Right ventricular function and outcome in patients undergoing transcatheter mitral valve repair

Objectives

This study sought to assess the impact of right ventricular dysfunction (RVD) on event-free survival after transcatheter mitral valve repair (TMVR) for severe mitral regurgitation.

Background

The prognostic value of left and RV global longitudinal strain (LV- and RV-GLS) on cardiovascular magnetic resonance feature tracking (CMR-FT) in patients undergoing TMVR is unknown.

Methods

Consecutive TMVR patients underwent pre-procedural and follow-up CMR-FT analysis. Kaplan-Meier estimates and multivariable Cox-regression analyses were performed, using a composite endpoint of heart failure hospitalization (HFH) and death.

Results

62 patients (78.3±7.0y/o, 45% female, EuroSCORE-II: 9.6±7.1%) underwent CMR-FT prior to TMVR, 24% had concomitant tricuspid edge-to-edge repair (TTVR). On presentation, 23 (37%) patients suffered RVD, defined as RV-GLS >−20% on CMR-FT. RVD was associated with reduced LV and RV ejection fraction (LVEF: 39.2 vs. 48.7%, p=0.008, RVEF: 35.1 vs. 46.7%, p<0.001), as well as impaired LV-GLS (−14.0 vs. −19.5%, p=0.012).

Eighteen events (12 deaths, 6 HFH) occurred during follow-up (11.4±9.1 months). On multivariable Cox-regression adjusted for baseline, procedural, imaging, and biomarker data, RV but not LV-GLS was significantly associated with outcome (adj.HR 2.50, 95% CI: 1.29–4.86, p=0.007 and 1.46, 95% CI: 0.50–4.28, p=0.491, respectively). Among various definitions of RVD on echocardiography and CMR, only RV-GLS on CMR-FT was significantly associated with outcome (RV-GLS >−20%: adj.HR 7.53, 95% CI: 2.07–27.42, p=0.002), but not RVEF on CMR or echo-indices of RV function (Central Illustration).

Follow-up CMR-FT was performed in 21 (34%) patients and RV-GLS significantly improved after TMVR (−20.6 to −25.2%, p=0.016), irrespective of additional TTVR.

Conclusions

RV-GLS, as determined on CMR-FT, rather than LV-GLS or RVEF, is an independent predictor of outcome in patients undergoing TMVR.

Funding Acknowledgement

Type of funding sources: None.

Life expectancy and early to mid-term dysfunction of transcatheter aortic prostheses: incidence, modes, correlates, and outcome

Backgrounds

Bioprosthetic valve dysfunction (BVD) is a major concern regarding transcatheter aortic valve implantation (TAVI) in low-risk patients.

Aims

To assess incidence, determinants, modes, and outcome of early to mid-term BVD after TAVI in relation with life expectancy.

Methods

Consecutive TAVI recipients (2007–2020) with a post-interventional follow-up ≥1-year were prospectively included. BVD components and bioprosthetic valve failure (BVF) were assessed according to updated Valve-Academic-Research-Consortium-3 criteria. Echocardiographic and laboratory follow-up was performed prior to discharge, at 3- and 12-months, and yearly thereafter. BVD/BVF and all-cause death served as endpoints. Average life expectancy was calculated from National Open Health Data and patients were stratified according to tertiles (1st: <6.85y, 2nd: 6.85–9.7y, 3rd: >9.7y).

Results

Of 1047 patients (81.6±6.8 y/o, 52.7% female, EuroSCORE II 4.5±2.5), ≥2 follow-ups were available from 622 (serial echo cohort). After a median echo follow-up of 12.2 months, incidence rates of BVD and BVF were 8.4% [95% confidence interval 6.7–10.3], and 3.5% [2.5–4.9] per valve-year, respectively, without differences between life expectancy tertiles (Figure 1). BVD incidence was double within the first year of implant (9.9% [7.7–12.6] per valve-year; mostly non-structural VD) vs. beyond (4.8% [3.1–7.2] per valve-year; structural and non-structural VD). Valve-in-valve procedure, and stenosis severity (both p<0.05), but not age/life expectancy (p>0.5) predisposed for BVD.

After 4.4±3.0 years, mortality was 36.7%. Time-dependent BVD/BVF were independently associated with outcome for patients in the first (adjusted hazard ratio [AHR] 1.72 [1.06–2.88]/ 2.97 [1.72–6.22]) and second (AHR 1.96 [1.02–3.73]/ 2.31 [1.00–5.30]), but not the third tertile of life expectancy (AHR 1.42 [0.66–3.12]/ 1.84 [0.71–4.79]; Figure 1).

Conclusions

In this large prospective observational cohort, early to mid-term BVD after TAVI occurred at the same rate across the spectrum of life expectancy and was not prognostic among those with the longest life expectancy.

Funding Acknowledgement

Type of funding sources: None.

Supervised learning-derived tailored risk-stratification in patients with severe secondary mitral regurgitation

Background

Mitral regurgitation secondary to heart failure (sMR) has considerable impact on quality of life, heart failure (HF) rehospitalizations and mortality. A diverse burden of comorbidities suggests multifaceted aspects of individual risks. This risk-spectrum has never been studied but is essential to understand disease trajectories.

Objectives

To provide a comprehensive and structured decision-tree-like approach to risk-stratification in patients with severe sMR.

Methods

This large-scale, long-term observational study included 1317 patients with severe sMR from the entire HF spectrum (preserved, mid-range and reduced ejection fraction). Primary endpoint was all-cause mortality and survival tree analysis, a supervised learning technique, was applied to identify patient subgroups with excessive risk of mortality (Figure 1).

Results

Eight distinct subgroups that differed significantly in long-term survival were identified (Figure 2). Subgroup 7, characterized by younger age (≤66), higher hemoglobin (>12.7 g/dl) and higher albumin levels (>40.6 g/l) had the best survival. In contrast, subgroup 5 displayed a 20-fold risk of mortality (HR 95% CI: 20.38 ([0.78–38.52]), P<0.001) and presented with older age (>68 years) and low serum albumin (≤40.6 g/l) and higher NT-proBNP levels (≥9750 pg/ml). Results were consistent in internal and temporal validation.

Conclusion

Supervised machine learning reveals an unexpected heterogeneity in the sMR risk-spectrum, indicating the clinical challenges tied to severe sMR. A decision-tree-like model can guide through the risk spectrum and provide tailored risk-stratification. This structured approach provides the foundation to generate hypotheses towards improved therapeutic strategies and optimized patient care.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund

Hepatic T1-time predicts cardiovascular risk in all-comers referred for cardiovascular magnetic resonance

Background

Liver damage is frequently observed in patients with cardiovascular disease (CVD) but infrequently quantified. We hypothesized that in patients with CVD undergoing cardiac magnetic resonance (CMR), liver T1-times indicate liver damage and are associated with cardiovascular outcome.

Methods

We measured hepatic T1-times, displayed on standard cardiac T1-maps, in an all-comer CMR-cohort. At the time of CMR, we assessed validated general liver fibrosis scores. Kaplan-Meier estimates and Cox-regression models were used to investigate the association between hepatic T1-times and a composite endpoint of non-fatal myocardial infarction, heart failure hospitalization, and death.

Results

1022 participants (58±18 y/o, 47% female) were included (972 patients, 50 controls). Hepatic T1-times were 590±89ms in patients and 574±45ms in controls (p=0.052). They were significantly correlated with cardiac size and function, presence of atrial fibrillation, NT-pro-BNP levels, and gamma-glutamyl-transferase levels (p<0.001 for all). During follow-up (58±31 months), a total of 280 (29%) events occurred. On Cox-regression, high hepatic T1-times yielded a significantly higher risk for events (adj.HR 1.66 [95% CI: 1.45–1.89] per 100ms increase, p<0.001), even when adjusted for age, sex, left and right ventricular ejection fraction, NT-proBNP, and myocardial T1-time. On restricted cubic splines, we found that a hepatic T1-time exceeding 610ms was associated with excessive risk.

Conclusion

Hepatic T1-times on standard CMR scans were significantly associated with cardiac size and function, comorbidities, natriuretic peptides, and independently predicted cardiovascular mortality and morbidity. A hepatic T1-time >610ms seems to indicate excessive risk.

Funding Acknowledgement

Type of funding sources: None.

Prevalence of cardiac amyloidosis in patients undergoing transcatheter edge-to edge mitral valve repair

Introduction

Cardiac amyloidosis (CA) is associated with severe aortic stenosis, however, its prevalence in patients with severe mitral regurgitation in elderly patients is unknown.

Methods

Patients scheduled for transcatheter edge-to edge mitral valve repair (TMVR) were prospectively screened for CA using 99m technetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy and subsequent serum as well as urine free light-chain quantification in case of a positive DPD scan, defined as visual cardiac update based on the Perugini grading scale.

Results

Out of 100 patients undergoing TMVR, 28 patients (28.0%) had a positive DPD-scan (DPD+). 14 patients (14.0%) showed Perugini grade I enhancement, 9 patients (9.0%) grade II enhancement, and in 5 patients (5.0%), grade III enhancement was present. 28 patients suffered from TTR and two from AL- amyloidosis (one patient had a combination of TTR and AL-amyloidosis). When compared to patients with a negative scan (DPD-), DPD+ patients presented with similar baseline characteristics such as age (DPD- vs DPD+ 76y/o vs 77y/o, p=0.44), gender (female; 62.7% vs 50.0%, p=0.25), coronary artery disease (59.7% vs 42.9%, p=0.13), previous valve surgery (25.4% vs 14.3%, p=0.24) and atrial fibrillation (68.7% vs 78.6%, p=0.33). Also, NYHA functional class and EuroScore II were similar (NYHA ≥ III; 85.1% vs 82.1%, p=0.72, and EuroScore II 9.9±9.8% vs 7.0±4.8%, p=0.21, respectively). On echocardiography, DPD+ patients presented with more pronounced left and right ventricular hypertrophy (interventricular septum: 15mm vs 13mm, p<0.01) but similar left ventricular ejection fraction (44.9% vs 42.3%, p=0.34). At 3-months after TMVR, DPD+ patients showed significant improvement in BNP serum levels when compared to DPD- patients (DPD+ vs DPD-: +315±2569pg/ml vs −2404±8696pg/ml, p=0.03), while NYHA functional class remained unchanged (NYHA improvement ≥1 class: 57.6% vs 50.0%, p=0.52)

Conclusions

In this single centre experience, CA was highly prevalent among elderly patients with severe mitral regurgitation scheduled for TMVR. TMVR in CA patients resulted in significant improvement of NT-pro BNP levels. Future studies need to clarify the prognostic relevance of CA in this specific patient population.

Funding Acknowledgement

Type of funding sources: None.

Cardiac imaging in tafamidis-treatment patients with transthyretin amyloid cardiomyopathy

Background

Tafamidis kinetically stabilizes the tetrameric form of transthyretin (TTR) and thus may halt disease progression in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). In our explorative analysis, we aimed to investigate the treatment effect on functional capacity and cardiac biomarkers as well as cardiac function and structure using echocardiography and cardiac magnetic resonance imaging (CMR), and to compare patients treated with tafamidis with an untreated control cohort.

Methods

Consecutive ATTR-CM patients either received tafamidis 61mg (n=64) or tafamidis 20mg (n=23) or were assigned to an untreated control cohort (n=54) reflecting the natural history of the disease. Subsequently, we performed clinical, laboratory, echocardiography and CMR follow-up at a median of 9 to 12.5 months.

Results

Main results are summarized in Table 1. In brief, we observed evidence of improvement in functional capacity as measured by the 6-minute walk distance (6MWD) in tafamidis 61mg treated patients (baseline: 377.1m vs. follow-up: 383.2m, p=0.678) compared to a significant decline in mean 6MWD in untreated patients (388.1m vs. 336.4m, p=0.002; cohort comparison: p=0.005). Analysis of cardiac biomarkers revealed evidence of therapeutic response by a decrease in median NT-proBNP levels in patients treated with tafamidis 61mg (2633.0pg/mL vs. 2244.0pg/mL, p=0.366), whereas a significant increase was observed in untreated patients (2798.0pg/mL vs. 3422.0pg/mL, p<0.001; cohort comparison: p<0.001). Echocardiographic findings revealed evidence of approximate stabilization in mean left ventricular (LV) strain (−11.75% vs. −11.58%, p=0.534) and mean right ventricular (RV) strain (−14.18% vs. −13.72, p=0.377) in the tafamidis 61mg treatment cohort compared to significant deterioration of mean LV longitudinal function (−11.71% vs. −10.59%, p=0.001) and mean RV longitudinal function (−14.36% vs. −12.99%, p=0.038) in the untreated cohort (cohort comparison: p=0.030 and p=0.269). Furthermore, cardiac structural assessment by CMR showed a significant increase in mean LV mass (199.1g vs. 214.3g, p=0.040) and mean extracellular volume (50.52% vs. 55.96%, p=0.026) in untreated patients, suggesting increased progression of myocardial amyloid deposition.

Conclusion

Treatment with tafamidis in patients with ATTR-CM results in significant improvements in functional capacity and cardiac biomarkers, and shows marked benefits in functional as well as structural imaging parameters compared with an untreated control cohort.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Pfizer Inc.

Cerebral protection in TAVR – can we do without? Impact on stroke rate, length of hospital stay and 12-month mortality

 

Stroke associated with transcatheter aortic valve replacement (TAVR) is a potentially devastating complication. Until recently, the Sentinel™ Cerebral Protection System (CPS; Boston Scientific) has been the only commercially available device for mechanical prevention of TAVR-related stroke. However, its effectiveness is still undetermined.

Methods

Between January 2019 and August 2020 consecutive patients were randomly assigned to TAVR with or without Sentinel™ in a 1:1 fashion. We defined as primary endpoint clinically detectable cerebrovascular events within 72 hours after TAVR, and as secondary endpoints LOS and 12-month mortality. Logistic and linear regression analyses were used to assess associations of Sentinel™ use with endpoints.

Results

Of 411 patients (80±7 y/o, 47.4% female, EuroSCORE II 6.3±5.9%), Sentinel™ was used in 213 (51.8%), with both filters correctly deployed in 189 (46.0%). 20 (4.9%) cerebrovascular events were recorded, 10 (2.4%) of which were disabling strokes. Sentinel™ reduced cerebrovascular events in univariate analysis by 71% (OR 0.29, 95% CI 0.11–0.82; p=0.02) and after multivariate adjustment by 75% (adj. OR 0.25; 95% CI 0.08–0.80; p=0.02). Sentinel™ use was also significantly associated with shorter LOS (8.4±9.6 versus 6.7±6.1 days; p=0.03) and lower 12-month all-cause mortality (15.7% versus 7.5%, p=0.01).

Conclusions

In the present prospective all-comers TAVR cohort, Sentinel™ significantly 1) reduced cerebrovascular events, 2) shortened LOS, and 3) improved 12-month survival. These data promote the use of a CPS when implanting TAVR valves.

Funding Acknowledgement

Type of funding sources: None.

Hepatic T2-times on cardiovascular magnetic resonance imaging reflect liver fibrosis and predict outcome in an all-comer cohort

Background

Non-alcoholic fatty liver disease (NAFLD) is associated with dismal outcomes in patients with cardiac disorders but infrequently assessed by cardiologists. Cardiovascular magnetic resonance (CMR) is evolving as one-stop-shop imaging modality in cardiology, allowing for non-invasive myocardial tissue characterization by T1-mapping. On standard CMR exams, hepatic tissue is also assessable on T1-maps. However, it is unknown whether hepatic T1-times are associated with 1) myocardial T1-times, 2) established NAFLD scores, and 3) outcomes in patients referred for CMR.

Methods

In consecutive patients undergoing CMR we assessed hepatic and myocardial T1-times, and the NAFLD Fibrosis Score (NFS). Correlation analyses were used to test the association between hepatic and myocardial T1-times as well as the NFS. We used Kaplan-Meier estimates and Cox-regression models to investigate the association between hepatic T1-times and a composite endpoint of heart failure hospitalization and cardiovascular death.

Results

513 patients were included (57±18 y/o, 49% female). Hepatic T1-times were 588±98ms on average and were correlated with myocardial T1-times (r=0.42, p<0.001) and – weakly – with the NFS (r=0.11, p=0.04). Patients with severe liver fibrosis or cirrhosis (n=47) had significantly higher hepatic T1-times as compared to patients with no or mild fibrosis based on the NFS (635±197ms versus 588±80ms, p=0.02). During follow-up (100±40 months), a total of 137 (27%) events occurred. When stratified by quartiles, patients in the highest hepatic T1-time quartile (>700ms) were at higher risk for events compared to all other quartiles (log-rank, p=0.01), which was consistent across different NAFLD risk groups based on the NFS (no/mild fibrosis, indeterminant score, severe fibrosis/cirrhosis). On Cox regression analyses, higher hepatic T1-times yielded significantly higher risk estimates for events (adj. HR 1.20 [95% CI: 1.04–1.38] per 1-SD increase, p=0.01) even when adjusted for age, sex, left and right ventricular ejection fractions, and myocardial T1-times.

Conclusion

Hepatic T1-times assessed on standard CMR reflect severity of NAFLD and predict outcome on top of established risk factors, including myocardial T1-times, in an all-comer CMR cohort.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Medical University of Vienna

Right ventricular function and outcome in patients undergoing transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Background. Right ventricular dysfunction (RVD) on echocardiography has been shown to predict outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). However, a comparison with the gold standard, RV ejection fraction (EF) on cardiovascular magnetic resonance (CMR), has never been performed.

Objectives. To compare RV function parameters on echocardiography and CMR for prognostication in TAVI patients.

Methods. Consecutive patients scheduled for TAVI underwent echocardiography and CMR.  RV fractional area change (FAC), TAPSE, RV free-lateral-wall tissue Doppler (S’) and strain were assessed on echocardiography, and RVEF on CMR. Patients were prospectively followed. Adjusted regression analyses were used to report the strength of association per 1-SD decline for each RV function parameter with 1) NT-proBNP levels, 2) prolonged in-hospital stay (>14 days), and 3) a composite of heart failure hospitalization and death.

Results. 204 patients (80.9 ± 6.6y/o; 51% female; EuroSCORE-II: 6.5 ± 5.5%) were included. At a cross-sectional level, all RV function parameters were associated with NT-proBNP levels, but only FAC and RVEF were significantly associated with a prolonged in-hospital stay (adj. OR 1.98 [95%CI: 1.15-3.41], p = 0.013 and 2.29 [95%CI: 1.43-3.67], p = 0.001, respectively). A total of 56 events occurred during follow-up (mean 13.7 ± 9.5months). After adjustment for the EuroSCORE-II and NT-proBNP levels, only RVEF was significantly associated with the composite endpoint (adj. HR 1.69 [95%CI: 1.24-2.30], p < 0.001, Figure 1).

Conclusions. RVD as defined by echocardiography is associated with an advanced disease state, but fails to predict outcomes after adjustment for pre-existing clinical risk factors in TAVI patients. In contrast, RVEF on CMR is independently associated with heart failure hospitalization and death.

Abstract Figure 1. Outcome analysis

Quantification of fluid status by bioelectrical impedance spectroscopy in patients with valvular heart disease: sex matters

Background

Fluid overload, which may finally lead to cardiac decompensation, is a major threat in valvular heart disease (VHD) patients. In clinical practice, leg edema, pulmonary congestion, and rapid weight gain indicate fluid overload. However, these parameters lack both specificity and sensitivity. Bioelectrical impedance spectroscopy (BIS) is an easy, non-invasive and reliable way to determine the extent of fluid overload. BIS it already used in patients on chronic haemodialysis to guide therapy. Whether fluid status as measured by BIS is associated with outcome in VHD patients is unknown.

Methods

Stable patients with moderate or severe VHD as diagnosed by transthoracic echocardiography underwent fluid status assessment by BIS at baseline and were prospectively followed. The primary endpoint was a composition of heart failure hospitalisation and cardiovascular death. Patients with overt cardiac decompensation or on intra-venous diuretic therapy were excluded from this study. Kaplan-Meier estimates and multivariable Cox-regression analysis were used to identify sex-specific factors associated with outcome. This study was registered at clinicaltrials.gov (NCT03372512).

Results

336 patients (51.8% female, 76±13 years) were included in the study. 26.2% (3.5% moderate, 22.7% severe) suffered from aortic stenosis, 50.9% from mitral regurgitation (16.1% moderate, 34.2%severe) and 11.8% (6.2% moderate, 5.6% severe) from aortic regurgitation. A total of 68.5% of the patients additionally presented with tricuspid regurgitation.

Mean overhydration was +0.6l with no significant differences between men and women (p=0.076). We did not observe sex-specific differences in baseline characteristics with the exception of higher left-ventricular ejection fraction (p=0.007) as well as better renal function (p=0.003) in women compared to men.

During a follow-up of 433±364 days, a total of 153 events (45.7%) occurred. 102 patients (30.4%) underwent valve intervention, which was not considered as an event, and were censored from the analysis.

Sex-specific stratification of patients based on OH tertiles revealed that overhydration was associated with significantly higher event-rates in men (log-rank p=0.002, see Figure 1), but not in women (p=0.127, see Figure 2). Similarly, in the multivariate cox-regression, OH was significantly associated with outcome only in men (p=0.009) after adjustment for cardiac size and function, NT-proBNP, diabetes, coronary artery disease, NYHA functional class, renal function, and history of cardiac decompensation. In female patients, only NT-proBNP (p=0.001) was significantly associated with outcome whereas OH was not (p=0.849).

Conclusions

Fluid status, as determined with BIS, is significantly associated with outcome in male but not in female patients with VHD. Sex-specific approaches for risk assessment and fluid management should be further examined.

Survival in VHD patients

Funding Acknowledgement

Type of funding source: None

Right ventricular rather than left ventricular systolic dysfunction predicts outcome in patients undergoing transcatheter aortic valve implantation: insights from cardiac magnetic resonance imaging

Background

Right ventricular (RV) function is strongly associated with outcome in heart failure. Whether it also adds important prognostic information in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown.

Methods

We consecutively enrolled patients with severe aortic stenosis (AS) scheduled for TAVI and preprocedural cardiac magnetic resonance (CMR) imaging. Kaplan-Meier estimates and multivariate Cox regression analyses were used to identify factors associated with outcome. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint.

Results

423 consecutive patients (80.7±7.3 years; 48% female) were prospectively included, 201 (48%) underwent CMR imaging. 55 (27%) patients presented with RV systolic dysfunction (RVSD) defined by RV ejection fraction (RVEF) <45%. RVSD was associated with male sex (69 vs. 40%; p<0.001), New York Heart Association (NYHA) functional status (NYHA ≥ III: 89 vs. 57%; p<0.001), NT-proBNP serum levels (9365 vs. 2715 pg/mL; p<0.001), and history of atrial fibrillation (AF: 51 vs. 30%; p=0.005). On CMR, RVSD was associated with left ventricular (LV) volumes (end-diastolic: 187 vs. 137 mL, end-systolic: 119 vs. 53 mL; p<0.001) and EF (39 vs. 64%; p<0.001).

A total of 51 events (37 deaths, 14 hospitalizations for heart failure) occurred during follow-up (9.8±9 months). While LVSD (LVEF <50%) was not significantly associated with outcome (HR 0.83, 95% CI: 0.33 – 2.11; p=0.694), RVSD showed a strong and independent association with event-free survival by multivariate Cox regression analysis (HR 2.47, 95% CI: 1.07–5.73; p=0.035), which was adjusted for all relevant CMR parameters (LV volumes and EF), cardiovascular risk factors (sex, NYHA, AF, diabetes mellitus type II, use of diuretics), and routine biomarkers (NT-proBNP, creatinine).

Conclusions

RVSD rather than LVSD, as determined on CMR, is an important predictor of outcome in patients undergoing TAVI. RV function might thus add useful prognostic information on top of established risk factors.

Figure 1. Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

Save your brain – does the sentinel cerebral protection device work?

Background

Transcatheter aortic valve implantation (TAVI) is increasingly used for the treatment of severe symptomatic aortic stenosis (AS), also in low-risk patients. Periprocedural embolic stroke is rare, but potentially associated with considerable morbidity and mortality. Thus, there is great interest in preventing any cerebral embolic event. At present, only one cerebral embolic protection systems (CPS) is commercially available and little is known about its efficacy in preventing stroke during TAVI. The Sentinel CPS is a FDA-approved system consisting of two inter-connected filters that are placed in the brachiocephalic trunk and the left carotid artery via the right radial artery.

Material and methods

Consecutive patients undergoing TAVI between 11/2018 and 11/2019 were enrolled. Consecutive patients treated by one operator received the Sentinel device, if anatomically possible. Periprocedural stroke rate, as defined by VARC2-criteria, and mortality up to 7 days after procedure was assessed. Descriptive statistics was performed to identify baseline variables associated with elevated risk of stroke and Cox-regression analysis was used to investigate its influence on outcome.

Results

268 patients (47.4% female, 81±7 years) were included. In 74 patients (27.6%), a Sentinel CPS was used, in 63 (23.5%) it was positioned correctly in the brachiocephalic trunk and left carotid artery. Only these patients were considered Sentinel-protected. Patients with and without Sentinel presented with similar baseline characteristics with regard to age (no CPS vs CPS; 80.3 vs 81.5 years; p=0.233), sex (female 47.3% vs 47.7%; p=0.967), previous stroke (6.9% vs 3.2%; p=0.373), peripheral artery disease (9.8% vs 4.8%; p=0.305), coronary artery disease (63.1% vs 57.1%; p=0.370), and kidney function (GFR 52 vs 56 ml/min/m2; p=0.283). The EuroScore II (6% vs 6%; p=0.937), periprocedural predilation (48.3% vs 47.6; p=0.925), postdilation (29.3% vs 31.7%; p=0.707) and procedure time (59min vs 66min; p=0.152) were not different. In total, 15 strokes (5.6%) occurred, of which 9 (3.3%) were disabling strokes as defined by the VARC2-criteria. In Sentinel-protected patients undergoing TAVI, no periprocedural stroke was observed (no CPS 7.3% vs 0.0%; p=0.026).

Conclusion

Our results suggest that Sentinel CPS significantly reduces periprocedural stroke rates in patients undergoing TAVI compared to patients without CPS. However, the study population is small and randomized trials are still needed.

Funding Acknowledgement

Type of funding source: None

Acute hemodynamic effects of iatrogenic inter-atrial shunts after percutaneous edge-to-edge mitral valve repair

Background

Implantable interatrial shunt devices improve pulmonary vascular function in patients with heart failure by transferring richly oxygenated blood to the right heart. Whether iatrogenic atrial septum defects (iASDs) after percutaneous edge-to-edge mitral valve repair (pMVR) are also associated with beneficial hemodynamic effects has not been investigated.

Methods

We consecutively enrolled patients with relevant functional (FMR) and degenerative mitral regurgitation (DMR) scheduled for pMVR. Invasive hemodynamic assessments were performed prior to and immediately after the procedure.

Results

97 consecutive patients (75.4±9.1 years; 58% female) were prospectively included, 65 (66%) presented with relevant FMR. At baseline when compared to the DMR group, FMR was associated with worse left ventricular (LV) function (LV ejection fraction: 39 vs. 49%; p=0.001), higher NT-proBNP levels (7404 vs. 5214 pg/mL; p=0.023), worse renal function (serum creatinine: 1.7 vs. 1.3 mg/dL; p=0.019), and higher usage of spironolactone (68 vs. 42%; p=0.018) and sacubitril/valsartan (33 vs. 0%; p<0.001).

Following pMVR, cardiac output (CO) and systemic blood flow (Qs) increased significantly (CO: 4.6 to 5.5 L/min; p<0.001; Qs: 4.9 to 5.8 L/min; p=0.002), with more pronounced changes in the FMR subgroup (ΔCO: 1.0 vs. 0.6 L/min; Figure 1A; ΔQs: 1.2 vs. 0.1 L/min), when compared to DMR. Pulmonary blood flow (Qp) increased by 26% (4.3 to 5.4 L/min; p=0.008), accompanied by a raise in pulmonary artery (PA) oxygen (O2) saturation from 73 to 77% (p<0.001). Arterial O2 saturation levels remained unchanged (98.3 to 98.7%; p=0.165), confirming no significant changes in systemic oxygenation. These changes were associated with a slight decline in pulmonary vascular resistance (PVR: 250 to 225 dynes*sec/cm5; p=0.369, Figure 1B), and a tendency towards improvement of pulmonary compliance (PAC: 3.6 to 4.0 mL/mmHg; p=0.414).

Conclusions

Invasively measured CO, Qs, Qp, and mixed-venous PA O2 saturation increased immediately after pMVR, alongside with potentially beneficial effects on pulmonary vasculature with marked improvements in PVR and PAC. These changes were more pronounced in the FMR subgroup. Further studies are required to assess long-term hemodynamic effects and underlying mechanisms of persistent iASDs on pulmonary vascular function.

Figure 1. Invasive hemodynamics

Funding Acknowledgement

Type of funding source: None

Effects of Levosimendan on cardiac function, size and strain in heart failure patients

Levosimendan improves cardiac function in heart failure populations; however, its exact mechanism is not well defined. We analysed the short-term impact of levosimendan in heart failure patients with ischemic and non-ischemic cardiomyopathy (CMP) using multiparametric cardiac magnetic resonance (CMR). We identified 33 patients with ischemic or non-ischemic CMP who received two consecutive CMR scans prior to and within one week after levosimendan administration. Changes in LV ejection fraction (LVEF) and LV volumes, as well as changes in strain rates, were measured prior to and within one week after levosimendan infusion. LV scarring, based on late gadolinium enhancement (LGE), was correlated to changes in LV size and strain rates. Both LV endiastolic (EDV) and endsystolic volumes (ESV) significantly decreased (EDV: p=0,001; ESV: p=0,002) after levosimendan administration, with no significant impact on LVEF (p=0.41), cardiac output (p=0.61), and strain rates. Subgroup analyses of ischemic or non-ischemic CMP showed no significant differences between the groups in terms of short-term LV reverse remodeling. The presence and extent of scarring in LGE did not correlate with changes in LV size and strain rates. CMR is able to monitor cardiac effects of levosimendan infusion. Short-term follow-up of a single levosimendan infusion using CMR shows a significant decrease in LV size, but no impact on LVEF or strain measurements. There was no difference between patients with ischemic or non-ischemic CMP. Quantification of LV scarring in CMR is not able to predict changes in LV size and strain rates in response to levosimendan.

P5261Feature tracking by CMR: left ventricular dysfunction predicts outcome in heart failure with preserved ejection fraction

Objectives

To investigate the association between global longitudinal strain (GLS) using feature tracking (FT) cardiovascular magnetic resonance imaging (CMR) and prognosis in patients with heart failure and preserved ejection fraction (HFpEF).

Background

Echocardiography-based studies have demonstrated that in HFpEF left ventricular (LV) strain analyses can detect impaired systolic function despite preserved ejection fraction and might also predict outcome. CMR also allows strain analysis using FT and is furthermore the gold standard for assessment of ventricular volumes and ejection fractions. In addition, T1-mapping allows non-invasive tissue characterization. However, the prognostic relevance of FT-CMR is unknown. In addition right ventricular (RV) FT-CMR is poorly investigated.

Methods

Consecutive patients with confirmed diagnosis of HFpEF underwent CMR on a 1.5T scanner. We used dedicated software (cvi42, Circle Cardiovascular Imaging Inc.) for global longitudinal left ventricular strain (LV-GLS) in a 3D and global longitudinal RV strain (RV-GLS) in a 2D model using feature tracking (FT). In addition, we performed uni- and multivariable Cox regression using a combined endpoint of heart failure hospitalizations, and cardiovascular death to determine the prognostic relevance of FT-CMR.

Results

We included a total of 131 HFpEF patients (70.4±8.6 years old, 70.2% female). Median LV-GLS by FT-CMR was −8% [IQR: −10% to 5%] and median RV-GLS was −11.9% [IQR: −16.57% to −12.23%]. LV and RV GLS values were significantly correlated with LV and RV ejection fractions (r=−0.463, p<0.001 for LV, and r=−0.306, p=0.001 and RV, respectively). 77 (58.8%) events were recorded during a follow-up of 42.0±31.4 months. Patients with an LV-GLS worse than the median (−8%) showed a significantly reduced event-free survival rate (log-rank, p=0.009).In a multivariable Cox-regression model correcting for the strongest clinical variables, including age (HR 1.018 [0.985–1.052], p=0.290), GFR (HR 0.987 [0.975–1.000], p=0.055), diabetes (HR 1.696 [1.028–2.799], p=0.039), and 6-min-walking distance (HR 0.997 [0.995–0.999)], p=0.014), LV-GLS remained significantly associated with outcome (HR 1.093 [1.039–1.150], p=0.001) while RV-GLS had no effect on outcome (p>0.05).

Conclusions

In patients with HFpEF, LV-GLS but not RV-GLS by FT-CMR is significantly associated with cardiovascular events.

P5258Native T1 time of right ventricular insertion points by CMR: relation with invasive hemodynamics and outcome in HFPEF

Background

Increased afterload to the right ventricle (RV) has been shown to induce myocardial fibrosis at the RV insertion points (RVIPs). Such changes can be discrete but potentially detected by cardiac magnetic resonance (CMR) T1-mapping. Whether RVIP fibrosis is associated with prognosis in heart failure with preserved ejection fraction (HFpEF) is unknown.

Methods

We prospectively investigated 167 consecutive HFpEF patients, a population frequently suffering from postcapillary pulmonary hypertension (PH), who underwent CMR including T1-mapping. 92,8% also underwent right heart catheterization for hemodynamic assessment. Kaplan–Meier analysis, cox regression analysis and Spearman's rank order correlation were applied as statistical methods. The parameter with the strongest discriminative power of each group (clinical, hemodynamic and CMR) by receiver operating curve analysis was selected to the enter the multivariate cox model.

Results

Native T1 times were 995±73 ms at the anterior and 1040±90 ms at the inferior RVIP. By Spearman's rank order testing, RVIP T1 times were significantly correlated with pulmonary artery pressure (mean PAP, r=0.313 and 0.311 for anterior and inferior RVIP, respectively), pulmonary artery wedge pressure (r=0.301 and 0.251) and right atrial pressure (r=0.245 and 0.185; p for all<0.05). During a mean follow-up of 43.2±22.6 months, 30 (18.0%) subjects died. By multivariable Cox regression, NTproBNP (Hazard ratio [HR] 2.105, 95% confidence interval [CI] 1.332–3.328; p=0.001), systolic PAP (HR 1.618, 95% CI 1.175–2.230; p=0.003), and native T1 time of the anterior RVIP (HR 1.659, 95% CI 1.125–2.445; p=0.011) were significantly associated with outcome. Also, by Kaplan-Meier analysis, T1 time at the anterior RVIP had a significant effect on survival (log-rank, p=0.002).

Kaplan Meier Curve

Conclusions

Interstitial expansion of the anterior RVIP as detected by CMR T1-mapping reflects hemodynamic alterations, and is independently related with prognosis in HFpEF.