Soluble Suppression of Tumorigenicity 2 (sST2) in Patients with Predominantly Decompensated Right Heart Failure-A Prospective Observational Study.

Right heart failure is a major challenge in clinical practice. Soluble Suppression of Tumorigenicity-2 (sST2), a member of the interleukin-1-receptor family, may have clinical prognostic value. The aim of this study was to analyze whether sST2 correlates with signs of acute right heart decompensation. This prospective single-center study included 50 patients admitted for clinical signs of predominant right heart decompensation. Signs of reduced blood supply to other organs (e.g., renal function parameter, troponin T, NT-proBNP), diuretics, and signs of venous congestion (inferior vena cava (IVC) diameter) with fluid retention (weight gain, peripheral edema) resulting from reduced RV function were analyzed. The degree of peripheral edema was defined as none, mild (5-6 mm depressible, regression in 15-60 s) or severe (>7 mm depressible, regression in 2-3 min). sST2 levels were measured at the day of hospitalization. A total of 78.7% showed severe peripheral edema. The median concentration of sST2 was 35.2 ng/mL (25.-75. percentiles 17.2-46.7). sST2 is correlated with the peripheral edema degree (rSpearman = 0.427, p = 0.004) and the diameter of IVC (r = 0.786, p = 0.036), while NT-proBNP (r = 0.114, p = 0.456), troponin T (r = 0.123, p = 0.430), creatinine-based eGFR (r = -0.207, p = 0.195), or cystatin C-based eGFR (r = -0.032, p = 0.839) did not. sST2, but no other established marker, is correlated with peripheral and central fluid status in patients with decompensated right heart failure.

Progression of Chronic Kidney Disease and All-Cause Mortality in Patients with Tricuspid Regurgitation.

Aim: The impact of chronic kidney disease (CKD) on patient-related outcomes in patients with tricuspid regurgitation (TR) is well known. However, the impact of the progression of CKD in patients with TR and potentially modifiable risk factors of progressing CKD is unknown. Methods: 444 consecutive adult patients with TR and CKD stage 1−4 admitted in an inpatient setting between January 2010 and December 2017 were included. During a median follow-up of two years, eGFR and survival status were collected. Independent risk factors for CKD progression and all-cause mortality were determined. Patient survival statuses were grouped according to different combinations of the presence or absence of CKD progression and the TR grade. Results: Progression of CKD (OR 2.38 (95% confidence interval 1.30−4.35), p = 0.005), the grade of TR (OR 2.38 (1.41−4.00), p = 0.001) and mitral regurgitation (OR 1.72 (1.20−2.46), p = 0.003) were independent risk factors for all-cause mortality. Haemoglobin at admission (OR 0.80 (0.65−0.99), p = 0.043) and the presence of type 2 diabetes (OR 1.67 (1.02−2.73), p = 0.042) were independent risk factors for CKD progression. The combination of the status of CKD progression and the TR grade showed a stepwise pattern for all-cause mortality (p < 0.001). Patients with CKD progression and TR grade 1 had comparable all-cause mortality with patients without CKD progression but with TR grade 2 or 3. Even in patients with TR grade 1, the risk for all-cause mortality doubled if CKD progression occurred (OR 2.49 (95% CI 1.38−4.47), p = 0.002). Conclusion: CKD progression appears to be a risk factor for all-cause mortality in patients with TR. Anaemia and diabetes are potential modifiers of CKD progression.

Direct Flow Medical vs. Edwards Sapien 3 Prosthesis: A Propensity Matched Comparison on Intermediate Safety and Mortality.

Aims: To compare intermediate performance and mortality rates in patients, who underwent transcatheter aortic valve implantation (TAVI) with two different types of prostheses: Edwards Sapien 3 (ES3) and Direct Flow Medical (DFM). Methods and Results: 42 consecutive patients implanted with a DFM prosthesis for severe aortic stenosis were matched 1:1 with an equal number of patients, who received an ES3 during the same period. Primary endpoint was mortality. MACE, as a composite of all-cause death, stroke, and re-do-procedure (valve-in-valve), was defined as secondary endpoint. Moreover, we compared NYHA class, NT-proBNP-levels and the extent of restenosis. Patients were followed for 2 years. DFM patients showed echocardiographic elevated mean pressure gradients compared to ES3 patients before discharge (11.2 mmHg ± 5.3 vs. 3.5 mmHg ± 2.7; p < 0.001) and upon 6-months follow-up (20.3 mmHg ± 8.8 vs. 12.3 mmHg ± 4.4; p < 0.001). ES3 candidates showed superior NYHA class at follow-up (p = 0.001). Kaplan-Meier analysis revealed significantly worse survival in patients receiving a DFM prosthesis compared to ES3 (Breslow p = 0.020). MACE occurred more often in DFM patients compared to ES3 (Breslow p = 0.006). Conclusions: Patients receiving DFM valve prostheses showed worse survival and higher rates in MACE compared to ES3. Prosthesis performance regarding mean pressure gradients and patients' NYHA class also favored ES3.

Natural course of tricuspid regurgitation and prognostic implications.

OBJECTIVE: Functional tricuspid regurgitation (TR) is a frequent finding in echocardiography. Literature suggests significant TR is associated with poor prognosis. Still, data remain limited. This study aimed to evaluate long-term prognostic implications in patients with TR. METHODS: In this observational cohort study, data from 1650 consecutive patients were analysed. Primary endpoint was all-cause mortality. Mean follow-up time was 1090 days. TR grades at baseline and follow-up were compared. Survival analyses were performed to identify prognostic factors. RESULTS: At baseline, 14.1% patients showed no, 63.8% mild, 17.4% moderate and 4.7% severe TR. 359 patients (21.8%) died within the study period. TR at baseline was associated with excess mortality. Moderate and severe TR were of prognostic implication in all subgroups irrespective of systolic pulmonary artery pressure (sPAP) (

Acute kidney injury may impede results after transcatheter aortic valve implantation.

INTRODUCTION: Severe complications after transcatheter aortic valve implantation (TAVI) are rare due to increasing procedural safety. However, TAVI procedure-related haemodynamic instability and increased risk of infection may affect renal functional reserve with subsequent renal acidosis and hyperkalaemia. OBJECTIVE: In this study, we investigated incidence, modifiable risk factors and prognosis of acute kidney injury (AKI) and AKI complicated by hyperkalaemia, pulmonary oedema or metabolic acidosis after TAVI. METHODS: In a retrospective single-centre study, 804 consecutive patients hospitalized during 2017 and 2018 for elective TAVI were included. AKI was defined according to the 'Kidney Disease Improving Global Outcome' (KDIGO) initiative. Variables on co-morbidities, intra-/post-interventional complications and course of renal function up to 6 months after index-hospitalization were assessed. In multivariate regression analyses, risk factors for the development of AKI, complicated AKI, renal non-recovery from AKI and in-hospital mortality were determined. RESULTS: Incidence of AKI was 13.8% (111/804); in-hospital mortality after TAVI was 2.3%. AKI was an independent risk factor for in-hospital mortality, odds ratio (OR) 10.3 (3.4-31.6), P < 0.001, further increasing to OR = 21.8 (6.6-71.5), P < 0.001 in patients with AKI complicated by hyperkalaemia, pulmonary oedema or metabolic acidosis, n = 57/111 (51.4%). Potentially modifiable, interventional factors independently associated with complicated AKI were infection [OR = 3.20 (1.61-6.33), P = 0.001] and red blood cell transfusion [OR = 5.04 (2.67-9.52), P < 0.001]. Valve type and size, contrast volume and other intra-interventional characteristics, such as the need for tachycardial pacing, did not influence the development of AKI. Eleven of 111 (9.9%) patients did not recover from AKI, mostly affecting patients with cardiac decompensation. In 18/111 (16.2%) patients, information concerning AKI was provided in discharge letter. Within 6 months after TAVI, higher proportion of patients with AKI showed progression of pre-existing chronic kidney disease compared with patients without AKI [14/29, 48.3% versus 54/187, 28.9%, OR = 2.3 (95% confidence interval 1.0-5.1), P = 0.036]. CONCLUSIONS: AKI is common and may impede patient outcome after TAVI with acute complications such as hyperkalaemia or metabolic acidosis and adverse renal function until 6 months after intervention. Our study findings may contribute to refinement of allocation of appropriate level of care in and out of hospital after TAVI.

Right Ventricular Longitudinal Strain Predicts Survival in Patients With Functional Tricuspid Regurgitation.

BACKGROUND: Functional tricuspid regurgitation (TR) is a frequent finding in echocardiography. Despite general consent that right ventricular (RV) dysfunction impacts outcome of patients with TR, it is still unknown which echocardiographic parameters most accurately reflect prognosis. In this study we aimed to evaluate the prevalence of RV dysfunction and its prognostic value in patients with TR. METHODS: Data from 1089 consecutive patients were analysed. Tricuspid annular plane systolic excursion (TAPSE), fractional area change, and right ventricular free wall longitudinal strain (RV strain) were used to define RV dysfunction. Patients were followed for 2-year all-cause mortality. For prediction of survival, reclassification and C statistics of RV functional parameters using TR grade as reference model were performed. RESULTS: Among the patients studied, 13.9% showed no TR, 61.2% had mild TR, 19.6% had moderate TR, and 5.3% had severe TR. The TR grade was associated with increased mortality (log rank, P < 0.001). Impaired RV strain and TAPSE were independent predictors for mortality (RV: hazard ratio [HR], 1.130; 95% confidence interval [CI], 1.099-1.160; P < 0.001; TAPSE: HR, 1.131; 95% CI, 1.085-1.175; P < 0.001). Both RV strain and TAPSE improved the reference model for survival prediction (RV: integrated discrimination improvement [IDI], 0.184; 95% CI, 0.146-0.221; P < 0.001; TAPSE: IDI, 0.057; 95% CI, 0.037-0.077; P < 0.001). CONCLUSIONS: Echocardiographic evaluation of RV function appears to useful for patients with TR. Assessment of RV strain provides additional value for prediction of 2-year mortality.

Post-procedural tricuspid regurgitation predicts long-term survival in patients undergoing percutaneous mitral valve repair.

BACKGROUND: Functional tricuspid regurgitation (TR) is frequently present in patients with severe mitral regurgitation and is associated with worse outcome. While percutaneous mitral valve repair (PMVR) is on the increase, the role of TR in those patients is unclear. This study aimed to compare pre- and post-procedural TR and investigated the impact of post-procedural TR and major clinical risk factors on long-term survival in patients undergoing PMVR. METHODS: In this retrospective observational cohort study, data from 213 consecutive patients at a tertiary care center undergoing PMVR from 2010 to 2016 were analyzed. Two different groups, dichotomized according to the degree of TR (none/mild and moderate/severe) were compared. Multivariable analyses were performed assessing predictors for long-term survival adjusting for major risk factors. RESULTS: Following PMVR TR was significantly reduced by at least 1 grade in 23.0% (p=0.001), while echocardiographic pulmonary pressure was decreased (TR Vmax 3.21±0.49m/s vs. 2.98±0.53m/s; p=<0.001). Patients with moderate or severe TR presented with worse New York Heart Association functional class and elevated N-terminal pro B-type natriuretic peptide levels compared to patients with none or mild TR. Median survival time was 1458 days. Proportional hazards model, adjusted for major risk factors, revealed post-procedural TR grade (HR 2.055, CI 1.317-3.206, p=0.02), severely impaired left ventricular function (HR 3.145, CI 1.199-8.250, p=0.020), and chronic kidney disease [glomerular filtration rate (GFR) 30-60ml/min HR 1.917, CI 1.109-3.314, p=0.020; GFR<30ml/min HR 3.969, CI 1.981-7.951, p<0.001] as independent predictors for long-term survival. CONCLUSION: Post-procedural moderate and severe TR predicts worsened long-term survival in patients undergoing PMVR and is associated with adverse clinical outcome. Whether outcome might be improved by interventional reduction of post-procedural TR has to be investigated in the future.