bluuebunny/crossref_metadata_2025_split huggingface dataset:
Comparison of effective regurgitant orifice area by the PISA method and tricuspid coaptation gap measurement to identify very severe tricuspid regurgitation and stratify mortality risk
Authors: Bohbot Y , Tordjman L , Dreyfus J , Le Tourneau T , Lavie Badie Y , Selton Suty C , Elegamandji B , L'official G , Fraix A , Aghezzaf S , Turgeon P Y , Enriquez Sarano M , Coisne A , Donal E , Tribouilloy C 
Published: November 2023

Abstract

Background
Various definitions of very severe (VS) tricuspid regurgitation (TR) have been proposed based on the effective regurgitant orifice area (EROA) or tricuspid coaptation gap (TCG). Because of the inherent limitations associated with the EROA, we hypothesized that the TCG would be more suitable for defining VSTR and predicting outcomes.

Purpose
To compare EROA and TCG for outcome prediction in patients with severe TR.

Methods
In this French multicentre retrospective study, we included 606 patients with ≥ moderate-to-severe isolated TR (without structural valve disease or an overt cardiac cause) according to the recommendations of the European Association of Cardiovascular Imaging. Patients were further stratified into VSTR according to the EROA (≥60 mm²) and then according to the TCG (≥10 mm). The primary endpoint was all-cause mortality and the secondary endpoint was cardiovascular mortality.

Results
The relationship between the EROA and TCG was poor (R²=0.21), especially when the size of the defect was large. Four-year survival was comparable between patients with an EROA &lt;60 mm² vs. ≥ 60 mm² (67±3% vs. 64±4%, p=0.64), even after adjustment, for all-cause (p=0.72) and cardiovascular mortality (p=0.18). A TCG ≥10 mm was associated with lower four-year survival than a TCG &lt;10 mm (53±7% vs. 69±3%, p&lt;0.001). After adjustment for covariates, including age, comorbidity, right heart failure, dose of diuretics, and right ventricular dysfunction, a TCG ≥10 mm remained independently associated with higher all-cause mortality (adjusted HR[95%CI]=1.46[1.15-2.18], p=0.015) and cardiovascular mortality (adjusted HR[95%CI]=1.95[1.22-3.14], p &lt;0.001), whereas an EROA ≥60 mm² was not associated with all-cause or cardiovascular mortality (adjusted HR[95%CI]:1.07[0.75-1.51], p=0.720, and adjusted HR[95%CI]:1.35[0.87-2.09], p=0.176, respectively).

Conclusion
The correlation between the TCG and EROA is weak and decreases with increasing defect size. A TCG ≥10mm is associated with increased all-cause and cardiovascular mortality and should be used to define VSTR in isolated TR.Correlation between EROA and TCGEvent free survival curves
Elderly patients with severe aortic stenosis - does moderate mitral regurgitation require simultaneous surgical intervention?
Authors: Kwiecien A , Kubacki K A , Krason M Z , Kaczmarczyk M , Glanowski M , Hirnle G , Rychter J , Pakula R J , Aidibi A , Jakimowicz K M , Barnak A , Hrapkowicz T B 
Published: November 2023

Abstract

Introduction
Some patients undergoing aortic valve replacement present additional moderate mitral valve regurgitation (MVI). The guidelines do not precise whether, in the case of coexisting moderate MVI in patients undergoing aortic valve surgery, mitral valve intervention should also be considered. In the group of older patients, an additional procedure may significantly increase the operative risk.

Purpose
The aim of the study was to assess whether elderly patients with severe aortic stenosis and moderate mitral regurgitation who undergo aortic valve replacement surgery have a worse prognosis than patients without mitral valve disease?

Methods
The study is a retrospective analysis of patients (n=441) over 74 years of age with significant aortic stenosis, who underwent isolated aortic valve replacement surgery between February 2006 and July 2021. The average age in the entire group was 78,1 year (SD=2.71, min.75, max.88). Patients were divided into 2 groups depending on the presence of moderate mitral regurgitation (n=61) or its absence (n=365). The incidence of perioperative complications, early mortality and long-term survival were assessed.

Results
Patients did not differ in most preoperative burdens. There were no differences between the study groups in terms of perioperative mortality, postoperative complications and MACE (myocardial infarction, stroke, pacemaker implantation and death) and long-term survival. The predictors of long-term mortality in the entire study population were age and the need for post-operative haemofiltration.

Conclusion
The coexistence of moderate mitral regurgitation does not require additional intervention during aortic valve replacement surgery in the population of elderly patients, as its presence does not impair early outcomes or long-term survival.
Assessment of aortic valve function in over 47,000 people using deep learning
Authors: Kany S , Ramo J , Hou C , Jurgens S , Nauffal V , Cunningham J , Lau E , Butte A , Ho J , Olgin J , Elmariah S , Lindsay M , Ellinor P , Pirruccello J P 
Published: November 2023

Abstract

Background
Aortic valve (AV) stenosis (AS) is associated with a high global burden of mortality and morbidity. Previous studies suggest that even mild AS is associated with worse outcomes, prompting interest in AV function in a healthy population. The UK Biobank is a prospective cohort study with ∼500,000 participants of whom ∼10% have undergone cardiovascular MRI (cMRI).

Purpose
We aimed to develop a deep learning model to study AV function in cMRI at population level in the UK Biobank.

Methods and Results
We developed a U-Net based segmentation model with a ResNet34 encoder to study the velocity-encoded image series, computing peak velocity (cm/sec), mean peak gradient ("mean gradient"; mmHg), and aortic valve area (cm2) (AVA) in 47,223 participants.
Next, we calculated reference values stratified by age and sex in participants without CVD. In healthy individuals (n=31,909), AVA was lower in older age groups, whereas peak velocity and mean gradient remained similar across age groups. Compared to women, men had greater AVA but similar peak velocity and mean gradient estimates.
In the biomarker analysis (taken ∼9.5 years before cMRI), we observed an association of apolipoprotein B (ApoB) (0.033 SD increase per SD, P=3.1×10-12) and lipoprotein a (Lp (a)) (0.027 SD increase, P=4.8×10-07) with higher peak velocity. Using Mendelian Randomization, we found genetic evidence that Lp(a) causally contributes to higher peak velocity (β=0.04, P=6.4 × 10-10) and smaller AVA (β=-0.056, P=1.3 × 10-4). Similarly, ApoB causally contributes to higher peak velocity (β=0.072, P=1.3 × 10-6) and smaller AVA (β=-0.065, P=1.3 × 10-5) in Mendelian Randomization.
Peak velocity was strongly associated with incident AV surgery (N=72, Hazard ratio [HR] 2.40 per SD, P=2.6×10-110) and AS (N=123, HR 2.10, P=7.7×10-138). The predictive power for AS was higher when using the top 10% vs the remaining 90% of distribution for mean gradient (N in top 10% with event=87, HR 24.91, P=2.4×10-43) and peak velocity (N=92, HR 33.01, P=3.0×10-43). After excluding individuals with at least mild aortic stenosis (peak velocity &gt; 2m/sec, mean gradient &gt;20mmHg, AVA &gt;1.5 cm2) the top 10% of the remaining population was still highly predictive for AS using mean gradient (N=30, HR 8.90, P=9.4×10-15) and peak velocity (N=35, HR 13.15, P=1.6×10-18).

Conclusion
We found both epidemiological and causal genetic evidence that elevated ApoB and Lp(a) cause a reduction in AVA. Even aortic velocities below the threshold for mild AS were predictive of future clinical disease, suggesting that there may be a role for monitoring at AVA below the current threshold for mild AS. Future work is needed to understand whether clinical outcomes are better predicted by universal or sex-specific cutoffs.Figure 1:Workflow of deep learning modeHR of incident valvular disease
Time of day dependent symptom onset is not associated with left ventricular function and myocardial damage after ST-segment elevation myocardial infarction
Authors: Holzknecht M , Lechner I , Reindl M , Tiller C , Fink P , Oberhollenzer F , Troger F , Mayr A , Bauer A , Reinstadler S J , Metzler B 
Published: November 2023

Abstract

Background
Circadian processes are suggested to influence ischemic injury in ST-segment elevation myocardial infarction (STEMI). Observational data suspect a circadian dependence of the occurrence of microvascular obstruction (MVO) in patients with STEMI. However, these observations derive from a small sample size and circadian variations in left ventricular function and myocardial damage after STEMI are still a matter of controversy.

Purpose
We aimed to investigate the association of time of day dependent symptom onset with left ventricular ejection fraction (LVEF), infarct size (IS) and MVO in a large cohort of STEMI patients treated with primary percutaneous coronary intervention (PCI).

Methods
This observational study investigated acute STEMI patients treated with primary PCI. Cardiac magnetic resonance (CMR) imaging was performed within 1 week after the index event for the determination of left ventricular function and infarct characteristics. The time of symptom onset was used to discriminate patients according to LVEF, IS as well as MVO occurrence and extent over a 24 hours cycle to evaluate circadian behavior.

Results
In final analysis, 889 acute STEMI patients treated with primary PCI with a delay of 189 [120-315] minutes were included. Median age of the overall cohort was 57 [51-66] years and 17% were female. Median LVEF was 49 [42-55]%, IS assumed 15.5 [8.0-24.7]% of left ventricular myocardial mass (LVMM) and MVO occurred in 57% of STEMI patients. No hourly differences between symptom onset and MVO occurrence (p=0.108), MVO extent (p=0.735), LVEF (p=0.644) and IS (p=0.722) have been evaluated. When comparing 3 hourly segments of symptom onset, no variations in MVO occurrence (p=0.114), MVO extent (p=0.308), LVEF (p=0.547) and IS (p=0.405) were observed.

Conclusions
No circadian variations in symptom onset and the occurrence and extent of MVO, LVEF and IS were observed in this large cohort of STEMI patients treated with primary PCI. Further research is needed to investigate the complex interplay between circadian processes and ischemic injury in this patient population.
Mitral annulus disjunction: a detailed magnetic resonance study of phenotype and clinical significance
Authors: Custodio P M , Campos P , Moura A R , Khanji M , Bicho J A , Lopes L R 
Published: November 2023

Abstract

Background
The clinical significance and arrhythmogenic propensity of mitral annulus disjunction (MAD) are not well established. Our aim was to characterize MAD in all-comers, analyzing the mitral valve apparatus in detail, scar burden and clinical outcomes.

Methods
Single-center retrospective analysis of all consecutive patients with MAD described by cardiovascular magnetic resonance (CMR) between 2010-2022. Medical history, imaging and arrhythmia data were analysed. Cardiovascular mortality was assessed. MAD was defined as a separation ≥2mm between the left ventricular myocardium and the mitral annulus. Presence and pattern of left ventricle (LV) late gadolinium enhancement (LGE) was assessed. Scar in the papillary muscles and areas adjacent to the MAD was identified as MAD-related. Ventricular arrhythmias (VA) were grouped into non-sustained (ectopies&gt;10%/24h or ventricular tachycardia) or sustained.

Results
Out of 341 patients who were initially identified as possibly having MAD, MAD was confirmed in 222. Mean age was 49.2±19.3 years, 126 were male (56.8%). Mean longitudinal MAD extent was 5±2.6mm, while circumferential involvement of a single segment (60º) was most commonly seen (n=99, 44.6%). The inferior wall was the affected segment (n=116, 52.2%) with more extensive MAD, followed by the inferolateral wall (n=71, 32%). Mitral valve (MV) annulus expanded during systole in patients with MAD ≥6mm, while annular contraction occurred in those with MAD &lt;6mm. Annular expansion was associated with MV prolapse (p=0.003), billowing (p=0.018) and curling (p&lt;0.001). LV LGE was present in 82 patients (36.9%), with 23 patients (10.4%) showing MAD-related LGE, but no association with disease extent (MAD length or circumferential involvement). Median follow-up time was 1392 (872-1922) days. No episode of sustained VA was observed. In univariable analysis non-sustained VA was significantly more prevalent in patients with MAD ≥6mm (p=0.002), although this tendency faded after multivariate analysis (p=0.053). The presence of non-sustained VA was associated with global LV LGE (p=0.005), but not MAD-related LGE in isolation - Table 1. Three patients died of cardiovascular causes (1.4%), but none had extensive MAD or MAD-related LGE. None died of sudden cardiac arrest.
To the best of our knowledge, this is the biggest dataset of MAD patients that simultaneously analysis phenotype, including LGE, and clinical outcomes.

Conclusion
Mitral valve dysfunction (prolapse/billowing) is linked to MAD severity. Scar is common, not related to the extent of MAD, but a predictor of VAs independently of its location. The risk of sustained ventricular arrhythmias and cardiovascular death appears to be low in this all-comers population.Table 1
Atrial functional tricuspid regurgitation in patients undergoing transcatheter aortic valve replacement
Authors: Loew K , Steffen J , Lux M , Haum M , Fischer J , Orban M , Theiss H , Braun D , Massberg S , Hausleiter J , Deseive S 
Published: November 2023

Abstract

Introduction
Recently, a novel entity of tricuspid regurgitation (TR) – atrial functional TR, which is caused by enlargement of the right atrium – has gained in awareness. In comparison, ventricular functional TR occurs in the setting of left heart disease with pulmonary hypertension and subsequent enlargement of the right ventricle. While it could be demonstrated that in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR), an improvement of moderate or severe tricuspid regurgitation (TR) can be observed in many patients, knowledge about the association between entity and improvement of TR is scarce.

Purpose
The aim of this study was to analyse if atrial functional TR, defined by the enlargement of the right atrium is associated with the persistence of TR after TAVR in patients with severe AS and at least moderate concomitant TR at baseline. Moreover, 3-year all-cause mortality in patients with atrial and ventricular TR was assessed.

Methods
We retrospectively examined 363 patients with at least moderate tricuspid regurgitation undergoing TAVR from January 2013 to December 2020 due to severe AS. Patients with primary TR, a history of tricuspid valve surgery or with TAVR due to severe aortic regurgitation were excluded. Endsystolic area of the right atrium (RA) and enddiastolic area of the right ventricle (RV) were assessed in transthoracic echocardiography and atrial TR was defined as RA/RV area ratio above the median value of 1.125.

Results
TR improvement of at least one grade after transcatheter aortic valve replacement was significantly less frequent in patients with atrial compared to patients with ventricular TR (29.2% vs. 60.3%, p &lt; 0.001, Figure 1). Multivariate logistic regression analysis with adjustment for left ventricular ejection fraction, Vena contracta and CT-determined tricuspid annulus diameter confirmed that atrial functional TR was an independent predictor for absence of TR improvement after TAVR (adjusted odds ratio: 3.03, 95% CI 1.65-5.64; p&lt;0.001). Moreover, improvement of TR was associated with a significantly lower 3-year all-cause mortality compared to patients with persistence of TR (log rank test p&lt;0.001, Figure 2A). However, no difference could be observed regarding 3-year all-cause mortality between patients with atrial and ventricular TR (log-rank test p=0.500, Figure 2B).

Conclusion
In patients undergoing TAVR for severe AS and at least moderate concomitant TR, atrial functional TR is an independent predictor for TR persistence. In addition, TR persistence is associated with increased 3-year all-cause mortality.Figure 1:Development of TR after TAVRFigure 2:3-year all-cause mortality
Echocardiographic features predict the performance of transthoracic echocardiography in ruling out infective endocarditis: a 5-year study
Authors: Zhang R Y K , Litkouhi P N , Ramanayake A , Youssef G 
Published: November 2023

Abstract

Background
Transoesophageal echocardiography (TOE) remains the gold standard imaging modality to aid in the diagnosis of infective endocarditis (IE), but is resource intensive and confers patient risk. Transthoracic echocardiography (TTE) is a more accessible alternative, but previous studies report varying ability of TTE to effectively rule out disease. As a result, negative TTE is often still followed with TOE when clinical suspicion remains. However, these studies did not account for TTE quality and other echocardiographic features within the TTE that may decrease its diagnostic utility and thereby reduce its ability to effectively rule out disease. Understanding the risk of missing IE for a given negative TTE could avoid the need for subsequent TOE.

Purpose
Our aim is to devise and test the validity of a scoring system which can stratify TTEs by quality to predict TTE performance and inform the decision for whether follow-up TOE is necessary.

Methods
In this retrospective single-centre study, the Predictor of TTE Performance (PTP) scoring system was developed and applied to patients undergoing both TTE and TOE for suspected IE at our tertiary centre between May 2017 and May 2022. Within the scoring system, a point was allocated for the presence of each of the following on TTE: a mobile echodensity; poor image quality; more than mild regurgitation; a prosthetic valve or prosthetic intracardiac material; and other valvular abnormalities. Poor image quality was defined as any TTE that was unable to achieve good endocardial visualisation from at least two views. Valvular abnormalities warranting a point included congenital abnormalities such as bicuspid aortic valve and acquired abnormalities such as rheumatic valvular disease, mitral valve prolapse and valvular stenosis. The negative predictive value (NPV) for TTEs in each score category was analysed using TOE as the gold standard.

Results
A total of 362 patients with paired TTE/TOE were included for analysis. 60 (16.6%) had positive TOE, with the overall NPV of TTE being 88.5% (95% CI: 84.6–91.5%). Using the PTP scoring system, patients were stratified into low-risk (score of 0, n = 116), moderate-risk (score of 1, n = 140) and high-risk (score greater than 1, n = 106) groups. Increasing PTP score was associated with poorer TTE performance, with the low-risk, moderate-risk and high-risk categories having NPVs of 98.3% (95% CI: 93.9–99.7%), 90.2% (95% CI: 83.9–94.2%) and 72.3% (95% CI: 61.8–80.8%) respectively.

Conclusion
The ability of TTE to exclude IE is excellent when patients have no echocardiographic features that reduce TTE quality or predict increased risk for endocarditis. In patients with a low PTP score, negative TTE may render follow-up TOE unnecessary.
One-year outcome of elderly patients with endocarditis: a retrospective observational study
Authors: Marchini F , Zanarelli L , Bianchi N , Tonet E , Passarini G , Guardigli G , Campo G , Pavasini R 
Published: November 2023

Abstract

Background
The incidence of infective endocarditis (IE) is rising in general population, especially in elderly, where it is associated with high morbidity and mortality. Health care procedures, degenerative heart valve diseases and intracardiac electronic devices are the main risk factors for IE in elderly population. Cardiac surgery is largely underused in these patients and the few available observational studies seem to confirm the positive outcome of surgery.

Purpose
The aim of the present study is to assess differences in survival between elderly patients affected by endocarditis treated with a conservative strategy or cardiac surgery.

Methods
We conducted a retrospective observational study of 143 elderly patients (age ≥ 70 years old) affected by endocarditis with at least one year of follow-up who were hospitalized between 2016 and 2022. The primary endpoint was the difference in one-year all-cause mortality between patients treated with a conservative strategy or cardiac surgery. The secondary endpoint was one-year mortality for sepsis or septic shock. The cumulative probability of survival was calculated using the Kaplan-Meier estimator. The log-rank test was used to compare between-group differences in survival and cox regression was used in the uni and multivariate analysis, a p&lt;0.05 was considered significant.

Results
Between 2016 and 2022, 242 patients have been diagnosed with IE. Between them, 143 patients were at least 70 years old (59%). Cardiac surgery was performed in 16 patients, while 127 were treated with medical therapy alone. Patients treated with cardiac surgery were younger (74y vs 80y, p=0.005) and had higher prevalence of severe valvular heart disease (69% vs 23%, p&lt; 0.001). The primary endpoint of one-year all-cause mortality occurred in 80 patients in the conservative strategy group and in 5 patients treated with surgery (p=0.015); the secondary endpoint occurred in 42 patients in conservative strategy group, while no patients treated with surgery died for sepsis or septic shock (p=0.006). Finally, surgery was associated with better one-year survival (HR 0.34, 95% CI 0.14 - 0.85).

Conclusions
IE in elderly patients is an emerging clinical matter since its incidence is rising but mortality has not significantly decreased. Current clinical guidelines do not give specific indication for elderly, who are generally excluded from surgery due to the high risk carried by age and comorbidities. Few previous studies have analyzed the best treatment strategy in this cohort of patients, but data from observational studies shows a better outcome among those undergone surgery. The result of our work confirmed that elderly patients with IE treated with cardiac surgery have better one-year survival and lower rate of death for all causes, sepsis or septic shockKaplan Mayer Curve For One-Year Survival