Smoking promotes vascular damage in apparently healthy men with low testosterone and increased subclinical inflammation

Background

Testosterone deficiency and increased inflammation are both associated with an unfavourable vascular profile. Aim of the study was to examine whether smoking significantly deteriorates the effect of these pathophysiological mechanisms on arterial wall properties.

Methods

Carotid intima media thickness (cIMT) and aortic pulse wave velocity (aPWV) were measured in 87 smokers and 112 aged-matched never smokers (mean age: 49±5 yrs) with no other cardiovascular (CV) risk factors/or manifest CV/atherosclerotic disease. Plasma total testosterone (TT) and high sensitivity reactive protein (hsCRP) levels were measured in the whole study population.

Results

Both smokers and never smokers were divided into four subgroups according to measured low or normal TT levels (low TT<3.5 ng/ml) and high or low hsCRP levels. BMI and LDL-C levels were not different between the subgroups. In smokers the four TT/CRP subgroups had comparable cumulative tobacco smoke exposure. In smokers the low TT/high CRP subgroup had significantly higher aPWV and cIMT compared to the three other subgroups (P<0.01 and P<0.05, respectively by ANOVA, figures A-B) while in never smokers the four TT/CRP subgroups had comparable aPWV and cIMT (all P>0.05, figures C-D). The differences in aPWV and cIMT measurements between TT/CRP subgroups in smokers remained statistically significant after adjustment for age.

Conclusions

The study shows that low TT combined with high CRP are associated with increased carotid IMT and aortic PWV in smokers with no other CV risk factors, while in never smokers the effect of combined low TT and high CRP concentration was not significant. Considering the predictive value of aortic stiffness and carotid thickness, the finding of this study imply interrelationships between tobacco cigarette smoke, subclinical inflammation and low testosterone level regarding changes in arterial wall properties.

Funding Acknowledgement

Type of funding sources: None.

Novel peripheral blood immune cell populations correlate with disease progression and reveal systemic interactions in severe aortic valve stenosis patients

Background

Osteoblastic differentiation is the key driver phenomenon underlying degenerative aortic valve stenosis (AS). It is characterized by a complex cellular interplay and infiltration by circulating immune cells. Moreover, AS demonstrates a diverse natural course, which is understudied.

Purpose

We sought to investigate the presence of AS clinical progression subphenotypes in the context of “AthenaValve” trial (NCT04312139).

Methods

Consecutive patients with severe AS undergoing TAVI or SAVR with complete clinical data, echocardiographic history (≥3 past years, corresponding from moderate to severe AS), along with matched healthy volunteers, were included. The median transaortic Vmax increase/month (Vi/m) was calculated and cluster analysis was used to reveal AS progression subgroups. Whole blood peripheral mononuclear cells (PBMCs) were isolated with density gradient centrifugation and cryopreserved into FBS-10% DMSO. PBMC populations were investigated with mass cytometry (CyTOF, Helios, Fluidigm) using a 30-marker antibody panel (Direct Immune Profiling Assay, Fluidigm) and analyzed with Flowjo and Cytobank software.

Results

A total of 67 patients fulfilling criteria were included (mean age 77.2±10 years, 61.2% males). Two-step cluster algorithm identified 2 clusters of AS progression: C1: 80%, mean Vi/m = 0.03±0.01 vs C2: 20%, Vi/m = 0.07±0.1 m/s/month, average silhouette = 0.7. Mean time to progression to severe AS differed significantly: C1: 59.5 (48.9,70.1) vs C2: 40.2 (29.2, 51.2) months, log rank p=0.05. Among those, 20 patients (C1: 10, C2: 10) and 10 healthy volunteers were included in CyTOF. Demographics, atherosclerotic clinical factors and renal function did not differ among patients-volunteers and C1-C2 groups. B cells, B-memory, B-naïve and pDendritic cells discriminated patients from healthy volunteers: ROC curve (AUC: 0.885, p=0.001), (0.913, p<0.001), (0.770, p=0.018), (0.282, p=0.056), profile (%): (5.3±3 vs 10.2±4), (0.86±0.4 vs 2.6±2), (4.4±3 vs 7.6±4), and (0.48±0.2 vs 0.3±0.1), respectively (mean live cells analyzed: 284028.8±52213.8). pDendritic cells and CD4-Th17-like cells discriminated C1 from C2 patients: ROC curve AUC: (0.804, p=0.005) and (0.268, p=0.031), profile (%): (0.6±0.2 vs 0.3±0.2) and (0.9±0.5 vs 2.6±0.9), respectively).

Conclusions

Aortic valve stenosis patients demonstrate two distinct phenotypes of disease progression from moderate to severe stage. Patients demonstrate reduced circulating B-cells and increased plasmatocytoid dendritic cells. The rapid progression subgroup of patients demonstrates reduced pDendritic and increased CD4-Th17-like cells. Further works are needed to expand and validate these results.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Co-Funded by Hellenic Ministry of Development and European Regional Development Fund in the context of an open call of “EATRIS-GR project: Infrastructure for preclinical and early-phase clinical development of drugs, therapeutics, and biomedical devices”

Risk and protective factors for atrial fibrillation after cardiac surgery and valvular interventions: an umbrella review of meta-analyses

Objective

Postoperative atrial fibrillation (POAF) is a common complication affecting approximately one-third of patients after cardiac surgery and valvular interventions. This umbrella review systematically appraises the epidemiological credibility of published meta-analyses of both observational and randomised controlled trials (RCT) to assess the risk and protective factors of POAF.

Methods

Three databases were searched up to June 2021. According to established criteria, evidence of association was rated as convincing, highly suggestive, suggestive, weak or not significant concerning observational studies and as high, moderate, low or very low regarding RCTs.

Results

We identified 47 studies (reporting 61 associations), 13 referring to observational studies and 34 to RCTs. Only the transfemoral transcatheter aortic valve replacement (TAVR) approach was associated with the prevention of POAF and was supported by convincing evidence from meta-analyses of observational data. Two other associations provided highly suggestive evidence, including preoperative hypertension and neutrophil/lymphocyte ratio. Three associations between protective factors and POAF presented a high level of evidence in meta-analyses, including RCTs. These associations included atrial and biatrial pacing and performing a posterior pericardiotomy. Nineteen associations were supported by moderate evidence, including use of drugs such as amiodarone, b-blockers, glucocorticoids and statins and the performance of TAVR compared with surgical aortic valve replacement.

Conclusions

Our study provides evidence confirming the protective role of amiodarone, b-blockers, atrial pacing and posterior pericardiotomy against POAF as well as highlights the risk of untreated hypertension. Further research is needed to assess the potential role of statins, glucocorticoids and colchicine in the prevention of POAF.

PROSPERO registration number

CRD42021268268.

The management of patent foramen ovale in divers: where do we stand?

Diving is a fascinating activity, but it does not come without any cost; decompression illness (DCI) is one of the most frequent diseases occurring in divers. Rapid surfacing after diving causes alveolar rupture and bubbles release, which enter in the systemic circulation and could embolize numerous organs and tissues. The presence of patent foramen ovale (PFO) contributes to the passage of venous gas bubbles into the arterial circulation, increasing the risk of complications related to DCI. The diagnosis is established with a detailed medical history, a comprehensive clinical evaluation, and a multimodal imaging approach. Although the percutaneous closure of PFO is ambiguous for divers, as a primary prevention strategy, transcatheter management is considered as beneficial for DCI recurrence prevention. The aim of this study is to introduce the basic principles of DCI, to review the pathophysiological connection between DCI and PFO, to highlight the risk factors and the optimal treatment, and, last but not least, to shed light on the role of closure as primary and secondary prevention.

Comparative assessment of myocarditis and pericarditis reporting rates related to mRNA COVID-19 vaccines in Europe and the United States

OBJECTIVES

The novel mRNA vaccines proved to be safe and effective in averting severe COVID-19. Vaccine-related complications recorded by pharmacovigilance systems, such as "EudraVigilance" in Europe and "VAERS" in the United States (US), rarely include myocarditis and pericarditis. Given the novelty of the platform and the increasing global-scale vaccine production needs, we assessed their reporting rates comparatively across continents.

METHODS

Data of myocarditis and pericarditis cases post COVID-19 vaccination reported through week 40/2021 were collected for mRNA vaccines from EudraVigilance and VAERS. The corresponding administered vaccine doses were used as denominators to estimate reporting rates for comparison purposes.

RESULTS

Low reporting rates of myocarditis (7.64/million vaccine doses) and pericarditis (5.32/million) was found, with higher rates of both disorders in EudraVigilance compared to VAERS; these differences were more pronounced post mRNA-1273 (~5-fold) than post BNT162b2 vaccination (~1.5-fold). Most myocarditis cases occurred in males <30 years. Pericarditis affected predominantly males <40 and both sexes >40 years. The extremely rare fatalities related to myocarditis (0.102/million) or pericarditis (0.017/million) were also higher in EudraVigilance versus VAERS.

CONCLUSIONS

Understanding the underlying causes of the observed differences could provide guidance for the enhanced quality of mRNA vaccines that would foster vaccine acceptance.

Risk and Protective Factors for Sudden Cardiac Death: An Umbrella Review of Meta-Analyses

Background

Sudden cardiac death (SCD) is a global public health issue, accounting for 10–20% of deaths in industrialized countries. Identification of modifiable risk factors may reduce SCD incidence.

Methods

This umbrella review systematically evaluates published meta-analyses of observational and randomized controlled trials (RCT) for the association of modifiable risk and protective factors of SCD.

Results

Fifty-five meta-analyses were included in the final analysis, of which 31 analyzed observational studies and 24 analyzed RCTs. Five associations of meta-analyses of observational studies presented convincing evidence, including three risk factors [diabetes mellitus (DM), smoking, and early repolarization pattern (ERP)] and two protective factors [implanted cardiac defibrillator (ICD) and physical activity]. Meta-analyses of RCTs identified five protective factors with a high level of evidence: ICDs, mineralocorticoid receptor antagonist (MRA), beta-blockers, and sodium-glucose cotransporter-2 (SGLT-2) inhibitors in patients with HF. On the contrary, other established, significant protective agents [i.e., amiodarone and statins along with angiotensin-converting enzyme (ACE) inhibitors in heart failure (HF)], did not show credibility. Likewise, risk factors as left ventricular ejection fraction in HF, and left ventricular hypertrophy, non-sustain ventricular tachycardia, history of syncope or aborted SCD in pediatric patients with hypertrophic cardiomyopathy, presented weak or no evidence.

Conclusions

Lifestyle risk factors (physical activity, smoking), comorbidities like DM, and electrocardiographic features like ERP constitute modifiable risk factors of SCD. Alternatively, the use of MRA, beta-blockers, SGLT-2 inhibitors, and ICD in patients with HF are credible protective factors. Further investigation targeted in specific populations will be important for reducing the burden of SCD.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020216363, PROSPERO CRD42020216363.

Parameters indicating development of hypertension in three-year follow-up study of subjects with high normal blood pressure

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

The clinical importance of a hypertensive response to exercise (HRE) in subjects with high normal blood pressure (BP) is not fully elucidated, while sympathetic overactivity followed by arterial stiffening are linked with development of hypertension (HTN).

Purpose

The aim of this study was to assess the relation of HRE with sympathetic drive as assessed by muscle sympathetic nerve activity (MSNA) and arterial stiffness in subjects with high normal BP who developed hypertension in a 3 year follow up.

Methods

100 subjects with high normal office BP [systolic BP=130-139 mmHg and diastolic BP=85-89 mmHg] underwent a treadmill exercise stress test. Arterial stiffness was evaluated based on carotid to femoral pulse wave velocity (PWV). Sympathetic drive was assessed by MSNA levels. Follow up was every 6 months for 3 years, where BP was measured at both office (OffBP) and ambulatory blood pressure monitoring (ABPM). All participants offered lifestyle advises. Endpoint was development of HTN diagnosed either from OffBP or from ABPM. Then they were divided into Group I: those developed HTN and Group II: those remained normotensive.

Results

Mean age 54±8 years, 42 males, baseline offBP: 132/82 mmHg, ABPM: 122/76 mmHg). Out of them, 50 subjects developed HRE (BP ³210mmHg in men and ³190 mmHg in women) and 40 HTN. Group I developed higher HRE (75% vs. 13%, p=0.026), higher levels of PWV (8.35 vs 7.5 m/sec, p=0.043) and MSNA levels (37 vs. 31 bursts, p=0.04), while did not differ at their metabolic profile. Echocardiographically left ventricular mass index did not differ statistically as E/A ratio of mitral valve inflow (0.92 vs 1.05, p=0.034). Those who developed HTN was related to night systolic BP from ABPM (116 vs 112 mmHg, p&lt;0.04), as also to intermediate stage intervals of 3 min (160 vs 147 mmHg, p=0.068) and 6 min (181 vs 164, p=0.035) of Bruce protocol. A novel metric, the SBP/MET-slope [(peak SBP—resting SBP)/(peak MET-1)] found to add crucial information. Regarding those who developed HTN, SBP/MET-slope was higher in all stages till peak exercise (stage 1: 6.25 vs 4.25, stage 2: 7.6 vs 5.3, peak: 7.22 vs 5.1, p=0.035). It was noticed that they performed a higher exercise capacity (10 vs 11.5 METs) and additionally differ significantly in their maximal heart rate (HR) at peak exercise (154 vs 164, p=0.001).

Conclusion

In subjects with high normal BP, a HRE, the intermediate BP intervals along with the SBP/MET-slope, identifies a state of systemic vascular resistance, arterial stiffening and sympathetic overdrive, as reflected by increased PWV and MSNA levels respectively. Additionally, exercise capacity demonstrates cardiovascular functional tolerance. These findings suggest that exercise testing provides determining clinical information regarding the overall cardiovascular status, proving its superior prognostic value as a hypertension screening tool, that alarms the physician to warn the patient to take action.

Chronic pericardial effusion: current concepts and emerging trends

INTRODUCTION

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

AREAS COVERED

: This review focuses on the pathophysiology, epidemiology, etiology, classification, clinical findings, diagnostic work-up, management and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis and evaluation of the hemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

EXPERT OPINION

The management of patients with PEFs is mainly based on four parameters namely hemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, "idiopathic" PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

Temporal relationship of myocarditis and pericarditis following COVID-19 vaccination: A pragmatic approach

Background

Complications following COVID-19 vaccination, particularly with mRNA vaccines, rarely include myocarditis and pericarditis. This work principally aimed at defining a realistic temporal relationship between vaccination and myocarditis/pericarditis development.

Methods

All relevant cases reported from week 52/2020 through week 41/2021 in the VAERS database were retrieved and analyzed for licensed vaccines. These included BNT162b2, mRNA-1273, and AD26.COV2·S. Incidence rates were calculated using the corresponding administered vaccine doses as denominators. Additionally, analyzed parameters included demographics, dose series, hospitalization length and outcome.

Results

Overall, 2016 myocarditis and 1380 pericarditis cases, (4.96/10⁶ and 3.40/10⁶ administered vaccine doses, respectively), were recorded. Most myocarditis cases occurred following BNT162b2 (5.60/10⁶ doses) in males <30 years. Pericarditis affected predominantly males <40, both sexes >40 years, and was most common post AD26.COV2·S (4.78/10⁶ doses). Hospitalization was required for 40.3% and 27.2% of myocarditis and pericarditis cases, respectively. A bimodal pattern was found for both myocarditis and pericarditis, with two peaks that coincided temporally, but were reversed in intensity. The first peak was recorded 1–3 days post-vaccination and was more pronounced in myocarditis, while the second was recorded 15–30 days post-vaccination and was more intense in pericarditis.

Conclusions

Myocarditis/pericarditis after COVID-19 vaccination is rare and depicts a bimodal pattern.

Left Atrial Function Post Radiofrequency and Cryoballoon Ablation Assessed by Volume-Pressure Loops

Background

Left atrial (LA) function is linked to atrial fibrillation (AF) pathogenesis. AF catheter ablation decreases disease burden with potentially favorable effects on cardiac function. Atrial volume-pressure loops can optimally assess the LA function.

Objective

To investigate changes in LA function by volume-pressure loops after paroxysmal AF ablation and explored potential differences between the radiofrequency and cryoballoon ablation.

Methods

We analyzed 44 patients undergoing paroxysmal AF ablation from 2 centers, 22 treated with radiofrequency and 22 with cryoablation. Pre- and post-procedure, all patients underwent a real-time three-dimensional transthoracic ECG to evaluate LA volume, while simultaneously recording LA pressure following transseptal puncture. Volume-pressure loops pre- and post-procedure were created by paired data. Areas of A-loop (LA booster pump function) and V-loop (LA reservoir function), and the stiffness constant determining the slope of the exponential curve during LA filling were calculated.

Results

Average LA pressure, A-wave amplitude, and V-wave amplitude were increased post-procedurally (p < 0.001). Overall, A-loop area decreased (p = 0.001) and V-loop area tended to increase (p = 0.07). The change in both A-loop and V-loop areas was similar between radiofrequency- and cryoballoon-treated patients (p = 0.18 and p = 0.52, respectively). However, compared with cryoballoon-treated patients, radiofrequency-treated patients had higher increase in the stiffness constant (b = 0.059; 95% CI: 0.022–0.096; p = 0.006).

Conclusion

AF catheter ablation by the radiofrequency or cryoballoon is associated with the decrease of the booster pump function and increase of the reservoir function. Moreover, there is a post-procedural increase of LA pressure which is associated with an acute increase in LA stiffness in radiofrequency ablation, but not in cryoablation.

Endothelial dysfunction in acute and long standing COVID−19: A prospective cohort study

Background

Coronavirus disease-19 (COVID-19) is implicated by active endotheliitis, and cardiovascular morbidity. The long-COVID-19 syndrome implications in atherosclerosis have not been elucidated yet. We assessed the immediate, intermediate, and long-term effects of COVID-19 on endothelial function.

Methods

In this prospective cohort study, patients hospitalized for COVID-19 at the medical ward or Intensive Care Unit (ICU) were enrolled and followed up to 6 months post-hospital discharge. Medical history and laboratory examinations were performed while the endothelial function was assessed by brachial artery flow-mediated dilation (FMD). Comparison with propensity score-matched cohort (control group) was performed at the acute (upon hospital admission) and follow-up (1 and 6 months) stages.

Results

Seventy-three patients diagnosed with COVID-19 (37% admitted in ICU) were recruited. FMD was significantly (p < 0.001) impaired in the COVID-19 group (1.65 ± 2.31%) compared to the control (6.51 ± 2.91%). ICU-treated subjects presented significantly impaired (p = 0.001) FMD (0.48 ± 1.01%) compared to those treated in the medical ward (2.33 ± 2.57%). During hospitalization, FMD was inversely associated with Interleukin-6 and Troponin I (p < 0.05 for all). Although, a significant improvement in FMD was noted during the follow-up (acute: 1.75 ± 2.19% vs. 1 month: 4.23 ± 2.02%, vs. 6 months: 5.24 ± 1.62%; p = 0.001), FMD remained impaired compared to control (6.48 ± 3.08%) at 1 month (p < 0.001) and 6 months (p = 0.01) post-hospital discharge.

Conclusion

COVID-19 patients develop a notable endothelial dysfunction, which is progressively improved over a 6-month follow-up but remains impaired compared to healthy controls subjects. Whether chronic dysregulation of endothelial function following COVID-19 could be accompanied by a residual risk for cardiovascular and thrombotic events merits further research.

The fundamental role of stress echo in evaluating coronary artery disease in specific patient populations

Stress echocardiography (SE) was initially used for assessing patients with known or suspected coronary heart disease by detecting and evaluating myocardial ischemia and viability. The implementation of SE has gradually been extended to several cardiovascular diseases beyond coronary artery disease, and SE protocols have been modified and adapted for the detection of coronary artery disease (CAD) or other cardiovascular diseases in specific patient populations. This review attempts to summarize current data concerning SE implementation and clinical value in these specific and diverse populations: patients with an intramural course of a coronary artery - known as a myocardial bridge, chronic severe or end-stage hepatic disease, chronic severe or end-stage kidney disease, cardiac allograft vasculopathy, patients scheduled for solid-organ transplantation and other intermediate and high-risk surgery and, finally, patients treated with anticancer drugs or radiotherapy.

Net clinical benefit of direct oral anticoagulants in atrial fibrillation patients with or without diabetes mellitus: A meta-analysis of outcome trials

AIM

To evaluate the net clinical benefit following direct oral anticoagulants (DOACs) vs warfarin by diabetes status in patients with non-valvular atrial fibrillation.

METHODS

We searched 3 electronic databases through end-February 2021 to identify relevant outcome trials in patients with and without diabetes mellitus (DM). All-cause death, non-fatal stroke/systemic embolism and major bleedings defined net clinical benefit. Outcome risk ratios and 95% confidence interval (CI), and absolute risk outcome reduction per 1000 treated patients were assessed.

RESULTS

Four trials of DOACs vs warfarin compared 22,087 patients with DM to 49,592 patients without DM. CHADS2 and 10-year fatal cardiovascular risk were higher in patients with vs those without DM (3.7 vs 2.5 and 28.4% vs 23.4%, respectively). DOACs were associated with more favorable net clinical benefit compared to warfarin in patients with and without DM (relative risk reduction, 0.85 [95% CI, 0.81-0.89] and 0.87 [95% CI, 0.79-0.96]; absolute risk reduction per 1000 patients treated, -33 [95% CI, -45, -21]) and -24 [95% CI, -43, -5]), but interaction test was not significant by relative and absolute numbers (P = 0.68 and P = 0.44, respectively).

CONCLUSION

Net clinical benefit following DOACs was not different between patients with and without DM over a period of 2.2 years.

A risk score for pericarditis recurrence

BACKGROUND

Currently, we remain uncertain about which patients are at increased risk for recurrent pericarditis. We developed a risk score for pericarditis recurrence in patients with acute pericarditis.

MATERIALS AND METHODS

We prospectively recruited 262 patients with a first episode of acute pericarditis. Baseline patients' demographics, clinical, imaging and laboratory data were collected. Patients were followed up for a median of 51 months (interquartile range 21-71) for recurrence. Variables with <10% missingness were entered into multivariable logistic regression models with stepwise elimination to explore independent predictors of recurrence. The final model performance was assessed by the c-index whereas model's calibration and optimism-corrected c-index were evaluated after 10-fold cross-validation.

RESULTS

We identified six independent predictors for pericarditis recurrence, that is age, effusion size, platelet count (negative predictors) and reduced inferior vena cava collapse, in-hospital use of corticosteroids and heart rate (positive predictors). The final model had good performance for recurrence, c-index 0.783 (95% CI 0.725-0.842), while the optimism-corrected c-index after cross-validation was 0.752. Based on these variables, we developed a risk score point system for recurrence (0-22 points) with equally good performance (c-index 0.740, 95% CI 0.677-0.803). Patients with a low score (0-7 points) had 21.3% risk for recurrence, while those with high score (≥12 points) had a 69.8% risk for recurrence. The score was predictive of recurrence among most patient subgroups.

CONCLUSIONS

A simple risk score point system based on 6 variables can be used to predict the individualized risk for pericarditis recurrence among patients with a first episode of acute pericarditis.

A case series of acute pericarditis following COVID-19 vaccination in the context of recent reports from Europe and the United States

Background

COVID-19 vaccines were efficacious and safe in clinical trials. We report nine events of acute pericarditis (AP) in eight patients following COVID-19 vaccination with BNT162b2 (6/9), AZD1222 (2/9) and mRNA-1273 (1/9).

Methods

All patients were referred for AP temporally linked with COVID-19 vaccination. Chest pain was the most common clinical manifestation. Alternative etiologies were excluded upon thorough diagnostic work up. AP diagnosis was established according to ESC guidelines.

Findings

Five events occurred after the first vaccine dose and four after the second. The mean age in this cohort was 65.8 ± 10.2 years and the men/women ratio 3/5. All events resolved without sequelae; two events were complicated by cardiac tamponade requiring emergent pericardial decompression. Hospitalization was required in four cases.

Interpretation

Although causality cannot be firmly established, AP has emerged as a possible complication following COVID-19 vaccination. Further investigation is indispensable to fully characterize this new entity.

Carotid Artery Temperature Reduction with Statin Therapy in Patients with Familial Hyperlipidemia Syndromes

Background: Microwave radiometry (MWR) assesses non-invasive carotid artery temperatures reflecting inflammation. In the present study, we aimed to investigate the impact of hypolipidemic therapy either with simvastatin or with combination simvastatin plus ezetimibe on carotid artery temperatures of patients with familial hyperlipidemia syndromes (FHS). Methods: Consecutive patients with diagnosis of either familial heterozygous hypercholesterolemia (heFH) or familial combined hyperlipidemia (FCH) were included in the study. Patients were assigned to either simvastatin 40 mg or simvastatin 40 mg plus ezetimibe 10 mg, according to the discretion of the physician. FHS patients who refused statin therapy were used as a control group. Common carotid intima-media thickness (ccIMT) was measured and ΔΤ (maximum-minimum) temperature measurements were performed across each carotid during MWR evaluation. RESULTS: In total, 115 patients were included in the study. Of them, 40 patients received simvastatin (19 heFH and 21 FCH), 41 simvastatin + ezetimibe (31 heFH and 10 FCH), and 34 (21 heFH and 13 FCH) no statin. Carotid artery temperatures were significantly reduced at 6 months in FH patients who received hypolipidemic treatment (0.83 ± 0.34 versus 0.63 ± 0.24 °C, p = 0.004 for simvastatin, 1.00 ± 0.38 versus 0.69 ± 0.23 °C, p < 0.001 for simvastatin + ezetimibe), but no change was recorded in controls (0.72 ± 0.26 versus 0.70 ± 0.26 °C, p = 0.86). Conclusions: Hypolipidemic therapy reduced carotid temperatures in FHS patients.

The Role of Endothelial Related Circulating Biomarkers in COVID-19. A Systematic Review and Meta-analysis

BACKGROUND

Several studies have revealed the link between Coronavirus Disease 2019 (COVID-19) and endothelial dysfunction. To better understand the global pattern of this relationship, we conducted a meta-analysis on endothelial biomarkers related to COVID-19 severity.

METHODS

We systematically searched the literature up to March 10, 2021, for studies investigating the association between COVID-19 severity and the following endothelial biomarkers: Intercellular Adhesion Molecule 1 (ICAM-1), Vascular Cell Adhesion Molecule 1 (VCAM-1), E-selectin, P-selectin, Von Willebrand Factor Antigen (VWF-Ag), soluble Thrombomodulin (sTM), Mid-regional pro-adrenomedullin (MR-proADM), and Angiopoietin-2 (Ang-2). Pooled estimates and mean differences (PMD) for each biomarker were reported.

RESULTS

A total of 27 studies (n=2213 patients) were included. Critically ill patients presented with higher levels of MR-proADM (PMD: 0.71 nmol/L, 95% CI: 0.22 to 1.20 nmol/L, p=0.02), E-selectin (PMD: 13,32 pg/ml, 95% CI: 4,89 to 21,75 pg/ml, p=0.008), VCAM-1 (PMD: 479 ng/ml, 95% CI: 64 to 896 ng/ml, p=0.03), VWF-Ag (PMD: 110.5 IU/dl, 95% CI: 44.8 to 176.1 IU/dl, p=0.04) and Ang-2 (PMD: 2388 pg/ml, 95% CI: 1121 to 3655 pg/ml, p=0.003), as compared to non-critically ill ones. ICAM-1, P-selectin and thrombomodulin did not differ between the two groups (p>0.05).

CONCLUSION

Endothelial biomarkers display significant heterogeneity in COVID-19 patients, with higher MR-proADM, E-selectin, VCAM-1, VWF-Ag, and Ang-2 levels being associated with increased severity. These findings strengthen the evidence on the key role of endothelial dysfunction in disease progress.

Impact of significant preprocedural mitral regurgitation on mortality after transcatheter aortic valve implantation

Background

Mitral regurgitation (MR) is commonly encountered in patients with severe aortic stenosis scheduled for transcatheter aortic valve implantation (TAVI). The presence of significant pre-procedural MR, however, has not been accounted in pivotal trials of TAVI and data regarding its independent impact on outcome are contradictory.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were stratified into two groups according to MR severity: ≤ grade 1 were defined as non-significant and ≥ grade 2 as significant. Change in MR was determined by comparison between baseline and 30-day echocardiogram. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

A total of 331 consecutive patients were enrolled in the study: 247 (74.6%) had non-significant MR and 84 (25.4%) patients had significant MR at baseline. Patients with significant pre-procedural MR had lower baseline ejection fraction (47.7±10.4% versus 51.2±8.4%, p=0.002), higher pulmonary artery systolic pressure (52±14.3mmHg versus 42.5±11.1mmHg, p&lt;0.0001) and higher rates of moderate or severe tricuspid regurgitation (TR) (50% versus 19.4%) compared to patients with non-significant MR. Of all patients, mitral regurgitation improved in 9.5%, remained the same in 83.9%, and worsened in 6.6% 30 days after TAVR. In a multivariable analysis, pre-procedural TR severity was predictor of improved mitral regurgitation [OR 3.003,(95% CI 1.216–7.417, p=0.017)].

The primary clinical end point occurred in 44.7% of all patients during a follow-up period of 36.6.±25.9 months. Patients with significant pre-procedural MR had significantly higher rates of all-cause mortality compared to patients with non-significant (54.7% and 41.3%, respectively; log rank p=0.015). Performing a multivariable analysis demonstrated that preprocedural MR severity could independently predict cumulative mortality [OR 0.480, (95% CI 0.247–0.932, p=0.03)].

Conclusion

Significant pre-procedural MR is common in patients undergoing TAVI and is associated with increased all-cause mortality. TAVI is associated with a significant improvement in MR, especially in severe types. These data provide new insights in the crucial role of mitral regurgitation in the risk assessment of TAVI candidates.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness of atrial fibrillation on high-intensity transient signals to cerebral circulation during TAVI

Background

Cerebral microemboliazations remain a major concern peri-operatively and following Transcatheter Aortic Valve Implantation (TAVI). We evaluated whether atrial fibrillation may predispose to an increased number of cerebrovascular emboli during the procedure.

Purpose

The aim of the study was to evaluate, using a transcranial doppler, the effect of atrial fibrillation on transient high-intensity signals to middle cerebral arteries during transcatheter aortic valve implantation.

Methods

Consecutive patients who underwent transfemoral TAVI with Evolut™ R bioprosthesis, were categorized into two groups. Group A patients with permanent atrial fibrillation (AF) on anticoagulation, Group B patients with sinus rhythm (SR). Dual antiplatelet therapy with aspirin and clopidogrel was administered to all patients 24 hours prior to the procedure at loading dose, with patients in Group A receiving in addition low-molecular-weight-heparin. The number of detected High Intensity Transient Signals (HITS) was assessed using Rimed Digi-Lite™ Transcranial Doppler on both cerebral arteries during the following phases of the procedure; Phase 0: 30 minutes prior to procedure initiation, Phase I: between access site puncture and introduction of the delivery system, Phase II: during the implantation of the bioprosthesis, until the removal of the delivery system. All implantations were performed without predilation. Furthermore, patients were evaluated by neurologist before TAVI and on discharge day. Safety was evaluated according to VARC-2 criteria.

Results

Twenty-eight patients were evaluated (81±6 years, 16 males (57.1%)). Group A had higher number of total (786±95 vs. 604±103, p=0.002) as well as Phase I HITS (393±94 vs. 285±86, p=0.002). One cerebrovascular event was recorded in Group A and one patient categorized to Group B developed major bleeding due to conversion to femoral surgical cut-down. The average number of received blood units, was higher in AF compared to SR Group (Group 1: 0.8±1.9 vs. Group 2: 0.5±0.7, p: 0.886), without however, reaching statistical significance.

Conclusion

Patients with atrial fibrillation had larger burden of embolic HITS during TAVI indicating high risk patients for embolic cerebrovascular events. This may has implications for future strategies for cerebral embolic protection.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Ippokrateio General Hospital of Athens

Effect of concomitant atrioventricular valve regurgitation on the outcome after transcatheter aortic-valve implantation

Background

Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or more. The impact of coexistent tricuspid regurgitation (TR) remains to be determined.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA)≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were divided into 4 groups according to MR and TR severity pre-procedurally: no/mild MR and TR, moderate/severe MR, moderate/severe TR, moderate/severe MR and TR. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

A total of 244 consecutive patients were enrolled in the study: 148 (60.7%) patients no/mild MR and TR, 32 (13.1%) moderate/severe MR, 35 (14.3%) moderate/severe TR, 29 (11.9%) moderate/severe MR and TR pre-procedurally. There was significant difference in pre-procedural pulmonary artery systolic pressure (PASP) among groups (no/mild MR and TR: 40.8±10 mmHg, moderate/severe MR: 46.6±11.2 mmHg, moderate/severe TR: 49.9±13mmHg, moderate/severe MR and TR: 59.8±15.2mmHg, p&lt;0.0001). The Kaplan–Meier curves for 2 year mortality showed that the severity of TR was associated with poor survival. Interestingly, patients with moderate/severe MR and TR had the worse survival (no/mild MR and TR (91.2%), moderate/severe MR (78.1%), moderate/severe TR (62.9%), moderate/severe MR and TR (62.1%), p&lt;0.0001).

Conclusion

The presence of concomitant moderate or severe mitral and tricuspid valve regurgitation was associated with the higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.

Funding Acknowledgement

Type of funding sources: None.