Comprehensive characterization of non-cardiac comorbidities in acute heart failure: an analysis of ESC-HFA EURObservational Research Programme Heart Failure Long-Term Registry

AIMS

To evaluate the prevalence and associations of non-cardiac comorbidities (NCCs) with in-hospital and post-discharge outcomes in acute heart failure (AHF) across the ejection fraction (EF) spectrum.

METHODS AND RESULTS

The 9326 AHF patients from European Society of Cardiology (ESC)-Heart Failure Association (HFA)-EURObservational Research Programme Heart Failure Long-Term Registry had complete information for the following 12 NCCs: anaemia, chronic obstructive pulmonary disease (COPD), diabetes, depression, hepatic dysfunction, renal dysfunction, malignancy, Parkinson's disease, peripheral vascular disease (PVD), rheumatoid arthritis, sleep apnoea, and stroke/transient ischaemic attack (TIA). Patients were classified by number of NCCs (0, 1, 2, 3, and ≥4). Of the AHF patients, 20.5% had no NCC, 28.5% had 1 NCC, 23.1% had 2 NCC, 15.4% had 3 NCC, and 12.5% had ≥4 NCC. In-hospital and post-discharge mortality increased with number of NCCs from 3.0% and 18.5% for 1 NCC to 12.5% and 36% for ≥4 NCCs.Anaemia, COPD, PVD, sleep apnoea, rheumatoid arthritis, stroke/TIA, Parkinson, and depression were more prevalent in HF with preserved EF (HFpEF). The hazard ratio (95% confidence interval) for post-discharge death for each NCC was for anaemia 1.6 (1.4-1.8), diabetes 1.2 (1.1-1.4), kidney dysfunction 1.7 (1.5-1.9), COPD 1.4 (1.2-1.5), PVD 1.2 (1.1-1.4), stroke/TIA 1.3 (1.1-1.5), depression 1.2 (1.0-1.5), hepatic dysfunction 2.1 (1.8-2.5), malignancy 1.5 (1.2-1.8), sleep apnoea 1.2 (0.9-1.7), rheumatoid arthritis 1.5 (1.1-2.1), and Parkinson 1.4 (0.9-2.1). Anaemia, kidney dysfunction, COPD, and diabetes were associated with post-discharge mortality in all EF categories, PVD, stroke/TIA, and depression only in HF with reduced EF, and sleep apnoea and malignancy only in HFpEF.

CONCLUSION

Multiple NCCs conferred poor in-hospital and post-discharge outcomes. Ejection fraction categories had different prevalence and risk profile associated with individual NCCs.

Cardiac rupture after ST elevation myocardial infarction – a decade's experience of a tertiary cardiology centre

 

Mechanical complications post ST elevation myocardial infarction (STEMI) are life-threating events, that require rapid recognition and appropriate management. Clinical diagnosis, considering high index of suspicion and bedside echocardiography should be considered in all STEMI patients

Despite the overall decrease of the incidence of cardiac rupture (CR) secondary to STEMI in context of early revascularization and the wide availability of primary PCI, CR has still an unacceptable high mortality.

Purpose

To provide demographic, clinical, management and prognostic data associated to cardiac rupture from a tertiary centre of cardiology in Romania and to better describe in-hospital trajectory.

The primary endpoint was defined as the incidence of CR and secondary endpoints were rate of surgical interventions, in-hospital mortality rate at 24 hours and after 24 hours during index hospitalization.

Methods

The analysis of the electronic medical records retrospectively identified 7703 patients admitted for STEMI between 01 Jan 2011 and 31 Dec 2020.

A database consisting of demographic data, medical history, cv and non-cv comorbidities, in-hospital management were recorded using an UiPath robotic process automation (RPA) technology. Characteristics of the patients +/− CR were compared, and data analysis was performed using SPSS 26 Ed.

Results

Of a total number of 7703 consecutive STEMI patients, CR has been identified in 185 patients (mean incidence of 2.4%). The annual rates for CR incidence remained stable during the past decade (Figure 1). Patients with CR were older compared with non-CR (71.6±10.2 vs 61.47±12.8 years; p<0.001) and more commonly female (3.92% vs 1.78% males, p=0.04).

The CR patients had more comorbidities and CV risk factors – HTN, smoker status, DLP, more AF, CKD, obesity and chronic cognitive deficit (p<0.05), but not DM (p=0.6).

Among the CR group patients, anterior MI was the frequent localisation (52%), followed by inferior MI (17%), infero-lateral (23%) and RV involvement MI (6.4%). According to the type of the mechanical complication, patients developed free wall rupture (50% of cases), 39% IVS rupture and 11% papillary muscle was involved; A number of 50 patients (27%), benefited from emergent cardiac surgery and 31.3% of CR patients received mechanical circulatory support. The overall STEMI mortality in the first 24-hours was 1.84% and in most of these patients the main cause of death was related to CR (31%). Overall total in-hospital mortality was 8.08% (6.5% non-CR group vs. 70.8% the CR group – Figure 1).

Conclusions

The study presents the epidemiological characteristics of CR complicating STEMI in the largest tertiary cardiovascular hospital in Romania. We have identified a stable trend for the incidence of CR incidence among patients with STEMI. In spite of the high rate of cardiac surgery and MCS, in-hospital mortality remains very high, particularly in the first 24 h since admission

Funding Acknowledgement

Type of funding sources: None.

Deep neural networks for ECG-free cardiac phase and end-diastolic frame detection on coronary angiographies

Invasive coronary angiography (ICA) is the gold standard in Coronary Artery Disease (CAD) imaging. Detection of the end-diastolic frame (EDF) and, in general, cardiac phase detection on each temporal frame of a coronary angiography acquisition is of significant importance for the anatomical and non-invasive functional assessment of CAD. This task is generally performed via manual frame selection or semi-automated selection based on simultaneously acquired ECG signals - thus introducing the requirement of simultaneous ECG recordings. In this paper, we evaluate the performance of a purely image based workflow relying on deep neural networks for fully automated cardiac phase and EDF detection on coronary angiographies. A first deep neural network (DNN), trained to detect coronary arteries, is employed to preselect a subset of frames in which coronary arteries are well visible. A second DNN predicts cardiac phase labels for each frame. Only in the training and evaluation phases for the second DNN, ECG signals are used to provide ground truth labels for each angiographic frame. The networks were trained on 56,655 coronary angiographies from 6820 patients and evaluated on 20,780 coronary angiographies from 6261 patients. No exclusion criteria related to patient state (stable or acute CAD), previous interventions (PCI or CABG), or pathology were formulated. Cardiac phase detection had an accuracy of 98.8 %, a sensitivity of 99.3 % and a specificity of 97.6 % on the evaluation set. EDF prediction had a precision of 98.4 % and a recall of 97.9 %. Several sub-group analyses were performed, indicating that the cardiac phase detection performance is largely independent from acquisition angles, the heart rate of the patient, and the angiographic view (LCA / RCA). The average execution time of cardiac phase detection for one angiographic series was on average less than five seconds on a standard workstation. We conclude that the proposed image based workflow potentially obviates the need for manual frame selection and ECG acquisition, representing a relevant step towards automated CAD assessment.

P1243 Nonbacterial thrombotic endocarditis (NBTE) of the aortic valve: incidental finding in hospitalized patients with advanced heart failure

Background

The presence of small mobile masses on the ventricular side of the aortic valves in the absence of valvular regurgitation and signs of systemic inflammation has been previously described as marantic endocarditis and is now referred to as nonbacterial thrombotic endocarditis (NBTE). It is thought to be associated with endothelial dysfunction and procoagulative status, as is the case of acute decompensated heart failure (HF).

Case description

We present a series of three male patients, with similar clinical characteristics, who were admitted for acute decompensated HF. All three patients had chronic HF, due to non-ischemic dilated cardiomyopathy with severe biventricular dysfunction, with resynchronization therapy, with elevated natriuretic peptides and previous HF hospitalizations in the past year requiring prolonged intravenous treatments. Other clinical, biological criteria for the definition of advanced HF were also met. All patients were under chronic anticoagulation treatment using a direct oral anticoagulant because of persistent atrial fibrillation. Thorough echocardiographic evaluation (both transthoracic and transoesophageal ultrasound) identified small mobile masses on the ventricular side of the aortic valves, centrally, on the line of cusp coaptation, with only minor central regurgitation. The lack of progression of valve lesion and the absence of gross signs of inflammation (no fever, normal hemoleucogram, normal CRP, repeated negative blood cultures) on serial examinations during several weeks follow-up allowed for the exclusion of infective endocarditis. In one case we also identified a left atrial appendage thrombus and presumably thrombotic masses attached to right side pacing leads. No clinically systemic embolic events were identified.

Conclusion

We consider this to be an incidental finding in the given subclinical prothrombotic and inflammatory predisposing milieu of advanced chronic HF and the increasing high quality echocardiography imaging. Its clinical significance is still unknown, while differential diagnosis from subacute or chronic endocarditis relies largely on clinical judgment.

504 Intramural hematoma post transcatheter valve replacement

Background

Transcatheter valve replacement (TAVR ) is currently the optimal treatment for patients with severe aortic stenosis who are considered to have an intermediate to high operative risk for surgical intervention. Intramural hematoma secondary to balloon-expandable TAVR is a poorly reported complication with unknown outcome. Among the risk factors associated with this complication are advanced age, female gender, bulky calcifications, significant basal hypertrophy and severe prothesis oversizing.

Case report

We report the case of a 84 year old woman with a history of permanent atrial fibrillation, who was diagnosed with severe aortic stenosis symptomatic with heart failure NYHA class III. An important comorbidity was liver cirrhosis of viral etiology (hepatitis C virus) with secondary thrombocytopenia.

Transthoracic and transoesophageal echocardiography (TEE) showed severe aortic stenosis with asymmetric calcifications, with preserved gradient (a peak velocity of 4.7 m/s, mean gradient of 63.3mmHg), mild left ventricular disfunction (ejection fraction 45%), and calculated aortic valve area of 0,9 cm2.

As a frail, high risk patient, the heart team recommended transcatheter aortic valve implantation. After complete computer tomographic evaluation, a 26 mm Edwards Sapien 3 valve was implanted through a femoral approach.

Intraprocedural transesophageal echocardiography showed the developement of an intramural hematoma in the aortic root (right coronary and noncoronary sinuses), associated with a small pericardial effusion. After administration of Protamine, betablockers and strict blood pressure control, no extension of the hematoma was noted.

Serial TEE showed significant regression of the hematoma and of the pericardial effusion, with normal parametres of the prothesis, with a transprothetic gradient of 23 mmHg, no aortic leak, no other complications.The patient was discharged 12 days after the procedure, clinically stable.

Conclusion

Aortic intramural hematoma may occur during intra-TAVR procedure. Although it may have a benign course, timely recognition and adequate imaging follow-up are mandatory in order to limit the extent and prevent life-threatening complications.

P1305 Rare complication of a frequent disease

Introduction

Splenic abcess represents a rare complication of left-sided infective endocarditis. Unlike splenic infarction, which is a more benign condition, splenic abcess requires rapid diagnosis and treatment as its course can be fatal.

We present the case of a 52- year old male, with diabetes and hypertension, admitted for shortness of breath and fever in the past two months.

Clinical examination revealed respiratory distress, tachypnea, diastolic murmur on the left sternal border. Baseline laboratory investigations showed elevated inflammation markers, leukocytosis and thrombocytosis. Enterococcus faecalis was isolated from the hemocultures.

Transthoracic echocardiography revealed a dilated left ventricle (LV), with preserved LV ejection fraction, with severe aortic regurgitation due to valve destruction. A large (11mm diameter) vegetation-like structure attached to the ventricular side of the right coronary cusp, protruding into the left ventricular outflow tract was identified. Further evaluation by transoesopahgeal echocardiography did not identify other lesions, except for secondary moderate mitral regurgitation, with intact mitral leaflets. Dual antibiotic therapy with Ampicilin and Gentamycin was initiated. Surgery was planned after infection control.

The first three days were uneventful, with rapid resolution of fever and inflammatory markers, but on the fourth day, the patient developed severe abdominal pain, with its focal point in the left hypochondrium. Contrast abdominal CT was performed and large multiple subcapsular lesions were identified. These findings, correlated with the symptomatology, suggested embolic splenic abcess and infarction.

The patient successfully underwent laparoscopic splenectomy, but soon after he developed sepsis with respiratory failure and neurological deterioration (with normal CT scan) and was admitted to the intensive care unit, where he was intubated and mechanically ventilated.

Consensus after discussions between cardiology, cardiac surgery and neurology services was to immediately replace the aortic valve, given the inability to otherwise control the infection. Intraoperative images were consistent with perforation of the right coronary cusp.

During hospitalization in the ICU following cardiac surgery, the patient was extubated and his neurological function markedly improved. Repeated TTE and TEE showed normal prosthetic valve function and resolution of mitral regurgitation. The patient continued to improve clinically until his discharge.

Conclusions

We presented a case of a rare pathogenic entity- splenic abscess and infarction- due to systemic embolization from infective aortic valve endocarditis. Multidisciplinary teamwork was required between cardiologist, intensive care specialist, neurologist, infectionist, general surgeon and cardiac surgeon. Splenectomy was performed before valve replacement, a treatment-course characteristic in the occurrence of these rare cases.

P264 Alcohol septal ablation in hypertrophic obstructive cardiomyopathy with mitral insufficiency of mixed mechanism

Alcohol septal ablation is a percutaneous intervention for hypertrophic obstructive cardiomyopathy, aiming to relieve symptoms, as an alternative to surgical myomectomy, in optimally treated but still symptomatic patients, with high surgical risk.

We present the case of 65-year-old female, with persistently elevated blood pressure, presenting with severe dyspnea and angina on exertion and frequent episodes of paroxysmal nocturnal dyspnea. Clinical examination revealed an intense left parasternal systolic murmur. Electrocardiographic findings were sinus rhythm and negative T waves in V2-V6. Transthoracic echocardiography showed a small LV cavity with severe asymmetric left ventricular hypertrophy (maximum basal interventricular septum thickness of 26 mm), with important obstruction in the left ventricular outflow tract - resting gradient 77mmHg, provoked gradient 100mmHg. TOE evaluation of the mitral valve revealed significant mitral regurgitation, with intermitent telesystolic anterior motion of the anterior mitral leaflet and also P2 scallop prolapse.

Further evaluation revealed a 60% stenosis of left anterior descending (LAD) artery of second segment, 60% stenosis of the left internal carotid artery, chronic renal disease (creatinine clearance 80ml/min), and moderate pulmonary hypertension.

Although surgery was initially proposed to the patient, given the high operative risk (EUROSCORE II 8.45%) for a complete surgical procedure (myomectomy, mitral valve repair and coronary bypass), we attempted a stepwise approach to alleviate her symptoms. Intensive medical treatment improved blood pressure control while angioplasty of the LAD alleviated her angina.

Echo-guided alcohol ablation of the interventricular septal wall was performed. Catheter-based contrast injection of a secondary septal branch of the LAD produced a subendocardial contrast in the contact area of anterior mitral valve leaflet; subsequently, embolizing the artery, producing an isolated necrosis at this level, with equalizing the pressure curves between LV and aorta.

Postintervention, initial gradients were 50mmHg at rest, 100mmHg on postextrasystolic measurement. Systolic movement of the anterior leaflet maintained a mezotelesystolic pattern. At 3-months follow-up, LVOT gradients were 27/100mmHg, without any increase in pulmonary artery pressure, but with significant improvement of dyspnea. Further risk assessment by Holter ECG monitoring identified non-sustained ventricular tachycardia, so an ICD was implanted.

The modest reduction in gradient was associated with significant clinical improvement in the patient’s symptomatology. This procedure has been refined in the last years, especially with the introduction of myocardial contrast echocardiography for better localizing the area at risk of infarction and to reduce the amount of alcohol used. Alcohol septal ablation may be part of a stepwise plan to improve symptoms, with lower procedural risks as compared to classic surgery.