Validation of virtual fractional flow reserve pullback curves.

BACKGROUND: Angiography-derived fractional flow reserve (virtual FFR) has shown excellent diagnostic performance compared with wire-based FFR. However, virtual FFR pullback curves have not been validated yet. OBJECTIVES: To validate the accuracy of virtual FFR pullback curves compared to wire-based FFR pullbacks and to assess their clinical utility using patient-reported outcomes. METHODS: Pooled analysis of two prospective studies, including patients with hemodynamically significant (FFR ≤ 0.80) coronary artery disease (CAD). Virtual and wire-based FFR pullbacks were compared to assess the accuracy of virtual pullbacks to characterize CAD as focal or diffuse. Pullbacks were analyzed visually and quantitatively using the pullback pressure gradient (PPG). Patients underwent PCI, and the Seattle Angina Questionnaire (SAQ) was administered at 3-month follow-up. RESULTS: A total of 298 patients (300 vessels) with both virtual and wire-based pullbacks who underwent PCI were included in the analysis. The mean age was 61.8 ± 8.8, and 15% were female. The agreement on the visual adjudication of the CAD pattern was fair (Cohen's Kappa: 0.31, 95% confidence interval: 0.18-0.45). The mean PPG were 0.65 ± 0.18 from virtual pullbacks and 0.65 ± 0.13 from wire-based pullbacks (r = 0.68, mean difference 0, limits of agreement -0.27 to 0.28). At follow-up, patients with high virtual PPG (>0.67) had higher SAQ angina frequency scores (i.e., less angina) than those with low virtual PPG (SAQ scores 92.0 ± 14.3 vs. 85.5 ± 23.1, p = 0.022). CONCLUSION: Virtual FFR pullback curves showed moderate agreement with wire-based FFR pullbacks. Nonetheless, patients with focal disease based on virtual PPG reported greater improvement in angina after PCI.

Lung ultrasound: a narrative review and proposed protocol for patients admitted to Cardiac Rehabilitation Unit.

Lung ultrasonography (LUS) has become in the last 10 years a technique that has reduced the need of second level diagnostic methods such as chest X-ray (CXR) and computerize tomography (CT) for the diagnostic imaging of lung and pleural space, throughout its diagnostic accuracy, radiation free, low cost, real time and bedside approach. The common use of LUS has been recently extend to cardiac and pulmonary disease even in context of Cardiac Rehabilitation Unit and it could be an additional tool for physiotherapist for the management of patients during Rehabilitation course. The authors performed a literature review in PubMed and suggested a new standardize protocol for LUS, based on guidelines and expert consensus document, for patients admitted to Cardiac Rehabilitation Unit. In this protocol, LUS should be performed in six scan each hemithorax, covering twelve imagine regions. For each scan will be noted a specific physiologic or pathological patterns. Furthermore, we suggest for each patient, the use of the Lung Ultrasound Score (LUS score) to obtain a global view of lung aeration and to monitor any changes during the hospitalization. An increase in score range indicates a more severe condition. This Lung Ultrasonography Protocol should be performed in all patients at the time of admission to Cardiac Rehabilitation Unit to monitoring the aeration of the lungs and the possible lung and/or pleura complications after a cardiac disease avoiding the use of second level surveys.

Improved diagnostic accuracy of vessel-specific myocardial ischemia by coronary computed tomography angiography (CCTA).

BACKGROUND: Discrepancies between stenosis severity assessed at coronary computed tomography angiography (CCTA) and ischemia might depend on vessel type. Coronary plaque features are associated with ischemia. Thus, we evaluated the vessel-specific correlation of CCTA-derived diameter stenosis (DS) and invasive fractional flow reserve (FFR) and explored whether integrating morphological plaque features stratified by vessel might increase the predictive yield in identifying vessel-specific ischemia. METHODS: Observational cohort study including patients undergoing CCTA for suspected coronary artery disease, with at least one vessel with DS â€‹≥ â€‹50 â€‹% at CCTA, undergoing invasive coronary angiography and FFR. Plaque analysis was performed using validated semi-automated software. Coronary vessels were stratified in left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA). Per vessel independent predictors of ischemia among CCTA-derived anatomical and morphologic plaque features were tested at univariable and multivariable logistic regression analysis. The best cut-off to predict ischemia was determined by Youden's index. Ischemia was defined by FFR≤0.80. RESULTS: The study population consisted of 192 patients, of whom 224 vessels (61 â€‹% LAD, 19 â€‹% LCX, 20 â€‹% RCA) had lesions with DS â€‹≥ â€‹50 â€‹% interrogated by FFR. Despite similar DS, the rate of FFR≤0.80 was higher in the LAD compared to LCX and RCA (67.2 â€‹% vs 43.2 â€‹% and 44.2 â€‹%, respectively, p â€‹= â€‹0.018). A significant correlation between DS and FFR was observed only in LAD (p â€‹= â€‹0.003). At multivariable analysis stratified by vessel, the vessel-specific independent predictors of positive FFR were percent atheroma volume (threshold>17 â€‹%) for LAD, non-calcified plaque volume (threshold >130 â€‹mm3) for LCX, and lumen volume (threshold <844 â€‹mm3) for RCA. Integrating DS and vessel-specific morphological plaque features significantly increased the predictive yield for ischemia compared to DS alone (AUC ranging from 0.51 to 0.63 to 0.76-0.80). CONCLUSIONS: Integrating DS and vessel-specific morphological plaque features significantly increased the predictive yield for vessel-specific ischemia compared to DS alone, potentially improving patients' referral to the catheterization laboratory.

Coronary Microvascular Dysfunction in Patients With Heart Failure: Characterization of Patterns in HFrEF Versus HFpEF.

BACKGROUND: Coronary microvascular dysfunction (CMD) is involved in heart failure (HF) onset and progression, independently of HF phenotype and obstructive coronary artery disease. Invasive assessment of CMD might provide insights into phenotyping and prognosis of patients with HF. We aimed to assess absolute coronary flow, absolute microvascular resistance, myocardial perfusion, coronary flow reserve, and microvascular resistance reserve in patients with HF with preserved ejection fraction and HF with reduced ejection fraction (HFrEF). METHODS: Single-center, prospective study of 56 consecutive patients with de novo HF with nonobstructive coronary artery disease divided into HF with preserved ejection fraction (n=21) and HFrEF (n=35). CMD was invasively assessed by continuous intracoronary thermodilution and defined as coronary flow reserve <2.5. Left ventricular and left anterior descending artery-related myocardial mass was quantified by echocardiography and coronary computed tomography angiography. Myocardial perfusion (mL/min per g) was calculated as the ratio between absolute coronary flow and left anterior descending artery-related mass. RESULTS: Patients with HFrEF showed a higher left ventricular and left anterior descending artery-related myocardial mass compared with HF with preserved ejection fraction (P<0.010). Overall, 52% of the study population had CMD, with a similar prevalence between the 2 groups. In HFrEF, CMD was characterized by lower absolute microvascular resistance and higher absolute coronary flow at rest (functional CMD; P=0.002). CMD was an independent predictor of a lower rate of left ventricular reverse remodeling at follow-up. In patients with HF with preserved ejection fraction, CMD was mainly due to higher absolute microvascular resistance and lower absolute coronary flow during hyperemia (structural CMD; P≤0.030). CONCLUSIONS: Continuous intracoronary thermodilution allows the definition and characterization of patterns with distinct CMD in patients with HF and could identify patients with HFrEF with a higher rate of left ventricular reverse remodeling at follow-up.

Characterisation of coronary microvascular dysfunction in patients with severe aortic stenosis undergoing TAVI.

BACKGROUND: Microvascular resistance reserve (MRR) is a validated measure of coronary microvascular function independent of epicardial resistances. AIMS: We sought to assess whether MRR is associated with adverse cardiac remodelling, a low-flow phenotype and extravalvular cardiac damage (EVCD) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). METHODS: Invasive thermodilution-based assessment of the coronary microvascular function of the left anterior descending artery was performed in a prospective, multicentre cohort of patients undergoing TAVI. Coronary microvascular dysfunction (CMD) was defined as the lowest MRR tertile of the study cohort. Haemodynamic measurements were performed at baseline and then repeated immediately after TAVI. EVCD and markers of a low-flow phenotype were assessed with echocardiography. RESULTS: A total of 134 patients were included in this study. Patients with low MRR were more frequently females, had a lower estimated glomerular filtration rate and a higher rate of atrial fibrillation. MRR was significantly lower in patients with advanced EVCD (median 1.80 [1.26-3.30] vs 2.50 [1.87-3.41]; p=0.038) and in low-flow, low-gradient AS (LF LG-AS) (median 1.85 [1.20-3.04] vs 2.50 [1.87-3.40]; p=0.008). Overall, coronary microvascular function tended to improve after TAVI and, in particular, MRR increased significantly after TAVI in the subgroup with low MRR at baseline. However, MRR was significantly impaired in 38 (28.4%) patients immediately after TAVI. Advanced EVCD (adjusted odds ratio 3.08 [1.22-7.76]; p=0.017) and a low-flow phenotype (adjusted odds ratio 3.36 [1.08-10.47]; p=0.036) were significant predictors of CMD. CONCLUSIONS: In this observational, hypothesis-generating study, CMD was associated with extravalvular cardiac damage and a low-flow phenotype in patients with severe AS undergoing TAVI.

Combined Cardiac Damage Staging by Echocardiography and Cardiac Catheterization in Patients With Clinically Significant Aortic Stenosis.

BACKGROUND: Cardiac damage (CD) staging enhances risk stratification in patients with clinically significant aortic stenosis (AS). We aimed to assess the prognostic value and reclassification rate of right heart catheterization (RHC) compared with transthoracic echocardiography (TTE) in characterising CD staging at 3-year follow-up in patients with clinically significant AS, to identify patients that would benefit from RHC for prognostic stratification, and to test the prognostic value of combined CD staging. METHODS: An observational cohort study of 432 AS patients undergoing TTE and RHC were divided into moderate or asymptomatic severe (m/asAS) and symptomatic severe (ssAS) AS. Kaplan-Meier curves were used to compare survival. The accuracy in prognostic stratification was tested by area under the receiver operating characteristic curve analysis and Delong test. RESULTS: In both cohorts, TTE- and RHC-derived staging systems had prognostic value, although the agreement between them appeared moderate. A higher proportion of patients were assigned to stage 2 by TTE than by RHC. Patients in TTE-derived stage 2 had a high reclassification rate, with 40%-50% presenting with right chamber involvement (stages 3-4) according to RHC. Discordant cases were significantly older, with higher prevalence of atrial fibrillation, markedly elevated N-terminal pro-B-type natriuretic peptide, and higher indexed left atrial volume, E/e', and systolic pulmonary artery pressure vs concordant cases (P < 0.05). The combined CD staging, integrating TTE and RHC, was more accurate in predicting mortality than the TTE-derived system (P < 0.05). CONCLUSIONS: In patients with m/asAS and ssAS, the combined CD staging, derived from TTE and RHC, was more accurate in predicting mortality than TTE alone. In a subset of AS patients, the integration of RHC may significantly improve prognostic stratification.

Absolute coronary flow and microvascular resistance before and after transcatheter aortic valve implantation.

BACKGROUND: Severe aortic stenosis (AS) is associated with left ventricular (LV) remodelling, likely causing alterations in coronary blood flow and microvascular resistance. AIMS: We aimed to evaluate changes in absolute coronary flow and microvascular resistance in patients with AS undergoing transcatheter aortic valve implantation (TAVI). METHODS: Consecutive patients with AS undergoing TAVI with non-obstructive coronary artery disease in the left anterior descending artery (LAD) were included. Absolute coronary flow (Q) and microvascular resistance (Rµ) were measured in the LAD using continuous intracoronary thermodilution at rest and during hyperaemia before and after TAVI, and at 6-month follow-up. Total myocardial mass and LAD-specific mass were quantified by echocardiography and cardiac computed tomography. Regional myocardial perfusion (QN) was calculated by dividing absolute flow by the subtended myocardial mass. RESULTS: In 51 patients, Q and R were measured at rest and during hyperaemia before and after TAVI; in 20 (39%) patients, measurements were also obtained 6 months after TAVI. No changes occurred in resting and hyperaemic flow and resistance before and after TAVI nor after 6 months. However, at 6-month follow-up, a notable reverse LV remodelling resulted in a significant increase in hyperaemic perfusion (QN,hyper: 0.86 [interquartile range {IQR} 0.691.06] vs 1.20 [IQR 0.99-1.32] mL/min/g; p=0.008; pre-TAVI and follow-up, respectively) but not in resting perfusion (QN,rest: 0.34 [IQR 0.30-0.48] vs 0.47 [IQR 0.36-0.67] mL/min/g; p=0.06). CONCLUSIONS: Immediately after TAVI, no changes occurred in absolute coronary flow or coronary flow reserve. Over time, the remodelling of the left ventricle is associated with increased hyperaemic perfusion.

Vascular Remodeling in Coronary Microvascular Dysfunction.

BACKGROUND: Approximately half of the patients with angina and nonobstructive coronary artery disease (ANOCA) have evidence of coronary microvascular dysfunction (CMD). OBJECTIVES: This study aims to characterize patients with ANOCA by measuring their minimal microvascular resistance and to examine the pattern of vascular remodeling associated with these measurements. METHODS: The authors prospectively included patients with ANOCA undergoing continuous thermodilution assessment. Lumen volume and vessel-specific myocardial mass were quantified using coronary computed tomography angiography (CTA). CMD was defined as coronary flow reserve <2.5 and high minimal microvascular resistance as >470 WU. RESULTS: A total of 153 patients were evaluated; 68 had CMD, and 22 of them showed high microvascular resistance. In patients with CMD, coronary flow reserve was 1.9 ± 0.38 vs 3.2 ± 0.81 in controls (P < 0.001). Lumen volume was significantly correlated with minimal microvascular resistance (r = -0.59 [95% CI: -0.45 to -0.71]; P < 0.001). In patients with CMD and high microvascular resistance, lumen volume was 40% smaller than in controls (512.8 ± 130.3 mm3 vs 853.2 ± 341.2 mm3; P < 0.001). Epicardial lumen volume assessed by coronary CTA was independently associated with minimal microvascular resistance (P < 0.001). The predictive capacity of lumen volume from coronary CTA for detecting high microvascular resistance showed an area under the curve of 0.79 (95% CI: 0.69-0.88). CONCLUSIONS: Patients with CMD and high minimal microvascular resistance have smaller epicardial vessels than those without CMD. Coronary CTA detected high minimal microvascular resistance with very good diagnostic capacity. Coronary CTA could potentially aid in the diagnostic pathway for patients with ANOCA.

Predictors of percutaneous coronary intervention derived from CCTA in patients with chronic coronary syndrome.

BACKGROUND: To identify anatomical and morphological plaque features predictors of PCI and create a multiparametric score to increase the predictive yield. Moreover, we assessed the incremental predictive value of FFRCT (Fractional Flow Reserve derived from CCTA) trans-lesion gradient (ΔFFRCT) when integrated into the score. METHODS: Observational cohort study including patients undergoing CCTA for suspected coronary artery disease, with FFRCT available, referred to invasive coronary angiogram and assessment of fractional flow reserve. Plaque analysis was performed using validated semi-automated software. Logistic regression was performed to identify anatomical and morphological plaque features predictive of PCI. Optimal thresholds were defined by area under the receiver-operating characteristics curve (AUC) analysis. A scoring system was developed in a derivation cohort (70 â€‹% of the study population) and tested in a validation cohort (30 â€‹% of patients). RESULTS: The overall study population included 340 patients (455 vessels), among which 238 patients (320 vessels) were included in the derivation cohort. At multivariate logistic regression analysis, absence of left main disease, diameter stenosis (DS), non-calcified plaque (NCP) volume, and percent atheroma volume (PAV) were independent predictors of PCI. Optimal thresholds were: DS â€‹≥ â€‹50 â€‹%, volume of NCP>113 â€‹mm3 and PAV>17 â€‹%. A weighted score (CT-PCI Score) ranging from 0 to 11 was obtained. The AUC of the score was 0.80 (95%CI 0.74-0.86). The integration of ΔFFRCT in the CT-PCI score led to a mild albeit not significant increase in the AUC (0.82, 95%CI 0.77-0.87, p â€‹= â€‹0.328). CONCLUSIONS: Plaque anatomy and morphology derived from CCTA could aid in identifying patients amenable to PCI.

Measuring Absolute Coronary Flow and Microvascular Resistance by Thermodilution: JACC Review Topic of the Week.

Diagnosing coronary microvascular dysfunction remains challenging, primarily due to the lack of direct measurements of absolute coronary blood flow (Q) and microvascular resistance (Rµ). However, there has been recent progress with the development and validation of continuous intracoronary thermodilution, which offers a simplified and validated approach for clinical use. This technique enables direct quantification of Q and Rµ, leading to precise and accurate evaluation of the coronary microcirculation. To ensure consistent and reliable results, it is crucial to follow a standardized protocol when performing continuous intracoronary thermodilution measurements. This document aims to summarize the principles of thermodilution-derived absolute coronary flow measurements and propose a standardized method for conducting these assessments. The proposed standardization serves as a guide to ensure the best practice of the method, enhancing the clinical assessment of the coronary microcirculation.

Comprehensive invasive evaluation of coronary microcirculation in patients with Takotsubo syndrome.

BACKGROUND AND AIMS: The etiology and pathophysiology of Takotsubo syndrome (TTS) remain a matter of debate. In murine models of coronary microvascular dysfunction (CMD), abnormalities in myocardial perfusion led to the development of TTS. Importantly, TTS was reversible when normal perfusion was restored. However, in clinical practice, the assessment of coronary microcirculation in patients with TTS has primarily relied on non-invasive or indirect, angiography-derived methods. METHODS AND RESULTS: For the first time, we performed invasive microcirculatory assessment, by both validated techniques currently available in the catheterization laboratory, namely intracoronary bolus and continuous thermodilution, in patients with TTS, upon hospital admission and at short term follow-up. Our findings demonstrate that CMD was consistently present in all patients upon hospital admission, as assessed by both techniques. At a median follow-up of 3 months, after the recovery of left ventricular ejection fraction, two third of patients no longer exhibited CMD. CONCLUSIONS: These findings support the hypothesis that an acute and transient worsening in coronary microvascular function plays a pivotal role in the pathophysiology of TTS.

Dual left anterior descending coronary artery and anomalous origin of left circumflex artery: a novel coronary anomaly revealed by CCTA.

In the rare coronary anomaly of Dual LAD, two segments of the vessel reside within the anterior interventricular sulcus. In our case, the short LAD originated from the Left Coronary Sinus (LCS), while the long LAD emerged from the Right Coronary Sinus (RCS). The LCx arose from the RCS, and the RCA displayed typical features. This anomaly was deemed incidental, prompting routine follow-up. It underscores the significance of integrating CCTA for a thorough assessment, offering crucial insights for patient management.

Aortic thoracic neuromodulation in heart failure with preserved ejection fraction.

The inadequacy of medical therapies for heart failure with preserved ejection fraction (HFpEF) is driving the development of device-based solutions targeting underlying pathophysiologic abnormalities. The maladaptive autonomic imbalance with a reduction in vagal parasympathetic activity and increased sympathetic signalling contributes to the deterioration of cardiac performance, patient fitness, and the increased overall morbidity and mortality. Thoracic aortic vagal afferents mediate parasympathetic signalling, and their stimulation has been postulated to restore autonomic balance. In this first-in-man experience with chronic stimulation of aortic vagal afferents (Harmony™ System, Enopace, Israel), we demonstrate improved left atrial remodelling and function parallel with improved left ventricular performance. The observed favourable structural and functional cardiac changes remained stable throughout the 1 year follow-up and were associated with improved symptoms and physical fitness. The current experience warrants further validation of the endovascular stimulation of aortic thoracic afferents as a new interventional approach for device-based treatment in HFpEF.

Innovative Device-Based Strategies for Managing Acute Decompensated Heart Failure.

Acute decompensated heart failure (ADHF) is a major cause of hospitalizations in older adults, leading to high mortality, morbidity, and healthcare costs. To address the persistent poor outcomes in ADHF, novel device-based approaches targeting specific pathophysiological mechanisms are urgently needed. The recently introduced DRI2P2S classification categorizes these innovative therapies based on their mechanisms. Devices include dilators (increasing venous capacitance), removers (directly removing sodium and water), inotropes (enhancing left ventricular contractility), interstitials (accelerating lymph removal), pushers (increasing renal arterial pressure), pullers (decreasing renal venous pressure), and selective drippers (selective intrarenal drug infusion). Some are tailored for chronic HF, while others focus on the acute setting. Most devices are in early development, necessitating further research to understand mechanisms, assess clinical effectiveness, and ensure safety before routine use in ADHF management. Exploring these innovative device-based strategies may lead to improved outcomes and revolutionize HF treatment in the future.

Association of Mild-to-Moderate Aortic Regurgitation With Outcomes in Heart Failure With Preserved Ejection Fraction.

OBJECTIVE: To assess aortic regurgitation (AR) prevalence, its hemodynamic effect, and long-term prognostic implications in patients admitted with de novo or worsened heart failure with preserved ejection fraction (HFpEF). METHODS: Consecutive patients hospitalized with de novo or worsened HFpEF between 2014 and 2020 were enrolled. Patients with more than moderate aortic and/or mitral valve disease were excluded. Based on the presence and degree of AR, patients were divided into those without AR, those with mild, and those with moderate AR. Data on cardiovascular death, heart failure (HF) rehospitalization, and their composite (major adverse cardiovascular events) were collected. RESULTS: The final study population consisted of 458 HFpEF patients: 156 (34.1%) with mild-AR, 153 (33.4%) with moderate-AR, and the remaining 149 (32.5%) with no AR. Mild-to-moderate AR patients were older, with larger left atrium-left ventricle (LV) volumes, greater LV mass index, higher filling pressure, and prevalence of diastolic dysfunction compared with the no-AR group (all P<.05). During 5-year follow-up, 113 patients died of cardiovascular causes, 124 patients were rehospitalized for HF, whereas 196 experienced the composite endpoint. Mild-to-moderate AR was identified as an independent predictor of all-cause death (HR, 1.62; 95% CI, 1.14 to 1.58; P=.04) and major adverse cardiovascular event occurrence (HR, 1.48; 95% CI, 1.05 to 2.09; P=.02). A total of 126 (35.5%) of 355 patients showed progression of AR at follow-up echocardiography. CONCLUSION: Mild-to-moderate AR is common among patients hospitalized for HFpEF. It is associated with adverse LV remodeling and worse long-term outcomes. These findings warrant further prospective studies addressing the importance of AR in prognostic stratification and exploring therapeutic strategies to mitigate its hemodynamic effect on HF.

Reproducibility of bolus versus continuous thermodilution for assessment of coronary microvascular function in patients with ANOCA.

BACKGROUND: A bolus thermodilution-derived index of microcirculatory resistance (IMR) has emerged as the standard for assessing coronary microvascular dysfunction (CMD). Continuous thermodilution has recently been introduced as a tool to quantify absolute coronary flow and microvascular resistance directly. Microvascular resistance reserve (MRR) derived from continuous thermodilution has been proposed as a novel metric of microvascular function, which is independent of epicardial stenoses and myocardial mass. AIMS: We aimed to assess the reproducibility of bolus and continuous thermodilution in assessing coronary microvascular function. METHODS: Patients with angina and non-obstructive coronary artery disease (ANOCA) at angiography were prospectively enrolled. Bolus and continuous intracoronary thermodilution measurements were obtained in duplicate in the left anterior descending artery (LAD). Patients were randomly assigned in a 1:1 ratio to undergo either bolus thermodilution first or continuous thermodilution first. RESULTS: A total of 102 patients were enrolled. The mean fractional flow reserve (FFR) was 0.86±0.06. Coronary flow reserve (CFR) calculated with continuous thermodilution (CFRcont) was significantly lower than bolus thermodilution-derived CFR (CFRbolus; 2.63±0.65 vs 3.29±1.17; p<0.001). CFRcont showed a higher reproducibility than CFRbolus (variability: 12.7±10.4% continuous vs 31.26±24.85% bolus; p<0.001). MRR showed a higher reproducibility than IMR (variability 12.4±10.1% continuous vs 24.2±19.3% bolus; p<0.001). No correlation was found between MRR and IMR (r=0.1, 95% confidence interval: -0.09 to 0.29; p=0.305). CONCLUSIONS: In the assessment of coronary microvascular function, continuous thermodilution demonstrated significantly less variability on repeated measurements than bolus thermodilution.

Outcomes in patients with moderate and asymptomatic severe aortic stenosis followed up in heart valve clinics.

BACKGROUND: Heart valve clinics (HVC) have been introduced to manage patients with valvular heart disease within a multidisciplinary team. OBJECTIVE: To determine the outcome benefit of HVC approach compared with standard of care (SOC) for patients with moderate and asymptomatic severe aortic stenosis (mAS and asAS). METHODS: Single-centre, observational registry of patients with mAS and asAS with at least one cardiac ambulatory consultation at our Cardiovascular Centre. Based on the outpatient strategy, patients were divided into HVC group, if receiving at least one visit at HVC, and SOC group, if followed by routine cardiac consultations. RESULTS: 2129 patients with mAS and asAS were divided into those followed in HVC (n=251) versus SOC group (n=1878). The mean age was 76.5±12.4 years; 919 (43.2%) had asAS. During a follow-up of 4.8±1.8 years, 822 patients (38.6%) died, 307 (14.4%) were hospitalised for heart failure and 596 (28%) underwent aortic valve replacement (AVR). After propensity score matching, the number of consultations per year, exercise stress tests, brain natriuretic peptide (BNP) determinations and CTs were higher in the HVC cohort (p<0.05 for all). A shorter time between indication of AVR and less advanced New York Heart Association class was reported in the HVC cohort (p<0.001 and p=0.032). Compared with SOC, the HVC approach was associated with reduced all-cause mortality (HR=0.63, 95% CI 0.40 to 0.98, p=0.038) and cardiovascular death (p=0.030). At multivariable analysis, the HVC remained an independent predictor of all-cause mortality (HR=0.54, 95% CI 0.34 to 0.85, p=0.007). CONCLUSIONS: In patients with mAS and asAS, the HVC approach was associated with more efficient management and outcome benefit compared with SOC.

Same Day Discharge Strategy by Default in a Tertiary Catheterization Laboratory in Belgium: Value Based Healthcare-Change in Practice.

AIMS: To assess the effects on outcomes and hospital revenues (societal cost) of a by default strategy of same day discharge (SDD) in patients undergoing a cardiac catheterization procedure in a Belgian Hospital. METHODS AND RESULTS: Outcome and complete financial data were obtained in all consecutive patients with a cardiac catheterization performed in 2019 (n=5237) and in 2021 (n=5377). Patient-reported experience, patient satisfaction and Net promotor score were obtained prospectively for the SDD cohort in 2021. The proportion of patients receiving catheterization procedure in SDD increased from 28 to 44 % (p<0.001). This translates to the saving of 889 conventional hospitalizations in 2021. All-cause death and readmission rate remained unchanged (0,17% vs 0,15% (p=0,004); and 0,7% vs 1,8% (p>0,05)) in 2019 and 2021, respectively. Patients satisfaction top box score was 91% and the Net Promotor Score was 89,5. The by default SDD strategy was associated with reduction in in-hospital health care spending, on average 3206€ per procedure is saved. This means a 57% decrease in hospital revenues and translates into an important decrease in physician income. CONCLUSION: Implementing a by default SDD cardiac catheterization strategy results in a reduction of societal cost, excellent patient satisfaction and unchanged clinical outcome. Yet, in the given context this approach negatively impacts hospital and physician revenues precluding the sustainability of such protocol.

Continuous vs Bolus Thermodilution to Assess Microvascular Resistance Reserve.

BACKGROUND: Coronary flow reserve (CFR) and microvascular resistance reserve (MRR) can, in principle, be derived by any method assessing coronary flow. OBJECTIVES: The aim of this study was to compare CFR and MRR as derived by continuous (CFRcont and MRRcont) and bolus thermodilution (CFRbolus and MRRbolus). METHODS: A total of 175 patients with chest pain and nonobstructive coronary artery disease were studied. Bolus and continuous thermodilution measurements were performed in the left anterior descending coronary artery. MRR was calculated as the ratio of CFR to fractional flow reserve and corrected for changes in systemic pressure. In 102 patients, bolus and continuous thermodilution measurements were performed in duplicate to assess test-retest reliability. RESULTS: Mean CFRbolus was higher than CFRcont (3.47 ± 1.42 and 2.67 ± 0.81 [P < 0.001], mean difference 0.80, upper limit of agreement 3.92, lower limit of agreement -2.32). Mean MRRbolus was also higher than MRRcont (4.40 ± 1.99 and 3.22 ± 1.02 [P < 0.001], mean difference 1.2, upper limit of agreement 5.08, lower limit of agreement -2.71). The correlation between CFR and MRR values obtained using both methods was significant but weak (CFR, r = 0.28 [95% CI: 0.14-0.41]; MRR, r = 0.26 [95% CI: 0.16-0.39]; P < 0.001 for both). The precision of both CFR and MRR was higher when assessed using continuous thermodilution compared with bolus thermodilution (repeatability coefficients of 0.89 and 2.79 for CFRcont and CFRbolus, respectively, and 1.01 and 3.05 for MRRcont and MRRbolus, respectively). CONCLUSIONS: Compared with bolus thermodilution, continuous thermodilution yields lower values of CFR and MRR accompanied by an almost 3-fold reduction of the variability in the measured results.

First-in-Man Robotic-Assisted Renal Denervation.

To the best of our knowledge, this is the first report of robotic-assisted renal denervation. Robotic-assisted renal denervation represents a new frontier in robotic-assisted percutaneous interventions. Robotic assistance provides increased procedural and technical accuracy while minimizing radiation exposure for both the operators and the patients. (Level of Difficulty: Advanced.).