Association of atrial mechanical dispersion with atrial fibrillation recurrence following catheter ablation: results of the ASTRA-AF pilot study.

AIMS: For patients with symptomatic drug-refractory atrial fibrillation (AF), catheter ablation to achieve rhythm control is an important therapeutic option. The atrial mechanical dispersion measured as standard deviation of the time to peak strain (SD-TPS) is associated with the risk of AF recurrence following catheter ablation. METHODS: The study cohort prospectively enrolled n = 132 consecutive patients with paroxysmal (n = 88) or persistent AF (n = 44) presenting for de novo pulmonary vein isolation (PVI) and followed for 1 year. We related left atrial (LA) volume, LA ejection fraction, SD-TPS, and global longitudinal strain of the left ventricle and clinical variables (sex, age, and type of AF) to AF recurrence. RESULTS: Kaplan-Meier curves showed higher AF recurrence rate with an increase of SD-TPS with the calculated cut-off of 38.6 ms. Uni- and multivariable Cox regression analysis could show that SD-TPS had the highest relevance regarding AF recurrence with a HR of 1.05 (95% CI, 1.01; 1.09, p = 0.01) and HR of 1.05 (95% CI, 1.01; 1.09, p = 0.02) per 10 ms increase. In the additional analyses for the model including the clinical variables age, sex, and type of AF with paroxysmal or persisting AF, SD-TPS did only show a trend and after adjusting for covariates, SD-TPS showed a HR of 1.04 (95% CI, 0.99; 1.09, p = 0.09) per 10 ms increase. CONCLUSION: Atrial mechanical dispersion was associated with recurrent AF.

Left atrial strain predicts the rhythm outcome in patients with persistent atrial fibrillation undergoing left atrial cryoablation during minimally invasive mitral valve repair.

Objectives: Patients with atrial fibrillation (AF) have lower left atrial (LA) strain, which is a predictor for LA function. Here, we evaluated the prognostic value of LA strain to predict the rhythm outcome in patients with persistent AF undergoing LA cryoablation concomitant to minimally invasive mitral valve repair. Methods: Between 01/2016 and 12/2020, 72 patients with persistent AF underwent LA cryoablation during minimally invasive mitral valve surgery. All patients received a complete LA lesion set and left atrial appendage (LAA) closure with a clip. All patients received preoperative transthoracic echocardiography (TTE) with LA and left ventricular strain measurements. Preoperative LA and LV strain analysis was correlated with postoperative rhythm outcome. Results: The mean age of the patients was 66.9 ± 7.2 years, of whom 42 (58%) were male patients. No major ablation-related complications occurred in any of the patients. Successful LAA closure was confirmed by intraoperative echocardiography in all patients. The 1-year survival rate was 97%. Freedom from AF at 12 months was 72% and 68% off antiarrhythmic drugs. Preoperative LA strain values were statistically significantly higher in patients with freedom from AF at 12 months of follow-up (12.7% ± 6.9% vs. 4.9% ± 4.1%, p = 0.006). Preoperative LV strain value was not associated with postoperative rhythm outcome. In multivariate logistic regression analysis, LA strain (p < 0.001) and AF duration (p = 0.017) were predictors for freedom from AF at 12 months of follow-up. Conclusions: In our study, LA strain analysis predicted the rhythm outcome in patients with persistent AF undergoing concomitant surgical AF ablation. In the future, LA strain might be a useful tool to guide decision-making on ablation strategies in patients with persistent AF.

PATHFINDER-CHD: prospective registry on adults with congenital heart disease, abnormal ventricular function, and/or heart failure as a foundation for establishing rehabilitative, prehabilitative, preventive, and health-promoting measures: rationale, aims, design and methods.

BACKGROUND: Adults with congenital heart defects (ACHD) globally constitute a notably medically underserved patient population. Despite therapeutic advancements, these individuals often confront substantial physical and psychosocial residua or sequelae, requiring specialized, integrative cardiological care throughout their lifespan. Heart failure (HF) is a critical challenge in this population, markedly impacting morbidity and mortality. AIMS: The primary aim of this study is to establish a comprehensive, prospective registry to enhance understanding and management of HF in ACHD. Named PATHFINDER-CHD, this registry aims to establish foundational data for treatment strategies as well as the development of rehabilitative, prehabilitative, preventive, and health-promoting interventions, ultimately aiming to mitigate the elevated morbidity and mortality rates associated with congenital heart defects (CHD). METHODS: This multicenter survey will be conducted across various German university facilities with expertise in ACHD. Data collection will encompass real-world treatment scenarios and clinical trajectories in ACHD with manifest HF or at risk for its development, including those undergoing medical or interventional cardiac therapies, cardiac surgery, inclusive of pacemaker or ICD implantation, resynchronization therapy, assist devices, and those on solid organ transplantation. DESIGN: The study adopts an observational, exploratory design, prospectively gathering data from participating centers, with a focus on patient management and outcomes. The study is non-confirmatory, aiming to accumulate a broad spectrum of data to inform future hypotheses and studies. PROCESSES: Regular follow-ups will be conducted, systematically collecting data during routine clinical visits or hospital admissions, encompassing alterations in therapy or CHD-related complications, with visit schedules tailored to individual clinical needs. ASSESSMENTS: Baseline assessments and regular follow-ups will entail comprehensive assessments of medical history, ongoing treatments, and outcomes, with a focus on HF symptoms, cardiac function, and overall health status. DISCUSSION OF THE DESIGN: The design of the PATHFINDER-CHD Registry is tailored to capture a wide range of data, prioritizing real-world HF management in ACHD. Its prospective nature facilitates longitudinal data acquisition, pivotal for comprehending for disease progression and treatment impacts. CONCLUSION: The PATHFINDER-CHD Registry is poised to offer valuable insights into HF management in ACHD, bridging current knowledge gaps, enhancing patient care, and shaping future research endeavors in this domain.

Heart Rate Reduction and Outcomes in Heart Failure Outpatients.

Aim. Pharmacologic reduction in heart rate with beta-blockers (BB) or ivabradine is associated with improved survival in heart failure (HF) with sinus rhythm. We analyzed the association of different heart rate-reducing drug treatments on outcomes in HF outpatients. Methods. Consecutive patients with HF in sinus rhythm referred to a specialized tertiary service were prospectively enrolled from August 2015 until March 2018. Clinical characteristics were assessed at baseline. We performed Cox regression analyses to examine the effect of the resting heart rate and different heart rate-reducing drug regimens on all-cause mortality and a composite endpoint of "all-cause mortality or heart transplantation" over a mean follow-up of 3.1 years. Results. Of the 278 patients included, 213 (76.6%) were male, the median age was 57.0 years (IQR 49.0-66.1), and 185 (73.7%) had an ejection fraction <40%. Most patients received BB in submaximal [n = 118] or maximum dose [n = 136]. Patients on BB in maximum dose plus ivabradine [n = 24] were younger (53.0 vs. 58.0 years) and had a lower EF (25 vs. 31%). Higher resting heart rate was associated with an increased risk of death or transplantation (HR 1.03 [1.01, 1.06], p = 0.0072), even after adjusting for age and sex. There were no differences between the groups concerning all-cause mortality or the composite endpoint. Conclusion. Our prospective study confirms the association between low heart rate and survival in HF patients receiving various heart rate-reducing medications. We could not identify a specific effect of either regimen.

Heart weight must not be measured before dissection during autopsies.

During autopsies, weighing the heart is a standard procedure. In addition to myocardial pathologies, heart size, and ventricular wall thickness, heart weight is a common parameter to describe cardiac pathology and should be recorded as accurately as possible. To date, there exists no standard for recording heart weight at autopsy, although some authors recommend weighing the heart after dissection and removal of blood and blood clots. In the study presented, the hearts of 58 decedents were weighed after being dissected out of the pericardial sac (a), after dissection using the short-axis or inflow-outflow method with manual removal of blood and blood clots (b), and after rinsing and drying (c). Depending on the dissection method, the heart weight was 7.8% lower for the inflow-outflow method and 11.6% lower for the short-axis method after dissection compared to before and correspondingly 2.9% to 5% lower again after rinsing and drying respectively. Accordingly, the heart should be dissected, blood and blood clots removed, rinsed with water, and dried with a surgical towel after dissection, before weighing.

Hemodynamics and Diastolic Function after Native Aortic Valve Preserving vs. Replacing Surgery.

BACKGROUND: Alterations in left ventricular (LV) diastolic function following native tissue-preserving aortic valve (AV) procedures have not been systematically investigated. Furthermore, no comparisons have been made between these changes and those observed after prosthetic AV replacement. METHODS: From October 2017 to August 2020, 74 patients aged <65 years were referred to our institution for elective AV surgery. Preoperative and postoperative (i.e., discharge, 3-month and 1-year follow-up) transthoracic echocardiography was analyzed. RESULTS: Native tissue-preserving surgery was performed in 55 patients (AV repair: n = 42, Ross procedure: n = 13). The remaining 19 patients underwent prosthetic AV replacement. Preoperatively and at discharge, transvalvular hemodynamics and LV diastolic function were comparable in both groups. At 1-year follow-up, native valve (NV) patients showed significantly lower mean transvalvular gradient (7 ± 5 vs. 9 ± 3 mmHg, p = 0.046) and peak velocity (1.74 ± 0.51 vs. 2.26 ± 0.96 m/s, p = 0.004), and significantly better septal e' (9.1 ± 2.7 vs. 7.7 ± 2.5 cm/s, p = 0.043) and lateral e' (14.7 ± 3.1 vs. 11.7 ± 3.7 cm/s, p = 0.001). From preoperatively to 1-year postoperatively, septal and lateral e' and E/e' improved markedly after NV preservation (septal e': +0.7 cm/s, p = 0.075; lateral e': +2.3 cm/s, p < 0.001; E/e': -1.5, p = 0.001) but not after AV replacement (septal e': +0.2 cm/s, p = 0.809; lateral e': +0.8 cm/s, p = 0.574; E/e': -1.2, p = 0.347). Significant negative linear correlations between postoperative transvalvular gradients and absolute changes in lateral e' and E/e' were detected during follow-up. CONCLUSION: Preservation of native tissue in AV surgery results in superior transvalvular hemodynamics compared with prosthetic AV replacement. This may induce faster LV reverse remodeling and may explain more pronounced improvement in LV diastolic function.

Residual risk identified in routine noninvasive follow-up assessments in pulmonary arterial hypertension.

Background: The 2022 ESC/ERS guidelines on pulmonary hypertension recommend noninvasive risk assessments based on three clinical variables during follow-up in patients with pulmonary arterial hypertension (PAH). We set out to test whether residual risk can be captured from routinely measured noninvasive clinical variables during follow-up in PAH. Methods: We retrospectively studied 298 incident PAH patients from a German pulmonary hypertension centre who underwent routine noninvasive follow-up assessments including exercise testing, echocardiography, electrocardiography, pulmonary function testing and biochemistry. To select variables, we used least absolute shrinkage and selection operator (LASSO)-regularised Cox regression models. Outcome was defined as mortality or lung transplant after first follow-up assessment. Results: 12 noninvasive variables that were associated with outcomes in a training sub-cohort (n=208) after correction for multiple testing entered LASSO modelling. A model combining seven variables discriminated 1-year (area under the curve (AUC) 0.83, 95% confidence interval (CI) 0.68-0.99, p=8.4×10-6) and 3-year (AUC 0.81, 95% CI 0.70-0.92, p=2.9×10-8) outcome status in a replication sub-cohort (n=90). The model's discriminatory ability was comparable to that of the guideline approach in the replication sub-cohort. From the individual model components, World Health Organization functional class, 6-min walking distance and the tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure (TAPSE/sPAP) ratio were sensitive to treatment initiation. Addition of TAPSE/sPAP ratio to the guideline approach numerically increased its ability to discriminate outcome status. Conclusion: Our real-world data suggest that residual risk can be captured by noninvasive clinical procedures during routine follow-up assessments in patients with PAH and highlights the potential use of echocardiographic imaging to refine risk assessment.

ObsErvatioNal prospective multicenter stuDy tO characterize the cLinical ANd DiagnoStiC feAtures of endocarditis in the contemPorary Era (ENDO-LANDSCAPE study): rationale and design.

BACKGROUND: Recent developments in the management of valvular heart disease and heart failure have resulted in a dramatic increase in percutaneous valve procedures and implanted devices. We hypothesize that this has impacted the epidemiology, diagnosis, and management of endocarditis. METHODS: The obsErvatioNal prospective multicenter stuDy tO characterize the cLinical ANd DiagnoStiC feAtures of endocarditis in the contemPorary Era (ENDO-LANDSCAPE study) is an observational, multicenter, and international study aimed to examine the epidemiology of endocarditis in the contemporary era. The study will constitute of a retrospective arm for the determination of the sample size of the prospective arm, where cases of endocarditis between 2016 to 2022 at three tertiary referral institutions will be analyzed. The prospective arm will examine all consecutive patients referred for an echocardiography with a suspected or confirmed diagnosis of endocarditis, and their clinical course followed up over 12 months for adverse outcomes. The primary aim of the study will be to characterize the epidemiology of endocarditis, focusing on patients with prosthetic or implanted devices. The secondary aims would be: the appropriateness of the requests for first-line echocardiographic imaging in exclusion of endocarditis; the role of other imaging modalities in the diagnosis of endocarditis; and the impact of a specialized endocarditis team on outcomes. IMPLICATIONS: The results of the ENDO-LANDSCAPE study will provide a contemporary update of the epidemiological trends in endocarditis. The data generated from this study would be useful in informing future clinical practice, potentially guiding future diagnostic and treatment algorithms in patients with endocarditis. CLINICALTRIALORG ID: NCT05547607.

Physical and Mental Recovery after Aortic Valve Surgery in Non-Elderly Patients: Native Valve-Preserving Surgery vs. Prosthetic Valve Replacement.

Background: Exercise capacity and patient-reported outcomes are increasingly considered crucial following aortic valve (AV) surgery in non-elderly adults. We aimed to prospectively evaluate the effect of native valve preservation compared with prosthetic valve replacement. Methods: From October 2017 to August 2020, 100 consecutive non-elderly patients undergoing surgery for severe AV disease were included. Exercise capacity and patient-reported outcomes were evaluated upon admission, and 3 months and 1 year postoperatively. Results: In total, 72 patients underwent native valve-preserving procedures (AV repair or Ross procedure, NV group), and 28 patients, prosthetic valve replacement (PV group). Native valve preservation was associated with an increased risk of reoperation (weighted hazard ratio: 10.57 (95% CI: 1.24-90.01), p = 0.031). The estimated average treatment effect on six-minute walking distance in NV patients at 1 year was positive, but not significant (35.64 m; 95% CI: -17.03-88.30, adj. p = 0.554). The postoperative physical and mental quality of life was comparable in both groups. Peak oxygen consumption and work rate were better at all assessment time points in NV patients. Marked longitudinal improvements in walking distance (NV, +47 m (adj. p < 0.001); PV, +25 m (adj. p = 0.004)) and physical (NV, +7 points (adj. p = 0.023); PV, +10 points (adj. p = 0.005)) and mental quality of life (NV, +7 points (adj. p < 0.001); PV, +5 points (adj. p = 0.058)) from the preoperative period to the 1-year follow-up were observed. At 1 year, there was a tendency of more NV patients reaching reference values of walking distance. Conclusions: Despite the increased risk of reoperation, physical and mental performance markedly improved after native valve-preserving surgery and was comparable to that after prosthetic aortic valve replacement.

Clinical phenotyping of plasma thrombospondin-2 reveals relationship to right ventricular structure and function in pulmonary hypertension.

Background: Converging evidence from proteogenomic analyses prioritises thrombospondin-2 (TSP2) as a potential biomarker for idiopathic or heritable pulmonary arterial hypertension (PAH). We aimed to assess TSP2 levels in different forms of pulmonary hypertension (PH) and to define its clinical phenotype. Methods: Absolute concentrations of TSP2 were quantified in plasma samples from a prospective single-centre cohort study including 196 patients with different forms of PH and 16 disease controls (suspected PH, but normal resting pulmonary haemodynamics). In an unbiased approach, TSP2 levels were related to 152 clinical variables. Results: Concentrations of TSP2 were increased in patients with PH versus disease controls (p<0.001 for group comparison). The discriminatory ability of TSP2 levels to distinguish between patients and controls was superior to that of N-terminal pro-brain natriuretic peptide (p=0.0023 for comparison of areas under the curve). Elevation of TSP2 levels was consistently found in subcategories of PAH, in PH due to lung disease and due to left heart disease. Phenotypically, TSP2 levels were robustly related to echocardiographic markers that indicate the right ventricular (RV) response to chronically increased afterload with increased levels in patients with impaired systolic function and ventriculoarterial uncoupling. Focusing on PAH, increased TSP2 levels were able to distinguish between adaptive and maladaptive RV phenotypes (area under the curve 0.87, 95% CI 0.76-0.98). Interpretation: The study indicates that plasma TSP2 levels inform on the presence of PH and associate with clinically relevant RV phenotypes in the setting of increased afterload, which may provide insight into processes of RV adaptability.

German Cardiac Arrest Registry: rationale and design of G-CAR.

BACKGROUND: In Germany, 70,000-100,000 persons per year suffer from out-of-hospital cardiac arrest (OHCA). Despite medical progress, survival rates with good neurological outcome remain low. For many important clinical issues, no or only insufficient evidence from randomised trials is available. Therefore, a systemic and standardised acquisition of the treatment course and of the outcome of OHCA patients is warranted. STUDY DESIGN: The German Cardiac Arrest Registry (G-CAR) is an observational, prospective, multicentre registry. It will determine the characteristics, initial treatment strategies, invasive procedures, revascularisation therapies and the use of mechanical circulatory support devices with a focus on extracorporeal cardiopulmonary resuscitation. A special feature is the prospective 12-month follow-up evaluating mortality, neurological outcomes and several patient-reported outcomes in the psychosocial domain (health-related quality of life, cognitive impairment, depression/anxiety, post-traumatic stress disorder and social reintegration). In a pilot phase of 24 months, 15 centres will include approximately 400 consecutive OHCA patients ≥ 18 years. Parallel to and after the pilot phase, scaling up of G-CAR to a national level is envisaged. CONCLUSION: G-CAR is the first national registry including a long-term follow-up for adult OHCA patients. Primary aim is a better understanding of the determinants of acute and long-term outcomes with the perspective of an optimised treatment. TRIAL REGISTRY: NCT05142124. German Cardiac Arrest Registry (G-CAR).

Clinical characteristics, causes and predictors of outcomes in patients with in-hospital cardiac arrest: results from the SURVIVE-ARREST study.

INTRODUCTION: In-hospital cardiac arrest (IHCA) is acutely life-threatening and remains associated with high mortality and morbidity. Identifying predictors of mortality after IHCA would help to guide acute therapy. METHODS: We determined patient characteristics and independent predictors of 30-day in-hospital mortality, neurological outcome, and discharge/referral pathways in patients experiencing IHCA in a large tertiary care hospital between January 2014 and April 2017. Multivariable Cox regression model was fitted to assess predictors of outcomes. RESULTS: A total of 368 patients with IHCA were analysed (median age 73 years (interquartile range 65-78), 123 (33.4%) women). Most patients (45.9%) had an initial non-shockable rhythm and shockable rhythms were found in 20.9%; 23.6% of patients suffered from a recurrent episode of cardiac arrest. 172/368 patients died within 30 days (46.7%). Of 196/368 patients discharged alive after IHCA, the majority (72.9%, n = 143) had a good functional neurological outcome (modified Rankin Scale ≤ 3 points). In the multivariable analysis, return of spontaneous circulation without mechanical circulatory support (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.21-0.64), invasive coronary angiography and/or percutaneous intervention (HR 0.56, 95% CI 0.34-0.92), and antibiotic therapy (HR 0.87, 95% CI 0.83-0.92) were associated with a lower risk of 30-day in hospital mortality. CONCLUSION: In the present study, IHCA was survived in ~ 50% in a tertiary care hospital, although only a minority of patients presented with shockable rhythms. The majority of IHCA survivors (~ 70%) had a good neurological outcome. Recovery of spontaneous circulation and presence of treatable acute causes of the arrest are associated with better survival. Clinical Characteristics, Causes and Predictors of Outcomes in Patients with In-Hospital Cardiac Arrest: Results from the SURVIVE-ARREST Study. ABBREVIATIONS: CPR, cardiopulmonary resuscitation; IHCA, In-hospital cardiac arrest; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; ROSC, return of spontaneous circulation; SBP, systolic blood pressure.

Treatment of advanced heart failure in adults with congenital heart disease: a narrative review and clinical cases.

Background and Objective: The number of adults with congenital heart disease (ACHD) is increasing worldwide. Almost all congenital cardiac lesions can be successfully treated due to the progress in neonatal surgery and pediatric cardiology with a high likelihood of surviving until adulthood. However, ACHD frequently develop sequelae related to the initial cardiac anomaly. Heart failure (HF) is one of the most common complications associated with a high morbidity and mortality. Methods: The authors did search the PubMed database regarding relevant content covering publications up to March 2022. Relevant manuscripts were classified according to the impact factor of the journal, being a guideline manuscript, a position paper by a society or a comprehensive review of the current literature. Key Content and Findings: Optimal HF treatment remains an unmet need in ACHD. In particular, advanced HF therapy with cardiac resynchronization therapy, ventricular assist devices or organ transplantation is still very different and more specific in ACHD compared to non-ACHD. This review aims to compile international views and evidence from the literatures on the treatment of advanced HF in ACHD. Current challenges, but also the success of different treatment strategies in ACHD are illustrated by clinical cases. Conclusions: The main finding of the review is that data is still scarce regarding ACHD with advanced HF and international efforts to collect data regarding these patients needed to improve the current standard of care.

[Sarcoidosis as prime example of a granulomatous disease]. / Sarkoidose als Paradebeispiel einer granulomatösen Erkrankung.

Sarcoidosis is the most frequent immunologically related granulomatous disease and can serve as a model for understanding diseases within this category. The evidence on the diagnostics and treatment is so far limited. It is therefore all the more important that two new and significant guidelines on diagnosis and treatment of sarcoidosis were published during the last 2 years. Additionally, there were more new publications, which were considered for this review article. In this context, this review article provides a current update and overview of sarcoidosis. Pathophysiologically, there is an increasing understanding of the complex processes and interactions involved in the inflammatory processes and granuloma formation. The probability of a diagnosis of sarcoidosis is determined by compatible histology, the exclusion of differential diagnoses and if possible evidence of a multiorgan manifestation. The clinical course is variable and ranges from an asymptomatic manifestation to severe life-threatening organ failure. The most frequently affected organ are the lungs. Pulmonary fibrosis is the most severe form and is also decisive for mortality. An increasing focus is on the extrapulmonary organ manifestations, in particular, cardiac, hepatosplenic, gastrointestinal, renal, ocular and neurological involvement. Treatment, which consists primarily of immunosuppression, should be initiated in cases of organ-threatening or quality of life-impairing activity of the disease. Additional organ-specific management must also be evaluated. In cases of organ failure transplantation should be considered. Due to the limited evidence especially for the treatment of multiorgan sarcoidosis, when possible, patients with this disease should be included in clinical trials.

Left Ventricular Diastolic Dysfunction Is Not Associated With Pulmonary Edema in Septic Patients. A Prospective Observational Cohort Study.

Purpose: We aimed to investigate whether left ventricular diastolic dysfunction (LVDD) is associated with pulmonary edema in septic patients. Methods: We conducted a prospective cohort study in adult septic patients between October 2018 and May 2019. We performed repeated echocardiography and lung ultrasound examinations within the first 7 days after diagnosis of sepsis. We defined LVDD according to the 2016 recommendations of the American Society of Echocardiography and-for sensitivity analysis-according to an algorithm which has been validated in septic patients. We quantified pulmonary edema using the lung ultrasound score (LUSS), counting B-lines in four intercostal spaces. Results: We included 54 patients. LVDD was present in 51 (42%) of 122 echocardiography examinations. The mean (±SD) LUSS was 11 ± 6. There was no clinically meaningful association of LVDD with LUSS (B = 0.55 [95%CI: -1.38; 2.47]; p = 0.571). Pneumonia was significantly associated with higher LUSS (B = 4.42 [95%CI: 0.38; 8.5]; p = 0.033). Conclusion: The lack of a clinically meaningful association of LVDD with LUSS suggests that LVDD is not a major contributor to pulmonary edema in septic patients. Trial Registration: NCT03768752, ClinicalTrials.gov, November 30th, 2018 - retrospectively registered.