Sex Differences in Epidemiology, Morphology, Mechanisms, and Treatment of Mitral Valve Regurgitation.

Sex-related disparities have been recognized in incidence, pathological findings, pathophysiological mechanisms, and diagnostic pathways of non-rheumatic mitral regurgitation. Furthermore, access to treatments and outcomes for surgical and interventional therapies among women and men appears to be different. Despite this, current European and US guidelines have identified common diagnostic and therapeutic pathways that do not consider patient sex in decision-making. The aim of this review is to summarize the current evidence on sex-related differences in non-rheumatic mitral regurgitation, particularly regarding incidence, imaging modalities, surgical-derived evidence, and outcomes of transcatheter edge-to-edge repair, with the goal of informing clinicians about sex-specific challenges to consider when making treatment decisions for patients with mitral regurgitation.

Technical and Clinical Outcomes After Transcatheter Edge-to-Edge Repair of Mitral Regurgitation in Male and Female Patients: Is Equality Achieved?

BACKGROUND: Currently, no clear impact of sex on short- and long-term survival following transcatheter edge-to-edge mitral valve repair (TEER) is evident, although no data are available on postprocedural life expectancy. Our aim was to assess sex-specific differences in outcomes of patients with mitral regurgitation (MR) treated by TEER. METHODS AND RESULTS: Short-term and 5-year outcomes in men and women undergoing TEER between 2011 and 2018 who were included in the large, multicenter, real-world MitraSwiss registry were analyzed. Outcomes were compared stratified by sex and according to MR cause (primary versus secondary). The impact of TEER on postprocedural life expectancy was estimated by relative survival analysis. Among 1142 patients aged 60 to 89 years, 39.8% were women. They were older, with fewer cardiovascular risk factors and lower functional capacity compared with men. Thirty-day mortality was higher in men than in women (3.3% versus 1.1%; odds ratio, 3.16 [95% CI, 1.16-10.7]; P=0.020). Five-year survival was comparable in both sexes (adjusted hazard ratio for 5-year mortality in men, 1.14 [95% CI, 0.90-1.44], P=0.275). Both men and women with either primary or secondary MR showed similar clinical efficacy over time. TEER provided high relative survival estimates among all groups, and fully restored predicted life expectancy in women with primary MR (5-year relative survival estimate, 97.4% [95% CI, 85.5-107.0]). CONCLUSIONS: TEER is not associated with increased short-term mortality in women, whereas 5-year outcomes are comparable between sexes. Moreover, TEER completely restored normal life expectancy in women with primary MR. A residual excess mortality persists in secondary MR, independently of sex.

Long-term results of transcatheter atrial fibrillation ablation in patients with impaired left ventricular systolic function.

INTRODUCTION: Long-term outcome of AF ablation in patients with impaired LVEF is unknown. The aim of this study is to evaluate sinus rhythm (SR) maintenance, clinical status, and echocardiographic parameters over a long-term period following atrial fibrillation (AF) transcatheter ablation in patients with left ventricular ejection fraction (LVEF) <50%. METHODS AND RESULTS: A total of 196 patients (87.2% males, age 60.5 ± 10.2 years) with LVEF <50% underwent radiofrequency transcatheter ablation for paroxysmal (22.4%) or persistent (77.6%) AF. Patients were followed up for 46.2 (16.4-63.5) months regarding AF recurrences, functional class, and echocardiographic parameters. All patients underwent pulmonary vein isolation, while 167 (85.2%) required additional atrial lesions. Eleven (5.6%) patients suffered procedural complications. During follow-up, 58 (29.6%) patients required repeated ablations. At the follow-up end, 15 (7.7%) patients died, while 74 (37.8%) documented at least one episode of AF, atrial flutter, or atrial ectopic tachycardia. Eighty-three (47.2%) patients maintained antiarrhythmic drugs. During follow-up, NYHA class improved by at least one class more frequently among patients maintaining SR compared to those experiencing relapses (70.6% vs 47.9%, P = 0.003). LVEF showed a broader relative increase in patients maintaining SR (32.7% vs 21.4%; P = 0.047) and mitral regurgitation grading significantly decreased (P <0.001) only within these patients. At multivariable analysis SR maintenance emerged as an independent predictor (odds ratio 4.26, 95% CI 1.69-10.74, P = 0.002) of long-term clinical improvement (reduction in NYHA class ≥ 1 and relative increase in LVEF ≥ 10%). CONCLUSIONS: Although not substantially worse than in patients with preserved LVEF, AF ablation in patients with impaired LVEF is affected by high long-term recurrence rate. Among these patients SR maintenance is associated with greater clinical improvement.

Positron Emission Tomography in Heart Failure: From Pathophysiology to Clinical Application.

Imaging modalities are increasingly being used to evaluate the underlying pathophysiology of heart failure. Positron emission tomography (PET) is a non-invasive imaging technique that uses radioactive tracers to visualize and measure biological processes in vivo. PET imaging of the heart uses different radiopharmaceuticals to provide information on myocardial metabolism, perfusion, inflammation, fibrosis, and sympathetic nervous system activity, which are all important contributors to the development and progression of heart failure. This narrative review provides an overview of the use of PET imaging in heart failure, highlighting the different PET tracers and modalities, and discussing fields of present and future clinical application.

Ablation of atrial fibrillation: does the addition of three-dimensional magnetic resonance imaging of the left atrium to electroanatomic mapping improve the clinical outcome?: a randomized comparison of Carto-Merge vs. Carto-XP three-dimensional mapping ablation in patients with paroxysmal and persistent atrial fibrillation.

AIMS: To compare in a randomized and prospective fashion the outcome of atrial fibrillation (AF) ablation either after one procedure or after two procedures using the Carto-XP vs. the Carto-Merge mapping system in two different AF populations. METHODS AND RESULTS: Two hundred and ninety-nine patients with paroxysmal and persistent AF were enrolled in the study. One hundred and fifty patients with paroxysmal or persistent AF were randomly assigned to the Carto-Merge group and 149 patients to the Carto-XP group. The Carto-Merge patients underwent magnetic resonance imaging (MRI) of left atrium (LA) the day before the ablation. The ablation scheme included electrical disconnection of the pulmonary veins plus linear lesions. In the Carto-Merge patients, the three-dimensional MRI of the LA reconstruction merged with the electroanatomical map, and in the Carto-XP patients, the electroanatomical map guided the procedure. Considering the overall population with paroxysmal AF, 54% maintained sinus rhythm (SR), whereas in the persistent AF population, SR was present in 43% of the patients at the 12-month follow-up. In patients with paroxysmal AF, 52% in the Carto-XP group and 55% in the Carto-Merge group maintained SR without drugs. Procedure durations and exposure to X-ray in the Carto-XP group were 94.6 +/- 17.5 and 40.4 +/- 13.5 min, respectively. In the Carto-Merge group, duration and X-ray exposure were 89 +/- 41.6 and 22.1 +/- 11.4 min, respectively. Considering the patients with persistent AF at the12-month follow-up, 44% in the Carto-XP group and 42% in the Carto-Merge group maintained SR without drugs. Procedure durations and X-ray exposure in the Carto-XP group were 102.9 +/- 22.9 and 58 +/- 8.7 min, respectively. In the Carto-Merge group, both duration and X-ray exposure were 114.4 +/- 50.9 and 28.8 +/- 14.3 min, respectively. CONCLUSION: Image integration using Carto-Merge in patients undergoing catheter ablation for paroxysmal and persistent AF does not significantly improve the clinical outcome, but shortens the X-ray exposure.

Electrocardiograms of Children and Adolescents Practicing Non-competitive Sports: Normal Limits and Abnormal Findings in a Large European Cohort Evaluated by Telecardiology.

OBJECTIVE: The objective of this study was to derive normal electrocardiographic values and to report the abnormal findings in a large contemporary European cohort of physically active children and young adolescents. METHODS: In a 3-month period, data derived from subjects aged between 3 and 14 years and referred to the Telecardiology Centre (Genoa, Italy) for electrocardiogram (ECG) evaluation as pre-participation screening for non-competitive sports were analyzed. RESULTS: A total of 2060 ECGs were recorded. Of those, 1962 did not show any morphological abnormality and were used to derive normality ranges for heart rate, PR interval, QRS duration, corrected QT interval, and voltage of R wave as measured in V1 according to age and sex. Findings and clinical implications of the 98 ECGs with abnormal findings were also reported. Abnormal ECG findings were not as uncommon as expected in this population, being manifest in about 5 % of subjects. However, major ECG anomalies (diffuse negative T-waves, pre-excitation) were present in just ten subjects (0.5 %). Lower mean heart rate values (from 90-100 bpm at 3 years of age to 80-85 bpm at 14 years of age) and lower rates of the prevalence of negative T-waves in the V3 lead (from 55-60 % at 3 years of age to 8-10 % at 14 years of age) were observed with increasing age. CONCLUSIONS: This is the first work reporting derived normal limits and abnormal ECG findings in a large contemporary European cohort of children and adolescents aged 3-14 years practicing non-competitive sports. Clear pathological alterations are extremely uncommon, deserving, when encountered, additional examinations. Even in a physically active population, the common features of an adult athlete's ECG are absent.

Early repolarization: an evolving concept for the past 70 years.

For more than 70 years, early repolarization has been considered to be a common normal variant. In the general population, the prevalence ranges between 5 and 13%, and in athletes, a rising trend is observed from 20 to 90%. Nevertheless, from the latter half of the 1990s, a growing number of case reports, series, observational and prospective studies reported that the presence of various electrocardiographic patterns attributed to early repolarization may constitute a potential marker for the increased risk of sudden death in otherwise normal individuals, casting a dark shadow on this ECG peculiarity. This review provides a historical summary of the evolution of the concept of early repolarization from its original description to the latest works and a guide to help physicians in evaluating individuals with this common electrocardiographic pattern.

Clinical, electrocardiographic, echocardiographic characteristics and long-term follow-up of elite soccer players with J-point elevation.

BACKGROUND: J-point elevation is common in athletes; nevertheless, the influence of structural changes associated with the athlete's heart and its prognostic impact are still debated. Our aim was to investigate the prevalence of J-point elevation, the associated clinical, electrocardiographic, and echocardiographic characteristics and its impact on long-term outcome in elite soccer players. METHODS AND RESULTS: Clinical, electrocardiographic, and cardiopulmonary exercise test data from 332 male professional soccer players were retrospectively analyzed. For 235 (70.7%) athletes echocardiographic data were also available. J-point elevation was defined as an elevation ≥1 mm in ≥2 contiguous leads. Long-term follow-up data were obtained for all athletes, whereas univariate and multivariable analyses were performed to assess the associated characteristics. Overall, 118 (35.6%) athletes showed a J-point elevation ≥1 mm. At multivariable analysis a significant direct association of interventricular septum thickness (odds ratio for 1 SD increase, 1.361; 95% confidence interval, 1.019-1.817; P=0.036) and Sokolow-Lyon index (odds ratio for 1 SD increase, 1.367; 95% confidence interval, 1.026-1.822; P=0.033) and an inverse association of baseline heart rate (odds ratio for 1 SD increase, 0.686; 95% confidence interval, 0.508-0.927; P=0.011) with J-point elevation were observed. During a long-term follow-up (median, 13.3 years; first and third quartiles, 10.1-17.0 years), a low mortality rate was observed, not related to cardiovascular causes. CONCLUSIONS: The correlation between J-point elevation and interventricular septum thickness suggests a possible mechanistic role of exercise-induced left ventricular hypertrophy as the basis for J-point elevation. After a long-term follow-up, no cardiac death was observed.

Left atrial volume at MRI is the main determinant of outcome after pulmonary vein isolation plus linear lesion ablation for paroxysmal-persistent atrial fibrillation.

AIMS: To assess retrospectively clinical and procedural predictors of long-term recurrences after atrial fibrillation ablation. METHODS: Two hundred and forty consecutive patients (201 men; mean age 60 +/- 10 years) undergoing pulmonary vein isolation (PVI) plus linear lesion ablation for antiarrhythmic drug-refractory atrial fibrillation between 2005 and 2007 were studied. Magnetic resonance imaging of the left atrium was performed in all the patients. Patients were followed up with clinical examination and ECG Holter at 1, 3, 6 months and every 6 months thereafter. In case of recurrence, a second procedure was offered. Clinical and procedural data were evaluated with univariate and multivariate analysis. RESULTS: At a mean follow-up of 30.3 +/- 9.2 months after one or two procedures, 99 (41.3%) patients were in sinus rhythm without antiarrhythmic drugs and 50 patients (20.8%) had arrhythmia recurrences. These groups were compared in order to identify the clinical predictors of recurrences. Variables directly related to failure at univariate analysis were: history of persistent atrial fibrillation, number of previous electrical cardioversions, left atrial volume (LAV) at MRI, presence of pulmonary vein anatomical variants and BMI. At multivariate analysis, only left atrial volume measured at MRI was an independent predictor of failure. CONCLUSION: With long-term follow-up, LAV at MRI represents the main determinant of outcome after PVI plus linear lesion for ablation of paroxysmal and persistent atrial fibrillation.