Gender differences in the diagnostic efficacy of coronary CTA: Overutilization of coronary CTA in pre- and perimenopausal females?

OBJECTIVES: Public campaigns such as the "Go-red-for-women"-initiative have raised heart-disease awareness and may trigger overutilization of coronary computed tomography angiography (CTA). Objective was to investigate the diagnostic efficacy of coronary CTA stratified by age and gender. METHODS: 1882 consecutive patients (58.9 ± 11 years;42.5% females) with low-to-intermediate pre-test-probability of coronary artery disease (CAD) referred to coronary CTA according to ESC-2019 guidelines, were included. Diagnostic efficacy was defined by the 1)negative CTA-rate 2)obstructive CAD (>50%stenosis) 3)High-risk-plaque and 4)CAC-score. RESULTS: The negative CTA rate was higher in females compared to males with 360/801 vs 292/1081 (45% vs 27%;p < 0.001). Females had a higher likelihood (OR 2.2:95%CI:1.81-2.67) of a negative CTA than males, despite they were older (p < 0.001). Obstructive disease prevalence was 25.6% and acceptable in both sexes (males vs females: 28.4% vs 21.8%;p = 0.0012). Males had more high-risk-plaque (23.6% vs 11.5%;p < 0.001). When stratifying age groups, negative CTA rate was highest in females <47 years (82.8%), but lower in males with 68.1% (p < 0.001), while obstructive disease prevalence was not different (males:6.5% vs females:4.6%:p = 0.874). Above 50 years, negative CTA rate (39.1% vs 17.6%,p < 0.001;OR 3.02:95%CI:2.381-3.823) was higher, and the obstructive disease rate was lower in females (24.8% vs 34.7%,p = 0.0003). SSPSTm(V.25,IBM) was used for statistical analysis. CONCLUSIONS: Above 50 years of age, diagnostic efficacy of coronary CTA is high in both males and females. In females <47 years, the negative CTA rate was highest with 82.8% and obstructive disease prevalence was low (4.6%), still justifying testing but recommending the use of specific tools (PROMISE minimal risk score) or other clinical tests for pre-selection.

Decongestion in Acute Heart Failure-Time to Rethink and Standardize Current Clinical Practice?

Most episodes of acute heart failure (AHF) are characterized by increasing signs and symptoms of congestion, manifested by edema, pleura effusion and/or ascites. Immediately and repeatedly administered intravenous (IV) loop diuretics currently represent the mainstay of initial therapy aiming to achieve adequate diuresis/natriuresis and euvolemia. Despite these efforts, a significant proportion of patients have residual congestion at discharge, which is associated with a poor prognosis. Therefore, a standardized approach is needed. The door to diuretic time should not exceed 60 min. As a general rule, the starting IV dose is 20-40 mg furosemide equivalents in loop diuretic naïve patients or double the preexisting oral home dose to be administered via IV. Monitoring responses within the following first hours are key issues. (1) After 2 h, spot urinary sodium should be ≥50-70 mmol/L. (2) After 6 h, the urine output should be ≥100-150 mL/hour. If these target measures are not reached, the guidelines currently recommend a doubling of the original dose to a maximum of 400-600 mg furosemide per day and in patients with severely impaired kidney function up to 1000 mg per day. Continuous infusion of loop diuretics offers no benefit over intermittent boluses (DOSE trial). Emerging evidence by recent randomized trials (ADVOR, CLOROTIC) supports the concept of an early combination diuretic therapy, by adding either acetazolamide (500 mg IV once daily) or hydrochlorothiazide. Acetazolamide is particularly useful in the presence of a baseline bicarbonate level of ≥27 mmol/L and remains effective in the presence of preexisting/worsening renal dysfunction but should be used only in the first three days to prevent severe metabolic disturbances. Patients should not leave the hospital when they are still congested and/or before optimized long-term guideline-directed medical therapy has been initiated. Special attention should be paid to AHF patients during the vulnerable post-discharge period, with an early follow-up visit focusing on up-titrate treatments of recommended doses within 2 weeks (STRONG-HF).

ECMO in Myocardial Infarction-Associated Cardiogenic Shock: Blood Biomarkers as Predictors of Mortality.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (va-ECMO) can provide circulatory and respiratory support in patients with cardiogenic shock. The main aim of this work was to investigate the association of blood biomarkers with mortality in patients with myocardial infarction needing va-ECMO support. METHODS: We retrospectively analyzed electronic medical charts from patients receiving va-ECMO support in the period from 2008 to 2021 at the Medical University Innsbruck, Department of Anesthesiology and Intensive Care Medicine. RESULTS: Of 188 patients, 57% (108/188) survived to discharge, with hemorrhage (46%) and thrombosis (27%) as the most frequent adverse events. Procalcitonin levels were markedly higher in non-survivors compared with survivors during the observation period. The multivariable model identified higher blood levels of procalcitonin (HR 1.01, p = 0.002) as a laboratory parameter associated with a higher risk of mortality. CONCLUSIONS: In our study population of patients with myocardial infarction-associated cardiogenic shock, deceased patients had increased levels of inflammatory blood biomarkers throughout the whole study period. Increased procalcitonin levels have been associated with a higher risk of mortality. Future studies are needed to show the role of procalcitonin in patients receiving ECMO support.

Impact of route of access and stenosis subtype on outcome after transcatheter aortic valve replacement.

Introduction: Previous analyses have reported the outcomes of transcatheter aortic valve replacement (TAVR) for patients with low-flow, low-gradient (LFLG) aortic stenosis (AS), without stratifying according to the route of access. Differences in mortality rates among access routes have been established for high-gradient (HG) patients and hypothesized to be even more pronounced in LFLG AS patients. This study aims to compare the outcomes of patients with LFLG or HG AS following transfemoral (TF) or transapical (TA) TAVR. Methods: A total of 910 patients, who underwent either TF or TA TAVR with a median follow-up of 2.22 (IQR: 1.22-4.03) years, were included in this multicenter cohort study. In total, 146 patients (16.04%) suffered from LFLG AS. The patients with HG and LFLG AS were stratified according to the route of access and compared statistically. Results: The operative mortality rates of patients with HG and LFLG were found to be comparable following TF access. The operative mortality rate was significantly increased for patients who underwent TA access [odds ratio (OR): 2.91 (1.54-5.48), p = 0.001] and patients with LFLG AS [OR: 2.27 (1.13-4.56), p = 0.02], which could be corroborated in a propensity score-matched subanalysis. The observed increase in the risk of operative mortality demonstrated an additive effect [OR for TA LFLG: 5.45 (2.35-12.62), p < 0.001]. LFLG patients who underwent TA access had significantly higher operative mortality rates (17.78%) compared with TF LFLG (3.96%, p = 0.016) and TA HG patients (6.36%, p = 0.024). Conclusions: HG patients experienced a twofold increase in operative mortality rates following TA compared with TF access, while LFLG patients had a fivefold increase in operative mortality rates. TA TAVR appears suboptimal for patients with LFLG AS. Prospective studies should be conducted to evaluate alternative options in cases where TF is not possible.

Invasive Fungal Infections after Liver Transplantation.

Invasive fungal infections represent a major challenge in patients who underwent organ transplantation. Overall, the most common fungal infections in these patients are candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Several risk factors have been identified, which increase the likelihood of an invasive fungal infection developing after transplantation. Liver transplant recipients constitute a high-risk category for invasive candidiasis and aspergillosis, and therefore targeted prophylaxis is favored in this patient population. Furthermore, a timely implemented therapy is crucial for achieving optimal outcomes in transplanted patients. In this article, we describe the epidemiology, risk factors, prophylaxis, and treatment strategies of the most common fungal infections in organ transplantation, with a focus on liver transplantation.

Incidence of Invasive Fungal Infections in Liver Transplant Recipients under Targeted Echinocandin Prophylaxis.

Invasive fungal infections (IFIs) are one of the most important infectious complications after liver transplantation, determining morbidity and mortality. Antimycotic prophylaxis may impede IFI, but a consensus on indication, agent, or duration is still missing. Therefore, this study aimed to investigate the incidence of IFIs under targeted echinocandin antimycotic prophylaxis in adult high-risk liver transplant recipients. We retrospectively reviewed all patients undergoing a deceased donor liver transplantation at the Medical University of Innsbruck in the period from 2017 to 2020. Of 299 patients, 224 met the inclusion criteria. We defined patients as being at high risk for IFI if they had two or more prespecified risk factors and these patients received prophylaxis. In total, 85% (190/224) of the patients were correctly classified according to the developed algorithm, being able to predict an IFI with a sensitivity of 89%. Although 83% (90/109) so defined high-risk recipients received echinocandin prophylaxis, 21% (23/109) still developed an IFI. The multivariate analysis identified the age of the recipient (hazard ratio-HR = 0.97, p = 0.027), split liver transplantation (HR = 5.18, p = 0.014), massive intraoperative blood transfusion (HR = 24.08, p = 0.004), donor-derived infection (HR = 9.70, p < 0.001), and relaparotomy (HR = 4.62, p = 0.003) as variables with increased hazard ratios for an IFI within 90 days. The fungal colonization at baseline, high-urgency transplantation, posttransplant dialysis, bile leak, and early transplantation showed significance only in a univariate model. Notably, 57% (12/21) of the invasive Candida infections were caused by a non-albicans species, entailing a markedly reduced one-year survival. The attributable 90-day mortality rate of an IFI after a liver transplant was 53% (9/17). None of the patients with invasive aspergillosis survived. Despite targeted echinocandin prophylaxis, there is still a notable risk for IFI. Consequently, the prophylactic use of echinocandins must be critically questioned regarding the high rate of breakthrough infections, the increased occurrence of fluconazole-resistant pathogens, and the higher mortality rate in non-albicans Candida species. Adherence to the internal prophylaxis algorithms is of immense importance, bearing in mind the high IFI rates in case algorithms are not followed.

Invasive Fungal Breakthrough Infections under Targeted Echinocandin Prophylaxis in High-Risk Liver Transplant Recipients.

Invasive fungal infections (IFIs) are frequent and outcome-relevant complications in the early postoperative period after orthotopic liver transplantation (OLT). Recent guidelines recommend targeted antimycotic prophylaxis (TAP) for high-risk liver transplant recipients (HR-LTRs). However, the choice of antimycotic agent is still a subject of discussion. Echinocandins are increasingly being used due to their advantageous safety profile and the increasing number of non-albicans Candida infections. However, the evidence justifying their use remains rather sparse. Recently published data on breakthrough IFI (b-IFI) raise concerns about echinocandin efficacy, especially in the case of intra-abdominal candidiasis (IAC), which is the most common infection site after OLT. In this retrospective study, we analyzed 100 adult HR-LTRs undergoing first-time OLT and receiving echinocandin prophylaxis between 2017 and 2020 in a tertiary university hospital. We found a breakthrough incidence of 16%, having a significant impact on postoperative complications, graft survival, and mortality. The reasons for this may be multifactorial. Among the pathogen-related factors, we identified the breakthrough of Candida parapsilosis in 11% of patients and one case of persistent IFI due to the development of a secondary echinocandin resistance of an IAC caused by Candida glabrata. Consequently, the efficacy of echinocandin prophylaxis in liver transplantation should be questioned. Further studies are necessary to clarify the matter of breakthrough infections under echinocandin prophylaxis.

Limbic Responses to Aversive Visual Stimuli during the Acute and Recovery Phase of Takotsubo Syndrome.

The role of the limbic system in the acute phase and during the recovery of takotsubo syndrome needs further clarification. In this longitudinal study, anatomical and task-based functional magnetic resonance imaging of the brain was performed during an emotional picture paradigm in 19 postmenopausal female takotsubo syndrome patients in the acute and recovery phases in comparison to sex- and aged-matched 15 healthy controls and 15 patients presenting with myocardial infarction. Statistical analyses were performed based on the general linear model where aversive and positive picture conditions were included in order to reveal group differences during encoding of aversive versus positive pictures and longitudinal changes. In the acute phase, takotsubo syndrome patients showed a lower response in regions involved in affective and cognitive emotional processes (e.g., insula, thalamus, frontal cortex, inferior frontal gyrus) while viewing aversive versus positive pictures compared to healthy controls and patients presenting with myocardial infarction. In the recovery phase, the response in these brain regions normalized in takotsubo syndrome patients to the level of healthy controls, whereas patients 8-12 weeks after myocardial infarction showed lower responses in the limbic regions (mainly in the insula, frontal regions, thalamus, and inferior frontal gyrus) compared to healthy controls and takotsubo syndrome patients. In conclusion, compared to healthy controls and patients suffering from acute myocardial infarction, limbic responses to aversive visual stimuli are attenuated during the acute phase of takotsubo syndrome, recovering within three months. Reduced functional brain responses in the recovery phase after a myocardial infarction need further investigation.

The Pulmonary Artery Catheter in the Perioperative Setting: Should It Still Be Used?

The pulmonary artery catheter (PAC) was introduced into clinical practice in the 1970s and was initially used to monitor patients with acute myocardial infarctions. The indications for using the PAC quickly expanded to critically ill patients in the intensive care unit as well as in the perioperative setting in patients undergoing major cardiac and noncardiac surgery. The utilization of the PAC is surrounded by multiple controversies, with literature claiming its benefits in the perioperative setting, and other publications showing no benefit. The right interpretation of the hemodynamic parameters measured by the PAC and its clinical implications are of the utmost essence in order to guide a specific therapy. Even though clinical trials have not shown a reduction in mortality with the use of the PAC, it still remains a valuable tool in a wide variety of clinical settings. In general, the right selection of the patient population (high-risk patients with or without hemodynamic instability undergoing high-risk procedures) as well as the right clinical setting (centers with experience and expertise) are essential in order for the patient to benefit most from PAC use.

Anesthesia-Induced Oxidative Stress: Are There Differences between Intravenous and Inhaled Anesthetics?

Agents used for the induction of anesthesia have been shown to either promote or mitigate oxidative stress. A fine balance between the presence of reactive oxygen species (ROS) and antioxidants is crucial for the proper normal functioning of the cell. A basal concentration of ROS is essential for the manifestation of cellular functions, whereas disproportionate levels of ROS cause damage to cellular macromolecules such as DNA, lipids, and proteins, eventually leading to necrosis and apoptosis. Increased ROS has been linked with numerous illnesses, such as cardiovascular, immune system, liver, and kidney, and has been shown to promote cancer and accelerate aging. Knowledge of the various pharmacologic agents that increase or reduce oxidative stress may promote a safer way of inducing anesthesia. Furthermore, surgery itself leads to increased ROS production and ischemia/reperfusion injury. Indeed, increased perioperative oxidative stress has been correlated with increased postoperative complications and prolonged recovery. Anesthesiologists care for patients during the whole spectrum of perioperative care and thus are in a unique position to deliver countermeasures to oxidative stress. Using preferentially an induction agent which reduces oxidative stress might lead to better clinical outcomes and fewer postoperative complications. Propofol has been shown in several studies to reduce oxidative stress, which reduces postoperative complications and leads to a faster recovery, and thus might represent the preferred induction agent in the right clinical setting.

The Atherosclerotic Profile of a Young Symptomatic Population between 19 and 49 Years: Coronary Computed Tomography Angiography or Coronary Artery Calcium Score?

(1) Background: Whether coronary computed tomography angiography (CTA) or the coronary artery calcium score (CACS) should be used for diagnosis of coronary heart disease, is an open debate. The aim of our study was to compare the atherosclerotic profile by coronary CTA in a young symptomatic high-risk population (age, 19-49 years) in comparison with the coronary artery calcium score (CACS). (2) Methods: 1137 symptomatic high-risk patients between 19-49 years (mean age, 42.4 y) who underwent coronary CTA and CACS were stratified into six age groups. CTA-analysis included stenosis severity and high-risk-plaque criteria (3) Results: Atherosclerosis was more often detected based on CTA than based on CACS (45 vs. 27%; p < 0.001), 50% stenosis in 13.6% and high-risk plaque in 17.7%. Prevalence of atherosclerosis was low and not different between CACS and CTA in the youngest age groups (19-30 y: 5.2 and 6.4% and 30-35 y: 10.6 and 16%). In patients older than >35 years, the rate of atherosclerosis based on CTA increased (p = 0.004, OR: 2.8, 95%CI:1.45-5.89); and was higher by CTA as compared to CACS (34.9 vs. 16.7%; p < 0.001), with a superior performance of CTA. In patients older than 35 years, stenosis severity (p = 0.002) and >50% stenosis increased from 2.6 to 12.5% (p < 0.001). High-risk plaque prevalence increased from 6.4 to 26.5%. The distribution of high-risk plaque between CACS 0 and >0.1 AU was similar among all age groups, with an increasing proportion in CACS > 0.1 AU with age. A total of 24.9% of CACS 0 patients had coronary artery disease based on CTA, 4.4% > 50% stenosis and 11.5% had high-risk plaque. (4) Conclusions: In a symptomatic young high-risk population older than 35 years, CTA performed superior than CACS. In patients aged 19-35 years, the rate of atherosclerosis was similar and low based on both modalities. CACS 0 did not rule out coronary artery disease in a young high-risk population.

Identifying the Location of an Accessory Pathway in Pre-Excitation Syndromes Using an Artificial Intelligence-Based Algorithm.

(1) Background: The exact anatomic localization of the accessory pathway (AP) in patients with Wolff-Parkinson-White (WPW) syndrome still relies on an invasive electrophysiologic study, which has its own inherent risks. Determining the AP localization using a 12-lead ECG circumvents this risk but is of limited diagnostic accuracy. We developed and validated an artificial intelligence-based algorithm (location of accessory pathway artificial intelligence (locAP AI)) using a neural network to identify the AP location in WPW syndrome patients based on the delta-wave polarity in the 12-lead ECG. (2) Methods: The study included 357 consecutive WPW syndrome patients who underwent successful catheter ablation at our institution. Delta-wave polarity was assessed by four independent electrophysiologists, unaware of the site of successful catheter ablation. LocAP AI was trained and internally validated in 357 patients to identify the correct AP location among 14 possible locations. The AP location was also determined using three established tree-based, ECG-based algorithms (Arruda, Milstein, and Fitzpatrick), which provide limited resolutions of 10, 5, and 8 AP locations, respectively. (3) Results: LocAP AI identified the correct AP location with an accuracy of 85.7% (95% CI 79.6-90.5, p < 0.0001). The algorithms by Arruda, Milstein, and Fitzpatrick yielded a predictive accuracy of 53.2%, 65.6%, and 44.7%, respectively. At comparable resolutions, the locAP AI achieved a predictive accuracy of 95.0%, 94.9%, and 95.6%, respectively (p < 0.001 for differences). (4) Conclusions: Our AI-based algorithm provided excellent accuracy in predicting the correct AP location. Remarkably, this accuracy is achieved at an even higher resolution of possible anatomical locations compared to established tree-based algorithms.

Bicuspid Aortic Valve Is Associated with Less Coronary Calcium and Coronary Artery Disease Burden.

(1) Background. Bicuspid aortic valve (BAV) is associated with genetic defects (NOTCH 1, GATA 5) and aortopathy. Differences in the flow patterns and a genetic predisposition could also affect coronary arteries. The objective was to assess the coronary artery calcium score (CACS) and coronary artery disease (CAD) burden by coronary computed tomography angiography (CTA) in patients with BAV stenosis, as compared to stenotic tricuspid aortic valves (TAV). (2) Methods. A retrospective case-control study. A total of 47 patients with BAV stenosis (68.9 years ± 12.9, 38.3% females) who underwent CTA were matched with 47 TAV stenosis patients for age, gender, smoking, arterial hypertension, dyslipidemia, diabetes, body-mass-index and chronic kidney disease. (3) Results. The coronary artery calcium score (CACS) was lower in BAV (237.4 vs. 1013.3AU; p < 0.001) than in TAV, and stenosis severity was less (CAD-RADTM: p < 0.001). More patients with BAV had CACS zero (27.7% vs. 0%; p < 0.001). The majority (68.1%) of patients with BAV had no or non-obstructive CAD but only 25.5% of TAV (p < 0.001). Obstructive CAD (>50% stenosis) by CTA was more frequently observed in patients with TAV (68.1%; p < 0.001). (4) Conclusions and Relevance. Patients with BAV stenosis have markedly less coronary calcium and less severe coronary stenosis. CTA succeeds to rule out obstructive CAD in the majority of BAV, with adherent implications for TAVR planning.

Smoking and obesity predict high-risk plaque by coronary CTA in low coronary artery calcium score (CACS).

BACKGROUND: The AHA recommends statins in patients with CACS>100 AU. However in patients with low CACS (1-99 AU), no clear statement is provided, leaving the clinician in a grey-zone. High-risk plaque (HRP) criteria by coronary CTA are novel imaging biomarkers indicating a higher a-priori cardiovascular (CV) risk, which could help for decision-making. Therefore the objective of our study was to identify which CV-risk factors predict HRP in patients with low CACS 1-99. METHODS: 1003 symptomatic patients with low-to-intermediate risk, a clinical indication for coronary computed tomography angiography (CCTA) and who had a coronary artery calcium score (CACS) between 1 and 99 AU, were enrolled. CCTA analysis included: stenosis severity and HRP-criteria: low-attenuation plaque (LAP <30HU, <60HU and <90HU) napkin-ring-sign, spotty calcification and positive remodeling. Multivariate regression models were created for predicting HRP-criteria by the major 5 cardiovascular risk factors (CVRF) (smoking, arterial hypertension, positive family history, dyslipidemia, diabetes) and obesity (BMI>25 â€‹kg/m2). RESULTS: 304 (33.5%) were smokers. 20.4% of smokers had HRP compared with only 14.9% of non-smokers (p â€‹= â€‹0.045). Male gender was associated with HRP (p â€‹< â€‹0.001). Smoking but not the other 5 CVRF had the most associations with HRP-criteria (LAP<60HU/≥2 criteria:OR 1.59; 95%CI:1.07-2.35), LAP<90HU (OR 1.57; 95%CI:1.01-2.43), Napkin-Ring-Sign (OR 1.78; 95%CI:1.02-3.1) and positive remodelling (OR 1.54; 95%CI:1.09-2.19). Smoking predicted fibrofatty LAP<90HU in males only. Obesity predicted LAP<60HU in both females and males. CONCLUSIONS: In patients with low CACS 1-99AU, male gender, smoking and obesity, but not the other CVRF predict HRP. These patients would rather benefit from intensification of primary CV-prevention measures such as statins.

Gender Differences in the Atherosclerosis Profile by Coronary CTA in Coronary Artery Calcium Score Zero Patients.

Background: The coronary artery calcium score (CACS) is a powerful tool for cardiovascular risk stratification. Coronary computed tomography angiography (CTA) allows for a more distinct analysis of atherosclerosis. The aim of the study was to assess gender differences in the atherosclerosis profile of CTA in patients with a CACS of zero. Methods: A total of 1451 low- to intermediate-risk patients (53 ± 11 years; 51% females) with CACS <1.0 Agatston units (AU) who underwent CTA and CACS were included. Males and females were 1:1 propensity score-matched. CTA was evaluated for stenosis severity (Coronary Artery Disease - Reporting and Data System (CAD-RADS) 0-5: minimal <25%, mild 25-49%, moderate 50-69%, severe ≥70%), mixed-plaque burden (G-score), and high-risk plaque (HRP) criteria (low-attenuation plaque, spotty calcification, napkin-ring sign, and positive remodeling). All-cause mortality, cardiovascular mortality, and major cardiovascular events (MACEs) were collected. Results: Among the patients, 88.8% had a CACS of 0 and 11.2% had an ultralow CACS of 0.1-0.9 AU. More males than females (32.1% vs. 20.3%; p < 0.001) with a CACS of 0 had atherosclerosis, while, among those with an ultralow CACS, there was no difference (88% vs. 87.1%). Nonobstructive CAD (25.9% vs. 16.2%; p < 0.001), total plaque burden (2.2 vs. 1.4; p < 0.001), and HRP were found more often in males (p < 0.001). After a follow-up of mean 6.6 ± 4.2 years, all-cause mortality was higher in females (3.5% vs. 1.8%, p = 0.023). Cardiovascular mortality and MACEs were low (0.2% vs. 0%; p = 0.947 and 0.3% vs. 0.6%; p = 0.790) for males vs. females, respectively. Females were more often symptomatic for chest pain (70% vs. 61.6%; p = 0.004). (4) Conclusions: In patients with a CACS of 0, males had a higher prevalence of atherosclerosis, a higher noncalcified plaque burden, and more HRP criteria. Nonetheless, females had a worse long-term outcome and were more frequently symptomatic.

Long-Term Technical Performance of the Osypka QT-5® Ventricular Pacemaker Lead.

BACKGROUND: Lead-associated complications and technical issues in patients with cardiac implantable electronic devices are common but underreported in the literature. METHODS: All patients undergoing implantation of the Osypka QT-5® ventricular lead at the University Clinic St. Pölten between 1 January 2006 and 31 December 2012 were retrospectively analyzed (n = 211). Clinical data including pacemaker follow-up examinations and the need for lead revisions were assessed. Kaplan-Meier analysis to estimate the rate of lead dysfunction during long-term follow-up was conducted. RESULTS: Patients were followed for a median of 5.2 years (interquartile range (IQR) 2.0-8.7). R-wave sensing properties at implantation, compared to last follow-up, remained basically unchanged: 9.9 mV (IQR 6.8-13.4) and 9.6 mV (IQR 5.6-12.0), respectively). Ventricular pacing threshold significantly increased between implantation (0.5 V at 0.4 ms; IQR 0.5-0.8) and the first follow-up visit (1.0 V at 0.4 ms; IQR 0.8-1.3; p < 0.001) and this increase persisted throughout to the last check-up (0.9 V at 0.4 ms; IQR 0.8-1.2). Impedance significantly declined from 1142 Ω (IQR 955-1285) at implantation to 814 Ω (IQR 701-949; p < 0.001) at the first check-up, followed by a further decrease to 450 Ω (IQR 289-652; p < 0.001) at the last check-up. Overall, the Osypka QT-5® ventricular lead was replaced in 36 patients (17.1%). CONCLUSIONS: This report shows an unexpected high rate of technical issues of the Osypka QT-5® ventricular lead during long-term follow-up.

Reciprocal communication of pericoronary adipose tissue and coronary atherogenesis.

OBJECTIVE: Pericoronary adipose tissue (PCAT) has been linked to underlying coronary artery disease (CAD) and proposed to modulate adjacent atherosclerotic plaque formation over pro-inflammatory pathways. In vitro and ex vivo studies support the bilateral communication of adipose tissue and vessel wall. We quantified PCAT and its dynamics in a low coronary risk cohort with a semi-automated software in serial coronary computed tomography angiography (CTA). METHODS: We retrospectively included patients from a tertiary care hospital who underwent serial coronary CTA with a low cardiovascular risk profile. All examinations were evaluated in a standardized approach: epicardial adipose tissue (EAT) volume and attenuation was quantified in total, in the atrioventricular (RCA, LCX) or interventricular (LAD) sulcus and within a 5 mm radius for each coronary artery (PCAT). Coronary plaques were quantified using a semi-automated software and compared for progression, stability or regression. RESULTS: Of 120 patients (27% females), 59.2% showed atherosclerotic plaques. After 36 months mean follow-up, 22 (18.3%) showed plaque regression, 39 (32.5%) were stable and 49 (40.8%) were progressive. Total EAT volume decreased by -15.6 ±â€¯37.2 mm³ in the regressive group, increased by 2.7 ±â€¯30.6 mm³ in the stable group and by 24.3 ±â€¯37.1 mm³ in the progressive group (p = 0.003). Per-vessel analysis showed a significant decrease of PCAT attenuation in patients with CAD regression (-3.8 ±â€¯7.6HU) compared to the stable (1.2 ±â€¯9.1HU) and progressive group (3.5 ±â€¯8.2HU, p < 0.0001). Mean sulcus EAT attenuation did not show a significant change (p = 0.135). CONCLUSION: Epicardial adipose tissue volume is mutually changing with the progression or regression of coronary artery disease. Perivascular but not epicardial attenuation levels correlate to adjacent plaque and support a direct bilateral influence.

Coronary atherosclerosis profile in patients with end-stage liver disease prior to liver transplantation due to alcoholic fatty liver: a coronary CTA study.

OBJECTIVES: To assess the coronary atherosclerosis profile by coronary computed tomography angiography (CTA) in patients with end-stage liver disease (ESLD) due to alcohol-related liver disease (ARLD) evaluated for liver transplantation (LT), in a retrospective matched case-controlled cohort study. METHODS: One hundred forty patients (age 60.6 years ± 9.8, 20.7% females) who underwent coronary CTA were included. Seventy patients with ESLD due to ARLD (ESLD-alc) were propensity score (1:1) matched for age, gender, and the major 5 cardiovascular risk factors with healthy controls. CTA analysis included the following: stenosis severity according to CAD-RADS as (0) = no, (1) minimal < 25%, (2) mild 25-50%, (3) moderate 50-70%, and (4) severe > 70% stenosis, total mixed plaque burden weighted for non-calcified component (G-score) and high-risk plaque criteria (Napkin-Ring, low attenuation plaque, spotty calcification, positive remodeling). RESULTS: Prevalence of coronary artery disease (CAD) was high (84.4%) in the ESLD-alc group but similar to controls. Stenosis severity was similar (CAD-RADS, 1.9 vs. 2.2, p = 0.289). High-grade stenosis (> 70%) was observed in 12.5% of ESLD-alc patients. High-risk plaques were less frequent in the ESLD-alc cohort as compared to controls (4.5% vs. 37.5%, p < 0.001), and total mixed plaque burden was lower (G-score, 4.9 versus 7.4, p = 0.001). Plaque density was lower in controls (56.6HU ± 3.2 vs. 91.3HU ± 4.5, p = 0.007) indicating more lipid-rich in controls, but higher mixed fibro-calcific plaque component in those with alcohol-related ESLD. CONCLUSION: Patients with alcohol-related ESLD exhibit more mixed fibro-calcified plaques but less plaque with high-risk features and less fibro-fatty plaque burden, while total CAD prevalence is high. KEY POINTS: • Patients with ESLD prior to LT have a high total prevalence of CAD and stenosis severity, which is similar to those of healthy controls with an identical cardiovascular risk profile. • Patients with ESLD prior to LT due to alcohol abuse have more calcific but less fibro-fatty plaque and less high-risk plaque. • CTA seems to be a useful imaging technique for risk stratification prior to LT.

Central Sleep Apnea and Pacing-Induced Cardiomyopathy.

The role of central sleep apnea (CSA) in pacing-induced cardiomyopathy (PICM) remains speculative. In a prospective trial entitled UPGRADE, the presence of CSA was assessed by single-night polysomnography (PSG) in 54 PICM patients within 1 month after left ventricular lead implantation (with biventricular stimulation still not activated). CSA was diagnosed in half of patients (n = 27). Patients with moderate or severe CSA were randomized to cardiac resynchronization therapy (CRT) versus right ventricular pacing (RVP) in a double-blinded cross-over design and re-scheduled for a follow-up PSG within 3 to 5 months. After crossing-over of stimulation mode another PSG was conducted 3 to 5 months later. CRT led to a significant increase in left ventricular ejection fraction and significant reduction in left ventricular end systolic volumes and N-terminal pro brain natriuretic peptide plasma levels, whereas no significant effects were observed with ongoing RVP. CSA was significantly improved after 3.9 (3.2 to 4.4) months of CRT: apnea-hypopnea index decreased from 39.1 (32.1 to 54.0) events per hour at baseline to 22.2/h (10.9 to 36.7) by CRT (p <0.001). Central apnea index decreased from 27.1/h (17.7 to 36.1) at baseline to 6.8/h (1.1 to 14.4) after CRT activation (p <0.001). Ongoing RVP yielded only a minor improvement in apnea-hypopnea index and central apnea index. Pre-existent CSA did not affect structural response rate and had no impact on mid-term follow-up (median 2.8 years). In conclusion, CSA is highly prevalent in patients with PICM. CRT upgrading significantly improves CSA leading to a similar outcome in PICM patients without pre-existent CSA.

Supplemental dataset on the influence of cardiac resynchronisation therapy in pacing-induced cardiomyopathy and concomitant central sleep Apnea.

This article contains supplemental data to the publication "Central Sleep Apnea and Pacing-Induced Cardiomyopathy" [1], which was the most recent publication of the "UPGRADE" study. It provides in-depth analysis of the effects of cardiac resynchronisation therapy (CRT) in patients suffering from pacing-induced cardiomyopathy (PICM) on cardiac remodeling as well as functional cardiac parameters in comparison to continuous right ventricular pacing (RVP). Furthermore, it also covers additional data on several sleep parameters, which were not presented in the main article including the index for obstructive sleep apnea (OSA), the index for mixed sleep apnea and the oxygen saturation measurements during polysomnography. Further, Kaplan-Meier curves are presented for major adverse cardiac events (MACE) and overall mortality by severity of sleep apnea. Generally, the "UGRADE" study was a single-center prospective double-blinded randomized controlled trial lasting from 2014 to 2020. The methodology included a cross-over design giving the possibility to detect differences while CRT was activated and while continuous RVP was applied. The presented data should aid clinicians in daily practice as upgrading to CRT is not limited to improvement in cardiac parameters, but also modifies sleep apnea in patients with PICM, a generally sparsely studied entity of heart failure.