Preprocedural and procedural variables that predict new-onset conduction disturbances after transcatheter aortic valve replacement.

BACKGROUND: Conduction disturbances are a common complication after transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate the preprocedural and procedural variables that predict new-onset conduction disturbances post-TAVR (hereafter CD/CDs). METHODS: Consecutive patients who underwent TAVR during December 2009-March 2021 at the Faculty of Medicine Siriraj Hospital, Mahidol University-Thailand's largest national tertiary referral center-were enrolled. Patients with prior implantation of a cardiac device, periprocedural death, or unsuccessful procedure were excluded. Clinical and electrocardiographic data, preprocedural imaging, including membranous septum (MS) length, and procedural variables, including implantation depth (ID), were analyzed. CD was defined as new left or right bundle branch block, significant intraventricular conduction disturbance with QRS interval ≥ 120 ms, new high-grade atrioventricular block, or complete heart block. Multivariate binary logistic analysis and receiver operating characteristic (ROC) curve analysis were used to identify independent predictors and the optimal ∆MSID (difference between the MS length and ID) cutoff value, respectively. RESULTS: A total of 124 TAVR patients (mean age: 84.3 ± 6.3 years, 62.1% female) were included. The mean Society of Thoracic Surgeons score was 7.3%, and 85% of patients received a balloon expandable transcatheter heart valve. Thirty-five patients (28.2%) experienced a CD, and one-third of those required pacemaker implantation. The significant preprocedural and procedural factors identified from univariate analysis included intraventricular conduction delay, mitral annular calcification, MS length ≤ 6.43 mm, self-expanding device, small left ventricular cavity, and ID ≥ 6 mm. Multivariate analysis revealed MS length ≤ 6.43 mm (adjusted odds ratio [aOR] 9.54; 95% CI 2.56-35.47; p = 0.001) and ∆MSID < 0 mm (adjusted odds ratio [aOR] 10.77; 95% CI 2.86-40.62; p = < 0.001) to be independent predictors of CD. The optimal ∆MSID cutoff value for predicting conduction disturbances was less than 0 mm (area under the receiver operating characteristic curve [AuROC]: 0.896). CONCLUSION: This study identified MS length ≤ 6.43 mm and ∆MSID < 0 mm as independent predictors of CDs. ∆MSID < 0 was the strongest and only modifiable predictor. Importantly, we expanded the CD criteria to cover all spectrum of TAVR-related conduction injury to lower the threshold of this sole modifiable risk. The optimal ∆MSID cutoff value was < 0 mm. TRIAL REGISTRATION: TCTR, TCTR20210818002. Registered 17 August 2021-Retrospectively registered, http://www.thaiclinicaltrials.org/show/TCTR 20210818002.

Prevalence and characters of anomalous coronary artery from coronary magnetic resonance angiography.

BACKGROUND: Many types of anomalous coronary artery have been reported. Some forms of the anomaly are potentially malignant and can lead to sudden death. OBJECTIVE: To determine the prevalence and characters of anomalous coronary artery, including the associations of myocardial ischemia. MATERIAL AND METHOD: This is a retrospective study. The authors enrolled patients who were referred for cardiac magnetic resonance (CMR) and had magnetic resonance coronary angiography (MRCA) images. Imaging of the coronary arteries was acquired. The presence and patterns of anomalous coronary artery and the presence of myocardial ischemia was recorded. Myocardial perfusion study was also performed in most patients using adenosine stress test. RESULTS: Anomalous coronary artery was detected in 56 out of 3,703 patients (1.51%). There were 24 men (42.9%). Average age was 62.1 +/- 15.0 years. Most common type was right coronary artery (RCA) from left coronary cusp. Malignant form was demonstrated in 31 patients (55.4%) and myocardial ischemia was detected in 10 patients (23.3%). CONCLUSION: Prevalence of anomalous coronary artery was 1.5%. Most common types were RCA from left coronary cusp (30%) and high take-off RCA (30%).

Utilizing a registry for ST segment elevation myocardial infarction from a tertiary care hospital in Thailand: opportunities to improve the quality of care.

BACKGROUND: Treatment of acute coronary syndrome requires a reliable measurement of quality for ensuring evidence-based care. Clinical registries have been used to support quality improvement activities in some countries, but there are few data concerning their implementation in developing countries. In 2008, a multidisciplinary Siriraj ST segment elevation myocardial infarction (STEMI) registry team was formed with the intention to improve the process of care. This report summarizes observational data collected within the first year to characterize the clinical profile, management and in-hospital outcomes of STEMI patients at the author's institute. MATERIAL AND METHOD: The present study is a prospective, observational study. From June 2008 through June 2009, data from all consecutive patients presenting within 24 hours of STEMI at Siriraj Hospital were collected. The patient's data on demographics, procedures, medications and in-hospital outcomes were collected. RESULTS: During the 1-year period, 112 patients with STEMI were enrolled. The mean age was 59.3 years old and 81.3% were males. There was a high prevalence of diabetes, hypertension, dyslipidemia and current smoking. Median time from symptom onset to presentation was 120 minutes. 98 patients (84.8% of the patients) received reperfusion therapy in the form of thrombolytic therapy (21.4%) or primary percutaneous coronary intervention (PCI, 63.40%). For thrombolytic therapy, the median door to needle time was 68 minutes. Rescue PCI was performed in 20.8% of the thrombolytic treated patients. For primary PCI, the median door to balloon time was 118 minutes. In-hospital coronary artery bypass graft surgery was performed in 6% of the patients. In-hospital mortality rate was 9.8%. Re-infarction and stroke were rare events. CONCLUSION: Despite a high utilization rate of reperfusion therapy the time to reperfusion therapy exceeds the length of time recommended by current guidelines. The authors' findings provide important data for future benchmarking and represent a significant opportunity for quality improvement in STEMI-related care and outcomes.

Inter-site validations of the Pixel-Wise method for cardiac T2* analysis in transfusion-dependent Thai thalassemia patients.

OBJECTIVE: To compare inter-site observer variability of the Pixel- Wise (PW) method for cardiac T2* analysis in thalassemia patients using the mono-exponential with a constant fitting (offset) model and to compare the cross-model variability of the offset model to the mono-exponential (typical) model. MATERIAL AND METHOD: Eighty-eight cardiac T2* measurements were performed on 72 Thalassemia major patients. Both bright- and black-blood techniques were acquired and analyzed at both the reference (REF) and local (LOC) sites using the PW method by defined region of interest on the whole (at the REF site) and partial (at the LOC site) septum. The offset model was analyzed at the reference site while both the offset and typical models were performed at the local site. The inter-site variability of the T2* values were analyzed by independent observers blinded to the results. RESULTS: The T2* values from the REF-offset, LOC-offset and LOC-typical methods were statistically comparable on both scanning techniques. The inter-site variations of the offset model were about 5.2% and 4.4% on the bright- and black-blood techniques, respectively, which was about 1.7% higher than from the intra-site, but was still in a reasonable range compared to the conventional method of around 5.4%. The cross-model comparisons presented with 0.4 ms of bias and variation of about 6.9% and 4.7%, respectively, which is about 1.4% higher than from the intra-site. CONCLUSION: The observer variability on the PW method using the offset or typical model provided equivalent coefficient of variation on both scanning techniques, which was also comparable to the previous reports. The inter-site variability of the offset and cross models was also in a reasonable range, being less than 2% higher than the intra-site with bias of about 0.4 ms.

Can we predict final outcome of internal medicine residents with in-training evaluation.

OBJECTIVE: To assess the predictive value of in-training evaluation for determining future success in the internal medicine board certifying examination. MATERIAL AND METHOD: Ninety-seven internal medicine residents from Faculty of Medicine Siriraj Hospital who undertake the Thai Board examination during the academic year 2006-2008 were enrolled. Correlation between the scores during internal medicine rotation and final scores in board examination were then examined. RESULTS: Significant positive linear correlation was found between scores from both written and clinical parts of board certifying examination and scores from the first-year summative written and clinical examinations and also the second-year formative written examination (r = 0.43-0.68, p < 0.001). Monthly evaluation by attending staffs was less well correlated (r = 0.29-0.36) and the evaluation by nurses or medical students demonstrated inverse relationship (r = -0.2, p = 0.27 and r = -0.13, p = 0.48). CONCLUSION: Some methods of in-training evaluation can predict successful outcome of board certifying examination. Multisource assessments cannot well extrapolate some aspects of professional competences and qualities.

Immediate aortic dissection after transcatheter aortic valve replacement: A case report and review of the literature.

-Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67-year-old man with symptomatic severe aortic stenosis after TAVR. -Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.

Comparison of cardiovascular magnetic resonance of late gadolinium enhancement and diastolic wall thickness to predict recovery of left ventricular function after coronary artery bypass surgery.

BACKGROUND: The objective was to compare the value of late gadolinium enhancement (LGE) and end-diastolic wall thickness (EDWT) assessed by cardiovascular magnetic resonance (CMR) in predicting recovery of left ventricular function after coronary artery bypass surgery (CABG). METHODS: We enrolled patients with coronary artery disease and left ventricular ejection fraction < 45% who were scheduled for CABG. Regional contractility was assessed by cine CMR at baseline and 4 months after CABG. EDWT and LGE were assessed at baseline. Predictors for improvement of regional contractility were analyzed. RESULTS: We studied 46 men and 4 women with an average age of 61 years. Baseline left ventricular ejection fraction was 37 +/- 13%. A total of 2,020 myocardial segments were analyzed. Abnormal wall motion and the LGE area were detected in 1,446 segments (71.6%) and 1,196 segments (59.2%) respectively. Wall motion improvement was demonstrated in 481 of 1,227 segments (39.2%) that initially had wall motion abnormalities at baseline. Logistic regression analysis showed that the LGE area, EDWT and resting wall motion grade predicted wall motion improvement. Comparison of Receiver-Operator-Characteristic (ROC) curves demonstrated that the LGE area was the most important predictor (p < 0.001). Adding information from LGE to the EDWT can decrease the number of false predictions by EDWT alone from 483 to 127 segments. CONCLUSION: LGE and EDWT are independent predictors for functional recovery after revascularization. However, LGE appears to be a more important factor and independent of EDWT.

High-sensitivity cardiac troponin T in stable patients undergoing pharmacological stress testing.

BACKGROUND: Acute changes in high-sensitivity troponin T (hs-TnT) are induced by myocardial ischemia during exercise stress testing, but there are no reports of pharmacological stress testing. HYPOTHESIS: The pattern of troponin release by myocardial ischemia-induced pharmacological stress testing differs according to the ischemic burden in stable patients. METHODS: In total, 250 patients with suspected coronary artery disease underwent pharmacological stress magnetic resonance imaging (MRI). The amount and degree of myocardial ischemia on MRI and ischemic outcomes at 6 months were determined. hs-TnT levels were measured at baseline and 1 and 3 hours after testing. The 6-month clinical outcome was prespecified. RESULTS: Fifty-one patients had moderate to severe myocardial ischemia (group A), and 199 patients had no or mild myocardial ischemia (group B). hs-TnT levels were significantly higher in group A than B at baseline (11 vs 8 pg/mL, P = 0.016) and at 1 hour (12 vs 8 pg/mL, P = 0.009) and 3 hours after testing (12 vs 9 pg/mL, P = 0.012). Baseline hs-TnT levels of ≥14 pg/mL showed a 43% sensitivity and 77% specificity in predicting moderate to severe ischemia by MRI (P = 0.03; area under the curve: 0.608, P = 0.017). Patients administered dobutamine had a higher acute change in hs-TnT levels 3 hours after testing than did those administered adenosine (21 vs 0 pg/mL, P < 0.001). There was a trend toward a higher incidence of myocardial infarction in patients with baseline hs-TnT levels of ≥14 pg/mL. CONCLUSIONS: hs-TnT levels are significantly higher in patients with moderate to severe than no or mild myocardial ischemia.

Prognostic value of combined magnetic resonance myocardial perfusion imaging and late gadolinium enhancement.

Late gadolinium enhancement (LGE) and myocardial perfusion study by cardiac magnetic resonance (CMR) have a diagnostic and prognostic value in patients with suspected coronary artery disease (CAD). The purpose of this study was to determine the prognostic value of combined myocardial perfusion CMR and LGE in patients with known or suspected CAD. We studied patients with known or suspected CAD. All patients underwent CMR for functional study, myocardial perfusion and LGE. Myocardial ischemia by CMR was defined as a perfusion defect in patients without LGE or a perfusion defect beyond the LGE area. Patients were followed up for cardiovascular outcomes including hard cardiac events (cardiac death or non-fatal myocardial infarction) and major adverse cardiac events (MACE) which included cardiac death, non-fatal myocardial infarction, hospitalization for unstable angina, and heart failure. There were a total of 587 men and 645 women. Average age was 64.6 ± 11.1 years. LGE was detected in 326 patients (26.5%). Myocardial ischemia by CMR was detected in 423 patients (34.3%). Average follow-up duration was 34.9 ± 15.6 months. Univariate analysis showed that age, diabetes, use of beta blocker, left ventricular ejection fraction, left ventricular mass, wall motion abnormality, LGE, and myocardial ischemia are predictors for hard cardiac events and MACE. Multivariable analysis revealed that myocardial ischemia was the strongest predictor for hard cardiac events and MACE. Other independent predictors were age, use of beta blocker, and left ventricular mass. Myocardial ischemia by CMR has an incremental prognostic value for cardiac events in patients with known or suspected CAD.

Prognostic value of late gadolinium enhancement in hypertensive patients with known or suspected coronary artery disease.

To determine the prognosis of a myocardial scar assessed by a late gadolinium enhancement (LGE) technique of cardiac magnetic resonance (CMR) in hypertensive patients with known or suspected coronary artery disease (CAD). Patients with systemic hypertension with known or suspected CAD without a clinical history of myocardial infarction were enrolled. All patients underwent CMR for assessment of cardiac function and LGE. Prognostic data was determined by the occurrence of a hard cardiac endpoint, defined as cardiac death or a non-fatal myocardial infarction, or major adverse cardiac events (MACEs), defined as cardiac death, a non-fatal myocardial infarction, or hospitalization due to heart failure, unstable angina, or life-threatening ventricular arrhythmia. A total of 1,644 patients were enrolled; 48% were males and the mean age was 65 +/- 11 years. The average follow-up time was 863 +/- 559 days. Four hundred fifty-three (28%) patients had LGE. LGE was the strongest and most independent predictor for hard events and MACEs with hazard ratios of 4.77 and 3.38, respectively. Other independent predictors of hard events and MACEs were left ventricular ejection fraction and mass, the use of a beta-blocker, and a history of heart failure. The risk of cardiac events increased as the extent of LGE increased; the hazard ratio was 12.74 for hard events for those with a LGE >20% of the myocardium. LGE is the most important and independent predictor for cardiac events in hypertensive patients with known or suspected CAD.

Comparison of diagnostic and prognostic value of different electrocardiographic criteria to delayed-enhancement magnetic resonance imaging for healed myocardial infarction.

The accuracy of various electrocardiographic (ECG) criteria for the diagnosis of healed myocardial infarction (MI) has never been validated. The objective of this study was to determine the accuracy and prognostic value of standard ECG criteria for the diagnosis of healed MI compared with cardiac magnetic resonance (CMR). Consecutive patients with known or suspected coronary artery disease who were referred for CMR were studied. Twelve-lead electrocardiography and CMR were performed the same day. A standard CMR protocol including a delayed-enhancement (DE) technique was performed. The prognostic value of using various ECG criteria and DE-CMR was assessed for the occurrence of cardiac death, nonfatal MI, or major adverse cardiac events. We studied 1,366 patients. Average follow-up was 31.4 +/- 15.8 months. Myocardial scar was detected in 507 patients (37.1%) using DE-CMR. Healed MI using various ECG criteria had sensitivity, specificity, and accuracy of 44% to 59%, 91% to 95%, and 75% to 79% compared with DE-CMR, respectively. Multivariable Cox regression analysis showed that myocardial scar using DE-CMR was the most powerful predictor for cardiac events, followed by left ventricular ejection fraction. In the absence of DE-CMR data, MI using European Society of Cardiology/American College of Cardiology (ESC/ACC) 2000 criteria was the most powerful predictor. In conclusion, various ECG criteria had limited sensitivity, but high specificity, for the diagnosis of healed MI compared with myocardial scar using DE-CMR. Myocardial scar, left ventricular ejection fraction, and MI using ESC/ACC 2000 criteria were important predictors for cardiac events.