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Pereyra Pietri M, Farina JM, Mahmoud AK, Scalia IG, Galasso F, Killian ME, Suppah M, Kenyon CR, Koepke LM, Padang R, Chao CJ, Sweeney JP, Fortuin FD, Eleid MF, Sell-Dottin KA, Steidley DE, Scott LR, Fonseca R, Lopez-Jimenez F, Attia ZI, Dispenzieri A, Grogan M, Rosenthal JL, Arsanjani R, Ayoub C. The prognostic value of artificial intelligence to predict cardiac amyloidosis in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:295-302. [PMID: 38774378 PMCID: PMC11104461 DOI: 10.1093/ehjdh/ztae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/15/2024] [Accepted: 03/05/2024] [Indexed: 05/24/2024]
Abstract
Aims Cardiac amyloidosis (CA) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Cardiac amyloidosis has poor outcomes, and its assessment in all TAVR patients is costly and challenging. Electrocardiogram (ECG) artificial intelligence (AI) algorithms that screen for CA may be useful to identify at-risk patients. Methods and results In this retrospective analysis of our institutional National Cardiovascular Disease Registry (NCDR)-TAVR database, patients undergoing TAVR between January 2012 and December 2018 were included. Pre-TAVR CA probability was analysed by an ECG AI predictive model, with >50% risk defined as high probability for CA. Univariable and propensity score covariate adjustment analyses using Cox regression were performed to compare clinical outcomes between patients with high CA probability vs. those with low probability at 1-year follow-up after TAVR. Of 1426 patients who underwent TAVR (mean age 81.0 ± 8.5 years, 57.6% male), 349 (24.4%) had high CA probability on pre-procedure ECG. Only 17 (1.2%) had a clinical diagnosis of CA. After multivariable adjustment, high probability of CA by ECG AI algorithm was significantly associated with increased all-cause mortality [hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.01-1.96, P = 0.046] and higher rates of major adverse cardiovascular events (transient ischaemic attack (TIA)/stroke, myocardial infarction, and heart failure hospitalizations] (HR 1.36, 95% CI 1.01-1.82, P = 0.041), driven primarily by heart failure hospitalizations (HR 1.58, 95% CI 1.13-2.20, P = 0.008) at 1-year follow-up. There were no significant differences in TIA/stroke or myocardial infarction. Conclusion Artificial intelligence applied to pre-TAVR ECGs identifies a subgroup at higher risk of clinical events. These targeted patients may benefit from further diagnostic evaluation for CA.
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Affiliation(s)
- Milagros Pereyra Pietri
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Juan M Farina
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Ahmed K Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Isabel G Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Francesca Galasso
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Michael E Killian
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Mustafa Suppah
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Courtney R Kenyon
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Laura M Koepke
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - John P Sweeney
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - F David Fortuin
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - David E Steidley
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Luis R Scott
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Rafael Fonseca
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | | | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Martha Grogan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Julie L Rosenthal
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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Parikh PB, Mack M, Stone GW, Anker SD, Gilchrist IC, Kalogeropoulos AP, Packer M, Skopicki HA, Butler J. Transcatheter aortic valve replacement in heart failure. Eur J Heart Fail 2024; 26:460-470. [PMID: 38297972 DOI: 10.1002/ejhf.3151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 01/06/2024] [Accepted: 01/17/2024] [Indexed: 02/02/2024] Open
Abstract
Patients with severe aortic stenosis (AS) may develop heart failure (HF), the presence of which has traditionally been deemed as a final stage in AS progression with poor outcomes. The use of transcatheter aortic valve replacement (TAVR) has become the preferred therapy for most patients with AS and concomitant HF. With its instant afterload reduction, TAVR offers patients with HF significant haemodynamic benefits, with corresponding changes in left ventricular structure and improved mortality and quality of life. The prognostic covariates and optimal timing of TAVR in patients with less than severe AS remain unclear. The purpose of this review is to describe the association between TAVR and outcomes in patients with HF, particularly in the setting of left ventricular systolic dysfunction, acute HF, and right ventricular systolic dysfunction, and to highlight areas for future research.
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Affiliation(s)
- Puja B Parikh
- Department of Medicine, Stony Brook Renaissance School of Medicine, Stony Brook, NY, USA
| | - Michael Mack
- Department of Cardiac Surgery, Baylor Scott & White Health, Plano, TX, USA
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Charité-Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Ian C Gilchrist
- Department of Medicine, Stony Brook Renaissance School of Medicine, Stony Brook, NY, USA
| | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Hal A Skopicki
- Department of Medicine, Stony Brook Renaissance School of Medicine, Stony Brook, NY, USA
| | - Javed Butler
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
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Ismayl M, Abbasi M, Al-Abcha A, El-Am E, Alkhouli M, Guerrero M, Dispenzieri A, Nkomo VT, Abou Ezzeddine OF, Grogan M, Anavekar NS. Outcomes of transcatheter aortic valve replacement in patients with and without amyloidosis: A nationwide analysis from the United States. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 58:34-42. [PMID: 37468384 DOI: 10.1016/j.carrev.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/18/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Amyloidosis is a common comorbidity in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR). This study aims to assess the impact of amyloidosis on the clinical outcomes of TAVR. METHODS This is a retrospective study of the National Inpatient Sample database that identified adult patients (≥18 years) with AS hospitalized for TAVR from 2016 through 2020 to compare outcomes in those with versus without amyloidosis. Our primary outcome was in-hospital mortality. Secondary outcomes included procedural complications, hospital length of stay (LOS), and total costs. TAVR trends in both cohorts were also evaluated. RESULTS The total cohort included 304,710 patients with AS undergoing TAVR, of whom 410 had amyloidosis. Over the study period, TAVR trends increased significantly in patients with and without amyloidosis (both ptrend < 0.01). Patients with amyloidosis were more likely to be older males with atrial fibrillation/flutter, congestive heart failure, renal disease, and dementia compared to non-amyloidosis patients. After adjustment for baseline characteristics, patients with amyloidosis had similar odds of in-hospital mortality (adjusted odds ratio [aOR] 1.66, 95 % confidence interval [CI] 0.34-3.63), heart block (aOR 1.33, 95 % CI 0.84-2.10), permanent pacemaker insertion (aOR 0.67, 95 % CI 0.27-1.66), stroke (aOR 0.90, 95 % CI 0.32-3.13), acute kidney injury, major bleeding, blood transfusion, vascular complications, in addition to similar LOS (p = 0.21) and total costs (p = 0.18) compared to patients without amyloidosis. CONCLUSION In patients with AS undergoing TAVR, comorbid amyloidosis is associated with similar in-hospital mortality and procedural complications compared to patients without amyloidosis.
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Affiliation(s)
- Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA.
| | - Muhannad Abbasi
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Abdullah Al-Abcha
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Edward El-Am
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Angela Dispenzieri
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Omar F Abou Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Martha Grogan
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
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Prognostic Value of Preprocedural LV Global Longitudinal Strain for Post-TAVR-Related Morbidity and Mortality: A Meta-Analysis. JACC Cardiovasc Imaging 2023; 16:332-341. [PMID: 36889849 DOI: 10.1016/j.jcmg.2023.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/26/2022] [Accepted: 01/03/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Left ventricular ejection fraction (LVEF) demonstrates limited prognostic value for post-transcatheter aortic valve replacement (TAVR) outcomes. Evidence regarding the potential role of left ventricular global longitudinal strain (LV-GLS) in this setting is inconsistent. OBJECTIVES The aim of this systematic review and meta-analysis of aggregated data was to evaluate the prognostic value of preprocedural LV-GLS for post-TAVR-related morbidity and mortality. METHODS The authors searched PubMed, Embase, and Web of Science for studies investigating the association between preprocedural 2-dimensional speckle-tracking-derived LV-GLS and post-TAVR clinical outcomes. An inversely weighted random effects meta-analysis was adopted to investigate the association between LV-GLS vs primary (ie, all-cause mortality) and secondary (ie, major cardiovascular events [MACE]) post-TAVR outcomes. RESULTS Of the 1,130 identified records, 12 were eligible, all of which had a low-to-moderate risk of bias (Newcastle-Ottawa scale). On average, 2,049 patients demonstrated preserved LVEF (52.6% ± 1.7%), but impaired LV-GLS (-13.6% ± 0.6%). Patients with a lower LV-GLS had a higher all-cause mortality (pooled HR: 2.01; 95% CI: 1.59-2.55) and MACE (pooled odds ratio [OR]: 1.26; 95% CI: 1.08-1.47) risk compared with patients with higher LV-GLS. In addition, each percentage point decrease of LV-GLS (ie, toward 0%) was associated with an increased mortality (HR: 1.06; 95% CI: 1.04-1.08) and MACE risk (OR: 1.08; 95% CI: 1.01-1.15). CONCLUSIONS Preprocedural LV-GLS was significantly associated with post-TAVR morbidity and mortality. This suggests a potential clinically important role of pre-TAVR evaluation of LV-GLS for risk stratification of patients with severe aortic stenosis. (Prognostic value of left ventricular global longitudinal strain in patients with aortic stenosis undergoing Transcatheter Aortic Valve Implantation: a meta-analysis; CRD42021289626).
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Xiao Y, Bi W, Qiao W, Wang X, Li Y, Ren W. Prognostic value of ventricular longitudinal strain in patients undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:965440. [PMID: 36093137 PMCID: PMC9448921 DOI: 10.3389/fcvm.2022.965440] [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: 06/09/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Strain obtained by speckle tracking echocardiography (STE) can detect subclinical myocardial impairment due to myocardial fibrosis (MF) and is considered a prognostic marker. Aortic stenosis (AS) is not only a valve disease, but also a cardiomyopathy characterized by MF. The purpose of this study was to systematically review and analyze ventricular strain as a predictor of adverse outcomes in patients with AS undergoing transcatheter aortic valve replacement (TAVR). Methods PubMed, Embase, and the Cochrane library were searched for studies that investigated the prognostic value of impaired ventricular strain on patients with AS undergoing TAVR with all-cause mortality (ACM) and major adverse cardiovascular events (MACE). Pooled odds ratios (ORs), hazard ratios (HRs), and 95% confidence intervals (CIs) were calculated to assess the role of left (LVLS) and right (RVLS) ventricular longitudinal strain in the prognostic prediction of patients with AS undergoing TAVR. Sensitivity and subgroup analysis was performed to assess heterogeneity. Results Twelve studies were retrieved from 571 citations for analysis. In total, 1,489 patients with a mean age of 82 years and follow-up periods varying between 1 year and 8.5 years were included. Meta-analysis showed the impaired LVLS from eight studies was associated with an increased risk for combined ACM and MACE (OR: 1.08, 95% CI: 1–1.16; p = 0.037), and ACM alone (HR: 1.08, 95% CI: 1.01–1.16; p = 0.032). Impaired RVLS from four studies was associated with an increased risk of combined ACM and MACE (OR: 1.08, 95% CI: 1.02–1.14; p < 0.01), and ACM alone (HR: 1.07, 95% CI: 1.02–1.12; p < 0.01). Conclusions This meta-analysis demonstrated that ventricular strain, including LVLS and RVLS, had a substantial prognostic value in ACM or combined ACM and MACE, which could be used as a valid marker for risk stratification in patients with AS undergoing TAVR.
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Reduction in Afterload Reveals the Apical Sparing Phenotype. Circ Cardiovasc Imaging 2022; 15:e014549. [DOI: 10.1161/circimaging.122.014549] [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: 11/16/2022]
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Antonopoulos AS, Panagiotopoulos I, Kouroutzoglou A, Koutsis G, Toskas P, Lazaros G, Toutouzas K, Tousoulis D, Tsioufis K, Vlachopoulos C. Prevalence and Clinical Outcomes of Transthyretin Amyloidosis: A Systematic Review and Meta-analysis. Eur J Heart Fail 2022; 24:1677-1696. [PMID: 35730461 DOI: 10.1002/ejhf.2589] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: a) the prevalence of cardiac amyloidosis in various patient subgroups, b) survival estimates for ATTR subtypes and c) the effects of novel therapeutics on the natural course of disease. METHODS A systematic review of literature published in Medline before 31/12/2021 was performed for the prevalence of cardiac amyloidosis & all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2 and 5-years. Subgroup analyses were performed for ATTR subtype i.e., wild type ATTR (wtATTR) vs. hereditary ATTR (htATTR), htATTR genotypes and treatment subgroups. RESULTS We identified a total of 62 studies (n=277,882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, HFpEF, and elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n=18,238 ATTR patients). Patients with wtATTR were older (p=7x10-10 ) and more frequently male (p=5x10-20 ) vs. htATTR. The 2-year survival of ATTR was 73.3% (95%CI 71.6-76.2); for non-subtyped ATTR 70.4% (95%CI 66.9-73.9), for wtATTR (76.0%, 95%CI: 73.0-78.9) and for htATTR (77.2%, 95%CI: 74.0-80.4); in meta-regression analysis wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and htATTR genotypes (p=10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95%CI: 74.4-85.3 vs. 72.4%, 95%CI 69.8-74.9, p<0.05). CONCLUSIONS We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Ioannis Panagiotopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Alexandrina Kouroutzoglou
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Pantelis Toskas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Lazaros
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
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