Incidence of endoleak type IA in patients undergoing chimney endovascular aortic repair (ChEVAR) vs. standard endovascular repair.

Objectives: Almost half of endovascular aortic aneurysm repair (EVAR) procedures are performed in hostile anatomy, increasing the risk of procedure related complications such as type IA endoleaks, which may be prevented with the chimney technique in EVAR (ChEVAR). Our aim is to describe the differential characteristics between EVAR in favorable anatomy and ChEVAR in hostile necks. Materials and methods: A cohort of patients with infrarenal abdominal aortic aneurysms (AAA) that were treated with EVAR or ChEVAR were included. The primary outcome was the incidence of type IA endoleak. Secondary outcomes were the rate of chimney occlusion, reintervention, migration, rupture, acute limb ischemia, sac growth, and aneurysm-related mortality during the follow-up period. Results: . With a median follow-up of 11.5 months, 79 patients were treated with EVAR and 21 with ChEVAR. The overall age was 76.49 ± 7.32 years old, and 82% were male. The ChEVAR cohort had a higher prevalence of tobacco use than the EVAR cohort (38.1% vs. 17.7%, p = 0.041), and a shorter neck (7.88 mm ± 5.73 vs 36.28 mm ± 13.73, p<0.001). There were no differences in type IA endoleak incidence between the groups (a single endoleak type IA in the EVAR group, p = 0.309). One patient experienced an asymptomatic chimney occlusion in the ChEVAR group, and another patient required a reintervention due to chimney occlusion. Sac regression and reinterventions were not different between groups. There were no migration, rupture, acute limb ischemia, or aneurysm-related mortality events. Conclusions: . In patients with abdominal aortic aneurysms, ChEVAR in hostile necks had similar event rates to EVAR in favorable necks.

Objetivos: Aproximadamente la mitad de las reparaciones endovasculares de aneurisma de aorta abdominal (AAA) son realizadas en anatomías hostiles, incrementando el riesgo de complicaciones como endoleaks tipo IA. La técnica con chimeneas (ChEVAR) es una alternativa para disminuir el riesgo de complicaciones en cuellos hostiles. Nuestro objetivo es comparar ambas técnicas (ChEVAR y reparación endovascular convencional [EVAR]) en nuestra medio. Materiales y métodos: Se realizó un trabajo de cohorte retrospectivo en pacientes con AAA tratados con EVAR o ChEVAR. El punto final primario fue la incidencia de endoleak tipo IA. Los puntos finales secundarios fueron la incidencia de oclusión de chimeneas, reintervención, migración, ruptura del saco, isquemia aguda de miembros, crecimiento del saco o mortalidad asociada al aneurisma durante el seguimiento. Resultados: Tras una mediana de seguimiento de 11,5 meses, 79 pacientes fueron tratados con EVAR y 21 con chEVAR. La edad promedio fue de 76,49 ± 7,32 años y 82% fueron de sexo masculino. Los pacientes con chEVAR tuvieron mayor prevalencia de consumo tabáquico que los pacientes con EVAR (38,1% vs. 17,7%, p=0,041) y un cuello más corto (7,88 mm ± 5,73 vs. 36,28 mm ± 13,73, p<0,001). No hubo diferencia de endoleak tipo IA entre los grupos. Dos pacientes presentaron la oclusión total de la chimenea, uno de los cuales requirió reintervención. No hubo diferencias en la regresión del tamaño del saco, así como tampoco hubo eventos de migración, ruptura, isquemia del miembro o mortalidad asociada al aneurisma. Conclusiones: En pacientes con AAA, la técnica ChEVAR en cuellos hostiles tuvo eventos similares que EVAR en cuellos favorables.

Clinical and Pharmacological Implications of Time to Treatment with Interleukin-1 Blockade in ST-Segment Elevation Myocardial Infarction.

Interleukin-1 (IL-1) blockade with anakinra given within 12 hours from reperfusion has been shown to reduce the inflammatory response as well as prevent heart failure (HF) events in patients with STEMI. We sought to determine whether time-to-treatment influences the efficacy of anakinra on systemic inflammation and incidence of HF events in patients with STEMI. We divided the cohort in two groups base6d on the median time from percutaneous coronary intervention (PCI) to investigational drug, and analyzed the effects of anakinra on the area-under-the-curve for C reactive protein (AUC-CRP) and on incidence of the composite endpoint of death or new onset HF. We analyzed data from 139 patients: 84 (60%) treated with anakinra and 55 (40%) with placebo. The median time from PCI to investigational treatment was 271 (182-391) minutes. The AUC-CRP was significantly higher in patients receiving placebo versus anakinra both in those with time from PCI to treatment <271 minutes (222.6 [103.9-325.2] vs. 78.4 [44.3-131.2], P < 0.001) and those with time from PCI to treatment ≥271 minute (235.2 [131.4-603.4] vs. 75.5 [38.9-171.9], P < 0.001) (P > 0.05 for interaction). Anakinra significantly reduced the combined endpoint of death or new onset HF in patients with time from PCI to treatment <271 minutes (5 [11%] vs. 9n[36%], log-rank χ 2 5.985, P = 0.014) as well as in patients with time from PCI to drug ≥271 minutes (2n[5%] vs. 7 [23%], log-rank χ 2 3.995, P = 0.046) (P > 0.05 for interaction). IL-1 blockade with anakinra blunts the acute systemic inflammatory response and prevents HF events independent of time-to-treatment. SIGNIFICANCE STATEMENT: In patients with ST segment elevation presenting within 12 hours of pain onset and treated within 12 hours of reperfusion, interleukin-1 blockade with anakinra blunts the acute systemic inflammatory response, a surrogate of interleukin-1 activity, and prevents heart failure events independent of time-to-treatment.

Cancer incidence and mortality in patients diagnosed with heart failure: results from an updated systematic review and meta-analysis.

BACKGROUND: Several cohort studies aimed at demonstrating an increased risk of cancer incidence and mortality in patients with a pre-existing diagnosis of heart failure (HF); however, conflicting results have been reported that call for systematic review and meta-analysis. METHODS: We conducted a systematic search of multiple databases from their inception through July 2022 and retrieved only papers reporting hazard ratios (HR). Random and fixed-effects models were fit for the study duration. RESULTS: The analysis included nine cohort studies for a total of 515'041 HF cases and 1'365'452 controls without HF. Although high heterogeneity among studies was observed, the HR for incident cancer in HF patients was statistically significant (1.45, 95% CI 1.31-1.61, p < 0.0001), which was confirmed by sensitivity analyses; however, by analyzing the few papers reporting HRs for cancer mortality, no significant difference between HF and non-HF patients could be detected (HR 2.03, 95% CI [0.93-4.43], p = 0.0736). Further scrutiny of studies with adjusted HRs, when available, confirmed that cancer incidence was significantly increased in patients with HF, as was cancer mortality as well. CONCLUSIONS: This meta-analysis shows that HF patients are at an increased risk of incident cancer. Increased mortality could not be firmly demonstrated by the available data. Our results call for inclusion of cancer-related endpoints in HF trials to adequately address this important clinical issue.

Sarcopenic Obesity Is Associated With Reduced Cardiorespiratory Fitness Compared With Nonsarcopenic Obesity in Patients With Heart Failure With Reduced Ejection Fraction.

BACKGROUND: Sarcopenia impairs cardiorespiratory fitness (CRF) in patients with heart failure with reduced ejection fraction (HFrEF). Obesity has also been shown to impair CRF; however, the effects of sarcopenia on CRF in patients with obesity and HFrEF are unknown. The aim of this analysis was to examine differences in CRF between patients with sarcopenic obesity (SO) and non-SO (NSO) with HFrEF. We also assessed associations between skeletal muscle mass index (SMMI) and CRF. METHODS: Forty patients with HFrEF and obesity underwent cardiopulmonary exercise testing to collect measures of CRF including peak oxygen consumption (VO2), circulatory power, oxygen uptake efficiency slope, O2 pulse, and exercise time. Body composition was performed in all patients using bioelectrical impedance analysis to quantify fat mass index and divide patients into SO and NSO based on SMMI cutoffs. Results are presented as mean (SD) or median [interquartile range] as appropriate. RESULTS: Nearly half (43% [n=17]) of patients had SO. Patients with SO had a lower SMMI than those with NSO, and no differences in fat mass index were observed between groups. Those with SO achieved a lower absolute peak VO2 (NSO, 1.62±0.53 L·min-1 versus SO, 1.27±0.44 L·min-1, P=0.035), oxygen uptake efficiency slope (NSO, 1.92±0.59 versus SO, 1.54±0.48, P=0.036), and exercise time (NSO, 549±198 seconds versus SO, 413±140 seconds, P=0.021) compared to those with NSO. On multivariate analysis, SMMI remained a significant predictor of absolute peak VO2 when adjusted for age, sex, adiposity, and HF severity. CONCLUSIONS: In patients with HFrEF and obesity, sarcopenia, defined as low SMMI, is associated with a clinically significant reduction in CRF, independent of adiposity.

Comparison of Different Stenting Techniques in Left Main Bifurcation Disease: Evidence From a Network Meta-Analysis.

OBJECTIVES: We aimed to assess which bifurcation technique performs best in unprotected left-main (LM) percutaneous coronary intervention (PCI). BACKGROUND: Provisional stenting was considered the preferred technique for LM bifurcation PCI due to the supposed lower risks of thrombosis and restenosis. However, recent studies showed potential advantages of double kissing (DK)-crush technique over the other strategies. METHODS: We performed a frequentist network meta-analysis comparing different stenting techniques in the setting of LM bifurcation. PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov were searched. Both randomized clinical trials and non-randomized clinical trials were considered eligible for inclusion. Incidence rate ratios (IRRs) were computed using a random-effects model for death, cardiac death, myocardial infarction, target-vessel revascularization, target-lesion revascularization, and stent thrombosis, including 95% confidence intervals (CIs). RESULTS: A total of 10 studies (2364 patients) were included. Compared with provisional stenting, DK-crush was associated with fewer cardiac deaths (IRR, 0.34; 95% CI, 0.17-0.70; P<.01), myocardial infarctions (IRR, 0.19; 95% CI, 0.08-0.44; P<.001), stent thromboses (IRR, 0.31; 95% CI, 0.14-0.69; P<.01), target-vessel revascularizations (IRR, 0.25; 95% CI, 0.14-0.46; P<.001), and target-lesion revascularizations (IRR, 0.25; 95% CI, 0.14-0.46; P<.001). DK-crush was also associated with a lower risk of myocardial infarction (IRR, 0.19; 95% CI, 0.05-0.76; P=.02) when compared with standard crush and lower risk of target-lesion revascularization when compared with culotte (IRR, 0.32; 95% CI, 0.12-0.83; P=.02) and crush (IRR, 0.07; 95% CI, 0.02-0.28; P<.001). CONCLUSIONS: DK-crush is the best technique for unprotected LM bifurcation PCI.

Effect of IL-1 Blockade With Anakinra on Heart Failure Outcomes in Patients With Anterior Versus Nonanterior ST Elevation Myocardial Infarction.

ABSTRACT: Patients with ST elevation myocardial infarction (STEMI) are at risk of future heart failure (HF), particularly those with anterior STEMI. Interleukin-1 (IL-1) is a key mediator of the inflammatory response, and its blockade has emerged as a potential therapeutic strategy to prevent HF events. The aim of this analysis was to explore the effects of anakinra, an IL-1 receptor antagonist, on HF outcomes based on anterior versus nonanterior location STEMI and to explore whether this effect is mediated through the amelioration of left ventricular systolic function and cardiac remodeling. We pooled data from 3 early phase randomized clinical trials. The primary end point was a composite of all-cause death and new-onset HF at 1-year follow-up. The left anterior descending coronary artery as culprit vessel was used to identify anterior STEMI. We included 139 patients, 47 (34%) with anterior STEMI and 92 (66%) with nonanterior STEMI. Anakinra significantly reduced the combined end point of death or new-onset HF in patients with anterior STEMI [4 (13%) vs. 7 (42%), log-rank P value = 0.049] and in patients with nonanterior STEMI [3 (6%) vs. 9 (24%), log-rank P value = 0.014]. We found no significant differences comparing anakinra versus placebo in interval changes in left ventricular ejection fraction and volumes in anterior and nonanterior STEMI. In conclusion, anakinra is associated with a reduction of HF events in patients with STEMI, irrespective of anterior or nonanterior location, or of changes in left ventricular ejection fraction or cardiac remodeling.

Novel Common Femoral Artery Lesion Classification in Patients Undergoing Endovascular Revascularization.

PURPOSE: Common femoral artery (CFA) is a critical segment of the lower-limb arterial tree. We sought to propose an extensive classification in order to appraise a diagnostic and therapeutic approach. METHODS: A retrospective cohort of CFA lesions with endovascular therapy was evaluated. We appraised the extension, the degree of stenosis and the calcium burden. A new group "IV" included lesions that started at the external iliac artery or common iliac artery extending into the CFA and affecting its bifurcation. The primary outcome was the need for a retrograde bailout access after failed anterograde access and the procedural time. RESULTS: From 2012 to 2020, a total of 58 lower limbs in patients with CFA lesions were included. New proposed group IV compromised 36% of lesions. Additionally, procedural time was significantly longer in group IV lesions compared with the rest (76.9 ± 32.23 min vs 47.67 ± 17.93 min, p < 0.01), as was the requirement of retrograde bailout access (23.8 vs 2.6%, p = 0.03). Occlusive lesions were associated with longer procedural times and bailout retrograde access compared to stenotic lesions (74.7 ± 33.6 min vs 48.29 ± 16 min, p < 0.001 and 26.1 vs 0%, p = 0.006, respectively), as well as heavy calcification compared to mild or moderate calcification (73.18 ± 28.15 vs 51.86 ± 25.1, p = 0.06 and 29.4 vs 2.4%, p = 0.009, respectively). Secondary clinical outcomes and target lesion revascularization did not differ among groups. CONCLUSIONS: Our classification includes a new group of extensive and frequent lesions, which did not fit in previous classifications.

Interleukin-1 blockade with anakinra and heart failure following ST-segment elevation myocardial infarction: results from a pooled analysis of the VCUART clinical trials.

AIMS: ST-segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response and an increased risk of death and heart failure (HF). In this study, we sought to evaluate the effect of anakinra, a recombinant interleukin-1 receptor antagonist, on the incidence of HF. METHODS AND RESULTS: We performed a pooled analysis of three early phase randomized clinical trials. The endpoints included the composite of all-cause death and new-onset HF, and the composite of all-cause death and hospitalization for HF at 1-year follow-up. Safety events, including injection site reaction and serious infections, were also recorded. We analysed 139 patients with STEMI from three separate trials: VCUART (N = 10), VCUART2 (N = 30), and VCUART3 (N = 99). Of these, 84 (60%) patients were randomized to anakinra and 55 (40%) to placebo. Treatment with anakinra significantly reduced the incidence of all-cause death or new-onset HF (7 [8.2%] vs. 16 [29.1%], log-rank P = 0.002) and of all-cause death or HF hospitalization (0 [0] vs. 5 [9.1%], log-rank P = 0.007). Patients treated with anakinra had significantly higher injection site reactions (19 [22.6%] vs. 3 [5.5%], P = 0.016) without a significant difference in the incidence of serious infections (11 [13.1%] vs. 7 [12.7%], P = 0.435). Treatment with anakinra significantly reduced the area under the curve for high-sensitivity C-reactive protein between baseline and 14 days (75.48 [41.7-147.47] vs. 222.82 [117.22-399.28] mg day/L, P < 0.001). CONCLUSION: IL-1 blockade with anakinra for 14 days in patients with STEMI reduces the incidence of new-onset HF or hospitalization for HF at 1 year following STEMI.

Sarcopenia index as a predictor of clinical outcomes in older patients undergoing transcatheter aortic valve replacement.

BACKGROUND: Sarcopenia is a prevalent condition in elderly patients and has been associated with adverse outcomes following transcatheter aortic valve replacement (TAVR). The present study aimed to determine the predictive value of serum creatinine-cystatin C ratio, that is, "Sarcopenia Index" (SI) as a surrogate marker of sarcopenia, and investigate its association with clinical outcomes after TAVR. METHODS: We conducted a retrospective observational study of patients undergoing TAVR between January, 2016 and December, 2018 at Hospital Italiano de Buenos Aires, Argentina. Patients were excluded if <65-years old, presented previous surgical aortic valve replacement, severe chronic kidney disease, or hemodialysis requirement. The SI was obtained at baseline before TAVR. All-cause mortality and/or readmissions for congestive heart failure (CHF) were defined as the primary endpoint. RESULTS: In total 100 patients met inclusion criteria for the purpose of the study. Sarcopenia Index was significantly correlated with Timed Up and Go (r = -0.272, p = .010) and Gait Speed (r = -0.278, p = .005). During follow-up, 5/100 patients died within 30 days and a total of 10/100 patients died at 1-year follow-up. Moreover, survival curves were significantly worse (Log-rank test = p = .02) and CHF readmissions were more prevalent in the lowest SI tertile (Log-rank test = p = .01). In multivariate Cox regression analysis, we identified low SI (cutoff ≤66) as an independent predictor of long-term adverse outcomes (HR = 4.01, 95% CI = 1.31-12.27, p = .015) at 1-year follow-up. CONCLUSION: Sarcopenia Index, surrogate for the degree of skeletal muscle mass (SMM), could be used as a predictor of adverse outcomes in patients undergoing TAVR.

A phase 1 clinical trial of SP16, a first-in-class anti-inflammatory LRP1 agonist, in healthy volunteers.

BACKGROUND: Endogenous serine protease inhibitors are associated with anti-inflammatory and pro-survival signaling mediated via Low-density lipoprotein receptor-related protein 1 (LRP1) signaling. SP16 is a short polypeptide that mimics the LRP1 binding portion of alpha-1 antitrypsin. METHODS: A pilot phase I, first-in-man, randomized, double blind, placebo-controlled safety study was conducted to evaluate a subcutaneous injection at three dose levels of SP16 (0.0125, 0.05, and 0.2 mg/kg [up to 12 mg]) or matching placebo in 3:1 ratio in healthy individuals. Safety monitoring included vital signs, laboratory examinations (including hematology, coagulation, platelet function, chemistry, myocardial toxicity) and electrocardiography (to measure effect on PR, QRS, and QTc). RESULTS: Treatment with SP16 was not associated with treatment related serious adverse events. SP16 was associated with mild-moderate pain at the time of injection that was significantly higher than placebo on a 0-10 pain scale (6.0+/-1.4 [0.2 mg/kg] versus 1.5+/-2.1 [placebo], P = 0.0088). No differences in vital signs, laboratory examinations and electrocardiography were found in those treated with SP16 versus placebo. CONCLUSION: A one-time treatment with SP16 for doses up to 0.2 mg/kg or 12 mg was safe in healthy volunteers.

Additive prognostic value of carbohydrate antigen-125 over frailty in patients undergoing transcatheter aortic valve replacement.

BACKGROUND: To evaluate the additive prognostic value of myocardial, inflammatory, and renal biomarkers according to frailty status in patients undergoing transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS). METHODS: A total of 111 subjects who underwent TAVR at Hospital Italiano de Buenos Aires, Argentina between January 2016 and December 2018 were retrospectively reviewed. Plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), high sensitivity troponin T (hs-cTnT), C-reactive protein (CRP), cystatin-c (Cys-C) and carbohydrate antigen-125 (CA-125) were assessed prior to TAVR. Frailty status was assessed according to the fried physical frailty phenotype (FPFP). The primary endpoint was defined as all-cause death and/or readmission for worsening congestive heart failure (CHF) within the first year after TAVR. RESULTS: Of the 111 patients included, 48/111 (43%) were considered to be "frail" according to the FPFP. Among biomarkers, we found CA-125 to be strongly associated with the primary endpoint (p = .006). CA-125 ≥ 18.2 U/ml was present in 41% and was associated with a higher rate of the primary endpoint (31% vs. 9%; p = .003). After multivariable adjustment, CA-125 ≥ 18.2 U/ml (hazard ratio [HR] 3.17; p = .024) was the only independent predictor of the primary endpoint. Finally, the inclusion of CA-125 to frailty significantly improved C-index (0.68-0.74; p < .05), and provided a Net Reclassification Improvement (NRI) of 0.34 (95% CI 0.19-0.49, p = .031), largely through reductions in risk estimates among pre-frail and frail patients. CONCLUSIONS: CA-125, a tumor biomarker, outperformed frailty for predicting the primary endpoint within the first year after TAVR.

Phase 1B, Randomized, Double-Blinded, Dose Escalation, Single-Center, Repeat Dose Safety and Pharmacodynamics Study of the Oral NLRP3 Inhibitor Dapansutrile in Subjects With NYHA II-III Systolic Heart Failure.

ABSTRACT: The NLRP3 inflammasome has been implicated in the development and progression of heart failure. The aim of this study was to determine the safety of an oral inhibitor of the NLRP3 inflammasome, dapansutrile (OLT1177), in patients with heart failure and reduced ejection fraction (HFrEF). This was a phase 1B, randomized, double-blind, dose escalation, single-center, repeat dose safety and pharmacodynamics study of dapansutrile in stable patients with HFrEF (New York Heart Association Class II-III). Subjects were randomized to treatment with dapansutrile for up to 14 days at a ratio of 4:1 into 1 of 3 sequential ascending dose cohorts (500, 1000, or 2000 mg) each including 10 patients. Subjects underwent clinical assessment, biomarker determination, transthoracic echocardiogram, and maximal cardiopulmonary exercise testing at baseline, day 14, and day 28 to ascertain changes in clinical status. Placebo cases (N = 2 per cohort) were used as a decoy to reduce bias and not for statistical comparisons. Thirty participants (20 men) were treated for 13 (12-14) days. No serious adverse events during the study were recorded. All clinical or laboratory parameters at day 14 compared with baseline suggested clinical stability without significant within-group differences in the dapansutrile-pooled group or the 3 dapansutrile cohorts. Improvements in left ventricular EF [from 31.5% (27.5-39) to 36.5% (27.5-45), P = 0.039] and in exercise time [from 570 (399.5-627) to 616 (446.5-688) seconds, P = 0.039] were seen in the dapansutrile 2000 mg cohort. Treatment with dapansutrile for 14 days was safe and well tolerated in patients with stable HFrEF.

Acute Effects of Interleukin-1 Blockade Using Anakinra in Patients With Acute Pericarditis.

Interleukin-1 (IL-1) receptor antagonist (anakinra) has been shown to be effective in steroid-dependent recurrent pericarditis resistant to nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine. We sought to evaluate the acute efficacy of anakinra given early in patients with acute pericarditis. We enrolled patients within 24 hours of presentation of a first or recurrent episode of acute pericarditis who were experiencing severe pain (≥6 in 11-point Likert scale), despite treatment with at least one dose of NSAIDs and of colchicine. The primary outcome was pain relief at 24 hours. Subcutaneous anakinra 100 mg was administered in all patients, whereas NSAIDs and colchicine were suspended for 24 hours. Serum levels of interleukin-6 (IL-6) were measured at baseline and 24 hours. Data are reported as median (interquartile range). We treated 5 patients (4 male and 1 female; 38 [31-54] years old). Anakinra significantly reduced pain from 6.0 (6.0-7.5) to 4.0 (2.5-4.0) at 6 hours (P = 0.012 vs. baseline) and to 2.0 (1.5-2.5) at 24 hours (P = 0.0025 vs. baseline). No patients required rescue pain medication. IL-6 levels were also significantly reduced from 95.3 (24.2-155.1) to 23.9 (4.5-71.9) pg/mL at 24 hours (P = 0.037). The reduction in pain intensity paralleled the reduction in IL-6 serum levels (R = +0.966, P = 0.007). No adverse events related to treatment occurred. The administration of anakinra given early in acute pericarditis treatment course rapidly and significantly improved chest pain from acute pericarditis. The improvement is correlated with a reduction in IL-6 levels.