly, calcification and osteogenic markers (bone morphogenetic protein-9, periostin, osteocalcin and Sox-9) was greatly enhanced in men AVs as compared to women. These findings were confirmed in isolated VICs. At baseline, male VICs presented higher myofibroblast-like phenotype than female VICs. In line with our ex vivo results, male VICs exhibited increased inflammatory, oxidative stress, fibrotic and osteogenic differentiation markers.

Conclusions

Our results suggest that the mechanisms driving the AV pathogenesis could be different in men and women patients with the same AS severity. Male AVs and isolated VICs presented more inflammation, oxidative stress, fibrosis and ECM remodelling including extensive calcification as compared to female. A better knowledge of the pathophysiological pathways in AVs and VICs will allow developing sex-specific options for AS treatment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III
Sex related differences in exercise performance in patients with hypertrophic cardiomyopathy: hemodynamic insights through non-invasive pressure volume analysis
Authors: Argiro A , Rosenblum H , Griffin J , Batra J , Cappelli F , Burkhoff D , Maurer M , Olivotto I
Published: October 2021

Background

Women with HCM have worse cardiopulmonary exercise performance compared to men. We used non-invasive pressure-volume (PV) analysis to delineate sex related hemodynamic differences in HCM.

Methods

PV loops were constructed from echocardiograms using left ventricular (LV) volumes indexed to body surface area, Doppler estimates of LV end-diastolic pressure and blood pressure. The end-systolic PV relationship (ESPVR) and end-diastolic PV relationship (EDPVR) were derived from validated single-beat techniques. The area between the ESPVR and EDPVR (isovolumetric PV area), was indexed to an LV end-diastolic pressure of 30mmHg (PVAiso30), as the integrated metric of LV function. LV volume at an end-diastolic pressure of 30mmHg (V30) indexed ventricular capacity.

Results

202 patients were included, 56 women. Women were older (51 vs 44 yrs, p=0.012) and had reduced exercise capacity (5.6 vs 6.9 METs, p<0.001). Only 32 patients (16%) had a peak gradient >30mmHg at rest with no sex differences. Women had significantly lower indexed PVAiso30 (6577 vs 7767 mmHg·mL/m2, p<0.001) driven by reduced ventricular capacitance (V30 54 vs 62 ml/m2, p<0.001). In multivariable linear regression indexed V30 was an independent predictor of exercise capacity.

Conclusion

Impaired exercise capacity in women with HCM appears strongly related to abnormalities in passive diastolic properties, suggesting a unique pathophysiology compared to men, and a potential difference in viable therapeutic molecular targets

Funding Acknowledgement

Type of funding sources: None.
Prognostic value of secondary cardiac alterations in patients with moderate aortic valve stenosis
Authors: Stoebe S , Kandels J , Metze M , Lenk K , Kuehne C , Lavall D , Laufs U , Hagendorff A
Published: October 2021

Purpose

Echocardiographic characteristics that predict the progression of moderate aortic valve stenosis (mAS) are lacking. The aim of the present study was to evaluate the prognostic value of left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with mAS.

Methods

A total of 137 patients with asymptomatic mAS (age 72±10 years; females: 51 (37%); Blood Pressure: 143±21 / 78±13 mmHg) were included. Echocardiography was performed at baseline and at follow-up every six or/and twelve months. Patients with concomitant valvular defects, hypertrophic cardiomyopathy or chronic obstructive pulmonary disease were excluded. mAS was defined by current guideline criteria. Left ventricular ejection fraction (LVEF), LVH (LV mass index, males: >115g/m2, females: >95 g/m2), DD (E/e' >14) and PAH (maximum regurgitant velocity of tricuspid valve (TRVmax) >2.8m/s) were assessed.

mAS patients were divided into 4 subgroups based on the number of secondary cardiac alterations: (0) no; (1) one; (2) two; (3) three cardiac alterations. The primary endpoint was progression to severe AS with indication for treatment (effective aortic orifice area (EOA) by continuity equation <1 cm2/<0.6 cm2/m2) or the onset of symptoms.

Results

mAS patients showed (0) no secondary cardiac alterations in 20% (n=28), (1) one in 40% (n=55), (2) two in 26% (n=35) and (3) three in 14% (n=19). Among mAS subgroups, no significant differences were observed for age and comorbidities. Echocardiographic parameters are summarised in Tab.1. In general, mAS patients with ≥ two cardiac alterations showed significantly smaller EOA ((0): 1.32±0.19 vs. 1.29±0.19, p>0.05; (1): 1.26±0.21 vs. 1.18±0.21, p>0.05; (2): 1.29±0.20 vs. 1.01±0.20, p<0.01; (3): 1.31±0.16 vs. 1.06±0.25, p<0.01) and higher mean pressure gradients (PGmean) ((0): 19.8±6.64 vs. 21.8±6.32, p>0.05; (1): 20.0±9.26 vs. 22.3±9.94, p>0.05; (2): 22.7±9.32 vs. 30.5±12.61, p<0.01 (3): 25.0±8.87 vs. 29.4±10.67, p<0.01) between baseline and follow-up (mean follow-up 20±9 months). Further, decrease of EOA/days was significantly higher in these patients ((0) −0.003; (1) −0.006; (2) −0.016; (3) −0.028; p<0.01, Fig. 1). As shown in Kaplan-Meier curve, mAS with ≥ two cardiac alterations showed rapid progression of moderate to severe AS (Fig. 2).

Conclusions

In 40% of patients with mAS ≥ two secondary cardiac alterations (LV hypertrophy, DD and PAH) were observed. The presence of ≥ two of these secondary cardiac alterations is associated with rapid progression of mAS.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Percutaneous bioprosthetic aortic valve durability: results a single center after ten years of follow-up ago
Authors: Munoz-Garcia M , Munoz-Garcia E , Munoz Garcia A J , Dominguez-Franco A J , Alonso-Briales J H , Jimenez-Navarro M F , Hernandez-Garcia J M , Gomez-Doblas J J
Published: October 2021

The durability of transcatheter heart valves and long-term clinical outcomes are unknown. The aim of this study was to evaluate clinical and hemodynamic outcomes 10 years after Transcatheter Aortic Valve Implantation (TAVI).

Methods

Between April 2008 and December 2011, 230 patients underwent TAVI for the treatment of severe symptomatic aortic stenosis with the auto-expandable prosthesis.

Results

The mean age, logistic EuroSCORE and STS score were 79.3±6.4 years, 19.8±13% and 6.8±5% respectively. Mean aortic valve gradient decreased from 49.8±15 mm Hg to 8.6±3.8 mmHg after TAVI, to 11.1±9 mm Hg at 5 years, and 25.7±12 mmHg at 7 years (p for post-TAVI trend 0.03). Mean aortic valve area increased from 0.63±0.16 cm2 to 1.57±0.3cm2 after TAVI to 1.48±0.2 at 5 years and 0.87±0.3 cm2 at 7 years (p for post-TAVI trend 0.01). Mean left ventricular ejection fraction increased from 61.1±15% to 65.5±11% after TAVI, to 58.2±17% at 5 years and 57.2±8% at 7 years (p for post-TAVI trend 0.001).

The total mortality after a mean of 53±34 months was 73% and 34.4% was cardiovascular mortality. Survival rates at 1 to 10 years were at 86%, 75.4%, 64.9%, 59.6%, 52.6%, 33.1%, 24.9%, 20.7%, 10.4% and 10.4% respectively. Only 4 patients had severe prosthetic valve dysfunction (severe stenosis and moderate-severe transvalvular regurgitation). Median survival time after TAVI was 6 years (95% confidence interval [CI]: 5.89 to 6.28), and the risk of death was significantly increased in patients with frailty (adjusted hazard ratio [HR]: 1.874; 95% CI: 1.028 to 3.418), p=0.040, Charlson index [HR=1.212 (95% CI: 1.094–1.341), p<0.001], and age [HR=1.03; (95% CI: 1.001–1.062), p=0.049].

Conclusions

In our center, the transcatheter aortic valve implantation in patients at high surgical risk, presented favourable clinical outcomes and hemodynamic performance after ten years of follow-up.

Funding Acknowledgement

Type of funding sources: None.
Heart rate variability in patients with tetralogy of Fallot
Authors: Otero Luna A V , Church S , Loza A , Rueda-Ochoa O L , Rey Coy M A , Gonzalez Marin C H , Beach C
Published: October 2021

Background

Heart rate variability (HRV) can be used to evaluate cardiac autonomic nervous system activity. In the adult population decreased HRV has been associated with increased mortality in patients with cardiac disease, however, application of HRV in patients with congenital heart disease is not well established.

Purpose

To describe and compare HRV parameters obtained by clinical Holter monitoring in patients with Tetralogy of Fallot (TOF) and healthy controls and to evaluate its association with different clinical outcomes.

Methods

Data from 489 patients were obtained; 150 had undergone repair of TOF and 339 were healthy controls. Using propensity score matching (PSM), 149 TOF patients were matched for sex, age at Holter,body mass index, use of beta-blockers, and ectopic beats with 149 healthy patients. Minimum, maximum, average heart rate and time domain HRV parameters (ASDNN5, SDANN5, SDNN, RMSSD, PNN50) and clinical outcomes (arrhythmias, hospital admission for cardiac disease, and functional class) were compared between groups using simple and multiple linear regression models as well as logistic regression analysis.

Results

No significantdifference was found in time domain HRV parameters between the two groups, though average (−7.0253, p=0.000) and maximum (−15.8585, p=0.000) heart rate values were significantly lower in patients with TOF compare with controls. Logistic regression analysis showed an association between maximum heart rate values and the development of arrhythmias (OR=0.9817, p=0.013), as well as the functional class (OR=0.9706, p=0.03).

Conclusion

Average and maximum heart rates are significantly lower in patients with repaired TOF compared to the control population. Time domain HRV parameters were not associated with clinical outcomes in patients with TOF when compared to healthy controls. Further investigation assessing frequency domain parameters may provide further insight.

Funding Acknowledgement

Type of funding sources: None.
Normal values for paediatric biventricular volumes, ejection fraction and mass – influence of cardiovascular magnetic resonance analysis techniques
Authors: Hinz S , Caliebe A , Wage R , Boroni Grazioli S , Uebing A , Voges I , Krupickova S
Published: October 2021

Background

Measurement of ventricular volumes and function by steady-state free precession (SSFP) cardiovascular magnetic resonance (CMR) is an important diagnostic tool in the treatment and follow-up of paediatric congenital heart disease. However, normal values are rare and the CMR analysis methods are inconsistent.

Aims

We sought to create two sets of ventricular normal values for different CMR analysis (contouring) methods.

Methods

In a retrospective study design, CMR data sets of 154 healthy children with an age range between 4 and 18 years from two centers in the UK and Germany were evaluated. Left and right ventricular end-diastolic and end-systolic volumes (LVEDV, LVESV, RVEDV, RVESV), ejection fraction (RVEF, LVEF) and myocardial mass (LVMM, RVMM) were analysed from short axis steady-state free precession images by using two different analysis techniques: 1) papillary muscles, myocardial trabeculations and the moderator band were included in the ventricular volume and excluded from the ventricular mass (Figure 1), 2) papillary muscles, myocardial trabeculations and the moderator band were excluded from the ventricular volume and included in the ventricular mass (Figure 2). Sex-specific reference curves were created separately for both ventricular contouring methods using the lambda mu sigma method. Correlations between variables were analyzed with the Spearman's rank correlation. Contouring methods were compared through Bland-Altman analysis.

Results

The mean age was 13.85±2.8 years (53 girls).

In children from 4 to 10 years average ventricular volumes and mass normalized for body surface area (BSA) measured:

In children from 11 to 18 years average ventricular volumes and mass measured:

Separate centile charts and centile tables for boys and girls for all cardiac parameters were created.

Conclusion

We provide paediatric CMR reference values for biventricular volumes, ejection and masses for two different CMR contouring methods. They can be used in the diagnosis and follow-up of congenital or acquired heart disease in children and for research purposes.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Transcatheter versus surgical valve repair in patients with severe mitral regurgitation
Authors: Koschutnik M , Dannenberg V , Dona C , Nitsche C , Kammerlander A A , Mora B , Bartunek A , Wiedemann D , Zimpfer D , Huelsmann M , Schneider M , Bartko P E , Goliasch G , Hengstenberg C , Mascherbauer J
Published: October 2021

Background

Transcatheter edge-to-edge mitral valve repair (TMVR) is increasingly performed, however, its efficacy in comparison with surgical MV treatment (SMV) is unknown.

Methods

Consecutive patients with severe mitral regurgitation (MR) undergoing TMVR (68% functional, 32% degenerative) or SMV (9% functional, 91% degenerative; 23% MV replacement) were enrolled. To account for differences in baseline characteristics, propensity score-matching including age, EuroSCORE-II, left ventricular ejection fraction, and NT-proBNP was performed. A composite of heart failure (HF) hospitalization/death was defined as primary endpoint. Kaplan-Meier curves and Cox-regression analyses were used to investigate associations between baseline, imaging, and procedural parameters and outcome.

Results

Between July 2017 and April 2020, 245 patients were enrolled, of which 102 patients could be adequately matched (73y/o, 61% females, EuroSCORE-II: 5.7%, p>0.05 for all). Despite matching, TMVR patients were sicker at baseline (higher rates of prior myocardial infarction, coronary revascularization, pacemakers/defibrillators, and diabetes mellitus, p<0.009 for all).

Patients were followed for 28.3±27.2 months, during which 27 events (17 deaths, 10 HF hospitalizations) occurred.Postprocedural MR reduction (MR grade <2: TMVR vs. SMV: 88% vs. 94%, p=0.487) and freedom from HF hospitalization/death (log-rank: p=0.221) were similar at two years. By multivariable Cox analyses, EuroSCORE-II (adj.HR 1.07 [95% CI: 1.00–1.13], p=0.027) and postprocedural MR severity (adj.HR 1.85 [95% CI: 1.17–2.92], p=0.009) emerged as independent predictors of outcome.

Conclusions

In this propensity matched, all-comers cohort, 2-year outcomes after TMVR versus SMV were similar. Given the reported favorable long-term durability of TMVR, the interventional approach emerges as valuable alternative for a substantial number of patients with functional and degenerative MR at high/prohibitive surgical risk.

Funding Acknowledgement

Type of funding sources: None.
The impact of valve selection on haemodynamics in patients with small annuli undergoing contemporary transcatheter aortic valve implantation
Authors: Medranda G , Rogers T , Zhang C , Case B C , Yerasi C , Forrestal B J , Chezar-Azzerad C , Bendor I , Satler L F , Waksman R
Published: October 2021

Background/Introduction

The use of smaller THVs in transcatheter aortic valve implantation (TAVI) can result in suboptimal haemodynamics with long-term implications on valve durability in patients with smaller aortic annuli.

Purpose

The objective of this study was to examine the predictive value of aortic annulus size on THV haemodynamics in patients with small annuli undergoing contemporary TAVI.

Methods

This was a retrospective, observational study of 857 patients who underwent TAVR using either the intra-annular SAPIEN 3 THV or the supra-annular CoreValve Evolut PRO THV at our institution between 2015–2020. Patients were dichotomized based on a native aortic annulus size above or below 430mm2. We then examined 30-day hemodynamics and outcomes in each subgroup and based on THV selection.

Results

The majority of patients with an annular area <430mm2 were females (82.5%). Of the 857 patients screened, 542 had an annular area >430mm2 and the remaining 315 had an annular area <430mm2. In patients with small aortic annuli, mean gradients were lower at 30 days if they received a supra-annular THV (8.1mmHg vs. 13.8mmHg; p<0.001) which led to lower rates of moderate or severe patient prosthesis mismatch (36.7% vs. 85.4%; p<0.001) (Table 1). All-cause mortality was similar in small annuli between THV groups at 1 year (Table 2).

Conclusions

The majority of patients with small aortic annuli (<430mm2) undergoing TAVI with contemporary THVs were females. Those that received a supra-annular THV saw superior haemodynamics at 30-days with similar mortality at 1 year.

Funding Acknowledgement

Type of funding sources: None.
Factors determining mitral valve dysfunction in patients who underwent surgical mitral valve replacement with bio-prosthetic valves
Authors: Gwak S Y , Kim D Y , Seo J W , Cho I S , Lee S H , Lee S , Hong G R , Ha J W , Shim C Y
Published: October 2021

Background

There is increasing Interest in bio-prosthetic MVD as recent advances in transcatheter MV interventions, but there is limited data.

Objectives

The aim of this study was to identify the factors determining mitral valve (MV) dysfunction (MVD) in patients who underwent MV replacement with bio-prosthetic valves. Also, we sought to investigate clinical outcomes in patients with bio-prosthetic MVD.

Methods

A total of 233 patients underwent surgical bio-prosthetic MV replacement between June 1996 and May 2015. Finally, 226 patients (mean age 66.9±11.5 years, 74.3% of women) were analyzed, excluding patients who followed-up for less than 5 years and patients whose baseline or follow-up echocardiography could not be analyzed. Clinical, echocardiographic, and laboratory data were collected early after the surgery and during follow-up. MVD was defined as an increase in mean gradient ≥5 mmHg with leaflet motion limitation and/or newly developed MV regurgitation during follow-up. Clinical outcome was defined as a composite of cardiovascular death, redo MV surgery or intervention, and hospitalization for heart failure.

Results

During a median of 102.0 months (interquartile range 72.0 to 132.0 months), 65 patients (28.8%) revealed MVD. 8 (12.3%) patients revealed predominant MV obstruction, and 57 (87.7%) showed predominant MV regurgitation. Factors associated with bio-prosthetic MVD by multivariate regression analysis were young age at operation (hazard ratio 0.97, 95% CI 0.95–0.99, p=0.001), end-stage renal disease (hazard ratio 4.29, 95% CI 1.45–12.71, p=0.007), elevated mean diastolic pressure gradient>5.5 mmHg across the bio-prosthetic MV early after operation (hazard ratio 1.86, 95% CI 0.97–3.74, p=0.063) and anemia after operation (hazard ratio 0.84, 95% CI 0.74–0.95, p=0.007). However, the presence of hypertension, dyslipidemia, or porcine bio-prosthesis was not related to the bio-prosthetic MVD. Kaplan-Meier curves revealed significant differences in event-free survivals for the occurrence of bio-prosthetic MVD according to each factor (Figure 1). Patients with bio-prosthetic MVD showed significantly poor clinical outcomes compared with those without bio-prosthetic MVD (event-free survival 43.1% vs. 91.9%, log-rank p<0.001) during the follow-up.

Conclusions

Young age at operation, end-stage renal disease, elevated mean pressure gradient early after the operation, and anemia after operation were associated with bio-prosthetic MVD in patients who underwent bio-prosthetic MV replacement.

Funding Acknowledgement

Type of funding sources: None.
Effect of antimicrobial therapy on the embolic events in patients with infective endocarditis
Authors: Povalyaev N , Kotova E , Pisaryuk A , Karaulova Y , Kobalava Z
Published: October 2021

Background

Embolic events (EE) are presented in up to 50% of the cases of infective endocarditis (IE). Main approach in prevention of the embolisms is properly timed surgery and antimicrobial therapy. But specific antimicrobial drug to prevent embolic events is not yet established.

Purpose

To analyze effect of a distinct group of an antimicrobials on association with embolic events in patients with IE.

Methods

255 patients with verified IE (DUKE 2009, 2015), hospitalized and treated from January 2010 to January 2020, were included in the study. Patients underwent clinical investigation including physical examination, laboratory and instrumental studies.

Results

About one quarter (27.5%) of the patients had an embolic event after initiation of antimicrobial therapy. Embolism localizations include: brain (30%), lungs (47%), kidneys (20%), spleen (14%), coronary (8%) and peripheral arteries (5.7%). Most common causative agent was Staphylococcus aureus (25.5%). There were no clinical association between a certain group of antimicrobials and embolic outcome (table). However, effectiveness of the first-line antimicrobial, eradication of pathogen and abscence of infection persistence was associated with lower rate of embolism

Conclusion

In correspondence to guidelines adequate antimicrobial therapy (eradication of a pathogen and abscence of infection persistence) is associated with lower thromboembolic risk regardless of certain group of antimicrobials.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): RUDN University Strategic Academic Leadership Program.
Natural history of left ventricular hypertrophy in infants of diabetic mothers
Authors: Monda E , Verrillo F , Altobelli I , Lioncino M , Caiazza M , Rubino M , Cirillo A , Fusco A , Di Fraia F , Pacileo R , Gragnano F , Passariello A , Calabro' P , Russo M G , Limongelli G
Published: October 2021

Background

Left ventricular hypertrophy (LVH) in infants of diabetic mothers (IDMs) has been generally considered a benign condition, which usually regresses as the stimulus for the insulin production disappears, resulting in normalized left ventricular wall thickness in the 6 months of life. However, these conclusions have been based on small, mostly outdated cohort studies. Indeed, it has been recently shown that increased left ventricular mass persists in late infancy (6 to 12 months), long after the intrauterine exposure has been removed, suggesting that other factors may potentially contribute.

Purpose

This study sought to describe the characteristics and the natural course of LVH in a well-characterized consecutive cohort of IDMs.

Methods

Sixty consecutive IDMs with LVH have been retrospectively identified and enrolled in the study. All IDMs were evaluated at baseline and every 6 months until LV wall thickness regression, defined as the decrease of wall thickness measurement into the normal reference range for cardiac parameters (z-score >−2 and <2). A comprehensive assessment was performed in those patients with diagnostic markers suggestive of a different cause and/or without significant reduction of the LVH during follow-up.

Results

At 1-year follow-up, all IDMs showed a significant reduction of maximal wall thickness (MWT) (MWT-mm: 6.67±2.37 vs. 5.83±1.70, p-value<0.001; MWT-z-score: 6.67±4.71 vs. 2.39±2.55, p-value<0.001) and left ventricular outflow tract (LVOT) gradient (15.35±15.58 vs. 11.22±8.14, p-value<0.004), compared to baseline, and all patients showed LV wall thickness regression or residual mild or moderate LVH (57%, 28%, and 12%, respectively) (Figure 1), except 2 patients with persistent severe LVH, that after a comprehensive clinical-genetic assessment were diagnosed as Noonan syndrome with multiple lentigines.

At multivariate analysis, MWT was significantly associated with LV wall thickness regression at 1-year follow-up (MWT-mm: OR 0.48 [0.29–0.79], p-value=0.004; MWT-z-score: OR 0.71 [0.56–0.90], p-value=0.004) in an inversely proportional fashion.

Overall, 59%, 72% and 79% of IDMs with LVH showed a complete LV wall thickness regression at 1-year, 2-year and 3-year follow-up, respectively (Figure 2). Excluding the two patients with a different cause of LVH, all IDMs showed a LV wall thickness regression in the first 6 years of life.

Conclusions

LVH in IDMs represents a benign condition with complete regression during the first years of life. In those patients without LV wall thickness regression, combined with clinical markers suggesting a specific disease, a complete work-up is required for a definite diagnosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Long term outcomes for adults with complete atrioventricular septal defects
Authors: Seitler S , Al-Sakini N , Lacerna A , Flick C , West C , Senior R , Gatzoulis M A , Li W
Published: October 2021

Background/Introduction

Complete Atrio-Ventricular septal defect (AVSD) is a complex congenital cardiac disease, characterised by malformation at the atrio-ventricular junction and AV valve abnormalities. Long- term outcome data is limited.

Purpose

We sought to describe the long-term outcomes of adults with repaired complete AVSD in a tertiary adult congenital heart centre.

Methods

We retrospectively recruited patients with complete AVSD who underwent surgical repair between 1973 and 2001 in our centre. All clinical and echocardiographic data were collected and analysed for evidence of atrio-ventricular valve (AVV) deterioration, or cardiac dysfunction. We also assessed for the requirement for further surgical intervention throughout the follow up period.

Results

A total of 345 patients with AVSD were identified, partial AVSD 211, unrepaired 82. Fifty-two with repaired complete AVSD formed study group, female 36 (69%) and male 16 (31%), Trisomy 21 (23, 44%). Mean age at initial repair was 44 months (median 12, IQR 31.5). Mean follow up was 25.3 years (Median 24, IQR 9.75).

Clinical status: At the latest follow-up, most patient were asymptomatic with NYHA I-II (n=46) Majority (n=36, 69%) required only initial repair and no further intervention. Further surgeries were performed in 16 patients including AVV repair (n=9) and LVOTO relief (n=3). Permanent pacemaker insertion needed in 6 (12%), all for heart block following valve repair. 7 patients (14%) had documented arrythmia, 4 (8%) requiring ablations and only 1 had endocarditis.

Echo findings: AV Valve dysfunction was more commonly regurgitant rather than stenotic. More than moderate AVV regurgitation was present in 83% of patients, Left AVV (n=25, 48%), Right AVV (n=18, 35%) compared to 4% stenosis (LAVV n=1, RAVV n=1). Ventricular outflow tract obstruction was present in 8% of patients, RVOT obstruction (2, one native, one secondary to prior banding), LVOT obstruction (2, both native, one requiring surgical intervention).

Right ventricular systolic dysfunction was present in 6% of patients (n=3), with mean TAPSE 14.1mm (SD± 3.1mm). Left ventricular dysfunction was present in 4% (n=2), mean LVEF 58.9% (SD±7.1%) and mean LV EDVi 55.06mL/m2 (SD±13.2 mL/m2). Only one patient had significant pulmonary hypertension (Mean PAP 48 mmHg).

Conclusion

Long-term outcomes of surgically repaired AVSD are highly favourable. Left AVV regurgitation is the most common residual lesion requiring further surgical intervention. Ventricular outflow tract obstruction was much less common, as was ventricular systolic dysfunction. Complete heart block was associated with surgical repair and arrhythmias were potential late complications.

Funding Acknowledgement

Type of funding sources: None.
Usefulness of transthoracic echocardiography for pulmonary artery aneurysm screening in patients with pulmonary arterial hypertension
Authors: Guisasola Cienfuegos M , Nuche J , Lareo A , Alonso S , Arribas-Ynsaurriaga F , Escribano Subias P , Jimenez Lopez-Guarch C
Published: October 2021

Background/Introduction

Pulmonary artery aneurysm (PAA), defined as a pulmonary artery (PA) diameter >40 mm, is a common finding among pulmonary arterial hypertension (PAH) patients. Although often asymptomatic, PAA may lead to life-threatening complications such as left main coronary artery compression or PA dissection. Transthoracic echocardiography (TTE) is regularly employed for risk assessment in PAH patients. However, TTE accuracy for PA measurement has not been evaluated, and current practice guidelines lack formal recommendations for PAA screening and follow-up. We aim to determine whether TTE is an appropriate tool for PA diameter measurement and determine an optimal cut-off point to diagnose a PAA through TTE.

Methods

We retrospectively analyzed a cohort of 657 PAH patients followed up at a national referral centre. For this analysis, we selected those patients who had undergone at least one TTE and one computed tomography (CT) or magnetic resonance (MR) within six months before or after the TTE. We performed an agreement analysis between CT/MR-based and TTE-based PA diameter using the Passing–Bablok method. Furthermore, we calculated the area under the curve for the identification of a PAA with a TTE (compared to CT/MR).

Results

We analyzed 281 simultaneous CT/MR and TTE of a total of 178 PAH patients (71% women). Median age at diagnosis was 42.1 (32.2–58.0) years. PAH etiology was idiopathic or familial in 67 (38%), associated with congenital heart disease in 28 (16%) and associated with connective tissue disease in 36 (20%) patients. In 46 (26%) patients PAH was associated with other entities, such as human immunodeficiency virus, pulmonary veno-occlusive disease, drugs or portal hypertension. We found a significant correlation between PA diameter measured in TTE and CT/CMR (Lin's concordance correlation coefficient = 0.851) (Figure 1). The area under the curve for the detection of PAA was 0.91 (95% CI 0.88–0.95, p=0.018) (Figure 2). We selected a TTE-based PA diameter 37 mm as the optimal cut-off point for PAA identification. This diameter correctly classified 85.4% of measurements with a sensitivity and a specificity of 83.2% and 87.2%, respectively.

Conclusion

Our study demonstrates that TTE is an adequate tool for PA diameter quantification with a strong correlation with CT/MR. This good correlation makes TTE an excellent tool for PAA screening among PAH patients, avoiding unnecessary CT or MR scan and helping to identify those patients in whom close follow-up is advisable. Based on these results, we recommend the inclusion of PA diameter measurement in TTE acquisition protocols for PAH patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Passing–Bablok regression lineFigure 2. ROC curve for PAA detection with TTE
Mitral annular disjunction and cardiovascular outcome in Marfan syndrome
Authors: Demolder A , Muino-Mosquera L , Timmermans F , Duytschaever M , De Backer J
Published: October 2021

Background

Mitral annular disjunction (MAD) has received growing interest in patients with mitral valve prolapse (MVP), ventricular tachycardia (VT) and sudden cardiac death (SCD). The clinical significance of MAD in Marfan syndrome (MFS) remains largely unexplored.

Purpose

To define the prevalence of MAD and examine the relation with cardiovascular outcomes and arrhythmia in patients with MFS.

Methods

The presence of MAD was assessed by echocardiography and the extent of MAD was categorized in tertiles. Patients also underwent resting ECG and 24-hour Holter monitoring. Outcomes included aortic events (aortic dissection or prophylactic aortic surgery), arrhythmic events (VT/SCD) and mitral valve surgery.

Results

A total of 142 patients (median age 25 years [range 2–64], 51% women) were evaluated. Forty-eight (34%) patients had MAD. Patients with MAD had larger aortic root Z-scores (4.1 [2.8–5.7] vs. 3.0 [1.8–4.0], p<0.001) and more often showed MVP (71% vs. 15%, p<0.001), ventricular ectopy (42% vs. 21%, p=0.027) and non-sustained ventricular tachycardia (39% vs. 17%, p=0.014) than patients without MAD. During follow-up, aortic events occurred at similar rates in patients with vs. without MAD (35% vs. 25%, p=0.103), but patients in the upper MAD tertile (>10mm) showed a higher occurrence of aortic events (60% vs. 21%, p=0.011) compared to patients with MAD(+) ≤10mm. Arrhythmic events and a need for mitral valve surgery were observed exclusively in patients with MAD (p=0.004 and p<0.001, respectively).

Conclusions

MAD is associated with a higher need for mitral valve intervention, occurrence of arrhythmic events and, in patients with extensive MAD, more aortic events. Cardiac imaging in MFS should consider the assessment of MAD as a potential marker for adverse outcome.

Funding Acknowledgement

Type of funding sources: None. Cardiovascular outcome and arrhythmia
Angioplasty of flow limiting stenosis improves left ventricular diastolic dysfunction in patients with peripheral artery disease
Authors: Baasen S , Stern M , Heinen Y , Goerdes L , Sansone R , Heiss C , Kelm M , Busch L
Published: October 2021

Background

Peripheral artery disease (PAD) is associated with hypertension and left ventricular diastolic dysfunction (LVDD).

Objective

We hypothesized that endovascular treatment of flow limiting peripheral stenosis may improve LVDD.

Methods

In this prospective single center trial, 23 patients with PAD Rutherford stage 2–4 were included. Augmentation index (AIx), central systolic blood pressure (cSBP) and ankle brachial index (ABI) were measured at baseline one day before, one day after and at follow up 4 months after angioplasty. LVDD was assessed by echocardiography at baseline and at follow up.

Results

Mean E/E' ratio was significantly lower at follow up (11.9±4.4 to 10.2±4.4; p<0.01). Likewise, left atrial size (17.2±5.3 to 13.6±4.7 mm; p=0.014) decreased significantly, but not left atrial volume index (LAVI, 49.73±21.6 to 38.29±17.3 mL/m2; p=0.062). ABI acutely increased in the intervened leg and remained stable at follow up (0.71±0.13 to 0.84±0.13 to 0.89±0.18; p<0.001). AIx (from 30.5±6.1 to 26.5±9.2; p=0.03) and cSBP (from 133±21 to 126±20 mmHg; p=0.05) acutely decreased after angioplasty. At follow up, there was no significant change in central hemodynamics (AIx, cSBP) as compared to baseline.

Conclusion

Chronic effects of angioplasty are associated with favorable improvement of diastolic function but not central hemodynamics.

Funding Acknowledgement

Type of funding sources: None.
Repeat revascularization impact on 10-year survival after PCI or CABG: post-hoc analysis of the SYNTAXES trial
Authors: Lunardi M , Ono M , Onuma Y , Serruys P
Published: October 2021

Background

Available data comparing Percutaneous Coronary Interventions (PCI) and Coronary Artery Bypass Graft (CABG) in multivessel or left main coronary artery disease (CAD) suggest higher rates of repeat revascularization events after PCI than CABG, with a negative influence on outcomes up to 5 years. The impact of repeat revascularization on very long-term outcomes remains unclear.

Aims

This study aims to investigate the impact on 10-year all-cause death of repeat revascularizations in patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD).

Methods

The SYNTAXES study evaluated the vital status out to 10-year of patients with 3VD and/or LMCAD enrolled in the SYNTAX trial. Repeat revascularization events occurred within the first 5 years from the index procedure were adjudicated by an independent clinical events committee. Effects of repeat revascularizations on 10-year all-cause death were investigated through time-dependent Cox regression analysis.

Results

During the first 5 years, 330 out of 1800 patients (18.3%) underwent a minimum of one repeat revascularization, for a total of 459 repeat revascularization procedures, mostly consisting of repeat-PCI (393, 85.6%). Repeat revascularizations were more frequent among patients initially randomized to PCI (HR 2.3, 95% CI: 1.8–3.0, p<0.0001). At 10 years, all-cause death was comparable between patients underwent any repeat revascularization and those not (27.6% vs. 25.1%, adjusted HR 2.3, 95% CI: 0.8–6.2, p=0.11). However, among patients requiring repeat revascularizations, who underwent initial PCI versus initial CABG presented a significantly higher 10-year all-cause death (32.7% vs 17.3%, p=0.004). The adjusted risk for 10-year all-cause death according to the subtypes of repeat revascularizations revealed only revascularization with CABG was an independent predictor (HR 6.2, 95% CI: 1.5–25.2, p=0.011).

Conclusions

In the SYNTAX trial, repeat revascularizations were more frequent after initial PCI. Although no difference on 10-year all-cause death was observed between patients who did undergo repeat revascularizations and who did not, higher death rates were reported among those required any repeat procedures after initial PCI or revascularization with CABG. These exploratory findings should be investigated with larger population in future studies.

Funding Acknowledgement

Type of funding sources: None. Survival curves at 10-year follow-up
Biodegradable polymer drug eluting stents versus durable polymer drug eluting stents for percutaneous coronary intervention
Authors: Kheifets M , Levi A , Bental T , Perl L , Codner P , Wittberg G , Talmor-Barkan Y , Landes U , Samara A , Greenberg G , Erez A , Vaknin-Assa H , Kornowski R
Published: October 2021

Background

Invasive angiography with subsequent revascularization is a widely used treatment method in patients with coronary heart disease. Although biodegradable polymer drug eluting stents (BP-DES) have been used for almost a decade now, clinical trials regarding their long-term outcomes are both sparse and inconsistent. We aimed to compare the long-term outcomes of patients undergoing percutaneous coronary intervention (PCI) with BP-DES versus durable polymer drug eluting stents (DP-DES).

Methods

Among 11,517 PCIs with second generation drug eluting stents preformed in our institution between 2007 and 2019, we identified 8042 procedures performed using DP-DES and 3475 using BP-DES. The primary outcome was the composite of all-cause mortality, recurrent myocardial infarction (re-MI), target vessel revascularization (TVR) and coronary artery bypass grafting (CABG). Propensity score matching was used to create a well-balanced cohort.

Results

Mean follow up was 4.8 years. Of the 3,413 matched pairs, 21% were females, and the mean age was 66. At one year, the primary outcome occurred in 9.6% patients versus 8.3% (p=0.05), and TVR rate was 4.1% versus 3% (p=0.005) in patients with DP-DES and BP-DES respectively. Within 5 years, the primary outcome occurred in in 24.9% versus 24.8% (p=0.83), and the rate of TVR was 9.8% versus 9.1% (p=0.07) in patients with DP-DES and BP-DES respectively.

Conclusions

Similar rates of the composite outcome were observed throughout the entire follow-up. TVR rates were lower in the DP-DES group at 1-year but equalized within 5 years.

Funding Acknowledgement

Type of funding sources: None.
In hospital outcomes of orbital/rotational coronary atherectomy in diabetic vs non-diabetic population: insights from the nationwide inpatient sample
Authors: Kurpad K , Mehta H , Sohal S , Garg N , Gopal S , Zainib M , Suthar K , Jumkhawala S , Ahsan M , Hawthorne K
Published: October 2021

Background

Atherectomy (AT) using an orbital/rotational system is useful in altering calcified plaque thereby facilitating stent placement and optimal stent expansion. Patients with diabetes mellitus (DM) are known to have a higher rate of complications after percutaneous coronary intervention. We aimed to assess the incidence of major adverse cardiovascular events after atherectomy in the diabetic population using a nationwide inpatient sample (NIS).

Methods

NIS-HCUP database from 2015–2017 was used to identify patients who underwent atherectomy. A cohort of patients with and without diabetes was identified. Demographics, in-hospital outcomes, complications in both groups were compared. Statistical significance was assigned at p<0.05.

Results

Out of 6184 patients who underwent AT, 3134 (50.6%) patients had DM. Baseline characteristics have been outlined in the table below. Complications were comparable between the two groups except for higher incidence of post-procedure VTE in Diabetic patients. In-hospital mortality was lower among patients with DM (2.24% vs 3.29%, p-0.27), while the mean length of stay (5.92 vs 4.91 days, p-0.002) and the hospitalization charges ($165118.4 vs 151226, p-0.04) were higher, but this difference in length of stay and hospitalization charges were nullified on multivariate regression.

Conclusion

Our study suggests that an AT for severely calcified plaque in the coronary artery is a safe option in patients with DM with comparable in-hospital complications and outcomes to non-DM patients.

Funding Acknowledgement

Type of funding sources: None. Demographics and Outcomes of Atherectomy
Association between recovered acute kidney injury within 48hours and mortality in patients following coronary angiography: a cohort study
Authors: Li Q , Chen S Q , Huang H Z , Liu L W , Chen W H , Zhou J H , Tan N , Liu J , Liu Y
Published: October 2021

Background

The association of recovered acute kidney injury (AKI) with mortality was controversial. Our study aims to investigate the impact of recovered AKI on mortality in patients following coronary angiography (CAG).

Methods

Our study retrospectively enrolled 3,970 patients with pre-operative serum p creatinine (Scr) and twice measurements within 48hours after procedure. Recovered AKI defined as the diagnosis of AKI (Scr >0.3 mg/dL or >50% from the baseline level) on day 1 when Scr failed to meet the criteria for AKI on the day 2. Maintained AKI was defined as AKI not meeting the definition for recovered AKI. The primary outcome was 1-year all-cause mortality. Multivariable logistic regression was used to assess the association between recovered AKI and 1-year mortality.

Results

Among 3,970 participants, 861 (21.7%) occurred AKI, of whom 128 (14.9%) was recovered AKI and 733 (85.1%) was maintained AKI. 312 (7.9%) patients died within 1-year after admission. After multivariable analysis, recovered AKI was not associated with higher 1-year mortality (adjusted odds ratio [aOR], 1.37; CI, 0.68–2.51) compared without AKI. Among AKI patients, Recovered AKI was associated with a 52% lower 1-year mortality compared with maintained AKI. Additionally, maintained AKI was significantly associated with higher 1-year mortality (aOR, 2.67; CI, 2.05–3.47).

Conclusions

Our data suggested that recovered AKI within 48h was a common subtype of AKI following CAG, without increasing mortality. More attention need to be paid to the patients suffering from maintained AKI following CAG.

Funding Acknowledgement

Type of funding sources: None. Association of AKI and mortalitySubgroups analysis
Left ventricular outflow morphology as a predictor of arrhythmic disturbances after TAVI
Authors: Espejo Paeres A C , Marroquin L , McInerney A , Hennessey B , Perez-Vizcayno M J , Tirado G , Macaya F , Nunez-Gil I , Mejia-Renteria H , Gonzalo N , Salinas-Sanguino P , Fernandez-Ortiz A , Escaned J , Nombela-Franco L , Jimenez-Quevedo P
Published: October 2021

Introduction

Left bundle branch block (LBBB) and permanent pacemaker (PM) are frequent complications after transcatheter aortic valve implantation (TAVI), but few predictors have been reported.

Purpose

This study sought to determine the relationship between left ventricular outflow tract (LVOT) morphology and the development of conduction disturbances after TAVI.

Methods

From 1/2020 to 12/2020 consecutive patients who underwent TAVI and an analyzable CT scan in our center were selected. Patients were categorized according to the LVOT morphology into three groups. The delta value between mean aortic root diameter (AA-d) and mean LVOT-d were calculated, and divided into terciles. In patients in the third tercile the AA-d was greater than LVOT-d and was defined as tapered-LVOT (group 1). First and second terciles had tubular or flared-LVOT shape and were defined as group 2. We compared conductance disorders after TAVI with and without tapered-LVOT. Primary endpoint was the combined of new-onset of transient/persistent LBBB, and PM. Factors with p<0.05 on the univariate analysis were entered into the multivariate analysis.

Results

Among 98 eligible patients thirty-two patients (33%) presented a tapered-LVOT (Group 1) and 66 (67%) had tubular or flared-LVOT morphology (group 2). The mean age was 80.5±5.5 years and 60% were female. Baseline characteristics were similar between groups except for the incidence of dyslipidemia that was higher in group 2. The primary study endpoint was significantly higher in group 1 (78% vs. 59%: p=0.036). After adjusting for confounding factors, this relationship remained statistically significant (OR: 2.81 (CI95%: 1–7.96), p 0.046). Independent predictors of conduction disturbance were: tapered-LVOT, prior coronary artery disease and prior surgical valve replacement.

Conclusions

After TAVI, patients presenting a tapered-LVOT morphology have a 2.8-fold greater risk to develop LBBB or require permanent PM when compared to another LVOT shapes.

Funding Acknowledgement

Type of funding sources: None.