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Demirel C, Halavina K, Hamzaraj K, Klement J, El-Shaer M, Hemetsberger R, Winter MP, Koschatko S, Jantsch C, Andreas M, Loewe C, Kammerlander A, Hengstenberg C, Bartko PE. Low Bone Mineral Density on Computed Tomography: Association with Poor Survival after Transcatheter Aortic Valve Replacement. J Clin Med 2024; 13:2698. [PMID: 38731227 PMCID: PMC11084390 DOI: 10.3390/jcm13092698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/25/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Transcatheter aortic valve replacement (TAVR) has evolved as first-line therapy for severe aortic valve stenosis (AS), with pre-procedural computed tomography (CT) providing critical anatomical information. While primarily used for anatomical planning, TAVR-CT also offers an opportunity to assess low bone mineral density (BMD), a known indicator of frailty. Despite this, the prognostic role of BMD in TAVR patients remains unknown. This study aimed to evaluate BMD on routine TAVR-CT and its impact on long-term survival. Methods: In this retrospective study, 770 consecutive TAVR patients (mean age 80.7 ± 6.7 years, 54.0% males) between November 2015 and March 2022 were included. BMD was measured from a single axial image at the thoracic vertebral level on unenhanced CT scans. Cox regression models assessed the impact of BMD on mortality, and Restricted Cubic Spline models identified potential mortality thresholds. Results: The mean BMD value, as measured on non-contrast CT, was 147.5 ± 5.4 Hounsfield units, demonstrating a noteworthy association with mortality (adjusted hazard ratio per 100 HU decrease: 1.27 [95%CI: 1.01-1.59], p = 0.041). Restricted cubic spline analysis indicated that BMD below 200 HU was linked to a substantial increase in mortality risk. Upon crude Cox regression analysis, every 100 HU decrease was associated with a 32% increase in risk for death (HR 1.32 [95%CI: 1.068-1.65)], p = 0.010). Conclusions: In conclusion, low BMD on TAVR-CT is independently associated with reduced survival, suggesting its potential as a tool for comprehensive frailty assessment and improved risk prediction in TAVR patients.
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Affiliation(s)
- Caglayan Demirel
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Kseniya Halavina
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Kevin Hamzaraj
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Johanna Klement
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Manar El-Shaer
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Rayyan Hemetsberger
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Max Paul Winter
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Sophia Koschatko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Charlotte Jantsch
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Martin Andreas
- Department of Internal Medicine II, Clinical Division of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Christian Loewe
- Department of Radiology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Andreas Kammerlander
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Christian Hengstenberg
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
| | - Philipp E. Bartko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (K.H.); (K.H.); (J.K.); (M.E.-S.); (R.H.); (M.P.W.); (S.K.); (A.K.); (C.H.)
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2
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Demirel C, Winter MP, Nitsche C, Koschatko S, Jantsch C, Mascherbauer K, Halavina K, Heitzinger G, Dona C, Dannenberg V, Spinka G, Koschutnik M, Andreas M, Hengstenberg C, Bartko PE. Mixed aortic valve disease: association with paravalvular leak and reduced survival after transcatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging 2024; 25:718-726. [PMID: 38236149 DOI: 10.1093/ehjci/jeae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024] Open
Abstract
AIMS Transcatheter aortic valve replacement (TAVR) revolutionized the therapy of severe aortic stenosis (AS) with rising numbers. Mixed aortic valve disease (MAVD) treated by TAVR is gaining more interest, as those patients represent a more complex cohort as compared with isolated AS. However, concerning long-term outcome for this cohort only, limited data are available. The aim of the study is to assess the prevalence of MAVD in TAVR patients, investigate its association with paravalvular regurgitation (PVR), and analyse its impact on long-term mortality after TAVR. METHODS AND RESULTS We conducted a registry-based cohort study using the Vienna TAVR registry, enrolling patients who underwent TAVR at Medical University of Vienna between January 2007 and May 2020 with available transthoracic echocardiography before and after TAVR (n = 880). Data analysis included PVR incidence and long-term survival outcomes. A total of 647 (73.52%) out of 880 patients had ≥ mild aortic regurgitation next to severe AS. MAVD was associated with PVR compared with isolated AS with an odds ratio of 2.06, 95% confidence interval (CI): 1.51-2.81 (P = <0.001). More than mild PVR after TAVR (n = 168 out of 880: 19.09%) was related to higher mortality compared with the absence of PVR with a hazard ratio (HR) of 1.33, 95% CI: 1.05- 1.67 (P = 0.016). MAVD patients developing ≥ mild PVR after TAVR were also associated with higher mortality compared with the absence of PVR with an HR of 1.30 and 95% CI: 1.04-1.62 (P = 0.022). CONCLUSION MAVD is prevalent among TAVR patients and presents unique challenges, with increased PVR risk and worse outcomes compared with isolated AS. Long-term survival for MAVD patients, not limited to those developing PVR post-TAVR, is compromised. Earlier intervention before the occurrence of structural myocardial damage or surgical valve replacement might be a potential workaround to improve outcomes.
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Affiliation(s)
- Caglayan Demirel
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Max Paul Winter
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Sophia Koschatko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Charlotte Jantsch
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Katharina Mascherbauer
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Kseniya Halavina
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Carolina Dona
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Varius Dannenberg
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
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3
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Demirel C, Sulzgruber P, Winter MP, Mascherbauer K, Halavina K, Heitzinger G, Dona C, Koschatko S, Jantsch C, Andreas M, Hengstenberg C, Bartko PE. Impact of stroke history on procedural cerebrovascular insult probability and long-term outcome after TAVI. Eur J Clin Invest 2024; 54:e14099. [PMID: 37771050 DOI: 10.1111/eci.14099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/21/2023] [Accepted: 09/11/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND In TAVI procedural stroke is one of the most feared complications and for this reason also extensively studied. But there is a lack of data concerning the impact of previous stroke on procedural stroke and on long-term survival. The aim of this registry-based cohort study is to evaluate the prevalence of previous stroke in TAVI patients and its impact on procedural stroke risk as well as long-term outcome. METHODS We included all patients treated with TAVI between January 2007 and December 2020 and investigated concerning previous stroke in their medical history. Among 958 patients, 55 patients had previous stroke and were included in the present analysis. RESULTS The salient finding of the present study is that previous stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI. This is also observed after adjusting for confounders like EuroSCORE II (European system for cardiac operative risk evaluation) and AF (atrial fibrillation) as one of the main underlying diseases for cerebrovascular insult (CVI). However, previous stroke is not associated with higher rates of procedural CVI. CONCLUSION A history of stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI without higher rates of procedural stroke.
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Affiliation(s)
- Caglayan Demirel
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Patrick Sulzgruber
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Max Paul Winter
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Katharina Mascherbauer
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kseniya Halavina
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Carolina Dona
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Sophia Koschatko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Charlotte Jantsch
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
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4
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Koschutnik M, Donà C, Nitsche C, Kammerlander AA, Dannenberg V, Brunner C, Koschatko S, Mascherbauer K, Heitzinger G, Halavina K, Spinka G, Winter MP, Hülsmann M, Bartko PE, Hengstenberg C, Mascherbauer J, Goliasch G. Impact of right ventricular-to-pulmonary artery coupling on remodeling and outcome in patients undergoing transcatheter edge-to-edge mitral valve repair. Clin Res Cardiol 2023:10.1007/s00392-023-02318-w. [PMID: 37870628 DOI: 10.1007/s00392-023-02318-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/29/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Right ventricular-to-pulmonary artery (RV-PA) coupling has recently been shown to be associated with outcome in valvular heart disease. However, longitudinal data on RV dysfunction and reverse cardiac remodeling in patients following transcatheter edge-to-edge mitral valve repair (M-TEER) are scarce. METHODS Consecutive patients with primary as well as secondary mitral regurgitation (MR) were prospectively enrolled and had comprehensive echocardiographic and invasive hemodynamic assessment at baseline. Kaplan-Meier estimates and multivariable Cox-regression analyses were performed, using a composite endpoint of heart failure hospitalization and death. RESULTS Between April 2018 and January 2021, 156 patients (median 78 y/o, 55% female, EuroSCORE II: 6.9%) underwent M-TEER. On presentation, 64% showed impaired RV-PA coupling defined as tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) ratio < 0.36. Event-free survival rates at 2 years were significantly lower among patients with impaired coupling (57 vs. 82%, p < 0.001), both in patients with primary (64 vs. 91%, p = 0.009) and secondary MR (54 vs. 76%, p = 0.026). On multivariable Cox-regression analyses adjusted for baseline, imaging, hemodynamic, and procedural data, TAPSE/PASP ratio < 0.36 was independently associated with outcome (adj.HR 2.74, 95% CI 1.17-6.43, p = 0.021). At 1-year follow-up, RV-PA coupling improved (TAPSE: ∆ + 3 mm, PASP: ∆ - 10 mmHg, p for both < 0.001), alongside with a reduction in tricuspid regurgitation (TR) severity (grade ≥ II: 77-54%, p < 0.001). CONCLUSIONS TAPSE/PASP ratio was associated with outcome in patients undergoing M-TEER for primary as well as secondary MR. RV-PA coupling, alongside with TR severity, improved after M-TEER and might thus provide prognostic information in addition to established markers of poor outcome.
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Affiliation(s)
- Matthias Koschutnik
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Carolina Donà
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Andreas A Kammerlander
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Varius Dannenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christina Brunner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sophia Koschatko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Katharina Mascherbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Kseniya Halavina
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Max-Paul Winter
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Department of Internal Medicine 3, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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5
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Heitzinger G, Pavo N, Koschatko S, Jantsch C, Winter M, Spinka G, Dannenberg V, Kastl S, Prausmüller S, Arfsten H, Dona C, Nitsche C, Halavina K, Koschutnik M, Mascherbauer K, Gabler C, Strunk G, Hengstenberg C, Hülsmann M, Bartko PE, Goliasch G. Contemporary insights into the epidemiology, impact and treatment of secondary tricuspid regurgitation across the heart failure spectrum. Eur J Heart Fail 2023; 25:857-867. [PMID: 37062864 PMCID: PMC10947083 DOI: 10.1002/ejhf.2858] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/17/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023] Open
Abstract
AIM Tricuspid regurgitation secondary to heart failure (HF) is common with considerable impact on survival and hospitalization rates. Currently, insights into epidemiology, impact, and treatment of secondary tricuspid regurgitation (sTR) across the entire HF spectrum are lacking, yet are necessary for healthcare decision-making. METHODS AND RESULTS This population-based study included data from 13 469 patients with HF and sTR from the Viennese community over a 10-year period. The primary outcome was long-term mortality. Overall, HF with preserved ejection fraction was the most frequent (57%, n = 7733) HF subtype and the burden of comorbidities was high. Severe sTR was present in 1514 patients (11%), most common among patients with HF with reduced ejection fraction (20%, n = 496). Mortality of patients with sTR was higher than expected survival of sex- and age-matched community and independent of HF subtype (moderate sTR: hazard ratio [HR] 6.32, 95% confidence interval [CI] 5.88-6.80, p < 0.001; severe sTR: HR 9.04; 95% CI 8.27-9.87, p < 0.001). In comparison to HF and no/mild sTR patients, mortality increased for moderate sTR (HR 1.58, 95% CI 1.48-1.69, p < 0.001) and for severe sTR (HR 2.19, 95% CI 2.01-2.38, p < 0.001). This effect prevailed after multivariate adjustment and was similar across all HF subtypes. In subgroup analysis, severe sTR mortality risk was more pronounced in younger patients (<70 years). Moderate and severe sTR were rarely treated (3%, n = 147), despite availability of state-of-the-art facilities and universal health care. CONCLUSION Secondary tricuspid regurgitation is frequent, increasing with age and associated with excess mortality independent of HF subtype. Nevertheless, sTR is rarely treated surgically or percutaneously. With the projected increase in HF prevalence and population ageing, the data suggest a major burden for healthcare systems that needs to be adequately addressed. Low-risk transcatheter treatment options may provide a suitable alternative.
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Affiliation(s)
- Gregor Heitzinger
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Noemi Pavo
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Sophia Koschatko
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Charlotte Jantsch
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Max‐Paul Winter
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Georg Spinka
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Varius Dannenberg
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Stefan Kastl
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Suriya Prausmüller
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Henrike Arfsten
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Carolina Dona
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Christian Nitsche
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Kseniya Halavina
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | | | | | - Cornelia Gabler
- IT Systems and CommunicationsMedical University of ViennaViennaAustria
| | | | | | - Martin Hülsmann
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Philipp E. Bartko
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Georg Goliasch
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
- Department of Internal MedicineUniversity of SzegedSzegedHungary
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Heitzinger G, Spinka G, Koschatko S, Baumgartner C, Dannenberg V, Halavina K, Mascherbauer K, Nitsche C, Dona C, Koschutnik M, Kammerlander A, Winter MP, Strunk G, Pavo N, Kastl S, Hülsmann M, Rosenhek R, Hengstenberg C, Bartko PE, Goliasch G. A streamlined, machine learning-derived approach to risk-stratification in heart failure patients with secondary tricuspid regurgitation. Eur Heart J Cardiovasc Imaging 2023; 24:588-597. [PMID: 36757905 PMCID: PMC10125224 DOI: 10.1093/ehjci/jead009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/29/2022] [Indexed: 02/10/2023] Open
Abstract
AIMS Secondary tricuspid regurgitation (sTR) is the most frequent valvular heart disease and has a significant impact on mortality. A high burden of comorbidities often worsens the already dismal prognosis of sTR, while tricuspid interventions remain underused and initiated too late. The aim was to examine the most powerful predictors of all-cause mortality in moderate and severe sTR using machine learning techniques and to provide a streamlined approach to risk-stratification using readily available clinical, echocardiographic and laboratory parameters. METHODS AND RESULTS This large-scale, long-term observational study included 3359 moderate and 1509 severe sTR patients encompassing the entire heart failure spectrum (preserved, mid-range and reduced ejection fraction). A random survival forest was applied to investigate the most important predictors and group patients according to their number of adverse features.The identified predictors and thresholds, that were associated with significantly worse mortality were lower glomerular filtration rate (<60 mL/min/1.73m2), higher NT-proBNP, increased high sensitivity C-reactive protein, serum albumin < 40 g/L and hemoglobin < 13 g/dL. Additionally, grouping patients according to the number of adverse features yielded important prognostic information, as patients with 4 or 5 adverse features had a fourfold risk increase in moderate sTR [4.81(3.56-6.50) HR 95%CI, P < 0.001] and fivefold risk increase in severe sTR [5.33 (3.28-8.66) HR 95%CI, P < 0.001]. CONCLUSION This study presents a streamlined, machine learning-derived and internally validated approach to risk-stratification in patients with moderate and severe sTR, that adds important prognostic information to aid clinical-decision-making.
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Affiliation(s)
- Gregor Heitzinger
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Sophia Koschatko
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Clemens Baumgartner
- Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Varius Dannenberg
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Kseniya Halavina
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Katharina Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Caroliná Dona
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Andreas Kammerlander
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Max-Paul Winter
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Guido Strunk
- Complexity-Research, Schönbrunner Str. 32 / 20A, 1050 Vienna, Austria
| | - Noemi Pavo
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Stefan Kastl
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Raphael Rosenhek
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.,Herzzentrum Währing, Theresiengasse 43, 1180 Vienna, Austria
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7
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Koschutnik M, Dona C, Nitsche C, Dannenberg V, Koschatko S, Mascherbauer K, Beitzke D, Loewe C, Huelsmann M, Schneider M, Bartko P, Goliasch G, Hengstenberg C, Kammerlander A, Mascherbauer J. Right ventricular function and outcome in patients undergoing transcatheter mitral valve repair. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
This study sought to assess the impact of right ventricular dysfunction (RVD) on event-free survival after transcatheter mitral valve repair (TMVR) for severe mitral regurgitation.
Background
The prognostic value of left and RV global longitudinal strain (LV- and RV-GLS) on cardiovascular magnetic resonance feature tracking (CMR-FT) in patients undergoing TMVR is unknown.
Methods
Consecutive TMVR patients underwent pre-procedural and follow-up CMR-FT analysis. Kaplan-Meier estimates and multivariable Cox-regression analyses were performed, using a composite endpoint of heart failure hospitalization (HFH) and death.
Results
62 patients (78.3±7.0y/o, 45% female, EuroSCORE-II: 9.6±7.1%) underwent CMR-FT prior to TMVR, 24% had concomitant tricuspid edge-to-edge repair (TTVR). On presentation, 23 (37%) patients suffered RVD, defined as RV-GLS >−20% on CMR-FT. RVD was associated with reduced LV and RV ejection fraction (LVEF: 39.2 vs. 48.7%, p=0.008, RVEF: 35.1 vs. 46.7%, p<0.001), as well as impaired LV-GLS (−14.0 vs. −19.5%, p=0.012).
Eighteen events (12 deaths, 6 HFH) occurred during follow-up (11.4±9.1 months). On multivariable Cox-regression adjusted for baseline, procedural, imaging, and biomarker data, RV but not LV-GLS was significantly associated with outcome (adj.HR 2.50, 95% CI: 1.29–4.86, p=0.007 and 1.46, 95% CI: 0.50–4.28, p=0.491, respectively). Among various definitions of RVD on echocardiography and CMR, only RV-GLS on CMR-FT was significantly associated with outcome (RV-GLS >−20%: adj.HR 7.53, 95% CI: 2.07–27.42, p=0.002), but not RVEF on CMR or echo-indices of RV function (Central Illustration).
Follow-up CMR-FT was performed in 21 (34%) patients and RV-GLS significantly improved after TMVR (−20.6 to −25.2%, p=0.016), irrespective of additional TTVR.
Conclusions
RV-GLS, as determined on CMR-FT, rather than LV-GLS or RVEF, is an independent predictor of outcome in patients undergoing TMVR.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- M Koschutnik
- Medical University of Vienna AKH , Vienna , Austria
| | - C Dona
- Medical University of Vienna AKH , Vienna , Austria
| | - C Nitsche
- Medical University of Vienna AKH , Vienna , Austria
| | - V Dannenberg
- Medical University of Vienna AKH , Vienna , Austria
| | - S Koschatko
- Medical University of Vienna AKH , Vienna , Austria
| | | | - D Beitzke
- Medical University of Vienna AKH , Vienna , Austria
| | - C Loewe
- Medical University of Vienna AKH , Vienna , Austria
| | - M Huelsmann
- Medical University of Vienna AKH , Vienna , Austria
| | - M Schneider
- Medical University of Vienna AKH , Vienna , Austria
| | - P Bartko
- Medical University of Vienna AKH , Vienna , Austria
| | - G Goliasch
- Medical University of Vienna AKH , Vienna , Austria
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8
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Heitzinger G, Spinka G, Koschatko S, Dannenberg V, Halavina K, Mascherbauer K, Winter MP, Strunk G, Pavo N, Kastl S, Huelsmann M, Rosenhek R, Hengstenberg C, Bartko PE, Goliasch G. A streamlined, machine learning-derived approach to risk-stratification in heart failure patients with secondary tricuspid regurgitation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Secondary tricuspid regurgitation (sTR) is the most frequent valvular heart disease and has significant impact on mortality. A high burden of comorbidities often worsens the already dismal prognosis of sTR, while tricuspid interventions remain underused and initiated too late.
Objectives
To examine the most powerful predictors of all-cause mortality in moderate and severe sTR using machine learning techniques and to provide a streamlined approach to risk-stratification using readily available clinical, echocardiographic and laboratory parameters.
Methods
This large-scale, long-term observational study included 3359 moderate and 1509 severe sTR patients encompassing the entire heart failure spectrum (preserved, mid-range and reduced ejection fraction). A random survival forest was applied to investigate the most important predictors and group patients according to their number of adverse features (Figure 1).
Results
The identified predictors and thresholds, that were associated with significantly worse mortality were higher age (≥75 in moderate and ≥70 years in moderate and severe sTR respectively), higher NT-proBNP (≥4000 pg/ml), increased high sensitivity C-reactive protein (≥1.0 mg/dl), serum albumin <40 g/L and hemoglobin <13 g/dL. Additionally, grouping patients according to the number of adverse features yielded important prognostic information, as patients with 4 or 5 adverse features had a sevenfold risk increase in moderate sTR (7.11 [2.27–4.30] HR 95% CI, P<0.001) and fivefold risk increase in severe sTR (5.08 [3.13–8.24] HR 95% CI, P<0.001) (Figure 2: A moderate sTR derivation, B moderate sTR validation, C severe sTR derivation, D severe sTR validation).
Conclusion
This study presents a streamlined, machine learning-derived and internally validated approach to risk-stratification in patients with moderate and severe sTR, that adds important prognostic information to aid clinical decision-making.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund
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Affiliation(s)
| | - G Spinka
- Medical University of Vienna , Vienna , Austria
| | - S Koschatko
- Medical University of Vienna , Vienna , Austria
| | | | - K Halavina
- Medical University of Vienna , Vienna , Austria
| | | | - M P Winter
- Medical University of Vienna , Vienna , Austria
| | - G Strunk
- FH Campus Vienna and Complexity Research , Vienna , Austria
| | - N Pavo
- Medical University of Vienna , Vienna , Austria
| | - S Kastl
- Medical University of Vienna , Vienna , Austria
| | - M Huelsmann
- Medical University of Vienna , Vienna , Austria
| | - R Rosenhek
- Medical University of Vienna , Vienna , Austria
| | | | - P E Bartko
- Medical University of Vienna , Vienna , Austria
| | - G Goliasch
- Medical University of Vienna , Vienna , Austria
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9
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Heitzinger G, Brunner C, Koschatko S, Dannenberg V, Mascherbauer K, Halavina K, Doná C, Koschutnik M, Spinka G, Nitsche C, Mach M, Andreas M, Wolf F, Loewe C, Neumayer C, Gschwandtner M, Willfort-Ehringer A, Winter MP, Lang IM, Bartko PE, Hengstenberg C, Goliasch G. A Real World 10-Year Experience With Vascular Closure Devices and Large-Bore Access in Patients Undergoing Transfemoral Transcatheter Aortic Valve Implantation. Front Cardiovasc Med 2022; 8:791693. [PMID: 35127860 PMCID: PMC8814307 DOI: 10.3389/fcvm.2021.791693] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/17/2021] [Indexed: 12/19/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has established itself as a safe and efficient treatment option in patients with severe aortic valve stenosis, regardless of the underlying surgical risk. Widespread adoption of transfemoral procedures led to more patients than ever being eligible for TAVR. This increase in procedural volumes has also stimulated the use of vascular closure devices (VCDs) for improved access site management. In a single-center examination, we investigated 871 patients that underwent transfemoral TAVR from 2010 to 2020 and assessed vascular complications according to the Valve Academic Research Consortium (VARC) III recommendations. Patients were grouped by the VCD and both, vascular closure success and need for intervention were analyzed. In case of a vascular complication, the type of intervention was investigated for all VCDs. The Proglide VCD was the most frequently used device (n = 670), followed by the Prostar device (n = 112). Patients were old (median age 83 years) and patients suffered from high comorbidity burden (60% coronary artery disease, 30% type II diabetes, 40% atrial fibrillation). The overall rate of major complications amounted to 4.6%, it was highest in the Prostar group (9.6%) and lowest in the Manta VCD group (1.1% p = 0.019). The most frequent vascular complications were bleeding and hematoma (n = 110, 13%). In case a complication occurred, 72% of patients did not need any further intervention other than manual compression or pressure bandages. The rate of surgical intervention after complication was highest in the Prostar group (n = 15, 29%, p = 0.001). Temporal trends in VCD usage highlight the rapid adoption of the Proglide system after introduction at our institution. In recent years VCD alternatives, utilizing other closure techniques, such as the Manta device emerged and increased vascular access site management options. This 10-year single-center experience demonstrates high success rates for all VCDs. Despite successful closure, a significant number of patients does experience minor vascular complications, in particular bleeding and hematoma. However, most complications do not require surgical or endovascular intervention. Temporal trends display a marked increase in TAVR procedures and highlight the need for more refined vascular access management strategies.
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Affiliation(s)
- Gregor Heitzinger
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Brunner
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Sophia Koschatko
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Varius Dannenberg
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Katharina Mascherbauer
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Kseniya Halavina
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Carolina Doná
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Spinka
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Nitsche
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Markus Mach
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Wolf
- Department of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Department of Cardiovascular and Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Christoph Neumayer
- Department of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Michael Gschwandtner
- Division for Angiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Andrea Willfort-Ehringer
- Division for Angiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Max-Paul Winter
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Irene M. Lang
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Philipp E. Bartko
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Division for Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- *Correspondence: Georg Goliasch
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10
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Koschutnik M, Dannenberg V, Donà C, Nitsche C, Kammerlander AA, Koschatko S, Zimpfer D, Hülsmann M, Aschauer S, Schneider M, Bartko PE, Goliasch G, Hengstenberg C, Mascherbauer J. Transcatheter Versus Surgical Valve Repair in Patients with Severe Mitral Regurgitation. J Pers Med 2022; 12:jpm12010090. [PMID: 35055405 PMCID: PMC8779938 DOI: 10.3390/jpm12010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022] Open
Abstract
Background. Transcatheter edge-to-edge mitral valve repair (TMVR) is increasingly performed. However, its efficacy in comparison with surgical MV treatment (SMV) is unknown. Methods. Consecutive patients with severe mitral regurgitation (MR) undergoing TMVR (68% functional, 32% degenerative) or SMV (9% functional, 91% degenerative) were enrolled. To account for differences in baseline characteristics, propensity score matching was performed, including age, EuroSCORE-II, left ventricular ejection fraction, and NT-proBNP. A composite of heart failure (HF) hospitalization/death served as primary endpoint. Kaplan-Meier curves and Cox-regression analyses were used to investigate associations between baseline, imaging, and procedural parameters and outcome. Results. Between July 2017 and April 2020, 245 patients were enrolled, of whom 102 patients could be adequately matched (73 y/o, 61% females, EuroSCORE-II: 5.7%, p > 0.05 for all). Despite matching, TMVR patients had more co-morbidities at baseline (higher rates of prior myocardial infarction, coronary revascularization, pacemakers/defibrillators, and diabetes mellitus, p < 0.009 for all). Patients were followed for 28.3 ± 27.2 months, during which 27 events (17 deaths, 10 HF hospitalizations) occurred. Postprocedural MR reduction (MR grade <2: TMVR vs. SMV: 88% vs. 94%, p = 0.487) and freedom from HF hospitalization/death (log-rank: p = 0.811) were similar at 2 years. On multivariable Cox analysis, EuroSCORE-II (adj.HR 1.07 [95%CI: 1.00–1.13], p = 0.027) and residual MR (adj.HR 1.85 [95%CI: 1.17–2.92], p = 0.009) remained significantly associated with outcome. Conclusions. In this propensity-matched, all-comers cohort, two-year outcomes after TMVR versus SMV were similar. Given the reported favorable long-term durability of TMVR, the interventional approach emerges as a valuable alternative for a substantial number of patients with functional and degenerative MR.
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Affiliation(s)
- Matthias Koschutnik
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Varius Dannenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Carolina Donà
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Christian Nitsche
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Andreas A. Kammerlander
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Sophia Koschatko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria;
| | - Martin Hülsmann
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Stefan Aschauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
- Department of Internal Medicine, Franziskus Hospital Margareten, Nikolsdorfergasse 32, 1050 Vienna, Austria
| | - Matthias Schneider
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin (Campus Virchow-Klinikum), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Philipp E. Bartko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Georg Goliasch
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
| | - Julia Mascherbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (M.K.); (V.D.); (C.D.); (C.N.); (A.A.K.); (S.K.); (M.H.); (S.A.); (M.S.); (P.E.B.); (G.G.); (C.H.)
- Department of Internal Medicine 3, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, Dunant-Platz 1, 3100 St. Poelten, Austria
- Correspondence: ; Tel.: +43-1-40400-46140; Fax: +43-1-40400-42160
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11
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Koschutnik M, Dona C, Nitsche C, Dannenberg V, Koschatko S, Beitzke D, Loewe C, Huelsmann M, Schneider M, Bartko PE, Goliasch G, Hengstenberg C, Kammerlander AA, Mascherbauer J. Right ventricular longitudinal strain on cardiovascular magnetic resonance imaging predicts outcome in patients undergoing transcatheter mitral valve repair. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The prognostic value of left and right ventricular global longitudinal strain (LV and RV GLS) derived from cardiovascular magnetic resonance (CMR) feature tracking in patients with severe mitral regurgitation (MR) undergoing transcatheter mitral valve repair (TMVR) is unknown.
Methods
Consecutive patients scheduled for TMVR underwent pre-procedural and follow-up CMR imaging including feature tracking strain analysis. Kaplan-Meier estimates and multivariate Cox-regression analyses were used to identify the prognostic impact of LV and RV GLS on CMR using a composite of heart failure hospitalization and death.
Results
A total of 62 patients (78.3±7.0y/o, 45% female, EuroSCORE II: 9.7±7.2%) with severe MR underwent CMR prior to TMVR. 23 (37%) patients presented with right ventricular dysfunction (RVD) defined by RV GLS >−20% on CMR. At baseline, RVD was associated with NT-proBNP levels (9510 vs. 4064pg/mL, p=0.030). On CMR, RVD was associated with reduced left and RV ejection fraction (LVEF: 39.2 vs. 48.7%, p=0.011, RVEF: 35.1 vs. 46.7%, p<0.001), as well as increased LV GLS (−14.0 vs. −19.5%, p=0.003).
A total of 18 events (12 deaths, 6 hospitalizations for heart failure) occurred during follow-up (mean 11.4±9.1months). While LV GLS was not significantly associated with outcome (HR 0.95, 95% CI: 0.90–1.01, p=0.082), RV GLS showed a strong and independent association with event-free survival by multivariate Cox-regression analysis (adj.HR 0.91, 95% CI: 0.83–0.99, p=0.033) after adjustment for relevant baseline and procedural data (EuroSCORE II, post-procedural residual MR), imaging parameters (TAPSE, LV and RVEF on CMR), and cardiac biomarkers (NT-proBNP). When compared with the “gold standard” RVEF on CMR (RVEF <45%: adj.HR 0.86, 95% CI: 0.23–3.20, p=0.825) and TAPSE on echo (TAPSE <17mm: adj.HR: 2.77, 95% CI: 0.72–10.70, p=0.140), only RVD (RV GLS >−20%: adj.HR 5.05, 95% CI: 1.23–20.63, p=0.024) was significantly associated with the composite endpoint (Figure 1). Follow-up CMR was performed in 21 (34%) patients. RV GLS significantly improved after TMVR (−20.6 to −25.2%, p=0.016, Figure 2).
Conclusions
RV rather than LV GLS, as determined on CMR, is an important predictor of outcome in patients undergoing TMVR. At 1 year follow-up, RV function significantly improved, and thus might add useful prognostic information on top of established risk factors.
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Affiliation(s)
- M Koschutnik
- Medical University of Vienna AKH, Vienna, Austria
| | - C Dona
- Medical University of Vienna AKH, Vienna, Austria
| | - C Nitsche
- Medical University of Vienna AKH, Vienna, Austria
| | - V Dannenberg
- Medical University of Vienna AKH, Vienna, Austria
| | - S Koschatko
- Medical University of Vienna AKH, Vienna, Austria
| | - D Beitzke
- Medical University of Vienna AKH, Vienna, Austria
| | - C Loewe
- Medical University of Vienna AKH, Vienna, Austria
| | - M Huelsmann
- Medical University of Vienna AKH, Vienna, Austria
| | - M Schneider
- Medical University of Vienna AKH, Vienna, Austria
| | - P E Bartko
- Medical University of Vienna AKH, Vienna, Austria
| | - G Goliasch
- Medical University of Vienna AKH, Vienna, Austria
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12
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Dona C, Nitsche C, Koschutnik M, Koschatko S, Dannenberg V, Kammerlander A, Goliasch G, Bartko P, Schneider M, Traub-Weidinger T, Hacker M, Hengstenberg C, Mascherbauer J. Prevalence of cardiac amyloidosis in patients undergoing transcatheter edge-to edge mitral valve repair. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Cardiac amyloidosis (CA) is associated with severe aortic stenosis, however, its prevalence in patients with severe mitral regurgitation in elderly patients is unknown.
Methods
Patients scheduled for transcatheter edge-to edge mitral valve repair (TMVR) were prospectively screened for CA using 99m technetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy and subsequent serum as well as urine free light-chain quantification in case of a positive DPD scan, defined as visual cardiac update based on the Perugini grading scale.
Results
Out of 100 patients undergoing TMVR, 28 patients (28.0%) had a positive DPD-scan (DPD+). 14 patients (14.0%) showed Perugini grade I enhancement, 9 patients (9.0%) grade II enhancement, and in 5 patients (5.0%), grade III enhancement was present. 28 patients suffered from TTR and two from AL- amyloidosis (one patient had a combination of TTR and AL-amyloidosis). When compared to patients with a negative scan (DPD-), DPD+ patients presented with similar baseline characteristics such as age (DPD- vs DPD+ 76y/o vs 77y/o, p=0.44), gender (female; 62.7% vs 50.0%, p=0.25), coronary artery disease (59.7% vs 42.9%, p=0.13), previous valve surgery (25.4% vs 14.3%, p=0.24) and atrial fibrillation (68.7% vs 78.6%, p=0.33). Also, NYHA functional class and EuroScore II were similar (NYHA ≥ III; 85.1% vs 82.1%, p=0.72, and EuroScore II 9.9±9.8% vs 7.0±4.8%, p=0.21, respectively). On echocardiography, DPD+ patients presented with more pronounced left and right ventricular hypertrophy (interventricular septum: 15mm vs 13mm, p<0.01) but similar left ventricular ejection fraction (44.9% vs 42.3%, p=0.34). At 3-months after TMVR, DPD+ patients showed significant improvement in BNP serum levels when compared to DPD- patients (DPD+ vs DPD-: +315±2569pg/ml vs −2404±8696pg/ml, p=0.03), while NYHA functional class remained unchanged (NYHA improvement ≥1 class: 57.6% vs 50.0%, p=0.52)
Conclusions
In this single centre experience, CA was highly prevalent among elderly patients with severe mitral regurgitation scheduled for TMVR. TMVR in CA patients resulted in significant improvement of NT-pro BNP levels. Future studies need to clarify the prognostic relevance of CA in this specific patient population.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- C Dona
- Medical University of Vienna, Wien, Austria
| | - C Nitsche
- Medical University of Vienna, Wien, Austria
| | | | | | | | | | - G Goliasch
- Medical University of Vienna, Wien, Austria
| | - P Bartko
- Medical University of Vienna, Wien, Austria
| | | | | | - M Hacker
- Medical University of Vienna, Wien, Austria
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