Clinical and echocardiographic characterization of patients hospitalized for severe tricuspid valve regurgitation: a single tertiary-care center experience with two-year follow-up.

INTRODUCTION: Tricuspid regurgitation (TR) is a common acquired valvular heart disease. Recently new transcatheter treatment options for severe TR have emerged that could change the management of this condition, which warrants better characterization of this specific patient group. OBJECTIVES: The aim of the study was to describe the clinical and echocardiographic characteristics of patients with severe TR and to evaluate their short- and mid-term prognosis. PATIENTS AND METHODS: This retrospective, observational single-center study enrolled consecutive patients with severe TR hospitalized between January 2016 and September 2021 in the 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland. The severity of heart failure (HF) was evaluated using New York Heart Association (NYHA) classification. Echocardiographic assessment was performed by experienced sonographer. EuroSCORE II and TRI-SCORE were computed for each patient. 12- and 24-month clinical outcomes were reported. RESULTS: There were 172 patients [93 female (54.1%)] included. The mean age was 76.4 (± 10.5) years. The most common comorbidities included: atrial fibrillation (84.9%), hypertension (68.0%), chronic kidney disease (54.1%), coronary artery disease (45.3%), diabetes mellitus (30.9%). The median EuroSCORE II and TRI-SCORE values were 4.68% and 14.0%, respectively. The median follow-up was 24 months. The overall mortality was 29.7% at 1 year and 47.3% at 2 years. TR grade, TAPSE <17 mm, TAPSE/SPAP <0.26 and right atrial area were significant factors associated with mortality. CONCLUSIONS: Patients presenting with severe TR are characterized by a large comorbidity burden and poor prognosis, despite intensive heart failure management.

An update on cardiovascular disorders in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a complex multifactorial etiology that develops as a result of autoimmune processes, leading to widespread inflammation and malfunction of multiple tissues and organs, and, as a consequence, triggers arterial hypertension, conduction disorders, valvular heart disease, pulmonary hypertension (PH), and venous thromboembolism events (VTE), contributing to increased mortality. Moreover, autoimmune abnormalities can accelerate atherogenesis and lead to many SLE manifestations, including coronary artery disease (CAD) and cerebrovascular events. The current review aimed to systematize existing data from the latest works and summarize published guidelines and recommendations. In particular, the prevalence of cardiovascular disorders in SLE patients, advances in diagnostics (including imaging methods and biomarker laboratory testing), the possible future direction of therapy, and the latest European Alliance of Associations for Rheumatology (EULAR) guidelines for optimal management of cardiovascular risk in SLE were overviewed.

Strategy to optimize PeriproCeduraL AnticOagulation in structural transseptal interventions: Design and rationale of the STOP CLOT trial.

BACKGROUND: Both transcatheter edge-to-edge repair (TEER) of mitral regurgitation or left atrial appendage closure (LAAC) require periprocedural anticoagulation with unfractionated heparin (UFH) that is administered either before or immediately after transseptal puncture (TSP). The optimal timing of UFH administration (before or after TSP) is unknown. The Strategy To Optimize PeriproCeduraL AnticOagulation in Structural Transseptal Interventions trial (STOP CLOT Trial) was designed to determine if early anticoagulation is effective in reducing ischemic complications without increasing the risk of periprocedural bleeding. METHODS: The STOP CLOT trial is a multicenter, prospective, double-blind, placebo-controlled, randomized trial. A total of 410 patients scheduled for TEER or LAAC will be randomized 1:1 either early UFH administration (iv. bolus of 100 units/kg UFH or placebo, given after obtaining femoral vein access and at least 5 minutes prior to the start of the TSP) or late UFH administration (iv. bolus of 100 units/kg UFH or placebo given immediately after TSP). Prespecified preliminary statistical analysis will be performed after complete follow-up of the first 196 randomized subjects. To ensure blinding, a study nurse responsible for randomization and UFH/placebo preparation is not involved in the care of the patients enrolled into the study. The primary study endpoint is a composite of (1) major adverse cardiac and cerebrovascular events (death, stroke, TIA, myocardial infarction, or peripheral embolization) within 30 days post-procedure, (2) intraprocedural fresh thrombus formation in the right or left atrium as assessed with periprocedural transesophageal echocardiography, or (3) occurrence of new ischemic lesions (diameter ≥4 mm) on brain magnetic resonance imaging performed 2 to 5 days after the procedure. The safety endpoint is the occurrence of moderate or severe bleeding complications during the index hospitalization. CONCLUSIONS: Protocols of periprocedural anticoagulation administration during structural interventions have never been tested in a randomized clinical trial. The Stop Clot trial may help reach consensus on the optimal timing of initiation of periprocedural anticoagulation. CLINICAL TRIALS REGISTRATION NUMBER: The study protocol is registered at ClinicalTrials.gov, identifier NCT05305612.

Multimodality OCT, IVUS and FFR evaluation of coronary intermediate grade lesions in women vs. men.

Background: The pathophysiology of atherosclerotic plaque formation and its vulnerability seem to differ between genders due to contrasting risk profiles and sex hormones, however this process is still insufficiently understood. The aim of the study was to compare the differences between sexes regarding the optical coherence tomography (OCT), intravascular ultrasound (IVUS) and fractional flow reserve (FFR)-derived coronary plaque indices. Methods: In this single-center multimodality imaging study patients with intermediate grade coronary stenoses identified in coronary angiogram (CAG) were evaluated using OCT, IVUS and FFR. Stenoses were considered significant when the FFR value was ≤0.8. Minimal lumen area (MLA), was analyzed by OCT in addition to plaque stratification into fibrotic, calcific, lipidic and thin-cap fibroatheroma (TCFA). IVUS was used for evaluation of lumen-, plaque- and vessel volume, as well as plaque burden. Results: A total of 112 patients (88 men and 24 women) with chronic coronary syndromes (CCS), who underwent CAG were enrolled. No significant differences in baseline characteristics were present between the study groups. The mean FFR was 0.76 (0.73-0.86) in women and 0.78 ± 0.12 in men (p = 0.695). OCT evaluation showed a higher prevalence of calcific plaques among women than men p = 0.002 whereas lipid plaques were more frequent in men (p = 0.04). No significant differences regarding minimal lumen diameter and minimal lumen area were found between the sexes. In IVUS analysis women presented with significantly smaller vessel area, plaque area, plaque volume, vessel volume (11.1 ± 3.3 mm2 vs. 15.0 ± 4.6 mm2 p = 0.001, 6.04 ± 1.7 mm2 vs. 9.24 ± 2.89 mm2 p < 0.001, 59.8 ± 35.2 mm3 vs. 96.3 (52.5-159.1) mm3 p = 0.005, 106.9 ± 59.8 mm3 vs. 153.3 (103-253.4) mm3 p = 0.015 respectively). At MLA site plaque burden was significantly greater for men than women (61.50 ± 7.7% vs. 55.5 ± 8.0% p = 0.005). Survival did not differ significantly between women and men (94.6 ± 41.9 months and 103.51 ± 36.7 months respectively; p = 0.187). Conclusion: The presented study did not demonstrate significant differences in FFR values between women and men, yet a higher prevalence of calcific plaques by OCT and lower plaque burden at the MLA site by IVUS was found in women vs. men.

Complications following transcatheter edge-to-edge mitral valve repair: Personal experience and review of the literature.

Mitral valve dysfunction affects around 2% of the population and its incidence is still increasing, making it the second most common valvular heart disease, after aortic stenosis. Depending on the etiology of the disease, it can be classified into primary or secondary mitral regurgitation. The first line of treatment is optimal medical therapy. If ineffective, mitral valve intervention can be considered. For patients disqualified from surgical treatment, transcatheter edge-to-edge repair with the use of MitraClip may be considered. Over 100,000 MitraClip procedures have been performed which makes this the most established transcatheter technique for the treatment of severe mitral regurgitation. The aim of this review is to discuss the technical details of the MitraClip procedure, clinical evidence regarding the efficacy of MitraClip, complications related to the clip implantation alongside with acute complications based on the currently available evidence and clinical experience.

Optimal Management of Patients with Severe Coronary Artery Disease following Multidisciplinary Heart Team Approach-Insights from Tertiary Cardiovascular Care Center.

Background: The purpose of this retrospective study was to investigate outcomes of patients with severe coronary artery disease (CAD) after implementing various treatment strategies following multidisciplinary Heart Team (MHT) discussion. Methods Primary and secondary endpoints and quality of life during a mean (SD) follow-up of 37 (14) months of patients with severe CAD (three-vessel [3-VD] or/and left main [LM] disease) qualified after MHT discussion to optimal medical treatment (OMT) alone, OMT and coronary artery bypass grafting (CABG), or OMT and percutaneous coronary intervention (PCI) were evaluated. As the primary endpoint, major adverse cardiac or cerebrovascular events (MACCE) (i.e., death from any cause, stroke, myocardial infarction, or repeat/need for revascularization) were considered. Result: From 2016 to 2019, 176 MHT meetings were held, and a total of 1286 participants with severe CAD and completely implemented MHT decisions (OMT, CABG, or PCI for 251, 356, and 679 patients, respectively) were included. The occurrence of the primary endpoint was significantly increased in OMT-group (154 (61.4%) vs. CABG and PCI groups­110 (30.9%) and 302 (44.5%) patients, respectively (p < 0.05). For interventional strategies only­CABG was associated with reduced rates of MACCE and repeat revascularization, while the superiority of PCI for stroke and disabling stroke was observed (p < 0.05). The general health status assessed at the end of the follow-up was significantly better for patients who underwent CABG or PCI than in the OMT group (p < 0.05). Conclusions: In this real-life study, we presented a single-center experience of providing optimal medical care for patients with severe CAD following MHT discussion.

Influence of Apnea Hypopnea Index and the Degree of Airflow Limitation on Endothelial Function in Patients Undergoing Diagnostic Coronary Angiography.

Background: Obstructive sleep apnea is associated with an increased prevalence of cardiovascular disease. The mechanism of these associations is not completely understood. We aimed to investigate the association of the apnea hypopnea index and the degree of airflow limitation with endothelial dysfunction. Methods: This was a single-center prospective study of patients admitted for diagnostic coronary angiography (CAG). Endothelial function was assessed by the non-invasive EndoPAT system by reactive hyperemia index (RHI) and divided into two groups: endothelial dysfunction and normal endothelial function. Sleep apnea signs were detected by WatchPAT measuring the respiratory disturbance index (pRDI), the apnea and hypopnea index (pAHI), and the oxygen desaturation index (ODI). Patients underwent spirometry and body plethysmography. Based on CAG, the severity of coronary artery disease was assessed as follows: no significant coronary artery disease, single-, two- and three-vessel disease. Results: A total of 113 patients were included in the study. Breathing disorders measured by WatchPAT and spirometry were more severe in patients with endothelial dysfunction: pRDI (27.3 vs. 14.8, p = 0.001), pAHI (24.6 vs. 10.3, p < 0.001), ODI (13.7 vs. 5.2, p = 0.002), forced expiratory volume in one second (FEV1) (81.2 vs. 89, p = 0.05). In a multivariate regression analysis, pAHI and FEV1 were independent predictors of endothelial dysfunction assessed by RHI. There was no correlation between the severity of coronary artery disease and endothelial dysfunction. Conclusions: Obstructive sleep apnea signs and greater airflow limitation were associated with endothelial dysfunction regardless of the severity of the coronary artery disease.

Long-term outcomes and quality of life following implementation of dedicated mitral valve Heart Team decisions for patients with severe mitral valve regurgitation in tertiary cardiovascular care center.

BACKGROUND: This study was purposed to investigate which treatment strategy was associated with the most favourable prognosis for patients with severe mitral regurgitation (MR) following Heart Team (HT)-decisions implementation. METHODS: In this retrospective study, long-term outcomes of patients with severe MR qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and MitraClip (MC) procedure or OMT and mitral valve replacement (MVR) were evaluated. The primary endpoint was defined as cardiovascular (CV) death and the secondary endpoints included all-cause mortality, myocardial infarctions (MI), strokes, hospitalizations for heart failure exacerbation and CV events during a mean (standard deviation [SD]) follow-up of 29 (15) months. RESULTS: From 2016 to 2019, 176 HT meetings were held and a total of 157 participants (mean age [SD] = 71.0 [9.2], 63.7% male) with severe MR and completely implemented HT decisions (OMT, MC or MVR for 53, 58 and 46 patients, respectively) were included into final analysis. Comparing OMT, MC and MVR groups statistically significant differences between the implemented procedures and occurrence of primary and secondary endpoints with the most frequent in OMT-group were observed (p < 0.05). However, for interventional strategy MC was non-inferior to MVR for all endpoints (p > 0.05). General health status assessed at the end of follow-up were significantly the lowest for MVR, then for MC and the highest for OMT-group (p < 0.01). CONCLUSIONS: In the present study it was demonstrated that after careful HT evaluation of patients with severe MR at high risk of surgery, percutaneous strategy (MC) can be considered as equivalent to surgical treatment (MVR) with non-inferior outcomes.

Percutaneous tricuspid edge-to-edge repair - patient selection, imaging considerations, and the procedural technique. Expert opinion of the Working Group on Echocardiography and Association of CardioVascular Interventions of the Polish Cardiac Society.

Tricuspid regurgitation (TR) is a common acquired valvular heart disease (VHD). TR has progressive character and is associated with impaired long-term survival in both symptomatic and asymptomatic subjects. Despite this knowledge, the overall number of tricuspid valve surgeries is very low worldwide and many patients with clear indications for intervention are left untreated. The development of less invasive transcatheter techniques may offer new treatment options in this growing population of patients. Out of various percutaneous methods proposed, tricuspid edge-to-edge repair has recently gained considerable attention. The article summarizes available data regarding this new treatment method.

Atherogenesis in Native Coronary Segments and In-Stent Neoatherogenesis Beyond Three Years After First-Generation Drug-Eluting Stent Implantation: Angiographic and Optical Coherence Tomography Study.

OBJECTIVES: The mechanisms underlying the development of neoatherosclerosis following stent implantation remain to be further elucidated. The aim of this study was to investigate the association between subclinical in-stent neoatherosclerosis (NA) and atherosclerosis progression of native coronary segments in patients with chronic coronary syndrome 3 and 9 years after first-generation drug-eluting stent implantation. METHODS: This is a prespecified analysis of the prospective cohort study evaluating long-term neointimal healing in consecutive patients undergoing elective percutaneous coronary intervention with sirolimus-eluting stent (SES) or paclitaxel-eluting stent (PES) implantation. Quantitative coronary angiography (QCA) was evaluated in non-stented coronary segments. RESULTS: Forty-three patients underwent optical coherence tomography (OCT) and QCA at 3 years and 21 patients at 3 years and 9 years after SES or PES implantation. NA was identified in 44.2% at 3 years and in 66.7% at 9 years after the index procedure. NA at 3 years was more frequently observed in patients with atherosclerosis progression in native coronary segments than without (66.7% vs 15.8%; P<.01). Higher low-density cholesterol level (93 mg/dL vs 77 mg/dL; P=.04), greater maximal neointimal thickness (0.74 mm vs 0.37 mm; P<.001), and presence of peristrut low-intensity areas (57.9% vs 20.8%; P=.01) were more frequent in patients with NA. NA progression (P=.01) along with greater neointimal growth (P<.01) were detected in serial analysis between 3-year and 9-year OCT assessments. CONCLUSIONS: OCT-confirmed NA formation after first-generation drug-eluting stent implantation was associated with QCA-defined atherosclerosis progression in non-stented segments between 0 and 3 years. NA and neointimal proliferation continued between 3 and 9 years.

OCT-Derived Plaque Morphology and FFR-Determined Hemodynamic Relevance in Intermediate Coronary Stenoses.

BACKGROUND: optical coherence tomography (OCT) might allow identifying lesion features reportedly associated with plaque vulnerability and increased risk of clinical events. Previous studies on correlation between OCT and functional lesion significance indices reported contradictory results, yet integration of complementary information from both modalities is gaining increased interest. The aim of the study was to compare plaque morphology using OCT in hemodynamically relevant vs. non-relevant lesions by fractional flow reserve (FFR). METHODS: consecutive patients with intermediate grade coronary stenoses by angiography were evaluated by both FFR and OCT in this single-center study. Stenoses were labeled hemodynamically relevant in case of the FFR ≤ 0.80. Minimal lumen area (MLA), fibrous cap thickness (FCT), minimal cap thickness over the calcium, angle of the calcium, and necrotic core within the lesions were evaluated. RESULTS: a total of 105 patients (124 vessels) were analyzed. Of them, 65 patients were identified with at least one lesion identified as hemodynamically relevant by FFR (72 vessels, 58.1%). Lesions with FFR ≤0.80 presented with lower mean and minimal lumen area (3.46 ± 1.29 vs. 4.65 ± 2.19, p =0.001 and 1.84 ± 0.97 vs. 2.66 ± 1.40, p = 0.001) compared to patients with FFR > 0.80. No differences were found between groups in the mean and minimal FCT, mean, and maximal necrotic core, calcium angle, as well as the overall rate of calcified and lipid plaques. CONCLUSION: hemodynamic relevance of intermediate grade lesions correlated moderately with the luminal assessment by OCT. No differences were identified in the plaque morphology between relevant and non-relevant coronary stenoses by FFR.

The function of the heart after successful transcatheter mitral valve repair due to severe functional regurgitation.

INTRODUCTION: The function of the heart after successful transcatheter edge­to­edge mitral valve repair (TMVR) remains not fully investigated. OBJECTIVES: The aim of our study was to assess the direct impact of effective TMVR on the strains of the left atrium (LA), the left ventricle (LV), and the right ventricle (RV) in patients with functional mitral regurgitation due to coronary artery disease or dilated cardiomyopathy. PATIENTS AND METHODS: Out of a group that successfully underwent TMVR, we selected 28 patients for the analysis. The remodeling of the LA, the LV, and the RV as well as their strains were assessed. RESULTS: In the short­term follow­up, we found a positive change of LA and LV volumes, RV dimensions but not LV ejection fraction. No strain improvement was observed in the pre and post analysis of LV, RV, LA, and LA in phase 3 (contraction phase). We found a deterioration of LA strain in phases 1 (reservoir phase) and 2 (conduit phase) in patients with a history of paroxysmal atrial fibrillation (phase 1, 2.5% [0%-5.47%]; P = 0.01; phase 2, -3.1% [-0.75% to -6.61%]; P = 0.004) and with coronary artery disease (phase 1, 2.2% [-0.82% to 5.47%]; P = 0.049; phase 2, -3.7% [-7.48% to -1.25%]; P = 0.01). CONCLUSIONS: Our data indicate that no improvement of heart strains can be expected after suc-cessful TMVR in the short­term follow­up, and the function of the LA may even deteriorate in some subpopulations.

Peri-strut low intensity areas and in-scaffold neointima growth after bioresorbable scaffold implantation in STEMI. A serial optical coherence tomography study.

BACKGROUND: Peri-strut low intensity areas (PLIA) visualized by optical coherence tomography (OCT) have been related to neointimal proliferation and increased incidence of target lesion revascularization in stable coronary artery disease. The aim of this study was to determine the association between PLIA by OCT and the long-term vascular healing response after bioresorbable scaffold (BRS) implantation in the setting of ST-segment elevation myocardial infarction (STEMI). METHODS: This is a single-centre, longitudinal, cohort study with a serial: baseline, 1, 2 and 5 years OCT evaluation of neointimal response (lumen area and neoatherosclerosis) after percutaneous coronary intervention (PCI) with BRS Absorb™ 1.0 implantation in patients presenting with STEMI. PLIA was analyzed in every cross section and scored: 0-no PLIA; 1-PLIA < 1 quadrant; 2-PLIA ≥ 1 and <2 quadrants; 3-PLIA ≥ 2 and <3 quadrants; 4-PLIA in ≥3 quadrants. RESULTS: Of the 23 patients implanted BRS, 18 completed 2-year follow-up, whereas complete OCT data up to 5 years were available in 12 patients. Presence of PLIA was identified in 100% patients at 1 and 2 years, whereas at 5 years neither PLIA nor scaffold struts were visualized by OCT. Neoatherosclerosis was identified in 73,68% patients after 1 year and in all patients at 2 and 5 years. The mean PLIA score > 1 at 2 years was associated with greater percentage of minimum lumen area decrease after 2 years from index procedure. CONCLUSIONS: The extent of PLIA by OCT at 2 years after primary PCI with BRS was associated with lumen area decrease. Neoatherosclerosis formation was detected in all patients at 2 and 5 years. PLIA assessment could serve as an additive means to predict neointimal healing pattern after next generation BRS implantation.

Platelet to red cell distribution width ratio for predicting clopidogrel efficacy in patients undergoing percutaneous coronary interventions: insights from the ONSIDE-TEST study.

INTRODUCTION Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel remains a cornerstone of pharmacotherapy after percutaneous coronary intervention (PCI). It has been demonstrated that even up to 30% of patients receiving DAPT have inadequate response to clopidogrel, namely, high on­treatment platelet reactivity (HPR). The platelet to red cell distribution width (P­RDW) ratio represents an indicator of cardiovascular risk and may be related to HPR. OBJECTIVES The aim of the present study was to establish whether the P­RDW ratio predicts HPR in clopidogrel­treated patients undergoing elective PCI. PATIENTS AND METHODS This was a subanalysis of the prospective randomized­controlled ONSIDE TEST study. A total of 70 patients were included in the analysis, of whom 12 were identified with HPR. The HPR was defined as the values above the threshold of 208 platelet reactivity units (PRU >208) by the VerifyNowP2Y12 assay. RESULTS The P­RDW ratio was lower in patients with HPR than in those without HPR (mean [SD], 14.37 [4.13] vs 17.734 [4.96]; P = 0.03). A logistic regression analysis showed that the P­RDW ratio was associated with HPR (P = 0.03). Using a cut­off level of 15.23, the P­RDW ratio predicted HPR with a sensitivity of 69% and specificity of 75% (odds ratio, 6.67; 95% CI, 0.561-0.890; P = 0.02; are under the receiver operating characteristic curve, 0.723). CONCLUSIONS The P­RDW ratio may serve as a supplementary tool for identification of patients at risk of HPR. Further studies are warranted to assess its role in planning DAPT among patients undergoing PCI.

A serial 3- and 9-year optical coherence tomography assessment of vascular healing response to sirolimus- and paclitaxel-eluting stents.

Early-generation drug-eluting stents (DES) have been demonstrated to delay vascular healing. Limited optical coherence tomography (OCT) data on the very long-term neointimal response after DES implantation are available. The aim of this study was a serial OCT assessment of neointimal thickness, stent strut coverage, malapposition, and protrusion as markers of neointimal response at 3 and 9 years after implantation of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES). In this single-centre, longitudinal study consecutive patients undergoing elective PCI with SES or PES were included. OCT analysis was performed after 3 and 9 years by the independent core laboratory. A total of 22 subjects (8 SES and 14 PES) underwent an OCT assessment at 3 and 9 years post index procedure. The lumen, neointimal and malapposition area and the neointimal thickness (SES ∆50 µm, p = 0.195, PES ∆10 µm, p = 0.951) did not change significantly over the 6 year follow-up. No differences in the incidence of uncovered, malapposed or protruding struts were found in each type of stent. At 3 and 9 years after PCI, implantation of early-generation SES and PES may be associated with similar neointimal thickness, strut coverage, malapposition and protrusion, as assessed by serial OCT examination among patients with uneventful follow-up at 3 years post procedure. The small size of the study warrants judicious interpretation of our results and confirmation in larger multimodality imaging studies, including patients treated with contemporary stent platforms.