Prognosis prediction in cardiac amyloidosis by cardiac magnetic resonance imaging: a systematic review with meta-analysis

Cardiac involvement is the foremost determinant of the clinical progression of amyloidosis. The diagnostic role of cardiac magnetic resonance (CMR) imaging in cardiac amyloidosis has been established, but the prognostic role of various right and left CMR tissue characterization and functional parameters, including global longitudinal strain (GLS), late gadolinium enhancement (LGE), and parametric mapping, is yet to be delineated. We searched EMBASE, PubMed, and MEDLINE for studies analysing the prognostic use of CMR imaging in patients with light chain amyloidosis or transthyretin amyloidosis cardiac amyloidosis. The primary endpoint was all-cause mortality. A random effects model was used to calculate a pooled odds ratio using inverse-variance weighting. Nineteen studies with 2199 patients [66% males, median age 59.7 years, interquartile range (IQR) 58-67] were included. Median follow-up was 24 months (IQR 20-32), during which 40.8% of patients died. Both tissue characterization left heart parameters such as elevated extracellular volume [hazard ratio (HR) 3.95, 95% confidence interval (CI) 3.01-5.17], extension of left ventricular (LV) LGE (HR 2.69, 95% CI 2.07-3.49) elevated native T1 (HR 2.19, 95% CI 1.12-4.28), and functional parameters such as reduced LV GLS (HR 1.91, 95% CI 1.52-2.41) and reduced LV ejection fraction (EF; HR 1.20, 95% CI 1.17-1.23) were associated with increased all-cause mortality. Unlike the presence of right ventricular (RV) LGE (HR 3.40, 95% CI 0.51-22.54), parameters such as RV GLS (HR 2.08, 95% CI 1.6-2.69), RVEF (HR 1.13, 95% CI 1.05-1.22), and tricuspid annular systolic excursion (TAPSE) (HR 1.11, 95% CI 1.02-1.21) were also associated with mortality. In this large meta-analysis of patients with cardiac amyloidosis, CMR parameters assessing RV and LV function and tissue characterization were associated with an increased risk of mortality.

479 ECHOCARDIOGRAPHIC ESTIMQTION OF CQRDIQC POWER IN CARDIOGENIC SHOCK: CORRELATION WITH INVASIVE HEMODYNAMICS AND PROGNOSTIC IMPLICATIONS

Background

Cardiac power output (CPO) is currently used for cardiogenic shock patient's evaluation including shock phenotyping, mechanical circulatory support selection and weaning algorithms. Despite its remarkable prognostic role, CPO use is limited by the need for a Swan-Ganz catheter. Aim of this study was to evaluate the feasibility and accuracy of echocardiographic estimation of CPO compared to RHC-derived measurement. We also aimed to investigate the prognostic role of non-invasive CPO in the specific setting of cardiogenic shock.

Methods

We performed blinded echocardiography in all consecutive heart failure (HF) patients undergoing RHC as a part of their evaluation at Cardiology Department of Città della Salute e della Scienza University hospital in Turin. Echocardiographic CPO was calculated as: (cardiac output * mean arterial pressure)/451. eCPO was subsequently assessed in 80 patients admitted for cardiogenic shock in cardiac ICU of centers participating at the Altshock registry during the first 24 hours from shock onset. Primary endpoint was in-hospital MACE (death, heart transplantation or LVAD implantation during the index hospitalization).

Results

103 HF patients (57.6 ± 11.3 years, 63% males, median left ventricle ejection fraction 25% [IQR 20-51%]) were included in the derivation cohort. Mean invasive CPO was 0.72 ± 0.27 W, while eCPO was 0.74 ± 0.27 W. eCPO showed a good correlation with invasive CPO (Pearson r: 0.96, p<0.001). In the Altshock registry cohort (80 patients, 81% males, mean age 62.5 ± 14.4 years, in-hospital mortality 31.4%) eCPO <0.6 (HR 2,48 [95% CI 1,06 - 5,85], p=0,04), hemoglobin (p=0.005), systolic blood pressure (p=0.05) and SCAI class (p=0.02) were associated with increased risk of in-hospital MACE at univariate analysis. Echocardiographic CPO <0.6 remained significantly associated with MACE also after adjustment at multivariate Cox analysis (HR 2,87 [95% CI 1,03 - 7,96] p=0,043).

Conclusion

Echocardiographic estimation of CPO (eCPO) is feasible and showed a good agreement with invasive CPO. Reduced eCPO during the first 24 hours was associated with increased in-hospital MACE in cardiogenic shock patients.

831 ECHO-API: CORRELATION WITH INVASIVE API AND PROGNOSTIC ROLE IN HEART FAILURE

Background

The benefit of invasive hemodynamic assessment in the setting of heart failure (HF) is still controversial. Increased right and left filling pressure have been shown to be associated with adverse prognosis, while reduced cardiac index (CI) has not. For this reason, novel hemodynamic indexes have been developed aiming to better describe the cardiac function in different loading conditions. In this context, the aortic pulsatility index (API) is a hemodynamic variable integrating LV function and loading condition which has the potential to better predict clinical outcome. It is calculated as systolic blood pressure (SBP) minus diastolic blood pressure (DBP) divided by pulmonary capillary wedge pressure (PCWP); the difference between SBP and DBP, known as arterial pulse pressure, correlates with SV, while PCWP is a marker of the degree of pulmonary congestion. API has been shown to predict long-term outcomes in acute decompensated HF and advanced HF cohorts. To the best of our knowledge, hemodynamically-derived API has never been compared to echocardiography-estimated API.

Purpose

To evaluate the accuracy of API obtained with echocardiographic methods (echo-API) compared with the invasive hemodynamic measure obtained with right heart catheterization (RHC) and to explore its prognostic role in a HF cohort.

Methods

Consecutive patients referred for RHC to Città della Salute e della Scienza hospital from May 2019 to August 2022 underwent complete two-dimensional echocardiographic evaluation and RHC. Patients ≥ 18 years with either acute or chronic HF, irrespective of etiology, were included. For the calculation of Echo-API PCWP was estimated using the average E/e’ ratio. The association between echo-API with MACE (composite of death, LVAD implantation or heart transplantation) at 1 year follow-up was evaluated.

Results

112 patients were included in the analysis. They were mostly male, mean age was 57 years and the underlying heart disease was predominantly idiopathic dilated cardiomyopathy (32%), followed by ischemic (30%); mean LVEF was 35,07%.

Mean Echo-API was 3,54. Echo-API showed a significant correlation with invasive API using the Pearson correlation coefficient (r = 0,6591, 95% CI 0,4639–0,7933, p < 0,0001) and showed a linear correlation at Bland-Altman plot. At multivariate regression analysis Echo-API was significatively associated with primary outcome (OR 0.469, 95% CI 0.26–0.84, p 0,011).

Conclusions

Echocardiographically-derived aortic pulsatility index can be obtained in all patients with advanced HF and shows a good correlation with invasive API; it is associated with MACE, representing a useful tool for non-invasive hemodynamic evaluation and risk stratification.

Changes in Right Ventricular-to-Pulmonary Artery Coupling After Transcatheter Edge-to-Edge Repair in Secondary Mitral Regurgitation

BACKGROUND

Preprocedural right ventricular-to-pulmonary artery (RV-PA) coupling is a major predictor of outcome in patients with secondary mitral regurgitation (SMR) undergoing transcatheter edge-to-edge mitral valve repair (M-TEER). However, clinical significance of changes in RV-PA coupling after M-TEER is unknown.

OBJECTIVES

The aim of this study was to evaluate changes in RV-PA coupling after M-TEER, their prognostic value, and predictors of improvement.

METHODS

This was a retrospective observational study, including patients undergoing successful M-TEER (residual mitral regurgitation ≤2+ at discharge) for SMR at 13 European centers and with complete echocardiographic data at baseline and short-term follow-up (30-180 days). RV-PA coupling was assessed with the use of echocardiography as the ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP). All-cause death was assessed at the longest available follow-up starting from the time of the echocardiographic reassessment.

RESULTS

Among 501 patients included, 331 (66%) improved their TAPSE/PASP after M-TEER (responders) at short-term follow-up (median: 89 days; IQR: 43-159 days), whereas 170 (34%) did not (nonresponders). Lack of previous cardiac surgery, low postprocedural mitral mean gradient, low baseline TAPSE, high baseline PASP, and baseline tricuspid regurgitation were independently associated with TAPSE/PASP improvement after M-TEER. Compared with nonresponders, responders had lower New York Heart Association functional class and less heart failure hospitalizations at short-term follow-up. Improvement in TAPSE/PASP was independently associated with reduced risk of mortality at long-term follow-up (584 days; IQR: 191-1,243 days) (HR: 0.65 [95% CI: 0.42-0.92]; P = 0.017).

CONCLUSIONS

In patients with SMR, improvement in TAPSE/PASP after successful M-TEER is predicted by baseline clinical and echocardiographic variables and postprocedural mitral gradient, and is associated with a better outcome.

Evolution of tricuspid regurgitation after transcatheter edge-to-edge mitral valve repair for secondary mitral regurgitation and its impact on mortality

AIM

To evaluate short-term changes in tricuspid regurgitation (TR) after transcatheter edge-to-edge mitral valve repair (M-TEER) in secondary mitral regurgitation (SMR), their predictors and impact on mortality.

METHODS AND RESULTS

This is a retrospective analysis of SMR patients undergoing successful M-TEER (post-procedural mitral regurgitation ≤2+) at 13 European centres. Among 503 patients evaluated 79 (interquartile range [IQR] 40-152) days after M-TEER, 173 (35%) showed ≥1 degree of TR improvement, 97 (19%) had worsening of TR, and 233 (46%) remained unchanged. Smaller baseline left atrial diameter and residual mitral regurgitation 0/1+ were independent predictors of TR ≤2+ after M-TEER. There was a significant association between TR changes and New York Heart Association class and pulmonary artery systolic pressure decrease at echocardiographic re-assessment. At a median follow-up of 590 (IQR 209-1103) days from short-term echocardiographic re-assessment, all-cause mortality was lower in patients with improved compared to those with unchanged/worsened TR (29.6% vs. 42.3% at 3 years; log-rank p = 0.034). Baseline TR severity was not associated with mortality, whereas TR 0/1+ and 2+ at short-term follow-up was associated with lower all-cause mortality compared to TR 3/4+ (30.6% and 35.6% vs. 55.6% at 3 years; p < 0.001). A TR ≤2+ after M-TEER was independently associated with a 42% decreased risk of mortality (p = 0.011).

CONCLUSION

More than one third of patients with SMR undergoing successful M-TEER experienced an improvement in TR. Pre-procedural TR was not associated with outcome, but a TR ≤2+ at short-term follow-up was independently associated with long-term mortality. Optimal M-TEER result and a small left atrium were associated with a higher likelihood of TR ≤2+ after M-TEER.

Determinants and prognostic impact of afterload mismatch after MitraClip implantation

Introduction

Mitral transcatheter edge-to-edge repair (TEER) is a widespread option to treat mitral regurgitation in high-risk patients. The sudden reduction of mitral regurgitation (MR) following TEER abruptly eliminates the low-impedance regurgitant flow into the left atrium, leading to an increase in left ventricle (LV) afterload with possible impairment of LV systolic function, defined afterload mismatch (AM).

Purpose

To explore a new definition of AM and to analyze the determinants and prognostic role of AM in patients with functional MR (FMR) undergoing TEER.

Methods

This was an international multicenter case-control study including adult patients with severe FMR and LVEF ≤35% undergoing TEER between 2012 and 2020. AM was defined as the acute need to initiate or increase inotropic support by a vasoactive inotropic score ≥3 or the need for a mechanical circulatory support following TEER.

Results

80 patients with AM were compared to 80 consecutive patients undergoing TEER not meeting the criteria for AM. Median age was 67 years, 79% of patients were male, had a median LVEDV of 240 ml with severely reduced LVEF (median 26%) and pulmonary hypertension (median 48 mmHg). Median EROA/LVEDV ratio was 0.17 (IQR 0.12–0.24) based on which 37% of the total population presented with proportionate MR. Levosimendan was administered before TEER in 42% of patients while intravenous vasodilators in 43%. In most patients more than 1 clip were needed (2 clips in 88 patients, 3 clips in 11). Patients presenting AM more commonly had a lower EROA/LVEDV ratio (0.14 vs. 0.18, p&lt;0.001) leading to a higher percentage of patients with proportionate MR (55% vs. 22%, p&lt;0.001; Figure 1) and had more clips implanted (p=0.008). AM was graded as mild in 74% of patients, moderate in 15% and severe in 11%. At multivariate analysis, patients with proportionate MR were more likely to develop AM after TEER (OR 2.95, 95% CI: 1.32–6.60, p=0.008), while those treated with levosimendan (OR 0.32, 95% CI: 0.15–0.71, p=0.005) and/or IV vasodilators (OR 0.44, 95% CI: 0.21–0.96, p=0.040) before TEER were less likely to suffer from AM. In-hospital death occurred in 7 cases, all being part of AM group. Patients were more likely to die in-hospital if AM was more severe (OR 2.56, 95% CI: 1.19–5.54, p=0.017), and for higher grades of residual MR (OR 3.35, 95% CI: 1.27–8.79, p=0.014). The 2-year survival rate did not differ significantly between groups (66% vs 75%, HR 1.51, 95% CI: 0.73–3.12, p=0.270; Figure 2). At 2 years 51 patients (32%) were re-hospitalized for HF, independently from post-procedural AM (HR 1.36, 95% CI: 0.70–2.67, p=0.363).

Conclusions

In patients with LVEF ≤35% and severe FMR undergoing TEER, the development of AM predicted in-hospital mortality, while long-term outcomes were not affected by acute AM. The use of levosimendan or intravenous vasodilators during the pre-procedural phase reduced the risk of acute AM.

Funding Acknowledgement

Type of funding sources: None.

Echocardiographic-derived Pulmonary Artery Pulsatility Index: towards non-invasive evaluation of right ventricular function

Funding Acknowledgements

Type of funding sources: None.

Background. Pulmonary artery pulsatility index (PAPi)(1) is a powerful predictor of right ventricular failure in patients with acute inferior myocardial infarction(2) and in patients with heart failure undergoing LVAD implantation(3). PAPi derivation requires invasive right heart catheterism (RHC), thus limiting availability and seriate assessment of right ventricular function.

Purpose. Aim of the study was to evaluate accuracy and agreement of echocardiographic derived PAPi (ePAPi) compared to right heart catheterism derived PAPi in heart failure with reduced ejection fraction (HFrEF) patients.

Methods. ePAPi was defined as the ratio of pulmonary artery pulse pressure (sPAP – dPAP) to right atrial pressure (RAP). Systolic pulmonary artery pressure (sPAP) was determined from tricuspid regurgitation (TR) velocity using the simplified Bernoulli equation(4): sPAP = 4 x (peak TR jet velocity)2 + RA pressure. Diastolic pulmonary artery pressure (dPAP) was calculated as: dPAP = 4 x (end-diastolic pulmonary regurgitant velocity)2 + RA pressure. Simplified ePAPi, defined as peak TR pressure to RA pressure ratio was also investigated. Pearson and Spearman correlation tests were performed. A Bland-Altman plot analysis was performed to assess agreement between ePAPi and invasive PAPi. ROC curves were made to assess ePAPi accuracy in identifying patients with low PAPi (defined as PAPi &lt; 2 and PAPi &lt; 3.65).

Results. 66 HFrEF patients (age 59 ± 10 years, 63% males, mean EF: 35 ± 9%) underwent RHC and blinded echocardiogram in a single center Cardiology Departement. Mean invasive derived PAPi was 4.4 ± 3.6, while ePAPi was 3.9 ± 2.3. ePAPi showed an excellent correlation with invasive PAPi (Pearson r: 0.80, p &lt; 0.001; Spearman rho: 0.83, p &lt; 0.001) and good agreement as shown in Bland Altman plot (figure 1). In ROC analysis, ePAPi accurately identified patients with low hemodynamic PAPi &lt; 2 (Sensibility: 100%; Specificity: 87.2%; AUC: 0.97; Youden criterion: ePAPi &lt; 2.3) and PAPi &lt; 3.65 (Sensibility: 81.8%; Specificity: 84%; AUC: 0.89; Youden criterion: ePAPi &lt; 3.6)(figure 2). Simplified ePAPi also showed good correlation and agreement (Pearson r: 0.58, p &lt; 0.001; Spearman rho: 0.81, p &lt; 0.001).

Conclusions. In patients with HFrEF, echocardiographic derived PAPi showed a good agreement and correlation with invasive derived PAPi. ePAPi was also accurate in identifying patients with low PAPi values associated with poor outcomes and may be of interest for non-invasive right ventricular function seriate assessment. Further studies are needed to investigate prognostic implications. Abstract Figure.  Abstract Figure 2

Percutaneous coronary intervention versus coronary artery surgery for left main disease according to lesion site: A meta-analysis

BACKGROUND

Comparative data after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) disease according to lesion site (ostial/shaft vs distal) are scant. The aim of this meta-analysis was to investigate outcomes after PCI or CABG for ULMCA disease according to lesion site.

METHODS

Randomized controlled trials (RCTs) and adjusted observational studies that compared PCI versus CABG in patients with ULMCA disease and reported outcomes according to lesion site were systematically identified. Major adverse cardiovascular events (MACE; a composite of all-cause death, myocardial infarction, stroke, and repeat revascularization) and all-cause death were the co-primary end points. Individual components of MACE were secondary end points. Sensitivity analysis including RCTs only were performed for each outcome.

RESULTS

Nine studies (3 RCTs, 6 adjusted observational), encompassing 6296 patients (2274 and 4022 treated for ostial/shaft or distal ULMCA, respectively) were included. At the 5-year follow-up, there were no significant differences between CABG and PCI for MACE, death, or any other secondary outcome for ostial/shaft ULMCA lesions (MACE: hazard ratio [HR], 1.0 [95% confidence interval (CI), 0.79-1.27]; death: HR, 1.10 [95% CI, 0.84-1.46]). For distal ULMCA, PCI was associated with an increased risk of MACE (HR, 1.32; 95% CI, 1.10-1.58), death (HR, 1.56; 95% CI, 1.19-2.04), and revascularization (HR, 2.07; 95% CI, 1.5-2.84). The benefit of CABG for MACE and revascularization was confirmed in the analysis limited to RCTs, whereas the benefit for mortality was not.

CONCLUSIONS

Among patients with distal ULMCA disease, CABG is associated with lower incidence of MACE and revascularization compared with PCI, whereas no differences in outcomes were observed for ostial/shaft ULMCA disease.

Identification of novel circulating microRNAs in advanced heart failure by next-generation sequencing

Aims

Risk stratification in patients with advanced chronic heart failure (HF) is an unmet need. Circulating microRNA (miRNA) levels have been proposed as diagnostic and prognostic biomarkers in several diseases including HF. The aims of the present study were to characterize HF‐specific miRNA expression profiles and to identify miRNAs with prognostic value in HF patients.

Methods and results

We performed a global miRNome analysis using next‐generation sequencing in the plasma of 30 advanced chronic HF patients and of matched healthy controls. A small subset of miRNAs was validated by real‐time PCR (P < 0.0008). Pearson's correlation analysis was computed between miRNA expression levels and common HF markers. Multivariate prediction models were exploited to evaluate miRNA profiles' prognostic role. Thirty‐two miRNAs were found to be dysregulated between the two groups. Six miRNAs (miR‐210‐3p, miR‐22‐5p, miR‐22‐3p, miR‐21‐3p, miR‐339‐3p, and miR‐125a‐5p) significantly correlated with HF biomarkers, among which N‐terminal prohormone of brain natriuretic peptide. Inside the cohort of advanced HF population, we identified three miRNAs (miR‐125a‐5p, miR‐10b‐5p, and miR‐9‐5p) altered in HF patients experiencing the primary endpoint of cardiac death, heart transplantation, or mechanical circulatory support implantation when compared with those without clinical events. The three miRNAs added substantial prognostic power to Barcelona Bio‐HF score, a multiparametric and validated risk stratification tool for HF (from area under the curve = 0.72 to area under the curve = 0.82).

Conclusions

This discovery study has characterized, for the first time, the advanced chronic HF‐specific miRNA expression pattern. We identified a few miRNAs able to improve the prognostic stratification of HF patients based on common clinical and laboratory values. Further studies are needed to validate our results in larger populations.

Prognostic implication of sodium nitroprusside vasodilator test in pulmonary hypertension and left heart disease: insights from PUSHON registry

Background

Definition of combined post and pre-capillary pulmonary hypertension (Cpc-PH) is controversial, despite involving up to 25% of patients with heart failure with reduced ejection fraction (HFrEF). The 2019 World Symposium on PH focused on conflicting results and potential misleading interpretation of mean transpulmonary gradient (TPG) and diastolic transpulmonary gradient (DPG) in predicting outcomes in type 2 PH patients. A new Cpc-PH definition has been proposed, basing on pulmonary arterial wedge pressure (PAWP) &gt;15 mmHg and pulmonary vascular resistance (PVR) &gt;3 WU. In this setting, the role of vasodilator challenge has marginally been explored.

Purpose

This study aims to investigate whether vasodilator test increases prognostic accuracy in PH-LHD comparing to PVR and TPG.

Methods

125 patients with a first diagnosis of PH-LHD were selected within the PUlmonary hypertenSion in rigHt heart catheterization (PUSHON) registry. All patients underwent right heart catheterization and sodium nitroprusside vasodilator infusion. Hemodynamic response was defined as decrease of mean pulmonary arterial pressure (mPAP) &lt;25 mmHg with maintenance of systemic systolic arterial pressure &gt;85 mmHg. Primary endpoint was a composite of cardiac death, heart transplantation and urgent LVAD implant at 2 years.

Results

34 (27%) patients were sodium nitroprusside responders. Normalization of mPAP during acute vasodilator challenge was associated with higher event-free survival at 2 years (HR 2.46, 95% C.I. 1.29–4.69, p=0.006). Responders to nitroprusside showed lower baseline pressure regimens in pulmonary artery (sPAP 56.4±12.9 vs 63.2±12.4 mmHg, p=0.009; mPAP 38.1±6.9 vs 44.7±8.8 mmHg, p=0.001) and lower Wedge Pressure (25.1±6.6 vs 29.8±6.6 mmHg, p=0.001). Also, patients with positive vasodilator test showed better right ventricular function expressed by TAPSE (17.2±4.3 vs 15.4±3.8 mm, p=0.05) and higher EF (34.6±15.3% vs 28.1±13.1%, p=0.023). Interestingly, nitroprusside responders exhibited lower DPG (−0.11±5.30 vs 2.04±5.21 p=0.04). At multivariate analysis PVR and TPG ≥12 mmHg fail to independently predict primary endpoint, while positive vasodilator response was independently associated with better outcome (OR 0.22, 95% C.I. 0.09–0.52, p=0.001). The same results were confirmed in the Cpc-PH subgroup (OR 0.54, 95% C.I. 0.08–0.78, p=0.018).

Conclusions

Nitroprusside vasodilator response was associated with a higher event-free survival at 2 years follow-up in our cohort of patients with PH-LHD. Larger studies with prospective hemodynamic evaluations are needed to support our hypothesis.

Figure 1

Funding Acknowledgement

Type of funding source: None