Comparative prognostic value of parameters of right ventricular pulsatile afterload in patients with advanced heart failure awaiting heart transplantation

Background

Right ventricular (RV) function demonstrated a strong impact on survival of patients with advanced heart failure with reduced ejection fraction (HFrEF). In particular, increased RV pulsatile afterload (RVPA) was associated with poor prognosis. Several right heart catheterization-derived parameters have been proposed to characterize RVPA, including pulmonary artery compliance (PAC), elastance (PAE) and pulsatile index (PAPi). However, among these indices, the best prognostic indicator is undetermined.

Purpose

To assess the prognostic relevance of RVPA parameters in patients with advanced HFrEF evaluated for heart transplantation.

Methods

149 patients with end-stage HFrEF underwent right heart catheterization during the evaluation for heart transplantation. All patients were clinically followed up until death or any censoring events including heart transplantation, left ventricular assist device (LVAD) and hospitalization for acute heart failure. Cox regression and ROC-curve analysis were used to test the prognostic value of RVPA determinants. Multivariate regression models with C-statistics were used to test the independent predictive value of RVPA indices.

Results

The mean age of the study population was 56.6±10.1 years and 85.2% were male. The most frequent aetiology of HFrEF was ischemic cardiomyopathy (52.3%). Mean LV ejection fraction was 25.7±10.2%.

During a mean follow up time of 17±15 months, 29 (19.5%) patients met the primary endpoint: 9 (6%) patients died, 4 (2.68%) patients underwent an urgent heart transplantation, 11 (7.3%) patients underwent urgent LVAD implantation (as bridge to transplantation therapy) and 5 (3.3%) were hospitalized for HF.

Patients who met the primary endpoint were significantly older patients (61.2±7.8 vs 55.4±10.2, p=0.006) and with worse hemodynamic profile than event-free survivors (PAC [1.8±0.8 vs. 2.7±2.0, p=0.01], mPAP [33.5±11.3 vs. 29.3±11.0, p=0.05], PVR [3.0±1.6 vs. 2.6±2.0, p=0.09] and PAE [1.12±0.5 vs. 0.98±0.6, p=0.04]).

Among the RVPA parameters PAC<1.9 mL/mmHg (HR 4.0, CI 1.3–6.0, p=0.007) and PAE>0.9 mmHg/mL (HR 2.5, 95% CI 1.1–5.2, p=0.02) were associated with the primary endpoint. On the contrary, PAPi was not significantly associated with the outcome.

PAC demonstrated a superior predictive value for the composite adverse outcome compared with pulmonary vascular resistances (PVR) (AUC comparison p=0.019) and PAPi (p=0.03) but similar compared with PAE (p=0.19) and mPAP (p=0.51). In multivariable regression models, PAC, but not PAE showed incremental prognostic value compared with cardiac index (p=0.02).

Conclusions

Hemodynamic indices of RVPA are associated with worse survival in patients with end-stage heart failure. In particular, PAC and PAE demonstrated superior prognostic value compared with PAPi and steady-state PVR. Moreover, PAC showed incremental prognostic value compared with cardiac index in patients awaiting heart transplantation.

Funding Acknowledgement

Type of funding sources: None.

A 2D-speckle tracking analysis in patients undergoing trastuzumab in non-metastatic breast cancer

Background

Trastuzumab (TZ) is widely used for his key role in HER2 positive breast cancer. However, the most concerning cardiovascular complication is cardiotoxicity. Many studies have highlighted the importance of screening for subclinical myocardial dysfunction using left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). However, there are only few studies investigating a possible atrial damage.

Purpose

Aim of this study is to analyze the modification of GLS and peak atrial systolic longitudinal strain (PALS) in patients undergoing therapy with TZ in a follow-up period of 12 months. The eventual fluctuation of left atrial function under chemotherapy was evaluated and the correlation between subclinical atrial disfunction and early left ventricular impairment was investigated.

Methods

105 women affected by breast cancer treated with TZ were enrolled. Each patient underwent a complete echocardiography at baseline and every 3 months. 37 patients (35%) were excluded from the left atrial function analysis while LV function evaluation was performed in 83 patients (21%). Exclusion criteria were poor quality imaging and lack of a complete follow up with consequent missing data. 2D-Speckle tracking analysis was performed at baseline and at each examination using Tomtec software in order to analyze both atrial and left ventricular function. Subclinical LV disfunction was defined as a GLS reduction of ≥15% compared to the baseline value. Left atrial impairment was arbitrary defined as a PALS reduction of ≥25% compared to the initial value. Finally, trends of GLS and PALS during 12 months-follow up periods were analyzed. Additionally, we explored if diabetes and renal impairment were associated with more prevalent atrial subclinical disfunction as demonstrated in previous studies.

Results

A total of 49% patients developed subclinical LV dysfunction. Similarly, 48% patients showed a left atrial impairment. Interestingly a significant (p=0.0001) reduction in GLS was observed during the follow-up, particularly in the first six months of treatment. PALS showed a similar trend with a significant decrease during the whole 12 months-follow up (p=0.0001) and mostly in the first 6 months.

6 patients presented a diagnosis of diabetes at baseline, and presented lower PALS compared to the non-diabetic counterpart (37.6±9.9% vs 48.7±12.2%, p=0.03).

2 patients presented a significant renal impairment (eGFR ≤30 ml/min). Similarly, these patients presented a lower PALS at baseline (32±7 and 48±7; p=0.05).

Conclusions

In patients treated with Trastuzumab development of left atrial impairment is frequent and PALS modifications follow a similar pattern to GLS variations during the treatment, suggesting a possible cardiotoxic effect of such therapy on both atrial and left ventricular myocardium and physiology.

Funding Acknowledgement

Type of funding sources: None.

Predictors and outcomes of acute, sub-acute and early stroke following transcatheter aortic valve implantation

Background

Stroke is one of the most devastating complications after transcatheter aortic valve implantation (TAVI). The recent third Valve Academic Research Consortium (VARC-3) proposes new stroke terminology according to time between TAVI and stroke onset.

Purpose

We aimed to identify predictors and assessed mortality in patients undergoing transfemoral TAVI complicated by acute, sub-acute and early stroke.

Methods

Patients undergoing transfemoral TAVI were included in a global patient level database. Acute stroke was defined as stroke occurring ≤24 hours after the index procedure. Sub-acute stroke was defined as stroke occurring between >1 day and ≤30 days and early stroke as >30 and ≤365 days following TAVI, according to VARC-3. We identified predictors for these complications using multivariate logistic regression analysis and assessed mortality outcomes in these patients.

Results

A total of 11230 patients underwent transfemoral TAVI. Mean age was 81.5±7.0 years, 58% was female and median STS-PROM score was 6.5% (4.0%-13.2%). A total of 405 (3.6%) experienced stroke during the first year after TAVI. Of these 93 (23%) had acute stroke, 195 (46%) sub-acute stroke and 117 (27%) early stroke. One year mortality was highest after acute stroke (56.9%), followed by sub-acute stroke (41.7%), and early stroke (29.0%), but one-year mortality in all stroke patients was higher than in non-stroke patients (40.5% vs 15.8%, p<0.001). Glomerular filtration rate was an independent predictor for acute stroke (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.9–1.0, p=0.03). Previous cerebrovascular events independently predicted sub-acute stroke (OR 2.1, 95% CI 1.4–3.1, p=0.001). Independent predictors for early stroke were age (OR 1.0 per year, 95% CI 1.0–1.0, p=0.04) and peripheral vascular disease (OR 2.0, 95% CI 1.4–3.0, p<0.001).

Conclusions

Patients undergoing transfemoral TAVI complicated by stroke showed higher one-year mortality than non-stroke patients. Earlier timing of post-TAVI stroke was associated with increased mortality. Acute stroke was predicted by renal impairment; sub-acute stroke by previous cerebrovascular events and early stroke by age and peripheral vascular disease, suggesting different pathways leading to stroke in these patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Hartstichting

Spontaneous, independent, single-center renal denervation registry of a resistant hypertension multidisciplinary team

Background

Uncontrolled resistant hypertension (URH) is defined as PAS ≥140mmHg despite the adherence to at least 3 maximally tolerated doses of antihypertensive medications. In the adult population URH is a common condition with a prevalence that ranges between 10–15% and is related with poor prognosis and higher risk of major adverse cardiovascular events.

Renal sympathetic denervation (RDN) has recently proved efficacy in different hypertensive subsets of patients. However, patients with chronic kidney disease (CKD) IIIB-V stages (i.e. glomerular filtrate rate <45 ml/min) have been systematically excluded from randomized clinical trials (RCT).

Purpose

To evaluate the safety and the efficacy of RDN in a daily practice population of patients with URH on top of medical therapy, including patients with renal function impairment (GFR<45ml/min).

Methods

Consecutive unselected patients with URH undergoing RDN were enrolled. Indication of RDN was assessed in a multidisciplinary team involving cardiologist, nephrologist and hypertension specialists, after secondary forms of hypertension had been excluded. Efficacy was defined as the inter-individual change of office (OBP) and ambulatory blood pressure monitoring (ABPM) at 3, 6 and 12 months after RDN. Safety as the absence of any device-related major complication (BARC classification), end-stage renal disease, stroke, acute myocardial infarction and any cause of death within 1 month of the procedure. Safety and efficacy profile was assessed in patients with an estimated GFR below 45 ml/min/1.73 m2.

Results

Seventy-two patients underwent RDN for URH from 2012 to 2022. The population presented with multiple comorbidities and target organ damage: almost 50% were smoker, 43% diabetic, 33% PAD, 25% CAD and 60% CKD. Isolated systolic hypertension prevalence was 53%. The average number of antihypertensive medications at baseline was 5.3±1.1. Baseline OBP and ABPM were 158.8/86.6±23.4/15.3 mmHg and 151.4/87.6±18.8/14.2 mmHg, respectively. The vast majority of the procedures were performed with tetrapolar radio-frequency catheter (91.7%), with 37.3±14.3 number of ablations per procedure. The average amount of contrast medium was 72.1±38.1 ml. At 12-month follow-up a significant reduction of office and ambulatory systolic BP, respectively by −15.66±29.73 mmHg (P<0.01) and by −11.3±23.1mmHg (P<0.05), was noticed. BP reduction at 12-month follow-up among patients with eGFR <45 ml/min was similar to that obtained in patients with higher eGFR. No major complications were observed and renal function was stable up to 12 months, even in patients with lowest eGFR at baseline.

Conclusion(s)

RDN is safe and feasible in patients with URH on top of medical therapy, even in a high-risk CKD population with multiple comorbidities. Our experience underlines the central role of multidisciplinary team evaluation for the targeted management of uncontrolled resistant hypertension.

Funding Acknowledgement

Type of funding sources: None.

C90 PRE–EXISTING CORONARY ARTERY DISEASE AMONG COVID–19 PATIENTS: A SYSTEMATIC REVIEW AND META–ANALYSIS

Background

The prevalence and prognostic implications of coronary artery disease (CAD) in patients infected by the novel coronavirus 2019 (COVID–19) disease remain unclear.

Methods

We conducted a systematic review and meta–analysis to investigate the prevalence and mortality risk in COVID–19 patients with pre–existing CAD. We searched Medline and Scopus to locate all articles published up to December 8, 2021, reporting data of COVID–19 survivors and non–survivors with pre–existing CAD. Data were pooled using the Mantel–Haenszel random effects models with odds ratio (OR) as the effect measure with the related 95% confidence interval (CI).

Results

Thirty–eight studies including 27.435 patients [mean age 61.5 and 70.9 years] were analysed. The pooled prevalence of pre–existing CAD was 12.6% (95% CI: 11.2–16.5%, I2:95.6%), and resulted higher in ICU patients (17.5%, 95% CI: 11.9–25.1, I2: 88.4%) and in European cohorts (13.1%, 95% CI: 7.8–21.6%, p < 0.001, I2: 98.4%). COVID–19 patients with pre–existing CAD had a twofold risk of short–term mortality (OR 2.61, 95% CI 2.10–3.24, p < 0.001, I2=73.6%) (Figure 1); this risk was higher among Asian cohorts (OR: 2.66, 95% CI: 1.79–3.90, p < 0.001, I2: 77.3%) compared to European (OR: 2.44, 95% CI: 1.90–3.14, p < 0.001, I2:56.9%) and American (OR: 1.86, 95% CI: 1.41–2.44, p < 0.001, I2: 0%) populations (Figure 2). The association between CAD and poor short–term prognosis was influenced by age, prevalence of HT, DM and CKD.

Conclusions

Pre–existing CAD is present in approximately 1 in 10 patients hospitalised for COVID–19 and significantly associated with an increased risk of short–term mortality, which is influenced by age, HT, DM and CKD.

P73 ANGIOGRAPHY–DERIVED INDEX OF MICROVASCULAR RESISTANCE (IMR–ANGIO) IN TAKOTSUBO SYNDROME

Introduction

Coronary microvascular dysfunction (CMD) has been proposed as a key driver in the etiopathogenesis of Takotsubo syndrome (TTS), likely related to an “adrenergic storm” upon a susceptible microvascular circulation. The aim of our manuscript was to assess and quantify CMD in patients with TTS through non–invasive angio–derived index of microcirculation (IMRangio) and evaluate its correlation with clinical and instrumental presentation.

Methods

41 consecutive TTS patients were retrospectively analyzed. Three different formulas for compute Non–Hyperemic IMRangio (NH–IMRangio) derived by 3D–Quantitative Coronary Angiography (3D–QCA) and Quantitative Flow Reserve (QFR) analysis were used according to each fluidodynamic mathematical expression as reported by respective authors. CMD was defined as an IMRangio ≥ 25. The correlation between NH–IMRangio and clinical presentation and the comparation between the three formulas were provided.

Results

Median age was 76 years, 85.7% were women and mean left ventricular ejection fraction (LVEF) at first echocardiogram was 41.2%. NH–IMRangio was higher in Left Anterior Descending artery (LAD) than Circumflex artery (CX) and Right Coronary artery (RCA) with either NH–IMRangio 1 (52.7 vs 35.3 vs 41.4), NH–IMRangio 2 (47.2 vs 31.8 vs 37.3) or NH–IMRangio 3 (52.7 vs 36.1 vs 41.8). All patients presented CMD with NH–IMR angio ≥ 25 in at least one territory with each formula. NH–IMRangio in LAD territory was significantly higher in patients presenting with LVEF impairment (≤40%) than in those with preserved ventricular global function (NH–IMRangio LAD 1: 59.3 vs 46.3, p. value=0.030; NH–IMRangio LAD 2: 52.9 vs 41.4, p–value=0.037; NH–IMRangio LAD 3: 59.2 vs 46.3, p–value=0–035). Association between NH–IMRangio computed in LAD and LVEF showed a moderate correlation (NH–IMRangio 1: r = –0,3485, Rho = 0,1214, p = 0,0256; NH–IMRangio 2: r = –0,3513; Rho = 0,1234, p = 0,0256; NH–IMRangio 3: r = –0,3326, Rho = 0,1106, p = 0,0336). Finally, Bland–Altman plot analysis showed good agreement between NH–IMRangio 1 and 3, while NH–IMRangio 2 showed a consistent bias of –5 units against both NH–IMRangio 1 and NH–IMRangio 2 with increasing difference at higher absolute values.

Conclusion

CMD, assessed with NH–IMRangio, is a common finding in TTS and it is inversely correlate with LVEF dysfunction. The available formulas for NH–IMRangio computation have a substantial superimposable diagnostic performance in assessing CMD.

P428 PRESCRIPTION APPROPRIATENESS AND EFFECTIVE CLINICAL IMPACT OF EXERCISE STRESS TEST IN ROUTINE DAILY PRACTICE

Rationale

In the clinical setting, and particularly in the cardiovascular field, an exponential increase of non–invasive diagnostic tests has been observed. Between these, the exercise stress test represents a low–sensitivity and low–specificity diagnostic approach and its use has been less and less recommended in national and international guidelines. However, in the Italian clinical common practice it continues to be extensively prescribed both for chronic coronary syndrome (CCS) follow–up and for screening of coronary artery disease (CAD) in asymptomatic patients with multiple cardiovascular risk factors.

Materials and Methods

A retrospective cohort single–center study was conducted and 968 consecutives patients undergoing ECG stress test at our Department between October 2018 and March 2019 were included. Appropriateness of prescription and impact on the following diagnostic and therapeutic pathway has been analyzed.

Results

In this series, the main indication for exercise stress test was subclinical ischemia detection in CCS follow–up (312 pts, 32.3%). 181 tests (18.2%) were undertaken for CAD detection in patients symptomatic for chest pain and 171 (17.7%) for CAD detection in asymptomatic patients with multiple cardiovascular risk factors. At last, 97 tests (10%) were prescribed for arrhythmic burden evaluation and exercise response in patients with documented hyperkinetic arrhythmias. 590 tests (61%) were considered significative for reaching heart rate significance threshold (85% of target heart rate); between these 53 (9%) were positives for symptoms or ECG modifications. Among the positive tests, 25 patients (2.6%) went to the catheterization laboratory for coronary angiography: the indications for the exercise stress testing were chest pain for 14 of these patients while 7 undertook the examination for CCS follow–up. No asymptomatic patient presented for CAD screening undertook coronary angiography. At the end of the diagnostic pathway, 9 patients (0.9% of the complete cohort) received percutaneous or surgical revascularization.

Conclusions

Routinary and extensive use of exercise stress test can lead to dispersion of resources with many inappropriate examinations. Accurate clinical evaluation and appropriate prescription, especially regarding chest pain evaluation, are the foundations for a significative impact on clinical history of patients.

P290 CARDIAC AMYLOIDOSIS, A CHALLENGING DIAGNOSTIC WORK – UP

 

A 79 years–old male presented to our outpatient clinic with symptoms of an initial heart failure. He had an history of atrial fibrillation (AF), anaemia and thrombocytopaenia, which have never been deeply investigated, bilateral carpal tunnel syndrome. Electrocardiogram (EKG) showed AF with normal ventricular rate and low peripherical QRS voltages. Laboratory testing was significant for NT proBNPelevation, pancytopenia and iron overload. An echocardiogram (ECHO) was done showing a hypokinetic and dilated biventricular cardiopathy. The therapy was therefore optimized with clinical benefit. At coronary angiography a severe stenosis of left coronary artery was observed with normal myocardial perfusion imaging. Cardiovascular magnetic resonance (CMR) excluded an iron intramyocardial overload (in contrast to the hepatic and splenic parenchyma) and detected a subendocardial pattern of LGE at lateral and mid–basal septal area. Emochromatosis and Gaucher disease were excluded. As suggested by hematologists, he underwent osteomedullary biopsy (OMB) and a myelodysplastic syndrome (MDS) was diagnosed. He was still symptomatic for dyspnea on mild exertion. The following ECHO revealed normal left ventricular (LV) size with moderate concentric remodeling, mildly impaired LV systolic function and LV filling pattern suggestive of restrictive cardiomyopathy. All these data prompted suspicion for an infiltrative cardiopathy. Nuclear scintigraphy with the use of bone seeking agent was done and showed Perugini grade 2 cardiac uptake. Moreover, amyloid deposits were identified after Congo red–staining from OMB. immunoglobulin light chain (LA) amyloidosis was excluded.

Conclusion

based on the above findings, Cardiac Amyloidosis TTR–related wild type was diagnosed. The diagnosis of MDS and the identification of iron overload were incidental findings. The patient, currently in follow up at our center, is a candidate to Tafamidis.

Long term prognosis and cardiovascular complications of patients with systemic sclerosis-related cardiomiopathy

Background

Both primary (SSc related cardiomyopathy) and secondary cardiac involvement in systemic sclerosis (SSc) is frequent albeit mostly asymptomatic. It represents a negative prognostic factor as almost 25% of SSc patients die from either heart failure or arrhythmia complications. Speckle tracking global longitudinal strain has been proven to be an effective tool both to identify and detect the progress of subclinical heart disease in SSc. The aim of our study was to assess the association between SSc diagnosis and the development of heart failure, pulmonary hypertension, death and need for hospitalization.

Materials and methods

We conducted an observational prospective study enrolling all patients with a diagnosis of SSc and no overt cardiac disease. We excluded all patients with a known diagnosis of pulmonary hypertension and atrial fibrillation. For each patient standard echocardiogram and GLS variables were collected.

Results

We enrolled 70 patients (61 females, age 56.2±15.4 years) who were followed for a median of 3 years. 68% of the patients had a limited variant of the disease.

All-cause mortality was 10% in a 5-year follow-up. During the same period, PH was reached in 13% of all patients, HF in 7% and 18% required at least one hospital admission for cardiovascular causes. A diagnosis of PH was associated with an increased risk of death (ARR 34%; p&lt;0.001) and hospitalization for CV causes (ARR 73%; p&lt;0.001). Moreover, a diagnosis of HF was associated with an increased risk of death (ARR 50%; p&lt;0.001) and hospitalization for CV causes (ARR 61%; p&lt;0.001). A 1% worsening of GLS was associated with an increased risk to develop PH in the following 5 years, both for the left ventricle (OR 1.2; 95% CI: 1.1–1.4; p=0.043) and for the right ventricle (OR 1.1; 95% CI: 1.1–1.3; p=0.045).

Conclusions

Pulmonary hypertension and heart failure often occur in patients with cardiac involvement. Both proved themselves to be associated with an increased risk of death and hospitalization for CV causes. Moreover, GLS worsening of both the left and right ventricles may allow us to predict the diagnosis of PH and therefore preemptively start appropriate management.

Funding Acknowledgement

Type of funding sources: None.

Speckle tracking assessment of the atrial function in patients with systemic sclerosis

Background

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by small vessel vasculopathy, autoantibodies production and exaggerated extracellular matrix deposition, leading to extensive tissue fibrosis. Cardiac involvement in SSc, albeit often asymptomatic, is frequent and represents a negative prognostic factor. Speckle tracking global longitudinal strain (GLS) has proved itself to be an effective tool to identify the presence and the progression of subclinical SSc-related cardiomyopathy.

The aim of our study was to assess whether SSc-related cardiomyopathy affects not only the ventricles but also the right (RA) and left atria (LA) in patients with SSc and no overt cardiac disease nor pulmonary hypertension.

Materials and methods

Observational prospective study enrolling all consecutive patients with SSc age- and gender-matched 1:1 to healthy controls. Patients with structural heart disease, heart failure, atrial fibrillation and pulmonary hypertension were excluded.

For every patient, standard echocardiographic parameters and speckle-tracking derived variables were registered. The reservoir function (from the end of ventricular contraction to mitral valve opening), conduit function (from mitral valve opening through the onset of atrium contraction) and contraction function (from the onset of atrium contraction to the end of ventricular diastole) were assessed via GLS. Zero strain reference was set at left ventricular end diastole.

Results

Fifty-two SSc patients and 52 matched controls were consecutively enrolled. Left ventricular ejection fraction (66.5%±7.4% vs. 66.1%±5.9%; p=ns) right fractional area change (49.4%±9.6% vs. 49.2%±9.2%; p=ns) and mean sPAP (29.0%±5.3% vs. 24.4%±4.1%; p=ns) were well within the normal range and similar between SSc patients and controls. Right atrial reservoir function (35.0%±7.3% vs. 42.3%±8.5%; p=.024) and contraction function (14.8%±4.3% vs. 18.5%±4.1%; p=.034) were significantly lower in SSc patients when compared to matched controls. No difference was seen in right atrial conduit function or left atrial strain.

In patients with SSc, RA reservoir (r=.194; p=.033) and conduit function (r=.174; p=.036) were directly associated to right ventricular GLS. LA reservoir (r=.260; p=.008) and conduit function (r=.271; p=.006) were directly associated with left ventricular GLS. No association was observed between contraction function and GLS in both left and right chambers. Moreover, RA and LA reservoir (r=.358; p=.02), conduit (r=.525; p=.004) and contraction functions (r=.30; p=.0.18) were directly correlated.

Conclusions

While no significant difference was seen between cases and controls in terms of common echocardiographic parameters, RA reservoir and contraction function assessed through GLS were significantly impaired in patients with SSc. The correlation between impaired atrial and ventricular GLS in SSc may represent another indirect evidence of SSc-related heart global involvement.

Funding Acknowledgement

Type of funding sources: None.

Obesity paradox in 12,381 patients undergoing transfemoral transcatheter aortic valve implantation: from the CENTER-collaboration

Background

Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic aortic valve stenosis. The majority of patients treated are overweight or obese. Obesity has traditionally been linked to reduced survival and worse cardiovascular outcomes. However, an “obesity paradox” has been described in some diseases, with improved survival of obese patients after invasive and surgical procedures.

Methods

The CENTER-collaboration included data from 10 registries or clinical trials of patients undergoing transfemoral TAVI from 2007 to 2018. Patients were divided in four groups according to body mass index (BMI): underweight: BMI &lt;18.5 kg/m2, normal weight: BMI 18.5 to 24.9 kg/m2, overweight: BMI 25 to 29.9 kg/m2, and obese: BMI ≥30 kg/m2. The primary endpoints of this analysis were differences in 30-day all-cause mortality and stroke after TAVI.

Results

Of the 12,381 patients analysed, 2% (n=205) were underweight, 29% (n=3552) had normal weight, 44% (n=5460) were overweight and 25% (n=3140) obese. Older patients had lower BMI (median of 84 years for underweight and 81 years for obese patients, p&lt;0.001). Cardiovascular risk factors such as hypertension, diabetes mellitus and dyslipidaemia increased progressively with increase of BMI category. As to clinical outcomes, there were no differences for stroke rates across BMI groups. In-hospital mortality was highest in patients who were underweight, namely 8.4%, compared to normal weight, overweight and obese patients (6.2%, 4.3% and 4.6% respectively, p&lt;0.001) as was 30-day mortality (9.8% compared to 6.9%, 5.3% and 5.2% respectively, p=0.001). On the other hand, extremely obese patients (BMI ≥40.0 kg/m2) also had worse prognosis, with a 30-day mortality of 7.6%.

Conclusions

In this global analysis of more than 12 000 patients undergoing transfemoral TAVI, overweight and obese patients had better in-hospital and 30-day survival than normal weight patients, confirming the obesity paradox. There was an inverted J-shaped relationship of body mass index with prognosis, with higher mortality rates for underweight and extremely obese patients.

Mortality and stroke per BMI category

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Dutch Heart Foundation; Netherlands Organisation for Health Research and Development

Is TAVI superior to surgery in high-risk patients? Insight into the concept of individual risk assessment

The prevalence of aortic valve stenosis (AS) is growing in developed countries because its prevalence increases with age. A growing number of elderly patients are currently referred to specialized centres to be evaluated for potential therapeutic strategies. Indeed, two techniques are nowadays able to treat high-risk AS patients: TAVI and surgical replacement (AVR). It is the purpose of the present review to summarize current knowledge on safety and efficacy of AVR and TAVI in high-risk patients; to focus on some aspects of recently published guidelines; to emphasize the growing importance of pre-operative individual risk assessment, which is considered the real crucial point for patient selection and trial's comparisons. Indeed, it is worth of noting that currently adopted risk-scores do not show satisfactory performances. Accordingly, it becomes of utmost importance to investigate several baseline but still neglected patients' characteristics (e.g. frailty, functional status, co-morbid conditions, etc.), as well as their pathogenetic relationships with interventional results and follow-up prognosis. All these items are emphasized in the present review. Finally, we have tried to anticipate future scenarios in terms of both ongoing clinical trials and improvements of risk-scores.

Tobacco smoke affects expression of peroxisome proliferator-activated receptor-gamma in monocyte/macrophages of patients with coronary heart disease

BACKGROUND AND PURPOSE

Tobacco smoke represents a relevant risk factor for coronary heart disease (CHD). Although peroxisome proliferator-activated receptor (PPAR)gamma activation reduces inflammation and atherosclerosis, expression of PPARgamma in cells and its modulation by smoking are poorly investigated. We previously reported that monocyte/macrophages from healthy smokers exhibited an enhanced constitutive expression of PPARgamma. Here, we evaluated PPARgamma expression and basal cytokine release in monocytes and monocyte-derived macrophages (MDMs) from 85 CHD patients, classified by their smoking habit (smokers, non-smokers and ex-smokers), and assessed the role of PPARgamma ligands in this context.

EXPERIMENTAL APPROACH

PPARgamma protein was detected by Western blot and semi-quantified by PPARgamma/beta-actin ratio; cytokine release was measured by elisa and nuclear factor-kappaB (NF-kappaB) translocation by electrophoretic mobility shift assays.

KEY RESULTS

As compared to the other groups, MDMs from smoker CHD patients exhibited a reduced PPARgamma/beta-actin ratio and an increased spontaneous release of tumour necrosis factor-alpha (TNF-alpha) and interleukin-6, but with no major variations in monocytes. In cells from selected CHD patients, rosiglitazone inhibited TNF-alpha release and NF-kappaB translocation induced by phorbol-12-myristate 13-acetate. The selective PPARgamma antagonist GW9662 reversed these effects, with some variations related to smoking habit.

CONCLUSIONS AND IMPLICATIONS

In CHD patients, exposure to tobacco smoke profoundly affected PPARgamma expression, and this was related to levels of secretion of pro-inflammatory cytokines. MDMs from CHD smokers showed the lowest PPARgamma expression and released more inflammatory cytokines. Moreover, rosiglitazone's ability to inhibit cytokine release and its reversal by GW9662 clearly indicated PPARgamma involvement in these changes in CHD patients.

A novel activity for substance P: stimulation of peroxisome proliferator-activated receptor-gamma protein expression in human monocytes and macrophages

BACKGROUND AND PURPOSE

Substance P (SP) and peroxisome proliferator-activated receptor-gamma (PPAR-gamma) play important roles in different inflammatory conditions and are both expressed in human monocytes and macrophages. However, it is not known whether or not they interact. This study was undertaken to evaluate the effects of SP on PPAR-gamma protein expression in monocytes and macrophages (MDMs: monocyte-derived macrophages) from healthy smokers and non-smokers.

EXPERIMENTAL APPROACH

PPAR-gamma protein was detected by western blot and quantified by calculating the ratio between PPAR-gamma and beta-actin protein expression. Constitutive tachykinin NK(1) receptor expression in monocytes and MDMs from healthy smokers and non-smokers was evaluated by western blot. Cytokine release was evaluated by ELISA.

KEY RESULTS

In the concentration range 10(-10)-10(-6) M, SP stimulated PPAR-gamma protein expression in monocytes and MDMs, being more effective in cells from healthy smokers. Moreover, in these cells there was a constitutively increased expression of NK(1) receptors. SP-induced expression of the PPAR-gamma protein was receptor-mediated, as it was reproduced by the NK(1) selective agonist [Sar(9)Met(O(2))(11)]SP and reversed by the competitive NK(1) antagonist GR71251. SP-induced maximal effects were similar to those evoked by 15-deoxy-Delta(12,14)-prostaglandin J(2); an endogenous PPAR-gamma agonist, and were significantly reduced by a PPAR-gamma antagonist. NK(1) and PPAR-gamma agonists exerted opposite effects on TNF-alpha release from monocytes and MDMs.

CONCLUSIONS AND IMPLICATIONS

Enhancement of PPAR-gamma protein expression represents a novel activity for SP, which could contribute to a range of chronic inflammatory disorders.

The role of nitric oxide in the peripheral vasoconstriction caused by human placental lactogen in anaesthetized pigs

Regional intra-arterial infusion of human placental lactogen in anaesthetized pigs has been shown to cause coronary, renal and iliac vasoconstriction by antagonizing the vasodilatory effects of beta2-adrenergic receptors. Since nitric oxide is known to modulate or mediate beta2-adrenergic effects, the present study was planned in the same experimental model to determine the role of nitric oxide in the above vascular responses to human placental lactogen. In eight pigs anaesthetized with sodium pentobarbitone, changes in anterior descending coronary, left renal and left internal iliac blood flow caused by intra-arterial infusion of human placental lactogen at constant heart rate and arterial blood pressure were assessed using electromagnetic flowmeters. Intra-arterial infusion of the human placental lactogen caused decreases in coronary, renal and iliac blood flow which, respectively, averaged 16.7, 8.1 and 12.2% of the baseline values. The role of nitric oxide in this response was studied in the same pigs by repeating the experiments, after measured blood flows had returned to baseline values, following intra-arterial administration of N(omega)-nitro-L-arginine methyl ester (L-NAME). The subsequent intra-arterial infusion of human placental lactogen did not cause any significant changes in measured blood flows, even when performed after reversing the increase in arterial blood pressure and coronary, renal and iliac resistance caused by L-NAME with continuous intravenous infusion of papaverine. These results indicate that the coronary, renal and iliac vasoconstriction caused by human placental lactogen, known to involve antagonism of beta2-adrenergic vasodilatory effects, was mediated by inhibition of nitric oxide release.

Human Placental Lactogen Decreases Regional Blood Flow in Anesthetized Pigs

In 22 pigs anesthetized with sodium pentobarbitone, changes in blood flow caused by infusion of human placental lactogen into the left renal, external iliac, and anterior descending coronary arteries were assessed using electromagnetic flowmeters. In 17 pigs, infusion of human placental lactogen whilst keeping the heart rate and arterial pressure constant decreased coronary, renal and iliac flow. In 5 additional pigs, increasing the dose of human placental lactogen produced a dose-related decrease in regional blood flow. The mechanisms of the above response were studied in 15 of the 17 pigs by repeating the experiment of infusion. The human placental lactogen-induced decrease in regional blood flow was not affected by blockade of cholinergic receptors (5 pigs) or of alpha-adrenergic receptors (5 pigs), but it was abolished by blockade of beta2-adrenergic receptors (5 pigs). The present study showed that intra-arterial infusion of human placental lactogen primarily decreased coronary, renal and iliac blood flow. The mechanism of this response was shown to be due to the inhibition of a vasodilatory beta2-adrenergic receptor-mediated effect.

Tissue plasminogen activator antigen is strongly associated with myocardial infarction in young women

Women who develop acute myocardial infarction (AMI) at a young age have fewer classical risk factors and less coronary stenosis than older women. In this rare population, it is plausible that a heightened hemostatic system may play an important mechanistic role in thrombus formation and in the development of AMI. We chose to investigate whether or not there is an association between premature AMI and the plasma concentrations of five hemostatic measurements that had been previously established as risk factors for AMI, and of the inflammation marker C-reactive protein (CRP). Women who had survived AMI at the age of 45 years or less (n = 141) were drawn from those admitted to 125 Italian coronary care units over a 3-year period. In them, and in an equal number of controls, plasma levels of immunoreactive tissue plasminogen activator (tPA), plasminogen activation inhibitor 1 (PAI-1), von Willebrand factor (VWF), fibrinogen, D-dimer and CRP were measured. Higher levels of VWF, fibrinogen, CRP and tPA were associated with AMI. After adjustment for both classical and hemostatic risk factors, only tPA maintained an independent association with AMI: the odds ratios (taken as an index of relative risk) for tPA values in the middle and higher tertiles were 2.86 (CI 1.63-5.02) and 8.18 (CI 2.66-25.20), respectively. In conclusion, there is a strong association between non-fatal AMI and increased plasma levels of tPA antigen. This finding is thought to be the expression of a reduced rather than enhanced fibrinolytic activity.

Clinical characteristics and outcome of patients with early (<2 h), intermediate (2-4 h) and late (>4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction

AIMS

We examined the clinical characteristics and outcome of patients with early (<2 h), intermediate (2-4 h) and late (>4 h) presentation treated by primary angioplasty or thrombolytic therapy for acute myocardial infarction.

METHODS AND RESULTS

We studied 2635 patients enrolled in 10 randomized trials of primary angioplasty (n=1302) vs thrombolytic therapy (n=1333) in acute myocardial infarction, and baseline characteristics of the two groups were comparable. Increase in presentation delay is associated with older age, female gender, diabetes and an increased heart rate. We classified the patients according to the time delay from symptom onset to presentation into three categories: early presentation (<2 h), intermediate presentation (2-4 h), and late presentation (>or=4 h). At 30 days the combined rate of death, non-fatal reinfarction and stroke in patients presenting early was 5.8% in the angioplasty group vs 12.5% in the thrombolysis group, in patients with intermediate presentation, 8.6% vs 14.2%, respectively, and in patients presenting late 7.7% vs 19.4%, respectively. With increasing time from symptom onset to presentation, all major adverse cardiac event rates show a trend to a larger increase in the thrombolysis group compared to the angioplasty group, both at 30 days and at 6 months after the acute event.

CONCLUSIONS

Major adverse cardiac event rates are lower after angioplasty compared to thrombolysis, irrespective of time to presentation. With increasing time to presentation major adverse cardiac event rates increase after thrombolysis but appear to remain relatively stable after angioplasty.

In-stent restenosis

Even after optimal immediate results, restenosis still occurs in a relevant percentage of patients after stent implantation. This disappointing outcome has strong clinical and socio-economical implications and has become a major target of research in cardiology. The conceptual difference between the mere resolution of the restenotic lesion and the understanding of the mechanisms of restenosis creates a dichotomy between daily practice in the catheterization laboratory and questions raised in the research laboratory that commonly divides people (clinicians and researchers) and budgets (industries and academic institutions). As a consequence, efforts are aimed at treating the consequences of unsuccessful stenting on the one hand, and to understand the causes of excessive neointimal proliferation on the other. However, the commitment of researchers and the large clinical experience accumulated in these years are by-products of the symbiosis between manufacturers and scientists, and it seems as though the fight against restenosis is about to be won with the further setting-up of adequate means that act effectively on the target, even though it has not been clearly understood or identified. Such a pragmatic position, although possibly effective, should remind us that the ancient peoples used natural medicines to cure diseases that they never understood.

Morphological analysis of atherosclerotic plaque retrieved by coronary atherectomy

The development of atherectomy catheters and their use in clinical practice during percutaneous revascularization procedures permitted the analysis of the pathophysiology of obstructive coronary disease in vivo. The various clinical presentations of coronary disease are related to distinct morphological aspects of the culprit coronary stenosis as assessed by angiography, angioscopy or intravascular ultrasound imaging. Analysis of plaque fragments revealed the underlying histopathology. Restenotic lesions following various mechanical interventions have been studied in detail both in native coronary arteries and in bypass conduits. The biological reaction to implantation of endovascular stents involves inflammation around the stent wires as well as smooth muscle cell proliferation. Specific processes such as nitric oxide production or the activity of intramural proteases can be characterized and contribute to identify targets for future pharmacological therapy.

Angiographic follow-up after coronary implantation of the Multilink stent: a prospective observation

BACKGROUND

A growing variety of coronary stents is becoming available on the market. Results of randomized trials may be difficult to apply to less selected patients, and experience with every device cannot be obtained in every center. Detailed information about the immediate and long-term results achieved with one device can be a helpful reference for interventional cardiologists. The aim of this study was to test the applicability and the clinical and angiographic results, both immediate and at 6 months, of the Multilink coronary stent in a cohort of unselected patients undergoing coronary angioplasty.

METHODS

From March 1997 to June 1998 coronary angioplasty was performed in 391 patients in our center, with the use of stents in 339 patients.

RESULTS

Three hundred and seventeen Multilink stents were successfully implanted in 295 lesions in 277 patients; an acute coronary syndrome was present in 209 cases (75%), and lesion types B2 and C accounted for 30% of lesions. In 7 cases (2.4%) the Multilink stent did not cross the lesion, and another device was implanted. Subacute stent occlusion occurred in 1 patient (0.36%) after primary angioplasty. After 6 months from the procedure, clinical follow-up data were available for 252 out of 254 patients: none had died, and angina or myocardial ischemia occurred in 25 patients (9.9%). A control angiogram was performed in 239 out of 254 patients (94%) at 178 +/- 34 days. Restenosis occurred in 44/239 patients (18.4%) and in 48/247 lesions (19.4%). In patients with vs without restenosis the original lesion was longer (p = 0.009), and diabetes mellitus was more frequent (p = 0.002), as was the use of multiple stents (p = 0.005). In single 15, 25 and 35 mm long stents restenosis occurred in 13.9, 15.5 and 46.2% of cases, respectively (p = NS).

CONCLUSIONS

The Multilink stent showed a low rate of subacute occlusion (0.36%) and could be used safely also in patients with acute coronary syndromes. The use of a single, 15 or 25 mm long Multilink stent was associated with a low angiographic recurrence rate (14-16%).

Pulmonary artery hypertension in adult patients with symptomatic valvular aortic stenosis

Pulmonary hypertension (PH) has been reported in patients with valvular aortic stenosis (AS) and has been found to be associated with a more severe clinical picture and a poor prognosis after aortic valve replacement. The aim of this study was to assess the prevalence of PH in adult patients with symptomatic AS undergoing cardiac catheterization, and to evaluate the relation between pulmonary artery (PA) systolic pressure and hemodynamic and clinical variables to further clarify the pathogenetic mechanisms. We assessed right-sided heart hemodynamics during cardiac catheterization in 388 patients with symptomatic isolated or predominant AS. PA systolic pressure between 31 and 50 mm Hg was used to define mild to moderate PH, whereas PA systolic pressure >50 mm Hg was used to define severe PH. PA systolic pressure showed no significant difference according to age and sex, although it was significantly higher in patients in New York Heart Association functional classes III and IV and in patients with coexistent systemic hypertension than in the others. PH was absent in 136 patients (35%, group 1), mild to moderate in 196 patients (50%, group 2), and severe in 58 patients (15%, group 3). Only the prevalence of overt heart failure was significantly higher in group 3 patients. AS severity was similar among the 3 groups, and PA systolic pressure showed no relation to aortic valve area in the entire population. Also, a poor correlation was found between PA pressure and left ventricular (LV) ejection fraction (r = -0.28), with several patients having moderate or severe PH despite a preserved LV systolic function. PA systolic pressure significantly correlated with LV end-diastolic pressure (r = 0.50) and with PA wedge pressure (r = 0.84). Furthermore, transpulmonary pressure gradient, an index of resistance across the pulmonary vascular bed (obtained as the difference between PA mean and PA wedge pressure), was significantly higher in patients with PH, especially in those with a marked increase in PA systolic pressure, suggesting a reactive component of PH.

[Heart catheterization via the femoral artery with a 4 French and mobilization at 2 hours]

The use of small catheters for cardiac catheterization, as well as for other diagnostic and interventional procedures, can reduce iatrogenic trauma on cardiac and vascular structures. Early patient mobilization may thus reduce both patient discomfort and the length and cost of stays. The performance of 4 French catheters was evaluated in a pilot cohort of consecutive in patients who underwent coronary arteriography with the use of the femoral Judkins technique and who had no restriction to full ambulation. Patients were helped to resume full ambulation two hours after the procedure, and the femoral access site was inspected 24 hours later upon discharge. Coronary arteriography with 4 French catheters was performed in 45 patients (10 women) aged 62 +/- 10 years. In one patient with anomalous origin of the right coronary artery, selective catheterization of the coronary ostium required a catheter style available only in 5 French. In all cases, selective opacification with 4 French catheters was adequate for diagnosis. Forty-three patients were mobilized 115 +/- 10 minutes after the end of manual compression. Hematoma, bleeding or limb perfusion disturbances were absent in all cases upon inspection 22 +/- 4 hours later. This pilot experience indicates that coronary arteriography with femoral 4 French Judkins catheters is technically feasible and that patient ambulation 2 hours later is safe. This data requires confirmation in a larger patient cohort and can lead to new standards for both patient comfort and the use of hospital resources in coronary arteriography.