Genetic associations of cardiovascular risk genes in European patients with coronary artery spasm

BACKGROUND

Coronary artery spasm (CAS) is a frequent finding in patients presenting with angina pectoris. Although the pathogenesis of CAS is incompletely understood, previous studies suggested a genetic contribution. Our study aimed to elucidate genetic variants in a cohort of European patients with angina and unobstructed coronary arteries who underwent acetylcholine (ACh) provocation testing.

METHODS

A candidate association analysis of 208 genes previously associated with cardiovascular conditions was performed using genotyped and imputed variants in patients grouped in epicardial (focal, diffuse) CAS (n = 119) and microvascular CAS (n = 87). Patients with a negative ACh test result (n = 45) served as controls.

RESULTS

We found no association below the genome-wide significance threshold of p < 5 × 10-8, thus not confirming variants in ALDH2, NOS3, and ROCK2 previously reported in CAS patients of Asian ancestry. However, the analysis identified suggestive associations (p < 10-05) for the groups of focal epicardial CAS (CDH13) and diffuse epicardial CAS (HDAC9, EDN1). Downstream analysis of the potential EDN1 risk locus showed that CAS patients have significantly increased plasma endothelin-1 levels (ET-1) compared to controls. An EDN1 haplotype comprising rs9349379 and rs2070698 was significantly associated to ET-1 levels (p = 0.01).

CONCLUSIONS

In summary, we suggest EDN1 as potential genetic risk loci for patients with diffuse epicardial CAS, and European ancestry. Plasma ET-1 levels may serve as a potential cardiac marker.

Characterization of Tricuspid Valve Anatomy and Coaptation Gap in Subjects Receiving Tricuspid Transcatheter Edge-To-Edge Repair: Observations From the bRIGHT TriClip Study

BACKGROUND

Transcatheter edge-to-edge repair (TEER) for the treatment of tricuspid regurgitation (TR) has experienced fast adoption following commercial approval. Defining the appropriate target population for TEER therapy is important to guide patient selection. The aim of this study was to characterize tricuspid valve anatomy and coaptation gap in subjects receiving TEER for the treatment of TR in a contemporary postmarket setting.

METHODS

The bRIGHT study is a prospective, multicenter, single-arm, postmarket study evaluating the safety and effectiveness of the TriClip device. Procedural outcomes included implant success, acute procedural success, TR severity, major adverse events, single-leaflet device attachment, and embolization through 30 postprocedure days. Tricuspid valve characteristics, including morphology, annulus size, and leaflet mobility, were assessed via two-dimensional transesophageal echocardiography from the screening visit by an independent echo core lab to characterize subject variability. Coaptation gap measurements were taken in both the transgastric short-axis (TG SAX) and RV inflow/outflow views.

RESULTS

The independent echo core lab performed a detailed assessment of the tricuspid valve on 135 consecutive subjects with available TG SAX views from 24 sites. Tricuspid valve morphologies included 2 to 5 leaflets, with a non-trileaflet valve in 28% of subjects and ≥4 leaflets in 21% of subjects. The etiology of TR was functional in 91% (96/105), mixed in 7% (7/105), and lead induced in 2% (2/105) of subjects. Leaflet mobility was mildly restricted in 69% (78/113) and moderately restricted in 7% (8/113) of subjects. Annulus diameter averaged 4.7 ± 0.7 cm with a range of 2.5 to 6.2 cm. From the TG SAX view, the coaptation gap measured 8.1 ± 3.1 and 5.2 ± 2.3 mm in the central and mid regions of the anterior-septal coaptation line and 6.6 ± 3.2 and 3.8 ± 2.1 mm in the central and mid regions of the septal-posterior coaptation line, respectively. From the right ventricular inflow/outflow view, the coaptation gap measured 4.7 ± 2.4, 5.2 ± 2.4, and 4.6 ± 3.0 mm in the anterior, mid, and posterior regions of the tricuspid valve, respectively. Thirty-day TR reduction (by number of grades) was similar among subjects with coaptation gaps of <7 mm, 7 to 10 mm, and >10 mm.

CONCLUSION

A broad range of anatomies was observed in this postmarket population. Characterization of the tricuspid valve and coaptation gap will help to better understand and better define the target patient population for tricuspid TEER therapy.

Axillary vs Femoral Arterial Cannulation in Acute Type A Dissection: International Multicenter Data

BACKGROUND

Cannulation strategy in acute type A dissection (ATAD) varies widely without known gold standards. This study compared ATAD outcomes of axillary vs femoral artery cannulation in a large cohort from the International Registry of Acute Aortic Dissection (IRAD).

METHODS

The study retrospectively reviewed 2145 patients from the IRAD Interventional Cohort (1996-2021) who underwent ATAD repair with axillary or femoral cannulation (axillary group: n = 1106 [52%]; femoral group: n = 1039 [48%]). End points included the following: early mortality; neurologic, respiratory, and renal complications; malperfusion; and tamponade. All outcomes are presented as axillary with respect to femoral.

RESULTS

The proportion of patients younger than 70 years in both groups was similar (n = 1577 [74%]), as were bicuspid aortic valve, Marfan syndrome, and previous dissection. Patients with femoral cannulation had slightly more aortic insufficiency (408 [55%] vs 429 [60%]; P = .058) and coronary involvement (48 [8%] vs 70 [13%]; P = .022]. Patients with axillary cannulation underwent more total aortic arch (156 [15%] vs 106 [11%]; P = .02) and valve-sparing root replacements (220 [22%] vs 112 [12%]; P < .001). More patients with femoral cannulation underwent commissural resuspension (269 [30.9%] vs 324 [35.3%]; P = .05). Valve replacement rates were not different. The mean duration of cardiopulmonary bypass was longer in the femoral group (190 [149-237] minutes vs 196 [159-247] minutes; P = .037). In-hospital mortality was similar between the axillary (n = 165 [15%]) and femoral (n = 149 [14%]) groups (P = .7). Furthermore, there were no differences in stroke, visceral ischemia, tamponade, respiratory insufficiency, coma, or spinal cord ischemia.

CONCLUSIONS

Axillary cannulation is associated with a more stable ATAD presentation, but it is a more extensive intervention compared with femoral cannulation. Both procedures have equivalent early mortality, stroke, tamponade, and malperfusion outcomes after statistical adjustment.

Non-femoral focused transaxillary access in TAVI: GARY data analysis and future trends

BACKGROUND

In patients not suitable for transfemoral transcatheter aortic valve implantation (TAVI), several access strategies can be chosen.

AIM

To evaluate the use and patient outcomes of transaxillary (TAx), transapical (TA), and transaortic (TAo) as alternative access for TAVI in Germany; to further evaluate surgical cutdown vs. percutaneous TAx access.

METHODS

All patients entered the German Aortic Valve Registry (GARY) between 2011 and 2019 who underwent non-transfemoral TAVI were included in this analysis. Patients with TA, TAo, or TAx TAVI were compared using a weighted propensity score model. Furthermore, a subgroup analysis was performed for TAx regarding the percutaneous or surgical cutdown approach.

RESULTS

Overall, 9686 patients received a non-transfemoral access. A total of 8918 patients (92.1%) underwent TA, 398 (4.1%) TAo, and 370 (3.8%) TAx approaches. Within the TAx subgroup, 141 patients (38.1%) received subclavian cutdown, while 200 (54.1%) underwent a percutaneous approach. The TA patients had a significantly lower 30-day survival than TAx patients (TA 90.92% vs. TAx 95.59%, p = 0.006; TAo 92.22% vs. TAx 95.59%, p = 0.102). Comparing percutaneous and cutdown TAx approaches, no significant differences were seen. However, more vascular complications occurred (TA 1.8%, TAo 2.4%, TAx 12.2%; p < .001), and the hospital length of stay was shorter (TA 12.9 days, TAo 14.1 days, TAx 12 days; p < .001) after TAx access.

CONCLUSION

It may be reasonable to consider TAx access first in patients not suitable for TF-TAVI, because the 30-day survival was higher compared with TA access and the 1-year survival was higher compared with TAo access. It remains important for the heart teams to offer alternative access modalities for patients not amenable to the standard TF-TAVI approaches.

Deep Learning-Based Automated Labeling of Coronary Segments for Structured Reporting of Coronary Computed Tomography Angiography in Accordance With Society of Cardiovascular Computed Tomography Guidelines

PURPOSE

To evaluate a novel deep learning (DL)-based automated coronary labeling approach for structured reporting of coronary artery disease according to the guidelines of the Society of Cardiovascular Computed Tomography (CT) on coronary CT angiography (CCTA).

PATIENTS AND METHODS

A retrospective cohort of 104 patients (60.3 ± 10.7 y, 61% males) who had undergone prospectively electrocardiogram-synchronized CCTA were included. Coronary centerlines were automatically extracted, labeled, and validated by 2 expert readers according to Society of Cardiovascular CT guidelines. The DL algorithm was trained on 706 radiologist-annotated cases for the task of automatically labeling coronary artery centerlines. The architecture leverages tree-structured long short-term memory recurrent neural networks to capture the full topological information of the coronary trees by using a two-step approach: a bottom-up encoding step, followed by a top-down decoding step. The first module encodes each sub-tree into fixed-sized vector representations. The decoding module then selectively attends to the aggregated global context to perform the local assignation of labels. To assess the performance of the software, percentage overlap was calculated between the labels of the algorithm and the expert readers.

RESULTS

A total number of 1491 segments were identified. The artificial intelligence-based software approach yielded an average overlap of 94.4% compared with the expert readers' labels ranging from 87.1% for the posterior descending artery of the right coronary artery to 100% for the proximal segment of the right coronary artery. The average computational time was 0.5 seconds per case. The interreader overlap was 96.6%.

CONCLUSIONS

The presented fully automated DL-based coronary artery labeling algorithm provides fast and precise labeling of the coronary artery segments bearing the potential to improve automated structured reporting for CCTA.

Impact of Access Site on Periprocedural Bleeding and Cerebral and Coronary Events in High-Bleeding-Risk Percutaneous Coronary Intervention: Findings from the RIVA-PCI Trial

INTRODUCTION

The preference for using transradial access (TRA) over transfemoral access (TFA) in patients requiring percutaneous coronary intervention (PCI) is based on evidence suggesting that TRA is associated with less bleeding and fewer vascular complications, shorter hospital stays, improved quality of life, and a potential beneficial effect on mortality. We have limited study data comparing the two access routes in a patient population with atrial fibrillation (AF) undergoing PCI, who have a particular increased risk of bleeding, while AF itself is associated with an increased risk of thromboembolism.

METHODS

Using data from the RIVA-PCI registry, which includes patients with AF undergoing PCI, we analyzed a high-bleeding-risk (HBR) cohort. These patients were predominantly on oral anticoagulants (OAC) for AF, and the PCI was performed via radial or femoral access. Endpoints examined were in-hospital bleeding (BARC 2-5), cerebral events (TIA, hemorrhagic or ischemic stroke) and coronary events (stent thrombosis and myocardial infarction).

RESULTS

Out of 1636 patients, 854 (52.2%) underwent TFA, while 782 (47.8%) underwent the procedure via TRA, including nine patients with brachial artery puncture. The mean age was 75.5 years. Groups were similar in terms of age, sex distribution, AF type, cardiovascular history, risk factors, and comorbidities, except for a higher incidence of previous bypass surgeries, heart failure, hyperlipidemia, and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) < 60 ml/min in the TFA group. No clinically relevant differences in antithrombotic therapy and combinations were present at the time of PCI. However, upon discharge, transradial PCI patients had a higher rate of triple therapy, while dual therapy was preferred after transfemoral procedures. Radial access was more frequently chosen for non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP) cases (NSTEMI 26.6% vs. 17.0%, p < 0.0001; UAP 21.5% vs. 14.5%, p < 0.001), while femoral access was more common for elective PCI (60.3% vs. 44.1%, p < 0.0001). No differences were observed for ST-segment elevation myocardial infarction (STEMI). Both groups had similar rates of cerebral events (TFA 0.2% vs. TRA 0.3%, p = 0.93), but the TFA group had a higher incidence of bleeding (BARC 2-5) (4.2% vs. 1.5%, p < 0.01), mainly driven by BARC 3 bleeding (1.5% vs. 0.4%, p < 0.05). No significant differences were found for stent thrombosis and myocardial infarction (TFA 0.2% vs. TRA 0.3%, p = 0.93; TFA 0.4% vs. TRA 0.1%, p = 0.36).

CONCLUSIONS

In HBR patients with AF undergoing PCI for acute or chronic coronary syndrome, the use of TRA might be associated with a decrease in in-hospital bleeding, while not increasing the risk of embolic or ischemic events compared to femoral access. Further studies are required to confirm these preliminary findings.

Aortic Valve Repair Results in Better 1-Year Survival Than Replacement: Results From German Aortic Valve Registry

BACKGROUND

Aortic valve (AV) repair is an evolving surgical strategy in the treatment of nonelderly adults with aortic regurgitation. We aimed to determine the 1-year outcome after AV repair vs surgical AV replacement (sAVR) using real-world data from the German Aortic Valve Registry.

METHODS

A total of 8076 aortic regurgitation patients (mean age, 59.1 ± 15.0 years; 76% men; mean The Society of Thoracic Surgeons score, 1.3 ± 1.1), who underwent AV surgical procedures between 2011 and 2015, were identified from German Aortic Valve Registry. The AV was repaired in 2327 patients (29%), and the remaining 5749 patients (71%) underwent sAVR. A weighted propensity score model, including the variables of age, sex, and The Society of Thoracic Surgeons score, was used to correct for baseline differences between AV repair and sAVR cohorts. The primary end point was 1-year survival after AV repair vs sAVR. Secondary end points were freedom from cardiac events and AV reinterventions.

RESULTS

Survival at 1 year was 97.7% (95% CI, 97.0%-98.5%) in the AV repair cohort vs 96.4% (95% CI, 95.9%-96.9%) in the propensity score-weighted sAVR cohort (log-rank P < .001). Cox regression revealed a significant advantage of AV repair vs sAVR (hazard ratio, 0.68; 95% CI, 0.51-0.90; P < .0001) on 1-year survival, which was independent of age. Cardiac event-free survival at 1 year was 85.7% (95% CI, 483.8%-87.7%) in the AV repair group vs 81.7% (95% CI, 80.7%-82.9%) in the sAVR group (log-rank P < .001). AV reintervention was required in 38 AV repair patients (1.6%) compared with 1.6% in the sAVR cohort (P = .59).

CONCLUSIONS

AV repair surgery, whenever intraoperatively feasible, is associated with a significantly better 1-year survival and 1-year cardiac event-free survival compared with sAVR.

Comparison of contemporary transcatheter heart valve prostheses: data from the German Aortic Valve Registry (GARY)

BACKGROUND

Various second-generation transcatheter heart valve (THV) prostheses with high clinical efficacy and safety are available, but there is limited large-scale data available comparing their hemodynamic performance and clinical implications.

OBJECTIVE

To compare the hemodynamic performance and short-term clinical outcome of four second-generation THV prostheses.

METHODS

24,124 patients out of the German Aortic Valve Registry who underwent transfemoral transcatheter aortic valve implantation (TAVI) (Evolut™ R n = 7028, Acurate neo™ n = 2922, Portico n = 878 and Sapien 3 n = 13,296) were included in this analysis. Propensity-score weighted analysis was performed to control for differences in age, left ventricular function, STS score and sex. Primary endpoint was survival at one-year, secondary endpoints were 30 days survival, pre-discharge transvalvular gradients, paravalvular leakage and peri-procedural complications.

RESULTS

Thirty-day and one-year survival were not significantly different between the four patient groups. Transvalvular gradients in Evolut™ R and Acurate neo™ were significantly lower as compared to Portico and Sapien 3 at hospital discharge. This difference exists across all annulus sizes. Paravalvular leakage ≥ II occurred significantly less often in the Sapien 3 group (1.2%, p < 0.0001). Rate of severe procedural complications was low and comparable in all groups. Permanent pacemaker implantation rate at one year was lowest in the ACUARATE neo group (13.0%) and highest in the Evolut™ R group (21.9%).

CONCLUSION

Albeit comparable short-term clinical outcomes there are certain differences regarding hemodynamic performance and permanent pacemaker implantation rate between currently available THV prostheses which should be considered for individual prosthesis selection.

Persistent atrial fibrillation without the evidence of low-voltage areas: a prospective randomized trial

BACKGROUND

An effective therapy of persistent atrial fibrillation beyond pulmonary vein isolation remains unsatisfactory. Targeting endocardial low-voltage areas represents an approach of substrate modification. This prospective, randomized study investigated the efficacy of ablation of low-voltage areas versus PVI and additional linear ablations in patients with persistent atrial fibrillation in terms of single-procedure arrhythmia-free outcome and safety.

METHODS AND RESULTS

A total number of 100 patients undergoing de-novo catheter ablation for persistent AF were randomized in a 1:1 ratio into two different treatment arms: group A: pulmonary vein isolation (PVI) and, if low-voltage areas were present, a substrate modification. Group B: PVI and, if atrial fibrillation persisted, additional ablations, such as linear ablation and/or ablation of non-PV triggers. A total of 50 patients were randomized into each group without significant differences in baseline characteristics. During a mean follow-up of 17.64 ± 4.5 months after a single procedure, 34 (68%) patients of group A were free of arrhythmia recurrence versus 28 (56%) patients in group B (p = ns). In group A, 30 (60%) patients did not show endocardial fibrosis and received solely PVI. Both procedures were performed with a low number of complications; no pericardial effusion or stroke were seen in either group.

CONCLUSIONS

A significant proportion of patients with persistent atrial fibrillation do not show low-voltage areas. A total of 70% of the patients receiving solely PVI did not show any recurrence of atrial fibrillation, and therefore, extensive additional ablation should be avoided in de-novo patients.

Editor's Choice - Trends in Management and Outcomes of Type B Aortic Dissection: A Report From the International Registry of Aortic Dissection

OBJECTIVE

To describe the trends in management and outcomes of patients with acute type B aortic dissection in the International Registry of Acute Aortic Dissection.

METHODS

From 1996 - 2022, 3 908 patients were divided into similar sized quartiles (T1, T2, T3, and T4). In hospital outcomes were analysed for each quartile. Survival rates following admission were compared using Kaplan-Meier analyses with Mantel-Cox Log rank tests.

RESULTS

Endovascular treatment increased from 19.1% in T1 to 37.2% in T4 (ptrend < .001). Correspondingly, medical therapy decreased from 65.7% in T1 to 54.0% in T4 (ptrend < .001), and open surgery from 14.8% in T1 to 7.0% in T4 (ptrend < .001). In hospital mortality decreased in the overall cohort from 10.7% in T1 to 6.1% in T4 (ptrend < .001), as well as in medically, endovascularly and surgically treated patients (ptrend = .017, .033, and .011, respectively). Overall post-admission survival at three years increased (T1: 74.8% vs. T4: 77.3%; p = .006).

CONCLUSION

Considerable changes in the management of acute type B aortic dissection were observed over time, with a significant increase in the use of endovascular treatment and a corresponding reduction in open surgery and medical management. These changes were associated with a decreased overall in hospital and three year post-admission mortality rate among quartiles.

Direct oral anticoagulants versus vitamin K antagonist after transcatheter aortic valve implantation

OBJECTIVE

After transcatheter aortic valve implantation (TAVI), the optimal regimen of anticoagulant therapy in patients with an additional indication for oral anticoagulation remains a matter of debate. This study investigates the efficacy of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients after TAVI in a real-world population.

METHODS

The German Aortic Valve RegistrY (GARY) is a prospective, multicentre registry enrolling patients undergoing invasive treatment for aortic valve disease. From January 2011 to December 2019, 1 41 790 patients from 92 hospitals in Germany were enrolled. Anticoagulatory treatment regimens were assessed at hospital discharge for patients after TAVI procedures. All-cause mortality and the combined endpoint 'cardiac and cerebrovascular events' containing myocardial infarction, stroke, transient ischaemic attack, aortic prosthesis reintervention and all-cause mortality in the first year after TAVI were examined by treatment regimen.

RESULTS

Of 45 598 patients (mean age 80.7±5.7 years, 49.3% males) undergoing TAVI, 16 974 patients (37.2%) received an anticoagulant regimen that included VKA or DOAC. Hereof, the majority of patients were prescribed VKA (n=11 333, 66.8%) compared with DOAC (n=5641, 33.2%) with an increase of DOAC use from 9.4% in 2011 to 69.9% in 2019. During the 1-year follow-up, the absolute event rates per 100 person-years for all-cause mortality and the combined endpoint cardiac and cerebrovascular events were 1.9 and 1.3 for VKA-treated and 1.7 and 1.2 for DOAC-treated patients, respectively. After adjustment for baseline confounders, all-cause mortality (HR 0.95, 95% CI 0.88 to 1.01, p=0.114) and cardiac and cerebrovascular event-free survival (HR 0.93, 95% CI 0.86 to 1.01, p=0.071) did not differ significantly between VKA and DOAC groups.

CONCLUSIONS

This study supports evidence of the efficacy of DOAC use after TAVI in patients with an indication for oral anticoagulation.

Characterization and implications of intracoronary hemodynamic assessment during coronary spasm provocation testing

BACKGROUND

Current diagnostic criteria for coronary spasm are based on patient's symptoms, ECG shifts and epicardial vasoconstriction during acetylcholine (ACh) spasm testing.

AIMS

To assess the feasibility and diagnostic value of coronary blood flow (CBF) and resistance (CR) assessment as objective parameters during ACh testing.

METHODS

Eighty-nine patients who underwent intracoronary reactivity testing including ACh testing with synchronous Doppler wire-based measurements of CBF and CR were included. Coronary microvascular and epicardial spasm, respectively, were diagnosed based on COVADIS criteria.

RESULTS

Patients were 63 ± 13 years old, predominantly female (69%) and had preserved LV ejection fraction (64 ± 8%). Overall, assessment of CBF and CR during ACh testing revealed a decrease in CBF of 0.62 (0.17-1.53)-fold and an increase of CR of 1.45 [0.67-4.02]-fold in spasm patients compared to 2.08 (1.73-4.76) for CBF and 0.45 (0.44-0.63) for CR in patients without coronary spasm (both p < 0.01). Receiver operating characteristic revealed a high diagnostic ability of CBF and CR (AUC 0.86, p < 0.001, respectively) in identifying patients with coronary spasm. However, in 21% of patients with epicardial spasm and 42% of patients with microvascular spasm a paradoxical response was observed.

CONCLUSIONS

This study demonstrates feasibility and potential diagnostic value of intracoronary physiology assessments during ACh testing. We observed opposite responses of CBF and CR to ACh in patients with positive vs. negative spasm test. While a decrease in CBF and an increase in CR during ACh seem pathognomonic for spasm, some patients with coronary spasm demonstrate paradoxical ACh response demanding further scientific investigations.

Drug repurposing-a promising approach for patients with angina but non-obstructive coronary artery disease (ANOCA)

In today's era of individualized precision medicine drug repurposing represents a promising approach to offer patients fast access to novel treatments. Apart from drug repurposing in cancer treatments, cardiovascular pharmacology is another attractive field for this approach. Patients with angina pectoris without obstructive coronary artery disease (ANOCA) report refractory angina despite standard medications in up to 40% of cases. Drug repurposing also appears to be an auspicious option for this indication. From a pathophysiological point of view ANOCA patients frequently suffer from vasomotor disorders such as coronary spasm and/or impaired microvascular vasodilatation. Consequently, we carefully screened the literature and identified two potential therapeutic targets: the blockade of the endothelin-1 (ET-1) receptor and the stimulation of soluble guanylate cyclase (sGC). Genetically increased endothelin expression results in elevated levels of ET-1, justifying ET-1 receptor blockers as drug candidates to treat coronary spasm. sGC stimulators may be beneficial as they stimulate the NO-sGC-cGMP pathway leading to GMP-mediated vasodilatation.

Short-term Outcomes of Tricuspid Edge-to-Edge Repair in Clinical Practice

BACKGROUND

Severe tricuspid regurgitation (TR) is known to be associated with substantial morbidity and mortality.

OBJECTIVES

To study the acute outcomes of subjects treated by tricuspid transcatheter edge-to-edge repair with the TriClip system in a contemporary, real-world setting.

METHODS

The bRIGHT post-approval study is a prospective, single-arm, open-label, multicenter, post-market registry conducted at 26 sites in Europe. Echocardiographic assessment was performed at a core laboratory.

RESULTS

Enrolled subjects were elderly (79 ± 7 years) with significant comorbidities. Eighty-eight percent had baseline massive or torrential TR and 80% percent of subjects were in NYHA class III or IV. Successful device implantation occurred in 99% of subjects and TR was reduced to ≤moderate at 30 days in 77%. Associated significant improvements in NYHA class (20% to 79% I/II, p < 0.0001) and KCCQ score (19 ± 23 points improvement, p < 0.0001) were observed at 30 days. With baseline TR grade removed as a variable, smaller RAV and smaller tethering distance at baseline were independent predictors of TR reduction to ≤ moderate at discharge (OR:0.679, CI: [0.537, 0.858], p = 0.0012; OR: 0.722, CI: [0.564, 0.924], p=0.0097). Fourteen (2.5%) subjects experienced a major adverse event at 30 days.

CONCLUSIONS

Transcatheter tricuspid valve repair was found to be safe and effective in treating significant TR in a diverse, real-world population.

Development and validation of explainable machine learning models for risk of mortality in transcatheter aortic valve implantation: TAVI risk machine scores

Aims

Identification of high-risk patients and individualized decision support based on objective criteria for rapid discharge after transcatheter aortic valve implantation (TAVI) are key requirements in the context of contemporary TAVI treatment. This study aimed to predict 30-day mortality following TAVI based on machine learning (ML) using data from the German Aortic Valve Registry.

Methods and results

Mortality risk was determined using a random forest ML model that was condensed in the newly developed TAVI Risk Machine (TRIM) scores, designed to represent clinically meaningful risk modelling before (TRIMpre) and in particular after (TRIMpost) TAVI. Algorithm was trained and cross-validated on data of 22 283 patients (729 died within 30 days post-TAVI) and generalisation was examined on data of 5864 patients (146 died). TRIMpost demonstrated significantly better performance than traditional scores [C-statistics value, 0.79; 95% confidence interval (CI)] [0.74; 0.83] compared to Society of Thoracic Surgeons (STS) with C-statistics value 0.69; 95%-CI [0.65; 0.74]). An abridged (aTRIMpost) score comprising 25 features (calculated using a web interface) exhibited significantly higher performance than traditional scores (C-statistics value, 0.74; 95%-CI [0.70; 0.78]). Validation on external data of 6693 patients (205 died within 30 days post-TAVI) of the Swiss TAVI Registry confirmed significantly better performance for the TRIMpost (C-statistics value 0.75, 95%-CI [0.72; 0.79]) compared to STS (C-statistics value 0.67, CI [0.63; 0.70]).

Conclusion

TRIM scores demonstrate good performance for risk estimation before and after TAVI. Together with clinical judgement, they may support standardised and objective decision-making before and after TAVI.

Usefulness of wearable electrocardiography devices in patients experiencing paroxysmal cardiac-related symptoms: A case series of the "CardioSecur" system

Background

Electrocardiograms (ECGs) recorded with wearable devices and additional smartphone apps play an increasing role in cardiology.

Case summaries

We present two cases in which it was possible to record an ECG during cardiac-related symptoms using the patients' smartphones. Previous standard resting and 24-hour ECGs had revealed no pathologies. In one case, AV nodal reentry tachycardia was detected and treated accordingly. In the second case, ischemic ECG changes were recorded in a young woman without cardiovascular risk factors during a chest pain episode. Suspecting a coronary vasomotion disorder, an invasive diagnostic procedure was performed. The acetylcholine spasm provocation test revealed coronary microvascular spasm and appropriate therapy was initiated.

Discussion

Smartphone-based ECG systems which can be used by the patient independently while experiencing cardiac-related symptoms are a modern diagnostic tool. Considering the use of these systems is beneficial for early diagnosis and appropriate treatment for paroxysmal arrhythmias and coronary vasomotion disorders.

Feasibility and Challenges of Transcatheter Edge-to-Edge Repair for Very Large Tricuspid Valve Gaps

Massive and torrential tricuspid regurgitation may be accompanied by very large gaps, posing a challenge for transcatheter edge-to-edge repair (TEER). These 2 cases involve patients who underwent successful TEER despite very large gaps. Both patients experienced significant improvement after TEER. Feasibility and challenges of TEER in very large gaps are presented. (Level of Difficulty: Advanced.).

Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection

BACKGROUND

Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details.

METHODS

Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI.

RESULTS

A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001).

CONCLUSIONS

AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.

Current status of antithrombotic therapy and in-hospital outcomes in patients with atrial fibrillation undergoing percutaneous coronary intervention in Germany

BACKGROUND

Little is known about current patterns of antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in clinical practice in Germany.

METHODS

The RIVA-PCI is a prospective, non-interventional, multicenter study with follow-up until hospital discharge including consecutive patients with AF undergoing PCI.

RESULTS

Between January 2018 and March 2020, 1636 patients (elective in 52.6%, non-ST elevation acute coronary syndrome [NSTE-ACS] in 39.3%, ST-elevation myocardial infarction in 8.2%) from 51 German hospitals were enrolled in the study. After PCI a dual antithrombotic therapy (DAT) consisting of OAC and a P2Y12 inhibitor was given to 66.0%, triple antithrombotic therapy (TAT) to 26.0%, dual antiplatelet therapy to 5.5%, and a mono-therapy to 2.5% of the patients. Non-vitamin K antagonist oral anticoagulants (NOACs) were given to 82.4% and vitamin K antagonists to 11.5% of the patients. In-hospital events included death in 12 cases (0.7%), myocardial infarction, stent thrombosis, and ischemic stroke in four (0.2%) patients each, while 2.8% of patients had bleeding complications. The recommended durations for DAT or TAT at discharge were 1 month (1.5%), 3 months (2.1%), 6 months (43.1%), and 12 months (45.6%), with a 6-month course of DAT (47.7%) most often recommended after elective PCI and a 12-month course of DAT (40.1%) after ACS.

CONCLUSION

The preferred therapy after PCI in patients with AF is DAT with a NOAC and clopidogrel. In-hospital ischemic and bleeding events were rare. The recommended durations for combination therapy vary considerably.

Rivaroxaban in Patients With Atrial Fibrillation Who Underwent Percutaneous Coronary Intervention in Clinical Practice

Little is known about the efficacy and safety of rivaroxaban in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) in clinical practice. We therefore conducted a prospective observational study to determine the rate of ischemic, embolic, and bleeding events in patients with AF and PCI treated with rivaroxaban in a real-world experience. The RIVA-PCI ("rivaroxaban in patients with AF who underwent PCI") (clinicaltrials.gov NCT03315650) is a prospective, noninterventional, multicenter study with a follow-up until 14 months, including patients with AF who underwent PCI discharged with rivaroxaban. Between January 2018 and March 2020, 700 patients with PCI treated with rivaroxaban (elective in 50.1%, non-ST-elevation acute coronary syndrome 43.0%, ST-elevation myocardial infarction in 6.9%) were enrolled at 51 German hospitals. After PCI, a dual antithrombotic therapy consisting of rivaroxaban and a P2Y12 inhibitor was administered in 70.7% and triple antithrombotic therapy in 27.9%, respectively. Follow-up information could be obtained in 695 patients (99.3%). Rivaroxaban has been stopped prematurely in 21.6% of patients. Clinical events under rivaroxaban during the 14-month follow-up compared with those observed in the PIONEER-AF PCI trial included cardiovascular death (2.0% % vs 2.0%), myocardial infarction (0.9% vs 3.0%), stent thrombosis (0.2% vs 0.8%), stroke (1.3% vs 1.3%), International Society on Thrombosis and Haemostasis major (4.2% vs 3.9%), and International Society on Thrombosis and Haemostasis nonmajor clinically relevant bleeding (15.3% vs 12.9%). Therefore, in this real-world experience, rivaroxaban in patients with AF who underwent PCI is associated with ischemic and bleeding event rates comparable with those observed in the randomized PIONEER-AF PCI trial.

[Clinical and procedural characteristics of patients with acute coronary syndrome during the COVID-19 pandemic 2020 compared to a control group from 2019]

BACKGROUND

During the COVID-19 pandemic medical treatments including emergencies were often delayed, in part because of fear of an infection with Sars-CoV-2. Even patients with an acute coronary syndrome (ACS) were affected by these circumstances. In the present study we provide a systematic comparison of patients with ACS during the COVID-19 pandemic compared to a control group.

METHODS

This is a retrospective cross-sectional study including all patients admitted with an ACS (STEMI, NSTEMI, unstable angina) undergoing coronary angiography between March 2019 and June 2019 (group A) and between March 2020 and June 2020 (group B). Demographic factors, cardiovascular risk factors and procedural data (extent of coronary disease, clinical diagnose, revascularisation strategy and outcome, use of mechanical support devices, door-to-needle time and in-hospital mortality) were compared.

RESULTS

469 patients were included in the present study (239 patients in group A and 230 in group B, mean age 69 years, 71% male). Compared to group A there were fewer patients with STEMI and unstable angina (p=0,033) but more patients with NSTEMI (p=0,047) in group B. Patients in group B had less often single vessel disease (p=0,001) but in contrast more often triple vessel disease compared to group A (p=0,052).

CONCLUSION

Despite overall comparable numbers of ACS patients those admitted during the COVID-19 pandemic were more frequently diagnosed with NSTEMI and had a larger extent of coronary disease compared to a control group.

CMR findings in patients referred for suspected myocarditis following mRNA-based COVID vaccination compared with pre-COVID myocarditis referrals: A single-centre observational study

Background

Vaccination is considered the key to overcome the COVID pandemic. For the first time mRNA-based vaccinations are used in humans. Case series suggested an increased risk of myocarditis after vaccination. This study sought to describe CMR findings in patients with suspected mRNA-vaccine associated myocarditis.

Methods

A total of 33 consecutive patients referred for CMR work-up of suspected myocarditis associated with mRNA-based vaccination were included. A historical cohort of 135 consecutive patients referred for suspected myocarditis in the pre-COVID era served as control group. All patients underwent multi-parametric CMR including CINE and late gadolinium enhancement (LGE) imaging as well as parametric T1/T2 mapping of the left ventricular myocardium.

Results

Patients referred for suspected vaccination-related myocarditis were more often female (55 % vs 32 %, p = 0.015) and demonstrated smaller LV dimensions as well as a better LV function compared to patients of the control group. CMR revealed a lower prevalence of non-ischemic LGE in patients with suspected vaccination-myocarditis (6 % vs 22 %, p = 0.04). However, among patients without LGE we observed a higher prevalence of an abnormal T1/T2 mapping result in patients with suspected vaccination-myocarditis compared to the control group (45 % vs 18 %, p = 0.010).

Conclusion

In this small single-centre study, compared to myocarditis referrals in the pre-COVID era, patients currently referred for CMR work-up of suspected mRNA-vaccination-associated myocarditis demonstrated lower prevalence of LGE but higher prevalence of abnormal T1/T2 mapping. These hypothesis-generating observations may point towards a rather subtle myocardial damage and support the routine use of T1/T2 mapping in this indication.

TAVI With or Without Predilation: Trends From a Large, Propensity-Score Weighted German Aortic Valve Registry (GARY) Population

BACKGROUND AND AIMS

Currently, it is unclear whether transcatheter aortic valve implantation (TAVI) without predilation (direct TAVI; d-TAVI) or with preimplantation balloon valvuloplasty (b-TAVI) provides similar clinical safety and efficacy. Therefore, we analyzed patients undergoing d-TAVI or b-TAVI for severe aortic stenosis (AS) with either self-expanding or balloon-expandable transcatheter heart valves (THVs) from the German Aortic Valve Registry (GARY).

METHODS

Between 2011 and 2017, a total of 44,783 TAVI patients were collected, with 25,717 (57.4%) receiving a balloon-expandable THV and 19,066 (42.6%) receiving a self-expanding THV. A propensity-score weighted model was used to compare d-TAVI vs b-TAVI regarding differences in outcome.

RESULTS

B-TAVI was performed in 71% and d-TAVI was performed in 29% of patients. In the investigated time interval, frequency of b-TAVI declined from 88.4% to 58.2%, accompanied by a constant rate of postdilation. After propensity weighting of patients receiving balloon-expandable THV, d-TAVI vs b-TAVI was associated with more frequent postoperative transvalvular mean pressure gradients (mPG) >15 mm Hg (20.7% vs 18.4%; P<.001), similar rates of paravalvular leakage (PVL) ≥ moderate (18.0% vs 16.9%; P=.08), fewer postdilations (13.4% vs 15.5%; P<.001), and fewer complications (permanent pacemaker implantation, 10.2% vs 11.9% [P=.01]; vascular complications, 1.9% vs 2.6% [P<.01]; pericardial tamponade, 0.5% vs 0.9% [P<.01]; and stroke, 0.9% vs 1.3% [P=.02]). In patients receiving self-expanding THVs, d-TAVI vs b-TAVI was associated with more frequent postimplantation mean PG ≥ 15 mm Hg (12.7% vs 10.4%; P<.01), higher rates of PVL ≥ moderate (24.8% vs 16.5%; P<.001), and similar complication rates including permanent pacemaker implantation.

CONCLUSIONS

The safety and efficacy of d-TAVI vs b-TAVI depends on the type of THV implanted. For balloon-expandable valves, d-TAVI provides an advantage, while self-expanding valves offer a similar safety profile for d-TAVI compared with b-TAVI. However, increased mPG post intervention with both valve types and more significant PVL in self-expanding THVs emphasize the importance of proper patient selection and evaluation of valve anatomy to identify suitable cases for d-TAVI.

A Novel Model to Predict 1-Year Mortality in Elective Transfemoral Aortic Valve Replacement: The TAVR-Risk Score

OBJECTIVES

We aimed to develop and validate an effective prediction model for 1-year mortality risk in elective transfemoral transcatheter aortic valve replacement (TAVR), ie, the TAVR-Risk (TARI) model.

BACKGROUND

TAVR is the primary treatment for patients with symptomatic severe aortic valve stenosis; however, risk assessment tools for longer-term outcomes after TAVR remain scarce.

METHODS

This retrospective cohort study used logistic regression to test univariate and multivariate associations. The German Aortic Valve Registry (GARY) was the derivation (n = 20,704) and the Swedish SWEDEHEART TAVR Registry (SWENTRY) was the validation cohort (n = 3982). The main outcome was the area under the curve (AUC) in the prediction of 1-year mortality. The final model included 12 parameters that were associated with 1-year mortality in a multivariate analysis.

RESULTS

The TARI model (AUC, 0.66; 95% confidence interval [CI] 0.65-0.67) performed better as compared with the Society of Thoracic Surgeons (STS) score (AUC, 0.63; 95% CI, 0.62-0.64; P<.001) and logistic EuroSCORE I (AUC, 0.60; 95% CI, 0.59-0.61; P<.001) in the GARY derivation cohort, and discriminated the risk for 1-year mortality better than logistic EuroSCORE I in the SWENTRY validation cohort (AUC, 0.62; 95% CI, 0.60-0.64 vs AUC, 0.59; 95% CI, 0.57-0.61; P=.04).

CONCLUSIONS

This novel TARI score provides a relatively easy-to-use risk model and offers a superior prediction for 1-year mortality in European TAVR patients.

TAVI versus SAVR in intermediate-risk patients with severe aortic stenosis and chronic kidney disease: a matched comparison in a subcohort from the GARY registry

Background

According to American and recent European guidelines, both transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) may be used to treat severe aortic stenosis in a subgroup of patients with intermediate surgical risk, in spite of slight differences in recommended age limits (ACC/AHA: 65–80 years and ESC/EACTS: &lt;75 years). A shared therapeutic decision is made with the patient, based on a heart team assessment. For this, individual factors should be taken into account. Concomitant chronic kidney disease (CKD) is a prognostic factor in such patients, and CKD stage ≥3a and ≥3b has been shown to be a significant independent risk factor for SAVR and TAVI, respectively.

Purpose

To compare TAVI vs. SAVR outcomes in a subgroup of patients for whom both therapies could possibly be considered according to current guidelines.

Methods

The large nation-wide German Aortic Valve Registry (GARY) includes data from patients treated with TAVI or SAVR. A subcohort of patients from GARY with intermediate surgical risk (age ≤80 years, STS-score 4–8) and moderate-to-severe chronic kidney disease (CKD stages 3a, 3b, and 4) was selected. A matched analysis of 704 patients undergoing TAVI and 374 undergoing SAVR was carried out using a propensity score method. Primary endpoint was 1-year survival. Clinical complications and specifically the need for postprocedural new-onset dialysis were secondary endpoints.

Results

TAVI and SAVR showed similar survival results at 1 year in a Kaplan-Meier analysis (HR [95% CI] for TAVI: 1.271 [0.795,2.031], p=0.316). Despite a numerically higher post-procedural short-term survival in TAVI patients and a numerically higher 1-year survival in SAVR patients, such differences did not reach statistical significance (96.4% vs. 94.2%, p=0.199, and 86.2% vs. 81.2%, p=0.316, respectively). In weighted analyses, need for permanent pacemaker, vascular complications, and moderate-to-severe valvular regurgitation were significantly more common with TAVI, whereas patients undergoing SAVR had significantly higher rates of myocardial infarction, and transient ischaemic attack, needed more transfusions for bleeding, and had a significantly longer intensive care unit stay and overall hospital stay. The need for new-onset dialysis for a limited time was more common after SAVR (p&lt;0.0001); however, very few patients required chronic dialysis either after TAVI or after SAVR.

Conclusion

In a matched analysis of intermediate-risk patients with severe aortic stenosis and a concomitant moderate-to-severe CKD, for whom both TAVI and SAVR could possibly be considered, both approaches showed excellent and comparable results.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The registry receives financial support in the form of unrestricted grants by medical device companies (Edwards Lifesciences, JenaValve Technology, Medtronic, Sorin, St. Jude Medical, Symetis S.A.).In addition, there is unrestricted support by funding statisticians by the DZHK (Deutsches Zentrum für Herz-Kreislaufforschung).

Impact of coaptation gap location on procedural strategy and outcomes following tricuspid transcatheter edge-to-edge repair: insights from the TriClip bRIGHT study

Background

As tricuspid transcatheter edge-to-edge repair (TEER) gains momentum, a better understanding of coaptation gap size and location becomes increasingly important to properly select patients for this therapy. The tricuspid valve is complex and patient phenotypes may be highly variable. It is currently unknown how location of the coaptation gap may impact procedural strategy and clinical outcomes.

Purpose

To characterize the coaptation gap in patients receiving tricuspid TEER and investigate the effect of coaptation gap location on procedural strategy and short-term outcomes.

Methods

bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe tricuspid regurgitation. Detailed echocardiographic coaptation gap measurements were performed on 135 subjects (from 24 sites) with available echo. Procedural and short-term outcomes were stratified by coaptation gap location.

Results

The biplane RV inflow/outflow and short-axis transgastric (SAX TG) views were available in 90% (122/135) and 56% (76/135) of subjects, respectively. From the SAX TG view, coaptation gap measured 8.2±3.4 and 5.2±2.4 mm in the central and mid regions of the anterior-septal (AS) coaptation line, and 6.5±3.0 and 3.7±2.0 mm in the central and mid regions of the septal-posterior (SP) coaptation line (Figure 1). Coaptation gap measured 4.7±2.4, 5.2±2.4 and 4.6±3.0 mm in the anterior, mid and posterior aspects of the RV inflow/outflow view. The largest coaptation gap presented in the AS region in 79% (95/120) of subjects. A comparison of baseline characteristics, procedural strategy and outcomes stratified by location of the largest coaptation gap is provided in Table 1. Annulus and right ventricle size and presence of pacemakers were similar between groups. Torrential TR at baseline was more common in the SP group. Clipping strategy was similar with the majority of implants placed in the AS region. Implant success and acute procedural success (APS) were achieved in the majority of patients in both groups, with the SP group showing higher APS rates, 96% vs 85%, respectively. At 30-day follow-up, subjects with the largest gap in the SP region experienced more TR reduction at 30-day follow-up, 2.8±1.6 vs 2.1±1.3 grade reduction, respectively. Clinical improvements were observed in both groups: KCCQ increased by more than 15 points on average and the majority of subjects in both groups were NYHA I/II at 30-day follow-up.

Conclusion

Coaptation gap size varies across the tricuspid valve and measurements at the intended clipping location should be taken into account when determining appropriateness of a given anatomy for tricuspid TEER. TriClip TEER offered high rates of implant and procedural success and improved clinical outcomes regardless of coaptation gap location. Subjects with SP coaptation gap localization are infrequent but should not be excluded from TEER therapy.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott

Coronary tortuosity in patients with acetylcholine-induced coronary microvascular spasm

Background

Angina pectoris in the absence of relevant epicardial stenoses (ANOCA) is frequently caused by coronary microvascular spasm. It has been speculated that the morphology of epicardial coronary arteries is associated with microvascular spasm. One hypothesis is that the vasoconstriction of microvessels leads to intraluminal pressure increase in the vascular segments proximal to the spasm, which may shift the balance of vessel forces toward vessel elongation resulting in coronary tortuosity.

Purpose

We assessed the relationship between epicardial coronary tortuosity and coronary spasm to elucidate a potential relationship between structural and functional coronary abnormalities.

Methods

610 patients (39% male, mean age 61 years) with stable angina yet unobstructed coronary arteries (&lt;50% stenosis) were included in this study. All patients underwent invasive diagnostic coronary angiography followed by intracoronary acetylcholine (ACh) testing according to a standardized protocol. The ACh test was considered “positive” in the presence of (a) angina, ischemic ECG shifts during the test and ≥90% coronary diameter reduction (“epicardial spasm”) or (b) all above without epicardial spasm (“microvascular spasm”). Assessment of coronary tortuosity was performed using left and right coronary images in multiple projections in a blinded fashion. The number and angles of the coronary curves in late diastole determined the severity of coronary tortuosity previously defined by Eleid. Patients were divided into those with at least moderate tortuosity versus those with no or mild tortuosity.

Results

ACh-testing revealed epicardial spasm in 179 (29%) and microvascular spasm in 172 (28%) patients. The ACh-test was negative/inconclusive in the remaining 259 patients (43%). There were 298 patients (49%) with at least moderate coronary tortuosity. The remaining 312 patients had no or mild coronary tortuosity (51%). Patients with at least moderate tortuosity were more likely to have microvascular spasm (99 patients of 172 with microvascular spasm had at least moderate coronary tortuosity (58%) vs. 76 patients of 179 with epicardial spasm (43%) vs. 126 patients of 259 with negative/inconclusive ACh test (49%), p=0.017). Analysis of coronary tortuosity in patients with positive ACh-test showed that patients with at least moderate coronary tortuosity (n=175) had significantly more microvascular spasm (57%) than epicardial spasm (43%) (p=0.005). We also found that at least moderate coronary tortuosity was significantly more often found in patients with hypertension compared to patients without hypertension (230/438 vs. 71/172, p=0.015).

Conclusions

In this large cohort of ANOCA patients coronary tortuosity was associated with hypertension and microvascular spasm. Our results provide interesting insights into the relationship of coronary morphology and vasomotor function.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Berthold-Leibinger-Foundation, Ditzingen, Germany

Survival after operative repair of acute type A aortic dissection varies according to the presence and type of preoperative malperfusion

OBJECTIVE

Approximately one-quarter of patients with acute type A aortic dissection (TAAD) present with concomitant malperfusion of coronary arteries, mesenteric circulation, lower extremities, kidneys, brain, and/or coma. It is generally accepted that TAAD patients who present with malperfusion experience higher mortality rates than patients without, although how specific malperfusion syndromes, alone or in combination, affect mortality is not well described.

METHODS

The International Registry of Acute Aortic Dissection database was queried for patients who underwent surgical repair of TAAD. Patients were stratified according to the presence/absence of malperfusion at presentation. Multivariable logistic regression was used to evaluate in-hospital mortality according to malperfusion type. Kaplan-Meier estimates were used to estimate 30-day postoperative survival.

RESULTS

Six thousand four hundred thirty-seven patients underwent surgical repair of acute TAAD, of whom 2642 (41%) had 1 or more preoperative malperfusion syndromes. Mesenteric malperfusion (adjusted odds ratio [AOR], 4.84; P < .001) was associated with the highest odds of in-hospital mortality, followed by coma (AOR, 1.88; P = .007), limb ischemia (AOR, 1.73; P = .008), and coronary malperfusion (AOR, 1.51; P = .02). Renal malperfusion (AOR, 1.37; P = .24) and neurologic deficit (AOR, 1.35; P = .28) were not associated with increased in-hospital mortality. In patients who survived to discharge, there was no difference in 1-year postdischarge survival in the malperfusion and no malperfusion cohorts (P = .36).

CONCLUSIONS

Survival during the index admission after TAAD repair varies according to the presence and type of malperfusion syndromes, with mesenteric malperfusion being associated with the highest odds of in-hospital death. Not only the presence of malperfusion but rather specific malperfusion syndromes should be considered when assessing a patient's risk of undergoing TAAD repair.

Propensity matched comparison of TAVI and SAVR in intermediate-risk patients with severe aortic stenosis and moderate-to-severe chronic kidney disease: a subgroup analysis from the German Aortic Valve Registry

OBJECTIVE

We compared TAVI vs. SAVR in patients with moderate-to-severe chronic kidney disease (eGFR 15-60 ml/min/1.73 m²) for whom both procedures could possibly be considered (age ≤ 80 years, STS-score 4-8).

BACKGROUND

According to both ACC/AHA and ESC/EACTS recent guidelines, aortic stenosis may be treated with either transcatheter (TAVI) or surgical (SAVR) aortic valve replacement in a subgroup of patients. A shared therapeutic decision is made by a heart team based on individual factors, including chronic kidney disease (CKD).

METHODS

Data from the large nationwide German Aortic Valve Registry were used. A propensity score method was used to select 704 TAVI and 374 SAVR matched patients. Primary endpoint was 1-year survival. Secondary endpoints were clinical complications, including pacemaker implantation, vascular complications, myocardial infarction, bleeding, and the need for new-onset dialysis.

RESULTS

One-year survival was similar (HR [95% CI] for TAVI 1.271 [0.795, 2.031], p = 0.316), with no divergence in Kaplan-Meier curves. In spite of post-procedural short-term survival being numerically higher for TAVI patients and 1-year survival being numerically higher for SAVR patients, such differences did not reach statistical significance (96.4% vs. 94.2%, p = 0.199, and 86.2% vs. 81.2%, p = 0.316, respectively). In weighted analyses, pacemaker implantation, vascular complications, and were significantly more common with TAVI; whereas myocardial infarction, bleeding requiring transfusion, and longer ICU-stay and overall hospitalization were higher with SAVR. Temporary dialysis was more common with SAVR (p < 0.0001); however, a probable need for chronic dialysis was rare and similar in both groups.

CONCLUSION

Both TAVI and SAVR led to comparable and excellent results in patients with moderate-to-severe CKD in an intermediate-risk population of patients with symptomatic severe aortic stenosis for whom both therapies could possibly be considered.

Management of patients with ST-segment myocardial infarction and multivessel disease: what are the options in 2022?

Multivessel coronary disease is a frequent finding in patients with STEMI. However, choosing the optimal treatment strategy for these patients can be challenging. The benefit of complete versus culprit-vessel-only revascularization demonstrated by several studies led to a change in the current 2018 ESC/EACTS revascularization guidelines recommending treatment of nonculprit lesions before hospital discharge. This article summarizes current data in this area, looks at remaining knowledge gaps and gives an outlook regarding ongoing trials. The latter will provide further robust evidence for the optimal management of patients with STEMI and multivessel disease.

Impact of machine-learning-based coronary computed tomography angiography-derived fractional flow reserve on decision-making in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

OBJECTIVES

To evaluate feasibility and diagnostic performance of coronary CT angiography (CCTA)-derived fractional flow reserve (CT-FFR) for detection of significant coronary artery disease (CAD) and decision-making in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) to potentially avoid additional pre-TAVR invasive coronary angiography (ICA).

METHODS

Consecutive patients with severe AS (n = 95, 78.6 ± 8.8 years, 53% female) undergoing pre-procedural TAVR-CT followed by ICA with quantitative coronary angiography were retrospectively analyzed. CCTA datasets were evaluated using CAD Reporting and Data System (CAD-RADS) classification. CT-FFR measurements were computed using an on-site machine-learning algorithm. A combined algorithm was developed for decision-making to determine if ICA is needed based on pre-TAVR CCTA: [1] all patients with CAD-RADS ≥ 4 are referred for ICA; [2] patients with CAD-RADS 2 and 3 are evaluated utilizing CT-FFR and sent to ICA if CT-FFR ≤ 0.80; [3] patients with CAD-RADS < 2 or CAD-RADS 2-3 and normal CT-FFR are not referred for ICA.

RESULTS

Twelve patients (13%) had significant CAD (≥ 70% stenosis) on ICA and were treated with PCI. Twenty-eight patients (30%) showed CT-FFR ≤ 0.80 and 24 (86%) of those were reported to have a maximum stenosis ≥ 50% during ICA. Using the proposed algorithm, significant CAD could be identified with a sensitivity, specificity, and positive and negative predictive value of 100%, 78%, 40%, and 100%, respectively, potentially decreasing the number of necessary ICAs by 65 (68%).

CONCLUSION

Combination of CT-FFR and CAD-RADS is able to identify significant CAD pre-TAVR and bears potential to significantly reduce the number of needed ICAs.

KEY POINTS

• Coronary CT angiography-derived fractional flow reserve (CT-FFR) using machine learning together with the CAD Reporting and Data System (CAD-RADS) classification safely identifies significant coronary artery disease based on quantitative coronary angiography in patients prior to transcatheter aortic valve replacement. • The combination of CT-FFR and CAD-RADS enables decision-making and bears the potential to significantly reduce the number of needed invasive coronary angiographies.

Outcomes of aortic valve repair: early results from the German Aortic Valve Registry

OBJECTIVES

Aortic valve (AV) repair is an evolving surgical strategy in the treatment of young patients with aortic regurgitation (AR) and/or aortic root aneurysm. We aimed to determine the clinical outcome following AV repair/AV sparing root surgery using real-world data from the German Aortic Valve Registry (GARY).

METHODS

A total of 2327 patients with AR (mean age 55.2 ± 15.0 years, 76% men), who underwent AV repair/AV sparing root surgery between 2011 and 2015 (i.e., 5% of 42.868 AV surgery patients enrolled in the GARY registry during the same period) were included. Study cohort was subdivided according to the technique of AV repair: isolated AV repair without root surgery (Group I) (n = 914), AV sparing root surgery (i.e., reimplantation or remodelling) without cusp repair (Group II) (n = 1077), and AV sparing root surgery (i.e., reimplantation or remodelling) with simultaneous cusp repair (Group III) (n = 336). Primary end-point was 1-year survival after AV repair/AV sparing root surgery. Secondary end-points were freedom from cardiac adverse events and freedom from AV reinterventions at 1-year follow-up.

RESULTS

30-day mortality was 19 (0.8%) in the whole study cohort without significant differences in the three subgroups (4 (0.4%) patients in Group I vs 14 (1.3%) patients in the Group II vs 1 (0.3%) patient in the Group III (p = 0.054)). Postoperatively, 1445 (74%) patients had no residual AR, 474 (24%) patients had mild AR, and 40 (2%) patients had moderate/severe AR at the time of hospital discharge. One-year survival (95% CI) was 97.7% (97.1-98.3) in the whole study cohort and without significant difference among the three subgroups. One-year cardiac adverse event-free survival (95% CI) was 85.7% (84.2-87.1) and was similar in all three study groups in propensity-score weighted analysis. A total of 38 (1.6%) patients required AV reintervention during a 1-year follow-up, without significant difference among subgroups (p = 0.11).

CONCLUSIONS

AV repair/AV sparing root surgery is performed in 5% of patients requiring AV surgery in Germany. Our data demonstrate very satisfactory periprocedural and 1-year survival and cardiac event-free survival after AV repair surgery. Implementation of specific surgical techniques during the index procedure seems to result in comparable outcomes.

Pulmonary vein isolation with high power, short duration ablation leads to shorter procedure times associated with high success rates: a Prospective Randomized Trial

Funding Acknowledgements

Type of funding sources: None.

Background

The single procedure success rates of durable pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) varies between 85 and 90 %.

This prospective, randomized study investigated the efficacy of high power, short duration ablation in a temperature-controlled mode versus standard power settings in terms of single-procedure arrhythmia-free outcome, safety and procedural time.

Methods and results

A total number of 176 patients undergoing de-novo catheter ablation for paroxysmal AF were randomized to two different treatment arms. In group-A patients, PVI was performed with RF-energy with standard power settings of 30 Watts in a temperature-controlled mode.

The ablation procedure in group B was performed with RF-energy with higher power settings of 45 Watts. In both groups the ablation was performed with ablation index (AI) and following the CLOSE protocol (Biosense Webster Thermocool STSF).

A total of 88 patients were randomized into each group without significant differences in baseline characteristics.

During a mean follow-up of 12 ± 4 months after a single procedure, 79 (90%) patients of group A were free of arrhythmia recurrence versus 82 (93 %) patients in group B (p=ns).

With regard to the procedural data, the procedure time was significantly shorter in group B (115.35 ± 15.38 versus 96.45 ± 17.19; p&lt;0.01), the flouroscopy time and dose area were also significantly lower in Group B (9.66 ± 3.86 vs 5.45 ± 2.35; 330.84 ± 150.36 vs 202.51 ± 135.23) and total ablation times were significantly shorter in group B ((Table 1). Both procedures were performed with a low number of complications, no pericardial effusion was seen in either group, in both groups two patients had a significant hematoma of the groin with the need of surgical repair.

Conclusions

RF-ablation with high power (45 Watts) in combination with ablation index and following the CLOSE protocol leads to shorter procedure times, a lower total ablation time and a good safety profile.

Characterization of coaptation gap in patients receiving tricuspid transcatheter edge-to-edge repair: initial observations from the bRIGHT TriClip study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

As tricuspid transcatheter edge-to-edge repair (TEER) gains momentum, the proper measurement of coaptation gap to determine optimal patients for this therapy becomes increasingly important. Currently, a single septo-lateral measurement from the short-axis transgastric (SAX TG) or RV inflow/outflow biplane view is commonly used as the representative coaptation gap measurement for a patient. However, this measurement is not necessarily performed at the intended location for TEER and may overestimate the coaptation gaps to be treated.

Purpose

To characterize the coaptation gap in patients receiving tricuspid TEER which may provide insights on how to best determine eligibility for edge-to-edge repair.

Methods

bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe tricuspid regurgitation. Detailed echocardiographic coaptation gap measurements were performed on the first 46 subjects with available echo data by two experienced echocardiographers.  Coaptation gap was measured at four levels in the SAX TG view (Figure 1) and also at the resulting long axis view from a orthogonal view taken from a RV inflow/outflow view obtained at the anterior, mid and posterior aspect of the tricuspid valve (Figure 2).

Results

The biplane RV inflow/outflow and SAX TG views were available in 91% (42/46) and 93% (43/46) of subjects, respectively. From the SAX TG view, coaptation gap measured 9.0 ± 3.9 and 4.9 ± 2.7 mm in the central and mid regions of the anterior-septal coaptation line, and 7.6 ± 3.4 and 4.0 ± 2.1 mm in the central and mid regions of the septal-posterior coaptation line (Figure 1). The largest coaptation gap presented between the anterior and septal leaflets in 78% (33/43) of subjects, with the gap extending across the anterior-septal and septal-posterior coaptation lines in  98% (42/43) of subjects.  Coaptation gap measured 6.2 ± 2.8, 6.6 ± 2.8 and 6.0 ± 3.5 mm in the anterior, mid and posterior aspects of the RV inflow/outflow view (Figure 2). In subjects with both views available, the SAX TG view resulted in larger coaptation gap measurements (+3.4 ± 3.0 mm) in 95% (38/40) of subjects. A significant, positive correlation was observed between the maximum biplane and transgastric measurements (rho = 0.648, p &lt; 0.0001).

Conclusion

A single septo-lateral measurement may overestimate the actual gap size and potentially exclude patients who are viable candidates for TEER. Measurements in both the SAX TG and RV inflow/outflow biplane should be taken into account when determining appropriateness of a given anatomy for tricuspid TEER Future work in larger cohorts is needed to determine which coaptation gap measurements are predictive of procedural outcomes and how these measurements may influence treatment strategy. Abstract Figure 1  Abstract Figure 2

Real-world outcomes for tricuspid edge-to-edge repair: initial echocardiographic results from the TriClip bRIGHT study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

Tricuspid regurgitation (TR) is a frequent disease with a graded increase in mortality as disease severity increases. The TriClip tricuspid valve repair system (TVRS) recently gained CE mark approval in March 2020 as a transcatheter treatment option for severe TR. The bRIGHT study was initiated to evaluate real-world safety and efficacy in patients treated with the TriClip TVRS and gather data to better understand these patients and this disease.

Purpose

To report real-world, core lab adjudicated changes in TR severity and echocardiographic parameters from baseline through 30-day follow-up in subjects treated with tricuspid transcatheter edge-to-edge repair (TEER).

Methods

bRIGHT is a prospective, multi-center, single arm post-market study evaluating the safety and effectiveness of the TriClip device in symptomatic patients with severe TR.  Detailed echocardiographic assessment was performed on all available echo data for the first 175 enrolled subjects by an independent echo core lab. TR was categorized using a 5-grade scale, with the traditional "severe" grade further characterized as severe, massive and torrential.

Results

At baseline, TR was "severe" in 98% (143/146) of subjects, which further stratifies to severe in 9% (13/146), massive in 63% (92/146) and torrential in 26% (38/146) of subjects using the 5-grade scale. At 30 days, TR was reduced by ≥1 grade in 81% of subjects, with 70% of subjects at moderate or less residual TR compared to only 1% at baseline (p &lt; 0.0001, Figure 1). Vena contracta width decreased from 0.79 ± 0.56 mm at baseline to 0.41 ± 0.37 mm at 30 days. Effective regurgitant orifice (EROA) area decreased from 0.87 ± 0.57 cm2 at baseline to 0.38 ± 0.25 cm2 at 30-days. Similarly, regurgitant volume, PISA radius and jet area showed significant reductions (Table 1). RV end diastolic dimension decreased from 4.70 ± 0.85 cm at baseline to 4.22 ± 0.83 cm at 30 days. No changes were observed in right atrial volume or right ventricular function. Subjects were treated with 1.9 ± 0.7 clips on average, with less than a 1 mmHg increase in mean tricuspid valve gradient; average gradient was 1.12 ± 0.65, 1.92 ± 1.15 and 1.97 ± 1.81mm Hg at baseline, discharge and 30 days respectively.  Tricuspid annular diameter was significantly higher in subjects with torrential TR at baseline compared to subjects with severe or massive TR (p &lt; 0.001).

Conclusions

Tricuspid TEER with the TriClip device showed significant reduction in TR severity in a real-world setting. Significant reduction were seen in vena contracta width, PISA radius, EROA, regurgitant volume and jet area among others. The majority of patients had massive TR at baseline. Future studies in larger cohorts are needed to investigate the relationship between the extent of TR reduction and clinical outcomes. Abstract Figure 1  Abstract Table 1

Procedural Results of Patients Undergoing Transcatheter Aortic Valve Implantation With Aortic Annuli Diameter ≥26 mm: insights from the German Aortic Valve Registry

Patients presenting with severe aortic stenosis and large aortic annuli are challenging to treat because of the size limitations of available transcatheter heart valves. In this study, we aimed to determine clinical and hemodynamic outcomes in patients presenting with large aortic annuli who underwent transcatheter aortic valve implantation (TAVI). Patients from the German Aortic Valve Registry who underwent TAVI either with the Edwards Sapien (ES) or Medtronic CoreValve (MCV) systems from 2011 to 2017 were included. They were further stratified into a large (aortic annulus diameter 26 to 29 mm for ES; 26 to 30 mm for MCV) and extra-large (aortic annulus diameter >29 mm for ES; >30 mm for MCV) group and analyzed using propensity score adjustment. Extra-large was set beyond the sizing limitations according to the manufacturer's instructions for use. Patients in the large (n = 5,628) and extra-large (n = 509) groups were predominantly male (large: 92.6% vs extra-large: 91.9%). The 30-day mortality was comparable (large: 3.9% vs extra-large: 5.0%, p = 0.458). Procedure duration (large: 78.9 minutes ± 0.82 vs extra-large: 86.4 minutes ± 1.9, p <0.001) was longer in the extra-large group. Likewise, vascular complications (large: 6.2% vs extra-large: 12%, p = 0.002) and the need for a permanent pacemaker implantation (large: 18.8% vs extra-large: 26.0%, p = 0.027) were more often present in the extra-large group. Aortic regurgitation ≥II after valve implantation was numerically higher (large: 3.0% vs extra-large: 5.3%, p = 0.082) in patients with extra-large anatomy. In conclusion, patients with large and extra-large aortic annulus diameters who underwent TAVI have comparable 30-day mortality. Beyond the recommended annulus range, there is a higher risk for vascular complications and permanent pacemaker implantation.

Definitions and Epidemiology of Coronary Functional Abnormalities

Coronary functional abnormalities are frequent causes of angina pectoris, particularly in patients with unobstructed coronary arteries. There is a spectrum of endotypes of functional coronary abnormalities with different mechanisms of pathology including enhanced vasoconstriction (i.e. coronary artery spasm) or impaired vasodilatation, such as impaired coronary flow reserve or increased microvascular resistance. These vasomotor abnormalities can affect various compartments of the coronary circulation such as the epicardial conduit arteries and/or the coronary microcirculation. Unequivocal categorisation and nomenclature of the broad spectrum of disease endotypes is crucial both in clinical practice as well as in clinical trials. This article describes the definitions of coronary functional abnormalities with currently accepted cut-off values, as well as diagnostic methods to identify and distinguish endotypes. The authors also provide a summary of contemporary data on the prevalence of the different endotypes of coronary functional abnormalities and their coexistence.

Long-term follow-up of patients with MINOCA (myocardial infarction with unobstructed coronary arteries) undergoing intracoronary spasm provocation testing

Background

Up to 30% of patients presenting with acute coronary syndrome undergoing coronary angiography are found to have no culprit lesion. Among them, epicardial or microvascular spasm can be diagnosed in ∼50% of patients undergoing provocative testing. While prognostic data in patients with coronary spasm and stable angina are abundant, the outcome of patients with myocardial infarction and unobstructed coronaries (MINOCA) and coronary spasm is not clear.

Purpose

The aim of this study was to investigate the prognosis of a cohort of patients presenting with MINOCA undergoing intracoronary acetylcholine (ACH) spasm testing.

Methods

We evaluated consecutive patients with MINOCA undergoing acetylcholine testing to detect epicardial or microvascular spasm from 2014 to 2017. Other aetiologies for MINOCA such as myocarditis, supraventricular tachycardia, pulmonary embolism etc. were excluded. Data regarding mortality (cardiac/non-cardiac), nonfatal myocardial infarction (MI), repeated coronary angiography and percutaneous coronary intervention (PCI) were recorded.

Results

Of 112 patients in our study, follow-up data were available for 96 patients (86%, 51% women, mean age 63±13 years). Acetylcholine testing was positive in 51 (53%) patients. Among patients with a positive test, epicardial spasm was detected in 26 (51%) and microvascular spasm in 25 (49%) patients. After a median follow-up of 5±3.5 years, 7 deaths (7%) and 20 nonfatal myocardial infarctions (21%) occurred. Moreover, 19 patients (20%) underwent coronary angiography and 9 patients (9%) received a PCI. Comparisons of the Kaplan–Meier curves by log-rank test showed that patients with positive acetylcholine test had a worse outcome compared to those with a negative test in terms of death from any cause (p=0.01), myocardial infarction (p=0.03) and repeated coronary angiography (p=0.05).

Conclusion

This follow-up study shows that prognosis of MINOCA patients with coronary spasm on provocative testing is worse compared to patients with an uneventful test. The results underline the potential prognostic value of spasm testing in MINOCA patients.

Funding Acknowledgement

Type of funding sources: None.

Refined prediction and validation of individual risk using machine learning in transcatheter aortic valve implantation: TAVI Risk Machine (TRIM) scores

Background

Given the recent option for treatment using TAVI irrespective of surgical risk, general surgical risk scores have become less relevant, while TAVI-specific scores require refinement. Additionally, post-TAVI risk models are lacking; however, such risk models can support decision between post-TAVI treatment approaches, such as early discharge or close surveillance.

Purpose

This study aimed to predict 30-day mortality following transcatheter aortic valve implantation (TAVI) based on machine learning (ML) using data from the German Aortic Valve Registry.

Methods

Mortality risk was determined using a random forest ML model that was condensed in the newly developed TAVI Risk Machine (TRIM) scores, designed to represent clinically meaningful risk modelling before (TRIMpre) and after (TRIMpost) TAVI. Algorithm was trained and cross-validated on data of 24,452 patients and generalisation was examined on data of 5,889 patients.

Results

TRIMpost demonstrated significantly better performance than traditional scores (C-statistics value, 0.79; 95% confidence interval [CI] [0.74; 0.83]). An abridged TRIMpost score comprising 25 features (calculated using a web interface) exhibited significantly higher performance than traditional scores (C-statistics value, 0.74; 95% CI [0.70; 0.78]).

Conclusion

TRIM scores have high performance for risk estimation before and after TAVI. Together with clinical judgement, they may support standardised and objective decision-making before and after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Improved durable pulmonary vein isolation with shorter procedure times and lower energy levels using RF ablation with ablation index and a stringent lesion contiguity

Background

The single procedure success rates of durable pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) varies between 80 and 90%. Ablation index, incorporating contact force, stability, time and power is a more profound parameter of significant lesion size and has been established. Equally important is a stringent contiguity of the lesion set.

Methods and results

A total number of 100 consecutive patients undergoing de-novo catheter ablation for paroxysmal atrial fibrillation (PAF) were analyzed between 2016 and 2019. In the first 50 patients (group A) PVI was performed using a surround flow, contact force catheter (Biosense Webster Thermocool STSF, Biosense Webster, USA) with a drag-and-ablate technique to encircle the PVs. In the following 50 patients (group B), PVI was performed using ablation index and a stringent lesion contiguity with an interlesion distance (ILD) of <5 mm. The baseline characteristics showed no significant differences between both groups. During a mean follow-up of 18 ± 3 months after a single procedure, 36 (72%) patients of group A were free of arrhythmia recurrence versus 43 (86%) patients in group B (p = 0.047). A total of 14 patients (group A: 10 (20%), group B: 4 (8%); underwent a redo-procedure. 7 patients of group A (14%) and 2 patients of group B (4%) showed recovered veins. In 3 patients of group A and 2 patients of group B the PVs were durably isolated. In these patients persistent AF recurrence was caused by extra-PV AF sources. Four patients of group A and three patients of group B had continued paroxysmal or persistent AF but did not undergo redo-procedure. With regard to the procedural data, the procedure time, the total energy and the fluoroscopy time were significantly lower in group B (AI and ILD <5 mm) (128.86 ± 18.19 versus 115.35 ± 15.38; p < 0.05; 1619.16 ± 988.56 versus 1186.26 ± 756.34; p < 0.05; 11.49 ± 3.20 versus 9.66 ± 3.86; p = 0.04). Both procedures were performed with a low number of complications, no pericardial effusion was seen in either group.

Conclusions

PVI using ablation index in combination with a stringent lesion contiguity improves clinical outcome after first-time PVI with lower PVI recovery, shorter procedure times, lower total energy and shorter fluoroscopy times and therefore, is more efficient.

Long-term risk of sudden cardiac death in hypertrophic cardiomyopathy: a cardiac magnetic resonance outcome study

AIMS

Sudden cardiac death (SCD) is an appalling complication of hypertrophic cardiomyopathy (HCM). There is an ongoing discussion about the optimal SCD risk stratification strategy since established SCD risk models have suboptimal discriminative power. The aim of this study was to evaluate the prognostic value of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) for SCD risk stratification compared to the European Society of Cardiology (ESC) SCD risk score and traditional risk factors in an >10-year follow-up.

METHODS AND RESULTS

Two hundred and twenty consecutive patients with HCM and LGE-CMR were enrolled. Follow-up data were available in 203 patients (median age 58 years, 61% male) after a median follow-up period of 10.4 years. LGE was present in 70% of patients with a median LGE amount of 1.6%, the median ESC 5-year SCD risk score was 1.84. In the overall cohort, SCD rates were 2.3% at 5 years, 4.8% at 10 years, and 15.7% at 15 years, independent from established risk models. An LGE amount of >5% left ventricular (LV) mass portends the highest risk for SCD with SCD prevalences of 5.5% at 5 years, 13.0% at 10 years, and 33.3% at 15 years. Conversely, patients with no or ≤5% LGE of LV mass have favourable prognosis.

CONCLUSIONS

LGE-CMR in HCM patients allows effective 10-year SCD risk stratification beyond established risk factors. LGE amount might be added to established risk models to improve its discriminatory power. Specifically, patients with >5% LGE should be carefully monitored and might be adequate candidates for primary prevention implantable cardioverter-defibrillator during the clinical long-term course.