Myocardial injury associated with transcatheter aortic valve implantation (TAVI)

LncRNA Zfas1 boosts cell apoptosis and autophagy in myocardial injury induced by hypoxia via miR-383-5p/ATG10 axis

Background

Myocardial injury has been regarded as a major cause of several heart diseases. Long non-coding RNA (lncRNA) has emerged as a key regulator in a wide array of diseases.

Aim of the study

This study aims to explore the role of Zfas1 in myocardial injury.

Methods

3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was adopted to evaluate the proliferative capability of H9c2 cells. Terminal deoxynucleotidyltransferase dUTP nick end labeling (TUNEL) and flow cytometry assays were employed to measure cell apoptosis. The expression of proteins related to apoptosis and autophagy was examined by Western blot. Immunofluorescence (IF) assay was performed to monitor the process of autophagy. Real-time reverse-transcription polymerase chain reaction (RT-qPCR) was employed to determine the expressions of autophagy-related gene 10 (ATG10), miR-383-5p and Zfas1. The interacting relationship between miR-383-5p and ATG10 (or Zfas1) was assessed by luciferase reporter and RNA-binding protein immunoprecipitation (RIP) assays.

Results

The treatment of hypoxia hindered cell proliferation but accelerated cell apoptosis and autophagy. ATG10 exhibited higher mRNA and protein expression in H9c2 cells induced by hypoxia. MiR-383-5p was revealed to be the upstream gene of ATG10 and could interact with ATG10. Zfas1 was validated to sponge miR-383-5p and positively regulated ATG10 expression. Zfas1 knockdown-mediated cellular proliferation, apoptosis and autophagy phenotypes were counteracted by ATG10 abundance.

Conclusions

LncRNA Zfas1 boosts cell apoptosis and autophagy in myocardial injury induced by hypoxia via miR-383-5p/ATG10 axis, indicating that Zfas1 may be utilized as a therapeutic target for myocardial injury.

Impact of periprocedural myocardial injury after transcatheter aortic valve implantation on long-term mortality: a meta-analysis of Kaplan-Meier derived individual patient data

Background

Periprocedural myocardial injury (PPMI) frequently occurs after transcatheter aortic valve implantation (TAVI), although its impact on long-term mortality is uncertain.

Methods

We performed a pooled analysis of Kaplan-Meier-derived individual patient data to compare survival in patients with and without PPMI after TAVI. Flexible parametric models with B-splines and landmark analyses were used to determine PPMI prognostic value. Subgroup analyses for VARC-2, troponin, and creatine kinase-MB (CK-MB)-defined PPMI were also performed.

Results

Eighteen observational studies comprising 10,094 subjects were included. PPMI was associated with lower overall survival (OS) after two years (HR = 1.46, 95% CI 1.30-1.65, p < 0.01). This was also observed when restricting the analysis to overall VARC-2-defined PPMI (HR = 1.23, 95% CI 1.07-1.40, p < 0.01). For VARC-2 PPMI criteria and VARC-2 troponin-only, higher mortality was restricted to the first 2 months after TAVI (HR = 1.64, 95% CI 1.31-2.07, p < 0.01; and HR = 1.32, 95% CI 1.05-1.67, p = 0.02, respectively), while for VARC-2 defined CK-MB-only the increase in mortality was confined to the first 30 days (HR = 7.44, 95% CI 4.76-11.66, p < 0.01).

Conclusion

PPMI following TAVI was associated with lower overall survival compared with patients without PPMI. PPMI prognostic impact is restricted to the initial months after the procedure. The analyses were consistent for VARC-2 criteria and for both biomarkers, yet CK-MB was a stronger prognostic marker of mortality than troponin.

Effects of low versus high inspired oxygen fraction on myocardial injury after transcatheter aortic valve implantation: A randomized clinical trial

BACKGROUND

Oxygen therapy is used in various clinical situation, but its clinical outcomes are inconsistent. The relationship between the fraction of inspired oxygen (FIO2) during transcatheter aortic valve implantation (TAVI) and clinical outcomes has not been well studied. We investigated the association of FIO2 (low vs. high) and myocardial injury in patients undergoing TAVI.

METHODS

Adults undergoing transfemoral TAVI under general anesthesia were randomly assigned to receive FIO2 0.3 or 0.8 during procedure. The primary outcome was the area under the curve (AUC) for high-sensitivity cardiac troponin I (hs-cTnI) during the first 72 h following TAVI. Secondary outcomes included the AUC for postprocedural creatine kinase-myocardial band (CK-MB), acute kidney injury and recovery, conduction abnormalities, pacemaker implantation, stroke, myocardial infarction, and in-hospital mortality.

RESULTS

Between October 2017 and April 2022, 72 patients were randomized and 62 were included in the final analysis (n = 31 per group). The median (IQR) AUC for hs-cTnI in the first 72 h was 42.66 (24.82-65.44) and 71.96 (35.38-116.34) h·ng/mL in the FIO2 0.3 and 0.8 groups, respectively (p = 0.066). The AUC for CK-MB in the first 72 h was 257.6 (155.6-322.0) and 342.2 (195.4-485.2) h·ng/mL in the FIO2 0.3 and 0.8 groups, respectively (p = 0.132). Acute kidney recovery, defined as an increase in the estimated glomerular filtration rate ≥ 25% of baseline in 48 h, was more common in the FIO2 0.3 group (65% vs. 39%, p = 0.042). Other clinical outcomes were comparable between the groups.

CONCLUSIONS

The FIO2 level did not have a significant effect on periprocedural myocardial injury following TAVI. However, considering the marginal results, a benefit of low FIO2 during TAVI could not be ruled out.

Myocardial Injury After Transcatheter Aortic Valve Replacement According to VARC-3 Criteria

BACKGROUND

The Valve Academic Research Consortium (VARC)-3 definition for myocardial injury after transcatheter aortic valve replacement (TAVR) lacks of clinical validation.

OBJECTIVES

This study sought to determine the incidence, predictors, and clinical impact of periprocedural myocardial injury (PPMI) following TAVR as defined by recent VARC-3 criteria.

METHODS

We included 1,394 consecutive patients who underwent TAVR with a new-generation transcatheter heart valve. High-sensitivity troponin levels were assessed at baseline and within 24 hours after the procedure. PPMI was defined according to VARC-3 criteria as an increase ≥70 times in troponin levels (vs ≥15 times according to the VARC-2 definition). Baseline, procedural, and follow-up data were prospectively collected.

RESULTS

PPMI was diagnosed in 193 (14.0%) patients. Female sex and peripheral artery disease were independent predictors of PPMI (P < 0.01 for both). PPMI was associated with a higher risk of mortality at 30-day (HR: 2.69, 95% CI: 1.50-4.82; P = 0.001) and 1-year (for all-cause mortality, HR: 1.54; 95% CI: 1.04-2.27; P = 0.032; for cardiovascular mortality, HR: 3.04; 95% CI: 1.68-5.50; P < 0.001) follow-up. PPMI according to VARC-2 criteria had no impact on mortality.

CONCLUSIONS

About 1 out of 10 patients undergoing TAVR in the contemporary era had PPMI as defined by recent VARC-3 criteria, and baseline factors like female sex and peripheral artery disease determined an increased risk. PPMI had a negative impact on early and late survival. Further studies on the prevention of PPMI post-TAVR and implementing measures to improve outcomes in PPMI patients are warranted.

Predictors and Prognostic Implications of Myocardial Injury After Transcatheter Aortic Valve Replacement

Myocardial injury (MI) is not unusual after transcatheter aortic valve replacement (TAVR). To determine precipitating factors and prognostic outcomes of MI after TAVR, we retrospectively investigated relationships between MI after TAVR and aortic root dimensions, baseline patient characteristics, echocardiographic findings, and procedural features. Of 474 patients who underwent transfemoral TAVR for severe aortic stenosis in our tertiary center from June 2011 through June 2018, 188 (mean age, 77.7 ± 7.7 yr; 96 women [51%]) met the study inclusion criteria. Patients were divided into postprocedural MI (PMI) (n=74) and no-PMI (n=114) groups, in accordance with high-sensitivity troponin T levels. We found that MI risk was associated with older age (odds ratio [OR]=1.054; 95% CI, 1.013-1.098; P=0.01), transcatheter heart valve type (OR=10.207; 95% CI, 2.861-36.463; P=0.001), distances from the aortic annulus to the right coronary artery ostium (OR=0.853; 95% CI, 0.731-0.995; P=0.04) and the left main coronary artery ostium (OR=0.747; 95% CI, 0.616-0.906; P=0.003), and baseline glomerular filtration rate (OR=0.985; 95% CI, 0.970-1.000; P=0.04). Moreover, the PMI group had a longer time to hospital discharge (P=0.001) and a higher permanent pacemaker implantation rate (P=0.04) than did the no-PMI group. Our findings may enable better estimation of which patients are at higher risk of MI after TAVR and thus improve the planning and course of clinical care.

Impact of bioprosthetic valve type on peri-procedural myocardial injury and mortality after transcatheter aortic valve replacement

Peri-procedural myocardial injury (PPMI) is a common complication after transcatheter valve replacement (TAVR), often remaining clinically silent. The role of valve type on PPMI and the association between PPMI and mortality are still unclear. We sought to evaluate predictors and outcome of PPMI after TAVR, and the impact of self-expandable valve (SEV) vs. balloon-expandable valve (BEV) deployment on PPMI. Consecutive patients who underwent successful TAVR in a single-center from January 2014 to December 2019 were included. PPMI was defined according to a modified Valve Academic Research Consortium (VARC)-2 definition as a post-procedure elevation of troponin (with a peak value ≥ 15-times the upper-reference limit) < 72 h after TAVR. We included 596 patients, of whom 258 (43.3%) were men. Mean age was 83.4 ± 5.5 years. We deployed 368 (61.7%) BEV and 228 (38.3%) SEV. PPMI was observed in 471 (79.0%) patients. At multivariable analysis, SEV (OR 2.70, 95% CI 1.64-4.55, p < 0.001), creatinine clearance (OR 0.98, 95% CI 0.97-1.00, p = 0.011), and baseline ejection fraction (OR 1.05, 95% CI 1.02-1.07, p < 0.001) were independent predictors of PPMI; these findings were also confirmed using a propensity-weighted analysis. Thirty-day and 1-year all-cause mortality rates were 2.5% and 8.1%, respectively. No associations between PPMI and 30-day (p = 0.488) or 1-year (p = 0.139) all-cause mortality were found. Independent predictors of 30-day mortality were increasing EUROSCORE II (HR 1.16 per score point, 95% CI 1.08-1.19, p < 0.001) and life-threatening/major bleeding complications (HR 5.87, 95% CI 1.28-26.58, p = 0.019), whereas EUROSCORE II (HR 1.08, 95% CI 1.04-1.13, p = 0.031) and acute kidney injury (HR 2.59, 95% CI 1.20-5.35, p = 0.020) were related to 1-year mortality. PPMI is frequent after TAVR, but it does not affect 30-day or 1-year all-cause mortality. SEV implantation is associated with an increased frequency of PPMI.

Transcatheter Aortic Valve Repair in a Patient With Anomalous Right Coronary Artery Originating From the Left Aortic Sinus and Myelodysplastic Syndrome

We report a patient with symptomatic low-flow high-grade aortic valve stenosis and myelodysplastic syndrome. Preinterventional imaging revealed an anomalous origin of the right coronary artery only defined by CT. The patient was classified as high risk in regard to conventional cardiac surgery by our heart team and therefore scheduled for transcatheter aortic valve repair (TAVR). The case presentation describes the potential effect of this anatomical coronary variant with regard to the peri- and postinterventional outcome: anomalous origin of the right coronary artery may lead to severe ischemia during TAVR due to occlusion of the coronary vessel. Conversion to open surgery with immediate coronary bypass surgery may rapidly restore myocardial perfusion and enhance clinical outcome of the patient.

Invasive hemodynamics and cardiac biomarkers to predict outcomes after percutaneous edge-to-edge mitral valve repair in patients with severe heart failure

BACKGROUND

Percutaneous mitral valve repair (PMVR) via MitraClip implantation is a therapeutic option for high-risk or non-surgical candidates with severe mitral regurgitation (MR) and advanced stages of heart failure (HF). However, these patients have a high mortality despite PMVR, and predictors for outcomes are not well established. Here, we evaluated invasive hemodynamics, echocardiography parameters, and biomarkers to predict outcomes after PMVR in severe HF patients.

METHODS

Patients with reduced ejection fraction (EF) and severe and moderate-to-severe MR undergoing PMVR at our centre between September 2009 and January 2016 were analysed retrospectively. Inclusion criteria were: left ventricular EF < 45%, preoperative right heart catheterization, successful MitraClip deployment ("technical success"), and follow-up for at least 1 year after the procedure. Data from preoperative right heart catheterization, echocardiography, and biomarkers were assessed. Primary endpoint was all-cause mortality at 1 year after PMVR. We performed univariate and multivariate Cox regression analyses and generated a risk score to predict outcomes.

RESULTS

Of 174 patients with PMVR and severe HF, 79.9% had functional MR. Mean EF was 25% (17.2; 30.7) and advanced New York Heart Association functional class was prevalent (class II: 13%; class III: 70%; and class IV: 17%). The cumulative incidences of all-cause death were 6.9% and 17.8% at 30 days and 1 year, respectively. In the Cox multivariate model, high-sensitive troponin T [hsTnT; hazard ratio (HR) 1.01; confidence interval (CI) 1.01-1.02; p < 0.0001] and mixed venous O₂-saturation (HR 0.92; CI 0.89-0.96; p < 0.0001) were found to significantly and independently predict outcomes. A simple risk score including these two parameters was sufficient to discriminate between low- and high-risk patients (HR 7.22; CI 3.4-15.5; p < 0.001).

CONCLUSION

In a cohort of patients with severe HF undergoing PMVR, patients with elevated hsTnT and reduced mixed venous O₂-saturation carried the worst prognosis. A simple risk score including these two parameters may improve patient selection and outcomes after PMVR.

Heart Valve Disease Awareness Survey 2017: what did we achieve since 2015?

AIMS

The 2015 Heart Valve Disease Awareness Survey showed a low knowledge and awareness about heart valve disease in the general population despite its high prevalence and morbidity. The 2017 survey was conducted to re-evaluate concern and knowledge about heart valve disease after 2 years of rapidly increasing patient numbers presenting with heart valve disease.

METHODS AND RESULTS

A total of 12,820 people aged 60 years or older in 11 European countries took part in the survey. While the number of people concerned most about heart valve disease increased significantly (2015:1.7% vs. 2017:2.1%; p < 0.001), it is still very low compared to cancer (28.8%) or Alzheimer's disease (20.9%). More people claim to be familiar with heart valve disease in general (2015: 17.1% vs. 2017: 20.0%; p < 0.001) and the majority claims to know of at least one therapy for heart valve disease (61.9%). Nevertheless, only 3.8% could correctly identify aortic stenosis (AS), which is significantly less than in 2015 (7.2%; p < 0.001). As before, the majority of the respondents claimed to rarely or never undergo a stethoscope check from their general practitioner (2015: 54.2% vs. 2017: 50.6%, p < 0.001); nevertheless, a positive trend can be seen. People wish heart valve disease to be part of regular checks by the general practitioners.

CONCLUSION

The general population's knowledge of heart valve disease in general slightly increased over the last 2 years. However, detailed understanding of aortic stenosis and its treatment options is still low, as is the level of concern shown for heart valve disease. Nevertheless, the general population cites heart valve disease as a condition they wish to be checked for regularly.

Myocardial injury after endovascular revascularization in critical limb ischemia predicts 1-year mortality: a prospective observational cohort study

BACKGROUND

Patients with critical limb ischemia (CLI) are at increased risk of cardiovascular complications and mortality. To determine (1) incidence of myocardial injury following endovascular revascularization, and (2) relationship between myocardial injury with 1-year mortality and major adverse cardiovascular events (MACE; i.e., composite of myocardial infarction, stroke, and death).

METHODS AND RESULTS

Single-center, prospective cohort study of CLI patients ≥ 45 years of age, who underwent endovascular revascularization with overnight hospitalization. High-sensitive troponins T (hsTnTs) were measured on admission, 3-6 h after endovascular revascularization and the subsequent morning. Myocardial injury after endovascular revascularization was defined as an hsTnT ≥ 14 ng/L with a relative increase ≥ 30% from the baseline value. We also evaluated other myocardial injury hsTnT thresholds (i.e., ≥ 30, ≥ 40, ≥ 60, and ≥ 80 ng/L). 239 consecutive patients (56% male, mean age 71.5 ± 10.1 years) were included; one patient was lost to follow-up. At 1 year, there were 34 deaths (14.2%), and 48 MACE (20.5%). Myocardial injury with the hsTnT threshold of 14 ng/L and relative increase by ≥ 30% from the baseline level occurred in 61 patients (25.5%). Myocardial injury was independently associated with 1-year mortality ([aHR], 2.44; 95% CI 1.18-5.06, for hsTnT ≥ 14 ng/L to aHR, 3.34; 95% CI 1.29-8.65 for hsTnT ≥ 80 ng/L). Myocardial injury was also independently associated with 1-year MACE ([AOR] 2.89; 95% CI 1.41-5.92 for hsTnT ≥ 14 ng/L to AOR, 6.69; 95% CI 2.17-20.68 for hsTnT ≥ 80 ng/L). 85.2% patients who had myocardial injury did not have ischemic clinical symptoms or electrocardiography changes. In sensitive analysis with exclusion of symptomatic patients that developed myocardial injury for the hsTnT ≥ 14 ng/L threshold, both the 1-year mortality (aHR: 2.19; CI 1.02-4.68; p = 0.04), and 1-year MACE (OR 2.25; CI 1.06-4.77; p = 0.036) remained significant.

CONCLUSIONS

Myocardial injury is common following endovascular revascularization for CLI and associated with the risk of 1-year mortality and MACE.

Association between low diastolic blood pressure and subclinical myocardial injury

BACKGROUND

Coronary arteries perfuse cardiac myocytes during diastole. We hypothesized that marked lowering of diastolic blood pressure (DBP) is associated with increased risk of subclinical myocardial injury (SC-MI).

METHODS

This analysis included 6107 participants without history of cardiovascular disease (CVD) from the third National Health and Nutrition Examination Survey. SC-MI was determined by a validated electrocardiogram-based scoring system. Logistic regression was used to examine the cross-sectional association between DBP (< 70, 70-80 mmHg (reference group), and > 80 mmHg; and per each 10 mmHg decrease, separately) with SC-MI across levels of systolic blood pressure (SBP) (< 120, 120-139, or > 140 mmHg).

RESULTS

In a multivariable model, DBP < 70 mmHg was associated with a higher risk of SC-MI [OR (95% CI) 1.40 (1.02, 1.94)] in participants with SBP > 140 mmHg. This association was consistent in subgroups stratified by age, race, diabetes, hypertension, obesity and smoking, but was stronger in women than in men [OR (95% CI) 1.58 (1.06, 2.37) vs. 1.10 (0.62, 1.94), respectively; interaction p value = 0.006]. Also, among participants with SBP > 140 mmHg, every 10 mmHg decrease in DBP was associated with a 12% increased odds of SC-MI [OR (95% CI) 1.12 (1.01, 1.23)]. No significant associations between DBP and SC-MI were observed in those with SBP < 120 mmHg or 120-139 mmHg, or between DBP > 80 mmHg and SC-MI in any of SBP levels.

CONCLUSIONS

Low DBP < 70 mmHg in those with SBP > 140 mmHg carries higher risk of SC-MI, especially in women. Further research is needed to understand the therapeutic implications of these findings.

In-hospital outcome of transcatheter vs. surgical aortic valve replacement in patients with aortic valve stenosis: complete dataset of patients treated in 2013 in Germany

BACKGROUND

Transvascular (TV-AVI) or transapical (TA-AVI) aortic valve implantation (TAVI) is a treatment option for patients with aortic stenosis being at high or prohibitive risk for surgical aortic valve implantation (SAVR). Randomized data demonstrated that these subgroups can safely been treated with TAVI. However, a comparison of SAVR and TAVI in intermediate and low-risk patients is missing. Therefore, the aim of the analysis was to compare TAVI and SAVR in all patients who were treated for aortic valve stenosis in Germany throughout 1 year.

METHODS

The mandatory quality assurance collects data on the in-hospital outcome from all patients (n = 20,340) undergoing either SAVR or TAVI in Germany. In order to compare the different treatment approaches patients were categorized into four risk groups using the logistic EuroScore I (ES). In-hospital mortality and peri- and postprocedural complications were analyzed.

RESULTS

The in-hospital mortality did not differ between TV-AVI and SAVR in the low risk group (ES <10 %: TV-AVI 2.4 %, SAVR 2.0 %, p = 0.302) and was significantly higher for SAVR in all other risk groups (ES 10-20 %: TV-AVI 3.5 %, SAVR 5.3 %; p = 0.025; ES 20-30 %: TV-AVI 5.5 %, SAVR 12.2 %, p < 0.001; ES >30 %: TV-AVI 6.5 %, SAVR 12.9 %, p = 0.008). TA-AVI had a significantly higher mortality in all risk groups compared to TV-AVI. In comparison to SAVR, TA-AVI had a higher mortality in patients with ES <10, comparable mortality in ES 10-20 %, and lower mortality in patients with an ES >20 %. The overall stroke rate was 2.3 %. It occurred more frequently in patients with an ES <10 % treated with a transapical approach (SAVR 1.8 %, TV-AVI 1.9 %, TA-AVI 3.1 %, p < 0.01). There were no statistically significant differences in all other comparisons.

CONCLUSIONS

This study demonstrates that TAVI provides excellent outcomes in all risk categories. Compared with SAVR, TV-TAVI yields similar in-hospital mortality among low-risk patients and lower in-hospital mortality among intermediate and high-risk patient populations.