The German version of the Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire: reliability, responsiveness and structural validity.

PURPOSE: The Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire is the only existing disease-specific instrument for measuring quality of life after pulmonary embolism (PE). It includes six dimensions: frequency of complaints, limitations in activities of daily living, work-related problems, social limitations, intensity of complaints and emotional complaints. The present study aimed to determine the psychometric properties including responsiveness and structural validity of the German version. METHODS: The analysis used data from participants of the LEA cohort study at University Hospital Augsburg. The PEmb-QoL was administered via postal surveys 3, 6 and 12 months post-PE. Internal consistency and test-retest reliability were evaluated by calculating Cronbach's alpha and intra-class correlation coefficients (ICC). Standardized response means (SRM) were calculated for investigating responsiveness. For evaluating the fit of the factor structure, confirmatory factor analysis (CFA) was conducted. RESULTS: Overall, we used data from 299 patients 3 months after PE. Cronbach's alpha (0.87-0.97) and ICC (0.53-0.90) were in an acceptable to good range. SRM scores showed good responsiveness of all dimensions. CFA revealed the four-factor model including one general factor to have a good model fit. CONCLUSION: Despite existing floor effect, most standard criteria of reliability and validity were met and indications for appropriateness of the PEmb-QoL summary score could be found. Apart from some restrictions concerning the factor structure and the dimension of social limitations, our results support the use of the PEmb-QoL questionnaire for evaluating PE-specific quality of life. Future studies should seek replication in different samples to ensure generalizability of the findings.

Diagonal earlobe crease and long-term survival after myocardial infarction.

BACKGROUND: The association between the presence of a diagonal earlobe crease (DEC) and coronary artery disease has been prescribed earlier. However, it is unclear whether patients with acute myocardial infarction (AMI) and DEC have a higher risk of dying. METHODS: Study participants were persons with AMI who were included in the KORA Myocardial Infarction Registry Augsburg from August 2015 to December 2016. After taking pictures of both earlobes, two employees independently assessed the severity of DEC in 4°. For analysis, the expression of the DEC was dichotomized. Information on risk factors, severity and therapy of the AMI was collected by interview and from the medical record. Vital status post AMI was obtained by population registries in 2019. The relationship between DEC and survival time was determined using Cox proportional hazards models. RESULTS: Out of 655 participants, 442 (67.5%) showed DEC grade 2/3 and 213 (32.5%) DEC grade 0/1. Median observation period was 3.06 years (5-1577 days). During this period, 26 patients (12.2%) with DEC grade 0/1 and 92 patients (20.8%) with grade 2/3 died (hazard ratio 1.91, 95% confidence interval (CI) 1.23-2.96, p = 0.0037). In the fully adjusted model, patients with DEC grade 2/3 had a 1.48-fold increased risk of death compared to the DEC grade 0/1 patient group (CI 0.94-2.34, p = 0.0897). The fully adjusted model applied for 1-year survival revealed a significant, 2.57-fold hazard ratio of death (CI 1.07-6.17, p = 0.0347) for the patients with DEC grade 2/3. CONCLUSIONS: Our results indicate that DEC is independently associated with 1-year AMI survival.

Temporal variations in the triggering of myocardial infarction by air temperature in Augsburg, Germany, 1987-2014.

AIMS: The association between air temperature and mortality has been shown to vary over time, but evidence of temporal changes in the risk of myocardial infarction (MI) is lacking. We aimed to estimate the temporal variations in the association between short-term exposures to air temperature and MI in the area of Augsburg, Germany. METHODS AND RESULTS: Over a 28-years period from 1987 to 2014, a total of 27 310 cases of MI and coronary deaths were recorded. Daily meteorological parameters were measured in the study area. A time-stratified case-crossover analysis with a distributed lag non-linear model was used to estimate the risk of MI associated with air temperature. Subgroup analyses were performed to identify subpopulations with changing susceptibility to air temperature. Results showed a non-significant decline in cold-related MI risks. Heat-related MI relative risk significantly increased from 0.93 [95% confidence interval (CI): 0.78-1.12] in 1987-2000 to 1.14 (95% CI: 1.00-1.29) in 2001-14. The same trend was also observed for recurrent and non-ST-segment elevation MI events. This increasing population susceptibility to heat was more evident in patients with diabetes mellitus and hyperlipidaemia. Future studies using multicentre MI registries at different climatic, demographic, and socioeconomic settings are warranted to confirm our findings. CONCLUSION: We found evidence of rising population susceptibility to heat-related MI risk from 1987 to 2014, suggesting that exposure to heat should be considered as an environmental trigger of MI, especially under a warming climate.

Is acute pulmonary embolism more severe in the presence of obstructive sleep apnea? Results from an observational cohort study.

Obstructive sleep apnea (OSA) might influence disease severity in acute pulmonary embolism (PE). 253 survivors of acute PE were evaluated for sleep-disordered breathing by portable monitoring and nocturnal polysomnography. PE patients with an apnea-hypopnoea index (AHI) ≥ 15/h were significantly older (p < 0.001), had significantly impaired renal (p < 0.001) and left ventricular functions (p = 0.003), showed significantly elevated troponin I (p = 0.005) and D-dimer levels (p = 0.024), were hospitalised significantly longer (p < 0.001), and had significantly elevated PE severity scores (p = 0.015). Moderate or severe OSA was significantly (p = 0.006) more frequent among intermediate- and high-risk PE patients (81.0%) compared to the low-risk PE cohort (16.3%). Multiple logistic regression analysis revealed that PE patients in the AHI ≥ 15/h cohort were at significant risk for myocardial injury (p = 0.015). Based on clinical risk stratification models, patients with no relevant OSA syndrome tended to be at a lower risk for short-term mortality (p = 0.068). Acute PE might present more severely in OSA patients, possibly due to nocturnal hypoxemia or OSA-related hypercoagulability.

Acute myocardial infarction in the elderly: Treatment strategies and 28-day-case fatality from the MONICA/KORA myocardial infarction registry.

OBJECTIVES: Aim of this observational study was to analyze today's real-life treatment strategies in elderly patients with an acute myocardial infarction (AMI) and to assess the association between 28-day-case fatality and invasive strategy (percutaneous coronary intervention/coronary artery bypass grafting). BACKGROUND: Elderly patients increasingly constitute a large proportion of the AMI population. METHODS: The present study is an analysis of all patients aged 75-84 years, who were enrolled in the German population-based MONICA/KORA MI registry between 2009 and 2012 and who were defined as nonfatal at least 24 hours surviving AMI cases according to MONICA definition. Multivariable logistic regression analyses were conducted for the total study population and stratified by type of AMI (ST-segment elevation MI [STEMI], Non-ST-segment elevation MI [NSTEMI], and bundle branch block [BBB]). RESULTS: Out of the 1,191 elderlies, 61.9% were treated invasively. In the multivariable analysis, the odds ratio (OR) for 28-day-case fatality in patients treated with invasive versus conservative strategy was 0.43 (95% CI 0.27-0.69). Stratified analyses revealed an OR of 0.27 (95% CI 0.13-0.56) for patients with NSTEMI. In patients with STEMI or BBB also a positive trend for invasive strategy was observed (OR 0.40; 95% CI 0.13-1.27 and OR 0.76; 95% CI 0.16-3.66, respectively). CONCLUSIONS: Invasive revascularization therapy was independently associated with short-term survival in elderly patients, particularly in those with NSTEMI.

The prevalence of sleep-disordered breathing among survivors of acute pulmonary embolism.

BACKGROUND: Sleep-disordered breathing (SDB) is associated with prothrombotic effects that could lead to venous thromboembolic diseases. OBJECTIVE: The objective of this study is to clarify the prevalence of SDB among survivors of pulmonary embolism (PE). METHODS: One hundred six consecutive PE patients were prospectively evaluated by portable monitoring (PM). Nocturnal polysomnography was performed in all subjects who were diagnosed by PM to have an apnoea-hypopnoea index (AHI) > 15/h or evidence of increased daytime sleepiness. RESULTS: The overall SDB prevalence in the study population was 58.5 %. Mild obstructive sleep apnoea (OSA) was diagnosed in 35.8 % of patients. Of the subjects, 12.3 % suffered from moderate OSA. In 10.4 % of study participants, OSA was found to be severe. High-risk PE was significantly more frequent among subjects with an AHI > 15/h (p = 0.005). CONCLUSION: OSA is a common comorbidity of PE and possibly represents an additional risk factor for hemodynamic instability in PE patients.

Association of obesity and long-term mortality in patients with acute myocardial infarction with and without diabetes mellitus: results from the MONICA/KORA myocardial infarction registry.

BACKGROUND: Paradoxically, beneficial effects of overweight and obesity on survival have been found in patients after cardiovascular events such as acute myocardial infarction (AMI). This obesity paradox has not been analyzed in AMI patients with diabetes even though their cardiovascular morbidity and mortality is increased compared to their counterparts without diabetes. Therefore, the objective of this long-term study was to analyze the association between body mass index (BMI) and all-cause mortality in AMI patients with and without diabetes mellitus. METHODS: Included in the study were 1190 patients with and 2864 patients without diabetes, aged 28-74 years, recruited from a German population-based AMI registry. Patients were consecutively hospitalized between 1 January 2000 and 31 December 2008 with a first ever AMI and followed up until December 2011. Data collection comprised standardized interviews and chart reviews. To assess the association between BMI and long-term mortality from all causes, Cox proportional hazards models were calculated adjusted for risk factors, co-morbidities, clinical characteristics, in-hospital complications as well as medical and drug treatment. RESULTS: AMI patients of normal weight (BMI 18.5-24.9 kg/m(2)) had the highest long-term mortality rate both in patients with and without diabetes with 50 deaths per 1000 person years and 26 deaths per 1000 person years, respectively. After adjusting for a selection of covariates, a significant, protective effect of overweight and obesity on all-cause mortality was found in AMI patients without diabetes (overweight: hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.58-0.93; p=0.009; obesity: HR 0.64, 95% CI 0.47-0.87; p=0.004). In contrast, an obesity paradox was not found in AMI patients with diabetes. However, stratified analyses showed survival benefits in overweight AMI patients with diabetes who had been prescribed statins prior to AMI (HR 0.51, 95% CI 0.29-0.89, p=0.018) or four evidence-based medications at hospital-discharge (HR 0.52, 95% CI 0.34-0.80, p=0.003). CONCLUSION: In contrast to AMI patients without diabetes, AMI patients with diabetes do not experience a survival benefit from an elevated BMI. To investigate the underlying reasons for these findings, further studies stratifying their samples by diabetes status are needed.

Does marital status contribute to the explanation of the hypercholesterolemia paradox in relation to long term mortality in myocardial infarction? Findings from the MONICA/KORA Myocardial Infarction Registry.

OBJECTIVE: A recent study found long-term mortality after first acute myocardial infarction (AMI) to be particularly reduced among married individuals with hypercholesterolemia. This study explores, whether statin treatments during the last week prior to AMI offer an explanation to this phenomenon. METHODS: Data were retrieved 2000-2008 from the population-based KORA myocardial infarction registry, located in Bavaria, Germany. The sample included 3162 individuals, alive 28days after first AMI, who received statins both in hospital and at discharge. Associations with long-term mortality were examined via multivariable Cox regression. Among patients with hypercholesterolemia, individuals with and without prior statin treatment were each tested against the reference group "neither (hypercholesterolemia nor statin)" and tested for interaction with "marital status". RESULTS: Among patients with and without prior statins, hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.46-0.93 and HR 0.72, 95% CI 0.55-0.94, were observed, respectively. Mortality reductions diminished after introduction of the following interaction terms with marital status: HR 0.49, p 0.042 for patients with and HR 0.77, p 0.370, for patients without prior statins. CONCLUSIONS: Prior statin treatments appear to be an underlying factor for long-term mortality reduction in married AMI-survivors with hypercholesterolemia. Confirmation of our results in further studies is warranted.

The Burden of Diabetes Mellitus in Patients with Coronary Heart Disease: A Methodological Approach to Assess Quality-Adjusted Life-Years Based on Individual-Level Longitudinal Survey Data.

BACKGROUND: Reliable burden of disease (BOD) estimates are needed to support decision making in health care. OBJECTIVES: The objective of this study was to introduce an analysis approach based on individual-level longitudinal survey data that estimates the burden of diabetes in patients with coronary heart disease in terms of quality-adjusted life-years (QALYs) lost. METHODS: Data from two postal surveys (2006, N = 1022; 2010-2011, N = 716) of survivors from the KORA Myocardial Infarction Registry in Southern Germany were analyzed. Accumulated QALYs were calculated for each participant over a mean observation time of 4.1 years, considering the noninformative censoring structure of the follow-up study. Linear regression models were used to estimate the loss in (quality-unadjusted) life-years and QALYs between patients with and without diabetes, and generalized additive models were used to analyze the nonlinear association with age. The cross-sectional and longitudinal association with quality of life (QOL) and QOL change and the impact on mortality were analyzed to enhance the understanding of the observed results. RESULTS: Diabetes was associated with a reduced QOL at baseline (cross-sectional: ß = -0.069; P < 0.001), but not with a significant longitudinal QOL change. Mortality in patients with diabetes was increased (hazard ratio = 1.68; P < 0.005). This resulted in a loss of 0.14 life-years (P = 0.003) and 0.37 QALYs (P < 0.001). Results from generalized additive models indicated that the burden of diabetes is less pronounced in older subjects. CONCLUSIONS: The application of the proposed approach provides confounder-adjusted BOD estimates for the studied time horizon and can be used to compare the BOD across different chronic conditions. Curative efforts are needed to diminish the substantial diabetes-related QALY gap.

Are daylight saving time transitions associated with changes in myocardial infarction incidence? Results from the German MONICA/KORA Myocardial Infarction Registry.

BACKGROUND: Some studies suggest that transitions to and from daylight saving time (DST) have an influence on acute myocardial infarction (AMI) incidence. However, the available publications have a number of limitations e.g. regarding sample size, exclusion of fatal AMI cases, precise assessment of AMI onset, and consideration of possible confounders, and they were conducted in countries with different geographical location. The objective of this study was to examine the association of DST transitions with AMI incidence recorded in the population-based German MONICA/KORA Myocardial Infarction Registry. METHODS: The study sample consisted of 25,499 coronary deaths and non-fatal AMI cases aged 25-74 years. We used Poisson regression with indicator variables for the 3 days or the week after the spring and the autumn transition and adjusted for potential confounders to model the association between DST transitions and AMI incidence. In addition, we built an excess model by calculating observed over expected events per day. RESULTS: Overall, no significant changes of AMI risk during the first 3 days or 1 week after the transition to and from DST were found. However, subgroup analyses on the spring transition revealed significantly increased risks for men in the first 3 days after transition (RR 1.155, 95 % CI 1.000-1.334) and for persons who took angiotensine converting enzyme (ACE) inhibitors prior to the AMI (3 days: RR 1.489, 95 % CI 1.151-1.927; 1 week: RR 1.297, 95 % CI 1.063-1.582). After the clock shift in autumn, patients with a prior infarction had an increased risk to have a re-infarction (3 days: RR 1.319, 95 % CI 1.029-1.691; 1 week: RR 1.270, 95 % CI 1.048-1.539). CONCLUSIONS: Specific subgroups such as men and persons with a history of AMI or prior treatment with ACE inhibitors, may have a higher risk for AMI during DST. Further studies which include data on chronotype and sleep duration are needed in order to confirm these results.

Long-term survival among older patients with myocardial infarction differs by educational level: results from the MONICA/KORA myocardial infarction registry.

BACKGROUND: Socioeconomic disparities in survival after acute myocardial infarction (AMI) have been found in many countries. However, population-based results from Germany are lacking so far. Thus, the objective of this study was to examine the association between educational status and long-term mortality in a population-based sample of people with AMI. METHODS: The sample consisted of 2,575 men and 844 women, aged 28-74 years, hospitalized with a first-time AMI between 1 January 2000 and 31 December 2008, recruited from a population-based AMI registry. Patients were followed up until December 2011. Data on education, risk factors and co-morbidities were collected by individual interviews; data on clinical characteristics and AMI treatment by chart review. Cox proportional hazards models were used to assess the relationship between educational status and long-term mortality. RESULTS: During follow-up, 19.1% of the patients with poor education died compared with 13.1% with higher education. After adjustment for covariates, no effect of education on mortality was found for the total sample and for patients aged below 65 years. In older people, however, low education level was significantly associated with increased mortality (hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.05-1.98, p = 0.023). Stratified analyses showed that women older than 64 years with poor education were significantly more likely to die than women in the same age group with higher education (HR 1.57, 95% CI 1.02-2.41, p = 0.039). CONCLUSIONS: Elderly, poorly educated patients with AMI, and particularly women, have poorer long-term survival than their better educated peers. Further research is required to illuminate the reasons for this finding.

Mortality after first myocardial infarction in diabetic and non-diabetic people between 1985 and 2009. The MONICA/KORA registry.

The aim of the study was to analyse mortality after a first myocardial infarction (MI) and its trends in people with diabetes compared to those without diabetes in Southern Germany, 1985-2009. Using data of the population-based MONICA/KORA Myocardial Infarction Registry, we ascertained all patients with a first fatal or non-fatal MI between 1985 and 2009 (n = 16,478, age 25-74 years, 71% male, 29% with diabetes). The impact of diabetes and calendar time on mortality was examined using multiple logistic and Cox regression. Survival improved with calendar time: The crude cumulative 5-year survival was 26.9 and 46.3% among diabetic and non-diabetic individuals (both sexes combined) with a first MI in the years 1985-1989, and 53.6 and 66.6% among those with a first MI in the years 2005-2009. This significant decrease of mortality was confirmed in multivariate analyses. The proportion of fatal first MIs was significantly higher in diabetic compared to non-diabetic patients [adjusted odds ratio (OR) 1.26; 95% confidence interval 1.17-1.36]. This association persisted in a similar manner between both sexes with no consistent change of OR over calendar time in which first MIs have been observed. Likewise, multiple adjusted risk of death after a non-fatal first MI was significantly higher among both diabetic men and women [hazard ratio (HR) 1.64; 1.47-1.82, 1.83; 1.55-2.14] with constant HR over calendar time. During the past 25 years, survival has improved in both diabetic and non-diabetic patients with incident MI in a similar manner. However, mortality after a first MI remained significantly higher in the diabetic population, particularly in women.

Marital status shows a strong protective effect on long-term mortality among first acute myocardial infarction-survivors with diagnosed hyperlipidemia--findings from the MONICA/KORA myocardial infarction registry.

BACKGROUND: Reduction of long term mortality by marital status is well established in general populations. However, effects have been shown to change over time and differ considerably by cause of death. This study examined the effects of marital status on long term mortality after the first acute myocardial infarction. METHODS: Data were retrieved from the population-based MONICA (Monitoring trends and determinants on cardiovascular diseases)/KORA (Cooperative Health Research in the Region of Augsburg)-myocardial infarction registry which assesses cases from the city of Augsburg and 2 adjacent districts located in southern Bavaria, Germany. A total of 3,766 men and women aged 28 to 74 years who were alive 28 days after their first myocardial infarction were included. Hazard ratios (HR) for the effects of marital status on mortality after one to 10 years of follow-up are presented. RESULTS: The study population included 2,854 (75.8%) married individuals. During a median follow-up of 5.3 years, with an inter-quartile range of 3.3 to 7.6 years, 533 (14.15%) deaths occurred. Among married and unmarried individuals 388 (13.6%) and 145 (15.9%) deaths occurred, respectively. Overall marital status showed an insignificant protective HR of 0.76 (95% confidence interval (CI) 0.47-1.22). Stratified analyses revealed strong protective effects only among men and women younger than 60 who were diagnosed with hyperlipidemia. HRs ranged from 0.27 (95% CI 0.13-0.59) for a two-year survival to 0.43 (95% CI 0.27-0.68) for a 10-year survival. Substitution of marital status with co-habitation status confirmed the strata-specific effect [HR: 0.52 (95% CI 0.31-0.86)]. CONCLUSIONS: Marital status has a strong protective effect among first myocardial infarction survivors with diagnosed hyperlipidemia, which diminishes with increasing age. Treatments, recommended lifestyle changes or other attributes specific to hyperlipidema may be underlying factors, mediated by the social support of spouses. Underlying causes should be examined in further studies.

Unique 40-year survival after heart transplantation with normal graft function and spontaneous operational tolerance.

Unique 40-year survival after heart transplantation with normal graft function and spontaneous operational tolerance.

Presenting symptoms of myocardial infarction predict short- and long-term mortality: the MONICA/KORA Myocardial Infarction Registry.

BACKGROUND: It is unknown whether clinical outcomes differ with specific symptoms of an acute myocardial infarction (AMI). The objective of this study was to investigate the association between 13 self-reported symptoms and 28-day case fatality or long-term all-cause mortality in patients with AMI. METHODS: The sample consisted of 1,231 men and 415 women aged 25 to 74 years hospitalized with a first-time AMI recruited from a population-based AMI registry. Multivariable logistic regression modeling was used to assess the relationship between symptom occurrence and 28-day case fatality. Cox proportional hazards models were used to determine the effects on long-term mortality. Analyses were adjusted for sex, age, type of AMI, diabetes, prehospital delay time, and reperfusion therapy. RESULTS: The median observation time was 4.1 years (interquartile range 15 years). Twenty-eight-day case fatality was 6.1%, and long-term mortality was 10.6%. Patients who experienced fear of death (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.03-0.47), diaphoresis (OR 0.45, 95% CI 0.25-0.82), or nausea (OR 0.45, 95% CI 0.22-0.95) had a significantly decreased risk of dying within 28 days, whereas syncope (OR 5.36, 95% CI 2.65-10.85) was associated with a higher risk. A decreased risk for long-term mortality was found for people with pain in the upper abdomen (hazard ratio 0.43, 95% CI 0.19-0.97), whereas dyspnea was related to an increased risk (hazard ratio 1.50, 95% CI 1.11-2.06). The absence of chest symptoms was associated with a 1.85-fold risk for long-term mortality (95% CI 1.13-3.03). CONCLUSIONS: Specific symptoms are associated with mortality. Further research is required to illuminate the reasons for this finding.

Differences of cardiac output measurements by open-circuit acetylene uptake in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension: a cohort study.

BACKGROUND: As differences in gas exchange between pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) have been demonstrated, we asked if cardiac output measurements determined by acetylene (C2H2) uptake significantly differed in these diseases when compared to the thermodilution technique. METHOD: Single-breath open-circuit C2H2 uptake, thermodilution, and cardiopulmonary exercise testing were performed in 72 PAH and 32 CTEPH patients. RESULTS: In PAH patients the results for cardiac output obtained by the two methods showed an acceptable agreement with a mean difference of -0.16 L/min (95% CI -2.64 to 2.32 L/min). In contrast, the agreement was poorer in the CTEPH group with the difference being -0.56 L/min (95% CI -4.96 to 3.84 L/min). Functional dead space ventilation (44.5 ± 1.6 vs. 32.2 ± 1.4%, p < 0.001) and the mean arterial to end-tidal CO2 gradient (9.9 ± 0.8 vs. 4.1 ± 0.5 mmHg, p < 0.001) were significantly elevated among CTEPH patients. CONCLUSION: Cardiac output evaluation by the C2H2 technique should be interpreted with caution in CTEPH, as ventilation to perfusion mismatching might be more relevant than in PAH.

Acute pulmonary embolism in patients with obstructive sleep apnoea: does it affect the severity of sleep-disordered breathing?

BACKGROUND: Acute pulmonary embolism (PE) may result in an increase in central venous pressure, which may contribute to pharyngeal narrowing by fluid accumulation in nuchal and peripharyngeal soft tissues and therefore affect obstructive sleep apnoea (OSA). PURPOSE: This study aimed to clarify the impact of acute PE on the severity of sleep-disordered breathing in OSA patients. METHODS: Polysomnography (PSG) was performed in 15 OSA patients shortly after acute PE and again after 3 months of sufficient anticoagulation therapy. OSA remained untreated meanwhile. RESULTS: Acute PE did not significantly affect the apnoea-hypopnoea index (AHI). CONCLUSION: The diagnosis of OSA is representative in acute PE, as the transient increase of central venous pressure seems not to affect the AHI once the patients are clinical stable for PSG.

Ventilatory efficiency testing as prognostic value in patients with pulmonary hypertension.

BACKGROUND: Increased ventilatory response has been shown to have a high prognostic value in patients with chronic heart failure. Our aim was therefore to determine the ventilatory efficiency in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension by cardiopulmonary exercise testing (CPET) identifying PH-patients with increased risk for death within 24 months after evaluation. METHODS: 116 patients (age: 64 ± 1 years) with a mean pulmonary arterial pressure of 35 ± 1 mmHg underwent CPET and right heart catheterization. During a follow-up of 24 months, we compared the initial characteristics of survivors (n = 87) with nonsurvivors (n = 29). RESULTS: Significant differences (p ≤ 0.005) between survivors and nonsurvivors existed in ventilatory equivalents for oxygen (42.1 ± 2.1 versus 56.9 ± 2.6) and for carbon dioxide (Ve/VCO2) (47.5 ± 2.2 versus 64.4 ± 2.3). Patients with peak oxygen uptake ≤ 10.4 ml/min/kg had a 1.5-fold, Ve/VCO2 ≥ 55 a 7.8-fold, alveolar-arterial oxygen difference ≥ 55 mmHg a 2.9-fold, and with Ve/VCO2 slope ≥ 60 a 5.8-fold increased risk of mortality in the next 24 months. CONCLUSIONS: Our results demonstrate that abnormalities in exercise ventilation powerfully predict outcomes in PH. Consideration should be given to add clinical guidelines to reflect the prognostic importance of ventilatory efficiency parameters in addition to peak VO2.

Contemporary results of transcatheter mitral valve procedures: bi-centric retrospective analysis.

BACKGROUND: Transcatheter mitral valve-in-valve (TMVIV) or valve-in-ring (TMVIR) replacement offer an alternative therapy for high risk patients. We aimed to highlight the operative and postoperative results of TMVIV and TMVIR procedures. RESULTS: We included all patients underwent TMVIV and TMVIR procedures between 2017 and 2020 at two heart centers in Germany. We included a total of 36 high risk patients in our study where 12 received TMVIV and 24 received TMVIR. All patients underwent TMVIV or TMVIR with Edwards Sapien XT or S3 transcatheter valves (Edwards Lifesciences). The mean age was 79 (75-83 years old). The median (IQR) preoperative STS score was 9 (7-13)% and EuroSCORE II was 14.5% (12-16). The majority of our patients were operated via transapical approach (n = 26) and the minority via transseptal approach (n = 10). Out of our records, none of our patients required reopening for bleeding or any other surgical complications. None of our patients required reintervention during the 6 months follow-up period. One mortality was recorded on fifth postoperative day due to low cardiac output syndrome (obviously because of LVOT obstruction by the anterior mitral leaflet). The average blood loss was 200 ml in the first 24 h in patients underwent transapical approach. Average operative time was 93 min and all patients were immediately extubated after the procedure in the operating room (even the patient with echocardiographically documented LVOT obstruction who died on the fifth postoperative day). Length of Intensive Care Unit stay was 2 ± 1.2 days and length of hospital stay was 4.1 ± 1.2 days. In the follow up period, echocardiograms showed normal prosthetic valve function with low transvalvular gradients, no LVOT obstruction in TMVIR cases and no evidence of valve migration or thrombosis (except in one patient). Concerning 6 months readmission, it was recorded in 2 patients due to right sided heart failure symptoms due to preexisting high degree of tricuspid valve regurge which did not disappear or even decrease after the operation and the other patient due to gastrointestinal bleeding. CONCLUSIONS: TMVIV and TMVIR offer an efficient, safe and less invasive alternative in high surgical risk patients.