Calcific Aortic Valve Disease-Natural History and Future Therapeutic Strategies

Calcific aortic valve disease (CAVD) is the most frequent heart valve disorder. It is characterized by an active remodeling process accompanied with valve mineralization, that results in a progressive aortic valve narrowing, significant restriction of the valvular area, and impairment of blood flow.The pathophysiology of CAVD is a multifaceted process, involving genetic factors, chronic inflammation, lipid deposition, and valve mineralization. Mineralization is strictly related to the inflammatory process in which both, innate, and adaptive immunity are involved. The underlying pathophysiological pathways that go from inflammation to calcification and, finally lead to severe stenosis, remain, however, incompletely understood. Histopathological studies are limited to patients with severe CAVD and no samples are available for longitudinal studies of disease progression. Therefore, alternative routes should be explored to investigate the pathogenesis and progression of CAVD.Recently, increasing evidence suggests that epigenetic markers such as non-coding RNAs are implicated in the landscape of phenotypical changes occurring in CAVD. Furthermore, the microbiome, an essential player in several diseases, including the cardiovascular ones, has recently been linked to the inflammation process occurring in CAVD. In the present review, we analyze and discuss the CAVD pathophysiology and future therapeutic strategies, focusing on the real and putative role of inflammation, calcification, and microbiome.

Treatment of Severe TRIcuspid Regurgitation in Patients with Advanced Heart Failure with CAval Vein Implantation of the Edwards Sapien XT VALve (TRICAVAL): a randomised controlled trial

AIMS

The aim of our study was to compare the impact of implantation of a balloon-expandable transcatheter valve into the inferior vena cava (CAVI) on exercise capacity with optimal medical therapy (OMT) in patients with severe tricuspid regurgitation (TR) and high surgical risk.

METHODS AND RESULTS

Twenty-eight patients were randomised to OMT (n=14) or CAVI (n=14). The primary endpoint was maximal oxygen uptake at the three-month follow-up. Secondary endpoints included six-minute walk test, NYHA class, NT-proBNP levels, right heart function, unscheduled heart failure hospitalisation, and quality of life as assessed by the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Patients underwent follow-up examinations one, three, six, and twelve months after randomisation. Maximal oxygen uptake did not change significantly in either group after three months and there was no difference between the OMT and CAVI groups (-0.1±1.8 ml∙kg-1∙min-1 vs -1.0±1.6 ml∙kg-1∙min-1, p=0.4995). Compared to baseline, CAVI improved NYHA class, dyspnoea, and quality of life after three months. However, there were no statistically significant differences in the secondary endpoints between the groups. Four periprocedural complications occurred after CAVI, resulting in open heart surgery. Four patients in the OMT group and eight patients (including four after conversion to surgery) in the CAVI group died from right heart failure, sepsis or haemorrhage.

CONCLUSIONS

CAVI did not result in a superior functional outcome compared to OMT. Due to an unexpectedly high rate of valve dislocations, the study was stopped for safety reasons.

Hypothermia in patients with acute myocardial infarction: a meta-analysis of randomized trials

BACKGROUND

In patients with acute myocardial infarction (MI) receiving percutaneous coronary intervention (PCI), the role of systemic therapeutic hypothermia remains controversial. We sought to investigate the role of systemic therapeutic hypothermia versus standard of care in patients with acute MI treated with PCI.

METHODS

This is a study-level meta-analysis of randomized trials. The primary outcome was all-cause death. The main secondary outcome was infarct size. Other secondary outcomes were recurrent MI, ischemia-driven target vessel revascularization (TVR), major adverse cardiovascular events, and bleeding.

RESULTS

A total of 1012 patients with acute MI receiving a PCI in nine trials (503 randomly assigned to hypothermia and 509 to control) were available for the quantitative synthesis. The weighted median follow-up was 30 days. As compared to controls, patients assigned to hypothermia had similar risk of all-cause death (risk ratio, [95% confidence intervals], 1.25 [0.80; 1.95], p = 0.32), with a trend toward higher risk of ischemia-driven TVR (3.55 [0.80; 15.87], p = 0.09) mostly due to acute or subacute stent thrombosis. Although in the overall cohort, infarct size was comparable between groups (standardized mean difference [95% Confidence intervals], 0.06 [- 0.92; 1.04], p = 0.92), patients effectively achieving the protocol-defined target temperature in the hypothermia group had smaller infarct size as compared to controls (p for interaction = 0.016). Treatment strategies did not differ with respect to the other outcomes.

CONCLUSIONS

As compared to standard of care, systemic therapeutic hypothermia in acute MI patients treated with PCI provided similar mortality with a signal toward more frequent repeat revascularization. Among patients assigned to hypothermia, those effectively achieving the protocol-defined target temperature displayed smaller infarct size.

TRIAL REGISTRATION

PROSPERO, CRD42019138754.

Maier L, Sechtem U, Silber S, Thiele H. Percutaneous Coronary Intervention in Stable Coronary Heart Disease -Is Less More?

BACKGROUND

This review concerns the putative benefit of percutaneous coronary intervention (PCI) over optimal medical therapy (OMT) for symptomatic patients with stable angina pectoris, or for asymptomatic persons in whom screening tests have revealed coronary heart disease (CHD; this entity has been newly designated chronic coronary syndrome, or CCS). Moreover, it addresses the question whether the indications for which PCI is now performed in Germany on patients with CCS are consistent with current scientific knowledge.

METHODS

The pathophysiological concept of CHD and ischemia induction is discussed in the light of the scientific literature. This concept implies that PCI might be beneficial in the treatment of CCS. The benefit of PCI over OMT has now been evaluated in seven randomized trials (the so-called milestone trials). The current situation in Germany is presented here as well, on the basis of the available data.

RESULTS

The pathophysiological concept of CHD implies that the particular coronary artery stenoses that are likely to give rise to a myocardial infarction (the so-called vulnerable plaques) cannot be identified prospectively with current methods. Moreover, a coronary artery stenosis will not necessarily cause myocardial ischemia. All of the randomized trials carried out to date that have compared OMT to PCI-plus-OMT in patients with CCS have led to the conclusion that PCI, because it focuses on individual coronary artery stenoses, cannot prolong survival or lower the incidence of myocardial infarction over the long term. This remains the case even if a single coronary artery stenosis is known to be causing moderate or severe myocardial ischemia (a conclusion of the ISCHEMIA trial). A PCI performed only because the coronary stenosis or stenoses meet certain morphological criteria, without any demonstration of a resulting functional disturbance, is generally detrimental to the health of the patient, with rare exceptions, and is inconsistent with the recommendations of current guidelines. The number of PCIs being performed in Germany at present is high compared to other countries; this arouses concern that the indications for it may be dubious in many cases.

CONCLUSION

Current data imply that PCI for CCS does not improve outcomes in a large percentage of cases. A symptomatic benefit exists only in patients with frequent angina pectoris. The selection of CCS patients for PCI needs to be more strictly bound to the recommendations of current guidelines, particularly in Germany.

Comparison of newer generation self-expandable vs. balloon-expandable valves in transcatheter aortic valve implantation: the randomized SOLVE-TAVI trial

Aims

Transcatheter aortic valve implantation (TAVI) has emerged as established treatment option in patients with symptomatic aortic stenosis. Technical developments in valve design have addressed previous limitations such as suboptimal deployment, conduction disturbances, and paravalvular leakage. However, there are only limited data available for the comparison of newer generation self-expandable valve (SEV) and balloon-expandable valve (BEV).

Methods and results

SOLVE-TAVI is a multicentre, open-label, 2 × 2 factorial, randomized trial of 447 patients with aortic stenosis undergoing transfemoral TAVI comparing SEV (Evolut R, Medtronic Inc., Minneapolis, MN, USA) with BEV (Sapien 3, Edwards Lifesciences, Irvine, CA, USA). The primary efficacy composite endpoint of all-cause mortality, stroke, moderate/severe prosthetic valve regurgitation, and permanent pacemaker implantation at 30 days was powered for equivalence (equivalence margin 10% with significance level 0.05). The primary composite endpoint occurred in 28.4% of SEV patients and 26.1% of BEV patients meeting the prespecified criteria of equivalence [rate difference −2.39 (90% confidence interval, CI −9.45 to 4.66); Pequivalence = 0.04]. Event rates for the individual components were as follows: all-cause mortality 3.2% vs. 2.3% [rate difference −0.93 (90% CI −4.78 to 2.92); Pequivalence < 0.001], stroke 0.5% vs. 4.7% [rate difference 4.20 (90% CI 0.12 to 8.27); Pequivalence = 0.003], moderate/severe paravalvular leak 3.4% vs. 1.5% [rate difference −1.89 (90% CI −5.86 to 2.08); Pequivalence = 0.0001], and permanent pacemaker implantation 23.0% vs. 19.2% [rate difference −3.85 (90% CI −10.41 to 2.72) in SEV vs. BEV patients; Pequivalence = 0.06].

Conclusion

In patients with aortic stenosis undergoing transfemoral TAVI, newer generation SEV and BEV are equivalent for the primary valve-related efficacy endpoint. These findings support the safe application of these newer generation percutaneous valves in the majority of patients with some specific preferences based on individual valve anatomy.

Partial oral antibiotic therapy is non-inferior to intravenous therapy in non-critically ill patients with infective endocarditis : Review and meta-analysis

Background

Antimicrobial therapy is a cornerstone in the treatment of infective endocarditis (IE). Typically, intravenous (i.v.) therapy is given for 6 weeks or longer, leading to prolonged hospital stays and high costs. Several trials evaluating the efficacy of partial oral therapy (POT) have been published. This article aimed to review and meta-analyze studies comparing i.v. therapy versus POT in non-critically ill patients suffering from IE.

Methods

A structured database search (based on PRISMA guidelines) regarding POT versus i.v. therapy in IE was conducted using PubMed/Medline. Primary endpoint was all-cause mortality and a secondary endpoint IE relapse. Risk rates were calculated using a random effects model (DerSimonian and Laird). Heterogeneity was assessed using the I² statistics.

Results

After screening 1848 studies at title and abstract levels, 4 studies were included. A total of 765 patients suffered from primary left-sided IE, whereas right-sided IE was observed in 72 patients. Mortality rates were lower in POT versus i.v. therapy (risk ratio [RR] 0.38, 95% confidence interval, confidence interval [CI] 0.20–0.74; p = 0.004; I² 0%). IE relapse rates were similar (RR 0.63, 95% CI 0.29–1.37; p = 0.24; I² 0%).

Conclusion

Data comparing POT with standard care in IE is limited and to date only one sufficiently powered stand-alone trial exists to support its use. In this meta-analysis POT was non-inferior to i.v. therapy with respect to mortality and IE relapse in non-critically ill patients suffering from both left-sided and right-sided IE. These findings indicate that POT is a feasible treatment strategy in selected patients suffering from IE but further validation in future studies will be required.

Outcomes of TTVI in Patients With Pacemaker or Defibrillator Leads: Data From the TriValve Registry

OBJECTIVES

The interference of a transtricuspid cardiac implantable electronic device (CIED) lead with tricuspid valve function may contribute to the mechanism of tricuspid regurgitation (TR) and poses specific therapeutic challenges during transcatheter tricuspid valve intervention (TTVI). Feasibility and efficacy of TTVI in presence of a CIED is unclear.

BACKGROUND

Feasibility of TTVI in presence of a CIED lead has never been proven on a large basis.

METHODS

The study population consisted of 470 patients with severe symptomatic TR from the TriValve (Transcatheter Tricuspid Valve Therapies) registry who underwent TTVI at 21 centers between 2015 and 2018. The association of CIED and outcomes were assessed.

RESULTS

Pre-procedural CIED was present in 121 of 470 (25.7%) patients. The most frequent location of the CIED lead was the posteroseptal commissure (44.0%). As compared with patients without a transvalvular lead (no-CIED group), patients having a tricuspid lead (CIED group) were more symptomatic (New York Heart Association functional class III to IV in 95.9% vs. 92.3%; p = 0.02) and more frequently had previous episodes of right heart failure (87.8% vs. 69.0%; p = 0.002). No-CIED patients had more severe TR (effective regurgitant orifice area 0.7 ± 0.6 cm² vs. 0.6 ± 0.3 cm²; p = 0.02), but significantly better right ventricular function (tricuspid annular plane systolic excursion = 16.7 ± 5.0 mm vs. 15.9 ± 4.0 mm; p = 0.04). Overall, 373 patients (79%) were treated with the MitraClip (Abbott Vascular, Santa Clara, California) (106 [87.0%] in the CIED group). Among them, 154 (33%) patients had concomitant transcatheter mitral repair (55 [46.0%] in the CIED group, all MitraClip). Procedural success was achieved in 80.0% of no-CIED patients and in 78.6% of CIED patients (p = 0.74), with an in-hospital mortality of 2.9% and 3.7%, respectively (p = 0.70). At 30 days, residual TR ≤2+ was observed in 70.8% of no-CIED and in 73.7% of CIED patients (p = 0.6). Symptomatic improvement was observed in both groups (NYHA functional class I to II at 30 days: 66.0% vs. 65.0%; p = 0.30). Survival at 12 months was 80.7 ± 3.0% in the no-CIED patients and 73.6 ± 5.0% in the CIED patients (p = 0.30).

CONCLUSIONS

TTVI is feasible in selected patients with CIED leads and acute procedural success and short-term clinical outcomes are comparable to those observed in patients without a transtricuspid lead.

Systematic Review and Meta-Analysis of Interventional Emergency Treatment of Decompensated Severe Aortic Stenosis

AIMS

Patients in cardiogenic shock (CS) due to decompensated aortic stenosis (AS) evidence poor prognosis. Both emergency transcatheter aortic valve replacement (eTAVR) and emergency balloon aortic valvuloplasty (eBAV) have been reported in CS patients. We aimed to summarize and compare available studies on eBAV and eTAVR in patients suffering from CS due to decompensated AS with regard to safety and efficacy.

METHODS AND RESULTS

Study-level data were analyzed. Heterogeneity was assessed using the I2 statistic. Pooled proportions, ie, event rates, were calculated and obtained using a random-effects model (DerSimonian and Laird). Eight studies were found suitable for the final analysis, including 311 patients. Primary endpoint was mortality at 30 days. For eBAV (n = 238), 30-day mortality rate was 46.2% (95% confidence interval [CI], 30.3%-62.5%; I²=74%), major bleeding rate was 10% (95% CI, 5.4%-15.7%; I²=13%), and stroke rate was 0.7% (95% CI, 0.0%-2.7%; I²=0%). Aortic regurgitation (AR) ≥II was present in 8.6% (95% CI, 0.4%-23.5%; I²=86%). For eTAVR (n = 73), 30-day mortality rate was 22.6% (95% CI, 12.0%-35.2%; I²=26%), major bleeding rate was 5.8% (95% CI, 0.5%-14.7%; I²=0%), and stroke rate was 5.8% (95% CI, 0.5%-14.7%; I²=0%). AR ≥II was present in 4% (95% CI, 0.0%-12.1%; I²=0%).

CONCLUSION

Mortality in CS patients due to decompensated severe AS is high, regardless of interventional treatment strategy. Both eBAV and eTAVR seem feasible. As eTAVR is associated with better initial improvements in hemodynamics and simultaneously avoids sequential interventions, it might be favorable to eBAV in select patients. If eTAVR is not available, eBAV might serve as a "bridge" to elective TAVR.

Assessment of intermediate coronary lesions by fractional flow reserve and quantitative flow ratio in patients with small-vessel disease

BACKGROUND

Quantitative flow ratio (QFR) has recently been introduced as a novel, less-invasive, adenosine-free measure for functional coronary lesion assessment. Whether reference vessel dimensions affect functional lesion assessment is uncertain.

METHODS

A total of 436 patients with 516 interrogated coronary vessels by means of FFR were included in the study. Patients were dichotomized according to the median reference vessel diameter (group 1: ≤2.8 mm and group 2: >2.8 mm). QFR analyses were performed offline at the institution's core laboratories.

RESULTS

Reference vessel diameter was 2.5 [2.3-2.7] mm in group 1 and 3.3 [3.0-3.6] mm in group 2. Diameter stenosis (41.4 [36.4-47.6] % vs. 41.4 [36.4-45.7] %, p = .20) did not differ among groups. Median FFR values were lower in group 1 (0.87 [0.81-0.92]) as compared with group 2 (0.89 [0.84-0.93], p = .001). Consistently, QFR values were lower in group 1 (0.88 [0.82-0.92]) than in group 2 (0.91 [0.85-0.94], p = .001). The proportions of functionally significant coronary lesions as defined by FFR ≤0.80 were 24.1% and 14.2% in groups 1 and 2 (p = .005), and as defined by cQFR ≤0.80 20.4% and 11.8% (p = 0.009), respectively. In ROC analysis for an FFR ≤.80, the AUC was 0.89 (95% CI 0.85-0.93, p < .001) in group 1 and 0.81 (95% CI 0.76-0.86, p < .001) in group 2.

CONCLUSIONS

These results suggest that QFR measurements are accurate irrespective of the reference vessel diameter. Future studies are needed to elucidate the higher percentage of functionally significant lesions observed in small vessels despite a similar angiographic lesion severity.

P6394Neutrophil activation patterns in acute coronary syndrome with intact fibrous cap - results from the OPTICO-ACS study

Background

In up to one third of all cases, acute coronary syndrome occurs without signs of plaque rupture. Instead endothelial cell erosion is considered to be the hallmark of acute coronary syndrome with intact fibrous cap (IFC-ACS), with matrix metalloproteinase 9 (MMP9) directly linked to this pathology. The main source of MMP9 immediately after ACS are the neutrophil granulocytes. Therefore, their molecular activation patterns and subsequent MMP9 production are the objectives of the ongoing, translational OPTICO-ACS-Study, aiming to compare the mechanisms and prognosis of IFC-ACS and ACS with ruptured fibrous cap (RFC-ACS).

Methods

Local and systemic blood samples were simultaneously obtained from the site of the ACS-causing culprit lesion (LOC) using an aspiration catheter and from the systemic circulation (SYS). Using optical coherence tomography (OCT) the ACS-causing culprit lesion was characterized and two patient groups, patients with ACS caused by intact (IFC-ACS) and by ruptured fibrous cap (RFC-ACS) were compared. Each group consists of twenty patients (n=20) matched by age, gender and diabetes. Neutrophil counts and expression of activation markers were immediately quantified by whole-blood flow cytometry. Release of active MMP9 into the plasma was assessed by fluorescence-based zymography. Activation profiles of freshly isolated neutrophils, including MMP9 activity and effect on endothelial cell death, in response to toll-like receptor 2 (TLR2) stimulation was studied.

Results

Local neutrophils of patients with IFC-ACS show significantly higher expression of TLR2 in comparison to RFC-ACS neutrophils (LOC: 1866±382.1 vs. 1498±426.9; IFC-ACS vs. RFC-ACS, p=0.03). MMP9 activity is significant higher (p=0.01) in plasma obtained from the culprit site of IFC-ACS (74.1 U/ml±4.1) compared to those of RFC-ACS patients (70.0 U/ml±5.1) indicating secretion and activation of the enzyme during IFC-ACS. Importantly, in patients with IFC-ACS, TLR2-stimulation using Pam3CSK4 triggers higher activity rates of MMP9 only in neutrophils isolated directly from the culprit site (LOC), but not systemically (+27%±17.2% IFC-LOC vs. IFC-SYS; p=0.003). This effect was not observed in RFC-derived neutrophils. Inhibiting TLR2 by a monoclonal antibody, strongly reduced secretion of activated MMP9 only in the local neutrophils from IFC-ACS-patients (−54.6%±6.5% in IFC-LOC-anti-TLR2 vs. IFC-LOC-vehicle; p=0.008), but not from systemic IFC-neutrophils, nor from RFC-neutrophils. Furthermore, LOC IFC-ACS neutrophils aggravate endothelial cell death upon TLR2-activation in comparison to LOC RFC-ACS neutrophils (58.4±4.96% vs. 20±1.89%, IFC-ACS vs. RFC-ACS; p=0.0023).

Conclusion

We newly describe differential kinetics of MMP9 release by neutrophils in ACS patients with IFC versus RFC. Our data support a role of a TLR-2 activated and neutrophil-MMP9-mediated mechanism leading to endothelial cell erosion in patients with IFC-ACS.

Acknowledgement/Funding

DZHK (German Centre for Cardiovascular Research); BIH (Berlin Institute of Health)

P3668In non-critically ill patients suffering from endocarditis partial oral antibiotic therapy is non-inferior to intravenous therapy

Introduction

Antibiotic treatment for infective endocarditis is paramount typically consisting of intravenous therapy for up to eight weeks leading to long hospital stays. This often is associated with reduced quality of life for patients and might heighten complication rates. Recently, several trials evaluating the efficacy of partial oral treatment (switching to an oral antibiotic after an initial intravenous therapy for stabilization) versus an intravenous therapy were published. We here meta-analyze all available data.

Methods and results

Overall after screening 1848 studies at title and abstract level four studies including a total of 788 patients were included. Heterogeneity was assessed using the I2 statistic. Primary endpoint was all-cause mortality, secondary endpoint endocarditis relapse. Pooled event rates were obtained for each subset of studies and combined in a fixed-effect meta-analysis, and odds ratios were calculated using a fixed-effects model (Mantel-Haenszel).

A total of 765 patients suffered from primary left-sided endocarditis. From right-sided endocarditis suffered 72 patients. All treatment regimes were adjusted to susceptibility testing. Included patients were evaluated clinically and non-critically ill.

Rate of mortality was lower in partial oral versus intravenous strategy (OR 0.34 95% CI 0.17–0.68; p=0.003; I2 30%): In partial oral group, 11 of 379 patients died, whereas in the intravenous group, 33 of 409 patients died. Endocarditis relapse rates were not dissimilar between intravenous versus oral group (OR 0.55 95% CI 0.26–1.20; p=0.13; I2 0%) with, 10 of 459 patients in the partial oral group and 18 of 456 patients in the intravenous group evidencing a relapse.

Conclusion

Partial oral therapy is non-inferior to intravenous therapy with regards to endocarditis relapse in non-critically-ill patients suffering from both left- and right-sided endocarditis. In this meta-analysis, partial oral therapy was associated with lower mortality rates. This finding certainly needs validation in further future randomized trials comparing partial oral versus intravenous antibiotic treatment in non-critically-ill patients. As partial oral therapy allows shorter hospitalization it might be preferable and improve both quality of care and patients quality of life.

5938Mortality risk stratification in patients with severe tricuspid regurgitation - Insights from the Tricuspid Regurgitation REgistry (TRuE)

Background/Introduction

Severe tricuspid regurgitation (TR) is associated with progressive right atrial (RA) and ventricular (RV) dilation, dysfunction and increased mortality. Risk factors impacting the long-term prognosis in patients with severe TR are largely undetermined.

Purpose

Herein, we aimed to identify risk factors associated with long-term mortality in patients with severe TR and implement a novel risk stratification strategy based on an individual five-year mortality prediction score.

Methods

From January 2013 to December 2017, 1238 patients with severe functional TR were enrolled in the TRuE-registry, of which 914 with a complete dataset were included in the present study. Echocardiographic quantification of RV-function and size included measurements of tricuspid annular plane systolic excursion (TAPSE), the end-diastolic basal (RVDbasal) and longitudinal diameters (RVDlong) and the RA-volume index (RAVI). The cohort was randomly divided into a development (n=610) and validation (n=304) sample. A risk stratification model was developed using a multivariable Cox regression.

Results

The variables statistically significant to predict five-year-mortality, included in the final model and used as score parameters were: age, COPD, dialysis, pulmonary artery systolic pressure, RAVI, TAPSE RVDbasal, RVDlong and systolic hepatic vein flow reversal (sHVFR). Progressive enlargement of RV and RA and concomitant sHVFR was associated with higher values of hazard ratios (HR, Figure A). Based on the HR values, a risk score with 3 categories was developed (Figure B): low (0–2), intermediate (3–5), high (6–16). Among the risk groups, Kaplan Meier estimates of all-cause mortality at 5 years were 18%, 52% and 84% respectively (p<0.001; https://thetruerisk.com). The score showed good discrimination, with a concordance index of 0.75. At internal validation, a good agreement between the derivation and validation datasets indicated a good calibration of the survival curves.

Implementation of a long term risk score

Conclusion

The present study demonstrates the prognostic impact of comorbidities and right heart remodeling on long-term mortality in patients with severe TR. The presented risk score provides an easy and accurate estimation of long-term mortality and may thus help to guide therapeutic decision-making in this difficult group of patients.

P5249Comprehensive invasive and non-invasive assessment of coronary artery lesions with and without hemodynamic significance

Background

There is limited knowledge about specific morphological parameters beyond the degree of stenosis to further characterize hemodynamically relevant coronary lesions.

Objective

The goal of this study was to identify certain morphological or molecular characteristics that distinguish hemodynamically significant from non-significant coronary lesions using various invasive and non-invasive measures.

Methods

This clinical study included patients with symptoms suggestive of CAD who underwent native T1-weighted CMR and gadofosveset-enhanced CMR as well as invasive coronary angiography between 2015 and 2016. OCT of the culprit vessel to determine the plaque type was performed in a subset of patients. Functional relevance of all lesions was examined using quantitative flow reserve (QFR-Angio). Hemodynamically significant lesions were defined as lesions with a QFR <0.8. Signal intensity (contrast-to-noise ratios; CNRs) on native T1-weighted CMR and gadofosveset-enhanced CMR was defined as a measure for intraplaque hemorrhage and endothelial permeability respectively.

Results

Overall 13 patients (n=28 coronary segments) were included, whose invasive coronary angiograms projections were eligible for QFR analysis. Segments containing lesions with a QFR <0.8 (n=9) were associated with significantly higher signal enhancement on Gadofosveset-enhanced CMR as compared to segments containing a hemodynamically non-relevant lesions (lesion-QFR>0.8; n=19) (7.0±4.9 vs. 3.0±2.6; p=0.02). No differences in signal enhancement were seen on native T1-weighted CMR (2.1±4.3 vs. 3.3±4.1; p=0.24). 66,7% (4 out of 6) of all vulnerable plaque and 33.3% (2 out of 6) of all non-vulnerable plaque (fibroatheroma) as assessed by OCT were hemodynamically significant lesions.

Conclusion

The findings of this small feasibility study suggest that hemodynamically significant lesions are more advanced and associated with a higher grade of endothelial permeability while the presence of intraplaque hemorrhage may not be associated with hemodynamically relevant coronary lesions.

Facilitated Data Relay and Effects on Treatment of Severe Aortic Stenosis in Europe

Background

Many patients with severe aortic stenosis are referred late with advanced symptoms or inappropriately denied intervention. The objective was to investigate whether a structured communication to referring physicians (facilitated data relay) might improve the rate and timeliness of intervention.

Methods and Results

A prospective registry of consecutive patients with severe aortic stenosis at 23 centers in 9 European countries with transcatheter as well as surgical aortic valve replacement being available was performed. The study included a 3‐month documentation of the status quo (phase A), a 6‐month intervention phase (implementing facilitated data relay), and a 3‐month documentation of a legacy effect (phase‐B). Two thousand one hundred seventy‐one patients with severe aortic stenoses were enrolled (phase A: 759; intervention: 905; phase‐B: 507). Mean age was 77.9±10.0 years, and 80% were symptomatic, including 52% with severe symptoms. During phase A, intervention was planned in 464/696 (67%), 138 (20%) were assigned to watchful waiting, 8 (1%) to balloon aortic valvuloplasty, 60 (9%) were listed as not for active treatment, and in 26 (4%), no decision was made. Three hundred sixty‐three of 464 (78%) patients received the planned intervention within 3 months. Timeliness of the intervention improved as shown by the higher number of aortic valve replacements performed within 3 months (59% versus 51%, P=0.002) and a significant decrease in the time to intervention (36±38 versus 30±33 days, P=0.002).

Conclusions

A simple, low‐cost, facilitated data relay improves timeliness of treatment for patients diagnosed with severe aortic stenosis, resulting in a shorter time to transcatheter aortic valve replacement. This effect was mainly driven by a significant improvement in timeliness of intervention in transcatheter aortic valve replacement but not surgical aortic valve replacement.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02241447.

Procedural and clinical performance of dual- versus single-catheter strategy for transradial coronary angiography: A meta-analysis of randomized trials

OBJECTIVES

We sought to compare the procedural and clinical performance of dual- versus single-catheter strategy for transradial coronary angiography.

BACKGROUND

The radial artery (RA) is recommended as the vascular access of choice in patients undergoing coronary angiography and intervention. The procedural and clinical performance of dual- versus single-catheter strategy in patients undergoing transradial coronary angiography remains a matter of debate.

METHODS

This is a study-level meta-analysis of randomized trials. The primary outcome was procedure time. The main secondary outcome was fluoroscopy time. Other outcomes of interest were contrast volume, crossover to other catheter strategy and RA spasm.

RESULTS

A total of 2,062 patients (978 randomly assigned to dual-catheter and 1,084 to single-catheter strategy) included in seven trials were available for the quantitative synthesis. A dual-catheter strategy was associated with procedure time (standardized mean difference [95% confidence intervals (CI)], 0.55 [-0.69, 1.78]; p = .32), fluoroscopy time (-0.36 [-2.39, 1.67]; p = .68) and contrast volume (-0.93 [-3.79, 1.94]; p = .44) comparable to a single-catheter strategy. The risk for crossover was lower (risk ratio [95% CI], 0.14 [0.03, 0.70]; p = .025) while the risk for RA spasm was higher (1.81 [1.54, 2.12]; p < .001) among patients assigned to dual- versus single-catheter strategy.

CONCLUSIONS

This meta-analysis provides evidence for a comparable procedural performance of either dual- or single-catheter strategy for transradial coronary angiography. The fewer crossovers with dual-catheter strategy occur at the expense of more frequent radial artery spasm.

Age-Related 2-Year Mortality After Transcatheter Aortic Valve Replacement: the YOUNG TAVR Registry

OBJECTIVE

To comparatively assess the natural history of patients of different ages undergoing transcatheter aortic valve replacement (TAVR).

PATIENTS AND METHODS

For this study, we used the YOUNG TAVR, an international, multicenter registry investigating mortality trends up to 2 years in patients with aortic valve stenosis treated by TAVR, classified according to 3 prespecified age groups: 75 years or younger (n=179), 76 to 86 years (n=602), and older than 86 years (n=221). A total of 1002 patients undergoing TAVR were included. Demographic, clinical, and outcome data in the youngest group were compared with those of patients 76 to 86 years and older than 86 years. Patients were followed up for up to 2 years.

RESULTS

Compared with patients 75 years or younger (reference group), patients aged 76 to 86 years and older than 86 years had nonsignificantly different 30-day mortality (odds ratio, 0.76; 95% CI, 0.41-1.38; P=.37 and odds ratio, 1.27; 95% CI, 0.62-2.60; P=.51, respectively) and 1-year mortality (hazard ratio (HR), 0.72; 95% CI, 0.48-1.09; P=.12 and HR, 1.11; 95% CI, 0.88-1.40; P=.34, respectively). Mortality at 2 years was significantly lower among patients aged 76 to 86 years (HR, 0.62; 95% CI, 0.42-0.90; P=.01) but not among the older group (HR, 1.06; 95% CI, 0.68-1.67; P=.79). The Society of Thoracic Surgeons 30-day mortality score was lower in younger patients who, however, had a significantly higher prevalence of chronic obstructive pulmonary disease (P=.005 vs the intermediate group and P=.02 vs the older group) and bicuspid aortic valves (P=.02 vs both older groups), larger left ventricles, and lower ejection fractions.

CONCLUSION

In the present registry, mortality at 2 years after TAVR among patients 75 years or younger was higher compared with that of patients aged 75 to 86 years and was not markedly different from that of patients older than 86 years. The findings are attributable at least in part to a greater burden of comorbidities in the younger age group that are not entirely captured by current risk assessment tools.

Treatment of Aortic Stenosis With a Self-Expanding, Resheathable Transcatheter Valve: One-Year Results of the International Multicenter Portico Transcatheter Aortic Valve Implantation System Study

BACKGROUND

The aim of the Portico TAVI (transcatheter aortic valve implantation) system study was to evaluate outcomes ≤1 year after implantation of a novel resheathable, self-expanding TAVI system in a multicenter patient population with severe aortic stenosis (AS).

METHODS AND RESULTS

High-risk patients (n=222) with symptomatic severe AS (mean age, 83.0±4.6 years; 74.3% women) were enrolled across 12 centers in Europe and Australia. The study's primary end point was all-cause mortality at 30 days. A total of 209 patients who received the Portico TAVI system were available for follow-up after the 30-day visit. Data collection included hemodynamic assessment by echocardiography with core laboratory evaluation and assessment of functional status. Valve Academic Research Consortium-defined adverse events were adjudicated by an independent Clinical Events Committee. TAVI using the Portico valve led to a significant and persistent improvement in aortic valve function at 1 year. More than mild paravalvular leak was present in 5.7% and 7.5% of patients at 30 days and 1 year, respectively. Kaplan-Meier estimates at 30 days and 1 year were 3.6% and 13.8% for all-cause mortality, 3.6% and 9.6% for cardiovascular mortality, and 3.2% and 5.8% for major (disabling) stroke. After 30 days and ≤1 year of follow-up, adverse events included stage 3 acute kidney injury (n=3), major vascular complications (n=5), and life-threatening/disabling bleeding (n=3). Overall permanent pacemaker rate was 14.7%. At 1 year, 74.8% improved ≥1 New York Heart Association class compared with baseline (P<0.0001).

CONCLUSIONS

The Portico TAVI system is safe and effective at 1 year, yielding low mortality and stroke rates in high-risk patients with severe AS.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01493284.

Symptoms, disease severity and treatment of adults with a new diagnosis of severe aortic stenosis

OBJECTIVE

Contemporary data on patients with previously undiagnosed severe aortic stenosis (AS) are scarce. We aimed to address this gap by gathering data from consecutive patients diagnosed with severe AS on echocardiography.

METHODS

This was a prospective, multicentre, multinational, registry in 23 tertiary care hospitals across 9 European countries. Patients with a diagnosis of severe AS were included using echocardiography (aortic valve area (AVA) <1 cm², indexed AVA <0.6 cm²/m², maximum jet-velocity (V_max) >4 m/s and/or mean transvalvular gradient >40 mm Hg).

RESULTS

The 2171 participants had a mean age of 77.9 years and 48.0% were female. The mean AVA was 0.73 cm², V_max4.3 m/s and mean gradient 47.1 mm Hg; 62.1% had left ventricular hypertrophy and 27.3% an ejection fraction (EF) <50%. 1743 patients (80.3%) were symptomatic (shortness-of-breath 91.0%; dizziness 30.2%, chest pain 28.9%). Patients had a EuroSCORE II of 4.0; 25.3% had a creatinine clearance <50 mL/min, and 3.2% had an EF <30%. Symptomatic patients were older and had more comorbidities than asymptomatic patients. Despite European Society of Cardiology 2017 valvular heart disease guideline class I recommendation, in only 76.2% a decision was made for an intervention (transcatheter 50.4%, surgical aortic valve replacement 25.8%). In asymptomatic patients, 57.7% with a class I/IIa indication were scheduled for a procedure, while 36.3% patients without an indication had their valve replaced.

CONCLUSIONS

The majority of patients with severe AS presented at an advanced disease stage. Management of severe AS remained suboptimal in a significant proportion of contemporary patients with severe AS.

TRIAL REGISTRATION NUMBER

NCT02241447;Results.

Incidence and outcome of peri-procedural transcatheter heart valve embolization and migration: the TRAVEL registry (TranscatheteR HeArt Valve EmboLization and Migration)

Aims

Peri-procedural transcatheter valve embolization and migration (TVEM) is a rare but potentially devastating complication of transcatheter aortic valve implantation (TAVI). We sought to assess the incidence, causes, and outcome of TVEM in a large multicentre cohort.

Methods and results

We recorded cases of peri-procedural TVEM in patients undergoing TAVI between January 2010 and December 2017 from 26 international sites. Peri-procedural TVEM occurred in 273/29 636 (0.92%) TAVI cases (age 80.8 ± 7.3 years; 53.8% female), of which 217 were to the ascending aorta and 56 to the left ventricle. The use of self-expanding or first-generation prostheses and presence of a bicuspid aortic valve were independent predictors of TVEM. Bail-out measures included repositioning attempts using snares or miscellaneous tools (41.0%), multiple valve implantations (83.2%), and conversion to surgery (19.0%). Using 1:4-propensity matching, we identified a cohort of 235 patients with TVEM (TVEMPS) and 932 patients without TVEM (non-TVEMPS). In the matched cohort, all-cause mortality was higher in TVEMPS than in non-TVEMPS at 30 days (18.6% vs. 4.9%; P < 0.001) and after 1 year (30.5% vs. 16.6%; P < 0.001). Major stroke was more frequent in TVEMPS at 30 days (10.6% vs. 2.8%; P < 0.001), but not at 1 year (4.6% vs. 1.9%; P = 0.17). The need for emergent cardiopulmonary support, major stroke at 30 days, and acute kidney injury Stages 2 and 3 increased the risk of 1-year mortality, whereas a better renal function at baseline was protective.

Conclusion

Transcatheter valve embolization and migration occurred in approximately 1% and was associated with increased morbidity and mortality.

The History of Transcatheter Aortic Valve Implantation (TAVI)-A Personal View Over 25 Years of development

In the early 1990s, the idea of Transcatheter Aortic Valve Implantation (TAVI) emerged from clinicians by the insight that the long-term hemodynamic and clinical results of aortic balloon valvuloplasty to treat aortic stenonosis were not satisfying. Thus, Anderson and Cribier developed the balloon-expandable and Figulla and Laborde the self-expendable TAVI systems. Sceptical views by the surgical colleagues and the industry delayed the rapid development of this disruptive new therapy until 2002, when Alain Cribier demonstrated for the first time the proof of his concept. Bulky devices and paravalvular leakages in patients treated in terms of compassionate care resulted in high mortality rates. From 2005 onwards, the treatment of patients not at highest risk using smoother devices in clinical trials could demonstrate that the technology was equivalent to surgical aortic valve replacement. The transapical access route initiated the heart team approach with the surgical colleagues, however, this access route is presently expiring due to its greater trauma. The need to treat also aortic regurgitation is addressed by the "clipping technology" of JenaValve™. Ongoing clinical trials investigate an extended indication for TAVI at an earlier stage of aortic stenosis, or in reduced ejection fraction, and just demonstrated the safety and efficiency even in low surgical risk patients.

Effect on Outcomes: Infections Complicating Percutaneous Coronary Interventions in Patients ≥80 Years of Age

Data on the prevalence of infections in patients who underwent percutaneous coronary intervention (PCI) and their impact on outcomes are scarce. In this study, a total of 644 patients ≥80 years of age who underwent PCI were stratified according to the presence/absence of infections requiring antibiotic therapy. The primary end point was major adverse cardiovascular events (MACE) after discharge, a composite of all-cause mortality, nonfatal myocardial infarction, and rehospitalization for heart failure. Median follow-up was 1.2 (interquartile range 0.1 to 3.4) years. Of the 644 patients, 186 (28.9%) had infections during index hospitalization, with 84 (13%) and 59 (9.2%) patients having pneumonia and urinary tract infections, respectively. Patients with infections were older, more often women, and had an increased prevalence of atrial fibrillation and congestive heart failure. Infections prolonged hospital stay (10 [7 to 16] vs 5 [3 to 7] days, p <0.001), but were not related to rates of MACE (20% vs 19%, adjusted hazard ratio [HR] 1.41, 95% confidence intervals 0.84 to 2.38, p = 0.20). Pneumonia was significantly associated with increased rates of MACE (27% vs 18%, adjusted HR 2.19, 95% confidence intervals 1.23 to 3.91, p = 0.008) and rehospitalization for heart failure (17% vs 10%, adjusted HR 2.66 (1.25 to 5.63, p = 0.01), whereas urinary tract infections were not. In conclusion, concomitant infections are frequent in patients ≥80 years of age who underwent PCI, and associated with an increased risk of adverse events when affecting the respiratory system.

Real-world extravascular lung water index measurements in critically ill patients : Pulse index continuous cardiac output measurements: time course analysis and association with clinical characteristics

BACKGROUND

Pulse index continuous cardiac output (PiCCO) is used for hemodynamic assessment. This study describes real world extravascular lung water index (EVLWI) measurements at three time points and relates them to other hemodynamic parameters and mortality in critically ill patients admitted to a medical intensive care unit (ICU).

METHODS

A total of 198 patients admitted to a tertiary medical university hospital between February 2004 and December 2010 were included in this retrospective analysis. Patients were admitted for various diseases such as sepsis (n = 22), myocardial infarction (n = 53), pulmonary embolism (n = 3), cardiopulmonary resuscitation (n = 15), acute heart failure (AHF; n = 21) and pneumonia (n = 25).

RESULTS

Patients included in this analysis were severely ill as represented by the high simplified acute physiology score 2 (SAPS2, 42 ± 18) and acute physiology and chronic health evaluation score 2 (APACHE2' 22 ± 9). Real-world values at three time points are provided. Intra-ICU mortality rates did not differ between the EVLWI > 7 vs. the ELVWI < 7 groups (15% vs. 13%; p = 0.82) and no association between hemodynamic measurements obtained by PiCCO with long-term mortality could be shown.

CONCLUSION

There were no associations of any PiCCO measurements with mortality most probably due to selection bias towards severely ill patients. Future prospective studies with predefined inclusion criteria and treatment algorithms are necessary to evaluate the value of PiCCO for prediction of mortality against simple clinical tools such as jugular venous pressure, edema and auscultation.

Impact of concomitant mitral regurgitation on transvalvular gradient and flow in severe aortic stenosis: a systematic ex vivo analysis of a subentity of low-flow low-gradient aortic stenosis

AIMS

Evaluation of aortic stenosis (AS) is based on echocardiographic measurement of mean pressure gradient (MPG), flow velocity (Vmax) and aortic valve area (AVA). The objective of the present study was to analyse the impact of systemic haemodynamic variables and concomitant mitral regurgitation (MR) on aortic MPG, Vmax and AVA in severe AS.

METHODS AND RESULTS

A pulsatile circulatory model was designed to study function and interdependence of stenotic aortic (AVA: 1.0 cm², 0.8 cm² and 0.6 cm²) and insufficient mitral prosthetic valves (n=8; effective regurgitant orifice area [EROA] <0.2 cm² vs. >0.4 cm²) using Doppler ultrasound. In the absence of severe MR, a stepwise increase of stroke volume (SV) and a decrease of AVA was associated with a proportional increase of aortic MPG. When MR with EROA <0.2 cm² vs. >0.4 cm² was introduced, forward SV decreased significantly (70.9±1.1 ml vs. 60.8±1.6 ml vs. 47.4±1.1 ml; p=0.02) while MR volume increased proportionally. This was associated with a subsequent reduction of aortic MPG (57.1±9.4 mmHg vs. 48.6±13.8 mmHg vs. 33.64±9.5 mmHg; p=0.035) and Vmax (5.09±0.4 m/s vs. 4.91±0.73 m/s vs. 3.75±0.57 m/s; p=0.007). Calculated AVA remained unchanged (without MR: AVA=0.53±0.04 cm² vs. with MR: AVA=0.52±0.05 cm²; p=ns). In the setting of severe AS without MR, changes of vascular resistance (SVR) and compliance (C) did not impact on aortic MPG (low SVR and C: 66±13.8 mmHg and 61.1±20 mmHg vs. high SVR and C: 60.9±9.2 mmHg and 71.5±13.5 mmHg; p=ns) In concomitant severe MR, aortic MPG and Vmax were not significantly reduced by increased SVR (36.6±2.2 mmHg vs. 34.9±5.6 mmHg, p=0.608; 3.89±0.18 m/s vs. 3.96±0.28 m/s; p=ns).

CONCLUSIONS

Systemic haemodynamic variables and concomitant MR may potentially affect diagnostic accuracy of echocardiographic AS evaluation. As demonstrated in the present study, MPG and Vmax are flow-dependent and significantly reduced by a reduction of forward SV from concomitant severe MR, resulting in another entity of low-flow low-gradient aortic stenosis. In contrast, calculated AVA appears to be a robust parameter of AS evaluation if severe MR is present. Changes of SVR and C did not affect the diagnostic accuracy of AS evaluation.

Mechanical circulatory support with Impella versus intra-aortic balloon pump or medical treatment in cardiogenic shock-a critical appraisal of current data

AIMS

Patients suffering from cardiogenic shock (CS) have a high mortality and morbidity. The Impella percutaneous left-ventricular assist device (LVAD) decreases LV preload, increases cardiac output, and improves coronary blood flow. We aimed to review and meta-analyze available data comparing Impella versus intra-aortic pump (IABP) counterpulsation or medical treatment in CS due to acute myocardial infarction or post-cardiac arrest.

METHODS AND RESULTS

Study-level data were analyzed. Heterogeneity was assessed using the I² statistic. Risk rates were calculated and obtained using a random-effects model (DerSimonian and Laird). Four studies were found suitable for the final analysis, including 588 patients. Primary endpoint was short-term mortality (in-hospital or 30-day mortality). In a meta-analysis of four studies comparing Impella versus control, Impella was not associated with improved short-term mortality (in-hospital or 30-day mortality; RR 0.84; 95% CI 0.57-1.24; p = 0.38; I² 55%). Stroke risk was not increased (RR 1.00; 95% CI 0.36-2.81; p = 1.00; I²2 0%), but risk for major bleeding (RR 3.11 95% CI 1.50-6.44; p = 0.002; I² 0%) and peripheral ischemia complications (RR 2.58; 95% CI 1.24-5.34; p = 0.01; I² 0%) were increased in the Impella group.

CONCLUSION

In patients suffering from severe CS due to AMI, the use of Impella is not associated with improved short-time survival but with higher complications rates compared to IABP and medical treatment. Better patient selection avoiding Impella implantation in futile situations or in possible lower risk CS might be necessary to elucidate possible advantages of Impella in future studies.

Transcatheter aortic valve replacement for pure aortic valve regurgitation: "on-label" versus "off-label" use of TAVR devices

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has become the mainstay of treatment for aortic stenosis in patients with high surgical risk. Pure aortic regurgitation (PAR) is considered a relative contraindication for TAVR; however, TAVR is increasingly performed in PAR patients with unfavorable risk profile. Herein, we aim to summarize available data on TAVR for PAR with special emphasis on "on-label" versus "off-label" TAVR devices.

METHODS AND RESULTS

Pubmed was searched for studies of patients undergoing TAVR for PAR. Primary outcome was 30 day-mortality. Pooled estimated event rates were calculated. Twelve studies including a total of 640 patients were identified until December 2017. Among these, 208 (33%) patients were treated with devices with CE-mark approval for PAR ("on-label"; JenaValve and J valve). Overall, the procedural success rate was 89.9% (95% CI 81.1-96.1%; I² 80%). Major bleeding was reported in 6.4% (95% CI 2.9-10.8%; I² 48%). All-cause mortality at 30 days was 10.4% (95% CI 7.1-14.2%; I² 20%). Stroke occurred in 2.2% (95% CI 0.9-3.9%; I² 0%). A permanent pacemaker was required in 10.7% (95% CI 7.3-14.6%; I² 23%). At 30 days after TAVR, ≥ moderate AR post-interventional was observed in 11.5% (95% CI 2.9-23.6%; I² 90%). In the "on-label"-group, success rate was 93.0% (95% CI 85.9-98.1%; I² 52%). 30-day-mortality was 9.1% (95% CI 3.7-16.0%; I² 36%). More than trace AR was present in 2.8% (95% CI 0.1-7.6%; I² 0%). Compared to first-generation devices, second-generation devices were associated with significantly lower 30-day-mortality (r = - 0.10; p = 0.02), and significantly higher procedural success rates (r = 0.28; p < 0.001). Compared to other second-generation devices, the use of J valve or JenaValve was not associated with altered mortality (r = 0.04; p = 0.50), rates of > trace residual AR (r = - 0.05; p = 0.65) but with a significantly higher procedural success (r = 0.15; p = 0.042).

CONCLUSION

Based on this summary of available observational data TAVR for PAR is feasible and safe in patients deemed inoperable. First-generation TAVR devices are associated with inferior outcome and should be avoided. The "on-label" use of PAR-certified TAVR devices is associated with a significantly higher procedural success rate and might be favorable compared to other second-generation devices.

Noninvasive Imaging of Endothelial Damage in Patients With Different HbA1c Levels: A Proof-of-Concept Study

The aim of this study was to compare endothelial permeability, which is considered a hallmark of coronary artery disease, between patients with different HbA_1c levels using an albumin-binding magnetic resonance (MR) probe. This cross-sectional study included 26 patients with clinical indication for X-ray angiography who were classified into three groups according to HbA_1c level (<5.7% [<39 mmol/mol], 5.7-6.4% [39-47 mmol/mol], and ≥6.5% [48 mmol/mol]). Subjects underwent gadofosveset-enhanced coronary magnetic resonance and X-ray angiography including optical coherence within 24 h. Contrast-to-noise ratios (CNRs) were assessed to measure the probe uptake in the coronary wall by coronary segment, excluding those with culprit lesions in X-ray angiography. In the group of patients with HbA_1c levels between 5.7 and 6.4%, 0.30 increased normalized CNR values were measured, compared with patients with HbA_1c levels <5.7% (0.30 [95% CI 0.04, 0.57]). In patients with HbA_1c levels ≥6.5%, we found 0.57 higher normalized CNR values compared with patients with normal HbA_1c levels (0.57 [95% CI 0.28, 0.85]) and 0.26 higher CNR values for patients with HbA_1c level ≥6.5% compared with patients with HbA_1c levels between 5.7 and 6.4% (0.26 [95% CI -0.04, 0.57]). Additionally, late atherosclerotic lesions were more common in patients with high HbA_1c levels (HbA_1c ≥6.5%, n = 14 [74%]; HbA_1c 5.7-6.4%, n = 6 [60%]; and HbA_1c <5.7%, n = 10 [53%]). In conclusion, coronary MRI in combination with an albumin-binding MR probe suggests that both patients with intermediate and patients with high HbA_1c levels are associated with a higher extent of endothelial damage of the coronary arteries compared with patients with HbA_1c levels <5.7%.

Hypoglycemia but Not Hyperglycemia Is Associated with Mortality in Critically Ill Patients with Diabetes

BACKGROUND

Both severe hyperglycemia (> 200 mg/dL) and hypoglycemia (≤70 mg/dL) are known to be associated with increased mortality in critically ill patients. Therefore, we investigated associations of a single episode of blood glucose deviation (concentration either ≤70 mg/dL and/or > 200 mg/dL) during an intensive care unit (ICU) stay with mortality in these patients.

METHODS

A total of 4,986 patients (age 65 ± 15 years; 39% female; 14% type 2 diabetes [T2DM] based on medical records) admitted to a German ICU in a tertiary care hospital were investigated retrospectively. The intra-ICU and long-term mortality of patients between 4 and 7 years after their ICU submission were assessed.

RESULTS

A total 62,659 glucose measurements were analyzed. A single glucose deviation was associated with adverse outcomes compared to patients without a glucose deviation, represented by both intra-ICU mortality (22 vs. 10%; OR 2.62; 95% CI 2.23-3.09; p < 0.001) and long-term mortality (HR 2.01; 95% CI 1.81-2.24; p < 0.001). In patients suffering from T2DM hypoglycemia (30 vs. 13%; OR 2.94; 95% CI 2.28-3.80; p < 0.001) but not hyperglycemia (16 vs. 14%; OR 1.05; 95% CI 0.68-1.62; p = 0.84) was associated with mortality.

CONCLUSION

In patients with dia-betes, hypo- but not hyperglycemia was associated with increased mortality, whereas in patients without diabetes, both hyper- and hypoglycemia were associated with adverse outcome. Blood glucose concentration might need differential approaches depending on concomitant diseases.

Comparison of resting distal to aortic coronary pressure with angiography-based quantitative flow ratio

BACKGROUND

Quantitative flow ratio (QFR) is a novel, adenosine-free method for functional coronary lesion interrogation, which is based on 3-dimensional quantitative coronary angiography and computational algorithms. Data on QFR in all-comer patients with intermediate coronary lesions are scarce, and the diagnostic performance in comparison to resting distal to aortic coronary pressure (Pd/Pa) ratio unknown.

METHODS

A total of 436 patients with 516 vessels undergoing FFR measurements were included in the analysis. Diagnostic performance of QFR, distal to aortic coronary pressure (Pd/Pa) ratio, and anatomic indices versus FFR was assessed.

RESULTS

FFR ≤0.80 was measured in 19.4% of interrogated vessels. QFR significantly correlated with FFR (r = 0.82, p < 0.001) with good agreement between QFR and FFR (mean difference 0.011, 95% CI 0.008-0.015). The AUC for an FFR ≤0.80 was 0.86 (95% CI 0.83-0.89, p < 0.001) for QFR, 0.76 (0.72-0.80, p < 0.001) for resting Pd/Pa ratio, and 0.63 (0.59-0.67, p < 0.001) for diameter stenosis. The diagnostic accuracy for identifying an FFR ≤0.80 was 93.4% for QFR, 84.3% for resting Pd/Pa ratio, and 80.4% for diameter stenosis.

CONCLUSIONS

QFR provides a novel diagnostic tool for functional coronary lesion assessment with superior diagnostic accuracy as compared with resting Pd/Pa ratio and anatomic indices. Future studies are needed to determine the non-inferiority of QFR analysis to FFR assessment with respect to clinical outcomes.

Performance of One- Compared With Two-Catheter Concepts in Transradial Coronary Angiography (from the Randomized Use of Different Diagnostic Catheters-Radial-Trial)

The Use of Different Diagnostic Catheters-Radial-Trial sought to compare the safety and efficacy of one-catheter concepts (OCC) using Tiger II or BLK catheters with two-catheter concepts (TCC) using standard Judkins catheters for transradial coronary angiography. A total of 300 patients planed for coronary angiography were enrolled into this single-center, single-blinded trial. Patients were randomized in a 2:1 ratio to either OCC by Tiger II (n = 100) and BLK (n = 100) or TCC by Judkins (n = 100) catheters. Primary end point was time required to perform a complete coronary angiography. Coronary angiography duration was 603 ± 29 seconds and 552 ± 26 sec in the OCC and the TCC groups (p = 0.052). Fluoroscopy time was longer in the OCC (408 ± 28 sec) as compared with the TCC group (258 ± 28 sec, p = 0.009) and the amount of contrast volume used significantly higher (98 ± 5 ml vs 67 ± 4 ml, p < 0.001). Crossover rates were increased in the OCC as compared with the TCC group (37% vs 4%, p < 0.001). These effects were observed irrespective of OCC catheter type. In conclusion, this study demonstrates that OCC do not reduce angiography time, but are associated with an increased amount of contrast volume and longer fluoroscopy time as compared with TCC.

Correction to: Transcatheter valve-in-valve implantation (VinV-TAVR) for failed surgical aortic bioprosthetic valves

Unfortunately, an error occurred in the original article.

Multi-biomarker analysis in patients after transcatheter aortic valve implantation (TAVI)

BACKGROUND

In this study we sought to examine whether transcatheter aortic valve implantation (TAVI) is followed by a change in the plasma levels of novel cardiovascular biomarkers.

METHODS

We collected blood samples of 79 patients with severe aortic valve stenosis undergoing TAVI before and at 7 days, 1 month, 3 months and 6 months post TAVI and analyzed the plasma concentrations of GDF-15, H-FABP, fetuin-A, galectin 3, sST2 and suPAR by means of ELISA.

RESULTS

There was a significant increase in the concentration of fetuin-A (median: 52.44 mg/ml to 113.2 mg/ml, p < 0.001) and a significant decrease of H-FABP after TAVI (median: 4.835 ng/ml to 2.534 ng/ml, p < 0.001). The concentrations of suPAR and sST2 showed an initial increase (suPAR median: 2755 pg/ml 3489 pg/ml, p < 0.001; sST2 median: 5832 pg/ml to 7137 pq/ml, p < 0.001) and subsequently decreased significantly.

CONCLUSION

We hypothesize that the decrease of H-FABP and the increase of fetuin-A could be due to a hemodynamic improvement after valve replacement. The initial increase of suPAR could indicate an inflammatory stimulus and the significant increase in sST2 could be due to the mechanical strain caused by implantation of the valve.

Effect of Physical Disability on Mortality in Elderly Patients of ≥80 Years of Age Undergoing Percutaneous Coronary Intervention

Functional decrease has been linked with adverse events in different clinical contexts. The predictive role of activity of daily living status as assessed by the Barthel index (BI) in elderly patients who underwent percutaneous coronary intervention (PCI) has not been investigated, yet. In this study, a total of 616 patients (≥80 years) who underwent PCI between January 2009 and December 2014 and with available activity of daily living data on admission were stratified according to BI (low BI <85, intermediate BI 85 to 95, high BI 100). The primary end point was all-cause mortality at a total follow-up of 442 days (interquartile range 47 to 1243). Of the 616 patients, 178 (29%), 128 (21%), and 310 (50%) were in the low, the intermediate, and the high BI groups, respectively. All-cause mortality was 10%, 13%, and 5% in the low, the intermediate, and the high BI groups, respectively (log-rank p <0.001). Belonging to the high BI group was associated with a reduced risk of all-cause mortality (hazard ratio 0.35, 95% confidence interval 0.18 to 0.69, p = 0.002), and associations remained significant after multivariable adjustments (adjusted hazard ratio 0.34, 95% confidence interval 0.13 to 0.93, p = 0.04). Functional capacity was identified as independent predictor of survival in a large cohort of patients who underwent PCI. In conclusion, activities of daily living should be incorporated into the risk stratification of elderly patients with coronary artery disease.