Determinants and prognostic impact of afterload mismatch after MitraClip implantation

Introduction

Mitral transcatheter edge-to-edge repair (TEER) is a widespread option to treat mitral regurgitation in high-risk patients. The sudden reduction of mitral regurgitation (MR) following TEER abruptly eliminates the low-impedance regurgitant flow into the left atrium, leading to an increase in left ventricle (LV) afterload with possible impairment of LV systolic function, defined afterload mismatch (AM).

Purpose

To explore a new definition of AM and to analyze the determinants and prognostic role of AM in patients with functional MR (FMR) undergoing TEER.

Methods

This was an international multicenter case-control study including adult patients with severe FMR and LVEF ≤35% undergoing TEER between 2012 and 2020. AM was defined as the acute need to initiate or increase inotropic support by a vasoactive inotropic score ≥3 or the need for a mechanical circulatory support following TEER.

Results

80 patients with AM were compared to 80 consecutive patients undergoing TEER not meeting the criteria for AM. Median age was 67 years, 79% of patients were male, had a median LVEDV of 240 ml with severely reduced LVEF (median 26%) and pulmonary hypertension (median 48 mmHg). Median EROA/LVEDV ratio was 0.17 (IQR 0.12–0.24) based on which 37% of the total population presented with proportionate MR. Levosimendan was administered before TEER in 42% of patients while intravenous vasodilators in 43%. In most patients more than 1 clip were needed (2 clips in 88 patients, 3 clips in 11). Patients presenting AM more commonly had a lower EROA/LVEDV ratio (0.14 vs. 0.18, p<0.001) leading to a higher percentage of patients with proportionate MR (55% vs. 22%, p<0.001; Figure 1) and had more clips implanted (p=0.008). AM was graded as mild in 74% of patients, moderate in 15% and severe in 11%. At multivariate analysis, patients with proportionate MR were more likely to develop AM after TEER (OR 2.95, 95% CI: 1.32–6.60, p=0.008), while those treated with levosimendan (OR 0.32, 95% CI: 0.15–0.71, p=0.005) and/or IV vasodilators (OR 0.44, 95% CI: 0.21–0.96, p=0.040) before TEER were less likely to suffer from AM. In-hospital death occurred in 7 cases, all being part of AM group. Patients were more likely to die in-hospital if AM was more severe (OR 2.56, 95% CI: 1.19–5.54, p=0.017), and for higher grades of residual MR (OR 3.35, 95% CI: 1.27–8.79, p=0.014). The 2-year survival rate did not differ significantly between groups (66% vs 75%, HR 1.51, 95% CI: 0.73–3.12, p=0.270; Figure 2). At 2 years 51 patients (32%) were re-hospitalized for HF, independently from post-procedural AM (HR 1.36, 95% CI: 0.70–2.67, p=0.363).

Conclusions

In patients with LVEF ≤35% and severe FMR undergoing TEER, the development of AM predicted in-hospital mortality, while long-term outcomes were not affected by acute AM. The use of levosimendan or intravenous vasodilators during the pre-procedural phase reduced the risk of acute AM.

Funding Acknowledgement

Type of funding sources: None.

Long-term survival after TAVR in patients with low flow-low gradient vs high gradient aortic valve stenosis

Introduction

Transcatheter aortic valve replacement (TAVR) has become the treatment of choice in elderly patients affected by severe aortic stenosis (AS). In patients with low-flow low-gradient (LFLG) AS, a clear benefit of TAVR over conservative treatment has been demonstrated. Notwithstanding, patients with classical LFLG (cLFLG) AS have shown worse early post-procedural outcomes compared to those with high-gradient (HG) AS.

Purpose

Given the absence of data, we aimed to evaluate long-term survival (up to 10 years) after TAVR in patients with cLFLG and paradoxical LFLG (pLFLG) AS as compared to those with HG-AS.

Methods

Consecutive patients undergoing TAVR at our center with a minimum 5-year follow up (i.e. treated between June 2007 and December 2016) were considered for this analysis. According to baseline echocardiography, patients were divided in three groups: 1) HG-AS (MG >40 mmHg); 2) cLFLG-AS (MG <40 mmHg, EF <50%); and 3) pLFLG-AS (MG <40 mmHg, EF >50%). The study endpoint was post-procedural all-cause mortality. To test differences in long-term outcomes among groups, survival curves using the Kaplan Meier estimator were plotted and compared with the log-rank test. To adjust for possible baseline confounders, a propensity score weighted survival analysis was then performed (standard mean deviation <0.1 for all the considered covariates).

Results

A total of 574 subjects were included in the analysis (419 [73%] HG-AS; 91 [15%] pLFLG-AS; and 64 [11%] cLFLG-AS). Median survival time was 4.8 years [IQR 2.3–6.2], with a maximum of 12.3 years. Patients with cLFLG-AS presented higher baseline cardiovascular risk compared to those with both HG-AS and pLFLG-AS. At unadjusted survival analysis, patients with cLFLG-AS showed the worst long-term prognosis after TAVR (overall log-rank test p=0.023). However, after propensity weighted adjustment, the long-term survival of patients with cLFLG-AS was similar to those with HG-AS (p=0.77). Patients with pLFLG and HG-AS presented similar survival rate. Unadjusted (Panels A and C) and adjusted (Panels B and D) survival curves are reported in Figure 1. Out of 64 patients with cLFLG-AS, 43 (67%) presented an improvement in LV-EF (>15% from the baseline value) within the first year after TAVR. LV-EF improvement, but not baseline LV-EF, was apparently related to longer post-TAVR survival (Figure 2).

Conclusion

In the current study, patients with cLFLG-AS had worse long-term survival after TARV as compared to either HG or pLFLG-AS subjects. This difference was not present after adjusting for possible baseline confounders. Thus, the low-flow state condition per se might have a lower impact on long term prognosis of TAVR patients than previously hypothesized. Post-TAVR LV-EF recovery was common among patients with cLFLG-AS and was associated with improved long-term survival.

Funding Acknowledgement

Type of funding sources: None.

P129 IMPACT OF THE ATHEROSCLEROTIC PABULUM ON IN–HOSPITAL MORTALI–TY FOR SARS–COV–2 INFECTION. IS CALCIUM SCORE ABLE TO IDENTIFY AT RISK PATIENTS?

Background

Although the primary cause of death in COVID–19 infection is respiratory failure, there are evidences that cardiac manifestations may contribute to overall mortality and can even be the primary cause of death. More importantly, it is recognised that COVID–19 is associated with a high incidence of thrombotic complications.

Aim of the Study

evaluate if CAC score was useful to predict in–hospital mortality and complications in patients with COVID infection

Methods

Two–hundred–eighty–four patients with proven SARS–CoV2 infection who had a non–contrast Chest CT at our facility were retrospective analysed for coronary artery calcium (CAC) score. Primary endpoint was in–h mortality. Secondary end–points were need for mechanical ventilation and Intensive Care Unit admission. Clinical and radiological data were retrieved.

Results

Patients with coronary calcium had higher inflammatory burden at admission (D–dimer, CRP, Procalcitonin) and higher high–sensitive Troponin I (HScTnI) at admission and at peak. While there was no association with presence of consolidation and ground glass opacities, patients with coronary calcium had higher incidence of bilateral infiltration and higher in–hospital mortality. The main finding of our research is that CAC alone does not completely identify all the population at risk of events in the setting of COVID 19 patients. Peak HScTnI was associated with higher mortality, intensive care unit admission and mechanical ventilation in both univariable at multivariable analysis.

Conclusions

Together with the presence of higher inflammation burden CAC may be a useful marker in identifying patients at risk of cardiovascular complications and in hospital mortality.

C47 CORO–CT PLAQUE ANALYSIS IN ASSESSMENT OF CARDIOVASCULAR RISK

Background

Computed tomographic (CT) coronary angiography represents a non–invasive approach to assess plaque characteristics that provides information to change treatment of coronary artery disease (CAD) and to asses risk stratification.

Purpose

Analyze the differences in plaque composition between patients with different plaque features: soft unstable plaques, hard stable plaques and no plaques; identify whether there is a relationship between the plaque density and the pericoronary fat attenuation index (pFAI). Materials and methods: 372 patients retrospectively analyzed who underwent CTCA for exclusion of CAD. They were divided into three groups: 37 (10%) patients with high attenuated plaques (> 60HU), 137 (37%)with low attenuated plaques (<29 HU and a volume of at least 15 mm3 and/or 30–59 HU with a volume greater than 52 mm3) and 198 (53%) patients without significant CAD. For each patients we collected clinical, radiological and follow–up data.

Results and Discussion

Low–attenuated plaques are significantly associated with older age, male sex, dyslipidemia and diabetes mellitus (p < 0.001). Higher values of pFAI were more present in patients with soft plaques than in those with stable plaques and without plaques (p = 0.005). It was also found that soft plaques were present in more CA segments compared to stable plaques. Overall volume of soft plaque appears greater than hard plaques and mainly localized in the anterior descendant coronary artery with higher stenosis values (p < 0.001). Presence of plaques with soft or high–risk features predisposes significantly and independently (p < 0.001) to a composite outcome (death, in–hospital admissions for percutaneous angioplasty or by–pass procedures) at the follow up.

Conclusions

Coronary plaque analysis showed a good correlation between high–risk plaques and pFAI, supporting the hypothesis that the presence of high–risk plaques can be correlated to inflammatory burden. Furthermore, the presence of high risk plaques predispose to death or hospitalization for coronary intervention.