Neurological prognosis prediction upon arrival at the hospital after out-of-hospital cardiac arrest: R-EDByUS score.

AIM: To develop a new scoring model for patients with cardiogenic out-of-hospital cardiac arrest (OHCA) to facilitate neurological prognosis prediction upon hospital arrival by using prehospital resuscitation features alone. METHODS: Between 2005 and 2019, we enrolled 942,891 adult patients with OHCA of presumed cardiac aetiology from the All-Japan Utstein Registry. Scoring models applied prehospital resuscitation features a priori from the variables the American College of Cardiology algorithm including age, duration to return of spontaneous circulation (ROSC) or hospital arrival, no bystander cardiopulmonary resuscitation (CPR), unwitnessed arrest, and nonshockable rhythm (R-EDByUS score) to predict unfavorable neurological outcomes defined as Cerebral Performance Category 3, 4, or 5 at 1 month. We created nomograms as a "Regression-based model," and created a "Simplified model" in which points were assigned by category for predicting unfavorable neurological outcomes for both the prehospital ROSC cohort (67,064 patients) and the ongoing CPR cohort (875,827 patients). For internal validation, bootstrap optimism-corrected estimates of predictive performance were calculated. RESULTS: A total of 46,971 (70.0%) and 870,991 (99.4%) patients in the prehospital ROSC and ongoing CPR cohorts, respectively, had unfavorable neurological outcomes. In the prehospital ROSC cohort, the C-statistics of the Regression-based and Simplified models were 0.851 and 0.842, and the bootstrap-validated C-statistics were 0.852 and 0.841, respectively. In the ongoing CPR cohort, the C-statistics of the Regression-based and Simplified models were 0.872 and 0.865, and the bootstrap-validated C-statistics were 0.852 and 0.841, respectively. CONCLUSIONS: The R-EDByUS score accurately predicted the neurological prognosis of cardiogenic OHCA upon hospital arrival.

Severe Left Main Coronary Artery Stenosis and Aortic Regurgitation in a Patient Presenting with Takayasu Arteritis.

We herein report the case of a 46-year-old woman with Takayasu arteritis (TA), severe stenosis in the left main coronary artery (LMCA), and severe aortic regurgitation. Prednisolone and tacrolimus were initiated as TA treatments. Two months after initiating medical therapy, the aortic regurgitation severity improved to a moderate grade, although there was no obvious improvement in LMCA stenosis. Thus, after confirming the resolution of inflammation, we performed coronary artery bypass grafting alone without any aortic valve intervention. In TA patients with severe LMCA stenosis, surgical management of the coronary artery should therefore be considered only after successfully administering anti-inflammatory therapy.

Tricuspid annular area and leaflets stretch are associated with functional tricuspid regurgitation - insights from three-dimensional transesophageal echocardiography.

BACKGROUND: The presence of functional tricuspid regurgitation (TR) is associated with mortality and morbidity. Although uniform management with a tricuspid annuloplasty ring is currently considered as a standard surgical procedure, high rates of residual TR despite annuloplasty are reported. Therefore, the identification of the TR mechanisms would be necessary to provide personalized treatment for each TR patient. METHODS: This study population consisted of 106 patients with mitral regurgitation (MR) who were scheduled for procedure. Transthoracic and transesophageal echocardiography were performed prior to mitral valve intervention. We performed three-dimensional quantitative assessment including tricuspid annular (TA) area and the distance between the three commissures of tricuspid valve. RESULTS: Significant TR, which is defined as moderate or greater TR, was detected in 23 (22%). TA area (P < 0.01), the distance of septal-leaflet length (SL) (P = 0.03) and posterior-leaflet length (PL) (p = 0.02) were significantly associated with significant TR, while TA diameter assessed by transthoracic echocardiography was not. When patients were divided into four groups according to SL and PL, the group with longer SL and PL had a significantly higher incidence of significant TR (P < 0.01). CONCLUSIONS: Greater stretch of the septal and posterior leaflet between commissures and larger TA area are associated with significant TR in patients with severe MR. In order to prevent TR recurrence, the intervention of the septal leaflet in tricuspid annuloplasty may be beneficial. The precise implement of three-dimensional transesophageal echocardiography of tricuspid valve is valuable for a personalized strategy of tricuspid annuloplasty.

Artificial intelligence-based model to classify cardiac functions from chest radiographs: a multi-institutional, retrospective model development and validation study.

BACKGROUND: Chest radiography is a common and widely available examination. Although cardiovascular structures-such as cardiac shadows and vessels-are visible on chest radiographs, the ability of these radiographs to estimate cardiac function and valvular disease is poorly understood. Using datasets from multiple institutions, we aimed to develop and validate a deep-learning model to simultaneously detect valvular disease and cardiac functions from chest radiographs. METHODS: In this model development and validation study, we trained, validated, and externally tested a deep learning-based model to classify left ventricular ejection fraction, tricuspid regurgitant velocity, mitral regurgitation, aortic stenosis, aortic regurgitation, mitral stenosis, tricuspid regurgitation, pulmonary regurgitation, and inferior vena cava dilation from chest radiographs. The chest radiographs and associated echocardiograms were collected from four institutions between April 1, 2013, and Dec 31, 2021: we used data from three sites (Osaka Metropolitan University Hospital, Osaka, Japan; Habikino Medical Center, Habikino, Japan; and Morimoto Hospital, Osaka, Japan) for training, validation, and internal testing, and data from one site (Kashiwara Municipal Hospital, Kashiwara, Japan) for external testing. We evaluated the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy. FINDINGS: We included 22 551 radiographs associated with 22 551 echocardiograms obtained from 16 946 patients. The external test dataset featured 3311 radiographs from 2617 patients with a mean age of 72 years [SD 15], of whom 49·8% were male and 50·2% were female. The AUCs, accuracy, sensitivity, and specificity for this dataset were 0·92 (95% CI 0·90-0·95), 86% (85-87), 82% (75-87), and 86% (85-88) for classifying the left ventricular ejection fraction at a 40% cutoff, 0·85 (0·83-0·87), 75% (73-76), 83% (80-87), and 73% (71-75) for classifying the tricuspid regurgitant velocity at a 2·8 m/s cutoff, 0·89 (0·86-0·92), 85% (84-86), 82% (76-87), and 85% (84-86) for classifying mitral regurgitation at the none-mild versus moderate-severe cutoff, 0·83 (0·78-0·88), 73% (71-74), 79% (69-87), and 72% (71-74) for classifying aortic stenosis, 0·83 (0·79-0·87), 68% (67-70), 88% (81-92), and 67% (66-69) for classifying aortic regurgitation, 0·86 (0·67-1·00), 90% (89-91), 83% (36-100), and 90% (89-91) for classifying mitral stenosis, 0·92 (0·89-0·94), 83% (82-85), 87% (83-91), and 83% (82-84) for classifying tricuspid regurgitation, 0·86 (0·82-0·90), 69% (68-71), 91% (84-95), and 68% (67-70) for classifying pulmonary regurgitation, and 0·85 (0·81-0·89), 86% (85-88), 73% (65-81), and 87% (86-88) for classifying inferior vena cava dilation. INTERPRETATION: The deep learning-based model can accurately classify cardiac functions and valvular heart diseases using information from digital chest radiographs. This model can classify values typically obtained from echocardiography in a fraction of the time, with low system requirements and the potential to be continuously available in areas where echocardiography specialists are scarce or absent. FUNDING: None.

Impact of cystatin C-derived glomerular filtration rate in patients undergoing transcatheter aortic valve implantation.

Background: Chronic kidney disease (CKD) impacts prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). While estimated glomerular filtration rate (eGFR) calculated from serum creatinine [eGFR (creatinine)] is affected by body muscle mass which reflects frailty, eGFR calculated from serum cystatin C [eGFR (cystatin C)] is independent of body composition, resulting in better renal function assessment. Methods: This study included 390 consecutive patients with symptomatic severe aortic stenosis (AS) who underwent TAVI, and measured cystatin C-based eGFR at discharge. Patients were divided into two groups, with or without CKD estimated with eGFR (cystatin C). The primary endpoint of this study was the 3-year all-cause mortality after TAVI. Results: The median patient age was 84 years, and 32.8% patients were men. Multivariate Cox regression analysis indicated that eGFR (cystatin C), diabetes mellitus, and liver disease were independently associated with 3-year all-cause mortality. In the receiver-operating characteristic (ROC) curve, the predictive value of eGFR (cystatin C) was significantly higher than that of eGFR (creatinine). Furthermore, Kaplan-Meier estimates revealed that 3-year all-cause mortality was higher in the CKD (cystatin C) group than that in the non-CKD (cystatin C) group with log-rank p = 0.009. In contrast, there was no significant difference between the CKD (creatinine) and non-CKD (creatinine) groups with log-rank p = 0.94. Conclusions: eGFR (cystatin C) was associated with 3-year all-cause mortality in patients who underwent TAVI, and it was superior to eGFR (creatinine) as a prognostic biomarker.

Risk factors of pacing-induced cardiomyopathy-Insights from lead position.

There was no significant difference in the incidence of pacing-induced cardiomyopathy between right ventricular apex pacing group and OpenCurlyQuote;true CloseCurlyQuote; mid-right ventricular septum pacing group. The preoperative left ventricular end-systolic diameter and paced QRS duration were independent predictors of PICM.

Three-dimensional transesophageal echocardiographic morphological evaluation of the tricuspid valve.

OBJECTIVES: The morphology of the tricuspid valve (TV), particularly valves with two posterior leaflets, is attracting attention. The present study was performed to investigate the usefulness of three-dimensional transoesophageal echocardiographic data for morphological evaluation of the TV . METHODS: Sixty patients underwent morphological evaluation of the TV by preoperative transoesophageal echocardiography followed by TV repair with median sternotomy, and each leaflet was measured intraoperatively. We analysed the TV morphology in 51 patients whose preoperative echocardiographic findings were consistent with intraoperative findings. RESULTS: The mid-systolic echo data, which included the annulus diameter of each leaflet, were correlated with the intraoperative evaluation findings compared with those in the mid-diastole. The annulus and area of the posterior leaflet were larger in patients with two than one posterior leaflet valve (42.4 ± 13.5 vs 30.7 ± 9.1 mm, P < 0.001 and 327 ± 185 vs 208 ± 77 mm2, P = 0.006, respectively). In the severe tricuspid regurgitation patients, the annulus of the posterior leaflet was larger and the annulus of the anterior leaflet was smaller in patients with two than one posterior leaflet valve [posterior: 48 mm [95% confidence interval (CI), 41-54 mm] vs 36 mm (95% CI, 27-45 mm), respectively; P = 0.043 and anterior: 38 mm (95% CI, 33-42 mm) vs 46 mm (95% CI, 40-52 mm), respectively; P = 0.025]. CONCLUSIONS: Patients who had a TV with two posterior leaflets had a larger annulus and area of the posterior leaflets. Preoperative three-dimensional transoesophageal echocardiography is useful for the morphological evaluation of the TV.

Left atrial volume index predicts future improvement of B-type natriuretic peptide levels after transcatheter aortic valve replacement.

In patients with symptomatic severe aortic stenosis (AS), those who experienced readmission due to heart failure after transcatheter aortic valve replacement (TAVR) showed poor prognosis. Furthermore, poor B-type natriuretic peptide (BNP) improvement is associated with increased morbidity and mortality. However, little is known about the clinical parameters related to the change in BNP levels after TAVR procedure. This study population consisted of 127 consecutive patients of symptomatic severe AS with preserved ejection fraction (EF) who underwent transfemoral TAVR (TF-TAVR). Comprehensive transthoracic echocardiography was performed prior to the day of TF-TAVR. BNP was measured serially before and 1 year after TF-TAVR. The median BNP level was significantly decreased from 252.5 pg/ml to 146.8 pg/ml in all 127 patients 1 year after TF-TAVR (P < 0.01). However, the patients could be divided into 2 groups according to decrease (72%) or increase (28%) in plasma BNP level. Multivariate logistic regression analysis revealed that Aortic valve (AV) peak velocity, pre-procedural BNP, and larger left atrial volume index (LAVI) were found to be an independent predictor of increased BNP level 1 year after TAVR (OR 0.55, 95% CI 0.38-0.77; P < 0.01). LAVI were negatively correlated with the change in BNP level before and 1 year after TAVR (r = 0.47, P < 0.01). The ROC analysis demonstrated that 52.9 ml/m2 was the optimal cut-off value of LAVI for decreasing BNP 1 year after TAVR (area under the curve 0.69) with 64% sensitivity and 70% specificity. In addition to AV peak velocity and pre-procedural BNP, LAVI independently predicts future improvement of BNP levels 1 year after TAVR. Our findings indicate an additive predictive value of assessment of LAVI before TAVR procedure for risk stratification.

Kihon checklist is useful for predicting outcomes in patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Frailty is a major risk factor for death and disability following transcatheter aortic valve implantation (TAVI). The Kihon checklist (KCL) is a simple self-reporting yes/no survey consisting of 25 questions and is used as a screening tool to identify frailty in the primary care setting. No clinical studies have focused on frailty calculated by the KCL in the TAVI cohort. We investigated the 3-year prognostic impact of frailty evaluated by the KCL in patients who underwent TAVI. METHODS: This single-center prospective observational study included 280 consecutive patients with symptomatic severe aortic stenosis who underwent TAVI and evaluated pre-procedural physical performance focused on frailty at our institution. We assessed all patients' frailty by the KCL before TAVI, as described previously. We set the primary endpoint as the 3-year all-cause mortality after TAVI. RESULTS: The median patient age was 84 years (interquartile range, 81-87 years), and 31.1% were men. In the receiver operating characteristics curve, there were no significant differences between the KCL and Cardiovascular Health Study frailty index [area under the curve (AUC) 0.625 versus 0.628; p=0.93), KCL and Rockwood Clinical Frailty Scale (AUC 0.625 versus 0.542; p=0.15), and KCL and Short Physical Performance Battery (AUC 0.625 versus 0.612; p=0.91). The first and second tertiles of the total KCL score were 8 and 12, respectively. The multivariate Cox regression model indicated that the total KCL score [hazard ratio (HR), 1.104; 95% confidence interval (CI), 1.034-1.179; p=0.003], presence of diabetes mellitus (HR, 1.993; CI, 1.055-3.766; p=0.03), and presence of liver disease (HR, 3.007; CI, 1.067-8.477; p=0.04) were independently associated with 3-year all-cause mortality. CONCLUSIONS: The KCL is a simple and useful tool for evaluating frailty status and predicting 3-year all-cause mortality in patients undergoing TAVI.

Difference in risk factors of silent brain infarction between paroxysmal and persistent atrial fibrillation.

BACKGROUND: Although silent brain infarction is an independent risk factor for subsequent symptomatic stroke and dementia in patients with nonvalvular atrial fibrillation, little is known regarding differences in risk factors for silent brain infarction between patients with paroxysmal and persistent nonvalvular atrial fibrillation. METHODS: This study population consisted of 190 neurologically asymptomatic patients (mean age, 64 ± 11 years) with nonvalvular atrial fibrillation (119 paroxysmal, 71 persistent) who were scheduled for catheter ablation. All patients underwent brain magnetic resonance imaging to screen for silent brain infarction prior to ablation. Transthoracic and transesophageal echocardiography was performed to screen for left atrial abnormalities (left atrial enlargement, spontaneous echo contrast, or left atrial appendage emptying velocity) and complex plaques in the aortic arch. RESULTS: Silent brain infarction was detected in 50 patients (26%) [26 patients (22%) in paroxysmal vs. 24 patients (34%) in persistent, p = 0.09]. Multiple logistic regression analysis indicated that age and diabetes mellitus or chronic kidney disease (estimated glomerular filtration rate < 60 mL/min/1.73 m2) were associated with silent brain infarction in patients with paroxysmal nonvalvular atrial fibrillation (p < 0.05), whereas no modifiable risk factors of silent brain infarction were observed in patients with persistent nonvalvular atrial fibrillation. CONCLUSIONS: These findings suggest that intensive intervention for diabetes mellitus and renal impairment from the paroxysmal stage or ablation therapy at the time of paroxysmal stage to prevent progression to persistent nonvalvular atrial fibrillation may prevent silent brain infarction and consequently reduce the risk of future symptomatic stroke.

Presence of mitral stenosis is a risk factor of new development of acute decompensated heart failure early after transcatheter aortic valve implantation.

AIMS: Acute decompensated heart failure (ADHF) can occur early after transcatheter aortic valve implantation (TAVI), but the risk factors or mechanisms associated with it have not been fully determined. This hypothesis-generating study aimed to investigate the clinical indices associated with the development of ADHF within 72 hours after TAVI and to improve procedural approaches for TAVI. METHOD AND RESULTS: In this single-centre hypothesis generating prospective observational study, we enrolled 156 consecutive patients with severe aortic stenosis who underwent TAVI between January 2016 and February 2018 at our institution. We set the primary endpoint as the new development of ADHF within 72 hours after TAVI, and clinical indices associated with it were evaluated using a multivariable logistic model. The median age of the patients was 83 (quartile range 80-86) years, 48 (30.8%) were men and the median Society of Thoracic Surgery-Predicted Risk of Mortality was 7.1 (range 5.2-10.4). Mitral stenosis (MS), defined as mean transmitral valve pressure gradient ≥5 mm Hg, was present in 15 (9.6%) patients. After TAVI, the invasive mean transaortic valve pressure gradient (mAVPG) decreased from 48 (36-66) to 7 (5-11) mm Hg, and 12 (7.7%) patients developed ADHF within 72 hours after TAVI. Multivariable logistic regression analysis showed that MS (adjusted OR, 14.227; 95% CI 2.654 to 86.698; p=0.002) and greater decreases in mAVPG (1.038; 1.003 to 1.080; p=0.044) were associated with ADHF. CONCLUSIONS: MS and drastic improvement of mAVPG were associated with new development of ADHF within 72 hours after TAVI.

Prevalence and Risk Factors of Silent Brain Infarction in Patients with Aortic Stenosis.

INTRODUCTION: Silent brain infarction (SBI) is an independent risk factor for subsequent symptomatic stroke in the general population. Although aortic stenosis (AS) is also known to be associated with an increased risk of future symptomatic stroke, little is known regarding the prevalence and risk factors for SBI in patients with AS. METHODS: The study population comprised 83 patients with severe AS with no history of stroke or transient ischemic attack and paralysis or sensory impairment (mean age 75 ± 7 years). All patients underwent brain magnetic resonance imaging to screen for SBI and multidetector-row computed tomography to quantify the aortic valve calcification (AVC) volume. Comprehensive transthoracic and transesophageal echocardiography were performed to evaluate left atrial (LA) abnormalities, such as LA enlargement, spontaneous echo contrast, or abnormal LA appendage emptying velocity (<20 cm/s), and complex plaques in the aortic arch. RESULTS: SBI was detected in 38 patients (46%). Multiple logistic regression analysis indicated that CHA2DS2-VASc score and estimated glomerular filtration rate (eGFR) were independently associated with SBI (p < 0.05), whereas LA abnormalities and AVC volume were not. When patients were divided into 4 groups according to CHA2DS2-VASc score and eGFR, the group with a higher CHA2DS2-VASc score (≥4) and a lower eGFR (<60 mL/min/1.73 m2) had a greater risk of SBI than the other groups (p < 0.05). CONCLUSION: These findings indicate that AS is associated with a high prevalence of SBI, and that the CHA2DS2-VASc score and eGFR are useful for risk stratification.

Self-expandable transcatheter aortic valve replacement is associated with frequent periprocedural stroke detected by diffusion-weighted magnetic resonance imaging.

BACKGROUND: Little evidence is available regarding the risk of peri-procedural stroke detected by diffusion-weighted magnetic resonance imaging (DW-MRI) after transcatheter aortic valve replacement (TAVR). Our purpose was to evaluate stroke risk after TAVR using DW-MRI by enrolling consecutive patients who underwent transfemoral TAVR and post-procedural DW-MRI. METHODS: We prospectively enrolled 113 consecutive patients who underwent transfemoral TAVR and post-procedural DW-MRI. We used balloon-expandable valves as first-line therapy and selected self-expandable valves only for patients with narrow sinotubular junctions or annuli. We set the primary endpoint as the number of high intensity areas (HIA) detected by DW-MRI regardless of the size of the area. To evaluate the risks of the primary endpoint, we employed a multivariable linear regression model, setting the primary endpoint as an objective variable and patient and clinical backgrounds as explanatory variables. RESULTS: Median patient age was 84 years, and 36.3% were men. Ninety-three patients underwent balloon-expandable TAVR and 20 underwent self-expandable TAVR. Symptomatic stroke occurred in 6 (5.3%) whereas asymptomatic stroke occurred in 59 (52.2%) patients. The incidence of symptomatic and total stroke was higher in patients who underwent self-expandable TAVR than those who underwent balloon-expandable TAVR (30.0% vs. 0.0%, p<0.001 and 90.0% vs. 50.5%, p=0.001, respectively). A multivariable linear regression model demonstrated an increased primary endpoint when self-expandable TAVR was performed (p<0.001). The other covariates had no significant relationship to the primary endpoint. Akaike information criterion-based stepwise statistical model selection revealed that valve type was the only explanatory variable for the best predictive model. CONCLUSIONS: Self-expandable valves were associated with increased numbers of HIA on DW-MRI after TAVR in patients with severe aortic stenosis.

Arterial inflow line equipped with a side arm for circulatory support and catheter insertion during transcatheter aortic valve implantation for limited vascular access.

Transcatheter aortic valve implantation was performed on a 78-year-old patient. Elective circulatory support with cardiopulmonary bypass was planned because of left ventricular function impairment and hemodynamic instability. Limited vascular access was due to a severe atherosclerotic aorta distal to the origin of the left carotid artery. The right arm was the only safe vascular access site. However, at least 2 vascular access sites for angiographic catheter and inflow of circulatory support were required. An arterial inflow line equipped with a side arm was developed to enable single access to the right axillary artery to be used for the above purposes.

Greater Nocturnal Blood Pressure Is Associated With Natriuretic Peptide Level in Aortic Stenosis With Preserved Ejection Fraction.

BACKGROUND: Although careful monitoring of asymptomatic severe aortic stenosis (AS) is recommended to prevent missing the optimal timing of surgical or transcatheter aortic valve replacement, prophylactic treatment that could extend the asymptomatic period remains unknown. In a hypertensive population, high blood pressure (BP) measured at the doctor's office is known to be associated with B-type natriuretic peptide (BNP) level, a surrogate marker for symptomatic deterioration in AS. Little is known regarding the association between nocturnal BP variables and BNP in severe AS with preserved ejection fraction (EF). Methods and Results: The subjects consisted of 78 severe AS patients (mean age, 79±6 years) with preserved EF. Nocturnal BP was measured hourly using a home BP monitoring device. On multiple regression analysis, nocturnal mean systolic BP (SBP) remained independently associated with BNP after adjustment for age, sex, body mass index, estimated glomerular filtration rate, antihypertensive medication class, early diastolic mitral annular velocity, and left ventricular mass index (P=0.03), whereas diastolic BP (DBP) and variables of BP variability were not. CONCLUSIONS: Higher nocturnal SBP rather than DBP or indices of BP variability was independently associated with BNP in AS patients with preserved EF. Intervention for nocturnal SBP may therefore extend the asymptomatic period and improve prognosis.