Use of SAFARI 2™ as workhorse wire for left-sided structural heart interventions

BACKGROUND

With the advances in percutaneous treatment technologies, the left atrial appendage occlusion (LAAO) and the transcatheter mitral valve repair using MitraClip (TMVR) are increasingly being performed today. The SAFARI 2™ guidewire is primarily used during transcatheter aortic valve implantation (TAVI), our group has also been using it during MitraClip and LAAO procedures. Our clinical study aimed to share our data on the safety and effectiveness for the use of the SAFARI 2™ guidewire during MitraClip or LAAO procedures.

METHODS

This study included a total of 1730 patients (948 patients of MitraClip and 782 of LAAO). It was designed as single arm, retrospective, and multicenter between July 2016 and August 2022. SAFARI 2™ guidewire was used exclusively during all the procedures.

RESULTS

A total of 1730 patients (male 55.8 %) were included in the study. There was no guidewire-related complications, stroke/transient ischemic attack, bleeding (minor/major/life-threatening), need for cardiac surgery, pneumonia, and vascular dissection/rupture in patients undergoing LAAO. There were 2 device-related pericardial effusions without tamponade. No stroke/transient ischemic attack, bleeding (minor/major/life-threatening), mortality, need for cardiac surgery, pneumonia, guidewire-related complication, pericardial effusion, vascular dissection/rupture, or clip embolization was observed in patients undergoing MitraClip.

CONCLUSIONS

By taking advantage of its pre-shaped structure, the SAFARI 2™ guidewire seems to offer a reliable and safe device delivery for both MitraClip and LAAO procedures as a regular work horse wire. Our results should be confirmed by larger randomized or prospective trials.

Review of intravascular lithotripsy for treating coronary, peripheral artery, and valve calcifications

Management of intracoronary calcium (ICC) continues to be a challenge for interventional cardiologists. There have been significant advances in calcium treatment devices. However, there still exists a knowledge gap regarding which devices to choose for the treatment of ICC. The purpose of this manuscript is to review the principles of intravascular lithotripsy (IVL) and clinical data. The technique of IVL will then be compared to alternative calcium treatment devices. Clinical data will be reviewed concerning the treatment of coronary, peripheral artery and valvular calcifications. Controversies to be discussed include how to incorporate IVL into your practice, what is the best approach for treating calcium subtypes, how to approach under-expanded stents, what is the ideal technique for performing IVL, how safe is IVL, whether imaging adds value when performing IVL, and how IVL fits into a treatment program for peripheral arteries and calcified valves.

Open Radial Artery Study

Radial artery occlusion (RAO) has been the most common postprocedural complication of transradial artery access. The optimal method of prevention of RAO is still lacking. In our study, we aimed to evaluate the effect of patent hemostasis on early (24 hours) and late (2 weeks) RAO prevention. The Open Radial Artery Study was a single-arm, prospective, and multicenter study. The primary end points were early and late RAO at the vascular access site after transradial coronary procedures. Secondary end points were access site hematoma, pseudoaneurysm formation, arteriovenous fistula, and nerve injury. A total of 2,181 patients were analyzed (67% male, mean age 68 years). The mean interventional duration and hemostatic times were 75.6 ± 55.6 and 60 ± 5.6 minutes, respectively. Radial artery spasm occurred in 10% of patients (n = 218). Catheter kinking, radial artery rupture, or dissection were not observed during the procedure. RAO, hematoma, pseudoaneurysm, arteriovenous fistula, or nerve damage was not observed in any of the patients in the early or late period. In patients who undergo coronary diagnostic or interventional procedures through transradial artery access, the patent hemostasis method seems a critical step in the prevention of early and late RAO.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

C-reactive protein to albumin ratio predicts for severity of coronary artery disease and ischemia

OBJECTIVE

Myocardial perfusion scintigraphy (MPS) has prognostic importance in demonstrating myocardial ischemia, and the Syntax score (SS) in coronary angiography has prognostic importance in demonstrating the extent of coronary artery disease (CAD). C-reactive protein (CRP) and albumin are prognostic markers for both atherosclerosis and inflammation. In this study, we aimed at investigating the relationship of CRP/albumin ratio (CAR) with the severity of myocardial ischemia and SS in patients with stable CAD.

PATIENTS AND METHODS

We retrospectively evaluated 355 patients between January 2018 and January 2020. Patients were divided into normal, mild-moderate, and severe ischemia groups according to MPS. SS was classified as low risk (< 32) and high risk (≥ 32) groups. The association between CAR, SS, and MPS findings were analyzed.

RESULTS

The median CAR level was higher in the high-risk group compared to the low-risk group (20.7 vs. 13.8, p < 0.05), and higher in the low-risk group compared to the normal group (13.8 vs. 7.4, p < 0.05). The increase in CAR level was associated with increased ischemia severity (p < 0.001). Increased CAR level was found to be an independent predictor of both high-risk and severe ischemia (OR = 1.04, p = 0.006; OR = 1.05, p = 0.001, respectively). The cut-off value of CAR > 10.2 was a common point in predicting both low-risk and mild-moderate ischemia (AUC: 0.736, p < 0.001; AUC: 0.741, p < 0.001, respectively).

CONCLUSIONS

High CAR level was an independent predictor of both the severity of ischemia and the extent of CAD. Therefore, CAR can be a potential screening tool in patients with suspected CAD and in risk stratification.

The relationship of masked hypertension with autonomic dysfunction and cardiometabolic parameters: a case-control study

OBJECTIVE

Masked hypertension (MH) is associated with cardiovascular events and mortality. Data on the association between exaggerated blood pressure response (EBPR) to exercise, heart rate recovery (HRR), which are indicators of autonomic dysfunction, and MH are lacking. This study aimed at evaluating the association between EBPR, HRR, and MH.

PATIENTS AND METHODS

Between January 2020 and January 2021, 130 MH (57 male, median age = 52.8 years) and 60 healthy (28 male, median age = 40.8 years) subjects were included in this single-center, case-control, and cross-sectional study. Office blood pressure measurement, 24-hour ambulatory blood pressure monitoring, treadmill test, echocardiography, and specific biochemical parameters were evaluated.

RESULTS

The frequency of blunted HRR (73 subjects, 56.2%) and EBPR (40 subjects, 30.8%) were significantly higher in patients with MH (p < 0.001). Patients with MH had higher serum uric acid levels and frequency of hyperlipidemia (p < 0.05). Diameters of the left atrium (LA), aortic root, and ascending aorta were significantly higher in MH patients (p < 0.05). Thirty-two (24.6%) patients with MH had left ventricular hypertrophy and 33 (25.4%) had diastolic dysfunction (p < 0.001). Multivariate analysis identified the presence of blunted HRR as an independent predictor factor of MH as well as smoking, hyperlipidemia, GFR, LA diameter, and aortic root diameter were other independent factors.

CONCLUSIONS

The frequency of blunted HRR and EBPR were significantly higher in the MH group compared to the control group, suggesting a close relationship between MH and autonomic dysfunction.

Long-term predictive value of cardiac biomarkers in patients with COVID-19 infection

OBJECTIVE

Several studies have investigated the association between cardiac biomarkers and short-term prognosis in the COVID-19 infection. However, the data on the predictive value of cardiac biomarkers to predict long-term prognosis in COVID-19 infection are limited. We aimed at determining the relationship between N-terminal brain-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin I (hs-TnI) as cardiac biomarkers and in-hospital/long-term outcomes in COVID-19 infection.

PATIENTS AND METHODS

The study included a total of 916 patients with confirmed COVID-19 infection. The primary outcome was in-hospital and 1-year mortality. The secondary outcome was intensive care need at admission or the need to be transferred to the intensive care unit later on.

RESULTS

The study included 498 (54.4%) males and 418 (45.6%) females with a mean age of 55.1±18.5 years. The patients with known heart failure (HF), COVID-19-related HF, acute renal failure (ARF), chronic kidney disease (CKD), diabetes mellitus, hypertension, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD)/asthma, high CO-RADS score (≥ 4), lower EF, higher hs-TnI, and NT-proBNP levels had increased in-hospital and 1-year mortality. After multivariate analysis, NT-proBNP, hs-TnI, CKD, ARF, diabetes mellitus, and CAD were independent predictors of in-hospital and 1-year mortality. After ROC analysis, NT-proBNP cut-off levels of 1022.50 (sensitivity 87.5%, specificity 87.1%) and 1008 (sensitivity 88.6%, specificity 88.0%) were found to predict in-hospital and 1-year mortality, respectively. Hs-TnI cut-off levels of 49.6 (sensitivity 88.6%, specificity 88.9%) and 34.10 (sensitivity 83.8%, specificity 84.1%) were found to predict in-hospital and 1-year mortality, respectively.

CONCLUSIONS

The current study suggests that NT-proBNP and hs-TnI can be used as valuable cardiac biomarkers to predict short-term and long-term parameters in COVID-19 infection.

Autonomic dysfunction and metabolic disorders as the possible sequelae of COVID-19 infection

OBJECTIVE

The Coronavirus disease 2019 (COVID-19) infection is associated with autonomic dysfunction. Data on the long-term relationship between COVID-19 infection, heart rate recovery (HRR), and exaggerated blood pressure response to exercise (EBPR) are very limited. In our study, we aimed at investigating the long-term association between COVID-19, HRR, EBPR, metabolic, and echocardiographic parameters.

PATIENTS AND METHODS

The study included 65 patients in the study group (33 female, median age 46) and 57 in the control group (30 female, 39 median age) between 1 April 2020 and 1 January 2021. Office blood pressure measurement, 24-hour ambulatory blood pressure monitoring, treadmill test, echocardiography, and metabolic parameters were evaluated.

RESULTS

The frequency of blunted HRR (25 subjects, 38.5%, p < 0.001) and EBPR (7 subjects, 10.8%, p = 0.014) were significantly higher in study group. The study group had higher levels of white blood cell (p = 0.002), neutrophil, c-reactive protein, and uric acid (p < 0.001). Diameters of left atrium, aortic root, and ascending aorta were significantly higher in study group (p < 0.05). Age adjusted multiple logistic regression analysis showed that neutrophil levels (odds ratio (OR), 9.21; 95% confidence interval (CI), 1.52-55.75, p = 0.016), glomerular filtration rate (OR, 1.34; 95% CI, 1.13-1.59, p = 0.001), basal heart rate (OR, 1.58; 95% CI, 1.17-2.12, p = 0.003), and mean heart rate (OR, 1.22; 95% CI, 1.03-1.45, p = 0.0021) were independently associated with COVID-19 infection.

CONCLUSIONS

The frequency of blunted HRR and EBPR, and uric acid levels were significantly higher in the study group compared to the control group, suggesting autonomic dysfunction as the possible sequelae of the COVID-19 infection and increased risk of cardiovascular events in the future.

Association among CO-RADS score, co-morbid diseases, and short-term prognosis in COVID-19 infection

OBJECTIVE

CO-RADS scoring system is used as a diagnostic tool. However, the data about its association with co-morbid diseases and effectiveness in predicting intensive care need and short-term mortality are lacking. In our study, we aimed to investigate the association among CO-RADS score, co-morbid diseases, intensive care need, and 28-day-mortality.

PATIENTS AND METHODS

The study included 665 patients with COVID-19 infection suspicion between 30 May 2020 and 30 October 2020.

RESULTS

The sensitivity of CT was 77%, and specificity was 52%. A higher CT score was associated with the rate of positive PCR test results (p<0.001), and older patients had higher CO-RADS scores than younger patients (p<0.001). Hypertension (OR: 7.956; p=0.005) and diabetes mellitus (OR: 5.902; p=0.015) were associated with significantly higher CO-RADS scores. Most patients treated in the intensive care unit (ICU) had a CO-RADS score of 5. The CO-RADS score was 4 and above in 115 (89.2%) patients who were transferred to the intensive care unit due to worsening of clinical condition (p<0.001). The 28-day mortality was significantly higher in patients with a CO-RADS score of 4 and above than in patients with a score of 3 and below (97.3% vs. 2.7%) (p<0.001).

CONCLUSIONS

Irrespective of PCR results, a higher CO-RADS score gives us useful information about ICU need or mortality risk and alerts us for early treatment to reduce the risk of further transmission, intensive care need, and mortality particularly in patients with co-morbid diseases.

An extensive caseous calcification of the mitral annulus complicated with severe mitral regurgitation

Caseous calcification of the mitral annulus (CCMA) is considered a rare variant of mitral annular calcification (MAC) due to caseous transformation of the inner material and prevalence of CCMA, about 0.63% of all MAC cases and 0.06%-0.07% of the population. The precise pathophysiology of CCMA is still unknown. It is a chronic degenerative disorder common in the elderly, particularly in women. Caseous calcification of the mitral annulus (CCMA) is a soft peri-annular extensive calcification, resembling cardiac tumors, abscesses, vegetation, or calcified thrombus, which is composed of an admixture of calcium, fatty acids, and cholesterol with a toothpaste-like texture. In the characteristic appearance on echocardiography, the calcification is a round, large, soft mass with a central echo dense area, typically located at the basal area of the posterior mitral valve. It usually carries a benign prognosis but rarely may be complicated with mitral valve dysfunction (valve stenosis/mitral regurgitation) or systemic embolization. The current data suggest conservative medical therapy and clinical follow-up for management of CCMA unless there is a need of cardiac surgery for severe mitral stenosis and/or regurgitation. We present a case, complicated with severe mitral regurgitation, and need surgical resection of the CCMA because of the CCMA-induced symptomatic severe mitral regurgitation despite optimal medical therapy. Macroscopic and microscopic examination of caseous material also demonstrated the characteristic appearance of CCMA.