Cardiovascular magnetic resonance-derived intramyocardial hemorrhage after STEMI: Influence on long-term prognosis,adverse left ventricular remodeling and relationship with microvascular obstruction

Background

T2 weighted cardiovascular magnetic resonance (CMR) can detect intramyocardial hemorrhage (IMH) after ST-elevation myocardial infarction (STEMI). The long-term prognostic value of IMH beyond a comprehensive CMR assessment with late enhancement (LE) imaging including microvascular obstruction (MVO) is unclear. The value of CMR-derived IMH for predicting major adverse cardiac events (MACE) and adverse cardiac remodeling after STEMI and its relationship with MVO was analyzed.

Methods

CMR including LE and T2 sequences was performed in 304 patients 1 week after STEMI. Adverse remodeling was defined as dilated left ventricular end-systolic volume indexes (dLVESV) at 6 months CMR.

Results

During a median follow-up of 140 weeks, 47 MACE (10 cardiac deaths, 16 myocardial infarctions, 21 heart failure episodes) occurred. Predictors of MACE were ejection fraction (HR .95 95% CI [.93–.97], p = .001, per %) and IMH (HR 1.17 95% CI [1.03–1.33], p = .01, per segment). The extent of MVO and IMH significantly correlated (r = .951, p < .0001). dLVESV was present in 40% of patients. CMR predictors of dLVESV were: LVESV (OR 1.11 95% CI [1.07–1.15], p < .0001, per ml/m²), infarct size (OR 1.05 95% CI [1.01–1.09], p = .02, per %) and IMH (OR 1.54 95% CI [1.15–2.07], p = .004, per segment). Addition of T2 information did not improve the LE and cine CMR-model for predicting MACE (.744 95% CI [.659–.829] vs. .734 95% CI [.650–.818], p = .6) or dLVESV (.914 95% CI [.875–.952] vs. .913 95% CI [.875–.952], p = .9).

Conclusions

IMH after STEMI predicts MACE and adverse remodeling. Nevertheless, with a strong interrelation with MVO, the addition of T2 imaging does not improve the predictive value of LE-CMR.     

Five-year outcomes of surgical or percutaneous myocardial revascularization in diabetic patients

Background

The study compares five-year clinical outcomes of CABG vs PCI in a real world population of diabetic patients with multivessel coronary disease since it is not clear whether to prefer surgical or percutaneous revascularization.

Methods

Between July 2002 and December 2008, 2885 multivessel coronary diabetic patients underwent revascularization (1466 CABG and 1419 PCI) at hospitals in Emilia-Romagna Region, Italy and were followed for 1827 ± 617 days by record linkage of two clinical registries with the regional administrative database of hospital admissions and the mortality registry. Five-year incidences of MACCE (mortality, acute myocardial infarction [AMI], stroke, and repeat revascularization [TVR]) were assessed with Kaplan–Meier estimates, Cox proportional hazards regression and cumulative incidence functions of death and TVR, to evaluate the competing risk of AMI on death and TVR. The same analyses were applied to the propensity score matched subgroup of patients undergoing CABG or PCI with DES and with complete revascularization.

Results

PCI had higher mortality for all causes (HR: 1.8, 95% CI 1.4–2.2 p < 0.0001), AMI (HR: 3.3, 95% CI 2.4–4.6 p < 0.0001) and TVR (HR: 4.5, 95% CI 3.4–6.1 p < 0.0001). No significant differences emerged for stroke (HR: 0.8, 95% CI 0.5–1.2 p = 0.26).The higher incidence of AMI caused higher mortality in PCI group. Results did not change comparing CABG with PCI patients receiving complete revascularization or DES only.

Conclusions

Diabetics show a higher incidence of MACCE with PCI than with CABG: thus diabetes and its degree of control should be considered when choosing the type of revascularization.     

Effect of ischemic postconditioning on microvascular obstruction in reperfused myocardial infarction. Results of a randomized study in patients and of an experimental model in swine

Background

Ischemic postconditioning (PCON) appears as a potentially beneficial tool in ST-segment elevation myocardial infarction (STEMI). We evaluated the effect of PCON on microvascular obstruction (MVO) in STEMI patients and in an experimental swine model.

Methods

A prospective randomized study in patients and an experimental study in swine were carried out in two university hospitals in Spain. 101 consecutive STEMI patients were randomized to undergo primary angioplasty followed by PCON or primary angioplasty alone (non-PCON). Using late gadolinium enhancement cardiovascular magnetic resonance, infarct size and MVO were quantified (% of left ventricular mass). In swine, using an angioplasty balloon-induced anterior STEMI model, MVO was defined as the % of area at risk without thioflavin-S staining.

Results

In patients, PCON (n = 49) in comparison with non-PCON (n = 52) did not significantly reduce MVO (0 [0–1.02]% vs. 0 [0–2.1]% p = 0.2) or IS (18 ± 13% vs. 21 ± 14%, p = 0.2). MVO (> 1 segment in the 17-segment model) occurred in 12/49 (25%) PCON and in 18/52 (35%) non-PCON patients, p = 0.3. No significant differences were observed between PCON and non-PCON patients in left ventricular volumes, ejection fraction or the extent of hemorrhage. In the swine model, MVO occurred in 4/6 (67%) PCON and in 4/6 (67%) non-PCON pigs, p = 0.9. The extent of MVO (10 ± 7% vs. 10 ± 8%, p = 0.9) and infarct size (23 ± 14% vs. 24 ± 10%, p = 0.8) was not reduced in PCON compared with non-PCON pigs.

Conclusions

Ischemic postconditioning does not significantly reduce microvascular obstruction in ST-segment elevation myocardial infarction.Clinical Trial Registrationhttp://www.clinicaltrials.gov. Unique identifier: NCT01898546.     

Pro B-type natriuretic peptide plasma value: A new criterion for the prediction of short- and long-term outcomes after transcatheter aortic valve implantation

Background

To determine the prognostic value of pro B-type natriuretic peptide (pro-BNP) to predict mortality after transcatheter aortic valve implantation (TAVI). Logistic EuroSCORE (LES) overestimates observed mortality after TAVI. A new risk score specific to TAVI is needed to accurately assess mortality and outcome.

Methods

Eighty-five patients were included. Indications for TAVI were nonoperable or surgically high-risk patients (LES > 20%). Pro-BNP was measured 24 h before the procedure. Cox proportional hazards model was used to evaluate clinical factors. The predictive accuracy of these Cox models was determined by using time-dependent receiver operating characteristic (ROC) curves.

Results

Pro-BNP levels (log-transformed) were significantly higher in non-survivors than in survivors at 30 days (3.36 ± 0.43 vs. 3.81 ± 0.43, p < 0.004) and at the end of follow-up (3.34 ± 0.42 vs. 3.63 ± 0.48, p < 0.011). Multivariate analysis revealed that only increased log pro-BNP levels were associated with higher mortality rate at short [hazard ratio (HR) (95% confidence intervals (CI)] = 5.35 (1.74–16.5), p = 0.003] and long-term follow-ups [HR = 11 (CI: 1.51–81.3), p = 0.018]. LES was not associated with increased mortality at either time point [HR = 1.03 (CI: 0.95–1.10), p = 0.483 and HR = 1.03 (CI: 0.98–1.07), p = 0.230, respectively]. At 30, 90, 180, and 365 days, the c-index was 0.72 for log pro-BNP and 0.63 for LES (p = 0.044).

Conclusion

Pre-procedure log transform of plasma pro-BNP levels are an independent and strong predictor of short- and long-term outcomes after TAVI and are more discriminatory than LES.     

Pulmonary hypertension in young adults with repaired coarctation of the aorta: An unrecognised factor associated with premature mortality and heart failure

Background

Adults with repaired coarctation of the aorta (CoA) are at risk for premature cardiovascular death or heart failure (HF). We sought to evaluate risk factors for death or HF in young adults with repaired CoA in childhood.

Methods

The medical records of a cohort of 159 adults diagnosed with CoA repaired at a mean age of 4.1 ± 5.7 years were retrospectively reviewed to identify predictors of a combined endpoint of all cause death or hospitalisation for HF by using Cox proportional hazard models.

Results

Over a follow-up of 26 ± 8 years (median 27 years) after repair, 5 patients died and 7 developed HF requiring hospitalisation. Pulmonary artery systolic pressure > 40 mmHg (PH) was the main predictor of death or admission for HF (HR 32; 95% CI 4.0–250; p = 0.001). Neither systemic hypertension, recoarctation, aortic aneurysm, intracardiac lesions nor treatment with beta-blockers or ACEi/ARBs were statistically related to death or HF. Restrictive left ventricular physiology (RLVP) was the main predictor of PH by logistic regression analysis (OR 31; 95% CI 10–92; p < 0.001). Patients with severe PH (pulmonary artery systolic pressure > 60 mmHg) showed RLVP (9/10), severe elevation of end-diastolic LV pressure at cardiac catheterization (8/8) and subendocardial late gadolinium enhancement on MRI (5/5). Pathological examination of an explanted heart demonstrated extensive left ventricular subendocardial fibrosis.

Conclusions

Pulmonary hypertension related to restrictive left ventricular physiology was the strongest predictor of death or HF in young adults with CoA repaired in childhood. Persistent subendocardial fibrosis might be the structural substrate in some patients.     

Prognostic implications of quantitative evaluation of baseline Q-wave width in ST-segment elevation myocardial infarction

Objectives

To evaluate quantitative relationships between baseline Q-wave width and 90-day outcomes in ST-segment elevation myocardial infarction (STEMI).

Background

Baseline Q-waves are useful in predicting clinical outcomes after MI.

Methods

3589 STEMI patients were assessed from a multi-centre study.

Results

1156 patients of the overall cohort had pathologic Q-waves. The 90-day mortality and the composite of mortality, congestive heart failure (CHF), or cardiogenic shock (p < 0.001 for both outcomes) rose as Q-wave width increased. After adapting a threshold ≥ 40 ms for inferior and ≥ 20 ms for lateral/apical MI in all patients (n = 3065) with any measureable Q-wave we found hazard ratios (HR) for mortality (HR: 2.44, 95% confidence interval (CI) (1.54–3.85), p < 0.001) and the composite (HR: 2.32, 95% CI (1.70–3.16), p < 0.001). This improved reclassification of patients experiencing the composite endpoint versus the conventional definition (net reclassification index (NRI): 0.23, 95% CI (0.09-0.36), p < 0.001) and universal MI definition (NRI: 0.15, 95% CI (0.02–0.29), p = 0.027).

Conclusions

The width of the baseline Q-wave in STEMI adds prognostic value in predicting 90-day clinical outcomes. A threshold of ≥ 40 ms in inferior and ≥ 20 ms for lateral/apical MI enhances prognostic insight beyond current criteria.     

Redefining the ECG in urban South Africans: Electrocardiographic findings in heart disease-free Africans

Background

The 12-lead electrocardiogram (ECG) represents an important diagnostic tool for detecting heart disease, but the “normal” ECG in those of African descent has yet to be definitively described.

Methods

We systematically analysed 12-lead ECGs from 387 urban South Africans determined to be heart disease free (using the Minnesota code) following advanced cardiologic assessment, including echocardiography, at the Baragwanath Hospital in Soweto, South Africa.

Results

123 males (32%, 41.2 ± 14.5 years) and 264 females (37.4 ± 14.2 years) were studied. Most were in sinus rhythm (87%) and had normal axis (89%). Mean interval data were: PR interval (156 ± 28 ms; 95% CI: 153–159 ms), QRS duration (82 ± 16 ms; 95% CI: 80–84 ms), QT interval (379 ± 48 ms; 95% CI: 374–384 ms) and QTc interval (426 ± 32 ms; 95% CI: 423–429 ms). Overall, 199 (51%; 95% CI: 46.0% to 56.0%) subjects had an ECG “abnormality” or normal variant and 67 ECGs (17%; 95% CI: 13.3% to 20.7%) had major and minor abnormalities. ECG changes normally ascribed to myocardial ischaemia were: i) ST elevation (9.3%; 95% CI: 6.2 to 11.9%), ii) Q waves (7.4%; 95% CI: 4.4 to 9.5%) and iii) ST depression (2.3%; 95% CI: 0.8 to 3.8%). Sokolow–Lyon Index voltage exceeding 38 mm indicative of left ventricular hypertrophy was more prominent in males than females (23.6% vs. 6.4%; OR = 4.5; 95% CI: 2.3–8.5).

Conclusions

These data provide a contemporary reference to the 12-lead ECG in urban South Africans found to be heart disease free, with both major and minor abnormalities detected.     

Efficacy and safety of zotarolimus-eluting stents compared with sirolimus-eluting stents in patients undergoing percutaneous coronary interventions — A meta-analysis of randomized controlled trials

Background

Whether ZES can further improve angiographic and clinical outcomes compared to SES still remains uncertain.

Objectives

The aim of this study was to assess the efficacy and safety of zotarolimus-eluting stents (ZES) compared with sirolimus-eluting stents (SES) in patients undergoing percutaneous coronary interventions (PCI).

Methods

Major electronic information sources were explored for randomized controlled trials comparing ZES with SES among patients undergoing PCI during at least 9 months follow-up. The primary efficacy outcomes were target lesion revascularization (TLR), target vessel revascularization (TVR), and major adverse cardiac events (MACE); safety outcomes were stent thrombosis (ST), myocardial infarction (MI), and cardiac death.

Results

Seven comparative studies were identified (a total of 5983 patients). When compared with ZES at 12-month follow‐up, SES significantly reduced risk of MACE (relative risk [RR]: 0.74, 95% confidence interval [CI]: 0.61 to 0.89, p = 0.002), and TLR (RR:0.39; 95% CI: 0.29 to 0.52; p < 0.00001), without significant differences in terms of TVR (RR:0.68, 95% CI: 0.38 to 1.20; p = 0.18), ST (RR:0.71; 95% CI: 0.39 to 1.31; p = 0.28), cardiac death (RR:0.83; 95% CI: 0.49–1.42, p = 0.50) or MI (RR:1.08; 95%CI: 0.80 to 1.45; p = 0.62).

Conclusions

At 12-month follow-up, SES are superior to ZES in reducing the incidences of TLR and MACE in patients undergoing PCI, without significant differences in terms of TVR, ST, cardiac death, and MI.     

Prognostic significance of the absence of normal septal Q waves before aortic valve replacement

Purpose

Aim of this study was to investigate the prognostic significance of absence of septal Q waves in patients scheduled for aortic valve replacement.

Material and Methods

Sixty-one patients who underwent isolated aortic valve replacement for aortic stenosis were retrospectively evaluated. Septal Q waves were defined as Q waves of < 2 mm in amplitude and < 40 ms in width and absence of septal Q waves was defined as simultaneous loss of Q waves from at least three of the leads I, aVL, V5 and V6. Septal Q waves were absent in 17 patients (Group AQ, 27.8%) and were present in 44 patients (Group PQ, 72.1 %) preoperatively. Newly developed AV block > 1st degree and newly developed left bundle branch block were primary endpoints.

Results

Preoperatively, absence of normal septal Q waves was significantly associated with increased risk of postoperative AV block (HR: 11.18, range 1.37–91.21, 95% CI, p = 0.02) whereas it was not associated with increased risk for newly developed LBBB (HR: 3.15 0.62–15.83, 95% CI, p = 0.16).

Conclusion

Absence of normal septal Q waves in the preoperative ECG may predict further delay in conduction which might develop in the early postoperative course of aortic valve replacement.     

Prevention of heart failure in older adults may require higher levels of physical activity than needed for other cardiovascular events

Background

Little is known if the levels of physical activity required for the prevention of incident heart failure (HF) and other cardiovascular events vary in community-dwelling older adults.

Methods

We studied 5503 Cardiovascular Health Study (CHS) participants, age ≥ 65 years, free of baseline HF. Weekly metabolic equivalent task-minutes (MET-minutes), estimated using baseline total leisure-time energy expenditure, were used to categorize participants into four physical activity groups: inactive (0 MET-minutes; n = 489; reference), low (1–499; n = 1458), medium (500–999; n = 1086) and high (≥ 1000; n = 2470).

Results

Participants had a mean (± SD) age of 73 (± 6) years, 58% were women, and 15% African American. During 13 years of follow-up, centrally-adjudicated incident HF occurred in 26%, 23%, 20%, and 19% of participants with no, low, medium and high physical activity, respectively (trend p < 0.001). Compared with inactive older adults, age–sex–race-adjusted hazard ratios (95% confidence intervals) for incident HF associated with low, medium and high physical activity were 0.87 (0.71–1.06; p = 0.170), 0.68 (0.54–0.85; p = 0.001) and 0.60 (0.49–0.74; p < 0.001), respectively (trend p < 0.001). Only high physical activity had significant independent association with lower risk of incident HF (HR, 0.79; 95% CI, 0.64–0.97; p = 0.026). All levels of physical activity had significant independent association with lower risk of incident acute myocardial infarction (AMI), stroke and cardiovascular mortality.

Conclusion

In community-dwelling older adults, high level of physical activity was associated with lower risk of incident HF, but all levels of physical activity were associated with lower risk of incident AMI, stroke, and cardiovascular mortality.     

Impact of pulmonary hypertension on mortality after operation for isolated aortic valve stenosis

Background

Pulmonary hypertension (PH) is a well-known independent risk factor for mortality and morbidity after cardiac surgery. However, no weight is given to PH in the current guidelines for the management of patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of our study was to evaluate the impact of preoperative PH on early and five-year survival in patients with severe AS undergoing isolated AVR.

Methods

From January 2005 to July 2010, 422 consecutive patients with severe AS underwent isolated AVR. According to systolic pulmonary artery pressure (sPAP), PH was classified as none (sPAPS < 35 mmHg, N = 224), mild–moderate (35 ≤ sPAP < 50 mmHg, N = 159) and severe (sPAP ≥ 50 mmHg, N = 39).

Results

Overall in-hospital mortality was 2.8%. Unadjusted mortality was 0.9%, 3.8% and 10.2% for patients with normal, mild–moderate and severe PH (p = 0.003). In multivariable analysis, severe PH (OR 4.1, 95 CI 1.1–15.3, p = 0.04) and New York Heart Association class III–IV (OR 14.9, 95% CI 1.8–117.8, p = 0.01) were independent risk factors of in-hospital mortality. Multivariable predictors of five-year survival were extracardiac arteriopathy (HR 2.8, 95%CI 1.6–4.9, p < 0.0001), severe PH (HR 2.4, 95%CI 1.2–4.6 p = 0.01), NHYA III–IV class (HR 2.3, 95% CI 1.3–4, p = 0.003), preoperative serum creatinine (HR 2.2, 95%CI, 1.6–3.1,p < 0.0001) and age (HR 1.08, 95%CI 1.03 - 1.13, p = 0.01). Five-year survival was 86% ± 3% with normal sPAP, 81% ± 4% with mild–moderate PH and 63 ± 10% with severe PH (p < 0.001).

Conclusions

In patients undergoing isolated AVR with severe AS, severe PH is an independent predictor of in-hospital mortality and five-year survival     

Cardiovascular risk prediction in the general population with use of suPAR,CRP, and Framingham Risk Score

Background

The inflammatory biomarkers soluble urokinase plasminogen activator receptor (suPAR) and C-reactive protein (CRP) independently predict cardiovascular disease (CVD). The prognostic implications of suPAR and CRP combined with Framingham Risk Score (FRS) have not been determined.

Methods

From 1993 to 1994, baseline levels of suPAR and CRP were obtained from 2315 generally healthy Danish individuals (mean [SD] age: 53.9 [10.6] years) who were followed for the composite outcome of ischemic heart disease, stroke and CVD mortality.

Results

During a median follow-up of 12.7 years, 302 events were recorded. After adjusting for FRS, women with suPAR levels in the highest tertile had a 1.74-fold (95% confidence interval [CI]: 1.08–2.81, p = 0.027) and men a 2.09-fold (95% CI: 1.37–3.18, p < 0.001) increase in risk compared to the lowest tertile. Including suPAR and CRP together resulted in stronger risk prediction with a 3.30-fold (95% CI: 1.36–7.99, p < 0.01) increase for women and a 3.53-fold (1.78–7.02, p < 0.001) increase for men when both biomarkers were in the highest compared to the lowest tertile. The combined extreme tertiles of suPAR and CRP reallocated individuals predicted to an intermediate 10-year risk of CVD of 10–20% based on FRS, to low (< 10%) or high (> 20%) risk categories, respectively. This was reflected in a significant improvement of C statistics for men (p = 0.034) and borderline significant for women (p = 0.054), while the integrated discrimination improvement was highly significant (P ≤ 0.001) for both genders.

Conclusions

suPAR provides prognostic information of CVD risk beyond FRS and improves risk prediction substantially when combined with CRP in this setting.     

Complications in the clinical course of tako-tsubo cardiomyopathy

Objective

This study evaluated the frequency, severity and outcome of complications in the clinical course of tako-tsubo cardiomyopathy (TTC).

Background

TTC is regarded as a benign disease since left ventricular (LV) function returns to normal within a short time. However, severe complications have been reported in selected patients.

Methods

From 37 hospitals, 209 patients (189 female, age 69 ± 12 years) were prospectively included in a TTC registry.

Results

Complications developed in 108/209 patients (52%); 23 (11%) had > 2 complications. Complications occurred median 1 day after symptom onset, and 77% were seen within 3 days. Arrhythmias were documented in 45/209 patients (22%) including atrial fibrillation in 32 (15%) and ventricular tachycardia in 17 (8%). Of 8 patients resuscitated (4%), 6 survived. Additional complications were right ventricular involvement (24%), pulmonary edema (13%), cardiogenic shock (7%), transient intraventricular pressure gradients (5%), LV thrombi (3%) and stroke (1%). During hospitalization, 5/209 patients (2.5%) died. Patients with complications were older (70 ± 13 vs 67 ± 10 years, p = 0.012), had a higher heart rate (91 ± 26 vs 83 ± 19/min, p = 0.025), more frequently Q\ waves on the admission ECG (36% vs 21%, p = 0.019) and a lower LV ejection fraction (47 ± 15 vs 54 ± 14%, p = 0.002). Multivariate regression analysis identified Q-waves on admission (OR 2.49, 95% CI 1.23–5.05, p = 0.021) and ejection fraction ≤ 30% (OR 4.03, 95% CI 1.04–15.67, p = 0.022) as independent predictors for complications.

Conclusions

TTC may be associated with severe complications in half of the patients. Since the majority of complications occur up to day 3, monitoring is advisable for this time period.     

Cangrelor infusion is associated with an increased risk for bleeding: Meta-analysis of randomized trials

Context

Aggressive antiplatelet strategies unquestionably cause extra hemorrhagic risks. Bleeding episodes are associated with poor outcomes including increased mortality. However, lack of uniform reporting and adjudication of bleeding events might prevent objective evaluation of the efficacy/safety profile of antithrombotic agents.

Objective

We analyzed the bleeding rates by several previously used bleeding scales (TIMI, GUSTO, ACUITY, and BARC) after cangrelor in recent head-to-head randomized, controlled clinical trials (RCTs).

Results

Data for meta-analyses were pooled from 3 RCTs (CHAMPION-PLATFORM, CHAMPION-PCI and CHAMPION-PHOENIX) including 25,106 patients. In addition, the bleeding risks were also assessed from the small (n = 210) BRIDGE RCT. Cangrelor caused a significantly increased risk for major bleeding at 48 h according to the ACUITY scale (RR: 1.51, 95% CI: 1.32–1.72, p < 0.00001); however, this impact was less prominent according to less sensitive bleeding scales (GUSTO severe: RR: 1.21, 95% CI: 0.70–2.11, p = 0.49; TIMI major: RR: 1.00, 95% CI: 0.59–1.68, p = 0.99). There was also an obvious trend towards an increased risk for any transfusions (RR: 1.31, 95% CI: 0.97–1.77, p = 0.08) and TIMI major + minor bleeding events (RR: 1.30, 95% CI: 0.96–1.76, p = 0.09).

Conclusions

Cangrelor on top of aspirin or/and clopidogrel increases the risk for early bleeding events after PCI; however, it largely depends on the bleeding definition used, and how this excess risk of bleeding was captured. The bleeding hazard needs to be verified in the ongoing FDA secondary cangrelor review.     

Does residual aortic regurgitation after transcatheter aortic valve implantation increase mortality in all patients? The importance of baseline natriuretic peptides

Background

Aortic regurgitation (AR) is an important complication of transcatheter aortic valve implantation (TAVI) and even moderate AR is associated with increased mortality after TAVI. The association with decreased survival is unclear. We aimed to analyse the impact of AR after TAVI as a function of baseline NT-proBNP.

Methods

We included 236 consecutive patients implanted in our centre with the SAPIEN and SAPIEN XT valves, via the transfemoral route. AR was evaluated by transthoracic echocardiography. NT-proBNP was measured 24 h before implantation and patients were divided according to the median value.

Results

Median age was 85 years (80–89) and 137 (58.1%) were women. Patients with high NT-proBNP had lower left ventricular ejection fraction: 52% (35–65) vs. 63% (55–70), p < 0.001, larger telediastolic diameters: 56 mm (49–61) vs. 52 mm (46–56), p = 0.01, and more severe aortic stenosis: 0.62 ± 0.15 cm² vs. 0.70 ± 0.2 cm², p < 0.001. Pre-procedural moderate or severe AR (42% vs. 26%, p = 0.013) and mitral regurgitation (56% vs. 36%, p = 0.004) were more common in the high NT-proBNP group. After TAVI, moderate or severe AR occurred in 26% of patients and was associated with increased 2-year mortality only in the low NT-proBNP group, while patients in the high NT-proBNP group were not affected.

Conclusions

Moderate or severe AR after TAVI was not associated with increased 2-year mortality in patients with high baseline NT-proBNP. Our data suggest that the impact of AR after TAVI is absent in patients with significant pre-procedural AR or mitral regurgitation and more severe aortic stenosis.     

Chemerin levels as predictor of acute coronary events: A case–control study nested within the veterans affairs normative aging study

Objective

Chemerin is a recently identified adipocytokine that has been positively correlated with the presence and severity of coronary artery disease (CAD). However, no studies have examined circulating chemerin levels as a predictor of acute coronary syndrome (ACS). The purpose of this study is to evaluate whether chemerin levels predict the onset of ACS.

Materials/Methods

We studied 90 men whose serum had been collected at least 2 years before the development of ACS, and 162 controls matched with the cases in a 1:2 fashion for age and year of collection. The mean age of the cohort was 66.3 ± 9.6 years (range 34–84 years). Serum chemerin levels were measured with a commercially available enzyme-linked immunosorbent assay.

Results

Age was positively associated with chemerin levels (r = 0.39, p < 0.001). Logistic regression analysis, adjusting for years since blood collection, demonstrated a null association between chemerin levels and the odds ratio for development of ACS (OR: 0.99, 95% CI [0.99–1.001]). This association remained null after adjusting for age (OR: 0.99 95% CI [0.99–1.001]).

Conclusions

Although cross-sectional and case–control studies suggest a positive association between chemerin levels and CAD, we demonstrate that chemerin levels do not predict the development of ACS.     

Clampless off-pump surgery reduces stroke in patients with left main disease

Background

Surgical revascularization is the most appropriate therapy for patients with significant left main coronary-artery disease (LMD). An incidence of perioperative stroke remains an issue when compared to the early outcomes to percutaneous coronary intervention (PCI). This study evaluates the safety and impact of standardized “clampless” OPCAB techniques, composed of either complete in situ grafting or “clampless” device enabled techniques for stroke reduction in patients undergoing surgical revascularization for LMD.

Methods

Between 1999 and 2009, 1031 patients with LMD underwent myocardial-revascularization at our institution. Of these, 507 patients underwent “clampless” OPCAB and 524 patients underwent conventional on-pump CABG (ONCABG). Data-collection was performed prospectively and a propensity-adjusted regression-analysis was applied to balance patient characteristics. LMD was defined as a stenosis > 50% and endpoints were mortality, stroke, a cardiac-composite (including death, stroke and myocardial-infarction); a non-cardiac composite and complete-revascularization.

Results

In OPCAB patients, the cardiac composite (3.0% vs. 7.8%; propensity-adjusted (PA)OR = 0.27; CI95% 0.12–0.65; p = 0.003) as well as the occurrence of stroke (0.4% vs. 2.9%; PAOR = 0.04; CI95% 0.003–0.48; p = 0.012) were significantly lower while the mortality-rate was well comparable between groups (1.8% vs. 2.5%; PAOR = 0.44; CI95% 0.11–1.71; p = 0.24). The non-cardiac composite was also significantly decreased after OPCAB (8.9% vs. 19.7%; PAOR = 0.55; CI95% 0.34–0.89; p = 0.014) and complete revascularization was achieved for similar proportions in both groups (95.1% vs. 93.7%; p = 0.35).

Conclusions

This study shows the superiority of OPCAB for patients with LMD with regards to risk-adjusted outcomes other than mortality. A “clampless OPCAB strategy”, effectively reduces stroke yielding similar early outcomes as PCI.     

Impact of combined supine and prone myocardial perfusion imaging using an ultrafast cardiac gamma camera for detection of inferolateral coronary artery disease

Background

Although combined supine and prone acquisitions improve the detection of inferolateral obstructive coronary artery disease (CAD), the predictors of inaccurate detection of inferolateral ischemia have not been reported by using cadmium zinc telluride (CZT) myocardial perfusion imaging (MPI).

Methods and results

Vasodilator stress ^99mTc tetrofosmin MPI using CZT camera and coronary angiography was performed in 322 patients within an interval of 2 months. Prone MPI was performed immediately after supine MPI. Narrowing of the luminal diameter ≥ 75% was considered significant. The presence of an abnormality on both supine and prone images was considered significant. Combined supine and prone imaging, compared with supine-only quantification, was more specific (93% vs. 72%, respectively, p < 0.0001) and accurate (88% vs. 74%, p < 0.0001) without compromising sensitivity (82% vs. 68%, p = 0.10). The area under the curve for detecting inferolateral ischemia was 0.769 (95% CI 0.705–0.833) for supine imaging and 0.802 (95% CI 0.730–0.875) for combined supine and prone imaging (p < 0.05). Multivariable analysis revealed that previous inferolateral myocardial infarction was an independent predictor of a false diagnosis (odds ratio = 3.45, 95% confidence interval [CI] 1.62–7.37, p < 0.001).

Conclusions

Combined supine and prone quantitative CZT MPI enhances the detection of inferolateral CAD without adversely affecting its sensitivity. However, we recommend inferolateral ischemia be monitored in patients with a history of previous inferolateral MI because previous inferolateral MI is a predictor of inaccurate diagnosis.     

Congenital valvular aortic stenosis in young adults: Predictors for rate of progression of stenosis and aortic dilatation

Background

Congenital aortic stenosis (AS) is the most common obstructive left-sided cardiac lesion in young adults, however little is known about the progression in adults. Therefore, we aimed to evaluate the progression rate of AS and aortic dilatation in a large multicenter retrospective cohort of asymptomatic young adults with congenital valvular AS.

Methods

Data were obtained from chart abstraction. Linear mixed-effects models were used to evaluate the progression of AS and aortic dilatation over time. A joint model combining longitudinal echocardiographic and survival data was used for survival analysis.

Results

A total of 414 patients (age 29 ± 10 years, 68% male) were included. Median follow-up duration was 4.1 (2.5–5.1) years (1587 patient-years). Peak aortic velocity was 3.4 ± 0.7 m/s at baseline and did not change over time in the total patient population (− 0.01 ± 0.03 m/s/year). Increased left ventricular mass was significantly associated with faster AS progression (p < 0.001). Aortic dilatation was present in 34% at baseline and 48% at follow-up (p < 0.001). The aortic diameter linearly increased over time with a rate of 0.7 ± 0.2 mm/year. Rate of aortic dissection was 0.06% per patient-year. Seventy patients required an aortic valve intervention (4.4% per patient-year), with AS progression rate as most powerful predictor (HR 5.11 (95% CI 3.47–7.53)).

Conclusions

In the majority of patients with mild-to-moderate congenital AS, AS severity does not progress over time. However patients with left ventricular hypertrophy are at risk for faster progression and should be monitored carefully. Although aortic dissections rarely occur, aortic dilatation is common and steadily progresses over time, warranting serial aortic imaging.     

Post-shock sinus node recovery time is an independent predictor of recurrence after catheter ablation of longstanding persistent atrial fibrillation

Background

Electro-anatomical remodeling of the atria has been reported to be associated with sinus node dysfunction in patients with atrial fibrillation (AF). We hypothesized that post-shock sinus node recovery time (PS-SNRT: the time from cardioversion to the earliest sinus node activation) is related to the degree of left atrial (LA) remodeling and the clinical outcome of radiofrequency catheter ablation (RFCA) in patients with longstanding persistent AF (L-PeAF).

Methods and results

We included 117 patients with L-PeAF (82.0% males, 55.4 ± 10.7 years old) who underwent RFCA. PS-SNRTs were measured after internal cardioversion (serial shocks 2, 3, 5, 7, 10, and 15 J) before RFCA. All patients underwent the same ablation design, and we compared regional LA volume (3D-CT imaging) and LA voltage (NavX). Results: 1. During the 13.5 ± 5.8-month follow-up period, it was noted that the patients with recurrent AF 3 months after RFCA (n = 31) had longer PS-SNRTs (1622.90 ± 1196.92 ms vs. 1112.53 ± 690.68 ms, p = 0.005) and greater anterior LA volume (p = 0.032) than those who remained in sinus rhythm. 2. The patients with PS-SNRT ≥ 1100 ms showed lower AF-free rates (58.3%) compared to those with PS-SNRT < 1100 ms (89.5%, p < 0.001). However, shock energy, number of cardioversion, and LA volume were not different between two groups. 3. Multivariate Cox regression analysis demonstrated PS-SNRT ≥ 1100 ms was a significant predictor of clinical recurrence of AF (HR 5.426, 95% CI 2.099–14.028, p < 0.001).

Conclusion

In patients with L-PeAF, prolonged PS-SNRT is an independent predictor of clinical recurrence of AF after RFCA, but not closely associated with electro-anatomical remodeling of LA.