Pre-discharge 18F-Flourodeoxyglucose uptake pattern following transcatheter aortic-valve replacement and adverse prognostic features in aortic stenosis.

18F-Flourodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) has been shown to be of utility in transcatheter aortic valve replacement (TAVR) patients with suspected prosthetic valve endocarditis. In the present study, we sought to analyze the relationship between 18F-FDG-PET/CT performed before discharge in TAVR patients and adverse prognostic features of aortic stenosis. We analyzed the association between 18F-FDG-PET/CT uptake pattern and degree of left ventricular mass index, aortic root dilatation, and aortic leaflet calcification extent. This is the first study to demonstrate that pre-discharge 18F-FDG-PET/CT in patients undergoing TAVR shows a significant negative correlation between 18F-FDG uptake pattern and adverse prognostic features.

Native aortic leaflets and permanent pacemaker implantation risk following balloon-expandable transcatheter aortic valve implantation.

OBJECTIVE: Permanent pacemaker implantation (PPI) risk is higher following transcatheter aortic valve implantation (TAVI) than surgical valve replacement. Native aortic leaflets are retained in patients undergoing TAVI, unlike in surgical valve replacement. Whether the retained leaflets influence PPI risk because of their proximity to the conduction system is unknown. The study sought to determine the association between infra-annular extension of native right coronary cusp/noncoronary cusp (RCC/NCC) post balloon-expandable TAVI and PPI risk. METHODS: We performed a retrospective analysis of 190 patients undergoing balloon-expandable TAVI at a single center. Manifestation of infra-annular extension of RCC/NCC was considered to be present when part of leaflet extended below aortic-annular plane on post-implantation aortic-root angiography. RESULTS: Infra-annular extension of RCC/NCC was observed in 33 patients (17.37%). PPI incidence post-TAVI was higher in patients with infra-annular extension of RCC/NCC than in those without (36.36% versus 8.92%, relative-risk: 4.08, p˂0.0001). On logistic-regression analysis, preexisting right bundle-branch block (RBBB) (odds-ratio: 12.73, 95% confidence-interval: 2.16-74.93, p = 0.005), and infra-annular extension of RCC/NCC (odds-ratio: 5.63, 95% confidence-interval: 2.17-14.58, p < 0.0001) were independently associated with PPI risk. Preexisting RBBB (φ = +0.25, p = 0.001) and infra-annular extension of RCC/NCC (φ = +0.30, p < 0.0001) showed a positive-correlation with PPI risk. Infra-annular extension of RCC/NCC was a significant predictor of PPI risk on receiver-operating-characteristic curve analysis (area under-the-curve 0.67; 95% confidence-interval: 0.54-0.79, p = 0.006). CONCLUSION: The retained native aortic leaflets play a significant role in PPI risk following balloon-expandable TAVI. Infra-annular extension of RCC/NCC is a novel predictor, and is associated with a four-fold higher risk of PPI.

Outcomes Following Radiofrequency Renal Denervation According to Antihypertensive Medications: Subgroup Analysis of the Global SYMPLICITY Registry DEFINE.

BACKGROUND: The Global SYMPLICITY Registry DEFINE (Denervation Findings in Real World) investigates radiofrequency renal denervation (RDN) in a broad range of patients with hypertension. We evaluated whether the number or type of antihypertensive medications were associated with increased long-term blood pressure (BP) reductions and cardiovascular outcomes following radiofrequency RDN. METHODS: Patients underwent radiofrequency RDN and were categorized by baseline number (0-3 and ≥4) and different combinations of medication classes. BP changes were compared between groups through 36 months. Individual and composite major adverse cardiovascular events were analyzed. RESULTS: Of 2746 evaluable patients, 18% were prescribed 0 to 3 and 82% prescribed ≥4 classes. At 36 months, office systolic BP significantly decreased (P<0.0001) by -19.0±28.3 and -16.2±28.6 mm Hg in the 0 to 3 and ≥4 class groups, respectively. Twenty-four-hour mean systolic BP significantly decreased (P<0.0001) by -10.7±19.7 and -8.9±20.5 mm Hg, respectively. BP reduction was similar between the medication subgroups. Antihypertensive medication classes decreased from 4.6±1.4 to 4.3±1.5 (P<0.0001). Most decreased (31%) or had no changes (47%) to the number of medications, while 22% increased. The number of baseline antihypertensive medication classes was inversely related to the change in prescribed classes at 36 months (P<0.001). Cardiovascular event rates were generally low. More patients in the ≥4 compared with 0 to 3 medication classes had myocardial infarction at 36 months (2.8% versus 0.3%; P=0.009). CONCLUSIONS: Radiofrequency RDN reduced BP safely through 36 months, independent of the number and type of baseline antihypertensive medication classes. More patients decreased than increased their number of medications. Radiofrequency RDN is a safe and effective adjunctive therapy regardless of antihypertensive medication regimen. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01534299.

Cardiovascular Risk Reduction After Renal Denervation According to Time in Therapeutic Systolic Blood Pressure Range.

BACKGROUND: Renal denervation (RDN) has been shown to lower blood pressure (BP), but its effects on cardiovascular events have only been preliminarily evaluated. Time in therapeutic range (TTR) of BP is associated with cardiovascular events. OBJECTIVES: This study sought to assess the impact of catheter-based RDN on TTR and its association with cardiovascular outcomes in the GSR (Global SYMPLICITY Registry). METHODS: Patients with uncontrolled hypertension were enrolled and treated with radiofrequency RDN. Office and ambulatory systolic blood pressure (OSBP and ASBP) were measured at 3, 6, 12, 24, and 36 months postprocedure and used to derive TTR. TTR through 6 months was assessed as a predictor of cardiovascular events from 6 to 36 months using a Cox proportional hazard regression model. RESULTS: As of March 1, 2022, 3,077 patients were enrolled: 42.2% were female; mean age was 60.5 ± 12.2 years; baseline OSBP was 165.6 ± 24.8 mm Hg; and baseline ASBP was 154.3 ± 18.7 mm Hg. Patients were prescribed 4.9 ± 1.7 antihypertensive medications at baseline and 4.8 ± 1.9 at 36 months. At 36 months, mean changes were -16.7 ± 28.4 and -9.0 ± 20.2 mm Hg for OSBP and ASBP, respectively. TTR through 6 months was 30.6%. A 10% increase in TTR after RDN through 6 months was associated with significant risk reductions from 6 to 36 months of 15% for major adverse cardiovascular events (P < 0.001), 11% cardiovascular death (P = 0.010), 15% myocardial infarction (P = 0.023), and 23% stroke (P < 0.001). CONCLUSIONS: There were sustained BP reductions and higher TTR through 36 months after RDN. A 10% increase in TTR through 6 months was associated with significant risk reductions in major cardiovascular events from 6 to 36 months. (Global SYMPLICITY Registry [GSR] DEFINE; NCT01534299).

One-Year Outcomes for Patients Undergoing Transcatheter Aortic Valve Replacement: The Gulf TAVR Registry.

BACKGROUND: The use of transcatheter aortic valve replacement (TAVR) is steadily increasing with TAVR procedures offered to patients across the entire spectrum of surgical risks. The Gulf TAVR registry captures the demographics of patients undergoing TAVR in the Gulf region, comorbidities that drive outcomes, procedural success, complications, and one-year outcomes of death or rehospitalization. METHODS: This is a retrospective cohort study for adult patients aged at least 18 years undergoing TAVR at eight centers in the Gulf region. The primary outcome was a composite of death or re-hospitalization at one-year. Secondary outcomes included the individual components of the composite, stroke, and myocardial infarction (MI). We used multivariable Cox regression to determine factors associated with the composite endpoint. RESULTS: A total of 795 patients (56% male) were included in the final analysis with a mean age of 74.6 (standard deviation (SD) 8.9) years, Society of Thoracic Surgeons Score (STS) Score 4.9 (4.2), ejection fraction of 53% (12.7%). Transfemoral approach was employed in over 95% (762/795). The primary outcomes rate was 12.8% (95% confidence interval [CI]: 10.6-15.4); secondary endpoints were death 5.4% (95% CI 4.0-7.2); stroke 0.8% (95% CI 0.3, 1.7), MI 0.8% (95% CI 0.4-1.9), rehospitalization: 9.3% (95% CI 7.5-11.5) of whom 71.6% were related to cardiovascular causes. 77% of the cardiovascular admissions were attributable to heart failure or the need for pacemaker implantation. Stage IV or V chronic kidney disease was significantly associated with the primary composite endpoint (Hazard Ratio: 2.49, [95% CI: 1.31, 4.73], p = 0.005). Although not significant, paravalvular leak and severe left ventricular dysfunction showed a 2-fold and 3-fold increased risk for the composite endpoint, respectively. CONCLUSIONS: The Gulf TAVR registry is the first of its kind in the region. It profiles an elderly population with a high procedural success rate and a low rate of complications. One-year outcomes were primarily driven by repeat hospitalization for heart failure and pacemaker implantation indicating a need to optimize heart failure management and improve algorithms for the detection of conduction abnormalities.

Sonographic chest B-lines anticipate elevated B-type natriuretic peptide level, irrespective of ejection fraction.

BACKGROUND: Echocardiography and the N-terminal pro-brain-type natriuretic peptide (NT-proBNP) level are important tests for assessing left ventricular function in patients presenting to the emergency department with acute dyspnea. Chest ultrasound is becoming an important tool in diagnosing acute pulmonary edema. AIM: To assess the diagnostic accuracy of chest ultrasound examination using echocardiography and a curvilinear probe for detecting B-lines in patients presenting with acute pulmonary edema compared with assessment using NT-proBNP. METHODS: This paper reports a prospective observational study of 61 consecutive patients presenting with symptoms and signs of pulmonary edema and B-profile detected by echocardiography with a 5 MHz curvilinear probe. The emergency department physicians ordered NT-proBNP levels, and critical care physicians trained in ultrasound examination performed echocardiography and chest ultrasounds. The findings of the chest ultrasound were reviewed by another senior physician. RESULTS: Sixty-one participants were enrolled over a period of 6 months (49.2 % male, with a mean age 66.8). Forty-seven of the 61 patients had a B-profile. The median NT-proBNP level in the patients with B-profile was 6200, compared with the mean level in the patients with an A-profile of 180 (CI 0.33-0.82). The distributions in the two groups differed significantly (p = 0.034). Based on a threshold level of NT-proBNP in relation to age, the sensitivity and specificity (including the 95 % confidence interval) were determined; the sensitivity of finding B-profile on ultrasound was 92.0 %, and the specificity was 91.0 %. The positive predictive value of the B-profile was 97.0 %, and the negative predictive value was 71.0 %. The systolic function in the subjects with a B-profile was below 50 in 84.3 % of the subjects and normal in 15.7 % of the subjects. An A-profile was present in all of the subjects with systolic function >55 %. In the subjects with a B-profile, 94 % had a Framingham score of CHF >4; the subjects with all A-profile had scores <4, p < 0.0001. There was an NHANES score of >3 in 96 % of the subjects with a B-profile, and all of the subjects with an A-profile had scores <3 (p < 0.0001). CONCLUSIONS: Detecting the B-profile with an echocardiography probe (curvilinear 5 MHz) in lung ultrasound is highly sensitive and specific for elevated NT-proBNP helping in diagnosing pulmonary edema, although of resolution inferior to micro convex probes.

ST elevation without myocardial infarction.

Acute myocarditis may mimic myocardial infarction because the affected patients report 'classical' chest pain; the ECG changes and echocardiography are identical to those observed in acute coronary syndromes, and serum markers are increased. We describe a case with ST segment elevation on admission ECG, and coronary angiography was normal. Cardiac magnetic resonance with myocardial delayed enhancement sequences is a non-invasive alternative for diagnosing myocarditis.