Percutaneous Coronary Intervention Offers Clinical Benefits to Diabetic Patients With Stable Chronic Total Occlusion.

Whether percutaneous coronary intervention for chronic total occlusion (CTO-PCI) in diabetic patients offers more benefits compared with initial medical therapy (CTO-MT) is unclear. In this study, diabetic patients with one CTO (clinical manifestations: stable angina or silent ischemia) were enrolled. Consecutively, enrolled patients (n = 1605) were assigned to different groups: CTO-PCI (1044 [65.0%]) and initial CTO-MT (561 [35%]). After a median follow-up of 44 months, CTO-PCI tended to be superior to initial CTO-MT in major adverse cardiovascular events (adjusted hazard-ratio [aHR]: .81, 95% conference-interval: .65-1.02) and significantly superior in cardiac death (aHR: .58 [.39-.87]) and all-cause death (aHR: .678[.473-.970]). Such superiority mainly attributed to a successful CTO-PCI. CTO-PCI tended to be performed in patients with younger age, good collaterals, left anterior descending branch CTO, and right coronary artery CTO. While, those with left circumflex CTO and severe clinical/angiographic situations were more likely to be assigned to initial CTO-MT. However, none of these variables influenced the benefits of CTO-PCI. Thus, we concluded that for diabetic patients with stable CTO, CTO-PCI (mainly successful CTO-PCI) offered patients survival benefits over initial CTO-MT. These benefits were consistent regardless of clinical/angiographic characteristics.

Determinants of device success after transcatheter aortic valve replacement in patients with type-0 bicuspid aortic stenosis.

Background: Clinical evidence of transcatheter aortic valve replacement in patients with type-0 bicuspid aortic valve was relatively scarce. Aims: Our goal was to explore determinants of device success after transcatheter aortic valve replacement in patients with type-0 bicuspid aortic valve morphology. Methods: In this retrospective multicenter analysis, we included 59 patients with symptomatic severe aortic stenosis with type-0 bicuspid aortic valve morphology who underwent transcatheter aortic valve replacement. Type-0 bicuspid aortic valve was identified with multidetector computed tomography scans. The technical success rate was 89.8%, and the device success rate was 81.4%. Patients were divided into a device success group and a device failure group according to Valve Academic Research Consortium- 3 criteria. Results: When we compared the two groups, we found that the ellipticity index of the aortic root and the presence of bulky calcifications at the commissure were statistically different (ellipticity index 35.7 ± 1.7 vs. 29.7 ± 1.1, p = 0.018; bulky calcification at the commissure, 54.5% vs. 4.5%, p < 0.001). Further multivariate logistic analysis showed that bulky calcification at the commissure had a negative correlation with device success (odds ratio 0.030, 95% confidence interval 0.003-0.285, p = 0.002). Yet there was no statistical correlation between the ellipticity index and device success (odds ratio 0.818, 95% confidence interval 0.667-1.003, p = 0.053). Conclusions: The presence of bulky calcifications at the commissure is negatively correlated with device success after transcatheter aortic valve replacement in patients with type-0 bicuspid aortic valve.

Single femoral artery access is safe and feasible during transcatheter aortic valve replacement: a propensity score matched analysis.

Background: Transcatheter aortic valve replacement (TAVR) potentially may be significantly simplified by using the single artery access (SA) technique, which does not require a secondary artery access. Nevertheless, the safety and efficacy of this technique remains unclear. Our goal was to determine if single artery access TAVR (without upgrading the sheath size) is a feasible, minimally invasive procedure. Methods: Patients with symptomatic severe aortic stenosis who underwent TAVR via the femoral artery were consecutively enrolled in this study. Eligible individuals were divided into 2 groups: the SA group and the dual artery access (DA) group. The primary end point was device success (defined by the valve academic research consortium 3, VARC 3). A 6-month follow-up and propensity score matching analyses were performed. Results: After propensity score matching analysis, a total of 130 patients were included: 65 in the SA group and 65 in the DA group. The SA procedure achieved similar device success (95.4% vs. 87.7%; P = 0.115) compared with the DA procedure. The SA procedure shortened the operating time (102 min vs. 125 min; P = 0.001) but did not increase the x-ray time or dose. Both a 20 Fr and a 22 Fr sheath (without upgrading the sheath size) could be used for the SA procedure. There was no major vascular complication occurred in both groups. The incidence of minor main vascular and access complications in the SA group was comparable to those of the DA procedure (0.0% vs. 3.1%; P = 0.156). Conclusions: The SA access procedure is a promising minimally invasive TAVR technique with a low incidence of vascular complications and a high incidence of device success. It is safe and possibly applicable in all TAVR procedures.

Perioperative renal function change after transcatheter aortic valve replacement: A single-center retrospective study in China.

BACKGROUND: In recent years, the kidney function after Transcatheter Aortic Valve Replacement (TAVR) has gradually become a hot spot that arouse extensive attention.Our study is aimed to evaluate the incidence and predictors of acute kidney recovery (AKR) after TAVR. METHODS: A total of 102 patients undergoing TAVR in Beijing Anzhen Hospital from June 2021 to March 2022 were enrolled in our study. Patients were divided into AKR group (n = 54), unchanged group (n = 40) and acute kidney injury (AKI) group (n = 8) based on the percent change of estimated glomerular filtration rate (eGFR). Univariate analysis was used to compare the differences in general clinical characteristics and other related indicators between the three groups to analyze the risk factors of AKR. RESULTS: The incidence of AKR was 53% (54/102) after TAVR. Multivariate analysis showed that the incidence of age and proportion of severe NYHA class (III or IV) was significantly higher in the AKR group while renal dysfunction (eGFR <60 mL/min/1.73 m2) was lower. Besides, fluid management/volume therapy was significantly different among the three groups. CONCLUSIONS: AKR is a generalizable phenomenon occurring frequently after TAVR. The age, proportion of severe NYHA class and the baseline renal function are independent predictors of AKR events in patients with severe aortic stenosis undergoing TAVR.

Feasibility study of temporary permanent pacemaker in patients with conduction block after TAVR.

Background: Limited data exist on the use of temporary permanent pacemaker (TPPM) to reduce unnecessary PPM in patients with high-degree atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR). Objectives: This study aims to determine the feasibility of TPPM in patients with HAVB after TAVR to provide prolonged pacing as a bridge. Materials and methods: One hundred and eleven consecutive patients undergoing TAVR were screened from August 2021 to June 2022. Patients with HAVB eligible for PPM were included. TPPM were used in these patients instead of conventional temporary pacing or early PPM. Patients were followed up for 1 month. Holter and pacemaker interrogation were used to determine whether to implant PPM. Results: Twenty one patients met the inclusion criteria for TPPM, of which 14 patients were third-degree AVB, 1 patient was second-degree AVB, 6 patients were first degree AVB with PR interval > 240 ms and LBBB with QRS duration > 150 ms. TPPM were placed on the 21 patients for 35 ± 7 days. Among 15 patients with HAVB, 26.7% of them (n = 4) recovered to sinus rhythm; 46.7% (n = 7) recovered to sinus rhythm with bundle branch block. The remains of 26.7% patients (n = 4) still had third-degree AVB and received PPM. For patients with first-degree AVB and LBBB, PR interval shortened to < 200 ms in all 6 patients and LBBB recovered in 2 patients. TPPM were successfully removed from all patients and no procedure-related adverse events occurred. Conclusion: TPPM is reliable and safe in the small sample of patients with conduction block after TAVR to provide certain buffer time to distinguish whether a PPM is necessary. Future studies with larger sample are needed for further validation of the current results.

Chronic heart failure in patients with nonalcoholic fatty liver disease: prevalence, clinical features, and relevance.

Objective This study was performed to assess the prevalence of nonalcoholic fatty liver (NAFL) in patients with symptomatic congestive heart failure (CHF) and compare the clinical features with those of patients without NAFL. Methods In total, 102 patients with CHF were divided into NAFL and non-NAFL groups according to their hepatic ultrasonography findings. All patients underwent transthoracic echocardiography and cardiac magnetic resonance examination. Follow-up was performed for major cardiovascular events (MACE) and readmission due to heart failure at 1, 3, 6, and 12 months after the index hospitalization. Results NAFL was detected in 37 of 102 patients (36.27%). Compared with the non-NAFL group, patients with NAFL were younger, had a higher body mass index and left ventricular (LV) mass index, and had more severe fibrosis. MACE and readmission occurred in 15 patients in the NAFL group and 29 patients in the non-NAFL group, without a significant difference. Linear regression analysis revealed that after adjusting for confounders, NAFL was independently associated with the LV fibrosis size and the ratio of the LV fibrosis size to the LV mass index. Conclusions NAFL is present in more than one-third of patients with CHF and is associated with the severity of LV fibrosis.

Extracellular volume quantitation using dual-energy CT in patients with heart failure: Comparison with 3T cardiac MR.

BACKGROUNDS: Cardiac magnetic resonance (CMR) T1 mapping and the extracellular volume (ECV) have been developed to quantitative analysis of diffusely abnormal myocardial fibrosis (MF). However, dual-energy CT (DECT) has a potential for calculation of ECV. The aim of this study is to evaluate the feasibility and accuracy of DECT technique in determining the ECV in patients with heart failure, with 3T CMR as the reference. METHODS: Thirty-five patients with various reasons of heart failure were enrolled in this study. Both DECT and CMR exams were completed within 24 h. ECVs were calculated, and the relationship between DECT-ECV, CMR-ECV, and other heart function parameters, including left ventricular end systolic and diastolic volume, cardiac output and ejection fraction (LVESV, LVEDV, CO, LVEF), Brain natriuretic peptide (BNP) was determined. All participants gave informed consent, and the study was approved by the institutional review board. RESULTS: The median ECVs on DECT and CMR were 33% (95%CI: 32%-36%) and 30% (95%CI: 30% - 32%), respectively. A good correlation between myocardial ECV at DECT and that at CMR (r = 0.945, P < 0.001) was observed. Bland-Altman analysis between DECT and CMR showed a small bias (2.6%), with 95% limits of agreement of -0.4% and 5.6%. Interobserver agreement for ECV at DECT was excellent (ICC = 0.907). Both ECVs, for DECT and CMR, were inversely associated with LVEF and CO. CONCLUSION: DECT-based ECV could be an alternative non-invasive imaging tool for myocardial tissue characterization. However, overestimation of the extent of diffuse MF is observed with use of DECT.

Late Gadolinium Enhancement Amount As an Independent Risk Factor for the Incidence of Adverse Cardiovascular Events in Patients with Stage C or D Heart Failure.

Background: Myocardial fibrosis (MF) is a risk factor for poor prognosis in dilated cardiomyopathy (DCM). Late gadolinium enhancement (LGE) of the myocardium on cardiac magnetic resonance (CMR) represents MF. We examined whether the LGE amount increases the incidence of adverse cardiovascular events in patients with stage C or D heart failure (HF). Methods: Eighty-four consecutive patients with stage C or D HF, either ischemic or non-ischemic, were enrolled. Comprehensive clinical and CMR evaluations were performed. All patients were followed up for a composite endpoint of cardiovascular death, heart transplantation, and cardiac resynchronization therapy with defibrillator (CRT-D). Results: LGE was present in 79.7% of the end-stage HF patients. LGE distribution patterns were mid-wall, epi-myocardial, endo-myocardial, and the morphological patterns were patchy, transmural, and diffuse. During the average follow-up of 544 days, 13 (15.5%) patients had endpoint events: 7 patients cardiac death, 2 patients heart transplantation, and 4 patients underwent CRT-D implantation. On univariate analysis, LGE quantification on cardiac magnetic resonance, blood urine nitrogen, QRS duration on electrocardiogram, left ventricular end-diastolic diameter (LVEDD), and left ventricular end-diastolic volume (LVEDV) on CMR had the strongest associations with the composite endpoint events. However, on multivariate analysis for both Model I (after adjusting for age, sex, and body mass index) and Model II (after adjusting for age, sex, BMI, renal function, QRS duration, and atrial fibrillation on electrocardiogram, the etiology of HF, LVEF, CMR-LVEDD, and CMR-LVEDV), LGE amount was a significant risk factor for composite endpoint events (Model I 6SD HR 1.037, 95%CI 1.005-1.071, p = 0.022; Model II 6SD HR 1.045, 95%CI 1.001-1.084, p = 0.022). Conclusion: LGE amount from high-scale threshold on CMR increased the incidence of adverse cardiovascular events for patients in either stage C or D HF.

Left atrial functional remodeling in lone atrial fibrillation: a two-dimensional speckle tracking echocardiographic study.

OBJECTIVE: The aim of this study was to assess left atrial (LA) functional remodeling in lone atrial fibrillation (LAF) patients via two-dimensional speckle tracking echocardiography (2DSTE). METHODS: Forty-five paroxysmal LAF patients and 30 healthy controls underwent 2DSTE in sinus rhythm. Longitudinal LA strain/strain rate (LAS/LASR) of booster, reservoir, and conduit function in apical four- and two-chamber views were measured and averages of the 2 views were used. RESULTS: The 2 groups had similarity in LA volume. LAS and LASR of the 3 phasic functions were reduced in patients. Comparing the 2 groups, LA booster strain (LASa) and strain rate were -12.31 ± 3.15 versus -15.30 ± 2.52% and -1.64 ± 0.51 versus -2.08 ± 0.48 1/sec, respectively, P < 0.05 for both. Multivariate regression confirmed that LAF was an independent determinant of LAS/LASR reduction. LASa was the most accurate parameter for differentiating LAF patients from controls (area under receiver operating characteristic curve, 0.763; cutoff value, -14.3%; sensitivity, 71.1% and specificity, 70.0%). Finally, LASa decrement was found to be the only significant predictor of early atrial fibrillation (AF) recurrence (odds ratio [OR], 1.39 per unit decrement; 95% CI, 1.02-1.89; P = 0.038). CONCLUSIONS: Remodeling of LA booster pump, reservoir, and conduit function in LAF patients can be detected by 2DSTE before structural remodeling. Occurrence of LAF is associated with impairment of LA intrinsic myocardial properties. LASa can differentiate LAF patients and lower LASa is associated with early recurrence of AF after ablation.

Anatomic properties of coronary arteries are correlated to the corrected thrombolysis in myocardial infarction frame count in the coronary slow flow phenomenon.

BACKGROUND: Coronary slow flow phenomenon (CSFP) is an important, angiographic clinical entity, but its etiology remains unclear. The purpose of this study was to explore the potential role of local coronary anatomic properties in the genesis of CSFP. METHODS: One hundred and thirty-one consecutive patients with CSFP and 131 patients with angiographically normal coronary flow were prospectively enrolled after documenting coronary flow by corrected thrombolysis in myocardial infarction frame count (CTFC). Local anatomic parameters including the tortuosity index (TI), the ostial-to-middle diameter ratio, the ostial-to-middle cross-sectional area ratio, and the number of distal branches (NDB) of arteries at end-systole were compared between patients with CSFP and controls. RESULTS: For each major coronary artery, CSFP patients had higher TI and NBD compared with controls (all P<0.05). The diameter ratio and cross-sectional area ratio of the three major coronary arteries were higher in the CSFP group (P=0.004 and 0.020, respectively). The TI (r=0.476, P<0.001) and NDB (r=0.186, P=0.004) were significantly correlated with CTFC. However, the higher TI (ß=0.424, P<0.001) was the only independent correlate to CTFC. Multivariate logistic analysis revealed that TI (adjusted odds ratio 1.17, 95% confidence interval 1.11-1.23, P<0.001) and NDB (adjusted odds ratio 2.20, 95% confidence interval 1.50-3.21, P<0.001) were independent predictors of CSFP. CONCLUSION: The presence of CSFP was associated with higher tortuosity and more distal branches in coronary arteries, indicating that the anatomic properties of coronary arteries could also play a role in the pathogenesis of CSFP.

[Status quo and factors influencing smoking cessation in cigarette smoking patients with coronary artery disease].

OBJECTIVE: To investigate the status quo of smoking cessation and analyze factors influencing smoking cessation in cigarette smoking patients with coronary artery disease (CAD). METHOD: A total of 350 smoking patients with CAD was surveyed by questionnaire, logistic regression analysis was performed to analyze factors influencing smoking cessation. RESULTS: Incidence of smoking cessation was 57.1% (200/350) in this cohort. Patients were divided into two groups, the elderly (> 65 years old, n = 111) and the young group (≤ 65 years old, n = 239). The smoking cessation rate in the elderly group is significantly higher than in the young group (71.2% vs. 50.6%, P < 0.001). Aged patients and patients with high cultural level are easier to give up smoking. Logistic analysis showed that age ≤ 65 years old (OR = 2.336, P = 0.004), low cultural level (OR = 1.310, P = 0.028), PCI (OR = 0.261, P < 0.001), coronary artery bypass graft (OR = 0.107, P = 0.004), total family income > 4000 RMB/month (OR = 1.828, P = 0.003) are risk factors for failed smoking cessation. There are 76 patients smoking again in current smokers, most due to lack of self-control (76.3%). Compared to the elderly group, there is a higher proportion of smoking again due to the need of daily communication and work in the young group. CONCLUSIONS: We still need to raise the awareness of smoking cessation for smoking patients with CAD. Following factors should be focused for tobacco control in CAD patients: younger age, lower cultural level, not treated with PCI or CABG, patients with smoking family members, higher body mass index and higher total family income.

Can transthoracic Doppler echocardiography be used to detect coronary slow flow phenomenon?

BACKGROUND: Coronary slow flow phenomenon (CSFP) is an important, angiographic clinical entity but is lacking non-invasive detecting techniques. This study aimed to elucidate the value of transthoracic Doppler echocardiography (TTDE) in the diagnosis and monitoring of coronary slow flow in left anterior descending (LAD) coronary artery. METHODS: We consecutively enrolled 27 patients with CSFP in LAD detected by coronary arteriography from August 2009 to April 2010. Thirty-eight patients with angiographically normal coronary flow served as control. Corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) was used to document coronary flow velocities. All subjects underwent TTDE within 24 hours after coronary angiography. LAD flow was detected and the coronary diastolic peak velocities (DPV) and diastolic mean velocities (DMV) were calculated. RESULTS: Sixty of 65 (92.3%) subjects successfully underwent TTDE. Baseline clinical characteristics were similar between the two groups. Coronary DPV and DMV of LAD were significantly lower in the CSFP group than in the control group ((0.228 ± 0.029) m/s vs. (0.302 ± 0.065) m/s, P = 0.000; (0.176 ± 0.028) m/s vs. (0.226 ± 0.052) m/s, P = 0.000, respectively). There was a high inverse correlation between CTFC and coronary DPV and DMV (r = -0.727, P = 0.000; r = -0.671, P = 0.000, respectively). Receiver operating characteristic (ROC) curve showed that the area under the curve (AUC) was less than one half for coronary DPV (AUC = 0.104) and DMV (AUC = 0.204), respectively. CONCLUSIONS: In patients with CSFP, there is a high inverse correlation between CTFC and coronary diastolic flow velocities in the LAD coronary artery, as measured by TTDE. The value of TTDE in the monitoring and evaluation of coronary flow in patients with CSFP deserves further investigation.

[Effects of perindopril and spirolactone on plasma aldosterone and left atrial remodeling in a canine model of atrial fibrillation].

OBJECTIVE: To investigate the effects of perindopril and spirolactone on plasma aldosterone (Ald) and left atrial remodeling and function in a canine model of atrial fibrillation (AF). METHODS: Adult dogs were randomly assigned to receive normal diet (group A), perindopril (group B, 1 mgxkg(-1)xd(-1)) and spironolactone (group C, 10 mgxkg(-1)xd(-1), n = 6 each) and rapid paced (500 beats/min) for 8 weeks. Plasma Ald levels as well as atrial dimension and function at baseline and at 4 and 8 weeks after pacing were measured by RIA and echocardiography, respectively. Incidence of maintained AF and AF duration were recorded when pacing was stopped after 8 weeks of pacing. Left and right atrial tissues were collected for measurements of tissue Ald levels and fibrosis. RESULTS: Plasma Ald was similar among groups at baseline (P > 0.05) and significantly increased post 4 and 8 weeks pacing in group A (P < 0.05) while remained unchanged post pacing in group B and C (P > 0.05) compared to respective baseline level. Atrial Ald was significantly lower in group B and C compared that in group A post 8 weeks pacing (P < 0.05). Left atrial dimension, end-systolic and end-diastolic volume were significantly increased while left atrial ejection fraction (LAEF) was significantly reduced post pacing in group A (all P < 0.05 vs. baseline) and thses changes were significantly attenuated in group B and C (P < 0.05 vs. group A). Incidence of maintained AF and AF duration post pacing as well as interstitial collagen volume fraction were significantly lower in group B and C compared those in group A (P < 0.05). CONCLUSION: Increased Ald might be an important pathogenesis for AF formation and progression, spironolactone and perindopril could attenuate atrial remodeling and improve atrial function by reducing plasma and tissue Ald levels in this model.