Angiographic characteristics and long-term prognostic impact of coronary artery disease in survivors after sudden cardiac arrest with a non-diagnostic electrocardiogram.

OBJECTIVES: Our purpose was to describe the prevalence, distribution, extension, and prognostic value of coronary artery disease (CAD) in patients resuscitated from sudden cardiac arrest (SCA) with non-diagnostic electrocardiogram (ECG). BACKGROUND: The impact of CAD and the indication for cardiac catheterization (CC) in patients resuscitated from SCA with non-diagnostic ECG are uncertain. METHODS: We included prospectively and consecutively 545 patients resuscitated from SCA with at least one CC during hospitalization. From them, 203 patients with a non-diagnostic ECG formed our study population. Patients were followed-up 5 years after discharge. RESULTS: Overall, 125 (61.6%) patients had significant CAD, and at least one acute culprit lesion was found in 25 (12.4%). Regarding the burden and complexity of CAD, 78 (38.4%) patients had a CAD Prognostic Index of 0 and a SYNTAX score of 0. There was higher 5-year mortality only in patients with very high burden of CAD: three vessels with severe stenosis (P = 0.015) and CAD Prognostic Index Score ≥ 56 (P < 0.001). Tertiles of SYNTAX score did not predict higher 5-year mortality. CONCLUSIONS: In survivors from SCA with a non-diagnostic ECG, significant CAD is highly prevalent. SYNTAX score was not associated with a different long-term prognosis in this patient population. Patients with severe disease in the three main coronary vessels and patients with higher (≥56) CAD Prognostic Index Score had a worse long-term prognosis.

Discongruence Index　- Simple Indicator to Predict Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement.

BACKGROUND: Prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) remains an important issue. The aim of this study was to assess the value of a new discongruence index, to predict PPM after TAVR.Methods and Results: A total of 185 patients with severe aortic stenosis who underwent TAVR with the Edwards Sapien prosthesis or CoreValve Revalving system were included (Edwards valve, n=119; Core Valve Revalving system, n=66). Discongruence index was calculated pre-procedurally as the ratio of selected transcatheter valve size (mm) to body surface area (cm2). PPM was defined as effective orifice area (EOA) ≤0.85 cm2/m2 on transthoracic echocardiography before hospital discharge. Mean age was 82±5 years and 72 patients (38.9%) were men. The overall incidence of post-TAVR PPM was 35.1% (n=65). Discongruence index correlated with post-TAVR indexed EOA (y=0.18+0.057x; P<0.001). On multivariate logistic regression analysis, discongruence index was the only independent predictor of post-TAVR PPM (OR, 0.15; 95% CI: 0.03-0.66; P=0.012), and the area under the receiver operating characteristic curve was 0.62 (95% CI: 0.54-0.70, P=0.003), with an optimal cut-off point of 15.02 (sensitivity, 86.2%; specificity, 72.5%; positive predictive value, 74.3%; negative predictive value, 83.4%). CONCLUSIONS: The new discongruence index may be useful tool to predict PPM after TAVR.

Beta-blockers and renin-angiotensin system inhibitors for Takotsubo syndrome recurrence: a network meta-analysis.

INTRODUCTION: Takotsubo syndrome (TTS) is an acute heart failure syndrome, featured by transient left ventricular systolic dysfunction. Recurrences of TTS are not infrequent and there is no standard preventive therapy. The aim of this study was to evaluate in a network meta-analysis if beta-blockers (BB) and ACE inhibitors/angiotensin receptor blockers (ACEi/ARBs), in combination or not, can effectively prevent TTS recurrences. METHODS: We performed a systematic network meta-analysis, using MEDLINE/EMBASE and the Cochrane Central Register of Controlled Trials for clinical studies published between January 2010 and September 2022. We considered all those studies including patients receiving medical therapy with BB, ACEi/ARBs. The primary outcome was TTS recurrence. RESULTS: We identified 6 clinical studies encompassing a total of 3407 patients with TTS. At 40±10 months follow-up, TTS recurrence was reported in 160 (4.7%) out of 3407 patients. Mean age was 69.8±2 years and 394 patients (11.5%) out of 3407 were male. There were no differences in terms of TTS recurrence when comparing ACEi/ARBs versus control (OR 0.83; 95% CI 0.47 to 1.47, p=0.52); BB versus control (OR 1.01; 95% CI 0.63 to 1.61, p=0.96) and ACEi/ARBs versus BB (OR 0.88; 95% CI 0.51 to 1.53, p=0.65).Combination of BB and ACEi/ARBs was also not effective in reducing the risk of recurrence versus control (OR 0.91; 95% CI 0.58 to 1.43, p=0.68) vs ACEi/ARBs (OR 0.79; 95% CI 0.46 to 1.34, p=0.38)) and vs BB (OR 0.77; 95% CI 0.49 to 1.21, p=0.26). CONCLUSIONS: Our study did not find sufficient statistical evidence regarding combination therapy with BB and ACEi/ARBs in reduction of TTS recurrence.

Left ventricular outflow tract obstruction in Takotsubo syndrome with cardiogenic shock: prognosis and treatment.

BACKGROUND: Patients with Takotsubo syndrome (TTS) who develop cardiogenic shock may present with left ventricular outflow tract obstruction (LVOTO). The prognosis and treatment of this population have not been defined in previous studies. The aim of this study is to describe the clinical presentation, management, evolution and prognosis of a subgroup of patients with TTS and cardiogenic shock according to whether they present with LVOTO or not. METHODS: We analysed patients with TTS recruited from 2003 to 2022 in a multicentre registry. Patients were selected if they presented cardiogenic shock during their admission. This analysis was compared according to the presence or absence of LVOTO. RESULTS: 322 patients were included, 58 (18%) of whom had LVOTO. The majority were treated with vasoactive and inotropic therapy (VIT) and its use was strongly associated with having LVOTO (77.6% vs 57.6%, p<0.001). Only five (3.3%) patients without LVOTO and two (4.4%) in the LVOTO group treated with VIT developed or worsened the obstruction. Furthermore, patients with LVOTO presented higher in-hospital complications including ventricular arrhythmias (15.5% vs 8.7%, p=0.017), major bleeding (13.8% vs 6.1%, p=0.042) and acute kidney failure (48.3% vs 28.4%, p=0.003). However, at both 90 days and 5 years, the cumulative incidence of all-cause death was not significantly different between the patients with and without LVOTO (HR 1.20, 95% CI 0.60 to 2.40 for 90 days, and HR 1.69, 95% CI 0.89 to 3.21 for 5 years). CONCLUSIONS: LVOTO is not uncommon in patients with TTS and cardiogenic shock. It is associated with a more aggressive in-hospital course and our data is unable to rule out an association between the presence of LVOTO and long-term prognosis of patients with TTS. The development or worsening of LVOTO directly related to inotropic or vasoactive support was low.

Propensity-matched analysis of long-term clinical results after ostial circumflex revascularisation.

BACKGROUND: Percutaneous coronary intervention (PCI) of the ostium of the left circumflex artery (LCx) is technically challenging. The aim of this study was to compare long-term clinical outcomes of ostial PCI located in the LCx versus the left anterior descending artery (LAD) in a propensity-matched population. METHODS: Consecutive patients with a symptomatic isolated 'de novo' ostial lesion of the LCx or LAD treated with PCI were included. Patients with a stenosis of >40% in the left main (LM) were excluded. A propensity score matching was performed to compare both groups. The primary endpoint was target lesion revascularisation (TLR); other endpoints included target lesion failure and an analysis of the bifurcation angles. RESULTS: From 2004 to 2018, 287 consecutive patients with LAD (n=240) or LCx (n=47) ostial lesions treated with PCI were analysed. After the adjustment, 47 matched pairs were obtained. The mean age was 72±12 years and 82% were male. The LM-LAD angle was significantly wider than the LM-LCx angle (128°±23° vs 108°±24°, p=0.002). At a median follow-up of 5.5 (IQR 1.5-9.3) years, the rate of TLR was significantly higher in the LCx group (15% vs 2%); with an HR of 7.5, 95% CI 2.1 to 26.4, p<0.001. Interestingly, in the LCx group, TLR-LM occurred in 43% of the TLR cases; meanwhile, no TLR-LM involvement was found in the LAD group. CONCLUSIONS: Isolated ostial LCx PCI was associated with an increase in the rate of TLR compared with ostial LAD PCI at long-term follow-up. Larger studies evaluating the optimal percutaneous approach at this location are needed.

Takotsubo Syndrome, Stressful Triggers, and Risk of Recurrence.

The risk of recurrence in takotsubo syndrome (TTS) appears to be low, although previous studies have shown conflicting results and factors associated with recurrences are unclear. The aim of this study is to evaluate the incidence and predictors of TTS recurrences. Adult patients included in the Spanish Multicenter REgistry of TAKOtsubo syndrome (RETAKO) between January 2003 and September 2019 were identified. Patients were categorized based on recurrences during follow-up and a multivariate logistic regression model was used to identify factors associated with recurrences. A total of 1097 patients (mean age 71.0±11.9 years, 87% females) were included, repeated TTS events were documented in 44 patients (4.0%), including 13 patients with prior TTS and 31 patients with recurrent TTS during a median follow-up of 279 days. Two patients (0.02%) had two episodes of recurrence. Compared to patients who had no recurrence of TTS, those with recurrent TTS more frequently had no identifiable stressful trigger in the index admission (20 [64.5%] vs 352 [33.0%], p <0.001). Primary TTS, defined as TTS without physical trigger, was also more common in the recurrence group (93.5% vs 68.3%, p <0.001). The only factor independently associated with recurrences was the absence of an identifiable trigger (odds ratio 3.7 [95% confidence interval 1.8-7.8], p=0.001). In conclusion, our data indicate that for patients presenting with TTS, the rate of early recurrent TTS is approximately 4% per year. Among TTS patients, those who have no identifiable trigger events appear to have a higher rate of recurrence.

Antiplatelet therapy and outcome in COVID-19: the Health Outcome Predictive Evaluation Registry.

BACKGROUND: Standard therapy for COVID-19 is continuously evolving. Autopsy studies showed high prevalence of platelet-fibrin-rich microthrombi in several organs. The aim of the study was therefore to evaluate the safety and efficacy of antiplatelet therapy (APT) in hospitalised patients with COVID-19 and its impact on survival. METHODS: 7824 consecutive patients with COVID-19 were enrolled in a multicentre international prospective registry (Health Outcome Predictive Evaluation-COVID-19 Registry). Clinical data and in-hospital complications were recorded. Data on APT, including aspirin and other antiplatelet drugs, were obtained for each patient. RESULTS: During hospitalisation, 730 (9%) patients received single APT (93%, n=680) or dual APT (7%, n=50). Patients treated with APT were older (74±12 years vs 63±17 years, p<0.01), more frequently male (68% vs 57%, p<0.01) and had higher prevalence of diabetes (39% vs 16%, p<0.01). Patients treated with APT showed no differences in terms of in-hospital mortality (18% vs 19%, p=0.64), need for invasive ventilation (8.7% vs 8.5%, p=0.88), embolic events (2.9% vs 2.5% p=0.34) and bleeding (2.1% vs 2.4%, p=0.43), but had shorter duration of mechanical ventilation (8±5 days vs 11±7 days, p=0.01); however, when comparing patients with APT versus no APT and no anticoagulation therapy, APT was associated with lower mortality rates (log-rank p<0.01, relative risk 0.79, 95% CI 0.70 to 0.94). On multivariable analysis, in-hospital APT was associated with lower mortality risk (relative risk 0.39, 95% CI 0.32 to 0.48, p<0.01). CONCLUSIONS: APT during hospitalisation for COVID-19 could be associated with lower mortality risk and shorter duration of mechanical ventilation, without increased risk of bleeding. TRIAL REGISTRATION NUMBER: NCT04334291.

Calcified right ventricular thrombus and antiphospholipid syndrome.

Antiphospholipid syndrome has been associated with venous and arterial thrombotic events but intracardiac thrombosis is rare. We describe a case about a 30-year-old woman, admitted with a 6-month history of arthralgia, fatigue, and intermittent fever. Subsequent investigation revealed the presence of a large and calcified mass in the right ventricular outflow tract attached to the subvalvular tricuspid apparatus. Cardiac surgery was performed and histological examination demonstrated it to be composed entirely of calcified thrombus. Screening laboratory evaluation for hypercoagulable states confirmed the diagnosis of antiphospholipid syndrome.

ST-Elevation Myocardial Infarction in Patients ≤35 Years of Age.

ST-elevation myocardial infarction (STEMI) in very young patients is an uncommon entity but with significant clinical meaning for the patient. These individuals may have different risk profiles and prognosis. Few reports have described epidemiology, clinical features, and long-term outcomes of these patients in the era of percutaneous coronary intervention, particularly of those ≤35. This observational study evaluates the clinical characteristics of patients <35 years with STEMI between January 2004 and September 2016 in 3 different centers. We gathered data and follow-up from the prospective database of the interventional cardiology department, medical history, and phone interviews. Over a total of 3,883 STEMI, we retrieved 61 patients ≤35. They were mainly male (88%), smokers (80%), and overweight (67%). Twenty-six percent were drug consumers. Only 2 patients (3%) were free of conventional risk factors. In-hospital mortality was 5% (3 deaths). They were followed-up for 5.9 ± 4.2 years with a total survival of 96.6% (2 deaths). Major adverse cardiovascular events incidence at the end of follow-up was only 17.2% (10 patients). STEMI in the young is a rare condition. These patients have several modifiable predisposing factors, a low clinical risk profile, and excellent short- and long-term prognosis with state-of-the-art treatment.

Clinical and prognostic comparison between left ventricular transient dyskinesia and a first non-ST-segment elevation acute coronary syndrome.

OBJECTIVES: Apical ballooning shares features with acute coronary syndromes. Recently, atypical forms have been reported without apical involvement. Usually, the prognostic reports have compared them with ST-segment elevation infarction. Left ventricular transient dyskinesias (LVTD), however, frequently occur without ST-segment elevation and when present, these patients always have open arteries. Our aim was to assess the baseline features, clinical presentation, natural history and compare long-term prognosis in an LVTD-cohort with a first non-ST-segment elevation acute coronary syndrome (NSTEMI) group. METHODS: We performed a prospective observational study including consecutive patients in two groups: (i) LVTD group: 62 patients with this syndrome between 2003 and 2007. Inclusion criteria were LV segmental transient motion abnormalities; ECG new alterations and elevated troponin; absence of recent significant head trauma or obstructive coronary artery lesions. (ii) CONTROL GROUP: 169 patients admitted for a first NSTEMI in 2004. RESULTS: Median follow-up was 35 months. Mean age was 65 years. LVTD group included 83.9% females. NSTEMI group was predominantly males. Eleven in-hospital deaths happened in NSTEMI cohort and none in LVTD. Four patients in the LVTD group required readmission and two patients died. In the NSTEMI group, heart failure, unstable angina, myocardial infarction (P<0.001) and death (P=0.11) were more frequent. Cox regression showed that diabetes mellitus, significant onset mitral regurgitation and NSTEMI versus LVTD were found as event-independent predictors. CONCLUSION: LVTD diagnosis represents a decreased risk of events when compared with classic non-ST-segment acute coronary syndrome, pointing out a different pathophysiologic mechanism.

Impact of Calcium Score on Agreement Between Multidetector Computed Tomography and Invasive Coronary Angiography.

INTRODUCTION AND OBJECTIVES: Multidetector computed tomography (MDCT) has been demonstrated as a feasible alternative to invasive coronary angiography (ICA). However, contradictory results have been reported regarding the effect of coronary artery calcium score (CS) on the diagnostic accuracy of MDCT. Our aim was to assess the agreement of MDCT and ICA and to evaluate the influence of CS on this agreement. METHODS: We enrolled 266 consecutive patients who underwent evaluation with 64-slice MDCT and ICA. Standard CS software tools were used to calculate the Agatston score. Stenosis was qualitatively classified as mild, moderate, or severe by 1 blinded observer and the results were compared with those of ICA, which was used as the gold standard. RESULTS: The mean age of the patients was 65.4 ± 11.2 years, and 188 patients (70.3%) were men. A total of 484 segments with coronary stenosis ≥ mild were qualitatively evaluated and quantified with MDCT. Noninvasive measurements were concordant with ICA in 402 stenoses (83.05%; Kappa, 0.684), with no significant differences between vessels and with no statistically significant influence of CS on this agreement (OR, 0.93; 95%CI, 0.76-1.09; P = .21). Multidetector computed tomography had high sensitivity, specificity, positive predictive value, and negative predictive value on a per-segment, per-vessel, and per-patient basis. CONCLUSIONS: Non-ICA using MDCT showed good agreement with ICA in the qualitative quantification coronary stenosis and CS had no significant impact on this agreement.

Bifurcation Culprit Lesions in ST-segment Elevation Myocardial Infarction: Procedural Success and 5-year Outcome Compared With Nonbifurcation Lesions.

INTRODUCTION AND OBJECTIVES: We assessed short- and long-term outcomes of primary angioplasty in ST-segment elevation myocardial infarction by comparing bifurcation culprit lesions (BCL) with non-BCL. METHODS: Observational study with a propensity score matched control group. Among 2746 consecutive ST-segment elevation myocardial infarction patients, we found 274 (10%) patients with BCL. The primary outcome was a composite endpoint including all-cause death, myocardial infarction, coronary artery bypass grafting or target vessel revascularization, assessed at 30-days and 5-years. RESULTS: Baseline characteristics showed no differences after propensity matching (1:1). In the BCL group, the most frequent strategy was provisional stenting of the main branch (84%). Compared with the non-BCL group, the procedures were technically more complex in the BCL group in terms of need for balloon dilatation (71% BCL vs 59% non-BCL; P = .003), longer procedural time (70 ± 29minutes BCL vs 62.8 ± 28.9minutes non-BCL; P = .004) and contrast use (256.2 ± 87.9mL BCL vs 221.1 ± 82.3mL non-BCL; P < .001). Main branch angiographic success was similar (93.4% BCL vs 93.8% non-BCL; P = .86). Thirty-day all-cause mortality was similar between groups: 4.7% BCL vs 5.1% non-BCL; P = .84. At the 5-year follow-up, there were no differences in all-cause death (12% BCL vs 13% non-BCL; P = .95) or the combined event (22% BCL vs 21% non-BCL; P = .43). CONCLUSIONS: Primary angioplasty of a BCL was technically more complex; however, main branch angiographic success was similar, and there were no differences in long-term prognosis compared with non-BCL patients.

Coronary angiography findings in cardiac arrest patients with non-diagnostic post-resuscitation electrocardiogram: A comparison of shockable and non-shockable initial rhythms.

AIM: To investigate the impact of coronary artery disease in a cohort of patients resuscitated from cardiac arrest with non-diagnostic electrocardiogram. METHODS: From March 2004 to February 2016, 203 consecutive patients resuscitated from in or out-of-hospital sudden cardiac arrest and non-diagnostic post-resuscitation electrocardiogram (defined as ST segment elevation or pre-sumably new left bundle branch block) who underwent invasive coronary angiogram during hospitalization were included. For purpose of analysis and comparison, patients were classified in two groups: Initial shockable rhythm (ventricular tachycardia or ventricular fibrillation; n = 148, 72.9%) and initial non-shockable rhythm (n = 55, 27.1%). Baseline characteristics, coronary angiogram findings including Syntax Score and long-term survival rates were compared. RESULTS: Sudden cardiac arrest was witnessed in 95.2% of cases, 66.7% were out-of-hospital patients and 72.4% were male. There were no significant differences in baseline characteristics between groups except for higher mean age (68.1 years vs 61 years, P = 0.001) in the non-shockable rhythm group. Overall 5-year mortality of the resuscitated patients was 37.4%. Patients with non-shockable rhythms had higher mortality (60% vs 29.1%, P < 0.001) and a worst neurological status at hospital discharge based on cerebral performance category score (CPC 1-2: 32.7% vs 53.4%, P = 0.02). Although there were no significant differences in global burden of coronary artery disease defined by Syntax Score (mean Syntax Score: 10.2 vs 10.3, P = 0.96) there was a trend towards a higher incidence of acute coronary lesions in patients with shockable rhythm (29.7% vs 16.4%, P = 0.054). There was also a higher need for ad-hoc percutaneous coronary intervention in this group (21.9% vs 9.1%, P = 0.03). CONCLUSION: Initial shockable group of patients had a trend towards higher incidence of acute coronary lesions and higher need of ad-hoc percutaneous intervention vs non-shockable group.

Tricuspid annular plane systolic excursion inaccuracy to assess right ventricular function in patients with previous tricuspid annulopasty.

OBJETIVES: The clinical and prognostic usefulness of tricuspid annular plane systolic excursion (TAPSE) is well established. However, the ability of TAPSE to assess right ventricular (RV) function in patients with previous tricuspid valve annulopasty is controversial. This study examined the TAPSE suitability in patients with previous tricuspid valve annuloplasty using right ventricular fractional area change (RVFAC) as reference method. METHODS: We retrospectively analyzed 53 patients who underwent tricuspid valve annuloplasty at our hospital between 2013 and 2016. TAPSE and RVFAC were obtained in preoperative and postoperative periods using standard methodology. RESULTS: Mean age was 68±12years and 34 patients (64.1%) were women. TAPSE decreased significantly after surgery in comparison with pre-surgical values (17±4.2 Vs 12.9±4.1mm, p<0.001). On the contrary, RVFAC did not change significantly after surgery (37±9.2 Vs 36.2.9, p=0.25). The correlation between RVFAC and TAPSE was better in the preoperative (r=0.63, p<0.0001) than in the postoperative period (r=0.38, P=0.005). Good intra- and interobserver agreement for TAPSE and RVFAC was obtained, with intraclass correlation coefficients of 0.97 and 0.92 for TAPSE; and 0.90 and 0.85 for RVFAC, respectively. CONCLUSIONS: These findings suggest that TAPSE is not suitable after tricuspid valve annuloplasty and it leads to an underestimation of RV systolic function. It seems to be appropriate to rely on echocardiographic parameters of global RV function such as RVFAC in this context.

Proximal flow convergence method by three-dimensional color Doppler echocardiography for mitral valve area assessment in rheumatic mitral stenosis.

BACKGROUND: The two-dimensional (2D) proximal isovelocity surface area (PISA) method has important technical limitations for mitral valve orifice area (MVA) assessment in mitral stenosis (MS), mainly the geometric assumptions of PISA shape and the requirement of an angle correction factor. Single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions or the requirement of an angle correction factor. The aim of this study was to validate this method in patients with rheumatic MS. METHODS: Sixty-three consecutive patients with rheumatic MS were included. MVA was assessed using the transthoracic 2D and 3D PISA methods. Planimetry of MVA (2D and 3D) and the pressure half-time method were used as reference methods. RESULTS: The 3D PISA method had better correlations with the reference methods (with 2D planimetry, r = 0.85, P < .001; with 3D planimetry, r = 0.89, P < .001; and with pressure half-time, r = 0.85, P < .001) than the conventional 2D PISA method (with 2D planimetry, r = 0.63, P < .001; with 3D planimetry, r = 0.66, P < .001; and with pressure half-time, r = 0.68, P < .001). In addition, a consistent significant underestimation of MVA using the conventional 2D PISA method was observed. A high percentage (30%) of patients with nonsevere MS by 3D planimetry were misclassified by the 2D PISA method as having severe MS (effective regurgitant orifice area < 1 cm(2)). In contrast, the 3D PISA method had 94% agreement with 3D planimetry. Good intra- and interobserver agreement for 3D PISA measurements were observed, with intraclass correlation coefficients of 0.95 and 0.90, respectively. CONCLUSIONS: MVA assessment using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.