Prognostic Implication of Tricuspid Regurgitation in ST-segment Elevation Myocardial Infarction Patients

BACKGROUND

Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations, but currently no data is available about the prevalence and prognostic implication of TR in ST-segment elevation myocardial infarction (STEMI) patients.

OBJECTIVES

To investigate the possible implication of TR among STEMI patients.

METHODS

We conducted a retrospective study of STEMI patients undergoing primary percutaneous coronary intervention (PCI) and its relation to major clinical and echocardiographic parameters. Patient records were assessed for the prevalence and severity of TR, its relation to the clinical profile, key echocardiographic parameters, in-hospital outcomes, and long-term mortality. Patients with previous myocardial infarction or known previous TR were excluded.

RESULTS

The study included 1071 STEMI patients admitted between September 2011 and May 2016 (age 61 ± 13 years; predominantly male). A total of 205 patients (19%) had mild TR while another 32 (3%) had moderate or greater TR. Patients with significant TR demonstrated worse echocardiographic parameters, were more likely to have in-hospital complications, and had higher long-term mortality (28% vs. 6%; P < 0.001). Following adjustment for significant clinical and echocardiographic parameters, mortality hazard ratio of at least moderate to severe TR remained significant (hazard ratio 2.44; 95% confidence interval 1.06-5.62; P = 0.036) for patients with moderate-severe TR.

CONCLUSIONS

Among STEMI patients after primary PCI, the presence of moderate-severe TR was independently associated with adverse outcomes and significantly lower survival rate.

Prognostic Implication of Tricuspid Regurgitation in ST-segment Elevation Myocardial Infarction Patients

BACKGROUND

Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations but currently no data is available about the prevalence and prognostic implication of TR in ST-segment elevation myocardial infarction (STEMI) patients.

OBJECTIVES

To investigate the possible implication of TR among STEMI patients.

METHODS

We conducted a retrospective study of STEMI patients undergoing primary percutaneous coronary intervention (PCI), and its relation to major clinical and echocardiographic parameters. Patient records were assessed for the prevalence and severity of TR as well as the relation to the clinical profile, key echocardiographic parameters, in-hospital outcomes, and long-term mortality. Patients with previous myocardial infarction or known previous TR were excluded.

RESULTS

The study included 1071 STEMI patients admitted between September 2011 and May 2016 (age 61 ± 13 years; predominantly male). A total of 205 patients (19%) had mild TR while another 32 (3%) had moderate or greater TR. Patients with significant TR demonstrated worse echocardiographic parameters, were more likely to have in-hospital complications, and had higher long-term mortality (28% vs. 6%, P < 0.001). Following adjustment for significant clinical and echocardiographic parameters, mortality hazard ratio of at least moderate to severe TR remained significant (2.44, 95% confidence interval 1.06-5.6, P = .036) for patients with moderate to severe TR.

CONCLUSIONS

Among STEMI patients after primary PCI, the presence of moderate to severe TR was independently associated with adverse outcomes and significantly lower survival rate.

Spectrum of Cardiac Manifestations in COVID-19: A Systematic Echocardiographic Study

Supplemental Digital Content is available in the text.

Information on the cardiac manifestations of coronavirus disease 2019 (COVID-19) is scarce. We performed a systematic and comprehensive echocardiographic evaluation of consecutive patients hospitalized with COVID-19 infection.

Effectiveness and Safety of Transcatheter Aortic Valve Implantation in Patients With Aortic Stenosis and Variable Ejection Fractions (<40%, 40%-49%, and >50%)

We evaluated the safety and efficacy of transcatheter aortic valve implantation (TAVI) in aortic stenosis patients with mid-range ejection fraction (ASmrEF) and compared it to aortic stenosis patients with reduced ejection fraction (ASrEF) and preserved ejection fraction (ASpEF). TAVI cases were stratified by baseline ejection fraction (ASrEF, ASmrEF, ASpEF) and compared for characteristics, procedural outcomes, and change in echocardiographic parameters at 1 year and mortality over a 5-year follow-up. The final study population included 708 patients who underwent TAVI. ASmrEF patients presented with improved EF at 1-year after procedure (49.0 ± 9.8 at 1 year vs 43.0 ± 2.5 at baseline, p <0.001) and showed improvements in left ventricular (LV) diameters (LV end-diastolic diameter: 50.4 ± 6.0 at 1 year vs 53.0 ± 5.5 at baseline and LV end-systolic diameter 34.7 ± 7.8 at 1 year vs 39.5 ± 5.9 at baseline, p <0.001 for both). LVEF improved for patients with ASrEF but not in ASpEF patients. LV diameters did not improve for patients in either group. Procedural safety and success rates were similar between all heart failure groups. Survival rates over a 5-year follow-up post-TAVI were not different between patients with ASmrEF, ASrEF, and ASpEF (ASrEF 78.4%, ASmrEF 81.9%, ASpEF 78.3%, p = 0.327). TAVI for patients with ASmrEF is safe and effective and results in marked improvement of LV function and structure.

P1276 Excess mortality associated with atrial fibrillation complicating tricuspid regurgitation

Introduction

There is limited data regarding the prevalence of Atrial Fibrillation (AFib) in tricuspid regurgitation (TR) patients. In addition the influence on mortality of AFib on TR patients is not well studied. In the current study we aimed to examine whether the prevalence of AFib is related to the severity of TR and to assess effect of AFib on the mortality of TR patients.

Methods

The cohort included 397 patients (mean age 77.1 ± 15.2 Years; 36.3 % males) with TR of any cause that underwent quantitative prospective evaluation by the PISA method for regurgitant volume and effective regurgitant orifice (ERO). The primary outcome was all-cause mortality.

Results

251 (65.9%) of the patients were classified as mild to moderate TR (ERO &lt; 0.4) and 130 (33.6%) patients classified as severe TR ( ERO≥ 0.4)

The prevalence of AFib in the total cohort was 56.4%. The prevalence of AFib in the mild to moderate TR patients was lower than in the severe TR group (52.5% vs. 63.9%; p = 0.03). In univariate Hazard analysis atrial fibrillation was associated with increased mortality (HR = 1.18, P &lt; 0.04). In sub-group analysis atrial fibrillation was associated with excess mortality in the mild and moderate TR group (Log Rank Chi square = 3.11, p= 0.07) but not in the severe TR group.

Conclusions

The prevalence of AFIB among TR patients is high, and severe TR is associated with higher prevalence of AFIB compared to milder disease.

AFib is independently associated with mortality in patients with less than severe TR but not in the severe TR group.

Abstract P1276 Figure.

Contrast Volume to Glomerular Filtration Ratio and Acute Kidney Injury among ST-Segment Elevation Myocardial Infarction Patients Treated with Primary Percutaneous Coronary Intervention

INTRODUCTION

The ratio of contrast media volume to glomerular filtration rate (contrast/GFR) has been shown to correlate with the occurrence of contrast-induced acute kidney injury (CI-AKI) in unselected patient populations who underwent percutaneous coronary intervention (PCI).

OBJECTIVE

We evaluated the possible utilization of this marker and optimal cutoff among ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI.

METHODS

We retrospectively included 419 patients with STEMI treated with primary PCI. The occurrence of CI-AKI was defined by the KDIGO criteria as an increase in serum creatinine of ≥0.3 mg/dL within 48 h following PCI. A receiver-operator characteristic (ROC) curve was used to identify the optimal cutoff value of contrast/GFR ratio to predict CI-AKI. This value was then assessed using multivariable logistic regression.

RESULTS

The overall incidence of CI-AKI was 9%. The contrast/GFR ratio was significantly higher among patients with CI-AKI (2.7 ± 1.2 vs. 1.9 ± 0.9; p < 0.001). According to the ROC curve analysis, the optimal cutoff value of contrast/GFR ratio to predict AKI was measured as ≥2.13, with 70% sensitivity and 60% specificity (AUC 0.65, 95% CI 0.56-0.74; p = 0.002). In a multivariate logistic regression model, contrast/GFR ratio ≥2.13 was independently associated with CI-AKI (OR 2.46, 95% CI 1.09-5.57; p = 0.03).

CONCLUSIONS

Among STEMI patients undergoing primary PCI, contrast/GFR ratio ≥2.13 was independently associated with CI-AKI.

Quantitative assessment of effective regurgitant orifice: impact on risk stratification, and cut-off for severe and torrential tricuspid regurgitation grade

Aims 

Asses the added value of quantitative evaluation of tricuspid regurgitation (TR), the proper cut-off value for severe TR and ‘torrential TR’ based on outcome data. The added value of quantitative evaluation of TR, and the cut-off values associated with increased mortality are unknown.

Methods and results

In patients with all-cause TR assessed both qualitatively and quantitatively by proximal iso-velocity surface area method, long-term and 1-year outcome analysis was conducted. Thresholds for excess mortality were assessed using spline curves, receiver-operating characteristic curves, and minimum P-value analysis. The study involved 676 patients with all-cause TR (age 73.9 ± 14 years, male 45%, ejection fraction 52.9 ± 14%). Effective regurgitant orifice (ERO) was strongly associated with decreased survival in unadjusted [hazard ratio (HR) 2.38 (1.79–3.01), P &lt; 0.0001 per 0.1 cm2 increment] and adjusted [2.6 (1.25–5.0), P = 0.01] analyses. Quantitative grading was superior to qualitative grading in prediction of outcome (P &lt; 0.01). The optimal cut-off value for the best separation in survival between groups of patients with severe vs. lesser degree of TR was 0.35 cm2 [P &lt; 0.0001, HR =2.0 (1.5–2.7)]. ERO negatively impacted survival, even when including only the subgroup of patients with severe TR [HR 1.5 (1.01–2.3); P = 0.04]. The optimal threshold corresponding for the best separation for survival between groups of patients with severe vs. ‘torrential’ TR was 0.7 cm2 [P = 0.005, HR =2.6 (1.2–5.1)].

Conclusion 

TR can be severe and even ‘torrential’ and is associated with excess mortality. Quantitative assessment of TR by ERO measurement is a powerful independent predictor of outcome, superior to standard qualitative assessment. The optimal cut-off above which mortality is increased is 0.35 cm2, similar albeit slightly lower than suggested in recent guidelines. Torrential TR &gt;0.7 cm2 is associated with poorer survival compared to patients with severe TR (ERO &gt; 0.4 cm2 and &lt;0.7 cm2).

The interaction between anti-Ro/SSA and anti-La/SSB autoantibodies and anti-infectious antibodies in a wide spectrum of auto-immune diseases: another angle of the autoimmune mosaic

OBJECTIVES

The presence of anti-Ro/SSA and anti-La/SSB antibodies has been linked with autoimmunity in general and with several autoimmune diseases (AID) in particular. In the current study we evaluated these antibodies in a wide spectrum of AID as well as the links between them and anti-infectious antibodies.

METHODS

We examined 2082 sera from patients with 16 different AID compared to 524 sera from geographically-matched healthy controls, for the presence and titres of anti-Ro/SSA and anti-La/SSB. All samples were also tested for a variety of anti-infectious agents' antibodies using the BioPlex 2200-immunoassay (Bio-Rad, USA).

RESULTS

Anti-Ro/SSA was more prevalent, with significantly higher titre in 5 autoimmune diseases namely Sjögren's syndrome (SS), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS) both primary and APS linked to SLE, systemic sclerosis (SSc) and primary biliary cirrhosis (PBC). Anti-La/SSB was more prevalent with higher titers in SS, SLE, APS linked to SLE and PBC. Prevalence, but not titers, of both antibodies were higher also in polymyositis (PM). Additionally, we found a correlation between anti-Ro/SSA antibodies and antibodies of the IgM and IgG subtypes directed at cytomegalovirus as well as IgG-antibodies directed at Epstein-Barr virus (EBV) and toxoplasma (p<0.001). Anti-La/SSB antibodies correlated with the presence of IgG antibodies against EBV early antigen (p<0.001).

CONCLUSIONS

In a large cohort of patients with autoimmune diseases we found an association between anti-Ro/SSA and anti-La/SSB antibodies and 6 autoimmune diseases, amongst which primary APS and PM. Additionally, we observed linkages between these autoantibodies and anti-infectious antibodies directed at Epstein-Barr virus, toxoplasma and cytomegalovirus. Our findings support the concept of interplay between infectious agents and autoimmunity, such as the plausibility of an infectious agent that trigger the immune system to produce specific antibodies which will later result in a unique group of AID.

Eosinophilic Pneumonia Following Occupational Smoke Exposure

A 21-year-old male patient with a history of occupational exposure to open fire smoke was initially treated with empiric antibiotics for simple community-acquired pneumonia. However, he continued to deteriorate rapidly, developed respiratory failure and needed mechanical ventilation. After possible aetiologies were considered, acute eosinophilic pneumonia was suspected and confirmed by broncho-alveolar lavage. His condition improved dramatically soon after glucocorticoid administration and he was discharged without sequelae. Acute eosinophilic pneumonia should be considered in a patient with a history of exposure to smoke presenting with pneumonia that deteriorates rapidly despite broad antibiotics. An important clue for the diagnosis is eosinophilia in peripheral blood.

[Historical evidence of the beginning of modern medicine in the holy land: "list of medicinal preparations found in stores and dispensary on july 21st 1857"]

The London Society for Promoting Christianity Amongst the Jews established the first Western hospital in Jerusalem in the middle of 19th century. It was built for the benefit of the Jewish population of the city, and it transposed the Holy Land, from a medical point of view, to the modern era. The huge archives of the London Society in England contain many documents dealing with its activity. One document, revealed here for the first time, describes the content of the medicinal preparations held in the stores of the British hospital and dispensary in Jerusalem on July 21 1857. The list, presented here in full, is impressive in its length, containing hundreds of medicinal substances originating from plants, minerals, and animals that were used in the Western world at the time. Most of the chemicals in the list had never previously appeared in any published historical source concerning Palestine. The list is thus one of the first pieces of evidence of modern medical and pharmacological activities in the Holy Land. A comparison of the list with several other 19th century lists of medicinal substances found in professional literature revealed that it contains most of the known medicinal substances of that time. Compared with medieval documents, or lists of traditional substances compiled a few years earlier, the 1857 list is richer and contains new substances and preparations originating in the New World (America) and chemicals unknown in the region before. It is evidence of the change that occurred in the field of pharmacology owing to the penetration of the modern medicine into the Holy Land. The 1857 list contains 268 substances: 147 medicinal preparations of plant origin, 117 preparations of chemical and mineral origin, and only four of animal origin.