bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of direct and indirect admission to a cardiac arrest centre for intubated out-of-hospital cardiac arrest patients in the Northwest England: an audit
Authors: Yao Z , Darnley A , Duvva D , Appleby C
Published: October 2024

Background

Despite concerted global efforts to enhance cardio-pulmonary resuscitation (CPR) and post-resuscitation care, out-of-hospital cardiac arrest (OHCA) remains a significant cause of mortality. Current guidelines promote the concept of Cardiac Arrest Center (CAC), offering advanced post-resuscitation management with the aim of improving survival rates. However, it remains uncertain whether directly transporting OHCA patients from the scene to these centers would enhance their prognosis.

Purpose

This study aimed to assess whether direct transport of intubated OHCA patients to a higher-level cardiac arrest center in the Northwest of England yielded better outcomes compared to initial resuscitation in smaller local emergency departments followed by transfer.

Methods

Conducted as a retrospective analysis, the audit examined OHCA patients presenting at a single cardiac arrest center between October 2018 and April 2022. Only intubated patients were included. The study compared two groups based on the route of admission: direct admission to the cardiac arrest center from the field by emergency medical service providers versus indirect admission via inter-hospital transfer to the center. The primary outcomes assessed were inpatient survival and 30-day survival. Statistical analysis employed Student's T-test and Chi-square test for clinical significance.

Results

The audit included 214 patients, with 112 (52.34%) in the direct group and 102 (47.66%) in the indirect group. Baseline characteristics between the groups were similar, including age, gender, downtime, bystander CPR, haemodynamic status, initial presenting rhythm (VT/VF), post-arrest ECG (STEMI), comorbidities, and procedural outcomes (Table 1). However, the direct group exhibited significantly shorter average arrival times at the cardiac arrest center (72 minutes vs. 190 minutes, p=0.017), along with improved in-hospital survival (52.68% vs. 41.18%, p=0.009) and 30-day survival rates (52.68% vs. 37.25%, p=0.002).

Conclusion

The direct admission of intubated OHCA patients to a cardiac arrest center, as observed in this audit, was associated with improved outcomes attributed to expedited admission times. The study’s design limitations, including its non-randomized nature and single-center approach, underscore the need for further research.
Computed tomography-derived myocardial extracellular volume: a diagnostic marker for cardiac amyloidosis in transcatheter aortic valve implantation patients with biopsy confirmation
Authors: Terasaka K , Matsushita K , Kikuchi S , Kato S , Minamimoto Y , Cho T , Yamaguchi K , Hanajima Y , Gohbara M , Okada K , Kosuge M , Ebina T , Sugano T , Uchida K , Hibi K
Published: October 2024

Background

Transthyretin cardiac amyloidosis (ATTR-CA) appears to be prevalent in aortic stenosis (AS). The coexistence of ATTR-CA and severe AS is associated with an increased risk of hospitalization for heart failure after transcatheter aortic valve implantation (TAVI). The identification of ATTR-CA is of great clinical importance. In this study, we investigated the diagnostic value of computed tomography-derived myocardial extracellular volume (CT-ECV) for the diagnosis of biopsy-proven ATTR-CA.

Methods

From December 2022 to January 2024, we enrolled patients who underwent both TAVI and myocardial biopsy. CT-ECV was measured as part of routine CT imaging before TAVI and myocardial biopsy for definitive diagnosis of CA.

Results

Of 131 TAVI patients, 101 patients underwent myocardial biopsy. Eight patients (7.9%) were diagnosed with ATTR-CA. There were no significant differences in electrocardiographic parameters. On echocardiography, left ventricular ejection fraction (64 ± 16% vs. 65 ± 14%, p = 0.84) was similar between the 2 groups, whereas intraventricular septum and left ventricular posterior wall in diastole were thicker in the ATTR-CA group (15 ± 3mm vs. 13 ± 2mm, p = 0.04 and 14 ± 3mm vs. 12 ± 2mm, p <0.01, respectively). Significantly higher CT-ECV values were found in the ATTR-CA group than in the non-ATTR-CA group (32.6 ± 3.7% vs. 28.1 ± 3.7%, p = 0.001).

Conclusions

Patients with biopsy-proven ATTR-CA had high CT-ECV values. Routine CT-ECV evaluation before TAVI may be useful for the diagnosis of ATTR-CA.
Overview of the risk of myocardial infarction in patients with aortic stenosis: insights from the VALVENOR Registry
Authors: Lemesle G , Coisne A , Ninni S , Aghezzaf S , Verdier B , Schurtz G , Sudre A , Modine T , Tazibet A , Staels B , Montaigne D , Bauters C
Published: October 2024

Background

Close interaction between aortic stenosis (AS) and coronary artery disease (CAD) has been suggested. However, the risk of myocardial infarction (MI) in patients with AS is poorly described outside the context of aortic valve replacement.

Objectives

To assess the incidence, correlates and impact on outcomes of MI occurrence in patients with different degrees of AS severity.

Methods

Between 2016 and 2017, the multicenter prospective VALVENOR registry enrolled 2,830 outpatients with native valvular AS (peak aortic jet velocity (Vmax) ≥ 2.5m/s). AS was defined as mild (Vmax 2.5-2.9), moderate (Vmax 3-3.9) or severe (Vmax ≥4). MI was defined using the 4th universal definition (type 2 MI were not considered).

Results

The mean age was 76.0 years, 54% of the patients were men and 18.3% had experienced prior coronary event (PCE). Altogether, one third (n=820 [30.3%]) of the patients had diabetes.

At 5 years, the cumulative incidence of MI (death as competing event) was only 2.5% (n=72, 1/3 of ST-elevation MI). Sixty MI (83.3%) were categorized as type 1 MI while 12 were peri-procedural MI (surgical aortic valve replacement, n=5; transcatheter aortic valve replacement, n=2; coronary artery bypass surgery, n=1; percutaneous coronary intervention, n=3; coronary angiography, n=1).

PCE and angina symptoms were associated with an increased risk, whereas female gender with a decreased risk. By contrast, AS severity was not associated with the risk of MI. Five-year cumulative incidence of MI was 6.5% [95% CI, 4.5 - 8.9] in patients with PCE vs. 1.7% [95% CI, 1.2 - 2.3] in patients with no PCE (P<0.001), 8.3% [95% CI, 4.1 - 14.4] in patients with angina vs. 2.3% [95% CI, 1.8 - 2.9] in patients without angina (P<0.001), and 3.2% [95% CI, 2.4 - 4.2] in men vs. 1.8% [95% CI, 1.1 - 2.6] in women (P=0.014).

Subsequent mortality was high and at 52.8% during follow-up (median 648 days after MI occurrence). When analyzed as a time-dependent variable, incident MI was a powerful predictor of mortality (HR=2.00, P<0.001 after adjustment).

Conclusions

In patients with AS, the risk of MI is relatively low especially in patients without PCE and without angina. No association between the risk of MI and AS severity was observed. Although rare, incident MI is strongly associated with subsequent mortality.
Postoperative heart valve infection, when and which bacteria: a nationwide cohort study
Authors: Holgersson C , Oestergaard L , Havers-Borgersen E , Stahl A , Torp-Pedersen C , Koeber L , Fosboel E L
Published: October 2024

Background

In patients undergoing heart valve surgery, subsequent bacteremia and infective endocarditis are feared events due to the associated high mortality. Knowledge on the incidence and specification of bacteremia following left-sided valve surgery are sparse and may have implications for prophylactic strategies and follow-up.

Purpose

To examine the six months incidence of bacteremia and infective endocarditis following left-sided heart valve surgery.

Methods

In the period from January 2010 to December 2021 all patients undergoing left-sided valve surgery were identified using Danish nationwide registries. Patients were followed until a maximum of six months, end of study, emigration, death, or outcome of interest (i.e., bacteremia or infective endocarditis). Cumulative incidence curves were computed with death as a competing risk stratified on bacterial species and for subgroups of interest: type of valve surgery, age, and sex.

Results

A total of 14,305 patients were included in the study. The majority of the study population were male (68.6%), and the median age was 70.2 years (25th-75th percentile 62.0-76.0 years). In total, 10,469 (73.2%) of the study population underwent aortic valve surgery, 3,497 (24.5%) underwent mitral valve surgery, while 339 (2.4%) underwent surgery on both valves.

The cumulative incidence of bacteremia at six months of follow-up was 2.4% (95% CI 2.2-2.7%), Figure 1. For the overall study population, the most frequently occurring bacteremia was with Coagulase-negative Staphylococci (28%) and Staphylococcus aureus (14%). Within 30 days 0.35% of the patients had bacteremia with coagulase-negative staphylococci while this was 0.68% at six months of follow-up. For Staphylococcus aureus this was 0.19% and 0.34%, respectively.

The cumulative incidence of infective endocarditis at six months of follow up was 1.0% (95% CI 0.8-1.2%). The majority of the infective endocarditis incidents were blood culture negative (27%) or caused by Enterococci (19%), Streptococci (17%) or Coagulase-negative Staphylococci (17%) while Staphylococcus aureus accounted for 14%.

In crude analysis, simultaneous surgery on the mitral and aortic valve was associated with a statistically significant higher rate of bacteremia (P=0.004). Similarly, higher age was associated with a statistically significant higher rate of bacteremia (P<0.001). On the contrary, in crude analysis, no difference in the risk of bacteremia was found between sexes (P=0.9).

Conclusions

Bacteremia following left-sided heart valve surgery occurred in little over 2%. The majority was with Staphylococci, and half of these occurred within 30 days of the surgery. There is a continued need to optimize prophylactic strategies.
Changes and prognostic impact of right ventricular-to-pulmonary artery coupling after transcatheter aortic valve replacement
Authors: Fauvel C , Levesque T , Cabaye N , Barbe T , Tron C , Bouhzam N , Bettinger N , Hemery T , Eltchaninoff H , Durand E
Published: October 2024

Background

The ratio of tricuspid annular plane systolic excursion to systolic pulmonary artery pressure (TAPSE/sPAP), a good noninvasive approach for right ventricular to pulmonary artery (RV/PA) coupling, is of prognostic significance in many cardiovascular diseases. Yet, data regarding RV/PA coupling in transcatheter aortic valve replacement (TAVR) remain sparse.

Aims: To assess the change in TAPSE/sPAP between pre- and post-TAVR as well as its long-term prognostic value.

Methods: All patients who underwent TAVR for severe aortic stenosis between 2002 and 2022 at a university hospital, with an available TAPSE/sPAP assessed by echocardiography before and after procedure were included in this study. When available, TAPSE/sPAP was correlated with invasive right heart catheterization data. The primary endpoint was 5-years all-cause death or hospitalization for acute heart failure. C-tree analysis was used to find the best TAPSE/sPAP cut-off to be associated with the primary outcome.

Results: Two hundred and sixty-nine patients were included in this analysis (median age 85 years, 57% women, 63% NYHA III-IV). Balloon expandable valves was implanted in 90% of cases. TAPSE/sPAP was significantly improved by TAVR (0.52 vs 0.58 mm/mmHg, p=0.02). The lower the TAPSE/sPAP, the higher the NYHA functional class (p=0.0017), the higher the NTproBNP level (p <0.001) and the higher the logistic EuroSCORE (p<0.001). TAPSE/sPAP had a good correlation with pulmonary artery elastance (r=-0.61, p<0.001). Using C-tree analysis, TAPSE/sPAP ≤0.55 mm/mmHg was the best cut-off associated with the primary outcome (p=0.002). In multivariable Cox regression analysis, TAPSE/sPAP remained independently associated with the primary outcome even after adjustment with echocardiography, comorbidities or logistic EuroSCORE (Table 1). Both from baseline and follow-up assessment, patients with TAPSE/sPAP ≤0.55 mm/mmHg had worse event-free survival (Figure 1A-B). Interestingly, change in TAPSE/sPAP provided important prognostic value (Figure 1C).

Conclusion: This study emphasizes the prognostic value of TAPSE/sPAP in the field of TAVR and suggest considering RV/PA coupling assessment not only before or after procedure but also the change in TAPSE/sPAP to identify patients at higher risk of worse outcome.Table1.Multivariable Cox analysisFig1.Kaplan meier curves
Cardiac chamber three-dimensional volumes and deformation predict clinical outcomes in chronic mitral regurgitation
Authors: Berg-Hansen C E , Grymyr L M D , Sindre R B , Rogge B , Valeur A , Persson R M , Urheim S , Cramariuc D
Published: October 2024

Background

In patients with mitral regurgitation (MR), cardiac remodeling assessed by two-dimensional (2D) echocardiographic linear indexes is highly variable and not suitable for individualized risk assessment.

Purpose

To evaluate whether measurements of myocardial strain and left atrial (LA), left ventricular (LV) and right ventricular (RV) three-dimensional (3D) volumes improve risk assessment in MR.

Methods

In the prospective 3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation study (3D-PRIME), 176 patients with significant (moderate or greater) MR were investigated with 2D/3D echocardiography. Referral criteria for mitral intervention followed current guidelines. LA remodeling was assessed by the maximum and minimum 3D LA volume (3D-LAV), peak reservoir strain (LASr), and stiffness (i.e. the ratio: mitral peak E-wave divided by the annular e’ velocity (E/e´) / LASr). LV and RV were considered dilated in case of increased 3D end-diastolic (LV>=86/74 and RV>=87/74ml/m2 in men/women) and end-systolic volumes indexed for body surface area (LV>=41/33 and RV>=44/36ml/m2 in men/women). Peak global longitudinal strain was measured in the LV (LV-GLS) and the RV free wall (RV-FWS). The primary outcome was a composite of mitral valve surgery, percutaneous mitral edge-to-edge repair and death.

Results

During a 14 [8-24] months follow-up, the patients (70±13 years, 39% women) experienced 73 events including 14 deaths. In univariate survival analyses, LV and RV dilatation, but not LV-GLS and RV-FWS, were associated with the primary outcome (Figure) and had superior predictive value to 2D volumes and diameters (p<0.05). On contrary, both atrial size and function predicted outcome, with 3D-LAV (HR 1.01, 95% CI 1.00-1.01), LASr (HR 1.03, 95% CI 1.01-1.06) and increased LA stiffness (Figure) all significant predictors of events (p<0.05). In multivariate Cox analysis with adjustment for age, sex, body mass index and MR etiology, dilated LV (HR 2.6, 95% CI 1.5-4.4), dilated RV (HR 2.0, 95% CI 1.1-3.6) and increased LA stiffness ((HR 2.4, 95% CI 1.3-4.6) were independently associated with higher rate of events (p<0.05).

Conclusion

In patients with moderate or greater MR, increased cardiac chamber 3D volumes and LA stiffness, as well as impaired LA reservoir strain are associated with higher risk of disease progression towards mitral valve intervention and death. Our findings indicate that assessment of both cardiac chamber 3D size and LA deformation can contribute to increased diagnostic and prognostic precision in patients with MR.
Association of cardiac amyloidosis with cardiovascular outcomes after aortic valve replacement in patients with severe aortic stenosis: a systematic review and meta-analysis
Authors: Figueira T , Tao M , Masson R , Ibtida I , Kim P , Pastena P , Dusi S , Petrancosta J , Raven M , Rahman T , Parikh P , Mann N
Published: October 2024

Introduction

Aortic stenosis (AS) and cardiac amyloidosis (CA) frequently coexist and is commonly observed in older individuals referred for aortic valve replacement (AVR). However, the association of CA with adverse outcomes after AVR has not been well established.

Purpose

This meta-analysis aimed to evaluate the association of CA with adverse cardiovascular outcomes in patients with severe AS after undergoing AVR.

Methods

A literature search was performed for studies evaluating patients with severe AS undergoing AVR, comparing clinical endpoints on follow-up for patients with and without CA. The clinical endpoints included all-cause mortality and heart failure (HF) hospitalization. Databases searched included Ovid MEDLINE, Embase, and Web of Science. Subgroup analysis was performed for short term (<30 days) and long term (>30 days) mortality. The search was not restricted to time or publication status.

Results

Five studies including 1,105 patients with severe AS (111 with concurrent CA, 904 without CA) met inclusion criteria. The mean follow-up duration was 24.6 months, mean age was 81.2 years and 55.4% were men. Mean echocardiographic aortic valve parameters included valve area of 0.715cm2, mean gradient of 41.8 mmHg, and peak velocity of 4.2m/s. The mean left ventricular ejection fraction was 58%. All except 1 study included only patients with ATTR CA while excluding other causes of CA.

There was no statistically significant difference in all-cause mortality between patients with and without CA following AVR, both in short-term (OR 0.94; 95% CI 0.17-5.31; p=0.95) and long-term (OR 1.72; 95% CI 0.75-3.91; p=0.20) follow-up. However, patients without CA demonstrated a significantly lower risk of heart failure hospitalization post-AVR compared to those with CA (OR 2.49; 95% CI 1.18–5.23; p = 0.02).

Conclusion

In the context of patients with severe AS undergoing AVR, the presence of CA does not appear to significantly impact short-term or long-term all-cause mortality. Notably, patients without CA exhibited a lower risk of heart failure hospitalization following AVR. These findings underscore the importance of considering cardiac amyloidosis in the clinical management of severe AS and highlight potential differences in outcomes based on its presence or absence. Additional studies are needed to elucidate outcome differences for CA patients who undergo surgical versus transcatheter AVR.Figure 1
Long-term outcomes of aortic stenosis patients with different flow/gradient patterns undergoing transcatheter aortic valve implantation
Authors: Oikonomou G , Apostolos A , Drakopoulou M , Simopoulou C , Karmpalioti M , Toskas P , Stathogiannis K , Xanthopoulou M , Ktenopoulos N , Latsios G , Synetos A , Tsioufis C , Toutouzas K
Published: October 2024

Background

Few data exist on the comparative long-term outcomes of severe aortic stenosis (AS) patients with different flow-gradient patterns undergoing transcatheter aortic valve implantation (TAVI). This study sought to evaluate the impact of the pre-TAVI flow-gradient pattern on long-term clinical outcomes after TAVI.

Methods

Consecutive patients with severe AS undergoing TAVI in our institution were screened and prospectively enrolled. Patients were divided into four subgroups according to pre-TAVI flow/gradient pattern: (i) low flow—low gradient (LF-LG): stroke volume indexed (SVi) ≤ 35 mL/m2 and mean gradient (MG) < 40 mmHg); (ii) normal flow—low gradient (NF-LG): SVi > 35 mL/m2 and MG < 40 mmHg; (iii) low flow—high gradient (LF-HG): Svi 35 mL/m2 and MG ≥ 40 mmHg and (iv) normal flow—high gradient (NF-HG): SVi > 35 mL/m2 and MG ≥ 40 mmHg. Clinical follow-up was obtained at 12 months, and yearly thereafter until 5-year follow-up was complete for all patients.

Results

A total of 272 patients with complete echocardiographic and clinical follow-up were included in our analysis. Their mean age was 80 ± 7 years and the majority of patients (N = 138, 50.8%) were women. 62 patients (22.8% of the study population) were distributed in the LF-LG group, 98 patients (36%) were LF-HG patients, 95 patients (34.9%) were NF-HG, and 17 patients (6.3%) were NF-LG. There was a greater prevalence of comorbidities among LF-LG AS patients. One-year all-cause mortality differed significantly between the four subgroups of AS patients (log-rank p: 0.022) and was more prevalent among LF-LG patients (25.8%) compared to LF-HG (11.3%), NF-HG (6.3%) and NF-LG patients (18.8%). At 5-year follow-up, global mortality remained persistently higher among LF-LG patients (64.5%) compared to LF-HG (47.9%), NF-HG (42.9%), and NF-LG patients (58.8%) (log-rank p: 0.029) (Figure 1). At multivariable Cox hazard regression analysis, baseline SVi (HR: 0.951, 95% C.I.; 0.918–0.984), the presence of at least moderate tricuspid regurgitation at baseline (HR: 3.091, 95% C.I: 1.645–5.809) and at least moderate paravalvular leak (PVL) post-TAVI (HR: 1.456, 95% C.I.: 1.106–1.792) were significant independent predictors of late global mortality.

Conclusions

Patients with LF-LG AS have acceptable 1-year outcomes, but exhibit exceedingly high 5-year mortality following TAVI. The presence of low transvalvular flow and at least moderate tricuspid regurgitation at baseline and significant paravalvular leak post-TAVI were associated with poorer long-term outcomes in the entire cohort of AS patients.
Comparison of mortality scores performance in transcatheter aortic valve replacement: suiting up to percutaneous intervention
Authors: Martins A , Silva P , Garcia A B , Oliveira C , Azaredo Raposo M , Abrantes A , Gregorio C , Rosa Ferreira D , Cazeiro D , Nobre Menezes M , Carrilho P , Silva Marques J , Jorge C , Cardoso P , Pinto F J
Published: October 2024

Introduction

As transcatheter aortic valve replacement (TAVR) is increasingly relevant for patients with severe symptomatic aortic stenosis, having a reliable procedure specific risk-prediction tool is paramount to provide high-quality care. Surgical scores as the EuroScore II and the Society of Thoracic Surgeons (STS) score II have been widely used to identify patients with high surgical risk in whom percutaneous treatment might be more favorable. However, current literature lacks a consensual specific predictive model for short-term and mid-term prognosis in patients undergoing transcatheter aortic valve implantation (TAVI).

Purpose

We aimed to access short and midterm (30 days and one year) mortality and to access the ability of a directly adapted score in estimating mortality in a real-world population.

Methods

We conducted a retrospective observational study in patients who implanted TAVR in a single center. Surgical mortality scores – EUROSCORE II and STS score II – and adapted score Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) transcatheter valve therapy (TVT) score were used to estimate mortality. Predictive abilities of these three scores were compared using area under the receiver operating characteristics (ROC) curve for 30-day and one year mortality.

Results

From January 2018 to December 2021, 416 patients were submitted to TAVR procedure in our center. The mean age was 83+-6 years old and 229 (55%) were female. 94% had hypertension, 80% dyslipidemia, 40% diabetes mellitus, 35% coronary artery disease, 32% chronic kidney disease. Mean ejection fraction was 56%.

During a mean follow-up (FUP) of 816 ± 492 days, 30-day mortality was 1,7% and after 1 year mortality rate was 12,2% (higher than reported in PARTNER 3 trial, 8,5%).

The Mean EuroSCORE was 3,4±3,2, mean STS-II 3,9±1,8 and mean value for STS/ACC-TVT score was 3,55±1,34. ROC curve analysis showed a significantly higher discriminative power of STS/ACC-TVT (AUC 0,749, 95% CI 0,681-0,818) compared with surgical scores (p=0,001) – figure 1.

We also divided population into quartiles and compared the mortality rate at 30 days and 1 year in each quartile using either STSII or STS/ACC-TVT; As can be seen in figure 2, mortality rates correlated better with the STS/ACC-TVT score than with the STS score.

Conclusion

A score adapted to a TAVI population showed better predictive capacity than traditional surgical scores. Less preponderance of previous surgical status, relevance of access site and more adapted weight of age might explain the best performance of STS/ACC-TVT score. Surgical scores are helpful in choosing treatment option, but adapted scores are better to predict pos-TAVR mortality.
Clinical outcomes according to clinical and surgical risk scores for tricuspid regurgitation
Authors: Gwak S Y , Kim K , Lee H J , Cho I S , Hong G R , Ha J W , Shim C Y
Published: October 2024

Background

TRIO score, the clinical risk score in significant tricuspid regurgitation (TR), and TRI-SCORE, the surgical mortality risk for tricuspid valve (TV) surgery, have been proposed. We aimed to investigate the correlation and distribution of two risk scores, and to define the clinical benefit of TV surgery in patients with low or intermediate TRIO score and TRI-SCORE.

Methods

In a total of 10,054 patients diagnosed with moderate to severe TR between January 2008 to December 2020, TRIO score and TRI-SCORE were stratified into low, intermediate, and high-risk groups. Patients of all etiologies of TR were included and patients who underwent prior tricuspid valve surgery were excluded. The clinical outcome was all-cause death.

Results

TRI-SCORE and TRIO scores were moderately correlated (r =0.39, p<0.001). 9,104 (90.6%) patients (age 67 ± 14 years, 42% male) had low or intermediate TRI and TRIO score. During 12.6 ± 10.1 years, 885 (9.7%) underwent TV surgery and 1,268 (13.9%) experienced clinical outcomes. Kaplan-Meier analysis revealed significant differences in clinical outcomes according to TV surgery in both low and intermediate TRIO score patients (log-rank, p<0.001) and sub-analyzed them according to the TRI-SCORE group (Figure). In multivariable Cox regression analysis, TV surgery (HR 0.37, 95% CI 0.28-0.49, p<0.001) were significantly associated with clinical outcomes after adjusting confounding factors.

Conclusions

TV surgery is clinically beneficial in moderate to severe TR patients with a low or intermediate TRIO score and TRI-SCORE.
Incidence, predictors and outcomes of non-home discharge following transcatheter aortic valve implantation: a multicentre Australian experience. The NHD TAVI study
Authors: Butala A , Nanayakkara S , Navani R , Palmer S , Noaman S , Haji K , Htun N , Walton A , Stub D
Published: October 2024

Background

Patients undergoing transcatheter aortic valve implantation (TAVI) commonly experience non-home discharge (NHD), a phenomenon associated with increased health-care expenditure and possibly poorer outcomes. Despite its relevance to patients, post-TAVI NHD remains poorly explored in the literature.

Purpose

To characterise the incidence and predictors of NHD following TAVI, understand its impact on quality of life, and identify the proportion of patients that require long-term residential care following initial NHD.

Methods

Retrospective analysis of prospectively collected data of 2229 patients undergoing TAVI from 2010–2023 included in an Australian TAVI Registry.

Results

Median age was 82 (IQR: 78-86) years and 41% were female. 257 (11.5%) patients were not discharged home following TAVI, with incidence falling over time (R2=0.636, p<0.001). Multivariable logistic regression modelling for NHD prediction was developed with excellent calibration and discrimination (C-Statistic 0.835). Independent predictors of NHD were post-procedural stroke (adjusted odds ratio [aOR] 11.1), procedure at a private hospital (aOR 3.0), living alone (aOR 2.4), vascular access site complications (aOR 2.1), frailty (aOR 1.9), age>80 (aOR 1.8), hypoalbuminemia (aOR 1.8), NYHA III-IV (aOR 1.7) and hospital length of stay (aOR 1.1) (all p<0.05). NHD was not associated with mortality at 30-days and less than one percent of all patients required longer-term residential care.

Conclusion

While common following TAVI, NHD does not predict short-term mortality and most patients successfully return home within 30-days. When used appropriately, NHD may serve as a brief and effective method of optimising functional status without compromising long-term independence.Predictors of Non Home Discharge
The impact of diabetes on cardiac remodelling after transcatheter aortic valve implantation
Authors: Butala A , Sehgal K , Zhou J , Stub D , Palmer S , Noaman S , Haji K , Htun N , Johnston R , Gardner E , Lynch K , Walton A , Nanayakkara S
Published: October 2024

Background

Transcatheter aortic valve implantation (TAVI) induces reverse cardiac remodelling, an important outcome associated with lower mortality. Diabetes mellitus (DM) is common among TAVI patients and is one of the fastest growing chronic conditions worldwide. Despite its propensity to adversely affect myocardium, the influence of DM on post-TAVI remodelling remains poorly understood.

Purpose

To characterise the influence of DM on cardiac remodelling following TAVI.

Methods

Retrospective analysis of 202 patients undergoing TAVI at an Australian tertiary centre. 12-month myocardial remodelling was compared between DM and no DM groups.

Results

Of 202 patients, median age 82 (IQR: 76, 86) years, 50% female and median STS score 3.5 (2.5, 4.9), 62 (31%) had Type II DM. A robust multivariable analysis (C-Statistic 0.83) revealed DM (adjusted odds ratio [aOR] 2.3, p=0.042) and ≥ mild post-procedural paravalvular regurgitation (aOR 2.5, p=0.027) were independent predictors of poor left-ventricular mass index regression (LVMIr). Among diabetic patients, suboptimal disease control was associated with inferior LVMIr (6% vs -9%, p=0.011), while insulin dependency was not (-3% vs 2%, p=0.489). At 12-months, no differences were found in left-atrial remodelling, left and right-ventricular function, and prosthetic valve performance between DM and no DM groups. Poor LVMIr was associated with lower survival in Kaplan Meier analysis (65% vs 85%, log-rank p=0.049).

Conclusion

Among patients undergoing TAVI, those with DM demonstrate poorer LVMIr at 12-months. Improved glycaemic control may serve as an important strategy to optimise myocardial remodelling in diabetic patients undergoing TAVI.12-Month LVMI Regression
Two different hybrid vascular access closure strategies post transcatheter aortic valve implantation
Authors: Abdelaziz M S , Landt M , Mankerious N , Kurniadi A , Alotaibi S , Belhaj B , Alali A , Toelg R , Geist V , Abdel-Wahab M , Nef H , Allali A , Richardt G , Elbasha K
Published: October 2024

Background

The hybrid strategy combining plug-based and suture-based vascular closure devices (VCD) was introduced as a promising technique for vascular access hemostasis after transcatheter aortic valve implantation (TAVI) with satisfactory outcomes. However, data comparing two plug-based VCDs each in the combination with a suture-based VCD, namely ProGlide/FemoSeal (P/FS) with ProGlide/AngioSeal (P/AS) VCDs, is still lacking.

Aim

To compare the 30-day outcome of the hybrid strategy using P/AS versus P/FS for vascular access site closure after TAVI.

Methods

A retrospective single Centre observational study included 608 patients recruited from a prospective TAVI registry between 2016 and 2022. The composite endpoint was defined as any VCD related major vascular complications and/or bleeding more than type 1 according to Valve Academic Research Consortium (VARC-3) criteria.

Results

The current study reported a significantly higher rate of composite endpoint in P/AS group, which was driven by higher rate of major bleeding (5.4% vs 1.4%, p=0.036). We also found a higher rate of VCD related minor bleeding in P/AS group (16.3% vs 8.1%, p=0.013). Successful access site hemostasis was achieved in 83.1% of P/FS group versus 71.7% in P/AS group (p=0.006). The presence of anterior wall calcification at the access site was significantly associated with the composite endpoint (adj OR 2.49; 95% CI (1.08 – 5.75), p=0.032).

Conclusions

The hybrid strategy for large bore vascular access closure using P/FS showed a potentially better 30-day outcomes compared with P/AS. The presence of anterior calcification at the access site carries a significant risk of VCD related complications.
Predicting cardiovascular death 1-year after transcatheter aortic valve implantation: an artificial-intelligence based risk model
Authors: Minten L , Bamps K , Bennett J , Dubois C
Published: October 2024

Background

Prediction of cardiovascular death after transcatheter aortic valve implantation (TAVI) remains difficult. Currently, more lower risk patients are considered for TAVI and predicting not only immediate survival, but more longer-term outcomes seems important. Most developed risk tools use standard statistical approaches and focus mainly on short-term (30 days post-TAVI) outcomes.

Purpose

The aim of this project was to identify important predictors for worse outcomes after aortic valve replacement using machine learning features. Furthermore, we want to develop and artificial intelligence (AI) -model to predict cardiovascular death 1 year after TAVI.

Methods

For our analysis we used 725 patients with severe AS that underwent TAVI between 2008 and 2022 and were included in a prospective single centre observational study. Leveraging an automated machine learning framework, we systematically evaluated various machine learning algorithms including Random Forest, AdaBoost, Neural Networks, Randomized Decision Trees and and Gradient Boosting.

Results

We constructed prediction models utilizing three feature subsets: the top 10 most important features, the top 15 most important features (Figure 1), and all available features (n=66). Our analyses yielded area under curve (AUC) values of 0.71, 0.83, and 0.92, respectively (Figure 2). The best model was obtained by Randomized Decision Trees. NYHA classification, left ventricular ejection fraction, Charlson comorbidity index, posterior wall thickness and myocardial infarction 90-days before TAVI appeared as the most influential predictors for cardiovascular death within one year after TAVI.

Conclusions

Our model was able to identify the most important features indicating high risk for patients undergoing TAVI. Using the 15-feature model, we were able to accurately predict cardiovascular death 1 year after TAVI. AI-models to predict risk can be used to better inform/select patients undergoing TAVI.
Demographics and clinical outcomes of flow-gradient patterns of aortic stenosis: an analysis of the CURRENT AS Registry-2
Authors: Taniguchi T , Morimoto T , Takeji Y , Furukawa Y , Kimura T
Published: October 2024

Background

Low-gradient (LG) severe aortic stenosis (AS) has not been fully characterized compared with high-gradient (HG) AS.

Methods

Among 3369 patients with severe AS enrolled in the CURRENT AS Registry-2, the current study population consisted of 3363 patients with data on left ventricular ejection fraction (LVEF) after excluding patients with LG AS without indexed stroke volume data. Patients were divided into 4 groups (LG AS with reduced LVEF: N=285, paradoxical low-flow low-gradient [LFLG] AS: N=220, normal-flow low-gradient [NFLG] AS: N=872, and HG AS: N=1986).

Results

Compared to HG AS, LG AS with reduced LVEF more often had cardiovascular comorbidities, advanced cardiac damage stages, and frailty with less extensive aortic valve (AV) calcification by computed tomography (CT), and paradoxical LFLG AS more often had atrial fibrillation, concomitant valvular disease, advanced cardiac damage stages, and frailty with less extensive AV calcification, while NFLG AS were less often symptomatic, and had comparable cardiac damage stages, and frailty with less extensive AV calcification. Patients with the 3 types of LG AS less often underwent surgical or transcatheter aortic valve replacement than those with HG AS (cumulative 3-year incidence: LG AS with reduced LVEF: 64.5%, paradoxical LFLG AS: 59.1%, NFLG AS: 54.2%, and HG AS: 87.3%, P<0.001). Cumulative 3-year incidence of death or heart failure hospitalization was much higher in patients with LG AS with reduced LVEF and paradoxical LFLG AS than in those with HG AS (cumulative 3-year incidence: LG AS with reduced LVEF: 65.9%, paradoxical LFLG: 51.1%, NFLG: 35.5%, and HG: 30.5%, P<0.001). After adjusting confounders, LG AS with reduced LVEF and paradoxical LFLG AS compared with HG AS were independently associated with higher risk for death or heart failure hospitalization (HR: 1.82, 95%CI: 1.49-2.23, P<0.001; HR 1.43, 95%CI: 1.13-1.82, P=0.003, respectively), but not NFLG AS (HR 1.03, 95%CI: 0.88-1.21, P=0.68).

Conclusions

Aortic stenosis might be less severe in LG AS than in HG AS when assessed by the CT calcium score of the aortic valve, and each of the 3 hemodynamic types of LG AS had distinct clinical, and echocardiographic characteristics as well as clinical outcomes that were different from HG AS.Different patterns of severe AS
Gender-related differences in the timing of intervention for aortic stenosis: focus on cardiac damage
Authors: O'neill Gonzalez P , Gil C , Roman R , Luque M , Bassa R , Islas F , Gil-Abizanda S , Carnero M , Perez-Camargo D , Montero L , Jimenez P , Nombela L , De Agustin J A , Olmos C
Published: October 2024

Background and aim: There is an increasing awareness of gender-related differences in the management of cardiovascular diseases.

Our aim was to assess whether cardiac damage prior to intervention for severe aortic stenosis (AS) differs according to gender.

Methods

Retrospective analysis of a prospective cohort of patients with AS who underwent surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) in a tertiary care center from 2017 to 2022. Echocardiographic parameters prior to surgery were collected, and patients were classified into categories of a cardiac damage staging system. (1)

Several echocardiographic variables according to gender were evaluated.

Results

869 patients were included, of which 350 underwent TAVR and 519 were treated with SAVR. Females represented 52.4% (n=272) of TAVR patients and 37.7% (n=132) of SAVR patients.

In the echocardiogram performed before the intervention, both in the TAVR and the SAVR cohort, female patients had worse diastolic function (significantly higher values of E/e’), and greater involvement of pulmonary vasculature damage (significantly higher pulmonary artery systolic pressure and worse right ventricular-arterial coupling (Table-Figure 1).

When applying an available cardiac damage staging system (1), we documented that women were treated at a statistically significant more advanced stage compared to men (Figure 2).

Conclusions

There are gender-related differences in the timing of aortic stenosis intervention, both with TAVR and SAVR. Women are operated on at a more advanced stage of cardiac damage, particularly regarding the parameters of diastolic function and right-side damage.

These findings should be taken into account to improve intervention timing and outcomes, especially for women.Table-Figure 1Figure 2
Safety and efficacy of transcatheter aortic valve implantation (TAVI) for pure aortic regurgitation; a systematic review and meta-analysis
Authors: Ktenopoulos N , Apostolos A , Karanasos A , Drakopoulou M , Katsaros O , Simopoulou C , Oikonomou G , Kachrimanidis I , Koliastasis L , Benetos G , Tsalamandris S , Synetos A , Latsios G , Tsioufis C , Toutouzas K
Published: October 2024

Background

Although Transcatheter Aortic Valve Implantation (TAVI) has gained ground in the management of severe aortic stenosis (AS), evidence about its safety and efficacy for patients with pure native aortic regurgitation (AR) remains limited.

Purpose

The aim of the study is to systematically review and summarize available data regarding the safety and the outcomes of TAVI in pure AR.

Methods

This study was conducted according to the PRISMA guidelines. We systematically searched PubMed, SCOPUS, and Cochrane databases from their inception to February 1, 2024, for studies assessing the characteristics and outcomes of patients undergoing TAVI for pure AR. Primary endpoint of our systematic review and meta-analysis is the in-hospital, 30-days and 1-year mortality rates. Secondary endpoints comprised in-hospital stroke, major bleeding, and permanent pacemaker implantation (PPM) implantation. Endpoint definitions followed the Valve Academic Research Consortium 2 criteria. The cumulative incidence of primary and secondary endpoints and the corresponding 95% confidence intervals (CI) were estimated. A random effects model (DerSimonian-Laird) was used to account for heterogeneity among the included studies.

Results

Our meta-analysis included a total of 22 studies and 6,710 patients undergoing TAVI for pure-AR. Our analysis showed that patients undergoing TAVI for pure AR had 3.4% (95% CI: 2%-4.7%), 7.9% (95% CI: 5.2%-10.6%) and 15.5% (95% CI: 9.9%-21.2%) in-hospital, 30-days and 1-year all-cause mortality. In-hospital stroke occurred in 1.9% (95% CI: 1.5%-2.2%) of the patients, while 4.9% (95% CI: 3.3%-6.6%) of the patients suffered from major bleeding events. Finally, considering the PPM implantation rates, patients had a 10.7% (95% CI: 7.4%-13.9%) in-hospital incidence.

Conclusion

Our systematic review and meta-analysis shows a promising safety profile for TAVI treating pure AR. It demonstrated relatively low in-hospital, 30-days and 1-year mortality incidence, comparable to the TAVI treating severe AS, according to the existing literature. Taking into consideration that TAVI for pure-AR might be the only therapeutic option for an increasing number of patients, further studies are needed to further assess the safety and efficacy of the procedure.TAVI for pure AR mortality rates
Validation of the MIDA mortality risk score in a surgical cohort of patients with primary mitral regurgitation
Authors: O'neill Gonzalez P , Islas F , Parraga R , Gomez Lopez J A , Gutierrez E , Carnero M , Perez-Camargo D , Maroto L , Gil-Abizanda S , De Agustin J A , Olmos C
Published: October 2024

Background and aim

The MIDA scale is a prognostic tool for stratification of short- and long-term mortality risk in patients with primary mitral regurgitation (PMR).

The aim of this study is to validate the MIDA (1) score in our population of PMR treated with surgery.

Methods

Retrospective analysis of a prospective cohort of patients with PMR who underwent mitral valve surgery in a tertiary care center from 2014 to 2022.

The necessary parameters for calculating the MIDA Score (age, symptoms, atrial fibrillation, left atrial diameter, right ventricular systolic pressure (RVSP), left ventricular end-systolic diameter (LVESD), and LV ejection fraction (LVEF)) were collected, and the MIDA score for each patient was calculated. Thereafter, patients were classified into seven different risk groups. One year and long-term mortality during follow-up were recorded.

A logistic regression analysis was performed to evaluate the association of each parameter with outcomes. Finally, curves for the cumulative incidence of all-cause mortality according to the MIDA score were generated with the Kaplan–Meier method.

Results

A total of 349 patients were included. Mean age was 68.5 [12.4] years, 55.8% were male, and the median LVEF was 60% (55-65). Mean follow up was 3.28 (2) years.

One year mortality occurred in 29 (8.3%) patients, and long-term mortality in 59 (16.9%).

According to the MIDA score, the distribution of patients in each subgroup was as follows: score 0 (n=28), score 1-2 (n=35), score 3-4 (n=60), score 5-6 (n=99), score 7-8 (n=81), score 9-10 (n=35), score > 11 (n=11). Most of our cohort was classified as intermediate-risk patients, with a median score of 6 (3-8).

In the univariable logistic regression analysis, age, symptoms before surgery and RVSP were the only MIDA parameters significantly associated with mortality (Table-Figure 1).

In our population, the discriminatory capacity of the MIDA score, was moderate, with an area under the ROC curve of 0.676 CI (0.624-0.725) for one year mortality, and 0.702 (0.651-0.749) for long term mortality. The best cut-off point for predicting one-year and long-term mortality was a MIDA score of 7.

Kaplan-Meier curves for mortality during follow-up are shown in Figure 2.

Conclusions

The MIDA score showed a fair discriminatory capacity in our surgical cohort of patients with PMR. Variables included in the score that had a significant association with mortality were age, presence of symptoms and elevated RVSP.

LV parameters included in the MIDA, which are the current class I indication for surgery, did not show a significant association with outcomes.

Different echocardiographic variables to evaluate cardiac damage in PMR are needed to achieve better stratification.Table-Figure 1Figure 2
Machine-learning phenotyping of patients with functional mitral regurgitation undergoing transcatheter edge-to-edge repair - the MITRA-AI study
Authors: Angelini F , D'ascenzo F , Pancotti C , Perl L , Adamo M , Bocchino P P , Cavallone E , Morici N , Crimi G M , Roubin S R , Boretto P , Dusi V , Templin C , Frea S , De Ferrari G M
Published: October 2024

Background

Severe functional mitral regurgitation (FMR) may benefit from transcatheter mitral valve repair (TMVR), but selection of patients remains to be optimised.

Objectives

The aim of this study was to use Machine-Learning (ML) approaches to uncover concealed connections between clinical, echocardiographic, and hemodynamic data associated with patients' outcomes.

Methods

Consecutive patients undergoing TMVR from 2009 to 2020 were included in the MITRA-AI registry. Eleven relevant clinical and echocardiographic variables were selected in a clustering-based model. The primary endpoint was a composite of cardiovascular death or heart failure hospitalisation at one year, while its single components were secondary endpoints. External validation was performed on the Mitrascore dataset and comparison between clustering and Mitrascore was performed with Net Reclassification Index (NRI). Moreover cluster assignment was performed also on a cohort of patients with moderate-to-severe MR treated with medical therapy alone.

Results

822 patients were included in the derivation cohort. The composite primary endpoint occurred in 250 (30%) patients. Four clusters with decreasing risk of the primary endpoint were identified (42%, 37%, 25% and 20% from cluster 1 to cluster 4, respectively). Clusters were combined into a high-risk (clusters 1 and 2) and a low-risk phenotype (clusters 3 and 4). High-risk phenotype patients had larger LVs (> 107 ml/m2), lower LVEF (< 35%) and more prevalent ischemic aetiology (51% to 60% vs. 30% to 40%) compared to low-risk phenotype patients. Moreover, within the high-risk group, patients with diabetes mellitus and with advanced age were at increased risk. Within the low-risk group, ischemic aetiology increased the risk of cardiovascular death, while permanent atrial fibrillation amplified that of HF hospitalizations. In the Mitrascore validation cohort of 1119 patients, incidence of the primary end point varied consistently (48%, 52%, 35% and 42%). Clustering achieved a NRI in 27% of the patients in the derivation cohort and 7% in the validation group compared to Mitrascore. In the validation group of 207 patients treated medically, the incidence of the primary endpoint decreased from the first to the fourth cluster (53%, 42%, 30% and 30%).

Conclusions

A ML analysis identified meaningful clinical phenotypic presentations in FMR undergoing TMVR, with significant differences in terms of cardiovascular death and heart failure hospitalizations, confirmed in an external validation cohort. ML phenotyping also discriminated prognosis of medically treated patients with severe MR.Central Figure