Artificial intelligence-enabled assessment of right ventricular to pulmonary artery coupling in patients undergoing transcatheter tricuspid valve intervention

AIMS

Right ventricular to pulmonary artery (RV-PA) coupling has been established as a prognostic marker in patients with severe tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve interventions (TTVI). RV-PA coupling assesses right ventricular systolic function related to pulmonary artery pressure levels, which are ideally measured by right heart catheterization. This study aimed to improve the RV-PA coupling concept by relating tricuspid annular plane systolic excursion (TAPSE) to mean pulmonary artery pressure (mPAP) levels. Moreover, instead of right heart catheterization, this study sought to employ an extreme gradient boosting (XGB) algorithm to predict mPAP levels based on standard echocardiographic parameters.

METHODS AND RESULTS

This multicentre study included 737 patients undergoing TTVI for severe TR; among them, 55 patients from one institution served for external validation. Complete echocardiography and right heart catheterization data were available from all patients. The XGB algorithm trained on 10 echocardiographic parameters could reliably predict mPAP levels as evaluated on right heart catheterization data from external validation (Pearson correlation coefficient R: 0.68; P value: 1.3 × 10-8). Moreover, predicted mPAP (mPAPpredicted) levels were superior to echocardiographic systolic pulmonary artery pressure (sPAPechocardiography) levels in predicting 2-year mortality after TTVI [area under the curve (AUC): 0.607 vs. 0.520; P value: 1.9 × 10-6]. Furthermore, TAPSE/mPAPpredicted was superior to TAPSE/sPAPechocardiography in predicting 2-year mortality after TTVI (AUC: 0.633 vs. 0.586; P value: 0.008). Finally, patients with preserved RV-PA coupling (defined as TAPSE/mPAPpredicted > 0.617 mm/mmHg) showed significantly higher 2-year survival rates after TTVI than patients with reduced RV-PA coupling (81.5% vs. 58.8%, P < 0.001). Moreover, independent association between TAPSE/mPAPpredicted levels and 2-year mortality after TTVI was confirmed by multivariate regression analysis (P value: 6.3 × 10-4).

CONCLUSION

Artificial intelligence-enabled RV-PA coupling assessment can refine risk stratification prior to TTVI without necessitating invasive right heart catheterization. A comparison with conservatively treated patients is mandatory to quantify the benefit of TTVI in accordance with RV-PA coupling.

TRI-SCORE and benefit of intervention in patients with severe tricuspid regurgitation

BACKGROUND AND AIMS

Benefit of tricuspid regurgitation (TR) correction and timing of intervention are unclear. This study aimed to compare survival rates after surgical or transcatheter intervention to conservative management according to a TR clinical stage as assessed using the TRI-SCORE.

METHODS

A total of 2,413 patients with severe isolated functional TR were enrolled in TRIGISTRY (1217 conservatively managed, 551 isolated tricuspid valve surgery, and 645 transcatheter valve repair). The primary endpoint was survival at 2 years.

RESULTS

The TRI-SCORE was low (≤3) in 32%, intermediate (4-5) in 33%, and high (≥6) in 35%. A successful correction was achieved in 97% and 65% of patients in the surgical and transcatheter groups, respectively. Survival rates decreased with the TRI-SCORE in the three treatment groups (all P < .0001). In the low TRI-SCORE category, survival rates were higher in the surgical and transcatheter groups than in the conservative management group (93%, 87%, and 79%, respectively, P = .0002). In the intermediate category, no significant difference between groups was observed overall (80%, 71%, and 71%, respectively, P = .13) but benefit of the intervention became significant when the analysis was restricted to patients with successful correction (80%, 81%, and 71%, respectively, P = .009). In the high TRI-SCORE category, survival was not different to conservative management in the surgical and successful repair group (61% and 68% vs 58%, P = .26 and P = .18 respectively).

CONCLUSIONS

Survival progressively decreased with the TRI-SCORE irrespective of treatment modality. Compared to conservative management, an early and successful surgical or transcatheter intervention improved 2-year survival in patients at low and, to a lower extent, intermediate TRI-SCORE, while no benefit was observed in the high TRI-SCORE category.

Infective endocarditis after isolated aortic valve replacement: comparison between catheter-interventional and surgical valve replacement

BACKGROUND AND AIMS

Prosthetic valve endocarditis (PVE) is the prognostically most unfavourable complication after aortic valve replacement. This study aims to contribute to a better understanding of the different pathological and therapeutical aspects between PVE following surgical (SAVR) and transcatheter aortic valve replacement (TAVI).

METHODS

All patients who had undergone primary isolated SAVR (n = 3447) or TAVI (n = 2269) at our Centre between 01/2012 and 12/2018 were analysed. Diagnosis of PVE was based on Duke criteria modified in 2015. Incidence, risk factors, pathogens, impact of complications or therapy on mortality were analysed and compared between SAVR- and TAVI-PVE.

RESULTS

PVE incidence did not differ significantly after SAVR with 4.9/100 patient-years and TAVI with 2.4/100 patient-years (p = 0.49), although TAVI patients were older (mean 80 vs. 67 years) and had more comorbidities (STS score mean 5.9 vs. 1.6) (p < 0.001). TAVI prostheses with polymer showed a 4.3-fold higher risk to develop PVE than without polymer (HR 4.3; p = 0.004). Most common pathogens were staphylococci and enterococci (p > 0.05). Propensity-score matching analysis showed that the type of aortic valve replacement had no effect on the development of post-procedural PVE (p = 0.997). One-year survival was higher in TAVI-PVE patients treated with antibiotics only compared to additional surgical therapy (90.9% vs. 33.3%; p = 0.005). In SAVR-PVE patients, both therapies were comparable in terms of survival (p = 0.861). However, SAVR-PVE patients who were not operated, despite ESC-guideline recommendation, had significantly poorer one-year survival (p = 0.004).

CONCLUSION

TAVI patients did not have a significantly higher risk to develop PVE. Our data suggest that TAVI-PVE patients in contrast to SAVR-PVE patients can more often be treated with antibiotics only, presumably due to the lack of a polymeric suture ring.

Comparison of transcatheter leaflet-approximation and direct annuloplasty in tricuspid regurgitation

BACKGROUND

Transcatheter repair emerges as a treatment option in patients with tricuspid regurgitation (TR) and high surgical risk.

AIMS

This study aimed to compare leaflet-based and annuloplasty-based transcatheter repair in patients with TR.

METHODS

In a retrospective analysis consecutive patients undergoing either transcatheter edge-to-edge repair (TEER) or direct annuloplasty (AP) for relevant TR at 2 centers were compared with respect to baseline characteristics, procedural efficacy and safety (death, myocardial infarction, procedure or device-related cardiothoracic surgery, or stroke at 30 days).

RESULTS

161 patients (57% female, median age 79 [75-82] years) with comparable clinical baseline characteristics in the TEER (n = 87) and AP (n = 74) group were examined. Baseline TR grade was significantly less severe in the TEER compared to the AP group (torrential 9.2 vs. 31.1%, p = 0.001). Technical success and improvement of TR grades were not significantly different across groups. In analysis matched for baseline TR severity, reduction of TR grade to less than moderate was significantly more common in the AP group (47.8 vs. 26.1%, p = 0.031). Major or more severe bleeding occurred in 9.2% of TEER and 20.3% of AP patients (p = 0.049) without any fatal bleedings. Major adverse events (MAE) were similar across groups with four patients (4.7%) in the TEER group and five patients (6.9%) in the AP group (p = 0.733) and 6-month survival did not differ significantly.

CONCLUSIONS

Differences observed between patients treated with TEER and AP provide first evidence for tailoring distinct transcatheter treatment techniques to individual patient characteristics.

Safety and Long-Term Outcomes of Rotablation in Patients with Reduced (<50%) Left Ventricular Ejection Fraction (rEF) (The Rota-REF Study)

Clinical outcomes in patients with reduced left ventricular systolic function undergoing rotational atherectomy (RA) for percutaneous coronary intervention (PCI) remain understudied. Our study sought to evaluate the impact of RA-PCI in patients with LV systolic dysfunction on long-term outcomes. Between 2015 and 2019, 4941 patients with reduced LV function (rEF) undergoing PCI (with or without RA) were included in the hospital database. The primary endpoint was in-hospital major adverse cardiovascular and cerebral events (MACCE). The secondary endpoint was 3-year MACCE. In-hospital MACCE rates were significantly higher in RA-PCI compared to standard PCI without RA (PCI) (7.6% vs. 3.9%, p = 0.0009). However, 3-years MACCE rates were similar in RA-PCI and PCI (26.40% vs. 26.6%, p = 0.948). In conclusion, RA-PCI in patients with rEF is feasible, safe, and shows similar long-term results to PCI.

A Stepwise Approach for Transcatheter Edge-to-Edge Repair in Very Advanced Tricuspid Regurgitation

Transcatheter edge-to-edge repair (TEER) is the most widely used approach for tricuspid regurgitation in patients with prohibitive surgical risk. However, TEER might not be feasible in advanced tricuspid regurgitation. In such cases, a stepwise approach with initial annuloplasty and subsequent TEER can be a worthwhile alternative, which is reported in this series. (Level of Difficulty: Intermediate.).

Epiphenomenon or Prognostically Relevant Interventional Target? A Novel Proportionality Framework for Severe Tricuspid Regurgitation

Background Tricuspid regurgitation (TR) frequently develops in patients with long-standing pulmonary hypertension, and both pathologies are associated with increased morbidity and mortality. This study aimed to improve prognostic assessment in patients with severe TR undergoing transcatheter tricuspid valve intervention (TTVI) by relating the extent of TR to pulmonary artery pressures. Methods and Results In this multicenter study, we included 533 patients undergoing TTVI for moderate-to-severe or severe TR. The proportionality framework was based on the ratio of tricuspid valve effective regurgitant orifice area to mean pulmonary artery pressure. An optimal threshold for tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio was derived on 353 patients with regard to 2-year all-cause mortality and externally validated on 180 patients. Patients with a tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio ≤1.25 mm²/mm Hg (defining proportionate TR) featured significantly lower 2-year survival rates after TTVI than patients with disproportionate TR (56.6% versus 69.6%; P=0.005). In contrast with patients with disproportionate TR (n=398), patients with proportionate TR (n=135) showed more pronounced mPAP levels (37.9±9.06 mm Hg versus 27.9±8.17 mm Hg; P<2.2×10^-16) and more severely impaired right ventricular function (tricuspid annular plane systolic excursion: 16.0±4.11 versus 17.0±4.64 mm; P=0.012). Moreover, tricuspid valve effective regurgitant orifice area was smaller in patients with proportionate TR when compared with disproportionate TR (0.350±0.105 cm² versus 0.770±0.432 cm²; P<2.2×10^-16). Importantly, proportionate TR remained a significant predictor for 2-year mortality after adjusting for demographic and clinical variables (hazard ratio, 1.7; P=0.006). Conclusions The proposed proportionality framework promises to improve future risk stratification and clinical decision-making by identifying patients who benefit the most from TTVI (disproportionate TR). As a next step, randomized controlled studies with a conservative treatment arm are needed to quantify the net benefit of TTVI in patients with proportionate TR.

Pathogenic gene variants in CCDC39, CCDC40, RSPH1, RSPH9, HYDIN, and SPEF2 cause defects of sperm flagella composition and male infertility

Primary Ciliary Dyskinesia (PCD) is a rare genetic disorder affecting the function of motile cilia in several organ systems. In PCD, male infertility is caused by defective sperm flagella composition or deficient motile cilia function in the efferent ducts of the male reproductive system. Different PCD-associated genes encoding axonemal components involved in the regulation of ciliary and flagellar beating are also reported to cause infertility due to multiple morphological abnormalities of the sperm flagella (MMAF). Here, we performed genetic testing by next generation sequencing techniques, PCD diagnostics including immunofluorescence-, transmission electron-, and high-speed video microscopy on sperm flagella and andrological work up including semen analyses. We identified ten infertile male individuals with pathogenic variants in CCDC39 (one) and CCDC40 (two) encoding ruler proteins, RSPH1 (two) and RSPH9 (one) encoding radial spoke head proteins, and HYDIN (two) and SPEF2 (two) encoding CP-associated proteins, respectively. We demonstrate for the first time that pathogenic variants in RSPH1 and RSPH9 cause male infertility due to sperm cell dysmotility and abnormal flagellar RSPH1 and RSPH9 composition. We also provide novel evidence for MMAF in HYDIN- and RSPH1-mutant individuals. We show absence or severe reduction of CCDC39 and SPEF2 in sperm flagella of CCDC39- and CCDC40-mutant individuals and HYDIN- and SPEF2-mutant individuals, respectively. Thereby, we reveal interactions between CCDC39 and CCDC40 as well as HYDIN and SPEF2 in sperm flagella. Our findings demonstrate that immunofluorescence microscopy in sperm cells is a valuable tool to identify flagellar defects related to the axonemal ruler, radial spoke head and the central pair apparatus, thus aiding the diagnosis of male infertility. This is of particular importance to classify the pathogenicity of genetic defects, especially in cases of missense variants of unknown significance, or to interpret HYDIN variants that are confounded by the presence of the almost identical pseudogene HYDIN2.

Right coronary artery deformation and injury following tricuspid valve surgery

Background

Due to its close anatomical proximity to the annular plane of the tricuspid valve (TV), the right coronary artery (RCA) is at risk of injury and distortion during surgical and interventional repair. Recently, reversible, non-flow limiting, purse-string like deformations of the RCA following percutaneous TV annuloplasty have been described. In contrast, there are only anecdotal reports on RCA deformation following conventional TV surgery.

Materials and methods

A retrospective analysis of all patients undergoing TV surgery in our hospital between 2009 and 2019 was performed including all patients who received a post-operative coronary angiography (POCA). Angiographic footage was reviewed for RCA affections.

Results

A total of 1,383 patients underwent TV surgery (replacement and repair) for tricuspid regurgitation in our center. TV repair was performed in 1,248 (90.2%) patients and 135 (9.8%) patients underwent isolated TV surgery. Sixty-five patients (4.7%) underwent POCA within 48 h after surgery due to suspected myocardial ischemia, representing the final study population. Mean age was 70.3 ± 11.3 years, 56.3% were female. Mean EuroSCORE II was 9.8 ± 11.6%. Patients with the need for POCA due to suspected myocardial injury suffered from a higher mortality compared to event-free patients over the long-term follow up period (median 2.9 years) regardless of the observed coronary status. RCA affections were observed in 24 (36.9%) patients. A new RCA deformation without flow-impairment or vascular damage was found in 16 (24.6%) of the cases and was managed conservatively. There was no significantly worse outcome observed as compared to patients without RCA affections. Six (9.2%) patients showed an RCA deformation accompanied by subtotal occlusion. A complete RCA-occlusion was observed in 2 (3.1%) patients. Revascularization by percutaneous coronary intervention could be successfully performed in these patients. RCA deformation occurred exclusively after TV repair while no cases were observed after TV replacement.

Conclusion

Right coronary artery deformation without flow-limitation following surgical TV repair is a specific/typical phenomenon which might not impair patients’ outcome and could be managed conservatively in most of the cases. RCA injury indicating further interventional therapy is a rare complication of TV surgery. However, the need for immediate POCA in general appears to be associated with a worsened intermediate-term outcome.

Sekundäre AV-Klappeninsuffizienzen – Stellenwert der interventionellen Therapie

Sekundäre Mitral- und Trikuspidalklappeninsuffizienzen treten häufig im Kontext des Herzinsuffizienz-Syndroms auf durch geometrische oder funktionelle Veränderungen der Herzkammern und/oder -vorhöfe trotz strukturell intakter Klappe. Durch Volumenbelastung der Ventrikel können diese entscheidend zur Symptomatik und Progression der Herzinsuffizienz beitragen und sind dadurch von erheblicher prognostischer Bedeutung. Aufgrund des hohen OP-Risikos waren die Therapieoptionen traditionell oft auf eine Behandlung der Herzinsuffizienz beschränkt. Die Entwicklung von kathetergestützten Techniken ermöglicht die Behandlung der sekundären AV-Klappeninsuffizienz mit akzeptablem Risiko und ist aufgrund aktueller Studienergebnisse ein wichtiger Bestandteil der Herzinsuffizienz-Therapie. Im Folgenden geben wir einen Überblick über interventionelle Strategien zur Behandlung der sekundären AV-Klappeninsuffizienzen und deren aktuellen Stellenwert in der klinischen Praxis.

High-sensitivity cardiac troponin I after coronary artery bypass grafting for post-operative decision-making

AIMS

Current troponin cut-offs suggested for the post-operative workup of patients following coronary artery bypass graft (CABG) surgery are based on studies using non-high-sensitive troponin assays or are arbitrarily chosen. We aimed to identify an optimal cut-off and timing for a proprietary high-sensitivity cardiac troponin I (hs-cTnI) assay to facilitate post-operative clinical decision-making.

METHODS AND RESULTS

We performed a retrospective analysis of all patients undergoing elective isolated CABG at our centre between January 2013 and May 2019. Of 4684 consecutive patients, 161 patients (3.48%) underwent invasive coronary angiography after surgery, of whom 86 patients (53.4%) underwent repeat revascularization. We found an optimal cut-off value for peak hs-cTnI of >13 000 ng/L [>500× the upper reference limit (URL)] to be significantly associated with repeat revascularization within 48 h after surgery, which was internally validated through random repeated sampling with 1000 iterations. The same cut-off also predicted 30-day major adverse cardiovascular events and all-cause mortality after a median follow-up of 3.1 years, which was validated in an external cohort. A decision tree analysis of serial hs-cTnI measurements showed no added benefit of hs-cTnI measurements in patients with electrocardiographic or echocardiographic abnormalities or haemodynamic instability. Likewise, early post-operative hs-cTnI elevations had a low yield for clinical decision-making and only later elevations (at 12-16 h post-operatively) using a threshold of 8000 ng/L (307× URL) were significantly associated with repeat revascularization with an area under the curve of 0.92 (95% confidence interval 0.88-0.95).

CONCLUSION

Our data suggest that for hs-cTnI, higher cut-offs than currently recommended should be used in the post-operative management of patients following CABG.

Pre-Procedural Right Ventricular Longitudinal Strain and Post-Procedural Tricuspid Regurgitation Predict Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI)

Background: Right ventricular (RV) dysfunction has been linked to worse outcomes in patients undergoing TAVI. Assessment of RV function is challenging due to its complex morphology. RV longitudinal strain (LS) assessed by speckle-tracking echocardiography (STE) is a novel measure that may overcome most of the limitations of conventional echocardiographic parameters of RV function. The aim of current study was to assess the prognostic value of RV LS in patients undergoing TAVI and to assess echocardiographic predictors of long-term mortality. Methods and results: A retrospective analysis of all consecutive patients who underwent TAVI at our hospital between 1 January 2015 and 1 June 2016. Indication for TAVI was approved by a local heart-team. Echocardiographic data at baseline and after TAVI were re-analyzed and RV LS was measured in all patients with adequate image quality. A total of 229 patients were included in our study (mean age 83.8 ± 5 years, 62% women, mean EuroSCORE II 5.7 ± 5%). All-cause mortality occurred in 17.3% over a mean follow-up of 929 ± 373 days. In multivariate analysis, only baseline average RV free-wall LS (HR 1.05, 95% CI (1.01 to 1.10), p = 0.049) and more than mild tricuspid valve regurgitation (TR) after TAVI (HR 4.39, 95% CI (2.22 to 8.70), p < 0.001) independently increased the risk of all-cause mortality at long- term follow-up (2.5 years), while conventional echocardiographic parameters of RV function did not predict mortality. Conclusion: Pre-procedural RV LS and post-procedural tricuspid regurgitation significantly predicted long-term all-cause mortality in patients undergoing TAVI while conventional echocardiographic parameters of RV function failed in predicting long-term outcome. RV longitudinal strain by STE should be considered in the routine echocardiographic assessments of patients with severe AS.

Impact of impaired renal function on kinetics of high-sensitive troponin I (hs-cTnI) following cardiac surgery

Background

Renal insufficiency might result in increased levels of cardiac troponin due to decreased elimination. Hence, the diagnostic utility of hs-cTnI might be lower in patients with impaired renal function. There is only scarce data on kinetics of high-sensitivity cardiac troponin I (hs-cTnI) following cardiac surgery with regard to renal function.

Purpose

The aim of this study was to assess the impact of impaired renal function on the kinetics of hs-cTnI following cardiac surgery differentiating between patients with and without postoperative myocardial infarction (PMI) and to analyze the prognostic value of hs-cTnI elevations in patients with impaired renal function.

Methods

We performed a retrospective analysis of all adult patients (&gt;18 years) who underwent cardiac surgery at our hospital between Jan, 1st 2013 and May, 1st 2019.

Serial measurements of high-sensitive cardiac troponin I (hs-cTnI) were assessed from baseline up to 48 hours after surgery. Renal function was assessed based on estimated glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) formula with impaired renal function defined by GFR &lt;60 ml/min. Postoperative myocardial infarction was defined by new vessel occlusion on angiography. Predictors of long-term all-cause mortality were assessed by cox regression analysis.

Results

A total of 14,465 patients were included (51.4% underwent coronary artery bypass grafting (CABG), 39.4% had valvular procedures and 9.2% thoracic aortic procedures).

Levels of hs-cTnI were higher in patients with impaired renal function in the overall collective (figure 1). However, in patients with postoperative myocardial infarction levels of hs-cTnI did not differ with regard to renal function (figure 2).

Cox regression analysis showed postoperative elevation of hs-cTnI to be a significant predictor of long-term all-cause mortality over a median follow-up of 3.0 years regardless of baseline kidney function (Hazards ratio 1.67, 95% Confidence interval [1.46–1.91], p&lt;0.001).

Conclusion

Renal function had an impact on postoperative hs-cTnI kinetics only in patients with an uneventful postoperative course. In patients with postoperative myocardial infarction kinetics of hs-cTnI were not affected by baseline renal function. Moreover, elevated hs-cTnI levels were a significant predictor of all-cause mortality regardless of baseline renal function.

Funding Acknowledgement

Type of funding sources: None.

Prevalence of Sleep Disordered Breathing in Patients with Primary Mitral Regurgitation Undergoing Mitral Valve Surgery

BACKGROUND

Sleep disordered breathing (SDB) is a frequent comorbidity in cardiac disease patients. Nevertheless, the prevalence and relationship between SDB and severe primary mitral regurgitation (PMR) has not been well investigated to date.

METHODS

A cohort of 121 patients with significant PMR undergoing mitral valve surgery were prospectively enrolled and received a cardiorespiratory single night polygraphy screening using ApneaLink before surgery. Eighty-two of them underwent a follow-up examination including a follow-up single-night sleep study 3 months after surgery.

RESULTS

The mean age of patients was 65.3 ± 12.0 years. Sixty patients (49.6%) were female. The mean EuroSCORE II was 2.5 ± 2.4%. Initially, 91 (75.2%) patients presented with SDB, among whom 50.4% (46 patients, 38.0% of total cohort) were classified as moderate to severe. These patients tended to require significantly longer postoperative intensive care and mechanical ventilation. Among the 82 patients who completed follow-up exams, mitral valve surgery led to a significant reduction in relevant SDB (20.7%). The apnea-hypopnea index (from 11/h [4;18] to 4/h [3;14] (p = 0.04)), the oxygenation-desaturation index (from 8/h [3;18] to 5/h [3;12] (p = 0.008)) as well as the saturation time below 90% (from 32 min [13;86] to 18 min [5;36] (p = 0.005)), were all shown to be improved significantly.

CONCLUSION

The prevalence of SDB is very high in patients with severe primary mitral regurgitation and may contribute to postoperative complications and prolonged intensive care. A significantly reduced but still high prevalence of SDB was observed 3 months after mitral valve surgery, highlighting the bidirectional relationship between SDB and heart failure.

Catheter ablation for atrial fibrillation in patients with end-stage heart failure and eligibility for heart transplantation

Aims

Timely referrals for transplantation and left ventricular assist device (LVAD) play a key role in favourable outcomes in patients with advanced heart failure (HF). The purpose of the Catheter Ablation for atrial fibrillation in patientS with end‐sTage heart faiLure and Eligibility for Heart Transplantation (CASTLE‐HTx) trial is to test the hypothesis that atrial fibrillation (AF) ablation has beneficial effects on mortality and morbidity during ‘waiting time’ for heart transplantation (HTx) or to prolong the time span until LVAD implantation.

Methods and Results

CASTLE‐HTx is a randomized evaluation of ablative treatment of AF in patients with severe left ventricular dysfunction who are candidates and eligible for HTx. The primary endpoint is the composite of all‐cause mortality, worsening of HF requiring a high urgent transplantation, or LVAD implantation. The secondary study endpoints are all‐cause mortality, cardiovascular mortality, cerebrovascular accidents, worsening of HF requiring unplanned hospitalization, AF burden reduction, unplanned hospitalization due to cardiovascular reason, all‐cause hospitalization, quality of life, number of delivered implantable cardioverter defibrillator therapies, time to first implantable cardioverter defibrillator therapy, number of device‐detected ventricular tachycardia/ventricular fibrillation episodes, left ventricular function, exercise tolerance, and percentage of right ventricular pacing. Ventricular myocardial tissue will be obtained from patients who will undergo LVAD implantation or HTx to assess the effect of catheter ablation on human HF myocardium. CASTLE‐HTx will randomize 194 patients over a minimum time period of 2 years.

Conclusions

CASTLE‐HTx will determine if AF ablation has beneficial effects on mortality in patients with end‐stage HF who are eligible for HTx.

Usefulness of troponin in selecting patients for invasive coronary angiography after cardiac surgery

Background

Great uncertainty exists about the indication for invasive coronary angiography (ICA) in patients with suspected acute coronary syndrome following cardiac surgery.

Aim

The aim of this study was to define clinical criteria that best identify patients who benefit from ICA after cardiac surgery.

Methods

We performed a retrospective analysis of all patients who underwent cardiac surgery between January 2009 and May 2019 at our center. Exclusion criteria included pediatric patients as well as pacemaker, TAVR and LVAD implantation and heart transplantation procedures. The primary outcome was usefulness of ICA as defined by consequent PCI or re-operation due to ICA findings. ECG changes (ST-elevations) and high-sensitivity Troponin I (hsTrop I) were analyzed.

Results

48,136 patients were screened and after applying exclusion criteria 29,359 patients were finally included in the analysis (mean age 67.8±11.0 years, 31.1% females, Euroscore II 5.14±8.9%). A total of 1,171 patients (4%) underwent post-op ICA. The primary outcome occurred in 440 patients (1.5%) of which 290 underwent consequent PCI and 214 underwent consequent re-operation. Baseline characteristics are shown in table 1. Unadjusted analyses did not identify significant differences in the level of cardiac biomarkers between useful-ICA and unuseful-ICA groups.

In multivariate regression analysis, only ST-elevation on ECG predicted the primary outcome (OR 1.33, 95% CI 1.003–1.76).

Dichotomizing hsTrop I concentrations by applying the guideline-specified cut-off (&gt;70x URL) resulted in correct classification of useful-ICA patients in 95.7%. However, the false-positive rate was also extremely high (83.6%) with a positive predictive value (PPV) of 1.6% and a negative predictive value (NPV) of 99.6% (accuracy 17.5%).

Using area under the curve (ROC) analysis following optimal cut-off values for hsTrop I were identified: in CABG patients a cut-off value of &gt;650x URL (corresponding absolute value 17000 ng/L) was defined with a corresponding sensitivity of 83.3%, specificity of 83.6%, PPV of 8.9% and NPV of 99.6% (accuracy 83.6%). In non-CABG patients (i.e. valve or aortic procedures), the cut-off was about twice as high as that for CABG patients (1,350x URL or 35,000 ng/L) with a corresponding sensitivity of 84.1%, specificity of 89.2%, PPV of 5.9% and NPV of 99.9% (accuracy 89.1%).

Conclusion

Our study demonstrates that currently recommended cut-off concentrations of high-sensitivity troponin are not useful for guiding clinical decision-making in patients with suspected acute coronary syndrome following cardiac surgery, while substantially higher cut-off values might be useful. Those cut-off values critically depend on the type of cardiac surgery performed (CABG vs. non-CABG).

Troponin_Curves post-op

Funding Acknowledgement

Type of funding source: None

Myocardial adaptation as assessed by speckle tracking echocardiography after isolated mitral valve surgery for primary mitral regurgitation

The risk of left ventricular (LV) and right ventricular (RV) maladaptation after surgery for isolated primary mitral regurgitation (PMR) is poorly defined. We aimed to evaluate LV and RV contractile function using speckle-tracking analysis alongside with quantification of exercise tolerance in patients with PMR after mitral valve surgery. All consecutive patients with symptomatic PMR undergoing mitral valve surgery between July 2015 and May 2017 were prospectively enrolled. Sequential echocardiographic studies along with clinical assessment were performed before and three months after surgery. Mean age in 138 patients was 65.8 ± 12.7 years, 48.2% (66) of whom were female. Mean LV ejection fraction decreased from 57 ± 12% to 50 ± 11% (p < 0.001), LV global longitudinal strain deteriorated from -19.2 ± 4.1% to -15.7 ± 3.8% (p < 0.001), and mechanical strain dispersion increased from 88 ± 12 to 117 ± 115 ms (p = 0.004). There was a reduction in tricuspid annulus plane systolic excursion from 22 ± 5 mm to 18 ± 4 mm (p < 0.001), as well as a slight deterioration of RV free wall mean longitudinal strain from -16.9 ± 5.6% to -15.7 ± 4.1% (p = 0.05). The rate of moderate to severe tricuspid regurgitation significantly decreased (p < 0.005). Regarding exercise tolerance, the New York Heart Association class improved (p < 0.001) and the walking distance increased (p < 0.001). During mid-term follow up after surgery for PMR, a deterioration of LV and RV contractile function measures could be observed. However, the clinical status, LV dimensions, and concomitant tricuspid regurgitation improved which in particular imply more effective RV contractile pattern.

[Management of Primary Ciliary Dyskinesia]

Die Primäre Ciliäre Dyskinesie (PCD, MIM 242650) ist eine seltene hereditäre Multisystemerkrankung mit klinisch heterogenem Phänotyp. Leitsymptom ist eine chronische Sekretretention der oberen und unteren Atemwege, welche durch die Dysfunktion motiler respiratorischer Zilien entsteht. In der Folge kommt es zur Ausbildung von Bronchiektasen, häufig zu einer Infektion durch Pseudomonas aeruginosa sowie einer abnehmenden Lungenfunktion bis hin zum Lungenversagen.

Bislang gibt es kaum evidenzbasierte Therapieempfehlungen, da randomisierte Langzeitstudien zur Behandlung der PCD fehlten. In diesem Jahr wurden die Daten einer ersten placebokontrollierten Medikamentenstudie bei PCD veröffentlicht. Anlässlich dieses Meilensteins im Management der PCD wurde der vorliegende Übersichtsartikel als Konsens von Patientenvertretern sowie Klinikern, die langjährige Erfahrung in der Behandlung der PCD haben, verfasst. Diese Arbeit bietet eine Zusammenfassung aktuell eingesetzter Behandlungsverfahren, die überwiegend auf persönlichen Erfahrungen und Expertenmeinungen beruhen oder von anderen Atemwegserkrankungen wie der Cystischen Fibrose (CF), COPD oder Bronchiektasen-Erkrankung abgeleitet werden. Da es derzeit keine kurative Therapie für PCD gibt, stehen symptomatische Maßnahmen wie die regelmäßige Reinigung der Atemwege und die Behandlung von rezidivierenden Atemwegsinfektionen im Fokus. Nicht respiratorische Manifestationen werden organspezifisch behandelt. Um neben der ersten Medikamentenstudie mehr evidenzbasiertes Wissen zu generieren, werden weitere Projekte etabliert, u. a. ein internationales PCD-Register. Hierüber wird Patienten der Zugang zu klinischen und wissenschaftlichen Studien erleichtert und die Vernetzung behandelnder Zentren gefördert. Des Weiteren können Erkenntnisse über eine Genotyp-spezifische Erkrankungsschwere erlangt werden, um folglich die therapeutische Versorgung der Patienten zu verbessern und somit zu individualisieren.

Early effective treatment may protect from cognitive decline in paediatric multiple sclerosis

BACKGROUND

Cognitive impairment (CI) is a critical feature for patients with childhood or juvenile multiple sclerosis (MS).

OBJECTIVE

To promote the understanding of CI and to address the impact of different pharmacological treatment strategies on cognitive performance in this patient group.

METHODS

A cohort of 19 patients with therapy-naïve or ß-Interferon-treated juvenile MS completed a comprehensive neuropsychological assessment at initial presentation (baseline) and on average 2.5 years later (follow-up). The assessments were complemented with a neuropaediatric examination and conventional cerebral magnetic resonance imaging (MRI).

RESULTS

9 patients (47%) were impaired in at least one test at baseline (z-score <-1.645 compared with age-adjusted normative data), with the highest impairment frequency in the domains processing speed and attention & executive functions. At follow-up a higher impairment frequency was prominent in those patients whose therapy had not been escalated (N = 13, 69% impaired in at least one test), while cognition was preserved or ameliorated in patients whose treatment had been escalated to highly effective drugs (N = 6, 0% impaired) during the observational period. These group differences at follow-up were not attributable to differences regarding demographics, MRI metrics or cognitive performance at baseline.

CONCLUSION

Our findings confirm that paediatric MS is associated with considerable CI already in early disease stages. Early administration of highly effective treatment may protect from cognitive decline or alleviate CI in juvenile MS, but larger controlled trials are warranted to confirm these preliminary results.

P1002Echocardiographic assessment of optimal device position after percutaneous left atrial appendage occlusion - introduction of a novel classification and its impact on outcome

Background

Left atrial appendage occlusion (LAAo) is an established therapy in patients with atrial fibrillation. However, criteria regarding optimal device position are not well defined making comparability of procedural results virtually impossible. We therefore sought to a) introduce a classification describing optimal vs. suboptimal device-position by assessing predefined parameters in transoesophageal echocardiography (TEE) and to b) analyze the impact of device-position on outcome in patients treated with different LAAo devices.

Methods and results

We retrospectively analyzed 120 patients who were treated by LAAo and had undergone follow-up TEEs after 3 or 6 months. Patients were at mean age: 76±8 years; female 40% and presented an increased CHADS-VASC- (4.6±1.4) and HAS-BLED-score (3.7±1). TEE-guidance was performed in all cases.

In 62.5% (75/120) pacifier occluders (PO) (ACP/Amulet, Lambre, Ultraseal) were used, whereas 37.5% (45/120) were treated with non-pacifier occluders (NPO) (Watchman, Wavecrest, Occlutech). To assess device position, TEE images in a commissural view (60–90°) were analyzed and characterised by 1) implantation depth in the left atrial appendage, 2) peridevice flow (PF) and 3) the angle between occluder disc and pulmonal ridge (LUPV). For the purpose of this study, optimal device position was defined as a) ostial (LUPV length <10mm) or slightly subostial position (LUPV length ≤15mm, angle ≥100°) with b) the absence of major PF (>3mm).

Overall, occluders were implanted at a depth of 12±7.8 mm with ostial positioning being achieved in 47.5% (57/120). Major PF was seen in 7.5% (9/120). NPOs were implanted deeper than POs (depth: 15.6±7.1 vs. 9.8±7.4 mm, p<0.01; ostial position: 31.1% vs. 57.3%, p<0.01) and were associated with a higher incidence of major PF (15.6% vs. 2.7%, p=0.01). Also, the depth/angle ratio was higher (i.e. “worse”) in NPOs (18.3±9 vs. 14.6±8, p<0.04). As a result, optimal device position was achieved in 48.3% (58/120) of all patients, with lower rates in NPOs than in POs (26.7% vs. 61.3%, p<0.01). Procedural aspects revealed slight differences in occluder size (optimal: 23.7±3.2 vs. suboptimal: 24.5±3.7 mm, p=0.3), need for repositioning (10.3% vs. 17.7%, p=0.25) and procedural duration (48±36 vs. 52±34 min, p=0.3).

Of interest, device related thrombi (DRT) occurred less frequently in optimally implanted devices (3.4% vs. 12.9%, p=0.06). Hereby, implantation depth and depth/angle ratio were found to be predictors for DRT in ROC-analysis, respectively (AUC: 0.7, 95% Confidence interval [CI]: 0.56–0.84, p=0.05 and AUC: 0.72, 95% CI: 0.58–0.86, p=0.03).

Optimal vs. suboptimal position

Conclusion

Echocardiographic classification of device-position is warranted to provide comparability and appears to be feasible. Based on the novel classification provided, optimal device-position is achieved in 50% and is found more often with the use of POs. DRT appeared to occur more often in suboptimal device-position.

Internal Versus External Electrical Cardioversion of Atrial Arrhythmia in Patients With Implantable Cardioverter-Defibrillator: A Randomized Clinical Trial

BACKGROUND

Atrial arrhythmias are common in patients with implantable cardioverter-defibrillator (ICD). External shocks and internal cardioversion through commanded ICD shock for electrical cardioversion are used for rhythm-control. However, there is a paucity of data on efficacy of external versus internal cardioversion and on the risk of lead and device malfunction. We hypothesized that external cardioversion is noninferior to internal cardioversion for safety, and superior for successful restoration of sinus rhythm.

METHODS

Consecutive patients with ICD undergoing elective cardioversion for atrial arrhythmias at 13 centers were randomized in 1:1 fashion to either internal or external cardioversion. The primary safety end point was a composite of surrogate events of lead or device malfunction. Conversion of atrial arrhythmia to sinus rhythm was the primary efficacy end point. Myocardial damage was studied by measuring troponin release in both groups.

RESULTS

N=230 patients were randomized. Shock efficacy was 93% in the external cardioversion group and 65% in the internal cardioversion group (P<0.001). Clinically relevant adverse events caused by external or internal cardioversion were not observed. Three cases of pre-existing silent lead malfunction were unmasked by internal shock, resulting in lead failure. Troponin release did not differ between groups.

CONCLUSIONS

This is the first randomized trial on external vs internal cardioversion in patients with ICDs. External cardioversion was superior for the restoration of sinus rhythm. The unmasking of silent lead malfunction in the internal cardioversion group suggests that an internal shock attempt may be reasonable in selected ICD patients presenting for electrical cardioversion.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03247738.

[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

Second generation cryoballoon ablation for persistent atrial fibrillation: an updated meta-analysis

BACKGROUND

Catheter ablation is an established treatment option for patients with symptomatic atrial fibrillation (AF). The cornerstone of AF ablation is pulmonary vein isolation (PVI). The second-generation cryoballoon (2G-CB) has shown non-inferiority to radiofrequency (RF) ablation in paroxysmal AF in several trials. Growing evidence suggests that 2G-CB is also effective in patients with persistent AF (perAF). The aim of this study was to summarize and analyze available data on safety and mid-term (≥ 12 months) efficacy of PVI using 2G-CB in patients with perAF.

METHODS

We did a search in PubMed, Web of Science, Cochrane Library, and clinicaltrials.gov in December 2016 for studies of 2G-CB ablation for perAF. Studies reporting clinical success rates at a follow-up (FU) of ≥ 12 months were included. Success was defined as freedom from any atrial arrhythmia lasting > 30 s after an initial blanking period of 3 months. Acute success and complication rates were also assessed. Data were analyzed applying random-effects model.

RESULTS

A total of 917 patients from 11 studies meeting study inclusion criteria were analyzed. After a mean FU of 16.7 ± 3.0 months, 68.9% were free from recurrences [95% confidence interval (CI) 63.4-74.7%]. Overall acute success rate was 99.7% (95% CI 99.2-100%). Complications occurred in 5.5% (95% CI 2.4-9.6%). Vascular access complications were the most frequent 3.3% (95% CI 1.5-5.6%). The rate of phrenic nerve palsy/injury was 2.09% (95% CI 0.8-3.9%). No death, stroke or myocardial infarction was reported.

CONCLUSION

The 2G-CB seems to be safe and effective in the treatment of perAF in the mid-term.

Single-Readout High-Density Memristor Crossbar

High-density memristor-crossbar architecture is a very promising technology for future computing systems. The simplicity of the gateless-crossbar structure is both its principal advantage and the source of undesired sneak-paths of current. This parasitic current could consume an enormous amount of energy and ruin the readout process. We introduce new adaptive-threshold readout techniques that utilize the locality and hierarchy properties of the computer-memory system to address the sneak-paths problem. The proposed methods require a single memory access per pixel for an array readout. Besides, the memristive crossbar consumes an order of magnitude less power than state-of-the-art readout techniques.

[Association of sleep-disordered breathing and malignant arrhythmias in patients with ischemic and dilated cardiomyopathy]

Sleep-disordered breathing (SDB) has so far been a neglected comorbidity in patients with cardiac arrhythmias. Recently however, several studies have revealed a correlation between SDB and malignant ventricular arrhythmias. This review article is intended to provide the reader with an update on the pathophysiological association between SDB and ventricular arrhythmias, available clinical data, and therapeutic options.