Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy.

BACKGROUND: The role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains controversial. Furthermore, although improvement in left ventricular function is one of the goals of revascularization, its relationship to subsequent outcomes is unclear. METHODS: Among 601 patients who had coronary artery disease that was amenable to coronary-artery bypass grafting (CABG) and who had a left ventricular ejection fraction of 35% or lower, we prospectively assessed myocardial viability using single-photon-emission computed tomography, dobutamine echocardiography, or both. Patients were randomly assigned to undergo CABG and receive medical therapy or to receive medical therapy alone. Left ventricular ejection fraction was measured at baseline and after 4 months of follow-up in 318 patients. The primary end point was death from any cause. The median duration of follow-up was 10.4 years. RESULTS: CABG plus medical therapy was associated with a lower incidence of death from any cause than medical therapy alone (182 deaths among 298 patients in the CABG group vs. 209 deaths among 303 patients in the medical-therapy group; adjusted hazard ratio, 0.73; 95% confidence interval, 0.60 to 0.90). However, no significant interaction was observed between the presence or absence of myocardial viability and the beneficial effect of CABG plus medical therapy over medical therapy alone (P = 0.34 for interaction). An increase in left ventricular ejection fraction was observed only among patients with myocardial viability, irrespective of treatment assignment. There was no association between changes in left ventricular ejection fraction and subsequent death. CONCLUSIONS: The findings of this study do not support the concept that myocardial viability is associated with a long-term benefit of CABG in patients with ischemic cardiomyopathy. The presence of viable myocardium was associated with improvement in left ventricular systolic function, irrespective of treatment, but such improvement was not related to long-term survival. (Funded by the National Institutes of Health; STICH ClinicalTrials.gov number, NCT00023595.).

Effect of Polythiophene Content on Thermomechanical Properties of Electroconductive Composites.

The thermal, mechanical and electrical properties of polymeric composites combined using polythiophene (PT) dopped by FeCl3 and polyamide 6 (PA), in the aspect of conductive constructive elements for organic solar cells, depend on the molecular structure and morphology of materials as well as the method of preparing the species. This study was focused on disclosing the impact of the polythiophene content on properties of electrospun fibers. The elements for investigation were prepared using electrospinning applying two substrates. The study revealed the impact of the substrate on the conductive properties of composites. In this study composites exhibited good thermal stability, with T5 values in the range of 230-268 °C that increased with increasing PT content. The prepared composites exhibited comparable PA Tg values, which indicates their suitability for processing. Instrumental analysis of polymers and composites was carried out using Fourier Transform Infrared spectroscopy (FT-IR), thermogravimetric analysis (TGA), differential scanning calorimetry (DSC), dynamic mechanical thermal analysis (DMTA) and scanning electron microscopy (SEM).

3D and 2D left ventricular systolic function imaging-- from ejection fraction to deformation. Cardiac resynchronization therapy--substudy.

INTRODUCTION: 3D echocardiography offers options of left ventricular systolic function analysis. The aims of this study are: to assess the usefulness of 3D echocardiography, to test 3D regional measurements (with area strain) among a spectrum of patients and then to check prospectively the value of 3D echocardiography vs 2D in the assessment of response to resynchronization. METHODS: The first retrospective study group comprises 42 subjects: 23 consecutive patients with left ventricular systolic heart failure and 19 healthy control subjects. The left ventricle was assessed by: 2D-Simpson's biplane, 3D-triplane and -automated volumetric method. Next, 24 patients undergoing cardiac resynchronization therapy were prospectively assessed before and after 6 months. A haemodynamic response criterion of 15% left ventricular end-systolic volume (ESV) reduction was used. RESULTS: The 3D volumetric method was the fastest method for left ventricular ejection fraction assessment (bi-33 vs tri-53 vs145 sec, ANOVA P < 0.001). In heart failure the only strain parameter associated with QRS width was global peak longitudinal strain (r = 0.47, P = 0.023). A high agreement in left ventricular ejection fraction and volumes between methods was observed. The following measures select resynchronization candidates in the heart failure group: (1) 3D global longitudinal strain (AUC-0.756; P = 0.022; the cut-off value > -9.52%; 78% sensitivity, 80% specificity), radial strain (AUC-0.739; P = 0.086; cut-off value 20%; 78% sensitivity, 80% specificity) and area strain (AUC-0.733; P = 0.045; cut-off value > -13.5%; 67% sensitivity, 80% specificity). The agreement between the response assessment by Simpson's biplane and 3D was 78% with a negative predictive value of 100%. The lack of global area strain improvement after cardiac resynchronization therapy has a negative predictive value of 100% in the selection of non-responders. CONCLUSIONS: 3D echocardiography is applicable in the assessment of both preserved and reduced left ventricular ejection fraction. This assessment is fast and requires minimal user intervention. 3D strain may help in cardiac resynchronization therapy candidates and response assessment. After cardiac resynchronization, none of the patients were incorrectly identified as responder to cardiac resynchronization therapy by 3D algorithms compared to 2D Simpson's reference.

Echocardiographic predictors of positive left ventricular remodeling in patients with a history of active myocarditis.

INTRODUCTION: Myocarditis may be difficult to diagnose because of the variety of its clinical manifestations, and the clinical course of the disease can be unpredictable. Nevertheless, some patients may exhibit partial or full contractile recovery following myocarditis. Standard and speckle-tracking echocardiography may serve as tools to follow this recovery. OBJECTIVES: We aimed to evaluate predictors of positive left ventricular (LV) remodeling after active myocarditis (AM). PATIENTS AND METHODS: A database of a high­volume, tertiary cardiology center was searched for patients with AM hospitalized between 2016 and 2019. They were included in the analysis based on clinical manifestations and presence of at least 1 of the following diagnostic criteria: positive findings on electrocardiography / Holter monitoring, echocardiography, elevated troponin T/I levels, functional or structural abnormalities on cardiac imaging, or tissue characterization by cardiac magnetic resonance. LV global longitudinal strain and mechanical dispersion (MD; defined as SD of the time to peak longitudinal strain derived from all LV segments in 3 apical views) were determined. Echocardiographic response (positive LV remodeling measured by transthoracic echocardiography) was defined as end­systolic volume (ESV) reduction by 15% or greater or end-diastolic volume (EDV) reduction by 15% or greater from the baseline values. RESULTS: A total of 61 consecutive patients were recruited. The median follow­up was 1.4 years (range, 0.3-4). The mortality rate was 1.6%. Echocardiographic response was noted in 24 patients (39.4%). A multivariable Cox regression model including significant baseline differences as covariates showed that QRS duration (hazard ratio [HR], 1.31; 95% CI, 1.17-1.57; P = 0.049), MD (HR, 1.03; 95% CI, 1.01-1.07; P = 0.04), and mineralocorticoid receptor antagonist [MRA] use (HR, 8.60; 95% CI, 1.50-46.49; P = 0.01) were independently associated with positive LV remodeling with ESV reduction. MD (HR, 1.04; 95% CI, 1.02-1.06; P = 0.04) was also independently associated with positive LV remodeling with EDV reduction. CONCLUSIONS: Mechanical dispersion, QRS duration, and MRA use are independent predictors of positive LV remodeling in individuals with a history of AM.

Impact of lead position on tricuspid regurgitation, ventricular function, and heart failure exacerbation and mortality after cardiac implantable electronic device implantation. Preliminary results from the PACE-RVTR Registry.

BACKGROUND: The most frequent mechanism of lead-related tricuspid regurgitation (LRTR), which occurs in 7.2% to 44.7% of patients implanted with a cardiac implantable electronic device (CIED), is leaflet impingement or the restriction of its movement by a ventricular lead. It is unclear if the position of the lead tip - in the right ventricular apex (RVA) or other location (non-RVA) - has any influence on the development of LRTR. The study aimed to determine the impact of the CIED lead tip position on the development or progression of tricuspid regurgitation (TR) and its potential impact on heart failure exacerbation and mortality. METHODS: One hundred and two consecutive patients who received CIEDs between March 2020 and October 2021 were included in the prospective registry (PACE-RVTR). Patients were assigned to two groups depending on the lead position - the RVA group and the non-RVA group. All patients underwent echocardiographic evaluation before implantation and one year later. RESULTS: In terms of baseline clinical characteristics, the two groups did not differ. Before CIED implantation, patients in the non-RVA group had better left ventricular systolic function (P = 0.004). Pacemakers were implanted more often in the non-RVA group (P = 0.001) while implantable cardioverter-defibrillators in the RVA group (P = 0.008). Progression to severe or massive TR was more common in the non-RVA group (P = 0.005). CONCLUSION: Severe and massive TR occurred more often in patients with the non-RVA position of the lead. The right ventricular lead position did not impact heart failure progression or all-cause mortality at two-year follow-up.

Preliminary results from the Polish Infective Endocarditis Registry (POL-ENDO): Time to change clinical practice?

BACKGROUND: Infective endocarditis (IE) is a severe valvular disease associated with high morbidity and mortality. AIMS: This preliminary study aimed to evaluate patient profiles and treatment outcomes of IE in Poland and compare them with European IE characteristics. METHODS: We conducted a prospective multicenter observational cohort study - the POL-ENDO registry - in IE patients from 134 hospitals in Poland recruited between August 2022 and August 2023. We evaluated demographic, clinical, imaging, and treatment outcome data. A comparison of the Polish patients with those assessed in the EURO-ENDO registry between January 2016 and March 2018 was performed. RESULTS: Of a total of 880 IE patients, 622 were male (70.7%). The POL-ENDO participants were older (61.4 [16.7] years vs. 59.25 [18.03] years; P = 0.001). Native-valve IE occurred more often in Poland (82.3% vs. 56.6%; P <0.001). Transthoracic echocardiography was performed more frequently in Poland (93.6% vs. 89.8%; P <0.001). New imaging techniques (computed tomography/magnetic resonance imaging/positron emission tomography/single-photon emission computed tomography) were less frequently used in Poland (computed tomography: 41.3% vs. 53.2%; P <0.001; magnetic resonance imaging: 6.4% vs. 18.7%; P <0.001). Heart failure occurred more often in Poland as an in-hospital complication (31.4% vs. 14.1%; P <0.001). Surgical treatment was less frequently performed in Poland (36.9% vs. 51.2%; P <0.001). In-hospital mortality was higher in Poland (21% vs. 17%; P = 0.008). CONCLUSION: Polish IE patients were significantly older and had more comorbidities. New imaging techniques are less frequently used in Poland. Echocardiography was performed more frequently in Poland as the diagnostic mainstay. Surgical treatment was significantly less frequent in Poland. In-hospital mortality in Poland is higher.

Many response criteria are poor predictors of outcomes after cardiac resynchronization therapy: validation using data from the randomized trial.

AIMS: The aim of the study was to assess the predictive value for outcomes of various response criteria currently used in patients undergoing cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Data from TRUST CRT randomized trial in patients with New York Heart Association (NYHA) III-IV class, QRS ≥ 120 ms, ejection fraction ≤ 35%, and mechanical dyssynchrony was analysed. Ninety-seven subjects who survived 6 months after implantation of CRT-defibrillator were classified as responders or non-responders depending on 15 criteria used in most of the previous trials. Blindly adjudicated data on major adverse cardiac events (MACEs) within 1 year after classification were used to calculate the predictive value of response criteria. After adjustment for baseline confounding variables only eight criteria were significantly predictive for future MACEs. Sensitivity and specificity ranged substantially for clinical (32-94% and 26-63%) and echocardiographic criteria (40-93% and 22-70%, respectively). The most powerful clinical predictor was >a NYHA class reduction ≥ 1 [adjusted relative risk (RR) 4.41 for non-responders; 95% confidence interval (CI) 1.75-11.04, P = 0.002], while the strongest echocardiographic predictor was a reduction in the left ventricular end-systolic index by > 15% (RR 3.49; 95% CI 1.59-7.64, P = 0.002). A combination of these two criteria did not improve the predictive value of a single parameter. Both criteria showed multiple significant interactions with baseline patients' characteristics. CONCLUSION: Only some of the commonly used response criteria predict outcome in patients undergoing CRT. The predictive value varies substantially across different criteria, with a higher sensitivity observed for the clinical parameters and a higher specificity observed for echocardiographic parameters. Combining various criteria adds little to their prognostic value. The predictive accuracy of various criteria can be different in various subgroups due to multiple interactions with baseline characteristics. CLINICALTRIALS. GOV IDENTIFIER: NCT00814840.

Tricuspid Regurgitation (TR) after Implantation of a Cardiac Implantable Electronic Device (CIED)-One-Year Observation of Patients with or without Left Ventricular Dysfunction.

The frequency of tricuspid regurgitation (TR) progression after cardiac implantable electronic devices (CIEDs) implantation varies from 7.2% to 44.7%. TR is associated with increased mortality and hospitalizations due to heart failure (HF) decompensation. The aim of this study was to assess the rate of early TR progression after CIED implantation and the frequency of HF decompensation and mortality. The 101 patients, who received a CIED between March 2020 and October 2021, before the procedure were divided into two groups-one with left ventricle ejection fraction (LVEF) ≥ 40% (n = 60) and one with LVEF < 40% (n = 41). Lead-related tricuspid regurgitation (LRTR) was defined as an increase of TR by at least one grade. The follow-up period was similar between both groups and was on average 13 (12-16) months. In the whole study group, TR progression by one grade was 34.6% and by two or more grades 15.8%. The significant changes in the dynamic of TR degree were as follows before and after implantation: none/trivial TR in group 1 (61.7% vs. 28.3%, p = 0.01) and severe/massive TR in group 2 (0.0% vs. 14.6%, p = 0.03). The groups did not differ from each other in terms of survival from decompensation of HF (18.3% vs. 36.6%, p = 0.70) and survival from death (1.7% vs. 4.9%, p = 0.16). At the one-year follow-up, the baseline LVEF did not affect the survival rate from death or HF decompensation among patients with a progression of TR after CIED implantation. In this study, a progression by one grade was more common in group 1, but the occurrence of severe/massive TR after implantation was more specific for group 2.

Update of Potential Biomarkers in Risk Prediction and Monitoring of Atherosclerosis in Systemic Lupus Erythematosus to Prevent Cardiovascular Disease.

Systemic lupus erythematosus is a chronic connective tissue disease associated with an increased risk of premature atherosclerosis. It is estimated that approximately 10% of SLE patients develop significant atherosclerosis each year, which is responsible for premature cardiovascular disease that is largely asymptomatic. This review summarizes the most recent reports from the past few years on biomarkers of atherosclerosis in SLE, mainly focusing on immune markers. Persistent chronic inflammation of the vascular wall is an important cause of cardiovascular disease (CVD) events related to endothelial dysfunction, cell proliferation, impaired production and function of nitric oxide and microangiopathic changes. Studies on pathogenic immune mediators involved in atherosclerosis will be crucial research avenues for preventing CVD.

Lead-related tricuspid regurgitation and ventricle dysfunction: Current management and future perspectives.

The implantation of cardiac implantable electronic devices (CIEDs) may result in or worsen previously existing tricuspid regurgitation (TR). The prevelence of lead-related tricuspid regurgitation (LRTR) in patients with CIEDs is between 7.2% and 44.7% when the degree of worsening TR is not reported, or from 9.8% and 38% when it is diagnosed as worsening of TR severity by at least 2 grades after a CIED has been implanted. It has been suggested that a CIED lead positioned over or pinning a leaflet may be the main cause of TR in this patient population. The septal and posterior leaflets of the tricuspid valve have been reported to be the most affected by CIED leads. Severe LRTR is related to the development of heart failure (HF) or worsening of previously existing dysfunction; it is also associated with elevated mortality. However, there are no definitive predictors of LRTR development or standardized methods of treatment. Some studies have suggested that imaging-guided lead placement can reduce the occurrence of LRTR. This review summarizes current knowledge concerning the development, evaluation, consequences, and management of LRTR.

Management of valvular heart disease in patients with cancer: Multidisciplinary team, cancer-therapy related cardiotoxicity, diagnosis, transcatheter intervention, and cardiac surgery. Expert opinion of the Association on Valvular Heart Disease, Association of Cardiovascular Interventions, and Working Group on Cardiac Surgery of the Polish Cardiac Society.

The Association on Valvular Heart Disease, Association of Cardiovascular Interventions, and the Working Group on CardiacSurgery of the Polish Cardiac Society have released a position statement on risk factors, diagnosis, and management of patients with cancer and valvular heart disease (VHD). VHD can occur in patients with cancer in several ways, for example, it can exist or be diagnosed before cancer treatment, after cancer treatment, be an incidental finding during imaging tests, endocarditis related to immunosuppression, prolonged intravenous catheter use, or combination treatment, and nonbacterial thrombotic endocarditis. It is recommended to employ close cardiac surveillance for patients at high risk of complications during and after cancer treatment and for cancer treatments that may be cardiotoxic to be discussed by a multidisciplinary team. Patients with cancer and pre-existing severe VHD should be managed according to the 2021 European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) guidelines for VHD management, taking into consideration cancer prognosis and patient preferences.

Effect of cardiac resynchronization on gradient reduction in patients with obstructive hypertrophic cardiomyopathy: preliminary study.

BACKGROUND: The purpose of this study was to assess the effectiveness of cardiac resynchronization therapy (CRT) in terms of outflow tract gradient reduction and functional improvement in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) requiring implantable cardioverter-defibrillator (ICD) implantation. METHODS: Eleven consecutive symptomatic HOCM patients with a significant (≥40 mmHg) gradient and indications for ICD, but without indications for resynchronization, underwent CRT-D implantation. Nine of them (four female, median age of 50 years) in whom the procedure succeeded were screened for New York Heart Association (NYHA) class, outflow gradient, mechanical dyssynchrony, QRS-width change, and 6-minute walking distance (6MWD) and peak oxygen consumption (VO(2)peak) improvement after 6 months and remotely. RESULTS: After 6 months of pacing, NYHA class decreased (median 1 vs 2, respectively); peak (33 vs 84 mmHg) and mean (13 vs 38 mmHg) outflow tract gradients were reduced; and QRS width (143 vs 105 ms), intraventricular dyssynchrony (35 vs 55 ms), and VO(2)peak (19.5 vs 14.2 mL/kg/min) increased significantly (all P < 0.05) compared to baseline. In six of nine patients (67%), the peak gradient was reduced >50% and reached <40 mmHg. After a median of 36 months, the outflow gradient decreased even more (8 mmHg) and was significantly (P < 0.05) lower than after 6 months of CRT. CONCLUSIONS: These preliminary data suggest that CRT seems to be an effective method of reducing the outflow tract gradient and improving the functional status of symptomatic HOCM patients requiring ICD implantation. Our findings need to be confirmed by more extensive studies.

Graphene Oxide as a Collagen Modifier of Amniotic Membrane and Burnt Skin.

INTRODUCTION: The aim of this interdisciplinary study was to answer the question of whether active antioxidants as graphene oxide (GO), sodium ascorbate, and L-ascorbic acid modify at a molecular and supramolecular level the tissue of pathological amnion and the necrotic eschar degraded in thermal burn. We propose new solutions of modifiers based on GO that will become innovative ingredients to be used in transplants (amnion) and enhance regeneration of epidermis degraded in thermal burn. METHODS: A Nicolet 6700 spectrophotometer with Omnic software and the EasiDiff diffusion accessory were used in FTIR spectroscopic analysis. A Nicolet Magna-IR 860 spectrometer with an FT Raman accessory was used to record the Raman spectra of the samples. The surface of the samples was examined using a Phenom ProX scanning electron microscope with an energy-dispersive X-ray spectroscopy detector to diagnose and illustrate morphological effects on skin and amnion samples. SAXS measurements were carried out with a compact Kratky camera equipped with the SWAXS optical system. RESULTS: Characterisation of amide I-III regions, important for molecular structure, on both FTIR and FTR spectra revealed distinct shifts, testifying to organization of protein structure after GO modification. A wide lipid band associated with ester-group vibrations in phospholipids of cell membranes and vibrations of the carbonyl group of GO in the 1,790-1,720 cm-1 band were observed in the spectra of thermally degraded and GO-modified epidermis and pathological amnion. SAXS studies revealed that GO caused a significant change in the structure of the burnt skin, but its influence on the structure of the amnion was weak. CONCLUSION: Modification of burn-damaged epidermis and pathological amnion by means of GO results in stabilization and regeneration of tissue at the level of molecular (FTIR, FTR) and supramolecular (SAXS) interactions.

Expert opinion of the Heart Failure Working Group of the Polish Cardiac Society on the use of dapagliflozin in the treatment of heart failure with reduced ejection fraction.

Heart failure (HF) is a global health problem inherent in an aging population with coexisting cardiovascular diseases. Based on data from the Polish National Health Fund (Polish, Narodowy Fundusz Zdrowia), approximately 1.2 million people in Poland currently suffer from HF, and 140 000 of them die annually. Recently, Poland was ranked fifth among the European Union countries regarding the number of patients with diagnosed HF and first in terms of the number of HF hospitalizations (547 per 100 000 population) among 34 countries associated in the Organization for Economic Cooperation and Development. In recent years, a significant progress has been made in the diagnosis and treatment of HF with reduced left ventricular ejection fraction (HFrEF), which has resulted in a reduction in cardiovascular and total mortality. Despite these advantages, 5-year survival in the course of HF is still worse than that observed in some types of cancer, both in the populations of men and women. Hence, the search for drugs improving the prognosis in this group of patients is still ongoing. Sodium-glucose cotransporter 2 inhibitors represent a new group of drugs that will undoubtedly be a milestone in the treatment of patients with HFrEF. This expert opinion covers the history of dapagliflozin, which, from a drug dedicated to the treatment of type 2 diabetes, has become one of the most effective drugs improving prognosis and quality of life as well as reducing the number of hospitalizations in patients with HF. This document presents the opinion from the experts of the Heart Failure Working Group of the Polish Cardiac Society on the most relevant studies on dapagliflozin and indications for its use.

Polish Multicenter Registry (Pol-LAS-SE registry). Stress echocardiography in low-gradient aortic stenosis in Poland: numbers, settings, results, complications and clinical practice.

BACKGROUND: The diagnostic workup of low-gradient aortic stenosis (LG AS) is a challenge in clinical practice. AIMS: Our goal was to assess the diagnostic value of stress echocardiography (SE) performed in patients with undefined LG AS with low and preserved ejection fraction (EF) and the impact of its result on therapeutic decisions in Polish third level of reference. METHODS: All the patients with LG AS and with SE performed were recruited in 16 Polish cardiology departments between 2016 and 2019. The main exclusion criteria were as follows: moderate or severe aortic or mitral regurgitation and mitral stenosis. RESULTS: The study group included 163 patients (52% males) with LG AS who underwent SE for adequate diagnostic and therapeutic decision. In 14 patients DSE was non-diagnostic. The mean aortic valve (AV) pressure gradient was 24.1 (7.3) mm Hg, while an AV area was 0.86 (0.2) cm2. Among 149 patients with conclusive DSE, severe AS was found in 59.8%, pseudo-severe in 22%, and moderate AS in 18%. There were no cases of death or vascular events related to DSE. Among 142 patients 63 (44%) patients had an aortic valve intervention in a follow-up (median: 208 days; lower-upper quartile: 73-531 days). Based on the result of the DSE test, severe AS was significantly more often associated with qualification to interventional treatment compared to the moderate and pseudo-severe subgroups (P <0.0001). CONCLUSIONS: The DSE test in severe AS is a valuable diagnostic tool in patients with LG AS in Poland.

Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study.

BACKGROUND: Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality. METHODS: This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm2 and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality. RESULTS: Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94-0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05-2.82]; P=0.03). Furthermore aortic valve area <1cm2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality. CONCLUSIONS: Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.

Development and Validation of a Practical Model to Identify Patients at Risk of Bleeding After TAVR.

OBJECTIVES: No standardized algorithm exists to identify patients at risk of bleeding after transcatheter aortic valve replacement (TAVR). The aim of this study was to generate and validate a useful predictive model. BACKGROUND: Bleeding events after TAVR influence prognosis and quality of life and may be preventable. METHODS: Using machine learning and multivariate regression, more than 100 clinical variables from 5,185 consecutive patients undergoing TAVR in the prospective multicenter RISPEVA (Registro Italiano GISE sull'Impianto di Valvola Aortica Percutanea; NCT02713932) registry were analyzed in relation to Valve Academic Research Consortium-2 bleeding episodes at 1 month. The model's performance was externally validated in 5,043 TAVR patients from the prospective multicenter POL-TAVI (Polish Registry of Transcatheter Aortic Valve Implantation) database. RESULTS: Derivation analyses generated a 6-item score (PREDICT-TAVR) comprising blood hemoglobin and serum iron concentrations, oral anticoagulation and dual antiplatelet therapy, common femoral artery diameter, and creatinine clearance. The 30-day area under the receiver-operating characteristic curve (AUC) was 0.80 (95% confidence interval [CI]: 0.75-0.83). Internal validation by optimism bootstrap-corrected AUC was 0.79 (95% CI: 0.75-0.83). Score quartiles were in graded relation to 30-day events (0.8%, 1.1%, 2.5%, and 8.5%; overall p <0.001). External validation produced a 30-day AUC of 0.78 (95% CI: 0.72-0.82). A simple nomogram and a web-based calculator were developed to predict individual patient probabilities. Landmark cumulative event analysis showed greatest bleeding risk differences for top versus lower score quartiles in the first 30 days, when most events occurred. Predictivity was maintained when omitting serum iron values. CONCLUSIONS: PREDICT-TAVR is a practical, validated, 6-item tool to identify patients at risk of bleeding post-TAVR that can assist in decision making and event prevention.

Assessment of apical rocking: a new, integrative approach for selection of candidates for cardiac resynchronization therapy.

AIMS: Current attempts of improving patient selection in cardiac resynchronization therapy (CRT) are mainly based on echocardiographic timing of myocardial velocity peaks. Regional myocardial function is neglected. Apical transverse motion (ATM) is a new parameter to quantify apical rocking as an integrative surrogate of both temporal and functional inhomogeneities within the left ventricle. In this study, we tested the predictive value of apical rocking for response to CRT. METHODS AND RESULTS: Sixty-nine patients eligible for CRT were assessed by echocardiography before and 11 ± 5 months after pacemaker implantation. Response was defined as left ventricular (LV) end-systolic volume decrease >15%. Rocking was quantified (ATM) and visually assessed by four blinded readers. Predictive value for CRT response of both assessments was compared with conventional dyssynchrony parameters. ATM in the four-chamber view plane differentiated best between responders and non-responders (2.2 ± 1.5 vs. 0.06 ± 1.9 mm, P< 0.0001). Quantified ATM predicted reverse remodelling with a sensitivity, specificity, and accuracy of 75, 96, and 83% whereas visual rocking assessment resulted in 89, 75, and 83%, respectively. The accuracy of conventional parameters was significantly lower. CONCLUSION: Apical rocking is a new marker to assess LV dyssynchrony and predict CRT response. It is superior to conventional parameters. Even its simple visual assessment may be sufficiently accurate in the clinical setting.

Prognosis in diabetic patients with acute myocardial infarction treated invasively is related to renal function.

BACKGROUND: The prevalence of diabetes mellitus (DM) and chronic kidney disease (CKD) is rapidly increasing. Both comorbidities are considered significant risk factors for cardiovascular complications. The aim of the study was to evaluate the impact of DM with and without CKD on prognosis in patients with acute myocardial infarction (AMI) treated invasively. MATERIAL/METHODS: This single-center prospective study encompassed 3334 AMI-patients without cardiogenic shock, who were divided into 2 major groups: 999 patients with type 2 DM diagnosed prior to or during index hospitalization, and 2335 non-diabetics. All diabetic patients were divided with respect to their renal status into: diabetics with CKD (DM-CKD; n=264) and without (DM-nCKD; n=735). Short- and long-term outcomes were compared between study groups. Independent predictors of death and composite end-point were selected with multivariate Cox-regression model. RESULTS: Mortality rates were significantly higher in DM group compared to nDM in all observation periods. DM-CKD was associated with excessive total mortality (35.6%) when compared to DM-nCKD (11.6%, P<0.001) and to nDM (9.8%, P<0.001). Mortality and major adverse cardiovascular event rates did not differ significantly between DM-nCKD and nDM groups. Diabetes coexisting with CKD was one of the strongest independent risk factors for death (hazard ratio 1.93; confidence interval 1.79-2.07; P<0.001). CONCLUSIONS: The prognosis in diabetics with AMI is significantly related to renal function. Diabetics without CKD had similar prognosis to non-diabetics. Multivariate analyses showed that unlike diabetes without renal dysfunction, DM-CKD was an independent risk factor for cardiovascular complications and total mortality.

[Methodology and safety of transvascular reduction of severe ischaemic mitral insufficiency with MitraClip in high-surgical-risk patients - first three cases in Poland]. / Metodyka i bezpieczenstwo zabiegu przeznaczyniowej redukcji ciezkiej pozawalowej niedomykalnosci mitralnjec metoda MitraClip u 3 chorych wysokiego ryzyka leczenia operacyjnego - pierwsze polskie doswiadczenia.

The authors present the results of minimally invasive transvascular reduction of severe mitral insufficiency in the first three patients with extensive postinfarction cardiac injury treated in Poland. The positive early in-hospital outcomes in the first three patients encourage further implementation of this treatment method in patients with postinfarction cardiomyopathy and high perioperative risk.