Combination anticoagulation strategy in pregnancy with mechanical valves: The KYBELE study.

BACKGROUND: Optimal first-trimester anticoagulation is still challenging in pregnant women with mechanical heart valves (MHVs) requiring high-dose warfarin. This multicenter prospective study aims to determine the optimal anticoagulation regimens for pregnant patients with MHVs. METHODS: All women were allocated to one of three treatment options during first trimester including lone low-molecular-weight heparin (LMWH), combination of LMWH + 2.5 mg warfarin, and LMWH+4 mg warfarin. Primary maternal outcome included a combination of death, thromboembolism, severe bleeding, and need for treatment of mechanical valve thrombosis (MVT). Any fetal loss was determined as primary fetal outcome. RESULTS: The study included 78 pregnancies in 65 women with MHVs. Primary maternal outcome rate was 44%, 12.5%, 3.5%, respectively. The rates of primary maternal outcome (44 vs 3.5%, P < .001), obstructive MVT (16 vs 0%, P = .04), MVT requiring treatment (28 vs 0%, P = .003), and cerebral embolism (24 vs 3.4%, P = .041) were found to be significantly higher in lone LMWH group compared to LMWH + 4 mg warfarin group. Moreover, the rates of primary maternal outcome (12.5 vs 44%, P = .015) and treatment for MHV thrombus (4.2 vs 28%, P = .049) were significantly lower in LMWH + 2.5 mg warfarin group compared to lone LMWH group. The incidences of fetal loss were 8 (32%) in the lone LMWH group, 8 (33.3%) in LMWH + 2.5 mg warfarin group, and 11 (37.9%) in LMWH + 4 mg warfarin group (P = .890 for 3-group).Warfarin related-embryopathy was not observed in any case. CONCLUSIONS: The combined anticoagulation strategy of LMWH plus low-dose warfarin during the first trimester of pregnancy may result in less maternal complications with comparable fetal outcomes in patients with MHVs. CONDENSED ABSTRACT: Low-molecular-weight heparin (LMWH) is thought to be safer for the fetus, however it is suspected to be less protective for the mother. To solve this dilemma, the authors suggested a novel anticoagulation strategy in pregnant women with prosthetic valves. Seventy-eight pregnancies of 65 women (median age 32 [27-35] years) were included in the study. A combination of LMWH and a reduced dose warfarin were associated with low rates of thrombus-related complications in pregnant patients with mechanical heart valves.

Clinical implication of the Naples prognostic score on transcatheter aortic valve replacement in patients with severe aortic stenosis.

BACKGROUND: One of the hallmarks of frailty in patients with severe aortic stenosis (AS) is malnutrition, for which one of the most up-to-date scoring systems is the Naples prognostic score (NPS). This study sought to investigate the predictive role of the NPS in determining mortality in patients undergoing transcatheter aortic valve replacement (TAVR) under long-term follow-up. METHODS: A total of 430 consecutive patients with symptomatic severe AS who underwent TAVR were included retrospectively. The primary endpoint of the study was the long-term all-cause mortality. The study population was divided into two groups according to the NPS value, including Group 1 (NPS 0-2) and Group 2 (NPS 3-4). RESULTS: The all-cause mortality occurred in 250 patients (62.5%) patients during a follow-up time of 40.6 (22.0-69.4) months. During the follow-up period, all-cause mortality was higher in Group 2 compared with Group 1 (87.9% vs. 42.9%, p < 0.001). Older age (p < 0.001), chronic obstructive pulmonary disease (p = 0.015), left ventricular ejection fraction (p = 0.021), and being in Group 2 (high NPS) (hazard ratio: 7.058, 95% confidence interval: 5.174-9.629, p < 0.001) were found to be independent predictors of all-cause mortality at long-term follow-up. CONCLUSION: The NPS as a malnutrition and inflammation marker in patients with severe aortic stenosis who underwent TAVR provides valuable information for all-cause mortality under long-term follow-up.

Cardiovascular outcomes of complex bifurcation lesions following double kissing crush or nano-crush techniques: The multicenter EVOLUTE-CRUSH V study.

BACKGROUND: Double kissing crush (DKC) and nano-crush (NC) techniques are frequently used, but the comparison for both techniques is still lacking. The goal of this multicenter study was to retrospectively assess the midterm clinical results of DKC and NC stenting in patients with complex bifurcation lesions (CBLs). METHODS: A total of 324 consecutive patients [male: 245 (75.6%), mean age: 60.73 ± 10.21 years] who underwent bifurcation percutaneous coronary intervention between January 2019 and May 2023 were included. The primary endpoint defined as the major cardiovascular events (MACE) included cardiac death, target vessel myocardial infarction (TVMI), or clinically driven target lesion revascularization (TLR). Inverse probability weighting (IPW) was performed to reduce treatment selection bias. This is the first report comparing the clinical outcomes of DKC and NC stenting in patients with CBL. RESULTS: The initial revascularization strategy was DKC in 216 (66.7%) cases and NC in 108 (33.3%) patients. SYNTAX scores [25.5 ± 6.73 vs. 23.32 ± 6.22, p = 0.005] were notably higher in the NC group than the DKC group. The procedure time (76.98 ± 25.1 vs. 57.5 ± 22.99 min, p = 0.001) was notably higher in the DKC group. The incidence of MACE (18.5 vs. 9.7%, p = 0.025), clinically driven TLR (14.8 vs. 6%, p = 0.009), and TVMI (10.2 vs. 4.2%, p = 0.048) were notably higher in the NC group than in the DKC group. The midterm MACE rate in the overall population notably differed between the NC group and the DKC group (adjusted HR (IPW): 2.712, [95% CI: 1.407-5.228], p = 0.003). CONCLUSION: In patients with CBLs, applying the DKC technique for bifurcation treatment had better ischemia-driven outcomes than the NC technique.

Comparison of long-term outcomes of double kissing crush versus T and minimal protrusion techniques in complex bifurcation lesions: The EVOLUTE-CRUSH II registry.

BACKGROUND: Double kissing (DK)-crush and T-stenting and small protrusion (TAP) techniques are gaining popularity, but the comparison for both techniques is still lacking. This study sought to retrospectively evaluate the long-term outcomes of DK-crush and TAP techniques in patients with complex bifurcation lesions. METHODS: A total of 255 (male: 205 [80.3%], mean age: 59.56 ± 10.13 years) patients who underwent coronary bifurcation intervention at a single-center between January 2014 and May 2021 were included. Angiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven-target lesion revascularization (TLR). The regression models were adjusted applying by the inverse probability weighted (IPW) approach to reduce treatment selection bias. RESULTS: The initial management strategy was DK-crush in 152 (59.6%) patients and TAP in 103 (40.4%) cases. The SYNTAX scores (24.58 ± 7.4 vs. 24.26 ± 6.39, p = 0.846) were similar in both groups. The number of balloon (6.32 ± 1.82 vs. 3.92 ± 1.19, p < 0.001) usage was significantly higher in the DK-crush group than in the TAP group. The rates of TLF (11.8 vs. 22.3%, p = 0.025) and clinically driven TLR (6.6 vs. 15.5%, p = 0.020) were significantly lower in the DK-crush group compared to the TAP group. The long-term TLF was significantly higher in the TAP group compared to the DK-crush group (unadjusted HR: 1.974, [95% CI: 1.044-3.732], p = 0.035 and adjusted HR [IPW]: 2.498 [95% CI: 1.232-5.061], p = 0.011). CONCLUSION: The present study showed that the DK-crush technique of bifurcation treatment was associated with lower long-term TLF and TLR rates compared to the TAP technique.

Long-term outcomes following double kissing crush or mini-culotte stenting for complex coronary bifurcation lesions: the EVOLUTE-CRUSH IV study.

BACKGROUND: This study aimed to evaluate the long-term outcomes of double kissing crush stenting (DKC) and mini-culotte technique (MCT) in patients with complex bifurcation lesions. METHODS: This retrospective study enrolled 236 patients who underwent percutaneous coronary intervention (PCI) for complex coronary bifurcation disease between January 2014 and November 2022. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, myocardial infarction (MI), or clinically driven target lesion revascularization (TLR). The secondary endpoint was major cardiovascular and cerebral events (MACCE) including all-cause death, MI, TLR, stroke, or stent thrombosis. The regression models were adjusted by applying the inverse probability weighted (IPW) approach to reduce treatment selection bias. RESULTS: The initial management strategy was DKC in 154 (65.3%) patients and MCT in 82 (34.7%) patients (male: 194 [82.2%], mean age: 60.85 ± 10.86 years). The SYNTAX scores were similar in both groups. The rates of long-term TLF and MACCE rates were 17.4% and 20%, respectively. The rate of TLF (26.8% vs. 12.3%, p = 0.005) was higher in patients treated with MCT than those treated with the DKC technique, mainly driven by more frequent TLR (15.9% vs. 7.1%, p = 0.035). The long-term TLF and MACCE rates were notably lower in the DKC group compared to the others: adjusted hazard ratio (HR; IPW): 0.407, p = 0.009 for TLF, and adjusted HR(IPW): 0.391 [95% CI: 0.209-0.730], p = 0.003 for MACCE. CONCLUSION: At long-term follow-up, the rates of TLF and MACCE were 17.4% and 20%, respectively. However, long-term TLF was significantly higher in patients treated with MCT than those treated with the DKC technique, primarily due to a more frequent occurrence of clinically driven TLR.

Relationship between myocardial bridging and fatal ventricular arrhythmias in patients with hypertrophic cardiomyopathy: the HCM-MB study.

BACKGROUND: Myocardial bridging (MB) and hypertrophic cardiomyopathy (HCM) are associated with the risk of fatal ventricular arrhythmias (VAs). The goal of the study was to determine the relationship between MB and fatal VAs in HCM patients with implantable cardiac defibrillators (ICD). METHODS: A total of 108 HCM patients (mean age: 46.6 ± 13.6 years; male: 73) were enrolled in this retrospective study. All patients underwent transthoracic echocardiography and coronary computed tomography angiography. Fatal VAs including sustained ventricular tachycardia and ventricular fibrillation were documented in ICD records. RESULTS: There were documented fatal VAs in 29 (26.8%) patients during a mean follow-up time of 71.3 ± 30.9 months. Compared with the other groups, the fatal VA group had a higher incidence of the following: presence of MB (82.8 vs. 38%, p < 0.001), deep MB (62.1 vs. 6.3%, p < 0.001), very deep MB (24.1 vs. 0%, p < 0.001), long MB (65.5 vs. 11.4%, p < 0.001), presence of > 1 MB (17.2 vs. 0%, p = 0.001), and MB of the left anterior descending artery (79.3 vs. 17.7%, p < 0.001) . Sudden cardiac death (SCD) risk score (hazard ratio: 1.194; 95% CI: 1.071-1.330; p = 0.001) and presence of MB (hazard ratio: 3.815; 95% CI: 1.41-10.284; p = 0.008) were found to be independent predictors of fatal VAs in HCM patients. CONCLUSIONS: The current data suggest that the SCD risk score and presence of MB were independent risk factors for fatal VAs in patients with HCM. In addition to conventional risk factors, the coronary anatomical course can provide clinicians with valuable information when assessing the risk of fatal VAs in HCM patients.

Cardiovascular evaluation of pregnant women with hypertrophic cardiomyopathy.

BACKGROUND: The effect of physiological circulatory changes during pregnancy on hypertrophic cardiomyopathy (HCM) has been reported with limited data. This study aimed to provide information regarding outcomes of pregnant women with HCM and to identify predictors of major adverse cardiac event (MACE). METHODS: A total of 45 pregnancies with HCM were retrospectively reviewed. The primary endpoint was a MACE that occurred within an 8­week period after delivery, including maternal death, heart failure (HF), syncope, and malignant ventricular arrhythmias (VAs). Baseline and outcome data were analyzed for all patients. Patients with and without MACE were compared, and patients with obstructive HCM were compared with those who had non-obstructive HCM. The study population was divided into two subgroups of patients having or not having an implantable cardioverter defibrillator implantation (ICD). RESULTS: At least one MACE occurred in 11 patients (24.4%); six patients developed HF (13.3%), six had a ventricular tachyarrhythmia (13.3%), and two had syncope (4.4%). New York Heart Association functional class of ≥ II, presence of HF signs before pregnancy, increased left ventricular outflow tract (LVOT) gradient were significantly associated with MACE. Fatal VAs were seen during pregnancy in one of five HCM patients with ICD. In the ROC curve analysis, an LVOT gradient higher than 53.5 mm Hg predicted the presence of MACE with a sensitivity of 90.9% and a specificity of 73.5%. This study is the largest series in the literature representing pregnant women who had HCM and ICD. CONCLUSION: The current data suggest that HF and high LVOT gradients are important risk factors for the development of cardiac complications.

Monocyte to HDL ratio may predict thrombosis in patients with mechanical mitral and aortic valve prosthesis.

Increased inflammatory biomarkers have been reported in prosthetic heart valve thrombosis (PHVT). Monocyte to HDL ratio (MHR) and albumin to CRP levels (CAR) are two biomarkers used widely for systemic inflammation but there is a lack of data on prosthetic heart valves. This study aimed to find out the potential predictive value of MHR and CAR for PHVT. Patients who had the diagnosis of mechanical mitral/aortic PHVT and normally functioning prosthesis were retrospectively analyzed. Laboratory data including complete blood count and biochemistry were recorded. Transesophageal echocardiography was performed to diagnose PHVT. The study included 118 patients with mechanical PHVT and 120 patients with normally functioning prosthesis. White blood count, monocyte levels, C-reactive protein, MHR and CAR were significantly higher whereas the lymphocyte, HDL and INR levels on admission were lower in patients with PHVT. Multivariate analysis showed that as well as inadequate anticoagulation, MHR, but not CAR, was found to be an independent predictor of thrombosis in patients with PHVT. Receiver operating characteristic curve analysis was performed to detect the best cut-off value of MHR in the prediction of thrombosis in patients with prosthetic valves. MHR level of > 12.8 measured on admission, yielded an AUC value of 0.791 [(CI 95% 0.733-0.848 p < 0.001) sensitivity 71%, specificity 70%]. Inadequate anticoagulation is the primary cause that leads to thrombosis in mechanical prosthetic valves. Increased MHR, but not CAR, was also shown to be an independent predictor of thrombosis in patients with mechanical mitral and aortic prosthetic valves.

Serum sortilin as a predictor of stroke in patients with intermediate carotid artery stenosis.

BACKGROUND: Sortilin was an important molecular protein involved in the pathogenesis of atherosclerosis. Besides, serum sortilin was associated with adverse cerebrovascular events. Atherosclerotic stenosis in the carotid artery is a major etiology for ischemic stroke. The risk of stroke in patients with intermediate carotid artery stenosis (CAS) was unknown. Hence, the aim of the present study was to evaluate the relationship between serum sortilin levels and stroke in patients with intermediate CAS. METHODS: A total of 195 intermediate CAS patients were included in this cross-sectional study. The patients were divided into two groups as symptomatic (N = 95) and asymptomatic (N = 100) patients. Patients with a transient ischemic attack (TIA), retinal ischemic event, or ischemic stroke resulting from the narrowed carotid artery were considered to be symptomatic. Serum sortilin concentrations were measured using the enzyme-linked immunosorbent assay. RESULTS: Serum sortilin level was significantly higher in the symptomatic group than in the severe asymptomatic group (1.53 ± 0.25 ng/mL vs 1.34 ± 0.19 ng/mL, p < 0.001). Besides, high serum sortilin levels (odds ratio = 4.91, 95% confidence intervals 1.24-19.51, p = 0.023) were identified as independent predictors of symptomatic carotid plaque. In the receiver operating characteristic curve analysis, serum sortilin levels higher than 1.34 ng/mL predicted stroke/TIA with a sensitivity of 66.3% and a specificity of 67% (AUC = 0.725, p < 0.001). CONCLUSIONS: Serum sortilin level is increased in the presence of symptomatic intermediate CAS and may have clinical value in the management of patients with carotid artery disease.

Conscious sedation versus general anesthesia for transcatheter aortic valve implantation in patients with severe chronic obstructive pulmonary disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is considered a major risk factor for postoperative complications after transcatheter aortic valve implantation (TAVI). To date, there is no clear consensus on the best anesthesia management for these patients. We aimed to investigate the effects of types of anesthesia on clinical outcomes in patients with severe COPD undergoing TAVI. METHODS: This is a single-center, retrospective study comparing conscious sedation (CS) versus general anesthesia (GA) in 72 patients with severe COPD who underwent TAVI. The primary endpoints were 30-day all-cause mortality and postoperative pulmonary complications. RESULTS: The main outcome of interest of this study was that the frequency of pulmonary complications was statistically higher in the GA group (21.4% vs 3.3%, p = 0.038). These differences are most likely attributed to the GA because of prolonged mechanical ventilation, and longer ICU stay (2 (1.2-3) vs 2.5 (2-4) days, p = 0.029) associated with an increased risk of nosocomial infections. There were no significant differences in procedure complications and 30-day mortality between the two groups (GA; 19% vs CS; 13.3%, p = 0.521). One-year survival rates, compared by Kaplan-Meier analysis, were similar between groups (log-rank p = 0.733). CONCLUSION: In aortic stenosis patients with severe COPD undergoing TAVI, the use of GA compared with CS was associated with higher incidences of respiratory-related complications, and longer ICU length of stay. CS is a safe and viable option for these patients and should be considered the favored approach.

Association Between CRP/Albumin Ratio and Long-Term Mortality in Patients With cHronIc Limb-Threatening Ischemia Undergoing EndovaScular Therapy Below The Knee: The ACHILES-BTK Registry.

BACKGROUND: Chronic limb-threatening ischemia (CLTI), which presents with ischemic rest pain, ulceration, or gangrene, is a complex form of peripheral artery disease that can cause mortality and amputation. C-reactive protein (CRP), an inflammatory marker, indicates vascular inflammation resulting from the cytokine-dependent inflammatory process in the arterial wall, and arterial atherosclerosis resulting from the inflammation. Lower albumin levels are also associated with peripheral artery disease. We investigated the association between CRP/Albumin ratio (CAR) and long-term mortality in patients with CLTI. METHODS: A total of 172 patients who underwent endovascular treatment (EVT) for below the knee (BTK) lesions were enrolled in this study. Patients with acute infection requiring antibiotic therapy, chronic inflammatory disease, end-stage liver disease, malignancy were excluded from the study. Besides, patients with pre-follow-up intervention to the same vascular bed were also excluded from the study. The primary endpoint of the study was all-cause mortality. Patients were divided into 2 groups according to mortality. RESULTS: A total of 70 patients (40.6%) died during 32 ± 21 months of follow-up in the present study. The major amputation rate was 21.5%. The mortality (+) group was older and had higher rates of congestive heart failure, chronic kidney disease, history of stroke, and CRP levels. Moreover, statin and ACE inhibitor/angiotensin receptor blocker (ACE/ARB) use, GFR, and albumin levels were lower in the mortality (+) group. CAR was significantly higher in the mortality (+) group when comparing both groups (3.25 [1.46 - 7.86] vs. 9.75 [4.5 - 17.71], P < 0.001). CAR, congestive heart failure, chronic kidney disease, history of stroke, ACE/ARB, or statin use were independent predictors of all-cause mortality in multivariable Cox regression analysis. CONCLUSIONS: CAR was associated with mortality in CLTI patients undergoing EVT for BTK lesions. CAR may be a simple method to help patient selection, assessment, and intervention strategy for EVT and may improve patient outcomes.

Assessment of proarrhythmic ventricular electrophysiological remodeling in patients with rheumatoid arthritis.

INTRODUCTION: Rheumatoid arthritis (RA) is related to cardiovascular disease and results in increased mortality rates. Ischemia, autonomic nervous system dysfunction, impaired cardiac ionic currents, and genetic predisposition may be the underlying mechanisms. Proarrhythmic ventricular electrophysiological remodeling detected on the basis of Tp­e interval, Tp-e/QT, and Tp-e/QTc ratios plays a key role in the prognosis. Our aim was to assess proarrhythmic ventricular electrophysiological remodeling in patients with RA, a well-known chronic inflammatory disorder. MATERIALS AND METHODS: A total of 163 patients with RA and 47 patients as a control group were included in this retrospective study. Proarrhythmic ventricular electrophysiological remodeling markers were evaluated in both groups along with baseline demographic and clinical variables. Patients using medication or with chronic disorders that can affect ventricular repolarization markers were excluded. RESULTS: The patients with RA had prolonged Tp­e interval (66 ms [44-80]; 80 ms [78-96], p < 0.001) and increased Tp-e/QT ratio (0.18 [0.12-0.22]; 0.22 [0.20-0.24], p < 0.001) and Tp-e/QTc ratio (0.16 [0.11-0.19]; 0.20 [0.17-0.22], p < 0.001) compared to the control group. CONCLUSION: The Tp­e interval and Tp-e/QT ratio, which may help to clarify the pathophysiological mechanisms of ventricular arrhythmias, were increased in patients with RA.

Association of red blood cell distribution width, systemic-immune-inflammation index and poor cardiovascular outcomes in patients with newly diagnosed hypertension.

BACKGROUND: Red cell distribution width (RDW) and the systemic immune-inflammation index (SII) have been extensively studied as predictors of morbidity and mortality in several cardiovascular diseases. This prospective study aimed to investigate the relationship between long term major adverse cardiac events (MACEs) and simple hematological parameters in hypertensive patients. METHODS: The study included a total of 1202 patients with newly diagnosed HT. Of the patients, 662 (55.1%) were female and 540 (44.9%) were male, with a mean age of 53.0 ± 11.4 years. The primary endpoint of the study was long term MACE, including cardiac death, stroke, and myocardial infarction. This is the first study focusing on the association of SII with major adverse cardiovascular outcomes in patients with HT. RESULTS: Eighty-nine patients (8.7%) developed at least one MACE during a mean follow-up period of 82.2 ± 1.3 months. RDW (13.0 ± 0.9 vs. 13.5 ± 1.2%, p < .001) and SII [465.0 (353.4-609.4) vs. 584.4 (468.9-794.0) x103/µL, p < .001] were significantly higher in patients with MACEs. The prevalence of MACEs was significantly higher in patients with RDW>13.1% (10.4 vs. 5%; p < .001) and in patients with SII>465 x103/µL (11.8 vs. 3.1%; p < .001). The multivariate logistic regression analysis showed SII and RDW were independent predictors of MACEs. CONCLUSION: The results of the study demonstrated that the RDW and SII were independent predictors of long-term cardiovascular events in hypertensive patients. These simple hematological parameters may be used as prognosticators of MACE in patients with newly diagnosed HT.

The effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures (from the COMPLEX-CAS Trial).

BACKGROUND: Carotid artery stenting is a minimally invasive, durable alternative treatment option, which is an alternative to the reference method, carotid endarterectomy, for patients with carotid artery stenosis; however, silent new ischemic cerebral lesions (SNICLs) after carotid artery stenting remain as a matter of concern. Hence, we aimed to assess the effect of complex vascular anatomy on silent new ischemic cerebral lesions in carotid artery stenting procedures. METHODS: We prospectively evaluated 122 patients (mean age: 69.5 ± 7.1 years, male:83) who underwent carotid artery stenting for carotid artery revascularization. The patients having symptomatic transient ischemic attack or stroke after carotid artery stenting were excluded. The presence of a new hyperintense lesions on diffusion-weighted imaging without any neurological findings was considered as the SNICL. Patients were classified into two groups as DWI-positive and DWI-negative patients. RESULTS: Among the study population, 32 patients (26.2%) had SNICLs. The DWI-positive group had a significantly higher common carotid artery (CCA)-internal carotid artery (ICA) angle, older age, more frequent history of stroke, a higher proportion of type III aortic arch, and longer fluoroscopy time than the DWI-negative group. High CCA-ICA angle was identified as one of the independent predictors of SNICL (OR (odds ratio) = 1.103 95%CI (confidence interval): (1.023-1.596); p = 0.034), and CCA-ICA angle higher than 34.5 degrees predicted SNICL with a sensitivity of 62.5% and a specificity of 62.2% (area under the curve: 0.680; 95% CI: 0.570 to 0.789; p = 0.003). CONCLUSIONS: The higher CCA-ICA angle may predict pre-procedure SNICL risk in carotid artery stenting and may have clinical value in the management of patients with carotid artery stenosis.

The predictive value of CHADS2 score for subclinical cerebral ischemia after carotid artery stenting (from the PREVENT-CAS trial).

BACKGROUND: Carotid artery stenting (CAS) is being increasingly used as an alternative revascularization procedure to carotid endarterectomy; however, subclinical ischemic cerebral lesions after CAS remain as a matter of concern. Hence, we aimed to assess the clinical utility of the CHADS2 score in predicting subclinical ischemic events after CAS. METHODS: We prospectively evaluated 107 patients (mean age: 70.4 ± 6.6 years, male:77) who underwent CAS for carotid artery revascularization. The patients having symptomatic transient ischemic attack or stroke after CAS were excluded. The presence of new hyperintense lesion on diffusion-weighted imaging (DWI) without any neurological findings was considered as silent ischemia. Patients were classified into two groups as DWI-positive and DWI-negative patients. RESULTS: Among study population, 28 patients (26.2%) had subclinical embolism. The DWI-positive group had a significantly higher CHADS2 scores, older age, more frequent history of stroke, higher proportion of type III aortic arch, and longer fluoroscopy time than the DWI-negative group. Increased CHADS2 score was identified as one of the independent predictors of silent embolism (OR = 5.584; 95%CI: 1.516-20.566; p = .010), and CHADS2 score higher than 2.5 predicted subclinical cerebral ischemia with a sensitivity of 72% and a specificity of 71% (AUC: 0.793; 95% CI: 0.696 - 0.890; p < .001). CONCLUSIONS: CHADS2 score was able to predict the risk of periprocedural subclinical ischemic events in CAS and might be of clinical value in the management of patients with carotid artery stenosis.

The relationship between incomplete surgical obliteration of the left atrial appendage and thromboembolic events after mitral valve surgery (from the ISOLATE Registry).

Left atrial appendage (LAA) is a common site of thrombus formation especially in patients with atrial fibrillation (AF). Complete surgical LAA closure (cSLC) is the surgical aim, however incomplete surgical LAA closure (iSLC) is not rare. In this study, we aimed to evaluate the risk of thromboembolic complications (TEC) in AF patients with iSLC after mitral valve surgery. A total of 101 AF patients (mean age: 61.8 ± 11.8 years; male:32), who underwent surgical suture ligation during mitral valve surgery were enrolled in this retrospective study. All patients underwent transthoracic and transesophageal echocardiography (TEE) at least 3 months after surgery. The primary outcome was the occurrence of TEC including any ischemic stroke, transient ischemic attack, coronary or peripheral embolism. TEE examination revealed cSLC in 66 (65.3%) and iSLC in 35 patients (34.6%). A total of 12 TECs (11.9%) occurred during a mean follow-up time of 41.1 ± 15.6 months. TECs were found to be significantly higher in the iSLC group (25.7% vs 4.5%, p = 0.002). The prevalence of iSLC was significantly higher in patients with TEC (75 vs. 29.2%, p = 0.002). High CHA2DS2-VASc Score and iSLC were found to be independent predictors of TEC. Long term TEC free survival was found to be significantly decreased in patients with iSLC. The presence of iSLC was associated with a significantly increased risk of TEC in AF patients after mitral valve surgery. Routine intraoperative and postoperative screening for iSLC by TEE and long-term strict anticoagulation therapy are recommended in these patients.

Correlation between serum sortilin levels and severity of extracranial carotid artery stenosis.

OBJECTIVE: Atherosclerosis is a chronic inflammatory vascular condition characterised by intimal thickening with cholesterol accumulation and macrophage foam cell infiltration causing plaque formation at the site of the injured vessel wall. This condition is a major contributor to carotid artery stenosis (CAS). Sortilin, a member of the mammalian vacuolar protein sorting 10 protein family, promotes uptake of low-density lipoprotein particles into macrophages with consequent foam cell formation independent of the low-density lipoprotein receptor, and thereby, accelerates atherosclerotic plaque formation and progression. We investigated the correlation between serum sortilin levels and the severity of extracranial CAS. MATERIALS AND METHODS: The study included 149 patients who underwent carotid angiography for suspected carotid artery disease. The North American Symptomatic Carotid Endarterectomy Trial 2011 criteria were used to determine the degree of CAS. Serum sortilin concentrations were measured using the enzyme-linked immunosorbent assay. RESULTS: Serum sortilin levels were significantly higher in the severe CAS than in the non-severe CAS group (2.71 ± 0.71 ng/mL vs 1.63 ± 0.57 ng/mL, P < .001). Receiver operating characteristic curve analysis showed that serum sortilin levels >1.66 ng/mL predicted severe CAS with sensitivity of 83.49% and specificity of 56.76%. CONCLUSION: Current data suggest that prediction of severe CAS may serve as an atherosclerosis biomarker and significantly contribute to research on disease progression in atherosclerosis, as well as in other arterial diseases. Sortilin may be a potential therapeutic target owing to its role in the pathogenesis of atherosclerotic carotid artery disease.

Relationship between P wave peak time and coronary artery disease severity in non-ST elevation acute coronary syndrome.

BACKGROUND: Early diagnosis of non-ST elevation acute coronary syndrome (NSTE-ACS) and prediction of the severity of current coronary artery disease (CAD) play a major role in patient prognosis. Electrocardiography has a unique value in the diagnosis and provides prognostic information on patients with NSTE-ACS. In the present study, we aimed to examine the relationship between P wave peak time (PWPT) and the severity of CAD in patients with NSTE-ACS. METHODS: A total of 132 consecutive patients (female: 35.6%; mean age: 60.1 ± 11.6 years) who were diagnosed with NSTE-ACS were evaluated retrospectively. Gensini scores (GSs) were used to define the angiographic characteristics of the coronary atherosclerotic lesions. The patients were divided into two groups according to the GS. The PWPT was defined as the duration between the beginning and the peak of the P wave, and R wave peak time (RWPT) was defined as the duration between the beginning of the QRS complex and the peak of the R wave. RESULTS: There were 59 (44.6%) patients in the high-GS group (GS ≥25 ) and 73 (55.3%) patients in the low-GS group (GS <25 ). Presence of diabetes mellitus, low left ventricular ejection fraction, and high RWPT and PWPT were identified as predictors of a high GS in the study population. There was no significant difference between the area under the curves of PWPT and RWPT for predicting the severity of CAD (0.663 vs. 0.623, respectively; p = 0.573). CONCLUSION: The present study found that both PWPT and RWPT on admission electrocardiography were associated with the severity and complexity of CAD in patients with NSTE-ACS.

Increased epicardial adipose tissue thickness is associated with microalbuminuria in hypertensive patients with left ventricular hypertrophy.

OBJECTIVE: Epicardial adipose tissue (EAT) is a cardiometabolic risk factor, and its possible relationship with hypertension has been previously reported. Microalbuminuria (MA) is associated with target-organ damage, especially in patients with hypertension with left ventricular hypertrophy (LVH) and suggest endothelial dysfunction. This study aimed to investigate the relationship between echocardiographic EAT thickness and presence of MA in patients with hypertension. METHODS: A total of 297 newly diagnosed hypertension patients who applied to the outpatient clinic were enrolled consecutively in this study. Patients were divided into two groups regarding the presence of LVH in echocardiography. An age and gender matched control group was set including 156 healthy patients without HT. All subjects underwent transthoracic echocardiography for the measurement of EAT thickness. Spot urine samples were collected for the assessment of MA. RESULTS: In hypertensive patients with LVH, the EAT thicknesses (6.6 ± 1.8 vs 5.3 ± 1.5 vs 5.1 ± 1.3, p < .001; respectively) and prevalence of MA (41.2 vs 20.1 vs 3.2%; p < .001 respectively) were significantly higher than the other two groups. In hypertensive patiens without LVH, no relationship was found between the presence of MA and EAT thickness. In multivariate regression analyses, EAT thickness (OR: 3.141, 95%CI: 2.425-6.123, p < .001) and left ventricular mass index (OR: 1.339, 95%CI: 1.145-2.143, p = .003) were determined as independent predictors for MA development in hypertensive patients with LVH. CONCLUSION: Measurement of EAT thickness may help to identify high-risk hypertensive patients for target-organ damage especially among patients with LVH.

Comparison between PeRcutanEous and surgical femoral aCcess for endovascuLar aOrtic repair in patientS with typE III aortic Dissection (PRECLOSE Trial).

OBJECTIVES: Aortic dissections are cardiovascular events with high mortality and morbidity rates. Management might be either with medical or interventional approach. Recently, thoracic endovascular intervention (TEVAR) becomes the first treatment of choice because of its better results and lower rates of complications in patients with type III aortic dissections. The intervention might be performed via femoral artery either with percutaneous or with surgical approach. Because of large sheath insertion to femoral artery, Pre-close technique is described in literature. The aim of this study was to investigate and compare the outcomes and safety of 'Pre-close technique' to surgical approach in patients with type III aortic dissections who underwent TEVAR with femoral access ≥22 F. METHODS: A total of 96 patients whom had type III aortic dissection and was performed TEVAR were retrospectively included in the study. Fifty-six patients had TEVAR with percutaneous approach and these patients are named as P-TEVAR group, and 40 patients had TEVAR with surgical approach and these patients are named as S-TEVAR group. Pre- and post-procedural data with complications and procedural data during TEVAR were evaluated for both groups and compared in between. RESULTS: The main finding was that there was no significant difference between S-TEVAR and P-TEVAR groups in terms of complications and technical success. Operating room time was significantly decreased in P-TEVAR group (P < 0.001). Overall success rate for femoral approach in patients with Pre-close technique was 94.6% and was 100% for surgical approach. P-TEVAR group had post-operative complications in three patients and S-TEVAR group had in four patients. CONCLUSIONS: Total percutaneous approach with Pre-close technique using Pro-Glide device is a safe and feasible method of femoral access in patients with type III aortic dissections.