bluuebunny/crossref_metadata_2025 huggingface dataset:
New onset left bundle branch block after transcatheter aortic valve implantation and the effect on long-term survival – a UK wide experience
Authors: Arri S.S , Myat A , Malik I , Curzen N , Baumbach A , Gunning M , Henderson R , Ludman P , Banning A , Blackman D , Densem C , Stables R , Byrne J , Hildick-Smith D , Redwood S.R
Published: November 2020

Introduction

New onset left bundle branch block (LBBB) is the most common conduction disturbance associated with transcatheter aortic valve implantation (TAVI). It has been shown to adversely affect cardiac function and increase re-hospitalisation, although its impact on mortality remains contentious.

Methods

We conducted an observational cohort analysis of all TAVI procedures performed by 13 heart teams in the United Kingdom from inception of their structural programmes until 31st July 2013. The primary outcome was 1-year all-cause mortality. Secondary outcomes included left ventricular ejection fraction (LVEF) at 30 days and need for a post-TAVI permanent pacemaker (PPM).

Results

1785 patients were eligible for inclusion to the study. The primary analysis cohort was composed of 1409 patients with complete electrocardiographic (ECG) data pre- and post-TAVI. Pre-existing LBBB was present in 200 (14.2%) patients. New LBBB occurred in 323 (22.9%) patients post TAVI, which resolved in 99 (7%) patients prior to discharge. A balloon-expandable device was implanted in 968 (69%) patients, whilst 421 (30%) patients received a self-expandable valve. New LBBB was observed in 120 (12.4%) and 192 (45.6%) patients receiving a balloon- or self-expandable prosthesis respectively.

Overall 1-year all-cause mortality post TAVI was 18.7%. New onset LBBB was not associated with an increase in 1-year all-cause mortality (p=0.416). Factors that were associated with mortality included an increasing logistic EuroScore (p=0.05), history of previous balloon aortic valvuloplasty (p=0.001), renal impairment (p=0.003), previous myocardial infarction with pre-existing LBBB (p=0.028) and atrial fibrillation (p=0.039). Lower baseline peak and mean AV gradients were also associated with greater mortality at 1 year (p=0.001), likely reflecting underlying left ventricular dysfunction.

In the majority of patients, LVEF remained unchanged following TAVI. Interestingly, the presence or absence of new onset LBBB did not affect LVEF improvement at 30 days. 10% of patients required a PPM post TAVI. Predictors of PPM included new LBBB (OR 2.6, p<0.001), pre-TAVI left ventricular systolic impairment (OR 1.2, p=0.037), a self-expandable device (p<0.001), and pre-existing RBBB (OR 4.0, p<0.001).

Conclusions

These findings suggest that new onset LBBB post TAVI does not increase mortality at 1 year or adversely affect LVEF at 30 days.

Funding Acknowledgement

Type of funding source: None
Correlation of platelet inhibition and cerebral thromboembolic events, as expressed with number of high-intensity transient signals,during Transcatheter Aortic valve Implantation
Authors: Katsianos E , Vavuranakis M , Kalantzis C.K , Voudris V.V , Kosmas E.K , Iakovou I.I , Kalogeras K.K , Siasos G.S , Bei E.B , Katsarou O , Aznaouridis K , Toutouzas K.T , Moldovan C.M , Tousoulis D.T , Vavuranakis E.V
Published: November 2020

Background

It has been shown that high Residual Platelet Reactivity (RPR) may contribute to platelet aggregation which propagates thrombosis on implanted materials. Therefore, we evaluated whether high RPR may predispose to an increased number of cerebrovascular emboli during Transcatheter Aortic valve Implantation (TAVI).

Methods

Consecutive patients who underwent transfemoral TAVI with a self-expandable valve were prospectively studied. A loading dose of P2Y12 inhibitor 24 hours preprocedurally was given. Additionally, aspirin was started one week prior to procedure in all patients. Platelet inhibition was assessed with P2Y12 reaction units (PRU) (Verify Now assay) as well as percentage of inhibition 30 minutes prior to procedure initiation. The number of High intensity transient signals (HITS) was assessed with Rimed Digi-Lite™ transcranial Doppler, setting a threshold for detection of HITS at 3dB, continuously, on both middle cerebral arteries during the whole procedure. Two observers reviewed offline the number of HITS.

Results

In total, 84 patients underwent TAVI (53 males, mean age=81.9yrs old ±8,98). Mean baseline PRU and percentage of platelet inhibition was 258,24±43,03 (156–376) and 48,51%±40.05 (0–100%) respectively. In the treated patients the mean absolute total number of HITS and the number of HITS per minute recorded, was 566,63±272,32, (136–1432) and 6.7/min±3.3 (2.09–13.24) respectively. Significant positive correlation was found between baseline PRU levels and number of total HITS (r=0.261, p=0.017), (Figure 1). Multivariate regression analysis revealed that PRU was independent prognostic factor of total HITS (β=0.708, p=0.06),

In order to clarify the predictive role of platelet inhibition in the total number of recorded HITS a ROC analysis was performed, obtaining an area under the curve of 0.646 (95% CI 0.518 to 0.773, p=0.047). PRU-levels≥169 were shown to predict number of HITS at the upper quartile with 76% sensitivity and 65% specificity.

Conclusion

High RPR after dual antiplatelet loading with a P2Y12 inhibitor and aspirin, resulted in larger burden of embolic HITS during TAVI procedure. A cut off point of 169 PRU units with 76% sensitivity and 65% specificity predicted detection of HITS at the higher quartile.

PRU-HITS Correlation

Funding Acknowledgement

Type of funding source: None
Temporal trends in utilization of transcatheter aortic valve implantation and patient characteristics – a nationwide cohort study
Authors: Strange J.E , Sindet-Pedersen C , Gislason G , Torp-Pedersen C , Fosboel E.L , Butt J.H , Koeber L , Olesen J.B
Published: November 2020

Introduction

In recent years, there has been a surge in the utilization of transcatheter aortic valve implantation (TAVI) for the treatment of severe symptomatic aortic stenosis. Randomized controlled trials have compared TAVI to surgical aortic valve replacement (SAVR) in patients at high-, intermediate-, and low perioperative risk. As TAVI continues to be utilized in patients with lower risk profiles, it is important to investigate the temporal trends in “real-world” patients undergoing TAVI.

Purpose

To investigate temporal trends in the utilization of TAVI and examine changes in patient characteristics of patients undergoing first-time TAVI.

Methods

Using complete Danish nationwide registries, we included all patients undergoing first-time TAVI between 2008 and 2017. To compare patient characteristics, the study population was stratified according to calendar year in the following groups: 2008–2009, 2010–2011, 2012–2013, 2014–2015, and 2016–2017.

Results

We identified 3,534 patients undergoing first-time TAVI. In 2008–2009, 180 patients underwent first-time TAVI compared with 1,417 patients in 2016–2017, resulting in a 687% increase in TAVI procedures performed. During the study period, the median age remained stable (2008–2009: Median age 82 year [25th–75th percentile: 78–85] vs. 2016–2017: Median age 81 years [25th–75th percentile: 76–85]; P-value: 0.06). The proportion of men undergoing first-time TAVI increased over the years (2008–2009: 49.4% vs 2016–2017: 54.9%; P-value for trend: <0.05), also the proportion with diabetes increased (2008–2009: 12.2% vs. 2016–2017: 19.3%; P-value for trend: <0.05). The proportion of patients with a history of stroke decreased over the years (2008–2009: 13.9% vs. 2016–2017: 12.1%; P-value for trend: <0.05). The same trend was seen in patients with a history of myocardial infarction (2008–2009: 24.4% vs. 2016–2017: 11.9%; P-value for trend: <0.05), ischaemic heart disease (2008–2009: 71.7% vs. 2016–2017: 29.4%; P-value for trend: <0.05), and heart failure (2008–2009: 45.6% vs. 2016–2017: 29.4%; P-value for trend: <0.05).

Conclusions

In this nationwide study, there was a marked increase in the utilization of TAVI in the years 2008–2017. Patients undergoing first-time TAVI had a decreasing comorbidity burden, while the age of the patients at first-time TAVI remained stable.

Funding Acknowledgement

Type of funding source: None
Prognostic value of change in nutritional status after transcatheter aortic valve replacement
Authors: Lopez Otero D , Gonzalez Ferreiro R , Lopez Pais J , Alvarez Rodriguez L , Antunez Muinos P , Cid Menendez A , Otero Garcia O , Perez Poza M , Antonio Cacho C.U , Cid Alvarez B , Sanmartin Pena X.C , Trillo Nouche R , Cruz-Gonzalez I , Gonzalez Juanatey J.R
Published: November 2020

Introduction and purpose

Risk of malnutrition is a frequent condition among patients undergoing transcatheter aortic valve replacement (TAVR). Nutritional status assessed by nutritional risk index (NRI) is independently associated with an increased risk of death during long-term follow-up in these patients. The aim of the study is to determine the prognostic impact of the variation in nutritional risk after TAVR.

Methods

TAVR patients were included in an observational and prospective study between 2008–2019. Baseline and 3-months post-TAVR NRI were calculated as 1.519 x albumin (g/L) + 41.7 x (real weight [kg]/ideal weight [kg]). According to this parameter, the risk of malnutrition was severe (NRI<83.5), moderate (83.5≥NRI<97.5) and mild (97.5≥NRI<100). We analyzed the change in nutritional status after TAVR and the association between nutritional status variation and the clinical outcomes: all-cause mortality, heart failure hospitalization and the composite of all-cause death and/or heart failure hospitalization at 3 years follow-up using the Cox proportional hazards model.

Results

433 patients were included. 68.4% of patients with baseline nutritional risk had no nutritional risk after TAVR. The prevalence of risk of malnutrition was reduced to 25.2% after TAVR. During the follow-up (2.7±2.0 years), 157 (36.3%) patients died and 172 patients (39.7%) had heart failure hospitalization. Patients who remained at nutritional risk after TAVR had a higher risk of mortality (HR: 2.10 [95% CI: 1.30 to 3.39], p=0.002), heart failure hospitalization (HR: 1.97 [95% CI: 1.26 to 3.06], p=0.000) and the composite outcome (HR: 2.0 [95% CI: 1.37 to 2.91], p<0.001).

Conclusions

Risk of malnutrition was a frequent condition among TAVR patients, but most patients improved their nutritional status after the procedure. The change in nutritional status is associated with prognosis: post-TAVR nutritional risk improvement is associated with reduced heart failure hospitalization, and the change to non-nutritional risk after TAVR halved the risk of mortality and heart failure hospitalization during long-term follow-up. Persistent nutritional risk after TAVR was related to poor prognosis. Further studies are needed to identify whether at nutritional risk would benefit from nutritional intervention during processes of care of TAVR programs.

Change in NRI and prognostic value

Funding Acknowledgement

Type of funding source: None
Silent cerebral embolisation during TAVI: evolution, predictors and neurocognitive effects
Authors: De Carlo M , Liga R , Migaleddu G.M , Scatturin M , Spaccarotella C , Fiorina C , Orlandi G , De Caro F , Rossi M.L , Chieffo A , Indolfi C , Reimers B , Cosottini M , Petronio A.S
Published: November 2020

Background

Most patients undergoing transcatheter aortic valve implantation (TAVI) develop silent cerebral ischemic lesions (SCIL) detectable at magnetic resonance imaging (MRI). The natural history and clinical relevance of SCIL are not well established. We aimed to assess the characteristics, predictors, evolution, and neurocognitive effects of SCIL.

Methods

Cerebral MRI was performed within 7 days before TAVI to assess baseline status and age-related white matter changes (ARWMC) score. MRI was repeated postoperatively to assess the occurrence, location, number and dimensions of SCIL. Patients developing SCIL underwent a third MRI at 3–5 months follow-up. A neurocognitive evaluation was performed before TAVI, at discharge and at 3-month follow-up.

Results

Of the 117 patients enrolled, 96 underwent a postprocedural MRI; SCIL were observed in 76% of patients, distributed in all vascular territories, with a median number of 2 lesions, median diameter 4.5 mm, and median total volume 140 mm3. Independent predictors of SCIL occurrence were a higher baseline ARWMC score and the use of self-expanding or mechanically-expanded bioprostheses. Among 47 patients who underwent follow-up MRI, only 26.7% of postprocedural SCIL evolved into a gliotic scar. SCIL occurrence was associated with a more pronounced transient neurocognitive decline early after TAVI and with a lower recovery at follow-up.

Conclusions

SCIL occur in the vast majority of patients undergoing TAVR and are predicted by a more diffuse white matter damage at baseline and by the use of non-balloon-expandable prostheses. Although most SCIL disappear within months, their occurrence has a limited but significant impact on neurocognitive function.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): unrestricted grants from Edwards Lifesciences SA, Nyon, Switzerland, and from Medtronic Italia SpA, Milan, Italy
Indirect evaluation of device-endothelialization with cardiac-CT after transcatheter closure of atrial septal defect: how long should antiplatelet therapy last postoperatively?
Authors: Yan C , Li L , Pan X , Li S , Li H , Wan L , Wang L , Fang W
Published: November 2020

Background

After transcatheter closure of atrial septal defect (ASD), it is still unclear about the in-vivo process of device-endothelialization in humans, which determines the duration of antiplatelet therapy. Based on contrast-uptake within device, cardiac-CT might have the potential to assess device-endothelialization indirectly.

Purpose

The study was conducted to investigate the status of device-endothelialization with cardiac-CT after transcatheter closure of ASD.

Methods

After more than 6 months of transcatheter ASD closure, cardiac-CT was performed in 119 patients (48M/71F; age: 46.7±14.4 years). According to contrast-uptake within device, complete or incomplete device-endothelialization was determined. In the latter, it was further divided into partial-endothelialization (with filling-defect) and no-endothelialization (without filling-defect). Multivariate logistic regression was used to determine the risk factors of incomplete device-endothelialization. In addition, device-endothelialization was analyzed grossly and histopathologically in 7 patients.

Results

During the implantation-period of 2.57±2.59 years, incomplete device-endothelialization was identified in 43.7% of patients (partial-endothelialization in 36 patients and no-endothelialization in 16 patients). Complete device-endothelialization occurred in 14.3% of patients during 0.5–1 year and 73.8% after one year. After 6-month antiplatelet therapy, migraine restarted in 15 patients with incomplete device-endothelialization and 3 patients with complete device-endothelialization. After one-year antiplatelet therapy, migraine was still detected in 4 of 15 patients with incomplete device-endothelialization. There was a significant association between high in-vivo device-thickness and incomplete device-endothelialization (P<0.001) after adjusted for confounding factors. Pathological findings from 7 patients corresponded well with cardiac-CT.

Conclusions

Cardiac-CT had the potential to evaluate the status of device-endothelialization after transcatheter closure of ASD and there was a good clinico-pathological correlation. Incomplete device-endothelialization was common postoperatively in humans and was associated with device-oversizing. Further research is required to determine the appropriate duration of antiplatelet therapy after device implantation.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): National Natural Science Foundation of China
Efficacy and safety of percutaneous patent foramen ovale closure in patients with a hypercoagulable disorder
Authors: Ben-Assa E , Herrero-Garibi J , Cruz-Gonzalez I , Elmariah S , Al-Bawardy R , Sakhuja R , Lima F.V , Mingming N , Inglessis I , Palacios I.F
Published: November 2020

Background

Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke reduce the rate of recurrent events. Although presence of thrombophilia increases the risk for paradoxical emboli through a PFO, such patients were excluded from the large randomized studies.

Purpose

To examine the effect of hypercoagulable state on clinical outcomes after PFO closure.

Methods

We retrospectively analyzed data of 800 consecutive patients undergoing percutaneous PFO closure at the Massachusetts general hospital. We compared the safety and efficacy of the procedure in patients with and without a hypercoagulable state. Periprocedural treatment included 3 months of anticoagulation followed by low dose aspirin.

Results

A hypercoagulable disorder was found in 239 patients (29.9%). There were no significant differences in baseline demographics, echocardiographic characteristics, procedural success rate, or complication rate between both groups. At median follow-up of 41.9 months there were no differences in the rate of stroke/transient ischemic attack (2.5% in non-hypercoagulable group vs. 3.4% in hypercoagulable group, log-rank test p=0.349). Survival analysis of composite outcome that included: ischemic neurologic event, reintervention and procedural or neurologic death did not show significant difference between groups (Log-rank p=0.122).

Conclusion

Percutaneous PFO closure is a safe and effective therapeutic approach for patients with cryptogenic stroke and an underlying hypercoagulable state

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Research funds of the Massachusetts general hospital
Does left atrial appendage morphology have any impact on the results of percutaneous closure?
Authors: Constantin V , Cinaud A , Brigadeau F , Lepillier A , Pierre B , Deharo J.C , Defaye P , Montalescot G , Fauchier L , Mansourati J
Published: November 2020

Introduction

Transcatheter left atrial appendage (LAA) occlusion is an alternative treatment in patients with atrial fibrillation (AF), high CHADSVASC Score and a contra-indication to anticoagulants. This retrospective cohort study aims to evaluate the impact of LLA morphology on procedure outcomes.

Methods

Patients from eight French centers who underwent left atrial appendage occlusion from February 2012 to January 2017 were included in this retrospective cohort study. LLA morphology was described by preoperative cardiac computed tomography (CT). Clinical data and Transoesophageal echocardiography (TEE) or CT results were collected during follow-up.

Results

Among 469 included patients, LAA morphologies were described in 215 cases 45.8%), 150 patients (70%) were implanted with Watchman devices, 57 (26%) with Amplatzer devices and 8 procedures (4%) failed. LAA Morphology was Chicken Wing (34%), Windsock (45%), cauliflower (18%) and 3% had another morphology including Cactus.

There was no difference in patient characteristics between the different morphology groups. Mean follow-up was 9.6±11 months, during which 190 patients underwent LAA imaging (TEE in 171 and CT in 19 patients). There was no significant difference in the failure rate (p=0.72), duration of the procedure (p=0.065), peri-device leak (p=0.83) device-related thrombus (p=0.96) and the occurrence of stroke (p=1) during follow-up.

Conclusion

LLA morphology did not influence complication occurrence after occlusion in this cohort.

Funding Acknowledgement

Type of funding source: None
WATCHMAN versus ACP or amulet for left atrial appendage closure. Results from the LAARGE registry
Authors: Ledwoch J , Franke J , Akin I , Geist V , Weiss C , Zeymer U , Pleger S , Hochadel M , Mudra H , Senges J , Lewalter T , Brachmann J , Sievert H
Published: November 2020

Background

Several left atrial appendage (LAA) closure systems are available and due to differences in device design safety and efficacy of specific occluders derived from trials cannot be simply generalized to all devices.

Purpose

The present analysis sought to assess two contemporary LAA closure devices in clinical practice.

Methods

The present work represents a non-randomized sub-analysis of the prospective, multicenter, Left-Atrium-Appendage Occluder Register - GErmany (LAARGE) registry. The WATCHMAN (group 1) and the Amplatzer Cardiac Plug (ACP) or Amulet occluder (group 2) were assessed regarding technical success and procedural safety.

Results

A total of 641 patients at 38 centers were enrolled. Of them, 278 (43%) and 340 (53%) patients received the WATCHMAN and ACP/Amulet occluder, respectively. High technical success was achieved with a slight difference between the groups (96% in group 1 vs. 99% in group 2; p=0.007). Procedural safety did not differ (98% in group 1 vs. 97% in group 2; p=0.55). Chicken wing morphology of the LAA seemed to trigger the use of the ACP/Amulet (chicken wing in 36% of the cases in group 1 vs. 55% in group 2; p<0.001). The Kaplan Meier estimated 1-year composite of death or stroke was 12.0% and 12.9%, respectively (Figure 1A). The respective rates for the composite endpoint of death, stroke or systemic embolism were 12.0% and 13.2% (Figure 1B).

Conclusions

Both the WATCHMAN and the ACP/Amulet occluder provide excellent procedural results with comparable implantation success and no differences regarding procedural safety and long-term effectiveness.

Figure 1. Composite endpoints at 1-year

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Stiftung Institut für Herzinfarktforschung (IHF)
Machine learning for risk prediction of in-hospital mortality in adult cardiac surgery
Authors: Myslivecek L , Benedetto U.B
Published: November 2020

Background

Risk prediction plays a central role in clinical decision-making for patients undergoing cardiac surgery. The logistic EuroSCORE has demonstrated a dangerous calibration drift with the changing patient case-mix, resulting in a significant overestimation of mortality and risk-averse practice. Despite these limitations, it continues being used in the United Kingdom due to a lack of alternative validated models. It is urgent to find a replacement for EuroSCORE with a better calibrated prediction model. Machine learning models are increasingly used for risk prediction in medicine due to their potential of overcoming limitations of regression models. Precisely quantifying the risk of in-hospital mortality may better inform patient-centred decision-making and direct targeted quality improvement interventions.

Methods

This is a retrospective monocentric cohort study using prospectively collected fully anonymised data from the National Adult Cardiac Surgery Audit database, restricted to patients undergoing adult cardiac surgery at our institute from 1996 to 2017 (n=28,761). The aim was to develop a predictive model with improved discriminatory power and calibration using machine learning methods. Model calibration was assessed using the calibration belt method. Discrimination power of each model (area under the receiver operating characteristic curve [AUC]) was compared with the logistic EuroSCORE using the De Long's test.

Results

A time series of the observed:expected (O:E) ratio for the logistic EuroSCORE showed a linear decrease with a slope of −7.4x10–3. The calibration belt showed a significant risk overestimation across all risk categories (p<0.001). Model discrimination was excellent over time, with a marginal but significant linear trend in reducing the AUC (p=0.03). Although miscalibration was detected for all models (p<0.05), neural network achieved the best calibration with a test statistic of 13.3, followed by logistic regression (18.0), and EuroSCORE (228.7). The neural network achieved the highest AUC (0.82, 95% CI 0.78–0.85) of all models and was marginally non-significantly higher than that of the logistic EuroSCORE (0.79, 95% CI 0.75–0.83, p=0.056).

Conclusion

Our neural network model of cardiac surgery in-hospital mortality achieves slightly improved discriminatory power and significantly better calibration compared to that of EuroSCORE, making it more appropriate for dealing with the changing patient case-mix. Further model training on larger datasets with larger demographics is necessary. Clinical implementation of such models may reduce risk of overestimation of mortality.

Funding Acknowledgement

Type of funding source: None
Long-term outcomes following coronary artery bypass grafting: the role of off-pump strategy
Authors: Barili F , D'Errigo P , Rosato S , Grossi C , D'Ovidio M , Pagano E , Seccareccia F
Published: November 2020

Background

The debate on the advantages and limitations of off-pump (OPCAB) on long-term outcomes has not still arrived to a conclusion. This study was designed to compare the impact of OPCAB vs on-pump coronary artery bypass grafting (CABG) on long-term mortality and major adverse cardiac events (MACEs).

Methods

The PRIORITY project was designed to evaluate the long-term outcomes of 2 large prospective multicenter cohort studies on CABG conducted between 2002–2004 and 2007–2008. Data on isolated CABG were linked to 2 administrative datasets. Time-to-event methods were employed to analyze outcomes.

Results

The population consisted of 11021 patients who underwent isolated CABG (27.2% OPCAB) that were divided into development and validation datasets. The median follow-up time was 8 years (interquartile range 7.6–10 years) and was 100% complete. Unadjusted long-term survival was significantly worst for OPCAB, nonetheless the adjustment did not confirm OPCAB as a risk factor for mortality (HR 0.94, 95% CI 0.85–1.03, p=0.19). OPCAB was associated to an increased risk of MACE at 10 years (adjusted HR 1.14, 95% CI 1.06–1.23, p=0.001). Inside the MACEs, OPCAB was significantly related to increased incidence of rehospitalization for percutaneous cardiac intervention (PCI), (adjusted HR 1.33, 95% CI 1.16–1.53, p<0.001), demonstrating to be an independent risk factor for PCI with an hazard that is 33% higher than on-pump CABG.

Conclusions

OPCAB did not affect long-term mortality but is associated with an increased long-term risk of repeat PCI. These findings may have important implications towards health resources allocation, particularly in a climate of cost containment of healthcare expenditures.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Minister of Health
Preoperative status and in-hospital complications of coronary artery surgery in patients with pre-diabetes and type 2 diabetes mellitus
Authors: Bezdenezhnykh N , Bezdenezhnykh A , Sumin A , Barbarash O , Kuzmina A , Gruzdeva O
Published: November 2020

Aim

To assess the preoperative status and the rate of in-hospital complications of coronary artery surgery (CABG) in patients with pre-diabetes compared to patients with type 2 diabetes mellitus (type 2 DM) and normoglycemia.

Materials and methods

708 consecutive patients who underwent CABG between 2011 to 2012 were included in the study. All patients without positive history of diabetes underwent an oral glucose tolerance test (OGTT). The lab findings were interpreted in accordance with the recommended diagnostic criteria for diabetes and other glycemic disorders.

Results

DM screening before coronary artery bypass grafting allowed to diagnose type 2 diabetes in 8.9% (n=63) and prediabetes in 10.4% (n=74) of the study population. The preoperative screening increased the number of patients with DM from 15.2% (n=108) to 24.1% (n=171), and with prediabetes from 3.0% (n=21) to 13.4% (n=95). The total number of patients with carbohydrate metabolism disorders increased from 18.2% (n=129) to 37.5% (n=266). All patients were enrolled into 3 groups based on their glycemic status: Group 1 - without carbohydrate metabolism disorders (n=442), Group 2 - pre-diabetes (n=95), Group 3 - type 2 DM (n=171). The analysis of in-hospital complications reported that patients with pre-diabetes more often underwent urgent peripheral artery bypass compared to the other two groups (p1–2=0.002 vs. p1–3=0.023). The highest rate of wound complications was found in patients with pre-diabetes (p1–2=0.012). In addition, a clear trend towards the rate of other in-hospital complications of CABG in the groups with pre-diabetes and diabetes was found. The regression analysis shows that type 2 DM was associated with the total number of significant complications (odds ratio (OR) 1.731, 95% confidence interval (CI) 1.131–2.626, p=0.012), prolonged in-hospital stay (OR 2.2229, 95% CI 1.412- 3.519, p<0.001), the risk of urgent peripheral artery bypass (OR 1.638, 95% CI 1.009–15.213, p=0.020), multiple organ dysfunction syndrome (OR 2.911, 95% CI 1.072–7.901, p=0.039) and the need for hemostasis correction using the extracorporeal methods (OR 3.472, 95% CI 1.042–11.556, p=0.044). All the associations described above remained significant when pre-diabetes was introduced into the regression model and any carbohydrate metabolism disorder was considered as a potential predictor of in-hospital complications. Additionally, an association between pre-diabetes and diabetes and the risk of acute renal damage (OR 1.700, 95% CI 1.067–2.612, p=0.024) and wound complications (OR 1.547, 95% CI 1.073–2.231, p=0.019) was observed.

Conclusion

Pre-diabetes affects the in-hospital outcomes after CABG as well as diabetes mellitus. Our findings emphasizes the relevance of active preoperative detection of carbohydrate metabolism disorders.

Funding Acknowledgement

Type of funding source: None
Valvular calcium load assessment for predicting postprocedural paravalvular leakage: a comparison between surgical aortic valve replacement versus transcatheter implantation
Authors: Pollari F , Pfeiffer S , Grossmann I , Vogt F , Sirch J , Schwab J , Fischlein T
Published: November 2020

Background

Calcification of native aortic valve is a well known variable causing paravalvular leakage (PVL) following transcatheter aortic valve implantation (TAVI). However, there is currently no evidence to support the fact that patients with high calcium load could be better treated with surgical aortic valve replacement (SAVR).

Purpose

To assess the utility of preoperative assessment of valvular calcium load through computed tomography in patients affected by severe aortic valve stenosis undergoing SAVR or TAVI.

Methods

Between June 2016 and June 2018, 109 candidates for isolated SAVR through minimal invasive access underwent preoperative contrast enhanced multidetector computed tomography (MDCT) for the assessment of valve and aortic calcifications. Calcium load was quantitatively measured using a dedicated software in three regions on interest (aortic valve [AV], left ventricular outflow tract [LVOT] and device landing zone [DLZ], which is the sum of the earlier 2). Clinical, echocardiographic, and MDCT variables were collected and compared to a sample population of 107 patients that underwent TAVI (87 transfemoral, 20 transapical) for native aortic valve stenosis in the same period of time, in the same institution. A univariate and multivariate logistic regression analysis were performed on the whole study population to assess risk factors for the onset of postoperative PVL (any grade, defined as ≥ mild) at discharge.

Results

The two study groups were significantly different in terms of age (71.9±5 in SAVR; 81.5±6 in TAVI), gender (36% female in SAVR vs 51% in TAVI), Euroscore II (1.9%±0.8 in SAVR; 4.8%±2.7 in TAVI), annulus perimeter (79.5mm±8.2 in SAVR; 61.8mm±30.5 in TAVI), baseline ejection fraction (57%±8 in SAVR; 51%±12 in TAVI) and severe pulmonary hypertension (2%±13 in SAVR; 26%±44 in TAVI). Calcium load was not different between groups (DLZ 1066 mm3±716 vs 955mm3±639; total calcium in AV 987 mm3±678 vs 879 mm3±601; total calcium in LVOT 78 mm3±130 vs 77 mm3±100). 30-days-mortality was 1.8% in SAVR and 5.6% in TAVI group (p=0.17). At discharge, incidence of all grades PVL was 5.5% in SAVR (0.9% trace, 3.6% mild, 0.9% moderate) and 41% in TAVI group (12.1% trace, 25.2% mild, 3.7% moderate) (p<0.05). On logistic regression on the whole study population, DLZ calcium (OR 1.1, 95% CI 1–1.2 for 100 mm3, p=0.003) and the use of TAVI (OR 24, 95% CI 7.7–78, p<0.001) were identified as independently associated with the onset of PVL.

Conclusions

Aortic valve calcifications are a risk factor for the onset of PVL for both TAVI and SAVR. Nevertheless, the risk increases considerably with the use of TAVI. A deeper anatomical analysis of preoperative MDCT could improve the treatment selection and the outcome of patients affected by aortic valve stenosis.

Funding Acknowledgement

Type of funding source: None
Defying challenges: mid-term outcomes of international collaborations for a successful heart transplantation program in the middle east
Authors: Hamour I.M , Ferrer R , Atallah B , Gabra G , Soliman M , Sabbour H , Bader F
Published: November 2020

Introduction

Heart transplantation (HTx) is a successful treatment strategy for advanced heart failure. Survival rates exceed those achieved by medical therapy alone. Lack of suitable donors and cultural perception remain obstacles for receiving this novel therapy.

Methods

Overcoming challenges we adopted a first-of-a-kind multicenter HTx program, collaborating between Cardiac Centers in India and the United Arab Emirates (UAE). Patients were worked up as part of our newly established HTx program in the UAE, then referred to India for successful HTx. All post HTx follow-up care was continued in the UAE thereafter.

Results

We assessed 10 HTx recipients, [90% male; mean age 34 yrs]. Five patients required inotropes while one LVAD support pre transplant. Our data outline short waiting-list time and excellent 3 years clinical outcomes.

All patients are maintained on Tacrolimus and Mycophenolate Mofetil. Two patient developed acute rejection (celluar and humoral) with graft dysfunction within 18 months.

Seventy percent had non-ischemic cardiomyopathy pre-transplant. Three acquired donor transmitted coronary vascular disease. One patient developed aggressive allograft vasculopathy requiring coronary artery bypass grafting. Acute kidney injury requiring renal replacement therapy occurred in 1 patient.

Conclusion

Defying logistic challenges, donor availability and long HTx waiting list times, we have established a successful multi-center new concept HTx program with excellent mid-term outcome result. Diverse genetic background is evident in the presence of early coronary vascular disease in young donor hearts, requiring extra care in donor screening. This international collaboration has a promising future for new programs in the Middle East.

Funding Acknowledgement

Type of funding source: None
Factors associated with the cardiac allograft vasculopathy after heart transplantation
Authors: Szczurek W , Gasior M , Skrzypek M , Romuk E , Zembala M , Szygula Jurkiewicz B
Published: November 2020

Introduction

Cardiac allograft vasculopathy (CAV) is a major threat to long-term survival after heart transplantation (HT). The frequency of CAV is estimated to be 8% at 1 year after HT, 30% at the 5-year follow-up, and as high as 50% within 10 years after the procedure. Therefore, it is necessary to select those factors that are closely associated with the presence of CAV and facilitate the proper, fast and minimally invasive diagnosis of this disease.

Purpose

The aim of this study was determine risk factors associated with CAV detection in patients after HT.

Material and methods

We analyzed 299 consecutive patients after HT who underwent routine visits in our institution between 2015 and 2017. During the visit, echocardiography, routine coronary angiography, laboratory tests and immunosuppressive drug serum concentrations were performed in all patients. In addition, 10 ml of peripheral blood was collected to determine human interleukin 33 (IL-33) and IL-1 Receptor Like 1 (IL1RL1). IL-33 and IL1RL1 concentrations were measured by sandwich enzyme-linked immunosorbent assay (ELISA) with the commercially available kit. The diagnosis of CAV was based on the results of coronary angiography and defined according to the current International Society for Heart and Lung Transplantation (ISHLT) criteria.The Medical University Local Institutional Review Board approved the study protocol, and all patients provided informed consent.

Results

Patients' median age was 59.00 (45.00–66.00) years, and 74.2% were men. The median time from HT to study inclusion was 9.03 (6.02–13.01) years. The frequency of CAV according to the ISHLT criteria in the analysed population was 47.5%. At the time of enrolment all patients were receiving immunosuppressive therapy with calcineurin inhibitor and mycophenolate mofetil, and were free from acute rejection (diagnosed either by echocardiography or biopsy), clinical signs of infection or symptoms of acute heart failure. Multivariate analysis using logistic regression confirmed that IL-33 OR 0.958 (0.944–0.972), p<0.0001 as well as IL1RL1 OR 1.061 (1.040–1.083), p<0.0001) serum concentrations, donor age OR 1.046 (1.009–1.085) p=0.015, left ventricular diastolic dimension OR 1.081 (1.016–1.149) p=0.015, and time from HT to blood collection OR 1.256 (1.151–1.371), p<0.0001 were independent factors of CAV detection.

Conclusions

Lower IL-33 and higher IL1RL1 serum concentrations, as well as donor age, left ventricular diastolic dimension and time from HT to blood collection are independently associated with CAV. This study provides non-invasive, low-cost, and simple indicators for CAV detection.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of Silesia, Katowice, Poland
Risk prediction for subclinical carotid atherosclerosis in rotational shift workers in the arctic
Authors: Shurkevich N , Vetoshkin A , Gapon L , Simonyan A , Kuznetsov V
Published: November 2020

Introduction

High prevalence of cardiovascular events at northern latitudes determines the necessity of studying mechanisms of formation and early diagnosis of atherosclerotic process.

Purpose

To determine the most unfavorable prognostic factors that provide the percentage of correct prediction and high accuracy in detection of atherosclerotic plaque (ASP) in common carotid arteries (CCA) in rotational shift workers in the Arctic.

Methods

Within 2010–2012 a study of 424 males aged 30–59 years at the medical unit “Gazprom dobycha Yamburg” (Yamburg settlement, 68°N) was performed. Patients were randomized into 2 groups according to blood pressure (BP). Gr.I included 294 people with BP more than 140/90 mmHg, arterial hypertension (AH) of 1,2 stage and Gr.II included 130 people with BP less than 140/90 mmHg.

Groups did not differ in age (46.9±5.8 years, p=0.435); total work experience in the Arctic: 16.5±6.8 years (p=0.512) and rotational shiftwork duration: 12.5±4.6 years (p=0.597). Office BP was 149.4±13.3/97.1±7.3 mmHg in Gr.I and 123.4±7.5/80.5±5.5 mmHg in Gr.II.

Ultrasound examination of carotid arteries with determination of presence or absence of ASP in CCA and estimation of stenosis using NASCET method were performed; ambulatory blood pressure monitoring was conducted; blood glucose levels, total cholesterol, high-density lipoprotein cholesterol, low density lipoprotein cholesterol were determined. Statistical analysis was carried out using R (v. 3.6.1) programming language for statistical data processing of R Studio application package (v. 1.2.1335).

Results

Signs of CCA atherosclerosis were revealed in 56% of patients with AH and in 25% of those without AH. According to multivariate analysis, three variables with the most significant set of predictors, associated with ASP in CCA with the percentage of correct prediction of 75.9% were selected by step-by-step method: diastolic BP24 (<0.0001), glucose (0.0167) and cholesterol (0.0439). Based on the obtained model, it was concluded that 1 mmHg increase in diastolic BP24 increases the risk for developing ASP by 5.9%, Exp. (Beta) = 1.059, 1 mmol/l increase in glucose and cholesterol escalates the risk by 44.1% and 25.2%, respectively: Exp. (Beta) = 1.441 and Exp. (Beta) = 1.252.

Conclusion

The data obtained will improve accuracy for the early diagnosis of subclinical atherosclerosis of CCA, allow to prescribe lipid-lowering therapy timely and reduce the risk of adverse cardiovascular events in rotational shift workers in the Arctic.

Funding Acknowledgement

Type of funding source: None
The associations of circulating microRNA-133a with parameters of hypertension heart disease in patients with arterial hypertension and obesity
Authors: Yushko K , Koval S , Snihurska I , Mysnychenko O
Published: November 2020

Introduction

Blood pressure (BP) elevation leads to chronical increasing left ventricular (LV) overload, LV hypertrophy (LVH), impaired LV relaxation, development of LV diastolic dysfunction (DD), left atrial (LA) enlargement, which result in development of hypertension heart disease (HDD), increased risk of atrial fibrillation and heart failure. MicroRNA-133a is one the epigenetics factor, which has cardioprotective properties, but its role in the development of HHD in hypertension patients with obesity is not well understood.

Purpose

The aim of the study was to investigate the circulating microRNA-133a levels in patients with hypertension and obesity and to define its associations with components of HHD.

Methods

The study involved 82 patients with arterial hypertension grades 2–3 and obesity (44 men and 38 women) aged 43 to 70. All patients were separate in two groups: 45 patients with HHD (main group) and 37 patients without HHD (comparison group). The control group consisted of 21 practically healthy individuals of comparable gender and age. The HHD was defined as LVH in hypertension patients with/without LV DD. The LVH was determined according to the 2018 ESC/ESH guidelines. The LV DD was determined according to the 2016 ASE/EACVI recommendations. Obesity was diagnosed at body mass index ≥30 kg/m2. Circulating plasma microRNA-133a levels were obtained by polymerase chain reaction using the CFX96 Touch System, “TaqMan microRNA Assay” and “TaqMan® Universal PCR Master Mix” reagent kits.

Results

The levels of microRNA-133a in main group were significantly lower than in comparison group and control group (0.133 [0.099; 0.184] vs 0.238 [0.155; 0.410], p<0.05 and 0.382 [0.198; 0.474]), p<0.05). In the main group 23 patients had LV DD and 25 patients had normal LV diastolic function. In patients with LV DD the levels of circulating plasma microRNA-133a were significantly lower than in patients with normal LV diastolic function (0.094 [0.067; 0.147] vs 0.152 [0.092; 0.189]), p<0.05). In the main group there was a statistically significant negative correlation between microRNA-133a levels and LV mass index (R=−0.37, p<0.01) and no significant correlation with ejection fraction, LA size or E/e' (averaged) ratio (p>0.05). In patients of the comparison group there were not significant associations of microRNA-133a levels with LV parameters (p>0.05).

Conclusion

The results of the study indicate a significant role of decreased circulating plasma microRNA-133a levels in patients with arterial hypertension and obesity in the pathogenesis and development of HHD and such its components as LVH and LV DD.

Funding Acknowledgement

Type of funding source: None
Pulse wave velocity and blood pressure in athletes performing endurance and intense resistance training
Authors: Said Ouamer D , Guerchani Mohamed Karim M.K , Djermane D , Benkhedda S
Published: November 2020

Background

There have been contradictory reports regarding the impact of intense resistance exercise on arterial stiffness. We examined the effects of long-term endurance training and intense resistance training on central hemodynamic in athletes compared with healthy sedentary controls.

Purpose

We hypothesized that young adults participating in endurance sports would have decreased arterial stiffness, whereas those participating in intense resistance sports would have increased arterial stiffness.

Methods

One hundred thirty participants (20–30 years) including 46 intense resistance trained athletes (IRTA) (weight-lifters), 42 endurance trained athletes (ETA) (long and mid-long distance runners) and 42 sedentary individuals (SED) were investigated by aplanation tonometry and pulse wave analysis; aortic pulse wave velocity (PWV) was measured. Differences were tested by analysis of variance, covariance and multiple linear regressions after adjustment for confounders. The t-test and chi-square test were used to compare the different parameters studied between men and women. The difference between the types of sport in the female subgroup was tested by the Kruskall Wallis test. Quantitative data were expressed as means ±standard deviation or median

Results

There were no differences among all 3 groups regarding age, height, glucose, cholesterol and triglyceride levels. Anthropometrics were higher in IRTA compared to ETA. Heart rates at rest and augmentation index were lower in trained participants than in sedentary individuals. Brachial and aortic blood pressures were lower in ETA compared to IRTA. Aortic PWV was significantly lower (p<0.05) in ETA (mean ±SD: 5.58±1.00 m/s) compared to IRTA (7.06±0.87 m/s) and SED (7.18±1.06 m/s). The results of the statistical analysis in female subjects in the different groups were comparable to those found in men. A subgroup analysis comparing women and men found comparable results for PWV, but women had higher HR at rest and lower brachial and central blood pressures compared to men. After multiple regression analysis, diastolic blood pressure (DBP) remained the only hemodynamic parameter correlated to PWV, whatever the group.

Conclusion

Aortic stiffness is influenced by exercise modalities since ETA had better PWV than IRTA in both sexes. DBP is an important determinant and potential mediator of arterial stiffening in young adults.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): No funding sources