Functional (Re)Development of SYNTAX Score II 2020: Predictive Performance and Risk Assessment

The present study investigates the prognostic value of the Syntax Score II 2020 corrected for flow-limiting lesions and its ability to better address treatment by benefit prediction among patients with left main or multivessel disease. We analyzed 1274 patients from the HALE-BOPP cohort and integrated the Syntax Score II 2020 with the result of the fractional flow reserve (FFR) evaluation. Absolute risk difference (ARD) between surgical and percutaneous revascularization was calculated for anatomic and functional Syntax Score II 2020 predicted mortality. The ARD allowed to stratify the population into two large categories: "coronary artery bypass graft (CABG) better" with ARD ≥ 4.5% and "CABG-percutaneous coronary intervention (PCI) equipoise" with ARD < 4.5%. The mean global anatomical Syntax Score was 15.5 ± 9.2, whereas the functional one was 9.5 ± 10 (p < 0.01). Using the anatomic Syntax Score II 2020, 881 patients had a CABG-PCI equipoise. This number increased to 1041 after considering only flow-limiting lesions by FFR (p < 0.001); therefore, 40% of CABG better patients were reclassified within the CABG-PCI equipoise category. Kaplan-Maier curves showed similar actual survival rates for patients originally with CABG-PCI equipoise and those reclassified, in both cases higher than those from CABG better patients (p < 0.01). The integration between Syntax Score II 2020 and physiology is feasible, and merging clinical, anatomic and functional data allows for better risk prediction and therapeutic guidance.

Stroke volume index and transvalvular flow rate trajectories in severe aortic stenosis treated with TAVR

AIMS

The prognostic impact of flow trajectories according to stroke volume index (SVi) and transvalvular flow rate (FR) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) remains poorly assessed. We evaluated and compared SVi and FR prior and after TAVR for severe AS.

METHODS AND RESULTS

Patients were categorized according to SVi (<35 mL/m2) and FR (<200 mL/s). The association of pre- and post-TAVR SVi and FR with all-cause mortality up to 3 years was assessed with multivariable Cox regression models. Among 980 patients with pre-TAVR flow assessment, SVi was reduced in 41.3% and FR in 48.1%. Baseline flow status was not an independent mortality predictor [SVi: hazard ratio (HR) 1.22, 95% confidence interval (CI) 0.85-1.82, FR: HR 0.78, 95% CI 0.48-1.27]. Among 731 patients undergoing early (5 days, interquartile range 2-29) post-TAVR flow assessment, SVi recovered in 40.1% and FR in 49.0% patients with baseline low flow. Reduced FR following TAVR was an independent predictor of mortality (HR 1.67, 95% CI 1.02-2.74), whereas SVi was not (HR 0.97, 95% CI 0.53-1.78). Three-year estimated mortality in patients with recovered FR was lower than that in patients with reduced FR (13.3 vs. 37.7% vs, P = 0.003) and similar to that in patients with normal baseline FR (P = 0.317).

CONCLUSION

Baseline flow status was not an independent predictor of mid-term mortality among all-comers with severe AS undergoing TAVR. Flow recovery early after TAVR was frequent. Post-TAVR FR, but not SVi, was independently associated with mid-term all-cause mortality. By impacting flow status, AV replacement modifies the association of flow status with outcomes.

429 KOUNIS-ZAVRAS SYNDROME: UNDERREPRESENTED OR UNDERDIAGNOSED?

A 64-year-old man was admitted to the emergency department for a major allergic reaction to an insect bite. On physical examination, he presented with tachycardia, hypotension and diffuse pomphoid erythema requiring treatment with intravenous cortisone and antihistamines, with partial benefit. From his past medical history hypertension and previous percutaneous coronary intervention (PCI) with drug eluting stents (DES) on left anterior descendant (LAD) and circumflex coronary artery (Cx) for stable angina emerged.

Almost 15 minutes after his admission he developed oppressive chest pain and dyspnea, so an electrocardiogram (EKG) was performed showing an ST segment elevation in inferior-posterior-lateral leads. Therefore, the patient was transferred to the Cath Lab to perform a coronary angiography study with finding of intrastent thrombosis (IST) of Cx and LAD and sub-occlusion of the posterior interventricular branch of the right coronary artery (RCA), not responsive to nitrates. PCI was performed with manual thrombus aspiration and high pressure non-compliant balloons of the IST and PCI with a single DES of the RCA lesion. The patient was then transferred to coronary intensive care unit. Echocardiography revealed a normal left ventricle ejection fraction without any wall motion abnormalities and the EKG showed a complete ST resolution. Laboratory exams showed increased troponin, typical of myocardial infarction, and an increase in IgE and serum tryptase, typical for an allergic reaction. Based on clinical, angiographic and biochemical data, diagnosis of type III Kounis-Zavras (KS) syndrome was made. KS is an acute coronary event in the setting of a hypersensitivity reaction which trigger the release of inflammatory mediators by activated mast cell leading to coronary artery spasm, atheromatous plaque rupture or stent thrombosis. Optimal medical therapy for both ischemic heart disease and allergic reaction was set, with ace inhibitor, high dose statin, non-dihydropyridine calcium channel blocker, dual antiplatelet therapy, antihistamines and cortisone with a decalage scheme. There is no consensus for KS management and the difficulty lies in the fact that treating one of the two concomitant conditions could worsen the other.

Three variants of this syndrome have been described in the literature. Type I KS is characterized by coronary spasm in patients typically lacking cardiovascular risk factors and coronary arteries free from atheromatous lesions. Type II KS is characterized by instability of an already present coronary plaque. Type III KS is characterized by intrastent thrombosis in patients with previous coronary angioplasty. Several factors incriminated in KS syndrome have been described, including medications (such as antibiotics, analgesics and anti-inflammatories) and environmental factors (such as, bee sting, viper venom, wasp sting). The underlying pathophysiological process involves a series of mediators, such as histamine and tryptase, released by activated mast cells locally during an immunological reaction. KS syndrome is a real challenge since there is no definitive guidelines for diagnosis, management and treatment and the plethora of clinical presentation range from angina pectoris with mild atopic dermatitis to acute coronary syndrome with cardiogenic shock and anaphylaxis. This broad spectrum of clinical manifestations associated with the increasing new triggers (drugs, contrast dye, insects) often leads to a misdiagnosis with a delay of the proper administration of the effective therapy, sometimes resulting fatal.

891 EARLY EVOLUTION OF CARDIAC DAMAGE STAGING FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT: PREVALENCE, CLINICAL PATTERNS AND PROGNOSTIC SIGNIFICANCE

Background

The early evolution of extravalvular cardiac damage following transcatheter aortic valve replacement (TAVR) as assessed by a previous validated score system remains unstudied. We sought to assess the patterns of early cardiac damage change among patients with severe aortic stenosis (AS) undergoing TAVR and its prognostic implications.

Methods

The RECOVERY-TAVR is a multi-center, international retrospective registry including all consecutive patients undergoing TAVR in thirteen high-volume centers. All the enrolled patients with available paired echocardiography assessment pre- and post TAVR were included in this sub-analysis. Patients were categorized according to the extension of cardiac damage based on a previous published and validated classification (stage 0, no damage; stage 1, left ventricular damage; stage 2, left atrial or mitral valve damage; stage 3, pulmonary vasculature or tricuspid valve damage; and stage 4, right ventricular damage). The primary endpoint was a composite of all-cause mortality or first heart failure hospitalization at 1 year. The association of cardiac damage stage evaluated prior and following TAVR along with the staging evolution was assessed with multivariate Cox regression model (that include hemoglobin, NYHA class and max aortic valve gradient) for the primary outcome.

Results

Of 1331 Patients included in the RECOVERY-TAVR registry with a full echocardiographic pre-TAVR assessment, 892 patients with available paired echocardiography exams were finally included in this analysis (pre-TAVR assessment: median 8 days prior to TAVR; post-TAVR assessment: median 7 days post-TAVR). 63 (7.1%) had stage 0/1, 433 (48.2%) had stage 2, 235 (26.3%) had stage 3 and 161 (18%) had stage 4 myocardial damage. Pre-TAVR myocardial damage staging was associated with the primary outcome (Adj-HR for myocardial stage increase: HR 1.40, 95% CI 1.01–1.93). Following TAVR 274 (30.7%) patients experienced myocardial damage improvement and 161 (18.1%) myocardial damage worsening. Post-TAVR myocardial damage staging was more strongly associated with the primary outcome (HR 1.55, 95%CI 1.14–2.10) as compared to pre-TAVR assessment. Male Sex (p = 0.044) and post-procedural permanent pacemaker implantation (p = 0.044) was associated with myocardial damage worsening, while the use of a balloon-expandable valve (p = 0.011) was associated with myocardial damage improvement. Early myocardial damage worsening (HR 1.89, 95%CI 1.12–3.21), but not early myocardial damage improvement (HR 0.86, 95%CI 0.54–1.37) was associated with the primary outcome.

Conclusion

In patients undergoing TAVR, the extent of extravalvular cardiac damage prior to and early after TAVR has an independent prognostic value while early myocardial damage worsening following TAVR portends a poor prognosis. Whether strategies to improve procedural success and treatments addressing extravalvular myocardial damage early following TAVR may improve outcomes has to be prospectively assessed.

651 ZERO FLUOROSCOPY CARDIAC ABLATION: A NOVEL WORKFLOW FOR ATRIAL FIBRILLATION

Background and Rationale

A fluoroscopy-based approach to an electrophysiological procedure is widely validated and has been recognized as the gold standard for a long time. The use of fluoroscopy exposes both the healthcare staff and the patient to a non-negligible dose of radiation. To minimize the risks associated with the use of fluoroscopy, it would be reasonable to perform ablation procedures with zero fluoroscopy. This approach is widely used in simple ablation procedures, but not in complex procedures. In atrial fibrillation (AF) ablation procedures, fluoroscopy remains the main technology used, particularly to guide the transseptal puncture.

Main results and Implications

We present a workflow to perform a complete zero-fluoroscopy ablation for AF ablation procedures using a 3D electro-anatomical mapping system, intracardiac echocardiography and a novel steerable guiding sheath that can be visualized on the mapping system. We present two AF ablation procedures, one performed on a patient with paroxysmal AF (Fig.1) and one with persistent AF (Fig. 2, Fig 3) during which we applied this novel workflow, achieving a successful pulmonary vein isolation without complications and complete zero-fluoroscopy exposure.

Circulating Biomarkers of Endothelial Dysfunction and Inflammation in Predicting Clinical Outcomes in Diabetic Patients with Critical Limb Ischemia

Critical limb ischemia (CLI) is a severe manifestation of peripheral artery disease characterized by ischemic pain, which is frequently associated with diabetes and non-healing lesions to inferior limbs. The clinical management of diabetic patients with CLI typically includes percutaneous transluminal angioplasty (PTA) to restore limb circulation and surgical treatment of diabetic foot ulcers (DFU). However, even after successful treatment, CLI patients are prone to post-procedure complications, which may lead to unplanned revascularization or foot surgery. Unfortunately, the factors predicting adverse events in treated CLI patients are only partially known. This study aimed to identify potential biomarkers that predict the disease course in diabetic patients with CLI. For this purpose, we measured the circulating levels of a panel of 23 molecules related to inflammation, endothelial dysfunction, platelet activation, and thrombophilia in 92 patients with CLI and DFU requiring PTA and foot surgery. We investigated whether these putative biomarkers were associated with the following clinical endpoints: (1) healing of the treated DFUs; (2) need for new revascularization of the limb; (3) appearance of new lesions or relapses after successful healing. We found that sICAM-1 and endothelin-1 are inversely associated with DFU healing and that PAI-1 and endothelin-1 are associated with the need for new revascularization. Moreover, we found that the levels of thrombomodulin and sCD40L are associated with new lesions or recurrence, and we show that the levels of these biomarkers could be used in a decision tree to assign patients to clusters with different risks of developing new lesions or recurrences.

Relationship between PCSK9 and endothelial function in patients with acute myocardial infarction

BACKGROUND AND AIMS

While the role of PCSK9 in lipid metabolism is well established, its link with endothelial function is less clear. The aim of the present study is to evaluate the relationship between PCSK9 and endothelial dysfunction in the setting of acute myocardial infarction.

METHODS AND RESULTS

To this purpose, we analyzed the serum of 74 patients with ST-elevation myocardial infarction (STEMI) at the time of admission and after 5 days. Endothelial dysfunction was evaluated as rate of apoptosis (AR) of human umbilical vein endothelial cells incubated with patients' serum. There was a good correlation between PCSK9 and the apoptosis rate values, both at baseline (r = 0.649) and 5-day (r = 0.648). In the 5 days after STEMI, PCSK9 increased significantly (242-327 ng/ml, p < 0.001), while AR did not (p = 0.491). Overall, 21 (28%) patients showed a reduction of PCSK9, and they had a significantly higher decrease of AR as compared to others (-13.87 vs 5.8%, p = 0.002). At the univariable analysis, the 5-day change of PCSK9 resulted to be the only variable associated with the 5-day change of the apoptosis rate (beta 0.217, 95%CI 0.091-0.344, p = 0.001).

CONCLUSION

The variation of endothelial function and PCKS9 in the first days after an acute myocardial infarction are related. Further validation and research are necessary to confirm our findings.

CLINICAL TRIAL

NCT02438085.