Computed tomographic characteristics of congenital coronary artery fistulas in an adult population.

BACKGROUND: Coronary artery fistulas (CAFs) are usually congenital coronary artery anomalies of termination. AIMS: This study aimed to assess the prevalence, anatomic characteristics, and clinical significance of CAFs detected by computed tomography (CT) in an adult population. METHODS: We performed 45 817 CT examinations in 39 066 subjects between 2008 and 2020. The electronic database was manually checked using specific keywords to identify patients with CAFs. The CT characteristics of CAFs were evaluated. CAF was defined as clinically significant if it was the most plausible cause of myocardial infarction, infective endocarditis, heart failure, death during follow-up, hospitalization, or if it required either percutaneous or surgical intervention. RESULTS: Of 39 066 patients, 56 CAFs were detected in 42 subjects (20 men, 47.6%) with a prevalence of 0.11%. Most CAFs originated from the right coronary artery (RCA) (48.2%) and drained into the pulmonary artery (PA) (58.9%). CAFs terminating in the PA were more frequently multiple (P <0.001) and tortuous (P <0.001) as compared to CAFs without PA drainage. Clinically significant CAFs, identified in 7 of 42 patients, were more common in younger (P = 0.03) and male (P = 0.04) subjects and had larger lumen area and diameter at the site of origin (P = 0.03, P = 0.03, respectively). CONCLUSIONS: In the unselected adult population undergoing coronary CT angiography, the RCA and the PA are the most common sites of origin and termination of CAFs, respectively. CAFs draining into the PA are more often multiple and tortuous. Clinically meaningful CAFs are larger and most frequently detected in younger and male patients.

Heart failure with reduced, mildly reduced, and preserved ejection fraction: outcomes and predictors of prognosis.

INTRODUCTION: Recently, a stratification of the heart failure (HF) phenotypes, which classifies HF into 3 subtypes based on ejection fraction, has been introduced. Before that, clinical trials and registries have been mainly devoted to HF with reduced ejection fraction (HFrEF). As a result, data on long­term survival trends for individual HF phenotypes are scarce. OBJECTIVES: The study aimed to evaluate survival according to the HF phenotype and to identify predictors of mortality. PATIENTS AND METHODS: Patients hospitalized for HF in our referral center between January 2014 and May 2019 were included in the analysis. HF phenotyping was based on EF: reduced (HFrEF with EF <40%), mildly reduced (HFmrEF with EF = 40%-49%), and preserved (HFpEF with EF ≥50%). RESULTS: Of 2601 patients included in the study, 1608 individuals (62%) presented with HFrEF, 331 patients with HFmrEF (13%), and 662 patients with HFpEF (25%). The median follow­up was 2.43 years (interquartile range, 1.56-3.49). The risk of death was 61% higher in HFrEF than in HFpEF (P <0.001), while in HFmrEF and HFpEF it was similar. Survival rates at 1 and 5 years in HFrEF, HFmrEF, and HFpEF were 81%, 84%, 84%, and 47%, 61%, and 59%, respectively. The HF phenotypes differed in most of the parameters that affect prognosis. Only the use of inotropes, which was linked to an increased risk of death, and the use of angiotensin­converting enzyme inhibitors, which reduced this risk, were independent of the HF phenotype. CONCLUSIONS: Survival in HFrEF is worse as compared with HFmrEF and HFpEF, where it is similar. The HF phenotypes differ in most of the parameters that affect survival.

Association of left atrial enlargement and increased left ventricular wall thickness with arrhythmia recurrence after cryoballoon ablation for atrial fibrillation.

BACKGROUND: Left atrial enlargement (LAE) predicts atrial fibrillation (AF) recurrence after cryoballoon-based pulmonary vein isolation (CB). Increased left ventricular wall thickness (LVWT) is pathophysiologically associated with LAE and atrial arrhythmias. AIMS: To assess effect of increased LVWT on long-term outcomes of CB depending on coexistence of LAE. METHODS: LAE was defined using either echocardiography ( > 48 cm³/m²) or multislice computer tomography (MSCT, ≥63 cm³/m²). Increased LVWT was echocardiographic septal/posterior wall thickness > 10 mm in males and > 9 mm in females. All patients achieved 2-year follow-up. RESULTS: Of 250 patients (median [interquartile range, IQR] age of 61 [49.0-67.3] years; 30% female) with AF (40% non-paroxysmal), 66.5% had hypertension, and 27.2% underwent redo procedure. MSCT was done in 76%. During follow-up of 24.5 (IQR, 6.0-31.00) months the clinical success rate was 72%, despite 46% of patients having arrhythmia recurrence. Arrhythmia recurrence risk was increased by LAE and increased LVWT (hazard ratio [HR], 1.801; P = 0.002 and HR, 1.495; P = 0.036; respectively). The highest arrhythmia recurrence (61.9% at 2 years) was among patients with LAE and increased LVWT (33.6% of patients); intermediate (41.8%) among patients with isolated LAE; and lowest among patients with isolated increased LVWT or patients without LAE or increased LVWT (36.8% and 35.2% respectively, P = 0.004). After adjustment for body mass index (BMI), paroxysmal AF, CHA2DS2-VASc score, clinically-significant valvular heart disease, and cardiomyopathy, patients with LAE and concomitant increased LVWT diagnosis had a 1.8-times increased risk of arrhythmia recurrence (HR, 1.784; 95% confidence interval [CI], 1.017-3.130; P = 0.043). CONCLUSION: Joint occurrence of LAE and increased LVWT is associated with the highest rate of arrhythmia recurrence after CB for AF.

Epidemiology and clinical characteristics of hospitalized patients with heart failure with reduced, mildly reduced, and preserved ejection fraction.

INTRODUCTION: There is still little information regarding a detailed description and predictors of different subtypes of heart failure (HF) in the Polish population. OBJECTIVES: This study sought to characterize the differences between hospitalized patients with HF divided into HF with preserved ejection fraction (HFpEF; EF ≥50%), mildly reduced EF (HFmrEF; EF 40%-49%), and reduced EF (HFrEF; EF <40%), and to identify factors related to each HF subtype. PATIENTS AND METHODS: Patients from the hospital database whose hospitalization was coded as HF­related between 2014 and 2019 were included in the analysis. RESULTS: A total of 2601 patients were included, of whom 62% had HFrEF, 13% had HFmrEF, and 25% had HFpEF. The patients with HFpEF, as compared with those with HFrEF and HFmrEF, were older (70.5 vs 61.6 vs 66.5 years, P <0.001), less often male (44% vs 68.3% vs 81.3%, P <0.001), and less likely to have an ischemic etiology of HF (19.3% vs 49.8% vs 34.4%, P <0.001) but they were more likely to have hypertension (87.3% vs 78.2% vs 78.2%, P <0.001), atrial fibrillation (64.5% vs 55.6% vs 59.5%, P <0.001), cancer (32.2% vs 19.6% vs 28.7%; P <0.001), and anemia (25.5% vs 15.9% vs 20.5%, P <0.001). Of 3 multivariable models, the one predicting HFpEF was the strongest (P <0.001, area under the curve, 0.79), and included age, sex, aortic stenosis, hypertension, anemia, cancer, thyroid abnormality, atrial fibrillation, longer history of HF, ischemic etiology, coronary artery disease, diabetes mellitus, and liver failure. CONCLUSIONS: HFrEF and HFpEF differed significantly in terms of baseline characteristics, while HFmrEF was in the middle of the HF spectrum, tending to be a mixture of HFpEF and HFrEF characteristics.

Intra-Right Ventricle Course of the Coronary Arteries on Computed Tomography Angiography.

BACKGROUND: The clinical relevance and anatomic characteristics of intracavitary coronary arteries coursing within the right ventricle (RV) are largely unknown. OBJECTIVES: The aim of our study was to assess the clinical and computed tomographic characteristics of patients diagnosed with intracavitary coronary arteries coursing within RV (intra-RV coronaries). METHODS: Electronic records from a single high-volume cardiac center were retrospectively screened for the presence of intra-RV coronaries among consecutive patients who underwent coronary computed tomography angiography (coronary CTA) from 2008 to 2019. RESULTS: Overall, 31,748 coronary CTA reports were evaluated, and 17 subjects with intra-RV coronaries were identified. None of these patients was referred for subsequent invasive coronary angiography. One patient underwent coronary artery bypass grafting, 1 patient had a history of percutaneous coronary intervention, and 1 patient had a concomitant coronary anomaly: left circumflex coronary artery originating from the right coronary artery. All of the involved coronaries (n = 17) were the left anterior descending coronary arteries (LADs). Typical segmental coronary course within RV was along the border between free RV wall and interventricular septum (beneath interventricular groove), often within trabeculae carneae of the RV. Only the midsegment and distal segment of the LAD traversed within the RV. The mean ± SD distance from the aorta to the coronary entrance into the RV was 74.5 ± 17.1 mm, whereas the mean ± SD intra-RV coronary length was 25.1 ± 14.0 mm. CONCLUSIONS: Intra-RV course of the coronaries in an adult CTA population is an infrequent anatomical variant involving LAD. It may require additional attention during interventional and surgical interventions.

Effect on Mortality of Systemic Thromboinflammatory Response After Transcatheter Aortic Valve Implantation.

After transcatheter aortic valve implantation (TAVI) there is consistently identified decrease in platelets accompanied by a leucocyte (white blood cell, WBC) increase. We aimed to analyze the prognostic value of early platelet and WBC count changes (thromboinflammatory response) after successful TAVI. Among 432 consecutive patients [median 83.0 years of age, 63.4% women], platelets and WBCs were measured before and for 7 days post-TAVI. Follow-up was 36.9 (21.4 to 48.0) months. Platelet decrease (∆%Platelet-max) and parallel WBC increase (∆%WBC-max) were seen at days 1 to 3. Both ∆%Platelet-max ≤-37.6% and ∆%WBC-max >72.5% predicted mortality (area under the curve = 0.569 and area under the curve = 0.626). The 30-day and 1-year mortality (13.1% and 26.2%) were highest among 28% patients with a greater decrease in platelets and a greater increase in WBCs; intermediate (0.9% and 12.3%) among 52.5% patients with either a greater decrease in platelets or a greater increase in WBCs, but not both; and lowest (0% and 6.6%) among 19.5% patients with a lesser decrease in platelets and a lesser increase in WBCs (p <0.001). Estimated 4-year mortality rates were 53.7% versus 36.2% versus 24.5%, respectively, p <0.001. Bleeding, surgical wounds, acute kidney, and brain injury predicted a more intense thromboinflammatory response, whereas use of the newer generations had the opposite effect. In conclusion, substantial thromboinflammatory response identified after successful TAVI predicts a higher long-term mortality.

Mechanisms of Myocardial Infarction in Patients With Nonobstructive Coronary Artery Disease: Results From the Optical Coherence Tomography Study.

OBJECTIVES: This study sought to assess the presence and morphological features of coronary plaques on optical coherence tomography (OCT) as the causes of myocardial infarction with nonobstructive coronary arteries (MINOCA). BACKGROUND: Although coronary atherosclerosis has been postulated as a potential mechanism of MINOCA, the interaction between disrupted coronary plaques and myocardial injury remains unknown. METHODS: In a prospective study, consecutive patients with MI but without significant coronary stenosis (≥50%) at angiography underwent OCT and cardiac magnetic resonance (CMR) with late gadolinium-enhancement (LGE). The infarct-related artery (IRA) was identified by localization of ischemic-type LGE. RESULTS: Thirty-eight MINOCA patients (mean age 62 ± 13 years, 55% female, 39% with ST-segment elevation) were enrolled. Maximal diameter stenosis was 35% by angiography, and 5 patients (13%) had normal angiogram results. Plaque disruption and coronary thrombus were observed in 9 patients (24%) and 7 patients (18%), respectively. Sixteen of 31 patients (52%) undergoing CMR showed LGE. Ischemic-type LGE was present in 7 patients (23%) and was more common in patients with than without plaque disruption (50% vs. 13%, respectively; p = 0.053) and coronary thrombus (67% vs. 12%, respectively; p = 0.014). In the per-lesion analysis, the IRA showed significantly more plaque disruption (40% vs. 6%; p = 0.02), thrombus (50% vs. 4%; p = 0.014), and thin-cap fibroatheroma (70% vs. 30%; p = 0.03) than the non-IRA. CONCLUSIONS: Plaque disruption and thrombus are not uncommon in MI without obstructive coronary stenoses at angiography and may be associated with the presence and location of ischemic-type myocardial injury on CMR. OCT may be valuable in identifying atherosclerotic etiology in individuals with MINOCA. (Optical Coherence Tomography in Patients With Acute Myocardial Infarction and Nonobstructive Coronary Artery Disease [SOFT-MI]; NCT02783963).

Left aberrant subclavian artery. Systematic study in adult patients.

BACKGROUND: Left aberrant subclavian artery (LASA), is a type of right aortic arch (RAA) branching, which takes-off distally to the right subclavian artery and usually crosses behind the esophagus to the left upper limb. Taking into account the rarity of RAA, LASA is much more rarely seen than the right aberrant subclavian artery (RASA) originating from the left aortic arch. However, RAA may be associated with much more frequent presence of LASA, than left aortic arch with RASA. Anatomical LASA characteristics were not described up to date. METHODS: Individual patient records filed in the electronic database from a single high-volume tertiary cardiac center were retrospectively screened for the presence of RAA in the consecutive patients who underwent chest computed tomography from 2008 to 2016. RESULTS: 14 patients with LASA were identified. Only 3 were free of coexisting intra- or extra-cardiac anomalies. The most common defect was tetralogy of Fallot (3 patients). One patient had five congenital defects. Kommerell's diverticulum (KD) was present in 9 patients. In all patients the LASA course was retrotracheal and retroesophageal. In all but one patients esophageal modelling or compression by KD or LASA was present. CONCLUSIONS: Knowledge of Kommerell's diverticulum presence and morphology as well as the LASA course during preinterventional work-up of patients with congenital heart defects is critical, since it may have surgical implications during corrective procedures.

QTc prolongation in patients with hearing loss: Electrocardiographic and genetic study.

BACKGROUND: The aim of the study was to determine, whether electrocardiogram (ECG) screening could reduce the risk of sudden cardiac death in patients with hearing loss through the early diagnosis of Jervell and Lange-Nielsen syndrome and the introduction of the therapy. METHODS: One thousand and eighty patients with hearing loss (aged 21.8 ± 19.9 years) underwent ECG. Additionally, all subjects were asked to complete a 3-question survey. Those who met, at least, one of the high-risk criteria underwent further cardiac assessment and genetic testing. RESULTS: QTc assessment was possible in 1,027 patients. Mean QTc measured 422.8 ± 23.7 ms in 313 women, 414.9 ± 27.7 ms in 273 men and 421.1 ± 21.5 ms in 441 children (individuals younger than 14 years). Abnormal QTc was found in 13 (4.1%) women, 20 (7.3%) men, and 72 (16.3%) children. In the studied group, no recessive mutation of KNCQ1 or KCNE1 was found. In 6 patients, other mutations were found: in KCNQ1 (n = 1), in KCNH2 (n = 3) and in SCN5A (n = 1), which were pathogenic for long-QT-syndromes (LQTS), and 2 mutations of unknown clinical significance in SCN5A. Overall, out of these 6 patients LQTS was diagnosed in 3 asymptomatic patients, but with abnormal QTc and in 2 patients with normal QTc, but who were previously treated for epilepsy. CONCLUSIONS: Jervell and Lange-Nielsen syndrome is a very rare condition even in a population with hearing loss. In this population, the prevalence of prolonged QT interval is increased over the general population. Further investigations are necessary.