Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10-Year Retrospective Study.

BACKGROUND: Aortic stenosis (AS) is a representative geriatric disease, and there is an anticipated rise in the number of patients requiring noncardiac surgeries in patients with AS. However, there is still a lack of research on the primary predictors of noncardiac perioperative complications in patients with asymptomatic significant AS. METHODS AND RESULTS: Among the cohort of noncardiac surgeries under general anesthesia, with an intermediate to high risk of surgery from 2011 to 2019, at Samsung Medical Center, 221 patients were identified to have asymptomatic significant AS. First, to examine the impact of significant AS on perioperative adverse events, the occurrences of major adverse cardiovascular events and perioperative adverse cardiovascular events were compared between patients with asymptomatic significant AS and the control group. Second, to identify the factors influencing the perioperative adverse events in patients with asymptomatic significant AS, a least absolute shrinkage and selection operator regression model was used. There was no significant difference between the control group and the asymptomatic significant AS group in the event rate of major adverse cardiovascular events (4.6% at control group versus 5.5% at asymptomatic significant AS group; P=0.608) and perioperative adverse cardiovascular events (13.8% at control group versus 18.3% at asymptomatic significant AS group; P=0.130). Cardiac damage stage was a significant risk factor of major adverse cardiovascular events and perioperative adverse cardiovascular events. CONCLUSIONS: There was no significant difference in major postoperative cardiovascular events between patients with asymptomatic significant AS and the control group. Advanced cardiac damage stage in significant AS is an important factor in perioperative risk of noncardiac surgery.

Prognostic implication of left atrial strain in patients experiencing early recurrence of atrial fibrillation after totally thoracoscopic ablation.

Background: Although early atrial fibrillation (AF) events during the blanking period after AF ablation are risk factors for late recurrence, data on predictors of late recurrence in patients who experience early AF events are limited. In this study, we investigated the implications of left atrial (LA) strain with respect to long-term outcomes in patients experiencing early AF during the blanking period after totally thoracoscopic ablation (TTA). Methods: A total of 128 patients who underwent TTA between 2012 and 2015 were enrolled from a tertiary center. Peak longitudinal LA strain was measured preoperatively. Early recurrence (ER) was defined as any AF within the 3-month blanking period after TTA. The primary outcome was late recurrence of AF for 5 years, detected on 12-lead electrocardiogram or 24-hour Holter monitoring, excluding the blanking period. Results: Out of 128 patients, 42 (32.8%) experienced ER during the blanking period. Patients who experienced ER had a significantly higher risk of 5-year AF recurrence compared with those who did not [72.7% vs. 29.6%, hazard ratio (HR) =3.69, 95% confidence interval (CI): 2.14-6.36, P<0.001]. Within the group of 42 patients experiencing ER, LA strain with a best cutoff value of 18.6% was the only independent predictor of 5-year AF recurrence (adjusted HR =4.20, 95% CI: 1.08-16.29, P=0.038). Patients with ER and LA strain ≥18.6% had a risk of 5-year AF recurrence, similar to those without ER (35.2% vs. 29.6%, HR =1.21, 95% CI: 0.36-4.04, P=0.755). Patients with ER and LA strain <18.6% had a significantly higher risk of 5-year AF recurrence compared to those without ER (83.0% vs. 29.6%, HR =4.83, 95% CI: 2.75-8.48, P<0.01). Conclusions: Early AF during the blanking period is common in patients undergoing TTA. In patients with ER, LA strain was an independent predictor of long-term AF recurrence.

Antiplatelet therapy and long-term mortality in patients with myocardial injury after non-cardiac surgery.

BACKGROUNDS: Myocardial injury after non-cardiac surgery (MINS) has recently been accepted as a common complication associated with increased mortality. However, little is known about the treatment of MINS. The aim of this study was to investigate an association between antiplatelet therapy and long-term mortality after MINS. METHODS: From 2010 to 2019, patients with MINS, defined as having a peak high-sensitivity troponin I higher than 40 ng/L within 30 days after non-cardiac surgery, were screened at a tertiary centre. Patients were excluded if they had a history of coronary revascularisation before or during index hospitalisation. Clinical outcomes at 1 year were compared between patients with and without antiplatelet therapy at hospital discharge. The primary outcome was death, and the secondary outcome was major bleeding. RESULTS: Of the 3818 eligible patients with MINS, 940 (24.6%) received antiplatelet therapy at hospital discharge. Patients with antiplatelet therapy had a significantly lower mortality at 1 year than those without antiplatelet therapy (7.5% vs 15.9%, adjusted HR 0.60, 95% CI 0.45 to 0.79, p<0.001). A risk of major bleeding at 1 year was not significantly different between the patients with and without antiplatelet therapy (6.6% vs 7.6%, adjusted HR 0.85, 95% CI 0.62 to 1.17, p=0.324). In propensity score-matched analysis of 886 pairs, patients with antiplatelet therapy had a significantly lower risk of 1-year mortality (adjusted HR 0.53, 95% CI 0.39 to 0.73, p<0.001) than those without antiplatelet therapy. CONCLUSIONS: In patients with MINS, antiplatelet therapy at discharge was associated with decreased 1-year mortality.

Left atrial strain predicts fibrosis of left atrial appendage in patients with atrial fibrillation undergoing totally thoracoscopic ablation.

Background: Left atrial (LA) fibrosis is related with development and severity of atrial fibrillation (AF). The aim of this study was to investigate the association between LA strain and LA fibrosis in patients undergoing totally thoracoscopic ablation (TTA) for AF. Methods: Between February 2012 and March 2015, a total of 128 patients who underwent TTA were enrolled from a tertiary hospital. Left atrial appendage (LAA) was harvested during surgery to determine the degree of fibrosis. LAA fibrosis was classified as mild (1st quartile), moderate (2nd and 3rd quartile), or severe (4th quartile). Clinical outcome was 5-year recurrence rate of AF detected on electrocardiogram or 24 h Holter monitoring. Results: The mean age was 54.3 ± 8.8 years and 18.8% had paroxysmal AF. Patients with mild LAA fibrosis had a significantly lower rate of recurrent AF (23.3%) at 5 years after TTA compared with those with moderate (51.4%; hazard ratio [HR] 2.69; 95% confidence interval [CI] 1.19-6.12) or severe (53.2%; HR 2.84; 95% CI 1.16-6.97) fibrosis. Among clinical and echocardiographic parameters, peak LA strain was the only predictor of mild LAA fibrosis (coefficient 0.10, p = 0.005) with the best cutoff value of 14.7% (area under the curve 0.732). The prevalence of mild LAA fibrosis was 40.6% in patients with peak LA strain ≥14.7%, but only 6.8% in those with peak LA strain <14.7%. Conclusions: In patients undergoing TTA for AF, mild LAA fibrosis was associated with a lower risk of 5-year AF recurrence. LA strain was the only predictor of mild LAA fibrosis that reflects a lower risk of 5-year AF recurrence.

Sex differences in myocardial injury after non-cardiac surgery and postoperative mortality.

BACKGROUND: Myocardial injury after non-cardiac surgery (MINS) has recently been accepted as a predictor of mortality. However, sex differences in the incidence of MINS and survival thereafter are not fully understood. This study aimed to compare the incidence of MINS and mortality among male and female patients. METHODS: This single-center study was conducted using the database of a large tertiary referral hospital. Consecutive patients with cardiac troponin (cTn) detected within 30 days after non-cardiac surgery performed between January 2010 and June 2019 were grouped according to sex. The incidence of MINS and mortality of patients with MINS were compared between men and women. RESULTS: Of the 33,311 patients, 18,546 (55.7%) were men and 14,765 (44.3%) were women. In a multivariable analysis, women showed a significantly lower incidence of MINS than did men (17.9% vs. 14.2%; odds ratio, 0.76; 95% confidence interval [CI], 0.71-0.81; P < 0.001). In patients with MINS, the propensity-score-matched analysis showed that 30-day mortality did not differ according to sex, but mortality in females was significantly lower than that in males during the overall follow-up (33.0% vs. 25.7%; hazard ratio, 0.75; 95% CI, 0.66-0.84; P < 0.001). CONCLUSION: The incidence of MINS was lower in women than in men. In patients with MINS, female sex may be associated with a survival benefit. Further studies are needed to confirm these findings.

Association of longitudinal left atrial strain with mortality after tricuspid valve surgery.

AIMS: Tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR) is becoming more common, but the associated mortality remains high. Therefore, we evaluated the clinical and echocardiographic parameters associated with all-cause mortality in patients with severe functional TR who underwent TV surgery. METHODS AND RESULTS: A total of 286 patients with severe functional TR who underwent TV replacement or repair was analysed between January 2006 and December 2017. We assessed changes in conventional echocardiographic parameters and strain, such as peak atrial longitudinal strain (PALS). During a median follow-up period of 5.3 years, 71 (24.8%) patients died due to any cause. When comparing groups with and without all-cause deaths, there were no significant differences in terms of sex, co-morbidities, medication use, and surgery type. However, patients who died were older and more likely to have refractory atrial fibrillation (AF). With multivariate Cox modelling, age >65 years (adjusted hazard ratio [HR], 2.81, 95% confidence interval [CI], 1.59-4.96; P < 0.001), refractory AF (adjusted HR, 2.84, 95% CI, 1.36-5.94; P = 0.006), lower albumin level (adjusted HR, 0.50, 95% CI, 0.31-0.82), and reduced PALS (adjusted HR, 1.87, 95% CI, 1.06-3.33; P = 0.032) were significant determinants of all-cause mortality. PALS decline was associated with refractory AF (adjusted HR, 5.74, 95% CI, 2.81-11.7; P < 0.001) and the absence of a Maze procedure (adjusted HR, 2.95, 95% CI, 1.51-5.78; P = 0.002). CONCLUSIONS: A reduction in PALS was significantly associated with all-cause mortality in our cohort of patients with severe functional TR who underwent TV surgery. This phenomenon is related to refractory AF and more aggressive intervention for AF is necessary concomitant with TV surgery.

Prognosis of Myocardial Injury After Non-Cardiac Surgery in Adults Aged Younger Than 45 Years.

BACKGROUND: This study compared myocardial injury after non-cardiac surgery (MINS) and mortalities between patients under and over the age of 45 years.Methods and Results:From January 2010 and June 2019, patients with cardiac troponin measurement within 30 days after non-cardiac surgery were enrolled and divided into groups according to age: >45 (≥45 years) and <45 (<45 years). Further analyses were conducted only in patients who were diagnosed with MINS. The outcomes were MINS and 30-day mortality. Of the 35,223 patients, 31,161 (88.5%) patients were in the >45-year group and 4,062 (11.5%) were in the <45-year group. After adjustment with inverse probability of weighting, the <45-years group showed a lower incidence of MINS and cardiovascular mortality (16.6% vs. 11.7%; odds ratio, 0.77; 95% confidence interval [CI], 0.69-0.84; P<0.001 and 0.4% vs. 0.2%; hazard ratio [HR], 0.41; 95% CI, 0.19-0.88; P=0.02, respectively). In a comparison of only the <45-years group, MINS was associated with increased 30-day mortality (0.7% vs. 10.3%; HR, 10.48; 95% CI, 6.18-17.78; P<0.001), but the mortalities of patients with MINS did not differ according to age. CONCLUSIONS: MINS has a comparable prognostic impact in patients aged under and over 45 years; therefore, future studies need to also consider patients aged <45 years regarding risk factors of MINS and screening of perioperative troponin elevation.

Associations Between Preoperative Glucose and Hemoglobin A1c Level and Myocardial Injury After Noncardiac Surgery.

Background Perioperative blood glucose level has shown an association with postoperative outcomes. We compared the incidences of myocardial injury after noncardiac surgery (MINS) and 30-day mortality, according to preoperative blood glucose and hemoglobin A1c (HbA1c) levels. Methods and Results The patients were divided according to blood glucose level within 1 day before surgery. The hyperglycemia group was defined with fasting glucose >140 mg/dL or random glucose >180 mg/dL. In addition, we compared the outcomes according to HbA1c >6.5% among patients with available HbA1c within 3 months before surgery. The primary outcome was MINS, and 30-day mortality was also compared. A total of 12 304 patients were enrolled and divided into 2 groups: 8324 (67.7%) in the normal group and 3980 (32.3%) in the hyperglycemia group. After adjustment with inverse probability of weighting, the hyperglycemia group exhibited significantly higher incidences of MINS and 30-day mortality (18.7% versus 27.6%; odds ratio, 1.29; 95% CI, 1.18-1.42; P<0.001; and 2.0% versus 5.1%; hazard ratio, 2.00; 95% CI, 1.61-2.49; P<0.001, respectively). In contrast to blood glucose, HbA1c was not associated with MINS or 30-day mortality. Conclusions Preoperative hyperglycemia was associated with MINS and 30-day mortality, whereas HbA1c was not. Immediate glucose control may be more crucial than long-term glucose control in patients undergoing noncardiac surgery. Registration URL: https://www.cris.nih.go.kr; Unique identifier: KCT0004244.

Intraoperative blood loss may be associated with myocardial injury after non-cardiac surgery.

BACKGROUND: This study aimed to evaluate the association between intraoperative blood loss and myocardial injury after non-cardiac surgery (MINS), which is a severe and common postoperative complication. METHODS: We compared the incidence of MINS based on significant intraoperative bleeding, defined as an absolute hemoglobin level < 7 g/dL, a relative hemoglobin level less than 50% of the preoperative measurement, or need for packed red cell transfusion. We also estimated a threshold for intraoperative hemoglobin level associated with MINS. RESULTS: We stratified a total of 15,926 non-cardiac surgical patients with intraoperative hemoglobin and postoperative cardiac troponin (cTn) measurements according to the occurrence of significant intraoperative bleeding; 13,416 (84.2%) had no significant bleeding while 2,510 (15.8%) did have significant bleeding. After an adjustment with inverse probability weighting, the incidence of MINS was higher in the significant bleeding group (35.2% vs. 16.4%; odds ratio, 1.58; 95% confidence interval, 1.43-1.75; p < 0.001). The threshold of intraoperative hemoglobin associated with MINS was estimated to be 9.9 g/dL with an area under the curve of 0.643. CONCLUSION: Intraoperative blood loss appeared to be associated with MINS. Further studies are needed to confirm these findings. CLINICAL REGISTRATION: The cohort was registered before patient enrollment at https://cris.nih.go.kr (KCT0004244).

Elevated high-sensitivity C-reactive protein concentrations may be associated with increased postdischarge mortality in patients with myocardial injury after noncardiac surgery: A retrospective observational study.

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is one of the most common cardiovascular complications associated with mortality and morbidity during the first 2 years after surgery. However, the relevant variables associated with mortality after discharge in patients with MINS have not been fully investigated. OBJECTIVES: This study aimed to evaluate the association between persistent inflammation detected by high-sensitivity C-reactive protein (hsCRP) at discharge and postdischarge mortality after MINS. DESIGN: Retrospective observational analysis of acquired data from Samsung Medical Center Troponin in Noncardiac Operation (SMC-TINCO) registry. SETTING: A tertiary hospital from January 2010 to June 2019. PATIENTS: Patients who were discharged alive after a diagnosis of MINS. MAIN OUTCOME MEASURES: The primary endpoint was postdischarge 1-year mortality, and 30-day mortality and the mortality from 30 days to 1 year was also compared. RESULTS: Data from a total of 4545 adult patients were divided into two groups according to hsCRP concentration at discharge. There were 757 (16.7%) patients in the normal hsCRP group and 3788 (83.3%) patients in the elevated hsCRP group. After inverse probability weighting, 1-year mortality was significantly higher in the elevated group than the normal group (hazard ratio 1.93, 95% CI 1.45 to 2.57, P  < 0.001). Thirty-day mortality and the mortality from 30 days to 1 year were also increased in the elevated group. CONCLUSION: In patients with MINS, an elevated hsCRP concentration at discharge appeared to be associated with increased mortality. Further research is needed to determine whether controlling inflammation can be helpful in reducing mortality.

Pre-operative anaemia and myocardial injury after noncardiac surgery: A retrospective study.

BACKGROUND: Pre-operative anaemia is associated with adverse outcomes of noncardiac surgery, but its association with myocardial injury after noncardiac surgery (MINS) has not been fully investigated. OBJECTIVE: The association between pre-operative anaemia and MINS. DESIGN: A single-centre retrospective cohort study. SETTING: Tertiary care referral centre. PATIENTS: Patients with measured cardiac troponin (cTn) I levels after noncardiac surgery. INTERVENTIONS: Patients were separated according to pre-operative anaemia (haemoglobin <13 g dl-1 in men and <12 g dl-1 in women). Anaemia was further stratified into mild and moderate-to-severe at a haemoglobin level threshold of 11 g dl-1. MAIN OUTCOME MEASURES: The primary outcome was MINS, defined as a peak cTn I level more than 99th percentile of the upper reference limit within 30 postoperative days. RESULTS: Data from a total of 35 170 patients were collected, including 22 062 (62.7%) patients in the normal group and 13 108 (37.3%) in the anaemia group. After propensity score matching, 11919 sets of patients were generated, and the incidence of MINS was significantly associated with anaemia [14.5 vs. 21.0%, odds ratio (OR) 1.57, 95% confidence interval (CI) 1.47 to 1.68, P < 0.001]. For the entire population, multivariable analysis showed a graded association between anaemia severity and MINS (OR 1.32, 95% CI 1.22 to 1.43, P < 0.001 for mild anaemia and OR 1.80, 95% CI 1.66 to 1.94, P < 0.001 for moderate-to-severe anaemia compared with the normal group) and a significantly higher incidence of MINS for moderate-to-severe anaemia than mild anaemia (18.6 vs. 28.6%, OR 1.37, 95% CI 1.25 to 1.50, P < 0.001). The estimated threshold for pre-operative haemoglobin associated with MINS was 12.2 g dl-1, with an area under the curve of 0.622. CONCLUSIONS: Pre-operative anaemia was independently associated with MINS, suggesting that MINS may be related to the association between anaemia and postoperative mortality. TRIAL REGISTRATION: SMC 2019-08-048.

Association Between High Body Mass Index and Mortality Following Myocardial Injury After Noncardiac Surgery.

BACKGROUND: Despite an association between obesity and increased risks for various diseases, obesity has been paradoxically reported to correlate with improved mortality in patients with established cardiovascular disease. However, its effect has not been evaluated to date in patients with myocardial injury after noncardiac surgery (MINS). METHODS: From January 2010 to June 2019, of a total of 35,269 adult patients with postoperative cardiac troponin level data, 5633 (16.0%) patients had MINS as diagnosed by postoperative cardiac troponin I above the 99th-percentile upper reference of 40 ng·L-1 using the TnI-Ultra immunoassay. Patients with MINS were divided into 3 groups according to body mass index (BMI), with 3246 (57.6%) were in the normal (18.5-25 kg·m-2), 425 (7.5%) in the low BMI (<18.5 kg·m-2), and 1962 (34.8%) in the high BMI (≥25 kg·m-2) groups, respectively. The primary outcome was mortality during the first year after surgery, and the mortality during 30 days was also compared. RESULTS: Following adjustment for confounding with inverse probability of treatment weighting, mortality within the first year appeared to be significantly lower in the high BMI group compared with the normal (14.8% vs 20.9%; hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.66-0.85; P < .001) and the low BMI (14.8% vs 25.6%; HR: 0.56; 95% CI, 0.48-0.66; P < .001) groups. CONCLUSIONS: High BMI may be associated with decreased mortality following MINS. Further investigations are needed to support this finding.

The role of 18F-fluorodeoxyglucose-positron emission tomography/computed tomography in the differential diagnosis of pericardial disease.

This study aimed to assess the role of 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18FDG-PET/CT) in the differential diagnosis of pericardial disease. The diagnosis is often troublesome because pericardial fluid analysis or biopsy does not always provide answers. 18FDG-PET/CT can visualize both inflammation and malignancy and offers a whole-body assessment. Patients who visited the Pericardial Disease Clinic of Samsung Medical Center with an 18FDG-PET/CT order code were extracted. Exclusion criteria were as follows: (1) the purpose of the differential diagnosis was not pericardial disease; (2) the patient had a known advanced-stage malignancy; (3) the patient already have confirmative diagnosis using a serology, pericardial effusion analysis or biopsy. The analysis included 107 patients. The most common final diagnosis was idiopathic (n = 46, 43.0%), followed by tuberculosis (n = 30, 28.0%) and neoplastic (n = 11, 10.3%). A maximum standardized uptake value (SUVmax) ≥ 5 typically indicates tuberculosis or neoplastic pericarditis except in just one case of autoimmune pericarditis); especially all of the SUVmax scores ≥ 10 had tuberculosis. The diagnostic yield of pericardial biopsy was very low (10.2%). Interestingly, all of the pericardium with an SUVmax < 4.4 had nondiagnostic results. In contrast, targeted biopsies based on 18FDG uptake demonstrated a higher diagnostic yield (38.7%) than pericardium. The sensitivity of 18FDG-PET/CT was 63.6%. The specificity was 71.9%. The positive predictive value was 20.6%. The negative predictive value 94.5%, and the accuracy was 71.0% for excluding malignancy based upon the FDG uptake patterns. It is possible to explore the differential diagnosis in some patients with difficult pericardiocentesis or pericardial biopsy in a noninvasive manner using on the SUVmax or uptake patterns. In addition, the biopsy strategy depending on 18FDG uptake is helpful to achieve biopsy more safely and with a higher yield. 18FDG-PET may enhance the diagnostic efficacy in patients with pericardial disease.

Effect of Anti-Inflammatory Drugs on Clinical Outcomes in Patients With Malignant Pericardial Effusion.

BACKGROUND: Pericardiocentesis (PCC) with extended catheter drainage has become a relatively safe procedure to control pericardial effusion (PE), but little is known about long-term outcomes after PCC in malignant PE. OBJECTIVES: This study evaluated the effects of anti-inflammatory agents on long-term outcomes after effective drainage of PE in active cancer patients. METHODS: From May 2007 to December 2018, 445 patients with malignant PE who underwent echocardiography-guided PCC were enrolled. Clinical, laboratory, echocardiographic and procedural findings, and clinical outcome data were collected. Use of anti-inflammatory agents including colchicine, nonsteroidal anti-inflammatory drugs, or steroids after PCC was also analyzed. Colchicine was administered in a dose of 0.6 mg orally, twice a day for 2 months. The primary outcome was defined as a composite of all-cause death and re-PCC or pericardial window operation due to recurred PE. RESULTS: The procedure was successful in 97.0% of the cases, with 1 procedure-related death. During the follow-up of 2 years, 26.1% of patients developed recurrent PE, and 46.0% developed constrictive pericarditis. The colchicine treatment group showed a significantly lower risk of composite events (adjusted hazard ratio [aHR]: 0.65; 95% confidence interval [CI]: 0.49 to 0.87; p = 0.003) as well as all-cause death (aHR: 0.60; 95% CI: 0.45 to 0.81; p = 0.001) than did the noncolchicine group. On propensity score matching, colchicine after PCC was consistently associated with a lower composite events (aHR: 0.55; 95% CI: 0.37 to 0.82; p = 0.003). CONCLUSIONS: In cancer patients with malignant PE, PCC with extended drainage can be an appropriate therapeutic option and shows low complication rate. Patients receiving colchicine after successful PCC showed significant improvement in clinical outcome.

Diffuse Myocardial Fibrosis and Diastolic Function in Aortic Stenosis.

OBJECTIVES: The aim of this study was to investigate the relationship between extracellular volume fraction (ECV), a noninvasive parameter that quantifies the degree of diffuse myocardial fibrosis on cardiac magnetic resonance (CMR), and left ventricular diastolic dysfunction (LVDD) in patients with aortic stenosis (AS). BACKGROUND: Myocardial fibrosis on invasive myocardial biopsy is associated with LVDD. However, there is a paucity of data on the association between noninvasively quantified diffuse myocardial fibrosis and the degree of LVDD and how these are related to symptoms and long-term prognosis in patients with AS. METHODS: Patients with moderate or severe AS (n = 191; mean age 68.4 years) and 30 control subjects without cardiovascular risk factors underwent CMR. LVDD grade was evaluated using echocardiography according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as a composite of all-cause mortality or hospitalization for heart failure aggravation. RESULTS: Patients in higher ECV quintiles had a significantly higher prevalence of LVDD. Higher ECV was particularly associated with decreased myocardial relaxation (septal e' <7 cm/s) and increased LV filling pressure (E/e' ratio ≥15). Although both impaired diastolic function and higher ECV were significantly associated with a worse degree of dyspnea, patients with higher ECV showed greater dyspnea within the same grade of LVDD. During a median follow-up period of 5.6 years, 37 clinical events occurred. Increased ECV, as well as lower septal e' and higher E/septal e' ratio, were independent predictors of clinical events, irrespective of age, AS severity, aortic valve replacement, and left ventricular (LV) ejection fraction. ECV provided incremental prognostic value on top of clinical factors and LV systolic and diastolic function. CONCLUSIONS: Diffuse myocardial fibrosis, assessed using ECV on CMR, was associated with LVDD in patients with AS, but both ECV and LV diastolic function parameters provided a complementary explanation for dyspnea and clinical outcomes. Concomitant assessment of both LVDD and diffuse myocardial fibrosis may further identify patients with AS with greater symptoms and worse prognosis.

Postoperative statin treatment may be associated with improved mortality in patients with myocardial injury after noncardiac surgery.

Myocardial injury after noncardiac surgery (MINS) is recently accepted as a strong predictor of mortality, regardless of symptoms. However, anticoagulation is the only established treatment. This study aimed to evaluate the association between statin treatment and mortality after MINS. From January 2010 to June 2019, a total of 5,267 adult patients who were discharged after the occurrence of MINS were enrolled. The patients were divided into two groups according to statin prescription at discharge. The outcomes were 1-year and overall mortalities. Of the total 5,109 patients, 1,331 (26.1%) patients were in the statin group and 3,778 (73.9%) patients were in the no statin group. The 1-year and overall mortalities were significantly lower in the statin group compared with the no statin group (6.1% vs. 13.3%; hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.41-0.74; p < 0.001 for 1-year mortality and 15.0% vs. 25.0%; HR, 0.62; 95% CI, 0.51-0.76; p < 0.001 for overall mortality). Analyses after inverse probability treatment weighting showed similar results (HR, 0.61; 95% CI, 0.50-0.74; p < 0.001 for 1-year mortality and HR, 0.70; 95% CI, 0.54-0.90; p = 0.006 for overall mortality), and the mortalities did not differ according to the dose of statin. Our results suggest that statin treatment may be associated with improved survival after MINS. A trial is needed to confirm this finding and establish causality.

Comparison of acute and chronic myocardial injury in noncardiac surgical patients.

PURPOSE: Perioperative myocardial injury is a predictor of postoperative mortality, but the clinical impact of chronic injury during the perioperative period has not been fully investigated. This study aimed to evaluate chronic myocardial injury during the perioperative period in comparison with normal and acute myocardial injury. METHODS: Patients with serial cardiac troponin measurements before and within 30 days following noncardiac surgery were divided into three groups: normal, acute injury, and chronic injury groups. Acute and chronic myocardial injuries were stratified according to 2018 recommendations by the International Federation of Clinical Chemistry and Laboratory Medicine's Task Force on Clinical Applications of Bio-Markers. Thirty-day and one-year mortalities after surgery were compared. RESULTS: Of the 22,969 patients reviewed, 17,671 (76.9%) were classified into the normal, 5,179 (22.5%) into the acute injury, and 119 (0.5%) into the chronic injury groups. The acute and chronic injury groups had higher 30-day mortalities compared with the normal group (0.8% vs. 8.0%; hazard ratio [HR], 11.00; 95% confidence interval [CI], 9.05-13.37; P < 0.001 and 0.8% vs. 7.6%; HR, 10.55; 95% CI, 5.37-20.72; P < 0.001, respectively). In a direct comparison between the acute and chronic injury groups using an inverse probability of weighting adjustments, the 30-day and one-year mortalities were not significantly different. CONCLUSION: Chronic myocardial injury during the perioperative period may show similar clinical impacts on postoperative mortality compared with acute injury. Further studies are needed.

Prevalence and clinical significance of cardiovascular magnetic resonance adenosine stress-induced myocardial perfusion defect in hypertrophic cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is thought to be associated with microvascular dysfunction. Adenosine stress-perfusion cardiovascular magnetic resonance imaging (CMR) is a sensitive method for assessing microvascular perfusion abnormalities. We evaluated the prevalence and clinical characteristics of HCM patients with adenosine-induced perfusion defects on CMR. METHODS: Among 189 consecutive patients with HCM who underwent adenosine-stress perfusion CMR, 115 patients who had clinical, echocardiography, 24-h Holter monitoring and treadmill exercise test data were analyzed. We calculated myocardial perfusion ratio index from the intensity-over-time curve to quantify perfusion defects. The presence and extent of the stress-induced perfusion defect were compared with clinical characteristics, presence and extent of late gadolinium enhancement (LGE), left ventricular (LV) mass index and volume, presence of non-sustained ventricular tachycardia (NSVT) and results of treadmill exercise test. RESULTS: The mean age of enrolled patients was 51.8 ± 11.3 years. Most patients were asymptomatic except 25 subjects presented with New York Heart Association Class II dyspnea and 16 patients with atypical non-exertional chest discomfort. LGE was present in 103 (89.6%) subjects. Adenosine stress-induced perfusion defects were present in 48 (42%) subjects. None of the perfusion defects corresponded with a single or multiple coronary artery territories, showing a multiple patchy pattern in 24 (50.0%), a concentric subendocardial pattern in 20 subjects (41.7%), and as a single blot-like defect in the remaining 4 (8.3%). A perfusion defect was associated with NSVT, LV apical aneurysm, higher LV mass index, and higher LGE volume on univariate analysis. Multivariate analysis revealed female gender (P = 0.008), presence of apical aneurysm and NSVT (P = 0.036 and 0.047, respectively), and LV mass index (P = 0.022) to be independently associated with adenosine stress-induced perfusion defects. CONCLUSIONS: In patients with HCM, adenosine-stress perfusion defects on CMR are present in more than 40% of subjects. This perfusion defect is associated with NSVT, higher LV mass index, and apical aneurysms. The prognostic value of this finding needs further elucidation.

Comparison of tissue tracking assessment by cardiovascular magnetic resonance for cardiac amyloidosis and hypertrophic cardiomyopathy.

BACKGROUND: Administration of gadolinium-contrast can cause problems in cardiac amyloidosis (CA) patients with impaired renal function. PURPOSE: To compare patterns of cardiovascular magnetic resonance tissue tracking (CMR-TT) for CA and hypertrophic cardiomyopathy (HCM) and to assess the feasibility of CMR-TT to distinguish between these diseases without administration of gadolinium-contrast. MATERIAL AND METHODS: Included were 54 patients with biopsy-proven CA, 40 patients with HCM, and 30 healthy people. We calculated strain ratio of apex to base (SRAB) in the left ventricle (LV) using radial (R), circumferential (C), and longitudinal (L) strain from CMR-TT. The LV ejection fraction (LVEF) and the ratio of septal to posterior wall at basal level were also calculated. Late gadolinium enhancement (LGE) image analysis was performed for differential diagnosis. Area under the receiver operating characteristic curve (AUC) comparisons were used. RESULTS: All SRAB values were significantly different between CA and HCM (all P < 0.001). AUC values for parameters were 0.806 for LVEF, 0.815 for ratio of wall thickness, 0.944 for the LGE pattern, 0.898 for SRABR, 0.880 for SRABC, and 0.805 for SRABL. AUCs for the LGE pattern were significantly higher than for LVEF, ratio of wall thickness and SRABL (all P < 0.008). No significant differences were seen between AUCs for the LGE pattern, SRABR, and SRABC (all P > 0.109). CONCLUSION: SRABR and SRABC were reliable parameters for distinguishing between CA and HCM.

Predictive value of exercise stress echocardiography in asymptomatic patients with severe aortic regurgitation and preserved left ventricular systolic function without LV dilatation.

The management of asymptomatic patients with severe aortic regurgitation (AR) and preserved left ventricular (LV) systolic function remains controversial. We evaluated the predictive value of exercise stress echocardiography (ESE) in asymptomatic severe AR with preserved LV systolic function for identifying high risk patients who might benefit from early referral for surgery. Symptom-limited treadmill ESE was performed in 67 asymptomatic patients with severe AR (effective regurgitant orifice area > 30 mm2, regurgitant volume > 60 ml) and preserved LV systolic function without LV dilatation [ejection fraction (EF) ≥ 50% and LV end-systolic diameter ≤ 50 mm]. A post-exercise EF increase of > 4% was defined as presence of contractile reserve (CR). The primary outcome was defined as the composite of symptoms development, deterioration in LV function (EF < 50% in echocardiography) and aortic valve replacement (AVR) at follow-up. Operations performed within 60 days of ESE were excluded. Twenty-eight patients were CR (+) and 39 patients were CR (-). Compared with the CR (+) group, the CR (-) group was older (52.0 ± 14.0 years vs. 43.8 ± 10.6 years, p = 0.011) and had higher Ln N-terminal natriuretic peptide (NT-proBNP) [5.2 (4.5-5.7) vs. 4.1 (3.7-5.1), p = 0.001]. The CR (-) group showed lower exercise time than the CR (+) group (576 ± 159 s vs. 671 ± 108 s, p = 0.008). Otherwise, there were no differences in demographics and imaging data between the two groups. During a follow-up duration of 46 ± 23 months, the primary outcome occurred in 17 patients (25%) including development of symptoms (n = 9), new-onset LV systolic dysfunction (n = 1) and AVR (n = 7). Fourteen of 17 were CR (-) group patients. The survival rate during follow-up was significantly lower in the CR (-) group than in the CR (+) group of asymptomatic severe AR patients (log-rank p = 0.035). The absence of CR in ESE is independently associated with deterioration of symptoms or LV systolic function in asymptomatic patients with severe AR and preserved LV systolic function. It can further risk stratify asymptomatic patients with severe AR and preserved LV systolic function and may influence the optimal timing of AVR.