bluuebunny/crossref_metadata_2025_split huggingface dataset:
Effects of patient characteristics and comorbidities on temporal trends of low-flow, low-gradient aortic stenosis phenotypes
Authors: Sen J , Manning T , Innes-Jones K , Neil C , Marwick T.H 
Published: November 2020

Abstract

Background
Aortic stenosis (AS) is a common primary heart valve disease in the elderly. Low-flow, low-gradient (LFLG) AS is an increasingly important phenotype.

Purpose
To evaluate the temporal changes in incidence of severe AS phenotypes: paradoxical LFLG, classical LFLG and non-LFLG and explore risk factors that contribute to temporal trends.

Methods
We analyzed 25,507 consecutive transthoracic echocardiograms over 6½ years between 2013 and 2019 divided into deciles. LFLG-AS was defined as mean transvalvular pressure gradient &lt;40 mmHg and stroke volume index (SVi) &lt;35 mL/m2, aortic valve area (AVA) &lt;1 cm2 or indexed AVA &lt;0.6 cm2/m2, with either normal (paradoxical LFLG) or decreased (&lt;40%; classical LFLG) left ventricular ejection fraction. Trends and associations with patients characteristics and comorbidities were assessed over time in deciles.

Results
Of 891 cases that fulfilled severe AS criteria, there were 536 cases of LFLG-AS (85 classical and 451 paradoxical LFLG-AS). There was a statistically significant increase in incidence of paradoxical LFLG-AS between each time interval (p&lt;0.0001), while significant reduction in incidence of non-LFLG-AS (p=0.009) that was not seen with classical LFLG-AS (p=0.7) (Figure). More comprehensive echocardiographic assessment of relevant parameters over time assisted with identification of LFLG-AS cases. Intrinsic patient factors such as age and E/e' contributed towards the increasing trend of paradoxical LFLG-AS. There was a rising population aged over 70 years (p=0.01). Multivariate logistic regression analysis showed that age, sex, E/e', obesity, atrial fibrillation and heart rate were potential risk factors responsible for temporal trend towards rising paradoxical LFLG-AS incidence. There was also a gradual increase in number of patients with low transvalvular flow rate (&lt;200mL/s) over time (p=0.04).

Conclusion
The incidence of paradoxical LFLG-AS is rising in a hospital echocardiogram service. The parallel increase in LV filling pressure and age in AS patients suggests the increment in LFLG-AS is related to changes to the LV myocardium.
Subtypes of aortic stenosis over time

Funding Acknowledgement
Type of funding source: None
Survival of patients with moderate aortic stenosis: propensity score matching analysis
Authors: Itelman E , Vatury O , Ben-Zekry S , Kuperstein R , Fefer P , Barbash I , Klempfner R , Segev A , Feinberg M , Guetta V , Maor E 
Published: November 2020

Abstract

Introduction and purpose
Data on the survival of patients with moderate aortic stenosis (AS) is conflicting. The purpose of the current analysis was to assess survival of moderate AS patients.

Methods
SHARE is an historical retrospective cohort of all cardiovascular patients evaluated in an Israeli tertiary hospital between 2007 and 2019. The current analysis included all patients who underwent echocardiographic evaluation. Aortic stenosis severity was extracted for all patients from the echocardiographic reports. All-cause mortality and was available for all patients. Subjects with severe AS or aortic valve replacement were excluded from the analysis.

Results
Cohort included 97,561 subjects of whom 42,187 (43.2%) were outpatients. Final cohort included 93,889 patients with a mean age of 66±17 (58% men). There were 2,949 (3%) with moderate AS. During a median follow up of 52 [IQR 22–89] months 17,173 (18%) patients died. Kaplan-Meier survival analysis demonstrated worse cumulative probability of death of 51%±2% vs. 20%±0% at 5 years for patients with moderate AS vs. mild or no AS, respectively (p Log rank &lt;0.001). Sub-analysis of 32,745 patients for whom clinical laboratory and medication data was available yielded consistent results in a comprehensive multivariate model such that patients with moderate AS (N=1,381) were 26% more likely to die (95% CI: 1.17–1.37, p&lt;0.0001). Finally, a propensity score matching of patients with moderate AS and controls with no or mild AS (N=1,381) successfully demonstrated that patients with moderate AS were 40% more likely to die during follow up (95% CI 1.25–1.57, p&lt;0.001; FIGURE). Four-years mortality rates were 2 fold higher for patients with moderate AS compared with controls (OR = 1.96, 95% CI 1.6–2.4, p&lt;0.001). Interaction analysis demonstrated that the association of moderate AS with survival was not dependent on left ventricular ejection fraction.

Conclusion
Moderate AS is associated with worse survival. Our findings underscore the importance of careful clinical observation as well as the need for further studies.
Figure 1

Funding Acknowledgement
Type of funding source: None
Mitraclip for high risk patients with barlow mitral valve disease
Authors: Gavazzoni M , Taramasso M , Voci D , Pozzoli A , Miura M , Tagliari A.P , Zuber M , Maisano F 
Published: November 2020

Abstract

Background
No data have been published to now about the outcomes of MitraClip in inoperable patients with Barlow's Mitral Valve Disease. Despite the technical advantages of the new generation of MitraClips, the length and the thickness of the mitral leaflets and presence of flails with complete eversion and pseudo-cleft are challenging MitraClip procedure.

Purpose
To analyse the results of MitraClip in inoperable patients with Barlow's disease of Mitral valve.

Methods
We retrospectively collected the cases of MR in Barlow's disease treated with MitraClip in our institution from 2012 to 2018. The case were included in the analysis in presence of the following characteristics: bileaflet billowing or prolapse [or both], excessive leaflet tissue, and annular dilatation with or without calcification.

Results
We included in this analysis 59 patients (mean age 78±8 years, STS mortality score 4±2.9%). Echo data at baseline showed normal left ventricle ejection fraction and diastolic volume and increased left atrial volume index. Half of the included patients had a chordal rupture (n=27, 47%) and in 14 patients (23%) calcification of annulus and/or leaflet was diagnosed. The mean procedural time was 92±41min with a technical success (M-VARC) of 100% and more than 80% of patients requiring more than 1 clip. At 30 days follow-up the device success and the procedural success were respectively 59% and 56%. The mean diastolic mitral valve gradient was 3.1±1.5mmHg. At 30 days follow-up, 91% of the patients were NYHA class II stable patients; no death and no hospitalization occurred. During a median follow-up time of 412 days (IQR: 209–992 days) death for any cause occurred in 23% of the patients (n=14) and 16% of the patients (n=10) died because of a cardiovascular cause; 10 patients were re-hospitalized for heart failure and 5% of the patients (n=3) underwent an open-heart surgery at follow-up time. At univariate cox regression analysis the 1-Y composite end-point (death for any cause, HF re-hospitalization, MV surgery) was predicted by LV dimensions and 30 days procedural success.

Conclusions
To our knowledge, this is the first analysis of outcomes of Barlow's disease treated with MitraClip. Despite a high incidence of MR recurrence, we observed a good clinical response in term of NYHA class and mortality rate. Left ventricle size and 30-day procedural success predict outcomes.

Funding Acknowledgement
Type of funding source: None
Clinical outcomes from antihypertensive therapies in moderate or severe aortic stenosis: a systematic review and meta-analysis
Authors: Sen J , Chung E , Neil C , Marwick T 
Published: November 2020

Abstract

Background
Hypertension can negatively affect prognosis in moderate or severe aortic stenosis (AS), but antihypertensive therapy (AHT) is often avoided due to possible deleterious effects such as reduced coronary perfusion, left ventricular dysfunction and haemodynamic compromise.

Purpose
We systematically assessed and compared clinical outcomes in adults with moderate or severe AS treated with and without AHT.

Methods
Two independent reviewers performed screening, data extraction and risk of bias assessments from a systematic search of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and grey literature without language restrictions up to September 9, 2019. Conflicts were resolved by the third reviewer. Outcomes of interest included mortality, left ventricular (LV) mass index, systolic blood pressure, diastolic blood pressure, and LV ejection fraction. Meta-analysis with pooled effect sizes using random-effects model, were estimated in R.

Results
Of 3,024 citations, 30 studies (26,224 patients) were included in the qualitative synthesis and 23 studies in meta-analysis. AHT was associated with favourable clinical outcomes and was well tolerated. AHT was associated with lower risk of all-cause mortality (Risk Ratio (RR)=0.69, 95% CI: 0.53–0.90, p=0.01, Figure). The effect size appears to differ with type of aortic valve replacement (AVR). AHT was associated with lower risk of acute kidney injury post-transcatheter AVR (RR=0.13, 95% CI:0.05–0.35, p=0.007). Favourable outcomes such as improved haemodynamic and echocardiographic parameters were demonstrated in some studies, but when pooled in meta-analysis, the differences did not reach statistical significance. However, heterogeneity was significant across studies.

Conclusion
This is the first systematic review and meta-analysis to demonstrate that AHT is safe and has a clinical benefit in patients with advanced stages of AS with significant improvement in survival or reduction in mortality without haemodynamic compromise. Further studies are required to determine the best AHT for patients with moderate or severe AS.
Forest plot of AHT effect on mortality.

Funding Acknowledgement
Type of funding source: None
A novel quantitative grading system to further characterize the prognosis of patients with functional tricuspid regurgitation
Authors: Fortuni F , Dietz M.F , Prihadi E.A , De Ferrari G.M , Bax J.J , Delgado V , Ajmone Marsan N 
Published: November 2020

Abstract

Background
Recent studies have suggested that current grading of tricuspid regurgitation (TR) has significant limitations and specifically cannot identify the various grades of severe TR (such as torrential). New cut-off values for the recommended measures of vena contracta (VC) width and effective regurgitant orifice area (EROA) have been proposed but not yet validated.

Purpose
To test the prognostic utility of new cut-offs for VC width and EROA in a large registry of patients with functional TR (FTR) and to integrate them into a novel comprehensive grading system.

Methods
FTR severity was evaluated in 1148 patients (mean age: 69±13 years, 50% male) with significant FTR (≥ moderate). Patients with congenital heart disease or who underwent tricuspid valve repair during follow-up were excluded. The primary endpoint was all-cause mortality. Based on Kaplan-Meier survival analyses, VC width significantly differentiated the prognosis of patients with moderate FTR vs severe FTR (with a cut-off value of 7 mm), whereas EROA was able to further stratify patients with more than severe (torrential) FTR. Therefore these two parameters were combined into a novel grading system (Figure: Upper Panel) to define: moderate FTR (VC &lt;7 mm), severe FTR (VC ≥7 mm, EROA &lt;80 mm2) and torrential FTR (VC ≥7 mm, EROA ≥80 mm2).

Results
According to our novel grading system a total of 146 patients (13%) showed moderate FTR, 547 patients (48%) had severe FTR and 454 patients (39%) presented with torrential FTR. Patients with torrential FTR had greater right ventricular (RV) dimensions, lower RV systolic function and were more likely to receive diuretics. The cumulative 10-year survival rates were significantly different among the groups: 54% for moderate FTR, 43% for severe FTR and 32% for torrential FTR (P=0.004 Figure – Lower Panel). After adjusting for potential confounders, torrential FTR retained its association with worse prognosis compared with other FTR grades (HR 1.28; 95% CI 1.07–1.54; P=0.007) together with age, coronary artery disease, diabetes, severe renal impairment, lower RV or left ventricular systolic function, higher pulmonary artery pressures, and dilated tricuspid annulus. Differently, severe FTR graded according to current guidelines did not show any association with the primary outcome (HR for severe FTR vs moderate FTR 1.17; 95% CI 0.96–1.42; P=0.128).

Conclusion
The proposed novel grading system combining measures of VC width and EROA is able to further risk stratify patients with FTR and specifically to identify patients with torrential FTR, a new clinical condition associated with even worse mortality than severe FTR.
Figure 1

Funding Acknowledgement
Type of funding source: None
Prognostic impact and post-procedural development of severe tricuspid regurgitation in patients undergoing transcatheter edge-to-edge mitral valve repair
Authors: Kavsur R , Iliadis C , Metze C , Spieker M , Tiyerili V , Horn P , Baldus S , Kelm M , Nickenig G , Pfister R , Westenfeld R , Becher M.U 
Published: November 2020

Abstract

Purpose
The aim of this study was to investigate the clinical impact and post-procedural development of tricuspid regurgitation (TR) in patients undergoing the MitraClip procedure for severe mitral regurgitation.

Methods
In this present multicentre study, we included 940 patients undergoing MitraClip implantation for symptomatic mitral regurgitation from August 2010 to September 2018. Patients were categorized according to concomitant TR (none or mild vs moderate vs severe) and the prognostic impact of TR on 1-year mortality was evaluated. Moreover, in 377 patients, we assessed 3-months echocardiographic controls to further analyse the post-procedural development of TR.

Results
At baseline, concomitant TR was graded none/mild in 393 (42%), moderate in 316 (34%), and severe in 231 (25%) patients. During 1-year follow-up, 141 of 940 (15%) patients died. According to mild/none, moderate and severe TR, mortality rates were 13%, 12%, and 23%, respectively, revealing a higher prevalence of death in patients with severe TR (p=0.001). Kaplan-Meier analysis and log-rank test confirmed inferior survival rates for patients with severe TR (p=0.001), while there were no significant difference in survival rates between patients with none/mild vs moderate TR (p=0.561). Regarding 1-year mortality, multivariate cox regression analysis, revealed an odds ratio of 1.739 (1.024–2.953; p=0.041), associated with severe TR. After 3-months follow-up, echocardiography in 377 patients showed following TR grade distributions: 44% none/mild, 37% moderate and 19% severe TR. In 100 patients (27%), TR improved by one or more grades, while 64 patients (17%) showed a TR worsening. In patients with severe TR at baseline, 42 of 91 (46%) patients showed a reduction in TR of one or more grades. Patients with severe TR at baseline, who showed a TR improvement during 3-months follow-up, had lower rates of 1-year mortality (p=0.025). For these patients, in regression analysis, right atrial area was revealed as only predictor of TR improvement after MitraClip procedure [odds ratio 0.958 (0.918–0.999); p=0.046].

Conclusion
One-fourth of patients undergoing MitraClip procedure for mitral regurgitation had concomitant severe tricuspid regurgitation which was predictive for worse prognosis. Post-procedural TR improvement of one or more grades was frequent in these patients and was associated with higher survival-rates.

Funding Acknowledgement
Type of funding source: None
Transcatheter aortic valve replacement for bicuspid aortic valve stenosis with first- and new-generation bioprostheses: a systematic review and meta-analysis
Authors: Ueshima D , Nai Fovino L.N.F , Brener S.J.B , Pavei A.P , Fraccaro C.F , Napodano M.N , Tarantini G.T 
Published: November 2020

Abstract

Background
Subjects with bicuspid aortic valve (BAV) have been excluded from transcatheter aortic valve re- placement (TAVR) randomized trials.

Methods
With this meta-analysis of observational studies we first compared TAVR outcomes of BAV vs. tricuspid aortic valve (TAV) patients, stratifying the results by device generation. Then, we looked for differences between balloon-expandable (BE) and self-expandable (SE) bioprostheses in BAV patients. Primary outcome was 30-day mortality. Secondary outcomes were 30-day stroke, moderate-severe paravalvular leakage, new pacemaker im- plantation, vascular complications and 1-year mortality.

Results
Thirteen studies (11,032 patients, 7291 TAV and 3741 BAV) and seven studies (706 patients, 367 treated with BE, 339 with SE valve) met inclusion criteria. Thirty-day (OR=1.13; 95% CI: 0.88–1.46, p=0.33) and 1-year mortality (OR=1.02; 95% CI: 0.77–1.37, p=0.87) were similar between patients receiving TAVR for BAV or TAV. Subjects treated for BAV were at higher risk of conversion to conventional surgery (OR=2.35; 95% CI: 1.30–4.23, p=0.005), implantation of a second valve (OR=2.06; 95% CI: 1.31–3.25; p=0.002), moderate/severe paravalvular leakage (PVL) (OR=1.67; 95% CI: 1.29–2.17; p=0.0001) and device failure (OR=1.26; 95% CI: 1.02–1.56; p=0.04). Rates of adverse events decreased significantly with the use of new-generation devices, but outcome differences remained consistent. BAV patients treated with BE vs. SE valves had similar 30-day and 1-year mortality, stroke and moderate-severe PVL. Balloon-expandable valves were associated with lower rates of a second valve and new pacemaker implantation but carried higher risk of annular rupture.

Conclusions
BAV patients treated with TAVR had similar 30-day and 1-year mortality as well as stroke and new pacemaker implantation rates compared to TAV subjects, but carried higher risk of moderate/severe PVL, conver- sion to surgery and device failure. Event rates significantly decreased with the use of new-generation devices, but TAVR still showed better procedural results in TAV compared to BAV.

Funding Acknowledgement
Type of funding source: None
Hemodynamics during transcatheter aortic valve implantation in patients with severe aortic stenosis measured by invasive pressure volume loop analysis
Authors: Seppelt P.C , De Rosa R , Mas-Peiro S , Murray I , Zeiher A.M , Fichtlscherer S , Vasa-Nicotera M 
Published: November 2020

Abstract

Introduction
Transcatheter aortic valve implantation (TAVI) for a stenotic aortic valve reduces the ventricular to aortic gradient and is expected to improve diastolic and systolic left ventricular function over the long-term. However, information about the early hemodynamic changes are lacking. To address this open question, we performed invasive pressure volume loop analysis prior and immediately after TAVI.

Methods
Invasive left ventricular pressure volume loop analysis was performed in 8 patients with aortic stenosis (mean 81.3 years) prior and immediately after transfemoral TAVI (conductance catheter). Parameters for global hemodynamics, afterload, contractility and the interaction of the cardiovascular system were analyzed.

Results
After TAVI, left ventricular ejection fraction (53.9% vs. 44.8%, p=0.018) as well as parameters for myocardial contractility such as preload recruitable stroke work (68.5 vs. 44.8mmHg, p=0.012) and endsystolic elastance (3.55 vs. 2.17, p=0.036) declined significantly compared to baseline. As sign of impaired diastolic function, TAU, a preload-independent measure of isovolumic relaxation (37.3 vs. 41.8ms, p=0.018) and enddiastolic pressure (13.1 vs. 16.4mmHg, p=0.015) increased after valve implantation. Contrarily, decreased ventricular-arterial coupling indicated early improvements in global cardiovascular energy efficiency (1.40 vs. 0.97 p=0.036). Arterial elastance had a strong correlation with the number of conducted rapid ventricular pacings (Pearson correlation coefficient, 0.772, p=0.025).

Conclusion
Invasive left ventricular pressure volume loop analysis revealed impaired systolic and diastolic function in the early phase after TAVI in patients with severe aortic stenosis. Contrarily, decreased ventricular-arterial indicated early improvement of global cardiovascular energy efficiency.
PV Loop pre and post TAVI

Funding Acknowledgement
Type of funding source: None
The effect of underweight on mid-term outcome following transcatheter aortic valve implantation: an insight from multicenter registry
Authors: Tezuka T , Higuchi R , Hagiya K , Saji M , Takamisawa I , Shimizu J , Iguchi N , Takanashi S , Doi S , Okazaki S , Sato K , Tamura H , Takayama M 
Published: November 2020

Abstract

Background
Obesity has the adverse prognostic impact in the general population, whereas paradoxical effect of obesity has been reported in patients with heart failure. Several studies have suggested the same obesity paradox in patients undergoing transcatheter aortic valve implantation (TAVI), however, they included limited number of underweight patients.

Purpose
The aim of this study was to clarify the effect of underweight on outcome following TAVI.

Methods
We retrospectively analyzed consecutive 1,027 patients undergoing TAVI between April 2010 and June 2019. The patients were categorized according to body mass index (BMI) as follows: underweight (&lt;18.5 kg/m2, n=150), normal weight (18.5 to 25 kg/m2, n=657), and overweight (&gt;25 kg/m2, n=220). BMI was defined as body weight (kg) divided by the square of body height (m) measured at the hospital admission. We compared the short- and mid-term outcome after TAVI among three groups, and all clinical events were accordance with Valve Academic Research Consortium-2 criteria.

Results
Underweight patients were more often female, and had a higher prevalence of hypertension, dyslipidemia, peripheral artery disease, anemia, and hypoalbuminemia. They also presented lower ejection fraction, smaller aortic valve area, and higher surgical risk score. In procedural findings, device unsuccess and major vascular complication more occurred in underweight patients, but 30-day mortality was equivalent among three groups. The mid-term survival of the underweight was inferior to the other two groups (figure).In the multivariate analysis, female (hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.37–0.73, P=0.0002), atrial fibrillation (HR 2.22, 95% CI 1.56–3.17, P&lt;0.0001), albumin value (HR 0.37 per 1-g/dl increase, 95% CI 0.25–0.55, P&lt;0.0001), Society of Thoracic Surgeons score (HR 1.06 per 1% increase, 95% CI 1.02–1.06, P=0.0039), 30-day combined endpoint (HR 2.12, 95% CI 1.33–3.38, P=0.0017), and underweight (HR 1.59, 95% CI 1.04–2.37, P=0.026) were associated with the survival after TAVI.

Conclusion
The underweight had a worse mid-term prognosis, representing the obesity paradox in the TAVI population.
Kaplan-Meier curves

Funding Acknowledgement
Type of funding source: None