bluuebunny/crossref_metadata_2025 huggingface dataset:
Arrhythmogenic right ventricular cardiomyopathy: the importance of biventricular strain in risk-stratification
Authors: Chua A P A , Laenens D , Sarrazyn C , Lopez Santi P , Nabeta T , Myagmardorj R , Bootsma M , Barge- Schaapveld D Q C M , Bax J J , Ajmone Marsan N
Published: October 2024

Background

Despite Arrhythmogenic right ventricular cardiomyopathy (ARVC) being a predominant right ventricle (RV) disease, concomitant left ventricle (LV) involvement has been recognized. ARVC diagnosis is made through the RV-centric 2010 Task Force Criteria (TFC), but previous studies already suggested the use of echocardiographic strain measures to better depict RV and LV dysfunction in these patients. No data however is available on the additional value of combining biventricular strain in ARVC for risk stratification.

Purpose

To assess the prognostic value of measuring both LV global longitudinal strain (GLS) and RV free wall strain (FWLS) analysis in patients with ARVC.

Methods

A total of 204 patients who met the TFC for the ARVC spectrum were included. Patients were categorized based on a cut-off of -18% for strain impairment in both ventricles. The end-point was a composite of all-cause mortality, arrhythmic events, ICD therapy and heart failure events.

Results

Patients (age 41 ± 17 years, 55% males) were divided into impaired (n=33), discordant (either RV or LV impaired, n=70), and normal (n=101) strain groups (Fig. 1A). Definite and borderline ARVC were diagnosed in 78% and 39%, respectively, at the time of first available echocardiography. During a follow-up of 87 [24-136] months, 60 (29%) experienced the combined outcome, and a significant difference in event-free survival was observed (p<0.001) between the 3 groups (Fig. 1B). In the multivariate analysis (Fig. 2), the strain grouping remained associated with outcome (p=0.040) after adjusting for age, gender, history of syncope and definite ARVC diagnosis, which were also significantly associated with the endpoint at the univariate analysis. A sub-analysis including only definite and borderline ARVC patients confirmed that the strain grouping was an independent predictor of the composite endpoint (p=0.027).

Conclusion

Biventricular involvement by strain analysis has additional prognostic value in ARVC patients and outcome is worse for those with both RV and LV involvement.Strain groups and Kaplan Meier curvesMultivariate analysis
Impact of discordance in cardiac troponin T versus I on the performance of triage pathways for myocardial infarction
Authors: Glaeser J , Lopez-Ayala P , Spagnuolo C , Koechlin L , Nestelberger T , Bima P , Crisanti L , Boeddinghaus J , Miro O , Sanchez J M , Christ M , Mueller C
Published: October 2024

Background

Biological, analytical, and regulatory differences between high-sensitivity cardiac troponin T (hs-cTnT) and hs-cTnI could lead to an underestimation of the performance of a hs-cTnT-based triage-algorithm if evaluated against a hs-cTnI-based reference standard, and vice versa. Unfortunately, the impact of hs-cTnT/hs-cTnI-discordance on diagnostic performance measures is largely unknown.

Methods

We quantified the impact of hs-cTnT/hs-cTnI-discordance on the diagnostic performance of the three most widely used and guideline recommended hs-cTnT/I-based triage algorithms for patients presenting with symptoms suggestive of myocardial infarction (MI): the ESC 0/1h-algorithm, the ESC 0/2h-algorithm and the High-STEACS pathway. For the central adjudication of the final diagnosis (reference standard), two independent cardiologists had access to all available clinical information and applied the 4th universal definition of MI, one time with serial hs-cTnT-Elecsys measurements (gold standard T) and a second time with serial hs-cTnI-Architect measurements (gold standard I). The primary diagnostic endpoint for the rule-out of NSTEMI was sensitivity, while for rule-in of NSTEMI specificity.

Results

Among 7728 eligible patients, the final diagnosis was NSTEMI in 1463 patients (18.9%). Of these, NSTEMI was diagnosed with only one of the two adjudication methods (either gold standard T or I) in 167 (11.4%) patients. When the three hs-cTnT-based early-triage algorithms were evaluated using gold standard T and gold standard I, sensitivity was very high and comparable. In contrast, when the three hs-cTnI-based early-triage algorithms were evaluated using gold standard T and gold standard I, sensitivity was again very high, but consistently lower when using gold standard T as compared to gold standard I. The difference in sensitivity was 1.1% (95%CI, 0.6–1.7) for ESC hs-cTnI-0/1h (Table 1A), 1.0% (95% CI, 0.5—1.6) for ESC hs-cTnI-0/2h (Table 1B), and 2.6% (95%CI, 1.7—3.5) for High-STEACS (Table 2). The differences observed in specificity mirrored those for sensitivity, i.e. always lower specificity when using the other hs-cTnT/I-assay for adjudication.

Conclusion

The impact of hs-cTnT/hs-cTnI-discordance on the diagnostic performance of hs-cTnT/I-based triage algorithms is modest, but large enough to result in a fallacious underestimation of the rule-out safety when evaluating hs-cTnI-based strategies using a hs-cTnT-based reference standard.
Prognostic significance of the estimated pulse wave velocity in critically ill patients with coronary heart disease
Authors: Gu Y , Dang A
Published: October 2024

Background

The estimated pulse wave velocity (ePWV) has emerged as an alternative measurement of arterial stiffness which has been suggested as a potential marker for mortality and cardiovascular risk. Nonetheless, its prognostic significance in critically ill patients with coronary heart disease (CHD) remains uncertain.

Methods

Patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) were grouped into quartiles according to the ePWV levels. We conducted logistic and Cox regression analyses to examine the association between ePWV and both in-hospital and 1-year all-cause mortality among critically ill patients with CHD. Additionally, we employed restricted cubic spline (RCS) analysis to explore the relationship between ePWV as a continuous variable and mortality.

Results

A total of 11001 patients (men: 63.6%, age: 71.94 [IQR: 62.69-81.31]) were included in this study. In-hospital mortality and 1-year mortality rates were 9.1% and 25.1%, respectively. Multivariable logistic regression models demonstrated that ePWV was independently associated with an elevated risk of in-hospital mortality (OR 1.27; 95%CI [1.14-1.41]; p<0.001) and 1-year mortality (OR 1.49; 95% CI [1.38-1.60]; p<0.001]. The restricted cubic splines regression model revealed a linear relationship between ePWV and both in-hospital and 1-year mortality (p for non-linearity = 0.098 and p for non-linearity = 0.156, respectively).

Conclusion

Our findings indicate a linear association between ePWV levels and short- and long-term mortality in critically ill patients with CHD.
Interscan reproducibility of computed tomography derived coronary plaque volume measurements using a semi-automated analysis software
Authors: Iraqi N , Mortensen M B , Sand N P , Busk M , Grove E L , Dey D , Pedersen K B , Kanstrup H , Madsen K T , Parner E , Jensen J M , Noergaard B L
Published: October 2024

Background

Coronary computed tomography angiography (CCTA) enables detailed quantification and characterization of coronary atherosclerotic plaque, offering diagnostic and prognostic value. Despite the growing demand for accurate plaque analysis, studies on interscan reproducibility of automated plaque quantification are limited in number and size. Moreover, impact of clinical and technical factors on the reproducibility of plaque assessment tools are scarce.

Purpose

The objective of this study was to assess the interscan reproducibility of CCTA-derived plaque volume measurements and the implications of clinical and technical characteristics on interscan reproducibility.

Methods

A total of 101 patients with known coronary artery disease underwent two CCTA scans within hour interval using identical CT acquisition protocol. Coronary plaque volume measurements were quantified on a per-patient level using a contemporary semi-automated plaque analysis software.

Results

There was no statistically significant difference in median plaque volumes between the first and second scan. The direct correlation was excellent for volumes of non-calcified plaque (NCP), calcified plaque (CP), and total plaque (TP) across all analyses (Pearson’s coefficient 0.96 to 0.99), while moderate for low-density non-calcified plaque (LD-NCP) volumes (Pearson’s coefficient 0.77). Bland Altman analyses demonstrated high interscan agreement with narrow absolute and relative limits of agreement (LoA) across plaque subtypes, except for LD-NCP volumes (Table 1). Interscan reproducibility on CP volumes was affected by CT image quality with narrower LoA in scans with the highest image quality score (p = 0.003), or lowest image reconstructive iteration level (p <0.001). Limits of agreement were significantly narrower for NCP, CP, and TP volumes in lesions located in LAD compared to non-LAD lesions (p <0.001). However, no significant difference in LoA was present when comparing patients according to BMI (<27 and ≥27 kg/m2), heart rate (<65 and ≥65 beats per minute), or Agatston score (<193 and ≥193).

Conclusions

This comprehensive interscan reproducibility study revealed good agreement in the measurement of plaque subtypes. Adding new insight to existing literature, we have demonstrated that factors such as image quality, image reconstructive algorithms, and lesion location affect the reproducibility of plaque volume measurements. CT-derived plaque quantification using a semi-automated plaque analysis software holds potential for monitoring disease progression or regression in patients with CAD, provided high CCTA image quality.
Association of cardiac amyloidosis with periprocedural complications in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis
Authors: Figueira T , Tao M , Ibtida I , Masson R , Zhang D , Sharma A , Kim P , Pastena P , Gavalas M , Goldschmidt M , Tam E
Published: October 2024

Introduction

Cardiac amyloidosis (CA) has been frequently observed in patients with aortic stenosis (AS). While transcatheter aortic valve replacement (TAVR) may be an option, the association of CA with risk of periprocedural complications has not been well evaluated.

Purpose

This study aimed to evaluate the association of CA with periprocedural complications after TAVR in patients with severe AS.

Methods

A literature search was performed for studies evaluating patients with severe AS undergoing AVR, comparing periprocedural safety endpoints for patients with and without CA. The primary endpoints were vascular complications and bradyarrhythmias post-TAVR requiring permanent pacemaker (PPM) implantation. Secondary endpoints included periprocedural acute kidney injury (AKI), cerebrovascular accidents (CVA), and major bleeding events. Endpoints were defined using the Valve Academic Research Consortium-2 criteria. The search was not restricted to time or publication status.

Results

6 studies with 1,138 patients with severe AS (150 with CA, 988 without CA) met inclusion criteria. Mean age was 82 years, 52.4% were men, all except 1 study assessed only patients with ATTR CA. Echocardiographic mean aortic valve parameters included valve area of 0.718 cm2, mean gradient of 40.8, and peak velocity of 4.13 m/s. The mean left ventricular ejection fraction was 55.2%.

The presence of CA was not associated with an increased risk of periprocedural vascular complications (OR 0.69, 95% CI 0.25-1.88; p=0.47). While a trend toward higher risk of periprocedural PPM implantation was observed in patients with CA, this finding did not reach statistical significance (OR 1.51; 95% CI 0.77-2.94; p=0.23).

The presence of CA was not associated with increased risk of periprocedural AKI, CVA, or major bleeding (OR 1.3, 95% CI 0.32-5.3; p=0.72, OR 0.65, 95% CI 0.17-2.41; p=0.52; OR 0.55, 95% CI 0.16-1.87; p=0.34).

Conclusion

In the context of patients with severe AS undergoing TAVR, the presence of cardiac amyloidosis did not increase the risk of periprocedural complications, including vascular complications, AKI, CVA, or major bleeding. Although a trend toward a higher risk of bradyarrhythmias requiring PPM implantation was noted in patients with CA, further studies are warranted to confirm this observation. Overall, these findings contribute valuable insight into the safety profile of TAVR in the patients with CA.Figure 1Figure 2
Correlation of prosthesis position on mid-term pacing burden in patients with new permanent pacemaker after TAVI
Authors: Breitbart P , Schmitt R , Salz-Sculean Y , Hein J , Brado J , Hein M , Westermann D , Ruile P
Published: October 2024

Background

Prior studies suggest a strong correlation of the final prosthesis position on the occurrence of new conduction disturbances resulting in permanent pacemaker (PPM) implantation after transcatheter aortic valve implantation (TAVI). A high burden right ventricular pacing (PPM stimulation rate of > 20 %) is associated with poor long-term outcomes. So far, data about predictors influencing the PPM stimulation rate after TAVI are scarce.

Purpose

Thus, the purpose of this study was to evaluate the influence of the three-dimensional transcatheter heart valve (THV) position, as well as device landing zone characteristics or peri-/post-procedural factors on the stimulation rate in patients with new implanted PPM as TAVI complication.

Materials: We evaluated the final THV position of 387 patients (106 with self-expanding Evolut R THV, 281 with balloon-expandable Sapien 3 THV) using fusion imaging of pre- and post-TAVI computed tomography angiography (CTA) to obtain a three-dimensional reconstruction of the THV within the native annulus region. The length of the THV above and below the native annulus was measured within the fused images to assess the implantation depth. PPM stimulation rates were examined pre-discharge and after 3 months. Patient’s clinical long-term outcome was evaluated over 5 years via standardized questionnaire as well as contacting general practitioners.

Results

Out of the 387 patients 112 (29%) received a new PPM pre-discharge after TAVI between 2014 and 2022. They were grouped into patients with stimulations rate below and above 20%. A stimulation rate > 20% in the PPM control before discharge and after three months was detected in 69 % and 67 % of them, respectively.

Using uni- and multivariate logistic regression analysis, only new occurred third degree atrioventricular blocks (p=0.007) was identified as predictor for high burden right ventricular pacing after PPM-implantation as well as after 3 months. The implantation depth of the THV showed no influence on the PPM stimulation rate – neither the mean value nor the exact implantation depth adjacent the left, right and non-coronary cusp (P=0.455, P=0.108 and P=0.932, respectively).

There were no significant differences regarding MACE between both groups during long-term follow-up; only the degree of dyspnea 5 years after TAVI was significantly higher in patients with a stimulation rate > 20% (p=0.01).

Conclusion

We detected no correlation of the exact three-dimensional THV position on mid-term pacing burden in 112 patients implanted with a new PPM after TAVI using CTA fusion imaging. Only a new occurred third degree atrioventricular block was a predictor for a high burden right ventricular pacing (stimulation rate >20%). These results provide important insights into which patients actually require PPM implantation after TAVI.
Prospective evaluation of transcatheter aortic valve implantation (TAVI) with coronary alignment and impact on coronary access
Authors: Pavitt C , Arunothayaraj S , Michail M , Broyd C , Cockburn J , Hildick-Smith D
Published: October 2024

Introduction

Transcatheter aortic valve implantation (TAVI) with optimised coronary alignment aims to reduce coronary-commissural overlap (CCO) to facilitate future coronary intervention and reduce the risk of coronary obstruction after re-do TAVI, however, in-vivo data are lacking.

Aims

To determine the feasibility of TAVI with coronary alignment assessed by post-TAVI CT. Secondary endpoints included the incidence of adverse anatomical features which could impede coronary access (severe CCO and ostia below valve skirt) and their association with coronary engagement during invasive angiography.

Methods

30 patients underwent TAVI with optimised coronary alignment with either ACURATE neo2 or Evolut Pro+ and invasive coronary angiography and cardiac CT performed after valve deployment.

Results

15 patients received ACURATE neo2 (50%) and 26 patients (86.7%) underwent CT after TAVI. The mean inter-coronary angle was 140 (19.5)° and the median observed angular deviation from perfect alignment (0°) was 0.8° (IQR -4.5 to +10) ° with perfect alignment (±15°) observed in 21/26 cases (80.8%) and ≤mild misalignment (±30°) in 24/26 of cases (92.3%). The remaining two cases had moderate misalignment (30-45°) with no cases of severe misalignment. The angle between the coronary ostia and the nearest TAVI commissure was 46 (40 - 57) ° for the RCA and 50.5 (43 - 54) ° for the LCA which did not differ significantly from the native situation (both p>0.2), with 1 (3.8%) case of severe overlap. 46/55 (83.6%) coronary engagements were selective, 7/55 (12.7%) semi-selective and 2/55 (3.6%) unable to intubate. Non-selective engagement/unable to engage affected the RCA more than the LCA (6/27 [22.2%] vs. 3/28 [10.7%]) and was three-fold more common with the Evolut (7/29 [24.1%]) than the Acurate (2/26 [7.7%]. Coronary>commissural angle in those with unselective engagement was 43° (IQR 37 to 51°).

Conclusions

TAVI with optimised coronary alignment is technically feasible, safe and reduces coronary-commissural overlap which is important for future re-do TAVI procedures. Difficult coronary access was encountered more frequently following Evolut Pro+ and when engaging the RCA, but was unrelated to angular distance to nearest commissure.
Prognostic relevance of baseline right ventricular echocardiographic evaluation in patients undergoing valvular surgery with tricuspid intervention
Authors: Mane F , Luque M , Melo C , Azzam I K , Anguita Gamez M , Mahia P , Perez De Isla L , Olmos C , Marcos-Alberca P , Gomez-Polo J C , Perez-Villacastin J , De Agustin A , Maroto L , Carnero M , Pozo Osinalde E
Published: October 2024

Background

Tricuspid valve (TV) intervention is frequently performed both as part of multivalvular surgery and as an isolated procedure. Tricuspid regurgitation (TR) significantly worsen right ventricular (RV) function, which is a prognostic determinant in many clinical scenarios.

Purpose

Our aim was to evaluate the relevance of baseline right ventricular (RV) baseline echocardiographic in the prognosis after tricuspid valve surgery (TVS).

Methods

Retrospective observational study of patients undergoing TVS between 2009 and 2022 in our tertiary centre. Baseline right chambers echocardiographic parameters were evaluated: RV diameters (basal, mid and longitudinal), TAPSE, fractional area change (FAC), Doppler tissue velocity of the tricuspid annulus (RVS´) and free wall- (FW-) and 4 chambers- (4C-) global longitudinal strain (GLS). Likewise, systolic pulmonary artery pressure (sPAP) and left ventricular ejection fraction (LVEF) were collected among other variables. Association of echocardiographic parameters with major clinical events at year was explored.

Results

Finally 273 consecutive patients (71 ± 10.5 years old, 66.7% female) that underwent valvular surgery with tricuspid intervention were included. Multivalvular procedure was performed in 81.3% (50.6% mitral and tricuspid, 25.6% mitral, aortic and tricuspid and 5.1% aortic and tricuspid) and EuroScore was 5 [3-9]. The most common TV lesion was TR (97.8%), functional in 84.2%. The main surgical technique was tricuspid annuloplasty with prosthetic ring (57.9%). Preoperative echocardiographic parameters are presented in Table. Baseline LVEF was 59 [53-65]%. The most frequent postoperative complication was low output (23.4%) and there was an overall mortality rate of 8.3% during the first year of follow-up. Postsurgical low output state was associated with vena contracta TR (0,78 vs 0,66 cm; p <0.001) and 4C-GLS ((-15.7 vs -17.3%; p= 0.03). None of the baseline echocardiographic variables was associated with early mortality.

Conclusions

Baseline RV echocardiographic parameters were associated with postoperative low output but not mortality. The relatively preserved RV dimensions and function in our series may explain these findings.

Table. Baseline RV echocardiographic variablesTable
Measures of insulin resistance and aortic valve calcification in the general population
Authors: Wang Gottlieb A , Gottlieb-Vedi E , Norhammar A , Gyberg V , Spaak J , Lofmark H , Lind L , Soderberg S , Bjorck H , Engstrom G , Ostgren C J , Jernberg T , Bergstrom G , Settergren M , Shahim B
Published: October 2024

Background

Insulin resistance (IR) is a key component in several cardiovascular risk factors. The triglyceride-glucose index (TyG index), triglyceride to high density lipoprotein-cholesterol ratio (TG/HDL-C) and visceral adiposity index (VAI) are easily accessible surrogate measures of IR and have been associated with coronary artery calcification and other cardiovascular diseases. Less is known about IR and aortic valve calcification (AVC).

Purpose

To investigate the association between different measures of IR (TyG index, TG/HDL-C, VAI) and AVC.

Method

The Swedish Cardiopulmonary Bioimage Study (SCAPIS) recruited 30 154 randomly selected individuals aged 50 to 64 years from the general population in Sweden between 2013 to 2018. AVC was assessed visually on cardiac computed tomography and categorized as present or absent. TyG index was calculated based on triglyceride and glucose levels, TG/HDL-C ratio using triglyceride and HDL-C levels and VAI using waist circumference, triglyceride and HDL-C levels. The association between IR indexes (as continuous variables by 1 unit increment and categorical variables by quartiles) and AVC was assessed using multivariable logistic regression models.

Results

In total, measures of IR were available in 29 268 participants of whom 2118 (7%) had AVC. Mean IR index levels were higher in participants with compared to without AVC (TyG index: 8.65 vs. 8.49; p<0.01; TG/HDL-C: 1.11 vs. 0.91; p<0.01 and VAI: 1.73 vs. 1.48; p<0.01). All three indices of IR were associated with AVC in continuous analyses. Subsequently, in multivariable logistic regressions adjusted for age, sex, study site and smoking, there was a stepwise increase in the risk of AVC with increasing quartiles of TyG index, TG/HDL-C and VAI (Figure 1).

Conclusion

Three different surrogate measures of IR (TyG index, TG/HDL-C and VAI) were all associated with AVC in a middle-aged general population suggesting that they could all be used as risk markers in clinical practice.
Comparative analysis of a novel preoperative stratification method versus traditional scores in patients with severe aortic stenosis undergoing aortic valve surgery
Authors: Espinoza Romero C , Egypto Rosa V , Octavio Kormann S , De Santis Andrade Lopes A S , Spina G , Cordeiro Fernandes J R , Tarasoutchi F , Orismar Sampio R
Published: October 2024

Introduction

It is crucial to consider factors that complicate the indication of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS), such as narrow valve ring, extensive calcification or inadequate vascular access. (1-4) Thus, aortic valve replacement surgery (SAVR) remains a recommended indication, with its pre-surgical stratification being a challenge. (1-3) Despite the widespread use of scores like the STS and EuroSCORE II, they exhibit limitations, being validated primarily for populations outside Latin America and focusing predominantly on individual factors while often neglecting structural parameters like left ventricular hypertrophy, diastolic dysfunction, or left atrium volume. (3-5)

Purpose

This study aimed to assess whether a novel modified Généreux stratification method offers superior predictive value for postoperative mortality in AS patients compared to traditional scoring systems.

Methods

We conducted a retrospective, single-center study involving patients with confirmed severe AS who underwent aortic valve replacement surgery between January 2017 and December 2021. The new stratification method categorized patients into three stages based on echocardiographic parameters (see Figure 1). Univariate and multivariate Cox regression analyses were conducted to identify predictors of mortality, with survival analysis performed using Kaplan-Meier curves. A p-value <0.05 was considered statistically significant.

Results

A total of 508 patients were included in the study. Stage 1 patients had a lower median age (62 years vs. 67 years in stages 2 and 3). The median EuroSCORE and STS were 2.75 and 2.62%, respectively, with stage 3 showing significantly higher scores (p ≤0.001). Over a median follow-up of 81 months, 56 deaths occurred (11%). Kaplan-Meier curve analysis revealed significant differences in all-cause mortality among the three groups (HR 4.073, log-rank p≤0.001), as illustrated in Figure 1. Multivariate analysis identified the three preoperative stages (HR 3.22, [95% CI 1.44-7.20], p=0.004) and mean transaortic gradient (HR 0.96, [95% CI 0.92-0.99], p=0.021) as independent predictors of mortality. The new stages demonstrated a superior area under the ROC curve of 0.758 compared to traditional scores (see Figure 1).

Conclusions

The novel three-stage preoperative classification and low transaortic gradient serve as significant predictors of mortality in patients undergoing SAVR. These stages exhibit robust predictive capability for mortality compared to EuroSCORE II and STS.Baseline and multivariate analysisKaplan-meier and ROC curve
Extracellular volume analysis on cardiac computed tomography is useful to predict prognosis after cardiac resynchronization therapy
Authors: Suzuki K , Takaoka H , Kondo Y , Nishikawa Y , Matsumoto M , Aoki S , Yashima S , Kinoshita M , Kobayashi Y
Published: October 2024

Background

Left-ventricular (LV) extracellular volume (ECV) (LVECV) is often evaluated on magnetic resonance imaging (MRI), and the value is well correlated with biopsy-identified myocardial fibrosis. Recently, mechanical development has been achieved, and ECV analysis on cardiac computed tomography (CCT) has been eligible using the latest software, and the ECV on CCT is well correlated with the ECV on MRI. Cardiac resynchronization therapy (CRT) has been usually performed in cases with severe heart failure, but almost 30 percent of them are non-responders. Therefore, the indicators to predict non-responders to cardiac resynchronization therapy (CRT) have been sought in advance.

Purpose

The purpose of this study is to reveal the utility of LVECV on CCT for the prediction of patient prognosis in the candidates of cardiac resynchronization therapy (CRT) who have low LV function.

Methods

We analyzed 53 patients (30 males, 65 ± 14 years old) with heart failure who underwent CCT, including late phase scan, using 320-row detector CT (Aquilion One or Aquilion One ViSion Edition, Cannon Medical Systems) or 256-row detector CT (Revolution CT Apex, GE Healthcare), before the implantation of a CRT device from December 2008 to January 2024. The primary outcomes were defined as cardiac death, hospitalization due to HF, and fatal arrhythmia after CRT implantation. CRT responders were defined as the patients whose LV endo-systolic volume was decreased by 15% or more on transthoracic echocardiography.

Results

Twenty-two patients (42%) had primary outcomes (10 cardiac death, 7 fatal arrhythmia, 5 hospitalization due to HF). LVECV was lower in CRT responder (n = 23) than the others (n = 25) (35 ± 6.3% vs 41 ± 6.8%, P = 0.006). LVECV was higher in the patients with primary outcomes (n = 22) than the others (n = 31) (35 ± 5.0% vs 41 ± 7.8%, P = 0.019). Based on the receiver-operating characteristics curve analysis, the best cut-off of LVECV for predicting primary outcomes was 44.03% (B). In the survival analysis using the Cox proportional hazard model, LVECV on CCT was a significant predictor of primary outcomes (HR, 1.07; 95% CI, 1.13-1.01; P = 0.012). On Kaplan-Meier analysis, the higher LVECV group (≥ 44.03%) had a significantly greater number of primary outcomes than the others (P = 0.010) (C).

Conclusion

LVECV on CCT may be useful for predicting responders of CRT and prognosis after CRT implantation.ROC curve and Kaplan-Meier analysis
Prognostic impact of cardiac events in asymptomatic mitral regurgitation
Authors: Girdauskas E , Behrendt C , Baldus S , Mboulla Nzomo M , Marschall U , Acar L
Published: October 2024

Background

Mitral regurgitation (MR) is the most common valvular heart disease in adults and is associated with increased morbidity and mortality. Treatment recommendations of degenerative MR have been liberalized, however, the role of asymptomatic patients is still insufficiently defined.

Purpose

The purpose of this study were to evaluate the prevalence of cardiac events in a large asymptomatic MR cohort, based on health insurance data analysis, in comparison with healthy propensity score-matched general population and to define the prognostic impact of such cardiac events on ten-year survival.

Methods

We retrospectively analyzed health insurance claims data from Germany’s second largest health insurance fund, which maintains longitudinal data on outpatient and inpatient medical services for 8.7 million German residents. We included all patients with an outpatient diagnosis of MR (I34.0) in a minimum of two quarters during a calendar year and first recorded diagnosis between 2008 and 2011. To identify an asymptomatic MR cohort (study group), all patients with at least one complication attributable to MR / mitral valve intervention during the incidence quarter of MR were excluded. Ten-year outcomes were compared between study group vs. age- and sex-matched healthy control group. Cardiac events of interest were new congestive heart failure, new-onset atrial fibrillation, pulmonary hypertension, or cardiac decompensation.

Results

A total of 56.577 (62.7%) asymptomatic MR patients were identified from the whole cohort of 90.245 individuals with a newly diagnosed MR in the BARMER database. During a ten-year follow-up, 26.282 (46.5%) patients in the study group experienced at least one cardiac event vs. 11.763 (20.8%) individuals in the control group (OR: 3.31, 95%CI: 0.251-0.262, P<0.0001). The occurrence of at least one cardiac event (i.e., congestive heart failure, new-onset atrial fibrillation, pulmonary hypertension or cardiac decompensation) in the study group was associated with a significantly worse ten-year survival as compared to the control group. The risk of cardiac events was age- and sex-dependent, while female patients with an asymptomatic MR had a lower risk as compared to males in all age groups (OR: 0.38, 95%CI: -1.193- -0.754, P<0.0001). Only 1.530 (2.7%) patients underwent mitral valve (MV) intervention in the study group during ten-year follow-up.

Conclusions

Our study reveals high incidence of asymptomatic MR in a representative cohort of health insurance claims data in Germany. Every second patient with an asymptomatic MR experiences at least one cardiac event during a ten-year follow-up period that is associated with a significantly worse survival. The definition of asymptomatic MR cohort at risk of developing cardiac events may potentially improve early treatment strategies and lead to better outcome in the future.Abstract picture
Left ventricular longitudinal strain analysis using cardiac computed tomography for the diagnosis of cardiac amyloidosis
Authors: Kinoshita M , Takaoka H , Ota J , Matsumoto M , Nishikawa Y , Aoki S , Suzuki K , Yashima S , Sasaki H , Suzuki-Eguchi N , Yoshida K , Kanaeda T , Kobayashi Y
Published: October 2024

Introduction

Cardiac amyloidosis (CA) results in a restrictive cardiomyopathy caused by extracellular deposition of proteins in the myocardium, demanding early identification for effective management.

Left ventricular (LV) strain, mainly evaluated by echocardiography or cardiac magnetic resonance, provides sensitive and specific indicators for detecting CA, particularly apical sparing. It represents a pattern where the longitudinal strain (LS) in the basal and middle segments of LV is more impaired compared to the apical segments.¹

Cardiac computed tomography (CT) is useful not only for coronary artery evaluation but also for myocardial assessment, including LV ejection fraction (LVEF). Advanced software made it possible to analyse LS on cardiac CT (Figures A,B).

Hypothesis: LS analysis using four-dimensional cardiac CT is helpful for the differential diagnosis of LV hypertrophied myocardial diseases and for detecting CA.

Methods

We analyzed 60 patients with LV hypertrophied myocardial diseases who underwent cardiac CT using 256-detector row or 320-detector row CT since 2009. Twenty patients of them were diagnosed with CA ( 70 ± 10 years, 14 males), the other 20 patients were diagnosed with hypertrophic cardiomyopathy (HCM) ( 60 ± 14 years, 12 males), and the rest of the 20 patients were diagnosed with severe aortic valve stenosis (AS) ( 86 ± 6 years, nine males). We analyzed LV global LS (GLS) and segmental LS using specific software and four-dimensional CT data. We evaluated relative apical LS as the value dividing the average LS of apical segments by the sum of the average LS of basal segments and mid-ventricular segments (Figure C). If the value was ≥ 1, apical sparing was defined as present. We compared the LS data and the percentage of apical sparing among those three myocardial diseases.

Results

There was no significant difference in LVEF among the three groups (52 ± 14%, 55 ± 27%, and 50 ± 18%, respectively; P = 0.15). There was no significant difference in GLS among the three groups (-10.6 ± 3.6%, -10.2 ± 5.2%, and -11.6 ± 3.8%, respectively; P = 0.87). Apical sparing was observed in 13 cases (65%) of CA, which was significantly higher than 3 cases (15%) of HCM or 4 cases(20%) of AS (P = 0.0002).

Conclusions

LV strain analysis using cardiac CT is helpful for detecting apical sparing. Advanced image analysis software has enabled LV strain analysis by cardiac CT, which is useful for the differential diagnosis of CA among LV hypertrophied diseases.Figure A,B,C
Association between left atrial dysfunction and adverse outcomes after tricuspid valve surgery for atrial functional tricuspid regurgitation
Authors: Lee J W , Kim K , Gwak S Y , Lee H J , Cho I S , Lee S H , Lee S , Hong G R , Ha J W , Shim C Y
Published: October 2024

Objectives

To identify factors associated with clinical outcomes in patients undergoing tricuspid valve (TV) surgery for atrial functional tricuspid regurgitation (AF- TR).

Methods

Among 1,670 patients who underwent TV surgery between January 2000 and December 2020, we included 83 AF-TR patients (69.1±9.2 years, 50 women) who had severe TR without any cause other than atrial fibrillation. A comprehensive analysis of right ventricular (RV) and left atrial (LA) function on preoperative and postoperative echocardiography was performed. LA function was evaluated by LA emptying fraction (LAEF), LA reservoir strain, and LA stiffness index. The primary outcome was a composite of all-cause death and heart failure hospitalization during follow up after surgery.

Results

For a median of 39.9 (interquartile range 19.9 to 55.8) months, the primary outcome occurred in 20 (24.1%) patients. Patients with a primary outcome showed significantly lower LAEF (9.7±7.3 vs. 21.8±6.7 %, p<0.001) and LA reservoir strain, and higher LA stiffness index than those without. However, there was no difference in RV chamber size and functional parameters according to the occurrence of a primary outcome. The restricted cubic spline plot exhibited a significant relationship between LAEF and primary outcome. The low baseline LAEF (<17%) group showed a poorer outcome than the high LAEF group (log rank p<0.001). In the Cox regression analysis, the low LAEF (<17%) was independent predictor for primary outcome (adjusted hazard ratio 13.5, 95% confidence interval 3.1–58.6).

Conclusion

In patients undergoing TV surgery with AF-TR, preoperative LA dysfunction was independently associated with adverse outcomes.Figure1
Transcatheter valve replacement as rescue treatment for heart failure in infective endocarditis. A multinational series.
Authors: Fernandez Hidalgo N , Villamarin Melio M , Arregle F , Urena M , Pascale R , Escrihuela F , Pulido P , Snygg-Martin U , Ternacle J , Boutoille D , Calvino Santos R , De Alarcon A , Fernandez Oses P , Goikoetxea A J , Amat I
Published: October 2024

Background

Transcatheter valve replacement (TVR) could be a therapeutic alternative for refractory heart failure in patients with infective endocarditis (IE) unsuitable for open surgery. However, evidence of tis use in this scenario is limited to isolated case reports.

Purpose

We aimed to describe the clinical characteristics and outcome of IE patients in whom a TVR was performed during the active phase of infection in a multinational case series.

Methods

This retrospective study was conducted in 23 referral hospitals for IE and TVR procedure in 8 countries. All consecutive adult patients (≥18 y) with definite IE in whom a TVR was performed during antimicrobial treatment of within the 3 three months after its withdrawal were included. The inclusion period was between July 2011 and July 2023. Baseline, IE-related, TVR-related, outcome and follow-up (min. 3 months) variables were collected.

Results

Forty-five patients [median age 74 years (IQR 64 – 82), 35 males (78%), median Charlson comorbidity index 6 (4 – 7) points] were included in the study: 42 aortic TVR, 2 mitral TVR and 1 tricuspid TVR. In 20 patients (44%) TVR was performed on a native valve and in 25 on a prosthetic valve. The most frequent microorganisms causing IE were streptococci (n=16, 36%), staphylococci (n=13, 29%) and enterococci (n=5, 11%).

Acute heart failure was present in 41 (91%). Of them, 23 (51%) developed acute pulmonary oedema or cardiogenic shock. The main reasons for excluding open surgery were: high surgical risk [n=39, 87%; median EuroSCORE 17 (9 – 28)] and technical impossibility (n=3, 7%).

TVR was performed during antimicrobial treatment in 27 cases (60%) [median 25 (13 – 54) days after initiation] and within the first three months after its completion in 18 (40%) [median 25 (17 – 68) days after discontinuation].

Four patients (9%) died during admission. Over a median follow-up of 10 (6 -30) months, 7/41 patients (17%) died and there were 2/41 (5%) relapses, one of which required open valve replacement surgery 17 days after TVR procedure. Two other patients underwent open surgery due to paravalvular leaks (11 and 44 days after TVR). All cases of relapse and open surgery occurred when TVR was performed during antibiotic treatment.

Conclusion

TVR could be an option as rescue treatment for heart failure in selected IE patients unsuitable for open surgery. This represents a paradigm shift in the management of IE and may change the natural history of the disease in patients who would otherwise die.
Extracranial systemic embolic events in patients with atrial fibrillation: an individual patient-level meta-analysis of 71 683 patients randomized to NOAC vs warfarin from the COMBINE-AF study
Authors: Al Said S , Braunwald E , Palazzolo M G , Geller B J , Ruff C T , Antman E M , Carnicelli A P , Connolly S J , Eikelboom J W , Granger C B , Patel M R , Wallentin L , Giugliano R P
Published: October 2024

Background

Atrial Fibrillation (AF) poses a significant risk for both ischemic stroke and systemic embolic events (SEE). While the effectiveness of NOAC in preventing ischemic stroke is well-established, there is a lack of detailed analyses specifically characterizing SEE, which constitutes 5- 10% of all embolic events.

Purpose

To study the clinical characteristics, procedural management, and outcomes by randomized treatment (NOAC vs warfarin) of patients with SEE.

Methods

Using the COMBINE AF dataset, we conducted an individual patient level meta-analysis of 4 global RCTs (RE-LY, ROCKET AF, ARISTOTLE, ENGAGE AF-TIMI 48) of warfarin vs. NOAC in AF to assess risks of SEE. Outcomes were analyzed as time-to-first-event using a Cox proportional hazards model. Two authors independently reviewed deaths within 30 days after SEE to identify fatal SEE. Moreover, we independently assessed post SEE procedures to determined relatedness to SEE.

Results

There were 188 total SEEs, 9 patients (5%) had SEE then developed ischemic stroke; 16 patients (9%) had ischemic stroke then developed SEE; 1 patient had SEE and ischemic stroke simultaneously. Among the 171 patients with SEEs as first event, the median (IQR) age was 75 (68-80) years, 49.7% were female, median (IQR) of BMI was 27.5 (23.5-30.7) kg/m2, mean (SD) of CHADS2-VASC score was 4.7 (1.5). As compared with ischemic stroke (n=1789), SEE patients were more likely to have, PAD (16.5% vs. 5.4%, p <0.001), prior MI (24% vs. 17%, p = 0.02), be Vitamin K Antagonist experienced (57% vs 46%; p=0.007), have worse renal function (median CrCl mL/min; 58 vs 62, p = 0.02) and less likely to have paroxysmal AF (14% vs. 20%, p = 0.05). Of the total of 188 SEEs, 33 (18%) were fatal, 62 (31%) patients underwent surgical or percutaneous intervention (Fig). Standard dose (SD) NOAC significantly reduced the risk of SEE by 29% (95% CI 1-49%, p=0.04) compared with warfarin, However, no significant difference in the risk of SEE was observed between low dose (LD) NOAC and warfarin (Fig).

Conclusion

Standard dose NOAC was superior to warfarin in preventing SEE in AF patients. This benefit trends to be more pronounced for fatal cases. While SEE were about 1/10th as frequent as ischemic stroke in patients with AF, they were associated with significant morbidity and mortality and often required surgical or percutaneous intervention to restore blood flow.
Plasma cytokines are associated with major adverse cardiovascular events in follow-up of patients undergoing carotid endarterectomy
Authors: Nardi V , Di Venanzio L , Mahmoudi Hamidabad N , Copley E A , Tiwari A , Rajai N , Rajotia A , Lutgens E , Lerman L O , Lerman A
Published: October 2024

Background

Patients with carotid artery disease undergoing carotid endarterectomy (CEA) have a high risk of experiencing Major Adverse Cardiovascular Events (MACE) after surgery. The occurrence of MACE in CEA-treated patients is not predicted by common cardiovascular (CV) risk factors.

Purpose

We aimed to identify the association between plasma and plaque inflammatory cytokines and the incidence of MACE in the follow-up after CEA. We hypothesized that MACE is related to a higher level of circulating inflammatory cytokines at the time of surgery.

Methods

We prospectively enrolled patients with carotid artery disease undergoing CEA. Plasma and carotid plaques were collected during the surgery. Inflammatory cytokines (MCP-1/CCL2, IL-8/CXCL8, IFN-gamma, IL-10, IL-1beta/IL-1F2, IL-6, PDGF-AA, PDGF-AB/BB, TNF-alpha, VEGF) were measured in plasma and tissue homogenates using a customized 10-plex Luminex assay.

Baseline demographics and clinical data for all the patients were extracted from electronic health records. MACE after CEA was defined as a composite measure of nonfatal cardiac events such as myocardial infarction with or without revascularization, cerebrovascular events (ischemic stroke, TIA, and amaurosis fugax), and all-cause mortality.

Results

Of 107 patients who underwent CEA with a median age of 73 (67-78) years, 57 (53.2%) experienced MACE during a median follow-up of 5.2 [2.2-9.3] years: 23 (40.3%) cardiac events, 9 (15.7%) CVA, and 25 (43.8%) all-cause mortality. Plaque cytokines levels did not differ between the groups with and without MACE in the follow-up after CEA. Instead, plasma cytokines were associated with MACE in the follow-up after CEA, as summarized in Figure 1.

In the logistic regression analysis, plasma levels of MCP-1/CCL2, IFN-gamma, and TNF-alpha were independent predictors of MACE in follow-up post-CEA in univariate and multivariable models adjusted for CV risk factors such as age, BMI, systolic and diastolic blood pressure, low-density lipoprotein, high-density lipoprotein, and glucose level: MCP1/CCL2 (HR 1.009 [1.002-1.015]; p=0.007), IFN-gamma (HR 1.368 [1.014-1.845]; p=0.040), and TNF-alpha (HR 1.121 [1.022-1.228]; p=0.015) (Table 1).

Conclusions

Plasma levels of CCL2, IFN-gamma, and TNF-alpha are associated with the high incidence of MACE in the follow-up after CEA, indicating that these are potential biomarkers of MACE in this patient population and potential therapeutic targets in patients' progression of systemic atherosclerosis.Plasma cytokines and MACE after CEACytokines logistic regression analysis
Heparin reversal for coronary artery perforation
Authors: Sawayama Y , Sasaki K , Taninobu N , Ikuta A , Osakada K , Kubo S , Tada T , Fuku Y , Tanaka H , Kadota K
Published: October 2024

Background/Introduction

In the management of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI), heparin reversal can provide hemostatic effects but raises concerns about potential coronary thrombosis if an intracoronary artery guidewire or balloon is in place.

Purpose

We aimed to evaluate the safety and efficacy of heparin reversal during device insertion for CAP. We also aimed to determine the optimal target activated clotting time (ACT) to maintain when performing heparin reversal.

Methods

We analyzed cases of CAP which occurred during PCI procedures in a single center from January 2006 to October 2023. Patients were assigned to two groups according to whether they received heparin reversal with a device in place. The safety outcome was the periprocedural myocardial infarction (creatine kinase-MB >5 times the upper normal limit), and the efficacy outcome was successful hemostasis at the end of the procedures (complete absence of CAP on angiography).

Results

Among the 22,368 cases, 368 (1.6%) developed CAP, consisting of main vessels 45%, distal vessels 43%, and collateral vessels 12%. Heparin reversal with a device in place was implemented in 211 (57%) cases. Of these, 16 (7.6%) experienced coronary thrombosis. After adjusting covariates by the multivariable logistic regression model, heparin reversal with a device in place was significantly associated with a higher incidence of periprocedural myocardial infarction (11% vs 4.5%; adjusted OR: 3.11; 95% CI: 1.24–7.78; P = 0.015) and a higher rate of successful hemostasis (91% vs 73%; adjusted OR: 2.78; 95% CI: 1.27–6.09; P = 0.011). In the analysis of cases where minimum ACT value was available (n = 251), this value was significantly correlated with coronary thrombosis (r = −0.16, P = 0.012). When the cutoff values of minimum ACT were set at 200, 150, and 120 seconds as a binomial variable, the correlation coefficient was r = −0.08 (P = 0.158), r = −0.16 (P = 0.009), r = −0.20 (P = 0.001), respectively.

Conclusions

Heparin reversal after CAP with an intracoronary artery device in place was significantly associated with a higher incidence of periprocedural MI but also a higher rate of successful hemostasis. A minimum ACT value <150 seconds was significantly correlated with coronary thrombosis. These results propose a novel algorithm for CAP management strategies.Management algorithm for CAP