Prognostic impact of shock in patients with type A acute aortic syndrome. Results of a nationwide multicenter study

OBJECTIVE

To evaluate the clinical characteristics, imaging findings, treatment and prognosis of patients with type A acute aortic syndrome (AAS-A) presenting with shock. To assess the impact of surgery in this patient population.

METHODS

The study included 521 patients with A-AAS enrolled in the Spanish Registry of Acute Aortic Syndrome (RESA-III) from January-2018 to December-2019. The RESA-III is a prospective, multicenter registry that contains AAS data from 30 tertiary-care hospitals. Patients were classified in two groups according to the clinical presentation with or without shock. Shock was defined as persistent systolic blood pressure <80mmHg despite adequate volume resuscitation.

RESULTS

97 (18.6%) patients with A-AAS presented with shock. Clinical presentation with syncope was much more common in the Shock-group (45.4% vs 10.1%, p=0.001). Patients in the Shock-group had more complications at diagnosis and before surgery: cardiac tamponade (36.2% vs 9%, p<0.001), acute renal failure (28.9% vs 18.2%, p=0.018) and need for orotracheal intubation (40% vs 9.1%, p<0.001). There were no significant differences in aortic regurgitation (51.6% vs 46.7%, p=0.396) between groups. In-hospital mortality was higher among patients with shock (48.5% vs 27.4%, p<0.001). Surgery was associated with a significant mortality reduction both in patients with and without shock. Surgery had an independent protective effect on mortality (OR 0.03, 95% CI (0.00-0.32)).

CONCLUSIONS

Patients with AAS-A admitted with shock have a heavily increased risk of mortality. Syncope and pericardial effusion at diagnosis are strongly associated with shock. Surgery was independently associated with a mortality reduction in patients with AAS-A and shock.

Improvement of Early Outcomes in Type A Acute Aortic Syndrome After an Aorta Code Implementation

BACKGROUND

Reduction of variability through process reengineering can improve surgical results for patients with type A acute aortic syndrome. We compare short-term results before and after implementation of an Aorta Code for patients with type A acute aortic syndrome who underwent surgery.

METHODS

The Aorta Code was implemented in a 5-hospital healthcare network in 2019. This critical pathway was based on a simple diagnostic algorithm, ongoing training, immediate patient transfer, and treatment by an expert multidisciplinary team. We retrospectively compared all patients operated on in our center before (2005-2018) and after (January 2019 to February 2023) its implementation.

RESULTS

One hundred two and 70 patients underwent surgery in the precode and code periods, respectively. In the code period the number of patients operated on per year increased (from 7.3 to 16.8), and the median elapsed time until diagnosis (6.5 hours vs 4.2 hours), transfer (4 hours vs 2.2 hours), and operating room (2.7 hours vs 1.8 hours) were significantly shorter (P < .05). Aortic root repair and total arch replacement were more frequent (66.7% vs 82.9% [P = .003] and 20.6% vs 40% [P = .001]). Cardiopulmonary bypass and ischemia times were also shorter (179.7 minutes vs 148.2 minutes [P = .001] and 105 minutes vs 91.2 minutes [P = .022]). Incidence of prolonged mechanical ventilation (53.9% vs 34.3%, P = .011), major stroke (17.7% vs 7.1%, P = .047), and 30-day mortality (27.5% vs 7.1%, P = .001) decreased significantly.

CONCLUSIONS

An Aorta Code can be successfully implemented by using a standardized protocol within a hospital network. The number of cases increased; time to diagnosis, transfer, and operating room were reduced; and 30- day mortality significantly decreased.

Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis

INTRODUCTION AND OBJECTIVES

Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE.

METHODS

From 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis.

RESULTS

The prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy.

CONCLUSIONS

Valvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Evolution and Prognostic Significance of Patient-Reported Symptoms After Intervention in Severe Aortic Stenosis

OBJECTIVE

To describe the evolution of symptoms in patients with symptomatic severe aortic stenosis (sSAS) undergoing valve replacement, the predictors of the persistence of these symptoms, and their prognostic significance. The evolution of symptoms after intervention in sSAS and their association with outcome are unknown.

PATIENTS AND METHODS

Data from patients with sSAS who underwent intervention were collected. All-cause mortality and cardiovascular mortality were considered events. The evolution of symptoms and their association with events were studied.

RESULTS

In this study, 451 consecutive patients with sSAS and no other valvular or coronary disease who were alive 30 days after intervention were included. Before valve replacement, 133 of the 451 patients (29.5%) had congestive heart failure requiring hospitalization. Of the remaining 318 patients, 287 (90.2%) had dyspnea on effort, 129 (40.6%) had angina, and 59 had syncope (18.6%). Symptoms disappeared after intervention in 192 of the 451 patients (42.6%) and remained in 259 (57.4%): 193 dyspnea, 9 angina, 17 syncope, and 60 admission for heart failure. Syncope on effort persisted in 4 of 33 patients (12.1%) and at rest in 11 of 20 (55.0%; P<.001). Age, body mass index, previous admission for heart failure, and chronic obstructive pulmonary disease were independently related to persistence of symptoms. Over a median follow-up of 56 months in our cohort of 451 patients, 129 deaths were registered (28.6%), 40 of which were cardiovascular (8.9%). Age, chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, heart failure, and persistence of symptoms were independently associated with all-cause mortality.

CONCLUSION

Symptoms attributed to SAS remain after intervention in a high proportion of patients, particularly dyspnea on effort and syncope at rest. The persistence of symptoms after intervention identifies patients with poor outcome.

Regional differences in infective endocarditis epidemiology and outcomes in Spain. A contemporary population-based study

INTRODUCTION AND OBJECTIVES

Our aim was to describe the contemporary epidemiological profile of infective endocarditis (IE) in Spain, and to evaluate variations in IE incidence, characteristics, and outcomes among the different Spanish regions (autonomous communities [AC]).

METHODS

We conducted a retrospective, population-based study, using data obtained from national in-patient hospital activity of all patients discharged with a diagnosis of IE from hospitals included in the Spanish National Health System, from January 2016 to December 2019. Differences in the IE profile between the 17 Spanish AC were analyzed.

RESULTS

A total of 9008 hospitalization episodes were identified during the study period. Standardized incidence of IE was 5.77 (95%CI, 5.12-6.41) cases per 100 000 population. Regarding predisposing conditions, 26.8% of episodes occurred in prosthetic valve carriers, 36.8% had some kind of valve heart disease, and 10.6% had a cardiac implantable electronic device. Significant differences were found between AC in terms of incidence, predisposing conditions, and microbiological profile. Cardiac surgery was performed in 19.3% of episodes in the total cohort, and in 33.4% of the episodes treated in high-volume referral centers, with wide variations among AC. Overall in-hospital mortality was 27.2%. Risk-adjusted mortality rates also varied significantly among regions.

CONCLUSIONS

We found wide heterogeneity among Spanish AC in terms of incidence rates and the clinical and microbiological characteristics of IE episodes. The proportion of patients undergoing surgery was low and in-hospital mortality rates were high, with wide differences among regions. The development of regional networks with referral centers for IE could facilitate early surgery and improve outcomes.

[Acute aortic syndrome]

Acute aortic syndrome embraces a group of heterogenous pathological entities involving the aortic wall with a common clinical profile. The current epidemiology, clinical presentation, diagnosis and treatment strategy are discussed in this review. Besides, the importance of multidisciplinary aortic teams, aortic centers and the implementation of an aortic code are emphasized.

Sex Differences in Clinical Outcomes after Aortic Valve Intervention for Isolated Severe Aortic Stenosis

There are known pathophysiologic and clinical differences according to sex in patients with aortic stenosis (AS). To evaluate if these differences persist after valve replacement, we conducted an observational study including 451 patients with symptomatic AS who survived aortic valve intervention (AVI) in two centers. Clinical data and mortality were evaluated at a mean follow-up of 5 years. 56% of patients were women. At baseline, women were older (80.6 vs. 78 years, p = 0.013), presented higher mean gradient (48 vs. 45 mmHg, p = 0.023), lower aortic valve area (0.70 vs. 0.74 cm2, p = 0.002) and higher systolic pulmonary artery pressure (36 vs. 33 mmHg, p = 0.016). They underwent percutaneous aortic valve replacement more frequently than men (47 vs. 35.9%, p = 0.017). At 5 years follow-up, women required more admissions due to heart failure (23 vs. 9%, p = 0.046) but they did not present higher cardiovascular nor overall mortality (27.7% vs. 29.8%, p = 0.741; 11.1 vs. 10.1%, p = 0.619, respectively). Female sex was an independent predictor of heart failure hospitalization at follow-up (HR 95% 1.16-4.22, p = 0.016). Women undergo AVI at a more advanced stage than men, resulting in a higher frequency of readmissions due to heart failure during the follow-up period, but not in higher mortality.

Recurrence of syncope after valve replacement in severe aortic stenosis

OBJECTIVE

The recurrence of syncope after valve intervention in severe aortic stenosis (SAS) and its impact on outcome are unknown. We hypothesised that syncope on exertion will disappear after intervention, whereas syncope at rest might recur. Our aim has been to describe the recurrence of syncope in patients with SAS undergoing valve replacement and its impact on mortality.

METHODS

Double-centre observational registry of 320 consecutive patients with symptomatic SAS without other valve disease and/or coronary artery disease who underwent valve intervention and were discharged alive. All-cause mortality and cardiovascular mortality were considered events.

RESULTS

53 patients (median age 81 years, 28 men) had syncope (29 on exertion, 21 at rest, 3 unknown). Clinical and echocardiographic variables were similar in patients with and without syncope (median vmax 4.44 m/s, mean gradient 47 mm Hg, valve area 0.7 cm2, left ventricular ejection fraction 62%). After a median follow-up of 69 months (IQR: 55-88), syncope on exertion did not recur in any patient. In contrast, 8 of the 21 patients with syncope at rest had postintervention syncope at rest (38%; p<0.001): 3 needed a pacemaker, 3 were neuromediated or hypotensive and 2 arrhythmic. Only recurrence of syncope was associated with cardiovascular mortality (HR 5.74; 95% CI 2.17 to 15.17; p<0.001).

CONCLUSIONS

Syncope on exertion in patients with SAS did not recur after aortic valve intervention. Syncope at rest recurs in a high proportion of patients and identifies a population with increased mortality. According to our results, syncope at rest should be thoroughly evaluated before proceeding to aortic valve intervention.

Kounis and Takotsubo, Two Syndromes Bound by Adrenaline: The "ATAK" Complex

Background. The term "ATAK" complex has been coined by the association of adrenaline, takotsubo, anaphylaxis and Kounis syndrome. We present an uncommon case of an "ATAK" complex with biphasic onset and a midventricular takotsubo pattern. Case Summary. A 50-year-old male was brought to the emergency department in anaphylactic shock. He had progressive exertional dyspnea and angina for the past 2 days. The intravenous administration of adrenaline for anaphylactic shock resulted in chest pain and concerning ECG repolarization findings. The patient was immediately transferred to the catheterization laboratory. Coronary angiography showed a midventricular ballooning pattern without significant coronary stenosis, with subsequent recovery during hospitalization, suggestive of takotsubo syndrome. The allergy tests remained inconclusive for the trigger. Discussion. Adrenaline-mediated stress is the link between these two entities, in which Kounis syndrome itself or anaphylactic shock treatment (adrenaline) are potential triggers for takotsubo syndrome.

Impact of transfer to reference centres and surgical timing on the prognosis of surgically treated patients with infective endocarditis: a prospective multi-centre cohort study

OBJECTIVES

To compare outcomes in patients with infective endocarditis (IE) first treated in secondary hospitals and then transferred to reference centres for surgery with those in patients diagnosed in reference centres, and to evaluate the impact of surgery timing on prognosis.

METHODS

Analysis of a prospective cohort of patients with active IE admitted to three reference centres between 1996 and 2022 who underwent cardiac surgery in the first month after diagnosis. Multi-variable analysis was performed to evaluate the impact of transfer to reference centres and time to surgery on 30-day mortality. Adjusted ORs with 95% CIs were calculated.

RESULTS

Amongst 703 patients operated on for IE, 385 (54.8%) were referred cases. All-cause 30-day mortality did not differ significantly between referred patients and those diagnosed at reference centres (102/385 [26.5%] vs. 78/385 [24.5%], respectively; p 0.552). Variables independently associated with 30-day mortality in the whole cohort were diabetes (OR, 1.76 [95% CI, 1.15-2.69]), chronic kidney disease (OR, 1.83 [95% CI, 1.08-3.10]), Staphylococcus aureus (OR, 1.88 [95% CI, 1.18-2.98]), septic shock (OR, 2.76 [95% CI, 1.67-4.57]), heart failure (OR, 1.41 [95% CI, 0.85-2.11]), acute renal failure before surgery (OR, 1.76 [95% CI, 1.15-2.69]), and the interaction between transfer to reference centres and surgery timing (OR, 1.18 [95% CI, 1.03-1.35]). Amidst referred patients, time from diagnosis to surgery longer than a week was independently associated with 30-day mortality (OR, 2.19 [95% CI, 1.30-3.69]; p 0.003).

CONCLUSION

Among referred patients, surgery performed >7 days after diagnosis was associated with two-fold higher 30-day mortality.

Validation of the TRI-SCORE in patients undergoing surgery for isolated tricuspid regurgitation

INTRODUCTION

Estimation of peri-procedural risk in patients with tricuspid regurgitation (TR) undergoing isolated tricuspid valve surgery (ITVS) is of paramount importance. The TRI-SCORE is a new surgical risk scale specifically developed for this purpose, which ranged from 0 to 12 points and included eight parameters: right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin (with a value of 2 points), age ≥70 years, New York Heart Association Class III-IV, left ventricular ejection fraction <60% and moderate/severe right ventricular dysfunction (with a value of 1 point). The objective of the study was to evaluate the performance of the TRI-SCORE in an independent cohort of patients undergoing ITVS.

METHODS

A retrospective observational study was performed in four centres, including consecutive adult patients undergoing ITVS for TR between 2005 and 2022. The TRI-SCORE and the traditional risk scores used in cardiac surgery (Logistic EuroScore (Log-ES) and EuroScore-II (ES-II)) were applied for each patient, and discrimination and calibration of the three scores were evaluated in the entire cohort.

RESULTS

A total of 252 patients were included. The mean age was 61.5±11.2 years, 164 (65.1%) patients were female, and TR mechanism was functional in 160 (63.5%) patients. The observed in-hospital mortality was 10.3%. The estimated mortality by the Log-ES, ES-II and TRI-SCORE was 8.7±7.3%, 4.7±5.3% and 11.0±16.6%, respectively. Patients with a TRI-SCORE ≤4 and >4 had an in-hospital mortality of 1.3% and 25.0%, p=0.001, respectively. The discriminatory capacity of the TRI-SCORE had a C-statistic of 0.87 (0.81-0.92), which was significantly higher than both the Log-ES (0.65 (0.54-0.75)) and ES-II (0.67 (0.58-0.79)), p=0.001 (for both comparisons).

CONCLUSION

This external validation of the TRI-SCORE demonstrated good performance to predict in-hospital mortality in patients undergoing ITVS, which was significantly better than the Log-ES and ES-II, which underestimated the observed mortality. These results support the widespread use of this score as a clinical tool.

Contemporary Clinical Profile of Left-Sided Native Valve Infective Endocarditis: Influence of the Causative Microorganism

Studies focused on the clinical profile of native valve endocarditis are scarce and outdated. In addition, none of them analyzed differences depending on the causative microorganism. Our objectives are to describe the clinical profile at admission of patients with left-sided native valve infective endocarditis in a contemporary wide series of patients and to compare them among the most frequent etiologies. To do so, we conducted a prospective, observational cohort study including 569 patients with native left-sided endocarditis enrolled from 2006 to 2019. We describe the modes of presentation and the symptoms and signs at admission of these patients and compare them among the five more frequent microbiological etiologies. Coagulase-negative Staphylococci and Enterococci endocarditis patients were the oldest (71 ± 11 years), and episodes caused by Streptococci viridans were less frequently nosocomial (4%). The neurologic, cutaneous or renal modes of presentation were more typical in Staphylococcus aureus endocarditis (28%, p = 0.002), the wasting syndrome of Streptococcus viridans (49%, p < 0.001), and the cardiac in Coagulase-negative Staphylococci, Enterococci and unidentified microorganism endocarditis (45%, 49% and 56%, p < 0.001). The clinical signs agreed with the mode of presentation. In conclusion, the modes of presentation and the clinical picture at admission were tightly associated with the causative microorganism in patients with left-sided native valve endocarditis.

The three-noes right-sided infective endocarditis: An unrecognized type of right-sided endocarditis

The "3 noes right-sided infective endocarditis" (3no-RSIE: no left-sided, no drug users, no cardiac devices) was first described more than a decade ago. We describe the largest series to date to characterize its clinical, microbiological, echocardiographic and prognostic profile. Eight tertiary centers with surgical facilities participated in the study. Patients with right-sided endocarditis without left sided involvement, absence of drug use history and no intracardiac electronic devices were retrospectively included in a multipurpose database. A total of 53 variables were analyzed in every patient. We performed a univariate analysis of in-hospital mortality to determine variables associated with worse prognosis. the study was comprised of 100 patients (mean age 54.1 ± 20 years, 65% male) with definite 3no-RSIE were included (selected from a total of 598 patients with RSIE of all the series, which entails a 16.7% of 3no-RSIE). Most of the episodes were community-acquired (72%), congenital cardiopathies were frequent (32% of the group of patients with previous known predisposing heart disease) and fever was the main manifestation at admission (85%). The microbiological profile was led by Staphylococci spp (52%). Vegetations were detected in 94% of the patients. Global in-hospital mortality was 19% (5.7% in patients operated and 26% in patients who received only medical treatment, P < .001). Non-community acquired infection, diabetes mellitus, right heart failure, septic shock and acute renal failure were more common in patients who died. the clinical profile of 3no-RSIE is closer to other types of RSIE than to LSIE, but mortality is higher than that reported on for other types of RSIE. Surgery may play an important role in improving outcome.

Mitral and tricuspid valve disease: diagnosis and management. Consensus document of the Section on Valvular Heart Disease and the Cardiovascular Imaging, Clinical Cardiology, and Interventional Cardiology Associations of the Spanish Society of Cardiology

The diagnosis and management of mitral and tricuspid valve disease have undergone major changes in the last few years. The expansion of transcatheter interventions and widespread use of new imaging techniques have altered the recommendations for the diagnosis and treatment of these diseases. Because of the exponential growth in the number of publications and clinical trials in this field, there is a strong need for continuous updating of local protocols. The recently published 2021 European Society of Cardiology guidelines for the management of valvular heart disease did not include some of the new data on these new therapies and, moreover, the number of mitral and tricuspid interventions varies widely across Europe. Therefore, all this information must be summarized to facilitate its use in each specific country. Consequently, we present the consensus document of the Section on Valvular Disease, Cardiovascular Imaging, Clinical Cardiology, and Interventional Cardiology Associations of the Spanish Society of Cardiology for the diagnosis and management of mitral and tricuspid valve disease.

Echocardiographic evolution of patients undergoing 99mTc-DPD scintigraphy for suspected cardiac amyloidosis

Introduction

Cardiac transthyretin amyloidosis (ATTR) is usually associated with thickening of the interventricular septum (IVS), although this finding is not specific and can be attributed to other diseases such as high blood pressure (HBP) or hypertrophic cardiomyopathy. The objective was to evaluate echocardiographic changes over time in patients with ventricular hypertrophy, undergoing 99mTc-DPD scintigraphy (DPD), in order to compare findings between patients with cardiac amyloidosis and other etiologies.

Methods

Retrospective registry of 63 patients who underwent DPD due to suspected cardiac amyloidosis in our center between 2018 and 2021. Clinical and echocardiographic characteristics were collected, including 2 echocardiograms per patient, with a minimum separation of one year (echo1, echo2). We compared patients diagnosed with ATTR, with positive scintigraphy grade 2–3 (ATTR group), with patients with negative scintigraphy (grade 0, nATTR group).

Results

The mean age of the patients was 81.3±8.6 years, 67.7% males. 83.9% of patients had HBP, without differences between groups (table1). DPD was positive in 32 (51.6%) patients. Patients with a negative DPD were diagnosed with hypertensive heart disease. The median time between echo1 and echo2 was 3.5 years (IQR 1.2–7), with no differences between groups (4.9 years in nATTR group vs 3.8 years in ATTR group, p=0.2). Results are shown in table1. In echo1, no significant differences were observed in the IVS and biventricular function between both groups. However, in echo3, patients in the ATTR group had significantly greater interventricular septum (IVS) thickness and a worse biventricular function compared to the nATTR group.

A significantly greater growth of the IVS and deterioration of left ventricular ejection fraction (LVEF) between echo1 and echo2 was observed in the ATTR group (table1). The percentage of IVS increase respect to the basal value was also significantly higher in ATTR group. There were no significant differences in the IVS growth per year. In the multivariable analysis LVEF and IVS thickness were independent predictors of a positive DPD.

Conclusions

The increase in thickness of the IVS and deterioration of left ventricular ejection fraction during follow-up of patients with ventricular hypertrophy could be a differential characteristic of ATTR, compared to patients with ventricular hypertrophy of other etiologies. This echocardiographic findings could help to suspect the presence of ATTR.

Funding Acknowledgement

Type of funding sources: None.

Development of a new score to predict left ventricular reverse remodelling in patients with nonischemic cardiomyopathy

Background and purpose

Implantable cardioverter-defibrillator is indicated in patients with dilated non-ischemic cardiomyopathy (DCM) and severely depressed left ventricular ejection fraction (LVEF) after a wait-and-see period of 3–9 months under optimised medical therapy. However, in the first 6 months after the disease debut, around 2% of patients might suffer life-threatening arrhythmias.

The appearance of left ventricular reverse remodelling (LVRR) in patients with DCM is associated with a lower incidence of ventricular tachyarrhythmias. Therefore, it is relevant an early identification of the patients who will experience LVRR during the follow-up.

Our aim was to develop a score to predict the appearance of LVRR in patients with DCM.

Methods

From 2014 to 2021, 201 patients with DCM and LVEF ≤45% were prospectively evaluated in our tertiary care hospital. All patients underwent a transthoracic echocardiogram and 1.5 Tesla scanner cardiac magnetic resonance (MR) as part of the diagnostic workup. LVRR was defined as an increase in LVEF ≥10 points or absolute LVEF ≥50% associated with a reduction in left ventricular end-diastolic diameter ≥10%.

Results

The median age of our cohort (n=201) was 61.6 (14.7) years, and 68% were male. Most patients (&gt;90%) were treated with beta-blockers or RASS blockers, and 72% with mineralocorticoid receptor antagonists.

During a mean follow-up period of 37.6 (33.9) months 45% of patients had LVRR.

Patients with LVRR had a lower cardiovascular mortality (3.33 vs 9.59%; p=0.153), lower mortality due to heart failure (0% vs 8.22%; p=0.023), and a lower incidence of ventricular tachyarrhythmias (1.67% vs 19.18%; p=0.001).

Table 1 shows the echocardiographic, MR and clinical characteristics of patients who experienced LVRR.

Variables significantly associated with LVRR in the univariable analysis and considered clinically relevant were included in a multivariable logistic regression analysis. The final model included the presence of right ventricular end systolic volume index (RVESVi) &gt;50 ml/m2 (2 points), left bundle brach block (LBBB) echo pattern (1 point), female gender (1 point) and tachycardiomyopathy/idiopathic/alcoholic/chemotherapy induced cardiomyopathy as the potencial cause of DCM (1 point).

The score showed a good discrimination, with an area under the ROC curve of 0.82 (95% CI 0.69 to 0.94), 84% sensitivity and 80% specificity. The presence of 3 or more points was associated with a high probability to had LVRR (0 points: 1%; 1 points: 17%; 2 points: 38%; 3 points: 64%; 4 points: 84%%; 5 points: 94% and 6 points: 98%) (Figure 1).

Conclusion

A new score with four variables (RVESV, LBBB echo pattern, female gender and tachycardiomyopathy/idiopatic/alcoholic/chemotheapy induced cardiomyopathy as potential cause) accurately predicts the probability of LVRR. Considering patients who experience LVRR have less cardiovascular events, this score may be a helpful tool for patients' risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Impact of diabetes mellitus in non-ischemic dilated cardiomyopathy: focus on diastolic dysfunction

Introduction

In patients with diabetes mellitus (DM), the presence of myocardial dysfunction in the absence of coronary artery disease, valvular disease and other conventional cardiovascular risk factors has been defined as diabetic cardiomyopathy. Left ventricle concentric hypertrophy and myocardial fibrosis are the structural hallmarks that lead to overt diastolic dysfunction.

The impact of DM in imaging features and clinical outcomes of patients with non-ischaemic dilated cardiomyopathy (DCM) has not been completely elucidated yet.

Purpose

We aim to describe advance imaging and clinical characteristics of DCM's patients with DM, and its potential impact on cardiac morphology and function in comparison to non-diabetic patients.

Methods

From 2014 to 2021, all patients with DCM were prospectively evaluated in our tertiary care hospital.

All patients underwent a transthoracic echocardiogram and 165 patients underwent a 1.5 Tesla scanner cardiac magnetic resonance (CMR) as part of the diagnostic workup. Left ventricle ejection fraction (LVEF), mechanical dyssynchrony, and diastolic function were analyzed according to current guidelines. Late gadolinium enhancement (LGE) was assessed visually and its extent was calculated as the number of affected myocardial segments.

Heart failure (HF) hospitalizations, arrhythmic events and mortality were assessed during follow-up.

Results

The median age of our cohort (n=227) was 61.6 (14.7) years, 66% were male, and DM was present in 57 patients (25.1%). Mean follow-up was 37.6 (33.9) months. Diabetic patients were significantly older, more frequently male, and with more comorbidity. Left bundle branch block was more frequent in patients with DM. The use of SGLT2 inhibitors was higher in diabetic patients (47.4% vs 21.1%; p&lt;0.05). No significant differences were observed regarding other guideline-recommended HF drugs.

With regard to imaging features, no significant differences were found in LVEF and global longitudinal strain between the two groups. There was a trend toward a higher left ventricle mass index measured by CMR in diabetic patients (p=0.364). Parameters of mechanical dyssynchrony and diastolic dysfunction were worse in diabetic patients (Table 1). High-risk LGE pattern (defined as the presence of epicardial, transmural or septal plus free-wall LGE) was more frequently observed in the diabetes group (p&lt;0.05).

Finally, the diabetic group had a higher incidence of HF hospitalization (45.61% vs 22%, p&lt;0.001) and all-cause mortality (24.6% vs 11.8%, p&lt;0.05), as shown in Figure 1. There was also a trend toward a higher cardiovascular mortality (12.3% vs 6.5%, p=0.164) in this group.

Conclusion

DM confers a high-risk profile to DCM patients, explained by extracardiac (more comorbidities) and cardiac (more diastolic dysfunction and high-risk LGE pattern) reasons. These patients may benefit from a close monitoring, and new therapies should be developed to improve their prognosis.

Funding Acknowledgement

Type of funding sources: None.

Effects of intravenous lysine acetylsalicylate versus oral aspirin on platelet responsiveness in patients with ST-segment elevation myocardial infarction

Background

Prasugrel and ticagrelor, new P2Y12-ADP receptor antagonists, are associated with greater pharmacodynamic inhibition and reduction of cardiovascular events in patients with an acute coronary syndrome. However, evidence is lacked about the effects of achieving faster and stronger cyclooxygenase inhibition with intravenous lysine acetylsalicylate (LA) compared to oral aspirin on prasugrel inhibited platelets in patients with an ST-segment elevation myocardial infarction (STEMI).

Methods

This is a prospective, randomized, multicenter, open platelet function study conducted. STEMI patients were randomly assigned to receive a loading dose (LD) of intravenous LA 450mg plus oral ticagrelor 180mg, or LD of aspirin 300mg plus ticagrelor 180mg orally. Platelet function was evaluated at baseline, 30 min, 1h, and 24h using multiple electrode aggregometry and vasodilator-stimulated phosphoprotein phosphorylation (VASP). The primary endpoint of the study is the inhibition of platelet aggregation after arachidonic acid (AA) 1.5mM at 30 min. Secondary endopoints are the inhibition of platelet aggregation after AA baseline and at 1h, and 24h, and measurement of aggregation with other platelet test (ADP, collagen and VASP).

Results

A total of 32 STEMI patients were randomized (16 LA, 16 aspirin). The inhibition of platelet aggregation after AA 1.5 mM at 30 min was greater in subjects treated with LA compared with aspirin: 166 vs. 412 respectively, p=0.001. This differential effect was observed at 1 hour (p=0.01), but not at 24 hours. Subjects treated with LA presented less variability and faster and greater inhibition of platelet aggregation with AA compared with aspirin (Figure 1).

Conclusions

The administration of intravenous LA resulted in a significantly reduction of platelet reactivity compared to oral aspirin on ticagrelor inhibited platelets in patients with STEMI. Loading dose of LA achieves an earlier platelet inhibition, and with less variability than aspirin.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the CTU-SCReN (Clinical Trial Unit – Spanish Clinical Research Network) from San Carlos University Hospital (Madrid, Spain), financed by the ISCII (Project PI16/00191)

Contemporary comparison of infective endocarditis caused by Candida albicans and Candida parapsilosis: a cohort study

Among 1655 consecutive patients with infective endocarditis treated from 1998 to 2020 in three tertiary care centres, 16 were caused by Candida albicans (CAIE, n = 8) and Candida parapsilosis (CPIE, n = 8). Compared to CAIE, CPIE were more frequently community-acquired. Prosthetic valve involvement was remarkably more common among patients with CPIE. CPIE cases presented a higher rate of positive blood cultures at admission, persistently positive blood cultures after antifungals initiation and positive valve cultures. All patients but four underwent cardiac surgery. Urgent surgery was more frequently performed in CPIE. No differences regarding in-hospital mortality were documented, even after adjusting for therapeutic management.

Accuracy of 18F-FDG PET/CT in patients with the suspicion of cardiac implantable electronic device infections

BACKGROUND

Utility of 18F-FDG PET/CT in diagnosing infective endocarditis (IE) associated with cardiac implantable electronic devices (CIEDs) is not well established. Current ESC guidelines recommend the use of FDG-PET imaging in patients with CIEDs and positive blood cultures, but the number of studies evaluating the diagnostic performance of FDG-PET imaging in these patients remain limited. Our objective was to assess the diagnostic yield of 18F-FDG PET/CT in patients with suspected CIED infections, differentiating between pocket infection (PI) and lead infection (CIED-IE).

METHODS AND RESULTS

From 2013 to 2018, all patients (n = 63) admitted to a hospital with suspected CIED infection were prospectively recruited, undergoing a diagnostic work-up including a PET/CT. Explanted devices and material from the pocket were cultured. 14 cases corresponded to isolated PI and 13 were categorized as CIED-IE. Considering radionuclide uptake in the intracardiac portion of the lead, sensitivity and specificity of PET/CT for CIED-IE were 38.5% and 98.0%, respectively. Positive (19.2) and negative (0.6) likelihood ratio values, suggest that a positive PET/CT is much more probable to correspond to a patient with CIED-IE, whereas it is not possible to exclude this diagnosis when negative. For PI, sensitivity and specificity were 72.2% and 95.6%, respectively.

CONCLUSIONS

The yield of 18F-FDG PET/CT for suspected CIED infections differs depending on the site of infection. Due to very high specificity but poor sensitivity, negative studies must be interpreted with caution if the suspicion of CIED-IE is high.

Reassessment of vegetation size as a sole indication for surgery in left-sided infective endocarditis

BACKGROUND

Guidelines recommend surgery in left-sided infective endocarditis (LSIE) associated with large vegetations. Given that most patients who undergo surgery also have other indications (heart failure and/or uncontrolled infection), it is not settled whether surgery should be routinely recommended in patients with large vegetations but no other predictors of poor outcome.

METHODS

A total of 726 patients with definitive LSIE were included in our analysis. Mean age was 64.9 years, 61% were male. Multivariate analysis of all patients was performed to determine if vegetation size is related to death in LSIE. Then, patients were divided in two groups according to vegetation size: Group A (>10 mm, n=420) and group B (≤10 mm, n=306). Univariate and multivariate analyses of group A patients were carried out to identify the variables related to death in this group. Impact of surgery on mortality of group A patients without heart failure or uncontrolled local infection (n=139) was assessed.

RESULTS

Age, Staphylococcus aureus, perivalvular complications, heart failure, kidney failure and septic shock, but not vegetation size, were associated with death. Patients with large vegetations showed increased mortality (31.7% in group A vs 24.8% in group B, p=0.045). Group A had more valve rupture and valve regurgitation than group B, but heart failure (55% vs 53%, p=0.678), stroke (22% vs 17.0%, p=0.091), systemic embolism (39% vs 32%, p=0.074), perivalvular complication (28% vs 28%, p=0.865) or septic shock (15% vs 13%, p=0.288) were similar in both groups. In patients from group A without heart failure or uncontrolled infection mortality was similar with and without surgery (n=139; n=70 with surgery, n=69 without surgery; mortality 18.6% vs 11.6% respectively, p=0.251).

CONCLUSIONS

large vegetations identify patients with poor outcome in LSIE. However, surgery is not associated with a better prognosis in patients with large vegetations if they do not present with another predictor of poor outcome such as heart failure or uncontrolled infection. These findings challenge whether vegetation size alone should be an indication for surgery in LSIE.

Cancer and Infective Endocarditis: Characteristics and Prognostic Impact

Background: The interplay between cancer and IE has become of increasing interest. This study sought to assess the prevalence, baseline characteristics, management, and outcomes of IE cancer patients in the ESC EORP EURO-ENDO registry.

Methods: Three thousand and eighty-five patients with IE were identified based on the ESC 2015 criteria. Three hundred and fifty-nine (11.6%) IE cancer patients were compared to 2,726 (88.4%) cancer-free IE patients.

Results: In cancer patients, IE was mostly community-acquired (74.8%). The most frequently identified microorganisms were S. aureus (25.4%) and Enterococci (23.8%). The most frequent complications were acute renal failure (25.9%), embolic events (21.7%) and congestive heart failure (18.1%). Theoretical indication for cardiac surgery was not significantly different between groups (65.5 vs. 69.8%, P = 0.091), but was effectively less performed when indicated in IE patients with cancer (65.5 vs. 75.0%, P = 0.002). Compared to cancer-free IE patients, in-hospital and 1-year mortality occurred in 23.4 vs. 16.1%, P = 0.006, and 18.0 vs. 10.2%; P < 0.001, respectively. In IE cancer patients, predictors of mortality by multivariate analysis were creatinine > 2 mg/dL, congestive heart failure and unperformed cardiac surgery (when indicated).

Conclusions: Cancer in IE patients is common and associated with a worse outcome. This large, observational cohort provides new insights concerning the contemporary profile, management, and clinical outcomes of IE cancer patients across a wide range of countries.

Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review

The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.

Prognostic Value of the PROFUND Index for 30-Day Mortality in Acute Heart Failure

Background and Objectives: The prevalence and incidence of heart failure (HF) have been increasing in recent years as the population ages. These patients show a distinct profile of comorbidity, which makes their care more complex. In recent years, the PROFUND index, a specific tool for estimating the mortality rate at one year in pluripathology patients, has been developed. The aim of this study was to evaluate the prognostic value of the PROFUND index and of in-hospital and 30-day mortality after discharge of patients admitted for acute heart failure (AHF). Materials and Methods: A prospective multicenter longitudinal study was performed that included patients admitted with AHF and ≥2 comorbid conditions. Clinical, analytical, and prognostic variables were collected. The PROFUND index was collected in all patients and rates of in-hospital and 30-day mortality after discharge were analyzed. A bivariate analysis was performed with quantitative variables between patients who died and those who survived at the 30-day follow-up. A logistic regression analysis was performed with the variables that obtained statistical significance in the bivariate analysis between deceased and surviving subjects. Results: A total of 128 patients were included. Mean age was 80.5 +/− 9.98 years, and women represented 51.6%. The mean PROFUND index was 5.26 +/− 4.5. The mortality rate was 8.6% in-hospital and 20.3% at 30 days. Preserved left ventricular ejection fraction was found in 60.9%. In the sample studied, there were patients with a PROFUND score < 7 predominated (89 patients (70%) versus 39 patients (31%) with a PROFUND score ≥ 7). Thirteen patients (15%) with a PROFUND score < 7 died versus the 13 (33%) with a PROFUND score ≥ 7, p = 0.03. Twelve patients (15%) with a PROFUND score < 7 required readmission versus 12 patients (35%) with a PROFUND score ≥ 7, p = 0.02. The ROC curve of the PROFUND index for in-hospital mortality and 30-day follow-up in patients with AHF showed AUC 0.63, CI: 95% (0.508–0.764), p <0.033. Conclusions: The PROFUND index is a clinical tool that may be useful for predicting short-term mortality in elderly patients with AHF. Further studies with larger simple sizes are required to validate these results.

Contemporary comparison of infective endocarditis caused by Candida albicans and Candida parapsilosis: a cohort study

Background

Although Candida albicans is the most frequent microorganism causing fungal endocarditis, its incidence has decreased during the last two decades, and that of non-albicans Candida species has risen. Among the last, Candida parapsilosis is of particular interest, representing the second most frequent Candida species causing IE1, 2.

Purpose

To compare the clinical course, imaging findings and outcomes among patients with IE caused by C. albicans (CAIE) and C. parapsilosis (CPIE) in order to identify organism-specific peculiarities.

Methods

From January 1998 to June 2020, all consecutive cases of CAIE and CPIE (n=16), admitted to a hospital network composed of 3 tertiary hospitals and prospectively recruited on a multipurpose database, were retrospectively analysed. All cases were evaluated by the Endocarditis Team (ET) and underwent a thorough diagnostic work-up, including blood cultures at admission, transoesophageal echocardiography (TEE) and culture of the valves extracted at surgery. Other imaging tests, such as PET/CT, were performed at the ET's discretion. Diagnosis of IE was made according to the modified Duke criteria until 20153, and the European Society of Cardiology (ESC) 2015 modified diagnostic criteria thereafter4.

Results

Eight patients were diagnosed with CAIE and 8 with CPIE. Regarding predisposing conditions, a higher prevalence of prosthetic valves was found among CPIE. Other population's baseline information is shown in Table 1. Compared to CAIE, CPIE presented a longer time from the beginning of symptoms to hospital admission (40 vs 7 days; p=0.062), but no differences regarding signs and symptoms were observed. Aortic location was the most frequent infection side in both groups, but prosthetic valve involvement was remarkably more frequent among patients with CPIE (75% vs 37.5%; p=0.315. Figure 1). CPIE also presented a higher rate of positive blood cultures at admission (100% vs 62.5%; p=0.200), persistently blood cultures 48–72 hours after antifungals initiation (100% vs 0%; p=0.021) and positive valve cultures (83.3% vs 57.1%; p=0.569). No differences regarding TEE and other imaging tests findings were observed. All patients but 4 underwent valve replacement surgery. No differences in in-hospital complications or in mortality were observed between CAIE and CPIE, even after adjusting for therapeutic management.

Conclusions

Compared to CAIE, CPIE presented a more frequent involvement of prosthetic valves, a longer course of symptoms before admission and a bigger proportion of persistently positive blood cultures. In-hospital complications and mortality were similar between the two groups.

Funding Acknowledgement

Type of funding sources: None. Table 1. Population characteristicsFigure 1. Valve involvement distribution

Analysis of right ventricle echocardiographic function parameters for the prediction of outcomes in significant functional tricuspid regurgitation

Introduction

Functional tricuspid regurgitation is a common disease that significantly impairs survival and quality of life. The role of echocardiographic right ventricular (RV) function parameters to detect patients with worse prognosis that may benefit from invasive treatment is still under debate.

Methods

121 consecutive patients with grade III and IV functional tricuspid regurgitation were evaluated. RV function parameters and clinical variables were assessed at baseline, and then patients were prospectively followed-up. The primary endpoint was the combination of death or heart failure (HF) admissions. Comparison of imaging parameters was done using receiver-operating characteristics (ROC) curves. Multivariate logistic regression analysis was preformed to establish independent predictors of outcomes.

Results

Median follow up was 27.3 months. 73.6% of the patients were female, and mean age was 80.4 years. 63.6% were grade IV tricuspid regurgitation.

In the univariate analysis using the area under the ROC curve (AUC), RV-free wall strain (RVS, AUC=0.633) and pulmonary artery systolic pressure (PASP, AUC=0.605) were the best predictors of death and HF admissions, although the individual diagnostic performance was weak.

In the multivariate analysis including either clinical and echocardiographic variables, independent predictors of death and HF admissions were Age (OR 1.07, p=0.029), RVS &gt;−16 (OR 5.0, p=0.001), Diabetes mellitus (OR 3.0, p=0.011), eGFR (ml/min, OR 0.96, p=0.001) and Hemoglobin (g/dL, OR=0.74, p=0.048). The model including these variables was superior than RVS and PASP alone (AUC 0.884, p&lt;0.001) (graph 1), showing high sensitivity (78.8%) and specificity (67.3%).

Conclusions

In patients with significant functional tricuspid regurgitation, RVS and PASP show the best performance for the detection of death and HF admissions. A multivariate model including age, diabetes, eGFR, hemoglobin and RVS was superior than the individual imaging parameters.

Funding Acknowledgement

Type of funding sources: None. Table 1Graph 1

Impact of frailty on elderly patients with infective endocarditis

Introduction

Frailty studies focused on patients with infective endocarditis (IE) are scarce and its potential impact on patient outcomes is not well known.

The aim of this study is to describe the clinical profile and prognosis of elderly patients with IE, comparing patients who met the frailty criteria versus those who did not.

Methods

A total of 121 cases of confirmed IE were consecutively collected in three tertiary hospitals between 2017 and 2019. The patients were classified into two groups: Group I (n=49), patients with IE who met the Frail criteria for frailty, and Group II (n=72), those patients without frailty by this scale.

Results

The median age of our cohort was 77 years (69–82), and 62.8% were men. Frail patients were older than those in Group II, as shown in Table 1.

Regarding comorbidity, chronic anemia (40.8% vs 25%; p&lt;0.060) was more common in Group I, as well as rheumatic manifestations at admission (12.2% vs 1.4%; p=0.014).

The most frequently isolated microorganisms were S. aureus (n=25), coagulase negative staphylococci (n=25), viridans group streptococci (n=14), and enterococci (n=14). Enterococci (16.3% vs 8.3%, p=0.177) and non-viridans streptococci (10.2% vs 2.8%); p=0.086) were more frequent in frail patients.

Vegetation (79.6% vs 80.6%; p=0.896) and periannular complications (24.5% vs 29.2%; p=0.571) were similar in both groups. No significant differences were found regarding the location of the infection.

The incidence of in-hospital complications was similar between both groups. Frail patients underwent surgery less frequently than those in Group II, and had higher predicted mortality on surgical risk scale scores. However, the percentage of patients who met the surgical criteria and were considered inoperable was similar (33.3% vs 26.2%; p=0.415). In-hospital mortality was similar in both groups. When analyzing in-hospital mortality according to the therapeutic strategy in Group I, a mortality of 34.5% was observed in frail patients with conservative medical treatment, compared to 47.1% in those patients who underwent surgery in the same group.

One third of our patients received outpatient antibiotic treatment, being significantly more frequent in Group I (39.6% vs 29.0%; p=0.232).

Conclusions

The elderly patients with IE and frailty criteria were older and more frequently had rheumatic symptoms at admission. Enterococci and non-viridans streptococci were isolated more frequently than in non-frailty patients. Surgery was less performed among frail patients, who had a higher predicted surgical risk. Although complications and in-hospital mortality were similar between both groups, in the group of frail patients, those with conservative management showed lower mortality compared to surgery.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of cardiac surgery in left-sided infective endocarditis according to risk profile

OBJECTIVE

To evaluate the prognostic impact of urgent cardiac surgery on the prognosis of left-sided infective endocarditis (LSIE) and its relationship to the basal risk of the patient and to the surgical indication.

METHODS

605 patients with LSIE and formal surgical indication were consecutively recruited between 2000 and 2020 among three tertiary centres: 405 underwent surgery during the active phase of the disease and 200 did not despite having indication. The prognostic impact of urgent surgery was evaluated by multivariable analysis and propensity score analysis. We studied the benefit of surgery according to baseline mortality risk defined by the ENDOVAL score and according to surgical indication.

RESULTS

Surgery is an independent predictor of survival in LSIE with surgical indication both by multivariable analysis (OR 0.260, 95% CI 0.162 to 0.416) and propensity score (mortality 40% vs 66%, p<0.001). Its greatest prognostic benefit is seen in patients at highest risk (predicted mortality 80%-100%: OR 0.08, 95% CI 0.021 to 0.299). The benefit of surgery is especially remarkable for uncontrolled infection indication (OR 0.385, 95% CI 0.194 to 0.765), even in combination with heart failure (OR 0.220, 95% CI 0.077 to 0.632).

CONCLUSIONS

Surgery during active LSIE seems to significantly reduce in-hospital mortality. The higher the risk, the higher the improvement in outcome.

Heart Stroke Plus: Analysis of quality indicators to create an improved pathway for patients following an acute coronary syndrome

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Sanofi Aventis S.A.

Introduction

Optimisation of the care of patients after an acute coronary syndrome (ACS) is a fundamental step to improve health outcomes and avoid consecutive cardiovascular events however data on how care is provided is often absent.

Purpose

Our objective was to analyse the main quality indicators in the post-ACS patient pathway so as to determine the actions which avoid future CDV events.

Methods

In a random sample of 100 patients between January 2018 and December 2019, we selected the indicators which most affect secondary prevention in patients post-ACS. All patients had been diagnosed with ACS within a tertiary-care hospital with a 24h interventional cardiology lab.  The indicators were retrospectively analysed using the patients’ health record.

Results

The main results are presented in Table 1.

Conclusions

Based on this, we proposed an integrated protocol for all patients post-ACS which will begin in 2021 within this tertiary-care hospital. Within this protocol, the information contained in the discharge report will be improved and automatized as much as possible so as re-evaluate at a later date.

Table 1: Demographics and results Title of the indicator Yes (%) No (%) Men 76 24 STEMI 40 60 NSTEMI 60 40 Dual antiplatelet therapy included in discharge report 100 0 High doses statins at discharge 98 2 BMI included in discharge report 0 100 LDL objective included in discharge report 14 86 HbA1c objective included in discharge report 13 87 Physical activity included in discharge report 15 85 Flu vaccination recomendations included in discharge report 0 100 Complete blood analysis completed 4-6 weeks after discharge 100 0 Blood pressure is measured on first post-discharge consultation 100 0 Blood pressure medication is changed on first post-discharge consultation 28 78 Patient arrives with measurement for HbA1c on first post-discharge consultation 78 22 Antidiabetic medication is modified on first post-discharge consultation 8 92 BMI is registered on first post-discharge consultation 0 100 Patients with LDL below 55mg/dl on first post-discharge consultation 29 71 Lipid-lowering medications is changed on first post-discharge consultation 29 71

Not All Heart Uptakes on 99mTc-DPD Scintigraphy Are Amyloidosis: Chloroquine-Induced Cardiomyopathy

ABSTRACT

This was the case of a 61-year-old woman with a medical history significant for hypertension and rheumatoid arthritis treated with chloroquine for the last 10 years. She was admitted to our hospital for heart failure symptoms. Echocardiography revealed severe concentric left ventricular hypertrophy. Serum and urine immunofixation electrophoresis and serum light chain assay were negative. No late gadolinium enhancement was observed on cardiovascular magnetic resonance. 99mTc-99mTc-DPD (3,3-diphosphono-1,2-propanodicarboxylic acid) scintigraphy showed myocardial uptake (Perugini score 2/3). Genetic testing excluded hereditary transthyretin cardiac amyloidosis. Endomyocardial biopsy analysis did not show findings suggestive of amyloidosis but consistent with chloroquine toxicity. Chloroquine-mediated cardiotoxicity is rare, and there are very few reports about bone scintigraphy imaging features.

Endovascular treatment of coronary subclavian steal syndrome: a case series highlighting the diagnostic usefulness of a multimodality imaging approach

Background

Coronary subclavian steal syndrome (CSSS) is an uncommon complication observed in patients after coronary artery bypass surgery with left internal mammary artery (LIMA) grafts. It is defined as coronary ischaemia due to reversal flow from the LIMA to the left subclavian artery (SA) when a proximal left SA stenosis is present. In practice, the entire clinical spectrum of ischaemic heart disease, ranging from asymptomatic patients to acute myocardial infarction, may be encountered.

Case summary

Three cases of CSSS recently detected at our hospital are being described. Two patients presented with an acute coronary syndrome, so diagnosis was suspected based on coronary angiography findings, as retrograde blood flow from LIMA to the distal SA was present. Myocardial ischaemia was documented by myocardial perfusion scintigraphy in one case. The third patient was asymptomatic and CSSS was suspected during physical examination and confirmed by computed tomography (CT). Endovascular intervention with balloon-expandable stent implantation of the stenotic SA was performed by vascular surgeons in all patients. No periprocedural complications occurred, and complete resolution of symptoms was achieved.

Discussion

In CSSS, subclavian angiography is the standard diagnostic test. However, other diagnostic techniques may be valuable to better clarify this challenging diagnosis. In the herein small series, the usefulness of a multimodality imaging approach including Doppler ultrasound, myocardial perfusion scintigraphy, and CT is well demonstrated. Furthermore, this study endorses the safety and utility of endovascular treatment in different clinical scenarios, including asymptomatic patients.

The SADDEN DEATH Study: Results from a Pilot Study in Non-ICU COVID-19 Spanish Patients

Introduction: The worldwide pandemic, coronavirus disease 2019 (COVID-19) is a novel infection with serious clinical manifestations, including death. Our aim is to describe the first non-ICU Spanish deceased series with COVID-19, comparing specifically between unexpected and expected deaths. Methods: In this single-centre study, all deceased inpatients with laboratory-confirmed COVID-19 who had died from March 4 to April 16, 2020 were consecutively included. Demographic, clinical, treatment, and laboratory data, were analyzed and compared between groups. Factors associated with unexpected death were identified by multivariable logistic regression methods. Results: In total, 324 deceased patients were included. Median age was 82 years (IQR 76–87); 55.9% males. The most common cardiovascular risk factors were hypertension (78.4%), hyperlipidemia (57.7%), and diabetes (34.3%). Other common comorbidities were chronic kidney disease (40.1%), chronic pulmonary disease (30.3%), active cancer (13%), and immunosuppression (13%). The Confusion, BUN, Respiratory Rate, Systolic BP and age ≥65 (CURB-65) score at admission was >2 in 40.7% of patients. During hospitalization, 77.8% of patients received antivirals, 43.3% systemic corticosteroids, and 22.2% full anticoagulation. The rate of bacterial co-infection was 5.5%, and 105 (32.4%) patients had an increased level of troponin I. The median time from initiation of therapy to death was 5 days (IQR 3.0–8.0). In 45 patients (13.9%), the death was exclusively attributed to COVID-19, and in 254 patients (78.4%), both COVID-19 and the clinical status before admission contributed to death. Progressive respiratory failure was the most frequent cause of death (92.0%). Twenty-five patients (7.7%) had an unexpected death. Factors independently associated with unexpected death were male sex, chronic kidney disease, insulin-treated diabetes, and functional independence. Conclusions: This case series provides in-depth characterization of hospitalized non-ICU COVID-19 patients who died in Madrid. Male sex, insulin-treated diabetes, chronic kidney disease, and independency for activities of daily living are predictors of unexpected death.

Infective endocarditis in patients with aortic grafts

BACKGROUND

Infective endocarditis (IE) in patients with a valve-tube ascending aortic graft (AAG) is a rare entity with a challenging diagnosis and treatment. This study describes the clinical features, diagnosis and outcome of these patients.

METHODS

Between 1996 and 2019, 1654 episodes of IE were recruited in 3 centres, of which 37 patients (2.2%) had prosthetic aortic valve and AAG-IE (21 composite valve graft, 16 supracoronary graft) and conformed our study group.

RESULTS

Patients with aortic grafts were predominantly male (91.9%) and the mean age was 67.7 years. Staphylococci were the most frequently isolated microorganisms (32%). Viridans group streptococci were only isolated in patients with composite valve graft. TEE was positive in 89.2%. PET/CT was positive in all 15 patients in whom it was performed. Surgical treatment was performed in 62.2% of patients. In-hospital mortality was 16.2%. Heart failure and the type of infected graft (supracoronary aortic graft) were associated with mortality. Mortality among operated patients was 21.7%. Interestingly, 14 patients received antibiotic therapy alone, and only one died. Mortality was lower among patients with a composite valve graft compared to those with a supracoronary graft (4.8% vs 31.3%; p = 0.03).

CONCLUSIONS

In patients with AAG and prosthetic aortic valve IE, mortality is not higher than in other patients with prosthetic IE. Multimodality imaging plays an important role in the diagnosis and management of these patients. Heart failure and the type of surgery were risk factors associated with in-hospital mortality. Although surgical treatment is usually recommended, a conservative management might be a valid alternative treatment in selected patients.

Multivariate analysis of right ventricle echocardiographic function parameters for the prediction of outcomes in significant functional tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Functional tricuspid regurgitation is a common disease that significantly impairs survival and quality of life. The role of echocardiographic right ventricular (RV) function parameters to detect patients with worse prognosis that may benefit from invasive treatment is still under debate.

Methods

121 consecutive patients with grade III and IV functional tricuspid regurgitation were evaluated. RV function parameters and clinical variables were assessed at baseline, and then patients were prospectively followed-up. The primary endpoint was the combination of death or heart failure (HF) admissions. Comparison of imaging parameters was done using receiver-operating characteristics (ROC) curves. Multivariate logistic regression analysis was preformed to establish independent predictors of outcomes.

Results

Median follow up was 27.3 months. 73.6% of the patients were female, and mean age was 80.4 years. 63.6% were grade IV tricuspid regurgitation.

In the univariate analysis using the area under the ROC curve (AUC), RV-free wall strain (RVS, AUC = 0.633) and pulmonary artery systolic pressure (PASP, AUC = 0.605) were the best predictors of death and HF admissions, showing better diagnostic performance than tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC) and tricuspid S’ (p &lt; 0.001 for each comparison) (graph 1A).

In the multivariate analysis including either clinical and echocardiographic variables, independent predictors of death and HF admissions were Age (OR 1.07, p = 0.029), RVS&gt;-16 (OR 5.0, p = 0.001), Diabetes mellitus (OR 3.0, p = 0.011), eGFR (ml/min, OR 0.96, p = 0.001) and Hemoglobin (g/dL, OR = 0.74, p = 0.048) (table 1). The model including these variables was superior than RVS and PASP alone (AUC 0.884, p &lt; 0.001) (graph 1B), showing high sensitivity (78.8%) and moderate specificity (67.3%).

Conclusions

In patients with significant functional tricuspid regurgitation, RVS and PASP show the best performance for the detection of death and HF admissions. A multivariate model including age, diabetes, eGFR, hemoglobin and RVS was superior than the individual imaging parameters.

Table 1 Variable OR 95% CI P value Age (years) 1.07 1.01-1.13 0.029 Diabetes Mellitus 3.00 1.29-7.00 0.011 RV free wall strain &gt;-16 5.01 1.87-13.4 0.001 Hemoglobin (d/dL) 0.74 0.55-1.00 0.048 eGFR (ml/min) 0.96 0.94-0.98 0.001 OR odds ratio. CI: confidence interval. eGFR: estimated glomerular filtration rate (CKD-EPI formula). Abstract Figure. Graph 1