Frailty assessment and impact of frailty on outcomes after transcatheter aortic valve replacement

Introduction: Certain frail patients fail to achieve adequate functional or mortality benefit despite successful transcatheter aortic valve replacement (TAVR). Therefore, frailty assessment methods are becoming an important tool to identify and intervene on this high-risk patient subset for improving clinical outcomes.

Areas covered: The authors provide an overview of frailty and frailty assessment tools being used in clinical practice and discuss the impact of frailty on the cardiac patients, particularly among the TAVR population.

Expert commentary: Available evidence suggests that frailty assessment is critical for identifying patients at high risk of morbidity and mortality after TAVR procedures. However, there is lack of consensus for the best methodology to determine frailty and its optimal management in TAVR populations. Although, physical exercise is a commonly employed intervention to reduce frailty, a greater attention towards improving nutrition may convey more benefit than either intervention alone. Ongoing studies are investigating the benefits of a multicomponent approach to improve clinical outcomes in frail patients undergoing TAVR.     

Triple Vectors Expand AAV Transfer Capacity in the Retina

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Sleep Mediates the Association Between PTSD Symptoms and Chronic Pain in Youth

Symptoms of post-traumatic stress disorder (PTSS) and chronic pain have been shown to co-occur at high rates in adolescents and this co-occurrence is linked to worse pain and quality of life. Sleep disturbance has been posited as a mechanism underlying this co-occurrence in conceptual models of mutual maintenance. This study examined the mediating role of sleep in the relationship between PTSS and pain in youth (aged 10–17 years) with chronic pain. Ninety-seven participants completed measures of PTSS, pain (intensity and interference), anxiety symptoms, and sleep quality, in addition to demographic characteristics. Mediation models were conducted. Findings revealed that, over and above the influence of associated demographic characteristics (age, race) and anxiety symptoms, sleep quality partially mediated the relationships between PTSS and pain intensity and interference for youth with chronic pain. Specifically, higher levels of PTSS was linked to higher levels of pain intensity and pain interference, and these relationships were partially explained by poor sleep quality. Findings highlight the potential mechanistic role of sleep in explaining the co-occurrence of chronic pain and PTSS and suggest sleep might be an important target in future interventions.

Detection of myocardial iron overload by two-dimensional speckle tracking in patients with beta-thalassaemia major: a combined echocardiographic and T2* segmental CMR study

We aimed to evaluate the role of two-dimensional speckle tracking imaging (2DSTI) in detecting early changes of myocardial deformation in patients affected by thalassemia major (TM) and its relation with myocardial iron overload (MIO) detected by T2* cardiovascular magnetic resonance (CMR). We studied 28 TM patients (15 males, 37.4?±?10 years). All patients underwent CMR and echocardiography in the same day. Segmental and global T2* values were measured. Values of global longitudinal strain (GLS) were derived from the three apical views, while radial and circumferential strain were obtained as average strain from the short axis views at basal, mid and apical level. Six patients (21.4%) showed significant MIO (global heart T2*?<?20 ms). GLS showed a significant correlation with T2* values (R?=??0.49; P?=?0.001) and it was significantly lower in patients with a significant MIO than in those with no significant MIO (?18.3?±?2 vs. ?21.3?±?2.7, P?=?0.02). No significant difference was found for radial and circumferential strain in relation to the severity of MIO. Patients with impaired GLS (<?19.5%) had a significant higher risk of showing significant MIO (Odds-ratio-OR?=?17; 95%). GLS is related with global T2* in TM patients. Moreover, GLS can identify TM patients with severe MIO detected by CMR.     

Intramyocardial dissecting hematoma in anterior wall ST elevation myocardial infarction: impact on left ventricular remodeling and prognosis

Intramyocardial dissecting hematoma is an uncommon complication of myocardial infarction potentially leading to cardiac rupture. The aim of the present study was to investigate coronary reperfusion results, left ventricular (LV) function recovery and remodeling and clinical outcomes in patients with anterior STEMI complicated by intramyocardial hematoma. We prospectively studied 87 patients (mean age 59?±?10 years; 88% male) with anterior STEMI (42 with intramyocardial hematoma) in order to evaluate coronary reperfusion results, LV remodeling (≥15% increase in end-systolic volume) and clinical outcomes (cardiac death, non-fatal reinfarction, and hospitalization for congestive heart failure) at 24 months. Thrombolysis in myocardial infarction (TIMI) flow score and myocardial blush grade (MBG) were assessed both pre- and post-percutaneous coronary intervention (PCI) and speckle-tracking echocardiography was performed post PCI and at 6-month follow-up. Patients with hematoma had lower post-PCI TIMI score and MBG, higher heart rate, worse LV ejection fraction and longitudinal or rotational function than their counterparts. LV remodeling occurred in 33 (78.6%) patients with hematoma and 11 (24.4%) patients without (p?<?0.001). Independent predictors of LV remodeling were heart rate (p?=?0.018), MBG (p?=?0.036) and presence of hematoma (p?<?0.001). Hematoma (log-rank test, χ²?=?9.849; p?=?0.002) and LV remodeling (log-rank test, χ²?=?13.770; p?<?0.001) were associated to a higher rate of adverse events. Cox analysis identified LV remodeling as the only independent predictor of adverse events (hazard ratio?=?3.912; 95% confidence interval, 1.429–10.714; p?=?0.008). Intramyocardial dissecting hematoma complicating anterior STEMI is an independent determinant of LV remodeling and is associated to poor prognosis.     

Incidental findings in multislice computed tomography prior to transcatheter aortic valve implantation: frequency,clinical relevance and outcome

Multislice computed tomography (MSCT) has emerged as the mainstay in patients planned for transcatheter aortic valve implantation (TAVI). Incidental findings (IF) in MSCT are common. However, the exact incidence, clinical relevance and further consequences of IF are unclear and it is controversial whether IF adversely affect patients’ outcome. We analyzed MSCT data of 1050 patients screened for TAVI between January 2011 and December 2014. Median follow-up of patients was 20 months. In total, 3194 IF were identified, which were classified into clinically non-relevant IF (2872, 90%) and clinically relevant IF (322, 10%). In 25% of patients (258/1050) at least one clinically relevant IF was present. Age (80?±?7 vs. 80?±?7 years; p?=?0.198) and EuroSCORE II (3.6% [2.1–5.7] vs. 3.6% [2.1–5.9]; p?=?0.874) was similar between patients with and without a clinically relevant IF. TAVI was performed less frequently in patients with a clinically relevant IF (76% vs. 85%; p?<?0.001), with more patients receiving surgical aortic valve replacement in that group (14% vs. 11%; p?=?0.042), possibly due to the high rate of incidental aneurysms of the ascending aorta (n?=?48). If TAVI was performed mortality did not differ (30-days: 4% vs. 3%; p?=?0.339, 1-year: 11% vs. 14%; p?=?0.226) between patients with and without a clinically relevant IF. Our study is the largest study to analyze prevalence, clinical relevance and therapeutic consequences of IF during screening for TAVI. IF in pre-procedural MSCT are common and clinically relevant in one-quarter of patients. However, these findings had no impact on overall mortality.     

Assessment of Remote Myocardium Heterogeneity in Patients with Ventricular Tachycardia Using Texture Analysis of Late Iodine Enhancement (LIE) Cardiac Computed Tomography (cCT) Images

Purpose

Diffuse remodeling of myocardial extra-cellular matrix is largely responsible for left ventricle (LV) dysfunction and arrhythmias. Our hypothesis is that the texture analysis of late iodine enhancement (LIE) cardiac computed tomography (cCT) images may improve characterization of the diffuse extra-cellular matrix changes. Our aim was to extract volumetric extracellular volume (ECV) and LIE texture features of non-scarred (remote) myocardium from cCT of patients with recurrent ventricular tachycardia (rVT), and to compare these radiomic features with LV-function, LV-remodeling, and underlying cardiac disease.

Procedures

Forty-eight patients suffering from rVT were prospectively enrolled: 5/48 with idiopathic VT (IVT), 23/48 with post-ischemic dilated cardiomyopathy (ICM), 9/48 with idiopathic dilated cardiomyopathy (IDCM), and 11/48 with scars from a previous healed myocarditis (MYO). All patients underwent echocardiography to assess LV systolic and diastolic function and cCT with pre-contrast, angiographic, and LIE scan to obtain end-diastolic volume (EDV), ECV, and first-order texture parameters of Hounsfield Unit (HU) of remote myocardium in LIE [energy, entropy, HU-mean, HU-median, standard deviation (SD), and mean absolute deviation (MAD)].

Results

Energy, HU mean, and HU median by cCT texture analysis correlated with ECV (rho?=?0.5650, rho?=?0.5741, rho?=?0.5068; p?<?0.0005). cCT-derived ECV, HU-mean, HU-median, SD, and MAD correlated directly to EDV by cCT and inversely to ejection fraction by echocardiography (p?<?0.05). SD and MAD correlated with diastolic function by echocardiography (rho?=?0.3837, p?=?0.0071; rho?=?0.3330, p?=?0.0208). MYO and IVT patients were characterized by significantly lower values of SD and MAD when compared with ICM and IDCM patients, independently of LV-volume systolic and diastolic function.

Conclusions

Texture analysis of LIE may expand cCT capability of myocardial characterization. Myocardial heterogeneity (SD and MAD) was associated with LV dilatation, systolic and diastolic function, and is able to potentially identify the different patterns of structural remodeling characterizing patients with rVT of different etiology.