bluuebunny/crossref_metadata_2025 huggingface dataset:
Radiation exposure in interventional cardiology: relationship between patient radiation dose, demographic characteristics and procedural factors
Authors: McCaughey C , Kumar R , Kumar J , Matiullah S
Published: November 2020

Introduction

There has been a significant increase in Interventional Cardiology (IC) procedures over last few decades across the globe. The introduction of newer techniques and procedure types in IC has contributed to an overall increase in radiation exposure to both operators and patients alike. Unlike diagnostic imaging, IC procedures are heterogeneous and vary in their complexity based on a myriad of factors, such as patient disease characteristics, anatomy, nature of lesions and operator technique.

Purpose

The aim of the study is to evaluate the demographic and procedural characteristics associated with increased radiation dose. Limited studies exist on the impact of demographic and procedural characteristics on cumulative radiation dose.

Methods

Single-centre retrospective observational study of elective Percutaneous Coronary Intervention (PCI) patients from October 2018 to December 2018 in a 24/7 Irish pPCI centre. Patient level data including weight, height, demographic and procedural characteristics were collected for 65 consecutive elective PCI cases. Radiation exposure metrics, including Kerma Area Product (Pka), Reference Air Kerma (Ka,r) and Fluoroscopy Time (FT), were also collected. A Mann-Whitney U Test was used to assess for differences in radiation exposure between groups and a multivariate regression analysis was performed in order to identify those variables which contributed to radiation exposure.

Results

Median total radiation exposure for our cohort was (Q1–3) -Pka 109 (61–154) Gy·cm2, Ka,r 1746 (1,082–2,530)mGy and FT 16 (10–25)mins. Males (n=48) had a significantly higher radiation exposure Pka 126 (84–171) vs 56 (27–114)Gy·cm2 p=0.001; Ka,r 2094 (1256–2936) mGy p=0.006) than females. Those who underwent femoral access had significantly lower radiation exposure (Pka 50 (38–77) vs 114 (63–158) Gy·cm2 p=0.019; Ka,r (897 (725–1094) vs 2020 (1092–2618) mGy; p=0.018) when compared to radial access. Increasing body mass index (BMI) (p=0.03), multi vessel PCI (p=0.001) and the use of a “sheathless” technique (p=0.029) were associated with increasing radiation exposure (r2=0.630 Pka; Ka,r r2=0.611). Stent characteristics and all other clinical risk factors (HTN, smoking, DM, renal impairment, previous PCI) had no significant impact on radiation exposure.

Conclusion

Radiation exposure during IC in our cohort was within the range of most European Diagnostic Reference Levels (DRL's). Increased BMI and male gender were associated with increased radiation exposure. Procedural characteristics such as radial access, multi vessel PCI and the use of sheathless technique were independently associated with increasing radiation exposure. We recommend dose documentation of all procedures for these patients to avoid radiation hazards; with periodic assessment of statistical dose recording and planned follow up.

Regression analysis

Funding Acknowledgement

Type of funding source: None
Complete revascularization for patients with multivessel coronary artery disease and ST-segment elevation myocardial infarction after the COMPLETE trial: a meta-analysis of randomized controlled trial
Authors: Bajraktari G , Bytyci I , Henein M.Y , Alfonso F , Ahmed A , Jashari H , Bhatt D.L
Published: November 2020

Background

The recently published COMPLETE trial has demonstrated that patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), who underwent successful percutaneous coronary intervention (PCI) of both culprit and non-culprit (vs. culprit-only) lesion had a reduced risk of major adverse cardiac events (MACE: cardiovascular mortality, myocardial infarction, or ischemia-driven revascularization), but not of cardiovascular or total mortality.

Aim

To assess the efficacy of complete revascularization for cardiovascular or total mortality reduction by meta-analysis of all available randomized controlled trials (RCTs) including the COMPLETE trial.

Methods

PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov databases search identified 10 RCTs of 7033 patients with STEMI and MVD which compared complete (n=3420) vs. only culprit lesion (n=3613) PCI for a median 28.7 months follow-up. Random effect risk ratios were used for efficacy and safety outcomes.

Results

Complete revascularization reduced the risk of MACE (10.4% vs. 16.6%; RR=0.59, 95% CI: 0.47 to 0.74, p<0.0001), CV mortality (2.87% vs. 3.72%; RR=0.73, 95% CI: 0.56 to 0.95, p=0.02), reinfarction (5.1% vs. 7.1%; RR=0.67, 95% CI: 0.52 to 0.86, p=0.002), urgent revascularization (7.92% vs. 17.4%; RR=0.47, 95% CI: 0.30 to 0.73, p<0.001), and CV hospitalization (8.68% vs. 11.4%; RR=0.65, 95% CI: 0.44to 0.96, p=0.03) compared with culprit only revascularization. All-cause mortality, stroke, major bleeding events, or contrast induced nephropathy were not affected by the revascularization strategy.

Conclusion

The findings of this meta-analysis suggest that in patients with STEMI and MVD, complete revascularization is superior to culprit-only PCI in reducing the risk of MACE outcomes, including cardiovascular mortality, without increasing the risk of adverse safety outcomes.

Funding Acknowledgement

Type of funding source: None
Impact of a CTO in a non-infarct-related artery on long-term mortality in patients undergoing primary PCI
Authors: Milasinovic D , Mladenovic D.J , Jelic D , Mehmedbegovic Z , Radomirovic M , Zobenica V , Pavlovic A , Vratonjic J , Vukcevic V , Asanin M , Stankovic G
Published: November 2020

Background

Previous studies showed increased mortality rates in patients with ST-elevation myocardial infarction (STEMI) and a chronic total occlusion (CTO) in a non-infarct-related artery, but long-term data are scarce.

Purpose

Our aim was to assess all-cause mortality during 5 years follow-up in patients with a remaining nonculprit CTO after being treated with primary PCI.

Methods

The study included 9504 patients admitted for primary PCI during 2009–2019, with available baseline angiography, from an electronic, prospective registry of a high-volume catheterization laboratory. Kaplan Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with the log-rank test, with landmarks set at 30 days and then annually up to 5 years follow-up. Adjusted Cox regression models were constructed to assess 30-day and 5-year mortality risk of a non-culprit CTO. Median follow-up was 1507 days.

Results

Nonculprit CTO was present in 13.2% of patients (n=1253). Presence of a nonculprit CTO was associated with older age (64 vs. 61, p<0.001), more frequent history of cardiovascular disease including prior MI (33% vs. 14%, p<0.001), stroke (10.3% vs. 5.9%, p<0.001) and CABG (10.5% vs. 1.5%, p<0.001), higher rates of renal failure (10.7% vs. 4.8%, p<0.001), as well as more often Killip class 2–4 on admission (29% vs. 16%, p<0.001) and a lower ejection fraction (40% vs. 47%, p<0.001). Crude mortality rates were significantly increased in patients with a nonculprit CTO vs. no CTO, at both 30 days (15.7% vs. 5.6%, p<0.001) and 5 years (54.6% vs. 27.9%, p<0.001). After adjusting for the observed baseline differences, nonculprit CTO was still associated with an elevated mortality risk at both 30-days (HR 1.5, CI95% 1.1–1.9, p=0.007) and 5 years (HR 1.6, CI95% 1.4–1.9, p<0.001). Landmark analyses showed continuously increasing risk of mortality in the presence of a nonculprit CTO, as compared with primary PCI-treated patients with no CTO (30 days to 1 year 11.4% vs. 4.9%, p<0.001; 1st to 2nd year of follow-up 6.3% vs. 3.4%, p<0.001; 2nd to 3rd year 6.2% vs. 2.8%, p<0.001; 3rd to 4th year 7.4% vs. 3.0%, p<0.001; and 4th to 5th year 5.2% vs. 3.6%, p=0.1).

Conclusions

Presence of a nonculprit CTO is independently associated with 5-year mortality after primary PCI. Importantly, the mortality risk increases continuously with an average annual absolute difference of 3%, in patients with a nonculprit CTO vs. those with no CTO.

Nonculprit CTO vs. no CTO

Funding Acknowledgement

Type of funding source: None
Infective endocarditis after transcatheter or surgical aortic valve implantation: pooled results from three randomized controlled trials
Authors: Lanz J , Popma J , Reardon M , Pilgrim T , Stortecky S , Deeb M , Yakubov S , Windecker S
Published: November 2020

Background

Infective endocarditis is a rare complication of aortic valve replacement with high morbidity and mortality. Data of randomized trials comparing the incidence and outcomes between surgical (SAVR) and transcatheter aortic valve replacement (TAVR) are scarce.

Purpose

To compare the frequency, timing and outcomes of infective endocarditis after TAVR and SAVR from 3 prospective randomized trials and examine the clinical outcomes.

Methods

Clinical data from the CoreValve Pivotal High-Risk, the intermediate-risk SURTAVI and the Evolut Low Risk randomized trials, which compared TAVR with a supra-annular, self-expanding transcatheter valve to SAVR, was pooled. Cases of infective endocarditis were independently adjudicated based on Duke's criteria necessitating 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. Baseline clinical and procedural characteristics for patients with and without endocarditis were obtained. The cumulative incidence of endocarditis through 5 years after TAVR or SAVR was determined using death as a competing risk. Kaplan-Meier estimates of all-cause mortality and the composite of all-cause mortality or stroke through 2 years were calculated for both treatment groups.

Results

Among 2249 TAVR patients, 12 cases of endocarditis (0.5%) were documented and among 1828 SAVR patients, 21 (1.1%) over a mean follow-up time of 2.25±1.58 years. Baseline characteristics were well-balanced between the TAVR and SAVR patients with endocarditis. The cumulative incidence of endocarditis at 5 years was significantly different between the two groups (figure). The prevalence of diabetes was significantly higher in patients with endocarditis than in those without (57.6% vs. 34.2%, p=0.005). In endocarditis patients the rate of all-cause mortality was 39.4% for TAVR patients and 67.8% for SAVR patients at 2 years (log-rank p=0.133). The rates of all-cause mortality or stroke were 55.0% for TAVR and 64.6% for SAVR patients (log-rank p=0.078).

Conclusions

In this pooled analysis of three randomized trials comparing TAVR with a supra-annular, self-expanding bioprosthesis to SAVR, overall rates of endocarditis were low. The cumulative incidence of infective endocarditis at 5 years was lower in the TAVR group. Mortality after endocarditis was high.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic
Randomized clinical trial comparing a rivaroxaban-based with an antiplatelet-based strategy for cerebral embolization after TAVR (EARTH TAVR)-a magnetic resonance imaging substudy of the GALILEO trial
Authors: Froehlich G.M , Falk V , Endres M , Stangl V , Woehrle J , Steinbeck L , Erbay A , Rudolph T , Geisler T , Leistner D , Nolte C , Hausler G , Fiebach J , Dangas G , Landmesser U
Published: November 2020

Background

Cerebral embolization in patients after Transcatheter Aortic Valve Replacement (TAVR) represents a serious complication, that was related to impaired bioprosthetic leaflet motion and new-onset atrial fibrillation (AFib).

Purpose

Hereafter we present the first randomized study comparing the effect of an anticoagulation plus antiplatelet with a dual antiplatelet antithrombotic treatment in patients after TAVR on cerebral embolizations as assessed by serial cerebral magnetic resonance imaging (MRI).

Methods

The Evaluation of Cerebral Thrombembolism After TAVR (EARTH - TAVR) study was conducted as an investigator initiated substudy of the multicenter, randomized, GALILEO study. After successful TAVR, patients without indication for chronic anticoagulation were randomly assigned to rivaroxaban 10mg plus acetylsalicylic acid 75–100mg once-daily or clopidogrel 75mg plus acetylsalicylic acid 75–100mg once-daily. Cerebral MRI scans were performed pre-TAVR as a baseline, post-TAVR (within 24–48 hours after TAVR) and 90 days after TAVR. The MRI protocol included diffusion-weighted (DWI) and fluid-attenuated inversion recovery (FLAIR) imaging. Cerebral embolic lesions were evaluated by an independent cerebral MRI core lab. The primary outcome measure of this study was the occurrence and extent of cerebral embolizations as measured by total volume of new ischaemic cerebral lesions.

Results

36 patients were enrolled in the EARTH and the GALILEO study. The DWI MRI scans revealed an increase of cerebral lesions and volume post-TAVR by a median of 4.75 (95% NBCI 2.1–8.9) and 0.26cm3 (95% NBCI 0.11–0.59). On FLAIR imaging, lesion number and volume increased by a median of 3 (95% NBCI 1.5–6) and 0.1 cm3 (95% NBCI 0.04–0.31). At the 90 days MRI scan, there was no statistically significant change in cerebral lesions, if compared to the post-TAVR scan, irrespective of the treatment arm.

Conclusion

Thromboembolic events occur largely in the periinterventional phase post TAVR. Thereafter, the risk for additional cerebral embolization is low. An additional rivaroxaban therapy beyond antiplatelet inhibition did not impact on cerebral thromboembolism.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bayer Pharmaceuticals
Incidence, clinical impact and treatment outcomes of valve thrombosis after transcatheter mitral valve implantation
Authors: Kikoine J , Urena M , Brochet E , Nguyen C , Carrasco J.L , Ducrocq G , Fuchs A , Vahanian A , Iung B , Himbert D
Published: November 2020

Background

Transcatheter mitral valve implantation (TMVI) is a new treatment option for high-risk surgical patients with degenerated bioprosthesis (ViV), failed annuloplasty rings (ViR) and severe mitral annular calcification (ViMAC). However, limited data exist on transcatheter heart valve thrombosis.

Purpose

The aim of this study was to report the incidence, clinical impact and treatment outcomes of transcatheter heart valve (THV) thrombosis in patients undergoing TMVI.

Methods

All consecutive patients undergoing TMVI in our center between July 2010 and September 2019 were included. A transoesophageal echocardiography and a computed tomography (CT) were performed before hospital discharge and at each clinical visit, at 3 months, at 1 year and yearly after. THV thrombosis was defined as the presence of at least one thickened leaflet with restricted motion suggestive of thrombus confirmed by TOE and/or contrast CT. All patients received anticoagulation therapy with vitamin K antagonists (VKA) and a low dose of aspirin for the first 3 months.

Results

A total of 132 patients underwent TMVI (62 ViV, 36 ViR and 34 ViMAC). Among them, 16 (12.1%) patients had a THV thrombosis. Median age was 67 years old and 56.2% of patients were women. Median time to diagnosis of THV thrombosis was 78 days. Early THV thrombosis was observed in 7 (43.7%) and in 13 (81.2%) patients THV thrombosis occurred within the first 6 months after the procedure. 8 out 9 patients with subacute or late THV thrombosis were not anticoagulated or with subtherapeutic anticoagulation. No stroke or thromboembolic events occurred in these patients. No change in mitral gradient was observed in 14 out 16 patients. VKA were indicated in all patients. THV thrombosis resolved in all but one patient.

Conclusion

THV thrombosis is frequent after TMVI, occurs mainly within the first 6-months after the procedure, are mostly subclinical and resolves after optimization of anticoagulation treatment. An anticoagulation therapy for at least 6 months may be necessary.

Timing of THV thrombosis

Funding Acknowledgement

Type of funding source: None
Long term survival in high-risk patients after percutaneous mitral leaflet repair in a single centre: comparable mortality regardless of aetiology
Authors: Connolly L , Rajani P , M-Labbe B , Davies A , Duncan A , Vazir A , Smith R
Published: November 2020

Background

Percutaneous mitral leaflet repair (PMVR) is a safe and effective alternative to conventional surgery in high-risk patients with both degenerative (DMR) and functional (FMR) mitral regurgitation. We present an analysis of a large cohort of consecutive patients treated with PMVR at a high-volume UK centre.

Purpose

We sought to analyse the outcomes of a group of patients undergoing PMVR over a 7-year period at a single centre, where surgery had been excluded. We hypothesised that the long-term mortality in this group would be high and would differ depending on the aetiology of MR.

Methods

We identified 246 consecutive patients over the duration of the PMVR programme, where follow up and pre-procedural data were available. We collected baseline characteristics including age at procedure, left ventricular ejection fraction (LVEF), left ventricular indexed diastolic volumes (LVEDVi) and aetiology of MR. Post procedural data included MR at end of procedure, all-cause mortality and duration of follow up.

Results

Baseline characteristics for the group, as a whole, were as follows: mean age 76±11 years, 170 (69%) male, DMR 136 (55%) vs. FMR 110 (45%), LVEF 49±15%. Baseline data by aetiology subgroup: mean age DMR 80±9 vs. FMR 71±11 (p<0.001), LVEF DMR 58±10 vs. FMR 40±14 (p<0.001), LVEDVi DMR 71±25 FMR 85±25 (p<0.001). 99% of patients were treated with the MitraClip® device (Abbott, US), 1% received the Pascal device (Edwards, US). Post-procedural MR grade was similar for both groups (DMR 1.5±0.8 vs. 1.4±0.8, p=NS). Overall procedural mortality was 0.4% and at a mean follow up of 1097 days (median 1021, IQR 289–1555) was 30.8%. Mortality was identical regardless of aetiology (DMR 30.9% vs. FMR 30.8%, p=NS).

Conclusions

This analysis of consecutive “real world” patients demonstrates encouraging survival outcome at a mean of 3 years after PMVR, regardless of MR aetiology. DMR patients tended to be older but with lower LVEDVi and significantly higher LVEF. These data compare favourably with the published literature, where mortality for mixed and similarly high-risk populations at 12 months averages approximately 20–25%. Mortality in our FMR group at 3 years was also similar to that seen in the recently published COAPT study at 2 years. We have demonstrated that PMVR is a safe option for our cohort of unselected high-risk patients presenting with either degenerative or functional MR. We hypothesise that the absence of survival difference could relate to the younger age of FMR patients despite the significantly lower baseline LVEF and higher ventricular volumes. This analysis encourages the more routine use of PMVR for FMR in the UK, where currently only DMR is commissioned.

Funding Acknowledgement

Type of funding source: None
Prior surgical mitral commissurotomy and echocardiographic score influence in mitral balloon valvuloplasty. Immediate post procedure results
Authors: Aragao I , Peixoto E.C.S , Peixoto R.T.S , Peixoto R.T.S , Dos Anjos I.L.P.B , Bandeira L.L.B , Macedo T.L.S , Dos Santos S.C.M , Santos C.T , Machado R.F.S , Aragao A.A.B
Published: November 2020

Introduction

Percutaneous mitral balloon valvuloplasty is effective in mitral stenosis. Objectives: to evaluate prior mitral surgical commissurotomy (PMC) and echocardiographic score (ES) in the results and complications of mitral balloon valvuloplasty (MBV).

Methods

From 1987 to 2013, 526 procedures with Inoue balloon, double or single Balt balloon technique; 480 without PMC named primary MBV group (PMBVG) and 46 that have been submitted to PMC, the PMC group. The PMCG was older than PMBVG (42.7±12.4 vs 36.9±12.5 years, p=0.0030). Gender, atrial fibrilation and NYHA functional class were similar. In PMBVG and PMCG, respectively, ES were 7.2±1,4 and 7.7±1.5 points (p=0.0158) and mitral valve area (MVA) 0.94±0.21 and 1.00±0.22 cm2 (p=0.0699).

Results

Pre-MBV: mean pulmonary artery pressures (MPAP) were 37.8±14.2 and 37.6±14.4 mmHg, p=0.9515; mean gradient (MG) 19.6±6.9 and 18.3±6.9 mmHg, p=0.2342; MVA 0.90±0.21 and 0.93±0.19 cm2, p=0.4092, respectively, whem compare PMBVG and PMCG. Post-MBV: MPAP were 26.8±10.2 and 26.6±10.9 mmHg, p=0.9062; MG 5.4±3.5 and 6.3±4.2 mmHg, p=0.1492; MVA 2.04±0.42 and 1.92±0.41 cm2, p=0.0801, respectively. Mitral regurgitation (MR) were similar pre and post-MBV. Severe MR post-MBV in 10 patients: 8 in PMBVG and 2 in PMCG, p=0.2048. As there were not found significant diferences, the total group were divided in ES ≤8 and >8 groups: Pre-MBV: MPAP 37.5±13.9 and 39.3±16.6 mmHg, p=0.4041; MG 19.7±6.8 and 18.3±7.3 mmHg, p=0.1753; MVA 0.90±0.21 and 0.94±0.20 cm2, p=0.0090 respectively. Post-MBV: MPAP 26.7±10.1 and 28.0±10.6 mmHg, p=0.3730, MG 5.5±3.6 and 5.5±3.3 mmHg, MVA 2.06±0.42 and 1.90±0.40 cm2, p=0.0090.

Conclusion

The groups with and without prior mitral commissurotomy in MBV were compare and no differences were found in pre- and post-procedure, as mean pulmonary artery pressure, mean mitral gradient, mitral valve area, and mitral regurgitation. Although PMCG was older, with higher ES, its hemodynamics datas were similar. Whem the entire group was divided based on echo scores, those with echo scores >8 had highse MV (p=0.0090). and smaler mitral valve areas post-valvuloplasty. The valve anatomy were more important than prior commissurotomy.

Funding Acknowledgement

Type of funding source: None
Acute hemodynamic effects of iatrogenic inter-atrial shunts after percutaneous edge-to-edge mitral valve repair
Authors: Koschutnik M , Goliasch G , Nitsche C , Kammerlander A.A , Dona C , Dannenberg V , Schneider M , Bartko P , Mora B , Bartunek A , Andreas M , Hengstenberg C , Mascherbauer J
Published: November 2020

Background

Implantable interatrial shunt devices improve pulmonary vascular function in patients with heart failure by transferring richly oxygenated blood to the right heart. Whether iatrogenic atrial septum defects (iASDs) after percutaneous edge-to-edge mitral valve repair (pMVR) are also associated with beneficial hemodynamic effects has not been investigated.

Methods

We consecutively enrolled patients with relevant functional (FMR) and degenerative mitral regurgitation (DMR) scheduled for pMVR. Invasive hemodynamic assessments were performed prior to and immediately after the procedure.

Results

97 consecutive patients (75.4±9.1 years; 58% female) were prospectively included, 65 (66%) presented with relevant FMR. At baseline when compared to the DMR group, FMR was associated with worse left ventricular (LV) function (LV ejection fraction: 39 vs. 49%; p=0.001), higher NT-proBNP levels (7404 vs. 5214 pg/mL; p=0.023), worse renal function (serum creatinine: 1.7 vs. 1.3 mg/dL; p=0.019), and higher usage of spironolactone (68 vs. 42%; p=0.018) and sacubitril/valsartan (33 vs. 0%; p<0.001).

Following pMVR, cardiac output (CO) and systemic blood flow (Qs) increased significantly (CO: 4.6 to 5.5 L/min; p<0.001; Qs: 4.9 to 5.8 L/min; p=0.002), with more pronounced changes in the FMR subgroup (ΔCO: 1.0 vs. 0.6 L/min; Figure 1A; ΔQs: 1.2 vs. 0.1 L/min), when compared to DMR. Pulmonary blood flow (Qp) increased by 26% (4.3 to 5.4 L/min; p=0.008), accompanied by a raise in pulmonary artery (PA) oxygen (O2) saturation from 73 to 77% (p<0.001). Arterial O2 saturation levels remained unchanged (98.3 to 98.7%; p=0.165), confirming no significant changes in systemic oxygenation. These changes were associated with a slight decline in pulmonary vascular resistance (PVR: 250 to 225 dynes*sec/cm5; p=0.369, Figure 1B), and a tendency towards improvement of pulmonary compliance (PAC: 3.6 to 4.0 mL/mmHg; p=0.414).

Conclusions

Invasively measured CO, Qs, Qp, and mixed-venous PA O2 saturation increased immediately after pMVR, alongside with potentially beneficial effects on pulmonary vasculature with marked improvements in PVR and PAC. These changes were more pronounced in the FMR subgroup. Further studies are required to assess long-term hemodynamic effects and underlying mechanisms of persistent iASDs on pulmonary vascular function.

Figure 1. Invasive hemodynamics

Funding Acknowledgement

Type of funding source: None
Percutaneous mitral balloon valvuloplasty. Single versus Inoue balloon. long term follow-up
Authors: Aragao I , Peixoto E.C.S , Peixoto R.T.S , Peixoto R.T.S , Dos Anjos I.L.P.B , Macedo T.L.S , Dos Santos S.C.M , Santos C.T , Machado R.F.S , Bandeira L.L.B
Published: November 2020

Introduction

The single balloon (SB) is the less expensive technique to perform mitral balloon valvuloplasty (MBV). Objectives: This study aimed to demonstrate that MBV with the Balt single (BSB) and Inoue ballon, the wordwire accepted technique, had similar outcome and long-term follow-up (FU).

Methods

From 1987 to 2013, 526 procedures were performed, being 312 with a FU, 56 (17,9%) with Inoue balloon (IB) and 256 (82,1%) with BSB. The mean FU 156±144 months, p<0.0001. Univariate analysis (UA) and multivariate Cox analysis (MCA) to determine independent predict variables of survival and event free survival (EFS) of death, cardiac surgery and new MBV, in both techniques groups.

Results

In IB and BSB groups there were, respectively: female 42 (75.0%) and 222 (86.7%); mean age 37.3±10.0 (19 to 63) and 38.0±12.6 (13 to 83) years, p=0.7138; sinus rhythm 51 (91.1%) and 215 (84.0%), p=0.1754; echo score (ES) 7.6±1.3 (5 to 10) and 7.2±1.5 (4 to 14) points, p=0.0528; echo mitral valve area (MVA) pre-MBV 0.96±0.18 and 0.93±0.21 cm2, p=0.2265; post-MBV mean MVA (Gorlin) were 2.00±0.52 and 2.02±0.37 cm2, p=0.9554; MBV dilatation área 6,09±0,27 and 7,02±0,30, p<0,0001. At the end of the FU, there were in IB and BSB groups, respectively: echo MVA 1.71±0.41 and 1.54±0.51 cm2, p=0.0552; new severe mitral regurgitation in 5 (8.9%) and 17 (6.6%) patients, p=0.5633; new MBV in 1 (1.8%) and 13 (5.1%), p=0.4779; mitral valve surgery in 3 (5.4%) and 27 (10.4%), p=0.3456; deaths 2 (3.6%) and 11 (4.3%), p=1.000; cardiac deaths 1 (1.8%) and 9 (3.5%), p=1.000; ME 5 (8.9%) and 46 (18.0%), p=0.1449. In UA and MCA the BSB or IB technique do not predict survival or EFS. The independent risk factors to survival were: age <50 years (p=0.016, HR=0.233, 95% IC 0.071- 0.764), ES ≤8 (p<0.001, HR=0.105, 95% IC 0.34–0.327), MBV dilatation area (p<0.001, HR 16.838, 95% IC 3.353–84.580) and no mitral valve surgery in the FU (p=0.001, HR0.152, 95% IC 0.050–0.459). Independent risk factors to EFS: no prior commissurotomy (p=0.012, HR=0.390, 95% IC 0.187–0.813) and post-MBV MVA ≥1.50 cm2 (p=0.001, HR=7.969, 95% IC 3.413–18.608).

Conclusion

In 25 years, survival and EFS were similar in BSB and IB technique. Independent predictors of surviva: age <50 years, ES≤8 points, MBV dilatation area >7 mm2 and no mitral valve surgery in the FU. Independent predictors of EFS: no prior commissurotomy and post-MBV MVA≥1.50 cm2

Funding Acknowledgement

Type of funding source: None
Impact of left atrial appendage closure on left atrial hemodynamics: a prospective single center study
Authors: Mertens E , Bouziri N , Guedeney P , Duthoit G , Redheuil A , Ceccaldi A , Chicheportiche T , Isnard R , Silvain J , Montalescot G , Hammoudi N
Published: November 2020

Background

Percutaneous left atrial (LA) appendage closure is increasingly used to prevent strokes in patients with atrial fibrillation (AF). While LA appendage plays a key role in LA physiology, data regarding the impact of LA appendage occlusion on LA hemodynamics are lacking. The alteration of LA compliance by LA appendage occlusion may represent a clinical issue in AF patients which are at high risk of heart failure.

Purpose

To describe the impact of LA appendage occlusion on LA hemodynamics.

Material and methods

From july 2015 to january 2020, all patients undergoing LA occlusion procedure at Pitié-Salpêtrière Hospital (Paris, France) in whom LA pressure curves were recorded, before and immediately after device implantation, were included. The LA mean pressure was measured at baseline and after LA appendage occlusion during the same procedure. Abnormal LA mean pressure was defined as >15mmHg. We also recorded cardiovascular death and hospitalization for congestive heart failure at longest follow-up.

Results

We enrolled 85 patients (78±8 years, 46 men), the CHA2DS2-VASc score was 5±1 and the HAS-BLED score was 4±1. The mean LA volume index was 51±15mL/m2, the left ventricular ejection fraction was 60±7%. The LA mean pressure increased significatively after LA appendage closure from 12.6±3.9mmHg to 15.5±5.2mmHg (p<0.0001, Figure). The prevalence of abnormal LA pressure was 20% (17/85) at baseline and 45% (38/85) after LA appendage closure (p=0.005). Post procedural LA pressure elevation was not related to procedure duration nor to fluid expansion volume.

During a median follow-up of 364 [124–726] days, 3 (3.5%) patients died from a cardiovascular cause. Hospitalization for heart failure occurred in 6 (16%) of the 38 patients with abnormal postprocedural LA pressure, whereas no congestive episode was observed in the rest of the study population (p=0.006).

Conclusion

Catheter-based LA appendage occlusion induces an acute alteration of LA hemodynamics. Post procedural abnormal LA pressure may be linked to heart failure episodes in some patients. Further studies are warranted to investigate heart failure as a potential late complication of LA appendage closure.

Variations of mean LA pressure

Funding Acknowledgement

Type of funding source: None
Outcomes after coronary artery bypass graft surgery: systematic review and meta-analysis comparing bilateral versus single internal thoracic artery grafts
Authors: Stefil M , Gaudino M , Benedetto U , Gray A , Gerry S , Lees B , Krzych L , Seevanayagam S , Taggart D , Flather M
Published: November 2020

Background

Patients with diabetes and/or obesity are at higher risk of adverse outcomes following coronary artery bypass grafting (CABG). The use of bilateral internal thoracic arteries (BITA) can potentially offer survival benefit in higher risk patients compared to single internal thoracic artery (SITA) in patients undergoing CABG, but the overall evidence base for BITA has not influenced guidelines, and there are concerns over increased risk of sternal wound complications.

Methods

We conducted a systematic review of the literature to identify observational studies and randomised controlled trials (RCT) comparing the efficacy (mortality) and safety (sternal wound infection) of BITA and SITA in diabetic and obese patients.

Results

We identified 18 observational studies and one RCT to obtain data comparing BITA and SITA in 19,589 diabetic patients, and two observational studies and one RCT comparing BITA and SITA in 6972 obese patients. Pooled analysis demonstrated significant mortality benefit of BITA compared to SITA in diabetic patients (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.70, 0.90; Z=3.62, p=0.0003; I2=88%) (Figure 1a). Pooled analysis in obese patients found no significant difference in mortality rates between BITA and SITA (RR 0.73, 95% CI 0.47, 1.12; Z=1.43, p=0.15; I2=78%) (Figure 1b). A significantly higher rate of sternal wound complications following BITA was observed in diabetic (RR 1.53, 95% CI 1.23, 1.90; Z=3.86, p=0.0001; I2=4%) and obese patients (RR 2.24, 95% CI 1.63, 3.07; Z=5.00, p<0.00001; I2=0%).

Conclusions

BITA is associated with better long-term survival in diabetic patients, but most of the supportive data comes from observational studies. The effects of BITA grafting in patients who are obese is uncertain due to low numbers. BITA is associated with higher rates of sternal wound complications than SITA in both diabetic and obese patients. Further research is needed to understand if BITA has a role in higher risk patients undergoing CABG.

Figure 1. Pooled all-cause mortality

Funding Acknowledgement

Type of funding source: None
Multi-omics approach to post-CABG renal impairment
Authors: Boerschel C , Geelhoed B , Conradi L , Girdauskas E , Mueller C , Reichenspurner H , Blankenberg S , Zeller T , Schnabel R.B
Published: November 2020

Background

Renal impairment is a common complication after CABG (coronary artery bypass graft) surgery associated with an adverse outcome.

Purpose

To further characterize the molecular framework of the disease through omics analyses.

Methods

In N=165 CABG patients we performed multi-omics-analyses in preoperatively collected blood and tissue samples as well as 991 creatinine measurements. We used multivariable mixed-model regression analyses to analyse post-operative creatinine increase and to find common genetic polymorphisms, transcripts, metabolites and/or proteins associated with changes in postoperative creatinine increase. Multiple testing was accounted for by setting a 5%-limit on the false discovery rate (FDR) using the Benjamini-Hochberg procedure.

Results

Post-operative increase of log transformed creatinine was 0.035 (8%); 95% confidence interval (CI) 0.025, 0.045; P<0.001. We identified 55 gene expressions and two proteins associated with post-CABG renal impairment. On the metabolomic and single nucleotide point mutation (SNP) level, no relevant targets were found. The three most important identified gene expressions were MIR3202.1 (beta of log transformed creatinine increase per standard deviation gene expression increase −0.034; 95% CI: −0.048, 0.020; P<0.001), LOC105374386 (−0.032; 95% CI: −0.046, 0.019; P<0.001) and maternal embryonic leucine zipper kinase (MELK) (−0.022; 95% CI: −0.032, 0.013; P<0.001). Expression of all three was associated with a lower risk of post-CABG renal impairment. The same applies to the identified protein CAPRIN2 (−0.042; 95% CI: −0.062, 0.022; P<0.001), while expression of the protein TUBB6 was associated with a higher risk (0.033; 95% CI: 0.017, 0.048; P<0.001).

Conclusions

In an integrated approach we identified omics-biomarkers for the prediction of renal impairment after CABG surgery. The underlying pathophysiological associations of these genes and proteins are not fully understood. MELK might be an interesting target for further investigations, as it plays a prominent role in cell cycle control, cell proliferation, apoptosis, cell migration and cell renewal. Our results may help to better identify individuals at risk and lay the methodological groundwork for further omics analyses.

Funding Acknowledgement

Type of funding source: None
Identification of trajectories of cardiac allograft vasculopathy after heart transplantation: a nationwide comparison
Authors: Bonnet G , Coutance G , Van Keer J , Raynaud M , Aubert O , Bories M.C , Bruneval P , Varnous S , Leprince P , Empana J.P , Naesens M , Patel J.K , Loupy A , Kobashigawa J , Jouven X
Published: November 2020

Background

Cardiac allograft vasculopathy (CAV) is a major contributor of heart transplant recipient's mortality. However, little is known about CAV trajectories at a population level.

Purpose

We aimed to identify the different profiles of CAV trajectories.

Methods

Heart transplant recipients receiving care at 4 academic centers (2004 to 2016) were included. Patients underwent prospective, protocol-based monitoring consisting of repeated coronary angiographies together with systematic assessment of clinical, functional, histological and immunological parameters. The mainoutcome was the CAV trajectories, identified with unsupervised latent class mixed models.

Results

Overall, 1,301 patients were included (609 in France, 206 in Belgium and 486 in the US). The median follow-up post-transplant was 6.6 years (IQR=4.7) with 4,710 coronary angiographies analyzed (3.6±1.6 CAV assessments per patient). In the French development cohort, we identified 4 distinct profiles of CAV trajectories over 10 years that were characterized by i) Patients without CAV at baseline and non-progression (n=317, 52.1%), ii) patients without CAV at baseline and late onset CAV progression (n=52, 8.5%), iii) patients with mild baseline CAV and mild progression (n=151, 24.8%), iv) patients with mild baseline CAV and accelerated CAV progression (n=89, 14.6%, discrimination 0.92). The 4 CAV trajectories were independently validated in the external validation cohorts from Belgium (discrimination=0.92) and the US (discrimination=0.97).

Conclusion

In a large multicentric and highly phenotyped prospective cohort of heart transplant recipients, we identified and validated 4 distinct CAV trajectories corresponding to specific initial CAV grades and subsequent evolutions. Our results provide the basis for a trajectory-based assessment for risk stratification at early-stage post heart transplantation.

Figure 1. Cardiac allograft vasculopathy trajectories in France (n=609), in Belgium (n=206), in USA (n=486). Thick lines represent latent class trajectory; thin lines represent CAV individual patient trajectory.

Funding Acknowledgement

Type of funding source: None
Clinical comparison of the two invasive treatments of hypertrophic obstructive cardiomyopathy: a systematic review and meta-analysis
Authors: Bytyci I , Bajraktari G , Henein M.Y
Published: November 2020

Background

The two available interventional treatment of patients with hypertrophic obstructive cardiomyopathy aresurgical myectomy (SM) and Alcohol septal ablation (ASA). The aim of this meta-analysis was to assess the efficacity of these two invasive strategies in relieving symptoms and left ventricular outflow tract obstruction (LVOTO).

Methods

We searched PubMed, EMBASE, Scopus, Google Scholar and Cochrane Central until February 2020 for RCTs and cohorts comparing clinical outcomes with alcohol septal ablation (ASA) vs surgical myectomy (SM) in patients with HCM. The endpoints were relieving symptoms, reduced left ventricular outflow tract obstruction (LVOTO) and the need for reintervention.

Results

We included 20 studies (n=4547; 3 RCTs and 17 cohorts) comparing ASA vs MS for a mean follow-up 5.2±2.1 year. Baseline mean LVOT gradient was not different between the ASA and the MS patient groups with weighted mean difference (WMD) = 1.50 [−3.47 to 6.46, p=0.56]. During follow-up, SM patients showed greater reduction in the LVOT gradient compared to ASA WMD = −9.61 [CI, 4.71 to 14.50, p=0.0001]. In addition, SM group had greater resolution of clinical symptoms compared to ASA (NYHA class III/IV, 17% vs. 6.2% R: 2.76, CI, 1.64 to 4.64, p<0.001, angina 46% vs. 15.7%, RR: 2.79 [CI, 1.14 to 6.82, p=0.02) and lower reinterventions (10.1% vs. 0.02%; RR=15.1, 95% CI: 6.10 to 37.1 p<0.001).

Conclusion

Compared with alcohol septal ablation, septal myectomy treatment of hypertrophic obstructive cardiomyopathy is associated with greater resolution of clinical symptoms and less need for reintervention.

Funding Acknowledgement

Type of funding source: None
The Gly460Trp polymorphism and the overnight sodium potassium excretion in hypertensives
Authors: Delgado C , Delgado-Lelievre M , Lelievre D , Delgado-Almeida A
Published: November 2020

Introduction

The Gly460Trp polymorphism is associated to hypertension and renal sodium (Na) potassium (K) exchange. This study explores the relationship between blood pressure (BP) and urinary overnight Na/K ratio (UONaK) in patients genotyped for Gly460Trp polymorphism, from a cohort of hypertensive (HT) and normotensive (NT) subjects from National Heart, Lung and Blood Institute funded, Family Blood Pressure Program (FBPP).

Hypothesis

Abnormal renal K and Na excretion is associated to the Trp allele of Gly460Trp polymorphism.

Methods

3,545 subjects genotyped for Gly460Trp polymorphism were analyzed from FBPP. Subjects with diastolic BP (DBP) ≥80 or systolic BP (SBP) ≥130 mmHg were classified HTN; subjects with SBP <130 and DBP <80 mmHg were classified as NT. UONAK was calculated by dividing overnight Na by K concentration. Correlation analysis done with partial variables (body mass index, waist hip ratio, overnight urine creatinine).

Results

In HTN group (n=1,464), 75% had Gly/Gly, 22% Gly/Trp and 3% Trp/Trp. HTN with Gly/Gly showed strong associations between UONaK and DBP (r=0.191 p<0.0001) and SBP (r=0.06, p=0.04); HTN with Gly/Trp showed strong association for DBP (r=0.123 p=0.025) but not for SBP (r=0.07, p=0.188); while HTN with Trp/Trp there was strong inverse association with SBP (r=−0.399, p=0.010; Fig. 1) and none with DBP (r=0.215 p=0.18). In NT group (n=2,081), 69% had Gly/Gly, 28% Gly/Trp and 3% Trp/Trp; NT with Gly/Gly showed strong associations between UONaK and DBP (r=0.104 p<0.0001) and SBP (r=0.09, p=0.0002); NT with Gly/Trp showed strong association for DBP (r=0.146, p=0.0004) but not for SBP (r=0.05, p=0.18); while NT with Trp/Trp showed no association with DBP (r=−0.003 p=97), or SBP (r=0.06, p=0.61).

Conclusions

Hypertensives with Trp/Trp showed strong correlation between systolic blood pressure and UONaK, indicating abnormal K excretion in hypertensives, and possible subgroup targeted to potassium sparing drugs.

Funding Acknowledgement

Type of funding source: None
Arterial stiffness is associated with elastin fragmentation and medial collagen content in the human aorta
Authors: Mahmud A , McNulty M , McGovern E , Spiers J.P , Kavanagh P , Tolan M , Young V , Feely J , Silke B
Published: November 2020

Background

Age-related changes in arterial stiffness are ascribed to collagen and elastin content in the aorta (Ao) which is modulated by the matrix metalloprotienases (MMPs). However, no study has directly compared arterial stiffness and arterial structure in man.

Methods

Aortic and internal mammary artery (IMA) tissue were obtained from 10 patients (62±1 years, 2 female) undergoing coronary artery bypass grafting (CABG). Aortic pulse wave velocity (PWV) was measured prior to CABG. Collagen content was assessed in tissue sections using Sirius Red staining and elastin by ACCUSTAIN. Elastin fragmentation in the Ao media was graded; increasing in severity from 1 to 4. MMP-2 and MMP-9 activity was quantified in the Ao using gelatine zymography. Results are expressed as mean±SEM, p<0.05 considered significant.

Results

The collagen concentration was 50% (intima), 42% (media)and 76% (adventitia) in the Ao but was lower in the IMA. PWV was significantly associated with Ao medial (r=0.79, p=0.03) but not intimal or adventitial collagen concentrations. Aortic intimal thickness was related significantly with age (r=0.70, p<0.05) but not PWV. There was no relationship between age and Ao collagen concentration. There was a significant association (p<0.001) between increasing elastin fragmentation in the aortic media and PWV but not age. There was no relationship between collagen concentration in the IMA and either PWV or age. Neither latent nor active MMP-2 activity was related with PWV or age. Latent MMP-9 expression was significantly associated with PWV (r=0.66, p<0.05) but not age.

Conclusions

Our proof-of-concept study is the first one to show that elastin fragmentation in the aorta may underlie arterial stiffening in man. In contrast, the internal mammary artery does not age, unlike the aorta, which makes it the reassuring choice for coronary artery bypass grafting.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Health Research Board, Ireland
Blood pressure response in exercise is associated with future cardiac structural alterations in hypertensive patients
Authors: Andrikou E , Dimitriadis K , Andrikou I , Kasiakogias A , Tatakis F , Dimitriadi M , Anastasiou A , Kintis K , Kalos T , Iliakis P , Tousoulis D , Tsioufis C
Published: November 2020

Background/Introduction

Exaggerated blood pressure response (EBPR) during the exercise treadmill test (ETT) is often observed in individuals without known cardiovascular disease. Although it is generally considered as an abnormal response and a risk factor for hypertension development, its clinical significance remains controversial. On the other hand, regression of left ventricular hypertrophy (LVH) is independently associated with improved cardiovascular outcome.

Purpose

In this study we aimed to investigate the role of EBPR during exercise in LVH regression in hypertensive subjects over time.

Methods

1413 hypertensive subjects, (mean age 57±11 years), 51% males, with baseline office blood pressure (BP) 144/89mmHg were followed for a mean period of 6.4±3.0 years. At baseline and last follow-up visit all patients underwent office BP, laboratory tests and echocardiographical determination of left ventricular mass index (LVMI). At baseline, all subjects underwent treadmill exercise testing (Bruce protocol) in order to identify the presence of EBPR based on the systolic BP elevation at peak exercise (> or =210 mmHg for men and > or =190 mmHg for women). Main outcome variable was LVH Regression/prevention (LVH Regr/prev), defined as: LVH at baseline visit with normal LVMI values at last visit or absence of LVH at baseline and last visit. BP control was considered optimal when the mean of office BP measurements during follow-up was <140/90mmHg.

Results

46% of study population presented LVH Regr/prev during follow-up period. Cox-regression analysis, after adjustment for clinical and biochemical variables, revealed that low levels of baseline LVMI (HR=0.98, 95% CI 0.97–0.99, p<0.0001), absence of EBPR (HR=0.81, 95% CI 0.67–0.98, p=0.02) and optimal BP control during follow-up (HR=1.19, 95% CI 1.01–1.56, p=0.03) were independent predictors of LVH Regr/prev during follow-up.

Conclusions

Beyond optimal BP control, EBPR is a significant predictor of left ventricular mass changes overtime. Hence, ETT can provide clinical relevant information, including EBPR, which may help in the improvement of risk stratification of hypertensive subjects.

Funding Acknowledgement

Type of funding source: None
Cardiovascular risk and outcome in patients with hypertensive emergencies and urgencies in an emergency department. an italian greek collaboration
Authors: Muiesan M.L , Salvetti M , Fragoulis C , Paini A , Bertacchini F , Stassaldi D , Dimitriadis K , Konstantinidis D , Kasiakogias A , Andrikou I , Siafi E , Leontsinis I , Iliakis P , Tousoulis K , Tsoufis K
Published: November 2020

Background

At present, few data are available on the prognosis of hypertensive emergencies and urgencies admitted to Emergency Departments (ED). The aim of our study was to evaluate the incidence of total and cardiovascular events during follow-up in hypertensive patients admitted in 2 ED in Italy and Greece with hypertensive emergencies or urgencies.

Methods

Medical records of patients aged >18 yrs, admitted to the ED with blood pressure values ≥180 mmHg (SBP) and/or ≥120 mmHg (DBP) were collected and analysed (24% of patients were classified as “hypertensive emergency” and 76% as “hypertensive urgency”). Data in 1218 patients (556 men and 662 women, mean age 70±13 years) were analysed; the mean duration of follow-up after admission to the ED was 19.5±7 months years.

Results

During the follow-up cardiovascular events occurred in 148 patients (69 cardiac events, 43 cerebrovascular events). In 272 pts (22%) a new episode of acute BP rise was recorded. A total of 87 deaths was recorded during follow-up (in 28 patients for cardiovascular causes). All cause and CV mortality were greater in patients with a previous hypertensive emergency (14.7 vs 4.7%, chi-square p=0.0001 and 5.8 vs 1.2% chisquare p<0.0001 for all-cause and for CV mortality, respectively). The incidence of non fatal cardiovascular events was 10,11 and 2,11 per 100 patient-years in patients with hypertensive emergency and urgency, respectively and similar results were obtained when we considered separately the occurrence of cerebrovascular events.

Conclusions

Admission to the ED for hypertensive emergencies identifies hypertensive patients at increased risk for fatal and non fatal cardiovascular events. Our results underline the need for an accurate follow-up in patients with hypertensive emergencies and urgencies.

Funding Acknowledgement

Type of funding source: None