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Nitsche C, Koschutnik M, Dona C, Mutschlechner D, Spinka G, Dannenberg V, Mascherbauer K, Sinnhuber L, Kammerlander A, Winter MP, Bartko PE, Goliasch G, Hengstenberg C, Mascherbauer J. Life expectancy and early to mid-term dysfunction of transcatheter aortic prostheses: incidence, modes, correlates, and outcome. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Backgrounds
Bioprosthetic valve dysfunction (BVD) is a major concern regarding transcatheter aortic valve implantation (TAVI) in low-risk patients.
Aims
To assess incidence, determinants, modes, and outcome of early to mid-term BVD after TAVI in relation with life expectancy.
Methods
Consecutive TAVI recipients (2007–2020) with a post-interventional follow-up ≥1-year were prospectively included. BVD components and bioprosthetic valve failure (BVF) were assessed according to updated Valve-Academic-Research-Consortium-3 criteria. Echocardiographic and laboratory follow-up was performed prior to discharge, at 3- and 12-months, and yearly thereafter. BVD/BVF and all-cause death served as endpoints. Average life expectancy was calculated from National Open Health Data and patients were stratified according to tertiles (1st: <6.85y, 2nd: 6.85–9.7y, 3rd: >9.7y).
Results
Of 1047 patients (81.6±6.8 y/o, 52.7% female, EuroSCORE II 4.5±2.5), ≥2 follow-ups were available from 622 (serial echo cohort). After a median echo follow-up of 12.2 months, incidence rates of BVD and BVF were 8.4% [95% confidence interval 6.7–10.3], and 3.5% [2.5–4.9] per valve-year, respectively, without differences between life expectancy tertiles (Figure 1). BVD incidence was double within the first year of implant (9.9% [7.7–12.6] per valve-year; mostly non-structural VD) vs. beyond (4.8% [3.1–7.2] per valve-year; structural and non-structural VD). Valve-in-valve procedure, and stenosis severity (both p<0.05), but not age/life expectancy (p>0.5) predisposed for BVD.
After 4.4±3.0 years, mortality was 36.7%. Time-dependent BVD/BVF were independently associated with outcome for patients in the first (adjusted hazard ratio [AHR] 1.72 [1.06–2.88]/ 2.97 [1.72–6.22]) and second (AHR 1.96 [1.02–3.73]/ 2.31 [1.00–5.30]), but not the third tertile of life expectancy (AHR 1.42 [0.66–3.12]/ 1.84 [0.71–4.79]; Figure 1).
Conclusions
In this large prospective observational cohort, early to mid-term BVD after TAVI occurred at the same rate across the spectrum of life expectancy and was not prognostic among those with the longest life expectancy.
Funding Acknowledgement
Type of funding sources: None.
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Schoenbauer R, Hana F, Duca F, Koschutnik M, Dona C, Nitsche C, Sponder M, Lenz M, Loewe C, Beitzke D, Hengstenberg C, Mascherbauer J, Kammerlander AA. Right atrial function in HFpEF in sinus rhythm vs. atrial fibrillation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
We sought to study the prognostic impact of right atrial (RA) size and function in patients with heart failure with preserved ejection fraction (HFpEF) in sinus rhythm (SR) vs. atrial fibrillation (AF).
Methods and results
Consecutive HFpEF patients were enrolled and indexed RA volumes and emptying fractions (RA-EF) were assessed by cardiac magnetic resonance imaging (CMR). For patients in SR during CMR feature tracking of the RA wall was performed (Figure 1). In addition, all patients underwent right and left heart catheterization, 6 min walk test, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) evaluation. We prospectively followed patients and used Cox regression models to determine the association of RA size and function with a composite endpoint of heart failure hospitalization and cardiovascular death. A total of 188 patients (71% female patients, 70±8 years old) were included of whom 96 (51%) were in SR. Eighty-five patients reached the combined endpoint during a follow-up of 72 (33–101) months. After multivariate cox regression analysis adjusted for age, NT-proBNP level, right ventricular ejection fraction and HF functional class, impaired RA strain (Figure 1A) (HR 0.959; 95% CI [0.924–0.996], P=0.024), RA conduit strain (Figure 1A) (HR 0.944; 95% CI [0.898–0.993], P=0.027) and RA conduit strain rate (Figure 1B) (HR 0.990; 95% CI [0.883–0.998], P=0.013) were significantly associated with adverse outcome for patients in SR (Table 1). In persistent AF, no RA imaging parameter was related to outcome after multivariate regression analysis.
Conclusions
In HFpEF patients in SR, CMR parameters of impaired RA conduit function show the best association with adverse cardiovascular outcome. In persistent AF, RA parameters lose their prognostic ability.
Funding Acknowledgement
Type of funding sources: None.
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Mascherbauer K, Dona C, Koschutnik M, Dannenberg V, Nitsche C, Duca F, Beitzke D, Loewe C, Waldmann E, Trauner M, Bartko P, Goliasch G, Mascherbauer J, Hengstenberg C, Kammerlander A. Hepatic T1-time predicts cardiovascular risk in all-comers referred for cardiovascular magnetic resonance. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Liver damage is frequently observed in patients with cardiovascular disease (CVD) but infrequently quantified. We hypothesized that in patients with CVD undergoing cardiac magnetic resonance (CMR), liver T1-times indicate liver damage and are associated with cardiovascular outcome.
Methods
We measured hepatic T1-times, displayed on standard cardiac T1-maps, in an all-comer CMR-cohort. At the time of CMR, we assessed validated general liver fibrosis scores. Kaplan-Meier estimates and Cox-regression models were used to investigate the association between hepatic T1-times and a composite endpoint of non-fatal myocardial infarction, heart failure hospitalization, and death.
Results
1022 participants (58±18 y/o, 47% female) were included (972 patients, 50 controls). Hepatic T1-times were 590±89ms in patients and 574±45ms in controls (p=0.052). They were significantly correlated with cardiac size and function, presence of atrial fibrillation, NT-pro-BNP levels, and gamma-glutamyl-transferase levels (p<0.001 for all). During follow-up (58±31 months), a total of 280 (29%) events occurred. On Cox-regression, high hepatic T1-times yielded a significantly higher risk for events (adj.HR 1.66 [95% CI: 1.45–1.89] per 100ms increase, p<0.001), even when adjusted for age, sex, left and right ventricular ejection fraction, NT-proBNP, and myocardial T1-time. On restricted cubic splines, we found that a hepatic T1-time exceeding 610ms was associated with excessive risk.
Conclusion
Hepatic T1-times on standard CMR scans were significantly associated with cardiac size and function, comorbidities, natriuretic peptides, and independently predicted cardiovascular mortality and morbidity. A hepatic T1-time >610ms seems to indicate excessive risk.
Funding Acknowledgement
Type of funding sources: None.
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Mascherbauer K, Donà C, Koschutnik M, Dannenberg V, Nitsche C, Duca F, Heitzinger G, Halavina K, Steinacher E, Kronberger C, Bardach C, Beitzke D, Loewe C, Waldmann E, Trauner M, Barkto P, Goliasch G, Mascherbauer J, Hengstenberg C, Kammerlander A. Hepatic T1-Time Predicts Cardiovascular Risk in All-Comers Referred for Cardiovascular Magnetic Resonance: A Post-Hoc Analysis. Circ Cardiovasc Imaging 2022; 15:e014716. [PMID: 36256728 DOI: 10.1161/circimaging.122.014716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Liver damage is frequently observed in patients with cardiovascular disease but infrequently quantified. We hypothesized that in patients with cardiovascular disease undergoing cardiac magnetic resonance, liver T1-times indicate liver damage and are associated with cardiovascular outcome. METHODS We measured hepatic T1-times, displayed on standard cardiac T1-maps, in an all-comer cardiac magnetic resonance-cohort. At the time of cardiac magnetic resonance, we assessed validated general liver fibrosis scores. Kaplan-Meier estimates and Cox-regression models were used to investigate the association between hepatic T1-times and a composite endpoint of non-fatal myocardial infarction, heart failure hospitalization, and death. RESULTS One thousand seventy-five participants (58±18 year old, 47% female) were included (972 patients, 50 controls, 53 participants with transient elastography). Hepatic T1-times were 590±89 ms in patients and 574±45 ms in controls (P=0.052). They were significantly correlated with cardiac size and function, presence of atrial fibrillation, NT-pro-BNP levels, and gamma-glutamyl-transferase levels (P<0.001 for all). During follow-up (58±31 months), a total of 280 (29%) events occurred. On Cox-regression, high hepatic T1-times yielded a significantly higher risk for events (adjusted hazard ratio, 1.66 [95% CI, 1.45-1.89] per 100 ms increase; P<0.001), even when adjusted for age, sex, left and right ventricular ejection fraction, NT-proBNP (N-terminal prohormone of brain natriuretic peptide), and myocardial T1-time. On receiver operating characteristic analysis and restricted cubic splines, we found that a hepatic T1-time exceeding 610 ms was associated with excessive risk. CONCLUSIONS Hepatic T1-times on standard cardiac magnetic resonance scans were significantly associated with cardiac size and function, comorbidities, natriuretic peptides, and independently predicted cardiovascular mortality and morbidity. A hepatic T1-time >610 ms seems to indicate excessive risk. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04220450.
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Nitsche C, Koschutnik M, Donà C, Mutschlechner D, Halavina K, Spinka G, Dannenberg V, Mascherbauer K, Sinnhuber L, Kammerlander A, Winter MP, Bartko P, Goliasch G, Pibarot P, Hengstenberg C, Mascherbauer J. Incidence, causes, correlates, and outcome of bioprosthetic valve dysfunction and failure following transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2022; 24:796-806. [PMID: 36099163 DOI: 10.1093/ehjci/jeac188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/14/2022] [Accepted: 08/18/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Bioprosthetic valve dysfunction (BVD) is a major concern regarding transcatheter aortic valve implantation (TAVI) durability. We aimed to assess incidence, correlates, causes, and outcome of early to mid-term BVD after TAVI in relation to patient's life expectancy. METHODS AND RESULTS Consecutive TAVI recipients (2007-20) with a follow-up ≥1 year were prospectively included. BVD and bioprosthetic valve failure (BVF) were assessed according to Valve-Academic-Research-Consortium-3. BVD/BVF and all-cause death served as endpoints. Average life expectancy was calculated from National Open Health Data and patients were stratified according to tertiles (1st: <6.85 years, 2nd: 6.85-9.7 years, 3rd: >9.7 years). Of 1047 patients (81.6 ± 6.8 years old, EuroSCORE II 4.5 ± 2.5), ≥2 follow ups were available from 622 (serial echo cohort). After a median echo follow up of 12.2 months, incidence rates of BVD/BVF were 8.4% (95% confidence interval 6.7-10.3), and 3.5% (2.5-4.9) per valve-year, respectively, without differences between life expectancy tertiles. The incidence of BVD was two-fold higher within the first year of implant (9.9% per valve-year) vs. beyond (4.8% per valve-year). Valve-in-valve procedure and residual stenosis, but not age/life expectancy predisposed for BVD. BVD/BVF were independently associated with outcome for patients in the first [adjusted hazard ratio (AHR) 1.72 (1.06-2.88)/2.97 (1.72-6.22)] and second [AHR 1.96 (1.02-3.73)/2.31 (1.00-5.30)], but not the third tertile of life expectancy (P = n.s.). CONCLUSIONS In this large prospective observational cohort, early to mid-term BVD after TAVI occurred at the same rate across the spectrum of life expectancy and was associated with increased mortality in patients with short but not in those with the longest life expectancy.
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Donà C, Nitsche C, Koschutnik M, Heitzinger G, Mascherbauer K, Kammerlander AA, Dannenberg V, Halavina K, Rettl R, Duca F, Traub-Weidinger T, Puchinger J, Gunacker PC, Lamm G, Vock P, Lileg B, Philipp V, Staudenherz A, Calabretta R, Hacker M, Agis H, Bartko P, Hengstenberg C, Fontana M, Goliasch G, Mascherbauer J. Unveiling Cardiac Amyloidosis, its Characteristics, and Outcomes Among Patients With MR Undergoing Transcatheter Edge-to-Edge MV Repair. JACC Cardiovasc Interv 2022; 15:1748-1758. [PMID: 36008266 DOI: 10.1016/j.jcin.2022.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/31/2022] [Accepted: 06/14/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Mitral regurgitation (MR) and cardiac amyloidosis (CA) both primarily affect older patients. Data on coexistence and prognostic implications of MR and CA are currently lacking. OBJECTIVES This study sought to identify the prevalence, clinical characteristics, and outcomes of MR CA compared with lone MR. METHODS Consecutive patients undergoing transcatheter edge-to-edge repair (TEER) for MR at 2 sites were screened for concomitant CA using a multiparametric approach including core laboratory 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid bone scintigraphy and echocardiography and immunoglobulin light chain assessment. Transthyretin CA (ATTR) was diagnosed by 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (Perugini grade 1: early infiltration; grades 2/3: clinical CA) and the absence of monoclonal protein, and light chain (AL) CA via tissue biopsy. All-cause mortality and hospitalization for heart failure (HHF) served as the endpoints. RESULTS A total of 120 patients (age 76.9 ± 8.1 years, 55.8% male) were recruited. Clinical CA was diagnosed in 14 patients (11.7%; 12 ATTR, 1 AL, and 1 combined ATTR/AL) and early amyloid infiltration in 9 patients (7.5%). Independent predictors of MR CA were increased posterior wall thickness and the presence of a left anterior fascicular block on electrocardiography. Procedural success and periprocedural complications of TEER were similar in MR CA and lone MR (P for all = NS). After a median of 1.7 years, 25.8% had experienced death and/or HHF. MR CA had worse outcomes compared with lone MR (HR: 2.2; 95% CI: 1.0-4.7; P = 0.034), driven by a 2.5-fold higher risk for HHF (HR: 2.5; 95% CI: 1.1-5.9), but comparable mortality (HR: 1.6; 95% CI: 0.4-6.1). CONCLUSIONS Dual pathology of MR CA is common in elderly patients with MR undergoing TEER and has worse postinterventional outcomes compared with lone MR.
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Amat-Santos I, Loureiro RE, Gonzalez IC, Pascual I, Mascherbauer J, Abdul-Jawad Altisent O, Nombela-Franco L, Nouche RT, Moreno R, Puri R, Gomez-Herrero J, Blasco-Turrion S. TCT-530 Short-Term Structural Remodeling Following Bicaval TricValve Implantation for Treating Severe Tricuspid Regurgitation. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Dachs TM, Duca F, Rettl R, Binder-Rodriguez C, Dalos D, Ligios LC, Kammerlander A, Grünig E, Pretsch I, Steringer-Mascherbauer R, Ablasser K, Wargenau M, Mascherbauer J, Lang IM, Hengstenberg C, Badr-Eslam R, Kastner J, Bonderman D. Riociguat in pulmonary hypertension and heart failure with preserved ejection fraction: the haemoDYNAMIC trial. Eur Heart J 2022; 43:3402-3413. [PMID: 35909264 PMCID: PMC9492239 DOI: 10.1093/eurheartj/ehac389] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 06/12/2022] [Accepted: 07/06/2022] [Indexed: 12/16/2022] Open
Abstract
AIMS The presence of pulmonary hypertension (PH) severely aggravates the clinical course of heart failure with preserved ejection fraction (HFpEF). To date, neither established heart failure therapies nor pulmonary vasodilators proved beneficial. This study investigated the efficacy of chronic treatment with the oral soluble guanylate cyclase stimulator riociguat in patients with PH-HFpEF. METHODS AND RESULTS The phase IIb, randomized, double-blind, placebo-controlled, parallel-group, multicentre DYNAMIC trial assessed riociguat in PH-HFpEF. Patients were recruited at five hospitals across Austria and Germany. Key eligibility criteria were mean pulmonary artery pressure ≥25 mmHg, pulmonary arterial wedge pressure >15 mmHg, and left ventricular ejection fraction ≥50%. Patients were randomized to oral treatment with riociguat or placebo (1:1). Patients started at 0.5 mg three times daily (TID) and were up-titrated to 1.5 mg TID. The primary efficacy endpoint was change from baseline to week 26 in cardiac output (CO) at rest, measured by right heart catheterization. Primary efficacy analyses were performed on the full analysis set. Fifty-eight patients received riociguat and 56 patients placebo. After 26 weeks, CO increased by 0.37 ± 1.263 L/min in the riociguat group and decreased by -0.11 ± 0.921 L/min in the placebo group (least-squares mean difference: 0.54 L/min, 95% confidence interval 0.112, 0.971; P = 0.0142). Five patients dropped out due to riociguat-related adverse events but no riociguat-related serious adverse event or death occurred. CONCLUSION The vasodilator riociguat improved haemodynamics in PH-HFpEF. Riociguat was safe in most patients but led to more dropouts as compared to placebo and did not change clinical symptoms within the study period.
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Nitsche C, Koschutnik M, Donà C, Radun R, Mascherbauer K, Kammerlander A, Heitzinger G, Dannenberg V, Spinka G, Halavina K, Winter MP, Calabretta R, Hacker M, Agis H, Rosenhek R, Bartko P, Hengstenberg C, Treibel T, Mascherbauer J, Goliasch G. Reverse Remodeling Following Valve Replacement in Coexisting Aortic Stenosis and Transthyretin Cardiac Amyloidosis. Circ Cardiovasc Imaging 2022; 15:e014115. [PMID: 35861981 DOI: 10.1161/circimaging.122.014115] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dual pathology of severe aortic stenosis (AS) and transthyretin cardiac amyloidosis (ATTR) is increasingly recognized. Evolution of symptoms, biomarkers, and myocardial mechanics in AS-ATTR following valve replacement is unknown. We aimed to characterize reverse remodeling in AS-ATTR and compared with lone AS. METHODS Consecutive patients referred for transcatheter aortic valve replacement (TAVR) underwent ATTR screening by blinded 99mTc-DPD bone scintigraphy (Perugini Grade-0 negative, 1-3 increasingly positive) before intervention. ATTR was diagnosed by DPD and absence of monoclonal protein. Reverse remodeling was assessed by comprehensive evaluation before TAVR and at 1 year. RESULTS One hundred twenty patients (81.8±6.3 years, 51.7% male, 95 lone AS, 25 AS-ATTR) with complete follow-up were studied. At 12 months (interquartile range, 7-17) after TAVR, both groups experienced significant symptomatic improvement by New York Heart Association functional class (both P<0.001). Yet, AS-ATTR remained more symptomatic (New York Heart Association ≥III: 36.0% versus 13.8; P=0.01) with higher residual NT-proBNP (N-terminal pro-brain natriuretic peptide) levels (P<0.001). Remodeling by echocardiography showed left ventricular mass regression only for lone AS (P=0.002) but not AS-ATTR (P=0.5). Global longitudinal strains improved similarly in both groups. Conversely, improvement of regional longitudinal strain showed a base-to-apex gradient in AS-ATTR, whereas all but apical segments improved in lone AS. This led to the development of an apical sparing pattern in AS-ATTR only after TAVR. CONCLUSIONS Patterns of reverse remodeling differ from lone AS to AS-ATTR, with both groups experiencing symptomatic improvement by TAVR. After AS treatment, AS-ATTR transfers into a lone ATTR cardiomyopathy phenotype.
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Dannenberg V, Koschutnik M, Donà C, Nitsche C, Mascherbauer K, Heitzinger G, Halavina K, Kammerlander AA, Spinka G, Winter MP, Andreas M, Mach M, Schneider M, Bartunek A, Bartko PE, Hengstenberg C, Mascherbauer J, Goliasch G. Invasive Hemodynamic Assessment and Procedural Success of Transcatheter Tricuspid Valve Repair—Important Factors for Right Ventricular Remodeling and Outcome. Front Cardiovasc Med 2022; 9:891468. [PMID: 35722132 PMCID: PMC9200997 DOI: 10.3389/fcvm.2022.891468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/28/2022] [Indexed: 12/21/2022] Open
Abstract
Introduction Severe tricuspid regurgitation (TR) is a common condition promoting right heart failure and is associated with a poor long-term prognosis. Transcatheter tricuspid valve repair (TTVR) emerged as a low-risk alternative to surgical repair techniques. However, patient selection remains controversial, particularly regarding the benefits of TTVR in patients with pulmonary hypertension (PH). Aim We aimed to investigate the impact of preprocedural invasive hemodynamic assessment and procedural success on right ventricular (RV) remodeling and outcome. Methods All patients undergoing TTVR with a TR reduction of ≥1 grade without precapillary or combined PH [mean pulmonary artery pressure (mPAP) ≥25 mmHg, mean pulmonary artery Wedge pressure ≤ 15 mmHg, pulmonary vascular resistance ≥3 Wood units] were assigned to the responder group. All patients with a TR reduction of ≥1 grade and precapillary or combined PH were classified as non-responders. Patients with a TR reduction ≥2 grade were directly classified as responders, and patients without TR reduction were directly assigned as non-responders. Results A total of 107 patients were enrolled, 75 were classified as responders and 32 as non-responders. We observed evidence of significant RV reverse remodeling in responders with a decrease in RV diameters (−2.9 mm, p = 0.001) at a mean follow-up of 229 days (±219 SD) after TTVR. RV function improved in responders [fractional area change (FAC) + 5.7%, p < 0.001, RV free wall strain +3.9%, p = 0.006], but interestingly further deteriorated in non-responders (FAC −4.5%, p = 0.003, RV free wall strain −3.9%, p = 0.007). Non-responders had more persistent symptoms than responders (NYHA ≥3, 72% vs. 11% at follow-up). Subsequently, non-response was associated with a poor long-term prognosis in terms of death, heart failure (HF) hospitalization, and re-intervention after 2 years (freedom of death, HF hospitalization, and reintervention at 2 years: 16% vs. 78%, log-rank: p < 0.001). Conclusion Hemodynamic assessment before TTVR and procedural success are significant factors for patient prognosis. The hemodynamic profiling prior to intervention is an essential component in patient selection for TTVR. The window for edge-to-edge TTVR might be limited, but timely intervention is an important factor for a better outcome and successful right ventricular reverse remodeling.
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Estévez-Loureiro R, Sánchez-Recalde A, Amat-Santos IJ, Cruz-González I, Baz JA, Pascual I, Mascherbauer J, Abdul-Jawad Altisent O, Nombela-Franco L, Pan M, Trillo R, Moreno R, Delle Karth G, Salido-Tahoces L, Santos-Martinez S, Núñez JC, Moris C, Goliasch G, Jimenez-Quevedo P, Ojeda S, Cid-Álvarez B, Santiago-Vacas E, Jimenez-Valero S, Serrador A, Martín-Moreiras J, Strouhal A, Hengstenberg C, Zamorano JL, Puri R, Íñiguez-Romo A. Six-Month Outcomes of the TricValve® System in Patients with Tricuspid Regurgitation: TRICUS EURO Study. JACC Cardiovasc Interv 2022; 15:1366-1377. [PMID: 35583363 DOI: 10.1016/j.jcin.2022.05.022] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Severe tricuspid regurgitation (TR) is frequently associated with significant morbidity and mortality; such patients often deemed to be at high surgical risk. Heterotopic bi-caval stenting is an emerging, attractive transcatheter solution for these patients. OBJECTIVES To evaluate the 30-day safety and 6-month efficacy outcomes of specifically designed bioprosthetic valves for the superior and inferior vena cava. METHODS TRICUS EURO is a non-blinded, non-randomized, single-arm, multicenter, prospective trial that enrolled patients from 12 European centers between December 2019 to February 2021. High risk individuals with severe symptomatic TR despite optimal medical therapy were included. Primary end point was quality of life (QOL) improvement measured by Kansas City Cardiomyopathy Questionnaire (KCCQ12) and New York Heart Association functional class (NYHA) improvement at 6-month follow-up. RESULTS 35 patients (mean age 76±6.8 years; 83% women) were treated with TricValve® system. All patients at baseline were at NYHA ≥ 3 status. At 30-days, procedural success was 94% with no procedural deaths or conversions to surgery. A significant increase in QOL at 6-months follow-up was observed (baseline and 6-month KCCQ: 42.01±22.3 vs. 59.7±23.6 respectively; p=0.004), correlating with a significant improvement in NYHA functional class with 79.4% of patients noted to be in class I or II at 6 months (p=0.0006). The 6-month all-cause mortality and heart failure hospitalization rates were 8.5% and 20%, respectively. CONCLUSIONS The dedicated bi-caval system for treating severe, symptomatic TR was associated with high procedural success rate and significant increase in both, QOL and functional improvements at 6-months follow-up.
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Traxler D, Krotka P, Laggner M, Mildner M, Graf A, Reichardt B, Wendt R, Auer J, Moser B, Mascherbauer J, Ankersmit HJ. Mechanical aortic valve prostheses offer a survival benefit in 50-65 year olds: AUTHEARTVISIT study. Eur J Clin Invest 2022; 52:e13736. [PMID: 34932232 PMCID: PMC9285970 DOI: 10.1111/eci.13736] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The present population-based cohort study investigated long-term mortality after surgical aortic valve replacement (AVR) with bioprosthetic (B) or mechanical aortic valve prostheses (M) in a European social welfare state. METHODS We analysed patient data from health insurance records covering 98% of the Austrian population between 2010 and 2018. Subsequent patient-level record linkage with national health data provided patient characteristics and clinical outcomes. Further reoperation, myocardial infarction, heart failure and stroke were evaluated as secondary outcomes. RESULTS A total of 13,993 patients were analysed and the following age groups were examined separately: <50 years (727 patients: 57.77% M, 42.23% B), 50-65 years (2612 patients: 26.88% M, 73.12% B) and >65 years (10,654 patients: 1.26% M, 98.74% B). Multivariable Cox regression revealed that the use of B-AVR was significantly associated with higher mortality in patients aged 50-65 years compared to M-AVR (HR = 1.676 [1.289-2.181], p < 0.001). B-AVR also performed worse in a competing risk analysis regarding reoperation (HR = 3.483 [1.445-8.396], p = 0.005) and myocardial infarction (HR = 2.868 [1.255-6.555], p = 0.012). However, the risk of developing heart failure and stroke did not differ significantly after AVR in any age group. CONCLUSIONS Patients aged 50-65 years who underwent M-AVR had better long-term survival, and a lower risk of reoperation and myocardial infarction. Even though anticoagulation is crucial in patients with M-AVR, we did not observe significantly increased stroke rates in patients with M-AVR. This evident survival benefit in recipients of mechanical aortic valve prostheses aged <65 years critically questions current guideline recommendations.
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Nitsche C, Mascherbauer K, Wollenweber T, Koschutnik M, Donà C, Dannenberg V, Hofer F, Halavina K, Kammerlander AA, Traub-Weidinger T, Goliasch G, Hengstenberg C, Hacker M, Mascherbauer J. The Complexity of Subtle Cardiac Tracer Uptake on Bone Scintigraphy. JACC: CARDIOVASCULAR IMAGING 2022; 15:1516-1518. [DOI: 10.1016/j.jcmg.2022.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 12/20/2022]
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Donà C, Koschutnik M, Nitsche C, Winter MP, Seidl V, Siller-Matula J, Mach M, Andreas M, Bartko P, Kammerlander AA, Goliasch G, Lang I, Hengstenberg C, Mascherbauer J. Cerebral Protection in TAVR-Can We Do Without? A Real-World All-Comer Intention-to-Treat Study-Impact on Stroke Rate, Length of Hospital Stay, and Twelve-Month Mortality. J Pers Med 2022; 12:jpm12020320. [PMID: 35207808 PMCID: PMC8878932 DOI: 10.3390/jpm12020320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Stroke associated with transcatheter aortic valve replacement (TAVR) is a potentially devastating complication. Until recently, the Sentinel™ Cerebral Protection System (CPS; Boston Scientific, Marlborough, MA, USA) has been the only commercially available device for mechanical prevention of TAVR-related stroke. However, its effectiveness is still undetermined. Objectives: To explore the impact of Sentinel™ on stroke rate, length of hospital stay (LOS), and twelve-month mortality in a single-center, real-world, all-comers TAVR cohort. Material and Methods: Between January 2019 and August 2020 consecutive patients were assigned to TAVR with or without Sentinel™ in a 1:1 fashion according to the treating operator. We defined as primary endpoint clinically detectable cerebrovascular events within 72 h after TAVR and as secondary endpoints LOS and 12-month mortality. Logistic and linear regression analyses were used to assess associations of Sentinel™ use with endpoints. Results: Of 411 patients (80 ± 7 y/o, 47.4% female, EuroSCORE II 6.3 ± 5.9%), Sentinel™ was used in 213 (51.8%), with both filters correctly deployed in 189 (46.0%). Twenty (4.9%) cerebrovascular events were recorded, ten (2.4%) of which were disabling strokes. Patients with Sentinel™ suffered 71% less (univariate analysis; OR 0.29, 95%CI 0.11–0.82; p = 0.02) and, respectively, 76% less (multivariate analysis; OR 0.24, 95%CI 0.08–0.76; p = 0.02) cerebrovascular events compared to patients without Sentinel™. Sentinel™ use was also significantly associated with shorter LOS (Regression coefficient −2.47, 95%CI −4.08, −0.87; p < 0.01) and lower 12-month all-cause mortality (OR 0.45; 95%CI 0.22–0.93; p = 0.03). Conclusion: In the present prospective all-comers TAVR cohort, patients with Sentinel™ use showed (1) lower rates of cerebrovascular events, (2) shortened LOS, and (3) improved 12-month survival. These data promote the use of a CPS when implanting TAVR valves.
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Fischer A, Hertwig A, Hahn R, Anwar M, Siebenrock T, Pesta M, Liebau K, Timmermann I, Brugger J, Posch M, Ringl H, Tamandl D, Hiesmayr M, Roth D, Zielinski C, Jäger U, Staudinger T, Schellongowski P, Lang I, Gottsauner-Wolf M, Mascherbauer J, Heinz G, Oberbauer R, Trauner M, Ferlitsch A, Zauner C, Wolf Husslein P, Krepler P, Shariat S, Gnant M, Sahora K, Laufer G, Taghavi S, Huk I, Radtke C, Markstaller K, Rössler B, Schaden E, Bacher A, Faybik P, Ullrich R, Plöchl W, Ihra G, Schäfer B, Mouhieddine M, Neugebauer T, Mares P, Steinlechner B, Schiferer A, Tschernko E. Validation of bedside ultrasound to predict lumbar muscle area in the computed tomography in 200 non-critically ill patients: The USVALID prospective study. Clin Nutr 2022; 41:829-837. [PMID: 35263692 DOI: 10.1016/j.clnu.2022.01.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS Skeletal muscle area (SMA) in the computed tomography (CT) at the third lumbar vertebra (L3) level is a proxy for whole-body muscle mass but is only performed for clinical reasons. Ultrasound is a promising tool to determine muscle mass at the bedside. It is still unclear how well ultrasound and which ultrasound measuring points can predict CT L3 SMA. METHODS This prospective observational trial included 200 non-critically ill patients, who underwent an abdominal CT scan for any clinical reason within 48 h before the ultrasound examination. Ultrasound muscle thickness was evaluated at 3 measuring points on the thigh and 2 measuring points on the upper arm with minimal compression. On the CT scan, the entire L3 SMA was measured based on Hounsfield units. Using a model selection algorithm based on the Bayesian information criterion (BIC) and clinical considerations, a linear prediction model for CT L3 SMA based on the ultrasound muscle thickness and other independent variables was fitted and assessed with cross-validation. RESULTS 67,5% and 32,5% of the patients were from surgical and medical wards, respectively. Mean ultrasound muscle thickness values were between 2,2 and 3,6 cm on the thigh and between 1,4 and 2,8 cm on the upper arm. All ultrasound muscle thickness values were higher in men than in women (P < 0,05). CT L3 SMA was 40 cm2 higher in men than in women (P < 0,001). The final prediction model for CT L3 SMA included the following 4 independent variables: ultrasound muscle thickness at the ventral measuring point of the thigh in the short-axis plane, sex, weight, and height. It had a similar BIC (BIC of 1515) compared to larger models with 6-8 independent variables including multiple ultrasound measuring points (BIC of 1506-1519). Additional clinical considerations to choose the final model were less time consumption when measuring a single ultrasound measuring point and better anatomical overview at the short-axis plane. The final model predicted CT L3 SMA with a R2 of 0,74 (P < 0,001) and a cross-validated R2 of 0,65. CONCLUSIONS One single ultrasound measuring point at the thigh together with sex, height and weight very well predicts CT L3 SMA across different clinical populations. Ultrasound is a safe and bedside method to measure muscle thickness longitudinally to monitor the effects of nutrition and physical therapy.
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Smiseth OA, Morris DA, Cardim N, Cikes M, Delgado V, Donal E, Flachskampf FA, Galderisi M, Gerber BL, Gimelli A, Klein AL, Knuuti J, Lancellotti P, Mascherbauer J, Milicic D, Seferovic P, Solomon S, Edvardsen T, Popescu BA. Multimodality imaging in patients with heart failure and preserved ejection fraction: an expert consensus document of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2022; 23:e34-e61. [PMID: 34729586 DOI: 10.1093/ehjci/jeab154] [Citation(s) in RCA: 139] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/10/2021] [Indexed: 12/27/2022] Open
Abstract
Nearly half of all patients with heart failure (HF) have a normal left ventricular (LV) ejection fraction (EF) and the condition is termed heart failure with preserved ejection fraction (HFpEF). It is assumed that in these patients HF is due primarily to LV diastolic dysfunction. The prognosis in HFpEF is almost as severe as in HF with reduced EF (HFrEF). In contrast to HFrEF where drugs and devices are proven to reduce mortality, in HFpEF there has been limited therapy available with documented effects on prognosis. This may reflect that HFpEF encompasses a wide range of different pathological processes, which multimodality imaging is well placed to differentiate. Progress in developing therapies for HFpEF has been hampered by a lack of uniform diagnostic criteria. The present expert consensus document from the European Association of Cardiovascular Imaging (EACVI) provides recommendations regarding how to determine elevated LV filling pressure in the setting of suspected HFpEF and how to use multimodality imaging to determine specific aetiologies in patients with HFpEF.
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Koschutnik M, Dannenberg V, Donà C, Nitsche C, Kammerlander AA, Koschatko S, Zimpfer D, Hülsmann M, Aschauer S, Schneider M, Bartko PE, Goliasch G, Hengstenberg C, Mascherbauer J. Transcatheter Versus Surgical Valve Repair in Patients with Severe Mitral Regurgitation. J Pers Med 2022; 12:jpm12010090. [PMID: 35055405 PMCID: PMC8779938 DOI: 10.3390/jpm12010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022] Open
Abstract
Background. Transcatheter edge-to-edge mitral valve repair (TMVR) is increasingly performed. However, its efficacy in comparison with surgical MV treatment (SMV) is unknown. Methods. Consecutive patients with severe mitral regurgitation (MR) undergoing TMVR (68% functional, 32% degenerative) or SMV (9% functional, 91% degenerative) were enrolled. To account for differences in baseline characteristics, propensity score matching was performed, including age, EuroSCORE-II, left ventricular ejection fraction, and NT-proBNP. A composite of heart failure (HF) hospitalization/death served as primary endpoint. Kaplan-Meier curves and Cox-regression analyses were used to investigate associations between baseline, imaging, and procedural parameters and outcome. Results. Between July 2017 and April 2020, 245 patients were enrolled, of whom 102 patients could be adequately matched (73 y/o, 61% females, EuroSCORE-II: 5.7%, p > 0.05 for all). Despite matching, TMVR patients had more co-morbidities at baseline (higher rates of prior myocardial infarction, coronary revascularization, pacemakers/defibrillators, and diabetes mellitus, p < 0.009 for all). Patients were followed for 28.3 ± 27.2 months, during which 27 events (17 deaths, 10 HF hospitalizations) occurred. Postprocedural MR reduction (MR grade <2: TMVR vs. SMV: 88% vs. 94%, p = 0.487) and freedom from HF hospitalization/death (log-rank: p = 0.811) were similar at 2 years. On multivariable Cox analysis, EuroSCORE-II (adj.HR 1.07 [95%CI: 1.00–1.13], p = 0.027) and residual MR (adj.HR 1.85 [95%CI: 1.17–2.92], p = 0.009) remained significantly associated with outcome. Conclusions. In this propensity-matched, all-comers cohort, two-year outcomes after TMVR versus SMV were similar. Given the reported favorable long-term durability of TMVR, the interventional approach emerges as a valuable alternative for a substantial number of patients with functional and degenerative MR.
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, Leyva F, Linde C, Abdelhamid M, Aboyans V, Arbelo E, Asteggiano R, Barón-Esquivias G, Bauersachs J, Biffi M, Birgersdotter-Green U, Bongiorni MG, Borger MA, Čelutkienė J, Cikes M, Daubert JC, Drossart I, Ellenbogen K, Elliott PM, Fabritz L, Falk V, Fauchier L, Fernández-Avilés F, Foldager D, Gadler F, De Vinuesa PGG, Gorenek B, Guerra JM, Hermann Haugaa K, Hendriks J, Kahan T, Katus HA, Konradi A, Koskinas KC, Law H, Lewis BS, Linker NJ, Løchen ML, Lumens J, Mascherbauer J, Mullens W, Nagy KV, Prescott E, Raatikainen P, Rakisheva A, Reichlin T, Ricci RP, Shlyakhto E, Sitges M, Sousa-Uva M, Sutton R, Suwalski P, Svendsen JH, Touyz RM, Van Gelder IC, Vernooy K, Waltenberger J, Whinnett Z, Witte KK. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace 2022; 24:71-164. [PMID: 34455427 DOI: 10.1093/europace/euab232] [Citation(s) in RCA: 124] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Patel KP, Scully PR, Nitsche C, Kammerlander AA, Joy G, Thornton G, Hughes R, Williams S, Tillin T, Captur G, Chacko L, Kelion A, Sabharwal N, Newton JD, Kennon S, Ozkor M, Mullen M, Hawkins PN, Gillmore JD, Menezes L, Pugliese F, Hughes AD, Fontana M, Lloyd G, Treibel TA, Mascherbauer J, Moon JC. Impact of afterload and infiltration on coexisting aortic stenosis and transthyretin amyloidosis. Heart 2022; 108:67-72. [PMID: 34497140 DOI: 10.1136/heartjnl-2021-319922] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/23/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The coexistence of wild-type transthyretin cardiac amyloidosis (ATTR) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). However, the impact of ATTR and AS on the resultant AS-ATTR is unclear and poses diagnostic and management challenges. We therefore used a multicohort approach to evaluate myocardial structure, function, stress and damage by assessing age-related, afterload-related and amyloid-related remodelling on the resultant AS-ATTR phenotype. METHODS We compared four samples (n=583): 359 patients with AS, 107 with ATTR (97% Perugini grade 2), 36 with AS-ATTR (92% Perugini grade 2) and 81 age-matched and ethnicity-matched controls. 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy was used to diagnose amyloidosis (Perugini grade 1 was excluded). The primary end-point was NT-pro Brain Natriuretic Peptide (BNP) and secondary end-points related to myocardial structure, function and damage. RESULTS Compared with older age controls, the three disease cohorts had greater cardiac remodelling, worse function and elevated NT-proBNP/high-sensitivity Troponin-T (hsTnT). NT-proBNP was higher in AS-ATTR (2844 (1745, 4635) ng/dL) compared with AS (1294 (1077, 1554)ng/dL; p=0.002) and not significantly different to ATTR (3272 (2552, 4197) ng/dL; p=0.63). Diastology, hsTnT and prevalence of carpal tunnel syndrome were statistically similar between AS-ATTR and ATTR and higher than AS. The left ventricular mass indexed in AS-ATTR was lower than ATTR (139 (112, 167) vs 180 (167, 194) g; p=0.013) and non-significantly different to AS (120 (109, 130) g; p=0.179). CONCLUSIONS The AS-ATTR phenotype likely reflects an early stage of amyloid infiltration, but the combined insult resembles ATTR. Even after treatment of AS, ATTR-specific therapy is therefore likely to be beneficial.
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Schönbauer R, Kammerlander AA, Duca F, Aschauer S, Koschutnik M, Dona C, Nitsche C, Loewe C, Hengstenberg C, Mascherbauer J. Prognostic impact of left atrial function in heart failure with preserved ejection fraction in sinus rhythm vs. persistent atrial fibrillation. ESC Heart Fail 2021; 9:465-475. [PMID: 34866363 PMCID: PMC8787979 DOI: 10.1002/ehf2.13723] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/17/2021] [Accepted: 11/06/2021] [Indexed: 12/03/2022] Open
Abstract
Aims We sought to determine the prognostic impact of left atrial (LA) size and function in patients with heart failure with preserved ejection fraction (HFpEF) in sinus rhythm (SR) vs. atrial fibrillation (AF). Methods and results We enrolled consecutive HFpEF patients and assessed indexed LA volumes and emptying fractions (LA‐EF) on cardiac magnetic resonance imaging. In addition, all patients underwent right and left heart catheterization, 6 min walk test, and N‐terminal prohormone of brain natriuretic peptide evaluation. We prospectively followed patients and used Cox regression models to determine the association of LA size and function with a composite endpoint of heart failure hospitalization and cardiovascular death. A total of 188 patients (71% female patients, 70 ± 8 years old) were included of whom 92 (49%) were in persistent AF. Sixty‐five patients reached the combined endpoint during a follow‐up of 31 (9–57) months. Multivariate Cox regression adjusted for established risk factors revealed that LA‐EF was significantly associated with outcome in patients in SR [adjusted hazard ratio 2.14; 95% confidence interval (1.32–3.47) per 1‐SD decline, P = 0.002]. In persistent AF, no LA imaging parameter was related to outcome. By receiver operating characteristic and restricted cubic spline analyses, we identified an LA‐EF ≥ 40% as best indicator for favourable outcomes in patients with HFpEF and SR. Persistent AF carried a similar risk for adverse outcome compared with impaired LA‐EF (<40%) in SR (log‐rank, P = 0.340). Conclusions In HFpEF patients in SR, impaired LA‐EF is independently associated with worse cardiovascular outcome, which is similar to persistent AF. In persistent AF, LA parameters lose their prognostic ability.
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Vamvakidou A, Annabi MS, Pibarot P, Plonska-Gosciniak E, Almeida AG, Guzzetti E, Dahou A, Burwash IG, Koschutnik M, Bartko PE, Bergler-Klein J, Mascherbauer J, Orwat S, Baumgartner H, Cavalcante J, Pinto F, Kukulski T, Kasprzak JD, Clavel MA, Flachskampf FA, Senior R. Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study. Circ Cardiovasc Imaging 2021; 14:e012809. [PMID: 34743529 DOI: 10.1161/circimaging.121.012809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality. METHODS This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm2 and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality. RESULTS Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94-0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05-2.82]; P=0.03). Furthermore aortic valve area <1cm2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality. CONCLUSIONS Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.
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Prausmüller S, Spinka G, Arfsten H, Stasek S, Rettl R, Bartko PE, Goliasch G, Strunk G, Riebandt J, Mascherbauer J, Bonderman D, Hengstenberg C, Hülsmann M, Pavo N. Relevance of Neutrophil Neprilysin in Heart Failure. Cells 2021; 10:2922. [PMID: 34831146 PMCID: PMC8616455 DOI: 10.3390/cells10112922] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
Significant expression of neprilysin (NEP) is found on neutrophils, which present the transmembrane integer form of the enzyme. This study aimed to investigate the relationship of neutrophil transmembrane neprilysin (mNEP) with disease severity, adverse remodeling, and outcome in HFrEF. In total, 228 HFrEF, 30 HFpEF patients, and 43 controls were enrolled. Neutrophil mNEP was measured by flow-cytometry. NEP activity in plasma and blood cells was determined for a subset of HFrEF patients using mass-spectrometry. Heart failure (HF) was characterized by reduced neutrophil mNEP compared to controls (p < 0.01). NEP activity on peripheral blood cells was almost 4-fold higher compared to plasma NEP activity (p = 0.031) and correlated with neutrophil mNEP (p = 0.006). Lower neutrophil mNEP was associated with increasing disease severity and markers of adverse remodeling. Higher neutrophil mNEP was associated with reduced risk for mortality, total cardiovascular hospitalizations, and the composite endpoint of both (p < 0.01 for all). This is the first report describing a significant role of neutrophil mNEP in HFrEF. The biological relevance of neutrophil mNEP and exact effects of angiotensin-converting-enzyme inhibitors (ARNi) at the neutrophil site have to be determined. However, the results may suggest early initiation of ARNi already in less severe HF disease, where effects of NEP inhibition may be more pronounced.
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Koschutnik M, Dona C, Nitsche C, Dannenberg V, Koschatko S, Beitzke D, Loewe C, Huelsmann M, Schneider M, Bartko PE, Goliasch G, Hengstenberg C, Kammerlander AA, Mascherbauer J. Right ventricular longitudinal strain on cardiovascular magnetic resonance imaging predicts outcome in patients undergoing transcatheter mitral valve repair. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The prognostic value of left and right ventricular global longitudinal strain (LV and RV GLS) derived from cardiovascular magnetic resonance (CMR) feature tracking in patients with severe mitral regurgitation (MR) undergoing transcatheter mitral valve repair (TMVR) is unknown.
Methods
Consecutive patients scheduled for TMVR underwent pre-procedural and follow-up CMR imaging including feature tracking strain analysis. Kaplan-Meier estimates and multivariate Cox-regression analyses were used to identify the prognostic impact of LV and RV GLS on CMR using a composite of heart failure hospitalization and death.
Results
A total of 62 patients (78.3±7.0y/o, 45% female, EuroSCORE II: 9.7±7.2%) with severe MR underwent CMR prior to TMVR. 23 (37%) patients presented with right ventricular dysfunction (RVD) defined by RV GLS >−20% on CMR. At baseline, RVD was associated with NT-proBNP levels (9510 vs. 4064pg/mL, p=0.030). On CMR, RVD was associated with reduced left and RV ejection fraction (LVEF: 39.2 vs. 48.7%, p=0.011, RVEF: 35.1 vs. 46.7%, p<0.001), as well as increased LV GLS (−14.0 vs. −19.5%, p=0.003).
A total of 18 events (12 deaths, 6 hospitalizations for heart failure) occurred during follow-up (mean 11.4±9.1months). While LV GLS was not significantly associated with outcome (HR 0.95, 95% CI: 0.90–1.01, p=0.082), RV GLS showed a strong and independent association with event-free survival by multivariate Cox-regression analysis (adj.HR 0.91, 95% CI: 0.83–0.99, p=0.033) after adjustment for relevant baseline and procedural data (EuroSCORE II, post-procedural residual MR), imaging parameters (TAPSE, LV and RVEF on CMR), and cardiac biomarkers (NT-proBNP). When compared with the “gold standard” RVEF on CMR (RVEF <45%: adj.HR 0.86, 95% CI: 0.23–3.20, p=0.825) and TAPSE on echo (TAPSE <17mm: adj.HR: 2.77, 95% CI: 0.72–10.70, p=0.140), only RVD (RV GLS >−20%: adj.HR 5.05, 95% CI: 1.23–20.63, p=0.024) was significantly associated with the composite endpoint (Figure 1). Follow-up CMR was performed in 21 (34%) patients. RV GLS significantly improved after TMVR (−20.6 to −25.2%, p=0.016, Figure 2).
Conclusions
RV rather than LV GLS, as determined on CMR, is an important predictor of outcome in patients undergoing TMVR. At 1 year follow-up, RV function significantly improved, and thus might add useful prognostic information on top of established risk factors.
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Dona C, Nitsche C, Koschutnik M, Koschatko S, Dannenberg V, Kammerlander A, Goliasch G, Bartko P, Schneider M, Traub-Weidinger T, Hacker M, Hengstenberg C, Mascherbauer J. Prevalence of cardiac amyloidosis in patients undergoing transcatheter edge-to edge mitral valve repair. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Cardiac amyloidosis (CA) is associated with severe aortic stenosis, however, its prevalence in patients with severe mitral regurgitation in elderly patients is unknown.
Methods
Patients scheduled for transcatheter edge-to edge mitral valve repair (TMVR) were prospectively screened for CA using 99m technetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy and subsequent serum as well as urine free light-chain quantification in case of a positive DPD scan, defined as visual cardiac update based on the Perugini grading scale.
Results
Out of 100 patients undergoing TMVR, 28 patients (28.0%) had a positive DPD-scan (DPD+). 14 patients (14.0%) showed Perugini grade I enhancement, 9 patients (9.0%) grade II enhancement, and in 5 patients (5.0%), grade III enhancement was present. 28 patients suffered from TTR and two from AL- amyloidosis (one patient had a combination of TTR and AL-amyloidosis). When compared to patients with a negative scan (DPD-), DPD+ patients presented with similar baseline characteristics such as age (DPD- vs DPD+ 76y/o vs 77y/o, p=0.44), gender (female; 62.7% vs 50.0%, p=0.25), coronary artery disease (59.7% vs 42.9%, p=0.13), previous valve surgery (25.4% vs 14.3%, p=0.24) and atrial fibrillation (68.7% vs 78.6%, p=0.33). Also, NYHA functional class and EuroScore II were similar (NYHA ≥ III; 85.1% vs 82.1%, p=0.72, and EuroScore II 9.9±9.8% vs 7.0±4.8%, p=0.21, respectively). On echocardiography, DPD+ patients presented with more pronounced left and right ventricular hypertrophy (interventricular septum: 15mm vs 13mm, p<0.01) but similar left ventricular ejection fraction (44.9% vs 42.3%, p=0.34). At 3-months after TMVR, DPD+ patients showed significant improvement in BNP serum levels when compared to DPD- patients (DPD+ vs DPD-: +315±2569pg/ml vs −2404±8696pg/ml, p=0.03), while NYHA functional class remained unchanged (NYHA improvement ≥1 class: 57.6% vs 50.0%, p=0.52)
Conclusions
In this single centre experience, CA was highly prevalent among elderly patients with severe mitral regurgitation scheduled for TMVR. TMVR in CA patients resulted in significant improvement of NT-pro BNP levels. Future studies need to clarify the prognostic relevance of CA in this specific patient population.
Funding Acknowledgement
Type of funding sources: None.
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Fukui M, Annabi MS, Rosa VEE, Ribeiro HB, Tarasoutchi F, Shelbert EB, Bergler-Klein J, Mascherbauer J, Rochitte CE, Pibarot P, Cavalcante JL. Impact of left ventricular fibrosis and longitudinal systolic strain on outcomes in low gradient aortic stenosis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
The clinical utility of comprehensive cardiac magnetic resonance (CMR) for the assessment of myocardial structure and function remains unknown in patients with low gradient (LG) aortic stenosis (AS).
Purpose
This study sought to compare CMR characteristics of myocardial structure and function according to different flow / gradient patterns of AS: classical low flow LG (LFLG); paradoxical LFLG; normal flow LG; and high gradient, and to evaluate their impact on the outcomes of these patients.
Methods
International multicentric prospective study included 147 patients with LG moderate to severe AS and 18 patients with high gradient severe AS who underwent comprehensive CMR evaluation of left ventricular global longitudinal strain (LVGLS), extracellular volume fraction (ECV), and late gadolinium enhancement (LGE).
Results
Patients with classical LFLG (n=90) had more LV adverse remodeling and impaired longitudinal function including higher ECV, and higher LGE and volume, and worst LVGLS, compared to other patterns of AS. Over a median follow-up of 2-years, 43 deaths and 48 composite outcomes of death or heart failure hospitalization occurred in LG AS patients. As LVGLS or ECV worsened, risks of adverse events also increased (per tertile of LVGLS: HR [95% CI] for mortality, 1.50 [1.02–2.20]; p=0.04; HR [95% CI] for composite outcome, 1.45 [1.01–2.09]; p<0.05) (per tertile of ECV: HR [95% CI] for mortality, 1.63 [1.07–2.49]; p=0.02; HR [95% CI] for composite outcome, 1.54 [1.02–2.33]; p=0.04). LGE presence was also associated with higher mortality (HR [95% CI], 2.27 [1.01–5.11]; p<0.05) and risk of the composite outcome (HR [95% CI], 3.00 [1.16–7.73]; p=0.02). The risk of all-cause death and of the composite outcome increased in proportion to the number of impaired components (i.e. LVGLS, ECV and LGE) (Figure) with and without adjustment for age, true severe AS, classical LFLG, and aortic valve replacement as a time-varying covariate.
Conclusions
In this international multicentric study of LG AS, comprehensive CMR assessment of myocardial structure and function provides independent prognostic value that is cumulative and incremental to clinical and echocardiographic characteristics.
Funding Acknowledgement
Type of funding sources: None.
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