bluuebunny/crossref_metadata_2025_split huggingface dataset:
Improving assessment of different flow state of aortic stenosis: implication for prognosis in patients undergoing transcatheter aortic valve replacement
Authors: Fusini L , Muratori M , Tamborini G , Ghulam Ali S , Gripari P , Mantegazza V , Roberto M , Trabattoni P , Agrifoglio M , Bartorelli A L , Pontone G , Pepi M 
Published: October 2022

Abstract

Background
Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (EF), and both situations represent the most challenging subset of patients with AS to manage and generally have a poor prognosis with conservative therapy but a high operative mortality if treated surgically. Few and controversial data exist on the outcomes of these patients compared to normal-flow high-gradient (NF-HG) AS following transcatheter aortic valve replacement (TAVR).

Purpose
This study aims to better characterize patients with different transvalvular flow-gradient patterns undergoing TAVR and to examine the prognostic value of these flow state.

Methods
Overall, 1208 patients with severe symptomatic AS undergoing TAVR were categorized according to flow-gradient patterns as follow: 976 patients NF-HG (DPmean &gt;40 mmHg), 107 paradoxical LF-LG (pLF-LG: DP mean &lt;40 mmHg, EF &gt;50%, and SVi &lt;35 mL/m2), and 125 classical LF-LG (DP mean &lt;40 mmHg, EF &lt;50%, SVi &lt;35 mL/m2).

Results
TAVR was feasible in all AS subtypes. When compared with NF-HG and pLF-LG, LF-LG had a worse symptomatic status (NYHA III–IV 86% vs 62% and 67%, respectively, p&lt;0.001), a higher prevalence of eccentric hypertrophy (Figure 1, left), a higher level of LV global afterload reflected by a higher valvuloarterial impedance and a higher pulmonary pressure (Table). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group. While intraoperative (p=0.935) and 30-day mortality (p=0.911) did not differ significantly among the 3 groups, LF-LG had a lower overall 5-year survival (LF-LG 50%, pLF-LG 65%, NF-HG 84%, p&lt;0.001) (Figure 1, right). LF-LG AS was associated with a hazard ratio for 5-year mortality of 2.416 (95% CI: 1.658–3.520, p&lt;0.001).

Conclusions
TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rate than patients with NF-HG, whereas survival in LF-LG patients was 2-fold higher. Therefore, being able to identify patients less likely to improve after TAVR may help to guide treatment decision.

Funding Acknowledgement
Type of funding sources: None.
Extent and determinants of dynamic mitral regurgitation unmasked by handgrip exercise in patients with primary mitral regurgitation
Authors: Spieker M , Lagarden H , Sidabras J , Veulemans V , Akhyari P , Horn P , Kelm M , Westenfeld R 
Published: October 2022

Abstract

Background
Bicycle exercise is the exercise modality of choice to unmask the dynamic nature of mitral regurgitation (MR). Handgrip exercise may serve as alternative exercise intervention, as it can be performed physically accomplished by the majority of patients. Until now, there are only scarce data on the prevalence and magnitude of dynamic MR during handgrip exercise.

Purpose
To assess extent and predictors of exercise-induced dynamic MR during handgrip exercise in patients with primary MR.

Methods
We prospectively included patients with primary MR and at least mild severity that underwent echocardiography at rest and during three minutes of handgrip exercise according to a standardized protocol.

Results
The final patient cohort included 166 patients. Mean age was 72±12 years, 57% were female and 53% had atrial fibrillation. At rest, MR severity was graded as mild in 57% of patients, moderate MR in 27% and severe in 16%. Handgrip exercise led to an increase in at least one grade in MR severity in 31 patients (19%), while 15 patients (9%) experienced a decrease of MR severity (Fig. 1B). Twenty patients (14%) of those with non-severe MR at rest, developed severe MR during handgrip exercise (Fig. 1B). According to a pre-defined cutoff of increase in effective orifice regurgitant area (EROA) &gt;10 mm2 during exercise, 19% of patients revealed a marked exercise-induced increase in MR, irrespective of the severity of MR at rest. Patients with marked exercise-induced increases in MR severity (EROA &gt;10 mm2) had elevated left- (53±22ml/m2 vs. 44±19ml/m2; p=0.036), and right atrial volumes (43±19ml/m2 vs. 34±18ml/m2; p=0.014), more often pathology of the anterior mitral leaflet (e.g. prolapse; flail leaflet) (65% vs. 33%; p&lt;0.001), and increased mitral annulus diameter (38±5mm vs. 36±4mm; p=0.003). The exercise-induced changes in EROA correlated with changes in estimated systolic pulmonary pressure from rest to exercise (r=0.438 (0.287 to 0.568); p&lt;0.001) (Fig. 1C).

Conclusion(s)
In patients with primary MR, handgrip echocardiography unmasks marked exercise-induced increases of MR severity in every fifth patient independent of the severity at rest. A relevant number of patients with non-severe MR at rest developed severe MR during exercise. Dynamic MR is associated with bi-atrial dilatation, increased mitral annulus diameter, and pathology of the anterior mitral valve leaflet. Moreover, changes in MR severity during handgrip exercise correlate with changes in pulmonary pressures.

Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich Heine University Düsseldorf Maximilian Spieker for a Clinician Scientist Track.
Development and validation of a diagnostic echocardiographic mass (DEM) score in the complex approach to cardiac masses
Authors: Angeli F , Paolisso P , Magnani I , Fabrizio M , Rinaldi A , Armillotta M , Stefanizzi A , Amicone S , Tattilo F P , Suma N , Bodega F , Canton L , Galie N , Foa A , Pizzi C 
Published: October 2022

Abstract

Background
Cardiac masses (CM) are an extremely heterogeneous clinical entity, including benign and malignant neoformations. 2D Echocardiography is nowadays the first-line approach to define nature and management of CM.

Purpose
The purpose of our study was to identify the echocardiographic predictors of malignancy and create a multiparametric score to further increase the diagnostic yield and accurately suggest the nature of CM.

Material and methods
249 consecutive patients undergoing a complete echocardiographic assessment for suspected cardiac mass were enrolled from January 2004 to December 2020. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. Logistic regression was performed to evaluate the ability of echocardiography to discriminate benign versus malignant masses.

Results
A scoring system was developed in a derivation cohort of 178 (70%) and validated in 71 (30%) patients. A weighted score [Diagnostic Echocardiographic Mass (DEM) Score] ranging from 0 to 9 was obtained from 6 variables: infiltration, polylobate mass, moderate-severe pericardial effusion, inhomogeneity, sessile and non-left localization. The AUC for the score was 0.965 (95% CI 0.938–0.993). In a logistic regression analysis using the DEM score as a predictor, the likelihood of malignancy increased more than 4 times for a 1-unit increase of the score (OR=4.468; 95% CI 2.733–7.304). The prognostic validity of the score was confirmed by its ability to predict survival during follow-up (median time of 31 months).

Conclusions
The application of a multiparametric echocardiographic score in the approach to CM accurately predicts mass malignancy thereby reducing the need for second-level investigations, and minimizing the diagnostic delay in such a complex clinical scenario.

Funding Acknowledgement
Type of funding sources: None.
Utility and futility of MitraClip implantation in secondary mitral regurgitation in a real-world population: the role of 3D transthoracic echocardiography
Authors: Mantegazza V , Muratori M , Ghulam Ali S , Garlasche' A , Gripari P , Fusini L , Vignati C , De Martino F , Agostoni P , Ferrari C , Bartorelli A L , Pontone G , Pepi M , Tamborini G 
Published: October 2022

Abstract

Introduction
Two recent prospective trials have been published, reporting opposite results on the efficacy and utility of the MitraClip (MC) procedure in patients with secondary mitral regurgitation (SMR). A ratio between the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV) ≥0.150 by two-dimensional (2D) transthoracic echocardiography (TTE) has been proposed to identify patients with disproportionate SMR, who would benefit from MC.

Purpose
To assess the prognostic role of clinical and echocardiographic parameters in a real-world population of SMR patients undergoing the MC procedure at our Institute.

Methods
Ninety-two patients underwent MC implantation. We retrospectively reviewed their clinical, and laboratory data, as well as 2D and three-dimensional (3D) TTE, and intraoperative transoesophageal echocardiography (Figure 1). The primary endpoint was a composite of cardiovascular death and/or hospitalisation for heart failure within 12-months follow-up.

Results
Thirty-one patients reached the endpoint (EP+), 61 did not (EP−). Demographics and anti-remodelling drugs were similar in EP+ and EP. Among comorbidities and laboratory data, EP+ significantly differed from EP− in smoking history, and extracardiac artery disease prevalence (65% vs. 39%, and 39% vs. 16%, respectively); EuroScoreII (12.2% vs. 5.2%); NYHA class ≥3 (94% vs. 69%); haemoglobin (12±2 vs. 13±2 g/dL), and brain natriuretic peptide levels (855 [426–1500] vs. 357 [170–902] pg/mL). At 2D TTE no significant difference emerged, including the SMR grade, except for the tricuspid annular plane systolic excursion (Figure 2). Biventricular 3D ejection fraction was significantly lower in EP+ vs. EP− (Figure 2). Residual intraoperative SMR grade after MC deployment was 1.9±0.6 in EP+ vs. 1.3±0.5 in EP− (p&lt;0.001).

Conclusion
The proposed cut-off for EROA/LVEDV ratio may be suboptimal for predicting the MC utility in real-world populations. Rather, prognosis may be more influenced by the patient's pre-operative clinical status, right ventricular systolic function, 3D left ventricular ejection fraction, and by the success of the procedure.

Funding Acknowledgement
Type of funding sources: None.
Supine ergometry for aged population with degenerative mitral regurgitation: evidence for prognostic yield
Authors: Armenis I , Demerouti E , Motsi A , Kyrzopoulos S , Tsiapras D , Athanassopoulos G 
Published: October 2022

Abstract

Introduction
Degenerative mitral regurgitation (MR) has an increased prevalence with aging with risk stratification evolving as a complex scenario. Semisupine bicycle ergometry (SBE) is a currently applied means to interrogate noninvasive hemodynamics.

Aim
Aim of the study was to interrogate prognostic parameters by SBE in asymptomatic moderate to severe degenerative MR for patients older than 65 years.

Patients and methods
One hundred seventy-four asymptomatic MR patients (pts), followed up on valve clinic in a tertiary center (age 56/14 female 71), were referred for SBE. MR related cardiac events (surgery, NYHA worsening) during follow up of 34/25 months occurred in 24 pts. Age group &gt;65 had 53 pts (age 71/4 vs 50/13 &lt;0.001, females 36% vs 43%). The following parameters (mean/SD) were estimated at rest (R) and SBE (Ex): Biplane left ventricular (LV) ejection fraction (EF), stroke volume (SV), 2D LV strain (SR), tricuspid peak gradient (TRpg), transmitral E/e, HR, systolic blood pressure (SBP), HR*SBP product and their respective % changes (%d).

Results
Group &gt;65 during SBE had a decreased workload (Watts: 74/22 vs 89/18, p&lt;0.001), similar % achieved target heart rate (73/11 vs 69/10), with more symptoms (30% vs 16%, p&lt;0.01). Event rate was greater (30% vs 7%, p&lt;0.001). Group aged&gt;65 had differences in SBPR (145/20 vs 132/19, p&lt;0.002), SREx (20/4 vs 21/5, p&lt;0.04), EFEx (64/9 vs 68/6, p&lt;0.01), TRpgR (34/11 vs 27/6, p&lt;0.001), TRPG Ex (55/13 vs 50/10, p&lt;0.02), E/eEx (14/6 vs 11/3, p&lt;0.006), %dSV (0.01/0.23 vs 0.14/0.25, p&lt;0.001) and %dEF (0.12/0.08 vs 0.15/0.11, p&lt;0.03). In stepwise logistic regression analysis for events, E/eEx was the only selected (log exp 0.89, p&lt;0.05). Classification for events by ROC analysis gave a E/eEx cut off 13 (area 0.67, p=0.01) with sensitivity/specificity 50/80%. Kaplan Meier analysis revealed prognostic contribution for E/eEx &gt;13 only in the age &gt;65 (log rank p&lt;0.04, Figure 1). Moreover, symptomatic SBE had a decisive prognostic contribution in the aged cohort (Kaplan-Meier log rank = 0.004, Figure 2).

Conclusion
SBE may be applied with an efficient performance in the older then 65 years age spectrum, within the context of asymptomatic moderate to severe degenerative MR, providing critical information for risk stratification

Funding Acknowledgement
Type of funding sources: None.
Correlation between NT-proBNP and pulmonary hypertension in patients with asymptomatic pirmary mitral regurgitation and preserved left ventricular ejection fraction
Authors: Dirsiene R , Tamulenaite E , Montvilaite A , Ereminiene E , Vaskelyte J J 
Published: October 2022

Abstract

Background
Pulmonary hypertension (PH) is a significant complication of mitral regurgitation (MR), leading to worse outcomes [1]. PH is not prominent at rest during an early stage of MR, but could be induced during stress. Elevated levels of natriuretic peptides are related to subclinical myocardial injury [2,3] including elevated systolic pulmonary artery pressure (SPAP) and it has a prognostic impact in patients with primary MR [4,5].

Aim
The aim of this study was to evaluate correlation between NT-proBNP and SPAP at rest and during stress in asymptomatic patients with primary MR and preserved left ventricular ejection fraction.

Methods
Resting and stress (veloergometry as per protocol 25+25 W every 3 minutes) 2D transthoracic echocardiography was performed for 60 asymptomatic patients (age 61.45±11.99 years) with moderate–severe MR and preserved left ventricular ejection fraction (&gt;60%) at rest. According to the presence of exercise induced pulmonary hypertension ((EIPH) SPAP &gt;60 mmHg during stress) patients were divided into PH (n=20, 33.33%) and non-PH (n=40, 66.67%) groups. Statistical analysis was performed using the SPSS 27.0 software. The value of p&lt;0.05 was considered as statistically significant.

Results
Age, gender ratio, clinical characteristics, LV volume and diameter indexes, RV size and conventional functional parameters were similar in both groups. NT-proBNP concentration was significantly higher in PH group than in patients without EIPH (261.50 [138–543] pg/ml vs. 92 [58.95–149.50] pg/ml, p=0.002). Also, NT-proBNP concentration has significant moderate correlation with SPAP at rest (r=0.599, p&lt;0.001) and during peak stress (r=0.652, p&lt;0.001). NT-proBNP &gt;122 pg/ml could predict the presence of EIPH with 91.7% sensitivity and 66.7% specificity in patients with primary moderate–severe MR with preserved left ventricular ejection fraction (Picture 2).

Conclusions
In patients with primary moderate-severe MR and preserved left ventricular ejection fraction, higher levels of NT-proBNP correlated with higher SPAP at rest and during stress and was related to EIPH. NT-proBNP &gt;122 pg/ml is a sensitive predictive value of EIPH in cases of primary MR and preserved left ventricular ejection fraction.

Funding Acknowledgement
Type of funding sources: None.
Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve intervention
Authors: Tanaka T , Sugiura A , Kavsur R , Oeztuerk C , Vogelhuber J , Kuetting D , Meyer C , Zimmer S , Grube E , Bakhtiary F , Nickenig G , Weber M 
Published: October 2022

Abstract

Background
The role of right-ventricular (RV) function in patients with tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI) is poorly understood. Although cardiac computed tomography (CCT) provides elaborate three-dimensional (3D) visualization of the entire anatomy of the RV and theoretically allows to assess the global RV systolic function. Nevertheless, the utility of the functional assessments of the RV using CCT remains unclear in patients undergoing TTVI.

Purpose
This study investigated the association of right-ventricular ejection fraction (RVEF) assessed by CCT with clinical outcome in patients undergoing TTVI.

Methods
We retrospectively assessed 3D-RVEF by using pre-procedural CCT images in patients undergoing TTVI with either edge-to-edge repair or annuloplasty device. RV dysfunction (RVD) was defined as a CT-RVEF &lt;45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within one year after TTVI.

Results
Of 157 patients, 58 (36.9%) presented with CT-RVEF &lt;45%. Patients with CT-RVEF &lt;45% were more likely to be male, to have a previous history of coronary artery disease, and had higher EuroSCORE II and a lower LVEF compared to those with CT-RVEF ≥45%, while the severity of TR was comparable between the groups.
Among the patients with CT-RVEF &lt;45%, acute procedural success was achieved in 93.1%, and in-hospital mortality was 1.7%, which were comparable to those with CT-RVEF ≥45%.
Patients with CT-RVEF &lt;45% had an improvement in New York Heart Association functional class at follow-up compared to baseline; however, CT-RVEF &lt;45% was associated with a higher risk of the composite outcome (adjusted hazard ratio: 3.23; 95% confidence interval: 1.52–6.88; p=0.002) (Figure 1). Furthermore, CT-RVEF had an additional value to stratify the risk of the composite outcome beyond two-dimensional transthoracic echocardiographic (TTE) assessments (Figure 2).
In addition, patients with CT-RVEF &lt;45% exhibited an attenuated association between a reduction in TR to &lt;3+ and a lower incidence of the composite outcome after TTVI compared to those with CT-RVEF ≥45%.

Conclusions
TTVI is safe and feasible regardless of baseline RV function, while RVD, defined as 3D-RVEF &lt;45%, is associated with a higher risk of the composite outcomes within one year after TTVI. Furthermore, our findings suggest that the prognostic benefits of TR reduction might be attenuated in patients with RVD. Given the additional prognostic value of CT-RVEF to the conventional echocardiographic assessments, the assessments of 3D-RVEF with CCT may refine the patient selection for TTVI.

Funding Acknowledgement
Type of funding sources: None.
A streamlined, machine learning-derived approach to risk-stratification in heart failure patients with secondary tricuspid regurgitation
Authors: Heitzinger G , Spinka G , Koschatko S , Dannenberg V , Halavina K , Mascherbauer K , Winter M P , Strunk G , Pavo N , Kastl S , Huelsmann M , Rosenhek R , Hengstenberg C , Bartko P E , Goliasch G 
Published: October 2022

Abstract

Background
Secondary tricuspid regurgitation (sTR) is the most frequent valvular heart disease and has significant impact on mortality. A high burden of comorbidities often worsens the already dismal prognosis of sTR, while tricuspid interventions remain underused and initiated too late.

Objectives
To examine the most powerful predictors of all-cause mortality in moderate and severe sTR using machine learning techniques and to provide a streamlined approach to risk-stratification using readily available clinical, echocardiographic and laboratory parameters.

Methods
This large-scale, long-term observational study included 3359 moderate and 1509 severe sTR patients encompassing the entire heart failure spectrum (preserved, mid-range and reduced ejection fraction). A random survival forest was applied to investigate the most important predictors and group patients according to their number of adverse features (Figure 1).

Results
The identified predictors and thresholds, that were associated with significantly worse mortality were higher age (≥75 in moderate and ≥70 years in moderate and severe sTR respectively), higher NT-proBNP (≥4000 pg/ml), increased high sensitivity C-reactive protein (≥1.0 mg/dl), serum albumin &lt;40 g/L and hemoglobin &lt;13 g/dL. Additionally, grouping patients according to the number of adverse features yielded important prognostic information, as patients with 4 or 5 adverse features had a sevenfold risk increase in moderate sTR (7.11 [2.27–4.30] HR 95% CI, P&lt;0.001) and fivefold risk increase in severe sTR (5.08 [3.13–8.24] HR 95% CI, P&lt;0.001) (Figure 2: A moderate sTR derivation, B moderate sTR validation, C severe sTR derivation, D severe sTR validation).

Conclusion
This study presents a streamlined, machine learning-derived and internally validated approach to risk-stratification in patients with moderate and severe sTR, that adds important prognostic information to aid clinical decision-making.

Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund
The 4A classification for patients with tricuspid regurgitation
Authors: Gonzalez Gomez A , Hinojar R , Fernandez-Golfin C , Monteagudo J M , Garcia-Martin A , Gacia-Sebastian C , Garcia-Lunar I , Sanchez-Recalde A , Salido L , Pardo A , Zamorano J L 
Published: October 2022

Abstract

Background
Significant Tricuspid Regurgitation (TR) is associated with increased morbi-mortality. Clinical evaluation of TR patients is challenging.

Purpose
To establish a new clinical classification specific for patients with TR, the 4A classification, and evaluate its performance on prognosis.

Methods
Consecutive patients with isolated at least severe TR and absence of episodes of heart failure (HF) evaluated in the Heart Valve Clinic were included. Signs and symptoms of Asthenia, Ankle swelling, Abdominal pain or distention and/or Anorexia where registered, follow up was performed every 6 months. 4A classification ranged from A0 (no A) to A4 (three or four A's present). A combined endpoint of hospital admission due to right HF and cardiovascular mortality was defined.

Results
135 patients with significant TR between 2016 and 2021 were included (69% females, mean age was 78±7 years). During a median follow-up of 26 months (IQR: 10–41 months), n=53 patients (39%) reached the combined endpoint. 52 (38%) admitted for heart failure and 11% (n=15) died. At baseline 94% of patients were in NYHA I or II whereas 24% presented A2 or A3. The presence of A2 or A3 showed a high incidence of events (figure). The change in 4A class and GGT remained independent predictor of HF and cardiovascular mortality (adjusted HR per unit of change of 4A class 1.95 [1.37–2.77], p&lt;0.001)

Conclusions
For the first time, we show the use of a new clinical classification, specific for patients with TR based on signs and symptoms of right HF that is prognostic of events.

Funding Acknowledgement
Type of funding sources: None.