The impact and challenges of implementing CTCA according to the 2019 ESC guidelines on chronic coronary syndromes: a survey and projection of CTCA services in the Netherlands

Background

The 2019 ESC-guidelines on chronic coronary syndromes (ESC-CCS) recommend computed tomographic coronary angiography (CTCA) or non-invasive functional imaging instead of exercise ECG as initial test to diagnose obstructive coronary artery disease. Since impact and challenges of these guidelines are unknown, we studied the current utilisation of CTCA-services, status of CTCA-protocols and modeled the expected impact of these guidelines in the Netherlands.

Methods and results

A survey on current practice and CTCA utilisation was disseminated to every Dutch hospital organisation providing outpatient cardiology care and modeled the required CTCA capacity for implementation of the ESC guideline, based on these national figures and expert consensus. Survey response rate was 100% (68/68 hospital organisations). In 2019, 63 hospital organisations provided CTCA-services (93%), CTCA was performed on 99 CTCA-capable CT-scanners, and 37,283 CTCA-examinations were performed. Between the hospital organisations, we found substantial variation considering CTCA indications, CTCA equipment and acquisition and reporting standards. To fully implement the new ESC guideline, our model suggests that 70,000 additional CTCA-examinations would have to be performed in the Netherlands.

Conclusions

Despite high national CTCA-services coverage in the Netherlands, a substantial increase in CTCA capacity is expected to be able to implement the 2019 ESC-CCS recommendations on the use of CTCA. Furthermore, the results of this survey highlight the importance to address variations in image acquisition and to standardise the interpretation and reporting of CTCA, as well as to establish interdisciplinary collaboration and organisational alignment.

Predictors of mortality in patients with left-side infective endocarditis, the ESC-EORP EURO-ENDO registry

Background/Introduction

Infective endocarditis (IE) is associated with high in-hospital mortality, ranging from 16% to 25%, despite improvement in diagnostic and therapeutic strategies, mainly due to complications and heterogeneity of the disease. Baseline risk stratification is essential, in order to focus an aggressive management toward high-risk patients.

Purpose

We sought to assess the association between surgery and 30-day mortality rate as related to vegetation size.

Methods

The ESC-EORP EURO-ENDO registry is a prospective multicentre observational study of patients presenting with definite or possible IE in Europe and ESC-affiliated/non-affiliated countries. Patients were included from January 2016 to 31 March 2018 in 156 centers from 40 countries. Clinical data, blood test analysis and multi-modality imaging tests (echocardiography, computed tomography, PET-CT, magnetic resonance) were collected. Primary endpoint was 30-day mortality. Multivariable logistic regression analysis was performed to assess variables associated with 30-day mortality. Besides, univariable analysis was performed to assess best vegetation size cut-off related to 30-day mortality.

Results

Among 2171 patients with left-side IE, 257 patients (11.8%) died during the first 30 days of IE diagnosis. Patient characteristics and univariable analysis are summarized in TABLE 1. Cut-off value for best vegetation size related to 30-day mortality was vegetation length >14mm, with a HR =2.00 (95% CI 1.59–2.51, p<0.0001) and a Harrell's Concordance of 0.58. After multivariable logistic regression analysis, factors associated with 30-day mortality risk were: vegetation size >14mm (OR =2.68, 95% CI [1.96–3.67], p<0.0001), previous stroke or transient ischemic attack (TIA) (OR =1.60, 95% CI [1.07–2.40], p=0.0235), creatinine >2mg/dL (OR =2.45, 95% CI [1.73–3.47], p<0.0001), presence of embolic events (OR =2.64, 95% CI [1.86–3.74], p<0.0001), hemorrhagic stroke (OR=3.71, 95% CI [1.80–7.64], p=0.0004), presence of heart failure or cardiogenic shock (OR =3.50, 95% CI [2.57–4.77], p<0.0001) and no cardiac surgery during the event (OR =4.07, 95% CI [2.93–5.67], p<0.0001). The C-statistic of the logistic model to predict 30-day mortality was 0.795.

Conclusion

Left-side infective endocarditis had a high 30-day mortality rate (11.8%). Presence of a large vegetation size (>14mm), embolic events, hemorrhagic stroke, renal failure, presence of heart failure or cardiogenic shock were associated with an increase in 30-day mortality. Performing cardiac surgery had a protective effect.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC-EORP EURO-ENDO project from the ESC society

Predictors of mortality in patients with right-side and cardiac device-related infective endocarditis, the esc-eorp euro-endo registry

Background/Introduction

Mortality in right-sided infective endocarditis (RSIE) and cardiac device-related IE (CDRIE) rates have increased mainly due derived complications and heterogeneity of the disease. A better understanding of associated risk factors to mortality in these entities are required in order to develop an efficient therapy.

Purpose

The aim of this study was to assess 30-day mortality rate and variables associated in RSIE and CDRIE.

Methods

The ESC-EORP EURO-ENDO registry is a prospective multicenter observational study of patients presenting with definite or possible IE in Europe and ESC-affiliated/non-affiliated countries. Patients were included from January 2016 to 31 March 2018 in 156 centers from 40 countries. Clinical data, blood test analysis and multi-modality imaging tests (echocardiography, computed tomography, PET-CT, magnetic resonance) were collected. Primary endpoint was 30-day mortality. Univariable analysis was performed to assess variables associated with 30-day mortality.

Results

Among 269 patients with RSIE, 24 patients (9.8%) died during the first 30-day of IE diagnosis. Cut-off value for best vegetation size related to 30-day mortality was vegetation length >19mm, with a HR = 2.88 (95% CI 1.26–6.58, p=0.01) and a Harrell's Concordance of 0.632. Factors associated with 30-days mortality by univariable analysis were: vegetation size >19mm (OR = 2.99, 95% CI [1.31–6.84], p=0.009), previous stroke or transient ischemic attack (OR = 5.10, 95% CI [1.19–21.88], p=0.029), HIV infection (OR = 3.52, 95% CI [1.03–12.10], p=0.046), chronic renal failure (OR = 2.66, 95% CI [1.06–6.71], p=0.038), congestive heart failure at admission (OR = 2.34, 95% CI [1.00–5.47], p=0.050) and severe regurgitation (OR = 3.77, 95% CI [1.56–9.09], p=0.003).

On the other side, among the 227 patients with CDRIE, 24 patients (8.8%) died during the first 30-day of IE diagnosis. Factors associated with an increase in 30-day mortality by univariate analysis were: age per 10 years (OR = 1.49, 95% CI [1.02–2.18], p=0.039), heart failure history (OR = 3.88, 95% CI [1.39–10.80], p=0.009), congestive heart failure on admission (OR = 5.80, 95% CI [2.31–14.55], p<0.001) and cardiogenic shock on admission (OR = 13.37, 95% CI [3.75–47.64], p<0.001). An increase in left ventricular ejection fraction (LVEF) per 10% was a protective factor (OR = 0.66, 95% CI [0.49–0.90], p=0.008).

Conclusions

Patients with RSIE and CDRIE had a not negligible 30-day mortality rate (9.8% and 8.8%, respectively). Factors associated with RSIE and CDRIE mortality are different; while in the right side location, the mortality was related with vegetation size and comorbidities, in the case of CDRIE, the mortality was mainly associated to the presence of heart failure.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Euro-Endo registry by European Society of Cardiology

Determining the optimal interval for imaging surveillance of ascending aortic aneurysms

Background

Cardiovascular guidelines recommend (bi-)annual computed tomography (CT) or magnetic resonance imaging (MRI) for surveillance of the diameter of thoracic aortic aneurysms (TAAs). However, no previous study has demonstrated the necessity for this approach. The current study aims to provide patient-specific intervals for imaging follow-up of non-syndromic TAAs.

Methods

A total of 332 patients with non-syndromic ascending aortic aneurysms were followed over a median period of 6.7 years. Diameters were assessed using all available imaging techniques (echocardiography, CT and MRI). Growth rates were calculated from the differences between the first and last examinations. The diagnostic accuracy of follow-up protocols was calculated as the percentage of subjects requiring pre-emptive surgery in whom timely identification would have occurred.

Results

The mean growth rate in our population was 0.2 ± 0.4 mm/year. The highest recorded growth rate was 2.0 mm/year, while 40.6% of patients showed no diameter expansion during follow-up. Females exhibited significantly higher growth rates than men (0.3 ± 0.5 vs 0.2 ± 0.4 mm/year, p = 0.007). Conversely, a bicuspid aortic valve was not associated with more rapid aortic growth. The optimal imaging protocol comprises triennial imaging of aneurysms 40–49 mm in diameter and yearly imaging of those measuring 50–54 mm. This strategy is as accurate as annual follow-up, but reduces the number of imaging examinations by 29.9%.

Conclusions

In our population of patients with non-syndromic TAAs, we found aneurysm growth rates to be lower than those previously reported. Yearly imaging does not lead to changes in the management of small aneurysms. Thus, lower imaging frequencies might be a good alternative approach.

Infarct characteristics and outcome of patients with transient ST-segment elevation myocardial infarction compared to ST-segment and non-ST-segment elevation myocardial infarction

Background

Up to one out of four patients with signs of ST-segment elevation myocardial infarction (STEMI) express complete normalization of ST elevation before primary revascularization procedure. This condition is commonly referred to as “transient ST-segment elevation myocardial infarction” (TSTEMI) and recent data suggests that this group of patients may have favorable outcome compared to STEMI patients. However, it is currently unknown how these patients compare to both STEMI and non-ST-segment elevation myocardial infarction (NSTEMI) patients with respect to infarct size characteristics and outcome.

Objective

This study aims to explore cardiac magnetic resonance (CMR) derived scar tissue and 1-year outcome in patients with TSTEMI by comparison to STEMI and NSTEMI.

Methods

Patients with STEMI were enrolled from two prospective studies (n=170); the patients with TSTEMI were recruited from the TRANSIENT trial (n=141); the patients with NSTEMI were prospectively and consecutively collected from local registries of Amsterdam UMC (n=57) and Maastricht UMC (n=51). All patients underwent CMR examination 2–8 days after the index event. Cine imaging was done for volume and function assessment. Late gadolinium enhancement imaging was performed to identify infarct size (in grams) and the presence of microvascular obstruction (MVO). All CMR images were processed in a single core laboratory (Amsterdam UMC). Clinical outcome after 1 year was measured by the incidence of major adverse cardiac events (MACE), defined as recurrent myocardial infarction (MI), revascularization and all cause death.

Results

The TSTEMI group demonstrated the lowest end-systolic left ventricular volume and highest left ventricular ejection fraction across the groups (overall p<0.001). Although there was a remarkably lower infarct size in TSTEMI patients compared to STEMI (1.41g [0.00–3.91] vs 13.48g [5.31–26.81], p<0.001), there was only a trend towards lower infarct size compared to NSTEMI patients (1.41g [0.00–3.91] vs 2.13g [0.00–8.64], p=0.06). Whilst MVO was observed less frequently in TSTEMI compared to STEMI patients (5 (4%) vs 53 (31%), p<0.001), no significant difference was seen between TSTEMI and NSTEMI patients (5 (4%) vs 5 (5%), p=0.72). Multivariable linear regression analysis identified infarct type, smoking, peak troponin-T and pre-PCI TIMI flow as predictors for infarct size (p=0.03, p=0.03, p<0.001 and p<0.001, respectively). One-year mortality rate was low in all 3 MI types (TSTEMI 3 (2.2%), NSTEMI 3 (3.1%), 4 (2.4%), log-rank test p=0.91). However, there was a significant difference in MACE at 1 year across the 3 MI types (TSTEMI 18 (13.2%), NSTEMI 19 (19.4%), STEMI 11 (6.7%), overall p<0.01).

Conclusion

In comparison to NSTEMI and STEMI, TSTEMI yielded favorable cardiac left ventricular function and scar mass. However, this did not lead to benefit in short term (1-year) outcome; further studies are needed with longer follow-up.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Association of Cardiovascular Imaging (EACVI) Research Grant

P989Determinants of beat-to-beat left ventricular function during atrial fibrillation: a combined clinical-computational study

Funding Acknowledgements

Netherlands Organisation for Scientific Research (NWO-ZonMw, VIDI grant 016.176.340)

Background

The rapid irregular atrial electrical activity during atrial fibrillation (AF) is associated with an irregular and variable left ventricular (LV) systolic pump function. The mechanisms determining LV function during AF remain incompletely understood.

Purpose

To assess the reliability of global longitudinal strain (GLS) as a measure of LV function during AF, and to elucidate how beat-to-beat changes in LV preload and afterload affect LV function during AF.

Methods

Beat-to-beat speckle-tracking echocardiography was performed in patients with persistent AF. A hundred consecutive beats in each patient were imaged during AF and we evaluated the relation between GLS in the image plane (4-chamber view) and (pre-)preceding cycle length (CL) in these patients. We used the CircAdapt cardiovascular system model to simulate cardiac mechanics and hemodynamics during AF for each individual patient 1) by imposing the exact irregular sequence of CL as measured in the patient and 2) by making the atrial myocardium non-contractile. These simulations enabled beat-to-beat quantification of preload (end-diastolic volume, EDV), afterload (systolic aortic pressure) and GLS during AF. 

Results

Clinical data and simulations both showed a negative non-linear relation between preceding CL and GLS (Panel A). Non-linearity was more pronounced at low preceding CLs (<750ms), while GLS at preceding CLs >750ms showed less dependence on CL. Simulating ventricular failure by a reduction in ventricular contractility led to a lower overall GLS and a loss of non-linear response at low CL (Panel A, right, diamonds). Increased GLS at high preceding CL (purple box) was explained by a higher preceding EDV (higher preload) (p < 0.002, Panel B), reflecting the Frank-Starling mechanism of contractile myocardium. At a given preceding CL, variability in GLS was explained by the afterload of the preceding beat, with a lower preceding afterload (systolic aortic pressure) leading to higher GLS (Panel C, yellow box, p < 0.002), but not by changes in preceding preload (Panel C, p non-significant). Preload of the pre-preceding beat also correlated with changes in GLS (Panel C, p < 0.005).  

Conclusions

During AF, GLS depends non-linearly on the preceding CL, with GLS measures performed at longer preceding CLs (>750ms in our cohort) showing a low beat-to-beat variability. Beat-to-beat hemodynamic changes in preceding afterload could explain differences in LV function at same preceding CL. Our combined clinical-computational study highlights the variability in GLS measurement during AF and provides new insight into the potential hemodynamic mechanisms determining LV function in AF patients.

Abstract Figure.

A patient with progressive dyspnoea

Our case report describes the strong ability of noninvasive diagnostic techniques to detect cardiac involvement in advanced systemic amyloid light chain amyloidosis, which was confirmed at autopsy.

Correlating both Aldrich and Hellemond score with cardiac magnetic resonance imaging endocardial surface area calculations in the estimation of the area at risk. Electrocardiography scores and endocardial surface area calculations: do they correlate?

INTRODUCTION

Having a bedside tool such as the ECG to assess the myocardial area at risk in a patient presenting with an ST-elevation myocardial infarction would be of great value to the clinician because this could give an insight in the efficiency of intervention therapy and the left ventricular rest function.

MATERIALS AND METHODS

From the MAST database (n=106), we included 84 patients, all meeting the STEMI criteria, with a first anterior and/or inferior STEMI. From the admission ECG the Aldrich and Selvester scores were measured and the combined Hellemond score was calculated and correlated with the Cardiac Magnetic Resonance (CMR) estimated endocardial surface area (ESA) using the Spearman coefficient.

RESULTS

The correlation between the Aldrich score was r=0.55 (p-value<0.0001) and Hellemond score r=0.45 (p-value<0.0001) with ESA. After exclusion of lateral involvement the correlation increased to 0.62 (p-value<0.0001) for the Aldrich and to 0.49 (p-value<0.0001) for the Hellemond score.

CONCLUSION

The additional ECG estimation of infarcted myocardium does not improve the ECG estimation of ischemic myocardium to CMR-based ESA estimation of the myocardial area at risk. The Aldrich score could be improved for STEMIs with lateral involvement.

Extensive injury after use of a mechanical cardiopulmonary resuscitation device

We report a case of a 49-year-old woman with a ruptured liver and spleen found at autopsy, which may have been related to the use of a mechanical cardiopulmonary resuscitation (CPR) device (AutoPulse, ZOLL Medical Corporation, Chelmsford, Mass). She was admitted because of an out-of-hospital resuscitation, and under the suspicion of a pulmonary embolism, a thrombolytic agent was administered. Despite prolonged continuation of mechanical CPR, she died of persistent asystole. The evidence for improved outcomes after the use of a mechanical CPR device during resuscitation is still scarce. To prevent the unique complications reported here, regular checking of proper position of the chest band during resuscitation is advised.

Cardiac cine MRI: comparison of 1.5 T, non-enhanced 3.0 T and blood pool enhanced 3.0 T imaging

INTRODUCTION

Cardiac cine imaging using balanced steady state free precession sequences (bSSFP) suffers from artefacts at 3.0 T. We compared bSSFP cardiac cine imaging at 1.5 T with gradient echo imaging at 3.0 T with and without a blood pool contrast agent.

MATERIALS AND METHODS

Eleven patients referred for cardiac cine imaging underwent imaging at 1.5 T and 3.0 T. At 3.0 T images were acquired before and after administration of 0.03 mmol/kg gadofosveset. Blood pool signal-to-noise ratio (SNR), temporal variations in SNR, ejection fraction and myocardial mass were compared. Subjective image quality was scored on a four-point scale.

RESULTS

Blood pool SNR increased with more than 75% at 3.0 T compared to 1.5 T (p<0.001); after contrast administration at 3.0 T SNR increased with 139% (p<0.001). However, variations in blood pool SNR at 3.0 T were nearly three times as high versus those at 1.5 T in the absence of contrast medium (p<0.001); after contrast administration this was reduced to approximately a factor 1.4 (p=0.21). Saturation artefacts led to significant overestimation of ejection fraction in the absence of contrast administration (1.5 T: 44.7+/-3.1 vs. 3.0 T: 50.7+/-4.2 [p=0.04] vs. 3.0 T post contrast: 43.4+/-2.9 [p=0.55]). Subjective image quality was highest for 1.5 T (2.8+/-0.3), and lowest for non-enhanced 3.0 T (1.7+/-0.6; p=0.006).

CONCLUSIONS

GRE cardiac cine imaging at 3.0 T after injection of the blood pool agent gadofosveset leads to improved objective and subjective cardiac cine image quality at 3.0 T and to the same conclusions regarding cardiac ejection fraction compared to bSSFP imaging at 1.5 T.

A 60-year-old male with dyspnoea

Images

Myocardial bridging

Images