Development of a Carbon Nanotube-Enhanced FAS Bilayer Amphiphobic Coating for Biological Fluids.

This study reports the development of a novel amphiphobic coating. The coating is a bilayer arrangement, where carbon nanotubes (CNTs) form the underlayer and fluorinated alkyl-silane (FAS) forms the overlayer, resulting in the development of highly amphiphobic coatings suitable for a wide range of substrates. The effectiveness of these coatings is demonstrated through enhanced contact angles for water and artificial blood plasma fluid on glass, stainless steel, and porous PTFE. The coatings were characterized using Fourier-transform infrared spectroscopy (FTIR), scanning electron microscopy (SEM), thermogravimetric analysis (TGA), atomic force microscopy (AFM), and contact angle (CA) measurements. The water contact angles achieved with the bilayer coating were 106 ± 2°, 116 ± 2°, and 141 ± 2° for glass, stainless steel, and PTFE, respectively, confirming the hydrophobic nature of the coating. Additionally, the coating displayed high repellency for blood plasma, exhibiting contact angles of 102 ± 2°, 112 ± 2°, and 134 ± 2° on coated glass, stainless steel, and PTFE surfaces, respectively. The presence of the CNT underlayer improved plasma contact angles by 29%, 21.7%, and 16.5% for the respective surfaces. The presence of the CNT layer improved surface roughness significantly, and the average roughness of the bilayer coating on glass, stainless steel, and PTFE was measured to be 488 nm, 301 nm, and 274 nm, respectively. Mechanistically, the CNT underlayer contributed to the surface roughness, while the FAS layer provided high amphiphobicity. The maximum effect was observed on modified glass, followed by stainless steel and PTFE surfaces. These findings highlight the promising potential of this coating method across diverse applications, particularly in the biomedical industry, where it can help mitigate complications associated with device-fluid interactions.

Outcomes and Direct Cost of Isolated Nonemergent CABG in Patients With Low Ejection Fraction.

OBJECTIVE: Preoperative left ventricular ejection fraction (LVEF) is one of the main predictors of outcomes in cardiac surgery. We present current era outcomes and associated direct cost in nonemergent isolated coronary artery bypass surgery (CABG) patients with LVEF <20% over the past 6 years and compare it with higher EF subgroups. METHODS: Six-year data from 2016 to 2022 at hospitals sharing Society of Thoracic Surgeons and financial data with Biome Analytics were analyzed based on 3 EF subgroups (EF ≤20%, EF 21% to 35%, and EF >35%). Outcomes and costs were assessed. RESULTS: Overall 30-day mortality of 12,649 patients was 1.9%. The EF ≤20% (n = 248), EF 21% to 35% (n = 1,408), and EF >35 (n = 10,993) cohorts had mortality of 6.9%, 3.7%, and 1.6%, respectively. The EF ≤20% subgroup had higher use of cardiopulmonary bypass, blood products, and mechanical support. In addition, the EF ≤20% subgroup had higher complication rates in almost all measured categories. Also, the EF ≤20% cohort had significantly higher length of stay, intensive care unit (ICU) hours, ICU and hospital readmissions, and lowest discharge to home rate. The strongest factors associated with mortality were postoperative cardiac arrest, renal failure requiring dialysis, extracorporeal membrane oxygenation, sepsis, prolonged ventilation, and gastrointestinal event. The overall median direct cost of care was $37,387.79 ($27,605.18, $51,720.96), with a median direct cost of care in the EF ≤20%, EF 21% to 35%, and EF >35% subgroups of $52,500.17 ($34,103.52, $80,806.79), $44,108.32 ($31,597.58, $63,788.03), and $36,521.80 ($27,168.91, $50,019.31), respectively. CONCLUSIONS: In nonemergent isolated CABG surgery, low EF continues to have higher surgical risks and higher direct cost of care despite advances in cardiovascular care.

Cautionary tale of right ventricular perforation during Micra™ leadless pacemaker insertion.

Transcatheter pacing systems are self-contained, leadless, devices that offer the potential benefits of avoiding complications related to pectoral pocket and upper extremity vascular access. These systems in preapproval trials demonstrated excellent safety profile with the incidence of device-related cardiac perforation as low as 1.6% with Micra™ (Medtronic) and 1.3% in Nanostim (Abbott). In post-approval registry of Micra™ TPS, the rate of major complications was even lower than in the investigational study ranging from 0.63% to 0.77%. Recently, published report found much higher rates of need for rescue surgery, shock, tamponade, and death among patients implanted with the Micra™ device when compared with transvenous devices. This case report describes two cases of major right ventricular perforation requiring surgical intervention.

A New Cell Topology for 4H-SiC Planar Power MOSFETs for High-Frequency Switching.

A new cell topology named the dodecagonal (a polygon with twelve sides, short for Dod) cell is proposed to optimize the gate-to-drain capacitance (Cgd) and reduce the specific ON-resistance (Ron,sp) of 4H-SiC planar power MOSFETs. The Dod and the octagonal (Oct) cells are used in the layout design of the 650 V SiC MOSFETs in this work. The experimental results confirm that the Dod-cell MOSFET achieves a 2.2× lower Ron,sp, 2.1× smaller high-frequency figure of merit (HF-FOM), higher turn on/off dv/dt, and 29% less switching loss than the fabricated Oct-cell MOSFET. The results demonstrate that the Dod cell is an attractive candidate for high-frequency power applications.

Recent Developments in Blood-Compatible Superhydrophobic Surfaces.

Superhydrophobic surfaces, as indicated in the name, are highly hydrophobic and readily repel water. With contact angles greater than 150° and sliding angles less than 10°, water droplets flow easily and hardly wet these surfaces. Superhydrophobic materials and coatings have been drawing increasing attention in medical fields, especially on account of their promising applications in blood-contacting devices. Superhydrophobicity controls the interactions of cells with the surfaces and facilitates the flowing of blood or plasma without damaging blood cells. The antibiofouling effect of superhydrophobic surfaces resists adhesion of organic substances, including blood components and microorganisms. These attributes are critical to medical applications such as filter membranes, prosthetic heart valves, extracorporeal circuit tubing, and indwelling catheters. Researchers have developed various methods to fabricate blood-compatible or biocompatible superhydrophobic surfaces using different materials. In addition to being hydrophobic, these surfaces can also be antihemolytic, antithrombotic, antibacterial, and antibiofouling, making them ideal for clinical applications. In this review, the authors summarize recent developments of blood-compatible superhydrophobic surfaces, with a focus on methods and materials. The expectation of this review is that it will support the biomedical research field by providing current trends as well as future directions.

Peripheral access size evaluation in transfemoral transcatheter aortic valve replacement.

BACKGROUND/AIM: Peripheral access vessel dimensions in the general patient population screened for transcatheter aortic valve replacement (TAVR) can offer insight into the indications for pre-TAVR computed tomography angiography (CTA) assessment. We seek to determine peripheral access vessel sizes in patients screened for TAVR and association with patient characteristics. MATERIALS AND METHODS: All patients with severe, symptomatic aortic stenosis screened for TAVR at a high-volume center from April 2012 to March 2019 were retrospectively reviewed. For each patient, contrast-enhanced CTA was used to determine the minimal luminal diameters (MLDs) of the transfemoral access vessels, as measured between the inguinal ligament and the deep femoral artery for the femoral artery, and proximal to the inguinal ligament for the external and common iliac arteries, respectively. Paired and independent samples t-tests were used to compare means and regression analyses were performed to determine factors associated with MLD. RESULTS: A total of 1049 screened patients were included of which 826 (78.7%) underwent TAVR and 551 (52.5%) were male. The mean age was 80.6 (±9.6) years and the mean body mass index (BMI) was 26.7 (±5.9) kg/m2 . About 152 (14.5%) had peripheral vascular disease and 153 (14.6%) had chronic kidney disease. The mean (±2 standard deviations) MLDs of the right and left femoral arteries were 7.73 mm (4.68-10.78) and 7.68 mm (4.63-10.72), respectively. Male sex and BMI were associated with larger average femoral MLD while hyperlipidemia, hypertension, smoking, peripheral vascular disease, and coronary artery disease were inversely associated. CONCLUSION: Most patients screened for TAVR have minimum peripheral access vessel sizes exceeding the recommended minimum access route diameters of modern transcatheter heart valves. As sheath sizes decrease, clinicians must carefully judge patient individual risk factors to determine whether a pre-TAVR CTA assessing peripheral access vessel dimensions and anatomical contraindications is indicated. Larger studies and randomized controlled trials are required to compare the outcomes of TAVR with and without preoperative CTA.

Safety and Efficacy of the Amplatzer Septal Occluder: A Systematic Review and Meta-Analysis.

OBJECTIVES: To assess the safety and efficacy of the Amplatzer Septal Occluder in the closure of secundum type atrial septal defects. BACKGROUND: The Amplatzer Septal Occluder (ASO; Abbott, St. Paul, MN) is an FDA-approved device for percutaneous closure of secundum type atrial septal defects (ASD). Previous small cohort trials have shown a favorable safety and technical efficacy profile. METHODS: We conducted a systemic review and meta-analysis of all prospective case series and controlled trials that evaluated the ASO's safety and implant efficacy. The primary endpoint was the technical success rate of implantations. Secondary outcomes included proportions of arrhythmias and embolism specific-adverse events. RESULTS: We included a total of 12 studies with 2972 patients. The ratio of device implantation was 2:1 by sex [female: male]. Pooled technical success rate of implantation was 98% (95% CI: 0.968-0.990, P < 0.01). The cumulative adverse event rate was 5.1% (95% CI: 0.035-0.068, P < 0.01), which included arrhythmia and embolism specific adverse event rates of 1.8% (95% CI: 0.007-0.032, P < 0.01) and 0.7% (95% CI: 0.002-0.013, P < 0.01), respectively. Sensitivity analysis did not significantly affect pooled outcomes for success rate and adverse events; both forest plot and Begg's and Egger's regression tests supported symmetricity. CONCLUSION: A high likelihood of technical success can be expected when implanting the ASO in secundum type ASDs. Adverse event rates are expected for one in twenty patients, and thus, our results support the safe use of ASO in secundum type ASDs closure. CONDENSED ABSTRACT: The AMPLATZER Septal Occluder is an FDA-approved device for percutaneous closure of secundum type atrial septal defects (ASD). We conducted a systemic review and meta-analysis of all prospective case series and controlled trials that evaluated the ASO's safety and implant efficacy. We included a total of 12 studies with 2972 patients. Pooled technical success rate of implantation was 98% (P < 0.01). The cumulative adverse event rate was 5.1% (P < 0.01), 1.8% (P < 0.01) rate of arrhythmias, and 0.7% (P < 0.01) rate of embolisms. A high likelihood of technical success can be expected with a low rate of adverse events.

Alternate accesses for transcatheter aortic valve replacement: A network meta-analysis.

BACKGROUND: When transfemoral (TF) access is contraindicated in patients undergoing transcatheter aortic valve replacement (TAVR), alternate access strategies are considered. The choice of one alternate access over the other remains controversial. METHODS: Following a comprehensive literature search, studies comparing any combination of TF, transapical (TA), transaortic (TAo), transcarotid (TC), and trans-subclavian (TS) TAVR were identified. Data were pooled using fixed- and random-effects network meta-analysis. Rank scores with probability ranks of different treatment groups were calculated. RESULTS: Eighty-four studies (26,449 patients) were included. Compared to TF access, TA and TAo accesses were associated with higher 30-day mortality (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.31-1.94; OR 1.79, 95% CI 1.21-2.66, respectively), while the TC and TS showed no difference (OR 1.12, 95% CI 0.64-1.95; OR 1.23, 95% CI 0.67-2.27, respectively); TF access ranked best followed by TC. There was no significant difference in 30-day stroke; TC access ranked best followed by TS. At a weighted mean follow-up of 1.6 years, TA and TAo accesses were associated with higher long-term mortality versus TF (incidence rate ratio [IRR] 1.31, 95% CI 1.18-1.45; IRR 1.41, 95% CI 1.11-1.79, respectively); there was no difference between TC and TS versus TF access (IRR 1.02, 95% CI 0.70-1.47; IRR 1.16, 95% CI 0.82-1.66, respectively); TF access ranked best followed by TC. At a weighted mean follow-up of 1.4 years, only TA access was associated with higher long-term stroke compared to TF (IRR 3.01, 95% CI 1.15-7.87); TF access ranked as the best strategy followed by TAo. CONCLUSION: TC and TS approaches are associated with superior postoperative outcomes compared to other TAVR alternate access strategies. Randomized trials definitively assessing the safety and efficacy of alternate access strategies are needed.

Characteristics, management, and outcomes among admissions for primary cardiac tumors: Results from the National Inpatient Sample.

INTRODUCTION: Primary cardiac tumors (PCT) are rare, and their contemporary outcomes are not well characterized in the literature. We assessed temporal trends in patient characteristics and management of admissions for PCT in US hospitals. METHODS: Admissions with the principal diagnoses of a PCT (benign neoplasm of heart: ICD-9 212.7, ICD-10 D15.1; malignant neoplasm of heart: ICD-9 164.1, ICD-10 C38.0) between 2006 and 2017 were extracted from the National Inpatient Sample. Trends in demographics and clinical profiles were evaluated. We conducted descriptive analyses on the cohort and compared outcomes between those managed medically and surgically. RESULTS: Between 2006 and 2017, 19,111 admissions had the primary diagnosis of a PCT. Of these, 91.1% were benign. Admissions were mostly female (65.0%), caucasian (72.0%), and aged more than 50 years (76.0%). The annual admission rate for PCT was similar from 2006 to 2017 (p trend > .05) and associated with congestive heart failure, diabetes, renal failure, and valvular lesions. PCTs were managed surgically in 12,811 (67.0%) of overall cases, 70.8% for benign and 28.3% for malignant tumors. Overall, the in-hospital mortality rate was 2.3%. Medically managed cases reported a 2.5% higher mortality (p < .001) than those surgically managed. Admissions with malignant tumors were more likely to expire during hospitalization than those with benign tumors (odds ratio, 9.75; 95% confidence interval 6.34-14.99; p < .001). CONCLUSION: Admissions for primary cardiac tumors were primarily women or in their fifth or sixth decade of life. Surgical intervention is more commonly practiced and is associated with better in-hospital survival.

Trends in the utilization and reimbursement of coronary revascularization in the United States Medicare population from 2010 to 2018.

OBJECTIVE: To determine utilization and reimbursement trends of coronary revascularization procedures in the US Medicare population from 2000 to 2018. BACKGROUND: US Medicare population is increasing, and coronary revascularization decreased in the 2000s. METHODS: This is a population-based, cross sectional study of US Medicare beneficiaries from 2010 to 2018. The Centers for Medicare and Medicaid Services' database was queried for revascularization procedures using the coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) current procedural terminology (CPT) codes. Trends in Medicare enrollees, PCIs, CABGs, and physician reimbursements were analyzed. RESULTS: Total utilization and reimbursement decreased for both revascularization procedures. The national CABG and PCI utilization per enrollee has decreased by 40.7% (best fit line: b coefficient, 95% CI; -0.297, -0.358 to -0.235) and 26.4% (best fit line: -0.229, -0.373 to -0.0858), respectively. For CABG, annual Medicare payout per enrollee and physician compensation per procedure has decreased by 49.3% (best fit line: -0.250, -0.315 to -0.185) and 14.5% (best fit line: -11.54, -15.62 to -7.452), respectively, and for PCI, decreased by 53.3% (best fit line: -0.373, -0.560 to -0.186) and 36.6% (best fit line: -34.15, -49.35 to -18.95), respectively. Amongst the states, there was significant variability in procedure utilization, and CABG reimbursement rates but minimal variability in PCI reimbursement rates. CONCLUSION: Even though the US population has aged, revascularization utilization and reimbursement continue to decline. Advancement in medical intervention strategies, particularly non-surgical management, may account for these trends. Further understanding of these trends will allow health systems to tailor resources to the aging population.

Intravascular Lithotripsy Enabled Transfemoral Transcatheter Aortic Valve Implantation via Percutaneous Axillary Access Approach.

Transfemoral (TF) access for transcatheter aortic valve implantation (TAVI) is the most commonly used site, however its use may be limited by prohibitive peripheral arterial disease. Although a number of alternative access techniques have been well described, each has been shown to be associated with increased risks when compared to a TF approach. Recently, planned treatment of iliofemoral artery disease using intravascular lithotripsy (IVL) has emerged as a means of preserving TF access. Ipsilateral or contralateral femoral artery access has been routinely used to perform IVL but its use may be limited in certain conditions. Here we describe the novel technique of using percutaneous axillary artery access to perform IVL of iliofemoral artery to facilitate its use for large bore access. We present a 78-year-old high surgical risk female with severe aortic stenosis who was found to have a prior stent in the contralateral iliac artery protruding into the aorta which limited a traditional 'up and over' approach, and thus axillary artery access was used to perform IVL. This is the first case in literature to describe the use of percutaneous axillary access to perform IVL of the iliac and common femoral artery to facilitate TF TAVI. Based on our previous experience we feel this technique holds promise for a routine use when use of other access sites is limited.

Meta-Analysis of the Effect of Vascular Complications on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has become an accepted treatment modality in the management of select patients with cardiopulmonary failure. As a result, its use has increased significantly over the past decade. However, the effect of complications on mortality is not clearly established. We performed a comprehensive, up-to-date meta-analysis of peer-reviewed literature focusing on the effect of vascular complications (VCs) on the survival of patients receiving venoarterial ECMO (VA-ECMO) with femoral cannulation. METHODS: A systematic search of 4 different databases (PubMed, Embase, Scopus, and Web of Science) was conducted from their inception to mid-September of 2019. To keep the pooled analysis current, only studies published within the past 5 years were included. Mortality was analyzed based on presence or absence of VCs. Studies with less then 10 patients, with incomplete mortality data, and not accessible in the English language were excluded. RESULTS: Ten studies were included in the analysis encompassing 1,643 patients over a 5-year period. There were 369 patients with a cumulative VC rate of 22.5% (range 9.4 to 43.9%). The pooled mortality rate for patients with and without VCs was 69.6% and 56.8%, respectively. Meta-analysis demonstrated a significant correlation between VCs and mortality with a relative risk (RR) of 1.36 (95% confidence interval (CI), 1.15-1.60; P = 0.0004). Covariate-adjusted meta-regression analysis revealed an inverse relationship between age and mortality for VCs, with an RR of 1.33 (95% CI, 1.15-1.54; P = 0.0184), and direct relationship between female gender and mortality from VCs, RR 1.39 (95% CI, 1.21-1.59; P = 0.0165). CONCLUSIONS: The most recently available data published in the literature demonstrate a significant correlation of VCs with mortality. Therefore, aggressive attempts should be made to minimize VCs in patients with femoral VA-ECMO cannulation.

Impact of Operator Characteristics on Outcomes in Transcatheter Aortic Valve Replacement.

BACKGROUND: Operator characteristics and outcome relationships have not been evaluated at the individual operator level. METHODS: From New York State Department of Health Statewide Planning and Research Cooperative System, 5896 elective transfemoral transcatheter aortic valve replacement (TAVR) procedures performed by 161 operators between 2012 and 2016 were analyzed. We examined the following characteristics of the primary operator: specialty (surgery vs cardiology), sex, medical school location, experience of cardiology practice, interventional cardiology credentialing, past-year TAVR volume, and first year performing TAVR in New York State. The primary outcome was a composite of inhospital mortality, stroke, and acute myocardial infarction. RESULTS: After adjusting for patient and other provider characteristics, there was no significant difference in the risk of major events between surgeons and cardiologists in performing TAVR (3.4% vs 3.6%, P = .60), between male operators and female operators (P = .80), and between operators who graduated from a US medical school and operators educated outside the United States (3.4% vs 3.6%, P = .73). In the subgroup analysis, interventional cardiology credentialing was not significantly associated with the inhospital major events (odds ratio 1.03; 95% confidence interval, 0.56 to 1.88; P = .80). CONCLUSIONS: Primary operator specialty and other characteristics for TAVR were not associated with a difference in risk-adjusted inhospital outcomes. That may be due to the heart team model that allows proceduralists of different backgrounds to lend their expertise to the procedure.

Valve-in-Valve Transcatheter Aortic Valve Replacement: A Review of Procedural Details, Safety, and Clinical Implications.

Bioprosthetic valves are increasingly being used to treat young patients needing surgical intervention. The rising number of young patients undergoing bioprosthesis implantation also means that many of these patients will ultimately require reintervention due to the deteriorative nature of these valves. Recently, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has become the preferred procedure to treat high-risk patients requiring repeat surgical aortic valve replacement. Despite being less invasive, ViV TAVR is accompanied by risks, including coronary obstruction, valvular thrombosis, and postoperative residual gradients. Furthermore, there are limited long-term data on ViV TAVR detailing prognosis, and operators often rely on anecdotal experience and personal judgment for clinical decision-making. In this article, we review the procedural details, safety, and clinical implications of ViV TAVR.

Prioritizing elective cardiovascular procedures during the COVID-19 pandemic: The cardiovascular medically necessary, time-sensitive procedure scorecard.

BACKGROUND: Following the surge of the coronavirus disease 2019 (COVID-19) pandemic, government regulations, and recommendations from professional societies have conditioned the resumption of elective surgical and cardiovascular (CV) procedures on having strategies to prioritize cases because of concerns regarding the availability of sufficient resources and the risk of COVID-19 transmission. OBJECTIVES: We evaluated the use of a scoring system for standardized triage of elective CV procedures. METHODS: We retrospectively reviewed records of patients scheduled for elective CV procedures that were prioritized ad hoc to be either performed or deferred when New Jersey state orders limited the performance of elective procedures due to the COVID-19 pandemic. Patients in both groups were scored using our proposed CV medically necessary, time-sensitive (MeNTS) procedure scorecard, designed to stratify procedures based on a composite measure of hospital resource utilization, risk of COVID-19 exposure, and time sensitivity. RESULTS: A total of 109 scheduled elective procedures were either deferred (n = 58) or performed (n = 51). The median and mean cumulative CV MeNTS scores for the group of performed cases were significantly lower than for the deferred group (26 (interquartile range (IQR) 22-31) vs. 33 (IQR 28-39), p < .001, and 26.4 (SE 0.34) vs. 32.9 (SE 0.35), p < .001, respectively). CONCLUSIONS: The CV MeNTS procedure score was able to stratify elective cases that were either performed or deferred using an ad hoc strategy. Our findings suggest that the CV MeNTS procedure scorecard may be useful for the fair triage of elective CV cases during the time when available capacity may be limited due to the COVID-19 pandemic.

Tricuspid Stenosis in Pregnancy: A Valve-in-Valve Conundrum.

Redo tricuspid valve replacement has high surgical operative mortality. Transcatheter valve-in-valve provides a viable option for valve replacement. We discuss the decision-making process involved in performing transcatheter tricuspid valve-in-valve replacement in a 23-week pregnant woman with multiple comorbidities and symptomatic severe bioprosthetic stenosis. (Level of Difficulty: Intermediate.).

Decrease in Hospital Admissions for Acute Surgical Conditions During the COVID-19 Pandemic.

MINI-ABSTRACT: The nature of emergency room admissions for acute surgical conditions changed during the COVID-19 pandemic with less admissions for potentially life threatening conditions.

Prognostic role of diastolic dysfunction in patients undergoing transcatheter aortic valve replacement.

OBJECTIVES: Prior studies have shown that left ventricular diastolic dysfunction (DD) is associated with increased mortality after surgical aortic valve replacement but studies on transcatheter aortic valve replacement (TAVR) are limited and have not taken into account mitral annular calcification (MAC), which limits the use of mitral valve annular tissue Doppler imaging. We performed a single-center retrospective analysis to better evaluate the role of baseline DD on outcomes after TAVR. METHODS: After excluding patients with atrial fibrillation, mitral valve prostheses and significant mitral stenosis, 359 consecutive TAVR patients were included in the study. Moderate-to-severe MAC was present in 58% of the patients. We classified patients into severe versus nonsevere DD based on the evaluation of elevated left ventricular filling pressure. The outcome measure was all-cause mortality or heart failure hospitalization. RESULTS: Over a mean follow-up time of 13 months, severe DD was associated with an increased risk for the outcome measure (HR 2.02 [1.23-3.30], p = .005). However, this association was lost in a propensity-matched cohort. In multivariate analysis, STS score was the only independent predictor of all cause mortality of heart failure hospitalization (HR 1.1 [1.05-1.15], p < .001). CONCLUSIONS: We evaluated the role of baseline DD on outcomes after TAVR by taking into account the presence of MAC. Severe DD was associated with increased all-cause mortality or heart failure hospitalization but not independently of other structural parameters and known predictors of the outcome measure.