Time-related aortic inflammatory response, as assessed with 18F-FDG PET/CT, in patients hospitalized with severely or critical COVID-19: the COVAIR study.

AIM: Arterial involvement has been implicated in the coronavirus disease of 2019 (COVID-19). Fluorine 18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging is a valuable tool for the assessment of aortic inflammation and is a predictor of outcome. We sought to prospectively assess the presence of aortic inflammation and its time-dependent trend in patients with COVID-19. METHODS: Between November 2020 and May 2021, in this pilot, case-control study, we recruited 20 patients with severe or critical COVID-19 (mean age of 59 ± 12 years), while 10 age and sex-matched individuals served as the control group. Aortic inflammation was assessed by measuring 18F-FDG uptake in PET/CT performed 20-120 days post-admission. Global aortic target to background ratio (GLA-TBR) was calculated as the sum of TBRs of ascending and descending aorta, aortic arch, and abdominal aorta divided by 4. Index aortic segment TBR (IAS-TBR) was designated as the aortic segment with the highest TBR. RESULTS: There was no significant difference in aortic 18F-FDG PET/CT uptake between patients and controls (GLA-TBR: 1.46 [1.40-1.57] vs. 1.43 [1.32-1.70], respectively, P = 0.422 and IAS-TBR: 1.60 [1.50-1.67] vs. 1.50 [1.42-1.61], respectively, P = 0.155). There was a moderate correlation between aortic TBR values (both GLA and IAS) and time distance from admission to 18F-FDG PET-CT scan (Spearman's rho = - 0.528, P = 0.017 and Spearman's rho = - 0.480, p = 0.032, respectively). Patients who were scanned less than or equal to 60 days from admission (n = 11) had significantly higher GLA-TBR values compared to patients that were examined more than 60 days post-admission (GLA-TBR: 1.53 [1.42-1.60] vs. 1.40 [1.33-1.45], respectively, P = 0.016 and IAS-TBR: 1.64 [1.51-1.74] vs. 1.52 [1.46-1.60], respectively, P = 0.038). There was a significant difference in IAS- TBR between patients scanned ≤ 60 days and controls (1.64 [1.51-1.74] vs. 1.50 [1.41-1.61], P = 0.036). CONCLUSION: This is the first study suggesting that aortic inflammation, as assessed by 18F-FDG PET/CT imaging, is increased in the early post COVID phase in patients with severe or critical COVID-19 and largely resolves over time. Our findings may have important implications for the understanding of the course of the disease and for improving our preventive and therapeutic strategies.

High-Intensity Endurance and Strength Training in Water Polo Olympic Team Players: Impact on Arterial Wall Properties.

INTRODUCTION: Regular physical activity is recommended to minimize health risk. However, the upper intensity threshold associated with the best health outcomes is difficult to be determined. Water polo (WP) Olympic athletes present unique characteristics such as high-intensity exercise, long training sessions, and a combination of endurance and strength training. Therefore, we examined in which way the long-term, intense, mixed endurance and strength training affects the peripheral and central hemodynamics. METHODS: The study population consisted of 20 WP Olympic team players, 20 matched recreationally active (RA) subjects, and 20 sedentary control subjects (Cl). Reflected waves were assessed with the augmentation index (AIx), central aortic stiffness with pulse wave velocity (PWV), and endothelial function with flow-mediated dilation (FMD). RESULTS: Amongst Cl subjects, RA subjects, and WP players, there was no difference in age (p = 0.33) as well as in brachial systolic pressure (p = 0.52), while there was a stepwise decrease in aortic systolic pressure (116 ± 16 mm Hg vs. 107 ± 14 mm Hg vs. 106 ± 6 mm Hg, p = 0.03). There was also a stepwise improvement in AIx (-4.22 ± 9.97% vs. -6.97 ± 11.28% vs. -12.14 ± 6.62%, p = 0.03) and FMD (6.61 ± 1.78% vs. 7.78 ± 1.98% vs. 8.3 ± 2.05%, p = 0.04) according to the intensity of exercise, with WP players having lower AIx and higher FMD compared to RA subjects and Cl subjects. No difference was found in PWV (Cl: 5.88 ± 0.72 m/s vs. RA: 6.04 ± 0.75 m/s vs. WP: 5.97 ± 1.09 m/s, p = 0.82) among the three studied groups. CONCLUSIONS: Young WP Olympic team players depict improved arterial wall properties and endothelial function compared to RA and Cl subjects.

Inferior epigastric artery as a landmark for transfemoral TAVI. Optimizing vascular access?

OBJECTIVES: This study sought to investigate whether the site of common femoral artery (CFA) cannulation in regard to the inferior epigastric artery (IEA) is associated with the incidence of vascular complications in patients undergoing transfemoral aortic valve implantation (TAVI). BACKGROUND: Vascular access complications are a main issue during TAVI and have been associated with significant increase of morbidity and mortality. The need for establishment of reliable predictors for these serious events remains important. METHODS: A total of 90 patients, who had undergone TAVI, were retrospectively studied. Vascular complications were defined as major and minor according to the Valve Academic Research Consortium (VARC) criteria. Patients were divided into high cannulation site (CS) group and low CS group depending on the common femoral artery puncture site position, in regards to the most inferior border of the IEA. RESULTS: Vascular complications were significantly more frequent in the high CS group versus the low CS group (32.3% vs. 11.9%, P = 0.039). High cannulation remained an independent predictor of vascular complications after adjustment for known risk factors (OR: 4.827, CI: 1.441-16.168; P = 0.011). CONCLUSIONS: In patients undergoing transfemoral TAVI, arterial puncture above the most inferior border of the IEA is associated with vascular complications.

Prevalence and clinical outcomes of transthyretin amyloidosis: a systematic review and meta-analysis.

AIM: Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: (i) the prevalence of cardiac amyloidosis in various patient subgroups, (ii) survival estimates for ATTR subtypes, and (iii) the effects of novel therapeutics on the natural course of disease. METHODS AND RESULTS: A systematic review of literature published in MEDLINE before 31 December 2021 was performed for the prevalence of cardiac amyloidosis and all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2, and 5 years. Subgroup analyses were performed for ATTR subtype, that is, wild-type ATTR (wtATTR) versus hereditary ATTR (hATTR), hATTR genotypes, and treatment subgroups. We identified a total of 62 studies (n = 277 882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, heart failure with preserved ejection fraction, and the elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n = 18 238 ATTR patients). Patients with wtATTR were older (p = 7 × 10-10 ) and more frequently male (p = 5 × 10-20 ) versus hATTR. The 2-year survival of ATTR was 73.3% (95% confidence interval [CI] 70.9-75.7); for non-subtyped ATTR 70.4% (95% CI 66.9-73.9), for wtATTR 76.0% (95% CI 73.0-78.9]) and for hATTR 77.2% (95% CI 74.0-80.4); in meta-regression analysis, wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and hATTR genotypes (p = 10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95% CI 74.4-85.3 vs. 72.4%, 95% CI 69.8-74.9, p < 0.05). CONCLUSIONS: We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified.

Biomarkers of Atrial Fibrillation in Metabolic Syndrome.

Whether the increased atrial fibrillation (AF) risk in metabolic syndrome (MetS) patients is due to the syndrome as a whole or simply the sum of the risks of its individual component parts is still obscure. These two clinical entities share many pathophysiological links and thus distinction between a casual observation and a significant association is difficult. Biomarkers associated with pathogenesis of AF in the context of MetS have the ability to refine future risk prediction. In the present review we identify circulating substances that could be regarded as potential biomarkers for prediction of incident AF, or of cardiovascular events in the setting of AF in patients with MetS. Cardiac myocyte injury and stress markers (troponin and natriuretic peptides), markers of renal function (glomeral filtration rate, cystatin-C), and inflammation markers/mediators (interleukin- 6, CRP) are promising biomarkers of patients with AF and MetS.

Effects of Intensive Blood Pressure Control in Patients with Evident Cardiovascular Disease: An Investigation Using the SPRINT Study Data.

BACKGROUND: Recent data advocate adoption of a more intensive treatment strategy for management of blood pressure (BP). OBJECTIVE: We investigated whether the overall effects of the Systolic Blood Pressure Intervention Trial (SPRINT) are applicable to cardiovascular disease (CVD) patients. METHODS: In a post hoc analysis we analyzed data from SPRINT that randomly assigned 9361 individuals to a systolic BP (SBP) target of <120 mmHg (intensive treatment) or <140 mmHg (standard treatment). 1562 patients had clinically evident CVD (age=70.3±9.3 years, 24% females) at study entry and were followed for 3.1 years. Further, we assessed the effect of low (<150 mmHg) baseline SBP on outcome. RESULTS: In CVD patients, there was no benefit from the intensive treatment regarding all endpoints, except for a marginally significant benefit on all-cause mortality (hazard ratio [HR]: 0.67; 95% confidence interval [CI], 0.45 to 1.00; p=0.0509). Further, while there was no increase in serious adverse events (SAE) in the intensive group, there was increased risk for study-related SAE, acute renal failure and electrolyte abnormalities. In patients with low baseline SBP there was a beneficial effect on allcause mortality (HR: 0.56; 95% CI: 0.33 to 0.96; p=0.033), but with greater stroke incidence (HR: 2.94; 95% CI: 1.04 to 8.29; p=0.042). CONCLUSION: We confirm the beneficial effect of the intensive strategy in SPRINT study on all-cause mortality and the harmful effect on specific adverse outcomes in patients with CVD. However, in patients with low baseline SBP stroke may increase.

Correlation of CoreValve implantation 'true cover index' with short and mid-term aortic regurgitation: A novel index.

BACKGROUND: 'Cover index' has been proposed to appraise the congruence between the aortic annulus and the device, with the assumption of not taking into account the actual device implantation depth. The aim of this study was to investigate whether the annulus-prosthesis mismatch, as expressed with the new proposed 'true cover index' according to actual implantation depth, can predict aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). METHODS: Patients who had undergone TAVI with the self-expandable CoreValve device, were retrospectively studied. All available prosthesis sizes were ex-vivo scanned and the precise diameter at 0.3mm intervals along each device was measured. The 'true cover index' was evaluated, as a ratio of the following: 100×([prosthesis actual diameter at implantation depth-annulus diameter]/prosthesis actual diameter at implantation depth). AR was echocardiographically evaluated at discharge and 30days and classified as prominent if moderate, or trivial if none or mild. RESULTS: Overall, 120 patients who had undergone TAVI, were considered eligible for the study. 'True cover index' was statistically significantly lower among patients with prominent AR in comparison with trivial AR at discharge (5.7±4.8mm vs 9±5.1, p=0.025), as well as at one month post-TAVI (5.4±5.1mm vs 9.0±5.1, p=0.023), indicating increased AR for smaller index. After adjustment for severe annulus calcification, impaired baseline LVEF and previous valvuloplasty, it remained an independent predictor of one month prominent AR (OR: 0.854, CI: 0.730-0.999; p=0.048). 'True cover index' of <4.3 was shown to predict one-month prominent AR with sensitivity =75% and specificity =82.5%. CONCLUSIONS: 'True cover index' is strongly and independently correlated with the short and mid-term AR after CoreValve implantation.

Diagnostic value of soluble adhesion molecule kinetics in patients with suspected myocardial ischemia undergoing dobutamine stress echocardiography.

INTRODUCTION: Previous studies have shown an exercise-induced increase in circulating adhesion molecules (sICAM-1 and sVCAM-1) in patients with coronary artery disease (CAD). The aim of this study was to evaluate the diagnostic role of changes in serum adhesion molecules in the setting of a dobutamine stress echocardiogram (DSE). METHODS: Thirty patients (18 men and 12 women aged 63.3 ± 10.67 years) with suspected myocardial ischemia underwent a DSE in our department's laboratory of echocardiography in order to identify inducible ischemia. Dobutamine was infused in incremental doses from 5 µg/kg/min up to 40 µg/kg/min. Blood samples were drawn at baseline as well as at peak stress and circulating adhesion molecules sVCAM-1 and sICAM-1 levels were measured by ELISA. Patients with a positive DSE underwent coronary arteriography within 2 weeks of the DSE study. RESULTS: Sixteen patients had a positive DSE for inducible ischemia while 14 had a negative test. Among the patients with positive DSE, 12 had angiographically significant CAD as well as statistically significantly higher levels of sICAM-1 than DSE negative patients (n=14), both at baseline (302.57 ± 43.37 vs. 267.47 ± 28.03 ng/mL, p=0.028) and at peak stress (322.07 ± 49.64 vs. 260.43 ± 36.45 ng/mL, p=0.001). A significant increase from baseline to peak stress was also noted in this group (from 302.57 ± 43.37 to 322.07 ± 49.64 ng/mL, p=0.043). There were no statistically significant differences in the levels of sVCAM-1 between groups at baseline and there was no change from baseline to peak stress. CONCLUSION: Plasma levels of sICAM-1 were found to be elevated in subjects with a positive DSE and angiographically significant CAD compared to patients with a negative DSE, both before and after inducible ischemia. In contrast, no changes were noted regarding sVCAM-1 levels.

Predictive factors of vascular complications after transcatheter aortic valve implantation in patients treated with a default percutaneous strategy.

BACKGROUND: Percutaneous approach techniques with closure device after transcatheter aortic valve implantation (TAVI) have diminished vascular complications (VC). In this retrospective study, we will report incidence and angiographic factors predisposing to major VC in patients undergoing TAVI using Prostar® XL closure device as a default strategy. METHODS: Consecutive patients, who underwent TAVI transfemorally using Prostar® XL, were evaluated for the incidence of VC according to VARC criteria. Using arterial angiography, the femoral-iliac arterial tortuosity was adjusted for large arterial diameters and expressed as the ratio total tortuosity/arterial diameter (TT/AD). Arterial calcification, the combination of angulation and atheromatosis at the puncture site and ideal puncture were evaluated too. In all patients, 30 days of follow-up was available. RESULTS: Eighty-four patients (80.2 ± 5.86 years, 39 males [46.4%]), who were consecutively treated with the transfemoral approach, were evaluated. In patients with major VC (17/84 [20.23%]) comparing to those without, arterial calcification (11 [64.7%] vs. 8 [11.9%], P < 0.01) and the TT/AD (30.2 ± 11.25 vs. 22.06 ± 8.64, P < 0.01) were independent predictors. Ideal puncture was achieved more frequently among patients without VC comparing to those with major (94.1% vs. 70.6%, P = 0.01). Blood transfusions (1.48 ± 0.37 vs. 2.45 ± 0.59, P = 0.023) were more frequent among patients with major VC. Finally, minimum creatinin clearance after TAVI predicted all-cause 30-day mortality (P = 0.021). CONCLUSIONS: Major VC after TAVI with the use of Prostar closure device can be predicted by arterial calcification at the puncture site and TT/AD ratio. Minimum creatinin clearance after TAVI predicted 30-day mortality.

Amino-terminal pro-C-type natriuretic peptide is associated with arterial stiffness, endothelial function and early atherosclerosis.

OBJECTIVE: C-type natriuretic peptide (CNP) is a paracrine molecule with effects on endothelial integrity, vascular tone and atherosclerotic process. Arterial stiffness, wave reflections, endothelial dysfunction and carotid intima-media thickness (IMT) are predictors of cardiovascular events. We investigated whether CNP is related to arterial structure and function in men. METHODS: We evaluated arterial structural and functional characteristics in 117 consecutive men (mean age 57.3 + or - 9.2 years), with and without cardiovascular risk factors, who had no established cardiovascular disease. Arterial elastic properties were evaluated with carotid-femoral pulse wave velocity (PWV), wave reflections with augmentation index (AIx), endothelial function with flow-mediated dilatation of the brachial artery (FMD) and early atherosclerosis with carotid IMT. Amino-terminal proCNP (NT-proCNP) was assessed in venous blood. RESULTS: The number of cardiovascular risk factors was inversely related to levels of NT-proCNP (P<0.01) and there was a progressive increase in Framingham risk score according to decreasing tertiles of NT-proCNP (P<0.001). In multivariable regression analysis NT-proCNP exhibited significant negative associations with PWV and IMT and positive association with FMD (all P<0.05) that were independent of age, blood pressure, smoking habits, body mass index, blood glucose, total triglycerides, low-density lipoprotein and endothelin-1 or high-sensitivity C-reactive protein. There was no relation between NT-proCNP and AIx. CONCLUSION: The present study is the first to demonstrate in a global arterial approach relationship between CNP and functional and early structural arterial changes. These findings elucidate pathophysiological links and may have important clinical implications for the estimation of cardiovascular risk in men.

Temporary cardiac tamponade secondary to chest tube placement for pneumothorax.

A 87-year-old woman was hospitalised because of a third-degree atrioventricular block. After the insertion of a temporary pacemaker lead through the left subclavian vein, she developed an ipsilateral pneumothorax. Although there were clinical and echocardiographic signs of cardiac tamponade after chest tube placement for pneumothorax, a second echocardiogram performed after transportation for surgical drainage failed to demonstrate the presence of any pericardial fluid, while the patient showed an unexpected clinical improvement. A new X-ray showed a collection of left pleural fluid. Over the following days a limited amount of blood was drained through the tube with disappearance of the pleural effusion and no further signs of major bleeding. A permanent DDD pacemaker was subsequently implanted and the patient was discharged in a good condition.