bluuebunny/crossref_metadata_2025 huggingface dataset:
Oral step-down antibiotic treatment in patients with prosthetic valve endocarditis; a POETry substudy
Authors: Pries-Heje M , Hjulmand J , Lenz I , Hasselbalch R , Povlsen J A , Ihlemann N , Tofterup M , Oestergaard L , Wienberg M , Christiansen U , Bruun N E , Fosboel E , Moser C , Iversen K , Bundgaard H
Published: October 2024

Background

Oral step-down antibiotic treatment (PO) was included in the 2023 ESC guidelines for treatment of infective endocarditis. In the nationwide POETry study(1), the use PO in patients with left-sided infective endocarditis (IE) was examined in Denmark, showing that almost half of possible candidates with left-sided IE received PO, with no signs of increased treatment failure.

Purpose

The aim of this study was to examine the prevalence and outcomes in patients with left-sided prosthetic valve IE (PVE) who recieved PO, compared to patients who recieved conventional intravenous antibiotic treatment only (IV).

Method

Patients with a left-sided PVE, diagnosed between May 2019 and December 2020 in Denmark were included retrospectively. Data was collected by medical chart review. Patients were followed for 6 months. Patients were considered possible candidates for PO if they had left-sided PVE with one of the following bacterial pathogens: Staphylococcus aureus, Enterococcus faecalis, any streptococci or coagulase-negative staphylococci. Patients were excluded if he/she died or were discharged as terminally ill prior to end of antibiotic treatment. The composite outcome consisted of I) embolism, II) non-planned heart valve surgery, III) relapse of bacteremia or IV) all-cause mortality, from end of antibiotic treatment until end of follow-up. Comparisons of primary outcome and all-cause mortality was analyzed with log-rank test.

Results

In total 158 patients (median age 77 years (IQR: 69-81, 42 female (23%)) with PVE were considered possible candidates for PO, of which 70 (45%) were switched to PO. Patients who received PO more often had diabetes (PO: 27% vs IV: 14%, p=0.03) and were more often non-surgically managed (PO: 86% vs IV: 71%, p =0.02). Median length of stay was reduced by 22 days (PO: 26 days IQR: 17-44 vs IV: 48 days, IQR: 43-61, p<0,001). After 6 months follow-up primary outcome had occurred in 7 (10%) patients who received PO and in 13 (15%) who received IV (p=0.34, Figure, panel A). Prevalence of all-cause mortality in patients who received PO was 4% (n=3) compared to 13% (n=11) for patients who received IV (p=0.07, Figure, panel B). There was no difference in the prevalence of primary outcome according to bacterial pathogen.

Conclusion

In patients with left-sided PVE who were potential candidates for oral step-down treatment, about half were switched to PO, with a relevant reduction of in-hospital length-of-stay of 22 days. There was no difference in the prevalence of primary outcome or all-cause mortality after 6 months between the two groups. These results support the safety of PO treatment for patients with PVE after stabilized infection.
Mechanical thrombectomy is associated with worse outcomes in infective endocarditis: a retrospective cohort study
Authors: Barlas R , Pana T , Myint P , Mamas M A
Published: October 2024

Background

Acute Ischaemic stroke (AIS) is a common complication in infective endocarditis (IE) and associated is with high mortality. There is a paucity of data evaluating mechanical thrombectomy (MT) in patients with AIS secondary to IE. Our retrospective cohort study aimed to quantify the efficacy and safety of MT in this patient population.

Methods

The National Inpatient Sample (NIS) was utilised. We obtained data from 2004 – 2019. We included all patients who had AIS and IE. We excluded patients who received thrombolysis. Those who received mechanical thrombectomy were compared to those who did not. Odds ratios were calculated using logistic regressions. We adjusted for multiple confounders. Outcomes included inpatient mortality, long length of stay (> 4 days), discharge status (normal vs ‘other’) and intracranial haemorrhage.

Results

The sample population consisted of 22,6390 patients (mean age 69, 52.3% female). ME was performed on 496 (2.2%). Patients with IE who received MT had a greater odds of death compared to those who did not (OR 1.91 95% CI 1.00 – 3.67). In addition, they had a greater odds of intracranial bleeding (OR 4.47 95% CI 2.78 – 7.20). Length of stay and neurological outcome did the significantly differ. We performed a sub-analysis, which included patients who had received thrombolysis in addition to MT. This did not modify the results for mortality and intracranial bleeding outcomes.

Conclusion

Mechanical thrombectomy was associated with increased mortality and intracranial bleeding in patients who have AIS associated with IE. While acknowledging the limitations of observational data, we therefore advise caution when considering mechanical thrombectomy in this patient population.
Enhancement of the Mayo Clinic Genotype Predictor Score using Cardiac MRI
Authors: Ferreira Felix I , Karlinski Vizentin V , Patel M , Bos M M , Geske J B , Giudicessi J R , Ackerman M J , Arruda-Olson A M
Published: October 2024

Introduction

Hypertrophic cardiomyopathy (HCM) is the most prevalent heritable cardiomyopathy typically transmitted in an autosomal dominant fashion. There is growing importance in identifying genetic test positive patients given its prognostic value. The Mayo HCM Genotype Predictor Score has been extensively validated for assessment of patient’s pre-test probability for genotype positive HCM and helps guide clinical decision-making based on clinical and echocardiographic variables. Herein, we evaluated the role of cardiac magnetic resonance (CMR) to enhance the genotype predictor score.

Purpose

Evaluate performance of the Mayo Clinic HCM Genotype Predictor Score using CMR variables, and develop an updated, CMR incorporated score.

Methods

Retrospective analysis was conducted on 175 unrelated HCM patients with at least 1 MRI and a HCM genetic testing seen at the Mayo Clinic between April 2004 and April 2018. Phenotyping information was obtained through review of electronic medical records. The original Mayo HCM Genotype Predictor Score was calculated using both echocardiography and clinical variables. An updated score was created incorporating CMR-specific variables. Diagnostic accuracy of the models was assessed thought Receiver Operating Characteristic (ROC) curves.

Results

Overall, 108 (62%) were males with a mean age at CMR of 51 ± 18 years. The yield of positive genetic test for the echocardiogram-derived Mayo HCM Genotype Predictor Score ranged from 38% for patients with -1 point to 100% for patients with 4 or 5 points. There was a significant incremental increase in diagnostic yield between score subgroups (p < 0.01) with an AUC of 0.659 (Figure 1A). Similar findings were observed using CMR variables (AUC of 0.697; Figure 1B). Univariate and multivariate analysis identified late gadolinium enhancement (LGE) as a strong predictor of a positive genetic test (OR 3.72; p=0.002), and it was added to the original score to create a new version. The Updated Mayo HCM Genotype Predictor Score predicted a positive genetic test ranging from 25% for patients with -1 point to 100% for patients with 5 or 6 points (p < 0.01). There was a significant increase in diagnostic accuracy when compared to the original score (AUC 0.724 vs 0.679; p=0.03; Figure 1C).

Conclusion

Using LGE, the updated CMR-based Mayo HCM Genotype Predictor score provides a simple and improved tool to aid in genetic counseling for HCM patients.
Prognostic role of ECG patterns in Anderson Fabry disease
Authors: Serratore S , Parisi V , Taglieri N , Lillo R , De Nicola F , Ditaranto R , Schiavo M A , Barile L , Fanciullo N , Ruotolo I , Indolfi C , Graziani F , Olivotto I , Galie N , Biagini E
Published: October 2024

Background

Anderson Fabry disease (AFD) is an X-linked lysosomal storage disorder leading to a deficiency in α-galactosidase A and globotriasylceramide (Gb3) deposition in different organs. Cardiac involvement is extremely common. It has been shown that the ECG abnormalities are directly correlated with the progressive accumulation of glycosphingolipids in the myocardium and cardiac conduction system. However, it is still unclear whether the ECG alterations are correlated with clinical events.

Purpose

To evaluate the prognostic role of ECG patterns in an unselected population of patients with AFD.

Methods

We conducted a retrospective multicenter study enrolling 215 consecutive patients. Based on the baseline ECG the study population was divided into the following five groups: 1) normal ECG or minimal alterations; 2) left ventricular hypertrophy (LVH) without signs of overload; 3) isolated negative T waves in the inferior and/or lateral leads; 4) LVH with signs of overload with or without incomplete right bundle branch block (RBBB); 5) complete RBBB. The primary endpoint was the composite of sudden cardiac death, resuscitated cardiac arrest, sustained ventricular tachycardia, and heart failure.

Results

Median age of study population was 45 years (32-57), and 86 patients (40%) were men. The rate of classic phenotype was 68%. Patients with ECG patterns 3 and 4 were older at baseline, more frequently affected by arterial hypertension, mostly male and showed greater left ventricular thickening, At a median follow up of 60 months (25-83) the overall Kaplan-Meier survival free from the primary endpoint was 57%: the Kaplan-Meier survival estimates of ECG groups were 66%, 75%, 68%, 27% e 52% respectively (log Rank 0.0026). On multivariable analysis patients belonging to either 3 or 4 group showed an increased risk of primary endpoint (HR= 2.45; 95% CI 1.04-5.78, p=0.040) compared to other groups.

Conclusion

ECG at baseline may be a useful tool to predict the risk of cardiovascular events in Anderson-Fabry Disease. Future studies should investigate if ECG may be useful also to evaluate the clinical response to specific therapy.
Assessment of coronary blood volume to left ventricular mass ratio: a comparative study among endurance athletes, hypertrophic cardiomyopathy patients and healthy controls
Authors: Kazum S , Aviv Y , Kornowski R , Hamdan A
Published: October 2024

Background

Pathologic left ventricular hypertrophy (LVH) may lead to a mismatch between left ventricular mass (LVM) and blood supply, potentially reducing coronary flowreserve. Typically, assessing this involves complex or invasive methods.

Objective

We assessed epicardial coronary blood volume (CBV) to LVM ratio (V/M) using coronary computed tomography (CT) angiography in athletes, HCM patients, and healthy controls.

Methods

A total of 169 individuals without obstructive coronary artery disease were included, comprising 39 endurance athletes, 55 HCM patients, and 79 healthy controls. Automated detection of the epicardial coronary tree facilitated the calculation of CBV, enabling the assessment of LVM and subsequent comparison of the V/M ratio.

Results

HCM patients had the highest LVM (242g ±115), followed by athletes (145g ±33.35) and healthy controls (106g ±22.53), the corresponding CBV were: (7ml ±2.09 ml), (6.35±1.68 ml), and (4.43±0.93 ml); respectively. V/M ratios were similar in athletes (0.04 ±0.01 ml/m2), and controls (0.04 ±0.01, P= 0.298 ml/m2), but were significantly lower in HCM patients (0.03 ±0.01, P<0.001 ml/m2). CBV and LVM significantly corelated among the three group (Figure).

Conclusions

Contrast CT findings reveal that unlike HCM patients with pathological LVH, athletes exhibit sufficient increase in CBV relative to LVM thereby maintaining normal V/M ratio.
The efficacy and safety of thrombolytic therapy for acute pulmonary embolism in patients with active malignant disease
Authors: Obradovic S , Dzudovic B , Matijasevic J , Salinger S , Kovacevic-Preradovic T , Miloradovic V , Mitevska I , Mitrovic B , Subotic B , Kafedzic S , Neskovic A
Published: October 2024

Background

Active malignant disease is associated with pulmonary embolism and the treatment of this condition is very challenging. The efficacy and safety of thrombolytic therapy for acute severe PE in patients with active malignant disease is unknown.

Aim

This study aimed to investigate hospital mortality rate and the incidence of major bleeding at 7 days according to the International Society of Thrombosis and Hemostasis (ISTH) criteria in patients with active malignant disease who were treated with thrombolytic therapy due to severe acute PE.

Methods

Patients with acute PE proven by computed tomography pulmonary angiography who were admitted to intensive care units have enrolled in the Regional PE Registry (REPER) since 2015, consisting of 10 hospitals from the 4 east Balkan countries. The decision to use thrombolytic therapy was at the discretion of the attending physicians, and it was used in high-risk, and intermediate-high-risk PE patients. Hospital mortality and the incidence of major bleeding at 7 days were compared between patients with active cancer and those without it who received thrombolytic therapy. Alteplase-based therapy was used.

Results

Among 2070 patients with acute PE enrolled in REPER, intermediate-high and high-risk PE had 795 patients without malignant disease and 135 had active malignant disease in the last 6 months. Patients with malignant disease had less chance to be treated with thrombolysis than patients without it (29.1% vs 44.7%, OR 0.508, 95%CI 0.341-0.756, p=0.001). For patients treated with thrombolysis, hospital mortality was non significantly higher in patients with the malignant disease compared to patients without it (25.6% vs 16,1%, OR 1.803, 95%CI 0.833-3.904, p=0.132), and the incidence of major bleeding at seven days was similar (15.4% vs 18.5%, OR 0.800, 95%CI 0.322-1.989, p=0.6131). There was no significant difference in age, sex, and PE risk distribution between patients with active malignant disease and those without it who were treated with thrombolysis.

Conclusion

Thrombolytic therapy seems to be underutilized in patients with the active malignant disease compared to patients without it in severe acute PE. In the selected patients who were treated with thrombolysis for severe acute PE, the efficacy and safety are similar between patients with and without active malignant disease.
Complication comparison in intermediate-to-high risk venous thromboembolism patients, treated with high vs standard dose apixaban and rivaroxaban after low molecular weight heparin
Authors: Garner A , Petersen J , Gleerup Fornitz G
Published: October 2024

Background

In patients with intermediate-to-high risk venous thromboembolism (VTE), current guidelines recommend initial treatment with low molecular weight heparin (LMWH), followed by an oral anticoagulant. However, the studies supporting these guidelines have only focused on the use of Edoxaban and Dabigatran after 5 days of LMWH treatment. To date there are no studies supporting similarly implemented guidelines for Apixaban and Rivaroxaban.

Purpose

To investigate the incidence of bleeding complications and thrombosis in intermediate-to-high risk VTE patients, when treated with either lead-in high or standard dose Rivaroxaban or Apixaban, following initial LMWH treatment.

Methods

Through a real-life retrospective study of 844 intermediate-to-high risk VTE patients, 584 were initially treated with LMWH and subsequently Apixaban or Rivaroxaban and divided into two groups. The first group of 514 patients, received high dose Apixaban or Rivaroxaban (10mg x 2 for 7 days and 15mg x 2 for 21 days respectively) before being reduced to their standard doses. The remaining 70 patients, instead transitioned directly to the standard doses (5mg x 2 and 20mg x 1 respectively) from LMWH. All patients started treatment between 2018 and 2023, and all complications were recorded until one year following initiation of treatment. Treatment complications include recurrent VTE, separated into deep vein thrombosis and pulmonary embolism, and bleeding complications in the form of fatal, non-fatal, minor and a drop in haemoglobin. The recurrence of VTE and incidence of bleeding complications were evaluated as the primary efficacy outcome and safety outcome respectively.

Results

Overall, 4.7% of patients treated with initial high dose Apixaban or Rivaroxaban suffered major bleeding complications as opposed to 2.9% treated with the standard dose (p=<0.05). Out of all complications, 5 were fatal, all of which were part of the high dose group and included 3 cerebral and 2 gastrointestinal bleeds. However, minor bleeding complications were more frequent in the standard dose group, presenting in 26.1% of patients, while, paradoxically, the high dose group had similar complications in only 15.8% of patients (p=<0.05). Although treated with a higher dose, 6/478 (1,26%) incurred a recurrent thrombus within a year of treatment, while the standard dose group had no cases of recurrence, though this was not a statistically significant result.

Conclusion

Directly transitioning from LMWH to standard dose Apixaban/Rivaroxaban in intermediate-to-high risk VTE, leads to a statistically significant reduced incidence of major bleeding complications, without an increased risk of recurrent thrombosis.
The role of cardiac magnetic resonance in patients with an angiographically diagnosed SCAD
Authors: Biondo A , Schweiger V , Schlenker R , Di Vece D , Gotschy A , Moser L J , Templin-Ghadri J R , Wilzeck V C , Alkadhi H , Templin C , Manka R
Published: October 2024

Background/Introduction

Spontaneous coronary artery dissection (SCAD) characterized by its non-atherosclerotic nature, poses challenges in diagnosis and management. While recent efforts shed light on SCAD's clinical aspects, the specific utility of CMR demands deeper investigation for enhanced diagnosis and patient care.

Purpose

This study aims to analyze the characteristics of patients with an angiographically diagnosed SCAD, evaluate qualitative and quantitative parameters of baseline CMR and investigate predictors of myocardial injury and the association between CMR parameters and clinical outcome (major adverse cardiac events, MACE).

Methods

The study is a prospective single-center analysis of 59 patients, presented acutely in our hospital, from March 2018 to November 2023, with an angiographically detected SCAD. CMR was performed after a median of 4 days (IQR 1.5-7) from the acute onset of symptoms. SCAD Types were angiographically categorized according to the Yip-Saw classification. Most patients (71%) were screened for fibromuscular dysplasia (FMD) with a brain MR and at least one contrast-enhanced abdominal vessels investigation (CT or MR). CMR imaging was performed on a clinical 1.5 T Scanner. T1-weighted, T2-weighted turbo-spin-echo (TSE) Black-Blood (BB) and Short-Tau-Inversion-Recovery (STIR) sequences in short-axis orientation were acquired. The scan protocol included standard cine and T1/T2-weighted TSE BB and Mapping sequences. Late gadolinium enhanced (LGE) images were acquired ≏10 min after the contrast injection and were visually assessed for the presence and extension of LGE areas. LGE quantification was assessed semiautomatically.

Results

40 (68%) were females. 54(92%) complained of chest pain, in 55 (93%) high-sensitive Troponin T was eleveted (>14 ng/l) and 24 (41%) presented with the clinical picture of STEMI on admission. From an angiographic point of view, the majority (69.5%) were classified as SCAD Type 2 (a+b). Among patients who underwent a proper screening, 7 patients (16%) were diagnosed with FMD. Baseline CMR showed signs of active injury in 81% and LGE in 93% of the population; however, it was often moderate in size (median of LGE segments 3, IQR 2-5). Most patients had a preserved LVEF (55±10%). STEMI presentation is an independent predictor of LGE extension (p=0.02, OddsRatio(95% CI)=7(2-24)). ScadType1 (p=0.01, OR=10( 2-39)) and N°LGE transmural segments >3 (p=0.03, OR=5.4(1.2-25)) were found to be significant predictor of MACE. 6 of the 11 MACEs were SCAD recurrence/progression, and 4 out of these 11 had already shown signs of previous myocardial injury in the baseline CMR.

Conclusion(s)

This study emphasized the significance of CMR, which may provide further insights into extend of myocardial damage and may aid in patients’ risk stratification.
Stroke-Heart syndrome: a population-based cohort study and cluster analysis
Authors: Choi S E , Tsang C T W , Huang J Y , Lau K K , Bucci T , Lam S H M , Yiu K H , Lip G Y H , Abdul-Rahim A H
Published: October 2024

Background

The onset of acute cardiovascular complications following a stroke, also known as "Stroke-Heart Syndrome", can occur in up to 20% of patients following a stroke. The syndrome remains under-investigated and limited data exists related to the occurrence and impact of the Stroke-Heart Syndrome in an Asian population.

Objectives

We aimed to investigate the potential impact of the Stroke-Heart Syndrome and its associations in a retrospective population based-cohort study.

Methods

The analysis included patients with new-onset ischaemic stroke (IS) June 2006 and May 2022 with 5 years’ follow-up. Patients who developed acute cardiovascular complications within 28 days of their index stroke were compared to patients who did not. The association between acute cardiovascular complications and longer term outcomes were evaluated using multivariate Fine-Grey analyses to adjust for competing risk of mortality, and a Cox regression model for all-cause mortality. Inverse probability of treatment weighting was applied prior to analysis. Furthermore, a hierarchical cluster analysis was performed in the cohort of stroke patients with "Stroke-Heart Syndrome", to further evaluate associations between the identified clusters and (i) longer term outcomes, as well as (ii) the development of acute cardiovascular complications.

Results

A total of 141,118 patients (median age 72.4 (IQR 62.6 to80.8) years; 45.4% female) were included in the analysis, 6,457 of who developed acute cardiovascular complications, and 134,661 of whom did not. At 5 years follow-up, acute cardiovascular complications were associated with a higher risk of developing recurrent ischaemic stroke (Sub-distribution Hazard Ratio [SHR]: 1.20, 95% Confidence Interval [CI]: 0. 1.12-1.28, p= <0.001), haemorrhagic stroke (SHR: 1.15, 95%CI: 1.03-1.28, p=0.014), myocardial infarction (SHR: 1.53, 95%CI: 1.39-1.69, p=<0.001), and cardiovascular death (SHR: 1.57, 95%CI: 1.45-1.71, p=<0.001) as well as all-cause mortality (HR: 1.07, 95%CI: 1.07-1.07, p=<0.001). A total of 4 clusters were identified in the cluster analysis. Compared to Cluster 3, the other Clusters were associated with increased 5-year risk of myocardial infarction, cardiovascular death and all-cause mortality (p=<0.001). In this cohort, compared to Cluster 2, the other clusters had an increased risk of developing acute cardiovascular complications, in particular acute ischaemic heart disease and acute heart failure (p=<0.001). Cluster 3 tended to be younger with fewer comorbidities and prescribed medications. Over 90% of the patients in Cluster 2 were aged over 75 (with 43% aged 85 years or over).

Conclusion

Stroke-Heart Syndrome was associated with long-term adverse cardiovascular events in this Asian cohort of ischaemic stroke patients.
Coronary slow flow as measured by corrected TIMI frame counts is associated with impaired microvascular resistance
Authors: Girolamo O , Ismali M D , Tavella R , Ooi E L , La S , Sheikh A , Zeitz C , Beltrame J
Published: October 2024

Background

The Coronary Slow Flow Phenomenon (CSFP) reflects an increased resting microvascular resistance and has been defined as a corrected thrombolysis in myocardial infarction frame count (cTFC) >27 in the in the absence of obstructive coronary artery disease (CAD). However, there is limited and conflicting data on the diagnostic utility of CTFC with respect to gold standard coronary haemodynamic parameters; namely coronary flow reserve (CFR) and hyperaemic microvascular resistance (hMR).

Purpose

To evaluate the relationship between angiography-derived cTFC and the coronary haemodynamic parameters (CFR and hMR).

Methods

Patients with angina and non-obstructive CAD (< 50% epicardial stenosis; ANOCA) underwent comprehensive functional coronary angiography utilising a dual sensor-tipped pressure-doppler flow wire during adenosine infusion for investigation of coronary microvascular impairment, and acetylcholine provocative testing for the diagnosis of coronary artery spasm.

Results

In 103 patients who underwent functional coronary angiography, 60 patients had CSFP and this was associated with low flow velocity and higher microvascular resistance at rest as compared with patients without CSFP (19.2 ± 7.3 versus 22.6 ± 6.7, p=0.024; and 5.9 ± 2.0 versus 4.6 ± 1.7, p=0.009, respectively). Whilst cTFC was poorly associated with CFR (r= 0.058, p= 0.564), there was a relatively strong, positive correlation with hMR (r=0.258, p=0.008). Furthermore, receiver operating characteristic analyses demonstrated that CTFC poorly predicts an impaired CFR <2.5 (AUC, 0.479 [0.36-0.59]) but does predict an impaired hMR >2.5 (AUC, 0.623 [0.51-0.74] p=0.037).

Conclusion

In patients with ANOCA, cTFC is associated with coronary microvascular dysfunction as measured by microvascular resistance during hyperaemia. This data suggests the cTFC may be a surrogate marker for impaired microvascular resistance.cTFC versus hMR
Index of microvascular resistance (IMR) and fractional flow reserve (FFR) relationship in patients with angina and non-obstructive coronary artery (ANOCA) disease
Authors: Galante D , Vicere A , Giuliana C , Viccaro V , Pollio Benvenuto C , Todisco S , Burzotta F , Trani C , Crea F , Leone A M
Published: October 2024

Background

Despite the plausible physiological connection between the index of microvascular resistance (IMR) and fractional flow reserve (FFR), a comprehensive understanding of their correlation is lacking.

Purpose

This study aims to elucidate the association between IMR and FFR in patients presenting with angina and non-obstructive coronary artery disease, employing various IMR threshold values.

Methods

Consecutively enrolled patients with angina and non-obstructive coronary artery disease underwent a thorough functional assessment encompassing both epicardial (Pd/Pa, FFR) and microvascular (coronary flow reserve, CFR; IMR) domains by the thermodilution technique. The hyperemic response to adenosine (Δ) was quantified as the disparity between Pd/Pa and FFR. Correlations between FFR and IMR, as well as between Δ and IMR, were examined globally and categorized based on the presence of coronary microvascular dysfunction (CMD, CFR<2). Subsequently, patients were stratified into three groups based on IMR values: Group 1 (IMR<25), Group 2 (25≤IMR<40), and Group 3 (IMR ≥ 40). Further analyses of adenosine hyperemic response, IMR, and FFR correlations were conducted within each group.

Results

A total of 116 patients and lesions were evaluated, with 71 in Group 1, 32 in Group 2, and 13 in Group 3. Globally, FFR showed no correlation with IMR (r = 0.025, p = 0.788), regardless of CMD presence (CMD, r = 0.210, p = 0.325; no CMD r = -0.051, p = 0.631). Same results were observed for the relationship of hyperemic response to adenosine and IMR (r = -0.0398, p = 0.673). However, upon stratification by IMR values, only patients in Group 3 exhibited a positive correlation between FFR and IMR (r = 0.580, p = 0.037), with a notable reduction in the hyperemic response to adenosine as IMR values increased (r = -0.5485, p = 0.052). After adjusting for potential confounding factors, a significant increase of 0.01 in FFR values was observed for every 10-unit rise in IMR (p = 0.045) in this Group.

Conclusions

FFR appears to be particularly influenced by elevated IMR values (≥40). Prudent interpretation of FFR values in such instances is imperative, especially in cases of functionally borderline epicardial stenosis.
Comparative analysis of post-PCI fractional flow reserve and quantitative flow ratio in predicting long-term Target Vessel Failure and hard endpoints
Authors: Csanadi B , Ferenci T , Gal R , Bora N , Piroth Z
Published: October 2024

Background

The role of functional assessment after angiographically acceptable post-PCI result is debatable.

Purpose

We sought to investigate the correlation between Fractional Flow Reserve measured directly after drug eluting stent (DES) implantation (post-PCI FFR) and post-PCI Quantitative Flow Ratio (post-PCI QFR), clarify their relationship with clinical parameters, and long-term target vessel failure (TVF: cardiac death (CD), non-fatal target vessel myocardial infarction (MI) and target vessel revascularisation (TVR)), and a composite of CD and MI (CD/MI).

Method

Coronary arteries that underwent post-PCI FFR measurement at our centre between 2012 and January 2021 were consecutively included in this registry. Post-PCI QFR was calculated blinded to the post-PCI FFR value. We analysed the influence of LAD vs. (non-LAD) location, gender, age, hypertension, diabetes mellitus, hyperlipidemia, indication (acute (ACS) vs. chronic coronary syndrome), stent diameter, in-stent restenosis (ISR) vs. de novo lesion category, estimated glomerular filtration rate, proximal vs. distal lesions, severe aortic stenosis, atrial fibrillation during the procedure (AF), and prior myocardial infarction in the supply area (prior MI) on post-PCI FFR and QFR. Optimal cut-off was determined by ROC curves.

Results

A total of 400 coronary arteries were analysed. LAD location (p<0.001), male gender (p=0.0029) and smaller stent diameter (p=0.0073) proved to be predictors of a lower post-PCI FFR. LAD location (p=0.001), ISR (p=0.02), distal location (p=0.0019), AF (p=0.042) and prior MI (p=0.029) were predictors of a lower post-PCI QFR. There was a systematic bias in post-PCI QFR compared to post-PCI FFR (bias 0.0614, 95% CI, 0.053 - 0.069). During a median follow-up of 45 months, 31 CD, 20 MI and 35 TVR occurred. Follow-up was complete in 100%. There was a significant inverse correlation between post-PCI FFR and TVF (p<0.001) as well as between post-PCI QFR and TVF (p=0.045). In-stent restenosis (p=0.014) and prior MI (p=0.002) were also predictors of higher TVF rate. The predictors of CD/MI were lower post-PCI FFR (p<0.001), smaller stent diameter (p=0.03), higher age (p=0.031) and ACS indication (p=0.048), whereas post-PCI QFR was not. The best post-PCI FFR cut-off to predict TVF was 0.87 (p<0.0001). There was no single optimal post-PCI QFR cut-off to predict TVF.

Conclusion

Post-PCI QFR shows a systematic bias compared to post-PCI FFR. Post-PCI FFR is a significant predictor of TVF as well as CD/MI, whereas post-PCI QFR predicts TVF. No significant correlation between post-PCI QFR and CD/MI could be demonstrated. Our findings underscore the importance of considering multiple clinical parameters in predicting long-term outcomes. The best post-PCI FFR cut-off to predict TVF was 0.87. However, there was no single, universally applicable post-PCI QFR threshold to predict TVF.
Safety and feasibility of nationwide invasive coronary function testing in patients with angina and no obstructive coronary artery disease (NL-CFT)
Authors: Crooijmans C , Jansen T P J , Meeder J G , Woudstra J , Meuwissen M , Olde Bijvank E G M , Arkenbout E A , Woudstra P , Stoel M G , Van Den Oord S C H , Widdershoven J W M G , Den Ruijter H M , Dimitriu-Leen A L , Elias-Smale S E , Damman P
Published: October 2024

Background and purpose

Patients with angina and no obstructive coronary artery disease (ANOCA) frequently have coronary vasomotor dysfunction (CVDys) as underlying pathophysiological mechanism, comprising epicardial spasm, microvascular spasm and/or microcirculatory dysfunction. These can be diagnosed by invasive coronary function testing (CFT), which has previously shown to be safe in tertiary and expert centres. The prevalence of CVDys and safety and feasibility of CFT is reported on in this first national collaboration network on CFT’s: NL-CFT.

Methods

NL-CFT is a prospective, observational registry of all consecutive patients undergoing clinically indicated CFT in 15 participating hospitals throughout the Netherlands. A complete CFT consisted of acetylcholine spasm provocation testing and assessment of microcirculatory function by either bolus thermodilution or Doppler flow velocity measurements. The prevalence of six different endotypes based on CFT results and overall safety were assessed and compared between tertiary (n=2) and non-tertiary centres (n=13). Tertiary was defined as having performed over 100 CFT’s prior to the start of NL-CFT and fulfilling a referral function with specialized ANOCA outpatient clinic.

Results

In total 1207 predominantly female (81%) patients with a mean age of 60±10 years were included. Traditional cardiovascular risk factors were frequently present. Almost all of the included 1207 patients underwent a complete CFT (93.4%) and prevalence of CVDys was high (77%, Fig. 1). There were 11 (0.9%) serious complications reported on, of which three were definitely related to CFT as depicted in Table 1. No procedural death, myocardial infarction or stroke was observed. Lastly, no differences were found in the occurrence of complications between tertiary an non-tertiary centres.

Conclusions

Coronary function testing is feasible and safe to perform nationally with a high diagnostic yield.Figure 1.Endotype distribution.Table 1.Side-effects&complication rates.
The impact of targeted bleeding source treatment on the risk of recurrent bleeding after percutaneous coronary intervention among patients with a history of prior bleeding
Authors: Bar S , Temperli F , Ueki Y , Spirito A , Kavaliauskaite R , Haner J D , Siontis G C M , Kakizaki R , Furholz M , Susuri-Pfammatter N , Stortecky S , Heg D , Windecker S , Losdat S , Raber L
Published: October 2024

Background

Prior bleeding is one of the strongest predictors for bleeding after percutaneous coronary intervention (PCI). Whether targeted treatment of the prior bleeding site affects the risk of bleeding after PCI is unknown to date.

Methods

From an all-comers population undergoing PCI between 2009-2019, patients with BARC 2-4 bleeding prior to index PCI were identified. Among those, the recurrence of BARC 2-5 bleeding at the same bleeding site, any BARC 2-5 bleeding, and mortality were compared throughout 1 year after PCI between patients with vs. without targeted treatment at the prior bleeding site. Targeted treatment was defined as medical, interventional, or surgical therapy targeted to cure the cause of bleeding. Adjusted hazard ratios (HRadj) were extracted from Cox regressions. Inverse probability weights were computed from a logistic regression with targeted treatment as dependent variable, and the following covariates: ARC-HBR variables associated with ≥4% 1-year bleeding risk in this registry (including oral anticoagulation), aspirin, potent P2Y12 inhibitor treatment, and prior bleeding site.

Results

Out of 18’510 patients enrolled from 2009-2019, 845 (4.6%) had a history of prior BARC 2-4 bleeding before PCI. Mean age was 71.6 years, 25% were female, and 52% presented with acute coronary syndrome. Patients with targeted treatment were significantly younger (70.3 vs. 72.5 years, p=0.005) and had more frequently malignancies (25% vs. 18%, p=0.012). 26/344 (7.6%) of patients with targeted treatment vs. 31/501 (6.2%) of patients without targeted treatment experienced recurrent BARC 2-5 bleeding at the same bleeding site (HRadj 1.35, 95% CI 0.79-2.30, p=0.268). 45/344 (13.1%) of patients with targeted treatment vs. 59/501 (11.8%) of patients without targeted treatment experienced any recurrent BARC 2-5 bleeding (HRadj 1.16, 95% CI 0.78-1.72, p=0.473). The rate of mortality was also similar between the groups (targeted treatment 13.7% vs. no targeted treatment 12.4%, HRadj 1.13, 95% CI 0.76-1.67, p=0.549).

Conclusions

Among patients with a bleeding history before PCI, half of the recurrent bleeding events throughout 1-year after PCI occurred at the same bleeding site, regardless of whether the bleeding source underwent targeted treatment. These findings imply that targeted treatment is not protective for recurrent bleeding events after PCI and that prior bleeding represents rather a systemic than local bleeding risk.Frequency of bleeding sitesKaplan Meier curves
Drug-coated balloon versus drug-eluting stent for de novo culprit lesion in acute coronary syndromes: a report from nationwide registry in japan
Authors: Takahashi T , Yamaji K , Kohsaka S , Ishii H , Mori Y , Wakatsuki T , Yamaguchi K , Nishioka D , Kusunose K , Amano T , Sata M , Kozuma K
Published: October 2024

Background

Randomized trials have demonstrated the non-inferiority of DCB strategy compared to DES strategy for ACS [1-3]. However, generalizability in clinical settings remains unclear.

Purpose

This study aims to compare the outcomes between drug-coated balloon (DCB) and drug-eluting stent (DES) strategies in percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) within a nationwide procedure-based registry.

Methods

This is a retrospective analysis of a cohort study from a prospective, nationwide registry from January 2017 to December 2020 in Japan, focusing on ACS patients who underwent DCB or DES strategy for a single de novo lesion. One-year incidence of all-cause death, cardiovascular death, non-cardiovascular death, non-fatal ACS, stroke, and major bleeding events were compared. Subgroup analysis included lesion-based and ST-elevation myocardial infarction/non-ST-elevation ACS stratification.

Results

Among 5,212 propensity-matched ACS patients, DCB and DES strategies showed no significant differences in one-year incidence of all-cause death (4.5% vs. 4.6%, hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.72-1.19), cardiovascular death (2.5% vs. 2.5%, HR: 0.90, 95% CI: 0.64-1.26), non-cardiovascular death (2.0% vs. 2.1%, HR: 0.96, 95% CI: 0.65-1.42), and non-fatal ACS (1.7% vs. 2.0%, HR: 1.04, 95% CI: 0.70-1.54). DCB showed higher stroke occurrence (0.8% vs. 0.3%, HR: 2.33, 95% CI: 1.06-5.08) but lower major bleeding events (1.4% vs. 2.3%, HR: 0.65, 95% CI: 0.43-0.99) (Figure 1). Subgroup analyses did not reproduce these findings (Figure 2).

Conclusions

ACS patients using the DCB strategy demonstrated clinical outcomes equivalent to those undergoing the DES strategy at one year. Further investigation with an extended follow-up is necessary to confirm these findings.
Prognosticating short-term outcomes in STE-ACS patients with intra-procedure slow flow/no-reflow: an analysis of predictive factors in primary percutaneous coronary revascularization
Authors: Safdar U , Kumar R , Sial J , Saghir T , Karim M
Published: October 2024

Background

"ST-segment elevation myocardial infarction (STEMI)" is the most lethal form of "ischemic heart disease (IHD).primary "percutaneous coronary intervention (PCI)" as the first-line treatment for STEMI patients, as it offers better outcomes compared to other medical or surgical options [1,2]. One major concern in interventional cardiology is the occurrence of "slow flow/no-reflow (SF/NR)", which refers to the poor myocardial perfusion to the infarct-related artery as a result of microvascular obstruction.

Objectives

In this study, we compared the incidence of short-term outcomes between two groups of patients based on the occurrence of intra-procedure "slow flow/no-reflow (SF/NR)" and identified predictors of short-term outcomes.

Method

This study enrolled a series of consecutive patients who underwent primary "percutaneous coronary intervention (PCI)" for "ST-elevation myocardial infarction (STEMI)". The patients who developed SF/NR during the procedure were compared with their counterparts for the incidence of short-term "major adverse cardiovascular events (MACE)". Furthermore, the study aimed to identify predictors of short-term mortality in these patients.

Result

In this study, a total of 2,582 patients were included. Among them, 79.1% (2,042) were male. The average age of the patients was 55.7 ± 11.2 years. Intra-procedure SF/NR was observed in 21.7% (560) of the patients. During median short-term follow-up of 180 [144-205] days, patients with SF/NR exhibited higher incidence of all-cause mortality (23.6% vs. 12.3%; p<0.001), and MACE (30.4% vs. 16.9%; p<0.001) with hazard ratio of 1.82 [1.46-2.27; p<0.001] and 1.69 [1.39-2.05; p<0.001], respectively. Among patients with SF/NR, adjusted odds ratio for total ischemic time: 1.04 [1.00-1.07; p=0.041], random blood sugar levels: 1.01 [1.00-1.01; p<0.001], intubation status: 2.79 [1.26-6.18; p=0.011], post-procedure sub-optimal flow: 1.76 [1.04-2.98; p=0.034], and intra-procedural arrhythmias: 5.48 [2.03-14.79; p<0.001] were found to be independent predictors of short-term mortality.

Conclusion

In conclusion, the presence of intra-procedure SF/NR carries significant prognostic implications. Patients with intra-procedure SF/NR face a significantly higher risk of short-term adverse outcomes.
Left atrioventricular coupling index is an independent associate of new-onset AF and stroke in hypertrophic cardiomyopathy: a CMR study
Authors: De Raffele M , Teis A , Weerts J , Niro L , Kasa G , Junca G , Cediel G , Bertini M , Bayes-Genis A , Delgado V
Published: October 2024

Background

Left atrial (LA) dysfunction is an important marker of disease progression in hypertrophic cardiomyopathy (HCM). LA volumes and functional parameters are associated with new-onset atrial fibrillation (AF) and its complications including stroke. The association between left atrioventricular coupling (LACI), a parameter reflecting the contribution of the left ventricular and LA remodeling to LA dysfunction, with the occurrence of new-onset AF and stroke has not been evaluated.

Aim

To investigate the association between LACI and the occurrence of new-onset AF or stroke in patients with HCM.

Methods

In patients with an established diagnosis of HCM and cardiac magnetic resonance (CMR) data, LACI was calculated as the ratio between the LA and the LV end-diastolic volumes. New-onset AF or occurrence of stroke comprised the primary combined endpoint. Cumulative event-free survival rates for the occurrence of the primary endpoint were estimated with the population divided according to a LACI cut-off value of 40%. The association between clinical and CMR variables and the primary endpoint was assessed with univariable and multivariable Cox proportional hazard regression models.

Results

Of 114 patients with HCM, (mean age 54±16 years, 33 (29%) female, LV ejection fraction 67.0±8.4%), 71 patients (49%) had a LACI > 40% (left atrioventricular uncoupling). During a median follow-up of 4.1 (1.8-6.4) years, 19 (16.7%) patients experienced new-onset AF or stroke. Patients with preserved left atrioventricular coupling (LACI ≤ 40%) had a lower cumulative rate of events compared to those with left atrioventricular uncoupling (log-rank p=0.031, Fig. 1). LACI was independently associated with new-onset AF or stroke after adjusting by the presence of late gadolinium enhancement (LGE) sex and age (HR=23.27, p=0.016).

Conclusions

In patients with HCM, the presence of left atrioventricular uncoupling is independently associated with the occurrence of new-onset AF or stroke.
Incidence of aortic valve reintervention in patients with aortic stenosis undergoing TAVI vs SAVR: A systematic review and meta-analysis of randomised controlled trials
Authors: Groberio J , Reginato P H , Streit R E , Rocha A , Florencio De Mesquita C , Udoma-Udofa O C , Ulbrich A , Farias F , Gomes W
Published: October 2024

Introduction

Transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) are two established treatments for severe aortic stenosis (AS). The relative comparison between TAVI and SAVR for recurrent aortic valve interventions is not well defined.

Purpose

We aimed to perform a systematic review and meta-analysis comparing the incidence of aortic valve reintervention in patients undergoing TAVI versus SAVR.

Methods

MEDLINE, Embase and Cochrane databases were searched for randomised controlled trials (RCT) that compared TAVI with SAVR for the treatment of AS reporting the occurrence of aortic valve reinterventions. We also performed a subgroup analysis of different types of TAVI prosthesis. We performed a meta-regression to evaluate the effect of age and Society of Thoracic Surgeons (STS) risk score in the outcome of interest. Statistical analysis was performed using RevMan 5.4.1 and RStudio 2023.12.1. Heterogeneity was assessed with I2 statistics.

Results

We included 8 RCTs with 8,698 patients, of whom 4,443 (51%) underwent TAVI. Mean follow-up ranged from 1 to 10 years. Aortic valve reintervention was significantly more common in patients treated with TAVI compared with SAVR (RR 1.89; 95%CI 1.24-2.88; p = 0.003). In a subgroup analysis stratified by balloon-expandable or self-expandable valves, there were no significant subgroup differences in their respective comparisons with TAVR (p = 0.20). In meta-regression analysis, older age (p = 0.008) and higher STS score (p = 0.009) were significantly associated with a higher incidence of aortic valve reinterventions with TAVI relative to SAVR.

Conclusion

In patients who undergo aortic valve replacement, TAVI is associated with a significantly higher incidence of aortic valve reinterventions relative to SAVR, particularly in populations with older age or higher STS score.
Comparison of mitral valve apparatus anomalies between sarcomeric hypertrophic cardiomyopathy and Fabry disease cardiomyopathy
Authors: D'andria P F , Disabato G , Attanasio A , Tondi L , Lombardi M , Guida G , Carugo S , Camporeale A
Published: October 2024

Background

Despite different etiopathogenesis, Fabry disease (FD) cardiomyopathy and sarcomeric hypertrophic cardiomyopathy (HCM) share a similar hypertrophic phenotype. Cardiac magnetic resonance (CMR) plays a pivotal role in distinguishing between these two clinical conditions, thanks to the thorough morphological definition of the phenotype and non-invasive tissue characterization. A high prevalence of mitral apparatus anomalies has been previously described both in sarcomeric HCM and FD cardiomyopathy.

Purpose

This study systematically compares the morphology of the mitral apparatus in sarcomeric HCM and FD cardiomyopathy, to add new insights into differential diagnosis.

Methods

CMR images of 120 patients were retrospectively analyzed and divided as follows: healthy controls CTRL (n=40), HCM (n=40), and FD (n=40) with left ventricular hypertrophy (LVH). The analyses included the measurement of I) papillary muscles’ hypertrophy, expressed as the maximum diameter (D max) of the anterolateral (AL) and posteromedial (PM) papillary muscles (see Figure 1 A and B); II) the anteriorization of the anterolateral papillary muscle defined as the distance between the anterolateral papillary muscle and the anterior interventricular junction (Anteriorization of AL) (Fig. 1 C); III) the length of the anterior mitral leaflet (MVL length) (Fig. 1 D). All measurements were performed on cine-SSFP sequences in diastole.

Results

Compared to healthy controls, HCM and FD patients showed significant hypertrophy of both papillary muscles (p<0.001) and elongation of the anterior mitral leaflet (p<0.001). Both papillary muscles in FD patients showed greater hypertrophy compared to HCM patients (D max AL p=0.017 and D max PM p=0.039). No significant differences were observed between FD and HCM regarding MVL length (p=0.078). Compared to FD (p=0.028) and healthy controls (p<0.001), HCM patients showed greater anteriorization of the anterolateral papillary muscle. (Results are summarized in Table 1).

Conclusions

From the comparison of mitral valve apparatus anomalies between HCM and FD, it emerged that patients with FD cardiomyopathy show a higher degree of papillary muscle hypertrophy, while patients with sarcomeric HCM display a greater anterior displacement of the anterolateral papillary muscle. The systematic analysis of the morphology of mitral apparatus can be integrated in the differential diagnosis between these two pathologies.Fig.1 Representation of MeasurementsTable 1.Summary results table