Prognostic value of left ventricular myocardial work indices in patients undergoing transcatheter aortic valve replacement

Introduction

Left ventricular myocardial work (LVMW) is a novel echocardiographic-based method to assess LV function using pressure-strain loops taking LV afterload into account. In patients with aortic stenosis (AS), this approach was shown to improve assessment of LV performance as compared to conventional and advanced parameters of LV systolic function, but data on its prognostic value are lacking.

Purpose

To evaluate the prognostic value of LVMW indices in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR).

Methods

LVMW indices, including LV global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were calculated in 281 patients with severe AS (age 82, IQR 78–85 years, 52% male) prior to the TAVR procedure. As previously validated, LV systolic pressure was derived non-invasively by adding the mean aortic gradient to the brachial systolic pressure. LV global longitudinal strain and LV systolic pressure were then incorporated to construct pressure-strain loops to determine the LVMW indices. The study endpoint was all-cause mortality.

Results

In the total population average GWI was 1872±753 mmHg%, GCW 2240±797 mmHg%, GWW 200 (IQR 127–306) mmHg% and GWE 89 (IQR 84–93)%. During a median follow-up of 52 (IQR 41–67) months, 64 patients died. These patients showed lower values of GWI (1644 vs 1940 mmHg%, p=0.006) and GCW (2010 vs 2307 mmHg%, p=0.009) as compared to patients who survived while GWW (197 vs 200 mmHg%, p=0.794) and GWE (88% vs 90%, p=0.102) were similar. While LV GCW, GWW and GWE did not show a significant association with the study endpoint, GWI was independently associated with all-cause mortality (HR per-tertile-increase 0.639; 95% CI 0.463–0.883; P=0.007), and the patients in the lowest GWI tertile showed the worst survival rates (Figure 1). Of interest, patients in the lowest GWI tertile were more likely to be male (63% vs 56% and 37% from the lowest to the highest tertile, P=0.001), had a higher prevalence of atrial fibrillation (26% vs 19% and 8% from the lowest to the highest tertile, P=0.006), worse renal function (53 mL/min/1.73 m2 vs 64 mL/min/1.73 m2 and 62 mL/min/1.73 m2 from the lowest to the highest tertile, P=0.038) and larger LV dimension (LVEDD 52 mm vs 47 mm and 46 mm from lowest through highest tertile, p<0.001). Importantly, when added to a basal model, LVGWI yielded a higher increase in predictivity compared to both conventional and advanced parameters of LV systolic function (Figure 2). Also, in a model corrected for the hemodynamic class of AS (high-gradient, low-flow low-gradient), GWI also showed a significant independent association (P=0.003) with all-cause mortality.

Conclusions

LVGWI is independently associated with all-cause mortality in patients undergoing TAVR and has a higher prognostic value compared to both conventional and advanced parameters of LV systolic function.

Funding Acknowledgement

Type of funding sources: None.

C40 THREE–DIMENSIONAL FINGER TEST: A NEW ECHOCARDIOGRAPHIC METHOD TO LOCATE THE BEST ACCESS SITE DURING NEOCHORD PROCEDURE

Background

The NeoChord procedure is a trans–ventricular, beating–heart chordal implantation for severe degenerative mitral valve regurgitation due to prolapse or flail leaflet and it is performed using a dedicated device (DS 1000 system, NeoChord, Inc. St. Louis Park, MN). The use of the transesophageal echocardiography (TEE) is crucial to guide the procedure. Bi–dimensional (2D) imaging completed with simultaneous biplane view during surgeon finger pushing on the LV wall (finger test) is currently used to choose the LV access, which is usually on the mid–distal infero–lateral wall (ILW), between the papillary muscles (PMs) at the inferior level of their insertion on LV wall. This simulation helps the operators to evaluate the safe distance to PMs to minimize the risk of damaging the sub–valvular apparatus during the insertion of the device. We aimed to compare a new 3D method with the conventional one in terms of safety and better localization of the desired entry site.

Methods

During the procedure finger test has been performed with conventional 2D imaging and simultaneous biplane method. It has been completed using the real time 3D TEE placing the sample box in the bi–commissural view of the LV including the PMs and the apex. The resulting 3D volume was subsequently edited to visualize the LV from above (surgical view) to localize the bulge of the operator finger pushing on the desired segment of the LV wall. We asked the first operator, the second operator and the cardiac surgery fellow, separately, to evaluate location of their finger pushing, in terms of desired position and safety of access, both with 2D method and the 3D method to estimate the inter–operator concordance.

Results

From March 2019 to September 2021 42 consecutive cases have been performed using finger test completed with 3D method without complications related to the trans–ventricular access. Regarding the choice of the right and safe entry site, the percentage of agreement between operators was higher using LV real time 3D rendering compared to the conventional finger test [82 + 21% Vs 59% + 29%, IC 95%, p: 0,04].

Conclusion

Three–dimensional finger test is easy to perform and decreases inter–operator variability of image interpretation facilitating the surgeons to choose the best entry site in term of anatomical localization and safety.

Left atrioventricular coupling index in hypertrophic cardiomyopathy and risk of new-onset atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

 In patients with hypertrophic cardiomyopathy (HCM) accurate risk stratification for new onset atrial fibrillation (AF) has important prognostic implications. Left atrioventricular coupling index (LACI) has been recently associated with the occurrence of AF in patients without history of cardiovascular disease.

Purpose

The objective of this study was to investigate the association between LACI and new onset AF in HCM patients and its incremental value over conventional left atrial (LA) parameters.

Methods

A total of 373 HCM patients without history of AF (48 ± 17 years, 66% men) were evaluated by transthoracic echocardiography. LACI was defined by the ratio of the LA end-diastolic volume divided by the LV end-diastolic volume. The cut-off value for LACI (≥40%) to identify LA-left ventricular (LV) uncoupling was chosen based on the risk excess of new-onset AF described with a spline curve analysis. Cox proportional hazard models were used to evaluate the association between LACI and the occurrence of AF.

Results

The median LACI was 38% (interquartile range: 24-56) and LA-LV uncoupling (LACI ≥40%) was observed in 171 (45.8%) patients. During a mean follow-up of 11.0 ± 5.6 years, 118 subjects (31.6%) developed new-onset AF. The cumulative event-free survival at 10 years was 53% for patients with LA-LV uncoupling (LACI ≥40%) versus 94% for patients without LA-LV uncoupling (LACI <40%) (p < 0.0001; Figure 1). Multivariable analysis showed an independent association between new-onset AF  and LA maximum volume indexed (LAVImax) (hazard ratio [HR], 1.03; 95% CI, 1.02–1.04), LA minimum volume indexed (LAVImin) (HR, 1.04; 95% CI, 1.03–1.05), LA emptying fraction (HR, 0.97; 95% CI, 0.96–0.98) and LACI (HR, 1.02; 95% CI, 1.01–1.02; all p < 0.0001). The inclusion of LACI in the multivariate model provided larger improvement in the risk stratification for new-onset AF, as compared to conventional LA parameters (Figure 2). Furthermore, the likelihood ratio test demonstrated incremental value of LACI assessment on the top of the multivariate model including LAVImin to predict new-onset AF (p = 0.02), while the addition of LAVImin did not improve the risk discrimination of the multivariate model including LACI (p = 0.36).

Conclusion

Greater LACI, indicative of LA-LV uncoupling, was independently associated with the occurrence of new-onset AF in patients with HCM and demonstrated a stronger risk discrimination power compared to conventional LA parameters. This simple ratio may be easily implemented in clinical practice to improve risk stratification for new-onset AF in HCM. Abstract Figure. Incident AF according to LACI  Abstract Figure.

In-hospital outcomes in nonagenarian patients undergoing primary percutaneous coronary intervention

Objective

The aim of the present analysis was to evaluate the incidence and predictors of in-hospital adverse outcomes in nonagenarian patients undergoing primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI).

Methods

Consecutive nonagenarian patients undergoing pPCI for STEMI from 2009 to 2019 were retrospectively included in an international multicenter registry. In-hospital all-cause death was the primary outcome.

Results

A total of 308 patients were included (mean age 92.5±2.5 years, 65.6% female). Mean systolic blood pressure (SBP) at hospital admission was 130.7±33.5 mmHg, 46 (17%) patients presented with a Killip class III-IV, mean left ventricle ejection fraction (LVEF) was 40.0±11.5% and 147 (58%) patients were independent in everyday activities. In-hospital death occurred in 99 patients (32%). [Figure 1] After multivariate adjustment, lower LVEF (OR per unit reduction 1.08, 95% CI 1.03–1.11, p-value <0.001), lower SBP (OR 0.98 per mmHg reduction, 95% CI 1.01–1.03, p-value 0.001) and being not independent at home (OR 2.56, 95% CI 1.25–5.26, p-value 0.01) resulted independent predictors of in-hospital mortality. [Figure 2] A sensitivity analysis performed in final TIMI 3 flow population confirmed the prognostic role of LVEF and independency on in-hospital mortality.

Conclusion

Nonagenarian patients presenting with STEMI and undergoing pPCI have high in-hospital mortality. Independency in everyday life is a strong independent predictor of survival to hospital discharge.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Prognostic impact of achieving LDL cholesterol guidelines-recommended target in secondary prevention: a real-world study

Background

Lipid management plays a key role in secondary prevention after acute coronary syndrome. The 2019 European Society of Cardiology guidelines recommend a more ambitious target than the previous guidelines version (i.e., to achieve LDL cholesterol [LDL-C] <55 mg/dL, and to reduce it ≥50% form baseline vs LDL-C<70 mg/dl or reduced ≥50% form baseline). Currently, data on the reduction of cardiovascular events in patients achieving the 2019 goals in a real-world population are missing.

Purpose

The aim of this study was to determine the risk of major adverse cardiovascular events (MACE) during follow-up in post myocardial infarction (PMI) patients according to the achievement of the guidelines-recommended goals in terms of LDL-C reduction.

Methods

We conducted a retrospective analysis of a monocentric observational registry prospectively enrolling patients admitted to our hospital for ST segment elevation myocardial infarction and followed-up in our dedicated PMI ambulatory. The analysis considered the patients enrolled between January 2011 and February 2019. Demographical and clinical data were extracted from a dedicated digital database, and the clinical events occurred during follow-up were obtained by telephone interviews or clinical records. We considered a combined endpoint of MACE defined as all-cause death, non-fatal MI, non-fatal stroke and unplanned revascularization. LDL-C was collected at baseline and at 1, 6 and 12 months after the event. The lower value collected at follow-up was used to define the achievement of the target goals. We conducted a Kaplan-Meier analysis and log-rank test comparing patients who achieved LDL-C <55 mg/dL and ≤50% from baseline (group 2019) vs those with LDL-C <70 mg/dL or ≤50% from baseline (group 2016). Continue variable are presented as median (interquartile range).

Results

A total of 1201 patients (23% female) were included in our analysis. Median age was 63 (54–72) years, 56% had hypertension, 17% diabetes, and 38% were smoker. Baseline LDL-C was 123 (97–148) mg/dL, the median LDL-C at follow-up was 63 (52–78) mg/dL, significantly reduced from baseline (P<0.0001). Between 6 and 12 months 83% of patients were treated with statin therapy alone (73% high intensity), and 17% with the addition of ezetimibe. The 2016 target was achieved in 828 patients (69%), while 270 patients (22.5%) obtained also the 2019 target. Median follow-up was 60 (40–77) months. The net incidence of MACE was 12.9% in group 2019 vs 23.7% in group 2016 (HR 0.61; 95% CI 0.42–0.88; P log-rank=0.0087; Number Needed to Treat=9; see Figure).

Conclusion

Our data from a real-world cohort of PMI patients emphasize the importance of achieving the guideline-recommended secondary prevention goals of LDL-C<55 mg/dl and ≤50% from baseline in order to reduce MACE.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular remodeling and prognostic relevance after ST-segment elevation myocardial infarction in patients treated with primary percutaneous coronary intervention

Background

ST-segment elevation myocardial infarction (STEMI) often involves changes in right ventricular (RV) function and size over time. However, the prognostic implications of RV remodeling after STEMI are unknown. The aim of current study was to characterize RV remodeling in post-STEMI patients and to investigate it's prognostic relevance.

Methods

RV remodeling in post-STEMI patients who underwent primary percutaneous coronary intervention (PCI) was defined by RV end-systolic area (RV ESA) change at 6 months after STEMI, compared to baseline. The optimal threshold of RV ESA change (≥40%) to define RV remodeling was derived from spline curve analysis (Figure 1A). The primary endpoint was the composite of all-cause mortality and heart failure (HF) hospitalization. Long term outcomes were compared between patients with and without RV remodeling by means of a log rank test.

Results

A total of 2280 patients were analyzed (mean age 60±11 years, 76% male) and RV remodeling was present in 320 patients (14%). After a median follow-up of 75 months (interquartile range 50–106 months), the composite endpoint of all-cause mortality and HF hospitalization occurred in 292 patients (13%). After adjustment for various risk factors, including tricuspid annular plane systolic excursion (TAPSE), post-STEMI RV remodeling was independently associated with a higher risk of all-cause mortality and HF hospitalization (HR=1.37, 95% CI 1.00–1.87, p=0.049. Finally, patients with RV remodeling were had a significantly lower event-free survival rate compared with patients without RV remodeling during follow-up (log-rank test p=0.009) (Figure 1B).

Conclusion

RV post-infarct remodeling is associated with mortality and HF hospitalization, independent of RV systolic function.

Funding Acknowledgement

Type of funding sources: None. Figure 1. A) Spline and B) Kaplan-Meier curve

Clinical outcomes following isolated transcatheter tricuspid valve repair: a meta-analysis and meta-regression study

Background

Significant tricuspid regurgitation (TR) is a common valvular heart disease worldwide.

Purpose

We aimed to assess the pooled clinical and echocardiographic outcomes of different isolated transcatheter tricuspid valve repair (ITTVR) strategies for significant (≥ moderate) TR.

Methods

We systematically searched the literature for studies evaluating the efficacy and safety of ITTVR for significant TR in adult. The primary outcomes were the improvement of New York Heart Association (NYHA) functional class and 6-minutes walking distance (6MWD) and the presence of severe or greater TR at the last available follow-up of each individual study. Random-effect meta-analysis was performed comparing outcomes before and after ITTVR.

Results

14 studies with 771 patients were included. Mean age was 77±8 years and mean EuroScore II was 6.8%±5.4%. At a weighted mean follow-up of 212 days, 209 (35%) patients had a NYHA III to IV functional class compared to 586 (84%) patients at baseline (risk ratio: 0.23, 95% CI 0.13 to 0.40, P-value<0.001). 6MWD significantly improved from 237±113 meters to 294±105 meters (mean difference: +50 meters, 95% CI +34 to +66 meters, P-value<0.001). 147 (24%) patients showed severe or greater TR after ITTVR compared to 616 (96%) at baseline (risk ratio: 0.29, 95% CI 0.20 to 0.42, P-value<0.001).

Conclusion

Patients undergoing ITTVR for significant TR experienced a significant improvement in NYHA functional status and 6MWD and a significant reduction in TR severity at mid-term follow-up.

Funding Acknowledgement

Type of funding sources: None.

Right ventricular myocardial work characterisation in patients with pulmonary hypertension: association with invasive haemodynamic parameters

Background

Non-invasive evaluation of indices of right ventricular (RV) myocardial work derived from RV pressure-strain loops may provide novel insights into RV function in pre-capillary pulmonary hypertension.

Purpose

This study was designed to evaluate the association between the indices of RV myocardial work and invasive haemodynamic parameters in a patient cohort with pulmonary arterial hypertension (Group I) or chronic thromboembolism pulmonary hypertension (Group IV).

Methods

The non-invasive analysis of echocardiography-derived RV myocardial work (Figure 1, upper panel) was completed in 51 patients (mean age 58.1±12.7 years, 31% male) with Group I (78%) or Group IV (22%) pulmonary hypertension. Conventional echocardiographic measurements of RV systolic function, RV global work index (RV GWI), RV global constructive work (RV GCW), RV global wasted work (RV GWW) and RV global work efficiency (RV GWE) were compared with parameters derived invasively during right heart catheterisation (RHC).

Results

The median RV GWI, RV GCW, RV GWW and RV GWE were 620 (443 to 857) mmHg%, 830 (650 to 1206) mmHg%, 105 (54 to 169) mmHg% and 87 (82 to 93)%, respectively. Compared to pulmonary artery systolic pressure and conventional echocardiographic parameters of RV systolic function (RV global longitudinal strain [GLS], tricuspid annular plane systolic excursion and RV fractional area change), RV GCW and RV GWI correlated more closely with invasively-derived RV stroke work index (R=0.63, P<0.001 and R=0.60, P<0.001, respectively) (Figure 1, lower panels). Invasively-derived pulmonary vascular resistance (PVR) correlated with RV GWW (R=0.63, P<0.001), RV GWE (R=0.48, P<0.001) and RV GLS (R=0.58, P<0.001). RV GLS correlated more closely with invasively-derived stroke volume index (R=−0.57, P<0.001) than RV GCW, RV GWI and RV GWE (R=0.34, P=0.016, R=0.48, P<0.001 and R=0.47, P<0.001, respectively).

Conclusions

In a patient cohort with Group I and Group IV pulmonary hypertension, indices of RV myocardial work were more closely correlated with invasively-derived RV stroke work index and PVR than conventional echocardiographic parameters of RV systolic function.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Method and correlations

Impact of tricuspid annular shape on late worsening tricuspid regurgitation after transcatheter aortic implantation: insight from multidetector row computed tomography assessment

Background

Worsening of tricuspid regurgitation (TR) in patients undergoing transcatheter aortic valve implantation (TAVI) is associated with adverse clinical outcomes. The geometrical factors that determine the occurrence of significant TR after TAVI are uncertain. Multi-detector row computed tomography (MDCT) may provide additional geometrical insights in the pathophysiology of worsening TR after TAVI.

Purpose

To investigate the impact of right atrial and tricuspid annular (TA) geometryassessed by MDCT on the occurrence of significant TR (≥ moderate) at 1-year after TAVI.

Methods

Patients without significant TR who had undergone a full-beat MDCT prior to TAVI were included. Right and left atrial and ventricular volumes and TA parameters including the anterior-posterior (AP) and septal-lateral (SL) diameters, area and circularity (AP/SL ratio) were measured and correlated to the occurrence of significant TR at 1-year after TAVI.

Results

A total of 205 patients (80±7 years, 51% male) who underwent TAVI for severe aortic stenosiswere included. Moderate or severe TR at 1-year follow-up occurred in 59 patients (29%). Patients who developed significant TR were more likely to have atrial fibrillation and lower left ventricular (LV) volumes, but larger right and left atrial volumes and TA dimensions at baseline. After adjusting for atrial fibrillation and LV and right atrial volumes, larger end-diastolic TA SL diameter (odds-ratio 1.182 95% CI 1.047–1.334, P=0.007) and more circular TA shape were independently associated with the occurrence of significant TR.

Conclusion

In patients without significant TR prior to TAVI, TA dilation and loss of the elliptical shape of the TA at baseline are associated with of the occurrence of significant TR 1-year after TAVI.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant 2018 Representative cases

Sex-specific difference in cardiac function in patients with systemic sclerosis: association with cardiovascular outcomes

Background

Cardiac involvement is an important cause of hospitalization and mortality in patients with systemic sclerosis (SSc) and advanced echocardiographic measures such as left ventricular (LV) global longitudinal strain (GLS) have already demonstrated to improve risk-stratification. However, possible sex differences in echocardiographic parameters including LV GLS have not been explored so far.

Purpose

To compare standard and advanced echocardiographic parameters between men and women with SSc and evaluate their association with cardiovascular outcomes.

Methods

A total of 746 SSc patients from four different centers were included of which 628 (84%, 54±13 years) women and 118 (16%, 55±15 years) men. Baseline transthoracic echocardiographic (TTE) data with standard and advanced (LV GLS) measurements as well as clinical characteristics were analysed. The study endpoint was the composite of all-cause mortality and cardiovascular hospitalisations.

Results

Men and women showed several differences in terms of disease characteristics: greater modified Rodnan skin score, higher prevalence of diffuse cutaneous SSc, lung fibrosis and myositis, more impaired pulmonary function (DLCO) and higher creatine phosphokinase were observed in men, while women were characterized by longer disease duration, higher NT-proBNP and lower glomerular filtration rate. By TTE, men showed larger LV indexed volumes, lower LV ejection fraction and more impaired LV GLS [−19% (IQR −20% to −17%) vs. −21% (IQR: −22% to −19%, p<0.001)]. Considering the significant differences in clinical characteristics between men and women, a propensity matching score was applied to explore whether sex-differences in TTE parameters were maintained. The matching was performed according to age, disease duration, presence of diffuse SSc, lung fibrosis, DLCO and NT-proBNP (n=140); after matching, LV GLS still showed significant difference between men and women [−19% (IQR −20% to −18%) vs. −20% (IQR −22% to −18%, p=0.03)] while LV volumes and ejection fraction did not. After a median follow-up of 48 months (IQR: 26–80), the combined endpoint occurred in 182 patients and Kaplan-Meier survival analysis (Figure) showed that men experienced higher cumulative event rates as compared to women (Chi-square 8.648; Log rank 0.003) even after matching for clinical characteristics (Chi-square 7.211; Log rank 0.007); however, sex difference in outcomes was neutralized after matching groups according to LV GLS. Furthermore, LV GLS showed a significant association with prognosis in the overall group (HR: 1.173; 95% CI: 1.106–1.244, p<0.001) without significant interaction with sex (p=0.373), indicating a consistent prognostic value of LVGLS for both men and women.

Conclusions

Among patients with SSc, LV GLS is more impaired in men as compared to women even after matching for clinical characteristics, and its impairment is associated with higher prevalence of death and cardiovascular hospitalization.

Funding Acknowledgement

Type of funding sources: None.

Valve-in-valve transcatheter aortic valve replacement or re-surgical aortic valve replacement in degenerated bioprostheses: a systematic review and meta-analysis of short and mid-term results

Introduction

Despite limited to short and mid-term outcomes, Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) has emerged as a less invasive alternative to redo surgery for high and intermediate-risk patients with good outcomes across different surgical risk profiles.

Purpose

The aim of the resent meta-analysis is to compare short and mid-term outcomes of VIV and surgical redo fo patients with a degenerative aortic bioprosthesis.

Methods

All studies comparing with multivariate adjustment between ViV TAVI and re-SAVR were screened. All-cause mortality at 30-day and at follow-up were the primary endpoints, while Valve Academy research Consortium (VARC) endpoints at 30 days including stroke, myocardial infarction (MI), major vascular complications, major bleeding, new onset atrial fibrillation (AF) and permanent pacemaker implantation (PPI) during the index hospitalization were the secondary endpoints. Subgroup analysis were performed according to the surgical risk. All the analyses were stratified according to the design of the study (observational vs propensity-matched study).

Results

We obtained data from 11 studies, encompassing 8570 patients, 4224 undergoing ViV TAVI and 4346 re-SAVR. Four studies included intermediate-risk patients and seven high-risk patients. Mean age was 76 and 71.5 years in the ViV and re-SAVR group respectively, with a 60.2% and 61.3% of male. For the ViV procedure, BE prostheses were used in the 49.6% of patients and SE prostheses in the 45.8%. The ViV group have higher prevalence of previous CAD (53.8% vs 41.1%) and CABG (35% vs 23.6%) and more history of HF (72.1% vs 65.6%), CKD (26.6% vs 14.8%) and COPD (25.4 vs 14.8%). 30-day all-cause and CV mortality were significantly lower in ViV (OR 0.43, 0.29–0.64 and OR 0.44, 0.26–0.73 respectively), while after a mean follow-up of 717 (180–1825) days, there were no difference between the two groups (OR 1.04, 0.87–1.25 and OR 1.05, 0.78–1.43 respectively). The result were consistent both in intermediate and high-risk classes. The risk of stroke (OR 1.03, 0.59–1.82), MI (OR 0.70, 0.34–1.44), major vascular complications (OR 0.92, 0.50–1.67) and permanent pacemaker implantation (OR 0.67, 0.36–1.25) at 30 days did not differ, while major bleedings and new onset atrial fibrillation were significantly lower in ViV patients (OR 0.41, 0.25–0.67 and OR 0.23, 0.12–0.42 respectively, all CI 95%).

Conclusions

In patients with a degenerated aortic bioprosthesis, ViV TAVI is associated with better short-term outcomes, including all-cause mortality, without any difference in all-cause and cardiovascular mortality at mid-term follow-up compared to surgical redo.

Funding Acknowledgement

Type of funding sources: None.

Renal function in patients with significant tricuspid regurgitation: pathophysiological mechanisms and prognostic implications

BACKGROUND

The pathophysiological mechanisms linking tricuspid regurgitation (TR) and chronic kidney disease (CKD) remain unknown. This study aimed to determine which pathophysiological mechanisms related to TR are independently associated with renal dysfunction and to evaluate the impact of renal impairment on long-term prognosis in patients with significant (≥ moderate) secondary TR.

METHODS

A total of 1234 individuals (72 [IQR 63-78] years, 50% male) with significant secondary TR were followed up for the occurrence of all-cause mortality and the presence of significant renal impairment (eGFR of <60 mL min-1  1.73 m-2 ) at the time of baseline echocardiography.

RESULTS

Multivariable analysis demonstrated that severe right ventricular (RV) dysfunction (TAPSE < 14 mm) was independently associated with the presence of significant renal impairment (OR 1.49, 95% CI 1.11 to 1.99, P = 0.008). Worse renal function was associated with a significant reduction in survival at 1 and 5 years (85% vs. 87% vs. 68% vs. 58% at 1 year, and 72% vs. 64% vs. 39% vs. 19% at 5 years, for stage 1, 2, 3 and 4-5 CKD groups, respectively, P < 0.001). The presence of severe RV dysfunction was associated with reduced overall survival in stage 1-3 CKD groups, but not in stage 4-5 CKD groups.

CONCLUSIONS

Of the pathophysiological mechanisms identified by echocardiography that are associated with significant secondary TR, only severe RV dysfunction was independently associated with the presence of significant renal impairment. In addition, worse renal function according to CKD group was associated with a significant reduction in survival.

Catheter ablation versus antiarrhythmic drugs as first-line therapy for symptomatic atrial fibrillation: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with symptomatic atrial fibrillation (AF), current international guidelines favor the use of antiarrhythmic drugs (AAD) as initial therapy for the maintenance of sinus rhythm. Previous studies have compared catheter ablation for pulmonary vein isolation versus AAD in this clinical scenario but the best first-line therapeutic option in patients with symptomatic AF candidates for rhythm control strategy remains an open issue.

Aim

To compare efficacy and safety of catheter ablation versus AAD as first-line therapy in patients with symptomatic AF.

Methods

We searched electronic databases for randomized controlled trials (RCTs) comparing catheter ablation versus AAD as first-line therapy for symptomatic AF. The primary efficacy outcome was any recurrence of atrial tachyarrhythmias. The secondary efficacy outcomes were symptomatic arrhythmic recurrences. The safety outcomes were serious adverse events related to the therapeutic regimen. Outcome events were defined according to the definition used in each original study. The effect size was estimated using a random-effect model as risk ratio (RR) and relative 95% confidence interval (CI) with the statistical software Review Manager 5.3.

Results

Five RCTs counting 997 patients (503 treated with catheter ablation and 494 with AAD) were included in the analysis. Mean age was 57 ± 3 years, 30% were female. Mean left ventricle ejection fraction was 60%±4% and mean left atrial diameter was 40 mm ± 1 mm. At baseline 52% of patients were treated with a beta-blocker and 11% with a calcium channel blocker. In the catheter ablation group 258 patients (51%) underwent cryoablation and 245 (49%) radiofrequency ablation. Median follow-up was 12 months (IQR 12-24 months). Patients treated with catheter ablation had statistically significant lower risk of atrial tachyarrhythmias recurrences (RR 0.59; 95%CI 0.45-0.76; p &lt; 0.0001 – Figure A) and of symptomatic arrhythmia recurrences (RR 0.45; 95%CI 0.25-0.80; p = 0.007 – Figure B) compared with those treated with AAD. The risk of serious adverse events related to the therapeutic regimen did not differ significantly between patients undergoing catheter ablations and those treated with AAD (RR 0.85; 95%CI 0.45-1.59 – Figure C).

Conclusions

In patients with symptomatic AF, catheter ablation as first-line therapy is associated with a reduced risk of atrial tachyarrhythmias recurrences compared with AAD, without statistically significant differences in the risk of serious adverse events related to the treatment. Abstract Figure.

A matter of proportions: a novel framework to classify functional tricuspid regurgitation

Background

Current approaches for the assessment of tricuspid regurgitation (TR) severity do not correct for right ventricular (RV) size. Similarly to what recently proposed for the left heart, we hypothesized that TR severity can be proportional or disproportional to RV dilation.

Purpose

To characterize the clinical features and the prognosis of patients with disproportionate vs proportionate functional TR (FTR).

Methods

A total of 345 patients (mean age: 70±12 years; 40% male) with significant (≥ moderate) FTR, preserved left ventricular systolic function and who did not undergo tricuspid valvular repair during follow-up were included. Proportional and disproportional FTR were defined according to the ratio between TR severity (vena contracta [VC] width) and RV size (tricuspid annulus [TA] diameter). A prognostic relevant cut-off for VC/TA was identified with spline curve analysis. The primary end-point was all-cause mortality and the event rates were compared between patients with proportionate and disproportionate FTR.

Results

The cut-off for disproportionate FTR associated with an increase in all-cause mortality was identified at 0.24 (Figure 1: left panel). According to this cut-off, 172 (50%) patients showed disproportionate FTR, while the remaining had proportionate FTR. Patients with disproportionate FTR were more frequently symptomatic, had smaller RV basal diameter, higher TR severity, greater left atrial volume, higher prevalence of mitral regurgitation, and higher pulmonary artery pressures compared to those with proportionate FTR. During a median follow-up of 61 (interquartile range, 28–101) months, 135 (39%) patients died. The cumulative 5-year survival rate was significantly worse in patients with disproportionate FTR (57% vs 74%, P=0.001; Figure 1: right panel) and on multivariable Cox regression analysis disproportionate FTR was independently associated with poor outcome (HR 1.56; 95% CI 1.06–2.29; P=0.023) together with age, coronary artery disease, renal impairment, reduced RV systolic function, and increased pulmonary artery pressures. Importantly, this novel framework outperformed the TR grading system recommended by current guidelines, which in this population was not able to effectively stratify the prognosis (HR for severe FTR vs moderate FTR 1.09; 95% CI 0.72–1.64; P=0.694).

Conclusions

In patients with significant FTR, characterization of TR severity in relation to RV size significantly improves risk-stratification since disproportionate FTR if left untreated is associated with worse prognosis compared with proportionate FTR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Regional left ventricular myocardial work index in culprit territory predicts early left ventricular remodelling in patients with st-segment elevation myocardial infarction

Background

The association between left ventricular (LV) myocardial work index (LVMWI) derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure recordings and adverse LV dilatation i.e. remodelling has not been evaluated.

Purpose

To assess the predictive value of regional LVMWI for LV remodelling at baseline echocardiography in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

This retrospective study included 350 patients (265 men, mean age: 61±10 years) with STEMI treated with primary percutaneous coronary intervention and optimal medical therapy. Clinical variables, conventional echocardiographic parameters, global and segmental measures of LVMWI were recorded at baseline. The primary endpoint was early LV remodelling defined as increase in LV end-diastolic volume (LVEDV) ≥20% at 3 months after the index event.

Results

Eighty-seven patients (24.9%) presented with early LV remodelling. The global and regional LVMWI in the culprit territory were significantly lower in patients with early LV remodelling. Univariate and multivariate logistic regression analyses were performed to identify predictors of early LV remodelling. At the index event, troponin I peak, LVEDV and LVMWI in the culprit territory were independently associated with early LV remodelling (Table).

Conclusions

In STEMI patients treated with primary percutaneous coronary intervention and optimal medical therapy, the regional LVMWI in the culprit territory at echocardiography before discharge is independently associated with troponin I peak and LVEDV in predicting early LV remodelling.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Society of Cardiology

The truly forgotten chamber: prognostic value of right atrial dilation in patients with sinus rhythm and significant functional tricuspid regurgitation

Background

Functional tricuspid regurgitation (FTR) can be caused by right ventricular (RV) and/or right atrial (RA) dilation, and it leads in turn to further RV and RA remodeling. While it is known that in these patients RV dilation is associated with worse prognosis, there are no data on the prognostic value of RA enlargement.

Purpose

To assess the prognostic impact of RA dilation in patients with significant (≥ moderate) FTR taking into account the presence of atrial fibrillation (AF).

Methods

1382 patients (mean age: 69±13 year; 50% male) with moderate or severe FTR were included. Patients with congenital heart disease were excluded. Significant RA enlargement was identified by the value of RA area associated with excess of mortality according to spline curve analysis in the overall population (30 cm2 – Figure: Left Panel). The prognostic value of RA enlargement was investigated separately in patients with sinus rhythm (SR) and AF. The primary endpoint was all-cause mortality.

Results

A total of 987 (71%) patients were in SR while the remaining 395 (29%) had AF at the time of significant FTR diagnosis. Patients in SR with RA enlargement were more likely to present with RV failure symptoms and to receive diuretics compared with patients in SR with non-enlarged RA, whereas these differences were not detected in patients with AF. During a median follow-up of 53 (interquartile range, 20–89) months, 698 (51%) patients died. The survival rates of patients in SR with RA enlargement were significantly worse compared to the ones of patients in SR with normal RA size (Figure: Right Panel). In contrast, RA enlargement did not affect the prognosis of patients in AF (Log-rank χ2: 0.41; P=0.522). RA enlargement was associated with 33% increase risk of all-cause mortality in patients with SR and this association was retained on a multivariable Cox regression analysis (HR 1.27; 95% CI 1.04–1.56; P=0.022) together with older age, coronary artery disease, diabetes, severe renal impairment, reduced left ventricular or RV systolic function, and increased pulmonary artery pressures.

Conclusion

RA enlargement has an independent prognostic value for all-cause mortality in patients with FTR and SR, and therefore its evaluation might be useful to further improve their risk stratification.

Funding Acknowledgement

Type of funding source: None

A novel quantitative grading system to further characterize the prognosis of patients with functional tricuspid regurgitation

Background

Recent studies have suggested that current grading of tricuspid regurgitation (TR) has significant limitations and specifically cannot identify the various grades of severe TR (such as torrential). New cut-off values for the recommended measures of vena contracta (VC) width and effective regurgitant orifice area (EROA) have been proposed but not yet validated.

Purpose

To test the prognostic utility of new cut-offs for VC width and EROA in a large registry of patients with functional TR (FTR) and to integrate them into a novel comprehensive grading system.

Methods

FTR severity was evaluated in 1148 patients (mean age: 69±13 years, 50% male) with significant FTR (≥ moderate). Patients with congenital heart disease or who underwent tricuspid valve repair during follow-up were excluded. The primary endpoint was all-cause mortality. Based on Kaplan-Meier survival analyses, VC width significantly differentiated the prognosis of patients with moderate FTR vs severe FTR (with a cut-off value of 7 mm), whereas EROA was able to further stratify patients with more than severe (torrential) FTR. Therefore these two parameters were combined into a novel grading system (Figure: Upper Panel) to define: moderate FTR (VC &lt;7 mm), severe FTR (VC ≥7 mm, EROA &lt;80 mm2) and torrential FTR (VC ≥7 mm, EROA ≥80 mm2).

Results

According to our novel grading system a total of 146 patients (13%) showed moderate FTR, 547 patients (48%) had severe FTR and 454 patients (39%) presented with torrential FTR. Patients with torrential FTR had greater right ventricular (RV) dimensions, lower RV systolic function and were more likely to receive diuretics. The cumulative 10-year survival rates were significantly different among the groups: 54% for moderate FTR, 43% for severe FTR and 32% for torrential FTR (P=0.004 Figure – Lower Panel). After adjusting for potential confounders, torrential FTR retained its association with worse prognosis compared with other FTR grades (HR 1.28; 95% CI 1.07–1.54; P=0.007) together with age, coronary artery disease, diabetes, severe renal impairment, lower RV or left ventricular systolic function, higher pulmonary artery pressures, and dilated tricuspid annulus. Differently, severe FTR graded according to current guidelines did not show any association with the primary outcome (HR for severe FTR vs moderate FTR 1.17; 95% CI 0.96–1.42; P=0.128).

Conclusion

The proposed novel grading system combining measures of VC width and EROA is able to further risk stratify patients with FTR and specifically to identify patients with torrential FTR, a new clinical condition associated with even worse mortality than severe FTR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Invasive versus conservative management in spontaneous coronary artery dissection: a meta-analysis and meta-regression study

Background

There is a paucity of data regarding the best treatment for spontaneous coronary artery dissection (SCAD).

Purpose

To compare the prognostic impact of conservative versus invasive treatment in patients with SCAD.

Methods

We systematically searched the literature for studies evaluating the comparative efficacy and safety of invasive revascularization versus medical therapy for the treatment of SCAD from 1990 to 2019. Random-effect meta-analysis was performed comparing clinical outcomes between the two groups.

Results

24 observational studies with 1720 patients were included. After 28±14 months, a conservative approach reduced target vessel revascularization rate compared with invasive treatment (OR=0.50; 95% CI 0.28–0.90; P=0.02). No difference was found regarding all-cause mortality (OR=0.81; 95% CI 0.31–2.08; P=0.66), cardiovascular mortality (OR=0.89; 95% CI 0.15–5.40; P=0.89), myocardial infarction (OR=0.95; 95% CI 0.50–1.81; P=0.87), heart failure (OR 0.96; 95% CI 0.41–2.22; P=0.92) and SCAD recurrence (OR=0.94; 95% CI 0.52–1.72; P=0.85). The meta-regression analysis suggested that male gender, diabetes mellitus, smoking habit, prior coronary artery disease, left main coronary artery involvement and lower ejection fraction at admission are related with higher overall mortality, whereas SCAD recurrence was higher among patients with fibromuscular dysplasia.

Conclusion

A conservative approach provides similar clinical outcomes and lower target vessel revascularization rates compared to an invasive strategy in the setting of SCAD; therefore, when feasible, it should be preferred in this scenario.

Forest plots on the study outcomes

Funding Acknowledgement

Type of funding source: None

Primary percutaneous coronary intervention in nonagenarian patients

Background

Given the continuous increase in life expectancy, elderly patients with ST segment elevation myocardial infarction (STEMI) are becoming a growing proportion of those referred for primary percutaneous coronary intervention (pPCI). However, this population is usually excluded from randomized trials and limited data are available to guide clinical decisions. The aim of this study-level meta-analysis was to describe and analyze the determinants of outcomes in this population.

Methods

We searched the literature for studies reporting ischemic and hemorrhagic outcomes and/or mortality in nonagenarian patients undergoing pPCI. An analysis of the heterogeneity between studies in outcome reports was performed with I2 test. A univariate meta-regression analysis was conducted to explore the relationship between outcomes of interest and classic cardiovascular risk factors, gender, previous myocardial infarction (MI), MI location, PCI characteristics, hemodynamic instability, vascular access, intra-aortic balloon pump (IABP) and Glycoprotein IIb/IIIa inhibitor (GPI) use.

Results

Overall, 15 observational studies met our inclusion criteria, with a total of 6787 patients; mean age was 92.4 and 35% were male.

The incidence of in-hospital death was 21.3%, 1.4% of our population suffered an in-hospital ischemic stroke and 11.1% faced acute renal failure; in-hospital major bleedings affected 1.7% of the population, but blood-transfusion was needed in 6.9%. Long-term mortality rate was 21.5%.

Killip III-IV at admission was related with increased in-hospital mortality (β: 0.2%; p: 0.041), but lower incidence of ARF (β: −0.6%; p: 0.004). Angiographic success was associated with a lower incidence of long-term all-cause mortality (β: −1.7%; p: 0.017) and higher incidence of ARF (β: 1.7%, p&lt;0.001). A higher number of coronary stents implanted was associated with a lower incidence of long-term all-cause mortality (β: −73%; p: 0.01). A higher long-term all-cause mortality was related with male gender (β: 0.9%; p: 0.027) and previous MI (β: 1.5%; p: 0.007). Diabetes was associated with a lower incidence of long-term all-cause mortality (β: −0.8%; p: 0.014) despite a higher incidence of in-hospital blood transfusion (β: 0.5%, p: 0.05), while a history of MI (β: 0.1%; p: 0.049), as well as the use of GPI (β: 0.04) was related with a higher incidence of in-hospital major bleeding. The use of IABP was related with a lower incidence of long-term all-cause death (β: 6.5%; p&lt;0.001) and in-hospital major bleeding (β: −0.4%; p: 0.038).

Discussion

Our meta-analysis, pooling the largest cohort of nonagenarians undergoing pPCI confirms the feasibility of urgent percutaneous coronary intervention also in this frail population. In particular, although angiographic success increased the incidence of in-hospital ARF, it was associated with a higher long-term survival underling the pivotal role of myocardial reperfusion.

Funding Acknowledgement

Type of funding source: None

Right ventricular myocardial work in patients with HFrEF

Background

Right ventricular myocardial work (RVMW) is a novel method of non-invasively quantifying right ventricular (RV) systolic function. Through the use of speckle tracking echocardiography-derived RV pressure-strain loops, RVMW provides a quantitative evaluation of afterload-dependent RV systolic function.

Purpose

To investigate RVMW in patients with heart failure and reduced ejection fraction (HFrEF) and compare to that of patients without cardiovascular disease (CVD) and a structurally and functionally normal heart.

Methods

Noninvasive analysis of RVMW was performed in 23 HFrEF patients and 23 patients without cardiovascular or structural heart disease. The novel indices of RV global constructive work (RVGCW), RV global work index (RVGWI), RV wasted work (RVWW) and RV global work efficiency (RVGWE) were analysed utilizing proprietary software originally developed for the assessment of left ventricular myocardial work by speckle tracking echocardiography. Parameters of RVMW were then compared between the two patient groups.

Results

The HFrEF group had lower left ventricular (LV) ejection fraction (18.7% [±6.7] vs 60.1% [±4.6], p&lt;0.0001), LV global longitudinal strain (−3.6% [±1.6] vs −20.4% [±2.1), p&lt;0.0001) and RV global longitudinal strain (−10.0% [±4.2] vs −22.0% [±3.1], p&lt;0.0001) when compared to those with no CVD. Estimated pulmonary artery systolic pressure (42.5mm Hg [±12] vs 22.5mm Hg [±3.7], p&lt;0.0001) and estimated right atrial pressure (8mm Hg (5 to 15) vs 5mm Hg (5 to 5), p&lt;0.0001) were significantly higher in the HFrEF group. RVGWI (259.7mmHg% [±135.0] vs 385.3mmHg% [±103.1], p=0.001), RVGWW (83.7mmHg% [±58.6] vs 14.5mmHg% [8.5 to 20.5], p&lt;0.0001) and RVGWE (77.2% [11.4] vs 95.5% [93.5 to 97], p&lt;0.0001) were significantly lower in the HFrEF group when compared to those without CVD. There was no statistically significant difference in RVGCW between the two groups (353.5mmHg% [±118.4] vs 417.2 [±102.1], p=0.057).

Conclusion

The novel parameters of RVGWI, RVGWW and RVGWE were significantly reduced in patients with HFrEF when compared to those without CVD. Further exploration of the clinical role and prognostic value of these afterload dependent parameters of RV systolic function is warranted.

Funding Acknowledgement

Type of funding source: None

Left ventricular myocardial work in patients with secondary mitral regurgitation

Background

Assessment of left ventricular (LV) function in patients with secondary mitral regurgitation (SMR) remains challenging because LV ejection fraction (LVEF) reflects changes in LV volume without taking into account the direction of the blood flow. LV global longitudinal strain better reflects active LV myocardial deformation but does not incorporate afterload. LV myocardial work derived from pressure-strain loops integrates speckle tracking echocardiography with non-invasive blood pressure measurement.

Purpose

To evaluate LV myocardial work components to better characterize LV function in patients with SMR.

Methods

378 patients (72% men, median age 68 [range 60 to 74 years]) with various grades of SMR were retrospectively analysed. LV myocardial constructive work, wasted work and work efficiency were measured with speckle tracking echocardiography.

Results

145 patients had mild SMR, 130 moderate SMR and 103 severe SMR. Patients with severe SMR had larger LV volumes, lower LVEF and more impaired LV GLS (Table 1). While LV constructive work was more impaired in patients with severe SMR, wasted work was lower as compared to mild SMR (Table 1). Consequently, patients with severe SMR had better myocardial work efficiency than patients with mild MR. This could reflect, the regurgitant volume which is pumped into a low pressure chamber (the left atrium) resulting in less myocardial wasted work and preservation of myocardial efficiency.

Conclusion

In patients with severe SMR, LVEF, LV GLS and myocardial constructive work are more impaired when compared to mild SMR. However, myocardial wasted work is lower, resulting in higher better LV myocardial work efficiency.

Funding Acknowledgement

Type of funding source: None

Right ventricular myocardial work: new method for non-invasive assessment of right ventricular function in HFrEF

Background

The prognostic significance of speckle tracking echocardiography derived right ventricular (RV) strain has been repeatedly demonstrated in the heart failure with reduced ejection fraction (HFrEF) patient group. Nevertheless, assessing RV systolic function in the context of afterload is vital as even minimal increases in pulmonary pressures may result in a substantial reduction in RV stroke volume. The novel assessment of Right Ventricular Myocardial Work (RVMW) through the evaluation of pressure-strain loops derived by echocardiography, provides a comprehensive evaluation of RV systolic function, integrating both RV strain and afterload.

Purpose

To explore the relationship between the non-invasive estimation of RVMW with invasive indices of right heart catherization (RHC) in a cohort of patients with HFrEF.

Methods

Noninvasive analysis of RVMW was performed in 23 HFrEF patients (median age 60.4 [58.0 to 66.0] years, 74% male) who underwent echocardiography and invasive RHC within 48 hours. The novel indices of RV global constructive work (RVGCW), RV global work index (RVGWI), RV wasted work (RVWW) and RV global work efficiency (RVGWE) were analysed utilizing proprietary software originally developed for the assessment of left ventricular myocardial work by speckle tracking echocardiography. These indices and other standard measurements of RV systolic function were then compared with invasively measured cardiac index (CI), derived by thermodilution during RHC.

Results

Mean left ventricular ejection fraction was 18.7% (±6.7), with a mean cardiac index of 2.2 L/min/m2(±0.7) and a mean pulmonary arterial pressure of 32 mm Hg (±13). None of the standard echocardiographic parameters of RV systolic function, including fractional area change, RV global longitudinal strain, RV free wall strain and TAPSE were significantly correlated with cardiac index in this cohort of HFrEF patients. In contrast, two of the novel indices derived non-invasively by pressure-strain loops, RVGCW and RVGWI, demonstrated a moderate correlation with invasively measured CI (r=0.55, p=0.006 and r=0.49, p=0.018).

Conclusion

RVGCW and RVGWI are novel parameters that provide integrative analysis of RV systolic function and correlate more closely with invasively measured CI than other standard echocardiographic parameters. Their potential role in aiding clinical decision-making merits further investigation.

Funding Acknowledgement

Type of funding source: None

Prognostic value of global myocardial constructive work in patients with secondary mitral regurgitation

Background

Left ventricular (LV) myocardial contractility evaluation is of crucial importance in patients with secondary mitral regurgitation (SMR). The most widespread echocardiographic tool, left ventricular ejection fraction (LVEF), might overestimate LV function, since it calculates the volume changes regardless of the flow direction. Global myocardial constructive work (GMCW) might be a more suitable tool, as LV myocardial work derived from pressure-strain loops obtained with speckle tracking echocardiography incorporates non-invasive blood pressure measurements.

Purpose

To evaluate the prognostic value of LV GMCW in patients with SMR.

Methods

378 patients (72% men, median age 68 [range 60 to 74 years]) with various grades of SMR were retrospectively analysed. LV global myocardial constructive work, wasted work and work efficiency were measured with speckle tracking echocardiography.

Results

There were 145 patients with mild SMR, 130 with moderate SMR and 103 with severe SMR. Patients with severe SMR had larger LV volumes, lower LVEF and more impaired LV GLS. GMCW was more impaired in patients with severe SMR, compared with mild MR (678 mmHg% vs. 845 mmHg% p&lt;0.001 respectively). After a mean follow-up of 59±37 months, 162 patients died. When dividing the population according to prognostically relevant cut offs derived by spline curve analysis, patients with a GMCW≤700 mmHg% had a worse prognosis, compared with their counterparts (Figure 1).

Conclusion

Global myocardial constructive work ≤700 mmHg% is associated with worse long-term survival in patients with SMR.

Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

D-dimer for the prediction of left atrial appendage thrombosis: daydream or reality? A meta-analysis

Introduction

Left atrial appendage thrombosis (LAAT) is a dangerous condition that mainly affects patients with atrial fibrillation (AF) or those with mitral stenosis (MS), increasing their risk of stroke. Transesophageal echocardiography (TEE) is the gold standard for the diagnosis of LAAT but some technical issues and the suboptimal sensitivity in identifying small thrombi, especially within a side lobe, can limit its clinical usefulness. Reliable non-invasive diagnostic methods could be useful in clinical practice. D-dimer, a fibrin degradation product already commonly used in the diagnostic work-up of conditions such as venous thromboembolism, may have a role as a non-invasive marker of LAAT.

Purpose

To evaluate the diagnostic performance of D-dimer for the detection of LAAT in patients with AF and/or MS, using TEE as the reference standard.

Methods

We searched the literature for studies that evaluated the ability of D-dimer to predict LAAT. For each study a 2x2 table of D-dimer positivity and LAAT presence was constructed. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. Considering the different diagnostic thresholds used in the included studies, the overall sensitivity and specificity were calculated using a hierarchal summary receiver operating characteristic (HSROC) model and a SROC curve was generated.

Results

6 studies, evaluating 1380 patients of whom 154 had LAAT, were included in the analysis. The prevalence of LAAT in the studies ranged from 9% to 26%, with a median of 12%. The mean age was 60±13 years, 63% were male. The mean left atrial diameter was 43±3 mm. The D-dimer diagnostic threshold ranged from 200 mcg/l to 1150 mcg/l. The overall sensitivity calculated with the HSROC model was 85%±28% and the overall specificity was 82%±29%. The negative predictive value was 98%. Figure 1 shows the summary ROC curve: individual studies are depicted by a clear circle; the red circle marks the pooled sensitivity and specificity across the 6 studies. The red dot-dashed-curve marks the boundary of the 95% credible region for the pooled estimates of sensitivity and specificity.

Conclusions

Our analysis shows that D-dimer has a good diagnostic performance with a very high negative predictive value for LAAT and therefore it might be of clinical aid for ruling out the presence of LAAT in patients with AF and/or MS. Further studies are needed to determine the best diagnostic threshold.

Figure 1

Funding Acknowledgement

Type of funding source: None

P569Efficacy and safety of direct Xa oral inhibitors versus warfarin in patients with atrial fibrillation and cancer: a meta-analysis of randomized controlled trials

Background

Patients with cancer are at higher risk of atrial fibrillation (AF) compared with the general population. Furthermore, cancer per se and anti-cancer treatments have been associated with thromboembolic complications and increased bleeding risk. Considering that only 12% of cancer patients can achieve a stable International Normalized Ratio target and the frequent need for invasive procedures, warfarin is not an ideal option. Direct oral anticoagulants may theoretically represent a valid alternative although their use in this population has been scarcely investigated.

Purpose

To compare efficacy and safety of direct oral Xa inhibitors (DOXaI) versus warfarin in patients with atrial fibrillation and cancer.

Methods

We searched electronic databases for randomized controlled trials (RCTs) that analyzed the use of DOXaI versus warfarin in patients with AF and cancer. The primary efficacy outcome was stroke or systemic embolism (SE). The secondary efficacy outcomes were ischemic stroke, myocardial infarction and all-cause death. The primary safety outcome was major bleeding; secondary safety outcomes were major or clinically relevant non-major bleeding, intracranial bleeding and any bleeding. The net clinical benefit was estimated as the composite of the two primary outcomes. A sensitivity analysis was performed to better define the incidence of these outcomes in patients with active cancer. The statistical software ProMeta 3 was used to estimate the risk ratio with a random-effect model.

Results

3 RCTs counting a total of 3029 cancer patients (1682 on DOXaI and 1347 on warfarin), 1354  of whom with active cancer (856 on DOXaI and 502 on warfarin), were included in the analysis. Mean age was 75.6 ± 1.2 years, and 32% were female. Mean follow-up period was 2.2 ± 0.6 years. The most common cancer sites were prostate (23%), gastrointestinal tract (22.2%), breast (12.1%) and genitourinary tract (10.6%). The mean CHADS2 score was 2.9 ± 0.6 and the mean HAS-BLED score was 2.6 ± 0.4.

There were no significant differences in the risk of stroke or SE (RR 0.76; 95% CI 0.52-1.10) as well as for all the other secondary efficacy outcomes. DOXaI significantly reduced the incidence of major bleeding in the overall cancer population (RR 0.79; 95% CI 0.63-0.99; p = 0.039); this finding was consistent also in patients with active cancer (RR 0.79; 95% CI 0.59-1.05) although the effect was not statistically significant.  DOXaI also significantly reduced intracranial bleeding in overall cancer population (RR 0.12; 95% CI 0.02-0.63; p = 0.013) and any bleeding in active cancer patients (RR 0.87; 95% CI 0.77-0.98; p = 0.026). Furthermore, DOXaI significantly reduced the composite endpoints of major bleeding and stroke or SE in overall cancer population (RR 0.78; 95% CI 0.64-0.94; p = 0.008).

Conclusions

Our metanalysis shows that, in patients with atrial fibrillation and cancer, DOXaI are safer and have a similar efficacy compared with warfarin.

Abstract Figure. Primary efficacy and safety outcomes

P1915Time to freeze - An updated meta-analysis on the efficacy and safety of cryoballoon versus radiofrequency ablation for atrial fibrillation

Background and aim

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Its efficacy to prevent recurrent arrhythmias in patients nonresponsive to antiarrhythmic drugs is proven. This procedure has a higher efficacy rate in patients with paroxysmal AF (PAF) compared with persistent AF (sustained AF - SAF). Radiofrequency (RF) ablation represents a standard of care for PVI, while, cryoballoon (CB) ablation has emerged as a valid alternative therapy. The aim of the present meta-analysis was to explore the comparative efficacy, and safety of CB compared with RF ablation for AF.

Methods

We searched PubMed and EMBASE for studies that investigated the comparative efficacy and safety of CB versus RF ablation for AF. The efficacy outcome was AF recurrence after the procedure. The safety outcomes were: incidence of pericardial effusion or cardiac tamponade, permanent phrenic nerve palsy, transient phrenic nerve palsy, vascular complications and major bleedings. The performance outcomes were: procedural time and fluoroscopy time. Random-effects Risk Ratios (RRs) were estimated using a DerSimonian-Laird model. Two subgroup sensitivity analyses were performed to stratify the result on the efficacy outcome according to type of AF (PAF versus SAF) and study design (randomized clinical trial (RCT) versus observational study (OS)).

Results

12 RCT and 34 OS were included in the analysis (n=13103). Mean follow-up was 14±6 months. 37 studies included only patients with PAF, while, 2 studies included only patients with SAF and the remaining 7 studies included both patients with SAF or PAF. Overall, CB ablation reduced the incidence of AF recurrence compared with RF ablation (RR 0.85; 95% CI 0.77–0.95; P=0.002 - Figure). However, this reduction was not consistent in the RCT subgroup (RR 0.90; 95% CI 0.72–1.13) and it was marginally non-significant in the SAF subgroup (RR 0.76; 95% CI 0.57–1.01). Regarding the safety outcomes, although CB had a significantly higher rate of transient nerve palsy compared with RF procedure (RR 7.46; 95% CI 4.67–11.90) this difference became non-significant when considering permanent phrenic nerve palsy (RR 1.24; 95% CI 0.66–2.34). Moreover, CB was related to a lower incidence of pericardial effusion or cardiac tamponade compared with RF (RR 0.51; 95% CI 0.37–0.69) and there was no significant difference in vascular complications or major bleedings between the two strategies. Focusing on performance outcomes, CB ablation had a shorter procedural time compared with RF (mean difference −20 minutes; 95% CI −30 to −10; P<0.001); whereas, there was no significant difference in fluoroscopy time between the two.

CB vs. RF in preventing AF recurrence

Conclusions

This large study level meta-analysis demonstrates that CB is at least as effective as RF ablation in preventing arrhythmic recurrence both in patients with PAF and SAF. Moreover, our study suggests that CB has a safer profile and shorter procedural time compared with RF ablation.

258Use of low-dose prasugrel vs. clopidogrel in elderly patients undergoing complex or non-complex PCI for acute coronary syndromes: insights from the Elderly ACS 2 study

Background

Prasugrel was superior to clopidogrel in the setting of acute coronary syndromes (ACS) and recent data highlighted its possible role in the setting of complex percutaneous coronary intervention (PCI). Nonetheless, evidence supporting its use in high bleeding risk population are lacking.

Purpose

The aim of this post-hoc subgroup analysis was to evaluate the impact of prasugrel administration in elderly patients undergoing complex PCI for ACS. A primary composite endpoint of composite of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year and secondary endpoints of all-cause mortality and any bleeding at 1 year were analyzed.

Methods

In the multicenter Elderly ACS 2 Study 1,443 patients aged >74 y were randomly assigned to receive low-dose prasugrel (5 mg) or clopidogrel (75 mg) and were prospectively followed for 1 year (Table 1). Complex PCI was defined if ≥3 lesions were treated, if ≥3 stents were deployed, or if any bifurcation, trifurcation, chronic total obstruction or moderate-to-severe calcified lesions were treated.

Results

Patients undergoing complex PCI (n=607) did not experience worse outcome, as compared to those with simpler PCI, in terms of primary endpoint (p=0.21, Figure 1A). Furthermore, in this subgroup, no significant difference was observed with prasugrel vs clopidogrel with regard to the primary endpoint (HR 1.17; CI 0.819–1.67; p=0.39, Figure 1A), all-cause death and bleeding (Figure 1C and 1D). No significant interaction was observed between treatment and PCI complexity (interaction p=0.34).

Table 1 Overall Non-complex PCI Complex PCI p value Age (y) 80.60±4.46 80.00 [77.00, 84.00] 80.00 [77.00, 83.00] 0.215 STE-ACS 595 (41.2) 272 (32.5) 323 (53.4) <0.001 Diabetes mellitus 253 (17.5) 159 (19.0) 94 (15.5) 0.104 LVEF 48.27±9.59 49.08±9.55 47.26±9.54 0.002 Total number of diseased vessels 2.29±1.06 2.22±1.06 2.38±1.05 0.005 Previous Myocardial Infarction 274 (19.0) 171 (20.4) 103 (17.0) 0.122 Randomized to prasugrel 713 (49.4) 404 (48.2) 404 (48.2) 0.307 Data are expressed as mean ± SD or [IQR] and count/valid %).

Figure 1

Conclusions

In elderly patients presenting with ACS low-dose prasugrel was comparable to clopidogrel in terms of all-cause mortality and any bleeding at 1 year.

Acknowledgement/Funding

None

P5554Follow the light - The prognostic value of late gadolinium enhancement in hypertrophic cardiomyopathy

Background and aim

Hypertrophic cardiomyopathy (HCM) is a genetic based cardiomyopathy with heterogeneous phenotypic expression. Since it is one of the most common cause of sudden cardiac death (SCD) in the young different risk score have been proposed to properly identify the patients that would benefit from a primary prevention with an implantable cardioverter-defibrillator (ICD). ESC guidelines on HCM suggest to estimate the risk of SCD considering clinical and echocardiographic parameters and mention the use of cardiac magnetic resonance (CMR) only in the case of poor echo windows. The aim of the present study-level meta-analysis was to explore the prognostic value of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) for adverse fatal events.

Methods

We searched PubMed and EMBASE for studies that investigated the prognostic value of LGE in patients with HCM. The outcomes of interest were SCD or aborted SCD, all-cause mortality and cardiovascular (CV) mortality. Random-effects Odds Ratios (ORs) were estimated using a DerSimonian-Laird method with a person-year approach. Moreover, an univariate meta-regression was performed to assess the moderator effect of mean age, LGE % of left ventricle (LV) and gender (expressed as male percentage).

Results

A total of 7 studies (n=3351) were included in the analysis. Mean follow-up was 3±0.63 years. Mean age was 47.7±14.6 years and 56.9% were male. LGE was detected in 1845 (55%) patients with a mean LGE percentage of LV of 7%. The presence of LGE was associated with an increased incidence of SCD or aborted SCD (OR 3.44; 95% CI 2.02–5.86; p<0.001- Figure), all-cause mortality (OR 1.92; 95% CI 1.31–2.81; p<0.001) and CV mortality (OR 3.16; 95% CI 1.77–5.64; p<0.001) compared with the absence of LGE at CMR. The LGE percentage of LV, mean age and gender did not have any moderator effect on the outcomes of interest. However, LGE % of LV was reported only in 4 studies and the absence of any moderator effect of this parameter could be due to a type II error.

Prognostic value of LGE for SCD

Conclusions

The presence of LGE at CMR in patients with HCM exhibited a substantial prognostic value in fatal events and, in particular, in the prediction of SCD. LGE assessment is an effective tool to stratify the arrhythmic risk in HCM. Therefore, it should be considered, especially in borderline cases, to improve the identification of HCM patients who could benefit from ICD implantation.

P1781Burden of significant valvular heart disease in elderly patients presenting with acute coronary syndromes

Background

Elderly patients with acute coronary syndromes (ACS) represent a group seldom included in clinical trials and in whom robust data regarding mid-term impact of significant concomitant valvular heart disease are lacking.

Purpose

Our aim was to evaluate the impact of moderate-to-severe mitral regurgitation (MR), moderate-to-severe aortic stenosis (AS), or both conditions combined on a primary composite endpoint of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year in a population of ACS patients included in the Elderly ACS 2 trial.

Methods

In the multicenter Elderly II ACS Study, 1,443 patients aged >74 y undergoing percutaneous coronary intervention (PCI) for ACS, were randomly assigned to receive prasugrel (5 mg) or clopidogrel (75 mg) and were prospectively followed for 1 year. Amongst these, 1,102 patients received full echocardiographic assessment and were included in the post-hoc analysis (Table 1).

Results

Survival analysis showed that patients presenting with moderate-to-severe MR, AS or both (Figure 1A), had worse outcome in terms of primary endpoint (p<0.001) as compared to no valve disease. A multivariable Cox regression model revealed that the presence of moderate-to-severe MR, AS or both were independent predictors of primary endpoint (HR 1.84; HR 2.8; HR 2.9 and p<0.001; p=0.004; p=0.01, respectively), regardless of age, gender, left ventricular ejection fraction, diabetes mellitus, history of cancer and total number of diseased vessels (Figure 1B).

Table 1 Overall No residual valvular heart disease Moderate-to-severe MR Moderate-to-severe AS Both Age (y) 80.68±4.50 80.40±4.42 81.47±4.45 82.92±5.42 83.23±5.42 Male gender 652 (59.2) 538 (61.6) 92 (48.4) 19 (73.1) 3 (23.1) STE-ACS 420 (38.1) 319 (36.5) 91 (47.9) 6 (23.1) 4 (30.8) Diabetes mellitus 203 (18.4) 158 (18.1) 35 (18.4) 5 (19.2) 5 (38.5) LVEF (%) 48.30±9.58 49.26±9.27 44.61±9.45 48.50±11.22 38.31±10.87 History of cancer 32 (2.9) 26 (3.0) 3 (1.6) 2 (7.7) 1 (7.7) Tot number of diseased vessel 2.31±1.05 2.28±1.04 2.49±1.05 2.04±0.87 2.54±1.13 Data are expressed as mean ± SD or count (valid %).

Figure 1

Conclusions

Moderate-to-severe MR and AS represent significant predictors of 1-year outcome in elderly patients hospitalized for ACS, even when other well-established prognostic factors are taken into account and after revascularization with PCI. Therefore, these patients should be carefully screened for the presence of valvular heart disease at the time of presentation and the need for surgical or percutaneous correction should be assessed accordingly.

Acknowledgement/Funding

None