Prolonged delirium during hospitalization is associated with worse long-term and short-term outcomes in patients with acute heart failure.

BACKGROUND: The association between prolonged delirium during hospitalization and long-term prognosis in patients with acute heart failure (AHF) admitted to the cardiac intensive care unit (CICU) has not been fully elucidated. METHODS: We conducted a prospective registry study of patients with AHF admitted to the CICU at 2 hospitals from 2013 to 2021. We divided study patients into 3 groups according to the presence or absence of delirium and prolonged delirium as follows: no delirium, resolved delirium, or prolonged delirium. Main outcomes were in-hospital mortality and 3-year mortality after discharge. RESULTS: A total of 1555 patients with AHF (median age, 80 years) were included in the analysis. Of these, 406 patients (26.1%) developed delirium. We divided patients with delirium into 2 groups: the resolved delirium group (n = 201) or the prolonged delirium group (n = 205). Multivariate Cox proportional hazards models for long-term prognosis demonstrated that the prolonged delirium group had a higher incidence of all-cause death (hazard ratio [HR], 1.52; 95% CI, 1.08 to 2.14) and non-cardiovascular death (HR, 1.84; 95% CI, 1.21 to 2.78) than the resolved delirium group. Regarding in-hospital outcomes, multivariate logistic regression modeling showed that prolonged delirium is associated with all-cause death (odds ratio [OR], 9.55; 95% confidential interval [CI], 2.99 to 30.53) and cardiovascular death (OR, 13.02; 95% CI, 2.86 to 59.27) compared with resolved delirium. CONCLUSIONS: Prolonged delirium is associated with worse long-term and short-term outcomes than resolved delirium in patients with AHF.

Clinical impact of native T1 mapping for detecting myocardial impairment in takotsubo cardiomyopathy.

AIMS: To investigate the clinical impact of T1 mapping for detecting myocardial impairment in takotsubo cardiomyopathy (TTC) over time. METHODS AND RESULTS: In 23 patients with the apical ballooning type of TTC, the following 3T magnetic resonance (MR) examinations were performed at baseline and 3 months after TTC onset: T2-weighted imaging, T2 mapping, native T1 mapping, extracellular volume fraction (ECV), and late gadolinium enhancement. Eight healthy controls underwent the same MR examinations. Serial echocardiography was performed daily for ≥7 days and monthly until 3 months after onset. The median time from onset to MR examination was 7 days. During the acute phase, patients had, relative to controls, higher native T1 (1438 ± 162 vs. 1251 ± 90 ms, P < 0.001), ECV (35 ± 5% vs. 29 ± 4%, P < 0.001), and T2 (90 ± 34 vs. 68 ± 12 ms, P < 0.001) for the entire heart. Per-region analysis showed that higher native T1 and T2 in the basal region were correlated with lower left ventricular ejection fraction (r = -0.599, P = 0.004 and r = -0.598, P = 0.003, respectively). Receiver operator characteristic analysis showed that the area under the curve for native T1 (0.96) was significantly larger than that for T2 (0.86; P = 0.005) but similar to that for ECV (0.92; P = 0.104). At 3-month follow-up, native T1, ECV, and T2 in the apical region remained significantly elevated in all patients with TTC. The number of left ventricular (LV) segments with elevated native T1 (cut-off value 1339 ms) was significantly correlated with prolonged LV wall motion recovery time (r = 0.494, P = 0.027). CONCLUSION: Characterization of myocardium with native T1 mapping is a promising method for predicting LV wall motion restoration in TTC.

Clinical Usefulness of an Echo-Doppler Model in Predicting Elevated Pulmonary Capillary Wedge Pressure in Patients With Heart Failure.

Although several tissue-Doppler imaging (TDI) models for pulmonary capillary wedge pressure (PCWP) estimation have been reported, their reliability remains uncertain. Our previous theoretical and experimental analyses suggest that right atrial pressure (RAP) corrected by tissue-Doppler imaging tricuspid/mitral annular peak systolic velocities (ST/SM) (RAP × ST/SM) reliably predicts elevated PCWP. We sought to investigate its clinical usefulness for predicting elevated PCWP in heart failure (HF) patients. Ninety-eight patients admitted with HF who underwent right heart catheterization were prospectively studied. RAP and PCWP were measured by right heart catheterization. Simultaneously, ST/SM, early diastolic transmitral flow velocity to mitral annular velocity ratio (E/Ea), and diameter of inferior vena cava at inspiration (IVCDi), a noninvasive surrogate for RAP, were measured by echocardiography. RAP correlated with IVCDi (R2 = 0.57). A significantly stronger correlation was observed between IVCDi corrected by ST/SM (IVCDi × ST/SM) and PCWP than between E/Ea and PCWP (R2 = 0.47 vs 0.18). Receiver-operating characteristic analyses indicated that IVCDi × ST/SM >16 mm predicted PCWP >18 mm Hg with 90% sensitivity and 77% specificity, and the area under the curve was 0.86, which was significantly larger than that of E/Ea (area under the curve=0.72). In conclusions, IVCDi × ST/SM is a new useful noninvasive model to predict elevated PCWP in HF patients.

Procedural challenge of coronary catheterization for ST-segment elevation myocardial infarction in patient who underwent transcatheter aortic valve replacement using the CoreValveTM.

A 73-year-old man with severe aortic valve stenosis successfully underwent transcatheter aortic valve replacement (TAVR) using CoreValveTM (29 mm, Medtronic Inc., Minneapolis, MN, USA). Four years after the TAVR, he was hospitalized due to anterior ST-segment elevation myocardial infarction. Despite the need for prompt restoration of coronary flow in the infarct-related artery, the implanted CoreValveTM profoundly restricted the manipulation of diagnostic catheters during the coronary angiography. In particular, (I) guidewire easily migrated into the space between CoreValveTM and aorta vessel wall; (II) the nickel-titanium frame of CoreValveTM limited the space to manipulate catheters, making difficult to advance Judkins left (JL) 4, Judkins right (JR) 4 and Amplatz left 1 into coronary cusps; and (III) selecting specific spot within frame was required for cannulation. Left and right coronary arteries were barely engaged by JL3.5 and modified JR4, respectively. Percutaneous coronary intervention (PCI) for culprit lesion in the left-anterior descending artery was successfully completed by 6-French JL3.5 (BritetipTM, Cordis, Milpitas, CA, USA) with drug-eluting stent implantation. Meticulous strategies and understanding of the prosthetic valve geometry are warranted to conduct PCI in patients who underwent TAVR.