Latest-iteration balloon- and self-expandable transcatheter valves for severe bicuspid aortic stenosis: the TRITON study

INTRODUCTION AND OBJECTIVES

No comparisons have been published yet regarding the newest iteration of balloon- and self-expandable transcatheter heart valves for the treatment of bicuspid aortic valve (BAV) stenosis.

METHODS

Multicenter registry of consecutive patients with severe BAV stenosis treated with balloon-expandable transcatheter heart valves (Myval and SAPIEN 3 Ultra, S3U) or self-expanding Evolut PRO+(EP+). TriMatch analysis was carried out to minimize the impact of baseline differences. The primary endpoint of the study was 30-day device success, and the secondary endpoints were the composite and individual components of early safety at 30 days.

RESULTS

A total of 360 patients (age 76.6±7.6 years, 71.9% males) were included: 122 Myval (33.9%), 129 S3U (35.8%), and 109 EP+(30.3%). The mean STS score was 3.6±1.9%. There were no cases of coronary artery occlusion, annulus rupture, aortic dissection, or procedural death. The primary endpoint of device success at 30 days was significantly higher in the Myval group (Myval: 100%; S3U: 87.5%; and EP+: 81.3%), mainly due to higher residual aortic gradients with S3U and greater≥moderate aortic regurgitation (AR) with EP+. No significant differences were found in the unadjusted rate of pacemaker implantation.

CONCLUSIONS

In patients with BAV stenosis deemed unsuitable for surgery, Myval, S3U and EP+showed similar safety but balloon-expandable Myval had better gradients than S3U, and both balloon-expandable devices had lower residual AR than EP+, suggesting that, taking into consideration the patient-specific risks, any of these devices can be selected with optimal outcomes.

Peri-procedural, 30-day and 1 year-outcomes in chronic dialysis patients undergoing transcatheter aortic valve implantation

Background

Patients on chronic dialysis (CD) due to end-stage renal disease (ESRD) with symptomatic severe aortic stenosis eligible for transcatheter aortic valve implantation (TAVI) were excluded from randomized clinical trials. Our study aimed to investigate the outcomes of patients with chronic dialysis who underwent TAVI.

Methods

Single center analysis on prospectively collected data of all consecutive patients who underwent TAVI between January 2011 and December 2020 according to baseline renal function: chronic dialysis group (CD) and control group (CTRL). Procedural, 30-day and 1-year outcomes were assessed. Outcomes were defined in accordance with the VARC-3 criteria.

Results

A total of 875 patients underwent TAVI during the study period, of whom 22 (2.5%) were on chronic dialysis. Patients on CD were younger (median age 80 years, [IQR 73–84] vs 84 years, [IQR 80–87]; p<0.001), more likely to be men [365/863 (42.8%) vs 18/22 (81.8%); p<0.001] and more likely to have peripheral vascular disease [41/853 (4.8%) vs 7/22 (31.8%); p=0.031] and lower body mass index (median 24.1 kg/m2, [IQR 21.5–26.5] vs 26.3 kg/m2, [IQR 23.7–29.3]). Short-term major or life-threatening bleeding were significantly higher in CD patients (odds ratio [95% confidential interval]: 3.67 [1.50–8.96], p 0.005). In contrast, no differences were found regarding rates of vascular complications requiring intervention (OR [95% CI]: 1.35 [0.31–5.90], p=0.662), permanent pacemaker implantation (OR [95% CI]: 0.87 [0.25–2.98], p=1.000) or stroke (OR [95% CI]: 1.51 [0.20–11.64], p=0.504). Importantly, dialysis patients had significantly higher rates of in-hospital, 30-day and 1-year mortality rates (13.6 vs 2.1%, p<0.001; 18.9% vs 2.9, p<0.001 and 26.4% vs 10.7%, p<0.001, respectively). On multivariate analysis, after adjusting for age, gender, relevant co-morbidities, and procedure-related complications, CD remained independently associated with mortality at 1-year. Survival curves during follow up are presented in Figure 1.

Conclusions

Chronic dialysis patients submitted to TAVI had significantly higher rates of short-term life threatening and/or major bleeding, short-term and long-term mortality. Careful selection of patients who would benefit from TAVI among patients with ERDS requiring dialysis is necessary to prevent high rates of postprocedural complications and improve outcomes of this high-risk population.

Funding Acknowledgement

Type of funding sources: None.

Vascular closure device in TAVI with a dedicated endovascular plug-based device – experience from a high-volume tertiary center

Background

Vascular complications at the access site are important adverse events during transcatheter aortic valve implantation (TAVI). Effective, reproducible, and safe closure of large bore arteriotomies remains challenging as management strategies vary among centers and operators. MANTAÒ is a dedicated plug-based vascular closure device (VCD) recently approved for percutaneous access site closure. This study aimed to describe our experience and to determine the safety and effectiveness of MANTAÒ for large bore arteriotomies during transfemoral TAVI.

Methods

Single center retrospective analysis on prospectively collected data of all consecutive patients who underwent transfemoral TAVI from 2018 to 2020. The primary safety outcomes were access-related vascular injury and bleeding complications according to VARC-3 criteria. Technical success was defined as puncture closure obtained with MANTAÒ without the use of unplanned endovascular or surgical intervention. A secondary analysis according to center experience was performed.

Results

Of the 535 patients that underwent transfemoral TAVI during the study period (median age = 84 [IQR 80–87], 39.4% male; median EuroSCORE II of 3.89% [IQR 2.62–5.39]), MANTAÒ VCD was deployed in 320 (59.8%). Overall, 32 (10.0%) patients suffered an access-related vascular injury and 22 (6.6%) had a bleeding complication (Figure 1A). Technical success was achieved in most cases (n=298; 93.1%). 30-day mortality rate was 1.6% (n=5). Since the first deployment in mid-2018, the rates of MANTA-related complications decreased with increasing experience and a steep learning curve effect was noted (Figure 1B).

Conclusions

MANTAÒ was rapidly adopted as the default strategy for vascular access site closure after TAVI at our center. A relatively steep learning was observed, suggesting that few procedures are required to acquire device proficiency. In addition, our results suggest that MANTA Ò can effectively close large bore arteriotomies with a low risk of severe complications.

Funding Acknowledgement

Type of funding sources: None.

SAECG - advances in Brugada stratification

Funding Acknowledgements

Type of funding sources: None.

Introduction

Brugada syndrome (BrS) is a relevant cause of sudden cardiac death (SCD) in young adults. Several risk factors have been identified, but clinical decision making remains extremely challenging, particularly in asymptomatic patients.

Purpose

To explore the usefulness of the non-invasive assessment of late potentials (LPs) based signal-averaged ECG (SAECG) for risk stratification in BrS.

Methods

Prospective single-center study of patients with BrS included from 2003 to 2021. LPs were evaluated by SA-ECG with determination of the total filtered QRS duration (fQRS), root mean square voltage of the 40ms terminal portion of the QRS (RMS40) and duration of the low amplitude electric potential component of the terminal portion of the QRS (LAS40) in conventional and modified right precordial leads.

The primary endpoint was the occurrence of malignant arrhythmic events (MAEs), defined as a composite of SCD or appropriate shocks. Uni- and multivariate Cox regression survival analyses were used to identify significant prognostic predictors considering the clinical, genetic, and electrocardiographic characteristics as well as the tercile distribution of the SAECG parameters. A risk score was computed incorporating the significant LPs variables and its usefulness for prognostic stratification was explored using Kaplan Meier survival analysis.

Results

Our cohort consisted of 117 patients (mean age: 47±13 years, 33% male), including 75 (65%) with type 1 spontaneous pattern and 92 (79%) asymptomatic individuals. Symptoms at presentation included syncope in 16 pts (14%) and polymorphic VT/cardiac arrest in 4 (3.4%).

During a median follow-up of 4.1±0.3 years, 8 pts (6.8%) suffered MAEs: 3 (2.6%) with SCD and 5 (4.3%) with appropriate shocks.

The risk of events differed in relation to the several SAECG parameters (Table 1), increasing linearly with the fQRS duration determined either in the conventional (HR 1.03, 95% CI 1.01-1.06, p=0.008) or modified leads (HR: 1.03, 95% CI 1.01- 1.05, p=0.003). The SAECG score incorporated as risk markers a fQRS ≥113ms and a RMS40 <13 μV. Patients with both risk markers presented a 7-fold increased risk (HR 7.17, 95% CI 1.29-40, p = 0.025), independently of the baseline symptomatic status and ECG pattern.

Conclusion

This study shows that the non-invasive assessment of LPs based on SAECG is useful for prognostic stratification of BrS. It was possible to identify a subset of patients presenting a high risk of events who may deserve individualized preventive strategies.

Non-ischemic cardiomyopathy: what predicts survival and ICD shocks after ventricular tachycardia ablation?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients (pts) with non-ischemic cardiomyopathy (NICM) present an increased morbidity and mortality from sustained monomorphic ventricular tachycardia (VT). Implantable cardiac defibrillators effectively terminate VT, but ablation is usually required to prevent recurrences and appropriate shocks. Although several risk factors have been pointed out, clear prognostic predictors need to be established and addressed.

Purpose

To evaluate risk factors associated with all-cause mortality and ICD shocks in NICM pts submitted to VT ablation.

Methods

Prospective, observational, single-centre study of pts with NICM submitted to VT ablation using high density mapping tools.The primary outcome was all-cause death or VT recurrence terminated with appropriate ICD shock during long-term follow up. Kaplan-Meier analysis was used to estimate the long-term event-free survival. Uni and multivariate Cox regression analyses were used to determine relevant prognostic predictors.

Results

A total of 27 consecutive pts with NICM were referred for a first-ever VT ablation procedure between June 2015 and June 2021 (males: 93%; mean age: 61±12 years). The mean left ventricular ejection fraction (LVEF) was 35±12% and 70% of pts had NYHA class I or II.

During a mean follow-up of 29 ± 19 months, VT recurrences requiring ICD shocks occurred in 25.9% of pts. VT ablation success and the risk of ICD shocks were not associated with any of the clinical characteristics. Long-term all-cause mortality was 37%. In univariate analysis, LVEF <30%, NT-proBNP, NYHA classification III-IV, chronic kidney disease (CKD), ICD for secondary prevention and prior VT ablation (p=0.08) were associated with reduced survival. On multivariate analysis, CKD was identified as the strongest independent survival predictor (HR 6.9; CI95%: 1.5-23-2, p=0.010)

Conclusions

In pts with NIDM, VT ablation may be successful even in pts with advanced heart disease. However, long-term survival will depend mostly on the stage of disease progression and is strongly associated with the clinical markers of end-stage heart failure. Therefore, a timely referral is crucial to derive the best clinical benefit from VT ablation in this population.

Epicardial mapping as first intention approach for structural ventricular tachycardia ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

In several structural arrhythmogenic diseases that comprise intricate endocardial, intramural and epicardial substrates, endocardial ablation of ventricular tachycardia (VT) is not sufficient and epicardial ablation has lately become a complementary and necessary tool.

Purpose

To evaluate the clinical characteristics of patients (pts) most suitable for first intention epicardial VT ablation.

Methods

Single-center prospective study of consecutive pts with structural heart disease undergoing first intention epicardial VT mapping between August 2015 and June 2021. Decision for epicardial approach was based on the etiology, VT electrocardiogram (ECG) and cardiac magnetic resonance (CMR) results. Under general anesthesia, subxiphoid access using a Tuhoy needle was done using fluoroscopic guidance and with high-density epicardial mapping was performed. Epicardial ablation was performed if relevant arrhythmogenic findings were locally confirmed.

Results

First intention epicardial VT ablation was attempted in 18 pts (mean age 59.8±12 years,94% male) of whom 16 had non-ischemic dilated cardiomyopathy (NICM,idiopathic:11; post-myocardis:4; hereditary:1) and 2 had right ventricular arrhythmogenic cardiomyopathy. Mean LVEF was 33% and 79% had a previous ICD (53% in primary prevenon). 69% were referred for ablation due to arrhythmic storm (1pt in cardiogenic shock). Epicardial access was achieved in 17 pts (94%), without acute complications. In 35% pts with NICM the decision for epicardial approach was based on the detection of subepicardial CMR delayed-hyperenhancement and relevant epicardial arrhythmic substrate was confirmed by mapping in all cases. In 3 pts radiofrequency (RF) applicaons were not performed at epicardium, as no abnormal electrograms were locally detected, and an addional endocardial approach was prosecuted. The mean overall procedure and fluoroscopic time were 123 and 28min, respectively, with a mean RF application me of 51min. After the procedure 1pt required pericardial drainage due to inflammatory pericardial effusion. No other acute complications occurred. During a mean follow-up of 2.8±1.8 years, only 3pts (17%) had VT recurrence; 5pts (28%) died due to end-stage heart failure and 2pts (11%) underwent heart transplantation.

Conclusion

In NICM a first intention epicardial VT ablation performed by experienced operators/centers is efficient, particularly if guided by CMR findings,and presents a safety profile.

Additional features in Brugada Syndrome stratification: frequent PVC and QRS duration

Funding Acknowledgements

Type of funding sources: None.

Introduction

Brugada syndrome (BrS) is a channelopathy with high prevalence of malignant arrhythmic events. The risk stratification in patients (pts) with Brugada electrocardiographic (ECG) pattern is of major importance, to prevent sudden cardiac death (SCD). A higher risk is evidenced in spontaneous type 1 pattern when compared with induced type-1 pattern, as so other electrocardiographic features have been explored aiming to detect additional prognostic factors.

Purpose

To evaluate the association of QRS duration and frequent premature ventricular contractions (PVC) with malignant arrhythmic events.

Methods

Prospective single-center study of consecutive pts with BrS, with spontaneous or induced type 1 pattern included from 2003 to 2021. All pts were enrolled in a protocol including annual non-invasive assessment with ECG and 24-hours Holter monitoring. Primary endpoints were defined as SCD or appropriate shocks in the context of ventricular tachycardia or fibrillation (VT/FV) during follow-up. Cox regression and Kaplan-Meier survival analyses were used to determine the association between the baseline ECG and Holter characteristics and the long-term risk of arrhythmic events.

Results

A total of 117 pts was included, 75 (65%) with a spontaneous type 1 pattern and 44 (33%) with an induced type 1 pattern. The mean age was 47±13years and 38 (32.5%) were male.

During a median follow-up of 4.1±0.3 years, the primary endpoint occurred in 8 (6.8%) pts, with sudden cardiac death in 3 (2.6%) and appropriate shocks due to VT/FV in 5 (4.3%). Pts who suffered arrhythmic events had presented at the study inclusion higher QRS duration (124±18 vs. 108±16ms, p= 0.014) and more frequent PVCs on 24-hour Holter (169±297 vs. 29±198; p = 0.001) - Figure 1. Indeed, the presence of QRS ≥119ms was associated with a 7-fold higher risk (HR: 7.250, 95% CI 1.619-32.461, p = 0.010) and the presence of more than 6 PVC on 24-hour Holter was also associated with a 5-fold higher risk of malignant arrhythmic events (HR 5.376, 95% 1.186-24.260, p = 0.029).

Conclusion

QRS duration and frequent PVC may established themselves as additional risk factors. In our cohort, they were both predictors of arrhythmic events during follow-up and thus can further complement BrS risk stratification.

Apical versus septal pacing - can we chose the localization of ventricular lead in order to prevent upgrade to cardiac resynchronization therapy?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Right ventricular apical pacing (RVAp) may be deleterious to ventricular function and hemodynamics due to pacing induced dyssynchrony. In the last decades, some studies showed that RVAp has been associated with heart failure, deterioration of left ventricular function and high mortality. Some patients (pts) may need, during the follow up (FUP), an upgrade to cardiac resynchronizaon therapy (CRT). New techniques have emerged such as RV lead implantation in the high septum or outflow RV tract (RVOT) and, more recently, His bundle/LB pacing.

Purpose

To compare the need for upgrade to CRT in patients with RVAp versus septal/RVOT pacing.

Methods

Retrospective single-center study of consecutive pts that implanted pacemakers in a tertiary center between January 1995 and December 2020. We collected data regarding pacing indication, RV pacing site (apex versus septum/RVOT) and need for an upgrade to CRT during follow up (FUP).

Our primary endpoint was upgrade to CRT during the FU period. In the model, the impact of localization of the implanted lead on the survival free from upgrade was estimated assuming a neutral effect on mortality. Statistical analysis was performed using T-student test and logistic regression.

Results

We included 8761 pts, 60.2% (n=5275) were male, with a mean age of 76.5±10.7 years. The main indications for pacemaker implantation were (1) complete atrioventricular (AV) block (2239, 25.6%), (2) sick sinus syndrome (2211, 25.2%), (3) atrial fibrillation with AV block or bradycardia with significant pauses (17.4%) and (4) Mobitz II 2nd degree AV block (1467, 16.7%).

RVAp was performed in 1746 (20%) patients and RVOT/septal pacing in 6933 patients (80%; RVOT in 657 (9,5%)). During FUP, 26 (1,5%) RVAp pts and 52 (0,8%) RVOT/septal pacing pts underwent upgrade to CRT, in a total of 78 pts (CRT-P in 54 patients and CRT-D in 24 patients).

We observed that patients with RVAp had twice the risk of CRT upgrade during FUP (OR: 2,0 (IC 95% 1,25-3,21), p=0,004) when compared to patients with RVOT/septal pacing.

Conclusions

Patients with RVAp presented a 2-fold higher risk for upgrade to CRT when compared to patients with RVOT/septal pacing in our center. This retrospective analysis shows that lead implantation in the septum/RVOT should be preferred instead of the apex to reduce pacing induced dyssynchrony and need for CRT upgrade.

Electrocardiography: an usefull tool for prediction of the diagnosis and severity of pulmonary embolism

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulmonary embolism (PE) is associated with morbidity and mortality. Immediate recognition of this condition is critical to commencement of early and appropriate therapy which could be lifesaving. Particularly in patients with suspected PE in which computed tomography pulmonary angiography (CTPA) is not promptly available or is contra-indicated, an electrocardiographic (ECG) score could serve as a ubiquitously available test to raise suspicion of PE. This study aimed to evaluate the diagnostic value of an ECG score for PE diagnosis.

Methods

Retrospective study of consecutive patients who performed CTPA in Emergency Department due to PE suspicion. All ECG were scored according to the previous published Daniel’s ECG score, by an investigator blinded for the CTPA result.

Results

The most common ECG findings in patients with PE were incomplete right-brand bock (48%), T wave inversion in DIII (48%), sinus tachycardia (41%) and Q wave in DII (31%). The S1Q3T3 sign was documented in 20% of patients.

The ECG score was significantly higher in patients with PE compared to those without PE (5.06 vs 3.70, p=0.005). ECG score showed moderate accuracy to detect PE (AUC: 0.60; 95%CI: 0.53-0.67; p=0.004), but it is of a particular value because of very high specificity: an ECG score > 12 identified PE with a specificity of 96% (95% CI 91.93 – 98.38).

The ECG score significantly increased the diagnostic accuracy of the diagnostic algorithm based on pretest clinical probability evaluated by Wells score combined with D-Dimer measurement (Wells & DD). In comparison to patients in which clinical pretest probability combined with D-dimer measurement considers PE excluded (Wells & ECG -), PE was 6.3 times more frequent in patients with Wells & DD +/ECG- (95% 2.7- 14.5) and 14.6 times more prevalent in the ones with Wells & DD +/ECG+ (95%CI: 4.1-51.3; p<0.001) – Figure 1.

Conclusion

In patients with clininal suspition of PE, na ECG score (Daniel’s score) >12 predicts PE with 96% specificity and could be used to increase the suspicion and define therapeutic strategy in patients in whom CTPA could not be immediately performed or is contra-indicated.

Is it possible to predict mortality and recurrence of VT afterablation? PAINESD risk score applicability vs new predictors

Funding Acknowledgements

Type of funding sources: None.

Introduction

Catheter ablation (CA) prevents ventricular tachycardia (VT) recurrences in patients (pts) with structural heart disease (SHD), and might have a favorable outcome, but is associated with severe short-term complications. Identification of pts at high risk of periprocedural acute haemodynamic decompensation has important implications at procedural planning.

The PAINESD risk score is a promising tool to predict VT ablation procedure-related mortality.

Aim

To evaluate the accuracy of the PAINESD risk score to predict short-term mortality after structural VT ablation and to compare it with other conventional clinical predictors.

Methods

Prospective, observational, single-centre study of consecutive pts with SHD (ischemic or nonischemic), referred for VT-CA. High-density substrate maps were collected, through endocardial, epicardial or combined endo-epicardial approaches according to clinical data and operator preference. The primary endpoint was 30-day mortality or hemodynamic decompensation. Univariate Cox regression analysis was used to identify relevant clinical predictors and to compare them with the PAINESD risk score. Multivariable Cox proportional hazards regression models were used to estimate predictors of 30-day mortality.

Results

A total of 102 pts with SHD referred for VT ablation were evaluated(mean age: 67±11 years, 94% male, 78.4% in NYHA class I-II; mean LVEF was 34±11%). The baseline PAINESD risk score was 12.39±5.8, 19.6% at low risk, 36.3% at intermediate risk and 27.5% at high risk of adverse events. Overall 30-day mortality was 4.9%. The PAINESD did not predict 30-days mortality or hemodynamic decompensation (p= 0.93). Indeed, a non- significant trend to higher short and long-term mortality was noticed in high-risk score pts – Figure 1. On univariate analysis age>65 years (p=0.019), LVEF <35% (p=0.049), body mass index<28kg/m2 (p=0.019), CKD (p=0.001) and previous VT ablation (p=0.022) were prognostic predictors. On multivariate analysis, only LVEF<35% (HR2.225; CI95% 1.004-4-774,p=0.038) and CKD (HR 3.35; CI95%: 1.31-8.51, p=0.011) were independent predictors of short-term prognosis.

Conclusions

In our population, LVEF<35% and CKD were the strongest predictors of short-term mortality. PAINESD risk score was not accurate in predicting adverse events. New score systems must be derived for prognostic stratification in this population, incorporating the reduction on the actual short-term event rates after VT ablation.

Upgrade pacemaker to CRT: predictors and the importance of LVEF

Funding Acknowledgements

Type of funding sources: None.

Introduction

Nowadays 10-15% of CRT implantaon is upgrading from paents (pts) with pacemaker (PMK) who develop reduced LVEF and worsening symptoms from HF. There are few retrospecve studies showing some predictors of pts with single or dual chamber PMK that may need upgrade to CRT, but it is not completely established which pts may benefit the most.

Purpose

To identify predictors at follow-up of upgrading pacemaker to CRT in a population with pacemaker implantation.

Methods

Single center case-control study of pts that performed upgrading to CRT-pacemaker (CRT-P) in our hospital. We excluded pts that performed upgrade to CRT-D. We compare to a PMK populaon matched to age at implantaon and cause of PMK implantaon. Demographic, clinic and electrocardiographic (ECG) data were considered at baseline. Echocardiographic evaluation was performed before pacemaker/CRT upgrading implantaon and at follow-up. Predictors of upgrading were evaluated by the Cox regression. Prognosc impact of LVEF was evaluated as upgrading to CRT-P by Kaplan-Meier curves.

Results

We included 71 pts that performed CRT-P upgrade (mean age 77±10; 49,6% male, mean LVEF before PMK 54.9±9.2%) and 71 pts with pacemaker implantaon (mean age 78 ± 11; 50,4% male; mean LVEF 60.9±7.2%). The clinical characteriscs, ECG and echocardiographic were similar between pacemaker and CRT-P-upgrade, except atrial fibrillaon being more prevalent in PMK group (57.5% vs 42.5% p=0.039). Mortality was not different duringfollow-up between the two groups. In univariate analysis, QRS duraon (PMK: 115ms vs upgrade CRT-P: 132 ms, p=0.038), LVEF (PMK: 60.9% vs upgrade CRT-P: 54.9%, p=0.002) and LV end-diastolic diameter (LVEDD) (PMK: 48.9.4 ± 6.6mm vs upgrade CRT-P: 56.4 ± 6.6mm, p=0.001), LV end-sistolic diameter (LVESD) (PMK: 29.5 ± 6.5mm vs upgrade CRT-P: 37.9 ± 9 mm, p=0.006) were associate to upgrading to CRT. In our population, the unique independent predictor was lower LVEF(Long Rank 6.108, p=0.013) – Figure 1. The best LVEF cut- off to predict upgradingto CRT was 55% (AUC 0.954, sensitivity 64%, specificity 84%) – Figure 2.

Conclusion

In our populaon of CRT upgrading pts, a broad QRS duraon, lower LVEF and a higher LVEDD and LVESD were associated to upgrade to CTR-P. We try to establish a new value for LVEF that could lead to upgradingto CRT-P, and maybe the classical cut-off of 50% should be reviewed.

Cardiac Optimal Point: Identifying high risk patients for an optimal approach

Funding Acknowledgements

Type of funding sources: None.

Introduction

In recent years it has been proposed the concept of cardiorespiratory optimal point (COP) to best characterize populations who underwent cardiac rehabilitation programmes (CRP). The COP is defined as the minimum ratio between ventilation and oxygen consumption (VE/VO2) obtained during the cardiopulmonary exercise test (CPET) and it has been suggested that COP values > 30 conveyed worse prognosis.

Purpose

To validate OP as a predictor of events and its correlation with exercise activity and quality of life on the long term.

Methods

Single center observational study of patients enrolled on CRP - from February 2018 to May 2019 – who did CPET as part of routine evaluation. COP was defined as the lowest point of VE/VO2 ratio. Clinical and laboratorial characteristics were obtained at admission and discharge of CRP. Exercise practice was accessed using IPAQ questionnaire and quality of life was assessed based on a validated inquire - Kansas City Cardiomyopathy Questionnaire (KCCQ-23) – both by phone interview.

Results

A total of 78 patients (mean age 63.2 ±11.6, 84.6% male) were evaluated and followed for a mean follow-up of 2,68±0,53 years. Main aetiology was ischemic heart disease (86%), followed by dilated cardiomyopathy (5,1%) and valvular heart disease (2,6%).

A COP value above 30 correlated with a worse global score in KCC-23 (r =0.283, p = 0.47), and in particular domains such as frequency and severity of symptoms (p = 0.046, r 0.335 and p=0.16, r= 0.4, respectively), quality of life (p=0.039, r= 0.293) and social limitation (p = 0.001, r=0.5). COP also correlated with VO2 peak in basal CPET (p<0.001, r= 0.450) and on follow-up CPET (p= 0.39, r= 0.303).

COP failed to predict events or levels of exercise activity on the long term, as evaluated by the IPAQ score. However, COP>30 did seem to correlate with a higher mortality rate on the follow-up although such trend was not statistically significant (possibly due to short follow-up time and sample size).

Conclusion

COP values > 30 identify patients with worse prognosis, predicting worse quality of life and higher mortality. Although it did not seem to be a good predictor of exercise adherence after CRP.

Shorter cardiac rehabilitation programs: taking time is taking effectiveness?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Due to the covid-19 outbreak, cardiac rehabilitation programs (CRP) underwent most needed adaptions to stay operative. To face all the requests and guarantee sanitary measures, we reduced the duration of the program from about 12 weeks to about 8 weeks, so we could have smaller groups but still respond to all patients who had been referred. However, it is still unclear whether less hours of contact and exercise sessions can achieve the same results as traditional CRP.

Objective

To analyse the effectiveness of shorter duration CRP on risk factor control and exercise tolerance after concluding the program.

Methods

Observational single center study including two groups of patients who underwent CRP: one group who had been in 12 weeks-CRP before the pandemic sprout and another group enrolled in an 8-week program after April 2021. Albeit differences in their duration, both CRP had the same structure: observation by cardiologist, physiatrist, specialist nurse, exercise (aerobic and strength exercises) and educational sessions, as well as nutrition and psychologist consultation.

Results

A total of 114 pts were analysed (mean age 62,4±11,6 years, 85.1% men, 86% with ischemic heart disease). Main comorbidities were hypertension (68,4%), dyslipidaemia (70%) and diabetes (30,7%). 78 pts completed a longer programme with 12 weeks duration while 36 underwent a shorter CRP with 8 weeks. There were no statistically significant differences between both groups regarding population demographics, aetiology, LVEF and co-morbidities.

After CRP, there was significant improvement in risk factor control (mainly lipidic profile and weight) and echocardiographic parameters in both groups. We noted an important reduction in LDL levels (85±42.6mg/dL before CRP and 67.68±28.45mg/dL after), approaching the guideline recommended levels (<55mg/dL): 29.8% before vs 42.6% after (p=0.079), with no difference between the two groups (p=0,65). Significant improvement of LVEF was also observed (53% to 57%, p <0.001) without difference between the two groups (p=0.112).

Exercise tolerance improved similarly in both groups, assessed by the time of exercise stress test: we registered a global increase of 65 ± 1.38s after CRP, with no difference between the two groups (p = 0.157).

Conclusion

Shorter duration CRP showed similar results concerning risk factor control, echocardiographic LVEF and exercise tolerance improvement, suggesting that they can be an effective alternative when needed.

Very acute benefits on physical performance in elderly patients who undergone TAVI

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) emerged as a safe and efficient procedure in patients with high or prohibitive surgical risk or in older patients. The prevalence of severe aortic stenosis is growing up, given de aging of population. These patients are much often frailty and experience low levels of physical activity and functional capacity as a result of their aortic valve disease and comorbidities. When untreated severe aortic stenosis has a poor prognosis so it is of utmost importance to restore the normal hemodynamic condition and consequently to improve functional capacity.

Aim

To assess the acute benefits (in 1 moth) of TAVI on functional capacity and physical performance.

Methods

Single center prospective study of patients submitted to TAVi between April 2021 and September 2021. Patients were evaluated at baseline (before TAVI) and one month after the procedure. To assess physical activity and functional capacity it was used the International Physical Activity Questionnaire (IPAQ) and the short physical performance battery (SPPB) which is a group of measures that combines the results of the gait speed (two timed trials of a 4-m walk – fastest recorded), chair stand (time to raise for a chair 5 times) and balance tests (ability to stand for 10 seconds with feet in 3 different positions). Additionally, patients were submitted to handgrip strength test. Paired sample t-test and Wilcoxon test were used to statistical analysis.

Results

We included 20 patients, with a mean age of 85±5,86 years, 40% (8) male. 19 patients undergone TAVI due severe native aortic stenosis and 1 due to bioprosthetic aortic valve dysfunction. The vascular access site was transfemoral in 19 patients and transapical in 1 patient.

No patient had vigorous physical activity either before or after TAVI, but the daily sitting time was lower after the procedure (mean time: 634 versus 570 minutes), however not statistically significant. Regarding the results of SPPB patients experience improvements in balance (p=0,035) and chair stand (time to raise for a chair 5 times: 19,04 versus 17,05 seconds), p=0,01.

Patients tended to be faster in 4m velocity test, however with no statistical difference (8,49 versus 6,6 seconds). No statistical differences were also observed in handgrip strength test.

Conclusion

In an elderly population, TAVI appears to have an early and beneficial effect (in 1 moth) on some domains oh physical activity and functional capacity.

Cardiorespiratory fitness assessment on active patients who kept attending their phase III exercise-based cardiac rehabilitation during the COVID-19 era

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorespiratory fitness (CRF) is a powerful predictor of all-cause mortality among individuals with coronary artery disease (CAD). A structured community-based phase III cardiac rehabilitation (CR) is very important in lifelong maintenance of phase II CRF and health gains. During the COVID-19 pandemic, CR programs had to adapt, mainly using new technologies and remote follow-up. The CRF impact in patients (Ps) who kept going their phase III program, during this troubled era is still unknown.

Purpose

Assess the variation in CRF and prognostic parameters in Ps with CAD who maintain high adherence levels in their phase III CR before and during the COVID-19 pandemic.

Methods

A cohort of Ps enrolled in a community-based phase 3 CR program, with active participation at the end of 2019, was included in this retrospective study. The inclusion criteria for this study were high levels of attendance (>80%) to the CR program before and during COVID-19 and high levels of physical activity with more than 150 mins of moderate to vigorous physical activity (MVPA). All Ps were evaluated with transthoracic echocardiography (TTE) and a cardiorespiratory exercise test (CPET) in a cycloergometer in 2019 and between october and november of 2021. All Ps had used accelerometers to measure their physical activity levels and dual-energy absorptiometry (DEXA) scan to evaluate their body composition. Between 2020 and 2021, Ps had online (in lockdown periods) and face to face exercise training sessions, 3xtimes per week, 60 mins each exercise session.

A t-test paired two sample for means was used to compare CPET variables before the beginning of the first COVID lockdown (end of 2019) and after the removal of the majority of restrictions (end of 2021).

Results

A total of 30 Ps with high levels of adherence were included (99.6% male, 65 ± 9 years old). In this cohort, the majority had history of an ACS before the referral to the CR program (73.3%) and 55.6 ± 10.4% of left ventricular ejection fraction.

There was no significant difference in body mass index (27.9 ± 3.2 kg/m2 vs 28.1 ± 3.6 kg/m2, p=0.493 but there was a significant increase in the percentage of body fat mass (30.1 ± 5.7% vs 31.0 ± 6.6%, p= 0.042). There was a maintenance on MVPA levels (352 ± 137 minutes/week vs 313 ± 194 minutes/week, p = 0.106) during this period.

When comparing the 2 CPET results, Ps achieved higher exercise loads in the 2021 test (175 ± 51W vs 185 ± 52W, p=0.005), higher VO2 peak (25.3 ± 6.9 ml/kg/min vs 21.5 ± 6.3 ml/kg/min, p =0.001) and higher percentage of predicted VO2max (78.8 ± 16.8% vs 95.27 ± 20.8%, p = 0.001).

Conclusion

In spite of all the difficulties in maintaining a phase III CR program during the COVID-19 pandemic, we observed that in physically active CAD Ps, with the aid of new technologies and remote follow-up (during the lockdown periods) and face to face exercise sessions, it is still possible to have functional gains and improvements in CRF.

Long term left ventricular impairment after SARS-COV2 infection

Funding Acknowledgements

Type of funding sources: None.

Introduction

The impact of acute infection by SARS-COV2 on the cardiovascular system has been previously reported in the literature, with a higher propensity in patients with more serious pattern of disease and pro-inflammatory status. Nevertheless, the long-term burden and sequels of COVID-19 on the cardiovascular system is still unknown.

Purpose

To evaluate the long-term impact of COVID-19 on left ventricular function in patients with severe clinical presentation requiring intensive care hospitalization.

Methods

 

This was a single-center observational, prospective study which included patients requiring admission to the Intensive Care Unit (ICU) due to COVID-19 infection from January to November 2020. All discharged patients were contacted to perform a clinical, electrocardiographic and echocardiographic evaluation and those who accepted were included on the protocol. Baseline and clinical characteristics were collected from clinical reports. For the global longitudinal strain (GLS) analysis all patients with significant wall motion abnormalities and valvular cardiopathy were excluded. Statistical analysis was performed with Mann-Whitney and a safety cut-off was established with ROC curve analysis.

Results

 

A total of 43 patients were included (mean age 64 ± 12, 67.4% males). During SARS-COV2 infection 49% presented with severe ARDS and 51% with moderate, 35% required invasive mechanical ventilation, 14% noninvasive mechanical ventilation and 52% with high nasal flow cannula. On the follow-up analysis, fatigue was the most reported in symptom (52% patients) and the majority did not present other signs or symptoms suggestive of heart failure, with the mean NT-proBNP of 49 ± 389 pg/dL. The standard ECG and echocardiogram did not show significant changes with a mean LVEF of 58 ± 7.8 and mean TAPSE of 21 ± 4. The strain analysis showed low value of GLS (mean GLS of -17.14 ± 2.36) for a reference cut-off of -18%, suggesting subclinical left ventricular dysfunction in this subset of patients with preserved ejection fraction. Maximum CPR values during ICU did not correlate either with the extent of disease evolvement in CT (p= NS) or ARDS severity (p= NS). Nevertheless, maximum CPR correlated significantly with GLS reduction (R = 0.44, p = 0.019). A CPR value higher than iger30mg/dL had 100% specificity for GLS reduction and a cut-off of 14gm/dL reported a sensitivity of 65% and specificity pf 75% for reduction in GLS.

Conclusion

In our study, we reported subclinical impairment in left ventricular function detected with global longitudinal strain after serious infection with SARS-COV2. The detected myocardial dysfunction was related with higher inflammatory as expressed by CPR values. Long-term monitoring of these patients should be undertaken in order to timely detect late complications. Abstract Figure.

Mitral valve prolapse: impact of mitral valve disjunction in a large single-center

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite being known for more than a century, mitral valve prolapse (MVP) is an

entity not fully understood with controversial data regarding the prognosis.

Aim

To characterize a sample of patients with MVP and to access the frequency of

complications associated with MVP (arrhythmias, hospital admissions and death).

Methods

Single-center retrospective study of consecutive patients with MVP documented in

transthoracic echocardiogram between January 2014 and October 2019. MVP was defined as

systolic displacement of the mitral leaflet into the left atrium≥ 2 mm from the mitral annular

plane. Demographic, clinical, echo, EKG data were collected as well as major adverse events at follow-up. Categorical variables were reported in absolute number and/or % and continuous variables were reported as mean and SD or median and IQR. The results were obtained using Chi-square and ANOVA tests.

Results

247 patients were included (mean age 62.9 ± 18 years, 61% male). The mean

distance of the MVP was 6mm (IQR 5-9). The posterior mitral valve leaflet (PL) was the most

frequently involved (49%), followed by involvement of both leaflets (BL) (27%) and the anterior

leaflet (AL) (25%). Patients with MVP of PL were older compared to patients with BL and AL

involvement (68 ±15 vs 58 ± 17 vs 59 ± 22 years, respectively, p &lt; 0.001) and had longer QT

interval (419 ± 35 vs 403 ± 25 vs 410 ± 34ms, respectively, p = 0.013). 70.4% (174) had

significant MR. Mitral annulus disjunction (MAD) was present in 9.3% (n = 23). The mean LVEF was 63% ± 6.3% and LV mass was 124,7 ± 41g/m2. Most of the patients were in sinus rhythm (SR) (78%). 13.3% had hospital admission for cardiovascular cause and 8.5% (n = 21) died.

During a mean follow-up of 30 ± 19 months, 25.1% of the patients had de novo atrial fibrillation (AF), 8 patients (3%) were submitted to supraventricular dysrhythmia ablation. 16.2% had premature ectopic ventricular complexes, 2.4% non-sustained VT, 0.4% sustained VT, 0.8% needed ICD, 8.5% had a pacemaker. 25% of the patients underwent mitral valve intervention (23.9% to surgical intervention and 3 to percutaneous). 12% of the patients had a hospital admission for CV cause and 8.5% of the patients died.

In multivariate analysis, hospitalization for CV cause (OR 7.27, p = 0.011, CI 95% 1.59- 33.3), higher NYHA class (III-IV) (p = 0.036 OR 5.7 CI95% 1.125-28.84) and the presence of LBBB (p = 0.021 OR = 6.78 CI95% 1.13-28.85) were independent predictors of mortality.

MAD was not associated with the outcomes. SR (OR 0.3, p = 0.014, CI95% 0.119-0.786) and prolapse (OR 0.37, p = 0.035, CI95%0.148-0.935) according to the ESC classification (comparing to flail and billowing) predicted survival.

Conclusion

MVP was traditionally described as a benign entity. However, in our population it was associated with significant mitral regurgitation, some requiring intervention. Besides that, 44% had arrhythmias, with AF occurring in about 25%, hospitalization in 13.3% and cardiovascular death in 8.5%.

Predictors of survival in patients submitted to typical atrial flutter ablation

Introduction

Cavo-tricuspid isthmus ablation (CTA) is the first line procedure in patients with typical atrial flutter (AFL) for adequate rhythm and symptoms control with low complication rates and excellent results. Given its apparent simplicity, rarely do we take clinical factors in account before referral.

Aim

To identify predictors of survival after typical AFL ablation.

Methods

Single-center retrospective study of pts with typical AFL submitted to ablation between 2015 and 2019. Pts clinical characteristics were collected. Statistical analysis was performed using Cox regression (for multivariate analysis), Chi-square and Mann-Whitney (for univariate analysis) to identify predictors of survival.

Results

A total of 476 pts (66±12 years, 80% males) underwent CTA. Regarding global clinical characteristics, median body mass index (BMI) 27.3 (IQ 24.5–30.4), median CHA2DS2-VASc score 2 (IQ 1–3), 27.3% with diabetes, 53.9% with dyslipidemia, 69.5% with hypertension, 12% with current tobacco abuse, thyroid disfunction in 10.9%, ischaemic cardiomyopathy in 13.7%, heart failure in 27.8% (3.6% of pts with reduced ejection fraction), chronic kidney disease (CKD) stage 3 or more in 17.7%, obstructive sleep apnea (OSA) in 11.9% and chronic obstructive pulmonary disease (COPD) in 9.5% of pts. Before CTA ablation, 444 pts were under anticoagulation, which was stopped in 293 pts after the procedure. The follow up period was 2.8 years.

In this population, COPD (p=0.005), CKD (p&lt;0.001), heart failure (p=0.0027) and BMI less than 25 (p=0.02) were associated with reduced survival on univariate analysis; patients with BMI between 25 and 30 had better prognosis. On multivariate analysis, CKD was the only independent predictor of reduced survival (HR 0.366; CI95%: 0.132–0.737, p=0.005). There was no difference between genders (p=NS).

A CHA2DS2-VASc score of ≥4 predicted higher mortality (HR: 3.0) in all three groups, although the anti-coagulation suspension had no impact on survival (p=NS).

Conclusion

In this subset of patients, the presence of COPD, heart failure, BMI less than 25 and CHA2DS2-VASc score ≥4 predicted reduced survival, being CKD stage 3 or more an independent predictor. The suspension of anti-coagulation didn't impact on survival. These results can help us to better select pts to the procedure and decide on whether to stop anti-coagulation, although larger studies are still needed.

Funding Acknowledgement

Type of funding sources: None. BMI impact on survivalCKD impact on survival

Cryoablation: safety of same day discharge

Introduction

Discharge after overnight hospital stay is standard procedure in patients submitted to elective atrial fibrillation (AF) ablation. Taking into consideration the low rate of cryoablation procedure complications could the same day discharge be an option?

Purpose

To assess the safety of same day discharge of patients submitted to AF cryoablation.

Methods

Single-center retrospective study of consecutive patients admitted to elective AF cryoablation in a tertiary center between February 2017 and November 2020. Patients were divided into two groups: same day discharge and next day discharge. Only patients submitted to ablation until 4 p.m. were included. Complication rates were obtained up to six months after the procedure. Complications were defined as death, pericardial tamponade, hematoma requiring evaluation and/or intervention, major bleeding requiring transfusion, hospital admission related to the procedure.

Results

One hundred fifty-four patients were included, with a mean age of 61±10.9 years, 66.2% were males, 18.2% with diabetes, 65.6% with dyslipidemia, 77.9% with hypertension, 10.4% with chronic kidney disease KDIGO stage 3 or more. Median follow-up of 436 [178 – 729] days. Most of the patients had paroxysmal (73.4%) and persistent short duration AF (23.4%). Sixty-two patients (40.3%) were early discharged and there were no differences between the two groups regarding epidemiological and clinical characteristics (p=NS).

A very low rate of complications in both groups was observed, occurring in 6.5% of patients with early discharge and in 8.7% of patients in overnight stay, without statistical significance between the two groups (p=0.61). The most frequent complications were local hematoma (5 patients, 2 in early discharged group), pericardial effusion (3 patients, all in overnight stay), femoral pseudo-aneurism (2 patients, 1 in each group) and arteriovenous fistula (1 patient in overnight stay group). The type of complications did not differ between the two groups (p=0.51). Two patients died during follow up, and this was unrelated to the procedure. In addition, no difference in success rate and arrhythmic recurrence was observed between the two groups (p=NS).

Conclusion

Our study suggests that it is safe to early discharge patients submitted to AF ablation, reducing the hospital stay length in selected patients. Larger studies are needed to confirm this data before routine implementation of this strategy.

Funding Acknowledgement

Type of funding sources: None.

TAVI via alternative access routes: patient selection and 10-year center experience

Background

Femoral access is considered the gold standard for transcatheter aortic valve implantation (TAVI). However, this route might be precluded due to the presence of tortuosity, small vessel diameter and/or peripheral artery disease. We aimed to investigate TAVI through an alternative access (AA), focusing on the selection criteria and clinical outcomes compared to the femoral route (TF).

Methods

We conducted an all-comers longitudinal single-centre prospective registry in whom a TAVI was performed. The feasibility, safety and efficacy of TAVI by means of an access route other than standard TF was assessed, according to the VARC-2 criteria. The prospective surgical criteria used at our institution to accept an AA route were: a) TF deemed inappropriate; b) acceptable haemorrhagic risk; c) acceptable general anaesthesia risk; and d) adequate anatomy and diameter within acceptable range (subclavian, axillar, transaortic) or e) age &lt;85 years and non-frail patient (transapical). The primary endpoint was all-cause death at 1-year.

Results

From 2008 to 2018, there were 548 patients submitted to TAVI [median age 84 (79–87) years, males 45.4%]. An AA route was used in 100 patients (79 trans-apical, 9 trans-aortic, and 12 trans-subclavian), with a decreasing rate over follow-up (−11% per year). Compared to TF, these patients were younger [80 (77–84) vs. 85 (80–87) years; p&lt;0.001) with a similar baseline surgical risk as per EuroSCORE II [5.1 (3.3–9.0) vs. 4.7 (3.3–7.0); p=0.410). AA patients presented a higher burden of atherosclerotic disease, namely coronary (54.0 vs. 41.3%; p&lt;0.001) and peripheral artery disease (35.0 vs. 16.5%, p&lt;0.001) despite a lower number of other comorbidities (e.g. glomerular filtration rate &lt;50mL/min: 53.1 vs. 64.8%; p=0.030). Left ventricular ejection fraction (56±13 vs 55±12%; p=0.203) and aortic stenosis severity (e.g. valve area: 0.70±0.19 vs. 0.67±0.18cm2; p=0.302) were similar between groups. Haemorrhagic events (minor or major) following TAVI were less often documented in the AA group (11.0 vs 21.7%; p=0.015), contrasting with de novo atrial fibrillation (18.5 vs 7.6%; p=0.048). Overall, 67 patients met the primary endpoint (18.8 vs 16.2%; p=0.584). After adjusted multivariate analysis, the independent predictors of one-year mortality did not include the TAVI access route.

Conclusion

In the first 10 years of experience, 1 in every 6 patients was treated with a TAVI by means of an AA, most often trans-apically initially and, nowadays, via a trans-subclavian approach. The use of meticulous prospective selection criteria seems to explain the one-year similar results, regardless of the access route.

Funding Acknowledgement

Type of funding sources: None.

Predicting pacemaker dependency after TAVI with pre-procedural MSCT

Background and aim

High degree conduction disturbances is a burdensome complication of transcatheter aortic valve implantation (TAVI). There is limited data whether such disorders are permanent or reversible. Anatomic surrogates, such as membranous septum [MS, a distance marker from aortic annulus to His-bundle surge] and calcium distribution within aortic valve have been associated with pacemaker (PM) implantation. The aim of our study was to assess predictors of long-term pacemaker dependency following TAVI.

Methods

Single center prospectively included patients that underwent pacemaker implantation following TAVI (March 2017 to September 2020). Patients who were lost to follow up, with bicuspid aortic valve, previously implanted PM and non-available or low quality MSCT exam were excluded. On MSCT, MS length was measured on modified coronal view, the aortic-valvular complex (AVC) was characterized by leaflet sector and calcium distribution was assessed on a J-score threshold of 850-Hounsfield units. Pacemaker dependency was assessed by reducing ventricular pacing to 30 bpm and defined by subsequent complete AV dissociation in patients in sinus rhythm or an escape rhythm &lt;50 bpm in atrial fibrillation, in addition of &gt;90% pacing percentage since implantation.

Results

From the 352 patients with inclusion criteria, 67 underwent PM implantation (19%) and 55 included in the analysis (male 33.9%, median age=85) (Figure). Median time for pacemaker implantation was 3 days [interquartile range (IQR) 3–5 days], mostly due to complete auriculo-ventricular block (76.4%, N=42). PM dependency occurred in 14 out of 55 (25.5%) patients at mean follow up of 500±363 days. Patients with PM dependency tended to have deeper implantation depth, (6.2 mm vs 5.5 mm, p=0.096) and a significantly shorter MS (5.8 mm vs 6.8 mm, P-value = 0.031) (Table). Increasing MS length was independently associated with a lower risk of PM dependency [odds ratio (OR) 0.58 per mm; 95% CI: 0.35–0.98, p=0.04] regardless prosthesis choice. MS length under 5 mm had 97.6% specificity (95% CI: 87.1–99.9) and 85.7% positive predictive value for pacemaker dependency (AUC=76.7; 95% CI 63.3–87).

Conclusion

Our findings highlight the importance of MSCT-derived MS length to stratify the risk of long term need for pacemaker. Patients with short MS (&lt;5mm) in addition to conduction abnormality following TAVI had a high likelihood of PM dependency on the long term and should be considered for prompt PM implantation.

Funding Acknowledgement

Type of funding sources: None.

The timing and mechanism of high-grade AV block post-TAVI: knowing your enemy

Background

Complete atrioventricular block (AVB) requiring permanent pacemaker implantation (PPMI) is still a major limitation of transcatheter aortic valve implantation (TAVI) procedures. Although right-bundle branch block (RBBB), membranous septum (MS) length and self-expandable prothesis are recognizable risk factors, their predictability to PPMI is far from satisfactory. While some patients develop persistent intra-procedure high-grade AVB (H-AVB), others present much later with severe bradycardia.

Purpose

This study aims to describe and compare the characteristics of patients who develop AVB during or after TAVI.

Methods

Single centre prospective registry of 506 consecutive patients submitted to TAVI with no previous pacemaker between 2017 and 2020. Post-procedure PPMI (up to 30 days after discharge) was studied and divided into two groups according to the development of persistent intra-procedure H-AVB (Group A) or post procedure H-AVB (Group B). Baseline ECG, computed tomography and TAVI-related characteristics were analyzed.

Results

A total of 88 patients (17,3%), aging 83±6 years, 36.4% male, underwent post-TAVI PPMI (6 after discharge). Previous conduction disturbances were present in 50 (56.8%) patients and 25 (28.4%) had RBBB. 83% were submitted to self-expandable TAVI. Forty-two patients (47.7%) had persistent intra-procedure H-AVB (Group A) whereas 52.3% had post-procedure H-AVB (Group B). In patients with persistent intra procedure H-AVB previous RBBB was significantly more frequent (45.2%, n=19) when compared to patients with post-procedure H-AVB (13%, n=6; p=0.001). Contrarily, AF and previous left-bundle branch block (LBBB) were more likely in Group B. No difference in valvular calcification, MS length, prosthesis type or implantation technique was noted (picture 1). In the group with post-procedure H-AVB, 21.7% had transient AVB during TAVI and all developed de novo LBBB or first-degree AVB post-TAVI. Among these, 33 patients (71.7%) developed delayed H-AVB (&gt;48h post-procedure) while the remaining presented earlier.

Conclusions

In patients with PPMI post-TAVI, those with persistent intra-procedure H-AVB had higher rates of previous RBBB, while those with post-procedure H-AVB frequently had a normal baseline ECG. Anatomical and procedural characteristics did not differ between groups. Further studies are needed to confirm these results.

Funding Acknowledgement

Type of funding sources: None.

Risk stratification in patients with Brugada syndrome: the role of the late potentials evaluated by signal-averaged ECG

Introduction

Brugada syndrome (BS) is a relevant cause of sudden death in individuals without structural heart disease. The accuracy of the available methods for risk stratification is very limited and the investigation of new methodologies to improve the identification of patients at risk is under intensive investigation. Recently the pathophysiological relevance of anomalous, fragmented and prolonged electrograms on the epicardial surface of the right ventricular outflow tract (RVOT) has been described. Therefore, the study of signal-averaged ECG (SA-ECG) has become attractive since it may allow the non-invasive evaluation of these electrical anomalies. In order to maximize the detection capacity and to focus the evaluation in the RVOT, we developed an alternative methodology of electrode positioning directed to this area of interest.

Purpose

To characterize the study of late potentials (LP) by SA-ECG in patients with SB and to evaluate its association with the occurrence of arrhythmia events.

Methods

Prospective single centre study of patients (pts) with BS. LP were evaluated by SA-ECG with determination of the total filtered QRS duration (fQRS), root mean square voltage of the 40 ms terminal portion of the QRS (RMS40) and duration of the low amplitude electric potential component (40 microV) of the terminal portion of the QRS (LAS40) in conventional and modified leads (addressed to RVOT). The association of LP with the risk of definite malignant dysrhythmias due to sudden death, ventricular fibrillation, ventricular tachycardia or appropriate shock of the implantable cardioverter defibrillator (ICD) was evaluated and the acuity of the prognostic stratification was determined by the area under the receiver operator characteristic curve (ROC).

Results

A total of 76 pts (69.7% men, age 48±12 years) were studied, of which 33 had a spontaneous type 1 pattern and 43 had a type 1 pattern induced by flecainide. During a median follow-up of 1.6 years, 13 pts (17.1%) had symptoms potentially related to BS and 6 (10.5%) had malignant arrhythmias [including two pts who suffered sudden death (2.6%).

The pts who had malignant dysrhythmias presented higher values of fQRS (125±23 vs. 108±18, p=0.046) and LAS40 (54±13 vs. 40±11, p=0.014), and lower values of RMS40 only in the modified leads (11±5 vs. 22±19, p=0.041). The parameters of the SA-ECG were significant prognostic predictors.

The acuity of each of the parameteres alone was moderate and the parameters that were identified as more powerful predictors of risk were those derived from the modified leads (Figure).

Conclusion

The LP evaluated by SA-ECG may be relevant in the prognostic stratification of patients with BS, since it seems to be associated with the risk of malignant ventricular arrhythmias.

Funding Acknowledgement

Type of funding sources: None.

Predictors of survival and ICD shocks in a population submitted to ventricular tachycardia ablation

Introduction

Sustained monomorphic ventricular tachycardia (VT) is associated with an increased risk of mortality and morbidity in patients with ischemic heart disease (IHD). While implantable cardiac defibrillators (ICD) have been shown to reduce mortality in patients with IHD and are effective in terminating VT, they are unable to prevent recurrent VT. Also, recurrent ICD shocks have been associated with an increase in all-cause mortality, hospitalizations for heart failure and are painful, resulting in impaired quality of life. Therefore, strategies to prevent ICD shocks are needed.

Aim

To evaluate risk factors associated to all cause Mortality and ICD shocks

Methods

We conducted a prospective, observational, single-centre and single-arm study involving patients with IHD, referred for Radiofrequency catheter ablation (RCA) procedure for VT using high-density mapping catheters. Variables selected from the univariate analyses (p&lt;0.10) were entered into multivariable Cox proportional hazards regression models to estimate predictors of ICD shocks recurrence and overall mortality. All analyses were 2-sided and a P-value &lt;0.05 was considered statistically significant. Statistical analysis was performed by using IBM SPSS Statistics 26™.

Results

From June 2015 to June 2020, a total of 64 consecutive patients were referred to our centre for a first RCA procedure using high density mapping for VT. The mean age was 68±9 years, 95% were male. 83% of patients were in NYHA functional class II or I and mean LV ejection fraction was 33±11%. All-cause mortality was 23.4%, an age higher than 70 years (p=0.01) and chronic kidney disease (CKD) were associated with reduced survival on univariate analysis. On multivariate analysis, CKD shown a tendency to reduced survival (HR 0.22; CI95%: 0.41–1.22, p=0.08). No risk factors for ICD shocks were found (table 2).

Conclusions

In our population, age and chronic kidney disease were associated with reduced survival, however no risk factors were associated with ICD shocks.

Funding Acknowledgement

Type of funding sources: None.

Is balloon cryoablation effective in common pulmonary trunk?

Introduction

Common pulmonary trunk (CPT) accounts for the most frequent pulmonary vein anatomical variation. The most frequent technique used for pulmonary vein isolation (PVI) is point-by-point radiofrequency, using cryoablation (CB) is still debatable. Some few studies have shown the feasibility and safety of CB in CPT atrial fibrillation (AF) patients (pts), most of them performed angio-CT prior to ablation.

Purpose

To analyzed AF pts with and without CPT submitted to CB in regarding of success rate and safety.

Methods

Single-center retrospective study of consecutive AF pts refractory to antiarrhythmics submitted to CB between 2017 and 2020. Before the procedure auriculography was performed in all pts to verify variations in pulmonary veins, however the procedure was not modify regarding the presence of CPT. Clinical records were analyzed to determine baseline characteristics, success rate and complications. Monitoring was performed with a 7-day event loop recorder at 3, 6 and 12 months and annually from the 2nd year. Success was defined by recurrence of AF (duration &gt;30 seconds). Kaplan Meier survival curves were used to estimate the risk of events and the groups were compared using Chi-square and Mann-Whitney analysis.

Results

A total of 232 pts (60±12 years, 68% males) underwent CB. 29 pts had CPT (28 – common left pulmonary trunk and 2 – common right pulmonary trunk). Baseline characteristics were similar between groups, except for CHA2DS2VASc score and prior cerebrovascular disease history which were higher in CPT pts (3±2 vs 2±2, p=0.001; 24.1% vs 6.8%, p=0.007, respectively). The mean baseline CHA2DS2VASc was 2±2 and the median post-CB follow-up was 135 (IQ 32–249) days.

Both the 1 and 3 year arrhythmic recurrence after AF ablation was not significantly different when comparing CPT and non CPT group with a 3 year success rate of 95.8% in pts with CPV against 86.5% in pts without CPT (p=0.299).

There was no difference between groups (p=0.296; p=0,164, respectively) regarding the time of the procedure, radiation dose and rate of complications.

Conclusions

In our experience, balloon cryoablation for PVI is a safe and successful procedure in patients with CPT anatomical variation.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemic on ST-elevation myocardial infarction: data from two Portuguese centers

Introduction

Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases.

Objectives

To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave.

Methods

Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods.

Results

A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed.

Conclusions

During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates.

Funding Acknowledgement

Type of funding sources: None.

Aortic atherosclerotic plaques: the role of anticoagulation

Introduction

Aortic atherosclerotic plaques (AAPs) are one of the major causes of spontaneous and iatrogenic stroke and peripheral emboli, carrying an high morbidity and mortality. Transoesophageal echocardiography (TOE) plays a key rule on detecting AAP. The therapeutic approach of this patients (pts) is not well stablished.

Purpose

To evaluate the impact of anticoagulation (ACO) therapy on major events in asymptomatic pts with AAP detected in TOE.

Methods

Single-center retrospective study of consecutive patients submitted to TOE between 2010 and 2019 with documentation of AAP. Plaques were described as complex (1) &gt;4mm, (2) ulcerated and (3) mobile thrombi. The plaque location was also documented. We consulted pts data charts for clinical characterization and events recording during the follow up. Major events were defined as stroke, bleeding, hospital admissions (either cardiovascular (CV) and non-CV) and death. Statistical analysis was performed using Cox regression and Chi-square tests.

Results

We enrolled 177 pts with a mean age of 70±10.5 years, 63.8% males, 31.1% diabetic, 73.4% hypertensive, 54.2% with dyslipidaemia, 62.7% obese, 25.4% with peripheral arterial disease, 25.9% with previous stroke and 55.4% with supraventricular arrhythmia. Most of pts had plaques &gt;4mm (80.8%), mobile thrombi in 11.9% and ulcerated plaques in 7.3%; most of the plaques were located in proximal descending aorta (50.3%) and aortic cross (38.4%). Regarding baseline therapy, 52% were under ACO and 50.3% under statin. The main indication of ACO was atrial fibrillation (45.8%).

During follow up (mean time: 1613±1255 days), 61.5% pts died (10.7% from CV causes, 13% with unknown cause), 17.5% had a stroke, 5.7% had other embolic event (lower limbs emboli, unilateral amaurosis and ischemic colitis). Bleeding occurred in 18.3% pts; 47% pts were hospitalized (28.3% from CV cause).

Adjusting for age and comorbidities, there were no significant differences between the group with and without ACO. ACO therapy prevented death from any cause, being also an independent predictor (p=0.08, OR 0.489, IC 95% 0.288–0.831) when adjusted for comorbidities and age. ACO was associated with bleeding events (p=0.003), but not with stroke or hospitalization from any cause (p=NS).

Conclusion

In this subset of pts, ACO therapy prevented death from any cause in pts with AAP. This may have therapeutic implications when approaching this pts, although larger studies to confirm these results are needed.

Funding Acknowledgement

Type of funding sources: None. Non-CV death and anticoagulation

Modified CHA2DS2-VASc can predict mortality in COVID-19 patients admitted to the emergency department

Introduction

CHA2DS2-VASc score is used to determine the thromboembolic risk, but its prognostic value has been demonstrated in several cardiovascular (CV) diseases. Except for female gender, many CV risk factors comprising this score are recognized as risk factors for mortality in COVID-19. Cetinak G. et al demonstrated the ability of modified CHA2DS2-VASc (M-CHA2DS2-VASc) to predict mortality in COVID-19, which is based on changing gender criteria from female to male.

Purpose

To evaluate the prognostic value of a M-CHA2DS2-VASc score to predict pulmonary embolism (PE) and mortality in pts with COVID-19 admitted at the emergency department (ED).

Methods

Retrospective study of pts admitted to the ED between June 2020-January 2021, who underwent computed tomography pulmonary angiography (CTPA) due to PE suspicion. Pts were stratified into 3 M-CHA2DS2-VASc risk groups: lower (0–1), intermediate (2–3) and high risk (≥4). Kruskal-Wallis and X-square test were used to compare score risk groups. Logistic regression was used to determine predictors of PE and mortality. ROC curve was performed to evaluate the discriminative power of the score.

Results

We included 300 pts: median age 71 years, 59% male. Hypertension (59%) chronic kidney disease (CKD, 33%), dyslipidemia (32%) and diabetes (28%) were the most common comorbidities. PE was diagnosed in 46 pts (15%). We found no difference in PE incidence according to M-CHA2DS2-VASc groups (p=0.531) and it showed no predictive value for PE (OR: 1.050, p=0.596). The AUC of M-CHA2DS2-VASc was 0.52, suggesting no discriminative power to predict PE.

Regarding mortality, M-CHA2DS2-VASc score was higher in non-survivors COVID-19 pts than in survivors [4 (IQR 3–5) vs 2 (1–4), respectively, p<0.001]. A multivariate logistic regression analysis was performed for mortality based on M-CHA2DS2-VASC, troponin, CKD and smoking history, and only M-CHA2DS2-VASc was identified as an independent predictor of mortality (OR: 1.406, p=0.007). Kaplan-Meier showed that M-CHA2DS2-VASc score was associated with mortality: the survival rate was 92%, 80% and 63% in the lower, intermediate and higher M-CHA2DS2VASc score risk group (logrank test p<0.001; Fig. A).

Most of the pts in the cohort were hospitalized (83%), but 21 pts (17%) discharged from the ED. Among these pts, 33% (n=17) had low risk, 37% (n=19) intermediate risk and 29% (n=15) high risk for mortality according to the M-CHA2DS2VASc score. The Kaplan-Meier individual survival analysis for hospitalized patients (Fig. B) and for those discharged from the ED (Fig. C) showed that M-CHA2DS2-VASc score had a good discriminative ability to predict short-term mortality for both groups (logrank test p<0.001 and p=0.007, respectively).

Conclusion

Considering the lack of validated scores to predict mortality in COVID-19 pts, the M-CHA2DS2-VASc might be a simple tool to predict short-term mortality in these pts, irrespectively of the need for hospitalization or not.

Funding Acknowledgement

Type of funding sources: None.

New foundational therapy in heart failure with reduced ejection fraction: should we keep following the 2016 European Society of Cardiology Heart Failure Guideline in 2021?

Introduction

The 2016 European Society of Cardiology Heart Failure Guidelines (2016 HF GL) suggest sequential therapy initiation with angiotensinogen converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), beta-blocker (BB) and mineralocorticoid receptor antagonist (MRA) for patients with heart failure with reduced ejection fraction (HFrEF). Since their publication, major trials established the benefit of sacubitril/valsartan (ARNi) and SGLT2 in HFrEF, and ARNi are suggested to replace ACEi/ARB as first line therapy. So, with HFrEF foundational therapy evolvement, the 2016 HF GL sequential therapy initiation algorithm has been raised into question.

Purpose

To compare in the real-world practice, the effect on all-cause mortality of the simultaneous use of every pharmacological class currently included in the HFrEF foundational therapy with conventional sequential therapy.

Methods

A population of consecutive patients (pts) included in a post-discharge structured follow-up programin in a tertiary center was analyzed. Two groups were defined: 1) patients medicated with all pharmacological classes considered the HFrEF foundational therapy (ARNi, BB, MRA and SGLT2 inhibitor), independently of the dosages – “FT group”; 2) patients medicated with ACEi/ARB, BB and MRA on maximal tolerated doses – “2016 HF GL group”. Pts under other therapeutical combinations were excluded. The study groups were compared with Chi-square and Mann-Whitney tests. Impact on all-cause mortality was established with Kaplan-Meier survival analysis and multivariate Cox regression after adjustment for age, sex and baseline creatinine, NYHA functional class and LVEF.

Results

From 2016 to February 2021, a total of 101 pts with HFrEF were included and followed for 25±16 months. 54 pts were included in the FT group and 47 in the 2016 HF GL. The study population (69.3% males, 64.6±11.4 years) were mainly in NYHA functional class II (48%) and III (48%). The most common HF aethiologies were ischemic heart disease (49.5%) and dilated cardiomyopathy (30.7%), median LVEF was 26% and 22% were under CRT. Baseline characteristics were similar between groups, except for diabetes (more common in FT group, 70 vs 22%, p&lt;0.001). All-cause mortality rate during follow-up was significantly different between two groups: 1.9% in FT group and 17% in the HF GL group (p: 0.047) – Figure 1. The implementation of all foundational therapy classes was an independent protective factor for all-cause mortality (HR 0.41; IQR 0.004–0.468; P: 0.010) in multivariate Cox regression.

Conclusion

This real-world study suggests that conventional sequential therapy suggested by the 2016 HF GL may be less effective on reducing all-cause mortality in HFrEF than simultaneous use of all pharmacological classes that nowadays compose the foundation therapy. These results support the hypothesis of promoting early introduction of all therapy classes followed by a tailored uptitration may be beneficial.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Long-term durability of transcatheter aortic valve replacement: outcomes from a contemporary cohort from a tertiary reference center at 5-years and beyond

Background and aim

Long-term data on the durability of transcatheter heart valves is scarce. This is of particular interest as indications expand to younger and lower surgical risk patients. We sought to assess the incidence of long-term structural valve dysfunction (SVD) and bioprosthetic valve failure (BVF) in a cohort of patients with TAVR who reached at least 5-year follow-up, as compared to surgical aortic valve replacement (SAVR), performed within the same time-frame at the same institution.

Methods and results

Consecutive patients with at least 5-year available follow-up, who underwent TAVR between November 2008 to December 2015 in a tertiary single center, were included. From a group of 246 patients undergoing TAVR, 126 had available follow-up data (age at implantation: 83.0 [77.8–87.0] years; EuroScore II: 4.54 [2.60–6.29]%; follow-up: 5.94 [5.06–7.67] years). First generation Corevalve® and Sapien® prosthesis were implanted in 56% and 38% patients, respectively.

SVD and BVF were defined according to the new consensus statement from the EAPCI endorsed by the ESC and the EACTS. Mean transaortic pressure gradients decreased from 53.2±1.3 mmHg (pre-TAVR) to 10.4±0.4 mmHg (at discharge or up to one-year after TAVR, p&lt;0.001), and there was a small non-significant increase at the fifth-year and the last available follow-up (11.2±0.6 mmHg; 14.7±1.8 mmHg, respectively). Moderate and severe SVD were reported in 12 and 4 patients, respectively (8-year cumulative incidence function to SVD: 2.67%; 95% CI, 2.12–3.89). Of these 8 had BVF, 7 of them with hospitalization for acute heart failure. A total of 4 patients died and none required reintervention (redo TAVR or SAVR). BVF for non-SVD were observed in 4 patients (2 subclinic thrombosis successfully treated with anticoagulation and 2 paravalvular regurgitation due to endocarditis).

As comparator, from a cohort of 587 patients submitted to biological SAVR, 247 (age 75.0 [70.0–79.0] years; EuroScore II 1.43 [1.06–2.17]%) had available long-term follow-up (6.89 [6.08–8.19] years). Moderate and severe SVD were reported in 42 and 3 patients, respectively (8-year cumulative incidence function to SVD: 3.13%; 95% CI, 2.45–4.21). These events were clinically relevant (BVF) in 19 of them: 8 performed TAVR valve-in-valve procedures and 3 redo SAVR. At the fifth-year of follow-up the incidence of SVD was not statistically different between TAVR (8%) and SAVR (15%), with a p for comparison of 0.137.

Conclusions

In our population of patients with symptomatic severe aortic stenosis treated with first-generation percutaneous bioprostheses, TAVR was associated with a low incidence of BVF and SVD at the long-term follow-up. These outcomes seem indistinct from those occurring in patients submitted to conventional SAVR

Funding Acknowledgement

Type of funding sources: None. KM curve reporting probability of SVD

Wells and Geneva decision rules to predict pulmonary embolism: can we use them in Covid-19 patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Pulmonary embolism (PE) is a recognized complication of SARS-COV2 infection due to hypercoagulability. Before the COVID era, the need for computed tomography pulmonary angiography (CTPA) to rule out PE was determined by clinical probability, based on Wells and Geneva scores, in association with D-dimer measurements. However, patients with SARS-COV2 infection have a pro-thrombotic and pro-inflammatory state which may compromise the usefulness of these algorithms to select patients for CTPA. 

Purpose

 To evaluate the accuracy of the Wells and Geneva scores to predict PE in patients with SARS-COV2 infection.

Methods

 Retrospective study of consecutive outpatients with SARS-COV2 infection proved by positive PCR who underwent CTPA due to suspected PE. The Wells and Geneva scores were calculated and the area under the curve (AUC) of the receiver operating characteristic curve was measured.

Results

 We enrolled 235 patients (61% males, mean age 69.10 ± 16.69 years) and the incidence of pulmonary embolism was 15% (35 patients). In patients with PE, emboli were located mainly in segmental arteries (60%) and bilaterally (46%). Patients with PE were older (mean age 75.06 ± 2.23 vs. 68.06 ± 1.21 years, p = 0.022), and did not differ in sex or risk factors for thromboembolic diseases from the non-PE group. Patients with PE had higher D-dimer levels (median 15.41 mg/dl, IQR 1.17 – 20.00) compared to patients without PE (median 5.99 mg/dl, IQR 0.47 – 2.82, p &lt; 0.001).

 There was no statically significant difference between the average Wells score in patients with PE and without PE (1.04 and 0.89 respectively, p = 0.733) and the AUC demonstrated that the Wells score had no discriminatory power (AUC = 0.52). Within patients with PE, 19 patients had a Wells score of zero. Regarding the Geneva score, there was also no difference between the average score in patients with and without PE (4.20 vs 3.93 respectively, p = 0.420). AUC for Geneva score was 0.54.

Clinical probability combined with D-dimer measurement had a 100% sensitivity for both Wells and Geneva scores, but a specificity of 10% and 11%, respectively. 

Conclusion

 PE diagnosis may be challenging in patients with SARS-COV2 infection since both conditions may have similar signs and symptoms and may be associated with increased D-dimers. According to our results, traditional clinical prediction scores have little discriminatory power in these patients and a higher D-dimer cut-off should be considered to better select patients for CTPA to minimize radiation exposure and contrast-related complications in COVID-19 patients.

Patients undergoing invasive coronary angiography after a positive single-photon emission computed tomography or a positive stress cardiac magnetic resonance - What to expect at the cath lab

Funding Acknowledgements

Type of funding sources: None.

Background

 Randomized controlled trials comparing stress cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) suggest similar diagnostic accuracy for detecting obstructive coronary artery disease (CAD). However, there are few data on whether or not this remains true in routine clinical practice.

The aim of this study was to assess the clinical and angiographic characteristics of patients undergoing invasive coronary angiography (ICA) after a positive stress CMR or positive SPECT, and to compare their positive predictive value with published results from the CE-MARC trial.

Methods

In this retrospective tertiary-center analysis, we included 429 patients (mean age 67 ± 10 years, 28% women, 42% diabetic) undergoing ICA between January 2016 and December 2020, after a positive stress CMR or positive SPECT. Regarding stress test, an adenosine protocol was performed in all stress CMR and in 76.4% (n = 272) of stress SPECT. 

Stress test results, including ischemia location and severity, were classified as reported by their primary readers. Patients with missing data on key variables, and those in whom microvascular disease was considered likely in the original stress test report were excluded. Obstructive CAD was defined as any coronary artery stenosis ≥ 50% in a vessel compatible with the ischemic territory on stress testing.

Results

Out of the total 429 patients, 356 (83%) were referred after a positive SPECT, and 73 (17%) after a positive stress CMR. Patients did not differ regarding age, cardiovascular risk factors, previous revascularization or left ventricular dysfunction, but patients with SPECT were more frequently male (p = 0.046). Overall, 320 patients (75%) had obstructive CAD on ICA. The prevalence of obstructive CAD was similar in patients with positive SPECT vs. positive stress CMR (76.1% vs. 80.8%, respectively, p = 0.385). There were also no significant differences in the prevalence of left main or 3-vessel disease (9.0% vs. 9.6%, p = 0.871, and 19.7% vs. 23.3% p = 0.483, respectively). Revascularization was performed or planned in 59.3% of patients in the SPECT group, and 52.1% of those in the stress CMR group (p = 0.255). The positive predictive values of both techniques were similar to those reported in the CE-MARC trial (Figure), and would increase to 88.1% and 89.4% for SPECT and stress CMR, respectively, if patients reported as having only mild ischemia were excluded.

Conclusion

In this tertiary center analysis, stress CMR and SPECT showed similar positive predictive values, comparable to those reported in the CE-MARC trial.

Long-Term outcome of ventricular tachycardia catheter ablation in ischemic heart disease patients using a high-density mapping substrate-based approach: a prospective cohort study

Funding Acknowledgements

Type of funding sources: None.

Introduction and objective

Radiofrequency catheter ablation (RCA) for ventricular tachycardia (VT) in patients with ischemic heart disease (IHD) is associated with a reduced risk of VT storm and implantable cardioverter defibrillator (ICD) shocks. We aim to report the long-term outcome after a single RCA procedure for VT in patients with IHD using a high-density substrate-based approach.

Methods

We conducted a prospective, observational, single-centre and single-arm study involving patients with IHD, referred for RCA procedure for VT using high-density mapping catheters. Substrate mapping was performed in all patients. Procedural endpoints were VT noninducibility and local abnormal ventricular activities (LAVAs) elimination. The primary end point was survival free from appropriate ICD shocks and secondary end points included VT storm and all-cause mortality.

Results

Sixty-four consecutive patients were included (68 ± 9 years, 95% male, mean ejection fraction 33 ± 11% , 39% VT storms, and 69% appropriate ICD shocks). LAVAs were identified in all patients and VT inducibility was found in 83%. LAVAs elimination and noninducibility were achieved in 93.8% and 60%, respectively. After a mean follow-up of 25 ± 18 months, 90% and 85% of patients are free from appropriate ICD shocks at 1 and 2 years, respectively. The proportion of patients experiencing VT storm decreased from 39% to 1.6%. Overall survival was 89% and 84% at 1 and 2 years, respectively.

Conclusions

RCA of VT in IHD using a high-density mapping substrate-based approach resulted in a long-term steady freedom of ICD shocks and VT storm. Abstract Figure. Appropriate shock & all cause mortality

Catheter ablation of long-standing persistent atrial fibrillation: the ugly type of AF?

Funding Acknowledgements

Type of funding sources: None.

Introduction

In atrial fibrillation (AF) patients (pts), catheter ablation (CA) by isolating pulmonary veins (PVI) is the most effective therapeutic option in order to maintain sinus rhythm. The success rate of CA relies on type and duration of AF, being more successful in pts with paroxysmal AF and presenting suboptimal success in pts with long-standing persistent AF (LSPAF, &gt;12 months).

Purpose

To evaluate the success of AF ablation, particularly in LSPAF.

Methods

Single-center prospective study of pts submitted to CA between 2004 and 2020. The strategy, regardless of the type of AF, was based on PVI, complemented by cavo-tricuspid isthmus line (CTI) in pts with history of flutter. Additional CA strategies were selectively considered in pts with stable atypical flutter conversion, persistent triggers or no electrograms in the VPs. Pts were monitored with Holter/7-day event loop recorder (3, 6, 12 months and annually up to 5 years). Success was assessed from the 90th day after ablation, with the absence of recurrences of any sustained atrial arrhythmias (&gt; 30 sec). Cox regression and Kaplan-Meier survival were used to compare the success of ablation as a function of the clinical type of AF.

Results

862 pts were submitted to AF ablation (67.3% male, mean age of 58 ± 0.41 years), including 130 pts (15.1%) with LSPAF, 63.3% with paroxysmal AF and 21.6% with short-duration persistent AF (SDPAF). In LSPAF, PVI was performed with irrigated catheter in 26.4%, PVAC in 39.5% and cryoablation in 34.1%. With a mean follow up period of 838 (IQ 159-1469) days, the 3-year success rate after a single procedure was 54.1% in LSPAF, compared to 72.4% in paroxysmal AF and 61.6% in SDPAF (LogRank - p &lt; 0.0001 - figure 1). The risk of arrhythmic recurrence was 37% higher in patients with LSPAF comparing with other groups (HR 0.63 CI 95% 0.43-0.92, p 0.016).

However after a mean of 1.17 procedures/patients, the success difference between groups was not detect (LogRank – p = 0.112 – figure 2). With additional ablation procedures (REDO), the success rate at 3 years was 82.9% LSPAF pts, compared 88.2% in paroxysmal AF pts and 83.6% in SDPAF pts.

In LSPAF pts, different ablation techniques did not predict arrhythmic recurrence. Regarding comorbidities, higher prevalence of peripheral arterial disease (PAD, p = 0.005) a higher NT-proBNP (p = 0.006) and left auricular volume (p = 0.045) were associated with arrhythmic relapse.

Conclusions

AF ablation is more effective when performed earlier in the natural history of the disease. However, even in LSPAF pts, with additional procedures an acceptable rate of success can be achieve, independently from the ablation techniques. Abstract Figures 1 and 2: Success of AF ablation

Can we use the CHA2DS2VASc score in Atrial Flutter?

Funding Acknowledgements

Type of funding sources: None.

Introduction

CHA2DS2VASc score is a well stablished prognostic score in atrial fibrillation population. However, considering patients with isolated atrial flutter no prognostic score are defined, regarding the embolic risk of this population.

Purpose

To evaluate the capacity of CHA2DS2VASc score to predict cardiovascular death and major adverse cardiovascular events (MACE) in flutter patients (pts).

Methods

Single-center retrospective study of pts submitted to CTA between 2015 and 2019, comprising two groups: I – pts with lone AFL; II – patients with AFL and prior AF. Clinical records were analyzed to determine the occurrence of MACE during the long-term follow up, defined as death (of cardiovascular or unknown cause), stroke, clinically relevant bleed or hospitalization due to heart failure or arrhythmic events. CHA2DS2VASc score was categorized into 3 groups: 0-1; 2-3; &gt;4. Kaplan Meier survival curves were used to estimate the risk of events and the groups were compared using uni- and multivariate Cox regression analyses.

Results

A total of 476 pts (66 ± 12 years, 80% males) underwent CTA: group I – 284 pts (60%), II – 192 pts (40%). Baseline characteristics were similar between groups, except for age with group I pts being older (68 ± 12, 64 ± 11, p &lt; 0.01). The mean baseline CHA2DS2VASc was 2.3 ± 1.5 and the median post-CTA follow-up was 2.8 year. Considering global population, CHA2DS2VASc score was an independent predictor of cardiovascular death (OR: 1.49 95%CI 1.09-1.79, p = 0.08) and was a predictor of MACE even after adjustment for the diagnose of prior AF (OR 1.88, 95% IC 1.094-3.249, p = 0.022). Considering only the pts in group I CHA2DS2VASc score was a predictor of MACE (OR 3.03, 95% CI 1.112-8.278, p = 0.03) after adjustment for sex and age. Regarding the different MACE components, the score was a predictor of stroke (OR 4.45, IC 1.66-13.39, p = 0.04). In flutter pts CHA2DS2VASc score did not predict cardiovascular death.

Conclusions

 In our population CHA2DS2VASc score was able to predict MACE events and stroke in patients with isolated atrial flutter. This suggests that in the future CHA2DS2VASc score could be applied to establish embolic risk in atrial flutter. Abstract Figure.

The pacemaker ventricular lead position and outcomes in patients upgrading to crt

Funding Acknowledgements

Type of funding sources: None.

Introduction

 

Adverse hemodynamic effects of right ventricular pacing are known, and the optimal right ventricular lead position is still being a matter of debate. According to the guidelines, upgrade to cardiac resynchronization therapy (CRT) is recommended in patients with indication for pacemaker and left ventricular ejection fraction less than 50% or who need more than 40% of ventricular pacing.

Purpose

 

To compare clinical outcomes and ejection fraction in patients with previous pacemaker (apical versus septal right ventricular pacing) who are upgrated to CRT. 

Methods

 

Single-center retrospective study of 94 consecutive patients who had previous pacemaker and upgraded to CRT over a 4-year period. Of these patients, 64 had previous apical lead pacemaker and 30 had previous septal lead pacemaker. Data on comorbidities, New York Heart Association (NYHA), left ventricular ejection fraction and hospitalizations due to heart failure were collected.

The results were obtained using Chi-square, Mann-Whitney and t-test.

Results

Patients with septal pacemaker had significantly more diabetes (p = 0.04) and chronic obstructive pulmonary disease (p = 0.01), tended to be more symptomatic (p = 0.198) and had more days of hospitalization before and after pacemaker implantation (12 ± 3 versus 7 ± 2 days and 8 ± 4 versus 3 ± 1 days, respectively), mostly due heart failure decompensation. 

Although there were no significant differences in the initial ejection fraction in patients with apical or septal pacemaker implantation (31.2 ± 1.2% and 29.1 ± 1.5%, respectively, p = 0.323), the time to upgrade to CRT was significantly shorter in patients with septal pacemaker implantation (1999 ± 227 days versus 3005 ± 279 days, p = 0.005). 

After upgrading to CRT, patients with apical lead had a significant increase in ejection fraction (8.2%, p = 0.011), while patients with septal lead had a non-significant improvement of ejection fraction (4.5%, p = 0.448). In both, apical and septal lead patients, there was a significant improvement in NYHA class after upgrade to CRT (p = 0.03 and p = 0.02, respectively).

Conclusion

 

Although patients with septal lead had more comorbidities and hospitalizations due to heart failure, they do not benefit from the upgrade to CRT, unlike what happens in patients with apical lead. These findings can be explained by the fact that the septal lead minimizes ventricular desynchrony induced by right ventricular pacing.

Long-term risk of major cardiovascular events after cavotricuspid isthmus ablation: when and in whom to discontinue oral anticoagulation?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cavotricuspid isthmus ablation (CTA) is the 1st line therapy to accomplish rhythm control in typical atrial flutter (AFL). Several studies have shown that AFL is frequently associated with AF, which may be silent, posing the patient at risk of systemic embolism. Nowadays, there are no formal recommendations for OAC after CTA in patients with isolated AFL.

Aim

To determine the risk of MACE after CTA and compare: 1) the presence of concomitant AF, 2) concomitantly performing PVI and 3) persistence on OAC.

Methods

Single-center retrospective study of  pts submitted to CTA between 2015 and 2019, comprising 3 groups: I – pts with lone AFL; II – patients with AFL and prior AF submitted to CTA only; and III – patients with AFL and prior AF submitted to PVI and CTA. Clinical records were analyzed to determine the occurrence of MACE - death (of CV or unknown cause), stroke, clinically relevant bleed or hospitalization due to HF or arrhythmic events. Long-term OAC was defined as its persistence over 18 months after CTA. Kaplan Meier survival curves were used to estimate the risk of events and the groups were compared using uni- and multivariate Cox regression analyses.

Results

A total of 476 pts (66 ± 12 years, 80% males) underwent CTA: group I – 284 pts (60%), II – 109 pts (23%) and III – 83 pts (17%). Baseline characteristics were similar between groups, except for age with group I pts being older (68 ± 12, 67 ± 11, 61 ± 11, p &lt; 0.03). The mean baseline CHA2DS2VASc was 2.3 ± 1.5 and the median post-CTA follow-up was 2.8 year. The 1-, 3- and 5-years MACE risk was 7%, 21% and 32%, respectively and did not differ significantly between groups. OAC was suspended on the long-term in 105 pts (23%), at a mean of 241 days post-CTA. Suspension of OAC was significantly associated with lower MACE risk (HR: 0.26, 95%CI 0.12-0.56, p = 0.001). This effect was independent of the age and CHA2DS2VASc. The prognostic benefit of OAC suspension was driven by the group I and was not verified in patients with concomitant AF. In group I, withdraw of OAC (56 pts - 27%) was associated with a 70% relative risk reduction in the 5-year MACE risk (16% vs 43%, HR: 0.30, 95%CI 0.13-0.69, p = 0.005). In group I, OAC was suspended in patient who were younger (65 ± 11 vs. 69 ± 12, p = 0.002), had lower CHA2DS2VASc (1.9 ± 1.6 vs. 2.7 ± 1.4, p &lt; 0.001) and less often had cerebral vascular disease (1% vs. 8%, p = 0.036), HF (14% vs. 38%, p = 0.001), ischemic cardiomyopathy (9% vs. 19%, p = 0.04) and HTN(61% vs. 75%, p = 0.019).

Conclusions

In pts with AFL submitted to CTA, the long-term risk of MACE is frighteningly high, even in the ones without prior documentation of concomitant AF. Pts with prior AF presenting at the electrophysiological procedure in typical AFL and submitted just to CTA were not significantly harmed, from a prognostic perspective. In pts with lone AFL submitted to successful CTA, it may be reasonable to suspend OAC within 18 months provided that the concomitant AF is carefully excluded. Abstract Figure.

Electrocardiographic markers of incident atrial fibrillation in patients with cryptogenic stroke

Funding Acknowledgements

Type of funding sources: None.

Introduction

Prolonged screening of AF in patients (pts) with cryptogenic stroke (CS) is recommended and electrocardiographic markers of atrial remodeling, like p-wave dispersion, have been described in literature. Electrocardiographic changes in pts with CS to predict AF in the follow up are not well-established.

Purpose

To identify ECG predictors of AF in a subset of pts with cryptogenic stroke.

Methods

We prospectively included consecutive pts admitted with CS. A surface 12-lead ECG was performed at admission, recorded at 25 mm/second and 10 mV/cm with commercially available imaging system. P-wave analysis of maximum (P max) and minimum (P min) duration, p-wave dispersion (PWD, defined as the difference between the P max and P min, being abnormal if &gt; 40 msec) and amplitude were evaluated by a two independent operator. P-wave axis was determined by an automated mode available in the equipment. ROC curve was analyzed to determine the optimal cut-off values.

Results

We enrolled 105 pts (55.2% males), with mean age of 68.18 ± 8.83 years, 79% had hypertension, 18.1% had diabetes, 44.8% with dyslipidemia, 21% current smokers.

During follow up period, 18 pts (17.1%) developed AF. We found that only PWD (AUC 0.706, IC95%: 0.564-0.848, p = 0.006) and P-wave axis (AUC 0.715, IC95%: 0.870-0.860, p = 0.004) were strong predictors of AF. PWD cut-off of 47.50 presented a sensitivity of 77.8% and specificity of 59.8% and P-wave axis cut off value of 75.50 had a specificity of 95.4%. Age (p = 0.032) and current smoking (p = 0.014) were associated with occurrence of AF during the follow up.

  Conclusion: PWD and P-wave axis predicted incident AF in this subset of pts with cryptogenic stroke. The ECG may be a toll to identify pts at risk of developing AF, although larger studies are needed to confirm these results. Abstract Figure.

Early discharge after cryoablation procedure: is it safe?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Discharge after overnight hospital stay is standard procedure in patients submitted to elective atrial fibrillation (AF) ablation. Taking into consideration the low rate of cryoablation procedure complications could the same day discharge be an option?

Purpose

To access the safety of same day discharge of patients submitted to AF cryoablation.

Methods

Single-center retrospective study of consecutive pts admitted to elective AF cryoablation in a tertiary center between February 2017 and November 2020. Patients were divided into two groups: same day discharge and next day discharge. Only patients submitted to ablation until 4 p.m. were included. Complication rates were obtained up to six months after the procedure. Complications were defined as death, pericardial tamponade, hematoma requiring evaluation and/or intervention, major bleeding requiring transfusion, hospital admission related to the procedure.

Results

One hundred fifty-four pts were included, with a mean age of 61 ± 10.9 years, 66.2% were males, 18.2% with diabetes, 65.6% with dyslipidemia, 77.9% with hypertension, 10.4% with chronic kidney disease KDIGO stage 3 or more. Median follow-up of 436 (IQ 178 – 729) days. Most of the pts had paroxysmal (73.4%) and persistent short duration AF (23.4%). Sixty-two pts (40.3%) were early discharged and there were no differences between the two groups regarding epidemiological and clinical characteristics (p = NS).

A very low rate of complications in both groups was observed, occurring in 6.5% of pts with early discharge and in 8.7% of pts in overnight stay, without statistical significance between the two groups (p = 0.61). The most frequent complications were local hematoma (5 pts, 2 in early discharged group), pericardial effusion (3 pts, all in overnight stay), femoral pseudo-aneurism (2 pts, 1 in each group) and arteriovenous fistula (1 pt in overnight stay group). The type of complications did not differ between the two groups (p = 0.51). Two pts died during the follow up, unrelated with the procedure.

In addition, no difference in success rate and arrhythmic recurrence was observed between the two groups. (p = NS)

Conclusion

Our study suggests that is safe to early discharge pts submitted to AF ablation, reducing the hospital stay length in selected pts. Larger studies are needed to confirm this data before routine implementation of this strategy.

Withdrawal of anti-arrhythmic therapy after cavo-tricuspid isthmus ablation of typical atrial flutter

Funding Acknowledgements

Type of funding sources: None.

Introduction

Medical management of typical atrial flutter (AFL) is sometimes unsuccessful and may have adverse effects. Symptom control using radiofrequency cavo-tricuspid isthmus ablation (CTA) is a feasible alternative, given the fact that it is a simple procedure with a low rate of complications. However, in some patients (pts), new atrial arrhythmias may develop and the decision of anti-arrhythmic therapy (AAT) withdrawal is usually patient-based.

Purpose

To predict the recurrence of atrial arrhythmias (AR) after CTI ablation between pts that suspended AAT and those that maintained AAT.

Methods

Single-center retrospective study of pts with typical AFL submitted to ablation between 2015 and 2019. Pts clinical characteristics, current and follow up therapy were collected. Holter and/or 7-day event loop recorder were performed during the follow up to identify AR. For statistical analysis, we applied Chi-square, Mann-Whitney and Cox regression to identify predictors of AR.

Results

CTA ablation was performed in 476 pts (mean age: 66.3 ± 11.7 years, 79.8% males). At time of ablation most pts were in EHRA II class (70.8%) and 44.6% of pts had at least mild left atrial dilatation on transthoracic echocardiography. The mean follow up time was 2.8 years.

Two-hundred sixty-nine pts (57,6%) were under anti-arrhythmic therapy (AAT) before the ablation. After the procedure, 58 pts withdrawn AAT before AR and 8 pts after AR. During the follow-up period, we observed AR of typical AFL in 17 pts (3.6%), atypical AFL in 35 pts (7.4%) and AF in 118 pts (24.8%).

There were no statistically significant differences regarding AR between pts that maintained and suspended AAT (p = NS). Concerning the pts that suspended AAT, thyroid disfunction (p = 0.012), higher CHADs-VASc score (p = 0.033), ischemic cardiomyopathy (p = 0.001) and tobacco abuse (p = 0.005) were predictors of AR, being the last two also independent predictors (HR 0.243; 95%CI 0.76-0.778, p = 0.017; HR 4.449; 95%CI 1.128-17.553, p = 0.033, respectively). 

Conclusion

After CTA ablation, AF is the most frequent recurrent arrhythmia. Interestingly, the withdrawn of AAT didn’t seem to predict the recurrence of arrhythmic events. The decision of stopping AAT must be individualized regarding patients’ clinical characteristics. Abstract Figure 1: AAT withdrawal and AR

Typical atrial flutter ablation and predictors of events in the follow-up

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cavotricuspid isthmus ablation (CTA) is considered the main treatment for rhythm control in patients (pts) with typical atrial flutter (AFL). Although there is an established risk for embolic events in atrial fibrillation (AF), the results are not standardized for typical AFL. Currently, anticoagulation in AFL pts submitted to ablation is not consensual.

Purpose

To determine the incidence and predictors of major cardiovascular events (MACE) of pts submitted to CTA of typical AFL.

Methods

Single-center retrospective study of patients (pts) submitted to CTA between 2015 and 2019, comprising three groups: I – pts with lone AFL; II – patients with AFL and prior AF submitted to CTA only; and III – patients with AFL and prior AF submitted to IVP and CTA. Clinical records were analyzed to determine the occurrence of MACE during the long-term follow up, defined as death (of cardiovascular or unknown cause), stroke, clinically relevant bleed or hospitalization due to heart failure or arrhythmic events. Kaplan Meier survival curves were used to estimate the risk of events and the groups were compared using uni- and multivariate Cox regression analyses

Results

A total of 476 pts (66 ± 12 years, 80% males) underwent CTA: group I – 284 pts (60%), II – 109 pts (23%) and III – 83 pts (17%). Baseline characteristics were similar between groups, except for age with group I pts being older (68 ± 12, 67 ± 11, 61 ± 11, p &lt; 0.03).

At presentation, the majority of the pts had palpitations (70.4%) and mild symptoms (70.8%). HTN and dyslipidemia were the most frequent cardiovascular risk factors, 69.5% and 53.9%, respectively, and heart failure was not frequent (27.7%) with only 5.4% of pts with LVEF &lt; 30% and 12.4% with left atrium &gt; 50ml/m2.

During a mean follow-up of 2.8 years, the incidence of MACE events was 102 (21,4%). Regarding MACE components: 54 pts (11.5%) died from cardiovascular death, 20 pts had stroke (4.5%), 13 (3.8%) had a clinically relevant bleeding event, and 51 pts (11.4%) were hospitalized due to heart failure or arrhythmic events.

On univariate analysis, arterial peripheric disease (p = 0.018), HTN (p = 0.046), chronic kidney disease (p &lt;0.001), chronic pulmonary disease (p = 0.0024), heart failure (p &lt;0.001), cerebrovascular disease (p 0.029), body mass index (p = 0.01), age (p &lt;0.001), CHADsVASc score (p &lt; 0.001) and left atrial diameter (p= 0.01) were associated with the occurrence of MACE.

However only age (HR 1.073; 95%CI 1.03-1.06, p &lt; 0.001) and chronic kidney disease (HR 0.37; 95%CI 0.186-0.765, p = 0.007) were independent predictors of major events.

Conclusions

In our cohort of pts with AFL, stroke and bleeding occurred in a minority of pts. Age and chronic kidney disease predicted MACE events during follow-up. Abstract Figure. CKD as FLA predictor

Should we redifine Hypertensive response in stress test to better predict cardiovascular risk?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Systolic blood pressure (SBP) rise during exercise is normal, but some patients present with hypertensive response to exercise (HRE). The clinical implication of such phenomenon is not fully elucidated, and treatment strategies are still uncertain.

Purpose

To evaluate the relationship between HRE and the development of major cardiovascular events (MACE) - death, acute coronary syndrome (ACS) and stroke.

Methods

Single-center retrospective study of consecutive patients submitted to exercise test (ET) from 2012 to 2015. Patient’s demographics, baseline clinical characteristics, vital signs during ET and MACE occurrence during follow-up were analysed. HRE was defined as a peak systolic blood pressure (PSBP) &gt;210 mmHg in men and &gt;190 mmHg in women, or a rise of the SBP of 60 mmHg in men or 50 mmHg in women or as a diastolic blood pressure &gt;90 mmHg or a rise of 10 mmHg.

Results

We included 458 patients with HRE (76% men, 57.5 ± 10.83 years). The most frequent comorbidities were hypertension (83%) and dyslipidaemia (61%). During a mean follow-up of 60 ± 2 months, the incidence of MACE was 9.2% with ACS being the most frequent (4.2%), followed by mortality (3.8%) and stroke (2.1%). Patients with inconclusive ET had a fourfold higher risk of acute coronary events (OR 4.1, CI 95% 1.55-11.14, p = 0.005). Baseline SBP and PSBP were predictors of MACE occurrence (OR 1.022, CI 95% 1.004-1.04, p = 0.016, OR 1.031 CI 95% 1.012-1.051, p = 0.001, respectively) and were both associated with cardiovascular hospitalization (p = 0.006; p &lt; 0.001, respectively). PSBP had moderate ability to predict hospitalization of cardiovascular (CV) cause (AUC 0.71, p &lt; 0.001) with a cut-off of 193 mmHg (sensibility 91%, specify 40%) and had moderate ability to predict MACE (AUC 0.67, p &lt; 0.001) with a cut-off of 198 mmHg (sensibility 78.6%, specify 46.1%). Regarding mortality, antihypertensive therapy prior to ET was protective (p = 0.042), with no difference between different classes of drugs.

Conclusion

Our data reveal a high rate of MACE occurrence between patients with HRE. The finding of diagnosed hypertension as a protective factor of stroke may be explained by the cardioprotective effect of antihypertensive drugs. An increased risk of ACS between patients with an inconclusive ET should lead to consider then for further investigation. HRE should be considered as part of CV risk assessment and adjusted lower HRE cut-off values should be considered in order to better predict MACE occurrence, particularly in high risk patients.

Abstract Figure.

Home-based cardiac rehabilitation during COVID-19 pandemic: effectiveness of an educational intervention

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patient education is considered a core component of cardiac rehabilitation (CR) and nowadays, particularly during the COVID-19 pandemic, online education programs are critical. However, the best strategy for implementing these digital programs to increase patients’ adherence and learning is not fully established.

Purpose

To assess the uptake and effectiveness of an educational intervention transmitted through video sessions integrated into a home-based CR program (CR-HB).

Methods

Prospective cohort study including patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB program during COVID-19 pandemic. The CR-HB  program consisted of a multidisciplinary online program with educational videos for pts and family members / caregivers, that aimed to educate on necessary behavioural and lifestyle changes. Weekly, a 15-minute video was uploaded and lectured by the correspondent health professional from the CR team. The educational sessions covered the following topics: COVID-19 and cardiovascular (CV) disease, coronary artery disease, hypertension, dyslipidemia, smoking cessation, diabetes, medical therapy and adherence, healthy diet, exercise and physical activity, sedentary behaviour and sexual dysfunction and CV disease.

At the end of the program we applied a 10 questions questionnaire to evaluate the knowledge of pts about the topics of educational sessions. All the pts answered the questionnaire and results were compared between the pts who attended the educational sessions and the ones who didn’t.

Results

 

116 pts with CV disease were included in the CR-HB program (62.6 ± 8.9 years, 95 males). Almost 90% (n = 103) of the participants had coronary artery disease and the mean LVEF was 52 ± 11%. Obesity was the most common risk factor (75%) followed by hypertension (60%), family history of CV disease (42%), dyslipidemia (38%), diabetes (18%), and smoking (13%).

The pts participated, on average, in 1.45 ± 2.6 education sessions (rate participation of 13.2%). About half of the pts (49%) attended, at least, one session and these pts attended, on average, 3 sessions (2.96 ± 3.0). The questionnaire results were better in pts who attended at least 1 educational session than in those who did not attend any (7.4 ± 1.9 vs 7,1 ± 1.7), however this difference was not statistically significant.

Regarding education status, 33 pts (45.2%) had a bachelor degree and this group of pts had a significant higher result in questionnaire (7.8 ± 1.9 vs 6.7 ± 1.8; p = 0.015) and tended to participate more often in education sessions (2.13 vs 1.6, p = 0.06).

Conclusions

Our study showed a low rate of participation in sessions, highlighting the importance of developing strategies to increase motivation and adherence to online educational programs. Also, more literate patients had significantly greater health knowledge and adherence to educational sessions, suggesting that this population could benefit more from this type of programs.

Cardiovascular risk factor control: is it possible with a home-based cardiac rehabilitation program?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiovascular risk factors (CVRF) control, needing different strategies, through patient education, lifestyle changes and therapeutic optimization is a central core of cardiac rehabilitation. However, further studies are needed to demonstrate effectiveness of home-based Cardiac Rehabilitation (CR-HB) programs in controlling CVRF.  

Purpose

To evaluate the effectiveness of a CR-HB program in controlling cardiovascular risk factors.

Methods

Prospective cohort study including patients who were previously participating in a centre-based CR program and accepted to participate in a CR-HB program due to forced closure of the centre-based CR program for COVID-19 pandemic. The CR-HB consisted of a multidisciplinary digital CR program, including patient regular assessment, exercise, educational, and psychological and relaxation sessions. A structured online educational program for patients and family members/caregivers was provided including educational videos, and powerpoints and webinars. A real time Webinar regarding "nutritional myths and facts" was organized with the duration of 90 minutes as a substitution of the regular face-to-face regular workshop provided at our centre-based CR program. Also, self-control of blood pressure and heart rate and of glycemia in diabetics were promoted, as well as smoking cessation.

To assess the impact of the CR-HB on risk factors control, all the patients were submitted to a clinical and analytical evaluation before and after the end of this at distance program. 

Results

116 cardiovascular disease patients (62.6 ± 8.9 years, 95 males) who were attending a face-to-face CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease. Regarding risk factors, obesity was the most prevalent risk factor (74.7 %) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). 

Regarding the blood pressure control, 80% of the patients stated that almost daily they measured blood pressure at home; baseline systolic pressure decreased from 117 ± 13 to 113 ±12mmHg, p = 0.007, while there was no significant change in diastolic pressure.  

The majority (76%) of diabetic patients said they controlled blood glucose; HbA1c decreased from 6.1 ± 1.1 to 5.9 ± 0.9mg/dL (p = 0.047).

Considering the lipid profile, LDL decreased (from 75 ± 30 to 65 ± 26mg/dL, p = 0.012). The Nt-proBNP also decreased (818 ± 1332 vs 414pg/ml ± 591, p = 0.042). There were no other statistically significant differences concerning risk factors modification. 

Conclusions

Our study showed that a Home-based Cardiac Rehabilitation program can improve or maintain cardiovascular risk factors control, which has important prognostic implications and is frequently a difficult task to achieve.

Hypertensive response in exercise - a tool to predict stroke risk?

Funding Acknowledgements

Type of funding sources: None.

Introduction

There is some evidence suggesting that exaggerated hypertensive response to exercise (HRE) may be associated with higher risk of future cardiovascular events, however the relationship between systolic blood pressure (SPB) during exercise test and stroke is not fully understood.

Purpose

To evaluate the ability to predict the risk of stroke in patients with HRE in exercise test.

Methods

Single-center retrospective study of consecutive patients submitted to exercise test from 2012 to 2015 with HRE to stress test. HRE was defined as a peak systolic blood pressure (PSBP) &gt; 210 mmHg in men and &gt; 190 mmHg in women, or a rise of the SBP of 60 mmHg in men or 50 mmHg in women or as a diastolic blood pressure &gt; 90 mmHg or a rise of 10 mmHg. Patient’s demographics, baseline clinical characteristics, vital signs during the stress test and the occurrence of stroke during follow-up were analysed

Results

We included 458 patients with HRE (76% men, 57.5 ± 10.83 years). The most frequent comorbidities were hypertension (83%), dyslipidaemia (61%), previously known coronary disease (32%), diabetes (28%) and smoking (38%). Atrial fibrillation was present in 5.9% of patients.

During a mean follow-up of 60 ± 2 months, the incidence of stroke was 2.1% (n = 8), all with ischemic origin. Considering the parameters analysed on exercise test, only PSBP demonstrated to be an independent predictor of stroke (HR 1.042, CI95% 1.002-1.084, p = 0.039,) with moderate ability to predict stroke (AUC 0.735, p = 0.0016) with a most discriminatory value of 203 mmHg (sensibility 56%, specify 67%). Regarding baseline characteristics, after age, sex and comorbidities adjustment, previously controlled hypertension was found to be an independent protective factor of stroke (OR 4.247, CI 95% 0.05-0.9, p = 0.036) and atrial fibrillation was an independent predictor of stroke occurrence (HR 8.1, CI95% 1.4-46.9, p = 0.018). Atrial fibrillation was also associated with hospitalization of cardiovascular cause and major cardiovascular events occurrence (mortality, coronary syndrome and stroke). Baseline SBP was associated with atrial fibrillation development (p = 0.008).

Conclusion

According to our results, PSBP during exercise test is an independent predictor of stroke occurrence and should be considered as a potencial additional tool to predict stroke occurrence, particularly in high risk patients. The identification of diagnosed hypertension as a protective factor of stroke may be explained by the cardioprotective effect of antihypertensive drugs.

Hypertensive response to exercise - to treat or not to treat?

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Hypertensive response to exercise (HRE) is often documented in individuals without known cardiovascular disease. However, its impact on patient prognosis and the necessity of treatment are still not clear.

Objective

 We aimed to evaluate the impact of a hypertensive response (HRE) on exercise test (ET) on clinical prognosis and outcome.

Methods

 This was a single-center retrospective study of patients with HRE on stress exercise testing (STE) performed between January 2012 and December 2015. In our center, we define HRE as systolic blood pressure (SBP) &gt; 210mmHg in men and &gt;190mmHg in women, diastolic blood pressure (DBP) &gt; 90mmHg or an increase in baseline systolic BP at least 60 mmHg in men or 50 mmHg in women, during exercise. Demographic, clinical, echocardiographic, electrocardiographic data were collected, and results were obtained using Chi-square and Student-t tests; logistic regression.

Results

 We evaluated 500 patients who underwent STE, 457 of which had hypertensive response vs 43 patients without HRE (mean age 57 ± 11 vs 61 ± 8 years, p = 0,01). Among the two groups there were no differences between gender (76.5% men vs 69.7%) and race nor between the cardiovascular risk factors, namely hypertension, diabetes and dyslipidaemia. We evaluated their responses in STE and their outcomes, with a mean follow-up of 60 ± 22 months.

In the univariate and multivariate analysis, presence of Sokolow-Lion criteria of left ventricular hypertrophy in the ECG was associated with HRE during the exam (OR 5.26; CI95% 2.4-11.6; p &lt; 0.001). In patients who had previously known hypertension, therapy with calcium channel blockers seemed to protect against hypertensive response prior to ET (OR 0.48, CI95% 0.24-0.97, p = 0.004) compared to other antihypertensive drugs.

Regarding the clinical outcomes, patients with HRE were associated with an increased risk of developing heart failure (p = 0.027) (versus patients without HRE) during follow up but failed to predict adverse outcomes such as acute coronary syndrome, atrial

fibrillation or stroke.

Within the patients with HRE in ET, 78 patients did not have an established diagnosis of HTA (mean age 49 ± 12.16 years, 75.6% men). In these patients we observed initiation on antihypertensive therapy after ET on 27.6% patients, but on univariate and multivariate analysis, starting therapy with anti-hypertensives did not have a significant impact on incidence of stroke, AF, HF, hospitalization for cardiovascular events or death.

Conclusions

 We did not observe any significant differences among the studied groups regarding prognosis, except for the highest incidence of heart failure in patients with HRE. Initiation of antihypertensive therapy in patients with HRE failed to modify outcomes,

however our sample was underpowered, so, further studies are required in order to clarify the value of treatment in patients with HRE.