bluuebunny/crossref_metadata_2025_split huggingface dataset:
Myocardial injury after transcatheter aortic valve replacement according to VARC-3 criteria
Authors: Real C , Avvedimento M , Nuche J , Franzone A , Farjat-Pasos J , Trinh K H , Delarochelliere R , Paradis J M , Poulin A , Dumont E , Kalavrouziotis D , Mohammadi S , Mengi S , Esposito G , Rodes-Cabau J 
Published: November 2023

Abstract

Background
Periprocedural myocardial injury (PPMI) is frequent in patients undergoing transcatheter aortic valve replacement (TAVR). PPMI after TAVR as defined by Valve Academic Research Consortium-2 (VARC-2) criteria occurs in &gt;50% of the patients and had inconsistent results regarding prognostic significance. However, recent VARC-3 definition is more specific, having increased the troponin threshold from 15-times to 70-times the upper reference limit (URL) to define PPMI. This recent definition of PPMI following TAVR lacks the clinical validation.

Objective
To determine the incidence, predictors and clinical impact of PPMI following TAVR as defined by recent VARC-3 criteria.

Methods
We included 1,394 consecutive patients who underwent TAVR with a new generation transcatheter heart valve in two tertiary centers in Canada and Italy, from 2015 to 2022. Patients undergoing a trans-aortic or a trans-apical approach were excluded. High-sensitivity troponin levels were assessed at baseline and within 24 hours after the procedure. PPMI was defined according to VARC-3 criteria as an increase ≥70 times in troponin levels (vs. ≥15 times according to VARC-2 definition). Baseline, procedural and follow-up data were prospectively collected in a dedicated database.

Results
PPMI was diagnosed in 193 patients (14%) according to the VARC-3 criteria. Female sex and peripheral artery disease were found independent predictors of PPMI in the multivariable analysis (p&lt;0.01 for both). PPMI was associated with a higher risk of mortality at 30-day (HR: 2.76, 95% CI: 1.54-4.95, p=0.001 for all-cause mortality; HR: 9.54, 95%CI: 2.69 to 33.80, p&lt;0.001 for cardiovascular mortality) and 1-year-follow-up (HR: 1.52, 95%CI: 1.02-2.27, p=0.037 for all-cause mortality; HR: 3.04, 95%CI: 1.68-5.50, p&lt;0.001 for cardiovascular mortality). PPMI according to VARC-2 criteria had no impact on mortality (Figure 1). According to restricted cubic splines analysis, the minimal threshold at which high-sensitivity troponin elevation is significantly associated with 1-year all-cause mortality is an 82-fold increase above URL (Figure 2).

Conclusions
About 1 out of 10 patients undergoing TAVR in the contemporary era had PPMI as defined by recent VARC-3 criteria and it had a negative impact on early and late survival. Baseline factors as female gender and peripheral disease increased the risk. Further studies on the prevention of PPMI post-TAVR and implementing measures to improve outcomes in PPMI patients are warranted.Kaplan-Meier estimates of mortalityRestricted cubic splines analysis
Biological versus mechanical SAVR patient's age threshold: PARTNER II study influenced real world practice in a large French cohort
Authors: Chabry Y , Baufreton C , Bouchot O , Camilleri L , Collart F , Demaria R , Frieh J P , Kindo M , Labrousse L , Leprince P , Marcheix B , Roussel J C , Verhoye J P , Vincentelli A , Caus T 
Published: November 2023

Abstract

Background/introduction
Published in 2016, PARTNER II study has shown TAVR to be non inferior to SAVR in intermediate risk patients. This result might influence the type of SAVR chosen in patients for whom a redo surgery would surely be a procedure at intermediate risk, based on estimated age at time for redo and taking into account ViV TAVI as a game changer for treating a degenerated biological prosthesis.

Purpose
To assess the choice of type of valve according to age in aortic position through the French National Database EPICARD before and after the publication of Parter II study.

Methods
We extracted from EPICARD all valvular patients operated on from 2007 to 2022 in 24 participating public or private centers chosen to represent a balanced representation of center sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded.

Results
From the obtained representative study population of 101,070 valvular patients, we studied 72,375 SAVR (mean age 71.4 +/- 12.2). We observed a mechanical versus biological prosthesis ratio (MBPR) of 0.14 for the overall aortic SAVR population. Before 50 y-o, MBPR was &gt;1.3 (p&lt;0.001) while patients above 60 y-o received principally biological SAVR (p&lt;0.0001). Concerning patients between 50-60 y-o patients, MBPR was 1.04 (p=0.03). Patients 50-60 y-o from the first and second quartile (before August 2015) received preferentially mechanical SAVR (p&lt;0.001). We observed a shift towards more biological SAVR (p&lt;0.001) for patients from the third and fourth quartile to reach a MBPR at 0.43 during the last years of the series. Incidentally, the choice of type of SAVR was influenced by associated procedures. Simultaneous mitral valve replacement were more common in case of mechanical SAVR (p&lt;0.0001), while associated CABGs were more frequent in case of biological SAVR (p&lt;0.0001).

Conclusion
In a large contemporary French patient population, real world practice showed that publication of the PARTNER II study was followed by a shift towards a lower threshold for biological SAVR as compared to ESC Guidelines.
Improvement of microcirculatory vessel density in the early post-operative period of heart valve surgery: an observational study
Authors: Tibirica E , Lorenzo A , Fernandes M V 
Published: November 2023

Abstract

Introduction
Cardiac surgery with cardiopulmonary bypass (CPB) is associated with microcirculatory perfusion disturbances that persist after the surgery and that can cause multiple organ dysfunction. Little is known about the effects of heart surgery on the microcirculation of patients in the postoperative period of heart valve surgery.

Purpose
The purpose of the study is to identify the alterations that occur in the sublingual microcirculation of patients submitted to heart valve surgery using cardiopulmonary bypass. Such findings may guide future implementation of routine microcirculation assessment in the postoperative period of cardiac surgery.

Methods
This was a single-center cross-sectional observational study that included thirty patients aged 52 ± 14 years and enrolled during a period of four months, scheduled for heart valve surgery with CPB at a quaternary public hospital. Sublingual microcirculatory density and perfusion were assessed using a handheld camera based on incident dark-field (IDF) imaging. Each recruited patient was evaluated in two stages: 1) during hospitalization, in the preoperative period of cardiac surgery to be performed within the next 48 hours; 2) in the early postoperative phase of cardiac surgery, within the first four hours of the patient's arrival at the intensive care unit. At least three videos of 5 seconds each were obtained in both stages. Images were analyzed using automated software as well as visual analysis. For analysis purposes, we considered vessels as capillaries if diameter ranges between 6.04-15.9 µm and non-capillaries if diameter ranges between 16-50 µm.

Results
We observed a statistically significant increase in the total number of vessels (TVN) after surgery (1076 ± 156) compared to values obtained before surgery (943 ± 117, P=0.0004). In addition, the total number of capillaries vessels (TNCV) was also greater after surgery (998 ± 132) compared to the preoperative period (877 ± 106; P=0.0001), the same being observed in the total length of capillaries vessels (TLCV) after surgery (28.7 ± 3.3 mm) compared to before surgery (25.8 ± 3.0 mm; P=0.0005) and capillary vessel density (CVD) (16.4 ± 1.9 and 14.8 ± 1.7 mm/mm2) after and before surgery, respectively (P=0.0005). With regard to non-capillary vessels, no difference was observed in total number of non-capillary vessels (TNNCV) after [68 (49-104)] and before surgery [69 (49-78)] (P=0.21), as well as in total length of non-capillary vessels (TLNCV) after [1.6 (1.2-2.4)] mm and before [1.5 (1.1-1.8.)] mm (P=0.25) surgery. Finally, non-capillary vessel density (NCVD) was also similar after [0.89 (0.67-1.36)] mm/mm2 and before surgery [0.83 (0.66-1.06)] mm/mm2 (P=0.34).

Conclusion
In patients undergoing heart valve surgery, there was a significant increase in postoperative microvessel number, mainly due to the increase in the density of capillaries vessels.
Left atrial pump strain predicts long-term mortality in patients undergoing transcatheter aortic valve implantation
Authors: Winkler N E , Anwer S , Rumpf P M , Tsiourantani G , Donati T G , Michel J , Kasel A M , Tanner F C 
Published: November 2023

Abstract

Introduction
Speckle-tracking echocardiography is an increasingly important tool for assessing aortic stenosis (AS). Left atrial reservoir (LARS) and pump strain (LAPS) were studied for their association with long-term mortality in AS patients undergoing transcatheter aortic valve implantation (TAVI).

Purpose
To investigate left atrial function assessed by LARS and LAPS and its association with all-cause mortality during long-term follow-up after TAVI.

Methods
From our prospective AS cohort study, 198 patients with severe AS were identified who underwent TAVI and had a comprehensive preinterventional echocardiographic examination allowing full target analysis. Five-year all-cause mortality was defined as the endpoint.

Results
Left atrial volume index (LAVI) was increased (mean (SD): 46.9 ml/m2 (±16.5)) and left atrial deformation impaired (LARS (21.7% (±6.9); LAPS (-9.5% (±4.5)), while left ventricular ejection fraction (LVEF) (56.7% (±11.5)) was preserved in the study population. Over a follow-up time of five years, 49 patients (24.7%) died. LARS and LAPS were more impaired in non-survivors (20.0% (±6.5) and -8.1% (±4.0), respectively; Figure) than in survivors (22.3% (±6.9); P=0.042 and -9.9% (±4.5), respectively; P=0.014; Figure), while LAVI did not differ (P=0.248). Univariable Cox regression models demonstrated that LAPS was associated with mortality (P=0.014), while LARS was not (P=0.066) (Table A). In bivariable and multivariable models, the association of LAPS with mortality was independent of LVEF and LAVI, and inclusion of LAPS improved the fitness (≤2) of these models (Table B). Furthermore, the improvement in ≤2 was significant for all models (ANOVA P=0.012, P=0.013, and P=0.015, respectively).

Conclusion
LAPS was associated with long-term mortality after TAVI, while LARS and LAVI were not. The association of LAPS was independent of LVEF and LAVI and showed potential incremental value for assessment of outcome association. Hence, LAPS may be useful for predicting long-term outcome after TAVI.
An artificial intelligence algorithm for detection of severe aortic stenosis: a clinical cohort study
Authors: Strom J , Playford D , Stewart S , Strange G 
Published: November 2023

Abstract

Background/Introduction
Despite guideline based indications, nearly 1/3 of patients with symptomatic severe aortic stenosis (AS) are not referred for intervention. Artificial Intelligence Decision-Support Algorithms (AI-DSAs) may be helpful to identify individuals with AS at risk for premature mortality but few have been validated for use.

Purpose
To evaluate an AI-DSA based on echocardiogram report data to augment the detection of severe AS within a well-resourced health care setting.

Methods
Blinded to clinical information, an AI-DSA trained to identify an aortic valve area (AVA) &lt;1cm2 using minimal input data was applied to routine transthoracic echocardiogram reports from 31,141 US Medicare beneficiaries (≥ 65 years old) at a large US academic medical center (2003-2017) (Figure).

Results
Performance of the AI-DSA to detect an AVA &lt;1cm2 was excellent (sensitivity 95.2%, specificity 94.8%, negative predictive value 99.8%). The AI-DSA identified 1,549 (5.0%) individuals with guideline-defined severe AS plus 463 (1.5%), 979 (3.1%), and 28,150 (90.4%) individuals with a severe AS (not meeting guidelines), moderate AS, and low-probability AS phenotypes. Five-year mortality was 73.9%, 77.1%, 71.2%, and 43.6% respectively (adjusted HR compared to low-probability AS, HR 1.40, 95% CI 1.31-1.50 [guideline severe], HR 1.31, 1.17-1.46 [non-guideline severe], HR 1.21, 1.12-1.23 [moderate], p &lt; 0.001 for all). Overall, rates of aortic valve replacement (AVR) remained low, even in those with an AVA &lt;1cm2 (21.9%), despite it being associated with improved survival. Findings remained consistent among outpatients, those investigated in the past decade and those with left ventricular systolic dysfunction.

Conclusions
Without relying on left ventricular outflow tract measurements, an AI-DSA used echocardiographic reports to reliably identify those with severe AS. These results suggest possible utility for this AI-DSA to enhance detection of individuals with the phenotype of severe AS, at risk for adverse outcomes.Figure:Graphical Abstract
Syncope at rest in severe aortic stenosis may persist after intervention and is associated with poor outcomes
Authors: Garcia M , Ybarra Falcon C , Martin Paniagua S , Lozano Ibanez A , Alanon Hernandez A , Cabezon G , Ramos N , Amat Santos I J , Sevilla T , Revilla A , Carrasco M , Lopez J , Rollan M J , Vilacosta I , San Roman J A 
Published: November 2023

Abstract

Background
syncope in patients with severe aortic stenosis (AS) is an indication for intervention (AVR). The evolution of syncope after AVR and its association to outcomes remain unknown.

Purpose
we aimed to describe the evolution of syncope in patients with symptomatic severe AS undergoing AVR, whether its trigger has an impact on outcomes, and its prognostic significance.

Methods
data from patients with severe AS who underwent AVR were collected. Total death and cardiovascular death were considered events.

Results
320 consecutive patients with severe AS, without other valve disease and/or coronary artery disease, who survived AVR were evaluated. The work focuses on the 53 patients who reported syncope (29 on effort, 21 at rest, 3 unknown). Clinical and echocardiographic variables were similar in patients with syncope and without syncope. After a median follow-up of 69 months (IQR: 55-88), no patient with syncope on effort before intervention had syncope after intervention. By contrast, 8 of the 21 patients with syncope at rest presented syncope during the follow-up (38%; p&lt;0.001); all 8 syncopes appeared at rest: 3 needed a pacemaker, 3 were diagnosed as neuromediated or of hypotensive origin and 2 were arrhythmic. Only syncope after intervention was associated with cardiovascular death (HR 5.74; 95%CI [2.17-15.17]; p&lt;0,001]).

Conclusions
syncope on effort in patients with severe AS disappears after AVR but syncope at rest remains in a high proportion of patients. Syncope after AVR is associated with poor prognosis. Our results suggest that, in patients with severe AS and syncope at rest, other causes of syncope must be ruled out before proceeding to AVR.Adjusted Kaplan Meier survival curves
Randomized study for the optimal treatment of symptomatic patients with low gradient severe aortic valve stenosis and preserved left ventricular ejection fraction (ROTAS trial)
Authors: Galli E , Coisne A , Le Ven F , Sportouch C , Lairez O , Bernard A , Oger E , Le Pabic E , Donal E 
Published: November 2023

Abstract

Background
the best management of symptomatic patients with low gradient (LG) severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF) has not been established in randomized controlled trials.
The ROTAS trial aimed to assess the superiority of aortic valve replacement (AVR) versus optimized medical therapy (OMT) in symptomatic patients with LG severe AS and preserved LVEF.

Methods and Results
Fifty-two patients (age 79±7 years; males 46%, mean aortic gradient: 31±5 mmHg; aortic surface: 0.8±0.1 cm², LVEF 61±8%) were randomized 1:1 to AVR or OMT.
The stroke volume index (SVi, cut-off 35 ml/m²) was considered for randomisation so that the same percentage of patients with reduced SVi was present in the two groups. The follow-up lasted 14±7 months.
An early interruption of the study occurred in 2021 because of the extremely low inclusion rate during the COVID-2019 pandemic and the large tendency to already implant TAVI in patients with severe LG AS with preserved LVEF.
In all patients, a multimodality approach, including dobutamine stress echocardiography and/or aortic calcium score was applied to confirm AS severity.
The primary end-point (a composite of overall death and heart failure hospitalisation) occurred in 13 (25%) patients.
Patients receiving OMT did not experience worse survival compared to patients receiving AVR (HR=1.57, 95% CI:0.51-4.83, p=0.4275). Kaplan-Meier curves showed similar event-free survival (log-rank p=0.4236) among the 2 groups (Figure 1).

Conclusions
In the randomized ROTAS trial, AVR was not associated with a better prognosis in symptomatic patients with LG severe AS and preserved LVEF.Figure 1
Is there an outcome penalty linked to guideline-based class-I indications for valvular surgery? long-term analysis of patients with high gradient severe aortic stenosis
Authors: De Azevedo D , Boute M , Hanet V , Tribouilloy C , Marechaux S , Altes A , Bohbot Y , Rusimaru D , Thellier N , Pouleur A C , Pasquet A , Gerber B L , Vanoverschelde J L , Vancraeynest D 
Published: November 2023

Abstract

Background
Current ACC/AHA guidelines recommend aortic valve replacement (AVR) as class-I triggers in patients with high-gradient severe aortic stenosis (HGSAS) in presence of symptoms and/or left ventricular dysfunction (LVEF&lt;50%). Whether waiting for these triggers could be associated with long-term outcome penalty after AVR remains poorly studied.

Objective
To examine the impact of guideline-based class-I triggers on long-term post-operative survival in patients with HGSAS.

Methods
We used an international registry including consecutive patients operated on for HGSAS between 2000 and 2017. 2030 Patients were included in the analysis and retrospectively classified according to the guideline-based indication: no Class-I trigger (no symptoms and LVEF&gt;50%, n=853), Symptoms with LVEF&gt;50% (n=965), or LVEF&lt;50% (regardless of symptoms, n=212). Survival was compared in a multivariate Cox-model and after inverse probability weighting-[IPW] for relevant variables. Finally, we explored the most sensitive left ventricular ejection fraction threshold for predicting mortality risk.

Results
10-years survival was better among patients without any class-I trigger than with symptoms or LVEF&lt;50% (67±3 vs 56±3 vs 53±7% respectively, p&lt;0.001). After adjustment for covariates, risk of death increased significantly when patients were operated on with symptoms (HR: 1.48, [95%CI: 1.17-1.86]) or with LVEF&lt;50% (HR: 1.47, [95%CI: 1.05-2.06]) compared to patients with no class-I trigger. Furthermore, LVEF&lt;55% emerged as a more sensitive threshold for the prediction of post-operative mortality in comparison with LVEF&lt;50% (see table), allowing a better separation of survival curves and indicating that patients with LVEF 50-55% are already at risk with long term consequences even after AVR. Interestingly, among asymptomatic patients with LVEF &gt;55%, performing AVR restituted a normal life expectancy (comparable to the Belgian population of same age, see figure). Finally, the outcome penalty after AVR when waiting for symptoms or LVEF&lt;55% was confirmed in IPW analysis (HR: 1.43, [95%CI: 1.13-1.82] and HR: 1.63, [95%CI: 1.19-2.23], respectively).

Conclusions
Guideline-based Class-I triggers for AVR in patients with HGSAS is associated with profound outcome consequences on long-term postoperative mortality. Our data argue that patients with HGSAS should be operated on before the onset of these triggers. Finally, our data suggest that a threshold of LVEF&lt;55% is a stronger predictor of outcome than LVEF&lt;50%.
Use of sex-specific thresholds for low flow in assessment of prognosis in concordantly and discordantly graded aortic valve stenosis
Authors: Bahlmann E , Gerdts E , Einersen E , Midtbo H , Pedersen E , Rossebo A , Willems S , Cramariuc D 
Published: November 2023

Abstract

Objective
Assessment of flow is important in grading of aortic valve stenosis (AS). Sex-specific thresholds for low flow were recently proposed (stroke volume index &lt;40 ml/m² in men and &lt;32 ml/m² in women, respectively). We tested the prognostic association of these cut-offs in AS patients with concordantly and discordantly graded AS based on pressure recovery adjusted aortic valve area.

Methods
Data from 1353 patients (38.6% women) with asymptomatic mild-moderate AS and preserved left ventricular ejection fraction enrolled in the Simvastatin and Ezetimibe in AS study was used. Discordantly graded AS (DGASEL) was defined as combined pressure recovery adjusted aortic valve area (energy loss) &lt;1.0 cm² and mean aortic gradient &lt;40 mmHg and concordantly graded mild-moderate AS as combined EL ≥1.0 cm² and mean aortic gradient &lt;40mmHg. Patients were further grouped into normal and low flow. Outcome was assessed using both Kaplan-Meier curves and Cox regression analyses with concordantly graded AS with normal flow as comparator.

Results
In the total study population, mild-moderate AS with normal flow was present in 915 patients, mild-moderate AS with low flow in 253 patients, DGASEL with normal flow in 57 patients and DGASEL with low flow in 126 patients.
During a median of 4.3 years follow-up, survival free of death and/or hospitalization for heart failure was significantly lower in patients with DGASEL irrespective of flow compared to those with mild-moderate AS with normal flow (both P&lt;0.05, Figure). In Cox regression analysis, after adjustment for hypertension, age, sex, heart rate, randomized study treatment, aortic valve replacement and degree of aortic valve calcification, DGASEL with normal or low flow were both associated with increased risk of combined death and hospitalization for heart failure (P&lt;0.05) (Table). However, no prognostic difference was found between groups with normal vs. low flow within groups of discordantly or concordantly graded AS.

Conclusions
Identification of low flow by the proposed sex-specific thresholds of stroke volume index &lt;40 ml/m² in men and &lt;32 ml/m² in women needs more validation before inclusion in clinical guidelines.
Figure. Kaplan-Meier plot of event-free survival from combined death and heart failure hospitalization in groups of patients with mild-moderate AS normal flow, mild-moderate AS low flow, DGASEL with normal flow and DGASEL with low flow.
Table. Association of combined death and hospitalization for heart failure in groups of concordantly and discordantly graded AS with normal and low flow. Multivariable Cox analysis.