Aortopathy and aortic valve surgery in patients with bicuspid aortic valve with and without raphe

AIM

To evaluate the association between raphe in bicuspid aortic valve (BAV) patients and valve dysfunction, aortopathy and aortic valve surgery in the REBECCA registry [REgistro della valvola aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging (SIECVI)].

METHODS

Prevalence of aortic valve dysfunction and aortopathy was investigated in BAV patients with and without raphe. Aortic valve dysfunction (regurgitation or stenosis) was categorized as mild, moderate and severe. Aortopathy was defined as annulus ≥14 mm/m2; root ≥20 mm/m2; sinotubular junction ≥16 mm/m2; ascending aorta ≥17 mm/m2, and classified in Type A, isolated ascending aorta dilatation; Type B, aortic root and ascending aorta dilatation; and Type C, isolated aortic root dilatation.

RESULTS

Overall, 695 patients with BAV were enrolled; 520 (74.8%) with raphe and 175 (25.2%) without raphe. BAV patients with raphe presented more frequently with moderate or severe aortic stenosis than BAV patients without raphe (183 [35.2%] vs 34 [19.4%], p < 0.001). A higher prevalence of aortopathy, particularly Type B, was observed in patients with vs without raphe. At multivariable analysis, raphe was a predictor of aortic valve surgery at three-year follow-up (odds ratio 2.19, 95% confidence interval 1.08-4.44, p < 0.001).

CONCLUSIONS

Patients with BAV and raphe have a higher prevalence of significant aortic stenosis, aortopathy, especially Type B, and a higher risk of undergoing aortic valve surgery at three-year follow-up.

Intravenous antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention : A report from the INVEST-STEMI group

The use of intravenous antiplatelet therapy during primary percutaneous coronary intervention (PPCI) is not fully standardized. The aim is to evaluate the effectiveness and safety of periprocedural intravenous administration of cangrelor or tirofiban in a contemporary ST-segment elevation myocardial infarction (STEMI) population undergoing PPCI. This was a multicenter prospective cohort study including consecutive STEMI patients who received cangrelor or tirofiban during PPCI at seven Italian centers. The primary effectiveness measure was the angiographic evidence of thrombolysis in myocardial infarction (TIMI) flow < 3 after PPCI. The primary safety outcome was the in-hospital occurrence of BARC (Bleeding Academic Research Consortium) 2-5 bleedings. The study included 627 patients (median age 63 years, 79% males): 312 received cangrelor, 315 tirofiban. The percentage of history of bleeding, pulmonary edema and cardiogenic shock at admission was comparable between groups. Patients receiving cangrelor had lower ischemia time compared to tirofiban. TIMI flow before PPCI and TIMI thrombus grade were comparable between groups. At propensity score-weighted regression analysis, the risk of TIMI flow < 3 was significantly lower in patients treated with cangrelor compared to tirofiban (adjusted OR: 0.40; 95% CI: 0.30-0.53). The risk of BARC 2-5 bleeding was comparable between groups (adjusted OR:1.35; 95% CI: 0.92-1.98). These results were consistent across multiple prespecified subgroups, including subjects stratified for different total ischemia time, with no statistical interaction. In this real-world multicenter STEMI population, the use of cangrelor was associated with improved myocardial perfusion assessed by coronary angiography after PPCI without increasing clinically-relevant bleedings compared to tirofiban.

Isolated Valve Amyloid Deposition in Aortic Stenosis: Potential Clinical and Pathophysiological Relevance

Amyloid deposition within stenotic aortic valves (AVs) also appears frequent in the absence of cardiac amyloidosis, but its clinical and pathophysiological relevance has not been investigated. We will elucidate the rate of isolated AV amyloid deposition and its potential clinical and pathophysiological significance in aortic stenosis (AS). In 130 patients without systemic and/or cardiac amyloidosis, we collected the explanted AVs during cardiac surgery: 57 patients with calcific AS and 73 patients with AV insufficiency (41 with AV sclerosis and 32 without, who were used as controls). Amyloid deposition was found in 21 AS valves (37%), 4 sclerotic AVs (10%), and none of the controls. Patients with and without isolated AV amyloid deposition had similar clinical and echocardiographic characteristics and survival rates. Isolated AV amyloid deposition was associated with higher degrees of AV fibrosis (p = 0.0082) and calcification (p < 0.0001). Immunohistochemistry analysis suggested serum amyloid A1 (SAA1), in addition to transthyretin (TTR), as the protein possibly involved in AV amyloid deposition. Circulating SAA1 levels were within the normal range in all groups, and no difference was observed in AS patients with and without AV amyloid deposition. In vitro, AV interstitial cells (VICs) were stimulated with interleukin (IL)-1β which induced increased SAA1-mRNA both in the control VICs (+6.4 ± 0.5, p = 0.02) and the AS VICs (+7.6 ± 0.5, p = 0.008). In conclusion, isolated AV amyloid deposition is frequent in the context of AS, but it does not appear to have potential clinical relevance. Conversely, amyloid deposition within AV leaflets, probably promoted by local inflammation, could play a role in AS pathophysiology.

Valve-in-Valve Transcatheter Aortic Valve Replacement: From Pre-Procedural Planning to Procedural Scenarios and Possible Complications

Over the last decades, bioprosthetic heart valves (BHV) have been increasingly implanted instead of mechanical valves in patients undergoing surgical aortic valve replacement (SAVR). Structural valve deterioration (SVD) is a common issue at follow-up and can justify the need for a reintervention. In the evolving landscape of interventional cardiology, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has emerged as a remarkable innovation to address the complex challenges of patients previously treated with SAVR and has rapidly gained prominence as a feasible technique especially in patients at high surgical risk. On the other hand, the expanding indications for TAVR in progressively younger patients with severe aortic stenosis pose the crucial question on the long-term durability of transcatheter heart valves (THVs), as patients might outlive the bioprosthetic valve. In this review, we provide an overview on the role of ViV TAVR for failed surgical and transcatheter BHVs, with a specific focus on current clinical evidence, pre-procedural planning, procedural techniques, and possible complications. The combination of integrated Heart Team discussion with interventional growth curve makes it possible to achieve best ViV TAVR results and avoid complications or put oneself ahead of time from them.

Arterial hypertension in patients with takotsubo syndrome: prevalence, long-term outcome, and secondary preventive strategies: a report from the Takotsubo Italian Network register

AIMS

The aim of this study was to investigate the long-term outcome of takotsubo syndrome (TTS) patients with and without hypertension (HT) and to evaluate the effectiveness of treatment with beta-blockers (BBs) and/or renin-angiotensin-aldosterone system inhibitors (RAASi).

METHODS AND RESULTS

The study population includes a register-based, multicentre cohort of consecutive patients with TTS, divided into two groups according to the history of HT. Further stratification was performed for BB/RAASi prescription at discharge. The primary outcome was the composite of all-cause death and TTS recurrence at the longest available follow-up. The propensity score weighting technique was used to account for potential confounding. In the overall population (903 patients, mean age 70 ± 11 years), HT was reported in 66% of cases. At a median 2-year follow-up, there was no difference in the risk of the primary composite outcome between patients with and without HT. The adjusted Cox regression analysis showed a significantly lower risk for the primary outcome [adjusted hazard ratio (aHR): 0.69; 95% confidence interval (CI): 0.49-0.99] in patients who received BB vs. those who did not. Renin-angiotensin-aldosterone system inhibitors treatment was not associated with the primary study outcome. The lower risk for the primary outcome with BB treatment was confirmed in patients with HT (aHR: 0.37; 95% CI: 0.24-0.56) but not in patients without (aHR: 1.83; 95% CI: 0.92-3.64; Pinteraction < 0.001).

CONCLUSION

In this TTS study, HT did not affect the long-term risk of adverse events but increased the probability of benefit from BB treatment after discharge. Owing to the favourable outcome impact of BB prescription in TTS patients with HT, a tailored pharmacological therapy should be considered in this cohort.

Machine learning-based prediction of in-hospital death for patients with takotsubo syndrome: The InterTAK-ML model

AIMS

Takotsubo syndrome (TTS) is associated with a substantial rate of adverse events. We sought to design a machine learning (ML)-based model to predict the risk of in-hospital death and to perform a clustering of TTS patients to identify different risk profiles.

METHODS AND RESULTS

A ridge logistic regression-based ML model for predicting in-hospital death was developed on 3482 TTS patients from the International Takotsubo (InterTAK) Registry, randomly split in a train and an internal validation cohort (75% and 25% of the sample size, respectively) and evaluated in an external validation cohort (1037 patients). Thirty-one clinically relevant variables were included in the prediction model. Model performance represented the primary endpoint and was assessed according to area under the curve (AUC), sensitivity and specificity. As secondary endpoint, a K-medoids clustering algorithm was designed to stratify patients into phenotypic groups based on the 10 most relevant features emerging from the main model. The overall incidence of in-hospital death was 5.2%. The InterTAK-ML model showed an AUC of 0.89 (0.85-0.92), a sensitivity of 0.85 (0.78-0.95) and a specificity of 0.76 (0.74-0.79) in the internal validation cohort and an AUC of 0.82 (0.73-0.91), a sensitivity of 0.74 (0.61-0.87) and a specificity of 0.79 (0.77-0.81) in the external cohort for in-hospital death prediction. By exploiting the 10 variables showing the highest feature importance, TTS patients were clustered into six groups associated with different risks of in-hospital death (28.8% vs. 15.5% vs. 5.4% vs. 1.0.8% vs. 0.5%) which were consistent also in the external cohort.

CONCLUSION

A ML-based approach for the identification of TTS patients at risk of adverse short-term prognosis is feasible and effective. The InterTAK-ML model showed unprecedented discriminative capability for the prediction of in-hospital death.

Obstructive Hypertrophic Cardiomyopathy and Takotsubo Syndrome: How to Deal With Left Ventricular Ballooning?

Currently, there are 2 proposed causes of acute left ventricular ballooning. The first is the most cited hypothesis that ballooning is caused by direct catecholamine toxicity on cardiomyocytes or by microvascular ischemia. We refer to this pathogenesis as Takotsubo syndrome. More recently, a second cause has emerged: that in some patients with underlying hypertrophic cardiomyopathy, left ventricular ballooning is caused by the sudden onset of latent left ventricular outflow tract obstruction. When it becomes severe and unrelenting, severe afterload mismatch and acute supply-demand ischemia appear and result in ballooning. In the context of 2 causes, presentations might overlap and cause confusion. Knowing the pathophysiology of each mechanism and how to determine a correct diagnosis might guide treatment.

Prognostic significance of the SYNTAX score and SYNTAX score II in patients with myocardial infarction treated with percutaneous coronary intervention

OBJECTIVES

We aimed to evaluate the prognostic significance of the SYNTAX score (SS) and SYNTAX score II (SS-II) in a contemporary real-world cohort of myocardial infarction (MI) patients treated with percutaneous coronary intervention (PCI).

BACKGROUND

The role of SS and SS-II in the prognostic stratification of patients presenting with MI and undergoing PCI has been poorly investigated.

METHODS

This study included MI patients treated with PCI from January 2015 to April 2020 at the University Hospital of Salerno. Patients were divided into tertiles according to the baseline SS and SS-II values. The primary outcome measure was all-cause mortality at long-term follow-up; secondary outcome measures were cardiovascular (CV) death and MI.

RESULTS

Overall, 915 patients were included in this study. Mean SS and SS-II were 16.1 ± 10.0 and 31.6 ± 11.5, respectively. At propensity weighting adjusted Cox regression analysis, both SS (hazard ratio [HR]: 1.02; 95% confidence interval [CI]: 1.02-1.06; p = 0.017) and SS-II (HR: 1.08; 95% CI: 1.07-1.10; p < 0.001) were significantly associated with the risk of all-cause mortality at long-term follow-up; both SS (HR 1.04; CI 1.01-1.06; p < 0.001) and SS-II (HR 1.08; CI 1.06-1.10; p < 0.001) were significantly associated with the risk of CV death, but only SS-II showed a significant association with the risk of recurrent MI (HR 1.03; CI 1.01-1.05; p < 0.001). At 5 years, SS-II showed a significantly higher discriminative ability for all-cause mortality than SS (area under the curve: 0.82 vs. 0.64; p < 0.001). SS-II was able to reclassify the risk of long-term mortality beyond the SS (net reclassification index 0.88; 95% CI: 0.38-1.54; p = 0.033).

CONCLUSIONS

In a real-world cohort of MI patients treated with PCI, SS-II was a stronger prognostic predictor of long-term mortality than SS.

Prognostic Impact of Mitral Regurgitation Before and After Transcatheter Aortic Valve Replacement in Patients With Severe Low-Flow, Low-Gradient Aortic Stenosis

Background There is little evidence about the prognostic role of mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). The aim of this study was to assess the prevalence and outcome implications of MR severity in patients with low-flow, low-gradient aortic stenosis undergoing TAVR, and to evaluate whether MR improvement after TAVR could influence clinical outcome. Methods and Results This study included consecutive patients with low-flow, low-gradient aortic stenosis undergoing TAVR at 2 Italian high-volume centers. The study population was categorized according to the baseline MR severity and to the presence of MR improvement at discharge. The primary outcome was the composite of all-cause death and hospitalization for worsening heart failure up to 1 year. The study included 268 patients; 57 (21%) patients showed MR >2+. Patients with MR >2+ showed a lower 1-year survival free from the primary outcome (P<0.001), all-cause death (P<0.001), and heart failure hospitalization (P<0.001) compared with patients with MR ≤2+. At multivariable analysis, baseline MR >2+ was an independent predictor of the primary outcome (P<0.001). Among patients with baseline MR >2+, MR improvement was reported in 24 (44%) cases after TAVR. The persistence of MR was associated with a significantly reduced survival free from the primary outcome, all-cause death, and heart failure hospitalization up to 1 year. Conclusions In this study, the presence of moderately severe to severe MR in patients with low-flow, low-gradient aortic stenosis undergoing TAVR portends a worse clinical outcome at 1 year. TAVR may improve MR severity in nearly half of the patients, resulting in a potential outcome benefit after discharge.

Moving toward Precision Medicine in Acute Coronary Syndromes: A Multimodal Assessment of Non-Culprit Lesions

Patients with acute coronary syndrome and multivessel disease experience several recurrent adverse events that lead to poor outcomes. Given the complexity of treating these patients, and the extremely high risk of long-term adverse events, the assessment of non-culprit lesions becomes crucial. Recently, two trials have shown a possible clinical benefit into treat non-culprit lesions using a fraction flow reserve (FFR)-guided approach, compared to culprit-lesion-only PCI. However, the most recent FLOW Evaluation to Guide Revascularization in Multivessel ST-elevation Myocardial Infarction (FLOWER-MI) trial did not show a benefit of the use of FFR-guided PCI compared to an angiography-guided approach. Otherwise, intracoronary imaging using optical coherence tomography (OCT), intravascular ultrasound (IVUS), or near-infrared spectroscopy (NIRS) could provide both quantitative and qualitative assessments of non-culprit lesions. Different studies have shown how the characterization of coronary lesions with intracoronary imaging could lead to clinical benefits in these peculiar group of patients. Moreover, non-invasive evaluations of NCLs have begun to take ground in this context, but more insights through adequately powered and designed studies are needed. The aim of this review is to outline the available techniques, both invasive and non-invasive, for the assessment of multivessel disease in patients with STEMI, and to provide a systematic guidance on the assessment and approach to these patients.

Soluble PCSK9 Inhibition: Indications, Clinical Impact, New Molecular Insights and Practical Approach-Where Do We Stand?

Current research on cardiovascular prevention predominantly focuses on risk-stratification and management of patients with coronary artery disease (CAD) to optimize their prognosis. Several basic, translational and clinical research efforts aim to determine the etiological mechanisms underlying CAD pathogenesis and to identify lifestyle-dependent metabolic risk factors or genetic and epigenetic parameters responsible for CAD occurrence and/or progression. A log-linear association between the absolute exposure of LDL cholesterol (LDL-C) and the risk of atherosclerotic cardio-vascular disease (ASCVD) was well documented over the year. LDL-C was identified as the principal enemy to fight against, and soluble proprotein convertase subtilisin kexin type 9 (PCSK9) was attributed the role of a powerful regulator of blood LDL-C levels. The two currently available antibodies (alirocumab and evolocumab) against PCSK9 are fully human engineered IgG that bind to soluble PCSK9 and avoid its interaction with the LDLR. As documented by modern and dedicated "game-changer" trials, antibodies against soluble PCSK9 reduce LDL-C levels by at least 60 percent when used alone and up to 85 percent when used in combination with high-intensity statins and/or other hypolipidemic therapies, including ezetimibe. Their clinical indications are well established, but new areas of use are advocated. Several clues suggest that regulation of PCSK9 represents a cornerstone of cardiovascular prevention, partly because of some pleiotropic effects attributed to these newly developed drugs. New mechanisms of PCSK9 regulation are being explored, and further efforts need to be put in place to reach patients with these new therapies. The aim of this manuscript is to perform a narrative review of the literature on soluble PCSK9 inhibitor drugs, with a focus on their indications and clinical impact.

[Diagnosis of cardiovascular involvement in Fabry disease]

Fabry disease is a rare X-linked genetic disorder, caused by partial or total loss of function of the lysosomal enzyme α-galactosidase A that induces glycosphingolipid accumulation in various organs and tissues, modifying their structure and function. Cardiovascular involvement in classic and late onset forms has emerged to be a major determinant of prognosis. In recent years, a constant evolution in imaging techniques and their mindful application has led to interesting results in the diagnostic workup, progressively reducing time required to recognize early signs of this disease. Owing to the growing awareness for diagnostic screening and the efficacy of the many therapeutic options currently available, the clinical history of Fabry patients has changed during the last decades. Therefore, an early diagnosis of Fabry disease and especially of cardiac involvement is essential to promptly adopt an adequate therapy.

992 EVALUATION OF MYOCARDIAL WORK INDEX IN PREDICTING IN-HOSPITAL COMPLICATION IN PATIENTS WITH TAKOTSUBO SYNDROME

Backgrounds

Tako-tsubo syndrome (TTS) is a reversible heart failure pathology characterized by transient myocardial left ventricular (LV) dysfunction. Although traditionally considered a benign condition in-hospital complications are frequent in this cohort. Non-invasive myocardial work (MW) parameters are considered as emerging indexes in evaluating global and regional myocardial systolic function.

Objective

to investigate the potential association of MW compared to standard echocardiography parameters, such as LV ejection fraction (EF) with in-hospital complications, in TTS patients.

Methods

thirty-eight patients (mean age, 68 ± 12 years, 35 women) with TTS diagnosed with Takotsubo Italian Network criteria were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24 hours from hospital admission. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating into its calculation the non-invasive brachial arterial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted myocardial work (WMW) were measured. In hospital complications (HC) were defined as a composite of apical LV thrombosis, hypokinetic arrhythmias (HA), supraventricular tachycardia (SVT), acute heart failure (AHF), ventricular tachycardia/fibrillation (VT/VF), cardiogenic shock (CS), respiratory arrest (RA), stroke and cardiac death (CD).

The normal values ​​for the echocardiographic parameters are reported in the Table. Odds ratio, sensitivity and specificity were used to quantify the ability of EF and MW (abnormal vs normal values) in predicting HC.

Results

HC occurred in 16 TTS patients (26% with AHF; 10% with SVT; 8% with CS; 5% with apical LV thrombosis; 5% with HA; 2,6% with RA; 2,6% with stroke; 2% with VT/VF). The MWI and CMW parameters appear to have the best performance in predicting in-hospital complications (odds ratio for having HC: 10.4 (95% confidence interval: 1.2 to 93.3); 8.6 (0.9 to 77.6) respectively, Table), followed by EF (odds ratio 7.0 (0.8 to 64.1)) and WMW (odds ratio 4.8 (0.9 to 26.7)). MWI has the same sensitivity (94%) as CMW and EF, but higher specificity (41% vs 32%). Of note, the highest specificity was obtained by the WMW parameter (41%).

Conclusion

global and regional myocardial performance is transiently impaired in TTS and significantly associated with HC. Although limited by the low number of patients, these results suggest that myocardial work parameters have a good sensistivity and may have a better performance than the EF value in predicting intra-hospital complications. Larger studies will be necessary to confirm these preliminary results.

345 INTRAVENOUS CANGRELOR INFUSION IN ELDERLY PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: A SUBANALYSIS OF THE ICARUS REGISTRY

Aims

To assess the clinical characteristics and compare in-hospital outcomes of elderly and non-elderly patients receiving cangrelor in the peri-percutaneous coronary intervention (PCI) phase.

Methods

Consecutive patients treated with cangrelor in 7 Italian institutions were retrospectively enrolled in the ICARUS (“Intravenous CAngrelor in high-bleeding Risk patients Undergoing percutaneouS coronary intervention”, NCT05505591) registry. Elderly patients were defined if age was ≥75 years at the time of PCI. The primary endpoint was net adverse clinical events (NACE), defined as a composite of cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis and Bleeding Academic Research Consortium (BARC) 2, 3 or 5 bleeding, at 48 hours. Secondary endpoints were assessed at 48 hours and throughout the hospital stay. Independent predictors of the primary endpoint were also assessed.

Results

Out of 551 patients undergoing PCI with cangrelor between January 2019 and August 2022, 174 (32%) were elderly. Mean age was 81±5 vs. 61±8 years in elderly vs. non-elderly patients (p&lt;0.001). Female sex (32% vs. 21%, p=0.006), atrial fibrillation (20% vs. 5%, p&lt;0.001), chronic kidney disease (30% vs. 6%, p&lt;0.001) and heart failure (14% vs. 8%, p=0.041) were more frequent in the elderly group, whereas presentation with acute coronary syndrome (ACS) was less frequent (69% vs. 83%, p=0.001). Elderly patients received shorter cangrelor infusion (122±25 vs. 134±43 minutes, p=0.001) and were more frequently administered with clopidogrel after PCI (50% vs. 19%, p&lt;0.001). At 48 hours, elderly patients had higher rates of NACE (13% vs. 6%, p=0.006) and BARC 2, 3 or 5 bleeding (11% vs. 5%, p=0.013), whereas the rates of other 48-hour and in-hospital clinical endpoints did not differ. At multivariable analysis, age ≥75 years (odds ratio [OR] 1.07, 95% CI 1.02-1.12, p=0.004), major anemia (OR 1.10, 95% CI 1.005-1.22, p=0.038), ACS at presentation (OR 1.08, 95% CI 1.03-1.14), femoral access (OR 1.13, 95% CI 1.06-1.22) and cardiogenic shock (OR 1.35, 95% CI 1.21-1.50) independently predicted the occurrence of 48-hour NACE.

Conclusions

Advanced age is a distinctive risk feature among patients receiving intravenous cangrelor in the peri-PCI phase. Elderly patients had higher rates of adverse events at 48 hours, with advanced age (≥75 years) being an independent predictor of NACE.

1044 CHARACTERISTIC AND OUTCOME IN PATIENTS WITH LOW FLOW, LOW GRADIENT AORTIC STENOSIS

Aim

The aim of this study was to assess the prevalence and outcome in patients with severe low flow, low gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve intervention (TAVI).

Methods

Patients with LFLG AS undergoing TAVI from 2013 to 2022 were prospectively collected.

Clinical, imaging data and procedural parameters were collected. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient &lt;40 mmHg and stroke volume index &lt;36 ml/m2. Overall population was classified in due subgroups: classical LFLG AS if left ventricular ejection fraction (LVEF) was &lt;50%, and paradoxical in patients with preserved LVEF. The major comorbidities and primary outcome defined as a composite of all-cause mortality and rehospitalization for worsening heart failure (HF) up to 1 year in the different subtypes of severe LFLG AS undergoing TAVI were evaluated.

Results

The study included 268 patients [81±6 years; 142 (53%) females]; of these, 155 patients (58%) had paradoxical LFLG AS and 113 patients (42%) had LFLG AS with low LVEF. Regarding echocardiography parameters, in the overall population the mean transaortic gradient was 31±6 mmHg, the mean iAVA 0.38±0.08 cm/m2, and the median LVEF 50% (IQR 38-55).

Compared with paradoxical LFLG AS, the patients with classical form were characterized by a lower percentage of women (43% vs. 60% p 0.07), worse renal function (46% vs. 30%, p 0.012), and a significantly higher number of cardiovascular disease as coronary artery disease (52% vs. 29%, p &lt;0.001) and atrial fibrillation (37% vs. 23%, p 0.018), resulting in higher Society of Thoracic Surgeons scores [7,34% (IQR: 4.96 to 13,25) versus 5,36% (IQR: 3,22 to 11); p value 0.037]. Higher percentage of patients of New York Heart Association functional class III or IV (61% vs. 27%; p 0.037) was observed in classical LFLG AS.

At one-year follow-up, the composite outcome was reported in 49 patients (18%), 21 patients (13%) had paradoxical LFLG AS and 28 patients (24%) had classical form.

Kaplan-Meier survival free from the composite outcome was significantly lower in patients with classical LFLG AS compared to those paradoxical LFLG AS (Log-Rank 0,022, Figure 1).

Conclusion

LFLG AS is a complex population with significant incidence of adverse event at one years. Patients with classical LFLG AS have higher number of risk factor and cardiovascular disease and lower survival compared paradoxical form.

Figure 1

1110 PROGNOSTIC IMPACT OF SIGNIFICANT MITRAL REGURGITATION IN PATIENTS WITH SEVERE LOW FLOW, LOW GRADIENT AORTIC STENOSIS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT

Aim

This study sought to determinate the prevalence, clinical impact, and clinical outcome of significant moderate-to-severe mitral regurgitation (MR) in patients with severe low flow, low gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR).

Methods

All consecutive patients with severe LFLG-AS undergoing TAVI in two high-volume Italian centres from 2013 to 2022 were prospectively included. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient &lt;40 mmHg and stroke volume index &lt;36 ml/m2. LFLG-AS was classified as classical if left ventricular ejection fraction (LVEF) was &lt;50%, and paradoxical in patients with preserved LVEF &gt;50%. Demographic, clinical, instrumental, and procedural features were systematically collected by using an electronic case report form. MR severity was graded according to the current guidelines, and patients were categorized based on the MR severity at baseline in two groups: mild and moderate-to-severe MR. The primary study outcome was the composite of all-cause mortality and rehospitalization for worsening heart failure (HF) up to 1 year; secondary outcomes were the single components of the primary outcome.

Results

The study included 268 patients [81±6 years; 142 (53%) females]; moderate-to-severe MR was reported in 57 patients (21%). At baseline moderate-to-severe MR compared to those with mild MR showed statistically significant differences between age (p 0.008), female sex (p 0.007), hypertension (p 0.036), diabetes (p 0.001) atrial fibrillation/flutter (p 0.018) and chronic kidney disease (p 0.012). In the overall population, only one patient died during the hospitalization and at one-year follow-up, the primary outcome was reported in 49 patients (18%); all-cause death occurred in 26 (10%), and HF rehospitalization in 24 (9%).

Regarding the two subgroups, Kaplan-Meier curves showed that survival free from the composite outcome was significantly lower in patients with moderate-to-severe MR compared to those with mild MR (Log Rank &lt;0.001, Figure 1A). Survival free from all-cause mortality and HF rehospitalization was also significantly lower in patients with moderate-to-severe MR (Log-Rank &lt;0.001 and Log-Rank=0.002, respectively; Figure 1B and 1C).

Conclusion

In this study, many patients with LFLG-AS undergoing TAVR had coexisting moderate-to-severe MR. TAVI confirmed a high safety profile, LFLG-AS patients showed a high incidence of adverse events up to 1 year, especially those with coexisting moderate-to-severe MR. Moderate-to-severe MR should be duly considered for better prognostic stratification and clinical management of these particular TAVR patients during follow-up.

Figure 1

330 INTRAVENOUS CANGRELOR INFUSION IN HIGH BLEEDING RISK PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: PRELIMINARY RESULTS OF THE ICARUS REGISTRY

Aims

To investigate the prevalence of high bleeding risk (HBR) criteria and compare clinical outcomes between HBR and non-HBR patients receiving cangrelor in the peri-percutaneous coronary intervention (PCI) phase.

Methods

Consecutive patients treated with cangrelor in 7 Italian institutions were retrospectively enrolled in the ICARUS (“Intravenous CAngrelor in high-bleeding Risk patients Undergoing percutaneouS coronary intervention”, NCT05505591) registry. HBR status was assessed according to the Academic Research Consortium (ARC-HBR) definition. The primary endpoint was net adverse clinical events (NACE), defined as a composite of cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis and Bleeding Academic Research Consortium (BARC) 2, 3 or 5 bleeding, at 48 hours. Secondary endpoints were assessed at 48 hours and throughout the hospital stay.

Results

We enrolled 551 patients undergoing PCI with cangrelor between January 2019 and August 2022. HBR definition was met in 33% of cases. HBR patients were older (76±10 vs. 63±10 years, p&lt;0.001), more frequently affected by peripheral arterial disease (16% vs. 8%, p=0.010), atrial fibrillation (24% vs. 2%, p&lt;0.001), chronic kidney disease (35% vs. 3%, p&lt;0.001), active cancer (7% vs. 0%, p&lt;0.001) and heart failure (17% vs. 7%, p&lt;0.001). At 48 hours, HBR patients had a significantly higher rate of NACE (13% vs. 6%, p=0.004), and BARC 2, 3 or 5 bleeding (12% vs. 4%, p=0.001). In the HBR group, the frequency of the primary endpoint increased proportionally to the HBR score. There was no significant difference with respect to other 48-hour and in-hospital endpoints.

Conclusions

Among consecutive patients treated with cangrelor in the peri-PCI phase, about 30% fulfilled the ARC-HBR definition. In the HBR subpopulation, the incidence of 48-hour adverse events was higher than in the non-HBR subgroup, primarily driven by a higher rate of clinically relevant and major bleeding.

349 INTRAVENOUS CANGRELOR INFUSION IN PATIENTS UNDERGOING COMPLEX VERSUS NON-COMPLEX PERCUTANEOUS CORONARY INTERVENTION: A SUBANALYSIS OF THE ICARUS REGISTRY

Aims

To compare the clinical characteristics and in-hospital outcomes of patients undergoing complex vs. non-complex percutaneous coronary intervention (PCI) with peri-procedural use of cangrelor.

Methods

Consecutive patients treated with cangrelor in 6 Italian institutions were retrospectively enrolled in the ICARUS (“Intravenous CAngrelor in high-bleeding Risk patients Undergoing percutaneouS coronary intervention”, NCT05505591) registry. Complex PCI was defined as any of the following: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length &gt;60 mm, or chronic total occlusion. The primary endpoint was net adverse clinical events (NACE), defined as a composite of cardiovascular death, myocardial infarction, stroke, definite or probable stent thrombosis and Bleeding Academic Research Consortium (BARC) 2, 3 or 5 bleeding, at 48 hours. Secondary endpoints were assessed at 48 hours and throughout the hospital stay.

Results

Among 551 patients enrolled in the ICARUS registry and undergoing PCI between January 2019 and August 2022, a total of 534 (97%) patients had complete information on PCI complexity, of whom 173 (32%) underwent complex PCI and 361 (68%) underwent non-complex PCI. In general, patients with complex PCI had similar clinical features compared with non-complex PCI patients, including comparable prevalence of high bleeding risk (HBR) status according to the ARC-HBR definition (35% vs. 30%, p=0.253), but complex PCI patients presented more often with cardiogenic shock (9% vs. 2%, p&lt;0.001). PCI with ≥3 stents implanted was the most frequent criterion of procedural complexity (62%). The incidence of the primary endpoint of 48-hour NACE (10% vs. 7%, p=0.264) and other clinical endpoints occurring at 48 hours or during hospitalization did not differ between complex and non-complex PCI patients.

Conclusions

Among patients receiving peri-procedural cangrelor, about 30% of cases underwent complex interventions. Notwithstanding higher procedural complexity, short-term clinical outcomes were similar between complex and non-complex PCI patients.

1048 MYOCARDIAL WORK AND OUTCOME IN PATIENTS PARADOXICAL WITH LOW FLOW, LOW GRADIENT AORTIC STENOSIS

Aim

The aim of this study was to investigate the potential impact of non-invasive derived myocardial work (MW) indexes on outcome of patients with severe paradoxical low flow, low gradient (PLFLG AS) undergoing transcatheter aortic valve implantation (TAVI).

Methods

Complete demographic, clinical characteristics, laboratory analyses and echocardiographic parameters were collected. Severe PLFLG AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient &lt; 40 mmHg and stroke volume index &lt;36 ml/m2 and preserved LVEF &gt;50%. MW was obtained from the non-invasive strain-pressure loop obtained pressure by combining GLS and the left ventricular systolic pressure, which was derived by adding the mean aortic valve gradient to systolic brachial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted MW (WMW) were measured. The normal values ​​considered for the MW parameters were: MWI ≥ 1300 mmHg%; CMW ≥ 1500 mmHg%; WMW &lt; 240 mmHg%; MWE ≥ 90%. Odds ratio, sensitivity and specificity were used to quantify the ability of MW parameters (abnormal vs normal values) in predicting the primary outcome defined as all-causes mortality.

Results

study population included 30 patients with severe PLFLG AS undergoing TAVI. The most frequent comorbidities were hypertension (93%; n=28), dyslipidaemia (66%; n=20), diabetes (23%; n=7). Atrial fibrillation/flutter and chronic kidney disease were identified in 12 (40%) and 18 (60%) patients, respectively. Concomitant coronary artery disease and history of stroke were reported in 23% (n=7) and 10% (n=3), respectively. Society of Thoracic Surgeons score in overall population was mean 11,34±4,34. During median of 209 days (IQR: 104–213 days) all-causes mortality occurred in 13 patients (43%) (just 1 for non-cardiac death). Abnormal values of MWI, CMW and MWE identified significant statistical correlation with primary outcome [(odds ratio for primary outcome: 7.5 (95% confidence interval: 1.4 to 39.8); 7.5 (1.4 to 39.5) and 5.2 (1.1 to 25.3) respectively, Table 1)]. The MWI, CMW and MWE have the same sensitivity (62%) but higher specificity (82% for MWI and CMW, 88% for WMW and 76% for MWE).

Conclusion

In a population of patients with PLFLG-AS characterized by normal ejection fraction the abnormal MW parameters seem to be significantly associated with all-causes mortality during mid-term follow up and might provide additional information on outcome of this peculiar subgroup of patients with AS.

Table 1

Lipoprotein(a) levels and risk of adverse events after myocardial infarction in patients with and without diabetes

Background

There is a positive continuous association between Lipoprotein(a) (Lp[a]) levels and the risk of recurrent ischemic events in patients with recent myocardial infarction (MI). However, the prognostic significance of the association between high Lp(a) levels and diabetes has been poorly investigated after MI.

Purpose

The aim of this study was to evaluate the association of Lp(a) levels with the long-term risk of adverse events in post-MI patients, and to investigate whether diabetes may influence this association.

Methods

Consecutive MI patients who underwent urgent/emergent coronary angiography at our Institution from February 2013 to June 2019 were prospectively collected. Lp(a) serum concentrations was expressed for increasing range values (≤10, &gt;10–30, &gt;30–50, &gt;50–70, and ≥70 mg/dL). The primary outcome was the recurrence of MI; the secondary outcome was all-cause death. The propensity score weighting technique was used to account for potential confounding between patients with and without diabetes.

Results

The study population consisted of 1018 post-MI patients (median age: 63 years; 76% males). Diabetes was reported in 280 patients (27.5%). The median value of Lp(a) was 10 mg/dL, and patients with diabetes showed significantly lower Lp(a) levels than patients without diabetes (p=0.025). At a median follow-up of 1121 days, the primary outcome was reported in 109 patients (10.7%), and the secondary outcome in 100 (9.8%). After propensity score weighting, there was a significant association between increasing Lp(a) range values and the primary outcome both in the overall population (p trend = 0.030) and in non-diabetic patients (p trend = 0.009), but not in diabetics.

Conversely, no significant association with the risk of all-cause mortality across increasing Lp(a) categories both in the overall population and in the study groups according to the presence or not of diabetes was found.

Compared with the lowest Lp(a) category, Lp(a) plasma levels &gt;70 mg/dL were independently associated with the risk of recurrent MI (HR: 3.222; 95% CI, 1.225–8.478, p=0.018) and all-cause death (HR: 2.656; 95% CI, 1.009–6.991, p=0.048) in non-diabetic patients, but not in diabetics.

Conclusions

In this real-world post-MI population, Lp(a) serum levels were lower in diabetic than in non-diabetic patients. Increasing Lp(a) levels were significantly associated with the risk of recurrent MI, and very high Lp(a) serum concentration (&gt;70 mg/dL) independently predicted recurrent MI and death in non-diabetic patients, but not in diabetics. These results reinforce the importance of routine assessment of Lp(a) levels after MI, particularly in patients without diabetes.

Funding Acknowledgement

Type of funding sources: None.

Clinical outcomes in patients with bicuspid aortic valves and ascending aorta dilatation equal or above 50mm

Background

Little is known about clinical outcomes in patients with bicuspid aortic valve (BAV) and ascending aortic diameters ≥50 mm where the elective surgical-indication zone begins.

Purpose

To assess incident aortic dissection (AoD), post-surgical survival and guideline implementation.

Methods

Multi-center retrospective study of BAV patients (≥18 years) with maximal root or tubular-ascending aortic diameters ≥50mm detected by transthoracic echocardiography at baseline. Ascertainment of aortic surgery, AoD and death was carried-out at their respective institutions. The primary outcome was AoD: “confirmed” AoD by surgery or death certificate, or “possible” AoD defined as sudden cardiac death of unknown cause by death certificate. Secondary outcomes were aortic surgery, post-surgical survival and guideline implementation.

Results

We included 506 consecutive BAV patients, mean age 61±14 years, 83% men, mean maximal aortic diameter 52±2 mm at baseline, ascending aorta was the most common segment ≥50mm (85%). During a median follow-up of 7.7 years, 356 (71%) underwent elective surgery (89% of class 1 patients). Early-surgery (≤6 months from baseline) occurred in 195 patients and 311 patients remained “under-surveillance”. Surgery under-surveillance (&gt;6 months from baseline) occurred in 161/311 (52%) patients at 2.6 [IQR: 1.5–4.7] years of follow-up. Surgical mortality was 1.4%. Ten-year post-surgical survival was &gt;90% and similar between early-surgery and surgery under-surveillance (p=0.8). Of 8 AoD events, 3 confirmed and 5 possible (all occurring in unoperated patients under-surveillance), 5 events occurred with maximal aortic baseline diameter ≥55 mm and/or &gt;1 year without clinical follow-up; therefore, under guideline non-compliance. Incidence of confirmed plus possible aortic dissection was 0.37% per year with size 50–54mm, 1.13% per year between 55–59mm, and 10.41% per year with size ≥60mm. Aortic stenosis was associated with AoD (p=0.04) and all-cause death in unoperated patients (p=0.001).

Conclusions

Our results suggest that BAV patients can be safely followed as per guidelines after aortic diameters enter the elective surgical zone (≥50mm), with excellent post-surgical survival regardless of whether surgery is early- or under-surveillance. Appropriate guideline implementation for surgical thresholds and interval clinical follow-up could have prevented most AoD events. Valvular disease guideline should also be followed to prevent AoD and improve survival in these patients.

Funding Acknowledgement

Type of funding sources: None.

Lipoprotein(a) levels and risk of adverse events after myocardial infarction in patients with and without diabetes

Introduction: The aim of this study was to evaluate the association of lipoprotein(a) [Lp(a)] levels with long-term outcome in patients with recent history of myocardial infarction (MI), and to investigate if diabetes may influence this association.

Methods: Consecutive MI patients who underwent urgent/emergent coronary angiography from February 2013 to June 2019 were prospectively collected. The primary outcome was the composite of MI recurrence and all-cause death. The propensity score weighting technique was used to account for covariates potentially influencing the relationship between Lp(a) levels and the study outcomes.

Results: The study population consisted of 1018 post-MI patients (median age 63 years). Diabetes was reported in 280 patients (27.5%), who showed lower Lp(a) levels than patients without diabetes (p = 0.026). At a median follow-up of 1121 days, the primary outcome was reported in 182 patients (17.9%). At univariable Cox regression analysis, Lp(a) was associated with the risk of the primary outcome in the overall population and in non-diabetic patients, but not in diabetics. The adjusted Cox regression analysis confirmed the independent association between Lp(a) values and the primary outcome in non-diabetic patients, but not in diabetics.

Lp(a) levels > 70 mg/dL were independently associated with the risk of the primary outcome in non-diabetic patients (adjusted HR: 2.839; 95% CI, 1.382–5.832), but not in diabetics.

Conclusions: In this real-world post-MI population, increasing Lp(a) levels were significantly associated with the risk of recurrent MI and all-cause death, and very high Lp(a) serum concentration independently predicted long-term outcome in non-diabetic patients, but not in diabetics.

The Role of Stress Echocardiography in Valvular Heart Disease

Purpose of Review

Stress echocardiography is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms during activities of daily living. We describe the current methodology and the evidence supporting these applications.

Recent Findings

The comprehensive stress echo assessment includes valve function (gradients and regurgitation), left ventricular global systolic and diastolic function, left atrial volume, pulmonary congestion, pulmonary arterial pressure, and right ventricular function, integrated with blood pressure response with cuff sphygmomanometer, chronotropic reserve with heart rate, and symptoms.

Summary

Recent guidelines recommend the evaluation of asymptomatic severe or symptomatic non-severe mitral regurgitation or stenosis with exercise stress and suspected low-flow, low-gradient severe aortic stenosis with reduced ejection fraction with low dose (up to 20 mcg, without atropine) dobutamine stress. Prospective, large-scale studies based on a comprehensive protocol (ABCDE +) capturing the multiplicity of clinical phenotypes are needed to support stress echo-driven treatment strategies.

Acute Coronary Syndrome in Patients with SARS-CoV-2 Infection: Pathophysiology and Translational Perspectives

Acute coronary syndromes (ACS) may complicate the clinical course of patients with Coronavirus Disease 2019 (COVID-19). It is still unclear whether this condition is a direct consequence of the primary disease. However, several mechanisms including direct cellular damage, endothelial dysfunction, in-situ thrombosis, systemic inflammatory response, and oxygen supply-demand imbalance have been described in patients with COVID-19. The onset of a prothrombotic state may also be facilitated by the endothelial dysfunction secondary to the systemic inflammatory response and to the direct viral cell damage. Moreover, dysfunctional endothelial cells may enhance vasospasm and platelet aggregation. The combination of these factors promotes atherosclerotic plaque instability, thrombosis and, consequently, type 1 myocardial infarction. Furthermore, severe hypoxia due to extensive pulmonary involvement, in association with other conditions described in COVID-19 such as sepsis, tachyarrhythmias, anemia, hypotension, and shock, may lead to mismatch between oxygen supply and demand, and cause type 2 myocardial infarction. A deeper understanding of the potential pathophysiological mechanisms underlying ACS in patients with COVID-19 could help the therapeutic management of these very high-risk patients.

Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome

OBJECTIVE

The advantage of beta-blockers has been postulated in patients with Takotsubo syndrome (TTS) given the pathophysiological role of catecholamines. We hypothesised that beta-blocker treatment after discharge may improve the long-term clinical outcome in this patient population.

METHODS

This was an observational, multicentre study including consecutive patients with TTS diagnosis prospectively enrolled in the Takotsubo Italian Network (TIN) register from January 2007 to December 2018. TTS was diagnosed according to the TIN, Heart Failure Association and InterTAK Diagnostic Criteria. The primary study outcome was the occurrence of all-cause death at the longest available follow-up; secondary outcomes were TTS recurrence, cardiac and non-cardiac death.

RESULTS

The study population included 825 patients (median age: 72.0 (63.0-78.0) years; 91.9 % female): 488 (59.2%) were discharged on beta-blockers and 337 (40.8%) without beta-blockers. The median follow-up was 24.0 months. The adjusted Cox regression analysis showed a significantly lower risk for all-cause death (adjusted HR: 0.563; 95% CI: 0.356 to 0.889) and non-cardiac death (adjusted HR: 0.525; 95% CI: 0.309 to 0.893) in patients receiving versus those not receiving beta-blockers, but no significant differences in terms of TTS recurrence (adjusted HR: 0.607; 95% CI: 0.311 to 1.187) and cardiac death (adjusted HR: 0.699; 95% CI: 0.284 to 1.722). The positive survival effect of beta-blockers was higher in patients with hypertension than in those without (pinteraction=0.014), and in patients who developed cardiogenic shock during the acute phase than in those who did not (pinteraction=0.047).

CONCLUSIONS

In this real-world register population, beta-blockers were associated with a significantly higher long-term survival, particularly in patients with hypertension and in those who developed cardiogenic shock during the acute phase.

P97 VALIDATION OF THE ACADEMIC RESEARCH CONSORTIUM HIGH BLEEDING RISK CRITERIA IN PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: A SYSTEMATIC REVIEW AND METANALYSIS OF 10 STUDIES AND 67,862 PATIENTS

Background

The Academic Research Consortium for High Bleeding Risk (ARC–HBR) has recently proposed, by consensus, twenty clinical criteria for the assessment of the bleeding risk after percutaneous coronary intervention (PCI). A major criterion was defined as any individual clinical condition conferring in isolation a risk for major bleeding ≥4% up to 1 year after PCI; instead, a minor criterion was considered to confer a bleeding risk of &lt; 4%. The aim of this meta–analysis was to assess the performance of the ARC–HBR criteria in stratifying the risk of bleeding and ischemic events after PCI.

Methods

MEDLINE, COCHRANE, Web of Sciences, and SCOPUS were searched for studies aimed at validating the ARC–HBR criteria in patients treated with PCI. The primary outcome measure of this meta–analysis was major bleeding.

Results

The analysis included 10 studies encompassing 67,862 patients undergoing PCI; the HBR definition was fulfilled in 44.7% of the cases. The risk of major bleeding was significantly higher in HBR vs. Non–HBR group (RR, 2.56, 95% CI 2.28–2.89). The average C–statistic was 0.64 (95% CI 0.60–0.68), indicating modest discrimination. The risk of intracranial hemorrhage, gastrointestinal bleeding, fatal bleeding, ischaemic stroke, cardiac death and all–cause death was higher in HBR vs. Non–HBR group. Despite a higher incidence of myocardial infarction and stent thrombosis in patients deemed at HBR, the rate of target lesion revascularization was comparable between groups (RR, 1.01, 95% CI 0.88–1.16). When assessed in isolation, the mean cumulative incidence of major bleeding at 1 year exceeded the cut–off value of 4% for all the major criteria and for two out of six minor criteria, including age ≥75 years and moderate chronic kidney disease (CKD) (Figure).

Conclusion

The ARC–HBR definition identifies patients at higher risk of major bleeding and other adverse cardiovascular events after PCI. Almost all major criteria, but also two of the minor criteria, were individually associated with rates of major bleeding above 4% thus fulfilling the definition of major HBR criteria. These findings corroborate the ability of ARC–HBR major criteria in identifying PCI patients who are more likely to develop adverse events, but also suggest caution in the decision making of patients with isolated minor criteria, including age≥75 years and moderate CKD.

Importance of Echocardiography and Clinical “Red Flags” in Guiding Genetic Screening for Fabry Disease

Introduction

Aim of this study was to evaluate, in a metropolitan area not already explored, the prevalence of Anderson–Fabry disease, by genetic screening, in patients with echocardiographic evidence of left ventricular hypertrophy (LVH) of unknown origin and “clinical red flags”.

Methods

From August 2016 to October 2017, all consecutive patients referring to our echo-lab for daily hospital practices with echocardiographic evidence of LVH of unknown origin in association with history of at least one of the classical signs and symptoms related to Fabry disease (FD) (neuropathic pain, anhidrosis/hypohidrosis, angiokeratomas, gastrointestinal problems, chronic kidney disease, or cerebrovascular complications) were considered eligible for the FD genetic screening program. Through dried blood spot testing, α-Galactosidase A (α-Gal A) activity and analysis of the GLA gene were performed.

Results

Among 3,360 patients who underwent transthoracic echocardiography in our echo-lab during the study period, 30 patients (0.89%; 19 men, mean age 58 ± 18.2 years) were selected. FD was diagnosed in 3 (10%) unrelated patients. Three different GLA gene mutations were detected, one of them [mutation c.388A > G (p.Lys130Glu) in exon 3] never described before. Moreover, probands' familiar genetic screening allowed the identification of 5 other subjects affected by FD.

Conclusion

In a metropolitan area not previously investigated, among patients with LVH of unknown origin associated with other “red flags,” undergoing genetic screening, the prevalence of FD was very high (10%). Our results highlight the importance of an echocardiographic- and clinical-oriented genetic screening for FD in patients with uncommon cause of LVH.

[Cardiovascular management of patients with chronic myeloid leukemia treated with BCR-ABL tyrosine kinase inhibitors: it is time for a shared management]

Chronic myeloid leukemia is a rare myeloproliferative disease, characterized by a chromosomal translocation detected in 95% of cases, defined as "Philadelphia chromosome", encoding for the BCR-ABL fusion protein with continuous activation of the tyrosine kinase domain. Over the last 20 years, treatment has been revolutionized by the use of BCR-ABL tyrosine kinase inhibitors (TKI). Imatinib is the first TKI approved with a good cardiovascular safety profile, while some second-generation (nilotinib and dasatinib) and third-generation (ponatinib) drugs, developed to overcame drug resistance, can be associated with cardiovascular adverse events. The major adverse effect of dasatinib is pulmonary hypertension, reversible after treatment discontinuation. Conversely, nilotinib or ponatinib assumption is associated with a higher incidence of ischemic events, including coronary artery disease, cerebral stroke and peripheral arterial disease. Therefore, the management of patients receiving TKI therapy should include an integrated multidisciplinary evaluation and follow-up, involving highly specialized figures such as a cardiologist, hematologist and/or oncologist and the application of dedicated pathways, in order to prevent the onset or manage cardiovascular complications associated with these drugs.

Negative prognostic impact of right ventricular free wall strain in patients with functional mitral regurgitation undergoing transcatheter edge-to-edge repair

Funding Acknowledgements

Type of funding sources: None.

Backgrounds

although right ventricular (RV) systolic dysfunction seems to be associated with adverse outcome after transcatheter edge-to-edge mitral valve repair (TEER) with the MitraClip system, the prognostic value of RV free wall strain in this setting has not been yet investigated. 

Purpose

aim of this study is to evaluate RV free wall strain as predictor of outcome in patients with severe or moderate-to-severe functional MR undergoing TEER and its prognostic role compared with tricuspid annular plane systolic excursion (TAPSE).

Methods

102 patients [73 (IQR 66.8-77.0) years, 73 males (71.6%)] were retrospectively selected from March 2012 to February 2021. Echocardiograms were performed by using General Electric machines. RV free wall strain was assessed through RV modified apical 4-chamber view, setting the region of interest to minimum size (Figure 1). Values of RV free wall strain &gt;-20% were recognized as abnormal. We considered a composite endpoint including rehospitalization for heart failure (HF) and overall death as primary outcome. Secondary outcomes were overall death, cardiac death and rehospitalization for HF. All patients were assessed at the longest available follow-up [median 22.1 (IQR 9.7-49.3) months].

Results

primary outcome was found in 60 (58.8%) patients, while secondary outcomes, i.e. overall death, cardiac death and rehospitalization for HF, were found respectively in 50 (50.0%), 31 (30.4%) and 36 (35.3%) patients. Mean TAPSE was 16.7 ± 4.0 mm and mean RV free wall strain was -16.9 ± 6.0%. At univariable analysis both TAPSE (HR 0.907, CI 0.848-0.970, p value 0.004) and RV free wall strain (HR 0.937, CI 0.897-0.979, p value 0.004) were significantly associated with the primary outcome. Kaplan-Meier survival curves showed that patients with TAPSE &lt;17 mm had a lower survival free from the composite outcome compared with those with TAPSE ≥17 mm (Log-Rank = 0.030); patients with RV free wall strain value &gt; -20% also showed a lower survival free from the composite outcome compared with patients with RV free wall strain ≤-20% (Log Rank 0.004). Among patients with preserved RV systolic longitudinal function as indicated by TAPSE ≥17 mm, subjects with RV free wall strain &gt;-20% had a significantly higher incidence of the composite outcome compare with those with RV free wall strain ≤-20% (Log-Rank = 0.008, Figure 2). Conversely, no difference was found among patients with TAPSE &lt;17 mm. 

Conclusions

RV dysfunction assessed either by TAPSE and RV free wall strain is associated with poorer outcome in patients with severe or moderate-to-severe functional MR undergoing TEER. Compared with TAPSE, RV free wall strain seems to be superior in identifying patients at higher risk of adverse events during follow-up. Our data encourage the use of this speckle tracking-derived echocardiographic parameter in routinely evaluation of patients with functional MR candidate for TEER. Abstract Figure.  Abstract Figure 2

Mitral regurgitation and in-hospital mortality in patients with heart failure and low flow low gradient aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Aim

this study sought to determine the prevalence, clinical impact, and in-hospital outcome of moderate to severe mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis (LFLG-AS) hospitalized for heart failure (HF).

Methods

Patients with aortic valve thickness and aortic velocities &gt;2.5 m/s hospitalized for heart failure in a single referral center were prospectively enrolled from 2013 to 2021.

LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient &lt;40 mmHg and stroke volume index &lt;36 ml/m2. Complete demographic, clinical characteristics and echocardiographic data were collected. Mitral regurgitation severity was graded according to current guidelines. Patients were divided into two subgroups according to MR severity: no/mild MR vs moderate/severe MR. In hospital all cause death has been considered as the primary outcome.

Results

A total of 136 patients  (78 ± 9 yy; 68 (50%) male) hospitalized for HF with a new diagnosis of LFLG-AS were included in the study.

The most frequent comorbidities were hypertension (121, 89%), dyslipidemia (106, 78%), chronic kidney disease (85, 63%), diabetes (56, 41%) and obesity (44, 32%). Atrial fibrillation/flutter was detected in 61 (45%) patients. Moderate to severe MR was detected in 33%. Mean functional NYHA class was 2,8 ± 0,8.

Concerning echocardiographic evaluation, the mean gradient of the aortic valve was 26 ± 7 mmHg and the mean iAVA was 0.42 ± 0.10 cm2/m2. The mean left ventricular ejection fraction (LV EF) was 46 ± 13%. Paradoxical LFLG-AS with a preserved LV EF was detected in 73 patients (54%) and the LFLG-AS with a low LV EF was detected in 63 (46%).

In this population, 26 patients (19%) underwent surgical valvular replacement, 15 patients (11%) had aortic percutaneous valvuloplasty and 33 patients (24%) underwent TAVI. The remaining patients (45%, n = 62) were maintained under optimized medical therapy.

In-hospital death occurred in 17 (12,5%) patients (just 1 for non-cardiovascular causes).

Moderate/severe MR was detected in 44 (33%) patients.

When comparing the two subgroups statistically significant differences between age (p = 0,035), male sex (p = 0,028), atrial fibrillation/flutter (p = 0,003), obesity (p = 0,040) and in-hospital mortality (p = 0,013) were detected. In the overall population the multivariate regression analysis showed that only the presence of moderate /severe MR was a significant independent predictor of all-cause in-hospital death (p = 0.017 ; OR 3.571 ; IC  1.257-10.151).

Conclusion. Moderate to severe MR is frequently detected in patients with LFLG AS and HF. In this peculiar cohort significant MR has a negative impact on outcome and is independently associated with in-hospital mortality.

Treatment and Outcome of Patients With Coronary Artery Ectasia: Current Evidence and Novel Opportunities for an Old Dilemma

Coronary artery ectasia (CAE) is defined as a diffuse or focal dilation of an epicardial coronary artery, which diameter exceeds by at least 1. 5 times the normal adjacent segment. The term ectasia refers to a diffuse dilation, involving more than 50% of the length of the vessel, while the term aneurysm defines a focal vessel dilation. CAE is a relatively uncommon angiographic finding and its prevalence ranges between 0.3 and 5% of patients undergoing coronary angiography. Although its pathophysiology is still unclear, atherosclerosis seems to be the underlying mechanism in most cases. The prognostic role of CAE is also controversial, but previous studies reported a high risk of cardiovascular events and mortality in these patients after percutaneous coronary intervention. Despite the availability of different options for the interventional management of patients with CAE, including covered stent implantation and stent-assisted coil embolization, there is no one standard approach, as therapy is tailored to the individual patient. The abnormal coronary dilation, often associated with high thrombus burden in the setting of acute coronary syndromes, makes the interventional treatment of CAE patients challenging and often complicated by distal thrombus embolization and stent malapposition. Moreover, the optimal antithrombotic therapy is debated and includes dual antiplatelet therapy, anticoagulation, or a combination of them. In this review we aimed to provide an overview of the pathophysiology, classification, clinical presentation, natural history, and management of patients with CAE, with a focus on the challenges for both clinical and interventional cardiologists in daily clinical practice.

Sacubitril/valsartan reduces indications for arrhythmic primary prevention in heart failure with reduced ejection fraction: insights from DISCOVER-ARNI, a multicenter Italian register

Aims

This sub-study deriving from a multicentre Italian register [Deformation Imaging by Strain in Chronic Heart Failure Over Sacubitril-Valsartan: A Multicenter Echocardiographic Registry (DISCOVER)-ARNI] investigated whether sacubitril/valsartan in addition to optimal medical therapy (OMT) could reduce the rate of implantable cardioverter-defibrillator (ICD) indications for primary prevention in heart failure with reduced ejection fraction (HFrEF) according to European guidelines indications, and its potential predictors.

Methods and results

In this observational study, consecutive patients with HFrEF eligible for sacubitril/valsartan from 13 Italian centres were included. Lack of follow-up or speckle tracking data represented exclusion criteria. Demographic, clinical, biochemical, and echocardiographic data were collected at baseline and after 6 months from sacubitril/valsartan initiation. Of 351 patients, 225 (64%) were ICD carriers and 126 (36%) were not ICD carriers (of whom 13 had no indication) at baseline. After 6 months of sacubitril/valsartan, among 113 non-ICD carriers despite having baseline left ventricular (LV) ejection fraction (EF) ≤ 35% and New York Heart Association (NYHA) class = II-III, 69 (60%) did not show ICD indications; 44 (40%) still fulfilled ICD criteria. Age, atrial fibrillation, mitral regurgitation > moderate, left atrial volume index (LAVi), and LV global longitudinal strain (GLS) significantly varied between the groups. With receiver operating characteristic curves, age ≥ 75 years, LAVi ≥ 42 mL/m2 and LV GLS ≥-8.3% were associated with ICD indications persistence (area under the curve = 0.65, 0.68, 0.68, respectively). With univariate and multivariate analysis, only LV GLS emerged as significant predictor of ICD indications at follow-up in different predictive models.

Conclusions

Sacubitril/valsartan may provide early improvement of NYHA class and LVEF, reducing the possible number of implanted ICD for primary prevention in HFrEF. Baseline reduced LV GLS was a strong marker of ICD indication despite OMT. Early therapy with sacubitril/valsartan may save infective/haemorrhagic risks and unnecessary costs deriving from ICDs.

600 Validation of the academic research consortium high bleeding risk criteria in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis of 10 studies and 67 862 patients

Aims

The Academic Research Consortium for High Bleeding Risk (ARC-HBR) has recently proposed, by consensus, 20 clinical criteria for the assessment of the bleeding risk after percutaneous coronary intervention (PCI). A major criterion was defined as any individual clinical condition conferring in isolation a risk for major bleeding ≥4% up to 1 year after PCI; instead, a minor criterion was considered to confer a bleeding risk of &lt; 4%. The aim of this meta-analysis was to assess the performance of the ARC-HBR criteria in stratifying the risk of bleeding and ischaemic events after PCI.

Methods and results

MEDLINE, COCHRANE, Web of Sciences, and SCOPUS were searched for studies aimed at validating the ARC-HBR criteria in patients treated with PCI. The primary outcome measure of this meta-analysis was major bleeding. The analysis included 10 studies encompassing 67 862 patients undergoing PCI; the HBR definition was fulfilled in 44.7% of the cases. The risk of major bleeding was significantly higher in HBR vs. Non-HBR group (RR: 2.56, 95% CI: 2.28–2.89). The average C-statistic was 0.64 (95% CI: 0.60–0.68), indicating modest discrimination. The risk of intracranial haemorrhage, gastrointestinal bleeding, fatal bleeding, ischaemic stroke, cardiac death and all-cause death was higher in HBR vs. Non-HBR group. Despite a higher incidence of myocardial infarction and stent thrombosis in patients deemed at HBR, the rate of target lesion revascularization was comparable between groups (RR, 1.01, 95% CI: 0.88–1.16). When assessed in isolation, the mean cumulative incidence of major bleeding at 1 year exceeded the cut-off value of 4% for all the major criteria and for two out of six minor criteria, including age ≥75 years and moderate chronic kidney disease (CKD) (Figure).

Conclusions

The ARC-HBR definition identifies patients at higher risk of major bleeding and other adverse cardiovascular events after PCI. Almost all major criteria, but also two of the minor criteria, were individually associated with rates of major bleeding above 4% thus fulfilling the definition of major HBR criteria. These findings corroborate the ability of ARC-HBR major criteria in identifying PCI patients who are more likely to develop adverse events, but also suggest caution in the decision making of patients with isolated minor criteria, including age ≥ 75 years and moderate CKD.

535 Right ventricular dysfunction is independent predictor of in-hospital mortality in patients with low flow low gradient aortic stenosis

Aims

Aim of the study is to assess the prevalence and in-hospital death in patients with low flow low gradient aortic stenosis (LFLG-AS) and right ventricular dysfunction (RVD) hospitalized for heart failure in a single referral centre.

Methods and results

Complete demographic, clinical characteristics, and imaging data were collected. Patients with LFLG AS hospitalized for heart failure were prospectively enrolled from 2013 to 2021. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient &lt; 40 mmHg, and stroke volume index &lt;36 ml/m2. RVD was defined as tricuspid annular plane systolic excursion (TAPSE) &lt; 16 mm at baseline in apical four chamber view according to current guidelines. Patients were divided into two subgroups according to the presence or absence of RVD. In hospitals all cause death has been considered as the primary outcome. A total of 130 patients [78 ± 10 yy; 67 (51%) male] with new diagnosis of LF-LG AS were included in the study. The most frequent comorbidities were hypertension (88.5%; n = 114), dyslipidaemia (74%; n = 96), and diabetes (38%; n = 49). Concomitant coronary artery disease and history of stroke were reported in 19% (n = 24) and 9% (n = 11), respectively. Society of thoracic surgeons score in overall population was 12.6 ± 4.5. Regarding echocardiographic evaluation, the mean transaortic gradient was 25.81 ± 7.42 mmHg and the mean iAVA was 0.42 ± 0.10 cm/m2. The mean left ventricular ejection fraction (LV EF) was 46 ± 13%. LFLG AS with a preserved LV EF was detected in 69 patients (53%) and the LFLG AS with a low LV EF was detected in 61 patients (47%). 26 patients (20%) underwent surgical valve replacement, 14 patients (11%) had aortic percutaneous valvuloplasty and 31 patients (24%) underwent TAVI. The remaining patients (45%, n = 59) were maintained under optimized medical therapy. In-hospital death occurred in 16 patients. When compared patients with RVD with those without a higher prevalence of atrial fibrillation/flutter (n = 21, 36%; P = 0.042) and in hospital death was observed (n = 8; 28%; n = 8, 8%; P = 0.026). In the overall population at multivariate regression analysis only RVD was a significant independent predictor of all-cause in-hospital death (P = 0.028; OR: 3.44; CI: 1.146–10.334).

Conclusions

RVD can be detected in more than one quarter of patient with new diagnosis of LFLG AS and is an independent predictor of all-cause in-hospital death. Quantification of right ventricular systolic function in these complex population give important information in identifying patients and higher risk requiring more aggressive therapy.

604 Echocardiographic assessment of right ventricular function and pulmonary pressures in hospitalized patients with COVID-19

Aims

Pulmonary involvement in Coronavirus 19 disease (COVID-19) may affect right ventricular (RV) function and pulmonary pressures resulting in further deterioration of patient clinical status. However, the prognostic value of echocardiographic parameters including tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (PASP), and TAPSE/PASP ratio has been poorly investigated in this clinical setting.

Methods and results

This is a multicentre Italian study including patients admitted for severe COVID-19 in seven Italian Hospitals. Transthoracic echocardiography (TTE) was performed within 48 h from admission in all cases. In-hospital mortality and pulmonary embolism (PE) were identified as the primary and secondary outcome measures, respectively. Of 1401 patients with severe COVID-19, 227 (16.1%) subjects underwent TTE within 48 h from admission and were included in this study. The mean age was 68 ± 13 years and 62.6% of patients were male. Intensive care unit (ICU) admission was reported in 73 patients (32.2%); ICU patients showed lower left ventricular ejection fraction (LVEF), lower TAPSE, and higher LV end systolic volume and PASP values than non-ICU patients. Also, ICU patients showed higher incidence of acute respiratory distress syndrome (82.2% vs. 30.5%; P &lt; 0.001), acute cardiac injury (46.6% vs. 22.7%; P &lt; 0.001), acute heart failure (34.2% vs. 9.1%; P &lt; 0.001), and death (63.9% vs. 14.3%; P &lt; 0.001) compared with non-ICU patients. By stratifying the study population into tertiles according to TAPSE, PASP, and TAPSE/PASP values, patients in the lower TAPSE and TAPSE/PASP ratio tertiles, and those in the higher PASP tertile, showed a significantly higher incidence of death during the hospitalization. At univariable logistic regression analysis, TAPSE, PASP, and TAPSE/PASP were significantly associated with a higher risk of death and PE, both in patients admitted or not to ICU. After propensity score weighting adjustment for multiple baseline potential confounders and further multivariable adjustment for LVEF value, the regression analysis showed that TAPSE, PASP and TAPSE/PASP were independently associated with risk of death (TAPSE: OR: 0.85, CI: 0.74–0.97, P = 0.017; PASP: OR: 1.08, CI: 1.03–1.13, P = 0.002; TAPSE/PASP: OR: 0.02, CI: 0.02 × 10−1—0.20, P &lt; 0.001) and with the risk of PE (TAPSE: OR: 0.70, CI: 0.60–0.82, P &lt; 0.001; PASP: OR: 1.10, CI: 1.05–1.14, P &lt; 0.001; TAPSE/PASP: OR: 0.02 × 10−1, CI: 0.01 × 10−2—0.04, P &lt; 0.001) during the hospitalization. The risk death according to TAPSE, PASP, and TAPSE/PASP ratio tertiles was estimated considering discharge alive as competing risk (Figure). The lowest TAPSE and TAPSE/PASP tertiles, and the highest PASP tertile, were significantly associated with poorer survival during the hosptialization (P &lt; 0.001).

Conclusions

Echocardiographic evidence of RV systolic dysfunction, increased PASP and a poor RV-arterial coupling assessed by TAPSE/PAPS ratio may help to identify COVID-19 patients at higher risk of mortality and PE during the hospitalization.

618 Clinical conditions and echocariographic parameters associated with mortality in COVID-19

Aims

Coronavirus disease 2019 (COVID-19) is a recently recognized viral infective disease which can be complicated by acute respiratory stress syndrome (ARDS) and cardiovascular complications including severe arrhythmias, acute coronary syndromes, myocarditis, and pulmonary embolism. The aim of the present study was to identify the clinical conditions and echocardiographic parameters associated with in-hospital mortality in COVID-19.

Methods and results

This is a multicentre retrospective observational study including seven Italian centres. Patients hospitalized with COVID-19 from 1 March to 22 April 2020, were included into the study population. The association between baseline variables and the risk of in-hospital mortality was assessed through multivariable logistic regression and competing risk analyses. Out of 1401 patients admitted at the participating centres with confirmed diagnosis of COVID-19, 226 (16.1%) underwent transthoracic echocardiography (TTE) and were included in the present analysis. The mean age was 68.9 ± 13.9 years and male sex was reported in 141 patients (62.4%). Admission in intensive care unit was required for 72 patients (31.9%); in-hospital death occurred in 68 patients (30.1%). At multivariable analysis, left ventricular ejection fraction (LVEF, P < 0.001), tricuspid annular plane systolic excursion (TAPSE, P < 0.001), and ARDS (P < 0.001) were independently associated with in-hospital mortality. At competing risk analysis, we found a significantly higher risk of mortality in patients with ARDS vs. those without ARDS (HR: 7.66; CI: 3.95–14.8), in patients with TAPSE ≤ 17 mm vs. those with TAPSE > 17 mm (HR: 5.08; CI: 3.15–8.19), and in patients with LVEF ≤ 50% vs. those with LVEF > 50% (HR: 4.06; CI: 2.50–6.59) (Figure).

Conclusions

TTE might be a useful tool in risk stratification of patients with COVID-19. In particular, reduced LVEF as well as reduced TAPSE may help to identify patients at higher risk of death during hospitalization. Our preliminary findings need to be confirmed in larger, prospective studies.

490 Right ventricular free wall longitudinal strain negatively impacts prognosis of patients with functional mitral regurgitation undergoing transcatheter edge-to-edge mitral valve repair

Aims

Although right ventricular (RV) systolic dysfunction seems to be associated with adverse outcome after transcatheter edge-to-edge mitral valve repair (TEER) with the MitraClip system, the prognostic value of RV free wall longitudinal strain (RVFWLS) in this setting has not been yet investigated. The aim of this study is to evaluate RVFWLS as predictor of outcome in patients with severe or moderate-to-severe functional MR undergoing TEER and its prognostic role compared with tricuspid annular plane systolic excursion (TAPSE).

Methods and results

102 patients [73 (IQR: 66.8–77.0) years, 73 males (71.6%)] were retrospectively selected from March 2012 to February 2021. Echocardiograms were performed by using General Electric machines. RVFWLS was assessed through RV modified apical 4-chamber view, setting the region of interest to minimum size. Values of RVFWLS &gt; −20% were recognized as abnormal. We considered a composite endpoint including rehospitalization for heart failure (HF) and overall death as primary outcome. Secondary outcomes were overall death, cardiac death and rehospitalization for HF. All patients were assessed at the longest available follow-up [median 22.1 (IQR: 9.7–49.3) months]. Baseline clinical and echocardiographic characteristics are listed in Table 1. Primary outcome was found in 60 (58.8%) patients, while secondary outcomes, i.e. overall death, cardiac death and rehospitalization for HF, were found respectively in 50 (50.0%), 31 (30.4%), and 36 (35.3%) patients. Mean TAPSE was 16.7 ± 4.0 mm and mean RVFWLS was −16.9 ± 6.0%. At univariable analysis both TAPSE (HR: 0.907, CI: 0.848–0.970, P-value: 0.004) and RVFWLS (HR: 0.937, CI: 0.897–0.979, P-value: 0.004) were significantly associated with the primary outcome. Kaplan–Meier survival curves showed that patients with TAPSE &lt;17 mm had a lower survival free from the composite outcome compared with those with TAPSE ≥17 mm (Log-Rank = 0.030); patients with RVFWLS value &gt; −20% also showed a lower survival free from the composite outcome compared with patients with RVFWLS ≤ −20% (Log Rank 0.004). Among patients with preserved RV systolic longitudinal function as indicated by TAPSE ≥ 17 mm, subjects with RVFWLS &gt; −20% had a significantly higher incidence of the composite outcome compare with those with RVFWLS ≤ −20% (Log-Rank = 0.008). Conversely, no difference was found among patients with TAPSE &lt;17 mm.

Conclusions

RV dysfunction assessed either by TAPSE and RVFWLS is associated with poorer outcome in patients with severe or moderate-to-severe functional MR undergoing TEER. Compared with TAPSE, RVFWLS seems to be superior in identifying patients at higher risk of adverse events during follow-up. Our data encourage the use of this speckle tracking-derived echocardiographic parameter in routinely evaluation of patients with functional MR candidate for TEER.

747 Long-term effects of pharmacological treatment in patients with takotsubo syndrome with or without hypertension: a report from the takotsubo Italian network

Aims

Hypertension (HT) is one of the most frequent comorbidities reported in patients with Takotsubo syndrome (TTS). However, the clinical outcome as well as the effect of pharmacological treatment on long-term follow-up have never been investigated in this cohort. To investigate the impact of the pharmacological treatment with beta-blocker (BB) and/or renin–angiotensin–aldosterone system inhibitor (RAASi) on long-term outcome of TTS patients with and without HT.

Methods and results

This study included TTS patients prospectively included in the Takotsubo Italian Network register from January 2007 to December 2018. The study population was divided in two groups according to the presence or not of HT. The effect of BB and RAASi at discharge was evaluated in these groups. The primary outcome was the composite of all-cause death and TTS recurrence; secondary outcomes were the single components of the primary outcome. The propensity score weighting technique was employed to account for potential selection bias in treatment assignment at discharge. The study population included 825 patients [median age 72 (63–78) years; 8.1% were males]; 525 (63.6%) patients had history of HT and 300 (36.4%) patients did not. At median follow-up of 24.0 months (11.0–38.0), the primary outcome occurred in 102 patients (12.4%); all-cause death and TTS recurrence were reported in 76 (9.2%) and 33 (4.0%), respectively. There were no differences in terms of the primary outcome (adjusted HR: 1.082; 95% CI: 0.689–1.700; P = 0.733), all-cause death (adjusted HR: 1.214; 95% CI: 0.706–2.089; P = 0.483) and TTS recurrence (adjusted HR: 0.795; 95% CI: 0.373–1.694; P = 0.552) between patients with vs. without HT. Among patients with HT, those receiving BB at discharge showed a significantly lower risk of the primary outcome (adjusted HR: 0.375; 95% CI: 0.228–0.617; P &lt; 0.001) compared with patients not receiving BB. There was also a significantly lower risk of all-cause death (adjusted HR: 0.381; 95% CI: 0.217–0.666; P &lt; 0.001) and TTS recurrence (adjusted HR: 0.393; 95% CI: 0.155–0.998; P = 0.049) in patients treated with BB. Among patients without HT, there was no significant association of BB treatment with any of the study outcomes. RAASi treatment showed no significant effect on the primary and secondary outcomes. These results were consistent between patients with and without HT.

Conclusions

TTS patients with HT patients experienced a survival benefit from BB treatment in terms of both all-cause death and TTS recurrence; this effect was not confirmed in patients without HT. Conversely, RAASi did not affect long-term outcome, independently from the coexistence of HT. Albeit hypothesis-generating, a such evidence supports a tailored pharmacological therapy after discharge in TTS patients taking into account the coexistence of HT.

454 Mitral regurgitation and in-hospital mortality in patients with heart failure and low flow low gradient aortic stenosis

Aims

This study sought to determine the prevalence, clinical impact, and in-hospital outcome of moderate to severe mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis (LFLG-AS) hospitalized for heart failure (HF).

Methods and results

Patients with aortic valve thickness and aortic velocities &gt;2.5 m/s hospitalized for heart failure in a single referral centre were prospectively enrolled from 2013 to 2021. LFLG-AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient &lt;40 mmHg, and stroke volume index &lt;36 ml/m2. Complete demographic, clinical characteristics, and echocardiographic data were collected. Mitral regurgitation severity was graded according to current guidelines. Patients were divided into two subgroups according to MR severity: no/mild MR vs. moderate/severe MR. In hospital all cause death has been considered as the primary outcome. A total of 136 patients [78 ± 9 yy; 68 (50%) male] hospitalized for HF with a new diagnosis of LFLG-AS were included in the study. The most frequent comorbidities were hypertension (121, 89%), dyslipidemia (106, 78%), chronic kidney disease (85, 63%), diabetes (56, 41%), and obesity (44, 32%). Atrial fibrillation/flutter was detected in 61 (45%) patients. Moderate to severe MR was detected in 33%. Mean functional NYHA class was 2.8 ± 0.8. Concerning echocardiographic evaluation, the mean gradient of the aortic valve was 26 ± 7 mmHg and the mean iAVA was 0.42 ± 0.10 cm2/m2. The mean left ventricular ejection fraction (LV EF) was 46 ± 13%. Paradoxical LFLG-AS with a preserved LV EF was detected in 73 patients (54%) and the LFLG-AS with a low LV EF was detected in 63 (46%). In this population, 26 patients (19%) underwent surgical valvular replacement, 15 patients (11%) had aortic percutaneous valvuloplasty, and 33 patients (24%) underwent TAVI. The remaining patients (45%, n = 62) were maintained under optimized medical therapy. In-hospital death occurred in 17 (12.5%) patients (just 1 for non-cardiovascular causes). Moderate/severe MR was detected in 44 (33%) patients. When comparing the two subgroups statistically significant differences between age (P = 0.035), male sex (P = 0.028), atrial fibrillation/flutter (P = 0.003), obesity (P = 0.040), and in-hospital mortality (P = 0.013) were detected. In the overall population the multivariate regression analysis showed that only the presence of moderate/severe MR was a significant independent predictor of all-cause in-hospital death (P = 0.017; OR: 3.571; CI: 1.257–10.151).

Conclusions

Moderate to severe MR is frequently detected in patients with LFLG AS and HF. In this peculiar cohort significant MR has a negative impact on outcome and is independently associated with in-hospital mortality.

Clinical conditions and echocardiographic parameters associated with mortality in COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a recently recognized viral infective disease which can be complicated by acute respiratory stress syndrome (ARDS) and cardiovascular complications including severe arrhythmias, acute coronary syndromes, myocarditis and pulmonary embolism. The aim of the present study was to identify the clinical conditions and echocardiographic parameters associated with in-hospital mortality in COVID-19.

METHODS

This is a multicentre retrospective observational study including seven Italian centres. Patients hospitalized with COVID-19 from 1 March to 22 April 2020 were included into study population. The association between baseline variables and risk of in-hospital mortality was assessed through multivariable logistic regression and competing risk analyses.

RESULTS

Out of 1401 patients admitted at the participating centres with confirmed diagnosis of COVID-19, 226 (16.1%) underwent transthoracic echocardiography (TTE) and were included in the present analysis. In-hospital death occurred in 68 patients (30.1%). At multivariable analysis, left ventricular ejection fraction (LVEF, P < .001), tricuspid annular plane systolic excursion (TAPSE, P < .001) and ARDS (P < .001) were independently associated with in-hospital mortality. At competing risk analysis, we found a significantly higher risk of mortality in patients with ARDS vs those without ARDS (HR: 7.66; CI: 3.95-14.8), in patients with TAPSE ≤17 mm vs those with TAPSE >17 mm (HR: 5.08; CI: 3.15-8.19) and in patients with LVEF ≤50% vs those with LVEF >50% (HR: 4.06; CI: 2.50-6.59).

CONCLUSIONS

TTE might be a useful tool in risk stratification of patients with COVID-19. In particular, reduced LVEF and reduced TAPSE may help to identify patients at higher risk of death during hospitalization.

Epidemiology, Pathogenesis, and Clinical Course of Takotsubo Syndrome

Takotsubo syndrome is an acute reversible heart failure syndrome, most frequently seen in postmenopausal women and precipitated generally by significant emotional stress or physical illness. A sudden sympathetic activation seems to play a key role in the pathophysiology, but growing evidence is emerging about the role of inflammation in the subacute and chronic phases. An incidence of life-threatening complications occurring in the acute phase and at long-term follow-up has been demonstrated, comparable with the acute coronary syndrome. Multimodality imaging could be useful to stratify in-hospital and long-term prognosis. The efficacy of specific medical treatments in long-term follow-up should be investigated.

Predictors of Recurrent Ischemic Events in Patients With ST-Segment Elevation Myocardial Infarction

Little is known about the predictors recurrent ischemic events in patients with ST-segment elevation myocardial infarction (STEMI). This study aimed at investigating the predictors of recurrent myocardial infarction (MI) at long-term follow-up in a real-world STEMI cohort. All consecutive STEMI patients who underwent emergent coronary angiography and primary percutaneous coronary intervention between February 2013 and June 2019 at our institution were included. The primary outcome was recurrent MI; secondary outcomes were all-cause death, target vessel revascularization (TVR), in-stent restenosis, definite stent thrombosis (ST) and non-TVR. The study population included 724 STEMI patients; at median follow-up of 803 (324 to 1,394) days, the primary outcome was reported in 70 patients (10.1%). All-cause death occurred in 6.8%, TVR in 4.2%, in-stent restenosis in 2.5%, and ST in 1.9% of cases. At multivariable analysis, diabetes (hazard ratio [HR] = 1.18), serum level of lipoprotein(a) [Lp(a), HR = 1.01], and angiographic evidence of restenotic lesion (HR = 2.98) resulted independent predictors of recurrent MI. Kaplan-Meier analysis confirmed that diabetes, restenotic lesion, and differential Lp(a) risk range values, identified patients with lower long-term survival free from recurrent MI. Lp(a) level ≥ 30 mg/dL had an incremental prognostic stratification capability in patients with diabetes (HR = 5.34), and in patients with both diabetes and restenotic lesion (HR = 17.07). In conclusion, in this contemporary cohort of STEMI patients, diabetes, Lp(a) serum levels and restenotic lesions were independently associated with recurrent MI at long term. The coexistence of Lp(a) level ≥ 30 mg/dL showed an incremental risk stratification capability, supporting its implementation for long-term prognostic assessment in this high-risk clinical setting.

Normal Values of Left Atrial Size and Function and the Impact of Age: Results of the World Alliance Societies of Echocardiography Study

BACKGROUND

Left atrial (LA) evaluation includes volumetric and functional parameters with an abundance of diagnostic and prognostic implications. Solid normal reference ranges are compulsory for accurate interpretation in individual patients, but previous studies have yielded mixed conclusions regarding the effects of age, sex, and/or race. The present report from the World Alliance Societies of Echocardiography study focuses on two-dimensional (2D) and three-dimensional (3D) measures of LA structure and function, with subgroup analysis by age, sex, and race.

METHODS

Transthoracic 2D and 3D echocardiographic images were obtained in 1,765 healthy individuals (901 men, 864 women) evenly distributed among age subgroups: 18 to 40 years (n = 745), 41 to 65 years (n = 618), and >65 years (n = 402); the racial distribution was 38.4% white, 39.9% Asian, and 9.7% black. Images were analyzed using dedicated LA analysis software to measure LA volumes and phasic function from 3D volume and 2D strain curves.

RESULTS

Three-dimensional maximum and minimum LA volumes adjusted for body surface area were nearly identical for men and women, but women demonstrated higher 3D total and passive emptying fractions (EFs). Two-dimensional reservoir strain was similar for both sexes. Age was associated with an incremental rise in LA volumes alongside characteristic shifts in functional indices. Total 2D EF and reservoir and conduit strain varied inversely with age, counteracted by higher booster strain, with a greater magnitude of effect in women. Active 3D EF was significantly higher, while total and passive EFs decreased with age. Interracial differences were noted in LA volumes, without substantial differences in functional indices.

CONCLUSION

Although similar normal values for LA volumes and strain can be applied to both sexes, meaningful differences in LA size occur with aging. Indices of function also shift with age, with a compensatory rise in booster function, which may serve to counteract observed lower total and passive EFs. Defining age-associated normal values may help differentiate age-associated "healthy" LA aging from pathologic processes.

Dynamic Left Intraventricular Obstruction Phenotype in Takotsubo Syndrome

Takotsubo syndrome (TTS) is characterized by acute, generally transient left ventricular (LV) dysfunction. Although TTS has been long regarded as a benign condition, recent evidence showed that rate of acute complications and in-hospital mortality is comparable to that of patients with acute coronary syndrome. In particular, the prevalence of cardiogenic shock ranges between 6% and 20%. In this setting, detection of mechanisms leading to cardiogenic shock can be challenging. Besides a severely impaired systolic function, onset of LV outflow tract obstruction (LVOTO) together with mitral regurgitation related to systolic anterior motion of mitral valve leaflets can lead to hemodynamic instability. Early identification of LVOTO with echocardiography is crucial and has important implications on selection of the appropriate therapy. Application of short-acting b1-selective betablockers and prudent administration of fluids might help to resolve LVOTO. Conversely, inotrope agents may increase basal hypercontractility and worsen the intraventricular pressure gradient. To date, outcomes and management of patients with TTS complicated by LVOTO as yet has not been comprehensively investigated.