Usefullness of peak mitral regurgitation velocity to left ventricular outflow tract time velocity integral ratio as a new prognostic marker for one year and long term mortality in failing heart

Background and aim

Systemic vascular resistance (SVR) is useful for risk estimation and therapy guidance in HF. It has been showed that the ratio of peak mitral regurgitation velocity (MRV) to left ventricular outflow tract velocity-time integral (LVOT VTI) correlated positively with SVR. We aimed to assess the association of MRV/LVOT VTI ratio with established prognostic markers and its prognostic role for predicting one year and long term composite end-points in patients with HF and reduced ejection fraction (HFrEF).

Material and methods

We prospectively enrolled a total of 72 patients with HFrEF and 10 control subjects. Patients were followed up patients for median 40.5 months. Primary composite endpoint (CEP) was defined as any of these outcomes including requiring mechanical circulatory support, cardiac transplantation and all-cause mortality.

Results

CEP(+) patients had higher MRV/LVOT VTI ratio than others (0.48±0.15 vs. 0.39±0.18 p=0.012). MRV/LVOT VTI ratio was positively correlated with functional status (β=0.539, p=0<001), serum BNP level (β=0.479, p<0.001),troponin I (β=0.415, p<0.001), and Uric acid level (β=0.235 p=0.018) and negatively correlated with SEATTLE score derived life expectancy (β=−0.248, p=0.032). Adjusted with other parameters, every 0.1 increase in MRV/LVOT VTI ratio increased the one-year CEP risk by 27% and long-term CEP risk by 24.6%. In Kaplan Meier analysis, patients with MRV/LVOTVTI ratio ≥0.39 had more long-term CEP compared to others.

Conclusion

MRV/LVOT VTI ratio seemed to be useful predictor of poor prognosis associated with other established HF prognostic markers.

Figure 1

Funding Acknowledgement

Type of funding source: None

Coronary sinus diameter to inferior vena cava diameter ratio in the diagnosis of cardiac tamponade: a novel approach

Background and aim

Coronary sinus (CS) as an intrapericardial, low-pressure, thin-walled structure can be easily compressed in cardiac tamponade. Whereas, inferior vena cava (IVC) is an extrapericardial structure which dilates in tamponade as opposed to the response of CS. The inverse relationship between these two venous structures may augment their role in the evaluation of tamponade imaging. Therefore, we assessed the usefullness of computerized tomographic measures of CS diameter, and also CS to IVC ratio (CS/IVC) to predict tamponade in clinically stable patients with large pericardial effusion.

Materials and methods

66 clinically stable patients who had large pericardial effusions, were included to the study. CS diameter was measured from the point at 1 cm proximal to the CS ostium11. IVC diameter was measured from the segment between its right atrial orifice and hepatic vein.

Results

Patients with tamponade had 40% smaller CS diameter (5.3±1.8 vs 8.8±2.6 mm p<0.001) and 35% lower CS/IVC ratio (20.7±5.5 vs 34.7±10.5% p<0.001).After adjusting with other parameters, only either CS diameter or CS/IVC ratio predicted tamponade respectively. (Nagelkerke r square value for CS diameter was 53.7% and 72.1% for CS/IVC ratio). 1 mm increase in CS diameter and 1% increase in CS/IVC ratio were associated with an increased odds ratio of 59% and 39% in predicting tamponade, respectively (p value <0.001).In ROC analysis, a cut of value of 6.85 mm for CS diameter, had 82.6% sensitivity and 83.7% specificity for predicting cardiac tamponade (Area under the curve 0.879, p<0.001). Additionally, a cut of value of 27% for CS / IVC ratio had 87.0% sensitivity and 86.0% specificity for predicting cardiac tamponade (Area under the curve 0.945, p<0.001).

Conclusion

The tomographic measures of both the CS diameter and the CS/IVC ratio predicted tamponade in clinically stable patients with large pericardial effusion. Compared with CS diameter, CS/IVC ratio seemed to be a more powerful predictor of tamponade

Figure 1

Funding Acknowledgement

Type of funding source: None

The Predictive Value of PRECISE-DAPT Score for the Thrombogenic Milieu in Left Atrium and Left Atrial Appendix in the Patients with Atrial Fibrillation Planned AF Ablation

Introduction and aim

Atrial fibrillation (AF) is the most common arrhythmia in the clinical practice. In AF patients, the assessment of thromboembolic risk and the initiation of anticoagulant therapy to appropriate patients play critical role in management of these patients. Current guidelines recommend to use CHA2DS2VASC score in evaluation of thromboembolic risk. However, the effectiveness of this score has been questioned recently. This situation requires new risk indicators. Although PRECISE-DAPT score was initially constituted to determine the duration of dual antiplatelet therapy in patients with PCI, current studies have reported that this score may also predict thrombotic events. In this study, we aimed to evaluate the effectiveness of PRECISE-DAPT score to predict thrombogenic milieu by comparing with CHA2DS2VASC score in non valvular AF patients whom referred TEE before AF ablation procedure.

Method

428 patients were included in the study. The presence of grade 2–3 SEC and thrombus in left atrium and/or left atrial appendage were accepted as thrombogenic milieu. The patients were divided into two groups according to the presence of thrombogenic milieu. In addition, we constituted three groups as grade 0–1 SEC group, grade 2–3 SEC group and thrombus group to evaluate the parameters in detail.

Results

Grade 2–3 SEC was found in 36 patients and thrombus was detected in 24 patients. 60 patients was included to the thrombogenic positive (artı) group while 368 patients was included to thrombogenic milieu (−) group. PRECISE-DAPT and CHA2DS2VASC scores were higher in thrombogenic positive (artı) group In multivariate logistic regression analysis, PRECISE-DAPT score was found to be an independent predictor of thrombogenic milieu (OR: 1.145, CI:1.083–1.211, p<0,001). The comparison of ROC curves was shown that PRECISE DAPT score was higher area under curve than CHA2DS2VASC score, 0,753 and 0,649 respectively.

Conclusion

In our study, in patients performed TEE before AF ablation, PRECISE-DAPT score was found to be an independent predictor for thrombogenic milieu presented as high grade SEC and thrombus, there by thromboembolic risk. PRECISE-DAPT score seems to be more effective than CHA2DS2VASC score. In AF patients, PRECISE-DAPT score may provide additional benefit in assessment of thromboembolic risk, thus enabling a more individual and accurate anticoagulation decision in these patients.

Funding Acknowledgement

Type of funding source: None

6121Phrenic nerve injury during pulmonary vein isolation using the second-generation cryoballoon: characteristics and follow-up - The YETI registry

Background

Second-generation cryoballoon (CB2) based pulmonary vein isolation (PVI) has emerged as a safe and effective treatment option for symptomatic atrial fibrillation (AF). Although published complication rates of CB2 based-PVI are relatively low and several safety algorithms have been implemented in the protocols the most frequent complication is right-sided phrenic nerve injury (PNI). The reported incidence of PNI varies from 2–5% of patients. However data on PNI characteristics as well as follow-up is sparse.

Purpose

We aimed to evaluate the incidence, characteristics and outcome of PNI during after CB2 based-PVI in a large patients population.

Methods and results

From July 2012 to November 2018 a total of 13693 patients received CB2 or CB3 (third-generation) based-PVI in 23 EP centers (Germany: 12, China: 1, Turkey: 3, Japan: 3, USA: 1, Austria: 1, Poland: 1, Swizerland: 1). A total of 596 (4.4%) of patients experienced PNI during treatment of the right superior (84%) right inferior (15%) right middle (0.3%) (and left superior (0.3%) pulmonary veins. The mean time to PNI was 127±51 seconds and the mean temperature at the time of PNI was −49±7 °C. The target PV was isolated at time of PNI in 84% of cases. The applications were interrupted using double-stop technique in (71%). In 212/306 (52%) a CMAP was utilized.

At the end of the procedure PNI persistent in 45% of patients. Fluoroscopic or sonographic evaluation of PNI was performed 1–3 days after the procedure and revealed persistent PNI in 35% of patients. Dyspnea before discharge was reported in 18% of patients with persistent PNI. Patients follow up at 1–3, and 6–12 months included fluoroscopy and a visit in an outpatient clinic. After 1–3 months 18% of patients showed persistent PNI including 13% of patients complaining of dyspnea. After 6–12 months of follow-up including fluoroscopic evaluation PNI was persistent in 1.8% of patients while dyspnea was reported by 1.7% patients. Only 0.08% of the overall population of 13693 patients showed permanent and symptomatic PNI.

Conclusion

The incidence of PNI during CB2-based PVI is low. About 55% of PNI recovered until the end of the procedure. Most of PNI recovered within 12 months. Symptomatic permanent PNI is very rare in patients after CB2/CB3-based PVI.

Erythropoietin stimulates the coronary collateral development in patients with coronary chronic total occlusion

Objective

Erythropoietin (EPO) improves cardiac function and induces neovascularisation in post-myocardial infarction heart failure. The aim of this study was to analyse the association between the serum erythropoietin level and coronary collateral development in patients with coronary artery disease and chronic total occlusion.

Methods

A total of 168 patients consisting of 117 with coronary artery disease (CAD, (62 with chronic total occlusion (CTO), 55 without CTO)) and 51 with healthy coronary arteries were included in the study. The patients were assigned as coronary artery disease without CTO (group 0), CAD with CTO (group 1: poor collateral development, group 2: good collateral development) and normal coronary arteries (group 3).

Results

There was a significant positive correlation between serum EPO levels and the Rentrop scores in angiography (r = 0.243, p = 0.001). Similarly, a positive correlation was found between serum EPO levels and the Syntax scores (r = 0.253, p = 0.001). Echocardiography revealed a negative correlation between serum EPO levels and the cardiac ejection fraction (r = −0.210, p = 0.006).

Conclusions

Serum EPO is a useful biomarker for coronary collateral development in patients with CTO.

Nebivolol therapy improves QTc and QTcd parameters in heart failure patients

Aim

It has previously been shown that β-blocker therapy reduces QT dynamics in heart failure patients. The aim of this study was to demonstrate this improvement with the third-generation β-blocker, nebivolol.

Methods

A total of 72 heart failure patients with systolic dysfunction were included in the study. Corrected QT (QTc) and QT dispersion (QTcd) were measured manually by two independent observers at baseline and after nebivolol use (5 mg/day) in the first and third months of follow up.

Results

Both QTc and QTcd were found to be significantly reduced in the first (455.3 ± 26.7 vs 441.2 ± 25.7 ms, p < 0.001 for QTc, and 65.6 ± 5.3 vs 58.2 ± 5.6 ms, p = 0.001 for QTcd) and third months (455.3 ± 26.7 vs 436.0 ± 28.7 ms, p < 0.001 for QTc, and 65.6 ± 5.3 vs 56.0 ± 6.2 ms, p < 0.001 for QTcd) compared with baseline values.

Conclusion

Nebivolol was associated with improved QT dynamics in heart failure patients with systolic dysfunction.

Aortic Pulse Pressure and Aortic Pulsatility in Patients with Coronary Slow Flow

OBJECTIVE

Coronary slow flow (CSF) is an angiographic phenomenon characterized by delayed opacification of coronary arteries in the absence of obstructive coronary disease. Recently, increased aortic pulse pressure (PP) and aortic pulsatility were both linked to the presence of angiographic coronary artery disease. In this study aortic PP and aortic pulsatility, derived from the invasively measured ascending aortic pressure waveform, were analyzed in patients with CSF and otherwise normal epicardial coronary arteries and compared with those with completely normal coronary arteries.

METHODS

Fifty consecutive patients with CSF (35 men, mean age: 51.7 +/- 10 years) and fifty age and gender-matched controls (34 men, 51.1 +/- 9 years) were included in the study. For determination of coronary flow, the thrombosis in myocardial infarction (TIMI) frame count method was used. Blood pressure waveforms of the ascending aorta were measured during cardiac catheterization with a fluid-filled system. Aortic pulsatility was estimated as the ratio of aortic PP to mean pressure.

RESULTS

Study groups were well matched with respect to age, gender and atherosclerotic risk factors. Although systolic, diastolic and mean pressures of the ascending aorta were similar, aortic PP (60.5 +/- 19 vs. 51.7 +/- 14 mm Hg, p = 0.01) and aortic pulsatility (0.63 +/- 0.1 vs. 0.54 +/- 0.1, p = 0.006) were significantly higher in patients with CSF compared with the controls. Besides, in all subjects, corrected TIMI frame counts of all three coronary arteries correlated with both ascending aorta PP and aortic pulsatility values. No association was found between corrected TIMI frame counts of coronary arteries and aortic mean blood pressure or brachial blood pressure parameters.

CONCLUSION

Our findings suggest that CSF is, as with obstructive coronary artery disease, associated with more diffuse vascular disease rather than being an isolated finding.