Implantation depth of balloon-expandable transcatheter heart valves and risks for permanent pacemaker implantation and midterm adverse events.

BACKGROUND: Permanent pacemaker implantation (PPI) remains a relevant complication after transcatheter aortic valve implantation (TAVI) and its impact on outcome remains controversial. AIMS: This study aimed to analyze the effects of implantation depth on PPI at 30 days and assess its impact on outcome with the balloon-expandable Sapien 3 (S3) prosthesis. METHODS: Between 2014 and 2018, 849 patients without previous pacemaker undergoing transfemoral TAVI with the S3 were included. Prosthesis implantation depth was measured and divided into Quintiles. An ordinal logistic regression was used to assess its association with PPI, while a multivariate logistic regression was performed to identify predictors of PPI. Survival analyses were performed with the Kaplan-Meier method and a multivariable Cox regression was performed to ascertain the impact of PPI on mortality. RESULTS: Overall, incidence of PPI at 30 days was 9.7%. Implantation depth decreased consistently from a median of 6.7 mm [5.55-8.00] in 2014 to 2.7 mm [2.30-3.50] in 2018 (p < 0.001). When considering Quintiles of implantation depth, incidence of PPI was significantly higher in upper Quintiles and risk for PPI was significantly lower for the 1. Quintile compared to the 5. Quintile (OR: 0.34, 95% CI: [0.16-0.73]; p = 0.003). In the adjusted multivariable logistic regression implantation depth persisted ad independent predictor of PPI at 30 days. Patients requiring PPI at 30 days displayed significantly higher mortality at 4 years compared to patients without PPI (49.5% vs. 40.0%; log-rank = 0.022). In a multivariate analysis, increased logistic EuroScore, diabetes mellitus, and history of atrial fibrillation, were independent predictors of all-cause mortality at 2 years. CONCLUSIONS: Higher prosthesis implantation relative to the virtual aortic annulus was significantly associated with reduced risk for PPI at 30 days. Patients with PPI at 30 days exhibited higher mortality during follow-up, however, only logistic EuroScore, diabetes mellitus, and history of atrial fibrillation were identified as independent predictors of mortality at 2 years.

Elevated high-sensitive cardiac troponin T in emergency department patients: insights from a retrospective descriptive cohort study.

BACKGROUND: High-sensitive cardiac troponin T (hs-cTnT) assessments are routinely conducted in German emergency departments (EDs). However, data describing a large number of ED patients with pathological hs-cTnT levels and subsequent clinical outcomes are limited. METHODS: This retrospective descriptive analysis included 141.892 patients who presented to the interdisciplinary ED at Klinikum rechts der Isar in Munich, Germany, between January 2019 and December 2021. Patients with trauma diagnoses were excluded, focusing on those with elevated hs-cTnT levels. These patients were categorized into three groups based on the International Classification of Procedures in Medicine (ICPM): those with elevated hs-cTnT who received no coronary angiography (NCA), those who underwent diagnostic coronary angiography (DCA), and those who received percutaneous coronary intervention (PCI). The objective of this study was to characterize a large emergency department patient cohort and assess their subsequent clinical outcomes. RESULTS: After initial Manchester Triage Sytem (MTS) categorization, 32.6% (46.307/141.892) of patients were identified as non-trauma cases. Of these, 9.9% (4.587/46.307) had hs-cTnT levels exceeding 14 ng/L. Within this subset, 70.4% (3.230/4.587) did not undergo coronary angiography, 15.4% (705/4.587) underwent DCA and 14.2% (652/4.587) received PCI. Chest pain occurred more frequently in the PCI group (28.0%, 160/652) compared to the DCA group (18.3%, 113/705) or NCA group (5.7%, 159/3230), p < 0.001. However, breathing problems occurred more frequently in the NCA group (23.2%, 647/3230) compared to the PCI group (17.7%, 101/652) or DCA group (21.8%, 135/705), p < 0.001. Also, collapse was more frequent in patients in the NCA group (4.0%, 112/3230) compared to the DCA group (3.4%, 21/705) or PCI group (3.5%, 20/652), p < 0.001. Overall, in-hospital mortality was significantly higher in the NCA group (7.9%, 256/3230) compared to the DCA group (2.3%, 16/705) or PCI group (4.1%, 27/652), p < 0.001. CONCLUSION: Emergency patients with elevated hs-cTnT who did not undergo coronary angiography faced a higher risk of in-hospital mortality in our retrospective descriptive study. Given the heterogeneous nature of presenting complaints in emergency departments, identifying at-risk patients can pose challenges for treating physicians.

Incidence of systemic inflammatory response syndrome and patient outcome following transcatheter edge-to-edge mitral valve repair.

OBJECTIVES: Systemic inflammatory response syndrome (SIRS) is a common finding after cardiovascular interventions. Data on the incidence of SIRS and its impact on outcome in patients undergoing transcatheter edge-to-edge mitral valve repair (MV-TEER) for mitral regurgitation (MR) is lacking. METHODS: From January 2013 to December 2020, 373 patients with moderate or severe MR undergoing MV-TEER were included. SIRS was defined as at least two of the following criteria within 48 h after the procedure: leucocyte count > 12.0 or < 4.0 × 109/l, respiratory rate > 20 breaths per minute or PaCO2 ≤ 4.3 kPa/32 mmHg, heart rate > 90 bpm and temperature > 38.0 °C or < 36.0 °C. The primary endpoint was 3-years all-cause mortality. RESULTS: SIRS was observed in 49.6% (185/373) of patients. Patients who developed SIRS presented more frequently with NYHA III/IV at baseline [SIRS: 82.4% (149/185) vs. no SIRS: 79.0% (147/188); p = 0.029]. Patients who developed SIRS spent more days on ICU (p < 0.001) and overall length of stay was longer (p < 0.001). Relevant residual MR, defined as MR ≥ III in-hospital, was present more often in patients who developed SIRS [SIRS: 11.3% (20/177) vs. no SIRS: 3.93% (7/178), p = 0.036]. At 3 years, all-cause mortality in the entire population was 33.5% (125/373) with an increased all-cause mortality in patients with SIRS compared to patients without SIRS (HR 1.49, [CI 95% 1.04, 2.13]; p = 0.0264). In the multivariate analysis development of SIRS (HR 1.479 [CI 95% 1.016, 2.154]; p = 0.041) was identified as predictor for 3-years all-cause mortality. CONCLUSIONS: SIRS is a common finding after MV-TEER occurring in approximately half of patients. SIRS after MV-TEER was associated with a longer in-hospital stay. In addition, we observed an increased 3-years all-cause mortality in patients with SIRS.

Aortic valve calcification volume and prognosis in patients undergoing transcatheter aortic valve implantation.

INTRODUCTION AND OBJECTIVES: It is unknown whether aortic valve calcium volume, as measured by contrast-enhanced computed tomography angiography (angio-CT), is associated with mortality in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to confirm that contrast-enhanced aortic valve calcium correlates with noncontrast-enhanced calcium score and provides useful prognostic information in patients undergoing TAVI. METHODS: This retrospective observational study included patients from 2 high-volume TAVI centers in Germany, all of whom underwent high-quality angio-CT prior to TAVI. Calcium volume in contrast-enhanced angio-CT was calculated using 3Mensio software (Pie Medical, The Netherlands), while the calcium score from noncontrast-enhanced angio-CT was obtained using the Syngo.via (Siemens Healthineers, Germany) workstation to validate contrast-enhanced angio-CT values. Calcium volume was dichotomized using the median based on to sex-specific values from contrast-enhanced angio-CT, and the risk associated with increased calcium volume was determined using Cox proportional hazard regression analysis. RESULTS: We included 3318 TAVI patients. A good correlation was observed between noncontrast-enhanced and contrast-enhanced angio-CT (r2 = 0.680; P < .001). The median values for sex-specific contrast-enhanced angio-CT calcium volume were 514 mm3 for women and 1025 mm3 for men. Patients with higher calcium volumes showed lower mortality at 1 year (8.8% vs 12.1%; adjusted hazard ratio [HR], 0.86; 95% confidence interval [95%CI], 0.75-0.98; P = .02) compared with those with lower calcium volumes. CONCLUSIONS: Calcium volume in contrast-enhanced angio-CT correlated well with noncontrast-enhanced angio-CT calcium score. Patients with higher calcium volume showed lower mortality at 1 year after TAVI.

Systemic inflammatory response syndrome in patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Data on systemic inflammatory response syndrome (SIRS) after transcatheter aortic valve implantation (TAVI) are scarce and limited to small cohorts. We aimed to investigate its incidence and mid-term impact in a large cohort of TAVI patients. METHODS: From January 2018 to December 2020, 717 patients with severe aortic valve stenosis undergoing TAVI were included. SIRS was defined as fulfilling at least two of the following criteria within 48 h from the procedure: leucocyte count >12.0 or <4.0 × 109/l, respiratory rate > 20 breaths per minute or PaCO2 ≤ 4.3 kPa/32 mmHg, heart rate > 90 beats per minute and temperature > 38.0 °C or <36.0 °C. Clinical endpoints were 1-year rehospitalization for chronic heart failure (CHF) and 2-years all-cause mortality. Event rates during follow-up were calculated as Kaplan-Meier estimates. RESULTS: SIRS developed in 56.3 % (404/717) of patients after TAVI. SIRS occurred more frequently in patients with post-dilatation (SIRS 34.7 % (140/404) vs. no SIRS 23.3 % (73/313); p < 0.001) and major vascular complications (SIRS 16.1 % (65/404) vs. no SIRS 8.6 % (27/313); p = 0.004). Further, ICU days were more in patients who developed SIRS (SIRS 1.56 ± 1.50 days vs. no SIRS 1.22 ± 1.02 days; p = 0.001). At 2-years, all-cause mortality in the entire population was 23.9 %. However, there was no difference in CHF at 1-year (5.9 % vs. 4.1 %; log-rank = 0.347) nor in all-cause mortality at 2-years (22.0 % vs. 26.2 %; log-rank = 0.690) between the groups. CONCLUSIONS: SIRS is a common finding after TAVI, which may prolong hospital stay but is without effect on mortality during 2-years follow-up.

Echocardiographic evaluation of left ventricular function using an automated analysis algorithm is feasible for beginners and experts: comparison with invasive and non-invasive methods.

AIMS: Echocardiographic measurement of left ventricular function using a user-friendly automated three-dimensional algorithm is highly attractive as it promises quick and accurate diagnosis, circumventing limitations associated with visual estimation or manual biplane measurements. We sought to assess the feasibility and correlation of such automated analysis with clinically established methods. METHODS: A total of 198 patients undergoing transthoracic echocardiography (TTE) with assessment of left ventricular parameters by automated software algorithm (Philips 3D-Heartmodel; 3D-HM) which additionally had either left ventricular angiography (LVA) or cardiac magnetic resonance (CMR) within 24 h of the TTE examination were analyzed. Left ventricular parameters (left ventricular end-diastolic volume, LVEDV, left ventricular end-systolic volume, LVESV as well as left ventricular ejection fraction, LVEF) were compared between 3D-HM, CMR and LVA. RESULTS: Correlation of left ventricular measurements was overall good to excellent and stronger for CMR (EF r = 0.824) than for LVA (EF r = 0.746). Unexperienced and expert clinicians yielded comparable good results. For CMR, highest correlation was detected in patients with BMI < 25 and excellent image quality. High agreement was seen between 3D-HM and CMR or LVA when stratifying patients according to heart failure categories. CONCLUSIONS: Echocardiographic quantification of left ventricular parameters using a software-based algorithm correlated well with established invasive and non-invasive modalities in the clinical setting, even for unexperienced clinicians. Such automated approaches are promising as they allow a reliable, more observer-independent as well as reproducible assessment of left ventricular function.

Neurotoxicity of different amyloid beta subspecies in mice and their interaction with isoflurane anaesthesia.

BACKGROUND: The aim of this study was to assess different amyloid beta subspecies' effects on behaviour and cognition in mice and their interaction with isoflurane anaesthesia. METHODS: After governmental approval, cannulas were implanted in the lateral cerebral ventricle. After 14 days the mice were randomly intracerebroventricularly injected with Aß 1-40 (Aß40), Aß 1-42 (Aß42), 3NTyr10-Aß (Aß nitro), AßpE3-42 (Aß pyro), or phosphate buffered saline. Four days after the injection, 30 mice (6 animals per subgroup) underwent general anaesthesia with isoflurane. A "sham" anaesthetic procedure was performed in another 30 mice (6 animals per subgroup, 10 subgroups in total). During the next eight consecutive days a blinded assessor evaluated behavioural and cognitive performance using the modified hole-board test. Following the testing we investigated 2 brains per subgroup for insoluble amyloid deposits using methoxy staining. We used western blotting in 4 brains per subgroup for analysis of tumour-necrosis factor alpha, caspase 3, glutamate receptors NR2B, and mGlu5. Data were analysed using general linear modelling and analysis of variance. RESULTS: Aß pyro improved overall cognitive performance (p = 0.038). This cognitive improvement was reversed by isoflurane anaesthesia (p = 0.007), presumably mediated by decreased exploratory behaviour (p = 0.022 and p = 0.037). Injection of Aß42 was associated with increased anxiety (p = 0.079). Explorative analysis on a limited number of brains did not reveal insoluble amyloid deposits or differences in the expression of tumour-necrosis factor alpha, NR2B, mGlu5, or caspase 3. CONCLUSIONS: Testing cognitive performance after intracerebroventricular injection of different amyloid beta subspecies revealed that Aß pyro might be less harmful, which was reversed by isoflurane anaesthesia. There is minor evidence for Aß42-mediated neurotoxicity. Preliminary molecular analysis of biomarkers did not clarify pathophysiological mechanisms.