bluuebunny/crossref_metadata_2025_split huggingface dataset:
Computed tomography-derived myocardial extracellular volume as a prognosis predictor in patients with severe aortic stenosis
Authors: Reis Santos R , Carvalho R , Lopes P M , Gama F , Freitas P , Guerreiro S , Abecasis J , Saraiva C , Teles R C , Almeida M S , Adragao P , Ferreira A M 
Published: October 2024

Abstract

Background
Patients with severe aortic stenosis (AS) face a higher risk of mortality, but prognosis is still heterogeneous and tools for prioritizing intervention are needed. Myocardial extracellular volume (ECV), measured non-invasively in pre-TAVR computed tomography (CT), is a marker of fibrosis that may reflect the degree of irreversible damage. The aim of this study was to assess the prognostic value of CT- derived ECV (ECVCT) in patients with severe AS referred for TAVR-planning CT.

Methods
Consecutive patients with severe symptomatic AS undergoing TAVR-planning CT between April and December 2022 at single centre were prospectively included. CT was performed on a 192-slice dual-source 3rdgeneration scanner. ECVCT was acquired during TAVR-planning using an additional post-contrast low-radiation-dose prospective acquisition. ECVCT was calculated as the ratio of change in CT attenuation (Hounsfield units [HU]) of the septal myocardium and the left ventricle (LV) blood pool before and after contrast administration, according to the equation: ECVCT = (1 – hematocrit) x (DHUmyo/DHUblood) – Figure 1A. The primary endpoint was all-cause mortality. The secondary endpoint was a composite endpoint including all-cause mortality and heart failure hospitalization.

Results
A total of 138 patients were included (mean age 81 ± 7 years; 46% male; mean transaortic gradient 51 ± 15 mmHg; mean aortic valvearea 0.75 ± 0.19 cm2; mean LV ejection fraction (EF) by 2D echocardiogram 57 ± 11%). No patient had a clinical diagnosis of cardiac amyloidosis. Mean ECVCT was 33.9 ± 8.0%. During a median follow-up period of 386 days (IQR 332 – 464), there were 18 deaths (13%), 13 before intervention and 5 after intervention; the secondary endpoint occurred in 26 patients (19%), 17 of which before intervention and 9 after. Patients who attained the primary endpoint were significantly older [81 ± 7 vs. 85 ± 7 years, P = 0.011], had lower left ventricular ejection fraction [51 ± 11 vs. 58 ± 11%, P = 0.015], higher NTproBNP levels [4739 (IQR 2003 – 9970) vs. 751 (IQR 314 – 2541), P &lt;0.001] and higher ECV values (39.9 ± 7.4% vs. 33.0 ± 7.7%, P &lt;0.001). After adjustment for age, LVEF and NTproBNP levels, ECVCT remained an independent predictor of all-cause mortality (adjusted HR 1.09 per 1% ECV increase, 95%CI 1.02 – 1.17, p=0.005 – Figure 1B) and also the secondary endpoint (adjusted HR 1.07 per 1% ECV increase, 95%CI 1.01 – 1.13, p=0.002).

Conclusions
In this prospective observational cohort study, interstitial fibrosis assessed by CT-derived ECV was associated with poor outcomes in patients with severe AS. ECVCT values may be useful to identify a subgroup of patients with higher risk who may benefit from earlier intervention.
Surgery versus thrombolytic therapy for the management of left-sided prosthetic valve thrombosis without hemodynamic compromise: a systematic review and meta-analysis
Authors: Chopard R , Vidoni C , Besutti M , Ismail M , Ecarnot F , Favoulet B , Badoz M , Schiele F , Perrotti A , Meneveau N 
Published: October 2024

Abstract

Background
The optimal strategy in prosthetic heart valve thrombosis (PVT) remains controversial, with no randomized trials and conflicting observational data.

Objectives
To perform a systematic review and meta-analysis of evidence comparing systemic thrombolysis and cardiac surgery in PVT.

Methods
We searched for studies on treatment strategies in patients with left-sided PVT since 2000 in PubMed, Cochrane and Embase. Primary outcome was mortality, secondary outcomes were major bleeding, and thrombo-embolism during follow-up.

Results
We identified 2,298 studies, of which 16 were included, comprising 1,389 patients with PVT (mean age, 50.4±9.3 years, 60.0% were women). Among them, 67.2% were New York Heart Association Stage III/IV at admission. Overall, 48.1% were treated with systemic thrombolysis, and 51.9% with cardiac surgery. Mortality was 10.8% in the thrombolysis group, and 15.3% in the surgery group (Figure 1). The pooled OR for mortality with systemic thrombolysis was 0.66 (95% CI, 0.46-0.96; I2 = 36.6%; τ2, 0.428; p = 0.03) versus cardiac surgery. Rates of both transient ischemic attack and non-central nervous system embolism were higher in the thrombolysis group (p=0.002 and p=0.02, respectively). Treatment success, major bleeding and stroke were similar between groups. Sensitivity analysis including studies that used low dose and/or slow infusion thrombolysis showed that mortality was lower, and treatment success was higher in patients referred to systemic thrombolysis, with similar rates of other secondary outcomes.

Conclusions
Thrombolysis seems to be the preferred option for the management of PVT without cardiogenic shock, pending future RCTs or larger observational studies.
Cusp-overlap technique to reduce permanent pacemaker implantation rate after transcatheter aortic valve implantation
Authors: Abrantes De Figueiredo M , Rodrigues I , Teixeira B , Grazina A , Albuquerque F , Carvalheiro R , Cacela D , Ramos R , Fiarresga A , Mendonca T , Cruz Ferreira R 
Published: October 2024

Abstract

Background
Persistent conduction disturbances requiring permanent pacemaker (PPM) implantation are one of the most common complications after Transcatheter Aortic Valve Implantation (TAVI). Cusp-Overlap Technique (COT) is a novel approach for self-expandable valve implantation to minimize the rate of procedural complications, mainly PPM implantation.

Purpose
To determine if the COT during TAVI with self-expandable valves leads to a reduction of PPM implantation rate in the real-world setting.

Methods
A retrospective analysis of consecutive patients undergoing TAVI between January 2020 and November 2023 in one high-volume tertiary care center in Portugal was conducted. Two groups were defined, the COT group and the control group based on the fluoroscopic approach. A baseline comparison between the 2 groups was made using independent-samples t-test and chi-square analysis to determine if there was a difference between the prevalence of known risk factors for PPM implantation after TAVI. Afterwards, chi-square analysis was used to determine if COT led to a reduction in the PPM implantation rate.

Results
Of the 539 completed procedures in this timeframe, 289 were excluded due to previous pacemaker implantation, use of a valve not amenable to COT or valve-in-valve implantation. COT was used in 57.6% of eligible cases. Baseline comparison did not show a significant difference in the prevalence of several known risk factors for PPM implantation, including complete right bundle branch block, atrio-ventricular block, calcium score, aortic ring dimensions and pre/post-dilation. PPM implantation after TAVI was required in 31.6% of cases. In the COT group the PPM implantation rate was 22.9% and in the control group 43.4%. Chi-square analysis showed a very statistically significant difference between the 2 analyzed groups (p-value = 0.001).

Conclusion
PPM implantation remains a frequent complication of TAVI. However, this study showed that the utilization of COT leads to a reduction of the PPM implantation rate.
Identifying missing tools in aortic systolic upstroke parameter for valvular aortic stenosis diagnosis
Authors: Wangpermpoon W , Sasiprapha T , Ngernsritrakul T , Chandavimol M 
Published: October 2024

Abstract

Background
Echocardiography is a widely accepted method for diagnosing severe aortic stenosis (AS), but it has certain limitations. Alternative methods, such as the direct catheter-based crossing of the valves, carry a risk of stroke. Delayed aortic upstroke parameters might predict the severity of aortic stenosis.

Objective
This study aimed to investigate the diagnostic utility of measuring catheter-based aortic acceleration time with ejection (AT/ET) for the diagnosis of severe aortic stenosis, including low-gradient (LG) AS.

Methods
We included 139 patients who underwent cardiac catheterization at our hospital, including patients with varying degrees of AS. Patients with LGAS were classified byan algorithm according to ESC guideline. All patients received echocardiographicassessments and direct hemodynamic measurements of AT/ET. The association between AT/ET and AS severity and other conventional utilities was analyzed using logistic regression and ROC analysis.

Results
Among the 139 patients, 73 had severe AS (52.5%), and 20 also had low gradient (27.3%). The mean AT/ET was 0.33 in the severe AS group and 0.28, 0.24 in moderate, and mild-no AS patients, respectively. AT/ET was significantly correlated with conventional echocardiographic and hemodynamic parameters. Furthermore, AT/ET is the strongest predictor of severe aortic stenosis using the multivariable test with relevant variables (OR; 2.01, 95% CI 1.17-3.45). Using a cut-off value of 0.30, catheter-based AT/ET had a sensitivity of 80% and specificity of 92% for diagnosing severe AS (AUC 0.94, 95% CI 0.90-0.97), withconsistent results from subgroup LGAS (AUC 0.94, 95% CI 0.93-0.99).

Conclusion
This study supports the use of catheter-based AT/ET of greater than 0.30 as a complementary diagnostic tool for severe aortic stenosis across the spectrum of low-gradient AS. Further studies are needed to validate these findings in larger, multicenter studies with more diverse patient populations.
Evaluation of renal tubulointerstitial damage as a residual renal risk factor for adverse cardiac events in patients with aortic valve stenosis
Authors: Kobayashi T , Nakamura T , Yoshizaki T , Yamaguchi K , Horikoshi T , Nakamura K , Ando R , Eguchi M , Sato A 
Published: October 2024

Abstract

Background
Renal dysfunction, defined as a lower eGFR, has been shown to be related to cardiovascular events in patients with aortic stenosis treated with transcatheter aortic valve implantation (TAVI). However, the contribution of renal tubulointerstitial damage to the predictive value for cardiovascular events remains unclear. The aim of this study was to elucidate whether renal tubulointerstitial damage is associated with the occurrence of all death and heart failure patients who have had TAVI.

Methods and results
In a cohort of 155 patients, urinary beta2-microglobulin (beta2MG) levels were measured. Patients were monitored for less than three years or until experiencing all-cause mortality or hospitalization due to heart failure. The cumulative all-cause mortality was 11.5%, and heart failure admission rate stood at 5.4%. Stratifying outcomes by beta2MG levels revealed significantly lower rates of all-cause mortality and heart failure in patients with beta2MG &lt;0.20 mg/gCre compared to those with beta2MG ≥0.20 mg/gCre (10.2% versus 24.2%, p=0.01). When outcomes were stratified according to the beta2MG levels in combination with eGFR levels, Kaplan-Meier analyses showed that all-cause mortality and heart failure rates increased depending on an increase in the beta2MG levels (p&lt;0.05) even if eGFR is above 60 ml/min. Moreover, multivariate Cox analyses revealed that high levels of beta2MG were an independent predictor of adverse events.

Conclusion
Renal tubulointerstitial damage is associated with the occurrence of all death and hospitalization for heart failure independent of renal glomerular function.
Bacteremia after transcatheter aortic valve implantation: a nationwide cohort study
Authors: Hadji-Turdeghal K , Petersen J K , Butt J H , Graversen P L , Strange J E , Ihlemann N , Dahl J S , Povlsen J A , Terkelsen C J , Freeman P , Nissen H , Backer O D , Koeber L , Oestergaard L , Fosboel E 
Published: October 2024

Abstract

Background
Bacteremia and infective endocarditis (IE) are rare but severe complications to transcatheter aortic valve implantation (TAVI). However, data on early bacteremia and microbiological etiological profile are scarce.

Purpose
The study aimed to investigate the incidence of bacteremia and IE within six months after TAVI.

Methods
Using Danish nationwide registries, we identified all patients who underwent TAVI from 2012 to 2021. These patients were matched 1:1 by age, sex, and index-year with individuals who underwent elective coronary angiography (CAG). The primary outcomes were bacteremia and IE within six months. Outcomes were compared with cumulative incidence functions and adjusted hazard ratios (HR). All patients were followed six months from the index date until the outcome of interest, death, emigration, or end of study (December 31st, 2021), whichever came first.

Results
We identified 5,990 patients undergoing first-time TAVI, of whom 56 % were men, and the median age was 81 years [IQR 77–85]. All patients were matched with controls undergoing CAG (56% men, median age 81 [IQR 77-85]). Patients undergoing TAVI had more comorbidities than controls. The six-month cumulative incidence of bacteremia was 4.2% [95% CI 3.7-4.7] and 2.6% [95% CI 2.2-3.0] after TAVI and CAG, respectively, corresponding to an adjusted HR of 1.57 (95% CI 1.27-1.96) (Figure 1). The common bacterial etiologies for bacteremia after TAVI were Streptococci (20%), Coagulase-negative staphylococci (CoNS) (19%), and Enterococci (18%). After CAG, CoNS (22%) and Staphylococcus aureus (16%) were the most frequent. By six months, 1.1% [95% CI 0.9-1.4] and 0.2% [95% CI 0.1-0.3] developed IE after TAVI and CAG, respectively, with an adjusted HR of 20.01 (95% CI 5.97-67.48).

Conclusion
In this nationwide cohort study, the risks of bacteremia and infective endocarditis within six months post-TAVI were significantly higher than in the matched coronary angiography population. Bacteremia post-TAVI was characterized by significantly more Enterococci spp. These results could have implications in the selection of peri-procedural antibiotics, as commonly used antibiotic regimens do not cover Enterococci spp.Cumulative incidence of bacteremia
Aortic valve calcium score to mean gradient ratio: a new frontier in aortic stenosis prognostication
Authors: Tsai C M , Foley T A , Scott C G , Thaden J J , Alsidawi S , Pislaru S V , Nkomo V T 
Published: October 2024

Abstract

Introduction
Aortic stenosis (AS) presents diagnostic challenges, especially in patients with discordant low gradient AS (LGAS), i.e., small aortic valve area (AVA) and low Doppler mean gradient (MG). LGAS is associated with worse outcomes compared to concordant AS. Aortic valve calcium score (AVCS) is a measure of AS severity independent of flow and helps diagnose severe AS. It is unknown if the degree of discordance in AVCS and MG is of any clinical significance. A high AVCS/MG ratio may indicate impaired ventricular function and response to pressure overload despite preserved LVEF, potentially contributing to worse outcomes.

Purpose
This study aims to elucidate the prognostic significance of the AVCS/MG ratio in patients with severe AS and preserved left ventricular ejection fraction (LVEF) undergoing TAVR. We hypothesized a higher AVCS/MG ratio correlates with increased mortality.

Methods
Patients who underwent transcatheter aortic valve replacement (TAVR) from 2010 to 2020 for native valve severe AS with LVEF≥50% were identiﬁed from an institutional database. AVCS were obtained within 90 days of pre-TAVR echocardiography. Patients were divided into tertiles based on their AVCS/MG ratio. Primary outcome was overall mortality.

Results
The analysis included 1067 patients (mean age 79±9 years, 43% female); overall AVA was 0.80±0.14 cm², LVEF 63±6%, MG 46±12 mmHg, AVCS 2630±1528 AU, and AVCS/MG ratio 58±31. Patients stratified by AVCS/MG tertiles showed no difference in overall comorbidity index across tertiles (Figure 1). However, the group in the highest tertile was the oldest (80±8 vs 79±8 vs 77±9 years), predominantly male (87% vs 61% vs 24%), with the highest prevalent atrial fibrillation (44% vs 28% vs 25%) and stroke volume index &lt;35 mL/m² (16% vs 11% vs 5%). 9-year survival was 15% vs 25% vs 36% (p&lt;0.001, Figure 2). In multivariate analysis adjusted for age, sex, comorbidities, LVEF and AVA, AVCS/MG ratio was independently associated with increased risk of mortality (HR 1.005; 95% CI [1.001-1.008], p=0.005).

Conclusion
Higher AVCS/MG discordance is associated with increased risk of mortality following TAVR. Serial AVCS measurements during progressive AS may help identify patients at higher risk who may potentially benefit from earlier aortic valve intervention.
Invasive hemodynamic response to exercise in hemodynamically significant aortic stenosis with preserved left ventricular ejection fraction
Authors: Ali M , Frederiksen P , Moeller J E , Mogensen N S B , Chemnitz A , Haujir A , Poulsen M K , Oevrehus K A , Pibarot P , Pellikka P A , Clavel M A , Dahl J S 
Published: October 2024

Abstract

Background
Guidelines acknowledge that discordant low-gradient (LG) aortic stenosis (AS) may be severe, but verifying this can be challenging. Right heart catheterization during exercise is considered the gold standard evaluating ventricular hemodynamics. No invasive studies have compared the hemodynamic response of discordant LG and severe AS during exercise.

Purpose
To describe exercise hemodynamics in patients with asymptomatic discordant AS and left ventricular ejection fraction ≥50%, and to identify the variables associated with the steepness of the pulmonary capillary wedge pressure (PCWP)/cardiac output (CO) slope defined as (peak exercise PCWP-rest PCWP)/(peak exercise CO-rest CO).

Methods
Patients with aortic valve area (AVA) ≤1.5 cm² underwent right heart catheterization at rest and during maximal exercise measuring pulmonary artery pressures, PCWP, CO and PCWP/CO slope. Patients were stratified in three groups: 1) discordant LG AS (AVA ≤1.0 cm² and mean gradient &lt;40 mmHg); 2) moderate AS (AVA &gt;1.0 cm²) and 3) high-gradient severe AS (AVA ≤1.0 cm² and mean gradient ≥40 mmHg).

Results
Among 86 patients, 17 (20%) had discordant LG, 49 (57%) moderate, and 20 (23%) high-gradient severe AS. The PCWP/CO slope was significantly steeper in discordant LG: median 3.3 mmHg/L/min (interquartile range: 2.2 mmHg/L/min) and high-gradient severe AS: 2.7 mmHg/L/min (1.5 mmHg/L/min) compared to moderate AS: 1.9 mmHg/L/min (2.0 mmHg/L/min), p=0.004. In a linear regression model adjusted for age, sex and rest PCWP, systemic arterial compliance and AS severity were significantly associated with the PCWP/CO slope. Furthermore, patients with discordant LG AS had a leftward and upward shift in the PCWP/CO slope.

Conclusions
Discordant LG and high-gradient severe AS had similar hemodynamic response to exercise with steeper PCWP/CO slope than in moderate AS, suggesting that discordant LG AS is a severe form of AS. In addition, the left-upward shift in PCWP/CO slope for discordant LG compared to high-gradient severe AS indicates that, this group also has latent heart failure with preserved ejection fraction physiology.
Prognostic implications of right ventricular dysfunction in degenerative mitral regurgitation
Authors: Bohbot Y , Essayagh B , Benfari G , Bax J J , Le Tourneau T , Topilsky Y , Rusinaru D , Ajmone Marsan N , Van Wijngaarden A , Hochstadt A , Roussel J C , Thapa P , Michelena H , Enriquez Sarano M , Tribouilloy C 
Published: October 2024

Abstract

Background
The prevalence and impact of right ventricular dysfunction (RVD) in degenerative mitral regurgitation (DMR) is unknown. We aimed to determine whether RVD assessed by echocardiography in routine clinical practice is independently associated with survival in patients with DMR.

Methods
We used data from the Mitral Regurgitation International DAtabase-Quantitative (MIDA-Q) which included patients with isolated DMR due to mitral valve prolapse from January 2003 to January 2020 from 5 tertiary centers across North America, Europe, and the Middle East. A cohort of 4,379 (mean age: 67 years, 64.6% males, follow-up:5.3[3.3-8.2]years) consecutive patients with significant (≥moderate) DMR was included and long-term survival was analyzed.

Results
RVD, identified in 584(13.3%) patients, was associated with reduced 10-year survival (49±3% vs. 67±1%; p&lt;0.001), overall and in all subgroups of patients, even after comprehensive adjustment including left ventricular dilatation and dysfunction, DMR severity, pulmonary pressures and surgery (adjusted HR[95%CI]=1.55[1.31-1.84]; p&lt;0.001). This excess mortality was observed under medical management (adjusted HR[95%CI]=1.39[1.12-1.72]; p=0.003) and after surgical correction of mitral regurgitation (adjusted HR[95%CI]=1.56[1.08-2.27]; p=0.019). Patients with RVD undergoing surgery within 3 months of diagnosis experienced a better 10-year survival (73±4% vs. 38±4%; p&lt;0.001), even after adjustment (adjusted HR[95%CI]=0.53[0.35-0.81]; p=0.003) despite an increase of 1-month post-operative mortality (5% vs 2.2% for patients without RVD; p&lt;0.001).

Conclusions
RVD is observed in 13.3% of significant DMR and exhibits a powerful and independent association with excess mortality partially attenuated by mitral surgery. Therefore, assessment of right ventricular systolic function should be included in routine DMR evaluation and in the clinical decision-making process.determinant ans prognosis of RVD in MR