Prognostic relevance of mitral and tricuspid regurgitation after transcatheter aortic valve implantation: Impact of follow-up time point for decision-making.

Background: In patients with aortic stenosis treated by transcatheter aortic valve implantation (TAVI), mitral and tricuspid regurgitation (MR and TR) at baseline and after TAVI are likely to be of prognostic relevance, and questions such as whether and when treatment further improves prognosis in these patients arise. Aims: Against that background, the purpose of this study was to analyze a variety of clinical characteristics including MR and TR with respect to their potential value as predictors of 2-year mortality after TAVI. Methods: A cohort of 445 typical TAVI patients was available for the study and clinical characteristics were evaluated baseline, 6 to 8 weeks as well as 6 months after TAVI. Results: In 39% of the patients relevant (moderate or severe) MR and in 32% of the patients relevant (moderate or severe) TR could be detected at baseline. The rates were 27% for MR (p = 0.001, compared to baseline) and 35% for TR (p = n.s., compared to baseline) at the 6- to 8-week follow-up. After 6 months, relevant MR was observable in 28% (p = 0.036, compared to baseline) and relevant TR in 34% (p = n.s., compared to baseline) of the patients. As predictors of 2-year mortality, a multivariate analysis identified the following parameters for the different time points: sex, age, AS entity, atrial fibrillation, renal function, relevant TR, systolic pulmonary artery pressure (PAPsys), and 6-min walk distance at baseline; clinical frailty scale and PAPsys 6-8 weeks after TAVI and BNP and relevant MR 6 months after TAVI. There was a significantly worse 2-year survival in patients with relevant TR at baseline (68.4% vs. 82.6%, p < 0.001; whole population, n = 445) and in patients with relevant MR at 6 months (87.9% vs. 95.2%, p = 0.042; landmark analysis: n = 235). Conclusion: This real-life study demonstrated the prognostic relevance of repeated evaluation of MR and TR before and after TAVI. Choosing the right time point for treatment is a remaining clinical challenge, which should be further addressed in randomized trials.

[Acute heart failure and cardiogenic shock : An update]. / Akute Herzinsuffizienz und kardiogener Schock : Ein Update.

Acute heart failure is a clinical syndrome resulting from elevated intracardiac filling pressures and a systemic venous congestion. In general, patients can present acutely without a history of structural cardiac disease (de novo heart failure) or with acute worsening of a pre-existing dysfunction of the right or left ventricle. The patient population is overall very inhomogeneous and as a result there is also a distinct heterogeneity with respect to the underlying cardiac pathology that leads to the acute presentation. Ultimately, ventricular dysfunction leads to increased preload and afterload resulting in decreased perfusion and retrograde congestion. The forward failure (hypoperfusion) and backwards failure (systemic congestion) can lead to impaired end organ function or even organ failure resulting in cardiogenic shock, in which sufficient organ and tissue perfusion is no longer possible. Consequently, therapeutic strategies currently focus on rectification of the underlying cardiac dysfunction, reduction of volume overload (decongestion) and hemodynamic stabilization with drugs supporting the circulation in the case of a hypoperfusion syndrome. Despite numerous new therapeutic strategies within the last two decades, the empirical data based on randomized trials is considerably less solid than in chronic heart failure, which is expressed in the almost unchanged 1­year mortality of approximately 20-30%.

Depression and anxiety in elderly patients with severe symptomatic aortic stenosis persistently improves after transcatheter aortic valve replacement (TAVR).

INTRODUCTION: Data on the prevalence of depression and anxiety in elderly cardiovascular disease patients are limited and there are only few studies focussing on treatment effects. Thus, the current study aimed to analyse elderly patients suffering from aortic stenosis (AS) and undergoing transcatheter aortic valve replacement (TAVR) with respect to both, prevalence rates before TAVR and dynamics in the clinical course. METHODS: The study included 140 AS patients undergoing TAVR (77.8 ±â€¯7.7 years, 42.9% male, mean STS-Score 4.4 ±â€¯2.2). Detailed clinical, laboratory and functional analysis was performed. In addition, quality of life (EQ-5D, EQ VAS), clinical frailty (CFS) and anxiety/depression (HADS-D), was assessed at baseline, 6 weeks, 6 months and 12 months after TAVR. RESULTS: Before TAVR, HADS-D revealed ≥8 points for anxiety and/or depression in 54 patients (38.6%), depression in 33 patients (23.6%) and for anxiety in 40 patients (28.6%). In the group showing HADS-D ≥8 points for anxiety, there was an improvement already 6 weeks after TAVR for anxiety (p < 0.05) but not for depression. In the group showing HADS-D ≥8 points for depression, there was a significant improvement at the 6 weeks' follow-up for both, depression (p < 0.001) and anxiety (p = 0.012) remaining stable for depression but not for anxiety until 12 months after TAVR. CONCLUSIONS: TAVR leads to reductions of depression and anxiety in patients showing pathologic baseline values in HADS-D. There were no associations between pre-existing depression and anxiety with long-term mortality in our study.

What's new in heart failure therapy 2018?

Even though significant progress has been made over the past 3 decades, heart failure remains one of the leading causes of mortality and morbidity in developed countries and contributes significantly to the economic burden of modern health care systems. Especially in patients with preserved ejection fraction, valid therapeutic options are missing due to a lack of evidence. In face of a very heterogeneous condition with an ongoing debate over aetiology and pathophysiology, clinicians face a challenge in providing optimal care for these patients. Recent data suggest that the optimal treatment of the underlying conditions as well as comorbidities that are associated with heart failure might play an ever increasing role in improving outcomes. This focused review summarizes and reviews current data for the treatment of heart failure with both preserved and reduced ejection fractions based on the latest recommendations covering medical therapy and interventional strategies.

Exercise training in cancer related cardiomyopathy.

The therapeutic options for malignancies have been expanding over the past decades. Since the rise of targeted therapies, improved survival rates and decreased morbidity of cancer patients are evident but these refined protocols have steadily increased the number of patients at risk for long-term side-effects of anti-neoplastic treatments. The leading causes of death in cancer survivors are now defined by cardiovascular disease. Thus, there is a growing need for understanding how cancer related cardiovascular diseases such as cardiomyopathies or vasculopathies develop and how this can be prevented. Besides classical symptoms of heart failure with or without decompensation, an overwhelming majority of cancer patients develop fatigue and a significant reduction in exercise capacity when compared to their pre-cancer state. These effects seem to be independent from the specific chemotherapeutic substance included in the treatment regimen. Recent trials have suggested beneficial effects of exercise regiments in early and late phases of cancer treatment regimens and during rehabilitation. This review focuses on the currently available literature and evidence for the role of exercise training in preventing declining cardiac function or improving an already impaired function during or after chemotherapy, radiation or other cancer-specific therapies.

The MOGE(S) classification for cardiomyopathies: current status and future outlook.

Cardiomyopathies are complex diseases of multifactorial pathogenesis and have a high morbidity and mortality. Over the past decades, several revisions of classifications and definitions of cardiomyopathies have been proposed, primarily focusing on the phenotypic characterization of cardiomyopathies. The MOGE(S) classification system published in 2013 encompasses the classification of rapidly growing knowledge on genetic mutations, acquired causes (i.e., intramyocardial inflammation, viral infections), and further conditions involved in the induction of cardiomyopathies (e.g., storage diseases, toxicity). It is based on five attributes, including morphofunctional characteristics (M), organ involvement (O), genetic or familial inheritance pattern (G), etiological annotation (E), and optional information about the heart failure functional status (S). This review summarizes the development, the cornerstones of the MOGE(S) classification, and the published data on the clinical relevance of the MOGE(S) classification. We furthermore discuss new issues which might be considered for future updates of the MOGE(S) classification of cardiomyopathies.

Time efficient 124I-PET volumetry in benign thyroid disorders by automatic isocontour procedures: mathematic adjustment using manual contoured measurements in low-dose CT.

BACKGROUND: Benign thyroid diseases are widely common in western societies. However, the volumetry of the thyroid gland, especially when enlarged or abnormally formed, proves to be a challenge in clinical routine. The aim of this study was to develop a simple and rapid threshold-based isocontour extraction method for thyroid volumetry from (124)I-PET/CT data in patients scheduled for radioactive iodine therapy. METHODS: PET/CT data from 45 patients were analysed 30 h after 1 MBq (124)I administration. Anatomical reference volume was calculated using manually contoured data from low-dose CT images of the neck (MC). In addition, we applied an automatic isocontour extraction method (IC0.2/1.0), with two different threshold values (0.2 and 1.0 kBq/ml), for volumetry of the PET data-set. IC0.2/1.0 shape data that showed significant variation from MC data were excluded. Subsequently, a mathematical correlation using a model of linear regression with multiple variables and step-wise elimination (mIC0.2/1.0), between IC0.2/1.0 and MC, was established. RESULTS: Data from 41 patients (IC0.2), and 32 patients (IC1.0) were analysed. The mathematically calculated volume, mIC, showed a median deviation from the reference (MC), of ±9 % (1-54 %) for mIC0.2 and of ±8.2 % (1-50 %) for mIC1.0 CONCLUSION: Contour extraction with both, mIC1.0 and mIC0.2 gave rapid and reliable results. However, mIC0.2 can be applied to significantly more patients (>90 %) and is, therefore, deemed to be more suitable for clinical routine, keeping in mind the potential advantages of using (124)I-PET/CT for the preparation of patients scheduled for radioactive iodine therapy.

Low-activity (124)I-PET/low-dose CT versus (131)I probe measurements in pretherapy assessment of radioiodine uptake in benign thyroid diseases.

CONTEXT: Radioiodine therapy of benign thyroid diseases requires pretherapy assessment of radioactive iodine uptake (RAIU) for reliable therapy planning. OBJECTIVE: Our objective was to assess RAIU by low-activity (124)I-positron emission tomography/low-dose computed tomography ((124)I-PET/CT) in comparison with standard (131)I probe measurements. DESIGN/SETTING: This prospective comparative study was conducted at the Jena University Hospital, Jena, Germany, in a referral center setting. PATIENTS: A total of 79 patients with benign thyroid diseases were screened, 40 of whom met the inclusion criteria (stable TSH, free T3 and free T4 levels; no thyroid-specific medication, no iodine contamination) and 24 of whom agreed to participate by signing an informed consent. INTERVENTIONS: All patients received the standard (131)I scintillation probe uptake test 30 hours after administration of 3 MBq (131)I. Seven days later, all patients were subjected to (124)I-PET/CT uptake measurement 30 hours after administration of 1 MBq (124)I. MAIN OUTCOME MEASURES: The decay-corrected uptake values of both techniques were compared. Additionally, 3 different volume-of-interest-based evaluation methods in PET/CT (whole neck [WN], automatic isocontour [IC], and manually contoured [MC]) were evaluated. RESULTS: The (131)I probe measurement and (124)I-PET.WN method provided very similar mean RAIU (30.7% ± 10.3%; 31.7% ± 8.9%), resulting in a significant positive correlation (r = 0.93, P < .001). Compared with (124)I-PET.WN, the (124)I-PET.IC (29.8% ± 8.6%) and the (124)I-PET.MC (24.5% ± 7.1%) demonstrated lower uptake values. CONCLUSIONS: Using activities as low as 1 MBq, the (124)I-PET.WN method shows a good correlation with conventional (131)I probe measurement. Thus, (124)I-PET/CT is a suitable alternative for pretherapy RAIU evaluations. This may offer potential additional benefits such as PET/ultrasound fusion imaging and CT volumetry.