Highlights From the Circulation Family of Journals.

Abstract

HomeCirculationVol. 136, No. 13Highlights From the Circulation Family of Journals Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBHighlights From the Circulation Family of Journals Originally published26 Sep 2017https://doi.org/10.1161/CIRCULATIONAHA.117.031303Circulation. 2017;136:1256–1261Circulation: Arrhythmia and ElectrophysiologyThis retrospective study analyzed patients undergoing atrial fibrillation ablation and postprocedural esophageal endoscopy to better understand the association of thermal esophageal lesions with clinical complications. The study found that 10% of patients with postablation esophageal ulcers progressed to perforation, whereas patients without esophageal ulcers did not progress to perforations. Ulcers were significantly predictive of perforations.Progression From Esophageal Thermal Asymptomatic Lesion to Perforation Complicating Atrial Fibrillation AblationA Single-Center RegistryPhilipp Halbfass, MDBorche Pavlov, MDPatrick Müller, MDKarin Nentwich, MDKai Sonne, MDSebastian Barth, MDKarsten Hamm, MDFranziska Fochler, MDAndreas Mügge, MDUlrich Lüsebrink, MDRainer Kuhn, MDThomas Deneke, MDCorrespondence to: Philipp Halbfass, MD, Heart Center Bad Neustadt, Clinic for Interventional Electrophysiology, Bad Neustadt an der Saale 97616, Germany. E-mail [email protected]BACKGROUND: Up to 40% of patients demonstrate endoscopically detected asymptomatic esophageal lesions (EDEL) after atrial fibrillation ablation.METHODS AND RESULTS: Patients undergoing first atrial fibrillation ablation and postinterventional esophageal endoscopy were included in the study. Occurrence of esophageal perforating complications during follow-up was related to documented EDEL (category 1: erythema/erosion; category 2: ulcer). In total, 1802 patients underwent first atrial fibrillation ablation procedure between January 2013 and August 2016 at our institution. Out of this group, 832 patients (506 male patients, 61%; 64.0±10.0 years) with symptomatic paroxysmal (n=345; 42%) or persistent atrial fibrillation underwent postprocedural esophageal endoscopy. Patients were ablated using single-tip ablation with conventional or surround flow irrigation and circular ablation catheters with open irrigation (nMARQ). In 295 of 832 patients (35%), a temperature probe was used. EDEL occurred in 150 patients (18%; n=98 category 1 EDEL, n=52 category 2 EDEL). In 5 of 832 patients (0.6%), an esophageal perforation (n=3) or an esophagopericardial or atrioesophageal fistula (n=2) occurred 15 to 28 days (19±6 days) after ablation. Two patients (1 atrioesophageal fistula and 1 esophagopericardial fistula) died. Esophageal perforation occurred only in patients with category 2 lesions (absolute risk, 9.6%). In a logistic regression analysis, ulcers were identified to be a significant predictor for esophageal perforating complications.CONCLUSIONS: Postablation endoscopy seems to identify patients at high risk of esophageal perforating complications only occurring in patients with category 2 EDEL. One out of 10 postablation esophageal ulcers progressed to perforation, and no patient without esophageal thermal ulcers showed the occurrence of perforating esophageal complications.Circ Arrhythm Electrophysiol. 2017;10:e005233. DOI: 10.1161/CIRCEP.117.005233.Circulation: Cardiovascular GeneticsBased on recent findings of the relationship between loss of Y chromosome in blood cells and a higher risk of cancer and mortality likely related to immunoregulatory function, this study investigated the potential association of loss of Y chromosome with cardiovascular disease. The hypothesis-generating results suggest that loss of Y chromosome in blood is independently associated with secondary major cardiovascular events in a severely atherosclerotic population.Loss of Y Chromosome in Blood Is Associated With Major Cardiovascular Events During Follow-Up in Men After Carotid EndarterectomySaskia Haitjema, MD, PhDDaniel Kofink, MScJessica van Setten, PhDSander W. van der Laan, PhDArjan H. Schoneveld, BScJames Eales, PhDMaciej Tomaszewski, MDSaskia C.A. de Jager, PhDGerard Pasterkamp, MD, PhDFolkert W. Asselbergs, MD, PhDHester M. den Ruijter, PhDCorrespondence to: Hester M. den Ruijter, PhD, Laboratory of Experimental Cardiology, University Medical Center Utrecht, Room G.03.550, Heidelberglaan 100, 3584 CX Utrecht, Netherlands. E-mail [email protected]BACKGROUND: Recent studies found an immune regulatory role for Y chromosome and a relationship between loss of Y chromosome (LOY) in blood cells and a higher risk of cancer and mortality. Given involvement of immune cells in atherosclerosis, we hypothesized that LOY is associated with the severity of atherosclerotic plaque characteristics and outcome in men undergoing carotid endarterectomy.METHODS AND RESULTS: LOY was quantified in blood and plaque from raw intensity genotyping data in men within the Athero-Express biobank study. Plaques were dissected, and the culprit lesions used for histology and the measurement of inflammatory proteins. We tested LOY for association with (inflammatory) atherosclerotic plaque phenotypes and cytokines and assessed the association of LOY with secondary events during 3-year follow-up. Of 366 patients with carotid endarterectomy, 61 exhibited some degree of LOY in blood. LOY was also present in atherosclerotic plaque lesions (n=8/242, 3%). LOY in blood was negatively associated with age (β=−0.03/10 y; r2=0.07; P=1.6×10–7) but not with cardiovascular disease severity at baseline. LOY in blood was associated with a larger atheroma size (odds ratio, 2.15; 95% confidence interval, 1.06–4.76; P=0.04); however, this association was not significant after correction for multiple testing. LOY was independently associated with secondary major cardiovascular events (hazard ratio=2.28; 95% confidence interval, 1.11–4.67; P=0.02) in blood when corrected for confounders.CONCLUSIONS: In this hypothesis-generating study, LOY in blood is independently associated with secondary major cardiovascular events in a severely atherosclerotic population. Our data could indicate that LOY affects secondary outcome via other mechanisms than inflammation in the atherosclerotic plaque.Circ Cardiovasc Genet. 2017;10:e001544. DOI: 10.1161/CIRCGENETICS.116.001544.Circulation: Cardiovascular ImagingThis study aimed to find specific predictors of arrhythmic death, rather than nonarrhythmic death, to better identify those who would benefit from implantable cardiac defibrillators among patients with ischemic cardiomyopathy who underwent positron emission tomography. The results of this pilot competing risks analysis suggest that distinct clinical and imaging variables, including volume of denervated myocardium obtained from positron emission tomography imaging, can distinguish between the risks of sudden and nonsudden cardiac death. These multivariable associations require prospective validation.Denervated Myocardium Is Preferentially Associated With Sudden Cardiac Arrest in Ischemic CardiomyopathyA Pilot Competing Risks Analysis of Cause-Specific MortalityJames A. Fallavollita, MDJonathan D. Dare, MARandolph L. Carter, PhDSunil Baldwa, MBBSJohn M. Canty Jr, MDCorrespondence to: James A. Fallavollita, MD, Division of Cardiovascular Medicine, University at Buffalo, Ste 7030, 875 Ellicott St, Buffalo, NY 14203. E-mail [email protected]BACKGROUND: Previous studies have identified multiple risk factors that are associated with total cardiac mortality. Nevertheless, identifying specific factors that distinguish patients at risk of arrhythmic death versus heart failure could better target patients likely to benefit from implantable cardiac defibrillators, which have no impact on nonsudden cardiac death.METHODS AND RESULTS: We performed a pilot competing risks analysis of the National Institutes of Health–sponsored PAREPET trial (Prediction of Arrhythmic Events with Positron Emission Tomography). Death from cardiac causes was ascertained in subjects with ischemic cardiomyopathy (n=204) eligible for an implantable cardiac defibrillator for the primary prevention of sudden cardiac arrest after baseline clinical evaluation and imaging at enrollment (positron emission tomography and 2-dimensional echo). Mean age was 67±11 years with an ejection fraction of 27±9%, and 90% were men. During 4.1 years of follow-up, there were 33 sudden cardiac arrests (arrhythmic death or implantable cardiac defibrillator discharge for ventricular fibrillation or ventricular tachycardia >240 bpm) and 36 nonsudden cardiac deaths. Sudden cardiac arrest was correlated with a greater volume of denervated myocardium (defect of the positron emission tomography norepinephrine analog 11C-hydroxyephedrine), lack of angiotensin inhibition therapy, elevated B-type natriuretic peptide, and larger left ventricular end-diastolic volume index. In contrast, nonsudden cardiac death was associated with a higher resting heart rate, older age, elevated creatinine, larger left atrial volume index, and larger left ventricular end-diastolic volume index.CONCLUSIONS: Distinct clinical, laboratory, and imaging variables are associated with cause-specific cardiac mortality in primary-prevention candidates with ischemic cardiomyopathy. If prospectively validated, these multivariable associations may help target specific therapies to those at the greatest risk of sudden and nonsudden cardiac death.CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT01400334.Circ Cardiovasc Imaging. 2017;10:e006446. DOI: 10.1161/CIRCIMAGING.117.006446.Circulation: Cardiovascular InterventionsThis study describes an optimized approach to coronary artery disease screening and management in patients undergoing transcatheter aortic valve replacement. The results found it feasible to screen for coronary artery disease at the same time as the transcatheter aortic valve replacement procedure by invasive coronary angiography and ad hoc percutaneous coronary intervention without an increase in periprocedural risks.Optimized Screening of Coronary Artery Disease With Invasive Coronary Angiography and Ad Hoc Percutaneous Coronary Intervention During Transcatheter Aortic Valve ReplacementMarco Barbanti, MDDenise Todaro, MDGiuliano Costa, MDGerlando Pilato, MDAndrea Picci, MDSimona Gulino, MDPiera Capranzano, MDKetty La Spina, MDEmanuela Di Simone, MDPaolo D’Arrigo, MDWanda Deste, MDAntonino Indelicato, MDStefano Cannata, MDDaniela Giannazzo, MDSebastiano Immè, MDClaudia Tamburino, MDMartina Patanè, MDSergio Buccheri, MDDavide Capodanno, MD, PhDCarmelo Sgroi, MDCorrado Tamburino, MD, PhDCorrespondence to: Marco Barbanti, MD, Division of Cardiology, Ferrarotto Hospital, University of Catania, Via Citelli 6, 95124 Catania, Italy. E-mail [email protected]BACKGROUND: We sought to describe an optimized approach to coronary artery disease (CAD) screening and management in patients undergoing transcatheter aortic valve replacement (TAVR).METHODS AND RESULTS: When invasive coronary angiography showed CAD, the treatment strategy and completeness of revascularization was determined based on coronary anatomy. TAVR was performed in the same setting if percutaneous coronary intervention (PCI) was uncomplicated; otherwise TAVR was postponed. A total of 604 patients undergoing CAD screening at the time of TAVR procedure were prospectively included in this study. Severe CAD was found in 136 patients (22.5%). Among patients with severe CAD, 53 patients (8.8%) underwent uncomplicated PCI. After PCI, TAVR was postponed in 2 patients (0.3%). In 83 patients (13.8%), coronary angiography showed severe CAD that was left untreated. After TAVR, all-cause and cardiovascular 30-day mortality rates were 2.4% and 1.4%, respectively. Disabling stroke, myocardial infarction, and life-threatening bleeding occurred in 0.5%, 0.8%, and 4.0% of patients, respectively. Acute kidney injury II or III rate was 3.3%. At 2 years, all-cause mortality rate was 14.1%. Disabling stroke and myocardial infarction occurred in 2.5% and 1.8% of patients, respectively. Patients undergoing TAVR and PCI in the same session had similar rate of the composite of death, disabling stroke, and myocardial infarction when compared with patients without CAD, and patients with severe CAD left untreated (TAVR+PCI: 10.4%; severe CAD left untreated: 15.4%; no-CAD: 14.8%; P=0.765).CONCLUSIONS: In patients undergoing TAVR, screening of CAD with invasive coronary angiography and ad hoc PCI during TAVR is feasible and was not associated with increased periprocedural risks. PCI followed by TAVR in the same session had similar outcomes than TAVR in which PCI was not performed.Circ Cardiovasc Interv. 2017;10:e005234. DOI: 10.1161/CIRCINTERVENTIONS.117.005234.Circulation: Cardiovascular Quality and OutcomesAlthough the interpretation may vary, preparticipation screening of young athletes by ECG improves the ability to detect serious cardiac disease. This study found a high degree of variation in the interpretation of ECGs and reports the possible financial impact of this variability. The results highlight an essential need for formal training with standardized diagnostic pathways to support cardiologists in ECG screening of young athletes.Inter-Rater Reliability and Downstream Financial Implications of Electrocardiography Screening in Young AthletesHarshil Dhutia, BSc, MRCPAneil Malhotra, BSc, MRCP, PhDTee Joo Yeo, MRCPIrina Chis Ster, MSc, PhDVincent Gabus, MDAlexandros Steriotis, MDHelder Dores, MDGreg Mellor, MB BChir, MRCPCarmen García-Corrales, MDBode Ensam, MRCPViknesh Jayalapan, MRCPVivienne Anne Ezzat, MBChB, PhDGherardo Finocchiaro, MDSabiha Gati, BSc, MRCP, PhDMichael Papadakis, MD, MRCPMaria Tome-Esteban, PhDSanjay Sharma, BSc, MDCorrespondence to: Sanjay Sharma, BSc, MD, Division of Cardiovascular Sciences, St. George’s University of London, Cranmer Terrace, London, SW17 0RE, UK. E-mail [email protected]BACKGROUND: Preparticipation screening for cardiovascular disease in young athletes with electrocardiography is endorsed by the European Society of Cardiology and several major sporting organizations. One of the concerns of the ECG as a screening test in young athletes relates to the potential for variation in interpretation. We investigated the degree of variation in ECG interpretation in athletes and its financial impact among cardiologists of differing experience.METHODS AND RESULTS: Eight cardiologists (4 with experience in screening athletes) each reported 400 ECGs of consecutively screened young athletes according to the 2010 European Society of Cardiology recommendations, Seattle criteria, and refined criteria. Cohen κ coefficient was used to calculate interobserver reliability. Cardiologists proposed secondary investigations after ECG interpretation, the costs of which were based on the UK National Health Service tariffs. Inexperienced cardiologists were more likely to classify an ECG as abnormal compared with experienced cardiologists (odds ratio, 1.44; 95% confidence interval, 1.03–2.02). Modification of ECG interpretation criteria improved interobserver reliability for categorizing an ECG as abnormal from poor (2010 European Society of Cardiology recommendations; κ=0.15) to moderate (refined criteria; κ=0.41) among inexperienced cardiologists; however, interobserver reliability was moderate for all 3 criteria among experienced cardiologists (κ=0.40–0.53). Inexperienced cardiologists were more likely to refer athletes for further evaluation compared with experienced cardiologists (odds ratio, 4.74; 95% confidence interval, 3.50–6.43) with poorer interobserver reliability (κ=0.22 versus κ=0.47). Interobserver reliability for secondary investigations after ECG interpretation ranged from poor to fair among inexperienced cardiologists (κ=0.15–0.30) and fair to moderate among experienced cardiologists (κ=0.21–0.46). The cost of cardiovascular evaluation per athlete was $175 (95% confidence interval, $142–$228) and $101 (95% confidence interval, $83–$131) for inexperienced and experienced cardiologists, respectively.CONCLUSIONS: Interpretation of the ECG in athletes and the resultant cascade of investigations are highly physician dependent even in experienced hands with important downstream financial implications, emphasizing the need for formal training and standardized diagnostic pathways.Circ Cardiovasc Qual Outcomes. 2017;10:e003306. DOI: 10.1161/CIRCOUTCOMES.116.003306.Circulation: Heart FailureThis study analyzed endogenous regenerative capacity as assessed by circulating progenitor cell number as a predictor of mortality in patients with heart failure. The investigators found that lower progenitor cell levels are significantly associated with higher risk. They suggest that more work is needed to understand the effect of improvement in endogenous regenerative capacity or increases in progenitor cells for the management of heart failure.Progenitor Cells and Clinical Outcomes in Patients With Heart FailureAyman Samman Tahhan, MDMuhammad Hammadah, MDPratik B. Sandesara, MDSalim S. Hayek, MDAndreas P. Kalogeropoulos, MD, PhDAyman Alkhoder, MDHeval Mohamed Kelli, MDMatthew Topel, MD, MScNima Ghasemzadeh, MDKaavya Chivukula, MDYi-An Ko, PhDHiroshi Aida, BSIraj Hesaroieh, MDErnestine Mahar, BSJonathan H. Kim, MDPeter Wilson, MDLeslee Shaw, PhDViola Vaccarino, MD, PhDEdmund K. Waller, MD, PhDArshed A. Quyyumi, MDCorrespondence to: Arshed A. Quyyumi, MD, Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd NE, Ste 507, Atlanta, GA 30322. E-mail [email protected]BACKGROUND: Endogenous regenerative capacity, assessed as circulating progenitor cell (PC) numbers, is an independent predictor of adverse outcomes in patients with cardiovascular disease. However, their predictive role in heart failure (HF) remains controversial. We assessed the relationship between the number of circulating PCs and the pathogenesis and severity of HF and their impact on incident HF events.METHODS AND RESULTS: We recruited 2049 adults of which 651 had HF diagnosis. PCs were enumerated by flow cytometry as CD45med+ blood mononuclear cells expressing CD34, CD133, vascular endothelial growth factor receptor-2, and chemokine (C-X-C motif) receptor 4 epitopes. PC subsets were lower in number in HF and after adjustment for clinical characteristics in multivariable analyses, a low CD34+ and CD34+/CXCR+ cell count remained independently associated with a diagnosis of HF (P<0.01). PC levels were not significantly different in reduced versus preserved ejection fraction patients. In 514 subjects with HF, there were 98 (19.1%) all-cause deaths during a 2.2±1.5-year follow-up. In a Cox regression model adjusting for clinical variables, hematopoietic-enriched PCs (CD34+, CD34+/CD133+, and CD34+/CXCR4+) were independent predictors of all-cause death (hazard ratio 2.0, 1.6, 1.6-fold higher mortality, respectively; P<0.03) among HF patients. Endothelial-enriched PCs (CD34+/VEGF+) were independent predictors of mortality in patients with HF with preserved ejection fraction only (hazard ratio, 5.0; P=0.001).CONCLUSIONS: PC levels are lower in patients with HF, and lower PC counts are strongly and independently predictive of mortality. Strategies to increase PCs and exogenous stem cell therapies designed to improve regenerative capacity in HF, especially, in HF with preserved ejection fraction, need to be further explored.Circ Heart Fail. 2017;10:e004106. DOI: 10.1161/CIRCHEARTFAILURE.117.004106.FootnotesCirculation is available at http://circ.ahajournals.org. Previous Back to top Next FiguresReferencesRelatedDetails September 26, 2017Vol 136, Issue 13 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.031303PMID: 28947481 Originally publishedSeptember 26, 2017 PDF download Advertisement