Changing trends in clinical characteristics and in-hospital mortality of patients with infective endocarditis over four decades

BACKGROUND

Infective endocarditis continues to be a significant concern and may be undergoing an epidemiological transition.

METHODS

Were studied 1804 consecutive episodes of infective endocarditis between 1978 and 2022. The mean age was 48 ( ± 19), and 1162 (64%) patients were male. Temporal trends in demographic data, comorbidities, predisposing conditions, microorganisms, complications and in-hospital death have been studied over the decades (1978-1988, 1989-1999, 2000-2010 and 2011-2022). The outcomes and clinical characteristics were modeled using nonlinear cubic spline functions.

FINDINGS

Valve surgery was performed in 50% of the patients and overall in-hospital mortality was 30%. From the first to the fourth decade studied, the average age of patients increased from 29 to 57 years (p < 0.001), with significant declines in the occurrence of rheumatic valvular heart disease (15% to 6%; p < 0.001) and streptococcal infections (46% to 33%; p < 0.001). Healthcare-associated infections have increased (9% to 21%; p < 0.001), as have prosthetic valve endocarditis (26% to 53%; p < 0.001), coagulase-negative staphylococcal infections (4% to 11%; p < 0.001), and related-complications (heart failure, embolic events, and perivalvular abscess; p < 0.001). These changes were associated with a decline in adjusted in-hospital mortality from 34% to 25% (p = 0.019).

INTERPRETATION

In the 44 years studied, there was an increase in the mean age of patients, healthcare-related, prosthetic valve, coagulase-negative staphylococci/MRSA infections, and related complications. Notably, these epidemiological changes were associated with a decline in the adjusted in-hospital mortality.

Incidental Diagnosis of Rheumatic Myocarditis during Cardiac Surgery-Impact on Late Prognosis

Rheumatic fever (RF) and rheumatic heart disease (RHD) are still highly prevalent, particularly in low- and middle-income countries. RHD is a neglected and underdiagnosed disease for which no specific laboratory diagnostic test is completely reliable. This is a retrospective observational study, which included 118 patients with RHD who underwent cardiac surgery from 1985 to 2018. The aim of this investigation was to evaluate the clinical, epidemiological, echocardiographic and pathological characteristics in two cohorts of RHD patients: one cohort with Aschoff bodies present in their pathological results and the other without such histopathological characteristics. No conventional clinical and laboratory tests for RHD myocarditis were able to identify active carditis during the preoperative phase of valve repair or replacement. Patients who had Aschoff bodies in their pathological results were younger (median age of 13 years (11-24 years) vs. 27 years (17-37 years), p = 0.001) and had higher rate of late mortality (22.9% vs. 5.4%, p = 0.043). In conclusion, the presence of Aschoff bodies in pathological findings may predict increased long-term mortality, emphasizing the importance of comprehensive pathology analysis for suspected myocarditis during heart surgery.

B-type natriuretic peptide and N-terminal Pro-B-type natriuretic peptide in severe aortic stenosis: a comprehensive literature review

B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro BNP) are cardiac biomarkers that are released in response to increased ventricular and atrial wall stress. Aortic stenosis (AS) leads to hemodynamic changes and left ventricular hypertrophy and may be associated with natriuretic peptide levels. Several studies have shown that increased natriuretic peptide levels are correlated with AS severity and can predict the need for intervention. It can be useful in risk stratification, monitoring follow-up, and predicting cardiovascular outcomes of patients with severe AS. This paper aims to summarize the evidence of the role of BNP and NT-pro BNP in AS, before and after intervention.

Valvular Heart Disease Emergencies: A Comprehensive Review Focusing on the Initial Approach in the Emergency Department

Valvular heart disease (VHD) is an increasing health problem worldwide. Patients with VHD may experience several cardiovascular-related emergencies. The management of these patients is a challenge in the emergency department, especially when the previous heart condition is unknown. Specific recommendations for the initial management are currently poor. This integrative review proposes an evidence-based three-step approach from bedside VHD suspicion to the initial treatment of the emergencies. The first step is the suspicion of underlying valvular condition based on signs and symptoms. The second step comprises the attempt to confirm the diagnosis and assessment of VHD severity with complementary tests. Finally, the third step addresses the diagnosis and treatment options for heart failure, atrial fibrillation, valvular thrombosis, acute rheumatic fever, and infective endocarditis. In addition, several images of complementary tests and summary tables are provided for physician support.

Non-contrast transcatheter aortic valve implantation for patients with aortic stenosis and chronic kidney disease: a pilot study

Background

Acute kidney injury (AKI) is frequently observed after transcatheter aortic valve implantation (TAVI). Of note, it is associated with a threefold increase in all-cause and cardiac death. We propose a new non-contrast strategy for evaluating and performing the TAVI procedure that can be especially valuable for patients with aortic stenosis (AS) and chronic kidney disease (CKD) to prevent AKI.

Methods

Patients with severe symptomatic AS and CKD stage ≥3a were evaluated for TAVI using four non-contrast imaging modalities for procedural planning: transesophageal echocardiogram (TEE), cardiac magnetic resonance, multidetector computed tomography (MDCT), and aortoiliac CO₂ angiography. Patients underwent transfemoral (TF) TAVI using the self-expandable Evolut R/Pro, and the procedures were guided by fluoroscopy and TEE. Contrast MDCT and contrast injection at certain checkpoints during the procedure were used in a blinded fashion to guarantee patient safety.

Results

A total of 25 patients underwent TF-TAVI with the zero-contrast technique. The mean age was 79.9 ± 6.1 years, 72% in NYHA class III/IV, with a mean STS-PROM of 3.0% ± 1.5%, and creatinine clearance of 49 ± 7 ml/min. The self-expandable Evolut R and Pro were implanted in 80% and 20% of patients, respectively. In 36% of the cases, the transcatheter heart valve (THV) chosen was one size larger than the one by contrast MDCT, but none of these cases presented adverse events. Device success and the combined safety endpoint (at 30 days) both achieved 92%. Pacemaker implantation was needed in 17%.

Conclusion

This pilot study demonstrated that the zero-contrast technique for procedural planning and THV implantation was feasible and safe and might become the preferable strategy for a significant population of CKD patients undergoing TAVR. Future studies with a larger number of patients are still needed to confirm such interesting findings.

Risk prediction in patients with classical low-flow, low-gradient aortic stenosis undergoing surgical intervention

Introduction

Classical low-flow, low-gradient aortic stenosis (LFLG-AS) is an advanced stage of aortic stenosis, which has a poor prognosis with medical treatment and a high operative mortality after surgical aortic valve replacement (SAVR). There is currently a paucity of information regarding the current prognosis of classical LFLG-AS patients undergoing SAVR and the lack of a reliable risk assessment tool for this particular subset of AS patients. The present study aims to assess mortality predictors in a population of classical LFLG-AS patients undergoing SAVR.

Methods

This is a prospective study including 41 consecutive classical LFLG-AS patients (aortic valve area ≤1.0 cm², mean transaortic gradient <40 mmHg, left ventricular ejection fraction <50%). All patients underwent dobutamine stress echocardiography (DSE), 3D echocardiography, and T1 mapping cardiac magnetic resonance (CMR). Patients with pseudo-severe aortic stenosis were excluded. Patients were divided into groups according to the median value of the mean transaortic gradient (≤25 and >25 mmHg). All-cause, intraprocedural, 30-day, and 1-year mortality rates were evaluated.

Results

All of the patients had degenerative aortic stenosis, with a median age of 66 (60-73) years; most of the patients were men (83%). The median EuroSCORE II was 2.19% (1.5%-4.78%), and the median STS was 2.19% (1.6%-3.99%). On DSE, 73.2% had flow reserve (FR), i.e., an increase in stroke volume ≥20% during DSE, with no significant differences between groups. On CMR, late gadolinium enhancement mass was lower in the group with mean transaortic gradient >25 mmHg [2.0 (0.0-8.9) g vs. 8.5 (2.3-15.0) g; p = 0.034), and myocardium extracellular volume (ECV) and indexed ECV were similar between groups. The 30-day and 1-year mortality rates were 14.6% and 43.8%, respectively. The median follow-up was 4.1 (0.3-5.1) years. By multivariate analysis adjusted for FR, only the mean transaortic gradient was an independent predictor of mortality (hazard ratio: 0.923, 95% confidence interval: 0.864-0.986, p = 0.019). A mean transaortic gradient ≤25 mmHg was associated with higher all-cause mortality rates (log-rank p = 0.038), while there was no difference in mortality regarding FR status (log-rank p = 0.114).

Conclusions

In patients with classical LFLG-AS undergoing SAVR, the mean transaortic gradient was the only independent mortality predictor in patients with LFLG-AS, especially if ≤25 mmHg. The absence of left ventricular FR had no prognostic impact on long-term outcomes.

Multimodality imaging methods and systemic biomarkers in classical low-flow low-gradient aortic stenosis: Key findings for risk stratification

Objectives

The aim of the present study is to assess multimodality imaging findings according to systemic biomarkers, high-sensitivity troponin I (hsTnI) and B-type natriuretic peptide (BNP) levels, in low-flow, low-gradient aortic stenosis (LFLG-AS).

Background

Elevated levels of BNP and hsTnI have been related with poor prognosis in patients with LFLG-AS.

Methods

Prospective study with LFLG-AS patients that underwent hsTnI, BNP, coronary angiography, cardiac magnetic resonance (CMR) with T1 mapping, echocardiogram and dobutamine stress echocardiogram. Patients were divided into 3 groups according to BNP and hsTnI levels: Group 1 (n = 17) when BNP and hsTnI levels were below median [BNP < 1.98 fold upper reference limit (URL) and hsTnI < 1.8 fold URL]; Group 2 (n = 14) when BNP or hsTnI were higher than median; and Group 3 (n = 18) when both hsTnI and BNP were higher than median.

Results

49 patients included in 3 groups. Clinical characteristics (including risk scores) were similar among groups. Group 3 patients had lower valvuloarterial impedance (P = 0.03) and lower left ventricular ejection fraction (P = 0.02) by echocardiogram. CMR identified a progressive increase of right and left ventricular chamber from Group 1 to Group 3, and worsening of left ventricular ejection fraction (EF) (40 [31-47] vs. 32 [29-41] vs. 26 [19-33]%; p < 0.01) and right ventricular EF (62 [53-69] vs. 51 [35-63] vs. 30 [24-46]%; p < 0.01). Besides, there was a marked increase in myocardial fibrosis assessed by extracellular volume fraction (ECV) (28.4 [24.8-30.7] vs. 28.2 [26.9-34.5] vs. 31.8 [28.9-35.5]%; p = 0.03) and indexed ECV (iECV) (28.7 [21.2-39.1] vs. 28.8 [25.4-39.9] vs. 44.2 [36.4-51.2] ml/m², respectively; p < 0.01) from Group 1 to Group 3.

Conclusions

Higher levels of BNP and hsTnI in LFLG-AS patients are associated with worse multi-modality evidence of cardiac remodeling and fibrosis.

Comprehensive myocardial characterization using cardiac magnetic resonance associates with outcomes in low gradient severe aortic stenosis

AIMS

This study sought to compare cardiac magnetic resonance (CMR) characteristics according to different flow/gradient patterns of aortic stenosis (AS) and to evaluate their prognostic value in patients with low-gradient AS.

METHODS AND RESULTS

This international prospective multicentric study included 147 patients with low-gradient moderate to severe AS who underwent comprehensive CMR evaluation of left ventricular global longitudinal strain (LVGLS), extracellular volume fraction (ECV), and late gadolinium enhancement (LGE). All patients were classified as followings: classical low-flow low-gradient (LFLG) [mean gradient (MG) < 40 mmHg and left ventricular ejection fraction (LVEF) < 50%]; paradoxical LFLG [MG < 40 mmHg, LVEF ≥ 50%, and stroke volume index (SVi) < 35 ml/m2]; and normal-flow low-gradient (MG < 40 mmHg, LVEF ≥ 50%, and SVi ≥ 35 ml/m2). Patients with classical LFLG (n = 90) had more LV adverse remodelling including higher ECV, and higher LGE and volume, and worst LVGLS. Over a median follow-up of 2 years, 43 deaths and 48 composite outcomes of death or heart failure hospitalizations occurred. Risks of adverse events increased per tertile of LVGLS: hazard ratio (HR) = 1.50 [95% CI, 1.02-2.20]; P = 0.04 for mortality; HR = 1.45 [1.01-2.09]; P < 0.05 for composite outcome; per tertile of ECV, HR = 1.63 [1.07-2.49]; P = 0.02 for mortality; HR = 1.54 [1.02-2.33]; P = 0.04 for composite outcome. LGE presence also associated with higher mortality, HR = 2.27 [1.01-5.11]; P < 0.05 and composite outcome, HR = 3.00 [1.16-7.73]; P = 0.02. The risk of mortality and the composite outcome increased in proportion to the number of impaired components (i.e. LVGLS, ECV, and LGE) with multivariate adjustment.

CONCLUSIONS

In this international prospective multicentric study of low-gradient AS, comprehensive CMR assessment provides independent prognostic value that is cumulative and incremental to clinical and echocardiographic characteristics.

Splenic Abscesses in Endocarditis: A Rare Disease with High Mortality. The Experience of a Heart Institute in Brazil

INTRODUCTION

Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition.

METHODS

Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed.

RESULTS

Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%.

CONCLUSION

Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.

Long-term prognostic impact of pulmonary vascular resistance in patients with rheumatic mitral stenosis undergoing percutaneous mitral balloon valvuloplasty

Background

Pulmonary hypertension (PH) has a well-known impact on the prognosis of patients with rheumatic mitral stenosis (MS). Some patients can present pre-capillary PH, defined as a pulmonary vascular resistance (PVR) ≥3.0 woods, and there is few data regarding the prognostic value of invasive measures of PVR in this context.

Purpose

To assess the impact of PVR on the long-term outcomes of patients with rheumatic MS undergoing percutaneous mitral balloon valvuloplasty (PMBV).

Methods

Unicentric, retrospective study, including patients with rheumatic MS undergoing PMBV from 2016 to 2020. All patients underwent clinical and laboratorial evaluation, and transthoracic echocardiogram before and after the procedure. During PMBV, transesophageal echocardiogram and hemodynamic measures were performed. The composite endpoint included death, reintervention and persistent NYHA FC III–IV in long-term follow-up.

Results

58 patients were included with a median age of 50.5 [42–60.5] years and 82.8% were female. Most important comorbidities were hypertension (55.2%), previous valvular intervention (22.4%), diabetes (20.7%), atrial fibrillation (18%), previous stroke/transient ischemic attack (3.4%), coronary artery disease (1.7%). Median mitral valve area was 1.2 [0.9–1.3] cm2, mean transmitral gradient was 8 [6–12] mmHg and pulmonary artery systolic pressure (PASP) was 42 [35–51] mmHg. Pre-procedure hemodynamic right atrium pressure (RAP) was 8 [6–10] mmHg, pulmonary artery mean pressure (mPAP) was 26 [21–31] mmHg, pulmonary capillary pressure (PCP) was 18 [15–22] mmHg and PVR was 2.15 [1.5–3.46] mmHg/min. Thirty-five (60.3%) patients underwent 1 balloon dilation, 10 (17.2%) 2 dilations, 3 (5.3%) 3 dilations and 1 (1.7%) 4 dilations. Only 1 (1.7%) case need conversion to open surgery. Post-procedure hemodynamic Δ mPAP was 4 [1–8] mmHg, Δ PCP was 5 [2–7] mmHg and Δ PVR was 0.03 [−0.072–0.99] mmHg/min. Median follow-up was 32.9 [20.2–43] months. Need for reintervention (surgery or PMBV) was 6.9%, mortality during follow-up was 1.7% and the composite endpoint occurred in 13 (22.4%) patients. By univariate analysis, echocardiographic PSAP (HR: 1.069, 95% CI 1.010–1.130, p=0.021), RAP (HR: 1.267, 95% CI 1.028–1.562, p=0.027), Δ hemodynamic PASP (HR: 0.927, 95% CI 0.866–0.991, p=0.026) and moderate or severe tricuspid regurgitation (HR: 6.318, 95% CI 1.734–23.023, p=0.005) were associated with the composite endpoint. By multivariate analysis adjusted by RVP, RAP (HR: 1.626, 95% CI 1.005–2.630, p=0.047) was the only independent predictor of the composite endpoint. The RAP cutoff found through the Youden index was 9.5 mmhg (Figure 1).

Conclusion

In patients with severe MS undergoing PMBV, RAP measurement in cardiac catheterization was the only independent predictor of combined outcome of death, reintervention and persistent NYHA FC III–IV in long-term follow-up. PVR had no impact on long-term outcomes.

Funding Acknowledgement

Type of funding sources: None.

Transcatheter aortic valve implantation without contrast media technique in chronic kidney disease population – pilot study

Background/Introduction

Acute Kidney Injury (AKI) is frequently observed after Transcatheter aortic valve implantation (TAVI), with rates ranging from 3% to 50%. In the Brazilian TAVI Registry, the incidence of AKI following TAVI was 18%, with 4.5% requiring dialysis. Its occurrence is associated with an increase in 3-fold all-cause and cardiac death. Since AKI is related to the volume of contrast media, avoiding contrast during TAVI procedure is advisable, especially in chronic kidney disease (CKD) patients.

Purpose

The aims of the proposed study are to: (1) evaluate the feasibility and safety of a zero-contrast technique for CKD patients undergoing TAVI and (2) define the role of each of the non-contrast imaging modalities in the preoperative assessment for TAVI and (3) evaluate the incidence of AKI post-TAVI in this population.

Methods

Patients with severe symptomatic aortic stenosis (AS) and CKD stage ≥3a where evaluated for TAVI with four preoperative exams: transesophageal echocardiogram (TEE), cardiac magnetic resonance, contrast and noncontrast computed tomography (MDCT) and aortoiliac co2 angiography. After safety measures of transfemoral (TF) viability and aortic valve favorable anatomy, patients were submitted to TF-TAVI with self-expandable Evolut R/Pro. The contrast MDCT was blinded to the operators and it is checked before the procedure, at a safety checkpoint, to exclude high-risk conditions not detected by non-contrast methods. During the procedure, another safety checkpoint was accomplished. Clinical and echocardiographic outcomes were assessed at 30 days.

Results

Between december 2020 to december 2021, a total of 25 patients underwent TF TAVI with zero-contrast technique. Mean age of 79.9±6.1 years, 52% male, 18 patients (72%) NYHA functional class III or IV, mean STS-PROM 3.0±1.5%, 12% had severe systolic dysfunction (left ventricle ejection fraction &lt;35%) and mean creatinine clearance of 49.1±7 mL/min. Self-expandable Evolut R was implanted in 80% of patients and Evolut Pro in 20% of them, the most frequent THV size was 29 mm (52%) and the mean implant depth was 6 mm in fluoroscopy and 4.5 mm in TEE. The mean procedural time was 138±56 minutes, with a median radiation dose of 6.6 mGy/cm2 [IQR, 2–6 mGy]. Definitive pacemaker was implanted in 17% of patients and AKI was seen in 6 patients (24%), with stage I (20%), stage II (4%) and no case needed hemodialysis. At 30 days, 84% were at functional class I, there was no death, one embolization requiring a second valve and the rate of device success (VARC-2) was 92%.

Conclusion

The proposed pilot study for transfemoral TAVI in CKD population with zero contrast technique was safe, with promising results and similar rates of success and complication, compared with the conventional TAVI approach.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): MedtronicAngiodroid

Delayed left main coronary obstruction following transfemoral inovare transcatheter aortic valve replacement: A challenging case

Coronary obstruction is an uncommon and severe complication after a transcatheter aortic valve replacement (TAVR), that occurs during the procedure in the vast majority of patients. In the present case even in the absence of classic risk factors, an acute coronary syndrome occurred one day after TAVR. Selective angiography revealed a severe left main ostium obstruction by the bulky native leaflet calcification. This is the first case of delayed presentation of coronary obstruction with a transfemoral balloon-expandable valve using the Inovare bioprosthesis (Braile Biomedica, Brazil). In addition, after drug-eluting stent placement in the left main coronary, intravascular ultrasound revealed severe stent underexpansion, so that a second layer of a bare-metal stent and high-pressure balloon post-dilatation was necessary to improve the final result. The patient was discharged after 7 days, and at the 6-month follow-up remained asymptomatic. <Learning objective: This case illustrates an unusual cause of an acute coronary syndrome 24 h after a transcatheter aortic valve replacement. This is the first report of this severe complication with delayed presentation following the balloon-expandable Inovare bioprosthesis. Even in the absence of classic risk factors this complication may occur, and percutaneous coronary intervention is feasible in the vast majority of cases, often requiring various percutaneous techniques and intravascular image to improve outcomes.>.

Perfil Clínico e Desfechos em 30 Dias de Pacientes Portadores de Valva Aórtica Bicúspide Submetidos à Cirurgia em Valva Aórtica e/ou Aorta

Fundamento

A válvula aórtica bicúspide (VAB) atinge de 0,5 a 2% da população e está associada a alterações valvares e de aorta. Há carência de estudos sobre o perfil desses pacientes na população brasileira.

Objetivo

Descrever o perfil de pacientes com VAB submetidos à cirurgia valvar e/ou de aorta em um centro cardiológico terciário, assim como os desfechos relacionados à intervenção.

Métodos

Coorte retrospectiva incluindo 195 pacientes (idade média 54±14 anos, 73,8% do sexo masculino) com diagnóstico de VAB submetidos à abordagem cirúrgica (valvar e/ou de aorta) no período de 2014 a 2019. Foram avaliados dados clínicos, ecocardiográficos e tomográficos, além das características da intervenção e eventos em 30 dias. O valor de p<0,05 foi considerado estatisticamente significante.

Resultados

Encontramos alta prevalência de aneurisma de aorta (56,5%), com diâmetro médio de 46,9±10,2 mm. Insuficiência aórtica importante foi encontrada em 25,1% e estenose aórtica importante em 54,9%. Cirurgia isolada em valva aórtica foi realizada em 48,2%, cirurgia isolada de aorta em 6,7% e cirurgia combinada em 45,1%. A mortalidade em 30 dias foi de 8,2%. Na análise multivariada, os fatores preditores de desfecho combinado em 30 dias (morte, fibrilação atrial e reoperação) foram idade (OR 1,044, IC 95% 1,009-1,081, p=0,014) e o índice de massa do ventrículo esquerdo (OR 1,009, IC 95% 1,000-1,018, p=0,044).

Conclusão

Pacientes com VAB abordados no nosso serviço apresentam uma maior incidência de aortopatia, com a necessidade adicional de avaliação da aorta com tomografia computadorizada ou ressonância magnética.

Valve-in-valve procedure for bioprosthesis dysfunction in rheumatic patients: a new procedure for an old disease

Background

Bioprosthetic heart valve has a limited durability and lower long-term performance especially in rheumatic patients. The standard treatment for degenerated bioprosthesis involves redo open-heart surgery, which is associated with significant morbidity and mortality, particularly in high-risk patients. Minimally invasive procedures, as valve-in-valve (ViV) implantation, may offer an attractive therapy alternative.

Methods

The aim of this study was to evaluate the characteristics and short-term post-procedure data of rheumatic and non-rheumatic patients undergoing aortic, mitral or tricuspid ViV procedure.

Results

Single centre data-base analysis study, with prospective data collection, during the period of May 2015 to September 2020. Among 106 patients included, 69 had rheumatic etiology and 37 were non-rheumatic. Rheumatic patients had higher incidence of female sex (73.9% vs 43.2%, respectively; p=0.004) and atrial fibrillation (82.6% vs 45.9%, respectively; p&lt;0.001). There were no statistical difference regarding number of previous surgeries (2 [3–1] vs 1 [2–1], respectively; p=0.103). There was a tendency towards higher 30-day mortality in rheumatic patients (21.7% vs 5.4%, respectively; p=0.057) and device success rate was low, but similar between groups (78.3% vs 72.0%, respectively; p=0.710). Transapical access rate was also higher in rheumatic group (92.6% vs 70.3%, respectively; p=0.008);

Conclusion

Rheumatic patients tend to have a higher mortality when undergoing ViV procedures, although not statistically significant. Rheumatic patients underwent a greater number of previous valve surgeries than reported in literature, and also had high rate of transapical ViV procedure, which may have contributed to higher 30-day mortality and a lower device success rate.

Funding Acknowledgement

Type of funding sources: None.

Rheumatic myocarditis: a poorly recognized etiology of left ventricular dysfunction in valvular heart disease patients

Background

Heart failure is present in about 10% of patients with acute rheumatic fever (RF), and several studies showed that cardiac decompensation in RF results primary from valvular disease, and not due to primary myocarditis. However, literature is scarce in this topic and a recent case series showed that recurrent RF could cause ventricular dysfunction even in the absence of valvular heart disease.

Purpose

To evaluate clinical, laboratory and echocardiographic profile of rheumatic fever patients with confirmed myocarditis diagnosis using Fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) or Gallium-67 cardiac scintigraphy.

Methods

Clinical, laboratory and imaging characteristics of 25 consecutive patients with diagnosis of myocarditis, using 18F-FDG PET/CT or gallium-67 cardiac scintigraphy (Figure 1A and 1B, respectively), and RF reactivation according to revised Jones Criteria, were evaluated. Patients underwent 3 sequential echocardiograms: (1) baseline, (2) during myocarditis and (3) post- corticosteroid treatment, and were divided according to the presence (Group 1) or absence (Group 2) of reduced left ventricular ejection fraction (LVEF) during myocarditis episode.

Results

Median age was 42 (17–51) years, 64% had more than 40 years and 64% were women. Comparing patients in Group 1 (n=16) with Group 2 (n=9), there was no demographic, echocardiographic or laboratory difference between groups, except for NYHA III/IV heart failure (Group 1: 100.0% versus Group 2: 50.0%; p=0.012) and LVEF (30 [25–37] versus 56 [49–62] %, respectively; p&lt;0.001), as expected. Group 1 patients had significant reduction of LVEF during carditis with further improvement after treatment (Figure 1C). There was no correlation between LVEF and valvular dysfunction during myocarditis. Of all patients, 19 (76%) underwent 18F-FDG PET/CT, with positive scan in 68.4% and 21 (84%) underwent Gallium-67 cardiac scintigraphy, with positive uptake in 95.2%, both with no difference between groups.

Conclusion

Myocarditis due to rheumatic fever reactivation can cause left ventricular dysfunction despite of valvular disease, and is reversible after corticosteroid treatment.

Funding Acknowledgement

Type of funding sources: None. Figure 1

COVID-19 in pregnant women with heart diseases. Adverse maternal and fetal outcomes. Case series from InCor registry of Pregnancy and Heart Disease

Background

Heart disease is the leading non-obstetric cause of maternal death during pregnancy. In this field, the emergence of pandemic COVID-19 has caused the worst-case scenario considering that pregnant women are more susceptible to viral infections, and preexisting cardiac disease is the most prevalent co-morbidity among COVID-19 deaths.

Purpose

To assess the maternal and fetal outcomes of COVID-19 during pregnancy of women with heart diseases.

Methods

During the year 2020, among 82 pregnant women with heart disease followed consecutively at the Instituto do Coração-InCor, seven of them with an average age of 33.2 years had COVID-19 during their pregnancies. The underlying heart diseases were rheumatic valve disease (5 pt), congenital heart disease (1 pt) and one case with acute myocarditis, without preexisting cardiopathy. The prescription (antibiotics, inotropes, corticosteroids and others) used was according to the clinical conditions required for each patient, however subcutaneous or intravenous heparin was used in all patients.

Results

Only one case had an uneventful maternal-fetal course, the other six women required hospitalization / ICU for an average of 25.3 days, including the need for mechanical ventilation in two of them. Serious complications were related to respiratory failure (ADRS), recurrent atrial flutter with hemodynamic instability, acute pulmonary edema, and cardiogenic shock associated with sepsis which caused two maternal deaths. There were two emergency mitral valve interventional, percutaneous balloon valvuloplasty and valve bioprosthesis replacement, respectively. There were five premature births with an average gestational age of 34.2 weeks of gestation, which resulted in one stillbirth. Pathological findings of three placental and the six-months follow-up of the babies did not confirm vertical transmission of COVID-19.

Conclusions

The uncertain evolution given of the overlapping complications of three conditions – COVID-19, pregnancy, and heart disease – implies an increased risk for women with heart diseases of childbearing age, for whom pregnancy should be discouraged and planned after vaccination

FUNDunding Acknowledgement

Type of funding sources: None.

Impact of left ventricular fibrosis and longitudinal systolic strain on outcomes in low gradient aortic stenosis

Background

The clinical utility of comprehensive cardiac magnetic resonance (CMR) for the assessment of myocardial structure and function remains unknown in patients with low gradient (LG) aortic stenosis (AS).

Purpose

This study sought to compare CMR characteristics of myocardial structure and function according to different flow / gradient patterns of AS: classical low flow LG (LFLG); paradoxical LFLG; normal flow LG; and high gradient, and to evaluate their impact on the outcomes of these patients.

Methods

International multicentric prospective study included 147 patients with LG moderate to severe AS and 18 patients with high gradient severe AS who underwent comprehensive CMR evaluation of left ventricular global longitudinal strain (LVGLS), extracellular volume fraction (ECV), and late gadolinium enhancement (LGE).

Results

Patients with classical LFLG (n=90) had more LV adverse remodeling and impaired longitudinal function including higher ECV, and higher LGE and volume, and worst LVGLS, compared to other patterns of AS. Over a median follow-up of 2-years, 43 deaths and 48 composite outcomes of death or heart failure hospitalization occurred in LG AS patients. As LVGLS or ECV worsened, risks of adverse events also increased (per tertile of LVGLS: HR [95% CI] for mortality, 1.50 [1.02–2.20]; p=0.04; HR [95% CI] for composite outcome, 1.45 [1.01–2.09]; p&lt;0.05) (per tertile of ECV: HR [95% CI] for mortality, 1.63 [1.07–2.49]; p=0.02; HR [95% CI] for composite outcome, 1.54 [1.02–2.33]; p=0.04). LGE presence was also associated with higher mortality (HR [95% CI], 2.27 [1.01–5.11]; p&lt;0.05) and risk of the composite outcome (HR [95% CI], 3.00 [1.16–7.73]; p=0.02). The risk of all-cause death and of the composite outcome increased in proportion to the number of impaired components (i.e. LVGLS, ECV and LGE) (Figure) with and without adjustment for age, true severe AS, classical LFLG, and aortic valve replacement as a time-varying covariate.

Conclusions

In this international multicentric study of LG AS, comprehensive CMR assessment of myocardial structure and function provides independent prognostic value that is cumulative and incremental to clinical and echocardiographic characteristics.

Funding Acknowledgement

Type of funding sources: None.

Multimodality imaging and systemic biomarkers in classical low-flow low-gradient aortic stenosis: key findings for cardiac remodeling evaluation

Background

Elevated levels of troponin I (hsTnT) and B-type natriuretic peptide (BNP) have been related with poor prognosis in patients with LFLG-AS. Biomarkers are less expensive, more practical and more accessible than imaging tests, so their use can be an alternative to imaging in the evaluation of patients with LFLG-AS.

Purpose

The aim of the present study is to assess multimodality imaging findings according to systemic biomarkers (i.e. hsTnT and BNP) in Low-Flow, Low-Gradient Aortic Stenosis (LFLG-AS) and reduced left ventricular ejection fraction (LVEF) patients.

Methods

Prospective study with LFLG-AS patients (LVEF &lt;50%, aortic valve area ≤1,0 cm2 and mean gradient &lt;40 mmHg) that underwent hsTNnT, BNP, cardiac magnetic resonance (CMR) with T1 mapping and 2 dimensional echocardiogram (2DEcho). All patients also underwent dobutamine stress echocardiogram to define aortic stenosis severity. Patients were divided into 3 groups according to BNP and hsTnT levels: Group 1: BNP and hsTnT levels below median (BNP &lt;395 pg/ml and TnI-Ultra &lt;0.042 ng/ml); Group 2: BNP or hsTnT higher than median; and Group 3: both hsTnT and BNP higher than median.

Results

49 patients with LFLG-AS were included (Group 1: 17 patients, Group 2: 14 patients and Group 3: 18 patients). Clinical characteristics (including risk scores) were not able to stratify these groups. Patients with elevation of both biomarkers had lower valvuloarterial impedance (P=0.03), lower LVEF (P=0.02), less moderate/severe mitral (P=0.01) and tricuspid regurgitation (P&lt;0.01) by 2DEcho. CMR identified a progressive increase (from Group 1 to 3) of right and left chamber volumes; reduction in right and left ejection fraction and a marked increase in myocardial fibrosis assessed by extracellular volume (ECV) and indexed extracellular volume (iECV) (Figure 1).

Conclusion

Higher levels of BNP and hsTnT in LFLG-AS patients were associated with worse multi-modality imaging parameters and can be a surrogate of cardiac remodeling.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): No funding

Transcatheter Valve-in-Valve Procedures for Bioprosthetic Valve Dysfunction in Patients With Rheumatic vs. Non-Rheumatic Valvular Heart Disease

Background: Bioprosthetic heart valve has limited durability and lower long-term performance especially in rheumatic heart disease (RHD) patients that are often subject to multiple redo operations. Minimally invasive procedures, such as transcatheter valve-in-valve (ViV) implantation, may offer an attractive alternative, although data is lacking. The aim of this study was to evaluate the baseline characteristics and clinical outcomes in rheumatic vs. non-rheumatic patients undergoing ViV procedures for severe bioprosthetic valve dysfunction.

Methods: Single center, prospective study, including consecutive patients undergoing transcatheter ViV implantation in aortic, mitral and tricuspid position, from May 2015 to September 2020. RHD was defined according to clinical history, previous echocardiographic and surgical findings.

Results: Among 106 patients included, 69 had rheumatic etiology and 37 were non-rheumatic. Rheumatic patients had higher incidence of female sex (73.9 vs. 43.2%, respectively; p = 0.004), atrial fibrillation (82.6 vs. 45.9%, respectively; p < 0.001), and 2 or more prior surgeries (68.1 vs. 32.4%, respectively; p = 0.001). Although, device success was similar between groups (75.4 vs. 89.2% in rheumatic vs. non-rheumatic, respectively; p = 0.148), there was a trend toward higher 30-day mortality rates in the rheumatic patients (21.7 vs. 5.4%, respectively; p = 0.057). Still, at median follow-up of 20.7 [5.1–30.4] months, cumulative mortality was similar between both groups (p = 0.779).

Conclusion: Transcatheter ViV implantation is an acceptable alternative to redo operations in the treatment of patients with RHD and severe bioprosthetic valve dysfunction. Despite similar device success rates, rheumatic patients present higher 30-day mortality rates with good mid-term clinical outcomes. Future studies with a larger number of patients and follow-up are still warranted, to firmly conclude on the role transcatheter ViV procedures in the RHD population.

Demographic, cardiological, microbiologic, and dental profiles of Brazilian patients who developed oral bacteria-related endocarditis

OBJECTIVE

Infective endocarditis (IE) may cause devastating complications with high morbidity and mortality rates. The aim of the present study was to study the demographic, cardiological, microbiologic, and dental profiles of patients with oral bacteria-related IE.

STUDY DESIGN

We present a retrospective study of patients with oral bacteria-related IE treated at Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil, between January 2009 and December 2019.

RESULTS

Of the 100 patients included, 70% were male with a mean age of 45.4 years at diagnosis. The most affected sites were aortic and mitral valves, 60% in prosthetic heart valves, 34% in native valves, and 3% in pacemakers. The most common cause of valvular disease was rheumatic cardiopathy (51.9%), and the most frequent complications were valvular and perivalvular damage (26%). Streptococcus viridans was the most common species (96%), dental caries were present in 57% of the patients, 78% had tooth loss, 45% had apical periodontitis, and 77% were at high/moderate risk for periodontal disease.

CONCLUSION

Oral bacteria-related IE among Brazilians was predominant in the prosthetic heart valves of young male adults previously affected by rheumatic cardiopathy. Streptococcus viridans was the main cause of IE, which was linked to patients with a poor oral health status.

Rheumatic Myocarditis: A Poorly Recognized Etiology of Left Ventricular Dysfunction in Valvular Heart Disease Patients

Background: Heart failure occurs in ~10% of patients with acute rheumatic fever (RF), and several studies have shown that cardiac decompensation in RF results primarily from valvular disease and is not due to primary myocarditis. However, the literature on this topic is scarce, and a recent case series has shown that recurrent RF can cause ventricular dysfunction even in the absence of valvular heart disease. Methods: The present study evaluated the clinical, laboratory and imaging characteristics of 25 consecutive patients with a clinical diagnosis of myocarditis confirmed by 18F-FDG PET/CT or gallium-67 cardiac scintigraphy and RF reactivation according to the revised Jones Criteria. Patients underwent three sequential echocardiograms at (1) baseline, (2) during myocarditis and (3) post corticosteroid treatment. Patients were divided according to the presence (Group 1) or absence (Group 2) of reduced left ventricular ejection fraction (LVEF) during myocarditis episodes. Results: The median age was 42 (17-51) years, 64% of patients were older than 40 years, and 64% were women. Between Group 1 (n = 16) and in Group 2 (n = 9), there were no demographic, echocardiographic or laboratory differences except for NYHA III/IV heart failure (Group 1: 100.0% vs. Group 2: 50.0%; p = 0.012) and LVEF (30 [25-37] vs. 56 [49-62]%, respectively; p < 0.001), as expected. Group 1 patients showed a significant reduction in LVEF during carditis with further improvement after treatment. There was no correlation between LVEF and valvular dysfunction during myocarditis. Among all patients, 19 (76%) underwent 18F-FDG PET/CT, with a positive scan in 68.4%, and 21 (84%) underwent gallium-67 cardiac scintigraphy, with positive uptake in 95.2%, there was no difference between these groups. Conclusion: Myocarditis due to rheumatic fever reactivation can cause left ventricular dysfunction despite valvular disease, and it is reversible after corticosteroid treatment.

Double transcatheter balloon-expandable valve implantation for severe valve dysfunction in high-risk patients: initial experience

OBJECTIVES

Concomitant valvular heart valve disease is a frequent finding, with higher morbidity and mortality among patients undergoing redo surgical procedures. Our goal was to report our initial experience with combined transcatheter Inovare bioprosthesis implants for severe valve dysfunction.

METHODS

Among 300 transcatheter procedures, a total of 6 patients had concurrent simultaneous transcatheter bioprosthesis implants for severe mitral bioprosthesis failure (valve-in-valve), with a second valve procedure that included native aortic (n = 2) or degenerated bioprostheses in the aortic position (n = 4). During the procedures, all patients were treated with a balloon-expandable Inovare transcatheter valve, using the transapical approach.

RESULTS

Patients were highly symptomatic [New York Heart Association (NYHA) functional class IV: 100%], with a mean age of 62 ± 5 years, yielding a mean European System for Cardiac Operative Risk II (EuroSCORE II) of 24.0 ± 10.1%. There was a mean of 1.6 ± 0.4 prior valve operations/patient, with a median time from prior mitral bioprosthesis surgery of 13.0 (9.2-20.0) years. Device success was 100% according to the Mitral Valve Academic Research Consortium and the Valve Academic Research Consortium-2 criteria. During the hospital stay, only 1 patient required dialysis, and the median intensive care unit and hospital lengths of stay were 5.0 (3.2-6.7) days and 16.0 (12.2-21.2) days, respectively. No deaths occurred at 30 days; at a median follow-up of 287 (194-437) days, 1 patient died of a non-cardiac cause and the rest of patients were in NYHA functional class I or II, with normofunctioning bioprostheses.

CONCLUSIONS

Transcatheter double valve interventions using the Inovare bioprosthesis in this initial series were shown to be a reasonable alternative to redo surgical operations. The short- and mid-term clinical and echocardiographic outcomes demonstrate promising results, although future studies with a larger number of patients and longer follow-up are warranted.

The Role of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in the Diagnosis of Left-sided Endocarditis: Native vs Prosthetic Valves Endocarditis

BACKGROUND

18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) has emerged as a useful diagnostic tool for suspected infective endocarditis (IE) in patients with prosthetic valves or implantable devices. However, there is limited evidence regarding use of 18F-FDG-PET/CT for the diagnosis of native valve endocarditis (NVE).

METHODS

Between 2014 and 2017, 303 episodes of left-sided suspected IE (188 prosthetic valves/ascending aortic prosthesis and 115 native valves) were studied. 18F-FDG-PET/CT accuracy was determined in the subgroups of patients with NVE and prosthetic valve endocarditis (PVE)/ascending aortic prosthesis infection (AAPI). Associations between inflammatory infiltrate patterns and 18F-FDG-PET/CT uptake were investigated in an exploratory ad hoc histological analysis.

RESULTS

Among 188 patients with PVE/AAPI, the sensitivity, specificity, and positive and negative predictive values of 18F-FDG-PET/CT focal uptake were 93%, 90%, 89%, and 94%, respectively, while among 115 patients with NVE, the corresponding values were 22%, 100%, 100%, and 66%. The inclusion of abnormal 18F-FDG cardiac uptake as a major criterion at admission enabled a recategorization of 76% (47/62) of PVE/AAPI cases initially classified as "possible" to "definite" IE. In the histopathological analysis, a predominance of polymorphonuclear cell inflammatory infiltrate and a reduced extent of fibrosis were observed in the PVE group only.

CONCLUSIONS

Use of 18F-FDG-PET/CT at the initial presentation of patients with suspected PVE increases the diagnostic capability of the modified Duke criteria. In patients who present with suspected NVE, the use of 18F-FDG-PET/CT is less accurate and could only be considered a complementary diagnostic tool for a specific population of patients with NVE.

Non-toxigenic Corynebacterium diphtheriae infective endocarditis with embolic events: a case report

Background

Corynebacterium diphtheriae (C. diphtheriae) infections, usually related to upper airways involvement, could be highly invasive. Especially in developing countries, non-toxigenic C. diphtheriae strains are now emerging as cause of invasive disease like endocarditis. The present case stands out for reinforcing the high virulence of this pathogen, demonstrated by the multiple systemic embolism and severe valve deterioration. It also emphasizes the importance of a coordinated interdisciplinary work to address all these challenges related to infectious endocarditis.

Case presentation

A 21-year-old male cocaine drug abuser presented to the emergency department with a 1-week history of fever, asthenia and dyspnea. His physical examination revealed a mitral systolic murmur, signs of acute arterial occlusion of the left lower limb, severe arterial hypotension and acute respiratory failure, with need of vasoactive drugs, orotracheal intubation/mechanical ventilation, empiric antimicrobial therapy and emergent endovascular treatment. The clinical suspicion of acute infective endocarditis was confirmed by transesophageal echocardiography, demonstrating a large vegetation on the mitral valve associated with severe valvular regurgitation. Abdominal ultrasound was normal with no hepatic, renal, or spleen abscess. Serial blood cultures and thrombus culture, obtained in the vascular procedure, identified non-toxigenic C. diphtheriae, with antibiotic therapy adjustment to monotherapy with ampicillin. Since the patient had a severe septic shock with sustained fever, despite antimicrobial therapy, urgent cardiac surgical intervention was planned. Anatomical findings were compatible with an aggressive endocarditis, requiring mitral valve replacement for a biological prosthesis. During the postoperative period, despite an initial clinical recovery and successfully weaning from mechanical ventilation, the patient presented with a recrudescent daily fever. Computed tomography of the abdomen revealed a hypoattenuating and extensive splenic lesion suggestive of abscess. After sonographically guided bridging percutaneous catheter drainage, surgical splenectomy was performed. Despite left limb revascularization, a forefoot amputation was required due to gangrene. The patient had a good clinical recovery, fulfilling 4-weeks of antimicrobial treatment.

Conclusion

Despite the effectiveness of toxoid-based vaccines, recent global outbreaks of invasive C. diphtheriae infectious related to non-toxigenic strains have been described. These infectious could be highly invasive as demonstrated in this case. Interdisciplinary work with an institutional “endocarditis team” is essential to achieve favorable clinical outcomes in such defiant scenarios.

Obesity paradox in 12,381 patients undergoing transfemoral transcatheter aortic valve implantation: from the CENTER-collaboration

Background

Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic aortic valve stenosis. The majority of patients treated are overweight or obese. Obesity has traditionally been linked to reduced survival and worse cardiovascular outcomes. However, an “obesity paradox” has been described in some diseases, with improved survival of obese patients after invasive and surgical procedures.

Methods

The CENTER-collaboration included data from 10 registries or clinical trials of patients undergoing transfemoral TAVI from 2007 to 2018. Patients were divided in four groups according to body mass index (BMI): underweight: BMI &lt;18.5 kg/m2, normal weight: BMI 18.5 to 24.9 kg/m2, overweight: BMI 25 to 29.9 kg/m2, and obese: BMI ≥30 kg/m2. The primary endpoints of this analysis were differences in 30-day all-cause mortality and stroke after TAVI.

Results

Of the 12,381 patients analysed, 2% (n=205) were underweight, 29% (n=3552) had normal weight, 44% (n=5460) were overweight and 25% (n=3140) obese. Older patients had lower BMI (median of 84 years for underweight and 81 years for obese patients, p&lt;0.001). Cardiovascular risk factors such as hypertension, diabetes mellitus and dyslipidaemia increased progressively with increase of BMI category. As to clinical outcomes, there were no differences for stroke rates across BMI groups. In-hospital mortality was highest in patients who were underweight, namely 8.4%, compared to normal weight, overweight and obese patients (6.2%, 4.3% and 4.6% respectively, p&lt;0.001) as was 30-day mortality (9.8% compared to 6.9%, 5.3% and 5.2% respectively, p=0.001). On the other hand, extremely obese patients (BMI ≥40.0 kg/m2) also had worse prognosis, with a 30-day mortality of 7.6%.

Conclusions

In this global analysis of more than 12 000 patients undergoing transfemoral TAVI, overweight and obese patients had better in-hospital and 30-day survival than normal weight patients, confirming the obesity paradox. There was an inverted J-shaped relationship of body mass index with prognosis, with higher mortality rates for underweight and extremely obese patients.

Mortality and stroke per BMI category

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Dutch Heart Foundation; Netherlands Organisation for Health Research and Development

Biomarkers for prediction of mortality in left-sided infective endocarditis

BACKGROUND

Evidence regarding biomarkers for risk prediction in patients with infective endocarditis (IE) is limited. We aimed to investigate the value of a panel of biomarkers for the prediction of in-hospital mortality in patients with IE.

METHODS

Between 2016 and 2018, consecutive IE patients admitted to the emergency department were prospectively included. Blood concentrations of nine biomarkers were measured at admission (D0) and on the seventh day (D7) of antibiotic therapy: C-reactive protein (CRP), sensitive troponin I (s-cTnI), procalcitonin, B-type natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL), interleukin 6 (IL6), tumor necrosis factor α (TNF-α), proadrenomedullin, alpha-1-acid glycoprotein, and galectin 3. The primary endpoint was in-hospital mortality.

RESULTS

Among 97 patients, 56% underwent cardiac surgery, and in-hospital mortality was 27%. At admission, six biomarkers were independent predictors of in-hospital mortality: s-cTnI (OR 3.4; 95%CI 1.8-6.4; P<0.001), BNP (OR 2.7; 95%CI 1.4-5.1; P=0.002), IL-6 (OR 2.06; 95%CI 1.3-3.7; P=0.019), procalcitonin (OR 1.9; 95%CI 1.1-3.2; P=0.018), TNF-α (OR 1.8; 95%CI 1.1-2.9; P=0.019), and CRP (OR 1.8; 95%CI 1.0-3.3; P=0.037). At admission, S-cTnI provided the highest accuracy for predicting mortality (area under the ROC curve: s-cTnI 0.812, BNP 0.727, IL-6 0.734, procalcitonin 0.684, TNF-α 0.675, CRP 0.670). After 7 days of antibiotic therapy, BNP and inflammatory biomarkers improved their performance (s-cTnI 0.814, BNP 0.823, IL-6 0.695, procalcitonin 0.802, TNF-α 0.554, CRP 0.759).

CONCLUSION

S-cTnI concentration measured at admission had the highest accuracy for mortality prediction in patients with IE.

P929Predictors of renal function improvement in patients with chronic kidney disease undergoing TAVR

Background

Chronic kidney disease (CKD) is common among patients undergoing transcatheter aortic valve replacement (TAVR). The prognosis of CKD on TAVR outcomes has been previously documented. However, there is a paucity of data about predictors of renal function improvement and its clinical relevance.

Purpose

To determine predictors of renal function improvement after TAVR among patients with CKD.

Methods

Prospective study, analyzing 819 patients from 22 centers with symptomatic severe aortic stenosis included in the Brazilian TAVR Registry between 2008 and 2015. CKD was defined as estimated glomerular filtration rate (eGFR) <60mg/dL, and patients without CKD were excluded. Groups were divided according to variation of eGFR between baseline and 7 days after TAVR: improvement (increase >10% in eGFR) in 197 (34.1%) patients, worsening (decrease >10% in eGFR) in 203 (35.2%), and stable (neither criteria) in 177 (30.7%). Logistic regression analysis was used to identify predictors of renal function improvement. One-year outcomes were determined as Kaplan-Meier survival curves.

Results

CKD was present in 577 (70%) patients. The mean age was 81.9±6.8 years, 56.2% were male, 31.7% had diabetes and 74.5% had hypertension. The mean STS score was 10.6±7.9%, the mean EuroSCORE II were 21.8±15.2% and the preferable access site was transfemoral (93.4%). The mean eGFR was 37.3±12.5 ml/min in the improvement group (IG), 39.6±11.7 ml/min in the stable group (SG) and 40.2±12.3 ml/min in the worsening group (WG), with significant statistical difference between IG and WG (p=0.044). There was no difference related to contrast midia volume between the 3 groups. In the multivariate analysis, coronary artery disease (OR: 0.69; 95% CI 0.48–0.98; p=0.039) and baseline eGFR (OR: 0.98; 95% CI 0.97–1.00; p=0.039) were associated with improvement in renal function. There was no significant difference in 1-year all-cause mortality between IG and SG (15.4 vs 9.5%, log rank p=0.141) (Figure 1A). However, the WG had higher mortality compared with the IG (29.3 vs 15.4%, log rank p<0,001) (Figure 1B).

Figure 1

Conclusion

Improvement in renal function after TAVR was frequently found among patients with CKD. The absence of coronary artery disease and lower baseline eGFR were independent predictors of improvement in renal function. Although the IG had lower 1-year all-cause mortality compared to WG, no difference were observed related to SG.

Acknowledgement/Funding

SBHCI

P6483Predictors of contractile reserve on dobutamine stress echocardiography in patients with classical low-flow, low-gradient aortic stenosis

Background

There is a lack of information on factors that influence contractile reserve (CR) on dobutamine stress echocardiography (DSE) in patients with classical low-flow, low-gradient aortic stenosis (LFLG-AS).

Purpose

This study sought to evaluate the predictors of CR in patients with LFLG-AS.

Methods

Prospective study including 43 consecutive LFLG-AS patients (aortic valve area [AVA] ≤1.0 cm2, mean transaortic gradient <40 mmHg, left ventricular ejection fraction [LVEF] <50%) with true severe aortic stenosis. All patients underwent dobutamine stress echocardiography and T1-mapping cardiac magnetic resonance (CMR). CR was defined as an increase ≥20% in the left ventricular stroke volume at peak stress. Patients with pseudo-severe aortic stenosis were excluded.

Results

All of the patients in the study had degenerative aortic stenosis, with a median age of 67 [60–74] years, most of them being male (83.7%). A high prevalence of comorbidities was found, highlighted by diabetes (42%), hypertension (70%), atrial fibrillation (25%) and coronary artery disease (38%). Mean transaortic gradient was 25 [20–33] mmHg, AVA was 0.88 [0.68–0.95] cm2, LVEF was 35 [28–43]% and 32.6% had moderate/severe functional mitral regurgitation. CMR myocardium extracellular volume fraction (ECV) was 28.8 [26.3–33.0] %, indexed ECV was 35.4 [25.0–41.2] ml/m2, 32.6% had positive transmural delayed-enhancement images and 25.6% had positive mesocardial delayed-enhancement images. On DSE, 30 patients (69.7%) had CR and 13 patients (30.3%) had no CR. Global longitudinal strain was 10 [7–12] %, Δ indexed flow rate was 25 [3–38] ml/m2.seg and Δ mean gradient was 10 [3–16] mmHg. By multivariate analysis, moderate/severe functional mitral regurgitation (HR 0.122, 95% CI 0.020–0.759, p=0.024) and AVA (HR 0.606, 95% CI 0.396–0.925, p=0.020 [for each increase of 0.05 cm2]) were the only factors associated with CR. ECV, indexed ECV and positive transmural or mesocardial delayed-enhancement images were not associated with CR in the univariate analysis.

Conclusions

In our study, the absence of moderate/severe functional mitral regurgitation and AVA were predictors of CR on DSE in patients with LFLG-AS. As AVA was smaller in patients with CR, our finding contradicts the hypothesis that more severe aortic stenosis could also contribute to the lack of CR. Other possible factors that are surrogate of myocardium fibrosis, as ECV, indexed ECV and positive delayed-enhancement images, were not associated with the absence of CR.

Acknowledgement/Funding

FAPESP

P2273Predictors of short- and mid-term outcomes after TAVR in low-flow, low-gradient aortic stenosis

Background

There is a lack of data on outcomes in classical (C-LFLG) and paradoxical low-flow, low-gradient aortic stenosis (P-LFLG) patients undergoing TAVR.

Purpose

We aim to compare baseline characteristic and procedural outcomes between C-LFLG, P-LFLG and high-gradient aortic stenosis (HG-AS) patients undergoing TAVR.

Methods

Patients included in the Transcatheter RegistrY of aorTic valve biOprosthesis in Latin-AMerica (TRYTOM Registry) were divided in 3 groups: 1) HG-AS: mean transaortic gradient (MG) ≥40 mmHg; 2) P-LFLG: MG <40 mmHg and left ventricular ejection fraction (LVEF) ≥50%; 3) C-LFLG: MG <40 mmHg and LVEF <50%. The outcomes were evaluated at 30-days and 1-year and were classified according to definitions of the VARC-2.

Results

1040 patients were included, 677 (65%) classified as HG-AS, 223 (21%) as P-LFLG and 140 (14%) as C-LFLG. Median follow-up was 16 months (range 0–109). There were baseline differences between HG-AS, P-LFLG and C-LFLG regarding age (80±7 vs 80±5 vs 78±8 years, respectively; p=0.017), NYHA FC III and IV (61.0 vs 72.6 vs 83.6%, respectively; p<0.001), coronary artery disease (44.1 vs 47.1 vs 57.9%, respectively; p=0.012), EuroSCORE II (7.2±6.3 vs 7.5±5.0 vs 12.9±10.4%, respectively; p<0.001), LVEF (56±11 vs 61±7 vs 32±9%, respectively; p<0.001), MG (53±13 vs 30±6 vs 27±7 mmHg, respectively; p<0.001), aortic valve area (0.65±0.16 vs 0.74±0.15 vs 0.70±0.16 cm2, respectively; p<0.001) and creatinine (1.2±0.7 vs 1.1±0.5 vs 1.5±1.3 mg/dl, respectively; p<0.001). Despite these significant baseline differences, we found similar outcomes after TAVR between HG-AS, P-LFLG and C-LFLG regarding device success (89.8 vs 95.1 vs 90.7%, respectively; p=0.057), in-hospital mortality (6.1 vs 5.9 vs 11.8%, respectively; p=0.144) and all other VARC-2 major outcomes, including major bleeding, major vascular complication and disabling stroke. In addition, female sex (OR 2.13, 95% CI 1.16–3.92, p=0.014), LVEF (OR 1.02, 95% CI 1.00–1.04, p=0.039) and MG (OR 0.97, 95% CI 0.95–0.99, p=0.004) were the only predictor of device success by multivariate analysis. Furthermore, 1-year mortality was similar among the groups (9.5 vs 8.3 vs 14.3%, respectively; p=0.358; Figure 1), and by multivariate analysis, diabetes (HR 2.44, 95% CI 1.10–5.41, p=0.028), creatinine (HR 1.65, 95% CI 1.17–2.33, p=0.004), conversion to general anesthesia (HR 7.93, 95% CI 2.08–30.20, p=0.002) and post-procedure disabling stroke (HR 12.84, 95% CI 3.09–53.40, p<0.001) predicted increased 1-year mortality, irrespective on the LVEF and MG.

Conclusions

Apart from baseline differences, TAVR in P-LFLG and C-LFLG was feasible and with similar clinical outcomes when compared to HG-AS. Mid-term mortality rates was associated with diabetes, creatinine and procedure complications.

Thrombocytopenia After Transcatheter Valve-in-Valve Implantation: Prognostic Marker or Mere Finding?

Objective

To analyze the behavior of platelets after transcatheter valve-in-valve implantation for the treatment of degenerated bioprosthesis and how they correlate with adverse events upon follow-up.

Methods

Retrospective analysis of 28 patients who received a valve-in-valve implant, 5 in aortic, 18 in mitral and 5 in tricuspid positions. Data were compared with 74 patients submitted to conventional redo valvular replacements during the same period, and both groups' platelet curves were analyzed. Statistical analysis was conducted using the IBM SPSS Statistics(r) 20 for Windows.

Results

All patients in the valve-in-valve group developed thrombocytopenia, 25% presenting mild (<150.000/µL), 54% moderate (<100.000/µL) and 21% severe (<50.000/µL) thrombocytopenia. The platelet nadir was on the 4^th postoperative day for aortic ViV, 2^nd for mitral and 3^rd for tricuspid patients, with the majority of patients recovering regular platelet count. However, the aortic subgroup comparison between valve-in-valve and conventional surgery showed a statistically significant difference from the 7^th day onwards, where valve-in-valve patients had more severe and longer lasting thrombocytopenia. This, however, did not translate into a higher postoperative risk. In our study population, postoperative thrombocytopenia did not correlate with greater occurrence of adverse outcomes and only normal preoperative platelet count could significantly predict a postoperative drop >50%.

Conclusion

Although thrombocytopenia is an extremely common finding after valve-in-valve procedures, the degree of platelet count drop did not correlate with greater incidence of postoperative adverse outcomes in our study population.

Relation of mitral valve morphology to surgical repair results in patients with mitral valve prolapse: A three-dimensional transesophageal echocardiography study

BACKGROUND

The identification of predictors of mitral valve (MV) repair results is important for quality improvement in cardiac surgery. The aim of this study was to evaluate the relationship between MV morphological quantification by three-dimensional (3D) transesophageal echocardiography and mitral repair results.

METHODS

Fifty-four patients with MV prolapse who were submitted to surgical repair were divided into 2 groups according to their postoperative mitral regurgitation (MR) degree (group 1, grade 0-I MR; group 2, ≥grade II MR). Morphological parameters related to the mitral ring, dimension of leaflets and prolapse, coaptation line, distance from papillary muscles to the leaflet border and valve angles were analyzed by 3D MV quantification. Cardiac remodeling and MR quantitative parameters were also evaluated.

RESULTS

There was no correlation between 3D MV quantification and surgical results; a multivariate analysis did not show an association between morphological parameters and surgical outcome. The distance from the posteromedial papillary muscle to the leaflet border was higher (P = .038) in patients with ≥grade II postoperative MR. The left atrial diameter, left ventricular end-systolic diameter, left ventricular end-diastolic and end-systolic volumes were larger in patients with a significant residual MR (P < .05).

CONCLUSION

Three-dimensional MV quantification did not predict the postoperative MR grade; however, the distance from the posteromedial papillary muscles to the leaflet border may be related to suboptimal repair results. Furthermore, excessive cardiac remodeling was related to postoperative MR ≥ grade II, what could suggest a potential benefit of early surgical treatment.

Impact of Acute Kidney Injury on Short- and Long-term Outcomes After Transcatheter Aortic Valve Implantation

INTRODUCTION AND OBJECTIVES

Acute kidney injury (AKI) is frequently observed after transcatheter aortic valve implantation (TAVI) and is associated with higher mortality. However, the impact of AKI on long-term outcomes remains controversial. Therefore, we sought to evaluate the impact of AKI on short- and long-term outcomes following TAVI using the Valve Academic Research Consortium 2 criteria.

METHODS

Consecutive patients (n = 794) with severe aortic stenosis who underwent TAVI were included in a multicenter Brazilian registry. Logistic regression analysis was used to identify predictors of AKI. Four-year outcomes were determined as Kaplan-Meier survival curves, and an adjusted landmark analysis was used to test the impact of AKI on mortality among survivors at 12 months.

RESULTS

The incidence of AKI after TAVI was 18%. Independent predictors of AKI were age, diabetes mellitus, major or life-threatening bleeding and valve malpositioning. Acute kidney injury was independently associated with higher risk of all-cause death (adjusted HR, 2.8; 95%CI, 2.0-3.9; P < .001) and cardiovascular mortality (adjusted HR, 2.9; 95%CI, 1.9-4.4; P < .001) over the entire follow-up period. However, when considering only survivors at 12 months, there was no difference in both clinical endpoints (adjusted HR, 1.2; 95%CI, 0.5-2.4; P = .71, and HR, 0.7; 95%CI, 0.2-2.1; P = .57, respectively).

CONCLUSIONS

Acute kidney injury is a frequent complication after TAVI. Older age, diabetes, major or life-threatening bleeding, and valve malpositioning were independent predictors of AKI. Acute kidney injury is associated with worse short- and long-term outcomes. However, the major impact of AKI on mortality is limited to the first year after TAVI.

Potential of transcatheter aortic valve replacement to improve post-procedure renal function

BACKGROUND

Baseline comorbidities including renal dysfunction are frequently found in patients treated with transcatheter aortic valve replacement (TAVR) and may increase the risks of acute kidney injury (AKI), although some of them may actually improve renal function. We aimed to evaluate the potential of TAVR to acutely improve post-procedure renal function.

METHODS

This is a prospective single-center registry of consecutive patients with severe symptomatic aortic stenosis treated by transfemoral TAVR. Creatinine levels were determined at baseline and daily until hospital discharge. AKI was defined according to VARC-2 criteria. Patients who had improvement of creatinine levels >25% were classified as having TAVR induced renal function improvement (TIRFI).

RESULTS

A total of 69 patients undergoing TAVR were included, with a mean age of 83.0±7.4 years, being 24.6% diabetics, with a median STS score of 9.2 (5.1-21.6). Using the VARC-2 criteria, the majority of patients (64.6%) did not have renal impairment, while AKI was detected in 35.4% of the patients. Importantly, in those with prior severe renal dysfunction (clearance <30mL/min/1.73m²) or diabetes, AKI reached up to 50% and 56.3% of the patients, respectively. Conversely, acute kidney recovery (TIRFI) occurred in 12 patients (18.5%) being >50% in 1 patient (1.5%), and at hospital discharge the majority of the patients (88.6%) left the hospital in their original or better renal function categories.

CONCLUSION

Despite multiple comorbidities in a selected TAVR-population and the use of contrast media, TAVR did not impair renal function in a majority of patients, with a significant proportion of them rather having acute renal function improvement.