Prevalence and prognostic impact of dynamic atrial functional mitral regurgitation assessed by isometric handgrip exercise.

AIMS: In atrial functional mitral regurgitation (aFMR), a considerable proportion of patients displays a discrepancy between symptoms and echocardiographic findings at rest. Exercise testing plays a substantial role in assessing the haemodynamic relevance of mitral regurgitation (MR) and is recommended by current guidelines. Here, we aimed to assess the prevalence, extent, and prognostic impact of exercise-induced changes in patients with aFMR. METHODS AND RESULTS: Patients with at least mild MR who underwent handgrip exercise echocardiography at the University Hospital Duesseldorf between January 2019 and September 2021 were enrolled. Patients were followed-up for one year to assess clinical outcomes. Eighty patients with aFMR were included (median age: 80 (77-83) years; 53.8% female). The median N-terminal pro brain natriuretic petide level was 1756 (1034-3340) ng/l. At rest, half of the patients (53.8%) had mild MR, 20 patients (25.0%) had moderate MR, and 17 patients (21.2%) had severe MR. In approximately every fifth patient (17.5%) with non-severe MR at rest, the MR became severe during exercise. Handgrip exercise led to a re-classification of MR severity in 28 patients (35.0%). At one-year follow-up, adverse events occurred more often in patients with severe MR at rest (76.5%) and exercise-induced dynamic severe MR (66.7%) than in those with non-severe MR (28.6%) (p < 0.001). CONCLUSIONS: Handgrip exercise during echocardiography revealed exercise-induced changes in aFMR in every third patient. These data may have implications for therapeutic decision-making in symptomatic patients with non-severe aFMR at rest.

Usefulness of Transcatheter Aortic Valve Implantation for Treatment of Pure Native Aortic Valve Regurgitation.

Patients with pure native aortic valve regurgitation (NAVR) and increased surgical risk are often denied surgery. This retrospective study aimed to evaluate the "off-label" use of transcatheter heart valves (THV) for the treatment of NAVR. A total of 254 high surgical risk patients with NAVR (age 74 ± 12 years, Society of Thoracic Surgeons risk score 6.6 ± 6.2%) underwent transcatheter aortic valve implantation (TAVI) with early generation (43%) or newer generation (57%) devices at 46 different sites. Device success was significantly higher in patients treated with newer as compared with early generation THV (82% vs 47%, p <0.001). The difference was driven by lower rates of device malpositioning (9% vs 33%) and aortic regurgitation (AR) ≥ moderate (4% vs 31%) and translated into higher clinical efficacy at 30 days in patients treated with newer as compared with early generation THV (72% vs 56%, p = 0.041). Both THV under- and oversizing were associated with an increased risk of THV malpositioning. In conclusion, TAVI is a feasible treatment strategy in selected high-risk patients with NAVR but is associated with a considerable risk of THV malpositioning and residual AR. Although newer-generation THV are associated with better outcomes, novel devices for the treatment of NAVR are warranted.

Dual vs single antiplatelet therapy in patients with lower extremity peripheral artery disease - A meta-analysis.

AIMS: Peripheral artery disease (PAD) is associated with increased risk of cardiovascular events. The benefits of dual antiplatelet therapy (DAPT) vs single antiplatelet therapy (SAPT) with aspirin in patients with PAD remain subject of ongoing debate. METHODS AND RESULTS: We performed a meta-analysis of studies comparing DAPT vs aspirin monotherapy in PAD. Incidence rate ratios (RR) and respective 95% confidence intervals (CI) were used as summary statistics. The primary outcome was mortality. Secondary endpoints were ischemic and bleeding outcomes. Ten studies including 65,675 patients have been included. Compared to SAPT, DAPT was associated with a significant reduction in mortality: RR, 0.89; 95% CI, 0.86-0.92; P < 0.001. Results were consistent across patients with symptomatic PAD and those undergoing bypass or percutaneous transluminal angioplasty (PTA). Similarly, DAPT significantly reduced the risk of repeat peripheral revascularizations (RR, 0.80; 95% CI, 0.69-0.92; P = 0.002). No significant increase of major bleeding complications was observed with DAPT as compared to SAPT (RR, 1.21; 95% CI, 0.87-1.68 P = 0.26). CONCLUSIONS: DAPT, as compared to SAPT, significantly reduces mortality in patients with PAD, with no significant increase in bleeding complications. These findings support DAPT as the mainstay antiplatelet therapeutic regimen in patients with PAD.

Red cell distribution width in anemic patients undergoing transcatheter aortic valve implantation.

AIM: To determine the impact of red blood cell distribution width on outcome in anemic patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: In a retrospective single center cohort study we determined the impact of baseline red cell distribution width (RDW) and anemia on outcome in 376 patients with aortic stenosis undergoing TAVI. All patients were discussed in the institutional heart team and declined for surgical aortic valve replacement due to high operative risk. Collected data included patient characteristics, imaging findings, periprocedural in hospital data, laboratory results and follow up data. Blood samples for hematology and biochemistry analysis were taken from every patient before and at fixed intervals up to 72 h after TAVI including blood count and creatinine. Descriptive statistics were used for patient's characteristics. Kaplan-Meier survival curves were used for time to event outcomes. A recursive partitioning regression and classification was used to investigate the association between potential risk factors and outcome variables. RESULTS: Mean age in our study population was 81 ± 6.1 years. Anemia was prevalent in 63.6% (n = 239) of our patients. Age and creatinine were identified as risk factors for anemia. In our study population, anemia per se did influence 30-d mortality but did not predict longterm mortality. In contrast, a RDW > 14% showed to be highly predictable for a reduced short- and longterm survival in patients with aortic valve disease after TAVI procedure. CONCLUSION: Age and kidney function determine the degree of anemia. The anisocytosis of red blood cells in anemic patients supplements prognostic information in addition to that derived from the WHO-based definition of anemia.