Elevated systolic pulmonary artery pressure is a substantial predictor of increased mortality after transcatheter aortic valve replacement in males, not in females.

BACKGROUND: While pulmonary hypertension (PH) in patients with severe aortic valve stenosis (AS) is associated with increased mortality after transcatheter aortic valve replacement (TAVR), there is limited data on gender differences in the effects on long-term survival. OBJECTIVE: The aim of this retrospective, multicenter study was to investigate the prognostic impact of pre-interventional PH on survival of TAVR patients with respect to gender. METHODS: 303 patients undergoing TAVR underwent echocardiography to detect PH prior to TAVR via measurement of systolic pulmonary artery pressure (sPAP). Different cut-off values were set for the presence of PH. The primary endpoint was all-cause mortality at 1, 3 and 5 years. RESULTS: Kaplan-Meier analysis by gender showed that only males exhibited significant increased mortality at elevated sPAP values during the entire follow-up period of 5 years (sPAP ≥ 40 mmHg: p ≤ 0.001 and sPAP ≥ 50 mmHg: p ≤ 0.001 in 1- to 5-year survival), whereas high sPAP values had no effect on survival in females. In Cox regression analysis based on the selected sPAP thresholds, male gender was an independent risk factor for long-term mortality after TAVR in all time courses. CONCLUSION: Male gender was an isolated risk factor for premature death after TAVR in patients with echocardiographic evidence of PH and severe AS. This could mean that, the indication for TAVR should be discussed more critically in men with severe AS and an elevated sPAP, while in females, PH should not be an exclusion criterion for TAVR.

Inverse Association between Educational Status and Coronary CT Calcium Scores: Should We Reflect This in Our ASCVD Risk Assumptions?

Education is not a factor included in most cardiovascular risk models, including SCORE2. However, higher education has been associated with lower cardiovascular morbidity and mortality. Using CACS as a proxy for ASCVD, we studied the association between CACS and educational status. Subjects, aged 40-69, from the Paracelsus 10,000 cohort, who underwent calcium scoring as part of screening for subclinical ASCVD, were classified into low, medium, and high educational status using the Generalized International Standard Classification of Education. CACS was dichotomised as either 0 or >0 for logistic regression modelling. Our analysis showed that higher educational status was associated with higher odds for 0 CACS (aOR 0.42; 95%CI 0.26-0.70; p = 0.001). However, there was no statistically significant association between the levels of total, HDL or LDL cholesterol and educational status, nor any statistical differences in HbA1c. SCORE2 did not differ between the three educational categories (4 ± 2% vs. 4 ± 3% vs. 4 ± 2%; p = 0.29). While our observations confirmed the relationship between increased educational status and lower ASCVD risk, the effect of educational status was not mediated via its impact on classical risk factors in our cohort. Thus, perhaps educational status should be taken into account to more accurately reflect individual risk in cardiovascular risk models.

Feasibility of Continuous Monitoring of Endoscopy Performance and Adverse Events: A Single-Center Experience.

BACKGROUND: We integrated a standardized questionnaire focusing on adverse events and performance measures in gastrointestinal endoscopy as a mandatory component of the electronical medical record. METHODS: This retrospective study was conducted using prospectively collected data on quality parameters and adverse events (AEPM) for all diagnostic and therapeutic endoscopic procedures at our center between 2018 and 2020. RESULTS: A total of 7532 consecutive endoscopic procedures were performed in 5035 patients. The proportion of high-risk examinations and high-risk patients was 20% and 23%, respectively. Severe adverse events (AEs, n = 21) occurred in 0.3% of procedures and significantly more often in patients with an ASA score > II (0.6%, p < 0.01). We observed no long-term morbidity after severe AEs. Mortality was 0.03% (n = 2). Following screening colonoscopy (n = 242), four endoscopists documented AEPM in more than 98% of the examinations. The cecal intubation rate was 97%, and the mean adenoma detection rate 60%. The quality of lavage was documented in 97% (rated as good in 70% and moderate in 24%). CONCLUSIONS: The risk of adverse events is significantly increased in patients with an ASA score > II, which should be considered when choosing treatment methods and precautionary measures. Continuous recording of AEPM can be effectively integrated into the clinical reporting process, enabling analysis of the data and feedback to be provided to endoscopists.

Pretreatment with Betablockers, a Potential Predictor of Adverse Cardiovascular Events in Takotsubo Syndrome.

Introduction: Treatment with betablockers is controversial in Takotsubo syndrome (TTS); however, many physicians intuitively initiate or continue betablocker therapy in these patients. The effect of preadmission betablocker use on adverse cardiovascular events has not been studied in the literature. Methods: To investigate this issue, we evaluated clinical complications, defined by the endpoint of occurrence of hemodynamically relevant arrythmia, cardiac decompensation, and all-cause adverse cardiac events, during hospitalization, in 56 patients hospitalized for TTS between April 2017 and July 2021. We compared the risk of adverse cardiovascular events between patients with preadmission betablocker therapy and those without preadmission betablocker therapy. Pretreatment betablocker therapy was defined as daily betablocker intake for more than a week including day of admission. Results: TTS patients taking preadmission betablockers had a significantly increased risk of all-cause complications relative to patients without betablockers in preadmission medication ((52.0% vs. 19.4%, p = 0.010; OR 4.5 (95% Cl 1.38-14.80)). Furthermore, TTS patients already taking betablockers on admission showed a statistically significant increased risk of cardiac decompensation when compared to patients without pretreatment with betablockers (p = 0.013). There were no significant differences in patient characteristics in patients who were taking beta blockers as an adjunct therapy prior to admission for TTS relative to those who were not. There is however an increase in comorbidities, hypertension, and atrial fibrillation, in past medical history in patients taking a preadmission betablocker. The difference is related to therapeutic applications for beta blockers and was not significant based on endpoints of our study. Conclusions: Preadmission betablocker treatment was associated with a 4.5 times higher risk of adverse cardiac events. This increased risk of all-cause complications and of cardiac decompensation within the acute phase of TTS is presumably due to the negative inotropic effects of betablockers and upregulation of ß-adrenergic receptors in patients with chronic betablocker therapy.

The differential diagnostic value of selected cardiovascular biomarkers in Takotsubo syndrome.

INTRODUCTION: Takotsubo syndrome (TTS) is clinically indistinguishable from an acute coronary syndrome (ACS). In the absence of valid markers for differential diagnosis, coronary angiography has been indispensable. METHODS: In our study, we evaluated the serum levels of sST-2, GDF-15, suPAR and H-FABP in 92 patients with the suspicion of TTS (51 TTS and 41 ACS patients) and 40 gender matched controls (no coronary artery disease or signs of heart failure) at baseline. RESULTS: H-FABP was significantly higher in ACS patients compared to TTS patients. Even in in propensity score matching for left ventricular ejection fraction, sex and cardiovascular risk factors, differences in the plasma levels of H-FABP in the matched cohort of TTS vs ACS remained statistically significant. Whereas, sST-2 was significantly elevated in TTS patients. H-FABP was superior for prediction of an ACS with even higher accuracy than hs troponin in differential diagnosis (AUC 0.797, p ≤ 0.0001); the optimal cut off for discrimination towards a TTS was calculated as 2.93 ng/ml (sensitivity 70.0%, specificity 82.4%, PPV 75.7%, NPV 77.4%). sST-2 seemed most appropriate for identification of a TTS (AUC 0.653, p = 0.012). The optimal cut off for differential diagnosis was 11018.06 pg/ml (sensitivity 82.0%, specificity 51.2%, PPV 69.4%, NPV 71.9 %). CONCLUSION: H-FABP and sST-2 are the most promising markers with better accuracy than preexisting biomarkers in differential diagnosis in our study and therefore, could be crucial for the guidance of treatment in patients with high bleeding risk, advanced renal failure or multimorbidity.

Single-center implementation of endoscopic submucosal dissection (ESD) in the colorectum: Low recurrence rate after intention-to-treat ESD.

BACKGROUND AND AIM: Colorectal endoscopic submucosal dissection (ESD) shows higher R0 resection and lower local recurrence rates than endoscopic mucosal resection (EMR) in Japan. In Europe, independent learning of ESD in the colorectum is feasible, but yet to be analyzed for curative resection and recurrence rates. METHODS: After experimental training under supervision by Japanese experts (T.O., N.Y.), three endoscopists independently carried out 83 ESD procedures intention-to-treat for lesions in the entire colorectum of 67 patients in a prospective registry (November 2009 to June 2016). RESULTS: ESD was feasible in 80 (96%) colorectal neoplasias (mean diameter 33.6 [± 1.8] mm), and three more required conversion to piecemeal EMR. The lesions were adenomas in 66% with low-grade intraepithelial neoplasia (LGIN), 29% with high-grade intraepithelial neoplasia, and 5% with carcinomas (G2, pT1). ESD had to be facilitated by the final use of snaring (hybrid-ESD, n = 45), especially in the initial learning period. En-bloc resection rate was 85%. Complications were microperforations (7%, conducive to one hemicolectomy), and delayed bleeding (1%) without mortality or long-term morbidity. Residual adenomas with LGIN (5%) after hybrid-ESD did not recur after endoscopic ablation. All malignant neoplasias (34%) were curatively resected without recurrence after a mean follow up of 19.5 (± 3.2) months. CONCLUSIONS: During independent ESD learning in the colorectum, ESD intention-to-treat showed a low recurrence rate after appropriate training, and hybrid-ESD showed acceptable complication and recurrence rates, justifying hybrid-ESD as a strategy for self-completion and rescue.