Pathophysiological mechanisms and prognostic implications of right atrial reservoir strain in patients with heart failure

Background

Renal and hepatic dysfunction complicate the treatment course of patients with heart failure and negatively affect outcomes. Because the right atrium functions as a reservoir between the right ventricle and the venous circulation, a reduced right atrial compliance may enhance venous congestion, thereby promoting worsening renal function and hepatic congestion.

Purpose

To evaluate the association between RA reservoir strain (RS) and end-organ dysfunction (renal dysfunction and hepatic congestion), as well as survival in patients with advanced HF.

Methods

RARS was evaluated with speckle-tracking echocardiography in patients with advanced HF (i.e. left ventricular ejection fraction <35% and persistent symptoms of HF despite optimal medical therapy). Linear regression analysis was used to investigate the association between RARS and renal function (i.e. estimated glomerular filtration rate [eGFR]) and hepatic congestion (i.e. gamma-glutamyl transferase [GGT]). Patients were followed-up for all-cause mortality.

Results

A total of 917 patients (mean age 65±11 years, 76% male) were included. Age, male sex, atrial fibrillation, larger left atrial and right ventricular dimensions and right ventricular systolic dysfunction were all associated with lower RARS values. On multivariable analysis (adjusting for age, sex, hypertension, diabetes mellitus, dyslipidemia, body mass index, ischemic etiology, atrial fibrillation, QRS duration, left ventricular end-diastolic volume, left ventricular ejection fraction, left atrial volume index, RV basal diameter and tricuspid annular plane systolic excursion), RARS was independently associated with eGFR (β 0.076; 95% CI 0.012 to 0.367; p=0.037) and GGT (β −0.122; 95% CI −1.800 to −0.034; p=0.038). On multivariable Cox regression analysis, adjusting for baseline clinical and echocardiographic variables, RARS was independently associated with all-cause mortality (HR 0.984; 95% CI 0.972 to 0.996; p=0.008) (Figure 1 and Table).

Conclusion

Reduced RARS is independently associated with renal dysfunction and hepatic congestion. In addition, RARS is independently associated with mortality. Consequently, RARS may be useful for the risk-stratification of patients with HF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

Additional value of left atrium remodeling assessed by three-dimensional echocardiography for the prediction of atrial fibrillation recurrence after cryoballoon ablation

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia and it is associated with a high risk of cardiovascular complications [1]. Cryoballoon ablation (CBA) has emerged as a safe and efficient therapeutic option for AF [2]. However, AF recurrence occurs in more than 25% of the patients, which leads to repeated ablations and increased rates of complications and hospitalizations [3]. Previous reports on the role of left atrial (LA) diameter and LA volume assessed by two-dimensional echocardiography (2DE) as predictors of AF recurrence after ablation have shown controversial results [4,5]. This might be explained by the fact that these methods imply geometrical assumptions of the LA remodeling, which is a three-dimensional process [6].

Purpose

The purpose of this study was to evaluate the additional value of LA remodeling assessed by three-dimensional echocardiography (3DE) to predict AF recurrence after CBA.

Methods

Consecutive patients with paroxysmal/persistent AF undergoing CBA were prospectively included. Echocardiography was performed before CBA, according to standard recommendations. Blanking period was defined as the first three months post-ablation. The primary endpoint was AF recurrence after the blanking period.

Results

One hundred seventy two patients (62.2±12.2 years, 61% male) were included in the analysis. During the follow-up period of 11.7±1.6 months, fifty (29%) patients had AF recurrence after the blanking period. 3DE LA maximum volume index (LAVI) had the highest incremental predictive value for AF recurrence (HR 5.50, 95% CI 1.34–22.45, p<0.001) (Figure 1). Twenty-two percent of the AF recurrences occurred in patients with non-dilated LA diameter index and LAVI by 2DE (68 (39.5% patients)). In this category of patients, LAVI by 3DE was able to discriminate AF recurrence with a sensitivity of 90% and a specificity of 66%, for an optimal cut-off value of 30.4 ml/m2.

Conclusion

This study showed that LAVI assessed using 3DE had an additional predictive value for AF recurrence after CBA. Moreover, LAVI by 3DE was able to discriminate AF recurrence even in patients with non-dilated LA by M-Mode and 2DE. These findings suggest that 3DE might reflect better and earlier the asymmetric and variable nature of LA remodeling and could be a potential tool in clinical practice for an improved risk stratification and pre-ablation selection of AF patients.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Universitair Ziekenhuis Brussel: Wetenschappelijk Fonds Willy Gepts of the UZ Brussel

Evolution of functional mitral regurgitation and left atrial function in patients receiving cardiac resynchronization therapy

Background

Left atrial (LA) function is a strong prognostic marker in patients with heart failure and patients with functional mitral regurgitation (MR). Although cardiac resynchronization therapy (CRT) has shown to improve MR severity, the interaction between a reduction in MR severity and an improvement in LA function, as well as their association with outcomes, has not been investigated.

Purpose

To investigate the association between a reduction in MR severity and an improvement in LA function, as well as their association with outcomes.

Methods

LA reservoir strain (RS) was evaluated with speckle tracking echocardiography in patients with moderate and severe functional MR. MR improvement was defined as at least 1 grade improvement in MR severity at 6 months after CRT implantation. The association between MR improvement and change in LARS was evaluated using multivariable logistic regression analysis. Patients were dividing into 3 groups: MR non-improvers; MR improvers with no LARS improvement; and MR improvers with LARS improvement. The primary endpoint was all-cause mortality.

Results

A total of 340 patients (mean age 66±10 years, 73% male) were included, of whom 200 (59%) showed MR improvement after CRT implantation. On multivariable analysis, an improvement in MR was independently associated with an improvement in LARS (OR 1.008; 95% CI 1.003–1.013; p=0.002) (Table 1). MR improvers showing LARS improvement had the lowest mortality rate, whereas outcomes were not significantly different between MR non-improvers and MR improvers showing no LARS improvement (p=0.236) (Figure 1).

Conclusion

In patients with HF and significant functional MR, an improvement in MR after CRT implantation is independently associated with an improvement in LARS, which in turn, is associated with better survival.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): ESC Training Grant App000064741

The impact of atrial fibrillation on prognosis in aortic stenosis

Background

Atrial fibrillation (AF) and aortic stenosis (AS) are both highly prevalent and increasing with age. Various studies have focused on the complex relationship between these entities that frequently coexist. AS might induce adverse cardiac remodelling, which is associated with poor prognosis in severe AS. Left atrial remodelling, especially left atrial enlargement, is also an important risk factor for AF.

Purpose

To evaluate the additive prognostic value of AF besides markers of left atrial and left ventricular remodelling in patients with AS, irrespective of severity of AS and left ventricular ejection fraction (LVEF).

Methods

Patients with moderate and severe AS were selected and history of AF was assessed. Subgroups were defined according to LVEF (reduced (<50%) vs. preserved (≥50%)) and severity of AS (moderate vs. severe). The endpoint was all-cause mortality. Unadjusted Kaplan-Meier survival curves were plotted. Four multivariable Cox regression models were constructed.

Results

In total, 2849 patients with moderate and severe AS (mean age 72±12 years, 54.7% men) were evaluated of whom 686 (24.1%) had a history of AF. Regarding the defined subgroups, 1091 (38.3%) patients had severe AS and 2207 (77.5%) patients had preserved LVEF. During a median follow-up time of 60 months (interquartile range 30 to 97), 1182 (41.5%) patients died. Ten-year mortality rate in patients with AF was 46.8% compared with 36.8% in patients with sinus rhythm (SR) (Figure 1) (p<0.001). In subgroup analysis, patients with AF and severe AS, moderate AS or preserved LVEF had worse survival than those who maintained SR (p=0.015, p<0.001 and p<0.001 respectively). On univariable (HR: 1.42; 95% CI: 1.25 to 1.62; p<0.001) and multivariable Cox regression analysis (HR: 1.19; 95% CI: 1.02 to 1.38; p=0.026) adjusting for age, body mass index, hypertension, diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, kidney function, New York Heart Association class, aortic valve replacement as a time-dependent covariate, left ventricular mass index, left ventricular end-diastolic volume index, LVEF, mean aortic valve gradient, tricuspid annular plane systolic excursion, AF is independently associated with mortality (Table 1; model 1). However, when correcting for LAVI, E/e' or both, AF is no longer independently associated with all-cause mortality (Table 1; model 2–4).

Conclusion

Patients with moderate or severe AS and AF have a significantly higher 10-year mortality rate than patients with SR. This finding is irrespective of AS severity and also apparent in the subgroup with preserved LVEF. Nonetheless, when correcting for markers of diastolic dysfunction, AF is not independently associated with outcome in patients with moderate or severe AS.

Funding Acknowledgement

Type of funding sources: None.

Prognostic relevance of left ventricular global longitudinal strain in patients with heart failure and reduced ejection fraction

Background

Patients with heart failure (HF) and reduced ejection fraction (HFrEF) are complex patients who often have a high prevalence of comorbidities and cardiovascular risk factors. However, risk stratification and treatment decision in these patients mainly depend on simple measurements of left ventricular (LV) ejection fraction (EF). In the present study, we investigated the prognostic significance of LV global longitudinal strain (GLS) along with important clinical and echocardiographic risk factors in patients with HFrEF.

Methods

Patients who had a first echocardiographic diagnosis of LV systolic dysfunction, defined as LVEF ≤45%, were identified. LV GLS was measured with speckle-tracking echocardiography and represented by a positive value. To divide the study population into 2 groups, spline curve analysis was used to derive the optimal threshold value of LV GLS (i.e. where the predicted hazard ratio for the endpoint was ≥1) (Figure 1). Patients were followed up for worsening HF, as well as the composite endpoint of worsening HF and all-cause mortality.

Results

A total of 2394 patients (mean age 63±12 years, 75% men) were analyzed. During a median follow-up of 60 months (interquartile range [IQR] 31–60 months), 306 patients (13%) experienced worsening HF and the composite endpoint of worsening HF and all-cause mortality occurred in 673 patients (28%). The 5-year event-free survival rates for the primary and secondary endpoint were significantly lower in the patients who had LV GLS ≤10% compared to the patients who had LV GLS >10% (Figure 2A for worsening HF and Figure 2B for the composite endpoint of worsening HF and all-cause mortality). After adjustment for important clinical and echocardiographic risk factors, including HF treatments and baseline LVEF, baseline LV GLS remained independently associated with a higher risk of worsening HF (HR=0.95, 95% CI 0.90–0.99, p=0.029) and the composite of worsening HF and all-cause mortality (HR=0.94, 95% CI 0.90–0.97, p=0.001).

Conclusions

Baseline LV GLS is associated with long-term prognosis in patients with HFrEF, independently from various clinical and echocardiographic risk factors.

Funding Acknowledgement

Type of funding sources: None.

Left atrial reservoir strain and long-term prognosis in patients with heart failure and reduced ejection fraction

Background

Cardiac damage in heart failure (HF) with reduced ejection fraction (HFrEF) often involves structural and functional left atrial (LA) abnormalities. Speckle-tracking echocardiography derived LA reservoir strain (LARS) is a sensitive measurement for early detection of LA dysfunction. However, the prognostic value of LARS is not well established in patients with HFrEF.

Methods

LARS was measured with speckle tracking echocardiography in patients who had a first echocardiographic diagnosis of reduced LVEF (≤45%). Patients with prior history of atrial fibrillation (AF) were excluded. The primary endpoint was newly onset AF, while the composite endpoint of newly onset AF and all-cause mortality was chosen as the secondary endpoint. The study population was divided into two groups according to the optimal threshold value of baseline LARS (derived from spline curve analysis) (Figure 1) and event-free survival rates were compared by the Kaplan-Meier method.

Results

A total of 997 patients (mean age 62±13 years, 73% men) were analyzed. At baseline, LA volume index was significantly larger (41±17 vs. 32±12 ml/m2, p<0.001), and LA reservoir function significantly more impaired (9±3.1 vs. 21±6.3%, p<0.001) in patients with LARS ≤14% compared to patients with LARS >14%. During a median follow-up of 60 months (interquartile range [IQR] 29–60 months), newly onset AF occurred in 75 patients (7.5%), while 254 patients (25.5%) experienced the composite endpoint of newly onset AF and all-cause mortality. The 5-year event-free survival rates for both endpoints were significantly lower in the LARS ≤14% group compared to LARS >14% group (Figure 1A for new onset AF and Figure 2B for the composite endpoint of newly onset AF and all-cause mortality). After adjustment for important risk factors, including HF treatments and echocardiographic predictors, baseline LARS remained independently associated with a higher risk of development of AF (HR=0.89, 95% CI 0.85–0.94, p<0.001) and the composite of newly onset AF and all-cause mortality (HR=0.93, 95% CI 0.91–0.96, p<0.001).

Conclusions

Baseline LARS is associated with long-term prognosis in patients with HFrEF and the association is independent from various clinical and echocardiographic predictors.

Funding Acknowledgement

Type of funding sources: None.

Left atrial appendage occlusion in recurrent ischaemic stroke, a multicentre experience

BACKGROUND

Oral anticoagulation therapy (OAC) remains the gold standard for ischaemic stroke prevention in patients with non-valvular atrial fibrillation (NVAF) and elevated stroke risk. Percutaneous left atrial appendage occlusion (LAAO) has emerged as a potential alternative for stroke prevention in patients who cannot tolerate OAC. Although no randomized data is available, recurrent stroke in NVAF-patients, while on adequate OAC, is regarded as a treatment failure and therefore is considered as a potential indication for LAAO, based upon expert opinion.

METHODS/OBJECTIVES

A multicentre retrospective cohort study evaluating efficacy, safety and mortality of LAAO in NVAF-patients presenting with recurrent ischaemic stroke, after excluding other plausible causes.

RESULTS

Fifteen LAAO have been performed in NVAF-patients with recurrent stroke despite ongoing OAC, after exclusion of other plausible causes. Mean age was 78.1 ± 5.8 years, mean CHA₂DS₂-VASc-score = 6 ± 1.2 and mean HAS-BLED-score = 5 ± 1.2. Successful implantation was achieved in all patients (73% Amplatzer device and 27% Watchman device), without any access-related complications and only one procedure/device-related complication (device embolization) was reported. In all but four patients, OAC was continued at long term after LAAO. No haemorrhagic strokes and only two ischaemic strokes were observed. During follow-up three patients died, all due to non-atrial fibrillation or non-device-related causes.

CONCLUSIONS

In NVAF-patients at high risk for stroke presenting with recurrent stroke despite adequate OAC, LAAO may be considered an adjunctive, but not alternative treatment to OAC with high feasibility and safety.

Abbreviations: AF: atrial fibrillation; ESC: European Society of Cardiology; INR: international normalized ratio; LAA: left atrial appendage; LAAO: left atrial appendage occlusion; NOAC: non-vitamin K oral anticoagulants; NVAF: non-valvular atrial fibrillation; OAC: oral anticoagulation; RS: recurrent (ischaemic) stroke; SD: standard deviation; TIA: transient ischaemic attack; TOE: transoesophageal echocardiography; TTE: transthoracic echocardiography; VKA: vitamin K antagonists.

Right ventricular remodelling in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Funding Acknowledgements

Type of funding sources: None.

Background

Inconsistent changes in right ventricular (RV) dimensions and function have been observed after tricuspid valve (TV) surgery and their associations with long-term outcomes have not been explored.

Purpose

To evaluate RV remodelling and RV function in patients with significant (moderate or severe) tricuspid regurgitation (TR) undergoing TV surgery and their association with outcome.

Methods

A total of 121 patients (mean age 63 ± 12 years, 47% male) with significant TR treated with TV surgery and who had an echocardiogram between 3 months and 1 year of follow-up, were included for this analysis. Remodelling was assessed by comparing dimensions and function at follow-up to baseline values. The population was stratified by tertiles of percentage reduction of RV end-systolic area (RVESA) and absolute change of RV fractional area change (RVFAC). Five-year mortality rates were compared across the tertiles of RV remodelling and the independent associates of mortality were investigated.

Results

Reduction in RVESA and improvement in RVFAC were significantly associated with better survival after TV surgery, whereas reduction in RV end-diastolic area was not (Figure 1). One third of the patients presented with a reduction in RVESA of at least 17.2% and improvement in RVFAC of at least 2.3%, constituting the third tertiles for comparison. Kaplan-Meier curves for overall survival according to RVESA- and RVFAC-tertiles are shown in Figure 2. Cumulative survival rates were significantly better in patients in the third tertile of RVESA reduction: 49%, 69%, and 90% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 12.526; p = 0.002); as well as according to RVFAC improvement: 57%, 65%, and 87% for tertile 1, tertile 2, and tertile 3, respectively (log-rank chi-square: 7.784; p = 0.02). Tertile 3 of RVESA-reduction as well as tertile 3 of RVFAC-change were both independently associated with better survival after TV surgery compared to tertile 1 (hazard ratio: 0.221 [95% CI: 0.074 to 0.658] and 0.327 [95% CI: 0.118 to 0.907], respectively).

Conclusion

The magnitude of RV reverse remodelling (based on reduction in RVESA) and improvement in RVFAC were associated with better survival at 5 years’ follow-up after TV surgery for significant TR. Abstract Figure 1: Spline curves  Abstract Figure 2: KM curves for overal survival

Left atrioventricular coupling index in hypertrophic cardiomyopathy and risk of new-onset atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

 In patients with hypertrophic cardiomyopathy (HCM) accurate risk stratification for new onset atrial fibrillation (AF) has important prognostic implications. Left atrioventricular coupling index (LACI) has been recently associated with the occurrence of AF in patients without history of cardiovascular disease.

Purpose

The objective of this study was to investigate the association between LACI and new onset AF in HCM patients and its incremental value over conventional left atrial (LA) parameters.

Methods

A total of 373 HCM patients without history of AF (48 ± 17 years, 66% men) were evaluated by transthoracic echocardiography. LACI was defined by the ratio of the LA end-diastolic volume divided by the LV end-diastolic volume. The cut-off value for LACI (≥40%) to identify LA-left ventricular (LV) uncoupling was chosen based on the risk excess of new-onset AF described with a spline curve analysis. Cox proportional hazard models were used to evaluate the association between LACI and the occurrence of AF.

Results

The median LACI was 38% (interquartile range: 24-56) and LA-LV uncoupling (LACI ≥40%) was observed in 171 (45.8%) patients. During a mean follow-up of 11.0 ± 5.6 years, 118 subjects (31.6%) developed new-onset AF. The cumulative event-free survival at 10 years was 53% for patients with LA-LV uncoupling (LACI ≥40%) versus 94% for patients without LA-LV uncoupling (LACI <40%) (p < 0.0001; Figure 1). Multivariable analysis showed an independent association between new-onset AF  and LA maximum volume indexed (LAVImax) (hazard ratio [HR], 1.03; 95% CI, 1.02–1.04), LA minimum volume indexed (LAVImin) (HR, 1.04; 95% CI, 1.03–1.05), LA emptying fraction (HR, 0.97; 95% CI, 0.96–0.98) and LACI (HR, 1.02; 95% CI, 1.01–1.02; all p < 0.0001). The inclusion of LACI in the multivariate model provided larger improvement in the risk stratification for new-onset AF, as compared to conventional LA parameters (Figure 2). Furthermore, the likelihood ratio test demonstrated incremental value of LACI assessment on the top of the multivariate model including LAVImin to predict new-onset AF (p = 0.02), while the addition of LAVImin did not improve the risk discrimination of the multivariate model including LACI (p = 0.36).

Conclusion

Greater LACI, indicative of LA-LV uncoupling, was independently associated with the occurrence of new-onset AF in patients with HCM and demonstrated a stronger risk discrimination power compared to conventional LA parameters. This simple ratio may be easily implemented in clinical practice to improve risk stratification for new-onset AF in HCM. Abstract Figure. Incident AF according to LACI  Abstract Figure.

Prognostic value of coronary artery calcium score in hospitalized COVID - 19 patients

Funding Acknowledgements

Type of funding sources: None.

Background

The association of known cardiovascular risk factors with poor prognosis of coronavirus disease 2019 (COVID-19) has been recently emphasized (1). Coronary artery calcium (CAC) score is considered a risk modifier in primary prevention of cardiovascular disease and has shown to improve cardiovascular risk prediction in addition to classical risk factors (2). 

Purpose

We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients.

Methods

We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with a history of coronary artery disease were excluded. Low dose non - contrast chest computed tomography (CT) was performed in all patients at admission. Visual assessment of CAC in every coronary artery was obtained by using an ordinal scoring of 0, 1, 2 or 3 corresponding to absent, mild, moderate or severe CAC score. A total score was calculated by summing the score of each vessel, which was further categorized as 0 (undetectable), 1-3 (mild), 4-5 (moderate) and ≥ 6 (severe). (Figure 1). Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in-hospital treatment, and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined as all - cause mortality, heart failure, acute coronary syndrome, atrial fibrillation and stroke.

Results

Two hundred eighty patients (63.2 ± 16.7 years old, 57.5% male) were included in the analysis. One hundred thirty one (46.7%) patients had a CAC score of 0. MACE rate was 21.8% (61 patients). Multivariable logistic regression showed that the absence of CAC was inversely associated with MACE (OR 0.209, 95% CI 0.052–0.833, p = 0.027), with a negative predictive value of 84.5% (sensitivity 72%, specificity 55%), independent of age, risk factors or disease severity (Figure 2).

Conclusion

The absence of CAC had a high negative predictive value for MACE in patients hospitalized with COVID-19, independent of the presence of cardiac risk factors or disease severity. These findings reinforce the idea that the assessment of CAC could be a useful marker for risk stratification and management of COVID - 19 patients. Future directions should focus on the implementation of CAC score into mid - term and long - term follow - up of this particular population, to provide a more precise and earlier estimation of cardiovascular risk. Abstract Figure.  Abstract Figure.

Prognostic value of coronary artery calcium score in hospitalized COVID-19 patients

Background

The association between known cardiovascular risk factors and poor prognosis of patients diagnosed with coronavirus disease 2019 (COVID-19) has been recently emphasized (1). Coronary artery calcium (CAC) score assessed by computed tomography (CT) is considered a risk modifier in primary prevention of cardiovascular disease and has shown to improve cardiovascular risk prediction in addition to classical risk factors (2).

Purpose

We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients.

Methods

We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with a history of coronary artery disease were excluded.Low dose non-contrast chest CT was performed in all patients at admission. Visual assessment of CAC in every coronary artery was obtained by using an ordinal scoring of 0, 1, 2 or 3 corresponding to absent, mild, moderate or severe CAC score. A total score was calculated by summing the score of each vessel, which was further categorized as 0 (undetectable), 1–3 (mild), 4–5 (moderate) and ≥6 (severe). (Figure 1). Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in–hospital treatment and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined as all-cause mortality and cardiovascular events (heart failure, myocarditis, arrhythmia, acute coronary syndrome, stroke, pulmonary embolism).

Results

Two-hundred eighty patients (63.2±16.7 years old, 57.5% male) were included in the analysis. One hundred thirty one (46.7%) patients had a CAC score of zero. MACE-rate was 24.2% (68 patients). Multivariate logistic regression showed that the absence of CAC was inversely associated with MACE (OR 0.264, 95% 0.071–0.981, p=0.047), with a negative predictive value (NPV) of 81.4%, sensitivity 70%, specificity 55%, independent of age, risk factors or disease severity (Table 1).

Conclusion

The absence of CAC translated into a low risk for MACE in COVID-19 patients, even in the presence of cardiac risk factors, which reinforces the idea that the assessment of CAC score in COVID-19 patients could be a useful marker for patients risk stratification and management. Future directions should focus on the implementation of CAC score into mid-term and long-term follow-up of this particular population, to provide a more precise and earlier estimation of cardiovascular risk

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Prognostic implications of staging right heart failure in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Introduction

Mortality of tricuspid valve (TV) surgery for severe secondary tricuspid regurgitation (TR) remains relatively high. Current guidelines advise surgery in patients with symptomatic severe TR as a concomitant procedure to left-sided valve surgery. Right ventricular (RV) dysfunction is an important prognostic marker and may appear late in the natural history of TR. How a staging algorithm of right heart failure (RHF) may impact on TV surgery outcomes has not been evaluated.

Purpose

To evaluate the impact of staging RHF on survival of patients with significant TR undergoing TV surgery.

Methods

Patients diagnosed with significant (moderate and severe) TR who subsequently underwent TV surgery, were staged into 4 groups of progressive disease according to the diagnosis of RV dysfunction and the presence of RHF: stage 1, at risk for RHF; stage 2, RV dysfunction without clinical symptoms of RHF; stage 3, RV dysfunction with symptoms of RHF, and stage 4, RV dysfunction with refractory symptoms of RHF (Figure 1). The study endpoint was all-cause mortality.

Results

A total of 279 patients (mean age 64±12 years, 49% male), were included in the analysis, of which 20 patients (7%) were in stage 1, 14 patients (5%) were in stage 2, 141 patients (51%) were in stage 3 and 104 patients (37%) were in stage 4.

The majority of the patients (266 patients, 95%) underwent TV annuloplasty. Most patients had TV surgery concomitant to left-sided valve surgery or coronary artery bypass grafting (254 patients, 91%). In per-group analysis, patients in stage 4 had significantly larger left ventricular (LV) and RV dimensions, lower LV ejection fraction and more severe diastolic dysfunction than patients in other RHF stages.

During a median follow-up of 65 [15 - 106] months after TV surgery, 145 deaths (52%) occurred. The cumulative survival rates were 88%, 77% and 60% at 1 month, 1 year and 5 years, respectively. The Kaplan-Meier curves for overall survival according to RHF stage are shown in Figure 2. Survival rates at 5 years were significantly worse in more advanced stages of RHF: 71% (stage 1 and 2), 66% (stage 3) and 49% (stage 4); log-rank chi-square: 11.302; p=0.004. Right heart failure stage was independently associated with all-cause mortality following adjustment for age, gender, LV ejection fraction, kidney function, TV annulus diameter, concomitant mitral valve surgery and time delay from diagnosis until surgery (p=0.021).

Conclusion

Patients diagnosed with significant TR may benefit from earlier referral for surgical intervention, before presenting with RV dysfunction and before the onset of symptoms of RHF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Stages of right heart failureFigure 2. Kaplan-Meier curves for overall survival

Troponin T in COVID-19 hospitalized patients: kinetics matter

Background

Coronavirus disease 2019 (COVID-19) pandemic continues to overwhelm healthcare systems worldwide, due to high numbers of critical cases over a short period of time (1,2). Elevated cardiac troponin (cTn), suggestive for myocardial damage, was associated with increased mortality of COVID-19 patients (3,4). However, data addressing the role of cTn in major adverse cardiovascular events (MACE) in COVID-19 patients is scarce.

Objectives

We aimed to assess the role of baseline cTnT and cTnT kinetics in the prediction of MACE and in - hospital mortality in COVID-19 patients. Furthermore, we assessed the association between cTnT kinetics and the need of cardiac imaging evaluation.

Methods

310 patients were included prospectively (age 64.6±16.7 years, 180 (58.1%) males), between March 2020 and April 2020. Clinical data including demographics,medical history,comorbidities,clinical evaluation,laboratory exams,in-hospital treatment,complications and outcomes were collected at admission and during hospitalization by physicians in charge. Two hundred and two patients (65.1%) with at least two cTnT values assessed during hospitalization, at 24–48 hours interval were included in the final analysis. cTnT-values >0.011 micrograms/L were considered elevated, according to hospital laboratory cut-offs. Patients were divided into 3 groups according to cTnT kinetics profile: 1 – variable, 2 – descending and 3 – constant. cTnT slope was defined as the ratio of the cTnT change and the change in time. MACE were considered as the primary endpoint and were composed by all-cause mortality, acute heart failure, acute coronary syndrome, pericarditis, myocarditis, atrial fibrillation or flutter and pulmonary embolism. In-hospital mortality was considered as the secondary endpoint.

Results

Mean hospitalization was 13.9±0.9 days. MACE occurred in 60 patients (29.7%) and in-hospital mortality in 40 (19.8%) patients. Baseline cTnT independently predicted MACE, (p=0.047, HR 1.805, 95% CI 1.009–3.231) and in-hospital mortality (p=0.009, HR 2.322, 95% CI 1.234–4.369) (Figure 1A, 1B). An increased cTnT slope independently predicted in-hospital mortality (p=0.041, HR 1.006, 95% CI 1.000–1.011). Constant cTnT was associated with lower MACE and mortality rates (p=0,000, HR 3.080, 95% CI, 1.914–4.954, p=0.000, HR 2.851. 95% CI 1.828–4.447, respectively) (Figure 1C, 1D, 2). Cardiac imaging evaluation was performed in 8 (16%) patients with constant cTnT, 30 (60%) with variable cTnT, and 12 (24%) with descending cTnT.(p<0.001)

Conclusions

Increased baseline cTnT independently predicted MACE and in-hospital mortality in COVID-19 patients. The magnitude of cTnT increase over time was associated with in-hospital mortality. On the contrary, patients with constant cTnT had lower MACE and in-hospital mortality rates. These finding emphasize the additional role of cTnT testing in COVID-19 patients for risk stratification and improved diagnostic pathway and management

Funding Acknowledgement

Type of funding sources: None.