Cerebral embolic protection devices during transcatheter aortic valve implantation, the current state of the art

Stroke after transcatheter aortic valve (TAVI) is a devastating adverse event. The majority of these occur in the acute phase following TAVI where cerebral embolic events are frequent. Cerebral embolic protection devices (CEPD) have been developed to minimise the risk of peri-procedural ischaemic stroke during TAVI. CEPD have the potential to lower intraprocedural burden of new silent ischaemic brain injury. Several CEPD have been developed, but their clinical benefit remains unknown. Herein, we aimed to review the impact of the use of CEPD, in patients undergoing TAVI, on the reduction of strokes or the onset of new ischaemic lesions.

Is there a relationship between heart rate recovery and blood pressure in white coat hypertension?

Aim    Increasing evidence suggests that autonomic dysfunction may be involved in the etiology of white coat hypertension (WCH). The aim of this study was to evaluate cardiac autonomic function by using heart rate recovery (HRR) indices in patients with WCH classified according to their circadian rhythm type of blood pressure (BP).Material and methods    This cross-sectional study included 120 participants over the age of 18 yrs, including 50 patients diagnosed with WCH and 70 healthy controls with normal in- and out-of-office BP and without any known disease. Circadian rhythm types, i.e., dippers and non-dippers, were identified using ambulatory BP monitoring. The HRR indices were calculated by subtracting the 1st-minute (HRR1), 2nd-minute (HRR2), and 3rd-minute (HRR3) heart rates from the maximal heart rate recorded during stress testing.Results    The lesser decline in nighttime BP (6.4±2.14 and 13.3±2.2 mmHg, respectively; p<0.001) and the smaller mean HRR1 (25.5±3.0 and 30.3±3.1 beats / min, respectively; p<0.001) were evident in WCH non-dippers compared to WCH dippers. Linear regression analysis showed that HRR1 (β±SE=0.43±0.11; p<0.001) and diastolic BP at maximum exercise (β±SE=0.14±0.07; p=0.040) are independent risk factors for the blunted decline in nighttime BP.Conclusion    Delayed recovery of heart rate after an exercise stress test is associated with non-dipper type of circadian rhythm of BP. This was more pronounced in WCH patients, and these patients are at risk of autonomic dysfunction.

Noninvasive Investigation of the Presence and Extent of Coronary Artery Disease by the Evaluation of Fingertip-Reactive Hyperemia

OBJECTIVE

Fingertip-reactive hyperemia-peripheral artery tonometry (RH-PAT) is an emerging novel noninvasive method for evaluating endothelial function. We aimed to evaluate endothelial function with fingertip-reactive hyperemia by RH-PAT in symptomatic patients undergoing elective coronary angiography and to assess the relationship between the degree of endothelial dysfunction (ED) and the presence and the severity of coronary artery disease (CAD).

SUBJECTS AND METHODS

We assessed 92 patients. Before coronary angiography, endothelial function was measured by RH-PAT and reactive hyperemia index (RHI) was obtained. For each patient, the Gensini score was calculated according to the coronary angiographic findings to evaluate the severity of CAD.

RESULTS

In CAD (+) group, RHI (1.35 ± 0.57 vs. 1.74 ± 0.46, p = 0.001) mean values were lower than CAD (-) group. In multivariate logistic regression analysis, age, high-density lipoprotein, and RHI were found to be independent parameters predicting the presence of CAD. In multivariate linear regression analysis, RHI was found to be an independent predictor associated with the severity of CAD. In receiver operating characteristic curve analysis, RHI achieved an area under the curve of 0.763 (95% confidence interval 0.663-0.846, p = 0.001) for the ability to predict the presence of CAD. A cut-off value of 1.49 for an RHI predicted the presence of CAD with a sensitivity of 75% and a specificity of 72.9%.

CONCLUSION

RH-PAT is an objective and highly reproducible test with superior diagnostic accuracy for the evaluation of ED. We found significant correlations between ED and the presence and the severity of CAD.

The impact of percutaneous left atrial appendage closure on left ventricular diastolic function and natriuretic peptide levels

OBJECTIVE

Although the efficacy and safety of left atrial (LA) appendage (LAA) closure in patients with atrial fibrillation (AF) have been well documented in randomized controlled trials and real-world experience, there are limited data in the literature about the impact of LAA closure on diastolic functions. The study aimed to examine the impact of LAA closure on diastolic function and natriuretic peptide levels in patients with AF.

PATIENTS AND METHODS

Twelve non-valvular AF patients with high risk for developing cardioembolic stroke and contraindications to warfarin underwent LAA occlusion with the WATCHMAN device (Atritech Inc., Plymouth, MN, USA). B-type natriuretic peptide levels and detailed diastolic parameters (mitral inflow velocities, deceleration time (DT), flow propagation velocity (Vp), isovolumetric relaxation time (IVRT), mitral annular e', TE-e', IVRT/TE-e', E/Vp, E/e', pulmonary vein flow parameters consisting of S, D, and S/D) were evaluated at baseline and 45 days after LAA closure.

RESULTS

The median age of the patients was 69 (54-78) years and 75% (n: 9) of them were male. All patients completed forty-five days of follow-up. Compared to the baseline values, E/Vp ratio and BNP levels (1.95 (0.94-3.32) vs. 2.37 (1.09-4.46), p= 0.015; 290.0 (90-1271) pg/ml vs. 322.00 (106-1635) pg/ml, p=0.018, respectively) increased, and pulmonary vein S wave and S/D ratio (0.67 (0.33-0.92) vs. 0.38 (0.23-0.91) m/sec, p=0.048; 1.62 (0.86-5.75) vs. 1.33 (0.11-3.35), p=0.019, respectively) decreased after LAA closure.

CONCLUSIONS

In the present study, we demonstrated that patients with AF have shown impaired diastolic functions and elevated BNP levels after the percutaneous closure of the LAA.

Association of changes in the infarct and remote zone myocardial tissue with cardiac remodeling after myocardial infarction: a T1 and T2 mapping study

Tissue structure in the infarct and remote zone myocardium post-acute myocardial infarction (MI) may offer prognostic information concerning left ventricular remodeling. We aimed to identify or establish a relationship between adverse remodeling (AR) and changes (Δ) in T1, T2 mapping and extracellular volume (ECV) in post MI periods. Fifty-four MI patients underwent 3 Tesla CMR performed 2 weeks (acute phase) and 6 months post-MI. We measured T1 mapping with MOLLI sequences and T2 mapping with TrueFISP sequences. Hematocrit was quantified in scanning time. ECV was performed post-gadolinium enhancement. AR was defined as an increase of ≥ 10% in left ventricular end-diastolic volume in 6 months. In the acute phase post-MI, high T2 relaxation times of the infarct and remote zone myocardium were associated with AR (OR 1.15, p = 0.023 and OR 1.54, p = 0.002, respectively). There was a decrease in T2 relaxation times of the remote zone myocardium at 6 months in patients with AR (42.0 ± 4.0 vs. 39.0 ± 3.5 ms, p < 0.001), while insignificant difference was found in patients without AR. Increased ΔECV (%) and decreased remote ΔT2 values were associated with AR (OR 1.04, p = 0.043 and OR 0.77, p = 0.007, respectively). The diagnostic performance analysis in predicting AR showed that acute-phase remote T2 was similar to that of remote ΔT2 (p = 0.875) but was superior to that of ΔECV (%) (ΔAUC: 0.19 ± 0.09, p = 0.038). In both acute phase and change of 6 months post-MI, the T2 relaxation times in remote myocardium are independently associated with AR, and this suggests higher inflammation in the remote myocardium in the AR group than the other group, even though no significant pathophysiological difference was observed in the healing of the infarct zone between both groups.

A systematic review on durability and structural valve deterioration in TAVR and surgical AVR

Mechanical valves and bioprosthetic heart valves are widely used for aortic valve replacement (AVR). Mechanical valves are associated with risk of bleeding because of oral anticoagulation, while the durability and structural valve deterioration (SVD) represent the main limitation of the bioprosthetic heart valves. The implantation of bioprosthetic heart valves is increasing precipitously due aging population, and the widespread use of transcatheter aortic valve replacement (TAVR). TAVR has become the standard treatment for intermediate or high surgical risk patients and a reasonable alternative to surgery for low risk patients with symptomatic severe aortic stenosis. Moreover, TAVR is increasingly being used for younger and lower-risk patients with longer life expectancy; therefore it is important to ensure the valve durability for long-term transcatheter aortic valves. Although the results of mid-term durability of the transcatheter heart valves are encouraging, their long-term durability remains largely unknown. This review summarises the definitions, mechanisms, risk factors and assessment of SVD; overviews available data on surgical bioprosthetic and transcatheter heart valves durability.

Vascular Complications in TAVR: Incidence, Clinical Impact, and Management

Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.

Current Recommendations on Atrial Fibrillation: A Comparison of the Recent European and Canadian Guidelines

BACKGROUND

Guidelines for the diagnosis and management of atrial fibrillation (AF) are frequently published and updated, reflecting the rapid evolution in AF pathogenesis and treatment modalities.

SUMMARY

Recently, 2 important guidelines for the diagnosis and management of atrial AF have been published by the European Society of Cardiology (ESC), and Canadian Cardiovascular Society (CCS). Although the evidence-based recommendations and statements are quite similar, there are some important differences between the ESC and CCS guidelines for AF. Herein, we compared the current recommendations and highlighted the differences from the most recent guidelines for AF. Key Messages: Specifically, key differences can be observed in methods evaluating the recommendations; classifications and the definitions; the symptom score used to guide management decisions, longitudinal patient assessment, and structured characterization; the stroke risk stratification algorithm used to determine indications for oral anticoagulation therapy; the role of acetylsalicylic acid in stroke prevention in AF; the antithrombotic regimens that are employed in the setting of chronic coronary syndromes, acute coronary syndromes, and percutaneous coronary intervention; the target heart rate for rate control; and the algorithms for integrated or holistic management of AF. Differences are observed, particularly when the quality of evidence is moderate or low. More research and randomized controlled studies on major gaps identified in current guidelines will further clarify and modify our future management strategies in AF.

The harm of anticoagulation in patients with low-risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc: inferences from TRAF cohort

OBJECTIVE

There is a gap in the knowledge concerning oral anticoagulation (OAC) in atrial fibrillation (AF) patients with a non-high risk of stroke. CHA2DS2VASc and CHADS2 scores generated imprecise risk estimates for low risk patients. We aimed to assess OAC in patients with low risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc.

PATIENTS AND METHODS

In this study, retrospective nationwide population-based study, data were obtained from the Turkish claims and utilization management system. Patients with non-valvular AF (n=451,113) between 2007 and 2012 sub-divided into those with a CHA2DS2VASc≥1 and CHADS2=0 (n=41,273) who were off-warfarin (n=29,448) and on-warfarin (n=11,825). Stroke and systemic embolism, major bleeding, all-cause mortality, net clinical benefit (NCB) and ultimate NCB (UNCB) were assessed.

RESULTS

Of the total cohort (mean age 66.1 ± 14.1 years, 56.1% female), CHA2DS2VASc improved the net reclassification index of observed 5-year composite thromboembolic endpoint by 6.9% (p<0.05). CHA2DS2VASc reclassified 9.7% low risk patients as high risk. Among reclassified-high-risk category (patients with a CHA2DS2VASc score of ≥1 and CHADS2 score of 0), major bleeding for that prescribed warfarin was 3% and higher than the rate of thromboembolism among those off-warfarin. NCB (-0.035) and UNCB (-0.021) were negative. Death and hospitalization at 1 year were significantly higher for on-warfarin group.

CONCLUSIONS

Clinical outcomes, net clinical benefit indices are negative; rates of death and hospitalization were significantly higher for OAC in reclassified category. This emphasizes the importance of greater attention to balancing the risks and benefits of OAC in patients with low risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc.

High Eosinophil Rates in Patients With Right-to-Left Shunts: An Expected Role, or an Unexpected Risk?

Background and objective Eosinophils are associated with thromboembolic events. Since eosinophils are eliminated in the pulmonary vasculature, right-to-left shunt (RLS) through patent foramen ovale may increase eosinophils in the peripheral blood. In this report, we evaluated the eosinophils of patients with regard to the presence of RLS and its quantity. Patients and methods In this retrospective observational study, we analyzed the complete blood cell count (CBC) of patients with RLS (n=47) and without RLS (n=31) diagnosed by contrast echocardiography (CE). RLS was identified as mild (5-10 bubbles) and moderate shunt (10-25 bubbles). Results Age and CBC were not significantly different between the groups, with the exception of eosinophils. Patients with RLS had higher eosinophils percentage compared to patients without RLS (3.1 ±1.5 vs. 1.7 ±0.7, p=0.001). Additionally, eosinophils percentage was significantly higher in the mild RLS group (2.4 ±0.9 vs. 1.7 ±0.7, p=0.016) and the moderate RLS group (4.3 ±1.6 vs. 1.7 ±0.7, p=0.001) compared to normal subjects. Also, it was significantly higher in the moderate RLS group compared to the mild group (4.3 ±1.6 vs. 2.4 ±0.9, p=0.001). Conclusions Eosinophils percentage was higher in patients with mild and moderate RLS compared to normal individuals. Moreover, the eosinophil rate was higher in patients with moderate RLS than in patients with mild RLS.

Echocardiographic assessment in cardiogenic shock

Echocardiography is the most helpful diagnostic modality in cardiogenic shock, the management of which still remains challenging despite advances in therapeutic options. The presence of cardiogenic shock portends high mortality rates. Therefore, rapid recognition, identification of the underlying cause, and evaluation of the severity of hemodynamic dysfunction are vital for correct management. Whether the cause of shock is unknown, suspected, or established, echocardiography is utilized in its diagnosis and management as well as to monitor progress. It is recommended as the modality of first choice. No other investigative bedside tool can offer comparable diagnostic capability, allowing for exact targeting of the underlying cardiac and hemodynamic problems. Echocardiography can promptly provide an impression of the etiology of shock and the potential line of treatment. Normal left ventricular and right ventricular systolic function, normal cardiac chamber dimensions, absence of any significant valvular pathology, and absence of any pericardial effusion virtually rule out a cardiac cause of shock. This review discusses the role of echocardiography as a decision-making tool in the evaluation and management of cardiogenic shock.

Targeted septal branch microcirculatory embolization with tris-acryl gelatin microspheres in hypertrophic obstructive cardiomyopathy

Background

Alcohol septal ablation (ASA) has been shown to be an effective treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM) who are refractory to medical treatment. ASA may cause some life-threatening complications including conduction disturbances, hemodynamic compromise, ventricular arrhythmias, distant and massive myocardial necrosis. Tris-acryl gelatin microspheres provide consistent and predictable results for effective targeted microcirculatory embolization.

Purpose

We aimed to report our initial experience in tris-acryl gelatin microspheres for septal ablation in HOCM.

Methods

Microspheres are biocompatible, hydrophilic, non-resorbable microspheres which are available in a range of calibrated sphere sizes. In our method, after the cannulation of the left anterior descending by a 6F-7F guiding catheter, a 0.014-inch guidewire is introduced through the catheter and advanced into the septal branch. This septal artery is selectively cannulated with a 4F catheter over the guidewire. Selective angiography of the septal artery is performed to show the anatomy and collateral branches to other coronary arteries. Contrast echocardiography is performed to make sure that the pertinent septal artery is the target vessel supplying the hypertrophied septum. A microcatheter is then advanced deep enough into the septal artery through the 4F catheter. Microspheres/contrast solution infused slowly under fluoroscopic guidance into the targeted septal branches initially using coronary arteriolar sized small particles (diameter 100–300 μm); then the particle size was stepped up to larger particles (diameter 300–500 μm) until a complete block of the arteriolar flow is achieved.

Results

Septal ablation with tris-acryl gelatin microspheres was performed in 6 patients (mean age = 47.8±11.5; 5 males). Immediately after the procedure peak left ventricular outflow (LVOT) gradient reduced significantly both for direct catheter (69.0±13.8 vs. 8.2±3.7 mmHg, P&lt;0.001) and Doppler echocardiographic measurements (78.8±19.9 vs. 12.0±5.1 mmHg, P&lt;0.001). Post-procedure peak serum CK- MB fraction concentration was 82±22 ng/ml (reference range is 0 - 4.9 ng/mL) and peak serum troponin T concentration was 1.2 ng/ml [(interquartile range, 0.4–1.4), (reference range is 0 - 0.017 ng/mL)]. LVOT tract gradient reduction persisted after 6 months follow-up. There was no significant complication during the procedure and within a 6 months follow-up period.

Conclusions

The novel strategy by targeted septal branch microcirculatory embolization with tris-acryl gelatin microspheres seems to be an efficient and safe approach to HOCM. Further experience is needed in order to assess the long-term efficacy and safety of this technique.

Funding Acknowledgement

Type of funding source: None

Effects of bisphosphonate and calcium carbonate on normal aortic valve and cholecalciferol induced in vivo rabbit aortic stenosis model

Background

Calcific aortic valve disease (CAVD) is the most common valvular heart disease. Bisphosphonates are stable analogs of pyrophosphates and commonly prescribed in the treatment of osteoporosis. The effects of bisphosphonate treatment on CAVD are not clearly known and there are inconsistent results. Similarly, the effect of calcium supplementation on CAVD remains controversial.

Purpose

The aim of this study was to assess the effects of bisphosphonate therapy on the normal aortic valve and vitamin D induced in vivo rabbit aortic stenosis (AS) model.

Methods

The impact of calcium supplementation on the rabbit AS model was also evaluated. A total of 30 New Zealand white rabbits were divided into five equal groups: no treatment (Group I); 25,000 IU/day vitamin D3 (cholecalciferol) (Group II, rabbit AS model); 25,000 IU/day cholecalciferol plus 2500 mg/day calcium carbonate (Group III); 20 μg/kg/week intravenous alendronate (Group IV) and 25,000 IU/day cholecalciferol plus 2500 mg/day calcium carbonate plus 20μg/kg/week alendronate (Group V). Echocardiography was performed at baseline and after 12 weeks of treatment. The left ventricular mass index (LVMI), aortic valve area (AVA), transvalvular velocities and gradients were recorded. Radiologic and histopathologic examination was performed at the end of the 12th week. Control animals displayed no abnormalities of the aortic valve.

Results

There was no echocardiographic change in Group IV. In Groups II, III and V, there was a significant decrease in AVA and increases in transvalvular velocities and gradients. However, these stenotic changes were significantly prominent in Group V (p=0.001 for all, via repeated measures ANOVA). Moreover, LVMI was only increased in Group V (p&lt;0.05). Calcification of aortic valvar complex was detected in 14 (46.7%) cases by radiologic imaging and 10 (33.3%) cases by histopathologic examination. Most frequent calcification was found in Group V (5 for each method, 83.3%). Agatston, volume and equivalent mass scores of calcific foci in Group V were significantly higher than other groups (p&lt;0.05 for all). There was no significant difference between groups regarding with presence of osteoclasts in calcific foci.

Conclusion

Calcium supplementation has no effect on the in vivo rabbit AS model. Alendronate treatment aggravates the stenosis and increases the calcification in the rabbit AS model. Alendronate treatment has no effect on the normal valve in which there was no osteogenesis and osteoclastogenesis. Based on these findings, in patients with CAVD, alendronate treatment should be given with regular echocardiographic follow-up or may not be preferred.

Central figure

Funding Acknowledgement

Type of funding source: None

Prolonged Tp-e interval and Tp-e/QT ratio in patients with mitral annulus disjunction

Background

Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point. MAD has been associated with mitral valve prolapse (MVP) and arrhythmic events. T-wave peak to T-wave end interval (Tp-e) and Tp-e/QTc are electrocardiographic (ECG) indices to predict ventricular tachyarrhythmia and cardiovascular mortality.

Purpose

We aimed to evaluate ventricular repolarization dispersion by using the Tp-e interval and Tp-e/QT ratio in patients with MAD and healthy controls.

Methods

A total of 35 patients with MAD (age 40.4±8.2 years; 66% female) and 37 healthy controls (age 37.6±9.5 years; 68% female) were enrolled. All subjects were evaluated by 12 lead standard ECG, 24-hour ambulatory ECG, and transthoracic echocardiography. The MAD distance was measured from the left atrial wall-mitral valve leaflet junction to the top of the left ventricular wall during end-systole in the parasternal long-axis view. The standard 12-lead electrocardiograms were analyzed; QTc, Tp-e and Tp-e/QTc were calculated. The Tp-e interval was defined as the interval from the peak of the T wave to the end of the T wave from precordial leads. Finally, the Tp-e/QT ratio was calculated from these measurements. The normality assumption was checked with the Shapiro-Wilk test and the Mann–Whitney U test was used for inter-group comparisons.

Results

Tp-e interval (61.9±6.0 ms vs. 77.1±5.9 ms, p&lt;0.001) and Tp-e/QT ratio (0.14±0.01 vs. 0.17±0.02, p&lt;0.001) were significantly prolonged in patients with MAD than in the control group. MVP was present in 24 (69%) patients with MAD. The prevalence of 30 premature ventricular contractions / hour were higher in MAD subgroup without MVP than those MAD with MVP (54.5% vs 16.7%, p=0.041). Mean MAD distance measured by echocardiography was 5.7±1.5 mm. The Spearman's rank-order correlation analyses revealed positive correlations of MAD distance with Tp-e interval (r=0.620, p=0.001) and Tp-e/QT ratio (r=0.372, p=0.028).

Conclusions

The patients with MAD had a prolonged Tp-e interval and Tp-e/QT ratio compared with normal subjects. Furthermore, this prolongation was well correlated with MAD distance. Patients with MAD, particularly with higher MAD distance, should be followed closely for arrhythmic outcomes.

MAD distance and Tp-e interval

Funding Acknowledgement

Type of funding source: None

The Issue of Subclinical Leaflet Thrombosis After Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) has been considered an important therapy for the treatment of symptomatic severe aortic stenosis. Although the devices and the techniques have been improved some complications may occur and several issues still need to be addressed. The issue of subclinical leaflet thrombosis (SLT) has been recognized as a complication after TAVI, and its incidence ranges from 0% to 40%. Nowadays, computed tomography is considered as the standard method for diagnosis of SLT. The concept of hypoattenuated leaflet thickening (HALT), reduced leaflet motion (RELM), and hypoattenuation affecting motion (HAM) have been used in this topic. Most patients who had SLT were taking single or dual antiplatelet therapy. In addition, these medications were not effective in resolving this complication after TAVI. However, there is a suggestion that oral anticoagulants have a protective and therapeutic effect. With the increasing use of TAVI, it is necessary to have better knowledge about several aspects of this complication, because it may have impact on prognosis. Therefore, some aspects of SLT diagnosis, management, and prognosis are not yet fully understood.

Evaluation of Effectiveness and Safety of Transcatheter Mitral Valve Repair Under Moderate Conscious Sedation

BACKGROUND

Transcatheter mitral valve repair (TMVR) using the MitraClip system (Abbott Vascular) has become a world-wide, well-established therapeutic alternative to symptomatic patients with severe mitral regurgitation (MR) and prohibitive surgical risk. Currently, TMVRs are performed under general anesthesia. Herein, we aimed to present the effectiveness and safety of TMVR under moderate conscious sedation (MCS).

METHODS

A total of 102 patients with severe MR (49 primary MRs and 53 secondary MRs) who underwent TMVR with MCS between December 2018 and December 2019 were included. We prospectively evaluated clinical and procedural outcomes using medical records of these patients.

RESULTS

Among all the patients, the mean age was 81.6 ± 3.5 years, 60 (59%) were women, and 72.7% had coronary artery disease. The mean left ventricular ejection fraction was 47.9 ± 12.7%, while the MR grade was 3+ in 18.2% of the patients and 4+ in 81.8%. A mean of 1.2 ± 0.4 clips (range, 1-2 clips) were implanted per patient. Postprocedural MR grade was 1+ or lower in 64 patients (63.6%) and 2+ in 38 patients (36.4%). Procedural duration, clip implant time, and fluoroscopy times were 60 ± 10.5 minutes, 19.5 ± 8.0 minutes, and 10.1 ± 2.1 minutes, respectively. The median required dosage of propofol was 140 mg (interquartile range, 84-156 mg). No complications arose from MCS. There was no need for conversion to general anesthesia in any of these patients during the procedure.

CONCLUSIONS

TMVR can be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the TMVR procedure and reduce procedural time and costs, while increasing overall patient satisfaction.

Switching from ramipril to sacubitril/valsartan favorably alters electrocardiographic indices of ventricular repolarization in heart failure with reduced ejection fraction

Background: Angiotensin receptor neprilysin inhibitor (ARNI, sacubitril/valsartan) reduces sudden death in heart failure with reduced ejection fraction (HFrEF). Corrected QT (QTc), T-wave peak to T-wave end interval (Tp-e) and Tp-e/QTc are electrocardiographic indices of ventricular repolarization heterogeneity. We aimed to assess the effects of switching from ramipril to ARNI on electrocardiographic indices of ventricular repolarization.Methods: A total of 48 patients with HFrEF (mean age: 63.3 ± 11.7 years; 36 males, 77.1% ischaemic etiology) were enrolled. All patients had New York Heart Association functional class II-III, left ventricular ejection fraction ≤35% and previously switched from ramipril to ARNI treatment. The standard 12-lead electrocardiograms on ramipril treatment and 1 month after ARNI treatment were analysed; heart rate, QTc, Tp-e and Tp-e/QTc were calculated. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores and N-terminal pro-BNP (NT-proBNP) values were recorded.Results: QTc (415.2 ± 19.7 ms vs. 408.5 ± 20.8 ms, p = 0.022), Tp-e (100.7 ± 13.8 ms vs. 92.9 ± 12.1 ms, p < 0.001), Tp-e/QTc (0.242 ± 0.028 vs. 0.227 ± 0.029, p = 0.003) and heart rate (73.2 ± 4.7 bpm vs. 71.1 ± 4.9 bpm, p = 0.027) were reduced after ARNI. ARNI switch associated with improvement in MLWHFQ scores (32.4 ± 7.1 ms vs. 22.6 ± 7.0 ms, p < 0.001) and reduction of NT-proBNP (2457 ± 1879 pg/ml to 1377 ± 874 pg/ml, p < 0.001). Pearson's correlation analysis revealed moderate correlations of MLWHFQ score with Tp-e (r = 0.543, p = 0.001) and Tp-e/QTc (r = 0.556, p = 0.001).Conclusions: Switching from ramipril to ARNI favourably alters QTc, Tp-e and Tp-e/QTc in HFREF. ARNI reduces symptoms of HFREF assessed by MLWHFQ and lowers NT-proBNP levels. Reduction in Tp-e and Tp-e/QTc correlate with clinical improvement in patients with HFrEF.

Atrial fibrillation in acute heart failure: A position statement from the Acute Cardiovascular Care Association and European Heart Rhythm Association of the European Society of Cardiology

Atrial fibrillation and acute heart failure frequently co-exist and can exacerbate each other. Their combination leads to increased morbidity and mortality. However, the prevalence and significance, as well as the treatment, of atrial fibrillation in acute heart failure are not well studied. Management of atrial fibrillation in acute heart failure requires a multidisciplinary team approach. Treatment of underlying disease(s), identification and treatment of potentially correctable causes and precipitating factors and anticoagulation are crucial. In this article, current evidence on atrial fibrillation in the setting of acute heart failure is summarised. The recommendations on management of atrial fibrillation in the prehospital stage, the treatment of reversible causes, when and how to use rate or rhythm control, maintenance of sinus rhythm, catheter ablation and pacing, anticoagulation, as well as measures on prevention of atrial fibrillation are provided.

Effects of angiotensin receptor neprilysin inhibition on P-wave dispersion in heart failure with reduced ejection fraction

BACKGROUND

Angiotensin receptor neprilysin inhibitors (ARNI; sacubitril/valsartan combination) decrease morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). Increased P‑wave duration and P‑wave dispersion (P_d) reflect prolongation of atrial conduction and correlate with atrial fibrillation. Here, we aimed to assess the effects of switching from valsartan to ARNI treatment on the basis of P‑wave indices.

METHODS

A total of 28 patients with HFrEF (mean age, 64.8 ± 10.6 years; 18 males, 78.6% ischemic etiology) were included. All patients had New York Heart Association functional class II-III, left ventricular ejection fraction ≤35%, and had been switched from valsartan to ARNI treatment. Standard 12-lead electrocardiograms from patients on valsartan treatment and electrocardiograms 1 month after ARNI treatment were analyzed; heart rate, maximum P‑wave duration (P_max), minimum P‑wave duration (P_min), and P_d were calculated. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores and N‑terminal pro-brain natriuretic peptide (NT-proBNP) values were recorded.

RESULTS

The P_max (135.6 ± 32.1 ms vs. 116.1 ± 14.1 ms, p = 0.041) and P_d (33.6 ± 7.9 vs. 28.6 ± 5.3, p = 0.006) values were significantly reduced after ARNI treatment. Furthermore, ARNI treatment was associated with an improvement in MLWHFQ scores (31.2 ± 6.2 ms vs. 23.2 ± 7.0 ms, p < 0.001) and with a reduction in NT-proBNP values (1827.3 ± 1287.3 pg/ml vs. 1074.4 ± 692.3 pg/ml, p < 0.001). There were moderately positive correlations between the reduction in P_d and the improvement in MLWHFQ scores (r = 0.408, p = 0.031) and the reduction in NT-proBNP values (r = 0.499, p = 0.007) CONCLUSION: Switching to ARNI treatment alters P_d and P_max favorably in patients with HFrEF. The reduction in atrial inhomogeneous conduction assessed by P_d was correlated with clinical improvement and reduced NT-proBNP levels in patients with HFrEF.

Assessment of Vascular Patency and Inflammation with Intravascular Optical Coherence Tomography in Patients with Superficial Femoral Artery Disease Treated with Zilver PTX Stents

PURPOSE

Zilver PTX nitinol self-expanding drug-eluting stent with paclitaxel coating is effective for treatment of superficial femoral artery (SFA) disease. However, as with any stent, it induces a measure of vascular inflammatory response. The current clinical trial (NCT02734836) aimed to assess vascular patency, remodeling, and inflammatory markers with intravascular optical coherence tomography (OCT) in patients with SFA disease treated with Zilver PTX stents.

METHODS

Serial OCT examinations were performed in 13 patients at baseline and 12-month follow-up. Variables evaluated included neointimal area, luminal narrowing, thrombus area, stent expansion as well as measures of inflammation including, peri-strut low-intensity area (PLIA), macrophage arc, neovascularization, stent strut apposition and coverage.

RESULTS

Percentage of malapposed struts decreased from 10.3 ± 7.9% post-intervention to 1.1 ± 2.2% at 12-month follow-up, but one patient showed late-acquired stent malapposition (LASM). The percent of uncovered struts at follow-up was 3.0 ± 4.5%. Average expansion of stent cross-sectional area from baseline to follow-up was 35 ± 19%. The average neointimal area was 7.8 ± 3.8 mm². Maximal luminal narrowing was 61.1 ± 25.0%, and average luminal narrowing was 35.4 ± 18.2%. Average peri-strut low-intensity area (PLIA) per strut was 0.017 ± 0.018 mm². Average number of neovessels per mm of stent was 0.138 ± 0.181. Average macrophage angle per frame at follow-up was 7 ± 11°. Average thrombus area at follow-up was 0.0093 ± 0.0184 mm².

CONCLUSION

At 12-month follow-up, OCT analysis of Zilver PTX stent shows outward remodeling and minimal neointimal growth, but evidence of inflammation including PLIA, neovessels, thrombus and macrophages.

SUMMARY

Thirteen patients with PAD had paclitaxel-coated stents implanted in their SFAs and were then imaged with OCT at baseline and 12-month follow-up. OCT proxy metrics of inflammation were quantified.

Association of Serum Copeptin Levels with Patency of Infarct-Related Arteries in Patients with ST-Segment Elevation Myocardial Infarction

Background

Copeptin is widely used as a predictor of an adverse prognosis in many clinical conditions. Reduced antegrade coronary flow in an infarct-related artery (IRA) is associated with adverse clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate whether copeptin level on admission was associated with IRA patency in STEMI patients.

Methods

A total of 88 patients were enrolled into the study and divided into two groups according to TIMI flow grade in the IRA before primary percutaneous coronary intervention.

Results

White blood cell count (p = 0.015), neutrophils (p = 0.047), N-terminal pro-brain natriuretic peptide (NTproBNP) (p < 0.001), copeptin (p < 0.001) and peak troponin I (p = 0.001) were significantly higher in the occluded IRA group with a significantly lower serum sodium level (p < 0.001). Age- and gender-adjusted multivariate analysis revealed that copeptin (OR = 1.970; p = 0.001), peak troponin I (1.055; p = 0.005) and NTproBNP (OR = 1.003; p = 0.010) were independent predictors of an occluded IRA. A copeptin cut-off value of > 6.8 ng/mL was found to predict an occluded IRA with a sensitivity of 80% and specificity of 100% (area under the curve: 0.917; p < 0.001). Performance ranking of the biomarkers that could predict an occluded IRA showed copeptin > peak troponin I = NTproBNP.

Conclusions

Copeptin levels were higher in the patients with an occluded IRA and STEMI. Higher levels of copeptin predicted an occluded IRA in the patients with STEMI who were admitted to the emergency department during the first three hours of chest pain.

Fingertip Reactive Hyperemia Peripheral Arterial Tonometry Score Predicts Response to Biventricular Pacing

Purpose

The objectives of this study were to: (i) evaluate endothelial function via fingertip reactive hyperemia peripheral arterial tonometry (RH-PAT) among heart failure (HF) patients receiving cardiac resynchronization therapy (CRT), (ii) assess the effects of CRT on RH-PAT score, and (iii) investigate whether RH-PAT score can identify CRT response.

Methods

A total of 63 patients (61.8 ± 10.3 years; 50 males; left ventricular (LV) ejection fraction 24.3 ± 3.9%) with HF who received CRT were enrolled. Endothelial function via RH-PAT was assessed 1 day before and 6 months after CRT. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) was used to assess clinical improvements. CRT response was defined as a reduction in LV end-systolic volume ≥ 15% at 6 months.

Results

A RH-PAT score of < 1.7 signified a cut-off for endothelial dysfunction (ED). Baseline ED was observed among 43 (68.3%) patients and was more prevalent in responders (76.1% vs. 47.1%, p = 0.037). RH-PAT score improved 6 months after CRT (1.58 ± 0.35 vs. 1.71 ± 0.31, p = 0.012). A RH-PAT score of < 1.7 was a significant independent predictor of CRT response in multivariate logistic regression analysis (β = 1.275, OR = 3.512, 95% CI = 1.231-11.477, p = 0.032). The severity of ED was an independent predictor of LV reverse remodeling (β = -8.873, p = 0.015). Spearman's correlation analysis revealed moderate positive correlations between an improvement in RH-PAT (ΔRH-PAT) and LV reverse remodeling (r = 0.461, p = 0.001) and MLWHFQ score (r = 0.440, p = 0.001).

Conclusions

ED detected via RH-PAT could predict the response to CRT. The RH-PAT score increased 6 months after CRT and was correlated with echocardiographic and clinical improvements.

Predictors of sinus rhythm after electrical cardioversion of atrial fibrillation: results from a data mining project on the Flec-SL trial data set

Aims

Data mining is the computational process to obtain information from a data set and transform it for further use. Herein, through data mining with supportive statistical analyses, we identified and consolidated variables of the Flecainide Short-Long (Flec-SL-AFNET 3) trial dataset that are associated with the primary outcome of the trial, recurrence of persistent atrial fibrillation (AF) or death.

Methods and results

The 'Ranking Instances by Maximizing the Area under the ROC Curve' (RIMARC) algorithm was applied to build a classifier that can predict the primary outcome by using variables in the Flec-SL dataset. The primary outcome was time to persistent AF or death. The RIMARC algorithm calculated the predictive weights of each variable in the Flec-SL dataset for the primary outcome. Among the initial 21 parameters, 6 variables were identified by the RIMARC algorithm. In univariate Cox regression analysis of these variables, increased heart rate during AF and successful pharmacological conversion (PC) to sinus rhythm (SR) were found to be significant predictors. Multivariate Cox regression analysis revealed successful PC as the single relevant predictor of SR maintenance. The primary outcome risk was 3.14 times (95% CI:1.7-5.81) lower in those who had successful PC to SR than those who needed electrical cardioversion.

Conclusions

Pharmacological conversion of persistent AF with flecainide without the need for electrical cardioversion is a powerful and independent predictor of maintenance of SR. A strategy of flecainide pretreatment for 48 h prior to planned electrical cardioversion may be a useful planning of a strategy of long-term rhythm control.

Physical inactivity and low quality of life of Turkish women after hospitalization for coronary heart disease: Inferences from EUROASPIRE III

OBJECTIVE

The present objective was to compare changes in lifestyle between (i) Turkish women and Turkish men, and (ii) Turkish women and European women, after hospitalization for coronary heart disease (CHD). Risk factor management, physical activity, mood, and quality of life (QOL) indices were compared.

METHODS

A total of 2268 women (25.3% of 8966 patients, mean age: 65.8±9.0 years) were interviewed using the European Action on Secondary and Primary Prevention by Intervention to Reduce Events III (EUROASPIRE III). In the Turkey cohort, 65 women (mean age: 63.3±9.9 years) and 273 men (mean age: 59.1±9.6 years) were interviewed, and underwent clinical and biochemical tests at a minimum of 6 months after hospital admission. Patients completed the Godin Leisure-Time Exercise Questionnaire (GLTEQ), the International Physical Activity Questionnaire (IPAQ), the Hospital Anxiety and Depression Scale (HADS), and questionnaires assessing QOL.

RESULTS

After hospitalization for CHD, (i) Turkish women have lower participation in cardiac rehabilitation (CR) programs and lower physical activity indices than European women, (ii) Turkish women have lower physical activity indices than Turkish men, (iii) HADS anxiety scores and HADS depression scores were higher for Turkish women than for Turkish men, (iv) HADS anxiety scores and HADS depression scores were higher for Turkish women than for European women, (v) QOL indices were lower for Turkish women than for either European women or Turkish men.

CONCLUSION

Turkish women engage in less physical activity, have lower QOL, and have higher rates of depression and anxiety after hospitalization for CHD than either of the other groups assessed. Every effort should be made to increase physical activity, and CR program adherence in general, particularly in female patients.