Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock

BACKGROUND

The effects of temporary mechanical circulatory support with a microaxial flow pump on mortality among patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock remains unclear.

METHODS

In an international, multicenter, randomized trial, we assigned patients with STEMI and cardiogenic shock to receive a microaxial flow pump (Impella CP) plus standard care or standard care alone. The primary end point was death from any cause at 180 days. A composite safety end point was severe bleeding, limb ischemia, hemolysis, device failure, or worsening aortic regurgitation.

RESULTS

A total of 360 patients underwent randomization, of whom 355 were included in the final analysis (179 in the microaxial-flow-pump group and 176 in the standard-care group). The median age of the patients was 67 years, and 79.2% were men. Death from any cause occurred in 82 of 179 patients (45.8%) in the microaxial-flow-pump group and in 103 of 176 patients (58.5%) in the standard-care group (hazard ratio, 0.74; 95% confidence interval [CI], 0.55 to 0.99; P = 0.04). A composite safety end-point event occurred in 43 patients (24.0%) in the microaxial-flow-pump group and in 11 (6.2%) in the standard-care group (relative risk, 4.74; 95% CI, 2.36 to 9.55). Renal-replacement therapy was administered to 75 patients (41.9%) in the microaxial-flow-pump group and to 47 patients (26.7%) in the standard-care group (relative risk, 1.98; 95% CI, 1.27 to 3.09).

CONCLUSIONS

The routine use of a microaxial flow pump with standard care in the treatment of patients with STEMI-related cardiogenic shock led to a lower risk of death from any cause at 180 days than standard care alone. The incidence of a composite of adverse events was higher with the use of the microaxial flow pump. (Funded by the Danish Heart Foundation and Abiomed; DanGer Shock ClinicalTrials.gov number, NCT01633502.).

Mortality Rates in Patients Undergoing Urgent Versus Elective Transcatheter Aortic Valve Replacement: A Meta-analysis

Patients with severe aortic stenosis (AoS) often present with acute heart failure and compensation, frequently leading to cardiogenic shock. Transcatheter Aortic Valve Replacement (TAVR) has been recently performed as a bailout treatment in such patients. The aim of our meta-analysis is to compare urgent TAVR with elective procedures. We systematically screened three databases searching for studies comparing urgent vs elective TAVR. Primary endpoint is the 30-days mortality. Secondary endpoints included in-hospital mortality, device success, periprocedural vascular complications, 30-days stroke, 30-days acute kidney injury (AKI), permanent pacemaker implantation (PPM), moderate or severe paravalvular leakage, and 30-days bleeding. Seventeen studies were included, with a total of 84,495 patients. Urgent TAVR was associated with an increased risk for 30-days mortality [Risk Ratio (RR): 2.53, 95% Confidence Intervals (CI): 1.81-3.54)], in-hospital mortality (RR: 2.67, 95% CI: 1.94-3.68), periprocedural vascular complications (RR: 1.91, 95% CI: 1.28-2.85) and AKI (RR: 2.83, 95% CI: 1.93-4.14), compared with elective procedure. No differences were observed in the other secondary endpoints. Urgent TAVR was associated with higher in-hospital and 30-days mortality, possibly driven by the increased incidence of AKI and vascular complications in urgent TAVR. The results highlight the importance of early TAVR in stable AoS patients.

Heparin dosing in patients with Impella-supported cardiogenic shock

BACKGROUND

Impella™ is increasingly used in cardiogenic shock. However, thromboembolic and bleeding events are frequent during percutaneous mechanical circulatory support (pMCS).

OBJECTIVE

Therefore, we aimed to explore the optimal anticoagulation regime for pMCS to prevent thromboembolism and bleedings.

METHODS

This hypothesis-generating multi-center cohort study investigated 170 patients with left-Impella™ support. We (A) compared bleeding/thrombotic events in two centers with therapeutic range (TR-aPTT) activated partial thromboplastin time (60-80s) and (B) compared events of these centers with one center with intermediate range aPTT (40-60s).

RESULTS

After matching, there were no differences in patients' characteristics. In centers aiming at TR-aPTT, major bleeding was numerically lower with aPTT <60s within 48 h of left-Impella™ support, versus patients that achieved the aimed aPTT of ≥60s [aPTT ≥60s: 22 (37.3%) vs. aPTT<60s 14 (23.7%); Hazard ratio [HR], 0.62 (95%) CI, 0.28-1.38; p = 0.234]. Major cardiovascular and cerebrovascular adverse events (MACCE) did not differ between groups. In comparison of centers, TR-aPTT strategy showed higher major bleeding rates [TR: 8 (47.1%) vs. intermediate range: 1 (5.9%); HR, 0.06 (95%) CI, 0.01-0.45; p = 0.006]. MACCE were lower in the intermediate range aPTT group as well [TR 12 (70.6%) vs. intermediate range 5 (29.4%) HR, 0.32 (95%) CI, 0.11-0.92; p = 0.034].

CONCLUSION

This pilot analysis showed that lowering UFH-targets in left-Impella™ supported CS patients seems to be a safe and promising strategy for reducing major bleedings without increasing MACCE. This needs to be validated in larger, randomized clinical trials.

Comparison of mid-term mortality after surgical, supported or unsupported percutaneous revascularization in patients with severely reduced ejection fraction: A direct and network meta-analysis of adjusted observational studies and randomized-controlled

INTRODUCTION

The optimal revascularization strategy in patients with heart failure with reduced ejection fraction (HFrEF) remains to be elucidated. The aim of this paper is to compare the mid-term mortality rate among patients with severely reduced ejection fraction (EF) and complex coronary artery disease who underwent coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) with Impella support, or without.

METHODS

Randomized control trials and propensity-adjusted observational studies including patients with ischemic cardiomyopathy (ICM) and severe EF reduction undergoing revascularization were selected. Different revascularization strategies (CABG, supported PCI, and PCI without Impella) were compared in pairwise and network meta-analysis. The primary endpoint was mid-term mortality (within the first year after revascularization).

RESULTS

Fifteen studies, mostly observational (17,841 patients; 6779 patients treated with CABG, 8478 treated with PCI without Impella, and 2584 treated with Impella-supported PCI) were included in this analysis. The median age was 67.8 years (IQR 65-70.1), 21.2% (IQR 16.4-26%) of patients were female sex, and a high prevalence of cardiovascular risk factors was noted across the entire population. At pairwise analysis, CABG and PCI without Impella showed similar one-year all-cause mortality (10.6% [IQR 7.5-12.6%] vs 12% [IQR 8.4-11.5%]) RR 0.85 CI 0.67-1.09, while supported PCI reduced one-year all-cause mortality compared to PCI without Impella (9.4% [IQR 5.7-12.5%] vs 10.6% [IQR 8.9-10.7%]) RR 0.77 CI 0.6-0.89. At network meta-analysis, supported PCI showed better results (RR 0.75, 95% CI 0.59-0.94) compared to CABG.

CONCLUSION

Our analysis found that supported PCI may have a benefit over standard PCI in patients in direct comparison, and over CABG from indirect comparison, and with HFrEF undergoing revascularization. Further RCTs are needed to confirm this result. (PROSPERO CRD42023425667).

Complete revascularization is associated with higher mortality in patients with ST-elevation myocardial infarction, multi-vessel disease and shock defined by hyperlactataemia: results from the Harefield Shock Registry incorporating explainable machine learning

AIMS

Revascularization strategy for patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease varies according to the patient's cardiogenic shock status, but assessing shock acutely can be difficult. This article examines the link between cardiogenic shock defined solely by a lactate of ≥2 mmol/L and mortality from complete vs. culprit-only revascularization in this cohort.

METHODS AND RESULTS

Patients presenting with STEMI, multi-vessel disease without severe left main stem stenosis and a lactate ≥2 mmol/L between 2011 and 2021 were included. The primary endpoint was mortality at 30 days by revascularization strategy for shocked patients. Secondary endpoints were mortality at 1 year and over a median follow-up of 30 months. Four hundred and eight patients presented in shock. Mortality in the shock cohort was 27.5% at 30 days. Complete revascularization (CR) was associated with higher mortality at 30 days [odds ratio (OR) 2.1 (1.02-4.2), P = 0.043], 1 year [OR 2.4 (1.2-4.9), P = 0.01], and over 30 months follow-up [hazard ratio (HR) 2.2 (1.4-3.4), P < 0.001] compared with culprit lesion-only percutaneous coronary intervention (CLOP). Mortality was again higher in the CR group after propensity matching (P = 0.018) and inverse probability treatment weighting [HR 2.0 (1.3-3.0), P = 0.001]. Furthermore, explainable machine learning demonstrated that CR was behind only blood gas parameters and creatinine levels in importance for predicting 30-day mortality.

CONCLUSION

In patients presenting with STEMI and multi-vessel disease in shock defined solely by a lactate of ≥2 mmol/L, CR is associated with higher mortality than CLOP.

Time to TAVI: streamlining the pathway to treatment

INTRODUCTION

Severe aortic stenosis is a major cause of morbidity and mortality. The existing treatment pathway for transcatheter aortic valve implantation (TAVI) traditionally relies on tertiary Heart Valve Centre workup. However, this has been associated with delays to treatment, in breach of British Cardiovascular Intervention Society targets. A novel pathway with emphasis on comprehensive patient workup at a local centre, alongside close collaboration with a Heart Valve Centre, may help reduce the time to TAVI.

METHODS

The centre performing local workup implemented a novel TAVI referral pathway. Data were collected retrospectively for all outpatients referred for consideration of TAVI to a Heart Valve Centre from November 2020 to November 2021. The main outcome of time to TAVI was calculated as the time from Heart Valve Centre referral to TAVI, or alternative intervention, expressed in days. For the centre performing local workup, referral was defined as the date of multidisciplinary team discussion. For this centre, a total pathway time from echocardiographic diagnosis to TAVI was also evaluated. A secondary outcome of the proportion of referrals proceeding to TAVI at the Heart Valve Centre was analysed.

RESULTS

Mean±SD time from referral to TAVI was significantly lower at the centre performing local workup, when compared with centres with traditional referral pathways (32.4±64 to 126±257 days, p<0.00001). The total pathway time from echocardiographic diagnosis to TAVI for the centre performing local workup was 89.9±67.6 days, which was also significantly shorter than referral to TAVI time from all other centres (p<0.003). Centres without local workup had a significantly lower percentage of patients accepted for TAVI (49.5% vs 97.8%, p<0.00001).

DISCUSSION

A novel TAVI pathway with emphasis on local workup within a non-surgical centre significantly reduced both the time to TAVI and rejection rates from a Heart Valve Centre. If adopted across the other centres, this approach may help improve access to TAVI.

Transcatheter Aortic Valve Replacement for Pure Native Aortic Valve Regurgitation: The PANTHEON International Project

BACKGROUND

Transcatheter aortic valve replacement (TAVR) in patients with pure severe native aortic valve regurgitation (NAVR) has been associated with suboptimal results. The available evidence concerns mostly outdated transcatheter heart valves (THVs).

OBJECTIVES

The aim of this study was to investigate the performance of new-generation THVs in patients treated for pure severe NAVR.

METHODS

The PANTHEON (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve) study retrospectively included patients who underwent TAVR with currently available devices (both self-expanding [SE] and balloon expandable [BE]) for severe NAVR. Technical and device success rates as well as a composite of all-cause mortality and heart failure rehospitalization at 1 year were evaluated. The rate and clinical consequences of acute transcatheter valve embolization or migration (TVEM) were also considered.

RESULTS

A total of 201 patients were included. Overall technical and device success rates were 83.6% and 76.1%, respectively, and did not differ between SE and BE devices. These figures were due mostly to TVEM occurrence (14.6% vs 16.1%; P = 0.47) and residual moderate or greater aortic regurgitation (9.2% vs 10.1%; P = 0.87). Patients who experienced TVEM compared with those without TVEM had a significantly higher incidence of the composite endpoint at 1 year (25.7% vs 15.8%; P = 0.05).

CONCLUSIONS

Despite improved THV platforms and techniques, TAVR for pure severe NAVR remains a challenging procedure, with significant risk for TVEM. SE and BE platforms demonstrated comparable performance in this setting. (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve [PANTHEON]; NCT05319171).

The BE-ALIVE score: assessing 30-day mortality risk in patients presenting with acute coronary syndromes

AIM

To create and validate a simple scoring system for predicting 30-day mortality in patients presenting with acute coronary syndromes (ACS) at their moment of admission.

METHODS AND RESULTS

2407 consecutive patients presenting to Harefield Hospital with measured arterial blood gases, from January 2011 to December 2020, were studied to build the training set. 30-day mortality in this group was 17.2%. A scoring algorithm that was built using binary logistic regression of variables available on admission was then converted to an additive risk score. The resultant scoring system is the BE-ALIVE score, which incorporates the following factors:Base Excess (1 point for <-2 mmol/L), Age (<65 years: 0 points, 65-74: 1 point, 75-84: 2 points, ≥85: 3 points), Lactate (<2 mmol/L: 0 points, 2-4.9: 1 point, 5-9.9: 3 points, ≥10: 6 points), Intubated (2 points), Left Ventricular function (mildly impaired or better: -1 point, moderately impaired: 1 point, severely impaired: 3 points) and External/out of hospital cardiac arrest 2 points).The scoring system was validated using a testing set of 515 patients presenting to Harefield Hospital in 2021. The validation metrics were excellent with a c-statistic of 0.9, Brier's score 0.06 vs a naïve classifier of 0.15, Spiegelhalter's z-statistic probability of 0.267 and a calibration slope of 1.08.

CONCLUSION

The BE-ALIVE score is a simple and accurate scoring system to predict 30-day mortality in patients presenting with ACS. Appreciating this mortality risk can allow prompt involvement of appropriate care such as the shock team.

Midterm Outcomes in Patients With Aortic Stenosis Treated With Contemporary Balloon-Expandable and Self-Expanding Valves: Does Valve Size Have an Impact on Outcome?

Background No data currently exist comparing the contemporary iterations of balloon-expandable (BE) Edwards SAPIEN 3/Ultra and the self-expanding (SE) Medtronic Evolut PRO/R34 valves. The aim of the study was the comparison of these transcatheter heart valves with emphasis on patients with small aortic annulus. Methods and Results In this retrospective registry, periprocedural outcomes and midterm all-cause mortality were analyzed. A total of 1673 patients (917 SE versus 756 BE) were followed up for a median of 15 months. A total of 194 patients died (11.6%) during follow-up. SE and BE groups showed similar survival at 1 (92.6% versus 90.6%) and 3 (80.3% versus 85.2%) years (P_log-rank=0.136). Compared with the BE group, patients treated with the SE device had lower peak (16.3±8 mm Hg SE versus 21.9±8 mm Hg BE) and mean (8.8±5 mm Hg SE versus 11.5±5 mm Hg BE) gradients at discharge. Conversely, the BE group demonstrated lower rates of at least moderate paravalvular regurgitation postoperatively (5.6% versus 0.7% for SE and BE valves, respectively; P<0.001). In patients treated with small transcatheter heart valves (≤26 mm for SE and ≤23 mm for BE; N=284 for SE and N=260 for BE), survival was higher among patients treated with SE valves at both 1 (96.7% SE versus 92.1% BE) and 3 (91.8% SE versus 82.2% BE) years (P_log-rank=0.042). In propensity-matched patients treated with small transcatheter heart valve, there remained a trend for higher survival among the SE group at both 1 (97% SE versus 92.3% BE) and 3 years (91.8% SE versus 78.7% BE), P_log-rank=0.096). Conclusions Real-world comparison of the latest-generation SE and BE devices demonstrated similar survival up to 3 years' follow-up. In patients with small transcatheter heart valves, there may be a trend for improved survival among those treated with SE valves.

Coronary-subclavian steal syndrome: a case report of a rare entity that can become a deadly threat

Background

In patients who underwent coronary artery bypass graft (CABG), the coronary-subclavian steal syndrome (CSSS) is characterized by a subclavian artery stenosis proximal to the origin of the internal mammary artery resulting in functional graft failure.

Case summary

A 62-year-old gentleman underwent CABG following a non-ST elevation myocardial infarction and an angiogram showing left main stem and three-vessel disease. Forty-eight hours later he developed cardiogenic shock that improved with inotropic support and intra-aortic balloon pump insertion. However, 7 days later, he deteriorated again and even though the myocardial injury markers and echocardiogram were normal, an angiography was performed showing significant CSSS. Due to the chronic nature of his subclavian stenosis and the severity of the cardiogenic shock, the heart team decided to treated his epicardial disease percutaneously and occlude the left internal mammary artery in its mid-segment with coils. The patient was discharged home 28 days after CABG and has remained since asymptomatic with improvement in his functional class.

Discussion

Coronary-subclavian steal syndrome is a rare but fatal complication with increased morbidity and mortality due to reduced awareness amongst medical professionals. Subclavian artery stenosis stenting is the gold standard treatment; herein we present a new approach for complex and very sick patients in whom it is not possible to open the subclavian artery percutaneously. Increased awareness and prompt diagnosis of this pathology in CABG patients are essential for successful outcomes.

Right ventricular failure: Current strategies and future development

Right heart failure can be defined as a clinical syndrome consisting of signs and symptoms of heart failure resulting from right ventricular dysfunction. Function is normally altered due to three mechanisms: (1) pressure overload (2) volume overload, or (3) a decrease in contractility due to ischaemia, cardiomyopathy or arrythmias. Diagnosis is based upon a combination of clinical assessment plus echocardiographic, laboratory and haemodynamic parameters, and clinical risk assessment. Treatment includes medical management, mechanical assist devices and transplantation if recovery is not observed. Distinct attention to special circumstances such as left ventricular assist device implantation should be sought. The future is moving towards new therapies, both pharmacological and device centered. Immediate diagnosis and management of RV failure, including mechanical circulatory support where needed, alongside a protocolized approach to weaning is important in successfully managing right ventricular failure.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Optimized patient selection in high-risk protected percutaneous coronary intervention

Percutaneous mechanical circulatory support (pMCS) is increasingly used in patients with poor left-ventricular (LV) function undergoing elective high-risk percutaneous coronary interventions (HR-PCIs). These patients are often in critical condition and not suitable candidates for coronary artery bypass graft surgery. For the definition of HR-PCI, there is a growing consensus that multiple factors must be considered to define the complexity of PCI. These include haemodynamic status, left-ventricular ejection fraction, clinical characteristics, and concomitant diseases, as well as the complexity of the coronary anatomy/lesions. Although haemodynamic support by percutaneous LV assist devices is commonly adopted in HR-PCI (protected PCI), there are no clear guideline recommendations for indication due to limited published data. Therefore, decisions to use a nonsurgical, minimally invasive procedure in HR-PCI patients should be based on a risk–benefit assessment by a multidisciplinary team. Here, the current evidence and indications for protected PCI will be discussed.

Specific clinical vignettes in high-risk protected percutaneous coronary intervention

There are several cardiac- and patient-related factors that come into play when considering patients for protected percutaneous coronary intervention (PCI). Cardiac factors include complexity/location of coronary lesions, the degree of left or right ventricular impairment, the presence of valvular lesions, and ventricular arrhythmias. Patient related factors include comorbidities that would render the patient at a higher risk of death should cardiogenic shock ensue during the procedure. Comorbidities include chronic lung disease (chronic obstructive airways disease, asthma, pulmonary fibrosis), renal or liver impairment, other cardiovascular diseases (such as previous cerebrovascular accident or transient ischemic attack, peripheral arterial disease, carotid stenosis), diabetes, frailty and advanced age. Here, we present three very different cases where left ventricular support was deemed appropriate to reduce peri-procedural risk and optimize outcomes.

Real-world intravascular ultrasound (IVUS) use in percutaneous intervention-naïve patients is determined predominantly by operator, patient, and lesion characteristics

BACKGROUND

Intravascular Ultrasound (IVUS) has been shown to improve clinical outcomes in patients undergoing percutaneous intervention (PCI) in numerous trials. However, it is still underutilized outside of trial settings, and most trials include a significant proportion of patients with prior PCI. The aim of this study is to look at real-world use and outcomes in PCI-naïve patients who undergo IVUS-guided intervention.

METHODS AND RESULTS

Prospectively collected data from 10,574 consecutive patients undergoing their index PCI was retrospectively analyzed. 455 (4.3%) patients underwent IVUS, with a median follow-up of 4.6 years. Patients undergoing IVUS had higher levels of comorbidities including diabetes (27.5% vs. 19.7%, p < 0.001), hypertension (58.0% vs. 47.9%, p < 0.001), hypercholesterolemia (51.6% vs. 39.2%, p < 0.001) and were generally older (65.9 ± 14.5 vs. 64.5 ± 13.4 years, p = 0.031) with higher mean baseline creatinine levels (95.4 ± 63.3 vs. 87.8 ± 46.1 μmol/L). The strongest predictor of IVUS use was the operating consultant graduating from medical school after the year 2000 [OR 14.5 (3.5-59.8), p < 0.001] and the presence of calcific lesions [OR 5.2 (3.4-8.0) p < 0.001]. There was no significant difference in MACE nor 1-year mortality between patients undergoing IVUS-guided or angiography-only PCI on unadjusted analysis [OR 1.04 (0.73-1.5), p = 0.81, OR 1.055 (0.65-1.71) p = 0.828] nor mortality throughout the study period (HR 0.93 (0.69-1.26), p = 0.638). This held true for stents longer than 28 mm. Propensity matched analysis of patients similarly showed no mortality difference between arms for all patients and those with longer stents (p = 0.564 and p = 0.919).

CONCLUSION

The strongest predictors of IVUS use in PCI-naïve patients are the operator's year of graduation from medical school and proxy measures of calcific lesions. On both matched and adjusted analysis there was no evidence of improved mortality nor reduced MACE in this specific retrospective cohort, although this may well be explained by significant selection bias.

Developing informatics infrastructure to curate datasets using electronic health record data from five hospitals for translational cardiovascular research

Introduction

It has been challenging for researchers to access granular electronic health record (EHR) data at scale. One emerging prospect is to use big data to traverse the translational spectrum from an early discovery phase to a later implementation phase.

Purpose

To create a research-ready dataset to support translational research in cardiovascular medicine, using routinely-collected EHR data from multiple hospitals. As an early discovery phase study, we estimated the effect of invasive versus non-invasive management on the survival of patients with non-ST elevation myocardial infarction (NSTEMI) aged 80 years or older (SENIOR-NSTEMI Study). As a later implementation phase study, we determined the relationship between the full spectrum of troponin level and mortality in patients in whom troponin testing was performed for clinical purposes (TROP-RISK Study).

Methods

Using Microsoft SQL we developed a dataset of 257948 consecutive patients who had a troponin measured between 2010 and 2017 at five hospitals. We extracted phenotypically detailed data, including demographics, blood tests, procedural data, and survival status.

For the SENIOR-NSTEMI Study, eligible patients were 80 years or older who were diagnosed with NSTEMI. We estimated mortality hazard ratios comparing invasive with non-invasive management. For the TROP-RISK Study, we modelled the relation between peak troponin level and all-cause mortality using multivariable adjusted restricted cubic spline Cox regression analyses.

Results

For the SENIOR-NSTEMI Study, 1500 patients with NSTEMI were included who had a median age of 86 (interquartile range (IQR) 82–89) years of whom (845 [56%]) received non-invasive management. During a median follow-up of 3 (IQR 1.2–4.8) years, the adjusted cumulative five-year mortality was 36% in the invasive and 55% in the non-invasive group (hazard ratio 0.68, 95% confidence interval 0.55–0.84).

For the TROP-RISK Study, during a median follow-up of 1198 days (IQR 514–1866 days), 55850 (21.7%) deaths occurred. There was an unexpected inverted U-shaped relation between troponin level and mortality in acute coronary syndrome (ACS) patients (n=120049) (Figure 1A). The paradoxical decline in mortality at very high troponin levels may be driven in part by the changing case mix as troponin levels increase; a higher proportion of patients with very high troponin levels received invasive management (Figure 1B).

Conclusion

Routine EHR data can be aggregated across multiple sites to create highly granular datasets for research. The SENIOR-NSTEMI Study showed a survival advantage of invasive compared with non-invasive management of elderly patients with NSTEMI, who were underrepresented in previous trials. The inverted U-shaped relationship between troponin and mortality in ACS patients in the TROP-RISK Study demonstrates that assembling sufficiently large datasets can cast light on patterns of disease that are impossible to adequately define in single centre studies.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1) NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative, and 2) British Heart Foundation

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction (NIHR Health Informatics Collaborative: TROP-CABG study)

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction(NIHR Health Informatics Collaborative:TROP-CABG study). Benedetto et al. BACKGROUND: The optimal timing of coronary artery bypass grafting (CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a) the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b) the interaction between troponin and time-to-surgery. METHODS AND RESULTS: Our cohort consisted of 1746 patients (1684 NSTEMI; 62 unstable angina) (mean age 69 ± 11 years,21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early (within 30 days) and late (beyond 30 days) survival. Average interval from peak troponin to surgery was 9 ± 15 days, with 1466 (84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4 ± 2 years (30-day survival 0.97 ± 0.004 and 5-year survival 0.83 ± 0.01). Peak troponin was a strong predictor of early survival (adjusted P = 0.002) with a significant interaction with time-to-surgery (P interaction = 0.007). For peak troponin levels <100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days (adjusted P = 0.64). CONCLUSIONS: Peak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.

Prognostic Significance of Ventricular Arrhythmias in 13 444 Patients With Acute Coronary Syndrome: A Retrospective Cohort Study Based on Routine Clinical Data (NIHR Health Informatics Collaborative VA-ACS Study)

Background A minority of acute coronary syndrome (ACS) cases are associated with ventricular arrhythmias (VA) and/or cardiac arrest (CA). We investigated the effect of VA/CA at the time of ACS on long-term outcomes. Methods and Results We analyzed routine clinical data from 5 National Health Service trusts in the United Kingdom, collected between 2010 and 2017 by the National Institute for Health Research Health Informatics Collaborative. A total of 13 444 patients with ACS, 376 (2.8%) of whom had concurrent VA, survived to hospital discharge and were followed up for a median of 3.42 years. Patients with VA or CA at index presentation had significantly increased risks of subsequent VA during follow-up (VA group: adjusted hazard ratio [HR], 4.15 [95% CI, 2.42-7.09]; CA group: adjusted HR, 2.60 [95% CI, 1.23-5.48]). Patients who suffered a CA in the context of ACS and survived to discharge also had a 36% increase in long-term mortality (adjusted HR, 1.36 [95% CI, 1.04-1.78]), although the concurrent diagnosis of VA alone during ACS did not affect all-cause mortality (adjusted HR, 1.03 [95% CI, 0.80-1.33]). Conclusions Patients who develop VA or CA during ACS who survive to discharge have increased risks of subsequent VA, whereas those who have CA during ACS also have an increase in long-term mortality. These individuals may represent a subgroup at greater risk of subsequent arrhythmic events as a result of intrinsically lower thresholds for developing VA.

Successful percutaneous closure of aortic root-to-right ventricle fistula after transcatheter aortic valve implantation: a valuable option in high-risk surgical patients

Background

Aortic-to-right ventricle (ARV) fistula is an uncommon complication of transcatheter aortic valve implantation (TAVI). Even though surgical closure is usually the treatment of choice in such communications, percutaneous treatment options are valuable alternatives for these high-risk surgical patients.

Case summary

In this article, we present the percutaneous closure of an ARV fistula after TAVI, in a highly symptomatic patient with recurrent episodes of heart failure decompensation with worsening right ventricular function, who failed conservative medical treatment and was deemed inoperable. Successful closure of the fistula with the use of the Amplatzer atrial septal occluder was performed 6 months post-TAVI, under general anaesthesia and transoesophageal echocardiography (TOE). A detailed multi-modality imaging pre-procedural planning was performed utilizing 4D cardiac computed tomography and echocardiography. The patient has remained asymptomatic and in good health 5 months after the ARV fistula closure, with marked improvement in his clinical picture and echocardiographic parameters.

Discussion

Aortic-to-right ventricle fistulas with significant shunt post-TAVI could lead to biventricular failure and are associated with increased mortality if left untreated. This case demonstrates that TOE-guided percutaneous closure of a TAVI-related ARV fistula, although technically challenging, is feasible, and can be a valuable option for the treatment of symptomatic high-risk surgical patients.

Mortality risk prediction of high-sensitivity C-reactive protein in suspected acute coronary syndrome: A cohort study

BACKGROUND

There is limited evidence on the use of high-sensitivity C-reactive protein (hsCRP) as a biomarker for selecting patients for advanced cardiovascular (CV) therapies in the modern era. The prognostic value of mildly elevated hsCRP beyond troponin in a large real-world cohort of unselected patients presenting with suspected acute coronary syndrome (ACS) is unknown. We evaluated whether a mildly elevated hsCRP (up to 15 mg/L) was associated with mortality risk, beyond troponin level, in patients with suspected ACS.

METHODS AND FINDINGS

We conducted a retrospective cohort study based on the National Institute for Health Research Health Informatics Collaborative data of 257,948 patients with suspected ACS who had a troponin measured at 5 cardiac centres in the United Kingdom between 2010 and 2017. Patients were divided into 4 hsCRP groups (<2, 2 to 4.9, 5 to 9.9, and 10 to 15 mg/L). The main outcome measure was mortality within 3 years of index presentation. The association between hsCRP levels and all-cause mortality was assessed using multivariable Cox regression analysis adjusted for age, sex, haemoglobin, white cell count (WCC), platelet count, creatinine, and troponin. Following the exclusion criteria, there were 102,337 patients included in the analysis (hsCRP <2 mg/L (n = 38,390), 2 to 4.9 mg/L (n = 27,397), 5 to 9.9 mg/L (n = 26,957), and 10 to 15 mg/L (n = 9,593)). On multivariable Cox regression analysis, there was a positive and graded relationship between hsCRP level and mortality at baseline, which remained at 3 years (hazard ratio (HR) (95% CI) of 1.32 (1.18 to 1.48) for those with hsCRP 2.0 to 4.9 mg/L and 1.40 (1.26 to 1.57) and 2.00 (1.75 to 2.28) for those with hsCRP 5 to 9.9 mg/L and 10 to 15 mg/L, respectively. This relationship was independent of troponin in all suspected ACS patients and was further verified in those who were confirmed to have an ACS diagnosis by clinical coding. The main limitation of our study is that we did not have data on underlying cause of death; however, the exclusion of those with abnormal WCC or hsCRP levels >15 mg/L makes it unlikely that sepsis was a major contributor.

CONCLUSIONS

These multicentre, real-world data from a large cohort of patients with suspected ACS suggest that mildly elevated hsCRP (up to 15 mg/L) may be a clinically meaningful prognostic marker beyond troponin and point to its potential utility in selecting patients for novel treatments targeting inflammation.

TRIAL REGISTRATION

ClinicalTrials.gov - NCT03507309.

Impella as unloading strategy during VA-ECMO: systematic review and meta-analysis

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used as mechanical circulatory support in cardiogenic shock (CS). It restores peripheral perfusion, at the expense of increased left ventricle (LV) afterload. In this setting, Impella can be used as direct unloading strategy. Aim of this meta-analysis was to investigate efficacy and safety of LV unloading with Impella during ECMO in CS. A systematic search on Medline, Scopus and Cochrane Library was performed using as combination of keywords: extracorporeal membrane oxygenation, Impella, percutaneous micro axial pump, ECPELLA, cardiogenic shock. We aimed to include studies, which compared the use of ECMO with and without Impella (ECPELLA vs. ECMO). Primary endpoint was short-term all-cause mortality; secondary endpoints included major bleeding, haemolysis, need for renal replacement therapy (RRT) and cerebrovascular accident (CVA). Five studies met the inclusion criteria, with a total population of 972 patients. The ECPELLA cohort showed improved survival compared to the control group (RR (Risk Ratio): 0.86; 95% CI (Confidence Interval): 0.76, 0.96; p = 0.009). When including in the analysis only studies with homogeneous comparator groups, LV unloading with Impella remained associated with significant reduction in mortality (RR: 0.85; 95% CI: 0.75, 0.97; p = 0.01). Haemolysis (RR: 1.70; 95% CI: 1.35, 2.15; p < 0.00001) and RRT (RR: 1.86; 95% CI: 1.07, 3.21; p = 0.03) occurred at a higher rate in the ECPELLA group. There was no difference between the two groups in terms of major bleeding (RR: 1.37; 95% CI: 0.88, 2.13; p = 0.16) and CVA (RR: 0.91; 95% CI: 0.61, 1.38; p = 0.66). In conclusion, LV unloading with Impella during ECMO was associated with improved survival, despite increased haemolysis and need for RRT, without additional risk of major bleeding and CVA.

Using base excess, albumin, lactate and renal function to predict 30-day mortality in patients requiring impella monotherapy for left-sided mechanical circulatory support: The BALLAR score

OBJECTIVES

To create a simple scoring system that can estimate 30-day mortality in patients requiring left-sided Impella implantation as standalone mechanical circulatory support (MCS).

METHODS

We retrospectively analysed 79 consecutive patients who required left-sided Impella MCS monotherapy. Regression analysis was used to elucidate significant associations between biochemical markers before Impella implantation and all-cause mortality at 30 days. Using these factors, a simple additive scoring system was created using a previously validated approach.

RESULTS

The BALLAR scoring system was created. Patients are assigned points based upon biochemical markers. These are summed and the final points tally provides an estimate of 30-day mortality. The points are assigned as follows: Lactate (mmol/l): ≤1.9: 0 points, 2-4.9: 1 Point, ≥5: 4 Points Creatinine Clearance (ml/min): ≤29.9: 6 points, 30-59.9: 4 points, 60-89.9: 1 point, ≥90: 0 points Serum Albumin (mmol/l): <25: 6 points, 25-34.9: 3 points, ≥35: 0 points Base Excess (mmol/L): < -2: 2 points, ≥-2: 0 points The total score can be used to estimate the probability of death at 30 days. A score less than 6 predicts a 30-day mortality of under 5%, whereas a score over 11 predicts a greater than 95% chance of death within 30 days.

CONCLUSION

Using this simple heuristic predicted 89% of 30-day deaths in our cohort. All the misclassifications were in the intermediate probability range (scores 5-11). This simple scoring system gives an effective estimate of the probability of death at 30 days in our cohort of patients.

Real-world comparison of the last generation balloon-expandable and self-expanding valves in patients undergoing TAVI

Background/Introduction

The balloon expandable (BE) Edwards Sapien-S3/Ultra, and the self-expanding (SE) Medtronic Evolut-Pro represent the main volume of transcatheter aortic valve implantation (TAVI) procedures conducted worldwide.

Purpose

The present study represents the largest real-world comparison of periprocedural and short-term outcome between the aforementioned last generation devices.

Methods

Consecutive patients who had undergone TAVI with either the BE (S3/Ultra) or SE (Evolut-Pro/R-34mm if 34mm valve was required) device, in five centers were retrospectively studied. Periprocedural and short-term outcomes were recorded and compared.

Results

In total, 1341 patients (58.5% male) were treated with contemporary BE and SE valves (574 and 767pts with BE and SE respectively) and followed up for a median of 18.7 (IQR 30) months. Baseline demographics were similar between the two groups apart from severe left ventricle (LV) systolic impairment and extensive aorta calcification, being more prevalent amongst BE and SE groups respectively. Patients treated with the Evolut-Pro/R34mm device had significantly lower peak (16±9mmHg for SE vs 23.9±6mmHg for the BE valves, p=0.001) and mean (8.6±6mmHg SE vs 11.2±5.2mmHg BE, p=0.001) gradients at discharge.

Conversely, the BE group demonstrated significantly lower rates of at least moderate residual aortic regurgitation (AR) post-operatively (0.7% vs 5.2% for BE and SE valves respectively, p&lt;0.001). Interestingly, the rate of new permanent pacemaker (PPM) required after the implantation in initially pacemaker-free patients, was higher for the S3/Ultra cohort compared to the self-expanding valve group (14.4% vs 12.3% respectively, p=0.001). No statistical difference was recorded between valve groups regarding cerebrovascular events (3.4% vs. 2.7% for SE and BE respectively, p=0.466), major vascular complications (4.2% vs. 3.0% for SE and BE respectively, p=0.251) and death to hospital discharge (1.6% vs. 2.9% for SE and BE respectively, p=0.117).

One-year Kaplan-Meier estimated survival was similar between the two groups (88.7% for BE vs. 91.4% for SE valves, plog-rank=0.093). When adjusting for age, extensive calcification of the aorta and baseline LV function all caused mortality hazard ratios were similar between patients treated with BE vs SE valves (HR 1.39; 95% CI 0.97 to 1.98, p=0.07).

Conclusions

Real life comparison of the last generation balloon expandable and self-expanding devices demonstrates superiority of the former in terms of residual PVL, at the expense of higher transvalvular gradients and higher need of new PPM implantation. The latter however may represent differences in center practices with regards to thresholds for permanent pacing. Long-term follow-up and future larger trials are required to establish any potential long-term difference in clinical outcomes and prognosis.

Funding Acknowledgement

Type of funding sources: None.

Predictors of Short-term Survival in Cardiogenic Shock Patients Requiring Left Ventricular Support Using the Impella CP or 5.0

Background

Percutaneous ventricular assist devices (pVADs) have been used to support patients who are in cardiogenic shock (CS). There is limited data on 30-day mortality predictors in patients supported by an Impella pVAD.

Methods

All CS patients requiring left-sided Impella implantation in Harefield Hospital (Greater London, United Kingdom) between 2017 and 2020 were included in the current study. Logistic regression analysis was used to identify predictors of 30-day mortality.

Results

A total of 92 patients were included. The mean age was 53.8 ± 14.9 years, and 78.3% were male. CS etiology was predominantly acute coronary syndromes (44.6%), followed by decompensated dilated cardiomyopathy (28.3%). Survival at 30 days was 63% (58 of 92). Deceased patients had a lower left ventricular ejection fraction (LVEF) (15.1 ± 9.6 vs 21.8 ± 14.2, P < 0.001), higher serum lactate levels (2.8[1.6 to 5.4] vs 1.45 [1.08 to 3.53], P = 0.012), a higher percentage of prolonged invasive ventilation (> 24 hours) (64.7% vs 13.8%, P < 0.001), and worse renal and liver function. Serum lactate, baseline LVEF, and prolonged ventilation (> 24 hours) were independent predictors of 30-day survival with an area under the curve of 0.85 (95% confidence interval 0.769 to 0.930), P < 0.001.

Conclusions

In the current retrospective registry of patients requiring Impella pVAD implantation, independent 30-day mortality predictors included serum lactate, baseline LVEF, and prolonged invasive ventilation (> 24 hours). These parameters could highlight patients who would benefit from earlier mechanical circulatory support escalation or neurologic assessment to inform withdrawal decisions.

A detailed explantation assessment protocol for patients with left ventricular assist devices with myocardial recovery

OBJECTIVES

Left ventricular assist device (LVAD) implantation for end-stage heart failure patients has been on the rise, providing a reliable long-term option. For some LVAD patients, longer term LV unloading leads to recovery; hence, the need for evaluating potential myocardial recovery and weaning eligibility has emerged.

METHODS

All patients who underwent contemporary LVAD explantation at our institution between 2009 and 2020 were included in the study. Patients in New York Heart Association I, left ventricular ejection fraction >40%, a cardiac index >2.4 l/min and a peak oxygen intake >50% predicted underwent a 4-phase weaning assessment. A minimally invasive approach using a titanium plug was the surgery of choice in the most recent explants. Kaplan-Meier curves were used to estimate the survival at 1 and 5 years.

RESULTS

Twenty-six patients (17 HeartMate II, 9 HeartWare) underwent LVAD explantation after a median 317 days of support [IQ (212-518)], range 131-1437. Mean age at explant was 35.8 ± 12.7 years and 85% were males. Idiopathic dilated cardiomyopathy was the underlying diagnosis in 70% of cases. Thirteen (48%) patients were on short-term mechanical circulatory support and 60% required intensive care unit admission prior to the LVAD implantation. At 1 year, Kaplan-Meier estimated survival was 88%, whereas at 6 years, it was 77%. The average left ventricular ejection fraction at 1 year post-explant was 44.25% ± 8.44.

CONCLUSIONS

The use of a standardized weaning protocol (echocardiographic and invasive) and a minimally invasive LVAD explant technique minimizes periprocedural complications and leads to good long-term device-free survival rates.

Is the quality-of-life improvement after transcatheter aortic valve implantation equivalent to that achieved by surgical aortic valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'is the quality-of-life (QoL) improvement after transcatheter aortic valve implantation (TAVI) equivalent to that achieved by surgical aortic valve replacement (sAVR)?' Literature search revealed 189 papers with reference to QoL after TAVI, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. QoL plays a crucial role in the decision-making process for procedures such as TAVI and sAVR. Current evidence included and analysed in this review have shown a clear improvement in QoL after both TAVI and sAVR. TAVI offers a rapid improvement of QoL, evident within the first 30 days. There is no difference in QoL at 2- and 5-year follow-up between TAVI and sAVR. There are currently paucity of data on long-term QoL and the potential impact of structural valve degeneration following TAVI.

Mid-term clinical outcomes from use of Sirolimus coated balloon in coronary intervention; data from real world population

BACKGROUND

Use of drug coated balloons (DCBs) in coronary intervention is escalating. There is a plethora of data on Paclitaxcel-DCB. However, when it comes of stents, Limus-drugs are preferred over Paclitaxel. There is very limited data on Sirolimus coated balloons (SCB). MagicTouch-SCB (Concept Medical, FL) elutes Sirolimus via nano-technology and have been used in our centers since March 2018. We report a mid-term follow-up with this relatively novel-technology.

METHODS AND RESULTS

We retrospectively analyzed all patients treated with MagicTouch-SCB between March-2018 and February-2019. Results are reported as cardiac-death, target-vessel myocardial-infarction (TVMI), target lesion revascularization (TLR) and Major Adverse Cardiac Events (MACE). During the study period, 288-patients (373-lesions) with a mean age of 65.8 were treated with MagicTouch-SCB. 84% (n = 241) were male, 155 (54%) were in the setting of acute coronary syndrome, 38% (n = 110) had diabetes and 62% (n = 233) were in de-novo lesions. Most lesions treated were in the LAD/diagonal-system (n = 170; 46%). Pre-dilatation was performed in 92% (n = 345) of cases. Bailout stenting was required in 9% lesions (n = 35). The mean diameter and length of SCBs were 2.64 ± 0.56 mm and 24 ± 8.9 mm respectively. During a median follow-up of 363 days (IQR: 278-435), cardiac death and TVMI occurred in 5-patients (1.7%) and 10-patients (3.4%) respectively, TLR per-lesion was 12%. The MACE rate was 10%. There were no documented cases of acute vessel closure.

CONCLUSIONS

The results from mid-term follow-up with this relatively new technology SCB is encouraging with a low rates of hard endpoints and acceptable MACE rates despite complex group of patients and lesion subsets.

Association of individual aortic leaflet calcification on paravalvular regurgitation and conduction abnormalities with self-expanding trans-catheter aortic valve insertion

Background

Complication rates of paravalvular aortic regurgitation (PVR) and permanent pacemaker insertion remain high in patients undergoing trans-catheter aortic valve insertion for severe aortic stenosis. The spatial distribution of calcium between individual aortic valve leaflets, and its potential role in these complications is gaining interest. We aimed to assess the accuracy of individual aortic valve leaflet calcium quantification, and to determine its effect on the frequency of these complications.

Methods

This was a retrospective study of 251 patients who underwent trans-catheter aortic valve insertion using the Evolut RTM valve. The off-line Terarecon software platform was used for Agatston scoring the short axis views.

Results

There was a correlation between the sum of the individual leaflet and the total aortic valve calcium score. There was a univariate association between an increase [per 100 Agatston unit (AU)] in both right coronary leaflet (RCL) and left coronary leaflet (LCL) calcium with the risk of PVR. There was an association between an increase in LCL calcium score (per 100 AU) and need for post-implantation balloon aortic valvuloplasty (BAV). There was no association between individual leaflet calcification on the risk of permanent pacemaker insertion.

Conclusions

This study supports the idea that a quantifiable and reproducible method of individual valve leaflet calcification score may serve as an independent risk factor for paravalvular regurgitation, beyond visual assessment of asymmetry. However, the same may not be true of spatial calcium distribution and permanent pacemaker implantation (PPI).

The missing acute coronary syndromes in the COVID-19 era

Aims:

To determine whether the number of patients presenting with acute coronary syndromes has reduced during the COVID-19 pandemic.

Methods:

Numbers of primary percutaneous coronary intervention (PPCI) activations, ST elevation myocardial infarctions (STEMIs) and non-ST elevation myocardial infarctions (NSTEMIs) in a large tertiary Greater London centre and a large district general hospital, both of which have on-site heart attack centres, were collected. We compared the number of PPCI activations, STEMI, NSTEMIs and all MIs prior to the COVID-19 era (January to third week of February 2020), after the start of some COVID-19 restrictions taking place (fourth week of February 2020) and after formal instruction by the United Kingdom Government that all citizens were to observe strict social distancing measures (20 March 2020). We further obtained data for the corresponding weekly figures from 2019.

Results:

The average weekly figure of all myocardial infarction in 2020, prior to the COVID-19 social distancing restrictions/awareness in the UK (beginning of January to third week of February), did not differ when compared with corresponding weeks in 2019 (23.3 ± 5.4 in 2019 versus 21.13 ± 3.5, p = 0.411).

With increased media reporting and associated public awareness of the threat of COVID-19 (last week of February), there was a significant reduction in all myocardial infarction (27.1 ± 4.7 in 2019 versus 15.9 ± 3.6 in 2020, p < 0.001). Following official governmental instruction that mandated strict social distancing and the ‘stay at home’ campaign, the weekly figures of STEMI (15 ± 3.5 in 2019 versus 10 ± 4.4 in 2020, p = 0.013), NSTEMI (13 ± 2.6 in 2019 versus 4.7 ± 2.3 in 2020, p = 0.038) and all myocardial infarction (28 ± 6.1 in 2019 versus 14.7 ± 5.7 in 2020, p = 0.008) have remained significantly reduced.

Conclusion:

We have observed an unexpected major decline in presentations (and treatment) of the entire spectrum of acute coronary syndromes following the beginning of the COVID-19 pandemic and nationwide public-health measures that have promoted the importance of strict social distancing and self-quarantine.

Optimal antithrombotic regimen in patients with cardiogenic shock on ImpellaTM mechanical support: less might be more

Background

Bleeding and ischemic complications are the main cause of morbidity and mortality in critically ill cardiogenic shock patients, supported by short-term percutaneous mechanical circulatory support (pMCS) devices. Hence, finding the optimal antithrombotic regimen is challenging. Bleeding not only occurs because of heparin and antiplatelet therapy (both required in the prevention of pump and acute stent thrombosis) but also because of device- and disease related coagulopathy. To prevent clotting-related device failure, most centers target full therapeutic heparin anticoagulation levels in left ventricular (LV) Impella™ supported patients in analogy with Veno-Arterial Extracorporeal Membrane Oxygenation. We aimed to investigate the safety (related to bleeding and thrombotic complications) of targeting low-dose versus therapeutic heparin levels in left Impella™-supported cardiogenic shock patients on dual antiplatelet therapy (DAPT).

Methods

In this hypothesis generating pilot study, we investigated 114 patients supported for at least two days by LV Impella™ mechanical support due to cardiogenic shock at three tertiary ICUs, highly specialized in mechanical support. Low-dose heparin (aPTT 40–60s or anti-Xa 0.2–0.3) was compared to standard of care (aPTT 60–80s or anti-Xa 0.3–0.5). Major adverse cardio- and cerebrovascular events (MACCE; composite of death, myocardial infarction, stroke/transient ischemic attack) and BARC bleeding (bleeding academic research consortium classification) during 30 day follow-up were assessed. Inverse probability of treatment weighting (IPTW) analysis was calculated with age, gender, arterial hypertension, diabetes mellitus, smoking, chronic kidney disease, previous stroke, previous myocardial infarction, previous coronary arterial bypass grafting, hypercholesterolemia and DAPT as matching variables. COX regression analysis was conducted to test for robustness.

Results

IPTW revealed 52 patients in the low-dose heparin group and 62 patients in the therapeutic group. Mean age of patients after IPTW was 62±16 years in the intermediate and 62±13 years in the therapeutic group (p=0.99). 25% and 42.2% were male (p=0.92). Overall bleeding events and major (BARC3b) bleeding events were higher in the therapeutic heparin group (overall bleeding: Hazard ratio [HR]=2.58, 95% confidence interval [CI] 1.2–5.5; p=0.015; BARC 3b: HR=4.4, 95% CI 1.4–13.6, p=0.009). Minor bleeding (BARC3a) as well as MACCE and its single components (ischemic events) did not differ between both groups. These findings were robust in the COX regression analysis.

Conclusion

In this pilot analysis, low-dose heparin in 114 LV Impella™ cardiogenic shock patients was associated with less bleeding without increased ischemic events, adjusted for DAPT. Reducing the target heparin levels in critically ill patients supported by LV Impella™ might improve the outcome of this precarious group. These findings need to be validated in randomized clinical trials.

Funding Acknowledgement

Type of funding source: None

Real-world comparison of the last generation main balloon-expandable and self-expanding valves in patients undergoing TAVI. Does the type matter?

Background/Introduction

The balloon expandable Edwards Sapien-S3 and Ultra, and the self-expanding Medtronic Evolut-Pro and Evolut-R 34mm represent the main volume of transcatheter aortic valve implantation (TAVI) procedures conducted worldwide.

Purpose

In the present study, we aim to compare the peri-procedural and one-year clinical outcomes between these last generation devices.

Methods

Consecutive patients from the ATLAS (Athens-Tokyo-London Aortic Stenosis) registry, who had undergone TAVI with either the S3/Ultra or Evolut-Pro/R 34mm device, in four centers were retrospectively studied. In-hospital procedural characteristics and outcomes were recorded and compared. Kaplan-Meier estimated 1-year all-cause mortality was compared between groups.

Results

In total, 692 patients (352pts treated with S3/Ultra and 340pts with Evolut-Pro/R34mm device) were included in the analysis. Baseline demographics (age, coronary artery disease risk factors, logistic Euroscore and aortic valve hemodynamics) were similar between the two groups.

In terms of peri-procedural and short-term outcomes, patients treated with the Evolut-Pro/R34mm device had significantly lower peak (25.4±3.6mmHg for S3/Ultra vs 14.9±0.6mmHg for the self-expanding valves, p=0.002) and mean (10.7±0.3mmHg S3/Ultra vs 7.9±0.4mmHg Evolut PRO/R34, p&lt;0.001) gradients at discharge.

Conversely, the S3 demonstrated significantly lower rates of at least moderate residual aortic regurgitation (AR) post-operatively (0.3% vs 4.8% for S3 and Evolut-Pro/R34mm respectively, p=0.001). Interestingly, the rate of new permanent pacemaker (PPM) required after the implantation in pacemaker-free patients on baseline, was higher for the S3/Ultra cohort compared to the self-expanding valve group (17.6% vs 11.7% respectively, p=0.054), however not reaching statistical significance yet. As expected, the need for balloon post dilatation of the implanted prosthesis was less among the S3/Ultra patients (5.5% vs 26.1%, p=0.001).

One-year Kaplan-Meier estimated survival was similar between the two groups (85.9% for S3 vs. 90% for Evolut-Pro/R34mm, plog-rank=0.071). Hazard ratio for all-cause mortality (Pro/R34 vs. S3/Ultra) after adjustment for gender and previous MI was similar between the groups (HR=0.73; 95% CI 0.47 to 1.14, p=0.165).

Conclusions

Real life comparison of the last generation balloon expandable and self-expanding devices demonstrates similar 1-year all-cause mortality. The S3/Ultra platforms, as compared to the Evolut-Pro/R34mm, demonstrate less paravalvular leak, at the expense of higher transvalvular gradients. Long-term follow-up and future larger trials are required to establish any potential long-term difference in clinical outcomes and prognosis.

Funding Acknowledgement

Type of funding source: None

Impact of early (&lt;24h) versus delayed (&gt;24h) intervention in patients with non ST segment elevation myocardial infarction (an observational study of 20882 patients)

Background

In patients presenting with non ST-segment elevation acute coronary syndromes (NSTE-ACS) an invasive approach has been shown to be superior to conservative management.

Purpose

We aimed to investigate the optimal timing of invasive coronary angiography and subsequent intervention.

Methods

We examined the impact ofearly (≤24h) versus delayed (&gt;24h) intervention in a large observational cohort of 20882 consecutive patients with acute NSTE myocardial infarction (NSTEMI) treated with PCI between 2005 and 2015 at 9 tertiary cardiac centers in London (UK) using Cox-regression analysis and propensity matching.

Results

Mean age was 64.5±12.7 years and 26.1% were females. A quarter (27.6%), were treated within 24h.Patients treated within 24h were slightly younger (62.8±12.8 vs. 65.2±12.6, p&lt;0.001), most commonly male (76% vs. 72.9%, p&lt;0.001) and were more frequently ventilated (2.3% vs. 1.4%, p&lt;0.001) and in cardiogenic shock (3.6% vs. 1.4%, p&lt;0.001) with dynamic changes on their ECG (84.5% vs. 76.1% p&lt;0.001). At a median follow up of 4.2 years (interquartile range 1.8 to 7) 17.7% of patients had died. Estimated 5-year survival in patients treated within 24h was 84.6% vs. 81% for those treated &gt;24h following their presentation (p&lt;0.001). This survival benefit remained following adjustment for confounders; HR (delayed vs. early management)1.11 (95% CI 1.003 to 1.23, p=0.046). In the propensity matched cohort of 4356 patients in each group, there remained a trend for higher survival in the early intervention group (p=0.061).

Conclusions

Notwithstanding the limitations of the retrospective design, this real-world cohort of NSTEMI patients suggests that an early intervention (≤24h) may improve mid term survival.

Figure 1

Funding Acknowledgement

Type of funding source: None

Outcomes of heart transplantation in patients bridged with Impella 5.0: Comparison with native chest transplanted patients without preoperative mechanical circulatory support

The Impella (Abiomed, Danvers, MA, USA) has become an important adjunct treatment modality in bridging patients with end-stage heart failure to recovery or orthotopic heart transplantation (HTx). We compared the outcome of patients directly bridged to HTx with the Impella 5.0 versus patients without mechanical circulatory support (MCS). Patients with no previous sternotomy or MCS, who were transplanted between September 2014 and March 2019 were included in this retrospective analysis. Impella 5.0 was implanted using surgical access and transesophageal echocardiography guidance. Forty-two out of 155 transplanted patients fulfilled the insertion criteria. Eight (19%) were bridged with Impella 5.0 to HTx. Recipient and donor baseline characteristics were comparable in both groups. There were no significant differences in survival between the groups at 30-day (94% no MCS vs. 87.5% Impella group, P = .47) or 6 months (94% vs. 87.5%, P = .51). Patients on Impella 5.0 showed a significant recovery of hemodynamic parameters and end-organ function. Average duration of support to HTx was 16 ± 17 days. Impella 5.0, when used in suitable patients in a timely fashion can be a good strategy for bridging patients to HTx. The axillary approach allows for early extubation and mobilization. Outcomes of patients bridged to HTx with Impella 5.0 in acute cardiogenic shock are comparable to those of patients with no MCS.

Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data

BACKGROUND

Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI.

METHODS

Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure.

FINDINGS

Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82-89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2-4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55-0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48-0·93).

INTERPRETATION

The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older.

FUNDING

NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative.

Left ventricular speckle tracking echocardiographic evaluation before and after TAVI

AIMS

To assess left ventricular (LV) function before and after transcatheter aortic valve implantation (TAVI) using conventional echocardiographic parameters and global longitudinal LV strain (GLS) and compare outcomes between Edwards S3 and Evolut R valves.

METHODS AND RESULTS

Data were collected for consecutive patients undergoing TAVI at Hammersmith hospital between 2015 and 2018. Of the 303 patients, those with coronary artery disease and atrial fibrillation were excluded leading to a total of 85 patients, which constituted our study group. The mean follow-up was 49 ± 39 days. In total, 60% of patients were treated with Edwards S3 and 40% Evolut R. TAVI resulted in an early improvement of GLS (-13.96 to -15.25%, P = 0.01) but not ejection fraction (EF) (47.6 to 50.1%, P = 0.09). LV mass also improved, especially in patients with marked baseline LV hypertrophy (P < 0.001). There were no appreciable differences of LV function improvement and overall LV remodelling after TAVI between the two types of valves used (P = 0.14).

CONCLUSIONS

TAVI results in reverse remodelling and improvement of GLS, especially in patients with impaired baseline LV function. There were no differences in the extent of LV function improvement between Edwards S3 and Evolut R valves but there was a greater incidence of aortic regurgitation with Evolut R.

Pharmacological management of cardiovascular risk in chronic inflammatory rheumatic diseases

INTRODUCTION

Cardiovascular comorbidity is a major burden in patients with chronic inflammatory rheumatic diseases and a significant determinant of their outcome. In addition to optimal management of the underlying inflammatory condition according to current guidelines, individual cardiovascular risk factors, particularly dyslipidaemia, hypertension, and impaired glucose tolerance should be assessed regularly and guide risk stratification and requirement for treatment.

AREAS DISCUSSED

We critically reviewed manuscripts and guidelines on the pharmacological management of dyslipidaemia, hypertension, and diabetes in patients with chronic inflammatory rheumatic diseases (PubMed, MEDLINE, EMBASE, Scopus, Web of Science and Google Scholar, up to 1 March 2020). Lifestyle changes are of paramount importance for the management of these risk factors. In the current narrative review, we discuss pharmacological therapies available and emerging therapies aiming to help patients achieve recommended targets, depending on their individual risk.

EXPERT OPINION

CVD risk is increased in people with chronic inflammatory rheumatic diseases. Cardiovascular risk factor management is an essential part of their care. Although relevant guidance exists, there are still major gaps in knowledge and risk factor management implementation in these patient groups. Some practical guidance based on our interpretation of existing data and experience in the field is provided in this review.

Subclavian Impella 5.0 to the rescue in a non-ST elevation myocardial infarction patient requiring unprotected left main rotablation: A case report

BACKGROUND

Often in patients with significant three-vessel or left main disease there is coexistent significant peripheral disease rendering them poor candidates for percutaneous left ventricular support during revascularization. Evidence on the management of such cases is limited.

CASE SUMMARY

We describe a case of such a patient with critical distal left main disease and chronically occluded right coronary artery who presented with chest pain and a non-ST elevation myocardial infarction and had significantly impaired left ventricular function. With the aid of our cardiothoracic surgeons a cut down subclavian Impella 5.0 was inserted and high risk rotablation percutaneous coronary intervention carried out successfully.

CONCLUSION

This case highlights the need for cross-specialty collaborations in such high-risk cases were alternative access is needed for insertion of large bore mechanical circulatory support devices.

Prognostic significance of troponin level in 3121 patients presenting with atrial fibrillation (The NIHR Health Informatics Collaborative TROP-AF study)

Background Patients presenting with atrial fibrillation (AF) often undergo a blood test to measure troponin, but interpretation of the result is impeded by uncertainty about its clinical importance. We investigated the relationship between troponin level, coronary angiography, and all-cause mortality in real-world patients presenting with AF. Methods and Results We used National Institute of Health Research Health Informatics Collaborative data to identify patients admitted between 2010 and 2017 at 5 tertiary centers in the United Kingdom with a primary diagnosis of AF. Peak troponin results were scaled as multiples of the upper limit of normal. A total of 3121 patients were included in the analysis. Over a median follow-up of 1462 (interquartile range, 929-1975) days, there were 586 deaths (18.8%). The adjusted hazard ratio for mortality associated with a positive troponin (value above upper limit of normal) was 1.20 (95% CI, 1.01-1.43; P<0.05). Higher troponin levels were associated with higher risk of mortality, reaching a maximum hazard ratio of 2.6 (95% CI, 1.9-3.4) at ≈250 multiples of the upper limit of normal. There was an exponential relationship between higher troponin levels and increased odds of coronary angiography. The mortality risk was 36% lower in patients undergoing coronary angiography than in those who did not (adjusted hazard ratio, 0.61; 95% CI, 0.42-0.89; P=0.01). Conclusions Increased troponin was associated with increased risk of mortality in patients presenting with AF. The lower hazard ratio in patients undergoing invasive management raises the possibility that the clinical importance of troponin release in AF may be mediated by coronary artery disease, which may be responsive to revascularization.

Ten-year improved survival in patients with multi-vessel coronary disease and poor left ventricular function following surgery: A retrospective cohort study

OBJECTIVE

Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF] < 30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients.

METHODS

We retrospectively reviewed our data for 321 patients with EF < 30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI.

RESULTS

214 patients underwent CABG (n [on-pump CABG] = 94; n [off-pump CABG] = 120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR] = 1.86, 95% confidence interval [CI] = 1.46-2.42; p < 0.001) and off-pump CABG (HR = 2.32, 95% CI = 1.75-3.15; p < 0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ = 13.5, 95% CI = 3.2-24.5; p = 0.012) and off-pump CABG (Δ = 16.1, 95% CI = 5.9-25.8; p < 0.001).

CONCLUSION

Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken.

Comparison of the self-expanding Evolut-PRO transcatheter aortic valve to its predecessor Evolut-R in the real world multicenter ATLAS registry

BACKGROUND

The Evolut PRO self-expanding transcatheter aortic valve has been designed to feature an outer pericardial wrap that aims to reduce paravalvular regurgitation (PVR) rates. Medium-term clinical outcomes, compared to its predecessor Evolut R, in a real-world setting, have not been investigated. The aim of the present study was to compare the two valves with regards to peri-procedural complications, early outcomes and mid-term survival.

METHODS

Consecutive patients, undergoing TAVI with either the Evolut PRO or Evolut R device, from the multicenter ATLAS registry were retrospectively studied. Outcomes studied included periprocedural complications, PVR at discharge, need for new pacemaker implantation and Kaplan-Meier estimated 1-year all-cause mortality.

RESULTS

Analysis included 673 patients (498 treated with Evolut R and 175 treated with Evolut PRO). At least moderate PVR was numerically lower amongst patients treated with Evolut PRO (7.4% vs 3.8% for Evolut R and Evolut PRO respectively, p = .108). Rates of new permanent pacemaker (PPM) implantation (21.1% vs. 11.9%, p = .023), and bail-out valve-in-valve (2.4% vs. 0%, p = .049) were significantly lower amongst the Evolut PRO group. No differences were demonstrated regarding bleeding, stroke or acute kidney injury. One-year Kaplan-Meier estimated survival was similar between groups (93% for Evolut R vs. 91.2% for Evolut PRO, p_log-rank = 0.806).

CONCLUSIONS

The Evolut PRO self-expanding valve demonstrates similar mid-term survival rates and numerically, yet not significant, lower incidence of PVR compared to its predecessor. Interestingly this new generation valve is associated with a significantly reduced rate for new PPM implantation. Future studies are required to confirm this finding.