Transcatheter Repair versus Mitral-Valve Surgery for Secondary Mitral Regurgitation.

BACKGROUND: Current treatment recommendations for patients with heart failure and secondary mitral regurgitation include transcatheter edge-to-edge repair and mitral-valve surgery. Data from randomized trials comparing these therapies are lacking in this patient population. METHODS: In this noninferiority trial conducted in Germany, patients with heart failure and secondary mitral regurgitation who continued to have symptoms despite guideline-directed medical therapy were randomly assigned, in a 1:1 ratio, to undergo either transcatheter edge-to-edge repair (intervention group) or surgical mitral-valve repair or replacement (surgery group). The primary efficacy end point was a composite of death, hospitalization for heart failure, mitral-valve reintervention, implantation of an assist device, or stroke within 1 year after the procedure. The primary safety end point was a composite of major adverse events within 30 days after the procedure. RESULTS: A total of 210 patients underwent randomization. The mean (±SD) age of the patients was 70.5±7.9 years, 39.9% were women, and the mean left ventricular ejection fraction was 43.0±11.7%. Within 1 year, at least one of the components of the primary efficacy end point occurred in 16 of the 96 patients with available data (16.7%) in the intervention group and in 20 of the 89 with available data (22.5%) in the surgery group (estimated mean difference, -6 percentage points; 95% confidence interval [CI], -17 to 6; P<0.001 for noninferiority). A primary safety end-point event occurred in 15 of the 101 patients with available data (14.9%) in the intervention group and in 51 of the 93 patients with available data (54.8%) in the surgery group (estimated mean difference, -40 percentage points; 95% CI, -51 to -27; P<0.001). CONCLUSIONS: Among patients with heart failure and secondary mitral regurgitation, transcatheter edge-to-edge repair was noninferior to mitral-valve surgery with respect to a composite of death, rehospitalization for heart failure, stroke, reintervention, or implantation of an assist device in the left ventricle at 1 year. (Funded by Abbott Vascular; MATTERHORN ClinicalTrials.gov number, NCT02371512.).

Epicardial fat volume is associated with primary coronary slow-flow phenomenon in patients with severe aortic stenosis undergoing transcatheter valve implantation.

BACKGROUND: Primary coronary slow flow (CSF) is defined as delayed opacification of the distal epicardial vasculature during coronary angiography in the absence of relevant coronary artery stenoses. Microvascular disease is thought to be the underlying cause of this pathology. Epicardial fat tissue (EFT) is an active endocrine organ directly surrounding the coronary arteries that provides pro-inflammatory factors to the adjacent tissue by paracrine and vasocrine mechanisms. The aim of the present study was to investigate a potential association between EFT and primary CSF and whether EFT can predict the presence of primary CSF. METHODS: Between 2016 and 2017, n = 88 patients with high-grade aortic stenosis who were planned for transcatheter aortic valve implantation (TAVI) were included in this retrospective study. EFT volume was measured by pre-TAVI computed tomography (CT) using dedicated software. The presence of primary CSF was defined based on the TIMI frame count from the pre-TAVI coronary angiograms. RESULTS: Thirty-nine of 88 TAVI patients had CSF (44.3%). EFT volume was markedly higher in patients with CSF (142 ml [IQR 107-180] vs. 113 ml [IQR 89-147]; p = 0.009) and was strongly associated with the presence of CSF (OR 1.012 [95%CI 1.002-1.021]; p = 0.014). After adjustment, EFT volume was still an independent predictor of CSF (OR 1.016 [95%CI 1.004-1.026]; p = 0.009). CONCLUSION: Primary CSF was independently associated with increased EFT volume. Further studies are needed to validate this finding and elucidate whether a causal relationship exists.

Regional extracellular volume within late gadolinium enhancement-positive myocardium to differentiate cardiac sarcoidosis from myocarditis of other etiology: a cardiovascular magnetic resonance study.

BACKGROUND: Cardiovascular magnetic resonance (CMR) plays a pivotal role in diagnosing myocardial inflammation. In addition to late gadolinium enhancement (LGE), native T1 and T2 mapping as well as extracellular volume (ECV) are essential tools for tissue characterization. However, the differentiation of cardiac sarcoidosis (CS) from myocarditis of other etiology can be challenging. Positron-emission tomography-computed tomography (PET-CT) regularly shows the highest Fluordesoxyglucose (FDG) uptake in LGE positive regions. It was therefore the aim of this study to investigate, whether native T1, T2, and ECV measurements within LGE regions can improve the differentiation of CS and myocarditis compared with using global native T1, T2, and ECV values alone. METHODS: PET/CT confirmed CS patients and myocarditis patients (both acute and chronic) from a prospective registry were compared with respect to regional native T1, T2, and ECV. Acute and chronic myocarditis were defined based on the 2013 European Society of Cardiology position paper on myocarditis. All parametric measures and ECV were acquired in standard fashion on three short-axis slices according to the ConSept study for global values and within PET-CT positive regions of LGE. RESULTS: Between 2017 and 2020, 33 patients with CS and 73 chronic and 35 acute myocarditis patients were identified. The mean ECV (± SD) in LGE regions of CS patients was higher than in myocarditis patients (CS vs. acute and chronic, respectively: 0.65 ± 0.12 vs. 0.45 ± 0.13 and 0.47 ± 0.1; p < 0.001). Acute and chronic myocarditis patients had higher global native T1 values (1157 ± 54 ms vs. 1196 ± 63 ms vs. 1215 ± 74 ms; p = 0.001). There was no difference in global T2 and ECV values between CS and acute or chronic myocarditis patients. CONCLUSION: This is the first study to show that the calculation of regional ECV within LGE-positive regions may help to differentiate CS from myocarditis. Further studies are warranted to corroborate these findings.

Prognostic impact of echocardiographic mean transvalvular gradients in patients with aortic stenosis and low flow undergoing transcatheter aortic valve implantation.

BACKGROUND: Blunted left ventricular hemodynamics reflected by a low stroke volume index (SVI) ≤35 mL/m2 body surface area (low flow [LF]) in patients with severe aortic stenosis (AS) are associated with worse outcomes even after correction of afterload by transcatheter aortic valve implantation (TAVI). These patients can have a low or high transvalvular mean pressure gradient (MPG). We investigated the impact of the pre-interventional MPG on outcomes after TAVI. METHODS: Patients with LF AS were classified into those with normal (EF ≥ 50%; LF/NEF) or reduced ejection fraction (EF < 50%; LF/REF) and were then stratified according to an MPG < or ≥ 40 mmHg. Patients with SVI >35 mL/m2 (normal flow; NF) served as controls. RESULTS: 597 patients with LF/NEF, 264 patients with LF/REF and 975 patients with NF were identified. Among all groups those patients with a low MPG were characterized by higher cardiovascular risk. In patients with LF/REF, functional improvement post-TAVI was less pronounced in low-MPG patients. One-year survival was significantly worse in LF AS patients with a low vs. high MPG (LF/NEF 16.5% vs. 10.5%, p = 0.022; LF/REF 25.4% vs. 8.0%, p = 0.002), whereas no differences were found in NF patients (8.7% vs. 10.0%, p = 0.550). In both LF AS groups, a low pre-procedural MPG emerged as an independent predictor of mortality. CONCLUSIONS: In patients with LF AS, an MPG cut-off of 40 mmHg defines two patient populations with fundamental differences in outcomes after TAVI. Patients with LF AS and a high MPG have the same favorable prognosis as patients with NF AS.

Does the severity of low-gradient aortic stenosis classified by computed tomography-derived aortic valve calcification determine the outcome of patients after transcatheter aortic valve implantation (TAVI)?

OBJECTIVES: Aortic valve calcification (AVC) determined by computed tomography has emerged as a complementary measure of aortic stenosis (AS) severity and as a predictor of adverse events. Thus, AVC can guide further treatment decisions in patients with low-gradient AS (LG-AS). We compared the symptomatic and prognostic outcome of patients with low vs. high AVC after transcatheter aortic valve implantation (TAVI). METHODS: Patients with an aortic valve area index ≤ 0.6 cm2/m2 and a mean pressure gradient (MPG) < 40 mmHg were classified as low-flow, low-gradient AS (LFLG-AS; stroke volume index [SVI] ≤ 35 ml/m2, left ventricular ejection fraction [LVEF] < 50%, n = 173), paradoxical LFLG-AS (pLFLG-AS, SVI ≤ 35 ml/m2, LVEF ≥ 50%, n = 233), or normal-flow, low-gradient AS (NFLG-AS, SVI > 35 ml/m2, LVEF ≥ 50%, n = 244); patients with MPG ≥ 40 mmHg (n = 1142) served as controls. Patients were further categorized according to published AVC thresholds. RESULTS: Demographic characteristics and cardiovascular risk were not different between patients with high vs. low AVC in any of the subgroups. Patients with low AVC had a lower MPG. Symptom improvement at 30 days was observed in the majority of patients but was less pronounced in LFLG-AS patients with low vs. those with high AVC. Kaplan-Meier 1-year survival curves were identical between patients with low and high AVC in all three LG-AS groups. CONCLUSIONS: The severity of LG-AS based on AVC has no impact on 1-year prognosis once TAVI has been performed. KEY POINTS: • Aortic valve calcification (AVC) determined by computed tomography has emerged as a complementary measure of aortic stenosis (AS) severity and is of prognostic value in selected patients. • Patients with inconsistent echocardiographic measures can be classified as having severe or nonsevere AS by the computed tomography-derived AVC score. • The prognostic value of AVC in patients with low-gradient AS is abrogated after correction of afterload by TAVI.

Effects of Statins After Transcatheter Aortic Valve Implantation in Key Patient Populations.

ABSTRACT: Statin therapy after transcatheter aortic valve replacement (TAVI) is associated with better short-term and long-term outcomes. It is of interest to identify specific patient populations that may profit from statin therapy. In this retrospective, observational analysis of 2862 patients with symptomatic aortic stenosis after successful transfemoral TAVI, survival during a three-year observation period was characterized by Kaplan-Meier analyses according to statin therapy. Hazard ratios and potential interactions for specific subgroups of patients were determined by Cox regression analyses. At hospital discharge 1761 patients were on low-intensity or moderate-intensity statins, 246 patients were on high-intensity statins, and 855 patients did not take statins. Statin therapy adherence during the first 3 months post-TAVI was 91%. Mortality rates were 18.5%, 12.9%, and 6.9% for patients with no statin, low-intensity or moderate-intensity statins, and high-intensity statins (P < 0.001). Any statin therapy proved to be effective in patients in different classes of age, risk, and manifest cardiovascular disease and was independent of background medication. Statins were of particular benefit in high-risk patients with coronary artery disease [hazard ratio (HR) = 0.57], ejection fraction <40% (HR = 0.64), or low-flow low-gradient aortic stenosis (HR = 0.58) and showed additional benefit even in patients taking renin-angiotensin system blockers (HR = 0.74). Statins also reduced mortality in patients with malignant disease (HR = 0.47). Our analysis confirmed the beneficial effect of statins on survival after TAVI and documented this phenomenon in key patient subsets. The protective effect of statins in our study is consistent with the cardioprotective mechanisms but must be explained by other, yet undetermined pleiotropic effects of statins.

Prospective validation of an acoustic-based system for the detection of obstructive coronary artery disease in a high-prevalence population.

Recent guidelines recommend a risk-adjusted, non-invasive work-up in patients presenting with chest discomfort to exclude coronary artery disease (CAD). However, a risk-adjusted diagnostic approach remains challenging in clinical practice. An acoustic detection device for analyzing micro-bruits induced by stenosis-generated turbulence in the coronary circulation has shown potential for ruling out CAD in patients with low-to-intermediate likelihood. We examined the diagnostic value of this acoustic detection system in a high-prevalence cohort. In total, 226 patients scheduled for clinically indicated invasive coronary angiography (ICA) were prospectively enrolled at two centers and examined using a portable, acoustic detection system. The acoustic analysis was performed in double-blinded fashion prior to quantitative ICA and following percutaneous coronary intervention (PCI). An acoustic detection result (CAD score) was obtained in 94% of all patients. The mean baseline CAD score was 41.2 ± 11.9 in patients with obstructive CAD and 33.8 ± 13.4 in patients without obstructive CAD (p < 0.001). ROC analysis revealed an AUC of 0.661 (95% CI 0.584-0.737). Sensitivity was 97.6% (95% confidence interval (CI) 91.5-99.7%), specificity was 14.5% (CI 9.0-21.7%), negative predictive value was 90.5% (CI 69.6-98.8%), and positive predictive value was 41.7% (CI 34.6-49.0%). Following PCI, the mean CAD score decreased from 40.5 ± 11.2 to 38.3 ± 13.7 (p = 0.039). Using an acoustic detection device identified individuals with CAD in a high-prevalence cohort with high sensitivity but relatively low specificity. The negative predictive value was within the predicted range and may be of value for a fast rule-out of obstructive CAD even in a high-prevalence population.

Comparison of First-generation and Third-generation Dual-source Computed Tomography for Detecting Coronary Artery Disease in Patients Evaluated for Transcatheter Aortic Valve Replacement.

PURPOSE: This study compared image quality and evaluability of coronary artery disease (CAD) in routine preparatory imaging for transcatheter aortic valve replacement using 64-slice (first-generation) to 192-slice (third-generation) dual-source computed tomography(DSCT). MATERIALS AND METHODS: The CT data sets of 192 patients (122 women, median age 82 y) without severe renal dysfunction or known CAD were analyzed retrospectively. Half were examined using first-generation DSCT (June 2014 to February 2016) and the other half with third-generation DSCT (April 2016 to April 2017). Per protocol, contrast material (110 [110 to 120] vs. 70 [70 to 70] mL, P <0.001) and radiation dose of multiphasic retrospectively gated thoracic CT angiography (dose-length-product, 1001 [707 to 1312] vs. 727 [474 to 1369] mGy×cm, P <0.001) were significantly lower with third-generation DSCT. Significant CAD was defined as CAD-RADS ≥4 by CT. Invasive coronary angiography served as the reference standard (CAD is defined as ≥70% stenosis or fractional flow reserve ≤0.80). RESULTS: In comparison with first-generation DSCT, third-generation DSCT showed significantly better subjective (3 [interquartile range 2 to 3] vs. 4 [3 to 4.25] on a 5-point scale, P <0.001) and objective image quality (signal-to-noise ratio of left coronary artery 12.8 [9.9 to 16.4] vs. 15.2 [12.4 to 19.0], P <0.001). Accuracy (72.9% vs. 91.7%, P =0.001), specificity (59.7% vs. 88.3%, P <0.001), positive (61.0% vs. 83.3%, P <0.001), and negative predictive value (91.9% vs. 98.2%, P =0.045) for detecting CAD per-patient were significantly better using third-generation DSCT, while sensitivity was similar (92.3% vs. 97.2%, P =0.129). CONCLUSIONS: Coronary artery evaluation with CT angiography before TAVI is feasible in selected patients. Compared with first-generation DSCT, state-of-the-art third-generation DSCT technology is superior for this purpose, allowing for less contrast medium and radiation dose while providing better image quality and improved diagnostic performance.

Native T1 is predictive of cardiovascular death/heart failure events and all-cause mortality irrespective of the patient's volume status.

Background: Native T1 has become a pivotal parameter of tissue composition that is assessed by cardiac magnetic resonance (CMR). It characterizes diseased myocardium and can be used for prognosis estimation. Recent publications have shown that native T1 is influenced by short-term fluctuations of volume status due to hydration or hemodialysis. Methods: Patients from a prospective BioCVI all-comers clinical CMR registry were included, and native T1 and plasma volume status (PVS) were determined according to Hakim's formula as surrogate markers of patient volume status. The primary endpoint was defined as combined endpoint of cardiovascular death or hospitalization for heart failure events, the secondary endpoint was defined as all-cause mortality. Results: A total of 2,047 patients were included since April 2017 [median (IQR); age 63 (52-72) years, 33% female]. There was a significant although weak influence of PVS on native T1 (ß = 0.11, p < 0.0001). Patients with volume expansion (PVS > -13%) showed significantly higher values for tissue markers than non-volume-overloaded patients [PVS ≤ -13%; median (IQR); native T1 1,130 (1,095-1,170) vs. 1,123 (1,086-1,166) ms, p < 0.003; and T2 39 (37-40) vs. 38 (36-40) ms, p < 0.0001]. In Cox regression analysis both native T1 and PVS were independently predictive of the primary endpoint and all-cause mortality. Conclusion: Despite a weak effect of PVS on native T1, its predictive power was not affected in a large, all-comers cohort.

Cardiac decompensation of patients before transcatheter aortic valve implantation-clinical presentation, responsiveness to associated medication, and prognosis.

Aims: Cardiac decompensation (CD) in patients with aortic stenosis is a "red flag" for future adverse events. We classified patients undergoing transcatheter aortic valve implantation (TAVI) into those with acute, prior, or no prior CD at the timepoint of TAVI and compared their clinical presentation, prognosis, and effects of the prescribed medication during follow-up. Methods: Retrospective analysis of patients of one center fulfilling the criteria of 30-day device success after transfemoral TAVI. Results: From those patients with no CD (n = 1,985) ranging to those with prior CD (n = 497) and to those with acute CD (n = 87), we observed a stepwise increase in the proportion of patients in poor clinical condition, NYHA class III/IV, low psoas muscle area, fluid overload (rales, oedema, pleural effusion), reduced ejection fraction, renal insufficiency, and anemia. More diuretics but less renin-angiotensin system inhibitors (ACEI/ARB) were prescribed for patients with acute CD compared to other groups. Prior CD (hazard ratio and 95% CI 1.40; 1.02-1.91) and acute CD (1.72; 1.01-2.91), a reduced general condition (1.53; 1.06-2.20), fluid overload (1.54;1.14-2.08), atrial fibrillation (1.76; 1.32-2.33), and anemia (1.43;1.08-1.89) emerged as strong independent predictors of one-year mortality. In all three classes of CD, prescribing of ACEI/ARB was associated with a substantial improvement of survival. Conclusions: The clinical presentation of (acute or prior) cardiac decompensation in patients with AS overlapped substantially with that of patients with classical signs of heart failure. Our results may support an early treatment strategy in patients with left ventricular dysfuntion before clinical signs of congestion are manifest. Moreover, these patients require intensive medical attention after TAVI.

Native T2 Predicts Myocardial Inflammation Irrespective of a Patient's Volume Status.

Myocardial inflammation and edema are major pathological features in myocarditis. Myocardial tissue water content and myocardial edema can be quantified via T2 mapping. Thus, cardiac magnetic resonance (CMR) is the noninvasive gold standard for diagnosing myocarditis. Several studies showed an impact of short-term volume changes on T2 relaxation time. Plasma volume status (PVS) is a good surrogate parameter to quantify a patient's volume status, and it is simple to use. The aim of this study was to determine the effect of PVS on the diagnostic value of T2 relaxation time in myocardial inflammation. Between April 2017 and December 2022, patients who were indicated for cardiac CMR were included in our prospective clinical registry. Patients with myocardial inflammation and those with unremarkable findings were analyzed in the present study. A blood sample was drawn, and PVS was calculated. Patients were separated into PVS tertiles to explore a possible nonlinear dose-response relationship. Logistic regression analysis was used to determine whether T2 is an independent predictor of myocardial inflammation. A total of 700 patients (47.43% female) were eligible for analysis. Of these, 551 patients were healthy (78.7%), while 149 (21.3%) showed signs of myocardial inflammation. The T2 relaxation time was elevated in patients with myocardial inflammation (40 ms [IQR 37-42 ms] vs. 38.0 ms [IQR 36-39 ms], p < 0.001). PVS showed no difference between the groups (-12.94 [IQR -18.4--7.28] vs.-12.19 [IQR -18.93--5.87], p = 0.384). T2 showed a clear dose-response relationship with PVS, with increasing T2 values along the PVS tertiles. In spite of this, T2 was found to be an independent marker of myocardial inflammation in logistic regression (OR T2 1.3 [95% CI 1.21-1.39], p < 0.001), even after adjusting for PVS (OR T2 [adj. PVS] 1.31 [95% CI 1.22-1.40], p < 0.001). Despite a dose-response relationship between T2 and the volume status, T2 was found to be an independent indicator of myocardial inflammation.

Outcomes After Early Postoperative Myocardial Infarction Due to Graft Failure in Patients Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: Early graft failure (EGF) after coronary artery bypass grafting (CABG) occurs in up to 12% of grafts, but is often clinically unapparent. EGF may result in perioperative myocardial infarction with consequently increased mortality. The aim of the present study was to analyze the incidence of clinically apparent EGF in patients undergoing CABG and the influence on mortality. METHODS: We analyzed outcomes of consecutive patients undergoing CABG from January 2015 to December 2018 with respect to postoperative emergency coronary angiography (CAG) due to suspected EGF and 30-day mortality. Patients with CAG-documented EGF were matched to patients without EGF to examine predictors of mortality. RESULTS: The analysis included 5638 patients undergoing CABG. Eighty-six patients (1.5%) underwent emergency CAG due to suspected EGF. Clinically apparent EGF was observed in 61 of these patients (70.9%), whereas 14 (16.3%) had a culprit lesion in a native coronary artery. The majority of patients (n = 45; 52.3%) were treated with percutaneous coronary intervention and 31 (36%) underwent re-do CABG. The remaining patients were treated conservatively. The 30-day mortality rate of suspected EGF patients undergoing CAG was 22.4% (n = 19), which was higher than the mortality rate of 2.8% overall (P<.001); this remained higher after matching the EGF patients with the control group (11 [20.4%] vs 2 [4.0%]; P=.02). CONCLUSION: Emergency CAG after CABG is rare and is primarily carried out in patients with EGF. The 30-day mortality rate of these patients is high, and EGF is an independent predictor of mortality. Perioperative CAG with subsequent treatment is mandatory in these patients.

Incidence and predictors of hemodynamic compromise due to high-grade AV block after TAVI.

Background: High-grade AV block (HAVB) is the most frequent adverse event after transcatheter aortic valve implantation (TAVI). In rare cases, HAVB is associated with hemodynamic compromise (HC) followed by syncope or application of cardiopulmonary resuscitation (CPR), but data on this severe complication are scarce. The aim of the present study was to investigate the incidence and predictors of HC due to HAVB in patients undergoing TAVI. Methods: In this retrospective analysis of 4,602 TAVI cases between 2010 and 2022, 466 developed HAVB. Baseline characteristics and procedural and postprocedural findings were compared for patients with HC versus those without. Univariate and multivariable regression analyses were used to investigate independent predictors of HC. Results: Forty-nine of 466 patients (10.5%) had HC due to HAVB after TAVI. Patients with HC had a longer hospital stay [10 (8-13) vs. 13 (9-18) days; p < 0.001], more frequent peripheral artery disease (PAD) (28.6% vs. 15.1%; p = 0.016), and lower hemoglobin levels [11.8 (±) vs. 12.5 (±) g/dl; p = 0.006]. In the HC group, HAVB onset post-TAVI was delayed compared with the non-HC group [2 (1-4) vs. 1 (0-3) days; p < 0.001]. Before HAVB onset, patients in the HC group more frequently developed post-TAVI delirium [18 (4.6%) vs. 11 (25.0%); p < 0.001]. In univariate regression analysis, PAD, hemoglobin, procedural time, contrast agent volume, and post-TAVI delirium were significant predictors of HC. After adjustment, only post-TAVI delirium and contrast agent volume remained independent predictors [OR 3.22 (95% CI: 1.05-9.89); p = 0.042 and OR: 1.01 (95% CI: 1.0-1.01); p = 0.04, respectively]. Conclusion: HC due to HAVB after TAVI occurred in over 10% of cases. Development of post-TAVI delirium and contrast agent volume are independent predictors of this severe complication.

Microvascular dysfunction and pulse wave reflection characterize different vascular pathologies in patients at cardiovascular risk.

BACKGROUND: Endothelial function and arterial pulse wave reflections play a crucial role in the pathogenesis of atherosclerosis. While the endothelium-dependent reactive hyperemia index (RHI) of the digital arteries is considered as a marker of microvascular function, an increased augmentation index (AI) may indicate beginning macrovascular damage. In this study we assessed the interrelationships among these noninvasive measures of vascular function. PATIENTS AND METHODS: In 178 all-comer patients with documented cardiovascular risk factors (22 % female; 65 % coronary artery disease, CAD), we measured radial AI (rAI) by radial applanation tonometry and digital AI (dAI) as well as RHI by using fingertip peripheral arterial tonometry. A modified SMART risk score was calculated in all participants based on cardiovascular risk factors and preexisting vascular disease. RESULTS: dAI and rAI demonstrated a significant and robust overall correlation (Pearson rank coefficient r = 0.63, p < 0.01), which was not affected by age, sex, diabetes mellitus and CAD. In contrast, both parameters demonstrated at most a weak correlation (dAI: r = 0.26, p < 0.01 and rAI: r = 0.12, p = 0.10) with microvascular function (RHI). While dAI and rAI were significantly correlated to female sex, age, low body height, low heart rate and the presence of CAD, RHI was associated with the presence of diabetes mellitus and nicotine use. Finally, only microvascular function was associated with the modified SMART risk score, but not augmentation indices. CONCLUSIONS: RHI and increased pulse wave reflection appear to represent two distinct vascular pathologies in patients with cardiovascular risk. In contrast, RHI might be useful to identify patients at highest cardiovascular risk once atherosclerotic disease has been diagnosed.

Micro-dislodgement of a self-expanding transcatheter heart valve: Incidence, predictors, and outcomes.

OBJECTIVES: Malpositioning of transcatheter heart valves increases the risk of procedural failure. For the ACURATE system, inadvertent movement of the prosthesis to a varying extent is sometimes observed upon full release, but the incidence, mechanisms, and clinical impact of such valve micro-dislodgement (VMD) are poorly understood. The aim of the present study was to assess the incidence, predictors, and clinical outcomes of VMD in an all-comers population that underwent transcatheter aortic valve implantation (TAVI) with the ACURATE neo2 prosthesis (NEO2). METHODS: This was a retrospective analysis of 448 consecutive patients who underwent transfemoral TAVI with NEO2 at our institution. VMD was defined as displacement ≥2 mm between the initial position and immediately after valve release as measured on fluoroscopy at the non-coronary cusp. The initial valve position prior to step 2 was categorized using the radiopaque marker band (RMB) relative to the annular plane. In addition, further anatomical and procedural characteristics were assessed. RESULTS: A total of 68 (15.2%) cases with VMD were identified. A larger cover index, higher RMB position, partial detachment of the lower crown, and severe parallax prior to deployment were independent predictors of VMD, whereas a position of the delivery system in the outer curvature was protective against VMD. Among patients with VMD, the rates of valvular malpositioning and thus technical failure (VARC-3) were higher, but mean transprosthetic gradients were lower. CONCLUSIONS: VMD occurs in a notable proportion of transfemoral TAVI cases with NEO2 and is associated with more frequent technical failure of the procedure.

Evaluation of Patients for Percutaneous Edge-to-edge Mitral Valve Repair: Comparison of Cardiac Computed Tomography Angiography With Transesophageal Echocardiography.

PURPOSE: We sought to compare parameters derived from cardiac computed tomography angiography (CCTA) with those from transesophageal echocardiography (TEE) for the evaluation of patients with severe mitral regurgitation (MR) before percutaneous edge-to-edge mitral valve repair (PE2E). TEE is the mainstay for PE2E, although it has specific limitations. CCTA enables measurements in any arbitrary plane with high spatial resolution and offers good calcium visibility. MATERIALS AND METHODS: Patients who underwent TEE and CCTA before scheduled PE2E at 2 medical centers were included in this retrospective analysis. Quantitative parameters relevant for PE2E were obtained from TEE and CCTA in a blinded manner and the intrareviewer variability was assessed. RESULTS: All 30 patients (15 female, 76±10 y) had secondary MR attributable to ischemic (60%) or nonischemic cardiomyopathy (40%). On comparing parameters from TEE and CCTA, left ventricular end-diastolic diameter was 60±11 versus 64±11 mm (r=0.90), intercommissural mitral annulus was 35±5 versus 35±5 mm (r=0.88), long-axis annulus was 33±5 versus 33±5 mm (r=0.74), the distance between the fossa ovalis and the leaflet coaptation was 42±5 versus 41±5 mm (r=0.81), the anterior mitral leaflet was 21±6 versus 20±7 mm (r=0.81), the posterior mitral leaflet was 13±2 versus 13±2 mm (r=0.91), and the median mitral calcification was 1 (interquartile range: 0 to 2) versus 0 (interquartile range: 0 to 1; r=0.53), respectively. Intrareviewer agreement was good and excellent for continuous and categorical variables, respectively. CONCLUSIONS: Our data suggest that evaluation of the mitral valve apparatus with CCTA in patients considered for PE2E is feasible, correlates well with TEE, and offers improved calcium visibility. In selected cases, additional information from CCTA may be helpful for achieving optimal interventional results.

Presepsin predicts 1-year all-cause mortality better than N-terminal pro-B-type natriuretic peptide in patients undergoing transcatheter aortic valve implantation.

Aim: Presepsin is a sensitive biomarker for the diagnosis and estimation of prognosis in septic patients. The prognostic role of presepsin in patients undergoing transcatheter aortic valve implantation (TAVI) has never been investigated. Patients, materials & methods: In 343 patients, presepsin and N-terminal pro-B-type natriuretic peptide were measured before TAVI. One-year all-cause mortality was used as outcome measure. Results: Patients with high presepsin levels were more likely to succumb than patients with low presepsin values (16.9% vs 12.3%; p = 0.015). Elevated presepsin remained a significant predictor of 1-year all-cause mortality (odds ratio: 2.2 [95% CI: 1.12-4.29]; p = 0.022) after adjustment. N-terminal pro-B-type natriuretic peptide did not predict 1-year all-cause mortality. Conclusion: Elevated baseline presepsin levels are an independent predictor of 1-year mortality in TAVI patients.

Presepsin is a rather novel blood parameter that is most commonly used for the detection of severe infections. However, in patients without infections who are undergoing elective surgery, elevated baseline presepsin levels were also found to be associated with worse survival. In this study, researchers wanted to know whether increased presepsin levels can also predict worse survival in patients who are planned for transcatheter aortic valve implantation. To do so, they looked at the 1-year death rate of these patients and distinguished between low and high presepsin levels determined before the procedure. Patients with elevated presepsin levels before the procedure had a worse outcome after 1 year compared with those with low presepsin levels. Measurement of presepsin before the transcatheter aortic valve implantation procedure could help identify patients who are at a higher long-term risk, and accordingly a closer monitoring of these patients during the follow-up period might be warranted.

Right Ventricular Strain by Magnetic Resonance Feature Tracking Is Largely Afterload-Dependent and Does Not Reflect Contractility: Validation by Combined Volumetry and Invasive Pressure Tracings.

Cardiac magnetic resonance (CMR) is currently the gold standard for evaluating right ventricular (RV) function, which is critical in patients with pulmonary hypertension. CMR feature-tracking (FT) strain analysis has emerged as a technique to detect subtle changes. However, the dependence of RV strain on load is still a matter of debate. The aim of this study was to measure the afterload dependence of RV strain and to correlate it with surrogate markers of contractility in a cohort of patients with chronic thromboembolic pulmonary hypertension (CTEPH) under two different loading conditions before and after pulmonary endarterectomy (PEA). Between 2009 and 2022, 496 patients with 601 CMR examinations were retrospectively identified from our CTEPH cohort, and the results of 194 examinations with right heart catheterization within 24 h were available. The CMR FT strain (longitudinal (GLS) and circumferential (GCS)) was computed on steady-state free precession (SSFP) cine CMR sequences. The effective pulmonary arterial elastance (Ea) and RV chamber elastance (Ees) were approximated by dividing mean pulmonary arterial pressure by the indexed stroke volume or end-systolic volume, respectively. GLS and GCS correlated significantly with Ea and Ees/Ea in the overall cohort and individually before and after PEA. There was no general correlation with Ees; however, under high afterload, before PEA, Ees correlated significantly. The results show that RV GLS and GCS are highly afterload-dependent and reflect ventriculoarterial coupling. Ees was significantly correlated with strain only under high loading conditions, which probably reflects contractile adaptation to pulsatile load rather than contractility in general.

Effects of renin-angiotensin system inhibitor type and dosage on survival after transcatheter aortic valve implantation.

AIMS: The objective of the study was to determine the effect of renin-angiotensin system inhibitors (RASI) on the survival of subgroups of patients with aortic stenosis after transcatheter aortic valve implantation (TAVI) and to assess the impact of types and dosages of RASI on outcomes. METHODS AND RESULTS: This single-centre, retrospective analysis included 2862 patients (n = 2227 with RASI and n = 635 without RASI) after successful TAVI. Propensity score matching established comparable patient populations (n = 625 per group). Survival was analysed by Kaplan-Meier curves and Cox regression and was corrected for baseline, procedural, and medical parameters. Self-reported adherence to RASI therapy 3 months after hospital discharge was 94%. Three-year all-cause mortality rates were 12.3% and 20.2% for patients with or without RASI, respectively (log-rank <0.001). In the matched study populations, mortality rates were 14.2% vs. 20.0% (log-rank <0.03). RASI was particularly beneficial in patients with ejection fraction <40% [adjusted hazard ratio (HR) and 95% confidence interval 0.50 (0.29-0.87)], EuroScore II ≥4% [HR 0.47 (0.35-0.65)], or low-flow, low-gradient aortic stenosis [HR 0.53 (0.31-0.93)] who were also on beta-blockers and statins. An association between discharge dosage and survival was observed, with HR 0.75 (0.58-0.96) and 0.57 (0.44-0.72) for patients on <50% and ≥50% target dose, respectively. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) reduced mortality rates similarly (13.9% vs. 9.8%, log-rank 0.103). CONCLUSIONS: The beneficial association between RASI after TAVI and improved survival during follow-up is particularly evident in high-risk patients and may be dose dependent. No superiority was noted in the effectiveness of ACEI or ARB.

Exercise MR-proANP unmasks latent right heart failure in CTEPH.

OBJECTIVE: The present study was designed to investigate the dynamics of right atrial pressure (RAP) and mid-regional pro-atrial natriuretic peptide (MR-proANP) during physical exercise in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and to determine whether these parameters might serve as a tool to measure exercise-dependent atrial stress as an indicator of right heart failure. METHODS: This prospective observational cohort study included 100 CTEPH patients who underwent right heart catheterization during physical exercise (eRHC). Blood samples for MR-proANP measurement were taken prior, during, and after eRHC. MR-proANP levels were correlated to RAP levels at rest, at peak exercise (eRAP), and during recovery. RAP at rest ≤7 mmHg was defined as normal and eRAP >15 mmHg as suggestive of right heart failure. RESULTS: During eRHC mean RAP increased from 6 mmHg (standard deviation, SD 4) to 16 mmHg (SD 7; p < 0.001). MR-proANP levels and dynamics correlated with RAP at rest (rs = 0.61; p < 0.001) and at peak exercise (rs = 0.66; p < 0.001). Logistic regression analysis revealed the peak MR-proANP level (B = 0.058; p = 0.004) and the right atrial area (B = 0.389; p < 0.001) to be associated with eRAP dynamics. A peak MR-proANP level ≥139 pmol/L (AUC = 0.81) and recovery level ≥159 pmol/L (AUC = 0.82) predicted an eRAP >15 mmHg. Physical exercise unmasked right heart failure in 39% of patients with normal RAP at rest; these patients were also characterized by a more distinct increase in MR-proANP levels (p = 0.005) and higher peak (p < 0.001) and recovery levels (p < 0.001). CONCLUSIONS: RAP and MR-proANP dynamics unmask manifest and latent right heart failure in CTEPH patients.