bluuebunny/crossref_metadata_2025_split huggingface dataset:
SCAI classification, the importance of its dynamic reclassification in the first 24 hours and the impact of risk modifiers in cardiogenic shock admissions
Authors: Presume J , Bello A R , Gomes D A , Brizido C , Strong C , Ferreira J , Tralhao A 
Published: November 2023

Abstract

Introduction
The Society for Cardiovascular Angiography and Interventions (SCAI) shock stage classification has been proposed as a simple, easily applied framework to stratify mortality risk across the spectrum of cardiogenic shock (CS) severity. This categorization has been recently refined (2022) to incorporate the continuum dynamic trajectory of the disease, as well as other risk modifiers.
The aims of this study were: 1) to validate the SCAI classification at admission in a cohort of patients admitted to the cardiac intensive care unit (CICU) due to CS; 2) evaluate the prognostic impact of SCAI stage variation during the first 24h of admission; 3) evaluate the prognostic impact of other risk modifiers.

Methods
We retrospectively analyzed patients consecutively admitted to the CICU with established CS (SCAI C and above) from all causes, from January 2017 to November 2022. SCAI staging was assessed at diagnosis and after 24 hours. The primary outcome was 30-day mortality.

Results
A total of 208 patients (66±16 years, 67% male) were included. Overall, 53% had an acute myocardial infarction, 34% were admitted due to decompensation of chronic heart failure, and 29.1% had a cardiac arrest. The proportion of patients in SCAI stage C to E at the time of diagnosis was 69% (n=143), 25% (n=52), and 6% (n=13), respectively. 30-day mortality increased across SCAI categories (p&lt;0.001 – figure 1.1).
After the first 24 hours, 34 (%) of patients improved SCAI category, 113 (%) remained in the same class, and 45 (%) worsened, with a 30-day mortality of 18%, 34%, and 62%, respectively (p&lt;0.001 – figure 1.2).
Risk modifiers also carried prognostic significance (figure 1.3). 30-day mortality was significantly higher in patients with acute myocardial infarction vs. other etiologies (52% vs. 32%; p=0.002), acute CS vs. acute-on-chronic CS (47% vs. 33%; p=0.034), and cardiac arrest (56% vs. 37%; p=0.005).

Conclusion
Early changes in SCAI classification reflect the dynamic nature of CS patients while retaining significant prognostic discrimination. 24h SCAI re-staging together with risk modifiers may be valuable in readjusting therapeutic strategies aiming at shock reversal.
Impact of high-profile transvalvular pumps in heasrt failure related cardiogenic shock
Authors: Kanwar M , Kataria R , Hernandez-Montfort J , Sinha S , Garan A R , Li B , Zhang Y , Burkhoff D , Kapur N K 
Published: November 2023

Abstract

Background
Heart failure-related cardiogenic shock (HF-CS) not related to acute MI is a leading cause of CS.(1) Congestion is a major predictor of mortality among patients with HF-CS, for whom in-hospital mortality remains between 25-40%.(2,3) Both low-profile (Impella CP) and high-profile (Impella 5.0/5.5) transvalvular pumps are used to manage these patients. In the last few years, use of Impella 5.0/5.5 pumps in these patients is increasing, although it is often used as an escalation strategy from other temporary mechanical circulatory support (tMCS) devices.

Purpose
To assess the impact of LV unloading using high profile transvalvular pump (Impella 5.0/5.5) compared to a low-profile pump (Impella CP) on outcomes in HF-CS.

Methods
The Cardiogenic Shock Working Group (CSWG) is a large, multi-center international prospective registry of CS patients.(1) For this analysis, we retrospectively reviewed patients with HF-CS who underwent Impella 5.0/5.5 therapy for HF-CS and compared them to patients who underwent an Impella CP. Patients who received an Impella device as part of their escalation strategy from another device (IABP) or concomitant or de-escalation strategy with ECMO were excluded.

Results
Of the 2,755 patients with HF-CS, 125 patients received an Impella 5.0/5.5 while 152 patients received an Impella CP alone; 13 patients were escalated from an Impella CP to 5.0/5.5 pump. Of these 292 patients who either received an Impella CP or 5.0/5.5 or a combination of the two, 228(78%) were male, 208(71%) were white with a mean LVEF at presentation of 19%. About a third (n=78, 27%) presented with de-novo HF-CS while 214(73%) were acute on chronic HF-CS. In-hospital mortality in the entire HF-CS cohort was 717(26%). Unadjusted mortality was higher in those who underwent Impella CP alone (n= 57; 38%) compared to patients with Impella 5.0/5.5 (n=27, 23%; p=0.01). This improvement in mortality was seen in acute on chronic HF-CS with Impella 5.5/5.0 vs CP (41% vs 26%, p=0.02), and as a trend in de-novo HF-CS (30% vs 14%, p=0.13). More patients on Impella 5.0/5.5 went on to receive heart replacement therapies (durable LVAD or heart transplantation) compared to Impella CP (56% vs 9%, p&lt;0.001).

Conclusion(s)
Use of a high-profile transvalvular pump (Impella 5.0/5.5) was associated with improved mortality compared to a low-profile transvalvular pump (Impella CP) in HF-CS.
Characteristics and outcomes of combination VA-ECMO for cardiogenic shock
Authors: Hernandez-Montfort J , Kanwar M , Sinha S , Garan R A , Borui L , Zhang Y , Burkhoff D , Kapur N 
Published: November 2023

Abstract

Background
Use of VA-ECMO for cardiogenic shock is growing exponentially. The impact of VA-ECMO on in-hospital mortality among patients with CS due to heart failure or acute myocardial infarction remains poorly understood. Furthermore, the combination of VA-ECMO with IABP or Impella is also growing despite limited data supporting this approach. We sought to quantify in-hospital mortality among patients with CS due to HF or AMI in the presence or absence of concomitant IABP or Impella use.

Methods
We utilized the Cardiogenic Shock Working Group multi-center registry and focused on data obtained between 2021 and 2022. Patients managed with VA-ECMO alone, VA-ECMO and IABP or VA-ECMO and any left-sided transvalvular pump (Impella) were included in the analysis. Patients receiving IABP or Impella without VA-ECMO were excluded.

Results
Of the 1,634 CS subjects included in the analysis, 240 patients received VA-ECMO. 61.7% (n=148) were male. Mean age was 54.4±14.5. Baseline SCAI stage on admission for CS was Stage D (41.1%, n=76) and Stage E (46.0%, n=85). Among these patients, 5% (81), 4.5% (73), 5.9% (97) subjects received either VA-ECMO alone, VA-ECMO+IABP, or VA-ECMO+Impella respectively. In-hospital mortality among these groups for all cause CS, HF-CS, and MI-CS are shown in Figure 1A. In-hospital mortality among HF-CS stratified by acute on chronic HF (ACHF) or de novo HF are shown in Figure 1B. In-hospital mortality among HF-CS stratified by STEMI or Non-STEMI are shown in Figure 1C.

Conclusions
In-hospital mortality among VA-ECMO recipients for CS remains high and distinct among HF-CS and AMI-CS populations. Further research is needed in order to better understand the impact and trajectory of combined use of IABP or Impella with VA-ECMO among HF-CS and AMI-CS population.
Determinants of exercise-induced B-lines in asymptomatic severe aortic stenosis
Authors: D'Alfonso M G , Mori F , Ciampi Q , Saad A K , Zagatina A , Colonna P , Merli E , Van De Heyning C M , Agostini R , Russo M , Padang R , Pellikka P A , Picano E 
Published: November 2023

Abstract

Background
Guidelines recognize the role of exercise stress testing in evaluating functional capacity in patients with asymptomatic severe aortic stenosis (AS). Exercise stress echocardiography (ESE) allows the detection of pulmonary congestion with B-lines by lung ultrasound (LUS).

Aim
To identify the prevalence, determinants, and functional correlates of B-lines during ESE in asymptomatic severe AS.

Methods
We enrolled 35 asymptomatic patients (age= 69±16 years, 69% male) with severe AS, aortic valve area (AVA) &lt;0.6 cm2/m2, mean aortic gradient (MAG) ≥ 40 mmHg, left ventricular ejection fraction ≥55%. All patients were referred for ESE (treadmill in 1, bicycle in 34 patients) in 7 experienced centers from 4 countries between 2021-2022. ESE assessment at rest and peak stress included global longitudinal strain (GLS), left atrial volume index (LAVI) and cardiac output (CO). B-lines were assessed by simplified LUS from 4 lung zones across the third intercostal space (2 on each side). Heart rate reserve (HRR) was measured as the peak/rest heart rate. CO reserve was calculated as the difference between peak stress CO and rest CO.

Results
B-lines (≥2) were present in 2 patients at rest and in 15 patients during ESE (6% vs 43%, p&lt;0.001). When compared to patients without B-lines during ESE (Group 1, n=20), patients with B-lines during ESE (Group 2, n=15) were older (Group 1= 64±18 vs Group 2=75±8 years, p=0.030) had larger LAVI, higher logNT-pro-BNP and a trend to higher systolic pulmonary artery pressures (SPAP), see Table. The 2 groups showed similar values of resting AVA (Group 1= 0.52±0.11 vs Group 2=0.47±0.15 cm2/m2, p=0.311), stress AVA (Group 1= 0.45±0.09 vs Group 2=0.49±0.13 cm2/m2, p=0.663), resting MAG (Group 1= 45±15 vs Group 2=46±10 mm Hg, p=0.491), and stress MAG (Group 1= 59±19 vs Group 2=58±11 mm Hg, p=0.665). Patients with B-lines during ESE showed lower HRR and CO reserve, with a trend towards lower peak GLS, see Table.

Conclusions
Exercise-induced pulmonary congestion as evidenced by development of sonographic B- lines on LUS were present commonly (43%) among patients with "asymptomatic" severe AS undergoing ESE. Patients with exercise-induced B-lines have larger resting LAVI, higher NT-pro-BNP levels, lower CO reserve, and blunted HRR. Exercise-induced B-lines might provide an early sign of cardiac decompensation in "asymptomatic" patients with severe AS, which is an important factor to consider in the decision to intervene.TableFigure
Resting and stress coronary flow velocity for identification of different endotypes and risk classes in ANOCA patients beyond coronary flow velocity reserve
Authors: Gaibazzi N , Cortigiani L , Ciampi Q , Rigo F , Picano E 
Published: November 2023

Abstract

Background
Coronary microvasculature disease (CMD) affects a subset of patients with angina with no obstructive coronary arteries (ANOCA) and is diagnosed with transthoracic echocardiography (TTE) through a reduction (≤2.0) of coronary flow velocity reserve (CFVR), measured as the stress/rest coronary flow velocity (CFV) ratio.

Aim
To assess the dominant (functional vs structural, high-rest vs low-stress CFV) mechanism of CMD and the corresponding long-term risk.

Methods
In a prospective multicenter study design, we enrolled 1,033 patients (age 63±11 years, 533 women, 230 diabetics, ejection fraction 59±5%) with ANOCA. Recruitment (years 2004-2022) involved 4 accredited laboratories, with inter-observer variability &lt;10% for CFV. CFV was obtained with TTE by pulsed-wave Doppler in the mid-distal left anterior descending coronary artery at rest and after dipyridamole stress. All-cause death was the only end-point. A receiver operating characteristic analysis was used to obtain the best prognostic predictor, corresponding to &gt;32 cm/s for resting and ≤53 cm/s for peak stress CFV.

Results
289 patients (28%) showed a reduction in CFVR. Four groups were identified: normal rest and peak CFV (Group 1, n=465), abnormal rest and normal peak CFV (Group 2, n=350), normal rest and abnormal peak CFV (Group 3, n=210), abnormal rest and peak CFV (Group 4, n=8).
During a mean follow-up of 4.8±4.1 years, 82 (8%) patients died. Eight-year mortality was 4% in Group 1, 11% in Group 2, 15% in Group 3, and 58% in Group 4 (p&lt;0.0001). Yearly mortality was 2.3% in patients with isolated abnormal rest CFV as well as in those with isolated abnormal peak CFV (p=0.89) (Figure).

Conclusion
TTE allows phenotyping of the presence of CMD in the heterogeneous garden variety of ANOCA patients. High resting with reduced peak CFV is the less frequent, and by far more malignant, endotype.
The importance of vasodilator stress echocardiography in predicting all-cause mortality and acute heart failure in hypertrophic cardiomyopathy
Authors: Tesic M , Djordjevic-Dikic A , Aguiar Rosa S , Cortigiani L , Rigo F , Nemes A , Ciampi Q , Beleslin B , Viegas J , Palinkas E D , Olivotto I , Picano E 
Published: November 2023

Abstract

Background
Reduced coronary flow velocity reserve (CFVR) in the left anterior descending coronary artery (LAD) during vasodilator stress echocardiography (VSE) is a marker of poor outcome and is associated with higher baseline coronary flow velocity (CFV) in hypertrophic cardiomyopathy (HCM). However, whether resting CFV has additive predictive value to CFVR during VSE in HCM is unknown.

Aim
To assess the prognostic value of baseline CFV and CFVR during VSE in HCM.

Methods
325 adult HCM patients (age=52+15 years, 147 [45%] females) with preserved left ventricular function and no known coronary artery disease who underwent VSE in 6 certified centers between 1999 and 2021 were prospectively analyzed. VSE modality was adenosine (0.14 mg/kg/min in 2', n=232) or dipyridamole (0.84 mg/kg in 6', n=93). CFVR in the LAD was assessed by transthoracic (n=306) or transoesophageal (n=19) echocardiography. Patients were followed for a median of 67 months (IQ range 31-103 months), the primary endpoint was a composite of all-cause mortality and acute heart failure (HF).

Results
Receiver operating characteristic analysis was used to determine the best cut-off value of CFV (&gt;31 cm/s, elevated) and CFVR (≤2.0, reduced) to predict the primary endpoint. Patients with reduced CFVR had more frequently elevated baseline CFV (75% vs 49%, p&lt;0.001). Elevated resting CFV was a predictor of composite endpoint at univariable (HR 2.04, 95% CI 11.05-3.97, p=0.035) but not at multivariable analysis. A reduced CFVR was an independent predictor of all-cause mortality (HR 5.50, 95% CI 1.94-15.59, p=0.001), acute HF (HR 5.80, 95% CI 1.60-21.00, p=0.007), and the composite end-point (HR 4.95, 95% CI 2.39-10.25, p&lt;0.001). The 5-year event rate was 6-fold higher in patients with reduced CFVR compared to patients with preserved CFVR (19% vs 3%, p&lt;0.001), with no additional impact of resting CFV (see Figure).

Conclusion
LAD CFVR ≤2.0 during VSE is a strong and independent predictor of all-cause mortality and acute HF in HCM. Elevated resting CFV is more frequent in patients with reduced CFVR, but has no independent prognostic value when CFVR is considered.Kaplan-Meier event-free survival curves
Mechanical LV support lowers diastolic LV pressure and prolongs diastolic coronary flow in the infarcted artery
Authors: Sakata T , Mavropoulos S , Mazurek R , Romeo F , Ravichandran A , Marx J , Kariya T , Watanabe S , Ishikawa K 
Published: November 2023

Abstract

Background
Percutaneous left ventricular (LV) assist device provides not only circulatory support but also LV unloading. However, impact of LV unloading on coronary flow and mechanisms by which it is regulated remain unclear. We aimed to elucidate potential effects of LV unloading on coronary physiology in a pig model of myocardial infarction (MI).

Methods
First, six Yorkshire pigs underwent mechanical LV unloading using Impella two weeks after percutaneous MI induction. Regional blood flow (RBF) in infarct, border and remote myocardium were measured by fluorescent microsphere injections before and 120 min after LV unloading (Study 1). Next, we investigated coronary flow patterns with detailed temporal information. Six Yorkshire pigs were subjected to 90-minute balloon occlusion of the middle left anterior descending artery followed by reperfusion. At 60 minutes after reperfusion, LV unloading was initiated and maintained at maximal support. LV pressure, coronary flow and pressure in the infarcted artery were simultaneously recorded. Measurements were repeated with and without LV mechanical support. Coronary wave intensity was calculated from the flow/pressure data (Study 2).

Results
In Study 1, RBF calculated using microsphere was significantly increased only in the infarct area, but not in the border or remote areas. In Study 2, LV unloading resulted in lower LV pressure during the whole diastolic phase and higher coronary pressure during the late diastolic phase in all animals. Coronary flow velocity was higher throughout the diastole under LV unloading. In addition, the proportion of diastole to the whole cardiac cycle was significantly prolonged with LV unloading. Accordingly, area under the curve of coronary flow was increased during diastole and also for the whole cardiac cycle. In the wave intensity analysis, the magnitude of forward wave intensity was reduced by LV unloading, suggesting that the impact of forces from the aortic side was less significant under continuous device support. The duration between backward suction and pushing waves was extended, implicating earlier relaxation and delayed contraction, further supporting prolonged diastole from the myocardial force perspective.

Conclusions
Mechanical LV unloading increases coronary flow by prolonging diastolic phase in the infarcted artery.
Sex differences in 82Rubidium PET-derived myocardial flow reserve and implications for long-term cardiac outcomes
Authors: Hojstrup S , Hansen K , Talleruphuus U , Marner L , Bjerking L , Bouchelouche K , Wiinberg N , Jakobsen L , Guldbrandsen K , Galatius S , Prescott E 
Published: November 2023

Abstract

Introduction
Coronary small vessel disease (CMD), defined by reduced myocardial flow reserve (MFR) in the absence of obstructive coronary artery disease, holds prognostic information on major cardiac events (MACE). We aimed to investigate if the prognostic value of MFR is independent of sex.

Method
A multicenter registry-based study of 7169 consecutive patients referred to clinically 82Rubidium PET myocardial perfusion imaging. We excluded patients with abnormal perfusion (defects &gt;5% at rest or stress), previous revascularization, cardiomyopathy, or a diagnosis of heart failure. Global MFR≤2 was considered reduced. Patients were followed in registries for major adverse cardiac events (MACE) comprising all-cause mortality and admission for myocardial infarction, stroke, heart failure or unstable angina pectoris.

Results
A total of 2591 patients were included, 51% women, median age 69 [IQR 60-75] years. Women were older and men had a higher burden of cardiovascular risk factors. Overall, 31% had MFR≤2 (34% women vs 28% men, p&lt;0.001). Mean MFR was lower in women compared with men (2.30 (SD 0.66) vs 2.44 (0.70), respectively) with higher myocardial blood flow both at rest and during stress among women (both p&lt;0.001, Figure 1). In a linear regression model, sex remained associated with MFR after adjustments for age (p&lt;0.001). At 3-year follow-up, MACE was less frequent in women than men (7.0% vs 9.4%, p=0.03). MFR≤2 was associated with MACE with an age-adjusted hazard ratio (HR) of 1.83 (95% CI: 1.20-2.77, p&lt;0.01) in women and 1.75 (1.21-2.54, p&lt;0.01) in men (p for interaction 0.82). The association remained significant after adjustments for left ventricular ejection fraction and charlson comorbidity index with a HR of 1.58 (1.07-2.31, p&lt;0.05) in men and a HR of 1.68 (1.09-2.58, p&lt;0.05) in women (p for interaction 0.69). On a continuous scale, MFR per every 0.1 unit decrease remained significantly associated to MACE (Figure 2).

Conclusions
Among patients suspected of obstructive CAD, CMD is more prevalent among women than men. The increased hazard of adverse outcomes with CMD did not differ by sex. This study provides new insight into the phenotype and prognosis of patients with CMD.Figure 1:Baseline distribution of MFRFigure 2:HR for MACE
Left atrial dysfunction during stress in patients with atrial fibrillation
Authors: Rivadeneira Ruiz M , Zagatina A , Kalinina E , Begidova I , Ciampi Q , Lowenstein J , Arbucci R , Boshchenko A , Manganelli F , Celutkiene J , Peteiro Vazquez J , Borguezan-Daros C , Merli E , Wierzbowska-Drabik K , Picano E 
Published: November 2023

Abstract

Background
Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS).

Objective
This study sought to assess LA function at rest and during stress across the spectrum of AF.

Methods
In a prospective, multicentric, observational study design, we studied a cohort of 2391 patients (age=67±12 years; 1459, 61% male): 2142 (89.6%) were in sinus rhythm (SR, Group 1), 165 (6.9%) had a history of paroxysmal AF (Group 2) and 84 (3.5%) were in permanent AF (Group 3). All patients were referred for CCS and underwent stress echocardiography (SE) with exercise (n=1092, 45.3%), dobutamine (n=320, 13.4%) or vasodilators (n= 989, 40.3%: dipyridamole n=963 and adenosine n=26). Left atrial volume index (LAVI) and LA reservoir strain (LASr) were assessed at rest and peak stress. Analysis with different vendors was performed offline on anonymized cine-loops by observers unaware of the study hypothesis.

Results
The progressive increase in LA dysfunction from Group 1 to 3 was accompanied by greater signs of pulmonary congestion and LV dysfunction (see Table 1). In particular, LASr progressively decreased from Group 1 to 3, both at rest and during stress, regardless of the stress employed (see Figure 1).

Conclusions
LA reservoir function can be easily assessed with deformation imaging at rest and during exercise or pharmacological stress echocardiography. LA dysfunction progressively increases from SR to paroxysmal to permanent AF and is associated with more important LV systolic dysfunction, LV filling pressure, and pulmonary congestion in CCS.Table 1.Echocardiographic parametersFigure 1.LAVI and LASr at rest and peak