Concomitant Valvular Heart Disease Research Articles

Predictors and Prognostic Factors of Heart Failure with Improved Ejection Fraction.

Heart failure with reduced ejection fraction (HFrEF) patients who have improved ejection fraction have a better prognosis than those with persistently reduced ejection fraction. This study aimed to analyze the predictors for progression of patients with HFrEF to heart failure with improved ejection fraction (HFimpEF), as well as their characteristics and analyze predictors for prognosis. A retrospective analysis was conducted on 1251 patients with HFrEF at baseline, who also had a second echocardiogram 3 months. After left ventricular ejection fraction (LVEF) reassessment, patients were separated into the HFimpEF group (n = 408) and the persistent HFrEF group (n = 611). The primary endpoint was a composite of cardiovascular death or heart failure hospitalization. Multivariate logistic regression showed that without history of alcohol consumption (OR: 0.47, 95% CI: 0.28-0.78), non-New York Heart Association (NYHA) class III-IV (OR: 0.28, 95% CI: 0.15-0.52), without dilated cardiomyopathy (OR: 0.47, 95% CI: 0.26-0.84), concomitant hypertension (OR: 1.53, 95% CI: 1.02-2.29), -blockers use (OR: 2.29, 95% CI: 1.54-3.43), and lower uric acid (OR: 0.999, 95% CI: 0.997-1.000) could predict LVEF improvement. Kaplan-Meier curves demonstrated that HFimpEF patients had a significantly lower incidence of adverse events than HFrEF patients (log Rank p 0.001). Multivariate Cox regression found that older age (HR: 1.04, 95% CI: 1.02-1.06), NYHA class III-IV (HR: 2.25, 95% CI: 1.28-3.95), concomitant valvular heart disease (HR: 1.98, 95% CI: 1.01-3.85), and higher creatinine (HR: 1.003, 95% CI: 1.001-1.004) were independent risk factors for the primary endpoint in HFimpEF patients. HFrEF patients without a history of alcohol consumption, non-NYHA class III-IV, without dilated cardiomyopathy, concomitant hypertension, -blockers use, and lower uric acid were more likely to have LVEF improvement. Although the prognosis of HFimpEF patients was better than that of HFrEF patients, older age, NYHA class III-IV, concomitant valvular heart disease, and higher creatinine were still risk factors for cardiovascular events in HFimpEF patients.

Cardiac Amyloidosis and Valvular Heart Disease.

Growing interest has accrued in the co-existence of cardiac amyloidosis and valvular heart disease. Amyloid infiltration from either transthyretin (ATTR) or of light chain (AL) origin may affect any structure of the heart, including the valves. The recent literature has mainly focused on aortic stenosis and cardiac amyloidosis, improving our understanding of the epidemiology, diagnosis, treatment and prognosis of this dual pathology. Despite being of high clinical relevance, data on mitral/tricuspid regurgitation and cardiac amyloidosis are rather scarce and mostly limited to case reports and small cases series. It is the aim of this review article to summarize the current evidence of concomitant valvular heart disease and cardiac amyloidosis by including studies on epidemiology, diagnostic approaches, screening possibilities, therapeutic management, and prognostic implications.

Abstract 13676: Characteristics and Outcomes of Patients With Clinically Significant Valvular Heart Disease and Cardiogenic Shock Admitted to Cardiac Intensive Care Units

Introduction: Little is known about the characteristics & outcomes of patients (pts) with significant valvular heart disease (VHD) and cardiogenic shock (CS). In addition, differences between pts with CS due to VHD vs VHD as “bystander” to CS have not been described. Methods: The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America coordinated by the TIMI Study Group. Participating centers capture all CICU admissions for 2 months annually. Pts with CS and significant VHD were classified as having CS due to VHD or CS with concomitant VHD not felt to be the cause of CS. Admissions from 2017 - 2021 were analyzed. Results: Of 3,974 CICU admissions with CS, 165 (4.2%) had CS due to VHD and 769 (19.4%) had CS with concomitant VHD. Pts with CS due to VHD were older (71 vs 67 y), less commonly had a hx of HF (47.3% vs 73.1%), & more commonly had LVEF>50% on admission (51.5% vs 16.8%); p<0.001 for all. Resource use varied significantly (Fig). Nearly 1/3 of pts (30.3%) with CS due to VHD underwent surgical/transcatheter valve procedures during CICU admission, contrasting with those with CS and concomitant VHD (13.5%; p<0.001). In-hospital mortality was similar between the 2 VHD groups (39.4% vs 33.8%, p=0.17). In-hospital mortality for allcomers with CS and VHD (concomitant or causative) was higher than in those with CS and no VHD (34.8% vs 29.7%; p=0.003), including adjusted for age, sex, SOFA score, and pre-CICU cardiac arrest (aOR 1.23; 1.03-1.47). Mortality was numerically lower in pts undergoing a valve procedure (23.4% died; 16% with CS due to VHD, 26.9% with CS and concomitant VHD; p=0.13), compared to pts who did not (37.1% overall; 49.6% & 34.9%, respectively; p=0.003). Conclusions: Although VHD is the primary cause of CS in a minority of pts, the presence of significant VHD is associated with higher mortality. In contemporary CICUs, procedural intervention is undertaken in ~1/3 of cases and mortality was numerically lower in pts who underwent valve procedures.

Surgical treatment of paroxysmal atrial fibrillation concomitant to coronary artery bypass grafting: pulmonary vein isolation or maze V?

Highlights. Maze V significantly reduces the recurrence of AF compared to bipolar RFA for PVI in the short and mid-term period.Aim. To assess the effectiveness and safety of pulmonary vein isolation (PVI) in comparison with Maze V for treating paroxysmal atrial fibrillation (AF) concomitant to coronary artery bypass grafting (CABG).Methods. Medical records of 139 patients with coronary artery disease and concomitant paroxysmal AF were retrospectively analyzed. All patients were divided into two groups: Group 1 patients (n = 71) underwent CABG + bipolar radiofrequency ablation for PVI, and Group 2 patients (n = 68) underwent Maze V + CABG. Propensity score-matched (PSM) analysis with a 1:1 nearest-neighbor matching was done. 30 patients were selected from each group. The exclusion criteria were as follows: emergent CABG, concomitant valvular heart disease, non-paroxysmal AF, decompensation of chronic diseases, and cancer. On-pump CABG was performed at normothermia with warm blood hyperkalemia cardioplegia. RFA for PVI and Maze V were performed before CABG under parallel perfusion without aortic cross-clamping. The primary and secondary endpoints included recurrent AF/atrial flutter, sinus rhythm at discharge and in the long-term period, permanent pacemaker implantation, major cardiovascular and cerebrovascular events.Results. After the PSM analysis, the CABG+Maze V group and CABG+RFA for PVI differed significantly in the duration of surgery (330 [310; 375] vs. 255 [225; 270] min, p = 0.0001), cardiopulmonary bypass time (131 [113; 144] min vs. 89 [74; 98] min, p = 0.0001), duration of AF treatment (53 [44; 59] min vs. 10 [9; 12] min, p = 0.0001). The structure and rate of complications in both groups were comparable. There were no in-patient deaths. Recurrent AF/atrial flutter significantly reduced in the CABG+Maze V group compared to the CABG+RFA for PVI group (13.3% vs. 33.3%, respectively; p = 0.044). Sinus rhythm was restored in all cases. The rate of transient sinus node dysfunction (no more than 5 days) was 6.7% in the Group 1 and 16.6% in the Group 2. The difference did not reach statistical significance (p = 0.128). The 12-months cumulative freedom from AF/atrial flutter without antiarrhythmic drug therapy was significantly higher in the CABG+Maze V group compared to the CABG+RFA for PVI group (97% vs. 83.5%, respectively; p = 0.020). The freedom from MACE in both groups was 96.7%.Conclusion. Maze V for treating concomitant paroxysmal AF prolonged the duration of cardiopulmonary bypass and the surgery itself, but did not affect the postoperative period, indicating its safety and effectiveness. Maze V procedure concomitant to CABG significantly reduced the recurrence of AF compared to RFA for PVI both in the short- and mid-term period. Thus, it is reasonable to perform Maze V+CABG in patients with paroxysmal AF and a high risk of disease progression.

Outcomes of Complex Percutaneous Cardiac Interventions in Women.

Complex percutaneous cardiac intervention (PCI) is a growing procedure in modern day cath labs. The treated population is often older, with multiple comorbidities, complex coronary anatomy, left ventricular dysfunction, and possibly concomitant valvular heart disease and/or cardiogenic shock. As such, PCI of bifurcations, chronic total occlusions, and atherectomy coronary interventions are becoming more common. The outcomes in terms of acute procedural success, procedure-related complications, and long-term mortality or heart failure hospitalizations are important to consider. Unfortunately, to date there is a paucity of data identifying sex and gender disparities following such interventions. With respect to bifurcation lesions, women usually have more comorbidities with less complex coronary anatomy. However, despite less complex anatomy, women have a significantly increased risk of MI. These differences are also noted with left main stem and multivessel disease, during which women appear to have a trend towards worse outcomes following PCI compared with coronary artery bypass grafting. Randomized trials have revealed that women present with increased cardiovascular risk factors, which may contribute to adverse longer-term outcomes. Revascularization of women with concomitant valvular heart disease is particularly challenging because the existing data are conflicted on not only the indication, but also the timing of revascularization. Similarly, women undergoing PCI of calcified lesions with drug-eluting stents have a worse clinical profile and remain at increased ischemic risk. The lower incidence of coronary calcification in women, combined with the under-representation of women in randomized trials, poses a real challenge when attempting to address safety and survival benefit in women undergoing complex interventions. This warrants dedicated trials exploring the safety and efficacy of complex interventions in women.

Incidence of maternal and fetal complications in pregnant with mechanical prosthetic cardiac valves: a cohort study

Abstract Background In developing countries, an unusually large number of women of childbearing age have mechanical valves because rheumatic fever and concomitant valvular heart disease are still common and most severely affect the young. Managing anticoagulation during pregnancy is challenging, and the rate of complications is relatively high. Purpose The aim of this study was to detect the incidence of maternal and fetal complications in pregnant women with prosthetic valve in a high-risk pregnancy unit in one of the developing countries. Methods This study included 106 pregnant women with prosthetic heart valves on oral anticoagulant therapy. Excluded from the study were patients with low ejection fraction (<50%), patients with other comorbidities that may affect the pregnancy outcomes and patients who were not willing to share their data. Patients were followed up since presentation to the high-risk pregnancy unit till delivery. At each visit, women were clinically assessed for the occurrence of complications (heart failure, infective endocarditis, prosthetic valve dysfunction, systemic emboli, new onset arrhythmia, antepartum hemorrhage, or death). Babies were evaluated by an Obstetrician for intrauterine growth retardation or fetal death, abortion, oligo or polyhydramnios, and congenital heart diseases. Results The mean age was 28.5±4.2 years, 58 patients (54.7%) had mitral valve prothesis, 34 (32.1%) had aortic valve prosthesis and 14 patients (13.2%) had double valve prothesis. Fifty-three patients (50%) received warfarin throughout pregnancy and the rest switched to heparin in the first trimester. Cerebrovascular stroke occurred in 4 patients (3.8%), all were on the 1st trimester and all were taking heparins. The mean gestational age at delivery was 36.2±4.8 weeks and the mean fetal birth weight was 2435±791.5 gm. Thirty-three abortions were reported and the mean gestational age for abortion was 13 weeks±6 days while the mean gestational age for intrauterine fetal death was 29±4 weeks, table. Two babies had congenital heart diseases (ventricular septal defect and patent ductus arteriosus) and in both, the mothers were taking warfarin >5 mg/day during the second and third trimesters. Conclusion In this tertiary care centre, the incidence of maternal complications was relatively small while the incidence of fetal complications was high, especially in mothers taking higher warfarin doses. Switching to heparin in the first trimester increased the risk of systemic embolization. Funding Acknowledgement Type of funding sources: None.

Comparison of Outcome of Bleeding with Single and Dual Antiplatelet Therapy in Beating Heart Surgery

Objective: To compare the outcome of Bleeding with Single and Dual Antiplatelet Therapy in Beating Heart Surgery Methodology: A total of 102 cases between 25 to 60 years, of either gender, advised CABG procedure and suitable for beating heart surgery were included in the study. Whereas those with known bleeding diathesis, not suitable candidate for beating heart surgery and with concomitant valvular heart disease were excluded from the study. These cases were enrolled through wards of Cardiothoracic Surgery Department, Shaikh Zayed Hospital, Lahore. Three groups were formed A,B and C. Group-A was assigned to DAPT, Group-B was SAPT (single anti platelet therapy) and Group ”C” was on DAPT that is ASPRIN 75 mg and CLOPIDOGREL 75mg till the time of surgery. Control group A was compared with group B (SAPT) and group C (DAPT) for bleeding risk. The indications of blood products transfusion was assessed by baseline HCT platelet counts, PT and APTT. The CABG was carried out through a full sternotomy incision, under general anesthesia by using routine cardio protective measures and surgical techniques. Operating surgeon decided for on pump or off pump CABG. All patients were assessed and managed in ICU after Coronary artery bypass grafting. Duty doctor and anesthetist decided about transfusion of any allogenic blood product. Transfusion decision was made on the basis of routine laboratory values of APTT, ACT, and INR of PT, as well as on Hb. and HCT levels. Moreover, the need of non-self blood products was predicted. Results: In our study, mean age was calculated as 52.65+7.48 years, 50.32+5.68 years and 48.47+5.96 years respectively, 61.76%(n=21) in Group-A, 52.94%(n=18) in Group-B and 44.12%(n=15) in Group-C were male whereas 38.24%(n=13) in Group-A, 38.24%(n=16) in Group-B and 55.88%(n=19) in Group-C were females, comparison of Perioperative blood loss as 597.29+129.26 in Group-A, 643.18+65.42 in Group-B and 654.70+59.16 in Group-C, p value was 0.02. Conclusion: We concluded that Dual Antiplatelet Therapy have more chances of Peri-Operative bleeding as compare to heparin only or Single Antiplatelet Therapy in Coronary artery bypasses grafting on Beating heart. However, it has advantage of short pre procedure stay, reduced chances of ischemic events, less chance of canula related cellulitis and less chances of HIT. Whereas the cases administered with Heparin alone are having a greater chance of canula related cellulitis, expensive, prolonged pre procedure hospital stay with increased chances of HIT (Heparin induced thrombocytopenia. Keywords: CABG , Perioperative bleeding, Dual Antiplatelet Therapy, Single Antiplatelet Therapy

Impact of Valvular Heart Disease on Mortality, Thromboembolic and Cardiac Events in Japanese Patients With Atrial Fibrillation - The Fushimi AF Registry.

There is a growing burden of valvular heart disease (VHD) and atrial fibrillation (AF) due to population aging, but data regarding the characteristics and outcomes of patients with AF and concomitant VHD are lacking. The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto. Among 3,566 patients with available echocardiographic data, 20% had VHD, consisting of 131 valvular AF (VAF: 3.7%) and 583 nonvalvular AF with VHD (NVAF-VHD: 16.3%). Here, VAF was defined as AF with mitral stenosis or a prosthetic heart valve. AF patients with VHD were older, had more comorbidities with a higher CHADS2 score, and were prescribed oral anticoagulants more frequently than those without VHD. After adjusting for confounders, VHD was not associated with stroke or systemic embolism, all-cause mortality, or cardiac death. NVAF-VHD was significantly associated with an increased risk of hospitalization for heart failure (adjusted hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.16-1.78), whereas VAF was not (HR, 1.28; 95% CI, 0.86-1.92). Among all types of VHD, aortic valve diseases were associated with a higher risk of cardiac events, whereas mitral valve diseases were not. Although VHD did not significantly affect thromboembolism or mortality, it affected cardiac events depending on type, with aortic valve diseases having higher risk, in Japanese patients with AF.

P291 Additional value of myocardial work in detecting subclinical systolic dysfunction in patients with bicuspid aortic valve and left ventricular hypertrophy

Abstract Background An impairment of speckle tracking derived left ventricular (LV) global longitudinal strain (GLS) has been observed in patients with bicuspid aortic valve (BAV) and referred to abnormalities of aortic elasticity properties. The impact of LV mass on myocardial deformation has still not been investigated. This issue can be now better addressed by myocardial work software, which incorporates both deformation and hemodynamic load in the analysis. Aim of the study To analyse the impact of both deformation and strain derived myocardial work in BAV patients with and without LV hypertrophy (LVH). Methods Sixty-five patients with BAV underwent a comprehensive echo exam, including speckle tracking derived calculation of GLS (in absolute value). Parameters of myocardial work such as global work index (GWI), global constructive work (GCW) global wasted work (GWW) and global work efficiency (GWE) were measured according to standardized procedures. Patients with reduced LV ejection fraction and with more than mild aortic stenosis and/or regurgitation were excluded. Other exclusion criteria included coronary artery disease, concomitant valvular heart disease, heart failure, primary cardiomyopathies, permanent and/or persistent atrial fibrillation and inadequate echo images. BAV patients were divided according to presence of LVH: 10 with LVH (LV mass index >47 g/m^2.7 in women and >50 g/m^2.7 in men) and 55 without LVH. Results The two groups were comparable for sex, age and heart rate whereas systolic blood pressure (p = 0.006) and pulse pressure (p = 0.002) were higher in patients with LVH, who also had higher relative diastolic wall thickness (p < 0.02). No significant difference in ejection fraction (p = 0.56), transmitral E/A ratio (p = 0.504) and E/e" (p = 0.311) was found between the two groups. GLS (19.1 ± 2.5 in LVH group and. 20.0 ± 2.4% in patients without LVH, p = 0.290), GWI (p = 0.356) and GCW (p = 0.396) did not differ significantly whereas GWW was higher (119.5 ± 72.9 vs. 72.3 ± 38.7 mmHg%, p = 0.003) and GWE lower (94.4 ± 3.0 vs. 92.2 ± 1.6%, p = 0.007) in BAV patients with LVH (Figure). In the pooled population, LV mass index was related with GWW (r = 0.26, p = 0.03) and GWE (r=-0.30, p < 0.01) but not with GLS (r=-0.22, p = 0.08). The relation between GWE and LV mass index remained significant even after adjusting for pulse pressure (partial r=-0.28, p < 0.02). Conclusion In patients with BAV, LVH plays a detrimental effect on LV systolic function which cannot be identified by ejection fraction and GLS assessment but is unmasked by the application of myocardial work. In presence of LVH, the wasted work of BAV patients is increased and myocardial efficiency is substantially reduced, it being negatively related to LV mass even after adjusting for a raw index of aortic stiffness such as pulse pressure. Abstract P291 Figure. GLS, GWW and GWE according to LVH

Corrigendum to: Subtypes of atrial fibrillation with concomitant valvular heart disease derived from electronic health records: phenotypes, population prevalence, trends and prognosis.

Corrigendum to: Subtypes of atrial fibrillation with concomitant valvular heart disease derived from electronic health records: phenotypes, population prevalence, trends and prognosis.

P4780Effectiveness and safety of non-vitamin k antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease

Abstract Background Patients with atrial fibrillation (AF) often have concomitant valvular heart disease (VHD), especially in Asia. There are limited data on non-vitamin K antagonist oral anticoagulants (NOAC) impact on outcomes for stroke prevention and bleeding for these patients in real world clinical practice. Purpose To investigate the effectiveness and safety of NOACs compared with warfarin in patients with AF and associated Evaluated Heartvalves, Rheumatic or Artificial (EHRA) type 2 VHD. Methods We identified oral anticoagulants naive patients with AF and EHRA type 2 VHD from the Korean National Health Insurance Service database between 2014 and 2016 (n=2,671 taking warfarin; n=3,058 taking NOAC). Six clinical outcomes including ischemic stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding (GI), major bleeding, all-cause death, and their composite outcome and fatal clinical events (any events that led to death within 30-day of its occurrence) were evaluated. Inverse probability of treatment weighting (IPTW) method was used to balance covariates between the two groups. Results After weighted using 5% trimmed IPTW method (n=2371 taking warfarin; n=2792 taking NOAC), the mean age was 71.2 years, male was 57% and CHA2DS2-VASc score was 3.9. During a mean 1.4-year follow-up, weighted incidence rate of ischemic stroke, ICH, GI bleeding, and all-cause death were lower in the NOAC group than in the warfarin group. Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.53–0.96), GI bleeding (HR 0.50, 95% CI 0.35–0.72) and major bleeding (HR 0.61, 95% CI 0.45–0.80). Although NOAC and warfarin groups showed similar incidence rate of ICH, NOAC group was associated with a significantly lower risk of fatal ICH compared to warfarin group (HR 0.28, 95% CI 0.07–0.83). Overall, NOACs were associated with a lower risk of the composite outcome (HR 0.68, 95% CI 0.58–0.80). For an exploratory analysis, patients with EHRA type 1 VHD (n=366 taking warfarin; n=345 taking NOAC) was evaluated. In multivariable Cox regression analysis, NOAC group showed a comparable risk of ischemic stroke, ICH, all-cause death and composite outcome. Clinical outcome in AF patients with VHD Conclusion In this nationwide Asian AF population with EHRA type 2 VHD, NOAC use was associated with lower risks of ischemic stroke, major bleeding, all-cause death, and the composite outcome compared to warfarin.

P1781Burden of significant valvular heart disease in elderly patients presenting with acute coronary syndromes

Abstract Background Elderly patients with acute coronary syndromes (ACS) represent a group seldom included in clinical trials and in whom robust data regarding mid-term impact of significant concomitant valvular heart disease are lacking. Purpose Our aim was to evaluate the impact of moderate-to-severe mitral regurgitation (MR), moderate-to-severe aortic stenosis (AS), or both conditions combined on a primary composite endpoint of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year in a population of ACS patients included in the Elderly ACS 2 trial. Methods In the multicenter Elderly II ACS Study, 1,443 patients aged >74 y undergoing percutaneous coronary intervention (PCI) for ACS, were randomly assigned to receive prasugrel (5 mg) or clopidogrel (75 mg) and were prospectively followed for 1 year. Amongst these, 1,102 patients received full echocardiographic assessment and were included in the post-hoc analysis (Table 1). Results Survival analysis showed that patients presenting with moderate-to-severe MR, AS or both (Figure 1A), had worse outcome in terms of primary endpoint (p<0.001) as compared to no valve disease. A multivariable Cox regression model revealed that the presence of moderate-to-severe MR, AS or both were independent predictors of primary endpoint (HR 1.84; HR 2.8; HR 2.9 and p<0.001; p=0.004; p=0.01, respectively), regardless of age, gender, left ventricular ejection fraction, diabetes mellitus, history of cancer and total number of diseased vessels (Figure 1B). Table 1 Overall No residual valvular heart disease Moderate-to-severe MR Moderate-to-severe AS Both Age (y) 80.68±4.50 80.40±4.42 81.47±4.45 82.92±5.42 83.23±5.42 Male gender 652 (59.2) 538 (61.6) 92 (48.4) 19 (73.1) 3 (23.1) STE-ACS 420 (38.1) 319 (36.5) 91 (47.9) 6 (23.1) 4 (30.8) Diabetes mellitus 203 (18.4) 158 (18.1) 35 (18.4) 5 (19.2) 5 (38.5) LVEF (%) 48.30±9.58 49.26±9.27 44.61±9.45 48.50±11.22 38.31±10.87 History of cancer 32 (2.9) 26 (3.0) 3 (1.6) 2 (7.7) 1 (7.7) Tot number of diseased vessel 2.31±1.05 2.28±1.04 2.49±1.05 2.04±0.87 2.54±1.13 Data are expressed as mean ± SD or count (valid %). Figure 1 Conclusions Moderate-to-severe MR and AS represent significant predictors of 1-year outcome in elderly patients hospitalized for ACS, even when other well-established prognostic factors are taken into account and after revascularization with PCI. Therefore, these patients should be carefully screened for the presence of valvular heart disease at the time of presentation and the need for surgical or percutaneous correction should be assessed accordingly. Acknowledgement/Funding None

Subtypes of atrial fibrillation with concomitant valvular heart disease derived from electronic health records: phenotypes, population prevalence, trends and prognosis.

AimsTo evaluate population-based electronic health record (EHR) definitions of atrial fibrillation (AF) and valvular heart disease (VHD) subtypes, time trends in prevalence and prognosis.Methods and resultsA total of 76 019 individuals with AF were identified in England in 1998–2010 in the CALIBER resource, linking primary and secondary care EHR. An algorithm was created, implemented, and refined to identify 18 VHD subtypes using 406 diagnosis, procedure, and prescription codes. Cox models were used to investigate associations with a composite endpoint of incident stroke (ischaemic, haemorrhagic, and unspecified), systemic embolism (SSE), and all-cause mortality. Among individuals with AF, the prevalence of AF with concomitant VHD increased from 11.4% (527/4613) in 1998 to 17.6% (7014/39 868) in 2010 and also in individuals aged over 65 years. Those with mechanical valves, mitral stenosis (MS), or aortic stenosis had highest risk of clinical events compared to AF patients with no VHD, in relative [hazard ratio (95% confidence interval): 1.13 (1.02–1.24), 1.20 (1.05–1.36), and 1.27 (1.19–1.37), respectively] and absolute (excess risk: 2.04, 4.20, and 6.37 per 100 person-years, respectively) terms. Of the 95.2% of individuals with indication for warfarin (men and women with CHA2DS2-VASc ≥1 and ≥2, respectively), only 21.8% had a prescription 90 days prior to the study.ConclusionPrevalence of VHD among individuals with AF increased from 1998 to 2010. Atrial fibrillation associated with aortic stenosis, MS, or mechanical valves (compared to AF without VHD) was associated with an excess absolute risk of stroke, SSE, and mortality, but anticoagulation was underused in the pre-direct oral anticoagulant (DOAC) era, highlighting need for urgent clarity regarding DOACs in AF and concomitant VHD.

Evaluation of Guideline-Directed Medical Therapy for the Reduction of Stroke and Systemic Embolism in Hospitalized Patients with Nonvalvular Atrial Fibrillation

Background: Guidelines recommend antithrombotic therapy in patients with nonvalvular atrial fibrillation (NVAF) to reduce the risk of stroke and systemic embolism (SSE) based on an assessment utilizing the CHA2DS2-VASc score. However, a treatment gap exists regarding patients at risk for thromboembolic events. Objectives: The aim of this study was to characterize the use of guideline-directed medical therapy (GDMT) to reduce the risk of SSE in patients with NVAF upon hospital discharge. Methods: This retrospective review evaluated patients admitted to a community hospital with NVAF in 2016. All patients were included except for the following: < 18 years of age, concomitant valvular heart disease, expired during hospitalization, or discharged on hospice care. Descriptive statistics were reported for all parameters. Results: A total of 2739 patients with NVAF were included with 59.9% discharged on GDMT to reduce the risk of SSE. A 1% increase in GDMT at discharge was observed in patients admitted with a history of NVAF (n = 2238; 60.1% vs 61.1%). Patients with first-detected NVAF (n = 501) were discharged on GDMT 54.5% of the time. In patients with a high stroke risk, concomitant heart failure ( P = .001) and a lower HAS-BLED score (mean = 2.85 vs 3.18; P < .0001) were associated with receiving GDMT upon discharge. However, patients with increased age (mean = 78.5 vs 76.4; P < .0001), vascular disease ( P = .02), prior major bleeding ( P < .0001), or first-detected NVAF ( P < .0001) were less likely to be discharged on GDMT. Conclusions: Consistent with published registry data, a gap was observed in the use of GDMT to reduce the risk of SSE in patients with NVAF at this institution. Further investigation into methods for improvement is warranted.

Spare Ronnie from Drowning: Reducing Heart Failure Symptoms in Hospice Patients Utilizing a New Guideline-Directed Medical Therapy Algorithm (TH371C)

•Differentiate the various etiologies of congestive heart failure, and describe how this understanding impacts treatment.•Utilizing a newly introduced, vital sign-driven, heart failure treatment algorithm, the attendee will have the capacity to devise an anti-congestive medication strategy tailored to each hospice patient, and to any point in that patient's life trajectory.•Following the patient's response to the treatment algorithm, each attendee will have an improved capacity to prognosticate life expectancy for each heart failure patient. Guideline Directed Medical Therapy (GDMT) is the foundation of current heart failure treatment. However, in end-stage disease, upon hospice enrollment, these medications are often either abandoned, or simply cut-and-pasted into the patient's new drug regimen without scrutiny. Neither approach serves the hospice patient well. Optimal treatment entails first defining the etiology of each patient's congestive failure, (preserved or reduced ejection fraction, and the presence or absence of concomitant valvular heart disease and/or atrial fibrillation). Application then of a streamlined, tiered algorithm of GDMT, specifically adapted to the hospice setting, best achieves, and preserves, optimal symptom management. The algorithm is vital sign qualified; each different tier of therapy requires a different level of systolic blood pressure and/or heart rate to permit medication administration. This dynamic automatically establishes a hierarchy of importance for the different medication groups, assists with formulating a rational initial medication regimen tailored to each patient, and prevents drug administration when, because of either relative hypotension or bradycardia, the agent could be deleterious. It also aids prognostication, and the eventual transitioning of patients off GDMT to only comfort medications (opioids and benzodiazepines) at the immediate end of life. Comparing statistics drawn from a 12-month chart review of heart failure patients admitted to our in-patient hospice facility prior to implementation of this algorithm, to an ongoing data analysis of current patients with the same primary diagnosis. Statistics reveal a 31% improvement in BORG scale, and a 28% improvement in PPS. The live discharge rate to home* has risen by 39%, with patients living (comfortably) weeks longer. Improved symptom management of hospice-enrolled patients with a primary diagnosis of heart failure underpin this treatment algorithm, with ongoing patient review. *“home” may include assisted or skilled nursing facility

Direct Oral Anticoagulant Use in Valvular Heart Disease

Direct oral anticoagulants (DOACs) are indicated by the European Medicines Agency and US Food and Drug Administration for stroke prevention in patients with nonvalvular atrial fibrillation (AF). The role of DOACs in patients with AF and concomitant valvular heart disease (VHD) is less clear. Recent subanalyses of randomized controlled trials and meta-analyses have evaluated the role of DOACs in patients with AF and VHD. Patients with native aortic valve disease, tricuspid valve disease, or mitral regurgitation will be the primary focus as these represent the majority of VHD represented in the DOAC AF trials. Limited data exist on the role in patients with rheumatic mitral stenosis, mechanical heart valves, and mitral valve repair. This review provides the current clinical and scientific data pertaining to the safety and efficacy of DOAC use in patients with VHD.

Stroke Prevention in Atrial Fibrillation and Valvular Heart Disease.

There is a clinically staggering burden of disease stemming from cerebrovascular events, of which a majority are ischemic in nature and many are precipitated by atrial fibrillation (AF). AF can occur in isolation or in association with myocardial or structural heart disease. In the latter case, and when considering health at an international level, congenital and acquired valve-related diseases are frequent contributors to the current pandemic of AF and its clinical impact. Guidelines crafted by the American Heart Association, American College of Cardiology, European Society of Cardiology and Heart Rhythm Society underscore the use of vitamin K antagonists (VKAs) among patients with valvular heart disease, particularly in the presence of concomitant AF, to reduce the risk of ischemic stroke of cardioembolic origin; however, the non-VKAs, also referred to as direct, target-specific or new oral anticoagulants (NOACs), have not been actively studied in this particular population. In fact, each of the new agents is approved in patients with AF not caused by a valve problem. The aim of our review is to carefully examine the available evidence from pivotal phase 3 clinical trials of NOACs and determine how they might perform in patients with AF and concomitant valvular heart disease.

A Pilot Study of Systolic Dyssynchrony Index by Real Time Three‐Dimensional Echocardiography and Doppler Tissue Imaging Parameters Predicting the Hemodynamic Response to Biventricular Pacing in the Early Postoperative Period after Cardiac Surgery

To evaluate systolic dyssynchrony index (SDI) measured by real time three-dimensional echocardiography (RT3DE) and Doppler tissue imaging (DTI) dyssynchrony parameters in predicting the hemodynamic response to biventricular (BIV) pacing in the early postoperative period after cardiac surgery. To compare right ventricular (RV) and BIV pacing using invasively measured hemodynamic values. A prospective randomized clinical study enrolling 11 patients with ischemic heart disease, concomitant valvular heart disease, and left ventricular ejection fraction (LVEF) ≤ 35% comparing preoperative SDI by RT3DE and DTI LV dyssynchrony parameters to hemodynamic values obtained during RV or BIV sequential (DDD) epicardial pacing in the first 72 hours after cardiac surgery. BIV pacing produced a statistically significant higher cardiac output (CO) (6.27 ± 1.55 L/min) and cardiac index (CI) (3.44 ± 0.93 L/min per m(2) ) than RV pacing (CO 5.44 ± 0.97 L/min, CI 3.03 ± 0.83 L/min per m(2) , P < 0.05). We found a statistically moderate correlation between preoperative SDI by RT3DE and CO (r = 0.596, P < 0.05) and a nonsignificant correlation to CI (r = 0.535, P < 0.10) during BIV pacing. No correlation was observed between DTI dyssynchrony parameters and measured hemodynamic values. BIV pacing reduced the ICU stay and inotropic support requirements of patients after heart surgery. SDI measured preoperatively using RT3DE can predict CO during BIV pacing in the early postoperative period after cardiac surgery. BIV pacing is more hemodynamically effective than RV pacing in patients with LV dysfunction after coronary artery bypass grafting with or without a valve procedure.

Gender-related differences in catheter ablation of atrial fibrillation

Women have an increased risk for atrial fibrillation (AF)-related complications and there is evidence towards a reduced efficacy of the rhythm control strategy than men. A catheter-based strategy is therefore widely attractive, but the impact of gender on catheter ablation (CA) of AF remains undefined. We included 221 consecutive patients (150 men) who underwent CA of drug-refractory AF. Gender differences in clinical presentation and outcomes were compared. Women were older (P = 0.002), had a longer history of AF (P = 0.04), and were more likely to have hypertension (P = 0.04). Moreover, a concomitant valvular heart disease tended to be more common in women (32.4 vs. 23.3%; P = 0.28) and left atrium dimensions were significantly larger (P = 0.003). However, acute success rate and complications rate were similar between genders. After 22.5 +/- 11.8 months of follow-up, the overall freedom from arrhythmia recurrences was similar (83.1 vs. 82.7% in men), and a similar improvement in SF-36 quality of life scores was achieved in both groups. Women are referred for AF ablation later with a more complex clinical pre-operative presentation. Despite this higher risk profile in women, no differences were detected in clinical outcomes. Our findings indicate that CA of AF appears to be safe and effective in women as in men.

Treatment decisions in stable coronary artery disease: Insights from the Euro Heart Survey on Coronary Revascularization

We sought to assess determinants of clinical decision making in patients with stable coronary artery disease. The 2936 patients with stable angina pectoris who enrolled in the Euro Heart Survey on Coronary Revascularization were the subject of this analysis. After the diagnosis has been confirmed, physicians decided on treatment: medical management or revascularization therapy by means of percutaneous coronary intervention or coronary bypass surgery. We applied logistic regression analyses to evaluate the relation between baseline characteristics and treatment decision: medical treatment versus percutaneous coronary intervention, medical treatment versus coronary bypass surgery, and percutaneous coronary intervention versus coronary bypass surgery. The median age was 64 years, 77% were men, and 20% had diabetes. Medical therapy was intended in 690 (24%) patients, percutaneous coronary intervention in 1503 (51%) patients, and coronary bypass surgery in the remaining 743 (25%) patients, respectively. Revascularization was generally preferred in patients with more severe anginal complaints, an intermediate-to-large area of myocardium at risk, and preserved left ventricular function who had not undergone prior coronary revascularization, provided lesions were suitable for treatment. Coronary bypass surgery was preferred over percutaneous coronary intervention in multivessel or left main disease, as well as in those with concomitant valvular heart disease, provided a sufficient number of lesions were suitable for coronary bypass surgery. In those with previous coronary bypass surgeries, more often percutaneous coronary intervention was preferred than redo coronary bypass surgery. Diabetes was not associated with more frequent preference for coronary bypass surgery. In the hospitals that participated in the Euro Heart Survey on Coronary Revascularization, treatment decisions in stable coronary artery disease were largely in agreement with professional guidelines and determined by multiple factors. Most important deviations between guideline recommendations and clinical practice were seen in patients with extensive coronary disease, impaired left ventricular function, and diabetes.