Prognostic significance of mean transmitral pressure gradient in degenerative non-rheumatic mitral valve: insights from a vast echocardiographic database

Background

The incidence and prevalence of senile, non-rheumatic mitral valve disease are increasing and there is a renewed interest in new transcatheter structural cardiac interventions intended to treat that valvular disorder. While the severity of rheumatic mitral valve disease can be accurately assessed by echocardiography using various parameters, including mean transmitral pressure gradient, these methods have been questioned for quantifying senile mitral valve disorder and their prognostic significance is still unknown.

Aims

The current study aims to document the natural history of patients with elevated senile mean transmitral pressure gradient (MG) and assess its prognostic significance.

Methods

A vast institutional echocardiography database was retrospectively analyzed from 2009 to 2020 for all patients aged over 60 years with a detailed echocardiography report with valid measurement of transmitral gradients. Patients with rheumatic valvular disease or who underwent surgical or transcatheter valvular replacement/repair were excluded. All-cause mortality was set to be the primary outcome, and survival models utilizing univariable and adjusted multivariable analysis for various clinical and echocardiographic variables were applied.

Results

A total of 5524 patients consisted of the final cohort. They were stratified by the MG into three groups: MG <3 (2914 patients, 53%), 3≤MG<6 (2079 patients, 37.6%) and MG ≥6 mmHg (531 patients,9.6%). The mean age of the total cohort was 77.2±7.9 years; 60.5% were female, 33.3% with diabetes mellitus, 15.1% with chronic kidney disease, and 14.1% with ischemic heart disease. An Adjusted Cox proportional hazard regression model demonstrated that MG is independently associated with all-cause mortality (adjusted HR 1.04 per 1 mmHg increase, 95% CI 1.02–1.05, p<0.001). Moreover, an elevated MG was associated with a rise in all-cause mortality (HR of 1.15 and 1.4 for patients with 3≤MG<6 and MG ≥6 mmHg, respectively (Fig. 1).

Conclusion

The elevated mean transmitral gradient in senile non-rheumatic valves is an independent predictor for all-cause mortality. Interventions and prospective trials intended to mitigate that risk should be needed.

Funding Acknowledgement

Type of funding sources: None.

Single versus dual antiplatelet therapy following transcatheter left atrial appendage closure

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial appendage occlusion (LAAO) had emerged as an alternative to anticoagulation in patients with non-valvular atrial fibrillation and a contraindication to long-term oral anticoagulants (OAC). LAAO implantation aims to reduce the risk of both systemic thromboembolism and the bleeding events associated with prolonged OAC. Post-procedural antithrombotic regimen varies among patients and may include antiaggregant (dual or single agents) or anticoagulation therapy in minority patients. The current study aims to compare the effectiveness and safety of post-procedural antithrombotic treatment with either dual antiplatelet therapy (DAPT) or single antiplatelet therapy (SAPT) in a real-world cohort.

Methods

The cohort consisted of 205 consecutive patients who had undergone LAAO at Sheba medical center between the years 2010-2020. We prospectively evaluated baseline characteristics and periprocedural clinical, laboratory, and imaging data. All patients were followed by scheduled in-clinic visits. After excluding patients prescribed OAC following the procedure or deceased in the index procedure, the study cohort was divided into two groups according to the antithrombotic regimen following the LAAO: SAPT (35 patients) versus DAPT (151 patients). A propensity analysis via the stabilized inverse-probability-of-treatment weighting (IPTW) was applied.

Results

The leading etiologies for transcatheter LAAO were previous gastrointestinal bleeding (41%) and previous intracranial bleeding (32%). The median CHADSVASC score is 5 [IQR:4-6]. Patients discharged with SAPT following LAAO were older (78±8 yrs vs.75±8 yrs), accompanied by an evident trend over the years of discharging more patients with SAPT instead of DAPT (Figure 1). No statistically significant differences were observed in other baseline characteristics, including gender, hypertension, diabetes mellitus, malignancy, chronic renal or heart failure. During two years of clinical follow-up, no differences in major adverse cardiovascular events were observed between the two groups (20% vs.19% for SAPT and DAPT, respectively). After applying an IPTW propensity analysis adjusting for several clinical and procedural relevant parameters, a K-M survival curve demonstrates no survival benefits of dual over single antiplatelet therapy (Figure 2).

Conclusions

Among patients undergoing LAAO, post-procedural DAPT provides no survival benefits over single antiplatelet therapy.

Occluded vein as a predictor for complications in non-infectious transvenous lead extraction

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiovascular implantable electronic device (CIED) use is steadily increasing, with subsequent need to solve lead failure issues and device upgrades with an occluded vein. Transvenous lead extraction (TLE) has inherent risks that must be carefully weighed. Currently there is lack of conclusive data regarding many non-infectious indications.

Methods

A retrospective study on indications and outcomes of TLE for non-infectious reasons at our medical center, between the years 2011 to 2020 was performed. Occluded vein (OV) presence was compared for characteristics, extraction methods and periprocedural complications and outcomes.

Results

A total of 88 patients underwent TLE for non-infectious reasons. The majority were referred due to lead malfunction (70.5%) and CIED upgrade with an OV (25%), while 4 patients had other TLE indication (intractable pain, heart transplant, severe Tricuspid regurgitation, and irradiation). fourteen patients referred due to lead malfunction had an OV observed during venography.

The OV group (36 patients) were significantly older (65.7±14.1 vs 53.8±15.9 respectively, p=0.001) and had more comorbidities. EF was significantly lower for the OV group (27.5% vs 57.5%, p=0.001) as was longer lead dwell time (3226±2324 vs 2191±1355 days, respectively, p=0.012).

Major complications were exclusive for the OV group (16.7% vs none, p=0.02), and most minor complications occurred in the OV group as well (38.9% vs 4.1% respectively, p<0.001). Laser sheath and Mechanical tools for TLE were frequently used for OV as compared to the non-occluded group (94.4% vs 73.5% respectively, p=0.012). Procedure success was higher in the non-occluded group compared to the OV group (98% vs 83.3%, respectively, p=0.047). Despite these results, peri-procedural mortality was similar between groups.

Conclusions

Among TLE for non-infectious reasons, vein occlusion appears as a major predictor for complex TLE tools use, complications, and procedural success. Venography should be routinely performed prior to non-infectious TLE to identify high-risk patients.

Predictors and outcomes of TLE via femoral vein bailout

Background

Transvenous Lead Extraction (TLE) is usually performed via a superior approach. Predictors and outcomes of TLE via femoral vein bailout are ill defined.

Methods

A single tertiary center cohort of 426 consecutive patients who underwent TLE between May 2010 and February 2020 were analyzed. Venography was routinely performed before system upgrade to identify occluded veins. Patients were divided into 2 groups on the basis of the need for femoral bailout extraction. Predictors for TLE requiring femoral bailout and outcomes were analysed.

Results

A total of 928 leads were extracted and femoral bailout approach was needed in 49 patients (11.5%). A higher proportion of RV leads required femoral bailout approach [51/499 (10.2%)]. Femoral bailout was more common among younger patients, longer lead dwell time, more pocket entries, higher number of extracted leads, presence of abandoned leads [14/49 (28.6%)], and among patients with occluded veins [10/22 (45.5%)]. The presence of abandoned leads, vascular occlusion and age remained a significant predictor for femoral bailout in multivariate analysis. Femoral bailout TLE resulted in a relatively higher rate of major complications [5/49 (10.2%) vs 9/377 (2.4%); p=0.02) but had no related intra-procedural mortality (0/3) and no additional 30 day mortality [2/49 (4.1%) vs 33/377 (8.8%); p=0.4].

Conclusion

TLE of abandoned leads, occluded veins and younger age were found to be predictors of femoral bailout requirement. Despite higher rates of major complications in femoral TLE bailout this did not result in increased mortality. Venography before TLE should be considered for procedure planning.

Funding Acknowledgement

Type of funding sources: None.

Platelets reactivity as a predictor of the extent of myocardial infarct damage and poor outcomes in STEMI patients undergoing primary PCI

Background

Despite optimized management of STEMI patients including primary PCI (PPCI) and use of novel anti-platelet agents, a substantial proportion still display a large infarct size and microvascular damage. The extent of MI and presence of microvascular damage as determined by cardiac MRI (CMR) are considered as powerful prognostic factors in predicting both early and long-term prognosis in those patients. Platelets reactivity has been implicated in pathogenesis of microvascular and subsequent myocardial damage including distal embolization, microvascular platelets plugging and inflammation.

Methods

We prospectively evaluated 105 consecutive STEMI patients, with no prior MI, who underwent PPCI. Patients underwent 2D-echocardiography within 48 hours of admission and cardiac MRI (CMR) 5±1 day post admission. All Patients were treated with dual antiplatelet agents and blood sample were analyzed for platelets reactivity (PA) at 72 hours post admission, using arachidonic acid (AA) and adenosine diphosphate (ADP) as agonists. Aspirin hypo-responsiveness was defined as AA-PA≥30%, and P2Y12 non-responsiveness as ADP-PA ≥50%. CMR was evaluated for late gadolinium enhancement (LGE) and microvascular obstruction (MVO), which reflects MI size and microvascular damage respectively. Both parameters were quantified as % of the LV mass. Major adverse cardiac events (MACE) were defined as the composite of death, MI, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year post AMI.

Results

AA and ADP inhibition were 22±17, and 34±16 respectively. Aspirin hypo-responsiveness was associated with significantly higher extent of LGE (p=0.04) and MVO (p=0.003). A multivariate logistic regression analysis revealed that AA-PA hypo-responsiveness is an independent predictor of both MI size as reflected in LGE (OR 3.87; 95% CI: 1.47–10.5, p=0.031), and higher extent of microvascular damage as reflected by MVO% of LV mass (OR 3.6; 95% CI: 1.15–10.3, p=0.027). Patients with aspirin hypo-responsiveness were significantly more likely to sustain MACE (36% vs 12%, HR 4.13, 95% CI: 1.52–10.2, p=0.003). As opposed to AA related platelets reactivity, no significant correlation was demonstrated between ADP induced platelets reactivity and either measures of MVO or LGE.

Conclusions

In patients undergoing PPCI for STEMI, platelets reactivity in response to AA is an independent predictor of the extent of both myocardial and microvascular damage. Aspirin hypo-responsiveness is associated with higher rate of adverse events during 1-year follow-up.

Funding Acknowledgement

Type of funding source: None

The extent of pericardial involvement evaluated by cardiac MRI in patients with ST-Segment elevation myocardial infarction: predictors and outcomes

Background

The clinical diagnosis of peri-myocardial infarction pericarditis declined dramatically in the era of primary PCI and novel antiplatelet agents. However, recent data documents the presence of pericardial effusion in substantial proportion of acute MI patients, while recent randomized trial showed that anti-inflammatory drugs seem to improve cardiovascular outcomes, although the mechanism of the benefit remains uncertain.

Methods

We prospectively evaluated 187 consecutive patients, without known prior coronary disease, who underwent primary PCI for STEMI. All patients underwent cardiac MRI (CMR) on day 5±1 post admission. CMR was performed using a 1.5 T (n=101) and 3 T (n=86) scanners. Delayed enhancement (DE) and microvascular obstruction (MVO) were quantified as % of the left ventricular mass (LV). The presence of DE and MVO was recorded according to the AHA segments model. DE was also qualitatively assessed for the degree of transmurality in each segment. CMR pericarditis was defined as evidence of pericardial enhancement on DE images. The presence of pericardial effusion was also documented. Pericarditis extent was expressed as the number of pericardial segments with increased DE. Major adverse cardiac events were defined as the composite of death, recurrent myocardial infarction, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year following STEMI.

Results

Pericardial effusion was found in 94 patients (50%) and enhancement of the pericardium on DE images in 120 patients (65%). In contrary, a clinical diagnosis of peri-myocardial infarction pericarditis was documented and anti-inflammatory therapy was initiated only in three patients (1%). A significant positive correlation was demonstrated between pericardial involvement and either quantitative or qualitative assessment of DE (p<0.001, r=0.34) and MVO (p<0.001, r=0.282). DE transmurality (per segment) was associated with both location of pericardial involvement and its extent (p<0.001). A multivariate logistic regression analysis revealed that DE extent and MVO were independent predictors of pericardial involvement (OR 1.07; CI 95% 1.06–1.13, p=0.02 and OR 1.29; CI 95% 1.01–1.64, p=0.04 for DE and MVO respectively). Additional parameters that were associated with CMR diagnosis of pericarditis included higher maximal CRP levels and proximal coronary lesions. The 1-year incidence of major adverse events was similar in patients with or without CMR-defined pericarditis.

Conclusions

In contrast to the low rate of clinically diagnosed pericarditis, CMR documented pericardial involvement in more than 65% of STEMI patients. This finding is independently associated with the extent and degree and location of myocardial damage.

Funding Acknowledgement

Type of funding source: None