Assessment of optimal renin-angiotensin-system inhibition strategy in Asian patients with STEMI after primary myocardial revascularization.

BACKGROUND: For the Asian patients with STEMI undergoing PCI, ACEIs are known to have a better outcome than ARBs. However, there is limited evidence to suggest so. METHODS: Among the STEMI registry consist of 1142 Korean patients, we compared the MACE, the composite of myocardial infarction, stoke, death, admission for heart failure, and target vessel revascularization, between the ACEI and ARB groups (Set 1). Further, we defined adequate medication as the administration of a dose equal to or higher than the initiation dose of ACEI according to the heart failure guideline recommendation with a mandatory addition of beta-blockers, and compared the outcomes between the inadequate and adequate medication groups (Set 2). Propensity score matching was used to eliminate difference. RESULTS: In the Set 1 comparison, patients in the ACEI group had a better outcome than those in the ARB group for both whole and matched populations (whole and matched population: Cox regression hazard ratio [HR], 0.645 and 0.535; 95% confidence interval [CI], 0.440-0.944 and 0.296-0.967; p = 0.024 and p = 0.039, respectively). In the Set 2 comparison for the whole population, patients in the inadequate medication group had more MACE than those in the adequate medication group (HR, 0.673; 95% CI, 0.459-0.985; p = 0.042). However, no difference was observed after propensity score matching (HR, 1.023; 95% CI, 0.654-1.602; p = 0.919). CONCLUSION: ACEIs might be a better choice than ARBs after primary revascularization. However, this study's findings suggest that early ACEI dose escalation combined with beta-blocker use may not improve prognosis.

Height Is Associated with Dyslipidemia in Korean Premenopausal Women: Data from the Korea National Health and Nutrition Examination Survey.

BACKGROUND: The association between height and cardiovascular disease (CVD) has been reported in epidemiological studies for decades; however, the mechanism for this relationship is still unclear. We previously reported that dyslipidemia was associated with adult height in Korean men without CVD. OBJECTIVES: This study explored the potential -relationship between height and dyslipidemia in premenopausal women. METHODS: This study used data from the 2007-2016 Korea National Health and Nutritional Examination Survey (KNHANES). We identified 16,361 premenopausal women aged ≥19 years without a history of CVD (myocardial infarction/stroke) or cancer. Fasting total cholesterol, triglyceride, and high-density lipoprotein cholesterol (HDL-C) levels were measured. Dyslipidemia was further classified as hypercholesterolemia (total cholesterol level ≥240 mg/dL or treatment with lipid-lowering medications), hypertriglyceridemia (triglyceride level ≥200 mg/dL), and low HDL-C (HDL-C level <40 mg/dL). Subjects were divided into four groups by their height (<155, 155-159.9, 160-164.9, and ≥165 cm), and the prevalence of dyslipidemia was compared. RESULTS: Multiple regression analysis revealed that short premenopausal women had a higher likelihood of hypercholesterolemia (ptrend = 0.002), hypertriglyceridemia (ptrend = 0.010), and low HDL-C (ptrend = 0.002) when adjusted for age, comorbidities, waist circumference, health-related habits, and economic status. CONCLUSION: There was a dose-dependent correlation between adult height and adverse lipid profile in premenopausal Korean women who did not have CVD. This finding could serve as further evidence that dyslipidemia can be a link between shortness and CVD.

Addition of routine blood biomarkers to TIMI risk score improves predictive performance of 1-year mortality in patients with ST-segment elevation myocardial infarction.

BACKGROUND: Several biomarkers have been proposed as independent predictors of poor outcomes in ST-segment elevation myocardial infarction (STEMI). We investigated whether adding information obtained from routine blood tests including hypoxic liver injury (HLI), dysglycemia, anemia, and high neutrophil to lymphocyte ratio (NLR) could improve the prognostic performance of the TIMI risk score for the prediction of 1-year mortality. METHODS: A total of 1057 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) between 2007 and 2014 were retrospectively enrolled from 4-regional hospitals. HLI and dysglycemia were defined as serum transaminase > twice the normal upper limit and glucose < 90 or > 250 mg/dL, respectively. The effect of adding biomarkers to the TIMI risk score on its discriminative ability was assessed using c-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). RESULTS: The 1-year mortality rate was 7.1%. The best cutoff value of NLR for the prediction of 1-year mortality was 4.3 (sensitivity, 67%; specificity, 65%). HLI (HR 2.019; 95% CI 1.104-3.695), dysglycemia (HR 2.535; 95% CI 1.324-3.923), anemia (HR 2.071; 95% CI 1.093-3.923), and high NLR (HR 3.651; 95% CI 1.927-6.918) were independent predictors of 1-year mortality. When these 4 parameters were added to the TIMI risk score, the c-statistic significantly improved from 0.841 to 0.876 (p < 0.001), and the NRI and IDI were estimated at 0.203 (95% CI 0.130-0.275; p < 0.001) and 0.089 (95% CI 0.060-0.119; p < 0.001), respectively. CONCLUSIONS: The addition of HLI, dysglycemia, anemia, and high NLR to the TIMI risk score may be useful for very early risk stratification in patients with STEMI receiving primary PCI.

The selection of ß-blocker after successful reperfusion in patients with ST-elevation myocardial infarction.

BACKGROUND: The selection of ß-blocker for survivors after primary intervention due to acute ST-elevation myocardial infarction seems crucial to improve the outcomes. However, rare comparison data existed for these patients. We aimed to compare the effectiveness of selective ß-blockers to that of carvedilol in patients treated with primary intervention. METHODS AND RESULTS: Among the 1,485 patients in the "INTERSTELLAR" registry between 2007 and 2015, 238 patients with selective ß-blockers (bisoprolol, nebivolol, atenolol, bevantolol, and betaxolol) and 988 with carvedilol were included and their clinical outcomes were compared for a 2-year observation period. In the clinical baseline characteristics, the unfavorable trends in the carvedilol group were high Killip presentation, lower ejection fractions, smaller diameters, and longer lengths of deployed stents. Although mortality (2.5% vs. 1.7%; p = 0.414) and the rate of stroke (0.8% vs. 0.6%; p = 0.693) were not different between groups, the rate of recurrent myocardial infarction (4.6% vs. 1.2%; p = 0.001) and of target vessel revascularization (4.2% vs. 0.9%; p < 0.001) were lower in the carvedilol group. After eliminating the difference by propensity matching, the similar outcome result was shown (all-cause death, 0.6% vs. 1.0%, p = 0.678; stroke, 0.6% vs. 1.2%, p = 0.479; myocardial infarction, 5.0% vs. 1.2%, p = 0.003; target vessel revascularization, 4.5% vs. 0.7%, p < 0.006) for 595 matched populations. The use of carvedilol was also determined to be an independent predictor for recurrent myocardial infarctions (hazard ratio = 0.305; p = 0.005; 95% confidence interval = 0.13-0.69). CONCLUSION: Use of a carvedilol in ST-segment myocardial infarction survivor is associated with lower recurrent myocardial infarction events. Thus, it might be the better choice of ß-blocker for secondary prevention in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention.

Comparison of Intracardiac Echocardiography and Transesophageal Echocardiography for Image Guidance in Percutaneous Patent Foramen Ovale Closure.

Background and Objectives: Transesophageal echocardiography (TEE) guidance is the current gold standard for catheter-based procedures in the treatment of structural heart diseases. Intracardiac echocardiography (ICE), which can be performed under local anesthesia, has been recently introduced and is becoming more widely used. We aimed to compare the efficacy and safety of ICE and TEE in patent foramen ovale (PFO) device closure. Materials and Methods: All 74 patients with a history of cryptogenic stroke undergoing PFO closure for secondary prophylaxis were selected from our registry. Intraprocedural TEE was performed by echocardiographer-cardiologists with the patient under general anesthesia. Conversely, ICE was performed with the patient under local anesthesia. Baseline characteristics, procedural details, and immediate outcomes were compared between the TEE and ICE groups (n = 49 and n = 25, respectively). Results: Although patients in the ICE group were older (47 ± 10 vs. 57 ± 7 years, p < 0.001), sex and comorbidity variables were similar between the two groups. The degree of inducible right-to-left shunt via the PFO, assessed using preprocedural TEE, was also comparable. Notably, fluoroscopy time (22 ± 18 vs. 16 ± 7 min, p = 0.030), radiation dose (498 ± 880 vs. 196 ± 111 mGy, p = 0.022), and total procedural time in the catheter laboratory (99 ± 30 vs. 67 ± 12 min, p < 0.001) were significantly lower in the ICE group than those in the TEE group. The entire hospital stay was similar between groups (3.8 ± 2.2 vs. 3.4 ± 1.3 days, p = 0.433). No procedural complications, such as device embolization, pericardial hemorrhage, major bleeding, mortality, or access-related vascular injury were reported in either group. Conclusions: ICE-guided PFO device closure is quicker and less hazardous in terms of radiation exposure than the TEE-guided procedure, with similar procedural outcomes and duration of hospital stay.

Residual Shunt after Patent Foramen Ovale Device Closure in Patients With Cryptogenic Stroke: Serial Bubble Contrast Transesophageal Echocardiography Data.

BACKGROUND: Percutaneous closure of patent foramen ovale (PFO) is an alternative option to medical treatment for secondary prevention for cryptogenic stroke (CS). Despite technical success of procedure, residual shunt (RS) which is a presumable cause for recurrent stroke is observed in some patients. We evaluated the RS with serial follow-up bubble contrast transesophageal echocardiography (BCTEE) after PFO closure. METHODS: Among consecutive 47 CS patients who underwent PFO closure, a serial follow-up BCTEE at 3 and 9 months after the index procedure was completed in 38 patients (81%, 46 ± 10 years, 19 men). To evaluate the efficacy of PFO closure, the incidence of any and significant RS (≥ moderate) was assessed. RESULTS: All PFO closure procedures were successful. The Amplatzer PFO Occluder (n = 19) or the Gore Septal Occluder (n = 19) were used. Any RS was observed in 13 (34%) and 10 patients (26%) at 3 and 9 months after the procedure. Significant RS was observed in 6 (16%) and 4 (11%) patients at 3- and 9-month follow-up BCTEE. Patients who were treated with the Gore Septal Occluder have a less incidence of any RS in 3 months, and any/significant RS in 3- and 9-month follow-up BCTEE without statistical significance. CONCLUSIONS: RS grade keeps decreasing after PFO closure, but it remains even after 9 months in some patients. Incomplete sealing of PFO should be taken into consideration in management of CS patients even after technically successful PFO closure.

Effect of patent foramen ovale closure for prevention on recurrent stroke or transient ischemic attack in selected patients with cryptogenic stroke.

OBJECTIVES: This study was sought to evaluate the effectiveness of patent foramen ovale (PFO) closure in selected patients (PFO shunt grade more than moderate) with cryptogenic stroke (CS). BACKGROUND: Whether closure of PFO is an effective treatment for prevention of CS is still unclear. METHODS: Consecutive 158 patients (mean age: 49.9 years old, closure group: 67 patients, medication group: 91 patients) were enrolled. The primary end point was a composite of recurrent stroke and transient ischemic attack. RESULTS: Baseline characteristics were similar between the two groups, except age which was younger in the closure group (47.7 ± 10.8 vs 51.9 ± 9.9, P = 0.013), and the presence of shunt at rest was more common in the closure group (35.8% vs 10.4%, P = 0.000). Procedural success was 94.0%. Over a mean follow-up of 27.8 months, a total of six primary end point, all of which were strokes, occurred only in the medication group (6.6% vs 0%, P = 0.039). Stroke-free survival rate was significantly higher in the closure group (P = 0.026) CONCLUSIONS: Our study showed that PFO closure may be an effective treatment strategy to prevent recurrent stroke or TIA for patients with CS if it is conducted in selective patients who have PFO shunt more than moderate grade.

Routine Indwelling Urethral Catheterization in Acute Heart Failure Patients Is Associated With Increased Urinary Tract Complications Without Improved Heart Failure Outcomes.

BACKGROUND: Indwelling urethral catheters (IUC) are routinely inserted for the purpose of monitoring urine output in patients with acute heart failure (AHF). The benefit of IUC in patients capable of complying with urine collection protocols is unclear, and IUC carry multiple risks. This study describes the impact of IUC on AHF treatment.Methods and Results:A total of 540 records were retrospectively analyzed. After exclusion criteria were applied, 316 patients were propensity matched to establish groups of 100 AHF patients who either did (IUC(+)) or did not receive an IUC (IUC(-)) upon admission. Hospital length of stay (9 vs. 7 days), in-hospital urinary complications (24 vs. 5%), and 1-year urinary tract infection rate (17 vs. 6%; HR, 3.145; 95% CI: 1.240-7.978) were significantly higher in the IUC(+) group (P<0.05 for all). There were no differences in 30-day rehospitalization (6 vs. 6%; HR, 0.981; 95% CI: 0.318-3.058; P=0.986) or major adverse cardiac/cerebrovascular events at 1 year (37 vs. 32%, HR, 1.070; 95% CI: 0.636-1.799; P=0.798). CONCLUSIONS: Based on this retrospective analysis, the routine use of IUC may increase length of stay and UTI complications in AHF patients without reducing the risk for major cardiovascular and cerebrovascular events or 30-day rehospitalization rate.

Post-operative left atrial volume index is a predictor of the occurrence of permanent atrial fibrillation after mitral valve surgery in patients who undergo mitral valve surgery.

BACKGROUND: Atrial fibrillation (AF) can occur even after the correction of mitral valve (MV) pathology in patients who have pre-operative sinus rhythm and undergo MV surgery. However, the factors associated with the occurrence of AF after MV surgery are still unclear. The aim of this retrospective study was to investigate the factors determining the occurrence of permanent AF after MV surgery in patients with preoperative sinus rhythm who underwent MV surgery. METHODS: Four hundred and forty-two patients (mean age 46 ± 12, 190 men) who underwent MV surgery and sinus rhythm were investigated retrospectively. Transthoracic echocardiography was performed before and after MV surgery at the time of dismissal. RESULTS: Permanent post-operative AF occurred in 81 (18%) patients even after successful MV surgery and preoperative sinus rhythm. It was more common in rheumatic etiology, a presence of mitral stenosis, lower pre- and post-operative left ventricular ejection fraction, higher post-operative mean diastolic pressure gradient across mitral prosthesis, larger post-operative left atrial volume index (LAVI) and lesser degrees of reduction in LAVI after surgery. In multiple regression analysis, post-operative LAVI was found to be an independent predictor for occurrence of AF. Post-operative LAVI > 39 ml/m2 was the cut-off value for best prediction of new onset permanent AF (sensitivity: 79%, AUC: 0.762, SE: 0.051, p < 0.001). CONCLUSION: New-onset permanent post-operative AF is not uncommon, even after successful MV surgery despite pre-operative sinus rhythm. Larger post-operative LAVI was an independent predictor for the occurrence of AF.

Casual alcohol consumption is associated with less subclinical cardiovascular organ damage in Koreans: a cross-sectional study.

BACKGROUND: Epidemiologic studies have presented protective effects of alcohol against cardiovascular (CV) events. However, such studies were performed mainly on Westerners. We investigated the effects of alcohol on the subclinical CV morbidity in healthy Koreans. METHODS: The coronary artery calcium (CAC) score, ankle-brachial pulse wave velocity (abPWV), and carotid intima-media thickness (cIMT) of 1004 subjects (age, years±standard deviation [SD] 53 ± 10; 72% were men) with no CV disease history were assessed. The subjects were divided into three groups based on their drinking patterns: Group 0 (abstainers), Group 1 (casual drinkers), and Group 2 (problematic drinkers; > 14 standard drinking/week for men, > 7 standard drinking/week for women). As drinking patterns can be influenced by age/sex, a regression analysis was performed in another four groups (men/women, age < 65/≥65 years). RESULTS: Group 1 exhibited lower CAC (score ± SD, 44 ± 155 vs. 13 ± 48 vs. 50 ± 159) and abPWV (cm/s ± SD, 1448 ± 284 vs. 1340 ± 190 vs. 1447 ± 245) scores and thinner cIMT (mm ± SD, 0.64 ± 0.14 vs. 0.59 ± 0.11 vs. 0.63 ± 0.13) than Groups 0 and 2 (p < 0.05 for all). Problematic drinking (odds ratio [OR]: 2.269; 95% confidence interval [CI]: 1.454-3.541) was associated with a high prevalence of CAC deposits among men aged < 65 years and casual drinking with a lower prevalence of CAC deposits (OR: 0.057; 95% CI: 0.023-0.140) among men aged ≥65 years. Conversely, problematic drinking in older women [OR: 0.117; 95% CI: 0.014-0.943) and casual drinking in younger women (OR: 0.349; 95% CI: 0.153-0.792) were associated with a lower prevalence of CAC deposits. Casual drinking was associated with a lower abPWV and thinner cIMT in the diabetes mellitus/hypertension-adjusted regression analysis. CONCLUSIONS: Compared with abstinence or problematic drinking, casual drinking was associated with less severe CV organ damage in the subclinical stages in Koreans.

Prognostic implication of left atrial sphericity in atrial fibrillation patients undergoing radiofrequency catheter ablation.

BACKGROUND: Left atrial (LA) sphericity can predict recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA). We sought to reconfirm the prognostic role of atrial sphericity after RFCA of atrial fibrillation (AF), assess any relationship between the atrial pressure and sphericity, and determine the characteristics of the patients for whom atrial sphericity was most highly predictive. METHODS: All 148 nonvalvular AF patients (57 ± 11 years, 121 men, 95 paroxysmal AF [PaAF]) who underwent RFCA were enrolled. The LA volume (LAV) was determined and LA sphericity assessed from three-dimensional computed tomographic images. The preprocedural mean LA pressure (mLAP) was measured. RESULTS: After a 3-month blanking period, AF/atrial tachycardia (AT) recurrences within 1 year were documented in 38 patients (26%). Patients with recurrence had a greater LAV (124 ± 35 mL vs 151 ± 45 mL, P < 0.001) and LA sphericity (0.669 ± 0.040 vs 0.684 ± 0.038, P = 0.041). In patients with smaller LAs (LAV < 125 mL), LA sphericity predicted AF/AT recurrences (odds ratio [OR]: 1.030 [for each 0.001 increase], 95% confidence interval [CI]: 1.008-1.053, P = 0.007), whereas the LAV did not. In patients with larger LAs (LAV ≥ 125 mL), the LAV could predict recurrence (OR: 1.021, 95% CI: 1.001-1.041, P = 0.036), while the LA sphericity could not. The LA sphericity and mLAP are linearly correlated (r = 0.345, P < 0.022) in persistent AF, but not PaAF. CONCLUSIONS: LA spherical change precedes severe LA enlargement in AF. It predicts 1-year AF/AT recurrence after RFCA and is more important than the LA size in patients with less severe LA enlargement.

Left Atrial Volume as a Predictor of Left Ventricular Functional Recovery in Patients With Dilated Cardiomyopathy and Absence of Delayed Enhancement in Cardiac Magnetic Resonance.

BACKGROUND: Improvement of left ventricular (LV) systolic dysfunction can occur in patients with dilated cardiomyopathy (DCM), and it is more frequently observed if patients have no delayed enhancement (DE) in cardiac magnetic resonance imaging (CMR). However, even in the absence of DE, not all patients have functional recovery. We retrospectively investigated the predictors of LV functional recovery in patients with DCM who had no DE in CMR. METHODS: A total of 136 patients with DCM underwent CMR. Among them, 44 (29 male, age 55 ± 14 years) showed no DE and these patients composed the study population. The study patients were divided into 2 groups according to the occurrence of functional recovery defined as an increase in LV ejection fraction to a level of ≥50% and net increase in ejection fraction of 20% or more: group 1 (n = 14) with functional recovery and group 2 (n = 30) without functional recovery. RESULTS: In patients who showed functional recovery, left atrial volume index (LAVI [26 ± 8 mL/m(2) vs 45 ± 18 mL/m(2)]) and LV end-diastolic dimension (62 ± 6 mm vs 67 ± 7 mm) were significantly smaller when compared with those without functional recovery (P <.05 for all). In Cox multiple regression analysis, LAVI was the only significant parameter associated with LV functional recovery (hazard ratio 0.932, 95% confidence interval 0.877-0.991, P = .024). LAVI < 38 mL/m(2) had 100% specificity in predicting the improvement of LV systolic dysfunction. CONCLUSION: In DCM patients who had no DE in CMR, LAVI predicts LV functional recovery with high specificity.

Comparison of Outcomes after Device Closure with Transseptal Puncture and Standard Technique in Patients with Patent Foramen Ovale and Ischemic Events.

OBJECTIVES: The purpose of this study was to compare the effectiveness of device closure with the transseptal puncture and standard technique in patients with patent foramen ovale (PFO) and ischemic events. METHODS: Eighty-two consecutive patients (men: 60 patients, mean age: 45.2 years) who underwent PFO closure with the Amplatzer PFO Occluder were enrolled. PFO closure with the transseptal puncture was performed in 22 patients (transseptal puncture technique, group I). In the remaining patients (n = 60), PFO closure was performed with the standard technique (group II). The co-primary end points were the incidence of significant residual shunt on follow-up transesophageal echocardiography (TEE) and a composite of death, stroke, transient ischemic attack (TIA), and peripheral embolism. RESULTS: Baseline characteristics were similar between the two groups. On TEE, despite similar grade of interatrial right-to-left shunt, shunt at rest/septal hypermobility was less common in group I than in group II (40.9% vs. 72.9%, P < 0.010). The device was successfully implanted in all patients. On follow-up TEE, significant residual shunt was more common in group I than in group II (28.6% vs. 4.3%, P = 0.021). In addition, composite of death, stroke, TIA, or peripheral embolism was more common in group I than in group II (13.6% vs. 0%, P = 0.017) during the follow-up period (mean 25.4 months). CONCLUSION: Compared to the standard technique, PFO closure with the transseptal puncture technique showed higher incidence of residual shunt and ischemic events. Therefore, this technique might be considered in only highly selected patients as the last option.

The Valsalva maneuver can misdiagnose 'normal' as 'pseudonormal': a word of caution for an echocardiographic evaluation of diastolic function.

OBJECTIVES: To identify differences in cardiac hemodynamic changes between the Valsalva maneuver and nitroglycerin (NTG) administration. METHODS: Fifty-three subjects (37 men, 43 ± 12 years) with normal cardiac function [left ventricular ejection fraction ≥55%, early to late mitral inflow velocity ratio (E/A) ≥1, left atrial volume index ≤34 ml/m(2) and early diastolic mitral annulus velocity (E') ≥8 cm/s] were enrolled. Doppler parameters were determined at rest, during the Valsalva maneuver and after NTG administration. RESULTS: Decreased E, A and E/A were observed both during the Valsalva maneuver and after NTG administration (p < 0.0001 for all). However, the reduction in E (ΔEValsalva: -30 ± 16 cm/s vs. ΔENTG: -17 ± 17 cm/s) and E/A (ΔE/AValsalva: -0.37 ± 0.28 vs. ΔE/ANTG: -0.19 ± 0.25) and the prolongation of the deceleration time (DT) of E (ΔDTValsalva: 105 ± 74 ms vs. ΔDTNTG: 83 ± 63 ms) were more prominent during the Valsalva maneuver than with NTG administration (p < 0.0001 for all). Particularly, a greater decrease in E' was observed during the Valsalva maneuver (ΔE'Valsalva: -3 ± 2 cm/s vs. ΔE'NTG: -2 ± 2 cm/s, p < 0.0001). Eighteen subjects (34%) showed ΔE/A ≥0.5 during the Valsalva maneuver; thus, they were mislabeled as 'pseudonormal', while only 3 subjects (6%) showed ΔE/A ≥0.5 after NTG administration. CONCLUSIONS: The Valsalva maneuver not only decreases preload but also affects myocardial performance, thus, its use can result in the mislabeling of normal subjects as pseudonormal.

Frequent premature ventricular complex is associated with left atrial enlargement in patients with normal left ventricular ejection fraction.

BACKGROUND: Premature ventricular complex (PVC) has been regarded as benign; however, when frequent, the arrhythmia can induce left ventricular (LV) systolic dysfunction. Meanwhile, the influence of PVCs on cardiac structural remodeling and functional change before occurrence of overt systolic heart failure has not been fully described. In this study, we attempted to identify early cardiac structural/functional manifestations of frequent PVCs in patients with normal LV systolic function. METHODS: A total of 146 patients (age: 55 ± 15 years, 48 males) with frequent PVCs observed on 24-hour Holter monitoring (>10/h) and normal LV ejection fraction (LV EF ≥ 55% on echocardiography) were enrolled. Clinical characteristics and echocardiographic parameters of the patients were compared with those of an age-/sex-matched control group (n = 292, age: 55 ± 15 years, 96 males). RESULTS: Patients with frequent PVCs had significantly larger left atrial volume index (LAVI [28 ± 9 mL/m(2) vs. 24 ± 7 mL/m(2) ]), along with larger LV end-diastolic dimension (49.4 ± 4.4 mm vs. 48.5 ± 3.9 mm), lower LV EF (63 ± 7% vs. 66 ± 6%), and lower peak systolic mitral annular velocity (7 ± 2 cm/s vs. 8 ± 2 cm/s; P < 0.05 for all), whereas other clinical characteristics were similar. In particular, in patients with frequent PVCs, LAVI showed linear correlation with PVC burden (R = 0.30, P < 0.001), and, in a multiple regression model, PVC burden independently estimated LAVI, even after controlling for age, sex, comorbidities, and systolic function (ß = 0.309, P < 0.001). CONCLUSION: Frequent PVC is associated with LA enlargement in patients with normal LV EF. Atrial anatomical remodeling may precede LV geometry change and systolic dysfunction in patients with frequent PVCs.

Extent of late gadolinium enhancement on cardiovascular magnetic resonance imaging and its relation to left ventricular longitudinal functional reserve during exercise in patients with hypertrophic cardiomyopathy.

BACKGROUND: The aim of this study was to investigate whether the extent of late gadolinium enhancement (LGE) on cardiovascular magnetic resonance imaging reflecting myocardial fibrosis correlates with left ventricular (LV) longitudinal function during exercise in hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS: Mitral annular velocities (E' and S') were measured on echocardiography at rest and during graded bicycle exercise (25 W, 3-min increments) in 46 HCM patients (mean age, 53 years; 32 men). LV longitudinal diastolic and systolic functional reserve indices were calculated as ΔE'×E'base and ΔS'×S'base, where ΔE' and ΔS' are the changes in E' and S' from baseline to 50 W of exercise, respectively. The patients were divided into 2 groups according to the extent of LGE (as "percentage of LV mass containing LGE": %LV with LGE; range, 0-37%; median, 6%): group 1 (n=23), %LV with LGE <6%, and group 2, %LV with LGE ≥6%. Baseline echocardiographic parameters were similar between the 2 groups, but changes in E' and S' during exercise were smaller in group 2 (ΔE': 2.8±1.8 cm/s vs.1.5±1.0 cm/s, P=0.007; ΔS': 2.2±1.2 cm/s vs. 0.9±0.8 cm/s, P<0.0001). LV functional reserve indices were also significantly lower in group 2 (ΔE'×E'(base): 12.8±7.7 vs. 5.5±3.4, P=0.001; ΔS'×S'(base): 12.6±7.4 vs. 4.7±4.5, P<0.0001). CONCLUSIONS: LV longitudinal function during exercise is influenced by the extent of LGE in HCM. Myocardial fibrosis may represent a pathologic substrate that determines LV functional reserve in patients with HCM.

Long-term clinical outcomes for patients with uncrossable patent foramen ovale.

Introduction: Patent foramen ovale (PFO) closure is performed in selected patients with cryptogenic stroke to prevent recurrence. The prognosis of patients with uncrossable PFO after failed guidewire or catheter passage during the procedure remains unknown. We compared the long-term prognosis between uncrossable PFO and successful PFO closure in patients with high-grade PFO shunts. Methods: We analyzed patients who underwent PFO closure for stroke or transient ischemic attack (TIA) prevention at Gachon University Gil Medical Center between April 2010 and March 2022. The primary outcome was a composite of recurrent stroke or TIA. Secondary outcomes included stroke, TIA, all-cause death, and a composite of stroke, TIA, and all-cause death. Results: Of 286 patients, 245 were included in the analysis after excluding those with transseptal puncture technique usage or concurrent atrial septal defect. Among them, 82 had uncrossable PFO, and 163 underwent successful PFO closure. Large shunts were more prevalent in the PFO closure group compared to the uncrossable PFO group (62.0% vs. 34.1%, P < 0.001), and resting shunts were also more common in the PFO closure group (17.8% vs. 2.4%, P < 0.001). Stroke or TIA occurred in 2 patients (2.4%) in the uncrossable PFO group and 8 patients (4.9%) in the PFO closure group (hazard ratio, 1.44; 95% confidence interval, 0.30-6.81; P = 0.647). Additionally, no disparities in the occurrence of stroke or TIA were found in subgroups divided by baseline characteristics, RoPE score, or shunt grade. Conclusion: Clinical outcomes for patients with uncrossable PFO seem similar to those with successful PFO closure.

Hemo-metabolic impairment in patients with ST-segment elevation myocardial infarction: Data from the INTERSTELLAR registry.

BACKGROUND: Not only hemo-dynamic (HD) factors but also hemo-metabolic (HM) risk factors reflecting multi-organ injuries are considered as important prognostic factors in ST-segment elevation myocardial infarction (STEMI). However, studies regarding HM risk factors in STEMI patients are currently limited. METHOD: Under analysis were 1,524 patients with STEMI who underwent primary percutaneous coronary intervention in the INTERSTELLAR registry. Patients were divided into HM (≥ 2 risk factors) and non-HM impairment groups. The primary outcome was in-hospital all-cause mortality, and the secondary outcome was 1-year all-cause mortality. RESULTS: Of 1,524 patients, 214 (14.0%) and 1,310 (86.0%) patients were in the HM and non-HM impairment groups, respectively. Patients with HM impairment had a higher incidence of in-hospital mortality than those without (24.3% vs. 2.7%, p < 0.001). After adjusting for confounders, HM impairment was independently associated with in-hospital mortality (inverse probability of treatment weighting [IPTW]-adjusted odds ratio: 1.81, 95% confidence interval: 1.08-3.14). In the third door-to-balloon (DTB) time tertile (≥ 82 min), HM impairment was strongly associated with in-hospital mortality. In the first DTB time tertile ( < 62 min), indicating relatively rapid revascularization, HM impairment was consistently associated with increased in-hospital mortality. CONCLUSIONS: Hemo-metabolic impairment is significantly associated with increased risk of in-hospital and 1-year mortality in patients with STEMI. It remains a significant prognostic factor, regardless of DTB time.

Right atrial anatomical remodeling affects early outcomes of nonvalvular atrial fibrillation after radiofrequency ablation.

BACKGROUND: The impact of the right atrial (RA) anatomical remodeling on outcomes of atrial fibrillation (AF) after radiofrequency ablation (RFA) is unclear. METHODS AND RESULTS: Sixty-three patients (50 men, 57±10 years, 23 persistent AF [PeAF]) who underwent RFA for AF were enrolled. Both RA and left atrial (LA) volumes, measured with multidetector computed tomography, as well as echocardiographic parameters were compared between subjects with early (<3 months, n=13) or 1-year (n=19) recurrence after RFA and without recurrence. The RA volume index (RAVI) was larger (98±21 vs. 77±22 ml/m²) and PeAF was more common (62% vs. 30%) in the early recurrence group (P<0.05 for all), whereas the LA volume index (LAVI) was similar between the 2 groups (78±15 vs. 72±19 ml/m², P=0.23). Notably, RAVI was the only independent predictor of early recurrence (for each 10 ml/m² increase, OR: 1.650, 95%CI: 1.017-2.677, P=0.04). PeAF was the only independent predictor of 1-year recurrence after RFA (OR: 4.496, 95%CI: 1.110-18.211, P=0.04), whereas RAVI and LAVI were not. CONCLUSIONS: RA anatomical remodeling might affect the early recurrence of AF after RFA. However, the chronicity of AF, rather than RA and LA anatomical remodeling, is a determinant of 1-year recurrence of AF after RFA.