Risk of Infective Endocarditis Associated with Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: A Propensity Score-Based Analysis.

Background: Infective endocarditis (IE) is a feared complication after surgical aortic valve replacement (SAVR)/transcatheter aortic valve implantation (TAVI). It is not certain which procedure carries a higher risk. Our aim was to assess the risk of IE after SAVR/TAVI. Methods: We conducted an observational study of a prospective cohort, including patients with TAVI/SAVR, from March 2015 to December 2020. IE was defined according to the modified Duke's criteria. IE occurring during the first 12 months of the procedure was considered early IE, and an episode occurring after 12 months was considered late IE. The propensity score was designed to include variables previously associated with TAVI/SAVR and IE. An inverse probability of treatment weight was generated. Results: In total, 355 SAVR and 278 TAVI were included. Median follow-up, 38 vs. 41 months, p = 0.550. IE occurred in 5 SAVR (1.41%, 95% CI 0.2−2.6) vs. 13 TAVI (4.65%, 95% CI 2.2−7.2), p = 0.016. TAVI patients had more frequent early IE (3.2% vs. 0.3%, p = 0.006). In the PS analyses, IE risk did not differ: OR 0.65, 95% CI 0.32−1.32. Factors associated with TAVI IE included younger age (74y vs. 83y, p = 0.030), complicated diabetes mellitus (38.5% vs. 6.8%, p = 0.002), COPD (46.2% vs. 16.3%, p = 0.015), advanced heart failure (100% vs. 52.9%, p < 0.001), and peripheral arteriopathy (61.5% vs. 26.7%, p = 0.011). Conclusions: Early IE was higher with TAVI, but in the PS analyses, the risk attributable to each procedure was similar. Studies are needed to identify and optimize the risk factors of IE prior to TAVI.

Endothelial dysfunction in patients with angina and non-obstructed coronary arteries is associated with an increased risk of mayor cardiovascular events. Results of the Spanish ENDOCOR registry.

BACKGROUND: Coronary endothelial dysfunction and vasospasm are potential causes of ischemia in patients without obstructive coronary stenoses (INOCA). OBJECTIVE: To evaluate the prevalence of endothelial dysfunction and the clinical profile of patients with INOCA in Spain, as well as to identify the predictors and the prognostic impact of endothelial dysfunction in this scenario. METHODS: A total of 438 consecutive patients with INOCA in whom the acetylcholine test was performed were prospectively enrolled. Patients were followed up at 1 and 2 years. RESULTS: Mean age was 62 ± 11 years with 60% female. Clinical presentation comprised 52.6% angina at rest, 61.2% exertional angina, and 31.7% dyspnea. There were no major complications of the acetylcholine test. Endothelial dysfunction was observed in 198 (45%) of patients, with severe vasoconstriction (defined as over 70% constriction), being observed in 101 (23%). Multivariable regression analysis showed that endothelial dysfunction was predicted by the presence of exertional angina (OR 2.2; CI95%1.01-2.55; p = 0.02), prior coronary disease (OR 2.46; CI95% 1.57-3.89; p < 0.01), and coronary intramyocardial bridging (2.35; CI95% 1.02-5.60; p = 0.04). Patients with endothelial dysfunction presented with worsening angina compared to those without endothelial dysfunction (25.6% vs. 12.8%) and also presented with increased levels of minimal effort angina (40% vs. 26,7%, p = 0.03) more frequently during the follow up than those without endothelial dysfunction. Endothelial dysfunction was also an independent predictor of the occurrence of myocardial infarction or unstable angina at one year (OR 2.85, CI 95% 1.01-9.25; p = 0.03). CONCLUSIONS: Endothelial dysfunction is present in almost half of patients with INOCA and is associated with worsening symptoms, as well as with a higher rate of adverse events.

Lack of Usefulness of Donor-Derived Cell-Free DNA as a Biomarker for Cardiac Allograft Vasculopathy: A Prospective Study.

Background: Cardiac allograft vasculopathy (CAV) remains a major cause of morbidity and mortality among long-term heart transplant recipients. There is an unmet need for a non-invasive biomarker of CAV that could obviate the need to perform surveillance coronary angiograms in these patients. Our aim was to evaluate the performance of Donor-derived Cell Free DNA (dd-cfDNA) as a biomarker of CAV. Methods: We prospectively measured dd-cfDNA levels in all patients undergoing routine coronary angiography >1 year after heart transplant at a single center. Endpoints included the association between dd-cfDNA levels and the presence CAV, according to several prespecified criteria. Results: We included 94 heart transplant recipients, a median of 10.9 years after transplant. Coronary angiogram revealed CAV0, CAV1, CAV2, and CAV3 in 61, 19, 14, and 6% of patients, respectively. Comparison of dd-cfDNA levels in patients with CAV0 and CAV1-2-3 (primary end-point) did not show significant differences (0.92%, IQR 0.46-2.0 vs. 0.46%, IQR 0.075-1.5, p = 0.059), nor did the comparison between patients with stable CAV (no new coronary lesions since previous angiogram, n = 77) and progressive CAV (n = 17); dd-cfDNA values 0.735% (IQR 0.195-2.0) vs. 0.9% (IQR 0.12-1.8), p = 0.76. However, we found an association between NTproBNP levels and CAV degree (p = 0.017). Dd-cfDNA levels did not correlate with NTproBNP (ρ = -0.095). Conclusion: In this study, dd-cfDNA did not perform as a useful biomarker to avoid surveillance coronary angiograms for CAV diagnosis. Clinical Trial Notation: Potential Role of Donor-derived Cell Free DNA as a Biomarker in Cardiac Allograft Vasculopathy, NCT04791852.

Transcatheter versus surgical aortic valve replacement in patients with morbid obesity: a multicentre propensity score-matched analysis.

BACKGROUND: Morbidly obese (MO) patients are increasingly undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS). However, the best therapeutic strategy for these patients remains a matter for debate. AIMS: Our aim was to compare the periprocedural and mid-term outcomes in MO patients undergoing TAVR versus SAVR. METHODS: A multicentre retrospective study including consecutive MO patients (body mass index ≥40 kg/m2, or ≥35 kg/m2 with obesity-related comorbidities) from 18 centres undergoing either TAVR (n=860) or biological SAVR (n=696) for severe AS was performed. Propensity score matching resulted in 362 pairs. RESULTS: After matching, periprocedural complications, including blood transfusion (14.1% versus 48.1%; p<0.001), stage 2-3 acute kidney injury (3.99% versus 10.1%; p=0.002), hospital-acquired pneumonia (1.7% versus 5.8%; p=0.005) and access site infection (1.5% versus 5.5%; p=0.013), were more common in the SAVR group, as was moderate to severe patient-prosthesis mismatch (PPM; 9.9% versus 39.4%; p<0.001). TAVR patients more frequently required permanent pacemaker implantation (14.4% versus 5.6%; p<0.001) and had higher rates of ≥moderate residual aortic regurgitation (3.3% versus 0%; p=0.001). SAVR was an independent predictor of moderate to severe PPM (hazard ratio [HR] 1.80, 95% confidence interval [CI]: 1.25-2.59; p=0.002), while TAVR was not. In-hospital mortality was not different between groups (3.9% for TAVR versus 6.1% for SAVR; p=0.171). Two-year outcomes (including all-cause and cardiovascular mortality, and readmissions) were similar in both groups (log-rank p>0.05 for all comparisons). Predictors of all-cause 2-year mortality differed between the groups; moderate to severe PPM was a predictor following SAVR (HR 1.78, 95% CI: 1.10-2.88; p=0.018) but not following TAVR (p=0.737). CONCLUSIONS: SAVR and TAVR offer similar mid-term outcomes in MO patients with severe AS, however, TAVR offers some advantages in terms of periprocedural morbidity.

Effect of Successful Edge-to-Edge Mitral Valve Repair on Ventricular Arrhythmic Burden in Patients With Functional Mitral Regurgitation and Implantable Cardiac Devices.

Significant mitral regurgitation (MR) may be present in up to half of patients with heart failure (HF) and it is associated with adverse cardiac remodeling and myocardial stretch. These are potential triggers for ventricular arrhythmias (VA) in patients with HF, and therefore MR may enhance electrical ventricular vulnerability. Our aim was to evaluate VA burden before and after percutaneous mitral valve repair (PMVR) in patients with implantable cardiac devices. We conducted a prospective registry of all consecutive patients (n = 34, age 69.0 ± 12.2 years, 77% male) with significant functional mitral regurgitation (FMR) who underwent MitraClip implantation in 2 centers between June 2014 and July 2018. VA burden was defined as the total number of events during device follow-up before and after PMVR. Among patients presenting VA during follow-up before or after PMVR, device success at hospital discharge was related to a significant reduction in the incidence of Nonsustained ventricular tachycardia (VT, p = 0.002) and any sustained VT or rapid VT/ventricular fibrillation (p = 0.034). Regarding implantable cardiac defibrillator (ICD) therapies, successful PMVR was related to a reduction in incidence of either antitachycardia pacing or appropriate shocks (p = 0.045) and in the occurrence of any defibrillation shocks (p = 0.045). Overall, effective repair lead to a significant reduction in the VA burden, with a significant decrease in the occurrence of any VA (p = 0.004) and any ICD therapies (p = 0.045). In conclusion, device success after PMVR was related to a reduction in overall arrhythmic burden and ICD therapies in our cohort.

Combined Percutaneous Treatment of Severe Triscuspid Regurgitation and Left Atrial Appendage Closure.

LAA closure and MitraClip implantation in the tricuspid position in the same procedure is a feasible and safe option in patients with a high surgical risk suffering from severe symptomatic tricuspid regurgitation and bleeding complications under anticoagulant therapy.